The Opening of South America's First Needle Exchange Program and an Epidemic of Crack Use in Salvador, Bahia-Brazil

Abstract

By 1998, 21% of cumulative AIDS cases in Brazil had occurred among injection drug users (IDUs). After a protracted political battle, the first needle exchange program (NEP) in South America opened in Salvador, Bahia. This paper uses a variety of quantitative and qualitative data sources to describe the opening of the NEP and the impact upon it of a crack cocaine epidemic that swept the region shortly after the NEP opened. Quantitative data sources include 3 cross-sectional studies conducted in various districts of Salvador before and after the NEP opened, and process measures from the NEP. Qualitative data sources include participant observation in Pelourinho, a heavy drug-use area of Salvador, the field notes of outreach workers, and newspaper articles from the most widely read local newspaper. The initial cross-sectional study demonstrated a 58% HIV seroprevalence and a similar percentage of IDUs reported needle-sharing. These data were used to support the need for a local NEP, which ultimately opened in March 1995. Use of the NEP in Pelourinho dropped precipitously with the arrival of a crack cocaine epidemic, documented clearly in the newspaper and outreach workers' field notes. The data permit an analysis of when the epidemic arrived and the geographical spread of the drug through Salvador. They also clearly document how drug users switched from cocaine injection to crack in large numbers and how the NEP was forced to adapt to these changes in drug-use patterns. Reductions in injection risk behavior are documented in Pelourinho, but are difficult to ascribe with certainty to the NEP because of the limited numbers of persons still injecting and the consequent selection bias. There are now 30 NEPs throughout Brazil.