Syringe exchange programs in Brazil preliminary

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					                                                                                                                     ARTIGO ARTICLE                 761




Syringe exchange programs in Brazil:
preliminary assessment of 45 programs

Programas de redução de danos causados
pelo uso de drogas no Brasil:
caracterização preliminar de 45 programas




                                                                                 Elize Massard da Fonseca           1

                                                                                 José Mendes Ribeiro 2
                                                                                 Neilane Bertoni 1
                                                                                 Francisco I. Bastos 1




                             Abstract                                            Introduction

1 Centro de Informação       The present study aims to evaluate the current      The use of injection drugs frequently causes
Científica e Tecnológica,
                             operation of Brazilian syringe exchange pro-        harm to the user, to the social network he par-
Fundação Oswaldo Cruz,
Rio de Janeiro, Brasil.      grams (SEP). After consulting national and re-      ticipates in, and, in some circumstances, to so-
2 Escola Nacional de Saúde   gional networks of people working in projects/      ciety at large. These harms include risk of over-
Pública Sergio Arouca,
                             programs aiming to reduce drug-related harm,        dose 1, risk of disease transmission (HIV, he-
Fundação Oswaldo Cruz,
Rio de Janeiro, Brasil.      we identified 134 potential participant pro-        patitis, and other blood-borne pathogens)
                             grams. Unfortunately, only 45 SEPs answered a       through sharing potentially contaminated nee-
Correspondence
                             survey, even after repeated attempts. The survey    dles and syringes, as well as eventual problems
E. M. Fonseca
Departamento de              addressed: coverage, funding, procurement of        arising from the inappropriate disposal of sy-
Informações em Saúde,        basic supplies, managerial capacity, and the lo-    ringes used in public places 2,3.
Centro de Informação
Científica e Tecnológica,
                             cal political environment. Findings were trian-         Some studies show that increasing access
Fundação Oswaldo Cruz.       gulated with in-depth interviews with key in-       for injection drug users (IDUs) to sterile nee-
Av. Brasil 4365,             formants. The main findings included: satisfac-     dles substantially reduces the transmission of
Rio de Janeiro, RJ
21045-900, Brasil.
                             tory adherence to the initiatives and adequate      HIV and other blood-borne pathogens, as well
emassard@cict.fiocruz.br     documentation, but deficiencies in terms of cov-    as reduces risk behaviors related to the use of
                             erage and monitoring, and uneven procurement        injection drugs, such as sharing needles, sy-
                             of resources. Program personnel work mostly on      ringes, and other paraphernalia used in prepar-
                             a provisional basis, despite the efforts of local   ing and self-administering injection drugs 4,5.
                             coordinators. Most programs are funded by the           With the emergence of AIDS in Western
                             National STDs/AIDS Program. A comprehensive         countries at the beginning of the 1980s, and
                             agenda aiming to improve current operations         the consequent risk of HIV dissemination, the
                             should include: concerted efforts to improve lo-    politics of “harm reduction” gained strength
                             cal and regional databanks, incentives/sanc-        in Europe and Australia 6. The first syringe ex-
                             tions toward full accountability of initiatives     change program (SEP), or be it, the first initia-
                             carried by the programs, and a genuine culture      tive to systematically exchange used syringes
                             of monitoring and evaluation.                       for new (sterile) syringes, was implemented
                                                                                 in Holland, in 1984, at the initiative of the drug
                             Syringe-Exchange Programs; Acquired Immun-          users themselves, in response to the alarm-
                             odeficiency Syndrome; Intravenous Substance         ing spread of hepatitis B and C in that popu-
                             Abuse                                               lation 7.



                                                                                     Cad. Saúde Pública, Rio de Janeiro, 22(4):761-770, abr, 2006
762    Fonseca EM et al.




