Harm reduction strategies are central to achieving UNAIDS’ goal of ending HIV by 2030; however, the provision of harm reduction services is still suboptimal, and people who use drugs continue to be left behind in HIV responses.

Key populations -including people who use drugs- and their sexual partners continue to bear a disproportionate burden of the pandemic. As reported by UNAIDS, in 2022, the relative risk of acquiring HIV was 14 times higher for people who inject drugs, 23 times higher for gay men and other men who have sex with men, nine times higher for sex workers, and 20 times higher for transgender women than in the wider adult (aged 15–49 years) population globally. Approximately, one in eight people who inject drugs, or about 1.6 million individuals are living with HIV, with the highest proportion of infections reported in South-West Asia (29.4%), Eastern Europe (25.6%) and Southern Africa (22.3%), with rates twice as high as the global average (11.6 %). It is also estimated that people who use drugs contributed to half of the new HIV cases in 2022 globally. People who inject drugs also carry a high burden of other infections, and nearly one in every two people who inject drugs is living with hepatitis C (HCV), with liver disease due to HCV being a major cause of drug-related deaths, accounting for more than half of the total number of deaths attributed to the use of drugs in 2019.

Among people who inject drugs, there are some groups of particular risk. While men outnumber women in injecting drug use, women carry a higher burden of health and social consequences. Women are 1.2 times more likely than men to be living with HIV. This is due to heightened vulnerability due to gender violence and power structures that can lead to unsafe sexual and injecting behaviours. For example, women who inject drugs are likely to have a male intimate partner who initiated them into drug use and may rely on them for injection. Women who use drugs are at higher risk of experiencing gender-based violence and sexual abuse perpetrated by both their intimate partners and by other people who use drugs around them, law enforcement officers and drug service providers. Young people who inject drugs also face significantly higher risks of contracting HIV and HCV compared to adults who inject drugs. They are 50% more likely to acquire HIV and HCV than their adult counterparts. In North America, young people are disproportionately affected by overdoses and drug poisonings, and overdose is now the third leading cause of death among this age group. LGBTQ+ people have historically been a marginalised and criminalised group, which has posed them with an increased risk of acquiring HIV while lacking access to life-saving treatment. With most harm reduction programmes still reliant on international funding, the growing number of foreign agents and anti-LGBTQI+ laws pose a significant threat to the continuation of HIV-related services and support for key population groups.

WHO, UNAIDS and UNODC have recognised harm reduction as part of the key comprehensive package of evidence-based interventions for HIV prevention, treatment and care for people who inject drugs; however, they remain severely underserved. As of 2024, HRI’s Global State of Harm Reduction reported that:

• 93 countries provide at least one Needle and Syringe Program (NSP), one more country than the previous report in 2022, with Brazil joining the list. However, the availability of NSPs still falls significantly short of the global demand. The latest review finds 190 countries and territories where injecting drug use has been documented, meaning people who inject drugs in 97 countries are unable to access an NSP anywhere.
• Opioid Agonist Therapy (OAT) programmes are available in 94 countries, compared to 88 in 2022. Despite the increase in the provision of OAT, the coverage varies across regions. Western Europe has the highest coverage with almost 70 OAT clients per 100 people who inject drugs, followed by Oceania and South Asia. Moderate coverage is registered in North America, where an estimated 21% of people who inject drugs receive OAT. In the rest of the regions, coverage is low, being particularly critical in Central Asia, Eastern Europe, Eastern and Southern Africa and West and Central Africa. Across these regions, fewer than 2% of people who inject drugs have access to OAT. OAT is prohibited by federal law in Russia despite around 90% of its 1.3 million people who inject drugs using opioids and needing access to the service.
• Only 18 countries have at least one Drug Consumption Room (DCRs), two more countries than 2022, namely Colombia and Sierra Leona. Distribution across regions remain uneven, as the majority of DCRs are concentrated in Western Europe.
• Take-home naloxone programmes are now available in 34 countries, a decrease of two countries since 2022.
• 108 countries include harm reduction in national policies, up from 105 in 2022. However, the scope and comprehensiveness of harm reduction policies vary significantly across nations. Some countries, such as Ethiopia and Malawi, have limited harm reduction in their policies, which only includes OAT in their national HIV plans. In contrast, Zimbabwe’s HIV plan includes three harm reduction services (OAT, NSP and naloxone distribution). Malawi has explicit references to harm reduction in several national policy documents, including the health sector’s strategic plan as well as the country’s specific plans on drugs, HIV, hepatitis and sexually transmitted infections (STIs). In Brazil, supportive references to harm reduction appear in several national plans (on drugs, HIV, hepatitis, and STIs), including references to different services (OAT, NSP, infectious disease care and services for non-injecting drug use). This is in line with international recommendations for more comprehensive responses.

