Harm reduction interventions for people who use drugs—such as needle and syringe programmes (NSP) and opioid agonist therapy (OAT)—are cost-effective, protect against HIV and hepatitis C, and save lives. The 2021-2026 Global AIDS Strategy explicitly prioritizes the need to focus on community-led responses and ‘intensify and redouble efforts to scale up comprehensive harm reduction for people who inject drugs in all settings. Yet, the global provision of harm reduction interventions is critically low, with only 1% of people who inject drugs living in countries with high coverage.

Harm reduction investment from international donors and governments in low and middle-income (LMI) countries totalled US$131 million in 2019 – just 5% of the US$2.7 billion UNAIDS estimates is required annually by 2025 for an effective HIV response among people who inject drugs. The Global Fund is the largest donor for harm reduction in LMI countries, providing at least 60% of all international donor support.

The Global Fund Seventh Replenishment fell short by US$3.75 billion to reach the target of at least US$18 billion. While the US$14.25 billion raised is more than any multilateral organisations has raised before, the shortfall will have grave implications as stated by the Communities Delegation to the Global Fund in their communique “As the Global Fund Board, we should not take our failure to meet the current replenishment targets lightly. This will severely impact our communities’ lives, hopes, needs and dreams.”

Harm reduction is over-reliant on the Global Fund, as the primary source of funds for sustaining harm reduction, ensuring access to health care, protecting the human rights of people who use drugs and strengthening community systems. Any reduction in harm reduction funding from the Global Fund will dramatically and disproportionately affect harm reduction programs in LMI countries resulting in service closures, a reversal of gains made in HIV prevention among people who use drugs and ultimately, lives lost. For the qualitative adjustment process, Harm Reduction International (HRI) identified twenty-one countries where harm reduction would be particularly at risk if Global Fund support reduced, due to epidemiological factors, low domestic investment in harm reduction and an over-reliance on the Global Fund.

The Global Fund Board must protect harm reduction programmes (and other key population programmes that are particularly reliant on the Global Fund and will be likely to close if this funding reduced) from any impact of a replenishment shortfall  

The Global Fund Board must ensure that harm reduction funding in middle-income countries, where most people who inject drugs live, is protected from the impact of the replenishment shortfall.

Catalytic investment funding provides crucial support for areas of programming that are less likely to be prioritised within national plans due to criminalisation, stigma and discrimination. This includes critical support to community-led and civil society advocacy for harm reduction and the legal and policy reform necessary to remove barriers to HIV prevention, treatment and care for people who use drugs.

The replenishment shortfall should not reduce the amount available for catalytic funding. This would have significant implications for harm reduction in LMI countries, including a rollback in service quality and in progress made in the reform of laws and policies that impede the HIV response and human rights of people who use drugs. As such, this would compromise the ability of the Global Fund to put people, communities and human rights at the centre of the fight to end pandemics and build a healthier and more equitable world, which is central to the successful implementation of the Global Fund Strategy 2023-2028.

The Global Fund has gradually increased the available funding for those areas of programming that cannot be captured in country grants but are crucial to the fight against the three diseases. For example, the Global Fund investment to reduce the human rights-related barriers to health services increased from US$10.6 million in 2014-2016 to US$78 million in 2017-2019 and over US$130 million in the current funding cycle (2020- 2022) across all three diseases. This funding must not be affected by the replenishment shortfall, including through the mobilization of other donors to fill any funding gaps.

Reduced catalytic investment funding would reduce the Global Fund’s capacity to champion harm reduction and use its diplomatic voice to support and call for law and policy reform as well as catalytic advocacy, that are crucial for ensuring access to services.

The Global Fund Board must protect catalytic investments for community-led responses, advocacy for harm reduction and the legal and policy reform that is crucial to ensuring harm reduction programmes can reach those who need them in LMI countries

The Global Fund support has strengthened community systems that are crucial to the HIV response and to the continuation of life-saving services (including providing food and shelter) during the COVID-19 pandemic. Between 2021-2023, the Global Fund invested US$4.9 billion to become the world’s largest multilateral provider of grants for strengthening systems for health, including community systems. Countries with strong harm reduction programmes and networks of people who use drugs provided some of the best examples of innovation and resilience in adapting service provision and pushing through policy reforms. Communities of people who use drugs were on the frontlines, providing life-saving and critical services and advocacy on behalf of their community, leveraging HIV investments. Any lesser funding on community-led responses, the strength of community systems will be under threat, weakening the health systems and infrastructure and the ability to respond to both HIV and emerging health threats.

The Global Fund Board must ensure funding for harm reduction advocacy and programming goes to community-led organisations, both within country grants and catalytic investments

The Global Fund Board must ensure its progress towards community-led response targets within the Global AIDS Strategy can be measured, through internal monitoring of funds allocated, disbursed and spent by community-led organisations

The Global Fund investment case outlines the need to catalyse domestic health investments up to US$59 billion (45% of total resource need) through co-financing requirements and technical assistance on health financing. Domestic funding for harm reduction remains limited and determined by political support rather than country-income status. COVID-19 has further constrained health budgets, with many governments scrambling to prop up overburdened and underfunded health systems. The Global Fund provides crucial funding for advocacy in the context of donor transition, where strong, sustained community-led advocacy is needed to drive domestic investment in high quality, human-rights based harm reduction approaches. The country-level structures established by the Global Fund and the standards with which they operate serve as a blueprint for good practice beyond the life of the grant. As international donors, including the Global Fund, reduce funding for middle-income countries, the success of efforts to increase domestic financing for harm reduction will determine the availability of lifesaving services for people who use drugs and the world’s ability to end AIDS by 2030.

This will only happen with strong community and civil society advocacy calling for change. The Global Fund is the largest source of funding for this work and a key mechanism for driving domestic investment through its focus on sustainability and transitions.

The Global Fund Board must prioritise funding for efforts to increase domestic investments in harm reduction and broader key population programming 

We urge the Global Fund Board to track the extent to which matching funds have led to investment in key population programming, including harm reduction. It is imperative that the matching funds mechanism enables the Global Fund to incentivise investment in rights-based, people centred harm reduction where it is needed most

During the 2023-2025 grant cycle, the impact of Covid-19, the war on Ukraine and ever-rising inflation will continue to negatively affect national economies. It may lead to changes in country income status during the grant cycle. Key population programmes, particularly those that are community-led, are often the first to be affected by restricted funding environments. It will be more important than ever for the Global Fund to ensure fluidity and responsiveness in its approach, including adjusting country envelopes during the grant cycle if required.

We urge the Global Fund Board to ensure adequate funding is available to protect harm reduction in crisis

We urge the Global Fund Board to ensure quick and timely adaptations to country plans can be implemented in the face of quick-changing crisis situations, including through the use of community-led monitoring and production of data and evidence