The research team conducted a doctrinal legal analysis combined with a normative-comparative approach, examining the national legislation of nine EU Member States—Belgium, Poland, Greece, Ireland, France, Germany, Italy, the Netherlands and Portugal—together with the United Kingdom, which was included because of its historically influential role in European pharmaceutical regulation despite its post-Brexit status. The frameworks reflected the law as it stood on 1 February 2026, drawing on primary legal texts retrieved from official national databases such as Légifrance, Gesetze im Internet, Normattiva, ISAP and legislation.gov.uk, alongside guidance from national regulators and reports from the European Union Drugs Agency. Three authors independently extracted data using a standardized form structured around seven criteria: legal classification, prescribing regime, physical storage, accountability systems, digitalization, destruction procedures and institutional oversight.

The jurisdictions were deliberately chosen to represent the full range of regulatory orientations found in European literature and in country assessments by the International Narcotics Control Board, covering Northern, Western, Southern and Eastern Europe. A country was assigned to a regulatory model when it exhibited the defining features of that model for at least five of the seven criteria, with no directly contradictory features among the remainder. Dual assignment was permitted where a jurisdiction displayed balanced features of two models, as occurred with Ireland. The typology had been formulated as an a priori scaffold from comparative pharmaceutical law scholarship and the INCB assessment framework, and the empirical verification stage confirmed rather than redefined it.

Four models emerged. The first, labeled Centralized-Procedural, groups France, Germany, Italy and Greece. It is characterized by detailed procedural regulation, centralized licensing, specialized prescription forms—notably the triplicate Betäubungsmittelrezepte in Germany and the numbered ricette ministeriali a ricalco in Italy—and strong administrative accountability through pharmaceutical oversight. Its strength lies in high traceability and clearly defined responsibilities; its weakness is a substantial administrative burden and limited flexibility. The second model, Digitalized-Integrated, covers Belgium and Poland, both of which have made electronic systems mandatory at national level: Poland introduced compulsory e-prescriptions for all I-N narcotic and II-P psychotropic drugs on 1 November 2023, after which paper prescriptions became invalid, while Belgium’s Narcoreg platform, mandatory since 1 September 2023, requires business-to-business transfers to be declared within 30 days.

The third, Harm-Reduction model, encompasses the Netherlands and Portugal. Both distinguish sharply between strict medical control of therapeutic use and a public-health-oriented social policy toward users. Portugal is the boldest case: Law 30/2000 decriminalizes possession of personal-use amounts of all controlled substances, up to a ten-day supply, shifting the response from criminal prosecution to administrative and health regulation, while medical use remains strictly controlled under Decreto-Lei 15/93. Evidence reviewed in the study indicates that Portuguese decriminalization, combined with investment in prevention and treatment, did not increase problematic drug use and was associated with improvements in public health indicators, although the model’s sustainability remains debated as patterns of substance use diversify. The Netherlands pairs its two-list Opiumwet system with digital registers in pharmacies and permits for hospital pharmacies issued by the Ministry of Health.

The fourth model, Institutional Accountability, is anchored in the United Kingdom and, jointly, Ireland. Its distinctive feature is the Controlled Drugs Accountable Officer, a designated individual required in every UK organization handling controlled medicines, responsible for standard operating procedures, internal audits and reporting to NHS England and the Care Quality Commission. No equivalent mandatory position exists elsewhere in Europe. Ireland shares the procedural features of the centralized model—bound Controlled Drugs Registers, safe-custody storage rules and supervised destruction—but also provides a designated internal responsible officer analogous to the CDAO, earning it dual placement in Models 1 and 4.

The quantitative contrasts the study documents are striking. Document retention requirements range from two to ten years, with France imposing the longest period: ten years for the narcotics register and destruction records, and three years for prescription copies. Portugal and Poland require five-year retention. Digitalization, operationalized as mandatory electronic use for prescription issuance, dispensing records or business-to-business reporting, was rated high in the Netherlands, Poland and Belgium; intermediate in Greece, Italy and the United Kingdom, where the Electronic Prescription Service covers some Schedule 3 to 5 drugs but Schedule 2 medicines still demand paper FP10PCD forms; and low in France, Germany, Portugal and Ireland, all of which still rely predominantly on paper-based tracking. Germany’s famous yellow triplicate forms, one copy each for prescriber, pharmacy and audit, remain entirely paper-based.

Even emergency provision splits the continent. Ireland permits pharmacists to make emergency supplies of CD2, CD3 and CD4 substances—up to five days of treatment or the minimum pack size—when they judge the supply safe, appropriate and necessary. The United Kingdom takes nearly the opposite position: emergency supply of Schedule 2 and most Schedule 3 drugs is effectively prohibited, with phenobarbital for epilepsy the sole exception. Destruction procedures diverge just as widely, from Belgium’s FAMHP-supervised sealing and three-copy destruction statements, through Poland’s documented transfer to licensed companies and Greece’s annual witnessed destruction events, to the pharmacist-led denaturing performed in French hospitals in the presence of a second pharmacist.

The fragmentation has tangible clinical consequences. The EU’s cross-border electronic prescription infrastructure, eHDSI or MyHealth@EU, currently excludes controlled substances altogether, so regulatory divergence directly disrupts continuity of care for patients with legitimate therapeutic needs who travel within the Union—a growing problem as patient and professional mobility increases. The study’s authors argue that harmonization should not mean uniformity, which they consider both unrealistic and undesirable, but rather the definition of minimum common standards for traceability, destruction documentation and digitalization thresholds, while preserving room for national adaptation. They also call for explicit recognition of hospital pharmacists, whom they describe as the critical legal-clinical interface between regulatory frameworks and daily practice.

From a hospital pharmacy perspective, the findings carry direct operational weight. In the low-digitalization countries, pharmacists shoulder manual paper-based verification, register maintenance and destruction documentation, tasks that consume time and raise the risk of transcription errors and accountability gaps; the Belgian and Polish digital models offer a route to reducing that burden while strengthening traceability. Scoping review evidence cited in the study confirms that inadequate safeguards in hospital controlled substance management are associated with drug diversion, with pharmacy playing a central role in both prevention and detection. The authors acknowledge limitations: the analysis examines codified law rather than implementation or clinical outcomes, uses purposive rather than statistically representative sampling, and involves interpretive judgment in borderline model assignments. Future research, they suggest, could evaluate the real-world effectiveness of each model, explore healthcare professionals’ experiences, analyze incident frequency across systems and assess whether artificial intelligence and blockchain technologies could further enhance traceability and security in this most tightly guarded corner of pharmaceutical practice.

Subject of Research: Comparative national regulation of medicinal products containing controlled substances in nine EU Member States and the United Kingdom

Article Title: Comparative analysis of national regulatory frameworks for medicinal products containing controlled substances in nine selected EU Member States and the United Kingdom

Article References: Stoyanova, D. D., Todorova, A. H., Pesheva, M. T., & Grigorov, E. E. (2026). Comparative analysis of national regulatory frameworks for medicinal products containing controlled substances in nine selected EU Member States and the United Kingdom. Pharmacia, 73, Article e197283. https://doi.org/10.3897/pharmacia.73.e197283

Image Credits: AI Generated

DOI: 10.3897/pharmacia.73.e197283

Keywords: controlled substances, pharmaceutical regulation, opioids, European Union, hospital pharmacy, digitalization, e-prescription, harm reduction, drug policy, regulatory harmonization, United Kingdom, misuse of drugs

The study was embedded in the second round of a bio-behavioral survey of people who inject drugs of any gender, conducted in Maputo, Beira, Tete, Quelimane and Nampula. From the larger survey sample, the researchers isolated 524 women who inject drugs, each of whom completed a structured questionnaire covering sociodemographic characteristics, drug use patterns, sexual behavior and healthcare access, and provided samples for rapid point-of-care testing for HIV, hepatitis B surface antigen and hepatitis C antibodies. Because people who inject drugs are difficult to reach through conventional household surveys, the team used respondent-driven sampling, a chain-referral technique in which initial participants, or seeds, recruit peers from their own social networks, and the resulting recruitment chains are statistically weighted to reduce the biases introduced by network-based recruitment.

Respondent-driven sampling allowed the investigators to calculate weighted prevalence estimates that better reflect the underlying population of women who inject drugs in each city rather than merely the convenience sample they managed to enroll. For HIV, the weighted prevalence of 28.6 percent came with a wide 95 percent confidence interval of 15.5 to 41.6 percent, a reflection of both the subgroup’s size and the variability of infection across cities. The weighted prevalence of hepatitis C antibodies, 19.7 percent, carried an even wider interval of 3.1 to 36.2 percent, underscoring how heterogeneous the epidemic is across urban settings. Hepatitis B surface antigen positivity, at 5.3 percent, was comparatively narrow at 3.4 to 7.3 percent.

