Global State of Harm Reduction - 2021 Update

The 2021 update to the key data in the Global State of Harm Reduction, found that the spread of harm reduction services continues to stall globally - a trend we have observed since 2012.

Findings

In 2021, the total number of countries implementing needle and syringe programmes (NSP) has increased by just one, from 86 to 87. The new country is Uganda.
Two new countries (Uganda and Mozambique) have begun implementing opioid agonist therapy (OAT) programmes since 2020. The total number of countries implementing OAT in 2021 is 86 (up from 84 in 2020).
There were no reports of countries ceasing implementation of NSP, OAT, peer distribution of naloxone or shutting down drug consumption rooms.
New search strategies identified an additional 11 countries with explicit supportive references to harm reduction in national policy documents. The total number in 2021 is 98.

The findings reflect the 95% funding gap for harm reduction in low-and middle-income countries. Rising new HIV infections among key populations, including among people who inject drugs, disruptions in HIV prevention programmes and services caused by the COVID-19 pandemic and ongoing human rights violations that prevent people from accessing services mean that we need urgent investment in harm reduction and HIV prevention. The concurrent economic downturn caused by the pandemic and shrinking donor investments in the HIV response have resulted in an unprecedented challenge in meeting the goal of ending AIDS by 2030.

However, the Global AIDS Strategy 2021-2026 gives exceptional urgency to HIV prevention and human rights by calling on governments and donors to significantly increase investments for harm reduction, including delivery by community-led organisations, and to remove policies and laws that prevent people who use drugs from accessing health and harm reduction services. Additionally, the newly adopted Global Fund Strategy 2023 -2028 puts people and communities at the front and centre of its work.

With only nine years left to meet the Sustainable Development Goals, we need governments and donors to step up and invest in harm reduction services and advocacy that will address inequalities driving poor health outcomes for people who use drugs.

The data presented here has been gathered over the course of 2021 from publicly available sources and in cooperation with our partners around the world. To report any inaccuracies, please contact us at office@hri.global

At least one OAT programme in prison and in the community
At least one OAT programme in the community only
No OAT available

At least one NSP in prison and in the community
At least one NSP in the community only
No NSP available

Country or territory	World Bank Income Group (2021)	Explicit supportive reference to harm reduction in national policy documents	At least one needle and syringe programme operational	At least one opioid agonist therapy operational	At least one drug consumption room	Peer distriburion of naloxone	OAT in at least one prison	NSP in at least one prison
Asia
Afghanistan	Low income	✓	✓	✓	✘	✓	✓	✘
Bangladesh	Lower middle income	✓	✓	✓	✘	✘	✘	✘
Bhutan	Lower middle income	✓	✘	✘	✘	✘	✘	✘
Brunei Darussalam	High income	✘	✘	✘	✘	✘	✘	✘
Cambodia	Lower middle income	✓	✓	✓	✘	✘	✘	✘
China	Upper middle income	✘	✓	✓	✘	✘	✘	✘
Hong Kong	High income	✘	✘	✓	✘	✘	✘	✘
India	Lower middle income	✓	✓	✓	✘	✓	✓	✘
Indonesia	Upper middle income	✓	✓	✓	✘	✘	✓	✘
Japan	High income	✘	✘	✘	✘	✘	✘	✘
Laos	Lower middle income	✘	✘	✘	✘	✘	✘	✘
Macau	High income	✓	✓	✓	✘	✘	✘	✘
Malaysia	Upper middle income	✓	✓	✓	✘	✘	✓	✘
Maldives	Upper middle income	✘	✘	✓	✘	✘	✘	✘
Mongolia	Lower middle income	✘	✘	✘	✘	✘	✘	✘
Myanmar	Lower middle income	✓	✓	✓	✘	✓	✘	✘
Nepal	Lower middle income	✓	✓	✓	✘	✘	✘	✘
Pakistan	Lower middle income	✓	✓	✘	✘	✘	✘	✘
Philippines	Lower middle income	✓*	✘	✘	✘	✘	✘	✘
Singapore	High income	✘	✘	✘	✘	✘	✘	✘
South Korea	High income	✘	✘	✘	✘	✘	✘	✘
Sri Lanka	Lower middle income	✓	✘	✘	✘	✘	✘	✘
Taiwan	High income	✓	✓	✓	✘	✘	✘	✘
Thailand	Upper middle income	✓	✓	✓	✘	✘	✘	✘
Vietnam	Lower middle income	✓	✓	✓	✘	✘	✓	✘
TOTAL: 25		16	14	15	0	3	5	0

