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Despite long-standing UN-wide recommendations for decriminalisation of drug use and possession and targets for harm reduction for prevention of HIV and viral hepatitis among people who inject drugs, globally there has been little change in the coverage of these services and the prevalence of these diseases over the past decade. Change must involve the end of stigma, discrimination, criminalisation and punitive approaches to drug use. There needs to be an urgent increase in the equitable coverage of harm reduction interventions for people who inject drugs taking into account local context, centring people and communities.