Factors associated with condom use in people living with HIV/AIDS

Abstract

Objective

Identify condom use in people living with HIV/AIS attended at a Specialized Care Service in STD/HIV/AIDS and associate it with sociodemographic and behavioral variables.

Methods

Cross-sectional study, involving 300 people living with HIV/AIDS between 18 and 66 years of age. Student’s t-test was used for intergroup comparison. The association between condom use and the sociodemographic and behavioral factors was verified using Pearson’s correlation tests and its effect was measured through the odds ratio.

Results

It was observed that 79.3% of the participants reported using condoms in sexual relations. Single people had less chance of using condoms than married women. And not revealing the HIV positive status to the partner increases the chances of using the condom.

Conclusion

Condom use is frequent among people living with HIV/AIDS, even when they do not reveal the positive serum status to their partners, but a significant part of the single people have unprotected sexual practices.

Condom; HIV seropositivity; Sexual behavior; Sexual partners; Unsafe sex; Safe sex

Resumo

Objetivo

Identificar o uso de preservativo em pessoas que vivem com HIV/AIDS atendidas em um Serviço de Assistência Especializado em DST/HIV/AIDS e associá-los a variáveis sociodemograficas e comportamentais.

Métodos

Estudo transversal, realizado com 300 pessoas vivendo com HIV/AIDS com idade entre 18 e 66 anos. O teste t Student foi utilizado para comparação entre os grupos. A associação entre o uso de preservativo e os fatores sociodemograficos e comportamentais foi verificada por meio dos testes de correlação de Pearson e medida seu efeito por meio da razão de chance.

Resultados

Observou-se que 79,3% dos participantes relataram o uso do preservativo nas relações sexuais. Os solteiros tinham menor chance de usarem o preservativo que os casados. E não revelar a sorologia HIV positiva para o parceiro, aumenta as chances de usar o preservativo.

Conclusão

O uso do preservativo é uma prática frequente entre as pessoas que vivem com HIV/AIDS, mesmo quando não revelam a sorologia positiva aos parceiros, porém uma parcela significativa de pessoas solteiras têm práticas sexuais desprotegidas.

Preservativo; HIV soropositivo; Comportamento sexual; Parceiros sexuais; Sexo sem proteção; Sexo seguro

Introduction

It is estimated that, today, about 34 million people around the world are infected by the acquired immunodeficiency virus (HIV), which is responsible for the development of the acquired immunodeficiency syndrome (AIDS), a pandemic condition that is considered a severe public health problem.(¹)

Condom use in people living with HIV/AIDS reduces the risk of transmitting the virus and also of contracting other sexually transmissible diseases, besides reducing the superinfection with different viral specimens, contributing to prevent more severe and resistant forms of the disease.(²,³)

The people living with HIV/AIDS have presented a healthy improvement in the quality of life and life expectancy, as a result of the advent of antiretroviral therapy and treatment access,(⁴) as opposed to some studies that show that the risk of practicing unsafe sex has increased in patients who are using antiretroviral drugs, due to the control of the viral loading and increased immunity, which lead to the absence of symptoms and improvement of these patients’ quality of life, discouraging safe sexual practices.(⁴,⁵)

Different sociodemographic and behavioral factors are involving in unsafe sex in HIV/AIDS patients and vary around the world, including sex, age, education, marital status, lack of perception of the severity of the disease due to the absence of symptoms, partner’s serum status, difficulty to negotiate on the condom use and fixed or casual partners.(⁶,⁷) This highlights the responsibility of health services to comprehensively and effectively monitor these clients, with a focus on the prevention of transmission and complications deriving from AIDS.

Therefore, understanding the factors that stimulate safe sexual practices, such as condom use in people living with HIV/AIDS, will permit developing concrete and contextualized actions with these clients, with strong implications in the execution of preventive measures and appropriate conducts in the control of this infection.

Hence, this study aimed to identify condom use in people living with HIV/AIDS attended at a Specialized Care Service in STD/HIV/AIDS and associate them with sociodemographic and behavioral variables.

