Preventing HIV Transmission -- Copyright -- Contents -- Preface -- Acknowledgments -- Executive Summary -- THE PROBLEM -- THE PANEL'S CHARGE -- SCIENTIFIC ASSESSMENT OF PROGRAM EFFECTIVENESS -- Needle Exchange -- Bleach Distribution -- COMMUNITY AND LEGAL FACTORS -- RECOMMENDED COURSE OF ACTION -- NOTE -- Introduction -- DIMENSIONS OF THE PROBLEM -- RESPONSES TO THE EPIDEMIC -- THE CHARGE TO THE PANEL -- THE PANEL'S REPORT -- Information Sources -- Approach -- Organization -- NOTES -- REFERENCES -- Part 1 Dimensions of the Problem -- 1 The Epidemiology of HIV and AIDS -- BIOLOGICAL MECHANISMS OF TRANSMISSION -- Injection Drug Use Transmission -- Direct Needle Sharing -- Indirect Needle Sharing -- Risk Behaviors and Interventions -- Sexual Transmission -- Perinatal Transmission -- Conclusion -- EPIDEMIOLOGIC DATA -- HIV and AIDS Surveillance -- Mode of Acquisition of Infection -- HIV AND AIDS AMONG INJECTION DRUG USERS -- Surveillance -- Sexual Transmission Among Injection Drug Users -- Perinatal Transmission from Injection Drug Users -- SUMMARY -- Conclusions -- Recommendations -- NOTES -- REFERENCES -- 2 The Epidemiology of Injection Drug Use -- ESTIMATES OF INJECTION DRUG USERS -- Geographic Variations -- National Surveys of Drug Abuse -- National Household Survey on Drug Abuse -- Washington DC Metropolitan Area Drug Study -- Surveys of Youth -- Conclusion -- CHARACTERISTICS OF INJECTION DRUG USERS -- A National Profile -- Local Drug Use Trends and Patterns -- SUMMARY -- Recommendation -- NOTES -- REFERENCES -- 3 Needle Exchange and Bleach Distribution Programs in the United States -- INTRODUCTION -- NEEDLE EXCHANGE PROGRAMS -- Legal Issues -- Program Operations -- Sites -- Staffing -- Policies -- Hours of Operation -- On-Site Services Offered -- Items Distributed -- Characteristics of Program Participants -- Cost and Cost-Effectiveness.

Organization Characteristics -- Three Simple Case Studies -- Two Complex Case Studies -- Comparisons Across Programs -- BLEACH DISTRIBUTION PROGRAMS -- Characteristics of Program Participants -- Outreach Strategies -- CONCLUSIONS -- REFERENCES -- 4 Community Views -- MORAL/ETHICAL ARGUMENTS -- PUBLIC OPINION POLLS -- AFRICAN AMERICAN VIEWS -- LATINO/HISPANIC VIEWS -- LAW ENFORCEMENT VIEWS -- HEALTH PROFESSIONAL VIEWS -- Pharmacists -- Treatment Service Providers -- Funding -- Treatment Efficacy -- Federal Regulations -- Condoning Drug Use -- SUMMARY -- CONCLUSIONS -- NOTE -- REFERENCES -- 5 The Legal Environment -- U.S. DRUG CONTROL POLICY -- Legislative/Statutory Environment -- State and Local Litigation -- DO PARAPHERNALIA AND PRESCRIPTION LAWS CONTRIBUTE TO HIV TRANSMISSION -- Needle Scarcity and Sharing -- Changes in the Laws in Connecticut -- Needle Sales -- Injection Drug Users' Behaviors -- SHOULD THE LAWS BE CHANGED -- Changing the Laws -- Consequences -- CONCLUSIONS -- RECOMMENDATIONS -- NOTE -- REFERENCES -- Part 2 The Impact of Needle Exchange and Bleach Distribution Programs -- 6 The Effectiveness of Bleach as a Disinfectant of Injection Drug Equipment -- TRANSMISSION OF HIV AMONG INJECTION DRUG USERS -- BLEACH AS A DISINFECTANT -- Definition of Terms -- The Role of Cleaning in Disinfection -- Susceptibility of HIV to Disinfection -- Laboratory Studies -- CDC Recommendations -- BLEACH DISTRIBUTION PROGRAMS -- Program Evaluation -- The Chicago Experience -- Limitations of Bleach Disinfection -- Impact of Bleach Disinfection on HIV Transmission -- SUMMARY -- Conclusions -- Recommendations -- NOTES -- REFERENCES -- 7 The Effects of Needle Exchange Programs -- POTENTIAL OUTCOMES -- Possible Positive Outcomes -- Possible Negative Outcomes -- THE PANEL'S APPROACH TO THE EVIDENCE.