Unadjusted analyses revealed striking patterns. HIV prevalence peaked among women aged 25 to 34 years and rose markedly with both age and the duration of injection drug use, a relationship consistent with cumulative exposure risk over years of sharing needles, syringes, cookers or other injection paraphernalia. Geography mattered as well: prevalence was highest in Maputo City, the capital and largest urban center, suggesting that dense urban drug markets and sexual networks may amplify transmission. The hepatitis C picture mirrored this concentration of risk, since the virus, which is transmitted efficiently through blood-to-blood contact, is a sensitive marker of unsafe injection practices accumulated over time.

To move beyond simple associations, the researchers applied modified Poisson regression with robust standard errors, a modeling approach well suited to binary outcomes such as infection status because it yields adjusted prevalence ratios that are easier to interpret than odds ratios when outcomes are common. After adjustment for confounding, two factors remained independently associated with HIV infection: older age, with women aged 35 years or older showing an adjusted prevalence ratio of 11.9 compared with those aged 16 to 17 years, a confidence interval of 4.0 to 35.6, and residence in Maputo. Conversely, secondary or higher education and the absence of recent symptoms of sexually transmitted infections were associated with lower HIV prevalence, pointing to the intertwined roles of educational attainment, sexual health and injection-related risk in shaping vulnerability.

The magnitude of the age effect deserves emphasis. An adjusted prevalence ratio of nearly twelve means that, after accounting for other measured factors, the oldest women in the sample were roughly twelve times more likely to be living with HIV than the youngest. This gradient is consistent with the natural history of an epidemic that has had years to accumulate in older cohorts of people who inject drugs, but it also signals that women who began injecting more recently are not spared risk; rather, they represent an opportunity for early intervention before infection becomes established in their networks.

The study also traced the HIV care continuum among the women found to be living with the virus, and the results reveal both progress and a persistent bottleneck. Among women who inject drugs living with HIV, 85.0 percent were aware of their status, a comparatively high level of knowledge that likely reflects the reach of community-based testing. Of those aware, 86.6 percent were on antiretroviral therapy, and of those on treatment, 75.7 percent had achieved viral suppression. Each stepwise attrition may seem modest, but compounded, they mean that only a fraction of all HIV-positive women who inject drugs in these cities are virally suppressed, the condition that both preserves individual health and prevents onward transmission.

The authors highlight the gap between antiretroviral therapy initiation and viral suppression as a priority for further investigation. Retention in care, adherence support, stigma within health facilities, interruptions in drug supply and the competing demands of daily survival for women who use drugs can all erode the effectiveness of treatment programs. Because viral suppression is the endpoint that matters most for both morbidity and prevention, understanding why nearly a quarter of women on treatment have not achieved it is a research question with direct programmatic consequences.

The hepatitis findings carry their own implications. A hepatitis B surface antigen prevalence of 5.3 percent places the surveyed women in a range consistent with intermediate endemicity, raising questions about access to hepatitis B vaccination, which in Mozambique is delivered through routine childhood immunization but may have missed adults now in their twenties and thirties. The anti-HCV prevalence of 19.7 percent, meanwhile, points to substantial exposure to hepatitis C, a curable infection since the advent of direct-acting antiviral agents, yet one that remains undiagnosed and untreated in most low-resource settings. Integrating hepatitis B and C testing, vaccination where indicated, and treatment into existing HIV and harm-reduction services would allow a single point of contact to address all three blood-borne viruses.

The study’s conclusions converge on a clear set of priorities: expanded harm-reduction services, including sterile injecting equipment and opioid substitution therapy where feasible; integrated testing and treatment for HIV, hepatitis B and hepatitis C; and prevention efforts targeted to the cities and age groups bearing the heaviest burden, particularly Maputo and women in mid-adulthood with long injection histories. Funded by the Global Fund to Fight AIDS, Tuberculosis and Malaria and approved by Mozambique’s national ethics bodies, the survey demonstrates that even in settings where women who inject drugs are few in number relative to men, their infection burden is severe enough to demand dedicated attention. Without such attention, the authors warn, the gaps documented here will continue to translate into preventable infections and preventable deaths.

Subject of Research: Prevalence and risk factors of HIV, hepatitis B, and hepatitis C among women who inject drugs in Mozambique

Article Title: Prevalence and risk factors of HIV, HBV, and HCV among women who inject drugs in five Mozambican cities: a subgroup analysis of a cross-sectional biological and behavioral survey, 2023–2024

Article References: Banze, Á. R., Muleia, R., Nuvunga, S., Craveiro, I., Seabra, S. G., & Baltazar, C. S. (2026). Prevalence and risk factors of HIV, HBV, and HCV among women who inject drugs in five Mozambican cities: a subgroup analysis of a cross-sectional biological and behavioral survey, 2023–2024. BMC Public Health. https://doi.org/10.1186/s12889-026-29934-1

Image Credits: AI Generated

DOI: 10.1186/s12889-026-29934-1

Keywords: HIV, hepatitis B, hepatitis C, women who inject drugs, Mozambique, harm reduction, respondent-driven sampling, antiretroviral therapy, viral suppression, cross-sectional survey, public health, Prevalence

The study, conducted from June to November 2025, used a structured online questionnaire distributed through pharmacy-related social media groups and professional pages across Kosova. Participants included pharmacists and pharmacy technicians directly involved in dispensing medicines and counseling patients. The 29-item instrument covered demographic and professional background, awareness of opioid abuse and misuse, attitudes toward counseling and harm reduction, reported practices, and self-reported confidence related to naloxone administration. Most participants were female (75.8 percent), aged 19 to 30 (57.7 percent), and held a Master of Pharmacy degree (65.4 percent). More than half reported one to four years of work experience, and most worked full time in urban pharmacies.

The results paint a picture of a workforce that is well informed on paper. A striking 93.5 percent of respondents reported understanding the difference between opioid abuse and opioid misuse, terms that carry distinct clinical meanings: misuse refers to using prescription opioids in a manner other than prescribed, while abuse refers more broadly to harmful or non-medical opioid use. Familiarity with naloxone and its mechanism of action was reported by 81.5 percent of participants. Internal consistency of the awareness items was good, with a Cronbach’s alpha of 0.81, suggesting the questions reliably captured a coherent construct of self-reported knowledge.

Attitudes toward professional involvement were similarly encouraging. Three quarters of respondents (75.8 percent) agreed that pharmacies are appropriate settings for counseling individuals suspected of opioid abuse, and 75.1 percent said they were willing to provide such counseling. Support for dispensing opioids only with a valid medical prescription was nearly universal at 93.5 percent, and 94.6 percent agreed that pharmacy professionals should not sell medications to individuals who appear to be abusing them. Almost all respondents (95.0 percent) agreed that pharmacy staff should be trained to recognize individuals with substance misuse, and 98.5 percent said staff should be informed about medications with abuse potential. The attitude scale showed acceptable internal consistency with a Cronbach’s alpha of 0.76.

Yet beneath these positive surface indicators, the survey exposed significant vulnerabilities. Only 56.2 percent of participants reported feeling either confident enough or very confident in administering naloxone in their pharmacy setting, while 43.8 percent reported not feeling confident at all. This is a substantial proportion of a workforce that, in many countries, is increasingly expected to serve as a frontline response to opioid overdose. More than half of respondents (54.2 percent) also expressed concern that administering naloxone would require more time than they could provide in routine pharmacy practice, pointing to workflow pressures as an additional barrier beyond knowledge alone.

Work experience emerged as a meaningful variable across multiple measures. Chi-square tests revealed statistically significant associations between years of practice and several responses, including views on prescription-only opioid dispensing (p = 0.013), training in recognizing substance misuse (p = 0.040), naloxone-related education (p = 0.001), and time constraints around naloxone administration (p = 0.027). Most notably, self-reported confidence in administering naloxone was significantly associated with work experience (p = 0.017), and familiarity with naloxone showed an even stronger association (p = 0.001). These findings align with previous international research suggesting that more experienced pharmacists often report greater comfort when addressing opioid-related situations and engaging in patient counseling.

The regulatory context in Kosova adds a layer of complexity that the authors emphasize. Although national legislation governs medicinal products and retail pharmacy services, the current framework does not explicitly provide community pharmacists or pharmacy technicians with the authority to administer naloxone. This means that participants’ responses regarding confidence in naloxone administration should be understood as perceptions of a potential role rather than reflections of established practice. The authors note that this regulatory uncertainty is particularly relevant when assessing pharmacy professionals’ willingness and confidence to participate in opioid overdose management, and that clearer professional and regulatory guidance may be needed to address the gap.

