RESEARCH ARTICLES
Perception of married women about the risk of HIV infection and preventive behavior
Leonardo Gomes de FigueiredoI; Richardson Augusto Rosendo da SilvaII; Ilisdayne Thallita Soares da SilvaIII; Karla Gardênia Silva SouzaIV; Francisca Francineide Andrade da SilvaV
INurse of the Family Health Strategy. Municipal City Hall of Bom Jesus. Rio Grande do Norte, Brazil. Email: leobjrn@yahoo.com.br
IINurse, Doctor of Health Sciences. Lecturer in the Graduate Course, Master's and Doctoral degrees in Nursing. Deputy leader of the Research Group Assists and Epidemiological Practices in Health and Nursing. Nursing Department. Federal University of Rio Grande do Norte. Natal, Rio Grande do Norte, Brazil. Email: rirosendo@yahoo.com.br
IIINurse of the Family Health Strategy. Municipal City Hall of Cuité. Paraíba, Brazil. Email: ilisdayne@yahoo.com.br
IVNurse. Labor Nurse Specialist by Integrated College of Patos. Natal, Rio Grande do Norte, Brazil. Email: karlagardenia@gmail.com
VNurse. Maternal and Child Health Specialist from the Federal University of Rio Grande do Norte. Santa Cruz, Rio Grande do Norte, Brazil. Email: francineide18@hotmail.com
ABSTRACT: The objective was to identify the perceptions risk of infection by the Human Immunodeficiency Virus (HIV) and preventive behavior of married women face to the feminization of Acquired Immunodeficiency Syndrome (AIDS). It is a quantitative and qualitative study conducted with 60 women users of a basic health unit in the city of Santa Cruz/RN. Data were collected through semi-structured interviews, between June and October 2010, and subjected to thematic analysis. From the analysis of the data, emerged three categories: transmission of HIV/AIDS, vulnerability to HIV/AIDS and prevention of HIV/AIDS, which demonstrate that gender relations is evident in the marital and sexual issues, contributing to the subjection of women to their partner. The existence of gaps in knowledge of the interviewed woman, in relation to the forms of contamination and prevention of HIV/AIDS, contribute to increase the risk to this infection.
Keywords: HIV; AIDS; feminization; risk.
INTRODUCTION
The epidemic of Human Immunodeficiency Virus infection (HIV) and Acquired Immunodeficiency Syndrome (AIDS) appears quite complex representing a global, dynamic and unstable phenomenon, whose form of occurrence in different regions of the world depends on the individual and collective human behavior. AIDS, since its origin, has been thoroughly discussed by the scientific community and by society in general and stands out as a public health problem, with significant morbidity and mortality rates, demonstrating that there are still obstacles to be overcome1,2.
In Brazil, the reason between the infected individuals with HIV in relation to sex has been suffering a gradual decline, observing a considerable increase in the number of Brazilian municipalities with at least one case of AIDS in women, since the beginning of the epidemic, indicating that the process of internalization of the HIV/AIDS has been accompanied by the feminization of the epidemic, which corresponds to the increase in numbers of cases in people of the female gender3.
Gender issues marked transformations in epidemiological profile of this infection, including groups that don't get noticed at risk of acquiring the disease, as heterosexual women married or in stable union4. This situation of experience stable relationships with one partner contributes to limit women's vision on the self-perception of risk5.
In front of the way that infection is spreading among women, especially those with a single partner, this study aimed to identify the perception of risk of HIV infection and preventive behavior of married women vis-à-vis the feminization of the AIDS epidemic.
The research is justified in front of the current time of the AIDS epidemic in the country, where is verified the growth in the number of infected women. Is relevant insofar as they intends to instigate the reflection about the perception of vulnerability and risk of contracting HIV/AIDS on the part of women, aiming at rethinking the preventive strategies for this population.
LITERATURE REVIEW
Currently, has been observed in Brazil a growing increase in the number of cases of women with AIDS when compared to males. The mortality rate among men has shown a decrease more expressive than in women6. They represent little more than half of all people living with AIDS in the world7.
When one analyses the evolution of the epidemic in the country, there are three distinct phases: the first until 1986, when the transmission by sexual route was the most important, being, at that time, partnerships with men who had sex with men. The second occurs between the late 80 's and early 90, where injecting drug use appears as an important form of transmission; and the third comprises the end of 90 years to the present moment, which presents clear predominance of heterosexual practice as a way of HIV transmission to women6.
It is observed that the vulnerability of women to HIV is pervaded by representations and behaviors related to gender issues, such as: sexual practice as obligation of wife, the trivialization of gender violence by intimate partner; unconditional love relationships, the family as the value for the quality of life and care8.
