ORIGINAL RESEARCH
Sexual knowledge and practices among HIV-positive pregnant women treated at a university hospital
Michelle Ribeiro de AssisI; Leila Rangel da SilvaII; Daiana Silva LimaIII; Cristiane Rodrigues da RochaIV; Mirian Santos PaivaV
INurse. Master of Nursing by the Universidade Federal do Estado do Rio de
Janeiro. Brazil. E-mail: mraunirio@gmail.com
IIObstetric Nurse. PhD. in Nursing. Professor, Universidade
Federal do Estado do Rio de Janeiro. Brazil. E-mail: rangel.leila@gmail.com
IIINurse. Master of Nursing by the Universidade Federal do
Estado do Rio de Janeiro. E-mail: dai.silvalima@gmail.com
IVPhD. in Nursing. Adjunct professor, Universidade Federal do
Estado do Rio de Janeiro. Brazil. E-mail: crica.rocha@hotmail.com
VNurse. PhD. in Nursing, Associate professor, School of Nursing of the
Universidade Federal da Bahia. Brazil. E-mail: paivamirian@hotmail.com
DOI: http://dx.doi.org/10.12957/reuerj.2016.12536
ABSTRACT
Objective: to discuss knowledge of means of preventing other sexually-transmitted infections and practicing safe sex. Method: in this quantitative descriptive study of a group of ten HIV-positive pregnant women at a university hospital in Rio de Janeiro, data were collected by semi-structured questionnaire between December 2012 and March 2013, and organized using Microsoft Excel®. Ethical requirements were met, and the project approved (CAAE-07639612.9.0000.5285). Results: the predominant reference for safe sex, mentioned by six women, was to use a male condom. Conclusion: the pregnant women were aware of safe sex practices, but the culture that condoms interfere with sexual intercourse, in addition to inequalities in gender relations, influenced the women's decision to adopt this practice.
Keywords: Women's health; safe sex; Acquired immunodeficiency syndrome; nursing.
INTRODUCTION
Sexually transmitted infections (STIs), as the second main cause of loss of a healthy life among 15- to 49-year-old women, are a global public health concern and a major challenge for the Brazilian National Health Service (SUS) favoring the practice of safe sex outside pre-established times, such as the carnival. It is well known that different population segments need to be made aware of the benefits of condom use for good sexual and reproductive health1 as, between 2000 and 2012, 6367 cases of pregnant women infected with the human Immunodeficiency Virus (HIV) were reported in Rio de Janeiro alone2.
One study carried out with pregnant women living in the city of Rio de Janeiro indicated that unsafe sexual practices often result in unplanned pregnancies, as well as the acquisition of STIs3. Thus, any guidance that favors the use of condoms in all sexual relations should be delivered to the public; it is the responsibility of the managers of the public healthcare system to make this contraceptive available without red tape.
The use of the female condom in the scenario of STIs/acquired immunodeficiency syndrome (AIDS) could transform this situation of the vulnerability of women, as, with easy access, the decision to use a condom would be theirs. As this does not happen, what is still seen today is the restricted use female condoms compared to the use of the male condom.
The female insertion in the STI scenario brings cultural and social factors in the relationships between men and women to the forefront, including the discussion about unequal gender relationships within the scope of exercising sexuality, thereby surpassing the paradigm of just a biological vulnerability4.
Considering the above, the present study had the goal of studying the practice of safe sex in HIV-seropositive pregnant women with the following objectives: to discuss their knowledge, the form of prevention of other STIs and the practice of safe sex in this group of pregnant women.
Review of the literature
Currently, in the STI scenario, the Ministry of Health works with a syndromic approach5. One of the main characteristics of this approach is the use of flow charts by health professionals, aimed at helping to identify the causes of syndromes.
This assistance methodology aims to facilitate the identification of one or more syndromes and then to address them adequately. The syndromes related to STIs are grouped as follows: vaginal discharge, urethral discharge, genital ulcer and discomfort or pelvic pain in the woman.
