The outreach strategies used in bleach distribution programs are characterized by their emphasis either on (a) the development of individual behavioral skills to limit risk taking or (b) the modification of community norms to support changed behavior. Those concerned with the former are focused on counseling and behavioral skills training, and those concerned with the latter are focused on peer intervention and social contagion.

For programs that emphasize counseling and behavioral skills training, outreach mainly involves referring injection drug users to a community site at which they typically receive structured counseling and skills-building sessions (Rhodes, 1993). For programs that emphasize the peer intervention and social contagion approach, outreach workers, chosen for their knowledge of and status in the injection drug-using community, play a key role in the work of HIV and AIDS prevention by inserting themselves into the social network of injection drug users (Wiebel et al., 1993).

Outreach at the sites in the NADR project varied in terms of techniques used, from written instructions about the use of bleach to disinfect injection equipment, to demonstration of the technique in person, reverse demonstration (by the drug user to measure comprehension and competence), and videotapes. Information summarized from eight NADR sites is presented in Table 3.4. Two cities—San Francisco and Denver—reported ancillary techniques to promote the use of bleach to disinfect needles. In San Francisco, an individual was costumed as an 8-foot-tall superhero named ''Bleachman," with a plastic bottle for a head and a Clorox logo on his torso. Bleachman appeared on city streets to distribute small bottles of bleach (Broadhead, 1991). In Denver, outdoor murals were painted in the city to encourage risk reduction and the bleaching of needles and syringes.

There are limitations on the NADR data, which are discussed in Chapter 6. Although the NADR program provides information to describe and evaluate bleach distribution programs in the United States, it does not describe all existing bleach distribution programs. Also, the NADR programs used outreach workers to establish trust and rapport with injection drug users outside treatment for drug abuse; bleach distribution is thus intertwined with the intervention of community health outreach workers. Other bleach distribution occurs in the setting of needle exchange programs. The panel found no instance in the literature of self-service bleach bottles with printed instructions as the sole intervention.

One further limitation: reports from San Francisco describe the instructions provided by the NADR projects for the use of bleach to disinfect needles. Undiluted bleach was packaged in 1-ounce vials, to be flushed through a used syringe twice before injecting and following each bleach flushing with a flushing of water. The extent to which instructions varied