1. The global state of harm reduction funding
Catherine Cook
Senior Researcher
Harm Reduction International

2. Global availability of needle and syringe programmes
In 2014, the global response to HIV and hepatitis C related to unsafe injecting continued was still poor.
In terms of service provision, globally only 90 countries implement needle and syringe programmes (shown in red), and only 8 countries have any NSPs within prisons.
NSP in the community
NSP in the community and prison
NSP not available

3. Global availability of opioid substitution programmes
80 countries provide opioid substitution therapy and 43 of these have some provision of OST within prisons.
Where programmes are operating, coverage remains uneven in some countries very few people are reached, so inclusion on these maps doesn’t equate to scaled up responses.
There’s no map for this, but 91 countries include harm reduction in their national policy. But in many of these countries, there remain punitive drug policy measures in place, that act as a major barrier to service delivery.
So harm reduction coverage is poor, despite compelling evidence of its effectiveness and cost-effectiveness. Implementing harm reduction is one of the most effective and strategic things we can do to end AIDS, yet it remains one of the programme efforts most neglected.

4. Harm Reduction Coverage
We’ve been talking about a funding ‘crisis’ for harm reduction in our work. But in truth, harm reduction funding in many countries has always been so low that it could be said that it’s always been in crisis. We are hoping to have updated figures soon, but in 2010, just two needles and syringes were distributed per person who inject drugs per month. Just 8% of people who inject drugs had access to opioid substitution therapy (OST) . And only 4% of those living with HIV received anti-retroviral treatment.

5. Need vs spend
The truth is we don’t know what is being spent on HR at the global level with any certainty, because tracking spend is very challenging.
HRI looked at international donor investment in low and middle income countries and found that just US$ 160 million was invested. This was not easy information to gather. While donors like the Global Fund have information on their harm reduction spend within their online reports, others are not so transparent. To complicate matters further they all disaggregate their budgets differently and have different definitions of what constitutes harm reduction. So the US$ 160 million figure is a best guess. But even if it was four times that, it still would not even be close to what UNAIDS estimated the required amount to be.
US$2.3 billion was estimated to be needed in That figure just includes basic harm reduction services, without the ‘critical enablers’ like community mobilisation and advocacy for legal and policy reform. $160 million is just 7% of what is needed.
Where national governments are investing in harm reduction, this information is equally difficult to find. Most government reports to UNAIDS don’t include this, and those that do usually just have a top-level figure, which doesn’t tell us how and where funds were spent.
There is a need for increased transparency and agreed upon definitions among national governments and international donors in order to fully understand what is being spent. Need for leadership from UNAIDS/UNODC/WHO on this. These technical agencies need to be producing data that is showing the world how much is being invested in harm reduction, and where the gaps are. Instead we have seen civil society recognise the urgent need for this information and prioritise work in this area.

6. Harm reduction – dependent on international donors
Here we can see that harm reduction, particularly in Asia Pacific and Eastern Europe and Central Asia, is highly dependent on international donors. The donor investment has made a huge impact over the past decade – for example over 30,000 HIV infections averted in 10 years of harm reduction in Vietnam funded by DFID, World Bank and Global Fund. But these gains are now precarious as international donor trends are shifting funding away from middle-income to low-income countries. This is happening despite the fact that the majority of people who inject drugs (approximately 75 per cent) live in middle income countries.
Donor governments are relying on their contributions to multilateral agencies such as The Global Fund to Fight AIDS, Tuberculosis and Malaria to meet their key population funding targets. Yet Global Fund policy has also shifted with severe consequences for harm reduction in some countries.
National govts are investing more in their national HIV responses. In fact, they put in a bigger proportion now that international donors. Sadly, this doesn’t apply to domestic investment in harm reduction, which remains minimal in the majority of countries. UNAIDS reported that of ten priority countries for harm reduction, national government investment was less than 5% of overall spending on HIV. Many governments ignore the evidence of what works and don’t prioritise harm reduction programmes.
Underpinning many of these resource gaps lies a fundamental inhibiting factor – that harm reduction services are often politically unpopular. Stigmatising attitudes towards people who inject drugs and harm reduction exist in both public and community discourse, and amongst decision makers. The inhibit investment in harm reduction.

7. Global Fund investments in harm reduction R1-R10 (2002 – 2010)
Between 2002 and 2010 the GF rapidly became the largest donor of harm reduction services. This was one of the most significant developments for harm reduction.
When the NFM and the change in funding policy were introduced there were alarming indications for harm reduction. 24 of 58 countries that had received harm reduction money were no longer eligible or could not receive new money. Only 10 countries (5 MICs) were eligible for funding for critical enablers, essential and underfunded work. Of course, it is still the largest harm reduction donor and still prioritises this work. New funding for harm reduction will be available from GF in sub-Saharan Africa. But less money is available for harm reduction in middle-income countries and this is a problem, e.g. in Ukraine and Vietnam where funding is reducing without signs of successful transitions to nationally funded programmes. Where donors are retreating we need slow and responsible transitions so that national governments can prepare and take on this funding themselves. I’m not going to talk too much about the transitions or GF as we will hear more on this later.

8. International donor trends
DFID bilateral funding for harm reduction - reducing dramatically
Australian Government funding - reducing
Dutch Government funding – maintaining their commitment
PEPFAR funding – national ownership and technical support rather than programming
DFID – from one of the biggest harm reduction programme funders in 2007/2008 to nothing in 2016.
Australian government funding – large investment in harm reduction programmes in Asia Pacific region – very much reduced.
Dutch government funding – showcased in the report as maintaining their commitment to harm reduction and very much still present in middle-income countries.
PEPFAR – transitioning towards national ownership and technical support – less funding available for programming.
Important to add that many of these donors are also funding the GF, but whilst the GF funding formula is limiting investment in harm reduction in middle income countries, so too will these donors’ investments in harm reduction.

9. The way forward
Keep the global fund global
Invest strategically in harm reduction
Increase national harm reduction investment
Rebalance resources #10by20
In the funding crisis report, along with the International HIV/AIDS Alliance and IDPC, we called for the global fund to be kept global. To ensure that allocations factored in inequalities, willingness of governments to pay and policy barriers in a country, not simply country income classification and disease burden.
For investment to be strategic – for international donor to invest where national governments won’t or can’t, and to ensure responsible exit strategies and transitions to domestically funded programmes.
Of course, for governments to fund their national harm reduction programmes
And to rebalance resources from drug control and criminalisation to health and harm reduction
An estimated $100 billion is spent each year on drug control. A very small percentage of this could fully fund harm reduction in all countries.
The #10by20 campaign is the harm reduction sector’s global campaign to increase national and international financial support for harm reduction.
We are calling on governments to redirect 10 per cent of the resources that they currently spend on the ineffective punitive responses to drugs to harm reduction by 2020.

10. Civil society leading the way
EHRN Global Fund project
Asia Action (Vietnam, India, Malaysia, Cambodia, Indonesia & China)
Harm Reduction Works! (28 EU Member States; 7 country case studies - Portugal, Greece, Italy, Czech Republic, Hungary, Estonia and Lithuania)

11. Thank you!
Catherine Cook