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

Pathway of effects of adverse childhood experiences on the poly-drug use pattern among adults using drugs: A structural equation modeling

Introduction

Adverse childhood experiences (ACEs) are associated with an increased risk of poly-substance use among drug-using adults. However, there is a paucity of literature on a direct or indirect relationship between ACEs and drug use patterns. We thus aimed to identify the pathway of effects of ACEs on drug use patterns in adults by the structural equation model (SEM).

Methods

A cross-sectional study was conducted by respondent-driving sampling and consecutive sampling among adult drug users in Southwest China in 2021. Descriptive, univariate, and SEM analyses were performed by R software 4.2.1.

Results

Of 406 participants recruited from a drug abuse clinic, the average age was 34 years. The majority of the participants were male patients (98.3%) from ethnic minorities (79.6%), who were unmarried (71.6%) and employed (81.2%). Nearly 95.5% experienced ACEs with 46.6% of them reporting four or more ACEs. The median value of self-perception of drug abuse score, friend drug use score, and drug use score was 8.0 (3.0, 11.0), 1.0 (0.0, 1.0), and 1.0 (1.0, 2.0) respectively. In the confirmatory analysis part of SEM, the construct of latent variables fitted well with the data. Poly-drug use was significantly and directly affected by three predictors including monthly incomes (β = 0.09), friend drug use (β = 0.50), and ACEs (β = 0.11). The indirect effect of ACEs passing through self-perception of drugs (β = 0.09) was not significant.

Discussion

ACEs have an independent and direct effect on the drug user for poly-drug use apart from the effect of drug-using friends and family income.

Feasibility of dried blood spot for hepatitis C diagnosis in vulnerable subjects and people living in remote areas from Brazil

Background

Agile, accessible and cheap diagnosis of hepatitis C virus (HCV) infection is essential to achieve the elimination of this infection, worldwide, as mandated by the World Health Organzation as part of its strategy for 2030. Dried blood spots (DBS) can be an attractive alternative for sample collection among people living in remote areas and vulnerable populations due to the less invasive collection, its biosafety, and storage & transportation of samples at room temperature.

Design

This study aims to estimate the usefulness of dried blood spot samples for the diagnosis and the assessment of HCV infection rates in three different settings in Brazil. Cross-sectional analysis of a sample collection from different populations, aiming to assess the performance of the testing algorithms and respective procedures among different populations with diverse background infection rates.

Methods

We reported the evaluation of DBS as alternative samples for detecting anti-HCV in different groups in real life conditions: (I) Vulnerable subjects living in remote areas of Southeast, North and Northeast Brazil (n = 1464); (II) Beauticians (n = 288); (III) People who use non-injectable drugs (n = 201); (IV) patients referred to outpatient care (n = 275).

Results

General assay accuracy was 99%, with a weighted kappa value of 0.9, showing an excellent performance. Sensitivities ranged from 87.5% to 100.0% between groups and specificities were above 99.2%. A total of 194 individuals had HCV RNA in serum and concordance of anti-HCV detection in DBS was 98.4%.

Conclusions

DBS samples could be used for anti-HCV detection in different populations recruited in real life conditions and ambulatory settings, with a high overall sensitivity and specificity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-022-07717-4.

HIV and Substance Use in Latin America: A Scoping Review

This scoping review aims to explore the interplay between substance use (SU) and HIV in Latin America (LA). Database searches yielded 3481 references; 196 were included. HIV prevalence among people who used substances (PWUS) ranged from 2.8–15.2%. SU definitions were variable throughout studies, and thus data were not easily comparable. In 2019, only 2% of new HIV infections were attributed to injection drug use (IDU) in LA. Factors associated with HIV among PWUS included being female, IDU and homelessness, and PWUS were likely to engage in risky sexual behaviors, start antiretroviral treatment late, have poor adherence, have treatment failure, be lost to follow-up, have comorbidities, and experience higher mortality rates and lower quality of life, as has been reported in PLWH with SU in other regions. Five intervention studies were identified, and only one was effective at reducing HIV incidence in PWUS. Interventions in other regions have varying success depending on context-specific characteristics, highlighting the need to conduct more research in the LA region. Though progress has been made in establishing SU as a major concern in people living with HIV (PLWH), much more is yet to be done to reduce the burden of HIV and SU in LA.

Sociodemographic and clinical profile of crack cocaine treatment-seeking individuals living in “Crackland”, Brazil

ABSTRACT Objective: São Paulo‘s Crackland is the biggest and oldest open drug use scene in Brazil, yet little is known about the profile of crack cocaine treatment-seeking individuals living in this region. The aim of this crossectional study was to describe the demographics and clinical characteristics of treatment-seeking crack users living in the Crackland region. Methods: A sample of nighty eight individuals were screened for DSM-V substance use disorders, including substance use, impulsiveness, and psychiatric symptoms. Recent crack cocaine use was also tested using biologic specimens. Results: Results indicated severe social vulnerability, as participants experienced high rates of homelessness (46.9%), unstable housing (50%), unemployment (60.4%) and early school drop-out (27.5%). The average age of crack use onset was 20 years (SD = 6.9) and the mean duration of continuous crack use was 15 years (SD = 9.7). Most participants presented with concomitant mental health disorders, particularly alcohol use disorder (87.8%), as well high rates of psychiatric symptomatology and impulsiveness. More than half of the sample reported at least one previous inpatient (73.5%) and outpatient (65.3%) addiction treatment attempt. Conclusion: This population profile should inform mental healthcare services, promoting the provision of tailored assistance by targeting specific demands at all levels of treatment.

Polydrug Use and Co-occurring Substance Use Disorders in a Respondent Driven Sampling of Cocaine Base Paste Users in Santiago, Chile

We characterized substance use patterns and co-occurring substance use disorders among active cocaine base paste (CBP) users in Santiago, Chile using data from respondent-driven sampling (RDS) in three areas of Metropolitan Santiago. Recruitment began with nine seeds, reaching 398 active CBP users (18% women; mean age 37.7 years), defined as persons consuming CBP at least twice per week in the last three months. Population proportions and uncertainty were estimated accounting for individuals' social network and homophily. The median CBP age of initiation was 21 years, and the median number of years using CBP was 7 for women and 15 for men. The median days of use in the past month was 25 days, with a median of 56 doses per week. The proportion of monthly income spent on CBP was 65%. The prevalence of substance use disorders (SUDs) were: 98% for CBP, 67% for alcohol, 60% for marijuana, and 41% for cocaine hydrochloride. Heavy polydrug use patterns and co-occurring SUDs are frequent among active CBP users in the metropolitan area of Santiago. Traditional surveillance strategies may have underestimated polysubstance use and co-occurring SUDs in active CBP users. RDS proved to be a feasible methodology that could be effectively used for substance use surveillance among hard-to-reach populations.

Effectiveness of incorporating contingency management into a public treatment program for people who use crack cocaine in Brazil. A single-blind randomized controlled trial

BACKGROUND

Smoked cocaine (i.e., crack use) is a severe health problem in Brazil, with the country being reported as having the largest crack market in the world. The objective of this study was to evaluate the effectiveness of incorporating Contingency Management targeting cocaine abstinence into a public treatment program in Brazil.

METHODS

Single-blind randomized controlled trial conducted at Unidade Recomeço Helvétia (URH), a public ambulatory treatment program for persons who use crack and live in the "Crackland" region in downtown São Paulo, Brazil. In total, 98 treatment-seeking individuals who use crack were randomized to one of two treatment conditions. Participants allocated to the control condition (n = 48) received 12 weeks of the standard treatment provided at URH. Participants allocated to the experimental condition (n = 50) received the same treatment in combination with Contingency Management (URH+CM). In URH+CM, participants were provided with vouchers with monetary value for submission of negative cocaine urinalysis twice weekly.

RESULTS

Compared to the URH group, the URH+CM group was significantly more likely to submit a negative cocaine urinalysis during treatment, with odds ratios ranging from 4.17 to 6.78, depending on how missing data was accounted for (p<0.01). Participants receiving Contingency Management also had higher odds of achieving three or more weeks of continuous abstinence (OR= 8.07; 95% CI [2.48, 26.24]), achieved longer durations of abstinence (B = 2.14; 95% CI [0.67, 3.61]), submitted a higher percentage of negative urinalysis (B = 19.85; 95% CI [6.89, 32.82]), and were retained in treatment for a longer period (B = 3.00; 95% CI [1.04, 4.97]), compared to those receiving URH alone (p<0.01 for all).

