Tailoring an HIV-prevention intervention for cocaine injectors and crack users in Porto Alegre, Brazil

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1 AIDS Care, June 2005; 17(Supplement 1): S77 /S87 Tailoring an HIV-prevention intervention for cocaine injectors and crack users in Porto Alegre, Brazil C. G. LEUKEFELD 1, F. PECHANSKY 2, S. S. MARTIN 3, H. L. SURRATT 3, J. A. INCIARDI 3, F. H. P. KESSLER 2, M. M. ORSI 2, L. VON DIEMEN 2, & E. MEYER DA SILVA 1 1 University of Kentucky, Lexington, Kentucky, USA, 2 Federal University of Rio Grande do Sul, Porto Alegre, Brazil, and 3 University of Delaware, Coral Gables, Florida, USA Abstract Brazil has the second largest number of reported AIDS cases in the world. Porto Alegre, like most other large urban centres in Brazil, has been greatly impacted by an AIDS epidemic driven by high rates of drug use and risky sexual behaviours. While epidemiologic surveillance of HIV/AIDS and treatment initiatives for HIV-infected individuals are well developed in Brazil, comparatively little attention has focused on developing interventions directed toward high-risk populations. Intervention programmes, particularly those tailored for chronic drug users, are lacking. This pilot project successfully adapted and tailored a cognitive behavioural HIV intervention developed in the US to the cultural setting in Porto Alegre. The project established feasibility and acceptability of the approach for targeting risky drug and sexual behaviours among a group of male Brazilian drug users. A sample of 120 male cocaine users was recruited from a public health clinic serving the target population in the city of Porto Alegre. The average age of the participants was 29; they averaged less than 8 years of formal education; and less than half (41%) were married. Lifetime self-reported drug use was high with 93% reporting cocaine use, 87% reporting crack use, and 100% reporting marijuana use. 43% of the sample reported ever injecting drugs. Reports of risky sexual behaviours were similarly elevated. Almost half (45%) tested positive for HIV. Preliminary evidence suggests that intervention acceptability was high among participants. Given the reported high risk sexual and drug use behaviours among these men, HIV interventions must be evaluated and expanded to include this population as well as their sexual partners. Introduction With 257,780 cases reported through 2003, Brazil ranks second in the world in the total number of identified AIDS cases. AIDS increased dramatically in Brazil during the 1990s, and recent Brazilian Ministry of Health data estimate that some 540,000 Brazilians are currently living with HIV/AIDS. Overall, about 35,000 AIDS cases have been attributed to drug injecting, with an estimated 3,000 new cases associated with injection drug use occurring each year for the past ten years (Pechansky et al., 2000). Specifically, 25% of AIDS cases are related either directly or indirectly to the use of injection drugs, 38.2% of Correspondence: Carl G. Leukefeld, Professor and Director, University of Kentucky, Center on Drug and Alcohol Research, 643 Maxwelton Court, Lexington, KY Tel: Fax: cleukef@pop.uky.edu ISSN print/issn online # 2005 Taylor & Francis Group Ltd DOI: /

2 S78 C. G. Leukefeld et al. women with AIDS were infected through sexual contact with a drug injector, and 36% of paediatric AIDS cases are injection drug use related. Porto Alegre, Brazil s fifth largest city, has one of the largest concentrations of AIDS cases and the third highest incidence of AIDS in the country (Brazilian Ministry of Health, 2001). The cumulative number of AIDS cases in Porto Alegre through July 2004 was 11,573, accounting for 4.1% of the total number of cases in Brazil (Porto Alegre Municipal Secretary of Health, 2004). While injection drug use in Porto Alegre remains common, crack use is an emerging epidemic, and risky sexual behaviours are commonly reported among these drug-involved populations (Pechansky et al., 2000; Pechansky et al., 2003). Not surprisingly, these factors have resulted in high rates of infection with HIV in Porto Alegre, specifically among drug users. In fact, in the late 1990s, 44% of tested drug injectors seeking treatment tested HIV positive (Pechansky & Von Diemen, 1998). Because of widespread drug abuse, related high-risk HIV behaviours, and elevated HIV seropositivity, HIV interventions among at-risk groups are urgently needed in order to reduce the number of new infections. While epidemiologic surveillance of HIV/AIDS and treatment initiatives for HIV-infected individuals are well developed in Brazil, comparatively little attention has focused on increasing targeted prevention efforts and developing interventions among high-risk cocaine injectors and crack users. Within this context, the overall goal of this pilot project was to adapt and tailor a cognitive behavioural HIV intervention developed for drug