AN H.I.V. STRATEGY INVITES ADDICTS IN

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.

[sidebar]

AN ADDICT CROSSES A LINE, AND IS PULLED BACK

VANCOUVER, British Columbia -- Gregory Reeve could hardly have picked
a more Canadian way to become a heroin addict: a hockey puck in a
game with friends shattered his jaw.

A doctor at a public clinic put him on morphine and paid little
attention as he refilled his prescriptions for six months.

"It took away the physical pain, and it took away the psychological
pain," said Mr. Reeve, an articulate college graduate and former
flight attendant, who said he was angry at himself for not being as
ambitious as his parents wanted.

When the doctor abruptly retired and the clinic refused to renew his
prescription, he went into withdrawal.

That night, a friend's girlfriend offered him some heroin to inhale.

"I was freaked out," he said, "but within 10 minutes, I felt normal."

A few months later, drunk on sambuca, he asked another woman shooting
up how it felt. "Like an orgasm times 100," she said.

"I rolled up my sleeve," he said.

Now, at 43, he is homeless and jobless, sleeping in a church
basement, living on disability payments. (He qualifies because he has
hepatitis.) He is friendly and engaging, but clearly has worse
moments: he mentions facing charges of "uttering death threats."

He has been arrested for selling drugs and lives in fear of the
dealer who has threatened to cut off his fingers with a bolt cutter.
He is on methadone for the third time and calls it "liquid prison."
Because he must visit one pharmacy every other day, he can't leave
town. But he can't quit because, he says, the last time he tried, it
was so painful that he soiled his bed for days. "If I'd had a gun, I
would have killed myself," he said.

Also, he said, he can't pass a urine test to get into a detox program
because he still smokes crack sometimes, though he says he hates
himself for succumbing.

Several years ago, when he was using heroin, he bought four $10
packets one night -- a lot, even for him -- just before entering
Insite. He said he put three in a cooker "like a Barbie doll frying pan."

"Next thing I remember, I was looking up, lying on the floor with a
tongue depressor in my mouth, an oxygen mask and hooked up to an IV.
My girlfriend is crying, 'Oh my God, oh my God!' "

She was shooting up a few seats away and saw him slipping down in his chair.

"My face, my lips were all blue," he recalled. "She yelled for the
staff. They gave me Narcan. It reverses the effect -- it was gone,
boom. It's the oddest thing.

"If I had been outside, I would have died.

"You know," he added, "I didn't see any tunnels, any light, angels,
God, anything. Just a complete black abyss. When you're dead, you're dead."