Social, sexual and structural factors shaping HIV vulnerability among transgender women in Mali: a qualitative focus group study.

Transgender women (TGW) in Mali face discrimination and stigma, possibly exacerbating HIV vulnerability and limiting access to health services. We identified HIV vulnerability factors among TGW by exploring perceptions and experiences of TGW from urban, peri-urban and rural areas, and those of community workers, using six focus groups (n = 44) and a data thematic content analysis. The analysis highlighted that TGW's sexual networks included their cisgender wives and multiple male partners; these networks were shaped by social expectations to marry women and financial pressures leading to transactional sex. Barriers to condom use and other prevention strategies included limited HIV knowledge, partner pressure and sexual violence, resulting in unwanted unprotected sex. Barriers to health access included stigma, discrimination, forced disclosure of TGW identity and structural factors such as stock shortages of condoms, lubricants and STI/HIV treatment, and supply chain issues. The high risk of forced outing and mistreatment of TGW during sexual encounters and when seeking sexual health services highlights the need for tailored mobile HIV services that ensure confidentiality and guarantee community-based support for HIV, mental health and socioeconomic needs. Ensuring access to such services for highly marginalized populations is essential for public health in mixed HIV epidemic settings.