majority of studies of [program] clients demonstrate decreased risk of HIV drug risk behavior, but not decreased rates of HIV sex risk behavior'' (p. 18) In addition, "all but one of the 18 US and Canadian needle exchanges visited … stated that they provide referrals to drug abuse treatment" (p. 10) Finally, regarding possible negative outcomes, the report concluded that needle exchange programs have not increased the total number of discarded used needles and syringes (p. 16). The report goes on to state that there is no evidence that drug use among program participants increased, and there is no evidence of change in overall community levels of noninjection or injection drug use (Lurie et al., 1993:15).

EVIDENCE FROM RECENT STUDIES

This section is organized into topical areas that parallel the summaries of the GAO and University of California reports. Study findings are categorized according to the outcomes and expectations of program effects listed in Table 7.1; both possible positive and possible negative effects are reviewed. The information sources for this update comprise: (1) a review of abstracts from the 1994 International Conference on AIDS; (2) the 1994 American Public Health Association conference; (3) papers presented at the National Research Council/Institute of Medicine's Workshop on Needle Exchange and Bleach Distribution Programs (1994); and (4) articles appearing in refereed journals following the release of the University of California report. Since the University of California report was issued, a number of studies on the impact of needle exchange programs have been presented or published. These studies utilize a variety of designs, including an ecological design; a comparison of prevalence rates between injection drug users who use and those who do not use needle exchange programs; HIV incidence rates among needle exchange program attenders; and, using data collected prospectively, a comparison of HIV incidence rates between injection drug users who attend and those who do not attend a needle exchange program.

Possible Positive Outcomes
Reduction in Risk Behavior

Recent publications on needle exchange programs in San Francisco, New York City, and Portland, Oregon, have addressed the issue of the impact of the programs on HIV drug-use risk behaviors and sexual risk behaviors (Watters et al., 1994; Watters, 1994; Lewis and Watters, 1994; Des Jarlais et al., 1994a, 1994b, 1995; Paone et al., 1994a, 1994b; Oliver et al., 1994).

In an ecological study in San Francisco, Watters (1994) examined the



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