Increased pharmacy sales of sterile syringes can help reduce the risk of acquiring and transmitting blood-borne viruses among IDUs who continue to inject.

As of 2004, injection drug use accounted for about one-fifth of all HIV infections and most hepatitis C infections in the United States.^1,2 Injection drug users (IDUs) become infected and transmit the viruses to others through sharing contaminated syringes and other drug injection equipment and through high-risk sexual behaviors. Women who become infected with HIV through sharing needles or having sex with an infected IDU can also transmit the virus to their babies before or during birth or through breastfeeding.

To effectively reduce the transmission of HIV and other blood-borne infections, programs must consider a comprehensive approach to working with IDUs. Such an approach incorporates a range of pragmatic strategies that address both drug use and sexual risk behaviors. One of the most important of these strategies is ensuring that IDUs who cannot or will not stop injecting drugs have access to sterile syringes. (See the related fact sheet Access to Sterile Syringes.) This strategy supports the "one-time-only use of sterile syringes" recommendation of several institutions and governmental bodies, including the U.S. Public Health Service.³

How Can Pharmacies Help IDUs Obtain Sterile Syringes?

IDUs who continue to inject have several sources of syringes -- "black market" sources, friends or injection partners, physicians, pharmacies, and syringe exchange programs (SEPs). They can be assured of getting sterile syringes through only three of these sources -- physicians, pharmacies and SEPs.

Pharmacies therefore are a critically important element in efforts to help IDUs reduce their risks of acquiring and transmitting blood-borne viruses.

Recognizing the key role of pharmacy sales of sterile syringes, the American Medical Association, the American Pharmaceutical Association, the Association of State and Territorial Health Officials, the National Association of Boards of Pharmacy, and the National Alliance of State and Territorial AIDS Directors issued a joint letter in October 1999 urging state leaders in medicine, pharmacy, and public health to coordinate their actions to improve IDUs' access to sterile syringes through pharmacy sales.⁴

What Are the Advantages of Pharmacy Sales?

Pharmacies are a reliable source of sterile syringes. They:

• are conveniently located in most neighborhoods and often have extended hours of operation; some are open 24 hours a day;

• are staffed by trained, licensed health care professionals who are able to provide sound medical advice and to make referrals for a variety of related services, including HIV testing and counseling, substance abuse treatment, health care, and other community services;

• have the existing infrastructure, including the staff and inventory, to offer syringe sales as part of their ongoing services (an added benefit here is that because purchasers pay for the syringes, pharmacy sales require no expenditure of public funds);

• provide privacy for the person who does not want to be identified as an IDU by going to a physician or an SEP; and

• sometimes accept used syringes for safe disposal. (See the related fact sheet Syringe Exchange Programs.)

What Laws and Regulations Affect Pharmacy Sales?

A number of laws, regulations, and pharmacy practice policies effectively restrict pharmacy sales of sterile syringes to IDUs.⁵ For example, 47 states plus the District of Columbia and the Virgin Islands have drug paraphernalia laws that criminalize the sale and possession of syringes if it is known that they may be used to inject illegal drugs. Eight states and the Virgin Islands also have laws requiring individuals to have a valid medical prescription to purchase syringes. (See the related fact sheet, State and Local Policies Regarding IDUs' Access to Sterile Syringes.)

In addition, 23 states have pharmacy regulations or practice guidelines that restrict pharmacists from selling sterile syringes to IDUs or that impose additional requirements on customers who wish to purchase syringes. Some pharmacy chains and individually-owned pharmacies also have policies that restrict over-the-counter sales of syringes.⁶

Many individual pharmacists are also reluctant to sell sterile syringes to IDUs even where such sales are legal.^7,8,9 This reluctance stems from negative feelings toward IDUs, disapproval of injection drug use, concerns about unsafe disposal of used syringes, and concerns about safety and crime. Many pharmacists follow procedures that make it more difficult for IDUs to buy syringes, such as asking for photo identification, requiring the name and address of the customer, asking for confirmation of diabetic status, asking the customer to explain why they need to buy the syringes, or selling only to individuals who are known to the pharmacist.^7,8

What Have States Done to Increase Pharmacy Sales?

The Connecticut Experience

In 1992, Connecticut changed its laws to legalize both the nonprescription purchase and the possession of 10 or fewer sterile syringes. The results were encouraging. After the law changed, 83% of pharmacists sold nonprescription syringes.¹⁰ IDUs reported that their syringe purchases from pharmacies rose from 19% to 78%, and street or "black market" purchases fell from 74% to 28%.¹¹

Several state health departments are working with state pharmacy associations, medical societies, and boards of pharmacies to raise awareness about the barriers to the purchase of sterile syringes and to review laws and regulations. In Connecticut, Minnesota, and Maine, where laws prohibiting the purchase or possession of syringes have been repealed, health departments and pharmacies have formed partnerships to educate pharmacists, address their concerns, encourage them to sell sterile syringes to IDUs, and encourage participation in safe disposal efforts.

