Brazil

Anne-Lise Schmitt
Journalist specialised in Brazil

Barely ten years ago, the HIV/AIDS epidemic was accelerating in Brazil at a comparable rate to that occurring in African countries.
Thanks to the effective policy designed to inform the population at large and to reduce the harm done to injecting drug users (which account for one quarter of the HIV positive population in this country), the rate of contamination has been slowing down considerably since 1999. Brazil has become an example to the other Latin American countries.

In 2000, Brazil had 164 million inhabitants, 500,000 of whom were HIV positive. This is the fourth largest country in the world, the eighth in terms of economic power and one of the most densely populated States on the planet: Brazil is a giant. It is also characterized by extremes of social inequality: 20% of the population are illiterate, suffer from malnutrition and live under unhealthy conditions, with little access to information. The risk of HIV contamination is high, due to both sexual exposure (which was responsible for 52% of all the present cases) and drug injection practices (25%) (1).
Injecting drug users accounted for only 2.7% of all the cases of contamination in 1982, but the figure went up to 18.2% in 1998 and reached 25% in 2000. In view of the epidemiological upsurge, the public authorities decided during the 1990s to back harm reduction projects, which numbered 40 by the year 2000. Most of these projects involved heightening awareness or handing out sterile syringes, condoms and alcohol. In a study carried out by the Ministry of Health in 1999, the following information was obtained about the injecting drug users taking part in these programmes: 70% of them were males between 18 and 30 years of age, who were taking drugs in groups and sharing their syringes. 52% of them were sero-positive and 80% had hepatitis C.
In spite of this alarming situation, there were stillobstacles, particularly legal ones, to setting up programmes. Uner the present narcotics law (Law 6368 of 1976), anyone who encourages drug use, is liable to prosecution and this, if interpreted too narrowly, can also be taken to mean anyone who hands out syringes (cf. insert).
Three federated States located in areas with the highest risks have eluded the law by drawing up their own harm reduction* legislation based on the constitution, which states that in a national emergency involving risks to public health, every individual has the right to health and medical treatment.
In a country where 90% of the population are Catholics, the position adopted by the Church has caused rifts of opinion.
But behavioural changes are occurring, and injecting drug users themselves are increasingly taking part in harm reduction programmes and changing their practices.

The city of Porto Alegre has set up a system of local management with a view to developing a harm reduction policy based on mutual support and social integration.

SHARING EXPERIENCE

Participative democracy was established in Porto Alegre in 1989 by the Workers' Party, which includes extreme left movements, social democrats, progressive Christians and trade unionists. Local inhabitants form neighbourhood Committees presided by a city councillor, who acts simply as an observer, to decide on investment priorities. Budgetary allowances are divided up during the assembly of all the neighbourhoods, depending on the number of inhabitants they contain and their level of development. The budget is drawn up, signed by the mayor with no amendments, and then submitted to the city council for approval. The city has sixteen neighbourhood Committees of this kind, each involving about three hundred people (this amounts to 10% of the city's population). The members of these Committees are mostly members of the city's working and middle classes.
The first budgets approved by the Committees focused mainly on city infrastructure (streets, transport, ecology), violence and security, and were then gradually extended to include items such as education and access to health care for all citizens.
Recent activities include the efforts made to decrease the risk of contamination, for example. For the last four years, under the impetus of a recent law in the State of Rio Grande del Sul, many programmes have been developed in which drug addicts themselves participate.
Prevention specialists speak to associations, in schools, social centres, athletic clubs and clinics in order to get the prevention message across. They also distribute syringes and condoms. At public health centres, which are rather reluctant to admit drug addicts, they explain how to clean syringes and carry out HIV and Hepatitis C and B screening tests: these diseases are actually responsible for larger epidemics than HIV in the city. The teams also reach out to high-risk members of the population living on the streets, the prison inmates at the Porto Alegre central prison and other socially vulnerable communities. "We always start with what the subjects themselves have gone through, Mirtha Sendic explains, so that the IVD users can share their experience with their peers. We call it educating equals."