Methods

A cross-sectional study was undertaken at a Specialized Care Service for HIV/AIDS patients, which at the time of the study monitored 1020 people living with HIV/AIDS, located in the Brazilian Northeast. The sample was calculated using a formula for infinite populations. A prevalence ratio of 50% was adopted because if offers a maximum sample size, a significance level of α=0.05 and an absolute sampling error of 4%. To mitigate possible losses, 10% was added to the sample size (n=300 people living with HIV/AIDS).

The participants were randomly selected in accordance with the established eligibility criteria. The inclusion criteria were: patients aged 18 years or older, carriers of the HIV virus and registered at the Specialized Care Service in STD/HIV/AIDS. The exclusion criteria were: patients with cognitive deficit, communication deficit or severely ill.

The tool used to collect the data was a semistructured questionnaire involving sociodemographic characteristics (sex, ethnic origin, age, education, income, occupation, marital status, religion) and behavioral characteristics related to the sexual practices (sexual relation in the last three months, condom use in the last three months, difficulty to negotiate on condom use with the partner, revelation of HIV serum status to the partner, change in sexual desire after the serum status test, use of antiretroviral therapy, knowledge on reinfection). Before the actual data collection, the questionnaire was pretested in 10 participants. After the pretest, some questions were reconsidered and, then, the data were collected.

To collect the data, a 30-hour training was held with the field researchers. The data were collected between November 2013 and February 2014 in private rooms at the Municipal Referral Center in STD/HIV/AIDS. The patients were recruited at the waiting rooms of the medical and nursing appointments, after clarifications on the research objectives and methods.

The following outcome variable was selected: condom use (condom use in all sexual relations, whether vaginal, anal, oral in the last three months), while the sociodemographic and behavioral factors of sexual practice were the independent variable.

The processing of the data and the statistical analysis were undertaken in the software Statistical Package for the Social Sciences®, version 22.0. The quantitative variables were presented using descriptive statistics (mean and standard deviation), and the qualitative variables using proportions and 95% confidence intervals. First, the Kolmogorov-Smirnov test was applied to assess the normality of the quantitative variables. To analyze the difference of means, Student’s t-test was used for independent samples and, to check for associations among the variables, Pearson’s chi-square test was applied and its effect was measured using the odds ratio, with significance being set at p<0.05.

The study development complied with the Brazilian and international ethical standards of research involving human beings.

Results

In total, 300 people living with HIV/AIDS were assessed, with a predominance of the female gender (53.3%), the age ranged between 18 and 66 years, with a mean age of 37.1% (standard deviation 8.78), 80.3% were mulatto or black, 65% had studied less than ten years, 75.3% gained a monthly income of less than one minimum wage ($ 1851.41), 92.3% had an occupation, 52% were single, 93% had a religion.

In this study, most women had a paid job (p= 0.02), were married (p= 0.03) and reported having difficulties to negotiate on condom use with their partners (p= 0.002). No association was found between sex and age and condom use, as observed in table 1.

Table 1
Distribution of sociodemographic and behavioral variables of sexual practice in people living with HIV/AIDS

Variables	Sex		p-value
	Male n= 140 n(%)	Female n= 160 n(%)
Age
< 30 years	31(22.1)	41(25.6)	0.48
> 30 years	103(77.9)	119(74.4)
Education
<10 years	95(67.8)	100(62.5)	0.33
>10 years	45(32.2)	60(37.5)
Income
<= 1 salary	103(73.5)	123(76.8)	0.50
> 1 salary	37(26.5)	37(23.2)
Occupation
Yes	124(88.5)	153(95.6)	0.02
No	16(11.5)	07(4.4)
Marital status
Single	82(58.5)	74(46.2)	0.03
Married	58(41.5)	86(53.8)
Religion
Yes	128(91.4)	151(94.3)	0.31
No	12(8.6)	09(5.7)
Ethnic origin
White	22(15.7)	37(23.1)	0.10
Non white	118(84.3)	123(76.9)
Current sexual practice
Yes	131(93.5)	148(92.5)	0.71
No	9(6.5)	12(7.5)
Condom use
Yes	116(82.8)	112(76.2)	0.15
No	24(17.2)	38(23.8)
Difficulty to negotiate
Yes	13(3.2)	36(22.5)	0.002
No	127(90.8)	124(77.5)
Reveals the serum status to the casual partner
Yes	34(24.2)	48(30)	0.26
No	106(75..8)	112(70)
Reveals the serum status to the fixed partner
Yes	113(80.7)	133(83.1)	0.58
No	27(19.3)	27(16.9)
If does not reveal uses condom
Yes	137(97.8)	160(100)	0.06
No	03(2.2)	0
Knowledge on reinfection
Yes	116(82.8)	125(78.1)	0.30
No	24(17.2)	35(21.9)
Use ARVT
Yes	123(87.8)	130(81.2)	0.14
No	17(12.2)	29(18.8)
Change in sexual desire
Yes	43(30.7)	61(38.1)	0.17
No	97(69.3)	99(61.9)