Additionally, there are other practices associated to drug use to which traditional harm reduction interventions may not be appropriate to the need of people using drugs. That is the case of the sexualised drug use, which involves both sexual and drug-related high-risk behaviours including multiple sexual partners, the use of multiple drugs together, among others. For example, chemsex, the practice of using specific drugs to enhance and prolong sex (often involving group sex), is on the rise in Asia and has been associated with a higher risk of contracting HIV and other infections, according to studies from Malaysia, Hong Kong, Thailand and China. Common drugs used by people engaged in chemsex in Asia typically include methamphetamine, ecstasy (MDMA), poppers (alkyl nitrites), ketamine and gamma-hydroxybutyrate or gamma-butyrolactone (GHB/GBL) and will often involve the use of more than one type of drug during a chemsex session. Consequently, the chemsex scene may include various forms of drug use, such as ingesting, snorting, smoking and injecting, with many risks associated with their use and conventional harm reduction strategies may not adequately address the specific challenges associated with chemsex-related substance use.

People engaging in chemsex are an important target group for PrEP and PEP, and appropriate service provision can be key to access to these preventive medications. The few harm reduction services for chemsex are focused on gay, bisexual, and other men who have sex with men (GBMSS). However, these are not the only people who practice chemsex, whose needs may be overlooked. This highlights the importance of robust and tailored health interventions in reducing the risk of infections and providing effective care and treatment.

The funding landscape for harm reduction programs is at a critical juncture, particularly in middle and low-income countries (LMICs). Despite harm reduction showing to be highly cost-effective, cost-saving and efficient in preventing HIV and HCV among key populations, the funding remains severely inadequate. According to HRI’s report The Cost of Complacency: a harm reduction funding crisis, as of 2022, a total of USD 22.4 billion was made available for the HIV response in LMICs, leaving a 29% gap to meet estimated need by 2025. The funding gap for key population is even larger than the funding gap for the HIV response, standing at an estimated 90% in 2022. HRI identified USD 151 of harm reduction funding in 2022, amounting to just to just 6% of the USD 2.7 billion needed annually by 2025, leaving a funding gap of 94%.18

Countries still rely heavily on international donor funding, which comprised 67% of the total harm reduction funding in 2022.19 After the Global Fund, the largest donor is PEPFAR, which provided USD 74 million. The total PEPFAR expenditure on programmes for people who inject drugs amounted to USD 7.9 million in 2022, with most of this recorded expenditure (81%) going through HIV preventions programs for this specific population.20 In 2022, PEPFAR funds supported the provision of OAT to 27,000 people in seven countries (India, Kenya, Kyrgyzstan, South Africa, Tajikistan, Tanzania and Uganda), Notably, in January 2024 the USA announced a pause on all foreign assistance, including programs supported by PEPFAR. This triggered one of the more profound crises of harm reduction ever, with severe implications for people who use drugs and modelling indicating an increase in overdoses and HIV infections as a direct impact of the freeze. In addition, ‘stop work orders’ to multilateral agencies receiving PEPFAR support such as UNAIDS, UNODC and pooled mechanisms such as the Robert Carr Fund (RCF) are affecting activities at secretariat, country office and local level, disrupting services and crucial supportive processes that have implications for people who use drugs such as community-led monitoring and the roll-out of sustainability road maps. Given high level of uncertainty with international funding prone to shift in priorities, political leadership and ideology, the need for scaling up domestic funding for a more sustainable response is key.

