International Journal of Drug Policy 18 (2007) 129–135

Research paper

Implementation of harm reduction in Central and

Eastern Europe and Central Asia
Anya Sarang a,b,∗ , Raminta Stuikyte b , Roman Bykov b
a Russian Harm Reduction Network, Ilimskaya St., 4-1-38, 127576 Moscow, Russia
b Central and Eastern European Harm Reduction Network, Vilnius, Lithuania

Received 23 September 2006; received in revised form 12 November 2006; accepted 15 November 2006

Abstract

Harm reduction (HR) interventions began in Central-Eastern Europe and Central Asia in the mid-1980s with the establishment of substitution
treatment (ST) in Yugoslavia. In the mid-1990s, the first needle and syringe programmes (NSPs) opened in selected countries following the
outbreaks of HIV among injecting drug users (IDUs). The number of NSPs continues to increase via a combination of international and state
funding with large expansions made possible via the Global Fund to Fight AIDS, Tuberculosis and Malaria. While ST is still unaccepted
in several countries, others have made some progress which is especially visible in South Eastern and Central Europe and the Baltic States.
Development of regional networking including Central and Eastern European HR Network and a number of national networks helped to
coordinate joint advocacy effort and in some cases sustain HR services. Activism of drug users and people living with HIV (PLWH) increased
in the region in the last several years and helped to better link HR with the affected communities. Still a number of challenges remain
important for the movement today such as repressive drug policies; stigma and discrimination of IDUs, PLWH, sex workers and inmates,
including poor access to prevention and treatment; lack of important components of HR work such as naloxone distribution and hepatitis B
vaccination, prevention in prisons; issues of quality control; sustaining services after finishing of major international projects; reaching of
adequate coverage and others.
© 2006 Elsevier B.V. All rights reserved.

Keywords: Harm reduction; Needle and syringe programmes; Substitution treatment; Community activism; Networking; Central and Eastern Europe; Central
Asia; Russia; History

Introduction
The history of harm reduction (HR) in Central-Eastern
Europe and Central Asia (CEE/CA) began at least 18 years
ago when the first substitution treatment (ST) programmes
were established in Yugoslavia in mid-1980s (Subata &
Stuikyte, 2006) and the first needle and syringe programmes
(NSPs) opened in Poland, Slovenia and the Czech Republic
in late 1980s and early 1990s (EMCDDA, 2003). Back then
almost no country in the region reported more then few human
immunodeficiency virus (HIV) infections: in 1995 there were
still less then 30,000 cases throughout CEE/CA (Grund,
2001) and almost no cases registered among injecting drug
users (IDUs). In 1995–1996 the situation changed drastically:
∗ Corresponding author. Tel.: +7 926 5004818.
E-mail address: anyasarang@mail.ru (A. Sarang).
the region witnessed its first HIV outbreaks among IDUs in
Odessa and Nikolaev (Ukraine), Svetlogorsk (Belarus), and
Kaliningrad (Russian Federation (RF)) (Dehne, 1999; Grund,
2001). In the eastern part of the region the situation was get-
ting worse rapidly and by 1998 the number of people living
with HIV (PLWH) has increased more than eightfold (Dehne,
Grund, Khodakevich, & Kobyshcha, 1999). It became clear
that the regional explosive epidemic among IDUs (Rhodes
et al., 2002) can skyrocket and that without targeted harm
reduction activities it would be impossible to stop it.
Most countries in the region were not prepared to the
outbreaks, as the public health infrastructures were poorly
developed and weakened by the process of social–economic
transition (Rhodes & Simic, 2005). AIDS centres were
oriented towards soviet style epidemiology with its focus
on mass screening and mandatory testing of ‘risk groups’
(Dehne et al., 1999; Grund, 2001), and drug treatment facili-

