Rapidly responding to injecting drug use and HIV in Brazil: a field-report from São Vicente, São...

International Journal of Drug Policy 11 (2000) 133–144

Rapidly responding to injecting drug use and HIV in Brazil:a field-report from Sao Vicente, Sao Paulo State

Fabio Mesquita a,b,*, Regina Bueno a, Paula J. Araujo b, Daniela Piconez a,b,Giselda Turienzo L a, Ilham M.T. Haddad b

a Instituto de Estudos e Pesquisas em AIDS de Santos (IEPAS), Santos, Sao Paulo, Brazilb Secretaria da Saude de Sao Vicente, Sao Vicente, Sao Paulo, Brazil

Accepted 27 October 1999

Abstract

As part of Phase II of the World Health Organisation (WHO) Injecting Drug Use Multi-City Study, RapidAssessment and Response (RAR) methodology was used in Sao Vicente City (Sao Paulo State, Brazil) to analyse thesituation regarding injecting drug use and HIV infection. Over a period of 8 weeks, analysis of existing information,focus groups (four) and depth interviews (45) were conducted, with qualitative data analysis taking a further 12weeks. This work was undertaken by a team of six researchers (working mostly part-time on the project), and theresearch process was overseen by an Advisory Community Group. Key topics addressed included: the general druguse situation; HIV/AIDS and drugs; and harm reduction. Through the use of qualitative analysis it was found thatthere was: a negative moral status associated with drug use and drug users; prejudices against this group; and a lackof information about health services and HIV prevention programmes within Sao Vicente city. In regard to riskbehavior, injecting drug users reported awareness of risks and methods of prevention. However, safer sex wasconsidered difficult by all participants. Interventions were proposed by the research team to minimize problems andgaps in provision, and some of these have already occurred. A review of existing quantitative data found that somekey institutions do not collect systematic data on drug use. Conclusions of the study include the need for interventionsand the progress on Harm Reduction proposals and AIDS prevention among IDUs. © 2000 Elsevier Science B.V. Allrights reserved.

Keywords: Injecting drug use; Brazil; Rapid assessment; Harm reduction

www.elsevier.com/locate/drugpo

1. Introduction

It is almost a decade since the first studieson HIV prevalence and risk behavior among

Brazilian injecting drug users took place(Malliori et al., 1998). Conducted as part ofPhase I of the World Health Organisation(WHO) Multi-City Study, this researchdemonstrated high levels of HIV prevalence(63%) among injectors interviewed in the* Corresponding author.

0955-3959/00/$ - see front matter © 2000 Elsevier Science B.V. All rights reserved.

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F. Mesquita et al. / International Journal of Drug Policy 11 (2000) 133–144134

study site at Santos, Sao Paulo State, andsimilarly high levels of syringe sharing (55%)among the same group (Malliori et al., 1998).At the time, our institute — the Institute ofStudies and Research in AIDS of Santos(IEPAS) — was responsible for conductingthis work.

Whilst other studies have taken place inBrazil since the Phase I study — many ofwhich have been conducted in Santos byIEPAS (Bueno and Carvalho, in press) — aneed for further data on injecting drug useand HIV still exists, particularly in manyareas of Sao Paulo State where such informa-tion is not currently collected. In addition, itis now also recognized that although thequestionnaire methodology used in the PhaseI study was successful in collecting importantdata, the integrated use of qualitativemethodologies may compliment and informexisting epidemiological methods of data col-lection (Goldberg, 1998).

As a consequence, IEPAS is now partici-pating in Phase II of the WHO Multi-CityStudy. This phase aims to use a combinationof Rapid Assessment and Response Method-ologies (WHO, 1998a) and survey-based in-struments (WHO, 1998b) to collectquantitative and qualitative data on injectingdrug use and its related health consequences.This paper reports on work currently beingconducted in the city of Sao Vicente, SaoPaulo State, and outlines the initial findingsof a rapid assessment conducted betweenApril and August 1998. Results from theother survey mentioned above are currentlybeing analyzed and will be published shortly.

