Prática educativa com jovens usuários de crack visando a prevenção do HIV/AIDS* Practice with young crack users aiming the prevention of HIV/AIDS Práctica educativa con jóvenes usuarios de crack visando la prevención del VIH/SIDA

Objective: To report educational intervention with young crack users in order to prevent HIV/AIDS, using the Culture Circle methodology. Methods: Qualitative research, conducted in 2012 with 10 young crack users in a therapeutic community in Fortaleza-CE. Data collection included participant observation with field journal; photographic recording and filming; and, as production of the group, Puppet Theater. Results: Culture Circle has enabled young people to reveal their main vulnerabilities to HIV/AIDS as the sharing of straws and pipes in the use of cocaine/crack and loss of consciousness as influential in the diversity of sexual partners and not using condoms during sexual intercourses. Conclusion: The educational intervention has created possibilities for the insertion of the nurse in the therapeutic community setting, in order to strengthen the assembling of networks for the prevention work of HIV/AIDS among crack users.


INTRODUCTION
Crack is a public health problem of the first order because of the serious health and social consequences related to its use, such as high rates of violence, high rates of mortality, transmission of infectious diseases and family and social separation among users 1 .
In the same decade of the explosion of Acquired Immunodeficiency Syndrome (AIDS), crack became popular in the United States.At the end of the 1980s, emerged the first epidemiological evidences of increased risk of sexually transmitted infections (STI), including infections caused by Human Immunodeficiency Virus (HIV), on crack users 2 .
According to a survey held in 2012 by Fundação Oswaldo Cruz (FIOCRUZ), Brazil had 384,356 users of crack/similar.Of this total, about a third had between 18 to 24 years and were predominantly male.This study showed a prevalence of HIV infection among these users of 4.97%, approximately eight times the estimated HIV prevalence for the Brazilian general population 3 .
One of the possible mechanisms that explain the higher prevalence of HIV among non-injecting drug users (NIDUs) compared to the general population is the "bridge" between Injecting Drug Users (IDUs) and NIDUs, which can transmit HIV and other STIs through sexual relations, besides the possibility of infection through sharing equipment for drugs consumption 3 .
In addition, drug users often have sores on the nose and on the mouth, which can facilitate viral transmission.Another explanation may be related to high frequency of unprotected sexual practice, especially among users of stimulants, such as crack, cocaine and methamphetamine.
The crack consumption has been directly associated with HIV infection, and the most common risky behaviors observed are the high number of partners, unprotected sex and commercial sex for crack or money, to purchase the drug 4,5 .
The vulnerability of crack users to HIV is not restricted only to the risk of infection, but also to the worst disease evolution.This is because the drug can reduce the immune responses and interfere with the ability of the body's defense against infections 6 .
When considering the epidemiological and clinical relevance, 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 customers, it is imperative that the nursing professional take ownership of this problem and develop strategies for prevention, early detection and treatment that consider the peculiarities of users of crack/similar.
Based on the above, arose the following question: Which educational strategy nursing can develop to work the prevention of HIV and AIDS among young crack users?
Thus, this article aimed to report the educational intervention with young users of crack aiming at prevention of HIV/AIDS, using the Culture Circle methodology.

