HIV Prevention

Strategies to Improve Access to Sterile Syringes for Injection Drug Users

from The AIDS Reader ^®
Posted 01/15/2003

Josiah D. Rich, MD, MPH, Francis A. Wolf, BA, Grace Macalino, PhD, MPH

http://www.medscape.com/viewarticle/446813

Abstract and Introduction

Abstract

The high prevalence of infection with HIV and other blood-borne pathogens in injection drug users (IDUs) is directly related to the lack of syringe access. Needle exchange programs (NEPs), syringe prescription, and syringe deregulation are 3 approaches to increasing access to sterile syringes for IDUs. The benefits of NEPs have been repeatedly demonstrated, but the impact of NEPs has been limited by a lack of federal funding. Syringe prescription for IDUs is a promising new strategy supported by many organizations; legalizing syringe purchase and possession has led to a substantial improvement in syringe access in many states. Because each approach has unique advantages, providing IDUs with a variety of options for syringe access is likely to be most beneficial.

Introduction

The primary route of HIV transmission among injection drug users (IDUs) is the sharing of contaminated injection equipment. Injection drug use accounts for more than one third of all AIDS cases^[1] and half of all hepatitis C cases in the United States.^[2] Soon after initiation of injection drug use, 50% to 95% of IDUs are infected with hepatitis C virus^[3] and 70% are infected with hepatitis B virus.^[4] IDUs also face other health problems associated with nonsterile injection, including abscesses, cellulitis, sepsis, endocarditis, tetanus, and wound botulism.^[5]

The high proportion of HIV/ AIDS and infection with other blood-borne pathogens in IDUs is directly related to lack of syringe access; frequently, injection-related risk behaviors are associated with restricted syringe access.^[6-8] A wealth of evidence confirms that access to sterile syringes is a critical component in preventing HIV infection among IDUs,^[2,6,9] which has prompted the US Department of Health and Human Services to recommend that all IDUs who continue to inject drugs use a new, sterile syringe for each injection.^[10]

In July 2000, we described strategies for optimizing the impact of needle exchange programs (NEPs).^[11] Here we update our previous report on NEPs and compare that approach with other emerging strategies for increasing access to sterile syringes, namely syringe prescription and deregulation. Providing IDUs with a variety of options for syringe access is likely to have added benefits.

Some IDUs may prefer the camaraderie of an NEP, some the convenience of a local pharmacy, and others the confidentiality and associated medical services of a health care provider's office.

Access to sterile syringes is only 1 component of what should be a comprehensive approach, including outreach, prevention, and drug treatment, to the problem of HIV/AIDS connected with injection drug use. This article focuses on syringe access in the United States, but HIV is rapidly spreading in many developing and transitional countries, and HIV prevention for IDUs is an international concern.

http://www.medscape.com/viewarticle/446813_2

Strategies to Improve Access to Sterile Syringes

from The AIDS Reader ^®

Needle Exchange Programs

NEPs -- also referred to as syringe exchange programs -- were first established in the United States in 1988 with the dual objectives of providing IDUs with sterile injection equipment and removing used and potentially contaminated syringes from circulation. Participants who attend NEPs turn in used, potentially contaminated syringes in exchange for new, sterile syringes, free of charge and usually on a "1-for-1" basis.^[12]

While the primary goal of NEPs continues to be providing clean needles for IDUs, many programs also offer additional services. These services may include the provision of condoms, safer injection equipment (cookers, sterile water, cotton, bleach), information on sexually transmitted diseases, referral to drug treatment and other services, HIV testing and counseling, and even primary medical care.^[13,14] There are a variety of types of NEPs, including fixed sites and mobile sites, activist-organized NEPs, community-based NEPs with or without government sponsorship, and state and local government-sponsored programs. NEPs may be legal, illegal but tolerated, or illegal and "underground."^[12]

Despite the ongoing ban on the use of federal funds for NEPs, the number of NEPs in the United States has been increasing steadily: in July 2002, there were 211 NEPs in 36 states, the District of Columbia, and Puerto Rico (D Purchase. North American Syringe Exchange Network, unpublished data, July 2002) -- an 87% increase from the 113 NEPs that were operating in 1996, when 30 states had at least 1 program.^[15]

