Needle and syringe programmes (NSPs) are a type of harm reduction initiative that provide clean needles and syringes to people who inject drugs (PWID). The World Health Organisation (WHO) recommends providing 200 sterile needles and syringes per drug injector per year, in order to effectively tackle HIV transmission via this route.1
Many programmes supply other equipment to prepare and consume drugs such as filters, mixing containers and sterile water. The majority of NSPs are run by drug services or pharmacies and operate from a range of fixed, mobile and outreach sites.2
NSPs aim primarily to reduce the transmission of HIV and other blood-borne viruses caused by the sharing of injecting equipment. Many also work to reduce other harms associated with injecting drug use by providing:
- advice on safer injecting practices
- advice on minimising the harm done by drugs
- advice on how to avoid and manage an overdose
- information on the safe handling and disposal of injecting equipment
- referrals to HIV testing and treatment services
- help to stop injecting drugs, including access to drug treatment (such as opioid substitution therapy (OST)) and encouragement to switch to safer drug taking practices
- other health and welfare services (including condom provision).2
A study by the WHO reported that:
"NSPs substantially and cost effectively reduce the spread of HIV among PWID and do so without evidence of exacerbating injecting drug use at either the individual or societal level." 3
How are needle and syringe programmes delivered?
Fixed NSP sites are typically located where there is an open drug scene (where drugs are bought and sold openly). They are normally converted shops or offices and have a reception area for clients where they give out new, and receive used, injecting equipment.
At fixed sites, it is easier to offer additional services such as healthcare alongside testing and counselling for HIV and other blood-borne viruses.4
Mobile NSPs operate from a van or bus with needles and syringes distributed through a door or window. Some large mobile NSP sites act like fixed sites with testing and other healthcare services also available.
Other mobile NSPs run in conjunction with fixed sites. In these instances, the fixed site is typically located in an area with high numbers of PWID with the mobile NSP focussing on harder to reach or smaller populations.4
Mobile NSPs can be more accessible than fixed NSPs and often face less opposition than sites such as the Insite facility in Vancouver, Canada.5
Outreach programmes take many forms including mobile units (such as a van or bus), backpacking services on the street or even home deliveries.6
They typically operate where there is a shortage of funding for NSPs. For example, it is the preferred method of delivery in Haryana, India, where peer educators reach out to PWID who do not openly buy or sell drugs.7
Some outreach NSPs exist to complement fixed or mobile NSPs where PWID are not engaging with established services. Outreach workers are tasked with encouraging PWID to use existing fixed or mobile sites.4
Syringe vending machines
Countries including the Netherlands, Germany, Italy and Australia use syringe vending machines in addition to other forms of NSPs. Syringe vending machines accept coins and tokens (typically distributed by outreach workers) in return for harm reduction packs. In Australia, these packs include several needles and syringes as well as alcohol swabs, cotton wool, sterile water and spoons. Others contain educational materials.8
The machines are typically mounted on the outside walls of fixed NSP sites. They are also installed in places where needles and syringes are hard to access. Most provide needles and syringes 24 hours a day, 7 days a week.4
Pharmacy-based NSPs operate in a number of ways. Some sell needles and syringes directly to PWID, while others exchange harm reduction kits for vouchers. The main advantage of pharmacy NSPs is that in many places, pharmacy networks are already well established and often located near to large groups of PWID. Their open hours are often more convenient than those at fixed sites.4
However, pharmacy-based NSPs are very limited in low-income countries. Even where they do exist, some pharmacists are reluctant to sell needles and syringes to PWID or deal with their disposal.9 Moreover, they rarely offer education and additional healthcare services.4
Needle and syringe programme coverage worldwide
In 2014, there were 158 countries worldwide that reported people who inject drugs, but just 90 of these countries implement needle and syringe programmes. Five countries (the Dominican Republic, Colombia, Jordan, Kenya and Senegal) have introduced NSPs since 2012.10
Asia and the Pacific
17 countries and territories in Asia implement NSPs. In Cambodia, Mongolia, the Philippines and Thailand, NSP provision exists on a very small scale. In others, NSP provision has nearly doubled since 2012, such as in Malaysia and Australia. Despite progress in some countries, Bangladesh, China, Pakistan and Vietnam have reported declines in NSP provision since 2012. For example, Vietnam has dropped the number of needles distributed per PWID from 180 in 2012 to 98 in 2014.10
NSPs in Asia are delivered in a number of ways. In some places, fixed NSPs have been integrated with other facilities such as health clinics and pharmacies. In Laos, there is just one community-based NSP, on the border with Vietnam.11 NSP coverage is still too low to have a significant impact on HIV prevalence among PWID, with a lack of human resources, inflexible hours and harsh drug policies cited as barriers to their access.12 10
In the Pacific (Oceania), Australia and New Zealand are the only countries that have figures on PWID, and both provide NSP services. In fact, they have one of the highest NSP coverage rates in the world. Political support and public funding for harm reduction services has helped to keep HIV transmission from unsafe injecting very low.10
Eastern Europe and Central Asia
All 29 countries and territories in Eastern Europe and Central Asia have NSPs, although there is a huge disparity in the number available in each country. For example, there are 1,667 in Ukraine but only two in Albania.10 A report by the Eurasian Harm Reduction Network estimated that only 10% of PWID in Eastern Europe and 33% of PWID in Central Asia are able to access NSPs.13
Since 2012, Bosnia and Herzegovina, Croatia and Ukraine have scaled up their NSP provision, but large drops have been recorded in Poland. Coverage remains very low across the region, with the lowest number of syringes distributed per PWID (50).10
