Pathways linking internalized HIV stigma to attitudes and beliefs toward ART through depression: Conditional indirect effects of food insecurity

BACKGROUND: Antiretroviral therapy (ART) adherence remains suboptimal in sub-Saharan Africa despite expanded access, particularly in Ghana, where structural and psychosocial stressors such as internalized HIV stigma, depression, and food insecurity interfere with sustained ART engagement. Although these factors are often studied separately, limited research has examined how they interact to influence beliefs and attitudes toward ART. METHODS: We conducted a cross-sectional analysis among 170 adults living with HIV in the Volta Region of Ghana. Participants completed validated measures assessing internalized HIV stigma, depressive symptoms, household food insecurity, beliefs, and attitudes towards ART. We applied mediation and moderated mediation models to test whether depression mediated the association between internalized HIV stigma and beliefs and attitudes toward ART, and whether these indirect effects varied based on food insecurity. RESULTS: Internalized HIV stigma was associated with more negative beliefs and attitudes toward ART (B = .16, SE = .02, p < .001; B = .08, SE = .02, p < .001). Depression significantly mediated these associations (B = .10, 95% CI [.06, .14]; B = .09, 95% CI [.05, .14]), and food insecurity moderated the association between internalized HIV stigma and depression (B = .36, SE = .13, p = .004). Conditional indirect effects were stronger at high (B = .11, SE = .03, 95% CI [.06, .17]) versus low (B = .06, SE = .02, 95% CI [.03, .10]) food insecurity. CONCLUSIONS: These findings indicate a syndemic interaction between internalized HIV stigma, depression, and food insecurity. Addressing psychological distress alone may not improve ART adherence unless accompanied by efforts to reduce internalized stigma and improve food security. Integrating depression management, stigma reduction interventions, and food security support within HIV services may better enhance treatment engagement in Ghana and similar settings.