Diverse L.A. Drug Culture Threatens AIDS Outreach

Paul Rosas and Ronny Alvarado were out trawling for hypes in a wild pocket of downtown Los Angeles, carrying the message about AIDS and dirty needles to an urban prairie where an addict can get high for as little as 25 cents.

A man squatted on the curb, pumping heroin into a dappled arm. Nearby, another guided a skillet over an open fire, sauteing fish. People stood, slumped, against a chain-link fence, smoking cocaine. A woman flashed a leering grin at Alvarado.

Alvarado approached her. Had she heard about AIDS? Did she know the risks of dirty needles and unprotected sex? Could she use a few condoms? Nope, the woman retorted perfunctorily: She was a woman; she didn’t need one.

It’s not easy spreading the word about AIDS to intravenous drug users, now a prime target of the epidemic in Los Angeles County. The obstacles range from the life styles of many addicts to the complex culture of drug use in the nation’s second-largest city.

Geography is destiny in Los Angeles County: The sprawl of the region has shaped the drug market, and thus the AIDS epidemic. The county’s vastness has slowed the spread of AIDS among drug users, but it is making it difficult to reach those at greatest risk.

In East Coast cities like New York, intravenous drug use is centralized. Hundreds of addicts share needles daily in shooting galleries. As a result, more than half of New York City’s estimated 200,000 addicts are believed to be infected with the AIDS virus.

But that same density makes addicts easy to find. Public health workers routinely canvass the shooting galleries of cities such as New York and Newark. They have alerted addicts to the risk of AIDS and thus helped cut down on the sharing of contaminated needles.

In Los Angeles County, by contrast, there are few places, except Skid Row, where addicts congregate in large numbers. Drug use is spread out and tends to occur among small groups. Those who share needles tend to do so with a few friends, again and again.

For that reason, and the fact that the virus came late to the West Coast, the HIV infection rate among addicts here appears to have remained relatively low. Just 3% to 5% of the county’s estimated 80,000 to 120,000 intravenous drug users are infected, researchers believe.

Difficult to Reach

But that same diffuseness makes it difficult to reach users. They are scattered all over the county, only occasionally in pockets. Public-health workers find themselves forced to go door to door, scouring neighborhoods for an entree, hoping to happen upon a user.

Gangs, too, create obstacles to spreading the word. Their role in drug dealing creates risks for public health workers in some areas. Most outreach workers say they avoid working after dusk--the time when, some acknowledge, addicts are most accessible.

The county’s cultural mix makes their task even more complex. In some Latino communities, experts say addicts are inadvertently protected. Sheltered at home, rather than forced out, they are harder to reach. Their families may offer the only access.

“Intravenous drug use is happening all over,” said John L. Brown, who runs one of the five county-funded programs doing outreach with addicts. “But it manifests itself differently depending on culture, socioeconomic circumstances and even the neighborhood.

“So what really burns me is people from San Francisco and New York who say, ‘This is how you do street outreach,’ ” said Brown, director of the Los Angeles Centers for Alcohol and Drug Abuse. “It’s a much more complicated problem than that.”

But without effective outreach, experts believe infection inevitably will spread.

Many addicts here admit they still share needles and syringes. Those who use bleach to sterilize their equipment say they do so only intermittently. Many use condoms only rarely, yet condoms offer the only means of avoiding infection during sex.

One preliminary survey of 100 addicts in the San Fernando Valley found that needle-sharing remains common. Yet use of bleach to clean needles was relatively rare. Many of the users surveyed had multiple sex partners or frequented prostitutes, but few reported using condoms.

Even so, county-funded AIDS outreach workers remain barred by the Board of Supervisors from giving out condoms or bleach--an approach used widely elsewhere in the United States and abroad and credited with having helped change addicts’ behavior.

Among the homeless, activists believe drug use is rising. Among bisexual drug users, as many as 30% to 40% may be infected, researchers say. Some say there may also be a “microepidemic” of infection among the county’s prostitutes.

Others in the field see a rise in “dual addiction,” especially among Mexican-American addicts--the supplementing of a heroin habit with low-priced cocaine. They find that ominous: Dual addiction is especially risky and can be more difficult to treat.

Treatment--getting off drugs--is the ultimate form of AIDS “risk reduction.” But access to programs remains a problem in the county. The wait for admission to a subsidized program ranges from weeks to months. And the price often serves as a powerful deterrent.

“What makes people comfortable (ignoring the threat of AIDS for addicts) is the thought that if they wanted help, they could get it,” Brown said. “The reality is, if they all decided to kick, there’s nothing for them.”

How fast the AIDS virus is spreading among drug users is not entirely clear.

