SUPPLEMENT ARTICLE

Drug Use, Harm Reduction, and Health Policies

in Argentina: Obstacles and New Perspectives
Silvia Inchaurraga
Drug Abuse and AIDS Advanced Studies Center of the Universidad Nacional de Rosario, Rosario, and Argentinean Harm Reduction Association,
Buenos Aires, Argentina; and Latin American Harm Reduction Network

High human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) incidence among

injection drug users (IDUs) shows the failure of traditional health policies. The preference of IDUs for injected
cocaine exposes them to high risks for contracting HIV because of the frequency of drug use. The correlation
of poverty with the selling of drugs, especially the so-called “drugs of poverty”—freebase cocaine and crack—
is a consequence of prohibitions against drug use and of urban unemployment. In Argentina, “zero-tolerance”
approaches and punishment for personal drug use tend to exclude IDUs from the country’s health care system.
A historical perspective is presented regarding approaches to the prevention of HIV/AIDS and harm reduction
in Latin America and Argentina, where, despite isolated efforts, IDUs had no free access to sterile needles
until the end of the 1990s. We present the impact of programs and campaigns of the Argentinean Harm
Reduction Association, showing how and why, even with obstacles, harm reduction is possible and necessary.

BACKGROUND
High HIV/AIDS incidence among injection drug users
(IDUs) and health problems among drug users (DUs)
in general show the failure of traditional public policies
in Argentina. Prevalence rates of HIV/AIDS are high
among IDUs. Studies show that, in Rosario, ∼65% of
IDUs are infected with HIV/AIDS [1] and that 57% of
IDUs in Buenos Aires are infected [2]. Sharing infected
needles and other injecting equipment is a very efficient
way to transmit HIV directly into the bloodstream. Be-
cause of the rapid diffusion of HIV among IDUs, the
epidemic has grown more rapidly among IDUs than in
any other group. The need for HIV prevention among
IDUs is obvious.
The preference of IDUs for cocaine as their injection
drug of choice exposes them to a high risk of acquiring
HIV/AIDS because of the frequency of use associated
with cocaine [3]. Data of the World Health Organi-
zation multicenter study on injection drug use in Ar-
Reprints or correspondence: Dr. Silvia Inchaurraga, Juan Manuel de Rosas, 1058
(2000) Rosario, Argentina (sinchaur@sede.unr.edu.ar).
Clinical Infectious Diseases 2003; 37(Suppl 5):S366–71
 2003 by the Infectious Diseases Society of America. All rights reserved.
1058-4838/2003/3712S5-0008$15.00
gentina shows that cocaine IDUs can inject the drug
up to 30 times daily [4]. New risk-behaviors associated
with cocaine use are the injection of nonconventional
drugs, such as deodorants, and of synthetic drugs. The
correlation of injection drug use with poverty, including
the selling of drugs, may mean that selling drugs can
support personal use, but also the income of a disad-
vantaged family. The expanded drug enforcement effort
and the black market seem to be related to conse-
quences of poverty and marginalization. The devel-
opment of the so-called “drugs of poverty,” freebase
cocaine and crack, is associated with prohibitions
against drug use and with urban unemployment.
In Argentina, as in most Latin American countries,
there is not a tradition of tracking facts related to drug
abuse or of conducting an epidemiological study on
drugs. Valid and systematic data on the extent and na-
ture of illicit drug abuse are still rare, and there are
only isolated records and studies, which usually cannot
be effectively compared. The lack of valid data makes
it difficult to plan and to evaluate interventions [5].
The process of introducing harm-reduction polices
in Latin America has been erratic because of strong
opposition from conservative forces and prejudice

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 against most of the core components of harm-reduction pol-
icies, such as condom distribution [6].
“Zero-tolerance” approaches and drug control laws have shut
DUs out of the health system in Argentina [7]. Most of the
drug-related criminal procedures in Argentina are related to
possession of drugs for personal use, and those found guilty
are punished under Article 14 of Drug Law 23.737. Because
drug use is against Argentinean laws, DUs and IDUs are ex-
posed to many health and social risks.
Argentina has one of the highest rates of HIV incidence
among IDUs in Latin America. In Argentina, IDUs represent
the key problem related to the AIDS epidemic. Official epi-
demiological data show that almost 40% of all AIDS cases in
Argentina are associated with injection drug use [8]. However,
little comprehensive or solid scientific data exist on the extent
or specifics of the problem of drug use and IDUs, and only a
few interventions—but almost no state policy—have been put
into practice in recent years to reduce the enormous social
harm and the costs associated with this phenomenon.
METHODS
There is extensive documentation of the effectiveness of HIV/
AIDS prevention interventions among DUs and IDUs in the
developed world but very limited information on interventions
in developing and transitional countries, especially in Latin
America. This issue has been pointed out by several authors [9].
