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Nurses help addicts inject heroin at controversial clinic battling H.I.V.

April 13, 2014 at 11:00 AM EDT
British Columbia has successfully stemmed an epidemic of AIDS in one of the hardest to reach populations: intravenous drug addicts. Correspondent William Brangham examines the ways that medical professionals are taking on the spread of H.I.V, including a look inside a controversial facility where nurses help drug addicts inject illegal drugs.

Editor’s note: This video report contains depictions of intravenous drug use that may be disturbing to some viewers.

WILLIAM BRANGHAM: Vancouver, British Columbia is considered one of the most beautiful, livable cities in North America.

But there’s a small part of the city that’s stunning in a different way. The downtown east side neighborhood is a grim reminder of the toll drug addiction takes.

Everywhere you look, emaciated addicts walk the streets. Police generally don’t see the point of locking them up. Drugs are exchanged openly in broad daylight. Women on the street prostitute themselves. Over the course of a few concentrated blocks, you’ll see people smoking crack right on the sidewalk, or injecting themselves in an alley with heroin or cocaine.

Not surprisingly, this neighborhood has been visited by another plague: back in the 1990s, this was the epicenter for one of the fastest growing AIDS epidemics in the world.

DR. THOMAS KERR: Vancouver experienced what has been described as the most explosive epidemic of H.I.V. ever observed outside of Sub-Saharan Africa.

WILLIAM BRANGHAM: But that’s changed now, thanks to a plan that’s dramatically reduced the spread of the disease. It’s happening, supporters say, by getting free H.I.V. medication to addicts who share needles.  They’re also steering addicts to this controversial facility where medical staff actually help them inject illegal drugs.

The strategy being deployed in British Columbia is being studied closely – by the U.S., by China and by Europe – for how it’s successfully fought an epidemic among a very hard-to-reach population.

So how does it work? Sometimes, it starts with people like Tracy D’Souza pounding the pavement. D’Souza’s a registered nurse, one of a small army of nurses working this neighborhood.

WILLIAM BRANGHAM: Now, I thought nurses wore white shoes. What’s the deal?

NURSE TRACY D’SOUZA: [laughs] You don’t wear white shoes in the downtown eastside. [laughs] that’s for sure.

WILLIAM BRANGHAM: With her medical kit strapped to her back, D’Souza’s off to see one of the dozen or so H.I.V.+ patients she cares for, wherever they are.

NURSE TRACY D’SOUZA: If I have come in the alley to find you? No problem. If I have to come to your home? No problem.

COLIN: Well, I feel like a nut.

NURSE TRACY D’SOUZA: How’s your energy?

WILLIAM BRANGHAM: D’Souza’s working with Colin today, who she’s known for several years. He likely contracted H.I.V. through sharing a needle. And even though he’s still using, he’s seeing D’Souza or other nurses every few weeks, and he diligently takes daily HIV retroviral drugs on his own.

NURSE TRACY D’SOUZA: I think it’s a fallacy that just because people are using drugs, or selling sex that they don’t care about their health. I think they care very much — I think because of their mental health and addiction issues, it might be tougher.

WILLIAM BRANGHAM: This early and consistent H.I.V. treatment is a central pillar of British Columbia’s strategy, and it’s one that began with important discoveries by this man’s team:

DR. JULIO MONTANER: … and I said, oh, my god, this is huge. This is bigger than I thought. This actually can turn the epidemic around.

WILLIAM BRANGHAM: Dr. Julio Montaner is among the world’s experts on treating H.I.V. Born in Argentina, now a Canadian, Montaner helped found the British Columbia Centre for Excellence in H.I.V. and AIDS.

Back in the mid-1990s, his team was one of the first to demonstrate what was then a contested idea: that aggressively treating H.I.V. in individuals not only helps them, but can prevent the spread across an entire community.

Here’s how: it’s well-known that people with untreated H.I.V. are full of the virus, and if they share a needle with others, they’ll likely infect them and spread the disease. But treating those original patients with HIV medicine dramatically suppresses the amount of virus in their blood, which, research has shown, makes transmission to others much less likely. (According to Dr. Monatner, it’s more than 90% less likely.)

DR. JULIO MONTANER: In fact, the single most powerful predictor of you as an injection drug user to contract H.I.V. was the amount of virus that was circulating in the community, which, upon bringing treatment to that community, came down. And so the number of new infections came down in parallel. In other words, it’s not the needles, stupid. It’s the virus.

NURSE: I’m gonna go ahead and poke…

WILLIAM BRANGHAM: These findings triggered an even more aggressive campaign to test as many people as possible, and to get anyone who tests positive onto the meds as quickly as possible.  This overall strategy is now called “treatment as prevention”

But public health advocates in British Columbia didn’t stop there: Dr. Montaner – along with many others – pushed for the creation of this facility, which is called “InSite.”

