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North America - Regional Overview
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Both Canada and the USA have key harm reduction programmes in place and support harm reduction in some aspects of national policy. However, in both countries, service provision is inconsistent and influenced by local law and policies – which in many cases favour repressive drug law enforcement and abstinence-only approaches to drugs. The USA’s Federal ban on funding for needle and syringe exchange programmes (NSPs) has had a profound impact on coverage, and there are still several areas of the country with little or no access to NSPs. Despite early leadership in opioid substitution therapy provision, access in the USA remains geographically inconsistent. Canada has recently seen a political shift from public health oriented drug policies to one focused on harsh penalties for drugs. Canada has the region’s only official safer injecting facility (in Vancouver), but this is under constant scrutiny despite numerous positive evaluations.
In both countries, it is ethnic minorities and indigenous populations that are particularly affected both by drug related harms such as HIV and hepatitis C, as well as punitive drug law enforcement. The USA has the largest prison population in the world – largely due to the mandatory minimum sentencing for drug offences. The overwhelming majority of those incarcerated on drug related offences in the USA are African-American or Hispanic. Neither the USA nor Canada have implemented a comprehensive harm reduction response in prison settings, where NSP remains unavailable in both countries. Most Canadian prisons do provide opioid substitution therapy, but it is rarely accessible for prisoners in the USA.
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Injecting Drug Use, HIV and Hepatitis C
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The following maps and table outline the current available data on injecting drug use, as well as the prevalence of HIV and hepatitis C among injecting populations in North America.
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The map below illustrates HIV prevalence among injecting drug users in countries of the region.
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The map below illustrates hepatitis C prevalence among injecting drug users in countries of the region.
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The following table provides the latest estimates of HIV and hepatitis C prevalence within injecting populations, as well as the estimated total number of injecting drug users in countries of the region.
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Countries/territory with reported injecting drug use
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| | Adult HIV prevalence amongst people who inject drugs**
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| Adult HCV prevalence amongst people who inject drugs***
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*Mathers, B. et al. Reference Group to the United Nations on HIV and injecting drug use (2008)
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The global epidemiology of injecting drug use and HIV among people who inject drugs: a systematic review. The Lancet 2008, Volume 372.
**Mathers, B. et al. Reference Group to the United Nations on HIV and injecting drug use (2008) The global epidemiology of injecting drug use and HIV among people who inject drugs: a systematic review. The Lancet 2008, Volume 372.
***Cook, C & Kanaef, N (2008) The Global State of Harm Reduction: Mapping the global response to drug-related HIV and hepatitis C epidemics. International Harm Reduction Association, UK
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Harm Reduction Policies
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Policy in both Canada and the USA has fluctuated in recent years, but both include an explicit reference to harm reduction in national policy on HIV and/or drugs, as illustrated in the map and table below.
Although policy wording is not necessarily indicative of the implementation of effective harm reduction measures in a country, it does indicate governmental commitment to tackling drug related harms and is therefore an important advocacy target.
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| Explicit reference to harm reduction policies in official documents*
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*International Harm Reduction Association (March 2009) Harm Reduction Policy and Practice Worldwide: An overview of national support for harm reduction in policy and practice [PDF:2.59KB]
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Harm Reduction Programmes
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Key harm reduction interventions – including needle and syringe programmes (NSP) and opioid substitution therapy (OST) – are available in both the USA and Canada, as illustrated in the maps and table below. In addition, Canada has a highly successful safer injecting facility – the only one in the Americas. However, huge areas of both countries remained uncovered by NSP and OST programmes. In addition, strict drug law enforcement acts as a deterrent from accessing services for many people, whilst also increasing the region’s prison population.
The USA has the largest prison population in the world – in large part due to the mandatory minimum sentencing for drug offences. The overwhelming majority of those incarcerated on drug related offences in the USA are African-American or Hispanic. Neither the USA nor Canada have implemented a comprehensive harm reduction response in prisons. Needle and syringe programmes for prisoners remain unavailable in both countries. Most Canadian prisons provide opioid substitution therapy but it remains rarely accessible for prisoners in the USA.
The following table indicates which countries have a) one or more needle and syringe exchange sites operational both in and outside prisons, b) prescription of opioid substitution therapy for maintenance in and outside of prisons c) one or more drug consumption rooms in countries of the region.
A tick in this table does not indicate the scope, quality or coverage of services. Also it should be noted that in some countries, harm reduction services, NSP in particular, are NGO-driven and may be operating without government support.
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*International Harm Reduction Association (March 2009) Harm Reduction Policy and Practice Worldwide: An overview of national support for harm reduction in policy and practice [PDF:2.59KB]
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The map below shows which countries have operational needle and syringe programmes and opioid substitution therapy programmes. Countries which have drug consumption rooms are also indicated.
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The map below shows which countries have prison-based needle and syringe exchange programmes and opioid substitution therapy prescription.
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