Drug Use, Harm Reduction, and Health Policies in Argentina: Obstacles and New Perspectives

SUPPLEMENT ARTICLE Drug Use, Harm Reduction, and Health Policies in Argentina: Obstacles and New Perspectives Silvia Inchaurraga Drug Abuse and AIDS Advanced Studies Center of the Universidad Nacional de Rosario, Rosario, and Argentinean Harm Reduction Association, Buenos Aires, Argentina; and Latin American Harm Reduction Network High human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) incidence among injection drug users (IDUs) shows the failure of traditional health policies. The preference of IDUs for injected cocaine exposes them to high risks for contracting HIV because of the frequency of drug use. The correlation of poverty with the selling of drugs, especially the so-called drugs of poverty freebase cocaine and crack is a consequence of prohibitions against drug use and of urban unemployment. In Argentina, zero-tolerance approaches and punishment for personal drug use tend to exclude IDUs from the country s health care system. A historical perspective is presented regarding approaches to the prevention of HIV/AIDS and harm reduction in Latin America and Argentina, where, despite isolated efforts, IDUs had no free access to sterile needles until the end of the 1990s. We present the impact of programs and campaigns of the Argentinean Harm Reduction Association, showing how and why, even with obstacles, harm reduction is possible and necessary. BACKGROUND High HIV/AIDS incidence among injection drug users (IDUs) and health problems among drug users (DUs) in general show the failure of traditional public policies in Argentina. Prevalence rates of HIV/AIDS are high among IDUs. Studies show that, in Rosario, 65% of IDUs are infected with HIV/AIDS [1] and that 57% of IDUs in Buenos Aires are infected [2]. Sharing infected needles and other injecting equipment is a very efficient way to transmit HIV directly into the bloodstream. Because of the rapid diffusion of HIV among IDUs, the epidemic has grown more rapidly among IDUs than in any other group. The need for HIV prevention among IDUs is obvious. The preference of IDUs for cocaine as their injection drug of choice exposes them to a high risk of acquiring HIV/AIDS because of the frequency of use associated with cocaine [3]. Data of the World Health Organization multicenter study on injection drug use in Ar- Reprints or correspondence: Dr. Silvia Inchaurraga, Juan Manuel de Rosas, 1058 (2000) Rosario, Argentina (sinchaur@sede.unr.edu.ar). Clinical Infectious Diseases 2003; 37(Suppl 5):S366 71 2003 by the Infectious Diseases Society of America. All rights reserved. 1058-4838/2003/3712S5-0008$15.00 gentina shows that cocaine IDUs can inject the drug up to 30 times daily [4]. New risk-behaviors associated with cocaine use are the injection of nonconventional drugs, such as deodorants, and of synthetic drugs. The correlation of injection drug use with poverty, including the selling of drugs, may mean that selling drugs can support personal use, but also the income of a disadvantaged family. The expanded drug enforcement effort and the black market seem to be related to consequences of poverty and marginalization. The development of the so-called drugs of poverty, freebase cocaine and crack, is associated with prohibitions against drug use and with urban unemployment. In Argentina, as in most Latin American countries, there is not a tradition of tracking facts related to drug abuse or of conducting an epidemiological study on drugs. Valid and systematic data on the extent and nature of illicit drug abuse are still rare, and there are only isolated records and studies, which usually cannot be effectively compared. The lack of valid data makes it difficult to plan and to evaluate interventions [5]. The process of introducing harm-reduction polices in Latin America has been erratic because of strong opposition from conservative forces and prejudice S366 CID 2003:37 (Suppl 5) Inchaurraga

against most of the core components of harm-reduction policies, such as condom distribution [6]. Zero-tolerance approaches and drug control laws have shut DUs out of the health system in Argentina [7]. Most of the drug-related criminal procedures in Argentina are related to possession of drugs for personal use, and those found guilty are punished under Article 14 of Drug Law 23.737. Because drug use is against Argentinean laws, DUs and IDUs are exposed to many health and social risks. Argentina has one of the highest rates of HIV incidence among IDUs in Latin America. In Argentina, IDUs represent the key problem related to the AIDS epidemic. Official epidemiological data show that almost 40% of all AIDS cases in Argentina are associated with injection drug use [8]. However, little comprehensive or solid scientific data exist on the extent or specifics of the problem of drug use and IDUs, and only a few interventions but almost no state policy have been put into practice in recent years to reduce the enormous social harm and the costs associated with this phenomenon. METHODS There is extensive documentation of the effectiveness of HIV/ AIDS prevention interventions among DUs and IDUs in the developed world but very limited information on interventions in developing and transitional countries, especially in Latin America. This issue has been pointed out by several authors [9]. Although there are