Faculty Bibliography

AIMS/OBJECTIVE:To describe AIDS and malaria geography in Brazil, highlighting the role of injecting drug users (IDUs) in malaria outbreaks occurring in malaria-free regions, and the potential clinical and public health implications of malaria/HIV co-infection. DESIGN/METHODS:Review of the available literature and original analyses using geoprocessing and spatial analysis techniques. FINDINGS/RESULTS:Both HIV/AIDS and malaria distribution are currently undergoing profound changes in Brazil, with mutual expansion to intersecting geographical regions and social networks. Very recent reports describe the first clinical case of AIDS in a remote Amazonian ethnic group, as well as malaria cases in Rio de Janeiro state (hitherto a malaria-free area for 20 years); in addition, two outbreaks of both infections occurred at the beginning of the 1990s in the most industrialized Brazilian state (São Paulo), due to the sharing of needles and syringes by drug users. Spatial data point to: (a) the expansion of HIV/AIDS towards malarigenic areas located in the centre-west and north of Brazil, along the main cocaine trafficking routes, with IDU networks apparently playing a core role; and (b) the possibility of new outbreaks of secondary malaria in urban settings where HIV/AIDS is still expanding, through the sharing of needles and syringes. CONCLUSIONS:New outbreaks of cases of HIV and malaria are likely to occur among Brazilian IDUs, and might conceivably contribute to the development of treatment-resistant strains of malaria in this population. Health professionals should be alert to this possibility, which could also eventually occur in IDU networks in developed countries.

Drug injectors have simultaneously faced a devastating HIV I AIDS epidemic and an intense program of government repression and media demonization known as the "War on Drugs." We address patterns of association (networks) among drug injectors; how these networks shape their norms toward condom use and safer sex; the extent to which drug injectors take it upon themselves to promulgate safer sex norms to others; and, on a different level of analysis, the extent to which drug injectors have created organizations to reduce HIV transmission and to deal with other problems. Data from 767 street-recruited Brooklyn drug injectors indicate that about half of their drug- injector network ties, and of their sexual network ties, have lasted for at least five years; perceived peer norms supportive of condom use are widespread; almost half had told others (in the last month) that they should use condoms, and this was particularly likely among those in an ethnographically defined core group; consistent condom use with non-drug-injectors is reported for 44 percent of such relationships, and is most likely if the drug injector is HIV-infected, if the relationship is not *very close," if peer norms support condom use and among those without network ties to the ethnographic core group. Observational and historical research on drug users' organizations is used to describe the activities of "users' groups" around the world. In spite of the pressures they have been under, drug users' organizations exist in many cities and are active in anti-HIV efforts. Thus, norms and networks affect risk networks; and norms themselves vary by social network location and by social role. In spite of being subjected to intense repression and stigma, drug users have acted to shape their own culture, to protect themselves and others against HIV/AIDS and, to some extent, have engaged in collective action through formal organizations. The possibility of dialectic response seems to extend even to the most oppressed, dependent and stigmatized members of humanity.