Burundi is ranked 184 out of 188 on the UN Development Programme’s Human Development Index. As a result of a failed coup in 2015 and a long-lasting socioeconomic crisis, Burundi is a fragile and unstable country. The latter translates into difficulties in accessing basic services, high levels of poverty and unemployment, and prolonged history of unstable governance and weak institutions. In terms of tackling illegal drugs, Burundi has adopted a prohibitionist approach, but lacks the institutional, human resource and financial capacity to effectively respond to this phenomenon.

According to the Global Organized Crime Index (2021), Burundi is a minor actor in the drug trade, but trafficking cocaine and heroin is a reality in the country as a result of inadequate border controls. Heroin is trafficked through Burundi’s eastern border on its way to Europe by air, or via land. With regard to cocaine, Burundi is an emerging transit country that connects South American cocaine markets via the DRC and Kenya to European markets via land routes until arriving at Entebbe International Airport in Uganda concealed as luggage or cargo, or through drug mules. The drug trade used in Burundi uses the following corridor: India/Pakistan, Indian Ocean, Horn of Africa, Kenya, Tanzania, Burundi. Burundi is a producer of cannabis, which is often trafficked to neighbouring countries, such as Rwanda. In this regard, Burundi also appears to be a transit or destination country for cannabis produced by neighbouring countries, such as the DRC (Global Organized Crime Index, 2021). Finally, khat is also produced in the country.

According to the UNAIDS Laws and Policies Scorecard (2018), transgender people and sex workers are criminalized and/or prosecuted. Same-sex sexual acts are also criminalized. Finally, the possession of drugs for personal use is specified as a criminal offence. Burundi’s dichotomous approach to drug policies is rife with contradictions between public health concerns and its criminal law, which sets the course for highly punitive and repressive state responses to the drug phenomenon, especially drug use.

Within this harsh environment, few civil society organisations (CSOs) that have dared to focus their efforts on drug use, harm reduction practices and human rights have done so with little to no resources available and often in the shadows, as their interventions are often regarded as the promotion of drug use by many. According to Mainline interviews with key informants, this situation further promotes invisibility of key populations, especially people who use drugs, and makes it difficult for them to access basic services, as many people who use drugs shy away from health services when in need as a result of stigma (especially self-stigma), discrimination and violence.

These highly adverse conditions have also led to a lack of data available with regard to the number of people who use drugs in Burundi and their specific needs and individual social determinants of health.

The legal and regulatory framework applicable to the use of drugs in Burundi is made up of legal instruments under domestic and international law. In domestic law, the use of drugs and narcotics is governed by Law No. 1/05 of 22 April 2009 revising the Penal Code, Decree No. 100/150 of 20/9/1980 organising the practice of pharmacy and Ministerial Order No. 630/140 of 26 May 1989 listing substances classified as narcotics. In terms of international law, Burundi has ratified the three United Nations Conventions. Through their ratification these conventions have been incorporated into domestic law and are therefore applicable on the same footing as the provisions of domestic law.

The Burundian Penal Code has included the repression of drug use in its Title 7, Chapter 6, Articles 489 to 497, which deal with offences against public security. These provisions define the repressive regime applied to any person who uses drugs. As per the provisions set forth in Article 490 of the Penal Code, the cultivation, sale, transport, possession and consumption of narcotic drugs are prohibited, except in the cases and conditions determined under order of the Ministry of Public Health. Drug use is regulated under Article 494 of the Penal Code, which states that anyone who has, in an illicit manner, consumed or held one of the substances classified as narcotics shall be punished with penalties of one year to five years, and a fine of fifty thousand francs to one hundred thousand francs, or one of these penalties only. In addition, article 497 of the Penal Code states that for any offence involving the use of narcotics, the judge shall impose socio-judicial supervision (or some type of probation) as an additional penalty in accordance with the provisions of Articles 78 to 81 of the Penal Code: supervision and assistance measures to prevent recidivism.

As per Mainline interviews with key informants, socio-judicial supervision is rarely implemented due to the lack of institutional, human resource and financial capacity. The Penal Code does not provide for therapeutic injunction measures, as there is a lack of adequate facilities that meet the specific needs of people who use drugs. Still, in the case of young people who use drugs (provided they have not committed a crime, such as theft), parents may be asked by a judge if they are willing to hospitalize their children in a psychiatric ward – with little to no impact on their drug use (Mainline interviews with key informants).

