The middle-aged man always wears the same clothes to work: a black suit, sleek black shoes and a white shirt, with the top two buttons undone. Four golden rings, two on each hand, gleam as he explains his routine. When he dons his large brown sunglasses and smiles, his freshly-shaved face exudes a strong whiff of perfume. He has the air of a high-caliber businessman.

But his work in Prague is anything but normal.

Every day, Horvat meets drug users in the capital city’s cobbled lanes and alleys. Most of them are Roma. He wants to help them to kick the habit, but it’s a complex, and sometimes hopeless, task. At the same time, he gives them new needles and syringes in exchange for their used ones. If they’re going to inject drugs, the equipment they use to give themselves their daily fixes must at least be clean, is Horvat’s attitude.

EPIDEMIC WAITING TO HAPPEN?

The medical basis of needle exchange is that it drastically lowers the chances of contracting HIV through drug use, because sharing needles that are contaminated with HIV is one of the surest ways to become infected with the AIDS virus.

“I am from the streets myself. I am a Gypsy and I feel at home here, though I’ve never used drugs myself,” he mutters. “But I know what drugs mean.”

Horvat has first-hand experience of the horrors of drug abuse: he and his family struggled for many years to help his brother fight addiction. Eventually, they were successful and his brother abandoned drugs. But the helper in Horvat had been awakened by his experience.

“When I saw an ad in the paper saying, ‘We are looking for Romani street workers,’ I grabbed it,” he says. “I knew my job would be important.”

Horvat is one of two street workers from the Romani organization Romodrom, which reaches out to drug users in this community in Prague. He believes drug use among Roma is a massive problem that is being underestimated.

There are approximately 5,000 drug users in the city who’ve registered with Romodrom. At least 40 percent of them are Roma, the organization believes – even though Roma make up only an estimated 2 percent of the 10 million people in the Czech Republic. Last year, Romodrom had contact with about 6,000 clients and distributed 25,000 clean needles.

About 140 Roma seek the center’s help every day, Horvat says.

Romodrom has a special program devoted to drug users aimed at preventing their infection with various transmissible agents, such as hepatitis and HIV.

In the Czech Republic in 2004, almost 9 percent of people with HIV became infected as a result of injecting drugs, according to The United Nations AIDS agency. No one, however, knows how many of those people were Roma, as Czech law prevents health data from being collected on the basis of ethnicity.

A 2004 UN Development Program study on Roma and HIV/AIDS found a dramatic increase of HIV infection rates in Central Europe. According to the study, HIV/AIDS affects groups that are prone to high poverty rates, high mobility, and limited social services to a greater extent. Although the total number of people living with HIV in the Czech Republic is low, about 0.1 percent of the population according to a 2005 estimate by UNAIDS, the Roma seem to possess all the traits that make people vulnerable to contracting HIV: They are far more likely to be poor, women are generally disempowered, parents and children rarely talk about sexual matters, alcohol abuse is high, and condom use is extremely low.

LIFE ON THE WRONG SIDE OF THE TRACKS

Photo: Petru Zoltan

Housing where Roma live in the Czech Republic.

What makes a dire situation even worse is that many Roma do not possess identification documents, aid workers say, so they therefore have limited access to health care. They’re therefore less able to receive preventive information on the virus or get tested for it. And those who do have access to health care and information have a deep distrust of the state health care system – especially Romani women, who in the past were often sterilized without their consent as a result of government fears of their high birth rate.

Very little formal data exists about the health and drug problems among Czech Roma – especially with regard to HIV. And this void increases the potency of an already dangerous situation.

A few kilometers outside Prague, a narrow path along a train track winds its way up a hill past a desolate playground. The smooth, asphalt pathway leads past a row of small houses until the pavement suddenly stops, as does any indication of development. Two rundown buildings, surrounded by pools of black mud, loom into view, at a distance from the other houses. A large white dog lies in front of one of the many cracked doors. The glass of many windows is broken and exposed electrical cables snake their way across the peeling walls. Each building has two floors – and families staying on the top floor don’t have toilets or bathrooms in their apartments. They share dirty, bad smelling communal bathrooms without hot water.

This is where the Roma live – in isolated enclaves, “on the wrong side of the tracks” in the small town of Libcice nad Vltavou.

Of the 150 Roma living here, only eight of 80 adults have ever held a job. The other 70 Roma in this part of town are children.

Unemployment and poverty seem to follow the Roma wherever they go. A 2005 study by the Research Institute for Labor and Social Affairs in Prague estimated the jobless rate among Roma at 70 percent. Most Roma who do find jobs are limited to unskilled employment. As a result, most Czech Roma rely on state social payments either directly or through family members.

INTEGRATION THROUGH DRUGS

Photo: Petru Zoltan

Apartment building where Roma live in the Czech Republic.

Jozef, a sturdy man in his early thirties, is one of the few in the village with a job. He has better furniture and food in his house than most of his fellows. But he’s angry and paces up and down. He wants to talk about the drug problem in his community. His father, however, intervenes to stop him from speaking. Jozef’s father is worried that his family could suffer repercussions among their peers if they speak out about drug use.

"Things can happen to you here," Jozef’s father mutters. He fears that people will start calling them traitors and troublemakers. By speaking, you can get your loved ones into trouble, the Roma say.

