Difficult-To-Reuse Needles for the

Prevention of HIV Infection Among Injecting

Drug Abusers

October 1992

OTA-BP-H-103

NTIS order #PB93-101749
Recommended Citation:

U.S. Congress, Office of Technology Assessment, Difficult-to-Reuse Needles for the

Prevention of HIV Infection Among Injecting Drug Users--Background Paper, OTA-IW-H103 (Washington, DC: U.S. Government Printing Office, October 1992).

For sale by the U.S. Government Printing Office

Superintendent of Documents, Mail Stop: SSOP, Washington, DC 20402-9328

ISBN 0-16 -038097- 9
Foreword

Substance abuse places a significant burden on both our Nation’s citizens and our

economy. The high incidence of human immunodeficiency virus (HIV) and acquired

immunodeficiency syndrome (AIDS) among injecting drug users through the sharing of

needles compound this problem. One-third of all cases of HIV are directly or indirectly linked

to needle sharing at a cost to Federal taxpayers in excess of $1 billion during 1992 alone. To

reduce the spread of HIV among injecting drug users, their children, and their sexual partners,

some health experts including C. Everett Koop, the former Surgeon General of the United

States, have proposed altering the design of needles and syringes so they are difficult or

impossible to reuse.

This study was conducted in response to a request by the Subcommittee on Regulation,

Business Opportunities, and Energy of the House Committee on Small Business. We evaluate

the likelihood that a redesign of injection equipment would actually reduce HIV infections.

We also examine the proposal’s feasibility and some of its implications for the use of needles

and syringes within the health care system.

This background paper is the ninth in OTA’s series of studies on HIV-related issues. The

preceding papers in this series were: Do Insects Transmit AIDS? (9/87); AIDS and Health

Insurance--An OTA Survey (2/88); How Effective Is AIDS Education? (6/88); The Impact of

AIDS on the Kaiser Permanence Medical Care Program (Northern California Region) (7/88);

How Has Federal Research on AIDS/HIV Disease Contributed to Other Fields? (4/90); The

Effectiveness of Drug Abuse Treatment: Implications for Controlling AIDS/HIV Infection

(9/90); HIV in the Health Care Workplace (11/91); and The CDC’S Definition of AIDS:

Implications of the Proposed Revisions (8/92). Previous OTA reports addressing AIDSrelated issues include: Blood Policy and Technology (1/85); Review of the Public Health

Service’s Response to AIDS (technical memorandum, 2/85); The Cost of AIDS and Other HIV

Infections: Review of the Estimates (staff paper, 5/87); Medical Testing and Health Insurance

(8/88); and Adolescent Health (11/91).

/(’2? @’4.J4’ k

JOHN H. GIBBONS

U Directo r

. . .

Ill
Difficult-to-Reuse Needles and Syringes for the Prevention of HIV Infection

Among Injecting Drug Users

Background Paper

Prepared for OTA by:

Don C. Des Jarlais

Beth Israel Medical Center

New York, NY

Michael E. Gluck, Project Director, HIV-Related Series

Sharon Hamilton, Research Assistant

Julie B. Livingston, Research Assistant

This background paper was prepared as part of OTA’s

ongoing HIV-related assessment.
Glossary of Abbreviations

DTR -difficult to reuse

AIDS —acquired immunodeficiency syndrome

—human immunodeficiency virus

WHO —World Health Organization
Contents

summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .00..0.. .

Scope of the Background Paper . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Economic Factors in the Injection of Illicit Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

World Health Organization Plans for Self-Destructing Syringe Designs . . . . . . . . . . . . . . . . . . . . .

Conceptual and Definitional Clarification of Single-Use Injection Equipment . . . . . . . . . . . . . . .

System Issues . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

The Critical Policy Question . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Users’ Views . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

New Design Criteria and New Technologies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● . . . . . . . . . . . . . .

Distribution Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ● *.**... . . . . . . .

The Blanket Strategy vs. Targeted Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Targeted Distribution of Difficult-to-Reuse Injection Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . .

Implications of Difficult-to-Reuse Syringes for General Medical Use . . . . . . . . . . . . . . . . . . . . . . .

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Difficult-to-Reuse Needles for the Prevention of

HIV Infection Among Injecting Drug Users

SUMMARY

Substance abuse is a major social problem with

enormous human and economic costs against which

the United States directs significant resources for

law enforcement, interdiction, treatment, and prevention. Greatly increasing the costs of substance

abuse is the problem of human immunodeficiency

virus (HIV) infection among persons who inject

illicit drugs. In the United States, approximately

one-third of all cases of acquired immunodeficiency

syndrome (AIDS) has been associated with the

sharing of drug injection equipment either as a direct

risk behavior or by being the child or sexual partner

of someone who injects illicit drugs. A wide variety

of prevention programs-from drug abuse treatment

to over-the-counter sales of injection equipment to

syringe exchange to bleach distribution-have led to

large-scale reductions in AIDS risk behavior among

injecting drug users. No prevention program, however, has led to complete risk elimination, and the

persistence of new HIV infections among injecting

drug users in places such as Amsterdam in the

Netherlands (which has developed a relatively

comprehensive AIDS prevention program) suggests

the need for new strategies. The use of either

single-use, self-destructing, non-reusable or autodestruct injection equipment has received some

attention as a possible means for further reducing

HIV transmission among injecting drug users.

This paper reviews various possibilities of using

non-reusable injection technologies for reducing

HIV transmission among injecting drug users in the

United States. It does not put forth the redesign of

injection equipment as a policy option for congressional consideration; it merely examines some of the

implications of a proposal put forth by some health

experts. Sources of data used in this review include

scientific publications, presentations at professional

meetings, and interviews with knowledgeable individuals: active drug injecters, designers of new

injection equipment, and officials of the Netherlands

and Australia (where plans to utilize non-reusable

injection equipment were considered but not implemented).

The analyses in this paper indicate that redesigning injection equipment is unlikely to reduce the

spread of HIV and may have other unintended

consequences. There is no syringe yet designed and

feasible to manufacture that could not be defeated by

someone seeking to reuse it. Distributing enough

syringes to prevent the establishment of a black

market for injection equipment that can be easily

reused presents significant logistical and ethical

dilemmas. In addition, evidence indicates that many

of the proposed redesigns would interfere with usual

drug-taking practices, making many drug users

unlikely to accept them. Redesigned syringes would

also likely cost more than current syringes and could

significantly add to medical waste problems. Some

injecting drug users have, however, indicated a

willingness to use redesigned injection equipment in

order to reduce the transmission of HIV. “Targeted” distribution of redesigned injection equipment could be used to identify those situations in

which: 1) injecting drug users would be least likely

to try defeating difficult-to-reuse equipment; 2) the

cost, supply, and safe disposal problems would be

manageable; and 3) use of difficult-to-reuse equipment would have the greatest impact on reducing

HIV transmission among injecting drug users.

New designs of injection equipment have also

been proposed to replace equipment that is currently

intended to be reused with different patients in

medical care settings and to reduce accidental

puncture (needle stick) injuries. These purposes are

substantially different from the purpose of reducing

HIV transmission among persons injecting illicit

drugs, and new designs for these purposes will be

touched on only briefly in this paper.

From the perspective of a drug user, intravenous

injection is by far the most cost-efficient method of

administering drugs such as heroin and cocaine.

Injection provides a strong drug effect through the

rapid accumulation of drug in the brain, and allows

almost all of the drug to be consumed. For persons

who use illicit drugs, powerful economic incentives

favor the injection method of administration. In a

situation where injection equipment was scarce,

even stronger economic incentives would favor

reuse of injection equipment. Many of the current

single-use, but easy-to-reuse needles and syringes

available can be used dozens of times before the

needle becomes too dull for further injection or the

–l–
2 ● Difficult-to-Reuse Needles for the Prevention of HIV Infection Among Injecting Drug Users

syringe becomes clogged. Strategies for possible use

of non-reusable injection equipment would thus

need to include consideration of the strong economic

incentives for injecting illicit drugs and for obtaining

reusable injection equipment for use with illicit

drugs.

It is probably better to consider potential new

injection equipment as difficult-to-reuse (DTR)

rather than truly non-reusable, and that is the term

that will be used in this background paper. All

designs of injection equipment surveyed for this

paper could be defeated through one or more

methods. Even if it was possible to produce impossibleto-reuse injection equipment, a system of nonreusable injection equipment could be defeated

through: 1) hand-assembled, easy-to-reuse injection

equipment; 2) illicitly manufactured, easy-to-reuse

injection equipment; or 3) importation of easy-toreuse injection equipment from other areas.