2. Injecting drug use and HIV in Brazil

The HIV/AIDS epidemic appears to havebegun in Brazil in the late 1970s, with thefirst AIDS case in Brazil occurring in Sao

Paulo in 1982. At the time, cases were beingreported among homosexual and bisexualmen, usually from higher social classes withhigh educational levels (Ministerio da Saude,1998). However, almost 20 years later, thissituation has changed, and there is a signifi-cant trend in HIV/AIDS among heterosexualwomen, and the lower social classes (Ministe-rio da Saude, 1998). The south-east is still apriority area in Brazil in terms of AIDScases, although the south is now gaining im-portance.

According to a recent Epidemiological Bul-letin (Ministerio da Saude, 1999), 155 590AIDS cases were reported in Brazil between1980 and 1999, with around 70% being re-ported among men, and 30% in women. Peo-ple aged between 30 and 34 constitute 22% ofthe total number of cases.

Injecting drug use has played an importantrole in the transmission of HIV throughoutthis epidemic. Epidemiological studies in San-tos City provide an example of the situation(Table 1). Recent studies also support thistrend, indicating that in small cities in thecentral and south-eastern region of Brazil,injecting has played an important role in thespread of HIV (Bastos et al., 1998). Othersources indicate that around 35% of the totalnumber of AIDS cases reported in women inSao Paulo State (between 1983 and 1992)were related to unsafe sex with partners whoinject drugs (Secretaria de Estado da Saudede Sao Paulo, 1996).

Although the AIDS epidemic in Brazil nowindicates a more stable situation — with anincidence of 11 new cases per 100 000 be-tween 1995 and 1997 (Ministerio da Saude,1998) — preventative work with IDUs is stillrequired. Whilst official Harm ReductionProgrammes (HRP) have been in operationin Brazil since 1993, they initially experienceda large number of legal problems (Mesquitaand Bastos, 1994; Mesquita and Ribeiro,

F. Mesquita et al. / International Journal of Drug Policy 11 (2000) 133–144 135

1996); delaying important work and interven-tion with the IDU population. There are nowapproximately 15 HRP in Brazil, with mostoperating in areas with a high prevalence ofHIV among IDUs. However, this is still arelatively small number in comparison to thescale of the problem.

3. Sao Vicente: rationale for response

Situated on the coast, Sao Vicente is 70 kmfrom Sao Paulo city, and is part of the largerBaixada Santista metropolitan area (whichitself is part of Sao Paulo State). The BaixadaSantista area is associated with high inci-dences of AIDS cases, and has traditionallybeen a nucleus for investment (coming fromFederal and Sao Paulo State Governments)in HIV/AIDS prevention and health careprogrammes.

Of the approximately 284 540 inhabitants

Table 2Brazilian cities ranked by reported AIDS cases,Brazil, 1999a

Incidence (per 100 000)StateCity

Itajaı 845.7SantaCatarinaState

Balneareo de 710.5SantaCamboriu Catarina

StateFlorianopolis Santa 642.1

CatarinaState

Santos 628.1Sao PauloStateSao PauloBebedouro 566.6State

Ribeirao Preto Sao Paulo 552.0State

Sao Jose do 534.7Sao PauloRio Preto State

498.7Barretos Sao PauloState

470.1Sao Vicente Sao PauloState

448.0Catanduva Sao PauloState

a Source: Ministerio da Saude, 1999.

Table 1HIV prevalence among IDUs, Santos, 1991–1994

WHO Projeto BrasilbDataMulticity (1994)Studya (1991)

Number of IDUs 140220interviewed

63HIV prevalence 65among IDUs (%)

7155Needles andsyringes shared(%)

Pharmacies PharmaciesMain syringesource

19.7Age of the first 19injection

CocaineMain drug injected Cocaine

Gender of the IDUs83.158.3Male (%)

41.8Female (%) 16.9

a WHO, 1994.b Bueno and Carvalho, in press.

of Sao Vicente, the majority live in precari-ous conditions and have low levels of educa-tion. There are few industrial areas in thecity, and consequently levels of unemploy-ment are high. In addition, only one-fifth ofthe city has access to water supplies andsewage systems, which means that there are anumber of public health problems aside fromHIV and AIDS.

According to epidemiological data fromthe Ministry of Health, in terms of notifiedAIDS case rates, Sao Vicente ranks as theninth highest city in Brazil with around 470cases per 100 000 of the population (Ministe-rio da Saude, 1999) (Table 2). The city has1318 notified cases of AIDS, with around30% of cases reported as being related to


injecting drug use (Secretaria da Saude deSao Vicente, 1999). This may be the partialresult of Sao Vicente’s reputation as a keyarea for drug trafficking, with the activityreportedly being a source of income for manyresidents.

