Margaret Munro
Sun Science Reporter

AIDS In the street: A special report

Dr. Stephanee Strathdee and some of the participants in her HIV study: "The rate of infection may be a lot higher than we think." Photo: Glen Baglo, Vancouver Sun

AIDS in the labs, new drugs provide hope.
On the street, it's a different story

He scribbles on the board stressing that exacting use of the new drugs could turn AIDS into a manageable disease. "Like diabetes," suggests Montaner, who as co-director of Canada's HIV drug trials and co-chair of next week's 11th International Conference on AIDS is privy to the latest findings from the world's research labs.

"It's too early to talk about the eradication but it's possible to think of this, at least theoretically," Montaner said recently of the test results sure to be a sensation at the conference.

New drug combinations have driven the virus down to undetectable levels in many men that have been testing the drugs in Vancouver, Toronto, the U.S., Europe and Australia, he said: "We have shown that we can suppress viral replication and keep it there."

Out on East Hastings Street, the prognosis is not so good.

Public health sleuths tracking the virus say breakthrough drugs will do little to remedy the ignorance, poverty, despair and fear that keeps driving the epidemic.

Fifteen years after the first documented case of AIDS, 45,000 Canadians are infected with HIV, the virus that causes the disease. AIDS is the leading killer of young men in Toronto, Montreal and Vancouver and remains a serious threat to young gay men. Intravenous drug users and native indians, especially native women, are being infected with the virus at an alarming rate.

"There is not a country in the world where HIV is under control," notes Dr. Stephanee Strathdee, whose work on Vancouver's downtown eastside points to one of the big reasons the virus won't be under control in Canada anytime soon.

Her team's work, which involves interviewing hundreds of drug users, details how the HIV virus continues to flow, in many cases, straight into people's veins.

A report on the first 281 interviews, to be presented at next week's conference, says infected addicts often share and reuse needles and have unprotected sex. It notes that there is financial incentive for HIV positive prostitutes to spread disease since johns will pay more for condom-free sex.

As one prostitute told the researchers: "Girls will do it because they need the money."

"That happens a lot," says Strathdee, manager of epidemiology at the B.C. Centre for Excellence in HIV/AIDS, who describes the downtown eastside as B.C.'s most volatile AIDS incubator.

"The epidemic in the province is being driven by what's happening down here," Strathdee said this week as she strolled down Hastings past the Sunrise and Balmoral Hotels where addicts loitered in the doorways. More than 500 people have overdosed on speedballs and other deadly drug concoctions on these streets in the last three years, and almost as many have picked up HIV.

The B.C. Centre for Disease Control estimates that at the current rate of infection there will be more than 600 infected addicts roaming Vancouver's poorest streets by the end of this year.

"That's more than twice as many as there were last year.

"And the rate of infection may be a lot higher than we think," says Strathdee.

Curbing the spread of HIV among drug addicts and other marginalized, impoverished groups is clearly tougher than dealing with AIDS in the gay community. Drug addicts do not have a great will to live, or to follow the path to safer, cleaner living.

And it's doubtful many of them will be lining up in front of Montaner's office looking for the new anti-viral pills. Many addicts can't even be bothered to go for an AIDS testing. And it's doubtful the anti-virals will work well when mixed with heroin and cocaine shot right into the arm.

It's an understatement to say the addicts lead troubled lives:

Almost two thirds of the 281 respondents in Strathdee's study said they've attempted suicide.

Forty per cent have been forced to have sex against their will, many of them before their 12th birthday.

Twenty per cent first injected drugs for 12 years, and using both heroin and cocaine. Many are hooked on speedballs, a highly addictive combination of both drugs, which are injected up to 20 times a day.

Almost 90 per cent of the addicts are on welfare, and almost all "enhance" their income through crime and the sex trade.

While the addicts are a huge concern to public health officials, AIDS is not a pressing issue for many addicts.

It's your nest fix; you're not concerned about your health or nothing, all you're concerned about is your next fix," said one of the addicts, who were paid $20 each to participate in the study.

"To a lot of addicts HIV is something that may or may not lead to symptoms 10 years down the road," says Strathdee, sidestepping a panhandler on the street. "Their much , much more immediate concerns are finding food, a place to stay. And more drugs.

"It's like having a huge parasite on your back that has to be fed 20 times a day, then you feed yourself."

More than half the addicts, who get most of their needles free from the government-funded needle exchange program, reported sharing needles regardless of the risk of infection.

Many said that when they get together to shoot drugs they can't keep all their drug paraphernalia straight and their needles -- "rigs" in the street vernacular -- get mixed up.

"When you get high, people get a bit freaky," one user reported. "They all of a sudden stand up and take my rig, and move it over there, things get mixed up, spoons get mixed up, water gets mixed up."

To reduce mix-ups, Strathdee says needle exchange workers now hand out colored stickers that the addicts can put on their needles.

Another factor driving infection is the AIDS stigma. Several HIV-positive addicts told the researchers they share their needles because they don't want anyone to suspect they're infected. Others said they avoid testing for fear of being singled out and ostracized." And several sex trade workers reported they felt no sense of obligation to protect their sex trade clients," says Strathdee, noting that condom-free sex commands a higher price on the street.

All of which indicates that the HIV positive prostitutes are spreading disease to their customers -- fellows like the man Strathdee recently saw picking up a prostitute in east Vancouver in his family car, complete with baby seat, at 7:30 a.m.

Prostitutes and addicts are often so despondent and so depressed they don't care whether they live or die, let alone whether they have safe sex or use clean needles, she says. "When they're feeling lousy they're going to use the needle in front of them whether it's clean or not."

