Drugs and AIDS Prevention Project
BACKGROUND AND JUSTIFICATION
Epidemiological Situation of AIDS in Brazil
Brazil is among the first four countries in the world with the highest number of registered AIDS cases. However, when the relative incidences towards the population are taken into account, Brazil is ranked between the 40th and 50th position.
With respect to the Epidemiological Surveillance System, AIDS was first identified in 1982, in Brazil. A case was retrospectively recognized in the state of S?o Paulo in 1980.
According to the World Health Organization (WHO) approximately 550.000 persons are infected by the HIV in Brazil.
Considering the incubation period of the HIV, it is possible to deduct that the introduction of the virus in the country probably occurred at the end of the 70's and its diffusion, at first, in the main Center-South metropolitan area, followed by a dissemination process to the others regions of the country in the first half of the 80's. The majority of the registered cases are concentrated in the Southeast region with 76% of the notifications for the 1980-1996 period and 68% of the cases for the 1995-97 period. The States of Rio de Janeiro and S?o Paulo, for the period of 1995-97, still hold the 60% of registered cases of the country. Since the beginning of the epidemic until 01 March 1998, 120.399 cases were registered by the National Coordinating Office of STD and AIDS - NC-STD and AIDS.
The Units of the Federation with higher accumulated incidence of AIDS per hundred thousand inhabitants are: S?o Paulo (174,4), Rio de Janeiro (115,8), Federal District (92,8), Santa Catarina (77,5), and Rio Grande do Sul (60,8).
The epidemic of the infection of the HIV/AIDS in Brazil has presented important changes in its epidemiological profile over the last years, and disclosed different patterns at the national level. The sexual transmission has been the predominant category followed by an occurrence frequently higher of the blood transmission among intravenous drug users.
In Brazil, the cases that contracted the HIV by blood transfusion, in 1985, represented 25% of the occurrences of blood transmission. In 1995, this component contributed with 10.8% of the cases.
AIDS and Injecting Drug Use Situation in Brazil
Out of the 7% of the cases attributed to the sharing of needles and syringes during the use of injectable drugs in 1984 (0,7% of the total registrations), this component represented 84,9% of the blood transmissions in 1997 (24.9% of the total registers). In 1985, 2.7% (14 registered cases) of all cases were linked to the use of drugs and by 1997 its share had risen to 21.20% of all cases (25.529 registered cases).
With respect to the geographical distribution, the occurrences of AIDS cases associated with the use of injecting drugs have been predominantly taking place in the Center-South of the country (97% of the total IDUs), especially the States of S?o Paulo, Santa Catarina, Paran? and Mato Grosso do Sul. In some cities such as Santos (SP) and Itaja? (SC) they represent the predominant category. This area coincides with the main routes of drug trafficking in Brazil. A significant amount of cocaine produced in Colombia, Peru and Bolivia enters in Brazil through northern and western boundaries. The destination of a portion of this cocaine is the consumption in Brazil, while the remaining portion is exported to the United States and Europe. According to estimates from the Government of the United States of America, approximately 20 tons of cocaine is trafficked to or through Brazilian territory.
Transmission of AIDS through the use of contaminated injection equipment is responsible for the growing number of cases among women, sexual partners of IDUs, and consequently of pediatric AIDS as well. Approximately 26% of the registered cases among women are due to the use of intravenous drugs, used by themselves or their partners. It can be concluded that the control of AIDS in Brazil will only be possible through the control of the HIV transmission among intravenous drug users. This assumption becomes even more evident, if data of the epidemiological surveillance of the States of S?o Paulo and Santa Catarina are taken into account.
In cities like Santos-SP and in Itaja?-SC the HIV prevalence among injecting drug users reaches the alarming rate of more than 60%. In places like Sydney, Australia, where the government has adopted official policies of Harm reduction, the seroprevalence of HIV among intravenous drug users is only of 2%.
A recent study supported by the NC-STD and AIDS, carried out by IEPAS, an NGO from Santos-SP, showed the introduction of heroin in Brazil. Out of a total of 701 IDUs involved in the study, 13% reported the use of heroin in Salvador and 17% in Rio de Janeiro. This is an important alert to the public health authorities in the country for the necessity of adequate assistance for heroin users, which requires specific methods.
