Countries’ stability is a precondition for the sustainability of harm reduction efforts. The Global State of Harm Reduction (GSHR) has documented how economic, political, humanitarian, and environmental crises threaten evidence-based and human rights-based drug policies and services.

In Afghanistan, the Taliban retook control of the country in August 2021, leading to a setback to the progress in harm reduction policies that the country had experienced in the last decades. Despite internal conflict and political instability, Afghanistan had been a rare example of success in implementing harm reduction. Since the fall of the Taliban in 2011, harm reduction programs started to be implemented and had progressively improved in terms of availability, quality and accessibility. During the COVID-19 pandemic, the government and NGOs showed resilience, adapting their approach to harm reduction to include take-home methadone and distribution of harm reduction kits containing sterile needles, syringes, condoms, and medicines, among other products.

However, progress stopped when Taliban retook control in 2021, banning all forms of drug production and consumption and adopting a strictly punitive approach to drugs. Since then, there has been a collapse of harm reduction services in five provinces that previously relied on government funding to provide such services, resulting in staff going unpaid, a lack of harm reduction kits, shortages of medicines and other medical equipment, and the shutdown of HIV prevention services. This is compounded by the criminalisation, over-policing, arbitrary arrest of and violence against people who use or are associated with drugs and forced “treatment”. At the same time, many who relied on opium cultivation and trade for economic survival became severely impoverished, and more and more people who use drugs are reportedly experiencing homelessness.

After the COVID-19 pandemic had stressed the health system and put harm reduction services at risk, Russia’s invasion of Ukraine in 2022 deepened the pressure on harm reduction services in Ukraine and neighbouring countries.5 Community and Civil Society organisations (CSOs) have led responses to the humanitarian crisis; providing shelter and food and securing the evacuation of people who use drugs from Donetsk and Luhansk regions. They also helped to secure the provision of medicines and harm reduction supplies to Ukrainian regions that were cut off from supply chains or where people could not leave their homes. Thanks to their advocacy, OAT protocols were updated and to receive treatment without having to be registered in a particular city. Take-home naloxone doses were also implemented.

Additionally, Ukrainian citizens who fled to neighbouring countries have faced multiple challenges when trying to access harm reduction services. Despite border countries issuing special decrees to ensure the continuation of treatment and access to medicines for Ukrainian refugees, many people who use drugs hide their status and avoid the public health systems due to fear of stigma and discrimination, and bureaucratic hurdles further obstacle or at least delay access to services. Despite the support from local organisations to assist refugees in navigating the health system, the sudden influx of new clients has highlighted deficiencies in existing HIV and harm reduction services and the absence or limited availability of social and psychological support and shelters for people who use drugs.

The COVID-19 pandemic stressed health systems and disproportionately impacted the provision of harm reduction services. However, in some countries, service providers showed resilience by responding quickly and adapting their service delivery. Community-led organizations paved the way towards new service models, including online support and take-home doses of opioid agonist therapy (OAT) and naloxone. These actions ensured many people continued to access essential harm reduction interventions.

In some countries, peer-led services provided take-home doses of OAT including long-acting injectable options (such as depot buprenorphine). Take-home OAT increased access and allowed the continuation of treatments while COVID-19 restriction measures were in place. It also reduced in-person visits to clinics or service centres, improving beneficiaries’ experience and reducing the risk of both clients and staff contracting COVID-19. In Nepal, the success of peer-led take-home OAT has led to discussions to revise and update the existing guidelines to incorporate these new practices. In Eastern and Southern Africa, there was an expansion in the provision of take-home OAT between 2020 and 2022. In Sydney, Australia between 24 and 69% of people on OAT had access to take-home doses and telehealth services. Services in Aotearoa-New Zealand relaxed monitoring procedures and increased flexibility in OAT service delivery by dispensing extra take-home options. Civil society sources report that this did not result in an increase in overdoses.

The COVID-19 pandemic accelerated the digitisation of harm reduction information and services, which expanded the pool of clients and made services more accessible. For example, in the United States, the implementation of mail orders improved access to naloxone, particularly for people in rural areas. In Aotearoa-New Zealand, peer-led harm reduction organisations responded quickly to lockdowns turning to online delivery of education and distribution of sterile injecting equipment via post, including provision for safe disposal of used equipment. To date, online services in Australia and Aotearoa-New Zealand have continued, despite the lifting of COVID-19 restrictions. The COVID-19 pandemic also resulted in an increase in the practice of ‘virtual spotting’, whereby people who use drugs can be in touch with a virtual companion (either by phone or online) while using, who can alert emergency services if the person becomes unresponsive. One such programme is the Never Use Alone hotline, which operates 24/7 from the United States.

Harm reduction services have now had time to shift and institutionalise adaptations to service provision. Yet more work is required to guarantee accessibility and availability of quality harm reduction services for everyone.

Investment in harm reduction falls far short of need. Meanwhile, countries spend over 750 times more on punitive drug policies that underlie the criminalisation and discrimination of people who use drugs and lead to negative health outcomes.

HRI has monitored the funding landscape for harm reduction since 2007 and consistently found that international commitments to end AIDS, tuberculosis and viral hepatitis by 2030, have not galvanised required action in low- and middle-income countries (LMIC).