Benefits

There are a number of benefits associated with NEPs, including outreach to high-risk IDUs, decreased risk behaviors among participants, decreased disease transmission, and successful linkage to medical and drug treatment services. The potential of NEPs to reduce the sharing of syringes and needles by participants has been repeatedly demonstrated.^[16,17] Initiation and continued use of an NEP are independently associated with cessation of syringe sharing,^[18] and participants reuse their syringes fewer times after joining an NEP.^[17]

A recent study by Sears and coworkers^[19] found that IDUs who were assigned to an NEP/community activity intervention had a lower risk of HIV infection than did those in a nonintervention group. In Seattle, IDUs who had attended an NEP were more likely to report a reduction in injection than those who had never been to an NEP.^[20] NEPs have consistently been associated with a reduced incidence of HIV infection, and a number of studies have found reduced prevalence of HIV infection among IDUs in cities that initiated NEPs early in the HIV epidemic.^[21-23]

Des Jarlais and colleagues^[24] found that IDUs who did not use NEPs were more than 3 times as likely to become infected with HIV as were IDUs who attended NEPs. In New York City, NEPs appear to be making an important contribution to the declining phase of the city's large HIV epidemic; participants in New York City-based NEPs reported reductions in 5 risk behaviors and an increase in HIV testing and counseling.^[25]

NEPs also provide indirect protection against disease in the form of "secondary exchange," or the provision of sterile syringes by NEP participants to IDU peers in the community who are without a needle or lack access to needles.^[26] Although direct use of NEPs provides more protection against HIV infection than does receiving syringes indirectly from an NEP participant,^[27] secondary exchange and "relay" of syringes, safer injection materials, and disease prevention information may be an important mechanism for reaching some IDUs.

NEPs have the potential to serve as a source of additional health and medical services for IDU populations that can be beneficial to participants and to community health and that are cost-effective. For example, an NEP in the United Kingdom specifically targets commercial sex workers and seeks to improve their health,^[28] and some NEPs serve as a location for tuberculosis (TB) testing.^[29] Perlman and colleagues^[30] demonstrated that providing TB screening at an NEP is cost-effective. NEPs can even serve as a source of pri-mary medical care: in New Haven, Conn, an NEP that provides acute medical care for IDUs from a van is associated with reduced emergency department utilization.^[14] NEPs may also provide food, case management, assistance in enrolling in Medicaid/welfare, transportation, support groups, and birth control.^[31]

Another important function of NEPs is their ability to act as conduits to drug treatment and rehabilitation for drug-addicted participants.^[11,32-34] In Seattle, Hagan and colleagues^[20] found that new users of an NEP were 5 times more likely to seek drug treatment than were IDUs who had never been to an NEP, and IDUs who attended an NEP were more likely to remain in drug treatment.^[20]

In addition to these benefits, NEPs represent a cost-saving strategy from a societal perspective. Laufer^[35] recently demonstrated the cost-effectiveness of NEPs approved by New York State, finding a savings of $21,000 per HIV infection averted.

Concerns

Recognizing and addressing the concerns of local communities, health care providers, and drug treatment agencies are crucial to the successful establishment, use, and effectiveness of local NEPs. The most common concerns regarding NEPs relate to the impact these programs might have on drug use frequency, disease transmission, and improperly discarded syringes.

Despite these concerns, no studies have shown that NEPs increase existing drug use or lead to initiation of drug use.^[36] On the contrary, an Amsterdam report found that injection drug use rates had declined significantly in the presence of extensive harm-reduction and NEP projects.^[37] In Baltimore, the creation of an NEP did not increase the number or change the distribution of discarded syringes,^[38] and Galea and colleagues^[39] found no association between experiencing violence and proximity to an NEP, suggesting that NEPs do not adversely affect rates of violence in the surrounding area.

Another concern about NEPs is that IDUs will establish new relationships with other high-risk persons through the programs. Junge and associates,^[40] however, have demonstrated that 6 months after enrollment in the Baltimore NEP, 92.3% of participants had not made any new contacts.

Although many studies have demonstrated beneficial effects of NEPs on both the frequency of syringe sharing and the transmission of blood-borne infections, 2 Canadian studies have reported a higher incidence of HIV infection among NEP participants compared with nonparticipants.^[41,42] While these findings have caused some controversy, they can be explained by selection bias,^[26] an interpretation that is offered by the study authors themselves, who suggest that their findings reflect the attraction of a higher-risk IDU population to the NEP caused by social, economic, and situational factors rather than by an adverse effect of the NEP itself.^[43] Fisher and associates^[44] have confirmed that selection bias occurs among IDUs who participate in NEPs: IDUs who both inject and share needles more frequently were more likely to attend an NEP.