Thus, the female vulnerability to HIV necessarily refers to the ways in which men and women relate in society, the dynamics of power that permeates such relationships and to the collective imagination in relation to gender roles, which are important variables in the conformation of the current profile of the epidemic6.
METHODOLOGY
It is a study of descriptive character with quantitative and qualitative approach developed in basic health unit (BHU) of Maracujá neighborhood, located in the municipality of Santa Cruz, country of Rio Grande do Norte (RN) and distant 115 km from the capital.
For delimitation of the population under study, were adopted the following inclusion criteria: married women above 19 years, registered in BHU, which agreed to participate voluntarily in the research, and signed an Informed Consent Form (IFC).
Thus, for the sizing of the sample of the survey was used the sampling criterion for saturation, which is a tool used to establish or close the final size of a sample under study, interrupting or suspending the attracting new participants when the data obtained present, in the evaluation of researcher, certain redundancy or repetition of components9.
Considering this criterion, were interviewed 60 married women and users of BHU of Maracujá neighborhood in Santa Cruz/RN. The data collection technique consisted of semi-structured interview. The data were collected in the months of June and October 2010.
Women were addressed, by researcher, to participate in the research as they attend the service, with or without prior scheduling. The study and the ICF were presented and as acceptance and signature of the term, at the beginning of the interview. This was recorded with a tape recorder and held in the meeting room of the said BHU, which allows greater privacy, since it consists of a space that is not used routinely.
In order to preserve the identity of the participants, their names were replaced by the letter I, which means interviewed, followed by the number that indicates the order of the interview.
The data were transcribed in full and submitted to thematic analysis, which consists in discovering the nuclei of meaning that makes up the communication and whose presence, or frequency of appearance can mean something to the chosen analytic object10.
In this way, the data analysis followed three steps. The first, called pre-analytic, are performed the reading material floating field, the constitution of the corpus, and the formulation and reformulation of hypotheses and objectives. On the second one, it happens the exploration of the material, on which there is the search by categories (significant expressions resulting from a process of reduction of the text). In the third, is developed the treatment results and interpretation in accordance with the pre-established theoretical framework, and may also trigger new theoretical and interpretative dimensions10.
The research project was submitted to the Committee of Ethics in Research (CER) of the State University of Rio Grande do Norte (UERN), obtaining approval through the opinion number 012/10.
RESULTS AND DISCUSSION
The interviews were conducted with 60 women, young, aged between 20 and 36 years, an average of 28 years, being the predominant age range of 26 to 30 years (52%). With regard to education, it was observed that the greatest concentration of women had the first degree incomplete, corresponding to 67% of respondents; 21% of participants completed the first degree and only 12% had incomplete secondary school. The predominant family income in the sample studied 73% was of a minimum wage and 27% were receiving up to two minimum wages.
From the transcript of the interviews and after reading detailed lines, emerged three categories: transmission of HIV/AIDS; vulnerability to HIV/AIDS; and HIV/AIDS prevention, which will be discussed below.
Transmission of HIV/AIDS
In relation to this category, it was observed in the testimony of women that the main form of transmission of HIV/AIDS is unprotected sexual relation. However, it also pointed out the transmission of the virus through kissing, or contact with secretions such as saliva, characterizing the existence of a partial ignorance still present with regard to transmission of the disease, as can be seen in the following statements:
Having sex without a condom and through contact with contaminated blood and saliva [...]. (I1)
In this case, the relationship without using a condom or through the kiss if you have any injury, bleeding or any secretions can pass to the partner or your partner [...]. (I25)
In my opinion, AIDS takes in the relationship or sitting. So when the person with AIDS sits and then another person sit down, catch AIDS. In the kiss, too. Drinking water in the glass of a person with AIDS, too. (I10)
If you can get through sexual relation, the kiss and the contamination of the blood. I've heard that even in conversation, can transmit [...]. (I3)
As regards to the contact with carriers of the HIV/AIDS it is noted that rejection and prejudice increase to the extent that grows the possibility of rapprochement, intimacy and interaction. Such situations prove the little information of the population in relation to exposure to viruses by social contact and the strong stigma of the disease, generating estrangement of people with HIV/AIDS and its consequent discrimination11.
It is mister to emphasize that HIV/AIDS cannot be transmitted by hug and handshake, as well as with their belongings not involving secretion with blood, sperm, vaginal secretion, internal bodily fluids, menstruation and inflammatory exudates. In this way, rejects exclusion of individuals infected with the social interaction, and defends the respect and dignified treatment of the same, assisting them in matters of psychological character, spiritual, affective, social and family, involved in this problem12.