                                             Through these programs, IDUs have access                The AIDS epidemic in Brazil has evolved
                                         to new/sterile syringes by exchanging used ones,        heterogeneously, as a function of the affected
                                         which are thus collected from the community.            geographical regions and populations. IDUs
                                         This has the effect of reducing the circulation of      have an important role in the dynamic of the
                                         potentially contaminated syringes, as well as           epidemic in some regions of the country (South-
                                         providing an opportunity to contact this popula-        east, South, coastal Northeast, and Midwest) 15,
                                         tion, which is otherwise difficult to access, in        significantly affecting resident populations not
                                         order to implement, in an integrated way, di-           just in metropolitan areas, but also in mid-
                                         verse public health efforts, such as: distribution      sized municipalities 16.
                                         of condoms, counseling, hepatitis B vaccina-                In diverse Brazilian contexts (with the ex-
                                         tion, and directing drug users to treatment ser-        ception of the southern coast), there has been
                                         vices 8. These programs have been implemented           a decline in HIV infection rates among IDUs in
                                         throughout the world, contributing to the reduc-        recent years, in addition to a decline in the in-
                                         tion of infection rates by HIV and other blood-         cidence of HIV among IDUs relative to overall
                                         borne infectious agents in countries such as the        incidence in local and regional populations
                                         United Kingdom, Australia, Canada, Spain, Thai-         (reflecting former exposure to HIV ) 17. In one
                                         land, and some locations in the United States (a        study, coordinated by the World Health Organi-
                                         country where these initiatives benefit from lo-        zation from 1999/2001, with users recruited
                                         cal and regional, but not federal, funding) 6,8,9,10.   from drug use scenes, there was a substantial
                                             The first attempt to implement such harm            reduction in HIV infection rates (prevalence
                                         reduction strategies in Brazil occurred in the          and incidence estimates) in Rio de Janeiro, from
                                         city of Santos, São Paulo, in 1989. However,            25% 18 to, approximately, 8%, parallel to the de-
                                         during that era, the Public Ministry of São Paulo       cline in infection rates of other pathogens,
                                         filed civil and criminal actions against the pro-       such as Hepatitis B and C 17,19. Similar decline
                                         gram organizers and the city government of              was also observed in two other cities in the
                                         Santos. The legal argument was based on                 study: Santos and Salvador 12,20. The reasons
                                         Statute No. 6,368/76. The attorneys interpreted         for the decline observed in these three cities in-
                                         these needle exchange initiatives as a means to         clude saturation of this population segment,
                                         “stimulate the consumption of drugs” 11.                whose size is relatively restricted 21, transfor-
                                             The first Brazilian syringe and needle ex-          mations in the drug scene 20, spontaneous
                                         change program to be effectively implemented            change in the behavior of IDUs (safer behav-
                                         was in Salvador, Bahia, in 1995, stemming from          iors), and the role of prevention programs,
                                         an initiative by the Center for Drug Abuse Stud-        helping drug users and reinforcing their behav-
                                         ies and Therapy (CETAD), Medical School, Fed-           ioral change to less risky behaviors 17.
                                         eral University of Bahia, with the support of the           The drug use scene in Brazil is experiencing
                                         state and city governments of Salvador 12.              substantial changes, and the current drug of
                                             Changes in the scope of the National STDs/          choice among the Brazilian IDUs population is
                                         AIDS Commission, in 1996, accelerated harm              cocaine 22,23,24. In recent years, there has been
                                         reduction programs in Brazil. The first World           a progressive increase in cocaine consump-
                                         Bank loan and resources from the United Na-             tion, in the form of powder (snorted or inject-
                                         tions International Drug Control Program                ed) and crack rock (smoked or, eventually, in-
                                         (UNDCP), with the specific objective of pre-            jected) 25, besides the emergence in the scene
                                         venting the AIDS epidemic among IDUs, would             of diverse new substances, such as “synthetic
                                         provide fundamental assistance to harm re-              drugs” (designer drugs) 26 and the further dis-
                                         duction incentives countrywide 13.                      semination of traditional drug consumption,
                                             In 1998, Brazil hosted the 9th International        such as solvents 27.
                                         Conference on the Reduction of Drug Related                 Preliminary compilations of available infor-
                                         Harm. These meetings represented an impor-              mation indicate that more than one hundred
                                         tant moment of articulation of harm reduction           SEP (in Brazil, called Harm Reduction Programs
                                         professionals, culminating in the creation of two       in recognition that the scope of their activities
                                         harm reduction associations: the São Paulo              extends beyond just needle exchange) current-
                                         Harm Reduction Association (APRENDA), and               ly operate within Brazil in different regions,
                                         other association of national scope, the Brazil-        states, and municipalities 3,28. These programs
                                         ian Harm Reduction Association (ABORDA) 11.             are being implemented by universities, govern-
                                         In March of that same year, the first state harm        mental institutions, such as health secretaries,
                                         reduction law was passed in São Paulo (State            and NGOs 14.
                                         Statute no. 9,758/97). Subsequently, other states           The present study sought to evaluate the ef-
                                         and districts approved similar laws 14.                 fective implementation of harm reduction poli-



