Preventing HIV Transmission: The Role of Sterile Needles and Bleach
CONTENTS
- PREFACE xi
- ACKNOWLEDGMENTS xv
- EXECUTIVE SUMMARY 1
- The Problem, 1
- The Panel's Charge, 3
- Scientific Assessment of Program Effectiveness, 3
- Community and Legal Factors, 5
- Recommended Course of Action, 6
- INTRODUCTION 9
- Dimensions of the Problem, 9
- Responses to the Epidemic, 11
- The Charge to the Panel, 12
- The Panel's Report, 14
PART 1
DIMENSIONS OF THE PROBLEM
- 1 THE EPIDEMIOLOGY OF HIV AND AIDS 23
- Biological Mechanisms of Transmission, 24
- Injection Drug Use Transmission, 24
- Sexual Transmission, 28
- Perinatal Transmission, 29
- Conclusion, 30
- Epidemiologic Data, 31
- HIV and AIDS Surveillance, 31
- Mode of Acquisition of Infection, 32
- HIV and AIDS Among Injection Drug Users, 37
- Surveillance, 37
- Sexual Transmission Among Injection Drug Users, 40
- Perinatal Transmission from Injection Drug Users, 43
- Summary, 44
- Conclusions, 45
- Recommendations, 45
- 2 THE EPIDEMIOLOGY OF INJECTION DRUG USE 57
- Estimates of Injection Drug Users, 58
- Geographic Variations, 59
- National Surveys of Drug Abuse, 60
- Characteristics of Injection Drug Users, 64
- A National Profile, 64
- Local Drug Use Trends and Patterns, 66
- Summary, 69
- Recommendation, 69
- 3 NEEDLE EXCHANGE AND BLEACH DISTRIBUTION PROGRAMS IN THE UNITED STATES 74
- Introduction, 74
- Needle Exchange Programs, 75
- Legal Issues, 75
- Program Operations, 77
- Characteristics of Program Participants, 83
- Cost and Cost-Effectiveness, 86
- Organizational Characteristics, 89
- Comparisons Across Programs, 93
- Bleach Distribution Programs, 95
- Characteristics of Program Participants, 96
- Outreach Strategies, 97
- Conclusions, 99
- 4 COMMUNITY VIEWS 103
- Moral/Ethical Arguments, 105
- Public Opinion Polls, 106
- African American Views, 107
- Latino/Hispanic Views, 120
- Law Enforcement Views, 121
- Health Professional Views, 123
- Pharmacists, 123
- Treatment Service Providers, 126
- Summary, 133
- Conclusions, 133
- 5 THE LEGAL ENVIRONMENT 143
- U.S. Drug Control Policy, 143
- Legislative/Statutory Environment, 145
- Judicial Rulings, 147
- Do Paraphernalia and Prescription Laws Contribute to HIV Transmission?, 149
- Needle Scarcity and Sharing, 150
- Changes in the Laws in Connecticut, 152
- Should the Laws Be Changed?, 155
- Changing the Laws, 156
- Consequences, 157
- Conclusions, 158
- Recommendations, 158
PART 2
THE IMPACT OF NEEDLE EXCHANGE AND
BLEACH DISTRIBUTION PROGRAMS
- 6 THE EFFECTIVENESS OF BLEACH AS A DISINFECTANT OF INJECTION DRUG EQUIPMENT 167
- Transmission of HIV Among Injection Drug Users, 168
- Bleach as a Disinfectant, 169
- Definition of Terms, 169
- The Role of Cleaning in Disinfection, 170
- Susceptibility of HIV to Disinfection, 172
- Bleach Distribution Programs, 175
- Program Evaluation, 177
- The Chicago Experience, 180
- Limitations of Bleach Disinfection, 186
- Impact of Bleach Disinfection on HIV Transmission, 187
- Summary, 190
- Conclusions, 191
- Recommendations, 192
- 7 THE EFFECTS OF NEEDLE EXCHANGE PROGRAMS 198
- Potential Outcomes, 199
- Possible Positive Outcomes, 199
- Possible Negative Outcomes, 199
- The Panel's Approach to the Evidence, 200
- The Traditional Approach: Considering the Preponderance of the Evidence, 200
- An Alternative Approach: Looking at the Patterns of Evidence, 201
- The Panel's Synthesis, 204
- U.S. General Accounting Office Review, 205
- Procedure, 205
- Results, 206
- University of California Report, 208
- Procedure, 208
- Results, 210
- Possible Positive Outcomes, 211
- Possible Negative Outcomes, 214
- Summary, 216
- Evidence from Recent Studies, 217
- Possible Positive Outcomes, 217
- Possible Negative Outcomes, 224
- The New Haven Studies, 226
- Program Implementation, 228
- Estimated Effects on HIV Incidence, 229
- Assessment of the Models, 230
- New Initiates to Injection Drug Use, 231
- Enrollment in Drug Treatment, 232
- Alternative Explanations, 232
- Summary, 233
- The Tacoma Studies, 234
- The Program, 235
- HIV Seroprevalence Studies, 240
- Hepatitis Surveillance and Case Reporting, 240
- Hepatitis B and C Case-Control Study, 242
- Interview Studies with Injection Drug Users, 243
- Potential Alternative Explanations, 244
- Program Effects on New Initiates to Drug Use or Abuse, 248
- Summary, 250
- Conclusions, 251
- Recommendations, 252
- 8 DIRECTIONS FOR FUTURE RESEARCH 263
- Research on Program Effectiveness, 264
- Needle Exchange Evaluation, 264
- Program Characteristics, 267
- Research on Bleach Efficacy in Disinfection, 270
- Epidemiologic Research, 270
- Research on Community Issues, 272
- Other Future Research Issues, 273
- Deregulation of Syringe Sale and Possession, 273
- Incarcerated Populations, 274
- Randomized Trial of Needle Exchange Programs, 274
- Broader Issues, 275
- Conclusion, 276
APPENDIXES
- A. DESCRIPTION AND REVIEW OF RESEARCH PROJECTS IN THREE CITIES 281
- San Francisco, 281
- Review, 283
- Montréal, 285
- Needle Exchange Evaluation Project, 285
- Epidemiologic Study, 289
- Chicago, 293
- Demand for Free Needles and Their Effect on Injecting Frequency and Needle Use, 293
- Effects of Exchange Use on HIV Risk Behavior and Incidence, 302
- Conclusion, 304
- B. PROFESSIONAL ASSOCIATION POSITIONS ON NEEDLE
EXCHANGE AND BLEACH DISTRIBUTION PROGRAMS 307
- C. BIOGRAPHICAL SKETCHES 313
- INDEX 321
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