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The most effective risk reduction behavior, cessation of drug use, was not a realistic option for many injection drug users because of the nature of the addictive process and limited treatment resources Murphy, Social norms for sharing injection equipment among injection drug users, as well as legal and economic constraints, all placed restrictions on an individual's ability and motivation to keep a needle and syringe set for personal use only Des Jarlais et al.

Therefore, the option of disinfecting needles and syringes seemed to hold the greatest promise for realistic interventions to limit HIV transmission among injection drug users. Ethnographic studies were conducted in San Francisco to determine characteristics that would make a disinfection strategy acceptable to injection drug users Newmeyer, In determining an appropriate disinfectant, published studies available at the time—particularly those of Martin et al.

Based on these studies, several disinfectants were considered, including bleach, hydrogen peroxide, and isopropyl alcohol. According to Newmeyerhydrogen peroxide was rejected due to its limited shelf life and sensitivity to light exposure; the potential for isopropyl alcohol to be confused with other readily available sources of alcohol in beer, wine, and hard liquors eliminated it from consideration.

Boiling syringes in water for 15 minutes was another strategy considered; however, this strategy was deemed impractical due to the length of time required, the facilities needed, and the fact that boiling melted the syringe Murphy, As a result of these considerations, household bleach approximately 5 percent sodium hypochlorite was determined to be the most feasible.

Bleach met the criteria for cost and availability, and reviews of the available literature Becker et al. Aside from fading the numbers inscribed on the syringe barrel Newmeyer, and corrosion of the rubber stopper of the plunger of the syringe, bleach did not seem to have excessive deleterious effects on the injection equipment. Following the selection of bleach as the disinfectant of choice, community health outreach workers in San Francisco began a campaign of bleach distribution and provided simple, graphic instructions for its use in disinfecting needles and syringes Watters, The initial bleach distribution efforts were part of a broader education program to decrease the risk of HIV infection among injection drug users that included condom distribution and voluntary HIV counseling and testing.

The educational message delivered was: These initial disinfection guidelines recommended the use of full-strength bleach, which was believed by the San Francisco community health outreach workers to provide a more potent and convenient disinfectant than the diluted bleach preparations used in the early laboratory studies.

Page Share Cite Suggested Citation: With few exceptions Flynn et al.

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As a result, awareness of bleach disinfection strategies among injection drug users is high Meyers et al. Therefore, a review of the studies that have evaluated cleaning techniques used by injection drug users provides indications concerning user compliance with the recommended bleach techniques.

The bleach distribution program in San Francisco was well accepted by injection drug users. Among those interviewed in neighborhoods with high drug use, Wattersreported that prior to initiation of the outreach program, only 3 percent of the sample used bleach to clean their equipment. In contrast, 9 months after beginning the community health outreach worker CHOW intervention, 76 percent of injection drug users interviewed reported bleach use. In addition, prior to program initiation, regular cleaning of needles and syringes was reported by only 21 percent of those who reported any cleaning attempts.

In the follow-up interview, injection drug users who used bleach reported doing so 90 percent of the time. Although other reports Chaisson et al. Moreover, in these early studies of the adoption of bleach disinfection by injection drug users, a significant positive relationship was observed between access to community health outreach workers and reported use of bleach disinfection Watters, Another important variable in the success of bleach education programs appears to be the direct provision of bleach to injection drug users.

Evaluation of the impact of this program found that only low levels of regular bleach use were noted both at baseline and during follow-up interviews 16 and 18 percent, respectively. In interpreting these results, Neaigus and colleagues suggested that outreach efforts aimed at increasing bleach use should include distribution of bleach.

Following the lead of San Francisco, bleach distribution programs proliferated rapidly in cities across the United States. Using techniques adopted from medical epidemiology and community ethnography, workers in Chicago Page Share Cite Suggested Citation: In an evaluation of this approach Wiebel et al.

Bleach use as a disinfection strategy was adopted by many injection drug users. Two-thirds of the study participants who initially used bleach "less than always" reported an increase in bleach use, with one-third of the follow-up sample reporting "always" using bleach.

Similarly, researchers in New York Friedman et al. Injection drug users in recovery provided HIV risk-reduction education for active users. These groups encouraged the adoption of safe sexual and drug-related behaviors and offered AIDS education, individual counseling, and HIV testing.

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In an evaluation of this program, follow-up comparisons were made between injection drug users who participated in the education and organizing effort and those who did not. Although use of new needles and condoms increased in both groups, only the organized injection drug users showed an increase in consistent bleach use.