users in the US to the cultural setting in Porto Alegre. The specific purposes of this article are to: (1) describe the high-risk drug using and sexual behaviours in Porto Alegre, as evidenced by the 120 male cocaine users who entered the pilot study; and (2) describe the processes by which the cognitive behavioural HIV risk-reduction intervention was successfully modified for the Brazilian cultural context, as well as the resulting content of the intervention. Methods The study sampled male cocaine users presenting for medical care at the Centros de Apoio e Orientação Sorológica (COAS). The COAS is a system of municipal and state public health centres serving indigent populations in all parts of Porto Alegre, providing free pregnancy testing, HIV testing, and other health care. The COAS centres are excellent locations for recruiting drug users for a variety of reasons: (1) the overwhelming majority of COAS clients are from Porto Alegre s many favelas (urban shanty towns) / places with high concentrations of drug users of all types; and (2) the COAS catchment areas include the entire city of Porto Alegre. A sample of 120 male active cocaine users were recruited during 2003 and 2004 for the purpose of piloting the new intervention described in this paper. While these individuals were not necessarily a representative sample of drug users throughout the city, their demographic and drug-use characteristics indicated that they comprised an appropriate group for piloting an HIV intervention targeting indigent, urban, male cocaine users. The overall approach had four components: Identification Potential participants were screened for eligibility, and, if eligible, the project was explained to them by project staff at the COAS clinic. The voluntary and confidential nature of the study, as well as the benefits of testing and the incentives for participation, were described.

3 HIV-prevention for injectors in Brazil S79 Informed consent was obtained using a form approved by Institutional Review Boards both in Brazil and the US. Session 1 / Assessment and intervention Each successfully screened and consented participant completed a baseline questionnaire and then was given the Standard Intervention developed by National Institute on Drug Abuse (NIDA) scientists and grantees, which served as HIV pre-test counselling. Urine and blood specimens were then collected. Although not the focus of this paper, participants were then randomized and assigned to one of two groups. One half were selected to end the intervention session at this point, getting the NIDA Standard Intervention as typically used by the COAS. The other half went on to receive the Porto Alegre Intervention, which followed the NIDA Standard Intervention with Structured Stories and Thought Mapping modules. At the end of either the Standard or Porto Alegre Intervention, an appointment was then made for the second session, where all participants received HIV test results and HIV post-test counselling, and the Porto Alegre Intervention participants received a booster session. Session 2 / Post-test counselling for all and problem-solving skills-building session for the Porto Alegre intervention The second intervention session was scheduled about two weeks after the baseline session for HIV post-test counselling (NIDA Standard) and follow-up intervention (for the Porto Alegre Intervention). Reassessment Participants were re-interviewed six weeks after the second session in order to assess changes in knowledge, attitudes, and risk behaviours. In this paper we report data on the baseline characteristics of this sample as well as the preliminary acceptability of the intervention. Subsequent reports will examine post / intervention outcome data on these participants. A battery of standardized data collection instruments were utilized in this study to capture information on demographics and risk behaviours among this sample. The primary instrument employed was the Risk Assessment Battery / Third Brazilian Version (Pechansky et al., 2002). This instrument includes questions designed to assess drug use in the last 30 days and six months, as well as risk situations and behaviours associated with HIV infection, including specific questions about lifetime number of sex partners, frequency of condom use, number of times the subjects had paid money for sex, the number of times they had injected, and their concerns regarding HIV infection. Results As noted in Table I, the participants had an average age of 29.1 years; 58% self-identified as bi-racial, while the remainder identified as white. The educational level of the sample was quite low with more than half (55%) failing to complete the eighth grade; overall the participants had an average of 7.2 years of education. The sample was economically disadvantaged, with nearly half reporting incomes of less than $40 per month. Overall, 45% of the sample tested positive for HIV.

