Blood-Borne and Sexually Transmitted Infections Among IDUs and Their Partners in the Western Hemisphere: Exchange of Experiences and Lessons Learned

United States

Sponsored by: Pan American Health Organization, World Health Organization, National Institute on Drug Abuse, National Institutes of Health

Introduction

The conference was planned, organized and conducted by Jag H. Khalsa, Ph.D., and Henry Francis, M.D. of the Center on AIDS and Medical Consequences of Drug Abuse (CAMCODA), of the National Institute on Drug Abuse (NIDA), a part of the U.S. National Institutes of Health (NIH), and Rafael Mazin, M.D. Armando Peruga, M.D. and Fernando Zacarias, M.D. of the Pan American Health Organization (PAHO), World Health Organization (WHO), and Dr. Mercedes Weissenbacher of the National Center for AIDS Research, Buenos Aires, Argentina. The objectives of the conference were: (a) to facilitate the exchange of experiences, lessons learned and "best practices" between experts in the United States of America, Spain, and Latin America and the Caribbean who work in the area of blood-borne infections and sexually transmitted infections (STIs) among intravenous drug users and their partners; (b) to discuss medical, behavioral and other relevant public health consequences of injecting drug use, as well as the current situation and trends of it in both the U.S.A. and Latin America and the Caribbean; and (c) to review successful behavioral, medical and public health interventions implemented both in the U.S.A. and in Latin America and the Caribbean that may be adopted/adapted by each other.

A group of 32 participants (clinicians, scientists, and other health care providers) from the United States of America, Latin America, the Caribbean, and Spain discussed the state-of-the-art information on infections among injection drug users and their partners. The topics discussed included: (a) epidemiology of HIV/AIDS and drug abuse and associated health and psychosocial consequences in the Western Hemisphere, (b) political and cultural determinants of transmission of infections in HIV-infected drug abusers, with special emphasis on underserved populations including incarcerated and homeless and their sexual partners; (c) obstacles for the development of interventions (prevention and treatment) for HIV and drug abuse associated consequences; (d) health effects and health care issues (cost-effective interventions). In addition, the participants shared their experiences and lessons learned so that each country could design strategies for future research and develop policies/guidelines applicable to their respective countries. The participants also made excellent recommendations for future research on the subject.

Recommendations for Future Research

The recommendations included the study of: (a) incidence and prevalence of drug abuse and co-occurring infections (including HIV, hepatitis, STDs and TB) in Latin America and the Caribbean; (b) medical/health and psychosocial consequences of infections among IVDUs, their partners, with emphasis on under-served populations such as incarcerated and homeless men and women; (c) health care issues such as: recruitment/enrollment, adherence and compliance to treatment protocols, access to health care facilities and related issues; (d) interventions (prevention and treatment) that have been found effective and that can be exchanged between the countries; (e) effective collaborations among treatment centers/hospitals and basic research scientists to be able to exchange experiences and lessons learned; (f) attitudes and motivational items to measure the reasons for drug use or risk behaviors, tailored to each culture; g) risk behavior measurement and development of instruments applicable to culturally-divergent populations; (h) relationship indicators (e.g., closeness and relationship type: spouse/family member/drug partner) that influence drug use behaviors among HIV-infected populations. Support a surveillance system adopting multi-tiered measuring instruments and recruitment protocols for HIV-infected drug users. These are further elaborated below under Recommendations.

Abstracts

Drugs and AIDS

Franklin Alcaraz del Castillo, M.D.
Latin American Center of Scientific Investigation, La Paz, Bolivia

The first cases of HIV in Bolivia were reported in 1984. These cases were contracted abroad, but over the last twelve years, infections have been indigenous. The total of cases of HIV registered in Bolivia up to October 2001 reached 791, of which 42% had developed AIDS. The mortality rate was greater than 50%. Most cases were found in the city of Santa Cruz (285), followed by La Paz (151), Cochabamba (76) and Trinidad (30). The age group most affected is the 25-34 year-old group (41%), then the 35-44 group (23%), followed by the 15-24 year-old group (22%), people older than 45 years old (11%), and finally the group between 0 to 14 years old (3%). In Bolivia, there have been only three cases of AIDS associated with intravenous drug use.

The HIV Transmission Gradient: How Drug Injectors Protect Themselves and Their Partners

David C. Bell, Ph.D.
Affiliated Systems Corporation, Houston. United States

Since the advent of the HIV epidemic, tremendous public and private efforts have been directed toward reducing HIV risk behaviors among drug users and those who associate with them. A major component of these interventions has involved warning persons engaging in risk behaviors (drug injectors, sex partners) to treat their partners as if they might be HIV seropositive (HIV+). A sample of drug users, matched nonusers, and their risk partners (sex and injection partners) was collected to investigate patterns of HIV risk. A total of 267 persons were interviewed, and these persons named 1541 drug use, sex, and close partners. The sample was divided into HIV+ persons, their "proximal partners" (HIV seronegative drug use, sex, close partners), and "distal partners" (those who did not - as far as we know - have an HIV+ partner). An HIV transmission gradient was observed; that is, risk behaviors between one HIV+ person and another were at a very high level, while risks between HIV+ persons and their proximal partners were moderate (one third of that level), and risks between proximal and distal partners were very low (one fifth to one tenth). Risks between two distal partners were on average about the same as between an HIV+ person and a proximal partner. We interpret this to mean that, at least among and around the drug-using community in Houston, Texas, people are acting as if their risk partners may be HIV+. Public health messages about the risk of HIV have apparently been received, and persons are taking the disease status of their partners into account. There is still, however, substantial residual risk: risks have been reduced, but they have not been eliminated.

Drug Use and HIV in Spain: Lessons Learned about Public Health Decision-making

María José Bravo Portela, M.D., MPH
State Office for the National Plan on Drugs in Madrid, Spain

In Spain the evolution of HIV epidemic was shaped by several factors, both historical and epidemiological: 1) The high prevalence of drug use, specially heroin, in a context of a very fast transformation from an authoritarian leadership to a democratic system overloaded with several socio-economic problems; 2) The use of the intravenous route, which involved the overwhelming majority of heroin users during the first part of the epidemic; 3) The early introduction of HIV among drug injectors with a very high prevalence of sexual and injecting risk behaviors and very efficient mechanisms of contact for HIV transmission throughout the different subpopulations of drug users; and 4) The delay in developing effective prevention measures. ¹, ² Data from different resources, such as the Surveillance System on AIDS in Spain and cross-sectional studies on HIV prevalence and risk behaviors among intravenous drug users, were reviewed. Information on health policy is focused on the evolution of the different legal measures approved in order to control the access to methadone maintenance treatment. These measures started in 1985 under a very restrictive law. It was not until 1996 that the law recognized the necessity for massive access to this treatment, which had a proved preventive effect on HIV transmission. Some of the lessons are taken out so as to avoid health damage among illegal drug users and injectors living in other countries or territories.

• ¹De la Fuente L, Barrio G. Control de los problemas de salud asociados al consumo de drogas en España: hacia un abordaje científico y priorizado. Gac Sanit 1996;10:255-260.
• ² Bravo MJ, Barrio G, de la Fuente L, Colomo C, Royuela L. Persistencia de conductas de riesgo para la transmisión del VIH entre los inyectores de drogas de Madrid, Sevilla y Valencia. Gac Sanit 1999; 13(2):109-18.

