The Global State of Harm Reduction 2024 report by Harm Reduction International (HRI) provides a comprehensive analysis of harm reduction initiatives worldwide, emphasising the intersection of public health and human rights within current drug policies. This ninth edition offers valuable insights into the effectiveness and challenges of harm reduction efforts across various regions and populations.

The 2024 report is the most comprehensive global mapping of harm reduction responses to drug use, HIV, and viral hepatitis, offering the latest data and insights. The report is produced through a collaborative effort involving community members, civil society representatives, and researchers, ensuring a diversity of perspectives and expertise.

Emphasis on Neglected Issues and Populations

Asia

Asia's punitive drug laws hinder harm reduction efforts, causing severe humanitarian, social, and economic costs. Despite recognition of the need for change, zero-tolerance policies persist, leading to marginalisation, incarceration, executions, and extrajudicial killings. Sri Lanka's Operation Yukthiya led to mass arrests and human rights abuses. Indonesia's new leadership supports the death penalty for drug offences, raising concerns. In the Philippines, despite some positive steps, drug-related killings continue without accountability. Leaders use anti-drug campaigns as populist tools, sustained by punitive laws that criminalise drug use. Civil society is challenging these laws, and some countries are exploring reforms, potentially paving the way for more humane policies. While harm reduction services exist in Asia, disparities hinder their effectiveness. In India, high coverage in some states contrasts with low coverage in others. Thailand's opioid agonist therapy coverage is low, especially in Bangkok. Marginalised groups like Rohingya refugees in Bangladesh face barriers due to stigma and targeting by law enforcement. Programs often focus on injecting drugs despite a shift to methamphetamine use, which is heavily targeted by punitive policies. Positive developments include continued services in Myanmar, innovative community models in Vietnam and Taiwan, and increased access in Malaysia. Scaling up requires greater investment, involvement of users, and recognition of harm reduction's benefits.

Eastern Europe and Southern Africa

Eastern and Southern Africa has the world's highest HIV prevalence, with over 20 million people infected. HIV rates among people who inject drugs reach 21.8%, yet all regional countries criminalise drug use, hindering equitable HIV services and increasing risks. Though Botswana, Mozambique, and Namibia have adopted harm reduction policies, implementation lags with no new opioid agonist therapy or needle and syringe programs since 2022. Despite harm reduction efforts, punitive law enforcement prevails, leading to human rights violations and arrests. This contradiction between policy and practice is a major barrier, necessitating a review of current strategies to improve healthcare access for people who use drugs. Eastern and Southern Africa faces high poverty rates and low health investment, with most governments spending less than $100 per person annually. High national debts threaten HIV responses, leading to reliance on international funding and undermining sustainability. Despite some investments, harm reduction remains underfunded. South Africa funds 70% of its HIV response but allocates nothing to harm reduction. Uganda and Kenya also lack sufficient domestic funding for harm reduction programs. Access to these services is low, with coverage at 37% in Kenya, 27% in South Africa, 16% in Mozambique, and 4% in Uganda. With drug use projected to increase by 40% by 2030, urgent investment in harm reduction is needed, yet punitive enforcement prevails.

Euraisa

Global donors have funded harm reduction in Eurasia to combat HIV, establishing needle and syringe programs and opioid agonist therapy. However, laws criminalizing sex work, drug use, HIV transmission, and same-sex relationships hinder healthcare access. New "foreign agent" and anti-LGBTQI+ laws threaten harm reduction services reliant on international funding. Russia's Foreign Agent Law and propaganda laws have suppressed NGOs and serve as a model for similar legislation in neighbouring countries like Kyrgyzstan and Georgia. These laws force NGOs to register as foreign agents, leading to self-censorship and closures, undermining efforts to end AIDS by 2030. Urgent international attention is needed to protect harm reduction and human rights in the region. Despite legal challenges, the implementation of drug checking services in Eurasia is a significant step forward, with nine out of 28 countries offering some level of service. Mostly funded by international donors—except in Czechia and Slovenia where the state provides support—these programs distribute colorimetric reagent test kits for self-testing, as laws prohibit staff from handling substances. NGOs in countries like Hungary, Estonia, and Poland provide kits and counselling in nightlife settings. Slovenia's DrogArt collects samples for lab analysis. Limited resources and lack of state support hinder expansion. Initiatives like vending machines in Georgia aim to reach more users. Expanding these services is crucial for harm reduction amid rising new psychoactive substances.