In Brazil, the annual estimates by the World Health Organization (WHO) of STIs in the sexually active population are Syphilis: 937,000, Gonorrhea: 1,541,800, Chlamydia: 1,967,200, Genital herpes: 640,900 and HPV: 685,400. It is worth mentioning that regardless of gender, having other STIs, besides HIV, makes the organism more vulnerable to other diseases transmitted by unprotected sex, including AIDS, and is correlated to maternal and neonatal mortality6.
METHOD
This is a descriptive quantitative study. The scenario was a federal university hospital located in the city of Rio de Janeiro, in which prenatal care was not specific for seropositive pregnant women and was provided once a week. At the time of data collection, 46 pregnant women were being followed up; of these, 12 were seropositive, 10 of whom accepted to participate as study volunteers. All ethical aspects for research were respected with the project being submitted to the government registration of research projects (Plataforma Brasil) and approved under CAAE-07639612.9.0000.5285 on September 26, 2012.
Before starting data collection, the objectives of the research were explained to each pregnant woman making it clear that they could withdraw their consent to participate in the study at any time. Nevertheless, all the women signed the free and informed consent form required by Resolution 466/2012.
Data collection took place between the months of December 2012 and March 2013. The subjects were selected after an investigation of prenatal care records. The inclusion criteria for this study were HIV-positive pregnant women.
The study instrument, a semi-structured questionnaire assessing sociodemographic, gynecological and obstetrical information and sexual activity, included questions about the number of sexual partners, negotiation and use of condom with the partner, knowledge of STIs, the partner's serological status and pregnancy planning.
The Microsoft Excel® program was used to organize, analyze and interpret the data with statistical analysis using a calculation of the absolute frequencies.
RESULTS AND DISCUSSION
Characterization of subjects
Among the ten pregnant women interviewed, three had been living with HIV for less than one year, two between one to five years, four from five to 10 years, and one had had the virus for more than 10 years. The prevalent age range was 30 to 34 years. It is noteworthy that four pregnant women had not finished primary education, five had completed high school and one had not finished high school. As for the profession or occupation, four were homemakers, two were students, one was a cashier, one a hairdresser, one a teacher and one a singer/dancer. Seven women were married and three were single.
Official statistics show that in 2012, 3,707 of the total of 6,648 cases of HIV infection reported to the Brazilian Notifiable Diseases Information System (SINAN) were women of reproductive age, with the highest incidence being in the age group of 30 to 34 years (1093 notifications) thus corroborating the findings of the current study2.
The findings of this study in respect to the level of schooling agree with official sources, as well as the results of other studies 7-9. SINAN data show that women who had not finished elementary school, had completed elementary school, not finished high school and had completed high school were responsible for 729, 351, 215, and 489 notifications, respectively, in the period of 20122, confirming the higher number of cases in women with little schooling.
A study carried out in the south of Brazil found that the educational level is directly related to infection by HIV, as the incidence in women with eight or more years of formal education was lower than those who had three years or less of formal education10.
The economic dependence of pregnant women was verified in this study with only four having their own income, while the others were students or lived doing domestic duties, that is, they considered themselves homemakers.
Economic dependence of women is a risk factor for the acquisition of STIs as it has a direct implication on the bargaining power of women with their partners on the use of condoms11.
When considering the economic level and schooling in stable relationships, it is observed that the woman is much more vulnerable to STIs; stable unions usually generate feelings of protection and trust in the partner, especially for woman, who insist on living loving relationships romantically, thus maintaining their vulnerability12.
The results of this investigation highlight the issue of HIV infection in married women and show that the risk group theory is not really a situation that is part of the current scenario. The findings place stable marital relationships as a risk factor for the acquisition of new STIs, because they result in the couple abandoning the use of condoms.
Reproductive and sexual characteristics
Regarding pregnancy planning, two interviewees said they planned the current pregnancy, unlike the others who did not plan to get pregnant. When questioned whether this planning occurred before or after the HIV infection, both confirmed that they planned even knowing that they were HIV positive.