While there are interesting and important aspects

of the technology of DTR injection equipment, use

of such equipment to reduce HIV transmission

among injecting drug users may well be more a

question of the policy framework within which such

equipment is adopted than of specific technologies

proposed. DTR technology might, for instance, be

adopted within general medical settings without

simultaneous provision of equipment to persons

injecting illicit drugs. This situation would create a

scarcity of injection equipment in the illicit market,

and trigger attempts to defeat the DTR technology

through several means. This situation might actually

lead to more multiperson use (sharing) of illicit

drug-injection equipment and hence an increase in

HIV transmission among injecting drug users.

DTR technology might also be adopted for use

within general medical settings with concurrent

efforts to fully provide DTR equipment to injecting

drug users. The logistics of providing enough DTR

equipment to drug injecters and of safely disposing

of the used (potentially HIV-contaminated) equipment are, however, formidable problems. Redesigned syringes would also likely cost significantly

more than current syringes and would add to medical

waste. An additional problem would be the great

difficulty in doing any pilot testing of such a

strategy, given that a pilot test would require finding

a geographic area with at least a modest number of

illicit drug injecters and yet isolated from illicit

supplies of easy-to-reuse injection equipment.

Another strategy would be to target distribution of

DTR needles and syringes more selectively, to

situations where multiperson use of injection equipment is highly likely, such as “shooting galleries”

and among dealers who lend or give injection

equipment to their customers. Previous research has

indicated that sharing in these situations is particularly associated with rapid spread of HIV among

drug injecters. Implementation of such a strategy

would require cooperation between health care

workers and persons involved in illicit drug use of a

kind that would probably be difficult to achieve or to

maintain. Such a strategy could be field-tested,

however, without altering the use of injection

equipment within usual medical settings. It would

thus be possible to gain more field experience with

the likely frequency and methods for defeating DTR

technology, as well as provide the best means for

furthering cooperation between health care workers

and injecting drug users to reduce HIV transmission.

INTRODUCTION

Substance abuse is a major social problem with

enormous human and economic costs. Current

American efforts directed against this problem

include numerous programs and policies for law

enforcement, interdiction, treatment, and prevention. The elimination of illicit drug injection will no

doubt require continued diligence, creativity, and

resources. However, substance abuse does occur,

and the transmission of HIV through multiperson

use of equipment for injecting illicit drugs has

become a major public-health problem in itself.

Approximately one-third of AIDS cases in the

United States are associated with the injection of

illicit drugs. Moreover, HIV can spread very rapidly

once it has been introduced into a local community

of injecting drug users, with up to half of the drug

injecters becoming infected within the next few

years. Once HIV has become established among

injecting drug users, it can then spread to their sexual

partners and newborn children. In the United States,

over half of the cases of heterosexual and perinatal

transmission are related to illicit drug injection. (See

Des Jarlais et al. (7) for a recent review of the

international epidemiology of HIV among injecting

drug users). This paper specifically focuses on one

proposal to eliminate illicit drug injection as a route

of HIV transmission-the redesign of syringes and

needles to prevent their being used more than once.
Difficult-to-Reuse Needles for the Prevention of HIV Infection Among Injecting Drug Users ● 3

A number of different programs to prevent further

spread of HIV among injecting drug users have

already been implemented. In almost all other

countries, legal access to sterile injection equipment,

whether through syringe exchanges, over-thecounter sales, or both, has been the predominant

prevention strategy. In the United States, on the

other hand, the expansion of drug abuse treatment

programs and the distribution of bleach for disinfecting used injection equipment have so far been the

preferred prevention strategies. (However, the National Commission on AIDS has recently called for

legal access to sterile injection equipment for

injecting drug users (14)).

A wide variety of AIDS prevention programs has

led to risk reduction among injecting drug users (5),

but a substantial number of new HIV infections are

still occurring. This fact remains true even in places

like Amsterdam that have both large-scale drug

abuse treatment programs and large-scale syringe

exchange programs (27). This discouraging trend

suggests the need for additional AIDS prevention

strategies for injecting drug users, in conjunction

with drug abuse treatment, legal access to (current

types of) injection equipment, and distribution of

bleach programs.

The development of either single-use, selfdestructing, or auto-destruct syringes as another

method of preventing the transmission of HIV

among injecting drug users has been advocated in

the United States and in other countries. Former

Surgeon General C. Everett Koop (21) has been one

of the foremost advocates of such ‘‘selfdestructing” syringes in the United States. “Singleuse” or “self-destructing” syringes had also been

considered at one time as a means for reducing the

spread of HIV among injecting drug users in both the

Netherlands and Australia, although the method was

not adopted in either country.

Scope of the Background Paper

This paper examines the possibility of how

single-use, self-destructing, or auto-destruct syringes might best be used to help reduce the

transmission of HIV among persons who inject

illicit drugs in the United States. It does not put forth

the redesign of injection equipment as a policy

option for congressional consideration; it merely

examines some of the implications of the proposal

by Dr. Koop and others. The analysis includes an

examination of potential policy, technical, and

organizational problems that would have to be

addressed in order to implement the use of such

syringes in the United States. The question of

whether persons who inject illicit drugs would have

legal access to this new injection equipment and,

even if they did have legal access, how sufficient

quantities of equipment would be distributed, are

two of the major policy and organizational issues

addressed.

Before considering the problem of how new

designs for injection equipment might be used to

reduce the transmission of HIV among injecting

drug users, it is important to note two points. First,

most injection equipment used for medical purposes

in the United States is intended only to be used once

even though their designs permit multiple use. And

second, the problem of HIV among injecting drug

users is not the only reason for redesigning injection

equipment. Some groups are involved in redesigning

injection equipment in order to reduce the chances of

accidental needle stick injuries that occur in health

care settings with present equipment. Others are

redesigning the injection equipment that is reused in

health care settings in developed countries so that it

would be single-use in the sense that it was intended

to be used with only one patient (11). Most of these

redesigns would not, however, prevent the equipment from being reused, especially if it was obtained

for use in injecting illicit drugs. Consideration of

these other reasons for redesigning injection equipment is beyond the scope of the present paper.

However, before any such new designs were adopted

on a large scale in the United States, some consideration should be given to the question of how the new

designs might affect HIV transmission among persons who inject illicit drugs.

The World Health Organization (WHO) is also

working toward using new designs for injection

equipment in its childhood immunization programs

in developing countries. The purpose of the new

WHO designs is to reduce the chances of transmitting HIV and other blood-borne pathogens. This

concern is also a fundamentally different problem

than reducing HIV transmission among injecting

drug users, but shares an important similarity in

that-in the context both of developing countries

and of illicit drug injection-there may be substantial economic and logistical incentives to reuse the

injection equipment. This paper will therefore also

consider some of the design criteria and design
4 ● Difficult-to-Reuse Needles for the Prevention of HIV Infection Among Injecting Drug Users

solutions now being developed through the WHO

efforts.

METHODS

Several methods were used to obtain the data

presented in this paper, including a review of the

very limited literature now available on single-use

syringes for injecting illicit drugs. In addition,

interviews were conducted with: 1) a manufacturer

of single-use syringes; 2) persons operating a

syringe exchange in the United States; 3) 17 drug

users attending syringe exchanges in the United

States; 4) drug users who were part of a small field

test of one possible design; and 5) officials who

considered using single-use syringes in the Netherlands and Australia.

ECONOMIC FACTORS IN THE

INJECTION OF ILLICIT DRUGS

The official policy of the United States is to

discourage the nonmedical use of drugs such as

heroin and cocaine by making them very expensive

to the user (17). Some drug users spend literally

hundreds of dollars per day on illicit drugs, such that

the economics of obtaining drugs can become the

dominating factor in their lives. Thus, before considering the various types of redesigned syringes, it will

be very helpful frost to consider some of the basic

economic factors of injecting illicit drugs versus

other routes of administration, and of easy-to-reuse

versus DTR equipment.

The relatively high price for the user in itself

creates economic pressure to use methods of drug

administration that the user finds cost-efficient. If

the drug has been obtained at a high cost, the user

will be motivated to administer the drug in a manner

which both provides an intense drug effect and uses

as much as possible of the drug. From the user’s

perspective, intravenous injection is by far the most

cost-efficient method for administering most illicit

drugs. Intravenous injection not only provides a

particularly strong drug effect-because of how

rapidly the drug is delivered to the brain-but also

uses almost all of the drug. Of course, smoking a

drug also provides rapid delivery to the brain, but a

sizable portion of the drug fumes are not inhaled.