METHODS
Qualitative research, based on the Culture Circle 7 methodology.This is a space for work, research, dynamics and experiences that enable the development of collective knowledge and critical reflection of the environment in which the subject is inserted.
The educational intervention followed the stages of theoretical method of Paulo Freire, adapting them to the achievement of the proposed objectives: discovery of vocabulary universe; dynamics of awareness and refuge; building situations for questioning -work the guiding question(s); theoretical and scientific basis, encouraging critical reflection; synthesis of what was experienced; and evaluation 8 .
Participated in this study ten young users of crack attended at a reference therapeutic community of Fortaleza, which is dedicated to the work of prevention of drug abuse and to physical, psychological and spiritual recovery of the chemical dependent, as well as to their reintegration into society, without distinction of race, social status, political or religious denomination.
For the selection of subjects, it was used the inclusion criteria: male, users of the treatment units/clinic for drug addicts and who reported having made use of crack.It was adopted as the age group of young people an indication of the United Nations, which indicates that this is an individual between 15 and 24 years old 9 .
Data collection occurred in two moments: visits to the therapeutic community -held in the months from January to April -and educational meeting guided by the principles of the Culture Circle, held in May of 2012 -including participant observation with annotations in a field journal, photographic recording and filming, as production of the group, puppet theater.
In total, there were four visits carried out by the researcher and by a member of the AIDS Project: Education and Prevention, lasting 1 hour, all on the morning shift.The educational meeting lasted two and a half hours, took place on the premises of the therapeutic community and was mediated by the researchers.
For analysis of the information it was used the triangulation of data, whose process refers to convergence or corroboration of data obtained by different methods and techniques used in research, aiming at quality, depth and validity of qualitative analysis 10 .
It is also proposed to the researcher a critical and broad analysis on the interpretation of empirical material extracted.This process took place through detailed description of events occurring in the Culture Circle, from the statements of the subject, observations, participation in discussions, experience of group activities with emphasis on the production of puppet theater, feature used for questioning of vulnerability to HIV/AIDS, and the meaning of educational experience in the Culture Circle by those involved.
The interpretation of the material took place in dialogue with the pertinent literature on the subject, with consideration of theoretical bases deemed relevant and enriching to the critical study of the speeches.

Educational practice with young crack users
Pinto ACS, Beserra EP, Luna IT, Bezerra LLAL, Pinheiro PNC The study followed ethical and legal aspects of research involving human beings 11 , and it was approved by the Research Ethics Committee of the Universidade Federal do Ceará (COMEPE), protocol No. 303/11.The Informed Consent (IC) was signed by young people and their guardians.In this sense, young people have been identified by the term user (U) followed by a number of the sequence of speeches (U1, U2, U3 and successively).

RESULTS AND DISCUSSION
The ten young participants in this study were male and ranged between 18 and 24 years.Regarding the level of education, one of the respondents had not completed elementary school, two did complete it, five adolescents had not concluded high school and only two had a high school degree.
As for marital status, two were married, two lived as married couples and six said they were single.Most of the teenagers had some kind of informal employment and were away from work to treat the crack addiction, since it was impossible to work under the effect of the drug.

Visits to the Therapeutic Community -determining the vocabulary context
The stage of the discovery of the universal vocabulary of young people was held at the first moment of stage of visits to the therapeutic community, which allowed the immersion of the researcher in the convivial setting of the young people, the participation in activities carried out by the institution, the recognition of its mission and also the rules and routines of the two types of treatment (outpatient and inpatient), and also the work done by professionals who worked there.
In the clinic, the participants have a minimum age of ten years and are of both sexes, may be people in the community who are chemically dependent or ex-intern.The chemical dependent participates in individual and group consultations in the following areas: Psychology (Psychotherapy), Social Service, Occupational Therapy and Christian Orientation.It is also offered supplementary education for Elementary and High School.
In the internment center are offered the same individual and group consultations, in addition, it has the labortheraphy, sports and leisure, productive workshops, family visits and visits from internal to their houses, which are scheduled.This center is unique to men over 16 years, who stay for a period of seven months, and may extend up to nine by the assessment of the technical team.
Factors related to the treatment of the chemical dependent, as appropriate staff to care of young people, enabling the bond and welcoming, promote involvement in the treatment and the implementation of activities more interesting and motivating to the young people 12 .
The approach occured through four visits.At the end of the last, it were questioned the reasons that motives the adolescents to use drugs, if they knew something about HIV/AIDS and if they considered themselves vulnerable to this disease as drug users.Then, proceeded to the explanation of the objectives and strategies to be built along with the young people who would participate.
It was possible to understand the social space of coexistence of young people, knowing their tastes, preferences, habits, stories and life experiences, as well as the way they relate to others.The visits were paramount, given the need to conduct educational practice in which learning becomes an act based on the actual situation experienced by the youth group, as well as a result of a critical approach of this reality.
The circle of Culture constituted a space for meeting and discovery of the other as subjects and experiences that need to be uncovered from the dialogue in the group, participation in discussions, exchange of knowledge and experiences.Thus, knowing their culture is necessary factor in this process 13 .

