HIV Prevalence and Associated Factors among Transgender Individuals in Kasur, Pakistan

HIV Prevalence and Associated Factors among Transgender Individuals in Kasur, Pakistan | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article HIV Prevalence and Associated Factors among Transgender Individuals in Kasur, Pakistan Dr. Emram Ezra, Miss Komal Sarbuland, Dr. Sharoon Hanook, Mr. Yeshoo Ezra, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8105009/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Transgender and hijra communities in Pakistan remain among the most marginalized groups, facing discrimination, violence, and exclusion from education, employment, and healthcare. These social inequalities heighten their risk of HIV infection and limit access to prevention and treatment services. The Khawaja Sira Society (KSS), a community-based organization working in Punjab since 2012, provides HIV prevention, testing, counselling, and treatment referral services for transgender individuals. However, limited district-level evidence exists on the magnitude of HIV infection and its determinants in smaller cities such as Kasur. Aims: This study aimed to determine the prevalence of HIV among transgender individuals in Kasur and identify socioeconomic, behavioral, and structural factors associated with infection. Methods: A cross-sectional study was conducted among 150 transgender individuals registered with KSS. Data were collected using structured questionnaires and HIV testing. Associations between HIV status and participant characteristics were analyzed using chi-square tests. Results: Of 150 participants, 50 (33.3%) tested positive for HIV. Infection was significantly associated with low income, engagement in sex work, longer duration of sex work, living in a dera or with a guru , inconsistent syringe sterilization, and multiple sexual partners. Eighty-two percent of those diagnosed were successfully linked to antiretroviral therapy. Conclusion: A high HIV burden among transgender individuals in Kasur reflects socioeconomic vulnerability and social exclusion. Strengthening community-led interventions like KSS can improve prevention, care, and treatment outcomes. HIV transgender individuals STIs prevalence in Pakistan socioeconomic factors public health Figures Figure 1 Figure 2 Figure 3 Introduction The Khawaja Sira Society (KSS) is a community-based organization that has been providing HIV and sexually transmitted infection (STI) prevention, testing, and treatment services to transgender and hijra communities across Punjab since 2012. The organization provides free HIV testing, counselling, and treatment referral services, along with screening and management of other STIs in districts such as Lahore, Kasur, Sheikhupura, and Sargodha. Despite national progress in HIV control, transgender individuals in Pakistan continue to experience disproportionately high rates of infection due to social exclusion, poverty, discrimination, and limited access to healthcare. In districts like Kasur, many transgender people engage in high-risk occupations, often without consistent access to prevention tools or reliable health information. These structural and behavioral vulnerabilities contribute to the growing burden of HIV within this population. This study was therefore conducted to assess the prevalence of HIV and to identify the socioeconomic, behavioral, and structural factors associated with infection among transgender individuals in Kasur, Pakistan, with the goal of informing more inclusive and community-centered HIV prevention strategies. Methods Study Design This research employed a cross-sectional and correlational design to examine the prevalence of HIV and associated socioeconomic, behavioral, and structural factors among transgender individuals living in Kasur, Pakistan. Study Population and Sampling A total of 150 transgender individuals (both transgender women and men) participated in the study. Participants were recruited through community networks, peer referrals, and outreach programs facilitated by the Khawaja Sira Society (KSS). Inclusion criteria required participants to be aged 18 years or older and permanent residents of Kasur. Both individuals living with and without families were included. Data Collection Tools Data was collected using a self-structured questionnaire consisting of 37 items. The questionnaire included sections on: Demographic characteristics : age, education, income, and living conditions. Behavioral factors : sexual practices, substance use, and number of sexual partners. Structural factors : HIV testing frequency, access to sterile syringes, and linkage to HIV care. Questions were a combination of multiple-choice, dichotomous (yes/no), and five-point Likert-scale items. For participants unable to read or write, trained field workers read the questions aloud and recorded responses accordingly. HIV Testing Procedure Rapid HIV testing was conducted using Determine HIV-1/2 kits for initial screening, followed by confirmatory testing using Uni-Gold HIV kits for reactive samples. Each test required 2–3 drops of whole blood or serum/plasma, and results were read within 20–25 minutes. Testing was carried out from May 2023 to December 2024. Out of 700 transgender individuals screened in Kasur during this period, 74 tested positive. Of these, 67 individuals were successfully linked to antiretroviral therapy (ART) at the Baba Bullay Shah Hospital ART Centre, while 4 individuals died before initiating treatment and 3 were lost to follow-up. Data Collection Procedure Following HIV testing, participants were invited to complete the structured questionnaire. Data were collected confidentially, with each participant completing the survey within approximately 10–15 minutes. Responses were entered into Microsoft Excel and later imported into SPSS version 27 for analysis (IBM SPSS, 2020). Data Analysis Data analysis included both descriptive and inferential statistics. Descriptive analyses were used to summarize demographic and behavioral characteristics (Pallant, 2020 ). Chi-square tests were applied to identify associations between HIV diagnosis and key variables, including income, education, source of income, years in sex work, living conditions, and syringe sterilization practices. Statistical significance was set at p < 0.05 (Pallant, 2020 ). Ethical Considerations Ethical approval for this study was granted by the Khawaja Sira Society’s internal ethics review committee. Informed consent was obtained from all participants prior to data collection. Participants were informed of the study’s purpose and assured that their responses would remain anonymous and confidential. Individuals testing positive for HIV were referred to appropriate counselling and treatment