Drug users report that intravenous injection is

approximately three times as effective as other

methods of administration in terms of drug effect per

unit cost (3). This increased efficiency is clearly

relevant only to drug users who are willing to inject

and in situations where the cost of the drug is an

important factor. In many parts of the United States,

the supplies of heroin and cocaine are abundant

enough that price is not an overriding factor for

many drug users. Once a drug user develops an

ever-increasing dependence on a drug, however,

cost is likely to become an important factor for that

individual, even if the drug is plentiful and lowpriced in the city as a whole.

Drug injecters in New York had at one time

reported that some needles and syringes were being

reused in shooting galleries as many as 40 to 50

times-until the syringe clogged or the needle

became too dull for another injection (12). The

economic advantage of injection equipment easily

reusable over one-use-only equipment is thus potentially very great. Again, the practical importance of

this economic advantage would vary according to

the relative availability of equipment for injecting

illicit drugs. Currently, injection equipment in many

localities throughout the United States is sufficiently

available that many drug injecters often use a needle

and syringe once and then discard the equipment (9).

As will be discussed below, however, the introduction of new needle-syringe designs, if carried out

under policy guidelines that forbade supplying

injection equipment to injecting drug users, could

dramatically increase the street value of easily

reusable equipment.

These cost-efficiency factors become decisive

only under conditions of great scarcity-both of the

drugs themselves and of the injection equipment—

and obviously apply only to persons who are willing

to inject illicit drugs. While great scarcity of either

injection equipment or drugs may not occur often

among drug users, such scarcity is also not a rare

occurrence. As tolerance for a drug increases,

scarcity may occur at an individual level even if it is

not occurring in a geographical area as a whole.

Whether equipment for injecting illicit drugs would

become scarce under a system of DTR syringes is

one of the most important questions to be considered

in assessing the likely effectiveness of any system

that would attempt to use new syringe designs to

reduce HIV transmission among injecting drug

users.

This discussion of economic factors of injecting

versus non-injecting and of easy-to-reuse equipment

versus DTR equipment is not meant to imply that
Difficult-to-Reuse Needles for the Prevention of HIV Infection Among Injecting Drug Users ● 5

economic factors are the sole determinant of the

ways people use illicit drugs. In particular, it is not

meant to imply that persons who inject illicit drugs

are not concerned about AIDS. In fact, a great

amount of evidence indicates that drug injecters

throughout the world are concerned about AIDS, and

further, that they have changed their behavior to

reduce their risk of developing AIDS (7). Most of

this risk reduction has occurred in the context of an

increased supply of easy-to-reuse injection equipment. In situations of drug scarcity, economic

considerations will strongly favor injection over

other routes of administration, and in situations of

equipment scarcity, economic considerations will

strongly favor equipment that can easily be reused.

WORLD HEALTH ORGANIZATION

PLANS FOR SELF-DESTRUCTING

SYRINGE DESIGNS

As noted above, the WHO plans to use DTR

syringes for childhood immunization programs in

developing countries. Economic factors helped create the possibility for reuse of needles and syringes

in the WHO program. The WHO childhood immunization program, thus, has important similarities with

single-use illicit drug injection programs, where

there also may be important economic factors

leading to reuse of injection equipment.

The WHO initially formulated performance criteria for prospective self-destructing syringes; manufacturers then submitted over 200 different designs

in accordance with these criteria. Not only did small

entrepreneurial companies respond quite enthusiastically, but after some initial reluctance, large

manufacturers also expressed positive interest (8). It

now appears likely that the WHO will adopt a

self-destructing syringe design (or will use machines

that do not require needles for injection of childhood

immunizations).

Several important differences can be noted between the WHO’s modest performance criteria for

single-use syringes, compared with what would be

desirable performance criteria for the single-use

syringes that could reduce HIV transmission among

injecting drug users. The WHO criteria required

only that the needle and syringe be difficult to

reuse-not impossible or even exceedingly difficult.

Additionally, in the case of childhood immunization, persons attempting to defeat single-use syringes will clearly not expend more than the legal

cost of additional syringes to defeat the single-use

design. In the illicit drug injection situation, however, if a scarcity of injection equipment exists, it

may be quite profitable to expend many times the

legal costs of additional syringes to defeat the

single-use design. Finally, the WHO performance

criteria applied only to needles and syringes combined as a single unit. The much more difficult

problem of simultaneously designing separate singleuse needles and single-use syringes was not addressed.

Based on the designs submitted to the WHO and

presented at the First International Conference on

Self-Destructing (Non-Reusable) Syringes (13), four

general approaches to creating self-destructing, nonreusable, auto-destruct or single-use syringes can be

considered:

A hydrophilic gel that can be placed within

the syringe to disable the plunger or close the

passageway through the syringe and needle.

The gel will absorb water and expand when it

comes in contact with the solution to be

injected. This expansion can either close the

passageway through the syringe and needle

directly, or else mechanically trigger a device

that closes the passageway or disables the

plunger in the syringe. Such syringe designs

could be defeated either by removing the gel

before the first use of the syringe, or by

scavenging useful parts of the needle and

syringe for use with hand-assembled injection

equipment (e.g., cutting off the needle and

attaching it to another syringe or syringelike

device). (This latter strategy can, of course, be

used to defeat almost all types of DTR syringe

designs.) Moreover, two or more persons could

potentially inject using a single syringe before

the gel had expanded sufficiently to disable the

syringe. The hydrophilic gel design also clearly

could not be applied to many medical needles

where a solution passes through the needle for

an extended time, such as the needles used for

intravenous infusions.

Plungers that are disabled when the user

attempts to reload the syringe for a second

injection. Such syringe designs often involve a

ratchet device that makes it difficult to pull the

plunger back once the plunger has been fully

inserted into the syringe barrel; the ratchet

mechanism also creates a weak point in the

plunger so that the plunger will break easily
6 ● Difficult-to-Reuse Needles for the Prevention of HlV Infection Among Injecting Drug Users

when the user attempts to pull-back past the

ratchet device. Such syringe designs could be

defeated by removing the ratchet device or

reinforcing the plunger so that it does not break

when pulled back past the ratchet. The designs

could also be defeated by removing the plunger

and putting a suction bulb on the end of the

syringe barrel. Parts might also be scavenged

for use in hand-assembled injection equipment.

One design of this plunger-disabling syringe

was inadvertently tested at an American syringe exchange site when the difficult to reuse

syringes were accidentally included with other

syringes to be exchanged. The drug user who

received these syringes was amused to discover

these syringes and reported that it took him

about 30 seconds to defeat the disabling device.

(He injected without pulling the plunger back

far enough to disable it.)

Needles that are disabled after the first use of

the syringe. The WHO found these designs

proved the least satisfactory. They were often

the most mechanically complicated and, thus,

prone to failure, whether while giving the initial

injection or during the disabling. Even a very

modest failure rate for the purposes of administering the initial injection would of course

make these unacceptable for general medical

use. Moreover, many of these devices required

that the user actively disable the needle, so that

a user who did not want to disable the syringe

would not have to. Parts could also be scavenged for hand-assembled injection equipment.

The major advantage of these designs-rather

than in preventing reuse-appears to be in their

potential for reduction in accidental needle

stick injuries after the syringes have been used.

Preventing such needle stick injuries is an

important aspect of HIV transmission in health

care settings, but is, nonetheless, a different

issue than preventing HIV transmission among

injecting drug users.

Valves that prevent a second loading of the

syringe. Many of these values incorporate a

one-way flow mechanism that is activated after

the syringe is loaded. The syringe can thus be

emptied but not reloaded. However, many of

these designs can be defeated by simply removing the valve mechanism in the following

manner: First the plunger is removed, then the

barrel of the syringe is cut near the needle end,

then the valve mechanism is removed, and

finally a bulb is placed over the end of the barrel

to provide the suction necessary for further

injections. Even for those designs where the

valve mechanism could not be removed without totally destroying the syringe barrel, the

needle could still be clipped off and combined

with a medicine dropper for multiple-use injections.

Variations on these four types could conceivably

be considered, as well as methods for defeating the

specific variations. However, given that over 200

designs were submitted to the WHO, this review

could lead to a long and extremely technical

discussion. More useful to policy makers is to

consider some general principles regarding singleuse syringes.

CONCEPTUAL AND

DEFINITIONAL CLARIFICATION

OF SINGLE-USE INJECTION

EQUIPMENT

The terms single-use, self-destructing, and nonreusable are confusing and, indeed, are probably

misnomers with respect to injection equipment.