3.1. Rationale for response

Although the rapid assessment could havebeen conducted in a number of cities in theBaixada Santista area, Sao Vicente was se-lected for three key reasons. Firstly, becauseof the lack of data in the city about drug useand HIV prevention. Secondly, due to theexistence of a political will and commitmentto developing public health interventions forinjecting drug users (this was evident in thegood relationship shared by the researchteam, the authorities, the public attorneysand the politicians of the city). Thirdly, as aseries of basic HIV prevention interventionsalready existed in the city including: a HarmReduction Programme run by the STD/AIDS Programme of Sao Vicente city (whichhas been in operation for 3 years, with needleexchange being offered for 2 years); a com-mitted Health Secretariat (governmental or-ganisation that operates public interventionsfor health care); a programme on workingwith key social groups at risk of STDs/HIV;and an HIV/AIDS holistic treatment centre(with free statutory treatment for AIDSpatients).

4. The rapid assessment process

The rapid assessment took place betweenApril and August 1998, and was conductedby a research team of six people (three mem-bers from STD/AIDS Programme of theHealth Secretariat of Sao Vicente; threemembers from IEPAS). The rapid assessment

was mainly conducted in the central area ofSao Vicente city, but research participantscame from all areas.

It took the research team approximately 1week to organise and prepare instruments, 8weeks to complete fieldwork, and 12 weeks toanalyze the data from this. In this time anextensive amount of existing data were col-lected, and 45 interviews and four focusgroups (with 42 participants) were also un-dertaken. Only one researcher was able todedicate a large amount of time to the assess-ment (80 h) and this was spread across avariety of tasks. The other five researchersworked almost exclusively on data collectionand analysis (around 40 h). However, onreflection, the research team agreed that ifthey could all have dedicated themselves ex-clusively to the task, the rapid assessmentcould have been accomplished in around 6weeks.

The different activities in the rapid assess-ment process are summarised below. It isimportant to note, however, that in practicethese activities often ran in parallel, ratherthan as separate steps.

4.1. Aims and objecti6es

The rapid assessment aimed to collect datawhich would inform the development of HIVprevention interventions. This required col-lecting information which embraced the fol-lowing themes:� Drugs: concept of drugs; user profiles; rea-

sons for drug use; age and social stratainvolved in drug use; relationship betweenprostitution and drugs;

� Drug use: most popular drugs consumedin the city; route of administration; howthe drugs arrive in the city; distributionnetworks; price and quality; use of inject-ing drugs and specific information onheroin;


� AIDS and drugs: identification of currentSTD/AIDS prevention activities and eval-uation of their application for drug userpopulations; the existence of knowledgeamong study participants about suchhealth care and prevention programmesfor STD/AIDS;

� Harm reduction: awareness among studyparticipants about the concept and prac-tice of Harm Reduction (particularly inthe City); perceptions of Needle ExchangeProgrammes (NEPs), and drug userorganisations.

4.2. Organisation

The involvement and support of the com-munity was felt to be important to the rapidassessment’s success. To help achieve this, anAdvisory Community Council (ACC) was or-ganised. This group was created to steer theresearch process, and membership included aDirector of the Health Secretariat, a Directorof the Citizenship and Social Action Secretar-iat (SECIAS — a governmental organisationthat is responsible for operating programmesto tackle social problems), a memberof the City Council on Drugs, one Munic-ipal Legislator of the city, and a former druguser.

The proposed study was presented to theACC and was well received. A number ofsuggestions were made on how to make im-portant contacts with the community,and members of the ACC agreed to helpby contacting specific people. During therapid assessment, three further meetingswere held in order to update the ACCon progress, and discuss emerging results. Itwas also agreed that at the end of the assess-ment, a public seminar would be held inorder to inform the community and the re-search participants about the results of thestudy.

4.3. Data collection

4.3.1. Existing informationThe first stage in the rapid assessment was

to systematize existing information on druguse in Sao Vicente. This was accomplished inseveral localities described above where re-searchers attempted to obtain a descriptionof the drug use situation and related issues. Areview of existing information was under-taken which included: local media (newspa-pers); drug treatment centres; mental healthservices; local general hospitals; legal MedicalInstitute; the HRP; the prison system of SaoVicente (composed of four units); SECIAS;the STD/AIDS Program; and a number ofprevious Epidemiological Studies (Malliori etal., 1998; Bueno and Carvalho, in press).

