Short Communication CHANGING PATTERNS OF COCAINE USE AND HIV RISKS IN THE SOUTH OE BRAZIL^ James A. Inciardi, Ph.D.* Hilary L. Surratt, Ph.D.** Flavio Pechansky, M.D., Ph.D.* Felix Kessler, M.D., M.Sc.*** , Lisia von Diemen, M.D.**** Eiisabeth Meyer da Siiva, B.A., M.Sc. Steven S. Martin, M.Sc, M.A.***** Abstract—For well over a decade, researchers in Porto Alegre, Brazil, have been documenting the extent of the AIDS epidemic in the region, with a specific focus on the linkages between drug use and HIV seropositivity. Virtually all of the studies conducted during those years found injection drug use (IDU) to be the major vector for HIV seropositivity in this population. However, recent research found that the number of IDUs had declined significantly. Qualitative interviews and focus groups suggested many reasons for this decline: (1) many had died, because they had never heard of AIDS or HIV, and were unaware of how HIV is transmitted. As a result, they had become infected through the sharing of injection para- phernalia. (2) The quality of street cocaine had declined, mak- ing injection difficult. (3) Because of a fear of AIDS, some shifted to the smoking of crack, which had become a newly availability commodity in the street culture. Within this con- text, this article describes the qualitative data describing the decline of cocaine injecting and the corresponding emergence of crack use in Porto Alegre, Brazil, and related HIV risks. Keywords—Brazil, crack, cocaine, drug users, HIV, injec- tion Through June of 2005, Brazil had reported almost .372,000 documented cases of AIDS to the World Health Organization (Brazilian Ministry of Health 2005). As such, Brazil had the second largest number of known AIDS cases in the Americas, surpassed only by the United States. In addition to these confirmed cases of AIDS, UNAIDS esti- mates that there are some 620,000 persons currently living with HIV infection in Brazil, with the majority located in the heavily populated southeastern part of the country (UNAIDS 2006). In the months since then, it is likely that many thousands more have become infected with HIV. The initial cases of AIDS in Brazil were identified in 1982 in the states of Rio de Janeiro and Sao Paulo, where one and four cases were recorded, respectively (Rodrigues & Chequer 1989). In 1983,31 more cases were recognized, with notable increases in subsequent years. By the 1990s, the annual incidence rates per hundred thousand popula- tion had increased significantly, from 10.6 in 1992, to 11.8 in 1993, to 17.5 by 1998, to a peak of 19.2 in 2003 (Brazil- ian Ministry of Health 2005). The highest concentrations of AIDS cases have oc- curred in the southeastem and southern regions of the country, in the cities of Sao Paulo (19.3%), Rio de Janeiro (9.5%), and Porto Alegre (3.6%), with the majority among persons in the 25- to 40-year-old age group (Brazilian Min- istry of Health 2003). Sexual transmission accounts for the overwhelming majority of cases, followed by injection drug use (IDU), other/unknown causes, receipt of contaminated blood products, and perinatal transmission. The actual num- ber of AIDS cases in Brazil is no doubt grossly underestimated, given diagnostic deficiencies and the pre- vailing social climate which reflects a generalized (and sometimes quite specific) discrimination against people with AIDS (UNAIDS 2004; Inciardi, Surratt & Telles 2000; Parker 1999; Daniel & Parker 1993; Quinn, Narain & Zacarais 1990). In Brazil as a whole, some 51,000 cases of AIDS have been attributed exclusively to injection drug use since the beginning of the epidemic. Each year in Brazil, approxi- mately 3,000 new AIDS cases are diagnosed in which injection drug use is identified as the primary exposure category. The cities with the highest AIDS incidence rates in Brazil have large populations of injection drug users. Incidence rates in these municipalities at the end of 2002 tThis research was supported, in part, by HHS grant ROIDA11611 from the National Institute on Drug Abuse. *Professor and Director, Center for Drug and Alcohol Studies, University of Delaware, Coral Gables, FL; Center for Drug and Alcohol Research, Federal University of Rio Grande do Sul, Brazil. • • Scientist , Center for Drug and Alcohol Studies, University of Delaware, Coral Gables, FL; Center for Drug and Alcohol Research, Federal University of Rio Grande do Sul, Brazil. • • • Associat e Director, Center for Drug and Alcohol Research, Federal University of Rio Grande do Sul, Brazil. • • • • Dat a Manager, Center for Drug and Alcohol Research, Federal University of Rio Grande do Sul, Brazil. • • • • • Senio r Scientist and Associate Director, Center for Drug and Alcohol Studies, University of Delaware, Coral Gables, FL. Please address correspondence and reprint requests to James A. Inciardi. Ph.D., University of Delaware Research Center, 2100 Ponce de Leon Boulevard, Suite 1180, Coral Gables, FL 33134. Journal of Psychoactive Drugs 305 Volume 38 (3), September 2006