How India's LGBTQIA+ Communities are Shaping HIV Strategy, All While Being Left Out of it

For over three decades, India's public health establishment has viewed its LGBTQIA+ communities almost exclusively through one narrow lens of HIV transmission. Since the National AIDS Control Programme (NACP) launched in 1992, transgender women, hijras, and men who have sex with men have been visible to the state primarily as "high-risk groups" rather than as whole persons deserving comprehensive healthcare.

The numbers tell part of the story. HIV prevalence data from Integrated Biological and Behavioural Surveillance (IBBS) 2015 showed transgender/hijra populations at 7.20% and men who have sex with men at 4.30%, compared to 0.29% among pregnant women. But these statistics, while justifying targeted interventions, have also cemented a dehumanising narrative that persists today.

The National AIDS Control Organisation's 2017 blood donation guidelines exemplify this approach—Clauses 12 and 51 permanently defer transgender persons, men who have sex with men, and female sex workers from donating blood, citing them as "at risk for HIV infection". This ban remains in effect despite a pending Supreme Court challenge filed by transgender activist Santa Khurai.

The contradictions are stark. India celebrated the 2018 decriminalisation of Section 377, which had criminalised consensual same-sex relations for 157 years, and passed the Transgender Persons Act in 2019. Yet public health infrastructure continues to treat queer bodies as vectors rather than full citizens. Organisations like Humsafar Trust, founded in 1994 in Mumbai, and Naz Foundation in Delhi have spent decades filling gaps the government leaves empty; providing mental health support, legal aid, gender-affirming care, and dignified HIV services that mainstream systems fail to deliver.

When Mainstreaming Means Marginalisation

On September 6, 2018, India's Supreme Court unanimously struck down Section 377 in a historic five-judge bench decision that recognised discrimination based on sexual orientation as a violation of fundamental constitutional rights. Legal victories, however, have not translated into equitable health policy.

India's current HIV strategy under NACP Phase-V (2021-2026) continues prioritising targeted interventions for key populations, aiming to reduce new annual HIV infections. But as health systems move toward mainstreaming HIV services into primary healthcare, critical cracks are appearing.

"Many public health facilities still lack the sensitivity and systems required to provide gender-affirming, stigma-free care, including mental health support," says Sakshi Mane, Team Lead and Director of Health at Humsafar Trust. "Trans and queer individuals often face misgendering, discrimination, and breaches of confidentiality when accessing HIV testing or ART, making linkage and retention challenging."

Mane points to geographic disparities that compound the problem. "While major cities have stronger community-led services, smaller and semi-urban areas continue to lack targeted outreach, PrEP awareness, STI management, and crisis support."

The shift from community-based organizations to ASHA workers and Auxiliary Nurse Midwiferies (ANMs) for service delivery exemplifies these concerns. While the government frames this as "mainstreaming," it often means handing specialised queer health services to workers with zero training in LGBTQ+ competency. The loss of peer educators and community health workers—people who share lived experiences with those they serve—has eroded trust and accessibility.

"Although PrEP awareness is increasing, access remains limited due to inconsistent supply, a small number of prescribing centers, affordability issues, and low provider awareness," Mane adds. "Structural discrimination in healthcare, employment, housing, and policing continues to impact access and adherence, limiting the overall effectiveness of HIV programmes for LGBTQ+ communities."

The Prevention Tools That Don't Reach Those Who Need Them

Pre-exposure prophylaxis (PrEP) represents one of the most significant advances in HIV prevention, yet its availability in India remains woefully inadequate. While TDF/FTC has been approved as PrEP by the Drug Controller General since 2016, and NACO has developed National Technical Guidelines for HIV PrEP, the government does not provide it as a free service. Only scattered NGO initiatives and private doctors prescribe it, leaving access fragmented and inequitable.

Safe Access, a queer health organisation led by CEO Shubham Choudhary, responded to this gap by launching India's first PrEP and PEP Locator in September 2024. The community-sourced directory provides information on providers offering preventive HIV care across India, including pricing details, online/offline availability, and whether medicines can be shipped to patients. The tool addresses urgent need—PEP must be started within 72 hours of potential exposure, a narrow window made even tighter by stigma and discrimination.

"A queer inclusive HIV strategy must begin with a simple principle- meet people where they are. HIV science has evolved dramatically over the last two decades, but our systems, strategies, and services have not kept pace," Shubham says. "Funding needs to reach those who are already doing the work on the ground. Community led queer and trans organisations are often the first source of support when someone needs support. They deserve direct and sustained investment, not one time token partnerships."

Shubham also emphasises that outreach must evolve. "Queer people seek care and information in community centers, nightlife, dating apps, WhatsApp groups, and online networks built from trust. And above all, dignity has to be non negotiable. Queer inclusive HIV care means being affirmed for who you are in every healthcare setting, without judgment, questions, or fear of discrimination."

Communities Building What the State Won't

The landscape of queer socialising and sex work has transformed dramatically over the past decade through dating apps and social media, yet HIV programs remain anchored in outdated models. New prevention technologies offer potential breakthroughs. Recent efficacy and safety data on twice-yearly lenacapavir for HIV prevention has opened new horizons, with Indian drugmakers agreeing to sell generic versions for about $40 per year beginning in 2027.

"There have been recent studies about the effectiveness about Long-acting injectable-pre-exposure prophylaxis (LAI-PrEP), requiring less frequent dosing as a potential new prevention method which provides a wider choice in addition to the existing prevention methods," says Dr. Aqsa Shaikh, Professor of Community Medicine at Hamdard Institute of Medical Sciences & Research (HIMSR). "Additionally, it is important that the policies must have a focus on digital intervention and community engagement to ensure that we reach the last mile."

Mane emphasises the need for services to adapt to younger generations. "As younger queer people grow up with new identities, risks, and online habits, HIV services need to change to meet their needs. Services should be more welcoming to all identities, easier to reach through phones and the internet, and offer flexible options like community-based testing and PrEP access at CBO level."

Yet technology alone cannot solve systemic discrimination. Community organisations continue filling critical gaps. Humsafar Trust has conducted research on over 25 national and international studies, established India's first integrated community-based HIV treatment center with support from Mumbai District State AIDS Control Society and FHI 360, and currently reaches 7,500 MSM and transgender individuals in Mumbai. Naz Foundation, which led the landmark legal challenge against Section 377, continues providing holistic care including counseling, HIV testing, home-based support, and advocacy.

"Policymakers need to hear this clearly: queer communities are not hard to reach. We are simply not reached by systems that refuse to see us," Choudhary says. "When investment follows trust, when strategy follows lived experience, and when dignity becomes the baseline, then our HIV response will finally cater to queer and trans communities."

Between Supreme Court victories and stubborn policy failures, India's LGBTQIA+ communities are refusing to wait for the state to catch up. They're building their own networks, creating their own tools, and demanding more than survival, they're insisting on dignity. The question now is not whether queer-led organisations can fill the gaps in India's HIV response. They already are. The question is whether policymakers will recognize this work as essential infrastructure rather than charitable supplement, and fund it accordingly. Every day that answer remains unclear, lives hang in the balance.