"Syringe exchange programs (SEPs) provide sterile syringes in exchange for used syringes to reduce transmission of human immunodeficiency virus (HIV) and other bloodborne infections associated with reuse of contaminated syringes by injection-drug users (IDUs). . . . SEPs can help prevent bloodborne pathogen transmission by increasing access to sterile syringes among IDUs and enabling safe disposal of used syringes. Often, programs also provide other public health services, such as HIV testing, risk-reduction education, and referrals for substance-abuse treatment."

"For injecting drug users who cannot gain access to treatment or are not ready to consider it, multi-component HIV prevention programs that include sterile needle and syringe access reduce drug-related HIV risk behavior, including self-reported sharing of needles and syringes, unsafe injecting and disposal practices, and frequency of injection. Sterile needle and syringe access may include needle and syringe exchange (NSE) or the legal, accessible, and economical sale of needles and syringes through pharmacies, voucher schemes, and physician prescription programs. Other components of multi-component HIV prevention programs may include outreach, education in risk reduction, HIV voluntary counseling and testing, condom distribution, distribution of bleach and education on needle disinfection, and referrals to substance abuse treatment and other health and social services."

"After reviewing all of the research to date, the senior scientists of the Department and I have unanimously agreed that there is conclusive scientific evidence that syringe exchange programs, as part of a comprehensive HIV prevention strategy, are an effective public health intervention that reduces the transmission of HIV and does not encourage the use of illegal drugs."

"Programs that provide access to sterile syringes have been proven time and again to reduce HIV transmission without either encouraging drug use or increasing drug related crime. Syringe exchange, as well as similar measures such as nonprescription pharmacy sale of syringes, is an effective and life-saving health intervention. Yet syringe exchange is banned in much of the United States and, where it is allowed, is obstructed by laws forbidding the possession of drug paraphernalia. Other modes of syringe access, such as nonprescription pharmacy sale of syringes, are as of this writing forbidden in five states: California, Massachusetts, New Jersey, Delaware, and Pennsylvania. Almost all fifty states have enacted drug paraphernalia laws similar to model legislation written by the Drug Enforcement Agency in 1979 under President Jimmy Carter. Drug paraphernalia laws are encouraged by United Nations anti-drug conventions, which call on governments to take aggressive law enforcement measures against illicit drug use."

"Although most US states have legal restrictions on the sale and possession of syringes, pharmaceutical practice guidelines often allow pharmacists discretion in syringe sales decisions; this may lead to wide variation in syringe sales by individual pharmacists and to discrimination based on gender, age, race, ethnicity, or socioeconomic status. Individual-level factors associated with pharmacists' relative willingness to sell syringes include familiarity with customers; concerns about deception, disease transmission, improperly discarded syringes, and staff and customer safety; business concerns, including fear of theft and harassment of other customers by IDU patrons; and fear of increased drug use because of easier syringe access."

"Studies on behalf of the US government conducted by the National Commission on AIDS, the University of California and the Centers for Disease Control and Prevention, the National Academy of Science, and the Office of Technology Assessment all concluded that syringe prescription and drug paraphernalia laws should be overturned or modified to allow IDUs to purchase, possess, and exchange sterile syringes."

"Pediatricians should advocate for unencumbered access to sterile syringes and improved knowledge about decontamination of injection equipment. Physicians should be knowledgeable about their states' statutes regarding possession of syringes and needles and available mechanisms for procurement. These programs should be encouraged, expanded, and linked to drug treatment and other HIV-1 risk-reduction education. It is important that these programs be conducted within the context of continuing research to document effectiveness and clarify factors that seem linked to desired outcomes."

"Anti-OTC laws [laws against the over-the-counter sale or purchase of syringes without prescriptions] are not associated with lower population proportions of IDUs. Laws restricting syringe access are statistically associated with HIV transmission and should be repealed."

"The data in this report offer no support for the idea that anti-OTC laws prevent illicit drug injection. However, the data do show associations between anti-OTC laws and HIV prevalence and incidence. In an ongoing epidemic of a fatal infectious disease, prudent public health policy suggests removing prescription requirements rather than awaiting definitive proof of causation. Such action has been taken by Connecticut, by Maine, and, recently, by New York. After Connecticut legalized OTC sales of syringes and the personal possession of syringes, syringe sharing by drug injectors decreased. Moreover, no evidence showed increased in drug use, drug-related arrests, or needlestick injuries to police officers."

