Short Communication

Short Communication CHANGING PATTERNS OF COCAINE USE AND HIV RISKS IN THE SOUTH OE BRAZIL^

in the Americas, surpassed only by the United States. In addition to these confirmed cases of AIDS, UNAIDS estimates that there are some 620,000 persons currently living with HIV infection in Brazil, with the majority located in the heavily populated southeastern part of the country (UNAIDS 2006). In the months since then, it is likely that many thousands more have become infected with HIV. The initial cases of AIDS in Brazil were identified in 1982 in the states of Rio de Janeiro and Sao Paulo, where one and four cases were recorded, respectively (Rodrigues & Chequer 1989). In 1983,31 more cases were recognized, with notable increases in subsequent years. By the 1990s, the annual incidence rates per hundred thousand population had increased significantly, from 10.6 in 1992, to 11.8 in 1993, to 17.5 by 1998, to a peak of 19.2 in 2003 (Brazilian Ministry of Health 2005). The highest concentrations of AIDS cases have occurred in the southeastem and southern regions of the country, in the cities of Sao Paulo (19.3%), Rio de Janeiro (9.5%), and Porto Alegre (3.6%), with the majority among persons in the 25- to 40-year-old age group (Brazilian Ministry of Health 2003). Sexual transmission accounts for the overwhelming majority of cases, followed by injection drug use (IDU), other/unknown causes, receipt of contaminated blood products, and perinatal transmission. The actual number of AIDS cases in Brazil is no doubt grossly underestimated, given diagnostic deficiencies and the prevailing social climate which reflects a generalized (and sometimes quite specific) discrimination against people with AIDS (UNAIDS 2004; Inciardi, Surratt & Telles 2000; Parker 1999; Daniel & Parker 1993; Quinn, Narain & Zacarais 1990). In Brazil as a whole, some 51,000 cases of AIDS have been attributed exclusively to injection drug use since the beginning of the epidemic. Each year in Brazil, approximately 3,000 new AIDS cases are diagnosed in which injection drug use is identified as the primary exposure category. The cities with the highest AIDS incidence rates in Brazil have large populations of injection drug users. Incidence rates in these municipalities at the end of 2002

James A. Inciardi, Ph.D.* Hilary L. Surratt, Ph.D.** Flavio Pechansky, M.D., Ph.D.* Felix Kessler, M.D., M.Sc.*** , Lisia von Diemen, M.D.**** Eiisabeth Meyer da Siiva, B.A., M.Sc. Steven S. Martin, M.Sc, M.A.*****

Abstract—For well over a decade, researchers in Porto Alegre, Brazil, have been documenting the extent of the AIDS epidemic in the region, with a specific focus on the linkages between drug use and HIV seropositivity. Virtually all of the studies conducted during those years found injection drug use (IDU) to be the major vector for HIV seropositivity in this population. However, recent research found that the number of IDUs had declined significantly. Qualitative interviews and focus groups suggested many reasons for this decline: (1) many had died, because they had never heard of AIDS or HIV, and were unaware of how HIV is transmitted. As a result, they had become infected through the sharing of injection paraphernalia. (2) The quality of street cocaine had declined, making injection difficult. (3) Because of a fear of AIDS, some shifted to the smoking of crack, which had become a newly availability commodity in the street culture. Within this context, this article describes the qualitative data describing the decline of cocaine injecting and the corresponding emergence of crack use in Porto Alegre, Brazil, and related HIV risks. Keywords—Brazil, crack, cocaine, drug users, HIV, injection

Through June of 2005, Brazil had reported almost .372,000 documented cases of AIDS to the World Health Organization (Brazilian Ministry of Health 2005). As such, Brazil had the second largest number of known AIDS cases tThis research was supported, in part, by HHS grant ROIDA11611 from the National Institute on Drug Abuse. *Professor and Director, Center for Drug and Alcohol Studies, University of Delaware, Coral Gables, FL; Center for Drug and Alcohol Research, Federal University of Rio Grande do Sul, Brazil. ••Scientist, Center for Drug and Alcohol Studies, University of Delaware, Coral Gables, FL; Center for Drug and Alcohol Research, Federal University of Rio Grande do Sul, Brazil. •••Associate Director, Center for Drug and Alcohol Research,

