Background: The ongoing opioid epidemic has been associated with increases in emergency department visits and hospitalizations for drug overdose and injection-related infections. These encounters with the health care system provide an opportunity to offer drug treatment linkage and support for people with opioid use disorder (OUD). There is a need for interventions that enhance linkage to and engagement in treatment with medication for opioid use disorder (MOUD) for people with OUD identified in hospital settings as they transition back to community settings. Objective: The mTools4life (Johns Hopkins University) study aimed to develop and evaluate a peer-led intervention integrating narrative-based health communication into a mobile health (mHealth) app to increase posthospitalization engagement in MOUD and reduce substance use. Methods: The formative phase of the study consisted of semistructured interviews with people with OUD and clinicians who provide care to people with OUD. Interviews sought to identify salient content to include in visual narratives within the mHealth app and information that may increase motivations for behavior change related to MOUD engagement. The intervention was developed in accordance with the information-motivation-behavioral skills model, transportation theory, and the transtheoretical model. The pilot phase of mTools4Life (Johns Hopkins University) aimed to evaluate the acceptability and usability of the intervention. People with OUD were recruited from the Johns Hopkins Hospital Emergency Department and consented to receive the intervention for a 3-month period. Participants completed a study survey at baseline and a 3-month follow-up. Data on demographics, past 30-day substance use, MOUD, and intervention appropriateness and acceptability were obtained at both time points. Additional data on intervention uptake and frequency of use were collected at follow-up. Dependent samples 2-tailed t tests were conducted on continuous data, and Fisher exact tests were conducted on count data. Results: Twenty people with OUD piloted the intervention. The sample was mostly male (13/20, 65%) and non-Hispanic White (13/20, 65%) with a mean age of 41.1 (SD 8.7) years. Most participants (16/20, 80%) completed the 3-month follow-up. Fewer participants reported opioid use at follow-up (9/16, 56.3%) compared to baseline (20/20, 100%; P=.001, and mean days of opioid use out of the past 30 days declined from baseline (19.9, SD 11.7) to follow-up (8.3, SD 11.4; P=.002). MOUD treatment in the prior 3 months was reported by 65% (13/20) of participants at baseline and 81.3% (13/16) at follow-up (P=.46). Most participants used the app (11/16, 68.8%) or engaged with their peer navigator (10/16, 62.5%) during the intervention period. At follow-up, mean acceptability and appropriateness scores (scale 0-5; higher score indicating greater acceptability or appropriateness) were 4.5 (SD 0.5) and 4.3 (SD 0.8), respectively. Conclusions: This study demonstrates the feasibility of the development and deployment of a narrative-based mHealth intervention to support OUD care engagement and preliminary data in support of the intervention's acceptability, appropriateness, and effectiveness

Background Sexual minority men (SMM) in Nigeria face a disproportionate burden of HPV-related diseases, yet HPV vaccination uptake remains limited due to structural, financial, and sociocultural barriers. Understanding SMM's preferences for vaccination delivery is critical to designing accessible, affirming, and equitable prevention strategies. Methods A discrete choice experiment (DCE) was conducted with 250 SMM receiving HIV-related care at an affirming clinic in Abuja, Nigeria. Seven attributes were identified through literature review and stakeholder engagement. Participants completed 12 choice tasks comparing hypothetical HPV vaccination scenarios. Hierarchical Bayes estimation was used to derive individual-level utilities and attribute importance scores. Results Participants strongly preferred receiving HPV-related services in SMM-affirming settings and at no cost. Setting type (19.4%) and cost (19.2%) were the most influential attributes, followed by wart prevention (11.4%) and information availability (7.8%). Services described as protecting others from HPV-related outcomes, prevent warts, and require moderate travel (60 min) were moderately preferred. Higher levels of vaccine protection and information availability were less influential in decision-making. Conclusions Preferences among SMM in Nigeria emphasize the need for free, affirming, and inclusive HPV vaccination services. Addressing structural barriers, especially stigma and cost, will be essential to increasing vaccine uptake. Findings support targeted, community-informed strategies to reduce HPV disparities and promote health equity.

