Harm reduction

Definition

Harm reduc­tion refers to the laws, poli­cies, and prac­tices that seek to reduce harm asso­ci­ated with a par­tic­u­lar - rel­a­tively risky - behav­iour. Harm reduc­tion entails sub­sti­tu­tion of a high-risk behav­iour with a rel­a­tively less risky behav­iour. This requires a com­pre­hen­sive set of poli­cies to tackle a pub­lic health chal­lenge which might be banned or crim­i­nalised. For instance, some coun­tries have imple­mented syringe exchange pro­grammes to incen­tivize peo­ple who inject drugs to use a new nee­dle every time. These pro­grammes reduce chances of acquir­ing infec­tions like HIV, Hepati­tis B, and Hepati­tis C from the use of old nee­dles and thereby typ­i­cally improve health out­comes. Other such poli­cies include opi­oid sub­sti­tu­tion ther­apy, safe injec­tion sites and free dis­tri­bu­tion of nalox­one.

Crim­i­nal­iza­tion of HIV and cer­tain behav­iours such as drug use is one of the major imped­i­ments to the imple­men­ta­tion of harm reduc­tion. Crim­i­nal pun­ish­ment, or even the fear of fac­ing crim­i­nal pun­ish­ment, makes these poli­cies less acces­si­ble and thereby less effec­tive.

Effec­tive harm-reduc­tion laws, poli­cies, and prac­tices are rooted in human rights as it pro­tects indi­vid­ual auton­omy, cur­tails dis­crim­i­na­tion and pro­vides equal access to health­care. Despite the wide­spread evi­dence of pos­i­tive impact of harm reduc­tion poli­cies, many coun­tries con­tinue to fail to invest in harm reduc­tion, retrain­ing and sen­si­ti­sa­tion of health­care providers, and lack of com­mu­nity involve­ment while pro­mul­gat­ing and imple­ment­ing harm reduc­tion poli­cies.

States have recently adopted sev­eral inter­na­tional com­mit­ments relat­ing to harm reduc­tion, as reflected in the Lan­guage Com­pendium. These include com­mit­ments to increase national lead­er­ship and resource allo­ca­tion towards harm reduc­tion pol­icy inter­ven­tions.

Precedents

2021 Political declaration on HIV and AIDS

• “Increas­ing national lead­er­ship, resource allo­ca­tion and other evi­dence - based enabling mea­sures for proven HIV com­bi­na­tion pre­ven­tion, includ­ing con­dom pro­mo­tion and dis­tri­bu­tion, pre-expo­sure pro­phy­laxis, post-expo­sure pro­phy­laxis, vol­un­tary male med­ical cir­cum­ci­sion, harm reduc­tion, in accor­dance with national leg­is­la­tion, sex­ual and repro­duc­tive health-care ser­vices, includ­ing screen­ing and treat­ment of sex­u­ally trans­mit­ted infec­tions, enabling legal and pol­icy envi­ron­ments, full access to com­pre­hen­sive infor­ma­tion and edu­ca­tion, in and out of school.” (para­graph 30(a))

• “Note with con­cern that the major­ity of coun­tries and regions have not made sig­nif­i­cant progress in expand­ing harm reduc­tion pro­grammes, in accor­dance with national leg­is­la­tion, as well as anti­retro­vi­ral ther­apy and other rel­e­vant inter­ven­tions that pre­vent the trans­mis­sion of HIV, viral hepati­tis and other blood -borne dis­eases asso­ci­ated with drug use, par­tic­u­larly those who inject drugs, and call urgent atten­tion to the insuf­fi­cient cov­er­age of pro­grammes and sub­stance use treat­ment pro­grammes that improve adher­ence to HIV drug treat­ment ser­vices, the mar­gin­al­iza­tion of and dis­crim­i­na­tion against peo­ple who use drugs, par­tic­u­larly those who inject drugs, through the appli­ca­tion of restric­tive laws, which ham­per access to HIV-related ser­vices, and in that regard, ensure access to and use of the full range of such inter­ven­tions, includ­ing in pre­ven­tion, treat­ment and outre ach ser­vices, pris­ons and other closed set­tings, and pro­mot­ing in that regard the use, as appro­pri­ate, of the tech­ni­cal guid­ance issued by the World Health Orga­ni­za­tion, the United Nations Office on Drugs and Crime and the Joint United Nations Pro­gramme on HIV/AIDS, and note with con­cern that gen­der-based and age-based stigma and dis­crim­i­na­tion often act as addi­tional bar­ri­ers for women and for young peo­ple who use drugs, par­tic­u­larly those who inject drugs, to access and use these ser­vices.” (para­graph 37)

