More free syringes, fewer drug injectors in the case of Spain.

International policy on the prevention of HIV and other health problems among drug users should be guided by scientific evidence. However, it has frequently been argued that Needle Exchange Programs (NEPs) have negative effects such as facilitation of injection of illicit drugs, without providing evidence to support this hypothesis. Since the early 1980s Spain has experienced a severe HIV epidemic among drug injectors. A delayed but comprehensive implementation of harm reduction programs has taken place since the early 1990s. This paper assesses trends between 1991 and 2004, both in the number of sterile syringes exchanged or delivered by NEPs or other programs to improve injectors' access to sterile injection material, and in the number of injectors admitted to first treatment for heroin or cocaine dependence, as a proxy for trends in the number of new drug injectors in Spain. The results show increased access to sterile syringes and a sharp decrease in the number of new drug injectors, suggesting that NEPs have not promoted drug injection. A positive overall transition from injecting to smoking was also observed in the most frequent route of heroin or cocaine administration.