INTRODUCTION

Between 1.1 and 1.5 million people in the United States are injection drug users (Turner, Miller, and Moses, 1989), and over 3.2 million people have injected drugs at some point in their lives (National Institute on Drug Abuse, 1991). The sharing of injection equipment among drug users is the second most common risk behavior (Turner, Miller, and Moses, 1989), after male homosexual contact, among people with acquired immune deficiency syndrome (AIDS). It is also the major risk factor associated with heterosexual and perinatal transmission of the human immunodeficiency virus (HIV) in the United States (Centers for Disease Control and Prevention, 1993). By early 1993, according to the Centers for Disease Control and Prevention (1993), a third of the more than 280,000 people in the United States who had been diagnosed with AIDS were drug injectors (29 percent), people who had heterosexual contact with such a drug user (3 percent), or children born to injecting drug users or their sex partners (1 percent).

African-American and Latino communities have been particularly affected by drug-related transmission of HIV. In 1991, AIDS cases related to injection drug use accounted for 52 percent of African-American and 45 percent of Latino AIDS cases in the United States, compared with 19 percent for whites (Jones et al., 1991). Moreover, the proportion of AIDS cases occurring among people whose primary risk factor is injection drug use has been steadily increasing since the beginning of the epidemic (Krepcho et al., 1993).

Needle exchange programs, in which used needles and syringes are exchanged for new, sterile ones, are widely used in Europe and Australia as part of public health efforts to reduce the spread of HIV and other needle-borne infections among drug users and their sexual partners. Programs that distribute household bleach to injecting drug users so they can disinfect shared injection equipment have also been established abroad. In the United States, although needle exchange programs have been initiated in a number of cities, they are generally small and frequently operate illegally. In addition, health outreach workers in many U.S. communities distribute bleach as part of their work among drug users. In the U.S. Congress, an intense debate about whether needle exchange programs encourage either continued injection behavior or initiation of injection drug or other drug use has blocked any federal funding of needle exchanges. Prior to the passage of the ADAMHA Reorganization Act of 1992 (P.L. 102-321), the use of federal funds to evaluate needle exchange programs was also prohibited.

This proceedings presents original papers and the discussants' summaries from the Workshop on Needle Exchange and Bleach Distribution Programs. The workshop was structured to address, in five sessions, topics considered important to the panel's inquiry: (1) U.S. needle exchange data, (2) international evaluations of needle exchange programs, (3) legal issues and drug paraphernalia, (4) evaluation methods, and (5) bleach distribution programs. Following this brief introduction, these five areas also structure this report. In each area, the complete text of the workshop presentation is followed by a summary by the designated discussant for the session. The agenda and list of participants are included at the end of the report.



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Proceedings Workshop on Needle Exchange and Bleach Distribution Programs INTRODUCTION Between 1.1 and 1.5 million people in the United States are injection drug users (Turner, Miller, and Moses, 1989), and over 3.2 million people have injected drugs at some point in their lives (National Institute on Drug Abuse, 1991). The sharing of injection equipment among drug users is the second most common risk behavior (Turner, Miller, and Moses, 1989), after male homosexual contact, among people with acquired immune deficiency syndrome (AIDS). It is also the major risk factor associated with heterosexual and perinatal transmission of the human immunodeficiency virus (HIV) in the United States (Centers for Disease Control and Prevention, 1993). By early 1993, according to the Centers for Disease Control and Prevention (1993), a third of the more than 280,000 people in the United States who had been diagnosed with AIDS were drug injectors (29 percent), people who had heterosexual contact with such a drug user (3 percent), or children born to injecting drug users or their sex partners (1 percent). African-American and Latino communities have been particularly affected by drug-related transmission of HIV. In 1991, AIDS cases related to injection drug use accounted for 52 percent of African-American and 45 percent of Latino AIDS cases in the United States, compared with 19 percent for whites (Jones et al., 1991). Moreover, the proportion of AIDS cases occurring among people whose primary risk factor is injection drug use has been steadily increasing since the beginning of the epidemic (Krepcho et al., 1993). Needle exchange programs, in which used needles and syringes are exchanged for new, sterile ones, are widely used in Europe and Australia as part of public health efforts to reduce the spread of HIV and other needle-borne infections among drug users and their sexual partners. Programs that distribute household bleach to injecting drug users so they can disinfect shared injection equipment have also been established abroad. In the United States, although needle exchange programs have been initiated in a number of cities, they are generally small and frequently operate illegally. In addition, health outreach workers in many U.S. communities distribute bleach as part of their work among drug users. In the U.S. Congress, an intense debate about whether needle exchange programs encourage either continued injection behavior or initiation of injection drug or other drug use has blocked any federal funding of needle exchanges. Prior to the passage of the ADAMHA Reorganization Act of 1992 (P.L. 102-321), the use of federal funds to evaluate needle exchange programs was also prohibited. This proceedings presents original papers and the discussants' summaries from the Workshop on Needle Exchange and Bleach Distribution Programs. The workshop was structured to address, in five sessions, topics considered important to the panel's inquiry: (1) U.S. needle exchange data, (2) international evaluations of needle exchange programs, (3) legal issues and drug paraphernalia, (4) evaluation methods, and (5) bleach distribution programs. Following this brief introduction, these five areas also structure this report. In each area, the complete text of the workshop presentation is followed by a summary by the designated discussant for the session. The agenda and list of participants are included at the end of the report.