CONCLUSIONS

The incorporation of Contingency Management was effective in promoting cocaine abstinence and treatment retention. The large-scale dissemination of Contingency Management may be an effective strategy to treat Brazilians with cocaine use disorders.

Examining a migration-based phenomenon of heroin use in an urban drug scene in Sao Paulo, Brazil

Purpose

Brazil’s street-based drug use is mostly characterized by non-injection psychostimulant (e.g. crack-cocaine) drug use in Brazil, with limited interventions and service availability. Recently, an influx of multi-ethnic migrants within an urban drug scene in Sao Paulo was associated with heroin use, a drug normatively absent from Brazil. The purpose of this paper is to characterize and compare heroin use-related characteristics and outcomes for an attending sub-sample of clients from a large community-based treatment centre (“CRATOD”) serving Sao Paulo’s local urban drug scene.

Design/methodology/approach

All non-Brazilian patients (n = 109) receiving services at CRATOD for 2013–2016 were identified from patient files, divided into heroin users (n = 40) and non-heroin users (n = 69). Based on chart reviews, select socio-demographic, drug use and health status (including blood-borne-virus and other infections per rapid test methods) were examined and bi-variately compared. Multi-variate analyses examined factors independently associated with heroin use.

Findings

Most participants were male and middle-aged, poly-drug users and socio-economically marginalized. While heroin users primarily originated from Africa, they reported significantly more criminal histories, drug (e.g. injection) and sex-risk behaviors and elevated rates of BBV (e.g. Hepatitis C Virus and HIV). A minority of heroin users attending the clinic was provided methadone treatment, mostly for detoxification.

Originality/value

This study documented information on a distinct sample of mostly migration-based heroin users in Sao Paulo, Brazil. Based on the local experience, global migration dynamics can bring changes to established drug use cultures and services, including new challenges for drug use-related related behaviors and therapeutic interventions that require effective understanding and addressing.

Detection and Genetic Characterization of Hepatitis B and D Viruses: A Multi-Site Cross-Sectional Study of People Who Use Illicit Drugs in the Amazon Region

Hepatitis B (HBV) and delta (HDV) viruses are endemic in the Amazon region, but vaccine coverage against HBV is still limited. People who use illicit drugs (PWUDs) represent a high-risk group due to common risk behavior and socioeconomic factors that facilitate the acquisition and transmission of pathogens. The present study assessed the presence of HBV and HBV-HDV co-infection, identified viral sub-genotypes, and verified the occurrence of mutations in coding regions for HBsAg and part of the polymerase in HBV-infected PWUDs in municipalities of the Brazilian states of Amapá and Pará, in the Amazon region. In total, 1074 PWUDs provided blood samples and personal data in 30 municipalities of the Brazilian Amazon. HBV and HDV were detected by enzyme-linked immunosorbent assay and polymerase chain reaction. Viral genotypes were identified by nucleotide sequencing followed by phylogenetic analysis, whereas viral mutations were analyzed by specialized software. High rates of serological (32.2%) and molecular (7.2%) markers for HBV were detected, including cases of occult HBV infection (2.5%). Sub-genotypes A1, A2, D4, and F2a were most frequently found. Escape mutations due to vaccine and antiviral resistance were identified. Among PWUDs with HBV DNA, serological (19.5%) and molecular (11.7%) HDV markers were detected, such as HDV genotypes 1 and 3. These are worrying findings, presenting clear implications for urgent prevention and treatment needs for the carriers of these viruses.

Hepatitis E Virus in People Who Use Crack-Cocaine: A Cross-Sectional Study in a Remote Region of Northern Brazil

People who use crack-cocaine (PWUCC) have numerous vulnerabilities and pose a challenge to health and social assistance services. The exposure to pathogens and risk situations occur differently according to each individual, region and social group. This study identified the presence, genotypes and factors associated with hepatitis E virus (HEV) exposure among a community-recruited cohort of 437 PWUCC in northern Brazil. Epidemiological information was collected through community-based assessments and interviews. Thereafter, blood and fecal samples were collected and tested for HEV using an immunoenzymatic assay, and the genotype was identified by PCR. Logistic regressions were used to identify the risk factors independently associated with exposure to HEV. In total, 79 (18.1%) PWUCC were exposed to HEV: 73 (16.7%) for IgG and six for IgG + IgM. HEV RNA was detected in six fecal samples and in two blood samples from PWUCC with IgM + IgG. Subtype 3c was identified in all of the samples. The factors associated with exposure to HEV were low monthly income, unstable housing (e.g., homelessness), crack-cocaine use ≥40 months, and the shared use of crack-cocaine equipment. The current study provides unique initial insights into HEV status and risk factors among PWUCC in a remote area in Brazil, with diverse implications for urgently improved diagnosis, prevention, and treatment intervention needs.

Factors associated with crack-cocaine early initiation: a Brazilian multicenter study

BACKGROUND

Crack-cocaine dependence is a serious public health issue, related to several psychiatric and psychosocial problems. Crack-cocaine users are usually embedded in a context of great social vulnerability, often associated with violence, poverty, family conflict and easy and early access to alcohol, tobacco and other drugs.

METHODS

This cross-sectional study enrolled a consecutive sample of 577 patients admitted to 20 therapeutic communities located in Southern Brazil, between September 2012 and September 2013. A structured interview assessed life-time exposure to risk and protective factors for drug use, such as parental monitoring in childhood, deviant behaviors and peer pressure.

RESULTS

Presence of family conflict (p = 0.002), maltreatment (p = 0.016), and deviant behavior prior to age 15 in a bivariate analysis predicted an earlier age of crack-cocaine initiation, whereas adolescents experiencing parental monitoring during adolescence started use later (p < 0.001). In the multivariate model, perceptions related to ease of access of illicit drugs (marijuana: p = 0.028, 95% CI = - 3.81, - 0.22; crack-cocaine: p < 0.001, 95% CI = - 7.40, - 4.90), and deviant behavior (threatening someone with a gun: p = 0.028, 95% CI = - 2.57, - 0.14) remained independent predictors of early age of crack-cocaine initiation.

CONCLUSIONS

Early onset of crack-cocaine use seems to be associated with exposure to family conflict, easy access to drugs and deviant behavior. Treatment and preventive programs should take these factors into account when designing and implementing community interventions.

Oral HPV among people who use crack-cocaine: prevalence, genotypes, risk factors, and key interventions in a remote Northern Brazilian region

OBJECTIVES

This study estimated the prevalence, genotype distribution, and the factors associated with oral human papillomavirus (HPV) in people who use crack-cocaine (PWUCC) in a remote Brazilian region.

MATERIALS AND METHODS

This cross-sectional study used community-based snowball sampling methods for participant recruitment. Socio-demographic, economic, drug use, and health-related information was collected from 278 PWUCC in the cities of Bragança and Capanema in northern Brazil. HPV diagnosis and genotyping were performed by a real-time polymerase chain reaction. Logistic regression identified the factors independently associated with oral HPV.

RESULTS

In total, 111 (39.9%) PWUCC had HPV DNA. Several genotypes were identified, some of them with high oncogenic potential. Crack-cocaine use ≥40 months, unprotected sex, more than 10 sexual partners in the last 12 months, oral sex, exchange of sex for money or illicit drugs, oral mucosa lesions, not having access to public health services, and the absence of vaccination against HPV was all associated with HPV DNA.

CONCLUSIONS

This study identified important epidemiological characteristics of oral HPV infection among PWUCC-a highly marginalized risk population-underlining the high prevalence of oral HPV with oncogenic potential and the urgent need for control and prevention measures, especially vaccination against this virus.

CLINICAL RELEVANCE

It is necessary to understand the prevalence and risk factors of oral HPV in risk populations as people who use crack-cocaine.

Argyrophilic nucleolar organizer regions in oral mucosa cells of crack and cocaine users: a cross-sectional study

The objective of this study was to analyze and compare the presence of argyrophilic nucleolar organizer regions (AgNORs) in exfoliated cells obtained from the buccal mucosa among crack and cocaine users and non-users by the AgNOR staining technique. Seventy-three males ≥ 18 years were categorized into two groups: 38 crack and/or cocaine users and 35 non-user volunteers. They were interviewed and responded a questionnaire regarding general health and drug addiction. Exfoliative cytology specimens were collected from the clinically intact buccal mucosa, and cytological preparations were fixed and stained by AgNOR technique. The mean number of AgNORs (p = 0.02) and the percentage of epithelial cells with more than 3 (p = 0.01) and 4 (p = 0.04) AgNORs/nucleus were significantly higher in the non-user group. In conclusion, the frequency and diversity of substances present in the drugs-cocaine, crack, and alcohol-consumed by the volunteers of this study may have influenced the number of AgNORs and the response to damage and consequent effect on protein synthesis.

