This book reports on research on and experience with needle exchange and bleach distribution programs and their effects on rates of drug use, the behavior of injection drug users, and the spread of HIV and other infectious diseases among injection drug users. It discusses U.S. needle exchange data, international evaluations of needle exchange programs, legal issues and drug paraphernalia laws, evaluation methods, and bleach distribution programs.

Contents

• PANEL ON NEEDLE EXCHANGE AND BLEACH DISTRIBUTION PROGRAMS
• PREFACE
• INTRODUCTION
• U.S. NEEDLE EXCHANGE DATA
  • The University of California Needle Exchange Program Evaluation Project: Methods, Conclusions, and Recommendations
    • Methods
    • Conclusions
    • Recommendations
    • Appendix
    • References
  • Risk for Human Immunodeficiency Virus and Hepatitis B Virus in Users of the Tacoma Syringe Exchange Program
    • Introduction
    • Methods
    • Results
    • Discussions
    • References
  • Behavioral and Community Impact of the Portland Syringe Exchange Program
    • Program Overview
    • Methods
    • Results
    • Conclusions
    • Acknowledgments
    • Reference
  • New York City Syringe Exchange: An Overview
    • Introduction
    • Overview of Evaluation
    • Methods
    • Results
    • Problem Solving
    • Discussion
    • Acknowledgments
    • References
  • Discussion: U.S. Needle Exchange Data
• INTERNATIONAL EVALUATIONS OF NEEDLE EXCHANGE PROGRAMS
  • Evaluation of the Needle/Syringe Exchange in Amsterdam, the Netherlands
    • AIDS and HIV in the Netherlands and Amsterdam
    • Background Information on Amsterdam Drug Policy
    • The Amsterdam Cohort Study on HIV Infection and AIDS Among Drug Users
    • Prevalence and Incidence of HIV Infection
    • Risk Reduction and the Exchange Program
    • Conclusions
    • Literature
  • Evaluation of Human Immunodeficiency Virus Prevention Programs for Injection Drug Users in Canada
    • The Pilot Programs
    • Evaluation Approaches
    • Selected Findings of Process Evaluations
    • Client Satisfaction Measures
    • Key Findings About Impact
    • Acknowledgment
    • References
  • Toronto's HIV Prevention Program for Injection Drug Users: Trends in Risk Behavior and HIV Seroprevalence Over Two and a Half Years
    • Introduction
    • Results
    • Conclusions
  • Evaluating Montréal's Needle Exchange CACTUS-Montréal
    • Introduction
    • Awareness, Utilisation, Satisfaction
    • HIV Antibody Seroprevalence and Seroincidence
    • Conclusion
    • Acknowledgment
    • References
  • Needle Exchange and Bleach Distribution Programs: The Australian Experience
    • Summary
    • Introduction
    • Epidemiology
    • Policy Response
    • NSEP Programmes
    • Evaluation
    • Non NSEP Programmes
    • Evaluation
    • Looming Problems
    • Relevance to Other Countries
    • References
  • Discussion: International Evaluations of Needle Exchange Programs
• LEGAL ISSUES AND DRUG PARAPHERNALIA
  • Law and Policy
    • Drug Control Policies that Limit the Supply of Sterile Injection Equipment
    • Proposal for Reforming Drug Paraphernalia Statutes
    • Legal Basis of Syringe Exchange Programs
    • Conclusion
    • References
  • New Connecticut Laws to Improve Access to Needles and Syringes: What is Their Impact?
    • Introduction
    • Evaluation Findings
    • Policy Recommendations
    • Comment
  • Canadian Pharmacies' Response to HIV and Harm Reduction Strategies: A Report from the National Survey on Community Pharmacies and HIV/AIDS Prevention
    • Introduction
    • Background
    • Method
    • Results
    • Summary and Conclusions
    • Acknowledgments
    • References
  • Discussion: Legal Issues and Drug Paraphernalia
• EVALUATION METHODS
  • Assessing the Efficacy of Needle Exchange Programs: An Epidemiological Perspective
    • Introduction
    • Causal Inference
    • Outcomes of Interest
    • Potential Relationships of Exposure to Outcome
    • Study Design
    • Issues of Methodological Bias
    • Statistical Power and Measures of Probability
    • Generalizability
    • Future Needs
    • Acknowledgments
    • References
  • An Evaluation of Needle and Syringe Exchange in San Francisco
    • Introduction
    • Methods
    • Results
    • Discussion
    • Acknowledgments
    • References
  • Using Qualitative Methods to Evaluate Needle Exchange
    • Introduction
    • Prevention Point
    • Study Design and Research Objectives
    • Theoretica; and Methodological Perspective
    • Sampling Strategies
    • The Interview
    • Qualitative Data Analysis
    • Validity and Reliability
    • Bibliography
  • Operational Modeling of Needle Exchange Programs
    • 1. Introduction and Motivation
    • 2. Estimating HIV Incidence Among Needle Exchange Participants (Kaplan and Heimer, 1994)
    • 3. The Physics of Needle Exchange (Kaplan, 1994)
    • 4. A Roll Call of Results from the New Haven Studies: What Was Learned versus What Might Have Been
    • 5. A Note on Validating Mathematical Models with Special Reference to AIDS
    • 6. Concluding Thoughts
    • Acknowledgments
    • References
  • Discussion: Evaluation Methods
• BLEACH DISTRIBUTION PROGRAMS
  • HIV-1 Prevention: Interdisciplinary Studies and Reviews on Efficacy of Bleach and Compliance to Bleach Prevention Protocols
    • Summary
    • Introduction
    • Risky Practices
    • Risky Environments
    • Prevalence of HIV-1 in Field Collected Needles and Syringes
    • Randomized Study of Field Collected Needles/Syringes
    • Inactivation of HIV-1 Pellets with Bleach
    • Inactivation of HIV in Blood Using Bleach Approximating Field Conditions
    • Tests Utilizing Diluted Bleach
    • Bleach Utilization and Compliance
    • Discussion
    • Conclusion
    • Acknowledgments
    • References
  • Inactivation and Disinfection of HIV: A Summary
    • Acknowledgment
    • References
  • Use of Bleach by Injection Drug Users
    • Introduction
    • Methods
    • Results
  • Discussion: Bleach Distribution Programs
• WORKSHOP AGENDA AND PARTICIPANTS

This project was sponsored by the National Institute on Drug Abuse.

NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.

This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine.

The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that require it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences.

The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievement of engineers. Dr. Robert M. White is president of the National Academy of Engineering.

The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine.

The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy's purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. Robert M. White are chairman and vice chairman, respectively, of the National Research Council.