0955-3959/$ – see front matter © 2006 Elsevier B.V. All rights reserved.
doi:10.1016/j.drugpo.2006.11.007
130 A. Sarang et al. / International Journal of Drug Policy 18 (2007) 129–135
ties inherited repressive soviet narcology which was closely
connected with police (Rhodes et al., 2006; Subata, 2001a).
There were few non-governmental organisations (NGOs) that
worked in the field and the legal and state support environ-
ment for these few was often not very enabling (Grund, 2001;
Rhodes & Simic, 2005).
However, the region was not the first in the world
to witness massive and rapid outbreaks of HIV among
IDUs—countries of South East Asia (Crofts, Reid, & Deany,
1998), Europe (EuroHIV, 2004) and the North America (Des
Jarlais et al., 1994) already had a similar experience. A recipe
for successful prevention existed—a combination of needle
and syringe provision, substitution treatment, outreach work
and community empowerment (Ball, 1998), but all these were
quite alien approaches to the post-soviet mentality. To avert
the HIV crisis it was necessary to challenge this mentality
and boost the energy of a few enthusiasts willing to develop
HR in the region.
The turning point in the history of resistance to the epi-
demic was establishment in 1995 of International Harm
Reduction Development Program (IHRD) of the Open Soci-
ety Institute (OSI) which aimed to assist in development
of HR initiatives in the region. In 1996 IHRD supported
12 pilot projects in Bulgaria, the Czech Republic, Hungary,
Latvia, Lithuania, Macedonia, Poland, the Slovak Republic,
and the Russian Federation (Coffin, 2002). Several projects
were supported by other international organisations, such as
a NSP bus in Saint Petersburg, RF (Medecins Du Monde)
and a peer outreach group in Moscow, RF (Medecins Sans
Frontieres, Netherlands) (Rhodes, Sarang, Bobrik, Bobkov,
& Platt, 2004) and others. Still, altogether the number of
projects was very small and their coverage inadequate.
Needle and syringe programmes
On August 27, 2003 the electronic news digest of Central
and Eastern European Harm Reduction Network (CEEHRN)
posted information about starting of a NSP in Armenia. This
was great news for CEEHRN, as now there was virtually no
country in the region without at least one NSP (CEEHRN,
2003).
The number of NSPs gradually expanded, starting from a
few programmes in early 1990s to 219 syringe exchange iden-
tified in CEEHRN review in 2004 (Bykov, Sarang, Stuikyte,
& Subata, 2004). This may not be an overwhelmingly impres-
sive figure given how large the region is, but one should
consider that for most countries establishing NSPs was not
an easy political decision. Introduction of a NSP by a country
was often taken as a signifier of a country having mobilised
towards more advanced policies to combat HIV among IDUs.
This symbolic meaning of needle exchange was sometimes
even more important than its practical effect. It was clear
from the very beginning that the small pilot projects would
not be able to curb the epidemic. The main expectation was
that countries would appreciate the results of the pilot pro-
grammes and eventually sustain and expand them out of their
own budgets. Therefore, the coverage of NSPs remained very
low in most countries while differing significantly across
the region: for example, according to CEEHRN estimates in
2001–2002, 13 syringe exchange programmes in the Czech
Republic served about 82% of the IDU population at least
once per year. At the same time, in Russia, 52 NSPs were
reaching only about 4.4% of the country IDU population
annually (Bykov et al., 2004).
Even when the idea of NSPs was accepted politically it
was difficult for countries surviving the period of economic
transition to provide any financial support to the programmes.
For example, in Kazakhstan and Belarus establishment of
NSPs was included in the national AIDS programmes and
was supposed to operate throughout each country (Belarus,
2000; Government of the Republic of Kazakhstan, 2000) in
reality it received no real funding or technical expertise.
The situation changed when the Global Fund to Fight
AIDS, Tuberculosis and Malaria (GFATM) was established
in 2001–2002. While in 2004, 8 out of 27 countries in the
region joined the European Union (EU) thus opening oppor-
tunities for albeit limited EU structural funds for public health
and social cohesion, others received an opportunity to apply
for funding to the GFATM. It is worth noting that GFATM not
only provided financial support to the countries but also mobi-
lized them politically, pushing for establishing of Country
Coordinating Mechanisms—a step which arguably improved
a coordinated response to the epidemic in many countries.
By the end of its fifth round of funding, GFATM approved 23
HIV programmes from 20 countries of the region with total
funding of almost US$ 418 million (GFATM, 2006).
Substitution treatment
While in the EU alone there was more than 450,000 people
receiving ST (EMCDDA, 2005), in CEE/CA countries its use
still remains extremely limited (Subata & Stuikyte, 2006)
(Table 1).
The first ST programmes in the region were established in
Yugoslavia (1984–1989), Slovenia (1990), the Czech Repub-
lic (1992) and Poland (1993) (EMCDDA, 2003; Subata &
Stuikyte, 2006). During the next decade, ST in these coun-
tries expanded to become national programmes. For example,
4 years after introduction of pilot programmes in Poland, ST
was approved by the national legislation. The adoption of
the official ST guidelines in the same year (1997) was fol-
lowed by establishment of more than 10 new programmes in
the period of 1998–2001 with all expenses covered by the
state (Kastelic, Zabranski, & Subata, 2003). This progress
though was not growing during the last 3 years and number
of people on ST decreased (Subata & Stuikyte, 2006). Sim-
ilarly Hungary and the Czech Republic witnessed growth of
the government funded methadone programmes. Montene-
gro and Albania are the countries where ST was introduced
the most recently, starting with 2005. Of the former Soviet
 A. Sarang et al. / International Journal of Drug Policy 18 (2007) 129–135 131

