drug users per year before being legally authorized, increased to serve nearly 8,000 injection drug users within the first 12 months afterward (Paone et al., 1993, 1994a, 1994b). This expansion led to considerable logistical problems in continuing to tag syringes. The volunteer staff, who did the actual tagging, complained that they were now spending all of their time tagging syringes and no longer had time to interact with the injection drug users coming to the exchanges. This personal interaction was viewed as a major benefit to the injection drug users and a primary opportunity for the volunteers to obtain a palpable sense of accomplishment.

Staff of the two largest legally authorized exchange programs in New York City had begun refusing to continue tagging when a negotiated compromise was reached between the State Health Department and the programs. An evaluation team offered to conduct a special tagging alternative study to determine the syringe return rates and thereby no longer require the programs to tag the syringes they were issuing. In this instance, then, an exchange procedure that had earlier appeared to be highly functional for small underground exchanges clearly became dysfunctional when the exchanges underwent rapid expansion.

Discussion Both the Manchester and the New York City tagging studies suggest the need to examine the organizational characteristics of needle exchange programs within the context of their entire developmental history, as well as in the larger context of drug injection and HIV and AIDS risk behavior in the surrounding community. These two case histories illustrate the possibility that a conclusion drawn from data collected at one point in time may be totally inappropriate for other points in time.

Comparisons Across Programs

It would of course be useful to compare organizational characteristics across programs. To date only two such comparative studies have been conducted (Table 3.3). Stimson and colleagues conducted an evaluation of the national system of needle exchange programs that was implemented in the United Kingdom from 1987 to 1988 (Stimson et al., 1988); it was the first to elaborate on the concept of user-friendliness in syringe exchange. Although they did not conduct formal quantitative analyses, they were able to show that user-friendliness was associated with both attracting and retaining injection drug users in needle exchange programs. (It should be noted that the participation of injection drug users in the U.K. needle exchanges was within a context of legal authorization that permitted both over-the-counter sales of needles and syringes and personal possession of equipment to inject illicit drugs.) As indicated in the first three case histories



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