The COVID-19 pandemic has underscored the intersection of public health crises and mental health challenges, particularly among disadvantaged and vulnerable populations such as people living with HIV (PLWH) (1). The added strain of the pandemic has exacerbated mental health problems, particularly depressive symptoms, among this group (2). Depressive symptoms, including persistent sadness, lack of interest in daily activities, cognitive difficulties, and physical malaise, are prevalent in PLWH due to the chronic nature of their condition (3–5). These symptoms may be exacerbated by the stressors and uncertainties of the COVID-19 pandemic, such as increased social isolation, fear of increased vulnerability to the virus, and disruptions in health care services (6, 7). A recent systematic review and meta-analysis study found that the pooled prevalence rate of (moderate-to-severe) depressive symptoms among PLWH during the COVID-19 was 16.9% [95% confidence interval (CI): 3.8–30.0%] (6). Winters and colleagues compared the prevalence of depression among PLWH in Shinyanga region, Tanzania before and during COVID-19 and found substantially higher prevalence of depression (prevalence differences: 38; CI: 34, 42) (8). Given the existing health complications and increased risk of mental health issues, understanding the interplay between predictive factors and depressive symptoms among PLWH during COVID-19 is of paramount importance to enable more tailored and effective interventions for this population.

Internalized HIV stigma has been found to be one of the most significant risk factors of depressive symptoms among PLWH (9, 10). This stigma involves the incorporation of negative societal attitudes about HIV, resulting in self-disparagement, feelings of rejection and guilt (11). The harmful self-perceptions that individuals hold may serve as a direct antecedent to depressive symptoms. This occurs as individuals cultivate a negative self-concept and engage in harmful self-evaluations (12). In support of Meyer’s minority stress theory, which emphasizes the consequential role of stigma in generating psychological distress, individuals who belong to disadvantaged minority groups, such as PLWH, exhibit greater susceptibility to both external and internal stressors (13). These stressors are inextricably intertwined with instances of stigma and discrimination, making PLWH more vulnerable to depressive symptoms than their non-HIV peers (13).

Simultaneously, the COVID-19 pandemic may exacerbate internalized HIV stigma in addition to depressive symptoms (14). The additional stigma associated with the pandemic may intersect with and reinforce existing HIV-related stigma, exacerbating depressive symptoms (2). Because of their interrelated nature, understanding the complex relationship between internalized HIV stigma and depressive symptoms in PLWH during the COVID-19 pandemic is critical. Internalized stigma may exacerbate depressive symptoms through feelings of isolation, self-blame, and anticipated rejection. Conversely, the presence of depressive symptoms may increase the experience of internalized stigma, as individuals may further blame themselves for their condition (15). Additionally, existing evidence suggests that several underlying problems experienced by PLWH during COVID-19 may exacerbate the incidence of internalized stigma and depressive symptoms. For example, a scoping review of 45 articles found that several factors were related to increased psychological distress during the pandemic, including substance use, social support, financial hardship, antiretroviral adherence, and economic vulnerability (16). A recent qualitative study revealed that medical mistrust among PLWH might be associated with HIV stigma during the COVID-19 pandemic (17). It is therefore important for HIV researchers to explore the potential relationship between internalized HIV stigma and depressive symptoms during the pandemic in this population.

Although numerous empirical studies have documented the strong association between internalized HIV stigma and depressive symptoms, there is still a research gap regarding the network analysis model between internalized HIV stigma and depressive symptoms among PLWH during the COVID-19 pandemic. In this study, we attempted to use a novel analytical method—psychometric network analysis—to explore the relationship between these two variables in the context of the COVID-19 pandemic.

In contrast to traditional approaches that treat internalized HIV stigma and depressive symptoms as latent variables that are independent of each other, network analysis offers an alternative methodology capable of visualizing and quantifying the complexity inherent in such a system of interrelated variables (18–21). It provides a detailed understanding of these complex interactions and sheds light on the interplay between internalized HIV stigma and depressive symptoms within a larger context of psychosocial factors (22, 23). Using network analysis, elements of internalized HIV stigma and depressive symptoms are conceptualized as “nodes,” while the relationships between these elements are referred to as “edges” (24). When these nodes coexist within a population, they are considered to be directly connected. These critical links that serve as conduits between internalized HIV stigma and depressive symptoms are referred to as “bridges” in the network model (25).