The political reaction to harm reduction services in the area continues to be hostile, forcing many NSPs to close. This severely affected Hungary, where its largest NSP was shut down, reducing the number of clean needles available in the country by around 40%.14
Western and Central Europe and North America
Generally, NSPs are widely available across Western and Central Europe and utilise fixed sites, pharmacy-based services, vending machines, outreach and mobile services.15 The number of syringes distributed per PWID is generally around the 200 mark, as recommended by the WHO. However, some countries, including Germany, do not rank as providing high coverage due to a lack of data processing despite a high number of NSPs (1,000).10
Barriers to NSP access in the region include PWID under the age of 18 being denied services, undocumented migrants not being reached, and rural areas having underdeveloped services available.10
NSPs are available in both the United States and Canada, but estimates of coverage are limited. The most recent estimates from 2010 found that only roughly 23 syringes were distributed per PWID per year.15
Only five countries in this region operate NSP programmes, with Brazil providing the most (between 150-450 sites). Argentina, Mexico, Paraguay and Uruguay make up the remaining four countries, however it is thought that NSP services are being scaled back in all countries as a result of declining injecting drug use in the region.10
The Middle East and North Africa
Nine countries in the Middle East and North Africa (MENA) currently implement NSP programmes.17 Iran has doubled its needle and syringe provision since 2012, with many PWID continuing to get new needles from pharmacies.18
NSP service coverage throughout MENA is thought to be extremely limited and remains too low to have a positive impact on the transmission of HIV and other blood-borne viruses.19
However, in June 2012, the Kenyan government announced plans to distribute over 8 million needles and syringes to 50,000 PWID nationwide.20 As of 2014, there are 10 operational NSP sites in the country. In Dar es Salaam, Tanzania, there were seven NSPs as of 2014, up from just one in 2012.10
Mauritius has the greatest NSP coverage in the region, and as a result, 83.8% of PWID used sterile injecting equipment in 2013.21
Data regarding people who inject drugs in the Caribbean is sparse, with reliable data only available for Puerto Rico and the Dominican Republic. They are the only two countries in the region that have NSPs.10
NSPs have been available in Puerto Rico since 2007, with six operating as of 2014. They have contributed to a 17.1% reduction in HIV infections as a result of unsafe injecting between 2007 and 2011.10 The Dominican Republic opened its first NSP in 2012, and between June and December that year it distributed 4,000 new syringes.22
Barriers to accessing needle and syringe programmes
Legal, social and cultural barriers
In many countries worldwide, criminalisation of PWID is a major barrier to NSP services. Criminalisation of possession of illicit substances and injecting equipment often forces PWID to hide their equipment and engage in unsafe injecting practices, with many threatened, abused, extorted or arrested by the authorities.15 One study from Northern Morocco reported that 87% of PWID had experienced police violence.23
Legal age restrictions for accessing NSPs in some countries prevent PWID under 18 years old from accessing these services despite evidence that people now start injecting drugs at an earlier age.24 Mandatory detention of PWID in drug detention centres in countries such as China is also a barrier to accessing NSPs.25
Even in places where it is legal to purchase needles and syringes, stigma, discrimination or disapproval from the community prevent many PWID from accessing NSP services.26 Moreover, in many places, PWID experience stigma and discrimination from healthcare workers, or receive services that are not delivered in a culturally sensitive way.15 27
Political and economic barriers
In many countries, there is a lack of political will resulting in a shortfall of funding for the implementation of NSPs.28 As a result, only 90 needles are available per person who injects drugs globally, which is far below the recommended 200.29
For example, in December 2011, the United States Congress reinstated a federal ban on funding for both domestic and international NSPs, marginalising existing programmes away from mainstream policy and funding.30 In Canada, a lack of federal support means NSPs are typically delivered by NGOs, civil society groups, provinces and territories, with service numbers varying dramatically between and within provinces.10
Russia doesn't provide state funding for NSPs with officials maintaining that they increase injecting drug use despite evidence to the contrary.31 However, international donors are funding a number of NSPs in cities across the country.32
Some countries suffer from the withdrawal of international funding for NSPs. For example, NSPs have proved highly successful in Romania, contributing to limiting HIV prevalence to 1% among PWID. However, since joining the European Union, the World Bank no longer classifies Romania as a developing country making it ineligible for a number of international grants, threatening a funding crisis.33
Physical and geographical barriers
In other places, access to NSPs is limited by geographical distance, particularly in remote and rural areas. Indeed, a number of studies have shown that PWID who live in close proximity to NSPs are more likely to use them.34
Even where they are in reach, many sites have restricted opening hours, long waiting times, insufficient resources (including needle and syringe supplies) as well as inadequately trained medical personnel.15 24 34
Photo credit: ©iStock.com/Dougall_Photography
- 1. IAVIReport (2006) 'Injection of Hope: Needle and syringe programs can lower HIV infection rates and provide important outreach to injection drug users'
- 2. a. b. National Institute for Health and Care Excellence (NICE) (2014) 'Needle and syringe programmes: NICE guidelines [PH52]'
- 3. WHO (2004) 'Effectiveness of sterile needle and syringe programming in reducing HIV/AIDS among IDUs'
- 4. a. b. c. d. e. f. WHO (2007) 'Guide to starting and managing needle and syringe programmes'
- 5. Huffington Post (2013, 18 September) 'Is InSite Really All It's Cracked Up To Be?'
