presented above, the concept of user-friendliness appears to be fundamental to at least the initial effectiveness of needle exchange programs.

The University of California, San Francisco, collected organizational data on 33 U.S. and 4 Canadian needle exchange programs (Lurie et al., 1993a). As the table shows, this study arrayed the programs according to a number of different organizational characteristics (e.g., status of legal authorization, funding sources, staffing) and was able to show some meaningful associations among them. Unfortunately, this study was not able to associate any of the organizational characteristics with any measures of effectiveness in behavior change or HIV transmission.

Although valuable in depicting the diversity in the type of needle exchange programs, there are certain limitations of this study that should be noted. First, the cost data used in the descriptions and analyses did not separate the costs of exchanging needles from the costs of other services. For this reason, these cost data should be used with extreme caution. Second, given the rapidly changing circumstances of needle exchange programs in the United States, the information provided by this study, as with any cross-sectional survey, represents a snapshot of a complex picture in a state of flux. As of October 1994, there were at least 76 needle exchange programs in the United States—a 130 percent increase over the number of exchanges itemized in the 1993 University of California, San Francisco, report (North American Syringe Exchange Network, 1994). In addition, many of the needle exchange programs included in the study have since undergone substantial changes. Data for the New York City exchanges, for example, do not take account of the legal authorization and expansion noted in the tagging case study presented above.

BLEACH DISTRIBUTION PROGRAMS

Unlike the situation for needle exchange programs, to date there has been no comprehensive survey of the total number of programs in the United States to distribute bleach or other disinfectants for the purpose of cleaning needles and syringes between uses. An extensive review of the literature has resulted in multiple studies that questioned injecting drug users about needle-cleaning practices, but these reports typically do not include descriptions of the characteristics of the bleach distribution programs per se (Longshore et al., 1993; Neaigus et al., 1990).

The most systematic information about bleach distribution programs in the United States comes from the National AIDS Demonstration Research (NADR) program, which was initiated in 1987 by NIDA.

The purpose of NADR was to assess the efficacy of different strategies of AIDS prevention with out-of-treatment injection drug users and their sexual partners. All these strategies—except those initiated in New Jersey—were



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