Abstract

The research, its objectives and methodological procedures: the paths followed in discussing desire as an investigative issue

Following the HIV/Aids pandemic, it became possible to understand issues of sexuality and human reproduction as a complex problem deserving public policy specific actions and interventions (WHO, 2006; Kennedy et al., 2010KENNEDY, C. E. et al. Linking sexual and reproductive health and HIV interventions: a systematic review. Journal of the International AIDS Society, Geneve, v. 13, n. 26, p. 1-10, 2010.; Gay et al., 2011GAY, J. et al. What works to meet the sexual and reproductive health needs of women living with HIV/AIDS. Journal of the International AIDS Society, Geneve, v. 14, n. 56, p. 1-10, 2011.).

Early on in the HIV/Aids epidemic, the few HIV infected women were discouraged from getting pregnant and, if they did so, were strongly censured by their health care team, often leading to abortion or abandoning medical treatment (Berer; Ray, 1997BERER, M.; RAY, S. Mulheres e HIV/AIDS: um livro sobre recursos internacionais: informação, ação e recursos relativos às mulheres HIV/AIDS, saúde reprodutiva e relações sexuais. São Paulo: Brasiliense, 1997.). Faced with the phenomenon of the feminization of the HIV/Aids epidemic, the focus of public health work has changed and these women's productive decisions have, thus, become crucial as a logical consequence of this is the risk of mother to child transmission (MTCT) and the expansion of the epidemic (Brasil, 2009BRASIL. Ministério da Saúde. Secretaria de Vigilância em Saúde. Programa Nacional de DST/Aids. Recomendações para a profilaxia da transmissão vertical do HIV e terapia anti-retroviral em gestantes. Brasília, DF, 2009. Disponível em: <http://bvsms.saude.gov.br/bvs/publicacoes/gestante2.pdf>. Acesso em: 15 abr. 2013.
http://bvsms.saude.gov.br/bvs/publicacoe... ; Myer; Morroni; El-Sadr, 2005MYER, L.; MORRONI, C.; EL-SADR, W. M. Reproductive decisions in HIV-infected individuals. The Lancet, Oxford, v. 366, n. 9487, p. 698-700, 2005.; Gonçalves et al., 2009GONÇALVES, T. R. et al. Vida reprodutiva de pessoas vivendo com HIV/AIDS: revisando a literatura. Psicologia & Sociedade, Belo Horizonte, v. 21, n. 2, p. 223-232, 2009.).

Numerous internationally recognized actions to deal with the epidemic have been established in Brazil (Barreto et al., 2011BARRETO, M. et al. Successes and failures in the control of infectious diseases in Brazil: social and environmental context, policies, interventions, and research needs. Lancet, London, v. 377, n. 9780, p. 1877-1889, 2011.), for example, universal access to antiretroviral drugs for all HIV/Aids patients (Berkman et al., 2005BERKMAN, A. et al. A critical analysis of the Brazilian response to HIV/Aids: lessons for controlling and mitigating the epidemic in developing countries. American Journal of Public Health, Washington, DC, v. 95, n. 7, p. 1162-1172, 2005.), as well as protocols to decrease the risk of HIV MTCT (Brasil, 2009BRASIL. Ministério da Saúde. Secretaria de Vigilância em Saúde. Programa Nacional de DST/Aids. Recomendações para a profilaxia da transmissão vertical do HIV e terapia anti-retroviral em gestantes. Brasília, DF, 2009. Disponível em: <http://bvsms.saude.gov.br/bvs/publicacoes/gestante2.pdf>. Acesso em: 15 abr. 2013.
http://bvsms.saude.gov.br/bvs/publicacoe... ).