Journal of Psychoactive Drugs

Federal University of Rio Grande do Sul, Brazil. ••••Data Manager, Center for Drug and Alcohol Research, Federal University of Rio Grande do Sul, Brazil. •••••Senior Scientist and Associate Director, Center for Drug and Alcohol Studies, University of Delaware, Coral Gables, FL. Please address correspondence and reprint requests to James A. Inciardi. Ph.D., University of Delaware Research Center, 2100 Ponce de Leon Boulevard, Suite 1180, Coral Gables, FL 33134.

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ranged from 78.9 per 100,000 in Balneirio Camboriu, to 90.6 cases per 100,000 in Porto Alegre—both port cities on the Atlantic coast in the South of Brazil (Brazilian Ministry of Health 2003).

COCAINE USE IN PORTO ALEGRE For well over a decade, researchers in Porto Alegre have documented the extent of the AIDS epidemic in the region, with a specific focus on the linkages between drug use and HIV seropositivity (De Boni & Pechansky 2002; Pechansky & Bicca 2002; Pechansky et al. 2000; Lima, Pechansky & Genro 2002). Virtually all of the studies conducted during these years found injection drug use (IDU) to be the major vector for HIV seropositivity in this population. For example, in an epidemiologic study conducted during the latter part of the 1990s, 695 drug users were recruited from various treatment locations in Porto Alegre and were subsequently interviewed about their HIV risk behaviors and were offered HIV testing. Of those tested, 23.6% of the males and 20.3% of the females were found to be HIV positive (Pechansky, Soibelman & Kohlrausch 1997). Among the 246 with a history of IDU, 44.2% tested positive for HIV (Pechansky et al. 2000). In addition to injection drug use, other predictors of HIV seropositivity included low education (31.5% seropositive among those with fewer than eight years of schooling) and low income (35.7% seropositive among those earning only one minimum wage—at the time, about US$72 per month). Among the 168 drug-using women interviewed in this study, 82% reported engaging in unprotected sex, and 33% reported sex with IDU partners (Pechansky & Von Diemen 1999).

THE SOUTH OF BRAZIL Comprising the states of Rio Grande do Sul, Santa Catarina, and Parana, the South of Brazil is closer to the southern cone of the South American continent than the well-known cities of Sao Paulo and Rio de Janeiro, and is the only part of Brazil below the Tropic of Capricorn. The South is considered the "breadbasket of Brazil," and Rio Grande do Sul, the largest of the three states, is the land of the "gauchos"—the cowboys of Brazil. Initially nomads, and today farmers and ranchers, the gauchos have maintained their culture and their picturesque costume: wide-brimmed brown hat, baggy trousers (bombachas), neck scarf, poncho, and wide leather belt (guaiaca). Their gear consists of a lasso for roping cattle; three balls of metal or stone tied to a rope (boleadeiras) and thrown in front cattle for the purpose of herding them; a special knife attached to the belt for cutting meat or making cigarettes; and a special belt (tirador) to hold a lasso. The gaucho's typical drink is a hot tea made of dried leaves of "erva mate" (chimarrao, in the local gaucho language) sipped from a hollow bowl, through a silver straw with a round metal spoon-like tip with dozens of small holes (bomba) to allow the hot beverage to be sipped, leaving the green leaves inside the bowl. The chimarrao is passed on to the next person with the right hand and received with the left hand ("from the heart") as a sign of friendship and social contact. Sipping chimarrao is a group activity by definition in this part of Brazil. The gaucho culture is extremely male-dominated, and "macho" displays are regarded as important, such as enduring pain, not crying, and manifesting aggressive mannerisms in behavior and voice tone. Later in this article reference is made to how the "gaucho culture" influences modes of drug use in Porto Alegre.

