Proceedings Workshop on Needle Exchange and Bleach Distribution Programs -- Copyright -- Contents -- PREFACE -- INTRODUCTION -- REFERENCES -- U.S. NEEDLE EXCHANGE DATA -- The University of California Needle Exchange Program Evaluation Project: Methods, Conclusions, and Recommendation -- METHODS -- Project Personnel -- Goal and Research Questions -- Ensuring Community and Expert Input -- Advisory Committee -- Expert Reviewers -- Kaiser Family Foundation Forum -- Consent and Confidentiality -- Formal Review of Existing Research -- Assessment of Data Needs -- Data Collection -- Data Synthesis -- Site Visits -- Identification of Sites and Interviewees -- Methodological Framework -- Training -- Site Observations -- Key Informant Interviews -- IDU Focus Groups -- Qualitative Analysis -- Mail Survey of NEPs Not Visited -- Cost-Effectiveness Modeling -- CONCLUSIONS -- How and Why Did NEPs Develop? -- How Do NEPs Operate? -- Do NEPs Act as Bridges to Public Health Services? -- How Much Does it Cost to Operate NEPs? -- Who Are the IDUs Who Use NEPs? -- What Proportion of All IDUs in a Community Uses the NEP? -- What Are the Community Responses to NEPs? -- Do NEPs Result in Changes in Community Levels of Drug Use? -- Do NEPs Affect the Number of Discarded Syringes? -- Do NEPs Affect Rates of HIV Drug and/or Sex Risk Behaviors? -- What is the Role of Studies of Syringes in Injection Drug Use Research? -- Do NEPs Affect Rates of Diseases Related to Injection Drug Use Other than HIV? -- Do NEPs Affect HIV Infection Rates? -- Are NEPs Cost-effective in Preventing HIV Infection? -- RECOMMENDATIONS -- Recommendations for the Federal Government -- Recommendations for State Governments -- Recommendations for Researchers -- APPENDIX -- Research Questions -- References.

Risk for Human Immunodeficiency Virus and Hepatitis B Virus in Users of the Tacoma Syringe Exchange Program -- INTRODUCTION -- METHODS -- The Intervention -- Studies of Risk Behavior in Local IDUs -- Surveillance of Blood-Borne Viral Infections -- Case-Control Study of Incident HBV Infections -- 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 -- Ethnographic Study -- Behavioral Change and Seroconversion -- Seroprevalence and Seroincidence -- RESULTS -- Organizational-System Issues -- Health Departments -- The American Foundation for AIDS Research (AmFAR) -- Syringe Exchange Programs -- Evaluation -- PROBLEM SOLVING -- Subject Characteristics -- Self-Reported Change in Risk-Taking Behavior -- 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 -- Behaviour Change -- Infection Rates -- Future Evaluation -- ACKNOWLEDGMENT -- References.

Toronto's HIV Prevention Program for Injection Drug Users: Trends in Risk Behavior and HIV Seroprevalence Over Two and a… -- INTRODUCTION -- RESULTS -- Key Findings -- Needle Use -- Sexual Behavior Over the Study Period -- HIV Testing -- 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 -- HIV Infection -- AIDS Data -- Comment -- POLICY RESPONSE -- NSEP PROGRAMMES -- Development and Expansion -- Unintended Negative Consequences -- EVALUATION -- NON NSEP PROGRAMMES -- EVALUATION -- LOOMING PROBLEMS -- Hepatitis C and Other Blood Borne Viruses -- Prisons -- Prohibition Under Increasing Scrutiny -- 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 -- Drug Paraphernalia Laws -- PROPOSAL FOR REFORMING DRUG PARAPHERNALIA STATUTES -- Needle Prescription Laws -- Proposal for Repeal of Needle Prescription Statutes -- LEGAL BASIS OF SYRINGE EXCHANGE PROGRAMS -- Harmonizing the Objectives of Law Enforcement and Public Health -- Establishing Authority for Needle and Syringe Exchanges -- Statutory Authority for Exchanges -- Judicial Declaration -- The Necessity Defense -- Balancing Governmental Interests -- 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 -- INTRODUCTION -- BACKGROUND -- Epidemiology of AIDS/HIV -- Canadian Response to HIV and Injection Drug Use -- Factors Influencing Canada's Response -- Canada's Health Case System: Its Funding and Organization -- Canada's Drug Strategy -- Canadian Drug Laws -- Canada's National AIDS Strategy (1990) -- Pharmacy Accreditations and Pharmacists Licensing -- Rationale for the Canadian Pharmacy Survey -- METHOD -- Analysis -- RESULTS -- Response -- Characteristics -- Current Practices -- Knowingly Served a Person with HIV -- Requests to Sell Needles and Syringes -- Comparison of Requests for Needles and Syringe Sales to Knowledge of Serving Persons Living With HIV -- Comparison of "Pharmacy Response" with "Requests to Sell" -- Pharmacy's Response to Requests to Purchase -- Provincial/Territorial Policy and Sale of Needles -- Discretion in Sales -- Professional Thinking and Potential Role for Pharmacies -- Pharmacy-Based Services for Injection Drug Users -- Agreement with Interventions to Prevent the Spread of HIV -- Perceptions of Factors Contributing to Injection Drug Use -- Endorsement of Future Preventive Interventions -- Change in Professional Thinking About Non-Diabetic Injection of Drugs -- 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 -- Outcomes Related to Reducing Risk of HIV Transmission -- HIV -- Behavior -- Surrogate Measures of HIV -- Number of Persons Sharing Each Syringe -- Outcomes Related to Injection Drug Use -- POTENTIAL RELATIONSHIPS OF EXPOSURE TO OUTCOME.

Duration Can Be Modelled in a Number of Different Ways -- The One-Hit Model -- The Threshold Model -- The Dose-Response Model -- Recency of Exchange Might Also Be Modelled in Different Ways -- Latency of Effects -- Transience of Effects -- Directness of Effects -- STUDY DESIGN -- Observational Studies of Populations (''Ecologic Studies") -- Experimental Trials of Populations (Community Intervention Trials) -- Observational Studies of Individuals -- Cross-Sectional Studies -- Case-Control Studies -- Cohort Studies -- Experimental Trials of Individuals -- ISSUES OF METHODOLOGICAL BIAS -- Confounding -- Selection Bias -- Information Bias -- STATISTICAL POWER AND MEASURES OF PROBABILITY -- GENERALIZABILITY -- FUTURE NEEDS -- ACKNOWLEDGMENTS -- References -- An Evaluation of Needle and Syringe Exchange in San Francisco -- INTRODUCTION -- METHODS -- Data Sources and Sampling -- Outcome Measures -- Statistical Analysis -- RESULTS -- Utilization of Syringe Exchange Program -- Frequency of Injection -- Recruitment of New and Younger Users into Injection Drug Use -- Syringe Sharing-Univariate Analysis -- Syringe Sharing-Multivariate Analysis -- DISCUSSION -- ACKNOWLEDGMENTS -- References -- Using Qualitative Methods to Evaluate Needle Exchange -- INTRODUCTION -- PREVENTION POINT -- STUDY DESIGN AND RESEARCH OBJECTIVES -- THEORETICA -- AND METHODOLOGICAL PERSPECTIVE -- Data Collection -- Triangulation -- SAMPLING STRATEGIES -- Providers -- Primary Exchangers -- Secondary Exchangers -- Non-Exchangers -- THE INTERVIEW -- QUALITATIVE DATA ANALYSIS -- Domain Analysis -- Coding -- Memoing -- Field Notes -- Data Organization -- 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).

2.1 An Idealized Research Environment.