At a domestic level, investment for HIV has increased over the last decades. However, the slowdown in domestic funding since mid-2010s and the recent flattening of funding levels since 2018 are concerning trends. In 2022 the overall domestic funding was 3% lower than in 2021 and accounted for 60% of the total HIV investment. The limited domestic funding available is directed to HIV treatment such as procurement of antiretroviral (ARV) medication, clinical services etc, with few domestic investments directed to support prevention for key population, including harm reduction. Although harm reduction funding appeared to be increasing in 2019, HRI observed a decrease in identified funding for countries with previously large investments, including Iran and Vietnam.21 As a result, domestic funding for harm reduction is around 33% of all harm reduction funding identified in 2022, a substantial reduction from 2019. To put it in a perspective, domestic investment in harm reduction accounted for a mere 0.4% of all domestic funding for HIV in 2022; and the amount of domestic harm reduction spending identified by HRI’s report is a paltry 1.7% of the estimated harm reduction resource need by 2025.

There are different avenues to integrate HIV services in the domestic funding- and such integration not only increase investment but saves money and strengthen health system. These avenues include increased funding of government department managing HIV response, inclusion of comprehensive HIV treatment and prevention services in the national health insurance scheme, direct funding to civil society and community-led organizations through social contracting and other strategic initiatives. The direct increased allocations on HIV will enhance to prevent new HIV infections more effectively and improve the readiness of health system, integration in national health insurance will ensure universal access to the services and social contracting will enhance the community system, a critical component to health system. For example, co-financing can have a catalytic effect on increasing government ownership of national harm reduction programmes. That is the case of Indonesia, from which the Global Fund has obtained a co-financing commitment that amounts to USD 20.1 million domestic funding for HIV prevention programmes for people who use drugs and their sexual partners over three years period (2023-2026). However, this represents only 3% of Indonesia total co-financing commitment for HIV and would amount a mere 9% per day per person who injects drugs. Another tool to encourage domestic investment used by the Global Fund is the matching funds mechanism, which allows the Global Fund to use its influence as a donor to incentivise investment in evidence-based prevention programmes for key population, including harm reduction, in cases where political will is often lacking.

A good example of how domestic funding can work is the case of Community Oriented Substance Use Programme (COSUP) in Tshwane, South Africa, which represents an innovative model of harm reduction funding that combines procurement contracting and grant funding. The Chair of the South African Network of People who Use Drugs (SANPUD) sits on COSUP’s central management team and peer educators from the community of people who use drugs are central to the programme and services. The City of Tshwane makes scheduled payments based on the Service Level Agreement (SLA) and contract timeline. However, COSUP also has access to the flexibility and up-front payments that are typical of grants. The level of trust and historical dealings with the Department of Family Medicine meant that the funding was flexible, and line items were adjusted as priorities shifted. Unlike other municipalities, interventions for drug use in Tshwane are funded by the Department of Health.22 The first agreement was signed in 2016. A total of 2,957 people who use drugs were enrolled in COSUP and attended 19,533 counselling, social work or support sessions between 2016 and 2020. More than 600 people initiated OAT, around half of whom were self-funded, and the other half were city funded. After a national lockdown was declared in 2020 due to the COVID-19 pandemic, COSUP continue providing services, which confirms the model’s inherent adaptability, collaboration and innovation in addressing healthcare challenges during time of crisis. Between 2020 and 2023 the programme focused on Phase II aimed to consolidate services and align COSUP with the National Draft Plan and other policy documents as well as capacitate and train more people who use drugs. In early 2024, In early 2024, the City of Tshwane entered into a new SLA worth USD 6.8 million with the University of Pretoria to continue the COSUP programme until 2026.

