needles and syringes previously used by others (see Chapter 6). Consequently, substantial uncertainty now exists among public health officials, laboratory scientists, community outreach workers, and injection drug users concerning the value of bleach disinfection as a public health intervention. Additional investigation into optimizing disinfection methods is clearly necessary.

The panel concludes:

  • Bleach, if used according to the recommendations of the Centers for Disease Control and Prevention, the National Institute on Drug Abuse, and the Center for Substance Abuse Treatment (see Chapter 6 for a detailed discussion of these recommendations), is likely to be an effective HIV prevention strategy for injection drug users who share needles and syringes.

  • Concerted efforts are essential to increase the awareness of injection drug users of the importance of disinfecting shared injection equipment and the importance of following the appropriate procedures.

Bleach use is clearly an intervention to be used when injection drug users have no safer alternatives.

  • Health research funding agencies (e.g., the National Institutes of Health, the Centers for Disease Control and Prevention, and the Agency for Health Care Policy and Research) should support research directed toward identifying the simplest to use and most effective disinfection strategies, employing agents that are readily available to injection drug users.

COMMUNITY AND LEGAL FACTORS

In policy decisions about needle exchange and bleach distribution programs, the scientific evidence on whether the behaviors of injection drug users change and the rates at which new infections are reduced are but one dimension of an immensely complex issue. These AIDS prevention programs, in different environments, face various levels of community support, different levels of HIV prevalence1 in the local population of injection drug users, and operate within different legal environments. And so the scientific issues cannot be viewed in isolation but must be considered along with these other factors.

A range of views about needle exchange programs has been expressed by various groups, including racial and ethnic minority representatives, law enforcement officials, pharmacists, and drug treatment providers. Specific community concerns range from fears that such programs will worsen already severe drug abuse problems and elevate extant high levels of crime to concerns that such programs promote immoral activities. Although there is much variety among the views of different groups, all share the concern that



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