The purpose of this paper is to describe the meaning of needle exchange programs from the perspectives of users who access such programs. We conducted observations, 33 semistructured interviews and two focus groups with users at four needle exchange sites. Qualitative description was used to analyse the data. Participants described experiences of trauma, abuse, violence and physical injuries that had damaged their lives and led to the use of drugs to numb the pain. Respect for persons and the development of trust with outreach staff for clients who use injecting drugs supported clients to feel safe in what for many was an unsafe world. Participants described the important role that needle exchange services play in reducing and countering negative stigma, as well as in providing access to clean supplies and to other services. The findings attest to the benefits of having trusted, safe needle exchange services that not only reduce risk behaviours that prevent infections, such as HIV and hepatitis C, but also open the door to other services. This finding is particularly important given that the majority of those interviewed were homeless and living in poverty. The need for both fixed sites and the integration of harm reduction services as part of a broader network of primary health-care services was reinforced. © 2010 Australasian Professional Society on Alcohol and other Drugs.