Culture Circle -vulnerability of young users of cocaine/crack to HIV/AIDS
The circle happened from the reflections that began in earlier time and according to the answers of the questions made to them in the last visit to the therapeutic community.From the reports, it became clear that the majority of young did not have adequate knowledge about HIV/AIDS, according to the speech of U7, 19 years:

I know almost nothing, only that aids is an infectious disease, that the person has sexual relations then get the disease, or it happen consuming drugs too? (U7)
It was identified that some of them do not recognize or do not know if they are vulnerable to HIV/AIDS because they are drug users, in the case of the study, cocaine/crack, although most stated there is a link:

I don't think drug consumption is related with HIV, because the drugged person is aware of what it does. (U8) I think it has, with the injectable drug. (U10)
Yes, we're vulnerable because there are women who prostitute themselves to use drugs, so she has many sexual partners and becomes infected without knowing, and the person who is not infected will have sex with that woman, even sometimes also by the drug, or because of the drug, and gets infected too.(U1) In this sense, the circle began by displaying an educational video about the effects of crack in the body.Then, another video was shown: What is HIV?This strategy aimed to deepen the knowledge about the effects of drugs and about HIV/AIDS in order to provide subsidies to enrich further discussions with the group about the proposed theme.
In a study, using videos as provocateurs of discussion in Culture Circle, in the life breath activity, there was the perception of the drug as harmful agent for the young, a one-way street Educational practice with young crack users Pinto ACS, Beserra EP, Luna IT, Bezerra LLAL, Pinheiro PNC with repercussions in different instances in family and social life, as well as the idea of preventive method attributed to the non-exposure to them.Therefore, these are means that promote reflection 14 .
By using the resources of the videos, the process of decision-making was facilitated and delivered care, providing to the subject space for reflection about the problematic of vulnerability of them to HIV/AIDS 15 .
At the end of the presentations of the videos, conversation circles were promoted, asking to young people what their perceptions on the content exposed are, what they addressed and what questions they would like to clarify together.Thus, the following lines are emerged: Everything that was spoken in the video is true, and I did not know that I could have had intoxication by aluminum for smoking crack, it was great to know how I felt in more detail and clarified.(U4) This question of hygiene is serious; we don't even remember to take care of ourselves.(U7) We don't have need of food, by the way, we don't feel hungry.(U3)

