Harm Reduction and the Global AIDS Response

Human dignity, community leadership and agency are the lessons – even in a pandemic year  

World AIDS Day

The HIV response has always been about community leadership and access to health services; but never before have these issues stood so prominently on the global agenda as in 2020 – image: Shutterstock, CC

By Naomi Burke-Shyne  – Harm reduction is intrinsically linked to the AIDS movement because core harm reduction services such as needle and syringe programmes prevent HIV transmission. Even more important is the approach that guides harm reduction: the idea that people should be met without judgment, and the recognition of the dignity and rights inherent to all humans. An idea that has been echoed for decades in the AIDS movement.

An estimated 269 million people use drugs around the world, of which 11.3 million people inject drugs. However, less than half of the 179 countries with reported injecting drug use provide essential harm reduction services. The latest global mapping of these services by Harm Reduction International reveals that harm reduction services and policies has effectively stalled since 2014. Every year progress in some countries is met with regression in others. In 2020:

  • The number of countries implementing needle and syringe programmes (NSPs) remained level at 86 (Algeria, Benin, Nigeria and Sierra Leone opened NSPs for the first time; while in Palestine, Jordan, Mongolia and Uganda, NSPs ceased to operate for a variety of reasons).
  • The number of countries where opioid agonist therapy (OAT) is available decreased by two to 84.
  • Peer-distribution of naloxone, a medicine which reduces overdose, is available in just 15 countries.

Even where harm reduction interventions are available, there is often insufficient coverage, barriers to services or issues with quality of services – this is particularly acute for women and gender non-conforming people who use drugs; for Black, brown and Indigenous people who face racism in drug law enforcement and structural barriers to services; and for people who are homeless. Stigma, discrimination and criminalisation force millions of people to conceal their drug use, pushing them into spaces where risks associated with drug use are increased, rather than reduced.

In the context of the unique and difficult global circumstances this World AIDS Day, there are three notable and interconnected shifts impacting the development of people, communities and organisations:

1) Inadequate funding for essential health services for people who use drugs

$100 billion is spent on global drug law enforcement every year, but just $188 million is spent on harm reduction. This means that we spend more than 500 times the amount on punitive responses to drug use than we do on life-saving services for people who use drugs. At the end of 2020 we are going to be almost 90% short of the estimated $1.5 billion required annually for an adequate harm reduction response.


At the same time, donors in the HIV, drug policy and harm reduction fields have also faced pandemic-related disruptions and funds are spread thin between competing priorities. It will be important to keep advocating for funding for health services for the most vulnerable people who use drugs at national and international levels.

2) Weak attempts at prioritising health over criminal justice

Detention settings are high-risk environments for the spread of infectious diseases, including HIV and COVID-19. The pandemic has catalysed the uptake of exceptional measures to decongest prisons by governments and prison administrations around the world.

Despite a surge of energy around reducing prison populations in the context of COVID-19, we found that a quarter of the 109 countries that moved to implement emergency decongestion measures explicitly excluded people detained for certain drug offences, regardless of whether they met other eligibility criteria related to their vulnerability, gender, HIV or other health status.

3) Transformative community leadership by networks of people who use drugs

While we are still understanding the full extent of how COVID-19 has affected people who use drugs and harm reduction services around the world, it is clear from our data collection and research that community leadership has been transformative throughout the pandemic. Peer networks were solving problems using innovative solutions and communicating critical information to reduce exposure to COVID-19; while everyone else was still working out how to use Zoom. The International and European Networks of People Who Use Drugs (INPUD and EuroNPUD), were the first to develop guidelines for people who use drugs – now available in 20 languages – and to publish harm reduction tips to support people to avoid COVID-19 in the context of drug use.


The pandemic has created new and important momentum for the acceptance of health interventions which place human dignity and agency at the centre of the response. The HIV response has always been about community leadership and access to health services; but never before have these issues stood so prominently on the global agenda as in 2020. Our annual day of unity and action against AIDS now carries additional urgency and meaning.

About Harm Reduction International

HRI – Harm Reduction International is a leading NGO dedicated to reducing the negative health, social and legal impacts of drug use and drug policy. We promote the rights of people who use drugs and their communities through research and advocacy to help achieve a world where drug policies and laws contribute to healthier, safer societies.