In 2008, Harm Reduction International released the Global State of Harm Reduction, a report that mapped responses to drug-related HIV and hepatitis C epidemics around the world for the first time.(1) The data gathered for the report provided a critical baseline against which progress could be measured in terms of the international, regional and national recognition of harm reduction in policy and practice. Since then, the biennial report has become a key publication for researchers, policymakers, civil society organisations and advocates, mapping harm reduction policy adoption and programme implementation globally.

Download the report (PDF - outside link)

In the second and third editions, the Global State ofHarm Reduction 2010: Key Issues for Broadening the Response(2) and The Global State of Harm Reduction 2012: Towards an Integrated Response,(3) important harm reduction issues were explored in a series of chapters on key topics, such as the response to amphetamine-related harms, harm reduction in prisons, effective harm reduction services for women who inject drugs, and access to harm reduction services by young people.

The Global State of Harm Reduction 2014 continues to map the response to drug-related HIV, viral hepatitis and tuberculosis. It also integrates updated information on harm reduction services into each regional chapter, including on needle and syringe programmes (NSPs) and opioid substitution therapy (OST) provision; harm reduction services in the prison setting; access to antiretroviral therapy for people who inject drugs; regional overdose responses; policy developments; civil society developments; and information relating to funding for harm reduction.

Methodology

The information presented in the two sections of the report has been gathered using existing data sources, including research papers and reports from multilateral agencies, international non-governmental organisations, civil society and harm reduction networks, organisations of people who use drugs, and expert and academic opinion from those working on HIV, drug use and harm reduction. Harm Reduction International has also enlisted support from regional harm reduction networks and researchers to gather qualitative information on key developmentsi and to review population size estimates, data on the epidemiology of HIV and viral hepatitis among people who inject drugs, and the extent of NSP and OST provision.

Quantitative data for the tables at the beginning of each chapter in Section 2 have been obtained from a variety of sources and are referenced in each regional update. These data reflect the most recent available estimates for each country at the time of the data collection exercise (June to October 2014). Where no source was available, the data were unpublished or their reliability were questioned by civil society organisations, researchers or other experts, we have sought expert opinion to identify additional sources and verify their reliability.

Where information in the tables is dated, we have provided footnotes with a year of estimate. Unless Harm Reduction International has been able to identify more recent data, prevalence figures for viral hepatitis have been sourced from the review of reviews published by Nelson and colleagues in 2011.(4) Data from Western Europe and some countries in Eurasia has been sourced from the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) 2014 Statistical Bulletin, unless otherwise stated in the text. Footnotes and references are provided for all estimates reported, together with any discrepancies in the data.

Figures published through international reporting systems, such as those undertaken by the United Nations Office on Drugs and Crime (UNODC), the World Health Organization and the Joint United Nations Programme on HIV/AIDS (UNAIDS), may differ from those collated here due to the varying scopes of monitoring surveys and reliability criteria, and a focus on regions that may include different country classifications.

Regions have been largely identified using the coverage of regional harm reduction networks. Accordingly, this report examines Asia, Eurasia (Central and Eastern Europe and Central Asia), Western Europe, Caribbean, Latin America, North America, Oceania, Middle East and North Africa, and sub-Saharan Africa. All regional updates have been peer reviewed by experts in the field (see Acknowledgements).

Data quality

For global population size estimates of people who inject drugs and HIV epidemiology, Harm Reduction International has presented the UN Reference Group(5) data where these are the most recent available estimates, and provided data from other sources where it is reliable. These include national global AIDS progress reports submitted to UNAIDS in March 2014, biobehavioural surveillance reports, systematic reviews and academic studies. Other experts have been consulted for information on the most recent number of NSP and OST sites.

We have sought input from harm reduction networks, researchers, academics and other experts to inform our reporting on the existence and coverage of harm reduction. Where no updates were available, data from The Global State of Harm Reduction 2012: Towards an Integrated Response(3) has been included, with footnotes provided on dates of estimate where necessary.

Although population size estimates for people who inject drugs have become available at the national level for several countries since 2008 (for example, through UNAIDS global AIDS progress reports), a systematic calculation of global population size estimates has not been conducted in the context of this report.

Our data on epidemiology and coverage represent the most recent, verifiable estimates available. However, a lack of uniformity in measures, data collection methods and definitions for the estimates provided make crossnational and regional comparisons challenging.

The significant gaps in the data are an important reminder of the need for a greatly improved monitoring and data reporting system on HIV and drug use around the world.

Limitations

The report aims to provide a global snapshot of harm reduction policies and programmes, and as such has several limitations. It does not provide an extensive evaluation of the quality of the services that are in place, although where possible, it does highlight areas of concern regionally.

While The Global State of Harm Reduction 2014 aims to cover important areas for harm reduction, it focuses primarily on public health aspects of the response. The report does not document all the social and legal harms faced by people who use drugs, nor does it cover all the health harms related to substance use, including those related to alcohol and tobacco.

Report structure

Section 1 provides a global overview of harm reduction policy and programming.

Section 2 contains nine regional updates: Asia, Caribbean, Eurasia (Central and Eastern Europe and Central Asia), Latin America, Middle East and North Africa, North America, Oceania, sub-Saharan Africa and Western Europe. These examine developments in harm reduction since 2012.

References

1. Cook C, Kanaef N. Global State of Harm Reduction 2008: Mapping the Response to Drug-related HIV and Hepatitis C Epidemics. London: 2008.
2. Cook C. Global State of Harm Reduction 2010: Key Issues for Broadening the Response. London: 2010.
3. Stoicescu C. The Global State of Harm Reduction 2012: Towards an Integrated Response. London: 2012.
4. Nelson PK, Mathers BM, Cowie B, Hagan H, Des Jarlais D, Horyniak D, et al. Global epidemiology of hepatitis B and hepatitis C in people who inject drugs: results of systematic reviews. Lancet. 2011;378(9791): 571-83.
5. Mathers BM, Degenhardt L, Ali H, Wiessing L, Hickman M, Mattick RP, et al. HIV prevention, treatment, and care services for people who inject drugs: a systematic review of global, regional, and national coverage. Lancet. 2010;375(9719):1014-28.