Drugs and AIDS: Surely Now It’s Time for a National Alert

Drug use is growing fast in Nicaragua and both drug addiction and AIDS cases are on the increase. Seeing Nicaragua as just a through-route for drug traffic is a great mistake, leading to the neglect of preventive education.

Fundación Nimehuatzin

In one of his writings, Leonardo Boff recalls the Greek myth of the rebirth of the eagle, similar to the phoenix of Egyptian culture. To achieve its rebirth, the eagle flies higher and higher until nearly reaching the sun. Then its feathers catch fire and it begins to burn, falling from the sky and plunging into cold water, from where it emerges renewed. Through this catharsis of fire and water, the eagle recovers its youth, grows new feathers and sharpened claws and recaptures a penetrating look in its eyes.

Many men and women who are in rehabilitation from long- or short-term addiction to drugs find encouragement for their own rebirth experience in the symbols of the eagle and the phoenix. Little is known about their lives and less still about how they came to find themselves enmeshed in addiction, at a time when more people are beginning a similar journey. Nor is it clear what can be done to prevent this drama from unfolding further or how to prevent drug-addiction damage from drugs reaching exponential growth rates.

Several surveys, many laws,
and more drug trafficking and use

There are now signs of the magnitude of the problem in Nicaragua. In a study by the Nimehuatzin Foundation, a young man explained that the military band of one Managua high school didn’t participate in the Independence Day celebrations of 2003 because all of its members had drugs problems and had given up practicing.

That same year, Dr. Mauricio Sánchez coordinated a survey covering more than 5,000 secondary students to learn about their alcohol, tobacco and drug consumption. One of its most significant findings showed that marihuana is the drug most used by students, above all boys (8.6%), followed by cocaine, both cocaine chlorohydrate (3.5%) and crack, a cocaine derivative obtained from interaction with other elements, including sodium bicarbonate (2%). Female students typically take unprescribed but legal substances, including sleeping tablets (13.7%) and stimulants (8%). In all of the drugs studied, including substances such as tobacco and alcohol that don’t depend so much on purchasing power, the extent of usage was greater in private schools.

This survey formed part of the research conducted in Central America, Panama and the Dominican Republic by the National Institute on Drug Abuse (NIDA), a US-based organization. The investigation, which used a methodology established by the Inter-American System of Uniform Data on Drug Consumption, was backed by Johns Hopkins University and the Inter-American Commission for the Control of Drug Abuse (CICAD/OEA), a body that administers funds authorized by NIDA. For 2006, Nicaragua’s National Institute of Statistics and Censuses (INEC) and the National Council for the Fight against Drugs announced a survey to learn about drug use patterns and their relationship to socio-demographic factors among more than 6,000 women and men aged between 12 and 65 years.

These surveys do not usually address the relationship between drug use and the risk of Human Immune-deficiency Virus (HIV) transmission, even though intravenous drugs are one of the main ways of becoming infected. During the UN’s special session on HIV in 2001, a UNAIDS information leaflet warned that 10% of HIV infections derived from the use of intravenous drugs and that over half of the infections in some countries of Europe and Asia were produced among drug users.

At the beginning of the 1990s, Nicaragua’s drug problem was a result of our geographical location: we were a transit country. Soon, geography combined with economic factors: the profits made from transporting or selling drugs were much greater than those obtained from agriculture or fishing. In just one step, the drug phenomenon had become a social problem. Today, the internal demand and consumption of drugs is on the increase.

In May 1994, the National Assembly approved Law 177 regulating Narcotics, Hallucinogens and Other Controlled Substances. In 1999, it approved Law 285, which reformed and amended Law 177. In that same year, the executive branch submitted a regulatory bill to back Law 285. In 2000, the National Assembly approved Law 370, which gave rise to the Institute against Alcoholism and Drug addiction, which now has its own regulatory law as well. In spite of this cast of laws, drug trafficking and consumption continues to rise.

AIDS: A new infection every day

Nicaragua’s first case of AIDS was registered in 1987 in the department of Rivas. From then until June 2005, the Health Ministry (MINSA) registered 1,835 cases of HIV. According to more recent official information—dated March 2006—there are now 2,116 registered infections. And the number of women living with the infection is on the increase. In 1997 the proportion of HIV cases was 7 men to 1 woman. Now the proportion is lower than 3 to 1. According to official statistics, more than half the people living with HIV are between 15 and 39 years old and one in ten is a teenager.

