Determinants of inconsistent condom use during penetrative and receptive anal intercourse among hijra and transgender people in India

Abstract

Introduction

Receptive anal sex drives HIV transmission. Hijra and transgender persons in India experience a high burden of HIV and face multiple social and behavioral vulnerabilities. We examined the determinants of inconsistent condom use during receptive and penetrative anal sex among hijra and transgender people in India.

Methods

We analyzed data from 3789 hijra and transgender people enrolled in the National Integrated Biological and Behavioral Surveillance, a large national survey conducted under the National AIDS Control Programme. Logistic regression models with backward elimination were used to identify factors independently associated with inconsistent condom use in receptive and penetrative roles.

Results

A total 3789 hijra and transgender persons were included in the analysis. During receptive anal sex, higher inconsistent condom use was associated with lower education (aOR: 1.46; 95% CI: 1.14, 1.86), experience of violence (aOR: 2.14; 95% CI: 1.71, 2.78), alcohol use (aOR: 1.44; 95% CI: 1.17, 1.77), regular non-paying male partner (aOR: 1.53; 95% CI: 1.23, 1.89), and regular non-paying hijra partners (aOR: 1.51; 95% CI: 1.19, 1.91). Those engaged in sex work (aOR: 0.75; 95% CI: 0.60, 0.95), living alone (aOR: 0.76; 95% CI: 0.59, 0.98), and people living with HIV (aOR: 0.67; 95% CI: 0.45, 0.99) had lower odds of inconsistent condom use. During penetrative anal sex, inconsistent condom use was higher among younger (aOR: 1.91; 95% CI: 1.05, 3.45) and older participants (aOR: 2.80; 95% CI: 1.43, 5.46) compared to those in the middle of age-group distribution. Engagement in sex work (aOR: 0.27; 95% CI: 0.15, 0.46), high-risk occupations (aOR: 0.19; 95% CI: 0.05, 0.81), and living alone (aOR: 0.51; 95% CI: 0.28, 0.94) were associated with higher odds of consistent condom use.

Conclusions

Inconsistent condom use among hijra and transgender people in India is shaped by educational, social, and behavioral factors, with distinct patterns observed by sexual role. Interventions should be role-specific and partner-focused, and should strengthen condom negotiation skills, address alcohol use, and prevent physical and sexual violence. Co-designed and produced community-based approaches that reduce social vulnerability, particularly among younger individuals, are essential to improve HIV prevention outcomes.