Local newspapers from March 1996 toMarch 1998 were reviewed and articles aboutdrug use in Sao Vicente city were identified,as well as features on public health informa-tion about drugs, drug-related crime, andHIV/AIDS prevention. A profile of drugusers and drugs that were used was alsocompiled using data from drug treatmentcentres, mental health services, HRP and SE-CIAS. Notably, data from the local generalhospital and the legal medical institute wereused to ascertain the situation regardingoverdose. Information from the prison sys-tem on drug-related crime and drug traffick-ing was also collected, and the STD/AIDSprogramme and recent studies (Malliori etal., 1998; Bueno and Carvalho, in press) wereused to collate epidemiological data on HIVand AIDS among IDUs.

4.3.2. Focus groupsFocus groups and in-depth individual in-

terviews started almost concurrently with thecollection of existing information. Four focusgroups were undertaken. The first two groupswere conducted with drug users living in the


city (IDUs, DUs and ex-IDUs), whilstthe third group was comprised of eight

drug treatment professionals (workingin public and non-governmental drug treat-ment services). The fourth group was asample of nine ‘community-based pro-fessionals’ in contact with drug users.This focus group included teachers, policechiefs, psychologists, pharmacists andothers.

The initial recruitment of the drug userfocus groups was undertaken by outreachworkers at the HRP in Sao Vicente,with further participants being contactedthrough snowball sampling. Participantsfor the two other focus groups wereselected during discussions with the ACC. Allfocus groups were held in a room insidethe Health Secretariat. Using outreach work-ers and the ACC as ‘key informants’ provedto be an efficient and fast method of recruit-ing focus group participants and intervie-wees.

4.3.3. Inter6iewsApproximately 45 people were interviewed

in-depth during the rapid assessment (10DUs, 10 IDUs, 10 former-IDUs, five peoplelinked to the justice services, five people fromthe community and five from the health ser-vices in general). Depth-interviews tended tobe semi-structured and took place in bars,health services, on the streets, in the druguser’s home or place of work. All respon-dents were alone with the interviewer duringthe interview. The recruitment of intervieweesfollowed the same procedure as that of focusgroups.

Both in-depth individual interviews andfocus groups were recorded with theconsent of participants. Drug users re-ceived a reimbursement at the end of theirinterview (transportation and food ex-penses).

4.4. Analysis

To aid the qualitative analysis of inter-views, the research team organised the datafrom the 45 in-depth interviews into six cate-gories: DUs; IDUs; former-IDUs; commu-nity professionals; criminal justice workers;and health professionals. As the study’s focuswas primarily HIV and AIDS prevention,priority was given to the analysis of the qual-itative data collected from participants whowere injecting drug users. Qualitative analysisof focus group data was conducted in thesame manner. The analysis of existing infor-mation was undertaken by aggregating infor-mation that had been collected (and anyobservations about this) by the institution itwas obtained from. It should be noted, how-ever, that many institutions could not supplydata that was originally requested. The keyfindings from this analysis are summarized inSection 4.4.1.

4.4.1. Summary of key findings from SaoVicente Rapid Assessment

4.4.1.1. Drug use. Crack (smoked) was themost popular drug in Sao Vicente accordingto all participants of the study. This wasfollowed by (in order): cocaine (intra-nasal),marijuana, and injectable cocaine. Otherdrugs were also mentioned including LSD,merla (cocaine paste), mesclado (mari-juana+crack), ecstasy, alcohol, am-phetamines and other commercialmedications. There is no use of heroin in SaoVicente according to participants, but all ofthem have heard of it and heroin use wasreported in the neighbouring city of Santos.Drugs can be purchased in most places inSao Vicente and originate from neighbouringplaces, such as Santos Harbor and otherBrazilian States. Researchers were informedthat part of the market is supplied through a


police storehouse of drugs confiscated duringarrest.

