Depression,Anxiety,Stress,Self-Esteem,and HIV-Related Stigma in Adolescents and Young Adults Living With Perinatally Acquired HIV in Northern Thailand

Abstract

Background

Adolescents and young adults with perinatally acquired HIV (AYA-PHIV) face psychosocial challenges that may be associated with antiretroviral treatment (ART) outcomes and quality of life.

Methods

We conducted a cross-sectional analysis among AYA-PHIV receiving care in northern Thailand. Depression, anxiety, stress, self-esteem, and internalized HIV-related stigma were assessed using Depression Anxiety Stress Scale–21, Rosenberg Self-Esteem Scale-10, and Thai Internalized HIV-related Stigma Scale-22. Virologic suppression status was obtained from clinical records. Group differences were examined using Independent Samples t-test.

Results

Participants without virologic suppression reported higher internalized HIV-related stigma scores than those with suppression (P < .001) and a higher prevalence of low self-esteem. Symptoms of depression, anxiety, and stress were not different.

Conclusions

Higher internalized stigma and lower self-esteem were observed among AYA-PHIV without virologic suppression in this clinic-based sample. Findings highlight the potential relevance of psychosocial support within adolescent HIV care. Larger longitudinal studies are needed to clarify pathways linking stigma, mental health, adherence, and virologic outcomes.

Keywords

depression anxiety stress self-esteem HIV-related stigma HIV Thailand

Introduction

In 2023, an estimated 1.37 million children under 14 years of age and 1.01 million adolescents aged 15 to 19 years were living with HIV globally.¹ In Thailand, approximately 25 643 adolescents and young adults aged 15 to 24 years were living with HIV.² Adolescence and young adulthood are critical developmental periods characterized by substantial cognitive, emotional, and social changes.^3–6 During this period, adolescents and young adults living with HIV are particularly vulnerable to psychosocial challenges.

HIV-related stigma refers to the internalization of negative beliefs, shame, and devaluation associated with living with HIV, which may shape individuals’ self-perceptions and social experiences. Self-esteem reflects a person's overall evaluation of self-worth and personal value, and has been linked to psychological well-being and health-related behaviors among adolescents and young adults. In adolescents and young adults living with perinatally acquired HIV (AYA-PHIV), stigma experiences, psychological distress (depressive symptoms, anxiety, and stress), and self-esteem are often interrelated and may co-occur within broader psychosocial contexts that influence engagement in care and treatment outcomes.

HIV-related stigma has been consistently associated with poorer mental health outcomes, including depression and anxiety, and is linked to suboptimal adherence to antiretroviral therapy (ART) and reduced likelihood of virologic suppression.^7–11 Among AYA-PHIV, higher rates of depression, anxiety, and psychological distress have been reported across diverse settings.^12–16 High levels of stigma may further undermine social support and engagement in care, adversely affecting ART adherence and clinical outcomes.^7,8

Suboptimal adherence to ART compromises virologic suppression and may increase the risk of HIV drug resistance.¹⁷ Despite the high burden of psychosocial difficulties, mental health problems among AYA-PHIV often remain underrecognized in routine clinical practice. This study therefore aimed to examine the prevalence of depression, anxiety, perceived stress, low self-esteem, and HIV-related stigma among AYA-PHIV receiving ART in Northern Thailand.

Conceptual framework illustrating hypothesized relationships among HIV-related stigma, mental health symptoms, self-esteem, engagement in care/ART adherence, and virologic outcomes among AYA-PHIV is shown in Figure 1. This framework guided variable selection and interpretation of associations in the present study. Given the cross- sectional design and limited sample size, the framework is descriptive and hypothesis-generating; formal mediation or causal pathways were not tested.

Figure 1.

Conceptual framework of psychosocial factors and virologic outcomes among AYA-PHIV.

This framework is descriptive and hypothesis-generating; formal mediation or causal pathways were not tested in the present cross-sectional study.

The primary objective of this study was to describe the prevalence and distribution of psychosocial characteristics, including symptoms of depression, anxiety, and stress, self-esteem, and internalized HIV-related stigma, among AYA-PHIV receiving ART in Northern Thailand. A secondary, exploratory aim was to examine whether these psychosocial measures differed between participants with and without virologic suppression at baseline. We hypothesized, a priori, that participants without virologic suppression would report higher levels of psychological distress and internalized stigma and lower self-esteem than those with virologic suppression; however, given the cross-sectional design and limited sample size, these hypotheses were evaluated descriptively rather than as tests of causal or directional effects.

Methods

Study Design and Participants

This cross-sectional study was conducted at the Research Institute for Health Sciences (RIHES), Chiang Mai University (CMU) in Northern Thailand. AYA-PHIV were recruited from HIV clinics in Chiang Mai, Lamphun, and Lampang provinces for participation in an interventional study, during July 2023 to June 2024. Baseline data was used in this analysis. Official letters were sent to the provincial and community hospitals in the 3 provinces. The principal investigator and study nurses subsequently met with the HIV clinic staff to provide study information, review eligibility criteria, and request referrals of potentially eligible AYA-PHIV to the study clinic at RIHES, CMU. Potential participants were invited to attend a screening visit at the study clinic, where detailed study procedures were explained. Written informed consent and/or assent, with parental or guardian consent as applicable, was obtained prior to screening for eligibility. Participants were eligible if they: (1) aged 15 to 24 years; (2) had documented perinatally acquired HIV infection; (3) were receiving dolutegravir-based ART regimens at the time of enrollment; and (4) provided written informed consent and/or assent, with parental or guardian consent as appropriate.

