Mulheres HIV positivas, reprodução e sexualidade

Motherhood and HIV: reproductive desire, ambivalent feelings and a/an (not) offered care

OBJECTIVE

To identify in the scientific literature the feelings of women living with HIV in relation to reproduction and motherhood, as well as the care provided by health professionals regarding reproductive health as a right.

METHOD

Integrative review carried out in 2017, in the databases LILACS, PUBMED, BDENF and SciELO Virtual Library. We analyzed 30 articles.

RESULTS

As feelings, the motivation for reproduction and self-care, fears, uncertainties and hopes were evidenced. As care, services that support reproductive decisions were evidenced, but, predominantly, the disregard for the desire and care incipience for reproductive planning.

CONCLUSION

There is no comprehensive and humanized work on the reproductive issues of these women, either through the neglect of the desire and viability of gestation or by the incipient care to the ambivalent emotional experiences. There is a need to qualify the care model in order to configure it, in fact, as care, aiming at guaranteeing reproductive rights.

[Trajectories of women living with HIV/AIDS in Brazil. Progress and permanence of the response to the epidemic]

This article analyzes the trajectories of 85 women living with HIV/AIDS in six Brazilian cities: Belém, São Paulo, Ribeirão Preto, Goiânia, Recife and Pelotas, to understand some specific aspects of their experiences before and after diagnosis. It is based on in-depth interviews conducted in 2009 addressing women diagnosed with HIV between 1 and 20 years previously. The results show a profile characterized by limited access to school, health services and labor and a marked presence of violence. The reasons for applying HIV tests vary over time and there is an increase in prenatal testing, although no modifications in the context of the infection are apparent. For some women, the diagnosis determines changes in lifestyle. However, for the majority, social and labor experiences and the decisions about love, sexuality and reproduction seem to respond to their immediate demands and opportunities. The management of the diagnosis and the support received influence living with HIV/AIDS. These results show the need for actions for prevention and testing not restricted to pregnant women, even in the context of a concentrated epidemic. Studies adopting a biographical perspective can contribute to prevent or improve living with HIV/AIDS appropriate to the different moments of the womens' trajectories.

Reproductive desire among women living with HIV/AIDS in Central Brazil: Prevalence and associated factors

Background

The purpose of this study was to estimate the prevalence and examine the factors associated with reproductive desire among women living with HIV/AIDS (WLWHA) in Central Brazil.

Methods

A cross-sectional study involving 274 WLWHA, aged 18 to 49 years, was conducted with the support of treatment services and non-governmental organizations that assist people living with HIV/AIDS. Data regarding sociodemographic characteristics, substance use, sexual behavior, and reproductive variables were collected through interviews. Poisson regression with robust variance was used to analyze the factors associated with reproductive desire.

Results

The prevalence of reproductive desire was 25.9% (95.0% confidence interval [CI]: 21.1–31.4%). This outcome was associated with age < 30 years (adjusted prevalence ratio [APR]: 2.93; p < 0.001), black skin color or race (APR: 2.28; p = 0.017), partner's reproductive desire (APR: 7.55; p < 0.001), absence of children (APR: 2.13; p = 0.003), history of abortion (APR: 1.65; p = 0.045) and undetectable viral load at the time of data collection (APR: 1.92; p = 0.043).

Conclusion

The prevalence of reproductive desire among WLWHA was relatively high. It is necessary to include fertility issues as part of assistance and counseling for women in referral services to support them with their feelings, goals, and needs regarding reproductive choices.

Strategies to prevent HIV transmission to serodiscordant couples

INTRODUCTION

The use antiretroviral reduces the sexual transmission of HIV, expanding interventions for serodiscordant couples.

OBJECTIVE

This article aims to review the use of antiretroviral and other prevention interventions among serodiscordant couples and to analyze its use in Brazil.

METHODS

A retrospective review was performed through the MEDLINE database and bases included in the Biblioteca Virtual em Saúde.

RESULTS

The articles recovered exhibit four main strategies: (1) condom; (2) reduction of risks in sexual practices; (3) use of antiretrovirals, particularly early initiation of antiretroviral therapy (TASP) and pre-exposure prophylaxis (PrEP); (4) risk reduction in reproduction.

DISCUSSION

TASP is highly effective in reducing sexual transmission, PrEP was tested in serodiscordant couples and both reduce the sexual transmission risk in different sexual practices, enabling individualized prevention strategies.

CONCLUSIONS

When used in combination, antiretrovirals and sexual practices with condoms offer greater efficacy than any single strategy. The combined use of new and old strategies allows us to build a prevention policy for all.

Sociodemographic and clinical factors of women with HPV and their association with HIV

OBJECTIVE:

to identify the association between HIV-seropositive or HIV-seronegative status and the sociodemographic and clinical variables of women with genital HPV infection.

METHOD:

cross-sectional, retrospective study in a reference service in Ribeirão Preto. A total of 824 women undergoing HIV testing who had high or low grade cervical intraepithelial lesions or condylomatous genital lesions caused by HPV were studied. The chi-square test and logistic regression analysis with the calculation of the odds ratio and a confidence interval of 95% were conducted to verify the association.

RESULTS:

a higher probability of seropositivity was identified for non-white women; with low education; widowed; who consumed alcohol, tobacco or illicit drugs; with hepatitis C; who had multiple partners; and that worked as prostitutes.

CONCLUSION:

the increasing impairment of women due to sexually transmitted infections, considering the influence of the socioeconomic and behavioral context on the course of these infections, highlights the importance of public policies that establish intervention strategies involving the prevention, early diagnosis and timely treatment of these diseases, so that there is the promotion of quality of life in this population.

