Canada and the United States are home to more than one-tenth of all people who inject drugs worldwide. Both countries 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 have historically favoured drug law enforcement and abstinence-only approaches to drugs.
In 2009, the Obama Administration in the US lifted the 21 year ban on federal funding for needle and syringe programmes. However, NSP and OST provision in the US remains geographically inconsistent. In Canada, a law enforcement approach to illicit drugs has predominated since 2008 at the expense of evidence-based health policy. Recent developments include the introduction of mandatory minimum sentencing for drug offences and continued legal challenges to Insite, the region’s only safer injecting facility, by the federal government.
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 US 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 US are African-American or Hispanic. Neither the US nor Canada has 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 US.
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* Please refer to the table below for ranges, where these are available. The maps display midpoint averages only.
| Country/territory with reported injecting drug use | People who inject drugsa | HIV prevalence amongst people who inject drugs | Hepatitis C antibody (anti-HCV) prevalence among people who inject drugs1 | Hepatitis B surface antigen (anti-HBsAg) prevalence among people who inject drugs1 | Harm reduction responseb | ||
|---|---|---|---|---|---|---|---|
| NSPc | OSTd | DCRe | |||||
| Canada | 286,987 (220,690–375,173) | 5.82 | 64 (51–77) | nk | Y(>775)f (s)(P)3 | Y(B,M) | Y |
| United States | 1,857,354 (1,294,929–2,589,858) | 15.57 (8.74–22.4) | 73.4 (69.7–77) | 11.8 (3.5–20) | Y(186)(P) | Y(1,433)(B,BN,M) | N |
nk = not known
(S) = sub-national data
a Unless otherwise stated, data are sourced from Mathers B et al. for the Reference Group to the UN on HIV and Injecting Drug Use (2008) Global epidemiology of injecting drug use and HIV among people who inject drugs: a systematic review, Lancet, 372( 9651):1733 – 1745.
b Unless otherwise stated, data on NSP and OST coverage are sourced from Mathers B, Degenhardt L, Ali H, Wiessing L, Hickman M, Mattick RP, Myers B, Ambekar A & Strathdee SA for the Reference Group to the United Nations on HIV and Injecting Drug Use (2010) HIV prevention, treatment and care for people who inject drugs: A systematic review of global, regional and country level coverage, Lancet, 375(9719):1014–28.
c The number in brackets represents the number of operational NSP sites, including fixed sites, vending machines and mobile NSPs operating from a vehicle or through outreach workers. (P) = needles and syringes reported to be available for purchase from pharmacies or other outlets, and (NP) = needles and syringes not available for purchase.
d The number in brackets represents the number of operational OST programmes, including publicly and privately funded clinics and pharmacy dispensing programmes. (M) = methadone, (B) = buprenorphine, (BN) = buprenorphine-naloxone combination, (O) = any other form (including morphine and codeine).
e DCR = Drug consumption room, also referred to as safer injection facility (SIF).
f This figure represents the number of sites in two Canadian provinces: British Columbia and Quebec. The number of sites in other provinces was not known at publication in July 2012.
1 Nelson PK et al. (2011) Global epidemiology of hepatitis B and hepatitis C in people who inject drugs: results of systematic reviews, Lancet, 378(9791): 571–583.
2 Public Health Agency of Canada (2011) Enhanced Surveillance of Risk Behaviours among People who Inject Drugs, Phase 3 (2010–2011). Unpublished data from I-Track, December 2011. Ottawa: Public Health Agency of Canada Surveillance and Epidemiology Division, Centre for Communicable Diseases and Infection Control.
