SEPTEMBER 2020 

Needs-Based Syringe Distribution and Disposal 

at Syringe Services Programs 

Frequently Asked Questions 

National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention

Division of HIV/AIDS Prevention

1 What is needs-based syringe distribution? 

Answer: Needs-based syringe distribution provides people who inject drugs (PWID) access to the number 

of syringes/needles they need with no restrictions, including no requirement to return used syringes. This 

approach has been shown to prevent new HIV and viral hepatitis infections. 

Infectious disease can be transmitted through multiperson use of contaminated syringes, which occurs more 

frequently when sterile syringe supply is low and syringe coverage is insufficient. To prevent bloodborne 

infections related to injection drug use, PWID must use one sterile needle and syringe for each injection, 

meaning that a never-used, sterile syringe should be used for each injection. Therefore, SSPs that implement 

a needs-based syringe distribution approach are more likely to ensure PWID have access to the number of 

syringes/needles they need to prevent transmission of infectious disease. 

2 Are SSPs that distribute a limited number of syringes effective? 

Answer: Although restrictive approaches are better than having no access to clean syringes at all, they are 

less effective than needs-based approaches because they do not provide reliable syringe access. Thus, PWID 

are unable to use “one needle, one syringe, only one time” and remain at high risk for contracting infectious 

diseases like HIV or hepatitis C. 

Restrictive laws and policies for syringe allocation are strong barriers to sterile syringe access for PWID. 

Generally, the most restrictive policy requires a one-to-one exchange, meaning that PWID need to bring in 

a used syringe for every sterile syringe they receive. Additional restrictions can include caps on how many 

syringes can be provided per visit and not providing additional syringes in case of emergencies. 

What is the average number of syringes that one PWID needs to receive 

for an SSP to be effective in reducing the transmission of HIV? 3 

Answer: The number of syringes that PWID need is based on frequency of injection, which varies greatly 

depending on the type of drug injected and the person’s tolerance levels for the drug. For example, daily 

frequency of injection is estimated to be 2.8 times per day for heroin,3 but the frequency of injection could 

be higher for fentanyl because of its shorter half-life compared to heroin. Therefore, SSPs that implement a 

needs-based syringe distribution approach are more likely to ensure people who inject drugs have access 

to the number of syringes/needles they need to prevent transmission of infectious diseases by using a clean 

syringe and needle every time they inject. 

Does allowing PWID to distribute new and sterile syringes acquired at an SSP to other PWID 4 (i.e. ‘secondary exchange’) reduce the risk for HIV or hepatitis C virus transmission?

Answer: Studies have shown that PWID can play an important role in supporting safer injection behaviors 

among their peers, and multiple studies have shown the effectiveness of employing peer outreach workers 

(e.g., SSP purposefully hiring and training current and former PWID to conduct outreach) to implement 

outreach efforts that reduce risk behaviors in their PWID peers.12 Secondary exchange is an approach that 

provides additional sterile syringes and other injection equipment to SSP clients to distribute to 

their peers who cannot or will not visit SSPs themselves. 
SEPTEMBER 2020

Secondary exchange, whether formal or informal, is considered a best practice for SSPs to reach the goal of 

providing a sterile syringe for each injection,13 and is an efficient way to increase sterile syringe coverage in 

the community, reaching those who cannot access an SSP. In the latest national survey of SSPs, 73% of rural, 

79% of suburban, and 71% of urban SSPs encouraged secondary exchange.14 

Frequently Asked Questions continued

continued

National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention

Division of HIV/AIDS Prevention

4

5 What is the best way to deal with syringe litter? 

Answer: Providing multiple options for disposal (e.g., sharps containers, drop boxes) and building a 

community-wide support for safe syringe disposal, including from PWID and law enforcement, will help in 

reducing syringe litter in the community. 

Studies have found that syringe litter is more likely in areas without SSPs, and that more restrictive approaches

do not reduce syringe litter in communities. Additionally, PWID will dispose of used syringes safely when 

given the options to do so and change their syringe-disposal behavior in response to increased safe disposal 

options.6, 7, 8 

In addition, drug paraphernalia laws, which can criminalize the possession of syringes, are also associated 

with an increased likelihood of unsafe and improper syringe disposal.9,10 Communities concerned about 

syringe litter could consider examining their drug paraphernalia laws in addition to policies that affect the 

presence of an SSP. For example, a state may exempt syringes from the definition of drug paraphernalia 

entirely or only under certain circumstances (e.g., if a person is a participant in an SSP). 