Health Care Access for Intravenous Drug Users (IDUs) with HIV

Stephen Crystal, Ph.D.
Institute for Health, Health Care Policy and Aging Research at Rutgers, The State University of New Jersey, United States

This presentation will discuss issues of health care access, utilization and persistence of treatment among injection drug users with comorbidities including HIV disease as well as other medical and psychiatric conditions. It will include results from analyses of data on care among a statewide study population of persons living with HIV, predominantly IDUs, in New Jersey, USA, as well as results from other US studies. The presentation will explore the multiple care needs of individuals and the need to coordinate care across multiple systems. It will explore the relationships among drug abuse treatment, case management, treatment of psychiatric comorbidities and use of HIV treatments, and the potential impact of drug abuse treatment in facilitating more appropriate use of HIV health care and treatments in multiple diagnosed populations. The presentation will discuss use of antiretrovirals among IDUs and non-IDUs with HIV, including the initiation of highly active antiretroviral therapy (HAART) regimens incorporating protease inhibitors and non-nucleoside reverse transcriptase inhibitors. It will also explore the extent to which IDUs and others with HIV are persistent on these regimens as an indication of the extent to which they may be good or bad risks for initiation of HAART. It will explore issues of psychiatric comorbidity in relation to drug abuse, the need to identify and treat comorbid psychiatric conditions and the potential impact of such treatment on HIV care. The presentation will discuss the issue of adherence and persistence with HIV regimens and the supports needed to improve adherence. Finally, the presentation will discuss the need for integrated treatment of multiple conditions often considered the province of separate and disjunctive services systems, in order to achieve secondary prevention and effective care.

Adherence to Heroin Dependence Treatment: WHO Project on Adherence to Long-term Therapies

Silvana De Castro, M.D.
World Health Organization, Geneva, Switzerland

Adherence rates for long-term therapies have been reported an average of 50% in developed countries and 20% in developing countries. The World Health Organization initiated a project, which aims at improving adherence rates world wide through applied research, network development and advocacy to policymakers. Adherence to heroin dependence treatment alters the natural history of heroin dependence, decreasing or prolonging periods of abstinence from heroin use. This literature review (Medline 1990-2001) retrieved articles mainly from developed countries (95.4%), reporting an average adherence prevalence of 60%, ranging from 2.35% (Russia) and 89% (Spain). The most used pharmacological interventions reported by authors were methadone, buprenorphine and naltrexone, with adherence rates at three months of 79%, 58%, and 35% respectively. A consistent declining time pattern was also reported (60%, 0% and 0% at 12 months, respectively). Reinforcement interventions such as take home doses, vouchers, and payment incentives significantly increased pharmacological adherence. Having an employment, high motivation, positive environmental influences, non-drug abuse partner and childcare responsibility are predictors of higher adherence rates. These results highlight the fact that methadone is an effective therapy for heroin dependence that demonstrated the best adherence rates. Reinforcement interventions are effective to enhance adherence rates. There is an urgent need to increase research in developing countries, as well as studies evaluating the cost-effectiveness of interventions for improving adherence.

Clinical Epidemiology/Services Research: Drug Use and HIV in the U.S.

Jerry Flanzer, D.S.W.
Services and Prevention Research at the National Institute on Drug Abuse, Bethesda, United States

Major findings and gaps of health services research on the prevalence and outcomes of HIV and drug abuse prevention and treatment services as measured on the patient and organization level in the United States were presented. Much of the latest thrust of health services research is on research to practice; informing practitioners about new, proven drug abuse treatment interventions; changing treatment organizations (creating a climate for change, building a culture to sustain change), and financing new treatments. Thus the presentation includes findings of a direct relationship between the quality of drug use treatment and the patients' program completion, the perception of the staff by the patient, feelings of self-empowerment and mitigation of patient and organizational readiness, the superiority of integrated care, as well as the primary reasons for delays in patients' with substance abuse problems seeking HIV care. Despite the research many substance abuse programs are still not teaching about or testing for HIV and persistent barriers to integration of care prevail.

Blood-borne and Sexually Transmitted Infections Among Drug Abusers: Research at the U.S. National Institute on Drug Abuse (NIDA)

Henry (Skip) Francis, M.D.
Center on Aids & Other Medical Consequences of Drug Abuse, National Institute on Drug Abuse, United States

The National Institute on Drug Abuse, a part of the National Institutes of Health, of the U.S. Department of Health and Human Services, supports about 85% of world's research on drug abuse. The Center on AIDS and Other Medical Consequences of Drug Abuse (CAMCODA), with a staff of 15+ clinicians/scientists, manages AIDS annual budget of approximately $250-300 million. It coordinates and collaborates with NIDA components, other NIH institutes, and supports AIDS research on medical, health and developmental consequences of drug abuse and co-occurring infections including HIV, hepatitis, TB, and sexually transmitted diseases. For an example, currently there are a number of active national and international research programs that deal with the incidence and prevalence of HIV/AIDS, prevention and treatment of infections among intravenous drug users (IVDUs), metabolic and endocrine consequences of HIV/AIDS and drug abuse, research on drug-drug interactions; linkage to health care access; and developmental consequences of drug abuse and co-occurring infections-exposed children and adolescents. A strong emphasis is placed on the inclusion of minorities, underserved populations, women and children in research. Further, currently the Center on AIDS has a number of excellent research projects on drug abuse and co-occurring infections in progress in Russia, China, and Thailand. We would be delighted to work with PAHO/WHO and you to develop research and interventions projects in Latin America and the Caribbean. The Center staff disseminates research findings via publications, and also by organizing workshops, meetings, and conferences at the national and international level such as this one.

Drugs, Harms and Health Polices in Argentina: Obstacles and New Perspectives

Silvia Inchaurraga, M.D., Ph.D.
Drug Abuse and AIDS Advanced Studies Center National University of Rosario, Argentina

High HIV/AIDS incidence in intravenous drug users (IDUs) shows the failure of traditional public policies in Argentina. Because of the elevated frequency of use of cocaine-the preferred intravenous drug-the user population is exposed to high risks. ¹ The high correlation between poverty, drug dealing and drug use shows a reality in which a few extra grams of the drug can support not only its own consumption, but also precarious subsistence economies. The prohibition rule associated with urban scenes of unemployment and poverty have led to the so-called "poverty drugs" (free base and crack) taking root. On the other hand, "zero tolerance" approaches and an Argentine drug law that punishes possession for personal use (the reason for the majority of the criminal procedures in Argentina), without resolving the drug use problem, have led drug users to distance themselves from the health system. A historic perspective is presented regarding approaches aimed at preventing HIV/AIDS and reducing the resulting harms in Latin America and Argentina. In spite of isolated efforts developed in Rosario and Buenos Aires in the early 90s, intravenous drug users in Argentina did not have free access to needle exchange programs until the end of that decade.² Resistance was based on moral issues that ignored scientific evidence. We present the impact of the programs and campaigns that the Argentine Harm Reduction Association (ARDA) is developing for specific populations (IDUs in shantytowns, prisoners, young users in rock concerts and health institutions) with the support of the Fight against AIDS and STD Program (LUSIDA) of the National Ministry of Health and, in particular, the Harm Reduction Program run by the University of Rosario, which is being innovative with an "Injection kit" and Handbook for IDUs and the Argentine Drug Users Defense Network (RADDUD) Campaign "If you do it, do it well" launched in three Argentine cities. We will review the effects of the Decree of the national drug agency, SEDRONAR, regarding harm reduction, the project to modify article 28 of Drug Law 23.737, the legalization of damage reduction measures, as well as the proposal to revoke article 14 and decriminalize possession for personal use submitted by ARDA and their basis, within the framework of the Latin American context.

