Skip to main content

Harm reduction & HIV

Find out everything you need to know about harm reduction and HIV. Explore our list of resources and find out how you can get involved.

I come here every day, inject my dope safely, clean my clothes, sleep for a few hours knowing that nothing bad is going to happen, have something to eat, see a doctor and participate in a workshop where I can make my own shampoo. And if I don’t want to do any of these, I can be just having a coffee with my friends … some of them [are] staff members.

Ana, service client at Metzineres in Barcelona, an integrated harm reduction site for women who use drugs

Key principles of harm reduction

Back to top

alternative text

What is harm reduction?

Harm reduction refers to a non-judgemental approach to policies, programmes and practices that aim to minimize the adverse health, social and legal impacts of drug use, drug policies and drug laws.

Harm reduction is an evidence-based approach to health programming. It can include such services as:

  • Needle and syringe programmes (NSPs)

  • Opioid agonist therapy (OAT)

  • Overdose response/reversal using naloxone

  • Advice for safer chemsex and slamsex practices

  • Access to prevention, treatment and care for HIV, sexually transmitted infections (STIs) and hepatitis

  • Sexual health services

  • Mental health services

  • Access to housing and provision of basic needs, including legal services

Harm reduction services should be integrated, person-centred, free from stigma and discrimination, and accessible to all.

What are safe needle and syringe programmes (NSPs)?

NSPs offer sterile needles and syringes to people who use drugs to prevent transmission of HIV and hepatitis B and C (HBV and HCV). NSPs are a life-saving and cost-effective harm reduction service.

What is opioid agonist treatment (OAT)?

OAT is given to people who are dependent on opioids like heroin, oxycodone, hydromorphone and fentanyl. Examples are methadone and buprenorphine. OAT can help reduce withdrawal symptoms and cravings after stopping the use of opioids.

For more information, see the Centre for Addiction and Mental Health’s Opioid agonist therapy factsheet.

What is overdose response/reversal?

Deaths from overdose can be prevented. Naloxone is a life-saving medication to prevent deaths from opioid overdose. Training on the recognition of and response to overdose, which includes giving naloxone, is recommended for people who are most likely to witness an overdose, such as first responders and safe injection site workers. Anyone, not just healthcare workers, can administer naloxone. It comes in an easy-to-use nasal spray.

If you use opioids, you may be able to carry naloxone yourself. If you do, tell people you have it, how to use it, and where to find it. When combined with enabling legal policies, overdose response allows immediate life-saving treatment.

For more information, see the WHO opioid overdose factsheet.

What are chemsex and slamsex?

Chemsex means sexual activity, while using drugs. Chemsex exists across all gender identities and sexual orientations but is more prevalent in men who have sex with men. Slamsex is a type of chemsex, referring specifically to injection drug use and sexual activity. Chemsex may increase the likelihood of transmission of sexually transmitted infections (STIs) and HIV, particularly if it includes sharing of injecting equipment, condomless sex or rougher sex than usual, which can cause bleeding. Chemsex Harm Reduction publishes guides on safer chemsex practices.

Information and resources on Chemsex from ChangeGrowLive:

There are three specific drugs usually involved in chemsex:

  • Methamphetamine is a stimulant. It is also known as crystal meth, crystal, meth, tina and crank. 

  • Mephedrone is a stimulant too. It is also known as meph, drone or meow meow.

  • GHB and GBL are sedatives. Their full names are gammahydroxybutyrate and gammabutyrolactone, and they are also known as G, gina, geebs and liquid ecstasy.

Harm reduction services need to reach people who practice chemsex. Doing so requires a comprehensive, non-judgemental, sex-positive and person-centred approach. This can include integrated sexual and reproductive health and rights, mental health, safe needle and syringe programmes (NSPs), opioid agonist treatment (OAT) and other diagnosis and treatment services. For more information about harm reduction in the context of chemsex, see the AIDS Action Europe Training manual and the International Drug Policy Consortium’s Chemsex in Asia – community manual.