Reported trends over the five-year period included increased use of bleach and alcohol by injection drug users to clean injection equipment in four of the seven cities studied: New York; Asbury Park, N. Additional studies conducted in Indianapolis and Los Angeles County have reported increased rates of bleach use McKee et al. These changes appear to reflect the increasing awareness and acceptance of bleach as an HIV prevention strategy.

In a survey of nearly 3, injection drug users in Baltimore conducted in andLatkin and colleagues reported that a variety of substances, including water, bleach, and alcohol, were used by injection drug users to clean contaminated needles and syringes.

In addition to the use of various agents, the methods reportedly used by injection drug users for syringe disinfection were often imprecise and variable. Gleghorn and colleagues Gleghorn et al. They found that more than 80 percent of the subjects studied used bleach for less than 30 seconds, although they reported cleaning for longer periods of time.

Study participants were then evaluated for proper disinfection technique 6 to 12 months following initial training. At follow-up, a substantial proportion of the injection drug users did not perform all of the previously taught steps, and less than half completely filled the syringe with bleach or rinsed the syringe twice with bleach.

These investigators also reported that compliance with disinfection methods decreased as the number of steps required increased. Several behavioral characteristics of injection drug users have been found to be associated with use or nonuse of needle and syringe disinfection Brown and Beschner, ; Latkin et al. Injection drug users who use shooting galleries, or who share needles and syringes with more than one partner, may be more likely to use bleach or alcohol for disinfection Latkin et al.

Neither injection frequency nor cocaine injection has been found to be associated with disinfectant use Latkin et al. Injection drug users who also smoke crack cocaine report a lower rate of cleaning needles and syringes prior to injecting than nonsmokers, even though they inject less frequently Edlin et al.

Crack cocaine-smoking injection drug users are also more likely to use unsafe needles and to share rinse water, cookers, and cotton Edlin et al. Injection drug users who disinfect their injection equipment with bleach or alcohol are also more likely to be acquainted with other HIV risk reduction behaviors Celentano et al. Knowledge of bleach effectiveness, condom effectiveness, and several other HIV transmission risks is higher among injection drug users with a history of bleach or alcohol disinfection.

Further studies of beliefs and attitudes that differentiate bleach users from nonusers or that predict bleach use are needed to increase the adoption of effective cleaning strategies.

A total of 28 sites participated in this aspect of the NIDA initiative. This undertaking has produced what is probably the largest single database on out-of-treatment injection drug users with evaluative data on outreach program effectiveness. Brown describes the NADR "standard" intervention as typically involving at least: In addition, 18 sites developed "enhanced" interventions involving didactic training sessions and other additional initiatives, including: As described in Chapter 3it is apparent that these outreach programs are multicomponent AIDS prevention programs that do not rely exclusively on distributing bleach bottles in their attempt to reduce HIV risk behaviors and the transmission of HIV infection.

However, only those participants whose initial and follow-up data could be linked 13, formed the basis of the program evaluation component of this project. As such, these data represent a fraction of the total number of injection drug users who were served or at least assessed by the NADR projects a 40 percent follow-up rate. For sex partners, 6, were assessed and 1, 26 percent were followed. Given the considerable potential problems associated with attempting to integrate these data, the following section summarizes the evaluation results of one specific NADR site that has provided detailed information on program delivery and comprehensive longitudinal data on meaningful outcome measures risk behaviors and HIV seroconversion.

The Chicago Experience Chicago's NADR program which is now supported by local funding collected longitudinal data over a 4-year period in an attempt to assess program impact on risk behaviors and HIV seroconversion Wiebel et al. This program was similar to the other NADR sites in its focus on out-of-treatment injectors and use of street outreach workers as HIV prevention educators; however, it had unique elements as well.

The project's prevention activities has six key features: The intervention is carried out by street outreach workers who are former injectors.

Outreach staff identify and target social networks of injectors, rather than isolated individuals. Complete confidentiality is stressed throughout. Staff then offer multiple options for coping with identified risks. Outreach workers carry supplies of bleach, water, cotton, condoms, and information pamphlets at all times and distribute materials as needed in all encounters.

In repeated encounters with injection drug users, outreach workers support and reinforce behavioral change. The intervention's impact is further extended by promoting prevention advocacy within injection drug user social networks for HIV risk reduction.

Chicago's program represents the more intensive end of the range of NADR outreach programs in the frequency and duration of contacts that take place between street outreach workers and networks of injection drug users. As stated above, this program cannot be considered simply a bleach distribution program, although it uses bleach and other injection supplies as tools to facilitate interaction with street addicts and to reduce injection harm. After her power boost, Jackie gains exhaust pipes on her right shoulder that covers enough of her body in muck that she can shatter the ground with a simple step.

Unlike the others in her group, as she was unable to protect her family with her power, Jackie hated her Fullbring and genuinely wished to be rid of it.