Latin America and the Carribean

Latin America and the Caribbean's drug policy landscape is a mix of progress and setbacks, with progressive administrations in countries like Colombia, Brazil, Mexico, and Chile, and conservative ones in others. Harm reduction strategies often coexist with punitive approaches within the same countries. Uruguay explicitly includes harm reduction in national policies, while Colombia, Mexico, and Brazil are reviewing their policies to incorporate new perspectives. Most countries lack national harm reduction policies, and civil society programs lack government funding amid decreasing international support. Personal drug use remains criminalised in most countries except Colombia, Uruguay, and Costa Rica. Violence linked to drug trafficking is increasing, underscoring the urgent need for reform based on harm reduction and human rights. Latin America and the Caribbean face complex social inequalities worsened by the COVID-19 pandemic, socio-political crises, and regressive policies, leading to increased unemployment, housing issues, and migration. Injecting drug use is uncommon but occurs along Mexico's northern border, Puerto Rico, and some Colombian cities, where harm reduction organisations provide needle and syringe programs and operate peer-led drug consumption rooms. Stimulant drug use, especially smoking cannabis and cocaine, is widespread, yet interventions like safer smoking kits are scarce. Despite low opioid and fentanyl use, media narratives have exaggerated fentanyl concerns, fueling alarmist discourse and enabling governments to adopt more punitive drug policies without evidence-based support.

Middle East and North Africa

Socio-cultural barriers—including stigma, discrimination, lack of public understanding, community resistance, and religious factors—significantly hinder access to health services for people who use drugs in the Middle East and North Africa. These obstacles are present both in society and within healthcare settings, affecting needle and syringe programs (NSP), opioid agonist therapy (OAT), and HIV services. Only four countries in the region have supportive harm reduction policies in their National HIV Strategic Plans. Punitive laws that criminalise drug use further impede harm reduction efforts, increasing stigma and discouraging service utilisation. Budget cuts leading to the closure of UNAIDS' regional office exacerbate challenges for community organisations supporting key populations most vulnerable to HIV. Representation and inclusion of people who use drugs are crucial for effective health responses in the Middle East and North Africa. However, these individuals often face significant barriers to participating in decision-making processes due to social and cultural factors, stigma, discrimination, lack of political will, and punitive legal frameworks. Despite these challenges, engagement of key populations has increased over the past two years. Organisations like MENAROSA and MENANPUD have collaborated on advocacy, planning, and implementation efforts. However, meaningful involvement remains inconsistent across the region. Continued efforts are needed to ensure people who use drugs are central to the development and execution of policies and services that affect them.

North America

Insite, opened in 2003 in Vancouver, was North America's first DCR and demonstrated success in achieving these goals, leading to 39 DCRs operating across Canada. Despite evidence of effectiveness, DCRs face backlash, such as Ontario's ban near schools. In the USA, only two DCRs operate in New York City due to legal and political barriers like the federal Anti-Drug Abuse Act. Extensive research confirms DCRs meet their objectives without negative consequences, yet political opposition hinders their wider implementation despite their potential to prevent overdose deaths. North America faces a worsening public health crisis due to accidental drug-related overdose deaths, which have increased over 600% in the USA since 2000 and over 500% in Canada since 2018. Overdose deaths disproportionately affect males, Black and Indigenous people, and those of Indigenous ancestry. The crisis is driven by the rise of illegally manufactured synthetic drugs like fentanyl, social and economic factors, and contaminated drug supplies. While harm reduction interventions exist, they are limited in scale and face barriers such as stigma and restrictive policies. Growing politicisation and backlash against harm reduction underscore the need for greater investment and action to address the crisis effectively.

