Despite the wealth of evidence supporting key harm reduction interventions such as needle and syringe programmes (NSPs) and opioid substitution therapy (OST), they remain woefully underfunded around the world. We know this by looking at the global coverage: just 8% of people who inject drugs have access to NSPs, and 8% have access to OST. The cost-effectiveness of these interventions has been verified by multiple studies: the economic return from OST (through averted infections, reduced crime, etc) is estimated to be around four times the treatment cost, and studies have shown that every $1 invested in NSPs returned more than $4 in health care savings alone.

In a recent “Investment Framework” proposed by UNAIDS and partners, it is projected that US$ 2.3 billion will be needed in 2015 to reach the optimal coverage of harm reduction interventions (falling to US$ 1.5 billion in 2020 through savings in averted infections etc) – but this compares to just US$ 0.5 billion said to be available in 2011. In a global economic crisis, and with on-going uncertainty concerning the Global Fund to Fight AIDS, Tuberculosis and Malaria (the leading international donor for harm reduction as things stand), only the most devoted optimist can foresee the US$ 2.3 billion need being met in three years’ time.

Crucially, however, even if this funding need was met, we would struggle to know it. Most donors are reluctant or unable to divulge how much they have spent on harm reduction approaches, with global data limited to “guesstimations”. In 2010, Harm Reduction International released “Three Cents a Day is Not Enough” – the first attempt to provide a comprehensive overview of harm reduction funding around the world. The result was shocking: just $160 million was invested in HIV-related harm reduction in low and middle income countries in 2007 – US$ 0.03 per person who injects drugs, per day. In fact, the largest funders for harm reduction were people who inject drugs themselves, with ‘out-of-pocket’ expenses accounting for a significant amount of the global resources – “an unfair burden… that would be unacceptable in any other medical or public health field”. The report also highlighted the difficulties in calculating harm reduction budgets at this level. The UNAIDS National AIDS Spending Assessments (NASA) proved of limited use, and many donors did not report or disaggregate their expenditure on this population.

Since 2007, there is reason to anticipate that the amount of funding has risen – but the gap between reality and need remains significant. Prompted by the recommendations of the “3 Cents” report, the Global Fund has now released the results of a year-long portfolio analysis. Between Round 1 of funding (2002) and Round 9 (2009), they approved up to US$ 430 million for services targeting people who inject drugs. In Round 10 (2010), they launched a dedicated funding reserve for most-at-risk populations, and approved a further US$ 152 million for this population – taking the total to US$ 582 million over the ten funding rounds. However, the positive trend in recent years was undone when the Global Fund decided to cancel Round 11 in 2011. A further sixteen HIV proposals have been accepted through the Transitional Funding Mechanism that was created to alleviate the impact of cancelling Round 11 – nine of which include harm reduction (the budgets for these new grants will only be available for analysis in 2013).

But the need clearly remains for donors to better track their spending for people who inject drugs (as well as on other key populations, such as sex workers and men who have sex with men). Harm Reduction International plan to repeat and update the “3 Cents” research in early 2013, in time for the harm reduction conference in Vilnius. But this work should not be the sole responsibility of a small NGO – it should be a core part of the UNAIDS remit, and particularly the role of the United Nations Office on Drugs and Crime (UNODC), as the leading UNAIDS co-sponsor for injecting drug use. Hopefully the 2013 research will come up with a figure larger than US$ 0.03 – but the previous conclusion that “More money is needed for harm reduction, and it is needed now” is likely to still be true.

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