The main form of transmission is sexual (94%). Included in this statistic are people who consider themselves homosexuals and men who do not but who have sex with other men (26%). Other forms of transmission are less frequent: sharing syringes to inject drugs (3%), perinatal or mother-infant transmission (2.8%) and blood transfusions (0.2%).

The most relevant epidemiological data on AIDS in Nicaragua, despite the under-registration of cases acknowledged by health authorities themselves, is the growth trend of infection rates. Every year sees a higher number of infections. In 1998, four people per month were registered as HIV positive. In 2004 and 2005, it was one person per day.

Without treatment and living in poverty

MINSA has offered free HIV testing since 1987, although not consistently in all of the Local Integral Health Care Systems (SILAIS). Sometimes the reactive agents to conduct the tests are unavailable, and HIV counseling isn’t provided as an ongoing or generalized service.

According to official data, MINSA began free antiretro-viral (ARV) treatment in May 2003 for 17 people. In 2005, 126 adults and 7 children received this treatment through the Global Fund against AIDS, Tuberculosis and Malaria. These are the only resources that the Nicaraguan government provides for ARV treatment. The anti-retroviral medicines are administered without charge, as they cost much more than families can afford, but they are only available from one Managua hospital and many people are left without access to the treatment that is saving lives and reducing the number of hospitalizations in Latin American countries such as Brazil, Argentina, Chile, Cuba, Mexico, Uruguay, Panama and Costa Rica.
The UNAIDS 2005 report on the situation of the epidemic put Nicaragua in the group of countries that continues to delay offering antiretroviral treatment to everyone who needs it. Others include El Salvador, Guatemala, Honduras and Paraguay.

Poverty is a very important factor in the adoption of high risk behavior that leads to the spread of HIV, especially through so-called transactional sex: sexual relations in exchange for food, liquor, a place to spend the night and even to keep one’s job. In transactional sex, a person is forced by another to have a relationship in conditions of disadvantage and without protection, even knowing that it is a great risk. And if poverty contributes to HIV infection, the virus in turn increases the families’ poverty, both before and after one or several relatives have died of AIDS.

In addition to poverty, other factors contributing to vulnerability include the high rates of sexually transmitted diseases, the migration of people to countries where HIV is more widespread, the lack of sexual and reproductive education, the patriarchal and macho culture that provokes high fertility rates, the large proportion of young people in the society, the early initiation of their active sex life, rejection of the condom and the penalization of sodomy by Law 150—the June 1992 Penal Code Reform.

In Managua and Chinandega:
Exploring the world of drugs

Between 2003 and 2005, the Nimehuatzin Foundation conducted an exploratory and qualitative study directed by the medical anthropologist Michele G. Shedlin, a researcher from the National Development and Research Institute of New York. The study was funded by the National Institute on Drug Abuse and four Nicaraguans participated: two psychologists (Rita Arauz and Mariana Aburto), a sociologist (Pascual Ortells) and a drugs counselor (Danilo Norori).

The study’s overall purpose was to describe the drug use patterns in Nicaragua, analyzing their potential connection to the spread of HIV. Its specific objectives were to identify methods for contacting the country’s drug-using population and exploring how drug consumption influenced HIV transmission. The study contributed useful information for guiding existing preventive work on drug addiction, as well as developing new preventive strategies to combat both addictions and HIV infection.

It focused on two cities, Managua and Chinandega, which are the capital cities of the two departments with the highest HIV infection rates in Nicaragua. Chinandega has 54.83 infections per 100,000 inhabitants and Managua 54.55 per 100,000, according to the Health Ministry in March 2006.

In Managua, demographic growth has accelerated in the last 20 years, increasing from 700,000 inhabitants in 1985 to more than double that today. As a result of the massive migration from the countryside to the city and the heightened economic crisis, unemployment is very high in the capital and many families live in poverty. The girls and boys who work in the street are a dramatic expression of this reality. Managua has more health infrastructure than the rest of the country, which may also be a reason for it having a greater number of registered infections than in other parts of the country. In 2000, the Managua SILAIS had 289 people registered as HIV positive, a cumulative figure taken since 1987, representing 45% of all infections registered in the country. Four years on, the number of infections registered in Managua has more than doubled. In June 2004, 670 people were registered as HIV positive, representing 48% of the national total.

