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European Journal of Psychotraumatology logoLink to European Journal of Psychotraumatology
. 2026 Jan 19;17(1):2602298. doi: 10.1080/20008066.2025.2602298

The efficacy and mechanism of an integrated mindfulness-based programme on posttraumatic stress disorder among people with HIV: a randomized controlled trial with 3-month follow up

La eficacia y el mecanismo de un programa integrado basado en mindfulness en el trastorno de estrés postraumático en personas con VIH: ensayo clínico controlado y aleatorizado con seguimiento a 3 meses

Chulei Tang a, Ting Zhao b, Simin Yu c, Yanfei Jin a, Honghong Wang b,CONTACT
PMCID: PMC12818290  PMID: 41552987

ABSTRACT

Background: Posttraumatic stress disorder (PTSD) is highly prevalent among people with HIV (PWH) and is associated with poor psychological functioning and reduced adherence to antiretroviral therapy (ART), threatening treatment outcomes. Although the Community Resiliency Model (CRM) and mindfulness-based stress reduction (MBSR) have separately demonstrated efficacy for PTSD, no intervention integrating these approaches has been specifically developed for PWH.

Objective: This study aimed to evaluate the efficacy and mechanisms of an Integrated Mindfulness-Based Programme (IMBP), combining CRM and MBSR, in reducing PTSD symptoms and enhancing ART adherence among PWH.

Methods: Eighty-two PWH with PTSD were assigned to either the IMBP intervention group or the control group. PTSD symptoms and ART adherence were assessed at baseline, post-intervention, and 3-month follow-up. Mindfulness, rumination, and resilience were evaluated as potential mediators. Data were analyzed using generalized estimating equations (GEE) and mediation modelling.

Results: Compared with the control group, participants receiving IMBP demonstrated significantly greater reductions in PTSD symptoms and improvements in ART adherence, both immediately post-intervention and at 3-month follow-up (all p < .01). Mediation analysis revealed that increased mindfulness, enhanced resilience, and decreased rumination partially mediated the effect of the intervention on PTSD symptoms.

Conclusion: The IMBP intervention was effective in reducing PTSD symptoms as well as improving ART adherence in PWH. The mediating roles of mindfulness, resilience, and rumination suggest plausible mechanisms through which the intervention operates. These findings support the clinical utility of IMBP as a low-resource intervention for addressing the dual challenges of trauma and treatment adherence in vulnerable HIV-positive populations.

KEYWORDS: Posttraumatic stress disorder, HIV/AIDS, randomized controlled trial, mindfulness-based stress reduction, community resiliency model

HIGHLIGHTS

  • The Integrated Mindfulness-Based Programme (IMBP) significantly reduced posttraumatic stress disorder (PTSD) symptoms and improved antiretroviral therapy adherence among people with HIV (PWH).

  • Increases in mindfulness and resilience, together with reductions in rumination, mediated the intervention’s effects on PTSD symptoms.

  • These findings support IMBP as a promising, low-resource intervention to address both trauma and treatment adherence in PWH.

1. Introduction

According to data from the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS), an estimated 39.9 million people worldwide were living with HIV as of 2023 (Lu et al., 2025). With the advent and widespread application of antiretroviral therapy (ART), HIV infection has transitioned from an acute and fatal disease to a manageable chronic condition. Nevertheless, the diagnosis of HIV remains a profoundly traumatic experience. Posttraumatic stress disorder (PTSD) is a severe mental health condition that can develop after exposure to traumatic events, profoundly affecting various aspects of life (American Psychiatric Association, 2013). Among people with HIV (PWH), the prevalence of PTSD (∼28%) (Tang et al., 2020) is significantly higher compared to the general population (∼3.9%) (WHO, 2024). This elevated prevalence is multifactorial. Beyond the initial trauma of diagnosis, PWH often experience ongoing stressors such as HIV-related stigma, social rejection, discrimination, and internalized shame, which may perpetuate trauma-related symptoms (Omann et al., 2024; Parcesepe et al., 2023). Biological mechanisms, including chronic immune activation and neuroinflammation associated with HIV infection, have also been implicated in increased vulnerability to PTSD (Fatokun et al., 2025; Neigh et al., 2016). Furthermore, structural inequities such as poverty, limited healthcare access, and exposure to violence, may compound psychological distress among PWH, especially in resource-limited settings (Brown et al., 2025). PTSD in PWH is associated with numerous negative outcomes, including suboptimal adherence to ART, elevated viral loads, accelerated disease progression, and poorer treatment outcomes (Cuca et al., 2019; Hou et al., 2020).

Addressing PTSD in this population has become an urgent public health priority. Traditional treatments for PTSD, including cognitive–behavioral therapy (CBT) and prolonged exposure therapy, have shown effectiveness in managing symptoms (López et al., 2025; Pacella et al., 2012). However, access to these treatments may be limited due to factors like cost, availability of trained professionals, and the reluctance of some individuals to engage in conventional mental health interventions with long treatment cycles. Emerging evidence suggests that cognitive restructuring alone yields limited efficacy in the treatment of PTSD (Roberts et al., 2022). Furthermore, repeated exposure to trauma-related content, particularly in the absence of adequate emotional regulation strategies, may heighten psychological distress and contribute to neurophysiological dysregulation, thereby potentially exacerbating PTSD symptoms (Felmingham et al., 2013; Theodoratou et al., 2023). More importantly, unlike other traumas, HIV infection entails persistent psychological and physical stress for patients. Additionally, stigma and discrimination may hinder access to essential medical services. Therefore, it is essential to develop innovative interventions that are cost-effective, easily scalable, specifically tailored to address PTSD among PWH.