Sorodiscordância e prevenção do HIV: percepções de pessoas em relacionamentos estáveis e não estáveis

Políticas referentes à profilaxia pós-exposição sexual (PEP sexual) e a estratégia “tratamento como prevenção” reforçaram as ações preventivas da transmissão do HIV. Este estudo objetivou descrever percepções de pessoas com HIV/aids sobre a prevenção da transmissão do HIV no contexto da sorodiscordância. Foram conduzidos dois grupos focais com 13 participantes com relacionamentos sorodiscordantes: um com pessoas em parcerias estáveis e outro em parcerias não estáveis. Pouco mais de um terço dos participantes tinham conhecimento sobre a PEP e o “tratamento como prevenção”. Houve consenso de que há mais facilidade na adoção de práticas sexuais seguras nas parcerias sorodiscordantes não estáveis. Vantagens das novas políticas foram relatadas, não obstante o receio de que possa haver negligência quanto ao uso do preservativo. Destaca-se a relevância da atuação de equipes de saúde com casais sorodiscordantes quanto à prevenção da transmissão sexual do HIV.

Coordenação da assistência prestada às pessoas que vivem com HIV/AIDS em um município do Estado de São Paulo, Brasil

Objetivou-se analisar a coordenação das ações e serviços de saúde na assistência às pessoas que vivem com HIV/AIDS. Trata-se de um estudo seccional com 301 pessoas que vivem com HIV/AIDS. A análise foi feita por técnicas descritivas, analise de variância e comparação múltiplas de médias. Encontrou-se que a coordenação da assistência foi satisfatória (média = 3,69 e DP = 1,74). As pessoas que vivem com HIV/AIDS utilizavam outros serviços de saúde além dos Serviços de Assistência Especializada em HIV/AIDS – SAE (Pronto Atendimento: 67%; atenção básica: 43,2%; outros serviços especializados: 23,6%; serviços privados: 15%). Os cinco SAE apresentaram diferentes desempenhos, bem como distintos contextos e composições assistenciais, entretanto adequado manejo dos aspectos clínicos em detrimento dos sociais. O fornecimento da guia de referência foi tido como satisfatório, entretanto a guia de contrarreferência insatisfatório. Há necessidade de estratégias que favoreçam o desenvolvimento de ações compartilhadas e cooperadas dentro das equipes dos SAE e entre os diferentes serviços com o intuito de fortalecer a produção de cuidado resolutivo.

[HIV seropositive women and their partners facing the decision of a pregnancy]

The purpose of this qualitative, descriptive exploratory study is to investigate the reasons why HIV seropositive women and their partners make the decision of becoming pregnant despite the risk of vertical transmission, contamination or reinfection of the partner. The subjects of this study were six pregnant women. Data collection was done through a semi-structured questionnaire which was organized in the NVIVO 2.0 software and interpreted through theme-based content analysis. Through this analysis three themes emerged: Pregnancy planning; Knowledge of HIV/AIDS transmission and treatment; Living in the context of HIV/AIDS. The relevance of this study resides on the fact that the desire of the couple in becoming parents remains, despite of the awareness regarding the risks of vertical transmission and contamination.

The hope of women with HIV/AIDS: evaluation using the Herth Scale

This descriptive cross-sectional study had the objective to evaluate the level of hope in women aged 50 or older suffering from HIV/AIDS, utilizing the Herth Hope Scale. The study involved 200 HIV- positive women, within the age bracket of interest, enrolled in three STI/AIDS specialized healthcare services in the city of São Paulo. The rules of the 196/96 Resolution were met and the study was approved by the Research and Ethics Committee. Data were collected in 2010 using two instruments: subjects' characterization and the Herth Hope Scale. Results demonstrated an average score of 36.75 (±4.52) on the Herth Hope Scale, with an interval of 12 to 48. This score is below the score obtained with the same scale for various pathologies, indicating a reduced perception of hope by the sample. Nurses should provide interventions to improve hope for these people, establishing realistic goals and strengthening social support.

[Motives and circumstances surrounding induced abortion among women living with HIV in Brazil]

The impact of HIV/AIDS infection on the decision of women living with HIV/AIDS to interrupt a pregnancy remains an understudied topic. In an effort to understand the influence of HIV/AIDS diagnosis on abortion practices, a qualitative study was carried out in seven Brazilian municipalities with women living with HIV/AIDS who reported inducing an abortion at some point in their lives. This study presents the analysis of interviews with thirty women who became pregnant after diagnosis. The results show that for some women, infection was the primary motive for terminating their pregnancy, while for others, the motives for abortion were predominantly related to life circumstances. The decision to abort due to HIV infection is not the same for all women. It is related to the timing of the diagnosis and other aspects of the woman's life during her pregnancy, such as the relationship with her partner, her job and family support. The results suggest the need for more attention from health services to the reproductive decisions of women living with HIV/Aids; the incorporation of men into sexual and reproductive health prevention actions; and a deeper discussion of the illegality of abortion in Brazil and its harmful consequences for women, men, and children.

[The profile of women with HIV/AIDS and their adherence to the antiretroviral therapy]

The objectives of this study were to characterize the sociodemographic and clinical profiles, health behaviors, beliefs and attitudes towards the disease and treatment of women with HIV/AIDS, outpatients of a university hospital located in the interior of São Paulo state, and to identify the factors that affect their adherence to antiretroviral therapy. The participants were 60 female outpatients of the referred service. The data were collected through semi-structured interviews. The women's mean age was 39.8 (standard deviation of 9.1) years; most of the women had a low education level, lived in deprived socioeconomic conditions, and were in a stable relationship. The most frequent form of infection was through a heterosexual relationship; 55% of the women had abandoned treatment, and their main reasons were the imposed therapeutic schemes, the side effects of antiretroviral drugs, coping with the disease, and the perspective of imminent death; 35% did not meet the adherence criteria, considered as taking 95% of the prescribed antiretroviral therapy.

Sexual life and fertility desire in long-term HIV serodiscordant couples in Addis Ababa, Ethiopia: a grounded theory study

Background

Even though remarkable progress has been achieved, HIV/AIDS continues to be a major global health priority. HIV discordant relationship is one of the emerging issues in HIV prevention endeavour. In Ethiopia, very little is known about HIV-serodiscordant couples particularly how they manage their sexual relationship and fertility desire. Therefore, we conduct this study with the aim of exploring the experiences of HIV discordant couples about their sexual life, and fertility desire in the context of long-term relationships in Addis Ababa, Ethiopia.