Data regarding the effectiveness of NEPs have convinced some former opponents of NEPs to change their minds and have led to increased public funding for NEPs,^[45] but scientific data alone may not be sufficient to change the opinions of others who oppose NEPs.^[46] Government support of NEPs remains a symbolic issue for many who are concerned that federal support would send a message to children that condones or encourages drug abuse,^[44] even though a recent study found that awareness of needle exchange was very low among youth and therefore would have little effect on their behavior.^[11]

Supporters and promoters of NEPs should emphasize the integration of NEPs into a comprehensive approach to drug addiction that includes drug treatment and prevention. NEPs that provide counseling and referrals to drug treatment may serve to demonstrate this idea. In Canada, making NEPs part of a comprehensive approach has helped make them acceptable: they have been subject to much less controversy and are federally funded.^[12]

Optimizing Programs

Although the number of NEPs in the United States has been steadily increasing, there are not nearly enough to provide adequate syringe coverage of all IDUs. NEPs in this country may seldom reach more than 30% of the IDUs in their communities. In 1996, the total number of syringes exchanged per year was reported to be 14 million, which falls far short of the estimated 1.3 billion injections per year that occur among IDUs.^[46] There is a lack of NEPs on a global level as well: Strathdee and Vlahov^[46] reported that while 134 countries, regions, and territories have reported HIV infection cases among IDUs, only 46 (34%) of these areas have at least 1 NEP.

To improve the impact of NEPs, strategies to increase the number of programs and the number of syringes distributed at each program are needed. Even in cities or regions where an NEP already exists, creating additional locations will provide access for more IDUs; in the United Kingdom, living near an NEP was associated with reduced syringe sharing.^[47] Thus, one of the first strategies a health care community can take is to support the establishment of an NEP in its location.^[48] Clinicians can act as advocates to effectively communicate the urgency of the HIV epidemic to policy makers and others in the community.^[49]

In creating and maintaining an NEP, communication with local agencies, officials, and organizations such as detoxification centers, drug treatment programs, and minority community organizations can be essential. In the past, failure to include people of color in discussions to establish an NEP has led to opposition to NEPs by African American leaders.^[12,49] Since the burden of injection drug use is felt disproportionately in communities of color, it is especially important to consult African American and Latino community leaders when establishing an NEP. Persons establishing or maintaining an NEP could also consider consulting IDUs in the community with regard to design and implementation of services.^[50],,

Collaboration with others in the community allows for creation of an NEP that is user-friendly for the community and for IDUs. User-friendly NEPs treat participants with dignity and respect and protect their anonymity.^[11] The location of the NEP can also have an impact on its effectiveness. Fear of identification as an IDU and/or of harassment by the police can prevent IDUs from attending an NEP^[51]; an NEP located in a multiservice building has the advantage of increased anonymity for participants. Lack of transportation can be an obstacle to NEP participation and can be addressed in part by establishing NEPs along public transportation routes when possible.

It is important to encourage frequent use of NEPs, because frequency of attendance is associated with less sharing of needles and other injection equipment and also with more frequent safe injection practices, such as cleaning the skin before injection.^[52] On the other hand, NEPs should not prohibit syringe relay/ secondary exchange for IDUs who are unable to come to the NEP and should not limit the number of syringes that can be exchanged at one time.^[27] NEPs can encourage frequent use by offering longer operating hours and more days of operation. Being open during both daytime and evening hours can increase access for different types of IDUs: Brahm- bhatt and colleagues^[53] found that IDUs who attended NEPs in the evening were younger and more ethnically diverse than were their daytime counterparts.

Despite the increasing legality of NEPs, many programs are forced to operate under questionable legal status. Legally sanctioned programs tend to be larger, have more sites, exchange more syringes, receive more funding, and provide more services than underground programs. Improving the legal status of exist- ing and planned programs has the potential to enhance participation, reach out to a greater number of IDUs, and expand the types of services provided and is therefore a worthwhile strategy to pursue.^[11]

In addition to providing convenient hours and locations and improving the legal status of NEPs, provision of additional services can be part of a strategy to optimize NEP participation and impact. The provision of sterile water, clean cotton, alcohol wipes, bleach, other safe injection equipment, condoms, and sanitary supplies can make an NEP more user-friendly and increase disease protection for participants.

