Needle sharing among intravenous drug users is fueling the modern HIV epidemic. A public health approach to needle-borne infection has three components: prevention and education, availability of sterile injection equipment, and drug treatment. This essay examines the most controversial aspect of this strategy–sterile needle distribution and exchange. The sharing of drug injection equipment is the critical factor in the transmission of HIV in the drug using population. Sharing is not merely a learned response, but is also the result of a limited supply of needles and syringes. Limiting the supply of sterile equipment results from a policy choice which includes: (i) the adoption of drug paraphernalia statutes which criminalize the possession of equipment with the intention of using it for drug injection; (ii) the adoption of needle prescription statutes which criminalize the sale of needles and syringes without a medical prescription; and (iii) the failure to adopt a comprehensive program for the distribution, exchange, or sterilization of equipment. A public health approach to reduce the needle-borne HIV epidemic would repeal needle prescription laws, limit drug paraphernalia laws so they apply only to illicit sellers, and establish needle exchange programs with an array of education and drug treatment services attached.