BACKGROUND: We report findings from a multi-method study investigating drug injectors' access to needles and syringes in three large Russian cities (Moscow, Volgograd, Barnaul). METHODS: We undertook 209 qualitative interviews among drug injectors, and supplemented these with baseline data from a community-recruited survey of 1473 drug injectors. FINDINGS: Almost all (93%; 1277) injectors used pharmacies as their main source of clean injecting equipment, and only 7% (105) reported ever having had contact with city syringe exchange projects. Good access to syringes has coincided with the expansion of private pharmacies. Key factors contributing to pharmacy access included: geographic proximity; low cost; and the restrictive policies of exchange instituted at local syringe exchanges. A fear of police interference surrounded the use of pharmacies and syringe exchanges, and fed a reluctance to carry used needles and syringes, which in turn acted as a disincentive to syringe exchange attendance. The perceived benefits of syringe exchanges over pharmacies included the additional health services on offer and the social support provided, but these benefits were over-shadowed by disadvantages. Multivariable analyses of survey data in two cities show no differences on account of risk behaviour among injectors sourcing equipment from pharmacies compared to syringe exchanges. CONCLUSIONS: HIV prevention coverage indicators need to include measures of pharmacy-based syringe distribution and not only measures of syringe exchange coverage. There is an urgent need to pilot pharmacy-based distribution and exchange projects in Russia as well as other forms of secondary syringe distribution. Alongside expanding the reach of dedicated syringe exchange projects, pharmacy-based syringe distribution, and exchange, may help improve coverage of cost effective HIV prevention measures targeting drug injectors.