The stigmatized status of injecting illicit drugs use and human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome in Pakistan, enlists HIV positive injection drug users (IDUs) at preeminent risk for poor mental health. This study aims to investigate the potential link between enacted HIV stigma, community attachment, and mental health problems in HIV-positive IDUs, along with mediating role of community attachment and moderating role of drug type. Correlation analysis revealed that enacted HIV stigma and community attachment were significantly negatively associated with mental health. Mediation analysis indicated that enacted HIV stigma influences mental health indirectly by shaping individuals' level of attachment to the community of IDUs. Moderation analysis revealed that synthetic illicit drugs significantly moderated the association between enacted HIV stigma and mental health. The findings highlight the need for targeted interventions addressing enacted HIV stigma among IDUs to effectively improve their mental health outcomes.
HIV remains a major global public health challenge. Although antiretroviral therapy (ART) effectively reduces morbidity and mortality, its success depends on sustained adherence to treatment. Barriers such as stigma, psychosocial problems, and limited access to healthcare continue to compromise adherence among people living with HIV (PLHIV). Adherence counseling (AC) has been increasingly implemented to address these challenges and improve treatment outcomes. This study aimed to map and synthesize the types and effectiveness of AC interventions in improving ART adherence among PLHIV. A scoping review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines. Literature searches were performed in Scopus, ScienceDirect, ProQuest, and PubMed using population, intervention, comparison, and outcomes-based keywords. Eligible studies evaluated AC interventions with ART adherence as an outcome and were published in the last 5 years. Of the 689 identified articles, 13 met the inclusion criteria. Most studies were conducted in Uganda and focused on intensive AC (IAC). IAC improves ART adherence and viral load suppression, particularly when delivered through structured, patient-centered approaches. However, the effectiveness varied according to social, health system, and contextual factors. Digital-based interventions, including real-time medication monitoring and mobile health applications, have also demonstrated promising effects on adherence. IAC plays an important role in improving ART adherence among PLHIV. Its effectiveness is influenced by the quality of counseling, social support, and health system integration. Combining face-to-face counseling with digital innovations and community-based support offers the most sustainable strategy for enhancing adherence and achieving viral suppression in PLHIV.
The use of authorized medicinal products under conditions other than those approved, commonly referred to as off-label use, is an increasingly frequent practice in health care. It is particularly relevant in the therapeutic management of human immunodeficiency virus infection, where treatment innovation often outpaces regulatory updates. In the absence of specific protocols to guide the appropriateness of off-label prescribing, this narrative review analyses, from an ethical and legal perspective, the conditions under which off-label use may be considered an appropriate therapeutic option. To this end, we examine the clinical foundations of off-label use, including the quality and certainty of the available scientific evidence and its impact on the benefit-risk and cost-benefit balance, the exceptional nature of its use, and the application of decision-making algorithms to guide prescribing. We also identify the main ethical dilemmas associated with off-label use from principlist, virtue-based, and utilitarian bioethical perspectives, as well as the principal conflicts of interest among the different stakeholders involved in the off-label use of antiretroviral drugs. Finally, we propose strategies aimed at promoting a more prudent, equitable, and transparent use of off-label medicines, strengthening responsible, patient-centered decision-making.