She eventually got her wish after she seemingly sacrificed herself to get Renji out of Yukio's Fullbring, feeling some regret in losing her power while promised a position in Yukio's company alongside the other surviving members of their group.

These timers are linked to specific conditions that Giriko himself can set. But once the time period is established, however, not even Giriko himself can deactivate and the subject must attain the conditions or be burned away by time itself.

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After Xcution steals Ichigo's Fullbring powers, Giriko gained the ability to increase his body mass and strength in relation to the simplicity of his ability's condition. But to his shock, Giriko is easily killed off by Kenpachi Zaraki. But the downside is that the longer he uses it, the weaker he becomes. After the fight between the Soul Reapers and Xcution conclude, Shishigawara was last seen carrying the dying Tsukishima away.

Their attire usually consists of long white trench coats fitted with numerous buttons, a cape, a belt usually a piece individual to each memberand a five-pointed cross, the Quincy Zeichen, somewhere upon the uniform. Apparently founded by the survivors of the Quincy massacre a millennium ago, the Wandenreich have been preparing to exact revenge on the Soul Reapers once amassing enough power to do so once their leader is revived.

In the aftermath of Aizen's defeat, the Wandenreich conquered Hueco Mundo and captured numerous Arrancars including the former Espada Tier Harribel to serve as their personal Vanguards and foot soldiers. However, after absorbing Ichigo's powers and the last two Sternritter survivors, Yhwach reveals his true goal was to eliminate all life in existence for bringing ruin and death to all living begins including his children, the Quincys for all eternity.

Yhwach is also the son of the Soul King, the being whose existence is vital to the Soul Society. At its full capability, the ability can also alter the future in any way Yhwach wishes. When Yhwach was born, he already demonstrated supernatural abilities through infusing a part of his soul in other people to heal them of injuries and disabilities. But the moment a person healed this way dies, Yhwach regains that fragment while gaining that person's abilities and knowledge.

As this extended his life, revered as a holy child, Yhwach took the name of YHWH which the people proclaimed in his presence. Yhwach resolved to destroy the current reality to create a world without death, defeated by Yamamoto a millennia prior to the events of the series and sealed away for nine centuries and nine decades.

It appears his time imprisoned has left his sanity in question; he claims everything he is doing is for peace despite his sadistic behavior and dark humor. Months after Aizen's defeat, Yhwach conquers Hueco Mundo by defeating its current leader Tier Harribel and imprisoning her while employing Arrancars as foot soldiers for the Wandenreich in preparation to invade the Soul Society.

But once Yhwach arrives and executes Royd, he steals Yamamoto's Bankai and uses it to kill him. Shortly after, Yhwach is then confronted by Ichigo and has a brief battle with him, during which he reveals that his mother Masaki was a Quincy before departing. Shortly thereafter, Yhwach launches another attack on the Soul Society, replacing the Seireitei with Silbern. He oversees the battle and renders judgement on his subordinates who lost their battles, namely Cang Du and BG9.

It is revealed that Yhwach spread pieces of his soul all over the Seireitei so that each death that occurs on the battlefield would prolong his life. Yhwach eventually absorbed the entirety of the Soul King and Mimihagi's power before transforming the Soul King realm into the Wahrwelt, eventually revealing his intentions to be the only living thing in existence as he proceeds to carry out the task with Ichigo pursuing him.

Dying after telling Ichigo he condemned the world to continue the cycle of life and death, Yhwach's spiritual pressure would briefly manifest ten years later before being extinguished. Being a rare Quincy as he was born with the same power as Yhwach as he can possess his power while the older Quincy rests, Haschwalth lived with his uncle as a child before watching him die in a forest fire incited by Yhwach.

Though Haschwalth and his childhood friend Bazz-B trained to someday avenge their losses, they ended up in the Wandenreich with Haschwalth's ability recognized by Yhwach and made his right-hand instantly.

Like the rest of the Wandenreich, Haschwalth was sent to deliver their leader's war declaration, killing Squad 13's Hidetomo Kajomaru during the first invasion.

Sometime later, Haschwalth helps Yhwach in his plan to steal Yamamoto's bankai by accompanying Royd Lloyd after he assumed their leader's form. After Yamamoto's death, Haschwalth is told to convey to the other Sternritter that they were to raze Soul Society before Ichigo arrived.

He watches his master fight Ichigo before being called back to their palace, before which he easily breaks Ichigo's bankai. Though Haschwalth breaks through the barrier, he is called back by Yhwach to punish the Sternritters who lost their respective fights.