M. Douglas Anglin, who heads UCLA’s Drug Abuse Research Group, has studied rates of infection among addicts in treatment. His findings and others suggest that perhaps 2% were infected in 1986 and that the rate is still below 5%.

History of Drug Use

According to those studies, the virus appears to be “pooled” among male intravenous drug users with some history of homosexual activity, and among women intravenous drug users with some history of prostitution, Anglin said.

But some authorities have wondered whether the findings are reliable; that is, are addicts in treatment representative of addicts on the street? If men and women in treatment are less likely to be infected, the overall rate could be higher.

Anglin expressed confidence in the data. He said the county could have as much as a three- to-five-year grace period before the infection rate reaches that critical 6% to 8% level at which a rapid rise could be expected to occur.

Who are the drug users at risk in Los Angeles County? They are as diverse as the county itself. They include longshoremen, physicians, mothers, truck drivers and prostitutes, from San Pedro and East Los Angeles to the San Fernando Valley.

Their drugs of choice, and their using patterns, vary widely. Heroin remains dominant among Latino addicts, experts say. Cocaine has eclipsed heroin in the black community. Both those drugs, as well as methamphetamine and PCP, are widely used by Anglos.

The following sketches hint at the extraordinary diversity of drug use in Los Angeles County. While the people profiled have escaped infection, their stories illustrate the insidious power of addiction and a life style with potentially lethal consequences.

Take Cheryl, a 33-year-old mother of three from East Los Angeles, who asked not to be identified by her real name. Experts in drug addiction say her experience is common among women addicts: They fall into drug use on the heels of men.

Cheryl grew up in East Los Angeles, one of five children. Her father is a transit worker; one sister is an aspiring wrestler. She completed high school and, she says, she had little interest in drugs until she met the man who would become her second husband.

Ten years ago, faced with his growing addiction, Cheryl tried heroin. It was a reckless bid for attention; his drug use seemed to have shouldered her out of his life. She followed him into the bathroom where he was fixing, and insisted he inject her too.

For several years, Cheryl used only occasionally. But when her husband began dealing, they both began using more often. Emerging, horrified, from a two-week binge, she resolved to quit. But when she tried, she became violently, intolerably sick.

After her husband was sent to prison, Cheryl tried to control her habit. She held down a job and cared for her children. Then one day, an old connection showed up at the furniture warehouse where she worked. As a favor, he gave her some heroin to sell.

Cheryl began dealing, and used up the rest of the supply. From there, she slid into prostitution. She lost jobs, was sent to jail and was briefly cut off by her family. She remembers spending Christmas on her parents’ front porch, barred from the house.

“In this type of life, it’s nothing but an evil merry-go-round,” she said recently, in an interview at a methadone-maintenance program where she is enrolled. “It’s a vicious master, you go in a circle. It’s a never-ending circle.”

A similar tale comes from a man who asked to identify himself only as Doc, a 35-year-old psychologist living in Los Angeles County. He began using heroin while working as a drug-addiction researcher at a prominent Southern California university.

Intrigued by the world of the men and women he was interviewing in motel rooms throughout the state, Doc began experimenting with heroin. He compares his curiosity to that of an apple researcher who has never tasted the fruit: “I wanted to taste the apple.”

Two years ago, he began using more frequently, driving from his home in the San Fernando Valley to the heart of East Los Angeles to score. Even after his wife overdosed, and with a 10-month-old child at home, Doc found himself powerless to quit.

Rebuilding His Life

Early last year, he entered a residential treatment program. His wife had left him, taking their child. He was having difficulty holding down jobs. He has remained clean ever since, he says, and is in the process of piecing together his life.

“It will kill you,” said Doc, who, like Cheryl, escaped without becoming infected with the human immuno-deficiency virus, which causes AIDS. “If you’re lucky, it will only kill you psychologically. So you have a chance for another life.”

Contrary to stereotypes, the life of an addict can be cruelly demanding--in ways that make it difficult to get the AIDS message across. It is a life in which immediate needs eclipse longer-term goals, in which caution is not a top priority.

Many addicts, for example, rise before dawn to get high. Then they turn immediately to the urgent business of securing their next fix--a task that may entail shoplifting, theft, prostitution, moving hot goods, wheeling and dealing, or selling drugs.

Paul Rosas, a former addict, supported his habit for a time by ripping off other addicts, peddling crack vials filled with soap or peanuts. He became so hated on the streets that, he recalls, he could only come out at night, his head covered by a hood.

Personal hygiene, even eating, often fall by the wayside. Many addicts have chronic health problems, from tooth decay to liver and lung disease. Suspicious of institutions, and sometimes mistreated by doctors, many shy away from medical clinics.