High prevalence of Hepatitis C Virus infection among people who use crack cocaine in an important international drug trafficking route in Central-West Region Brazil

In this study, the prevalence rate, associated risk factors and genetic diversity of hepatitis C virus (HCV) infection were determined among people who use crack from an international drug trafficking route in Central-West, Brazil. Blood samples were collected from 700 users of crack from Campo Grande and two border cities of Mato Grosso do Sul State and tested for HCV infection using serological and molecular testing methodologies. Anti-HCV was detected in 31/700 (4.5%, 95% CI: 2.9-6.0%) and HCV RNA in 26/31 (83.9%) of anti-HCV positive samples. Phylogenetic analysis of three HCV sub-genomic regions (5'UTR, NS5B and HVR-1) revealed the circulation of 1a (73.9%), 1b (8.7%) and 3a (17.4%) genotypes. Next-generation sequencing and phylogenetic analysis of intra-host viral populations of HCV HVR-1 showed a significant variation in intra-host genetic diversity among infected individuals, with 58.8% composed of more than one sub-population. Bayesian analysis estimated that the most recent common HCV ancestor for strains identified here was introduced to this region after 1975 following expansion of intravenous drug use in Brazil. Multivariate analyses showed that only 'ever having injected drugs' was independently associated with HCV infection. These results indicate an increasing spread of multiple HCV strains requiring public health intervention, such as harm reduction, testing services and treatment among crack users in this important border region of Central Brazil.

Hepatitis B Virus Infection among People Who Use Illicit Drugs: Prevalence, Genotypes and Risk Factors in the State of Amapá, Northern Brazil

Background: Several records of high prevalence of HBV have been made in northern Brazil. Among risk groups for viral infection, people who use illicit drugs (PWUDs) stand out, especially if they inject drugs and engage in risky sexual behavior. Objectives: In this study, the prevalence, genotype distribution and factors associated with hepatitis B virus (HBV) exposure in PWUDs were estimated. Methods: This cross-sectional study used snowball sampling from nine different sites. Socio-demographic, economic, drug use and health-related information were collected of 308 PWUDs from nine municipalities in the state of Amapá, northern Brazil. Blood samples were tested for the presence of HBV using enzyme-linked immunosorbent assay (ELISA) and real-time polymerase chain reaction (PCR). Logistic regressions were run to identify factors independently associated with HBV exposure. Results: In total, seventy (22.7%) PWUDs were exposed to HBV, and 12 (3.9%) had DNA HBV. Genotypes A (58.4%), D (33.3%) and F (8.3%) were identified. Age ≥35 years, use of injectable drug, daily use of drugs, use of drugs over 12 years, unprotected sex, exchange sex for money/drugs, and >12 sexual partners in the last 12 months were associated with exposure to HBV. Conclusions: This study identified important information on the epidemiological scenario of HBV infection in PWUDs, highlighting the high prevalence of HBV exposure and the urgent need for measures for control and prevention, especially vaccination against this hepatotropic virus.

Estimating the size of crack cocaine users in France: Methods for an elusive population with high heterogeneity

BACKGROUND

Despite several sources corroborating an expanding market and increased visibility and greater diversity in users' profiles, very little is known about the number of crack cocaine users in France.

METHOD

The estimates rely on a single data source capture-recapture method. Annual data are extracted from treatment centres nationwide. To account for heterogeneity, we use an innovative zero-truncated geometric, regression-based estimator controlling for individual and centre characteristics. We use the well-known Zelterman estimator as a benchmark.

RESULTS

The number of crack cocaine users received in treatment centres increased dramatically, from 3388 in 2010 to 5143 in 2017 (+52%). The estimated number of crack cocaine users is believed to have tripled over the course of the same period (from 9775, 95% CI [8288-11530] to 28983 [24876-33766], respectively), with prevalences below 1‰, similar to other European countries. The coverage rate (observed number/estimated number of users) decreased in a similar fashion, indicating lower utilization. In particular, females and younger users are underestimated by data from treatment centres.

CONCLUSION

The prevalence of crack cocaine use is fairly low but steadily increasing. The diversity in users' profiles is a challenge to prevention and public health policies that should expand their scope to a more inclusive perspective of what defines crack cocaine users. Our method overcomes several methodological issues (data sources, data linkage, heterogeneity) and can be easily applied to a wide range of settings.

Crack cocaine smoke on pregnant rats: Maternal evaluation and teratogenic effect

This study aimed to evaluate maternal toxicity, teratogenic, and placental oxidative effects resulting from the exposure of rats to crack cocaine smoke during pregnancy. Pregnant rats were exposed either to the smoke of crack and ashes (Crack) or to the smoke of ashes alone, nonexposed or pair-fed with the Crack group. Crack group was exposed to the smoke resulting from the burning of 250 mg of crack for 10 min, twice a day, from 7 days prior to mating until cesarian on gestational day 20. Placental oxidative stress and classical parameters of maternal and fetal evaluation were studied, in addition to the morphometric analysis of the fetal metamers. Even in the absence of changes in body weight gain and feed intake, crack altered the reproductive performance of dams. Exposure to the drug promoted late closure of the fetal fontanel. Furthermore, the morphometric study of the brain mass (BM)/skull cap ratio revealed a decrease in the BM of the fetuses exposed to the drug. Exposure to crack has an oxidative potential in fetal development, since exposure to the drug promoted placental lipid peroxidation. Our study showed that daily exposure to crack, even in lower frequency than that performed by users, has a teratogenic potential.

Distinct effects of cocaine and cocaine + cannabis on neurocognitive functioning and abstinence: A six-month follow-up study

BACKGROUND AND AIMS

Cannabis use is frequent among individuals with cocaine use disorder. Despite recent non-controlled studies advocating a therapeutic role of smoked cannabis, there is a paucity of evidence-based data on potential therapeutic and cognitive side-effects of this association.

METHODS

We examined 63 cocaine-addicted subjects who used cannabis more than 50 times in lifetime (COC + CAN), 24 cocaine-addicted patients who use cannabis less than 50 times (COC), and 36 controls (CON). Participants were evaluated with an extensive battery of neurocognitive tests after two weeks of supervised detoxification in an inpatient treatment program. Patients were followed up in one, three, and six months after discharge.

RESULTS

Both groups of patients performed worse than CON on working memory, processing speed, inhibitory control, mental flexibility, and decision making. COC + CAN performed worse than COC on speed processing, inhibitory control and sustained attention, while COC performed worse than COC + CAN on mental flexibility. Concomitant cannabis use did not decrease relapses to cocaine use after one, three and six months. Among COC + CAN, earlier cocaine and cannabis use, and impaired executive functioning were predictive of relapse on cocaine after six months.

CONCLUSION

Our results did not support the recommendation of smoked cannabis as a safe therapeutic approach for cocaine-addicted patients due to significant negative cognitive side-effects and absence of efficacy. Further studies investigating frontal brain morphology, neuromaturation, and prescription of the non-psychoactive constituent of cannabis sativa cannabidiol among cocaine-addicted patients who use cannabis are warranted.

Female crack cocaine users under treatment at therapeutic communities in southern Brazil: characteristics, pattern of consumption, and psychiatric comorbidities

OBJECTIVE

To explore and describe sociodemographic characteristics, crack consumption patterns, and psychiatric comorbidities of female crack users receiving treatment at therapeutic communities.

METHODS

This was a cross-sectional, descriptive, quantitative study. Forty-six women who abstained from crack use were assessed using a sociodemographic questionnaire, the Mini-Mental State Examination (MMSE), the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I), and a profile of crack use questionnaire. Descriptive statistical analyses were conducted.

RESULTS

Participants had a mean age of 31.02 years (standard deviation [SD] = 7.73), most were single (76.1%), white (67.4%) and had complete or incomplete elementary education (43.5%). Before treatment, 65.2% of the women reported using crack every day; 46.3% smoked between 10 to 30 crack rocks per week. Mean treatment time was 63.56 days (SD = 75.85), with a mean of 80.41 days of abstinence (SD = 74.52) and 3.37 previous treatments (SD = 5.49). Mean age upon crack use initiation was 22.61 years (SD = 8.06), and the most frequent motivation to start using crack was curiosity (78.3%). The mean lifetime duration of crack use was 82.26 months (SD = 74.76), and the physical complications most frequently reported were weight loss (93.5%), followed by sleep problems (87%). In this study, the most prevalent psychiatric diagnoses were major depressive episode (60.87%), followed by post-traumatic stress disorder (52.17%) and generalized anxiety disorder (13.07%).