The Community Resiliency Model (CRM) and Mindfulness-Based Stress Reduction (MBSR) have emerged as promising interventions for PTSD treatment in PWH. Rooted in mindfulness, CRM (Miller-Karas, 2015) emphasizes the body's natural ability to recover from trauma by teaching simple, body-based skills to restore balance to the nervous system. This model is particularly suited for diverse populations characterized by disparities in health literacy and differential access to healthcare infrastructure (Freeman et al., 2022). CRM can be implemented by non-professionals and has been successfully applied across various countries and populations, demonstrating promising outcomes in PTSD treatment (Duva et al., 2022; Habimana et al., 2021).

As an emerging effective treatment for PTSD, MBSR fosters non-judgmental, focused awareness, effectively reducing maladaptive cognitive patterns and enhancing emotional regulation (Grossman et al., 2004; Liu et al., 2022). Among PWH, a systematic review and meta-analysis (Gan et al., 2017) demonstrated that MBSR can effectively alleviate psychological stress and anxiety in PWH, while also contributing to improvements in CD4 T lymphocyte (CD4) counts and overall physical functioning. Sibinga et al. (2022) reported that adolescents and young adults living with HIV who participated in MBSR demonstrated a greater improvement in ART adherence compared to those receiving general health education. However, no prior studies have specifically integrated these two complementary approaches for PTSD among PWH.

To summarize, this study innovatively proposes an Integrated Mindfulness-Based Program (IMBP), which uniquely combines CRM’s somatic recovery skills with MBSR’s mindfulness techniques. The IMBP aims to provide an effective, low-resource, and easily scalable intervention to reduce PTSD symptoms among PWH. Moreover, the mechanisms through which IMBP exerts its effects remain insufficiently understood. Investigating mediators that account for the effects of IMBP, which provide a test of the theoretical mechanisms that account for treatment outcomes, can identify its most effective components and potentially guide subsequent refinements.

The current study focused on mindfulness, resilience, and rumination. Individuals with PTSD frequently harbour distorted appraisals of their traumatic experiences (Stein et al., 2024). Resilience and rumination play pivotal roles in reshaping these cognitions: enhanced resilience fosters adaptive coping (She et al., 2025), whereas persistent rumination sustains distress (Brown et al., 2021). Mindfulness training cultivates non-judgmental, open, and purposeful awareness that can disrupt maladaptive thought patterns (Maltais et al., 2019). Although emerging evidence indicates that mindfulness-based interventions attenuate rumination and bolster resilience by fostering mindfulness (O’Connor et al., 2023; Webb et al., 2021), it is unclear whether IMBP elicits similar changes among PWH or whether such changes mediate IMBP’s impact on PTSD symptoms.

Therefore, the first aim of the proposed study was to investigate the effect of IMBP on primary outcomes of PTSD symptoms and secondary outcomes of ART adherence among PWH at post-intervention and 3-month follow-up. To better understand the mechanisms through which the intervention influences PTSD symptoms, the second objective was to examine whether changes in mindfulness, rumination and resilience mediate the intervention's effects on PTSD symptoms.

2. Methods

2.1. Study design

This study employed a randomized controlled trial (RCT) design, conducted in Changsha, China, from July 2020 to January 2021. A parallel-group design was employed, with participants randomly allocated to either the intervention or control group. The intervention spanned 8 weeks, with assessments conducted at baseline, post-intervention (week 8), and at a 3-month follow-up to evaluate sustained effects. This study adheres to the Consolidated Standards of Reporting Trials (CONSORT) 2025 guidelines and was registered with the Clinical Trials Registry (registration number: NCT05588596).

2.2. Participants and setting

Participants were recruited from HIV clinics and wards of the First Hospital of Changsha, which serves as the primary HIV treatment centre in Changsha, the capital city of Hunan Province, China. This hospital services over 8,000 individuals living with HIV/AIDS across various regions of the province. The study targets PWH who met the inclusion criteria of being 18 years or older, having a confirmed HIV diagnosis, with positive PTSD symptoms screened by the PTSD Checklist-Civilian Version (Wilkins et al., 2011), and currently receiving ART. Exclusion criteria included severe psychiatric conditions requiring immediate intervention, current enrolment in another psychosocial programme, and inability to provide informed consent. Additionally, individuals currently using psychotropic medication were excluded to avoid potential confounding effects on the intervention outcomes.

2.3. Sample size

The sample size was determined based on a randomized controlled trial design (Spence et al., 2011) evaluating the effects of a network-based cognitive intervention on PTSD symptoms using similar scales. With a 90% power, 5% margin of error and effect size (d) of 10.79, the minimum required sample size was calculated to be 31 participants. Considering an average attrition rate of 27% commonly observed in mindfulness-based self-help interventions (Cavanagh et al., 2014), a conservative dropout rate of 30% was applied to ensure adequate power. Accordingly, a total of 82 participants (41 in the intervention group and 41 in the control group) was deemed sufficient.