(2008) "An estimated 425,000 U.S. residents aged 12 or older used a needle to inject heroin, cocaine, methamphetamine, or other stimulants during the past year, according to combined data from the 2006, 2007, and 2008 National Survey on Drug Use and Health (NSDUH). Many of these injection drug users reported engaging in unsafe needle practices the last time they injected drugs. The majority (71.0%) did not clean their needle with bleach before using it. Approximately one-half (51.0%) reused a needle they had used before and 17.7% reported that someone else used their needle after them. More than one in ten (13.0%) reported using a needle they know or suspected someone else had used before them."

(2005) In 2005, the US Centers for Disease Control published the results of a survey conducted by staff from Beth Israel Medical Center and the North American Syringe Exchange Network (NASEN) of 148 Syringe Exchange Program (SEP) directors around the country (of whom 126 completed the survey). According to the report:

"These 126 SEPs reported operating in 102 cities in 31 states and the District of Columbia (DC). More than two-thirds (86) of SEPs were in seven states: California (25), Washington (15), New Mexico (14), New York (12), Wisconsin (eight), Massachusetts (six), and Oregon (six). "SEP size was classified by the number of syringes exchanged (Table 1); 119 SEPs reported exchanging a total of 24,878,033 syringes; seven SEPs did not track the number of syringes exchanged. The 11 largest programs exchanged 49% of all syringes."

(2002) "SEPs provided other services in addition to syringe exchange. One hundred ten (87%) SEPs provided male condoms, 96 (76%) female condoms, 111 (88%) alcohol pads, and 86 (68%) bleach; 97 (77%) provided referrals for substance-abuse treatment; 91 (72%) offered voluntary on-site counseling and testing for HIV, 54 (43%) for hepatitis C, and 37 (29%) for hepatitis B; 42 (33%) provided vaccination for hepatitis A and 45 (36%) for hepatitis B; 39 (31%) offered sexually transmitted disease (STD) screening; 29 (23%) provided on-site medical care; and 28 (22%) provided tuberculosis screening. Most programs provided risk-reduction and risk-elimination education to IDUs. One hundred fifteen (91%) programs provided education on hepatitis A, B, and C; 114 (90%) on HIV/AIDS prevention; 111 (88%) on safer injection practices; 104 (83%) on abscess prevention and care; 100 (79%) on vein care; 110 (87%) on STD prevention; 110 (87%) on male condom use; and 94 (75%) on female condom use."

(2002) "The findings indicate that in 2002, for the first time in 8 years, the number of SEPs, the number of localities with SEPs, and public funding for SEPs decreased nationwide; however, the number of syringes exchanged and total budgets across all programs continued to increase."

(2002) "During 2002, a total of 126 SEPs maintained an average of six exchange sites each (median: 3.0; range: 1-47). SEPs served clients for an average of 26 hours/week (median: 18 hours/ week; range: 1-202 hours/week). Buildings (e.g., storefronts, clinics, or health centers) were the most commonly reported sites; 68 total SEPs (54%) operated 156 sites/week for 1,334 hours/week). Forty-five (36%) programs served clients through health vans or car stops (203 sites/week for 616.5 hours/week), and 25 (20%) operated other types of fixed sites, such as at tables on streets, in private homes, or at shooting galleries (i.e., locations where persons inject drugs) (141 sites/week for 413.5 hours/week). Fifteen (12%) programs used mobile workers on foot or bicycle (81 sites/week for 202.0 hours/ week). Of the 126 total SEPs in 2002, 69 (55%) had multiple types of exchange sites, 36 (29%) were entirely building-based, 14 (11%) were vehicle-based, five (4%) used other fixed sites, and two (2%) used mobile sites only. Delivery of syringes and other risk-reduction supplies to residences or meeting spots was reported by 62 (49%) SEPs. Secondary exchange (i.e., exchange of syringes on behalf of other persons) was allowed by 103 (82%) programs."

"While it is not feasible to do a randomized controlled trial of the effectiveness of needle or syringe exchange programs (NEPs/SEPs) in reducing HIV incidence, the majority of studies have shown that NEPs/SEPs are strongly associated with reductions in the spread of HIV when used as a component of comprehensive approach to HIV prevention. NEPs/SEPs increase the availability of sterile syringes and other injection equipment, and for exchange participants, this decreases the fraction of needles in circulation that are contaminated. This lower fraction of contaminated needles reduces the risk of injection with a contaminated needle and lowers the risk of HIV transmission. "In addition to decreasing HIV infected needles in circulation through the physical exchange of syringes, most NEPs/SEPs are part of a comprehensive HIV prevention effort that may include education on risk reduction, and referral to drug addiction treatment, job or other social services, and these interventions may be responsible for a significant part of the overall effectiveness of NEPs/SEPs. NEPs/SEPs also provide an opportunity to reach out to populations that are often difficult to engage in treatment."

