Use of Psychoactive Substances and Risky Behavior

The article by Bastos et al 1 (2008), published in the Re-vista de Saúde Pública, forms an important contribution towards studies on the use of psychoactive substances and their relationship with behavior leading to risks to sexual and reproductive health. As the authors emphasize in their introduction, there are many health problems relating to the use of alcohol and other substances, which makes it extremely relevant to study them on a population basis in Brazil. The aim of this letter is to highlight certain points relating to alcohol use that, in our opinion, were insuffi ciently discussed by these authors. The fi rst of these points relates to the notion of regular use. The authors established that the consumption of alcoholic drinks more than four times a week constituted regular use, through the question: " Have you, at any time of life, started to drink regularly (more than four times a week)? ". Although " frequency " is a signifi cant marker, recent studies have emphasized the importance of also assessing the quantity of alcohol consumed on each occasion, given the relationship between quantity and health problems. 6 In fact, frequent use is not necessarily risky use, and it may even be associated with protective factors. A study conducted among men whose lifestyle was considered healthy (nonsmokers with adequate diets, body mass index less than 25 and daily practice of physical activity) found decreased risk of myocardial infarct among those who consumed between 5.0 and 29.9g of alcohol per day, in comparison with those who abstained from all alcohol. 4 Although the defi nitions vary, risky use (" binge drinking ") is considered to consist of the intake of four or more drinks per occasion for women and fi ve or more for men, within a short space of time. 3 Laranjeira et al, 5 from a national sample, estimated that the prevalence of risky use in Brazil was 14% among men and 3% among women. In the study by Bastos et al, 1 among those who consumed alcohol frequently, there are subjects who consumed large quantities alongside others who consumed small quantities per occasion, which may have affected the analyses. Taking condom use as an example, it can be seen that the authors did not fi nd any association between " not using condoms " and making frequent use of alcohol. This probably occurred because subjects with very different …

The fi rst of these points relates to the notion of regular use.The authors established that the consumption of alcoholic drinks more than four times a week constituted regular use, through the question: "Have you, at any time of life, started to drink regularly (more than four times a week)?".Although "frequency" is a signifi cant marker, recent studies have emphasized the importance of also assessing the quantity of alcohol consumed on each occasion, given the relationship between quantity and health problems. 6In fact, frequent use is not necessarily risky use, and it may even be associated with protective factors.A study conducted among men whose lifestyle was considered healthy (nonsmokers with adequate diets, body mass index less than 25 and daily practice of physical activity) found decreased risk of myocardial infarct among those who consumed between 5.0 and 29.9g of alcohol per day, in comparison with those who abstained from all alcohol. 4though the defi nitions vary, risky use ("binge drinking") is considered to consist of the intake of four or more drinks per occasion for women and fi ve or more for men, within a short space of time. 3Laranjeira et al, 5 from a national sample, estimated that the prevalence of risky use in Brazil was 14% among men and 3% among women.In the study by Bastos et al, 1 among those who consumed alcohol frequently, there are subjects who consumed large quantities alongside others who consumed small quantities per occasion, which may have affected the analyses.Taking condom use as an example, it can be seen that the authors did not fi nd any association between "not using condoms" and making frequent use of alcohol.This probably occurred because subjects with very different patterns of alcohol use were combined into the same category.If it were possible to separate them, it is possible that the association between unsafe sex and binge drinking would have been shown to be signifi cant, as recent studies have indicated. 2nally, we wish to congratulate the authors for accomplishing this study, while adding that cross-sectional studies that cover different aspects of general health -such as alcohol and sexual and reproductive health -are still necessary in Brazil.Research of this nature will make it possible to identify behavioral changes that are taking place in this country, thus identifying groups that are at risk and providing support for creating public policies.

Maria Cristina Pereira Lima
Florence Kerr Correa Faculdade de Medicina de Botucatu The deepest lesson I ever read on such issue was written by J.L. Borges, in a single-paragraph text called "Del rigor en la ciencia". 2Borges told us about a kingdom where the art of cartography had reached such a high standard of perfection that the available maps could no longer satisfy the royal cartographers.With the progressive enlargement and sophistication of the successive maps, a giant map was fi nally created, reproducing every minute detail of the kingdom, in a one by one correspondence with the original geography.The huge map proved however to be useless and cumbersome, functioning rather as an impediment of the free movement of people and sunlight.The map became a ragged amount of paper, serving as a hide for animals and beggars, whereas geography was crowned as the kingdom's highest creed.

Ligia Regina Franco Sansigolo Universidade Federal do Ceará
Briefl y, we capture what the very mesh (loose or tight) of the nets we throw on reality afford us to catch (or lose).In our paper, we analyze data from a large survey, representative of Brazil's urban population, with the main purpose to evaluate data on sexual and reproductive health, in the context of HIV/AIDS.The section on the use and misuse of alcohol and illicit drugs was a small component of a comprehensive questionnaire, highlighting other issues.In this sense, the reasoning by Lima, Correa and Sansigolo that assessments on drug consume should be integrated with additional data, such as information on nutrition, body index, and physical activity is absolutely right, but goes beyond the data collected by our survey.
Much possibly, we oversimplifi ed our assessment, choosing too broad criteria to defi ne the regular consume of alcohol, but our choice was motivated by the key need to have statistical power to analyze a set of relatively sparse events in this household survey targeting the so-called "general population".This constitutes a clear limitation, speaking in favor of alternative designs, targeting specifi c populations or maybe twostage surveys, beginning with a screening of the general population, followed by a detailed assessment of the characteristics of vulnerable populations (e.g.their drinking patterns).
We agree also that literature highlights the benefi cial effects of the moderate ingestion of alcohol on cardiovascular parameters, in the context of healthy habits, 3 but our analysis are restricted to the interrelationships between substance use and risk behaviors related to the acquisition of HIV and other sexually transmitted infections, as well as unplanned pregnancies.Much probably, some of the putative associations pointed out by Lima, Correa and Sansigolo were not made evident by the strategy used by our group, either due to the sparseness of some events and the broad defi nition of what constitutes regular drinking.A recent paper 1 analyzes data collected by our research group in Rio, as well as data from other 11 cities from developing countries.Such fi ndings clearly demonstrate that hazardous drinking constitutes an independent risk factor for HIV acquisition, among injecting drug users.
Much has to be investigated respecting the complex interrelationship between substance misuse and sexuality.We hope our conclusion that such issues should

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be always viewed in an integrated perspective, both in terms of the research agenda and preventive interventions, could be further pursued.We also hope that the provisional cartography of such subtle interrelationships does not follow the infamous fate of Borges' huge but useless map.
Francisco I. Bastos Centro de Informação Científi ca e Tecnológica Fundação Oswaldo Cruz Cartas ao editor | Letters to the editor Rio de Janeiro, November 25 th 2008.Dear editors, I would like to thank Lima, Correa and Sansigolo for their insightful comments on a recent paper published by our research team in this journal.The comments focus on a key theme of epistemology and epidemiology: what is actually measured and how?