users. Since 1990, a public health nurse has been stationed at the fixed outdoor sites to administer tuberculosis screening tests (the PPD skin test). Those who are given the screening test return to the exchange to have their results read, and further medical workup is arranged for those with positive skin tests. Patients who require antituberculosis medications are scheduled to receive directly observed therapy at the needle exchange. Tuberculosis prevention education is provided to all needle exchange participants through one-to-one counseling and a small-media approach. An average of 175 tuberculosis screening tests are administered to exchange participants each year (Hagan et al., 1992b:8).

HIV testing has also been provided to exchange participants to a limited extent; full implementation has been hindered by the physical setting of the exchange. Both asymptomatic HIV-positive participants and those who have progressed to AIDS are eligible to receive AIDS case management services. The support services given to case management clients provide stability in housing and health care access.

The needle exchange has also become an important source of referral to drug treatment programs in the community. In the first 11 months of 1994, an average of 65 persons were referred to treatment each month. Methadone drug treatment programs, in particular, noted that recruitment at the exchange resulted in enrolling a higher proportion of injection drug users with no previous history of treatment. Furthermore, in 1991 and 1992, the needle exchange was the largest single source of recruitment to methadone treatment programs in the county (Hagan et al., 1993:1694-1695). Since that period, referrals to methadone treatment from the exchange have increased, but program capacity has not kept up with the demand as the number of low-cost, publicly funded treatment slots has plateaued.

In the Tacoma community, the exchange's function of safe disposal of contaminated injection equipment has been considered important. In fact, the local police chief cited public safety and protection of his officers from accidental needlestick injury as the basis for his support of the exchange program (affidavit of Raymond Fjetland, in Tacoma Pierce County Health Department v. City of Tacoma). In addition, a maintenance supervisor responsible for keeping public areas in the vicinity of one of the fixed outdoor sites free of trash and litter noted a dramatic decline in the number of discarded syringes picked up by his crews (affidavit of James Burgess, in Tacoma Pierce County Health Department v. City of Tacoma). In 1990, a sample of returned syringes was collected from the exchange and tested for HIV (Hagan et al., 1991). The virus was detected in 1 percent of 1,200 syringes tested; 2 percent of syringes with visible blood or dirt were HIV-positive. That year, approximately 120,000 used syringes were collected and safely disposed of by the needle exchange.

In Table 7.6 appears a list of five studies that examine various aspects



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