“The Roma see drug use as a way of getting integrated into the larger society,” says Ivan Vesely, who heads Dzeno, one of the largest Roma advocacy groups in Prague. “It’s harder for us to integrate through education and employment – there’s so much discrimination against Roma in these fields. By taking drugs, the Roma imitate non-Romas and their lifestyle," he says.

Roma living in cities usually take heroin and pervitin, a locally-made amphetamine, Horvat says. In rural areas, the drugs of choice are inhaled toluene, a cheap paint thinner, and Kanagon glue, which is chewed mostly by children, according to Marta Hudeckova, director of Manusa (People), a Romani women’s organization.

Horvat says the situation is so serious that many “desperate mothers report their children to the police for false robbery just to get them jailed for a year or two” so that they can get off drugs, in the belief that drugs are less accessible behind bars.

“Children as young as 12 and 13 have problems with addiction,” Horvat says. “But they can’t be helped – it’s against the law for NGOs to work with these children because they are under 15 and must have a legal representative.”

NGOs like Romodrom and Manusha have responded by running information campaigns at schools to draw attention to the drug problem among Romani children. For young children they do dramatic skits that explain what to do when someone offers them drugs, or how to tell their parents that they are on drugs.

“We want to really change something for our people,” says Marie Gailova, Romodrom’s chairperson. “We work 13 to 14 hours a day and help 300 Roma clients daily in the five regions where we work.”

Not talking openly about drug use in communities is not the only challenge the Roma face. It’s equally unacceptable to talk about sex.

“WE DON'T USE THOSE FUNNY THINGS”

Jozef’s partner, Gabriela, 29, tightly clutches their two-year-old son in her arms. It’s clear that he’s her treasure.

Jozef and Gabriela are not married. They don’t see the need. Theirs is a relationship based on trust – a relationship that strictly excludes discussions about sex or HIV.

“I have never used a condom, because I can trust my partner,” Gabriela says. “I don’t know if my friends use condoms, because we don’t talk about sex. But I don’t think they do.”

Neither Gabriela nor Jozef has ever taken an HIV test.

A recent study by the Wisconsin Medical College in the United States found that condom use among the Roma in Central and Eastern Europe was rare and mostly associated with contraception. Starting in the 1950s, Czechoslovak authorities employed sterilization, sometimes accompanied by cash payments, to slow the growth of the Romani population. Several Romani women who claim they were sterilized without informed consent have sued the Czech and Slovak governments.

Once women were sterilized they often refused to use condoms, as they perceived them to protect against pregnancy but not against sexually transmitted diseases. The study also showed that Romani men have far greater sexual freedom before and during marriage than women. They engage in unprotected sexual practices with outsiders and have much more power in relationships than women. The study found that Roma in Europe are aware of HIV, but don’t feel personally threatened by it.

“Sex is something everyone does, but nobody talks about,” says Lida Polackova, a Romani adviser at the social affairs department in the city government of Ostrava, an industrial city in the eastern Czech Republic where many Roma live. “Almost no one in Roma communities knows whether they’re HIV-positive or negative. And premarital sex is completely natural, starting at 13 or 15 years of age.”

Back in Libcice nad Vltavou, two teenage girls in tight jeans are coyly whispering about sex as they smoke outside one of the apartment buildings in the Romani neighborhood. They’re giggling and making jokes about it. Both have had sex with their 16- and 18-year-boyfriends. They blush when asked about condoms. “We don’t use those funny things," one says. “Condoms are not for us.”

A long train lurches past on the nearby track, making talk impossible even if there were anyone the girls outside. There’s nothing around the two buildings, no greenery, no people, and no sign of hope. Instead of place where dozens of people live, the apartments could easily be mistaken for train station storage buildings.

HIV prevention for the Roma can’t be addressed in isolation, Horvat says.

Improved access to health care, education, and employment is part of the solution, nearly everyone agrees, from street workers to high-powered experts from the European Union and the World Bank. None of the many problems facing Roma in places like Libcice can be addressed on its own. Horvat and others who know the Romani community believe that it's unrealistic to expect Roma to quit drugs and in so doing cut their vulnerability to HIV/AIDS when drugs offer their only escape from the harsh reality of the poverty, discrimination, and segregation they face in everyday life.

And when many Roma continue to live in rundown housing with inadequate hygiene, it’s too much to expect them to care about safer sex, even if they are informed about sexually transmitted disease.

In his Prague office, a restless Horvat fidgets as he analyzes strategies to help his people.

“For me the best moment in my job would be when I see that there are hardly any drug users or HIV infections anymore,” he says. “When services like mine are not needed anymore and everyone has access to services that can help them.”

He sighs, and returns to his work. Redundancy still seems a very long way away for people like Milan Horvat.

Mia Malan is the Internews Senior Health Journalism Adviser in Washington, D.C. Jayalakshmi Shreedhar is the Internews Project Director of the Local Voices Project in India.

Lucia Curejova, Maria Husova, Petrana Puncheva, and Petru Zoltan contributed to this article, which was produced during a TOL health reporting seminar. Susan Mathew, Internews Health Program Associate, also contributed to this article.