Published in PLOS One on 2026-06-09, this study is presented as an attributed evidence briefing. The excerpts below are the original researchers’ words, reproduced under their Creative Commons Attribution licence. Health Signal has selected the abstract and, where needed, opening background paragraphs; the complete methods, results, limitations and references remain in the linked paper.
Original authors: Setor K Sorkpor, Jerry John Ouner, Rachel G A Thompson, Robert Kaba Alhassan, Akua O Gyamerah, Ibrahim Yigit
Source: PLOS One • DOI 10.1371/journal.pone.0350297
Read the complete primary study ↗ · Creative Commons Attribution licence
From the researchers
Abstract
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.
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.
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.
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.
Introduction
Despite considerable global investment in human immunodeficiency virus (HIV) prevention and treatment, achieving optimal adherence to antiretroviral therapy (ART) remains a significant challenge, especially in sub-Saharan Africa (SSA), where approximately two-thirds of all people living with HIV (PLWH) reside [1]. Recent evidence suggests wide variability in ART adherence across the region, with systematic reviews reporting that only 43% to 84% of PLWH achieve optimal adherence [2]. In Ghana, where approximately 350,000 individuals are living with HIV [3], ART uptake has increased, but sustained adherence and viral suppression remain suboptimal due to intersecting structural and psychosocial barriers [3,4]. Thus, understanding the factors that contribute to suboptimal adherence and its underlying causes is crucial for developing tailored interventions to improve the physical and psychological health of PLWH.
Among these barriers, internalized HIV stigma, depressive symptoms, and household food insecurity may be critical determinants of HIV-related health behaviors [5–7]. Depression is a well-established barrier to ART adherence, contributing to diminished motivation, lower self-efficacy, and disengagement from care [5,8]. In Ghana and other low- and middle-income countries (LMICs), depression frequently co-occurs with food insecurity and stigma, stressors that independently predict poor ART outcomes [7,9]. In particular, internalized HIV stigma, defined as the internalization of society’s negative evaluations and perceptions about having HIV and applying them to onesef [6,10] can erode psychological resilience and negatively influence health behaviors through impaired self-worth and heightened distress [6,11,12]. Likewise, food insecurity exacerbates stress and depressive symptoms, further compromising ART engagement [7]. Ghana adopted the World Health Organization (WHO) “Treat All” strategy in 2016 to promote universal ART initiation regardless of CD4 count [13]. While this policy has expanded access, barriers such as long travel distances, medication stockouts, and under-resourced clinics persist. These challenges are particularly acute in the Volta Region, where stigma remains prevalent due to entrenched misinformation, cultural norms, and gaps in mental health services [5,11]. Such structural and social conditions are likely to increase psychological vulnerability and undermine sustained engagement in HIV care.
Reading this evidence
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This briefing makes the source accessible within the wider research & evidence desk. It does not assess an individual patient or certify a product. When considering relevance to another health system, examine the original authors’ account of context and limitations, then seek local implementation evidence. The related reporting below provides other studies to read alongside this one; it is a topic connection, rather than a claim that their results are directly comparable.
© 2026 Setor K Sorkpor, Jerry John Ouner, Rachel G A Thompson, Robert Kaba Alhassan, Akua O Gyamerah, Ibrahim Yigit. Excerpts reproduced under CC BY. Selection, formatting and contextual notes by Health Signal. The researchers are the authors of the source study, not members of Health Signal’s staff.
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