Abstract

Objective

To analyze frequency of condom use according to vulnerability factors for sexually transmitted infections in quilombola communities in Sergipe state, Brazil.

Methods

This was a descriptive cross-sectional study carried out in 2016-2017. A structured questionnaire with sociodemographic and behavioral questions was used; rapid HIV and syphilis tests were performed. Comparisons between categorical variables were performed using Fisher’s exact test.

Results

Among the 367 individuals from 14 communities, the majority had low levels of education (72.8%), were not working (59.7%) and had a stable sex partner (90.7%). Lack of access to prevention supplies and information accounted for respondent programmatic vulnerability. There was a higher proportion of inconsistent condom use with a stable partner (90.1%) among individuals who reported lack of access to information (p=0.001) and inconsistent use with a casual partner (p<0.001).

Conclusion

Frequency of condom use with a stable partner was significantly proportional to condom use with a casual partner and access to information on prevention.

Keywords:
HIV; Syphilis; Condoms; Health Vulnerability; African Continental Ancestry Group; Epidemiology, Descriptive

Introduction

Every day, globally, there are more than 1 million new cases of curable sexually transmitted infections (STIs) among people aged 15 to 49 years old, according to data published by the World Health Organization in 2019.¹1. Organização Mundial da Saúde (OMS). Organização Pan-Americana de Saúde (OPAS). A cada dia, há 1 milhão de novos casos de infecções sexualmente transmissíveis curáveis [Internet]. Brasília: OPAS; 2019 [citado 2017 ago 31]. Disponível em: https://www.paho.org/bra/index.php?option=com_content&view=article&id=5958
https://www.paho.org/bra/index.php?optio... Correct and consistent condom use is an efficacious method for reducing STIs transmission, although effective adoption of this method depends on the person’s willingness, motivation and capability, as well as that of their partner.²2. Ajayi AI, Ismail KO, Akpan W. Factors associated with consistent condom use: a cross-sectional survey of two Nigerian universities. BMC Public Health [Internet]. 2019 Dec [cited 2021 Jan 6];19(1):1207. Available from: https://doi.org/10.1186/s12889-019-7543-1
https://doi.org/10.1186/s12889-019-7543-... In some traditional settings, such as quilombola (maroon) communities, the subject can be a cause of embarrassment and often be seen as taboo.³3. Nascimento VB, Nascimento Martins NV, Ciosak SI, Nichiata LY, Santos Oliveira JS, Bezerra LO, et al. Vulnerabilidades de mulheres quilombolas no interior da Amazônia às infecções sexualmente transmissíveis: um relato de experiência. Interdiscip J Health Educ [Internet]. 2017 Jan-Jul [cited 2021 Jan 6];2(1):68-73. Disponível em: https://doi.org/10.4322/ijhe.2016.029
https://doi.org/10.4322/ijhe.2016.029...

Low adherence to consistent condom use can be found in quilombola communities in different regional contexts, including in the states of Pará,³3. Nascimento VB, Nascimento Martins NV, Ciosak SI, Nichiata LY, Santos Oliveira JS, Bezerra LO, et al. Vulnerabilidades de mulheres quilombolas no interior da Amazônia às infecções sexualmente transmissíveis: um relato de experiência. Interdiscip J Health Educ [Internet]. 2017 Jan-Jul [cited 2021 Jan 6];2(1):68-73. Disponível em: https://doi.org/10.4322/ijhe.2016.029
https://doi.org/10.4322/ijhe.2016.029... Maranhão,⁴4. Cardoso RLS. Vulnerabilidades às DSTs/Aids entre jovens de uma comunidade quilombola do município de Turiaçu-MA [dissertação]. São Luís: Universidade Federal do Maranhão; 2011. Disponível em: https://tedebc.ufma.br/jspui/handle/tede/1080
https://tedebc.ufma.br/jspui/handle/tede... Goiás and Mato Grosso do Sul.⁵5. Nascimento LB, Santos Carneiro MA, Teles SA, Lopes CL, Silva Reis NR, Costa Silva ÁM, et al. Prevalência de infecção por HTLV-1 em quilombos remanescentes no Brasil Central. Rev Soc Bras Med Trop [Internet]. 2009 dez [citado 2021 jan 6];42(6):657-60. Disponível em: https://doi.org/10.1590/S0037-86822009000600009
https://doi.org/10.1590/S0037-8682200900... Standing out among the reasons for not using this prevention method is lack of perception of the risk of contracting STIs.