In 1995 and 1996, the Connecticut Department of Public Health sponsored an intervention in which a University of Connecticut School of Pharmacy (UCSP) faculty member and the local health department AIDS coordinators in two cities worked with local pharmacists to encourage them to sell or provide free an "IDU packet" containing two sterile syringes and two condoms. The local health department supplied the packets. A key part of the intervention was visits to the pharmacies by the UCSP professor and the local health department AIDS coordinator. This gave the health department a chance to talk about the importance of access to sterile syringes in reducing disease transmission, and it allowed the local pharmacists to ask questions and express their concerns. Results from this program showed that pharmacists can become active participants in AIDS prevention activities and that pharmacies, schools of pharmacy, and local health departments can collaborate in HIV prevention for IDUs.¹²

Additional Activities Undertaken by Communities

• Reviewing the public health impact of policies and regulations that restrict pharmacy sales of syringes, of laws that require a prescription to purchase syringes, and of laws that make possession and distribution of syringes a crime. An important element of this process was clarifying that preventing the transmission of HIV and other blood-borne infections is a legitimate medical purpose for the sale of sterile syringes to IDUs who continue to inject.

• Encouraging pharmacists to work with local medical societies and physicians to increase physician prescription of sterile syringes. (See the related fact sheet Physician Prescription of Sterile Syringes to Injection Drug Users.)
• Educating pharmacists that increasing IDUs' access to sterile syringes does not increase the number of people who inject drugs or the number of drug injections.^13,14

• Addressing pharmacists' public health concerns about the safe disposal of used syringes. (See the related fact sheet Syringe Disposal.)

• Discussing the public health contribution of pharmacy-based sales to controlling the HIV and viral hepatitis epidemics at pharmacy schools, continuing education programs, and other venues.

• Recruiting pharmacists to participate in HIV Prevention Community Planning Groups and other public health activities.

For More Information

Read A Comprehensive Approach: Preventing Blood-Borne Infections Among Injection Drug Users, which provides extensive background information on HIV and viral hepatitis infection in IDUs and on the legal, social, and policy environment. It also describes strategies and principles for addressing these issues.

Sources

1. Glynn M, Rhodes P. Estimated HIV prevalence in the United States at the end of 2003. 2005 National HIV Prevention Conference; June 12-15, 2005. Atlanta, GA. Abstract T1-B1101.
2. Centers for Disease Control and Prevention (CDC). Hepatitis C fact sheet. Accessed December 22, 2005 from www.cdc.gov/ncidod/diseases/hepatitis/c/fact.htm.
3. Centers for Disease Control and Prevention, Health Resources and Services Administration, National Institute on Drug Abuse and Substance Abuse and Mental Health Services Administration. HIV prevention bulletin: Medical advice for persons who inject illicit drugs. May 9, 1997.
4. National Alliance of State and Territorial AIDS Directors. HIV prevention and access to sterile syringes. Joint letter issued by the American Medical Association, American Pharmaceutical Association, Association of State and Territorial Health Officials, National Association of Boards of Pharmacy, National Alliance of State and Territorial AIDS Directors. October 1999.
5. Gostin LO, Lazzarini Z, Flaherty K, Jones TS. Prevention of HIV/AIDS and other blood-borne diseases among injection drug users: A national survey on the regulation of syringes and needles. JAMA 1997;277(1):53-62.
6. Jones TS, Taussig J. Should pharmacists sell sterile syringes to injection drug users? Journal of the American Pharmaceutical Association 1999:39(1):8-10.
7. Case P, Beckett GA, Jones TS. Access to sterile syringes in Maine: Pharmacy practice after the 1993 repeal of the syringe prescription law. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology 1998;18(Suppl 1):S94-S101.
8. Gleghorn AA, Gee G, Vlahov D. Pharmacists' attitudes about pharmacy sale of needles/syringes and needle exchange programs in a city without needle/syringe prescription laws. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology 1998;18(Suppl 1):S89-S93.
9. Wright-De Agüero L, Weinstein B, Jones TS, Miles J. Impact of the change in Connecticut syringe prescription laws on pharmacy sales and pharmacy managers' practices. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology 1998;18(Suppl 1):S102-S110.
10. Valleroy LA, Weinstein B, Jones TS, Groseclose SL, Rolfs RT, Kassler, WJ. Impact of increased legal access to needles and syringes on community pharmacies' needle and syringe sales -- Connecticut, 1992-1993. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology 1995;10:73-81.
11. Groseclose SL, Weinstein B, Jones TS, Valleroy LA, Fehrs LJ, Kassler WJ. Impact of increased legal access to needles and syringes on practices of injecting-drug users and police officers -- Connecticut, 1992-1993. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology 1995;10:82-89.
12. Weinstein B, Toce P, Katz D, Ryan LL. Peer education of pharmacists and supplying pharmacies with IDU packets to increase injection drug users' access to sterile syringes in Connecticut. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology 1998;18(Suppl 1):S146-S147.
13. Normand J, Vlahov D, Moses LE, eds. Preventing HIV transmission: the role of sterile needles and bleach. Washington (DC): National Academy Press, 1995.
14. Needle RH, Coyle SL, Normand J, Lambert E, Cesari H. HIV prevention with drug-using populations -- current status and future prospects: introduction and overview. Public Health Reports 1998;113(Suppl 1):4-18.