Participants were excluded if they had known or suspected psychosis, major depressive disorder or other severe psychiatric conditions that, in the judgment of the investigator and based on available medical records, would preclude safe participation in the study procedures. This exclusion criterion was implemented for ethical and safety considerations, as the study procedures and available resources were not designed to provide comprehensive psychiatric care for individuals with severe mental health conditions. This exclusion was not intended to improve the accuracy of prevalence estimates; rather, it may introduce selection bias by systematically excluding individuals with more severe mental health conditions. Consequently, the study sample may not fully represent the entire spectrum of mental health status among AYA-PHIV, and the findings were interpreted with this limitation in mind.

The sample size for this baseline cross-sectional analysis was determined based on feasibility considerations and the availability of the target population within the study setting. Given the descriptive and exploratory nature of this analysis, a formal a priori power calculation was not undertaken.

A total of 57 participants were included, representing all eligible individuals who met the inclusion criteria during the recruitment period. This sample size is considered appropriate for a hypothesis-generating cross-sectional analysis, enabling the characterization of baseline demographic and clinical profiles, as well as the exploration of preliminary associations among key variables.

Importantly, the findings from this baseline analysis are intended to inform the design and statistical assumptions of subsequent analyses, including effect size estimation and sample size calculations for adequately powered future studies.

While the sample size may limit the generalizability of findings, it provides essential preliminary data to guide future confirmatory research.

The reporting of this cross-sectional study conforms to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement.¹⁸ The completed STROBE checklist is provided as a Supplemental File.

Data Collection and Outcome Measures

Self-administered questionnaires were administered at enrollment visit at the Family Clinic, RIHES, CMU. ART adherence was assessed using a questionnaire adapted from the IMPAACT 2017 study instruments and approved by the Ethics Committee prior to implementation. CD4 cell counts and HIV-1 RNA levels were extracted from the National AIDS Program database.

Mental health and psychosocial measures included the Depression Anxiety Stress Scale–21 (DASS-21), Rosenberg Self-Esteem Scale (RSES-10), and the Thai Internalized HIV-related Stigma Scale (Thai-IHSS). The DASS-21 is a self-report instrument assessing depression, anxiety, and stress.¹⁹ The Thai version has demonstrated good internal consistency and validity (Cronbach's alpha = 0.82). DASS-21 score interpretation is provided in Appendix A. RSES-10 is a widely used measure with established reliability and validity, including in Thai populations.^20,21 The Thai-IHSS, developed by Uthis et al,²² comprises 22 items across 4 domains: negative self-concept (5 items), anticipated stigma (7 items), effects of negative self-concept (6 items), and effects on family and access to healthcare services (4 items). Items are rated on a 4-point Likert scale (strongly disagree to strongly agree), with higher scores indicating greater internalized HIV-related stigma.

Data Analysis

Demographic characteristics were summarized using descriptive statistics, including frequencies and means (standard deviations) or medians (ranges), as appropriate.

Analyses were conducted to address the prespecified exploratory aims. Group differences in psychosocial measures by virologic suppression status were examined descriptively using nonparametric tests. Exploratory regression analyses were conducted to characterize patterns of association with virologic outcomes. Given the small sample size and sparse data, no formal multivariable or mediation models were specified, and all estimates were interpreted cautiously as descriptive.

Depression, anxiety, stress, self-esteem, and HIV-related stigma were assessed using validated self-report instruments administered at entry visit. Scale scores were computed according to standard scoring procedures for each instrument, with higher scores indicating greater symptom severity or higher levels of perceived stigma, as appropriate. For scales containing reverse-coded items, responses were recoded prior to score computation.

Internal consistency reliability was examined using Cronbach's alpha for the composite Depression–Anxiety–Stress Scale, RSES-10, and the Thai Internalized HIV-related Stigma Scale (Thai-IHSS). Item–rest correlations were calculated to evaluate the contribution of each symptom domain to the overall construct. Interitem Pearson correlation coefficients were examined to assess the degree of association among depression, anxiety, and stress, self-esteem, and internalized HIV-related stigma and to support the conceptual coherence of these domains as indicators of related psychosocial measures. All reliability analyses were conducted using standard reliability procedures.

Between-group differences in depression, anxiety, stress, self-esteem, and HIV-related stigma by viral load status were examined using independent samples t-tests, comparing participants with virologic suppression (VL < 50 copies/mL) and those with detectable viral load (VL ≥ 50 copies/mL). This approach was selected to assess cross-sectional differences at entry visit.