Not all findings were uniformly positive. While 78.1 percent of respondents reported suggesting safer alternatives when misuse was suspected, only 31.9 percent reported contacting nearby pharmacies to inform them of an individual suspected of opioid misuse. This pattern, in which pharmacists feel comfortable with individual counseling but hesitate when broader professional collaboration is required, has been observed in other studies and may reflect barriers to inter-professional communication that were not directly examined in the present research. Additionally, 38.5 percent of participants agreed that the sale of controlled medications without a prescription represents an important source of pharmacy income, a finding the authors say should be interpreted cautiously as it reflects perceptions rather than dispensing practices.

The study has several limitations that shape how the results should be read. The cross-sectional design captures attitudes at a single point in time and cannot establish causality. Responses were self-reported rather than directly observed, meaning actual behavior and practical competence may differ from what participants described. Social desirability bias may have influenced answers to questions about professional responsibility and ethical practice. The voluntary online recruitment through social media may have attracted pharmacy professionals with a stronger interest in public health, potentially skewing responses toward more positive attitudes. The questionnaire was developed specifically for this study without formal pilot testing, and confidence in naloxone administration was assessed using a single item. Pharmacists and pharmacy technicians were also analyzed together without separate analysis by professional qualification.

Despite these limitations, the findings carry practical weight for a region where empirical evidence on pharmacy involvement in opioid harm reduction has been scarce. The authors conclude that strengthening the role of community pharmacy professionals in opioid abuse prevention will require more than awareness alone. Practice-oriented training, clear professional guidance, and supportive regulatory frameworks are needed to translate positive attitudes and self-reported knowledge into genuine confidence at the counter. International evidence suggests that successful pharmacist involvement in opioid harm reduction is most likely when training, regulatory clarity, and institutional support are aligned, and in settings where access to specialized addiction services is limited, community pharmacies may represent one of the most promising settings for early identification of opioid-related concerns and overdose prevention.

Subject of Research: Community pharmacists' awareness, attitudes, and confidence regarding opioid abuse and naloxone use in Kosova

Article Title: Community pharmacists’ awareness, attitudes, and confidence regarding opioid abuse and naloxone use in Kosova: A cross-sectional survey

Article References: Ibraimi, Z., Haxhiu, A., Shabani, D., Qeriqi, V., Bresa, A., & Haliti, D. (2026). Community pharmacists’ awareness, attitudes, and confidence regarding opioid abuse and naloxone use in Kosova: A cross-sectional survey. Pharmacia, 73, Article e204449. https://doi.org/10.3897/pharmacia.73.e204449

Image Credits: AI Generated

DOI: 10.3897/pharmacia.73.e204449

Keywords: opioid abuse, naloxone, community pharmacists, Kosova, harm reduction, cross-sectional survey, Community, pharmacists, awareness, attitudes, confidence, regarding

The research team, led by Nassoro Mwanyalu of the Mombasa County Department of Health Service together with collaborators from Kenya’s Field Epidemiology and Laboratory Training Program, conducted a retrospective review of records for opioid-dependent persons enrolled in methadone treatment at the Kisauni clinic between 2017 and 2019. Of 457 records examined, 443 met the inclusion criteria, excluding clients who had transferred into or out of the clinic or had been in treatment for less than three months. The team defined a poor clinical or health-related treatment outcome as any client who was lost to follow-up, acquired HIV, hepatitis B, or hepatitis C while on methadone, missed two or more monthly antiretroviral therapy pickups, or died during treatment, regardless of cause.

The demographic picture that emerged was strikingly male-dominated. Men comprised 90.7 percent of the eligible clients, with an overall mean age of 37 years. Female clients were markedly younger, with 79.1 percent aged 35 or below, compared with a male distribution concentrated in the 36 to 45 age bracket. Women were also more educated than their male counterparts, with 27.9 percent of female clients reaching post-primary education versus 15 percent of males. Yet women carried a disproportionate burden of infectious disease: 39.5 percent of female clients were HIV positive, compared with 8.75 percent of males, and 18.6 percent of women were hepatitis C positive versus 7.75 percent of men. Overall HIV prevalence across the cohort stood at 13.1 percent, hepatitis B at 7.2 percent, and hepatitis C at 8.8 percent.

Drug use histories reflected the coastal heroin trade that funnels through Mombasa’s position along Indian Ocean trafficking routes. At enrollment, 98.1 percent of clients were mixing heroin with other drugs, and the median duration of opioid use before joining methadone treatment was six years. Roughly 28.4 percent of clients were categorized as injecting drug users, while the remaining 71.6 percent were non-injectors, primarily smoking or inhaling heroin. During treatment, 15.8 percent of clients continued to use illicit substances, with cannabis accounting for the majority of concurrent use at 65.6 percent, followed by benzodiazepines and tricyclic antidepressants.

Treatment outcomes told a story of both success and attrition. Three-quarters of clients remained active in the program, a retention rate the authors attribute in part to a defaulter-tracking collaboration between clinic staff and two civil society organizations, the Muslim Education and Welfare Association and Reach Out Centre Trust, whose outreach workers identify and re-induct clients who drop out. Nevertheless, 22.8 percent of clients were lost to follow-up, defined under Kenya’s national protocol as missing 30 or more consecutive daily methadone doses. Five clients died during treatment, four acquired HIV, five became hepatitis B positive, and five turned hepatitis C positive while on methadone. In total, 27.5 percent of enrolled clients experienced at least one poor clinical or health-related outcome during the study period.

The statistical analysis, performed with Epi Info 7 using prevalence odds ratios and 95 percent confidence intervals, identified three factors significantly associated with being lost to follow-up. Lack of formal education carried the strongest association, with a prevalence odds ratio of 2.7, meaning clients without schooling had nearly triple the odds of dropping out. Unemployment followed with an odds ratio of 2.4, and being a non-injecting drug user at enrollment carried an odds ratio of 1.7. Notably, the period of opioid use before treatment, polysubstance use during methadone therapy, the specific type of illicit drug used while on treatment, and living with HIV were all assessed and found to have no significant effect on attrition.

The education and unemployment findings carry particular technical weight because they point to structural barriers rather than pharmacological ones. The authors suggest that clients lacking primary school education may lack employability skills, hampering reemployment during recovery and leaving them unable to finance daily travel costs to the clinic. The restricted morning service delivery model for daily observed therapy may compound the problem: employed clients cannot work regular hours before picking up their dose, and job-seeking clients may find the clinic schedule incompatible with interviews and work commitments. The authors argue this dynamic may create the perception that methadone clients are still active drug users, rendering employment difficult and increasing time spent in drug consumption spaces, which in turn raises dropout risk.

The non-injector finding stands in contrast to much of the international literature. Studies by Ledgerwood and colleagues and by Nordt and colleagues found no significant effect of heroin administration route on treatment outcomes. The Mombasa team proposes a plausible biological and behavioral explanation: injecting drug users are more likely to be HIV positive, which may increase their timely health-seeking behavior and adherence to scheduled clinical reviews and psychological support. This echoes findings by Morgan and colleagues in South Africa, who reported that non-injectors had poorer treatment outcomes than injectors in inpatient rehabilitation settings, adding African evidence to a pattern that challenges assumptions about which opioid users need the closest monitoring.

HIV treatment integration emerged as a technical bright spot. All 58 HIV-positive clients, including the four new infections acquired during treatment, were linked to a Comprehensive Care Clinic either at the Kisauni facility or nearby, and all were receiving antiretroviral therapy. Among the eight clients taking their antiretroviral medication directly at the Kisauni clinic, 75 percent had undetectable viral loads, implying that supervised antiretroviral therapy combined with daily methadone intake enhances treatment adherence. Only 3.6 percent of HIV-infected clients linked to care defaulted from antiretroviral therapy. These results align with prior research in Nairobi and Dar es Salaam reporting improved antiretroviral adherence among opioid-dependent clients on methadone, though the authors note that the proportion of HIV-positive clients taking their medication at the Kisauni clinic itself remained low.

The authors conclude that the Kisauni model confirms the effectiveness of a low-threshold, one-stop-shop methadone program integrating HIV, viral hepatitis, and sexually transmitted infection prevention and treatment. But they caution that without a more patient-centred approach, methadone risks being perceived as simply replacing one drug with another. Their recommendations include refresher training for staff, alternative dispensing models, short treatment breaks and take-home doses as incentives for stable and drug-free clients, and full integration of comprehensive HIV care into methadone services. They also call for closer monitoring of clients who are unemployed, non-injecting, or lack formal education, and for further research addressing the vulnerability of female and young opioid users, whose disproportionate infectious disease burden in Mombasa demands targeted intervention.

Subject of Research: A retrospective records review of methadone maintenance treatment clients in Mombasa, Kenya, identifying socioeconomic and behavioral risk factors for poor treatment outcomes and dropout.

