"How many ganchos are you going to use," asks Irma.
"Two or three," responds the thin man wearing no shirt, ripped shorts, and shoes without soles. With this, he extends his hand.
  The woman gives him three small bags and continues her walk, while the man guards the bags like a treasure, hiding them in his pants.
  Gancho or pico. Some of the many expressions that drug users use to refer to the act of injection. Irma asks "how many" because it is her job. The bags that she hands out include disposable syringes, injection equipment, and condoms. Her walk, along the narrow alleys of a neighborhood in Sarandi in Avellaneda, a bag in hand filled with the "kits," has already become part of her routine. The 44 year old woman is one of the community outreach workers for Intercambios, a non-governmental organization that hands out materials to drug users. Intercambios is operating a harm reduction program, which is to say that they seek to prevent the harms that are associated with injection drug use, most importantly the transmission of HIV. And, for the first time, their program is financed by the government. Twice each week they work in three neighborhoods in Avellaneda. Pagina 12 spent an afternoon with the outreach workers and observed them handing out materials.
  "Having syringes available insures that drug users use clean needles and do not look for used ones," explains Pablo Cymerman, coordinator of the Argentinean Harm Reduction Network, adding, "It is important that it be clear that having clean syringes available does not create an incentive for people to use drugs. We offer clean syringes in order to prevent the spread of serious illnesses like HIV and Hepatitis C, among others."
  "Loco, take care of yourself. Don't share syringes." People read this message on one of the stickers that is included in the kits that Irma hands out in her own neighborhood: a collection of humble houses along a maze of narrow alleyways along side a small river in Sarandi that contains more trash than water. The kit contains two syringes, a small bottle of sterile water, a filter, two alcohol swabs, a bottle cap in which to place the drug before injecting, and educational materials about HIV prevention.
"This job changed my life," says Irma. "Today, I am a somebody in my neighborhood. Everybody knows me."
  Every person who we pass greets Irma enthusiastically. She responds, between smiles, by handing out the injection materials, which people use once and then throw away, just as they read on the stickers that they see stuck to the windows of old cars and in the streets. Another sticker says, "I do mine with a condom."
  "How many do you need?" asks Irma, without hesitation, and she hands over the condoms. With syringes she is even more direct, "How many ganchos are you going to give yourself?" and she hands out the quantity for which they ask, but never more.
Irma knows that she must never find herself with no kits. Somebody could always come knocking on her door unexpectedly, asking for a syringe, and she always needs to have a supply. A clean syringe can save a person's life because "at that certain moment," confides Marcelo, who defines himself only half jokingly as a "very good client of Irma's", "a needle can cost more than drugs. Everyone would prefer to spend their money on drugs than on syringes."
  Adriana Procupet, coordinator of epidemiological surveillance for LUSIDA (the national program for the struggle against AIDS and sexually transmitted diseases, a division of the national ministry of health), explains that "harm reduction is a public health strategy that seeks to minimize the risks associated with drug use more than to prevent drug use itself: the objective is to change the attitudes and high risk behaviors that lead to the transmission of disease."
  The coordinator explains that handing out the "kits" "is the first time that we have adopted harm reduction as an official policy." She explains that, according to a study conducted by LUSIDA, drug users (called IDUs by experts), are the group most affected by HIV. The report revealed that the transmission of HIV between IDUs represents 40% of the total AIDS cases in the country. Cymerman explained that harm reduction policies "try to improve the quality of people's lives, as a showing of respect for their human rights."

"Like Bread"
  "How can we involve the community in this project when, at the moment there is so much distrust and disbelief?" This was the question that Cymerman asked himself when the project began to take shape two years ago. "In our first encounters with the community, one person asked us if we were checking in with the police. Of vital importance was establishing a network of drug users in order to generate confidence and trust, which are always fundamental".
  Juan and Diego are the other Intercambios outreach workers who hand out materials. Juan is a humorous and fun loving type. He is 42 years old, but looks younger. "I work as a harm reduction activist and I do it with joy. I go to the houses of the users, I enter the cuevas - the places where users gather to inject themselves. I have been using drugs for 25 years, and many of my friends have died." However, Juan has not lost hope. "Houses are built brick by brick and if I can save even one life, I will be satisfied."
  Intercambios' program serves 55 drug users. "I know that it is not much," admits Cymerman, "but you have to work qualitatively if you are unable to reach more people. We are doing something that should not be an isolated experience. If it is, it will never respond to the true size of the epidemic."
  Juan works with his backpack and a form on which he notes the sex and age of the people to whom he gives the kits.
  "Ratón, over here," people yell out to him as he walks by, and he goes over to the meet them.
  "I go and I distribute materials in the street, in an alley. I see that I am doing good, and the people who use the syringes agree". And Juan does not lie. "They are really changing the people in the neighborhood," says Leo, as he walks away with a kit in hand. "Even better," adds another, "the condoms and the syringes are like bread."
  Diego is 24 years old and he shares his particular battle against AIDS, it is his Moby Dick. "I have something personal against HIV. I know that it is very important that we hand out equipment in order to avoid infection. It is difficult to reduce the amount drugs that you use, but not to avoid infection. I have been able to change the attitudes of a lot of people. Telling the story of his drug use gives Diego the strength to be an outreach worker. "I began injecting drugs when I was 18 years old, but it has been over a year now that I have not injected, it no longer seems like a good idea to me. I had to distance myself from my friends and it was difficult for me to assume the life of a careta." In the community, "caretas" are the people who do not use drugs. "Everything was boring to me. Many times I wake up and I go through the entire day with a syringe on my mind," he admits.

