As HIV has become a chronic condition requiring long-term engagement with health services, attention has increasingly extended beyond treatment access and biomedical outcomes to how people living with HIV experience their care. People-centered care emphasizes respect for individuals' values, preferences, experiences, and needs and includes communication, confidentiality, involvement in decision-making, continuity, and responsiveness to psychosocial needs [1]. Mental health and human immunodeficiency virus (HIV) remain closely interconnected public health challenges, particularly in sub-Saharan Africa (SSA), where both conditions are prevalent and highly stigmatized [1,2]. Globally, more than 40.8 million people are living with HIV, with the majority residing in low- and middle-income countries (LMICs).[3] Although advances in antiretroviral therapy (ART) have substantially reduced HIV-related morbidity and mortality, mental health conditions continue to affect the health and well-being of people living with HIV (PLHIV) [4]. Mental health symptoms have been reported in up to 62% of PLHIV [5], while depression occurs at considerably higher rates among PLHIV than in the general population.[6,7] These challenges can affect treatment engagement, adherence, quality of life, and overall well-being.

People-centered approaches have been associated with improved ART adherence, reduced psychological distress, and stronger patient-provider relationships.[8] However, delivering people-centered HIV care remains challenging in many LMICs because limited human resources, fragmented services, weak referral systems, stigma, and resource constraints can affect continuity, confidentiality, coordination, and responsiveness.[9] Mental health and psychosocial support represent one important component of this broader care experience. [10,11] In Rwanda, mental health conditions affect approximately 20.49% of the general population[12], while 16.4% of PLHIV have been reported to experience at least one mental health disorder.[13] Rwanda has made substantial progress in HIV care through expanded ART coverage, decentralized HIV services, and strengthened treatment delivery. Mental health has also been recognized within national HIV guidelines as an important component of comprehensive HIV care.[14] Despite these advances, PLHIV continue to experience depression, psychological distress, stigma, and other mental health challenges, suggesting that expanding access alone may not fully address their mental health and psychosocial needs.[15]

Despite Rwanda's substantial progress in HIV service delivery, limited empirical evidence describes how people living with HIV experience the different dimensions of people-centered care in routine HIV services. Overall satisfaction alone may obscure important differences in experiences of communication, involvement in care, continuity, coordination, accessibility, and responsiveness to psychosocial needs. Understanding these experiences and how they vary across patient and service characteristics can help identify aspects of HIV service delivery requiring further attention. Therefore, this study aimed to assess overall and dimension-specific patient-reported experiences of people-centered HIV care among adults receiving HIV services at two health centers in Rwanda and to describe how these scores varied across selected sociodemographic, HIV-related, clinical, and psychosocial characteristics.

Material and Methods

Study design and setting

We conducted a facility-based quantitative cross-sectional study at Muhoza Health Center and Biryogo Health Center in Rwanda. Muhoza Health Center is located in a semi-urban area of Musanze District in the Northern Province, while Biryogo Health Center serves an urban population in Nyarugenge District, Kigali City. Both facilities provide routine HIV care, including antiretroviral therapy, clinical monitoring, counseling, and referral services. Data were collected from May to June 2026.

Study population and eligibility

The study population consisted of adults living with HIV who were receiving care at either of the two facilities. Participants were eligible if they were aged 18 years or older, had received HIV care at the selected facility for at least six months, were medically stable at the time of recruitment, and were willing and able to provide written informed consent. Clients requiring urgent medical attention or those with severe cognitive or communication difficulties that prevented them from understanding the consent process or completing the questionnaire were excluded. Interviews were paused or discontinued if a participant experienced emotional distress.

Sample size and sampling

The accessible population was estimated at 4,760 people living with HIV, including 1,560 receiving care at Muhoza Health Center and 3,200 at Biryogo Health Center. The overall recruitment target was determined using a finite population formula for estimating a single proportion. Because there was limited prior evidence on patient-reported people-centered HIV care in Rwanda, an expected proportion of 50% was used as a conservative assumption. Using a 95% confidence level and a margin of error of 6.14%, the required sample size was 242 participants.

NZ2p(1-p)d2N-1+Z2p(1-p)

Where:

n = required sample size

N = accessible population size (4,760)

Z = standard normal value corresponding to a 95% confidence level (1.96)

p = estimated proportion of client satisfaction (0.50)

d = margin of error (0.0614)

A proportion of 50% was used because there was limited previous evidence on patient experiences of people-centered HIV care in Rwanda. This value also provides a conservative estimate of the required sample size.

