Roman Shrestha

The surge of fentanyl in the US drug supply has fueled the opioid overdose problem to unprecedented record levels (Ciccarone, 2019; Vickers-Smith et al., 2025). It is a highly potent synthetic opio...

Background: New HIV cases among Malaysian men who have sex with men continue to rise, with young men who have sex with men (YMSM) accounting for 44% of new infections and experiencing high rates of comorbidities. Mobile health (mHealth) apps offer a promising approach to addressing these challenges by providing discreet access to health information, screening tools, and linkage to services. Given the near-universal smartphone ownership among Malaysian YMSM and high levels of mobile gaming engagement, gamified mHealth apps may be particularly effective in sustaining engagement and promoting HIV prevention behaviors and comorbidity management. However, realizing their full potential requires identifying the features and design principles that are most important to Malaysian YMSM and that can support sustained engagement and improve health outcomes in this vulnerable population. Objective: This study used an interdisciplinary expert panel approach to identify the key features, design principles, and gamification elements to be incorporated into MY-Hero, a gamified mHealth app designed to support HIV prevention, comorbidity management, and overall well-being among Malaysian YMSM. Methods: Guided by the integrated behavioral model (IBM), we conducted an interdisciplinary expert panel comprising experts in health, technology, and design sciences, as well as health care professionals with expertise in the Malaysian YMSM population, along with local lesbian, gay, bisexual, transgender, queer, and others (LGBTQ+) community leaders. Through a structured series of discussions and thematic analysis, we identified culturally appropriate design principles and key features for MY-Hero that align with the health needs and sociocultural context of Malaysian YMSM. Results: Three expert panel sessions were conducted with 9 experts. Several key themes emerged: (1) the importance of establishing clinical affiliation and facilitating linkage to HIV testing, pre-exposure prophylaxis (PrEP), and related services, including harm reduction services; (2) the need to enhance user interface (UI) and user experience (UX) by optimizing usability, interactivity, and engagement to maintain user interest; (3) the incorporation of customizable health content to tailor interventions based on individual characteristics and preferences; (4) the use of gamification mechanisms, such as reward systems and progression tracking to promote adoption and sustained engagement with health services; and (5) the importance of privacy and data security as critical design considerations for ensuring user safety, confidentiality, and trust. Conclusions: The findings highlight the importance of user-centered design, contextualized health content, and gamification mechanisms in mHealth tools for Malaysian YMSM. These insights provide practical guidance for developing culturally appropriate gamified mHealth interventions for vulnerable populations by informing strategies to enhance user engagement, reduce HIV prevention fatigue, and support the well-being of YMSM in stigmatized contexts.

Introduction: People who use opioids (PWUO) experience a disproportionately high burden of suicidal risk. Syringe services programs (SSPs) are a critical point of contact for this population, providing low-threshold, harm-reduction services. However, gaps persist in understanding suicidal risk among individuals attending SSPs and the extent to which such risk is associated with mental health service utilization in this setting. This study aimed to assess the prevalence and specific risk factors for suicidal ideation (SI) in PWUO, as well as their use of and barriers to accessing mental health services. Methods: We conducted a cross-sectional survey between April and June 2024 among PWUO (N = 199) who were utilizing services in the SSP in New Haven, Connecticut. We used the ninth item from the Patient Health Questionnaire (PHQ-9) scale, which assesses passive thoughts of death and self-harm in the past two weeks, as a proxy measure for the SI. Additionally, participants reported their use of and barriers to accessing mental health services in the past six months. Bivariate and multivariable logistic regression were conducted to examine factors associated with SI. Results: Approximately 84% of participants met the criteria for opioid dependence, and more than two-thirds (71.9%) were currently receiving medication for opioid use disorder. Over one-third of the sample reported SI in the past two weeks (34.7%). Additionally, over one-third of participants (36.2%) reported unmet mental health needs, and 84.4% reported experiencing at least one barrier to accessing mental health services. Individuals with depressive symptoms (aOR: 5.4; 95% CI: 2.5–11.7) were more likely to report SI, while those who were aware of naloxone (aOR: 0.2; 95% CI: 0.1–0.6) were less likely to report SI in the past two weeks. Conclusion: Our study showed a high prevalence of SI among SSP clients who use opioids and a low use of mental health services due to access barriers. These findings support incorporating a brief suicide risk screening and referral options within SSPs and other settings serving PWUO and addressing key access issues like cost and transportation that can prevent timely linkage to mental health services.

