Harm reduction is often a response to crisis. A public health approach which emphasizes reducing the negative effects of drug use rather than eliminating drug use or attaining abstinence (Riley et al., 1999) , harm reduction has been adopted around the world to mitigate the effects of epidemics and emergencies, such as the HIV/AIDS pandemic and hepatitis outbreaks, on people who use drugs (PWUD) and the broader community (Des Jarlais & Friedman, 1993; Marlatt, 1998; O'Hare, 2007) . Throughout harm reduction's long history, PWUD have effectively improved their lives in the face of public health crises. PWUD are no strangers to managing risk of infection let alone the risks of withdrawal, arrest, stigma, or marginalisation. One of the ways this is achieved is through creating intimate connections based on care, trust, and respect amongst PWUD and between PWUD and harm reduction providers.
In the face of the current crisis caused by the global COVID-19 pandemic, PWUD and harm reductionists are now faced with new challenges. A significant consequence of the pandemic is the way that individuals, communities, and organisations have been forced to rethink how they interact with each other. Formal and informal interactions are influenced by the guidelines issued by public health agencies to limit the spread of COVID-19, such as social distancing, handwashing, and masking. These guidelines, however, may be complicating public health efforts that directly affect PWUD.
In this Viewpoint, we discuss the effects of COVID-19 guidelines on the practice of harm reduction in the United States. We argue that there are several contradictions between the guidelines for curbing the transmission of COVID-19 and the highly physically, socially, and emotionally intimate nature of drug use, particularly injection drug use. These intertwined forms of intimacy often enable people to survive physically and mentally through marginalisation associated with their drug use. With public health agencies and harm reduction organisations recommending social distancing practices, such as limiting contact between peers who use drugs and other risk reduction practices, PWUD are now asked to choose between avoidance of COVID-19 and the intimacies of drug use that contribute to their survival. Moreover, we argue that the guidelines necessitate a reconfiguration of the intimacy and care so central to harm reduction, which may impede organisations from still meeting the health and social needs of the PWUD that they serve.
PWUD often rely on others to obtain the drug needed to avoid painful withdrawal symptoms, as well as to access survival resources such as food and shelter. These interdependencies are central to one's ability to maintain physical health, and they intensify the emotional intimacy of relationships between PWUD. Moreover, drug consumption practices, such as sharing injection equipment and providing injection assistance, produce and maintain physical, social, and emotional intimacy (Epele, 2011; Seear et al, 2012; Simmons & Singer, 2006) . These practices often foster a sense of social belonging painfully lacking in the lives of some PWUD (Bourgois & Schonberg, 2009) . They contribute to what anthropologist Angela Garcia (2014) calls a "relational mix": "a kind of 'ethical substance' through which care [is] performed and [social] commitment reaffirmed" (323).
Harm reduction interventions such as naloxone distribution rely on the relational mix for their effectiveness. As Rachel Faulker-Gurstein (2017) writes, these interventions are built on a "social logic" that considers social networks and contexts of drug use key resources for intervention. These approaches leverage the intimacies cultivated when people use drugs together to promote safer drug use. They validate the significance of social relationships in the lives of PWUD, rather than pathologising them. They exist in sharp contrast to interventions focused on decontextualized individuals, as well as prohibitionist policies such as drug criminalization and abstinence-only treatment and that aim to isolate PWUD from one another and the social contexts of drug use.
Social solidarity among PWUD has long been central to harm reduction practice (Zigon, 2019) . Harm reduction organisations have increasingly promoted interventions based on a social logic as opioid-related overdoses have increased sharply in the United States in the last twenty years, particularly naloxone distribution. Prior to the COVID-19 pandemic, harm reductionists distributed naloxone to PWUD and strongly advised them to never use drugs when alone. Now, harm reductionists and the people they serve must reconcile the central social logic of these interventions with public health efforts to stem the spread of COVID-19. Social distancinglimiting physical contact with others (CDC, 2020)-is a fundamental public health response to the pandemic. Social distancing guidelines render the relational mix through which PWUD enact care and social commitment-central to the lives of PWUD-a threat. As a result, PWUD may experience social distancing as further isolating and marginalizing, exacerbating the mental health consequences of COVID-19 for individuals who are already subject to deep social stigma.