2019 Political declaration of the HLM on UHC

• “Imple­ment mea­sures to pro­mote and improve men­tal health and well-being as an essen­tial com­po­nent of uni­ver­sal health cov­er­age, includ­ing by scal­ing up com­pre­hen­sive and inte­grated ser­vices for pre­ven­tion, includ­ing sui­cide pre­ven­tion, as well as treat­ment for peo­ple with men­tal dis­or­ders and other men­tal health con­di­tions as well as neu­ro­log­i­cal dis­or­ders, pro­vid­ing psy­choso­cial sup­port, pro­mot­ing well-being, strength­en­ing the pre­ven­tion and treat­ment of sub­stance abuse, address­ing social deter­mi­nants and other health needs, and fully respect­ing their human rights, not­ing that men­tal dis­or­ders and other men­tal health con­di­tions as well as neu­ro­log­i­cal dis­or­ders are an impor­tant cause of mor­bid­ity and con­trib­ute to the non-com­mu­ni­ca­ble dis­eases bur­den world­wide.” (para­graph 36)

2018 CND On mother-to-child transmission among women who use drugs

• “Encour­ages Mem­ber States, as appro­pri­ate, within their national and regional con­texts, to pro­mote, among rel­e­vant agen­cies and social ser­vices sec­tors, non-stig­ma­tiz­ing atti­tudes in the devel­op­ment and imple­men­ta­tion of sci­en­tific evi­dence-based poli­cies related to the avail­abil­ity of, access to and deliv­ery of health, care and social ser­vices for drug users, includ­ing women and girls who use drugs or who are exposed to risk fac­tors asso­ci­ated with drug use, and to reduce any pos­si­ble dis­crim­i­na­tion, exclu­sion or prej­u­dice that these peo­ple may encounter.” (para­graph 2)

• “Requests Mem­ber States, as appro­pri­ate, within their national and regional con­texts, to con­tinue to enhance inclu­sive­ness in devel­op­ing rel­e­vant pro­grammes and strate­gies, to seek opin­ions and con­tri­bu­tions from women and girls who use drugs and from orga­ni­za­tions and fam­i­lies and com­mu­nity mem­bers who work with them and sup­port them, and to facil­i­tate devel­op­ment of sci­en­tific evi­dence-based poli­cies regard­ing the avail­abil­ity of, access to and deliv­ery of ser­vices to women and girls who use drugs.” (para­graph 3)

• “Fur­ther calls upon Mem­ber States to offer women who use drugs, espe­cially those who have recently shared inject­ing equip­ment, and/or have been sex­u­ally assaulted, access to health clin­ics and, where pos­si­ble, assisted refer­ral, and access to post-expo­sure pro­phy­laxis, in accor­dance with national leg­is­la­tion and tak­ing into account the United Nations Office on Drugs and Crime guide­lines in the pub­li­ca­tion Address­ing the Spe­cific Needs of Women who Inject Drugs: Prac­ti­cal Guide for Ser­vice Providers on Gen­der-Respon­sive HIV Ser­vices.” (para­graph 8)

2017 Resolution on international cooperation to address and counter the world drug problem

• “Urges Mem­ber States to increase the avail­abil­ity, cov­er­age and qual­ity of sci­en­tific evi­dence-based pre­ven­tion mea­sures and tools that tar­get rel­e­vant age and risk groups in mul­ti­ple set­tings, reach­ing youth in school as well as out of school, among oth­ers, through drug abuse pre­ven­tion pro­grammes and pub­lic aware­ness-rais­ing cam­paigns, includ­ing by using the Inter­net, social media and other online plat­forms, to develop and imple­ment pre­ven­tion cur­ric­ula and early inter­ven­tion pro­grammes for use in the edu­ca­tion sys­tem at all lev­els, as well as in voca­tional train­ing, includ­ing in the work­place, and to enhance the capac­ity of teach­ers and other rel­e­vant pro­fes­sion­als to pro­vide or rec­om­mend coun­sell­ing, pre­ven­tion and care ser­vices.” (para­graph 15)

• “Encour­ages Mem­ber States to pro­mote the inclu­sion in national drug poli­cies, in accor­dance with national leg­is­la­tion and as appro­pri­ate, of ele­ments for the pre­ven­tion and treat­ment of drug over­dose, in par­tic­u­lar opi­oid over­dose, includ­ing the use of opi­oid recep­tor antag­o­nists, such as nalox­one, to reduce drug-related mor­tal­ity.” (para­graph 19)

