Structural associations between health insurance and mental well-being among people living with HIV: a multi-method analysis

In the post-antiretroviral therapy (ART) era, HIV care has shifted towards maximizing multidimensional Health-Related Quality of Life (HRQoL), yet a “clinical-social disconnect” persists among virally suppressed patients. This study investigates the structural associations between institutional health insurance tiers and mental well-being among people living with HIV (PLWH), exploring an ‘Environment-Centric’ associational framework. A cross-sectional observational study was conducted among 710 virally suppressed PLWH in Western China using consecutive sampling. Participants were stratified by health insurance schemes: National Free, Resident, and Urban Employee. Inverse Probability of Treatment Weighting (IPTW) was utilized to robustly balance baseline socioeconomic and clinical confounders (including age, gender, education, employment, and CD4 counts), and multiple imputation was applied to address missing data. The multi-method analytical framework integrated Structural Equation Modeling (SEM) to examine exploratory associational pathways, alongside subgroup analyses to evaluate health equity. Disease-specific HRQoL was comprehensively assessed using the WHOQOL-HIV BREF and the MOS-HIV. Generic utility instruments (EQ-5D-5L and SF-6Dv2) exhibited pronounced ceiling effects, failing to detect socioeconomic disparities, whereas the WHOQOL-HIV Environment domain demonstrated superior discriminatory power. SEM revealed a significant indirect statistical association: the psychological advantage associated with Urban Employee insurance was predominantly linked to ameliorated environmental (Standardized β = 0.049, p = 0.009) and financial burdens, with no significant direct association with mental health (p = 0.077). Furthermore, subgroup analyses identified significant heterogeneity across social strata, indicating that the marginal environmental benefits of comprehensive insurance were heavily concentrated among socioeconomically vulnerable populations, particularly those with lower educational attainment (p = 0.004) and lacking spousal support (p = 0.037). Comprehensive health insurance is structurally associated with enhanced mental well-being among PLWH, statistically reflecting fortified external environmental and financial support systems. To mitigate the persistent clinical-social disconnect, future public health strategies must transcend the traditional biomedical paradigm and one-size-fits-all reimbursement models, advocating instead for holistic interventions that provide targeted socioeconomic safety nets for the most vulnerable PLWH. Multi-method framework: Integrated IPTW, SEM, and machine learning to resolve confounding biases. Measurement properties: Generic utility scales (EQ-5D-5L) exhibited severe ceiling effects in PLWH. Environment-centric association: Financial and environmental support statistically explained mental well-being. Clinical-social disconnect: High virological suppression masks persisting socioeconomic distress. Social buffering effect: Comprehensive insurance predominantly benefits vulnerable populations.