Conhecimento de homens jovens usuários de crack perante o HIV/ Knowledge of young male crack users on HIV

Objetivou-se identificar o conhecimento e as situacoes de vulnerabilidade de homens jovens usuarios de crack perante o HIV. Trata-se de pesquisa exploratoria, descritiva e qualitativa, realizada em uma comunidade terapeutica do municipio de Fortaleza-CE, entre janeiro e marco de 2012. Participaram do estudo 10 jovens, com idades entre 18 e 24 anos. As informacoes foram coletadas por meio de anotacoes em diario de campo e de entrevista semiestruturada, e os dados obtidos foram analisados pela tecnica de analise de conteudo. Os resultados indicaram quatro categorias tematicas: quem sao os usuarios de crack ?; o conhecimento acerca do HIV; prevencao; e situacoes de vulnerabilidade ao HIV. Os jovens demonstraram pouco conhecimento sobre a AIDS, com predominância de mitos, e se consideravam vulneraveis ao HIV, visto que o compartilhamento de cachimbos para o uso do crack e a perda da consciencia favoreciam o nao uso do preservativo durante as relacoes sexuais e a multiplicidade de parceiros. A pesquisa traz subsidios para que o profissional de saude se aproprie das necessidades relatadas pelos jovens e planeje estrategias educativas que possam permitir uma reflexao sobre a tematica das drogas e sua relacao complexa com os varios fatores que cercam essa questao, inclusive o HIV.


INTRODUCTION
The crack phenomenon emerges as a complex element in the process experienced in the adolescence and the youth that may have a significant impact on multiple dimensions of life, seducing adolescents with the disguises of transgression, affirmation of autonomy, obtention of pleasure, relief of distress and supposed openness to new realities (1) .
Crack users represent a population that is very vulnerable to infection by the Human Immunodeficiency Virus (HIV).A national study found that the consumption of this drug has been associated directly with HIV infection, and the most common risky behaviors observed are the high number of partners, unprotected sex and the exchange of sex for crack or for money to buy drugs, and the habit of sharing the same pipe for using crack (2) .In addition, users often have sores and cracks in the nose and mouth, what could facilitate viral transmission (3) .
Brazilian survey of crack users in 2013 revealed a prevalence of HIV infection among crack users and/or similar drugs of 4.97%, about eight times the prevalence of HIV estimated for the Brazilian general population.About 1/3 of these users are concentrated in the age group of 18 to 24 years and are mostly male (4) .Therefore, this group has attracted the attention of professionals that work with HIV prevention and health promotion (4) .
Given the relationship between vulnerability, HIV and young crack users, it is important that professionals who work in various scenarios of health care get closer to the reality of these young people, so that they may plan prevention strategies for drug users aimed at modifying their behavior related to drug use and risky sexual behavior.
When considering the epidemiological and clinical relevance of the disease, in addition to individual and collective consequences related to the risk of HIV infection and implications for the evolution of the disease in this group of patients, it is suggested that strategies of prevention, early detection and treatment take into account the particularities of crack users.
This study aimed to identify the knowledge that young men who are crack users have on HIV and their situations of vulnerability.

METHODOLOGY
Exploratory and descriptive study with qualitative approach.The techniques for gathering information included semistructured interviews and notes in field diaries in which informal conversations were recorded as well as gestures, behaviors and expressions related to the theme HIV/crack.
A total of ten young crack users assisted in a reference therapy community in Fortaleza-CE and for the selection of subjects, the following inclusion criteria were used: users of the treatment units for drug addicts and who reported having made use of crack.The age groups indicated by the Estatute of Youth (Law 12,852 / 13) was adopted as reference.This indicates that young people refer to individuals between 15 and 29 years old, as the internment center is exclusive for men over 16 years (5) .
Data collection was conducted from January to March 2012 and January-February was the period when the researcher immersed into the research setting.In March, pre-scheduled individual interviews with young people and with the institution were carried out.
Data were submitted to thematic content analysis and were organized in accordance with the following stages: pre-analysis, material exploration and treatment of results, inference and interpretation (6) .The corpus was made up of ten interviews, and after reviewing the reports, four categories emerged: who are the users of crack?; knowledge about HIV; prevention; and situations of vulnerability to HIV.
The interpretation of the material took place in dialogue with the literature on the subject, with consideration of the theoretical bases considered relevant and enriching for critical study of the speeches.
The study followed the ethical and legal aspects of research involving human beings (7) and it was approved by the Ethics Committee of the Federal University of Ceará, Protocol n° 303/11.The Informed Consent (IC) was signed by young men and their guardians.In this sense, young people have been identified by the term user (U), followed by serial number of lines.