First, most needles and syringes are already single

use in that they are intended to be used only once and

then discarded. The present equipment can, however, easily be reused many times. With respect to

possible new designs, no design appears to be truly

a ‘‘needle and syringe that cannot under any

circumstances be used more than once. In the

words of one manufacturer whose design was

approved by the WHO, “All designs can be defeated.’ Of course, there can be no absolute

certainty whether someone might develop a design

for a needle and syringe that could not be reused and

that could be produced at a reasonable cost. Unfortunately, there also can be no certainty that what

initially appeared to be a truly undefeatable design

might not eventually be defeated-even after it was

adopted for general medical use in the United States.

Therefore, rather than speak of single-use, selfdestructing, or auto-destruct syringes, we will instead speak of difficult-to-reuse syringes. This more

precise terminology is intended to change the focus

to what realistically may be attainable with some

creative “thinking and resources.
Difficult-to-Reuse Needles for the Prevention of HIV Infection Among Injecting Drug Users ● 7

SYSTEM ISSUES

Rather than just considering the merits of individual syringe or needle designs, policymakers should

concentrate on the difficulties in establishing any

system of single-use injection equipment, even if a

perfect single-use syringe was developed. First, as

suggested above, any attempt to impose either a

single-use or difficult to reuse syringe system on

illicit drug users can be defeated by the use of

hand-assembled injection equipment. Indeed, prior

to the introduction of the inexpensive, disposable

but multiple-use diabetic combined needles and

syringes, most illicit drug users did use handassembled injection equipment. The most common

method these drug users used was to attach a medical

needle to a medicine dropper (25). Many longtime

heroin injecters say they preferred this type of

equipment because the bulb permitted them finer

control of the injection process. It is also worth

noting that illicit drug users prefer medical needles,

for injection over such hand-assembled equipment,

but medical needles were far from required. In fact,

needles used for inflating sports equipment have

been sharpened by filing them against concrete, and

then used for injecting drugs.

Thus, this potential for hand-assembled injection

equipment by itself would be sufficient to defeat a

single-use syringe system in the United States, even

if there was a perfect single-use combined needle

and syringe. We have yet to see any designs that

would render all medical needles truly single-use

and cannot imagine designs for reasonably priced

single-use medicine droppers, single-use baby pacifiers, or single-use needles for inflating sports

equipment.

Another factor worth noting is that some handassembled injection equipment may transmit more

blood than the diabetic syringes now commonly

used for injecting illicit drugs. Because some

hand-assembled injection equipment would not

require a lubricated plunger, it could also be reused

more times than the diabetic syringes. Thus, the

hand-assembled equipment might be more likely to

transmit HIV.

Moreover, a systematic plan to use single-use/

DTR syringes in the United States could be defeated

by illicitly importing multiple-use syringes from

other areas. According to one drug user interviewed

for this paper, many of the syringes used for the

297-941 0 - 92 - 2 : QL 3

injection of illicit drugs in southern California are

already smuggled in from Mexico (2). If a scarcity

of illicit injection equipment occurred in major

cities, one would predict moderate-to-large-scale

smuggling of multiple-use needles and syringes into

the United States from other countries would transpire. For instance, in New York City, the current

street value of a new illicit multiple-use needle and

syringe ranges from $1 to $5 (the latter where the

demand is high), but New York City also has a

relatively steady supply of multiple-use injection

equipment diverted from medical sources. If a

scarcity led to a major increase in street prices for

multiple-use injection equipment, then one would

have to expect an even larger smuggling system to

develop. Indeed, the lack of a sufficiently isolated

geographic area was the reason the Dutch abandoned

a plan to try single-use syringes as a method for

reducing HIV transmission among injecting drug

users (l).

If illicit importing of multiple-use injection equipment developed on a large scale, it is likely that only

the multiple-use needles (i.e., without syringes)

would be smuggled into the United States. Smuggling only needles would greatly reduce the bulk of

the material to be smuggled, and these needles could

then be readily affixed to medicine droppers or baby

pacifiers to provide users with true multiple-use

injection equipment.

If a severe shortage of illicit injection equipment

developed and other countries also banned multipleuse injection equipment, then large-scale illicit

manufacturing of multiple-use injection equipment

might occur. It is difficult to formulate even an

imprecise estimate of the likelihood of these events

concurring. Given the ease with which injection

equipment can now be hand-assembled, large-scale

illicit manufacture of multiple-use injection equipment is probably quite unlikely. However, since

there is relatively large-scale manufacturing of other

paraphernalia for illicit drug use, such as plastic

crack vials, the possibility of large-scale illicit

manufacturing of multiple-use needles and syringes

cannot be totally ignored. As is the case with the

potential smuggling situation, it is likely that domestic illicit manufacturing would concentrate on producing multiple-use needles, which could then be

affixed to medicine droppers or baby pacifiers to

create multiple-use injection equipment. Needles are

both relatively easy and inexpensive to manufacture.

The precedent for the domestic manufacture of metal
8 ● Difficult-to-Reuse Needles for the Prevention of HIV Infection Among Injecting Drug Users

drug paraphernalia already exists: cocaine spoons,

for instance, were successfully manufactured and

sold, even though they provided no cost-effective

advantage in drug consumption to users.

Even though a system of single-use needles and

syringes does not provide the perfect solution for

drug users who might share equipment because they

could be defeated through one or more of the above

mechanisms, nevertheless distribution of single-use/

DTR equipment could help reduce HIV transmission

among injecting drug users. Planning for how DTR

needles and syringes might be used to reduce HIV

transmission does, however, require recognition of

the certainty that a supply of multiple-use injection

equipment available for illicit drug use will always

be available. This fact leads to the policy and

organizational questions that policymakers need to

address as part of any plan to use DTR syringes to

reduce HIV transmission among injecting drug

users. The next section examines these questions in

greater detail.

As noted above, others are working to redesign

injection equipment to reduce both the reuse of

injection equipment in health care settings and the

chances of accidental puncture injuries (needle

sticks) in such settings. Most of these new designs

are easy-to-reuse and, thus, would not raise new

questions about the spread of blood-borne pathogens

among persons who inject illicit drugs. Some of the

designs, however, are difficult to reuse and their

widespread adoption within health care settings

would raise important policy questions in regard to

HIV transmission among illicit drug injecters.

THE CRITICAL POLICY

QUESTION

The most important question in considering the

possible effect of DTR syringes on the transmission

of HIV among injecting drug users is not the

technical question of exactly how difficult to reuse

the syringes might be. Instead, the critical policy

question is should legal injection equipment be

supplied to persons who want to inject illicit drugs?

If a policy decision was made to adopt or require

DTR injection equipment for general medical use,

but such equipment were not to be supplied to

persons injecting illicit drugs, HIV transmission

among drug injecters would actually increase. Most

needles and syringes used by illicit drug injecters are

diverted from medical sources and can be easily

reused. However, it is very unlikely that enough

extra needles and syringes would be diverted from

medical sources to make up for the increased

difficulty in re-using the new equipment. In particular, one of the most common sources of needles and

syringes for illicit drug injection is the sale by

diabetics of their injection equipment. If diabetic

syringes were truly difficult to reuse, then a real

scarcity of equipment for injecting illicit drugs could

develop.

The substitution of truly DTR injection equipment for the current easy-to-reuse disposable equipment would mean a scarcity-but not an absenceof multiple-use injection equipment available to

illicit drug injecters. As noted above, some multipleuse equipment would still be available, whether

through defeating the single-use design, through

hand-assembled equipment, or through purchasing

illicitly imported or manufactured equipment. The

most likely outcome of such a situation would be an

increase in the number of persons sharing the

reduced numbers of multiple-use injection equipment, and hence an increase in the transmission of

blood-borne viruses among drug injecters. A reduction in the availability of sterile injection equipment

for illicit drug users appears to have been one of the

major reasons for the very rapid spread of HIV in

Edinburgh (20). The consideration of this possible

factor for the increase in HIV transmission led

participants at the First International Conference on

Self-Destructing Syringes to adopt a resolution that

single-use syringes should not be considered for

normal medical uses unless injection equipment

were simultaneously supplied to illicit drug injecters

(13).

At present, no consensus has developed in the

United States on whether injection equipment

should be made legally available to persons who

inject illicit drugs. The issue comes to bear on two

sets of relevant State laws. Twelve States require

prescriptions for the sale of injection equipment;

these States tend to have large numbers of persons

injecting illicit drugs (e.g., New York, California,

Illinois). Moreover, 48 States (19) have laws criminalizing the possession of paraphernalia for illicit

drug injection. Over the past several years, however,

two States (Hawaii and Connecticut) have changed

their laws to permit syringe exchange, and legislators in several states are considering legalizing

over-the-counter sales of injection equipment. Many

people still greatly oppose providing legal injection
Difficult-to-Reuse Needles for the Prevention of HIV Infection Among Injecting Drug Users ● 9

equipment to persons injecting illicit drugs. Even if

it is technically feasible to supply DTR syringes-or

true single-use syringes, this opposition might

remain.

