The persistence of sexual risk behavior among young people living with HIV (YPLHIV) even after diagnosis and enrollment in care represents a critical public health paradox in Nigeria. Although multi-level determinants of such behavior are widely acknowledged, the specific contributions of psychological distress and economic pressure and their relationship to both sexual risk behavior and ART adherence outcomes remain inadequately examined in the context of insecurity in Northern Nigeria. Drawing on a qualitative-dominant mixed-methods exploratory case study of 48 YPLHIV aged 15–24 years in high-security risk zones of Sokoto, Kebbi, and Zamfara States, this study foregrounds the study’s quantitative hypothesis-testing findings and integrates them with thematic qualitative evidence. Spearman rank-order correlation analysis revealed a statistically significant, moderately strong positive relationship between psychological distress and sexual risk behavior (rₛ = 0.592, p < 0.01, N = 48), confirming that depressive symptomatology is a central, not a peripheral, determinant of risk engagement. A chi-square test found no statistically significant association between economic pressure and sexual risk behavior (χ²(2, N = 48) = 1.77, p = .413), though directional trends in the crosstabulation showed that economically vulnerable respondents were disproportionately concentrated in the high-risk category (52.6% vs. 33.3%). Fisher’s exact test found no significant association between case management support and ART adherence (p = 1.000), interpreted as a ceiling effect produced by near-universal case management access rather than program ineffectiveness. Qualitative data contextualized these patterns through eight interlocking themes: diagnosis as biographical disruption, health system responsiveness as a structural driver of adherence, social support as distributed coping infrastructure and disclosure as strategic social negotiation. The findings demonstrate that mental health integration is not optional but essential within HIV case management and that the non-significance of economic pressure in statistical testing masks a substantive social vulnerability that qualitative evidence consistently affirms. The policy and practice implications are discussed about fragile and conflict-affected settings across Northern Nigeria.
Keywords: psychological distress; sexual risk behavior; economic pressure; ART adherence; YPLHIV; mixed methods; Northwestern Nigeria; case management