In spite of this favorable situation, certain stu­dies have revealed health care teams violations of reproductive rights toward women living with HIV/Aids, for instance by facilitating access to sterilization (Hopkins et al., 2005HOPKINS, K. et al. The impact of health care providers on female sterilization among HIV-positive women in Brazil. Social Science & Medicine, Oxford, v. 61, n. 3, p. 541-554, 2005.), or even anti-family stigma that would explain a tendency on the part of the health care team to criticize patients who decide to have children (Oliveira; França-Junior, 2003OLIVEIRA, L.; FRANÇA-JUNIOR, I. Reproductive demands and health care for people living with HIV/Aids: limits and possibilities within the context of specialized health care. Cadernos de Saúde Pública, Rio de Janeiro, v. 19, p. 315-323, 2003. Supplement 2.). These studies reveal that this topic is still controversial among health care professionals and that these women's reproductive decisions may involve issues that had not been fully investigated.

The first studies into reproductive decisions of women living with HIV/Aids covered the decision whether to have children or not from the point of view of a stated desire, seeking to investigate whether these women wanted to have children. It was observed that these women's serological status, or even having developed Aids, did not block them from getting pregnant or from wanting to have children (Sowell et al., 2002SOWELL, R. L. et al. Factors influencing intent to get pregnant in HIV-infected women living in the southern USA. Aids Care, London, v. 14; n. 2, p. 181-191, 2002.; Santos et al., 2002SANTOS, N. J. S. et al. Mulheres HIV positivas, reprodução e sexualidade. Revista de Saúde Pública, São Paulo, v. 36, p. 4-11, 2002. Suplemento 4.; Silva; Alvarenga; Ayres, 2006SILVA, N. E. K.;; ALVARENGA, A. T. AYRES, J. R. C. M. Aids e gravidez: os sentidos do risco e o desafio do cuidado. Revista de Saúde Pública, São Paulo, v. 40, n. 3, p. 474-481, 2006.). The study by Sowell et al. (2002)SOWELL, R. L. et al. Factors influencing intent to get pregnant in HIV-infected women living in the southern USA. Aids Care, London, v. 14; n. 2, p. 181-191, 2002. reports that these women's reproductive decisions are based on various factors related to their circumstances, although it highlights that the women appear to have better guidance in adopting traditional gender roles. Santos et al. (2002)SANTOS, N. J. S. et al. Mulheres HIV positivas, reprodução e sexualidade. Revista de Saúde Pública, São Paulo, v. 36, p. 4-11, 2002. Suplemento 4. also observed a positive association between thinking of having children and motivation to fight for life and greater engagement with the treatment.

Faced with a diagnosis of HIV, the woman may feel certain constraints such as facing social or professional disapproval in case of pregnancy; or being unable to breastfeed as the first "symptom" revealing HIV status to others (Campos, 1998CAMPOS, R. Aids: trajetórias afetivo-sexuais das mulheres. In: BRUSCHINI, C. Horizontes plurais: novos estudos de gênero no Brasil. São Paulo: Editora 34, 1998. p. 85-109.); and uncertainty whether the child(ren) produced will be infected (Tunala, 2002TUNALA, L. Fontes cotidianas de estresse entre mulheres portadoras do HIV. Revista de Saúde Pública, São Paulo, v. 36, p. 24-31, 2002. Suplemento 4.), among others. On the other hand both Campos (1998)CAMPOS, R. Aids: trajetórias afetivo-sexuais das mulheres. In: BRUSCHINI, C. Horizontes plurais: novos estudos de gênero no Brasil. São Paulo: Editora 34, 1998. p. 85-109. and Knauth (1999)KNAUTH, D. R. Subjetividade feminina e soropositividade. In: BARBOSA, R.; PARKER, R. (Org). Sexualidades brasileiras: direitos, identidades e poder. São Paulo: Editora 34, 1999. p. 121-136. highlight that the status of being a mother appears to restore their identity to these women as "respectable women" or "victims of the epidemic".

Another study investigating the reproductive decisions of seropositive patients shows that, in contrast to other studies conducted in developing countries, the desire to have children was more common among men (Paiva et al., 2007PAIVA, V. et al. Desire to have children: gender and reproductive rights of men and women living with HIV: a challenge to health care in Brazil. AIDS Patient care and STDs, Larchmont, v. 21, n. 4, p. 268-277, 2007.), with the independently factors associated with the desire to have children as follows: being male, being of a younger age, not having children, living with one or two children and having a heterosexual partner (Paiva et al., 2003OLIVEIRA, L.; FRANÇA-JUNIOR, I. Reproductive demands and health care for people living with HIV/Aids: limits and possibilities within the context of specialized health care. Cadernos de Saúde Pública, Rio de Janeiro, v. 19, p. 315-323, 2003. Supplement 2.).

