Detailed ethnographic mapping of the IDU community may be helpful in identifying sites and times that make it convenient for the majority of IDU to attend. It may also be helpful to staff the exchange with recovering IDU drawn from the communities they serve. Recovering IDU have ethnographic knowledge of the IDU community, and are more likely to be viewed as peers or role models of behavioral change.
Penetration and volume can be achieved in other ways. Des Jarlais and colleagues recommend a social change approach to needle exchange, in which drug users exchange for others in their friendship networks.(25) Because of arrest warrants, parole violations, or other reasons, some IDU may not be willing to attend needle exchange themselves, but may know of others who would exchange for them. Surrogate or “secondary” exchanging can greatly increase the number of IDU effectively served by a needle exchange. A pager-initiated exchange in Sacramento, CA makes home delivery of syringes to more than 50 IDU who regularly exchange an average of 65 syringes for themselves and others.(26) Home delivery is an attractive alternative to fixed-site exchange for communities in which needle exchanges face NIMBY (not-in-my-backyard) opposition. Even where needle exchange has local support, home delivery complements fixed site exchange by making syringes available to IDU unable or unwilling to attend needle exchange.