Several arguments have been advanced in opposi- —

tion

●

●

●

to legal availability of injection equipment:

One is that, by removing the fear of AIDS, legal

availability of injection equipment would lead

to an increase in illicit drug injection. However,

all studies to date of legal availability have

failed to substantiate any increase in illicit drug

injection (6). The possibility that legally available single-use injection equipment would lead

to a reduction in HIV transmission would not

counter this argument; if anything, it would

reinforce the argument.

A second argument is that legal distribution of

injection equipment would “send the wrong

message” about illicit drug use, and appear to

“condone” illicit drug use. Again, legal distribution of DTR or single-use equipment rather

than multiple-use equipment would not appear

to counter this argument, and may reinforce it.

A third argument against legal distribution is

simply that such programs would not work, that

illicit drug injecters would continue to share

injection equipment even if it were legally

available; in particular, that they would still

share ‘‘cookers”l and rinse water. Single-use

or DTR syringes would directly address part—

but not all-of this argument against legal

distribution.

Hence, the policy controversy around legal access

to injection equipment is one of the greatest impediments to the implementation of DTR syringes in the

United States. Opponents of legal access for multipleuse equipment also tend to be no less opposed to

legal access for DTR equipment. Moreover, even

many potential proponents of DTR injection equipment have stated that they will not support use of

such equipment in general medical care unless the

same injection equipment is simultaneously made

legally available to injecting drug users. Until this

impasse is resolved at a national level, any plan to

use DTR injection equipment could not be implemented in the United States.

Despite this great obstacle to implementation of

any plan for DTR injection equipment, it is still

worthwhile to examine what forms such plans might

take. Before doing so, however, it will be helpful to

consider the views of active drug injecters themselves toward single-use/DTR syringes. The views

of active drug users provide important insights as to

why drug users might defeat DTR injection equipment programs, even if legal equipment was legally

available to them.

USERS’ VIEWS

Active drug injecters were interviewed in Australia when DTR syringes were being considered as a

possible HIV prevention technique in that country

(28). Also, we interviewed a group of active drug

injecters in the United States specifically for this

paper. (In both countries, the interviews were

conducted with the explicit assumption that injection equipment would be legally available.) In

addition, an ex-drug user who is now a research

professional has devoted considerable thought to the

issues involved (25). Although the drug injecters in

both Australia and the United States expressed

considerably diverse opinions, several common

themes emerged from both sets of interviews.

First, many drugs injecters expressed a general

receptiveness to the idea of DTR syringes. Of

course, the drug injecters interviewed in both

countries were aware of the threat of AIDS, and thus

were generally open to ideas about how they might

protect themselves from AIDS.

However, the drug users revealed specific concerns about DTR injection equipment beyond the

possibility of HIV transmission. Many drug injecters, particularly in the United States, practice

what is called ‘‘booting’ when they inject. Booting

refers to injecting some of the drug solution,

partially refilling the syringe with blood from the

vein and then again injecting part of the drug/blood

solution. The specific partial injection/refilling procedure is repeated several times within a single

complete injection. The multiple-pulsed delivery of

drug to the brain that occurs with booted injections

is believed to create a more extended and pleasurable

drug effect than can be achieved with a single-pulse

injection. In many ways, booting resembles multiple

I c~cooker~?$ me ~e~ ~Me caps or Spmm us~ t. Prepwe drugs for injection. The drug and water are pked in tie cooker which is then h~t~

until the drug is dissolved.
10 ● Difficult-to-Reuse Needles for the Prevention of HIV Infection Among Injecting Drug Users

injections, and most (though not all) of the designs

for DTR syringes also do not permit booting.

Interviewees disclosed that the lack of a booting

possibility would lead many injecters to find or

make multiple-use injection equipment even if DTR

equipment was readily available.

Secondly, injecting drug users often have difficulty in locating veins suitable for injection, usually

because so many veins have already collapsed due to

frequent injections. Many injecters will pull back the

syringe plunger to determine if they have successfully located a vein. Syringes that would not provide

for such aspiration would not be useful to them and

would lead to a large demand for multiple-use

injection equipment.

A third concern voiced by the drug users is the

need to inject successfully, or at least to be able to

recover the drug if something should go wrong

during injection. Even with the multiple-use equipment currently in use, many things can go wrong

while attempting to inject, and such problems would

be compounded with many of the DTR-syringe

designs. For instance, if the user is having prolonged

difficulty in hitting a vein, the hydrophilic gel-type

syringes could have already shut off the plunger by

the time the drug could be injected. In general, then,

the greater design complexity of the DTR equipment

not only increases the likelihood that something

would go wrong during the injection, but also make

it that much more difficult to recover the drug if

something did go wrong. It would not take a large

number of occasions where expensive drugs were

lost due to problems incurred with DTR equipment

in order to prompt drug injecters to go back to

multiple-use equipment.

Even with a very large effort to supply equipment

to drug injecters, DTR equipment would probably

increase the likelihood of a drug user finding himself

or herself with drugs to inject, but without working

injection equipment. This scenario would be an

extremely frustrating situation. Many of the interviewed drug users anticipated this situation arising

with DTR equipment, and stated that they would

always keep a multiple-use needle and syringe as

backup. Thus, even among drug injecters who were

regularly using DTR equipment a demand for

supplemental multiple-use equipment would still

remain.

Finally, many of the interviewed users simply did

not believe that DTR equipment was necessary to

reduce HIV transmission and that availability of

DTR equipment would not reduce transmission.

They believed that sharing of injection equipment

was primarily due to lack of readily available

injection equipment. If enough equipment for

everyone to have his or her own needle and syringe

existed, then injecters would have no reason to

share, and DTR equipment would not be necessary

anyway. Moreover, because so much more equipment would be needed with DTR equipment, changing to DTR might actually lead to a reduction in the

overall availability of sterile injection equipment,

and thus to increased sharing of the limited multipleuse equipment that was still available.

The opposition to DTR syringes expressed by

drug users in Australia was sufficient to lead

officials there to abandon their plans for using such

equipment to reduce HIV transmission among injecting drug users (28). A fundamental aspect of the

national AIDS prevention strategy in Australia is to

work collaboratively with drug users to change their

injection and sexual behavior. Therefore, an attempt

by health authorities to unilaterally impose DTR

equipment over the objections of a large segment of

the user population would greatly damage the trust

and cooperative relationships that health officials

have worked hard to establish.

Both the Australian and United States drug users

expressed a similar range of opinions about DTR

syringes. While some users seemed open to exploring almost any method for reducing HIV transmission, others voiced strong concerns about the

specific injection needs of persons injecting illicit

drugs, and a general skepticism about the whole idea

of non-reusable injection equipment as a method of

AIDS prevention.

NEW DESIGN CRITERIA AND

NEW TECHNOLOGIES

As noted above, the DTR syringe design criteria

adopted by the WHO for its childhood immunization

program are different from the criteria that one

would use for DTR injection equipment for persons

injecting illicit drugs. The WHO criteria not only

presumed a lower motivation to defeat the single-use

features, but also did not address the special

concerns of illicit drug injecters, such as booting or

the recovery of expensive illicit drugs if the initial

injection is not successful.
Difficult-to-Reuse Needles for the Prevention of HIV Infection Among Injecting Drug Users ● 11

Thus, if DTR injection equipment is to be

successfully used to reduce HIV transmission among

injecting drug users, anew process of setting design

criteria-and of evaluating proposed designs against

those criteria-would need to be implemented. First,

it would be helpful if either current or former drug

injecters should participate in the process of setting

design criteria and evaluating the proposed designs.

Since reduction of HIV transmission depends greatly

on whether drug injecters are willing to actually

use-rather than try to defeat—the DTR equipment,

it will be important to be aware of their perspective

throughout the design process.

Second, it would be advisable to broaden the

scope from designing single-use or difficult-to-reuse

injection equipment to a concept of controlled reuse

injection equipment. A needle and syringe that could

be reused only after cleaning with a viricidal

disinfectant (such as bleach or alcohol) might be

quite effective in reducing HIV transmission among

injecting drug users. This latter possibility would

have the advantage of requiring fewer needles and

syringes to be distributed to injecting drug users.

This second observation is not meant to advocate

either of these two types of needles and syringes.

Moreover, it would be just as important as with DTR

equipment that any such controlled reuse injection

equipment be designed to meet the specific injection

needs of the drug injecters. Controlled reuse equipment may, however, provide some possibilities of

reaching the same goal of AIDS prevention through

slightly different means.