Assumptions of normality and homogeneity of variances were assessed prior to hypothesis testing (Levene's test for heterogeneity) Effect sizes (Cohen's d) were reported to quantify the magnitude of between-group differences and to facilitate interpretation beyond statistical significance. All statistical tests were 2-sided, with a significance level set at α = 0.05.

All analyses were conducted using the Jamovi program, version 2.7.^23–25

Results

Demographic Characteristics

Among 57 participants, 68% were female, with a median age of 21.5 years (range: 15-24 years). Educational attainment varied; 9 participants (16%) had completed university education. Employment and educational status differed significantly between participants with HIV-1 RNA ≥50 copies/mL and those with virologic suppression (P < .05) (Table 1).

Table 1.

Demographic Characteristics of Study Participants (n = 57).

Characteristic	HIV-1 RNA <50 c/mL N (%)	HIV-1 RNA ≥ 50 c/mL N (%)	Total N (%)
Biological sex
Female	16 (28)	21 (64)	37 (65)
Age (years)
Median	21.5 (2)	21 (4)	21.5 (3.5)
5 (21)	9 (27)		14 (25)
19 (80)	24 (73)		43 (75)
Education
University graduated	5 (21)	4 (12)	9 (16)
Undergraduated	19 (79)	29 (88)	48 (84)
Employment/educational status
Working	13 (54)	11 (33)	24 (42)
Studying	9 (38)	16 (48)	25 (44)
Neither studying nor working	2 (8)	6 (18)	8 (14)
HIV-1 RNA (Log₁₀ copies/mL)
<1.7 Log₁₀	24 (100)	0 (0)	24 (42)
1.7-3 Log₁₀	0 (0)	19 (58)	19 (33)
4-7 Log₁₀	0 (0)	14 (42)	14 (25)
ART adherence
Low (<95%)	9 (38)	22 (67)	31 (54)

ART, antiretroviral treatment.

Depression, Anxiety, and Stress and Self-Esteem

The internal consistency of the mental health symptom scale (depression, anxiety, and stress) was high, with a Cronbach's alpha of 0.882, indicating good reliability (Table 2). The overall scale mean was 2.99 (SD = 2.56). Item–rest correlations were strong across all 3 domains, including depression (r = 0.757), anxiety (r = 0.741), and stress (r = 0.822), suggesting that each subscale contributed meaningfully to the overall construct.

Table 2.

Reliability of Depression, Anxiety, and Stress.

Reliability Analysis
Scale reliability statistics
	Mean	SD	Cronbach's α
Scale	2.99	2.56	0.882
Item reliability statistics
	Mean	SD	Item–rest correlation
Depress	2.63	2.78	0.757
Anxiety	2.70	2.74	0.741
Stress	3.63	3.00	0.822

Interitem correlations demonstrated moderate to strong positive associations among depression, anxiety, and stress (r = 0.65-0.76; Figure 2), reflecting substantial overlap among negative affective symptoms. The strongest correlation was observed between depression and stress (r = 0.76), followed by anxiety and stress (r = 0.74), and depression and anxiety (r = 0.65). These findings support the coherence of the 3 domains as indicators of observed indicators of psychological distress.

Figure 2.

Interitem correlation heatmap of depression, anxiety, and stress.

The internal consistency reliability of the HIV-related stigma scale was good, with a Cronbach's alpha of 0.841 (Table 3), indicating a high level of internal consistency among the items. The mean stigma score was 26.0 (SD = 15.8), suggesting moderate variability in perceived stigma within the study population.

Table 3.

Reliability of HIV-Related Stigma.

Reliability Analysis
Scale reliability statistics
	Mean	SD	Cronbach's α
Scale	26	15.8	0.841
Item reliability statistics
	SD
Stigma	17.5
Record ID	16.6

Item-level variability was observed, with standard deviations indicating heterogeneity in responses. The correlation structure (Figure 3) further supported the coherence of the scale, demonstrating that the items were sufficiently interrelated to reflect a common underlying construct of HIV-related stigma.

Figure 3.

Item-level correlation heatmap of HIV-related stigma.

The stigma scale demonstrated good internal consistency in this sample, consistent with established thresholds indicating acceptable to strong reliability (α ≥ 0.80). This finding supports the use of the scale as a composite measure of HIV-related stigma in adolescents and young adults.

The relatively large standard deviation suggests substantial variability in stigma experiences, which is expected given the influence of diverse social, cultural, and contextual factors. The observed internal consistency indicates that, despite this variability, the items function cohesively to capture a unified construct.

From a methodological perspective, the adequate reliability of the stigma scale justifies its use as a single composite score in subsequent analyses, including between-group comparisons and longitudinal modeling. This enhances interpretability while maintaining measurement validity.

The HIV-related stigma scale demonstrated good internal consistency (Cronbach's α = 0.841), supporting its reliability as a composite psychosocial measure in this study. These findings justify its use as an outcome variable in subsequent statistical analyses.

The internal consistency reliability of the self-esteem scale was acceptable, with a Cronbach's alpha of 0.792 (Table 4), indicating a satisfactory level of internal consistency in the current sample. The mean self-esteem score was 15.2 (SD = 5.31), suggesting moderate variability among participants.

Table 4.

