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.
However, 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,” he said.
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 HIV, 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 Centre for Excellence in HIV/AIDS at St Paul’s Hospital in Vancouver 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 US 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 HIV. 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 UN’s 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 US. Much of the US 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 US federal government is conducting a three-year study of “test and treat” in the Bronx and Washington.
Because the medication can have unpleasant side effects, many US 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.
However, 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 Julio Montaner, director of the St Paul’s program and a former president of the International AIDS Society.