Harm reduction is internationally recognised as an essential component of an effective, evidence-based HIV response. The 2021 UN Political Declaration on HIV and AIDS explicitly recognises harm reduction as part of combination HIV prevention and commits states to expanding access to these interventions. Methadone and buprenorphine are also included in WHO’s Model List of Essential Medicines for opioid use disorders.

This recognition is increasingly reflected in national policies. As of 2025, 112 countries explicitly recognise harm reduction in national policy documents. However, policy recognition does not necessarily translate into adequate service provision or sustainable domestic financing. In low- and middle-income countries (LMICs), just USD 151 million was invested in harm reduction in 2022, against an estimated annual requirement of USD 2.7 billion. Recent international funding cuts have further exposed the fragility of services, including through closures and reduced community-led capacity.

Governments must translate commitments into predictable domestic financing and integrate HIV and harm reduction services into primary healthcare, in prisons and post-release care, in accordance with human rights obligations. International assistance remains essential where domestic resources are insufficient. National strategies must also address criminalisation and discriminatory practices, ensure meaningful community participation in resource allocation and service delivery, and incorporate community-led monitoring of discrimination, accessibility and continuity of care. 

Effective measures must address both interpersonal stigma and the laws and institutional practices that sustain it. Priorities include anti-discrimination protections, accessible complaints and legal redress mechanisms, training for healthcare professionals and law enforcement, and voluntary, confidential services led by or developed with affected communities. Decriminalising drug use and possession for personal use, removing barriers to harm reduction and ending arbitrary detention can help reduce fear of seeking HIV testing, treatment and prevention. 

Community-led harm reduction programmes provide practical models for reaching people who may avoid mainstream services, because peers help to design, deliver and evaluate them. HRI’s joint submission to OHCHR on access to medicines and harm reduction documents persistent legal, policy and institutional barriers to accessing essential harm reduction medicines and services, and calls for their removal. HRI’s GSHR 2024 also documents persistent gaps in service availability, including in prisons, and highlights how punitive drug policies fuel stigma and deter people from seeking care. Harm reduction received only 0.7% of HIV funding in 2022, although people who inject drugs accounted for 8% of new infections. HRI’s research further demonstrates that funding cuts have resulted in service closures and interruptions to outreach activities. 

However, programme availability alone does not demonstrate reduced stigma. Governments should measure progress through disaggregated surveys, including the People Living with HIV Stigma Index, community-led monitoring and reporting of discrimination in healthcare, detention and community settings. UNAIDS data show that stigma remains widespread; the global target of fewer than 10% experiencing stigma and discrimination has not been achieved.

Criminalisation of drug use and possession, restrictions on harm reduction, compulsory rehabilitation and punitive policing obstruct HIV prevention, treatment and care. Detention may further disrupt treatment continuity where equivalent harm reduction and HIV services are unavailable. HRI’s research on human rights in detention identifies inadequate access to essential harm reduction interventions as a persistent concern. Age restrictions also create barriers as, in some countries, people under 18 are formally excluded from needle and syringe programmes and drug consumption rooms, limiting adolescents’ access to essential harm reduction services. Restrictive HIV-specific laws and practices—including criminalisation of non-disclosure, exposure or transmission, mandatory testing and travel restrictions—also require review to ensure they are evidence-based, proportionate and consistent with human rights obligations.

Good practice includes decriminalising drug use and possession for personal use, removing legal obstacles to evidence-based harm reduction, replacing compulsory treatment with voluntary healthcare, and guaranteeing equivalent services in detention and after release. Governments should also remove age-related barriers and ensure that adolescents can independently consent to HIV testing, treatment and harm reduction services, in accordance with their evolving capacities and best interests. Reform must be assessed through implementation, not legislation alone: governments should monitor enforcement practices, police harassment, access to confidential services, treatment retention and community-reported experiences. UNAIDS has emphasised that punitive legal environments undermine access to HIV services and progress towards ending AIDS. 

Achieving the 30-80-60 targets requires more than consultation: communities must have decision-making authority, adequate resources and the capacity to independently monitor implementation. In many LMICs, there are few public policies or measures to ensure community leadership in achieving these targets, while community-led service delivery remains heavily dependent on international donors. HRI’s 2024 research found little evidence that progress towards the 30-80-60 targets was being adequately monitored. Similarly, fewer than half of Global Prevention Coalition countries had set targets for community-led services, falling to just 4 of 14 countries where HIV epidemics primarily affect key populations. In 2020, less than 10% of Global Fund prevention funding for people who inject drugs went to community-based organisations. 

Funding data reaching community-led organisations remain insufficiently transparent in many settings, making impact difficult to assess. Although social contracting offers a mechanism for channelling public resources to community-led organisations, its availability remains limited and funding is often small-scale, restrictive and unpredictable. Governments should establish direct, accessible and predictable multi-year public funding for community-led organisations, including those led by people who use drugs, through dedicated budget lines and simplified grant procedures. They should also publish disaggregated budget and expenditure data, identify barriers to accessing public resources, and track funding by recipient leadership and service area. UNAIDS’ 2026 technical guidelines provide a framework for costing and budgeting sustainable community-led HIV responses.