4 S80 C. G. Leukefeld et al. Table I. Selected demographics characteristics. Total (N/120) Age 18 / % 25 / % 30/ 47.9% Mean 29.1 Race White 42.0% Multiracial 58.0% Education Seventh grade or less 56.3% Eighth grade or more 43.7% Marital Status Married 41.0% Non-married 59.0% Employment Regular work 40.3% Income Less than US $40/month 48.7% HIV Status HIV Positive 45.0% As noted in Table II, participants reported extremely high levels of lifetime drug use, primarily alcohol (98%), powder cocaine (99%), crack cocaine (86%), and marijuana (100%). Lifetime use of amphetamines and opiates was low, at 18% and 13%, respectively. Current drug use was also high, with some 84% using alcohol and marijuana in the 30 days prior to interview. In addition, approximately three-quarters of participants reported 30- day use of powder cocaine (77%) and crack cocaine (73%), while opiate and amphetamine use remained minimal. Self-reported frequency of drug use in the prior month was considerable as well. Specifically, alcohol was used on a mean of 14.7 days, marijuana on 23.3 days, powder cocaine on 7.7 days, and crack cocaine on 14.4 days. Table III presents self-reported HIV risk behaviours in the six months prior to interview. Overall, 23% of the sample reported having more than four female sexual partners in the previous six months, and 17% had sexual contact with a male partner in this same time period. Low levels of condom use were commonplace, with nearly two-thirds (66%) reporting that they did not use a condom regularly. In addition, over a quarter (27%) of the sample reported having sex with an HIV-infected person, 14% reported receiving drugs for Table II. Drug use: lifetime, past month, and days used in the past month (N/120). Type of drug Lifetime Past month Mean days in past month Alcohol 98% 84% 14.7 Cocaine 99% 77% 7.7 Crack cocaine 86% 73% 14.4 Marijuana 100% 84% 23.3 Amphetamines 18% 0% / Opiates 13% 3% 4.6

5 HIV-prevention for injectors in Brazil Table III. Self-reported HIV risk behaviours in the previous six months by HIV serostatus (N/120). S81 HIV Risk behaviour Total (N/120) HIV Positive (N/54) HIV Negative (N/66) P-value More that 4 female sex partners 23% 19% 27% 0.39 Any male sex partners 17% 23% 12% 0.14 No regular condom use 66% 55% 77% B/0.01 Had sex with an infected person 27% 43% 14% B/0.001 Received drugs for sex 14% 19% 11% 0.29 Paid for sex 25% 28% 23% 0.53 Injected Drugs 43% 77% 17% B/0.001 sex, and a quarter (25%) reported paying for sex in the previous six months. In terms of drug use, 43% reported injecting cocaine in the previous six months. Comparing HIV-positive participants with seronegative participants, several differences in reported risk behaviours emerged. Specifically, HIV positive participants were less likely to report inconsistent condom use (55% vs. 77%, pb/.01); were more likely to report sexual contact with an HIV-infected person (43% vs. 14%, pb/.001); and were more likely to report use of injection drugs (77% vs. 17%. pb/.001). These data demonstrate a substantial level of HIV risk behaviours and elevated perceptions of risk among the drug-involved individuals who participated in this pilot project. Among the seronegative participants, nearly two-thirds reported being very concerned about becoming infected with HIV. Finding high levels of HIV risk behaviours among drug using participants was expected, based on previous studies in Porto Alegre (Pechansky et al., 2000; Pechansky et al., 1997; Pechansky & Von Diemen, 1998; Pechansky et al., 2003). Moreover, the fact that 45% tested positive for HIV was not unexpected, given that similar rates were found in prior studies of drug users in Porto Alegre (Pechansky & Von Diemen, 1998). Importantly, however, these preliminary data indicate that it is feasible to recruit and intervene with high-risk individuals not yet infected with HIV. Developing the HIV risk-reduction intervention One of the more widely used HIV/AIDS-prevention protocols in Porto Alegre is a Brazilian adaptation of the National Institute on Drug Abuse (NIDA) Standard HIV Intervention (Inciardi et al., 1999). The current project, funded by the National Institute on Drug Abuse as a supplement