Burundi’s national policies mentions drug treatment and a national goal of reaching universal health coverage by 2025, but harm reduction is not explicitly supported in a national strategic policy. On the other hand, it is worth mentioning that, even though at the time of this study, there were no national strategic plans on harm reduction at national level, CSO advocacy efforts focus on developing and implementing a national harm reduction strategy and opioid substitution programmes (for example, the Global Fund in Burundi’s 2021-2023 grant has requested to implement opioid agonist treatment programs in two regional public hospitals, but the country is lacking political will in addition to the lack of adequately trained people). In February 2022, CSO (including BAPUD with the support of Coalition Plus) are expected to organise a meeting with public decision makers, the Ministry of Health and experts to define a roadmap on harm reduction (Mainline interviews with key informants). Homosexuality and sex work are also punishable by law in the country. According to a baseline done by UHAI, the Ministerial Order nº 620/613 of 7/6/2011 fixing the school regulations provides that homosexuality is among "the faults which deserve a dismissal and a non-admission in any establishment" (article 9).

Finally, Burundi’s National Strategic Plan on HIV/AIDS (2014-2017) mentions specifically key populations that should be targeted for the prevention of HIV transmission, including people who use drugs and people who inject drugs. Burundi has also implemented a national policy plan for hepatitis C and a recent change in policy means that people who use drugs shall have access to hepatitis C treatment.

According to HRI (2018), even though harm reduction has not yet been implemented as a national policy in Burundi, the latter should not hinder the implementation of harm reduction efforts, especially at a community level. Still, Burundi’s national legal and policy framework allows for little to no room to implement harm reduction interventions. Therefore, most activities focus on prevention and awareness-raising efforts (Mainline interviews with key informants).

According to HRI's Global State of Harm Reduction (2018), there is no data available on the number of people who inject drugs in Burundi. However, a number of focalised studies around 2017-2019 have allowed collecting data with regard to drug use, especially injecting drug use and health-related risks. More recent grass-roots work done by UHAI collected data on different sub-groups of PWUD, including those smoking their substances. 

A rapid assessment conducted in 2017 within the context of a Global Fund regional grant identified 127 people who inject drugs in Bujumbura. However, there is ample evidence that the number of people who inject drugs is underestimated. According to BAPUD's (Burundi Association of People who Use Drugs) representative, it has been reported that over 979 people who inject drugs in Bujumbura and Gitega have been reached by an awareness-raising intervention within the framework of Global Fund supported programme work. Therefore, an updated population size estimation study should be prioritized within the 2020-2022 Global Fund country proposal for Burundi, as current studies only focus on Bujumbura. Still, according to Mainline interviews with key informants, the latter has yet to be implemented. In addition, key informants believe the government has tried to manipulate IBBS studies carried out by the Minister of Health in order to prove that Burundi has not a drug problem.

According to the above mentioned rapid assessment among 127 people who inject drugs in Bujumbura in 2017, 24.4% of people who inject drugs used at least two types of drugs during the first year of drug use and 12.6% used at least three types of drugs during the first year. The drug most commonly used as a first drug was cannabis (84.3%). However, 26 combined other drugs in the same year and 81 spent the first year using only cannabis. The reasons for switching from cannabis to other drugs were mainly that the drug was no longer effective. Many people who inject drugs use several types of drugs at the same time. For instance, 91.1% of people who inject drugs who had been injecting drugs for more than a year had used cannabis in the three months preceding the survey, whereas only 30.6% had used cocaine. Only 33.3% of the people who inject drugs surveyed (36 out of 127) had ever used cocaine. Heroin is often consumed in combination with anti-inflammatories and paracetamol in a local mix known as “boost”. Finally, synthetic drug consumption is low. As of 2021, heroin use is rising in Burundi.