many information gaps, recent efforts to implement harm reduction and HIV/AIDS prevention programs among DUs in Argentina reveal an emerging picture of problems and responses. In Argentina, despite isolated efforts developed in Rosario City in the early 1990s, IDUs did not have free access to needle exchange [10]. Obstacles and objections are based on moral issues, disregarding scientific evidence. Interventions. Intervention can be understood as any action that is taken to help reduce the adverse consequences of drug use and the practice of injecting drugs. Included is intervention at the individual, community, policy, and environmental levels. Intervention may be in the areas of prevention, health promotion, treatment, and policy responses [11]. This article focuses on interventions in Argentina that aim to prevent HIV/AIDS and other bloodborne diseases among the DU and IDU populations. In Argentina, most of the interventions aimed at prevention of HIV/AIDS are directed to sexual transmission, and the majority of those related to drug use focus on abstinence-based interventions, in which HIV/AIDS prevention is synonymous with prevention of drug use and abstinence from drugs. Public drug policies in Latin America focus on drugs, especially on the control of supply and demand. All Latin American countries have a national drug control agency, whose main aim is coordinating efforts to control illicit drug use. Regarding health policies, abstinence-based treatment interventions, most of them through therapeutic communities, are the rule. But even for the world s best services, the recovery level of licit and illicit DUs in abstinence-based programs is only 30% [12]. Available evidence supports the conclusion that 80% of DUs do not accept therapeutic treatment, and half of the attending population wants to continue with their use [13]. Behavioral changes by IDUs regarding risks is possible through public health approaches [14], controlling the AIDS epidemic through the public health measures of easy treatment access and harm reduction interventions. Programs based on harm reduction were begun in the 1990s in Latin America by the Civil Society, including universities and nongovernmental organizations. The University of Rio de Janeiro, the University of Bahia (Drug Abuse and Alcohol Studies Center [CETAD]), Drug Abuse and AIDS Advanced Studies Center of the University of Rosario (CEADS-UNR), and nongovernmental organizations Instituto de Estudos e Pesquisa de AIDS de Santos, Fundacion Oswaldo Cruz, and Intercambios are the main references. With the advent of HIV/AIDS in the Southern Cone region of South America in the last decade, few interventions have been developed related to harm reduction. In 1995, San Salvador de Bahia developed the first needle exchange program in Latin America, and its example was followed by other Brazilian cities. In 1998, the first Latin American pilot substitution program, which used buprenorphine to replace opiates, was established in Rosario City, in Argentina [15]. The fight for a harm reduction strategy targeted to IDUs within the framework of public health polices began after 1992 in Brazil and after 2000 in Argentina, when the government obtained financial and technical support from the World Bank for AIDS prevention, with a priority on IDUs and their sex partners [16]. In this connection, in Argentina, the Ministry of Health supports 3 communication campaigns targeted at IDUs (2 nongovernmental organizations and the Argentinean Harm Reduction Association [ARDA]) and 10 programs for HIV prevention directed at DUs [17]. Several HIV prevention programs that include HIV testing, pretest and posttest counseling, and instruction in condom use are also being implemented; however, interventions related to instruction on the effects of drugs and instruction on disinfecting injection equipment and disposing of materials are seldom available. Outreach programs. Outreach programs that provide HIV prevention information and sometimes condoms for DUs are being implemented in Argentina. Recently, ARDA began an AIDS prevention and harm reduction campaign in Argentina, targeted to youth at rock concerts, which used realistic Drug Use, Harm Reduction, and Health Policies in Argentina CID 2003:37 (Suppl 5) S367

materials in the language of youth. The materials include information about the risks of combining drugs, ways of administering drugs, problems with the police, and emergency situations. In the most recent intervention, 20,000 youth received information and condoms [18]. There is also a harm reduction program for youth at rave parties that utilizes innovative techniques such as in situ pill testing. Studies based on the rapid assessment and response methodology have been shown to be useful among hard-to-reach populations of IDUs in Argentina [3]. The collaboration of DUs, serving as outreach workers, was also a part of these interventions. Peer education and social network interventions. National harm-reduction associations have been created in Argentina, as well as in Brazil, Bolivia, and, recently, Uruguay and Chile. For example, self-organizing movements related to cooperative-based interventions involve local and national DU organizations. Since its creation in 1998, RELARD, the Latin American Harm Reduction Network, has played an increasing role in supporting harm-reduction policies and practices