In addition to the set of individual vulnerabilities related to sexual risk behaviors, social factors act as strong predictors.⁶6. Bajaj S, Shravan R, Enebeli S, Nsohtabien H, Andkhoe M, et al. Factores de riesgo en Canadá para enfermedades de transmisión sexual y sus variaciones. Med Soc [Internet]. 2016 [citado 2021 jan 6];11(2):58-65. Disponível em: https://www.medicinasocial.info/index.php/medicinasocial/article/view/943
https://www.medicinasocial.info/index.ph... With regard to ethnic and racial inequalities in Brazil, the situation of the quilombolas deserves special attention, in view of the historic vulnerability of these communities.⁷

The results of studies on sexual behavior and vulnerability to STIs among Brazilians of African descent should serve to inform the design and implementation of public policies, both general and specific. However, such results are scarce regarding STIs in quilombola communities in the state of Sergipe.³3. Nascimento VB, Nascimento Martins NV, Ciosak SI, Nichiata LY, Santos Oliveira JS, Bezerra LO, et al. Vulnerabilidades de mulheres quilombolas no interior da Amazônia às infecções sexualmente transmissíveis: um relato de experiência. Interdiscip J Health Educ [Internet]. 2017 Jan-Jul [cited 2021 Jan 6];2(1):68-73. Disponível em: https://doi.org/10.4322/ijhe.2016.029
https://doi.org/10.4322/ijhe.2016.029...

4. Cardoso RLS. Vulnerabilidades às DSTs/Aids entre jovens de uma comunidade quilombola do município de Turiaçu-MA [dissertação]. São Luís: Universidade Federal do Maranhão; 2011. Disponível em: https://tedebc.ufma.br/jspui/handle/tede/1080
https://tedebc.ufma.br/jspui/handle/tede... ^-55. Nascimento LB, Santos Carneiro MA, Teles SA, Lopes CL, Silva Reis NR, Costa Silva ÁM, et al. Prevalência de infecção por HTLV-1 em quilombos remanescentes no Brasil Central. Rev Soc Bras Med Trop [Internet]. 2009 dez [citado 2021 jan 6];42(6):657-60. Disponível em: https://doi.org/10.1590/S0037-86822009000600009
https://doi.org/10.1590/S0037-8682200900... ^,88. Silva MJG, Lima FSS, Hamann EM. Uso dos serviços públicos de saúde para DST/HIV/aids por comunidades remanescentes de Quilombos no Brasil. Saúde Soc [Internet]. 2010 [citado 2021 jan 6];19(2):109-20. Disponível em: https://doi.org/10.1590/S0104-12902010000600011
https://doi.org/10.1590/S0104-1290201000... As such, this study aims to contribute to increasing knowledge and the situation of vulnerability (individual, social and programmatic) of this population, commonly underrepresented in epidemiological studies on the theme of sexual health.

From this point of view, the objective of this study was to analyze frequency of condom use according to vulnerability factors for sexually transmitted infections in quilombola communities in Sergipe state, Brazil.

Methods

This is a descriptive cross-sectional study conducted in quilombola communities in the state of Sergipe, Northeast region of Brazil, between 2016 and 2017.

According to the Palmares Cultural Foundation, as at September 2017, 2,526 certificates had been issued for 3,010 quilombola communities in Brazil, 35 of which are located in Sergipe and distributed over 11 municipalities.⁹9. Fundação Cultural Palmares (BR). Comunidades quilombolas [internet]. Brasília: Fundação Cultural Palmares; 2017 [citado 2017 jul 21]. Disponível em: http://www.palmares.gov.br/?page_id=88
http://www.palmares.gov.br/?page_id=88...

The selected quilombola communities are located in the basins of the Japaratuba, São Francisco, Costeiro do Sapucaia and Sergipe rivers, and in the Médio Sertão Sergipano, Grande Aracaju, Baixo São Francisco Sergipano and Leste Sergipano territories.

Adults aged 18 years old or over, living in quilombola communities in the state were eligible to take part in the study. Individuals with clinical diagnosis of severe mental impairment, recorded on medical records held at the primary health care center linked to their community, and those who had never had sexual intercourse, were excluded.

