ARTICLE
Comparative study on sexual and reproductive health of adolescents with and without aids: is there a difference in knowledge between the two groups?

RESULTS

The sociodemographic profiles of both HIV-positive and HIV-negative adolescents studied were similar, except for religion, city where they lived, and who they lived with (p<0.05) (Table 1). In HIV-positive group, there was a high frequency of individuals who lived in two nongovernmental organizations (31.1%), which served as shelter homes where they could stay up to the age of 18 years. More than half of the institutionalized individuals reported no religion (p<0.001). All HIV-positive adolescents met the definition criteria for AIDS according to the Ministry of Health¹³.

Table 1:

Sociodemographic profile of the HIV-positive and HIVnegative adolescents.

^*Student's t-test; ^#Fisher's exact test; ^&among the two categories with higher frequencies; ^$Pearson χ² test.

In the analysis of the responses to the open-ended questions "What is your understanding of sexual health?" and "What is your understanding of reproductive health?" the responses were categorized according to the central idea (focus) on the behavior. Regarding sexual health, responses were grouped into four categories; and regarding reproductive health, they were grouped into three (Table 2).

Table 2:

Distribution of the responses of HIV-positive and HIV-negative adolescents to the questions: "What is your understanding of sexual health?" and "What is your understanding of reproductive health?" Question: "What is your understanding of sexual health?"

^*Pearson χ² test: p=0.01. ^#Pearson χ² test: p=0.48.

With regard to the responses to the first question, the groups differed in those categorized as "Sex/pleasure" with higher frequency in HIV-positive group, and "Condoms/STD" with higher frequency in HIV-negative group (p=0.01). Examples of responses categorized as "Condoms/STD": "Always in sexual encounters you must always use condoms because you can get a disease like AIDS" (12-year-old HIV-negative female) and as "Sex/pleasure": "To know if you want a life with sex, have sex to have children or do not intend to have children, just sex" (12-year-old HIV-positive female). In the analysis of the responses related to reproductive health, it was observed that the frequencies were similar between HIV-positive and HIV-negative adolescents (p>0.05). Examples of responses categorized as "Reproduction/Sexual intercourse": "Sexual activity of a couple who reproduces through sex" (15-year-old HIV-positive female) and as "Prevention/Awareness": "If you take care using condoms and contraceptives to avoid become pregnant, or take care not to transmit to the child" (16-year-old HIV-positive female).

Responses "Blank/do not know" from both groups to both questions showed that the frequency of ignorance about the reproductive health was higher than the frequency of ignorance about the sexual health (p=0.01) (Table 2).

As the sexual and reproductive rights serve as references for the exercise of sexuality, individuals were asked whether they read about those issues, what their sources of information were, whether they had received guidance, and what their opinion on the subject was.

When asked whether they had read about sexual and reproductive rights, 34.4% of HIV-positive and 42.6% of HIV-negative adolescents responded yes (p=0.45). In HIV-positive group, the source of information most widely used was the Internet (p=0.08), and in HIV-negative group, the source was the materials from the Ministry of Health (p=0.05).

In relation to the guidance received about these rights, 63.9% of HIV-positive and 59.0% of HIV-negative group said yes (p=0.70). Most of the individuals did not express their opinions about those rights when asked, and this frequency was higher in the HIV-negative group (73.8 versus 54.1%; p=0.07). The following questions were asked to both groups: "Should adolescents infected with HIV relate to their 'date'/boyfriend or girlfriend in the same manner that the adolescents who are not infected with HIV?" and "Why?"

In HIV-positive group, most of the adolescents responded yes (61.0%) and justified their responses similarly. In the group HIV-negative, the majority of the adolescent did not express an opinion (43.0%) or responded no (39.0%), justifying their opinion with prejudiced and discriminatory statements (Table 3). Examples of "yes" categorized responses as "Juvenile omnipotence/Magical thinking": "Because we forget that we have AIDS" (13-year-old HIV-positive female) and as "Care/Magical thinking": "Because if you love you cannot infect the other, be more careful" (12-year-old HIV-positive female). In these two categories of responses, "Magical thinking" in the HIV-positive group was a frequent finding, on the other hand, it was not possible to classify any of the responses of the HIV-negative group.