Reliability of Self-Esteem.

Reliability Analysis
Scale reliability statistics
	Mean	SD	Cronbach's α
Scale	15.2	5.31	0.792
Item reliability statistics
	SD	Item–rest correlation
Self-esteem^a	4.42	0.270
VL < 50 copies/mL	7.07	0.889
Record ID	7.07	0.889

Note. ^areverse scaled item.

Item-level analysis showed a relatively low item–rest correlation for the reverse-scored self-esteem item (r = 0.270), indicating a weaker contribution of this item to the overall scale compared with other components. In contrast, other items demonstrated strong item–rest correlations (r = 0.889), suggesting that they were highly consistent with the underlying construct.

The correlation structure (Figure 4) generally supported the coherence of the scale, although some heterogeneity across items was observed.

Figure 4.

Item-level correlation heatmap of self-esteem.

The self-esteem scale demonstrated acceptable internal consistency in this study, supporting its use as a composite measure. A Cronbach's alpha close to 0.80 indicates that the scale is sufficiently reliable for research purposes, although there may be minor inconsistencies across individual items.

The relatively low item–rest correlation for the reverse-scored item suggests that participants may have interpreted this item differently, a common issue in scales that include reverse-worded questions. Reverse-coded items can introduce measurement noise due to response patterns or misunderstanding, particularly in younger populations or cross-cultural contexts.

Despite this, the overall reliability remained within an acceptable range, indicating that the scale as a whole captures the construct of self-esteem adequately. From a methodological standpoint, the findings support retaining the composite score while acknowledging potential limitations related to reverse-coded items.

The self-esteem scale demonstrated acceptable internal consistency (Cronbach's α = 0.792), supporting its use as a composite measure in this study. However, variability in item performance, particularly for the reverse-coded item, suggests that results should be interpreted with some caution.

Between-group comparisons of mental health symptoms by viral load status (VL < 50 vs VL ≥ 50 copies/mL) showed no statistically significant differences in depression (t(55) = −0.69, P = .247) or stress (t(55) = −1.09, P = .140). Anxiety demonstrated a borderline difference between groups (t(55) = −1.68, P = .050), with higher anxiety scores observed among participants with VL ≥ 50 copies/mL compared with those who were virally suppressed. Effect sizes were small for depression (Cohen's d = −0.18) and stress (d = −0.29), and small-to-moderate for anxiety (d = −0.45) (Table 5).

Table 5.

Independent Samples t-Test for Depression, Anxiety, and Stress.

Independent Samples t-Test
		Statistic	df	P	Mean Difference	SE Difference		Effect Size
Depress	Student's t	−0.687	55	.247	−0.515	0.750	Cohen's d	−0.184
Anxiety	Student's t	−1.676	55	.050	−1.212	0.723	Cohen's d	−0.450
Stress	Student's t	−1.090	55	.140	−0.875	0.803	Cohen's d	−0.292

Note. H_a μ_VL _< _{50 copies/mL} < μ_{VL ≥ 50 copies/mL.}

Between-group comparison of self-esteem by viral load status (VL < 50 vs VL ≥ 50 copies/mL) showed no statistically significant difference (t(55) = 1.19, P = .119). Although the mean self-esteem score was descriptively higher in the virally suppressed group, the magnitude of the between-group difference was small to moderate (Cohen's d = 0.32), indicating limited practical significance (Table 6).

Table 6.

Independent Samples t-Test for Self-Esteem.

Independent Samples t-Test
		Statistic	df	P	Mean Difference	SE Difference		Effect Size
Self-esteem	Student's t	1.19	55.0	.119	1.28	1.07	Cohen's d	0.320

Note. H_a μVL < 50 copies/mL > μVL ≥ 50 copies/mL.

HIV-Related Stigma

Between-group comparison of HIV-related stigma by viral load status (VL < 50 vs VL ≥ 50 copies/mL) demonstrated a highly significant difference (t(55) = −10.00, P < .001). Participants with VL ≥ 50 copies/mL reported substantially higher stigma scores than those with VL < 50 copies/mL, with a very large effect size (Cohen's d = −2.68). The mean difference between groups was −28.2 (SE = 2.82), indicating markedly greater perceived stigma among participants with detectable viral load (Table 7).

Table 7.

Independent Samples t-Test for Stigma.

Independent Samples t-Test
		Statistic	df	P	Mean Difference	SE Difference		Effect Size
Stigma	Student's t	−10.00^a	55.0	<.001	−28.2	2.82	Cohen's d	−2.68

Note. H_a μVL < 50 copies/mL < μVL≥ 50 copies/mL.

^aLevene's test is significant (P < .05), suggesting a violation of the assumption of equal variances.

Levene's test indicated heterogeneity of variances (P < .05). Accordingly, the between-group difference remained robust when accounting for unequal variances, supporting the stability of the observed effect.

Discussion

This cross-sectional analysis examined baseline mental health and psychosocial characteristics among AYA-PHIV who were screened for participation in an interventional study, comparing those with virologic suppression (n = 24) and nonsuppression (n = 33). Measures included depressive symptoms, anxiety, stress, self-esteem, and internalized HIV-related stigma. Overall, the observed associations between psychosocial measures and virologic outcomes should be interpreted as unadjusted and exploratory, and estimates were characterized by limited precision with wide confidence intervals.