According to the rapid assessment among 127 people who inject drugs in Bujumbura in 2017, a minority of participants were female (7%). On average, people who use drugs were 24 years of age (median) and with high levels of homelessness (22%) (Platt et al., 2019). In addition, the main drug injected was heroin, but between 6% and 10% injected crack/cocaine (Platt et al., 2019). The median duration of injecting was 4.5 years and 21% injected daily. Pharmacies were the main source for obtaining new needles/syringes (61%) then friends or drug dealers (27%), with health facilities the least common (5%) (Platt et al., 2019). Qualitative data indicated that cost and pharmacy restrictions selling needles/syringes to people who use drugs was related to the sharing of injecting equipment (Platt et al., 2019). In the last three months, 49% had injected with a used needle/syringe, 53% shared injecting equipment (filters, spoons, rinse water), and roughly 70% used the same needle/syringe for injecting twice or more over the same time period (Platt et al., 2019). There is only one syringe for every 10 people who inject drugs or needles collected in the bins. This is a reality experienced by many young people who use drugs in urban areas. People who inject drugs cannot afford to buy needles, their priority being purchasing drugs. 

The same rapid assessment mapped an HIV prevalence of 22% among women and 9% among men (Platt et al., 2019). Overall, there was a high prevalence of HIV and HBsAg but low prevalence of HCV among people who inject drugs (Platt et al., 2019). Participants reported poor access to drug treatment and health facilities (Platt et al., 2019). Half of participants had ever been tested for HIV, but only the minority had been tested for HCV (5%) (Platt et al., 2019). Serological testing indicated that 10% of the sample were positive for antibodies to HIV, 6% to HCV and 9% to HBsAg. There were few cases of HIV/HCV co-infection, HIV/HBsAg, and no cases of HCV/HBsAg co-infection or triple infection (Platt et al., 2019).

A baseline run by UHAI in 2021 consulted 144 people who use drugs from different sub-groups in the cities of Bujumbura Mairie, Gitega, Ngozi, Muyinga, Rumonge and Makamba. Sub groups involved PWUD living with HIV, MSM, LGBTQI, sex workers, and women/girls who use drugs. They found that the vast majority of PWUD were stigmatised and discriminated against by their families and the surrounding community, and suffered from verbal or physical violence (86%). Violence and stigma was specially high among intersecting populations of sex workers and transgender (sex workers). Sex workers also carry a high risk for STIs, as clients are not required to use condoms, and sometimes higher prices are negotiated by agreeing to unprotected sex. Unprotected sex also often resulted in unwanted pregnancies. Fear of severe stigma and physical violence restrain (young) women from searching for Sexual and Reproductive Health Rights (SRHR) services. 

Among the sample consulted by UHAI (2021), most people who use drugs had been in prison more than once, and most where unemployed, affirming they had lost their job following the accusation of irresponsibility in their tasks, absenteeism, repetitive delays, and reduced concentration. Most also had  limited access to social and health care services. Female members of the LGBTQI community reported having extra difficulties in accessing health services, since the only project supporting the community is only dedicated to MSM. About one third (45 out of 144) of the respondents consulted by UHAI were women, and it was noted that women who use drugs had a more degraded state of physical and mental health when compared to men. Despite the perceived needs, experiences of women who use drugs remain mostly unknown. 

Different from the rapid assessment from 20127, most of the respondents (71,5%) from UHAI's baseline reported to smoke or inhale their drugs, while only 15% reported to inject and 13% orally consume their substances. This shows that more attention needs to be paid to those not injecting their drugs, both in terms of mapping needs and risk behaviour and providing services to cater for their specific needs.

Unfortunately in Burundi, according to HRI's Global State of Harm Reduction (2018), there are no explicit supportive references to harm reduction in national policy documents. In addition, there are no needle and syringe programmes operational, no Opioid Agonist Treatment programme operational (OAT- both Buprenorphine and Methadone), no drug consumption rooms, and no naloxone peer distribution programme operational.

According to Mainline interviews with key informants, due to the lack of a national policy or protocol on needle and syringe exchange programmes, CSOs carry out awareness-raising activities focusing on behavioural changes and the non-sharing of needles or paraphernalia. CSOs' actions are limited to the prevention of HIV transmission and other sexually transmitted infections as a result of the repressive drug policy framework and the lack of strategies that describe how to properly distribute or collect syringes in the communities.