to an ongoing HIV-prevention project in Delaware, modified and tailored a US-based HIV-prevention intervention for use in Brazil. Called the Porto Alegre HIV Intervention, this adaptation has three components: (1) the Brazilian version of the NIDA Standard HIV intervention; (2) the addition and discussion of structured stories ; and (3) the addition of a Thought Mapping module to encourage more thought about personal risk behaviours and mechanisms for change. The following sections describe the three parts of the intervention: (1) The Brazilian NIDA Standard Intervention; (2) Structured Stories; and (3) Thought Mapping / and how each was adapted to the setting in Porto Alegre. Part One: The NIDA HIV standard intervention The original NIDA Standard was a two session cue-card based intervention developed and modified by NIDA staff and Principal Investigators as part of the AIDS Cooperative Agreement in the early 1990s. It was later revised to incorporate more information on crack cocaine use and sexual risks for HIV (Wechsberg et al., 1997). Session 1 of the intervention

6 S82 C. G. Leukefeld et al. includes HIV pre-test counselling and gives information on: HIV disease, transmission routes, risky behaviours, indirect sharing, risks associated with crack and other cocaine use, male and female condom use, communication with sexual partners, stopping unsafe sexual practices, cleaning and bleach disinfection of injection equipment, disposal of hazardous waste material, stopping unsafe drug use, and the benefits of drug treatment. In addition, the correct use of male and female condoms and proper needle cleaning techniques are demonstrated and rehearsed. Written information about HIV, service referrals, and hygiene kits containing risk-reduction supplies are distributed, and voluntary HIV testing is offered to all participants. A second session, about two weeks later, provides and discusses the HIV test results, and provides appropriate referrals for each person who consents to testing. As noted above, an adapted version of the NIDA Standard Intervention has been produced in Portuguese and used in Rio de Janeiro and in Porto Alegre by the local group of collaborators in recent years (Inciardi et al., 1999). The translation was conducted, critiqued by a number of Brazilian health professionals, and back translated into English to evaluate fidelity. Since results in Brazil were being compared to results in US sites as part of the NIDA Cooperative Agreement, the adaptation needed to be linguistically and idiomatically appropriate to the Brazilian Portuguese speakers, but comparable in content and delivery to the NIDA Standard being used in the US sites. The NIDA Intervention is standardized in a series of cue cards, which a counsellor reviews with the participant. To illustrate the technique, Figure 1 below provides one of the cards as it appears in English and as it appears in Portuguese. In both US and Brazilian settings, the counsellor reads the content and a script elaborating on the content to ensure that literacy is not a barrier. Full What You Need to Know About Female Condoms Female condoms reduce the risk of acquiring sexually transmitted diseases and of become pregnant. Female condoms are polyurethane, bag like devices that are placed in the female genital canal to protect it from seminal fluid and blood. Female and male condoms should never be used at the same time. Each female condom can be used only once. It must be thrown away after each sex act. Preservativo feminino O preservativo feminino pode reduzir o risco de infecção com o HIV e outras doenças sexualmente transmissíveis, assim como também o risco de gravidez. O preservativo feminino é feito de um tipo de borracha e parece se com um saco de plástico que é colocado na vagina, a fim de conter o líquido ejaculado (esperma, porra) pelo homem. O preservativo feminino jamais deve ser usado ao mesmo tempo com uma camisinha. De forma semelhante ao preservativo masculino, o preservativo fe minino só deve ser usado uma única vez e deve ser jogado fora depois de cada at o sexual. Figure 1. One of the NIDA Intervention cue cards as it appears in English and as it appears in Portuguese.