With advances in tackling the problem of MTCT it has become evident that the issue of desiring pregnancy and maternity among these women involves more than a considered, objective decision, i.e. such research have brought with them advances in approaching, albeit not doing away with this problem. Thus, a complex problem such as the issue of women living with HIV/Aids desiring pregnancy is more than an object for a field of knowledge, but rather involves a challenge of technical-practical articulations to which the field of public health has been called to respond (Alvarenga, 1994ALVARENGA, A. T. A saúde pública como campo de investigação interdisciplinar e a questão metodológica. Saúde e Sociedade, São Paulo, v. 3, n. 2, p. 22-41, 1994.).

If, at first, research founded that women living with HIV/Aids do, in fact, want to have children, a relevant issue that arises is what drives this desire and, finally, what is this desire? The essential question that arises is whether it is possible to equate the desire for pregnancy with the willingness to get pregnant.

There is a vast array of literature pertinent to the topic of sexual and reproductive health from the perspectives of gender, feminism or Social Psychology. Although recognizing the importance of this field, the research conducted proposes a different point of view. Thus, Psychoanalysis may contribute as it presents its own epistemological theory for understanding the issue of desire and, although there have been several studies on the issue of MTCT of HIV, there has been little investigation into the unconscious aspects in women faced with a reproductive decision in such a context. Taking this situation into consideration, the research objectives were defined. This report forms part of a broader investigation by Zihlmann (2005)ZIHLMANN, K. F. A questão do desejo da gravidez e da maternidade em mulheres vivendo com HIV/Aids, na perspectiva psicanalítica. 2005. Dissertação (Mestrado em Saúde Pública) - Faculdade de Saúde Pública da Universidade de São Paulo, São Paulo, 2005. and the study aims to discover how women living with HIV/Aids perceive and attribute meaning to their reproductive decisions, as well as characterizing the different ways in which this unconscious desire manifests itself, through Lacanian psychoanalysis.

In order to understand a complex decision such as having a child, especially in the particular condition of a woman living with HIV/Aids, a qualitative study was conducted with 15 HIV seropositive women, over 18, who were pregnant or who had had children after discovering they were HIV seropositive. They were women who were being monitored on an outpatient basis or in a hospital specialized in infectious diseases, as well as women who attended an Non-Governmental Organization (NGO) support group for HIV positive pregnancies, both institutions in the city of São Paulo, Brazil. In-depth interviews were conducted following a thematic script (Meihy; Holanda, 2011MEIHY, J. C. S. B.; HOLANDA, F. História oral: como fazer, como pensar. São Paulo: Contexto, 2011.) and including questions on socio-demographic characterization, perceptions of the infection and disease and questions on sexuality and reproductive decisions. The interviewees were selected following the criteria of intentional convenience (Turato, 2003TURATO, E. R. Tratado de metodologia da pesquisa clínico-qualitativa: construção teórico-epistemológica, discussão comparada e aplicação nas áreas da saúde e humanas. Petrópolis: Vozes, 2003.), in other words, they met the objectives of research irrespective of their clinic stage or socio-economic condition.

In order to analyze the data, reports were created about the life trajectory of each of the interviewees, using the thematic oral history technique (Meihy; Holanda, 2011MEIHY, J. C. S. B.; HOLANDA, F. História oral: como fazer, como pensar. São Paulo: Contexto, 2011.). In addition, through explaining the concept of unconscious desire and femininity in the theoretical outline of psychoanalysis, reference is made to Zizek's (1992)ZIZEK, S. Eles não sabem o que fazem: o sublime objeto da ideologia. Rio de Janeiro: Jorge Zahar, 1992. contribution to the Lacanian theory of desire, seeking to recognize the concepts of imaginary identification [i(a)] and symbolic identification [I(A)] in the interviewees discourse as logical analysis operators. The study was approved by the Ethical Committees of the institutions involved and subjects signed an informed consent form which rigorously followed CNS Resolution 196/96.