2.4. Recruitment, randomization, and blinding

Participants were recruited through clinic referrals and informational flyers distributed at HIV clinics and wards. Two research investigators (ZT and YS) who have received standardized training screened and recruited research subjects. Research purpose, significance, and content of the project were explained to the research subjects in advance. Participants were assured of confidentiality, and their right to withdraw from the study at any time without penalty was emphasized. Signed informed consent forms were obtained if they were fully informed and voluntary. Each participant received a compensation of RMB 50 (approximately USD 6.91) following each assessment. The study protocol was reviewed and approved by an institutional review board (the Institutional Review Board of Xiangya Nursing School, Central South University, No.2018040).

An independent postgraduate student, uninvolved in both intervention and data collection, generated a sequence of 82 random numbers using SPSS 22.0. Odd numbers were pre-assigned to the intervention arm and even numbers to the control arm. Each number was placed in an opaque, sealed envelope labelled sequentially from 1 to 82 to ensure allocation concealment. These envelopes were opened in sequence after baseline assessments, only once participants’ identifying information was documented.

Given the nature of the behavioural intervention and ethical constraints, it was impractical to blind the intervention providers and participants. Consequently, the study utilized a single-blind approach, where only the assessors evaluating outcomes remained unaware of group assignments.

2.5. Measures

2.5.1. Demographic and clinical information questionnaire

Demographic information of the patients was gathered at baseline using a self-developed questionnaire. This data encompassed age, gender, marital status, educational level, religion, monthly income, and living conditions. Clinical data, including time since diagnosis, medical insurance status, route of infection, and CD4 cell counts, were collected by reviewing medical records and conducting patient interviews.

2.5.2. PTSD symptoms

The PTSD Checklist-Civilian Version (PCL-C) was developed by Weathers et al. (1993) and is among the most widely used tools for evaluating PTSD. In this study, the Chinese version of PCL-C was employed. To ensure contextual relevance, the instructions were adapted to specify that all items referred to participants’ problems in response to their HIV diagnosis and related stressors. Several items were linguistically modified to reflect HIV-specific distress (e.g. ‘Repeated, disturbing dreams of a stressful experience from the past?’ was revised to ‘Repeated, disturbing dreams about your HIV diagnosis’). This 17-item self-report scale has been previously validated in Chinese PWH. Each item is rated on a 5-point Likert scale ranging from 1 (‘not at all’) to 5 (‘extremely’), reflecting the respondent’s level of distress related to each symptom over the past month. The total score represents the severity of PTSD symptoms. According to DSM criteria for PTSD, a symptom is considered present if the corresponding item score is ≥3. The PCL-C assesses three symptom clusters: B (re-experiencing, 5 items), C (avoidance, 7 items), and D (hyperarousal, 5 items). A positive PTSD symptom diagnosis requires at least one re-experiencing symptom, three avoidance symptoms, and two hyperarousal symptoms meeting the threshold. In this study, the total scale showed a Cronbach’s α of 0.937, with subscales ranging from 0.843 to 0.883.

2.5.3. ART adherence

A self-reported visual analogue scale (Wang et al., 2008) with score ranging from 0 (0%) to 10 (100%) was used to assess patients’ adherence to taking antiretroviral drugs as prescribed – both in timing and dosage – over the past 7 days, based on their doctor's instructions. Participants were instructed to select only integer values (0–10), and higher scores indicate better adherence to antiretroviral treatment.

2.5.4. Mindfulness

The Short Inventory of Mindfulness (SIM-C), developed by Duan and Li (2016) was used to assess patients’ mindfulness levels over the past week. The scale consists of 12 items, each rated on a 5-point Likert scale from 1 (‘never’) to 5 (‘always’), yielding a total score ranging from 12 to 60. Higher scores indicate greater overall mindfulness awareness. In this study, the total scale showed a Cronbach’s α of 0.912.

2.5.5. Resilience

The Connor-Davidson Resilience Scale (CD-RISC), developed by Connor and Davidson (2003). It consists of 25 items across three dimensions: optimism, strength, and tenacity. Each item is rated on a 5-point Likert scale from 0 (‘never’) to 4 (‘always’), with higher scores indicating greater resilience. In this study, the CD-RISC demonstrated a total Cronbach’s α of 0.954, with subscale values ranging from 0.712 to 0.937.

2.5.6. Rumination

Rumination was assessed with the 22–item Ruminative Responses Scale (RRS) (Nolen-Hoeksema & Morrow, 1991). Each item is rated on a 4–point scale from 1 (never) to 4 (almost every day), producing total scores between 22 and 88; higher scores indicate more severe rumination. In the present sample, the RRS exhibited excellent internal consistency (Cronbach’s α  =  0.956).

2.5.7. Implementation outcome measures

The Acceptability of Intervention Measure (AIM), Intervention Appropriateness Measure (IAM), and Feasibility of Intervention Measure (FIM), developed by Weiner (Weiner et al., 2017), were administered following the intervention. These measures comprise a total of 12 items, each rated on a 5-point Likert scale ranging from ‘1’ (completely disagree) to ‘5’ (completely agree). Higher average scores on each dimension indicate greater participant perceptions of the intervention’s acceptability, appropriateness, and feasibility.

