Falck R, Wang J, Siegal H, Carlson R. (2000) Longitudinal application of the Medical Outcomes Study 36-item short form health survey with not-in-treatment crack-cocaine users. Medical Care, 39(9):902-910.
In the past year, the Brazilian Federal Government and society have reported and acted on a crack use epidemic, which has been exacerbated by the media. This study hypothesized that crack use has not increased at the rate suggested by the Brazilian media. A cross-sectional survey was carried out in 2010 usinga multistage probabilistic representative sample of Brazilian middle and high school students in the country's 27 state capitals. A total of 50,890 valid questionnaires were weighted, analyzed and results compared to the 2004 national school survey dataset. Considering lifetime and past year crack use, no change in consumption was found between 2004 and 2010. Official data in Brazil on middle and high school students does not support the assertion of a crack epidemic widely publicized by the media. Government measures to treat and prevent crack use are encouraged; however, the term epidemic has been inappropriately used to represent the static prevalence of crack consumption among students.
Crack Carlson Survey 2012
To evaluate the validity of massive public mobilization related to a possible uncontrolled increase in crack use in Brazil, we used the 2010 national survey of middle and high school students from the 27 Brazilian state capitals, since it provides the most recent national epidemiological data available in Brazil. We hypothesized that the use of crack has not increased at the rate suggested by the media.
To evaluate the statistical significance of differences in prevalence at two points in time (2004 and 2010), we used the 2004 Brazilian National Middle and High School Survey dataset provided by the authors 17. The Fifth National Survey, carried out in 2004, was the first to include a question about crack use. This survey and the Sixth National Survey, carried out in 2010 used the same instruments, sample design and data collection methods. Since private schools were included for the first time in the 2010 survey, changes in prevalence in time were evaluated using only the data for public schools.
Regarding rates of lifetime and past year drug use among youth, no statistically significant difference was found between the 2004 and 2010 surveys using the Cochran-Armitage test. In 2004, of a total sample of 48,155 youth, 341 reported lifetime use of crack (0.7%, considering sample weighting) and 203 students reported past year use (0.4%, considering sample weighting). In 2010, 227 public school students reported lifetime crack use (0.7%; 95%CI: 0.6%-0.8%) and 140 students reported using crack in the past year (0.4%; 95%CI: 0.3%-0.5%). The analysis of differences in prevalence overtime (2004 to 2010) resulted in a p-value of 0.932 for lifetime use and a p-value of 0.876 for past year use. This data is not shown in the table.
The exact prevalence of crack use in Brazil remains unknown. Media reports have disseminated WHO estimates of six million crack users in the country, while the Ministry of Health says there are two million 22. However, epidemiological data does not confirm such growth, at least among the middle and high school student population. A comparison of the two national surveys showed no difference in lifetime and past year use of crack between 2004 and 2010. Additionally, crack occupies the penultimate place in the ranking of the 12 most commonly used drugs. Studies with college students show a similar phenomenon 23, where crack is ranked fourteenth among the 16 most commonly used drugs and the prevalence of recent crack use did not change between 1996 and 2009 surveys.
In a similar study, Orcutt & Turner 35 evaluated data from the North-American media during the period of the "crack epidemic". They found that there was an intentional distortion of data from National surveys on drug use among students and small differences in drug consumption from one year to the nextwere over emphasized in graphs.
Nevertheless, based onthe epidemiological data analyzed by this study and given the CDC definition presented above 18, the crack situation in Brazil does not fit the concept of epidemic. Lifetime crack use did not increase in the two surveys analyzed, supporting the hypothesis that the crack epidemic does not exist. On the other hand, it is difficult to extrapolate this finding to the general population, since crack use is likely to affect the frequency of school attendance 1. However, assuming that there is a true epidemic, lifetime prevalence in this population would be affected 37.
One of a number of potential limitations of this study is that the use of survey data from high school students that may not reflect the overall impact of crack use on Brazilian society. Another limitation of a student survey is that it is not possible to extrapolate these findings to those students who were absent at the day of the survey or to adolescents who are not attending schools in Brazil. It is important to note that around one fifth of the students were absent on the day of the survey and these students are the ones that are most likely to be using crack as discussed above. However, the high response rate for the samples may be considered a significant advantage of this study, since almost all invited students agreed to participate.
Project Encuentro consisted of four components designed to increase HIV testing and reduce sexual risk behaviors among crack users: rapid HIV testing in community sites; community events; social network HIV testing; and small peer-led group interventions for crack users. Intervention components were introduced sequentially and, once introduced, were continued until the end of the project. (See Fig. 1 for a timeline of intervention components and assessments.) The duration of Project Encuentro with the introduction of the four components was 42 months. The cumulative effects of intervention exposure on self-reported sexual risk behaviors was evaluated by seven cross-sectional surveys of crack users recruited through respondent-driven sampling. All seven cross-sectional surveys were identical and included the same measures. Results of these analyses were reported elsewhere [20]. The present study reports on the addition of the small group intervention (the last Encuentro component to be introduced) on monthly testing rates. Participants who either self-referred for an HIV test or came in with a referral coupon received from a peer took a small risk survey, and, if eligible, received coupons and instructions to recruit up to three peers for an HIV test. All participants who received any intervention components, i.e. an HIV test, participated in small group interventions, or participated in a survey, provided their written informed consent.
Taking an HIV test may also result in testers reducing their sexual risk behaviors. The present study also used cross-sectional surveys of crack users recruited through respondent driven sampling to assess the effects of Encuentro components on HIV risk among crack users in the community. Participants did not have to participate in any intervention components as surveys were designed to discover the reach of the intervention into the community and community-level effects of the intervention on HIV risk. Participants who reported taking an HIV test in a community location or receiving a coupon and taking an HIV test (i.e. participating in the Social Network HIV testing intervention), as well as those who reported exposure to more than one Encuentro component, also reported reductions in condomless sex compared to those who received no intervention. However, the small group intervention did not reduce sexual risk behaviors on its own if participants did not also engage in HIV testing. Thus, small group interventions may work best by reinforcing the importance of HIV testing among a high-risk group of crack users which, in turn, may reduce sexual risk behaviors. 2ff7e9595c
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