Country or territory	World Bank Income Group (2021)	Explicit supportive reference to harm reduction in national policy documents	At least one needle and syringe programme operational	At least one opioid agonist therapy operational	At least one drug consumption room	Peer distriburion of naloxone	OAT in at least one prison	NSP in at least one prison
Eurasia
Albania	Upper middle income	✓	✓	✓	✘	✘	✓	✘
Armenia	Upper middle income	✓	✓	✓	✘	✘	✓	✓
Azerbaijan	Upper middle income	✘	✓	✓	✘	✘	✘	✘
Belarus	Upper middle income	✓	✓	✓	✘	✘	✘	✘
Bosnia and Herzegovina	Upper middle income	✓	✓	✓	✘	✘	✓	✘
Bulgaria	Upper middle income	✓	✘	✓	✘	✘	✓	✘
Croatia	High income	✓	✓	✓	✘	✘	✓	✘
Czechia	High income	✓	✓	✓	✘	✘	✓	✘
Estonia	High income	✓	✓	✓	✘	✓	✓	✘
Georgia	Upper middle income	✓	✓	✓	✘	✓	✓	✘
Hungary	High income	✓	✓	✓	✘	✘	✓	✘
Kazakhstan	Upper middle income	✓	✓	✓	✘	✘	✘	✘
Kosovo	Upper middle income	✓	✓	✓	✘	✘	✘	✘
Kyrgyzstan	Lower middle income	✓	✓	✓	✘	✘	✓	✓
Latvia	High income	✓	✓	✓	✘	✘	✓	✘
Lithuania	High income	✓	✓	✓	✘	✘	✓	✘
Moldova	Lower middle income	✓	✓	✓	✘	✘	✓	✓
Montenegro	Upper middle income	✓	✓	✓	✘	✘	✓	✘
North Macedonia	Upper middle income	✓	✓	✓	✘	✘	✓	✓
Poland	High income	✓	✓	✓	✘	✘	✓	✘
Romania	High income	✓	✓	✓	✘	✘	✓	✘
Russia	Upper middle income	✘	✓	✘	✘	✘	✘	✘
Serbia	Upper middle income	✓	✓	✓	✘	✘	✓	✘
Slovakia	High income	✓	✓	✓	✘	✘	✘	✘
Slovenia	High income	✓	✓	✓	✘	✘	✓	✘
Tajikistan	Low income	✓	✓	✓	✘	✘	✓	✓
Turkmenistan	Upper middle income	✘	✘	✘	✘	✘	✘	✘
Ukraine	Lower middle income	✓	✓	✓	✘	✓	✓	✘
Uzbekistan	Lower middle income	✓	✓	✘	✘	✘	✘	✘
TOTAL: 29		26	27	26	0	3	21	5

Country or territory	World Bank Income Group (2021)	Explicit supportive reference to harm reduction in national policy documents	At least one needle and syringe programme operational	At least one opioid agonist therapy operational	At least one drug consumption room	Peer distriburion of naloxone	OAT in at least one prison	NSP in at least one prison
Latin America and the Caribbean
Argentina	Upper middle income	✓	✘	✓	✘	✘	✘	✘
Bolivia	Lower middle income	✘	✘	✘	✘	✘	✘	✘
Brazil	Upper middle income	✘	✘	✘	✘	✘	✘	✘
Chile	High income	✘	✘	✘	✘	✘	✘	✘
Colombia	Upper middle income	✓	✓	✓	✘	✘	✘	✘
Costa Rica	Upper middle income	✓	✘	✘	✘	✘	✘	✘
Dominican Republic	Upper middle income	✓	✓	✘	✘	✘	✘	✘
Ecuador	Upper middle income	✓	✘	✘	✘	✘	✘	✘
El Salvador	Lower middle income	✘	✘	✘	✘	✘	✘	✘
Guatemala	Upper middle income	✘	✘	✘	✘	✘	✘	✘
Guyana	Upper middle income	✘	✘	✘	✘	✘	✘	✘
Haiti	Low income	✘	✘	✘	✘	✘	✘	✘
Honduras	Lower middle income	✘	✘	✘	✘	✘	✘	✘
Jamaica	Upper middle income	✘	✘	✘	✘	✘	✘	✘
Mexico	Upper middle income	✓	✓	✓	✘	✓	✘	✘
Nicaragua	Lower middle income	✘	✘	✘	✘	✘	✘	✘
Panama	High income	✘	✘	✘	✘	✘	✘	✘
Paraguay	Upper middle income	✘	✘	✘	✘	✘	✘	✘
Peru	Upper middle income	✘	✘	✘	✘	✘	✘	✘
Puerto Rico	High income	✓	✓	✓	✘	✓	✘	✘
Suriname	Upper middle income	✘	✘	✘	✘	✘	✘	✘
The Bahamas	High income	✓	✘	✘	✘	✘	✘	✘
Uruguay	High income	✓	✘	✘	✘	✘	✘	✘
Venezuela	Upper middle income	✘	✘	✘	✘	✘	✘	✘
TOTAL: 24		9	4	4	0	2	0	0