DISTRIBUTION ISSUES

If reducing HIV transmission among drug injecters is to be accomplished with DTR injection

equipment, then the method selected to provide the

equipment to the drug injecters becomes a critical

question. If not enough equipment is provided, then

one has to expect that the drug injecters will attempt

to defeat the single-use designs, to hand-assemble

multiple-use equipment, or to purchase smuggled or

illicitly manufactured multiple-use equipment. As

noted above, a situation where DTR equipment was

used for normal medical injections without simultaneous provision of equipment to illicit drug injecters

might actually lead to increased transmission of

HIV.

The specifics of how DTR injection equipment

might be distributed to illicit drug injecters clearly

depend on the characteristics of the specific injection equipment. If controlled reuse equipment rather

than single-use equipment is to be used, then the

distribution problems would be different, and probably much less difficult. Even without knowing the

specifics of the equipment to be used, however, it is

possible to outline two different types of distribution

strategies.

The Blanket Strategy vs. Targeted Approach

Most planning for DTR injection equipment has

used a blanket distribution strategy. In that strategy,

DTR equipment would replace the current multipleuse equipment for medical injections. (Note that it

would be impossible to replace all multiple-use

needles and syringes with truly non-reusable needles

and syringes.) At the same time that use of the

current injection equipment for medical uses was

being replaced by DTR equipment, large-scale

efforts to provide DTR injection equipment to illicit

drug injecters would be undertaken. These efforts

would probably have to include both over-thecounter sales of such injection equipment and

syringe-exchange programs.

Implementing such a blanket approach poses

several obvious difficulties. The first problem is the

sheer number of needles and syringes that would

have to be distributed to drug injecters. Many

persons injecting, heroin typically inject several

times per day on a regular basis. In Amsterdam,

which has both over-the-counter sales and largescale syringe exchanges-and where heroin is the

predominant drug for injection-each needle and

syringe is used an average of two times (l). This

average usage rate would imply that the number of

needles and syringes in circulation among injecting

drug users would have to be doubled for DTR

injection equipment.

The blanket distribution problem would be even

worse in the context of cocaine injection. Most of the

persons who inject illicit drugs in the United States

inject cocaine as well as heroin. Persons who inject

cocaine often do so in “binges,” when they will

inject from 10 to 20 times in rapid succession.

(Typically, they continue to inject until the supply of

cocaine is exhausted.) DTR syringes would require

either that cocaine injecters store large surplus

numbers of syringes, or that a superb distribution

system be set up for getting enough DTR injection

equipment to drug users.
12 ● Difficult-to-Reuse Needles for thePrevention of HIV Infection Among Injecting Drug Users

Using the above Amsterdam estimate on the

number of DTR syringes needed per year per

injecter--and, conservatively, doubling it to adjust

for the higher frequencies of cocaine injection—

would require a system that could distribute from 1

billion to 11/2 billion sterile DTR needles and

syringes annually to injecting drug users in the

United States. (An estimated 1 to 1.5 million

injecting drug users live in the United States). New

York City alone, with its estimated 200,000 drug

injecters, would need to distribute 200 million DTR

syringes per year. Such a system would require

over-the-counter sales (given the large numbers and

extensive geographic coverage provided by pharmacies), many syringe-exchange locations (probably

including call-in exchange delivery, such as a few

exchanges already provide), and numerous exchange/

vending machines, where new injection equipment

could be obtained by placing either used equipment

or special tokens into the machine.

The ultimate test of a blanket distribution system

for DTR injection equipment is the comparison

between the ease of obtaining multiple-use equipment (thus defeating the system) versus the ease of

obtaining new DTR equipment (thus preserving the

system). It is worth recalling that the drug users

interviewed for this paper did not believe that a

sufficiently extensive and efficient distribution system would ever be set up for DTR needles and

syringes. The great majority of them stated that they

would keep a multiple-use needle and syringe as

backup, in case they could not readily obtain DTR

needles and syringes.

The other aspect of the distribution problem, of

course, is safe disposal of this greatly increased

volume of potentially HIV-contaminated injection

equipment. Syringe exchanges throughout the world

have return rates that range from about 60 percent to

almost 100 percent, depending on the policies,

operating hours and other characteristics of the

exchange. Studies of syringe exchanges have found

that successful exchange programs actually reduce

the number of needles and syringes left in public

places (18). Syringe exchanges have reduced the

public-discarding of used injection equipment by

giving economic value to the used equipment (i.e.,

it can now be exchanged for free new injection

equipment). DTR injection equipment, however,

would have considerably less economic value than

multiple-use injection equipment, and one would

have to expect that return rates would decrease as the

absolute numbers of needles and syringes distributed increased. At the very least, numerous publicly

accessible, tamper-proof ‘sharps’ containers would

have to be setup in high-drug-use areas, in order to

make safe disposal of used injection equipment as

easy as possible.

Policymakers should note that failure to safely

dispose of the increased number of DTR needles and

syringes would be a serious problem. A public

perception that legalizing the distribution of DTR

syringes to drug users would lead to an increase in

HIV-contaminated litter in public areas would

greatly undermine support for the distribution of

DTR equipment to that population.

The distribution and disposal systems would not

only have to be large and efficient, but would also

have to protect the anonymity of the injecting drug

users. As long as possession of the drugs to be

injected is a crime, drug injecters will want to protect

their identities when they participate in the distribution and disposal programs. The need to protect

anonymity is of great importance with respect to

law-enforcement personnel, but also applies to

friends, employers, relatives and sexual partners.

Having to handle much larger numbers of needles

and syringes could itself compromise the person’s

ability to keep his or her drug injection a secret.

Consideration of the problems in distributing and

safely disposing of the large numbers of needles and

syringes leads back to one of the concerns expressed

by many of the drug users interviewed in both the

United States and Australia. Rather than attempting

to setup the very extensive and efficient distribution

and disposal systems that would be needed to

provide large amounts of DTR injection equipment

to the drug users, many of the drug users said that it

would be simpler to provide them with enough

multiple-use equipment so that everyone could

always have his or her own equipment, without

having to share.

The aforementioned problems with a blanket

approach to distributing DTR injection equipment to

drug users do not necessarily imply, however, that

the approach would fail to reduce HIV transmission

among the drug users. Rather, these potential

problems merely indicate that this strategy could not

be expected to work perfectly (i.e., in such a way that

all injections are with new equipment and that no

“needle sharing” transmission of HIV occurs).

Nonetheless, a blanket DTR equipment distribution
Difficult-to-Reuse Needles for the Prevention of HIV Infection Among Injecting Drug Users ● 13

system, even though it might be far from perfectly

implemented, could still reduce HIV transmission

sufficiently to justify its costs. The task of evaluating

precisely how well such a system would have to

work leads to a final problem with the blanket

approach. This measurement problem produces the

great difficulty in conducting any pilot study of the

approach. Such a study would require finding a

location that was sufficiently isolated that large

amounts of multiple-use injection equipment could

not be smuggled in easily. As noted above, Dutch

officials were at one time interested in conducting a

pilot study of the effectiveness of DTR injection

equipment, but abandoned their plan when they

could not find a suitable location for the pilot study.

A suitable location would also require a large

enough number of drug users to conduct the pilot

test. Unless the illicit drugs were being produced

locally, this location would have to be one where

large amounts of illicit drugs were being brought in

from elsewhere to supply the local market of drug

injecters. It is difficult to imagine an area anywhere

in the developed world where, if large amounts of

illicit drugs are being shipped in, large amounts of

multiple-use injection equipment could not be

shipped in simultaneously. Such locations might be

found in the countries where heroin and cocaine are

produced, but the results from a trial study conducted in other countries might not reflect what

would happen in the United States.

The difficulties in finding such an isolated locality

suggest that any pilot program would have to be

conducted on a national basis. Bringing multiple-use

injection equipment into a given locality would

simply be too easy without national borders and

customs barriers to interdict illicit equipment. Considering the many things that might go wrong in a

pilot study, conducting the study on a national basis

would require an extraordinary degree of confidence

and courage among the public-health, community,

and political leaders of the country.