If you are taking antiretrovirals (ARVs), it is important to discuss your chemsex or slamsex practices with your healthcare provider so that you can more safely use drugs and continue to take your prescribed ARVs.

What approaches can undermine harm reduction strategies?

Criminalization and punitive drug policies continue to be significant structural barriers to successful implementation of harm reduction strategies. Decriminalization of drug use and possession for personal use, steps to reduce incarceration, removal of administrative penalties and depenalization are necessary to ensure equitable access to harm reduction.

Policies and laws are needed to decriminalize specific elements of harm reduction services, including the possession and use of sterile needles and syringes. This allows use of needle and syringe programmes (NSPs) and legalizing opioid agonist treatment (OAT) and overdose prevention approaches for people who are opioid dependent.

People who use drugs continue to experience stigma and discrimination in health services, which directly impacts the ability for effective harm reduction to be accessed and delivered. Health services must be based on principles of medical ethics, avoidance of stigma, non-discrimination and the right to health for all.

Harm reduction for people living with HIV and who use drugs

Back to top

alternative text

Why is harm reduction important for people living with HIV?

Harm reduction services include a non-judgemental approach combined with health and social services for people living with HIV who use drugs. They allow you to protect yourself and others and protect against the transmission of HIV, hepatitis and sexually transmitted infections (STIs).

Harm reduction is an evidence-based approach to health programming. It can include such services as:

  • Needle and syringe programmes (NSPs)

  • Opioid agonist therapy (OAT)

  • Overdose response/reversal using naloxone

  • Advice for safer chemsex and slamsex practices

  • Access to prevention, treatment and care for HIV, sexually transmitted infections (STIs) and hepatitis

  • Sexual health services

  • Mental health services

  • Access to housing and provision of basic needs, including legal services

These services may also be combined with other services, including contraceptive care, safe abortion, family planning, antenatal and postpartum care, and screening for alcohol or drug dependence.

Integrated services may be offered in one place where you can access all the health and social services you need.

For more information, see the WHO Recommended package of interventions for HIV, viral hepatitis and STI prevention, diagnosis, treatment and care for people who inject drugs and the UNODC HIV Prevention, Treatment, Care and Support for People Who Use Stimulant Drugs. Technical Guide.

Should I continue taking antiretroviral therapy (ART) if I currently use drugs?

If you are living with HIV and use drugs, let your healthcare provider know what drugs you use. This will allow your healthcare provider to ensure that the ART you take best suits you.

Some drugs, particularly stimulant drugs like cocaine, mephedrone (4MMC) and methamphetamines, can interact with antiretroviral drugs (ARVs) and can make side effects or overdose more likely. If you use drugs for chemsex, you can use harm reduction approaches to make this safer for you. For more information on safer chemsex, see Chemsex Harm Reduction guides for individuals.

It is important to continue taking your prescribed ART to stay healthy and reduce HIV transmission. Once your viral load is undetectable, there is zero risk of transmitting HIV to someone else. Always talk to your healthcare provider before making any changes to your ART.

How can I protect my sex partner(s) from acquiring HIV?

It is important to continue safer sex practices when you are using drugs. Using condoms can protect your partners from acquiring HIV. Condoms also protect you and your sex partners from sexually transmitted infections (STIs), hepatitis and unintended pregnancies.

By taking your prescribed ARVs, you can reduce your viral load and minimize HIV transmission to your sex partners. If your viral load is undetectable, you cannot transmit HIV sexually to your partners. If you do not know your viral load, ask your healthcare provider for a test. Your viral load should be checked annually and more often if you have recently started or restarted ART.

Your sex partners can use pre-exposure prophylaxis (PrEP) or post-exposure prophylaxis (PEP) to protect them from acquiring HIV. PrEP or PEP do not protect you from STIs or hepatitis.

Needle and syringe programmes (NSPs) can provide you with sterile equipment and support to reduce the transmission of HIV if you are sharing drug equipment with your sex partners.