DR. THOMAS KERR: So InSite is a very unique facility. It’s the only one of its kind in North America.

WILLIAM BRANGHAM: Dr. Thomas Kerr is an AIDS researcher who works at Dr. Montaner’s center and has done several published studies of InSite.

DR. THOMAS KERR: It is a place where people who inject illicit drugs, such as heroin and cocaine, can come with drugs that they’ve obtained on the street, and inject under the supervision of a nurse.

WILLIAM BRANGHAM: Every morning, the minute the doors open, a group of addicts file in – the first of more than 700 who come here every day to shoot up. All the paraphernalia is laid out, free for the taking.

Under the watchful eye of a team of specially trained nurses, addicts take a seat at one of a dozen different booths to do whatever drugs they’ve been able to buy on illegally the street.

InSite opened in 2003, granted an exemption by the then Liberal government of Canada to allow the use of illegal drugs in a facility partly funded by taxpayers.

On this morning, a woman named Jody allowed us to film her as she injected. She says she’s been an addict, on the streets for more than a decade… She’s been shooting up for so long that many of her veins are collapsed or covered with scars, and this morning, after repeated tries, she can’t find one that’ll work.

NURSE: You finding it?


WILLIAM BRANGHAM:  So…one of the InSite nurses comes over to help her. 

JODY: Right there—

NURSE: It’s itty bitty. It’s really tiny.

WILLIAM BRANGHAM: Ever since this place opened, critics have been trying to shut this facility down. The now Conservative national government says InSite enables drug use, not prevents it. It’s tried to close this facility, and prevent others from opening in Canada:

WILLIAM BRANGHAM: In 2005, Canadian Prime Minster Stephen Harper said, “We as a government will not use taxpayers’ money to fund drug use … that is not the strategy we will pursue.”

But in 2011, the Supreme Court of Canada ruled Insite can stay open.

InSite’s supporters argue that not only does the facility cut drug overdose deaths, reduce disorder in the area, and get more addicts into treatment programs… but they argue: its crucial in the campaign against H.I.V.

Addicts who come here can get tested for the disease and referred for treatment if they’re positive… they’re not sharing infected needles… and they’re in regular contact with nurses and medical staff who want to help them.

DR. THOMAS KERR: If this facility wasn’t there, these people would be injecting in alleyways, running from the police, and would continue to be disconnected from the health care system. But we’ve now found a mechanism to connect with these people, and provide them with much needed care.

WILLIAM BRANGHAM: (to Dr. Montaner)  I hear everything that you’re saying. And your critics would argue that having someone on site, a nurse who could even help someone find a vein, that is partly condoning and making it easier for them. What is your argument against that?

DR. JULIO MONTANER: You know, I used to think the same way as you just described, that all of this was enabling. You mean that I’m going to ask my junior staff, my residents to actually witness somebody injecting? Jeez, i’m out of my mind. Well, you know, the problem is that this is not about doing the right thing or the wrong thing. The addicted person is injecting. Let’s face the music–

WILLIAM BRANGHAM: They’re going to do it regardless.

DR. JULIO MONTANER: This is happening. This is happening in every single city in America. So by pretending that this is not happening, then you’re taking the same approach that the Prime Minister of my country is taking saying, “This shall not happen!” And so what? This is still happening, and he wants to criminalize them. And, you know what? He’s making the situation worse.

WILLIAM BRANGHAM: The data show their strategy has been working: by dramatically increasing the number of people being treated for H.I.V. in British Columbia, the number of new diagnoses of H.I.V. has been decreasing – cut by more than half.

Even as they’re looking harder for the disease, they’re finding less of it.

Dr. Montaner says, not only are they helping people, but they’re saving money. For every person who doesn’t contract H.I.V. in British Columbia, the government saves an estimated quarter-of-a-million dollars it doesn’t have to spend treating that person.

DR. JULIO MONTANER: Investing more on this strategy is cost saving. It’s not just cost effective. It’s cost averting.

WILLIAM BRANGHAM: So wait, you’re arguing that if you spend more money on treating active H.I.V.cases in the end you will save more money because you’re not adding new patients to the pool of infected people.

DR. JULIO MONTANER: William, I’m not arguing. I’m telling you. This is the way it is. And I don’t mean to be too provocative about it but the data is all in. You know, we have randomized clinical trials that now show that treating virtually stops transmission. We know that it stops disease progression. I mean, what else do we need? It’s obvious.

WILLIAM BRANGHAM: British Columbia’s success preventing the spread of H.I.V. has prompted Chinese health officials (who’re also grappling with twin epidemics of H.I.V. and IV-drug addiction) to commit to a nationwide “treatment as prevention” model, based on this same strategy.  The U.S. is doing two similar pilot studies, and “treatment as prevention” has now been adopted as the principal H.I.V. strategy by the World Health Organization, U.N. AIDS, and the International AIDS Society.