      Cad. Saúde Pública, Rio de Janeiro, 22(4):761-770, abr, 2006
                                                                                                       SYRINGE EXCHANGE PROGRAMS IN BRAZIL            763



cies related to drug use by NGOs and Brazilian          restricted coverage of the official data, informa-
governmental agencies and the daily operation           tion was solicited (via personal contact, tele-
of SEPs in Brazil. Through compilation and              phone, mail, and e-mail) about SEPs operating
analysis of a systematic register of 45 programs        in each region, starting with the regional asso-
in Brazil, the study evaluated both the financ-         ciations.
ing mechanisms of these programs and cover-                 Information about the study population (the
age and structural aspects of the NGOs and              assemblage of SEPs in operation) was, there-
governmental agencies that implemented harm             fore, obtained by integrating and conforming
reduction activities. In addition, the principal        regional lists of 134 programs functioning in
obstacles to the spread and consolidation of            the country in 2004. Of these, it was only possi-
these programs were listed and analyzed.                ble to obtain responses from 45 programs, de-
                                                        spite innumerable requests.
                                                            The programs were evaluated using infor-
Methodology                                             mation pertaining to five thematic blocks: “pro-
                                                        gram coverage”, “financing”, “resource control”,
The present study used a cross-sectional sur-           “organizational capacity”, and “political envi-
vey instrument to collect data about SEPs func-         ronment”. The questions were closed, generat-
tioning in Brazil. The survey procedures in-            ing quantitative or categorical responses.
volved the distribution, systematization, and               The first thematic block (“program cover-
analysis of data using a self-filled question-          age”) involved evaluation of the number of
naire, responded to by NGO directors and gov-           beneficiaries (classified as regular, occasional,
ernmental agencies that developed SEPs. The             and abandoned) and of degree of beneficiary
questionnaires were distributed and respond-            adherence (according to interval scales). The
ed to during the period from October, 2004 to           second block (“financing”) involved sources of
March, 2005. The target population included             funds (from summary of revenue and expens-
HRPs in Brazil in 2004 that conducted syringe           es), sustainability (evaluated as chance of main-
exchange during the six months prior to the             taining resources, using interval scales and di-
distribution of the questionnaire and that were         chotomous variables) and audit results (using
identified in a register developed through con-         dichotomous variables). The “resource control”
sultation with the Health Ministry, ABORDA, 11          block involved the control of syringes and oth-
State Harm Reduction Programs (Acre, Amapá,             er injection equipment (statistics of distribu-
Bahia, Ceará, Espírito Santo, Minas Gerais, Ma-         tion and collection). The “organizational ca-
to Grosso do Sul, Pernambuco, Paraná, Rio de            pacity” block included: worker affiliations, man-
Janeiro, Rio Grande do Sul), and the State STD/         agement autonomy (information furnished ac-
AIDS Coordination of São Paulo.                         cording to the distribution of professionals, by
    The first stage of the study included a system-     type of contract, and management structure,
atic search for HRPs operating in the country. It       according to number of coordinators, special-
sought to ascertain the actual number of pro-           ists, and field workers), and documentation and
grams, through telephone contact and electronic         registration (using dichotomous variables). Fi-
mail with governmental and nongovernmental              nally, the “political environment” block involved
institutions. The second phase involved applying        administrators’ perceptions of the environ-
the questionnaires, contacting key informants,          ment, with respect to support and obstacles
and analyzing the resulting information.                perceived/confronted by the programs (interval
    The SEPs in Brazil were characterized ac-           scale referring to the perception of assistance).
cording to the definition of the Health Ministry            Development of the instrument benefited
14 (p. 12): “Health Reduction Programs comprise         from items used in a questionnaire formulated
a series of activities, developed in the field by es-   by the National STD/AIDS Program, UNDCP, and
pecially trained community health agents [called        the Federal University of Minas Gerais, in an
outreach workers], which include needle ex-             empirical study in Brazil: AjUDE-Brasil II Pro-
change and distribution, information, educa-            ject 3,15.
tion, and communication activities (IEC), coun-             A pre-test of the instrument was completed
seling, guidance, vaccination against hepatitis,        with three programs in September, 2004, lead-
and other activities”.                                  ing to necessary adaptations. Dissemination of
    The National STDs/AIDS Program made                 the questionnaires was done directly (by hand)
available a list of the state harm reduction as-        for organizations in Rio de Janeiro, and by fax
sociations, also used by ABORDA. In fact, it was        and electronic mail (e-mail) for the other states.
not possible to obtain any systematic list or of-       Additional information was collected by means
ficial registry with national coverage. Given the       of telephone contact.