This history of adrenaline and dopamine is very interesting. (U1)
The speech fragments show that young people already knew many crack effects in the body, although they have been surprised by the issue of aluminum intoxication, the adrenaline and dopamine liberation and why they always want to use more drugs and failing to stop.
The aluminum intoxication may occur during the process of firing and burning crack, which is sold in the form of stone and needs to be heated to release the smoke that is inhaled or smoked.It is very common that the crack user makes use of cans of soda or beer to throw the pebble inside.With a lighter, it heats up the can and, consequently, the stone also, which turns out to release the smoke that will be quickly vacuumed by the individual, passing into the bloodstream and then to the brain in seconds.This form of consumption makes aluminum also release from the can and part of the smoke that is aspirated by the individual.This aluminum enters into bloodstream and is distributed throughout the body, causing damage to the brain, bone and kidney 16 .None of the young people in the study reported knowing this consequence of the use and were surprised by the possibility of being intoxicated by aluminum.
The crack has anorexic effect by reducing the sense of hunger of the individual who not eating well, and will have deficiency of protein, vitamins and minerals, leaving the body weakened quickly, also damaging the immune system and opening up possibilities of infections in many ways.In addition, this drug inhibits sleep, leaving the individual without sleeping for long periods, until the body cannot stand this state of alert and the subject "goes out".When it wakes up, will look for something to eat, then go after the drug again, which is its only reason for living.In discussing this point with the young respondents, it was noticed how thin they arrived to start the treatment 17 .At the time of the circle, they made "sarcasm" of their skeletal images, but revealed that they were unrecognizable of such thinness.
About the effects of crack in the heart, it is known that the drug inhibits the removal of the dopamine that is released constantly by the brain, causing induction of the release of adrenaline too, causing an increase of heartrate and blood pressure, and thereby increasing the risk of myocardial infarction and stroke 18 .
As for muscles, this drug causes irreversible degeneration of the musculature, called rhabdomyolysis.In addition, on the neurological system, the crack causes lesions on the brain and consequent loss of neurons, resulting in memory loss, difficulty concentrating and variations in mood more frequently, leading the subject to a severe emotional instability 17,18 .
These feelings were evident during the contact with the adolescents, because, according to the following reports, they did not remember neither the name of the partner who they were having relationship, or information which had been shown in a lecture a week ago, demonstrated instability in mood and considerable difficulty concentrating:

I'm dating with a girl, but I don't remember her name (laughs). Not because she didn't tell me, but because I forget. (U2) I attended a lecture about STDs last week and now I cannot remember what the girl told me, so I couldn't answer you. (U6) I wish that you would put on our meeting activities where we could move, make crafts, because we concentrate more. (U10)
As for the harms of the drug, the individual may also present psychiatric disorders such as psychosis, in which the subject reveals a bipolar disorder frame, persecutory paranoia or persecution mania, in which he feels constantly pursued and thinks that there is always someone trying to harm him, the police wants to catch him, everything bad is looking for him and he needs to hide.Hallucinations and delusions also occur frequently, according to reports of the adolescents:

I spent the big part of the day on the beach, when I went to the parties in the nightclubs, and I used cocaine and ecstasy, I kept seeing wave, fish, things flashing all the time. (U3)
In relation to sexual activity, at the beginning of the use of the drug, the subject feels more sexually active, but then occurs the reverse process and the boys start to have difficulty in Educational practice with young crack users Pinto ACS, Beserra EP, Luna IT, Bezerra LLAL, Pinheiro PNC erection, in addition to gradually lose interest in sex, as the drug provide a greater sense of pleasure than the sexual act properly.In this sense, the users, in order to get money to buy drugs and continue feeling pleasure, start practicing prostitution and becoming vulnerable to contraction of serious STIs, particularly AIDS, considering that the evolution of this disease in a very weakened body occurs quickly.An aggravating factor in this situation is that, in many cases, users do not seek treatment.U2 was the one who revealed to have had a STI:

Just one time I have a STD, what people say harming, but the doctor just gave me some medicine and an injection. The doctor also did not tell me the name, just passed the medicines. (U2)
Another consequence of the use of crack is the lack of hygiene.Users lose interest for basic hygiene habits, such as shower, brush the teeth, etc. U7 was the only one who spoke about it: This question of hygiene is serious; we didn't even remember to take care of ourselves.(U7) Through the speeches and discussions of young people about drugs and STI, it turns out that their knowledge requires the need for an intervention work of community nursing in favor of these young people, on the control of this vulnerability 19 .
As for the video about HIV, the following questions came up: Most of the adolescents did not know the difference between HIV and AIDS.This permeated all the discussion about the video.It was possible, based on the curiosity of the subject, talk about AIDS in its full issues' dimension.One study that addressed the prevention of HIV/AIDS with adolescents belonging to religious groups 20 and others who worked the same theme with teenagers that lived on the streets 21 also discussed the same issues dealt with young people in this circle: the difference between HIV and AIDS; opportunistic diseases; their transmission and their prevention; myths and taboos; the diagnostic tests; the origin of this disease.Relevant themes referring to the issue of HIV/ AIDS which is then funneled to each specific population studied.
After these discussions based on the videos, dramatization was used to help in the process of collective deconstruction, construction and reconstruction.The group was asked to prepare and present two dramatizations using the puppet theater, and was divided into three subgroups.The first represented the following situation: the drug use and HIV infection; the second represented the use of drugs and no HIV contamination; and the third represented the jury to judge the best presentation.
The first presentation: the drug use and HIV infection with music in the background of the presentation (Figure 1).José: Hey, Marcela, are you all right?The party is good.Let's get anything to drink?Marcela: No, thanks.Tonight you will not catch me.We can just dance.José: Well, let's dance.Marcela: Oh, my God, he's kissing me... João: Hey guys, are you okay?Let's have some drugs.I have here to sell.José: Yes, dude.Right, Marcela?Marcela: I don't want anything.John: Look, I have marijuana, good stone and cocaine.José: Well, give me fifty reais of the good stone, dude.João: Here you are.José: Thanks.Look, Marcela, I bought fifity reais in good stone for us.Let's go to the restroom?Marcela: All right.José: Oh, that's crazy, let's go to a hotel, sweet?Marcela: Yes, I'm stoned.José: Let's have sex, Marcela, take your clothes off, I'm crazy.Marcela did not think and took her clothes off, and they had sex without mentioning the possibility of using a condom.The end! Educational practice with young crack users Pinto ACS, Beserra EP, Luna IT, Bezerra LLAL, Pinheiro PNC The study with the boys on the streets also used drama as a way of learning to talk about risky behavior and safe behavior on STI/AIDS.For them, this activity was motivating, since among the teenagers was one that had circus experience and was familiar with this kind of creation, showing skills in the construction of small plays, making that the interest and creativity of colleagues increase, making it a very enjoyable activity, as well as it was for the study group 21 .
When I was on drugs, I "had many relations" with people who were cocaine/crack users, and I had sex for money or drugs, but I used a condom in every relationship.On the speeches, the adolescents revealed a worrying scenario, where the consumption of drugs, especially crack, has been strongly associated with a possible HIV infection.The most frequent risk behaviors were the large number of partners, sex for money or drugs and loss of consciousness, which favors non-use of condoms during the intercourses.Moreover, none of the adolescents reported knowing of the possibility of HIV infection through sharing straws and pipes for use of cocaine and crack, respectively.
Nursing plays an important role in promoting the health of individuals, since it encourages reflection about their lifestyles, in order to turn them into individuals capable to take healthy decisions, but also to be protagonists in the fight for their rights.It is important to debate the actual situation experienced by specific groups so that the individual seeks to identify the vulnerability in its context.
For Freire, teaching and learning cannot take place outside of demand, out of prettiness and happiness.It is necessary to persist not thinking that the educational practice lived with affection and joy dispenses the serious scientific formation and the clarity of educators and students.The educational practice is that: affection, happiness, scientific capacity, technical domain in service of change or, unfortunately, today's permanence 23 .
The following presents the second dramatization: the use of drugs and no HIV contamination (Figure 2).In the evaluation of young people, the theatre with puppets was the best and most fun way to learn.The challenge to plan and present a dramatization of short duration was very motivating and, at the same time, marked by several difficulties presented by young people, as regards to the ease of staging, even with the puppets.But, at the end of creation, it was realized how pleasant for them it was to portray the drama of the real context in which they were inserted.
In the Nursing field, theater is a practice commonly used in the health education of the population that aims for creativity and communication, in a playful perspective, facilitating the teachinglearning process.This method also allows introducing an educational work with diverse themes in a cheerful and relaxed atmosphere, generating charged expressions of freedom 22 .
In the opinion of the jury, group two was better, letting everybody very happy and satisfied.