How can I protect myself from hepatitis?

Hepatitis, particularly hepatitis C (HCV), can be easily transmitted by sharing needles, syringes and other drug-injecting equipment. Using clean equipment and avoiding sharing injecting equipment can reduce blood-to-blood transmission of hepatitis.

Hepatitis B and C can also be transmitted through unprotected sex with a partner with the diagnosis. Condom use can prevent the transmission of hepatitis through sex and protect from sexually transmitted infections (STIs) and unintended pregnancies.

Screening for hepatitis will allow you to be diagnosed and access treatment services. If you use drugs, have a sex partner or share drug-injecting equipment with someone who is diagnosed with hepatitis, ask your healthcare provider for a test. Treatment for hepatitis can slow down the progression and achieve a cure for hepatitis C.

Vaccines are available for hepatitis A (HAV) and hepatitis B (HBV); you should talk to your healthcare provider to see if you can be vaccinated.

How can I protect myself from sexually transmitted infections (STIs)?

It is important to continue safer sex practices when you are using drugs. Condom use can prevent sexual transmission of STIs through vaginal or anal sex.

STIs often do not cause any symptoms. If you are worried that you might have been exposed to an STI, have any symptoms or know that your sex partner has been diagnosed with an STI, ask your healthcare provider for testing.

Regular screening for STIs can allow early and effective diagnosis and treatment to reduce long-term effects and reduce transmission of STIs to sex partners.

DoxyPEP stands for “doxycycline post-exposure prophylaxis”. Doxycycline is an antibiotic that is used to treat some STIs. Studies show that doxycycline can reduce the chance of acquiring syphilis, chlamydia and gonorrhoea when it is taken after a condomless sex encounter. Evidence on DoxyPEP is being used to develop guidelines for its use.

For more information on DoxyPEP, see the Chemsex Harm Reduction factsheet.

Harm reduction for people vulnerable to HIV acquisition and who use drugs

Back to top

alternative text

How can harm reduction help prevent transmission of HIV?

Integrated harm reduction services can minimize the adverse effects related to drug use (injecting and non-injecting) and other behaviours, like condomless sex, that make people more vulnerable to acquiring HIV.

Integrated harm reduction services that help prevent transmission of HIV include:

  • Needle and syringe programmes (NSPs)

  • Condoms and lubricant

  • Pre-exposure prophylaxis (PrEP)

  • Post-exposure prophylaxis (PEP) for HIV

  • Prevention of vertical transmission of HIV

  • Advice for safer chemsex/slamsex practices

  • HIV testing

  • Antiretroviral therapy (ART)

How can HIV and hepatitis be transmitted through drug use?

Sharing needles, syringes and drug-injecting equipment increases your chance of acquiring HIV and hepatitis B and C viruses (HBV and HCV) through the transfer of blood from person to person.

Sharing drug-injecting equipment is at least three times more likely to result in transmission of HIV than sexual intercourse. It is estimated that half of the people who inject drugs are living with hepatitis C.

When you use drugs (injecting and non-injecting), you are also statistically more likely to take part in sex behaviours, like condomless sex, that make you more vulnerable to acquiring HIV and hepatitis.

How can I protect myself from acquiring HIV and hepatitis if I use drugs?

If you use drugs, you can reduce your chances of acquiring HIV and hepatitis if you:

  • Avoid sharing drug equipment and use new, clean needles and syringes every time you inject. Needle and syringe programmes (NSPs) can give you sterile needles, syringes and cleaning kits without judgement or law enforcement involvement.

  • Use a condom for anal or vaginal intercourse.

  • Consider taking pre-exposure prophylaxis (PrEP) if your sex partner or someone whom you share drug-injecting equipment with is living with HIV.

  • Consider taking post-exposure prophylaxis (PEP) after contact with the bodily fluids of a person living with HIV through sex or drug use.

  • Ask about hepatitis A and B vaccinations (HAV and HBV).

