HIV/AIDS in the Caribbean Basin.

After Sub-Saharan Africa, the Caribbean Basin has the second highest rate of HIV/AIDS in the world. The number of HIV cases in the region is likely to increase significantly over the next decade due to patterns of sexual behaviour, drug use, migration, and the sociocultural practices and legal and religious taboos which serve as barriers to safe sex, as well as stigma, shame, and denial which preclude many issues from being openly discussed and addressed. Studying the HIV epidemic in the Caribbean Basin is difficult, as efforts to synthesize information are often hampered by a lack of uniformity and availability of surveillance data in many parts of the region. In addition, behavioural surveillance is limited, and interventions addressing the cultural context of Caribbean populations are few in number. Overall, the geographic, political, cultural, and linguistic diversity of the Caribbean underscores the complexity of understanding broader regional patterns of HIV infection and developing and implementing targeted and appropriate responses.

Emerging linkages between substance abuse and HIV infection in St. Croix, US Virgin Islands.

In the US Virgin Islands 575 cases of AIDS had been reported to the Centers for Disease Control and Prevention through mid-2003. Although males continue to be most affected by HIV/AIDS, the feminization of the epidemic is evidenced by recent data showing rates of infection increasing rapidly among women. This paper focuses on the role of substance abuse and the socially and culturally based gender issues that influence risk and vulnerability to HIV in this setting. 254 chronically drug- or alcohol-involved men and women were recruited and interviewed using targeted sampling strategies. Crack use was overwhelmingly reported by females when compared to males (84.7% vs. 48.8%). Women also reported a significantly higher number of sexual partners in the past month (5.6 vs. 2.3) and significantly more occasions of unprotected vaginal sexual contact (11.2 vs. 6.5). Rates of self-reported HIV infection were elevated among women as well (8.8% vs. 1.4%). Women's precarious economic position and lack of access to legitimate income-generating activities tended to drive them into 'survival sex' to support their subsistence and drug needs. As such, it would appear that substance abuse has an emerging role in the spread of the epidemic in St. Croix, particularly among women.

Tailoring an HIV-prevention intervention for cocaine injectors and crack users in Porto Alegre, Brazil.

Brazil has the second largest number of reported AIDS cases in the world. Porto Alegre, like most other large urban centres in Brazil, has been greatly impacted by an AIDS epidemic driven by high rates of drug use and risky sexual behaviours. While epidemiologic surveillance of HIV/AIDS and treatment initiatives for HIV-infected individuals are well developed in Brazil, comparatively little attention has focused on developing interventions directed toward high-risk populations. Intervention programmes, particularly those tailored for chronic drug users, are lacking. This pilot project successfully adapted and tailored a cognitive behavioural HIV intervention developed in the US to the cultural setting in Porto Alegre. The project established feasibility and acceptability of the approach for targeting risky drug and sexual behaviours among a group of male Brazilian drug users. A sample of 120 male cocaine users was recruited from a public health clinic serving the target population in the city of Porto Alegre. The average age of the participants was 29; they averaged less than 8 years of formal education; and less than half (41%) were married. Lifetime self-reported drug use was high with 93% reporting cocaine use, 87% reporting crack use, and 100% reporting marijuana use. 43% of the sample reported ever injecting drugs. Reports of risky sexual behaviours were similarly elevated. Almost half (45%) tested positive for HIV. Preliminary evidence suggests that intervention acceptability was high among participants. Given the reported high risk sexual and drug use behaviours among these men, HIV interventions must be evaluated and expanded to include this population as well as their sexual partners.

The effect of serostatus on HIV risk behaviour change among women sex workers in Miami, Florida.

