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Preventing HIV Transmission: The Role of Sterile Needles and Bleach
mobile exchanges, there is no maximum number of syringes that may be exchanged at any time, and single exchanges of more than 1,000 syringes have been recorded. The purpose of imposing no limit on the number of syringes is to encourage injection drug users to build up a large reserve of clean syringes to perhaps enable them to better avoid high-risk situations when they have exhausted their supply. It is estimated that 900,000 syringes were exchanged in Tacoma needle exchange programs in 1994 (90,000 from the pharmacy, the remainder from the fixed outdoor and mobile programs).6
Assistance from injection drug users willing to act as "secondary exchangers" is encouraged, and several have been identified via the mobile exchange program. They have included representatives from groups of gay and bisexual injection drug users and other injection drug user groups who report they are fearful of being exposed as drug injectors if they come to the fixed sites. With each of the secondary exchanges, there is an explicitly stated expectation that syringes will not be sold. Although for a few months in 1993 the pharmacy exchange asked needle exchange participants for donations, at present there is no cost for syringes or any services provided directly by any exchange.
The Tacoma needle exchange program has been the primary source of AIDS education for injection drug users in the county. Exchange workers spend time each day talking with individuals about their own and other injection drug users' behavior in relation to risk of exposure to HIV and other pathogens and about specific prevention strategies. When it was apparent that the exchange was a better setting for one-to-one education than were ad hoc encounters on street corners, the local health department's small-scale "bleach and teach" outreach campaign moved to the needle exchange site. Eventually, needle exchange staff assumed responsibility for providing one-to-one education and counseling to local injection drug users, primarily because regular and frequent visits to the exchange by their clientele offered an opportunity for follow-up contact and counseling. From January to November 1994, a monthly average of 511 one-to-one contacts were made (range 411-724), which consisted of individualized education, counseling, and referral to other services.
Condoms and sexual risk reduction education have been included among the basic services since the program began. The fixed outdoor exchange sites are both within police-defined areas of prostitution in the city, and there are many female and male sex workers among needle exchange participants. In the first 11 months of 1994, approximately 2,900 condoms (range from 2,100 to 3,900) were distributed each month at the exchange sites.
The fixed needle exchange sites have become the primary locations in the county for bringing health and social services to local injection drug