It was really cool, and it is because we have no experience, but next time will be better. (U5)
It was a lot of fun while we were learning; we were giving many laughs with the performance of our colleagues.(U10) Educational practice with young crack users Pinto ACS, Beserra EP, Luna IT, Bezerra LLAL, Pinheiro PNC In this sense, young people evaluated the meeting with various feelings aroused that day: I loved this day.When it is the day that the lady comes, we wake up at 5am. (U5)

It was really cool. (U4)
It was noticed in the dramatizations, that the participants showed faithfully the vulnerability of drug users, especially the crack users, as for HIV/AIDS.From this experience, the adolescents understand the relation between being a drug user and increased vulnerability to HIV/AIDS.
It is important to consider in the treatment of substance abuse, strategies based on therapy, including the behavioral and therapies focused on the family, for the use of medicine, as well as education for the diverse situations of vulnerability that can be experience.Among these, the infection or transmission of STIs 24 .

FINAL CONSIDERATIONS
The development of this study made possible to conduct an educative intervention with young users of crack about the vulnerability of them to HIV/AIDS in the therapeutic community.
It was evident that the approach of this issue for young people is very complex, especially because the subject involves their intimacy.To break this barrier, it was tried to use a dynamic and playful educational resource, approaching their reality in order to make them feel comfortable to participate spontaneously, without fears and shames of the colleagues, building the knowledge collaboratively during the educative intervention.
The problematization provided by the Culture Circle enabled the young crack users the unveiling of their vulnerability to HIV/ AIDS, since the prior knowledge of these adolescents about the disease was incipient and with the predominance of myths.Then, with the group discussion, it was possible to recognize that the sharing of straws and pipes for the use of cocaine/crack and the loss of consciousness favored the non-use of condoms during sexual intercourses and multiplicity of partners, thereby increasing the risk of HIV/AIDS infection.
The educative intervention has created possibilities for the insertion of nurses in the therapeutic community scenario, in order to strengthen network for HIV/AIDS prevention work among crack users.
It is important to highlight the limitations of the study: the teenagers did not have in their continuous process of treatment reflective practices that can take them to adopting a proactive during the actions taken and the lack of continuity of educational activities with the purpose of promoting a process of recovery of these subjects.
It should be emphasized the necessity on further studies with a larger sample and using instruments that allow the evaluation of the Culture Circle as a methodological strategy that favors the construction of critical and reflective space on the prevention of HIV/AIDS among young users of crack.
do we do this HIV test?What are the types?Can pregnant women do?Is it fast or normal?But now I want to know where did the AIDS come from?How does it appear?(U5) Doctor, what is the difference between HIV and AIDS?Is it the same thing or not?(U1) I don't understand the concept of immunological window, can you explain it again?(U7) I heard that the AIDS virus is hidden in the bone marrow, is it true?(U8) The person does not die of AIDS, it dies because of the opportunistic diseases.(U3) Now I'm worried thinking that the pipe I was smoking crack, if I shared it, I could have been infected with HIV.(U6)

Figure 1 .
Figure 1.Preparation and dramatization about the drug use and the HIV contamination produced by the young people during the Culture Circle.
(U1) I think some situations experienced by me could have facilitated HIV infection: when making homemade tattoo, when using drugs and when I took multiple stab wounds in a fight.(U2) I had sexual intercourse with women crack users.(U3) I believe that there is an association between being user of drugs and HIV infection, since the individual is vulnerable because of the effect of the drug, and that sometimes the person wanted to have sex, have sex with someone and not remember wanting to protect yourself, use a condom.(U5) I believe that by not having sexual intercourse, I had no risk of being infected by the virus.(U7) I got sexually involved with many prostitutes and women drug users.(U8)

Figure 2 .
Figure 2. Preparation and dramatization about the use of drugs and not HIV contamination produced by the young people during the culture Circle.