Methods

A grounded theory approach was employed using in-depth interviews among 36 informants in ART/PMTCT centers of three public hospitals, a health center and one PLHIV association in Addis Ababa. Theoretical sampling was used to recruit 28 clients who lived in a discordant relationship and eight health care providers as key informants. Data collection and analysis were undertaken simultaneously using a constant comparison. The analysis was facilitated using OpenCode software.

Results

A grounded theory pertaining to sexual life and desire to have a child among HIV discordant couples emerged as “maintaining the relationship” as a core category. Couples pass through a social process of struggle to maintain their relationship. The causal conditions for couples to enter into the process of struggle to maintain their relationship were collectively categorized as “Entering in-to a transition” (knowing HIV serostatus) and this includes mismatch of desire to have a child, controversy on safe sex versus desire to have a child, and undeniable change in sexual desire and practice through time were the features in entering into-transition. Then after the transition, couples engaged in certain actions/strategies that are categorized as “dealing with discordancy” such as entertaining partner’s interest by scarifying once self interest to maintain their relationship.

Conclusions

HIV discordant couples’ relationship is filled with controversies of maintaining relationship versus fear of getting infected. The findings of this study have suggested the need to view discordant couple’s actions as a process of maintaining their relationship in the context of eminent risks. Further study should be done among HIV discordant couples to assess the fitness of the current model in different setups and population. In addition, a study could begin to test the hypotheses proposed in this study.

Discussing childbearing with HIV-infected women of reproductive age in clinical care: a comparison of Brazil and the US

Despite long term access to highly active antiretroviral therapy in Brazil and the US, little is known about women's communication with their HIV provider regarding childbearing or the unmet need for reproductive counseling. We utilized identical survey questions to collect data from HIV-infected women of reproductive age in Rio de Janeiro (n = 180) and Baltimore (n = 181). We conducted univariate analyses to compare findings between samples of women and multivariate logistic regression to determine factors associated with childbearing desires, childbearing intentions, and provider communication among the combined sample of women (n = 361). Over one-third of women in Rio de Janeiro and nearly one-half of women in Baltimore reported the desire for future childbearing. Nevertheless, the majority of women in clinical care had not discussed future childbearing with their HIV provider. Even in countries with an advanced approach to HIV care, we found low and inadequate communication between providers and female patients about childbearing.

[Validation of an educational video for the promotion of attachment between seropositive HIV mother and her child]

The objective of this research was to build an educational video to promote the attachment of HIV-positive mother and her child. That was a randomized clinical trial. The phases of the study was constituted by the development of the script, followed by the assessment, recording and editing of video, data collection, and validation and filming of the binomial. The roadmap has been assessed by technical experts and content. Data collection occurred between May and October 2008. 24 women attending HIV in the period, 12 of the control group and 12 in the intervention group took part of the study. We validated the video with the Protocol for Observation of mother-infant interaction. The mothers in the intervention group obtained more favorable results than the control one, showing the effectiveness of the video.

Access of people living with HIV to infertility services: perspective of Brazilian healthcare professionals

OBJECTIVE

To evaluate the perspective of professionals in university and public assisted reproductive technology (ART) and HIV/AIDS services in Brazil, on the demand of people living with HIV wishing to conceive.

DESIGN

Mixed qualitative and quantitative, descriptive, cross-sectional and case study.

METHODS

The quantitative component was based on telephone interviews to women's health and HIV/AIDS program managers at state and municipal level. For the qualitative case study, semi-structured interviews were conducted with health professionals of ART and HIV/AIDS services.

RESULTS

Only one university ART service provided care for seropositive couples, but 64% of the HIV/AIDS services at state level and 73% of municipal HIV/AIDS services offered reproductive counseling focused on preventing pregnancy. Difficulty in discussing desire to conceive, lack of political decision and of human and financial resources were the main reasons given by service managers for not offering the opportunity for HIV couples. Lack of appropriate referrals and of updated knowledge on reproductive options were constrains according to the interviews.

CONCLUSION

Desire to reproduce among people living with HIV is poorly addressed in public services in Brazil.

[Quality of life in women with HIV/AIDS in a municipality in the state of São Paulo]

High potency antiretroviral therapy brings benefits to people with HIV/AIDS, related to survival, chronicity and quality of life. The objective of this quantitative and cross-sectional study was to assess the quality of life of women with HIV/AIDS, using the WHOQOL--HIV bref and its association with sociodemographic variables. The study was performed in outpatient clinics specialized in care to HIV/AIDS patients. Of the 106 interviewed women, 99.1% were heterosexual and 92.4% were infected sexually. Among the domains of quality of life, spirituality had the highest score (65.7), followed by physical (64.7), psychological (60.6), social relationships (59.5). Level of independence (58.6) and environment (54.5) scored the lowest. The factors low socioeconomic and educational levels were associated with different domains of quality of life, showing the relationship between quality of life and living conditions. Challenges persist in the scope of social, affective and financial relations, which require effective interventions regarding empowerment of women with HIV/AIDS.

Influence of culture on contraceptive utilization among HIV-positive women in Brazil, Kenya, and South Africa

Contraceptive choice and discontinuation are poorly understood among HIV-positive women, and HIV disease and culture may influence decisions. We assessed factors influencing contraceptive decision-making among HIV-positive women in three countries. This qualitative assessment of 108 HIV-positive women (36/site, selected by age and parity strata) was conducted in Rio de Janeiro, Brazil; Kericho, Kenya; and Soweto, South Africa. Freelist interviews assessed knowledge and attitudes towards contraception and were analyzed enumerating frequency and saliency of mentions. There was intersite consensus around list items but priority and themes varied. Site-specific factors influencing contraceptive choice were male partner wishes and fertility desire (Brazil), side-effects (South Africa), and impact on health and HIV progression (Kenya). Age, parity, and taking antiretroviral therapy (ART) impacted some themes. Contraceptive use among HIV-positive women is substantially influenced by culture and other factors. Counseling efforts should consider individual factors in method selection and offer method variety to accommodate changing needs.

Patient-provider communication and reproductive health among HIV-positive women in Rio de Janeiro, Brazil

OBJECTIVE

To qualitatively assess the influence of patient-provider communication on contraceptive choice among HIV-positive women in the context of universal antiretroviral therapy (ART) access.