Article Title: Risk factors for poor treatment outcomes among opioid-dependent clients taking methadone in Mombasa, Kenya

Article References: Mwanyalu, N., Nunga, M., Mwanyamawi, R., Abdallah, S., & Owiny, M. (2024). Risk factors for poor treatment outcomes among opioid-dependent clients taking methadone in Mombasa, Kenya. Advances in Drug and Alcohol Research, 4, Article 11791. https://doi.org/10.3389/adar.2024.11791

Image Credits: AI Generated

DOI: 10.3389/adar.2024.11791

Keywords: methadone maintenance treatment, opioid dependence, Kenya, Mombasa, lost to follow-up, HIV, hepatitis C, treatment retention, harm reduction, unemployment, non-injectors, antiretroviral therapy

The research team, led by Kirsten Paulus and Sarah Bauerle Bass of Temple University College of Public Health, applied the Health Belief Model, a long-standing behavioral framework, to understand pandemic decision-making among people who use drugs. The model proposes that a person’s belief in the threat of a disease, together with their belief in the effectiveness of a proposed protective behavior, predicts the likelihood that they will actually perform that behavior. It rests on six constructs: perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action, and self-efficacy. Public health professionals have used the model for decades to design interventions that increase uptake of behaviors like disease screening, and during the COVID-19 pandemic it was successfully applied to predict vaccine intention and adherence to prevention practices across many population groups. What it had never been used for, until now, was understanding pandemic behavior among people who use drugs.

To fill that gap, the researchers conducted a cross-sectional survey between September and December 2021 with 75 clients of a large harm reduction organization in Philadelphia, an agency that serves more than 25,000 unique clients with services including medication for opioid use disorder, behavioral health care, infectious disease prevention, syringe exchange, medical treatment, and housing support. Research staff approached clients while they were receiving services, obtained informed consent in a private area, and administered the survey verbally on an iPad, entering responses into REDCap. Participants received a paper survey and a laminated scale sheet to improve visibility and comprehensibility, and each session took roughly 15 minutes under strict COVID-19 protocols. The instrument combined validated measures with study-specific items derived from earlier qualitative interviews, covering 18 sociodemographic questions and 22 thematic sections on COVID-19, vaccination, harm reduction, sex work, drug use, and basic needs. Five sections mapped directly onto Health Belief Model constructs, with respondents rating statements from zero for highly disagree to ten for highly agree.

The analytic centerpiece was a k-means cluster analysis, a non-hierarchical statistical method that discerns latent subgroups within a sample by assigning individual cases to clusters according to their proximity to the nearest centroid of constituent items, iterating until the desired cluster solution is achieved. Classification was based on four items capturing each participant’s relationship with COVID-19: whether they had ever tested positive, whether they knew someone who had the disease, whether they believed they were susceptible to getting it in the future, and a sum score of their perceived resiliency against difficult things. After accounting for missing data on 15 cases, the final analytic sample was 60 participants. Convergence was achieved after eight iterations, and a two-cluster solution emerged that was independent of every demographic variable measured.

The first cluster, 28 participants or 47 percent of the sample, was more likely to believe they had not been significantly affected by COVID-19 and that it posed no potential future threat, scoring a mean of 2 on the perceived impact item, and showed high overall resiliency with a mean score of 21. The researchers labeled this group Less COVID impact/High resilience, or NoCOV/HR. The second cluster, 32 participants or 53 percent, believed they had been significantly affected by COVID-19 or would be in the future, with a mean of 5, and had lower resiliency, with a mean of 13. This group was labeled High COVID impact/Low resilience, or COV/LR. Strikingly, the two clusters did not differ on age, gender, race, education, employment, income, housing status, vaccination status, or COVID-19 knowledge. Instead, the segmentation was defined by what the authors call psychographic characteristics, meaning perceptions and attitudes rather than demographic descriptors, a novel approach to understanding populations in COVID-19 research.

When the researchers compared the clusters on Health Belief Model constructs using Student’s t-tests and chi-square tests at a 0.05 significance level, meaningful differences appeared across four of the five construct sections. The COV/LR cluster more strongly agreed that people they know had gotten COVID-19, scoring a mean of 8.09 versus 5.61 for the NoCOV/HR group, indicating higher perceived susceptibility. The low-resilience cluster was also far more likely to agree that it is difficult to follow prevention instructions such as mask wearing and social distancing, with a mean of 3.94 versus 0.63, and more likely to report lacking things to keep them safe, such as masks or hand sanitizer, at 2.16 versus 0.67. On the severity side, 58.1 percent of the COV/LR cluster agreed they had to continue working in close contact with people who might be infected, compared with 26.9 percent of the high-resilience cluster, and 71.9 percent reported an increase in mental health problems or symptoms such as mood, anxiety, or stress, versus 46.4 percent.

The high-resilience cluster showed its advantages on the self-efficacy and cues-to-action constructs. Those participants agreed more strongly that they know what is safe and not safe to protect themselves from COVID-19, scoring a mean of 9.29 versus 8.38, and that messages about how to protect themselves and others are easy to understand, at 9.71 versus 8.81. In other words, the psychologically resilient group not only felt less personally impacted by the pandemic but also felt confident in its ability to act on protective information, while the low-resilience group, despite clearly fearing COVID-19’s impact, was less confident in its ability to adhere to preventative behaviors. The authors note that respondents in both clusters often fell on the same end of the agree-disagree scale, diverging mainly in magnitude, which suggests that messaging or interventions aimed at improving resiliency for everyone should yield improvement across both groups.

The findings also illuminate the connection between resilience and mental wellbeing during the pandemic. Those with lower resilience reported an increase in mental health problems, an association consistent with prior work showing that the experience of a high perceived threat can itself erode resilience. COVID-19 restrictions may have exacerbated these negative outcomes, the authors write, because government-enforced curfews and decreased capacity of community agencies reduced access to life-protecting harm reduction services, leading to increased drug use, feelings of isolation, and diminished resilience. Notably, the clusters did not differ on any non-HBM topic blocks, including knowledge of COVID-19, trust of information sources, coping, vaccine beliefs, and neighborhood and community needs, which the authors say highlights how important the Health Belief Model constructs and resiliency are to consider, and illustrates the stability of the two-cluster solution.

Practically, the results suggest concrete tools for harm reduction practitioners. The authors propose that easy screeners could be incorporated to assess overall resilience or beliefs in disease severity and susceptibility, enabling staff to quickly gauge where a client is in their thinking and tailor communication or intervention accordingly. Increasing perceived threat of COVID-19 so that people who use drugs can act upon it is one piece of the puzzle, they write, but increasing resiliency and perceived self-efficacy to use preventative behaviors is key. This may include targeting the susceptibility and severity constructs by ensuring messages are catered to the way this population does or does not believe it is susceptible to an infectious disease, then boosting self-efficacy through cues to action or increased access to protective supplies, alongside community-building techniques to create a resilient community at large.

The study carries important limitations. Because the data are cross-sectional, temporality cannot be inferred, and the reliance on self-reported data means social desirability bias should be considered. Results may not generalize to the broader population of people who use drugs, since the study was conducted only in Philadelphia among clients of a large social services agency that adapted its operations during the pandemic, likely leaving the sample feeling resourced and knowledgeable about staying safe, which may not hold for people without such access. The relatively small sample size limited the use of alternate statistical models and covariate controls, and the clustering variables overlapped conceptually with the perceived susceptibility construct. Still, the core message stands: resilience appears central to protecting this vulnerable population from future infectious disease outbreaks, and interventions aimed at increasing it may improve preventative behavior uptake and decrease disease burden when the next pandemic arrives.

Subject of Research: Health Belief Model constructs and resilience in COVID-19 prevention behavior among people who use drugs

Article Title: Using health belief model constructs to understand the role of perceived disease threat and resilience in responding to COVID-19 among people who use drugs: a cluster analysis

Article References: Paulus, K., Bass, S. B., Kelly, P. J. A., Pilla, J., Otor, A., Scialanca, M., Arroyo, A., & Faison, N. (2024). Using health belief model constructs to understand the role of perceived disease threat and resilience in responding to COVID-19 among people who use drugs: a cluster analysis. Advances in Drug and Alcohol Research, 4, Article 12197. https://doi.org/10.3389/adar.2024.12197

Image Credits: AI Generated

DOI: 10.3389/adar.2024.12197

Keywords: people who use drugs, Health Belief Model, COVID-19, resilience, cluster analysis, harm reduction, perceived susceptibility, self-efficacy, pandemic preparedness, mental health, vulnerable populations, infectious disease

The original analysis, published earlier in 2026 in the same journal under the title Untangling the Web of Hepatitis C Risk in Rural Communities, drew on the authors’ combined expertise in behavioral science, community health education, and clinical medicine. Bailey, who leads the correspondence from the Center on Drug and Alcohol Research at the University of Kentucky, has spent her career examining how substance use environments drive infectious disease transmission in Appalachia and similar regions. Tarplin brings a public health perspective on how community-level education and prevention infrastructure function, while Kang contributes the clinical vantage point of a physician-scientist embedded in pediatric and general care systems. Together, the three argued that hepatitis C in rural areas follows a distinctive epidemiological pattern shaped by limited treatment capacity, dispersed populations, and the evolving landscape of injection drug use.