• ¹Siri, P, Inchaurraga S. (2000) First steps: using rapid assessment and response methods to develop research, intervention and advocacy capacity for addressing drug use in Rosario city, Argentina, IJDP International Journal of Drug Policy , Elsevier Science, Amsterdam, 1-2, page 125-
• ²Inchaurraga S. (2001) "Drogas y políticas públicas. El modelo de reducción de daños" Ed. Espacio, Buenos Aires.

Obstacles for the Development of Prevention and Health Care Policies

Patricia Insúa, Ph.D.
University of the Basque Country, Spain

Background: Harm Reduction Programs were implemented in Spain only after verifying the impossibility of maintaining only abstinence objectives in the drug abuse treatment approach and because of the serious situation of the AIDS epidemic among intravenous drug users (IDUs) in the country. It is now acceptable for different institutions to talk about prevention of the risks associated with drug use, and to meet the need to train health care professionals by teaching them how to implement AIDS prevention programs with drug users. Materials and Method: We designed, implemented and evaluated a Training Program for Trainers focused on changing the beliefs, attitudes and behaviors of health care professionals working with drug users towards drug use and towards the users themselves. Results: We present the evaluation results of the implementation and impact of this Training Program for designing, implementing and evaluating prevention programs of health problems associated with drug use, that were carried out with 56 public health care professionals in the country. We found an important increase in all of the necessary personal abilities of the trainers' to implement this kind of program and this increment in their abilities remains over time. These professionals also implemented and evaluated AIDS Prevention Programs with 670 IDUs in their respective autonomous communities. The evaluation of these programs shows an increase of safe injection practices and sexual behaviors among the IDUs that participated in the programs. Conclusions: The results of the Training Program for Trainers confirm the adaptation of the designed program to the target population. The results of the evaluation of the programs with the IDUs also confirm the need and usefulness of training health care professionals to implement AIDS Prevention Programs with the drug users.

Medical and Health Consequences of Drug Abuse and Co-occurring Infections Research at NIDA

Jag H. Khalsa, Ph.D.
Center on AIDS and Other Medical Consequences of Drug Abuse (CAMCODA), National Institute on Drug Abuse, United States

Currently, we support an outstanding portfolio of research on medical and health consequences of drug abuse (non-AIDS), and drug abuse and co-occurring infections including HIV (AIDS research), other infections such as hepatitis, TB, and STDs. Examples include projects on the clinical consequences of marijuana, cardiovascular consequences of cocaine and HIV/AIDS, the metabolic and endocrine consequences of drug abuse with or without HIV/AIDS, the role of micronutrients in HIV disease progression. The latter was based on preliminary studies that showed that persons with low levels of antioxidant selenium and drug abuse were at an increased of mortality. Research is underway to study the molecular mechanism of selenium action in HIV disease. Research is also underway to study nutrition in HIV-infected drug abusing Hispanics. In a new area of research at NIDA, the Center is developing a significant portfolio of research on pharmacokinetic and pharmacodynamic interactions among antiretrovirals and pharmacotherapeutics used in the treatment of HIV disease, drug addiction, and mental disorders. We have supported this research by using a number of funding mechanisms including investigator-initiated grants (R01), small grant research (R03), innovative research (R21), research career development grants (K), cooperative agreement (U) programs and others. We disseminate these research findings via NIDA's website, publications in professional journals (the most recent in JAIDS), and also by organizing workshops, meetings, and conferences at the national and international level. These and other issues were discussed.

Sexual Interventions for Drug Users: What works?

Mary Latka, MPH, Ph.D.
New York Academy of Medicine, New York. United States

Since the beginning of the HIV/AIDS epidemic in the US, intravenous drug users (IDUs) have reduced drug-related risk behavior, but still practice risky sexual behavior. Correlates of sexual risk transcend several levels, suggesting that successful interventions are those that intervene at multiple levels. Levels of sexual risk arise from: personal factors like knowledge, perceived vulnerability and self-efficacy; and prior sexual abuse; relationship issues such as gender dynamics and partner risk profile; social factors such as peer norms and the sexual mixing patterns among and between networks; and finally, community-level factors such as the prevalence of a sexually-transmitted pathogen within a network. For drug users in particular, the above factors plus the intersection of concurrent drug use and sex, and gender-related issues pose additional prevention challenges that elevate sexual risk-especially among women. Several strategies and technologies have been evaluated which may help drug users reduce sexual risk. Risk reduction strategies have spanned the range from simple individual counseling sessions to more intensive, interactive, multiple-group risk-reduction workshops. Additional prevention strategies have promoted the use of multiple types of barrier methods at once (for example both male and female condoms, and microbicides) to improve acceptability and boost the overall use of protection. Adding in new prevention technologies that can be used and initiated by women for sexual protection is especially important given the ample evidence that female drug users are often at disproportionate risk for sexual infections. This presentation described novel prevention strategies and technologies that hold promise for reducing sexual infections among IDUs.

VIH Prevention through Sexual Transmission and Mother-to-Child Transmission among Intravenous Drug Users (IDUs) and Non-Intravenous Drug Users (NIDUs) and their Partners within the Public Health System of the Municipality of the City of Rosario

Damián Lavarello, M.D.
Rosario's Municipal Program on AIDS, Santa Fe, Argentina

In Rosario, 5O% of AIDS cases occur in cocaine and opiates IDUs. Moreover, many heterosexual people AIDS cases and the majority of the mother-to-child HIV transmissions are related to IDUs or NIDUs. The social harms and costs related to the illicit drug use in our setting are hard to estimate, but indirect evidence suggests their relevance.¹ In the analysis of the sexual networks of the IDUs and NIDUs, we must distinguish aspects of partnership, pleasure, procreation, and power. Our preventive and health care activities integrate these aspects in a temporal and evolutionist approach, promoting dialogue, condoms, and voluntary HIV testing and counseling. The number of condoms distributed and of HIV tests requested increases steadily. Health teams evaluate with gender perspective the reproductive intentions of couples, and discuss condoms birth control capacities, a non-evident dissuasive issue for their use. Serodiscordant couples in search of children are told to only sustain sexual intercourse without condoms during the fertile days of the woman cycle. These actions may be completed in Primary Care Health Centers with needle and syringes distribution or exchange, thus building a comprehensive set of preventive actions.² Our activities dealing with mother to child transmission include: one or more HIV tests for each pregnant woman, counseling to prevent HIV infection during pregnancy or lactation, condoms promotion, and invitations to their mates in order to include them and offer them HIV tests. A pregnant woman and her baby are treated with antiretrovirals according to national guidelines, optional elective cesarean section, breast feeding substitution, and anti-conception methods. Our frequency of MTCT is about 2%. At the moment, we are reshaping the way we conceive these population, their reproductive expectations, and their vital projects, with the objective of improving our future strategies.