HIV prevention and risk reduction are especially salient and timely issues for women, particularly among those who are drug-involved or who exchange sex for drugs or money. Studies suggest that HIV-prevention measures can be effective with highly vulnerable women, and have the potential to produce significant reductions in risk behaviours among both HIV-negative and HIV-positive women. Within this context, this paper examines risk behaviours and HIV serostatus among 407 drug-involved women sex workers in Miami, Florida, and investigates the effects of participation in HIV testing, counselling, and a risk-reduction intervention on subsequent behavioural change among this population. Overall, at follow-up, the HIV-positive women were 2.4 times more likely than the HIV-negative women to have entered residential treatment for drug abuse, 2.2 times more likely to have decreased the number of their sex partners, 1.9 times more likely to have decreased the frequency of unprotected sex, 1.9 times more likely to have reduced their levels of alcohol use, and 2.3 times more likely to have decreased their crack use. These data support the importance of HIV testing and risk-reduction programmes for drug-involved women sex workers.

HIV risk, seropositivity and predictors of infection among homeless and non-homeless women sex workers in Miami, Florida, USA.

Although homelessness has frequently been associated with substance abuse, and has been established as a predictor of HIV risk among substance abusers, little is known about the impact of homelessness on HIV risk among female sex workers. This analysis investigated the contribution of homelessness to sexual risk taking among a sample of 485 female sex workers recruited into an HIV prevention programme in Miami, Florida, 41.6% of whom considered themselves to be currently homeless. Findings indicated that in comparison to non-homeless sex workers, significantly more homeless sex workers were daily users of alcohol and crack, and their past month sex work reflected significantly more frequent vaginal and oral sex acts, higher levels of unprotected vaginal sex and more numerous sexual activities while 'high' on drugs. At the same time, a significantly greater proportion of homeless sex workers encountered customers that refused to use condoms than did the non-homeless sex workers. There were no significant differences in HIV seropositivity between the homeless and non-homeless women (22.5 and 24.9%, respectively), primarily because the majority of the women in the study cycled in and out of homelessness.

Cross-cultural approaches to harm reduction research: some considerations on the Brazil experience.

Harm reduction initiatives for drug users comprise a range of approaches, including drug-user treatment, advocacy for changes in drug policy, needle exchange programs, bleach distribution, and broad-based interventions that focus on both safer drug use and less risky sexual behaviors. In many developing nations, harm reduction is a relatively new strategy, which focuses almost exclusively on the connections between drug use and the spread of HIV infection. In Brazil, harm reduction programs are few, and little has been documented about their scope, experience, and effectiveness. This paper reviews the status of Brazilian harm reduction initiatives in general, with a specific focus on lessons learned from the conduct of cross-national research in Rio de Janeiro. The study demonstrated the feasibility of implementing a community-based prevention program among an at-risk population of cocaine users in Brazil, and in other countries where there is little tradition of research with out-of-treatment drug users. Finally, the paper addresses aspects of the harm reduction movement that tend to hamper its progress in both developed and developing nations.

Drug use, street crime, and sex-trading among cocaine-dependent women: implications for public health and criminal justice policy.

The linkages between the sex-for-crack exchanges, prostitution, and rising rates of HIV and other sexually transmitted diseases among cocaine-dependent women have been well documented. As crack began to disappear from the headlines during the 1990s, however, it was assumed by many that crack had fallen on hard times in the street drug culture. Within this context, this article examines the extent to which crack has remained primary in the culture of cocaine-dependent women. Data are drawn from a study of 708 cocaine-dependent women in Miami, Florida, during the years 1994 to 1996, and qualitative data gathered during 1998 and 1999 in the same field areas. Analyses focus on drug use, criminality and HIV/AIDS risk behaviors. Implications for policy alternatives in criminal justice and public health approaches for assisting this population are discussed.

AIDS susceptibility in a migrant population: perception and behavior.

