Key drug use, health and socio-economic characteristics of young crack users in two Brazilian cities

Implementation of Brazil's "family health strategy": factors associated with community health workers', nurses', and physicians' delivery of drug use services

BACKGROUND

Brazil's "family health strategy" (ESF), provides primary care, mostly to individuals in impoverished communities through teams of physicians, nurses, and community health workers (CHWs). ESF workers are called upon to offer drug use services (e.g., referrals, counseling) as drug use represents an urgent public health crisis. New federal initiatives are being implemented to build capacity in this workforce to deliver drug use services, yet little is known about whether ESF workers are providing drug use services already. Guided by social cognitive theory, this study examines factors associated with ESF workers' provision of drug use services.

METHODS

Cross-sectional surveys were collected from 262 ESF workers (168 CHWs, 62 nurses, and 32 physicians) in Mesquita, Rio de Janeiro State and Santa Luzia, Minas Gerais State.

OUTCOME VARIABLE

provision of drug-use services.

PREDICTORS

capacity to engage in evidence-based practice (EBP), resource constraints, peer support, knowledge of EBP, and job title. Logistic regression was used to determine relative influence of each predictor upon the outcome.

RESULTS

Thirty-nine percent reported providing drug use services. Younger workers, CHWs, workers with knowledge about EBP and workers that report peer support were more likely to offer drug use services. Workers that reported resource constraints and more capacity to implement EBP were less likely to offer drug use services.

CONCLUSION

ESF workers require education in locating, assessing and evaluating the latest research. Mentorship from physicians and peer support through team meetings may enhance workers' delivery of drug use services, across professional disciplines. Educational initiatives aimed at ESF teams should consider these factors as potentially enhancing implementation of drug use services. Building ESF workers' capacity to collaborate across disciplines and to gain access to tools for providing assessment and treatment of drug use issues may improve uptake of new initiatives.

Drug use as a driver of HIV risks: re-emerging and emerging issues

PURPOSE OF REVIEW

We reviewed the studies published in 2012-2013 that focused on re-emerging and emerging injection and noninjection drug use trends driving HIV risk behaviors and transmission in some parts of the world.

RECENT FINDINGS

Although HIV incidence has declined in many countries, HIV epidemics remain at troubling levels among key drug-using populations, including females who inject drugs (FWIDs), FWIDs who trade sex, sex partners of people who inject drugs, young people who inject drugs, and people who use noninjection drugs in a number of low-income and middle-income countries such as in Central Asia, Eastern Europe, Southeast Asia, and parts of Africa.

SUMMARY

HIV epidemics occur within the contexts of global economic and political forces, including poverty, human rights violations, discrimination, drug policies, trafficking, and other multilevel risk environments. Trends of injection and noninjection drug use and risk environments driving HIV epidemics in Central Asia, Eastern Europe, Southeast Asia, and parts of Africa call for political will to improve HIV and substance use service delivery, access to combination HIV prevention, and harm reduction programs.

Exploring sex differences in drug use, health and service use characteristics among young urban crack users in Brazil

Introduction

Studies have shown important gender differences among drug (including crack) users related to: drug use patterns; health risks and consequences; criminal involvement; and service needs/use. Crack use is prevalent in Brazil; however, few comparative data by sex exist. We examined and compared by sex key drug use, health, socio-economic indicators and service use in a bi-city sample of young (18–24 years), regular and marginalized crack users in Brazil.

Methods

Study participants (total n = 159; n = 124 males and n = 35 females) were recruited by community-based methods from impoverished neighborhoods in Rio de Janeiro and Salvador. Assessments occurred by an anonymous interviewer-administered questionnaire and serum collection for blood-borne virus testing between November 2010 and June 2011. Descriptive statistics and differences for key variables by sex were computed; in addition, a ‘chi-squared automatic interaction detector’ (‘CHAID’) analysis explored potential primary factors differentiating male and female participants.

Results

Most participants were non-white, and had low education and multiple income sources. More women had unstable housing and income from sex work and/or panhandling/begging, whereas more men were employed. Both groups indicated multi-year histories of and frequent daily crack use, but virtually no drug injection histories. Men reported more co-use of other drugs. More women were: involved in sex-for-drug exchanges; Blood-Borne Virus (BBV) tested and HIV+. Both groups reported similar physical and mental health patterns; however women more commonly utilized social or health services. The CHAID analysis identified sex work; paid work; begging/panhandling; as well as physical and mental health status (all at p < 0.05) as primary differentiating factors by sex.