For more information on HIV and injecting drugs, see the CDC factsheet.

Should I be tested for HIV, hepatitis or sexually transmitted infections (STIs)?

Testing for HIV, STIs and hepatitis B and C should be available for people who use drugs as part of integrated harm reduction services.

If you do not know your HIV status, take an HIV test. If you test positive, then it is important to start HIV treatment as soon as possible. You can ask for or use an HIV test at any time, and ideally, you should have a test every year so you know your status. HIV self-testing is a convenient, reliable and confidential way to check your HIV status and is available in many regions.

STIs often do not cause any symptoms. If you are worried that you might have been exposed to an STI, have any symptoms or know that your sex partner has been diagnosed with an STI, ask your healthcare provider for testing. Effective treatment is available for STIs and will reduce your chance of transmitting STIs to others.

Hepatitis B and C can be transmitted through drug-injecting equipment and can cause acute or chronic symptoms. If you use drugs, share drug equipment or have a sex partner with a diagnosis of HBV or HCV, you can ask for a test to know your status. All people using drugs can be offered routine tests for hepatitis B and C.

What is pre-exposure prophylaxis (PrEP)?

PrEP is the use of antiretroviral (ARV) drugs by people who are not living with HIV to reduce the risk of acquiring HIV through sex or injecting drug use. PrEP can be taken as an oral pill, a long-acting injection or a vaginal ring.

“On-demand” PrEP refers to taking PrEP only when you are at risk of acquiring HIV, that is, taking two pills 2-24 hours before sex, one pill 24 hours after the first dose, and one pill 24 hours after the second dose. Studies have shown that on-demand PrEP is effective for protecting gay men and other men who have sex with men when having condomless sex. On-demand PrEP is also called 2+1+1, event-based, intermittent or non-daily PrEP.

See the CDC resource on PrEP for more information.

What is post-exposure prophylaxis (PEP)?

PEP can be taken if you think you have been in contact with bodily fluids that may contain HIV in the past 72 hours. PEP should be taken as early as possible to help reduce the potential transmission of HIV.

PEP usually includes taking a course of ARVs for 28 days. A healthcare professional will help you assess your exposure to HIV and whether PEP is a suitable option for you. A follow-up HIV test will be performed after completing treatment.

For more information, see the CDC resource on PEP.

What is DoxyPEP?

DoxyPEP stands for doxycycline post-exposure prophylaxis. Doxycycline is an antibiotic that is used to treat some sexually transmitted infections (STIs). Studies have shown that doxycycline can reduce the chance of acquiring bacteria like syphilis, chlamydia and gonorrhoea when it is taken after a condomless sex encounter.

Evidence on DoxyPEP is being used to develop guidelines for its use. DoxyPEP does not contain antiretroviral (ARV) drugs and does not reduce HIV transmission.

For more information, see the DoxyPEP guide by Chemsex Harm Reduction.

Case study: Integrated harm reduction during the COVID-19 pandemic-related restrictions 

Source for image: Verter AC on X

Back to top

alternative text

Read the case study

Integración Social Verter provides harm reduction services for key populations in Mexicali Baja, Mexico, near the Mexico-US border. These services include: testing and treatment for HIV, viral hepatitis, syphilis and tuberculosis; distribution of safe-injecting equipment, condoms and naloxone; sexual and reproductive health services; and counselling and support. Since 2018, Verter has operated La Sala, a pioneering safe consumption site. La Sala offers a service to detect illicit fentanyl and other adulterants that may be present in the substances that are brought to the site. 

As an integrated health centre, Verter was positioned to respond to the COVID-19 pandemic-related restrictions and meet the needs of its clients in a way that most local medical centres could not. Long-standing relationships with the local community allowed Verter to provide information and resources on COVID-19 alongside its core services and outreach programmes. 