7 HIV-prevention for injectors in Brazil S83 versions of the NIDA Standard in English or Portuguese are available from the authors upon request. Part Two: Structured story Structured story presentation is an additional and relatively new technique that has been incorporated into several recent HIV interventions in the US structured stories are directed and scripted narratives that target specific risk situations in order to help participants explore the connections between behavioural choices and subsequent outcomes. Interventionists use structured stories to help participants understand the relationships between specific behaviours, feelings and thoughts, and their consequences, and to consider behavioural alternatives (Leukefeld et al., 2002). In this way, structured stories allow participants to practice specific skills with behavioural rehearsals (Clark et al., 2002; Leukefeld et al., 1999a), and to explore alternative solutions to problem or risky behaviours that may facilitate contemplation or action according to the Transtheoretical Model of Change (Leukefeld et al., 1999b). Using structured stories that are similar to those of the participants, individuals are cued to think about personal situations of risk, and the structured format assists participants in evaluating their own behaviours. Structured stories reinforce participants thought and decision making processes by focusing on a specific event in context (Antecedent), relating actions to the problem (Behaviour), and exploring behavioural outcomes (Consequences). In the US, stories have been tailored for rural probationers in Kentucky and urban probationers in Wilmington, Delaware using a staged iterative process of focus groups, key informants, pre testing, and more focus groups with revisions occurring at each stage. A similar process was followed in the Porto Alegre study. Porto Alegre structured story Structured stories were developed in Porto Alegre for the project s target population / younger, male, injecting drug users and crack smokers with limited income and education. The stories are grounded in the input of local health professionals working with druginvolved individuals, as well as feedback from members of the target population in Porto Alegre. Structured stories were developed in Porto Alegre through a series of focus groups in which psychiatrists, psychologists, and social workers were asked to identify characteristics that were common to the male drug users they typically encountered. These characteristics included age, places of birth, education, family history, and drug-use history. The commonly identified characteristics were used to draft initial structured stories and efforts were made to culturally situate the stories through the use of common proper names, local place names, and local activities that were selected to increase the realism of the stories for the participants. The structured stories were then piloted with Porto Alegre drug users both individually and in focus groups. Final changes were made to the structured stories after their input. Changes typically focused on improving the realistic aspects of the story, and increasing their similarity to the stories told by focus group participants about their own experiences. The primary objective was to produce a story that participants could easily identify with, one that would cue drug users to relate their own personal situations of risk. As an example, Alex s story is presented below. Alex was born and raised in the countryside of the State of Rio Grande do Sul, but moved to a poor working class section of Porto Alegre when he was in elementary school. He never had any close friends, and after he dropped out of school he became pretty much of a loner.