The research subjects and their life trajectories

So as to characterize the women interviewed, table 1 presents a summary of the main data from each interview, illustrating the subjects' discourse. These discourses reveal that, in general, the women reorganize their personal life around pregnancy, received support from their family and other institutions, as well as the reception from the specialized care team.

As a general characterization of the group studied, we can state that the women interviewed were aged between 18 and 37 (mean 27) years old, the majority (60% of interviewees) reported being in a "stable relationship", although none of them reported being married. Only 13% of the interviewees reported being in a relationship of fewer than 12 months' duration, with the majority reporting relationships of between one and five years. Most of them (67%) were from the Southeast of Brazil and the predominant level of schooling was not having finished elementary school (40%). As for personal income, 33% stated that they had no income and another 33% reported an income of between one and three minimum wages. Only one of the interviewees reported having completed higher education. The remaining interviewees reported that they worked at home or autonomously.

Most of the interviewees (80%) had been aware of their HIV status for more than three years, 60% of them had started treatment at least three years previously. In 47% of cases, the partner was also HIV positive, with 33% reporting that their partner was either unaware of their own status or had not yet, at the time of the interview, been tested. Four of the interviewees (27%) reported that their partner had died through Aids complications. Most of the women reported becoming infected through sexual contact with a companion or boyfriend (93%), with only one interviewee stating that she had become infected through a blood transfusion during one of her pregnancies.

Regarding number of children, two of the interviewees were pregnant; the majority (67%) had more than one child and one reported that one of her children had died at four months as Aids consequence. Most of the women interviewed (60%) did not discover their HIV status whilst pregnant (discovering it either before the pregnancy or between pregnancies). Five interviewees (33%) discovered they were HIV positive before becoming pregnant, and later became pregnant. Several of the interviewees (27%) already had children, found out they had HIV, and then decided to have more children. Some of them (20%) had HIV positive children, with the majority (73%) having access to MTCT prevention during all pregnancies (the pregnant interviewee had begun MTCT prevention monitoring during the second month of pregnancy).

Most of the interviewees reported that they did not use condoms consistently (67%), of whom only 20% adopted this behavior as a result of deciding to get pregnant. Some of the interviewees (20%) stated that they became pregnant as a result of the condom splitting and two (13%) said that they became pregnant because they used condoms only sporadically in their sexual relations.

Constructing a new view of the object of the investigation: the psychoanalytic concept of unconscious desire

We recognize that, in order to understand the psychoanalytical concepts involved in the issue of desire, a certain level of familiarity with this theory, more specifically, with the Lacanian psychoanalytical approach, is needed. We therefore refer readers to Lacan's work, especially in the 1957 - 1960 period when that author worked on the concept of Desire based on the Graph of desire, a complex development articulating various psychoanalytical concepts (Lacan, 1998LACAN, J. Subversão do sujeito e dialética do desejo no inconsciente freudiano. In:______. Escritos. Rio de Janeiro: Zahar, 1998. p. 807-842., ¹⁹⁹⁹LACAN, J. O seminário: livro 5 - as formações do inconsciente. Rio de Janeiro: Zahar, 1999.).

In order to situate understanding the meaning of a HIV diagnosis, based on the psychoanalytical approach, it should be remembered that, in this reading, this is a situation that could lead to raising the issue of castration, to the extent that the subject feels that something, i.e. being healthy, has been lost. It is a harrowing experience that may leed to feel that something is lacking and that they need to seek out something. We can, therefore, articulate the notion of desire as something that, in the end, they lack (Kaufmann, 1996KAUFMANN, P. Dicionário enciclopédico de psicanálise: o legado de Freud e Lacan. Rio de Janeiro: Jorge Zahar, 1996.).