Table 1
Population and number of substitution treatment clients in countries of Central and Eastern Europe and Central Asia
Country Population, 2004a Total number of ST ST clients per 100,000 Maintenance is used
clients, end 2005 population
Albania 3,111,720 120 3.9 No, but in preparation
Armenia 3,026,089 No ST
Azerbaijan 8,306,400 95 1.1 No
Belarus 9,824,469 No ST
Bosnia and Herzegovina 3,909,479 179 4.6 No
Bulgaria 7,761,000 770 9.9 No
Croatia 4,442,350 4500 101.3 Yes
Czech Republic 10,216,050 2586 25.3 Yes (pilot project in 2 prisons)
Estonia 1,348,999 695 51.5 No
Georgia 4,517,981 70 1.5 No
Hungary 10,107,100 740 7.3 No
Kazakhstan 14,993,530 No ST
Kyrgyz Republic 5,092,802 81 1.6 No, but in preparation
Latvia 2,312,791 50 2.2 No
Lithuania 3,435,585 436 12.7 No
Macedonia, FYR 2,030,491 526 25.9 Yes
Moldova 4,217,911 12 0.3 Yes
Montenegro 650,575 50 7.7 Yes
Poland 3,818,220 720 18.9 Yes
Romania 21,684,880 570 2.6 No
Russian Federation 143,849,600 No ST
Serbia 10,700,000 325 3.0 Yes
Slovak Republic 5,382,450 n/a No
Slovenia 1,997,000 2600 130.2 Yes
Tajikistan 6,430,265 No ST
Turkmenistan 4,766,009 No ST
Ukraine 47,451,290 160 0.3 No
Uzbekistan 26,209,060 95* 0.4 No
Total 15380
* Data for July 1, 2006.
a World Development Indicators 2006, World Bank.