NEPs can help address the health problems of IDUs by providing referrals, medical care, vaccines, overdose prevention, education, and disease testing for participants. For example, IDUs have disproportionately high rates of mental illness, especially depression,^[54] and NEPs could offer mental health screening and referrals to participants. Motivational interviewing at an NEP to reduce heavy alcohol consumption has been successful^[55] and could also be an important component of disease prevention considering that heavy alcohol use among IDUs is associated with needle sharing.^[56]

NEPs can further benefit participants by helping to arrange health insurance for those who are uninsured. Having health insurance is associated with increased health care utilization and with increased substance abuse treatment.^[57] NEPs and other harm-reduction efforts should also seek to establish interventions for adolescent IDUs. Although IDUs tend to be older than 18 years, the age of initiation appears to be decreasing.^[58]

Outreach to IDUs and encouraging them to begin drug treatment are important parts of preventing HIV transmission. For example, there is growing literature confirming that methadone treatment reduces drug injection, high-risk practices, and HIV seroconversion,^[59,60] while drug injectors who do not enter treatment are up to 6 times more likely to become infected with HIV.^[61] However, more than 80% of drug users in the United States are not in any form of drug treatment at any one time.^[62] NEPs can act as an important source of entry into drug treatment. Bluthenthal and associates^[63] found that a majority (56.5%) of NEP participants in Providence, RI, were in the "determination or ready-to-change stage" with regard to their drug use. Many IDUs surveyed at an NEP in Calgary, Alberta, were also interested in drug treatment.^[64] Given this interest in drug treatment, NEPs that seek to provide referrals and improve linkages to substance abuse treatment programs can potentially increase drug treatment among the participants.

Barriers and Limitations

The inadequate growth of NEPs in the United States is particularly apparent when compared with the expansion of programs in other countries, such as Australia, where an IDU-associated HIV epidemic has been successfully averted.^[65] The ban on federal funding of NEPs that continues despite a number of government-sponsored reports that recommend lifting the ban is perhaps the most significant barrier to widespread implementation and expansion of NEPs and to realizing the potential of NEPs to prevent disease.^[66] Although cost varies with size and the services provided, the median cost of operating an NEP is $168,650 per year.^[12] This limits the number of NEPs that can be established. Federal funding and support of NEPs would not only allow more NEPs to be established but would also allow for increased provision of important medical and social services at NEPs.

While NEPs are important, they are not a panacea for disease among IDUs. NEPs have been shown to reduce HIV infection incidence, but their impact on hepatitis C has been limited.^[67-69] This may be due in part to continued sharing of injection equipment, such as cotton, cookers, and rinse water,^[67] and to the persistence of unsafe injection practices at some NEPs,^[70] including syringe sharing, especially among close friends. Valente and Vlahov^[70] found that most (78.3%) of NEP participants who reported sharing syringes shared with a close friend.

Although the risks of syringe sharing are fairly well known, disease transmission through sharing of other injection equipment, such as cookers, rinse water, and cotton, has been less publicized. It may be important, therefore, to provide more "cognitive" interventions, such as risk-reduction and safe-injection counseling and literature to emphasize the risks of sharing any injection equipment, even with close friends. Given these limitations, other approaches to improving access to syringes should be implemented to complement NEPs.

http://www.medscape.com/viewarticle/446813_3

Strategies to Improve Access to Sterile Syringes

from The AIDS Reader ^®

Syringe Prescription to Prevent Disease

In many states, physicians can legally prescribe syringes for IDUs to prevent disease. Although this approach to syringe access has not yet been widely adopted, it has been recognized as an important and promising strategy by the CDC, the AMA, and many other organizations.

