that include needle and syringe exchange. These are defined as interventions that combine needle and syringe exchange with any one or more of the following services: outreach, health education in risk reduction, condom distribution, bleach distribution coupled with education on needle disinfection, and referrals to substance abuse treatment and other health and social services. In this report, the term multi-component HIV prevention programs does not include drug dependence treatment and other medical or social services (discussed in Chapter 2), but does include referrals to these services. While this separation may seem somewhat artificial, the Committee felt it was necessary to accurately describe the evidence related to needle and syringe exchange.

The following two sections then examine alternatives to NSE for providing access to clean injecting equipment. One of these two sections focuses on pharmacy and prescription sales, vending machines, and supervised injecting facilities, while the other section focuses on disinfection distribution and education programs.

The chapter then evaluates empirical evidence on the effectiveness of outreach and education in preventing HIV transmission among IDUs. Outreach and education are sometimes part of multi-component HIV prevention programs, as they are often used to direct drug users to services such as needle and syringe exchange. They can also stand alone as a means of educating IDUs on HIV prevention, and can also be used to refer drug users to drug treatment and other health and social services. The final section of the chapter discusses specific areas in need of further research in high-risk countries.

NEEDLE AND SYRINGE EXCHANGE

To evaluate the effectiveness of NSE, the Committee reviewed studies identified by a literature review (see Appendix B). As discussed in Chapter 2, the Committee then used a structured qualitative method based on an approach developed by the GRADE Working Group to evaluate the strength of the evidence (GRADE Working Group, 2004) (see Chapter 2 for further detail).

The majority of evidence on the effectiveness of NSEs comes from observational studies, including numerous prospective cohort studies, supplemented by results from ecological and cross-sectional studies. (Appendix D provides a summary of these studies, grouped by study design.) The Committee did not identify any randomized controlled trials of NSE. This is not completely unexpected for such a public health intervention, particularly one with such immediacy and assumed efficacy and face validity. The Committee identified three case-control studies. Such studies enroll participants based on the presence or absence of a disease, and then com-



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