Revist a de Saúde Pública
I SSN 0034- 8910 versão im pressa
Rev Saúde Pública 2003; 37(5)
Factors associated with HIV risk perception am ong hospital
postpartum wom en
Neide de Souza Pr açaa, Maria do Rosário Dias de Oliveira Lat orreb andNorm an Hearstc
a
Depart am ent o de Enferm agem Mat erno- I nfant il e Psiquiát rica of t he Escola de Enferm agem da Universidade de São Paulo. São Paulo, SP, Brasil. bDepar t am ent o de Epidem iologia of t he Faculdade de Saúde Pública da USP. São Paulo, SP, Brasil. cUniv er sit y of Califor nia, San Fr ancisco, USA
ABSTRACT
Objective
To assess fact or s associat ed w it h HI V r isk per cept ion am ong post par t um w om en adm it t ed t o philant hr opic m at er nit y hospit als.
Methods
Results
Nearly 29% of post part um w om en considered t hem selves at risk for HI V infect ion. They w ere single, had prior STD and believed “ m arried m en enj oy him self in t he sam e way as single m en do” . Pr event ion and healt h m aint enance behavior s w er e also ident ified.
Conclusions
Wom en’s knowledge on AI DS seem s t o affect t heir individual risk percept ion. Fut ure HI V/ AI DS pr ev ent ion cam paigns should be focused on incr easing couples and adolescent s’ inv olv em ent .
Keywords
HI V infect ions, t ransm ission. Acquired im m unodeficiency sy ndr om e. Know ledge, at t it udes, pr act ice. Wom en's healt h. Per cept ion. Risk fact or s. Puer per ium . HI V infect ions, pr event ion and cont r ol. HI V. Socioeconom ic fact or s. Sex ually t r ansm it t ed diseases.
I N TRODUCTION
Epidem iological st udies in Brazil have show ed increasing cases of HI V infect ion am ong w om en at childbearing age.
Dat a from t he Brazilian Minist ry of Healt h for t he period bet w een 1980 and March 20024 sh ow t h at perinat al t ransm ission com prised 3.0% of t ot al HI V/ AI DS cases r epor t ed for bot h sex es. The highest rat e of HI V/ AI DS w om en w as seen am ong t hose w ho had het erosexual exposure ( 85.5% ) , follow ed by I V drug users ( 13% ) . The current t rend of growing het erosexual HI V infect ion in Brazil has brought w om en int o t he sexual and perinat al cont inual progressing chain of t ransm ission.
HI V pr event ion am ong het er osexuals is ham per ed by beliefs and cult ur al pr act ices t hat im pair individual risk percept ion in a populat ion. Aft er int erview ing 2,681 w om en in t he Nat ional Sur v ey on Dem ogr aphy and Healt h ( PNDS) of t he st at e of São Paulo it w as found t hat 45.3% did not per ceiv e t hem selves at risk of HI V infect ion, 37.9% perceived t hem selves at low risk, 6.9% at m oderat e risk, and 4.5% at high risk.1
Anot her st udy revealed t hat w om en w it h a st eady fam ily living in a slum in t he cit y of São Paulo dem onst rat ed som e know ledge on HI V rout es of t ransm ission and sexual prevent ion but t hey did not apply t heir k now ledge because t hey r elied on t heir par t ner being fait hful to t hem and did not per ceiv e t hem selves at r isk of HI V infect ion.1 0
M ET HODS
The st udy sam ple com pr ised 384 post par t um w om en of t w o char it able m at er nit y hospit als in t he cit y of São Paulo. The sam ple size w as defined as per cent age of w om en w ho per ceiv ed t hem selv es at r isk of HI V infect ion based on Badiani et al1 estim a t ion’s of 55% . I t w er e used 10 confidence int er v als and 5% p- value and t he sam ple size was calculat ed according t o Hulley and Cum m ing.9 Post par t um w om en w ho did not hav e any chr onic diseases and had liv e new bor ns w er e int er v iew ed at least 12 hour s aft er delivery, regardless delivery rout e.
