(June 2001) Dorival de Oliveira, a 39-year-old “paper catcher” in Brazil, makes a living collecting paper off the streets and selling it to recyclers. For 20 years, he was a drug user. Having lost his home and his family, he sleeps under a bridge in Osasco, a suburb of São Paulo. Like 50 percent of Brazil’s injecting drug users, he has contracted HIV. Now, Mr. Oliveira is a valuable part of one of Brazil’s most innovative programs in the fight to reduce HIV transmission, having been recruited by the nongovernmental organization (NGO) Associação Lar.

For wages of US$75 a month, more than he made collecting paper, Mr. Oliveira walks daily through empty lots and abandoned buildings. Armed with gloves and tweezers, he picks up used needles and syringes left by drug users and leaves in their place clean and sterile injecting equipment. When he comes into contact with the users, he also gives them condoms and HIV-related information.

Aptly called the “catcher-exchanger” program, the effort is a prime example of the two main aspects of Brazil’s battle for HIV risk reduction. The first aspect involves outreach to drug-using communities and populations, which tend to be young and poor. The second is the collaboration between the government and Brazil’s civil sector through activist NGOs and universities.

“NGOs and other components of the civil sector are responsible for about 50 percent of what we do,” says Dr. Denise Doneda, special assistant to the Minister of Health in charge of Risk Reduction Programs.

Among Brazil’s 170 million inhabitants, the government estimates that more than half a million people have HIV, with 203,000 confirmed cases since 1980. According to statistics compiled by the Ministry of Health, 74.7 percent of the confirmed cases are male, 25.3 percent female. Children under the age of 13 account for 3.5 percent of confirmed cases. The rate of new AIDS cases has been stable since 1996 at 14 per 100,000 inhabitants, or about 20,000 per year. HIV infection among heterosexuals is growing. In 1998, the number of new HIV cases among heterosexuals increased by 25.3 percent, to 43.5 percent of all new cases reported. Among homosexuals and bisexuals, the growth rate of HIV infection is stable at 8.9 percent.

In the last few months, Brazil has received worldwide attention for the distribution of free AIDS drugs to anyone infected and the effective monitoring of their use. But while the country has turned a corner where the treatment of the disease is concerned, it is still fighting to control its spread.

HIV Transmission Rates Decline Among Drug Users

HIV infection among drug users is considered one of the most critical areas. It is also the area where Brazil has achieved most success, since drug users are the only population group in which HIV transmission rates have fallen. This group registered a decrease in transmission of the virus of 7.6 percent in 1997 and 17.9 percent in 1998. Health officials believe that there could be several reasons for the decrease, including changes in drug habits, risk reduction programs, and the high mortality rate of this group.

The first HIV infection among injecting drug users was registered in 1982. Today, about 20.5 percent of new AIDS cases reported to the Ministry of Health are drug related. In 1985, that number stood at 2.7 percent. At its peak, in 1991, the number reached 25.5 percent. Alarmingly, over 75 percent people with HIV who contracted the virus between the ages of 12 and 19 were infected through drug use.

Even though transmission rates have fallen among drug users, there is still cause for concern. There are no firm numbers on illegal drug users who have HIV, but the government calculates that seroprevalence in larger cities, especially among younger users between the ages of 12 and 19, is about 50 percent. In some cities, such as Santos in the State of São Paulo, HIV seroprevalence among injecting drug users is estimated at more than 60 percent.

While heroin use in Brazil is growing, 90 percent of injecting drug users in the country use cocaine. Cocaine users can inject themselves between 20 and 30 times a night, compared with many fewer chances for HIV transmission for heroin users.

“As an added risk, cocaine is a major stimulant,” says Dr. Sergio Seidel, a psychiatrist in São Paulo who specializes in the treatment of drug users. “The cocaine user is not under control, does not much care where his next needle will come from, and does not tend to use condoms when having sex while high, especially in a country that culturally is already opposed to the use of condoms.”

Risks for Women Remain High

Thirty percent of HIV-infected women in Brazil are partners of drug users, and according to the Ministry of Health, HIV infection by drug injection is responsible for the growing number of AIDS cases among women in the country. According to Flavio Pontes, press officer of the Ministry of Health, “this is currently the most alarming trend in HIV transmission in Brazil.”

During the period 1994–1998, AIDS cases among men grew by close to 8 percent. By contrast, the increase among women was 71 percent. As the infection rate grows, health officials worry that AIDS may soon become the main killer of women in Brazil who are between the ages of 15 and 49.

Needle-Exchange Programs Seek Full Community Effort

Brazil started trying to implement needle-exchange programs in the early 1990s. Initial efforts met with strong resistance from judicial and law-enforcement sectors of the society and from religious institutions that defend abstinence. The first programs led to the jailing of doctors and other volunteers who participated in the distribution of needles. For years, the only possible method of risk reduction for injecting drug users in Brazil was the use of bleach to disinfect syringes.

In 1994, the federal government finally adopted the implementation of risk-reduction programs as an official policy of its AIDS programs. “Slowly, we learned that there had to be a method to the implementation of each needle-exchange program that goes through the mobilization of several sectors of each community where it can be implemented,” says Dr. Doneda.

This methodical work includes the education of four levels of the local population: government officials, media, law enforcement (police and judges), and finally, the community as a whole. On a parallel track, NGOs work on the establishment of contacts among the drug-using community. From the first initiative until the actual exchange of needles, the work can take six to 12 months.

Today, there are needle-exchange programs in most of Brazil’s major cities, most of them funded in part by the government and executed at the base by NGOs. The government estimates that 1 million syringes were exchanged last year and that 30,000 injecting drug users benefited.

Four of Brazil’s 26 states — São Paulo, Santa Catarina, Rio Grande do Sul, and Espírito Santos — have laws explicitly allowing for the distribution or exchange of needles and syringes to drug users, unimpeded by police raids. Laws are made necessary, depending on how liberal or conservative the population of each state is. For instance, in the northern state of Bahia, where the first needle-exchange program was implemented in 1995, the programs have never met any resistance. At the end of 2000, the government of current president Fernando Henrique Cardoso formally proposed to Congress that needle-exchange programs for HIV risk reduction be part of new legislation that deals with the drug traffic in Brazil.

While Brazil’s needle-exchange programs are still young and there are few studies about their rates of success, Dr. Doneda notes that behavior indicators are very positive. Research conducted by the Ministry of Health shows that injecting drug users in needle-exchange programs do diminish the rate at which they share needles and that they increase their use of condoms. Some 23 percent of them seek some sort of treatment against drug use, and most start regular testing for HIV.

Flavia Sekles is a Brazilian freelance writer based in Washington, D.C.

For More Information

Status and trends of HIV/AIDS in Brazil and in Latin America and the Caribbean www.aids.gov.br.

HIV/AIDS site for adolescents in Brazil (in Portuguese) www.adolesite.aids.gov.br.