8 S84 C. G. Leukefeld et al. He started smoking cigarettes at age 12, and started drinking at age 13 when he accompanied his father, an alcoholic, to the neighborhood bar. By age 14 he was snorting cocaine with some drug users from his neighbourhood. This was the first time in his life that he had people to hang out with. He also had a girlfriend, Lucia, and before long they were both injecting cocaine together. Alex and Lucia began selling drugs to support their addictions, and Lucia started sleeping around to get extra money. That upset Alex, and they broke up. A year later, he ran into her on the street, and she told him she was HIV positive. That was a wake-up call for him, so he asked his older brother, who had once been addicted to cocaine, to help him get into treatment. Since then, he has been clean, and has a pretty good job in his uncle s auto repair business. Last Friday he went out with friends from work and he ended up going to a club, and he ran into Lucia. She looked pretty good, and she gave him some crack to try. It made him feel great. After a while they left together and went to her place, and... Part Three: Thought mapping Thought mapping is the third component of the intervention, and it builds on the material provided in the first two modules. Thought mapping is a visual technique that targets personal drug using and risky sexual behaviours (Gordon, 1983). Thought mapping is grounded in Cognitive Node Mapping (Knight et al., 1994) which has been found to be effective with cocaine abusers (Joe et al., 1994), for individuals with little education (Pitre et al., 1996), with probationers in residential drug abuse treatment (Czurchry & Dansereau, 1999), and with probationers in community settings seeking to change their HIV risk behaviours (Martin et al., 2003). Thought mapping connects an individual s thoughts and feelings to a problem behavior or experience. Participant behaviors are visually recorded on paper using a pre-formatted map (Leukefeld et al., 1999b) which is useful for substance abusers (Clark et al., 2002). Thought Mapping visually charts thoughts and behaviours using this pre-formatted map, so participants can see how their behaviours and feelings are directly linked to behavioural consequences as well as subsequent thoughts and feelings (Leukefeld et al., 1999b). Mapping provides an approach to help participants relate what came before / antecedents / to high risk behaviour, as well as their own thoughts and feelings associated with high risk situations, the potential consequences of their own behaviours, and alternative behavioural responses. The technique can help participants identify a problem and consider lower risk solutions to the problem. In this way, it provides a tool participants can use to recognize problem situations, to recognize the thoughts and feelings that precede these situations, as well as the consequences that follow, and to think about alternative ways to incorporate lower risk behaviours into their repertoire / in this case to reduce their risk for HIV (Weinhardt et al., 1999). Porto Alegre thought mapping. The procedure used in Porto Alegre was very similar to that used in previous studies in the US. The thought map template (see Figure 2) was translated into Portuguese for use with participants, and project staff underwent extensive training in its use. The thought map provides a simplified visual diagram of the steps in an individual s decision-making process. The interventionist and the participants initially thought mapped one of the structured stories in order to have them become comfortable with the process before moving on to their own issues and experiences. This was followed by the mapping of the participants issues and experiences. In this process, participants were asked to link antecedents, behaviours and consequences of their own sexual and drug using behaviours, and to map these components visually together with the interventionist. The process ended

9 2. What came before the problem or experience? Thought Map HIV-prevention for injectors in Brazil My feelings What others thought What I did Leads to S85 1. What is the problem or experience? 3. What happened? Problem Consequences 4. What could I have done instead? Different Behavior Different Consequences 5. What would be different? 6. How would things be different? My feelings What others would think and do What I would do Figure 2. The thought map template. with a discussion of behavioural alternatives in which participants developed personalized action plans for subsequent behaviour change. Discussion The project s approach successfully recruited an at-risk sample of male cocaine users through contact in public health clinics in Porto Alegre. A primary objective of the pilot study was to demonstrate the feasibility of recruiting eligible participants and delivering the tailored intervention in this public health setting. The pilot study produced structured stories and used thought mapping techniques that were readily acceptable to Brazilian drug users. Preliminary data indicate that the overall project was successfully implemented. Successful implementation included not only anecdotal feedback about the overall acceptability of the intervention using thought mapping, but also the structured stories which were developed and tailored using focus groups. In addition, the project was able to address a number of implementation issues related to feasibility, which included recruiting hard-to-reach male cocaine users at high risk for AIDS, as well as integrating the project into a public health clinic and scheduling so participants could have the opportunity to volunteer and consent to participate in the project. Given the concern about HIV among crack cocaine users and powdered cocaine injectors as well as the need to develop tailored interventions, establishing the feasibility of entering participants into the project was critical. Contacting participants was facilitated by clinic staff, particularly clinic HIV-prevention staff, who realized the potential importance of introducing a tailored intervention. Clinic staff not only made the use of their crowded clinic facility available, but they also willingly described the pilot project to potential participants so the clinic users could have the opportunity to volunteer for the project. In addition, trained outreach workers who were in close contact with the public health clinic and its programmes and who are located in the many favelas (shantytowns) of Porto Alegre, were able to conduct outreach and bring possible participants to the project.