For Psychoanalysis desire goes beyond the biological aspect and involves the field of relationships between humans. For Freud (1996FREUD, S. As teorias sexuais infantis. In:______. Obras completas. Rio de Janeiro: Imago, 1996. v. 9, p. 117-229.)³3 Originally published in 1905., we can translate desire as "desires" or as a specific particular desire focused on an empirical object. Lacan (1998)LACAN, J. Subversão do sujeito e dialética do desejo no inconsciente freudiano. In:______. Escritos. Rio de Janeiro: Zahar, 1998. p. 807-842., in turn, establishes a trilogy to explain that the human dimension goes beyond that of biology and is inserted within a system of relationships which, ultimately, concern Language. Lacanian theoretical construction, which aims to explain the difference between the notions of need, demand and desire, is essential for the process of introducing the subject into a relationship with the Unconscious. In this trilogy, the term demand is related to the level of the instinctive, lost forever in the speaking subject (i.e. inserted into the field of Language). The term want refers to the speaking subject who by demanding (asking) is faced with the "misunderstanding" of Language, and the subject therefore never obtains the object he longs for (complete satisfaction). Demanding, the subject comes face to face with the structural ambiguity of Language and the unconscious desire remains (and will remain) unsatisfied, as there will always be a "misunderstanding", in so far as the speech will never encompass complete satisfaction.

The main contribution of this theoretical dialogue is in explaining the complexity of the issue of desire in the subjects, i.e., in fact, stating they "want" something (as a synonym for conscious and objective will) is very different from "desiring" something (such as something unconscious) as, from the subject's point of view, the problem of desire often causes real alienation in that he may not recognize himself in what he thinks he desires. In this sense, unconscious desire is based on the paradoxical status of the drive, responding to both the constructive (life drive), and destructive aspects (death drive). So we cannot establish a direct relationship between "desire to have children" with something positive or constructive, for what seems to be in question is the unconscious desire, which may jeopardize other factors beyond those morally accepted socially.

Desire to have children and feminine desire⁴4 We emphasize that we rely on the Lacanian psychoanalytic concept of the femininity, that is, from a specific point of view. We recognize that other relevant theories discussed femininity, women and feminism widely, but they are not part of the scope of this work.: what does psychoanalysis have to say about this?

In Freud's view, feminine desire itself cannot avoid passing through the issue of producing a "child-phallus", an attempt at narcissistic restoration possible for women. It became clear then, for Freud, after a certain course as an analyst, that the issue of feminine sexuality was more than reproduction, highlighting it as an "enigma" (Prates, 2001PRATES, A. L. Feminilidade e experiência psicanalítica. São Paulo: Hacker, 2001.).

Research based on gender theory also show that, for a HIV positive woman, maternity takes on a meaning of narcissistic reassurance, as well as the role of guaranteeing survival, making them dependent on the partner. Thus, the woman's place in our society is still seen as "passive", an object of another's desire. It can still be observed today in the economy of symbolic exchange, women adopt an attitude of "consenting complicity" in relation to supposed male desire (Barbosa; Villela, 1996BARBOSA, R. M.; VILLELA, W. A trajetória feminina da Aids. In: PARKER, R.; GALVÃO, J. (Org). Quebrando o silêncio: mulheres e Aids no Brasil. Rio de Janeiro: Relume-Dumará, 1996. p. 17-32.; Ventura-Filipe et al., 2000VENTURA-FILIPE, E. M. et al. Risk perception and counseling among HIV-positive women in São Paulo, Brazil. International Journal of STD & Aids, Thousand Oaks, v. 11, n. 2, p. 112-114, 2000.).

Without disregarding this approach and following another path of analysis, the Lacanian perspective emphasizes that "there is no such thing as a feminine essence", meaning that there is no "natural instinct" that explained or justified the desire to have children. Lacan (1985)LACAN, J. O seminário: livro 20 - mais, ainda. Rio de Janeiro: Zahar, 1985. observed that women often "have a child" in an attempt to "hold on to the phallus", as an "artifice" to deny castration and the lack of a final response to what "makes a woman" (Prates, 2001PRATES, A. L. Feminilidade e experiência psicanalítica. São Paulo: Hacker, 2001.). If Freud came to the end of his life asking "what do women want?" it needs to be understood that he is not asking "what does a mother want?" as for him it is evident that a mother wants a child. Based on this question, Lacan moves forward and highlights that the issue of femininity imposes itself on the subjects as an unavoidable enigma and that, although women often try to respond to this enigma with pregnancy in the end the bigger issue - the issue of femininity - is more than just maternity (Prates, 2001PRATES, A. L. Feminilidade e experiência psicanalítica. São Paulo: Hacker, 2001.).

