People Who Inject Drugs and Harm Reduction: a Global Perspective

Feb 05, 2024

Approximately 15 million people inject drugs, according to the best available evidence—equivalent to three in every 1,000 people on the planet.

People who inject drugs (PWID) are some of the most marginalized people in society, and vulnerable to myriad harms. Widespread stigma, discriminatory drug policies and criminalization are calamitous for social health. PWID face systemic barriers to accessing health care, leading to prolonged suffering, delayed treatment, and ill health. They frequently face police abuses and long-term ensnarement in criminal-justice systems. And drug prohibition fosters riskier drug supplies and practices, costing many lives.

People injecting drugs are particularly concentrated in North America and Eastern Europe. In both regions, more than one in every 100 people inject drugs.

It is vital that we understand people who inject drugs better in order to work for a more equitable world. To this end, my colleagues and I conducted an international study of this population, which we published in The Lancet Global Health earlier this year.

People injecting drugs are particularly concentrated in North America and Eastern Europe. In both regions, more than one in every 100 people inject drugs. Estimates of PWID in the world’s regions are as follows:

* East and Southeast Asia: 3.8 million people (0.24 percent of the adult population)

* North America: 3.3 million people (1.38 percent)

* Eastern Europe: 2.3 million people (1.08 percent)

* South Asia: 1.8 million people (0.14 percent)

* Sub-Saharan Africa: 1.3 million people (0.21 percent)

* Western Europe: 1 million people (0.35 percent)

* Latin America: 600,000 people (0.15 percent)

* Middle East and North Africa: 320,000 people (0.10 percent)

* Central Asia: 240,000 people (0.51 percent)

* Australasia: 120,000 people (0.62 percent)

* Caribbean: 96,000 people (0.31 percent)

According to our data, this global population is overwhelmingly male; about one-fifth of people who inject drugs are women. Compared to the general population, there is slightly higher reported prevalence of sexuality diversity, with more people identifying as gay, lesbian or bisexual. Unfortunately, there is a dearth of evidence on sexuality and gender identity among PWID, with barriers to disclosure in many places. While we investigated transgender identity among PWID, few countries had available data.

Almost one-third of people who inject have been incarcerated in the past year. In both Sub-Saharan Africa and Eastern Europe, 60 percent of PWID have been recently arrested.

People who inject drugs are often living in circumstances that make good health untenable and perpetuate a cycle of marginalization. Unstable housing or homelessness is alarmingly high among PWID in North America, for example, with recent experiences reported by over half of the population. PWID in South Africa and Czechia reported similarly high prevalence.

When responses to illicit drug use are highly punitive in most countries, it is unsurprising that almost one-third of people who inject have been incarcerated in the past year. In both Sub-Saharan Africa and Eastern Europe, 60 percent of PWID have been recently arrested.

Marginalized populations often overlap substantially, and vulnerabilities to certain clinical harms and trauma can be compounded. For instance, 15 percent of PWID worldwide report engaging in sex work—which is also widely criminalized—and many more report exchanging sex for drugs. This is more pronounced in countries where paid work, social security, or other methods of funding drug use are harder to obtain. In Sierra Leone and Ghana, local studies suggest that nearly everyone who injects drugs is involved in sex work.

In Russia and Estonia, every second person who injects drugs is living with HIV—equating to well over half a million people.

Despite a global expansion of HIV testing and treatment and harm reduction service availability, we have only seen a modest reduction in HIV prevalence among people who inject drugs. Worldwide, 2.3 million PWID are currently living with HIV.

Over one-third of this group lives in Eastern Europe. PWID in Belarus, Moldova and Ukraine all bear a shockingly high burden of HIV, with prevalence ranging from 20-30 percent. More alarming still is the burden in Russia and Estonia, where every second person who injects drugs is living with HIV—equating to well over half a million people. Harsh drug laws, lack of available treatment, and restrictions on harm reduction services and information make it near-impossible for Russia to reduce this prevalence.

Additionally, nearly 6 million people who inject drugs are living with the hepatitis C virus. Untreated hepatitis C can cause fatal liver damage and cancer over 15 to 20 years, but it can also compromise the immune system, leaving people unable to fight other infections. This is critical, when injecting may expose the body to bacteria or fungi that can become septic or result in other invasive and life-threatening infections. Just in the past year, one-third of PWID reported an injecting-related skin or soft tissue infection, and evidence suggests that these infections and others are rapidly increasing.