2.6. Creation of intervention

The intervention was developed by the researcher based on literature review (Grossman et al., 2004; Kabat-Zinn et al., 1992; Miller-Karas, 2015), preliminary surveys and expert consultation. The design of IMBP drew upon CRM and MBSR, both of which emphasize body awareness, stress regulation, and mindful attention to present experiences. The researcher had formal training in MBSR and prior experience in implementing mindfulness-based programmes. The research team also included mindfulness therapists, licensed counsellors, and mental health experts who provided professional input during the development and refinement of the intervention.

The one-to-one intervention comprises eight sessions, held once weekly, with each session lasting about 45 to 60 minutes. Each session is structured around specific objectives and thematic focuses related to stress reduction and psychological well-being. It integrates mindfulness practices, psychoeducation, and discussions, emphasizing both the instruction and practical application of mindfulness-based techniques (Table S1 in Supplement). No HIV-specific psychoeducational content was included to minimize the risk of reinforcing internalized stigma among participants. Instead, examples and discussions during sessions were framed around general chronic illness management and everyday stress-related scenarios, enabling participants to relate to the material while maintaining emotional safety. HIV-related experiences were discussed only when participants voluntarily raised them and expressed readiness to explore such topics within a supportive environment. Session topics are structured sequentially as follows:

  • Session 1: Introduction, explanation of the programme's operational plan, defining resilient zone, stress, trauma and its causes. Tracking and Mindful Diet.

  • Session 2: Emotions and Perceptions. Body scan and Grounding.

  • Session 3: Mindful Yoga and Mindful Walking.

  • Session 4: Mindful Breathing, Gesturing & Spontaneous Movement.

  • Session 5: Resourcing and Metta Meditation.

  • Session 6: Amp Down/Ramp Up and Sitting Meditation.

  • Session 7: Shift and Stay.

  • Session 8: Conclusion of the Program, Farewell and a New Beginning.

Prior to initiating the main study, a pilot study was carried out from May to July 2020 involving six PWH who met the inclusion criteria. This pilot study aimed to evaluate the feasibility and acceptability of the intervention. Based on the findings, further modifications to the content, structure, and flow of the programme were implemented to enhance participant engagement and optimize intervention delivery. For instance, the first session was designed as a face-to-face intervention to establish a trusting relationship, while the subsequent seven sessions were primarily delivered in a face-to-face format, with full consideration of patients’ actual situations and individual preference. Weekly home practice assignments were kept brief to facilitate sustained and internalized engagement, with greater emphasis placed on specific application examples and participants sharing their experiences. Detailed pilot results are provided in the supplementary material (Table S2).

Both groups completed the demographic and clinical information questionnaire once, and the scales on three occasions: initially as a pre-test prior to the programme (T0), then as a post-test upon its completion (T1), and again at a 3-month follow-up (T2).

2.7. Intervention group

Patients in the intervention group received the intervention in addition to standard medical care. Intervention materials and guided audio recordings were distributed weekly by the intervener (TC). The programne consisted of 2 modules: Module 1 (session 1-6) focused on specific trauma recovery mindfulness skills, while Module 2 (session 7-8) emphasized integrated practice and real-life application to foster mindfulness in patients’ daily routines. Each session was accompanied by 2–3 audio recordings to support self-guided exercises. The sessions were provided by a certified instructor in MBSR and supervised by a psychologist. Throughout the intervention period, participants were expected to engage in mindfulness practice at least 5 days per week, completing the home exercises assigned in each module. To promote continuity of practice throughout the week and facilitate the internalization of the training, home assignments for the upcoming session were provided to participants at the end of each session. Participants’ adherence to the intervention was monitored through weekly self-reports and regular check-ins with the facilitator. During the intervention, the facilitator was responsible for addressing patients’ questions related to self-guided exercises, providing regular practice reminders, and offering ongoing support and encouragement.

2.8. Control group

The control group received standard care, which included regular medical follow-ups, free counselling, ART adherence support, and access to psychological services as needed. This group did not participate in the mindfulness-based sessions but underwent the same assessment schedule as the intervention group. Upon completion of the study, the participants were offered the full programme, together with all accompanying audio recordings and support materials.

2.9. Data analysis strategy

Statistical analysis was conducted using SPSS version 25.0 (IBM, New York, USA), adhering to the intention-to-treat principle. Descriptive data were presented as means and standard deviations for continuous variables, and as frequencies and percentages for categorical variables. Normality was assessed using the Shapiro–Wilk test. Baseline comparisons between the two groups were made using independent t-tests for normally distributed continuous variables, Mann–Whitney U tests for non-normal distributions, and chi-square tests for categorical data. Generalized Estimating Equations (GEE) were used to assess changes in PTSD symptoms, ART adherence mindfulness, rumination and resilience over time between the intervention and control groups. Baseline characteristics, including demographic and clinical information, were included as covariates to adjust for potential confounding variables. Effect size is an important indicator for evaluating intervention effectiveness. In this study, η² and r were used for its calculation. Structural equation modelling was conducted in AMOS 22.0 with full-information maximum-likelihood estimation. Mediation effects were evaluated via MacKinnon’s PRODCLIN2 procedure, using 5,000 bootstrap resamples to generate bias-corrected 95 % confidence intervals.