Table 3:

Distribution of the responses of HIV-positive and HIV-negative adolescents to the question: "Should adolescents infected with HIV relate to their 'date'/boyfriend or girlfriend in the same manner that adolescents who are not infected with HIV?" and "Why?"

Source: Data from the research (2013). ¹Pearson χ² test: p<0.01.

Responses equivalent to "no", categorized as "Care/Prejudice": "Because the others care and have responsibility and those infected with HIV do not" (16-year-old HIV-negative female) and categorized as "Transmission/Prejudice": "Because the infected teenagers do not use prevention" (18-year-old HIV-negative female). It was not possible to classify any responses of the HIV-positive group in these two categories.

In adolescence, sexual games such as "hook up," "play the field," "casual relationship," and "steady relationship" are part of the discovery and experience of sexuality and have different names and meanings according to the period in time and culture. In relation to "hook up"/"steady relationship," we observed a higher frequency in the HIV-negative group as compared with HIV-positive group ("hook up": 74.6 versus 60.7%; p=0.15) ("steady relationship": 50.8 versus 35.0%; p=0.11). The frequency of adolescents who reported having had sex was similar in both groups (p=1.00) (Graph 1).

Graph 1:

Distribution of the frequencies of social and sexual practices reported by HIV-positive and HIV-negative adolescents.

With regard to the onset of sexual activity among those who responded and in both groups, six initiated before the age of 15 years and seven initiated after that age (p=0.95). In both the groups, the sex partner was the "date"/boyfriend or girlfriend and in almost all cases (except one in each group) the use of condoms was reported. The majority of the individuals (84.6% HIV-positive and 61.5% HIV-negative) reported using condoms in all sexual encounters (p=0.21). However, most teenagers said they do not usually pick condoms up (61.7% of the HIV-positive and 63.3% of the HIV-negative groups; p=1.00).

The reproductive health care includes the right to information, access to contraceptive methods and techniques, and services that contribute in preventing and solving reproductive health problems of men and women¹⁴. For this reason, adolescents were asked if they received guidance on contraception, emergency contraception, pregnancy, abortion, and STDs.

Table 4 shows that most of the adolescents were guided on contraceptive methods, and no difference was observed in relation to the knowledge of the various contraceptive methods. With regard to emergency contraception, it was observed that 21.7% of the HIV-positive group and 52.5% of the HIV-negative group received guidance, and this difference was statistically significant (p<0.001). HIV-positive girls received less guidance on emergency contraception in relation to HIV-negative girls (22.6 versus 54.8%; p=0.01). The same pattern was observed among boys (20.7 versus 50.0%; p=0.02). The groups received similar guidance on preventing pregnancy, abortion, and STDs.

Table 4:

Guidance received by HIV-positive and HIV-negative adolescents.

Note: Fisher's exact test. STD: sexually transmitted disease.

Comparing boys and girls, it was observed that HIV-positive boys received more guidance on STD (89.3 versus 60.0%; p=0.01).

A higher frequency of guidance on STDs received from education professionals was observed for both the groups.

DISCUSSION

Advances in medicine have been decreasing morbidity and mortality rates related to AIDS, and the risk of vertical transmission can be reduced to less than 2%. Children with perinatal HIV infection are reaching adolescence and young adulthood, bringing new challenges to health services, society, and public policies. Attention needs to encompass the aspects of sexuality, reproductive health, and mental health, and also discussion on the educational and professional projects of these adolescents in coordination with governmental and nongovernmental organizations should be carried out.

By analyzing the sociodemographic profile of these groups, it was observed that the majority of the HIV-positive lived with "Others" or in "Institutions," as a consequence of the death or illness of their parents in most cases, evidencing that these adolescents were exposed to orphanhood^3,4,5.

Both groups showed more lack of knowledge about reproductive health. A multicenter study in Brazil showed that only few professionals discussed the fertility and family planning as options for HIV-positive people. Probably, this happened to avoid stimulating women to consider pregnancy. Those professionals also admitted of being uncomfortable in discussing sexuality issues while counseling on reproductive health, particularly for HIV-positive people¹⁵. The reports of adolescents in this study confirm the limited access to advice on sexual and reproductive health, a fact that has hindered the knowledge acquisition on these issues and, consequently, the conscious and responsible decisions, including those related to drug interactions between antiretrovirals and contraceptives.