Within the framework of the Health Belief Model, this paper examines correlates of perception of AIDS susceptibility among 846 drug-using migrant farm workers and their sex partners. Significant but relatively small differences by ethnicity and gender were found. The data showed a consistent significant statistical relationship between frequency of drug use, high-risk sexual behavior, and perception of AIDS susceptibility. Perception of AIDS susceptibility was significantly related to a subsequent reduction in sexual risk behaviors. Consistent with the Health Belief Model, the data suggest that increasing perception of AIDS susceptibility may be an important motivator in reducing high-risk behaviors.

Drug use and HIV risks among migrant workers on the DelMarVa Peninsula.

Because high rates of drug use have been documented in the migrant farm worker population, the National Institute on Drug Abuse funded the Migrant Health Study to examine HIV risk behaviors among drug-using farm workers and their sexual partners. Many of these individuals were home-based in South Florida and migrated during the work season to various points along the Eastern Migratory Stream. The focus of this paper is a description of the characteristics and behaviors of the 151 respondents contacted on the DelMarVa Peninsula during 1994 and 1995. The data indicate that drug use was widespread in this population, a significant proportion were at risk for HIV infection, and 6% were HIV positive. As a result of these findings, public health agencies on the peninsula have instituted HIV education programs in those clinics utilized by both local and transient agricultural workers.

A postmarketing surveillance program to monitor Ultram (tramadol hydrochloride) abuse in the United States.

Tramadol HCl, marketed as Ultram in the USA, was introduced as a non-scheduled drug in April 1995 based on the assumption that the risk of abuse was sufficiently low to warrant a non-scheduled status. However, approval was contingent upon the development of an innovative proactive surveillance program, to be overseen by an independent steering committee, which would detect unexpectedly high levels of abuse. The postmarketing surveillance program consisted of systematic collection and scientific evaluation of reports of suspected abuse in high-risk populations surveyed through an extensive key informant network of drug abuse specialists and all spontaneous reports of abuse received through the FDA MedWatch system. Methods to estimate the number of patients prescribed tramadol were also developed. Monthly rates of abuse were calculated as an index of the risk-benefit ratio (i.e., abuse cases per 100,000 patients prescribed the drug). The data for the 3 years since the drug was introduced show that the reported rate of abuse has been low. Although a period of experimentation seemed to occur in the first 18 months after its introduction--which reached a peak rate of approximately two cases per 100,000 patients exposed--during the 2 year period prior to June 1998, the reported rate of abuse has significantly (P = 0.011) declined, reaching levels of less than one case per 100,000 patients in the last 18 months. The overwhelming majority of abuse cases (97%) have been found to occur among individuals with a history of substance abuse and the abuse has been confined to isolated pockets around the country-notably none of which have significant populations of street drug abusers. Thus, the data support the decision not to schedule tramadol and, furthermore, suggest that a proactive post-marketing surveillance program can be successfully developed to effectively monitor abuse of new medications.

Unraveling the concept of race in Brazil: issues for the Rio de Janeiro Cooperative Agreement site.

Scholars throughout the Americas have spent much of the 20th century studying race and its meaning in Brazil. Racial identities in Brazil are dynamic concepts which can only be understood if situated and explored within the appropriate cultural context. Empirical evidence of the fluidity of racial identification quickly came to the authors' attention within the context of a prevention initiative targeting segments of the Rio de Janeiro population at high risk for HIV/AIDS. Because the main objective of this program was to slow the spread of AIDS through an intervention designed to promote behavioral change, comparisons of client data at the baseline and follow-up assessments form the core of the analyses. Through quality control procedures used to link client information collected at different points in time, it was revealed that 106 clients, or 12.5% of the follow-up sample, had changed their racial self-identification. The authors' attempts to engage project staff in a dialogue about the fluidity of racial identity among these clients have provided some insight into what might be called the "contextual redefinition" of race in Brazil. Within the framework of this study, the ramifications of this phenomenon are clear. Racial comparisons of HIV risk, sexual activity, drug use, and behavioral change, which are part and parcel of U.S.-based research, would appear to be of little utility in this setting.

