Global coverage of interventions to prevent and manage drug-related harms among people who inject drugs:A systematic review

Background: Harm reduction and treatment programs are essential for reducing harms experienced by people who inject drugs (PWID). We aimed to update estimates from a 2017 review of global coverage of needle-syringe exchange programmes (NSPs), opioid agonist treatment (OAT), and other harm reduction services that target PWID (take-home naloxone [THN] programs, supervised consumption facilities, and drug checking services).Methods: We conducted a systematic review of available evidence from peer-reviewed and grey literature databases. Programmatic data were collected on the availability of services, as well as the number of sites, people accessing services, and equipment distributed in countries where there is evidence of injecting drug use. National estimates of coverage of OAT (i.e., number of people accessing OAT per 100 PWID) and NSP (i.e., number of needle-syringes distributed per PWID per year) were generated where available, using the most recent data. Regional and global estimates were derived and compared to the World Health Organization indicators.Findings: We included 195 studies and found there were 89 countries implementing OAT (75% of PWID population) and 91 countries implementing NSP (88% of the global PWID population). Only five countries (2% of the global PWID population) are providing high coverage of both services. Far fewer countries were found to be implementing THN programs (n=40), supervised consumption facilities (n=16), and drug checking services (n=23), with nine countries implementing all five services. Globally, we estimated there were 18 (95% uncertainty intervals [UI]=12-27) people accessing OAT per 100 PWID, and 35 (UI=24-52) needle-syringes being distributed per person who injects drugs per year. More countries reported high (OAT 24; NSP 10), moderate (OAT 8; NSP 15), and low (OAT 37; NSP 46) coverage of services compared to the previous review.Interpretation: Global coverage of OAT and NSP has increased modestly in the past five years but remains low for most countries. Programmatic data on other key harm reduction interventions are scarce.