Jessica F. Magidson

Introduction:Substance use disorder (SUD) represents a pervasive public health crisis. The criminal legal system represents an enriched environment for SUD. Adult drug treatment courts (ADTCs) offer court-supervised treatment for individuals with criminolegal involvement (CLI). Behavioral activation (BA) is an evidence-based intervention designed to support individuals with SUD by facilitating engagement in rewarding, substance-free activities through principles of positive reinforcement. Previous work has demonstrated that adapting BA for delivery by peer recovery specialists (PRSs), individuals with lived experience of substance use and recovery, is both feasible and effective in clinical settings. Presently, adapting a PRS-delivered BA for ADTCs has been unexamined. The current study employed a qualitative approach to examine rural ADTC participant and staff perspectives regarding the integration of a PRS-delivered BA intervention and obtain feedback to identify optimal implementation methods for an ADTC context.Methods:We conducted twenty-seven semi-structured interviews with majority rural ADTC participants and staff in Maryland to assess perspectives of 1) ADTC structures; 2) views of a PRS-delivered BA intervention; and 3) specific adaptations to consider for implementation in this setting. Interview transcripts were analyzed with thematic analysis.Results:Participants and staff perceived a PRS-delivered BA as feasible and acceptable in a rural ADTC context. Additionally, participants noted that to be effective, the PRS-delivered BA must be adaptable, allowing for flexible meeting times and settings, and should accommodate preferences for group peer support. Conclusion:Findings suggest that a PRS-delivered BA may be an acceptable and feasible intervention to improve rural ADTC engagement and retention. Further research is needed to guide further implementation.

Background: A substance use disorder (SUD) treatment gap exists globally, with the greatest gaps in settings with the fewest resources. Integrating SUD care into primary care is needed to expand access to SUD care and support adherence to chronic disease services, especially HIV, in high-burden areas. Guided by stakeholder feedback, our team has previously adapted and piloted a peer-delivered behavioral intervention for antiretroviral therapy (ART) adherence for people with HIV and SUD in HIV care (“ Khanya ”)—based on behavioral activation, problem-solving, motivational interviewing, and mindfulness-based relapse prevention skills—which was shown to be feasible, acceptable, and preliminarily effective. Objective: This study builds upon prior work to conduct a fully powered, randomized hybrid type 2 effectiveness-implementation trial (n=160) to evaluate the effectiveness of a stepped-care model of Khanya versus enhanced treatment as usual (ETAU) on ART adherence and substance use, implementation outcomes, and cost-effectiveness over 12 months. Methods: The trial is being conducted at two public primary care clinics that integrate HIV and other chronic disease services in a high-prevalence HIV setting in South Africa. We are recruiting people with HIV who self-report SUD and demonstrate one or more indicators of ART nonadherence. Eligible participants are randomized 1:1 to Khanya or ETAU. Participants randomized to Khanya first receive “step 1”—a single-session Life-Steps intervention for ART adherence delivered by a peer interventionist, followed by 2 weeks of real-time electronically monitored ART adherence using Wisepill to determine step-up decisions (ie, Khanya intervention). The RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework guided outcome measure selection, including effectiveness (ART adherence: Wisepill; substance use: urinalysis and WHO ASSIST [World Health Organization’s Alcohol, Smoking and Substance Involvement Screening Test]); implementation (feasibility, acceptability, fidelity, and uptake assessed using 2 validated quantitative measures and qualitative feedback over 6 months); and cost-effectiveness (microcosting, health care use, and health-related quality of life using the EuroQol-5D). Descriptive analysis will be used to summarize implementation outcomes, and intent-to-treat analysis using a linear mixed model will be conducted for effectiveness outcomes. Results: Funded in August 2022, recruitment for the trial began in June 2023, and primary data collection is projected to be completed in February 2027. Recruitment for the clinical trial (n=162) was completed in March 2026. It is projected that all exit interviews will be completed by March 2027. Conclusions: This trial builds upon formative work to evaluate the effectiveness, implementation, and cost of a peer-delivered, stepped care intervention integrated into primary care. A stepped-care design to maximize optimal use of resources and integration into primary care is a necessary step to increase accessible intervention programs for people with HIV with comorbid SUD globally.