The study sample was stratified between the quilombola communities, identified from the data recorded by the National Institute for Colonization and Agrarian Reform in Sergipe: families in registered territories, registered as descendents of quilombola communities. After having set up the database of the territories and the registered individuals, the random sampling without replacement procedure was used.

The study outcome was condom use (always; frequently; sometimes; never) with dichotomized alternatives (inconsistent use; consistent use), where ‘consistent use’ was considered to be only when individuals chose the alternative ‘always’. Interviewees were also asked about condom use depending on the type of relationship they were involved in: stable partners or casual partners.

The other variables studied included the dimensions of vulnerability proposed by Jonathan Mann et al. and also by Ayres (the latter in Brazil):¹⁰10. Ayres JRCM, França-Júnior I, Calazans GJ, Saletti-Filho HC. O conceito de vulnerabilidade e as práticas de saúde: novas perspectivas e desafios. In: Czeresnia D, Freitas CM. Promoção da saúde: conceitos, desafios, tendências. 2. ed. Rio de Janeiro: Fiocruz; 2016. p. 121-44.^-1111. Mann J. Aids no mundo. Rio de Janeiro: Relume Dumará; 1993.

The data were collected between September 2016 and June 2017. The team of researchers presented the project to each quilombola leader and scheduled the most convenient date for a data collection event, respecting the chronological order of each leader’s request and confirmation of availability of a public space in the community: primary health care center, schools, community centers etc.

The interviews involved administering a questionnaire structured according to items related to social, individual and programmatic vulnerability; the interviews were conducted individually in previously scheduled public places or at the interviewee’s home when it was impossible for them to get to the place scheduled for the interviews.

After the interview, the participants were invited to take a rapid test for HIV and syphilis. Those who consented underwent individual counseling (pre-test counseling) and then the serological material was collected from them in a private room. The test results were given during further individual counseling (post-test counseling), which also included health education and recommendations for prevention based on each diagnosis.

HIV infection was identified by the BioManguinhos HIV-1&2 and Abon rapid tests. The Alere test was performed when Treponema pallidum antibodies were detected, thus enabling identification of occurrence syphilis, regardless of whether it was early, diagnosed at two years old, or late, i.e. more than two years after effective contact with the bacteria. The tests were performed in accordance with Ministry of Health Ordinance No. 34, dated July 28^th 2005, and Ordinance No. 3242, dated December 30^th 2011.

All participants with positive test results were referred to the primary health care center responsible for coverage of their territory, where they presented the appropriate forms: HIV and Syphilis Referral Form; one copy of the clinical form; and the Fique Sabendo (Find Out testing campaign) form, of the Sergipe STI, AIDS and Viral Hepatitis Department.

The sample size calculation was based on statistical power of 80%, a two-tailed alpha level of 0.05 and minimum detectable difference between groups of 15%, totaling at least 333 individuals to be interviewed. A further 10% was added to compensate for any missing data and losses.

Before being administered by the researchers, the questionnaire underwent a process of contents validation by five acknowledged experts in interdisciplinary matters relating to Health and Environment, Public Health and Sexual Health, as well as being used to train the interviewers who were 20 undergraduate and postgraduate students taking Health-related courses. These strategies sought to reduce measurement bias.

Statistical analysis was performed using Stata version 15.0. The continuous variables were described in means and standard deviations (SD); while the categorical variables were described in absolute and percentage values, together with a 95% confidence interval (95%CI), estimated using the “exact” binomial method. Fisher’s exact test was used to compare condom use distribution among the other variables comprising vulnerability to STIs. The two-tailed p-value <0.050 was taken to be the criterion for statistical significance. Sexual intercourse with a stable partner was used as the reference, since it represented the greater part of the population.

The study project was approved by the Tiradentes University Research Ethics Committee as per its Opinion No. 1.685.357, dated August 18^th 2016. It was also approved by the Sergipe State Health Department and Municipal Health Departments covering communities that would be involved in the study. All participants signed a Free and Informed Consent form.