Although there are many information gaps, recent efforts to
implement harm reduction and HIV/AIDS prevention pro-
grams among DUs in Argentina reveal an emerging picture of
problems and responses. In Argentina, despite isolated efforts
developed in Rosario City in the early 1990s, IDUs did not
have free access to needle exchange [10]. Obstacles and objec-
tions are based on moral issues, disregarding scientific evidence.
Interventions. Intervention can be understood as any ac-
tion that is taken to help reduce the adverse consequences of
drug use and the practice of injecting drugs. Included is in-
tervention at the individual, community, policy, and environ-
mental levels. Intervention may be in the areas of prevention,
health promotion, treatment, and policy responses [11]. This
article focuses on interventions in Argentina that aim to prevent
HIV/AIDS and other bloodborne diseases among the DU and
IDU populations. In Argentina, most of the interventions aimed
at prevention of HIV/AIDS are directed to sexual transmission,
and the majority of those related to drug use focus on absti-
nence-based interventions, in which HIV/AIDS prevention is
synonymous with prevention of drug use and abstinence from
drugs.
Public drug policies in Latin America focus on drugs, es-
pecially on the control of supply and demand. All Latin Amer-
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ican countries have a national drug control agency, whose main
aim is coordinating efforts to control illicit drug use.
Regarding health policies, abstinence-based treatment inter-
ventions, most of them through therapeutic communities, are
the rule. But even for the world’s best services, the recovery level
of licit and illicit DUs in abstinence-based programs is only 30%
[12]. Available evidence supports the conclusion that ∼80% of
DUs do not accept therapeutic treatment, and half of the at-
tending population wants to continue with their use [13].
Behavioral changes by IDUs regarding risks is possible
through public health approaches [14], controlling the AIDS
epidemic through the public health measures of easy treatment
access and harm reduction interventions.
Programs based on harm reduction were begun in the 1990s
in Latin America by the Civil Society, including universities and
nongovernmental organizations. The University of Rio de Ja-
neiro, the University of Bahia (Drug Abuse and Alcohol Studies
Center [CETAD]), Drug Abuse and AIDS Advanced Studies
Center of the University of Rosario (CEADS-UNR), and non-
governmental organizations Instituto de Estudos e Pesquisa de
AIDS de Santos, Fundacion Oswaldo Cruz, and Intercambios
are the main references. With the advent of HIV/AIDS in the
Southern Cone region of South America in the last decade, few
interventions have been developed related to harm reduction.
In 1995, San Salvador de Bahia developed the first needle
exchange program in Latin America, and its example was fol-
lowed by other Brazilian cities. In 1998, the first Latin American
pilot substitution program, which used buprenorphine to re-
place opiates, was established in Rosario City, in Argentina [15].
The fight for a harm reduction strategy targeted to IDUs
within the framework of public health polices began after 1992
in Brazil and after 2000 in Argentina, when the government
obtained financial and technical support from the World Bank
for AIDS prevention, with a priority on IDUs and their sex
partners [16].
In this connection, in Argentina, the Ministry of Health sup-
ports 3 communication campaigns targeted at IDUs (2 non-
governmental organizations and the Argentinean Harm Re-
duction Association [ARDA]) and 10 programs for HIV
prevention directed at DUs [17].
Several HIV prevention programs that include HIV testing,
pretest and posttest counseling, and instruction in condom use
are also being implemented; however, interventions related to
instruction on the effects of drugs and instruction on disin-
fecting injection equipment and disposing of materials are sel-
dom available.
Outreach programs. Outreach programs that provide HIV
prevention information—and sometimes condoms—for DUs
are being implemented in Argentina. Recently, ARDA began
an AIDS prevention and harm reduction campaign in Argen-
tina, targeted to youth at rock concerts, which used realistic
 materials in the language of youth. The materials include in-
formation about the risks of combining drugs, ways of ad-
ministering drugs, problems with the police, and emergency
situations. In the most recent intervention, 20,000 youth re-
ceived information and condoms [18]. There is also a harm
reduction program for youth at “rave” parties that utilizes in-
novative techniques such as in situ pill testing. Studies based
on the rapid assessment and response methodology have been
shown to be useful among hard-to-reach populations of IDUs
in Argentina [3]. The collaboration of DUs, serving as outreach
workers, was also a part of these interventions.
Peer education and social network interventions. Na-
tional harm-reduction associations have been created in Ar-
gentina, as well as in Brazil, Bolivia, and, recently, Uruguay and
Chile. For example, self-organizing movements related to co-
operative-based interventions involve local and national DU
organizations. Since its creation in 1998, RELARD, the Latin
American Harm Reduction Network, has played an increasing
role in supporting harm-reduction policies and practices in the
region [19].