Verter understood the value of maintaining service provision and recognized that closing even for a short time risked losing client contact and years of work. Verter got permission from the government to keep offering life-saving services to people who use drugs at a time when more overdose incidents were being seen. At an early stage in the pandemic, temperature checks, sanitizing stations and physical distancing measures were put in place to ensure that clients could access harm reduction services while minimizing their exposure to COVID-19.

"They make me feel that I’m still a human being." – Verter client

With an established community presence, Verter could still arrange for clients to visit the private methadone clinic and cooperate with local shelters. When the general medical centre became overwhelmed, Verter used its connections with Border Kindness, which provides services to asylum seekers, migrants and refugees, to expand its medical staff. Since early 2020, Verter reports, it has more clients and is reaching more new populations, including people experiencing homelessness and migrants.



References

International Drug Policy Consortium COVID-19 Stories of Substance Newsletter No 4. COVID-19 Stories of Substance #4: Crisis

Behaviour change after fentanyl testing at a safe consumption space for women in Northern Mexico: A pilot study. Goodman-Meza et al. International Journal of Drug Policy 106: August 2022 103745 https://doi.org/10.1016/j.drugpo.2022.103745

Impact of an overdose reversal program in the context of a safe consumption site in Northern Mexico. Goodman-Meza et al. Drug Alcohol Depend Rep. 2022 Mar; 2: 100021 https: //doi.org/10.1016/j.dadr.2021.100021

[Spanish] Changes in access to harm reduction services for people who inject drugs during the COVID-19 pandemic in Mexicali, Baja California. Chapter 4 of Drugs and violence in times of pandemic. Consequences and responses, González Nieto et al. Programa de Política de Drogas PPD, 2023, México. https://politicadedrogas.org/site/evento/id/95.html

Implementation guidance for harm reduction services for people living with and affected by HIV

Back to top

alternative text

What are the key barriers for people who use drugs when accessing health services?

Criminalization and punitive and restrictive policies, combined with stigma, increase exposure to violence, human rights abuses and discrimination for people who use drugs. These barriers result in reduced access to prevention, testing and treatment services.

Stigma and discrimination can result in denial of care, substandard care, physical or verbal abuse, involuntary disclosure of HIV status, and loss of confidentiality. Mistreatment makes it less likely that people who use drugs will access mainstream health services or be reached by outreach workers, especially those who are not from the community.

Women who use drugs face specific barriers to accessing services, including gender-based violence and lack of gender-sensitive services.

Enabling interventions include:

  • Removing punitive laws, policies and practices

  • Reducing stigma and discrimination

  • Community empowerment

  • Addressing violence

  • Provision of integrated person-centred harm reduction services

Why are integrated person-centred harm reduction services recommended?

Integrated services, as defined by the World Health Organization, are organized and managed to ensure that people get the care they need when they need it and in client-friendly ways. Client-friendly ways include shared clinical decision making, community-delivered care, peer support and expert clients.

Harm reduction services should be integrated with other health and social services to reach key and affected populations and meet their needs holistically.

Harm reduction is a non-judgemental and evidence-based approach to health programming. It can include such services as:

  • Needle and syringe programmes (NSPs)

  • Opioid agonist therapy (OAT)

  • Overdose response/reversal using naloxone

  • Advice for safer chemsex and slamsex practices

  • Access to prevention, treatment and care for HIV, sexually transmitted infections (STIs) and hepatitis

  • Sexual health services

  • Mental health services

  • Access to housing and provision of basic needs, including legal services

Integrated person-centred harm reduction services can respond and adapt to the needs of people who use drugs. They allow people access to a broader range of health services in one place or with robust and client-friendly referral pathways between them.

Integrated harm reduction services that treat people without judgement are uniquely positioned to encourage trust between clients and service providers. Providers of integrated services are also more likely to understand the preferred means of communication and contact that work best for their clients.

What examples exist of successful integrated person-centred harm reduction services?

The Harm Reduction International Briefing: Integrated and person-centred harm reduction services found that:

  • Integrated services are better placed to treat people holistically instead of as “symptoms” or “challenges”.

