A day in the life of Monica Malta

Oswaldo Cruz Foundation, Brazilian Ministry of Health, and IAS Member

My organization runs an HIV outreach programme targeting HIV-positive sex workers and/or crack-cocaine users who live in the slums and favelas of Rio de Janeiro, Brazil.

In many parts of the world, there is a significant overlap between populations of sex workers and drug users (DU), and, more recently, between crack cocaine use and unprotected commercial sex. In settings as diverse as India, China, Indonesia, Russian Federation, and Ukraine, the HIV epidemic has rapidly spread among sex workers and/or DU and HIV prevalence has been as high as 70% in some sex workers and DU populations.

Some drug users turn to sex work out of financial need to support their addiction, while some sex workers seek escape through drug use. In both cases, the exchange of sex for drugs or money under the influence of drugs is a high-risk encounter that can compromise judgment and the ability to practice safe sex.

In Brazil, the drug in question is typically cocaine, particularly crack-cocaine. Due to specific patterns of cocaine use – constant and repetitive use in a single day – active cocaine users frequently engage in risk behaviors to maintain their patterns of consumption.

Once a week, our team (psychologist, clinical immunologist, obgyn, and lab technician) visits Vila Mimosa, Rio's largest open-air red-light district in our van. We are volunteers from an outpatient unit located nearby, ambulatório da Providência (founded in 1983 & sponsored by the Catholic Church). During this visit, we talk to several sex workers who are HIV-positive, and provide ARVs for those who are not able to attend our outpatient unit nearby. Everyone receives adherence counseling and we develop together an adherence plan that is feasible and suits their lifestyle (e.g. working all night long and sleeping all morning, or unable to keep meds in a refrigerator).

We provide rapid HIV testing and counseling to several sex workers who don’t know their HIV status. They receive pre and post counseling, condoms and flyers offering tips on how to practice safe sex. Pregnant women see the obgyn and receive counseling and referrals wherever needed. We distribute condoms, preventive information and flyers with the outpatient unit contact information.

Crack cocaine causes blisters, sores, and cuts on the lips and inside the mouths of those who smoke it, and such sores may facilitate the oral transmission of HIV. Therefore, crack-cocaine users are referred to a local NGO that conducts outreach work in several slums from Rio de Janeiro, offering referral and distributing ‘safer crack use kits’ (filter, crack pipe, mouthpiece, condoms, lip balm, and information materials concerning safer crack use and treatment of oral sores and lesions). During our visits drug users also receive counseling and referral to our outpatient unit, where they will have access to individual psychiatric and psychological treatment. During the other weekdays, I work part-time at the outpatient unit nearby Vila Mimosa, coordinating the following activities: waiting room debates, harm reduction strategies, drug addiction treatment and once a week our ARV adherence group.

Three volunteers from Ambulatório da Providencia (psychiatric, psychologist and clinical immunologist), including myself, work as researchers and professors at the Oswaldo Cruz Foundation (FIOCRUZ), the largest biomedical research institution in Latin America. FIOCRUZ forms part of the Brazilian Ministry of Health and plays an important role in the area of science and technology in health. This joint appointment allows us to facilitate collaboration between our outpatient unit and the innovative technology and expensive treatments available at FIOCRUZ, providing a disenfranchised population with the possibility to access free of charge care, including HIV genotyping and drug resistance testing, management of patients with chronic hepatitis and/or co-infected patients (HIV/HCV, HIV/HPV, etc.)

Female commercial sex workers who use crack experience a synergy of health and social problems, increasing their vulnerability to HIV infection. Efforts to prevent HIV infection among this population require multifaceted, culturally appropriate and gender-tailored interventions. NGO, outreach work and community-based organizations are key actors to promote behavioral changes and the maintenance of protective behavior over time.

Our working days are intense, however I am continually motivated by the knowledge that I’m actually trying to make a difference in the lives of this disenfranchised and usually forgotten community.