Rich Port, Poor Port

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Science  28 Jul 2006:
Vol. 313, Issue 5786, pp. 475-476
DOI: 10.1126/science.313.5786.475

Good HIV/AIDS care and strong research in this U.S. commonwealth often mean little to the island's many heroin addicts

SAN JUAN, PUERTO RICO—If Viviana Valentin lived on any other Caribbean island, she'd likely be dead by now. Diagnosed with an HIV infection in 1990, Valentin has developed resistance to several antiretroviral drugs and once had a CD4 count of zero, an indicator that HIV had decimated her immune system. She has two children and no job. Yet today, Valentin is receiving T-20, the most expensive anti-HIV drug, which retails for more than $20,000 a year and requires twice-daily injections. She's also benefiting from state-of-the-art care at the University of Puerto Rico (UPR), where she is enrolled in a clinical trial studying neurological complications of the disease. “I have the best doctors,” says Valentin, who was born and raised in New York City and moved to Puerto Rico when she was 21. “They've done a wonderful job.”

Prickly issues.

Injecting drug users at this San Juan shooting gallery have severely limited access to health care and drug substitutes such as methadone.

As a commonwealth of the United States, Puerto Rico enjoys one of the strongest economies in the Caribbean, which supports not only the topnotch care many HIV-infected people receive but also a burgeoning research community. But that's the rosy picture. There are thorns as well. Puerto Rico's per capita income is lower than that of any state on the mainland. Because it is a U.S. territory, HIV/AIDS prevalence figures are lumped with those on the mainland, a practice that many experts think masks the extent of Puerto Rico's epidemic. “We're submerged into the U.S. statistics,” says virologist Edmundo Kraiselburd, who directs both UPR's NeuroAIDS research program and the Caribbean Primate Research Center.

And unlike the epidemics in the rest of the Caribbean, Puerto Rico's is driven primarily by injecting drug users (IDUs), who are often discriminated against at clinics or emergency rooms. “The doctors don't want them,” says José “Chaco” Vargas Vidot, a clinician who in 1990 started an outreach program for IDUs called Iniciativa Comunitaria. Vargas Vidot complains that the country has too few methadone treatment clinics and needle-exchange programs, which elsewhere have proven key to lowering transmission rates. “The government is ignoring our AIDS epidemic,” he charges.

So although Puerto Rico is indeed a rich port for patients such as Viviana Valentin and many HIV/AIDS researchers, IDUs often have a starkly different vantage.

Heroin hub

On an early weekday afternoon in a barrio outside San Juan called La Colectora, a dozen men and one woman pay $1 each to enter a shooting gallery, a small house where users inject and then typically collapse into a chair. Out front, two outreach workers and a doctor from Iniciativa Comunitaria set up a needle-exchange program. Julio, a 33-year-old heroin addict, shuffles up and lays eight syringes on the ground, receiving an equal number in exchange. Julio, who is homeless, does not shuffle because he is high: Injecting has left him with bloody and blackened abscesses on his calves that may be gangrenous, says Angel González, a clinician with the program.

Julio says the stench coming from his legs makes a bad situation even worse. He couldn't make it to his methadone treatment program, he says, because “they started to refuse to let me on the bus. … The smell was bad, and people would complain.” He says an emergency room also sent him away without care.

González says Julio is one of many addicts the system has failed. “Patients have to go through so many obstacles to get treatments,” says González. “We need big changes here.” UPR's Carmen Albizu-García, who is conducting a small drug-substitution program with addicted prisoners, is also deeply frustrated by the official resistance to proven HIV prevention methods. “In Puerto Rico, we've been very, very hesitant to do what we have to do to control the epidemic,” she says.

Heroin's popularity on the island has many roots, but it's clearly tied to its strategic location for South American traffickers. The Puerto Rican Department of Health says that half of the AIDS cases reported to date are heterosexual IDUs, while another 7% are IDU males who have sex with men. UPR obstetrician/gynecologist Carmen Zorrilla says that roughly two-thirds of 2000 HIV-infected women she is following were infected by having sex with men who were IDUs. The HIV/IDU situation in Puerto Rico is “a public health emergency,” says Sherry Deren, director of the Center for Drug Use and HIV Research in New York City.

Deren, along with sociologist Rafaela Robles and epidemiologist Héctor Colón of the Central University of the Caribbean in Bayamón, Puerto Rico, led a provocative study comparing 399 IDUs in San Juan to 800 Puerto Rican IDUs living in New York City. Between 1996 and 2004, the researchers found, users in Puerto Rico injected nearly twice as frequently, favored mixtures of heroin and cocaine known as speedballs, and were more than three times as likely to share needles. Between 20% and 25% of the IDUs were infected in both locales, but the new infection rate in Puerto Rico (3.4% per year) was nearly four times higher. The study also found significantly fewer needle-exchange and methadone programs in Puerto Rico, and twice as many HIV-infected participants in New York were receiving antiretroviral drugs. Not surprisingly, the mortality rate in Puerto Rico was almost three times higher. If a city or state on the mainland had these statistics, says Deren, “I think there'd be much more attention given to the problem.” Colón points a finger at policymakers who “still believe that treating drug users is a waste of money.”

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