services, and participation was voluntary, with the right to withdraw at any time. Results Participant Characteristics A total of 150 transgender individuals participated in this study. Most respondents (36%) were aged 21–31 years, 25% were 32–41 years, 16% were 18–20 years, and 8% were above 50 years. Nearly half (45%) reported a monthly income between PKR 25,000 and 50,000, while 28% earned below PKR 25,000. Educational attainment was low, with 45% having no formal education and only 6% completing higher secondary or above. More than half of participants (58%) lived with a guru or within a dera community, 21% lived with family, and 21% lived alone. The majority relied on sex work or begging as their main income source, reflecting severe socioeconomic exclusion. Table 1 Socio-demographic and Economic Characteristics of Transgender Participants (N = 150) Variable Category Frequency (n) Percentage % Age group (years) 18–20 24 16.0 21–31 54 36.0 32–41 38 25.3 42–50 22 14.7 > 50 12 8.0 Education level No formal education 67 44.7 Primary 48 32.0 Secondary 26 17.3 Higher Secondary + 9 6.0 Monthly Income (PKR) 50,000 40 26.7 Living status With guru/dera 87 58.0 With family 31 20.7 Alone 32 21.3 (Table 1 summarizes the socio-demographic and economic characteristics of participants.) HIV Prevalence Among all participants, 50 individuals (33.3%) tested positive for HIV . This demonstrates a substantial burden of infection within the transgender population of Kasur District, much higher than the national average HIV prevalence in Pakistan. (Fig. 1 presents the overall HIV prevalence among transgender individuals in Kasur.) Associations Between HIV and Socioeconomic and Behavioral Factors Several key variables were significantly associated with HIV status. Participants earning less than PKR 25 000 per month had a higher prevalence of HIV ( p = 0.015 ), suggesting that financial instability increases vulnerability to infection. Those engaged primarily in sex work were far more likely to be HIV-positive than individuals relying on other income sources ( p < 0.001 ). Longer duration of sex work was also linked with infection ( p < 0.001 ); participants working for more than 10 years showed the highest positivity. Living status demonstrated a strong relationship with HIV, as individuals living with a guru or at a dera were more frequently infected ( p = 0.001 ). Unsafe syringe practices were prevalent—74% of HIV-positive respondents reported inconsistent or no syringe sterilization ( p < 0.001 ). Table 2 Association Between Socioeconomic and Behavioral Factors and HIV Status Variable Category HIV Positive (n = 50) HIV Negative (n = 100) χ² p-value Age group (years) 18–20 6 (12%) 18 (18%) 8.74 0.0068 21–31 18 (36%) 36 (36%) 32–41 14 (28%) 24 (24%) ≥ 42 12 (24%) 22 (22%) Monthly Income (PKR) 50,000 8 (16%) 32 (32%) Source of Income Sex work 35 (70%) 26 (26%) 67.44 < 0.001 Begging/Other 15 (30%) 74 (74%) Duration of Sex work (years) < 5 8 (16%) 42 (42%) 40.58 10 22 (44%) 36 (36%) Living status With guru/dera 29 (58%) 58 (58%) 15.49 0.001 Family / Alone 21 (42%) 42 (42%) Syringe Sterilization Always 13 (26%) 62 (62%) 21.43 < 0.001 Sometime/Never 37 (74%) 38 (38%) Sexual Partners (past 6 months) 50 19 (38%) 6 (6%) Distribution of Major Risk Factors To visualize these findings, Fig. 2 illustrates the main behavioral and socioeconomic risks associated with HIV infection. It highlights that individuals from lower income groups, those reporting irregular syringe sterilization, and those having multiple sexual partners exhibited markedly higher infection rates. These patterns reinforce the statistical associations shown in Table 2 and reveal how overlapping social and behavioral risks drive the HIV epidemic among transgender individuals in Kasur. Linkage to Care and Treatment Among the 50 HIV-positive participants, 41 (82%) were successfully linked to antiretroviral therapy (ART) through the Khawaja Sira Society’s referral and counselling system. The remaining 9 (18%) had not initiated treatment due to stigma, mobility, or lack of family support. This high rate of linkage demonstrates the effectiveness of community-based outreach programs in connecting marginalized transgender individuals to life-saving treatment. (Fig. 3 depicts the HIV testing and linkage-to-care cascade.) Discussion This research study provides an important insight into the prevalence and associated factors of HIV among transgender individuals in Kasur, Pakistan. The findings indicate a high rate of HIV infection, highlighting the urgent need for comprehensive and targeted interventions within this marginalized population. The analysis reveals that socioeconomic, behavioral, and structural determinants collectively shape HIV vulnerability among transgender people. Socioeconomic Determinants A significant association was found between monthly income and HIV diagnosis, consistent with prior studies conducted in Punjab and Lahore. Lower socioeconomic status often limits access to education, healthcare, and preventive services. Many transgender individuals in Pakistan are excluded from formal employment and social protection systems, forcing them into sex work as a means of survival. This dependence on high-risk income sources perpetuates exposure to unsafe sexual practices. Similar findings were reported by Ahmed, Hashmi, and Khan ( 2019 ), who highlighted the role of poverty and social exclusion in amplifying HIV vulnerability among marginalized populations. These patterns are also consistent with earlier work among hijra populations showing high HIV and STI burden driven by socioeconomic and structural exclusion (Khan et al., 2013 ). Behavioral Determinants Risky sexual behaviors, such as having multiple sexual partners and inconsistent condom use, were strongly linked to HIV infection in this research study. These results align with the findings of Javed et al. ( 2023 ), who documented a high incidence of sexually transmitted infections among transgender sex workers in Punjab. Substance use and limited knowledge of safe sexual practices further contribute to the risk. Behavioral vulnerabilities among transgender populations often stem from broader psychosocial factors such as trauma, discrimination, and mental health challenges. As Manzoor et al. ( 2022 ) observed, “stigma and mental distress can lead individuals to engage in coping behaviors that elevate their risk of HIV infection”. Structural Determinants Structural barriers such as limited access to healthcare services, inadequate HIV testing, and weak linkage to treatment programs exacerbate the epidemic. The current study found a significant association between living status and HIV diagnosis, with higher infection rates among those living in derras . Communal living may foster shared