• ¹ Social harms and costs related to illicit drugs in Latin America, priorities and difficulties, Argentina as a Case Study. Inchaurraga, Silvia; Siri, Pablo, en Abstracts, 12th International Conference on the Reduction of Drug Related Harm, April 1-5, 2001, New Delhi, India.
• ² Harm Reduction for Intravenous Drug Users in a Primary Care Health Center of Rosario, Argentina. Lottero, M., Toledo A., in Abstracts, V Argentinean AIDS Congress, November 15-19, 2001, Mendoza, Argentina.

Improving Hepatitis B Virus Immunization Among Young Injectors in San Francisco

Paula J. Lum, M.D., M.P.H.
University of California, San Francisco, United States

Background: Hepatitis B virus (HBV) infection is highly prevalent (44-80%) in intravenous drug using populations, and nearly 60% of IDUs under the age of 30 in San Francisco are at risk of infection. We examined cash incentives plus street-based outreach in improving completion of the HBV immunization series by young IDU. Methods: 170 HBV-naive IDUs under age 30 were offered three recombinant HBV vaccine doses on a flexible 0, 1-2, and 4-6 month schedule. They received reminders from outreach workers and $10 cash for their 2nd and 3rd doses. We examined factors associated with vaccine completion and measured post-vaccination antibody response (anti-HBs > 10 mIU/ml) in 49 completers. Results: 128/170 (75%) received the second dose and 80 (47%) completed the series. Vaccine completion was associated with geographic stability, a prior HIV test, hepatitis C (HCV) status, injecting daily, syringe exchange use, not obtaining syringes from friends, an IDU sex partner, and sources of social support. Multivariate predictors of completion were San Francisco residence for 3 months or longer (AOR, 2.41; 95% CI, 1.20-4.82), a prior HIV test (AOR, 2.79; 95% CI, 1.05-7.41), not obtaining syringes from friends (AOR, 0.43; 95% CI, 0.21-0.87), and ability to rely on an outreach worker for social support (AOR, 2.49; 95% CI, 1.23-5.05). A protective antibody response was observed in 38/49 (78%) of vaccine completers. Among anti-HCV+ vaccine completers, 12/17 (71%) demonstrated anti-HBs > 10 mIU/ml, compared to 26/32 (81%) anti-HCV negative vaccine completers (OR, 0.55; 95% CI 0.12, 2.82). Conclusions: HBV immunization completion is more likely in geographically stable, young IDU, who identify as drug users and engage in other prevention activities, such as HIV testing and syringe exchange. Street-based outreach and reimbursement may improve completion rates. Given suboptimal vaccine responses among vaccine completers, repeated or higher dose immunization schedules may be important for young injectors.

Case-management of HIV-infected Injection Drug Users: A Case Study in Rio de Janeiro

Mônica Siqueira Malta, Ph.D.
Oswaldo Cruz Foundation, Rio de Janeiro, Brazil

Introduction: Our team has been involved in the provision of care/support to HIV+ drug users, trying to improve their quality of life, in a context of universal access to antiretroviral (ARV) therapy.¹ Specific goals are: to improve adherence to ARV and drug treatment referral and to integrate management of drug abuse and HIV infection. Setting: An outpatient unit with a socially deprived clientele, many of them abusing alcohol/drugs and engaged in marginal/illicit activities.

First initiative: Using a mobile unit
This experience is described elsewhere.² It represents a first attempt to integrate outreach activities and backup reference services, linking prevention and treatment.
Second initiative: Case management of people living with HIV/AIDS (PLWHAs)
Case management of PLWHAs has being seldom attempted in Brazil./1 Case management, particularly for those from disenfranchised populations:

• Is an essential tool for improving their quality of life, 
• Helps to manage daily challenges towards optimal care, and 
• Helps to improve HAART adherence.

Cases are being managed in cooperation with a team from the outpatient facility and strategies are discussed with the patients themselves. The facility has a 4-bed day-care unit. An ARV adherence group has been meeting on a weekly basis. Role-playing and psychodrama activities have been introduced. "Waiting room debates", covering a broad range of issues, have been promoted on a monthly basis. Lessons Learned: Brazil is in a unique position among developing countries with regards to ARV therapy.¹ Brazil also has a network of preventive programs targeting drug users, with over 50 syringe exchange programs (SEPs). However, much has to be done in a huge country where social and economic inequalities, stigma and prejudice against dispossessed communities and minorities reach unacceptable levels.¹

• ¹ Bastos FI et al. (2001). Treatment for HIV/AIDS in Brazil: Strengths, challenges, and opportunities for operations research. AIDScience 1(15), November 27.
• ² Malta M et al. Two successful experiences of caring and supporting HIV-infected DUs in RJ, Brazil. To be presented at the XIII International Conference on the Reduction of Drug Related Harm, Ljubljana, Slovenia, 3-7th March 2002.

Obstacles for the Development of AIDS Prevention Policies: Who is Responsible for these Policies?

Raquel Magri, M.D.
Presidential Board on Drugs, Uruguay

Some of the answers to the HIV/AIDS problem are similar to the ones we give to the drug problem. Although it is necessary for the Government to have the primary responsibility, the receptor should also participate in the process. Based on previous research, there are areas in which the receptor should actively participate in the design of the strategies, for example, in the messages to be delivered, in their format and in their distribution channels. If we want to give a message to a rural community, we can not use nicely printed messages from other areas, but some that have the local flavor of the continent. If we are planning an activity with students, we have to think about them, about their beliefs and their attitudes. We must also take into account their parents and their teachers, keeping in mind that the drug problem also affects parents and teachers. They need to participate in the design of those strategies, as well as in the diagnosis and further evaluation of the actions designed for all of them. Actions should be diverse and they also have to be systematized and continuous. Diverse, because whether talking about HIV/AIDS or drugs, there is not just one problem, but rather there is such a diversity of problems as there are people, situations or geographical places. Systematized, because we have to consider all the different stages of the infection-disease, with a different plan for each group, and an integrated one for all the groups. And continuous because it would not be reasonable that these actions, nor any of the campaigns, should be designed for a definite period or have a timetable with a fixed ending. To summarize, we must actively incorporate the receptors into the strategies and the responsibilities.

Preventing HIV: Best Practices or Better Known Practices?