Many of the China’s 2.5 million PWID are subjected to mandatory drug treatment, entailing human rights abuses.

Given the circumstances many face, it is unsurprising that people who inject drugs often experience complex mental health disorders—issues that often go untended. In China, more than 90 percent of PWID have clinical depression. Many of the country’s 2.5 million PWID are subjected to mandatory drug treatment, entailing human rights abuses. A significant proportion of this population dies by suicide, contributing to one of China’s leading causes of death.

Globally, more than 80 percent of people who inject drugs mainly use opioids. We know that methadone and buprenorphine treatment greatly reduce chances of opioid overdose, and of contracting HIV, hepatitis C and other infections. Access to these medications also improves quality of life, mental health, and other factors that create stability for people. In the United States, medications for opioid use disorder (MOUD) are associated with savings of up to $105,000 per person in health-care and other costs.

Yet less than half of countries have these medications available, we found in our companion study of global harm reduction interventions, also published in The Lancet Global Health this year. For every 100 people injecting opioids globally, only 21 are accessing MOUD. In Central Asia, Eastern Europe, Latin America and Sub-Saharan Africa, only one out of every 100 people injecting opioids is accessing MOUD.

Globally, syringe service programs only distributed around 35 needles per person who injected in 2021—less than one needle a week.

We also know that syringe service programs (SSP) greatly reduce people’s chances of blood-borne diseases, overdose, infections and other harms. As well as syringes, they provide people with other harm reduction supplies, also connecting them with social and wider health services. We found that there are now 94 countries that have implemented such programs.

But globally, SSP only distributed around 35 needles per person who injected in 2021—less than one needle a week. Most people inject daily or more frequently, and a lack of access to sterile syringes leaves many needing to share or to re-use blunted equipment.

Only a few Latin American countries had operating SSP in 2017, and since then most of them have been shut down. National officials claim that this is due to a lack of injecting drug use; in reality, this leaves more than half a million people without sterile equipment and other harm reduction resources.

At the same time, the changing political landscape in Latin America has seen increasing enforcement of punitive drug policies. Even in Uruguay, where cannabis has been legalized for some time and the prevalence of injecting drug use is estimated to be 0.26 percent (equivalent to the global level), there is no access to SSP or MOUD.

Relatively speaking, Australia is a harm reduction haven for people who inject drugs. It’s one of five countries that are implementing both MOUD programs and SSP at a high level, according to the World Health Organization—the others are Austria, Canada, the Netherlands and Norway.

In Australia, the equivalent of 508 needles per person injecting were distributed in 2021. Besides all the health harms prevented, from 2000 to 2010, these efforts saved the country up to $140 million (US) in health care costs. Australia also offers drug-checking services, take-home naloxone, and some access to safe consumption sites. Yet we know that people in remote settings and from marginalized backgrounds still face gaping inequities. There’s also a lack of treatment options and harm reduction provisions for people injecting methamphetamine, who constitute more than half of PWID in Australia.

There is a lack of political will in many countries to provide basic overdose prevention measures. That brings us back to the costs of stigma.

Globally, very few countries have introduced overdose-prevention services such as safe consumption sites or take-home naloxone distribution. These services save lives, improve quality of life, and reduce strain on hospital and health-care department resources. Despite hundreds of thousands of people experiencing overdose (both fatal and non-fatal) each year, there is a lack of political will in many countries to provide basic prevention measures. That brings us back to the costs of stigma.

That it took more than two decades of increasing overdose fatalities, and more than 1 million lives lost, for the United States to open any safe consumption sites tells us of a devastating inertia when it comes to harm reduction.

Evidence is critical for bolstering advocacy. Global monitoring is essential in understanding the world’s harm reduction landscape and its glaring implementation gaps; it gives us clearer understanding of the complex social and structural barriers to health.

It is critical that we recognize the imperative of strongly evidenced interventions that empower people who inject drugs and mitigate suffering, bolstering community, support and compassion. Harm reduction—serving the wider goal of promoting health, justice and humanity—must be central to our global response to drug use.

Image of world cities at night via NARA & DVIDS Public Domain Archive