Objectives <p>Mindfulness interventions can improve mental health and medication adherence, with most led by non-community members. Community-led approaches are considered best practice among female sex workers (FSW). We describe the development and initial piloting of a community-based mindfulness intervention with FSW in the Dominican Republic (DR).</p> Method <p>Nested in a cohort study assessing social-structural and behavioral factors on HIV outcomes among FSW, we first conducted longitudinal in-depth interviews with FSW (<i>n</i> = 20) to identify stressors and the role of mindfulness practices to manage stressors. Leveraging formative findings, we conducted initial piloting of an adapted group mindfulness intervention with 11 FSW peer leaders. We assessed the pilot using pre-post surveys (Cognitive Affective Mindfulness Scale-Revised; CAMS-R) and post-intervention in-depth interviews and a focus group. We employed descriptive statistical and thematic qualitative analysis.</p> Results <p>Formative interview participants described HIV and sex work stigma as stressors leading to poor mental health and HIV outcomes. Mindfulness practices were found to help alleviate stressors and improve adherence&#xa0;to antiretroviral therapy. Peer leaders from the community-based mindfulness intervention pilot found it to be beneficial, reporting the methods learned provided them with tools to cope with stressors. Participants specifically highlighted improvements in mental health (lower stress, anxiety and depression), less pain and better sleep, and improved adherence to ART; almost all CAMS-R items improved. All peer leaders were interested in being trained as facilitators and offered suggestions to improve intervention accessibility.</p> Conclusions <p>This community-based mindfulness intervention with FSW shows promise for improving mental health and HIV outcomes, meriting further implementation and evaluation.</p>