18 February 2026
“Needle and syringe programs are essential public health interventions…yet in many countries, access to effective needle and syringe programs remains far from adequate. Services are often too limited, too vertical, too restricted, and shaped by neglect and stigma rather than by public health need. This new operational guide is designed to change that.”
These powerful words from Dr Tereza Kasaeva, Director of the Department for HIV, TB, Hepatitis and STIs at the World Health Organization, opened a recent global webinar launching WHO’s revised operational guide on needle and syringe programmes for people who inject drugs.
The webinar was co-hosted by the International Network on Health and Hepatitis in Substance Users and Médecins du Monde, and brought together WHO technical leads, community representatives, implementers, and researchers.
Below, we summarise the key takeaways from each speaker.
Dr Tereza Kasaeva, World Health Organization
Dr Kasaeva framed the revised guide as a practical response to persistent gaps in NSP access and quality.
- People who inject drugs face disproportionately high risks of HIV, viral hepatitis, other preventable infections and overdose
- In many countries, NSP services remain limited, overly restrictive, or shaped by stigma rather than public health need
- NSPs are essential interventions that prevent HIV and hepatitis C, reduce otherinjection-related infections, and support overdose prevention
- NSPs often provide the first, and sometimes only, point of contact with health services
- Effective access requires sufficient sterile equipment, flexible delivery models, and respectful, non-judgmental care
- People who inject drugs are experts and leaders in NSP design and delivery, not just service users
- Stigma, discrimination, and criminalisation directly undermine health outcomes and must be addressed
This guide is grounded in evidence, shaped by practice, and guided by human rights. We hope it will help countries strengthen and expand needles and syringe programs and accelerate progress towards our shared 2030 goals.
Dr Antons Mozalevskis, World Health Organization
Antons presented the rationale, structure, and practical focus of the revised operational guide, which is structured around five modules:
- Module 1: Assessment and planning: Guides countries to assess need, context, and feasibility, including population estimates, drug use patterns, and legal and policy environments. Emphasises acting with the best available information rather than delaying implementation while waiting for perfect data
- Module 2: Implementation models: Outlines a range of NSP delivery approaches, including fixed sites, outreach, mobile services, secondary distribution, and pharmacy-based models. Stresses flexibility and adaptation to local contexts and constraints
- Module 3: Comprehensive services: Positions NSPs as part of a broader package of health and social services, including HIV and hepatitis testing, overdose prevention, referral pathways, and psychosocial support, while recognising NSPs as a critical entry point to care
- Module 4: Monitoring and evaluation: Provides guidance on monitoring coverage, quality, and reach, with an emphasis on meaningful indicators beyond simple distribution counts. Supports continuous learning and programme improvement
- Module 5: Scaling up: Focuses on long-term integration of NSPs into national health systems, including financing, procurement, workforce planning, and policy reform. Addresses how to sustain and expand services over time.
There is a very important clarification that we emphasise in this guide: the global health sector strategy of 300 syringes per person is a population-level indicator and is not meant for programme planning. In practice, programmes often require, or people who inject drugs require, for example three syringes per person per day, which would translate into around 1,000 syringes per person per year.
Dr Annie Madden, International Network of People Who Use Drugs
Annie spoke on community values and preferences, drawing on lived experience and global practice.
- Despite strong evidence, many NSPs still fall short due to inadequate supplies, poor procurement, small budgets, and unwelcoming services
- The key question is not what works, but whose voices guide decisions
- Community involvement is the foundation of effective harm reduction, not an optional extra
- Consulting people who inject drugs builds trust, relevance, and service uptake
- Values and preferences research improve procurement decisions and the use of limited resources
- Lack of an established drug user network should not be a barrier to meaningful engagement: There is a growing amount of specialist technical assistance available to NSP services, including from international, regional, and country-based networks of people who use drugs
- Values and preferences work can catalyse the development of community networks
- Consultation must be ongoing and transparent, with clear communication about what can and cannot change
Values and preferences work is not rocket science. You don’t need a big research grant to get started. What matters is engaging meaningfully, listening carefully, and listening continuously. The revised guide includes a dedicated section and practical annex outlining a five-step process for incorporating community values and preferences into NSP planning and procurement.