  • Community leadership and involvement is essential and leads to positive change.

  • Integrating services makes them more accessible.

  • Integrated services can adapt to their environment.

Integrated person-centred harm reduction services were uniquely placed to provide services during COVID-19 pandemic-related restrictions experienced in many regions in 2020-2022. Despite challenges due to closures, reduced hours or lack of outreach work, many harm reduction services were able to adapt and, in some cases, expand their reach to vulnerable populations.

Successful examples identified are:

  • Integrated COVID-19 services and harm reduction services

  • Innovative service delivery, including the use of telehealth and online counselling

  • Community-led services and peer involvement in addressing mental health issues

  • Extended outreach programmes, including home deliveries, to increase coverage in rural areas

Emerging evidence from the Alliance for Public Health in Ukraine demonstrates that integrated harm reduction services, combining outreach and digital health approaches, can effectively reach more vulnerable communities during crises and forced migration.

How can harm reduction services help us prevent and manage future pandemics?

Harm reduction should be recognized as an essential public health intervention during pandemics. Integrated and person-centred harm reduction services were, and continue to be, crucial in ensuring continuity of care for people who use drugs during the COVID-19 pandemic. In addition to providing harm reduction services, they were also able to minimize exposure to COVID-19 in healthcare facilities and improve linkage to care for a vulnerable population more likely to develop severe COVID-19.

Because of the stronger relationships between integrated service providers and their clients, the providers are more aware of the needs of their communities than in standalone services. Therefore, harm reduction services have the potential to expand their outreach programmes and use innovative ways to deliver care, as seen during the COVID-19 pandemic.

The global harm reduction community continues to advocate for the meaningful engagement of vulnerable communities in developing the pandemic preparedness and response accord. This would ensure the protection, promotion and empowerment of vulnerable, marginalized and criminalized communities in pandemic preparedness and response, including proposing human rights principles for a pandemic treaty.

What are the opportunities for integrated harm reduction within HIV services?

A common misconception is that harm reduction approaches increase drug use – there is no evidence to support this statement.

Harm reduction approaches can be successfully integrated into HIV prevention, treatment and care services and contribute to the global HIV response. HIV prevalence is up to seven times higher in people who inject drugs than in adults who do not use drugs. Providing harm reduction services to people who use drugs directly contributes to ending the HIV pandemic.

Harm reduction is an essential component of combination HIV prevention. There is an opportunity to explore how to integrate harm reduction more consistently into HIV prevention services. Integration of HIV testing with harm reduction services makes testing more convenient for people attending health facilities and increases the uptake.

Providing person-centred care for people living with HIV addresses their health needs beyond just HIV. Harm reduction services can be delivered as part of differentiated service delivery models for HIV.

Examples of integrated harm reduction within HIV services

In Kenya, the Bar Hostess Empowerment and Support Programme focuses on peer delivery of services with a drop-in centre and outreach programme model. Core services of HIV prevention (including PrEP), testing, treatment and care are provided alongside integrated harm reduction approaches. Sex workers and women who use drugs can access sterile needles and syringes, overdose management, and alcohol and drug dependence support, as well as screening and testing for TB, STIs, HBV and HCV. Support services are also provided for women experiencing or impacted by violence or needing legal aid.

SPARSHA Nepal, a community-supported NGO, provides integrated harm reduction services for people living with HIV and people who use drugs. Peer-led outreach through NSPs or community-led testing reaches clients who can be referred to a “one-stop-shop” drop-in centre. As the sole NGO providing an ART clinic in Nepal, SPARSHA offers testing and treatment for HIV, TB and HCV alongside OAT and psychological support. The client’s needs are met by a robust multidisciplinary approach with established links to other health services. For more information, see Harm Reduction International’s Integrated and person-centred harm reduction services.

Why is it important to include mental health services in harm reduction services?

People who use drugs are often marginalized and experience stigma and discrimination, which results in a higher prevalence of adverse mental health impacts than in the general population. This was particularly seen during the COVID-19 pandemic. Mental health services are essential components of integrated harm reduction programmes.

