participants, but also show that the effect extends into the broader community. Studies are needed to determine the relative effectiveness of programs that concentrate on intensively serving a limited client base versus those serving a broad population and providing fewer services.

An issue related to the policy of setting limits on the number of syringes provided to individual participants per visit was raised earlier in this report. The potential effects of such program policies need to be further researched. Enforcing limits may discourage unintended consequences (e.g., individuals selling the needles they obtain); however, it could discourage participation because it may be inconvenient from the viewpoint of program participants (especially if participants have to travel a distance to reach the exchange). Specifically, research in this area should address questions such as: What are the relative benefits and risks associated with program policies related to the number of needles distributed? What are the potential benefits (e.g., broader diffusion of sterile equipment, reduced sharing) and harms (e.g., source of income for participants that may impact severity of drug addiction) that are related to other environmental and personal characteristics of program participants?

Differential effectiveness of these programs across racial/ethnic, age, and gender populations must be further explored. Little is currently known about the relative effectiveness of these programs across population subgroups. In addition to research on the demographic characteristics, more research needs to be done to better understand how programs can have the most impact while taking into account the risk behaviors of program participants (i.e., drug use, sexual risks), both across and within programs. For example, the severity of drug addiction may be more pronounced in certain programs or within subsets of program participants, reflecting different risks that should be considered by program operations. Such research (e.g., development of needs assessment methods) could assist program operators in establishing the most effective combination of ancillary services particular to specific situations.

The panel's review revealed that little is known about the effects of these programs on the level of illicit drug use in the community at large. Research indicates that the programs do not affect the level of drug use of their participants and do not appear to recruit new drug abusers to injection drug use. But results in this country necessarily relate to a relatively short time horizon. In principle, findings on a time scale of, say, a decade might be different. Here, then, are questions calling for research.

Another unexplored area of research concerns the potential adverse effects these programs may have on certain risk behaviors of program participants (e.g., severity of drug use and sexually transmitted diseases). Do they inadvertently generate new social networks of drug users, which then may serve as a mechanism to facilitate viral spread, depending on the risk characteristics—drug

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