In this clinically engaged cohort, higher levels of depressive symptoms, anxiety, stress, and lower self-esteem tended to co-occur with virologic nonsuppression. However, the cross-sectional design precludes inference regarding directionality, and the modest sample size limited the precision of effect estimates. The prevalence of mild-to-moderate depressive, anxiety, and stress symptoms observed in this study was broadly comparable to prior reports among AYA-PHIV in Thailand and other settings.^26–29 The absence of clear associations for some psychosocial measures in our analyses may reflect limited statistical power rather than the absence of underlying relationships.

Self-esteem and internalized HIV-related stigma differed between participants with and without virologic suppression in this sample. Prior studies in diverse settings have reported associations between stigma, psychological distress, ART adherence, and virologic outcomes,^30–32 although direct comparisons should be interpreted cautiously given differences in study design and populations. The present findings are characterized by substantial uncertainty and should be viewed as preliminary. External literature is therefore used here to contextualize these observations rather than to compensate for inconclusive evidence within the current dataset.

The observed virologic suppression rate in this cohort was similar to reports from other settings,³³ highlighting ongoing challenges in achieving optimal virologic outcomes among AYA-PHIV and in meeting global treatment targets.³⁴ However, participants were recruited through HIV clinics and were required to travel to a research site, likely resulting in a clinically engaged and relatively stable sample. As such, these findings may not generalize to less-engaged AYA-PHIV or those facing greater structural barriers to care.

Although ART adherence is central to virologic outcomes, it could not be meaningfully incorporated into analytic models in this small sample without risking model instability. Consequently, the observed associations between psychosocial measures and virologic outcomes should be interpreted independently of adherence effects.

The observed differences between virologic suppression groups should be interpreted in light of the study's prespecified exploratory aims. The analyses were not designed to test causal hypotheses or mechanistic pathways, and findings are best viewed as hypothesis-generating.

Future research should prioritize adequately powered, longitudinal designs to clarify temporal relationships among mental health, stigma, self-esteem, ART adherence, and virologic outcomes.

Qualitative approaches, such as in-depth interviews or focus groups, may complement quantitative findings by providing contextual insight into mechanisms linking psychosocial experiences to engagement in care and treatment outcomes among AYA-PHIV.

Strengths and Limitations

A key strength of this study is its focus on AYA-PHIV in northern Thailand, a population with unique psychosocial and healthcare access challenges. However, several limitations should be acknowledged, including potential transportation barriers affecting participation, the absence of age-, education-, and employment-matched comparison groups, and the cross-sectional design, which precludes causal inference regarding the relationships between mental health, stigma, and virologic outcomes. Additionally, selection bias may have occurred, as the pilot intervention cohort included a limited number of participants with virologic suppression.

The exclusion of participants with known or suspected major depressive disorders or severe psychological conditions may have introduced systematic selection bias, resulting in an underrepresentation of individuals with higher mental health burden. Consequently, the observed prevalence of depressive symptoms and the strength of associations with HIV-related stigma and clinical outcomes may represent conservative estimates.

Refusal rates and basic characteristics of individuals who declined participation were not systematically recorded, precluding formal assessment of nonresponse bias and limiting inferences regarding the representativeness of the study sample

The cross-sectional nature of the data precludes conclusions regarding causal pathways between mental health outcomes, HIV-related stigma, and clinical indicators.Longitudinal studies are needed to better elucidate the temporal and potentially causal relationships among these variables.

The modest sample size and imbalance between comparison groups limited the statistical power to detect small-to-moderate effects and reduced the precision of effect estimates, as reflected by relatively wide confidence intervals. Consequently, both statistically nonsignificant and significant findings should be interpreted with caution, and the possibility of Type II error cannot be excluded.

Accordingly, the clinical and programmatic implications of these findings should be interpreted as preliminary, given the limited precision of the estimates arising from the small and imbalanced sample.

Despite these limitations, the findings provide insights into mental health and stigma experiences among clinically engaged AYA-PHIV, highlighting potential entry points for integrating psychosocial interventions within routine HIV care settings.

This study has several important limitations that constrain inference. First, the cross-sectional design precludes any assessment of temporal ordering or causal pathways between stigma, mental health, self-esteem, adherence, and virologic outcomes. Second, the modest sample size and imbalance between virologic suppression groups resulted in limited statistical power and imprecise estimates, reflected in wide confidence intervals and unstable effect estimates in regression analyses. Third, recruitment through clinic referral and the requirement to travel to a research site likely selected for a clinically engaged population, introducing selection bias and limiting generalizability to less engaged AYA-PHIV. However, recruitment from communities outside healthcare facilities could be associated with the risk of inadvertent social disclosure of HIV status followed by enacted stigma or social discrimination. Fourth, exclusion of participants with known or suspected major psychiatric disorders may have led to systematic underrepresentation of those with more severe mental health needs, which is particularly relevant given that depression was a key construct of interest. Finally, we have not collected data on refusal rates and characteristics of nonparticipants, which could bring about nonresponse bias.

