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Preventing HIV Transmission: The Role of Sterile Needles and Bleach
TABLE 7.1 Possible Outcomes and Expectations of Successful Needle Exchange Programs
Possible Positive Outcomes:
Possible Negative Outcomes:
Reduction in pool of infected needles
Increase in drug use among needle exchange program clients
Reduction in drug-related risk behavior
Increase in new initiates to injection drug use
Reduction in sexual risk behavior
Increase in drug use in wider community
Increase in referrals to drug abuse treatment
Increase in number of contaminated needles unsafely discarded (e.g., on streets)
Reduction in new infections among client population
in the number of improperly discarded used needles. Another possibility is that the issuance of injection equipment, condoned by government, will "send a message" undercutting efforts at combatting illegal drug use and will promote more drug use (with more attendant HIV incidence). A third possible negative outcome is that needle exchanges will lower the perception of risk of injection drug use and thus attract more users to inject drugs and to other forms of illegal drug use.
Appraisal of the success of a needle exchange program, then, should also attend to measures of these possible negative outcomes. An observed pattern of negative outcomes would weigh against the idea that needle exchange programs are beneficial.
Assessment of the effects of needle exchanges involves the simultaneous consideration of a number of intended positive and unintended negative outcomes (Table 7.1). Ideally, a successful exchange program would reduce the risk of new infection among injection drug users without increasing drug use and health risks to the public.
THE PANEL'S APPROACH TO THE EVIDENCE
The purpose of this section is to clearly explain the panel's perspective in assessing the effectiveness of needle exchange programs. We first briefly review the basis for the traditional review procedures. We then outline the argument for a different approach—one that examines the patterns of evidence in order to assess effectiveness.
The Traditional Approach: Considering the Preponderance of the Evidence
Traditional reviews of experimental analysis search for studies with well-controlled research designs. By well-controlled designs, we mean ones