Stigma, Mental Health, and HIV Adherence: A Cross-sectional Structural Equation Modeling Study Exploring Direct and Indirect Effects Among School-Engaged Ugandan Adolescents Living With HIV.

Our study examined how multiple dimensions of HIV-related stigma affect mental health and antiretroviral therapy (ART) adherence among school-engaged adolescents living with HIV in Uganda. Using structural equation modeling with 833 participants recruited from 42 HIV clinics, we examined multiple dimensions of internalized and externalized HIV stigma, and their associations with adherence outcomes. We found that internalized shame and family-based stigma were significantly associated with poor mental health which, in turn, strongly predicted nonadherence to ART. Mediation analyses confirmed indirect pathways from family-based stigma and internalized shame to ART nonadherence via poor mental health. Disclosure stigma was unexpectedly associated with better ART adherence, suggesting possible benefits of selective self-disclosure. However, school-based stigma was not associated with mental health or ART adherence, possibly because of nondisclosure within school settings. Findings underscore the need for multilevel stigma reduction interventions that address internalized and family-level stigma to support ART adherence among school-engaged adolescents living with HIV.