                                                                                       Cad. Saúde Pública, Rio de Janeiro, 22(4):761-770, abr, 2006
764    Fonseca EM et al.




                                             Systematization, administration, and analy-                45 programs responded to the survey, despite
                                         sis of the data were completed using the soft-                 repeated requests.
                                         ware program SPSS 11.5 (SPSS Inc., Chicago,                        The program coverage in relation to the tar-
                                         USA), with basically descriptive aims.                         get population was considered poor or average
                                             In addition to the information described                   by the majority (~60%) of administrators. In
                                         above, two key informants were interviewed in                  weighing coverage deficiency, clientele adher-
                                         order to hear their considerations as regional ad-             ence was considered good or very good for a
                                         ministrators of a number of HIV/AIDS programs.                 substantial majority (~70%) of administrators.
                                         Both were senior managers of programs in the                   Similarly, interviewees considered the docu-
                                         state of São Paulo, with degrees in psychology,                mentation and registry of programs sufficient-
                                         and not directly involved in SEP administration.               ly adequate (Table 1).
                                         These interviews were conducted using a prelim-                    The majority (64%) of programs report veri-
                                         inary interview schedule, although interviewees                fying adherence of the target population, al-
                                         were allowed the liberty to discuss related topics.            though no program systematically used valid
                                                                                                        verification or measurement instruments.
                                                                                                            An especially worrying finding is that 20%
                                         Results                                                        of administrators report insufficient syringes
                                                                                                        and equipment to attend to their activities.
                                         Of the 134 programs in the general registry, 18                Thirteen programs report experiencing inter-
                                         programs were excluded from the start because                  ruptions to providing syringes. Despite these
                                         they did not conform to the criterion of the                   discontinuities, the great majority (90%) of
                                         study’s definition of SEPs (having conducted                   SEPs report controlling the stock of supplies
                                         syringe exchange during the six months prior                   used by the program.
                                         to inclusion in the study) (Figure 1). Effectively,                The 45 SEPs distributed, in total, 126,452
                                                                                                        syringes and needles. They collected 90,516, or
                                                                                                        72% of those distributed. The proportion of sy-
                                                                                                        ringes and needles distributed/collected var-
      Figure 1                                                                                          ied substantially between programs. A subset
                                                                                                        of 16 HRPs collected less than 30% of syringes
      Location of syringe-exchange programs (SEP), by municipality and state,                           distributed. Just eight SEPs obtained a satisfac-
      data referring to 116 programs*, 2005.                                                            tory level of collection of syringes and needles,
                                                                                                        defined here as 80% return of distributed ma-
                                                                                                        terial (Figure 2).
                                                                                                            As showed in Table 2, interviewees pointed
                                  RR
                                                        AP
                                                                                                        out that the most pertinent assistance afforded
                                                                                                        SEPs came from federal, state, and municipal
                                                                                                        organs. In other words, it came from public
                                                                                                        sources, and predominantly from the federal
                        AM                         PA                   MA               CE
                                                                                              RN
                                                                                                        government. On the other hand, assistance
                                                                                               PB       from religious leaders and from the police was
                                                                              PI              PE
                  AC
                                                                                                        very limited, when it existed at all.
                                                                                                   AL
                             RO
                                                                  TO                                        The professionals who created these pro-
                                                                                              SE
                                                                               BA                       grams ( Table 3) served principally in au-
                                            MT
                                                                   DF
                                                                                                        tonomous (55%) and volunteer (31%) capaci-
                                                             GO
                                                                                                        ties, or, in other words, had precarious and/or
                                                                         MG                             unstable affiliations. More sustainable hiring
                                             MS
                                                                                                        mechanisms, such as assigned public employ-
                                                                                         ES
                                                                                                        ees and using contracts managed by the Con-
                                                                  SP
                                                                                    RJ                  solidation of Employment Laws (CLT; Consoli-
                                                        PR
      SEP
                                                                                                        dação das Leis Trabalhistas), had a very minor
                                                             SC
                                                                                                        role (7% each).
            1
                                                  RS                                                        The structural organization of SEPs is basi-
            2-3                                                                                         cally vertical. Just four SEPs report non-verti-
            4-6
                                                                                                        cal management structures, with staff com-
                                                                                                        prised exclusively of health agents (outreach
                                                                                                        workers). All the other programs show some
                                                                                                        degree of centralization, with the presence of,
      * Excludes 18 programs that did not meet inclusion criteria.                                      at least, a coordinator. One half of the pro-