All post part um wom en who had delivered in t he previous 24 - hour period w ere recorded on a daily basis in t he post part um unit ’s hospit al adm ission regist ry. Aft er confirm ing all inclusion crit eria were m et , t he int er v iew er w ould look for each pat ient . She w ould int r oduce her self and aft er get t ing pat ient ’s consent for enr olling in t he st udy , she w ould conduct an int er v iew in a separ at e r oom . Ex cept for t w o w om en w ho r efused t o par t icipat e, all ot her s agr eed t o be included in t h e st u dy .
Each char it able m at er nit y hospit al pr ov ided 50% of par t icipant s in t he st udy sam ple. The char act er ist ics of t he m at er nit y hospit als w er e as follow s: one is a gener al hospit al locat ed in t he cit y ’s east er n ar ea, and it s m at er nit y unit adm it s pat ient s from t he Unified Nat ional Syst em ( SUS) and pr ivat e HMOs w it h a m ont hly aver age of 800 deliver ies. The second one is a m at er nit y hospit al locat ed in t he cit y ’s sout her n ar ea w it h an av er age of 700 deliv er ies a m ont h and adm it s ex clusiv ely SUS p at ien t s from various m unicipalit ies in t he Great er São Paulo.
Dat a collect ion w as car r ied out at t he sam e t im e in bot h m at er nit y hospit als by t w o nur sing st udent s t r ained for t his pur pose. A quest ionnair e consist ing of 80 quest ions on sociodem ogr aphics, sex ual and r epr oduct iv e healt h pr act ices, HI V/ AI DS k now ledge, at t it udes, and HI V r isk per cept ion w as applied t o par t icipant w om en.
The quest ionnair e w as st r uct ur ed based on Pr aça and Gualda’s1 0 r esult s of a qualit at iv e et hnogr aphic st udy conduct ed in an ur ban slum com m unit y in t he cit y of São Paulo in 1998. The aut hor s’ pur pose w as t o ascer t ain HI V r isk per cept ion am ong slum w om en w ho had a st eady fam ily. Wom en’s r isk per cept ion w as assessed confr ont ing t heir k now ledge, beliefs and at t it udes concer ning HI V pr ev ent ion w it h r ecom m ended act ions t o fight t he HI V/ AI DS epidem ic. Their HI V suscept ibilit y w as also discussed. A pilot st udy w as car r ied out in 10 post par t um w om en adm it t ed t o a univ er sit y m at er nit y hospit al in t he cit y of São Paulo, w hich m ost ly assist s w om en w it h a sim ilar profile t han t hose assist ed by t he t w o st udy m at er nit y hospit als.
HI V risk percept ion w as defined as t he dependent variable ( yes= 1 and no= 0) and independent v ar iables w er e sociodem ogr aphics ( age, occupat ion, schooling, m ar it al st at us, and fam ily incom e) , STD and HI V/ AI DS knowledge ( inform at ion sources, rout es of HI V t ransm ission, prevent ion m easur es) , and gender- r elat ed at t it udes and behav ior .
St at ist ical analysis w as per for m ed using Chi- squ ar e t est cor r ect ed by Yat es f or t h e associat ion bet ween risk percept ion and t he independent variables and a m ult iple logist ic regression m odel, st epw ise for w ar d r egr ession, w as used in t he com bined analy sis as v ar iable select ion st r at egy . All v ar iables w it h p< 0.200 in t he associat ion analy sis w er e analy zed in t he m ult iple regression m odel. All st at ist ically significant variables ( p< 0.050) rem ained in t he m ult iple regression m odel. The variable schooling w as used as cont rol in t he m ult iple regression m odel.
part ic ipant s w er e assur ed t heir r ight t o anonym ous par t icipat ion as w ell as r efusal of par t icipat ing in t he st udy w it hout any com pr om ises t o t heir car e in t he inst it ut ion.
