VANCOUVER'S BOLD HIV EXPERIMENT

Safe Injection Site On City's Notorious Eastside Leads To Lower AIDS
Infection Rates

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 centre, 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 get worse.

By offering clean needles and aggressively testing and treating those
who may be infected with HIV, 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 per cent less infective.

Pioneering work by the British Columbia Centre for Excellence in
HIV/AIDS at St. Paul's Hospital here demonstrated that getting most of
the infected onto medication could drive down the community's rate of
new infections.

According to one of the centre'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 per cent of those with HIV. The number of
annual new infections dropped by 52 per cent. 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 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 neighbourhoods,
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.

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.)

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. "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 native,
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 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 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, HIV infection dropped six per cent a year among drug
injectors, while in 51 cities without, it rose by about six per cent.
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 five per cent of the injections in the city and want
permission from the national government to open more sites.

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,"
Kerr said.

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.