Community-led services can play a pivotal role in addressing mental health issues for people who use drugs. Community-led services are those where clients are meaningfully involved in designing, developing, implementing and monitoring services. Involving peers in service delivery can build trust and provide valuable knowledge exchange.

Listening to the problems of a client and treating people who use drugs with dignity and respect can help mental well-being. Providing counselling services with outreach and referring clients to psychologists improves access to mental health services in vulnerable communities.

Mental health services have been historically indirectly included in harm reduction programmes. More direct integration of these services is needed to build on evidence-based practices.

How can we provide sex-positive services free from stigma and discrimination?

Countries that adopt a holistic approach to drug use can deliver better health outcomes for people who use drugs. Approaches should ensure that all intersectional topics (for example, chemsex, sex work, mental health and homelessness) are considered.

Countries should ensure that all people who use drugs can access services in line with the United Nations Human Rights Council Recommendations:

  • Voluntary referrals to health, social, harm reduction and treatment services grounded in evidence, human rights and gender sensitivity

  • Non-discriminatory health and harm reduction measures in prisons

  • Intersectional approaches working with community leaders to improve the ability of people to cope with discrimination and stigma

  • Community initiatives and alliance building to ensure that the voices and lived experiences of key and other vulnerable populations are amplified

  • Key populations and affected communities and groups meaningfully participating in planning, implementation and monitoring of services

Advocating for a human rights approach to policies related to harm reduction

Source for image: Metzineres

Back to top

alternative text

How do discriminatory laws and practices hinder progress towards ending the HIV pandemic?

Criminalization of drug use significantly undermines progress towards ending the HIV pandemic. It is estimated that USD 100 billion is spent on drug law enforcement and only USD 131 million on harm reduction (HRI). Lack of investment is a significant barrier to the effective use of harm reduction and global goals to end the HIV pandemic. Redirecting 7.5% of funds spent on drug law enforcement towards harm reduction could fully fund an effective harm reduction response.

Harm reduction initiatives in low- and middle-income countries are heavily dependent on international donors, with an estimated 5% of the level needed currently provided. The 7th replenishment of the Global Fund offers the opportunity to contribute to the funding need, but further commitment is required to reduce the gap.

What is the Global Drug Policy Index (GDPI), and why is it important?

The GDPI is a tool that reports on drug policies worldwide. Within the GDPI, each country is scored between 0 and 100 on 75 policy indicators across five dimensions (the absence of extreme responses, the proportionality of the criminal justice system, health and harm reduction, access to controlled medicines, and development). The score indicates how these policy indicators align with the United Nations principles of human rights, health and development.

The Harm Reduction Consortium created the GDPI in 2021 with civil society and community organizations. The GDPI aims to promote and measure countries’ alignment with United Nations recommendations.

How do harm reduction interventions differ globally?

Harm Reduction International estimates that fewer than 1% of people who inject drugs live in countries with the recommended levels of harm reduction services. In some countries, no harm reduction services exist.

A systematic review in 2023 estimated that 90 countries implement opioid agonist treatment (OAT) and 94 countries implement needle and syringe programmes (NSPs). Coverage of take-home naloxone, supervised consumption facilities and drug-checking services were less frequently identified. Despite evidence of increases from previously reported data, significant gaps exist. Global coverage of harm reduction interventions must be higher, with most countries failing to meet global coverage targets.

The 2023 update to the Global State of Harm Reduction reports an increase in national policy documents (109 compared with 87 in 2020), demonstrating more commitment and implementation of harm reduction services globally despite the challenges of the COVID-19 pandemic.

Disparities are evident between regions, with programmes and policies more absent in Africa, Latin America and the Middle East. Services within countries also demonstrated variability, with rural areas largely underserved. Further commitment and progress are required to improve the availability of programmatic data and service coverage.

How has the global HIV response supported integrated harm reduction services?