Previous UNDCP and Ministry of Health Cooperation
The National Coordinating Office of STD and AIDS, of the Ministry of Health, is the executing agency of Project "Drug Abuse Prevention with Special Emphasis on Prevention of HIV Infection among Intravenous Drug Users" in partnership with UNDCP. The project was signed in August 1994, effectively started in November 1994, and will finish in December 1998.
Through this project, the Government of Brazil aims at: preventing drug abuse and HIV transmission among the general population, with an emphasis on populations with high-risk behaviors; and reducing or stabilizing the transmission of HIV/AIDS and other STD among IDUs directly covered by project activities (approximately 6,000 IDUs) within a period of 3 years, with interventions at the treatment, rehabilitation and reinsertion levels.
The present project is concentrating efforts in ten priority states as regards the epidemiological situation of the HIV infection and the use of injectable drugs. These states are: Cear?, Bahia, Rio de Janeiro, S?o Paulo, Rio de Janeiro, Paran?, Rio Grande do Sul, Mato Grosso do Sul, Mato Grosso and the Federal District. In addition to these, some other states were incorporated directly by the executing agency, as Espirito Santo, Pernambuco and Piau?, or indirectly by the subprojects, as Goi?s, through the activities of the Training Center for the Center-West region.
It is important to emphasize the effort of developing a network of political and technical coordination among these subprojects and different institutions at the municipal, state and federal levels. The effective coordination of the different institutions involved in this field has strongly contributed to the sustainability of these subprojects.
The original goal of 52 subprojects was surpassed and presently 66 subprojects are receiving direct support of Project AD/BRA/94/851. During Project execution a strong demand for specific projects dealing directly with injecting drug users was detected and covered. Therefore, the number of treatment centers and harm reduction projects was increased.
According to recommendation from the UNAIDS, a UN Theme Group was created in Brazil, in 1997. Other agencies of multi- and bilateral cooperation, working in Brazil, are also participating in the Group, such as USAID and the European Union. Therefore, the present project proposal is part of a major initiative of interagency cooperation with the Government of Brazil. The National Coordinating Office of STD and AIDS will be the executing agency of four different Projects with UNDP, UNICEF, UNESCO and UNDCP. These agencies will work in close collaboration, according to each one’s mandate in order to cost-efficiently support the development of projects in the field of STD/HIV/AIDS prevention.
Drugs and AIDS Prevention Project Proposal
Due to the good results of the investments of the Government of Brazil in the field of HIV/AIDS and Drugs prevention and the necessity of consolidation and institutionalization of the interventions, the National Coordinating Office of STD and AIDS is designing a new program for the next 4 years. The Ministry of Health intends to continue working in close partnership with UNDCP and the World Bank.
The new program will concentrate efforts in health promotion, STD/HIV/AIDS and Drug abuse prevention, and monitoring and evaluation of the interventions.
The executor will be the National Coordinating Office of STD and AIDS, through implementing agencies at the state and municipal levels. NGO´s will continue to be important partners in the new program of Drugs and HIV/AIDS prevention. Presently, 20 NGO´s carry out activities in the fields of prevention, health promotion and assistance within Project AD/BRA/94/851. In addition, partnership with universities, as implementing agencies, will also be emphasized in the new program.
The main target-groups of the new program will be:
young people from low-income communities, with a special emphasis to adolescents in schools and in street situation;
Women, drug user or partner of drug user and adolescents;
Drug users and injecting drug users.
According to the UNAIDS, 2.6 million young people acquire the HIV virus every year worldwide. This translates into 5 young people every minute. In Brazil, 13,4% of the total number of AIDS cases are distributed in the age group of 15 to 24, while 56,90% are distributed in the group of 15-34 (Ministry of Health, 1997). Since the beginning of the epidemic, a progressive increase in the relative frequency of younger patients (20-29) has been observed.
Young people from low income communities are part of the target-group of the present project in face of the epidemiological trend of increase of AIDS cases in heterosexuals groups, mainly poor, with a lower or no educational level.
At the beginning of the epidemic in Brazil, 5% of the AIDS cases were among women, while presently, this participation increased to 30%. Out of a total number of AIDS cases of 120,399, the number of infected women is of 25,497. The proportion of AIDS cases between men and women went from 28:1 in 1985, to 7:1 in 1988, reaching 3:1 in 1996/7. This is considered the main indicator of the increase of the heterosexual transmission to women that are infected by the HIV, due to the high rates of prevalence of the virus among bisexuals masculine and heterosexuals injecting drug users (Quinn, 1989).