IDUs, working as peer educators or health agents, have been
shown to be key elements in accessing hard-to-reach IDUs,
especially in marginal areas and other locations where drug use
takes place close to drug-selling settings. This have been shown
through the development of DUs’ organizations in Latin Amer-
ica, such as RADDUD, Argentinean Network on Defense of
Drug Users’ Rights, born in 2000.
The importance of the involvement of DUs and IDUs in
prevention interventions has been reported by several Latin
American organizations. Few of these organizations have been
oriented to young DUs, unlike the programs of CEADS-UNR
in Argentina, in which young DUs between 15 and 20 years of
age have been involved as outreach workers [20].
Based on preliminary reports about drug use in marginally
poor sectors, such as slums, the national campaign “If you do
it, do it well” was begun at the end of 2001 for the cities of
Buenos Aires, Rosario, and Cordoba, by ARDA, with support
from the Project to Fight against AIDS and Other Sexually
Transmitted Diseases (LUSIDA). Interventions were based on
peer education, outreach, and harm-reduction strategies, and
were targeted to the use of crack and freebase cocaine, as well
as to the combined use of alcohol and cocaine. In the inter-
vention, information about the drug law and the risks related
to the enforcement of the law, corruption, and social problems
played a key role [21].
Cleaning injection equipment. Bleach distribution pro-
grams and education programs about how to disinfect injection
equipment have been developed in Argentina. This intervention
has been shown to be an effective method for avoiding the
social, political, and economic difficulties of distributing or
exchanging syringes [22]. Adequate interventions in countries
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in which needle and syringe distribution and exchange is re-
stricted [23] show, not only that a supportive policy environ-
ment is necessary, but also that there are alternatives to reduce
the risks related to equipment sharing and reuse. For example,
there is a current innovative approach to promote harm re-
duction in prisons through workshops that teach how to dis-
infect needles used in injection drug use and tattooing [24].
Provision of sterile injection equipment. Needle distri-
bution and exchange in Latin America began in Brazil in 1995.
In Argentina, distribution began in 1999–2000 in Rosario and
Buenos Aires City. The first Argentinean injection kit, with the
support of the Ministry of Health, was developed by the Na-
tional University of Rosario in 2000 [25].
Drug treatments. In Argentina, the therapeutic infrastruc-
ture is poor. Most of the drug treatment centers are therapeutic
communities and religious-oriented programs that make no
provision for HIV risk-management if relapse occurs. Adequate
provision of drug abuse treatment programs can have an im-
portant effect on limiting the spread of HIV/AIDS [26] and
appears to be an urgent priority in Argentina.
With regard to what is known as the “low-threshold assis-
tance model” (an assistance-based model in which abstinence
of drugs is not the goal), some IDUs could be prepared to enter
into drug treatment but not prepared to stop injecting or using
drugs. Drug treatment centers in Argentina seldom use this
strategy. However, in a public mental hospital in Argentina, a
friendly and psychoanalytical approach has been associated with
harm-reduction workshops and with the substitution of bu-
prenorphine for illicit drugs since 1994 [27].
Opiate substitution in Argentina has only been used in a
public health hospital in Rosario City. Substitution with bu-
prenorphine began in a pilot program in 1998 [28]. Another
pilot project of substitution of methadone had been conceived
[29]. The Argentinian experience with opiate substitution pro-
grams is concordant with the international experience with
similar programs, showing that the contact of IDUs with the
health system, plus the medical administration of drugs, helped
modify risk behaviors. Substitution treatments for opiate users
have shown that such treatments are appropriate and feasible
in the context of polydrug use and that they constitute a good
strategy for contact with difficult-to-reach cocaine users.
In regard to access to treatment, the key strategies are avail-
ability of HIV testing and of systematic diagnosis, treatment of
sexual diseases, and free access to HAART, which is available
in Argentina.
Rosario as a case study of best practice. Rosario is the
second most important city in Argentina, located in the south
of the province of Santa Fe. It has almost 1 million inhabitants
living in a metropolitan area of nearly 200 km2. More than half
of the HIV cases in Rosario are related to the sharing of in-
jection equipment. Research to assess the IDU situation and
 its consequences using the rapid assessment and response meth-
odology, which was proposed by the World Health Organiza-
tion, showed that 91% of IDUs in Rosario had not accessed
any health service for treatment of their addiction, 70% shared
or reused injection equipment, and 65% were HIV-positive [3].