Country or territory	World Bank Income Group (2021)	Explicit supportive reference to harm reduction in national policy documents	At least one needle and syringe programme operational	At least one opioid agonist therapy operational	At least one drug consumption room	Peer distriburion of naloxone	OAT in at least one prison	NSP in at least one prison
Middle East and North Africa
Algeria	Lower middle income	✘	✓	✘	✘	✘	✘	✘
Bahrain	High income	✘	✘	✘	✘	✘	✘	✘
Egypt	Lower middle income	✓	✓	✘	✘	✘	✘	✘
Iran	Upper middle income	✓	✓	✓	✘	✘	✓	✘
Iraq	Upper middle income	✘	✘	✘	✘	✘	✘	✘
Israel	High income	✓	✓	✓	✘	✘	✓	✘
Jordan	Upper middle income	✘	✘	✘	✘	✘	✓	✘
Kuwait	High income	✘	✘	✘	✘	✘	✘	✘
Lebanon	Upper middle income	✓	✓	✓	✘	✘	✓	✘
Libya	Upper middle income	✘	✘	✘	✘	✘	✘	✘
Morocco	Lower middle income	✓	✓	✓	✘	✘	✓	✘
Oman	High income	✓	✘	✘	✘	✘	✘	✘
Palestine	Lower middle income	✓	✘	✓	✘	✘	✓	✘
Qatar	High income	✘	✘	✘	✘	✘	✘	✘
Saudi Arabia	High income	✘	✘	✘	✘	✘	✘	✘
Syria	Low income	✘	✘	✘	✘	✘	✘	✘
Tunisia	Lower middle income	✓*	✓	✘	✘	✘	✘	✘
United Arab Emirates	High income	✘	✘	✘	✘	✘	✘	✘
Yemen	Low income	✘	✘	✘	✘	✘	✘	✘
TOTAL: 19		8	7	5	0	0	6	0

Country or territory	World Bank Income Group (2021)	Explicit supportive reference to harm reduction in national policy documents	At least one needle and syringe programme operational	At least one opioid agonist therapy operational	At least one drug consumption room	Peer distriburion of naloxone	OAT in at least one prison	NSP in at least one prison
North America
Canada	High income	✓	✓	✓	✓	✓	✓	✓
United States	High income	✓	✓	✓	✘	✓	✓	✘
TOTAL: 2		2	2	2	1	2	2	1

Country or territory	World Bank Income Group (2021)	Explicit supportive reference to harm reduction in national policy documents	At least one needle and syringe programme operational	At least one opioid agonist therapy operational	At least one drug consumption room	Peer distriburion of naloxone	OAT in at least one prison	NSP in at least one prison
Oceania
Australia	High income	✓	✓	✓	✓	✓	✓	✘
Fiji	Upper middle income	✘	✘	✘	✘	✘	✘	✘
Kiribati	Lower middle income	✘	✘	✘	✘	✘	✘	✘
Marshall Islands	Upper middle income	✘	✘	✘	✘	✘	✘	✘
Micronesia	Lower middle income	✘	✘	✘	✘	✘	✘	✘
New Zealand	High income	✓	✓	✓	✘	✓	✓	✘
Palau	High income	✘	✘	✘	✘	✘	✘	✘
Papua New Guinea	Lower middle income	✘	✘	✘	✘	✘	✘	✘
Samoa	Upper middle income	✘	✘	✘	✘	✘	✘	✘
Solomon Islands	Lower middle income	✘	✘	✘	✘	✘	✘	✘
Tonga	Upper middle income	✘	✘	✘	✘	✘	✘	✘
Vanuatu	Lower middle income	✘	✘	✘	✘	✘	✘	✘
TOTAL: 12		2	2	2	1	2	2	0