Harm reduction is a crucial component of the Global AIDS Strategy (UNAIDS) 2021-2026 targets:

  • 90% of people who inject drugs have access to comprehensive harm reduction services integrated with or linked to hepatitis C, HIV and mental health services.

  • 50% of people who inject drugs and are opioid dependent have access to opioid substitution therapy.

  • 30% of testing and treatment services and 60% of programmes to support societal enablers are delivered by community-led organizations; 80% of service delivery for HIV prevention programmes for key populations and women are delivered by community, key population and women-led organizations.

  • Less than 10% of people who inject drugs or are living with HIV experience stigma or discrimination, less than 10% of women who use drugs or are living with HIV experience gender inequality/violence, and less than 10% of countries have punitive legal policies environments that lead to denial or limitation of services.

The Global AIDS Strategy (UNAIDS) emphasizes integrated andcommunity-led services.The 2021 Political Declaration on HIV and AIDS commits UN Member States to provide integrated services for HIV and other infectious diseases, non-communicable diseases, sexual and reproductive health, gender-based violence, mental health, alcohol and drug use, legal needs and other needs for their overall health and well-being by 2025.

The Global Fund considers harm reduction a “programme essential” that should be integrated into a country’s comprehensive HIV response. Its 2023-2025 priorities reaffirm that harm reduction is high-impact and cost-effective HIV prevention for people who use drugs in all countries. Despite focus and inclusion in the HIV response, the global targets will not be met without consistent implementation across all countries.

What legal reforms can provide a supportive environment for key populations?

Legal reforms and policy measures are needed to reach the 2025 global 10-10-10 targets:

  • Less than 10% of people living with HIV and key populations experience stigma and discrimination.

  • Less than 10% of people living with HIV, women and girls and key populations experience gender-based inequalities and gender-based violence.

  • Less than 10% of countries have punitive laws and policies.

IAS – the International AIDS Society – uses “key populations” to refer to gay men and other men who have sex with men, people who inject drugs, people in prisons and other closed settings, sex workers and their clients, and trans people.

A priority action of the Global AIDS Strategy for 2021-2026 is to create an enabling legal environment by removing punitive and discriminatory laws and policies, including laws that criminalize sex work, drug use or possession for personal use and consensual same-sex sexual relations, or that criminalize HIV exposure, non-disclosure or transmission. Access to justice and legal reform is estimated to account for 45% of the resource needs for an improved enabling environment.

It is also imperative that legal reforms support equitable access to acceptable, accessible and quality HIV services and related social and legal protection. Policy and legal frameworks should also be adopted to integrate post-exposure prophylaxis (PrEP) into services for survivors of gender-based violence and ensure that school environments are free from all forms of violence, including gender-based violence, stigma and discrimination.

How do interventions to reduce homelessness relate to harm reduction?

People experiencing homelessness also experience a higher burden of HIV, tuberculosis, mental health challenges, drug dependence and physical and sexual violence than individuals who are stably housed. Inadequate housing has particularly adverse impacts on people who use drugs, including contributing to increased vulnerability to overdose, viral acquisition, mental health challenges, social isolation and insufficient employment, nutrition and sleep to support well-being.

Accessing essential housing services is often difficult for people who use drugs experiencing homelessness because they tend to face stigma, discrimination, exclusion and criminalization. The needs of people who use drugs experiencing homelessness are unique and complex and require an approach that is integrated, person-centred and firmly grounded in evidence-based harm reduction principles.

Early identification of people vulnerable to homelessness can reduce the use of acute health and social services.

When provision of shelter is integrated with harm reduction services, it can provide a holistic approach for people who use drugs experiencing homelessness. Access to housing, case management and integration of health and social services, such as HIV, harm reduction and sexual and reproductive health services that include family support, can be vital.

IAS & harm reduction

Guidance & resources

Global guidance & reports


Factsheets & tools

The IAS acknowledges the collaborative efforts with Harm Reduction International in shaping the content of this resources page.