In 2019, in order to gain insight on Kenya’s harm reduction experience, a team of doctors, a counsellor and a national coordinator of a network of people who used drugs visited the Reach Out Center Trust in Mombasa in order to inform the development of Burundian harm reduction programme. Among other activities, they observed the delivery of OAT programmes so as to understand how methadone is dispensed. There, they also spoke with peer educators and outreach officers, and were trained on data collection for programme monitoring. According to Mainline interviews with key informants, there is no protocol for the distribution of methadone or naloxone, because there is a contradiction with the penal law. Indeed, methadone is not authorised under penal law, which is why CSOs have led advocacy efforts on the public-health front to engage in criminal law reform. According to a recent study done by UHAI, the Global Fund will support OAT in the country in the 2021-2023 grant by means of an appropriate arrangement in 2 National Hospitals of Gitega and Bujumbura.

According to a rapid assessment among 127 people who inject drugs in Bujumbura in 2019, experience of overdosing was high (40%) (Platt et al., 2019). Unfortunately, most people die without medical assistance – this is especially the case if the police arrive and everyone flees. Usually the police will take a person who overdoses to the police station rather than to a health care centre (Mainline interviews with key informants). In case of an overdose, peer educators assess the situation and accompany the person to a health facility, but each centre has its own way of dealing with an overdose, as there is no protocol (Mainline interviews with key informants). Peer educators are trained in overdose management – that is, positioning to avoid swallowing their tongue, resuscitation, etc. (Mainline interviews with key informants). But, as already mentioned, there is no naloxone peer distribution programme operational. BAPUD advocates to the government and the Global Fund for overdose management protocols to be developed and implemented, but unfortunately this is regarded as promoting drug use. 

Via the Global Fund sub-regional East Africa programme, 440,247 USD were allocated to prevention of HIV among people who inject drugs in Burundi between 2016 and 2018. During this time, pilot projects focusing on awareness-raising, screening and referrals to health care services for people who inject drugs were implemented by the Burundi Alliance against AIDS (ABS) in Burundi through the sub-regional HIV and Harm Reduction project led by the Kenyan AIDS NGOs Consortium (KANCO) (HRI, 2018). The National Strategic Plan on HIV/AIDS (2014-2017) sought to promote voluntary testing, community-based testing and provider-initiated testing among sex workers, men who have sex with men, prisoners and people who use drugs. But, according to Mainline interviews with key informants, there are no HIV self-testing programmes at community level.

According to HRI's Global State of Harm Reduction (2018), HCV testing is available in Burundi (albeit costly), including laboratory based antibody testing and antibody rapid testing (estimated cost through the public sector is 5.29 USD and private sector 6.35 USD). Viral load testing is available (albeit costly), but priced at 158.65 USD in the public sector and 132.21 USD in the private sector. It is reported that the yearly HCV treatment uptake was less than 1% of people living with chronic HCV in 2018 (HRI, 2018).

With regard to HIV, drug use and harm reduction, through the sub-regional HIV and Harm Reduction project led by the Kenyan AIDS NGOs Consortium (KANCO), Burundi was tasked to set up the Burundi Network of People who Use Drugs (BAPUD) (Mainline interviews with key informants). Even though at present there is little to no opportunities to access funding, the National Network of Youth Living with HIV (RNJ+) has donated the first equipment for the installation of BAPUD offices (Mainline interviews with key informants). BAPUD’s objective is to facilitate access to different services for people who use drugs, but with a very limited budget from the Global Fund. Overall, BAPUD has evolved in a positive manner, despite having no direct access to funding and no management of large portfolios. This is why BAPUD works in partnership with other civil society organisations (Mainline interviews with key informants).

In terms of meaningful involvement in needs assessments and training, the National Association for the Support of HIV-positive and AIDS Patients (ANSS) has signed a partnership agreement with BAPUD in 2020. Upon signing this agreement, ANSS has met with people who use drugs in outreach centres for community follow-up, care services for people who inject drugs infected with HIV, and capacity building of BAPUD members (ANSS, 2020). At present, ANSS is in the process of providing ongoing training for health care providers on medical and psychosocial care for people who use drugs (ANSS, 2020).