• “Empha­sizes the need to enhance the knowl­edge of pol­i­cy­mak­ers and the capac­ity, as appro­pri­ate, of rel­e­vant national author­i­ties on var­i­ous aspects of the world drug prob­lem in order to ensure that national drug poli­cies, as part of a com­pre­hen­sive, inte­grated and bal­anced approach, fully respect all human rights and fun­da­men­tal free­doms and pro­tect the health, safety and well-being of indi­vid­u­als, fam­i­lies, vul­ner­a­ble mem­bers of soci­ety, com­mu­ni­ties and soci­ety as a whole, and to that end encour­ages the coop­er­a­tion of Mem­ber States with, and coop­er­a­tion among, the United Nations Office on Drugs and Crime, the Inter­na­tional Nar­cotics Con­trol Board, the World Health Orga­ni­za­tion and other rel­e­vant United Nations enti­ties, within their respec­tive man­dates, includ­ing those rel­e­vant to the above-men­tioned issues, and rel­e­vant regional and inter­na­tional orga­ni­za­tions, as well as with civil soci­ety and the pri­vate sec­tor, as appro­pri­ate.” (para­graph 27)

• “Calls upon Mem­ber States to enhance access to treat­ment for drug use dis­or­ders for those who are incar­cer­ated and pro­mote effec­tive over­sight and encour­age, as appro­pri­ate, self-assess­ments of con­fine­ment facil­i­ties, tak­ing into con­sid­er­a­tion the United Nations stan­dards and norms on crime pre­ven­tion and crim­i­nal jus­tice, includ­ing the United Nations Stan­dard Min­i­mum Rules for the Treat­ment of Pris­on­ers (the Nel­son Man­dela Rules), imple­ment, where appro­pri­ate, mea­sures aimed at address­ing and elim­i­nat­ing prison over­crowd­ing and vio­lence, and pro­vide capac­ity-build­ing to rel­e­vant national author­i­ties.” (para­graph 30)

• “Urges all Mem­ber States to enact com­pre­hen­sive mea­sures aimed at stem­ming the abuse of pre­scrip­tion drugs, in par­tic­u­lar through the estab­lish­ment of aware­ness-rais­ing ini­tia­tives tar­get­ing the gen­eral pub­lic and health-care providers.” (para­graph 45)

• “Calls upon Mem­ber States to con­tinue efforts to iden­tify and mon­i­tor trends in the com­po­si­tion, pro­duc­tion, preva­lence and dis­tri­bu­tion of new psy­choac­tive sub­stances, as well as pat­terns of use and adverse con­se­quences, and assess the risks to the health and safety of indi­vid­u­als and soci­ety as a whole and the poten­tial uses of new psy­choac­tive sub­stances for med­ical and sci­en­tific pur­poses, and on that basis to develop and strengthen domes­tic and national leg­isla­tive, reg­u­la­tory, admin­is­tra­tive and oper­a­tional responses and prac­tices by domes­tic and national leg­isla­tive, law enforce­ment, judi­ciary, social and wel­fare, edu­ca­tional and health author­i­ties.” (para­graph 55)

• “Encour­ages Mem­ber States to ensure that mea­sures to pre­vent the illicit cul­ti­va­tion of and to erad­i­cate plants con­tain­ing nar­cotic and psy­chotropic sub­stances respect fun­da­men­tal human rights, take due account of tra­di­tional licit uses, where there is his­tor­i­cal evi­dence of such use, and of the pro­tec­tion of the envi­ron­ment, in accor­dance with the three inter­na­tional drug con­trol con­ven­tions, and also take into account, as appro­pri­ate and in accor­dance wi th national leg­is­la­tion, the United Nations Dec­la­ra­tion on the Rights of Indige­nous Peo­ples.” (para­graph 63)