During the course of new research in 2003 targeting cocaine injectors and their female sex partners, recruitment and screening were conducted with individuals presenting for treatment at the Centros de Apoio e Orienta9ao Sorol6gica (COAS) in Porto Alegre. The COAS is a system of municipal and state public health centers serving indigent populations in all parts of Porto Alegre, providing free pregnancy testing, HIV testing, and other health care. The COAS centers are excellent locations for recruiting drug users and their sex partners for a variety of reasons: (1) the overwhelming majority of COAS clients are from Porto Alegre's many favelas (urban shanty towns) - places with high concentrations of drug users of all types; (2) the COAS catchment areas include the entire city of Porto Alegre; and (3) COAS centers are the only places in the city offering basic health care at no cost, thus attracting patients from throughout Porto Alegre and surrounding areas. As such, the drug users presenting for public health treatment at COAS are likely representative of the wider population of indigent drug users in the city. At the outset of the research, initial screening interviews found few IDUs. This appeared to be unusual, given prior research documenting that injecting and snorting were the primary modes of cocaine ingestion in Porto Alegre (Pechansky et al, 2003; Pechansky, Soibelman & Kohlrausch 1997). Further inquiries suggested that there had been a recent and dramatic decline in the size of the city's IDU population, with a concomitant rise in the

Rio Grande do Sul, the largest of the three states making up the South of Brazil, has the third highest number of AIDS cases in the country, as well as the highest HIV prevalence among women in any region of Brazil (BergenstrOm & Sherr 20(X)). Moreover, the most frequent exposure category for women in Rio Grande do Sul is "heterosexual contact with a high-risk partner," who is typically either HIV-positive or an injection drug user. Porto Alegre, the capital of Rio Grande do Sul, is the fifth largest city in Brazil. It has a population of 1.5 million, is surrounded by many satellite cities containing hundreds of thousands of residents, and is a major manufacturing center in South America (Menegat 1999). Porto Alegre also accounts for some 70% of the AIDS cases in the State of Rio Grande do Sul, and significant numbers of these are among injection drug users. Journal of Psychoactive Drugs

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smoking of cracifc-cocaine, which was a considerable surprise to most observers in the local research community. Although the use of crack had become visible in Sao Paulo during 1990 and 1991 (Ferri et al. 1997; Inciardi 1993), crack had rarely been seen in other Brazilian cities, including Porto Alegre. Within this context, this brief communication reports on qualitative research conducted to document the changing patterns of drug use in Porto Alegre, the reasons for these changes, and how the emerging patterns of drug use are impacting HIV risk behaviors in this context.

The reasons given for the decline in the number of IDUs included: • High mortality among IDUs, because they had never heard of AIDS or HIV, and were unaware of how HTV is transmitted. As a result, they had become infected through the sharing of injection paraphemalia. • The declining quality of street cocaine, which made injection difficult. • A shift to the smoking of crack, which had become a newly available commodity in the street culture, due to a fear of HIV and AIDS.

METHODS

Needle Sharing and Syringe Exchange It was generally agreed that although there were still some injection drug users throughout Porto Alegre, they tended to congregate where the cocaine dealers could be found—in the dilapidated neighborhoods and favelas where there are numerous alleys and dead-end streets. These "closed streets," as they are referred to locally, provide cover for both users and dealers, and most of the activity occurs from sunset to very early morning. Some injectors use drugs right out on the streets, but most prefer shooting galleries, or "bretes" (the local gaucho term for the location where cattle are vaccinated). A few of the group members, however, tended to be more practical: "If you have the drug, any place will do." Needles and syringes can be legally purchased without a prescription in Brazil, but focus group participants agreed that if a user had the funds to buy injection equipment, he or she would choose to buy drugs instead. It is for this reason that needle/syringe sharing proliferated during the past few decades, leading to the establishment of the syringe exchange harm reduction program during the late 1990s (Surratt & Telles 2000), which is praised by local and national policymakers as the most organized and efficacious needle exchange program in the country. One focus group member remarked that because of the harm reduction program, "there are plenty of syringes—there are more syringes than drugs in the streets." There is a generalized perception that needle use and needle sharing, as well as syringe exchange, is diminishing in Porto Alegre, most likely the result of the fear of AIDS and the deaths of so many injectors. One of the outreach workers from the syringe exchange program indicated:

In 2004, the authors conducted a series of 19 key informant interviews and five focus groups with a wide variety of individuals who had knowledge of the local drug scene—including male and female drug users (including cocaine injectors, snorters, and smokers), HIV prevention outreach workers who were former drug users, harm reduction workers from the city's syringe exchange program, and public health and community leaders with knowledge of the local street drug culture. Although the key informants included both drug users and nonusers, there were 25 focus group participants, all of whom were active drug users. They were recruited from many different areas of the city, and virtually all living in either favetas or extremely poor adjacent neighborhoods. The study protocol was approved by the Institutional Review Boards of both the University of Delaware and the Federal University of Rio Grande do Sul; infonned consent was obtained; and all focus group participants were paid R$ 20 (about US $8) for the 90minute group discussions. A semistructured interview guide was used in both the focus groups and key informant interviews, examining such topics as patterns of drug use in Porto Alegre, places where drug use occurs, injection drug use, the emergence and extent of crack use, changes in drug use profiles, and sex-for-crack exchanges. All focus group sessions were audiotaped, and the tapes were fully transcribed. Although qualitative software was not used in the analysis, subject areas were coded and condensed into meaningful categories for the sake of facilitating a thorough examination of the data. RESULTS Throughout Brazil, the use of heroin. Ecstasy, and hallucinogens is rare, and prescription drug abuse is not part of the drug culture (Galdur6z et al. 2004,2003; Nappo et al. 2002). This is also the case in Porto Alegre, where the primary drugs of abuse are marijuana and powder cocaine. All of the focus group participants emphasized, however, that the local drug scene had changed in recent years, in that the number of injection drug users had declined dramatically, and that crack use was reaching epidemic levels. Journal of Psychoactive Drugs

The number of syringes exchanged has gone down in the last few years. When I started working in the program in 1997,1 got scared by the amount of needles being exchanged— around 1,000 per week! Wherever you walked by, there were syringes all over the ground. The collection boxes were always full! Now we exchange only about 50 to 100 syringes per week.

In a related context, knowledge of HIV transmission via needle sharing varied among the drug users at the start 307


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of the epidemic. One of the focus group participants, who is HIV-negative. reported that he would always bend his needle after injecting the drug, so that no one would reuse his works. However, another respondent, who is HIV-positive and has a longer drug-using career, said that when he started injecting he was unaware of the risk for AIDS, and never considered that sharing works or drugs might be dangerous. In addition, he suggested that: "The guys who share today are the ones who still don't know about the harm reduction [syringe exchange] program." When this comment was discussed by the group, there was agreement that there were still some IDUs in Porto Alegre who were unaware of HIV and AIDS. Many injectors are members of "closed networks"—drug using friends who inject together in the same shooting gallery, often with the syringes that are distributed by harm reduction programs. At the same time, however, it was emphasized that in the areas where the syringe exchange program has no outreach, injectors continue to share, and that if the program had started 10 years earlier, there would be thousands of IDUs who would not have become infected with HIV.

for the epidemic, and many more were afraid of being infected. In addition, because cocaine was routinely being cut with marble powder, many more had switched to snorting because cocaine of a quality and purity that could be injected had become too costly (Inciardi, Surratt & Telles 2000). For injectors in Porto Alegre, perhaps the most significant phenomenon contributing to the decline in injection drug use was the appearance of crack-cocaine on the streets of the asfalto and in the alleys of the favelas. TVansitions to Crack-Cocaine Historically, cocaine users in Porto Alegre begin their careers with snorting the drug, later moving on to injecting. Focus group participants stressed that as cocaine users shifted away from injecting, they were not being replaced by new, younger injectors. However, with crack, wherever it is found, it seems that there are always new users coming along (Davis, Johnson & Liberty 2004; Gentry 2004; Neale & Robertson 2004; Wechsberg, Lam & Zule 2004; Butters & Erickson 2003; Roberts, Wechsberg & Zule 2003). In Porto Alegre, the evolution from snorting to injecting and then smoking cocaine has been replaced by a move directly from snorting to smoking. As one focus group member put it:

The Quality of Cocaine As is the case in other parts of the world, Porto Alegre is no exception with respect to the cutting of cocaine with adulterants or "expanders." Focus group participants noted that cocaine is passed hand-to-hand—sometimes through five or six different individuals—before it eventually reaches the streets. One participant explained:

They go straight to the rock, because they don't want to inject themselves. You put the rock in the can, and you have your hit right there. It is the same as injecting, and you don't get AIDS.