To address desire in women living with HIV / Aids: desire as a response in relation to the other

Based on Zizek's (1992)ZIZEK, S. Eles não sabem o que fazem: o sublime objeto da ideologia. Rio de Janeiro: Jorge Zahar, 1992. reading of the Graph of Desire (Lacan, 1998LACAN, J. Subversão do sujeito e dialética do desejo no inconsciente freudiano. In:______. Escritos. Rio de Janeiro: Zahar, 1998. p. 807-842.), certain meanings stand out based on the interviewees' discourse on unconscious desire: femininity and the subject's constitution in the social bond. From this, we can see how the process of imaginary identification [i(a)] and symbolic identification [I(A)] occurs between these subjects (table 2).

In Zizek's (1992)ZIZEK, S. Eles não sabem o que fazem: o sublime objeto da ideologia. Rio de Janeiro: Jorge Zahar, 1992. reading of the process of imaginary identification [i(a)], we have the descriptive traces representing the subject and that author comments that, schematically, this would be "how the subject sees himself". Imaginary identity is related to the ideal I, with the subject identifying himself with an image representing "what he would like to be". In this process of imaginary identification we imitate the other in the level of similarity, that is, we identify ourselves with the image of the other so as to "be like him" with an idealized function.

In the case of the interviewees, the image these women had of themselves indicated that they identified themselves with the image of women marked out by the revelation of their HIV diagnosis, meaning that appeared in the discourse of all the interviewees were "being HIV positive", "being a mother or being pregnant and lacking guidance", "needing care and support", among others. The interviewees revealed that their HIV diagnosis made them into "victims in need of support and guidance and feeling guilty". A statement by Mariana illustrates this aspect: being pregnant and having Aids is something that leaves us disoriented. We need support that we don't always get. I lost a child to Aids and I feel it was my fault.

At this level of imaginary identification, the women take on the idealized role of the supposed "good patient" who, by adopting the health care team's recommendations without complaints or questions, would supposedly be welcomed and accepted. Such meanings can be seen in the statements from Flavia, Miriam, Bianca, Dia and Débora.

As for symbolic identification [I(A)], (Zizek 1992ZIZEK, S. Eles não sabem o que fazem: o sublime objeto da ideologia. Rio de Janeiro: Jorge Zahar, 1992., p.107) refers to is as "the place in which the subject observes himself as worthy of being loved". This refers to the way the subject looks at the other which, in the end, indicates the way he looks at himself (Zizek exemplifies this process as "the being for the other is the being for itself"). Symbolic identification [I(A)] depends on the subject's relationship with the symbolic order, that is, the subject seeks a "attribute" that represents him, and in this sense, he takes on a "mission", that may be unconscious for the subject.

At the level of symbolic identification [I(A)], we observe that the women interviewed saw HIV positive women who decide to have children as being "crazy" or "irresponsible". When evaluating their own decision to have a child, however, a contradictory understanding appears, as they justify their own reproductive decisions by placing the responsibility on another. In their discourse, their pregnancies were "an accident", "it was my husband who wanted it", "all women want children and I didn't want to be any different", "it was carelessness". The attribute that characterizes them is their subjective position of avoiding responsibility when faced with the desire, as they try to blame someone else. They try to justify their acts based on the "imposition" of another, as a "mission" they take on in the attempt to be accepted for the other.

We observed, however, that the women interviewed clung to the imaginary identification, taking on an identity of "victim" in an attempt to be accepted (loved) by the other, but this strategy does not allow them to avoid the question of castration as a persistent "reminder" presenting itself in the dimension of desire. Desire in this way takes the subject outside of the comfort of the imaginary identification and, by trying to correspond to what he "supposes to be the desire of the other", the subject comes up against an unsolvable enigma (the enigma of femininity, which is not limited to the issue of maternity) and, thus, in anguish, they resort to artifice to deal with the dissatisfaction: the subject offers himself to the other, as the object of his desire.The "mission" related by the interviewees is a type of sacrifice in which the subject offers himself to the other's supposed desire and, therefore, having a child transforms becomes a trial the objective of which is to generate a HIV negative offspring. This aspect is explained in the statements by Rita, Flávia, Mariana, Bianca, Dia and Débora.

