studies across programs are sparse. It also is clear from the data on individual programs that some recruit small and others large numbers of participants. If prevention programs are to be effective, it seems reasonable to suggest that they need to be able to recruit large numbers of individuals at risk. Another purpose of this chapter is therefore to summarize case studies of selected programs to examine organizational characteristics that might affect their recruitment of participants. The chapter includes a brief discussion of the cost associated with operating a needle exchange program and cost-effectiveness estimates from the literature.

The material presented in this chapter contributes to the panel's overall assessment of the effectiveness of needle exchange and bleach distribution programs, and its findings and conclusions are integrated in the recommendations that appear in Chapter 7. As stated in the Introduction, this approach reflects the development of the panel's deliberations on the issues.

NEEDLE EXCHANGE PROGRAMS

Needle exchange programs either distribute sterile needles or exchange used needles for new ones. (The first programs were initiated by activists and advocacy groups in violation of prescription drug laws and drug paraphernalia laws.) Most also offer a variety of other services and/or referrals, including HIV screening and counseling, screening for tuberculosis and sexually transmitted diseases, substance abuse counseling, primary medical care, case management, health education, and condom and bleach distribution.

The primary sources for the information that follows are a report prepared by the School of Public Health, University of California, Berkeley, and the Institute for Health Policy Studies, University of California, San Francisco (Lurie et al., 1993a, 1993b), and reports on the Washington, D.C., and Baltimore needle exchange programs, which opened subsequent to the University of California report.

Legal Issues

The status of needle exchange programs according to existing laws primarily determines their characteristics. The most important laws affecting needle exchange programs are drug paraphernalia and prescription drug laws. A total of 45 states and the District of Columbia (Valleroy et al., in press) have paraphernalia laws that prohibit the possession of needles and syringes for the purpose of using illicit drugs (Figure 3.1). Of the states operating needle exchange programs, Alaska is the only one not restricted by such a law.

Nine states and the District of Columbia (Valleroy et al., in press) have



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