Oceania

Oceania, including Australia, Aotearoa New Zealand, Fiji, Papua New Guinea, and Tonga, criminalises and stigmatises people who use drugs, hindering harm reduction efforts. Australia and Aotearoa New Zealand have pioneered harm reduction and HIV prevention, implementing needle and syringe programs since the 1980s. However, no country in the region fully decriminalises drug use; only the Australian Capital Territory decriminalised small amounts in October 2023. Criminalization and stigma prevent access to essential services and hinder the development of harm reduction interventions. Even in Australia and Aotearoa New Zealand, funding for harm reduction is declining, while drug-related overdoses are increasing, leading to preventable deaths. Aotearoa New Zealand and Australia have multiple harm reduction programs like festival-based initiatives, take-home naloxone, needle and syringe programs (NSPs), opioid agonist therapy (OAT), drug checking, medically supervised injecting centres, and peer-led organisations. Despite some progress, funding remains insufficient; only 1.6% of Australia's drug budget in 2021/22 was spent on harm reduction, compared to 64.3% on law enforcement. Other Oceania countries have limited or no harm reduction services, increasing risks of HIV and hepatitis C due to rising stimulant use and injection. There's an urgent need for expanded harm reduction programs and dedicated funding across the region.

West and Central Africa

Out of 25 countries in West and Central Africa, only 10 offer needle and syringe programmes (NSPs), and six provide opioid agonist therapy (OAT). Despite increases in the number of people who inject drugs, harm reduction services remain inadequate due to criminalization, stigma, and a preference for law enforcement over health approaches. Peer-led services are crucial but underdeveloped, with a lack of specialised training for peer workers. Women who inject drugs face additional barriers and lack gender-sensitive services. Emerging drug mixtures like kush pose new health threats, and countries are unprepared for potential increases in opioid use. Encouragingly, Ghana and Liberia have enacted laws supporting harm reduction. Adequate, long-term funding is crucial for sustaining and expanding harm reduction programs in West and Central Africa. Despite initial successes in reducing HIV infections through rapid funding, the region now faces a significant funding gap, with domestic HIV funding declining by 7% between 2018 and 2022. Reliance on external donors like the Global Fund and PEPFAR remains high, but overall contributions are decreasing and insufficient. This underinvestment has hindered the scale-up of essential services like needle and syringe programs and opioid agonist therapy. Over-reliance on external funding can lead to poor program implementation and delays, as seen in Nigeria and Sierra Leone. To ensure sustainability, governments must increase domestic funding, prioritise HIV and harm reduction in national budgets, and mobilise both external and local resources.

Western Europe

Western Europe widely provides harm reduction services like needle and syringe programs (NSPs) and opioid agonist therapy (OAT), and includes them in national drug strategies. However, marginalised groups such as women, LGBTQI+ individuals, migrants, and incarcerated people face barriers accessing these services. Young people under 18 who use drugs are the least served due to age restrictions and controversy over harm reduction in schools. People engaging in chemsex are underserved, especially those outside traditional focus groups. Migrants confront legal status issues, discrimination, and language barriers. To ensure appropriate access, it's crucial to involve peers from diverse drug-use groups in designing and implementing tailored harm reduction services. Drug checking services analyse drug samples submitted by users, offering feedback and counselling to reduce risks from unknown components and harmful interactions. They play a crucial role in monitoring drug markets and identifying emerging trends, such as synthetic cannabinoids detected in Switzerland. Available in 13 of 25 Western European countries—though in Ireland and Greece only at music festivals—these services influence user behaviour by deterring drug use when unexpected or suspicious results are found. Despite proven benefits, legal barriers and lack of political will hinder their expansion. With the rise of synthetic opioids in Europe, drug checking services are essential tools for enhancing safety and informed decision-making among people who use drugs.