There are some guys who will get some coke, snort half of it, mix the rest and sell it. From the hills [places in lhe favelas where drugs are stocked] to the asphalto [urban areas of the city, where it is sold in small quantities], it will pass through at least three hands.

Focus group participants reported a sudden increase in the prevalence of crack use beginning in 2001. Many mentioned that the drug had come from Sao Paulo, and that when it first arrived in Porto Alegre, the word on the street was that "crack kills everyone that uses i t " Local folklore quickly proved to be false, and the use ofthe drug became widespread. Much of the crack that is sold in Porto Alegre carries a price of R$5 (US$ 1.70) for a small rock, with larger rocks costing double that or more. When crack first became popular, most users made their own rocks, which was also the case when crack first appeared in the United States (Inciardi 1992; Chitwood, Rivers & Inciardi 1996). By 2004. however, virtually all of the crack for sale on the streets of Porto Alegre was ready for smoking. Rather than glass crack pipes often seen in the United States, however, focus group members mentioned that aluminum cans (from beer or guarand [a Brazilian soft drink]) were frequently converted for smoking crack. As one crack user pointed out:

According to some of the group members, street cocaine is no more than 20% pure. The additives include many different types of material, including milk sugar, powdered drink mixes, fluorescent light bulb powder, chalk, toothache medication, com starch, marble powder, and aspirin. Many of these adulterants do not fully dissolve, and are impossible to inject. One of the focus group participants noted: Buying in the streets is a bad choice. They will sell crushed medication inside the bag—pharmacy aspirin at R$S, R$10. In \\\e favelas, up on the hills, the drug is purer. Real drug users buy cocaine up on the hills. Some die, not because of the drugs; they will die because ofthe mixtures, the adulterants.

The mixing of cocaine with marble powder is not uncommon and has been observed in other parts of Brazil. In Rio de Janeiro during the 1990s, for example, there was a decline in the number of injection drug users in both \h& favelas and the asfalto. Many had died from AIDS, numerous others had gone into hiding because they were being blamed


You take the empty can, smash it, make a few holes with a nail or something else, put cigarette ashes on top of it, and the ashes help the rock to burn. When there are no cans available, a bottle of water or a plastic pipe will do.

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In some cases, the local gaucho culture has provided a unique sort of drug using paraphernalia: focus group participants reported that crack users smoke crack from the bomba de chimarrao noted earlier in this article. Users make the holes in the bomba (the metal straw) much larger, usually with a nail, put the crack rock on top of the holes and heat it from below. In all of these situations, the cracksmoking paraphemalia are passed from person to person and from mouth to mouth, as is the custom of the chimarrao ritual. However, the majority of smokers do not consider the potential for transmitting disease through this community smoking process, even though, as one user noted: "Crack can make blisters on the mouth; if the can heats up too much and you smoke too heavily, you will get blood blisters on your lips." Key informants reported that since the introduction of crack in 2001, its quality has declined dramatically, and because of this, the effects of crack are minimal. To compensate for the limited high, many users smoke macaquinho ("little monkey")—a marijuana cigarette laced with crack. As one informant put it: "Macaquinho is not as good as smoking from the can [smoking crack]. If you smoke from the can, you're gonna be craving, drinking and smoking all night. But macaquinho gives almost the same effect as pure crack."