- 6. Welsh Goverment (2011) 'Substance Misuse Treatment Framework (SMTF) Service Framework for Needle and Syringe Programmes in Wales'
- 7. Jain, B. et al (2014) 'Effect of peer-led outreach activities on injecting risk behavior among male drug users in Haryana, India' Harm Reduction Journal 11(3)
- 8. McDonald, D. (2007) 'The evaluation of a trial of syringe vending machines in Canberra, Australia' The International Journal of Drug Policy 20(4):336-339
- 9. Vorobjov, S. et al (2009) 'Should Pharmacists have a Role in Harm Reduction Services for IDUs? A Qualitative Study in Tallinn, Estonia' Journal of Urban Health 86(6):918-928
- 10. a. b. c. d. e. f. g. h. i. j. k. l. m. n. IHRA (2015) ‘The Global State of Harm Reduction Report 2014’
- 11. UNAIDS (2014) ‘Lao PDR Country Progress Report 2014’
- 12. WHO, UNODC & UNAIDS (2012) 'Technical guide for countries to set targets for universal access to HIV prevention, treatment and care for injecting drug users'
- 13. Eurasian Harm Reduction Network (2013) 'Quitting While Not Ahead: The Global Fund’s retrenchment and the looming crisis for harm reduction in Eastern Europe and Central Asia'
- 14. Drug Reporter 'Hungary is facing an HIV epidemic among drug users' [accessed online November 2015]
- 15. a. b. c. d. e. IHRA (2012) 'Global State of Harm Reduction 2012'
- 16. Mathers, B.M. et al (2010) 'HIV prevention, treatment, and care services for people who inject drugs: a systematic review of global, regional, and national coverage' The Lancet 375(9719):1014-1028
- 17. Mumtaz, G.R. et al (2014) 'HIV among People Who Inject Drugs in the Middle East and North Africa: Systematic Review and Data Synthesis' PLOS Medicine 11(6)
- 18. Iran Ministry of Health and Medical Education (2014) 'Islamic Republic of Iran AIDS Progress Report'
- 19. Nasirian, M. (2012) 'Modeling of new HIV infections based on exposure groups in Iran' LAP Lambert Academic Publishing: Saarbrücken, Germany
- 20. IRIN Africa (2012, 7 June) 'KENYA: Needles to be distributed to injecting drug users'
- 21. Republic of Mauritius (2015) 'Country progress report 2015'
- 22. Coin/CVC (2013) 'Open Doors: A needle exchange programme for injecting drug users'
- 23. Association de lutte contre le sida (ALCS) and Open Society Institute (26 October 2011) 'For a New Approach Toward Drug Users, Based on Health and Human Rights' National Conference, Morocco
- 24. a. b. Zindagi, N. (2009) 'Rapid Situation Assessments of HIV prevalence and risk factors among people injecting drugs in four cities of Punjab'
- 25. Zhang, L. et al (2013) 'Ability to access community-based needle-syringe programs and injecting behaviors among drug users: a cross-sectional study in Hunan Province, China' Harm Reduction Journal 10(8)
- 26. Petersen, Z. et al (2013) 'Availability of HIV prevention and treatment services for people who inject drugs: findings from 21 countries' Harm Reduction Journal 10(13)
- 27. Australian National Council on Drugs (ANCD) (2011) 'Injecting drug use and associated harms among Aboriginal Australians'
- 28. Degenhardt, L. et al (2014) 'What has been achieved in HIV prevention, treatment and care for people who inject drugs, 2010-2012? A review of the six highest burden countries' The International Journal on Drug Policy 25(1):53-60
- 29. UNAIDS (2014) 'The Gap Report'
- 30. The White Hours (2012) 'Federal Funding Ban on Needle Exchange Programs'
- 31. openDemocracy (2009, 5 November) 'Russia's drugs problem: blame the West'
- 32. Sarang, A. et al (2008) 'Access to syringes in three Russian cities: implications for syringe distribution and coverage' The International Journal on Drug Policy 19(Supplement 1):25-36
- 33. TIME (2010, 20 September) 'Eve of an HIV Epidemic in Romania'
- 34. a. b. NICE (2008) 'Needle and syringe programmes for injecting drug users: Synopsis of the evidence and economic modelling'