Continued Focus on Viral Hepatitis Services:

The report continues to map the implementation of viral hepatitis services for people who use drugs, underscoring the ongoing efforts to combat this global health issue.

These key points illustrate the report's comprehensive scope, its collaborative and expert-driven approach, and its commitment to shedding light on often-overlooked populations and issues within harm reduction efforts. The above points align with Substancy's mission to promote safer and more informed drug use practices.

Top Trends

Incremental Increase in Needle and Syringe Programmes (NSPs):

As of 2024, 93 countries now provide at least one NSP, up from 92 countries in 2022. This gradual increase reflects ongoing global efforts to reduce the transmission of blood-borne infections among people who inject drugs.

Expansion of Opioid Agonist Therapy (OAT) Programmes:

94 countries now offer OAT programmes, compared to 88 in 2022. Despite the growth, coverage remains varied and limited, highlighting the need for broader accessibility and implementation worldwide.

Growth in Drug Consumption Rooms (DCRs) and Overdose Prevention Centres:

The number of countries with DCRs or overdose prevention centres has risen from 16 to 18 countries since 2022. Colombia and Sierra Leone are the new additions, indicating a slow but positive shift towards embracing harm reduction facilities in diverse regions. Although the overall number is still small, the increase signifies growing recognition of the benefits these services provide.

Slight Decrease in Take-Home Naloxone Programmes:

34 countries now have take-home naloxone programmes, a slight decrease from 35 in 2022. This reduction points to a minor setback in the availability of critical overdose reversal interventions, emphasising the need for renewed focus and support.

These key points highlight both the progress and ongoing challenges in global harm reduction efforts: The incremental increases in NSPs and OAT programmes demonstrate positive trends but also underscore the need for expanded coverage and consistent implementation. The introduction of DCRs in new countries like Colombia and Sierra Leone showcases a willingness to adopt innovative harm reduction strategies in diverse settings. The decrease in take-home naloxone availability serves as a reminder of the fragile nature of harm reduction services and the importance of sustained commitment and resources.

Punitive Approach Continues

Slight Increase in Harm Reduction Services Since 2022:

There has been a modest uptick in the availability of harm reduction services globally since the last report in 2022. This indicates progress but also highlights the slow pace of implementation.

Persistent Regional Disparities:

Substantial regional differences in the availability and quality of harm reduction services still exist. Some regions have advanced programs, while others lack basic services, leading to unequal health outcomes.

Stigmatisation and Criminalisation as Major Barriers:

The stigmatisation and criminalisation of people who use drugs remain significant issues worldwide. These factors impede access to existing harm reduction services and discourage individuals from seeking help. They also undermine political and financial support, making it challenging to implement and expand necessary services.

Contradictions in National Policies vs. Practices:

While 108 countries include harm reduction in their national policies, punitive approaches to drug use remain dominant. Criminalisation and punitive responses continue to fuel stigma and discrimination. This contradiction undermines harm reduction efforts and deters people from accessing vital, life-saving services.

Need to Address Key Contradictions for Meaningful Progress:

To make meaningful progress, it's crucial to resolve the inconsistency between supportive policies and punitive practices. Addressing this contradiction is essential for reducing stigma and improving health outcomes for people who use drugs.

Call for Policy and Attitudinal Change:

The report emphasises the necessity of shifting from punitive approaches to evidence-based, compassionate strategies. Eliminating stigma and criminalisation will enhance access to harm reduction services and save lives.

These key points highlight the current state of harm reduction globally. They underscore the importance of aligning national policies with practical implementation and the need to address stigma and criminalisation to improve harm reduction efforts. They also illustrate the challenges and necessary steps for advancing harm reduction, aligning with Substancy's mission to promote safer and more informed drug use practices.

