Abstract

Introduction

In Brazil, AIDS cases in the female population have increased since 2000 ¹1. Boletim Epidemiológico AIDS e DST. Brasília: Ministério da Saúde, 2010; 7(1). Disponível em http://www.aids.gov.br/publicacao/boletim-epidemiologico-2010 (Acessado em 02 de setembro de 2012).
http://www.aids.gov.br/publicacao/boleti... . The prevalence of HIV in Brazilian pregnant women in 2004 and 2006 was 0.41% ²2. Swarcwald CL, Barbosa Junior A, Miranda AE, Paz LC. Resultados do estudo sentinela-parturiente, 2006: Desafios para o controle da sífilis congênita no Brasil. DST. J Bras Doenças Sex Transm 2007; 19(3-4): 128-33. and the estimated rate of vertical HIV transmission in 2004 was 6.8% ³3. Succi RCM, Grupo de Estudo da SBP TV do HIV. Protocolo Colaborativo Multicêntrico Brasileiro para Avaliar as Taxas de Transmissão Materno-Infantil do HIV em Filhos de Mulheres com Diagnóstico da Infecção pelo HIV realizado antes, durante ou até três meses após o Parto. Sociedade Brasileira de Pediatria; 2004. . Vertical transmission is the primary mode of HIV infection in the child population ⁴4. Boletim Epidemiológico AIDS e DST. Brasília: Ministério da Saúde, Coordenação Nacional de DST/AIDS, 2007; 4(1). Disponível em http://www.aids.gov.br/sites/default/files/ Boletim2007_internet090108.pdf (Acessado em 04 de setembro de 2012).
http://www.aids.gov.br/sites/default/fil... . Nearly 65% of vertical HIV transmission occurs during labor and delivery ⁵5. Bertolli J, St Louis ME, Simonds RJ, Nieburg P, Kamenga M, Brown CL et al. Estimating the timing of mother-to-child transmission of human immunodeficiency virus in a breast-feeding population in Kinshasa, Zaire. J Infect Dis 1996; 174(4): 722-6. . Continuing maternal breastfeeding contributes to an additional risk of 7% to 22% ⁶6. Dunn TDT, Newell ML, Ades AE, Peckham CS. Risk of human immunodeficiency virus type 1 transmission through breastfeeding. Lancet 1992; 340: 585-8. . Prenatal care is an opportune time to reduce the incidence of vertical transmission through early diagnosis and adequate treatment⁷. However, a sentinel study conducted with parturients in Brazil estimated the effective coverage of serological HIV tests during pregnancy to be 63% ²2. Swarcwald CL, Barbosa Junior A, Miranda AE, Paz LC. Resultados do estudo sentinela-parturiente, 2006: Desafios para o controle da sífilis congênita no Brasil. DST. J Bras Doenças Sex Transm 2007; 19(3-4): 128-33. .

The Ministry of Health recommends that anti-HIV tests should be performed with counseling during pregnancy and, whenever possible, so should the repetition of serology in the beginning of the 3^rdtrimester, using fast tests if necessary ⁷7. Ministério da Saúde, Secretaria de Vigilância em Saúde, Programa Nacional de DST e Aids. Recomendações para Profilaxia da Transmissão Vertical do HIV e Terapia Antirretroviral em Gestantes: manual de bolso . Brasília: Ministério da Saúde, 2010. Disponível em http://www.ensp.fiocruz.br/portal-ensp/judicializacao/pdfs/490.pdf (Acessado em 03 de setembro de 2012).
http://www.ensp.fiocruz.br/portal-ensp/j... . These tests have a simple methodology ⁸8. Carvalho LR, Krahe C, Farina G, Paula DO, Richetti N, Crossetti T. Teste rápido para diagnóstico da infecção pelo HIV em parturientes. RBGO 2004; 26(4): 325-8. , they are adequate for situations that require preventive interventions for specific emergencies, such as vertical HIV transmission prevention during delivery, and they have been used with this purpose in Brazil since 1999 ⁹9. Dhalia CBC, Díaz-Bermúdez XP (org.). Teste Rápido - por que não? Estudos que contribuíram para a política de ampliação da testagem para o HIV no Brasil . Ministério da Saúde, Secretaria de Vigilância em Saúde, Programa Nacional de DST e Aids. Brasília: Ministério da Saúde, 2007. Disponível em http://www.ppge.ufrgs.br/ats/extensao/ custo%20efetividade%20teste%20rapido%20brasil.pdf (Acessado em 02 de setembro de 2012).
http://www.ppge.ufrgs.br/ats/extensao/ c... . The results of HIV rapid tests must be produced in a maximum of 30 minutes and be made available before delivery, as the anti-HIV chemoprophylaxis during delivery is known to be effective. Women must receive pre- and post-test counseling from health professionals and tests must be performed after verbal consent ⁷7. Ministério da Saúde, Secretaria de Vigilância em Saúde, Programa Nacional de DST e Aids. Recomendações para Profilaxia da Transmissão Vertical do HIV e Terapia Antirretroviral em Gestantes: manual de bolso . Brasília: Ministério da Saúde, 2010. Disponível em http://www.ensp.fiocruz.br/portal-ensp/judicializacao/pdfs/490.pdf (Acessado em 03 de setembro de 2012).
http://www.ensp.fiocruz.br/portal-ensp/j... .