3. Results

3.1. Participant enrolment and dropouts

Of the 748 individuals screened, 82 met the inclusion criteria, provided informed consent, and were randomized, forming the intention-to-treat sample. By the post-intervention assessment, 73 participants completed all outcome measures; attrition involved 3 participants from the intervention arm and 6 from the control arm. Baseline demographic and clinical characteristics did not differ significantly between completers and those lost to follow-up (all p > .05). The participant enrolment and dropouts are summarized in Figure 1.

Figure 1.

Figure 1.

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CONSORT (Consolidated Standards of Reporting Trials) flowchart of the study.

Note: T1: post intervention; T2: 3-month post intervention.

3.2. Baseline characteristics

Participants had a mean age of 30.46 ± 9.74 years (range 18–60) and were predominantly male (86.6 %). In addition, 67.1 % had completed college or higher education. Baseline demographic and clinical characteristics did not differ significantly between the intervention and control groups (all p > .05) (Table 1).

Table 1.

Demographic and clinical characteristics of participants in the intervention and control groups (N = 82).

Characteristics   Control group n(%) Intervention group n(%) t/Z/χ2 p value
Gender Male 35(85.4) 36(87.8) 0.105 .746
  Female 6(14.6) 5(12.2)    
Residence City 32(78.0) 34(82.9) 0.311 .577
  Countryside 9(22.0) 7(17.1)    
Religion No 33(80.5) 36(87.8) 0.823 .364
  Yes 8(19.5) 5(12.2)    
Education level Middle school or below 15(36.6) 12(29.3) 1.402 .496
  College 15(36.6) 13(31.7)    
  Bachelor or above 11(26.8) 16(39.0)    
Marital status Single 26(63.4) 30(73.2) 1.055 .590
  Married 8(19.5) 5(12.2)    
  Divorced/widowed/separated 7(17.1) 6(14.6)    
Living status Alone 10(24.4) 10(24.4) 0.067 .967
  With family 18(43.9) 19(46.3)    
  With someone 13(31.7) 12(29.3)    
Personal monthly income(Yuan a) ≤3000 20(48.8) 14(34.1) 1.883 .390
3000–7000 14(34.1) 19(46.3)    
>7000 7(17.1) 8(19.5)    
Duration of HIV diagnosis 1–12 month 14(34.1) 20(51.3) −1.389 .165
13–36 month 13(31.7) 9(23.1)    
  >36 month 14(34.1) 10(25.6)    
Sexual orientation Homosexual 28(68.3) 27(65.9) 0.055 .814
Heterosexual 13(31.7) 14(34.1)    
ART adherence Median(IQR) 9(7, 9) 8(8, 9) −0.074 .941
CD4+T (cells/μL) <200 8(19.5) 12(29.3) −1.235 .217
200–350 6(14.6) 9(22.0)    
  350–500 15(36.6) 10(24.4)    
  ≥500 12(29.3) 10(24.4)    
Medical insurance Yes 21(51.2) 28(68.3) 2.485 .115
No 20(48.8) 13(31.7)    
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Note: a1 Yuan = US $0.14.

3.3. Effect on outcomes

Following the intervention, participants rated the acceptability, appropriateness, and feasibility of the intervention as 4.32 ± 0.38, 4.30 ± 0.47, and 4.36 ± 0.47, respectively. Participants in the intervention group practiced IMBP for a median of 20 (15, 30) minutes per day, across an average of 39.68 ± 9.67 days, corresponding to an adherence rate of 55.3%. GEE analyses demonstrated a significant association between practice days and reductions in PTSD symptoms (p = .001), indicating that higher engagement in home practice significantly enhanced treatment outcomes (Table S3 in Supplement).

The results demonstrated significant time × group interactions for PTSD symptoms and ART adherence (p < .01), indicating differing trajectories across these measures between the two groups over the three assessment points. The detailed results of GEE analyses based on the intention-to-treat sample are presented in Table 2. To further clarify the temporal effects, pairwise comparisons of estimated marginal means were conducted, as shown in Table 3.

Table 2.

Model effect estimation using generalized estimated equations based on the intention-to-treat sample.

Outcome Wald Chi-Square Test Degrees of Freedom p value
PTSD symptom      
 Group 30.094 1 <.001
 Time 111.330 2 <.001
 Time × group 62.887 2 <.001
ART adherence      
 Group 8.500 1 .004
 Time 1.482 2 .477
 Time × group 10.111 2 .006
Resilience      
 Group 3.110 1 .078
 Time 80.602 2 <.001
 Time × group 56.440 2 <.001
Rumination      
 Group 27.336 1 <.001
 Time 165.884 2 <.001
 Time × group 96.122 2 <.001
Mindfulness      
 Group 11.311 1 .001
 Time 92.839 2 <.001
 Time × group 61.791 2 <.001
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Table 3.

Descriptive statistics of outcomes and marginal mean differences estimated using generalized estimated equations.