METHODS

Focus group discussions (FGD; n=3), in-depth (IDI; n=15) and freelist interviews (FLI; n=36) were conducted with HIV-positive women aged 18-40 years recruited from public health units in Rio de Janeiro/Brazil.

RESULTS

Of 70 participants, 49 used ART and the median time since HIV diagnosis was 6 years (range: 1-18). The majority of participants (71.4%) reported some degree of dissatisfaction with their health providers (usually lack of open dialogue) and a few reported experiences of stigma/prejudice during appointments. Intra, interpersonal and social factors modulated behaviors and reproductive health decisions, and those issues were rarely addressed by providers during HIV clinical care.

CONCLUSION

Despite dramatic increases in survival and life quality after universal ART implementation in Brazil, reproductive health issues are neglected by multiple cadres of HIV health providers. Communication on reproductive health issues remains fragmented and potentially contradictory, compromising care in these settings.

PRACTICE IMPLICATIONS

Adequate provider training to address reproductive health-related issues in a comprehensive, culturally sensitive manner and improved integration of HIV and reproductive health care are urgently needed in this setting.

Mulheres Negras e HIV: determinantes de vulnerabilidade na região serrana do estado do Rio de Janeiro

Trata-se de estudo de base quantitativa que teve como objetivo central analisar componentes socioculturais e comportamentais relacionados ao processo de vulnerabilização ao HIV/aids a partir da percepção de mulheres negras na região serrana do estado do Rio de Janeiro. Para tal, foram entrevistadas 1.464 mulheres negras dos diferentes municípios que compõem essa região. Os principais determinantes que marcaram com maior intensidade a vulnerabilidade dessas mulheres associaram-se aos seguintes fatores: baixa escolaridade, renda e, consequentemente, acesso a bens e serviços, baixo índice de uso sistemático do preservativo e percepções de gênero, que reforçam a menor autonomia feminina na tomada de decisões protetoras.

Convivendo com a diferença: o impacto da sorodiscordância na vida afetivo-sexual de portadores do HIV/AIDS

Este estudo descritivo exploratório e qualitativo objetivou descrever e analisar o impacto da sorodiscordância na vida afetivo-sexual de indivíduos com HIV/AIDS que convivem em parceria heterossexual e soronegativa ao HIV. Foram entrevistados 11 portadores do HIV/AIDS que realizavam acompanhamento clínico ambulatorial em um hospital universitário-referência do interior paulista. Os dados foram coletados através de entrevista individual gravada, e analisados segundo análise de Prosa. A vivência com a sorodiscordância ao HIV/AIDS impõe a esses casais o manejo de muitas dificuldades relacionadas à sua intimidade, diante da possibilidade de transmissão do HIV para o parceiro soronegativo, com impacto negativo na vivência da sexualidade entre parceiros sorodiscordantes, repercutindo em alterações da resposta sexual humana, favorecendo até mesmo a abstinência sexual. Apontamos a necessidade de atendimento por equipes interdisciplinares junto aos portadores do HIV/AIDS, e também de sua parceria sexual, proporcionando assistência integral, contemplando a sexualidade e as dificuldades advindas com a sorodiscordância.

[Women's perception about female vulnerability to STD and HIV]

This is a descriptive study using a qualitative approach. The purpose was to analyze women's perception about female vulnerability to acquire STD/HIV. The study took place in 2006 at a university campus in the city of Rio de Janeiro. Interviews were carried out with 12 women, older than 18 years, of different educational levels, ethnic origins and religions. The women were students, technical-administrative workers and faculty members, among other users. The study complied with the requirements of the National Research Ethics Committee. Data analysis was performed according to the premises of Content Analysis. Results revealed two large dimensions: one related with the women's personal perception and their behaviors, and another related with these women's opinion about other women's behavior. This article discusses the data regarding the collective dimension. It was concluded that the interviewed women recognize vulnerability factors in other women and realize the risk that others face of acquiring STD/HIV, but do not consider themselves to be at risk.

Vulnerabilidade ao HIV/AIDS e a prevenção da transmissão sexual entre casais sorodiscordantes

Este estudo descritivo e exploratório objetivou descrever e analisar a vulnerabilidade de casais sorodiscordantes ao HIV, e foi realizado em um Serviço Ambulatorial Especializado em aids de um município do estado de São Paulo. Os dados foram coletados através de entrevistas individuais com 11 portadores do HIV/AIDS, que convivem com parceria sabidamente sorodiscordante. Para organização e análise dos dados, empregamos o método de análise de Prosa e o conceito de vulnerabilidade como referencial teórico. A naturalização da infecção do HIV/aids como doença controlável por medicamentos, crença na impossibilidade de transmissão do HIV relacionadas com carga viral indetectável, sentimento de invencibilidade que surge com o tempo de convívio entre o casal, e sua influência na manutenção do sexo seguro são fatores de vulnerabilidade para a parceria sexual soronegativa. Serviços especializados no atendimento a indivíduos com HIV/aids necessitam incluir a parceria sexual nas ações educativas/preventivas promovidas pelos profissionais de saúde.

Avaliação das ações de prevenção da transmissão vertical do HIV e sífilis em maternidades públicas de quatro municípios do Nordeste brasileiro

Este artigo avalia a assistência às mulheres em quatro maternidades públicas do Nordeste brasileiro quanto às medidas de intervenção adotadas pelo Projeto Nascer para redução da transmissão vertical do HIV e sífilis, em 2005. Trata-se de um estudo de casos múltiplos, abrangendo uma abordagem retrospectiva e outra transversal. O modelo lógico da intervenção tem cinco componentes: prevenção, vigilância epidemiológica, assistência farmacêutica, laboratorial e clínica. Para cada componente selecionaram-se indicadores de estrutura e processo. As maternidades foram classificadas em: aceitável, parcialmente implantado, inaceitável e não implantado. A maior aderência às normas foi observada na maternidade A (62,5%), classificada em parcialmente implantada, e a menor na maternidade C (30,6%), enquadrada como inaceitável. O estudo destaca a importância das ações de prevenção, vigilância epidemiológica, assistência farmacêutica, laboratorial e clínica para redução da transmissão vertical do HIV e da sífilis.

