Structural Equation Modeling of Depression, Stigma, and Social Support among People Living with HIV on Second-Line ART in Northeast Ethiopia: A Cross-Sectional Study

Background Stigma forces individuals to hide their HIV status, discourages medical visits, hinders medication adherence, and restricts access to social support. HIV stigma refers to the process in which people living with HIV are socially discredited and devalued due to their HIV status. Hence, the aim of this study was to determine internalized stigma and associated factors among PLHIV on second-line ART in northeast Ethiopia. Method A facility-based cross-sectional study was conducted from January 13 to April 13, 2025, involving 825 randomly selected PLHIV on second-line ART. Data were gathered through document review and face-to-face interviews and analyzed with STATA version 17. Depression, social support and internalized stigma were assessed using the PHQ-9, Oslo-3 scales and HIV stigma scale, respectively. Structural equation modeling was applied, with statistical significance set at P < 0.05 and effect sizes reported with 95% confidence intervals. Result In structural equation model, internalized stigma was significantly associated with depression [\(\:\widehat{\beta\:}\) = 0.19, (95% CI: 0.11–0.26)] and perceived stigma [\(\:\widehat{\beta\:}\) = 0.92, (95% CI: 0.806–1.042)], indicating that higher level of depression and perceived stigma were related to higher level of internalized stigma. Whereas, social support was inversely associated with internalized stigma [\(\:\widehat{\beta\:}\) = -0.80, (95% CI: -0.862 to -0.732)], suggesting that greater social support was linked to lower internalized stigma. Conclusion This finding suggests that perceived stigma and depression fully mediate the relationship between social support and internalized stigma among PLHIV on second-line ART. Moreover, perceived stigma and depression functioned as parallel mediators in the relationship between social support and internalized stigma while also having a direct positive effect on internalized stigma. Social support, perceived stigmas and depression were significance predictors of internalized stigma.