BackgroundThe rate of hepatitis C virus (HCV) treatment initiation and cure is suboptimal among people experiencing homelessness. A recent randomized controlled trial conducted by our study team compared peer-assisted telemedicine for HCV (TeleHCV) to peer-assisted referral to local providers (enhanced usual care [EUC]) in a rural population in Oregon. We hypothesized that the TeleHCV treatment model is more effective than EUC among those with unstable housing.MethodsIn this secondary analysis of the Oregon TeleHCV randomized controlled trial in adults with HCV and injection drug use (n = 203), we explored the role of unstable housing as an effect modifier of the TeleHCV intervention using a Poisson regression analysis. Randomized arm, frequency of peer contacts, and medication lockers were exposures of interest. HCV cure, defined as undetectable HCV RNA 12 weeks after treatment initiation, is the primary outcome.ResultsOverall, attaining HCV cure was less likely for those with unstable housing (RR = 0.68, 0.49–0.96, p = 0.026). However, unstably housed participants assigned to the TeleHCV arm were more than 6 times more likely to achieve HCV cure compared to unstably housed EUC participants (RR = 6.47, 3.12–13.43, p < 0.001) with a statistically significant interaction between treatment assignment and housing status (p = 0.022). The impact of TeleHCV on HCV cure was also identified among stably housed participants, but with a smaller effect size (RR = 2.15, 1.19–3.89, p = 0.012). Among participants with unstable housing, greater peer engagement was associated with an increased likelihood of both treatment initiation (RR = 1.24, p < 0.001) and HCV cure (RR 1.26; p < 0.001).ConclusionsThe peer-assisted TeleHCV intervention was substantially more effective for achieving HCV cure among participants with unstable housing at baseline compared to those unstably housed who received EUC. The treatment model should be broadly disseminated to target populations with HCV and high rates of homelessness to achieve HCV elimination goals.Clinical trials registrationNCT04798521.

Sex workers who use drugs are disproportionately impacted by the current overdose crisis and face many structural barriers to health and harm reduction services. Delivered in either community (e.g., embedded in supportive housing) or clinic (e.g., hospitals) settings, overdose prevention services are crucial harm reduction interventions. Gaining insight into which services sex workers use, and whether sex worker-specific programs impact this use, is key to identifying targeted prevention strategies and enhancing the continuum of overdose care for this population. Data were derived from An Evaluation of Sex workers' Health Access (AESHA), a prospective, community-based cohort of women (trans-inclusive) sex workers in Vancouver, Canada (March 2017-March 2024). We plotted biannual trends in use of overdose prevention services, comparing community-based and clinic-based services (Aim 1), and used generalized linear mixed models to characterize uptake of overdose prevention services, including potential differences between community and clinic-based services (Aim 2). Finally, we evaluated the association between use of sex worker-specific programs and uptake of overdose prevention services, including potential differences between community or clinic-based services over the 7-year study period (Aim 3). Among 503 sex workers who used drugs, 82.1% (N = 413) used any overdose prevention services over the seven-year study. Uptake of community-based versus clinic-based overdose prevention services was 70.2% (N = 353) and 60.2% (N = 303), respectively. Use of sex worker-specific programs was positively associated with use of overdose prevention services (adjusted odds ratio [AOR] 2.18, 95% confidence interval [CI] 1.82-2.62), and this association was strongest for community-based services (AOR 2.66, 95% CI 2.21-3.20) as opposed to clinic-based services (AOR 1.73, 95%CI 1.41-2.13). Uptake of overdose prevention services among sex workers is relatively high, but faced concerning declines over the study period, highlighting the need for additional interventions to scale-up access. Use of sex worker-specific programs facilitated wider access to overdose prevention services. Findings underscore the importance of expanding sex worker-specific and peer-led programs as part of scaling up overdose prevention efforts.

