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

This mixed-methods study in India demonstrates that while a peer-led running intervention improves mental health for adolescents with perinatally acquired HIV, its effectiveness is significantly hindered for girls by gendered social barriers, highlighting the urgent need for gender-transformative program designs to ensure equitable outcomes.

The Gist

Imagine a group of teenagers in India who are growing up with HIV, a virus they were born with. For these young people, life isn't just about managing a medical condition; it's like trying to run a race while wearing heavy, invisible backpacks filled with shame, fear, and strict social rules. In many places, especially for girls, there are extra chains on their ankles—cultural rules that say, "Don't run, don't sweat, don't draw attention to yourself."

This paper tells the story of a project called "Positive Running," which tried to help these teenagers by simply getting them to run together. But the researchers didn't just look at whether they got fitter; they wanted to understand how the "backpacks" of stigma and the "chains" of gender rules affected the race.

Here is the story of what they found, broken down into simple parts:

1. The Starting Line: Who was running?

The study gathered 150 young people (mostly 17 years old) in southern India. About two-thirds were boys, and one-third were girls. They were all virally suppressed, meaning their medication was working well to keep the virus under control. The goal was to see if running together could help lift the heavy mental weight of depression and anxiety they were carrying.

2. The Race: Who showed up?

The program was a mix of running and peer support (where older teens helped younger ones).

• The Boys: They showed up to the track more often. About 57% of the boys attended most of the sessions.
• The Girls: They struggled to get to the starting line. Only 20% of the girls attended regularly.

Why the difference?
Imagine a girl trying to join a running club, but her family says, "It's not modest for a girl to run in public," or "You need to ask your father for permission to leave the house." The study found that girls faced a "wall of rules" that boys didn't have to climb. They felt watched, judged, and restricted by modesty norms and a lack of freedom to make their own choices.

3. The Finish Line: Did it help their minds?

Before the program, many of these teens were struggling with their mental health. About 60% showed signs of depression or anxiety.

• The Good News: For the boys, the more they ran, the lighter their mental "backpacks" became. The running and the friendship acted like a shield, lowering their odds of feeling depressed.
• The Mixed News: For the girls, the story was different. Even though they had the same program, the mental health benefits didn't show up as strongly. Why? Because the barriers (the chains on their ankles) were too heavy. Even when they did run, the stress of breaking social rules and the fear of judgment canceled out some of the good feelings.

4. The Secret Ingredient: What actually works?

The researchers realized that just saying "go run" isn't enough. To help the girls, the program needs to be a customized key for their specific lock.

• Role Models: Seeing other women running helped the girls feel, "If she can do it, so can I."
• Autonomy: The girls needed to feel like they had a choice, not that they were being forced.
• Safe Spaces: They needed a place where they wouldn't be judged for sweating or running fast.

The Big Takeaway

Think of this intervention like a garden.

• The boys had a garden where the soil was ready, the sun was shining, and they could plant seeds (running) that grew into strong mental health flowers.
• The girls were trying to plant seeds in the same garden, but the soil was rocky, and the weather was stormy because of societal rules. Even with the same seeds, the flowers struggled to bloom.

The Conclusion:
Running together is a powerful tool to heal the mind, but it doesn't work the same way for everyone. To help adolescent girls with HIV, we can't just give them the same program as the boys. We need to first remove the chains (the restrictive rules) and clear the rocky soil (the stigma) so they can run freely. Only then will the running truly heal their hearts and minds.

Technical Summary

Technical Summary: Positive Running Intervention for Adolescents with Perinatally Acquired HIV in India

1. Problem Statement

Adolescents and young adults (AYAs) with perinatally acquired HIV in India face a complex syndemic of challenges, including high burdens of stigma, mental health distress, and restrictive gender norms. While physical activity interventions have shown promise for mental health, there is a critical knowledge gap regarding how intersectional vulnerabilities (specifically the interplay of HIV status, age, and gender) influence engagement and outcomes. Existing programs often fail to account for gendered social constraints that limit participation, particularly for females, potentially exacerbating health inequities.

2. Methodology

The study employed a convergent parallel mixed-methods design conducted between March and April 2024 in the Indian states of Karnataka and Tamil Nadu.

• Study Population: 150 adolescents and young adults (100 males, 50 females) with perinatally acquired HIV. The median age was 17 years (IQR 15–19).
• Intervention: "Positive Running," a peer-led, community-embedded physical activity program.
• Quantitative Component:
  • Measures: Sociodemographics, viral suppression status, intervention adherence, and mental health screening using validated tools: PHQ-9 (depression) and GAD-7 (anxiety).
  • Analysis: Fisher's exact tests for gender-disaggregated comparisons; logistic regression to estimate prevalence odds ratios (OR) for common mental health disorders (CMD) based on adherence.
• Qualitative Component:
  • Data Collection: Four focus group discussions (FGDs, n=28) stratified by age and gender, and four in-depth interviews (IDIs) with peer implementers.
  • Analysis: Thematic analysis utilizing Grounded Theory and Braun & Clarke's framework, interpreted through the lenses of Intersectionality and Self-Determination Theory (SDT).

3. Key Results

Quantitative Findings:

• Viral Suppression: 91% of the cohort was virally suppressed.
• Adherence Disparities: Overall mean adherence was 64%. However, high attendance (≥65%) was significantly lower among females (20%) compared to males (57%; p<0.001).
• Mental Health Burden: 59% of participants screened positive for at least one CMD. Females exhibited significantly higher prevalence rates than males for:
  • Depression: 66% vs. 43% (p=0.009).
  • Any mental health condition: 72% vs. 52% (p=0.022).
• Intervention Impact: Higher adherence was associated with lower odds of CMD overall (OR 0.44, 95% CI 0.23–0.85).
  • Gender Stratification: This protective association was significant for males (aOR 0.33, 95% CI 0.14–0.75) but not statistically significant for females.

Qualitative Findings:

• Barriers: Females faced distinct structural and cultural barriers, including restrictive gender norms, expectations of modesty, stigma against women in sports, and limited autonomy in decision-making.
• Mechanisms of Action: The intervention successfully fostered Self-Determination Theory constructs (autonomy, competence, relatedness) through structured training, peer mentorship, and visible female role models. However, for girls, external constraints attenuated these benefits, preventing the translation of participation into mental health gains.

4. Key Contributions

• Intersectional Evidence: The study provides empirical evidence that physical activity interventions do not yield uniform benefits across genders for adolescents with HIV. It highlights that without addressing specific gendered barriers, interventions may inadvertently widen health disparities.
• Theoretical Integration: It successfully integrates Intersectionality and Self-Determination Theory to explain why the intervention worked for males but failed to protect females, moving beyond simple participation metrics to understand the quality of engagement.
• Programmatic Insight: It identifies that "peer-led" models alone are insufficient if they do not actively dismantle the specific socio-cultural constraints (e.g., modesty, autonomy) facing young women.

5. Significance and Implications

The study concludes that while peer-led physical activity is feasible and beneficial for this population, gender-responsive design is non-negotiable for equitable outcomes.

• Policy & Practice: Future interventions must move beyond a "one-size-fits-all" approach. To ensure mental health benefits for adolescent girls, programs must be autonomy-supportive and explicitly address intersectional vulnerabilities (e.g., providing safe spaces, engaging families to support female participation, and challenging norms regarding women in sports).
• Public Health Impact: Addressing these barriers is critical for improving the holistic well-being of adolescents with perinatally acquired HIV, ensuring that mental health gains are not limited to male participants.