Chinandega’s geographical location makes it vulnerable because of its proximity to Honduras and the port of Corinto. It also has high unemployment. Among the people we interviewed in depth, we found that unemployment was higher than in Managua. People from Chinandega migrate for short periods of time to Guatemala, El Salvador, Costa Rica or the USA. In December 2000, 92 HIV cases were registered in Chinandega, representing 14% of all cases in the country. In June 2004, the accumulated register of HIV cases had risen to 245, an increase to 17% of the recorded national total.

Profile of people interviewed

The study is framed within the qualitative and ethnographic research method, in which a key element for learning about the so-called “hidden populations” is the capacity to reach them and obtain trustworthy information through in-depth interviews and field observation. Three types of interviews were carried out: individual interviews with drug users, individual interviews with key informants and collective interviews with 13 focus groups—7 in Managua and 6 in Chinandega—to approach the situation from different angles.

Of the 99 people who participated in the groups, 41% were women. In each of the two cities, two groups were organized with mental health professionals, two with sex workers, two with men who consider themselves homosexuals, two with university students, two with taxi drivers, two with relatives of people with drug addiction problems and one in Managua only with users of intravenous drugs, who were in the rehabilitation group “Like the Eagles.” Almost 30 hours of audiotape were transcribed from recordings taken during group discussions. The analysis of the content was made with the Atlas.ti program and the statistical information with the SPSS program.

Of the 121 people interviewed in depth, 64 were active users, 47 were undergoing rehabilitation, 6 had finished their rehabilitation some time ago, and 4 did not use drugs, although they had served jail sentences for dealing. 81% were men and 19% were women. 75% were between 18 and 34 years of age with an average of 30 years. 79% had been born in Managua or Chinandega. Most had a higher level of education than the Nicaraguan average, as only 6% did not know how to read or write and 26% had studied at a university or technical college, although only four men and one woman had finished their studies. 17% said they could speak or understand English.
Their jobs covered a wide range of occupations, from housewives to economists. Most said they had a job, eight had none and 15% said they were students. In terms of religion, 34% indicated that they didn’t belong to any church, 44% said they were Catholic and 16% Evangelical.

A total of 58% had traveled to other countries, mainly in Central America or the United States, either to look for work, visit relatives, for tourism or to get treatment for drug addiction. The female sex workers of Chinandega explained that their occupation took them frequently to other provinces or outside Nicaragua to other Central America countries or the US. Nearly 8 out of every 10 interviewees had some relative or friend living abroad—in Central America, Mexico, the United States, Canada or Europe—and 4 out of every 10 were in touch with them.

Meanwhile, 64% admitted to having been arrested or jailed at least once and 14 of the 121—12 men and 2 women—had been imprisoned more than 10 times, including in other countries (USA, Switzerland, Panama). Amongst their crimes were buying drugs for others as “middlemen”, selling them, violence or gang activity and, in one case, burning the house of a member of an enemy gang. But, as one of the men explained, jail didn’t resolve the problem of addiction or the risks it carried: “In jail sex is exchanged for drugs and the dealer offers you drugs for sex.”

Marihuana, crack, cocaine, pills and now ecstacy

Crack has invaded the Nicaraguan market and established itself as the drug of choice, a fact affirmed by 93% of the 121 people interviewed in depth. The use of crack is higher in Managua than in Chinandega. Only in Managua were there cases of people exclusively using crack—four women and nine men interviewed. In Managua, crack is prepared (“cooked”) in the retail distribution points. The combination of crack and marihuana, called “wash,” is also more frequent in Managua than in Chinandega.

The combination of several drugs is a widespread practice, in Managua as well as Chinandega. Crack is used on its own or combined with other substances, both prohibited (cocaine and marihuana) and legal (alcohol). “It’s better to combine crack with liquor because on its own it destroys your nervous system, and with liquor you can keep an even keel, reach a balance,” said one interviewee. The use of cocaine is mentioned in 81% of the interviews, together with other substances. Only one woman spoke about just using cocaine. Cocaine and marihuana are also combined, producing something called “plantain with cheese.” Five interviewees mentioned the combination of valium or diazepam pills with marihuana and cocaine. “I combined pharmaceutical pills—prozac, valium, rophypnol—with booze or beer and used ketamine, which is an anesthetic for cats,” one woman told us. The study also found that new substances such as ecstasy are being introduced into the market. “Now acid pills are coming in, like ecstasy, but they’re expensive.” You can only find ecstasy in exclusive circles, like some discos.

