Yadis, a 40-year-old homeless drug user in San Juan who asks that her last name be withheld, says the community-based group Iniciativa Communitaria has been “a blessing” for her. She started using drugs when she was 14 and has suffered a variety of mental illnesses including depression. Iniciativa Communitaria offered her a warm bed, shower, detox for her cocaine habit and a supportive environment. “I have a lot of good motivation to [quit],” she says. “The drugs are worse now. They have more chemicals, more poison, and people are getting sicker. Every time it’s harder to get the money, and you want more. They make it that way.”
Injection-drug use is the leading cause of HIV infection in Puerto Rico. Recent studies have found that more than 20 percent of injection-drug users (IDUs) there are living with the virus, and approximately half of the new infections stem from injection-drug use. And for women like Yadis who aren’t injection-drug users, the combination of homelessness and addiction puts them at high risk for engaging in activities that make them vulnerable to HIV.
Created by renowned doctor Jose Vargas Vidot, Iniciativa Communitaria works to tackle the problem of drug use and other factors that play a role in HIV risk. The organization, founded in 1990, assists homeless individuals, sex workers, drug users, high school dropouts and other people at high risk for contracting HIV. In recent years, Dr. Vargas Vidot has been forced to shift his personnel after budget cuts, switching full-time workers to part-time and relying heavily on the hard work of volunteers. A program directed at sex workers took the hardest hit—in 2007, the Puerto Rican Health Department slashed funding, decreasing the number of women it served from about 1,775 to around 600.
Vargas Vidot says the stigma around sex work and injection-drug use fuels the city’s reluctance to fund CBOs like Iniciativa Communitaria. “Many doctors think drug users are low-compliance people [and don’t want to waste] medications on them if they will not use them,” he says. “But that’s not [our] experience.” He adds that it has been hard to reach drug users with needle-exchange and other services because users are often moved from abandoned buildings, where they gather in the city, to remote mountainous areas. José Colón agrees: “People in Puerto Rico are begging for money because they’re IDUs, and they’re treated like criminals when they’re sick and they need medications. They’re dropping homeless people off out of the municipality, far away. How do you get back home? How do you get back to your support group?”
I spent one day as a tourist, walking around the streets of Old San Juan, visiting San Jose Church, one of the oldest churches in the Western Hemisphere, and La Fortaleza, the governor’s mansion. I passed a family of four, arms full of shopping bags, and I heard the mother ask her daughter for the time. “It’s 7 o’clock,” the girl responded. “But that’s U.S. time.”
The comment reflects the cultural and national dislocation that many Puerto Ricans experience, feeling not quite American, yet not quite foreign, either. Some activists feel that a desire to uphold Puerto Rico’s image as an exotic getaway from the States—lush beaches, luxury hotels—keeps local and federal officials from acknowledging that the Puerto Rican AIDS crisis is also a U.S. AIDS crisis. Many activists, moreover, feel that the separatist nature of the territory affects not only HIV/AIDS, but also numerous factors that lead to infection. “One of our major problems in Puerto Rico is that we are not a territory, we’re a colony,” says Lopez-Fontanez. “So if things go bad in the U.S., the impact in Puerto Rico will be tripled. We have to import almost everything [here]. The school system is also in shambles. [And] when you talk about the way the U.S. economy is right now...it’s bad over there, but triple that [for] us here.”
The most widely proposed solution for tackling the problem of delayed reimbursements and unused federal AIDS funding in Puerto Rico is a third party that would take the funds from HRSA and deliver them directly to the CBOs. Such a plan would mean acknowledging a problem within the San Juan Department of Health and Puerto Rico Department of Health, an idea neither office is quick to embrace.
The Puerto Rico Department of Health maintains that it has strived to improve care in recent years for people living with HIV/AIDS. “The government has aggressively improved responsiveness to patients, pharmaceutical providers and organizations that support treatment and prevention efforts in Puerto Rico,” Jorge Delgado-Rivas, of the department’s HIV/AIDS program, told POZ. Delgado-Rivas adds that a majority of the department’s “community partners” are reimbursed for services within 30 days and that new department initiatives—such as a pharmacy benefits manager, who will monitor and ensure treatment for ADAP-eligible patients—show the health department’s devotion to battling the island’s epidemic. “The government’s commitment to proactively addressing HIV/AIDS in Puerto Rico has never been stronger,” he says, citing added staffing to the department’s HIV/AIDS team.
Delgado-Rivas does agree that the island’s territorial status affects its HIV/AIDS treatment. “Puerto Rico would qualify for substantial federal investment if Medicaid funding rules were applied in equitable fashion to Puerto Rico,” he says. (It has a tighter Medicaid funding cap than that of the States.) “While Puerto Rico’s HIV/AIDS prevalence and infection rates are low compared to its Caribbean neighbors, they are still too high in comparison to the States.”
Third-party plans have been launched in places like the U.S. Virgin Islands and New York. The head of HIV/AIDS at HRSA, Doug Morgan, says the U.S. government will start a third-party plan only if Puerto Rico’s local governments accept it. “Essentially they would have to agree: The grantee would enter into a contract,” he says, adding that HRSA is “trying to do the best we can to work [with them], and we hope some of them have begun to make some changes.”
Through all the discouragement, there has been one source of hope—the indomitable spirit of those fighting for Puerto Ricans living with HIV. This summer, members of New York City–based advocacy group Housing Works visited the island to support an activist in the eastern city of Fajardo. Gloria Gonzalez, a former drug user, is working there to start a community-based clinic for people at high risk for HIV, including homeless injection-drug users. But Housing Works president and CEO Charles King says his organization’s role is not one of stepping in and “saving the day.” Adds King, “I think [it is] dangerous for people to think they’re going to go in and help like they know it all; [that would] do a terrible disservice to the people that are working very hard there and the people living with HIV/AIDS. [But] I think we have an absolute obligation to be working and demanding that the federal government take appropriate action.”
Still, as we come to the conclusion of yet another article about the crisis, one in which activists have again spoken out and government officials have again pledged to work to end the problem, the questions remain: Who does need to step in and save the day? Who, ultimately, is responsible for saving lives in Puerto Rico? And, when will they start?