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Rapid Assessment and Response in Karachi, Pakistan

Mainline implemented a Rapid Assessment and Response (RAR) approach, together with Research and Development Solutions (RADS). The goal is to provide recommendations for improving harm reduction interventions and services in the field of health promotion of people who use drugs, focusing on harm reduction. The assessment seeks to identify and understand groups of people who use and inject drugs that may not have access to existing services, assess their needs and challenges, and propose strategies for outreach and service improvement.


research questions

  • Are there (sub)groups of people who inject and use drugs in Karachi currently not accessing harm reduction, HIV, and other drug use related services?
  • Among these ‘hidden’ groups of potential service beneficiaries, what are their reasons for not accessing services?
  • What are effective strategies to reach these (sub) groups, and how could existing outreach strategies be expanded to improve reach?
  • How can existing harm reduction and HIV services be adjusted to improve the fit between potential beneficiaries and the available interventions?


Fieldwork revealed a varied drug scene in Karachi. People who use drugs select hotspots for open drug use based on factors such as privacy from authorities, easy access to their drug of choice, the presence of friendly peers, and nearby access to free food. Visited hotspots ranged from isolated and ruined buildings, graveyards, and parks to crowded community neighborhoods and busy roads. Hotspots were often divided into those where people inject drugs and those where they do not, although the population would also be mixed in some spots. A high number of people not injecting (but using) drugs was found in the hotspots.

With harm reduction services primarily targeting people who inject drugs, this new group is left underserved. Vulnerability and violence were prevalent among people who use drugs, with experiences of stigma, abuse, and violence from the police, communities, and drug sellers. Overdose incidents and bacterial infections are also concerns, with limited knowledge on prevention and treatment.


  1. Expand the harm reduction program to include people who smoke heroin and methamphetamines, given recent shifts in drug use patterns and the associated higher HIV risk.
  2. Broaden the focus of the harm reduction program beyond HIV and infectious diseases to provide comprehensive support to street-based groups, including wound care, dental care, mental health, and hygiene services, creating new indicators of success beyond HIV and aligning with global guidelines for harm reduction.
  1. Provide a comprehensive harm reduction package, including primary healthcare services, basic medicines, dental care, opioid agonist treatment, education materials, basic needs support, safety measures, peer support networks, and improved access to Antiretroviral Therapy (ART) and Pre-Exposure Prophylaxis (PreP).
  2. Reduce cases of preventable death by identifying causes of death among the assisted population, training staff and beneficiaries in overdose prevention, providing Naloxone for overdose response, and offering tests and antibiotics for common bacterial infections.
  3. Reduce loss to follow-up by cross-checking program data on individuals leaving the program, tracking detained clients, and monitoring migration patterns.
  4. Diversify outreach methods by investing in peer-based outreach models, extending outreach efforts to underserved subgroups, reintroducing centralized safe spaces, expanding outreach in prison settings, enhancing family support, and establishing strong partnerships with organizations serving vulnerable populations.
  5. Develop partnerships with drug rehabilitation centers and law enforcement officers to facilitate integrated care, ensure accessibility of rehabilitation services, sensitization of law enforcement, and cooperation with jails and correctional facilities.
  6. Introduce community assessments to address data deficiencies, enhance data quality, and investigate topics such as causes of death, violence experienced by people who use drugs, quality standards of rehabilitation facilities, emerging drug trends, and mental health support.
  7. Support awareness campaigns to combat stigma related to drug use, HIV, and dependency, integrating religious and cultural values, offering sensitization training, increasing social mobilizers, and promoting nuanced public debates.
  8. Monitor the drug market to proactively address challenges, predict drug trends, mitigate overdose risks, prioritize public health over enforcement, and establish contingency plans.
  9. Policy recommendations include setting quality standards for rehabilitation services, initiating prison reform to reduce incarceration for drug related crimes, especially drug use, and reforming police practices to reduce arbitrary arrests and raids.

You can request more information about this project via Machteld Busz.

Machteld Busz
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Support and finance

This project is done in collaboration with Research and Development Solutions (RADS). The project is funded via UNDP Pakistan, through Global Fund’s grant for HIV.


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