In addition, potential confounding was not addressed, as the limited sample size and sparse cells precluded stable multivariable adjustment for key covariates (eg, age, sex, socioeconomic factors, and ART adherence), raising the possibility of residual confounding.

In the context of a relatively small sample size, this baseline cross-sectional analysis was not designed to detect statistically robust associations or to support causal inferences. Additionally, the presence of substantial background psychosocial support across participants may further limit the ability to distinguish meaningful variability in key outcomes.

Nevertheless, the observed patterns provide valuable preliminary insights into participant characteristics and potential associations among psychosocial and behavioral factors. These findings are best interpreted as hypothesis-generating and highlight the potential relevance of incorporating creative and culturally sensitive approaches, such as music-based elements, into adherence support frameworks—particularly for adolescents and young adults, who may be less engaged with conventional modalities.

Importantly, these initial observations will inform the design of future adequately powered studies, including refinement of intervention components, identification of relevant subgroups, and estimation of effect sizes for more definitive evaluation.

Implications and Future Directions

These findings highlight the importance of integrating stigma-reduction and self-esteem–enhancing interventions into HIV care for AYA-PHIV. Future research employing qualitative methods, such as focus group discussions and in-depth interviews, may provide deeper insights into context-specific strategies to reduce stigma, strengthen self-esteem, and improve ART adherence and virologic outcomes.

Larger, adequately powered studies are warranted to confirm these preliminary findings and to provide more precise estimates of the relationships between mental health, HIV-related stigma, and clinical outcomes in this population.

Conclusion

In this clinic-based sample of AYA-PHIV in northern Thailand, internalized HIV-related stigma and low self-esteem were more prevalent among participants without virologic suppression, while symptoms of depression, anxiety, and stress were observed across both groups. While the study could not establish causal pathways, the results highlight the potential relevance of psychosocial factors within the context of routine HIV care for adolescents who are engaged in clinical services. Future research employing larger, longitudinal designs with comprehensive assessment of adherence, stigma, and mental health is needed to more robustly characterize pathways and to inform the development and evaluation of integrated psychosocial interventions aimed at improving both mental health and HIV-related outcomes among AYA-PHIV.

Supplemental Material

sj-doc-1-jia-10.1177_23259582261451684 - Supplemental material for Depression, Anxiety, Stress, Self-Esteem, and HIV-Related Stigma in Adolescents and Young Adults Living With Perinatally Acquired HIV in Northern Thailand

Supplemental material, sj-doc-1-jia-10.1177_23259582261451684 for Depression, Anxiety, Stress, Self-Esteem, and HIV-Related Stigma in Adolescents and Young Adults Living With Perinatally Acquired HIV in Northern Thailand by Chintana Khamrong, Rattika Thammalangka, Kalunyu Kotchawat, Nakhon Khamrong, Linda Aurpibul, Jakkrit Klaphajone, Teerawan Teerapong and Natthapol Kosashunhanan in Journal of the International Association of Providers of AIDS Care (JIAPAC)

Supplemental Material

sj-docx-2-jia-10.1177_23259582261451684 - Supplemental material for Depression, Anxiety, Stress, Self-Esteem, and HIV-Related Stigma in Adolescents and Young Adults Living With Perinatally Acquired HIV in Northern Thailand

Supplemental material, sj-docx-2-jia-10.1177_23259582261451684 for Depression, Anxiety, Stress, Self-Esteem, and HIV-Related Stigma in Adolescents and Young Adults Living With Perinatally Acquired HIV in Northern Thailand by Chintana Khamrong, Rattika Thammalangka, Kalunyu Kotchawat, Nakhon Khamrong, Linda Aurpibul, Jakkrit Klaphajone, Teerawan Teerapong and Natthapol Kosashunhanan in Journal of the International Association of Providers of AIDS Care (JIAPAC)

Supplemental Material

sj-docx-3-jia-10.1177_23259582261451684 - Supplemental material for Depression, Anxiety, Stress, Self-Esteem, and HIV-Related Stigma in Adolescents and Young Adults Living With Perinatally Acquired HIV in Northern Thailand

Supplemental material, sj-docx-3-jia-10.1177_23259582261451684 for Depression, Anxiety, Stress, Self-Esteem, and HIV-Related Stigma in Adolescents and Young Adults Living With Perinatally Acquired HIV in Northern Thailand by Chintana Khamrong, Rattika Thammalangka, Kalunyu Kotchawat, Nakhon Khamrong, Linda Aurpibul, Jakkrit Klaphajone, Teerawan Teerapong and Natthapol Kosashunhanan in Journal of the International Association of Providers of AIDS Care (JIAPAC)

Supplemental Material

sj-docx-4-jia-10.1177_23259582261451684 - Supplemental material for Depression, Anxiety, Stress, Self-Esteem, and HIV-Related Stigma in Adolescents and Young Adults Living With Perinatally Acquired HIV in Northern Thailand