There are increasing calls for cross-cutting approaches to reducing stigma in health systems that do not silo specific identities, conditions, or practices. In our previous work, we proposed a 'universal precautions' approach to addressing stigma and its negative effects (Treloar et al. in Harm Reduct J 19(1):74, 2022), whereby health systems assume that all people who enter a health service might be concerned about being treated negatively or excluded in some way. This paper explores the possibilities and limitations of such an approach to stigma reduction by canvassing key stakeholder perspectives. Qualitative interviews were conducted with 20 key stakeholders with extensive experience working within the alcohol and other drugs, blood-borne viruses, and sexually transmissible infections sectors. Participants were asked to reflect on the concept of a universal precautions approach to stigma reduction, including its acceptability, feasibility, utility in practice, and key challenges. Although interview participants strongly advocated for a need to address all stigma within health care, there were mixed attitudes towards the use of the term, 'universal precautions'. Some participants believed it would be useful to draw on a lexicon more familiar to health workers, while others expressed ambivalence and confusion about the term. Participants reflected on the possibilities of universality, in treating everyone with respect and providing non-judgemental care, while also emphasising that different client populations have specific needs that must be addressed. Many participants emphasised strongly that such an approach would need to be embedded at a systemic level, including having support from executive leadership, to address the structural forces that (re)produce stigma. Participants emphasised that centring the voices and perspectives of people with lived experience of stigma is integral to any approach to reducing stigma in health systems. Findings highlight the various possibilities of adopting a universal approach that recognises the diversity and intersections in experiences of stigma. This research informs the development and implementation of novel stigma reduction initiatives in health care settings.

BackgroundEnergy drinks are stimulant-containing beverages, primarily formulated with caffeine and marketed to enhance mental and physical performance. Unlike coffee, tea, or caffeinated soft drinks, these products are specifically designed as functional stimulants.PurposeThis study aimed to assess university students’ awareness of energy drinks and evaluate their consumption patterns, associated side effects, and reasons for use.MethodsThis cross-sectional observational study was conducted from April to August 2023 at three major universities in Kabul, Afghanistan: Kabul University of Medical Sciences, Kabul Education University, and Kabul University. We distributed 401 questionnaires to students across these institutions, achieving a response rate of 96.76% (n = 379 completed questionnaires). Thirteen students (3.24%) did not return their questionnaires. All collected data were entered and analyzed using SPSS software (version 21).ResultsAll participants were male, with ages ranging from 17 to 29 years (mean = 21.1 years; SD = 3.9). Energy drink consumption was reported by 89.97% of participants, of whom 41.34% were occasional users (less than one drink per week) and 56.59% were habitual consumers (3–4 drinks per week). Higher consumption (more than one can) was significantly associated with living alone (P = 0.000) and daily coffee intake (P = 0.005). The primary reasons for consumption included needing energy (33.66%, n = 169), enjoying the taste (24.90%, n = 125), and increased use during exams to improve alertness (12.35%, n = 62). There were no significant differences in energy drink consumption across academic years (P > 0.05). Most students recognized caffeine (86.8%) and sugar (89.97%) as key ingredients. Habitual consumers reported reducing sleep hours more frequently than occasional consumers (34.89% vs. 18.18%; P < 0.05) and were more likely to use it to aid studying/major projects (83.28% vs. 14.66%; P < 0.05). Adverse effects were reported by 67.44% (n = 230), primarily palpitations (44.54%) and insomnia (21.56%).ConclusionThis study identifies frequent energy drink consumption among university students, driven primarily by the desire to boost energy, enjoy the taste, and enhance exam-time alertness. Over half of participants reported adverse effects, such as palpitations and insomnia. These results suggest a role for targeted educational programs to increase awareness of health risks. Further, policymakers may need to evaluate existing regulations on energy drink marketing and availability to address potential public health concerns.