Background: South Africa has a high prevalence of HIV and substance use, with 13% of the population meeting criteria for lifetime substance use disorder (SUD). Substance disorders are associated with adverse health outcomes, including poor adherence to antiretroviral therapy (ART), reduced health-seeking behaviour and increased risk-taking behaviour. Limited research has explored the perspectives of people with HIV in low- and middle-income countries when accessing substance use treatment. Objectives: To identify barriers and facilitators influencing engagement in substance use treatment programmes among people with HIV and SUDs, drawing on perspectives from both patients and healthcare providers. Method: This qualitative study analysed individual interviews from Project Khanya, a peer-delivered intervention promoting ART adherence among adults living with HIV with at least a moderate SUD. Using criterion sampling, 34 adults with HIV and nine healthcare providers involved in HIV or substance use care were included. Inductive thematic analysis of transcripts from audio recordings identified individual, social, and structural factors influencing treatment engagement. Results: Participants had a mean age of 39.2 years and 48% were female; providers had a mean age of 40.8 years and were predominantly female. Five main subthemes influenced engagement in substance use treatment: social support, substance use, service-related factors, readiness to change, and financial constraints. Facilitators included strong social support, positive healthcare experiences, outreach, psychoeducation, insight, and reduced substance use, while barriers included poor support, stigma, negative healthcare interactions, financial challenges, and ongoing substance use. Conclusion: Intersectional stigma, privacy concerns, and ongoing substance use hinder engagement in HIV and SUD treatment, whereas holistic, person-centred approaches can improve programme attendance and health outcomes.

Stigma acts as a barrier to the diagnosis and effective treatment of tuberculosis (TB). Individuals with TB who also use alcohol or drugs (AODs), including methamphetamine, may experience intersectional stigma. Further, the nature and intensity of these intersecting stigmas may be compounded by co-morbidities like HIV and marginalized social status. Despite this, AOD use stigma has rarely been studied in the context of TB and other co-occurring conditions. We examined the perceptions and experiences of AOD use-related stigma among individuals who were previously diagnosed with TB or were at increased risk of TB based on their close contacts, in a rural community in the Western Cape, South Africa. We analyzed qualitative data collected by two studies (study 1: five focus groups (n=34), study 2: ten focus groups (n=84)). Findings highlighted that study participants who use AODs experienced intersectional stigma from multiple sources. AOD use- and TB-related stigma were experienced from friends, family, healthcare providers, and the broader community, particularly for those who used illicit drugs. Participants discussed stigma’s effects on their health and well-being. The negative effects of AOD use stigma were particularly salient among female participants. Findings indicate that intersecting stigmas exist at multiple levels for people who use AODs with/at risk of TB, and that these stigmas hinder healthcare utilization in this rural setting. Future interventions to improve TB service uptake need to address intersectional AOD use and TB stigma.

Peer recovery specialists (PRS) are increasingly recognized as key members of the substance use disorder (SUD) treatment workforce. Recent efforts have focused on expanding PRS roles to include the delivery of behavioral evidence-based interventions (EBIs), such as motivational interviewing, cognitive-behavioral therapy techniques, and brief interventions. This scoping review aims to identify the determinants that influence the implementation of PRS-delivered behavioral EBIs and the strategies used to optimize their delivery within diverse SUD treatment contexts. A systematic search was conducted in APA PsycINFO, Web of Science, Scopus, PubMed, and Google Scholar, following PRISMA-ScR guidelines. Studies were included if they examined PRS delivering behavioral EBIs for SUD and reported on at least one implementation outcome as defined by Proctor et al. (2011). Data extraction and thematic synthesis were conducted using a hybrid deductive-inductive coding framework. Twelve studies met inclusion criteria. The most commonly studied interventions included behavioral activation, motivational interviewing, and Screening, Brief Intervention, and Referral to Treatment (SBIRT). PRS-delivered behavioral EBIs demonstrated high acceptability, appropriateness, and feasibility, with strong participant engagement and satisfaction. Facilitators of implementation included the integration of PRS within existing service structures, the adaptability of interventions, and the unique relatability of PRS. Barriers included PRS role ambiguity, gaps in training, and systemic challenges such as lack of funding and limited access to adjunctive support services. Implementation outcomes such as adoption, sustainability, and cost were infrequently assessed, highlighting gaps in the current literature. The findings suggest that PRS-delivered behavioral EBIs hold promise in expanding access to evidence-based care for individuals with SUD. However, structured training, supervision, and organizational support are critical for successful implementation. Future research should prioritize evaluating long-term sustainability, supervision, and strategies to enhance the integration of PRS within healthcare systems. Incorporating methods to address systemic barriers faced by service recipients will be essential for maximizing the impact of PRS-delivered interventions in SUD treatment.