risk behaviors and limited privacy, which can impede regular health-seeking practices. Stigma within healthcare institutions also deters many transgender individuals from seeking timely diagnosis or treatment. These findings echo those of Khan et al. ( 2024 ), who emphasized the critical need for stigma reduction and capacity building among healthcare providers. This is consistent with national reports documenting a rapid rise in HIV cases across Pakistan (Muhammad et al., 2023 ). Access to sterile syringes and safe injection practices emerged as additional structural determinants. Although HIV transmission through injection drug use was not directly measured, inadequate sterilization practices indicate potential routes for infection. The study’s findings correspond with national data suggesting that gaps in infection control and harm-reduction programs continue to hinder HIV prevention efforts in Pakistan (Raza et al., 2024 ). Testing and Linkage to Care A positive outcome of this research is the strong linkage between HIV diagnosis and initiation of antiretroviral therapy. The majority of participants diagnosed with HIV began treatment within one month, primarily through referrals from the Khawaja Sira Society. This demonstrates the pivotal role of community-based organizations in bridging the gap between high-risk populations and formal healthcare systems. Sustained community engagement and peer counselling can enhance adherence, reduce stigma, and improve retention in care. Co-infections The association between HIV and other sexually transmitted infections observed in this study underscores the interconnected nature of these epidemics. Participants with histories of chlamydia, gonorrhea, or herpes were significantly more likely to be HIV-positive. These findings were consistent with Javed et al. ( 2023 ), who highlighted overlapping risk networks and inadequate STI control measures. Integrated programs that combine HIV and STI prevention, diagnosis, and treatment are therefore essential for improving sexual health outcomes among transgender populations. Conclusion and Recommendations The findings of this study highlight an alarmingly high prevalence of HIV among transgender individuals in Kasur, Pakistan. Socioeconomic deprivation, behavioral risk factors, and structural barriers such as limited healthcare access and stigma collectively increase HIV vulnerability within this community. Transgender individuals engaged in sex work and those lacking consistent access to sterilized medical equipment face particularly elevated risks. These results underscore the urgent need to strengthen HIV prevention, testing, and treatment services for transgender populations at the community level. The role of organizations such as the Khawaja Sira Society is vital in bridging service gaps and fostering trust between healthcare providers and transgender individuals. Tailored health education, routine HIV screening, and peer-led interventions can promote safer sexual practices and earlier diagnosis. Policymakers should also address the systemic issues that perpetuate vulnerability. Integrating mental health support within HIV prevention programs, expanding access to stigma-free clinics, and training healthcare professionals in gender sensitivity are essential steps toward equitable healthcare. Furthermore, data collection and surveillance systems must better capture the health needs of transgender people to guide evidence-based programming and resource allocation. By addressing both individual and structural determinants, Pakistan can make significant progress toward controlling HIV transmission among key populations. A multi-sectoral approach that is combining public health, community engagement, and social protection, will be critical in achieving lasting impact. Declarations Acknowledgments The authors express their sincere gratitude to the Khawaja Sira Society, for their continuous support throughout the data collection, community mobilization, and ethical approval processes. Their collaboration was instrumental in facilitating respectful access to the transgender community and ensuring that the research was conducted with integrity and inclusion. The authors also thank all study participants for their time, trust, and openness in sharing their experiences. Ethical Approval Ethical approval for this study was granted by the Khawaja Sira Society (KSS) Internal Ethics Review Committee. Human Ethics and Consent to Participate This study was conducted in accordance with the Declaration of Helsinki. Consent to Participate Written informed consent was obtained from all participants through a Google Form Consent Sheet, approved by the KSS Ethics Committee. Consent for Publication Not applicable. Author Contributions Dr. Emram Ezra , Miss Komal Sarbuland , Dr. Sharoon Hanook , Mr. Yeshoo Ezra , Miss Shapher Ezra , Miss Sobo Malik , Miss Mahnoor Chaudhary and Dr. Sadya Salar collaboratively designed the study and developed the research questionnaire. Dr. Emram Ezra led the data collection, field coordination, and manuscript preparation. Miss Komal Sarbuland conducted data analysis and assisted in literature review. Dr. Sharoon Hanook , Mr. Yeshoo Ezra and Miss Shapher Ezra contributed to data interpretation and critical manuscript revisions. Miss Sobo Malik , Miss Mahnoor Chaudhary and Dr. Sadya Salar facilitated ethical approval, review the data to accuracy, supported data management and use for the study. Conflict of Interest The authors declare that there are no conflicts of interest related to this study. Funding This study received no external funding. It was conducted as part of the ongoing community health and HIV prevention initiatives of the Khawaja Sira Society, Pakistan . References Ahmed A, Hashmi FK, Khan GM. HIV outbreaks in Pakistan. Lancet HIV. 2019;6(7):e418. IBM, SPSS. (2020). Statistics for Windows (Version 27.0) [computer software]. Khan AA, Rehan N, Qayyum K, Khan A. Correlates and prevalence of HIV and sexually transmitted infections among Hijras (male transgenders) in Pakistan. Int J STD AIDS. 2013;19(Suppl 1):817–20. Manzoor I, Khan ZH, Tariq R, Shahzad R. Health problems and barriers to healthcare services for the transgender community in Lahore, Pakistan. Pak J Med Sci. 2022;38(1):138–44. Javed H, Bano A, Fatima W, Khan R, Akhtar A. Sexually transmitted infections and associated risk factors among the transgender population of Pakistan. BMC Infect Dis. 2023;23(1):618. Muhammad R, Salman M, Hussain A, Ullah A, Khan M. A staggering rise of HIV cases in Pakistan. Asian Pac J Trop Med. 2023;16(3):143–4. Raza HA, Raja MHR, Khakwani MM, Jamil B. Pakistan's HIV high-risk populations: critical appraisal of failure to curtail spread beyond key populations. IJID Reg 2024;100364. Khan J, Qaiser KT, Siddiqui A, Sarmad SF, Javed J. Enhancing healthcare systems to tackle rising HIV cases in Pakistan: overcoming challenges for effective control. J Xi’an Shiyou Univ Nat Sci Ed. 2024;20(4):445–6. Pallant J. SPSS survival manual: A step-by-step guide to data analysis using IBM SPSS. Routledge; 2020. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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1","display":"","copyAsset":false,"role":"figure","size":82177,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eHIV Prevalence Among Transgender Individuals in Kasur (N = 150)\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8105009/v1/54e1739564b0fdb530a05941.jpg"},{"id":96400663,"identity":"62e17b15-79b9-4513-8a83-01656f1d9262","added_by":"auto","created_at":"2025-11-20 16:06:50","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":146630,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDistribution of major behavioral and socioeconomic risk factors among HIV-positive transgender individuals in Kasur.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Picture2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8105009/v1/53d2375f0c36c57070e74573.jpg"},{"id":96454504,"identity":"583ea548-7ef1-485e-8752-acef4fa0e5dd","added_by":"auto","created_at":"2025-11-21 10:02:51","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":98988,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eHIV testing outcomes and linkage-to-care cascade among transgender individuals in Kasur, Pakistan.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Picture3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8105009/v1/c597c20a6de8058082470f08.jpg"},{"id":97898011,"identity":"c8091513-4a50-4b1c-b61d-a8fa7ccc01ba","added_by":"auto","created_at":"2025-12-10 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The organization provides free HIV testing, counselling, and treatment referral services, along with screening and management of other STIs in districts such as Lahore, Kasur, Sheikhupura, and Sargodha. Despite national progress in HIV control, transgender individuals in Pakistan continue to experience disproportionately high rates of infection due to social exclusion, poverty, discrimination, and limited access to healthcare. In districts like Kasur, many transgender people engage in high-risk occupations, often without consistent access to prevention tools or reliable health information. These structural and behavioral vulnerabilities contribute to the growing burden of HIV within this population. This study was therefore conducted to assess the prevalence of HIV and to identify the socioeconomic, behavioral, and structural factors associated with infection among transgender individuals in Kasur, Pakistan, with the goal of informing more inclusive and community-centered HIV prevention strategies.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design\u003c/h2\u003e\u003cp\u003eThis research employed a cross-sectional and correlational design to examine the prevalence of HIV and associated socioeconomic, behavioral, and structural factors among transgender individuals living in Kasur, Pakistan.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eStudy Population and Sampling\u003c/h3\u003e\n\u003cp\u003eA total of 150 transgender individuals (both transgender women and men) participated in the study. Participants were recruited through community networks, peer referrals, and outreach programs facilitated by the Khawaja Sira Society (KSS). Inclusion criteria required participants to be aged 18 years or older and permanent residents of Kasur. Both individuals living with and without families were included.\u003c/p\u003e\n\u003ch3\u003eData Collection Tools\u003c/h3\u003e\n\u003cp\u003eData was collected using a self-structured questionnaire consisting of 37 items. The questionnaire included sections on:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eDemographic characteristics\u003c/b\u003e: age, education, income, and living conditions.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eBehavioral factors\u003c/b\u003e: sexual practices, substance use, and number of sexual partners.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eStructural factors\u003c/b\u003e: HIV testing frequency, access to sterile syringes, and linkage to HIV care.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eQuestions were a combination of multiple-choice, dichotomous (yes/no), and five-point Likert-scale items. For participants unable to read or write, trained field workers read the questions aloud and recorded responses accordingly.\u003c/p\u003e\n\u003ch3\u003eHIV Testing Procedure\u003c/h3\u003e\n\u003cp\u003eRapid HIV testing was conducted using \u003cem\u003eDetermine HIV-1/2\u003c/em\u003e kits for initial screening, followed by confirmatory testing using \u003cem\u003eUni-Gold HIV\u003c/em\u003e kits for reactive samples. Each test required 2\u0026ndash;3 drops of whole blood or serum/plasma, and results were read within 20\u0026ndash;25 minutes. Testing was carried out from May 2023 to December 2024.\u003c/p\u003e\u003cp\u003eOut of 700 transgender individuals screened in Kasur during this period, 74 tested positive. Of these, 67 individuals were successfully linked to antiretroviral therapy (ART) at the Baba Bullay Shah Hospital ART Centre, while 4 individuals died before initiating treatment and 3 were lost to follow-up.\u003c/p\u003e\n\u003ch3\u003eData Collection Procedure\u003c/h3\u003e\n\u003cp\u003eFollowing HIV testing, participants were invited to complete the structured questionnaire. Data were collected confidentially, with each participant completing the survey within approximately 10\u0026ndash;15 minutes. Responses were entered into Microsoft Excel and later imported into SPSS version 27 for analysis (IBM SPSS, 2020).\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cp\u003eData analysis included both descriptive and inferential statistics. Descriptive analyses were used to summarize demographic and behavioral characteristics (Pallant, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Chi-square tests were applied to identify associations between HIV diagnosis and key variables, including income, education, source of income, years in sex work, living conditions, and syringe sterilization practices. Statistical significance was set at \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 (Pallant, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eEthical Considerations\u003c/h3\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003cp\u003e for this study was granted by the Khawaja Sira Society\u0026rsquo;s internal ethics review committee. Informed consent was obtained from all participants prior to data collection. Participants were informed of the study\u0026rsquo;s purpose and assured that their responses would remain anonymous and confidential. Individuals testing positive for HIV were referred to appropriate counselling and treatment services, and participation was voluntary, with the right to withdraw at any time.