In HIV-positive group, the number of adolescents who responded "Blank/do not know" for questions related to sexual and reproductive health was higher than in the HIV-negative group. The lack of knowledge on these issues of the HIV-positive adolescents brings vulnerabilities to the hetero- and homosexual relationships, being a risk factor for the vertical transmission of HIV and other STDs. Both seroconcordant and serodiscordant couples wishing to have children should undergo an interdisciplinary assessment and receive information on reproductive planning to reduce the risks of transmission and to prevent the worsening of the immunodeficiency¹⁶. The vulnerability of females to HIV infection among the population aged 15-64 years was identified in all risk practices related to HIV¹⁷. Given women's vulnerability, the health services need to carefully analyze the profile of their patients and their social and educational contexts to assess the need of specific care for women. Thus, the debate about gender may equip them to build or rebuild the relationship with their companions, also contributing to the reduction of gender violence in the next generations.

The responses of infected adolescents about sexual health were more related to "Sex/pleasure," with no relation to the prevention actions even after being aware of their HIV serostatus, while HIV-negative adolescents showed greater association between the use of condoms and prevention of STD and pregnancy. These results point to a sexuality exercised with little protection and information, adding another risk factor for both groups of adolescents. However, specifics should be considered in the attention to sexual and reproductive health of people living with HIV and AIDS, to better understand their behavior. The fear of infecting partners or being rejected by their HIV serostatus, the stigma associated with AIDS, their negative effects on self-esteem, and the possible difficulties in using condoms are the various aspects to be considered in the care offered by the health services, both for the teenagers and their caregivers^{15,16,17,18,19}.

Less than half of the adolescents of both groups responded "yes" to the question whether they had read about sexual and reproductive rights. In HIV-positive group, the most used source of information was the Internet, and in the HIV-negative group, it was the materials from the Ministry of Health. If HIV-positive adolescents have regularly attended both health services and schools, why have the materials of the Ministry of Health hardly constituted as a source of information for them, especially for such a subject? Teenagers from the HIV-positive group read less, but received more guidance than the teenagers in the HIV-negative group. More than half of the adolescents of both groups paradoxically had no opinion or did not know about these issues, when asked about their opinion on these rights.

The results in HIV-positive group related to health and sexual, and reproductive rights showed that despite existing guidelines and materials, the content, approaches, and reflections directed to these groups need to be reviewed and the health professionals need to be trained. Patients infected with HIV have major challenges to overcome during their adolescence such as learning how to deal with their biopsychosocial transformations, with their chronic disease, and with stigmas and prejudices associated with it. In this scenario, the exercise of sexual and reproductive rights is an important tool in relationships and self-care. On the other hand, the responses of HIV-negative adolescents also revealed the need to improve information on these issues and to reduce the prejudice and stigma associated with the health and rights of HIV-positive adolescents.

The opinions of the adolescents related to the following question showed significant differences: "Should adolescents infected with HIV relate to their 'date'/boyfriend or girlfriend in the same manner that adolescents who are not infected with HIV?" and "Why?" Among those who responded that the relationships were similar, thoughts and behavior of the HIV-positive group indicated lack of knowledge of risk and protective factors, of sexual transmission of HIV, and of self-care and care for the partner. Another aspect may be the willingness or necessity of these adolescents to deny their illness and the reality imposed by the disease, so as to simply live and feel like teenagers. We also noticed that the feeling of invulnerability and the "magical thinking" (abstract thought) predominated in both genders, regardless of age and education.

The study by Benincasa et al.²⁰ showed the importance of psycho-emotional characteristics of the adolescents, a finding that was similar to this study. They identified the predominance of the "magical thinking," the belief that something bad could hardly happen and a feeling of immunity against the risks involved in unprotected sex. They noted that although the majority had knowledge about the means of transmission of STDs and prevention, the information was often incorrect or inconsistent. Many of the findings of that study were similar to those found in the HIV-positive group of this study. Also in HIV-negative group, some opinions pointed to the "strength" of the adolescence, as if it could be stronger than the disease. Studies have found that the lack of opportunity for young people to reflect on the risks to which they are daily exposed prevents them from reviewing their opinions, habits, and in finding possible protective solutions for such risks. Although they have heard about the potential damage caused by unprotected sex, they reported that they never thought about how much their attitude left them exposed²¹.