Union countries, the Baltic States were first to have picked
on advantages of opioid maintenance (Coffin, 2002). Already
in mid-1990s ST programmes were established in all three
Baltic countries—in Lithuania (1995), Latvia (1996), and
Estonia (1997) (Subata, 2001).
The situation was less favourable in the countries of the
Commonwealth of Independent States (CIS) where the HIV
epidemics hits IDUs the hardest and where services for
drug users are generally limited (CEEHRN, 2002; Subata
& Stuikyte, 2006). While ST was told to have existed in
the Soviet Union even in the times of the World War II
and was formally banned only in the 1970s (OHI, 2006)
the post-soviet countries are very resistant in implementing
these programmes. Analysing the roots of this resistance,
Subata (2001a) suggests several main reasons such as tra-
ditional to soviet narcology focus on abstinence as the only
goal of treatment; absence of scientific data in the Russian
language; caution regarding a possibility of diversion to the
black market in the setting of poor and corrupted medical and
law enforcement structures.
In 2001 Kyrgyzstan was the first CIS country that decided
to start ST. Mamasobyr Burhanov, the director of the central
drug treatment clinic of Osh Oblast, said “we went for it out of
desperation” since drug dependency and consequent harms
in the Central Asian countries are especially harsh given their
proximity to the main drug-producing areas (Sarang, 2003).
In 2002 piloting of methadone programmes was sanctioned
in Osh and Bishkek and first 50 clients in each city were
enrolled. As a result of its success, additional funding was
received from the United Nations agencies in February 2003,
and is now funded by GFATM and other international projects
(Subata & Stuikyte, 2006).
At the time of CEEHRN review back in 2004 substi-
tution treatment with methadone and buprenorphine was
still not available in nine countries of the region: Albania,
Armenia, Belarus, Georgia, Kazakhstan, Russia, Tajikistan,
Turkmenistan, and Uzbekistan.1 Two years later, only three
countries in the region, namely Russia, Tajikistan, and Turk-
menistan still legally ban it (Parfitt, 2006). Difficulties in
starting the programmes are also reported from Arme-
nia, Belarus and Kazakhstan (Grigoryan, 2006; Subata &
Stuikyte, 2006). In other countries the situation changed
and first patients started or are preparing for their ther-
apy. Methadone and buprenorphine have been registered
1 Also substitution treatment started in Montenegro only in 2005, however
in 2003 it was part of the country of Serbia and Montenegro and announced
its independency in 2006.
132 A. Sarang et al. / International Journal of Drug Policy 18 (2007) 129–135
in Ukraine and the pilot programmes with buprenorphine
started. The aims of these programmes, among others, include
improved adherence to antiretroviral HIV therapy which in
the only last 4 months of 2005 expanded from few tens to 200
patients through the GFATM-funded national programme;
there are plans to expand this number to up to 7000 by the
end of 2008 which also depends on how soon methadone
is introduced and all technical procedures settled (IHRD,
2006; Subata & Stuikyte, 2006). Pilot projects started in
Moldova and Azerbaijan (2004), Georgia (2005), and Uzbek-
istan (2006) (CEEHRN, 2005b, 2006; Subata & Stuikyte,
2006).
Speaking quantitatively, according to 2004 CEEHRN
review, 76 programmes were identified in the region. In
2004, 6565 patients in CEE/CA countries were receiving
methadone or buprenorphine increasing to more than 15,000
in the middle of 2006 (Subata & Stuikyte, 2006). However,
as the estimates for number of IDUs in the region vary from
2.3 to 3.2 m (Aceijas, Stimson, Hickman, & Rhodes, 2004)
we see that the volume of ST provision is highly inadequate.
Besides, the main share of patients comes from just a few
countries: in 2005 Croatia, the Czech Republic and Slovenia
alone offered substitution treatment to 9686 patients, or more
than 60% of all patients in CEE/CA and making ST acces-
sible to 20% or more estimated IDUs in those countries. In
other states, even those with 10 years of successful history
with ST, a number of clients on ST does not exceed 1000
per country and has less than 5% national coverage of esti-
mated IDUs. Lithuania, where HR is part of national HIV
and drug strategies and whose strategies is widely used by
other former Soviet Union countries in understanding, intro-
ducing and developing ST, experienced major political crisis
in 2005 when newly elected politicians threatened future of
ST. While this slam to HR was successfully reversed by inter-
national and national stakeholders in next 6–9 months, it is
demonstration that in most of the region ST successes remain
fragile.
Situation with resistance to ST in Russia deserves a spe-
cial story which is told in this issue by Mendelevich and
co-workers (2006). Acceptance of ST by almost all of Rus-
sia’s neighbours as well as its own grave drugs situation does
not inspire the country’s bureaucrats to move away from their
rigid positions inhibiting access to effective HIV/drug pre-
vention and treatment to the country’s estimated 1.8 m opiate
dependent individuals (Altshuler, 2001).
There is some good news, too. In Slovenia, Croatia and
a number of other countries, patients have free access to
methadone. Poland has led the way in terms of integrated
models of treatment and care for HIV positive IDUs: in
the city of Chorzow the AIDS Centre was one of the first
institutions in the region that started to offer ST as an
integrated component of HIV treatment for opiate depen-
dent patients (CEEHRN, 2004a). In Slovenia, Croatia, and