The domestic funding increment requires technical financing knowledge and curated budget advocacy to convince the policy makers to make more investment in HIV and harm reduction. There are positive examples across the globe where budget advocacy has successfully increased domestic funding and have channelled the funding through social contracting. The advocacy however requires resources; and the international agency must provide such resource on budget advocacy. The resources can be core funding to advocacy organizations and flexible advocacy grant.

The following paragraphs will provide a brief, summarised review of key barriers.

• Criminalisation of key populations (such as people who use drugs, sex workers, and people living with HIV) is in itself an extremely significant barrier to monitoring state practices, as well as to protecting and promoting human rights in relation to the HIV response. With regards to drug use specifically, literature clearly shows the impact of criminalisation on a vast array of fundamental rights. Among many others, criminalisation prevents access to harm reduction and other health services by instilling fear and stigma among people who use drugs; thus impinging on the promotion of the right to health of people who use drugs. Criminalisation also leads to (over)incarceration, which in turn is an almost insurmountable barrier to accessing HIV services and enjoying fundamental rights.
• Stigma and discrimination, including in healthcare settings, create hostile environments that deter key populations from seeking care. For example in Egypt, a 2023 study found that healthcare staff in hospitals regularly stigmatise and discriminate against people who use drugs, directly impacting access to services. In many contexts these are exacerbated byc ultural and religious taboos that further marginalise women, migrants, and LGBTQI+ people, often making them invisible in national HIV strategies. For example, in Algeria, religious barriers prevent people from seeking NSP services because using drugs is considered a major sin. In Iran, unrealistic expectations from family and society, as well as stigma and the intertwining of treatment with ethical and religious principles, are identified as the most significant socio-cultural barriers to harm reduction and HIV treatment. Criminalisation, stigma and discrimination have broader impacts. On one hand, they prevent the meaningful participation of civil society and communities in the development, monitoring and implementation of policies, in contravention of fundamental human rights and with an impact on the effectiveness of policies. In some contexts, this is exacerbated by shrinking civic space and repression of civil society. This is particularly apparent in Eastern Europe and Central Asia. Organisations in Georgia, Russia, Kazakhstan and Tajikistan indicated that civil society in their countries is under threat for delivering or being involved in harm reduction services and advocacy; while the growing number of foreign agent and anti-LGBTQI+ laws poses a significant threat to the continuation of HIV-related services and support for key population groups, particularly in countries where the response relies on international donors.
• On the other hand, they obstacle the collection of complete and updated data, creating a vicious cycle of lack of reporting and thus luck of adequate policy responses. The lack of disaggregated data is particularly evident, to capture the situation and needs of people who use drugs who experience intersectional forms of discrimination, such as women, people belonging to racial and ethnic minorities, indigenous people, and LGBTQI+ individuals.
• At a national level, the lack of comprehensive, updated and disaggregated data on drug law enforcement, including stops and searches has mainly been associated with State’s failure to collect data and/or unwillingness to release such information. Even when data is collected on several grounds – such as ethnicity, gender and age – it is presented in a siloed way that hinders its analysis with an intersectional approach. Such lack of data is mirrored at the international level. As already indicated in other submissions, the Annual Report Questionnaire (ARQ) – the international data-collection mechanism used by UNODC to collect evidence on the state of the “world drug problem” – continues to attract criticism around lack of impact and human rights indicators. The data collected through this mechanism is used to produce what is supposed to be the most authoritative resource on current developments in drug policy globally: UNODC’s annual World Drug Report. However, this questionnaire does not measure many impacts – including human rights impacts – of drug policies with an intersectional approach. The lack of disaggregated data, especially on the targets of drug law enforcement and the functioning of the criminal legal system, has the effect of making some populations invisible, ‘hiding’ their experiences, and their being disproportionately impacted.
• For indigenous people, accessibility and acceptability of services are negatively impacted by, among others, the lack of culturally appropriate options which explicitly integrate spirituality, holistic healing and wellness care into OAT, as well as the absence of specialised expertise and training (including intergenerational trauma).
• Among the many groups facing unique barriers are young people. As further detailed in HRI’s Global State of Harm Reduction 2024,39 the lack of youth-specific harm reduction services, coupled with the absence of youth-friendly approaches, significantly limits young people’s ability to access needed care; in turn, this often results in low engagement and poor outcomes. In South Africa for example, the lack of youth-specific harm reduction services means that young people, particularly young women, often end up in facilities not designed to meet their needs; leaving them vulnerable to violence and abuse, not only from partners but also from law enforcement officers who coerce young women to provide sex in order to avoid arrest. In Ireland, the scarcity of youth-specific services further exacerbates the challenges young people face, while stigma and legal fears hinder young people’s access to the limited support on offer. This is especially the case in rural Irish areas where young people who use drugs often struggle to find the support they need.
• The slight global increase in the number of countries where harm reduction is explicitly included in policy documents does not reflect the harsh realities that people who use drugs experience. For example, in Mozambique, where OAT is included in the national HIV plan, there have been reports of police arresting people for carrying injecting equipment. In Iran, which mentions harm reduction in its national HIV policy, the government executed 459 people in 2023 for drug-related offences, the highest number since 2015. In South Africa, the Networking HIV and AIDS Community of Southern Africa reported 600 human rights violations against people who use drugs in just three months in 2023 (including assaults and unlawful arrests).