The US Office of National Drug Control Policy in 2005 was caught by the Washington Post misrepresenting the results of research on syringe exchange programs. According to the Post in its editorial, "Deadly Ignorance":

"An official who requested anonymity directed us to a number of researchers who have allegedly cast doubt on the pro-exchange consensus. One of them is Steffanie A. Strathdee of the University of California at San Diego; when we contacted her, she responded that her research 'supports the expansion of needle exchange programs, not the opposite.' Another researcher cited by the administration is Martin T. Schechter of the University of British Columbia; he wrote us that 'Our research here in Vancouver has been repeatedly used to cast doubt on needle exchange programs. I believe this is a clear misinterpretation of the facts.' Yet a third researcher cited by the administration is Julie Bruneau at the University of Montreal; she told us that 'in the vast majority of cases needle exchange programs drive HIV incidence lower.' We asked Dr. Bruneau whether she favored needle exchanges in countries such as Russia or Thailand. 'Yes, sure,' she responded. 'The Post further noted: 'The Bush administration attempted to bolster its case by providing us with three scientific articles. One, which has yet to be published in a peer-reviewed journal, was produced by an author unknown to leading experts in this field who is affiliated with a group called the Children's AIDS Fund. This group is more renowned for its ties to the Bush administration than for its public health rigor: As the Post's David Brown has reported, it recently received an administration grant despite the fact that an expert panel had deemed its application 'not suitable for funding.' The two other articles supplied by the administration had been published in the American Journal of Public Health. Although each raised questions about the certainty with which needle-exchange advocates state their case, neither opposed such programs."

"Access to sterile needles and syringes is an important, even vital, component of a comprehensive HIV prevention program for IDUs. The data on needle exchange in the United States are consistent with the conclusion that these programs do not encourage drug use and that needle exchanges can be effective in reducing HIV incidence. Other data show that NEPs help people stop drug use through referral to drug treatment programs. The studies outside of the United States are important for reminding us that unintended consequences can occur. While changes in needle prescription and possession laws and regulations have shown promise, the identification of organizational components that improve or hinder effectiveness of needle exchange and pharmacy-based access are needed."

(2007) "Respondents reported injecting a median of 60 times per month, visiting the syringe exchange program a median of 4 times per month, and obtaining a median of 10 syringes per transaction; more than one in four reported reusing syringes. Fifty-four percent of participants reported receiving fewer syringes than their number of injections per month. Receiving an inadequate number of syringes was more frequently reported by younger and homeless injectors, and by those who reported public injecting in the past month."

"The purchase of syringes through pharmacies may be a major source of contact with the health service for some injectors, and the potential to exploit this contact point as a conduit to other services clearly exists. Work to motivate and support pharmacists to develop the services they offer to drug users could form an important part of extending the role of pharmacies, but to date only France, Portugal and the United Kingdom appear to be making significant investments in this direction."

"We found that a large proportion of SEP [syringe exchange program] participants in NYC do not obtain adequate numbers of syringes from the SEPs to meet their monthly injecting needs. In addition, characteristics of social marginalization and vulnerability – homelessness and public injecting – were associated with inadequate syringe acquisition. For SEP participants with inadequate coverage, most reported "not needing" more syringes, but many also identified program limits and fear of police contact as main reasons for not obtaining adequate syringes at their most recent visit to the SEP."

"We found that the odds of being arrested or cited for drug paraphernalia in a 6-month period were significantly higher for clients of legal SEPs [syringe exchange programs] when compared to clients of illegal SEPs. Although both illegal and legal SEPs operate in neighborhoods with heavy drug use and drug sales, policing strategies may be heavily concentrated around the known presence of a legal SEP. Illegal SEPs may operate in more hidden venues or use program methods, such as syringe exchange delivery and satellite exchange models to reduce or eliminate exposure to law enforcement."

"We found that in cities with NEPs HIV seroprevalence among injecting drug users decreased on average, whereas in cities without NEPs HIV seroprevalence increased. A plausible explanation for this difference is that the NEPs led to a reduction in HIV incidence among injecting drug users. "NEPs have the potential to decrease directly HIV transmission by lowering the rate of needle sharing and the prevalence of HIV in needles available for reuse, as well as indirectly through activities such as bleach distribution, referrals to drug treatment centres, provision of condoms, and education about risk behaviour. Although these mechanisms have strong theoretical support, the published evidence for NEP effectiveness is limited. Previous studies of the effect of NEPs on HIV incidence used observational designs or statistical models. ... Our study is distinguished from previous work by its worldwide scope and its design, which compares changes in HIV seroprevalence in cities with and without NEPs, rather than changes within a single city."

