Organizational Characteristics Of Programs

At first glance (and regrettably, in much of the public debate about needle-exchange programs thus far), the operation of a program seems quite simple—one would merely select a location and provide staff who could trade new injection equipment for used. In practice, since the exchanges are service-delivery programs, the organization of the services is critical to their effectiveness. Some programs are heavily utilized—for example, the Amsterdam programs exchange approximately 6 million needles and syringes per year in a city with an estimated 3,000 injection drug users. In contrast, the first legal program in New York City traded fewer than 1,000 needles and syringes per year in a city with an estimated 200,000 injecting drug users.

As of 2000, there have been only two comparative studies of the organizational characteristics of the programs (Stimson et al., 1988; Lurie & Reingold, 1993). According to the Stimson study, the most important aspect of an exchange program is "user-friendliness"—which includes such practical considerations as convenient location and convenient hours of operation but also addresses some of the philosophical issues involved.

Perhaps the most vital element of user-friendliness is the nonjudgmental attitude of the staff toward the participants in the exchange. Participants in a user-friendly program are treated with dignity and respect. They are not stigmatized as morally and psychologically impaired simply because they inject psychoactive drugs. The participants are presumed to care about their health and to be capable of taking actions to preserve their health and the health of others.

User-friendliness also requires that exchanges offer multiple services. Other concerns need to be addressed beyond the provision of sterile injection equipment; the sexual transmission of HIV also needs to be prevented, which includes the distribution of condoms without cost. Moreover, the trusting relationships that gradually develop between staff and participants lead to the discovery of other health and social-service needs, especially the need for drug-abuse treatment. The exchange service should be able to respond positively to such needs, either through referral or through on-site provision of assistance. Failure to do so would undermine the trusting relationships between staff and participants.

There is as yet no consensus as to which additional services should be offered on site and which ones through referral—or even a set of available guidelines for how an individual exchange program should decide which additional services to offer on site and which to offer through referral. However, a broad range of additional services are presently being offered on site, with some programs offering conventional drug-abuse treatment, self-help re covery groups, women's support groups, tuberculosis screening and treatment, and Bible study groups.

The need to provide on-site (or link to other) services means that exchange programs should be considered a part of a system of services for preventing HIV infection among injecting drug users, rather than as self-sufficient HIV prevention programs.

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