between the conflicting objectives of the campaigns against the two epidemics of drug abuse and HIV.

For example, when proponents of needle distribution argue that repeal of paraphernalia laws is more important than instituting discrete needle exchange programs because pharmacies are more plentiful, have more convenient hours, and cost less to operate, community concerns need to be acknowledged. Citizen groups and police are concerned about an increase in discarded needles and accidental needlesticks. Pharmacists are concerned about the impact on their other customers if they expand business to serve injection drug users. Public opinion polls are less supportive of needle distribution than they are of needle exchange. This combination of community views suggests that needle exchange, with the systematic collection of contaminated needles, is more palatable than outright needle distribution programs.

Another observation that arises from this chapter is that community support has built gradually for needle exchange and bleach distribution programs. Repeat surveys over time in a single geographic location are consistent in showing an increase in the proportion of respondents who react favorably toward needle exchange and bleach distribution programs. The most recent surveys in Baltimore and the state of Maryland show that a majority favors needle exchange. Similarly, quotes from politicians, drug abuse treatment providers, and African American clergy reflect a change in attitude over time. The change reflects the growing discussion of needle exchange and bleach distribution programs as part of a campaign aimed at stemming the epidemic of parenteral transmission of HIV infection—rather than as an incongruous initiative amidst a broader campaign aimed at drug abuse.

As community concerns are recognized and addressed, the concept of needle exchange and bleach distribution programs is refined. Initial constraints placed by communities on needle exchange programs in New York City and Washington, D.C. (as described in Chapter 3) resulted in programs that were universally recognized as ineffective. With continued dialogue and progressive iterations of balancing community concerns, the concept of needle exchange and bleach distribution programs continues to evolve.

When needle exchange and bleach distribution services are viewed as one of many components of a comprehensive strategy against HIV, a reduction in resistance and broader coalitions for these programs can be expected to follow. At the same time, efforts to develop comprehensive programs must recognize that change or expansion of needle exchange and bleach distribution programs must be combined with significant attention to long-term societal impacts (e.g., on community-level drug use). Failure to include community members in the decision-making process about the implementation



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