HRI’s recent research shows that in 2022, funding for harm reduction in LMICs was only 6% of the annual amount UNAIDS estimates to be required by 2025.23 Harm reduction remains overly reliant on a small number of international donors, with increasing reliance on the Global Fund.

Where governments are investing in HIV responses, budgetary support for harm reduction is often neglected. Granular data on government investments in HIV responses is not readily available, however, numerous national reports indicate that funds are directed to ARV procurement, condoms, human resources and behavioural change interventions. The same is true for national health insurance programmes where these are in place. For instance, the national health insurance schemes in Indonesia, Kenya, Nepal and Cambodia include ART, condoms and behavioural change interventions but continue to omit harm reduction. Health Insurance policies in some countries align with punitive policies against people who use drugs and explicitly forbid the inclusion of harm reduction interventions.

HRI’s research on six LMICs found that harm reduction and its funding continued to be confined within national HIV responses, and often failed to meet the standard of evidence-based and human rights-based approaches to drug use. All six countries were heavily dependent on external funding agencies, particularly the Global Fund and The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). Three countries had some domestic budget support for harm reduction. In Indonesia, government funding supported the purchasing of methadone at the national level, while provincial government budgets included a small amount of funding for harm reduction programs in two provinces. At the national level, however, domestic funding supports abstinence-based drug rehabilitation programs, despite evidence of ineffectiveness and an associated increased risk of health harms. In Nepal, government funds supported the operational cost of eight OAT sites in public hospitals, however this contribution amounted to less than 1% of the total HIV budget for the period 2019-2020. In South Africa, the government of the Tshwane province provided funding for comprehensive harm reduction programs at 17 sites across four districts. No domestic funding for harm reduction was reported in other three countries (Nigeria, Uganda and Kenya).

Effective harm reduction interventions rely heavily on community-led services and civil society organisations. For transition away from international donor funding to be effective, governments must be able to provide funds directly to these organisations, which usually requires social contracting mechanisms to be in place. Few countries currently employ social contracting to fund harm reduction interventions. Donor and international agency support is crucial for supporting governments to introduce and improve social contracting mechanisms and for the advocacy and technical support required to ensure that community-led and civil society organisations are supported to provide harm reduction. Countries usually do not have effective mechanisms in place to transition from donor to domestic funding for harm reduction. This has led to the interruption of services, including OAT and psychological support and concerns for the sustainability of harm reduction services are reported in Albania, Bosnia and Herzegovina, Bulgaria and Romania.

In contrast to insufficient investment in harm reduction, countries continue to invest vast amounts in punitive responses to drug use. Over US$100 billion is spent each year around the world. Some of this support has even come from aid budgets, with almost a billion dollars (more than USD 974 million) spent on the official OECD category of “narcotics control” in recipient countries between 2012-2021. This surpasses the amount spent through aid budgets on areas more aligned with global health and poverty reduction goals, such as labour rights and household and food security programmes. At least USD 70 million between 2012-2021 was spent in countries that have the death penalty for drug-related offenses. Such funding has undermined global development goals and “do not harm” principles. The consequences include mass incarceration and overpopulated prisons, death sentences, civilians killed during counter-narcotics operations, poor farmers’ livelihoods destroyed, rights violated by forced “treatment” programmes, discrimination, and barriers to health care.

Mathematical modelling showed that redirecting 7.5% of the funding for punitive drug policies to harm reduction would result in a 94% reduction in new HIV infections among people who inject drugs and a similar reduction in HIV-related deaths by 2030. With small shifts in how states spend existing resources, it is possible to virtually eliminate HIV among people who inject drugs by 2030.

Universal and equitable access to harm reduction is a human right obligation. It is recognised as an essential component of the right to the highest attainable standard of health for people who use drugs, from which States’ obligations derive, specifically, ensuring availability, accessibility, acceptability, and quality of harm reduction services, removing barriers to access services such as stigmatisation and criminalisation of drug use and other practices, among others. Denial of harm reduction services, including in detention or closed settings, violate human rights obligations and in some cases may amount to torture and other cruel, inhumane, and degrading treatment.

In line with the international standards, information provided in this submission and in addition to the recommendations outlined in A/HRC/56/52, we encourage the SR to recommend Member States to:

• Decriminalise drug use and drug possession and promote evidence-based and health- and human-rights centred alternatives to incarceration;
• Recognise harm reduction as an essential element to the right to health in national policies and strategies, which must be protected under all circumstances, including health emergencies, war or humanitarian crisis;
• Guarantee equal access to harm reduction services and programmes, including integrated services, in a no-discriminatory and non-stigmatizing way and consider the particular needs of the most vulnerable and marginalised groups, such as Black, Brown and indigenous population, LGTBQ+ people, sex workers, women among others;
• Guarantee the meaningful participation of civil society, community-led organisations and people who use drug in all process of drug policy decision-making, including the design and implementation of harm reduction interventions;
• Eliminate all form of forced drug dependency treatments;
• Critically evaluate States’ spending on drug control, divest from punitive drug control, and invest in evidence-based harm reduction programmes -beyond HIV prevention and treatment- ensuring the availability of funding for peer-led and community-led harm reduction initiatives, research, and innovation;
• Support and fund civil society, community-led and peer-led harm reduction interventions, and;
• Eliminate all legal and practical barrier to accessing harm reduction services, including those that affect marginalise populations including Black, Brown and ethnic minorities and indigenous populations, migrants, women, homeless and people living in poverty.