Counseling is an instrument that enables reflection and joint decision-making. It is based on active listening, through which health professionals seek to establish a relationship of trust, providing strategies that facilitate the recognition of users as participants in their own health condition ¹⁰10. Ministério da Saúde, Secretaria de Vigilância em Saúde, Programa Nacional de DST e Aids. Recomendações para profilaxia da Transmissão Vertical do HIV e Terapia Anti-Retroviral em Gestantes. Brasília: Ministério da Saúde, 2006. Disponível em http://www.nescon. medicina.ufmg.br/biblioteca/imagem/1929.pdf (Acessado em 02 de setembro de 2012).
http://www.nescon. medicina.ufmg.br/bibl... . Delivery and postpartum are not ideal moments to perform an anti-HIV test ¹1. Boletim Epidemiológico AIDS e DST. Brasília: Ministério da Saúde, 2010; 7(1). Disponível em http://www.aids.gov.br/publicacao/boletim-epidemiologico-2010 (Acessado em 02 de setembro de 2012).
http://www.aids.gov.br/publicacao/boleti... ^{, 11}11. Dias MAB, Deslandes SF. Expectativas sobre a assistência ao parto de mulheres usuárias de uma maternidade pública do Rio de Janeiro, Brasil: os desafios de uma política pública de humanização da assistência. Cad Saúde Pública 2006; 22(12): 2647-55. ; however, it is recommended that fast tests should be performed in parturients who met the criteria for its recommendation as instructions on its benefits, advantages and need were given. It is important to record the request for an anti-HIV test or its refusal by parturients in the patient chart, to provide emotional support and to guarantee the right to information about test results ²2. Swarcwald CL, Barbosa Junior A, Miranda AE, Paz LC. Resultados do estudo sentinela-parturiente, 2006: Desafios para o controle da sífilis congênita no Brasil. DST. J Bras Doenças Sex Transm 2007; 19(3-4): 128-33. .

Despite its relevance, little is known about the practice of counseling during the performance of the HIV rapid test during delivery. In view of the new reality resulting from the use of HIV rapid tests to diagnose the HIV status during delivery in a significant number of women ¹²12. Oliveira MIC, Silva KS, Gomes Junior SC, Fonseca VM. Resultado do teste rápido anti-HIV após o parto: uma ameaça à amamentação ao nascimento. Rev Saúde Pública 2010; 44(1): 60-9. , it is important to investigate whether the process of test performance and presentation of results is being conducted according to the Ministry of Health recommendations ¹⁰10. Ministério da Saúde, Secretaria de Vigilância em Saúde, Programa Nacional de DST e Aids. Recomendações para profilaxia da Transmissão Vertical do HIV e Terapia Anti-Retroviral em Gestantes. Brasília: Ministério da Saúde, 2006. Disponível em http://www.nescon. medicina.ufmg.br/biblioteca/imagem/1929.pdf (Acessado em 02 de setembro de 2012).
http://www.nescon. medicina.ufmg.br/bibl... . The present study aims to verify whether the performance of HIV rapid tests in parturients occurs through counseling and to analyze the factors associated with non-counseling.

