Positive Running: a gender-transformative physical activity intervention to overcome intersectional barriers among adolescents with perinatally acquired HIV in India

ABSTRACT Background Adolescents with perinatally acquired HIV in India experience a high burden of stigma and mental health distress alongside gendered social constraints that limit participation in supportive programs. While physical activity-based psychosocial interventions show promise for improving adolescent mental health, little is known about how gender norms and intersecting vulnerabilities shape engagement and outcomes among this population. This study examined gender-specific patterns of participation and associations with mental health in a peer-led running intervention in southern India using intersectionality and self-determination theory. Methods We conducted a convergent parallel mixed-methods evaluation between March-April 2024 among 150 adolescents and young adults with perinatally acquired HIV enrolled in a physical activity intervention ( Positive Running ) in Karnataka and Tamil Nadu. Surveys assessed sociodemographic characteristics, viral suppression, intervention adherence, and common mental health disorders using validated screening tools for depression (PHQ-9) and anxiety (GAD-7). Gender-disaggregated comparisons used Fisher’s exact tests, and logistic regression estimated prevalence odds ratios for common mental health disorders by intervention adherence. Qualitative data included four age- and gender-stratified focus group discussions (n=28) with participants, and four in-depth interviews with peer implementers. Transcripts were thematically analyzed using grounded theory and Braun & Clarke’s framework. Results Among 150 participants (100 males, 50 females; median age 17 years [IQR 15-19]), 91% were virally suppressed. Mean adherence to the intervention was 64%, with high attendance (≥65%) significantly lower among females than males (20% vs 57%, p<0.001). Overall, 59% screened positive for at least one common mental health disorder; with higher prevalence among females than males for depression (66% vs 43%, p=0.009), and for any mental health condition (72% vs 52%, p=0.022). Higher intervention adherence was associated with lower odds of common mental disorder overall (OR 0.44, 95% CI 0.23-0.85). In age-adjusted, gender-stratified analyses, this association was significant among males (aOR 0.33, 95% CI 0.14-0.75) but not among females. Qualitative findings identified gendered barriers to participation, including restrictive norms, modesty expectations, stigma toward women in sport, and limited decision-making autonomy. Self-determination theory-informed analyses highlighted how structured training, peer mentorship, and visible female role models supported autonomy, competence, and relatedness, while also revealing constraints that attenuated mental health gains for girls. Conclusions Peer-led, community-embedded physical activity interventions are feasible among adolescents and young adults with perinatally acquired HIV and may confer mental health benefits, though participation effects are gender-differentiated. Findings underscore the need for gender-responsive, autonomy-supportive program designs that address intersectional vulnerabilities to ensure equitable mental health impact, particularly for adolescent girls and young women.