The Jeringuera
  In addition to those who work directly for Intercambios, the program relies on several spontaneous contributors. Raul is 44 and together with his wife Nancy, age 37, he opens the doors of his house - in which he lives with his four children and which is located in the heart of one of the neighborhoods in which Intercambios works - in order to serve as a place where people can come and pick-up kits. "Now people call me the Jeringuera," says Nancy laughing. But at the same time, she sees the name as a compliment. "It is a way to help people," she says proudly. Both Nancy and Raul use drugs, but they do not inject. "We stay away from infection," they assert, almost at the same time.
  Raul is a long time expert in the field. He talks about some of the things that he did when he was younger and believes that he can use those experiences to help a lot of people. "On every corner there are two dealers selling drugs and the people in this neighborhood inject the product, so I try to help them."
  "Doesn't it bother you that they ring your bell at all hours of the night asking for syringes?"
  "You come and ask me for a syringe. It will not bother me," he assures. Again the topic of death comes to the surface. "Many of my friends have died of AIDS," he says and then makes a declaration of principle "We have to get out of this hole together, because nobody can do it alone."
  In the middle of the chat a man appears. He comes by, says hello, picks up a bag containing several kits, and he leaves. "What I do is nothing compared to Miguel," says Raul. The journalist wanted to talk more, but there was no time. "They will tell you," says Raul, already in the door.
  Raul says, "Miguel is 50 years old and he lives alone. Everybody knows him and they all stop by his house. They gather there, and hang out, and for that they use a lot of syringes." Without knowing it, the people who visit Miguel's house are participating in the same type of program that occurs in Holland and various other first world nations: a harm reduction center that serves as a meeting place for drug users.

The Profile of Addicts with HIV
  Fully 40% of all reported AIDS patients in Argentina contracted HIV when they shared syringes in order to inject drugs. This information, collected by LUSIDA (the national program for the fight against AIDS and sexually transmitted diseases), was critically important in the government's decision to offer official support to harm reduction programs.
  Considering only AIDS cases in people older than 12 years, the rate of HIV transmission related to needle sharing rises to 42.2% of the total AIDS cases. Because injection drug use leads to so many cases of HIV in the country, Argentina's AIDS epidemic is unique. The proportion of AIDS patients whose main risk factor for infection was injection drug use is one of the highest in the world.
  As of December 31st 2000, there were 18,826 AIDS cases reported to LUSIDA. Of these cases, which have been accumulating since the beginning of the epidemic, 25% have already died.
The LUSIDA study also included a profile of drug users who are living with the virus:
   ·An analysis of long term trends shows that the proportion of total AIDS cases who are injection drug users is shrinking.
   ·The ratio of male IDUs:female IDUs with AIDS is 6:1, while in the rest of the population the ratio is 3:1.
   ·The mean age of HIV positive male IDUs is 29, while in the rest of the HIV positive male population it is 34. For women, the mean ages are 28 and 30 respectively.
   ·Concerning residence, 94% live in urban areas. 53% live in Buenos Aires province (mostly in the immediate surroundings of the city proper); 30% live in the city of Buenos Aires itself, 9% live in the Province of Santa Fe (the majority in Rosario), and 2% live in Cordoba.
   ·The level of education in IDUs is lower than that for other HIV patients: only 17% of HIV positive IDUs completed high school, as compared to 44% of other HIV patients.