4.4.1.2. Risk beha6ior. Those IDUs inter-viewed appeared to be aware that needle andsyringe sharing was a key route for HIVtransmission. Most claimed to buy needlesand syringes in pharmacies, reporting thatsharing was not common, and noted thatwhen syringes were re-used that they wereusually cleaned with bleach.

4.4.1.3. Health. All IDUs interviewed hadnever witnessed a fatal overdose, but manywere aware of the symptoms and what actionto take. Unfortunately, it was reported byinterviewees that if an overdose did occur,that the local hospital was not able to reim-burse overdoses (rule from the Federal Gov-ernment), and because of this bureaucraticdecision, the local hospital never registered acase of overdose. In addition, the local hospi-tal reported that they do not admit patientsin chemical dependence, even in an emer-gency. However, this information was contra-dicted by the Legal Medical Institute ofSantos who reported two fatal overdosesfrom 1996 to 1998. Whilst information onHIV prevention was widespread, not every-one contacted practiced safe sex. It wasfound that there was a lack of knowledge onSTDs (but not HIV/AIDS) particularly con-cerning its symptoms, prevention and treat-ment. This was acute among the IDU, DUand community groups that participated inthe study. All the participants of the studyindicated low levels of knowledge about theSTD/AIDS attendance and prevention pro-grammes or drug treatment centres that ex-isted in Sao Vicente city. In addition, it wasfound that although drug users frequentlyused mental health services, that this was notformally recognized by the services them-selves. This was apparently because they

don’t consider it their responsibility to treatIDUs or DUs.

4.4.1.4. Drug ser6ices. Opinion on needle-ex-change was split among those interviewed orparticipating in focus groups. Supporterswere found in all groups, with a clear consen-sus in favour existing in those interviewedfrom the health and IDU, DU groups. How-ever, the ‘drug treatment’ and ‘community’focus groups were strongly against needle-ex-change, either favoring more abstinence-based approaches or refusing to discuss thesubject on the basis that there was a lack ofinformation. The HRP reported that someIDUs (40) were engaged in the NEP, but thisis likely to be a tiny proportion of the totalnumber of IDUs in the city. It was foundthat the aims and objectives of a drug userassociation were misunderstood by everyonequestioned (including drug users) and wasoften confused with another form of drugtreatment.

4.4.1.5. Existing information. There was alack of systematized data in the followinginstitutions: prison system; local hospitals;government and non-government drug treat-ment centres; and the mental health service.The Harm Reduction Project of the HealthSecretariat and the Legal Medical Institute ofSantos were the only institutions to keepsystematic data on drug use.

4.4.1.6. Media co6erage. Reports in the localpress almost exclusively portrayed drug useand drug users in negative terms (crimes in-volving drugs, violence related to the pay-ment of drug debts, apprehensions, andaccidents). This perception was also held bythose interviewed or participating in focusgroups (including drug users themselves). Alink was made with poorer areas in the city.The regional press (covering cities in Baixada


Santista) often reported on wider issues in-cluding AIDS and drugs statistics, needle-ex-change, drug treatment, prevention andstudies about drugs made in streets.

4.5. Identification of potential inter6entions

Once the data analysis stage was com-pleted, the research team met to identify pos-sible HIV prevention interventions. In orderto achieve this, a list was compiled of themain problems related to drug use in SaoVicente city, and key gaps were identified inthe provision of relevant services (as indi-cated through data analysis). Using this listas a basis for discussion, a series of feasibleand realistic interventions were then pro-posed. Notably, these interventions includeda number of suggestions made by study par-ticipants during the data collection phase.

From this process, the following potentialinterventions were suggested:

Drugs� organise a workshop for the local media

in order to improve their understandingof drug issues including appropriate andscientific concepts;

� improve HIV and drugs prevention inschools and community centres with afocus on scientific information aboutHIV risks, drug effects and healthconsequences;

� increase the level of harm reductionprojects taking place among drug users,with a particular focus on HIV preven-tion and challenging prejudices.

Drug use� increase levels of harm reduction

projects and drug treatment available tocrack users;

� discuss the final RAR report with lawenforcement agencies, particularly sec-tions on drug-related crime, and drugtrafficking among police staff;

� discuss data from rapid assessment onlinks between prostitution and drugswith an existing HIV prevention pro-gram for sex workers in Sao Vicente.