2016 Outcome Document of the Session on the World Drug Problem

• “Invite rel­e­vant national author­i­ties to con­sider, in accor­dance with their national leg­is­la­tion and the three inter­na­tional drug con­trol con­ven­tions, includ­ing in national pre­ven­tion, treat­ment, care, recov­ery, reha­bil­i­ta­tion and social rein­te­gra­tion mea­sures and pro­grammes, in the con­text of com­pre­hen­sive and bal­anced drug demand reduc­tion efforts, effec­tive mea­sures aimed at min­i­miz­ing the adverse pub­lic health and social con­se­quences of drug abuse, includ­ing appro­pri­ate med­ica­tion-assisted ther­apy pro­grammes, inject­ing equip­ment pro­grammes, as well as anti­retro­vi­ral ther­apy and other rel­e­vant inter­ven­tions that pre­vent the trans­mis­sion of HIV, viral hepati­tis and other blood-borne dis­eases asso­ci­ated with drug use, as well as con­sider ensur­ing access to such inter­ven­tions, includ­ing in treat­ment and out­reach ser­vices, pris­ons and other cus­to­dial set­tings, and pro­mot­ing in that regard the use, as appro­pri­ate, of the tech­ni­cal guide for coun­tries to set tar­gets for uni­ver­sal access to HIV pre­ven­tion, treat­ment and care for inject­ing drug users, issued by the World Health Orga­ni­za­tion, the United Nations Office on Drugs and Crime and the Joint United Nations Pro­gramme on HIV/AIDS.” (para­graph 1(o))

2011 Political Declaration on HIV and AIDS

• “Giv­ing con­sid­er­a­tion, as appro­pri­ate, to imple­ment­ing and expand­ing risk- and harm-reduc­tion pro­grammes, tak­ing into account the WHO, UNODC, UNAIDS Tech­ni­cal Guide for Coun­tries to Set Tar­gets for Uni­ver­sal Access to HIV Pre­ven­tion, Treat­ment and Care for Inject­ing Drug Users, 7 in accor­dance with national leg­is­la­tion.” (para­graph 59(h))

2010 ILO Recommendation concerning HIV and AIDS and the world of work

• “The Rec­om­men­da­tion sets out com­pre­hen­sive pro­vi­sions on safety and health mea­sures to be taken to pre­vent work­ers’ expo­sure to HIV, with par­tic­u­lar empha­sis on work­ers whose occu­pa­tions may place them at greater risk of expo­sure to HIV trans­mis­sion.” (para­graph 6)

2006 Political Declaration on HIV/AIDS

• “Reaf­firm that the pre­ven­tion of HIV infec­tion must be the main­stay of national, regional and inter­na­tional responses to the pan­demic, and there­fore com­mit our­selves to inten­si­fy­ing efforts to ensure that a wide range of pre­ven­tion pro­grammes that take account of local cir­cum­stances, ethics and cul­tural val­ues is avail­able in all coun­tries, par­tic­u­larly the most affected coun­tries, includ­ing infor­ma­tion, edu­ca­tion and com­mu­ni­ca­tion, in lan­guages most under­stood by com­mu­ni­ties and respect­ful of cul­tures, aimed at reduc­ing risk-tak­ing behav­iours and encour­ag­ing respon­si­ble sex­ual behav­iour, includ­ing absti­nence and fidelity; expanded access to essen­tial com­modi­ties, includ­ing male and female con­doms and ster­ile inject­ing equip­ment; harm-reduc­tion efforts related to drug use; expanded access to vol­un­tary and con­fi­den­tial coun­sell­ing and test­ing; safe blood sup­plies; and early and effec­tive treat­ment of sex­u­ally trans­mit­ted infec­tions.” (para­graph 22)

2000 WHA on HIV/AIDS: confronting the epidemic

• “Urges States to estab­lish or to expand coun­sell­ing ser­vices and vol­un­tary con­fi­den­tial HIV-test­ing in order to encour­age health-seek­ing behav­iour and to act as an entry point for pre­ven­tion and care.” (para­graph 1(18))

• “Urges States to con­tinue research on the pre­ven­tion of mother-to-child trans­mis­sion of HIV and to inte­grate inter­ven­tions for it into pri­mary health care, includ­ing repro­duc­tive health ser­vices, as part of com­pre­hen­sive care for HIV-infected preg­nant women and post­na­tal fol­low-up for them and for their fam­i­lies, ensur­ing that such research is free from inter­ests that might bias the results and that com­mer­cial involve­ment should be clearly dis­closed.” (para­graph 1(19))