Methods

A cross-sectional study was conducted as part of the inter-institutional research project entitled “Gender, Power and Citizenship: Are Women Participants in the Decision Process of Breastfeeding at Birth when the HIV Status is Ignored by Health Services?”. This study was approved by the Research Ethics Committee of the City of Rio de Janeiro Department of Health, official opinion 82A/2006 from July 31^st2006. The study population was comprised of all women who had the HIV rapid test performed during delivery in the five “Baby-Friendly Hospitals” of the High-Risk Pregnancy System in the city of Rio de Janeiro, between September 11^thand December 11^th2006. All mothers who underwent the HIV rapid test in these hospitals during the period of study with live newborns were included, regardless of having been tested for HIV during prenatal care or not. In contrast, mothers whose babies were born with an Apgar score at five minutes after birth lower than seven or who were hospitalized in a neonatal unit for any period of time were excluded from this study, as these conditions could hinder breastfeeding at birth, the main theme of this inter-institutional research project ¹²12. Oliveira MIC, Silva KS, Gomes Junior SC, Fonseca VM. Resultado do teste rápido anti-HIV após o parto: uma ameaça à amamentação ao nascimento. Rev Saúde Pública 2010; 44(1): 60-9. . The “Baby-Friendly Hospitals” were selected as setting for this study, as these hospitals were accredited for the fulfillment of the “10 Steps for Successful Breastfeeding”, whose fourth step was “To help mothers to begin to breast-feed in the first 30 minutes after birth” ¹³13. World Health Organization. Evidence for the Ten Steps to Successful Breastfeeding . Division of Child Health and Development. Geneva: World Health Organization; 1998. . High-Risk Pregnancy System units were selected as they met the conditions required to perform HIV fast tests, because they are referral units caring for pregnant women with HIV ¹⁴14. Ministério da Saúde, Secretaria de Políticas de Saúde, Departamento de Gestão de Políticas Estratégicas, Área Técnica de Saúde da Mulher. Gestação de Alto Risco: manual técnico . 3aed. Brasília: Ministério da Saúde, 2000. Disponível em http://www.enf.ufmg.br/ internatorural/textos/Manuais/Gesta%e7%e3o%20de%20Alto%20Risco%20-%20Manual%20T%e9cnico_arquivos/ (Acessado em 02 de setembro de 2012).
http://www.enf.ufmg.br/... .

The sample size was calculated according to the study conducted by Morimura et al. in the city of Recife, Northeastern Brazil ¹⁵15. Morimura MCR, Mendes MDC, de Souza AI, de Alencar LCA. Freqüência de testagem rápida para o HIV durante a admissão para o parto em puérperas no Instituto Materno Infantil Prof. Fernando Figueira, IMIP. Rev Bras Saúde Mater Infant 2006; 6 (S1): 69-76. , where a prevalence of counseling for the performance of the HIV rapid test of 7.7% was found. A sample size of 888 women was estimated for an expected prevalence of 5% among parturients with more than three prenatal consultations and a prevalence of 12% among parturients with a lower number of consultations, with a prevalence ratio of 0.42 and considering a significance level of 5% and power of 80%.

A daily survey was conducted in the laboratory of each hospital to identify parturients who underwent the HIV rapid test and this information was compared with the list of patients hospitalized in shared rooms on a daily basis. Trained and supervised interviewers applied semi-structured questionnaires to the mothers in shared rooms after these mothers themselves or their legal guardians signed an informed consent form, in accordance with the National Health Council Resolution 196/96. Additionally, birth records, the mothers' and babies' medical charts and Live Birth Certificates ¹²12. Oliveira MIC, Silva KS, Gomes Junior SC, Fonseca VM. Resultado do teste rápido anti-HIV após o parto: uma ameaça à amamentação ao nascimento. Rev Saúde Pública 2010; 44(1): 60-9. were used as data sources.

The outcome variable was non-counseling during the performance of the HIV rapid test during hospitalization for delivery. For the purpose of this study, it is understood that women were counseled when: 1) they were informed about the performance of HIV rapid tests; 2) they received explanations about the reasons for HIV rapid tests to be performed; and 3) they received the results of the HIV rapid test during hospitalization. In case one of these items had not been included, non-conformity to counseling would have been considered.

The following exposure variables were investigated: 1) maternal reproductive and socioeconomic characteristics such as age, ethnicity, level of education, maternal income, number of household goods (radio, refrigerator, washing machine, landline telephone, television), presence of partner and parity; 2) profile of prenatal care: trimester of the beginning of prenatal care, number of prenatal consultations, having the HIV rapid test performed during prenatal care; and 3) delivery care profile: hospital where delivery was performed, type of delivery.

The database was created using the Epi-INFO® software and the data analysis was performed with the SPSS® software. Initially, the simple frequency of variables was calculated to find out the profile of mothers, prenatal care and delivery. Subsequently, a bivariate analysis was performed to verify the prevalence ratio between each exposure variable and the outcome and respective statistical significance. Binomial regression was performed to analyze the factors associated with the outcome ¹⁶16. McCullagh P, Nelder JA. Generalized linear models . 2. ed. London: Chapman and Hall/CRC Press; 1989. . Modeling was conducted with the variables that reached a significance level lower than 20% and the final model was comprised of the variables with a significance level lower than 5%.