She and her colleagues say the government's free-needle program is essential. Without the program that will give out more than two million free needles this year the virus would be spreading much faster.

"But we have to do is convince these people their lives are worth living, that's the key," says Strathdee, who strikes up a friendly conversation with three men hanging out at Main and Hastings while she's posing for a photograph.

"A lot of people in Vancouver would like to write off this six blocks," she says as she heads down Hastings. "But there are not lives that you just can't dispose of."

"Even if you don't care about drug users, the costs to society are huge," Strathdee says. Each HIV infection is said to cost the medical system $100,000. The bill for 600 infected addicts adds up to $60 million.

"And they're likely to lead a life where they will infect at least one other person through sex or shared needles," she notes, adding that an estimated 64 per cent of Canadian women now getting infected with HIV are getting the virus from injecting drugs or having sex with infected drug users.

"Often it's some weekend warrior who parties hard and does the odd IV fix and his girlfriend doesn't have a clue," says Strathdee, who has spent years trying to sort out the social factors driving the epidemic. Sexual abuse, poverty alcohol and drug abuse all come into the deadly equation.

But she says sometimes it's simple things like the stigma associated with walking into the HIV clinic on isolated indian reserves. "Everybody know you're going for an AIDS testing, so nobody wants to go," Strathdee says.

And there are educational problems, which were highlighted this week with a study Strathdee and her colleagues released on the sexual behavior of young gay men in Vancouver.

The study of 301 men between the age of 18 and 30 found that almost half had unprotected sex in the last year.

"They don't see AIDS as a threat the way older gay men do, says Steve Martindale, who co-ordinated the study. "They haven't watched half their friends die."

"Some of them think they are invincible and that AIDS won't happen to them, others are convinced they're going to get it no matter what, so what's the point of being careful," adds Strathdee, who says society has a long way to go in reaching and accepting these vulnerable young men, more than 30 per cent of whom reported having sex in bathhouses and sex clubs.

"When was the last time you heard parents saying how great it was that their 18-year-old son was homosexual," Strathdee asks.

Her Boss, Dr. Martin Schechter, has charted the HIV movements in Vancouver for close to 15 years and stresses that the social factors driving the AIDS epidemic are as complex as the microbial factors.

"It's not a simple matter of giving people clean needles and condoms," Schechter says."Anything we do has to be multi-faceted." Free needles need to come with effective counselling and addiction treatment. Education has to be tailored to reach young people most at risk. Medical services have to be accessible.

Schechter, who is also co-chair of next week's conference, doesn't see any easy solutions on either the social or medical front.

Despite all the excitement about new drugs treatments for HIV, he and Montaner say there is much uncertainty about their long-term effectiveness.

The potent drug cocktails have cleared the virus from the blood system from hundreds of men involved in trials in Canada, the U.S. and Europe. But it is not known if they can get rid of HIV lurking in other cells such as the brain and lymph system.

"We don't know yet what effect the drugs have on latent viruses that have parked themselves in other tissues," Schechter says.

And even if the costly, complex drug treatments do prove capable of eradicating the virus from individuals, nobody is under any illusions that new therapies will eradicate HIV and AIDS from society.

As Montaner noted this week: "We've known how to treat and cure tuberculosis for decades but it's still spreading." That bacterial disease, which like HIV thrives in poor and marginalized communities, kills about three million people a year and remains the largest cause of adult deaths in the world.

The word on the street

On sharing needles:

You see a lot of people standing around waiting for the needle vans and stuff like that. If you want a fix you don't care, you go pick up a syringe off the street. I've seen so many people do it, I've done it myself.

I tried to keep sharing to a minimum. Like I wouldn't do it if there was any other choice -- but sometimes when you want a fix...you did what you did [shared needles].

It really screws up your head when you're high. You just don't care a lot of the time, you just want another fix and then you thing later "Ah, I shouldn't have done that" [shared needles] but it's too late.

People that have it [HIV] are giving it to people in vendetta or revenge.

If you get it, you get it, if you don't, you don't. It's just a risk you gotta take. It think a lot of that happens...I know a lot of that happens cause it's happened to me a couple of times where I just said: f--- it, man."

Most people have had a bad experience and turned to dope. You know, some time in their life they've had a trauma that they couldn't deal with. People don't want to be down here. It's not like you enjoy walking p wondering where you're going to get you're next fix -- robbing people, robbing cars, turning tricks -- nobody wants to...it ain't a choice, people can't get out.

All the stuff I went through growing up, all the abuse and s---, like that's nothing compared to this [being a HIV-positive addict living on Downtown Eastside]."

People get paid more, mind you I won't take it. I refused one and I seen another girl jump right in, she just dove in the car...girls will still do it because they need the money.

By the numbers

• The first five cases of the disease, later to be called AIDS, were reported in medical journals in 1981
  
• 45,000 Canadians are HIV positive, including 7,400 British Columbians
  
• 12,670 Canadians have AIDS, including 2,000 British Columbians
  
• 9,103 Canadians have died of AIDS
  
• Worldwide, more than 20 million people are living with HIV/AIDS, more that 93 per cent of them are from developing countries
  
• On average, people live with the HIV virus for 10 years before developing AIDS. Once they get AIDS, the disease can kill people within two years, although new drugs are extending lifespans of some people for about another two years.
  
• The newest trend in anti-HIV treatment are the protease inhibitors. The cost of three anti-HIV drugs per person each year is well over $10,000