Book Reviews 149

makers and citizens can apply in shaping future health care policy.

Universi O' of Wisconsin-Madison School of Nursing 600 Highland Ave. Madison, WI 53792-2455 U.S.A.

Linda Ciofu Baumann

REFERENCES

Ginzberg, E. and Ostow, M. (1997) Managed care--a look back and a look ahead. New England Journal of Medicine 336(14), 1018-1020.

Nation's Health (1997) Managed care: the president names commission to outline consumer rights. The Nation3 Health 1 April.

Preventing HIV Transmission: The Role of Sterile Needles and Bleach, edited by Jacques Normand, David Vlahov and Lincoln E. Moses. National Academy Press, Washington, 1995. 334 pp., $37.95 (hardback).

In July 1992, the U.S. Secretary of Health and Human Services requested the National Academy of Sciences to undertake a study about the impact of needle exchange and bleach distribution programmes on drug use behaviour and the spread of HIV. This book, therefore, is essentially a report about the work of the Academy's Panel of Experts charged with the investigation of these issues through a series of workshops and consultations with interested parties.

My expectation from perusing the title was that this book would be a thorough, but somewhat restricted, technical account about drug injecting practices and behaviours. The contents list. however, reveals an eclectic volume that locates this essential detail within the broader social and epidemiological debates about the prevention of H1V transmission through needle sharing. Following an execu- tive summary and brief introduction to the Panel's brief, the book divides into two parts entitled "The dimensions of the problem" and "The impact of needle exchange and bleach distribution programs". The former contains wide ranging surveys of the epidemiology of HIV/AIDS with particular reference to drug injection use, the characteristics of intervention programmes in the U.S., community debates about ethics and enforcement, and the potential for reforming the legislative environment. Part 2 is directly concerned with impacts and provides evaluations of the effectiveness of bleach as a disinfectant of injection drug equipment, the outcomes of needle exchange programmes and directions for future research. This part also contains an appendix giving evaluations of three unpublished studies of needle exchange programmes in Chicago, Montrral and San Francisco that were commented on by the Assistant Secretary of Health during the course of the Panel's deliberations.

The Panel makes numerous observations and recommen- dations aimed at reducing the prevalence of HIV among drug injectors and those behaviours linked to this risk. Bleach use, for example, is found to be an effective strategy if appropriate procedures are adhered to (p. 5), whereas the primary recommendation calls for the Surgeon General "to rescind the present prohibition against applying any federal funds to support needle exchange programs" (p. 7). This stress on the crucial importance of exchange programmes is based on findings from the scientific literature that suggest these schemes neither increase the frequency of injection among participants nor encourage new initiates. In addition, it is argued these schemes have public support, depending

on locality, which tends to increase over the duration of the programme. Many of the materials reviewed in the text, however, suggest the public's enthusiasm for such interventions might not be so easily sustained. In this respect, a recurring theme is the deeply held suspicion that these safety precautions are most likely to make opiate use more attractive and, thereby exacerbate the many social and behavioural problems associated with this habit.

This debate is most vividly illustrated in the chapter on "Community views". Here, for example, the African American's distrust for "white" public medicine is encapsulated by the quite common belief that HIV is manufactured and contaminated drugs are deliberately supplied to their communities. Moreover, their churches teach the immorality of the sexual and drug use behaviours associated with the transmission of HIV/AIDS which has stimulated resistance to needle exchange programmes. The response of law enforcement agencies has tended to be similarly negative but grounded on the ambivalence of their lending support to illegal activities. Pharmacists, while often agreeing with the principle of establishing programmes, were also concerned about their impact on the quality of services provided to customers other than injection drug users. In contrast, the favoured scientific evidence places stress on the argument that the complex aetiology of individual drug abuse is unlikely to be significantly affected by a single risk factor such as the availability of sterile needles.

These contradictory arguments and beliefs serve to illustrate the complex ethical and moral issues that impinge upon the prevention of HIV transmission by drug injection. This book succeeds in addressing these dilemmas with skill and sensitivity and its comprehensive coverage of recent research will prove to be a valuable resource for both seasoned practitioners and students coming to this topic for the first time. Whether its central policy recommendations are similarly successful, however, is much more difficult to evaluate. It is perhaps salutary that, after proposing a thorough agenda for needed research, the final chapter reaches the conclusion that "up-to-date measures of seroprevalence for HIV would help greatly to target program efforts and resources" (p. 276). The early detection of HIV infection in any community has long been recognised to be a key element of an effective prevention strategy, yet how this task might be combined with the measures proposed in this book remains a vexed question.

School of Geography University of Manchester Oxford Road Manchester MI3 9PL U.K.

Richard Thomas