Substituting the values into the formula:

4760(1.96)20.50(1-0.50)(0.0614)24760-1+(1.96)2 (0.5)(0.5)=242 participants

The two health centers were purposively selected. Within each facility, eligible participants were selected from HIV clinic registers or appointment lists using computer-generated random numbers. Selected clients were approached during routine clinic visits and invited to participate. The final sample included 109 participants from Muhoza Health Center and 133 from Biryogo Health Center as it is shown in table 1.

Table 1: Distribution of the study sample by health facility

Data were collected using a structured electronic questionnaire developed for this study and informed by the World Health Organization Framework on Integrated People-Centered Health Services (IPCHS). The questionnaire was available in English and Kinyarwanda and was administered electronically through KoboToolbox by seven trained data collectors. Before data collection, the data collectors received training on the study objectives, eligibility assessment, informed consent, confidentiality, participant safety, and the questionnaire. Interviews were conducted in private areas within the health facilities.

Study measures

Patient-reported perceptions of people-centered care were assessed using 33 items organized according to the five strategies of the WHO IPCHS framework: empowerment, governance and accountability, model of care, coordination of services, and enabling environment. The items addressed participants’ perceptions of routine HIV care, including communication, involvement in care, respect, accessibility, continuity, psychosocial support, and coordination of services. Each item was rated on a five-point scale ranging from 1 (“very dissatisfied”) to 5 (“very satisfied”). An overall composite people-centered care score was calculated as the mean of the 33 items, with a possible range from 1 to 5. Separate mean scores were also calculated for each of the five dimensions, with higher scores indicating more positive perceptions of people-centered care. A separate single-item question assessed participants’ overall satisfaction with care received at the facility and was not included in the 33-item composite score. The questionnaire was developed for this study based on the WHO IPCHS framework. Its content was reviewed by the research supervisors and individuals with experience in people-centered care to assess the relevance and clarity of the items. The questionnaire was pretested before the main data collection, and unclear wording and questionnaire flow were revised based on the pretest findings. Internal consistency of the 33-item people-centered care scale was assessed using Cronbach’s alpha, which showed high internal consistency (α = 0.91).

Data Analysis

Quantitative data were cleaned, coded, and analyzed using Stata version 17. Data were collected using the Kinyarwanda version of the questionnaire, and variable labels and responses were translated into English using a translation codebook for analysis and reporting. Before analysis, the dataset was examined for missing values, inconsistencies, duplicate records, outliers, and invalid responses. Categorical variables were numerically coded as appropriate.

Patient-reported perceptions of people-centered care were assessed using 33 Likert-scale items scored from 1 to 5, with higher scores indicating more positive perceptions of care. The items were organized according to the five dimensions of the World Health Organization IPCHS framework: empowerment, governance and accountability, model of care, coordination of services, and enabling environment. For each participant, an overall people-centered care composite score was calculated as the mean of the 33 items, resulting in a possible score ranging from 1 to 5. Separate mean scores were also calculated for each of the five dimensions, with higher scores indicating more positive perceptions of people-centered care. The overall composite score was retained as a continuous variable and was not categorized into high or low levels.

Descriptive statistics were used to summarize participant characteristics, service-related variables, and people-centered care measures. Frequencies and percentages were reported for categorical variables. Continuous variables were summarized using means and standard deviations and, where appropriate, medians, minimum values, and maximum values. The separate single-item measure of overall satisfaction with care was summarized using frequencies and percentages and was analyzed separately from the 33-item people-centered care composite score. The overall composite score and five dimension-specific mean scores were used to describe participants’ perceptions of people-centered HIV care.

Mean composite scores were further examined descriptively across selected sociodemographic, HIV-related, mental health service-related, clinical, and psychosocial characteristics, including health facility, age, gender, marital status, education, employment status, residence, duration in HIV care, receipt of mental health support, previous mental health screening, viral load status, chronic disease status, and HIV-related stigma or discrimination. These subgroup comparisons were exploratory and descriptive. No inferential statistical tests were conducted to assess statistical significance; therefore, observed differences were not interpreted as evidence of statistical associations, independent predictors, or causal relationships.