The technical core of their argument rests on the recognition that hepatitis C virus, a blood-borne RNA virus of the Flaviviridae family, spreads efficiently through even small-volume blood exposures. In urban contexts, transmission has historically clustered around dense networks of people who inject drugs, prison systems, and specific healthcare lapses. Rural settings invert many of these assumptions. Population dispersion means that risk networks are geographically stretched, yet socially tight: a small number of individuals may connect otherwise distant counties through shared equipment, transportation routes, or drug supply chains. The authors contend that standard surveillance models, calibrated to urban outbreak dynamics, systematically underestimate how quickly infection can propagate across a rural county once introduced.

Compounding this structural vulnerability is the well-documented shortage of primary care capacity in rural America. The authors anchor their reply in the framework established by the National Academies of Sciences, Engineering, and Medicine’s 2021 consensus report, Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care, which they cite as a foundational reference. That report characterized primary care as the only component of the health system for which universal continuous coverage produces better population health outcomes, and it warned that the erosion of rural primary care infrastructure undermines every downstream preventive service. For hepatitis C, the implications are direct: screening for the virus, linkage to curative antiviral therapy, and harm-reduction counseling all depend on a functioning primary care layer that many rural counties lack entirely.

The second pillar of the authors’ evidence base is a 2024 synthesis published in BMC Primary Care by Endalamaw and colleagues, which systematically reviewed barriers and strategies for primary health care workforce development. That synthesis identified chronic workforce shortages, maldistribution of trained clinicians, and weak retention mechanisms as persistent obstacles to primary care delivery in underserved areas. Bailey, Tarplin, and Kang invoke this literature to argue that hepatitis C elimination targets in rural regions are not primarily limited by virology or pharmacology. Direct-acting antiviral regimens cure more than 95 percent of chronic infections in as little as eight to twelve weeks of oral therapy. The bottleneck, they maintain, is the human infrastructure required to identify infected individuals, initiate treatment, and prevent reinfection and onward transmission.

The exchange that prompted the response letter illustrates how contested these interpretive frameworks remain. A prior letter to the editor had challenged elements of the original analysis, and the authors’ reply, published under the title Response to Re: Untangling the Web of Hepatitis C Risk in Rural Communities, defends their framing while engaging the critique on its merits. Scientific correspondence of this kind serves a technical function beyond academic courtesy: it forces explicit articulation of the causal assumptions underlying risk models, exposes points of disagreement about data interpretation, and refines the conceptual vocabulary that future empirical studies will inherit. In infectious disease epidemiology, where models of transmission dynamics directly inform resource allocation, such exchanges carry practical weight.

The stakes of this debate are grounded in a sober epidemiological reality. Hepatitis C virus chronically infects an estimated 2.4 million people in the United States, and the opioid-driven injection drug use crisis that intensified after 2010 produced sharp increases in acute hepatitis C incidence precisely in the rural counties least equipped to respond. The virus’s biology amplifies the challenge: most acute infections are asymptomatic or mildly symptomatic, allowing silent propagation through networks before clinical detection. Chronic infection, if untreated, progresses over decades toward hepatic fibrosis, cirrhosis, and hepatocellular carcinoma. The availability of curative therapy since 2013 transformed the disease into an elimination target, and the World Health Organization has set goals for viral hepatitis elimination by 2030, but those goals presuppose detection and treatment systems that rural America often cannot assemble.

The authors’ interdisciplinary composition reflects the analytical stance they defend. Bailey’s affiliation with a department of behavioral science and a center on drug and alcohol research signals attention to the behavioral substrate of transmission, the patterns of drug use, equipment sharing, and social network structure that determine where the virus moves. Tarplin’s community health education background foregrounds prevention messaging and the design of interventions that reach dispersed populations. Kang’s clinical position grounds the analysis in the realities of care delivery, where screening protocols, electronic health record triggers, and referral pathways determine whether a positive antibody test becomes a cured patient or a lost opportunity. The letter’s single-sentence contribution statement, crediting all three authors with conceptualization and writing of the original draft, underscores the deliberately integrated character of the argument.

The correspondence also carries methodological implications for how rural health research is conducted and evaluated. The authors’ web metaphor, the image of hepatitis C risk as an interlaced network rather than a linear chain of causes, resists reduction to any single intervention point. A syringe services program addresses one strand; telehealth-based treatment expands another; workforce development strengthens the clinical node; transportation assistance loosens the geographic constraints that bind the network together. The critique and response cycle, by testing which strands bear the most load, helps prioritize interventions empirically rather than ideologically. The authors report no funding associated with the letter and declare no competing interests, and the journal’s editorial process, from submission on 31 July to acceptance on 5 October 2026, moved the exchange into the published record within a single quarter.

What emerges from the exchange is a research agenda rather than a closed argument. The authors’ reply positions rural hepatitis C risk as a problem that demands simultaneous attention to virology, behavioral science, health services organization, and rural sociology, the very subject categories under which the journal indexes the work. As elimination timelines approach, the letter stands as a reminder that the final mile of infectious disease control is rarely a laboratory problem. It is a problem of networks, of geography, of workforce, and of the quiet structural choices that determine whether a curable virus persists in the communities least able to fight it. The technical conversation between Bailey, Tarplin, Kang, and their critics will continue in the literature, but its practical destination is fixed: translating a web of risk into a web of response.

Subject of Research: Hepatitis C virus transmission risk and primary care barriers in rural communities

Article Title: Response to Re: Untangling the Web of Hepatitis C Risk in Rural Communities

Article References: Bailey, A., Tarplin, S., & Kang, A. (2026). Response to Re: Untangling the Web of Hepatitis C Risk in Rural Communities. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10934-1

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10934-1

Keywords: hepatitis C, rural health, primary care, viral hepatitis, infectious disease epidemiology, harm reduction, workforce shortage, opioid crisis, direct-acting antivirals, health disparities, correspondence, public health

The research, led by Samuel Habimana of Loma Linda University and the Rwanda Resilience and Grounding Organization, together with colleagues from the University of Rwanda and other institutions, set out to untangle the web of sociodemographic characteristics, alcohol and substance dependence, and depressive symptoms associated with injection drug use. The timing matters. Globally, drug use has surged by 23 percent over the past decade, with roughly 296 million people now using drugs and approximately 78 percent of them residing in low- and middle-income countries. While African countries historically reported low rates of injecting drug use, heroin injection has been rising in large East African towns since 2009, and Rwanda is no exception to this troubling trend.

To reach a population that is largely hidden from official view—criminalization and cultural stigmatization of both drug use and same-sex behavior make these groups exceptionally hard to access—the researchers employed snowball sampling. Trusted outreach workers from the Rwandan Health Development Initiative (HDI) recruited participants through their social networks, with data collected at two sites in Kigali: the HDI headquarters and the Nyakabanda Health Clinic. Participants were eligible if they were at least 18 years old, lived in Kigali, and self-identified as men who have sex with men (MSM), female sex workers (FSW), people who inject drugs, or other substance users. Each participant completed a structured questionnaire administered in Kinyarwanda, received five US dollars in compensation, and underwent rapid HIV testing with pretest and posttest counseling.

The methodological toolkit was rigorous. Depressive symptoms were assessed using the Beck Depression Inventory-II (BDI-II), a 21-item instrument with strong psychometric properties in Rwandan populations, which achieved a Cronbach’s alpha of 0.898 in this study—indicating excellent internal consistency. Alcohol and substance dependence were evaluated with the Mini-International Neuropsychiatric Interview (MINI), a short structured diagnostic interview developed for DSM-IV and ICD-10 psychiatric disorders. Injection drug use was operationally defined as self-reported injecting of any illicit drug within the previous 12 months. Of the 480 participants, 151—31.5 percent—met this definition.

The demographic profile of those who injected drugs tells its own story. Among PWID, 93.4 percent were male, 89.4 percent were single, and more than half—52.3 percent—were between 18 and 25 years old. Bivariate analyses using Pearson’s chi-square tests revealed statistically significant associations between injection drug use and age, sex, MSM status, FSW status, marital status, and education level. Notably, MSM participants were heavily overrepresented among injectors: 72.8 percent of PWID identified as MSM, compared with 47.1 percent of non-injecting participants. Employment status, by contrast, showed no significant association.