      Cad. Saúde Pública, Rio de Janeiro, 22(4):761-770, abr, 2006
                                                                                                        SYRINGE EXCHANGE PROGRAMS IN BRAZIL            765



grams report not just a coordinator, but also          Table 1
specialized staff.
    Summary financials of SEP operations were          Operational characteristics of syringe-exchange programs, according
requested of directors. The information provid-        to information provided by their administrators. Brazil, data referring
ed was of variable quality and detail, permit-         to 45 programs, 2005.
ting only a partial synthesis of the results. So-
licited of each program were the following: (a)          Operational characteristics                                          N          %
revenue (in reais); (b) sources of this income;
                                                         Coverage*
(c) expenses, separated in four categories: edu-
                                                           Very poor/Poor                                                    10          22.7
cational materials, supplies (other than educa-
                                                           Average                                                           16          36.7
tional materials), equipment, per diem and
                                                           Good/Very good                                                    18          40.9
transportation, and other. This permitted an
initial evaluation of program sustainability.
                                                         Adherence*
    In sum, it is confirmed that the federal gov-
                                                           Very poor/Poor                                                     0           0.0
ernment, through the National STDs/AIDS Pro-
                                                           Average                                                           14          31.8
gram, represents the principal technical sup-
                                                           Good/Very good                                                    30          68.2
port, as described above, as the principal (but
not exclusive) source of income, whether it be           Documentation/registry*
in terms of resource volume or of regularity of            Very poor/Poor                                                     4           8.9
financial support. This analysis permitted the             Average                                                           10          22.2
identification of programs in vulnerable situa-            Good/Very good                                                    30          68.9
tions. Four programs counted not only this
source of income, but also a second source,              Verification of adherence*
whether it be governmental or other. The pro-              Yes                                                               28          63.6
grams with greatest income diversification                 No                                                                16          36.4
were, similarly, those with more elaborate or-
ganizational structure and administration. On            Availability of syringes and equipment

the other hand, three small programs counted               Yes                                                               36          80.0

exclusively on income deriving from NGOs and               No                                                                 9          20.0

had more fragile structures.
                                                         Stock control
    With regard to expenses, four programs re-
                                                           Yes                                                               41          91.1
ported having expenses greater than their cur-
                                                           No                                                                 4           8.9
rent income, with accumulating debt scenar-
ios. On the other hand, eight programs spent             Continuous availability
only a fraction of their income, suggesting low            Yes                                                               32          71.1
implementation capacity.                                   No                                                                13          28.9
    With regard to “per diem and transporta-
tion expenses” – undoubtedly an important as-            Register of activities
pect of articulating support and exchanging ex-            Yes                                                               45        100.0
periences – cases exist where financial equilib-           No                                                                 0           0.0
rium was compromised by excessive expenses
                                                       * Incomplete/illegible responses were excluded from the final tabulation.
in this area, with apparent harm to end-result
activities. Three SEPs show worrying budget
performance in this respect, with evident over-
estimation of expenses in this category (corre-
sponding to more than 30% of the overall ex-        not even possible to contact 25 of the supposed
penses).                                            programs listed by the regional associations,
                                                    there being serious doubts if these programs
                                                    are currently operating.
Discussion                                              In this respect, the Brazilian programs are
                                                    not substantially different than their interna-
This study created a register of NGOs and gov-      tional counterparts, being occupied by difficul-
ernmental agencies that developed SEPs in           ties created by conservative local forces, when
Brazil. The process proved complex and slow,        not in conflict with legal or police proceedings
due to the disperse and incomplete nature of        6. These programs typically face negative com-

the information in all consulted spheres,           munity opinions, which others authors call the
whether they be federal, state, or municipal,       NIMBY (non-in-my-backyard) syndrome, the
and whether they be public or private. It was       desire to maintaining undesirable populations



                                                                                        Cad. Saúde Pública, Rio de Janeiro, 22(4):761-770, abr, 2006
766    Fonseca EM et al.