Insufficient Funding

Cost-Effectiveness of Harm Reduction Services:

Needle and Syringe Programs (NSP) and Opioid Agonist Therapy (OAT) are proven to be cost-effective and cost-saving public health interventions. These services improve public health outcomes by reducing the transmission of infectious diseases and lowering drug-related harms. They contribute to reducing the negative social and economic impacts associated with drug use.

Severe Underfunding Despite Effectiveness:

Harm reduction is seriously underfunded in most regions, hindering the expansion and effectiveness of these services. In 2022, only USD 151 million was identified for harm reduction funding in low- and middle-income countries. This amount represents only 6% of the estimated USD 2.7 billion needed annually by 2025, leaving a staggering funding gap of 94%.

Mismatch Between Global Commitments and Funding:

Despite global commitments and international HIV prevention guidelines supporting the scaling up of harm reduction services, funding remains woefully insufficient. Harm reduction programs accounted for only 0.7% of total HIV funding in 2022, even though 8% of new HIV infections occur among people who inject drugs. This disparity highlights a significant disconnect between acknowledged needs and actual financial support.

Vulnerability Due to Limited Donors:

The number of international harm reduction donors remains small, making funding vulnerable to shifting priorities of these few donors. Reliance on a limited donor base poses risks to the sustainability of harm reduction programs.

Fragile Domestic Funding and Lack of Transparency:

Domestic funding for harm reduction is even more fragile than international funding. A lack of data on domestic funding levels prevents civil society from effectively monitoring investments and holding governments accountable. This opacity hampers efforts to advocate for increased domestic support and to ensure the continuity of harm reduction services.

These key points underscore the urgent need for increased and sustained funding for harm reduction services globally. Despite their proven effectiveness and cost-saving benefits, harm reduction initiatives face significant financial shortfalls. The contrast between global commitments to harm reduction and the minimal funding allocated highlights a critical area for advocacy and action. Addressing these funding gaps is essential to expand access to life-saving services, reduce the spread of infectious diseases, and improve public health outcomes.

Underserved Populations

Multiple and Intersecting Vulnerabilities:

Some people who use drugs face multiple, intersecting vulnerabilities that impede their access to harm reduction services. This includes women, LGBTQI+ individuals, Indigenous people, migrants, and people in prison. These groups experience additional marginalisation and discrimination, making them particularly underserved.

Barriers Faced by Young People:

Young people who use drugs encounter extra obstacles in accessing harm reduction services. Harm reduction for individuals under 18 years old is still considered a controversial issue. There are age restrictions in many countries, preventing minors from accessing services like Drug Consumption Rooms (DCRs), Needle and Syringe Programs (NSPs), and drug checking services. Even in regions like Western Europe, where harm reduction policies are more favourable, under-18s are not formally permitted to use these services.

Language and Cultural Barriers for Migrants:

Language barriers significantly hinder migrants' access to harm reduction services. The need for interpreters and multicultural mediators is crucial to ensure migrants can fully benefit from available services.

Racism and Increased Harm Among Indigenous and Racialised Communities:

Indigenous people and other racialised communities face racism in addition to stigma associated with drug use. These groups have higher rates of drug-related harm compared to the general population. Research from Canada, the USA, Australia, and Aotearoa New Zealand shows elevated harm rates among Indigenous populations. For example, opioid overdose deaths are seven times higher for the Kainai people in Alberta, Canada, than for the general population.

Uneven Geographical Coverage of Services:

Uneven geographical coverage remains a serious barrier to accessing harm reduction services worldwide. Even where services exist and are nationally recognized, individuals in remote or rural areas often struggle to access them.

Need for Inclusive Harm Reduction Strategies:

Addressing these barriers requires inclusive and targeted harm reduction strategies that consider the unique challenges faced by these populations. Enhancing accessibility involves policy changes, resource allocation, and community engagement to reach underserved groups.

