Luis Guilherme Paiva, National Secretary for Drug Policy, Brazil. The idea here is not to give a description of the programmes. We want this to be a roundtable event. We will have minutes for panellists, then a round of questions among them, and we will then open questions from the floor.

Luciana Temer, Secretary for social Assistance of Sao Paulo, Brazil. The Open Arms programme, when we talk about it, we are facing a specific portrait. It’s people who live in the streets and use drugs in the street. It’s a huge problem in Sao Paulo. The old town is a significant place in Sao Paulo and for years we have talked about people being there all day, all night using drugs. In 2012, the government tried a very repressive action. It was very sad because the government thought the problem would be solved via compulsory treatment. People would be hospitalised, be treated and you’d solve the problem. This was not. It was a lot of suffering and things remained the same when the police left. In 2014, the mayor made another plan. The Secretary of Health and Social Assistance organised equipment, and made contact with them to understand how to help them. We offered food, bathrooms, social assistance, etc. People started to come and after 4 months the group was very close to us and we started the dismantlement of the shacks. They said to us – we will dismantle the shacks if you give us a place to stay. They couldn’t believe that the municipality would give them a house, food, work – they thought we were joking. They believed when the day arrived. We came to dismantle the shacks and brought them to hotels. They then started to work with us, 4h a day. We helped them organise themselves. That’s what the work is for. Sometimes they didn’t sleep in the places, staying all day long in the street, but if they want to have a place to go, they know they have one. Same for food – they started to eat and become healthy. They said at the beginning that they would buy drugs with the money made. But then the said we’ll buy drugs and chocolates, then drugs and washing products. They also started writing, playing sports, doing music, etc. We pay 30 dollars a week to them and they have access to medical and social assistance campaigns. It worked very well. This integrated policy includes 5 secretaries. The approach to address the social problems in addition to health problems was very important. People know each other very well, they laugh together, they cry together… How do we know it works? We have a large group of public servants that since the beginning are suffering too much but don’t give up because they see people growing and changing.

Luis. What we’ve seen is that people are very vulnerable, many use many different drugs, many are willing to participate in treatment programmes. It was clear that we had to design programmes that could be accepted by these people.

Adilson Pires, Deputy Mayor and Secretary for Social Development of Rio de Janeiro, Brazil. When we took office, we knew things weren’t right but we didn’t know what to do and change the policy. With the help of many partners such as OSF, City of Vancouver and Lisboa, partners received us, we saw what was being done worldwide in 2014 onwards. Now we have policies based on drug practices worldwide and adapted them to Rio de Janeiro. The Rio Social Department has a reliable line of public servants who used what they were learning abroad. One of the results of this experience. The policy used in crack land was inspiring, we established links with drug users in these vulnerable areas. Since the programme began 2 years ago, we have an average of 442 monthly procedures dealt with by a multidisciplinary team of health care, social assistance, etc. There is an established trust between our professionals and users of the services we provide. What we saw on TV was that when the team from the city hall approached, we had drug users fleeing. This created chaos, especially in the main avenue of Brazil, with people involved in accidents by fleeing our teams. Now it’s not happening any more. Proximidade was a first pilot programme which has showed great results. It is being replicated in different areas of the city, in crackland but also in other areas. I want to thank you all for the invitation.

Liz Evans, Founder and former Executive Director of PHS Community Services Society, Vancouver, Canada. There is a lot of synergies between Vancouver and Bracos Abertos. I have had the privilege to go to Sao Paulo and Rio. In 1981, we opened a hotel in Vancouver for drug users, it was the first time this was happening and it was controversial. It was the first confrontation with the police – they didn’t understand what we were doing. The focus of the project was to improve people’s lives. That hotel with 70 people that was so controversial redefined later the policy of the provincial government. This was important in how we delivered healthcare. The public conversation was important. Police initially was very reluctant. There is now constant public dialogue. When you talk to police, they don’t see it as their job to facilitate health care, but they will be diverting people towards the safe injection site if they inject in the street. But we needed a lot of activism and public debate to get to that point.

Luis. Thanks for giving us perspective on the timeframe! The Attitude Programme developed to first reduce violence.

Sarah Evans. Luis explained the focus of this Attitude Programme – it was about violence reduction and homicide reduction. It’s around making a social connection and point of inclusion for highly stigmatised people. When violence is happening and there is no social response people feel they don’t matter. So we create a point of connection for people and get the off the street with housing programmes. People can access therapeutic programmes and live with a community, and other programmes include case management and rent, away from violence after they’ve gone through the programme. The programme is a continuum between these services and people can go back and forth. You meet people where they are at in their drug use and recovery. We have just done some evaluation of the programme which is not published yet. It’s about 300 pages long in Portuguese, but it’s clear that participants reported suffering from threats before and 70% reported being safer in the programme. 97% of people would recommend the programme to their friends, and reported many positive effects of the programmes. But there are limitations too.

Questions and answers

Person from Canada. With everything happening now, and with the SDGs, there are two questions – first is containment to deal with such an amount of flows going on in the country? Second is there enough subsidies granted to the programmes?

Bahamas. I am a member of a treatment centre as well, there are co-occurring concerns such as drug use and mental illness. How are you dealing with this?

IDPC. Do you have programmes specifically focused on women?

Luis. we are finding that the main problems with drug policies is that the efforts are not coordinated. Most programmes are well covered, we have lots of money in our budget for housing programmes and for healthcare services. We have well established social care programmes. So when we establish this cross-cutting programme, it takes more coordination than money. You have to keep some budget for people who use drugs, and you have to convince policy makers that they are a priority. It’s about having people who use drugs as entitled to access these services. These programmes made it easier for us to influence national level policies, we are trying to establish a narrative, that these programmes are worth it. We are establishing programmes in more than 20 cities. On the second question, I’m happy to have here the coordinator of the HIV programme in the Ministry of Health.

Fabio Mesquita. We’re talking about stimulants and crack. In Brazil we have more than 300 centres for psychosocial support for stimulant users that are evidence based. Some are specialised in alcohol and drugs, and are very well respected in the community. They have done a very interesting work to reinsert people in their lives. This works well for stimulant users. We also provide ART for all those living with HIV, as well has hep C treatment for free for many years now.

Adilson Pires. Regarding gender, we conducted a census in Rio, we saw 5,500 people living in the street. One of the most important issues was the situation of women living in the streets and using drugs. Many are pregnant or have small children with them. Pregnant women, once they give birth, the law orients the children to the care of the city hall. We conducted interviews with 333 women and came to the numbers: 291 women had already been pregnant before, there had been 319 abortions due to the street situation, 2.7 pregnancies per women, 765 children alive with the women in the streets. As a result, we approached the problem by developing a programme financed by the federal government to create Casa Viva, focused on pregnant women who use drugs, where they are able to keep their children. We work on the maternal instincts of women to build their strength and get out of drug use problems.

Luciana. We have a specific worry as they get pregnant all the time, sometimes unwillingly. We give them an injection if they want to, for 6 months so that they don’t get pregnant. It’s difficult to work with women who are pregnant and worry about their children. We therefore offer this programme to prevent unwanted pregnancy.

Luis. we’ve overcome the resistance from the public. We discussed earlier that we need to overcome public debate with evidence based approaches, I hope this project will enable us to do that.