Prescribing syringes for IDUs was first widely promoted in Rhode Island as a means to provide access to sterile syringes in an extremely restrictive legal environment. At that time, Rhode Island had syringe laws among the strictest in the country: syringe possession was considered a felony punishable by up to 5 years imprisonment, and syringes could not be purchased without a prescription. As a result, Rhode Island was 1 of only 4 states with more than 50% of AIDS cases related to injection drug use, and IDUs there re-used syringes more than 20 times on average.^[71]

A syringe prescription program was established for IDUs in Providence, RI, and has provided well over 70,000 syringes for more than 350 IDUs. Participants are encouraged to see the physicians who offer, in the setting of clinical care, a motivational intervention to encourage risk reduction, participation in substance abuse treatment, and mental health and other services when necessary. The clinical intervention includes free diagnostic screening; viral hepatitis vaccination; routine and subacute medical care; and referral for medical, substance abuse treatment, and social services. Participants receive a prescription for up to 100 syringes at a time, free of charge. An in-depth program evaluation includes a baseline interview and follow-up interviews at 3, 6, and 12 months.^[71,72]

Benefits

The Rhode Island pilot program has shown that prescribing syringes for IDUs is feasible and has the ability to reach out to high-risk IDUs. The syringe prescription program population has a proportion of racial/ethnic minority group members that is twice as high as that of the Providence NEP; at baseline, most participants (92%) were not employed on a full-time basis, and more than half of participants (53%) were homeless, suggesting that syringe prescription is an effective means to reach and enroll high-risk, hard-to-reach IDUs, who may not access syringes through the NEP.

While the program has successfully met the primary goal of providing access to sterile syringes for high-risk IDUs, it has also been tremendously successful in providing medical care for a population that has significant health needs. Eighty-seven percent of participants have seen a physician at least once, and the majority of these patients have undergone diagnostic screening for HIV infection, hepatitis B and C, and syphilis. Every week, patients are referred to primary care (for example, most female participants had not had a routine Pap smear in years); to the emergency department for a variety of conditions, including acute infections (such as abscesses) and acute psychiatric conditions; to the TB clinic; and to several medical subspecialists.

Prescription of syringes provides an enticement into care for IDUs, a population often on the fringe of traditional medical services. It opens the way for frank discussions regarding drug use and injection-related activities. Many participants were eager for help in navigating entry and reentry into substance abuse treatment.

Legality

According to a recent legal analysis, physician prescription of injection equipment for IDUs is legal in 48 of 52 US states, illegal in Delaware and Kansas, and questionable in Ohio and Oklahoma. A prescription is currently required for sale or possession of syringes, even by patients injecting prescribed medications, in 7 states: California, Delaware, Illinois, Massachusetts (except in an NEP), Nevada, New Jersey, and Pennsylvania. Seven states allow some sale or possession of syringes without a prescription (for example, no more than 10 syringes).

Thirty states or territories have drug paraphernalia laws that could be applied to syringes, and 14 more have laws that exempt some possession of syringes. Prescription of syringes for IDUs is legal in 40 of these 44 jurisdictions and possibly legal in 2 more.^[73] Even in states where prescription is not legally mandated, having a prescription can improve access by reducing fear of harassment by pharmacists.

Syringe prescription for IDUs is a nascent, promising strategy for improving syringe access and preventing spread of HIV infection and other diseases among IDUs and one that has the support of major medical and public health associations and organizations, including the AMA, the Infectious Diseases Society of America, the American Academy of Family Physicians, and the CDC. It has been shown to be feasible, and it not only reduces the sharing of syringes but also encourages and improves the provider-patient relationship, which allows the provision of health care and linkage to other medical, mental health, and substance abuse treatment services. Further studies are needed to evaluate implementation of this strategy in different locations and venues to examine costs and cost benefits and to encourage physicians and other health care workers to participate in prescribing syringes for IDUs. Syringe prescription can be limited by the willingness of health care providers to prescribe syringes for IDUs and by the difficulty in connecting IDUs with medical services.

http://www.medscape.com/viewarticle/446813_4

from The AIDS Reader ^®

Legalization of Syringe Sales and Possession

A third approach to providing access to sterile syringes is the deregulation of syringes to allow over-the-counter pharmacy sales of syringes and to allow IDUs to legally possess syringes. In some cases, such as in New York's Expanded Syringe Access Program, deregulation can also allow health care professionals to dispense syringes directly to IDUs to prevent disease. Many states currently have laws that restrict access to syringes through pharmacies and hinder disease prevention efforts, creating serious public health consequences for IDUs, their sex partners, and their children. These laws include legislation that requires a prescription for dispensing and possessing a syringe, at least in some circumstances ("prescription" laws), and laws that criminalize the possession of syringes for drug use, at least under some circumstances ("paraphernalia" laws).^[73]