Fear of injected drugs

Most participants in the focus groups didn’t know anyone who took heroine or who other injected drugs. The health professionals explained that a large part of the population was suspicious, fearful or rejecting of injections in general. Often, injections are used as a threat against children: “If you don’t eat, I am going to stick a needle in you!” In Nicaragua, injections are associated with hospitals, nurses and laypeople who specialize in this practice. There are signs in neighborhoods that say “We give injections.” The main forerunner of drugs in Nicaragua was marihuana. “If injected drugs are on the scene, it’s because of outside influence,” said one of the professionals.

The majority of interviewees were against injecting drugs. “They’re worse for your health.” Most people said they were afraid of needles and avoided injecting drugs because of the risk: brain damage, infection around the area of the injection, risk of hepatitis or AIDS. There were a number of ideas about the effects and the significance of injecting drugs: that they’re stronger, more addictive, that you can’t measure the dose, that they cause perverse behavior, that “they lead you to death,” that to use them means “you’ve really sunk low.”

At the start of the research, everything seemed to point to fear as the factor that has slowed the advance of injected drugs in Nicaragua. As one interviewee expressed: “I didn’t dare, I had tachycardia and I thought I’d paralyze my heart if I injected drugs; I was afraid of dying and that was my chance to stop using drugs.” However, as the research continued, we found that injected drugs are gaining ground despite cultural barriers. Although their use is almost invisible in Chinandega, it’s not in Managua. Several taxi drivers and university students said that heroine circulates among the upper classes. The health professionals also insinuated this and the sex workers knew some clients who shot up with heroine, although they said they tended to be foreigners.

The most dramatic finding of the whole study

As the interviews progressed with people who had a history of drug addiction, the most dramatic finding of the study became clear: the epidemic of injecting drugs has now begun in Nicaragua. An epidemic begins with just one case and the study found many more than one.

Fifteen people—thirteen men and two women—which is 13% of the 117 people interviewed who took drugs, said they had injected drugs at some time. One man told us he was injecting drugs at the time we interviewed him. In the study, six men were also interviewed as a group who had been injecting drugs until a few months previously and were in rehabilitation. Six out of every ten people interviewed knew someone who injected drugs—“I saw my uncle injecting cocaine”—and eleven knew more than ten cases.

Although injecting drugs is usually associated with heroine, the study also found instances of injected cocaine, especially related to overdoses. “A friend in Managua died from a heart attack as a result of injecting cocaine.” People also resorted to ketamine—cat anesthetic—and analgesics like demerol (mepiridine). The interviewees said they got needles from pharmacies. Although the price is a limitation, the use of injected heroine is growing at the pace of the trafficking of this drug in the country. According to one of the interviewees, the price of heroine is US$180 dollars per 3cc, and “you order it and have to wait two weeks for them to get it for you.”

It’s very probable that the consumption of injected drugs will increase in Nicaragua in the next few years. In the study, there are favorable comments about this type of drug usage. According to some people, “injected drugs calm my problems and other drugs don’t satisfy me any more.” One person called it “divine: it is the best there is, it’s a bit more expensive, but it gives you a greater high. To get it, you demolish whatever you find in your way.” Another person explained that they get it from abroad. “I used to inject myself with cocaine and rum, but now I do it with heroine. My brothers and a few friends send it to me from the States. They send it to me as a parcel, with people or by post. I’ve never had problems getting hold of it.”

Drugs for sale day and night

From the time he wakes up at midday until he falls asleep under the effects of a new dose, explained a young man, his life is dominated by one obsession: how to get hold of some drugs. And he explained: “Guide is what we call the first córdoba we get to buy drugs. Crack costs ten córdobas. The first córdoba I get is the guide. This gives me enough speed to get money any way I can: selling my things, stealing from my house. I became a craftsman: I made things of copper and sold them as if they were made of gold. I got along by cheating people.”

In the focus groups as well as the individual interviews, it became apparent that the offer, sale and use of drugs are becoming more and more open and visible, above all in Managua. According to some university students, a recent phenomenon is what they call “drug delivery,” which is an “indirect job opportunity for many people.” They explain it like this: “These are people who have their own house and a sports car and go around with a card and a cell phone that they give you. They contact you and say: call me on my cell if you want me to bring you three ounces.”