\u003c/p\u003e\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eParticipant Characteristics\u003c/h2\u003e\u003cp\u003eA total of \u003cb\u003e150 transgender individuals\u003c/b\u003e participated in this study. Most respondents (36%) were aged 21\u0026ndash;31 years, 25% were 32\u0026ndash;41 years, 16% were 18\u0026ndash;20 years, and 8% were above 50 years. Nearly half (45%) reported a monthly income between PKR 25,000 and 50,000, while 28% earned below PKR 25,000. Educational attainment was low, with 45% having no formal education and only 6% completing higher secondary or above. More than half of participants (58%) lived with a \u003cem\u003eguru\u003c/em\u003e or within a \u003cem\u003edera\u003c/em\u003e community, 21% lived with family, and 21% lived alone. The majority relied on sex work or begging as their main income source, reflecting severe socioeconomic exclusion.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSocio-demographic and Economic Characteristics of Transgender Participants (N\u0026thinsp;=\u0026thinsp;150)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCategory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFrequency (n)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePercentage %\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003eAge group (years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18\u0026ndash;20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e16.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e21\u0026ndash;31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e36.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e32\u0026ndash;41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e25.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e42\u0026ndash;50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e14.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e8.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eEducation level\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo formal education\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e44.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePrimary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e32.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSecondary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e17.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHigher Secondary +\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e6.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eMonthly Income (PKR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;25,000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e28.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e25,000-50-000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e68\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e45.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;50,000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e26.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eLiving status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWith guru/dera\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e87\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e58.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWith family\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e20.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAlone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e21.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003e(Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e summarizes the socio-demographic and economic characteristics of participants.)\u003c/h2\u003e\u003cdiv id=\"Sec13\" class=\"Section3\"\u003e\u003ch2\u003eHIV Prevalence\u003c/h2\u003e\u003cp\u003eAmong all participants, \u003cb\u003e50 individuals (33.3%) tested positive for HIV\u003c/b\u003e. This demonstrates a substantial burden of infection within the transgender population of Kasur District, much higher than the national average HIV prevalence in Pakistan.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003e(Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents the overall HIV prevalence among transgender individuals in Kasur.)\u003c/h2\u003e\u003cdiv id=\"Sec15\" class=\"Section3\"\u003e\u003ch2\u003eAssociations Between HIV and Socioeconomic and Behavioral Factors\u003c/h2\u003e\u003cp\u003eSeveral key variables were significantly associated with HIV status. Participants earning less than PKR 25 000 per month had a higher prevalence of HIV (\u003cem\u003ep\u0026thinsp;=\u0026thinsp;0.015\u003c/em\u003e), suggesting that financial instability increases vulnerability to infection. Those engaged primarily in sex work were far more likely to be HIV-positive than individuals relying on other income sources (\u003cem\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/em\u003e).\u003c/p\u003e\u003cp\u003eLonger duration of sex work was also linked with infection (\u003cem\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/em\u003e); participants working for more than 10 years showed the highest positivity. Living status demonstrated a strong relationship with HIV, as individuals living with a \u003cem\u003eguru\u003c/em\u003e or at a \u003cem\u003edera\u003c/em\u003e were more frequently infected (\u003cem\u003ep\u0026thinsp;=\u0026thinsp;0.001\u003c/em\u003e). Unsafe syringe practices were prevalent\u0026mdash;74% of HIV-positive respondents reported inconsistent or no syringe sterilization (\u003cem\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/em\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eAssociation Between Socioeconomic and Behavioral Factors and HIV Status\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCategory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHIV Positive (n\u0026thinsp;=\u0026thinsp;50)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHIV Negative (n\u0026thinsp;=\u0026thinsp;100)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eχ\u0026sup2;\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eAge group (years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18\u0026ndash;20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (12%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e18 (18%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e8.74\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e0.0068\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e21\u0026ndash;31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18 (36%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e36 (36%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e32\u0026ndash;41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14 (28%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e24 (24%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12 (24%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e22 (22%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eMonthly Income (PKR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;25,000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22 (40%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e20 (20%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e12.34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.015\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e25,000-50-000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20 (40%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e48 (48%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;50,000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 (16%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e32 (32%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSource of Income\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSex work\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35 (70%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e26 (26%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e67.44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBegging/Other\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15 (30%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e74 (74%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eDuration of Sex work (years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 (16%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e42 (42%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e40.58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6\u0026ndash;10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20 (40%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e22 (22%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22 (44%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e36 (36%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLiving status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWith guru/dera\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e29 (58%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e58 (58%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e15.49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFamily / Alone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21 (42%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e42 (42%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSyringe Sterilization\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAlways\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13 (26%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e62 (62%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e21.43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSometime/Never\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e37 (74%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e38 (38%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eSexual Partners (past 6 months)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13 (26%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e62 (62%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e19.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.002\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11\u0026ndash;50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18 (36%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e32 (32%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19 (38%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6 (6%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eDistribution of Major Risk Factors\u003c/h2\u003e\u003cp\u003eTo visualize these findings, Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e illustrates the main behavioral and socioeconomic risks associated with HIV infection. It highlights that individuals from lower income groups, those reporting irregular syringe sterilization, and those having multiple sexual partners exhibited markedly higher infection rates.\u003c/p\u003e\u003cp\u003eThese patterns reinforce the statistical associations shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and reveal how overlapping social and behavioral risks drive the HIV epidemic among transgender individuals in Kasur.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eLinkage to Care and Treatment\u003c/h2\u003e\u003cp\u003eAmong the 50 HIV-positive participants, \u003cb\u003e41 (82%) were successfully linked to antiretroviral therapy (ART)\u003c/b\u003e through the Khawaja Sira Society\u0026rsquo;s referral and counselling system. The remaining \u003cb\u003e9 (18%)\u003c/b\u003e had not initiated treatment due to stigma, mobility, or lack of family support.\u003c/p\u003e\u003cp\u003eThis high rate of linkage demonstrates the effectiveness of community-based outreach programs in connecting marginalized transgender individuals to life-saving treatment.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003e(Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e depicts the HIV testing and linkage-to-care cascade.)\u003c/h2\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis research study provides an important insight into the prevalence and associated factors of HIV among transgender individuals in Kasur, Pakistan. The findings indicate a high rate of HIV infection, highlighting the urgent need for comprehensive and targeted interventions within this marginalized population. The analysis reveals that socioeconomic, behavioral, and structural determinants collectively shape HIV vulnerability among transgender people.