Rafael Mazin, M.D., M.P.H.
Pan American Health Organization, Washington DC, United States

In a world where health promotion is avowed as the main avenue to improve and maintain health and to reduce inequities, only a minimal portion of health budgets for health is earmarked for prevention activities. This blatant contradiction may be related to the misconception that prevention does not require large investments and to the widespread idea that health care is only about fixing problems. In fact, even if the health expenditures are considerable and continuously increasing in all countries, most of the disbursement is still for curative and reparative interventions. Thus, the consensus about the need to put the accent on primary prevention of HIV infection that still exists is not translated into political and managerial decisions to carry out appropriate interventions and activities. In fact, the focus of general interest, concern and attention seems to be on medications, vaccines, and remedies to "solve the problem once and for all" with a great disregard for the countless preventive interventions that have proven efficient and effective. Evidence abounds that preventive efforts do work, but unfortunately it is oftentimes relegated to the pages of specialized publications. Many reported studies overuse the jargon of statisticians and public health professionals thus limiting their access to decision-makers, potential donors, education workers and the general public. Some valuable experiences have been published in languages other than English, which limits not only their wide dissemination, but in many cases also their impact and credibility because of ethnocentric bias. One additional limiting factor is the lack of a "culture of reporting" in many contexts where there is a great eagerness to "do things" but little inclination to monitor and evaluate the scope and impact of those activities. The limited dissemination of the results of preventive efforts, whether positive or not limits the mobilization of resources and the political commitment necessary for launching larger initiatives. Only those preventive efforts that were carefully reported or had the opportunity to be printed in widely disseminated publications are regarded as "best practices", the "golden standards" to be adopted. Since most of the preventive interventions must be highly specific for a given context, in a given historical moment, no models are to be ever adopted, let alone the few accessible ones. Adaptation, adjustment, and planning will ensure that behavior modification and educational theories and models are appropriately used to achieve behavioral and health objectives. The expertise to implement prevention projects exists almost everywhere but it needs to be strengthened with the development of the capacity to monitor and evaluate the impact of the interventions as well as the programmatic factors that facilitate or hamper the impact sought for.

Summary II Phase: WHO Multi-City Study on HIV and Hepatitis B/C Risks among Intravenous Drug Users in Bogota, Colombia: a Multi-method Study

Inés Elvira Mejía, Ph. D. 
Universidad de Los Andes, Bogotá, Colombia

Background: Currently Colombia is considered one of the main producers of opiates in the world. For this reason it is estimated that internal production and trafficking will increase local demand. Therefore, this study centered on identifying the factors that could be stimulating or limiting the expansion of intravenous drug use internally and of the factors that could be exacerbating or lessening the impact of drug injecting on the health of a group of IDUs in Bogota, Colombia. Methods: The first part of the study was designed according to the guidelines of the Rapid Assessment and Response Guide on Use of Intravenous Drugs, developed by the Centre for Research on Drugs and Health Behaviors (CRDHB) of London and the WHO. Data were collected using multiple methods and sources of information. The second part of the study will be carried out in 2002 and includes a component on the seroprevalence of HIV, Hepatitis B and C and a wider sample of IDUs in the city. Results: Given the lack of injecting tradition, basic norms of safe injection are unknown, and although sharing of needles/syringes is not a common practice (due to risk perception), indirect sharing (cookers, rinse water from a common container and filters) is very common. Hygienic injection is rare and overdoses are highly prevalent among those who use heroin. Injection commonly occurs in private and close settings given the stigmatization and harassment from authorities. Sexual risk behaviors are common; condom use is limited with primary and casual partners. Levels of information about HIV, HBV, HCV and other communicable diseases are limited too. Although sterile equipment is highly available, there is an absence of policies, programs and outreach actions targeting at this vulnerable group that discourage injection or prevent transitions to injecting. Conclusions:It is necessary to develop actions, strategies and infrastructure that promote the creation, continuity and impact of interventions for this vulnerable group. This infrastructure must allow the country to adequately face the potential expansion of this pattern of injecting and dependence on opiates. The existing information must also be widened to improve the possibilities of including the problem as a priority on the HIV/AIDS and drug consumption agenda.

AIDS Epidemic in Brazil among Intravenous Drug Users (UDIs) and the National Response

Fabio Mesquita, M.D., Ph.D.
STD/AIDS Program at the Ministry of Health of the City of Sao Paulo, Brazil

The role of intravenous drug users in the spread of the AIDS epidemic in Brazil was evident since its start. The first case registered under this category of transmission occurred in the State of Sao Paulo in 1982. Since 1997, there has been an increase of more than 3,000 new AIDS cases per year reaching a total of 22,879 cases among IDUs by May 31, 1997. These cases represented 20.6% of the total AIDS cases notified in the country as of that date. With a few variations, this proportion has remained the same throughout the Brazilian epidemic. The Ministry of Health estimates that as of December 2000, 25% of the AIDS cases were directly or indirectly related to intravenous drug use, with 38.2% of women with AIDS having contracted the virus through sharing of drug syringes or from an IDU partner, and with 36% of pediatric AIDS cases having an IDU mother or one who has a IDU sexual partner.

The first intent to set up a Harm Reduction Project in Brazil occurred in the city of Santos, State of Sao Paulo, in 1989. However, a governmental action prevented the distribution of syringes and needles at this time. Distribution only began in April 1995 in the city of Salvador in the State of Bahia. In 1998, the Governor of Sao Paulo passed the first Law in Brazil authorizing needle exchange programs. In December 2001, the President of the Republic passed a new Drug Law, which made syringe exchange programs legal in all the country. Today, Brazil has more than 100 projects in various States, most of them co-financed by the Federal Government.

Santos, State of Sao Paolo: Comparative Study of Tendencies in the 90s

The Santos Metropolitan Region is known as one of the areas with the greatest number of AIDS cases in proportion to the population in all of Brazil. The main objective of this work was to study the tendency of the HIV epidemic and it s determinants, among IDUs during the 1990s in the region. In 1991-92 (before any type of intervention occurred), 1994-1996 (harm reduction programs began), and in 1999 (with harm reduction programs and syringe exchange programs in place), three cross-sectional studies were carried out. A total of 468 IDUs were interviewed and tested for HIV, hepatitis B and C. Of these IDUs, 70% were men, 87% were younger than 40 years of age, and 84% had less than 9 years of formal education. The seroprevalence rates for HIV were 63%, 65% and 42%, respectively for the years studied. The use of crack increased from 11% to 60% and then 67% in the respective studies, while the frequency of intravenous drug use (>5 times daily) decreased from 42% in the first study to 30% and then to 15% in the subsequent studies. There was no significant alteration in the pattern of safe sex in the population. Concretely, the prevalence of HIV decreased during the second and third studies as did the frequency of intravenous drug use, while the use of crack increased. The studies concluded that the change in drug consumption patterns probably affected the HIV epidemic more than did the modest public health interventions carried out during the last 10 years.

Drug Treatment as HIV Prevention

David Metzger, Ph.D.
University of Pennsylvania, United States

The AIDS epidemic has had a profound impact on the drug using community and many prevention strategies have been implemented in an attempt to reduce the spread of HIV infection among drug users. These have included education regarding viral transmission and methods for reducing risk of infection; increased access to HIV testing and counseling; condom, bleach, and needle distribution; and expanded outreach. No intervention, however, has been as widely applied nor as carefully evaluated as substance abuse treatment. A substantial amount of data evaluating the direct relationship between treatment participation, HIV risk reduction, and infection with HIV will be presented. In reviewing the literature of the past twenty years, many studies have documented significantly lower rates of drug use, drug-related risk behaviors, and HIV infections occur among drug users who remain in treatment. Most of the currently available data is derived from studies of methadone treatment, a treatment commonly used by opiate injectors in many countries. However, emerging data will be reviewed regarding risk reduction associated with treatments for cocaine and non-injection drug use. The available data suggests that drug treatment, in conjunction with harm reduction and community based outreach, is essential to respond to the HIV epidemic among drug users and their sexual partners. Despite strong evidence of effectiveness and widespread support for the important public health role of drug treatment, its impact has been compromised by limited access.

