Emmanuel Ndahiro Manirafasha,1 Marguerite Mukarugwiza21Center for Nursing and Midwifery, University of Global Health Equity, Kigali, Rwanda; 2Department of Nursing and Midwifery, Adventist University of Central Africa, Kigali, RwandaCorrespondence: Emmanuel Ndahiro Manirafasha, Center for Nursing and Midwifery, University of Global Health Equity, Kigali, Rwanda, Tel +250788887265, Email emmyndahiro14@gmail.comAbstract: Rwanda has made substantial progress in HIV diagnosis, treatment, and viral suppression. However, these achievements do not necessarily reflect the mental health and psychosocial well-being of people living with HIV (PLHIV). Evidence from Rwanda indicates that mental health disorders remain underrecognized and undertreated, even among individuals achieving favorable HIV treatment outcomes. Although national HIV guidelines recommend routine mental health screening and referral, there is limited evidence on how consistently these recommendations are implemented across HIV services. This Perspective argues that the priority is not simply to advocate for mental health integration, but to make existing recommendations work in everyday clinical practice. Drawing on Rwanda’s experience with decentralized healthcare, task sharing, and supportive supervision, we propose a practical approach that connects mental health screening with appropriate assessment, first-line psychosocial support, referral, and follow-up. Key priorities include strengthening frontline provider competencies, establishing clear responsibilities across levels of care, involving PLHIV in service design, and monitoring whether patients receive appropriate support. These actions should be introduced progressively and evaluated for feasibility, acceptability, continuity of care, and sustainability. Strengthening mental health integration does not require specialist services in every ART clinic; it requires a coordinated system in which mental health needs are recognized, and patients can access appropriate care. Moving from policy recommendations to measurable improvements in service delivery is essential to advancing person-centered HIV care in Rwanda.Keywords: mental health, HIV care, mental health integration, people living with HIV, Rwanda, health service delivery
AliAkbar Haghdoost,1 Mostafa Hosseini Golkar,1 Hamid Sharifi,2,3 Farid Najafi,4 Alireza Alikhani51Social Determinants of Health Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran; 2HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran; 3Institute for Global Health Sciences, University of California, San Francisco, CA, USA; 4Research Center for Environmental Determinants of Health, Research Institute for Health, Kermanshah University of Medical Sciences, Kermanshah, Iran; 5Social Development and Health Promotion Research Center, Health Policy and Promotion Institute, Kermanshah University of Medical Sciences, Kermanshah, IranCorrespondence: Alireza Alikhani, Email alirezaalikhani8687@gmail.comIntroduction: Despite substantial progress in the global HIV response, the MENA region continues to face important challenges in HIV prevention and control. In Iran, fluctuations in the number of newly diagnosed HIV cases indicate an ongoing public health challenge and underscore the need to anticipate factors that may shape future diagnosis patterns.Methods: This study applied Trend Impact Analysis (TIA) to develop conditional projections of newly diagnosed HIV cases in Iran through 2030. Monthly surveillance data from 1998 to 2023 were modeled using an ARIMA(2,0,2) to establish a baseline trend which was subsequently modified through TIA based on expert-informed estimates of the timing and magnitude of key drivers. A panel of 30 experts in HIV/AIDS, epidemiology, public health, and health policy identified and assessed key drivers that could influence future trends. Expert- informed estimates of the timing, magnitude, and persistence of impacts, were then incorporated into the baseline projection to construct alternative future scenarios.Results: Expert panels identified 13 key drivers: eight adverse influences, including conflict risk, increased sex work, new stimulant drug use, online sexual platforms, socioeconomic crises, emerging epidemics, developing sex tourism, and HIV drug resistance, expected to increase the future number of newly diagnosed HIV cases. Conversely, five positive influences, including AI healthcare, effective vaccination access, efficient surveillance toward the 95– 95-95 objectives, PEP/PrEP implementation, and advanced therapies, expected to reduce the future number of newly diagnosed HIV cases. Quantitative estimates project 1698 new cases if current trends persist. Under optimistic scenarios, cases may decline by 51%, whereas pessimistic scenarios suggest an increase of 102%. The integrated TIA scenario projected an approximately 51% increase in newly diagnosed HIV cases by 2030, reaching 2558 cases by 2030, with an approximate 95% uncertainty interval of 2120– 2996 (± 2 SD).Conclusion: The scenario projections represent conditional future trajectories based on specified assumptions about the impact of different key drivers, The scenarios illustrate substantial uncertainty in the future number of newly diagnosed HIV cases in Iran, with scenario estimates ranging from approximately a 50% decrease to a 100% increase relative to the baseline projection.Keywords: health futures studies, trend impact analysis, scenario analysis, HIV/AIDS
Emmanuel Ndahiro ManirafashaCenter for Nursing and Midwifery, University of Global Health Equity, Kigali, RwandaCorrespondence: Emmanuel Ndahiro Manirafasha, Center for Nursing and Midwifery, University of Global Health Equity, Kigali, Rwanda, Tel +250788887265, Email emmyndahiro14@gmail.comAbstract: Nurses are central to HIV testing, treatment, prevention, differentiated service delivery, and increasingly integrated care. However, expanding their clinical responsibilities without corresponding leadership preparation, decision-making authority, and institutional support risks creating symbolic rather than effective leadership. This Viewpoint argues that the next phase of the HIV response requires prepared and accountable nurse leaders who can use program data, redesign workflows, strengthen referral systems, support quality improvement, and contribute to policy and resource decisions. Accountability must be reciprocal: nurse leaders should be responsible for quality, equity, patient experience, and workforce well-being, while institutions must provide adequate staffing, mentorship, reliable supplies, usable data, and enabling scopes of practice. Ministries, regulators, implementing partners, and HIV governance bodies should establish competency-based leadership preparation, align authority with responsibility, include nurses in decision-making, and involve communities in service design. Nursing leadership should be treated as essential HIV program infrastructure, not optional professional development.Keywords: nursing leadership, HIV response, professional accountability