According to the sex workers, some taxi drivers serve as intermediaries between the dealer and the buyer. On occasions, the dealer takes a taxi to deliver the drug to private houses and motels. The taxi drivers said they had seen passengers under the effects of drugs. Some told of their experiences in which a passenger had given them an address that turned out to be a drug outlet. All the groups had references of well-known places in Managua where you can buy drugs 24 hours a day—at gas stations, for example.

One taxi driver recalled a journalist’s report about the abundance of drug outlets identified by the police in Managua. He knew two or three places in each neighborhood. Indeed, in March 2003, an article in La Prensa signed by E. Espinales published a chart with data from the National Police, in which Managua was shown with 409 drug outlets that had an average of 195 customers per day. Those interviewed, including homosexuals who participated in the focus group, also mentioned bars, discos and casinos where you could get and take drugs.

In Chinandega, the drug outlets are more discreet than in Managua and there are fewer of them. According to the same article in La Prensa, the police had detected 34 outlets in Chinandega, which had about 20 customers a day. In Managua and Chinandega, according to 60% of the inter-viewees, there’s a custom of pooling money among several friends until there’s enough to buy drugs. They call this complicity “milking the cow.”

Only foreign influence or now graduates?

Seven out of every ten people interviewed felt there was foreign influence in drug consumption. They highlighted cultural influences, the introduction of fashions, parties like Halloween, the gang phenomenon and shops at gas stations. With respect to drug trafficking and money laundering, they mentioned Colombian and Costa Rican influence: “the foreign drug traffickers use Nicaragua as a transit country.” They also identified the influence of Spanish, Latin Americans and North Americans with regard to consumption: “Many Spanish and South American tourists take drugs. These foreigners are experts in making pipes to smoke, which are crafted with marihuana emblems. Their way of dressing is a model for young people. In addition, there are cases of Nicaraguans who return home with new spending patterns after finishing their studies or spending time with relatives abroad. There are also people who have been deported for crimes related to drugs.

Nevertheless, the interviewees highlighted that, although there was a foreign influence, the country has now “moved up a level” in drug addiction. One of the men explained that the foreigners do the trafficking, but the consumption is national. The country’s extreme vulnerability to drugs was shown in a tale of some young people who were washing cars in a market. “We started on heroine because some foreigners who came to get their car washed gave it to us. They themselves injected us. They have money; they have MI (International Mission) plates.”

To avoid feeling hunger
or pain and for fear of life

When we asked them at what age they had tried drugs for the first time, six out of ten people said it was before they were 16. Nine out of ten had used drugs habitually since they were 21. For 55% of the interviewees, this happened in the 1990s. Eight out of ten began with friends, schoolmates or neighbors. Only seven—one woman and six men—began taking drugs on their own. In 61% of the cases, their first drug was marihuana and to a lesser extent others: cocaine, toluene (shoe glue), pills and crack; 15% said their first drug was alcohol.

As to the reasons that led them into the world of drugs, the focus group of mental health professionals believed that the motivation stemmed from poverty and emotional problems, especially so as “not to feel hunger, pain, suffering,” or simply to feel OK: “just to have an experience of well-being.” The university students identified the lack of opportunities as one of the main reasons for young people getting involved with drugs. One parent expressed it like this: “I think that drug use is due to fear. Fear of life, for example, fear of what may lie ahead. It’s a way of avoiding what scares you about the future.”

The circumstances of the interviewees reflected these situations: pain from abandonment or the death of their father or mother, family conflicts, family disintegration, sexual abuse, despair. One woman said: “People with a lot of suffering look to drugs. I’ve thought about killing myself. I don’t do it because of my daughter.” A young man who described himself as a “druggie”—which is already a sign of low self esteem—explained his experience this way: “I became a druggie because of low spirits and low morale. My father abandoned me when I was nine years old. I was really close to him. My mother worked hard to earn money and keep the family going. She didn’t realize what we were doing. Now I’m really bitter towards my father.” In other cases, as one young woman related, the reason for getting into drugs is sexual abuse. It was a slow process, which began with a legal substance, diazepam:” My stepfather sexually harassed me. I couldn’t talk to anyone about it. When I was 14 years old, I began taking diazepam. Then alcohol, cocaine, crack…”

Other reasons have more to do with economics: poverty and unemployment. People also mentioned group pressure—“bad company”—or curiosity or recreation: “the euphoric experience of the moment.” Another factor recognized by 62% of the interviewees that influences the start of drug taking is that someone within the family—a parent, brother or sister, stepfather, uncle or cousin—has a drug addiction: “There are all sorts of addictions in my family,” said one. “I have an alcoholic uncle, a workaholic father, a grandfather addicted to betting and women, and a co-dependent mother.”