Abstract Background This study examined the role of emotional support networks in shaping health-related communication among sexual minority men (SMM) living with HIV in Nigeria, a context where criminalization and stigma limit social integration and access to care. We conducted a cross-sectional survey of 250 SMM receiving HIV care at an SMM-affirming clinic in Abuja. Methods Participants completed a structured questionnaire assessing demographics, HIV-related characteristics, HPV knowledge, anal cancer awareness, and emotional support network composition. Emotional support network attributes were compared by duration of HIV diagnosis (≤ 5 years vs. >5 years), and logistic regression models assessed factors associated with discussing anal cancer within support networks. Results Participants living with HIV for > 5 years had larger emotional support networks and were more likely to report discussing same-sex relationship issues and anal cancer with alters. Discussing same-sex relationships and receiving medical care support from alters were strongly associated with increased likelihood of discussing anal cancer. Network density (e.g., how well alters know one another) did not differ by duration of HIV diagnosis. Conclusion These findings highlight the influence of interpersonal trust and relationship context on communication about stigmatized health topics. Leveraging emotional support networks, particularly for individuals newly diagnosed with HIV, may strengthen engagement in preventive cancer care and improve health outcomes for SMM in hostile sociopolitical environments.

Background Sexual minority men (SMM) living with HIV face an elevated risk of anal cancer, and SMM-affirming HIV clinics serve as vital entry points for cancer prevention. We evaluated human papillomavirus (HPV) knowledge, vaccine acceptability and whether time living with HIV was associated with anal cancer symptom awareness.Methods A cross-sectional survey was conducted at an HIV clinic offering anal cancer prevention in Abuja, Nigeria. Descriptive statistics were used to summarize HPV knowledge and vaccine acceptability. Multivariable negative binomial regression evaluated the number of anal cancer symptoms correctly reported using adjusted prevalence ratios (aPR) and 95% confidence intervals (CIs).Results Among 249 SMM living with HIV, 20.5% reported having heard of HPV. Fewer than 20% correctly identified key anal cancer symptoms, including anal bleeding (15.7%) and a lump or mass in the anus (16.9%). Time living with HIV was initially associated with anal cancer symptom awareness, but not after adjustment (aPR 1.02, 95% CI 0.98-1.07). Other independent predictors of anal cancer symptom awareness were anal cancer screening (aPR 1.51, 95% CI 1.15-1.97) and knowing HPV vaccine can prevent anal cancer (aPR 1.52, 95% CI 1.18-1.98). Despite low HPV awareness, 93.6% of participants reported willingness to receive HPV vaccine.Conclusion Integrating cancer prevention services into SMM-affirming HIV care may offer an opportunity to strengthen HPV-related knowledge and reduce cancer disparities.

To increase testing for hepatitis C among people who inject drugs, a syringe service program (SSP) in the northeastern United States trained peer workers to offer testing at van-based clinics. Peer workers approached SSP clients from August 2019 through March 2020 and from June 2021 through March 2022 to discuss hepatitis C and offer rapid onsite hepatitis C antibody testing. Of 573 clients approached, 28 (5%) consented to testing. Reasons for refusal included: 1) already tested, 2) not enough time, and 3) not worried about hepatitis. Of 28 tested, 9 (32%) were positive for hepatitis C antibodies. Adjustments to peer-worker testing strategy may be needed to increase acceptance of testing in this high-risk population.

Objective: Transgender women experience significant health disparities and are at disproportionately high risk of violence, stigmatization, and discrimination. Stigma and discrimination are enacted by staff and leaders in multiple public and service sectors including housing, physical and behavioral health, criminal justice and law enforcement, workforce development, and education. Multisectoral approaches recognize that health involves coordination and cooperation across various sectors, government departments, and stakeholders. The purpose of this study was to assess readiness and capacity to provide gender-affirming services. Method: The Division Director of Access to Prevention, Advocacy, Intervention and Treatment/Special Services for Groups a nonprofit organization recruited participants via email from the following 10 sectors: behavioral health, medical, disability, law enforcement, criminal justice, housing, workforce development, faith-based, legal aid, and education. In-depth interviews were conducted with 44 participants. Interviews were transcribed and analyzed using a framework approach, a method of deductive analysis. Participants (n = 27) attended a follow-up meeting that included a presentation of the findings from the interview analysis and held small group discussions about sector capacity for gender-affirming services. Results: Findings indicated that the capacity of providing training, leadership support, and policies varied. Gaps included a lack of funding for trainings and programs, the need for a more exclusive focus on transgender issues, and inclusion of transgender women participation to ensure the inclusion of their lived experiences. Conclusion: Results suggest that a multisectoral approach is feasible. Across participants, best practices included clear and explicit trans-affirming policies, establishment of safe spaces/physical indicators of allyship, and representation within organizations of members of the lesbian, gay, bisexual, transgender, queer, intersex, asexual, and other sexual identities community (including employment and visible supportive images).

