People who use drugs, especially people who smoke or inject drugs, face additional risks and vulnerabilities to COVID-19 infection compared to the general population. Maintaining services for this population and safeguarding funding for harm reduction is therefore crucial.

The 2020 Global State of Harm Reduction reports that harm reduction service delivery has been disrupted by the pandemic. In Asia, accessing services due to quarantine and travel restrictions was a challenge, including receiving opioid agonist therapy (OAT) medications and HIV-related services. A regional survey found that young key populations experienced delays in accessing HIV and harm reduction services, and 70% reported anxiety over COVID-19. Access to OAT during the period of travel restrictions was also challenging in sub-Saharan Africa. The closure of international borders caused disruptions to the supply of OAT medication in eastern Europe and central Asia (e.g. in Moldova), while the COVID-related restructuring of government resources negatively impacted on harm reduction programmes in Bulgaria and Montenegro. Harm reduction services in most countries in the Middle East and North Africa faced similar problems and new needs such as food aid, housing support and financial aid emerged as a result of job losses. Containment measures in Asian countries have led to difficulties in accessing drugs, and there was also reportedly an increase in numbers of people newly initiating OAT, as many beneficiaries switched from their drugs of choice to OAT1. There is a concern that this may be a stop gap arrangement for some, with the likelihood of people resuming earlier patterns of drug use and increased cases of overdose once drugs become more available.

The COVID-19 pandemic, however, also resulted in some positive changes, with harm reduction services quickly adapting to the altered conditions. The most profound example is the change in OAT delivery across all regions. Out of the 84 countries worldwide where OAT is available, 47 countries (with at least one country in every region) expanded take-home capacities providing for longer take-home periods. Innovative measures were introduced to compensate for decreased availability, for example, online consultations replaced some face to face meetings in the Middle East and North Africa; and service providers introduced home delivery of harm reduction equipment in eastern Europe and central Asia. Community engagement and increased participation of the civil society in advocating for flexibility in services, appropriate response from the respective governments and enhanced participation of peers in providing critical harm reduction services have contributed to the continuity in service delivery. Community contribution, individual donor contribution and local NGO support is temporarily filling the need for food and shelter in some places to limited extent.

Key recommendations:

• Donors and governments must safeguard funding for harm reduction and continue to fund it. The pandemic showed that many harm reduction services are innovative and quick to adapt, and can maintain the best possible coverage, linking otherwise hidden key populations to other social and health care services.
• COVID-19 adaptations in OAT, NSP and treatment delivery should remain in place. Long-awaited changes in harm reduction service delivery took place during the pandemic. Longer take-home periods for OAT and less restrictive initiation procedures were set up in many countries, providing evidence that these are feasible and beneficial. Greater emphasis should be given to low threshold community settings in the distribution of harm reduction commodities.
• Greater community involvement is crucial to increase coverage and accessibility of services. Networks of people who use drugs played an important role during the pandemic, contributing to service delivery with secondary needle exchange, providing food and shelter, and disseminating crucial information among the drug user community. Peer involvement should be extended to provide more accessible services tailored for the needs of the community and appropriate funding should be made available.