Aborto induzido entre mulheres em idade reprodutiva vivendo e não vivendo com HIV/aids no Brasil

No presente estudo, buscou-se identificar e comparar as características das mulheres vivendo (MVHA) e não vivendo com HIV/aids (MNVHA) que declararam ter realizado aborto alguma vez na vida. Entre novembro de 2003 e dezembro de 2004, estudo de corte transversal foi conduzido com 1.777 MVHA e 2.045 MNVHA em treze municípios brasileiros. Após ajuste por algumas variáveis confundidoras, 13,3% das MVHA versus 11,0% das MNVHA relataram aborto induzido na vida (p>0,05). Para ambos os grupos, as variáveis que se mostraram associadas significantemente ao relato de aborto induzido após ajuste no modelo de regressão logística múltipla foram: idade, com as mulheres mais velhas relatando maiores proporções de aborto; residir na região Norte do país; idade na primeira relação sexual (até 17 anos); ter tido três ou mais parceiros sexuais na vida; ter usado drogas alguma vez na vida e ocorrência (auto-referida) de doença sexualmente transmissível. Os resultados sugerem que, de forma geral, o perfil das mulheres que relataram a prática de aborto é bastante semelhante entre MVHA e MNVHA, e que os contextos associados à infecção pelo HIV e às práticas e decisões reprodutivas podem guardar similaridades.

Vida reprodutiva de pessoas vivendo com HIV/AIDS: revisando a literatura

No contexto atual da epidemia de HIV/AIDS, temáticas como a reprodução e a transmissão materno-infantil tornaram-se frequentes e têm suscitado diversos posicionamentos por parte de pessoas portadoras e das equipes de saúde. O presente artigo teve por objetivo examinar o impacto da infecção por HIV/AIDS na vida reprodutiva de pessoas portadoras, considerando o direito à maternidade e à paternidade. Foi realizada uma revisão da literatura acerca de aspectos biológicos, psíquicos e sociais que compõem o cenário da assistência em saúde reprodutiva. Constatou-se que a prevalência da lógica biomédica e o impacto social da epidemia restringem o exercício do direito à maternidade e à paternidade dos indivíduos portadores de HIV/AIDS. Diante disso, entende se que as políticas públicas e as ações em saúde devem ser direcionadas pelo respeito ao princípio da integralidade e pelo respeito à autonomia individual, dentro de um contexto de apoio e orientação psicossocial.

Prevalência e fatores de risco associados à infecção pelo Vírus da Imunodeficiência Humana em parturientes

OBJETIVO: Determinar a prevalência e os fatores de risco associados à infecção pelo Vírus da Imunodeficiência Humana (HIV) em parturientes admitidas no Hospital Estadual de Presidente Prudente, SP. MÉTODOS: Estudo epidemiológico transversal com 873 parturientes admitidas no Hospital Estadual de Presidente Prudente, SP, entre 1º de março de 2005 a 30 de dezembro de 2006. Foi aplicado um questionário semi-estruturado e obtidas informações em prontuários e carteiras de pré-natal. As variáveis foram sócio-demográficas, gestacionais, assistenciais do pré-natal e específicas da população reagente. RESULTADOS: A prevalência de parturientes com HIV foi de 2,1%, com escolaridades mais baixas e médias de idade e de gestações superiores às não reagentes. Os fatores de risco associados foram a residência fora do município de tratamento e a baixa escolaridade. Houve um aumento da prevalência do HIV em parturientes em relação a dados anteriores. CONCLUSÃO: Os fatores de risco encontrados podem estar envolvidos no aumento da prevalência e no comprometimento da profilaxia pré-natal para o HIV.

Contextos de vulnerabilidade para o HIV entre mulheres brasileiras

Este artigo tem como objetivo identificar os contextos de vulnerabilidade para o HIV entre mulheres brasileiras. Entre novembro de 2003 a dezembro de 2004 foi realizado um estudo de corte transversal em 13 municípios distribuídos nas cinco regiões do país, incluindo, respectivamente, 1.777 mulheres com diagnóstico positivo para HIV e 2.045 mulheres usuárias de serviços públicos de atenção à saúde da mulher sem diagnóstico conhecido de soropositividade para o HIV. A comparação entre os dois grupos mostrou que as mulheres com diagnóstico de HIV/AIDS não apresentaram um número de parceiros significativamente diferente com relação às mulheres sem diagnóstico de HIV/AIDS. No entanto, as mulheres vivendo com HIV/AIDS apresentaram início da vida sexual mais precoce, menor aderência ao uso de preservativos, e uma maior proporção dessas mulheres relatou uso de drogas, ocorrência de DST e de violência sexual na vida. Tais resultados sugerem a importância de pensar em estratégias de prevenção voltadas para o fortalecimento das mulheres e não apenas focadas em seus comportamentos individuais.

Experiência da maternidade no contexto do HIV/Aids aos três meses de vida do bebê

O estudo investigou a experiência da maternidade em portadoras do HIV/Aids aos três meses de vida do filho/a. Participaram seis mães (19 a 30 anos), de nível sócio-econômico baixo, três das quais já eram portadoras da doença quando engravidaram, enquanto as demais souberam no parto. As mães foram entrevistadas e suas respostas foram examinadas por meio de uma análise de conteúdo qualitativa baseada em quatro eixos teóricos: vida-crescimento, relacionar-se primário, matriz de apoio e reorganização da identidade. Os resultados mostraram que as mães tinham muitas preocupações com a possibilidade de infecção do filho/a e com a saúde do bebê, além de sentimentos de incerteza quanto ao futuro, culpa e medo do preconceito. Esses temores pareciam mais intensos para as mães que tiveram seu diagnóstico no parto. O estigma do HIV/Aids, conflitos familiares, dificuldades com o diagnóstico e o tratamento, além de restrições sócio-econômicas e em sua rede de apoio exigiam grande esforço emocional dessas mulheres, sugerindo a necessidade de intervenções psicossociais visando à adesão ao tratamento, à qualidade de vida e ao desenvolvimento do bebê.

[Women living with HIV/AIDS who are sexual partners of injecting drug users]

OBJECTIVE

To analyze perceptions of risk, prevention strategies, their own relationship with drug use and that of their partner's, and future expectations among women living with HIV/AIDS whose partners are drug users.