Results

During the three months when this research project was conducted, there were 4,895 deliveries in the five “Baby-Friendly Hospitals” of the High-Risk Pregnancy System of the city of Rio de Janeiro. A total of 28.5% of parturients underwent the HIV rapid test, with an amplitude ranging from 18.4% to 50.7%. The hospital showing the highest number of deliveries was that with the lowest proportion of women submitted to the HIV rapid test. Of all 1,074 eligible mothers, 955 were interviewed and 11.1% were losses or refusals ¹²12. Oliveira MIC, Silva KS, Gomes Junior SC, Fonseca VM. Resultado do teste rápido anti-HIV após o parto: uma ameaça à amamentação ao nascimento. Rev Saúde Pública 2010; 44(1): 60-9. ( Table 1 ).

Table 2 shows that 26.6% of the population studied were adolescents aged between 13 and 19 years and 43.5% had completed up to seven years of school. The majority of mothers (72.4%) had no income or received up to one minimum wage and 37.5% of homes had between zero and three household goods. A total of 87.4% of women had a partner and 39.3% were primiparous. In the bivariate analysis, the socio-demographic and reproductive variables associated with non-counseling during the performance of HIV rapid tests with a statistical significance of up to 20% were as follows: level of education, maternal income and number of household goods.

Of all parturients, 8.6% did not receive prenatal care and 56.0% began prenatal care after the 1^sttrimester. The majority (80.1%) of pregnant women had four or more prenatal consultations. A total of 77.8% of them had an anti-HIV test during prenatal care. The hospital with the highest frequency of HIV rapid tests concentrated 41.0% of the interviewed women. Vaginal deliveries totaled 67.2% of all births. With regard to the characteristics of prenatal care and deliveries, the following were selected to comprise the multivariate model in the bivariate analysis: trimester of beginning of prenatal care, number of prenatal consultations, having had an HIV rapid test during prenatal care and hospital where delivery was performed ( Table 3 ).

Although all women included in this study were submitted to the HIV rapid test during hospitalization for delivery, when asked about whether the test had been performed, 2.5% reported it had not and 22.5% could not inform this. A total of 55.1% of women had not been given explanations about the performance of HIV rapid tests in the hospitals. Additionally, 46.5% of them received negative test results, 0.6% received positive results and 52.9% were not aware of these results in the moment of the interview. Among interviewed women, only 26.9% met the three outcome conditions selected: being informed about the performance of the HIV rapid test, receiving an explanation about the reason for its performance, and receiving the test results, i.e. 73.1% did not receive counseling ( Table 4 ).

In the multivariate analysis ( Table 5 ), the following were risk factors for not receiving counseling about the performance of the HIV rapid test: level of education lower than complete primary school and delivery occurring in hospitals where the HIV rapid test is performed in less than 50% of parturients. Having between zero and three prenatal consultations was a protective factor against not receiving counseling. The model had an accuracy of 72.5%.

Discussion

The moment of delivery requires special attention due to women's emotional and physical vulnerability ¹¹11. Dias MAB, Deslandes SF. Expectativas sobre a assistência ao parto de mulheres usuárias de uma maternidade pública do Rio de Janeiro, Brasil: os desafios de uma política pública de humanização da assistência. Cad Saúde Pública 2006; 22(12): 2647-55. , ¹⁵15. Morimura MCR, Mendes MDC, de Souza AI, de Alencar LCA. Freqüência de testagem rápida para o HIV durante a admissão para o parto em puérperas no Instituto Materno Infantil Prof. Fernando Figueira, IMIP. Rev Bras Saúde Mater Infant 2006; 6 (S1): 69-76. . In this context, counseling becomes a key tool, aiming to reduce the anguish caused by doubts and lack of information about the performance of the HIV rapid test. However, the present study shows that only one fourth of parturients were counseled and more than half were not even given an explanation about the reason for the HIV rapid test to be performed, indicating that this test has been performed forcefully, without women's consent. In the city of Recife, the prevalence of counseling for the HIV rapid test during delivery was even lower: 7.7% ¹⁵15. Morimura MCR, Mendes MDC, de Souza AI, de Alencar LCA. Freqüência de testagem rápida para o HIV durante a admissão para o parto em puérperas no Instituto Materno Infantil Prof. Fernando Figueira, IMIP. Rev Bras Saúde Mater Infant 2006; 6 (S1): 69-76. .

