According to the latest report from the United Nations Office on Drugs and Crime (UNODC), an estimated 11.3 million people inject drugs globally, while HIV prevalence is estimated to be 12.6% and hepatitis C prevalence 48.5% among this population. However, while 179 of 206 countries report some injecting drug use, 110 countries and territories worldwide have no data on its prevalence. This data gap highlights the need for more and higher quality data to inform our efforts to implement appropriate harm reduction services that can address public health issues, including HIV and hepatitis C, soft tissue infections, and overdose.

Harm reduction implementation has worsened since our last report in 2018, after having stalled since 2014. The number of countries where needle and syringe programmes (NSPs) remained level at 86, and the number of countries where opioid agonist therapy (OAT) is available decreased by two to 84. There are also large differences between the regions in terms of harm reduction implementation: while NSPs and OAT are available in most countries in Eurasia, North America and Western Europe, these core harm reduction interventions are severely lacking in the majority of countries in other regions. An unfavourable drug policy environment hinders harm reduction service implementation in many countries across Asia, Latin America and the Caribbean, the Middle East and North Africa (MENA), and sub-Saharan Africa. Several countries have adopted more punitive drug strategies since the Global State of Harm Reduction last reported in 2018, including Bangladesh, Brazil and Sri Lanka.

Even where harm reduction services are available, there is often insufficient coverage and quality, or a lack of access to these services. Significant geographical gaps and an uneven distribution of services exist even in countries pioneering harm reduction or in countries where harm reduction has been available for decades. Rural communities are particularly underserved in many countries and regions. In addition to the geographical gaps in coverage, there are sub-groups of people who use drugs that experience barriers in access because harm reduction services aren’t tailored to their unique needs. These groups include women who use drugs, men who have sex with men, people who use stimulants and/or non-injecting methods, and people experiencing homelessness.

Overarching structural problems also negatively affect access to services. Criminalisation, racism and discrimination against Indigenous, Black and brown people results in low household incomes, unemployment, food insecurity, poor housing and lower levels of education. This, in turn, results not only in worse health outcomes for these communities but also in people from these communities disengaging or actively avoiding health services.

Women who use drugs are still frequently overlooked despite the complex harms, stigmatisation and structural violence they face. A substantial increase in gender-sensitive services is necessary to appropriately address their needs.

For all people who use drugs, stigma and discrimination are public health issues creating barriers precisely where more support is needed. Harm reduction services are equipped to address these gaps, as non-judgmental, communitybased service delivery is among the core principles of harm reduction.