“There’s no reality outside of the next two to three hours,” said Barbara Casucci, director of Cornerstone Health Services, a methadone program in Pico Rivera. “There’s no long-term planning, no looking forward to Christmas or Easter. It’s just how are you going to get through the next two or three hours.”

For that reason, among others, AIDS outreach workers have a hard job. Just getting the attention of an addict on the street is no small feat. What should be a 20-minute presentation on AIDS and how to avoid it ends up abbreviated into a fleeting, one-minute rap.

Then there’s the problem of vocabulary--both language and lingo. In some communities, adults find it difficult to talk about sex. On Skid Row, phrases like “intravenous drug user” are jettisoned in favor of more graphic alternatives such as, “D’you slam?”

Bleach and condoms, many outreach workers say, would make their job easier. They would catch addicts’ attention and give them something for their time. They would also serve as invaluable tools in explaining precisely how to protect oneself against AIDS.

In the absence of those tools, outreach workers fall back on the power of repetition. By being visible on the streets, and offering repeated reminders, they hope they will eventually get across their point.

‘Ongoing Process’

“These people are busy. They’re trying to get money, trying to get paid, trying to get high,” said Rosas, who does outreach along Skid Row for Brown’s agency. “It’s an ongoing process. No one’s going to learn this in one shot.”

One afternoon this month, Rosas threaded his way down the crowded sidewalks of downtown Los Angeles making his regular rounds--past the park where addicts gather, past the curbside cardboard dormitories, past hotels where transvestites co-habit, four to a room.

Traveling with him was Ronny Alvarado, a 20-year-old former addict who works with the Homeless Outreach Project, a Skid Row agency that, among other things, accompanies AIDS outreach workers and makes available free condoms and bleach.

(That agency’s funding comes from the city, not the county. So it is not bound by the county supervisors’ ban on distributing condoms and bleach.)

The two men loped through the streets, greeting familiar faces, cajoling passers-by, scanning arms and necks for tracks. They offered pamphlets, condoms, information. Some people listened, others kept walking. A few protested, in mock offense, they were happily married.

“You can’t push yourself on nobody out here,” explained Rosas, a 225-pound man with a buzz cut who put in his own time on the New York City streets. “You got to know when to step, when to go. If you don’t, you may end up dead where you stand.”

Over the hills in the San Fernando Valley, three AIDS outreach workers from an agency called El Proyecto del Barrio were working Van Nuys, moving methodically from house to house on a run-down street where residents said drug deals regularly go down.

There, the obstacles are different. Drug use goes on mostly behind closed doors. “The biggest problem is identifying where these people are,” said John Paloma, 36, one of the outreach workers. “Then, when you’ve found them, it’s convincing them we’re not the police.”

The outreach workers watch for tell-tale signs: Cars pulling up outside certain houses, visitors returning one time too often. They ask questions: Any signs of drug use in the neighborhood? They hope their message makes its way into the right hands.

In Paloma’s experience, most addicts now know about bleach. Whether they use it, he cannot be certain. Most say they no longer share equipment, but Paloma remembers when he was using: Everyone shared because no one wanted to be caught carrying an outfit.

For that reason, Paloma used to stash equipment around town--for example, high atop public toilets. Now, working the parks, he occasionally runs a hand through those familiar crannies. When he comes upon a syringe, he leaves a pamphlet.

Are outreach programs working? In Los Angeles County, it is difficult to know. Most programs have been operating little more than a year. And there has been, so far, no comprehensive study assessing whether addicts’ practices have changed.

El Proyecto del Barrio, the agency that covers the San Fernando Valley, recently completed a survey of 100 intravenous drug users. The findings are preliminary and the study sample small, but the results indicate there is more work to be done.

Sharing Needles

Nearly 75% of those surveyed said they share needles, at least occasionally. More than half said they clean their equipment with water--which is ineffective. Only one third said they cleaned their equipment with bleach and water, the only proven method.

As for sex, 33% said they had multiple partners. Nearly one in five said they frequented prostitutes. Yet most never use condoms and only 30% use them sometimes. Four people said they used them all the time.

“Changing attitudes and behavior takes time,” said Kimberly Green, outreach project coordinator for El Proyecto del Barrio. “Eventually, they hit bottom. Then they become more vulnerable.”

Those spreading the word say they have no grandiose expectations.

“We’re not out to solve the problem of AIDS,” said Mike Neely, who runs the Homeless Outreach Project out of a storefront in the heart of Skid Row. “What we’re trying to do is keep the person in front of us alive long enough to deal with their life.

“If we can keep the person alive ‘til they’re ready to hear the message, maybe they’ll be OK,” said Neely. “If they die first, all we’ve got is a dead drug addict.”