After 30 years of extensive research on human immunodeficiency virus (HIV) among persons who inject drugs (PWID), we now have a good understanding of the critical issues involved. Following the discovery of HIV in 1981, epidemics among PWID were noted in many countries, and consensus recommendations for interventions for reducing injection related HIV transmission have been developed. While high-income countries have continued to develop and implement new Harm Reduction programs, most low-/middle-income countries have implemented Harm Reduction at very low levels. Modeling of combined prevention programming including needle exchange (NSP) and antiretroviral therapy (ARV) suggests that NSP be given the highest priority. Future HIV prevention programming should continue to provide Harm Reduction programs for PWID coupled with interventions aimed at reducing sexual transmission. As HIV continues to spread in low- and middle-income countries, it is important to achieve and maintain high coverage of Harm Reduction programs in these locations. As PWID almost always experience multiple health problems, it will be important to address these multiple problems within a comprehensive approach grounded in a human rights perspective. 1. Introduction We now have three decades of experience in HIV prevention for persons who inject drugs (PWID); a vast amount of data has been collected, and much is known. In this paper we will briefly review what has been learned in these three decades and discuss what we believe are several critical issues for future research and public health practice with respect to HIV and injecting drug use. We will not, however, undertake a systematic review of the epidemiology of HIV infection among PWID nor a review of the implementation of various interventions to prevent HIV infection among PWID. For those topics, we would refer readers to the Lancet series [1] and the most recent UNAIDS Annual Report [2]. (Though we would note much of this epidemiological and service provision information needs to be updated.) We will also not examine in depth the current international economics of HIV prevention for PWID. We would note that due to the international economic recession, there is declining international support for HIV prevention for PWID. The global fund for AIDS, tuberculosis, and malaria has had considerable difficulties in raising monies from high-income countries [3, 4], and the US President’s Emergency Program for AIDS Relief (PEPFAR), the largest single donor program, is now moving towards a “country ownership” stage, in which the
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