The Traditional Approach: Considering the Preponderance of the Evidence -- An Alternative Approach: Looking at the Patterns of Evidence -- Rationale -- Ruling In Plausibility -- The Panel's Synthesis -- U.S. GENERAL ACCOUNTING OFFICE REVIEW -- Procedure -- Results -- UNIVERSITY OF CALIFORNIA REPORT -- Procedure -- Results -- Possible Positive Outcomes -- Reduction in High-Risk Behavior -- Increased Referrals to Drug Treatment -- Reduction in HIV Infection Rates -- Possible Negative Outcomes -- Increase in Program Participant Drug Use -- Increase in New Initiates to Injection Drug Use -- Increased Drug Use in the Community -- Increase in Number of Contaminated Needles Unsafely Discarded -- Summary -- EVIDENCE FROM RECENT STUDIES -- Possible Positive Outcomes -- Reduction in Risk Behavior -- Reduction in HIV Infection Rates -- Possible Negative Outcomes -- Program Participant Drug Use -- New Initiates to Injection Drug Use -- Discarded Needles and Syringes -- THE NEW HAVEN STUDIES -- Program Implementation -- Estimated Effects on HIV Incidence -- Assessment of the Models -- New Initiates to Injection Drug Use -- Enrollment in Drug Treatment -- Alternative Explanations -- Summary -- THE TACOMA STUDIES -- The Program -- HIV Seroprevalence Studies -- Hepatitis Surveillance and Case Reporting -- Hepatitis B and C Case-Control Study -- Interview Studies with Injection Drug Users -- Potential Alternative Explanations -- Program Effects on New Initiates to Drug Use or Abuse -- SUMMARY -- Conclusions -- Recommendations -- NOTES -- REFERENCES -- 8 Directions for Future Research -- RESEARCH ON PROGRAM EFFECTIVENESS -- Needle Exchange Evaluation -- Categorization of Exposure to Intervention Condition -- Measurement of Alternative Sources of Sterile Syringes -- Community-Based Studies -- Appropriate Selection of Respondents.

Temporal Association of Participation in Programs and HIV Seroconversion -- Accounting for Alternative Risk Behaviors -- Consolidation and Coordination of Program Effects -- Program Characteristics -- RESEARCH ON BLEACH EFFICACY IN DISINFECTION -- EPIDEMIOLOGIC RESEARCH -- RESEARCH ON COMMUNITY ISSUES -- OTHER FUTURE RESEARCH ISSUES -- Deregulation of Syringe Sale and Possession -- Incarcerated Populations -- Randomized Trial of Needle Exchange Programs -- BROADER ISSUES -- CONCLUSION -- REFERENCES -- Appendixes -- APPENDIX A Description and Review of Research Projects in Three Cities -- SAN FRANCISCO -- Review -- MONTREAL -- Needle Exchange Evaluation Project -- Seroincidence -- Data from Correctional Institutions -- Review -- Epidemiologic Study -- Seroprevalence -- Seroincidence -- Review -- CHICAGO -- Demand for Free Needles and Their Effect on Injecting Frequency and Needle Use -- Review -- Effects of Exchange Use on HIV Risk Behavior and Incidence -- Review -- CONCLUSION -- REFERENCES -- APPENDIX B Professional Association Positions on Needle Exchange and Bleach Distribution Programs -- APPENDIX C Biographical Sketches -- Index.