Innovative harm reduction strategies can play a crucial role in enhancing service quality and extending outreach to individuals who –due to discrimination and stigmatisation- typically do not engage with conventional health and social services. While this response will highlight some examples, it is important to note that it is not exhaustive. For a more comprehensive and in-depth analysis of latest development in harm reduction please consult HRI’s Global State of Harm Reduction series and publications on innovation in harm reduction webpage here.

Low dead space syringes and needles (LDSS) is one such tool. Direct sharing of needles and syringes account for most HIV and HCV infections among people who inject drugs in many countries. A recent modelling study estimated that removing the transmission risk due to injecting drug use could prevent 43% of all new HCV infections globally. Low Dead Space Syringes (LDSS) minimise the volume of residual blood in syringes, reducing the risk of transmitting bloodborne viruses like HIV and Hepatitis C (HCV) when shared. They are innovative because they modify syringe design to reduce blood retention, addressing a direct pathway for HIV transmission.

Research shows LDSS are highly effective: Modelling shows that LDSS use could result in a decrease both for HIV and HCV prevalence. Furthermore, the results of a recent threshold analyses indicated that compared to HDSS, detachable LDSS would only need to reduce the risk of virus transmission by 0.26% to be cost saving and 0.04% to be cost-effective in a high-income setting. Although sufficient coverage of NSP should be prioritised at all times, there is an argument to be made that switching people who inject drugs from HDSS to LDSS should be included in comprehensive blood borne virus prevention programmes, as it could increase the effectiveness of NSPs even when coverage is inadequate.

LDSS are also cost-effective, as their implementation could lead to savings in long-term HIV treatment costs: the results of threshold analyses indicated that compared to HDSS, detachable LDSS would only need to reduce the risk of virus transmission by 0.26% to be cost-saving and 0.04% to be cost-effective in a high-income setting.

Integrated and person-centred services, while not new, remain an innovative approach, and one that should be further promoted to reduce HIV infections and safeguard the rights of people who use drugs. Integrated harm reduction services are sites or organisations that provide one or more ‘traditional’ harm reduction services (such as OAT or NSPs) alongside other health and social services, such as primary care, sexual and reproductive health services, legal aid, housing support, and more. In doing so, they ensure that a wide range of services are available and accessible to their clients, making them highly effective and cost-effective.

