1. Introduction
depression, psychiatric, depressive, depressive symptoms
HIV INFECTION, OPPORTUNISTIC INFECTIONS
Heavy alcohol use is negatively affecting antiretroviral therapy adherence, mental health and health-related quality of life among people living with HIV (PLWH). This paper aims to test the mediation model examining whether changes in depression symptoms mediate in the relationship between health-related quality of life and alcohol use among male PLWH who consume alcohol in India. The study is guided by the stress-coping model, which posits that individuals facing stress may turn to maladaptive coping mechanisms such as alcohol use to alleviate their distress, which includes depression and a low health-related quality of life due to various physical, psychological, and social factors associated with the HIV infection. This study used the data from a randomized controlled clinical trial entitled ‘Alcohol and ART adherence: Assessment, Intervention, and Modeling in India’. Participants completed surveys assessing demographic characteristics, health-related quality of life, depressive symptoms, and alcohol use. Multiple simple mediation models were investigated to examine whether changes in depression symptoms mediated the association between the changes in health-related quality of life and alcohol use after a 9-month follow-up. A total of 940 male PLWH were recruited and interviewed, with 564 participants in the intervention group and 376 participants in the control group. After a 9-month intervention, the mediation results showed that, among intervention participants, a decrease in depressiove symptoms mediated the relationship between improved health-related quality of life and lower alcohol use. However, among control participants, changes in depressive symptoms did not mediate the relationship between changes in health-related quality of life and alcohol use. The study findings have practical and theoretical implications. From a practical perspective, the results suggest that interventions aimed at simultaneously improving HRQoL and depressive symptoms among male PLWH with alcohol use may help reduce alcohol consumption. Therefore, interventions that address depressive symptoms in addition to improving HRQoL may have an even greater impact on reducing alcohol use among this population. Theoretically, the study supports the use of the stress-coping theory in understanding the association between HRQoL, mental health, and alcohol use among male PLWH, contributing to existing literature on a gap in our understanding of the interactions among these factors among PLWH. Human immunodeficiency virus (HIV) continues to remain a global public health concern despite significant advances in HIV prevention and treatment. With increasing access to effective HIV prevention, diagnosis, treatment and care, including for opportunistic infections, HIV has become a manageable chronic health condition, enabling people living with HIV (PLWH) to lead long and healthy lives [Quality of life refers to an individual’s subjective evaluation of their position in relation to their cultural and value systems, reference group, aspirations, expectations, standards, and concerns [Likewise, one of the most prevalent psychiatric conditions among PLWH is depression symptoms, with rates ranging from 9% to 78%, particularly in low-and middle-income countries [The association between alcohol use and HRQL has been also found not only in studies among PLWH, but also general populations [It is estimated that there were 2.4 million PLWH in 2021 in India, making India the country with the third-highest number of PLWH in the world [Our study is based on the stress-coping model framework [Based on the stress-coping theory, we propose that male PLWH may experience a decline in their HRQoL due to various physical, psychological, and social factors associated with the HIV infection. This decline in HRQL can lead to increased stress and negative emotions, including depression. As a result, some people with HIV may engage in maladaptive coping strategies, such as increased alcohol use, to manage these challenges. While informative, previous studies have mainly investigated the independent direct effects of HRQL, depression symptoms, and alcohol use on each other. However, there is still a gap in understanding how depression symptoms mediate the relationship between HRQoL and alcohol use in alcohol-consuming men living with HIV (PLWH) in low-resource settings such as India and other low- and middle-income countries. It is crucial to gain a better understanding of the extent of the indirect effect (i.e., mediation effect) to develop and implement targeted interventions. The purpose of this study was to assess the mediating role of depression symptoms in the relationship between HRQoL and alcohol use among male PLWH in India who consume alcohol. We tested the following hypotheses: improved HRQoL would be associated with reduced alcohol consumption; improvement in depression symptoms would be associated with reduced alcohol consumption; and improving HRQoL would lead to a decrease in depression symptoms, ultimately reducing alcohol consumption. The hypothesis was tested separately in both control and intervention groups. By comparing the outcomes between the two groups, we can assess the impact of the intervention on the relationship between HRQoL, depression symptoms, and alcohol use among male PLWH in India. Comparing results with a control group helps us draw stronger conclusions about the intervention’s effectiveness and control for other influencing factors.