BackgroundMost individuals self-excluding from gambling have lost control over their gambling behavior. Commercial solicitations are prohibited during the self-exclusion period, but resume immediately afterwards. The self-exclusion system appears insufficient, particularly for short self-exclusions and among the heaviest gamblers. We assessed the impact of extending suspension of commercial solicitations on gambling intensity.MethodsIn this parallel randomized study, we included 2548 French online gamblers who self-excluded for up to 3 months from May–November 2022. They were assigned 1:1 to optimized self-exclusion with extended commercial solicitations ban for 9 months or standard procedure. The primary outcome was the change in total loss over the past 4 weeks at Month 9. We also assessed total deposit, total stakes, compulsivity, number and duration of gaming sessions and subsequent self-exclusions at 6, 9, 12 and 18 months.ResultsParticipants were randomized to the optimized group (n = 1265) or standard group (n = 1283). The results didn’t show a significant difference in the reduction in total losses. The optimized group showed significantly reduced 4-week total deposits versus standard group at 6 months (455.68 euros vs. 319.65 euros, p = 0.017), 9 months (451.92 euros vs. 343.21 euros, p = 0.040), and 12 months (484.27 euros vs. 370.02 euros, p = 0.025). Significance was lost at 18 months (492.61 euros vs. 404.73 euros, p = 0.087).ConclusionsAn extended 9-month ban on direct commercial solicitations after self-exclusion significantly reduces gambling deposits during, and 3 months after, the ban. This supports the effectiveness of improving self-exclusion procedure. Future research should explore longer bans and indirect commercial solicitations.Trial registration: NCT05413564.

BackgroundPeople who use drugs possess valuable expertise, knowledge, needs, and preferences as part of their lived experience, which should be incorporated into overdose-focused public health programs and policies.MethodsWe formed a community advisory board composed of 16 clients from four syringe services programs (SSPs) in Wisconsin for an overdose prevention research study to inform project priorities. Over 6 meetings spanning 10 months, the board engaged in a root cause analysis facilitated by SSP staff and University researchers using a semi-structured assessment technique from the Community Anti-Drug Coalitions of America. The board then identified solutions to each root cause and rated solutions on two dimensions: impact and effort required to implement. Similar solutions were combined by averaging effort and impact scores respectively. After the activity concluded, we gathered members’ perceptions of the activity using a brief, open-ended questionnaire.ResultsMembers identified nine root causes of overdose that spanned individual (e.g., solitary drug use), structural (e.g., inaccessible or suboptimal substance use treatment programs), and policy (e.g., criminalization of drug use) drivers of overdose occurrence and fatality risk. Substance use stigma was a cross-cutting, fundamental driver of all root causes. The board proposed 28 solutions responsive to these root causes, including changing policies, implementing whole-person focused harm reduction and treatment programs, and incorporating people with lived/living experience of drug use into the design and implementation of public health programs. Members felt the activity was meaningful and effectively facilitated, but highlighted that several solutions were unable to be acted upon in the context of the research study.ConclusionThis work reinforces a need for multi-dimensional, comprehensive interventions, programs, and policies to address the overdose crisis. Collectively, new and continued overdose prevention programming should broaden access to and use of harm reduction tools (e.g., naloxone, drug checking) and substance use and mental health treatments as well as reform policies that negatively impact the health of people who use drugs. Our findings underscore the need to incorporate the expertise of directly impacted populations into future research and program planning focused on overdose prevention by partnering with people who use drugs.Supplementary InformationThe online version contains supplementary material available at 10.1186/s12954-025-01368-9.

BackgroundMothers and pregnant women who use opioids are particularly vulnerable. Mothers often fear surveillance, stigma, and loss of custody of their children when seeking treatment. Although opioid agonist therapy (OAT) has been shown to be effective, access varies regionally, and not all mothers can cease using opioids. This study compares outcomes of mothers who use opioids in the UK with universal healthcare and OAT access, and mothers in the U.S. with restricted healthcare and OAT access, focusing on their interactions with services.MethodsThis is a secondary data analysis of two studies on mothers who use opioids. Data were collected from nine mothers in Scotland (UK) and 20 mothers in New Jersey (US) through ethnographic, longitudinal studies spanning one year. The UK study used a “Learning Alliance” engagement approach, a patient/public engagement model that involves stakeholders in developing objectives and the dissemination of findings. The US study engaged “community-based consultants,” who are paid individuals with lived experience from the study field communities to assist researchers in recruitment and ethnographic fieldwork. Ethical approval was received from review boards. Data were anonymized before analysis, and people with lived experience provided feedback on findings. Grounded theory methods were used for analysis.ResultsFindings reveal both convergent and divergent experiences. Mothers in Scotland had more access to healthcare and social housing but faced increased surveillance, while New Jersey mothers often experienced housing insecurity and difficulty obtaining healthcare. Shared challenges included trust issues, stigmatization, inconsistent practitioner engagement, responsibilization, and unclear expectations from child protection services. While Scottish mothers had better access to OAT, both groups faced child custody loss due to unregulated drug use. Mothers in both studies were struggling to meet reunification requirements of abstinence (with or without OAT) within the required time frame.ConclusionsDiffering governance structures create persistent challenges across national boundaries. While health practitioners generally support harm reduction strategies, it does not go beyond OAT for mothers. Our findings indicate the need for radical harm reduction approaches with social justice for mothers who use drugs, including safer parental drug use strategies.