Conclusions

Crack users in our study showed notable differences by sex, including socio-economic indicators, drug co-use patterns, sex risks/work, BBV testing and status, and service utilization. Results emphasize the need for targeted special interventions and services for males and female crack users in Brazil.

Violent and sexual behaviors and lifetime use of crack cocaine: a population-based study in Brazil

OBJECTIVE

To estimate the prevalence of lifetime use of crack cocaine and to assess associations with violent and sexual behaviors in young adults selected from the general population of Pelotas, Southern Brazil.

METHODS

This cross-sectional population-based study included 1,560 participants aged 18-24 years. The use of alcohol and other substances, including crack cocaine, was assessed using the alcohol, smoking and substance involvement screening test. Other variables included violent behaviors, firearm possession, and sexual risk behaviors. The frequency of antisocial personality disorder was also investigated. Associations were analyzed using a crude model and models adjusted for sex, social class, and the use of snorted cocaine.

RESULTS

Lifetime prevalence of crack cocaine use was 2.51 %, and it was higher among males and individuals coming from more vulnerable social classes (D or E). In the final multivariate models, lifetime use of crack cocaine was associated with episodes of aggression and firearm possession, as well as with a higher chance of not having used condom in the last sexual intercourse. In less conservative models, crack cocaine use was associated with other violent and sexual risk behaviors.

DISCUSSION

The strong association observed between lifetime use of crack cocaine and different violent and sexual risk behaviors underscores relevant characteristics of people who use crack cocaine. Improving our understanding of possible causal chains leading to such associations should be a priority in future studies.

ICD-10 mental and behavioural disorders due to use of crack and powder cocaine as treated at a public psychiatric emergency service: an analysis of visit predictors

The present study investigated the predictors of an increased number of visits from individuals with some of the diagnoses noted in chapter F14 of ICD-10, from calls to the emergency psychiatric unit of a general hospital in São Paulo state, Brazil, in the period 2011-2012. Poisson regression models were carried out for the outcome variable, accounting for number of subsequent visits to the psychiatric emergency unit. For the analysis of this outcome we took into account the exposure time of each individual in the study. Our findings point to a population at risk for frequent psychiatric emergency service visits: individuals over 25 years. This population should be targeted for interventions on entry into public healthcare due to increased psychiatric morbidity and greater clinical morbidity already confirmed by previous studies. We discussed the need of these individuals for special attention during the clinical or psychiatric emergency consultation which, unfortunately, may be the access point for the public health system. None of the other variables were related to the outcome of interest, such as those related to the level of individual entry into the care network before and after treatment, and other variables related to medical acts during the visit.

“Crack Ends it all?” A Study of the Interrelations between Crack Cocaine, Social Environments, Social Relations, Crime, and Homicide among Poor, Young Men in Urban Brazil

In this article, actor network theory is used to explore the consumption of crack cocaine in street settings. The article is based on multiple periods of fieldwork over several years among young men in Salvador, Brazil. The contribution of the article is three-fold. First, it explores how two different socio-spatial contexts — the poor favela communities and the street settings located in a middle-class neighborhood — mediate and are mediated by crack use. Second, it examines how social relations are reconfigured, in the eyes of the users, after the arrival of the drug. Third, based on the users' accounts, it examines the causality between crack use, street crime, and homicide often emphasized in public discourse and medical research. By focusing on the complex processes in which crack use, street crime and homicides are embedded, the article problematizes such causalities and demonstrates the numerous actants involved, such as legal income-generating possibilities and public safety for crack consumers in the favelas and on the streets.

Performance of rapid hepatitis C virus antibody assays among high- and low-risk populations

BACKGROUND

Rapid tests for the detection of antibodies to hepatitis C virus (anti-HCV) can facilitate access to diagnosis.

OBJECTIVES

This study aimed to evaluate the performance of rapid tests for anti-HCV detection in the sera, whole blood, and oral fluid samples from individuals with different endemicity profiles and risk behaviors.

STUDY DESIGN

Three groups donated biological samples that were tested using three anti-HCV rapid tests (WAMA, Bioeasy and OraSure): (I) suspected cases of hepatitis C, (II) individuals who were living in remote areas in Brazil and (III) crack users and beauty professionals. Reproducibility, repeatability and cross-reactivity to other infectious agents (dengue, HIV, malaria, and syphilis) were also evaluated.

