to injection drug users. However, the record shows little evidence in support of these concerns.

• There is no credible evidence to date that drug use is increased among participants as a result of programs that provide legal access to sterile equipment. (Long-term effects are necessarily not yet known, providing a reason for continued monitoring for potential negative effects.)

• The available scientific literature provides evidence based on self-reports that needle exchange programs:

  • do not increase the frequency of injection among program participants and

  • do not increase the number of new initiates to injection drug use.

• The available scientific literature provides evidence that needle exchange programs:

  • have public support, depending on locality, and

  • have public support that tends to increase over time (where trend data are available).

The high level of concern about potential negative effects of needle exchange and bleach distribution programs cannot be ignored, despite the paucity of supporting evidence. Communities wracked with drug abuse and addiction, AIDS, crime, and poverty may well resent the institution of needle exchange and bleach distribution programs, seeing the programs as a wholly inadequate response to the key problems. Attention to comprehensive responses to the drug epidemic is clearly important, especially the expansion of drug treatment to make it more available. Needle exchange programs should be regarded as a public health promotion and disease prevention strategy that fits within the broader harm reduction approach to public health.

It is essential that prevention programs (including initiation of needle exchange programs) must vary regionally and locally to reflect those infected or at risk in any area. Thus, although the panel supports the use of needle exchange and bleach distribution programs as part of a nationwide HIV prevention strategy, it is absolutely critical that their use should be driven by the nature of the epidemic in different locales.

The specific charge to this panel was to examine the effectiveness of syringe exchange and bleach distribution as methods of reducing HIV transmission.