Results

The sample was comprised of 367 individuals from 14 quilombola communities in Sergipe, aged between 18 and 101 years old (mean 44.81 - SD=17.46). Among the 333 individuals (90.7%) who had sexual intercourse with a stable partner, 9.9% consistently used condoms in this exclusive form of relationship. With regard to the 191 (52.1%) who had sex with casual partners, 15.7% consistently used condoms. Within this same group, 42.7% had sexual intercourse with their stable partner and also with casual partners, and among these individuals who had two kinds of partners, 90.6% had unprotected sex with both kinds of partner - stable and casual.

The participants’ profile, in terms of social vulnerability, is described in Table 1. There was a predominance of Black people - of brown and black skin color (93.2%) -, economic class D/E (75.4%), females (73.0%), individuals with no schooling or incomplete elementary education (72.8%), with family income up to BRL 600 (66.5%) - equivalent to approximately US$ 190 at the time of the interview - and those who were not working (59.7%).

Alcohol consumption was reported by 61.1% of the population and, according to the ASSIST classification, 17.2% of the interviewees had risk or harmful use or high chance of dependency (Table 1). Use of other psychoactive drugs at some time in life - e.g., cannabis, cocaine, hypnotics and inhalants - was mentioned by around 10% of the population.

Syphilis prevalence was found to be 3.3%, there were no positive HIV test results and 6.8% reported previous STIs. With regard to individual vulnerability factors according to sexual behavior, 28.9% began their sex life before they were 15 years old and 3.3% reported having had more than five partners (Table 2).

In relation to programmatic vulnerability to STIs, the following percentages of participants had had HIV and syphilis detection tests at some time in their lives: 41.1% had tested for HIV and 35.4% had tested for syphilis. Lack of access to some sort of information about STIs prevention was reported by 41.1% of the interviewees, and 82.8% had not received prevention supplies in the last 12 months. With regard to government social STIs prevention programs that included people in the vicinity, 79.6% reported that they did not have this resource in their community and 83.9% used the local primary health care center for health checkups. The majority - 95.4% - reported low perception or never having perceived acts of racism in health services (Table 3).

Higher proportions of inconsistent condom use with stable partners were found among individuals who reported lack of access to information (p=0.001), as well as among individuals with casual partners (p<0.001) (Table 4). Consistent condom use with stable partners was found among females (78.8% - 95%CI 61.3;89.6) and those who were not working (69.7% - 95%CI 51.9;83.0), although the differences were not significant.

Discussion

Inconsistent condom use was reported by approximately one in ten inhabitants of quilombola communities in Sergipe. Just over half the respondents also had casual partners and had sex without condoms in both situations. There was higher proportion of consistent condom use with stable partners among individuals who also used them consistently with casual partners, and also, as expected, among those who had more access to information on prevention. Low levels of schooling and poor socioeconomic conditions were the main factors of their social vulnerability and, it should be recalled and highlighted, this is the same reality present in many communities in Brazil. This requires more in-depth reflection on matters concerning equal access to health.

The results presented need to be interpreted taking certain limitations into account. One of them is the scarcity of national studies on this theme, principally with regard to quilombola populations. This resulted in the need to include studies with different methodological approaches when discussing the results of this study. In turn, the study’s descriptive cross-sectional design makes it impossible to establish temporality for the analyses. It should be noted that the respondents were asked about their practices prior to the interview, and as such it is possible that their answers may have suffered memory bias. There is also the possibility of some answers corresponding to the “socially acceptable” standard.

A significant proportion of consistent condom use with casual partners and stable partners was to be expected. Theoretically, people who consistently use condoms with a stable partner would have less risk of contracting STIs,⁶6. Bajaj S, Shravan R, Enebeli S, Nsohtabien H, Andkhoe M, et al. Factores de riesgo en Canadá para enfermedades de transmisión sexual y sus variaciones. Med Soc [Internet]. 2016 [citado 2021 jan 6];11(2):58-65. Disponível em: https://www.medicinasocial.info/index.php/medicinasocial/article/view/943
https://www.medicinasocial.info/index.ph... because they would also protect themselves in the same way with casual partners. As for inconsistent condom use with stable partners and casual partners, other studies published between 2009 and 2017 conducted with quilombola communities in North, Northeast and Midwest Brazil, also mentioned this characteristic, including in situations involving multiple partners.³3. Nascimento VB, Nascimento Martins NV, Ciosak SI, Nichiata LY, Santos Oliveira JS, Bezerra LO, et al. Vulnerabilidades de mulheres quilombolas no interior da Amazônia às infecções sexualmente transmissíveis: um relato de experiência. Interdiscip J Health Educ [Internet]. 2017 Jan-Jul [cited 2021 Jan 6];2(1):68-73. Disponível em: https://doi.org/10.4322/ijhe.2016.029
https://doi.org/10.4322/ijhe.2016.029...