But why could having a child be a narcissistic rescue? The answer is that women living with HIV/Aids experience narcissistic damage and the act of producing a "healthy" (HIV negative) child gives them a fleeting sensation of completion and negates the lack, as, by producing healthy offspring, she accomplishes her "mission" and rescues the damaged narcissism. However, the statements of the women interviewed show that getting pregnant is not enough: even when the child they "produce" is HIV negative, there is still the issue of their own HIV status, representative of the subject's confusion when faced with a lack which is, after all, structural. When the child is HIV positive the sacrifice, rather than dampening the lack, brutally uncovers the problem of HIV infection in all of its anguish and structural lack (table 3).

The women's position of avoiding responsibility appears in the conjugal and affective relationships and tends to be repeated in the relationship with the health care team. This means that the way they treat the disease varies according to what the team presents to them as a reference in a mirrored and imaginary relationship. The health care professionals come to be the "other to be blamed or take responsibility" and, when the situation of pregnancy is distressing there is the risk of acting out. This appears in situations in which patients abandon or adhere poorly to treatment, or even fail to follow medical recommendations, creating great discomfort for the health care team. It is worth remembering, then, that it is important for the health care teams to be aware of and to understand that when the HIV positive women become pregnant, she engages in a type of mission and has expectations - concerning the pregnancy as well as her relationship with partners and with the health care team itself - expectations that are not always clear to the women themselves, as they are unconscious issues.

We should also clarify that when we state that the women "avoid responsibility" for their unconscious desire, we are not making any kind of moral judgement, we are not saying the women are "irresponsible". The concept of desire as unconscious allows to be understood that these issues and dynamics of women living with HIV/Aids are not conscious and may directly or indirectly affect the relationship with the team and, consequently, concretely affect health care.

Psychoanalysis contributions to the field of public health: after all, what is this desire?

Contributions from the field of Psychoanalysis become possible when we place the field of desire in a different register from the natural and/or biological environment, placing it in the symbolic field. We can thus state that being a mother is different from being a woman. Psychoanalysis does not aim to characterize a HIV positive woman's desire as "a natural desire to have children", nor does it characterize maternity and pregnancy as the insignia of being feminine. It is, then, not important whether the subject will have children or otherwise, Psychoanalysis concerns itself with knowing the position the subject occupies in relation to the unconscious desire.

The interviewees' statements show contradictions, anguish and idiosyncrasies, showing that their reproductive decisions are based on a particular subconscious logic placing them, in their singularity, face to face with the possibility of getting pregnant, without necessarily being conscious of these contradictions as it is, evidently, something unconscious. We can state that pregnancy in a HIV positive woman is an attempt at narcissistic restoration and, when pregnancy occurs, it becomes a trial the objective of which is to generate a HIV negative offspring.

