Injection and other illicit drug use plays a major role in the transmission of infection with human immunodeficiency virus (HIV), including cases among infants, children, and adolescents.1,2 Transmission to adolescents and adults occurs either directly from contaminated drug paraphernalia, including needles and syringes, or through sexual contact with an infected partner. Transmission to infants occurs transplacentally or perinatally from mothers who are most often either drug users themselves, or who have become infected from sexual partners who are injection drug users. It is therefore clear that a reduction in the transmission of HIV infection secondary to illicit drug use and the use of contaminated injection equipment is a pediatric concern and should be part of any prevention program.

The adverse consequences of illicit drug use are multiple and certainly not limited to the potential acquisition and transmission of HIV infection. Ideally, treatment and prevention programs should seek to reduce drug use itself, not solely HIV infection. However, many users of injection drugs do not enter drug treatment, remain in treatment, or maintain complete abstinence while in treatment. Therefore, promoting safer injection practices can provide an important public health benefit in lowering the risk of HIV transmission, while simultaneous efforts continue to reduce and eliminate drug use.

Initiatives with the singular objective of increasing access to sterile equipment are understandably controversial, as they do not directly address the causes and broader consequences of illicit drug use. In addition, there are continuing concerns that any program increasing access to sterile needles and syringes might actually increase injection drug use by creating the impression of relative safety and tacit community approval for such behavior.

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