People who use drugs are represented in the Global Fund mechanisms, but not at government level. This is the case of the CCM, in which BAPUD’s coordinator is also the representative of key populations as well as the representative of the platform of the key populations in Burundi. BAPUD’s participation in the Country Coordinating Mechanism (CCM) has allowed the network to speak up more freely, for instance, in the National Assembly or the Presidency to conduct high-level advocacy efforts (Mainline interviews with key informants).

CSO advocacy efforts focus on developing a national harm reduction strategy and implementing opioid substitution programmes. In February 2022, CSO (including BAPUD with the support of Coalition Plus) is expected to organise a meeting with public decision makers, the Ministry of Health and experts to define a roadmap for the national harm reduction strategy (Mainline interviews with key informants).

As a result of CSO advocacy efforts, the anti-drug police have shown willingness to implement strategies that focus on drug trafficking rather than on people who use drugs, but changes in government pose a real challenge to the sustainability of the actions implemented (Mainline interviews with key informants). BAPUD also organised a 3-day meeting with police commissioners to learn more about the reality of people who use drugs, but the activity received little positive feedback because of the repressive and prohibitive mentality within the police (Mainline interviews with key informants). BAPUD, on the other hand, has organised awareness-raising activities for parliamentarians to meet with people who use drugs with positive results (Mainline interviews with key informants).

Burundi’s legal environment criminalizes people who use drugs, creating fears of drug apprehension, incarceration, and police violence, which further prevent access to health services. Discrimination and stigmatization are pervasive and severely limit access of this population to health services. Until 2017, there were no specialized public health structures or harm reduction programs to provide care and support to people who inject drugs in Burundi. According to a rapid assessment among 127 people who inject drugs in Bujumbura in 2017, the living conditions of people who inject drugs, economic insecurity and concern about lack of money mean that when they fall ill and may die for lack of medical assistance. At the time of this study, there were no specialised centres that target the specific needs of people who use drugs or health structures with expertise in harm reduction approaches. When people who use drugs seek care in public health care services, there are no protocols for the treatment of drug use developed by the Ministry of Health (Mainline interviews with key informants).

According to the rapid assessment among 127 people who inject drugs in Bujumbura in 2017, the police had mistreated 77.2% of people who inject drugs during the year preceding the survey, and 75.6% had already experienced police arrest. This pattern showed the same trend two years later. The same assessment found that the police had arrested the majority in the last 12 months (76%) (Platt et al., 2019). Most had experienced violence from the police in the same time frame (77%) (Platt et al., 2019). Existing problems related to poverty were compounded by the need to bribe the police in order to avoid arrest as well as experiencing violence from police (Platt et al., 2019).

According to Mainline interviews with key informants, the police only arrest people who use drugs – rather than focusing their resources on drug trafficking. The police use excessive force against people who use drugs. In addition, corruption is a big issue in Burundi. People who use drugs go through great lengths to pay for the drugs they use, but they don't have money to bribe the police. On the other hand, some dealers are believed to be police officers as well. As women who use drugs and who are arrested by the police do not usually have the means to bribe the police, they offer sexual services to avoid going to the police station or prison. There are many cases of rape simply because women who use drugs are vulnerable to police arrests.

At present, CSO are systematising cases of human rights violations through data collection for advocacy efforts, but they are only in the early stages of the process; therefore, little data is available (Mainline interviews with key informants). BAPUD and Coalition Plus, for example, are called when people who use drugs are arrested by the police or even imprisoned, but they do not have any support from lawyers at the moment (Mainline interviews with key informants). According to a recent baseline done by UHAI, Burundi lacks lawyers specialising in defending the rights of marginalised populations. 

As pointed by UHAI, the laws criminalising the LGBTQI+ community in Burundi coupled with the stigma the population suffers in an homophobic and transphobic society lead to higher rates of depression, anxiety,

obsessive-compulsive and phobic disorders, suicidal tendencies, self-harm and substance abuse in this population. Drug use and sex work were also often found to walk hand in hand, with women either entering sex work to pay for drug consumption, or using drugs to be able to function as sex worker. 

