HIV infection and AIDS among drug injectors at Rio de Janeiro: perspectives and unanswered questions
Patterns of HIV increase among drug injectors
Seroprevalence among drug injectors by year
Secondary spread from drug injectors to their sexual partners and offspring
Drug injection and HIV risk at Rio de Janeiro
Research needs and activities
Public health Intervention
Author: E. S. LIMA , F. I. BASTOS , P. R. TELLES, S. R. FRIEDMAN
Pages: 107 to 115
Creation Date: 1993/01/01
HIV infection and AIDS among drug injectors at Rio de Janeiro: perspectives and unanswered questionsE. S. LIMA
F. I. BASTOS
P. R. TELLES
Nucleo de Estudos e Psquisas em Atencao ao Uso de Drogas, Universiy of Rio de Janeiro, Brazil S. R. FRIEDMAN National Development and Research Institutes, Inc., New York, New York, United States of America
Data from various countries show considerable variation in the rate of spread of the human immunodeficiency virus (HIV) among drug injectors. Although further research is needed to predict the rate of increase of seroprevalence at Rio de Janeiro, preliminary data confirm the presence of the virus, with a seroprevalence of about 33 per cent in 1990. Issues arising from research into the probable determinants of viral spread among the thousands of drug injectors in the city are outlined in the present paper. Even before the research is completed, however, it is clear that interventions are needed to reduce further viral transmission both among drug injectors and from them to their sexual partners and offspring. Efforts should be made to prevent the population at risk from initiating the practice of drug injection, and to promote a major expansion in drug abuse treatment facilities. Drug injectors should also be encouraged to reduce the risk of their becoming infected or passing on the virus to others, through educational outreach, through the distribution of supplies that facilitate risk reduction (bleach, syringes, condoms), and through innovative approaches to behaviour change.
More than 11,000 persons have been diagnosed as having AIDS in Brazil, and over 1,700 at Rio de Janeiro, of whom 82 were heterosexual drug injectors and 16 were homosexual or bisexual drug injectors  . The percentage of cases involving drug injectors increased from the 4 per cent recorded between 1982 and 1984 to the current figure of approximately 7 per cent  . The present paper contains data on international experience and local patterns of drug use that tend to suggest a further expansion in the number and percentage of cases of drug injecting. Gaps in the knowledge required to make adequate predictions are discussed, and activities designed to avert large-scale increases in infection pending further research are considered.
Previous research findings indicate that approximately 4 per cent of drug injectors in drug abuse treatment at Nucleo de Estudos e Pesquisas em Atencao ao Uso de Drogas, Universidade do Estado do Rio de Janeiro(NEPAD/UERJ) were infected with HIV in 1986  . Additional data were collected for 36 subjects interviewed in both treatment centres and "street" settings in 1990; 12 of them were infected, for a seroprevalence of 33 per cent. Although the number of subjects in the samples was small, the differences are statistically significant at the .05 level.
It is difficult to assess what the future of seroprevalence will be at Rio de Janeiro. Some of the possible patterns appear in the figure, which gives data on seroprevalence among drug injectors over time for a number of other cities. As reflected in the figure, seroprevalence can increase extremely rapidly, as was the case at Bangkok, where approximately one third of an estimated 100,000 or more drug injectors became infected within less than a year. On the other hand, an increase from about 20 per cent to 50 per cent can take several years, and then level off, as in the southern Manhattan district of New York City; or it can stabilize at 20 per cent or below, as it seems to have done at San Francisco [4, 5] .
The levelling-off of seroprevalence in New York City was accompanied by, and may have been in part due to, considerable risk-reducing behavioural change by drug injectors [4, 6] . Similarly, risk reduction involving both the use of household bleach as a decontaminant for syringes (as a result of an outreach campaign with a major focus on bleach use) and a decrease in the sharing of syringes among injectors also occurred at San Francisco  , [7-10] .