HIV and drugs� use existing HIV/AIDS prevention

projects to disseminate informationabout STD/AIDS programmes in SaoVicente;

� use the HRP to highlight existing ser-vices which are appropriate for drugusers;

� create a team within the STD/AIDSprogram to inform the general publicabout the availability of STD/AIDS ser-vices in Sao Vicente city;

� increase the number of drug treatmentcentres;

� devise health promotion initiatives topromote safer sex in all forms of sexualactivity.

Harm reduction� open a centre for drug users and aim to

transform this into a drug user associa-tion in the near future;

� re-organise and train the outreach work-ers team in Sao Vicente and re-evaluatecurrent fieldwork.

On the review of existing data� recommend that prison and police insti-

tutions modernise data collection on thereasons for arrest/incarceration;

� propose that the Ministry of Health re-imburse overdose treatment costs tohealth services;

� encourage the Health Secretariat to up-date data collection procedures relatedto drug use by framing the importanceof such data in defining public policyinterventions;

� suggest that drug treatment centresmodify the type of data collected, andrecommend that supplementary trainingcourses and computing resources aresupplied to them.


4.6. Community feedback

The results of the data analysis were pre-sented in a community seminar, as suggestedby the ACC group. This seminar took placein August 1999, and was after some of theproposed interventions had already started.This was an exciting experience and involvedmore than 60 persons, many of whom partic-ipated in the rapid assessment. Those attend-ing the seminar expressed enthusiasm aboutthe study and proposed interventions, andthe Director of the State Penitentiary (one ofthe institutions approached to provide data)requested that further interventions should beput into place, and asked to be supplied withAIDS and drugs prevention materials.

The results of the study were also madeavailable on the Internet in Portuguese forother researchers and interested parties(http://www.imesc.sp.gov.br).

4.7. Inter6ention de6elopment

The STD/AIDS Programme of Sao Vi-cente was given responsibility for implement-ing the intervention plan devised by theresearch team. The main priority for actionwas to re-organise existing HIV preventionprogrammes (with a specific focus on HRPs),and to improve interventions undertakenwith the community and the IDU/DU popu-lation. As a consequence, discussions wereheld with these programmes on improve-ments that could be made in the followingareas: provision of good quality informationabout drugs and health consequences; thereduction of prejudice against IDU and DU;and informing the wider public and IDUsabout STD/AIDS programmes.

In the harm reduction sector, a centre fordrug users was opened using funds obtainedfrom the local and Federal government, andthe UNDCP. Other interventions that are

contingent on political support are currentlyin negotiation.

5. Discussion

The use of qualitative methods can facili-tate the collection of rich, in-depth data (Sil-verman, 1997). These data can provide usefulinsights into the motivations, perceptions andunderstanding of different social groups andinstitutions. Whilst the primary aim of ourrapid assessment was to identify potentialinterventions to improve drug users’ health(particularly in relation to HIV), we wouldnow like to briefly reflect on four additionalfindings obtained from qualitative data anal-ysis which may also contribute to meetingthis aim.

Firstly, we would like to highlight the neg-ative moral status that drug use and drugusers have been ascribed in Sao Vicente. In-terviewees in the study frequently character-ised drug use in highly negative terms (evenamong a number of those drug users inter-viewed). This position was particularly acutein media reports, where drug use was re-ported in highly sensational and ideologicalterms. Such a stance is clearly more moralthan scientific, and its failure to take intoaccount the larger context and environment— such as inequalities in education, sanitaryconditions, better life conditions, employ-ment opportunity, emotional support,and other factors — has led to a situationwhere such factors and deeper analysis arerarely considered in more effective social pol-itics.

Secondly, we would like to briefly focus onthe status that drug users ascribe to their owndrug use. During interviews and focusgroups, users often talked about their druguse in both negative and positive terms. How-ever, whilst the discussion of positive experi-


ences included the recognition that drugscould be used in ways in which life and socialfunctions could be maintained, users still of-ten concluded that ‘drugs are not good’. Webelieve that such a view does not necessarilyreflect the views of the user, but an accep-tance of the socially excluded role ascribed tothem by wider society (Freire, 1987). Thisstance can be compared with that of the‘deserving poor’ who believed that sincepoverty has always existed, it is natural andtheir fault, and nothing can be done to trans-form this situation.