in the region [19]. IDUs, working as peer educators or health agents, have been shown to be key elements in accessing hard-to-reach IDUs, especially in marginal areas and other locations where drug use takes place close to drug-selling settings. This have been shown through the development of DUs organizations in Latin America, such as RADDUD, Argentinean Network on Defense of Drug Users Rights, born in 2000. The importance of the involvement of DUs and IDUs in prevention interventions has been reported by several Latin American organizations. Few of these organizations have been oriented to young DUs, unlike the programs of CEADS-UNR in Argentina, in which young DUs between 15 and 20 years of age have been involved as outreach workers [20]. Based on preliminary reports about drug use in marginally poor sectors, such as slums, the national campaign If you do it, do it well was begun at the end of 2001 for the cities of Buenos Aires, Rosario, and Cordoba, by ARDA, with support from the Project to Fight against AIDS and Other Sexually Transmitted Diseases (LUSIDA). Interventions were based on peer education, outreach, and harm-reduction strategies, and were targeted to the use of crack and freebase cocaine, as well as to the combined use of alcohol and cocaine. In the intervention, information about the drug law and the risks related to the enforcement of the law, corruption, and social problems played a key role [21]. Cleaning injection equipment. Bleach distribution programs and education programs about how to disinfect injection equipment have been developed in Argentina. This intervention has been shown to be an effective method for avoiding the social, political, and economic difficulties of distributing or exchanging syringes [22]. Adequate interventions in countries in which needle and syringe distribution and exchange is restricted [23] show, not only that a supportive policy environment is necessary, but also that there are alternatives to reduce the risks related to equipment sharing and reuse. For example, there is a current innovative approach to promote harm reduction in prisons through workshops that teach how to disinfect needles used in injection drug use and tattooing [24]. Provision of sterile injection equipment. Needle distribution and exchange in Latin America began in Brazil in 1995. In Argentina, distribution began in 1999 2000 in Rosario and Buenos Aires City. The first Argentinean injection kit, with the support of the Ministry of Health, was developed by the National University of Rosario in 2000 [25]. Drug treatments. In Argentina, the therapeutic infrastructure is poor. Most of the drug treatment centers are therapeutic communities and religious-oriented programs that make no provision for HIV risk-management if relapse occurs. Adequate provision of drug abuse treatment programs can have an important effect on limiting the spread of HIV/AIDS [26] and appears to be an urgent priority in Argentina. With regard to what is known as the low-threshold assistance model (an assistance-based model in which abstinence of drugs is not the goal), some IDUs could be prepared to enter into drug treatment but not prepared to stop injecting or using drugs. Drug treatment centers in Argentina seldom use this strategy. However, in a public mental hospital in Argentina, a friendly and psychoanalytical approach has been associated with harm-reduction workshops and with the substitution of buprenorphine for illicit drugs since 1994 [27]. Opiate substitution in Argentina has only been used in a public health hospital in Rosario City. Substitution with buprenorphine began in a pilot program in 1998 [28]. Another pilot project of substitution of methadone had been conceived [29]. The Argentinian experience with opiate substitution programs is concordant with the international experience with similar programs, showing that the contact of IDUs with the health system, plus the medical administration of drugs, helped modify risk behaviors. Substitution treatments for opiate users have shown that such treatments are appropriate and feasible in the context of polydrug use and that they constitute a good strategy for contact with difficult-to-reach cocaine users. In regard to access to treatment, the key strategies are availability of HIV testing and of systematic diagnosis, treatment of sexual diseases, and free access to HAART, which is available in Argentina. Rosario as a case study of best practice. Rosario is the second most important city in Argentina, located in the south of the province of Santa Fe. It has almost 1 million inhabitants living in a metropolitan area of nearly 200 km 2. More than half of the HIV cases in Rosario are related to the sharing of injection equipment. Research to assess the IDU situation and S368 CID 2003:37 (Suppl 5) Inchaurraga