The present experience of carrying out training activities for teachers and students presented very good results and should be expanded in the second phase of the Project. A total of 5,000 teachers and 30,000 students in 1,000 schools were trained as multiplying agents for the prevention of STD/HIV/AIDS and Drug abuse. The schools that participated in the first phase were mostly located in the capitals of the 10 priority states. For the second phase it is very important to follow the epidemiological trend of interiorization of the AIDS epidemic and plan interventions in more cities and in all states of the federation.
In the first phase of the Drugs and AIDS Prevention Project, the innovative aspect of the training centers supported was the training of key staff as multiplying agents and the monitoring of their projects, resulted from the training workshops. The new project proposes the implementation of 9 centers in the country reinforcing the aspect of monitoring of the projects elaborated by the multiplying agents, but also providing them with some minimal support for the initial phase of execution.
Project AD/BRA/94/851 is considered a reference for technology transfer in the field of Drugs and AIDS for the UNAIDS. In 1997, the Project was invited to provide 2 consultancies for the above mentioned institution, one in Brazil and a second one in Uruguay, in order to assist the elaboration of a specific project of intervention among IDUs in the South Cone. For instance, in Argentina, 44% of the registered AIDS cases are due to injecting drug use. The Brazilian harm reduction Projects will serve as sites of internships for the UNAIDS South Cone Project. Therefore, cooperation with other countries in the South Cone, other countries in Latin American and the Portuguese-Speaking African Countries will be strongly reinforced in the next Project.
DRUG CONTROL OBJECTIVE
To reduce the incidence of HIV among injecting drug users, and to reduce drug abuse and HIV transmission among vulnerable populations, including young people from low income communities and women.
Immediate Objectives
To promote actions for the primary prevention of drug abuse, STD/HIV/AIDS among young people from low income communities, with a special emphasis to women;
To promote actions for the prevention of STD/AIDS and other diseases of blood transmission within populations making abusive and risky use of drugs and/or unsafe sexual practices;
To stabilize or reduce the transmission of STD, HIV/AIDS and other sexually transmitted and blood-borne diseases among injecting drug users and their socialization networks reached by the Project activities;
To promote actions aiming at the consolidation of technical horizontal cooperation with the Mercosul and the Portuguese-Speaking African countries, with an integrated regional perspective;
To strengthen the provision of assistance services to drug users as concerns STD, AIDS and chemical dependency;
To develop research in the area of drugs and, above all, in the interface Drugs/AIDS with a view to scientifically justify, subsidize and evaluate the actions of the project;
Related Outputs & Activities
Health Promotion, Protection of the Rights of AIDS Patients and HIV Infected Individuals and Prevention of STD, HIV/AIDS and Drug Abuse
Support to prevention programs addressing STD, AIDS and drug abuse in-school;
To have supported 27 prevention programs in these areas;
Support to institutionalized programs of HIV prevention among injecting drug users and its socialization network, in all the states of the federation;
To have implemented 32 local/regional reference projects in support to other counterpart local intervention actions;
Professionals trained in the development of actions addressing HIV prevention among IDUs;
Strengthening of 9 training centers (regional or regionalized) with the purpose of training professionals in the prevention of AIDS and drug abuse;
9 training centers properly operating;
2.000 professionals adequately trained and monitored for the execution of prevention projects addressing AIDS and drug abuse;
Projects resulted from the workshop supported with some minimal resources;
Support to Non-Governmental Organizations working in the area of drugs and AIDS prevention directed to specific populations (such as women, adolescents and drug users) from low income communities;
58 NGO projects being carried out with appropriate financial, political and operational support;
Designing of educational and instructional material and reproduction of existing material, properly evaluated, so as to implement the activities of the project at the central and sub-project levels;
To have produced 3 bulletins per year, 2 primers, 2 manuals, 2 books and 2 videos;
To have selected and reproduced existing material of high quality for distribution among subprojects directly supported by the Executing Agency;
Institutional Strengthening of the Implementing and Co-Implementing Agencies
The creation of a working group, or the identification of a professional to act as a reference at the state level for the operationalization of the actions in the area of drugs and AIDS in each of the 27 states of the federation;
1 Working group created or 1 professional identified;
Provision of support for the creation of 27 state networks of projects in the area of drugs and AIDS with the purpose of optimizing a number of existing action lines in the localities where projects are being set-up;
27 state networks for projects in the area of drugs and AIDS properly integrated;
Promotion of discussions with professional corporations, health managers and other sectors of society working in the area of drugs, AIDS, blood-borne diseases and developing strategies to approach the issue;
To have promoted a number of seminars, courses, workshops, etc. with professional corporations, health managers and other sectors of society;
Establishment of a network of national and international specialists in the area of drugs and AIDS with the purpose of supporting the development of actions at the central level and at the sub-project level;
National and International specialists technically, scientifically and methodologically assisting the sub-projects;
Setting up of a computer-based network in the area of drugs and AIDS for the technical and financial monitoring of the activities of the projects;
Projects adequately monitored through a computer-based network;
Consolidation of technical horizontal cooperation enabling the inclusion of actions in the area of drugs and AIDS in the agendas of the Mercosul countries and the Portuguese-Speaking African countries, with an integrated regional perspective;
To have hold a sensitization workshop on the theme and the programming of activities;
To have involved professionals of the participating countries in training courses and internships;
To have established specific technical horizontal cooperation projects.