METHODS

This is a qualitative study of women living with HIV/AIDS who receive specialist treatment in Sao Paulo Municipality. Semi-structured interviews were carried out with 15 women, whose self-reported means of infection were heterosexual relations with a partner who is an injecting drug user. The script for the interviews covered the following areas: childhood, history of sexual relations, use of drugs, impact of seropositivity on daily life, understanding of the prevention of sexually transmitted infections, and perspectives of the future. The material from the interviews was analyzed using content analysis.

RESULTS

The study pointed to a difference in the ways that the women live with their own drug use and with that of their partners. Their partners' use of injecting drugs was not primarily associated with a risk of HIV infection, due to attempts to conceal the fact or because they believed that the monogamy-fidelity-confidence trinity would take precedence as a form of protection.

CONCLUSIONS

The women's different experiences of drug use should be taken into account and opportunities to discuss with them about the issue are important to ensure that more effective strategies for prevention and care are adopted.

Mulheres vivendo com aids e os profissionais do Programa Saúde da Família: revelando o diagnóstico

Trata-se de um estudo qualitativo realizado com mulheres infectadas pelo HIV/aids atendidas por um serviço especializado em DST/aids e matriculadas por uma equipe do Programa Saúde da Família. Teve como objetivo identificar quais as motivações para abrir a privacidade de suas informações para a equipe de PSF das mulheres soropositivas ao HIV/aids. Foi realizado por meio de entrevistas semi-estruturadas, analisadas com o referencial teórico da bioética. Verificou-se que as mulheres revelam o diagnóstico à equipe de PSF quando: o diagnóstico de soropositividade foi feito na unidade; sentem que são melhor atendidas por serem soropositivas ao HIV; têm vínculo como se fossem familiares; confiam; e sentem que não sentem pena. E não revelam quando: a atitude do profissional gerou medo e insegurança; acham que o PSF cuida de pessoas acamadas; não confiam por medo de quebra do sigilo; e já possuem toda assistência que precisam no SAE.

[Protective factors and resilience in people living with HIV/AIDS]

The aim of this theoretical review was to articulate the resilience concept with key aspects in the lives of people living with HIV/AIDS. We emphasize the analysis of protective factors traditionally related to resilience (personal characteristics and social and affective support networks). The reviewed studies show important protective factors that contribute to the health and well-being of people with HIV/AIDS, such as cognitive coping and acceptance of their HIV status, family participation in treatment and family support, the role of governmental and nongovernmental institutions, and religious beliefs. The concept of resilience defined as a dynamic process that allows human beings to overcome adversities is essential for understanding HIV infection and treatment of AIDS patients. It helps decrease stigmatization and prejudice towards the disease and patients. It also helps alter the notion that living with AIDS is incompatible with well-being and quality of life and fosters the creation of new HIV/AIDS prevention and treatment perspectives.

Mulheres, soropositividade e escolhas reprodutivas

O crescimento da epidemia do vírus da imunodeficiência humana entre as mulheres vem atualizando questões referentes à sexualidade e à reprodução. Este estudo investigou a percepção de mulheres portadoras do vírus da imunodeficiência humana positivo quanto às escolhas reprodutivas no contexto da soropositividade. Optou-se pela metodologia qualitativa, com a utilização de um grupo focal com mulheres soropositivas residentes no Distrito Federal. Na análise dos resultados, observou-se que as participantes estavam bem informadas sobre o processo de prevenção da transmissão vertical. A condição sorológica teve impacto na vida sexual e reprodutiva, evidenciado no adiamento ou extinção dos planos de ter filhos. A reação das pessoas em geral, bem como do profissional de saúde, diante do desejo de ter filhos por parte da mulher soropositiva foi apontada como desfavorável. Os achados do estudo, de caráter exploratório e preliminar, apontam para a relevância da realização de pesquisas na área, a fim de que os direitos reprodutivos das mulheres soropositivas sejam compreendidos, favorecendo sua valorização e respeito.

Vulnerabilidade ao HIV entre mulheres usuárias de drogas injetáveis

OBJETIVO: Analisar elementos da vulnerabilidade à infecção pelo HIV entre mulheres usuárias de drogas injetáveis. MÉTODOS: Foram realizadas 13 entrevistas semi-estruturadas com mulheres usuárias (ou ex-usuárias) de drogas injetáveis, moradoras da Zona Leste do município de São Paulo, no ano de 2002. O roteiro das entrevistas abordou quatro eixos temáticos: contexto socioeconômico e relações afetivas, uso de drogas, prevenção contra a infecção pelo HIV e cuidados com a saúde. As entrevistas foram analisadas por meio de análise de conteúdo. RESULTADOS: A pobreza, ausência de vínculos afetivos sólidos e continuados, expulsão da casa da família de origem e da escola, exposição à violência, institucionalização, uso de drogas, criminalidade e discriminação foram constantes nos relatos das entrevistadas. Esses elementos dificultaram a adoção de práticas de prevenção ao HIV como o uso de preservativos, seringas e agulhas descartáveis, e a busca de serviços de saúde. CONCLUSÕES: A vulnerabilidade ao HIV evidencia a fragilidade da vivência efetiva dos direitos sociais, econômicos e culturais, o que demanda políticas voltadas para o bem-estar social de segmentos populacionais específicos como mulheres (crianças e adolescentes), de baixa renda, moradores da periferia, com pouco acesso a recursos educacionais, culturais e de saúde. Este acesso é dificultado especialmente àquelas que são discriminadas por condutas como o uso de drogas.

