Needle and syringe programmes (NSPs) are a type of harm reduction initiative that provide clean needles and syringes to people who inject drugs (sometimes referred to as PWID).(WHO) recommends providing 200 sterile needles and syringes per drug injector per year, in order to effectively tackle HIV transmission via this route.
Many programmes supply other equipment to prepare and consume drugs such as filters, mixing containers and sterile water. The majority are run by drug services or pharmacies and operate from a range of fixed, mobile and outreach sites.
Programmes 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) and encouragement to switch to safer drug taking practices
other health and welfare services (including condom provision)
"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."
How are needle and syringe programmes delivered?
Fixed sites
Fixed sites are typically located where the 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.
Mobile programmes
Mobile programmes operate from a van or bus with needles and syringes distributed through a door or window. Some large mobile programmes act like fixed sites with testing and other healthcare services also available.
Others run in conjunction with fixed sites. In these instances, the fixed site is typically located in an area with high numbers of peopel who inject drugs with the mobile NSP focussing on harder to reach or smaller populations.
Mobile programmes can be more accessible than fixed sites and often face less opposition than fixed sites such as the Insite facility in Vancouver, Canada.
Outreach programmes
Outreach programmes take many forms including mobile units (such as a van or bus), backpacking services on the street or even home deliveries.
They typically operate where there is a shortage of funding for needle and syringe programmes. For example, it is the preferred method of delivery in Haryana, India, where peer educators reach out to people who inject drugs who do not openly buy or sell drugs.
Some outreach programmes exist to complement fixed or mobile NSPs where injecting drug users are not engaging with established services. Outreach workers are tasked with encouraging people who inject drugs to use existing fixed or mobile sites.
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 (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.
The machines are typically mounted on the outside walls of fixed 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.
Pharmacies
Pharmacy-based NSPs operate in a number of ways. Some sell needles and syringes directly to people, while others exchange harm reduction kits for vouchers.
The main advantage of this delivery mode is that pharmacy networks are often already well established and located near to large groups of people who inject drugs. In addition, their opening hours are often more convenient than those at fixed sites.
However, they are very limited in low-income countries. Even where they do exist, some pharmacists are reluctant to sell needles and syringes or deal with their disposal. Moreover, they rarely offer education and additional healthcare services.
Needle and syringe programme coverage
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.
Only 90 needles per year are available per person who injects drugs globally - far below the recommended 200.
Asia and the Pacific
17 countries and territories in Asia implement NSPs. In Cambodia, Mongolia, the Philippines andThailand, provision exists on a very small scale. In others, provision has nearly doubled since 2012, such as in Malaysia and Australia. Despite progress in some countries, Bangladesh, China, Pakistan and Vietnam have reported a decline in the number of programmes since 2012. Vietnam has dropped the number of needles distributed from 180 per person who injects drugs in 2012 to 98 in 2014.
NSPs in Asia are delivered in a number of ways. In some places, fixed sites have been integrated with other facilities such as health clinics and pharmacies. In Laos, there is just one community-based programme on the border with Vietnam. NSP coverage is still too low to have a significant impact on HIV prevalence among injecting drug users, with a lack of human resources, inflexible hours and harsh drug policies cited as barriers to their access.
In the Pacific (Oceania), Australia and New Zealand are the only countries that have figures on people who inject drugs, and both provide NSP services. In fact, they have one of the highest 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.
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. A report by the Eurasian Harm Reduction Network estimated that only 10% of people who inject drugs in Eastern Europe and 33% in Central Asia are able to access these services.
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 injecting drug user (50).
The political reaction to harm reduction services in the area continues to be hostile, forcing many services to close. This severely affected Hungary, where its largest programme was shut down, reducing the number of clean needles available in the country by around 40%.
Western and Central Europe and North America
Generally, NSPs are widely available across Western and Central Europe and use fixed sites, pharmacy-based services, vending machines, outreach and mobile services.
The number of syringes distributed per person who injects drugs 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).
Barriers to access in the region include under 18s being denied servics, undocumented migrants not being reached, and rural areas having underdeveloped services.
NSPs are available in both the United States of America (USA) and Canada, but estimates of coverage are limited. The most recent estimates from 2010 found that only 23 syringes were distributed per person who injects drugs per year.
Latin America
The most recent data available suggest that only 2% of people who inject drugs are accessing NSP services in Latin America, with only 0.3 syringes distributed per person per year.
Only five countries in this region operate these programmes, with Brazil providing the most (between 150 and 450 sites). Argentina, Mexico, Paraguay and Uruguay make up the remaining four countries, however it is thought these services are being scaled back in all countries as a result of declining injecting drug use in the region.
The Middle East and North Africa
Nine countries in the Middle East and North Africa (MENA) currently implement needle and syringe programme Iran has doubled its provision since 2012, with many people who inject drugs continuing to get new needles from pharmacies.
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.
Sub-Saharan Africa
NSP provision throughout sub-Saharan Africa is limited to interventions by non-government organisations (NGOs), due to a lack of political and financial support from domestic governments.
However, in June 2012, the Kenyan government announced plans to distribute over 8 million needles and syringes to 50,000 people who inject drugs nationwide. In 2014, there were 10 operational programmes in the country. In Dar es Salaam, Tanzania, there were seven NSPs in 2014, up from just one in 2012.
Mauritius has the greatest coverage in the region with 83.8% of people who inject drugs using sterile injecting equipment in 2013.
The Caribbean
Data regarding people who inject drugs in the Caribbean are 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.
NSPs have been available in Puerto Rico since 2007, with six operating as of 2014. Between 2007 and 2011, they led to a 17.1% reduction in HIV infections as a result of unsafe injecting. The Dominican Republic opened its first programme in 2012, and between June and December that year it distributed 4,000 new syringes.
Barriers to accessing needle and syringe programmes
Legal and social barriers
Criminalisation
In many countries worldwide, criminalisation of injecting drug use is a major barrier to NSP services.
Criminalisation of possession of illicit substances and injecting equipment often forces people who inject drugs to hide their equipment and engage in unsafe injecting practices, with many threatened, abused, extorted or arrested by the authorities. One study from Northern Morocco reported that 87% of this group had experienced police violence.
Legal restriction
Legal age restrictions for accessing NSPs in some countries prevent access to people who inject drugs under 18 years old, despite evidence that people now start injecting drugs at an earlier age.
Mandatory detention of injecting drug users in drug detention centres in countries such as China is also a barrier to accessing these services.
Stigma and discrimination
Even in places where it is legal to purchase needles and syringes, stigma, discrimination or disapproval from the community prevent many people who inject drugs from accessing NSP services.
They also experience stigma and discrimination from healthcare workers, or receive services that are not delivered in a culturally sensitive way.
Lack of political support and funding
In many countries, there is a lack of political will resulting in a shortfall of funding for the implementation of needle and syringe programmes
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.In Canada, a lack of federal support means that NSPs are typically delivered by NGOs, civil society groups, provinces and territories, with service numbers varying dramatically between and within provinces.
Russia doesn't provide state funding for NSPs with officials maintaining that they increase injecting drug use despite evidence to the contrary. However, international donors are funding a number of programmes in cities across the country.
Some countries have suffered from the withdrawal of international funding. For example, NSPs have proved highly successful in Romania, limiting HIV prevalence to 1% among people who inject drugs. 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.
Physical and geographical barriers
In other places, access to NSPs is limited by geographical distance, particularly in remote and rural areas. A number of studies have shown that people who inject drugs who live in close proximity to programmes are more likely to use the
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