New data confirm lack of progress in harm reduction after three decades of proven evidence of effectiveness.

HIV and viral hepatitis prevention services for people who inject drugs appear to have stagnated. Vulnerability to HIV and viral hepatitis among people who inject drugs is well recognised. This vulnerability has provoked repeated calls for increased access to prevention services, most of which seem to have gone unheeded according to new research published in The Lancet. Access to HIV and viral hepatitis services for people who inject drugs has stagnated, despite their vulnerability to HIV and viral hepatitis being well recognised. This vulnerability has provoked repeated calls for increased access to HIV and viral hepatitis prevention services, including harm reduction interventions, most of which seem to have gone unheeded according to new research published in The Lancet March 2023 by Degenhardt et al. [1] and College-Frisby et al [2]. This new evidence provides an update on the epidemiology of injecting drug use and the coverage of harm reduction services for people who inject drugs. It complements data collected by the United Nations (UN) [3], which is based on an annual global review that includes data reported from countries together with published scientific literature following a quality assessment based on objective and scientific criteria and that collected by Harm Reduction International [4], which is based on community-gathered information. Although data availability has improved over the years, the plausible bounds of global estimates of the number of people who inject drugs remain wide, and the quality of the data available for these estimates remains poor. However, overall it is clear that there is no substantial change in coverage of harm reduction services, and that these updates give a worrying indication of lack of progress, showing we are far from reaching the global goals of addressing HIV and viral hepatitis among people who inject drugs as well as those related to the treatment of drug use disorders. Degenhardt et al. estimate that globally, one in six people who inject drugs are living with HIV, four of 10 currently have hepatitis C virus infection, and one in 12 have chronic hepatitis B virus infection, although there are large regional variations. There has been no substantial change to these estimates since they were last published in 2017 [5]. People who inject drugs remain vulnerable to these three diseases, and other health issues, because of a combination of biological, structural and social issues. The Joint United Nations Programme on HIV and AIDS (UNAIDS) estimated that in 2021, people who inject drugs had a 35 times greater risk of acquiring HIV than people who do not inject drugs [6], and the World Health Organization (WHO) estimates that 23% of new hepatitis C virus infections globally are attributable to injecting drug use [3]. In almost every country, drug use or possession is criminalised and often considered immoral with significant stigma and discrimination experienced by people who inject drugs. Inequalities related to gender, poverty, education and race increase vulnerability of people who inject drugs. People who inject drugs experience high rates of violence, homelessness, and incarceration. In a companion review, College-Frisby et al. found consistently low coverage of the WHO-recommended package of harm reduction interventions to prevent HIV and viral hepatitis among people who inject drugs: needle/syringe programmes (NSP), opioid agonist maintenance therapy (OAMT) and community distribution of naloxone for opioid overdose management. The review showed modest increases in the estimated number of people accessing OAMT and the number of needles and/or syringes distributed per person who injects drug per year; however, both are still low coverage based on targets recommended by WHO, United Nations Office on Drugs and Crime and UNAIDS [7]. Similar to previous estimates [8], only five countries (all high income) provide high coverage of both OAMT and NSP. These findings are also consistent with other global reports of injecting drug use prevalence, service coverage, and HIV and viral hepatitis in people who inject drugs [3, 4]. The review found low coverage globally, despite an increase in the number of countries reporting availability of NSP and OAMT. This highlights a common issue with the implementation of harm reduction programmes in low- and middle-income countries, which are usually externally funded and often available as only a pilot or in limited geographic regions. Therefore, although a country can be included in lists of countries with NSP or OAMT programmes, these essential services can still remain out of reach for the majority of people who inject drugs, particularly those who live outside of capital cities, and even for those that can access, they may not be doing so regularly, and the quality of these services may not be high. This review shows us the important difference between measuring any availability and proper estimates of coverage, which give the true picture of availability and access. In 2022, WHO published updated Consolidated Guidelines for HIV, viral hepatitis and sexually transmitted infections (STIs) prevention, diagnosis, treatment and care for key populations, including people who inject drugs [9]. These guidelines recommend a comprehensive package of interventions for people who inject drugs comprising enabling interventions (addressing violence, reducing stigma and discrimination, empowering communities including engaging them in planning and delivering services, and decriminalising drug use and possession) and health interventions (harm reduction, other prevention, diagnosis and treatment of HIV, viral hepatitis and STIs, sexual and reproductive health services, mental health services, and others). These guidelines build on previous WHO guidance by giving an equal focus to HIV, viral hepatitis and STIs and encouraging a person-centred approach to providing integrated health services to people who inject drugs and other key populations. They also highlight intersecting vulnerabilities. As such, it is encouraging to see that the current reviews have expanded to consider more health interventions (such as supervised injecting facilities and drug checking services) and sociodemographic characteristics such as homelessness, sex work, history of incarceration, and mental health. This allows a better understanding of needs and pathways to reach people in different settings. For example, in Latin America, the review found that 43% of people who inject drugs are under 25 years old, a very different picture from Australasia, where only 6% are under 25 and requiring a different response and engagement with different groups. Despite long-standing UN-wide recommendations for decriminalisation of drug use and possession and targets for harm reduction for prevention of HIV and viral hepatitis among people who inject drugs, globally there has been little change in the coverage of these services and the prevalence of these diseases over the past decade. Change must involve the end of stigma, discrimination, criminalisation and punitive approaches to drug use. There needs to be an urgent increase in the equitable coverage of harm reduction interventions for people who inject drugs taking into account local context, centring people and communities. Virginia Macdonald: Conceptualization; supervision; writing—original draft; writing—review and editing. Bradley Mathers: Conceptualization; writing—review and editing. Keith Sabin: Conceptualization; writing—review and editing. Angela Me: Writing—review and editing. Chloe Carpentier: Conceptualization; writing—review and editing. Kamran Niaz: Writing—review and editing. Antons Mozalevskis: Conceptualization; writing—review and editing. Niklas Luhmann: Conceptualization; writing—review and editing. Monica Ciupagea: Writing—review and editing. Fariba Soltani: Writing—review and editing. Annette Verster: Conceptualization; writing—original draft; writing—review and editing. Bill and Melinda Gates Foundation. There are no competing interests. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.