Blood Transmission Infections and STI in IDU Patients and Their Sexual Partners

Graciela Moscatello, M.D. 
Hospital Francisco J. Muñiz, Infectious Diseases Unit, Buenos Aires, Argentina

Since 1983 we have diagnosed over 3,300 AIDS cases and nearly 9,000 infected asymptomatic people, of which 47% are IDUs. The prevalence rates in IDUs are quite high: HIV: 80%; HCV 92%; HBV 73%; HHV (17%; HTLV I/II 8%; TB 44%; TB-MR 30% (out of TB cases) Syphilis 22%, Gonococci 15%; HPV 3%. TB is the main health problem generated in IDUs, with HIV infection being the main risk factor. Among HIV+ IDUs the possibility of developing TB is twice as high as in non IDUs. From 1983 to June 2001, out of 3,292 AIDS cases, there were 1,472 TB cases registered. Since 1992, there have been 202 TB-MR cases, 75% in IDUs, 25% in non IDUs. From January 1992 to June 1999 TB grew from 26.2 cases per 100 persons to 36.8 and TB-MR from 2.2 to 8.5. Of these, 44% percent had a sexual couple that was HIV+; and 60% were IDUs that were HIV+. This is in addition to the poverty conditions that favor the development of TB, STI and increase the sexual/perinatal transmission of HCV. The higher rate of chronic hepatitis and cirrhosis in IDUs neutralizes the benefits derived from HAART therapy. Lamivudina eliminates HBV with an efficacy of 86%, in HIV+ patients after two years of treatment. Resistance occurs in 50% of the cases. The higher HCV incidence requires treatments with interferon/ribavirin treatments that increase the assistance costs and that have a higher toxicity, which is worsened by drug abuse. In IDU women, gonococci and HPV generate pelvic inflammatory disease (PID), cervical carcinoma, which can misdiagnosed.

Epidemiology of HIV and Other Blood-borne Pathogens among Injecting Drug Users Starting Detoxification in Metropolitan Barcelona

Roberto Muga, M.D., Ph.D.
Metropolitan Hospital, Barcelona, Spain

The majority (2/3) of the 61,000 AIDS cases in Spain are related to intravenous drug use and this pattern of spread has been observed since the beginning of the epidemic. Temporal trends in the epidemiology of HIV among IDUs from our hospital cohort of IDUs starting detoxification since 1987 indicate an overall decline in the prevalence of HIV among the new (<5 years of addiction) IDUs. However, prevalence of HCV is above 60% in the same population. In settings with a high residual prevalence of HIV, the emerging epidemic is related to HIV/HCV coinfected individuals surviving from AIDS but at risk of developing end-stage liver disease. Prevalence of HBV (HBsAg positive) and serologic syphilis (RPR/TPHA positive) remain stable over time. Tuberculosis is the most frequent opportunistic infection in Spain and the results from our area indicate that before the HAART era the risk of developing active TB among 184 HIV+ IDUs was 15% at 5 years of follow-up (incidence rate: 3/100 person-years). Concerning the incorporation of HIV+ IDUs to antiretroviral therapy (ART), our cohort of seroconverting patients indicates that 40% were receiving HAART as of January 2000. However, in a cross-sectional analysis among HIV+ IDUs admitted to detoxification between 1997 and 2000, 64% reported lifetime prevalence of ART use (current and past) but only 30 % were currently taking ART at admission. The impact of current intravenous drug use on discontinuation of ART could have consequences not only in the risk of disease progression but also on the transmission of MDR-HIV to the new injectors.

Challenges to Implementing Preventive Activities in a Developing Country

Maria Luz Osimani, Ph.D.
Research and Development Institute (IDES), Montevideo, Uruguay

With 3,400,000 inhabitants, Uruguay has, as of December 2001, 4,041 HIV positive cases and 1,788 AIDS cases.¹ Twenty-five percent of HIV-infected persons are intravenous drug users (IDUs). Forty percent of HIV+ children are born to drug-user mothers or who have UDI sex partners. Cocaine is the main intravenous drug used. Consumption begins at the ages between 11 and 15.²Intravenous injection begins at around 16 and 18 years of age. There is little perception of the risk of hepatitis B and C, HIV re-infection, interactions between drugs and fixing substances, nor about risky sexual behavior. The laws that are in force make it difficult for IDUs to have access to integral health service. Distribution of syringes is not allowed. Human rights for drug users are not taken into account. There is an absence of epidemiological studies of HIV/AIDS and hepatitis C in UDIs and an absence of preventive actions by local and national government, with regards to this population. There is a pilot experience in prevention and risk reduction at the community level that took place in Montevideo and was developed by IDES. It is urgent to implement research-based programs, sustainable for the long run, and to take urgent action in the intervention areas of sexual risks and problem drug use. Two important areas are training of health personnel to be able to bring in drug users into treatment at an early stage and obtaining legislative support to guarantee public health interventions.

• ¹National AIDS Program Bimestral Bulletin, Ministry of Public Health, 12/01 Uruguay.
• ²Qualitative investigation with injecting drug users 2000-2001, IDES Institute National AIDS Program- Ministry of Public Health- Thematic UNAIDS Group Supervision.

Harm Reduction among Drug Users from Poor Sectors of Buenos Aires, Argentina: Experiences, Obstacles and Challenges

Graciela Radulich, Prof.
National University of La Plata, Buenos Aires, Argentina

In order to study drug use within a context of poverty, it is necessary to undertake a complex analysis considering various perspectives to be able to understand the dense interweaving of socio-economic, political, and cultural factors. The analysis of this social scenario is our starting point in order to be able to plan holistic actions for the prevention of HIV-AIDS and other illnesses related to drug consumption. Merely copying "successful" models from developed countries-designed for other contexts and populations-would limit us to carrying out insufficient and ineffective actions. The ACCRAD/El Retoño is an NGO that has been working since 1985 towards the consolidation of a model of analysis and intervention that considers this complex framework and seeks to meet the needs of drug users from the poorest sectors of society. Our research on drug use and poverty, together with the documentation of harm reduction interventions carried out since 1997 demonstrate the need to implement the following strategies:

• Carry out prevention and care strategies specifically designed for sub-groups within the drug-using population: IDUs and non-IDUs, sex workers, immigrants, prison population, among others. 
• Bring into public debate the discussions and policies that promote the daily exclusion and criminalization of drug users. 
• Develop research and specific interventions for Hepatitis C. 
• Work closely with local health centers in order to guarantee the access and continuity of specific medical treatments. 
• Develop specific and gender sensitive interventions designed for women drug users. 
• Work with the society at large: a) on the micro level, empowering local community networks that can expand harm reduction actions, b) on a macro level, raising awareness and involving actors with political decision-making power.