Depression is prevalent among people who use opioids (PWUO) and may hinder mental healthcare access not only through reduced engagement but also through difficulty identifying where to obtain services. Information about available mental health care is often obtained through disclosure of symptoms and help-seeking interactions with providers or others. Concerns about how others may react to seeking care may discourage these interactions and limit guidance opportunities for care. However, few studies have examined whether depressive symptoms and anticipated stigma related to help-seeking perceived as a barrier to care are associated with reporting a mental health care service navigation knowledge barrier among PWUO. We analyzed data from a cross-sectional survey of 199 PWUO conducted in New Haven, Connecticut. Participants reported whether “being unsure where to go to get mental healthcare” was perceived as a barrier (mental health care service navigation knowledge barrier) and whether “being concerned about what others might think, say, or do” was perceived as a barrier (anticipated stigma related to help-seeking perceived as a barrier). Depressive symptoms were assessed with the PHQ-9 (score ≥ 10). Using adjusted multivariable logistic regression models, we examined separate and jointly adjusted associations and tested an interaction by depression screening status. Nearly 59% of participants screened positive for depressive symptoms. Depressive symptoms were associated with higher odds of reporting the service navigation knowledge barrier (aOR = 4.00; 95% CI: 2.10–7.88). Anticipated stigma related to help-seeking perceived as a barrier was also associated with higher odds of reporting the service navigation knowledge barrier (aOR = 5.16; 95% CI: 2.75-10.00). In a jointly adjusted model, both depressive symptoms (aOR = 3.50; 95% CI: 1.77–7.15) and anticipated stigma related to help-seeking perceived as a barrier (aOR = 4.67; 95% CI: 2.43–9.26) remained independently associated with the outcome. The interaction was not statistically significant (p = 0.052). Findings suggest that improving mental healthcare access for PWUO may require attention to both depressive symptoms and anticipated stigma related to help-seeking perceived as a barrier to care, alongside practical navigation and linkage supports embedded in harm reduction and substance use treatment settings.

Background: Opioids account for 76% of drug overdose deaths in the United States, with nearly 80,000 opioid overdose deaths annually. The risk of overdose is dynamic and influenced by rapidly changing behaviors and contexts that are not well captured by retrospective or infrequent assessments. Ecological momentary assessment (EMA) allows repeated near real-time reporting of behaviors and experiences in natural settings. Objective: This study evaluated the feasibility and acceptability of smartphone-based EMA among people who use opioids to monitor opioid use, overdose experiences, and naloxone access. Methods: Participants were recruited through the New Haven Syringe Services Program in New Haven, Connecticut, and completed fixed-time, twice-daily EMA prompts for 30 days using a smartphone app. EMA measures assessed behaviors and experiences occurring within the previous 12 hours, including opioid craving, plans to use drugs, opioid use, overdose experiences, and naloxone access. Feasibility was assessed through recruitment, retention, and EMA completion rates, as well as the reporting of drug use-related behaviors. Acceptability was evaluated using exit surveys assessing ease of use, burden, and privacy, as well as qualitative interviews. Results: Of the 13 screened individuals, 10 were enrolled and completed the baseline assessment. A total of 9 (90%) participants completed EMA and responded to 411 prompts, with an overall compliance rate of a mean of 85.0% (SD 8.7%). Compliance was similar across morning (84.2%, SD 13.1%) and evening (85.8%, SD 11.2%) prompts. Participants reported opioid cravings (274 reports), plans to use illicit drugs (252 reports), and opioid use (411 reports) during the study period. Two participants reported overdose events (5 reports) and were carrying naloxone during each overdose event. Acceptability ratings were high: all participants reported that EMA prompts were easy to understand and private, and most did not find them burdensome. Qualitative feedback further highlighted the ease of use, integration into daily routines, and increased self-awareness, although some participants reported emotional discomfort when reflecting on their substance use. Conclusions: Smartphone-based EMA was feasible and acceptable among people who use opioids recruited through a syringe service program. EMA may support the monitoring of opioid use, overdose experiences, and naloxone access, and it may inform future digital health interventions aimed at reducing harm, including overdose risk, among people who use opioids.