                                         Figure 2                                                  According to program directors, adherence
                                                                                               of drug users to the programs studied can be
                                         Number of syringe-exchange program by                 considered satisfactory, although their means
                                         proportion of syringes collected/distributed.         of measurement were not rigorous. Good ad-
                                         Brazil, data referring to 45 programs, 2005.          herence constitutes an indispensable require-
                                                                                               ment for the functioning of these programs, as
                                                                                               long as the discontinuation of activities sub-
                                                       80% or +
                                                                              < 30%            stantially limits the programs’ impact in terms
                                                           8                                   of offering clean syringes and withdrawing used
                                                                                16
                                                                                               syringes from circulation 32, as well as the pro-
                                                                                               grams’ capacity to serve as port of entry for the
                                                                                               network of treatment services 33.
                                                                                                   The key informants interviewed, with lengthy
                                                                                               experience managing HIV/AIDS programs,
                                                                                               considered the documentation and registry of
                                                           18
                                                                                               the majority of Brazilian SEPs to be adequate,
                                                        31-76%                                 due to the formal financing requirements, es-
                                                                                               pecially with respect to the federal govern-
                                                                                               ment. On the other hand, the traditional Brazil-
                                                                                               ian culture of “orality” (reiterated by both key
                                                                                               informants) would explain the almost com-
                                                                                               plete absence of systematic reports about the
                                                                                               day-to-day happenings of local programs. This
      Table 2                                                                                  characteristic of verbal communication is per-
                                                                                               vasive throughout the Brazilian culture, and
      Grades given by administrators on a scale of 1-5, referring to assistance                was discussed in detail by one of the authors of
      received from different sources. Brazil, data referring to 45 syringe-exchange           the present article in relation to Brazilian sci-
      programs (SEPs), 2005.                                                                   entific production regarding HIV/AIDS 34.
                                                                                                   According to the key informants, discontin-
        Assistance provided                         Mean ± SD        Median           Range    uous flow of supplies essential for the opera-
        for harm reduction*                                                                    tion of these programs would arise from the
                                                                                               lack of organization of these programs, even
        Federal organ                                 3.9 ± 1.2        4                 1-5
                                                                                               though they are observed in a positive light as
        State organ                                   3.7 ± 1.3        4                 1-5
                                                                                               regards the administrative sphere, considering
        Municipal organ                               3.5 ± 1.2        4                 1-5
                                                                                               that the majority of programs today have a
        Religious leadership                          2.1 ± 1.4        2                 1-5
                                                                                               manager in addition to a technical staff. The
        Press                                         2.9 ± 1.6        3                 1-5
                                                                                               precarious affiliations that the majority of pro-
        Police                                        2.6 ± 1.5        3                 1-5
                                                                                               fessionals tend to have with these programs
        Parliamentary members                         2.8 ± 1.4        3                 1-5
                                                                                               prevents them from consolidating organiza-
      * Never answered for the 45 programs in question. Variation of 40-43 SEPs.               tional cultures. Furthermore, constant rotation
                                                                                               of these professionals is seen to jeopardize pro-
                                                                                               gram activities.
                                                                                                   A minority of programs manage to optimal-
                                         separate from residents and recreation or work        ly combine the distribution and collection of
                                         areas 29. As for the Brazilian literature, resis-     used syringes and needles, as would justify
                                         tance to implementing these programs was              their being designated as programs that ex-
                                         documented by Andrade et al. 30.                      change and not distribute injection equipment.
                                             Our data show that almost 25% of the pro-         In is worth repeating at this point that the clas-
                                         grams report deficiencies in coverage, repro-         sic model for evaluating the impact of Needle
                                         ducing a deficiency common among these pro-           Exchange Programs, as regards transmission of
                                         grams at the global level 31. International arti-     HIV and other blood-borne pathogens, neces-
                                         cles have documented that it would be neces-          sarily involves not just increased access to ster-
                                         sary to increase greatly the coverage of these        ile needles, but also (and foremost) the with-
                                         programs, even in countries with a service            drawal from circulation of contaminated sy-
                                         structure and model availability of resources,        ringes 32. Furthermore, programs that do not
                                         as Canada 31, in order to actually reduce the         efficiently collect used syringes and needles, or
                                         dissemination of HIV and other blood-borne            that basically just distribute injection equip-
                                         and sexual infections.                                ment, tend to be seen poorly in their commu-