Country or territory	World Bank Income Group (2021)	Explicit supportive reference to harm reduction in national policy documents	At least one needle and syringe programme operational	At least one opioid agonist therapy operational	At least one drug consumption room	Peer distriburion of naloxone	OAT in at least one prison	NSP in at least one prison
Sub-Saharan Africa
Angola	Lower middle income	✘	✘	✘	✘	✘	✘	✘
Benin	Lower middle income	✘	✓	✘	✘	✘	✘	✘
Burkina Faso	Low income	✘	✘	✓	✘	✘	✘	✘
Burundi	Low income	✘	✘	✘	✘	✘	✘	✘
Cameroon	Lower middle income	✘	✘	✘	✘	✘	✘	✘
Cape Verde	Lower middle income	✘	✘	✘	✘	✘	✘	✘
Central African Republic	Low income	✘	✘	✘	✘	✘	✘	✘
Chad	Low income	✘	✘	✘	✘	✘	✘	✘
Côte d’Ivoire	Lower middle income	✓*	✘	✓	✘	✘	✘	✘
Democratic Republic of the Congo (DRC)	Low income	✘	✘	✘	✘	✘	✘	✘
Djibouti	Lower middle income	✘	✘	✘	✘	✘	✘	✘
Ethiopia	Low income	✘	✘	✘	✘	✘	✘	✘
Gabon	Upper middle income	✘	✘	✘	✘	✘	✘	✘
Gambia	Low income	✘	✘	✘	✘	✘	✘	✘
Ghana	Lower middle income	✓	✘	✘	✘	✘	✘	✘
Guinea	Low income	✘	✘	✘	✘	✘	✘	✘
Kenya	Lower middle income	✓	✓	✓	✘	✘	✓	✘
Lesotho	Lower middle income	✓	✘	✘	✘	✘	✘	✘
Liberia	Low income	✘	✘	✘	✘	✘	✘	✘
Madagascar	Low income	✘	✘	✘	✘	✘	✘	✘
Malawi	Low income	✘	✘	✘	✘	✘	✘	✘
Mali	Low income	✘	✓	✘	✘	✘	✘	✘
Mauritius	High income	✓	✓	✓	✘	✘	✓	✘
Mozambique	Low income	✘	✓	✓	✘	✘	✘	✘
Niger	Low income	✘	✘	✘	✘	✘	✘	✘
Nigeria	Lower middle income	✓	✓	✘	✘	✘	✘	✘
Rwanda	Low income	✘	✘	✘	✘	✘	✘	✘
Senegal	Lower middle income	✓	✓	✓	✘	✘	✘	✘
Seychelles	High income	✓	✘	✓	✘	✘	✓	✘
Sierra Leone	Low income	✓*	✓	✘	✘	✘	✘	✘
Somalia	Low income	✘	✘	✘	✘	✘	✘	✘
South Africa	Upper middle income	✓	✓	✓	✘	✘	✘	✘
Tanzania	Lower middle income	✓	✓	✓	✘	✘	✘	✘
Tanzania (Zanzibar)	Lower middle income	✓	✘	✓	✘	✘	✘	✘
Togo	Low income	✘	✘	✘	✘	✘	✘	✘
Uganda	Low income	✓	✓	✓	✘	✘	✘	✘
Zambia	Lower middle income	✓	✘	✘	✘	✘	✘	✘
Zimbabwe	Lower middle income	✓*	✘	✘	✘	✘	✘	✘
TOTAL: 38		15	11	11	0	0	3	0

Country or territory	World Bank Income Group (2021)	Explicit supportive reference to harm reduction in national policy documents	At least one needle and syringe programme operational	At least one opioid agonist therapy operational	At least one drug consumption room	Peer distriburion of naloxone	OAT in at least one prison	NSP in at least one prison
Western Europe
Andorra	High income	nk	nk	nk	✘	nk	nk	nk
Austria	High income	✓	✓	✓	✘	✘	✓	✘
Belgium	High income	✓	✓	✓	✓	✘	✓	✘
Cyprus	High income	✓	✓	✓	✘	✘	✓	✘
Denmark	High income	✓	✓	✓	✓	✓	✓	✘
Finland	High income	✓	✓	✓	✘	✘	✓	✘
France	High income	✓	✓	✓	✓	✘	✓	✘
Germany	High income	✓	✓	✓	✓	✘	✓	✓
Greece	High income	✓	✓	✓	✘	✘	✓	✘
Iceland	High income	✓	✓	✓	✘	✘	✓	✘
Ireland	High income	✓	✓	✓	✘	✘	✓	✘
Italy	High income	✓	✓	✓	✘	✓	✓	✘
Luxembourg	High income	✓	✓	✓	✓	✘	✓	✓
Malta	High income	✓	✓	✓	✘	✘	✓	✘
Monaco	High income	nk	nk	nk	✘	nk	nk	nk
Netherlands	High income	✓	✓	✓	✓	✘	✓	✘
Norway	High income	✓	✓	✓	✓	✓	✓	✘
Portugal	High income	✓	✓	✓	✓	✘	✓	✘
San Marino	High income	nk	nk	nk	✘	nk	nk	nk
Spain	High income	✓	✓	✓	✓	✘	✓	✓
Sweden	High income	✓	✓	✓	✘	✘	✓	✘
Switzerland	High income	✓	✓	✓	✓	✘	✓	✓
Turkey	Upper middle income	✘	✘	✓	✘	✘	✘	✘
United Kingdom	High income	✓	✓	✓	✘	✓	✓	✘
TOTAL: 24		20	20	21	10	4	20	4

* National Strategy expired but no new has been identified