Substance use patterns among injectors were equally revealing. Nearly three-quarters of PWID reported alcohol use, 61.6 percent reported marijuana use, and a remarkable 96 percent exhibited symptoms of drug dependence. Nearly half met criteria for alcohol dependence or abuse. Injectors were also significantly more likely to have sought treatment for substance use—29.1 percent versus 14.3 percent among non-injectors—and to smoke cigarettes or use diazepam. HIV prevalence in the overall sample was 4.7 percent, higher than the roughly 3 percent reported among Rwandan adults aged 15 to 49, though HIV status itself was not statistically associated with injection drug use in this sample.

The multivariate logistic regression analysis, which adjusted for potential confounders, distilled the picture to a handful of independent risk factors. Participants with substance dependence were nearly four times more likely to inject drugs (adjusted odds ratio [aOR] = 3.547; 95% CI 1.159–10.857). Marijuana users carried more than three times the odds (aOR = 3.261; 95% CI 1.380–7.708). MSM status tripled the odds (aOR = 3.20; 95% CI 1.816–5.640). Most strikingly, individuals with depressive symptoms had 4.5 times the odds of being injectors compared with those without such symptoms (aOR = 4.50; 95% CI 2.55–7.96, p = 0.018). Intriguingly, alcohol dependence was associated with lower odds of injection drug use (aOR = 0.511), as was cocaine use (aOR = 0.404) and female sex (aOR = 0.698)—patterns the authors suggest may reflect distinct trajectories of drug escalation, in which some users progress from alcohol or non-injection routes to injection over time.

The depression finding is the study’s most consequential contribution, and the authors are careful about its interpretation. The association is consistent with the self-medication hypothesis: in low-income settings with limited access to mental health resources, some individuals may turn to injecting drugs as a coping strategy for emotional distress. But because the study is cross-sectional, the reverse pathway is equally plausible. Substance-induced depression—whether during opioid or stimulant withdrawal or as a neuroadaptive consequence of chronic use—is well documented in the neuropsychopharmacology literature, meaning injection drug use may itself generate the depressive symptoms rather than result from them. Stigma surrounding injecting drug use may further discourage individuals with co-occurring depression from seeking mental health assistance, deepening the cycle.

The context of Rwanda makes these numbers even more sobering. Depression affects an estimated 35 percent of genocide survivors and 20 percent of the general population in the country—figures already considered high. Yet the 94 percent prevalence among injectors and 82.3 percent among other high-risk participants in this study dwarf both benchmarks. The findings align with research from China, Kenya, Vietnam, and Tanzania documenting tight links between depression, injecting drug use, and HIV risk behaviors, including studies showing that women who inject drugs and engage in sex work face elevated rates of suicidal ideation and equipment sharing. One unexpected result—a lower HIV prevalence among PWID (2.6 percent) than among other risk groups (5.7 percent)—warrants caution rather than reassurance, the authors note, because injectors were significantly younger and may simply have had less cumulative exposure time.

The study has limitations that temper its conclusions. The nonrandom snowball sampling and recruitment through a single NGO service provider may over-represent individuals already connected to services, and self-reported measures of both drug use and depressive symptoms are vulnerable to social desirability bias. The BDI-II is a screening tool, not a clinical diagnostic instrument, and the MINI’s reliance on DSM-IV criteria may introduce inconsistencies with the updated DSM-5. Family history of substance use, surprisingly, showed no statistical association with injection drug use—contrasting with European findings and possibly reflecting how new injection drug use is as a phenomenon in Rwanda. Still, the implications are clear. The authors call for integrated health services that address mental health, substance use, and HIV-related vulnerabilities together, particularly for young people and sexual minorities, and for longitudinal and mixed-methods research to clarify the temporal relationships at play. As injecting drug use expands across East Africa, harm-reduction strategies that embed mental health care may prove essential to preventing a wider HIV resurgence.

Subject of Research: Risk factors for injection drug use among populations at high risk for HIV/AIDS in Kigali, Rwanda

Article Title: Profile of risk factors for people who inject drugs among a sample at high risk of HIV/AIDS in Kigali, Rwanda

Article References: Habimana, S., Lister, Z., Biracyaza, E., Kagaba, A., Ndagijimana, A., Jansen, S., Rutembesa, E., & Montgomery, S. (2026). Profile of risk factors for people who inject drugs among a sample at high risk of HIV/AIDS in Kigali, Rwanda. Advances in Drug and Alcohol Research, 6, Article 16156. https://doi.org/10.3389/adar.2026.16156

Image Credits: AI Generated

DOI: 10.3389/adar.2026.16156

Keywords: injection drug use, HIV/AIDS, depression, Rwanda, substance dependence, harm reduction, public health, men who have sex with men, female sex workers, Kigali, mental health, cross-sectional study

The research, published in the journal Advances in Drug and Alcohol Research, tackles a deceptively simple problem. Clinical guidelines recommend that patients abstain from cannabis during pregnancy and lactation, and providers are encouraged to discuss use with their patients. But a growing body of evidence shows that a meaningful subset of perinatal patients continue to use cannabis even after receiving education about potential harms, whether because they perceive genuine benefits such as relief from nausea, anxiety, or sleep problems, or because they find it difficult to stop. For these patients, repeating warnings about risks is not only ineffective; research on motivational approaches in addiction treatment suggests that constraining a person’s choice can actually entrench the behavior, a phenomenon known as reactance.

Harm reduction offers an alternative philosophy. Rather than treating abstinence as the only acceptable outcome, harm reduction views any reduction in harm as a clinical success. It is already the standard evidence-based approach for other perinatal substance use disorders, most notably opioid use disorder, and studies show that pregnant and lactating patients are already improvising their own risk-reduction strategies and actively want more information about the relative safety of different modes of consumption. Yet despite this justification and demand, harm reduction counseling for perinatal cannabis use has never been formally codified, which has stalled its adoption in clinical settings.

The missing piece, the researchers argue, is a specification of the intervention’s core components: the essential, active ingredients that must be preserved when an intervention is adapted, scaled, or rolled out across different clinics. Without knowing which elements are truly indispensable, any attempt to spread the practice risks diluting or distorting the very features that make it work. To fill this gap, the team turned to the Consensus on Relevant Elements, or CORE, process, a structured methodology developed for exactly this purpose, in which a small expert panel iteratively drafts, refines, and reaches consensus on core components through alternating rounds of independent worksheet completion and moderated group discussion.

The process was rigorous and revealing. An expert panel of three, spanning implementation science, behavioral substance use treatment, and perinatal health, initially generated 23 candidate components after reviewing an educational pamphlet designed to support providers. Moderators then consolidated these suggestions into four thematic clusters and prepared targeted discussion questions. A pivotal moment came when the panel realized that many of their initial descriptions were so detailed that they described intervention content, the specific materials and scripts a provider might use, rather than core components, the higher-level essential elements that causally enable effectiveness. Once that distinction was drawn, the team preserved the detailed material in a separate column for future use and consensus moved rapidly.

Two cycles of worksheet completion and moderated discussion later, the panel converged on a final list of five core components organized into two domains. The first domain, provider training, concerns competencies that clinicians should develop before the clinical encounter. The first component is that the provider is skilled at facilitating conversation, which in practice means conducting trauma-informed discussions that empower patients to make informed decisions, practice reflexivity, and remain aware of power differentials when asking sensitive questions. The second is that the provider is educated about cannabis use, encompassing up-to-date knowledge of safety data and recommendations for pregnancy and breastfeeding, the limitations of existing evidence, the basic pharmacology of cannabinoids such as THC and CBD, modes of consumption, and evidence-based behavior change strategies for reducing harm.

The second domain, patient-facing work, describes what happens in the exam room itself. Providers should educate all patients about the safety of and recommendations concerning perinatal cannabis as soon as pregnancy is contemplated, ideally woven into broader conversations about prenatal vitamins, alcohol, and exercise, and should be candid about the limitations of the safety data. They should screen every patient for cannabis use, either verbally or with validated written instruments such as the TAPS, DAST-10, or NIDA quick screen, distinguishing recreational from medicinal use where use is endorsed. And once use is identified, they should deliver a brief harm reduction intervention following the framework recommended by the Substance Abuse and Mental Health Services Administration: educating about effects, offering advice on change, assessing readiness for change, negotiating goals and strategies, and arranging follow-up. Critically, if a patient is ready to quit, the goals focus on cessation; if not, the goals pivot to reducing harm from continued use, whether through cutting down or adopting safer behaviors.

Beneath the technical framework lies a deeper philosophical argument. The authors contend that harm reduction is not merely a set of concrete instructions but requires a fundamental shift away from the traditional paternalistic model of the patient-provider relationship, in which the provider gives directions and the patient is expected to follow them. Instead, providers must partner with patients, respect their autonomy to make decisions the provider might disagree with, and contend with the moral ambiguity that can arise when a pregnant patient’s choices affect both herself and her infant. The trauma-informed facilitation component explicitly returns power to the patient, and the readiness-based brief intervention refuses to push behavior change on someone not yet willing or able to change. The authors acknowledge this shift will be uncomfortable for some clinicians, particularly in the perinatal context, and argue that implementation strategies should include disseminating evidence that shared decision-making is both preferred by substance-using patients and linked to better outcomes, including greater utilization of care.