Abdullahi Hassan MohamudDepartment of Laboratory, Dr. Sumait Hospital, SIMAD University, Mogadishu, SomaliaCorrespondence: Abdullahi Hassan Mohamud, Department of Laboratory, Dr. Sumait Hospital, SIMAD University, Mogadishu, Somalia, Email abdullahihassanm@simad.edu.soAbstract: Somalia has a low-level HIV epidemic, but low prevalence does not necessarily mean that HIV testing is socially or psychologically low risk. This commentary examines "pre-test fear”, defined here as anticipatory concern before HIV testing about possible health, relational, social, or confidentiality consequences of being tested or receiving a reactive result. Somalia-specific evidence documents HIV-related stigma, non-consented disclosure, misinformation, and confidentiality concerns, but direct evidence on pre-test fear and the prevalence or regulation of premarital HIV testing remains limited. Accordingly, the article distinguishes local evidence from contextual evidence drawn from other settings and does not present new patient-level data. It proposes a conceptual privacy-first framework for routine and premarital HIV screening built around voluntary informed consent, brief culturally appropriate pre-test information, confidential laboratory workflows, confirmatory testing, linkage to care, and community health literacy. The framework is intended to generate testable implementation questions rather than to represent an empirically validated intervention. For Somalia, the principal implication is that diagnostic quality should include not only analytical accuracy but also the conditions that make people willing to test, receive results, and continue into confirmatory testing and care. Prospective mixed-methods and implementation studies are needed to measure pre-test fear, characterize premarital testing practices, assess confidentiality, and evaluate whether privacy-centered counseling improves acceptability and linkage.Keywords: health literacy, stigma, counseling, diagnostic quality, patient trust, public health policy
Ayda Mohammadnezamian,1 Keyghobad Ghadiri,2 Mosayeb Rostamian,2 Leila Solouki,3,4 Manizheh Azadian,1 Bahare Andayeshgar,3 Shahla Shahbazi,2 Roya Chegene Lorestani,1,5 Etrat Javadirad21Department of Pathology, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran; 2Infectious Diseases Research Center, Health Policy and Promotion Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran; 3Department of Biostatistics, School of Health, Kermanshah University of Medical Sciences, Kermanshah, Iran; 4Health Data Science Research Center, Health Research Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran; 5Department of Microbiology, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, IranCorrespondence: Roya Chegene Lorestani, Infectious Diseases Research Center, Health Policy and promotion Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran, Tel +98 8334262252, Email lorestani25@gmail.com Etrat Javadirad, Infectious Diseases Research Center, Health Policy and Promotion Institute, Kermanshah, Iran, Tel +98 8334262252, Email pathologist84@yahoo.comBackground and Objective: Considering the crucial role of CD4+ T-cell counts in disease control and management, the present study aimed to investigate changes in CD4+ T-cell counts among People Living with HIV (PLWH) at the Behavioral Diseases Counseling Center in Kermanshah Province. The study also assessed the impact of demographic and clinical factors, including age, gender, duration of infection, duration of antiretroviral therapy (ART), and CD4+ T-cell count, on changes in CD4+ T-cell counts during ART among PLWH.Methods: In this retrospective study, the medical records of 2909 PLWH who had attended the Kermanshah Behavioral Diseases Counseling Center between 2012 and 2023 were reviewed. Demographic, behavioral, and clinical data were extracted from the records. Ultimately, 728 individuals whose CD4+ T-cell counts were documented both at diagnosis and after treatment were included in the analysis. Data were analyzed using SPSS version 21. As CD4+ T- cell count changes were not normally distributed, robust linear regression was employed. Collinearity among independent variables and autocorrelation of errors were assessed and confirmed. The assumption of homoscedasticity of errors was also evaluated and satisfied.Results: Among the 728 PLWH, 519 (71.3%) were male and 209 (28.7%) were female. The mean age of the PLWH was 37.2 ± 11.5 years. The mean CD4+ T-cell count at diagnosis was 336.4 cells/μL, which increased to 526.4 cells/μL after treatment. The average duration of treatment was 57.8 months (SD = 34.5), and the average number of follow-up visits was 48.6 (SD = 36.9). Robust linear regression, with ART duration entered as a four-level category, showed that longer ART duration (1– 5 years: B=111.9; 5– 10 years: B=267.5; > 10 years: B=527.3, all vs < 1 year, p< 0.001), higher education (B=302.6, 95% CI: 171.5– 433.7), older age (B=5.3, 95% CI: 2.4– 8.3), and sexual transmission (B=101.6, 95% CI: 18.0– 185.2) were significantly associated with improved CD4+ T-cell recovery (p< 0.05). Female sex, more advanced clinical stage (III–IV), and certain occupational categories were also significantly associated with CD4+ T-cell recovery, while a longer duration of infection was associated with lower CD4+ T-cell recovery (all p< 0.05).Conclusion: Consistent with the well-established effect of antiretroviral therapy on CD4+ T-cell recovery, this study suggests that immune recovery is influenced by both treatment duration and patients’ demographic and clinical characteristics. These findings emphasize the importance of individualized HIV care, with closer monitoring and adherence support for patients at risk of poorer immune recovery.Keywords: HIV, CD4+ T cell counts, retrospective, Iran