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Proceedings Workshop on Needle Exchange and Bleach Distribution Programs The first workshop session on U.S. needle exchange data focused on what has been learned about the impact of needle exchange on HIV transmission and drug use behaviors in this country. Data were presented from evaluations of needle exchange programs in four cities: New York, New York; Portland, Oregon; San Francisco, California; and Tacoma, Washington. In addition, researchers from the University of California (Berkeley and San Francisco) presented highlights of their recent study on the impact of needle exchange programs in the United States and abroad, which involved an intensive review of the research literature and site visits to needle exchange programs in 10 U.S. and 5 foreign cities. The second session continued the theme of what has been learned about the impact of needle exchange programs on HIV transmission and drug use behaviors—but from programs outside the United States. Data were presented from evaluations of programs in the Netherlands, Canada, and Australia. In addition, findings were presented from a U.S. General Accounting Office evaluation of research results from nine needle exchange study projects, all but one of which involved needle exchange programs outside the United States. The focus of the third workshop session was the legal perspective on needle exchange programs, and three presentations were made. The first provided a description of drug paraphernalia and needle prescription laws in the United States and the obstacles they pose to needle exchange programs. The second reported on an evaluation of whether changes in Connecticut's drug laws had an impact on pharmacy practice, in regard to the sale of needles and the needle purchasing and usage behavior of injectors of illegal drugs. The third presentation described the results of a national survey of Canadian pharmacies in their response to HIV prevention and harm reduction strategies. The presentations in the fourth workshop session dealt with research methods and designs strategies used in studies of the impact of needle exchange and bleach distribution programs, as well as methodological issues that can arise in such studies. Four presentations were made: the first three discussed epidemiologic and qualitative methods of evaluating the impact of HIV prevention programs and related methodological issues. The fourth provided a detailed description of two mathematical models that were derived to assist researchers in estimating the impact of needle exchange programs. In the final workshop session, three presentations were made: the first reported on a series of investigations into the efficacy of bleach as an inactivation-disinfectant agent and the compliance of drug users with bleach protocols. The second provided a review of HIV inactivation and disinfection methods as background for an examination of why cleaning needles with bleach in the field may not work even though it has been shown to work in the laboratory. The third presentation described the results of a study of the compliance of injecting drug users with bleach protocols.

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Proceedings Workshop on Needle Exchange and Bleach Distribution Programs REFERENCES Center for Substance Abuse Treatment 1993 HIV/AIDS Prevention Bulletin April 19. Substance Abuse and Mental Health Services Administration, Public Health Service, U.S. Department of Health and Human Services. Centers for Disease Control and Prevention 1993 U.S. AIDS cases reported through March 1993. HIV/AIDS Surveillance Report 5(1) January. Public Health Service, U.S. Department of Health and Human Services. Jones, T., L. Slutsker, B. Frey, and B. Ward 1991 AIDS cases associated with injection drug use, United States 1991. In Final Program and Abstracts of the VIII International Conference on AIDS, 1992. Amsterdam. Krepcho, M., M. Fernandez-Esquer, A. Freeman, E. Magee, and A. McAlister 1993 Predictors of bleach use among current African-American injecting drug users: A community study. Journal of Psychoactive Drugs 25(2):135-141. National Institute on Drug Abuse 1991 National Household Survey on Drug Abuse: Population Estimates 1991. Rockville, MD: National Institute on Drug Abuse. Turner, C. F., H. G. Miller, and L. E. Moses, eds. 1989 AIDS: Sexual Behavior and Intravenous Drug Use. Washington, D.C.: National Academy Press.

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