RESULT S
Ther e w er e int er view ed 384 post par t um w om en in t he per iod bet w een Januar y and March 2 0 0 0 . Of t hese, 273 w om en ( 71% ) show ed no HI V r isk per cept ion. Mean age w as 23.5 year s ( st andar d deviat ion = 5.9 years) , 28% w ere t eenagers ( aged 12 t o 19 years) . Nearly 50% have not com plet ed elem ent ar y school and only 1% had at t ended univ er sit y . Of all, 60% had a m ont hly incom e less t han R$ 750.00* , corresponding t o less t han 5 m inim um wages at t he st udy t im e ( R$ 151.00 m ont hly) . Most ( 67% ) did not have an occupat ion and 3% w er e unem ployed and financially dependent on t heir part ner or fam ily. The m ost com m on occupat ions w er e t hose not r equir ing specific t r aining such as household m aids, aids, sales clerk and ot hers. Of all wom en, 78% lived wit h t heir part ner or husband and 71% were Cat holic. Only t wo wom en ( 0.5% ) report ed current drug use and 22 ( 6% ) re por t ed having used drugs in t he past , while 10 ( 3% ) said t heir current part ner has been current ly using dr ugs in cont r ast t o 27 ( 7% ) of t heir for m er par t ner s. Most ( 84% ) had never had an abor t ion and 70% w ere had one or t w o prior pregnancies. Only 15% report ed having t heir first sexual relat ionship aft er t he age 20, 46% said t hey had had m ore t han one part ner in t heir lifet im e, and 88% had only one par t ner in t he last t w o y ear s.
* The dollar currency rat e w as R$ 1.73 ( April 3, 2000) .
Table 1 show s HI V r isk per cept ion r elat ed t o sociodem ogr aphics. Ther e w as a st at ist ically significant associat ion bet w een HI V r isk per cept ion and age ( p= 0.023) and m ar it al st at us ( p= 0.020) . Wom en aged less t han 20 had higher r isk per cept ion t han w om en aged 20 and over . The sam e is t r u e f or m arit al st at us. HI V risk percept ion was sim ilar concerning schooling, incom e, and religion ( p= 0.384, p= 0.121, and p= 0.937 respect ively) .
Ta ble 1 – Sociodem ogr aphics and r isk per cept ion of st udied w om en. São Paulo, 2000.
Variable Risk
per cept ion
p*
Cat egor y No Ye s
N % N % Age ( y ear s)
12 – 19 66 6
2
41 3 8
0.0 23
20 – 25 12
5 7 7
37 2 3
26 – 42 82 7
1
33 2 9 Schooling
I llit er at e + I nc. elem ./ m iddle
13 9
7 4
48 2 6
0.3 84 Com p elem ./ m iddle + I n c.
high school
85 6 8
41 3 2 Com p hig h school + univ. 49 6
9
22 3 1 I ncom e ( R$) * *
25.00 – 300.99 47 7
0
20 3 0
0.1 75
301.00 – 750.99 12
7 7 7
7 7 3
751.0 and over 67 6
8
31 3 2 Mar it al st at us
Ye s 22
1 7 4
77 2 6
0.0 20
No 52 6
1
34 3 9 Religion
Cat holic 19
4 7 2
77 2 8
0.9 37
Ev angelic 50 6
9
22 3 1
Ot her 29 7
1
12 2 9
To t al 27
3 7 1 11 1 2 9
* p: descr ipt iv e lev el of no associat ion hy pot hesis t est ing
* * Ex cluded w om en w it h unk now n dat a.
Dollar currency rat e was R$ 1.73 and t he m inim um wage was R$ 151.00 at April 3, 2000.
Table 2 shows individual vulnerabilit y as per wom en’s assessm ent of her HI V knowledge and pr ev ent ion. A st at ist ically significant associat ion w as found only w it h STDs ( p= 0.016) . Wom en w ho had had prior STD had higher risk percept ion. Risk percept ion relat ed t o ot her variables was sim ilar.
Ta b le 2 – Char act er ist ics r elat ed t o individual vulner abilit y and r isk per cept ion of st udied w om en. São
Paulo, 2000.
