The woman was a crack user, engaged in the sex trade and living on the streets of San Salvador. When Julia Lechuga and other public health advocates first met her, she was seeking respite at a soup kitchen in the troubled city, where violence and illicit drug use was rampant.
The woman decided to take an HIV test offered by Project Encuentro, a five-year international project that Lechuga was helping to develop and implement to reduce risky behaviors among drug users, and thus, help curtail the spread of infectious diseases in El Salvador's capital city.
"We first established trust," says Lechuga, in explaining how the woman, in her 30s, had come to take the test after meeting project leaders at the soup kitchen. "We were there every day."
Learning she was "negative," the woman then opted to take part in an intensive two-day program that Project Encuentro also offered so that she could learn how to further protect herself, such as how to negotiate condom use with a partner, and to fortify her self-worth.
"We also cover human rights," says Lechuga, assistant professor of education and health, medicine and society. "The intervention is trying to give humanity back to this person who lost it somewhere."
Eventually, the woman's sex work stopped. She found a place to live and began reconciling with her four children. When she came back a year later to thank the project leaders, she carried the "intervention" manual she had been given, which also contained her reflections on her situation.
"Her story was powerful," says Lechuga. "She came back and said, 'When I'm feeling down, when I need something, I open [the manual] up and start reflecting again on why this is important.'"
Project Encuentro's preliminary findings show the woman's story was not an anomaly. Participating high-risk drug users became better at protecting themselves against HIV—their attitudes toward condom use improved, and those with multiple sex partners increasingly used condoms during sex, Lechuga says. The mean number of days that participants reported consuming crack cocaine dropped.
Also, using social network methodologies, project leaders saw a boost in HIV testing rates in the three community sites involved in the project. In a 12-month peer-referral period, in which participants were asked to refer others with whom they had used drugs or engaged in sex, 582 community members received HIV testing. That compared to 265 community members who received testing during a 12-month self-referral period.
"Once somebody knows their HIV status, they're more likely to change their behavior, and we're able to link them into care," she says. "The sooner you are diagnosed, the sooner you can get on medications. Your level of infectiousness is going to be reduced.
"Research suggests it does help—the harm reduction approach, the idea that you will help individuals who have self-efficacy to, for example, protect themselves when there are situations of risk."
Given the gains in San Salvador, Lechuga felt the intervention could be adapted to target drug users living along the U.S.-Mexico border, where heroin use is prevalent, in an attempt to reduce the spread of infectious diseases there. Using the preliminary findings from her work in San Salvador, she successfully sought funding from the National Institutes of Health.
Now in the first year of the five-year, $2.1 million study and outreach program, Lechuga is working with two community-based organizations—the Alliance of Border Collaboratives in El Paso, Texas, and Programa Compañeros in Ciudad Juárez, Mexico.
As in San Salvador, Project Encuentro will have three components: social network HIV testing for drug users, peer network intervention administered by trained peer leaders to small networks of drug users, and community events that will address topics perceived as important to reducing drug users' HIV risk.
The project aims to help the two organizations build their capacity to tackle the public health problem in the border communities.
"We are using a social network approach and these organizations are new to this approach," Lechuga says. "This is an approach that is evidence-based, and we are working to get them to implement these strategies, so that when the grant [money] is gone, the learning and the experience stays with them."
Lechuga was born and raised in a bilingual household in El Paso. She said her frustration in not knowing how to help family members who were substance abusers, as well as her deep love of her Latino community, led her to her research and advocacy. "It's very personal," she says.
She also recognizes the stigma around substance abuse and mental illness. "Trying to reduce that stigma as well is something that motivates me," she says.
The border cities of El Paso and Ciudad Juárez form a culturally distinct area of about 2.2 million people. Poverty is high. Each year, about 5 million people cross the bridges connecting the two cities, with many making their way, back-and-forth, to home and school and work.
"When you talk about illnesses and infectious diseases, this is really a place where the illness itself is crossing boundaries," she says.