Drugs and sex:
Exploring the relationship

Some people said that there’s a predisposition to drugs, an “addictive component” as one woman explained it: “I have my own thesis about addiction based on my experience. There’s an addictive component in people. If you have this condition and accumulate problems and have emotional weak spots, you begin to take drugs and, for certain, you’ll keep on taking them. That makes your problems worse, so you fall into a vicious circle; you can’t resolve your problems and your addiction destroys you unless you can find someone to help you in time.”

Of the 121 people interviewed, 66% said they were single, 14% married, 12% living with a partner and 8% divorced. Only one woman was a widow. Slightly more than half said in the interview that they had a partner, and in 39% of the cases, their partner also used drugs. 43% did not have children and 22% only had one son or daughter. Two men said they had fathered 13 or 14 children respectively and one woman had 18 children, all from the same father. Five women interviewees had never been pregnant, but among the other 18 women, there were a total of 120 pregnancies, an average of 6.5 each. Only a third of the 69 people with children—15 men and 6 women—said they had a good relationship with them.

Six out of every ten people interviewed had had occasional sexual partners, while 11% said they had had sexual relationships with the person who got them drugs and 37% said they had had sex for drugs or for money to buy drugs, a reply given by 32 men (32% of interviewees) and 10 women (43% of interviewees). Proportionately, women drug users are more vulnerable to exchanging sex for drugs. Several people who were interviewed insisted that women ran more risks: “With women who smoke crack, there are risks because they sleep with whomever.” Of the men interviewed, 23% said they had had sexual relations with other men: “To get drugs I did everything. I had sex with homosexuals, I stole from my family and from strangers, whatever came up.”

Another man explained: “I prostituted myself with homosexuals and also with men.” This expression is typical of men who have sex with other men without considering themselves homosexuals owing to their active—penetrative—role. They call themselves men who have sex with men. It needs to be taken into account that messages about the “risks of homosexuality” don’t mean anything to these men, given that they consider themselves “very male” and are certain that the other one is the homosexual. Four out of ten men interviewed affirmed that they knew the meaning of the expression “three dishes”: oral, vaginal and anal sex with the same person and during the same session. Three out of ten said they had practiced it, although half of the interviewees did not respond to these two questions.

On the use of condoms, six out of ten men said they had never used one or only did “sometimes.” “If I have a condom with me, I use it. If I don’t, I don’t.” Under the effects of drugs, as with alcohol, they forget about condoms. “When I’m really crazy, I don’t use it.” Nevertheless, four out of ten men said they used one, above all with casual partners in a heterosexual or homosexual relationship. Only one in every ten—two women and fourteen men—said they always used a condom, even in a stable relationship. The main reason they gave for doing so was to avoid diseases, although some also used it to avoid pregnancies. The data obtained in this study on the use of condoms goes beyond that collected by the Demographic and Health Survey, ENDESA 2001, given that scarcely 3.3% of women of fertile age at a national level declared that they were using a condom.

The risks of drugs and the shadow of HIV

The individual interviews reflect a broad range of drug-related problems: kidney pain, hepatitis, heart problems, high blood pressure, anorexia, stomach problems, weight loss, respiratory or lung infections, emphysema, hemorrhoids, a change in the nervous system, sinusitis, hallucinations, panic attacks, hospital treatment for psychiatric problems—in both New York and Managua—and overdoses, as well as violence and injuries due to aggressive behavior or accidents.

A full 55% of the interviewees knew of someone who had died as a result of drugs, mainly from an overdose. One assured us that he knew of 20 people who had suffered overdoses. Seven men had at least one experience of an overdose. Eleven people—3 women and 8 men—said they had suffered from drug poisoning and 28—7 women and 21 men – felt susceptible to illnesses.