For example in South Africa, a non-profit primary healthcare facility has designed and evaluated a decentralised, simplified, complete point-of-service model to screen and link people who inject drugs to HIV and HCV care. The programme provided harm reduction services (including OAT and harm reduction packs) alongside adherence support in the form of directly observed HCV therapy and peer support. Weekly financial allowances were offered to people receiving the service to reimburse transport costs and their time. Out of the 67% of people who tested HCV-antibody positive, 81% were assessed as eligible for therapy, and 93% of those eligible initiated it. This programme shows that a decentralised, person-centered harm reduction strategy can bridge gaps in treatment access for people who use drugs. However, to ensure the effectiveness of such interventions, community- and peer-led outreach campaigns, with collaborative treatment support and referrals, are needed alongside sustained, unrestricted access to harm reduction services, such as OAT, to decrease the risk of reinfection.

In recent times, innovative harm reduction approaches for chemsex have been monitored. One particularly relevant example is that of Digital Outreach and Online Harm Reduction Services; whereby Online platforms and mobile apps are being used to provide information on safer drug use, HIV prevention, and harm reduction strategies. Some examples include the Test BKK initiative in Thailand, which provides online guidance on safe chemsex practices and allows users to order prevention packages that include condoms, lubricants, HIV prevention resources, and free blood test. Similarly in Taiwan, Min-Sheng Hospital in Kaoshiung City supports the HERO (Healing, Empowerment, Recovery of chemsex) clinic, which uses an integrated health service model to create a one-stop health and social service designed to address the needs of gay men and other men who have sex with men who engage in chemsex. The clinic reportedly uses digital technologies to make the service easy to access, and centralises the diagnosis, treatment and prevention of STIs and mental health issues, including access to counselling and specialist care with an emphasis on tailoring care according to an individual’s self-assessed needs.

Another virtuous example is that of Lighthouse, a Hanoi-based organisation that caters specifically to gay, bisexual and other men who have sex with men, with a strong focus on community engagement. In addition to providing accessible peer support, harm reduction packages, sexually transmitted infection (STI) prevention services such as pre-exposure prophylaxis (PrEP) and specialist referrals, the organisation’s advisory board consists of gay men and other men who have sex with men. By taking this community-centred approach, the organisation is able to ensure that its efforts reflect the realities of the communities it supports.

Another important innovation that requires urgent scale-up is drug consumption rooms: Drug consumption rooms (DCRs) integrate harm reduction with HIV services, offering supervised drug use alongside testing, care, and referral pathways. Mobile, hospital-based, and housing-integrated DCRs extend services to hard-to-reach groups and improve service uptake.

During the global pandemic for COVID-19, some harm reduction services proved to be resilient and adapted to meet the new need of people who use drugs. Many countries eased OAT regulations and there were substantial moves towards take-home OAT. That is the case in the UK, where most people were moved onto 7 to 14 days prescription instead of daily or supervised intake. In Aotearoa-New Zealand, take-home naloxone and take-home OAT doses were rolled out for the first time following lockdown. Similarly, in Australia, after the experience lived during the pandemic, a four-year programme of take-home naloxone was initiated. The pandemic also created opportunity for increased digitisation of harm reduction services in the region thanks to the quick response of peer-led organisations that rapidly adapted to online delivery of education tools and distribution of sterile injecting equipment via post. These innovations not only increased accessibility during the pandemic but also contribute to reach people in rural and remote areas and remove some barriers that people who use drugs routinely face while accessing services improving the overall experience.

In  the current situation where key populations remain criminalised, stigmatised and discriminated against, the following actions are at-most important to be undertaken:

• Decriminalise possession and drug use; and further repeal punitive and discriminative laws against people who use drugs.
• Divest from the unjust drug war and related punitive drug law enforcement at the international, national, and subnational levels, and invest in programmes that prioritise community, health and justice.
• Ensure uninterrupted access to life saving harm reduction and HIV services and commodities
• Support initiative and increase funding for community-based organisations and civil societies to continue to monitor and advocate for the realisation of human rights of people who use drugs.