HIV Risks and Patterns of Drug Treatment and Health Care among Puerto Rican Drug Users in Puerto Rico and New York

Rafaela Robles, DS
Central University of the Caribbean's School of Medicine

The purpose of this study was to determine the HIV risk factors and health care use among Puerto Rican drug users residing in Puerto Rico and New York. The study was conducted in East Harlem, NY and Bayamón, PR. Ethnographic data was collected at baseline and follow-up. The sample comprised 800 drug users in NY and 399 in PR. Puerto Ricans residing in PR were more likely to be IDUs, males, less likely to have been in jail, and HIV seropositive than Puerto Ricans residing in NY. Puerto Ricans in PR were significantly more likely to inject more frequently, use shooting galleries, share syringes, have multiple partners, and not use condoms. Puerto Ricans residing in PR were less likely to use health services and drug treatment, including methadone treatment. Subjects who reported use of methadone treatment were less likely to inject more frequently than those who did not use this treatment. Conclusions: Puerto Rico needs to significantly improve access to health care, especially methadone treatment, to be able to reduce HIV risk behaviors, and the self-sustaining HIV epidemic.

Prevention in IDUs and their Partners. Lessons Learned in Latin America: The Argentine case

Diana Rossi, DSW
Intercambios Civil Association and the University of Buenos Aires, Argentina

In Argentina, 39% of those diagnosed with AIDS acquired the virus through intravenous drug use. Nevertheless, it was only in the 1990s that some harm reduction activities oriented to drug users were begun in the country. The research and intervention model has several successful examples in development. The application of the rapid assessment and response methodology helped in the development of the first syringe exchange program in the country.¹ Community based outreach is an appropriate model to use with poor populations in Buenos Aires. In that framework, seroprevalence studies and focalized preventative campaigns oriented to drug users, their sexual partners and children, have been developed.² A pilot prevention project geared towards pharmacies as a privileged environment through which to reach drug users was developed with the participation of 23 pharmacies in Buenos Aires City. The focalized campaign oriented to drug users was more effective after a cooperative work between 15 governmental and non-governmental organizations in the cities of Buenos Aires and Rosario, which allowed them to reach 900 IDUs with preventative messages in a three-month period. In each location the distribution of preventive material was in the hands of community operators (drug users and ex drug users) and a technical advisor from each organization. Six hundred (600) opinion surveys on the preventive materials that were distributed furnished evaluation indicators of the process. Research activities, community-based interventions and collaborative work between different organizations are making it possible to have more and better contact with the IDU population in Argentina.

• ¹D. Rossi, P. Cymerman, N. Ereñu, S. Faraone, P. Goltzman, E. Rojas, G. Touze, S. Vazquez "Rapid Assessment and Response in IDUs in Buenos Aires", 2000 Global Research Network Meeting on HIV Prevention in Drug Using Populations, NIDA, Washington, 2001, ps. 42/45.
• ²Rossi, D. (org) "AIDS and Drugs. Harm Reduction in the Southern Cone" Intercambios, UNAIDS, National AIDS Program of the Ministry of Health, Buenos Aires, 2001.

Drug Abuse in HIV-Infection: Risk of Neurological Disease and Treatment Issues

Walter Royal, M.D.
Morehouse School of Medicine, United States

Nervous system disease in HIV-1 (HIV) infection frequently occurs despite the availability of highly potent antiretroviral therapies. Among the manifestations associated with primary nervous system involvement, dementia and neuropathy remain significant causes of disability. In recent years, the use of more effective therapies has been associated with a decrease in the incidence of dementia. However, newer clinical cases have presented a clinical profile which suggests that cases may begin to appear in individuals with less severe immunocompromise. Clinical and pathological studies demonstrate that drug users might be at higher risk of developing these disorders, as well as other complications such as cerebrovascular disease. In this presentation will be discussed current approaches to the treatment of HIV dementia and neuropathy with an emphasis placed on issues pertinent to the treatment of VIH+ drug users with neurological disease.

HIV/AIDS Epidemiology in Intravenous Drug Users (IDUs) in Argentina

Sergio Sosa Estani, M.D., Ph.D.
National Center for Diagnosis and Research on Endemoepidemics, Buenos Aires, Argentina

Between 1982 and March 31, 2001, there were 19,193 officially-notified AIDS cases in Argentina. Eighty percent of these cases were found in large urban cities. Intravenous drug use was the main risk behavior among all of the notified cases of AIDS (39 %), followed by men who have sex with men (MSM) (24.9 %) and heterosexuals (23.9 %). The number of drug users in Argentina is estimated at around 671,584, of which about 10 % are IDUs. Based on the rate of HIV prevalence among IDUs obtained from several studies, it is estimated that there are between 12,137 and 34,538 IDUs that are HIV+. Several studies carried out between 1988 and 1999 show high rates (34.4%-63.9%) of HIV prevalence in IDUs. Serological studies for HIV in different populations from sentinel sites were performed in 2000. The mean prevalence for HIV in pregnancies was 0.7%; for STD consultations, 4.2%; for spontaneous consultations, 3.2%; in prisoners, 17.5%; blood donors, 0.2%; sex workers, 1.7%; MSM, 14.9%; and IDUs, 45.9%. Fifty-five per cent of HIV-infected children were born to IDU women or women whose partners were IDU. The practice of intravenous drug use is the main risk factor associated with HIV infection in Argentina. Therefore, it is necessary to develop actions in the short term to decrease such transmission.

References

• SEDRONAR. Estudio nacional sobre sustancias adictivas, Argentina, 1999.
• Bulletin on AIDS in Argentina, No. 20. Executive Coordination Unit on VIH/AIDS, Ministry of Health, 2001.

The Dynamics of HIV in Brazil: Empirical and Theoretical Considerations - The Case of IDUs in the Southern Region - The AjUDE-Brasil Project*

Waleska Teixeira Caiaffa, M.D., M.P.H., Sc.D.
Federal University of Minas Gerais, Brazil

Waleska Teixeira Caiaffa1, FA Proietti 1, SA Mingoti 2, AB Carneiro-Proietti 3, D Doneda 4, D Gandolfi 4 and AjUDE- Brasil I & II Projects
1Dept. of Preventive Medicine and 2 Dept. Statistics, Federal Unviersity of Minas Gerais, 3 Hemominas Foundation, 4 National STD/Aids Ministry of Health, Brazil

This study was aimed at discussing evidence of increased HIV prevalence in southern Brazil, using data from two cross-sectional multicenter studies on IDUs attending Syringe Exchange Programs (SEP). Interviews and blood spots for HIV serology were carried out. This analysis included 187 IDU from the 1st survey (1998) and 260 from the 1st phase of the 2nd survey (2000), who were living in Porto Alegre (RS) and Itajaí (SC). HIV seroprevalence increased in Porto Alegre (48.5 in 1998 and 77% in 2000) as well as the mean age (from 28 to 32) and the duration of drug use (from 11 to 13 years). On the contrary, a decline of HIV+ from 78 to 40% (p<0.05), age and duration of drug use was reported in Itajaí. Homelessness, joblessness and imprisonment increased significantly in Porto Alegre, as well as lifetime needle sharing (from 28 to 74%, p<0.05). In Itajaí, a significant reduction was reported in lifetime needle sharing (68 to 35%) but not in the past 6 months (43 to 75%). Condom use was similar by year of survey and by site, but an increased report of MSM was noted in Porto Alegre (from 15 to 39%). IDUs reported a higher use of SEP services in both sites, but only in Porto Alegre the average use went from 6 to 9 months (p<0.05). There was an increase in both sites of IDUs seeking health care (but not drug treatment) and HIV testing. Survival changes, lead and attendance bias, and modification in the dynamic of the transmission must be considered in studies of prevalence as well as age-sex structure of the population.