It is necessary to develop professionals to prepare educational programs for a sexual life that includes pleasure, self-care, and care for others. The information should include sexual development, the emotions, the types of sexual practices, the prevention of pregnancy, and the discussions on the STDs, and it should mainly empower adolescents to negotiate the use of condom, by listening to them without judgment, and making them confortable to expose their conflicts, fears, and doubts. It is also important to develop their self-esteem, resilience, body image, and affectivity^8,9,22. With regard to the 24 HIV-negative adolescents who responded that relationships were not similar, the prejudice and lack of knowledge of these adolescents were evident. Other studies have also found that young people generally think about AIDS by the biomedical aspect and associates HIV infection with the lack of concern with prevention and the irresponsibility of others^22,23.

The frequency of "hook up" and "steady relationship" was a little higher in HIV-negative group, but the groups were similar in age with regard to onset of sexual activity and the use of condoms in all sexual intercourses. A study involving students also showed that girls initiated sexual activity between 15.2 and 16 years of age and boys between 13.9 and 14.5 years of age^24,25.

Abramovay and colleagues found that young people justify the lack of prevention in a steady relationship by the trust in their partner. They reported that condoms should be used only when you do not know "very well" the other person and also mentioned the sensation of decreased pleasure while using them²⁵. The reasons for nonuse and negotiation about condoms were related to a number of factors that are still present nowadays, representing a challenge to public health. Despite the information available on AIDS and the free distribution of condoms by the Unified Health System (SUS) since 1994⁶, there are a considerable number of young people, infected or not, who do not use condoms regularly. In relation to the responses about the habit of getting condoms, more than half of the adolescents reported they were not used to getting condoms. How do they use condoms in all sexual intercourses but are not accustomed to picking them up? Did they only provide a socially acceptable response while reporting the use of condoms in all sexual intercourses? Therefore, understanding the challenges related to the formation and maintenance of intimate and romantic relationships can be used to improve the public health efforts to reduce HIV transmission, particularly if this population is able to disclose their status to their partners with less suffering²⁶.

With regard to the guidance received, HIV-positive adolescents received less guidance on emergency contraception. This finding is alarming, because adolescents and caregivers regularly attended the health services, and such orientation is part of the recommendations of the Brazilian Society of Pediatrics and the Brazilian Federation of Societies of Obstetrics and Gynecology since 2004²⁷.

The results showed that the physical, cognitive, and emotional characteristics that accompany adolescence and the brain transformation²¹, seem to overcome the serious and chronic aspect of a disease like AIDS. Chronic diseases of long evolution impose to patients and caregivers a suffering that surpasses symptoms, restrictions, and treatments. This may interfere in adolescents' feelings, making them more vulnerable to emotional stress. To develop or strengthen skills and knowledge in these adolescents is a protective factor for their quality of life^4,10,28, and the exercise of sexual and reproductive rights is an important means to acquire the skills to take care of their sexual and reproductive health throughout life^10,14,28.

It is necessary to conduct more research on affective and sexual behaviors that allow developing various prevention strategies for the health services that care for adolescents infected with HIV, strengthening their role in the daily coping with the disease. Thus, it is mainly the responsibility of the caregivers and health professionals to increase the awareness about AIDS as a serious disease that impacts romantic and social relationships and self-care, without developing a sense of inferiority in relation to the HIV-negative adolescents.

CONCLUSION

The lack of knowledge of the adolescents on reproductive health is greater than the lack of knowledge on sexual health. HIV-positive adolescents expressed more opinions on the sexual and reproductive rights, received less guidance on emergency contraception, "hooked up" and dated less than HIV-negative adolescents, but started the sexual life in the same age range as the HIV-negative group (approximately 15 years of age). Despite reporting the use of condoms, they were not accustomed to picking them up. The knowledge about sexual rights and sexuality, and the guidance provided for both groups of adolescents, did not seem to be sufficient to stimulate protective sexual attitude for STDs. It is necessary to conduct more research on affective and sexual behavior that allows developing prevention strategies, strengthening the skills to care for sexual and reproductive health.