Lithuania, methadone is delivered through the primary care
system, making it more accessible for patients. Slovenia has
methadone in prisons as do Croatia, Moldova, Poland, Serbia
and the Czech Republic (Sarang, Bykov, Subata, & Stuikyte,
2004; Subata & Stuikyte, 2006). In August, 2005 an inno-
vative project in Albania started to offer methadone in the
community settings, from the premises of an NGO “Aksion
Plus” in Tirana, so far the only NGO-based ST project in the
region (CEEHRN, 2005a).
Still, ST remains one of the most sensitive issues. Well
aware of this problem, in the beginning of 2004 CEEHRN
with their partners initiated their first letter to the Direc-
tor General of the World Health Organization (WHO)
(CEEHRN, 2004b) pointing out the need to address poor
access to HIV treatment for IDUs within WHO “3 × 5” ini-
tiative (WHO, 2003). Over 200 organisations from all over
the world signed the letter which particularly discussed oppo-
sition to ST by some national governments and suggestion to
include methadone and buprenorphine into the WHO Model
List of Essential Medicines (MLEM). After a year of careful
consideration and collection of international evidence, WHO
Expert Committee on the Use of Essential Drugs included
both substances into the MLEM sending “a clear message to
nations confronted by IDU-driven HIV epidemics that these
drugs are regarded as essential components of HIV preven-
tion and treatment for IDUs” (Kerr, Wodak, Elliot, Montaner,
& Wood, 2004).
Networking
The first few enthusiasts of harm reduction in the region
strongly felt the need for joint advocacy and mutual sup-
port. In 1997, 18 harm reduction activists met in Warsaw,
Poland, to discuss the ways of collaboration and support, of
bridging the geographical divides and bringing professional,
activists and people living with HIV/AIDS in the region
together. After 3 days of passionate discussions the Central
and Eastern European Harm Reduction Network was born
(Subata, 2001b). The network, then based in Hungary, started
producing English and Russian language newsletters and sup-
port electronic listserve. In 2001 the Secretariat of CEEHRN
moved to Vilnius, Lithuania and the first professional staff
fully dedicated to the network activities was hired.
The membership of the network was always open and
did not require any formal obligations so in several years
CEEHRN grew to unite over 200 organisations and indi-
viduals from 9 sub-regions and 45 international supporters
(Simon, 2005). The network became an important infor-
mation, training and advocacy resource and increasingly a
platform for the voices and activism of PLWH and IDUs.
The network has provided ongoing monitoring of national
drug and HIV policies, supported comprehensive databases
of regional services and experts and has helped to mobi-
lize national and regional community responses, coordinated
highly publicized actions through the network of friendly
media (Simon, 2005).
Provided with a good example of united work on the
regional level, a number of national and sub-regional HR
 A. Sarang et al. / International Journal of Drug Policy 18 (2007) 129–135
networks have been established. Among them the Macedo-
nian, Polish, Romanian, Russian, Kyrgyz, Tajik, Kazakhstan,
Georgian, Central Asian HR networks, Ukrainian HR Asso-
ciation, South Eastern European and Adriatic Addiction
Treatment Network and others. HR networks proved instru-
mental in many cases of advocacy, as well as sustaining HR
activities in their countries. For example, in 2005, the Rus-
sian HR Network alarmed the international community on the
problem of financial gap when ‘old’ donors, such as the UK
Department for International Development, were no longer
interested in supporting services for IDUs, and the ‘new’
funding, coming from the GFATM was not enough to support
even existing services, let alone expand them. Having failed
to attract any interest from bilateral donors and UN agen-
cies, the network together with the Community of PLWH in
Moscow and drug users organisation “Kolodets” applied to
the GFATM aiming exclusively at support of 28 existing and
5 new HR services and community development. Although
the application was not approved by Russia’s CCM which
apparently did not appreciate such focus on HR services, it
has been approved as a non-CCM proposal by the GFATM
and on 15 August 2006 the Euro 3.1 m grant for the first 2
years of the project has been signed off by the fund (RHRN,
2006).
Community activism
Involvement of people who use drugs (PWUD) and PLHW
in HR work and advocacy is an important feature of current
history in the region. While started not so long ago it seems
a key feature for success of HR work in the future.
Development of PWUD groups in the region started with
the help of their western comrades: in 2000 during the
International Drug User Day activists from western Europe
decided that “Europe would never be united in the way drug
users wished if the people from CEE/fSU did not partici-
pate in drug user activism, too” (Naydenova, 2004). Having
decided that, activists from the Dutch organisation LSD
started their technical assistance to PWUD organisations in
CEE/CA using small IHRD seed funding aimed primarily to
official registration of the groups and starting off their activi-
ties. If in 2002 there was a handful number of PWUD groups,
today more 25 PWUD organisation are operating in the region
and starting to have important effects both on the concept of
HR in the region and on the concept of HIV prevention, care
and treatment globally as people who use drugs become more
politically organised and acquire assertive expert voices. The
activities varies depending on the groups own interests and