It was observed that 79.3% of the people living with HIV/AIDS reported having used condoms in sexual relations in the last three months. This practice was predominant among women (51.3%), over thirty years of age (75.3%), mulatto or black (78.9%), studied less than ten years (64.2%), had a paid job (91.5%), gained a monthly income of less than one minimum wage (75.6%), married (50.9%), religious (92.4%).

As regards safe sex using condoms and sociodemographic factors, the chance of using condoms was lesser among single than among married participants (p=0.05; odds ratio=0.89), a statistically significant association (Table 2).

Table 2
Association between sociodemographic factors and condom use in people living with HIV/AIDS

Variables	Condom use		p-value	CR	95%CI
	Yes n=238	No n=62
	n(%)	n(%)
Sex
Male	116(48.7)	24(38.7)	0.15	1.08	0.96-1.12
Female	112(51.3)	38(61.3)
Age
< 30 years	59(24.7)	13(20.9)	0.53	1.04	0.91-1.18
> 30 years	179(75.3)	49(79.1)
Education
<10 years	153(64.2)	46(74.1)	0.16	0.91	0.81-1.02
> 10 years	83(35.8)	16(25.9)
Income
<= 1 salary	180(75.6)	46(74.1)	0.81	0.98	0.85-1.12
> 1 salary	58(24.4)	16(25.9)
Occupation
Yes	218(91.5)	59(95.1)	0.34	1.10	0.93-1.30
No	20(8.5)	03(4.9)
Marital status
Single	117(49.1)	39(62.9)	0.05	0.89	0.79-1.00
Married	121(50.9)	23(37.1)
Religion
Yes	220(92.4)	59(95.1)	0.45	1.08	0.90-1.30
No	18(7.6)	3(4.9)
Ethnic origin
White	50(21.1)	09(14.5)	0.25	1.08	0.95-1.23
Non white	188(78.9)	53(85.5)

Among 79.3% of the people living with HIV/AIDS who reported safe sexual practices with condom use, 33.9% had not used the condom because they had not had sexual practice in the last three months, 84.1% reported no difficulties to negotiate on the condom use, 72.3% did not reveal the HIV serum status to the casual partners, 82.3% reveal the positive HIV serum status to the fixed partners, 99.5% do not reveal the serum status but use condoms, 82.3% know about reinfection, 67.3% had no change in their sexual desire after the HIV positive diagnosis and 85.2% are taking antiretroviral drugs.

As regards the behavioral factors of sexual practice, it was observed that sexual practice in the last three months had a six times higher chance of taking place with condom use (p<0.0001; odds ratio = 6.80) and that not revealing the HIV positive serum status to the partner increases the chance of using condoms two times more (p= 0.04; odds ratio = 2.39) (Table 3).

Table 3
Association of behavioral factors of sexual practice with condom use in people living with HIV/AIDS

Variables	Condom use		p-value	CR	95%CI
	Yes n=238 n(%)	No n=62 n(%)
Current sexual practice
Yes	238(100)	41(66.1)	<0.0001	6.80	5.12-.9.02
No	0	21(33.3)
Difficulty to negotiate
Yes	38(15.9)	11(17.7)	0.73	0.97	0.82-1.14
No	200(84.1)	51(82.3)
Reveals serum status to casual partner
Yes	66(27.7)	16(25.8)	0.76	1.02	0.89-1.15
No	172(72.3)	46(74.2)
Reveals serum status to fixed partner
Yes	196(82.3)	50(80.6)	0.75	1.02	0.87-1.19
No	42(17.7)	12(19.4)
If does not reveal uses condom
Yes	237(99.5)	60(96.7)	0.04	2.39	0.48-11.8
No	01(0.5)	2(3.3)
Knowledge on reinfection
Yes	196(82.3)	45(72.5)	0.08	1.14	0.96-1.35
No	42(17.7)	17(27.5)
Use ARVT
Yes	203(85.2)	50(80.6)	0.33	1.08	0.90-1.30
No	34(14.8)	12(19.4)
Change in sexual desire
Yes	78(32.7)	26(41.9)	0.17	0.91	0.80-1.04
No	160(67.3)	36(58.1)