4. Cardoso RLS. Vulnerabilidades às DSTs/Aids entre jovens de uma comunidade quilombola do município de Turiaçu-MA [dissertação]. São Luís: Universidade Federal do Maranhão; 2011. Disponível em: https://tedebc.ufma.br/jspui/handle/tede/1080
https://tedebc.ufma.br/jspui/handle/tede... ^-55. Nascimento LB, Santos Carneiro MA, Teles SA, Lopes CL, Silva Reis NR, Costa Silva ÁM, et al. Prevalência de infecção por HTLV-1 em quilombos remanescentes no Brasil Central. Rev Soc Bras Med Trop [Internet]. 2009 dez [citado 2021 jan 6];42(6):657-60. Disponível em: https://doi.org/10.1590/S0037-86822009000600009
https://doi.org/10.1590/S0037-8682200900...

Insufficient information can aggravate the risk of infection, due to lack of knowledge about prevention methods and, consequently, the spreading of a variety of false beliefs about condoms.¹⁵15. Nascimento EGC, Fernandes C, Marília AA, João C. Adesão ao uso da camisinha: a realidade comportamental no interior do nordeste do Brasil. Rev Salud Pública [Internet]. 2017 [citado 2021 jan 6];19(1):71-80. Disponível em: https://doi.org/10.15446/rsap.v19n1.44544
https://doi.org/10.15446/rsap.v19n1.4454... ^-1616. Uribe-Alvarado JI, Bahamon-Muñeton MJ, Reyes-Ruíz L, Trejos-Herrera AM, Alarcon-Vásquez Y. Percepción de autoeficacia vs. rechazo del uso del condón en las prácticas sexuales de mujeres y hombres jóvenes. Psicogente [Internet]. 2017 [citado 2021 jan 6];20(37):25-35. Disponible en: https://doi.org/10.17081/psico.20.37.2416
https://doi.org/10.17081/psico.20.37.241... This situation is even more serious in the context of quilombola communities, often a long way from health centers, the majority facing adverse socioeconomic conditions, with fewer resources for their education, health and transport.

The participants’ sociodemographic profile was similar to that found in other studies conducted in quilombola communities: a predominantly Black population, with no schooling or incomplete elementary education, and not working. Families of poorer economic status can be seen to be predominant, this being a situation reported by studies published between 2009 and 2020 about quilombola populations in the states of Bahia,¹⁷17. Cardoso LGV, Melo AP, Cesar CC. Prevalência do consumo moderado e excessivo de álcool e fatores associados entre residentes de Comunidades Quilombolas de Vitória da Conquista, Bahia, Brasil. Ciên Saúde Coletiva [Internet]. 2015 [citado 2021 jan 6];20(3):809-20. Disponível em: https://doi.org/10.1590/1413-81232015203.12702014
https://doi.org/10.1590/1413-81232015203...