Diagnosis, Treatment and Assistance to STD/HIV/AIDS Infected Individuals
Setting up of a reference network for the identification, expansion and reinforcement of the assistance for drug users, particularly injecting drug users infected with HIV and AIDS patients;
To have set up adequate reference services for the assistance of drug users, AIDS patients and HIV infected individuals indicated by the Harm reduction projects;
To have set up reference services for the handling of drug users, infected with the HIV and Hepatitis B and C virus;
Sensitization of health managers and professionals from reference treatment units for drug users infected with HIV, particularly injecting drug users, and AIDS patients;
To have hold workshops for the discussion of particularities in the assistance of drug users infected with HIV and AIDS patients;
Production of a video addressing the issues discussed;
Training of health teams in assisting drug users infected with HIV, particularly injecting drug users, and AIDS patients;
Health teams trained;
To have elaborated a manual for the handling of drug users infected with HIV.
Strengthening of reference institutions for the assistance of chemical dependency which support intervention projects among drug users, particularly injecting drug users;
Professionals trained in the assistance to injecting drug users in mental health care services;
To have established 27 health care centers for chemical dependency, evenly distributed in the country to serve as reference centers for drug users accessed in the intervention and assistance activities directed to HIV infected individuals and AIDS patients;
Monitoring, Evaluation And Research
Carrying out of epidemiological, ethnographic, behavioral and project evaluation studies in the area of drugs and AIDS, supporting and applying the results of research of which content contribute to the proposed objectives of the project;
Baseline studies defining a basic set of indicators for each area, which will serve as pre-requisite for the approval of projects, allowing for the comparative analysis and evaluation of their impact;
Study for the determination of the use of drugs in-school;
Study for the determination of the use of licit and illicit drugs, including percentage of STD/HIV/AIDS in the Brazilian population, to be carried out in cooperation with the Federal Narcotics Council of the Ministry of Justice and other relevant institutions to be defined;
Study for the determination of drug use and of the profile of drug users in the country;
Transition studies of drug-consumption patterns;
Study for the determination of seroprevalence of HIV, HBV and HCV among the injecting drug users participating in the harm reduction projects;
Study for the determination of AIDS patients and infected injecting drug users maintaining the treatment of anti-HIV and AIDS;
Study of the impact of the participation of drug users in harm reduction projects on behavior and substance-consumption patterns;
Study of the impact of the social networks (family, peers, institutions, communities) on the transmission of HIV and on the abusive drug consumption, as well as their function in the respective treatments;
Promotion of research in the area of drug treatment evaluation (alternative intervention) and HIV/AIDS patients undergoing anti-retroviral treatment (i.e. number of individuals undergoing the treatment, etc.);
Research and intervention projects for the discussion of the ethic aspects in each specific area. Creation of an ethics forum for injecting drug users, primary and secondary students and adolescents;
To have prioritized the establishment of cohort studies;
Injecting drug users participating in harm reduction projects adequately trained in the methodological, operational, technical and scientific aspects;
Other cohort studies in specific populations such as primary and secondary students, undergraduate students, etc.;
Evaluation of the setting-up of projects in the area of drugs and AIDS;
Evaluation of the instructional material produced for future standardization and reproduction;
Managerial evaluation through computer-based monitoring of the proposed activities.