      Cad. Saúde Pública, Rio de Janeiro, 22(4):761-770, abr, 2006
                                                                                                             SYRINGE EXCHANGE PROGRAMS IN BRAZIL            767



nities, especially by conservative groups, which           Table 3
therein find support for their concerns that
these programs may stimulate the use of injec-             Staff profile and nature of professional afiliations that characterize the
tion drug use and criminality. Although such               syringe-exchange programs. Brazil, data referring to 45 programs, 2005.
fears have never been justified (increases in in-
jection drug use and criminality in locations                Variables                                                             N          %
covered by SEPs have never been documented
                                                             Type of affiliation
by international evaluations 10,35), the mere
                                                               Autonomous                                                        154          54.6
supposition that a program could increase in-
                                                               Contracts managed by CLT                                           19           6.7
jection drug use in a given community tends to
                                                               Ceded public employees                                             19           6.7
alarm those that oppose them 6.
                                                               Volunteers                                                         88          31.2
     The interviewees point out that the princi-
pal assistance provided to SEPs comes from
                                                             Program management forms
public federal, state, and municipal institutions,
                                                               Coordinator, technical staff, outreach workers                     23          50.1
in contrast to the case in the United States,
                                                               Coordinator, outreach workers                                      18          40.0
where the use of federal funds for this purpose
                                                               Outreach workers only                                               4           8.9
has been forbidden by successive administra-
tions and where the use of state funds is lim-
ited 35.
     The technical and financial assistance of
the National STDs/AIDS Program was found to             resources. Situations of exclusive assistance
be central to the functioning of these programs,        and financing are worrisome, especially in the
reflecting the involvement by the Health Min-           case of programs with more fragile structures
istry in these activities, partially financed through   and those that are not able to diversify their fi-
an agreement of cooperation with the World              nancial sources. These politics reflect, howev-
Bank. In this regard, there is reason for concern       er, the nature of the Brazilian health system
that a subgroup of these programs have debts            and the structure adopted by innumerable oth-
and financial disequilibrium, which apparently          er health actions developed in the country.
arises from excessive spending on “per diem                 The Brazilian health system is public and
and transportation,” such that their end-result         free to all Brazilian citizens. Such structure fa-
activities (such as syringe and needle exchange,        cilitates the adoption of public policies in dif-
distributing condoms, promoting educational             ferent areas. Even so, despite the fact of what-
activities, etc.) are jeopardized.                      ever health actions may be supported by law,
     The findings of the present study corrobo-         the implementation of harm reduction activi-
rate and augment the findings of earlier studies        ties did not occur without hesitation, surprise,
36,37 with restricted coverage, whether in terms        and objection 6,39.
of limited resources or of repeated non-cooper-             The programs here studied demonstrate
ation by programs in the evaluation process.            important and persistent vulnerabilities, in
     All of the evaluations developed thus far          terms of sustainability and coverage. It is im-
have identified deficiencies to be overcome, in-        perative that these programs be strengthened,
cluding: deficient monitoring of rates of infec-        since they deal with marginalized populations,
tion by HIV and other pathogens, and also in            whose actions are regulated by criminal legis-
relation to the possible impact that SEP activi-        lation.
ties have on risk behaviors.                                The principal challenges to strengthening
     A recent report by the World Bank 37 (p. i)        these initiatives institutionally and program-
affirms: “it is difficult to confirm what was ef-       matically involve improving their infrastruc-
fectively achieved by the Brazilian HIV/STD Pro-        ture and logistics, so that these programs do
gram and to define the contribution to the issue        not find themselves overcome by lack of sup-
by the World Bank”.                                     plies and other constraints to their full opera-
     It is worth noting that, in contrast to what       tion. It is necessary to increase their connec-
occurred in many countries worldwide, these             tions with civil society, especially with the press,
programs were not implemented by direct ini-            police, and religious and community leaders.
tiative on the part of target communities,                  The present study is at once victim and tes-
whether by local user associations, as in Hol-          tament to the difficulties encountered by these
land 7, or by local leaders, as in the first North      programs, having had to deal with a high rate
American programs 38.                                   of non-response, even though the research in-
     In Brazil, these efforts were and are basical-     strument was concise and simple. The absence
ly vertical, depending on federal incentives and        of comprehensive official databanks and resis-



                                                                                             Cad. Saúde Pública, Rio de Janeiro, 22(4):761-770, abr, 2006
768    Fonseca EM et al.