\u003c/p\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003eSocioeconomic Determinants\u003c/h2\u003e\u003cp\u003eA significant association was found between monthly income and HIV diagnosis, consistent with prior studies conducted in Punjab and Lahore. Lower socioeconomic status often limits access to education, healthcare, and preventive services. Many transgender individuals in Pakistan are excluded from formal employment and social protection systems, forcing them into sex work as a means of survival. This dependence on high-risk income sources perpetuates exposure to unsafe sexual practices. Similar findings were reported by Ahmed, Hashmi, and Khan (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2019\u003c/span\u003e), who highlighted the role of poverty and social exclusion in amplifying HIV vulnerability among marginalized populations. These patterns are also consistent with earlier work among hijra populations showing high HIV and STI burden driven by socioeconomic and structural exclusion (Khan et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2013\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003eBehavioral Determinants\u003c/h2\u003e\u003cp\u003eRisky sexual behaviors, such as having multiple sexual partners and inconsistent condom use, were strongly linked to HIV infection in this research study. These results align with the findings of Javed et al. (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), who documented a high incidence of sexually transmitted infections among transgender sex workers in Punjab. Substance use and limited knowledge of safe sexual practices further contribute to the risk. Behavioral vulnerabilities among transgender populations often stem from broader psychosocial factors such as trauma, discrimination, and mental health challenges. As Manzoor et al. (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) observed, \u0026ldquo;stigma and mental distress can lead individuals to engage in coping behaviors that elevate their risk of HIV infection\u0026rdquo;.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003eStructural Determinants\u003c/h2\u003e\u003cp\u003eStructural barriers such as limited access to healthcare services, inadequate HIV testing, and weak linkage to treatment programs exacerbate the epidemic. The current study found a significant association between living status and HIV diagnosis, with higher infection rates among those living in \u003cem\u003ederras\u003c/em\u003e. Communal living may foster shared risk behaviors and limited privacy, which can impede regular health-seeking practices. Stigma within healthcare institutions also deters many transgender individuals from seeking timely diagnosis or treatment. These findings echo those of Khan et al. (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2024\u003c/span\u003e), who emphasized the critical need for stigma reduction and capacity building among healthcare providers. This is consistent with national reports documenting a rapid rise in HIV cases across Pakistan (Muhammad et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAccess to sterile syringes and safe injection practices emerged as additional structural determinants. Although HIV transmission through injection drug use was not directly measured, inadequate sterilization practices indicate potential routes for infection. The study\u0026rsquo;s findings correspond with national data suggesting that gaps in infection control and harm-reduction programs continue to hinder HIV prevention efforts in Pakistan (Raza et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e\u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\u003ch2\u003eTesting and Linkage to Care\u003c/h2\u003e\u003cp\u003eA positive outcome of this research is the strong linkage between HIV diagnosis and initiation of antiretroviral therapy. The majority of participants diagnosed with HIV began treatment within one month, primarily through referrals from the Khawaja Sira Society. This demonstrates the pivotal role of community-based organizations in bridging the gap between high-risk populations and formal healthcare systems. Sustained community engagement and peer counselling can enhance adherence, reduce stigma, and improve retention in care.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e\u003ch2\u003eCo-infections\u003c/h2\u003e\u003cp\u003eThe association between HIV and other sexually transmitted infections observed in this study underscores the interconnected nature of these epidemics. Participants with histories of chlamydia, gonorrhea, or herpes were significantly more likely to be HIV-positive. These findings were consistent with Javed et al. (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), who highlighted overlapping risk networks and inadequate STI control measures. Integrated programs that combine HIV and STI prevention, diagnosis, and treatment are therefore essential for improving sexual health outcomes among transgender populations.\u003c/p\u003e"},{"header":"Conclusion and Recommendations","content":"\u003cp\u003eThe findings of this study highlight an alarmingly high prevalence of HIV among transgender individuals in Kasur, Pakistan. Socioeconomic deprivation, behavioral risk factors, and structural barriers such as limited healthcare access and stigma collectively increase HIV vulnerability within this community. Transgender individuals engaged in sex work and those lacking consistent access to sterilized medical equipment face particularly elevated risks.\u003c/p\u003e\u003cp\u003eThese results underscore the urgent need to strengthen HIV prevention, testing, and treatment services for transgender populations at the community level. The role of organizations such as the Khawaja Sira Society is vital in bridging service gaps and fostering trust between healthcare providers and transgender individuals. Tailored health education, routine HIV screening, and peer-led interventions can promote safer sexual practices and earlier diagnosis.\u003c/p\u003e\u003cp\u003ePolicymakers should also address the systemic issues that perpetuate vulnerability. Integrating mental health support within HIV prevention programs, expanding access to stigma-free clinics, and training healthcare professionals in gender sensitivity are essential steps toward equitable healthcare. Furthermore, data collection and surveillance systems must better capture the health needs of transgender people to guide evidence-based programming and resource allocation.\u003c/p\u003e\u003cp\u003eBy addressing both individual and structural determinants, Pakistan can make significant progress toward controlling HIV transmission among key populations. A multi-sectoral approach that is combining public health, community engagement, and social protection, will be critical in achieving lasting impact.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003ch3\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThe authors express their sincere gratitude to the\u0026nbsp;\u003cstrong\u003eKhawaja Sira Society,\u003c/strong\u003e for their continuous support throughout the data collection, community mobilization, and ethical approval processes. Their collaboration was instrumental in facilitating respectful access to the transgender community and ensuring that the research was conducted with integrity and inclusion. The authors also thank all study participants for their time, trust, and openness in sharing their experiences.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for this study was granted by the Khawaja Sira Society (KSS) Internal Ethics Review Committee.