Applied to the context of PLWH, this methodology can highlight specific attributes of internalized HIV stigma or specific depressive symptoms that exert a significant influence within the network. This identification is important for intervention development, as strategies can be tailored to address these key nodes, potentially leading to a more profound system-wide impact. In addition, network analysis helps to demystify the potential pathways linking internalized HIV stigma and depressive symptoms. Understanding these pathways is useful in creating predictive models, allowing clinicians and researchers to anticipate the progression of these symptoms based on network models (26). Such insights could provide timely indications for intervention, potentially averting further psychological distress. Therefore, network analysis can serve as a valuable tool for understanding and addressing the intertwined relationship between internalized HIV stigma and depressive symptoms among PLWH. By providing a nuanced and targeted understanding of this relationship, it can inform more effective strategies to alleviate psychological distress during challenging public health crisis in the future.

Data were drawn from a large cohort research project that attempted to explore the behavioral and mental health problems of PLWH in Guangxi, China (15, 27). The data were collected from May 2020 to October 2020. In collaboration with the Guangxi Center for Disease Control and Prevention (CDC), a strategic selection of study sites was made to conduct the research. We identified six hospitals and clinics in five cities based on their high numbers of HIV patients under care. This selection allowed us to focus on the sites with the largest HIV patient populations, thereby increasing the scope and relevance of our study. All participants were recruited from these local HIV clinics according to their medical records. This study was designed with precise inclusion criteria for participants: individuals who are aged between 18 and 60, diagnosed with HIV/AIDS, and have no plans to relocate from Guangxi for subsequent follow-up investigations lasting more than 12 months. Excluded from participation were those with language, mental, or physical impairments that might affect their ability to respond to assessment questions; those currently detained or institutionalized for drug use or involvement in commercial sex; or those intending to leave the province within the next year. In total, the study included 1,197 PLWH who successfully completed the survey. Sample demographics are shown in Table 1.

Ethical approval to conduct this study was granted by the Institutional Review Boards of University of South Carolina. The study procedures were fully disclosed to all participants, who were informed of the purpose of the study, the confidentiality of their responses, and their rights as participants. This information included their freedom to withdraw from the study at any time. After providing informed consent, participants were asked to complete a questionnaire administered by an interviewer. The interview-style questionnaires were administered by nurses trained by experts with more than 10 years of research experience with PLWH. In recognition of their contribution to the study, participants were offered an incentive of US$5.00 (equivalent to approximately 35 RMB, the Chinese currency).

Descriptive statistics for this study, including means, standard deviations, and intercorrelations of the variables of interest, are detailed in Table 2. In addition, Table 3 describes the names of the nodes used in the network analysis for internalized HIV stigma and depressive symptoms, and presents univariate statistics for each node.

In this study, network analysis was utilized to explore the network structures of internalized HIV stigma, depressive symptoms, and their interactions in a large sample of 1,197 Chinese PLWH during the COVID-19 pandemic. This investigation is innovative because, to our understanding, it is the first to explore network models of internalized HIV stigma and depressive symptoms. It also examines the possible co-occurrence of internalized HIV stigma and depressive symptoms and identifies the bridge between these two psychological phenomena among the marginalized and vulnerable population.