Variable Risk
per cept ion
p*
Cat egory No Yes
N % N %
Blood t ransfusion
Ye s 5 6
3
3 3
7 0. 8 83
No 26
8 7 1 10 8 2 9 STDs
Ye s 9 4
5
11 5 5
0. 0 16
No 26
4 7 3 10 0 2 7 Current drug use
Ye s 1 5
0
1 5
0 0. 9 03
No 27
2 1 0 9 Past drug use
Ye s 13 5
9
9 4
1 0. 3 00
No 26
0 7 2 10 2 2 8 Par t ner cur r ent dr ug user
Ye s 5 5
0
5 5
0 0. 2 52
No 24
7 7 1 10 0 2 9
Do not k now 21 7
8
6 2
2 Part ner form er drug user
Ye s 20 6
9
9 3
1 0. 6 90
No 10
0 7 1
41 2 9
Do not k now 8 8
9
1 1
1 Had only one
par t n er
14 5
7 1
60 2 9 # par t ner s in t he last 2
years
1–2 26
0 7 1 10 9 2 9 0. 2 87
3 and m ore 13 8
7
2 1
3 Condom use
Ye s 11
2 6 7
55 3 3
0. 1 57
No 16
1 7 4
56 2 6 Condom use in all
int er cour ses
Ye s 33 7
0
14 3 0
0. 2 66
No 79 6
6
41 3 4 Do not use
condom s
16 1
7 4
56 2 6 Already t est ed for HI V?
Ye s 23
0 7 2
91 2 8
0. 6 95
No 43 6
8
20 3 2
To t al 27
3 7 1 11 1 2 9
Table 3 show s couple’s behav ior char act er ist ics. A st at ist ically significant associat ion w as seen bet w een HI V risk percept ion and w om en’s beliefs her part ner could be at risk of HI V infect ion ( p< 0.001) , m arried m en spend t heir leisure t im e in t he sam e way single m en do ( p= 0.021) and m arried wom en spend t heir leisure t im e t he sam e way single wom en do ( p= 0.051) . When answers were affirm at ive, wom en showed higher risk percept ion. Risk per cept ion r elat ed t o ot her v ar iables was sim ilar.
Ta ble 3 – Couples’ behav ior char act er ist ics and r isk per cept ion, accor ding t o st udied w om en. São
Paulo, 2000.
Variable Risk percept ion p*
Cat egor y No Yes
N % N % Husband have ext ram arit al sex
Yes 8 50 8 5
0
0.162
No 23
3
72 90 2 8
Do not know 32 71 13 2
9 Husband has/ had sex wit h m en
Yes 1 10
0
– – 0.667
No 25
7
71 10 3
2 9
Do not know 15 65 8 3
5 Your husband is fait hful t o y ou?
Yes 21
4
73 79 2 7
0.169
No 59 65 32 3
5 Yo ur husband would use condom s in
ext ram arit al sex
Yes 17
0
70 72 3 0
0.605
No 29 67 14 3
3
Do not know 74 75 25 2
5 Par t ner could be at r isk of get t ing HI V
in f ect ed ?
Yes 46 35 86 6
5
< 0.00 1
No 12
9
90 14 1 0
Do not know 80 94 5 6
No cur r ent par t ner 18 75 6 2 5 Wom an and husband go out t o spend
leisure t im e
Yes 14
7
72 57 2 8
7 8
No 12
6
70 54 3 0 Married m en spend leisure t im e t he sam e
way singles do
Yes 40 59 28 4
1
0.021
No 23
3
74 83 2 6 Married wom en spend leisure t im e t he
sam e w ay singles do
Yes 13 52 12 4
8
0.051
No 26
0
72 99 2 8 Mar r ied m en go out t o hav e sex w it h
ot her w om en?
Yes 25
4
71 10 6
2 9
0.504
No 19 79 5 2
1 I s it easy for m ar r ied m en t o have
ext ram arit al sex?
Yes 24
4
70 10 4
3 0
0 . 262
No 29 81 7 1
9 I s it easy for m arried wom en t o have
ext ram arit al sex?
Yes 16
8
69 76 3 1
0.245
No 10
5
75 35 2 5 Couple should liv e t oget her for ev er
Yes 20
6
72 79 2 8
0.458
No 67 68 32 3
2
Tot al 27
3
71 11 1
2 9
* p: descr ipt iv e lev el of no associat ion hy pot hesis t est ing
None of t he var iables r elat ed t o HI V/ AI DS know ledge/ behavior including t hose r elat ed t o t he condom use w as st at ist ically associat ed w it h r isk per cept ion ( Table 4) .
Ta ble 4 – Var iables r elat ed t o HI V/ AI DS know ledge/ behavior and r isk per cept ion, accor ding t o
int erview ed w om en. São Paulo, 2000.