18. Gomes KO, Reis EA, Guimarães MDC, Cherchiglia ML. Utilização de serviços de saúde por população quilombola do Sudoeste da Bahia, Brasil. Cad Saúde Pública [Internet]. 2013 [citado 2021 jan 6];29(9):1829. Disponível em: https://doi.org/10.1590/0102-311X00151412
https://doi.org/10.1590/0102-311X0015141... ^-1919. Pereira RN, Mussi RFF, Rocha RM Acesso e utilização dos serviços de saúde por quilombolas contemporâneos baianos. Rev ABPN [Internet]. 2020 fev [citado 2021 jan 6];12(31). Disponível em: https://abpnrevista.org.br/index.php/site/article/view/739
https://abpnrevista.org.br/index.php/sit... Pará,³3. Nascimento VB, Nascimento Martins NV, Ciosak SI, Nichiata LY, Santos Oliveira JS, Bezerra LO, et al. Vulnerabilidades de mulheres quilombolas no interior da Amazônia às infecções sexualmente transmissíveis: um relato de experiência. Interdiscip J Health Educ [Internet]. 2017 Jan-Jul [cited 2021 Jan 6];2(1):68-73. Disponível em: https://doi.org/10.4322/ijhe.2016.029
https://doi.org/10.4322/ijhe.2016.029... Maranhão,⁴4. Cardoso RLS. Vulnerabilidades às DSTs/Aids entre jovens de uma comunidade quilombola do município de Turiaçu-MA [dissertação]. São Luís: Universidade Federal do Maranhão; 2011. Disponível em: https://tedebc.ufma.br/jspui/handle/tede/1080
https://tedebc.ufma.br/jspui/handle/tede... Goiás and Mato Grosso do Sul.⁵5. Nascimento LB, Santos Carneiro MA, Teles SA, Lopes CL, Silva Reis NR, Costa Silva ÁM, et al. Prevalência de infecção por HTLV-1 em quilombos remanescentes no Brasil Central. Rev Soc Bras Med Trop [Internet]. 2009 dez [citado 2021 jan 6];42(6):657-60. Disponível em: https://doi.org/10.1590/S0037-86822009000600009
https://doi.org/10.1590/S0037-8682200900...

North American studies conducted in the 1990s²⁰20. Wasserheit JN, Aral SO. The dynamic topology of sexually transmitted disease epidemics: implications for prevention strategies. J Infect Dis [Internet]. 1996 [cited 2021 Jan 6];174(Suppl 2):S201-13. Available from: https://doi.org/10.1093/infdis/174.Supplement_2.S201
https://doi.org/10.1093/infdis/174.Suppl... and during the last decade,⁶6. Bajaj S, Shravan R, Enebeli S, Nsohtabien H, Andkhoe M, et al. Factores de riesgo en Canadá para enfermedades de transmisión sexual y sus variaciones. Med Soc [Internet]. 2016 [citado 2021 jan 6];11(2):58-65. Disponível em: https://www.medicinasocial.info/index.php/medicinasocial/article/view/943
https://www.medicinasocial.info/index.ph... concluded that people of a high socioeconomic level tend to have much lower risk of contracting an STI. Level of education plays a fundamental role in the ability acquired to understand information that is provided, such as by prevention programs, and to respond to it. According to the above mentioned studies, populations that have at least complete elementary education are less susceptible to contracting an STI. These findings corroborate the situation of vulnerability to ISTs we identified in the quilombola communities of Sergipe.

The higher proportion of women using condoms with their stable partners may be a reflection of their insecurity about their partners being faithful, preventing pregnancy or greater concern about their health. It is known that for many couples, unprotected sex can be interpreted as a sign of intimacy and trust, resulting in a psychological barrier, not just against condom use but also to communication about safe sex in general.²2. Ajayi AI, Ismail KO, Akpan W. Factors associated with consistent condom use: a cross-sectional survey of two Nigerian universities. BMC Public Health [Internet]. 2019 Dec [cited 2021 Jan 6];19(1):1207. Available from: https://doi.org/10.1186/s12889-019-7543-1
https://doi.org/10.1186/s12889-019-7543-... However, the authors of a study dating from 2016, conducted with quilombola women in the state of Amazonas, found low condom use among the sexually active population, regardless of their marital status. Even so, the majority of women interviewed recognized that condoms are a safe method of preventing sexually transmitted infections.³3. Nascimento VB, Nascimento Martins NV, Ciosak SI, Nichiata LY, Santos Oliveira JS, Bezerra LO, et al. Vulnerabilidades de mulheres quilombolas no interior da Amazônia às infecções sexualmente transmissíveis: um relato de experiência. Interdiscip J Health Educ [Internet]. 2017 Jan-Jul [cited 2021 Jan 6];2(1):68-73. Disponível em: https://doi.org/10.4322/ijhe.2016.029
https://doi.org/10.4322/ijhe.2016.029...