6 Why don’t PWID bring their used syringes back to SSPs? 

Answer: PWID may not bring their used syringes back to SSPs for many reasons. A primary reason is fear 

of being arrested by law enforcement for possession of syringes or having their syringes confiscated by 

law enforcement.11 In this context, PWID may not feel safe storing and transporting syringes back to the 

SSP fearing that they may be arrested. When law enforcement does not arrest SSP clients for having used 

needles/syringes properly stored in a container. 

Additional reasons PWID may not return used syringes include: syringes may be taken by other PWID, 

because supply is low in the community and demand is high; safe storage space is lacking (e.g., no sharps 

containers); they may be lost because of homelessness and other living circumstances; and lack of 

transportation or distance to a SSP may make it difficult to return used syringes. 

7 What are some strategies to promote safe disposal of used syringes?

Answer: The following strategies promote safe disposal of used syringes implemented by SSPs and health 

departments in the United States: 

• Emphasizing the value in returning used needles/syringes through education and providing sharps containers 

with every visit. 

• Conducting community clean-ups and engaging the community in this effort. 

• Developing strong relationships with law enforcement to educate them on their role in promoting safe disposal. 

• Empowering police officers to collect used syringes safely by providing sharps containers for squad cars. 

• Providing syringe disposal boxes in communities most convenient to PWID to collect used needles/syringes. 

• Supporting programs where people in need of employment are hired by the city to pick up trash/recycling 

to include syringe pick up. This approach requires safety training and supplies. 

• Establishing a call number for community members to report the presence of syringe 

litter and ensuring a short timeframe for pick up. 
SEPTEMBER 2020

Resources

1 Kerr et al. Syringe sharing and HIV incidence among injection drug users and increased access to sterile 

syringes. AJPH 2010: https://ajph.aphapublications.org/doi/pdf/10.2105/AJPH.2009.178467.

2 Bluthenthal et al. Higher syringe coverage is associated with lower odds of HIV risk and does not increase unsafe syringe disposal among syringe exchange program clients. DAD 2007: https://www.ncbi. 

nlm.nih.gov/pmc/articles/PMC2562866/.

3 Tempalski et al. Correlates of syringe coverage for heroin injection in 35 large metropolitan areas in the 

US in which heroin is the dominant injected drug. Int J Drug Policy 2008: https://www.ncbi.nlm.nih.gov/ 

pmc/articles/PMC2706511/. 

4 Broz et al. Multiple injections per injection episode: High-risk injection practice among people who 

injected pills during the 2015 HIV outbreak in Indiana. Int J Drug Policy 2018: https://www.ncbi.nlm.nih. 

gov/pubmed/29278838. 

5 2018 Indiana Annual Report, February 2019.

6 Tookes et al. A comparison of syringe disposal practices among injection drug users in a city with versus a city without needle and syringe programs. DAD 2012: https://www.ncbi.nlm.nih.gov/pmc/articles/ 

PMC3358593/. 

7 Bluthenthal et al. Higher syringe coverage is associated with lower odds of HIV risk and does not increase unsafe syringe disposal among syringe exchange program clients. DAD 2007: https://www.ncbi. 

nlm.nih.gov/pmc/articles/PMC2562866/. 

8 de Montigny et al. Assessing a drop box programme: A spatial analysis of discarded needles. Int J Drug 

Policy 2010: https://www.sciencedirect.com/science/article/pii/S0955395909001108.

9 Csete J et al. Public health and international drug policy. Lancet. 2016;387(10026):1427–1480. doi:10.1016/ 

S0140-6736(16)00619-X.

10 Burris S et al. State syringe and drug possession laws potentially influencing safe syringe disposal 

by injection drug users. J Am Pharm Assoc (Wash). 2002;42(6 Suppl 2):S94–S98. doi:10.1331/1086-

5802.42.0.s94.burris

11 Davis SM et al. Barriers to using new needles encountered by rural Appalachian people who inject 

drugs: Implications for needle exchange. Harm Reduct J. 2019;16(23):11–8. https://doi.org/10.1186/s12954-

019-0295-5. 

12 Snead et al. Secondary syringe exchange among injection drug users. J Urban Health 2003: 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3456273/. 

13 Blumenthal et al. Recommended best practices for effective syringe exchange programs in the United 

States: Results of a consensus meeting. New York City Department of Health and Mental Hygiene 2010: 

https://www.rti.org/publication/recommended-best-practices-effective-syringe-exchange-programs-united-states

14 Des Jarlais et al. Syringe Service Programs for Persons Who Inject Drugs in Urban, Suburban, and 

Rural Areas — United States, 2013. MMWR 2015: https://www.cdc.gov/mmwr/preview/mmwrhtml/ 

mm6448a3.htm. 

National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention

Division of HIV/AIDS Prevention