The study has notable strengths, including the use of a formal methodological process and a panel whose members combined academic expertise with years of clinical practice as licensed psychologists, along with lived experience of receiving perinatal care themselves. But the authors are candid about limitations: the developers of the underlying educational pamphlet could not participate due to time constraints, the panel lacked a physician or midwife, one member served a dual role as both expert and moderator, and the panel was small, which may limit generalizability. The team also notes that the intervention has not yet been formally protocolized and tested, so fewer materials were available for expert review than in previous applications of the CORE process.

Future directions are clearly mapped. The researchers call for broader consensus-building, such as a Delphi study, to confirm the five components, followed by clinical testing and refinement using established methods for verifying intervention fidelity. They also emphasize the need to develop and evaluate implementation strategies that support sustained uptake of harm reduction counseling in real-world perinatal care. Finally, they highlight an uncomfortable truth underlying the entire enterprise: the field still lacks conclusive research on the health impacts of perinatal cannabis use, and because safety education is itself a core component of the intervention, better evidence on risks is essential if provider recommendations are to rest on solid ground. For now, this study represents a crucial first step, translating a contested clinical dilemma into a defined, teachable set of practices that could reshape how medicine meets one of the most common and complicated questions of the legalization era.

Subject of Research: Core components of harm reduction counseling for perinatal cannabis use

Article Title: Identifying an initial set of core components for perinatal cannabis use harm reduction counseling: An application of the Consensus on Relevant Elements (CORE) process

Article References: Albanese, A. M., Cramer, E. R., Frank, H. E., & Rogers, B. G. (2026). Identifying an initial set of core components for perinatal cannabis use harm reduction counseling: An application of the Consensus on Relevant Elements (CORE) process. Advances in Drug and Alcohol Research, 6, Article 15935. https://doi.org/10.3389/adar.2026.15935

Image Credits: AI Generated

DOI: 10.3389/adar.2026.15935

Keywords: cannabis, pregnancy, breastfeeding, harm reduction, perinatal health, counseling, core components, CORE process, implementation science, trauma-informed care, substance use, clinical guidelines

The research team, led by Joshua Dawe of the University of Bristol together with collaborators across multiple countries, built their analysis on an established database of cohort studies that estimate new infections among people who inject drugs. Their searches covered literature published between January 1, 2000 and June 9, 2026, spanning MEDLINE, Embase, and PsycINFO. After screening more than 82,000 records and re-reviewing 436 studies that reported HIV or HCV incidence, the investigators identified 62 studies examining whether sex work or male-with-male sexual activity modified infection risk. Crucially, they also contacted the authors of 36 studies to request unpublished estimates, achieving a 67 percent response rate, which brought the final pool to 57 studies contributing 164 estimates. Notably, 70 percent of those estimates were unpublished, a deliberate strategy to reduce publication bias and strengthen statistical power.

The headline result concerns HIV acquisition among men who inject drugs and also report recent male-with-male sexual activity. Across 13 studies, the pooled incidence rate ratio was 2.35, meaning these men acquired HIV at more than twice the rate of men who inject drugs without recent male-with-male sex. The 95 percent confidence interval ran from 1.51 to 3.66, and the estimate grew slightly stronger in adjusted analyses at 2.66. Lifetime male-with-male sexual exposure told a similar story, with a pooled crude incidence rate ratio of 2.44 for HIV acquisition. By contrast, the analysis found no statistical evidence linking male-with-male sex to HCV acquisition, with a pooled incidence rate ratio of 1.28 for recent exposure whose confidence interval crossed the null. The authors point to transmission biology as a likely explanation: HCV spreads far more efficiently through blood-borne exposure than through sexual contact, so a sexual behavior alone would not be expected to drive HCV incidence the way it drives HIV incidence.

Sex work showed a different and, in some ways, more complicated pattern. Among mixed-sex samples of people who inject drugs, recent sex work was associated with a 1.72-fold higher rate of HIV acquisition across 20 studies, and a 1.59-fold higher rate of HCV acquisition across 22 studies, with both associations persisting in adjusted analyses. But the sex-stratified results revealed striking asymmetries. For HIV, the association was strong among women who inject drugs, at an incidence rate ratio of 2.30, while no evidence of an association emerged among men, at 1.43. For HCV, the pattern reversed: recent sex work was associated with elevated risk among men who inject drugs, at 1.51, but not among women, at 1.26. These divergent findings suggest that different mechanisms operate for different outcomes and populations, and that a single pooled estimate can obscure risks that are concentrated in specific subgroups.

Quantifying how common these overlapping behaviors are underscores why the risk findings matter. The pooled analysis estimated that around one in nine people who inject drugs, or 10.6 percent, had recently engaged in sex work, with the figure far higher among women, at 27.2 percent, than among men, at 4.0 percent. Among men who inject drugs, roughly 4.8 percent reported recent male-with-male sex, while 21.9 percent reported lifetime exposure. In other words, a substantial fraction of the population that harm reduction services serve also belongs to populations traditionally served by separate sexual health programs, yet the services themselves rarely overlap.

Methodologically, the review took care to focus on recent exposure, defined as within the past 12 months, rather than lifetime exposure, because recent behavior aligns more closely with the period at risk for incident infections. The primary analyses used crude rather than adjusted estimates, a choice the authors justify on the grounds that factors commonly adjusted for, such as injecting frequency, housing instability, or sexual practices, may lie on the causal pathway between sex work or male-with-male sex and infection, meaning that adjustment could attenuate the very effects the analysis sought to detect. Adjusted estimates were examined as secondary analyses and generally produced similar pooled effects. Study quality was assessed with a modified Newcastle-Ottawa Scale, and funnel plots together with Egger’s tests found little evidence of publication asymmetry, with one exception among published studies of male-with-male sex and HIV.

The mechanisms behind the elevated risks are likely to be structural as much as behavioral, the authors argue. Sex workers who inject drugs are more likely to engage in street-based or survival sex work, which is associated with limited condom negotiation, rushed or unsafe injections, more frequent encounters with law enforcement, and greater exposure to physical and sexual violence. Criminalization of both sex work and drug use in most countries intensifies policing and incarceration, which disrupt access to health care and, as prior reviews from the same group have shown, independently elevate HIV and HCV risk. For men who have sex with men who use drugs, prior studies indicate higher rates of condomless anal sex and participation in sexualized drug use, including chemsex, which can involve multiple partners and injection practices that heighten transmission risk. Stigma related to sexuality and sex work further deters engagement with health services, compounding vulnerability.

The heterogeneity across studies was moderate to high for most pooled estimates, and subgroup analyses did not fully explain it. Some patterns were nonetheless informative. The association between sex work and HIV appeared stronger in studies with higher proportions of women, higher levels of recent incarceration, and higher-income settings, while no clear association emerged in low- and middle-income settings, though the authors caution that most subgroup estimates rested on small numbers of studies with wide confidence intervals. Intriguingly, the association between recent sex work and HIV was substantially larger in low-incidence settings, with an incidence rate ratio of 2.38 in studies where background HIV incidence was below two cases per 100 person-years, compared with 1.24 in higher-incidence settings, a pattern the authors partly attribute to the compression of relative measures when baseline risk is high.

The review acknowledges several limitations. Most estimates came from high-income countries, limiting generalizability to low- and middle-income settings where evidence remains scarce. Exposure was based on self-report and may be underreported where behaviors are heavily stigmatized, and in four studies lifetime male-with-male exposure was defined by sexual identity rather than behavior, potentially misclassifying men who have sex with men but identify as heterosexual. Transgender people who inject drugs could not be analyzed separately because insufficient data were available. Unpublished estimates, while valuable for reducing publication bias, did not undergo formal peer review, and responding cohorts may differ systematically from non-responding ones.

The central message for public health is a call to dismantle the silos that organize HIV and HCV prevention around single populations or behaviors. The authors advocate integrated, low-threshold services that combine harm reduction measures, including sterile injecting equipment and opioid agonist therapy, with sexual health care such as pre-exposure prophylaxis, condoms, sexually transmitted infection testing, and reproductive health services. Routine assessment of both injection-related and sexual risks, with prevention tailored to individuals rather than to behavioral categories, could reach people whose overlapping vulnerabilities are currently missed. They also emphasize the need for research into the factors driving elevated risk among people who belong to more than one affected population, particularly in low- and middle-income countries, so that interventions can be designed around the real, intersecting lives of the people they aim to protect.