Aspectos psicológicos da gestação e da maternidade no contexto da infecção pelo HIV/Aids

A epidemia de HIV/aids tem atingido cada vez mais mulheres em idade reprodutiva, sendo que muitas já são mães ou se tornam mães quando descobrem a infecção. Os estudos revisados indicam que a infecção pelo HIV/Aids pode alterar de muitas formas a experiência da gestação e da maternidade, gerando uma sobrecarga psicológica relacionada ao estigma e ao risco de transmissão para a criança. Apesar disso, pesquisas sugerem que muitas mulheres portadoras do HIV/Aids buscam transmitir uma identidade materna positiva para os filhos e se preocupam intensamente com o futuro deles. Foram encontrados poucos estudos brasileiros sobre aspectos psicológicos da maternidade nesse contexto, em especial a respeito do impacto da profilaxia para prevenção da transmissão vertical sobre a experiência da gestação, do parto e do puerpério. As dificuldades em aderir ao tratamento e a práticas sexuais seguras denotam a falta de atenção às demandas específicas dessas mães, sendo que o foco das políticas de saúde permanece sobretudo dirigido para a criança.

Desire for a child among women living with HIV/AIDS in northeast Brazil

In Brazil, an increasing proportion of new HIV infections and AIDS cases involve women of reproductive age. To describe the reproductive desire of women with HIV/AIDS and to identify factors associated with the desire for motherhood, a cross-sectional study was carried out in the referral hospital for infectious diseases in Ceará State, northeast Brazil. In total, 229 women were included in data analysis. Median age was 32 years (interquartile range, 26-37), and 63% had a monthly family income of less than 210 USD. Forty-nine percent were using a contraceptive method, and 37% wished to undergo tubal ligation. Sixty-four percent of the latter women were motivated by the fear of having an HIV-positive child. Forty percent of the participants wanted to have a child. In the multivariate regression analysis, variables independently associated with women's desire to have a child were: younger age (in years, odds ration [OR] = 0.94; 95% confidence interval [CI]: 0.90-0.98), number of children (OR = 0.73; 95% CI: 0.57-0.96), and partner's desire for a child (OR = 3.35; 95%CI: 1.75-6.39). Having a partner who did not know about the woman's positive serostatus was negatively associated with the woman's desire for a child (OR = 0.17; 95% CI: 0.04-0.69). No variable related to clinical status was significantly associated with the outcome variable. Our data showed that many unsterilized HIV-positive women in northeast Brazil, at whatever stage of illness, have a desire for children. We recommend that nondirective counseling, consisting of helping women evaluate their own feelings, goals and needs with respect to reproductive options be provided.

[Brazilian psychosocial and operational research vis-à-vis the UNGASS targets]

Items from the UNGASS Draft Declaration of Commitment on HIV/AIDS (2001) are analyzed. The Brazilian experience of new methods for testing and counseling among vulnerable populations, preventive methods controlled by women, prevention, psychosocial support for people living with HIV/AIDS, and mother-child transmission, is discussed. These items were put into operation in the form of keywords, in systematic searches within the standard biomedicine databases, also including the subdivisions of the Web of Science relating to natural and social sciences. The Brazilian experience relating to testing and counseling strategies has been consolidated through the utilization of algorithms aimed at estimating incidence rates and identifying recently infected individuals, testing and counseling for pregnant women, and application of quick tests. The introduction of alternative methods and new technologies for collecting data from vulnerable populations has been allowing speedy monitoring of the epidemic. Psychosocial support assessments for people living with HIV/AIDS have gained impetus in Brazil, probably as a result of increased survival and quality of life among these individuals. Substantial advances in controlling mother-child transmission have been observed. This is one of the most important victories within the field of HIV/AIDS in Brazil, but deficiencies in prenatal care still constitute a challenge. With regard to prevention methods for women, Brazil has only shown a halting response. Widespread implementation of new technologies for data gathering and management depends on investments in infrastructure and professional skills acquisition.

[Epidemiologic profile of puerperals and prevalence of antibodies for HIV and hepatitis C virus infection in Cuiabá, Mato Grosso]

A seroepidemiologic survey was performed aimed at estimating the prevalence of human immunodeficiency virus, the prevalence of hepatitis C virus antibodies (anti-HCV), the risk factors associated with human immunodeficiency virus transmission and the epidemiological profile of the women in puerperal period in three public Hospitals of Cuiabá City between December 2001 and March 2002. The sample was composed of 1,607 women who were interviewed in order to obtain information about socio-demographic aspects and risk behavior. Blood samples were drawn to detect HIV and HCV antibodies using the ELISA test. The prevalence of HIV infection in this population was 0.5% (IC95%= 0.2; 1.0). Most women had only basic level schooling (58.4%), and they presently held a relationship with a fix partner (73%). There were no statistically significant associations between HIV antibody and socioeconomic level, other procedures that involved the risk of HIV parenteral transmission, between anti-HIV positivity and the presence of sexual behavior of risk (relationships with multiple partners or bisexuality) by the women and their partners. Currently, it is presumed that heterosexual transmission is the main cause of infection among women in reproductive age in the study area. The anti-HCV prevalence was 0.4% (CI95%= 0.1; 0.8). Anti-HCV was more common among older women.

The impact of health care providers on female sterilization among HIV-positive women in Brazil

This paper explores the reproductive preferences and outcomes of HIV-positive women in two cities in Brazil. We used three types of data, all drawn from women who delivered in public sector hospitals: (1) clinical records of 427 HIV-positive women; (2) pre- and postpartum in-depth interviews with 60 HIV-positive women; and (3) a prospective survey carried out among 363 women drawn from the general population. The HIV-positive samples were collected on women who had prenatal care between July 1999 and June 2000, and the general population survey was conducted with women who started prenatal care between April 1998 and June 1999. Among the women in the clinic sample, we found dramatic differences in the proportion sterilized postpartum: 51% in Sao Paulo vs. 4% in Porto Alegre, compared to 3.4% and 1.1%, respectively, of women in the general population. Our qualitative data suggest that HIV-positive women in this study had strong preferences to have no more future children and that female sterilization was the preferred way to achieve this end. Therefore, we conclude that the large difference in rates is mainly due to HIV-positive women's differential access to sterilization in the two settings. In-depth interviews revealed that women in Sao Paulo were often encouraged by clinic staff to be sterilized postpartum. In contrast, HIV-positive women in Porto Alegre clinics were not offered sterilization as an option and those who requested it were repeatedly put off. The striking difference found in the frequency with which doctors provide postpartum sterilization to seropositive women in our study sites deserves attention and discussion in the respective medical communities. At the higher level of national policy on reproductive rights, there may be grounds for reopening discussion about the norms regarding postpartum procedures, and for devoting far more resources to expanding contraceptive options.