“Many of the people who have died from an overdose were on cocaine, I have known about eight,” said one man. “A friend of mine died from an overdose with crack,” said another. Another man had himself suffered a heroine overdose: “I went to the hospital because of a heroine overdose and was admitted for nearly a month. I injected myself with too much, first 6cc and then after five hours, another 6cc, and I began to froth at the mouth. When I realized, I was already in hospital.” They also mentioned situations in which drugs were the indirect cause of someone’s death. One of them was by accident: “He crossed a riverbed to buy drugs and the current swept him away.” The other case was suicide: “He came off drugs, but had a relapse and put a bullet through his head.”

As well as all these dangers, drugs increase the risk of sexually transmitted diseases, particularly HIV. Two out of every ten people interviewed in depth knew someone living with HIV and half knew someone who had died as a result of AIDS.

While73% considered that drugs increased the probability of contracting HIV, 30% admitted that the drugs led them to have sex without a condom. Only 16% identified the risk of sharing equipment—syringes and needles or the tube used for smoking crack—and 26% acknowledged that the risk came from sexual practices as much as from drugs. While 67% considered themselves to be at risk of HIV infection, 62% attributed it to their sexual practices without a condom and the other 5% related it to drugs. Only one person said it was possible to get infected with HIV through a blood transfusion.

Without protection:
Challenging or ignoring the danger

Some of the interviewees had had sexually transmitted diseases. One of them told us that he had suffered from gonorrhea (“purgation”), although he rejected that it might be as a result of sexual relations: “Once I got purgation, but it wasn’t from sexual relations; it was because I got a cold. This was about three years ago. I injected myself with procaine penicillin.” This way of thinking and acting—self medication—reflects ignorance and is a serious obstacle to fighting diseases and illnesses, including prevention of HIV.

In terms of preventive measures, 36% of the inter-viewees said they practiced safe sex by using a condom, although not all the time, 28% said they never used protection and 10.5% said they took the test for HIV antibodies—although the test doesn’t provide protection. Only 10% said they had just one partner and 8% said they protected themselves through sexual abstinence. The following expression demonstrates the idea of false security that people have about the test: “I already took the test and it came out negative.”

Those who don’t use protection usually adopt a challenging attitude towards the danger, or prefer to ignore it: “Yes, I know it’s dangerous, but in our neighborhood, we don’t pay any attention. We say that the more you think about it, the quicker you fall.” All the groups demonstrated that they had correct information about the forms of HIV transmission, but don’t always protect themselves. The sex workers assured us that they made their clients use condoms when they weren’t taking drugs, but admitted that they didn’t always do so under the effects of drugs. One male student spoke of the case of a young woman who prostituted herself on the street to get money to buy drugs. Another person said: “The syringe is what’s associated with AIDS, but when you’re high, you have sex without a condom.”

For now, people relate the risk of drugs to sexual relations: “Drugs lower your defenses. You don’t worry about using a condom. You have sex any old way.” Only some interviewees related the risk of sexually transmitted diseases to the sharing of needles or syringes for injecting drugs: “I like to inject heroine, but it’s very risky. My chronic hepatitis is because of sharing needles.”

Sharing needles and syringes to inject drugs is already an existing practice in Nicaragua, although the large majority of the population is unaware of this and the authorities don’t acknowledge it. According to official statistics, sharing syringes for injecting drugs produced 3% of HIV infections registered in Nicaragua. Four men who were interviewed said they had shared syringes and needles when using drugs. Another said he had seen several people inject themselves with the same needle and syringe, even though they were “disposable”: “Those who inject themselves tie their arms with a rubber strap and look for a vein. Several people use the same disposable syringe. A drug addict knows that AIDS can be passed through a syringe, but wants to get high, wants the trip.”

It’s necessary to highlight that people often think “disposable” needles by definition avoid the risk of transmitting HIV or other agents that cause illnesses such as hepatitis or syphilis. However, the risk lies in the fact that several people use the same needle without disinfecting it, independent of whether it is “disposable.”

How to rebuild these lives?

In the focus groups organized in Managua and Chinandega with relatives of people with drug addiction problems, a space was left for reflection on stigma and shame, which are strong obstacles to searching for help. One man said: “The most important problem is shame. The pain, suffering and sadness are what make us segregated.”

Attitudes of rejection towards the person with an addiction penetrate all family members. One mother recounted her experience: “I felt discrimination towards my daughter from my brothers, family and sister. They told me we should let her die in the streets. Why do you go after her like an idiot, looking for her? Leave her, let her die if that’s the life she wants.”