Thirdly, as a consequence, it is possiblethat such a perceived status (which is en-forced by wider opinion) may mean that drugusers will not attempt to access health ser-vices or health professionals, and similarlyhealth services or health professionals willnot try to access user populations. It is there-fore important that the HRP in Sao Vicentemakes efforts to overcome such a situation,by informing drug users about other healthservices and helping them to gain access tosuch places. Furthermore, if drug users feelthat they are socially excluded and isolated, itis possible that they may not be able toenvisage the creation of a collective associa-tion promoting the human and medical rightsof drug users. This feeling of exclusion maybe particularly strong in Brazil, where therights of poor or marginalised population areoften not generally respected.

Fourthly, it is arguable that the perceivedsocial status of drug users may perpetuate thelack of available systematic and scientificdata on drug use. Whilst drug use continuesto be linked to law-enforcement rather thanpublic health and welfare issues — with themedia playing a clear role through its sensa-tional focus on violent crime and trafficking,drug apprehensions, and other negative issues— then resources will probably not be di-rected towards improving drug users’ lives.

This may have an impact on available re-sources and systems for data collection, re-sulting in a continued lack of basic, scientificinformation on the phenomenon. Unfortu-nately, such a situation is probably not re-stricted to Sao Vicente city, and probablyalso applies to most of Brazil.

6. Conclusions

We can draw both methodological and so-cial conclusions from this study. Methodo-logically, the research team felt that the RARtechnology was useful in facilitating quite awide diagnosis of the drug use situation inSao Vicente, and highlighting its conse-quences for users’ health. The results of therapid assessment were also helpful in allow-ing the research team to produce proposalsfor potential interventions based on the re-sults. In the 8 weeks of fieldwork and 12weeks of analysis, a wide range of issues wereinvestigated, and it was felt that the RARmethodology could be applied to other healthand social problems.

Key conclusions from the rapid assessmentin terms of the need for specific interventionsincluded:� Drug use is always framed as a juridical

and law enforcement problem. However,the rapid assessment brought together ac-tors from a wide range of disciplines anddiscourse between these disciplines needsto be sustained;

� There are serious failures in the collectionof data on drug use by most services, andthis needs to be addressed to allow thebetter planning of health policies;

� There is a need to integrate scientific un-derstanding and facts into media reportingof drug issues. There is a need to movediscourse away from the criminal aspectsof drug use, and challenge the utility of a‘war on drugs’;


� Health services are experiencing difficultiesin attracting drug users (particularlyIDUs). It may be necessary for these ser-vices to consider the drug users’ percep-tions of current service delivery;

� Although Harm Reduction Programmes inSao Vicente have already overcome seriousproblems (even political resistance) andmade significant progress, further work isneeded (particularly the incorporation andreferral of drug users to existing healthand social services);

� Difficulties in promoting the establishmentof a drug user association are rooted indivisions between drug users (with a dis-tinction being made by users betweenthose using cannabis and cocaine, andthose injecting or smoking crack), and thesocial exclusion of drug users.Although further work is clearly needed, a

number of important successes were also ob-served. One very positive point arising fromfocus groups and interviews was that IDUswere capable of: preserving their own health;understanding and using safer means of con-suming drugs; and avoiding overdoses, con-tamination for HIV and other undesirablehealth consequences. It was also reportedamongst injectors that there has been a de-crease in the sharing of needles and syringesresulting from HIV prevention work, andwhilst a reported transition from injectingdrugs to smoking crack may not be necessar-ily associated with such prevention work, thisdeserves further investigation. Sadly, whilstIDUs are aware of HIV infection, they arenot as aware of other conditions that can betransmitted through injecting drugs such ashepatitis B and C, endocarditis and others.This indicates the need for further preventionwork by the HRP.

Finally, a further positive finding was themarked change in attitudes to harm reduc-tion and needle exchange compared to those

existing at the beginning of the 1990s. Fewpeople in the rapid assessment refused toengage in discussion about such initiativesand the only major refusal occurred becausethe ‘community’ focal group felt that theycurrently did not have enough information todiscuss the issue. Whilst some still opposeneedle exchange programmes, it is hoped thatthis willingness to enter into constructive de-bate indicates that such initiatives, and harmreduction approaches in general, are nolonger the ‘Forbidden Project’ that they oncewere.

Acknowledgements

This study received partial funds from NPSTD/AIDS Brazil.

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