situation in their countries. For example, in Macedonia, a
group called ‘PASSAGE’ organized workshops for public
health specialists with the aim to deliver users/patients per-
spective on the respected services (Dokuzovski, 2004), in
Kyrgyzstan a local group of HIV positive drug users ‘Renais-
sance +’ started a support group in the city prison within the
HIV ward that houses all of Kyrgyzstan’s HIV-positive pris-
133
oners (Tokombaev, 2004) and the Hampseed Association in
Hungary set a goal to fight for a more sensible cannabis pol-
icy and organized rallies and an annual charity ball in support
of a local harm reduction project (Sarosi, 2004).
In 2003 a first large scale grant programme to support com-
munity organisations was launched by the Tides Foundation
in partnership with OSI and the Ford Foundation to fund com-
munity activist programmes aiming to improve access to HIV
treatment and overcome stigma toward PLWH and IDUs.
This grant scheme was quite innovative as it allowed for com-
munity activists themselves to set priorities for grantmaking,
determine the process for request for proposals, allocate fund-
ing and monitor projects activities. This was made possible by
creation of the community review panel (CRP) elected by the
communities themselves (Schwartz, 2004). Similar process
to support DU groups specifically was launched by IHRD
and today OSI network provides direct support to more than
20 such organisations.
In 2003–2004, during the needs assessment survey by
CEEHRN and a Lithuanian drug users organisation IDUMS,
41 groups were identified in the region. Among them 15 were
primarily DU groups, 19 PLWH organizations; and 6 ones
were for HIV-positive drug users. Their activities varied from
self-support, information campaigns, trainings and seminars,
to advocacy for just drug policies and rights of people in drug
treatment, from monitoring of access to services, challenging
drug laws and direct actions to direct service provision includ-
ing HR, HIV treatment literacy and support, representation
of drug users in courts, other legal services, etc. Fourteen
assessed groups participated in AIDS decision making struc-
tures at national or local level, however, none of groups were
part of national structures on drug policy (Butkus & Stuikyte,
2004).
Some of the community organisations, such as Ukrainian
Network of PLWH became prominent players not only at the
national level, but also on the international arena, advocating
for the needs of PLWHA, affected communities and better
health policies and in 2006 won the international Red Ribbon
award for its work in addressing stigma and discrimination
related to HIV/AIDS (UNDP, 2006).
Two recent and important developments included estab-
lishment of the East Europe and Central Asia Union of PLWH
as well as support of a number of drug users organisations in
their advocacy activities by IHRD.
Instead of conclusion
Harm reduction went a long way in the region. From just a
few programmes in early 1990s to networks of harm reduction
projects and national programmes of HIV prevention among
IDUs in mid-2000s. The number and geographical coverage
of NSPs increased as did political support for this form of
prevention. While ST is still unaccepted in some countries,
like Russia, others have progressed to this or that extent in
implementing opioid maintenance. Activism of drug users
134 A. Sarang et al. / International Journal of Drug Policy 18 (2007) 129–135
and PLWH has helped to link harm reduction activities with
the communities which they addressed and enabled affected
people to participate in prevention and treatment work. HR
transforms into relatively institutionalised approaches rein-
forced by activism spirit and hard work of people in diverse
communities.
Being a part of an anniversary issue this article focuses
rather on achievements of HR work in the region. How-
ever, the list of challenges currently faced by CEE/CA harm
reductionists would almost certainly be longer than the list
of achievements. To name just a few, but most serious ones:
harsh drug policies and legal environment which remains the
major constraint in the successful implementation of harm
reduction projects and is the major cause of poor quality of life
of people who use illicit drugs in the region as well as in other
countries of the world; persisting stigma and discrimination
of IDUs and other vulnerable groups including poor access to
health services, especially to treatment of HIV and hepatitis
C; absence of some important components of harm reduc-
tion work, for example naloxone distribution, and hepatitis
B vaccination, difficulties with implementing harm reduction
measures in prisons where drugs are used and needles shared;
issues of sustainability of interventions, especially when large
international donors such as GFATM cease their support;
quality of harm reduction services and many others. Many
of these challenges mean broadening harm reduction agenda
and constituencies and going further beyond traditional con-
cept of harm reduction being HIV prevention through needle
exchange scheme and outreach. In some cases, existing inter-
national and national funding if purposively advocated could
help to address at least some of those challenges, includ-
ing getting hepatitis B vaccination or hepatitis C treatment.
As struggling among complex issues of sustainability, qual-
ity, coverage and range of services and other issues does not
give an easy answer, the harm reduction movement working
closely with PWUD, PLWH, and other stakeholders will have
to set the priorities for addressing the abovelisted challenges
and work in advocacy and services even harder in the future.
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