Decriminalisation, Harm Reduction, and the Economics of Justice: Why the New UNAIDS Guidance Must Be a Turning Point

Written by Catherine Cook, Executive Director, Harm Reduction International

This article is part of a series responding to the Joint United Nations Programme on HIV/AIDS, the United Nations Development Programme, and the International Network of People who Use Drugs' guidance note 'Decriminalization of drug use in the context of HIV.'

Read the companion piece by Mat Southwell and Alexei Lakhov here.

The publication of UNAIDS’ Decriminalization of Drug Use to Reduce HIV and Harm guidance marks a decisive moment at the intersection of drug policy, global health and human rights. It represents the most authoritative articulation to date from within the UN system that criminalisation is incompatible with an effective HIV response, and that decriminalisation is a critical element of one. The guidance reflects an extraordinary collaborative effort spanning civil society, community‑led networks, researchers, UN agencies and governments, and stands as the culmination of decades of advocacy to align global drug policy with evidence.

There is reason to celebrate this achievement. However, the real test begins now. Guidance alone does not save lives. Unless countries translate these recommendations into national law, policy, and practice, the harms of criminalisation will continue to undermine health systems, waste public resources, and cost lives. As Harm Reduction International's (HRI) data demonstrates, the global harm reduction response stands at a crisis point; one defined by chronic underfunding, shrinking donor commitments, and punitive drug policies that continue to absorb vast sums of public money. The UNAIDS guidance provides a clear roadmap out of this contradiction. The question is whether governments and donors will follow it.

The Global State of Harm Reduction

HRI’s monitoring of global harm reduction presents a mixed picture. More countries than ever have adopted harm reduction in policy, and a growing number have introduced OAT and NSPs, in some cases integrating them into national health systems. Some have embraced harm reduction as a philosophy rooted in compassion, human rights and dignity, not just a set of interventions. Yet in most places, criminalisation remains the dominant approach to drugs, and the scale of harm reduction services falls far short of what is needed. Dramatic shifts since 2025 have further heightened the precarity of harm reduction, underscoring the urgent need to safeguard the sustainability of programmes amid mounting threats.

Funding shifts within the broader public heath world in 2025 significantly affected harm reduction services across many countries. The US government’s PEPFAR was the second largest source of harm reduction funding in low- and middle-income countries (LMICs). When stop-work orders were announced in January 2025, the consequences were severe. As the largest contributor to the Global Fund, which remains the primary source of harm reduction funding in low- and middle-income countries, these disruptions had further devastating effects, with countries directed to reprioritise their HIV plans in light of reduced resources. Community-led efforts were among the hardest hit. More broadly, shrinking capacity within multilateral agencies and the tightening funding landscape for the human rights and advocacy infrastructure is deeply concerning, weakening monitoring and accountability functions and the push for the legal and policy reforms that harm reduction depends upon.

The human impact of these cuts has been devastating, driving preventable HIV and hepatitis C infections, deepening the overdose crisis, costing lives, and disconnecting people away from care and support they depend on, reversing hard‑won gains in access to life‑saving services.

Criminalisation as a Structural Barrier

Criminalisation of drug use remains one of the most entrenched structural barriers to harm reduction. It deters people from seeking services even where those services exist, as police harassment, arrest, and the threat of incarceration create powerful disincentives. Punitive drug laws also disproportionately target marginalised communities, deepening existing health inequities and compounding exclusion.

Criminalisation shapes how governments allocate resources. It systematically channels funding toward punishment rather than toward proven, community‑centred health and justice approaches. Beyond a policy choice, this is a systematic diversion of public funds toward punishment, with profound consequences for the reach, quality and effectiveness of harm reduction investment, and it reinforces the stigma that people who use drugs face every day.

