and that direct needle sharing constitutes only one of many potential sources of transmission. Unless needle exchange programs consistently provide a full range of sterile equipment and adequate education regarding these risky behaviors, it is likely that some transmission stemming from these other practices will continue. To date, no studies to quantify the risk associated with these other behaviors in relation to direct needle sharing are available.

In short, the effect of needle exchange on HIV incidence is likely to be confounded with other sources and modes of transmission. At best, these considerations point to the need for needle exchange programs to institute multidimensional approaches to prevention and not simply rely on distribution and exchange of needles. Providing sterile needles and syringes is necessary but insufficient to adequately address the problem of HIV transmission. Therefore, the relative effects of different components of needle exchange programs that target different risk behaviors associated with the different transmission routes (sexual risk versus sharing of contaminated injection equipment) need to be studied.

Consolidation and Coordination of Program Effects

What is learned about program effectiveness at one site may be of value at another; sharing and consolidating information increases its value. It is also essential to develop standard terms and a common format for record-keeping, as a way to ensure consistency in the collection of data from different programs at different sites. Consistency in data collection makes it possible to supply program operators and evaluators with more valid feedback about program effectiveness: what works in Denver may not work in Miami, but, without consistent information, it may not be possible to analyze the results of program evaluations across sites.

In funding considerations, coordination is also essential. The efficiency of needle exchange and bleach distribution programs would benefit from some centrally supplied funding and some central coordination of what could be a primarily collaborative enterprise. This could make provision for more reliable and swift learning from the experiences of programs already in operation.

Program Characteristics

Most evaluation research to date has focused on program effectiveness in isolation. Needle exchange and bleach distribution programs vary considerably in their characteristics (as noted in Chapter 3) and their effectiveness. Their success depends in part on the choices they make in setting their hours of operation, their location(s), their eligibility rules, and their



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