Background Participatory models can facilitate the design of substance use treatment programs that are best equipped to support their end users, yet many structural barriers limit people who use drugs from effectively engaging in decision-making roles. This study explored how well substance treatment programs are meeting the needs of a group of people who inject drugs (PWID), highlighting a persisting misalignment between their perceived treatment needs and actual treatment experiences. Methods 22 PWID completed one or two in-depth interviews between April 2023 and March 2024. Eligibility included having injected drugs in the past six months and reporting one or more lifetime experiences of trauma. A thematic analysis was conducted to synthesize participants’ descriptions of treatment gaps and the adverse impacts of these unmet needs. Results Participants reported a range of unmet substance use treatment needs, including (1) a lack of integrated mental health care; (2) insufficient incentive systems, punitive forms of accountability, and overly short programs; (3) persisting stigmatization from treatment professionals; and (4) limited recovery supports, including facing incarceration over treatment, unsafe housing spaces, and no opportunities for life skills development or employment access. These treatment gaps were associated with adverse substance use and recovery outcomes. Conclusions These findings demonstrate that many treatment programs continue to operate without meeting the perceived needs of their end users, suggesting the importance of scaling up consumer engagement models in the substance use treatment landscape. Participants highlight many opportunities for programmatic and policy-level changes that would enable treatment programs to better align with their needs. These include expanding the mental health workforce, adopting fair-chance hiring practices, and prioritizing system-wide efforts to reduce stigma toward people who use drugs. Finally, they reinforce the importance of adopting a non-punitive approach to substance use that treats opioid use disorder as a chronic condition rather than a crime.

Transgender women face a disproportionate burden of carceral violence, or violence related to policing and the criminal legal system, with transgender women of colour experiencing even greater disparities. Several frameworks conceptualise the mechanisms through which violence impacts transgender women. However, none of them directly explore the role of carceral violence, particularly as it is experienced by transgender women themselves. Sixteen in-depth interviews were conducted with a racially/ethnically diverse sample of transgender women in Los Angeles between May and July 2020. Participants were between 23 - 67 years old. Participants identified as Black (n = 4), Latina (n = 4), white (n = 2), Asian (n = 2), and Native American (n = 2). Interviews assessed experiences of multilevel violence, including from police and law enforcement. Deductive and inductive coding methods were used to identify and explore common themes concerning carceral violence. Experiences of law enforcement-perpetrated interpersonal violence were common and included physical, sexual and verbal abuse. Participants also highlighted structural violence, including misgendering, the non-acceptance of transgender identities, and police intentionally failing to uphold laws that could protect transgender women. These results demonstrate the pervasive, multilevel nature of carceral violence perpetrated against transgender women and suggest avenues for future framework development, trans-specific expansions of carceral theory, and system-wide institutional change.

Disclosing one's HIV status or drug use in healthcare settings has significant implications for public and individual health. It is related to reduced occupational risk of infection for medical providers, improved care, reduction in disease transmission, and other clinical benefits for patients. However, disclosure can be challenging and problematic due to its discrediting aspects. We explored HIV and drug use disclosure experiences in clinical settings among Ukrainian women who live with HIV (WLWH) and inject drugs. This study was conducted in Kyiv, Ukraine. 309 surveys were completed between December 2019 and November 2020, followed by qualitative in-depth interviews with 18 participants. Some women in our study believed that disclosing their status ensured optimal medical care and necessary precautions by providers (e.g., sterilizing equipment). Other participants said they did not disclose after experiencing mistreatment in healthcare settings in the past. Still others utilized alternative strategies to disclose, such as using indirect language or cautiously informing about a less stigmatizing condition such as hepatitis. Clinical implications include training women who live with HIV to use communication skills to support disclosure in healthcare settings, taking into consideration consequences of disclosure to medical professionals to increase women's self-efficacy around this process.