Supplemental material, sj-docx-4-jia-10.1177_23259582261451684 for Depression, Anxiety, Stress, Self-Esteem, and HIV-Related Stigma in Adolescents and Young Adults Living With Perinatally Acquired HIV in Northern Thailand by Chintana Khamrong, Rattika Thammalangka, Kalunyu Kotchawat, Nakhon Khamrong, Linda Aurpibul, Jakkrit Klaphajone, Teerawan Teerapong and Natthapol Kosashunhanan in Journal of the International Association of Providers of AIDS Care (JIAPAC)

Supplemental Material

sj-docx-5-jia-10.1177_23259582261451684 - Supplemental material for Depression, Anxiety, Stress, Self-Esteem, and HIV-Related Stigma in Adolescents and Young Adults Living With Perinatally Acquired HIV in Northern Thailand

Supplemental material, sj-docx-5-jia-10.1177_23259582261451684 for Depression, Anxiety, Stress, Self-Esteem, and HIV-Related Stigma in Adolescents and Young Adults Living With Perinatally Acquired HIV in Northern Thailand by Chintana Khamrong, Rattika Thammalangka, Kalunyu Kotchawat, Nakhon Khamrong, Linda Aurpibul, Jakkrit Klaphajone, Teerawan Teerapong and Natthapol Kosashunhanan in Journal of the International Association of Providers of AIDS Care (JIAPAC)

Footnotes

Acknowledgments

This study would not be possible without the dedication and diligent effort of 57 adolescents and young adults, their parents/ guardians, and healthcare providers, family clinic (IMPAACT) team, RIHES, CMU, my main advisor, Dr Natthapol Kosashunhanan, MD, my co-advisors, Dr Linda Aurpibul, MD, Assoc. Prof. Jakkrit Klaphajone, MD, and Assoc. Prof. Dr Teerawan Teerapong. Without the research fund support of CMU's Research Institute for Health Sciences, this study would not have been possible.

ORCID iDs

Chintana Khamrong

Linda Aurpibul

Teerawan Teerapong

Natthapol Kosashunhanan

Ethical Considerations

The study was approved by the Human Experimentation Committee at Research Institute for Health Sciences, CMU (Certificate Approval No. 30/2023).

The study was registered in the Thai Clinical Trials Registry. The TCTR identification number is TCTR20241231002 () on December 31, 2024.

Consent to Participate

Before enrollment, participants provided written informed consent for study participation, inclusion and use of data in publication; for those under 20 years of age, consent and assent were also obtained from the caregiver and the participant, respectively.

Author Contributions

Chintana Khamrong: contributed to the study's conceptualization and design; data acquisition, analysis, and interpretation; supervision; and drafting of the manuscript; Rattika Thammalangka and Kalunyu Kotchawa: contributed to data acquisition, analysis, and interpretation, and critical review of the manuscript; Nakhon Khamrong: contributed to conceptualization and design, data acquisition and interpretation, and critical review of the manuscript; Linda Aurpibul: contributed to conceptualization and design; data interpretation and analysis; supervision; and critical review of the manuscript; Jakkrit Klaphajone and Teerawan Teerapong: contributed to conceptualization and design, and critical review of the manuscript; Natthapol Kosashunhanan: contributed to conceptualization and design, data interpretation and analysis, supervision, and critical review of the manuscript.

Competing Interests 

All authors declare that they have no competing interests or other interests that might be perceived to influence the results and/or discussion reported in this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Research Institute for Health Sciences, CMU, Chiang Mai, Thailand (Grant No. 013/2566).

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Supplemental Material

Supplemental material for this article is available online.

References

UNICEF. Global and regional trends [Internet]. 2023 [cited 2023 Aug 18]. Available from: https://data.unicef.org/topic/hivaids/global-regional-trends/

State of HIV epidemic in Thailand in 2022 [Internet]. 2022 Available from: https://hivhub.ddc.moph.go.th/Download/RRTTR/HIV_Factsheet2022_EN_Final_220966.pdf

Piaget

. The Psychology of the Child. Basic Books; 1972.

Erikson

. Identity: Youth and Crisis. W. W. Norton & Company; 1968.

Harter

. The Construction of the Self: Developmental and Sociocultural Foundations. Guilford Press; 2012.

Hankin

Abramson

Moffitt

Silva

McGee

Angell

. Development of depression from preadolescence to young adulthood: Emerging gender differences in a 10-year longitudinal study. J Abnorm Psychol. 2010;119(5):811-833.

Yvonne

, et al. Role of self-stigma in pathways from HIV-related stigma to quality of life among people living with HIV. AIDS Patient Care STDS. 35(6). 10.1089/apc.2020.0236

Adimora

Aye

Akaneme

Nwokenna

Akubuilo

. Stigmatization and discrimination as predictors of self-esteem of people living with HIV and AIDS in Nigeria. Afr Health Sci. 2019;19(4):3160-3171. doi: 10.4314/ahs.v19i4.39. PMID: 32127893; PMCID: PMC7040355.

Huang

Zhang

, et al. The impact of stigma on self-management behavior among people with HIV in China: The role of social support and self-esteem. AIDS Patient Care STDS. 2024;38(9):453-462. doi: 10.1089/apc.2024.0104. Epub 2024 Aug 12. PMID: 39126267.