Kanishk Gupta, PATH
Kanishk presented the new NSP quantification tool developed with WHO to complement the new revised guidance.
- Many NSPs fail not due to lack of intent but due to weak quantification and planning, which can push people towards needle sharing
- The new tool integrates population size estimates, values and preferences data, and coverage goals
- It uses a needs-based approach aligned with real injecting practices
- The tool is designed for ease of use by implementers without specialist modelling experience
- Services should start even without perfect data, using programmatic knowledge and community engagement
- The tool calculates needles and syringes based on user needs and does not cap at 300 people
NSP quantification is not just a calculation. It is a core, evidence-driven strategy that incorporates community values and preferences, informs procurement and coverage decisions, and directly shapes health outcomes.
Tool available in Annex 3 of guide
Professor Lisa Maher, Kirby Institute, UNSW Sydney
Lisa presented Australia as a case study of long-term NSP scale and impact.
- Australia has consistently maintained HIV prevalence below 2 per cent among people who inject drugs
- Early adoption and rapid scale-up of NSPs were central to preventing an HIV epidemic
- Harm reduction was embedded in national drug policy from the mid-1980s
- Peer-led organisations played a central role in NSP delivery and acceptability
- Australia now has more than 4,500 NSP sites using multiple delivery models, including regional remote, where pharmacies lead the way
- National coverage equals 889 needles and syringes per person per year
- Surveillance and evaluation systems have supported sustained political support
- Every dollar invested in NSPs has generated substantial health system savings
A study in 2012 found that for every dollar spent on needle and syringe programmes, there was a return of $4.26 in averted health care costs. By 2024, we estimated that each dollar spent on NSPs in Australia would return $5.82 in averted health care costs.
Thet Soe Aung, Médecins du Monde, Myanmar
Thet Soe Aung described the implementation of NSP in conflict-affected Kachin State.
- Prolonged conflict and instability have increased vulnerability to drug-related harms and a 33.8% HIV prevalence among people who inject drugs
- Médecins du Monde carried out a population size assessment in three townships, with estimates of 12,000 heroin-injecting drug users
- Peer workers are central to reaching people who would not access fixed services, with 140 peer workers each responsible for a case load of approximately 100 people who use drugs – they have high autonomy on how best to reach their clients
- NSP is implemented through four channels: outreach, drop-in centres, mobile units, and secondary distribution
- This has resulted in high NSP coverage, even in highly constrained environments
- Increased NSP distribution was associated with reduced HIV incidence
In our programme, total needle and syringe consumption reached 5.4 million for around 11,000 clients. Increased NSP distribution was associated with reduced HIV incidence.
Ehab Salah, United Nations Office on Drugs and Crime
Ehab addressed NSPs in prisons and other closed settings.
- People in prison experience significantly higher rates of HIV and viral hepatitis
- International standards require the equivalence of healthcare between prisons and the community
- NSPs are proven to reduce infection risk in custodial settings
- Only a small number of countries have implemented NSPs in prisons
- Stigma, under-resourcing, and punitive policies remain major barriers
- Health outcomes in prison affect community health after release
- NSPs in prisons are evidence-based, cost-effective, and grounded in human rights
- Needle and syringe programs in prisons are essential for reducing HIV, viral hepatitis transmission. Yet in many countries, these programs are undermined by the lack of enabling policy frameworks, the lack of trained staff, and weak integration into prison health systems
- Only 11 countries worldwide have implemented NSPS into at least one prison site
Poor health outcomes during incarceration do not end at the prison gate. They continue to undermine the health of people with drug use disorders long after release. These impacts extend into the wider community, affecting families, straining health systems, and deepening existing health inequalities.
From evidence to implementation
The revised WHO operational guide reinforces that NSPs are not optional, temporary, or peripheral interventions. They are essential, evidence-based services that require adequate coverage, community leadership, and sustained political commitment.
The revised guide provides practical tools to help countries move from policy to implementation, even in complex and resource-constrained settings.