Men who have sex with men (MSM) have an elevated risk of adverse outcomes associated with cannabis use. Many studies have been conducted globally; however, there is a lack of research regarding the existing status and factors associated with cannabis use among MSM in Nepal. Therefore, this study aimed to examine the characteristics and factors associated with cannabis use among MSM in Nepal. A cross-sectional respondent driven survey was conducted among MSM in Kathmandu Valley, Nepal between October and December 2022. Overall proportions were weighted in respondent driven sampling analyst software, and 95% confidence intervals (CIs) were calculated. Bivariate and multivariable logistic regression analyses were used to evaluate independent correlates of cannabis use in the last 6 months. Among 250 participants, 27.3% of them used cannabis at least once in their lifetime, and 15.6% had used it within the last 6 months. Older MSM were less likely to have used cannabis (adjusted odds ratio [aOR]: 0.8, 95% CI: 0.7–0.9). Participants who were single (aOR: 21.5; 95% CI: 2.6–175.6), detained at least once by the police (aOR: 11.4; 95% CI: 2.2–58.4), and smoked tobacco daily (aOR: 4.6; 95% CI: 1.2–17.9) had higher odds of cannabis use. Participants who had seen a doctor in the last 6 months (aOR: 0.2; 95% CI: 0.1–0.6) and had trusted healthcare provider (aOR: 0.1; 95% CI: 0.01–0.2) were less likely to use cannabis. Given the known negative health effects of cannabis use such as increased risk of HIV transmission, polydrug use, and heightened sexual health risks, special attention should be directed toward MSM who are young, single, and daily smokers. Participants who had seen a doctor in the last 6 months and had trusted healthcare provider were less likely to use cannabis. This highlights the importance of connecting individuals to regular healthcare services and building trust with providers.

Pre-exposure prophylaxis (PrEP) is effective for HIV prevention, yet uptake remains suboptimal among people who inject drugs. A pilot randomized controlled trial examined the feasibility, acceptability, and preliminary efficacy of a nurse practitioner–led, same-day PrEP model (iRaPID) within a syringe services program. Forty-four people who inject drugs who were HIV-seronegative were randomized 1:1 to iRaPID or treatment-as-usual. In iRaPID, 12 of 22 participants filled a PrEP prescription at baseline, including nine on the same day. Only three participants refilled prescriptions at both the 30- and 90-day follow-ups. Acceptability was high (scale 1–5), with mean ratings of 3.9 at 30 days and 4.2 at 90 days. PrEP uptake at 30 days was significantly higher in iRaPID (odds ratio: 5.40; 95% confidence interval, 1.37–21.26; p = .016) but not sustained at 90 days (odds ratio: 0.19; 95% confidence interval, 0.02–1.67; p = .133). Findings support the feasibility and acceptability of nurse practitioner–led, same-day PrEP delivery through a syringe services program while highlighting challenges to sustaining uptake.

Background and Aims: HIV remains a global health concern, disproportionately affecting men who have sex with men (MSM). Discrimination, stigma, and other barriers in healthcare settings are common issues for MSM in Malaysia, resulting in sub‐optimal HIV testing and linkage to HIV prevention services. Thus, we created a clinic‐integrated HIV prevention app called “JomPrEP” to scale up HIV prevention efforts among this vulnerable group. This study aimed to explore the perceived utility, appeal, and functionality of the JomPrEP app for MSM in Malaysia to improve access to HIV prevention services. Methods: We conducted one‐on‐one qualitative interviews with 10 MSM and 10 healthcare stakeholders (i.e., physicians and administrators) using the ‘think‐aloud’ (TA) protocol. A brief example was provided to ensure participants understood the TA process, and then they were asked to open the app's web version in their browsers and share their screens. The TA procedure included 10 problem‐solving tasks, followed by a semi‐structured interview. These interviews aimed to delve deeper into the users' feedback on the pre‐specified tasks on nine features of the app. The TA sessions were video‐recorded and then transcribed verbatim. Theme analysis was used to analyze qualitative data. Results: MSM and stakeholder participants expressed most of the app features (e.g., app signup page, ordering HIV self‐test [HIVST] kits, and pre‐exposure prophylaxis [PrEP] medications) as being important and user‐friendly. Incorporating other features, particularly MedManager (e.g., a feature that sends reminders to users and tracks their medications) and reward systems (i.e., incentives for specific actions such as ordering HIVST or reviewing app resources), were well‐received. Conversely, participants also suggested (i.e., introducing edit and update options for PrEP and HIVST kit orders and incorporating confirmation messages for clinic appointments) to refine the app further. Conclusion: JomPrEP was found to be a functional, appealing, and useful platform to scale up HIV prevention services among MSM in Malaysia. Further refinements and pilot testing are needed to assess its impact on HIV prevention efforts for MSM in Malaysia.

