DEBATE DEBATE
Debate on the paper by David Vlahov & David D. Celentano
Debate sobre o artigo de David Vlahov & David D. Celentano
Flavio Pechansky
Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brasil fpechans@uol.com.br
The question of technology transfer: how does that apply to Brazilian reality?
The article by Vlahov & Celentano suggests very interesting questions for discussion. For example, the authors make a good point by stressing the importance of drug abuse treatment as a prevention tool for both HIV acquisition and transmission. However, when facing the reality of South America and Brazil, we must acknowledge that although "treatment" implicitly assumes a wide array of systems that allow for scaling the proper care according to the level of need of the client, there are no such systems in our environment. There are many potential explanations for this, but one of the most important reasons may be that scarce resources are not being properly distributed, since we seldom base our prevention and treatment choices on hard data. In fact, we struggle between passion and evidence to decide which are the best applications for government money (one such example is the government suggestion to provide "safe injection houses" a component of harm reduction practices to help injection drug users (IDUs) properly inject with lower risks of injury by using sterile injection equipments. Though this approach is quite established in developed countries 1,2, it is assumed that all other potential resources for drug users including IDUs are being provided in conjunction with this approach. This is certainly not the case of Brazil, where most parts of this complex infrastructure are missing, from hospital beds to continuous training of treatment and prevention teams. Therefore, advocating proper care for drug users particularly IDUs would mean recognizing this fact as one of the major issues that may prevent success.
Another point that must be taken into account is that the authors base most of their comments on IDUs who are mostly heroin users the typical reality of the Northern hemisphere. Again, this is not the reality of South America, where cocaine is the predominant drug for injection practices among drug users. This complicates the already tricky issues related to approaching IDUs either through conventional techniques, or through needle exchange programs: cocaine IDUs will inject more often than heroin users due to the much shorter half-life of cocaine when compared to heroin, thus potentializing their risks for HIV infection through exchanging unsterile equipment, as well as performing sex, for continuous drug use 3. It is reasonable to conclude that the wheel spins faster in such a cycle, therefore complicating approaches for IDUs based on harm reduction strategies that rely of reaching them on the field. The same seems to apply to crack smokers, which are reaching epidemic levels in Brazil 4.
The authors properly show that it may be difficult to field cohort studies or other prospective designs that include IDUs or intensive drug users. Although the techniques for such design are getting better, generating higher retention rates, there is a culture of rejection related to drug-using individuals in particular IDUs and crack smokers that is imbedded in the public approach to such clients. The Brazilian program of STDs/AIDS has been pushing hard to change this pattern by providing better opportunities reach and retain such groups of clients. However, even when properly retained in field programs, clients cannot find proper treatment slots even if they decide to quit their drug use, due to the "puzzle with missing pieces" that is the current atmosphere of drug treatment in Brazil 5.
Assuming that against all odds we would be able to overcome the above mentioned obstacles, we would have a drug-using client who is HIV positive or has AIDS, willing to submit to a HAART regimen. The problem of adherence would still need to be addressed. Even setting aside the ethical dilemma of drug treatment effectiveness leading to relapse to higher risk behaviors, as mentioned by the authors, we still do not have the appropriate tools to retain clients in hospital-based treatment settings. IDUs and crack smokers tend to shun hospital settings, and we have not developed appropriate methodologies to increase their levels of comfort. We might be better off by developing fast detox approaches including pharmacotherapy for cocaine injectors, as well as improving our mechanisms to retain drug users under systematic day hospital or inpatient treatment, thus opening the "windows of opportunity" for preventing HIV infection. This option of technology transfer may be more resilient to environmental aspects such as the ones described in this commentary.
1. Wood E, Kerr T, Small W, Li K, Marsh D, Montaner JSG, et al. Changes in public order after the opening of a medically supervised safer injecting facility for illicit injection drug users. CMAJ 2004; 171:731-4.
2. Kerr T, Wood E, Small D, Palepu A, Tyndall MW. Potential use of safer injecting facilities among injection drug users in Vancouver's Downtown Eastside. CMAJ 2003; 169:759-63.
3. Pechansky F, Lima AFBS, Genro V. Soropositividade para HIV entre usuários de drogas em Porto Alegre: uma comparação entre usuários e não-usuários de drogas injetáveis. J Bras Psiquiatr 2002; 51:323-6.
4. Nappo AS, Galduróz JC, Raymundo M, Carlinie EA. Changes in cocaine use as viewed by key informants: a qualitative study carried out in 1994 and 1999 in Sao Paulo, Brazil. J Psychoactive Drugs 2001; 33:241-53.
5. Pechansky F. Treatment for drug and alcohol problems in Brazil: a puzzle with missing pieces. J Psychoactive Drugs 1994; 27:117-23.