AIM:To characterise experiences with telehealth for Medications for Opioid Use Disorder (MOUD) services among patients, prescribers, nurses and substance use counsellors to inform future best practices. DESIGN:We engaged a qualitative descriptive study design. METHODS:Semi-structured interviews were conducted with prescribers (nurse practitioners and physicians, n = 20), nurses and substance use counsellors (n = 7), and patients (n = 20) between June and September 2021. Interviews were verbatim transcribed. Thematic analysis was conducted using a qualitative descriptive method. RESULTS:Among both providers and patients, four themes were identified: (1) Difficulties with telehealth connection (2) Flexibility in follow-up and retention, (3) Policy changes that enabled expanded care, (4) Path forward with telehealth. Two additional findings emerged from provider interviews: (1) Expansion of nurse-managed office-based opioid treatment, and (2) Novel methods to engage patients. CONCLUSIONS:Patients and providers continued to view telehealth as an acceptable means for delivery and management of MOUD, particularly when utilised in a hybrid manner between in-person visits. Nurse-managed care for this service was evident as nurses extended the breadth of services offered and utilised novel methods such as text messages and management of 'call-in' lines to engage patients. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE:Use of telehealth for MOUD should be incorporated into practice settings to reach patients in a flexible manner. Nurses in particular can use this medium to extend office-based opioid treatment by conducting assessments and expanding capacity for other wrap-around services. IMPACT:We identify recommendations for best practices in the use of telehealth for opioid use disorder management and highlight the value of nurse-managed care. REPORTING METHOD:The consolidated criteria for reporting qualitative research. PATIENT OR PUBLIC CONTRIBUTION:Patients with opioid use disorder and prescribers with experience using telehealth were interviewed for this study.

Group-based parent training (PT) is an evidence-based approach for strengthening parenting skills and reducing child behavior problems. However, there has been little research on the social connectedness (SC) formed among PT participants, particularly in low-income communities where parents may be more socially isolated. This study describes SC formed among parents in a group-based PT program implemented in their children's school and its association with changes in child behavior. Using a convergent mixed-methods design, data collection occurred between 2020 and 2022. Parents (n = 97) completed measures of their SC to other parents in their PT group and their child's behavior. Qualitative interviews with a representative subsample of parents (n = 17) were also conducted to understand parents' perceptions and experiences of SC within their PT group. Parents reported high levels of SC (M = 4.45 [range = 3.04-5 on scale of 1-5]; SD = 0.4). From baseline to postintervention, the number of children with child behavior problems significantly decreased (32.12%, 37.5% behavior intensity and problems, respectively). The magnitude of decline in child behavior problems was significantly related to parents' SC (b = -11.52, p = .02, SE = 4.99). Qualitative data confirmed high levels of SC, which parents linked to improvements in their parenting and children's behavior. Themes focused on the building of connections, committing to a safe space with parents who share similar goals, supporting one another, and gaining connections within the school environment and during the COVID-19 pandemic. Results highlight the potential synergistic effects of SC formed in the context of group-based PT with implications for strengthening parenting skills and children's well-being.

Intimate partner violence (IPV) remains a critical challenge to HIV prevention and treatment efforts across the globe. We examined recently published (January 9, 2017–January 9, 2023) integrated behavioral interventions designed to address IPV and HIV across the care continuum. Fifteen studies (involving n = 10,947 participants) met the inclusion criteria for this review. Majority (n = 13) of studies focused on IPV and HIV prevention whereas two studies addressed IPV and HIV care engagement among women living with HIV. Ten studies were conducted on the African continent representing 5 countries. Most interventions (n = 11) focused on individual-level outcomes among cisgender women although two involved male partners. About half of the interventions reviewed (n = 8) showed effectiveness on both IPV and HIV outcomes compared to control groups. Integrated HIV/IPV interventions are needed to address the synergistic nature of these epidemics among marginalized populations. Future studies should focus on developing and implementing strength-based interventions among people living with HIV, men, transgender people, and Black women in the USA. Additionally, researchers and program managers should consider addressing structural and internalized stigma as potential behavioral mechanisms for improving health among people simultaneously experiencing or at-risk for HIV and IPV.