Discussion

In this study, the goal was to identify the main factors related to safe sexual practice through condom use in patients living with HIV/AIDS. It was evidenced that condom use was a frequent practice in most study participants, but 20.7% still report sexual practices without condom use.

These study findings are almost the same as another cross-sectional study undertaken in the South of Brazil, where the prevalence of unsafe sexual practice corresponded to 25.3%,(⁸) similar to the findings in most studies involving people living with HIV/AIDS in cities in Italy,(⁹) Southern China,(¹⁰) African countries(¹¹,¹²) and lower than findings in Argentina(¹³)and the United States.(¹⁴)

Among the people living with HIV/AIDS under study, it was observed that the female sex was associated with having a paid job, being married and reporting difficulties to negotiate on condom use with the partners. These data evidence women’s increasing participation in the job market, which guarantees their permanent inclusion in the public sphere in recent decades. Despite their professional emancipation, women’s family and sexual issues are still based on the submission to the male sex.(¹⁵)

A Brazilian study involving 2780 women showed that they are more vulnerable to unprotected sexual practices, due to difficulties to negotiate on condom use with the partner, as they are linked to macho cultural factors and out of fear of male violence by their intimate partners.(¹⁶) Therefore, comprehensive care to these women, understanding all of their vulnerabilities and inviting sexual partners to participate in the health service, are necessary for the couple to understand the dimension of their sexuality and the HIV infection, turning them into protagonists of self-care, so as to promote pleasant and protected sexual practices and promote a better quality of life for these clients.

In this study, it was evidenced that single participants had a lesser chance of using condoms than married participants, similar to a study developed in Ethiopia involving people living with HIV/AIDS, where single people had a four times higher chance of engaging in unsafe sexual practices than married people(¹²) and differently from the study by Anand et al.,(¹⁷) where married people, due to the greater confidence between the partners, engage in sexual practices without condom use.

Therefore, the relevant contribution of the multidisciplinary team is highlighted, which works in the orientation and care for people living with HIV/AIDS, as most participants in this study reported on condom use and knowledge on reinfection. Nevertheless, preventive actions need to be reinforced for the single people, who still engage in risky sexual practices (without condom use), with a view to avoiding reinfection and reducing potential risks for transmission of the HIV virus.

The study showed that sexual practice in the last three months had more chance of happening with condom use, even when the HIV-positive serum status is not revealed to the partners, a fact that suggests the stigmatization and excluding potential the HIV/AIDS infection still produces in society. And it contrasts with the study by Engedashet et al.,(¹²) in which people who did not reveals their serum status had a greater chance of not using condoms.

In the course of this research, some limitations were faced, such as the sample from a single service, hampering the generalization of the results in relation to the general population.

As this was a cross-sectional study, the study participants could not be monitored with regard to their sexual practices. The assessment was only based on self-reporting and not other reliability measure of the report was obtained. Finally, there is the memory bias, as sexual practices in the last three months were investigated.

Therefore, despite the above limitations, the results of this study are relevant, contributing to the quality of care delivery to people living with HIV/AIDS and to the elaboration of appropriate prevention programs for these clients’ needs.

Thus, the development of similar studies in different geographical regions, with different methodological approaches, is important to support the health professionals’ work in the detection of possible risk behaviors and in planning appropriate prevention and control strategies for these clients.

Conclusion

The study shows that most people living with HIV/AIDS use a condom, even when they do not reveal their HIV positive serum status to their partners. Nevertheless, a significant part of single people still maintains unprotected sexual practices. Despite being professionally emancipated and mostly married, women still face difficulties to negotiate on condom use with their sexual partners.

Acknowledgements

The authors acknowledge the support of the Research and Scientific and Technological Development Support Foundation of the State of Maranhão (FAPEMA) in the development of the research.

