Direct and indirect factors associated with health-related quality of life among PLHIV on second-line antiretroviral therapy at Dessie and Woldia Comprehensive Specialized Hospitals in Ethiopia: application of structural equation modelling

Background People living with HIV have a longer lifespan and a lower mortality rate due to advancements in antiretroviral therapy. However, the clinical signs of HIV and psychological difficulties continue to impair their health-related quality of life. Therefore, this study aimed to assess health-related quality of life and examine the direct and indirect factors influencing it among people living with HIV on second-line antiretroviral therapy. Method An institutionally based cross-sectional study was conducted from January 13 to April 13, 2025, with 825 people living with HIV on second-line antiretroviral therapy selected through simple random sampling. Data were collected through face-to-face interviews, document reviews, and analyzed with STATA version 17. Quality of life was measured with the WHOQOL-HIV BREF, and depression with the PHQ-9. Structural equation modeling was employed to assess the direct and indirect effects of variables on quality of life. Statistical significance was declared at P < 0.05, and effect sizes are reported with 95% CIs. The findings were presented through text, tables, and graphs. Result The mean quality of life score was 48.7 (95% CI: (47.44, 49.96)). Internalized stigma had a direct [β ̂ = −0.59, (95% CI: -0.80, -0.381)] and indirect [β ̂ = −0.16, (95% CI: -0.249, -0.077)] negative effect on overall quality of life. The absence of opportunistic infection had a direct [β ̂ = 0.14, (95% CI: 0.028–0.248)] positive effect on overall quality of life. Depression had a direct [β ̂ = −0.54, (95% CI: -0.734, -0.339)] negative effect on the physical domain quality of life. Social support had a direct [β ̂ = 0.20, (95% CI: 0.046, 0.337)] positive effect on the social domain quality of life. Conclusion This study revealed that psychosocial factors significantly impacted the quality of people living with HIV on second-line antiretroviral therapy. Social support, depression, perceived stigma, internalized stigma, nonworkable functional status, and opportunistic infections were predictors of quality of life. Hence, healthcare facilities should integrate and strengthen routine mental health screenings and interventions in HIV care programs.