Global prevalence and biopsychosocial correlates of psychological distress among people living with HIV: an updated theory-informed meta-analysis

INTRODUCTION: Psychological distress (PD) is common among people living with HIV (PLWH), but prevalence estimates vary substantially. This study aimed to synthesize the prevalence of PD among PLWH and examine its heterogeneity and associated factors. METHODS: Following PRISMA 2020, we systematically searched seven electronic databases from inception to June 20, 2025, for observational studies on PD prevalence and associated factors among PLWH. PD was operationalized as a binary outcome using validated self-report instruments with explicit cut-offs. The pooled prevalence was estimated using a generalized linear mixed model, and associated factors were synthesized as pooled ORs. Subgroup analyses and univariable meta-regression were performed to explore heterogeneity. Study quality was assessed, and the certainty of evidence was rated using the Grading of Recommendations Assessment, Development and Evaluation framework. RESULTS: Sixteen studies (10,204 PLWH) were included. The pooled prevalence of PD was 0.40 (95% CI: 0.28-0.53), with considerable heterogeneity (I2  = 96.25%). Sensitivity analysis yielded a broadly similar estimate. Meta-regression suggested that geographic region and PD tool category were associated with prevalence heterogeneity. Poor ART adherence (OR = 4.55, 95% CI: 1.96-10.54), non-disclosure of HIV status (OR = 4.95, 95% CI: 3.23-7.58), low CD4 count (OR = 2.59, 95% CI: 1.62-4.13), and female sex (OR = 2.26, 95% CI: 1.67-3.07) were associated with higher odds of PD, whereas being married was associated with lower odds of PD (OR = 0.35, 95% CI: 0.26-0.47). CONCLUSION: PD is a common burden among PLWH, and this review provides an updated evidence base to identify vulnerable populations, refine measurement, and inform care priorities, though findings should be interpreted cautiously due to considerable heterogeneity and low to very low certainty of evidence. SYSTEMATIC REVIEW REGISTRATION: https://www.crd.york.ac.uk/PROSPERO/view/CRD420251089847, identifier (CRD420251089847).