Our study provides valuable insights into the network structure of internalized HIV stigma and depressive symptoms among PLWH during the COVID-19 pandemic. One of the key findings was that “ashamed of having HIV” emerged as the most central node within the internalized HIV stigma network, indicating its pivotal role in the interconnected system of stigma-related experiences. This suggests that shame associated with HIV diagnosis may significantly influence other stigma-related experiences and contribute to the overall burden of internalized stigma. Such a finding is consistent with previous research highlighting the detrimental effects of shame on individuals’ self-esteem and psychological well-being (41–44). The central role of shame in the internalized HIV stigma network underscores the need for interventions that specifically target and mitigate feelings of shame associated with an HIV diagnosis, especially when PLWH are facing public health crises. Our research recognizes that some components of internalized HIV stigma, such as the centrality of “ashamed of having HIV,” are not limited to the COVID-19 outbreak. Nonetheless, our investigation specifically sheds light on how the exceptional difficulties presented by the pandemic could have intensified and influenced these persistent factors of stigma and depression in individuals living with HIV. The COVID-19 pandemic has led to several challenges for PLWH, including amplified feelings of shame, guilt, and depressive symptoms due to increased social isolation, heightened health anxieties, and disruptions in healthcare services. Our network analysis, while based on established measures, contextualizes these phenomena within the specific challenges faced by PLWH during COVID-19, underscoring the pandemic’s impact on their mental health.

The centrality of “mind wandered during tasks” in the depressive symptoms network highlights the impact of cognitive dysfunction on PLWH’s daily functioning and mental health status. This finding aligns with previous research showing that cognitive difficulties are a common symptom of depression that can exacerbate other depressive symptoms and impede overall recovery (45–48). Cognitive difficulties can interfere with an individual’s ability to effectively engage in self-care behaviors, interpersonal interactions, and other activities critical to managing HIV and maintaining good mental health (49–51). Additionally, the process of mind wandering is often associated with a lack of focus, decreased productivity, and an overall diminished ability to engage in the present moment, all of which are common characteristics of depression (52–54). Frequent mind wandering may indicate a struggle to manage or control thoughts, which can lead to an increased experience of depressive symptoms (55, 56). Within the context of the COVID-19 pandemic, this finding suggests that pandemic-induced stressors, such as prolonged isolation and health anxiety, significantly worsen cognitive disruptions. Specifically, these factors have intensified PLWH’s difficulty in maintaining focus on daily tasks, a key aspect of depressive symptomatology.

Our network analysis also identified two critical bridge connections between the internalized HIV stigma and depressive symptoms communities—“inferiority due to HIV” and “gloomy feelings.” These bridge nodes suggest a reciprocal influence between these two psychological constructs, where feelings of inferiority due to HIV may lead to or exacerbate gloomy feelings, and vice versa. The bridge node “inferiority due to HIV” suggests that feelings of inferiority due to HIV status may act as a link between stigma and depressive symptoms. It may be that individuals who internalize societal stigma about HIV begin to perceive themselves as less than others because of their HIV status (57, 58). This sense of inferiority could subsequently trigger or exacerbate depressive symptoms. Inferiority could potentially lead to negative self-esteem and lack of self-worth, key aspects often associated with depressive states (59–64). On the other hand, “gloomy feelings” serving as a bridge node indicates that these symptoms are not only a consequence of internalized HIV stigma, but could also potentially feed back into the internalized HIV stigma cycle. Depression can lead to a negative cognitive bias, in which individuals interpret their experiences more negatively (65–67). Therefore, those with depressive symptoms may perceive their HIV status in a more negative light, thereby increasing the internalization of HIV stigma.

These bridge nodes highlight the possible bidirectional and complex relationship between internalized HIV stigma and depressive symptoms, suggesting a potentially cyclical and self-perpetuating system. The more an individual feels inferior because of their HIV status, the more susceptible they may become to depressive symptoms. In turn, these depressive symptoms could further increase feelings of stigma, creating a reinforcing loop. Recognizing the role of “inferiority due to HIV” and “gloomy feelings” as bridge nodes illuminates pathways through which HIV stigma and depressive symptoms may interact and influence each other. This insight underlines the importance of addressing both internalized HIV stigma and depressive symptoms in a holistic and integrated manner in mental health interventions, particularly in the context of the COVID-19 pandemic, which has exacerbated both of these challenges for PLWH.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving humans were approved by the Institutional Review Board of University of South Carolina. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

GY: Conceptualization, Data curation, Formal analysis, Methodology, Software, Validation, Visualization, Writing – original draft. SQ: Data curation, Investigation, Project administration, Resources, Supervision, Writing – original draft. XL: Data curation, Funding acquisition, Project administration, Resources, Supervision, Writing – original draft.