The Economic and Human Case Against Punitive Spending

HRI has documented the chronic underfunding of harm reduction for decades. In low- and middle-income countries, even before last year’s funding cuts, only six per cent of the US$2.7 billion needed annually was available. Domestic funding covered just one third of costs, with the remainder dependent on international donors whose commitments have grown increasingly unstable.

Simultaneously, governments collectively spend over US$100 billion every year on punitive drug control. This includes policing, incarceration, militarised enforcement, and surveillance. This figure dwarf’s investment in harm reduction, which stood at just US$151 million at last count. The contradiction is stark. Governments invest in harm reduction programmes whilst simultaneously investing far more in punitive systems that undermine this health-based approach.

Even official development assistance, i.e. funding explicitly intended to support health, development, and human rights, has been directed towards narcotics control efforts that violate rights and undermine public health. This is one of the most troubling findings to emerge from HRI's research: the war on drugs is so deeply embedded in global governance that even aid budgets are not immune to its influence.

The UNAIDS guidance directly confronts this contradiction. It states unequivocally that decriminalisation is essential to achieving HIV targets and that criminalisation is incompatible with human rights obligations. Countries cannot credibly claim to support evidence-based HIV responses whilst maintaining punitive drug laws that undermine those very responses.

A Moment of Opportunity and Risk

The risks facing harm reduction right now are stark. Recent analyses have laid bare the catastrophic impact of service disruptions, including projections that cuts to OAT and NSP provision could lead to thousands of additional HIV and hepatitis C infections. Civic space is shrinking, making it harder for communities to advocate for their rights. In many countries, punitive drug policies are being intensified, shaped by heightened securitisation and anti‑rights rhetoric. The gains of recent decades are far from secure. This convergence of pressures makes the current moment more dangerous, and more consequential, than any in recent memory.

Yet there are also grounds for cautious optimism. UNAIDS, WHO and UNDP are aligned in calling for decriminalisation and scaled‑up harm reduction, and the evidence base has never been stronger. Governments now have practical, operational UN guidance outlining steps they can take towards decriminalisation, informed by real‑world examples. Community‑led movements are increasingly organised, intersectional and globally connected. Some governments are beginning to recognise the inefficiency and injustice of punitive spending, and some donors are recognising the importance of core support for community‑led and civil society organisations. And the sudden cliff edge of international funding has underscored to governments worldwide the importance, and urgency, of investing in sustainable domestic harm reduction programmes.

Divest/Invest

The Divest/Invest campaign, led by HRI, calls for a fundamental shift away from punitive response. It calls for governments and donors to divest from the failed and unjust war on drugs, including expenditure on punitive drug law enforcement, incarceration, militarised policing, and coercive treatment. When this happens, this money can be invested instead in more effective responses like harm reduction and other programmes that are rooted in community, health and justice. This approach is particularly pertinent given the current context of fiscal constraint, where governments face difficult strategic choices about resource allocation.

Translating this into meaningful change requires action across several interconnected areas: national legal reform to remove criminal penalties for drug use and possession for personal use; transparent audits of drug policy spending with resources redirected towards health and social services; domestic investment in harm reduction; protected funding and meaningful participation for civil society and community-led organisations; an end to the use of official development assistance for punitive drug control; and robust monitoring mechanisms to hold governments and donors to account.

Conclusion

The UNAIDS decriminalisation guidance is the product of decades of advocacy, evidence, and community leadership. Its true significance, however, will be determined by what follows its publication.

Harm reduction services are under serious threat, funding is contracting, and punitive approaches continue to dominate the landscape. The consequences of inaction are measurable in increased HIV and hepatitis infections, overdose deaths, and many more lives harmed by punitive drug laws and policies.

The evidence for decriminalisation is clear, and this guidance provides the clearest UN endorsement yet. Governments face a choice: they can continue to direct resources towards punitive systems that are demonstrably costly, harmful, and counterproductive. Or they can follow the evidence, honour their human rights obligations, and redirect investment towards the communities, health systems, and legal reforms that will actually make a difference.