Variable Risk percept ion p*
Cat egor y No Yes
N % N % How got t o know about AI DS
TV/ r adio 15
9
72 61 2 8
0. 4 49
Sch ool 59 71 24 2
9
Fly er s/ r eading/ ot her 19 79 5 2
1
Relat iv es 9 75 3 2
5
Do not r ecall 27 60 18 4
0 Think w om en can get AI DS?
Ye s 27
3
71 11 1
2 9
–
No – – – –
Think w om en pr ot ect t hem selv es against AI DS?
Ye s 12
4
71 50 2 9
0. 5 56
No 13
5
70 58 3 0
Do not k now 14 82 3 1
8 Think AI DS is sexually t ransm it t ed?
Ye s 26
9
71 11 1
2 9
0. 4 67
No/ Do not know 4 10
0
– –
Afr aid of get t ing AI DS?
Ye s 24
1
70 10 4
3 0
0. 1 60
No 32 82 7 1
8 Changed y our life because of AI DS?
Ye s 10
0
67 49 3 3
0. 2 10
No 17
3
74 62 2 6 Think people should change t heir life
because of AI DS?
Ye s 19
7
70 83 3 0
0. 6 92
No 76 73 28 2
7 Can you know som eone is infect ed by
looking at him / her?
Ye s 31 69 14 3
1 11
No 23
2
71 95 2 9
Do not k now 10 83 2 1
7 Can you get AI DS by hugging?
Ye s 2 67 1 3
3 0. 7 90
No 26
6
71 10 9
2 9
Do not k now 5 83 1 1
7 Mot her can inf ect h er ch ild?
Ye s 24
0
71 10 0
2 9
0. 5 66
No 23 79 6 2
1
Do not k now 10 67 5 3
3 Can y ou get AI DS in t he doct or ’s office?
Ye s 21
4
71 87 2 9
0. 9 06
No 44 70 19 3
0
Do not k now 15 75 5 2
5 Can y ou get AI DS w it h condom s?
Ye s 12
2
70 53 3 0
0. 3 08
No 13
3
71 55 2 9 Hav e y ou ev er t alk ed w it h y our husband
about condom use?
Ye s 94 75 32 2
5 0. 5 34
No 16 73 6 2
7
He already uses condom s 16
3
69 73 3 1 Husband w ould accept t o use condom s
Ye s 12
2
77 37 2 3
0. 1 17
No 38 66 20 3
4
He already uses condom s 11
3
68 54 3 2 Husband w ould use condom s if t hey w er e
f r ee
Ye s 50 71 20 2
9 0. 2 57
No 11
1
76 36 2 4
He already uses condom s 11
3
3 2
Do not k now 18 86 3 1
4
Tot al 27
3
71 11 1
2 9
* p: descr ipt iv e lev el of no ass ociat ion hy pot hesis t est ing
Table 5 pr esent s a com bined analy sis of fact or s associat ed w it h HI V r isk per cept ion. I ndependent fact or s associat ed w it h HI V r isk per cept ion w er e as follow s: non- m arit al st at us ( OR= 1.75; p= 0.056) , prior STD ( OR= 3.33; p= 0.026) , and having t he belief m arried m en spend t heir leisure t im e t he sam e way single m en do ( OR= 2.04; p= 0.023) . Replacing t he variable m arit al st at us was replaced wit h age w as not st at ist ically significant . But t he v ar iables pr ior STD and hav ing t he belief m ar r ied m en spend t heir leisure t im e t he sam e way single m en do were st ill st at ist ically significant regarding HI V risk per cept ion. The follow ing var iables w er e t est ed in t he m ult iple r egr ession analysis but w er e excluded fr om t he m odel as t hey w er e not st at ist ically significant : incom e, condom use, husband has sex w it h ot her w om en, w het her husband is fait hful, belief t hat her par t ner could get HI V infect ed, belief t hat m arried wom en can spend t heir leisure t im e t he sam e way single wom en do, husband would agree t o use condom , and being afr aid of having HI V/ AI DS. The var iable schooling w as used as cont r ol.
