NEEDLE EXCHANGES HELP SAVE LIVES IN PUERTO RICO

SAN JUAN, PUERTO RICO -- They arrive gaunt and red-eyed, some wobbling on
rusty bicycles, others casting a wary eye as they walk quickly onto the
dusty courtyards of this city's housing projects.

Most carry their needles in bunches of twos and threes, but others bring
dozens in bags and small boxes. One woman carries 47 in a disposable-diaper
box.

It's needle exchange day at the Luis Llorens Torres housing project and
throughout Puerto Rico's capital city. Members of the Community Initiative,
the island's only needle-exchange group, have set out buckets for addicts
to drop their used needles into as the workers count out clean ones.

"Thirty-one, thirty-two, thirty-three," says one woman, as she drops her
used needles into a bucket beneath a large tree. Those who show up receive
exactly the number of needles they hand over.

"Yes, they're drug addicts. Yes, they're committing a crime with the
needles we give them," said Dr. Jose Vargas Vidot, the man behind this
effort. "But I'm a doctor, and the point here is to save lives. That should
be the most important thing for everyone involved in fighting AIDS."

Twenty years into the AIDS epidemic, needle exchange has emerged as one of
the more controversial tactics for curbing the spread of an epidemic
fraught with controversy and stigma. In Puerto Rico and on the U.S.
mainland, needle exchange programs are accused of fostering drug abuse, of
sanctioning criminal behavior.

But as with condom programs that target young teens, needle exchange
advocates argue that the severity of the epidemic demands drastic measures.

Stemming The Tide

Aside from programs that offer help to users trying to kick their
addictions, they argue, separate efforts must be made to prevent the spread
of a fatal disease before it engulfs addicts' sexual partners and children.

In Puerto Rico, the stakes are even higher: In contrast to the rest of the
United States and Caribbean, where the primary means of transmission is
sexual contact, more than half of Puerto Rico's HIV cases are infected
through drug abuse with needles. Another large percentage of new cases is
among those who have had sex with infected addicts. Health officials
estimate there are about 100,000 drug addicts in Puerto Rico.

Unlike people in developing countries, addicts in Puerto Rico can get
access to the expensive anti-retroviral medicines that have prolonged many
lives. But they face a staggering bureaucracy that many say is not equipped
to deal with such a troubled population.

"There are government programs to get them the medicine they need, but
they're really not designed for anybody suffering from addiction," said
Vargas Vidot. "They require multiple appointments, ask detailed questions
and really don't respect the privacy concerns that many people have."

As he sees it, the problem of drug abuse cannot be separated from economic
and social issues like the lack of jobs, housing and good education. Many
of the people in his program come from multigenerational families of
abusers and have been victims of violence and neglect in childhood, the
doctor said.

He's in an excellent position to know. A product of La Perla, one of the
island's most dangerous slums, Vargas Vidot grew up well-acquainted with
the dire social circumstances that propel many of his clients into drug
use. After studying in the Dominican Republic, he returned to Puerto Rico
in 1987 to oversee a small clinic just as AIDS was emerging on the island.

"It was just heartbreaking," he said. "We were doing something like 50 or
60 blood tests a day, and I'd say half of them were coming back positive.
There was no medicine for AIDS at the time, so you're basically telling
people they're going to die."

He couldn't save their lives, but he could improve them. He proceeded to
build a system of services that would include treatment facilities, a
pharmacy and later a group of residential homes for recovering addicts. The
Community Initiative was formally created in 1992.

Vargas Vidot, a heavyset man with a soft voice and a ponytail, has emerged
as one of the island's leading community health activists. He has been
recognized for his work with numerous awards in Latin America and the
United States, including a $100,000 award from the prestigious Robert Wood
Johnson Foundation. The organization has an annual budget of $1.3 million
and helps about 25,000 people each year.

Social And Health Help

Since its inception as what Vargas Vidot describes as an "underground
clinic" to supply needles in violation of Puerto Rico's laws at the time,
the Community Initiative has developed into a full-service organization
that helps both addicts and AIDS victims. It provides treatment but also
teaches clients how to navigate the system to improve their benefits. The
initiative is funded through a mix of government and private grants and
donations.

Possession of syringes still can be an "aggravating circumstance" under
Puerto Rico's tough drug laws, but the initiative is legally allowed to
provide needle exchange.

"We try to fool the system — that's the best way to put it," said Vargas
Vidot. "We put our clients through mock interviews. We teach them what
they're going to encounter when they seek medicine, what to say to what
questions, and how to fill out the forms.

"This is a very desperate population," he says. "Puerto Rico has an aging
population of addicts — people in their 30s and 40s who have been living
their lives like this for years. Each day they're searching for a fix.
They're not going to sit still very long in an office to get medicine if
they have HIV."

At one shooting gallery, an open-air wooden building in La Perla with a
spectacular view of the ocean, a 48-year-old woman named Maria said she's
seen three of her friends die of AIDS.

Maria, a native of New York's Puerto Rican community, came to the island
during the 1970s to work as a dancer. A girlfriend, who has since died,
introduced her to heroin. Now she's trying to get off heroin, but says it
helps her seek and do work as a maid in the island's hotels.

"The older you get, the harder it really gets to kick it," Maria said. "You
need it to get up in the morning. You need it to go to work each day. The
reality is I like the high. Being high — it's a feeling of success."

As the addicts deposit their used needles in a medical waste bucket, they
list their ages. The 21 addicts who deposit needles on this day range in
age from 33 to 52. They have been using an average of 11 years, with the
longest having used drugs for 28 years.

Saving The Young

But while the epidemic spreads in a hard-to-reach, desperate population,
prevention efforts are being geared to the next generation. As the island's
state epidemiologist describes it, anti-AIDS efforts have to function with
a sort of "triage" mentality — first save those who can still be saved from
the disease, then do what you can for the rest.

"I respect Dr. Vargas a great deal, and I understand his point of view, but
I'm worried most about our young people," said Dr. Angeles Rodriguez,
Puerto Rico's state epidemiologist. "You don't get too much time to get
their attention, and I think it's best that our efforts are best directed
at getting the message out to them.

"You're not going to get many of these addicts to take the medicine they
need — they're out looking for a fix every day," she said. "And the fact is
these drugs don't stop the disease forever. They only work so long, and
these people are going to die. We have to focus our effort on the next
generation."

But Vargas Vidot says every life should be given its due.

"You turn these people around, get them off drugs, get them the medicine
they need for their disease, and you really cannot say what their potential
is," he said. "What we're saying is that the potential is there, the
possibilities are there."