PIP: Although Brazil has always prided itself as being a place in which racial discrimination is not tolerated, most Black Brazilians recognize that they are discriminated against. Considerable research has been conducted during the 20th century upon race and its meaning in Brazil, a country in which racial identity is a dynamic concept capable of being understood only if situated and explored within the appropriate cultural context. In 1993, the National Institute on Drug Abuse funded a cooperative agreement project in Rio de Janeiro designed and implemented to slow the spread of HIV/AIDS through behavioral change. Data collection instruments developed for US populations were standardized across intervention sites, which allowed program participants to self-identify as Black, White, Hispanic, Asian, Native American, or other. However, these limited terms failed to capture the full extent of racial diversity in Brazil. More than 1500 clients were initially recruited, with follow-up interviews completed with 849. By follow-up, 106 clients, 12.5% of the follow-up sample, had changed their racial self-identification: 5.7% from Black to White, 30.2% from Black to Brown, 20.8% from White to Brown, 3.8% from White to Black, 23.6% from Brown to Black, and 15.1% from Brown to White. The study of race and race relations in Brazil is a complex undertaking which requires the thorough examination of Brazilian culture and history. Theories of race in Brazil and the self-identification of race in the Brazil cooperative agreement are discussed. Race is of little use in Brazil as a construct for analysis.

Effectiveness of HIV risk reduction initiatives among out-of-treatment non-injection drug users.

While attention has been paid recently to the effectiveness of HIV/AIDS interventions among injection drug users, less focus has been given to out-of-treatment noninjecting drug users. This study examines the the NIDA Cooperative Agreement standard intervention versus an enhanced intervention for HIV/AIDS risk among noninjecting drug users. Data come from five sites of the NIDA-funded Cooperative Agreement on HIV risk behaviors. The sample is comprised of those who never injected drugs or reported not injecting in the 12 months prior to the interview; and who completed a three-month follow-up assessment. Three risk behaviors in the prior 30 days were analyzed: frequency of crack/cocaine use, number of sex partners, and frequency of condom use. The levels of both baseline and follow-up risk were analyzed. Individuals remaining at low risk or decreasing risk behaviors were classified as "improved." Those increasing risk behavior or remaining at moderate or high levels were classified as "worsened." Of the 1,434 noninjecting crack/cocaine users, 82% improved crack/cocaine use at the follow-up. The enhanced intervention group showed more improvement in crack/cocaine use than the standard intervention group. Overall, 76% reported reducing sexual partners, maintaining a one-partner relationship, or abstaining from sex at both time periods. Women in the enhanced intervention group improved more than women in the standard intervention (81% versus 75%). In terms of condom use, more respondents worsened than improved (55% versus 45%). This study confirms that HIV/AIDS interventions can reduce crack/cocaine use; however, high-risk sexual behaviors are more difficult to change. Reasons for this lack of improvement and suggestions for future interventions are discussed.

HIV prevention protocols: adaptation to evolving trends in drug use.

Applied research in HIV prevention with out-of-treatment substance abusers takes place in a constantly changing environment. Researchers must be able to identify changes in drug use and sexual risk patterns, develop and evaluate appropriate interventions to respond to those changes, and find ways to make effective use of new technologies as they are developed. An example of this process is the collaborative revision made to NIDA's Standard Intervention for HIV prevention by the final six study sites funded under the NIDA Cooperative Agreements for AIDS Community-Based Outreach and Intervention Research. To illustrate the process of responding to changes in the substance abuse environment, to advances in knowledge about risk, and to newer technologies, this article provides an overview of the history of two federally funded HIV-prevention programs for out-of-treatment substance abusers and reviews recent changes made to the Standard Intervention protocol. The rationale for the changes is discussed, and the substance abuse population in the study is described.

Drug use and street crime in Miami: an (almost) twenty-year retrospective.