BREAKING DOWN THE BARRIERS BETWEEN DRUG USERS AND THE COMMUNITY

Participative democracy, whereby drug abusers participating in these programmes are eligible for membership of the neighbourhood Committees, has changed the way people think, and has enabled new players to become involved. Bars and restaurants have set up used syringe receptacles and distribute new syringes. On similar lines, companies have been organised into co-operatives through which drug addicts can find jobs. The aim of all these initiatives policy is basically to break down the barriers between drug abusers and the rest of the community. "It's by going to work every day that drug abusers will come to realise that they are the equals of all the other citizens, says Myrtha Sendic. IVD users often do not want to stop using drugs, but, once they have joined the working world, they learn to use them only in the evening rather than all day long."
The statistics have not yet shown a decrease in the number of cases of contamination (1), but over 75% of all the contaminated IVD users taking part in the programme have stopped sharing syringes. Another successful outcome is the fact that people on the fringes of society are given a hearing by local inhabitants, which, according to Mirtha Sendic, consolidates and strengthens the social fabric of the city and the feeling that these people belong to a community.

1 It has been estimated in one study that the number of new cases of AIDS among the Porto Alegre IVD users is increasing by 36% per year. This percentage is attributable to the high rate of drug consumption in the south and to the geographical position of this part of the country, which is on the route taken by the drug traffickers.
Contact: mirthasendic@

LEARNING TO COMMUNICATE
with high-risk populations and police officials

The first harm reduction project in Brazil was launched in the port of Santos in the State of Sao Paolo. It was based on experiments which began in Holland in 1982 and in Australia in 1985. The idea was to make syringes available at health posts. However, the medical team in charge, consisting mainly of doctors specialised in STDs, was soon being questioned by the police. Similar mishaps also occurred to workers involved in harm reduction early in the epidemic in Europe. Dr Tarcisio de Andrade, who currently heads CETADE (the Centre for Drug Abuse Study and Therapy) in Salvador de Bahia, has the honour of having started the first harm reduction project ever tolerated by the police in Brazil. This was the result of long efforts, where discussions with police officials were as important as those with the socially marginalised communities targeted by the programme.
In 1994, Tarcissio de Andrade focused his doctoral dissertation on the risks of contamination by the HIV virus run by homeless people and the inhabitants of the favelas, where he discovered that 50% of the IDUs were HIV carriers. He began to work "using whatever means came to hand". With the help of colleagues and volunteers, he produced local radio programmes to inform people about the precautions they should to take to protect themselves from the AIDS epidemic. The speaker would announce the times at which the mobile teams would be in the favelas to hand out condoms and syringes. In these broadcasts, the issue of morality was discussed, people were informed about the epidemiological situation and above all, they helped to counteract the tendency of locals to reject IDUs.

Making efforts to convince people that this project will not involve selling drugs.

Listeners asked non-stop questions: "the Church doesn't allow the use of condoms", "handing out syringes means you're encouraging young people to take drugs", etc. The planners had to explain their position clearly: "we're neither HIV positive nor representatives of the Church: the syringe exchange programme is mainly a response to a public health issue. We're here to give psychological and medical support to people who have the virus and we want to help both you and your children".
Long talks with the police were still necessary' to convince them that the permanent' premises were not going to be used to sell drugs. Three years later, CETADE, thanks to funding from the authorities (the Department of Health in the State of Bahia, the city of Santos and the Brazilian Federal government); finally opened a centre providing testing; syringes and condoms.
Nowadays, harm reduction has come to be fully recognised by police officials and locals'[ alike. According to Dr Tarcisio de Andrade, it is time to take things farther. He now wants to undertake programmes that will not distinguish between preventing drug use í and abuse, for "sub-dividing people into! users and non-users does not give us a very all-round prevention policy". In his opinion, ways of dealing with everyone have to be found "in order to break down the imaginary lines between people who use drugs and those who don't, so that the latter are no I longer looked upon as diabolical and can be brought back into the fold of the community".

Contact address: tarcisio@