Variablesa Time Control
mean(SD)		 Intervention
mean(SD)		 Within-
group Δ
(d) 		p
(within)		 Between- group Δ
(d) 		p
(between)		 ES(η2)
PTSD symptom T0 52.07(13.06) 50.00(10.81) — — −2.07 .428 —
T1 49.49(14.76) 30.47(7.98) −2.41/−19.79 .115/<.001 −19.46 <.001 0.403
  T2 48.59(14.52) 30.74(8.25) −4.40/−19.49 .020/<.001 −17.17 <.001 0.380
ART adherence T0 9(7, 9) b 8(8, 9) b — — −0.23c .818 —
T1 8(7, 9) b 9(8, 9) b −0.98 c /−3.58 c .325/<.001 −2.71 c .007 0.318d
  T2 8(6.25, 9) b 9(9, 9) b −0.98 c /−3.50 c .327/<.001 −3.01 c .003 0.360 d
Resilience T0 47.34(16.18) 42.90(13.14) — — −4.44 .167 —
  T1 49.89(18.84) 58.79(12.79) 1.52/15.97 .210/<.001 10.01 .004 0.074
  T2 50.00(18.58) 59.11(11.55) 1.22/16.27 .558/<.001 10.60 .003 0.084
Rumination T0 59.44 (11.99) 58.17 (8.66) — — −1.27 .578 —
  T1 58.69 (15.01) 40.13 (8.50) −1.30/−17.98 .274/<.001 −17.95 <.001 0.378
  T2 54.75 (11.85) 39.71 (9.62) −5.62/−18.43 .002/<.001 −14.07 <.001 0.336
Mindfulness T0 2.71(0.44) 2.43(0.40) — — −0.28 .002 —
  T1 2.79(0.53) 3.34(0.52) 0.07/0.91 .300/<.001 0.56 <.001 0.218
  T2 2.83(0.57) 3.46(0.50) 0.12/1.04 .152/<.001 0.64 <.001 0.268
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Note: a T0: baseline, T1: post intervention, T2: 3-month follow-up. b Median (IQR). c Z score. d ES(r)

Baseline PTSD symptoms and ART adherence scores did not differ significantly between groups (both p > .05). From baseline to post-intervention, PTSD symptom scores decreased (d = −19.79, ES(η2) = 0.517, p < .001) and ART adherence improved (z = −3.578, ES (r) = 0.410, p < .001) in the intervention group but not in the control group (d = −2.41, p = .115; z = −0.983, p  = .325). From baseline to follow-up, decreases in PTSD symptoms and increased ART adherence persisted. Between-group analyses revealed that PTSD symptom scores were significantly lower in the intervention group compared to the control group, with mean differences of −19.46 points at T1 (ES(η2) = 0.403, p < .001) and −17.17 points at T2 (ES(η2) = 0.380, p < .001). Additionally, ART adherence was significantly higher in the intervention group than the control group at both T1 (z = −2.714, ES (r) = 0.318, p  = .007) and T2 (z = −3.011, ES (r) = 0.360, p  = .003).

3.4. Effects on mediators

A GEE model was also employed to examine the intervention's impact on resilience, rumination and mindfulness. The analysis revealed significant time × group interaction effects (p < .001). As illustrated in Table 3, the intervention group exhibited significantly improved resilience and reduced rumination compared to the control group at T1 (d = 10.01, ES(η2) = 0.074, p  = .004; d = −17.95, ES(η2) = 0.378, p < .001) and T2 (d = 10.60, ES(η2) = 0.084, p  = .003; d =  −14.07, ES(η2) = 0.336, p < .001). Regarding mindfulness, baseline scores in the intervention group were initially lower than in the control group (d = −0.28, ES(η2) = 0.102, p = .002). However, mindfulness scores subsequently increased significantly in the intervention group, surpassing those of the control group at T1 (d = 0.56, ES(η2) = 0.218, p < .001) and T2 (d = 0.64, ES(η2) = 0.268, p < .001).

3.5. Mediation analyses

In alignment with the hypotheses of this research, a structural equation model was developed, as illustrated in Figure 2. The model demonstrated robust fit indices: Chi-square/df = 1.410, Tucker-Lewis Index (TLI) = 0.957, Incremental Fit Index (IFI) = 0.972, Normed Fit Index (NFI) = 0.911, Comparative Fit Index (CFI) = 0.971, and Root Mean Square Error of Approximation (RMSEA) = 0.077, collectively indicating excellent model fit.

Figure 2.

Figure 2.

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The mediation effects of resilience, rumination and mindfulness on the relationship between treatment assignment and PTSD symptoms from baseline to the end of the intervention.

Note: n.s.: statistically not significant. T0: baseline; T1: post intervention; T2: 3-month post intervention.

As detailed in Table 4, bootstrapping procedures and MacKinnon’s PRODCLIN2 method revealed that the 95% confidence intervals for all indirect effects excluded zero. These findings underscore that resilience and rumination partially mediate the efficacy of the intervention in alleviating PTSD symptoms among PWH. Additionally, mindfulness was found to indirectly reduce PTSD symptoms by influencing resilience and rumination.

Table 4.

The mediating effects of psychological resilience, rumination, and mindfulness.