The in-depth interviews were also used to broach the subject of stigma—“people reject us.” People with addiction problems are seen as “lacking character” because they don’t deal with their problems. Or worse still: they are considered “garbage.” In Chinandega, people with drug addictions are thought to be criminals and a bad example for the community.

Nevertheless, some interviewees said that several organizations are working to educate the population and make people see that addiction is an illness. They mentioned various religious groups, NGOs and self help groups: Narcotics Anonymous, Alcoholics Anonymous and the “12 steps” program. These rehabilitation resources are available in Managua. One that started in Chinandega had to shut soon afterwards because of lack of financing.

In the focus group in Managua, a taxi driver said: “On several occasions I’ve gone to leave five, ten, I don’t know how many people at those education centers. I‘ve gone as far as San Marcos, as Hodera, to leave them at the rehabilitation center. In this way, I think I’ve contributed to their being able to quit drugs.”

“There are thousands of
young people with this illness”

In spite of these initiatives, all of the focus groups agreed that there are few programs and centers, either for prevention or for rehabilitation. Many of the programs are just beginning and don’t have specialized staff or treatments. One relative explained: “What’s most worrying is that there are no specialized clinics in the country, nor are there specialized therapists who can really give follow up or treatment. It’s very worrying because there are thousands of young people with this problem.” Six out of every ten people interviewed in depth, who had a long history of drug addiction, had never been to any rehabilitation program or center.

There’s no gender focus on the treatment for addiction, as turned out to be very clear in the two focus groups with sex workers; they said there were no resources to treat them. Stigma and discriminatory attitudes towards women with drug addictions are stronger than towards men and, given that the consumption patterns of men and women are also different, they require differentiated treatment strategies, which do not yet exist in Nicaragua.

One person who was interviewed was aware that an addiction was an illness: “Now the drug problem is seen as an illness and not as something amoral. It’s a psychological problem, of addiction. One is already an addict before using drugs.” But there’s strong resistance to recognizing this idea, which, in didactic form, is communicated in the successful Brazilian soap opera, “The Clone,” about the case of Mel.

In Managua, we found people who considered addiction an illness, but even health professionals were not hopeful about the attitude of their colleagues in the health sector: “They don’t accept it, even when we explain it to them.” A participant in the focus group in Managua insisted that for many health personnel, “the best way of curing addicts was to let them die or to kill them.”

What the interviewees propose are educational campaigns (67%). These campaigns would have to present live testimonies (6%) and promote use of the condom (6%). Only 1% said there was a need for more government support. One woman expressed the importance of educational campaigns in the following way: “It’s necessary to begin education from early childhood. To include information in school programs about the damage drugs cause in all areas of your life.”

Alone in the face of drugs and addiction

Most of the factors contributing to the growth of the HIV epidemic are also present in the drugs epidemic: poverty, internal and external emigration and the large population displacement. In the past this was because of the war, sometimes because of natural disasters and in a silent and permanent way because of economic reasons. Other factors include the sexual exploitation of children and teenagers, transactional sex, the new scenarios brought by tourism, the influence of drug trafficking on the domestic market, especially among young people, the stigma surrounding homosexuality, the borders with countries that are transit routes for drug trafficking, unemployment, the lack of educational opportunities for women and for young men….

All these factors feed the growing supply of drugs. It’s easy to find them. There’s an established distribution network and a general perception—not to mention serious indications—that the authorities are participating in drug trafficking. In the face of all this, the community and school education programs to prevent drug use are insufficient and the resources for treatment of addictions are limited.

Taxi drivers, who are real empirical psychologists, witness the many hidden faces of drugs. Among them and all the other groups we explored, the concern for young people stands out—concern for girls and boys, older and younger, whom, in their eyes, have been left by society and the government to deal with drugs and addiction alone.

The mistake that would explain this “aloneness” has been to consider Nicaragua as just a transit route for drug trafficking. Based on this idea, strategies have been developed to repress drug trafficking, but forgotten in some drawer is everything related to preventive and non-punitive education. It is urgent to reflect and rectify this mistake. Surely it’s now time for a national alert. For the future’s sake.

Nimehuatzin Foundation is a Nicaraguan organization specializing in AIDS prevention based on sustainable human development.

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