Factors associated with reproductive options in HIV-infected women

A cross-sectional study was conducted in Campinas, Brazil, in HIV-infected women to evaluate factors associated with reproductive practices. A total of 112 HIV-infected women, 13 to 45 years old, with previous sexual experience were included in the study. Three groups were compared: pregnant women aware of their infection before current pregnancy, sterilized women who had made their reproductive choice after serodiagnosis and women using any reversible contraceptive method. Fisher's Exact Test and multivariate correspondence analysis were used in the statistical analysis. Among women interviewed, 23% were pregnant, 18% had been sterilized and 59% were using a reversible contraceptive method. Being younger was associated with reproductive practices that preserved the possibility of having a child. Reversible contraceptive users had fewer pregnancies and more often reported a desire to have children compared to the other groups. Partner's desire for parenthood was associated with pregnant and sterilized women. The clinical condition of the women and their partners, the serologic status of partner nor counseling about contraceptive choices influenced reproductive practices.

Women and AIDS: gender relations and condom use with steady partners

An educational project on sexuality, STDs, and AIDS was conducted for four years with some 500 women. As a result, changes were observed in HIV-related knowledge and attitudes, but not in risk behaviors for infection. This fact motivated the development of a qualitative study to learn the reasons why women failed to incorporate HIV preventive behaviors into their daily lives. Six focus groups were conducted with women who had participated in the educational project. The analysis was thematic. Women were familiar with HIV transmission routes and preventive measures. They admitted not using condoms due to fear of being suspected of infidelity and because this might lead to separation of the couple. Women reported that relationships with their partners had been difficult because of lack of dialogue and that men always had the final word. Although women had information about AIDS, they did not use preventive measures in steady relationships because they did not wield decision-making power. Gender inequality and fidelity were two significant issues related to the increase in AIDS among women.

Opções contraceptivas entre mulheres vivendo com HIV/AIDS

As novas possibilidades terapêuticas no controle da AIDS têm reforçado a esperança de vida entre os pacientes e estas circunstâncias influenciam nas decisões relativas ao planejamento familiar. O presente estudo de natureza qualitativa buscou conhecer as opções contraceptivas utilizadas por mulheres portadoras de HIV ou com aids, bem como suas dificuldades na utilização desses métodos. Foram estudadas 31 mulheres portadoras de HIV, atendidas em hospital público de Fortaleza-CE, em 2003. Das entrevistadas, 20 (64%) afirmaram ter vida sexual ativa. Destas, 17 (85%) referiram uso de algum tipo de opção contraceptiva, tais como: condom masculino (uso regular e irregular), coito interrompido, laqueadura tubária, Oginos-Knaus e abstinência sexual. Duas mulheres não mencionaram medida contraceptiva. As dificuldades apontadas foram o desconhecimento da anatomia do corpo, a falta de segurança e confiança nos métodos e as próprias limitações tanto para aceitar um método como para negociar o uso com o parceiro.

Medidas contraceptivas e de proteção da transmissão do HIV por mulheres com HIV/Aids

OBJETIVO: Atualmente, entre as mulheres, a relação sexual é a forma de transmissão que mais tem contribuído para a feminização da epidemia de HIV/Aids. Na busca constante de se estabelecer padrões mais adequados de orientação para saúde, investigou-se o uso de medidas contraceptivas, que também sirvam de proteção da transmissão do HIV, entre mulheres portadoras de HIV/Aids. MÉTODOS: Estudo exploratório desenvolvido em um serviço público ambulatorial de um hospital universitário, referência aos portadores de HIV/Aids da região centro-sul do Estado de São Paulo, no período de cinco meses (2000 a 2001). Foram estudadas 73 mulheres portadoras da infecção pelo HIV, ou com Aids. Os dados foram obtidos por meio de um formulário que investigava a caracterização sociodemográfica, as formas de anticoncepção utilizada e a situação sorológica do parceiro sexual. Os dados foram analisados descritivamente e os conteúdos das respostas abertas, agrupados em temas. Foi aplicado o teste exato de Fisher para análise de algumas variáveis, em nível de 5%. Para a análise de conteúdo utilizou-se a proposta de Bardin. RESULTADOS: A maioria das mulheres estava em fase de vida reprodutiva, eram casadas e foram contaminadas quase exclusivamente por meio da relação heterossexual. Entre elas, 35,4% referiam parceiro sexual discordante quanto à sorologia anti-HIV, e 13,7% utilizavam formas inadequadas de anticoncepção que também não protegiam da transmissão do HIV. CONCLUSÕES: Os resultados alertam para a necessidade de ações educativas continuadas quanto a experiências sexuais mais seguras entre portadoras de HIV/Aids, para que elas possam discutir com seus parceiros outras formas de exercerem sua sexualidade, sendo capazes de estabelecer opção contraceptiva mais consciente, de maneira a zelar pela sua saúde, do parceiro e até do concepto.

Esterilização feminina, AIDS e cultura médica: os casos de São Paulo e Porto Alegre, Brasil

Este artigo busca identificar os fatores que interferem nas escolhas reprodutivas de gestantes HIV positivo focalizando, em particular, o papel desempenhado pelos serviços de saúde e pela cultura médica nessas escolhas. O desejo e a realização de laqueadura tubária pós-parto constituem os eventos reprodutivos tomados como questões de análise. Os dados apresentados resultam de uma pesquisa desenvolvida em serviços de pré-natal nas cidades de São Paulo e Porto Alegre, que utilizou um desenho que combinou duas estratégias metodológicas: quantitativa, a partir de dados coletados em 427 prontuários clínicos, e qualitativa, por meio da observação etnográfica e realização de sessenta entrevistas em profundidade. A grande maioria de mulheres nas duas cidades manifestou o desejo de realizar a esterilização depois do parto. Entretanto, uma proporção muito maior de mulheres em São Paulo atingiu sua meta comparada a uma pequena proporção em Porto Alegre. A cultura médica local com relação à laqueadura, aliada à organização da prática de assistência ao pré-natal e parto, mostrou-se fator fundamental para compreender as diferenças encontrada nas duas cidades.