  Estimate SE Bootstrapping 95%CI Mackinnon’s PRODCLIN2 95% CI
Total Effect −18.60 1.91 (−22.323, −14.810) —
Direct Effect
PTSD symptom		        
T0 → T1 PTSD −20.34 2.94 (−25.833, −14.198) —
T1 PTSD → T2 PTSD 0.83 0.06 (0.725, 0.941) —
Indirect Effect        
Resilience        
T0 → T1 C → T2 C 6.00 2.97 (0.286, 12.228) (0.589, 12.348)
T1 C → T2 C → T2 PTSD −0.38 0.09 (−0.560, −0.199) (−0.589, −0.213)
Rumination        
T0 → T1 R → T2 R −12.21 2.34 (−17.308, −8.030) (−18.192, −7.297)
T1 R → T2 R → T2 PTSD 0.51 0.10 (0.324, 0.702) (0.325, 0.736)
Mindfulness        
T0 → T1 M → T1 PTSD −7.59 1.85 (−11.889, −4.494) (−13.504, −3.220)
T1 M → T1 PTSD→ T2 PTSD −0.96 0.16 (−1.277, −0.658) (−1.358, −0.609)
Resilience        
T0 → T1 M → T1 C 8.25 2.38 (4.341, 13.663) (3.669, 14.183)
T1 M → T1 C → T2 C 0.92 0.21 (0.540, 1.387) (0.519, 1.412)
T1 C → T2 C → T2 PTSD −0.38 0.09 (−0.560, −0.199) (−0.589, −0.213)
Resilience        
T0 → T1 M → T2 M 4.86 1.13 (2.955, 7.492) (2.304, 8.051)
T1 M → T2 M → T2 C 0.82 0.29 (0.415, 1.330) (0.437, 1.292)
T2 M → T2 C → T2 PTSD −0.58 0.20 (−0.984, −0.199) (−1.023, −0.252)
Rumination        
T0 → T1 M → T1 R −9.45 2.59 (−14.823, −4.830) (−16.430, −4.165)
T1 M → T1 R→ T2 R −0.90 0.17 (−1.223, −0.588) (−1.339, −0.548)
T1 R → T2 R → T2 PTSD 0.51 0.10 (0.324, 0.702) (0.325, 0.736)
Rumination        
T0 → T1 M → T2 M 4.86 1.13 (2.955, 7.492) (2.304, 8.051)
T1 M → T2 M → T2 R −0.88 0.12 (−1.125, −0.656) (−1.303, −0.537)
T2 M → T2 R → T2 PTSD −0.97 0.15 (−1.259, −0.674) (−1.436, −0.588)
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Note: C: Resilience, R: Rumination, M: Mindfulness. T0: baseline; T1: post intervention; T2: 3-month post intervention.

4. Discussion

To our knowledge, this study is the first to examine the efficacy of combining CRM and MBSR interventions for reducing PTSD symptoms among PWH. The present findings suggest that PWH in the intervention group reported not only significantly reduced PTSD symptoms but also enhanced ART adherence compared to those in the control group. Post-intervention and 3-month follow-up assessments confirmed that the improvements in PTSD symptoms and ART adherence observed in the intervention group were maintained over the 3-month post-intervention period.

The therapeutic efficacy of the intervention for PTSD is consistent with previous evidence. For instance, Berst’s (2016) application of CRM effectively alleviated PTSD symptoms in burn patients. Additionally, a systematic review of mindfulness-based interventions for PTSD (Xu et al., 2019) demonstrated that mindfulness practices yield significant therapeutic benefits across diverse PTSD-affected populations. The sustained reduction in PTSD symptoms observed in this study not only reinforces the value of IMBP in PWH populations, but also highlights the feasibility of achieving these effects through this non-pharmacological and scalable approach. Notably, the IMBP developed in this study does not require professional psychotherapy guidance, making it a practical and accessible self-help tool. Its ease of implementation enhances the potential for clinical scalability and broader dissemination among PWH. Clinically, this holds particular relevance given the high prevalence of trauma histories in PWH and the associated risk for chronic psychological distress, which often remains underdiagnosed and undertreated.

In parallel, the observed improvement in ART adherence supports findings from prior research that emphasize the role of emotional regulation and cognitive clarity in promoting consistent health behaviours. Wen et al. (2020) demonstrated that resilience is positively associated with ART adherence in PWH. Similarly, Tull et al. (2018) found that a brief behavioural activation therapy effectively reduced rumination in PWH, subsequently improving ART adherence. Given that suboptimal ART adherence is a major barrier to viral suppression and long-term prognosis, these findings underscore the potential of IMBP to yield measurable gains in physical health outcomes.

Although the clinical benefits of interventions targeting mindfulness, resilience, and rumination have been well documented, the underlying mechanisms through which these factors exert their influence on PTSD symptoms remain an area of ongoing investigation. The present study advances this field by providing empirical evidence for a multi-mediator model in which mindfulness, resilience, and rumination jointly contribute to symptom reduction. Specifically, the intervention appeared to strengthen participants’ capacity for adaptive self-regulation by enhancing present-focused awareness, bolstering psychological flexibility, and diminishing maladaptive cognitive perseveration.

