By Tim Collie
Sun-Sentinel

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.”

Tim Collie can be reach at tcollie@sun-sentinel.com or 954-356-4573.