Emphasising these issues sheds light on the necessity for comprehensive, inclusive approaches to harm reduction that address the specific needs of vulnerable populations. This aligns with the broader goal of promoting equitable health outcomes and underscores the importance of tailored interventions in the field of harm reduction.

People in Prison

Overrepresentation of Drug Users in Prisons Due to Punitive Policies:

Punitive drug policies have led to a disproportionate number of people who use drugs being incarcerated. An estimated one-third to half of the prison population has a history of drug use, highlighting the impact of criminalization.

Inadequate Access to Harm Reduction Services in Prisons:

Access to harm reduction services is even more inadequate in prisons compared to the general community. Despite the high need, harm reduction programs are less available inside prisons.

High-Risk Behaviours Increase in Prison Settings:

Many individuals continue or begin injecting drugs while in prison. High-risk behaviours, such as sharing injection equipment and unsafe tattooing, are more prevalent in prisons and other closed settings, increasing the risk of infectious diseases.

Limited Availability of Needle and Syringe Programs (NSPs) in Prisons:

Only 11 countries have an NSP in at least one prison, which is just 12% of the 93 countries that provide NSPs outside of prison. Identified prison NSPs are mainly in Eurasia (Armenia, Kyrgyzstan, Moldova, Tajikistan, Ukraine), Western Europe (Spain, Luxembourg, Germany, Switzerland), and Canada..

Scarcity of Naloxone Availability in Prisons:

Naloxone, a life-saving medication for opioid overdose, is available in at least one prison in only 11 countries across Europe, North America, and Australia. The limited availability underscores a critical gap in overdose prevention within prison systems.

Global Variance in Opioid Agonist Therapy (OAT) Provision:

OAT in prisons is available in at least 60 countries globally, but accessibility varies widely by region.In Asia,, only five countries offer OAT in at least one prison. Most European and Eurasian countries provide OAT in some prisons, but services are not uniformly accessible.

Barriers to Accessing Harm Reduction Services in Prisons:

Administrative and bureaucratic hurdles often prevent incarcerated individuals from accessing OAT and other services. For Example: OAT may be limited to those who had a prescription before incarceration. These barriers contribute to health disparities and ongoing transmission of infectious diseases within prisons.

Need for Policy Reform and Improved Service Provision:

The lack of adequate harm reduction services in prisons highlights the need for policy reform. Enhancing the availability and accessibility of NSPs, OAT, and naloxone in prisons is crucial for:

• Reducing the spread of infectious diseases such as HIV and hepatitis.
• Preventing overdose deaths among incarcerated populations.
• Supporting the health and rehabilitation of people who use drugs.

Conclusion – Addressing Inequalities in Harm Reduction:

To achieve meaningful progress in public health, it's essential to address the inequalities in harm reduction service provision between prison and community settings. Improving access to these services in prisons not only benefits incarcerated individuals but also has positive implications for public health upon their release.

The above sheds light on the critical gaps in harm reduction services within prisons and the urgent need for equitable access. Highlighting these issues aligns with the broader mission to advocate for health-focused, compassionate approaches to drug policy and rehabilitation.

Substancy is committed to advocating for increased investment in harm reduction, aligning with global efforts to promote safer and more informed drug use practices.

At Substancy, our commitment aligns seamlessly with the principles set forth in HRI’s report. Our mission to empower individuals through accurate knowledge, effective tools, and innovative solutions directly supports harm reduction. By addressing misinformation, promoting clear communication, and fostering innovation in the psychoactive drug sector, we aim to make drug use safer and more informed. Our databases, software, and AI-driven tools are designed to assist both professionals and individuals, reducing harm and enhancing well-being. Substancy is dedicated to a future where harm reduction is accessible and embedded in global healthcare frameworks, advocating for a safer and more productive world.

For a detailed understanding, you can access the full report here