Internalized Stigma, Emotional Stress, and Depressive Symptoms Among People Living with HIV in China: Age-Stratified Mediation Analyses

Objective HIV-related stigma is a well-established risk factor for depression among people living with HIV (PLWH), yet the underlying psychological mechanisms remain insufficiently understood. This study examined the mediating role of HIV-related stress in the stigma-depressive symptoms relationship among PLWH in China and explored whether this mediated pathway differed in pattern across age groups.Method A cross-sectional survey was conducted among 387 PLWH in Jinhua City, Zhejiang Province, China. Validated instruments measured HIV-related stigma, HIV-related stress, and depressive symptoms. Mediation analyses were conducted separately for younger (ages 18–29) and older (ages 30 and above) PLWH using the PROCESS macro, adjusting for sociodemographic and clinical covariates.Results Overall, 48.32% of participants screened positive for depressive symptoms, with higher prevalence among younger PLWH ages 18–29 (61.54%) versus those ages 30 and above (44.26%; p = 0.004). Across the full sample, negative self-image (NS) was the only stigma dimension with a significant total effect on depressive symptoms (β = 0.156, 95% CI [0.074, 0.237]), partially mediated by emotional stress (β = 0.084, 95% CI [0.039, 0.128]). Age-stratified analyses revealed that, among younger PLWH, NS was associated with depressive symptoms through emotional stress, with no significant direct effect. Among older PLWH, NS retained both direct and indirect effects, while concerns about public attitudes demonstrated a mixed effect on depressive symptoms, showing as a protective factor via a suppression effect.Conclusion Our findings reveal that the stigma–stress–depressive symptoms pathway differs in pattern across age groups among PLWH, with younger individuals being disproportionately vulnerable. These patterns are interpreted as exploratory and should be formally tested in future research. Results underscore the need for age-sensitive interventions tailored to different PLWH subgroups in China.