Proceedings Workshop on Needle Exchange and Bleach Distribution Programs

PANEL ON NEEDLE EXCHANGE AND BLEACH DISTRIBUTION PROGRAMS

Commission on Behavioral and Social Sciences and Education

National Research Council and

Institute of Medicine

NATIONAL ACADEMY PRESS
Washington, D.C.
1994



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Proceedings Workshop on Needle Exchange and Bleach Distribution Programs Proceedings Workshop on Needle Exchange and Bleach Distribution Programs PANEL ON NEEDLE EXCHANGE AND BLEACH DISTRIBUTION PROGRAMS Commission on Behavioral and Social Sciences and Education National Research Council and Institute of Medicine NATIONAL ACADEMY PRESS Washington, D.C. 1994

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Proceedings Workshop on Needle Exchange and Bleach Distribution Programs 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. This project was sponsored by the National Institute on Drug Abuse. Library of Congress Catalog Card No. 94-67632 International Standard Book Number 0-309-05084-7 Additional copies of this report are available from: National Academy Press 2101 Constitution Avenue N.W. Washington, D.C. 20418 Call 800-624-6242 or 202-334-3313 (in the Washington Metropolitan Area). B349 Printed in the United States of America Copyright 1994 by the National Academy of Sciences. All rights reserved.

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Proceedings Workshop on Needle Exchange and Bleach Distribution Programs PANEL ON NEEDLE EXCHANGE AND BLEACH DISTRIBUTION PROGRAMS LINCOLN MOSES (Chair), Department of Statistics, Stanford University RONALD S. BROOKMEYER, Department of Biostatistics, School of Hygiene and Public Health, The Johns Hopkins University LAWRENCE S. BROWN, Jr., Department of Medicine, Harlem Hospital, College of Physicians and Surgeons, Columbia University and Division of Medical Services Evaluation and Research, Addiction Research and Treatment Corporation, Brooklyn RICHARD F. CATALANO, Social Development Research Group, Seattle DAVID S. CORDRAY, Vanderbilt Institute for Public Policy Studies and Department of Human Resources, Peabody College, Vanderbilt University DON C. DES JARLAIS, Chemical Dependency Institute, National Development and Research Institutes, Inc., Beth Israel Medical Center, New York CASWELL A. EVANS, Jr., Public Health Programs and Services, County of Los Angeles Department of Health Services MARK B. FEINBERG, Gladstone Institute of Virology and Immunology, San Francisco HERBERT D. KLEBER, Department of Psychiatry, College of Physicians and Surgeons, and Center on Addiction and Substance Abuse, Columbia University PATRICK M. O'MALLEY, Institute for Social Research, University of Michigan, Ann Arbor NANCY S. PADIAN, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco General Hospital MARIAN GRAY SECUNDY, College of Medicine, Department of Community Health and Family Practice, Howard University DAVID VLAHOV, School of Hygiene and Public Health, The Johns Hopkins University W. WAYNE WIEBEL, AIDS Outreach Intervention Project and School of Public Health, Epidemiology and Biostatistics, University of Chicago at Illinois DAVID R. WILLIAMS, Institute for Social Research, University of Michigan, Ann Arbor National Research Council Staff SUSANNE M. STOIBER, Division Director (through January 1994) ALEXANDRA K. WIGDOR, Division Director (from February 1994) JACQUES L. NORMAND, Study Director SAHR J. KPUNDEH, Staff Officer ELAINE McGARRAUGH, Research Associate SUSAN R. McCUTCHEN, Senior Project Assistant Institute of Medicine Staff MICHAEL A. STOTO, Division Director LESLIE M. HARDY, Program Officer

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Proceedings Workshop on Needle Exchange and Bleach Distribution Programs CONTENTS   Preface   vii Introduction   1 U.S. Needle Exchange Data   5     The University of California Needle Exchange Program Evaluation Project: Methods, Conclusions, and Recommendations, Peter Lurie, James G. Kahn, Benjamin Bowser et al.,   7     Risk for Human Immunodeficiency Virus and Hepatitis B Virus in Users of the Tacoma Syringe Exchange Program, Holly Hagan et al.,   24     Behavioral and Community Impact of the Portland Syringe Exchange Program, Kathy Oliver et al.,   35     New York City Syringe Exchange: An Overview, Denise Paone et al.,   47     Discussion: U.S. Needle Exchange Data, Andrew Moss   64 International Evaluations of Needle Exchange Programs   65     Evaluation of the Needle/Syringe Exchange in Amsterdam, the Netherlands, Anneke van den Hoek and Roel Coutinho   67     Evaluation of Human Immunodeficiency Virus Prevention Programs for Injection Drug Users in Canada, Margaret Millson and Catherine Hankins   72     Toronto's HIV Prevention Program for Injection Drug Users: Trends in Risk Behaviour and HIV Seroprevalence Over Two and a Half Years, Margaret Millson et al.,   78     Evaluating Montréal's Needle Exchange CACTUS-Montréal, Catherine Hankins et al.,   83     Needle Exchange and Bleach Distribution Programs: The Australian Experience, Alex Wodak   91     Discussion: International Evaluations of Needle Exchange Programs, Peter Selwyn   109