CONCLUSIONS

Overall, a pattern of high consumption of crack was observed. The results show a high frequency of mood and anxiety disorders, with the highest frequencies found for major depressive episode and post-traumatic stress disorder.

Human T-lymphotropic virus 1 and 2 among people who used illicit drugs in the state of Pará, northern Brazil

People who used illicit drugs (PWUDs) represent an important population group for acquisition and viral dispersion. In Brazil, high rates of the human T lymphotropic virus 1 (HTLV-1) and 2 (HTLV-2) have been reported in epidemiological studies. However, the epidemiological scenario of HTLV-1/2 infections in PWUDs is still poorly understood. Thus, this cross-sectional study determined the prevalence, frequency of subtypes and factors associated with HTLV-1/2 infections among PWUDs in the Brazilian state of Pará, an area considered endemic for this virus and with poor health services. Among 826 PWUDs, 53 (6.4%) presented anti-HTLV-1/2 antibodies by EIA and 44 (5.3%) presented proviral DNA by PCR. HTLV-1 and HTLV-2 were detected in 25 (3.0%) and 19 (2.3%) PWUDs, respectively. Subtypes 1a (25/44), transcontinental (23/44) and Japanese subgroups (2/44), 2b (6/44) and 2c (13/44) were identified. Involvement in illicit/criminal activity, daily use of illicit drugs, illicit drug use over 12 years, unprotected sex with other PWUDs, changes in genitalia (including ulcers and wounds), and more than 12 sexual partners were associated with HTLV-1/2 in PWUDs. This high prevalence and intense circulation of subtypes and subgroups of HTLV-1/2 is very worrying, and indicate the need for urgent actions for its control, prevention and treatment.

Utility of oral fluid samples for hepatitis B antibody detection in real life conditions

BACKGROUND

Hepatitis B virus (HBV) testing in oral fluid samples may provide advantages in diagnosis, screening or prevalence studies, especially among individuals with venous access difficulties. This study aims to optimize one commercially available assay for detecting total anti-HBc marker in oral fluid samples and to evaluate its utility under real life conditions in different settings for the purposes of prevalence and diagnostic studies.

METHODS

Oral fluid was collected using a Salivette device and some parameters were initially evaluated: type of elution buffer and sample volume. Thereafter, the utility of oral fluid samples for detection of anti-HBc was evaluated in real life conditions in which, 1296 individuals gave serum and oral fluid samples. All serum samples were submitted to commercial EIAs to detect total anti-HBc, according to the manufacturer's instructions and oral fluid samples according to previous optimization.

RESULTS

In optimization evaluation, PBS/BSA 0.5% and 100 μL of oral fluid (volume was two-fold increased compared to serum in EIA) were chosen as transport buffer and sample volume. In the field study, anti-HBc was detected in 211 out of 1296 serum samples giving overall oral fluid sensitivity of 52.6% and specificity of 96%. Concordance was higher in ambulatory setting (67.7) compared to general population (31.8). Mean ± standard deviation values of optical density/cutoff (OD/CO) in serum samples were higher in false-negative oral fluid samples than those seen in true positive samples. Sensitivity was higher in those presenting active infection compared to anti-HBc isolate and past infection. Sensitivity also increased in the ambulatory group when HCV individuals were excluded.

CONCLUSIONS

It was possible to optimize a commercial EIA for detecting anti-HBc in oral fluid samples and where the highest concordance was found in ambulatory settings and among individuals with active infection.

Hepatitis C virus infection status and associated factors among a multi-site sample of people who used illicit drugs in the Amazon region

BACKGROUND

Elevated rates of Hepatitis C Virus (HCV) infection have been reported in epidemiological studies with people who used illicit drugs (PWUIDs) in different Brazilian regions. In Brazil's Amazon region, studies have already identified the common use of illicit drugs among adolescents and the high prevalence of HCV infections among PWUIDs. However, all studies done with PWUIDs were conducted with small samples and within limited geographic coverage. This study determined the prevalence and risk factors for HCV infection in PWUIDs in the Amazon region, northern Brazil, as well as estimating the prevalence and factors associated with the HCV spontaneous clearance (HSC).

METHODS

This cross-sectional study accessed 1666 PWUIDs from multiple municipalities of the Amazon region. Socio-demographic, economic, drug use and health-related information were collected through interviews. Blood samples collected were tested for the presence of anti-HCV antibodies and RNA-HCV. HCV genotypes were identified by real-time polymerase chain reaction (PCR). Logistic regressions were run to identify factors independently associated with HCV infection status and HSC.

RESULTS

In total, 577 (34.6%) featured HCV antibodies, of which 384 (23.1%) had active HCV infection and 193 (11.6%) indicated HSC. Genotypes 1 (80.2%) and 3 (18.8%) were detected. HCV infection status was associated with the length of illicit drug use history, factors related to parenteral and sexual transmission, and factors of socio-economic marginalization leading to potential risk activities for HCV. HSC was associated with the ethnic (including indigenous) background of participants.

CONCLUSIONS

High levels of HCV infection were detected in PWUIDs. Genotype 1 was predominant. Intense use of illicit drugs, unprotected sexual intercourse, high number of sexual partners and social marginalization were associated with all HCV infection. HSC was associated with origin (Amazonian-born) and non-white (e.g., Black or Indigenous) of PWUIDs. These findings emphasize the need for improve HCV prevention and control services and care for PWUIDs in the Brazilian Amazon region.

Contingency management is effective in promoting abstinence and retention in treatment among crack cocaine users with a previous history of poor treatment response: a crossover trial

BACKGROUND

Crack use has become a severe health problem in Brazil. Contingency management has shown robust evidence of efficacy in the treatment of cocaine use disorder (CUD) in high-income countries; however, it is still unclear how this intervention can impact treatment in low-income countries.

OBJECTIVE

To evaluate the efficacy of contingency management in the treatment of CUD among individuals with a previous history of poor treatment response in Brazil.

METHODS

Six months after the end of treatment, 32 participants previously allocated to the usual care condition (UCC) were invited to receive an additional 12 weeks of treatment in a contingency management condition (CMC), and 16 accepted the invitation. We compared data obtained from only the 16 participants (14 male) exposed to both treatment conditions.

RESULTS

Participants attended more treatment sessions and were retained in treatment for a longer period during the CMC than during the UCC (p < .01 for both). The proportion of negative cocaine samples submitted, the mean longest duration of cocaine abstinence, and the odds of being abstinent from cocaine during the 12 weeks of treatment were significantly higher during treatment in the CMC when compared to the UCC (p < .05).

CONCLUSIONS

This study provides further evidence that contingency management is effective in promoting abstinence and retention in treatment among individuals with CUD with a history of poor treatment response. Our findings argue for the incorporation of CM among public treatment services for CUD in Brazil.

TRIAL REGISTRATION

This study was registered at ClinicalTrials.gov as NCT01815645 on March 21, 2013.

Prevalence of hepatitis B and hepatitis C among diabetes mellitus type 2 individuals

Diabetes mellitus type 2 (DM2) patients have higher risk to be infected with parenterally transmitted viruses, like hepatitis B or C virus. This study aims to determine HBV and HCV infection prevalence in DM2 patients from Northeast and Southeast Brazil. A total of 537 DM2 patients were included, 194 (36.12%) males and 343 (63.87%) females, with mean age of 57.13±11.49 years. HBV and HCV markers were determined using serological and molecular analysis, and risk factors were evaluated in a subgroup from Southeast (n = 84). Two HBV acute (HBsAg+/anti-HBc -) and one HBV chronic case (HBsAg+/anti-HBc+) were found. Six individuals (1.1%) were isolated anti-HBc, 37 (6.9%) had HBV infection resolved (anti-HBc+/anti-HBs+), 40 (7.4%) were considered HBV vaccinated (anti-HBc-/anti-HBs+). Thirteen patients (2.42%) had anti-HCV and 7 of them were HCV RNA+. In the subgroup, anti-HBc positivity was associated to age and anti-HCV positivity was associated to age, time of diabetes diagnosis, total bilirubin, indirect bilirubin, alkaline phosphatase at bivariate analysis, but none of them was statistically significant at multivariate analysis. As conclusion, low prevalence of HBV and high prevalence HCV was found in DM2 patients.

Therapeutic communities in Santa Catarina, Brazil

Purpose

The purpose of this paper is to present a case study of a programme aimed at raising standards of care and levels of professionalism in private, drug-free therapeutic communities (TCs) in Santa Catarina, Brazil.

Design/methodology/approach

The paper describes the Reviver intervention in detail and draws on subjective insights collected during its implementation.

