TO THE EDITOR: From outside the United States, the article by Burris and colleagues (1) on prescribing needles and syringes seems to be a benchmark in the management of injection drug users. The United States has responded more cautiously to a problem considerably greater than ours. Key development of US policy has been of annual (and now biannual) interest at the international AIDS meetings since 1986, when great interest was shown in the British policy of syringe and needle exchange programs. These programs were developed after the 1985 discovery, through the newly available HIV antibody test, of an HIV epidemic among injection drug users in Edinburgh in 1982 and 1983 (2). Massive media coverage stimulated a national committee to consider a response, and within 12 months the first needle exchange programs and legal sanctions were in place (3). Although this seemed like the first national response to this type of crisis, the committee discovered that in Amsterdam in 1985, 100 000 sets of injection equipment had been distributed in a one-for-one needle exchange scheme. The committee also discovered that injection equipment was already sold at community pharmacies in many Italian cities. Since 1986, provision of injection equipment has become standard practice throughout the United Kingdom and many parts of Europe, and the United Kingdom has seen no instances of transmission from discarded needles and syringes. Most of the equipment is sold by community pharmacies with a wide network of distribution or by nonstatutory community groups. General medical practitioners in poorer areas are heavily involved in individual and local programs.

The initial legal anxieties and requirements for legal change emerged from the early committee work in Scotland and the subsequent statutory UK committee (4). Concern has arisen regarding the prescription of water for injection and the provision of other injection paraphernalia, but for most of us the system has worked extremely well, with few visible side effects. Now, however, renewed anxiety has developed about the level of needle-and paraphernaliasharing required to transmit hepatitis C virus, which continues to be identified in new and young injection drug users. Our data indicate that the sharing of spoons, filters, and water requires more attention. Physicians in the United States should be encouraged by these successes but should be aware of the detail required to adequately prevent hepatitis C virus transmission.