An H.I.V. Strategy Invites Addicts In

An H.I.V. Strategy Invites Addicts In
By DONALD G. McNEIL Jr.
http://www.nytimes.com/2011/02/08/health/08vancouver.html?ref=science&pagewanted=print

VANCOUVER, British Columbia — At 12 tables, in front of 12 mirrors, a dozen people are fussing intently in raptures of self-absorption, like chorus line members applying makeup in a dressing room.

But these people are drug addicts, injecting themselves with whatever they just bought on the street — under the eyes of a nurse here at Insite, the only “safe injection site” in North America.

“You can tell she just shot cocaine,” Thomas Kerr, an AIDS expert who does studies at the center, said of one young woman who keeps readjusting her tight tube top. “The way she’s fidgeting, moving her hands over her face — she’s tweaking.”

Insite, situated on the worst block of an area once home to the fastest-growing AIDS epidemic in North America, is one reason Vancouver is succeeding in lowering new AIDS infection rates while many other cities are only getting worse.

By offering clean needles and aggressively testing and treating those who may be infected with H.I.V., Vancouver is offering proof that an idea that was once controversial actually works: Widespread treatment, while expensive, protects not just individuals but the whole community.

Because antiretroviral medications lower the amount of virus in the blood, those taking them are estimated to be 90 percent less infective.

Pioneering work by the British Columbia Center for Excellence in H.I.V./AIDS at St. Paul’s Hospital here demonstrated that getting most of the infected onto medication could drive down the whole community’s rate of new infections.

According to one of the center’s studies, financed by the United States National Institutes of Health, from 1996 to 2009 the number of British Columbians taking the medication increased more than sixfold — to 5,413, an estimated 80 percent of those with H.I.V. The number of annual new infections dropped by 52 percent. This happened even as testing increased and syphilis rates kept rising, indicating that people were not switching in droves to condoms or abstinence.

Studies in San Francisco and Taiwan found similar results. So last July the United Nations’ AIDS-fighting agency made “test and treat” its official goal — although it acknowledged that it is only a dream, since global AIDS budgets aren’t big enough to buy medication even for all those hovering near death.

It is also only a dream in the United States. Much of the American epidemic is now concentrated in poor black and Latino neighborhoods, where health insurance is less common and many avoid testing for fear of being stigmatized. However, the federal government is conducting a three-year study of “test and treat” in the Bronx and the District of Columbia.

Because the medication can have unpleasant side effects, many American doctors delay prescribing it until their patients have low counts of CD4 cells, a sign that their immune systems are weakening. Doctors often feel a greater commitment to each patient’s comfort than to the abstract idea of fewer infections in a given city. But Vancouver is a different story. Canadian medical care is free, doctors are expected to pursue public health goals and Vancouver’s provincial health department aggressively hunts for people to test.

“In 2004, I rebelled when the government people started to say, ‘We need to get control over the budget for your program,’ ” said Dr. Julio S. G. Montaner, director of the St. Paul’s program and a former president of the International AIDS Society. “I went to the ministries of finance and health and told them: The best-kept secret in this field is that treatment is prevention. You need to let us treat more people, not less. And it worked.”

Even $50 million spent on drugs, he said, ultimately saves $300 million because roughly 400 people a year avoid infection. (The estimated lifetime cost of treating a Canadian with AIDS is $750,000.)

Dr. Montaner also pushed for the creation of Insite. There, addicts get clean needles, which they are not allowed to share with anyone else.

In return, they are safe from robbery, which is common on the streets outside, and from arrest. Insite has a special exemption from Canada’s narcotics laws.

They also know that if they overdose, they won’t die. In Insite’s seven years of operation, there have been more than 1,000 overdoses inside, but not a single death. (Mild overdoses are treated with oxygen, serious ones with Narcan, an opiate blocker.)

Also, the staff nurses give medical care: They drain and bandage abscesses from dirty needles, hand out condoms, offer gynecological exams and treatment for sexual diseases, refer addicts to treatment and offer AIDS tests.

“We feel very positive about Insite,” said Dr. Patricia Daly, chief public health officer for Vancouver Coastal Health, the branch of the health system that covers this part of the country. “There are fewer overdose deaths, less open drug use on the street, and we know it’s brought more people into detox.”