Findings

Over 100 TCs applied to the Reviver project, of which 83 qualified to participate. The large majority of TCs were found to combine community-as-method, religious worship and abstinence in their treatment model.

Research limitations/implications

The paper highlights the significant role religious organisations have in the treating substance dependency in Brazil and raises ethical and practical questions regarding the incorporation of religious TCs into mainstream public mental health provision.

Practical implications

The paper outlines the qualification process, control systems and monitoring procedures employed by the Reviver project.

Originality/value

The paper attends to the gap in English language publications regarding TCs in Brazil and raises important questions regarding the role of religion, faith and spirituality in the treatment of substance dependency.

Determination of hepatitis B, C and D prevalence among urban and Amerindian populations from the Eastern Brazilian Amazon: a cross sectional study

Background

This study was conducted to determine the prevalence of HBV, HCV, and HDV in urban populations and Amerindians living in the state of Tocantins (Eastern Amazon).

Methods

A total of 948 individuals were recruited in Tocantinopolis city (Tocantins state) of whom 603 were Amerindians (from 6 tribes) and 345 were non-Amerindians (6 urban areas of Tocantinópolis city). Anti-HCV, HBsAg, anti-HBc, anti-HBs, anti-HBc IgM, anti-HBe, HBeAg, and anti-delta antibodies were determined using enzyme immunoassay.

Results

HBV cleared infection (both anti-HBc/anti-HBs+), chronic inactive/immune controlled HBV infection (anti-HBc + only), previous HBV vaccination (anti-HBs + only), active HBV infection (HBsAg+), individuals susceptible to HBV, and anti-HCV reactivity were found in 12.9, 1.8, 27.2, 0.5, 57.7, 1.2% in Amerindians and 12.1, 2.0, 37.1, 0.3, 55.4, 0.3% in non-Amerindians respectively. Out of 139 anti-HBc reactive individuals, 70 were anti-HBe reactive and none presented HBeAg or anti-HBc IgM. Anti-HBc prevalence was associated to older age (p < 0.0001). Overall anti-Delta prevalence was 0.3% and regarding anti-HBc reactive individuals, anti-delta prevalence was 3.4 and 0% in Amerindians and non-Amerindians respectively.

Conclusions

Overall low prevalence of HBV and HCV infection was found in the populations studied, but high HBV and HCV prevalence was observed in Amerindians compared to non-Amerindians suggesting that these individuals have a higher likelihood of acquiring to these infections. Anti-delta antibodies were found among Amerindians from Eastern Amazon suggesting a risk for this population. Of note is that nearly half of Amerindians had no anti-HBs, indicating a need for HBV vaccination campaigns in this population.

HIV-1 infection among crack cocaine users in a region far from the epicenter of the HIV epidemic in Brazil: Prevalence and molecular characteristics

Brazil has the largest cocaine market in South America, and crack cocaine use is closely associated with HIV-1 infection. This study investigated the prevalence, risk factors, and HIV-1 subtypes, including recombinant forms and mutations associated with drug resistance, among crack cocaine users in Central-West Brazil. We recruited 600 crack cocaine users admitted to a referral hospital in Goiânia for psychiatric disorders. The participants were interviewed; blood samples were collected for anti-HIV-1/2 serological screening. HIV-1 pol gene sequences (entire protease [PR] and partial reverse transcriptase [RT]) were obtained from plasma RNA. HIV-1 subtypes, recombinant viruses, transmitted drug resistance (TDR), and secondary drug resistance mutations were investigated. The median participant age was 30 years (range, 18-68 years); most were male, single, unemployed, and of mixed races. Among them, 2.8% (17/600) were HIV-1 positive: 2.2% of men (11/507) and 6.5% of women (6/93). The main predictors of HIV-1 seropositivity were a sexual partner with HIV infection, irregular condom use, and previous homelessness. HIV-1 pol sequences (12/17) indicated the predominance of subtype B (n = 7), followed by recombinant forms FPR/BRT (n = 1) and BPR/FRT (n = 2) and subtypes F1 (n = 1) and C (n = 1). TDR prevalence was 58.3% (7/12). Isolates from two participants showed mutations associated with resistance to nucleoside reverse transcriptase inhibitors (NRTI) only (M41L, T125C, T125F, M184V), while an isolate from one patient who had received antiretroviral therapy (ART) since 2008 had a mutation associated with resistance to non-NRTI (G190S). Five isolates had secondary mutations to protease inhibitors (K20M, L10V, L33I, A71T, A71V). In conclusion, the findings of HIV-1 circulation, TDR to NRTI, and secondary mutations to protease inhibitors in ART-naïve crack cocaine users support the importance of monitoring this population in regions far from the epicenter of the HIV epidemic.

HIV Prevalence, Knowledge, Attitudes, and Practices Among Polydrug Users in Brazil: A Biological Survey Using Respondent Driven Sampling

Brazil has a concentrated HIV epidemic among key populations. In 2009, the Ministry of Health conducted a survey in 10 Brazilian cities aiming to estimate HIV prevalence, knowledge, and associated risk behaviors of polysubstance users (PSU). Using Respondent Driven Sampling (RDS), 3449 PSU were recruited, answered an Audio-Computer Self Assisted Interview (ACASI) and were tested for HIV and syphilis. Analyses were weighted by individual's social network size generated on RDSAT. Pooled HIV prevalence was 5.8% but varied across cities. Most PSU were male, non-white, without income, unemployed, with low levels of education. Overall, 12.0% used injectable drugs, 48.7% had sex with occasional partners and 46.4% engaged in commercial sex. A majority received free condoms (71.4%) but 76.7% exhibited inconsistent condom use. Findings can support policies aiming to improve health care and preventive interventions tailored to this population that remains at high risk of acquiring and transmitting HIV/STI in multiple scenarios.

Sociodemographic Characteristics, Patterns of Crack Use, Concomitant Substance Use Disorders, and Psychiatric Symptomatology in Treatment-Seeking Crack-Dependent Individuals in Brazil

Crack cocaine (crack) dependence is a severe disorder associated with considerable morbidity and mortality, constituting a major public health problem in Brazil. The aim of this study was to improve understanding of the profile of treatment-seeking crack-dependent individuals. We recruited 65 crack-dependent individuals from among those seeking treatment at an outpatient clinic for alcohol and drug treatment in the city of São Paulo, Brazil. Assessments, conducted between August 2012 and July 2014, focused on sociodemographic characteristics, the pattern/history of crack use, treatment history, concomitant substance use disorders, psychiatric symptomatology, and impulsivity. In the study sample, males predominated, as did unemployment, homelessness, and low levels of education. On average, the participants had smoked crack for 10 years. Most had previously been treated for crack dependence. Concomitant DSM-IV diagnoses of dependence on other substances were common, dependence on tobacco and alcohol being the most prevalent. Participants presented significant psychiatric symptomatology and impulsivity, with nearly half of the sample presenting psychotic symptoms, 90% presenting depressive symptoms, and 80% presenting anxiety symptoms. Most treatment-seeking crack-dependent individuals in Brazil are living in extremely poor social conditions and are struggling with the severe, chronic, and comorbid features of this disorder.

Crack cocaine users views regarding treatment with contingency management in Brazil

BACKGROUND

Contingency management (CM) has recently shown efficacy in promoting abstinence and retention in treatment among crack cocaine users in Brazil. However, partially because of unawareness and resistance among health care providers, CM has not been widely employed. The objective of this study was to conduct a secondary analysis in order to evaluate how CM participants perceive their treatment experience.

METHODS

Twenty-seven crack cocaine users, previously assigned to 12 weeks of CM treatment, were assessed with a structured questionnaire designed to assess their personal opinion of, difficulty in understanding, and acceptance of the CM intervention, as well as their opinion regarding its impact on their treatment responses.

RESULTS

Descriptive analyses showed that 92.6% of the participants found it very easy to understand the CM protocol. All participants reported liking their CM experience quite a bit. For the perceived effects of CM on their treatment response, 81.5% of the participants stated that CM helped them considerably, the mean score for the impact of CM on treatment response (out of a maximum of 10) being 9 (SD = 1.5). When asked if they believed CM could help other people with crack cocaine dependence, 92.6% of the participants stated that CM could help such people a lot and 7.4% stated that it could help them a little.

CONCLUSIONS

From the perspective of the patients, CM was easily assimilated, easily accepted, and had a direct positive effect on treatment response. These findings provide additional support for the incorporation of CM into substance abuse treatment services in Brazil.