RESULTS AND DISCUSSION
The ten young people were male and between 18 and 24 years old.Regarding the level of education, one had incomplete primary school, two had complete elementary school, five teenagers had not completed high school and only two had finished high school.
Regarding marital status, two were married, two coexisted maritally and six were single.Most adolescents had some kind of informal employment and were removed to treat crack addiction, because it was impossible to work under the effect of drugs.
The following categories emerged from the interviews, and are compiled in Table 1 and they present the description of crack users and their statements as to knowledge, prevention and vulnerabilities to HIV experienced by them.
The profile of crack users in this study confirm the results of national survey on the use of crack held in 2013.In this study, most users stated singleness 60.64%, and according to the 2010 Census, the proportion of singles in the Brazilian general population is 55.3%.Thus, there is an over representation of single people in crack scenes, as is often observed in different situations of loosening of family ties.The proportion of users in Brazil who attended/completed high school (16.49) showed to be bellow the very low proportion of users with higher education (2.35%), similar to this study (8) .
Authors have evaluated the relationship of school problems and the use of alcohol, tobacco and illicit drugs among 965 adolescents from Diadema (SP), and they found a correlation between the use of substances and repetition of school years, lack of concentration, poor grades, desire to leave school, feeling bored at school, not doing homework, missing/arriving late and losses resulting from drug use (9) .

User 3 (U3)
I am 18 years old, live with my mother, sister and two uncles.

User 10 (U10)
I'm 24 years old and live with my wife.At 19, I started using drugs: marijuana, ecstasy, alcohol and cocaine.The first time I used cocaine, it was aspiringit, I was at the home of a friend, who bought the drug, with three friends.I'm in outpatient treatment and "clean" for nine months (U10).

About AIDS, I know it's a disease that affects and weakens the immune system, and that the person does not die from AIDS, but it's a disease that the individual acquires. I think only through unprotected sex and sharing contaminated syringes is how one can get HIV (U10). I have a steady partner, my wife. But at the time I used to use drugs I never had sex with women that are drug users" (U10). I've had unprotected sex, which could have facilitated infection. I believe that there is a relationship between being drug users and HIV infection, but only with injecting drug users (U10).
Quadro 1. Descrição dos depoimentos dos usuários de crack e sua relação com as quatro categorias temáticas: quem são os usuários de crack?; o conhecimento acerca do HIV; prevenção; e situações de vulnerabilidade ao HIV, Fortaleza, CE, 2013.
It should be noted, however, that all young people in this study were at some point in school.This reinforces the importance of prevention programs in the school environment to be implemented since the initial levels of education, so that young people receive proper training, as well as the importance to increase the capacity of schools to deal with a population Cienc Cuid Saude 2016 Abr/Jun; 15(2):350-357 grappling with significant psychosocial problems (10) .
In this study, none of the young people were on the streets, which diverges from the reality found in the national survey on the use of crack, which found a significant proportion of users in this situation, around 40% (8) .Study carried out with children living on the streets shows that these adolescents have also the street as a place of easy sex, prostitution and indiscriminate use of drugs, factors that increase vulnerability to STD/AIDS (11) .
The most common way of getting money reported by users of crack and/or similar drugs in Brazil comprises sporadic or selfemployment, representing about 65% of cases, which is similar to the present research (8) .
The male gender, the adolescence, low job prospects and family breakdown are related to increasing contact with drugs and drug use itself, features present in the studied group and confirmed by scholars who conducted a review of 114 articles published between 2000 and 2010 on the risk factors associated with drug use by American teens (12) .
Crack users in Brazil and the youth of this study are basically poliusers, that is, crack is only one of a broad "portfolio" of psychoactive substances that they consume.Strong superposition of crack use with the consumption of licit drugs is observed, and alcohol and tobacco are the most frequently consumed (8,13) .It is known that the greater the variety of drugs consumed, the greater the damage to the body and the lower the chances of abandonment, because this creates dependence for different substances (13) .
The profile of young people in this study did not differ from a study of 196 adolescents that showed a prevalence of 17.9% drug consume, which occurs more frequently at friends (42.9%) and in the clubs and bars (34.3%).Noteworthy is that this consumption was started mainly in the age group of 14 to 16 years (57.1%).The most prevalent illicit drug used is marijuana (60%), followed by crack (20%), and the solvents (11.4%) (14) .
When questioned about the reasons that led them to try crack cocaine, most young people said that consumption occurred under the influence of friends.Curiosity and relatives who use drugs have also been reported.Similarly, studies show that having friends who consume any drugs is something that increases the possibility of the teen to use it, and it has been found that the young people try drugs as a result of misinformation, curiosity, dissatisfaction with life or when a parent uses drugs (15)(16)(17) .
Study on crack users pointed out the reasons that led them to consume crack at first, and over half of the users of Brazil said that such consumption was due to the curiosity of experiencing/feeling the drug effect (58.28 % [95% CI: 55.21 to 61.28)].Family problems or emotional loss was the main reason for starting using crack, reported by 29.19% of users (95% CI: 26.67-31.84),and the pressure/influence of friends was reported by 26.73% (95% CI: 23.94-29.72) of users (8) .
In the speeches of young people about knowledge on the subject of HIV, the content of the reports showed that some of the participants had some idea of what is the disease, its severity and that unprotected sex is the main route of infection.Some participants revealed that they had attended a lecture in the therapeutic community a few days ago, which shows that some information was actually assimilated by them.But most had a superficial knowledge, permeated by many myths about the disease.When they expressed that ignored the issue of HIV was realized that it was not just the lack of knowledge, but also the shame of addressing the issue that prevented teenagers from receiving the necessary guidelines for prevention.
Study with adolescents on the streets found that most young people were aware of the STD/AIDS and how to prevent, but they cannot realise the mode of infection of these diseases in their daily lives and in their relationships.For some of them, the risk of becoming infected with an STD is not reason enough to adopt appropriate preventive measures (11) .
As for prevention, the majority of young people reported that they already had active sex life.They mentioned the need to know if the partner is drug user or not, as they believe users offer a higher risk of infection with HIV.Study in Fortaleza with 69 adolescents followed by an institute specialized in chemical dependency showed that 47 (72.3%) of respondents preferred Cienc Cuid Saude 2016 Abr/Jun; 15(2):350-357 to relate with partners who are non-users because they feel safer (13) .
Some said that the most adopted method to prevent against HIV was by using condoms, although among those who had serious relationship, condom was not used.None of the young people raised concerns about pregnancy or other STDs.Study corroborates these results when point out that, although part of drug users have knowledge about preventive measures against HIV, they do not always use condoms (13) .
With regard to situations of vulnerability to HIV of young people as drug users, it was observed that most of them do not recognize or do not know if they were in a vulnerable situation because they are drug users, although others affirm that the relationship drug use/HIV exists, particularly when sharing pipes for the use of crack.Furthermore, loss of awareness or plain judgment may have favored the non-use of condoms during sex, and multiple partners, according to testimonies.
The adolescents in this study believe that only the injecting drug user can get infected with HIV, and that female prostitutes and women who use drugs, can be an additional risk to contract the disease, as well as by they reason that the fact of not having intercourse protects them from HIV.The fact that they are not injecting drug users and, therefore, would not be exposed to HIV through drug addiction is an untruth at the expense of other effects that the drug causes, leading the individual to unprotected sexual practices and to the practice of sex with unknown partners.
It was evident that the consideration of the issue of HIV in this population is essential and that the actions must not be restricted to the transmission of information, but must estimulate in young people a critical reflection about their vulnerability to HIV as crack users.