Pernida can also use that ability to manipulative inanimate objects and environments as well while absorbing the traits of those his Blut nerves infected. Though he effectively takes Kenpachi out of the fight by forcing the latter to amputate his distorted right arm, Pernida is forced to discard his cloak after Mayuri deduces the Quincy's attack method and severely injures him. Pernida proceeds to use his power as the Soul King's left arm to take out Mayuri, who wants to study the entity a while more.

But a Pernida clone manages to kill Nemu and eats her body, only to end up dying from excess regeneration due to the lieutenant's cellular makeup. During the Wandenreich's second invasion, Askin appears in the place that had housed the Soul Society's Research and Development Institute, surprising most of its inhabitants yet taking his leave when Mayuri and Nemu Kurotsuchi appear. But Urahara activates his Bankai to overwhelm Askin, distracting the Quincy long enough for Grimmjow to land the death blow from behind.

However, upon his death, Askin activate his Gift Ball Deluxe to increase in lethalness to kill both Urahara and Grimmjow resulting in the two being saved by Nelliel before they are taken by the poison. Bambietta fights with the 7th Division captain, Sajin Komamura, and steals his bankai. Like most of the Wandenreich, she is opposed to Uryu being named Yhwach's successor. During the Wandenreich's second invasion, she fought both Shinji Hirako and Komamura, the former of whom she manages to incapacitate despite his shikai state.

The two fight, with Komamura using his Human Transformation technique and bankai to overwhelm and defeat Bambietta. Though she barely survived Komamura's attack, Bambietta is killed off by her fellow female Quincies to be used as Giselle's zombie bodyguard. In this new state, she is later summoned by Giselle to fight Ikkaku and Yumichika and defeated by Charlotte Chuhlhourne before later being reduced to a lifeless corpse when Giselle is forced to drain her blood to treat her mortal injuries.

In battles, he has a tendency to rant about the nature of fear, believing that true fear is instinctual and therefore unavoidable. He later appears when Yhwach names Uryu Ishida as his successor.

Despite her relatively petite appearance, she is quite profane, as shown when she calls out Bambietta for her habit in killing handsome men for her pleasure. When she and the other female Sternritters attack Kenpachi in his weakened state after he defeated Gremmy, Liltotto devours many of the Soul Reaper reinforcements.

She later unsuccessfully attempts to attack Ichigo upon his return, thwarted by Ichigo himself, her fellow Sternritter Bazz-B, and then by several members of Gotei Devastated by the treachery, Liltotto barely manages to grab Giselle as they escape with their lives despite losing their Quincy powers. Hurt by Yhwach's betrayal, Liltotto joins forces with Bazz-B to ally themselves with the Soul Reapers in entering the Royal Realm to kill their former master.

Though she and Giselle reach Yhwach, they were overpowered and defeated. He is a childhood friend of Haschwalth, whom he nicknamed "Jugo", having crossed paths with him while the latter was hunting a rabbit. He vows to kill Yhwach ever since the sovereign burned down his home and trained with Haschwalth for five years, intending to earn Yhwach's trust afterward. Bazz-B defeated Izuru Kira and the other 3rd Squad members when he appeared in Soul Society, using his power to offset Head Captain Yamamoto's attack when it was about to consume him and his fellow Sternritters.

He was among one of the Quincy most opposed to Uryu Ishida being named Yhwach's successor, thinking Haschwalth would be the successor and confronting him about his acceptance to their leader's ruling.

Bazz-B later confronts Shinji, Momo, and Marechiyo, intending to stop them from intervening Kenpachi's fight with the other Sternritters. He then stops Candice and her group from fighting Ichigo any further prior to Yhwach's arrival to the battlefield. Bazz-B regroups with Liltotto and Giselle as they ally themselves with the Soul Reapers in entering the Royal Realm to kill their former master. But Bazz-B loses his right arm to Haschwalth before being left to bleed to death after being slashed down the left flank.

In the second invasion, Cang is ordered to personally kill Hitsugaya, interrupting the latter's fight with Bazz-B.

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Nevertheless, Cang was imprisoned alongside BG9 and brought before Yhwach for judgment. Though he uses his ability on the grounds of refusing to die by the hands of any other than Yhwach, Cang is bisected by Haschwalth. He is assigned in Hueco Mundo to capture Arrancars for Yhwach to use as Vanguards for the Wandenreich, having no toleration for disobedience and willing to act in a barbaric manner if offended. Receiving orders from Yhwach to keep Ichigo occupied while the Sternritter invade the Soul Society, Quilge struggles to keep up with Ichigo's movements and is unsuccessful in stealing Ichigo's bankai, causing Ichigo to assume the Wandenreich fear a Shinigami's bankai.

Falling for one of Ichigo's taunts, Quilge attempts a counterattack only to be shot from behind by Kisuke Urahara.