Contingency management targeting abstinence is effective in reducing depressive and anxiety symptoms among crack cocaine-dependent individuals

Although contingency management (CM) is effective in promoting abstinence and treatment retention among crack cocaine users who meet the criteria for cocaine dependence, less is known about its off-target effects. In this secondary analysis, we evaluated the impact of CM on depressive and anxiety symptoms in a sample of cocaine-dependent individuals under treatment. Sixty-five crack cocaine users who met the criteria for cocaine dependence were randomly assigned to receive 12 weeks of standard treatment alone (STA; n = 32) or 12 weeks of standard treatment plus CM (STCM; n = 33). The outcome measures of the secondary analysis were depressive and anxiety symptoms assessed with the Beck Depression Inventory-II (BDI-II) and the Beck Anxiety Inventory (BAI). At baseline, 59 (90.8%) of the participants reported at least mild depressive symptoms and 47 (72.5%) reported at least mild anxiety symptoms. The mean BDI-II (24.5 ± 12.1) and BAI (20.7 ± 13.5) scores in the sample as a whole was moderate. After treatment, the reported levels of depressive symptoms (β = -9.6, p < .05) and anxiety symptoms (β = -9.9, p < .05) were lower among the individuals receiving STCM than among those receiving STA. This study provides evidence that an STCM intervention targeting crack cocaine abstinence also produces significant reductions in depressive and anxiety symptoms. This low cost intervention also demonstrated significant promise and optimization potential for crack cocaine users in a setting of scarce resources and high mental health comorbidity. Relevance Statement: We found that the prevalence of depressive and anxiety symptoms were extremely high among crack cocaine users, and that, among such individuals, contingency management (CM) reduced depressive and anxiety symptomatology to a greater degree than did standard treatment. Our results suggest that CM targeting crack cocaine abuse can have off-target effects on psychiatric symptomatology. (PsycINFO Database Record

Hepatitis C virus infection among illicit drug users in an archipelago of the Amazon

Hepatitis C virus (HCV) infection causes acute and chronic liver disease and may lead to cirrhosis, liver failure or hepatocellular carcinoma. The behavior of illicit drug users (DUs) typically exposes them to risks of viral infection. In the Brazilian Amazon region, a number of studies have identified high rates of drug use among adolescents, and a high prevalence of HBV infection in DUs, disseminated by sexual and parenteral activities. However, the epidemiological scenario of HCV infection in the region is still poorly understood. This study determined the prevalence, genotypes, and risk factors for HCV infection among DUs of the Marajó Archipelago. This cross-sectional study collected samples and epidemiological information from DUs in 11 municipalities. The diagnosis was established by EIA and real-time PCR, and the samples were genotyped by multiplex real time PCR. The data were analyzed by simple and multiple logistical regression. In 466 DUs, 28.3% had anti-HCV antibodies, and 25.5% had HCV-RNA. In 92 injecting drug users, 88.0% had anti-HCV antibodies, and 80.4% had HCV-RNA. Genotypes 1 and 3 were detected, with three cases of mixed infections. The multivariate analysis indicated associations of HCV infection with age (≥ 35 years), tattoos, intravenous drug use, shared use of injection equipment, and the daily and long-term (> 3 years) use of illicit drugs. These findings will contribute to the development of effective measures for the prevention of HCV infection among Brazilian DUs, as well as its general population.

Erectile Dysfunction Symptoms in Polydrug Dependents Seeking Treatment

OBJECTIVE

To assess erectile dysfunction (ED) symptom prevalence, sexual behavior conditions, and risk factors associated to ED in a male polydrug dependent sample.

METHODS

A cross-sectional design study was conducted with 102 substance-dependent male polydrug users who sought outpatient treatment in São Paulo, Brazil. Sociodemographic data, drug of choice, chronic disease questions, sexually transmitted infections, International Index of Erectile Function (IIEF) scale, Sexual Addiction Screening Test (SAST), and WHOQOL-Bref instrument were used.

RESULTS

The erectile dysfunction prevalence was 32.3% and it was related to the marital status (single) (p < 0.001), occupational status (fully unemployed) (p < 0.001), presenting a chronic disease (p = 0.027), and with types of sexual partnerships (occasional partner) (p < 0.001). Alcohol (73.5%), tobacco (79.4%), cannabis (83.3%), and cocaine (snorted 78.4% and smoked 42.2%) were the drugs of choice. The ED risk decreased when marital status was married (odds ratio = 3.2 CI95% 1.411-7.518) and with chronic disease (odds ratio 0.06 CI95% 0.00-0.97), while having occasional sexual partners increased 14 times ED risk (OR 14.0 CI95%1.62-122.18). There were no significant associations between quality of life, DOC and ED.

CONCLUSION

Approximately one third of the substance dependents in this sample presented ED. There is a need to integrate psychiatric and clinical care in substance treatment services, and to improve the provision of sexual health care and support available for this population.

Revisão sistemática da literatura sobre crack: análise do seu uso prejudicial nas dimensões individual e contextual

RESUMO Este artigo visa investigar como se conformam, no Brasil e internacionalmente, as abordagens ao uso prejudicial do crack e outras drogas. Foi realizada uma revisão crítica da literatura acerca do padrão de consumo do crack e os fatores a ele relacionados com busca sistemática em bases eletrônicas no período de 2010 a 2016. Foram analisados 37 artigos por autor, ano, país do estudo, metodologia; padrão de consumo de crack e fatores individuais e contextuais relativos a esse uso. Conclui-se que a abordagem ao uso de drogas deve estar focada na perspectiva da redução de danos, na promoção da autonomia e dos direitos humanos, e não na utopia de eliminação do consumo e da produção de drogas.

Depression, anxiety, hopelessness and quality of life in users of cocaine/crack in outpatient treatment

Abstract Objective: To identify symptoms of anxiety, depression, and feelings of hopelessness in patients in outpatient treatment for substance dependency and to test for correlations with various aspects of their quality of life. Methods: A cross-sectional study of a sample of 25 men in recuperation from substance dependency, selected by convenience. We assessed symptoms of depression (Beck Depression Inventory-II), anxiety (Beck Anxiety Inventory), hopelessness (Beck Hopelessness Scale), and quality of life (World Health Organization Quality of Life instrument-Abbreviated version [WHOQOL-Bref]), and also analyzed sociodemographic profile, substance abuse, and family history. Categorical variables were expressed as frequencies and percentages and quantitative variables as means and standard deviations or as medians and interquartile ranges. We also analyzed Spearman correlations to a 5% significance level. Results: The study revealed prevalence rates of 32% for depression, 24% for anxiety, and 12% for hopelessness, at a moderate/severe level. Correlations between Beck scales and WHOQOL-Bref were significant; but impacts differed in the four areas evaluated. Conclusions: Overall, we observe global negative impacts on subjects' lives, affecting their psychiatric symptoms and quality of life and their relationships and occupational factors to a similar degree. The results show that the lower the scores on these scales, the better the quality of life in some areas, indicating that there is a negative correlation between psychiatric symptoms and quality of life.

Poor sensitivity of rapid tests for the detection of antibodies to the hepatitis B virus: implications for field studies

Rapid tests (RTs) can be used as an alternative method for the conventional diagnosis of hepatitis B virus (HBV). This study aims to evaluate antibodies to HBsAg (anti-HBs) and antibodies to HBeAg (anti-HBe) RTs under different Brazilian settings. The following three groups were included: GI: viral hepatitis outpatient services; GII: low resource areas; and GIII: crack users and beauticians. Imuno-rápido anti-HBsAg^™ and Imuno-rápido anti-HBeAg^™ RTs were evaluated and showed specificities greater than 95% in all groups. The sensitivity values to anti-HBs were 50.38%, 51.05% and 46.73% and the sensitivity values to anti-HBe were 76.99%, 10.34% and 11.76% in the GI, GII and GIII groups, respectively. The assays had a low sensitivity and high specificity, which indicated their use for screening in regions endemic for HBV.