Interview with a Brazilian Expert.
"We are health agents, not drug narcos."
  Harm reduction programs began in the 80's when a series of studies conducted in people living with HIV revealed that almost 80% had contracted the disease through sharing syringes to inject drugs. Needle exchange programs have existed in Europe since 1984, and there is concrete evidence demonstrating their efficacy in lowering rates of HIV/AIDS, Hepatitis, and other infections in injection drug users (IDUs): in those countries, and in those countries who have had needle exchange programs for more than 10 years, IDUs only represent 5% of total AIDS cases. In Latin America, the movement is advancing slowly. Brazil is the country with the greatest number of harm reduction programs. In 1995, the University of Bahia, Latin America's harm reduction pioneer, launched Brazil's first needle distribution program. There are currently over 50 programs in Brazil which reached over 32 thousand people and distributed over 300 thousand syringes in the year 2000 alone, resulting in a notable decrease in the rate of IDUs infected by HIV.
  Domiciano Siqueira, coordinator of the Harm Reduction Association of Brazil, came to Buenos Aires to give a talk about the Brazilian experience. While here, he talked to Pagina 12.

"What is harm reduction?"
  Harm reduction is a public health strategy that prescribes objective interventions to fight the transmission of diseases that are related to drug use like HIV and Hepatitis. The way to implement the strategy is to bring to drug users the basic tools that they need to avoid infection: beginning with syringes and condoms, but also including bottle caps so that people do not mix their drugs, cotton, and filters. Working to prevent diseases that are spread through needle sharing and sexual relations is difficult work because these are activities that go on behind closed doors.

"How do you reach them?"
  By working with other drug users. It is fundamental to have drug users as active participants in harm reduction programs. In Brazil, of the over 1000 people who work in harm reduction, 70% are drug users. I am convinced that this is the key to the programs' successes.

"How can you quantitatively measure that success?"
  There is objective data, collected in Salvador, Bahia. Ten years ago, 60% of IDUs had HIV. Today, that number has been reduced to 5%, because the number of needles used has gone up at the same time that the number of drug users has decreased. In the entire country, where there are over one million IDUs, 60% of the people who used to share syringes no longer do. This means a great deal to their health, as well as the health of the public in general, because IDUs do not live on an island. Furthermore, it is extremely important that the government finance and initiate harm reduction programs. Currently there are 50 programs in Brazil, 49 of which are financed by the state or federal governments. We are reaching 32,000 IDUs and this year we expect to distribute over 600,000 syringes.

"How much money do they invest in these programs?"
  It is much less than you might think. A program which employs 10 people and reaches 200 IDUs costs 25 thousand dollars.

"There were no negative reactions to harm reduction?"
  Yes there were negative reactions, because people stigmatize drug users. People think that drug users as delinquents or sick people who we must cure, but neither of these ideas is true. There are an enormous number of prejudices against users of illegal drugs and the stereotypes come from all of the institutions of modern society: to the religious, using drugs is a sin, to the courts it is a crime, and to health care professionals it is an illness. Another misconception that some people have is that by handing out injection equipment, we encourage drug use. We are not drug traffickers, we are public health agents. I hand out needles because I hope that the person who is injecting does not contract HIV or Hepatitis and that he can be more happy given the choices that he has already made. We have a responsibility to protect lives.

"Public campaigns associate drug use with death."
  This is another misrepresentation, clearly implemented in order to combat the use of drugs. They say "Live yes, drugs no" and it implies that people who use drugs do not live.   To the extent that they are dead, they are also excluded from all social life. But this campaign speaks only to the people who use illegal drugs, even though alcohol and tobacco are both drugs and there are more people who stop smoking marijuana than there are people who stop smoking tobacco or drinking alcohol.

Los Locos de Sarandi
  Intercambios is a non-governmental organization dedicated to the study of and attention to problems related to drug use and is part of the Argentinean Harm Reduction Network. The program Locos de Sarandi - so named because in the language of the drug users, loco is someone who uses drugs and careta is someone who does not - won a competition organized by the Ministry of Health and now has a budget of 30,000 dollars which will allow it to operate until October 2001.
  Adriana Procupet, coordinator of LUSIDA, told Pagina 12 that the project is funded 50% by the World Bank and 50% by the Ministry of Health. "This program is one of our focused campaigns," explained the specialist, "which is to say that unlike large scale campaigns, this program has a message that is targeted to a specific population, in this case people who use injection drugs. This type of campaign is a high priority," she added, "because it addresses a community with a very high proportion of people living with HIV."
Although the governmental organization does not abandon its goal helping people to stop using drugs, Procupet assures that, "It is fundamental that we make a stand that even if a person is unable to stop using drugs, that does not mean that there will be negative health consequences. We must avoid the continued spread of HIV, Hepatitis B and C, and sexually transmitted diseases in a mark of respect for human rights".