In relation to the transmission category of the virus through blood transfusion, it was observed that some women have cited this form of contamination, as can be seen below:
Through the act of sex without using a condom, through blood transfusion and through people who use injecting drugs can get AIDS [...]. (I20)
Through blood transfusion, sex without condoms and oral sex. Thus, by blood transfusion I think takes [...]. (I54)
It should be noted that the risk of contamination by blood transfusion is almost nonexistent these days12. In Brazil, according to epidemiological data, the blood transfusion accounts for 0.1% of AIDS cases notified in 2011, in males with 13 years or more of age. Among females, the total reported cases in the year of 8,147 2011, 0.1% also occurred by blood transfusion13. This situation can be explained by the effectiveness of the control laws of blood and blood products, with regard to HIV infection, imposed in Brazil in 198814.
As noted in the testimonies of the interviewed women, there is still a partial knowledge about the transmission of HIV/AIDS, contributing to greater vulnerability of women to this infection, in addition to increasing the stigma of the disease.
Vulnerability to HIV/AIDS
With regard to this category, it was observed in the testimonials of interviewed women who, when questioned about the possibility of contract the AIDS virus, the confidence in their partner has emerged as being a determining factor in the increased risk of them about this syndrome. When they sustain a marriage or a stable relationship, they realize with reduced or no risk to get infected by this disease, as can be seen below:
I think I have no chance because I have my husband, makes 10 years that I've lived with him and I trust him [...]. (I17)
I am married so I do not belong to the risk group, so I don't have to worry about condoms. Just who gets AIDS are gays, transvestites and prostitutes [...]. (I12)
As it stands the world nowadays, I think for us not to get AIDS, you have to take care a lot, but thank God my husband is a person of confidence [...] as I am happily married I don't have to worry about anything. (I9)
On the lines, it is observed that women do not consider themselves at risk in the face of HIV/AIDS because they are married. In this sense, marriage is highlighted as a protection factor to the disease, representing love, romanticism, respect, trust and complicity. There is an illusion that by taking these values in everyday life, women would be protected from the risk of contaminating.
Corroborating this perception, one study identified that women without regular partner is perceived more susceptible to AIDS, making condom use in their possible relationships. Already married or in stable union consider the prevention of AIDS something essential for all individuals, with the exception of themselves since, naively, they feel safe in their marital relations, because there is a feeling of love and confidence in the partner5.
In relation to reasons for non-use of condoms in sexual relations, was common among them, the claim that do not use due to their partners don't like it or that, with the use of the same, sexual relation is less enjoyable. In addition, it was observed that even when women try to talk with their companions about this subject, their complaints are not taken into consideration:
I don't use a condom, even though my husband is not a trusted person [...]. (I32)
I don't use a condom because he doesn't like, he says that is tasteless. I try to talk to him, but he takes as a joke [...]. (I7)
Another factor that presents as characterizes of female vulnerability to HIV/AIDS epidemic is the presence of extramarital practices in relationship:
I have a fixed partner and I'm sure he lives with other women and another sure I have is that he does not use a condom with them [...]. (I54)
The fact of married men engage in extramarital practices contributes to increase the risk of infection by AIDS and other sexually transmitted diseases (STD), leading often to a late diagnosis by married women5.
The obstacles to adoption of safe sex among women are related to the difficulty of negotiating condom use with their partners, agreeing with the idea that this difficulty is permeated by gender relations that determine social positions to be occupied by men and women, namely, women's vulnerability to HIV refers necessarily to social issues and patriarchal relations that still persist today. In the case of AIDS, one of the assumptions of romantic love is crucial to understanding the feminization of the epidemic. It can be assumed that using a condom is like sending a message to another that now can be infidelity15.
The inequality of power between genders, economic dependence and the need not to break with social values, which place women as responsible for family stability, are elements that hinder negotiations and safer sex practices with their partners16.
Due to the asymmetry of power, talk about AIDS within the relationships can generate new conflicts in intimacy. This situation is due to the fact of negotiating for condom use, towards the disposal of preventive measures, is linked to the imaginary as a token of love, in which the no total delivery to other opposes to confidence17.
In addition, extramarital relations are perceived by women as a necessity and as a natural and expected attitude within the concept that these women make the male universe because, although not a desired attitude, this reality is understood by the wife18. For these reasons do not trust the partner, but there is also no charges in relation to the use of condoms, demonstrating women's submission to men.