Subject of Research: HIV and hepatitis C acquisition risk among people who inject drugs who also engage in sex work or male-with-male sexual activity

Article Title: Sex work or male-with-male sexual activity and the risks of HIV and hepatitis C acquisition among people who inject drugs: a global systematic review and meta-analysis

Article References: Dawe, J., Trickey, A., Walker, J., Barrass, L., Njiro, B. J., Kundu, B., Hickman, M., Abramovitz, D., Aladashvili, M., Artamonova, I., Blouin, K., Boyd, A., Bruneau, J., DeBeck, K., Jarlais, D. D., Dietze, P., Dumchev, K., Hankins, C., Hatzakis, A., … Artenie, A. A. (2026). Sex work or male-with-male sexual activity and the risks of HIV and hepatitis C acquisition among people who inject drugs: a global systematic review and meta-analysis. eClinicalMedicine, 101, Article 104268. https://doi.org/10.1016/j.eclinm.2026.104268

Image Credits: AI Generated

DOI: 10.1016/j.eclinm.2026.104268

Keywords: HIV, hepatitis C, people who inject drugs, sex work, men who have sex with men, systematic review, meta-analysis, harm reduction, incidence rate ratio, public health, stigma, integrated services

The methodological architecture of the review is worth examining because it shapes what the conclusions can and cannot tell us. A systematized review, as the authors define it following the typology of Grant and Booth, applies systematic review principles—structured searches, explicit inclusion criteria, and standardized data extraction—without necessarily the full protocol registration and dual independent review apparatus of a gold-standard systematic review. The team searched across four conceptual domains: young adulthood, interventions, substance use, and traumatic stress, with homelessness terms added and removed to capture both directly relevant studies and the wider evidence base from which adaptable elements might be borrowed. Data were extracted using a structured coding framework organized around three domains: effectiveness, real-world implementation, and intervention characteristics. This tripartite structure reflects a growing recognition in implementation science that an intervention’s clinical efficacy in a controlled trial tells only part of the story; whether it can actually be delivered, sustained, and funded in a community drop-in center or shelter is a separate and equally consequential question.

On the effectiveness front, the headline numbers are encouraging. Over half of the 39 included studies used randomized controlled designs, the most rigorous method for establishing causal effects, and roughly three-quarters reported significant improvements across multiple outcomes, including reductions in substance use, decreases in traumatic stress symptoms, and broader gains in mental health. That such a large proportion of interventions produced measurable benefits suggests the field is not starting from zero. Yet the review’s finer-grained analysis reveals why these findings cannot simply be transplanted to young adults experiencing homelessness. The interventions were most commonly delivered in academic, clinical, or service settings—university counseling centers, primary care clinics, structured research programs—with enormous variation in duration, treatment modality, and theoretical orientation. A web-based alcohol prevention program for college students, a telephone-based intervention for heavy drinking in primary care, a family-based group intervention for HIV and drug risk among homeless families, and home-based telehealth skills training for women veterans all appeared in the evidence base, each built around assumptions about stability, scheduling, and access that homeless young adults often cannot meet.

The co-occurrence problem sits at the heart of the review’s rationale. Epidemiological research has long documented that trauma and substance use are deeply intertwined in this population. Studies cited by the authors, including work by Bender and colleagues on homeless youth in three U.S. cities and by Gwadz and colleagues on gender differences in traumatic events among homeless youth, show elevated rates of posttraumatic stress disorder and multiple victimization both before and after young people leave home. The self-medication hypothesis, articulated by Khantzian, offers one explanatory framework: substances are used to blunt the intrusive memories, hyperarousal, and emotional dysregulation that follow traumatic exposure. Trauma itself is increasingly understood as a transdiagnostic risk factor, elevating risk across a range of mental disorders, and homelessness compounds the problem by exposing young adults to ongoing victimization and instability that perpetuate both the traumatic stress and the substance use. The result is a cycle in which each element exacerbates the others, prolonging homelessness and degrading health outcomes. Yet the review found that interventions addressing both traumatic stress and substance use simultaneously were rare, and none had been built from the ground up for young adults experiencing homelessness.

The implementation findings are particularly revealing about the gap between what works in trials and what survives contact with real-world service systems. The review found strong participant retention across many studies, which is notable given that retention is often the Achilles heel of interventions with mobile, crisis-exposed populations. However, reporting on treatment fidelity—whether the intervention was actually delivered as designed—and on cost was strikingly limited. Fidelity monitoring matters because an intervention that shows effects in a tightly supervised trial may drift or degrade when handed to frontline staff with competing demands; without fidelity data, implementers cannot know which results are reproducible. Cost reporting matters because service agencies operating on thin budgets must make allocation decisions, and an intervention whose resource requirements are unknown cannot be planned for. These reporting gaps, the authors suggest, represent a critical blind spot for anyone hoping to move from the literature to practice.

Among the 39 studies, 16 included samples in which at least half of the participants experienced homelessness or housing instability, and these studies offer the closest available approximations to the target population. They include trials of strength-based outreach interventions linked to shelters or drop-in centers that reduced hard drug use among homeless youth, a randomized controlled trial of a smartphone application plus brief motivational intervention that reduced substance use and sexual risk behaviors among homeless young adults, a brief motivational interviewing-based group intervention showing 24-month effects on alcohol use among emerging adults experiencing homelessness, and a feasibility study of the HOME program combining housing with opioid use disorder prevention. Other work examined housing and supportive services for young mothers experiencing homelessness and intensive addiction and housing case management for homeless veterans. Collectively, these studies demonstrate that young adults experiencing homelessness can be recruited, retained, and helped—but each addressed only part of the problem, typically substance use alone, without an integrated traumatic stress component.

From this mosaic, the review distills a set of design principles for a future integrated intervention. First, delivery should be brief and flexible: long, multi-session protocols that assume reliable attendance are poorly matched to a population whose daily lives are governed by shelter curfews, survival needs, and sudden displacement. Second, harm-reduction approaches should anchor the substance use component. Rather than demanding immediate abstinence as a condition of care, harm reduction meets young people where they are, reducing the risks of use while building trust and engagement—a stance with particular resonance for a population that has often experienced rejection and coercion from institutions. Third, the intervention must be feasible within community-based service settings such as drop-in centers and shelters, which are where homeless young adults already present, rather than requiring referral into academic clinics that many will never reach. The authors frame these components as hypotheses to be tested, not a finished blueprint, and they are explicit that the review is a critical pre-implementation step in a longer development process.

The review also surfaces structural features of the existing literature that constrain its usefulness. The theoretical orientations of included interventions ranged widely, from motivational interviewing and cognitive behavioral approaches to transdiagnostic protocols such as the Unified Protocol, which targets emotional disorders broadly rather than any single diagnosis. Duration varied from single-session brief interventions to multi-month programs. Delivery modalities spanned in-person individual and group formats, family-based sessions, telephone contact, web-based programs, and smartphone applications. This heterogeneity, while a barrier to simple meta-analytic conclusions, is arguably an asset for intervention development: it provides a menu of tested mechanisms and delivery channels from which adaptable elements can be selected and recombined. The authors’ structured coding framework makes that menu explicit, which is precisely what a design team needs when assembling a new intervention rather than evaluating an old one.

What comes next, according to the authors, is direct testing within the population itself. Future research should prioritize intervention trials conducted with young adults experiencing homelessness, to determine which components retain their effectiveness and feasibility when the assumptions of stability and access no longer hold. The stakes are considerable. Homelessness among young adults is associated with elevated rates of mental health and substance use disorders, disrupted education, and long-term trajectories of instability, and the window of emerging adulthood is a developmental period in which effective intervention may alter lifelong outcomes. By systematically cataloguing what has been tried, what worked, how it was delivered, and where the evidence runs out, this review converts a scattered literature into a usable map. It does not offer a cure, and it is candid that none exists yet for this population. What it offers instead is something the field has lacked: a rigorous, transparent account of the raw materials available for building the first integrated traumatic stress and substance use intervention designed specifically for young adults experiencing homelessness, and a clear-eyed statement of the implementation conditions any such intervention must survive.

Subject of Research: Traumatic stress and substance use interventions for young adults experiencing homelessness

Article Title: A Systematized Review of Traumatic Stress and Substance Use Interventions in Young Adults: Implications for Intervention Development with Young Adults Experiencing Homelessness

Article References: Gamoran, J., Bushnell, A., Fragkos, E., Darbro, R., Gueye, A., & Snow-Hill, N. L. (2026). A Systematized Review of Traumatic Stress and Substance Use Interventions in Young Adults: Implications for Intervention Development with Young Adults Experiencing Homelessness. Community Mental Health Journal. https://doi.org/10.1007/s10597-026-01734-2

Image Credits: AI Generated

DOI: 10.1007/s10597-026-01734-2

Keywords: homelessness, young adults, traumatic stress, substance use, systematized review, intervention development, harm reduction, mental health, implementation science, PTSD, motivational interviewing, community-based services