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
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
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
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
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
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
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, pag 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
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-na•ve
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
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
AIDS Epidemic in Brazil among Intravenous Drug Users (UDIs) and the
Fabio Mesquita, M.D., Ph.D.
STD/AIDS Program at the Ministry of Health of the City of Sao Paulo,
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
Graciela Moscatello, M.D.
Hospital Francisco J. Muñiz, Infectious Diseases Unit, Buenos
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 15.2 Intravenous 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
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
- 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
- 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
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
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,
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
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
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.
- 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
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:
- Scarce development of research and its meager impact on the definition
of governmental policies.
- The characteristics of the legal framework regarding illegal drug
- The orientation of the health and social care services directed at
- Deficiencies in the training of technicians and professionals related
to these issues.
- 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
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.