Referências

• ¹
  Joint United Nations Programme on HIV/AIDS. Global report: UNAIDS report on the global AIDS epidemic 2010. Geneva: Joint United Nations Programme on HIV/AIDS. 2010. p.16-61.
• ²
  Allen C, Mbonye M, Seeley J, Birungi J, Wolff B, Coutinho A, Jaffar S. ABC for people with HIV: responses to sexual behavior recommendations among people receiving antiretroviral therapy in Jinja, Uganda. Cult Health Sex. 2011; 13(5):529-43.
• ³
  Kalichman SC1, Di Berto G, Eaton L.Human immunodeficiency virus viral load in blood plasma and semen: review and implications of empirical findings. Sex Transm Dis. 2008; 35(1):55-60.
• ⁴
  Granich R, Crowley S, Vitoria M, Smyth C, Kahn JG, Bennett R, et al. Highly active antiretroviral treatment as prevention of HIV transmission: review of scientific evidence and update. Curr Opin HIV AIDS. 2010; 5:298-304.
• ⁵
  Joseph HA, Flores SA, Parsons JT, Purcell DW. Beliefs about transmission risk and vulnerability, treatment adherence, and sexual risk behavior among a sample of HIV-positive men who have sex with men. AIDS Care. 2010; 22(1):29-39.
• ⁶
  Noar SM. Behavioral interventions to reduce HIV related sexual risk behavior: review and synthesis of meta-analytic evidence. AIDS Behav. 2008; 12(3): 335-53.
• ⁷
  Laisaar KT, Raag M, Rosenthal M, Uusküla A. Behavioral interventions to reduce sexual risk behavior in adults with HIV/AIDS receiving HIV Care: A systematic review. AIDS Patient Care STDS. 2015; 29(5):288-98.
• ⁸
  Cardoso LD, Malbergier A. Who is not using condoms among HIV-positive patients in treatment in the largest city in Brazil? AIDS Care. 2015; 27(5):629-36.
• ⁹
  Camoni L, Dal Conte I, Regine V, Colucci A, Chiriotto M, Vullo V, et al. Sexual behaviour reported by a sample of Italian MSM before and after HIV diagnosis. Ann Ist Super Sanita. 2011; 47(2):214-9.
• ¹⁰
  Wang XB, Tucker JD, Yang L, Zheng H, Zhang F, Cohen MS, et al. Unsafe sex and sti prevalence among hiv-infected adults in Guangzhou, China: Opportunities to Deamplify Sexual HIV Transmission. AIDS Behav. 2013; 17(3):1137-43.
• ¹¹
  Ayiga N. Rates and predictors of consistent condom-use by people living with HIV/AIDS on antiretroviral treatment in Ugand. J Health Popul Nutr. 2012; 30(3):270-280.
• ¹²
  Engedashet E, Worku A, Tesfaye G. Unprotected sexual practice and associated factors among people living with hiv at ante retroviral therapy clinics in Debrezeit Town, Ethiopia: a cross sectional study. Reproduct Health. 2014; 11:56.
• ¹³
  Valverde EE, Cassetti I, Metsch LR, Bugarin G, Bofill L, Laurido M, et al. Sex risk practices among HIV-positive individuals in Buenos Aires, Argentina. Aids Patient Care STDS. 2009, 23(7):551-6.
• ¹⁴
  Quirk CC, Pals SL, Colfax G, McKirnan D, Gooden L, Eroglu D. Factors associated with sexual risk behavior among persons living with HIV: gender and sexual identity group differences. AIDS Behav. 2008; 12(5):685-94.
• ¹⁵
  Bilac ED. Trabalho e família articulações possíveis. Tempo Social. 2014; 26(1):129-45.
• ¹⁶
  Barros C, Schraiber LB, França-Junior I. Association between intimate partner violence against women and HIV infection. Rev Saúde Pública. 2011; 45(2):365-72.
• ¹⁷
  Anand A, Shiraishi RW, Bunnell RE, Jacobs K, Solehdin N, et al. Knowledge of HIV status, sexual risk behaviors and contraceptive need among peopleliving with HIV in Kenya and Malawi. AIDS. 2009; 23(12):1565-73.

Publication Dates

• Publication in this collection
  Nov-Dec 2015

History

• Received
  23 July 2015
• Accepted
  4 Sept 2015