Although brief descriptions of needle exchange programs along selected dimensions are available, few studies thus far have examined the organizational characteristics of needle exchange programs themselves as potential determinants of the behavior of the injection drug users participating in the exchange. Since needle exchanges are service delivery organizations, it is reasonable to expect that the particular mode of organizing the services may in itself be a very important determinant of the HIV and AIDS risk behavior of the participants in the exchange.
In this section we review existing research on the organizational characteristics of needle exchange programs and outline possible directions for future research. Before reviewing the few available comparative studies of the organization of needle exchange programs, we briefly examine five case studies in which organizational issues were found to be critical to the effectiveness—or ineffectiveness—of needle exchange programs in reducing HIV risk behavior.
Dundee-Wishart, Scotland Many of the earliest needle exchange programs implemented in the United Kingdom were operated by preexisting drug service agencies that, in some cases, were lacking both the resources and the appropriate training for this challenging new task. Perhaps the clearest example of these problems was in the experience of the needle exchange program that operated from the premises of the Wishart Drug Problems Centre in Dundee-Wishart, Scotland, in summer 1988 (Stimson et al., 1988). At that time, the Dundee-Wishart facility was not only understaffed in relation to an already full caseload, but also encumbered with an ill-suited and overly rigid set of rules for a fledgling needle exchange. In addition, it was being operated by the staff of an abstinence-oriented treatment program who clearly felt overwhelmed by the sudden influx of injection drug users seeking only to exchange used needles for new ones and who plainly did not desire abstinence treatment. Indeed, injection drug users in the area came to perceive the primary aim of the exchange as recruiting them into the treatment program. Hence, very few participated in the exchange, causing it to close within 6 weeks.
New York City The first legally authorized needle exchange program in New York City opened in 1988 as a single-site operation, although it had originally been designed and proposed as a pilot study that aimed to compare injection risk behavior and the rates of entry into treatment among injection drug users seen at four different sites (Anderson, 1991; Joseph and