The percentage of participants reporting high-risk alcohol consumption was higher than that found by a study conducted in 2011 in quilombola communities in Bahia (11%),¹⁷17. Cardoso LGV, Melo AP, Cesar CC. Prevalência do consumo moderado e excessivo de álcool e fatores associados entre residentes de Comunidades Quilombolas de Vitória da Conquista, Bahia, Brasil. Ciên Saúde Coletiva [Internet]. 2015 [citado 2021 jan 6];20(3):809-20. Disponível em: https://doi.org/10.1590/1413-81232015203.12702014
https://doi.org/10.1590/1413-81232015203... although it must be taken into consideration that that study did not use ASSIST as its basis but rather a classification according to the number of measures of alcohol consumed weekly. Excessive consumption of alcoholic beverages is associated with increased probability of being diagnosed as having an STI. Some researchers have associated alcohol consumption with having multiple sex partners and, as a consequence, inconsistent condom use, thus resulting in greater risk of HIV transmission.²¹21. Kermode M, Sono CZ, Songput CH, Devine A. Falling through the cracks: a qualitative study of HIV risks among women who use drugs and alcohol in Northeast India. BMC Int Health Hum Rights [Internet]. 2013 [cited 2021 Jan 6];13(9):1-8. Available from: https://doi.org/10.1186/1472-698X-13-9
https://doi.org/10.1186/1472-698X-13-9... ^,2222. Choudhry V, Agardh A, Stafstrom M, Ostergren PO. Patterns of alcohol consumption and risky sexual behavior: a cross-sectional study among Ugandan university students. BMC Public Health [Internet]. 2015 [cited 2021 Jan 6];14(128):1-11. Available from: https://doi.org/10.1186/1471-2458-14-128
https://doi.org/10.1186/1471-2458-14-128...

Although syphilis prevalence was below 10%, it was three times higher than the rate found by a population-based study conducted with parturient women in Brazil,²³23. Cunha ARC. Sífilis em parturientes do Brasil: prevalência e fatores associados, 2010-2011 [dissertação]. Brasília (DF): Universidade de Brasília; 2015. Disponível em: http://bdtd.ibict.br/vufind/Record/UNB_f183ca35107a5525c5bdb1b7b1df939a taken as a proxy for the general population (0.89%). It should be highlighted that syphilis is a marker of unprotected sex and can potentialize HIV infection.²⁴24. Shilaih M, Marzel A, Braun DL, Scherrer AU, Kovari H, Young J, et al. Factors associated with syphilis incidence in the HIV-infected in the era of highly active antiretrovirals. Medicine [Internet]. 2017 [cited 2021 Jan 6];96(2):e5849. Available from: https://doi.org/10.1097/MD.0000000000005849
https://doi.org/10.1097/MD.0000000000005... ^,2525. Dai W, Luo Z, Xu R, Zhao G, Tu D, Yang L, Wang F, et al. Prevalence of HIV and syphilis co-infection and associated factors among non-commercial men who have sex with men attending a sexually transmitted disease clinic in Shenzhen, China. BMC Infect Dis [Internet]. 2017 [cited 2021 Jan 6];17(86). Available from: https://doi.org/10.1186/s12879-017-2187-1
https://doi.org/10.1186/s12879-017-2187-...

Factors related to difficulty in accessing HIV and syphilis tests, prevention and health care supplies, information and activities form part of the dimension of quilombola community programmatic vulnerability. Further to these findings are those of a study conducted in 2010 in quilombola communities throughout the national territory, which revealed the same difficulties in accessing STI prevention services.⁸8. Silva MJG, Lima FSS, Hamann EM. Uso dos serviços públicos de saúde para DST/HIV/aids por comunidades remanescentes de Quilombos no Brasil. Saúde Soc [Internet]. 2010 [citado 2021 jan 6];19(2):109-20. Disponível em: https://doi.org/10.1590/S0104-12902010000600011
https://doi.org/10.1590/S0104-1290201000... These are important conditions for the success of prevention actions. It is therefore expected that contact with information about reducing risk of STIs, availability of prevention supplies and diagnostic tests will leave individuals more prepared for practicing safer sex.²⁶26. Wasserheit JN, Aral SO. The dynamic topology of sexually transmitted disease epidemics: implications for prevention strategies. J Infect Dis [Internet]. 1996 [cited 2021 Jan 6];174(Suppl 2):S201-13. Available from: https://doi.org/10.1093/infdis/174.Supplement_2.S201
https://doi.org/10.1093/infdis/174.Suppl... ^,2727. La Croix JM, Pellowski JA, Lennon CA, Johnson BT. Behavioural interventions to reduce sexual risk for HIV in heterosexual couples: a meta-analysis. Sex Transm Infect [Internet]. 2013 [cited 2021 Jan 6];89(8):620-7. Available from: https://doi.org/10.1136/sextrans-2013-051135
https://doi.org/10.1136/sextrans-2013-05...