Ta ble 5 – Mult iple analy sis of fact or s associat ed t o HI V r isk per cept ion, São Paulo, 2000.
Variable Cat egory OR
adj ust ed p*
Model
Mar it al st at us
Yes 1. 00
No 1. 75 0. 0
56
STD Yes 3. 33 0. 0
26
No 1. 00
Married m en sam e leisure as single m en
Yes 2. 04 0. 0
23
No 1. 00
Schooling I llit erat e + I nc.
elem ./ m iddle
0. 73 0. 3 46 Com p elem ./ m iddle + I nc.
high school
1. 26 0. 5 14 Com p high school + univ. 1. 00
* p: descr ipt iv e lev el of Wald t est ing
D ISCUSSION
The associat ion bet w een HI V r isk per cept ion and age and m ar it al st at us suggest s t hat y ounger wom en wit h no st eady part ner are possibly m ore aware of HI V risk. These findings r eflect t he im pact of HI V/ AI DS cam paigns and healt h educat ion program s developed in t he last years.
Despit e w om en ident ified sex as a r out e of infect ion, t heir HI V r isk per cept ion w as not affect ed by t he num ber of part ners t hey had in t he last t w o y ear s. Condom use associat ed t o r isk per cept ion r ev ealed t hat a sm all per cent age per ceiv e t hem selv es at HI V infect ion r isk and do use condom s ( 55 w om en; 33% ) . I t could be eit her t hey do not per ceiv e t hem selv es at r isk or t hey do not per ceiv e t hem selv es at r isk j ust because t hey use condom s.
The r esult s show ed public healt h ser v ices in t he cit y of São Paulo ar e in com pliance w it h t he Minist r y of Healt h's r ecom m endat ions and m eet t he populat ion’s needs of pr enat al car e. These ser v ices offer HI V t est ing as it w as found 84% w er e t est ed in t he st udy sam ple and t w o t hir ds w er e t est ed dur ing pr enat al car e. Ther e w as no st at ist ically significant associat ion bet w een HI V t est ing and HI V r isk percept ion. I t is wort h exploring t he reasons why 63 wom en did not un dergo HI V t est ing during pr enat al car e. Regar dless t he specific r eason t his fact is im por t ant since pr enat al car e is a t im e w hen w om en ar e m ost likely t o get at t ent ion and have any disease ident ified. I t should also be consider ed w het her w om en w it h a negat ive HI V t est r esult per ceived t hem selves at no r isk for HI V infect ion.
Pr ior STDs seem t o r einfor ce w om en's HI V r isk per cept ion. This could r eflect t he effect of public healt h program s for educat ion on HI V/ AI DS et iology, t ransm ission rout es, prevent ion and t r eat m ent of HI V/ AI DS- r elat ed condit ions and ot her STDs. Also it should be t ak en int o account t hat t hose w ho had prior STDs could be aware t hey are not im m une t o diseases including HI V/ AI DS.
I t is also w or t h point ing out 76% of t he st udy w om en believ ed t heir husbands ar e fait hful t o t hem . Of t hese, 27% per ceiv e t hem selv es v ulner able t o HI V infect ion. Ther e is low er r isk per cept ion r egar dless w het her t hey believe or not t heir par t ner w ould use condom s in ext r am ar it al r elat ionships because wom en rely on t heir par t ner as conscient ious r egar ding t heir healt h and fam ily. The sam e w as found in a st udy conduct ed on a cult ur al gr oup in t he cit y of São Paulo1 0.
Unt r ust w or t hy par t ner s because of pr ev ious ex t r am ar it al r elat ionships w as t he r eason 91 w om en ( 2 4 % ) gav e for not r ely ing on t heir par t ner s’ fait hfulness. Ther e seem ed t o be a consensus am ong w om en t hat “ m en ar e not t o be t r ust ed,” “ t hey ar e all t he sam e,” and “ it is har d for m en t o be fait hful” .