RESULTS

In group I, specificities varied from 93.75% to 100% and sensitivities varied from 76.03% to 93.84% according to the EIA results. When anti-HCV/HCV RNA-reactive sera samples were considered true-positive HCV cases, the sensitivities and specificities varied from 86.3% to 99.09% and 93.75% to 100%, respectively. In group II, the OraSure rapid test presented the best performance. In group III, the Bioeasy assay performed best using saliva and whole blood and the OraSure assay performed best using oral fluid samples. The reproducibility and repeatability of the WAMA and Bioeasy tests were excellent. The level of concordance between the HCV EIAs and the rapid tests using samples that were reactive for other infectious agents varied from 82.35% to 100% for the WAMA assay and 94.11% to 100% for the Bioeasy assay.

CONCLUSION

All of the rapid tests could be used to identify active HCV infection among individuals with different endemicity profiles and risk behaviors.

Comparing key characteristics of young adult crack users in and out-of-treatment in Rio de Janeiro, Brazil

Background

Crack use is prevalent among street drug users in Brazilian cities, yet despite recent help system reforms and investments, treatment utilization is low. Other studies have identified a variety of – often inconsistent – factors associated with treatment status among crack or other drug users. This study compared socio-economic, drug use, health and service use characteristics between samples of young adult crack users in- and out-of-treatment in Rio de Janeiro, Brazil.

Findings

Street-involved crack users (n = 81) were recruited by community-based methods, and privately assessed by way of an anonymous interviewer-administered questionnaire as well as biological methods, following informed consent. In-treatment users (n = 30) were recruited from a public service in-patient treatment facility and assessed based on the same protocol. Key indicators of interest were statistically cross-compared. Not-in-treatment users were less likely to: be white, educated, stably housed, to be involved in drug dealing, to report lifetime marijuana and current alcohol use, to report low mental health status and general health or addiction/mental health care; they were more likely to: be involved in begging and utilize social services, compared to the in-treatment sample (statistical significance for differences set at p < .05).

Conclusions

In-treatment and not-in-treatment crack users differed on several key characteristics. Overall, in-treatment users appeared to be more socio-economically integrated and connected to the health system, yet not acutely needier in terms of health or drug problems. Given overall low treatment utilization but high need, efforts are required to facilitate improved treatment access and use for marginalized crack users in Brazil.

Patterns, determinants and barriers of health and social service utilization among young urban crack users in Brazil

Background

Crack use is prevalent across the Americas, and specifically among marginalized urban street drug users in Brazil. Crack users commonly feature multiple physical and mental health problems, while low rates of and distinct barriers to help service use have been observed in these populations. This study examined profiles and determinants of social and health service utilization, and unmet service needs, in a two-city sample of young (18–24 years), marginalized crack users in Brazil.

Methods

N = 160 study participants were recruited by community-based methods from impoverished neighborhoods in the cities of Rio de Janeiro (n = 81) and Salvador (n = 79). A mixed methods protocol was used. Participants’ drug use, health, and social and health service utilization characteristics were assessed by an anonymous interviewer-administered questionnaire completed in a community setting; descriptive statistics on variables of interest were computed. Service needs and barriers were further assessed by way of several focus groups with the study population; narrative data were qualitatively analyzed. The study protocol was approved by institutional ethics review boards; data were collected between November 2010 and June 2011.

Results

The majority of the sample was male, without stable housing, and used other drugs (e.g., alcohol, marijuana). About half the sample reported physical and mental health problems, yet most had not received medical attention for these problems. Only small minorities had utilized locally available social or health services; utilization appeared to be influenced by sex, race and housing characteristics in both sites. Participants cited limited service resources, lack of needs-specific professional skills, bureaucratic barriers and stigma as obstacles to better service access. However, most respondents stated strong interest and need for general social, health and treatment services designed for the study population, for which various key features were emphasized as important.

Conclusions

The study contributes substantive evidence to current discussions about the development and utilization of health and treatment interventions for crack use in Brazil. Based on our data, crack users’ social, service needs are largely unmet; these gaps appear to partly root in systemic barriers of access to existing services, while improved targeted service offers for the target population seem to be needed also.