With regard to the criminalization of people who use drugs, they are usually arrested and imprisoned or must pay fines. The penal code punishes people who use drugs with prison sentences. Unfortunately, there is no data available on the number of people who use drugs who are imprisoned in Burundi (Mainline interviews with key informants). According to prison insider, as of 2021, there were 11,675 prisoners in the country, among whom 6.4% are women. The prison density was 278%. Finally, 50.8% of the total prison population are awaiting trial (pretrial detention).

According to a rapid assessment among 127 people who inject drugs in Bujumbura in 2019, over half of participants (55%) had ever been in prison with 34% injecting with a used needle/syringe while in prison in Burundi (Platt et al., 2019). According to HRI's Global State of Harm Reduction (2018), there are no needle and syringe programme or opioid substitution programme (both Buprenorphine and Methadone) operational in prisons.

Burundi’s National Strategic Plan on HIV/AIDS (2014-2017), the country has 11 detention houses (one of which is for women only) across the country and the size of the adult prison population as of March 2014 was 7854, of which 382 were women. There is no recent study on HIV prevalence among prisoners, but according to an IBSS survey conducted in 2011, HIV prevalence in Burundi’s prisons was 3%. Prevalence was higher among women (5%) than among men (2.3%). According to National Strategic Plan on HIV/AIDS (2014-2017), 60% of prisoners have good knowledge of the usefulness of condoms and know how to use them and have easy access. The latter includes capacity building of peer educators in each key population group on condom use.

Unfortunately, there is little to no data available with regard to the situation of women who use drugs in Burundi. Mainline was able to gather some details with regard to their situation. According to Mainline interviews with key informants, women are doubly, even triply, stigmatised by communities and their families. They even commit suicide as a result of their situation. In addition, there are many cases of rape among female people who use drugs.

According to a rapid assessment among 127 people who inject drugs in Bujumbura in 2019, a minority of participants were female in Burundi (7%). On average, people who use drugs were 24 years of age (median) in Burundi and with high levels of homelessness (22%) (Platt et al., 2019). In addition, the high rate of HIV/AIDS among people who use drugs is due to the fact that people, especially girls and women, engage in sex work to pay for the drugs. 

According to Mainline interviews with key informants, as far as pregnant women who use drugs are concerned, peer educators refer sex workers and people who use drugs to pre- and post-natal health facilities. But there are many clandestine abortions with major risks that can even result in death. In addition, there are no services specifically targeting pregnant women who use drugs and their children and there are no sexual and reproductive services targeting these women either.

There are no social services for the care of mothers and their children (Mainline interviews with key informants). There is a problem of non-recognition of children by their fathers and families. So, often, women who use drugs and their children live on the streets. Childcare is free up to 5 years of age with a birth certificate. But often women drug users do not have birth certificates for their children, and without a birth certificate, there is no access to health care (Mainline interviews with key informants).

Among the very few gender-sensitive services targeting women who use drugs, BAPUD offers services for women who use drugs in women-only focus groups (Mainline interviews with key informants). On June 26, BAPUD organises activities within the framework of the Support Don't Punish campaign for men and for women separately. BAPUD also organises activities in the framework of violence against women.

Finally, in response to the lack of gender-sensitive services targeting women who use drugs, BAPUD would like to open a care centre for women with a multidisciplinary team (i.e. a doctor, a psychologist, a social worker, etc.) in Bujumbura and in the centre of the country. The care centre for women would cost USD 50,000 per year. Unfortunately, BAPUD does not have access to the necessary funds to implement its project (Mainline interviews with key informants).

According to a rapid assessment among 127 people who inject drugs in Bujumbura in 2017, the majority (61.4%) had no jobs; 39.7% resorted to petit theft to survive and buy drugs, 11.5% relied on street begging, and 26.9% on parental or friends’ support. In addition, 24.6% of them live with their families; almost 28% are homeless or have no fixed address, while others live with friends. Approximately half of the sample had ever exchanged sex for money, drugs or goods, among whom 63% used a condom at last sex work in Burundi. In Burundi 78% of women and 49% of men had engaged in sex work (Platt et al., 2019).