Vulnerabilidades clínicas e sociais em usuários de crack de acordo com a situação de moradia: um estudo multicêntrico de seis capitais brasileiras

Resumo: O estudo teve como objetivo avaliar a gravidade do uso de substâncias psicoativas, situações de violência, saúde física e emocional de usuários de crack que buscam atendimento em Centros de Atenção Psicossocial para Álcool e Drogas (CAPSad), em relação ao status de moradia. Trata-se de um estudo multicêntrico em seis capitais brasileiras, com 564 usuários de crack categorizados em dois grupos: (1) usuários que estiveram em situação de rua (n = 266) e (2) nunca estiveram em situação de rua (n = 298). Para avaliar a gravidade do uso de substâncias e as características dos indivíduos utilizou-se o Addiction Severity Index, 6ª versão (ASI-6). Os usuários do grupo 1 demonstraram piores indicadores em relação às subescalas álcool, problemas médicos, psiquiátricos, trabalho e suporte familiar, além de maior envolvimento com problemas legais, violência, abuso sexual, risco de suicídio e problemas de saúde como HIV/AIDS, hepatite e tuberculose, além de possuírem menos renda para pagar necessidades básicas. Após análises multivariadas ajustadas para possíveis confundidores, não possuir renda suficiente para pagar necessidades básicas, apresentar sintomas depressivos e ter sido preso por roubo permaneceram significativos. Este trabalho avaliou de forma mais abrangente a gravidade do uso de drogas e a situação de moradia de usuários de crack. Abordagens desenvolvidas nos dispositivos de tratamento extra-hospitalares devem ser projetadas e adequadas de acordo com perfis e demandas específicos dos usuários, em especial aqueles em situação de rua.

Profile and pattern of crack consumption among inpatients in a Brazilian psychiatric hospital

INTRODUCTION

Crack cocaine use is associated with polydrug abuse, and inpatients dependent on crack exhibit profiles of serious consumption patterns. Use of alcohol and tobacco and other drugs is a risk factor for experimentation of additional drugs, including crack cocaine.

OBJECTIVES

The present study describes the characteristics and crack consumption patterns among inpatients in treatment during 2011 and 2012 at the Hospital Psiquiátrico São Pedro (Porto Alegre, Brazil). An additional objective was to identify the sequence of alcohol and tobacco consumption prior to crack use.

METHODS

The participants were 53 male inpatients addicted to crack with a mean age of 27.5±7.3 years. A sociodemographic questionnaire; the Alcohol, Smoking and Substance Involvement Screening Test and the Mini Mental State Examination were all administered to participants. Inclusion criteria were crack cocaine dependency (based on the 10th edition of the International Classification of Diseases [ICD-10]) and being abstinent for 7 days. Patients with cognitive difficulties who were unable to understand and/or respond to the questionnaires were excluded from the sample.

RESULTS

The participants were young male adults with low educational level and low incomes and were polydrug users. The majority had made more than one attempt to quit. Use of legal drugs in early adolescence, prior to crack use, was identified.

CONCLUSIONS

The profiles of the inpatients addicted to crack treated at this hospital indicate a serious usage pattern among those who seek specialized support. Crack use is frequent and is associated with use of other drugs and with difficulty sustaining abstinence. The pattern of progression from alcohol and tobacco use to crack cocaine dependency demands the attention of those responsible for prevention policies.

Substance Use and Adherence Among People Living with HIV/AIDS Receiving cART in Latin America

This cross-sectional study describes substance use prevalence and its association with combination antiretroviral therapy (cART) adherence among 3343 individuals receiving care at HIV clinics in Argentina, Brazil, Chile, Honduras, Mexico, and Peru. A rapid screening tool evaluated self-reported 7-day recall of alcohol, marijuana, cocaine, heroin, and methamphetamine use, and missed cART doses. Overall, 29.3 % individuals reported having ≥1 alcoholic drinks, 5.0 % reported any illicit drug use and 17.0 % reported missed cART doses. In the logistic regression model, compared to no substance use, alcohol use [adjusted odds ratio (AOR) = 2.46, 95 % confidence interval (CI): 1.99-3.05], illicit drug use (AOR = 3.57, 95 % CI: 2.02-6.30), and using both alcohol and illicit drugs (AOR = 4.98, 95 % CI: 3.19-7.79) were associated with missed cART doses. The associations between substance use and likelihood of missing cART doses point to the need of targeting alcohol and illicit drug use to improve adherence among people living with HIV in Latin America.

Contingency management is effective in promoting abstinence and retention in treatment among crack cocaine users in Brazil: A randomized controlled trial

Crack cocaine dependence has become a severe public health problem in Brazil, and current psychosocial approaches to this problem have shown little or no effectiveness. Although contingency management is among the most effective behavioral treatments for substance use disorders, it has never been applied in the treatment of crack cocaine-dependent individuals in Brazil. The aim of this study was to evaluate the efficacy of incorporating contingency management into standard outpatient treatment for crack cocaine dependence, as well as the impact that doing so has on treatment attendance, retention in treatment, maintenance of abstinence, and the frequency of substance use. We evaluated 65 treatment-seeking, crack cocaine-dependent individuals, randomized to receive 12 weeks of standard treatment plus contingency management (STCM; n = 33) or 12 weeks of standard treatment alone (STA; n = 32). Those in the STCM group received monetary incentives for being abstinent, earning up to US$235.50 if they remained abstinent throughout the entire treatment period. The STCM group participants attended a mean of 19.5 (SD = 14.9) treatment sessions, compared with 3.7 (SD = 5.9) for the STA group participants (p < .01). Those in the STCM group were 3.8, 4.6, and 68.9 times more likely to be retained in treatment at weeks 4, 8, and 12 than were those in the STA group. The likelihood of detecting 4, 8, and 12 weeks of continuous abstinence was 17.7, 9.9, and 18.6 times higher in the STCM group than in the STA group (p < .05). Compared to the STA group, the STCM group submitted a significantly higher proportion of negative samples for crack cocaine, delta-9-tetrahydrocannabinol, and alcohol (p < .001) when all expected samples were included in the denominator but not when only submitted samples were considered. The average monthly cost/participant for incentives was $29.00. Contingency management showed efficacy in a sample of Brazilian crack cocaine users. The intervention holds promise for broader application in international settings. (PsycINFO Database Record

Un Jalón, Un Volteón, y Otra Vez: High-Risk Crack Smoking Paraphernalia in México City

During the past decade, crack smoking has increased in Mexico among poor urban populations. Despite this increasing prevalence, little is known about the types of paraphernalia used and related sharing practices and physical harms. Data come from in-depth semi-structured interviews and observations with 156 current crack smokers in Mexico City. Findings reveal a complex, crack-smoking process in Mexico City that represents an interconnected structure of paraphernalia items and pipes that could contribute to detrimental health consequences. Specifically, we identify essential paraphernalia items that make the smoking of crack possible; describe the homemade construction of two categories of pipes; and detail the sharing practices and physical harms associated with these paraphernalia. Results point towards a smoking process that is embedded in impoverished urban neighborhoods sustained by an accessible street-level crack market. Discussed are the policy and intervention implications associated with reducing crack-related health consequences in Mexico and other Latin American countries.

Usuários de Crack que Buscam Tratamento em Brasília

RESUMO Objetivando identificar o perfil de pacientes ambulatoriais que procuram tratamento para problemas relacionados com crack em Brasília, 132 usuários que recebem serviços psicológicos preencheram o Questionário sobre o Perfil de Consumo de Crack e o Cocaine Craving Questionnaire-Brief. Os participantes eram homens (83,6%), solteiros (38,8%) e possuíam residência (100%). O primeiro uso foi motivado pela curiosidade (65,9%), influência dos pares (58,3%) e fácil acesso (50,8%). A maioria (65,2%) relatou poliuso. O mais longo período de abstinência foi de quatro anos (1,5%) e a maioria (46%) relatou menos de 30 dias. O poder letal, dependência e contextos de vulnerabilidade social associados ao crack foram questionados neste estudo. São necessários esforços para melhor atender aos que não acessam o sistema de tratamento.

Evaluating HBsAg rapid test performance for different biological samples from low and high infection rate settings & populations

Background

Rapid tests (RTs) might have several advantages over standard laboratory procedures, increasing access to diagnosis, especially among vulnerable populations and/or those living in remote areas. The aim of this study was to evaluate the performance of RTs for the detection of hepatitis B virus surface antigen (HBsAg) in samples from different populations/settings.

Methods

Three RTs for HBsAg detection (Vikia® HBsAg, HBsAg Teste Rápido®, and Imuno-Rápido HBsAg®) and different biological specimens (serum, whole blood, and saliva) were evaluated. Analyses comprised a reference panel and samples from field studies targeting suspected cases of hepatitis B virus (HBV) (G I), individuals living in deprived areas (G II), and highly vulnerable individuals (G III). Enzyme immunoassay (EIA) was defined as the gold standard in this study. Reproducibility, repeatability, and cross-reactivity with other infectious agents such as dengue, immunodeficiency (HIV), and hepatitis C (HCV) viruses and T. pallidum were determined.

