The Vlahov et al. (1994) evaluation study also noted that the program was supplying both syringes and needles in a size incompatible with those used by injection drug users in the local community.

Discussion None of these three needle exchange programs would be considered user-friendly (a concept discussed below). Some of the unfriendliness in program operation stemmed from concessions to political opponents of needle exchange and some from research design requirements. Other aspects of the unfriendliness, such as tuberculosis screening, were required in a sincere belief that they were in the best interests of the participants. None of these three programs appears to have had any impact on HIV transmission in the local area, and it is not even likely that any of them had any meaningful impact on the HIV/AIDS risk behavior of the small numbers of people who participated.

Nonetheless, these three programs may provide valuable learning experiences for future exchanges. The New York City exchange in particular was the first to demonstrate that a needle exchange program could serve as a bridge to treatment (New York City Department of Health, 1989). The many similarities between the first legally authorized New York City needle exchange program (1988) and the Washington, D.C., program 4 years later (August 1992), however, raise the question of how the program planners can learn about important organizational issues from past experiences.

Two Complex Case Studies

The primary lesson to be drawn from the above three cases histories, of course, is that a needle exchange program needs to be user-friendly in order to attract participants and to have a public-health-level impact on HIV and AIDS risk behavior. This somewhat straightforward organizational lesson, however, does not illustrate any of the possible complexities involved in the organizational characteristics of a needle exchange program and its possible effectiveness. The following two case histories show some of the possible complexities.

Manchester In 1988, Klee conducted an interview study of HIV/AIDS risk behavior among injection drug users in Manchester, United Kingdom, and published results somewhat later (Klee et al., 1991). She found that some of the local injection drug users who had participated in the local needle exchange program had become known among the drug user community as sources of injection equipment. These injection drug users themselves were often socially pressured by other injection drug users to pass on injection equipment, and they actually did pass on their used injection equipment more frequently than did a comparison group of injection drug users who

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