In addition to the current barriers in reaching people who use drugs, as most drug users are homeless and live on the streets, according to Mainline interviews with key informants, researchers and CSOs are afraid to conduct research with key populations, especially people who use drugs. The government often regards CSOs as promoting certain behaviours, such as drug use. This is why the different interventions implemented by CSOs are extremely weak. The latter may also explain why the interventions are focused on HIV awareness and prevention rather than drug use.

According to a rapid assessment among 127 people who inject drugs in Bujumbura in 2017, people who inject drugs tend to live in hiding and do not spontaneously and openly use public health services except for those of a few CSOs that serve key populations. This results in a lack of access to curative health care, but also to preventive health care and basic information, which further increases discrimination and stigmatisation (Platt et al., 2019). According to Platt et al. (2019), barriers to accessing health services in Burundi included stigma and discrimination, as well as a lack of harm reduction services for people who inject drugs and high costs of accessing private health services. Even after a person overdoses and blacks out, and they attempt to go to the health facilities, they are delays to attend them, because society at large views them as useless or deviants, as mentioned in Mainline interviews with key informants.

There is much taboo around drug use in Burundi. Society at large tends to confuse addictions with psychiatric illnesses mainly due to a lack of information about drug use and human rights. People who use drugs are a historically invisible population and CSOs have experienced difficulties in working with this highly vulnerable population; hence, advocacy efforts focus on making the issue of drug use more digestible among decision makers, parliamentarians and Ministry of Health officials (Mainline interviews with key informants). Prejudice and stigma also affects other intersecting populations such as LGBTQI and sex workers.

Still, CSOs have been able to achieve major results in terms of advocacy efforts. During a campaign led the First Lady in 2020 on the mobilization of young people on wisdom, leadership, reproductive health, the fight against AIDS and COVID 19, representatives of people who use drugs could speak in public to decision-makers and technical and financial partners on their experiences as well as proposals for improving their living conditions. The same opportunity, however, was not given to LGBTQI and sex workers. Despite a few advances, CSOs need to move carefully in this highly repressive environment (Mainline interviews with key informants).

Based on data gathered via desk research and key informants, and on the extensive consultation done by UHAI's baseline in Burundi, we propose the following recommendations:

Advocacy & policy reform

• Advocate for decriminalisation of people who use drugs and other key populations 

• Develop specific national harm reduction policy documents focusing on drug use

• Strengthen the prevention policy concerning specific care for pregnant women and mothers dependent on drugs

• Strengthen and provide funding to grass roots organisations led by people who use drugs to support its official set up, development,  as well as advocacy interventions

• Support grass roots organisations in advocating for the removal of legal, social and cultural obstacles to the exercise of the full sexual, reproductive and human rights of all sub-groups of people who use drugs 

Awareness raising

• Awareness-raising among law enforcement and security forces with regard to stigma and discrimination of people who use drugs and other key populations

• Awareness-raising among school teachers with regard to stigma and discrimination of people who use drugs and other key populations, as well as reducing the harms of drug use

• Strengthen the skills of care providers in welcoming and caring for all sub-groups of people who use drugs, including training in human rights, sexual and reproductive health rights and harm reduction 

Community-based research and assessments

• Collect data with regard to drug use, including among other key populations: people in prison settings, transgender women, and sex workers

• Assess the needs of key populations who use drugs, specially women who use drugs, LGBTQI, and sex workers

Harm Reduction services

• Support CSOs to increase advocacy efforts to develop and implement NSP, OAT, and management of overdoses (including Naloxone distribution)

• Set up harm reduction services aimed meeting the specific needs of women who use and inject drugs, female sex workers, transgender women 

• Strengthen community-based interventions with the participation of peer educators and recognise peer work as paid staff

• Set up services to support PWUD and LBGTI communities in need of mental health support and social reintegration

• Promote vocational education for people who use drugs who have dropped out of school, and support those who are unemployed in finding a place and reintegrating to the job market 

• Provide legal empowerment and assistance to people who use drugs via grass roots organisations

Capacity building (or learning needs)

• Support the development of a pool of lawyers and peer paralegals specialising in defending the rights of marginalised populations 

• Strengthen the capacities of people who use drugs' led organisations in project management and monitoring and evaluation techniques to support the monitoring of service quality as well as organisation's autonomy to receive and manage funding