only recourse once addicted. One informant added: "Oral sex is R$5 (about US$1.70), which is what you need to buy a rock." Moreover, when exchanging sex for crack, there seem to be no barriers for the types and places of sexual transactions. One focus group participant explained: "When you are on drugs you don't care: you need it! They go to a comer, do it in any place, and it is live, everyone is seeing it. If you don't have a house, you do it in the street, in the alley." Sex-for-crack exchanges involve vaginal, anal, and oral sex. Condoms are rarely used, which increases the potential for the spread of HIV and other sexually transmitted infections. What all of this suggests is that crack users and their sex partners are at special risk for HIV acquisition and transmission. The compulsive nature of crack use suggests that effective prevention/intervention efforts would be difficult to implement, particularly those not undertaken within the context of intensive drug abuse treatment. DISCUSSION As in the United States, AIDS in Brazil was initially believed to be a disease of middle-class gay men. But as the epidemic expanded and the number of cases among women, heterosexual men, injection drug users, and children increased, efforts were mobilized by the country's Ministry of Health to curtail the spread of the disease. But because of Brazil's extensive poverty and inequality, its fragile economic situation, and limited network of health services, the scarce prevention resources generally have targeted only the most visible at-risk populations—gay men, sailors, sex workers, and street children (Parker 1999). Some attention in recent years has been directed toward injection drug users, but virtually forgotten have been Brazil's hidden populations of female drug users, as well as the wider populations of female sexual partners of drug users. With the introduction of crack to the South of Brazil, there is potential for significant increases in the already growing numbers of HIV-positive women. The number of reported AIDS cases among women grew 71% from 1994 to 1998—some nine times faster than the rate for men. Nearly 50,000 cases of AIDS had been reported among women in Brazil through September 2000, representing some 25.5% of all cases, with 68.8% occurring among women ages 20 to 39 (Brazilian Ministry of Health 2000). By 2003, 89,527 cases among women had been reported, representing 28.8% of total cumulative AIDS cases since the beginning of the epidemic (Brazilian Ministry of Health 2003). The rapid rise in the number of cases among women reflects the significant increase in the proportion of individuals infected through heterosexual contact in Brazil. In 1999, Brazil experienced a decline in the number of newly reported AIDS cases, and incidence rates fell in most of

Sex-for-Crack Exchanges Focus group participants and key informants agreed that crack users in Porto Alegre typically smoke for as long as they have the drug or the means to purchase it—money, personal belongings, sexual services, stolen goods, or other drugs. Similar to the patterns seen in the United States, it is rare that smokers in the South of Brazil have but a single "hit" of crack. More likely they spend all of their funds on what they call a sessao or missao (mission)—a three or four day binge, smoking almost constantly, up to 50 rocks per day. During these cycles, crack users rarely eat or sleep. And once crack use is initiated, for many users it is not long before it becomes a daily habit. The tendency to binge on crack for days at a time, neglecting food, sleep, and basic hygiene, severely compromises physical health. Consequently, crack users appear emaciated most of the time. They lose interest in their physical appearance. Many have scabs on their faces, arms, and legs —the result of bums, and picking at the skin (to remove bugs and other insects believed to be crawling under the skin). Crack users tend to have bumed facial hair from carelessly lighting their smoking paraphemalia; they have bumed lips and tongues from the hot stems of their pipes, and many seem to cough constantly. Among indigent women drug users in Porto Alegre, smoking crack is widespread, and sex-for-crack exchanges have become commonplace. Because women from ih.efavelas have limited sources of income, for many prostitution is their


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Brazil's major metropolitan areas. However, this decline has not been as dramatic among women or in the South of Brazil as in other regions of the country (Brazilian Ministry of Health 2003). Given the documented linkages between the use of crack, sex-for-crack exchanges among crack-dependent women, and the spread of HIV and other sexually transmitted infections, it would appear that there is an immediate need for culturally appropriate HIV prevention protocols

targeting drug-using women in the South of Brazil. Such interventions need to focus not only on the mechanisms of viral acquisition and transmission, but also on culturally sensitive approaches for addressing the cultural barriers to safe sex and drug use. These interventions are best developed, furthermore, through input from "cultural insiders," that is, members of the target population who are at risk for HIV infection.

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