There are attempts, too, to move drugs through the border crossing, the second busiest international point of entry into the United States. When those attempts fail, she says, a lot of the drugs wind up in the communities, leading to a high prevalence of substance abuse among mostly men, but also women.
"There's a lot of heroin use, and having access to clean syringes is a harm-reduction approach because that is going to prevent contagion and the spread of illness," she says. (Such distribution would only be possible in Ciudad Juárez, however, since it's illegal to distribute syringes in Texas.) "Another harm-reduction approach is distributing condoms to individuals who are at risk but also teaching them skills so that they can negotiate, for example, condom use with a partner."
Though crime has dropped in recent years, Ciudad Juárez suffered an unprecedented period of violence with drug cartels from 2008 to 2012. Murders were up. So were kidnappings. The crime wave also impacted public health. Epidemiological research conducted during the peak of the violence indicated that more people were engaging in sex work, that drug users were doing less to protect themselves against HIV and that police crackdowns were resulting in riskier behaviors among drug users.
As an example, Lechuga referenced a study of injection drug users in which half reported being arrested for possessing a syringe. Those arrested were twice as likely to report that they were sharing syringes and injecting in the street, according to the study. Participants also reported experiencing painful heroin withdrawal while jailed, then sharing syringes and injecting quickly after being released.
"We think of violence in terms of the crime problem, and we consider having more police officers or arresting more people," Lechuga says. "We don't think of the public health aspects of this."
In addition, many of the community centers in Ciudad Juárez that treated substance abuse and treated and prevented the spread of infectious diseases have closed—a result of people's attitudes toward drug users and harm-reduction approaches having soured, she says.
"It was like society took a step back," Lechuga says. "Without the resources and these approaches, we could be at the brink of an HIV epidemic in this area."
Those who are highly addicted tend to be alienated from their families and tend to develop relationships with those in similar situations, Lechuga says. As in San Salvador, the team will try to affect social norms so that high-risk drug users become better at protecting themselves against the other health ills.
"The underlying condition is the addiction itself, but many people are not ready to face their addiction," she says. "It's only until they are ready that they can take care of that, but they can do other things to help prevent something very bad from happening to them."
One man who had tested positive for HIV in San Salvador had been in shock at his status. Though project leaders made every effort to take him to the ministry of health for a confirmatory test and begin treatments, he left without getting additional help. However, a year later, Lechuga says, he returned.
"He said, 'I'm back, because when you told me my result, the only thing I wanted was to die. So I went out and started using more drugs, drinking more. And one of those days that I was on the streets, my head spinning, I just kept remembering the words you said to me: You deserve to live. You're a human being. Now I'm ready.' He followed up with the confirmatory test, treatment and interventions," she says.
"When I hear positive stories, it's what keeps me going."
In El Paso and Ciudad Juárez, Lechuga and her community partners have been conducting in-depth interviews and surveys with drug users to better understand living conditions and demographics. Where do people use drugs—at crack houses, in abandoned buildings, in their homes? Under what circumstances do they cross the border to use drugs? How often do they have sex, and with how many partners? What are some of the barriers they face in accessing health care? Do they have access to condoms and clean syringes?
Outreach workers will map the areas where people congregate to use drugs. "We want to get to the places where people will benefit the most," she says.
Next, the team will confer with its community advisory board members to decide how best to adapt the interventions used in San Salvador, where crack, not heroin, was the predominant drug.
"We're going to bring our findings to them, and we're going to say, 'Ok, this is our population. We have this intervention. What are we going to do?' And we're going to decide. Do we keep some activities? Do we modify some? What do we think will be the most successful?"
Education, though, will be key, so that drug users can learn about the effects of drugs on their brain and come to understand that addiction is not a moral failing but an illness, Lechuga says. Rapid HIV testing will be another harm-reduction strategy there.
"If medicine has advanced this far where we have HIV tests, where we have medication, but it's not getting to the people who need it most because of their social marginalization, that's a fundamental injustice. It's something that we can fix, and it's just wrong not to do it."
This story appears as "Social Justice and Public Health" in the 2017 Lehigh Research Review.