10 S86 C. G. Leukefeld et al. Support for the project was also evident in the approach used to adapt and tailor the intervention for Porto Alegre cocaine abusers, particularly in developing the reality based Structured Story for the targeted male injectors. For example, a frequently asked question was, What ever happened to Alex? and, It is just like what happened to me. Participant feedback and anecdotal information suggest that the intervention was well received by study participants. The pilot project also supports the feasibility of future projects, since study approaches were successfully modified and used during this pilot study. These procedures included approval by two Institutional Review Boards (at the University of Delaware and the Federal University of Rio Grande do Sul), implementing the protocol in a very busy intercity public health clinic, carrying out an intervention in a non-university community setting, and achieving an initial high follow-up rate of about 94%. As noted earlier, risk behaviours are higher for the HIV-positive participants than for the seronegative group, but those in the negative group still engage in many risk behaviours. The evidence suggests those yet uninfected are by no means unaffected. Their expressed concern about getting AIDS suggests the basis for a motivation to change behaviours among a very high-risk group not yet infected. Such an opportunity extends also to targeting intervention efforts at the women (and men) partners of these men. This targeting is underscored by the high rate of seropositivity (45%) among these male participants. In a related area, further information is needed to better understand the contexts in which drugs are used as well as the contexts for high-risk sexual behaviours / both separately and combined. Clearly, there is a need to develop interventions related to HIV risky behaviours, particularly prevention interventions, which are tailored to provide information for males as well as their female and other sexual partners. This pilot project is a preliminary study and necessarily has limitations. Participants were males only and were not randomly selected. Also, participants came only from one public health clinic in Porto Alegre. In terms of the data collected, the behaviours were selfreported, which can have recall limitations, both in terms or memory and in terms of participants selective editing of past recollections. And, always of concern even though participants volunteered and consented to participate, it is not known how truthful participants were about their reports of specific risky behaviours. Still, this concern is lessened by the obvious willingness of most participants to report a number of very personal and high-risk behaviours. Despite these limitations, pilot study findings support future project feasibility and represent a significant step in increasing our understanding of HIV/AIDS among indigent drug abusers in Porto Alegre, Brazil. This increased information is important since there is limited information available about drug abusers and interventions to decrease both drug use and HIV / both in Brazil in general and in Porto Alegre in particular. Future data from this project will help determine if culturally adapted interventions can most effectively change behaviours when compared, for example, to the NIDA Standard Intervention. Acknowledgements This study was supported by grant numbers R01DA11611 and R01DA11580 from the National Institute on Drug Abuse. The authors wish to acknowledge the invaluable help of Carla Machado, BA and staff of the COAS clinic who provided their support and logistics to the project.