                                         tance by many administrators represents a chal-           this situation should include: confronting po-
                                         lenge to any systematic evaluation. The frag-             litical resistance to implementation and full
                                         mentary registries and reports impose difficul-           operation of policies and SEPs; better dialogue
                                         ties to potential evaluators. Thus, the present           and integration with officials/institutions that
                                         study is basically descriptive and explanatory.           work with drug use and education, often with
                                         It is hoped, nevertheless, that this analysis             distinct if not opposed philosophies; and in-
                                         stimulates future evaluations, with a represen-           creased exchange with other vulnerable popu-
                                         tative sample of the whole set of SEPs in the             lations (prison inmates, sex workers, miners).
                                         country.                                                      Recommendations for a (re)formulation
                                             There is no remaining doubt that the diffi-           of harm reduction policies include: constant
                                         culties confronting these Brazilian programs              watchfulness of rates of infection by HIV and
                                         do not differ substantially from those dealt              other infections transmitted sexually through
                                         with by programs of a similar nature but in dif-          blood among IDUs, implementation of actions
                                         ferent contexts, due to the contradictions be-            aimed at improving SEP coverage, and provid-
                                         tween health and drugs policies 40.                       ing resources for the maintenance and empow-
                                             Dealing with a difficult-to-access popula-            erment of SEP professionals. To improve their
                                         tion that does not trust official authorities, and        effectiveness, it is important to implement reg-
                                         that, similarly, is not seen positively by those          ular monitoring/evaluation, using both the ca-
                                         same officials, that is the object o stigmatiza-          pacities of the SEPs and those of independent
                                         tion and criminalization, makes the imple-                auditors. It is fundamental to adopt two impor-
                                         mentation and evaluation of these programs a              tant practices to improve transparency and ren-
                                         challenge globally.                                       dering of accounts of these programs: (a) re-
                                             The principal challenges confronting the              quiring regular and systematic rendering of ac-
                                         politics of harm reduction in Brazil transcend            counts as pertains to resources received and
                                         the operation of these programs. Rather, they             (b) developing contracting mechanisms as per
                                         encompass a conjunction of public actions and             goals and objectives to structure the relation-
                                         relationships with civil society, its opinion lead-       ship between public financiers and the pro-
                                         ers, and its legislators. An agenda to address            grams.




                                         Resumo

                                         O presente estudo buscou avaliar a operação cotidia-      quanto aos insumos. Os profissionais que atuam nos
                                         na dos programas de troca de seringas brasileiros (co-    programas têm, em sua maioria, inserção profissional
                                         nhecidos, no país, como PRD). Foram identificados         precária, embora haja coordenação local, na maior
                                         134 PRD, com base na compilação de informações das        parte dos casos. A maioria dos programas é financiada
                                         redes que atuam na área. Por intermédio de uma            por verbas provenientes do Programa Nacional de
                                         pesquisa, avaliou-se a cobertura dos programas, o seu     DST/AIDS. Uma agenda abrangente nesse campo deve
                                         financiamento, o controle de insumos, a sua capaci-       compreender um aprimoramento dos bancos de dados
                                         dade organizacional e o contexto político local. Os       oficiais referentes aos programas, incentivos/sanções e
                                         achados, referentes a 45 programas (que, de fato, res-    a exigência de que reportem corretamente as suas ações,
                                         ponderam à pesquisa, após repetidos contatos), foram      além de investimento em monitoração e avaliação.
                                         triangulados com entrevistas com informantes-chave.
                                         Foi identificada adesão satisfatória às ações e adequa-   Programas de Troca de Seringas; Síndrome de Imuno-
                                         da documentação e registro, mas deficiências de co-       deficiência Adquirida; Uso Indevido de Drogas Paren-
                                         bertura e monitoramento, além de descontinuidades         terais




      Cad. Saúde Pública, Rio de Janeiro, 22(4):761-770, abr, 2006
                                                                                                              SYRINGE EXCHANGE PROGRAMS IN BRAZIL            769



Contributors                                               Acknowledgments

E. M. Fonseca planned and conducted the study un-          The project was partially financed by the Higher Edu-
der the supervision of J. M. Ribeiro and F. I. Bastos.     cation Improvement Commission (CAPES; Coorde-
Empirical data were analyzed in collaboration with         nação de Aperfeiçoamento de Pessoal de Nível Supe-
N. Bertoni. All authors participated in developing and     rior), with reference to the Masters Thesis in Public
revising the manuscript.                                   Health, Escola Nacional de Saúde Pública Sergio Arou-
                                                           ca, Fundação Oswaldo Cruz, 2004.
                                                               The authors would like to thank the National
                                                           STDs/AIDS Program, the Brazilian Harm Reduction
                                                           Association (ABORDA), the respective state associa-
                                                           tions, the 45 programs included in the present study,
                                                           and the key informants, that made this preliminary
                                                           evaluation possible.




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                                                                                                       Submitted on 24/Jun/2005
                                                                                                       Final version resubmitted on 26/Sep/2005
                                                                                                       Approved on 27/Sep/2005




      Cad. Saúde Pública, Rio de Janeiro, 22(4):761-770, abr, 2006