A literature review in 2004 by the European Union's drug monitoring agency, the European Monitoring Centre on Drugs and Drug Addiction, found that "Major reviews (summarised in Vlahov and Junge, 1998; Bastos and Strathdee, 2000; Ferrini, 2000) suggest that NSPs (Needle and Syringe Programs) may reduce rates of seroconversion to HIV and hepatitis by one third or more, without negative side effects on the number of IDUs (Vlahov and Junge, 1998). A landmark study from Hurley et al. combined HIV seroprevalence data from 81 cities with (n=52) or without (n=29) NSPs (Hurley et al., 1997). They showed that the average annual seroprevalence was 11% lower in cities with an NSP than in cities without an NSP, providing important evidence on the effectiveness of NSPs in reducing the spread of HIV."

According to a study in 1996, "Drug paraphernalia laws in 47 U.S. states make it illegal for injection drug users (IDUs) to possess syringes." The study concludes, "decriminalizing syringes and needles would likely result in reductions in the behaviors that expose IDUs to blood borne viruses."

"In multivariate analyses, we found that police contact was associated independently with residing in the area with no legal possession of syringes; among SEP users, those with access to SEPs without limits had lower syringe re-use but not lower syringe sharing; and that among non-SEP users, no significant differences in injection risk were observed among IDUs with and without pharmacy access to syringes. "Conclusion We found that greater legal access to syringes, if accompanied by limits on the number of syringes that can be exchanged, purchased and possessed, may not have the intended impacts on injection-related infectious disease risk among IDUs."

In 1998, Donna Shalala, then Secretary of Health and Human Services in the Clinton Administration, stated: "A meticulous scientific review has now proven that needle exchange programs can reduce the transmission of HIV and save lives without losing ground in the battle against illegal drugs."

According to a 1997 statement by the National Institutes of Health, "individuals in areas with needle exchange programs have an increased likelihood of entering drug treatment programs."

(1997) "Estimates of the annual number of syringes required to meet the single-use standard run in the range of 1 billion. The most recent estimate of the number of syringes distributed by needle exchange programs in the United States (1997) was 17.5 million."

Between 1991 and 1997, the U.S. Government funded seven reports on clean needle programs for persons who inject drugs. The reports are unanimous in their conclusions that clean needle programs reduce HIV transmission, and none find that clean needle programs cause rates of drug use to increase.

(1993) Needle exchange programs can "prevent significant numbers of [HIV] infections among clients of the programs, their drug and sex partners and their offspring. In almost all cases, the cost per HIV infection averted is far below the $119,000 lifetime cost of treating an HIV infected person."

"Researchers have found that police harassment is one of the most important factors that exacerbate risky behavior among drug users in Russia. In a 2002 study of drug use in five Russian cities, 44 percent of drug users said they had been stopped by the police in the month prior to being interviewed, and two third of these said that their injecting equipment had been confiscated by the police. Over 40 percent added that they rarely carried syringes for fear of encountering the police with them. In the Togliatti study, Rhodes and colleagues found that fear of being arrested or detained by the police was the most important factor behind the decision of drug users not to carry syringes, which in turn was an important determinant of sharing syringes during injection. This study concluded that drug users who had been arrested or detained by the police for drug-related offenses were over four times more likely than other users to have shared syringes in the previous four weeks. Drug users who feared the police in Togliatti tended to avoid not only syringe exchange services but also drug stores that sold syringes because police frequently targeted people buying syringes at such locations, a result also highlighted in a 2003 study of drug users in Moscow."

"State action that impedes people from protecting themselves from a deadly epidemic is blatant interference with the right of Russians to the highest obtainable standard of health. There is no dispute as to the effectiveness of sterile syringes for preventing HIV, hepatitis C and other blood-borne infections. Public health experts are virtually unanimous in the view that providing access to sterile syringes neither encourages drug use nor dissuades drug users from entering drug treatment programs. In reality, the near absence of humane treatment programs for drug addiction in Russia and the very nature of drug use guarantee that there will always be people who either cannot or will not stop using drugs. Impeding this population from obtaining or using sterile syringes amounts to prescribing death as a punishment for illicit drug use."