Aims: We review recent evidence of trends in HIV infection, risk behaviour and HIV prevention associated with injecting drug use in the Russian Federation. Methods: Findings draw on a review of English and Russian language research, published international conference abstracts, international agency and assessment reports, and centrally registered HIV surveillance data. Findings: We note the continued major importance of injecting drug use in mediating HIV transmission within Russia, noting recent evidence of HIV outbreaks associated with drug injecting. We note that high levels of risk behaviour associated with drug injecting may persist, but that evidence associates syringe distribution and exchange with reductions in risk behaviour. We summarise the development of 75 syringe distribution and exchange schemes and outreach interventions in the Federation, providing crude estimates of IDU population coverage and syringe distribution coverage. Conclusions: In the context of continuing levels of risk behaviour sufficient to sustain HIV transmission alongside evidence associating syringe distribution and exchange with risk reduction among IDUs, we note the critical importance of policy interventions to maximise syringe distribution coverage among IDU populations. © 2003 Published by Elsevier B.V.