Considering the vulnerability, its increase, seen the difficulty of adequate information, neglect and poor quality of health services, socio-economic barriers to access to information, housing, low educational level and social barriers in the adoption of protective measures. Thus, it is understood the vulnerability as a key-concept and an invitation to renew health practices, in order to guide humans to recognize the risk factors that contribute most to the chronic diseases and to recognize as careful constructors with their own body19.
HIV/AIDS prevention
It was noted in the transcript of the speeches of the interviewed several thoughts in relation to forms of HIV/AIDS prevention, and in all speeches the participants have cited the condom as the primary way to prevent disease, as the following lines:
Prevention is through guidance, information is the main thing, knowing that to prevent AIDS or any other sexually transmitted disease have to use condoms, use a condom [...]. (I48)
In the time that will have relationship always use condoms and find out if your partner is in good health so he doesn't contaminate you [...]. (I25)
Corroborating these perceptions, a study shows that the male condom use in sexual relations appears as the principal mechanism for HIV/AIDS prevention in the vision of women, assuming the same holds some knowledge on the subject, contributing for the reduction of vulnerability to disease20.
Another aspect noted in the analysis of the subjects was the fact that the knowledge of some of the participants in relation to the forms of HIV/AIDS prevention was wrong:
For me, not to take AIDS must use condoms and have to stay away from people who have the disease [...]. (I10)
Avoid contact with people who are already infected and to prevent through the condom [...]. (I3)
These perceptions will contribute to the establishment of stigmas and prejudices related to disease, associating it to devalued moral connotations and socially.
In addition, some women during the interviews cited that in order to prevent of the AIDS virus, some behaviors should be avoided, such as the high number of sexual partners, and the sharing of syringes in injecting drug user groups, in accordance with the following lines:
You can prevent AIDS by using a condom and not going out with a lot of people [...]. (E13)
Using a condom in sexual relations, not having multiple partners and avoid sharing syringes to inject drugs into a drug user group [...]. (I14)
A similar result was observed in another study, where it was possible to identify a strong association of AIDS to people who are regarded as risky behaviors, this logic that drove this disease of the universe of the participants of this study. It was observed that, when the conjugality is institutionalized, appears the idea of prevention linked to partner that is known and therefore there will be no exposure to risk21.
With regard to prevention in the context of the HIV/AIDS epidemic, this has been, from the beginning, a crucial issue for AIDS control programs. So, the best way to try to avoid sexual contamination is spreading wide the concept of safe sex, i.e. through the correct use of condoms in all sexual relation vaginal, anal or oral12.
It is worth noting that although no method of barrier be fully effective, consistent and correct use of condoms minimizes the risk of transmission of not only HIV, but also of other STDs, in addition to the risk of unwanted pregnancy.
All subjects are vulnerable to HIV infection, a result not only of intrinsic to the individual situations, but also related to social and cultural factors, as well as the gaps in public policies, educational and welfare that have great influence on the infection process of individuals by HIV/AIDS.
Among these subjects, monogamous profile women and involved in marital relationships are the least prevent against possible risks of transmission22.
Given this, we highlight the need to take into account the affective dimensions of the representations of HIV/AIDS among women who are in stable relationships, because it considers that the concepts of love, dedication and confidence remain as grounds of an unprotected sexual practice, contributing to the process of feminization of AIDS4.
In this context, health education is an instrument for the promotion of the quality of life of individuals, families and communities through the articulation of technical knowledge and popular, institutional and community resources, public and private initiatives, overcoming the conceptualization of biomedical healthcare and multi determinate s of health illness process encompassing-carefully23.
CONCLUSION
The study showed that women participants of this research do not consider themselves vulnerable in the face of HIV/AIDS because they are married. In this way, are at risk, due to issues such as: beliefs, values and gender that circulate the universe of these subjects. It is evident that, despite all the advances and achievements in the course of the years, still are notorious gender relations in marital, sexual and social issues.
As regards to preventive measures against HIV/AIDS, the study revealed that all the speeches mentioned the condom as the primary way to prevent the disease. However, despite quoting the condom as a fundamental means to prevent, women do not use in their sexual relations.
So it is suggested, to try to assist in the improvement of such framework, actions to promote women's health that take into account cultural factors, beliefs and values that influence the decision-making and attitudes. And also, to encourage the participation of its partners in educational actions, which are able to produce positive results.
It is emphasized the importance of nurses, in the search of transformation of health/disease process, especially in the formulation and implementation of healthy public policies aimed at reducing the vulnerability of women to HIV/AIDS infection.
This research presents the fact that limitations have been developed on a single basic unit of health and have investigated a reduced sample, which does not allow generalization of the findings: We must carry out new studies, making it possible to compare the perceptions of women from multiple variables such as class, culture and geographical location.
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