The view from New York
Positive Health Project Inc, 301 West 37th Street, New York 10018, USA.
The Positive Health Project started with an underground needle exchange in an area known as ‘Hell’s Kitchen’ in the upper West side of Manhattan. In July 1995 State authorisation was received to provide a needle exchange service from an office run by seven staff members and three volunteers. Since July 1995 about 4000 participants have been registered, 3000 of which are injectors. 70% are between the ages of 30 and 49 years old, and the majority are white males. When some people enrol they choose to be identified as transgender and many as female gender, so 20% are recorded as female transgender and the remainder are male.
Amongst the participants, the main drugs of choice are heroin, ‘crack’ and methadone. In the US methadone is viewed as just another drug and not medication because of the hostile environment provided by drug services. A person is no longer ‘clean’ or in treatment if they are being prescribed methadone, despite the fact it has been effective in stopping the person from injecting heroin. The methadone programmes in the US are not designed to deal with injecting drug behaviour or the use of other substances, although this use continues because the programmes are not holistic or comprehensive in addressing all the needs of users. Therefore more than 50% of participants are methadone patients who are also injecting other drugs. A small number of MDMA (ecstasy) and amphetamine users have recently started visiting the agency and there are also a significant number of steroid and hormone injectors. Therefore the agency does outreach work in gyms in both the gay and straight communities.
The project is the first in the US to offer an on-site hepatitis B vaccination for injecting drug users. The City and State departments would not help, so private funding was sought from the National Institute for Drug Abuse in order to conduct a small private study. The first national subway advertisement campaign was developed to promote the needle exchange. The first city bus campaign targets mothers of injecting drug users to recruit their drug using children into the programmes while they are using drugs, so that they can stay connected to supportive services. The agency serves the largest number of transgender individuals, and individuals injecting hormones, club drugs and steroids in New York City.
New York City is the largest city in the USA, and drug use and homelessness contribute to the largest number of new AIDS cases in the nation. An estimated 50% of all AIDS cases reported are directly attributed to injecting drug users. Of that number, 15-30% of New York’s 550,000 alcohol and other drug users who do not inject are HIV positive as well. It is important to identify these people. Services had been set up, but this was only secondary prevention as it was ‘late in the game’. Unfortunately when needle exchanges began, the people getting sterile syringes were already infected with Hepatitis B and C, and HIV.
Due to the location of the project near to Times Square bus terminal and the fashion centre, it became critical to develop strategies to address risky behaviours of individuals within certain sub-cultures, other than the injecting drug users that frequent the services on a daily basis. These sub-cultures include the S&M community and clubbers. The area contains several well-known topless bars and S&M clubs, so a club-based educational initiative was developed.
Clubs were provided with free condoms and educational materials on a monthly basis. This is actually very difficult because most are very resistant to having such materials in their clubs, and the project deals primarily with the heterosexual community. Drug users are criminalised in the US. Much support and unity is provided within the gay community but not the straight community. People are criminalised and ostracised, and if a person is an HIV positive drug user, others are doubly against them. It is very difficult to get involved in mainstream society, socialise and disclose one’s status to a potential partner in the heterosexual community. There is a high rate of rejection, anger and hostility because of the lack of unity and support, especially among heterosexual men and women.
Many HIV infected individuals questioned how their medication, infection and liver would be affected by taking club drugs. There is little information to provide good solid advice, so anecdotal information and basic tips were given on educational cards. Unfortunately, drug use and medication varies between individuals.
Due to the distribution of a series of ‘club drug’ cards, more clubbers joined the programme. In New York the basic price of ecstasy is US$20-25. It is common to combine ecstasy with LSD (this is known as ‘candy flipping’). Ecstasy with ketamine is called ‘devil’s dust’ and a mix of ecstasy, ketamine and ‘crystal’ (methamphetamine) is also consumed. Many of these combinations come prepared ready to sniff or inject.
Ketamine was often injected when it appeared on the New York streets in the 1970s, and it re-emerged in the 1980s and early 1990s as a popular drug in the gay community. It was digested in the pill form or sniffed, often in combination with stimulants and depressives. In the late 1990’s, ‘K’ was being used in the fashion industry by models and within club culture by people of all sexual orientations.
In spite of methamphetamine’s popularity in parts of the USA, it only surfaces in small pockets in New York City. ‘Crystal’ is popular in gay bath-houses and nightclubs. The combination of injecting and sexual risk puts individuals who use ‘crystal’ in danger of contracting hepatitis or HIV. Methamphetamine and cocaine injectors do so more frequently than heroin injectors and therefore require more sterile syringes on a daily basis. The average rate of injection per day of cocaine is about 8-10 times, as opposed to 4-5 times for heroin injectors.
Heroin use in New York City increased by 19% in the latter half of the 1990s, when heroin poured into the city through multiple sources. The main source was South America which had already established cocaine distribution. The Columbian Cartel realised that due to the lack of interest of cocaine in the 1980s because of the ‘crack’ epidemic in New York, they were losing revenue, so they began distributing heroin. The heroin coming to New York City has been extremely potent. Both injectors and ‘sniffers’ are 70% male and 30% female. Injectors are most often in their 30s and ‘snorters’ in their 20s to 30s.
In 1998, the mayor of New York shut all the topless bars and peep shows. This resulted in a major public health threat, as many women who were lap-dancing and stripping indoors were now forced onto the street to perform sex for money to supplement their once existing incomes. Many of these women started working in the S&M community with little information about performing safe S&M sex for novices. A focus group of experts and S&M club owners was organised to develop a safe S&M play-book. It listed common activities that people engaged in which could cause the contracting of infectious diseases. There is also a safe S&M manual with illustrations. It shows how to use condoms, sex toys, and latex gloves and provides information about infectious diseases.
In clubs there are t-shirts for sale and the proceeds go to support printing of educational materials that are not funded by the government. Pharmaceutical companies have also provided sufficient funding to develop a medical clinic for positive drug users. There are live safe sex demonstrations at different clubs. Once the demonstration is over, there is a table where volunteers provide information and education, for example, about working in the industry. To help with this, the support of a dominatrix was enlisted. The project works with established ‘dungeons’. People there are employees and individual contractors; these dungeons are not owned by ‘pimps’.
The Positive Health Project began by providing information for injecting drug users and has evolved and expanded to meet the needs of clubbers, S&M novices and other non-traditional sub-groups. The organisation is not sexual-orientation specific. Drug use is the common denominator. It understands the oppression that drug users live with, and being identified as criminals is a common bond which drives the building of a community