Ethical considerations

Ethical approval was obtained from the University of Global Health Equity Institutional Review Board (reference UGHE-IRB/2025/469; protocol 469). Full-board approval was granted on January 26, 2026, and became effective on January 27, 2026. Administrative permission was obtained from both participating health centers before data collection.

All participants provided written informed consent. Participation was voluntary, and participants could decline to answer any question or withdraw without affecting the services they received. No names or direct personal identifiers were collected. Interviews were conducted privately, and study data were stored securely with access limited to authorized members of the research team. Participants who experienced distress or required additional support were connected to the existing counseling, social work, mental health, or referral services available at the health facility.

Results

Participant characteristics

A total of 242 participants completed the study, giving a response rate of 100%. The mean age of participants was 39.1 years (SD = 11.6), with the largest proportion aged 35-44 years, 96 (39.7%). Most participants were female, 187 (77.3%). Regarding residence, 161 (66.5%) lived in urban areas, while 50 (20.7%) lived in peri-urban areas and 31 (12.8%) lived in rural areas. Most participants had completed primary education, 141 (58.3%), and 158 (65.3%) were unemployed. Table 4 presents the socio-demographic and contextual characteristics of the participants (Table 2).

Table 2. Sociodemographic and HIV care characteristics of participants (N = 242)

Age: mean 39.1 years, SD 11.6. Duration in HIV care: mean 13.8 years, SD 12.1.

Mental health support and clinical characteristics

Overall, access to mental health services appeared limited among participants. Only 28 of the 242 participants (11.6%) reported ever having been screened for a mental health condition, while the vast majority (87.2%) had never been screened. Among the 25 participants who reported a screening result, nearly two-thirds (64.0%) had screened positive for a mental health condition. Encouragingly, among those who provided information about follow-up care after a positive screening result, 11 out of 15 (73.3%) reported receiving mental health support or treatment.

Participants also expressed a considerable unmet need for mental health support within HIV care services. Almost four in ten participants (39.7%) reported that they had not received mental health support but would have liked to receive it. A further 35.5% said they received support occasionally, while only 6.6% reported receiving support on a regular basis. About one in five participants (18.2%) indicated that they had not received mental health support and did not feel they needed it.

With regard to HIV clinical status, most participants reported favorable viral load outcomes. More than half (54.1%) reported having a suppressed viral load, while 18.2% reported an undetectable viral load. However, one in five participants (20.7%) did not know their most recent viral load result, and 7.0% reported an unsuppressed viral load. Nearly one-quarter of participants (24.4%) reported living with another chronic disease in addition to HIV. Among the total sample, 17.8% reported receiving treatment for a chronic condition, whereas 5.8% reported having a chronic condition but not receiving treatment. Experiences of HIV-related stigma and discrimination remained common. More than one-third of participants (37.2%) reported having experienced stigma or discrimination related to their HIV status, highlighting the ongoing psychosocial challenges faced by people living with HIV (Table 3).

Table 3. Mental health service, clinical, and psychosocial characteristics

The overall composite mean score was 3.81 out of 5 (SD 0.59). Among the five people-centered care dimensions, the enabling environment received the highest mean score (4.17, SD 0.66), followed by the model of care (3.99, SD 0.61) and governance and accountability (3.80, SD 0.90). Empowerment had a mean score of 3.68 (SD 0.70). Coordination of services received the lowest mean score (3.05, SD 1.01), indicating that coordination was the least positively rated dimension (Table 4).

Table 4. Overall and dimension-specific people-centered care scores (N = 242)

Descriptive variation in people-centered care scores

Mean composite scores varied across selected participants and service characteristics. Participants from Biryogo Health Center had a higher mean score than those from Muhoza Health Center (3.91 versus 3.69). Urban residents had a mean score of 3.86, compared with 3.54 among rural residents. Participants with no formal education had a lower mean score (3.50) than those who had completed primary education (3.89).

Participants who wanted but had not received mental health support had a mean score of 3.62. This compares with 3.96 among those receiving support sometimes and 3.95 among those receiving it regularly. Participants reporting undetectable or suppressed viral loads had mean scores of 3.89 and 3.87, respectively, compared with 3.64 among both those with unsuppressed viral loads and those who did not know their results. Participants with another chronic disease had a mean score of 3.68, compared with 3.85 among those without another chronic disease.

These comparisons were descriptive and were not tested for statistical significance (Table 5).

Table 5: Mean overall satisfaction score by people-centered care dimensions and selected respondent characteristics, N = 242