members was identified in published writings as either in favor of or opposed to needle exchange programs. In a process that included discussions with an advisory committee, public health officials, needle exchange program staff members, researchers, experts in drug abuse treatment and injection drug use, and community leaders, a list of 14 research questions was generated: (1) How and why did needle exchange programs develop? (2) How do needle exchange programs operate? (3) Do needle exchange programs act as bridges to public health services? (4) How much does it cost to operate needle exchange programs? (5) Who are the injection drug users who use needle exchange programs? (6) What proportion of all injecting drug users in a community uses the needle exchange program? (7) What are the community responses to needle exchange programs? (8) Do needle exchange programs result in changes in community levels of drug use? (9) Do needle exchange programs affect the number of discarded syringes? (10) Do needle exchange programs affect rates of HIV drug and/or sex risk behaviors? (11) What is the role of studies of syringes in injection drug use research? (12) Do needle exchange programs affect rates of diseases related to injection drug use other than HIV? (13) Do needle exchange programs affect HIV infection rates? and (14) Are needle exchange programs cost-effective in preventing HIV infection?

The investigators conducted a formal review of existing research; made site visits and sent mail surveys to needle exchange programs; formed focus groups with injection drug users; and applied statistical modeling techniques. Data collected from each approach were sorted into 1 of the 14 questions about impact of needle exchange programs. The aim of the literature review was to identify a maximum of written works relating to the effectiveness of needle exchange programs. Computer searches of AIDS line and Medline provided a first cut and were augmented by items from the bibliographies of articles found therein. In addition, the research team reviewed abstracts from the annual International Conference on AIDS from 1988 to 1993 and the annual meetings of the American Public Health Association from 1987 to 1992. To identify unpublished materials, needle exchange program staff were contacted about internal reports, and a search was made for newspaper and magazine clippings, government and institutional reports, and relevant book chapters.

From this effort, 1,972 data sources were identified, which included 475 journal articles, 381 conference abstracts, 236 reports, 159 unpublished materials, 499 newspaper and magazine articles, 94 books or chapters, and 128 personal communications or other sources. All materials were reviewed and coded according to which research question(s) they addressed. Project members were assigned responsibility for synthesizing information for each of the 14 research questions. Each of the studies was assessed using a standardized format and ranked on a scale from 1 to 5:

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