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHuman Ethics and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from all participants through a Google Form Consent Sheet, approved by the KSS Ethics Committee.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eDr. \u003cstrong\u003eEmram Ezra\u003c/strong\u003e, Miss \u003cstrong\u003eKomal Sarbuland\u003c/strong\u003e, Dr. \u003cstrong\u003eSharoon Hanook\u003c/strong\u003e, Mr. \u003cstrong\u003eYeshoo Ezra\u003c/strong\u003e, Miss \u003cstrong\u003eShapher Ezra\u003c/strong\u003e, Miss \u003cstrong\u003eSobo Malik\u003c/strong\u003e, Miss \u003cstrong\u003eMahnoor Chaudhary\u0026nbsp;\u003c/strong\u003eand Dr.\u0026nbsp;\u003cstrong\u003eSadya Salar\u003c/strong\u003e collaboratively designed the study and developed the research questionnaire.\u003cbr\u003eDr.\u0026nbsp;\u003cstrong\u003eEmram Ezra\u003c/strong\u003e led the data collection, field coordination, and manuscript preparation.\u003cbr\u003eMiss\u0026nbsp;\u003cstrong\u003eKomal Sarbuland\u003c/strong\u003e conducted data analysis and assisted in literature review.\u003cbr\u003eDr. \u003cstrong\u003eSharoon Hanook\u003c/strong\u003e, Mr. \u003cstrong\u003eYeshoo Ezra\u003c/strong\u003e and Miss\u0026nbsp;\u003cstrong\u003eShapher Ezra\u003c/strong\u003e contributed to data interpretation and critical manuscript revisions.\u003cbr\u003eMiss \u003cstrong\u003eSobo Malik\u003c/strong\u003e, Miss \u003cstrong\u003eMahnoor Chaudhary\u003c/strong\u003e and Dr. \u003cstrong\u003eSadya Salar\u0026nbsp;\u003c/strong\u003efacilitated ethical approval, review the data to accuracy, supported data management and use for the study.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eConflict of Interest\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThe authors declare that there are no conflicts of interest related to this study.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThis study received no external funding. It was conducted as part of the ongoing community health and HIV prevention initiatives of the\u0026nbsp;\u003cstrong\u003eKhawaja Sira Society, Pakistan\u003c/strong\u003e.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAhmed A, Hashmi FK, Khan GM. HIV outbreaks in Pakistan. Lancet HIV. 2019;6(7):e418.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eIBM, SPSS. (2020). Statistics for Windows (Version 27.0) [computer software].\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKhan AA, Rehan N, Qayyum K, Khan A. Correlates and prevalence of HIV and sexually transmitted infections among Hijras (male transgenders) in Pakistan. Int J STD AIDS. 2013;19(Suppl 1):817\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eManzoor I, Khan ZH, Tariq R, Shahzad R. Health problems and barriers to healthcare services for the transgender community in Lahore, Pakistan. Pak J Med Sci. 2022;38(1):138\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJaved H, Bano A, Fatima W, Khan R, Akhtar A. Sexually transmitted infections and associated risk factors among the transgender population of Pakistan. BMC Infect Dis. 2023;23(1):618.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMuhammad R, Salman M, Hussain A, Ullah A, Khan M. A staggering rise of HIV cases in Pakistan. Asian Pac J Trop Med. 2023;16(3):143\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRaza HA, Raja MHR, Khakwani MM, Jamil B. Pakistan's HIV high-risk populations: critical appraisal of failure to curtail spread beyond key populations. IJID Reg 2024;100364.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKhan J, Qaiser KT, Siddiqui A, Sarmad SF, Javed J. Enhancing healthcare systems to tackle rising HIV cases in Pakistan: overcoming challenges for effective control. J Xi\u0026rsquo;an Shiyou Univ Nat Sci Ed. 2024;20(4):445\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePallant J. SPSS survival manual: A step-by-step guide to data analysis using IBM SPSS. Routledge; 2020.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"HIV, transgender individuals, STIs prevalence in Pakistan, socioeconomic factors, public health","lastPublishedDoi":"10.21203/rs.3.rs-8105009/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8105009/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003eTransgender and hijra communities in Pakistan remain among the most marginalized groups, facing discrimination, violence, and exclusion from education, employment, and healthcare. These social inequalities heighten their risk of HIV infection and limit access to prevention and treatment services. The Khawaja Sira Society (KSS), a community-based organization working in Punjab since 2012, provides HIV prevention, testing, counselling, and treatment referral services for transgender individuals. However, limited district-level evidence exists on the magnitude of HIV infection and its determinants in smaller cities such as Kasur.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAims:\u003c/strong\u003e This study aimed to determine the prevalence of HIV among transgender individuals in Kasur and identify socioeconomic, behavioral, and structural factors associated with infection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e A cross-sectional study was conducted among 150 transgender individuals registered with KSS. Data were collected using structured questionnaires and HIV testing. Associations between HIV status and participant characteristics were analyzed using chi-square tests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Of 150 participants, 50 (33.3%) tested positive for HIV. Infection was significantly associated with low income, engagement in sex work, longer duration of sex work, living in a \u003cem\u003edera\u003c/em\u003e or with a \u003cem\u003eguru\u003c/em\u003e, inconsistent syringe sterilization, and multiple sexual partners. Eighty-two percent of those diagnosed were successfully linked to antiretroviral therapy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e A high HIV burden among transgender individuals in Kasur reflects socioeconomic vulnerability and social exclusion. Strengthening community-led interventions like KSS can improve prevention, care, and treatment outcomes.\u003c/p\u003e","manuscriptTitle":"HIV Prevalence and Associated Factors among Transgender Individuals in Kasur, Pakistan","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-20 16:06:45","doi":"10.21203/rs.3.rs-8105009/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ae5b1a5d-8259-4f8d-b94a-61c56b166a9c","owner":[],"postedDate":"November 20th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-12-10T08:54:12+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-20 16:06:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8105009","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8105009","identity":"rs-8105009","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}