Since 2016, over 50,928 people have died of an opioid-related overdose in Canada. The unregulated supply of drugs is increasingly toxic and volatile, and fentanyl from unregulated, street-based markets is driving this epidemic. Concerns that existing overdose prevention approaches were insufficient to address the rising number of overdoses led to the implementation of safer supply programs (SSPs) in Canada. SSPs provide prescribed medications to people who use drugs and are designed for individuals at high risk of overdose for whom existing care options have been ineffective or inappropriate. Evidence of SSP impact is growing but implementation processes, including admissions, are not well understood nor well-described in practice guidelines. Our purpose was to describe how the admission processes of four Ontario SSPs evolved and how these changes influenced program reach and perceived effectiveness. During 2021, we conducted short demographic and semi-structured interviews with healthcare providers (n = 21) from four SSPs in Ontario about implementation processes, challenges, and impacts. Thematic analysis of data concerning admission processes was conducted in MAXQDA and descriptive statistics in SPSSv28. Although the desire was for SSPs to have a broad reach, programs quickly realized they needed to develop strategies to manage the high demand for their programs. To manage this demand, strategies were implemented like waitlists, which were later replaced by points-based admission criteria. These admission criteria evolved over time, leading to a client population with high medical and social needs. The combination of high-acuity clients, limited capacity, and funding constraints, exacerbated by COVID-19, caused significant distress and burnout among service providers, prompting further changes to the SSPs. The implementation of SSPs in Ontario highlights the challenges of addressing intersecting public health emergencies in a resource-constrained healthcare system. SSPs, were adaptive and evolved in real time; while these adaptations addressed significant equity gaps, they also underscored the limitations of operating within an under-funded primary care model. The narrowing of admission criteria, necessitated by overwhelming demand and limited resources, ultimately constrained their reach and potential population-level impact.

BackgroundDrug checking is a harm reduction intervention that combines the identification of the chemical content of a drug with an information-sharing intervention concerning the risks of drug use. Despite growing evidence of the usefulness of this method, legal obstacles in many countries constrain the implementation of drug checking. The purpose of this Finnish study was to evaluate the usefulness of a paraphernalia-based drug-checking protocol.MethodsA total of 503 drug paraphernalia samples were submitted between April 2022 and July 2024 to 9 different harm reduction services. The samples were analysed monthly via chromatography‒mass spectrometry, and the visitors had the option to return to discuss the results after laboratory analysis. The questionnaire data were collected both during sample submission and the discussion of the results. Additionally, six thematic paired interviews were conducted with staff who performed drug checking at different service locations.ResultsThe concordance between the promised and detected contents varied greatly depending on the submitted substance. Over two-thirds of the samples were submitted by visitors who had never used substance use services before. The visitors returned for the laboratory results for only 208 samples. The interviewed staff believed that a long waiting time was the main reason for the low return rate. The staff also identified several advantages. The sample submission as well as the dissemination of the recent results via posters at the service points offered an easy way to approach people and discuss different topics related to drug use, harm reduction, and social and health issues.ConclusionThe protocol used was too slow for visitors to make preconsumption decisions. However, this shortcoming was not directly connected to the use of paraphernalia samples instead of actual drug samples, as the protocol could be accelerated with sufficient resources. The use of paraphernalia also caused uncertainties related to presubmission contamination. However, the protocol proved to be beneficial for initiating harm reduction discussions during the submission of the samples and the public dissemination of the results at the service locations, and should be considered as a starting point for drug checking when the use of actual drug samples is not possible.