FINAL CONSIDERATIONS
Young people are a public that is vulnerable to HIV infection, and this vulnerability is associated with factors related to the family, to oneself, to school, to the availability of drugs and to social factors.As for the young crack users, additionally to the various factors listed above, the stimulating effects caused by this substance consists in making the the individual feel invulnerable for a few seconds, and then immediately feel the urge to repeat the use.That is why the substance causes dependence in a few weeks of use.
Adolescents in the study showed inarticulated knowledge with predominance of myths about HIV prevention.They reported never having used injecting drugs, but the minority recognized that they still consider themselves vulnerable to HIV, since sharing pipes for the use of crack, and loss of consciousness or judgment may favor the non-use of condom during sex, as well as the practice of sex with multiple partners.Friends of these young people were the main influencers making them come to experience the crack.
In the midst of this reality, the professionals who work in the various sectors of health care and that promote prevention and health promotion need to be increasingly trained in order to assist the young drug addict in his entirety.
In this sense, health professionals may be better able to plan and execute interventions that facilitate a reflection on HIV among the users of crack and other drugs, and must favor the exchange of experiences between young people by using participatory methodologies such as Paulo Freire's, sensitizing subjects to develop critical thinking, decision making, problem solving, that is, the skills for a healthier life.
We emphasize the need for further studies with a larger sample and using instruments that allow the use of educational strategies that may promote the construction of critical and reflective space on the prevention against HIV among young users of crack.

CATEGORIES/TESTIMONIALS Crack users Who are the users of crack? Knowledge about HIV Prevention Situations of vulnerability to HIV
mixed, a much more potent drug.Today I am in hospital treatment and "clean" for 40 days.I have a two kids from different women, a boy and a girl, they are the same age, seven.I only know the girl, the boy I know only by photo (U2).

Crack users Who are the users of crack? Knowledge about HIV Prevention Situations of vulnerability to HIV
Two years ago I started using drugs.First I used marijuana, and added cocaine/crack and ecstasy.I myself bought the crack and used alone, in a party.I am undergoing treatment for two months.I have only girlfriend and I have no children (U3).