Date of Award


Degree Type


Degree Name

Doctor of Philosophy (PhD)


Public Health

First Advisor

Laura F. Salazar, Ph.D.

Second Advisor

Seema Sahay, Ph.D.

Third Advisor

Richard Rothenberg, M.D. M.P.H.



Transgender women (TGW) experience disparities in a multitude of aspects, such as education, health, housing, employment, legal, and human rights. One of the significant health issues TGW face is the HIV epidemic. We conducted three studies to address different but related gaps in the literature.

Study 1: A systemic review of the evidence-based interventions to prevent HIV burden among TGW. We adapted the modified social ecological model for TGW, describing the multiple levels of risk factors for HIV epidemic. Fifteen articles were selected for systematic review. Six studies targeted individual level factors, three focused on community-level factors, and six focused on multi-level factors. There is a need for more interventions focusing on network level factors, community level intervention specifically designed for TGW, and multi-level interventions with rigorous evaluations.

Study 2: A qualitative study to describe the context of the syndemic effect of psychosocial factors on increased risk of HIV infection in sexual and gender minorities in India. Data were collected through in-depth interviews from a purposive sample of TGW and MSM (n=10). We used syndemic theory to identify deductive codes and grounded theory approach to generate inductive codes. Major themes were derived from the data, and a descriptive model was developed. Stigma, discrimination, child sexual abuse, lack of family support, Guru-Chela relationship dynamics, economic hardships, misuse of discriminatory laws by the police, and need of love and intimacy in relationships emerged as important themes. Model described the pathways leading to violence, mental health issues, substance abuse, and their syndemic effect on increased HIV risk. Results call for focus towards the psychosocial factors, and interventions addressing the co-occurrence of these factors to reduce the burden of HIV infection in India.

Study 3: A pilot study to examine the relationship of Hormone therapy (HT), HIV infection, and Anti-retroviral therapy (ART) on the Telomere length (TL) in TGW. In this cross-sectional study, a convenient sample of TGW (n=86) were recruited in Atlanta. Structured interviews were conducted to administer survey instrument and saliva samples were collected for TL measurement. Multivariable linear regression model was used to estimate the association of HT, HIV, and ART, with TL measured in kilobase pairs (kbp). Sensitivity analysis were conducted to account for an unmeasured variable, pre-exposure prophylaxis use. Average TL of the participants was 23.63 (SD = 9.52) kbp. We found the interaction of HT and HIV was significantly associated with TL (B = -24.52, p = 0.03). This suggests that HT in the presence of HIV infection, HT decreases TL and may induce adverse effects associated with shorter TL. Considering the importance of HT and HIV in TGW, more research is needed to understand the effects of this relationship.

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