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The continuing threat posed by HIV, HCV, drug overdose, and other injectionrelated health problems in both the United States and Canada indicates the need for further development of innovative interventions for drug injectors, for reducing disease and mortality rates, and for enrolling injectors into drug treatment and other health care programs. Governmentally sanctioned "safer injection facilities" (SIFs) are a service that many countries around the world have added to the array of public health programs they offer injectors. In addition to needle exchange programs, street-outreach and other services, SIFs are clearly additions to much larger comprehensive public health initiatives that municipalities pursue in many countries. A survey of the existing research literature, plus the authors' ethnographic observations of 18 SIFs operating in western Europe and one SIF that was recently opened in Sydney, Australia, suggest that SIFs target several problems that needle exchange, street-outreach, and other conventional services fall short in addressing:(1) reducing rates of drug injection and related-risks in public spaces; (2) placing injectors in more direct and timely contact with medical care, drug treatment, counseling, and other social services; (3) reducing the volume of injectors' discarded litter in, and expropriation of, public spaces. In light of the evidence, the time has come for more municipalities within North America to begin considering the place of SIFs in public policy and health initiatives, and to provide support for controlled field trials and demonstration projects of SIFs operating in injection drug-using communities. BROADHEAD, KERR, GRUND, ALTICE 330JOURNAL OF DRUG ISSUES

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AIDS prevention efforts for injection drug users (IDUs) since 1988 in over 60 inner-city areas within the United States have been based on a “provider-client” model called “street-based outreach.” We document the research showing that these traditional outreach projects operate under conditions that cause hierarchy and supervision to break down easily. The result is an array of organizational problems that push outreach projects toward inertia, and invite high levels of mal- and nonperformance by outreach workers (OWs) as rational adaptations to their work conditions. Nevertheless, research has also documented that IDUs responded very impressively to the outreach services they received. Based on IDUs' responsiveness, we outline the operational features of a “Peer-Driven Intervention” (PDI) that relies on an active collaboration with IDUs in place of a “provider-client” model. Based on a comparative study in eastern Connecticut, we present preliminary impact data comparing the effectiveness of a PDI with a traditional outreach intervention in terms of recruitment power, educational effectiveness of IDUs in the community, and comparative intervention costs.

Needle exchange is a practical and important part of the Dutch prevention strategy to check the spread of HIV among injecting drug users (IDUs). However, needle-exchange programs are often tied to drug treatment programs that only reach a limited number of IDUs. To overcome this limitation, alternative designs are considered and initiated. This article describes a community-based approach to needle exchange that is built on empowerment of, and intense participation by, known IDUs to target unknown IDUs for delivery of clean needles. The needle-exchange patterns of the IDUs participating in this collective scheme are compared to those of other users who exchanged needles on an individual basis. It was found that this approach extended the reach of the program to a great degree and that it was well received in the IDU community. However, the results were negatively influenced by police activities aimed at closing down places where drugs were used and sold. It is concluded that engaging IDUs in peer-group-directed prevention efforts is both feasible and promising.

KOBYSHCHAOur objective is to describe recent patterns and trends in HIV and injecting drug use and to explore possible determinants of the epidemics in eastern Europe.The available data confirm a rapid spread of HIV among injecting drug users (lOUs) in the newly independent states (NIS) and suggest that all successor states of the former Soviet Union are now threatened by such epidemics, while central and southeast Europe have so far been spared from large-scale outbreaks and seem at lower risk. The future course of the epidemic in the NIS will largely depend on trends in drug injecting and on the success of harm reduction programs. Furthermore, there is potential for the further spread of HIV, via heterosexual intercourse, into the general population.

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