Mediation analysis revealed that mindfulness, resilience, and rumination served as significant mediators in the pathway from intervention to PTSD symptom improvement among PWH. These findings suggest a synergistic mechanism wherein mindfulness facilitates a shift in attentional focus and emotional reactivity (Åsli et al., 2021; Buric et al., 2024), thereby enhancing resilience and mitigating the frequency and intensity of ruminative thought patterns. Increased resilience, in turn, may buffer the psychological impact of trauma by fostering a sense of control, meaning-making, and goal-directed coping (Krok et al., 2023). Meanwhile, the attenuation of rumination may interrupt the maintenance of PTSD symptoms by reducing cognitive intrusions and negative affective spirals (Brown et al., 2021). Collectively, these processes form a coherent psychocognitive framework that accounts for both immediate and sustained therapeutic effects.

Furthermore, these psychological changes are likely supported by neurobiological adaptations, particularly in brain regions implicated in emotion regulation and stress response. Existing neuroimaging studies (Bremner et al., 2017; Noda et al., 2023) have demonstrated that mindfulness-based practices can modulate activity in the anterior cingulate cortex, prefrontal cortex, and limbic structures such as the amygdala. Such neural plasticity may underlie the improvements in executive function, attentional control, and autonomic regulation observed in mindfulness interventions (Moreira et al., 2024; Whitfield et al., 2022). In summary, the identification of mindfulness, resilience, and rumination as key mediators highlights actionable therapeutic targets for future interventions and supports the integration of transdiagnostic mechanisms in the design of scalable, evidence-based mental health strategies for vulnerable clinical groups.

The current study has several noteworthy limitations. First, participants were recruited from a single hospital, limiting the representativeness of the sample and, consequently, the generalizability of the findings to the broader PWH population in China. The sample was small and largely male, with most participants identifying as men who have sex with men (MSM). This reflects the local epidemiology of HIV but restricts generalization to regions where women or heterosexual transmission predominate, such as Sub-Saharan Africa. Future studies should recruit more diverse samples to enhance external validity. Second, a standard-care control group was used instead of an active comparator. Future trials should include active psychosocial or mindfulness-based comparators to better isolate treatment effects. Third, the follow-up period was limited to 3 months. A longer observation period would be necessary to determine the durability of the intervention effects. Fourth, while outcome assessors were blinded to group allocation, the interventionists were not, which may have introduced performance or expectancy biases. Finally, although anonymous self-report measures were used to encourage honest and uninhibited responses, the possibility of ceiling effects and social desirability bias cannot be ruled out. In addition, ART adherence was assessed by a self-reported visual analogue scale. Future studies should incorporate objective adherence indicators, such as pharmacy refill records or electronic monitoring, to enhance measurement validity.

4.1. Clinical and research implications

The findings of this study have important implications for both clinical practice and future research. Clinically, the IMBP intervention represents a feasible and low-cost strategy for addressing two of the most critical barriers to successful HIV management: psychological trauma and poor treatment adherence. The intervention’s flexibility and lack of need for professional facilitation make it especially well-suited for implementation in various health settings or in low-resource environments where access to specialized psychological services is limited. Future studies should seek to replicate and extend these findings in larger, more diverse samples and across varied clinical contexts. Long-term follow-up studies are needed to assess the durability of intervention effects and explore the potential for broader implementation. Additionally, mechanistic investigations using physiological or neurobiological markers could further elucidate the pathways through which the IMBP exerts its effects, informing the refinement and personalization of future interventions.

5. Conclusions

This study demonstrated that the IMBP significantly reduced PTSD symptoms and improved ART adherence among PWH, with effects maintained at 3-month follow-up. Furthermore, the mediating roles of mindfulness, rumination, and resilience provide preliminary evidence for the psychological mechanisms underlying these improvements. Clinically, the IMBP may represent a feasible, low-cost, and potentially scalable intervention for managing PTSD among PWH. Future studies should replicate these findings in larger, more diverse samples, conduct longer-term follow-ups to validate sustained effects, and explore underlying neurobiological mechanisms to further refine and personalize this promising intervention.

Supplementary Material

Supplementary Material.docx
ZEPT_A_2602298_SM8278.docx (23.9KB, docx)

Acknowledgements

The authors would like to thank all of the participants for their contribution in the study. We thank Elaine Miller-Karas for her important support. CT and HW conceived the study. TZ, SY and CT collected the data, while CT and TZ conducted the analysis and interpretation. CT, HW, TZ and YJ collaboratively wrote and revised the manuscript. All authors contributed to the study design, reviewed the manuscript, and approved the final version.

Funding Statement

This work was supported by Hunan Provincial Innovation Foundation for Postgraduate 1053320182614 and the Innovation-Driven Project of Central South University 2019zzts091. The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Ethical approval and consent to participate

This study was approved by the Institutional Review Board of Xiangya Nursing School, Central South University, China (No. 2018040). All experiments were conducted in accordance with the Declaration of Helsinki. Informed consent was obtained from all the participants.

Data availability statement

The data supporting all the findings in this study may be available to researchers in anonymized form by the first author with reasonable request.

Supplemental Material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/20008066.2025.2602298.

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Supplementary Materials

Supplementary Material.docx
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Data Availability Statement

The data supporting all the findings in this study may be available to researchers in anonymized form by the first author with reasonable request.

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