Results

For the reference panel, the sensitivity and specificity of all HBsAg RTs were higher than 93.00 %. G I presented the highest kappa values for all rapid assays using sera samples. When using serum, the sensitivity values were higher than 93.40 for G I, 60.00 % for G II and 66.77 % for G III, and the specificity values were higher than 99.50 for GI, 97.20 for G II and 99.10 % for G III for all tests. For whole blood samples & the Vikia® HBsAg assay, the best performance was achieved for GIII (k = 79.75 %). For saliva samples, the Imuno-Rápido HBsAg® assay showed the highest concordance values with EIA for G I (40.68 %) and G II (32.20 %). The reproducibility and repeatability of all RTs for serum and saliva were excellent, and the concordance between HBsAg EIAs and RTs using samples reactive with other infectious agents varied from 70.10 % to 100.00 %.

Conclusions

The overall performance of RTs for HBsAg in serum was high/moderately high for all groups, thereby promoting increased access to HBV diagnosis among vulnerable populations as well as samples from individuals in emergency settings or remote areas. Rapid tests for HBsAg using whole blood could be used in prevalence studies, though these assays should not be used for saliva samples.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-015-1249-5) contains supplementary material, which is available to authorized users.

Hepatitis C in key populations in Latin America and the Caribbean: systematic review and meta-analysis

Objectives

Summarize hepatitis C virus (HCV) prevalence in injecting (IDU) and non-injecting drug users (NIDU), men who have sex with men (MSM), sex workers, and prison inmates in Latin America and the Caribbean (LAC).

Methods

Systematic review on HCV prevalence in sub-populations in LAC. Databases searched from 1-1-2000 to 10-30-2013. Inclusion criteria: prevalence studies in sub-populations in LAC. HCV-antibody was marker for prevalence of current/past HCV infection and HCV-RNA for prevalence of HCV current infection.

Results

IDU HCV current/past infection presented highest prevalence, from 1.7 % in Colombia to over 95 % in Ciudad Juarez and Tijuana, Mexico and pooled regional anti-HCV prevalence was 49 % (CI 95 % 22.6–76.3 %). NIDU, MSM and sex workers anti-HCV prevalence was below 10 %, and pooled regional prevalence of 4 % (CI 95 % 2.6–4.5 %), 3 % (CI 95 % 1.7–4.5 %) and 2 % (CI 95 % 1.0–3.4 %), respectively. Prison inmates presented higher values, but prevalence decreased over the 15-year time span (p < 0.001). Current HCV infection from three countries showed prevalence under 10 % in prison inmates and 1–46 % among drug users.

Conclusions

Disease burden is high and surveillance, prevention and treatment should target these groups in LAC.

Electronic supplementary material

The online version of this article (doi:10.1007/s00038-015-0708-5) contains supplementary material, which is available to authorized users.

The interplay between drug-use behaviors, settings, and access to care: a qualitative study exploring attitudes and experiences of crack cocaine users in Rio de Janeiro and São Paulo, Brazil

Background

Despite the growing attention surrounding crack cocaine use in Brazil, little is understood about crack users’ histories, use patterns and the interplay of drug-use behaviors, settings, and access/barriers to care. Qualitative studies seldom cross-compare findings regarding people who use crack from different settings. This study aims to explore the insights of regular crack users in two major Brazilian cities and to examine how social and contextual factors, including stigma and marginalization, influence initial use and a range of health and social issues.

Methods

In-depth interviews and focus groups were conducted with 38 adult crack cocaine users recruited from impoverished neighborhoods in Rio de Janeiro and São Paulo. Interviews and focus groups were audio recorded and transcribed verbatim. Qualitative analysis was carried out, and content was organized and analyzed by recurrent themes relevant to study interests.

Results

For study participants from both cities, frequent crack cocaine use plays a central role in daily life and leads to a range of physical, psychological, and social consequences. Common concerns among users include excessive crack use, engagement in risky habits, infrequent health service utilization, marginalization, and difficulty reducing use.

Conclusions

Disadvantaged conditions in which many crack cocaine users grow up and live may perpetuate risk behaviors and stigma may further marginalize users from necessary health and recovery services. Reducing stigma and moralizing discourse related to drug use, especially among health professionals and law enforcement personnel, may help encourage users to seek necessary care. New harm-reduction-based care and treatment alternatives for marginalized drug users are being developed in parts of Brazil and elsewhere and should be adapted and expanded for other populations in need.

Usuários de crack em situação de rua – características de gênero

O aumento do uso de crack tem se constituído em um desafio para a saúde pública no Brasil. Os objetivos deste artigo são identificar como se constituem as relações de gênero no cotidiano dos usuários de crack; e analisar a dinâmica que permeia a construção destas relações que envolvem troca e poder. Estudo qualitativo, descritivo, exploratório, de orientação fenomenológica. Dados coletados com usuários de crack em situação de rua, na comunidade de Manguinhos, no Rio de Janeiro. Realizados oito grupos focais (n = 31) e duas entrevistas individuais, entre Junho e Agosto de 2011. Nos grupos, os relatos dos rapazes e moças investigados diferiram quanto ao estabelecimento dos vínculos de afeto; no papel atribuído ao crack como operador na mediação de conflitos; no uso do corpo como moeda de troca/prostituição e na geração e cuidado da prole. Foram observados alguns deslocamentos com relação aos acordos tradicionais e hierárquicos de gênero. O estudo das relações estabelecidas na pesquisa revela que não é possível apontar para algozes ou vítimas. O que surge nas análises é um universo plural e fluido, em permanente construção, com deslizamentos que privilegiam ora as mulheres e ora os homens.

Prevalence of hepatitis B and C virus infections among military personnel

BACKGROUND

Data regarding Hepatitis B and C viruses (HBV and HCV) prevalence among military personnel in Brazil are lacking, but the work-related risk of exposure can be high. The objective of this study was to estimate the seroprevalence of HBV and HCV and the risk factors associated to HBV exposure among Brazilian military personnel.

METHODS

A cross-sectional study was conducted and included 433 male military adults aged 18-25 years old working in Rio de Janeiro during October 2013. All individuals completed a questionnaire to assess their risk of exposure and provided a blood sample to HBV and HCV testing.

RESULTS

None of the participants presented HBsAg or anti-HBc IgM, 18 (4.1%) were positive for total anti-HBc, 247 (57.0%) were positive for anti-HBs, and 3 (0.7%) were anti-HCV reactive. The majority of military personnel with past HBV infection (anti-HBc reactive) and HBV immunity (anti-HBs reactive) had a history of prior dental procedures (88.9% and 77.3%), consumption of alcohol at least once a week (50% and 55.9%), and practiced oral sex (61.1% and 58.3%, respectively). In addition, anti-HBc positivity was common among individuals with a history of surgery (44.4%) and practice of anal sex (50%). At univariate analysis, age group was associated to anti-HBc and anti-HBs positivity.

CONCLUSIONS

Low rates of HBV and HCV infection were observed among Brazilian military personnel in comparison to the general Brazilian population. HBV immunity rates were relatively low indicating the need for vaccination campaigns in this group.

Effectiveness of secondary prevention and treatment interventions for crack-cocaine abuse: a comprehensive narrative overview of English-language studies

There are an estimated several million crack-cocaine users globally; use is highest in the Americas. Most crack users are socio-economically marginalized (e.g., homeless), and feature elevated risks for morbidity (e.g., blood-borne viruses), mortality and crime/violence involvement, resulting in extensive burdens. No comprehensive reviews of evidence-based prevention and/or treatment interventions specifically for crack use exist. We conducted a comprehensive narrative overview of English-language studies on the efficacy of secondary prevention and treatment interventions for crack (cocaine) abuse/dependence. Literature searches (1990-2014) using pertinent keywords were conducted in main scientific databases. Titles/abstracts were reviewed for relevance, and full studies were included in the review if involving a primary prevention/treatment intervention study comprising a substantive crack user sample. Intervention outcomes considered included drug use, health risks/status (e.g., HIV or sexual risks) and select social outcome indicators. Targeted (e.g., behavioral/community-based) prevention measures show mixed and short-term effects on crack use/HIV risk outcomes. Material (e.g., safer crack use kit distribution) interventions also document modest efficacy in risk reduction; empirical assessments of environmental (e.g., drug consumption facilities) for crack smokers are not available. Diverse psycho-social treatment (including contingency management) interventions for crack abuse/dependence show some positive but also limited/short-term efficacy, yet likely constitute best currently available treatment options. Ancillary treatments show little effects but are understudied. Despite ample studies, pharmaco-therapeutic/immunotherapy treatment agents have not produced convincing evidence; select agents may hold potential combined with personalized approaches and/or psycho-social strategies. No comprehensively effective 'gold-standard' prevention/treatment interventions for crack abuse exist; concerted research towards improved interventions is urgently needed.