Prior to 1993, the instructions for bleach use disseminated across the country were relatively consistent with the methods developed by the Mid-City Consortium in San Francisco (Gleghorn, 1993). With few exceptions (Flynn et al., 1994), bleach has been exclusively promoted as the disinfectant of choice for injection equipment. As a result, awareness of bleach disinfection strategies among injection drug users is high (Meyers et al., 1990). Therefore, a review of the studies that have evaluated cleaning techniques used by injection drug users provides indications concerning user compliance with the recommended bleach techniques.
The bleach distribution program in San Francisco was well accepted by injection drug users. Among those interviewed in neighborhoods with high drug use, Watters (1987, 1994) reported that prior to initiation of the outreach program, only 3 percent of the sample used bleach to clean their equipment. In contrast, 9 months after beginning the community health outreach worker (CHOW) intervention, 76 percent of injection drug users interviewed reported bleach use. In addition, prior to program initiation, regular cleaning of needles and syringes was reported by only 21 percent of those who reported any cleaning attempts. In the follow-up interview, injection drug users who used bleach reported doing so 90 percent of the time. Although other reports (Chaisson et al., 1987) from San Francisco reported less dramatic (approximately fivefold) increases in bleach use, they noted important additional effects of outreach efforts that included bleach distribution on other HIV-related risk behaviors, including decreases in needle sharing and increases in condom use (Chaisson et al., 1987; Sorensen et al., 1989).
Moreover, in these early studies of the adoption of bleach disinfection by injection drug users, a significant positive relationship was observed between access to community health outreach workers and reported use of bleach disinfection (Watters, 1987). Another important variable in the success of bleach education programs appears to be the direct provision of bleach to injection drug users. For example, the AIDS Outreach Program (AOP) provided street-level education on bleach use but did not actually distribute bleach (Neaigus et al., 1990). Evaluation of the impact of this program found that only low levels of regular bleach use were noted both at baseline and during follow-up interviews (16 and 18 percent, respectively). In interpreting these results, Neaigus and colleagues (1990) suggested that outreach efforts aimed at increasing bleach use should include distribution of bleach.
Following the lead of San Francisco, bleach distribution programs proliferated rapidly in cities across the United States. Using techniques adopted from medical epidemiology and community ethnography, workers in Chicago