A number of states, including Connecticut, Hawaii, Maine, Minnesota, New Hampshire, New Mexico, New York, Rhode Island, and Washington, have deregulated the purchase and possession of syringes as part of an effort to slow the HIV epidemic among IDUs.^[72] Evaluations of these changes in law have shown an increase in pharmacy syringe sales, no increase in injection drug use or in the number of publicly discarded syringes, and in some cases decreased syringe sharing. Connecticut's syringe laws were changed in 1992 to allow for the sale and possession of up to 10 syringes for persons over 18. Following the change, a study reported decreased syringe sharing (52% before vs 31% after; P =.02), increased utilization of pharmacies as a source of syringes, and reduced numbers of IDUs who purchased syringes on the street.^[74]

Benefits

Legalizing the sale of syringes by pharmacies creates reliable, accessible, and affordable sources of sterile syringes for IDUs. Pharmacies can provide increased access for IDUs because of their convenient locations and hours; unlike NEPs, pharmacies are common in every US city and generally have relatively extended hours of operation that include both day and evening. Pharmacists are trained medical professionals who can provide medical advice and referrals for IDUs -- including information on safe disposal. The existing infrastructure of pharmacies allows them to provide syringes without requiring additional staffing, supplies, or funding. Removing legal penalties for syringe possession allows IDUs to carry their own syringes without fear of arrest (although some IDUs report still being harassed by police after syringe deregulation).

Strategies for Syringe Policy Change

Health care professionals can have a direct influence on syringe policy in their states. Persons in states where syringes are restricted can encourage organizations such as their State Medical Society and Health Department to support syringe deregulation and can meet with politicians directly to express their views on disease prevention. In Rhode Island, a small group of doctors was instrumental in convincing legislators of the need for action, successfully gained the support of state agencies, and helped draft the new legisla-tion. Persons working for legislative change may wish to consult others in states where changes in the laws have already occurred.

Any syringe access efforts that turn to pharmacies as a source of syringes by deregulation should take into account the considerable control that pharmacists have over syringe sales even in states where over-the-counter sales are legal. Laws that allow for syringe sales without a prescription generally do not require pharmacists to sell a syringe to someone without a prescription.

In practice, pharmacy associations, corporations, and individual pharmacists retain discretion with regard to sales of nonprescribed syringes. Many pharmacists are eager to contribute their valuable services to preventing the spread of HIV infection, while others have concerns about providing syringes to IDUs. Thus, depending on pharmacist attitudes and practices, access to syringes could remain limited even in areas where syringes can be legally purchased.

In New York State, a survey of pharmacists found that only about 50% supported providing needles to IDUs, fewer than half were aware of New York's new syringe laws, and many believed that making syringes available would increase drug use.^[75] In Louisiana, where over-the-counter syringe sales are legal, only one fourth of pharmacists surveyed had ever sold a syringe to someone they suspected of being an IDU; in Maine, only 15% of pharmacists were willing to sell a syringe to an IDU "with no additional requirements," although doing so is legal; and in Baltimore, more than half reported having requirements that inhibited sales, such as requesting photo identification for purchasing a syringe.^[76] While pharmacists can play an important role in provision of sterile syringes, training and education programs may be important for this approach to be effective.

Because pharmacy sales of syringes do not require exchange and appropriate disposal of used syringes, addressing the issue of syringe disposal is important. Syringe disposal is an issue not confined to persons who inject illicit drugs. A call for a comprehensive approach to syringe disposal has recently been made by several national agencies.*

http://www.medscape.com/viewarticle/446813_5

Strategies to Improve Access to Sterile Syringes

from The AIDS Reader ^®

Conclusion

NEPs, syringe prescription, and syringe deregulation are 3 approaches to increasing access to sterile syringes for IDUs, and each has its own benefits and limitations. NEPs continue to expand in the United States but remain severely hampered by the ongoing ban on their use of federal funding. Syringe prescription for IDUs is a promising new strategy that is supported by many organizations; optimal implementation of this strategy still needs to be explored. Legalizing syringe purchase and possession to allow pharmacy sales has led to a substantial improvement in syringe access in many states but may need to be combined with efforts to ensure safe disposal and to link IDUs to medical care and other services. Other approaches to providing sterile syringes that can be considered include mass distribution, vending machines, and pharmacy-based NEPs.^[77]

*Interested parties should contact the Coalition for Safe Community Needle Disposal at 800-643-1643 .