Researchers at the University of Delaware have been conducting field studies of drug use and crime in Miami, Florida, since 1977. This paper reviews this research and its contributions to understanding drugs-crime relationships. Early studies tested mechanisms for accessing street populations of heroin users and assessing the nature and extent of their drug use and criminality. Subsequent studies targeted a variety of crime-involved heroin and cocaine users, including women as well as men, serious delinquents, adolescent and adult crack users, and cocaine users in treatment as well as on the street. Major findings include the low risk of arrest for income-generating crimes committed by heroin users, and the prevalence of HIV-risk behaviors among both serious delinquents and women crack users. Analyses consistently show the critical importance of sample characteristics in research on drug use, including age, cohort, and street-versus-treatment status.

Children in the streets of Brazil: drug use, crime, violence, and HIV risks.

The presence of vast numbers of unsupervised and unprotected children is a phenomenon that is common throughout Latin America, and in few places are the street children more visible, and reviled, than in Brazil. Estimates of their numbers in Brazil have ranged from 7 to 17 million, but more informed assessments suggest that between 7 and 8 million children, ages 5 to 18, live and/or work on the streets of urban Brazil. Accounts of drug misuse among street youths in Brazil are commonplace. Numerous scientific studies and media stories have reported the widespread use of inhalants, marijuana and cocaine, and Valium among street children. Also common is the use of coca paste and Rohypnol. Risk of exposure to HIV is rapidly becoming an area of concern because of the large number of street youths engaging in unprotected sexual acts, both renumerated and nonrenumerated. Moreover, Brazil's street children are targets of fear. Because of their drug use, predatory crimes, and general unacceptability on urban thoroughfares, they are frequently the targets of local vigilante groups, drug gangs, and police "death squads." Although there have been many proposals and programs for addressing the problems of Brazilian street youth, it would appear that only minimal headway has been achieved.

Risk behavior and HIV seroprevalence among injecting drug users in Rio de Janeiro, Brazil.

OBJECTIVE: To characterize HIV seroprevalence and risk behavior among injecting drug users (IDUs) in Rio de Janeiro, Brazil, between 1990 and 1996. DESIGN: We report data from three separate cross-sectional samples of IDUs in Rio de Janeiro: the World Health Organization (WHO) sample (n = 479), the Proviva sample (n = 138) and the Brasil sample (n = 110). These data provide the most comprehensive view available, to date, of this understudied population in Rio. METHODS: Demographic characteristics, HIV/AIDS risk behavior and HIV seroprevalence were compared across the three samples and combined analyses were performed to determine the factors associated with injecting risk behavior, sexual risk behavior and HIV seropositivity. RESULTS: The overall HIV seroprevalence among IDUs was 25%. Two encouraging findings of the present analysis were the lower levels of needle-sharing among participants recruited in the latest years (1995-1996) and the lower HIV seroprevalence in the Proviva sample composed mainly of less educated, poorer IDUs living in deprived neighborhoods. No trends toward safer behavior were found for sexual risk, younger age being the principal factor associated with high risk. CONCLUSIONS: Levels of needle-sharing and sexual risk among IDUs in Rio remain high, demonstrating the urgent need to increase the limited preventive measures undertaken so far. Seroprevalence levels for HIV remain significantly lower in the most deprived sample, arguing for the fundamental importance of prompt and effective prevention strategies to keep infection rates from rising among the poorest and largest strata of Rio's IDUs.

Rohypnol misuse in the United States.

Rohypnol, a potent sedative-hypnotic drug prescribed extensively throughout the world, is illicit in the United States. Recently, this drug has gained popularity among United States youths as a cheap means of intoxication and subsequently has become the focus of numerous criminal investigations. College men are alleged to slip Rohypnol tablets into unsuspecting women's drinks and then sexually abuse their sedated victims. Although law enforcement agencies and drug policy groups consider Rohypnol to be an "imminent problem," little is actually known about patterns of misuse. Presented here is a brief overview of Rohypnol's contemporary appearance in the United States.