Background: Although medications exist to effectively treat opioid use disorder (OUD), treatment retention is a pressing challenge. Peer recovery specialists (PRSs) may play an important role in OUD treatment retention, yet few evidence-based interventions to support OUD retention have been developed specifically for PRS delivery. Behavioral activation is a brief, reinforcement-based intervention with empirical support for improving depression and substance use outcomes, delivered typically by specialist mental health providers. Informed by key stakeholder feedback, our team adapted a behavioral activation and problem-solving intervention for PRS delivery (“Peer Activate”) to improve methadone treatment retention. Building on a successful open-label pilot trial demonstrating initial feasibility, acceptability, and preliminary effectiveness of Peer Activate, the current type 1 hybrid randomized controlled trial evaluates the effectiveness of Peer Activate compared to treatment as usual on six-month methadone retention (primary) and longer-term implementation outcomes.Methods: The trial is being conducted at a large methadone treatment program in Baltimore City, Maryland. We are enrolling 200 patients who recently initiated methadone treatment or are experiencing challenges with methadone adherence in a randomized 1:1 ratio to receive Peer Activate plus treatment as usual (PA + TAU) or TAU only. Additionally, we are recruiting 12 stakeholders to provide feedback on implementation and sustainability. Peer Activate consists of four core intervention sessions delivered by a PRS with relevant lived experience and training in the intervention. Sessions focus on problem-solving barriers to retention and behavioral activation—increasing value-driven, substance-free activities—and continued skill practice and relapse prevention. Assessments are administered at baseline, post-treatment (approximately 3 months), and 6 months. The primary effectiveness outcome is methadone retention over 6 months, measured using chart review. Implementation outcomes are defined based on Proctor’s model, including feasibility, acceptability, and fidelity of the intervention.Discussion: This trial will provide insight as to whether a PRS-delivered intervention may be effective and feasible for improving methadone treatment retention and other behavioral health outcomes. If findings are promising, Peer Activate may provide a platform on which to incorporate an evidence-based behavioral activation approach into PRS training nationally.Clinical trial registration: NCT05299515.

Stress is a challenge among non-specialist health workers worldwide, particularly in low-resource settings. Understanding and targeting stress is critical for supporting non-specialists and their patients, as stress negatively affects patient care. Further, stigma toward mental health and substance use conditions also impacts patient care. However, there is little information on the intersection of these factors. This sub-analysis aims to explore how substance use and mental health stigma intersect with provider stress and resource constraints to influence the care of people with HIV/TB. We conducted semi-structured interviews (N=30) with patients (n=15) and providers (n=15, non-specialist health workers) within a low-resource community in Cape Town, South Africa. Data were analyzed using thematic analysis. Three key themes were identified: (1) resource constraints negatively affect patient care and contribute to non-specialist stress; (2) in the context of stress, non-specialists are hesitant to work with patients with mental health or substance use concerns, who they view as more demanding and (3) stress contributes to provider stigma, which negatively impacts patient care. Findings highlight the need for multilevel interventions targeting both provider stress and stigma toward people with mental health and substance use concerns, especially within the context of non-specialist-delivered mental health services in low-resource settings.

Implementation outcomes, which focus on the barriers to, and facilitators and processes of healthcare delivery, are critical to translating research evidence to health planning and practice and to improving healthcare delivery. This article summarises key quality issues in reporting of implementation science outcomes within global health and describes the ways in which this presents a challenge for shifting health planning and practice across low‐resource health systems. This article also suggests that the wider use of reporting guidelines for implementation outcomes could help address this issue.