its consequences using the rapid assessment and response methodology, which was proposed by the World Health Organization, showed that 91% of IDUs in Rosario had not accessed any health service for treatment of their addiction, 70% shared or reused injection equipment, and 65% were HIV-positive [3]. Since the early 1990s, CEADS-UNR has been working hard within the official abstinence-based context of a war on drugs to reduce drug-related harm in Rosario City. CEADS decided to implement a harm-reduction program with interventions in several locations where open drug use, prostitution, and other risky behaviors were common. Since this effort began, in 1993 and 1994, the program has included outreach activities such as use of a low-threshold assistance model in a public mental health hospital and harm-reduction workshops about needle disinfection. Since 1998, the program has used opiate substitution with buprenorphine and has implemented a needle distribution policy. This harm-reduction program received the endorsement of the Regional Ministry of Justice, which in 1999 signed a resolution declaring that harm reduction and the program were officially approved. Since 2000, with the support of the National Ministry of Health and LUSIDA and with funds from the World Bank, the program has used innovative approaches to contact DUs via a harm-reduction bus. This bus travels to urban locations where open drug use or drug selling is common, including marginal areas, parks, and centers of night life, delivering pragmatic information about drugs, dispensing condoms, and distributing pamphlets promoting the program and its services. New harm-reduction materials, entitled How to Use Cocaine, Pills, and Ecstasy with Less Risks and Any Way You Do It, are being distributed. Peer education by IDUs and educational materials created by IDUs in the form of comics that use language characteristic of DUs are key elements of the intervention. The front pages of prominent national newspapers have proclaimed that the first program with official support that uses injection kits began in Rosario [30 32]. The injection equipment is part of a kit called La Cajita, which includes 2 syringes, a sterile container, needles, 2 alcohol wipes, 2 ampules of sterile water, 2 condoms, and information about the kit s contents and how to use them. The kit is accompanied by an injection handbook, the first in Spanish in Latin America. This material, developed by CEADS-UNR with the collaboration of ARDA, informs IDUs about safe injection and how to avoid HIV/AIDS, hepatitis, abscess, and overdoses, and it contains specific information about injecting cocaine, the use of condoms, what to do in case of emergency, and the emergency and assistance services in the city. This new handbook, made for and by IDUs, promotes the message If you are going to use drugs, do it with fewer risks and harms. The impact of the program could modify the perception that valid interventions should be abstinence-based, especially because the Regional Ministry of Health signed an agreement with CEADS- UNR to replicate the program throughout the province. This initiative was selected by RELARD as a best-practice case because of its emphasis on the low-threshold model in the public mental hospital, its offering of assistance and counseling in a friendly manner, and its training of DUs to develop their own harm-reduction campaigns in the community, including involving them in the distribution of condoms and pamphlets. This process contributed to the creation of the Drug Users Network RADDUD whose mission is to improve the quality of life of IDUs. CONCLUSION Harm-reduction approaches especially in climates in which there is social and legal opposition to needle exchanges must go beyond needle exchange alone to include counseling, referral to a variety of treatment options, and, where necessary, the prescription of legally-supplied substitute drugs. These approaches should also include changes to the law if the law is found to be exacerbating, rather than reducing, drug-related harm. An example of a beneficial law is Resolution 351 of the Secretaria de Prevención de la Drogadicción y Lucha contra el Narcotráfico [33], in Argentina, which endorses interventions aimed at reducing risks among the population of IDUs not in treatment and which provides for a more liberal judicial environment with respect to public health initiatives. Another example of a legal approach to harm-reduction is a project of ARDA aimed at the derogation of Article 14 of the Argentinian Drug Control Law 23.737 and the depenalization of drug possession for personal use [34]. ARDA has taken a key role in helping support and strengthen the harm-reduction initiatives aimed at preventing health problems and social harms associated with unsafe and illegal drug use (e.g., HIV, hepatitis, and other infections; criminalization and social exclusion). The task is to definitively involve harm reduction in the official policy. The Regional Ministry of Health in Santa Fe has just included harm reduction in the official policy of the Santa Fe AIDS Program, which amplifies on the Rosario CEADS-UNR program throughout the province through a program entitled Let s Reduce Risks: Syringes and Condoms, implemented in the health services of the region. This strategy is also being used in the Southern Cone Project under development in Rosario and Buenos Aires in Argentina and as pilot programs in other countries of the region (see the Joint United Nations Programme on HIV/AIDS, United Nations Office on Drugs and Crime project, 2003). Further research is required on the risks to and behavioral changes of DUs and IDUs enrolled in the harm-reduction programs in Argentina. Strong evidence in the developed world shows that increasing the availability of injection equipment, Drug Use, Harm Reduction, and Health Policies in Argentina CID 2003:37 (Suppl 5) S369

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