11 HIV-prevention for injectors in Brazil S87 References Brazilian Ministry of Health (2001). Boletim epidemiologic AIDS, 14(2), April/June. Brazilian national AIDS program webpage ( table XIII-AIDS cases in the 100 cities with the largest number of notified cases, according to the year of diagnosis, 1980/2002. Clark, J., Leukefeld, C., Godlaski, T., Garrity, T., Brown, C., & Hays, L. (2002). Developing, implementing, and evaluating a treatment protocol for rural substance abusers. The Journal of Rural Health, 18, 396/406. Czurchry, M., & Dansereau, D.F. (1999). Node-link mapping and psychological problems: Perceptions of a residential drug abuse treatment program for probationers. Journal of Substance Abuse Treatment, 17, 321/329. Gordon, R.S. (1983). An operational classification of disease prevention. Public Health Reports, 98, 107/109. Inciardi, J.A., Surratt, H.L., & Pechansky, F. (1999). Redução de risco para HIV/AIDS entre usuários de drogas: Um guia para trabalhadores e aconselhadores de saúde pública. New York: University of Delaware Research Center. Joe, G.W., Dansereau, D.F., & Simpson, D.D. (1994). Nodal-link mapping for counseling cocaine users in methadone treatment. Journal of Substance Abuse Treatment, 6, 393/406. Knight, K., Simpson, D.D., & Dansereau, D.F. (1994). Knowledge mapping: A psychoeducational tool in drug abuse relapse prevention training. Journal of Offender Rehabilitation, 20, 187/205. Leukefeld, C.G., Godlaski, T., Hays, L., & Clark, J. (1999a). Developing a rural therapy with big city approaches. Substance Use and Misuse, 34, 747/762. Leukefeld, C.G., Godlaski, T., Logan, T.K., & Warner, B. (1999b). Thought mapping: HIV behavioral intervention for drug abusers. Conference Proceedings: HIV Prevention in Rural Communities, Indianapolis, IN, Leukefeld, C.G., Goldlaski, T., Clark, J., Brown, C., & Hays, L. (2002). Structured stories: Reinforcing social skills in rural substance abuse treatment. Health & Social Work, 27, 213/217. Martin, S.S., O Connell, D.J., Inciardi, J.A., Surratt, H.L., & Beard, R.A. (2003). HIV/AIDS among probationers: An assessment of risk and results from a brief intervention. Journal of Psychoactive Drugs, 35, 435/442. Pechansky, F., Inciardi, J.A., Surratt, H.L., Lima, A.F.B.S., Kessler, F.P., Soibelman, M., & Hirakata, V. (2000). Estudo sobre as characterísticas de usuários de drogas injetáveis que buscam atendimento em Porto Alegre, RS (a study on the characteristics of intravenous drug users who seek treatment in the city of Porto Alegre, Brazil). Revista Brasileira de Psiquiatria, 22, 164/171. Pechansky, F., Metzger, D., & Hirakata, V. (2002). Adaptation and validation of a questionnaire about risk behaviors for AIDS among drug users. Revista Brasileira de Psiquiatria, 24, 130/136. Pechansky, F., Soibelman, M., & Kohlrausch, E. (1997). Assessment of risk situations for HIV transmission among drug abusers in Porto Alegre, Brazil. Journal of Drug Issues, 27, 147/154. Pechansky, F., & Von Diemen, L. (1998). Homens and mulheres usuarios de drugas: Semelancas e diferancas na exposicao ao virus HIV em Porto Alegre. Alcool e Drogas Revista de ABEAD, 1&2, 15/25. Pechansky, F., Von Diemen, L., Kessler, F., Hirakata, V., Metzger, D., & Woody, G.E. (2003). Preliminary estimates of human immunodeficiency virus prevalence incidence among cocaine abusers in Porto Alegre, Brazil. Journal of Urban Health: Bulletin of the New York Academy of Medicine, 30, 115/126. Pitre, U., Dansereau, D.F., & Joe, G.W. (1996). Client education levels and the effectiveness of node/link maps. Journal of Addictive Diseases, 15, 27/44. Porto Alegre Municipal Secretary of Health (2004). AIDS surveillance, 1983/ July. Wechsberg, W.M., Macdonald, B.R., Dennis, M.L., Inciardi, J.A., Surratt, H.L., Leukefeld, C.G., Farabee, D., Cotller, L.B., Compton, W.M., Hoffman, J., Klein, H., Desmond, D., & Zule, B. (1997). The standard intervention for reduction in HIV risk behavior: Protocol changes suggested by the continuing HIV/AIDS epidemic. Bloomington, IL: Chestnut Health Systems. Weinhardt, L.S., Carey, M.P., Johnson, B.T., & Bickham, N.L. (1999). Effects of HIV counseling and testing on sexual risk behavior: A meta-analytic review of published research, 1985/1997. American Journal of Public Health, 89, 1397/1405.

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