Against the Ministry of Health recommendations, in the present study, the majority of mothers had not yet received the result of the HIV rapid test in the moment of interview. There was not a well-established routine to deliver these results and to counsel women. Increasing the serological coverage of parturients is as important as the role of counseling about the performance of the HIV rapid test. Women must have autonomy when deciding to have this test performed, to be instructed on HIV and vertical transmission prevention actions, and to receive information about test results. HIV prevention becomes really effective when individuals reflect on their own life situation as participants capable of changing their behavior. As half of parturients received the test results in the present study, this could be reflecting advances in such routine or regional differences, as a study conducted in the city of Recife in 2003 showed that only 3.8% had received the HIV rapid test results ¹⁵15. Morimura MCR, Mendes MDC, de Souza AI, de Alencar LCA. Freqüência de testagem rápida para o HIV durante a admissão para o parto em puérperas no Instituto Materno Infantil Prof. Fernando Figueira, IMIP. Rev Bras Saúde Mater Infant 2006; 6 (S1): 69-76. .

The hospital that submitted more than half of parturients to the HIV rapid test was the one where counseling was most frequently performed. In this hospital, 85.5% of mothers did not breast-feed in the first hour of life ¹²12. Oliveira MIC, Silva KS, Gomes Junior SC, Fonseca VM. Resultado do teste rápido anti-HIV após o parto: uma ameaça à amamentação ao nascimento. Rev Saúde Pública 2010; 44(1): 60-9. , suggesting that counseling could be associated with the need to justify the restriction to breastfeeding while the test results are not available, rather than being a way of listening to and instructing women. The remaining hospitals had a profile of non-counseling, increasing its prevalence by 1.7 times.

The small number of prenatal consultations was a protective factor against non-counseling about the performance of HIV rapid test in hospitals. Information about prenatal consultations is usually available in prenatal care cards and patient charts or it can be obtained from the mothers themselves. Health professionals often consider women who do not receive prenatal care or those who had few prenatal consultations as more vulnerable. In this way, they tend to provide more information during hospital procedures, including the time when the HIV rapid test is performed in this population. In contrast, a study on anti-HIV tests performed prior to delivery, conducted in the city of Porto Alegre, showed that the absence of prenatal care, the use of the HIV rapid test, multiparity and low income increased the chance of non-counseling ¹⁷17. Goldani MZ, Giugliani ERJ, Scanlon T, Humberto R, Castilhos K, Feldens L et al. Voluntary HIV counseling and testing during prenatal care in Brazil. Rev Saúde Pública 2003; 37(5): 552-8. .

Low-income women were expected to receive more care and, consequently, more counseling from the health team. However, low income was not associated with the outcome and a low level of education increased the prevalence of non-counseling. Although important to enable better care from the health team, information about the low level of education of women is yet undervalued in the hospital environment, apart from professionals' difficulty in accessing it. Another alarming factor is that women's low level of education hinders the search for information about their health condition and the hospital procedures performed.

Finally, certain limitations of this study should be considered, such as the potential memory bias with regard to receiving counseling. The moment of delivery is when women are more vulnerable and when they undergo a series of procedures and receive information that may not be entirely recalled. However, the questionnaire structure was designed to help mothers recall this information, which could have contributed to reduce such bias. All interviewers selected for the research field work were women, aiming to minimize possible embarrassment when asking parturients about intimate issues, such as the performance of the HIV rapid test and the counseling received.

Additionally, it should be emphasized that the present study was restricted to “Baby-Friendly Hospitals” of the High-Risk Pregnancy System¹⁴, where prenatal and delivery care is a benchmark for the remaining hospitals. If the situation found in these hospitals was not satisfactory, an even more unfavorable reality would be expected in the other network hospitals.

All parturients should be informed about the test performance, receive explanations about the reason for such test, and receive the test results. Pre- and post-test counseling is key to help individuals cope with stressful situations brought about by the need to have the HIV rapid test during delivery ¹⁸18. Araújo MAL, Vieira NFC, Bucher JSNF. Aconselhamento pré e pós-teste anti- HIV como estratégia de melhoria da cobertura de testagem em gestantes e prevenção da transmissão vertical do HIV. Boletim Epidemiológico de Aids. Ministério da Saúde: Coordenação Nacional de DST/AIDS 2006; 1(1):16-22. .

Health professionals must be sensitized and their capacity built, so that pre- and post-test counseling can be provided in the hospital environment and the relationship between patients and the health team can be strengthened. Dialogue, the exchange of information and knowledge and the democratization of power relations in the hospital environment are essential to achieve this.

It is paramount that women be included as participants in the health care process. The feminization of AIDS has contributed to the increasing trend towards the demand for such test. Additionally, if the current routines continue, more and more women will have their rights violated. There are countless movements seeking to recognize user rights based on their needs, as recovery of the principle of patient autonomy is a precondition to achieve health and citizenship.

References

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