capacity to provide such a service are somewhat dependent on site of operation (roving van versus a storefront, for example) and types and number of staff. A critical component of education involves sexual behaviors and practices and the use of condoms. The majority of the programs surveyed by Lurie et al. (1993a) reported that they distribute educational materials most often in the form of health pamphlets. The need for and value of targeted education and behavior modification efforts directed at injection drug users at risk of HIV transmission have been clearly demonstrated in programs that do not include needle exchange (Wiebel et al., 1993).

Additional services include HIV testing and counseling, tuberculosis screening, screening and treatment of sexually transmitted diseases, primary medical care and case management, drug treatment, assertiveness training focused on negotiation skills, and other health and social services. The ability to provide these additional services on site is related to space and available personnel, which are in turn related to funding and whether programs are legally authorized. At the time of the Lurie et al. (1993a) report, the only two programs to offer all of these above services were The Works (Boulder, Colorado) and the Tacoma-Pierce County Health Department (Tacoma, Washington). Both of these programs are legally authorized, are government administered and funded, have paid staff, and are open more than 10 hours per week.

For the most part, the needle exchange programs that offer primary medical care and/or substance abuse treatment have paid staff. HIV testing and counseling, however, are provided by both paid and volunteer employees.

Although a minority of programs have the capacity to provide all of the services mentioned above, the majority do refer participants to services. For instance, of all U.S. programs surveyed by Lurie et al. (1993a, 1993b), all but one program provided referrals to drug abuse treatment.

Items Distributed

In addition to sterile needles, the programs distribute other paraphernalia and supplies. These typically include cotton, sterile cookers, sterile water bottles, and alcohol wipes. With a few exceptions, all programs also distribute bleach, condoms, and health pamphlets. Because of concerns about the efficacy of bleach in inactivating HIV in injection equipment, some of the providers are reluctant to provide it (see Chapter 6).

Characteristics of Program Participants

The variation in the demographic characteristics of needle exchange program participants is one of the most notable features of the programs

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