In parallel to testing for HIV and syphilis, using public health services can reduce programmatic vulnerability. The actions of social programs are also of extreme importance: according to a study conducted in 2017 in Coimbra, Portugal, following intervention via an education program to reduce risky sexual behavior, the people reached by the intervention were more likely to have used a condom the last time they had sex with their stable partner (odds ratio = 4.61 - 95%CI 1.31;16.20) and to test for HIV (odds ratio = 7.59 - 95%CI 3.33;17.35).²⁸28. Oliveira ACGDPC, Caramelo F, Patrício M, Camarneiro AP, Cardoso SM, Pita JR. Impacto de um programa de intervenção educativa nos comportamentos sexuais de jovens universitários. Rev Enf Ref [Internet]. 2017 [citado 2021 jan 6];4(13):71-82. Available from: https://doi.org/10.12707/RIV17022
https://doi.org/10.12707/RIV17022...

The majority of interviewees had health checkups at their local primary health care centers. Another study, focusing on quilombola communities in the southwest region of the state of Bahia in 2013, revealed difficulty in accessing and underuse of public health services, which only 57.1% of the community inhabitants used.¹⁸18. Gomes KO, Reis EA, Guimarães MDC, Cherchiglia ML. Utilização de serviços de saúde por população quilombola do Sudoeste da Bahia, Brasil. Cad Saúde Pública [Internet]. 2013 [citado 2021 jan 6];29(9):1829. Disponível em: https://doi.org/10.1590/0102-311X00151412
https://doi.org/10.1590/0102-311X0015141... Although on the formal level, the communities have access to the Family Health Strategy, it has not come into effect in everyday quilombola life due to barriers to access.⁸8. Silva MJG, Lima FSS, Hamann EM. Uso dos serviços públicos de saúde para DST/HIV/aids por comunidades remanescentes de Quilombos no Brasil. Saúde Soc [Internet]. 2010 [citado 2021 jan 6];19(2):109-20. Disponível em: https://doi.org/10.1590/S0104-12902010000600011
https://doi.org/10.1590/S0104-1290201000... ^,1919. Pereira RN, Mussi RFF, Rocha RM Acesso e utilização dos serviços de saúde por quilombolas contemporâneos baianos. Rev ABPN [Internet]. 2020 fev [citado 2021 jan 6];12(31). Disponível em: https://abpnrevista.org.br/index.php/site/article/view/739
https://abpnrevista.org.br/index.php/sit... In the quilombola communities in Sergipe we found that access to primary health care centers is made difficult due to distance and shortage of health workers. Moreover, for some of these communities the service was only an itinerant one.

The perception of the majority of the respondents was that racial discrimination was absent or slight in health services, which, theoretically, would reduce the possibility of staying away from the health service because of being discriminated. However, it is important to note that some individuals reported medium to high perception of institutional racism in health services. We highlight that the consolidation of the idea of structural racism in the formation of Brazilian social inequality occurred, and occurs, in a non-linear manner, suffering strong contestations, inflections and various obstacles along the way.²⁹29. Oliveiva DO, Brandão WN, Araújo Madeira MZ. Justiça racial e direitos humanos de povos e comunidades tradicionais. Revista Katálysis [Internet]. 2020 maio-ago [citado 2021 jan 6];23(2):317. Disponível em: https://doi.org/10.1590/1982-02592020v23n2p317
https://doi.org/10.1590/1982-02592020v23... Moreover, the hypothesis of distorted understanding of concepts about racism, racial prejudice and discrimination among the general population cannot be ruled out. In addition, difficulty in access may in itself represent yet another barrier to people providing an answer on this aspect.

The results presented here trace a profile of individual, social and programmatic vulnerabilities in relation to IST prevention in the quilombola communities of Sergipe. Frequency of condom use with stable partners was directly proportional to their use with casual partners and to access to information on prevention. The results reinforce the need to strengthen strategies that enable the consolidation of sexual education practices, through more effective individual and collective policies, expanding the services provided by the health system to the quilombola communities of Sergipe.

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