INTRODUCTION:People who inject drugs (PWID) have a greater burden of multimorbid chronic diseases than the general population. However, little attention has been paid to the engagement in primary care for services related specifically to injection drug use and management of underlying chronic comorbid diseases for this population. This systematic review identified facilitators and barriers to healthcare engagement in the primary care setting among PWID.DESIGN AND METHODS:Studies were identified by a literature search of PubMed, CINAHL, and EMBASE, and by searching the references of retrieved articles. Studies were included if they measured active injection drug use, and outcomes related to primary care engagement characterized by: diagnosis of a health condition, linkage or retention in care, health condition-related outcomes, and reported patient-provider relationship.RESULTS:Twenty-three articles were included. Using the behavioral model, factors within predisposing, enabling, need, and health behavior domains were identified. Having co-located services and a positive patient-provider relationship were among the strongest factors associated with healthcare utilization and engagement while active injection drug use was associated with decreased engagement.CONCLUSIONS:To our knowledge, this is the only review of evidence that has examined factors related to primary care engagement for people who inject drugs. Most articles were observational studies utilizing descriptive designs. Although the assessment of the evidence was primarily rated 'Good', this review identifies a significant need to improve our understanding of primary care engagement for PWID. Future research and intervention strategies should consider these findings to better integrate the holistic care needs of PWID into primary care to reduce morbidity and mortality associated with injection drug use and chronic disease.CLINICAL RELEVANCE:Primary care engagement is important for preventative care, early diagnosis of disease, and management of chronic diseases, including addressing problems of substance use. This review highlights factors nurses can utilize to facilitate primary care engagement of PWID.

Introduction: Despite global reductions in HIV incidence and significant investment in local harm reduction services, Ukraine continues to experience high HIV and HCV prevalence among people who inject drugs (PWID). Place-based factors and social norms affect drug use-related risk factors, but research has paid little attention to the relationship between drug use practices and place in Ukraine, including how these factors may contribute to or protect against HIV/HCV risk.Methods: This project used a sequential mixed methods design. Between March and August 2018, we interviewed 30 PWID in Dnipro, Ukraine. Participants completed a single in-depth interview in which they described where and with whom they lived; how they generated income; and where, when, how, and with whom they purchased and used drugs. Between May 2019 and March 2020, we recruited 150 PWID in Dnipro to complete a survey that was designed based on interview findings and consisted of three components: an activity space inventory, an egocentric social network inventory, and an HIV risk behavior assessment.Results: Both interview and survey respondents reported consistent use of pharmacies to acquire syringes and nearly universal use of new syringes when injecting. Interview participants reflected that while syringe sharing was previously considered a "common practice," PWID now viewed it as infrequent and unacceptable. However, interview respondents enumerated the contexts in which needle and syringe reuse occurred, including purchasing drugs directly from a dealer and chipping in with other PWID to prepare drugs bought through a stash.Conclusion: Participants described relatively easy access to new needles and syringes through pharmacies and expressed strong social sanctioning against reusing needles or syringes. However, equipment sharing behaviors and norms persisted in certain contexts, creating an opportunity for further harm reduction campaigns that incorporate changing norms in these situations to "close the gap" and further reduce HIV and other infections among PWID.

Alcohol use among persons living with HIV (PWH) can lead to poor disease outcomes. Disclosure of alcohol consumption to physicians is critical to inform HIV care. HIV stigma is associated with poor care engagement, and this relationship is partially mediated by depression. However, less is known about how HIV stigma and depression affect reporting of alcohol use to care providers. We used baseline data from an HIV intervention trial of 330 adult PWH in Baltimore, MD. We fit a path model to examine whether HIV stigma was associated with increased depression symptoms and whether higher levels of depression were, in turn, associated with underreporting of alcohol use to physicians. Among PWH reporting past 6-month alcohol use (n = 182, 55%), 64% met symptom criteria for probable depression, 58% met criteria for hazardous drinking, and 10% reported not disclosing alcohol use to their physician. HIV stigma was associated with higher levels of depression (beta = 0.99, p < .0001); depression was associated with a lower likelihood of alcohol disclosure (beta = -0.04, p < .0001); and depression mediated the indirect pathway from stigma to alcohol disclosure (beta = -0.04, p < .01). Methods to augment or strengthen alcohol self-report may be useful in HIV care, particularly among PWH experiencing HIV stigma and depression.