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.