Table 2. PRESENT (ongoing program operations) themes.

Theme	Categories	Classification	Illustrative Quotes
3. The Legal Conundrum	a.Paraphernalia laws that lead to confiscation and/or arrest of PWID for possessing needles	Barrier	So the police officer who participates got permission from the chief of police to participate and then we, our medical director and myself went over and had a face to face meeting with our city police chief because we felt like we needed them on our side.. . .we didn’t want to get to a point where we were giving out syringes, they would arrest somebody, confiscate those syringes and then… basically harm reduction is now no longer available to the community. (Free Clinic NEP Director)
	b. Law enforcement confusion regarding the action to take upon discovery of needles c. Differing opinions between law enforcement leadership and staff	Barrier	What my instructions have been is if you catch somebody coming out of [the NEP] with a bag of clean needles, or somebody that comes out of pharmacy, that’s not really drug paraphernalia. It’s got to be in conjunction with you know you’ve got the spoon, you’ve got the tie off, you know it’s clear that that’s what they’re using it for. And that’s typically what, you know we’re going on overdose calls, we’ll make an arrest in finding paraphernalia in you know the rig as they call it on somebody and charge them that way. (White, Male, Police Chief) It’s still drug paraphernalia…If you’re stopped by law enforcement, it’s not an exemption because you’re not supposed to be out here walking the streets carrying your drug paraphernalia and that kind of stuff. You know like I said they know what they’re dealing with and they know the actual laws for the use of. Yeah, don’t draw attention to yourself and then you might get by. (White, Male, Police Officer)
	d. PWID reports of needle confiscation and/or legal sanctions for possession of needles whether clean or used	Barrier	I had to go to court. I had three of them. They weren't even used. They were brand new. I got a $195.00 fine. (White, Female, PWID, Health Department NEP Participant) I went to court yesterday over paraphernalia charges because I was caught with three rigs…They were clean…Brand new… I got $175 for each needle. (White, Male, PWID, Health Department NEP Participant) Right here in this town, I got a misdemeanor possession, 15 grams or less. How retarded is that? 15 grams or less? I could see if it was dirty, and I didn't have no lids for it, you know what I mean? (White, Male, PWID, Free Clinic NEP Participant)
	e. PWID confusion over whether or not needles obtained from the exchange can be possessed	Barrier	They give you a card and I got pulled over and I showed them that card and they said that, that didn't matter at all. All that did was show where I got them from, that it was still paraphernalia and that it was still a misdemeanor. (White, Female, PWID, Health Department NEP Participant) I came across a policeman, and he was searching my stuff because I was around someone on house arrest. He was into my stuff. He seen my card from the [NEP]. He was like, "This is illegal. I know why you go there. This is illegal." I'm like, "No, it's not. It's not illegal to go there and get syringes." He's like, "Yes, it is, and I'm going to make sure they close down”. (White, Female, PWID, Free Clinic Participant)
4. Location is Everything	a. Program location unreachable by some participants in the rural setting	Barrier	Yeah [PWID] will car pool. They'll put five, six people in a car to come down here and to do the needle exchange.. . .it's like now. It's been months since we've been able to get down here and do this. Today is the first day. (White, Female, PWID, Health Department NEP Participant) …[you can get to the exchange] if you have money for public transportation, stuff like that, but normally that's how you buy your drugs. You don't have a dollar on you. (White, Female, PWID, Health Department NEP Participant) I have a friend in PA, and they don't do anything like this. She asks me all the time like, "I wish I lived in West Virginia, so I could get them.” (White, Female, PWID, Free Clinic NEP Participant)
	b. Program located near police department	Barrier	It absolutely sucks…on one side of the street you go to jail and the other side of the street you go to get your needles so you can continue on with illicit behavior. It’s a mixed message. It’s a mixed metaphor. (White, Male, Police Chief)
5. Harm Reduction For All	a. Potential to reduce the spread of disease for program participants b. Potential to reduce the spread of disease for law enforcement officials	Facilitator Facilitator	It's a life changer, really. It's a life changer that you can come up here once or twice a week and get what you need other than going and trying to go and find it [needles] on the street. It's saving lives. (White, Female, PWID, Free Clinic, Participant) Well myself personally you know I’ve got a family. You know I don’t want to be out here and you know being on the front line dealing with these addicts you know. I don’t want to be stuck with a dirty needle. I’ve been stuck with a dirty needle before and it’s not very pleasant the treatment that you have to go through. (White, Male, Police Officer)
	c. Concerns over increasing amounts of discarded needles in the community	Barrier	I took my kid to the park, and I'm not kidding you, the only thing I don't like about it [the exchange], and it's people in general, some people … I take my child to the park, and you see something like that [needle] laying on the ground. It's my child. What I do to myself is on me, and that's something I have to live with. I'm not going to do it in front of my child. To me that's disrespectful. Getting rid of them on the street. They was thinking about stop doing it [the exchange] because people was throwing them out like that. (White, Female, PWID, Free Clinic NEP Attendee) …when you do this program that this is a secondary effect because there are people who see them in the community parks, they see them in the playgrounds. They get thrown in trashcans and your sanitation workers in the city grab these bags and throw them in and they’re going to get needle sticks. (Health Department NEP Administrator)
6. Not Just A Needle	a. Comprehensive harm reduction services beyond just the provision of needles	Facilitator	You get everything that you need to use. They even give you something that you can throw them away in instead of just tossing them. (White, Female, PWID, Free Clinic NEP) Helps you stay sanitary. They tell you how to use everything all that, give you instructions and all that. (White, Male, PWID, Health Department NEP Participant)
	b. Linkage to drug treatment services made the program more acceptable to law enforcement members	Facilitator	But then you also have that real fine line. Are you encouraging the continued use of an illegal controlled substance or are you treating it? And I think the panacea is there are two different things. You’re trying to intervene on the [blood borne] pathogens. And through that blood borne pathogen intervention you’re trying to reach out to change the thought processes of the illicit drug user. And I think that’s where people lose the message here that it’s not one you know feeding the other. It’s one or the other, because that’s what you have. The needle exchange is a blood born pathogen intervention not a drug intervention. But they’re trying to pull the drug intervention in by getting a hold of them through the medical intervention. (White, Male, Police Chief) We probably wouldn’t have bought into it, wouldn’t have supported it had there not been a detox part of it. I know that public funding probably would not have been there had there not been a process of detox, not just here, here’s your needle. (White, Male, Police Chief)