This necessarily led to some consideration of other methods of reducing HIV transmission.

Reducing drug use would serve to reduce HIV transmission as well as to achieve other important social and public health goals. Comprehensive drug treatment is one important way to reduce drug use. However, (1) treatment, especially comprehensive treatment, is inadequately available; (2) treatment does not work for all individuals who enter it; and (3) not all drug abusers currently are willing ("wish") to enter treatment.

For all of these reasons, researchers have explored the efficacy of more limited programs, such as needle exchange and bleach distribution, as a means of reducing the risk of HIV infection by providing users not able to undertake drug treatment access to uncontaminated injection equipment.

Based on a comprehensive review of the research literature, the panel concludes that well-implemented needle exchange programs can be effective in preventing the spread of HIV and do not increase the use of illegal drugs. Hence, we recommend that:

• The Surgeon General make the determination called for in P.L. 102-394, section 514, 1993, necessary to rescind the present prohibition against applying any federal funds to support needle exchange programs.

Observe that the panel does not recommend a mandated national program of needle exchange and bleach distribution. As documented in this report, regional variation in prevalence of HIV infection, the extent and kind of drug use, the presence of other AIDS programs, operational characteristics of existing needle exchange programs, and the attitudes and needs of local communities all influence the potential effects of needle exchange programs and militate against such a mandate. The recommendation is to allow communities that desire such programs to institute them, using resources at their disposal and unencumbered by the specific funding handicap that is now in place.

If needle exchange programs become available tools of public health and disease prevention, certain implementation measures become desirable. In particular, the panel recommends that:

• Local community members (e.g., police, church, treatment providers, pharmacists, local public health authorities) should be involved in determining whether such programs should be implemented locally and how they should be institutionalized.

• Attention must be given to the development of site-specific programs that are community based, culturally sensitive, and capable of demonstrating respect for the concerns of the communities in which they are to