I n cont r ast , t hose w ho r elied on t heir par t ner s’ as fait hful ( 293 wom en; 76% ) believed t heir part ners could be t r ust ed because of t heir day - t o- day life t oget her claim ing “ I know him ” . Som e wom en even believ ed t hat in case t heir husbands w ould be unfait hful t hey w ould be t old so t hey could pr ot ect t hem selves against HI V infect ion. On t hat Bast os et al,3 Mar t in,9 Goldst ein6 and Guim arães7 show ed w om en ar e not aw ar e of t heir par t ner s’ r isk for HI V infect ion. These aut hor s have assessed w om en’s t r ust on t heir par t ner s and found t hat only w hen w om en t est posit iv e t hey get t o k now about t heir husbands' r isk y behav ior and it is not uncom m on for t hese w om en t o be alr eady infect ed. These findings are corroborat ed in wom en’s referral services.
an aspect of Br azilian cult ur e of accept ing m en's social behav io r even if t his m eans posing w om en at hom e at higher HI V infect ion risk.
Ev en if w om en could hav e fr ee access t o condom s, 68% said t hey w ould not use t hem indicat ing t hat higher condom av ailabilit y w ould not incr ease t heir use. Ther e is an act ual need of r ising couples’ aw ar eness on condom use. I n t he st udy sam ple, 38% ( 148 w om en) said t hey have never used condom s, 15% ( 22) said t hey have never t alked t o t heir husband on condom use and of t hose w ho already did, 25% ( 32 wom en) perceived t hem selves at risk of HI V infect ion. A low per cent age of m en w ould not use condom s ( 58 m en; 27% ) com pared t o t hose w ho w ould use t hem ( 159 m en; 73% ) .
Wom en said t heir part ner w ould use condom w hen engaging in risky behaviors, such as “ having sex w it h pr ost it ut es” , “ he w ould hav e a disease,” “ he w ould eit her be hav ing an affair or hav e a disease,” and “ he w ould probably have m isbehaved” .
Wom en said STD and HI V/ AI DS pr event ion and cont r acept ion m ake couples use condom s. But w hen it w as com par ed t o condom use, it w as found t hat t he act ual m ot iv at ion w as cont r acept ion. Condom-cont r acept ion r elat ion helps ex plaining t he low per cent age of post par t um w om en w ho r efer r ed condom use. These findings show t here are im pedim ent s for condom use as disease prevent ion m et hod.
All wom en recognized t hey are vulnerable t o HI V/ AI DS and 380 ( 99% ) said t here could be sexual infect ion. How ev er , 193 ( 51% ) said w om en do not pr ot ect t hem selv es against HI V infect ion ev en t hough 58 ( 30% ) perceived t hem selves at risk.
Wom en’s k now ledge w as also ascer t ained w hen t hey point ed out ot her r out es of HI V infect ion. They m ent ioned dr ug use, blood, hospit al supplies, m ult iple par t ner s, sex w it h infect ed m en, no condom use, at bir t h, dent ist ’s t r eat m ent , m anicur e, and blood t r ansfusion. Ther e w er e how ev er m isconcept ions on HI V infect ion: blood donat ion, bat hr oom s, cocaine use, and sex w it h a st r anger . Cast r o5 recognizes public init iat ives for dissem inat ing HI V/ AI DS knowledge and prevent ion educat ion ar e not alw ay s successful. Wom en in t he st udy believ ed fir st TV t hen scho ols are m aj or sources of inform at ion on HI V/ AI DS. Nonet heless, prevent ion cam paigns oft en are broadcast in t he m edia for short periods of t im e and are int ensified on high- r isk seasons such as car niv al.
The fear of get t ing HI V/ AI DS is r elat ed t o t he disease sev er it y , fat alit y , and w ide dist r ibut ion. Som e w om en st at ed t he follow ing: “ t her e’s no cur e” , “ any one can get t his disease,” “ t his disease k ills,” “ I don’t want t o die,” “ I ’m afraid of dying and leaving m y children behind,” “ it is a t errible disease t hat causes t oo m uch suffer ing, ” “ I don’t w ant t o hav e a point less deat h, ” “ ev er y body has it . Once y ou get it y ou k now y ou ar e sent enced,” “ it is w ast ing life,” “ t his is a t r aum at ic disease,” “ y ou get ugly , lose hair and w eight and feel a lot of pr ej udice, ” t his is a “ widespread” disease, “ only by m ent ioning AI DS I get scar ed of being t est ed” . Sim ilar findings w er e found in t he qualit at iv e et hnogr aphic st udy car r ied out in slum wom en.1 0
Wom en claim ing t hey had changed t heir behavior because of HI V/ AI DS gave t he following reasons: I got m or e “ car eful about dr ugs and st ar t ed t o pr ot ect m y self dur ing sex ,” “ I don’t w ant t o be fr iends wit h anyone. I avoid having friends,” “ I don’t go out wit h any person any m ore,” “ I ’m m ore afraid of going out wit h m en,” “ I ’m afraid of going t o t he dent ist ’s, dr aw ing blood and check if t hey ar e using disposable it em s,” “ I ’m less r est less. I no longer go t o dance par t ies because t hey ar e point less and I could get a disease,” “ I ’m m ore concerned because of m y husband,” “ I ’m afraid because m y husband does not use condom s” .
