Exploring HIV vulnerability among transgender people in Pakistan: a qualitative investigation.

Background: This study explored the lived experiences of transgender people in Pakistan, focusing on stigma, discrimination, family rejection, education, and unemployment and their contribution to HIV vulnerability. Methods: The qualitative investigation included 35 transgender individuals aged 19 to 49 years from diverse professions, recruited through purposive sampling via community-based contacts and referrals from transgender community leaders. Interviews were conducted in public venues (parks and restaurants) between 12 February and 5 March 2024, primarily in Urdu (33) and Punjabi (2). Thematic saturation was reached after the 30th interview, confirming adequacy of the sample. The study used a self-developed, open-ended, semi-structured questionnaire, informed by literature in similar cultural contexts and validated through expert review and pilot testing for clarity and cultural relevance. All participants identifying as transgender men and women were included after written consent. Participant demographics were described to contextualize the sample, and Braun and Clarke's thematic analysis approach was used to interpret qualitative results. Results: Primary risk factors for HIV transmission included unprotected receptive sex, inconsistent condom use, multiple sexual partners, and substance use. Economic hardships and limited employment opportunities were key drivers of engagement in sex work. Many participants reported experiencing discrimination in healthcare settings, which discouraged timely HIV testing and treatment-seeking behavior. Conclusions: Transgender people in Pakistan are involved in high-risk behaviors because of family rejection, homelessness, social marginalization, discrimination, and limited access to education and employment opportunities. This qualitative study was conducted in Lahore, Pakistan, with 35 transgender participants aged 19 to 49 years from diverse professions. Participants were recruited through trusted community leaders and interviewed between February and March 2024. A semi-structured questionnaire, developed from regional and international studies and refined through pilot testing, guided open-ended discussions on HIV transmission, stigma, discrimination, health, and survival. All interviews were recorded, transcribed, translated, and analyzed using Braun and Clarke's thematic framework. Ethical approval and informed consent were ensured throughout.