These women's discourses contains a contradiction: they evaluate the reproductive decisions of other HIV positive women as "crazy" or "irresponsible", whereas they seek to avoid responsibility for their own reproductive decisions. From the point of view of psychoanalysis, when we say that the interviewees avoid responsibility for their desire we are not making any kind of moral judgment. Psychoanalysis allows it to be understood that, when these women act thus, they do it for "a good reason". The issue of unconscious desire is something that imposes on the subject in an unavoidable way and often, the more they try to escape it, the more they are faced with the structural lack and with the unsatisfied desire. In attempting to deal with lack and with castration, the interviewees appear to engage themselves in an uncontrolled project that, in the end, does not protect them from experiencing distress. The pregnancy, then, can become something that explains a acting out (Kaufmann, 1996KAUFMANN, P. Dicionário enciclopédico de psicanálise: o legado de Freud e Lacan. Rio de Janeiro: Jorge Zahar, 1996.) not permitting the elaboration of the anguish but rather explaining it. When the subject tries to avoid responsibility towards the desire, psychoanalysis takes into consideration that this has consequences and, in the case of the interviewees, one can observe the anguish of castration made explicit in their discourse. It is also worth remembering that, on becoming mothers, they are far from answering or elaborating the question of the enigma of femininity. These data may be articulated with the results of research by Paiva et al. (2007)PAIVA, V. et al. Desire to have children: gender and reproductive rights of men and women living with HIV: a challenge to health care in Brazil. AIDS Patient care and STDs, Larchmont, v. 21, n. 4, p. 268-277, 2007. reporting that the desire to have children was more expressive in men living with HIV/Aids. The gender approach contributes to this issue by placing the focus on the man-woman relationship in the social context (Scott, 1989SCOTT, J. Gender: a useful category of historical analyses: gender and the politics of history. New York: Columbia University, 1989. Disponível em: <http://www.direito.mppr.mp.br/arquivos/File/SCOTTJoanGenero.pdf>. Acesso em: 1 nov. 2013
http://www.direito.mppr.mp.br/arquivos/F... ). In this sense, psychoanalytical and gender readings come together, as the statements by the interviewees allow us to understand that the women tend to take on the desire of the other - in this case, the man - as their own, something that presents itself as the structuring of subconscious desire itself. Moreover, they establish complicity with their partners and trick themselves in the project of having a child in order to cushion their loss. This relationship produces a type of bond with the partner that does not necessarily involve the issue of affection, nor is it conscious, which may explain the so-called "classical unplanned" pregnancies.

We observed that this position of avoiding responsibility is also evident in the conjugal-emotional relationships and tends to be repeated in the relationship with the health care team. The women's discourse shows that their behavior is not necessarily determined by the guidance received from the team but it was possible to identify the need to show themselves to be "good patients", adhering to treatment and, above all, grateful for the institutional support received. Moreover, as Campos (1998)CAMPOS, R. Aids: trajetórias afetivo-sexuais das mulheres. In: BRUSCHINI, C. Horizontes plurais: novos estudos de gênero no Brasil. São Paulo: Editora 34, 1998. p. 85-109. and Knauth (1999)KNAUTH, D. R. Subjetividade feminina e soropositividade. In: BARBOSA, R.; PARKER, R. (Org). Sexualidades brasileiras: direitos, identidades e poder. São Paulo: Editora 34, 1999. p. 121-136. also point out, being pregnant appears to require (currently, as there have been advances in attaining the rights of individuals living with HIV/Aids) special reception on the part of the team, beyond providing them with access to certain benefits for themselves and the baby (such as, for example, facilitated access to ante-natal appointments in institutions prepared to deal with their reality, receiving formula milk to substitute breast feeding, in some cases receiving clothing, being able to participate in support groups, among others). The interviewees revealed that through the pregnancy they could join (or rejoin) groups and obtain help and support, both objective and subjective. This relation even occurred with the participants of the group itself, in the form of a bond in which information and experiences were exchanged helping them to construct (or even reconstruct) professional training as well as citizenship.

Although we have seen great advances in recent decades in terms of access and rights for these patients, we see that there are often conflicts in the doctor-patient relationship, in other words, the behavior of these women when trying to show themselves as "grateful" and "good patients" often serves as a shield against a series of subconscious conflicts that could damage their health care itself. It was observed that the confusion of the (mis)match between health care professionals and patients reveals a need for a more in-depth understanding of these phenomena. A view based on Psychoanalysis is, in this context, an invitation for the subject to become aware of his idiosyncrasies, and thus take a position of being responsible for his behavior. Similarly, psychoanalysis can contribute to the field of public health, based on including the subjects' idiosyncrasies. Thus the rescue of the singularity of the subject's unconscious desire is possible, and allows reflection on how these issues affect comprehensive care, which, after all, can interfere with the reception of the complex needs of women living with HIV / Aids.

Acknowledgements

Thanks to Carla Vasquez, PhD, infectious diseases specialist, for referring the patients from her clinic to participate in the research. To the women interviewed for their generosity in sharing their life stories, viewing the field of desire with courage and delicacy.

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