Since the early 1990s, CEADS-UNR has been working hard
within the official abstinence-based context of a “war on drugs”
to reduce drug-related harm in Rosario City. CEADS decided
to implement a harm-reduction program with interventions in
several locations where open drug use, prostitution, and other
risky behaviors were common. Since this effort began, in 1993
and 1994, the program has included outreach activities such
as use of a low-threshold assistance model in a public mental
health hospital and harm-reduction workshops about needle
disinfection. Since 1998, the program has used opiate substi-
tution with buprenorphine and has implemented a needle dis-
tribution policy. This harm-reduction program received the
endorsement of the Regional Ministry of Justice, which in 1999
signed a resolution declaring that harm reduction and the pro-
gram were officially approved. Since 2000, with the support of
the National Ministry of Health and LUSIDA and with funds
from the World Bank, the program has used innovative ap-
proaches to contact DUs via a harm-reduction bus. This bus
travels to urban locations where open drug use or drug selling
is common, including marginal areas, parks, and centers of
night life, delivering pragmatic information about drugs, dis-
pensing condoms, and distributing pamphlets promoting the
program and its services. New harm-reduction materials, en-
titled “How to Use Cocaine, Pills, and Ecstasy with Less Risks”
and “Any Way You Do It,” are being distributed. Peer education
by IDUs and educational materials created by IDUs in the form
of comics that use language characteristic of DUs are key el-
ements of the intervention.
The front pages of prominent national newspapers have pro-
claimed that the first program with official support that uses
injection kits began in Rosario [30–32]. The injection equip-
ment is part of a kit called “La Cajita,” which includes 2 sy-
ringes, a sterile container, needles, 2 alcohol wipes, 2 ampules
of sterile water, 2 condoms, and information about the kit’s
contents and how to use them. The kit is accompanied by an
injection handbook, the first in Spanish in Latin America. This
material, developed by CEADS-UNR with the collaboration of
ARDA, informs IDUs about safe injection and how to avoid
HIV/AIDS, hepatitis, abscess, and overdoses, and it contains
specific information about injecting cocaine, the use of con-
doms, what to do in case of emergency, and the emergency
and assistance services in the city. This new handbook, made
for and by IDUs, promotes the message “If you are going to
use drugs, do it with fewer risks and harms.” The impact of
the program could modify the perception that valid interven-
tions should be abstinence-based, especially because the Re-
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gional Ministry of Health signed an agreement with CEADS-
UNR to replicate the program throughout the province.
This initiative was selected by RELARD as a best-practice
case because of its emphasis on the low-threshold model in the
public mental hospital, its offering of assistance and counseling
in a friendly manner, and its training of DUs to develop their
own harm-reduction campaigns in the community, including
involving them in the distribution of condoms and pamphlets.
This process contributed to the creation of the Drug Users
Network—RADDUD—whose mission is to improve the quality
of life of IDUs.
CONCLUSION
Harm-reduction approaches—especially in climates in which
there is social and legal opposition to needle exchanges—must
go beyond needle exchange alone to include counseling, referral
to a variety of treatment options, and, where necessary, the
prescription of legally-supplied substitute drugs. These ap-
proaches should also include changes to the law if the law is
found to be exacerbating, rather than reducing, drug-related
harm. An example of a beneficial law is Resolution 351 of the
Secretaria de Prevención de la Drogadicción y Lucha contra el
Narcotráfico [33], in Argentina, which endorses interventions
aimed at reducing risks among the population of IDUs not in
treatment and which provides for a more liberal judicial en-
vironment with respect to public health initiatives. Another
example of a legal approach to harm-reduction is a project of
ARDA aimed at the derogation of Article 14 of the Argentinian
Drug Control Law 23.737 and the depenalization of drug pos-
session for personal use [34].
ARDA has taken a key role in helping support and strengthen
the harm-reduction initiatives aimed at preventing health prob-
lems and social harms associated with unsafe and illegal drug
use (e.g., HIV, hepatitis, and other infections; criminalization
and social exclusion). The task is to definitively involve harm
reduction in the official policy. The Regional Ministry of Health
in Santa Fe has just included harm reduction in the official
policy of the Santa Fe AIDS Program, which amplifies on the
Rosario CEADS-UNR program throughout the province
through a program entitled “Let’s Reduce Risks: Syringes and
Condoms,” implemented in the health services of the region.
This strategy is also being used in the Southern Cone Project
under development in Rosario and Buenos Aires in Argentina
and as pilot programs in other countries of the region (see the
Joint United Nations Programme on HIV/AIDS, United
Nations Office on Drugs and Crime project, 2003).
Further research is required on the risks to and behavioral
changes of DUs and IDUs enrolled in the harm-reduction pro-
grams in Argentina. Strong evidence in the developed world
shows that increasing the availability of injection equipment,
 along with needle exchange programs and pharmacy outlets,
reduces both needle sharing and the risk of HIV infection
among IDUs [35–38].
Data from interventions in Argentina support the impor-
tance of targeting underserved populations, such as marginal
DUs and IDUs in poor communities and prisons, young DUs,
and IDUs among street children; of adapting the programs
specifically to those who inject cocaine, among whom the high
frequency of injections means the necessity of guaranteeing a
large amount of injection equipment; and of involving all of
the interventions addressed to changing risk behaviors—out-
reach, peer education, information delivery, and health care
assistance.
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