The AIDS Protocol Clinical Trial Group (ACTG 076) has recommendations to reduce mother-to-child transmission from 25% to 1-2%, namely: serology for HIV in prenatal care, use of antiretroviral drugs during pregnancy from the 14th week of gestation with triple therapy, labor and delivery, treatment of the exposed child for 42 days after birth and no breastfeeding13.
In this study, unplanned pregnancy appears as an alarming fact, because among the ten participants, eight became pregnant without planning. Thus, it is worth remembering that public health measures should be carried out to promote good sexual and reproductive health with HIV-positive subjects. Hence, reproductive planning should be considered from the perspective of preventing STIs/HIV/AIDS14.
Reproductive planning counseling should also be organized and designed differently for this group, considering the specific issues of women living with sexual activity and motherhood with HIV15. Information on conception and contraception needs should be accompanied by gestation planning with clinical timing, which includes rigorous assessment of the viral load and lymphocyte count15. Condom use is required by the pregnant woman for her and her partner's protection. Moreover, guidance on conception options that have a lower risk of contamination for the couple and for the concept is necessary including self-insemination and assisted reproduction techniques with counseling that takes into account possible drug interactions of oral contraceptives and antiretroviral drugs.
HIV-positive women using antiretroviral therapy, who do not wish to become pregnant, need to have safe methods of contraception available. Birth control pills are among the most effective contraceptives because they do not interfere with the immune and viral responses but share metabolic pathways with antiretroviral drugs, and this may interfere with the pharmacodynamics or pharmacokinetics of the pill. Infectologists and gynecologists who provide assistance to HIV-positive women should consider the possibility that these drugs might interact and therefore provide individualized counseling that considers the best type of contraceptive, dose and route of administration with the antiretroviral therapy as the basis16.
Living with HIV brings a series of changes in life, and often not even the woman, her family or the health team are prepared to face the difficulties. For this, the role of mother may be threatened by the fear of transmitting the infection to the concept, a situation that can be reinforced by unprepared health professionals who judge that the woman and the couple have no right to form a family17.
The gestation of HIV-positive women involves the management of complex situations, with one of the greatest difficulties being living, day-to-day, with the possibility of mother-to-child transmission. This is due to the preconception that persists around this infection causing limitations in one's care and in social interaction. One of the great repercussions of this prejudice is the fact that women feel obliged to hide their serostatus from their relatives and their sexual partners because they fear the consequences that revelation will bring in their family and social relationships. Furthermore, there is still the question of not being able to breast-feed their newborn, which in general can compromise the secrecy around their serological condition, as well as favor isolation with the psychological pain that some feel due to mechanical suppression of lactation, considered a painful and punitive act17.
Regarding the number of sexual partners in the previous year, the majority of participants (seven) did not report having more than one sexual partner; one reported having had two, one had three, and one mentioned having had six partners.
All the participants said they knew the diseases transmitted by sexual intercourse. The most commonly cited by them were HIV followed by syphilis, human papillomavirus (HPV), hepatitis, herpes, gonorrhea and chancroid. When questioned about STIs and whether they already had had an STI, nine considered HIV to be an STI and one participant did not report having any type of STI. With this response, the pregnant woman was questioned about how she could have been infected with HIV, and she stated it was sexually. Two participants had HPV and one genital herpes in addition to HIV infection.
STIs bring serious problems to the sexual and reproductive health of men and women, for example, they increase the possibility of HIV infection by up to 18 times, and when pregnant women are affected, they can affect the fetus and impair its development, causing abortions or ectopic pregnancies, and also cause children to have congenital malformations 18.
The findings of this study reinforce the STI statistics, as among the participants there was evidence of co-infections, which may have favored the spread of HIV. It is worth noting that only one case of neonatal mortality was reported among the participants. The infections concomitant with HIV were herpes and HPV. These, as well as HIV infection, are infections for which cures are still unknown and pose a risk to the health of the concept.
Sexual Knowledge and Practice
When questioned about the practice of safe sex during the current gestation, six pregnant women reported using condoms, two reported not using condoms and two said they did not always use a condom.
