The period right after someone starts injecting drugs is especially risky.
People are still learning how to inject, how to make their injections safer, and how to get in touch with harm reduction providers. Because of this relative lack of experience, people are much more likely to share injecting equipment, acquire HIV and viral hepatitis, and experience opioid overdose in the one-two years following initiation. Some new initiates to injecting drug use may also not yet think of themselves as a person who injects drugs and may therefore be hesitant to engage with harm reduction services.
Despite this heightened risk, harm reduction responses tailored specifically to people newly injecting are limited. Technical guidance from UN agencies like the World Health Organisation (WHO) and others often mention “less experienced injectors” or those “new to injecting”, but fail to provide tailored support or advice on how to engage them.
In 2025, the WHO published its Needle and Syringe Programmes for People Who Inject Drugs updated operational guide, emphasising that harm reduction services are most effective when they recognise and adapt to the known diversity of injecting behaviours and associated risks.
As per the guide, “reaching less-visible groups such as new and young injectors…requires tailored, inclusive approaches”.
The release of the guide coincided with work we had recently completed in Kachin State, Myanmar, exploring the harm reduction needs of people who had initiated injecting drug use within the past 12 months.
We brought these two threads together in a commentary in the International Journal of Drug Policy, arguing that the release of the WHO guide represents a key opportunity to focus efforts on tailored harm reduction for new initiates.
Lessons from Myanmar
As one of the world’s primary producers of illegal drugs, Myanmar experiences high levels of injecting drug use and related blood borne virus infections and overdose; these harms are concentrated in areas of local drug production and trafficking and facilitated further by recent political unrest.
Uptake of injecting drug use is high. National surveillance in 2018 [report linked at the bottom of article] reported a quarter of the population of people who inject drugs had only initiated injecting within the past year, and that one in five of this group were already HIV-positive. This rapid escalation of HIV prevalence concords with research conducted by members of our group in Kachin, showing higher HIV incidence among those newer to injecting.
In response, we spoke with people who injected drugs and harm reduction service providers in Kachin State. Together, we explored the circumstances and risks surrounding peoples’ first episodes of injecting drug use. We discussed the ways in which services are provided to new initiates, learning that no tailored harm reduction interventions were offered.
When services do encounter new initiates, it is often in locations different from people who had been injecting for longer, and new initiates were often reluctant to have contact with service providers at all. Importantly, we also learned that the average age of new initiates in Kachin that have been reached by services is over 30 years, contesting standard thinking that new initiates are a young population.
We worked with our cohort to co-design harm reduction programs, exploring ways to better tailor services to the needs of new initiates. Co-designers conceived tailored harm reduction kits that would include specialised education materials and harm reduction equipment and different methods by which services could identify and engage with new initiates.
Crucially, this work recognised the expert knowledge held by those with lived experience, helping us to develop interventions with the people for whom they are intended to reach.
Time for focused harm reduction
Recognising the lack of harm reduction focus on new initiates, and following the work conducted in Kachin, our commentary echoed statements made in the new WHO operational guideline that harm reduction interventions should recognise the varied practices, risks and needs of different groups of people who inject drugs. Alongside other recognised vulnerabilities — such as gender or poly-drug use — time since initiation represents a distinct risk factor in its own right.
To have greater impact, harm reduction interventions should be tailored to address these risks and needs, and this tailoring must centre the living experiences, values and preference of people who use drugs. We ended our commentary by making two recommendations.
First, we recommended creating an international definition for new initiates. Such definitions will support service delivery, monitoring and research. When categorising groups according to public health risk, it is important to clearly articulate where risk lies. Given new initiates to injecting drug use experience heightened risk, with our research suggesting heightened risk is prolonged across at least the first one-two years of injecting drugs, time since injecting initiation must be a key consideration for focussed harm reduction programming.
The timeframe in which someone is classified as an “initiate” should capture the period of heightened risk but also be long enough to enable services an opportunity to identify, engage, and gain the trust of new initiates. While injecting risk obviously persists beyond a defined timeframe, earlier, targeted and sustained intervention would potentially reduce overall risk across a person’s lifetime.
Second, we recommended greater focus on new initiates in international technical guidance documentation. Supported by an internationally accepted definition, greater focus in guidance documents – particularly from multilateral organisations and NGOs – would facilitate development, implementation, evaluation, and refinement of tailored interventions.
Considering the strong evidence of heightened risk for new initiates, the absence of effective interventions and targeted guidance is a harm reduction policy failure. Engaging people who inject drugs as soon as possible after initiation, when vulnerability to blood-borne infections and overdose is greatest, will maximise the preventive impact of interventions, providing enduring public health outcomes across people’s lifetimes.
Following updated WHO guidance, now is the perfect time to re-frame this conversation and re-focus these efforts.
Document: Myanmar IBBS and Population size estimates among PWID 2017-2018