As for prevent ion m easures against HI V infect ion, w om en point ed out : hav ing few er sex par t ner s, use of m ale condom s or fem ale condom s aft er negot iat ing w it h t heir par t ner s, adv ising t heir husbands t o use condom s in ext ram arit al relat ionships, m aking sure t hey t hem selves and hospit al personnel use disposable supplies, m andat ory t est ing for blood t ransfusion, prevent ing from illegal drug use, and HI V t est ing.
Wom en said t hey get ex posed t o HI V v ir us as follow s: husband’s unfait hfulness ( m ost fr equent ly m ent ioned) , blood t r ansfusion, infect ed supplies, and dent ist ’s office and hospit al.
Mult iple r egr ession analysis show ed HI V r isk per cept ion is st r ongly associat ed w it h w om en w ho do not have a st eady relat ionship wit h t heir part ner, had prior STDs, and believe m arried m en spend t heir leisur e t im e t he sam e w ay single m en do. These var iables associat ion indicat e t he r isks w om en per ceiv e in t heir par t ner s’ social behav ior w hen t hey hav e r elat ionships w it h ot her w om en. Par t icipant s per ceiv ed t his sit uat ion as r isk y since m en ar e unaw ar e of their new part ner( s) ’ HI V st at us posing t heir w om en at hom e at r isk .
Having pr ior STDs is an oppor t unit y for w om en t o get t o know pr event ion m easur es and disease t reat m ent including HI V/ AI DS. This knowledge helps building up wom en’s awareness and enables t hem t o ident ify r isk y sit uat ion t hey ar e ex posed t o.
I n cont r ast , w om en's non- m arit al st at us m akes t hem m ore likely t o have m ore part ners increasing t heir risk. This allied t o HI V/ AI DS knowledge on infect ion and prevent ion proved t o increase wom en’s aw ar eness of t heir HI V vulnerabilit y.
The st udy findings indicat e t he need for im proving healt h educat ion program s in t he com m unit y, out pat ient clinics and hospit als for dev eloping w om en’s sex ual conscient iousness. These pr ogr am s should encour age couples t o at t end workshops for safe sex prom ot ion. There is also a need of inform at ion dist ribut ion on HI V/ AI DS epidem ic wit h com m unit y involvem ent in disease prevent ion.
ACKNOWLED GEM ENT S
To t he Minist ér io da Saúde, STD/ AI DS Nat ional Program Coordinat ion for t he proj ect ’s select ion , Serviço de Enferm agem do Hospit al Sant a Marcelina and Managem ent Coor dinat ion of t he Am paro Mat er nal Mat er nit y for st udy aut hor izat ion and dat a collect ion.
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9 . Mart in D. Mulheres e Aids: um a abordagem ant ropológica. Rev USP 1997; 33: 88-
Praça NS, Gualda DMR. A cuidadora e o ( ser) cuidado: um a relação de dependência no enfrent am ent o da Aids. Rev Paul Enferm 2000; 19: 43- 52.
Address to correspondence
Neide de Souza Pr aça
Av. Dr. Enéas de Carvalho Aguiar, 419 05403 - 000 São Paulo, SP, Brasil E- m ail: ndspraca@usp.br
Resear ch suppor t ed by t he Minist r y of Healt h’s STD/ AI DS Nat ional Pr o gram Coordinat ion/ UNESCO ( Pr ocess TC # 397/ 99) .
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