10.

Sudjaritruk

Aurpibul

Songtaweesin

, et al. Integration of mental health services into HIV healthcare facilities among Thai adolescents and young adults living with HIV. J Int AIDS Soc. 2021;24(2):e25668.

11.

Zhou

Qiao

Cheng

, et al. Factors associated with depression among HIV/AIDS children in China. Int J Ment Health Syst. 2019;13:10.

12.

Mallinson

Rajabiun

Coleman

. The provider role in client engagement in HIV care. AIDS Patient Care STDS. 2007;21(s1):S77-S84.

13.

Dowshen

D'Angelo

Cheng

Castillo

. Adolescents living with HIV: Challenges in transition to adult care. Mt Sinai J Med. 2010;77(2):161-166.

14.

Nyongesa

Mwangi

Kinuthia

, et al. Prevalence, risk and protective indicators of common mental disorders among young people living with HIV compared to their uninfected peers from the Kenyan coast: A cross-sectional study. BMC Psychiatry. 2021;21(1):90.

15.

Dow

Turner

Shayo

Mmbaga

Cunningham

O’Donnell

. Evaluating mental health difficulties and associated outcomes among HIV-positive adolescents in Tanzania. AIDS Care. 2016;28(7):825-833. 10.1080/09540121.2016.1139043

16.

Mutumba

Bauermeister

Musiime

, et al. Psychological distress among Ugandan adolescents living with HIV: Examining stressors and the role of coping strategies. AIDS Behav. 2015;19(10):1936-1945. 10.1007/s10461-015-1099-3

17.

Kang

Delzell

Chhabra

Oberdorfer

. Factors associated with high rates of antiretroviral medication adherence among youth living with perinatal HIV in Thailand. Int J STD AIDS. 2015;26(8):534-541.

18.

von Elm

Altman

Egger

Pocock

Gøtzsche

Vandenbroucke

; STROBE Initiative. The strengthening the reporting of observational studies in epidemiology (STROBE) statement: Guidelines for reporting observational studies. Lancet. 2007;370(9596):1453-1457.

19.

Lovibond

. Manual for the Depression Anxiety Stress Scales. 2nd Ed. Psychology Foundation; 1995.

20.

Alessandri

, et al. The association of self-esteem variability with diurnal cortisol patterns in a sample of adult workers. Biol Psychol. 2023;176:108470.

21.

Wongpakaran

. A comparison of reliability and construct validity between the original and revised versions of the Rosenberg Self-Esteem Scale. Psychiatry Investig. 2012;9(1):54-58.

22.

Uthis

, et al. The Thai Internalized HIV-Related Stigma Scale. Front Psychol. 2023;14:1134648.

23.

The jamovi project. 2025. jamovi. (Version 2.7) [Computer Software]. Retrieved from https://www.jamovi.org.

24.

R Core Team. 2025. R: A language and environment for statistical computing. (Version 4.5) [Computer software]. Retrieved from https://cran.r-project.org. (R packages retrieved from CRAN snapshot 2025-05-25).

25.

Revelle

. 2025. psych: Procedures for psychological, psychometric, and personality research. [R package]. Retrieved from https://cran.r-project.org/package=psych.

26.

Peltzer

Pengpid

. Depression and anxiety among HIV-infected adolescents in Thailand: A cross-sectional study. AIDS Care. 2017;29(6):737-744.

27.

Lolekha

Kullerk

Wolfe

, et al. Depression, stigma, and virologic outcomes among adolescents with perinatally acquired HIV in northeast Thailand. J Adolesc Health. 2014;55(1):102-108.

28.

Lee

Thammawijaya

Jiraphongsa

Rotheram-Borus

. Stigma, social support, and depression among people living with HIV in China. AIDS Patient Care STDS. 2009;23(8):635-641.

29.

Kim

Mazenga

, et al. Factors associated with depression among adolescents living with HIV in Malawi. AIDS Care. 2015;27(8):1028-1032.

30.

Dow

Turner

Shayo

, et al. Evaluating mental health and adherence to antiretroviral therapy among adolescents living with HIV in Tanzania. AIDS Care. 2016;28(7):825-833.

31.

Mutumba

Bauermeister

Musiime

, et al. Psychosocial challenges and strategies for coping with HIV among adolescents in Uganda: A qualitative study. AIDS Care. 2015;27(1):86-94.

32.

Nichols

, et al. HIV-related stigma, depressive symptoms, and viral suppression among adolescents living with HIV in the United States. J Adolesc Health. 2020;67(1):122-129.

33.

Kacanek

Huo

Malee

, et al. Nonadherence and unsuppressed viral load across adolescence among US youth with perinatally acquired HIV. AIDS. 2019;33(12):1923-1934.

34.

Lee

Hazra

. Achieving 90-90-90 in paediatric HIV: Adolescence as the touchstone for transition success. J Int AIDS Soc. 2015;18(Suppl 6):20257.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.05 MB

0.03 MB

0.17 MB

0.08 MB

0.03 MB

0.00 MB