By Leo Beletsky, Pieter Baker, Jaime Arredondo, Ashley Emuka, David Goodman-Meza, Maria Elena Medina-Mora, Dan Werb, Peter Davidson, Joseph J Amon, Steffanie Strathdee, Carlos Magis-Rodriguez

The first safe consumption facility (SCF) opened its doors in 1986, in Bern, Switzerland, intending to curb drug overdose-related deaths and prevent other drug-related harm in people who inject drugs (PWID).1 Since then, communities who have adopted the SCF approach have seen decreases in HIV incidence, injection related litter and disorder, and drug overdose.2,3 Use of SCFs is also associated with uptake of treatment for drug use and other recovery assistance services.4

Mounting evidence that SCFs are both highly successful and cost-effective has made them a core public health response to problematic drug use and its sequelae.5,6 Nowadays, more than 100 SCFs are in operation across Europe, Australia, and Canada, with Canada having recently approved dozens of additional facilities to address the country’s overdose crisis.7 Although several US locales have made concrete steps towards opening SCFs, progress has been dismally slow, and the ultimate fate of these efforts remains uncertain.

Shockingly, not one such programme operates in low-income and middle-income countries, despite the reality that these countries bear a disproportionate burden of the harm to public health associated with drug use. For example, the prevalence of HIV infection in PWID living in Latin America (35·7%), South Asia (19·4%), and eastern Europe (24·7%) is markedly higher than the global average (17·8%).

Although technically a high-income country, Russia now has the third highest HIV incidence in the world, driven primarily by injection-related transmission.8 Moreover, abusive law enforcement practices are prevalent in areas with a weak rule of law and widespread informal settlements.9,10 Adverse encounters with police and other security personnel exacerbate the health risk to PWID, while limiting the accessibility of harm reduction services.11 In such contexts, the human rights and public health imperatives of safe consumption spaces are especially pressing, whereas their absence plainly offends global equity principles.

Tijuana, Mexico is illustrative of a global setting where the potential benefit of SCFs is readily evident. As a border node in the international drug trade, rates of drug consumption, injection-related infectious disease, and overdose are high.12 Reflective of many other places in low-income and middle-income countries, access to naloxone and opioid substitution therapy in Tijuana (and elsewhere in Mexico) is limited. If operated at scale, a SCF could substantially decrease overdose-related morbidity and mortality while facilitating access to appropriate drug treatment.12 Tijuana’s street market for opioids does not yet appear to be dominated by fentanyl, but such a shift would almost certainly cause a surge in overdose fatalities.

Existing drug consumption dynamics and the proliferation of informal and unsafe injection sites leave PWID in Tijuana vulnerable to police harassment.10,11 In the context of structural challenges and poor coverage of high-quality and accessible harm reduction programmes, a SCF could save lives and reduce drug-related harm. The integration of SCFs with a range of assistance programmes would also catalyse the connection of marginalised drug users to other essential services. Analogous to several jurisdictions in the global South, Tijuana’s legal environment is already favourable to the operation of a SCF because small-scale drug possession is decriminalised.10 Finally, a department-wide police education programme in Tijuana has built a foundation for better alignment of law enforcement with harm reduction programmes like SCFs.13

In Tijuana, as elsewhere, SCFs provide an opportunity to integrate a suite of key harm reduction services under one roof. However, these spaces potentiate much more than access to sterile equipment and basic medical help. In contexts where the lived experience of PWID is characterised by pervasive exposure to police violence, poor availability of stable housing and basic sanitation, and little ability to vindicate one’s rights, SCFs can create a rare oasis of structural safety and empowerment. The diversity of models for SCF—ranging from simple pop-up and mobile sites to fully-integrated clinics—create an opportunity to tailor interventions to particular environments and resources available globally. Despite barriers to operating SCFs in high-income settings, advocacy and persistence have supported the diffusion of this intervention throughout Europe, Australia, and Canada.1 With pressing public health and global equity imperatives to support this cause, the time to scale SCFs globally has long arrived.