Expert precedents

2022 OHCHR Annual Report on Human Rights and HIV/AIDS

• “Rec­om­mend that States end the prac­tice of com­pul­sory drug deten­tion and drug treat­ment; repeal all manda­tory min­i­mum prison sen­tences for drug offences; ensure access to essen­tial ser­vices for peo­ple who use drugs, includ­ing vol­un­tary refer­rals to health, social, harm reduc­tion and treat­ment ser­vices that are grounded in evi­dence, human rights and gen­der sen­si­tiv­ity; apply a mora­to­rium on admis­sions to com­pul­sory drug deten­tion cen­tres and pri­vate treat­ment cen­tres; and imme­di­ately release per­sons con­fined against their will in pri­vate or pub­lic drug treat­ment facil­i­ties.” (para­graph 15(f))

• “Rec­om­mend that States imple­ment, main­tain and scale up non-dis­crim­i­na­tory health and harm reduc­tion mea­sures in pris­ons, in accor­dance with best prac­tices in pub­lic health and pro­fes­sion­ally accepted stan­dards, and in con­sul­ta­tion with detainee groups and com­mu­nity health orga­ni­za­tions, to ensure oper­a­tional suc­cess, tak­ing into account the need for cul­tur­ally appro­pri­ate and gen­der-spe­cific pro­grammes.” (para­graph 15(g))

Evidence

2022 WHO Guidance on Differentiated and Simplified PrEP for HIV Prevention

• “A review of PrEP deliv­ery for peo­ple who inject drugs found that inte­grated PrEP ser­vices with com­pre­hen­sive com­mu­nity-based harm reduc­tion pro­grammes are likely to be most effec­tive in reach­ing peo­ple who inject drugs, and harm reduc­tion ser­vices are key to increas­ing aware­ness of and link­age to PrEP ser­vices.” (p. 24)

2022 WHO Consolidated Guidelines on HIV, Viral Hepatitis and STI Prevention, Diagnosis, Treatment and Care for Key Populations

• “At the time of writ­ing there is extremely low cov­er­age of the evi­dence-based pack­age of NSPs and OAMT. As a direct result, peo­ple who inject drugs are dis­pro­por­tion­ately affected by HIV and viral hepati­tis.” (p. 49)

2021 WHO Consolidated Guidelines on HIV Prevention, Testing, Treatment, Service Delivery and Monitoring

• “Nee­dle and syringe pro­grammes are highly effec­tive in reduc­ing HIV and hepati­tis C trans­mis­sion through inject­ing drug use. Opi­oid sub­sti­tu­tion ther­apy with methadone or buprenor­phine is the most effec­tive form of treat­ment for opi­oid depen­dence and has the addi­tional ben­e­fit of effec­tively reduc­ing HIV trans­mis­sion through inject­ing drug use. Opi­oid sub­sti­tu­tion ther­apy is also effec­tive in improv­ing ART uptake and adher­ence for peo­ple depen­dent on opi­oids.” (p. 66)

2016 Prevention Gap Report

• “Nee­dle-syringe pro­grammes reduce the spread of HIV, hepati­tis C and other blood­borne viruses. Opi­oid sub­sti­tu­tion ther­apy and other evi­dence-informed forms of drug depen­dence treat­ment curb drug use, reduce vul­ner­a­bil­ity to infec­tious dis­eases, and improve uptake of health and social ser­vices.” (p. 44)

• “Decades of expe­ri­ence within dozens of coun­tries sup­ports the effec­tive­ness of nee­dle–syringe pro­grammes. Across eight coun­tries in east­ern Europe and cen­tral Asia, a tripling of nee­dle–syringe pro­gramme cov­er­age between 2005 and 2010 reduced inject­ing risk behav­iour related to HIV and hepati­tis C and reduced new infec­tions. Many indi­vid­ual pro­grammes have achieved out­stand­ing results. Ten years of nee­dle–syringe pro­gram­ming in Aus­tralia reduced the num­ber of cases of HIV by up to 70% and reduced the num­ber of cases of hepati­tis C by up to 43%. In New York a sharp decrease in new HIV infec­tions among peo­ple who inject drugs between 1992 and 2012 has been attrib­uted to the imple­men­ta­tion and expan­sion of syringe exchange since 1992.” (p. 46)

• “Sub­sti­tu­tion ther­apy has also been shown to decrease the risk of hepati­tis C infec­tion, to increase adher­ence to anti­retro­vi­ral ther­apy for HIV, to lower out-of-pocket health expen­di­tures, and to reduce opi­oid over­dose risk by almost 90%. The scale-up of methadone main­te­nance ther­apy in diverse coun­try con­texts, includ­ing Por­tu­gal, Viet Nam and New Zealand, has also been asso­ci­ated with a decrease in crimes com­mit­ted by peo­ple who use drugs.” (p. 48)