As for the use before the current gestation, six said they used, three did not use and one reported sporadic use of condoms. The prevalent type of condom was the male condom among nine women, and one used the female condom. When they were approached about the difficulty in using condoms, seven had no difficulty and three had trouble. Among the difficulties, two reported that their partner did not accept and one said that it disrupted sexual intercourse. Participants confirmed that they used condoms to prevent illness and pregnancy; those who did not use them, claimed that they trusted their partners, they were pregnant or refused to use one.
For three pregnant women, the use of condoms is strictly linked to the prevention of pregnancy, which is a matter of concern, since it demonstrates once again the difficulty of women to deal with sexual issues, prevention of infection and exposure of the concept. It is necessary to reinforce with HIV-positive women that being HIV-positive does not make them immune to other infectious diseases.
In 2012, in Rio de Janeiro, 170,000 female condoms were distributed compared to more than 5,499,960 male condoms19. Thus, when considering the total number of condoms distributed to men and women in that year, approximately 3% were allocated to the female population, showing an unequal ratio in the distribution.
The current public health policy for the distribution of female condoms provides access only to sex workers, women in situations of domestic or sexual violence, HIV-positive women and partners of HIV-positive men, drug users and partners of injectable drug users, STI carriers and women with low incomes who use services for women 20.
The vulnerability of the women participating in this study for other STIs demonstrates a submissive and inferiority posture to the male sex, thus perpetuating an unequal gender relationship due to the difficulty of talking about and negotiating a safe sexual relationship with their partner. Women are considered the only ones responsible for contraception and conception by most of society, and thus they cannot fully exercise their sexual and reproductive rights. Thus, sexual intercourse continues to be experienced unequally by both sexes, with the woman remaining in a position where she only fulfills her partner's wishes.
The availability of the female condom does not guarantee its use nor its acceptance by the partner; therefore, the greatest benefit is in providing autonomy for female use. It is an efficient method of contraception and prevention of STIs/AIDS. The advantages of its use are, among other things, the feasibility of inserting it hours before sexual contact, the possibility of its use favoring the woman in the best knowledge of her anatomy and supplying insufficient vaginal lubrication at menopause21.
The lack of condom use by the study participants becomes even more significant when one observes that when asked about the serological status of their partners, four stated that their partners were seroconcordant, three serodiscordant, and three others were unaware of their status. Seven partners knew the status of their partners and three partners were unaware of it, denying the other the right to prevent infection and/or the right to choose about the risk consciously.
The difference in the serological status of individuals living with HIV/AIDS constitutes a new challenge in breaking the transmission chain of infection, as it no longer deals with the possibility of the other having the infection or not, but with certainty. The challenge in these cases is to convince the women that the partner may become infected even though this has not happened to date. Although there may be an additional stimulus for safe sex among the serodiscordant couples, maintaining this care is not an easy task. Some barriers constitute a challenge for this group in maintaining safe sexual relationships, such as the alteration of sexual satisfaction, the difference of acceptance between men and women in the systematic use of condoms, and the low use of the female condom as an alternative method of prevention21.
CONCLUSION
HIV/AIDS infection is a pandemic that can affect any individual, regardless of gender, age, culture, religion and social class. In this study, the focus was on the insertion of pregnant women in this scenario, as well as the question of other STIs and the difficulties to practice safe sex. It is necessary to address the feminization of AIDS by addressing aspects such as gender relationships and unequal attention within the scope of the SUS, the non-availability of female condom, reproductive planning focused on the specific needs of HIV-positive women and the actions of health professionals.
Although the pregnant women in this study knew about which infections can be sexually transmitted, they are more vulnerable because they have a low level of schooling, economic dependence on their partners, or trust in the fidelity of the other. By using health education, it is necessary to reflect on sexual intercourse and conscious living in order to understand how the act of sex can influence the woman's life and the experience of motherhood.
Among the limitations of the study, the low number of participants in only one setting are important as these factors prevent the generalization of the findings.
Acknowledgments
Thanks to the Ministry of Health for the granting of a scholarship for residence in nursing.
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