Harm reduction organisations have attempted to adapt social distancing guidelines to the lives of PWUD by recommending that they minimize close contact with others and reduce the need to share injection supplies (Harm Reduction Coalition, 2020). Furthermore, innovative harm reduction practices have emerged in the pandemic. In addition to existing harm reduction programs such as the Never Use Alone hotline that provides overdose prevention by telephone ("Never Use Alone," n.d.), virtual injection supervision has allowed individuals to inject in the presence of an observer on the internet who is prepared to intervene in the event of an overdose.
Virtual peer support similarly utilizes the internet to make social support available to PWUD at a physical distance.
Yet, as anthropologist Shanti Parikh stresses, pandemics exacerbate inequalities, and prevention messages may have harmful unintended consequences (Savat, 2020) . The ability to engage in social distancing, virtual injection supervision, and virtual peer support is not equal.
The most socioeconomically marginalised PWUD may not be able to survive economically without work in formal or informal economies that exposes them to the virus. Continued social contact between PWUD, driven by the intimacies central to injection drug use, may lead these individuals to be stigmatized for failure to adhere to social distancing guidelines. Moreover, PWUD may have limited or no access to the technologies required to engage virtual support (Arcaya & Figueroa, 2017) . Thus, the public health response to the pandemic may intensify race, class, and other disparities in drug use-related harms, namely social alienation, stigma, and overdose death.
The COVID-19 pandemic presents harm reductionists with a stark challenge: to reconfigure interventions that hinge on the physical, social, and emotional intimacies of drug use in order to stem the spread of COVID-19 among PWUD who are highly vulnerable to the virus.
How can they maintain the social orientation of harm reduction that is so critical to the humane treatment of PWUD, while avoiding an individual orientation that broader public health guidelines for social distancing promote?
The pandemic provides opportunities to rapidly expand our understanding of the intimacies of drug use and harm reduction praxis. The innovative harm reduction practices that are emerging online, such as virtual peer injection supervision, highlight the trust and care possible in digital spaces when in-person contact is not viable. These digital practices of virtual intimacy, especially those driven by people with lived experience with drug use, will help us better understand how the social logics of harm reduction translate to digital social spaces. It is imperative that harm reductionists and their researcher-allies attend to how intimacy is cultivated and trust, care, and respect are communicated in these spaces in the absence of physical presence. We must ask ourselves: How is intimacy translated to digital spaces? What is gained and lost in virtual interactions? What beneficial practices are emerging that should endure beyond the pandemic? The challenges presented by COVID-19 provide the opportunity to use the digital as a new avenue for thinking about intimacy and care in harm reduction.
Commentators have noted that telehealth and virtual healthcare are "here to stay" (Bakken, 2020) . Researchers, however, warn against the "digital divide" forming because of differential access to this technology due to social and societal factors, such as economic instability and low digital literacy (Ramsetty & Adams, 2020) . As these practices become increasingly routine in healthcare and harm reduction, the inequalities they exacerbate must be addressed. Harm reduction advances both the health and human rights of PWUD, yet if it is increasingly delivered via technologies only accessible to some, inequalities will surely intensify.
This dilemma points to the urgent need to address structural barriers to technology access as a harm reduction advocacy goal.
Finally, as the pandemic is ongoing and harm reductionists continue to do their best to respond to the needs of PWUD, it is essential to attend to practices emerging from harm reductionists on the ground. While some health researchers and interventionists focus on established interventions and evidence-based practices, in this time of both crisis and opportunity it is essential to focus on the needs of PWUD and how they are creatively responding to them.
There are no simple answers to these challenges, but one thing is certain: PWUD and harm reductionists know how to navigate trials and tribulations. COVID-19 is the latest obstacle that they must face to ensure the survival of PWUD. With the United States as one of the pandemic's epicentres, harm reductionists throughout the country will need to work within public health guidelines for some time. Whether or not guidelines will be modified based on new epidemiological information, harm reductionists will continue to do the best by their clients.
We do not believe that the intimate connections upon which so much harm reduction work is based will be lost. Our hope is that the kind of care they can offer given the confines of COVID-19 can reach the PWUD who need it the most.
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Do you have any competing interests to declare; including any direct or indirect connections with the alcohol, gambling, tobacco or pharmaceutical industries?
Have you obtained ethical approval for the conduct of your study?
No because this article does not contain primary data requiring human subjects research ethics approval.