In New York City, where there are an estimated 100,000 infected drug injectors out of a total population of 6 to 7 million, there have been a total of over 27,000 AIDS cases  . Of these, approximately 900 have involved heterosexual transmission to a person who does not inject drugs, and previous research indicates that over 80 per cent of the heterosexual transmission cases involve HIV transmission from a drug injector  The data also show that 554 cases have involved perinatal transmission; of these, 365 were infected by a drug-injecting mother, and 129 by a mother who had a drug-injecting sexual partner. Thus, 89 per cent of the perinatal transmission cases can be traced back to a drug injector who was infected.
Data from Rio de Janeiro about the extent to which heterosexual and perinatal transmission can be traced to drug injectors have not yet been studied. Recent data show that the number of confirmed AIDS cases in subjects under the age of 15 was 43 for the State of Rio de Janeiro. Among these cases, 12 involved perinatal transmission, 5 (42 per cent) being children with a drug-injecting father or mother  .
Unfortunately, research on drug use at Rio de Janeiro began relatively recently, and is still quite limited. Research focused on drug injectors is even rarer. Furthermore, most existing research has focused either on drug treatment samples [3, 14] or on surveys of drug use among selected populations such as high-school students  . The samples, however, may not have been representative, and, in particular, there may have been an insufficient sampling of youth who are not in school; of favelapopulations, particularly among those residents of favelaswho are involved in delinquency; of convicts; and of people who live in street settings far from drug abuse treatment facilities.
Research and clinical observation to date present a disturbing pattern. In a random sample of over 2,000 high-school students surveyed in 1989, over 3 per cent reported that they had used cocaine at some time in their lives, and almost I per cent reported having done so in the previous 30 days. Fourteen of 2,114 reported that they had injected drugs at least once. The figure of 0.66 per cent of injectors may seem small, but implies that 660 per 100,000 high-school students may have risked injecting HIV into their bodies. Furthermore, there is some reason to think that cocaine use, and perhaps injecting, may be greater among poor youth than among those more likely to be in high school. One common pattern, for example, is that children in their early teenage are used as runners from the dealers at the top of favelasto customers at the bottom, and that these runners are sometimes paid in drugs for their own use.
By the end of 1990, 97 intravenous drug users had been recruited, and blood-testing yielded a seroprevalence of 37 per cent  . Through 1991 recruitment and interviewing continued, reaching a cumulative seroprevalence of 38 per cent in a sample of 400 intravenous drug users  . In that year a first comparative study of the Rio de Janeiro sample and a New York City subsample of primarily cocaine and "speedball" injectors disclosed that although fewer intravenous drug users share syringes at Rio de Janeiro than among New York City cocaine injectors, intravenous drug users at Rio de Janeiro engage in fewer activities aimed at reducing the probability of HIV transmission  .
On the basis of what is now known, an increase in the number of AIDS cases who are drug injectors can be predicted at Rio de Janeiro in the coming years. Current knowledge does not allow an estimate of the magnitude of the increase at present. Questions that need to be answered include the following:
How many drug injectors are there?
What percentage of them are infected with HIV?
What patterns of risk behaviour do they engage in?
How knowledgeable are they about the risks and about how to avoid them?
To what extent are they already engaging in risk reduction?
In answering all these questions, it will be important to study class and other differences among local drug injectors, and thus to assess the extent to which the answers to the questions differ by class, neighbourhood and the nature of links with illegal activities (including drug dealing in particular), and the extent to which there is interaction among drug injectors who differ in the characteristics that might spread HIV from one group to another.
NEPAD/UERJ, a drug abuse treatment and research centre near downtown Rio de Janeiro, has been involved in studies of the social and demographic profile of, and the risk of suicide among, drug users, as well as of HIV seroprevalence [3, 4, 15, 19, 20] . The studies show that most drug users and drug injectors are male, and that drug use patterns and risk behaviour are more related to social class than to ethnic or racial background. Cocaine injection predominates. Heroin use is rare, and occurs primarily among those who have travelled abroad.