COUNTERPART, INSTITUTIONAL SETTING AND IMPLEMENTATION ARRANGEMENTS
Within the scope of the Ministry of Health there are already some interfaces with other offices, which should be broadened. They are as follows:
Mental Health Coordinating Office (COSAM) - Secretariat of Health Policies/Ministry of Health
Strengthening of political and operational integration with the Mental Health Coordinating Office/SPS/MS with a view to optimizing and increasing resources in the areas of: a) prevention of drug abuse; b) chemical dependence assistance; c) specific intervention on harm reduction projects. This partnership will allow for the utilization of the structure of both coordinating offices and of their respective collaborating institutions at the state and municipal levels. The partnership will also be put into practice through the discussion of common issues, the testing of new technologies in the area, participation in workshops and the carrying out of evaluation activities.
Advisory Office for Special Health Affairs (AESA) - Cabinet of the Ministry of Health
To maintain and enhance contact with international institutions and international experts with the purpose of exchanging information and training national project personnel in the areas of chemical dependency and improving harm reduction strategies, particularly those resulting from cocaine and heroin.
Secretariat of Health Policies
To optimize the available resources for the development of evaluation actions in the area of drugs and AIDS prevention.
National Coordinating Office for Immune-predictable Diseases - National Health Foundation
To consolidate political and operational integration with the National Health Foundation/Ministry of Health, particularly with: a) The Viral Hepatitis Management Unit; b) The National Coordinating Unit for Sanitary Pneumology; c) The Technical Management Unit for the Control of Chagas Disease, with a view to establishing cooperation lines in the blood-borne diseases/drugs interface;
Some interfaces already exist, at the external level, but should be broadened.
Federal Narcotics Council - Ministry of Justice
Strengthening of political and operational integration with the Federal Narcotics Council so as to mutually approach drug issues and the treatment of chemical dependency, optimizing resources from both institutions as well as from their collaborating institutions at the state and municipal levels.
Interface works will include: a) the coordination of a network of organizations at the federal level, which will provide the means for the treatment of chemical dependency; b) mutual subsidy for proposals in this area; c) political support for the development of strategies, such as harm reduction, resulting from possible interfaces with the appropriate sectors of the Judiciary and the police structures.
Ministry of Education and State and Municipal Secretariats of Education
To strengthen the transference of technology to teachers and students who will be responsible for implementing actions at their final stage. In this context, partnerships with the education structures in the country play an important role also providing information on the degree of institutionalization of the actions. At the federal level coordination mechanisms with the Ministry of Education is being fostered. At the state and municipal levels secretariats of health and education are working in close collaboration in the development of the prevention programs in the schools.
House of Representatives and Senate
To establish integrated actions with parliamentarians so as to subsidize the formulation of laws in the area of drugs and AIDS, taking into account the sanitary aspects in the handling of such issues.
Universities
To promote and strengthen partnerships with professional teams, teachers, high-quality programs and services in the area of STD/HIV/AIDS and drug abuse prevention for the development of actions involving specialized training, technical and scientific advisory and principally research.
BIBLIOGRAPHY
Ministry of Health of Brazil. "Boletim Epidemiol?gico de AIDS", Year X, N°04, Epidemiological Week 36/97 to 48/97, September to November 1997;
Ministry of Health of Brazil / CN-DST/AIDS and United Nations International Drug Control Programme. "Uso Indevido de Drogas & DST/AIDS", Year I, N° 1, 2, 1997;
Ministry of Health of Brazil and United Nations International Drug Control Programme. "Project AD/BRA/94/851 Document", August 1994;
Ministry of Health of Brazil and United Nations International Drug Control Programme. "Project AD/BRA/94/851 Revision D", November 1995;
Ministry of Health of Brazil and United Nations International Drug Control Programme. "O Uso de Drogas Injet?veis e a Transmiss?o da AIDS no Brasil", July 1997;
Ministry of Health of Brazil. "AIDS II: Desafios e Propostas", 2° Version, March 1998;
UNAIDS (Joint United Nations Programme on HIV/AIDS). "News Conference in Moscow held by Dr. Peter Piot", April 1998.
UNDCP (United Nations International Drug Control Programme). "World Drug Report", 1997.
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