The question of the future of US harm reduction comes at an important moment in American history. With the installation of the Obama administration, political support and public funding for harm reduction will be likely to increase. For President Obama, supporting harm reduction could be part of two campaign promises: to overhaul the health insurance system and to re-establish the United States in the community of nations. Adopting the United Nations position endorsing harm reduction would certainly contribute to the latter.
Des Jarlais et al. focus upon (i) approaches to reach injecting drug users (IDUs) and retain them in services; (ii) operational issues, especially inadequate funding; and (iii) the future of harm reduction in the United States. The success of US syringe programmes depends on both liberal policies emphasizing peer-based distribution (‘secondary’ exchange) and on the provision of diverse health and social services to needle syringe programme (NSP) participants. The overwhelming majority of investigated programmes permit and encourage secondary exchange. The effectiveness of these programmes, and their ability to leverage scarce funding, depend upon secondary exchange becoming a national modus operandi (fewer than 10% of all NSPs provided over 500 000 needles and syringes/year but accounted for 55% of the total needles and syringes distributed in 2007).
Secondary exchange engages IDUs in personal and collective prevention efforts within their own networks, dovetailing with naturally occurring communication and exchange practices common to shadow economies . The wide application of respondent-driven sampling  and peer-driven interventions  attests further to the potential of such ‘fellow networks’ for health interventions. However, secondary exchange is also a clear expression of the International Guidelines on HIV/AIDS and Human Rights  requirement that ‘the most effective responses to the epidemic grow out of people's action within their own community and national context’. Des Jarlais et al. suggest that the US harm reduction community has effectively taken this message to the streets.
Fellow network prevention approaches target IDUs and other vulnerable populations who engage in high-risk behaviours [7,8] but are unreached by health services, and who may avoid regular NSP participation [e.g. lesbian, gay, bisexual or transgender (LGBT), or underage IDUs]. Table 4 of the Des Jarlais paper  shows that US NSPs further offer an impressive range of on-site health services. As the paper does not include data on utilization or coverage of these services, this may present somewhat of a ‘Director's Cut’ but, in particular, overdose prevention/naloxone distribution is a prime example of innovative harm reduction. Overdose is an increasing concern in the European Union (EU) , but in few countries has the issue been taken on with the enthusiasm of the US harm reduction community . None the less, Ukrainian NSPs have recently started distributing naloxone, relying solely upon Global Fund support.
US harm reduction programmes are ‘becoming an alternative health-care system for injecting drug users’ and while they acknowledge important advantages, Des Jarlais et al. principally reject this development, arguing instead that a fair and just health-care system has an inherent responsibility to address the needs of IDUs. However, the future development of harm reduction in the United States is not necessarily a discussion of principles but is largely a practical issue.
Table 5 suggests that most problems encountered by SEPs emanate from lack of political commitment and funding. This situation and the grassroots model of harm reduction that has evolved in the United States are intricately connected. US harm reduction is part of a political movement against social and health-care inequalities, the continuing absence of a proper health insurance system being the most salient example. In the European Union, where political commitment and funding for harm reduction (and health insurance) are higher, the harm reduction models that have emerged are far more institutionalized than in the United States. However, despite being part of large mental health and addiction care agencies, direct service provision to IDUs and other vulnerable populations remains largely separate from mainstream health care. Indeed, as Des Jarlais et al. argue, the issue of stigma and segregated health care is ‘certainly not relevant only to the US’.
Nevertheless, harm reduction is now endorsed by the United Nations and becoming mainstream globally, making inroads in many new countries, despite insufficient funding. In response to this situation, a mixed model of harm reduction has emerged in which both grassroots harm reduction non-governmental organizations (NGOs) and governmental health services compete for scarce funding. Many, if not most, harm reduction projects in Eastern Europe or Asia can be maintained only by the grace of the Global Fund or other international support.
An essential question is how increases in funding for harm reduction in the United States (and the inevitable regulation and institutionalization that will accompany it) can be managed in a way that preserves its unique features (low threshold, addressing immediate needs, respect for human rights, consumer-driven). The EU situation suggests that within a more favourable political and funding climate the harm reduction landscape will inevitably change, with new players and a concomitant risk of dilution of key harm reduction principles and practice. With its feet in best practice and through collaborations with the scientific community, US harm reduction has reason and evidence on its side, but can it face up to the challenges that liberalization poses?
Perhaps President Obama's plan to make health insurance affordable and accessible should include a provision that allows for billing of harm reduction services to regular health insurance companies (preferably through contracting). This would place harm reduction competitively in the mainstream health market of which it will inevitably become part, and may lead to an infusion of the harm reduction philosophy into the regular health-care system, with obvious benefits. As Obama himself said during his campaign: ‘It's not just enough to change the players. We've gotta change the game’. Advancing harm reduction in the United States will require not just a change in administration, but a careful approach to the way in which harm reduction is mainstreamed.