Since 1991, NEPAD has been developing Prevention and Information on AIDS, a project sponsored by the Ministry of Health, which is expected to cover the major states of Brazil. It focuses on the following three main areas:
Activities directed to the staff of the drug treatment centres, who receive a brief training course on sexually transmitted diseases and AIDS clinics and prevention strategies;
Activities directed to persons within local communities (health agents and leaders) who deal with the problem in their own areas, making use of information material appropriate to the level of knowledge of the layperson, including audiovisual materials such as videocassettes, slides, comic strips etc.;
Activities directly targeting intravenous drug users, based on group dynamics, distribution of condoms (since harm reduction efforts based on needle and syringe distribution and disinfection techniques are precluded by Brazilian law) and production and evaluation of culturally sensitive educational material. Such activities can be performed both in assessment centres or in the street.
The project is currently in its initial phase, but an early evaluation of the first training courses in the drug treatment centres and of community agents dealing with drug abuse and AIDS prevention among street children is encouraging  .
In spite of the lack of information, international experience suggests several ways of intervening to reduce the spread of HIV by drug injection. Several kinds of intervention that may work are briefly outlined below.
Drug prevention activities. The surest way to protect individuals against injecting HIV is to help them avoid becoming drug users or injectors.
Drug treatment. Drug treatment is an effective prevention strategy. Unfortunately, the total capacity of treatment programmes at Rio de Janeiro is limited. Thus, unpublished data from a survey of high-school students indicate that up to 3.3 per cent of students (mean age, 16.8; range, 13-25) had used illicit drugs in the previous 30 days, their frequency of use during the period ranging from 6 to 20 times. The sample may underestimate drug use, since it omits the large segment of youth of high -school age who are not in school. Extrapolating from these numbers to estimate the total number of drug users among the 3,500,000 people between the ages 15 and 49 at Rio de Janeiro yields approximately 100,000 regular drug users in the city. Regrettably, there are only six well-established drug abuse treatment institutions in the city (plus some self -help groups and religious programmes that usually remain open only a short period of time). Their capacity falls far short of demand. Further, only one of them (NEPAD) provides treatment free of charge, which means that low-income drug users have even less treatment available. Thus, one vital need is to increase the drug treatment capacity.
Encouragement of risk reduction. Many drug injectors will not try to stop using drugs. Limited treatment capacity and the fact that treatment will not succeed with some users mean that safer injection techniques are needed even for persons who want to stop using drugs. In order to encourage risk reduction, techniques are needed to persuade injectors to reduce their risk of HIV transmission or acquisition through injection, and also to reduce their risk of sexual transmission or acquisition. Such techniques involve both encouraging behavioural change and providing easy access to materials (sterile injection equipment, bleach and condoms) that make risk reduction more feasible.
The most widely used approaches to encouraging safer injecting have been outreach programmes and needle exchanges. Outreach usually involves ex-users, current users or other persons who know and are respected by drug injectors in a given community. Staff members are provided with materials to distribute, and participate in ongoing education and discussion about AIDS, drug use and the community in which they are working. Such outreach activities have been found to lead to bleach use [8-10] and to other drug and sexual risk reduction  .
Needle exchanges are set up to provide sterile injection equipment to drug injectors at minimal or no cost (in order to maximize the use of sterile syringes for injections), to withdraw potentially infected syringes from circulation, and, of extreme importance, to establish communication and friendship between staff and injectors. Needle exchanges have been shown to lead to reduced sharing of injection equipment and to other risk reduction, and no evidence has been found to indicate that they increase the amount of drug injection or the number of drug injectors [23-25] .
Finally, innovative interventions can be useful. In New York City, for example, a project was established in 1987 to see if drug injectors could be organized to reduce risks. The model was based on the successes that homosexual male , organizations have had in fighting AIDS transmission by provoking discussion and other activities that led to changes in the norms, values and perceived interests of gay men. Although the New York City project has had some difficulty in implementing its organizing approach, it has led to considerable drug and sexual risk reduction among drug injectors in the neighbourhood where it has been conducted  .
HIV transmission is occurring among drug injectors at Rio de Janeiro and other cities in Brazil, as is heterosexual and perinatal transmission from them to others. Both research and intervention efforts are needed in order to minimize the loss of life and the potential social and economic disruption that AIDS can cause.
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