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THE BRAZILIAN CASE STUDY (City of Sao Paulo Harm
Reduction Project)
REGINA BUENO Psychologist, Member of the Sao
Paulo State Council on Drugs and Director of the
Harm Reduction Project of the City of Sao Paulo
Health Department (PRD Sampa)
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Sao Paulo is the biggest City of Brazil with
around 11 million inhabitants.
For political reasons, local authorities did not
implemented some of the national directions for
the public health system in Brazil from 1992 to
2000.
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• New Constitution was established in 1988
• Unified public health system (SUS) defined in
• 1990 by law
• Principles
• Universal Access
• Decentralization
• Integrality
• Community Participation

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• Universal access to care, medication as well as
  means of prevention
• Decentralization with the Municipality being the
  key actor in the process of providing public
  health responses
• Integrality including attention, care and
  prevention
• Community Participation with an open door for
  partnerships with NGOs, Community Based
  Organizations, Universities and Private
  Companies.

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The Brazilian Drug Policy is controversial.
It follows mostly the American war on drugs
style, however it is opened for alternative
solutions such as Harm Reduction as one of the
officials national policy.
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In 2001 we received the responsibility of the
direction of the STD/AIDS Program of the City of
Sao Paulo. The City had at that time, 22 of the
total AIDS cases in Brazil. From them
(approximately 47.000 AIDS cases), 20 were
Injecting Drug Users. Among the proposed
prevention strategy one of them was the
organization of the local Harm Reduction Project,
named PRD Sampa (PRD Sampa)
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Most of the HRP in Brazil (nowadays around 120 in
the country) started from to community to the
service. The PRD Sampa instead, started into
the public health services and latter on, went to
the community.
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We (as a activist group) were in the introduction
of the Harm Reduction concept in Brazil since
1989, in the City of Santos, when first needle
and syringes exchange was proposed in Brazil to
control de spread of HIV among and from IDUs.
At least three persons of our current group of
work are in the field of HR since them.
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Even with such previous experience, we were
scared by the new responsibility to implement a
response broader enough for a City of 11 million
inhabitants. When we first came to Sao Paulo, the
City had already organized 19 STD/AIDS services
with many structural problems because of its
political situation. The majority of these
services were built during the year of 1996. Most
of them used to treat AIDS but none were used to
deal with injecting drug users and never before
had any HRP.
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• Our first goal was the training of the health
  professionals.
• We conducted 96 training courses enrolling around
  700 health professionals from the front door
  people to the doctor of every health center
  specialized in STD/AIDS in the City.
• Weve learned a lot from this process.

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Even in services that were used to deal with Sex
workers, transgender, gays and other specific
populations with HIV and AIDS they did not
recognized into their clients the injecting or
even no injecting drug user population. Even in
contradiction with the data information generated
by them, they were used to say that there were no
drug users any more among their clients.
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• The resistance was associated to misconceptions
  and prejudice against drug users that included
• fear of their aggressive behavior
• fear of drug dealers
• fear of violence
• fear of problems with the Police
• miscomprehension that the distribution of the
  safe kit for prevention could be an incentive for
  the use of drugs
• Many fantasies based on the common sense !

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• We started by the concept that a HRP is not only
  for distribution of clean needles
• We insisted that the key point was to transform
  the public health services suitable for this
  special segment of the population
• Activities offered should included
• prenatal and health attention for females drug
  users
• vaccination for hepatitis B for all of them
• diagnosis and care based on syndromes for STD
• referral for drug treatment under request of the
  client
• antiretroviral therapy when it is the case
• diagnosis and treatment for hepatitis C

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We supported supervision after the training
(still ongoing process) trying to overcome their
prejudice and really open the doors of the
services for their current drug users as well as
for new ones. It was interesting that they almost
started to visualize drug users that were already
their clients but never before were identified as
so. This change in health professionals attitude
promoted a strong attraction for new clients as
well.
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We also scientifically supported the answers to
the doubts of the physicians related to drug
interaction, demonstrating that there is no
interaction among Antiretroviral therapy and the
use of marijuana, alcohol and or cocaine (the
most popular illegal drug in Brazil). This was
crucial to avoid the common sense that to go
through ARV therapy they should quit the use of
illicit drugs.
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Based on the broader perspective of the project,
the intense debate around the matter and the
crucial visibility of the IDU afterwards, the
human rights perspective started to be a key
perspective of the project.  
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• In June of 2002
• we trained 80 outreach workers
• we hired 23 of them in the municipality
• 5 NGO hired some other
• This decision improved strongly the services
  provided to drug users in the City.

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Of course the velocity of the development is not
the same everywhere and depends on the direction
of the services, the quality of the health
professionals (including commitment with the
cause) and the quality of the outreach workers
recruited. We can say that most of the 19
specialized services in the City are doping quite
well, considering this is a very recent
initiative in Sao Paulo.
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• Our future challenges are
• to improve the quality of the services to make
  them more suitable to drug users
• keep the supervision to the health professionals
• improve the number of outreach workers
• give some special attention for females drug
  users
• In any case we fell as a successful intervention
  so far !

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THANKS