*Sponsored by: The Brazilian Ministry of Health's National STD/Aids Program

Obstacles for the Development of Prevention and Health Care Policies in Argentina

Graciela Touzé, DSW
Intercambios and University of Buenos Aires, Argentina

The spread of HIV/AIDS epidemic and its impact on the IDU population occurred while governmental social assistance diminished and poverty increased within the Argentinean population. Five main obstacles for the development of HIV/aids prevention policies in IDUs have been identified:

1. Scarce development of research and its meager impact on the definition of governmental policies. 
2. The characteristics of the legal framework regarding illegal drug use. 
3. The orientation of the health and social care services directed at drug users. 
4. Deficiencies in the training of technicians and professionals related to these issues. 
5. The characteristics of the allocation of existing resources.

International agencies play a very important role in this context. As an example, the influence of UNAIDS on the Project "Prevention of HIV infection in IDUs in the Southern Cone" is remarkable. The project is being carried out in Argentina, Chile, Paraguay and Uruguay. The first phase was developed in the four countries in the year 2000. The project is sustained through a collaboration between the State and the civil society, and is characterized by the work being carried out between the governmental area of aids and an NGO in each country. The second phase, which shall begin in the year 2002, will continue with this model, and Brazil will enter as another partner as well as the United Nations Office for Drug Control and Crime Prevention (UNODCCP) with economic support. This model is a challenge to the sustainability of research and intervention projects in the region, and is seeking consensus for the development of harm reduction policies, and for needs that must be supported and replicated to help to solve the identified obstacles.

Effect of Methadone and Drug Free Treatment on Service Use Indicative of Poor Health in HIV+ Drug Users.

Barbara J Turner MD, MSEd*, Christine L. Laine, MD, MPH**, Walter W. Hauck PhD**.
*University of Pennsylvania, Philadelphia, PA; ** Thomas Jefferson University, Philadelphia, PA.

Barbara J. Turner, M.D., MSEd
University of Pennsylvania, Philadelphia, United States

Long-term (6+ months) methadone (METH) treatment appears to improve the health status of opiate abusers. However, few studies have evaluated long-term, medically-supervised, drug free (DF) treatment that is used for cocaine or other non-opiate drug abusers. In a population-based cohort of HIV+ drug users enrolled in New York State Medicaid in 1996-97, we examined the associations of long-term METH and DF treatment with repeated ER visits and hospitalization as services that reflect poor health status. From Medicaid claims files, we defined long-term METH and DF care, regular medical care, and clinical conditions in 1996 as well as the outcomes of 2+ ER visits and any hospitalization in 1997. Only 17.5 of METH clients (n=4,569) and 16.6% of DF clients (n=126) had 2+ ER visits vs. 29.2% of (n=6,861) other drug users with little or no drug treatment (P<0.001). Hospitalization occurred in 47.8% of METH and 34.1% of DF clients vs. 61.3% of other drug users (P<0.001). After adjusting for demographics and clinical factors, the adjusted odds ratio (AOR) of 2+ ER visits for METH clients was 0.72 (CI 0.66-0.80) and for DF clients was 0.56 (CI 0.35-0.90) vs. other drug users. The AOR for hospitalization in METH clients was 0.75 (CI 0.69, 0.82) and DF clients was 0.44 (CI 0.30, 0.64). Treatment with long-term METH or DF care was associated with significant reductions in the use of medical services that reflect poor health status in HIV+ drug users but DF treatment had a stronger protective association with reduced hospitalization.

Seroprevalence of HIV, HBV, HCV, HTLV-I/II Infections in Intravenous Drug Users in Buenos Aires, Argentina*

Mercedes Weissenbacher, M.D., Ph.D.
National Reference Center for AIDS, School of Medicine, University of Buenos Aires, Argentina

The spread of HIV and hepatitis viruses related with intravenous drug use has become an important public health problem in Argentina. The aim of this study was to determine the seroprevalence of infections with HIV, Hepatitis B (HBV), Hepatitis C (HCV) and Human T-Lymphotrophic Virus, Types I and II (HTLV-I/II) in IDUs in Argentina. From June 2000 through March 2001, blood samples were taken from 174 IDUs from the surrounding areas of the city of Buenos Aires. Of these, 78.7 % (137/174) were men; 83 % were heterosexual; 94 % injected cocaine. The average age was 30 years for both sexes. Seroprevalence in the IDUs studied was 44.3% for HIV; 54.6 % for HCV; 42.5 % for HBV; 2.3 % for HTLV-I and 14.5 % for HTLV-II. Analysis of the 174 IDUs showed that only 37 % had no virus infection and 63 % had one or more viruses. Of the infected ones, 21 % had simple infections, 26 % had two viruses, 35 % had three viruses and 18 % had four viruses simultaneously. Seroprevalence for HIV, hepatitis B and hepatitis C viruses was high in the IDU population studied. The risk for HIV-infected people of being co-infected with any of the other tested viruses (HBV, HCV, HTLV-I, HTLV-II) was highly significant. The high prevalence of different viruses found in the studied population and the lack of both assistance and prevention shows the need of developing prevention and medical assistance directed at the IDUs.

NIH:NIDA:CAMCODA:JHK:301.443.2159:6/18/2002:abstracts-all-english1a

Recommendations

Areas Recommended for Future Emphasis

Research: Consensus was reached that NIDA/NIH and/or world organizations such as the PAHO/WHO should support research on drug abuse and co-occurring infections including HIV, hepatitis, tuberculosis, and sexually transmitted diseases. Suggested areas of research were: (i) epidemiology, basic, clinical, diagnosis, prevention, treatment, and health care access, with emphasis on high risk sub-populations including IVDUs, men who have sex with men, women, children, adolescents and youth; (ii) behavioral (attitudinal and motivational) research applicable to different cultures; (iii) development of instruments to evaluate HIV and HCV prevention knowledge and service needs of drug users and that are applicable to various Latin and North American countries; (iv) development of strategies and infrastructure to further encourage collaborations in the United States, Latin America and the Caribbean Islands; and (v) establish special funding programs dedicated for less developed Latin and Caribbean countries to improve the capacity to provide health care.

Protocol development: Support the development of standard research protocols that could be used in different cultures, countries, regions and communities to foster the utilization of clinical and applied research findings applicable to a wide variety of infected drug users.

Intervention (prevention/treatment): Develop actions, strategies and infrastructure to promote development, continuity and impact of interventions (prevention, treatment), and risk reduction programs for drug abusers with co-occurring infections.

Publication/Dissemination: Disseminate research findings and best practices via publications, conferences and workshops to professionals engaged in providing health care at the clinic and community levels in Latin America and the Caribbean Islands.

Training: Develop programs of training investigators and other professionals in the areas of epidemiology, intervention, diagnosis, management of infections, and health care access specific to minorities in Latin America and the Caribbean Islands; develop bilingual training manuals for professionals engaged in providing health care access to drug users with infections; provide travel awards/scholarships to young investigators to attend international meetings on AIDS and Drug Abuse.

Policy: Based on sound research, formulate/design policies that would promote sound health care practices applicable to drug users with co-occurring infections in Latin America and the Caribbean Islands.