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Proceedings Workshop on Needle Exchange and Bleach Distribution Programs Legal Issues and Drug Paraphernalia   111     Law and Policy, Lawrence Gostin   113     New Connecticut Laws to Improve Access to Needles and Syringes: What Is Their Impact?, Samuel L. Groseclose and Linda A. Valleroy et al.,   132     Canadian Pharmacies' Response to HIV and Harm Reduction Strategies: A Report From the National Survey on Community Pharmacies and HIV/AIDS Prevention, Ted Myers et al.,   135     Discussion: Legal Issues and Drug Paraphernalia, Lane Porter   152 Evaluation Methods   153     Assessing the Efficacy of Needle Exchange Programs: An Epidemiological Perspective, Noreen V Harris et al.,   155     An Evaluation of Needle and Syringe Exchange in San Francisco, John K Watters et al.,   170     Using Qualitative Methods to Evaluate Needle Exchange, Sheigla Murphy   187     Operational Modeling of Needle Exchange Programs, Edward H. Kaplan   202     Discussion: Evaluation Methods, Robert Booth   250 Bleach Distribution Programs   253     HIV-1 Prevention: Interdisciplinary Studies and Reviews on Efficacy of Bleach and Compliance to Bleach Prevention Protocols, Clyde B. McCoy and Paul Shapshak et al.,   255     Inactivation and Disinfection of HIV: A Summary, Linda S. Martin   284     Use of Bleach by Injection Drug Users, Alice A. Gleghorn   294     Discussion: Bleach Distribution Programs, T. Stephen Jones   303 Workshop Agenda and Participants   305

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Proceedings Workshop on Needle Exchange and Bleach Distribution Programs PREFACE The July 1992 ADAMHA Reorganization Act mandated that the Secretary of Health and Human Services, acting through the Director of the National Institute on Drug Abuse, request the National Academy of Sciences to conduct a study on the impact of needle exchange and bleach distribution programs on drug use behavior and the spread of the human immunodeficiency virus. In response to that legislative directive, the National Research Council and the Institute of Medicine of the National Academy of Sciences organized the Panel on Needle Exchange and Bleach Distribution Programs in May 1993, under the auspices of the Committee on AIDS Research and the Behavioral, Social, and Statistical Sciences. Specifically, the panel was asked to: (1) examine the scientific evidence pertaining to the effects of needle exchange and bleach programs on rates of drug use and the behavior of drug users in the United States; (2) evaluate the efficacy of needle exchange and bleach programs in reducing the spread of HIV and other infectious diseases among injecting drug users and their partners, and (3) evaluate the potential risks and benefits associated with the implementation of such programs. The panel is examining related issues of importance to the research and service communities (e.g., characteristics associated with successful programs, community issues, and service delivery issues) and will make recommendations regarding future research directions and appropriate methods for evaluating needle exchange and bleach programs. In its effort to gather and analyze the relevant scientific evidence, the panel invited both U.S. and foreign experts to participate in a two-day workshop September 27-28, 1993, devoted to the presentation and discussion of recent research on and experience with needle exchange and bleach distribution programs. (A second workshop, held in January 1994, elicited the views of the many communities with a stake in the outcome of the ongoing needle exchange and bleach distribution debate.) The agenda for the workshop was designed to inform the further work of the panel by focusing on particular salient issues to be considered in the establishment of needle exchanges and bleach distribution programs. Because substantial public interest in data on the efficacy of needle exchange and bleach distribution programs has been expressed and most of the presentations made at this workshop summarize ongoing research projects, panel members decided it would be beneficial to publish the papers. This proceedings is organized to follow the five sessions that constituted the workshop: U.S. needle exchange data, international evaluations of needle exchange programs, legal issues and drug paraphernalia laws, evaluation methods, and bleach distribution programs. Each section consists of the papers that were presented, followed by a brief summary of the presentations by the designated discussant. Panel members are indebted to the presenters and discussants who participated in this workshop and to the workshop participants who volunteered time to share their insights and expertise. We note with sadness the recent death of Noreen Harris, one of the presenters, and offer our sympathy to her family and colleagues. Noreen's research has contributed greatly to enhancing the knowledge and understanding of critical issues in the areas of HIV/AIDS and drug abuse.

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Proceedings Workshop on Needle Exchange and Bleach Distribution Programs The panel extends its sincere thanks and appreciation to Sander Genser and Peter Hartsock of the National Institute on Drug Abuse and T. Stephen Jones of the Centers for Disease Control and Prevention for their valuable assistance in organizing the workshop. The panel also benefited from the work of the staffs of the National Research Council and the Institute of Medicine, including Susanne Stoiber, Michael Stoto, and Leslie Hardy, who provided valuable suggestions for this panel activity. Special thanks are due to the panel staff: Jacques Normand, study director; Sahr John Kpundeh, staff officer; Elaine McGarraugh, research associate; and Susan McCutchen, senior project assistant, for their many hours of work expended in bringing this workshop to fruition and producing this proceedings. Lincoln E. Moses, Chair Panel on Needle Exchange and Bleach Distribution Programs