While the city’s large gay community has more infected individuals, the drug-using community is harder to reach. Many addicts are mentally ill or barely educated; many are homeless. About a quarter are Indians, who have historical reasons to view government testing with suspicion.

Also, addicts are often so consumed with finding their next hit of heroin, cocaine or methamphetamine that they ignore everything else and will sell anything, including their antiretrovirals.

“I love a lot of the people here,” said Hugh Lampkin, 48 and a heroin addict since he was 16, as he led a tour of the Downtown Eastside neighborhood. He is vice president of the Vancouver Area Network of Drug Users, an addicts’ organization formed in 1997 during a wave of overdose deaths. “You get to know them, they’re really decent. But you always have to watch yourself. Everybody is predatory. Drugs make you that way.”

Downtown Eastside is a shock even to someone familiar with the Lower East Side of Manhattan in the 1980s or the Tenderloin in San Francisco. Even on a balmy fall afternoon, having 5,000 addicts concentrated in a small neighborhood can make a walk feel like a visit to the set of a zombie movie. On its core blocks, dozens of people are shuffling or staggering, flinching with cocaine tics, scratching scabs. Except for the young women dressed to lure customers for sex, many are in dirt-streaked clothing that hangs from their emaciated frames. Drugs and cash are openly exchanged.

The alleys are worse — people squat to suck on crack pipes, openly undress to find veins or lie down so friends can inject their jugulars — a practice, known as “jugging,” that Insite discourages. The puddles, smelling of urine and feces, are sometimes drawn up into syringes, Mr. Lampkin says — one reason that heart infections hospitalize more addicts than overdoses do.

Even in this milieu, where almost everyone admits being a current or former drug user, denial about AIDS is rife.

Admitting that you are H.I.V.-positive, said Ann Livingston, a founder of the drug users’ network, means ostracism: forget about sex, and forget about sharing drugs.

Also, Ms. Livingston said, many users are in and out of prison, where it can be dangerous to admit being infected.

The city began handing out free needles in the late 1980s after studies concluded that the practice lowered rates of hepatitis and AIDS. A 1997 study in The Lancet found that in 29 cities worldwide with needle exchange, H.I.V. infection dropped 6 percent a year among drug injectors, while in 51 cities without, it rose by about 6 percent. A Vancouver study found it did the same. In 2003, at the insistence of a new mayor who was a former police officer and chief coroner, Vancouver went further, opening Insite as a safe haven supervised by nurses.

About 800 injections take place there daily. However, officials think that is only 5 percent of the injections in the city and want permission from the national government to open more sites. “People can’t wait to shoot up,” said Jim Jones, who was handing out syringes at a city-financed “needle depot” in a Downtown Eastside alley. At Insite, Mr. Jones said, “they may have to wait 20 minutes, half an hour. When you’re dope-sick, that’s too long.”

Mr. Lampkin agreed. “People grab a rig, go two feet from here and do their smash,” he said. “Or they don’t even cook up, they shake and bake: pour their drugs right in the syringe, shake it with water, and try to heat the barrel. Shake and bake is how you get endocarditis.”

At Insite, clients are left alone, unless they ask for help. Bad vision is common, and many users have veins clogged with scar tissue. The nurses can help find a vein, “but they cannot push the plunger,” Dr. Kerr said.

Needle litter has decreased in the area, and Insite’s backers assert that violence has gone down, too. Female addicts are often attacked for their drugs or money, Dr. Montaner explained, so they must get men to protect them, which often means payment with sex, which increases infection risk.

Although the Canadian Medical Association and the public health officers of Canada’s 17 largest cities have endorsed supervised sites, no more have opened because the national government refuses to grant more exemptions to the federal narcotics laws.

Insite opened when the Liberal Party was in power. The Conservative-led government that came to power in 2006 has sued to shut it. Local courts have refused to close it, accepting the city’s argument that an addict’s need for opiates is like a diabetic’s for insulin and that a citizen’s right to health — recognized in Canada’s version of the Bill of Rights — outweighs narcotics law.

Canada’s Supreme Court is to take up the case in May.