BACKGROUND Opioids account for 76% of drug overdose deaths in the US, with nearly 80,000 opioid overdose deaths annually. Overdose risk is dynamic and influenced by rapidly changing behaviors and contexts that are not well captured by retrospective or infrequent assessments. Ecological momentary assessment (EMA) allows for repeated, near real-time reporting of behaviors and experiences in natural settings. OBJECTIVE This study evaluated the feasibility and acceptability of smartphone-based EMA for monitoring opioid use, overdose experiences, and naloxone access among people who use opioids (PWUO). METHODS Participants were recruited through the New Haven Syringe Services Program (NHSSP) in New Haven, Connecticut, and completed twice-daily EMA prompts for 30 days using a smartphone application. EMA measures included opioid craving, plans to use drugs, opioid use, overdose experiences, and naloxone access. Feasibility was assessed through recruitment, retention, and EMA completion rates, as well as reporting of drug use-related behaviors. Acceptability was evaluated using exit surveys assessing ease of use, burden, and privacy, along with qualitative interviews. RESULTS Of 13 individuals screened, 10 were enrolled and completed baseline assessment. Nine participants (90%) completed EMA assessments and responded to 411 prompts with an overall compliance rate of 85.0% (SD 8.7%). Compliance was similar across morning (84.2%) and evening (85.8%) surveys. Participants reported opioid cravings (257 reports), plans to use any illicit drugs (235 reports), and opioid use (385 reports) during the study period. Two participants reported overdose events (5 reports) and were carrying naloxone during each overdose report. Acceptability ratings were high: all participants reported that surveys were easy to understand and private, and most did not find them burdensome. Qualitative feedback further highlighted the ease of use, integration into daily routines, and increased self-awareness, while some participants reported emotional discomfort when reflecting on substance use. CONCLUSIONS Smartphone-based EMA was feasible and acceptable among PWUO recruited through a syringe service program. EMA may support real-time monitoring of opioid use, overdose experiences, and naloxone use and may inform future digital health interventions aimed at reducing overdose risk among PWUO.

BACKGROUND Motivational interviewing (MI) is a structured, person-centered approach that increases a patient’s likelihood of engaging in healthy behaviors. MI can be delivered by non-specialists, making it promising for low- and middle-income countries (LMICs), where mental health specialists are scarce. Community health workers (CHWs) are well-positioned to deliver MI but often lack structured supervision, leading to skill decay after training. Because CHWs work primarily in communities rather than clinics, direct observation and timely feedback are difficult. Digital mobile health (mHealth) tools can help bridge this supervision gap, yet real-world evidence on their acceptability and feasibility remains limited. OBJECTIVE To assess the acceptability and feasibility of COMMIT-D, an mHealth tool designed to support CHWs in delivering motivational interviewing for depression care and receiving remote supervision in rural Nepal. METHODS We conducted a single-arm, mixed-methods study (2019–2022) to develop and pilot test COMMIT-D, a community-based mHealth tool for CHWs. The study was implemented within a primary care system in Dolakha, Nepal, where CHWs are responsible for coordinating care for noncommunicable diseases, mental health, and maternal health. COMMIT-D provides guided prompts on MI skills, captures patient medication adherence and stages of change, and enables audio recording of consented interactions for asynchronous supervisor feedback. A total of 20 CHWs delivered MI to patients with depression identified as having suboptimal care engagement. Quantitative measures included patient-reported adherence and stages of change, as well as a 9-item survey assessing CHW acceptability and feasibility. Qualitative data were collected in two rounds (January and August 2022) using focus group discussions with CHWs (total 7 FGDs, n=41) and semi-structured interviews with CHWs’ supervisors (n=8) and patients (n=13). RESULTS Of 340 patients with depression in the electronic health record, 71 (20.9%) had limited engagement with care. Of those, 65 (91%) were approached, and 37 (58%) completed three MI visits by CHWs. More than 40% of the CHWs delivered four or more MI sessions. All CHWs knew how to seek MI support, and 64% received supervisory feedback at least once. Perceived acceptability among CHWs was high, with more than 94% reporting that MI improved their ability to understand and respond to patients’ needs, and over 80% agreed that MI is applicable to other noncommunicable diseases beyond depression. Findings from CHW focus groups and interviews with supervisors and patients indicated that, despite initial challenges related to audio recording for supervision and the use of MI skills, all participants found COMMIT-D acceptable and feasible. CONCLUSIONS COMMIT-D was feasible and acceptable to CHWs, supervisors, and patients, demonstrating that an mHealth tool can support MI delivery and remote supervision within routine CHW workflows. By addressing supervision barriers and supporting MI practice, COMMIT-D offers a scalable approach for strengthening patient engagement in depression care in rural LMICs. CLINICALTRIAL This study was registered at ClinicalTrials.gov on August 12, 2020 (Registration Number: NCT04510909; Title: COMMIT Depression Trial Nepal).