Injection of illegal drugs using unsterile needles and syringes has been a significant source of HIV infection in the United States, contributing to nearly one-third of US AIDS cases (CDC, 2008). The US Public Health Service deems one-time-only use of sterile syringes to be essential to reducing rates of transmission among injection drug users (IDUs) (USPHS, 1997).
A comprehensive approach to limiting HIV spread via unsterile needles includes syringe exchange programs (SEPs), sale of syringes in pharmacies and other retail outlets without prescription or other limitation, and elimination of laws and law enforcement practices that deter IDUs from possessing syringes. SEPs have the added benefit of facilitating entry into drug treatment, which is independently protective against HIV (Metzger et al., 1998).
Despite substantial evidence that expanded syringe access benefits public health without causing other harms, state laws on syringe distribution and possession, law enforcement practices, and actions by the US Congress that limit federal funding for SEPs may be inhibiting the potential of syringe access programs to prevent HIV.
Access to sterile syringes through SEPs or retail outlets remains uneven and incomplete in the US. In 2005, there were 185 syringe exchange programs (SEPs) in 36 States, the District of Columbia, and Puerto Rico (CDC, 2007). In 14 states, state legislatures have explicitly authorized SEPs, but in most of these, SEPs are limited to a small number of sites or require additional local authorization. In three states, SEPs operate by local government authorization in just one or two cities. In at least 15 states, SEPs operate without claim to legality (Burris, 2008). All U.S. SEPs are still covered by a Congressional ban on the use of federal funds to pay for syringes or their distribution (Burris et al., 2003).
Since the beginning of the HIV epidemic, 14 states have taken affirmative legislative measures to reduce or eliminate restrictions on retail sale of syringes to IDUs. In most states, however, IDU purchase and possession of syringes are limited by drug paraphernalia laws, syringe prescription requirements and/or various pharmacy regulations governing sales (such as buyer identification or legitimate medical purpose requirements) (Burris, 2008).
Coverage, the extent to which sterile syringes are available to meet local need, remains insufficient. After many years of expansion, the number of SEPs has stopped growing (CDC, 2005). Just six states account for more than two-third of needle exchanges. And while SEPs collectively distribute more than 22 million syringes every year (CDC, 2005), a study of the 36 largest US metropolitan areas estimated that SEPs were providing enough syringes to cover only 3 percent of the estimated injections (Tempalski et al., 2008). There are no comparable data on the number of syringes that IDUs obtain from retail outlets. Although policy changes to allow non-prescription sale have been shown to increase access (Fuller et al., 2002); (Neaigus et al., 2008); (Deibert et al., 2006), most states have taken no action to reduce legal barriers to retail syringe purchase and possession. Factors like law enforcement resistance and lack of pharmacy interest can blunt the impact of syringe access initiatives.
Thus, policy-makers are confronted with the question of whether they should act to extend the reach of syringe access initiatives, which could require revisiting funding prohibitions and reforming prescription, possession and other pharmacy laws. Evidence gathered in peer-reviewed research suggests that local, state and federal policies should be geared toward limiting the spread of HIV via unsterile needles. Four specific policy areas that need to be re-examined and modified are:
1. Legal barriers to the operation of syringe exchange programs, such as restrictions on syringe sales and possession or elements of drug paraphernalia laws that effectively prohibit free syringe distribution outside pharmacies.
2. Restrictions on federal funding for SEPs, which include a ban on funding syringe exchanges that since 1998 has been part of the annual appropriations legislation for the Departments of Labor, Health and Human Services, and a statuary ban on funding needle exchange programs contained in Title XXVI of the Public Health Service Act. (In 2008, Congress lifted a ban that had prevented the District of Columbia from using its own funds for SEPs.)
3. State laws and regulations limiting the purchase of syringes in pharmacies or other retail establishments. These include pharmacy regulations and more or less formalized pharmacy board policies that may influence the willingness of pharmacists to sell syringes to suspected IDUs.
4. Legal barriers that can deter possession and proper disposal of legally obtained syringes, such as laws against possessing a syringe if it is for injecting illegal drugs, and laws that allow even a minute amount of drug residue in the barrel of a used syringe to be used as evidence of a drug crime.