TARGETED DISTRIBUTION OF

DIFFICULT-TO-REUSE

INJECTION EQUIPMENT

Rather than trying to get all drug injecters to use

new equipment each time they inject (the blanket

distribution approach), it might be possible to use

DTR equipment in a more targeted distribution to

prevent HIV transmission among injecting drug

users. All illicit drug injections are not equally likely

to transmit HIV. Injections where each person is

injecting alone, using his or her own equipment, can

be considered as posing zero risk of HIV transmission. Conversely, some injection situations are

particularly likely to lead to rapid transmission of

HIV (10). “Shooting galleries,” where users rent

injection equipment, use it, and then return the

needle and syringe to the owner of the gallery-who

then rents it to the next drug injecter--are especially

dangerous in terms of HIV transmission. Similarly,

injection with ‘ ‘dealer’s works’ ’-equipment that a

drug dealer lends to customers who want to inject

immediately after purchasing-is also highly likely

to spread HIV among a population of drug injecters.

Even if only shooting gallery equipment and

dealer’s works equipment could be replaced with

DTR injection equipment, there could be a very

significant impact on HIV transmission. (The exact

impact would depend on the frequency, within a

given area, of injections occurring in shooting

galleries or with dealer’s works, as well as the

background HIV seroprevalence in that area, among

other factors.)

A major advantage of placing DTR equipment in

shooting galleries and with dealers is that individual

injecters would not be reusing the equipment, and

thus would have no economic interest in multipleuse equipment. Given their concerns about AIDS,

these injecting drug users would therefore be likely

to prefer DTR equipment.

Obviously, the person who is operating the

shooting gallery, or the dealer who is lending out

injection equipment, would still have an economic

preference for multiple-use injection equipment.

This economic preference could be reversed, however, if DTR equipment was supplied to the gallery

operators and dealers at no cost (probably on an

exchange basis).

Conducting such targeted distribution of DTR

injection equipment would require cooperation between health care workers, on the one hand, and

shooting gallery operators and dealers, on the other.

Establishing such cooperation is obviously not easy,

but it has previously been done in New York (22),

Miami (4) and in Minneapolis-St. Paul (16) for the

purposes of bleach distribution and research.

Moreover, the aforementioned distribution and

disposal problems would obviously be far more
14 ● Difficult-to-Reuse Needles for the prevention of HIV Infection Among Injecting Drug Users

manageable with a targeted (rather than a blanket)

distribution system—although maintaining the anonymity of the shooting-gallery operators and dealers

would remain an important issue.

Targeted distribution of DTR injection equipment

also would not require changes in the normal

medical use of the current styles of needles and

syringes. This fact is a major advantage in terms of

designing equipment for drug injecters, but it also

means that the overall market for the successful

design would be quite limited. Finding a manufacturer might also prove difficult.

Admittedly, the concern that successful distribution of DTR equipment would have no major

advantage over successful distribution of multipleuse injection equipment could apply to targeted

distribution as much as it does to blanket distribution. The targeted situations, however, are situations

where multiple-use equipment would have no economic advantage for the drug user, and where

multiple-person use of the same equipment would

otherwise continue to be particularly likely to lead to

rapid HIV transmission among drug injecters in the

community. In that sense, targeted distribution of

DTR equipment could even be fully compatible with

simultaneous large-scale distribution of multipleuse equipment to injecting drug users in the community at large.

A final advantage of a targeted distribution

approach is that small pilot studies could be (relatively) easily conducted. If the pilot studies were

successful, then staged expansion could gradually be

added. That targeted distribution would ever expand

to the level of full blanket distribution is unlikely,

but local experts could monitor the drug scene to

identify places where particularly high-risk injection

was occurring.

IMPLICATIONS OF DIFFICULTTO-REUSE SYRINGES FOR

GENERAL MEDICAL USE

This paper is concerned with the possible use of

difficult-to-reuse injection equipment to reduce the

transmission of HIV and other blood-borne pathogens among injecting drug users in the United

States. It is not intended to examine the possible use

of new technologies to reduce the transmission of

HIV and other viruses within health care settings.

With the possible exception of the Florida dentist

case, health care worker-to-patient transmission of

HIV within health care settings does not appear to be

a substantial problem in the United States. Similarly,

patient-to-patient transmission of HIV through reuse

of injection equipment without proper sterilization

also has not been an important mode of transmission

in the United States (15,26).

The AIDS epidemic has, however, led to increased concern over infection control procedures

within health care settings. This increased concern

has led to suggested redesigns of injection equipment to reduce the need to use the same equipment

for different patients, and to reduce the likelihood of

accidental puncture wounds (needle sticks) with

injection equipment. Such redesign does not necessarily make the equipment more difficult to reuse.

For most injection equipment used in this country’s

health care settings, little if any economic incentive

to reuse the equipment exists, and thus little purpose

in making it difficult to reuse. To the extent that new

designs are difficult to reuse, the implications for

HIV transmission among injecting drug users should

be considered, but it would appear unlikely that

transmission among persons using illicit drugs

would be a major consideration in the possible

adoption of new designs to improve infection

control in health care settings.

On the other hand, the implications for health care

are important to consider settings if difficult to reuse

equipment were adopted in order to reduce HIV

transmission among injecting drug users in the

United States. The implications for health care

settings would to some extent depend on the

particular DTR technologies adopted but, to a much

greater extent, they would depend on the policy

framework within which the DTR technologies were

implemented.

If a system of DTR injection equipment was

implemented with a policy decision not to provide

legal equipment to injecting drug users, then there

would be several likely consequences for health care

settings. DTR injection equipment is likely to cost as

much or more than the current single-use but

easy-to-reuse equipment. The additional cost would

depend on the specific design and is impossible to

predict at present, though some designs submitted to

the WHO appear to cost about the same as current

equipment.

The use of DTR equipment in health care settings

might also slightly increase medical-waste disposal
Difficult-to-Reuse Needles for the Prevention of HIV Infection Among Injecting Drug Users ● 15

costs. Costs for proper disposal of potentially

infectious medical waste are already rising as

universal precautions are adopted in more health

care settings. The additional disposal costs incurred

by substituting a one-time-only use policy for

equipment that is currently used multiple times

would probably not be a major factor in any

continued rise.

If there was to be a large-scale substitution of

difficult-to-reuse equipment for the current easy-toreuse equipment within a policy framework of not

providing equipment to injecting drug users, one

should expect a substantial increase in the illicit

market value for injection equipment. The increase

in the illicit market value would be particularly high

for injection equipment where the DTR features

could easily be defeated, and for injection equipment

such as intravenous infusion needles, where it may

not be possible to incorporate DTR features.

A large increase in the illicit market value for

injection equipment could lead to an increase in

security problems for many large urban hospitals.

While no quantitative data could be located for this

paper, security at many large urban hospitals is

already a major concern, and an increase in the illicit

market value for injection equipment would only

add to that concern. At this point, however, no

predictions can be made about the costs for added

security.

The situation of diabetic injections with DTR

equipment requires special consideration. First,

while diabetic injections are supposed to be with

single-use needles and syringes, many diabetics do

reuse the current easy-to-reuse equipment. No quantitative data could be located on how frequently

injection equipment is reused but, from several

informal interviews with diabetics, this practice

appears to be a common one. Substitution of DTR

injection equipment would thus lead to a real

increase in costs for diabetic injections or attempts

by diabetics to defeat the DTR features. The mix of

increased cost and the practice by diabetics of

defeating the DTR features would probably depend

on the specific nature of the DTR equipment (how

easily it could be defeated) and who is paying for the

injection equipment.

The substitution of DTR equipment for diabetic

injections is also important for another reason.

While it was not possible to obtain quantitative data,

interviews with several AIDS prevention researchers (2,23,24) indicated that diabetic syringes are the

predominant type of needle and syringe used for the

injection of illicit drugs. In cities where prescriptions are required for the purchase of syringes, these

needles and syringes are often sold by diabetics

(who reuse single-use equipment for their own

insulin injections). If the illicit market value of

injection equipment was to increase markedly,

diabetics with legal access to injection equipment

would have more incentive to defeat the DTR

features of syringes for their insulin injections and

sell more needles and syringes on the illicit market.

Substitution of DTR injection equipment for the

present easy-to-reuse equipment without simultaneous provision of equipment to injecting drug

users, thus, could have very mixed effects on

diabetics. For diabetics who did not attempt to defeat

the DTR features, the substitution would probably

lead to increased costs. For diabetics able to defeat

the DTR technology and willing to sell some

injection equipment on the illicit market, it could

lead to a sizable increase in illicit income for them.

If a policy decision was made to substitute DTR

equipment for current equipment that can be easily

reused and to provide equipment to injecting drug

users (via a blanket distribution approach discussed

above), then there would be substantially different

implications for health care settings. Within a

blanket distribution approach, concern would not be

with eliminating all sources of reusable injection

equipment, but focused only on major sources.

To the extent that the blanket distribution of DTR

equipment was providing drug injecters with sufficient injection equipment, there would be little or no

economic incentive to obtain easy-to-reuse equipment. (Although, as noted in the interviews with

active drug injecters, most of them would want to

keep at least one easy-to-reuse needle and syringe in

reserve.) A large-scale supply of DTR injection

equipment would also reduce economic motives for

diversion or theft of injection equipment from health

care settings, so that the increased security needs

discussed above would not be as great. Use of DTR

equipment in health care settings would further

reduce economic incentives for diversion or theft.

Whether DTR equipment was used for particular

types of injections in health care settings would

probably depend heavily on the additional costs for

adding DTR mechanisms to the specific injection

equipment.
16 ● Difficult-to-Reuse Needles for the Prevention of HIV Infection Among Injecting Drug Users

As noted above, substitution of DTR injection

equipment for diabetic use would lead to some

mixture of increased cost and of attempts to defeat

the DTR technology. An increase in costs to

diabetics may be provoke resentment on their part

when injection equipment is being provided free (on

an exchange basis) to persons who are injecting

illicit drugs. Diabetics protested and delayed implementation of syringe-exchange programs in Canada

(that provide easy-to-reuse equipment), because the

diabetics believed it was unfair for the government

to provide free injection equipment to illicit drug

users while the diabetics themselves had to pay for

their injection equipment. Hence, it is likely that free

difficult-to-reuse injection equipment would also

have to be offered to diabetics in the United States

on an exchange basis as part of any plan to use DTR

equipment within a blanket system for distributing

to drug injecters.

A targeted distribution approach, which would

place DTR injection equipment only into very

high-risk injection situations such as shooting galleries and dealer’s works, would not require changing the single use but easy-to-reuse equipment

currently in medical use. This strategy would thus

allow time for gaining some practical experience

with the distribution of DTR equipment to injecting

drug users-and their reactions in the field to such

equipment—without at the same time having to

change the patterns of normal medical injections.

CONCLUSION

The analyses in this paper indicate that most

proposals for utilizing redesigned injection equipment are unlikely to reduce the spread of HIV and

may have other unintended consequences. There is

no syringe yet designed and feasible to manufacture

that could not be defeated by someone seeking to

reuse it. Distributing enough syringes to prevent the

establishment of a black market for injection equipment that can be easily reused presents significant

logistical and ethical dilemmas. In addition, evidence indicates that many of the proposed redesigns

would interfere with usual drug-taking practices,

making most drug users unlikely to accept them.

Redesigned syringes would also likely cost more

than current syringes and could significantly add to

medical waste problems. Some injecting drug users

have, however, indicated a willingness to use

redesigned injection equipment in order to reduce

the transmission of HIV. Targeted distribution of

redesigned injection equipment could be used to

identify those situations in which: 1) injecting drug

users would be least likely to try to defeat DTR

equipment; 2) the cost, supply, and safe disposal

problems would be manageable; and 3) the use of

DTR equipment would have the greatest impact on

reducing HIV transmission among injecting drug

users.

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

REFERENCES

Buning, E., Municipal Health Service, Amsterdam,

The Netherlands, personal communication, March

1992.

Case, P., Harvard AIDS Institute, Harvard University, Boston, MA, personal communication, January

1992.

Casriel, C., Des Jarlais, D.C, Rodriguez, R., et al.,

“Working With Heroin Sniffers: Primary Prevention

of IV Drug Use Related AIDS,’ Journal of Substance Abuse Treatment 7(1):1-10, 1990.

Chitwood, D.D., McCoy, C. B., Inciardi, J.A., et al.

“HIV Seropositivity of Needles From Shooting

Galleries in South Florida,” American Journal of

Public Health 80(2):150-152, 1990.

Des Jarlais, D. C., and Friedman, S.R., “AIDS

Prevention Programs for Injecting Drug Users,”

AIDS and Other Manifestations of HW Infection,

Second Edition, G.P. Wormser (cd.) (New York NY:

Raven Press, in press).

Des Jarlais, D. C., and Friedman, S.R., “The AIDS

Epidemic and Legal Access to Sterile Equipment for

Injecting Illicit Drugs,” Annals of the American

Academy of Political and Social Science 52:42-65,

1992.

Des Jarlais, D. C., Friedman, S.R., Choopanya, K., et

al., “International Epidemiology of HIV and AIDS

among Injecting Drug Users,” AIDS, in press.

Evans, P., “The State of the Art of Self-Destruct

Syringe Design,” Proceedings of the First International Conference on Self-Destructing (NonReusable) Syringes: Strategies for Blocking Transmission of W, Hepatitis and Other Blood-Borne

Pathogens (New Yorlq NY: New York University

Medical Center, 1991).

Friedman, S.R., National Development and Research

Institute, Inc., New York, NY, personal communication, June 1992.

Friedman, S.R., and Des Jarlais, D.C., “HIV Among

Drug Injecters: The Epidemic and the Response,”

ALDS Care 3(3):237-248, 1991.

Gerberding, J.L., and Schecter, W.P., “Surgery and

AIDS: Reducing the Risk” [editorial], Journal of the

American Medical Association 265(12):1572-1573,

1991.
Difficult-to-Reuse Needles for the Prevention of HIV Infection Among Injecting Drug Users ● 17

12.

13.

14.

15.

16.

17.

18.

19.

Hopkins, W., New York State Division of Substance

Abuse Services, New York, NY, personal communication, September 1984.

Marrnor, M. (cd.), Proceedings of the First International Conference on Self-Destructing (NonReusable) Syringes: Strategies for Blocking Transmission of HN, Hepatitis and Other Blood-Borne

Pathogens (New York NY: New York University

Medical Center, 1991).

National Commission on AIDS, Report: The Twin

Epidemics of Substance Use and HN (Washington,

DC: U.S. Government Printing Office, 1991).

National Commission on AIDS, Preventing HIV

Transmission in Health Care Settings (Washington,

DC: U.S. Government Printing Office, 1992).

Needle, R., National Institute on Drug Abuse, Rockville, MD, personal communication, September 1989.

Office of National Drug Control Policy, Executive

Office of the President, National Drug Control

Strategy: A Nation Responds to Drug Use (Washington, DC: U.S. Government Printing Office, 1992).

Oliver, K.J., Friedman, S.R., Maynard, H., et al.,

“Impact of Needle Exchange Program on Potentially

Infectious Syringes in Public Places,” JournaZ of

AIDS 5(5):534-535, 1992.

Pascal, C. B., “Intravenous Drug Abuse and AIDS

Transmission: Federal and State Laws Regulating

Needle Availability,” Needle Sharing Among Intravenous Drug Abusers: National and International

Perspectives, R.J. Battjes and R.W. Pickens (eds.),

Research Monograph 80, U.S. Department of Health

and Human Services, Public Health Service, Alcohol,

Drug Abuse, and Mental Health Association, National Institute on Drug Abuse, DHHS Pub. No.

(ADM) 88-1567 (Rockville, MD: 1988).

20.

21.

22.

23.

24.

25.

26.

27.

28.

Robertson, J.R., Bucknall, A.B.V., Welsby, P.D., et

al., “Epidemic of AIDS-Related Virus (HTLV-111/

LAV) Infection Among Intravenous Drug Abusers,”

British Medical Journal 292(6519):527-529, 1986.

Samuels, M.E., Koop, C.E., and Hartsoclq P.I.,

“Single-Use Syringes” [letter], New England Journal of Medicine 324(14) ;996-997, 1991.

Serrano, Y., Association for Drug Abuse, Prevention,

and Treatment, New York, NY, personal communication, March 1988.

Sotheran, J., National Drug and Research Institute,

Inc., New York, NY, personal communication,

February 1992.

Stephenson, B., National Development and Research

Institute, Inc., New York, NY, personal communication, June 1990 and July 1992.

Stephenson, B., “Thoughts on Self-Destruct Syringes

From a Former User,” Proceedings of the First

International Conference on Self-Destructing (NonReusable) Syringes: Strategies for Blockz”ng Transmission of HW, Hepatitis and Other Blood-Borne

Pathogens (New York NY: New York University

Medical Center, 1991).

U.S. Congress, Office of Technology Assessment,

HIV in the Health Care Workplace% OTA-BP-H-90

(Washington, DC: U.S. Government Printing Office,

November 1991).

van Ameijden, E.J.C., van den Hock, A., and

Coutinho, R.A., “Risk Factors for HIV Seroconversion in Injecting Drug Users in Amsterdam, the

Netherlands,” abstract no. TH.C.104, paper presented at the Seventh International Conference on

AIDS, Florence, Italy, July 1991.

Wodak, A., St. Vincent’s Hospital, Sydney, Australia, personal communication, March 1992.

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