Aspects that influence the self-care of patients living with human immunodeficiency virus *

ABSTRACT Objective: to analyze aspects related to the increase or decrease of self-care in patients living with human immunodeficiency virus treated in a specialized outpatient service. Method: analytical cross-sectional study with 135 patients aged 18 and over, of both sexes, who are followed up on the service. The independent variables and outcomes were collected from the nursing consultation instrument, whose theoretical reference is the Orem’s Theory. The data were analyzed by parametric approach. Relationships or differences were considered significant if p <0.05. The analysis was done with SPSS v21.0 software. Results: most participants were male (56.3%), with a mean age of 42.1 years. Patients who needed to conceal the diagnosis had less self-care (β = -0.72 (-1.38, -0.06), p <0.031). The chance of performing self-care decreased with increasing age (OR = 0.93 (0.89, 0.97), p <0.003). On the other hand, patients with a permanent partner had a higher chance of performing self-care (OR = 3.46 (1.27, 9.46), p <0.015). Conclusion: aspects related to the increase or decrease of self-care in patients living with human immunodeficiency virus were evidenced. However, further studies are necessary to emphasize the analytical character of the self-care of these patients.

The criterion that defined the patients for the study sample was the attendance on the days that the nursing consultation happens to the PLWHA.
However, in order to estimate the minimum differences that could be detected with n = 135 respondents, Alencar RA, Parenti ABH, Lopes CC, Ramos FT, Ciosak SI.
we considered simple random sampling, with type I error equal to 0.05 and type II error equal to 0.20, absence of confounding, standard deviation of the outcome equal to 2, "allocation" ratio equal to 1:1 for the binary independent variables and normality for the distribution of the outcome. With these assumptions, it was observed that the sample of 135 interviewees allowed detecting significant differences between two categories of a binary variable above a point.
The nursing consultation has taken place in the specialized outpatient clinic of infectology since October 2013. It is developed by one of the authors and by students of the nursing undergraduate course who undergo training in this service, under the supervision of the researcher. In order to perform the nursing consultation, an instrument was constructed that had as theoretical reference the Orem's Self-Care Theory. The construction of this instrument was based on authors who also perform the nursing consultation with PLWHA in other services, using instruments with the same theoretical framework (7-9) .
The data collection was carried out between October 2014 and June 2017, in one of the outpatient clinics that take place on Wednesdays and has approximately 200 PlwHA enrolled. The data were collected on the same day of the nursing consultation.
Four people refused to participate. In order to achieve the objective of the present study, it was necessary to elaborate an instrument with questions taken from a larger instrument, the nursing consultation, as quoted above. The consultations were carried out in a private environment, allowing the secrecy and confidentiality of the information obtained. It should be emphasized that in order to avoid repetition of the participants, all the PLWHA who perform the nursing consultation were registered in an Excel spreadsheet. Thus, before including a new participant, it was verified whether the participant was already part of the study.
The study included patients aged 18 years and older, of both sexes, with clinical and cognitive conditions to answer the study questions. Facing the absence of a parameter to establish the aspects related to the increase or decrease of selfcare in the PLWHA, the Universal Self-Care Score was elaborated consisting of the simple sum obtained from the answers given to 12 items that express universal self-care. Therefore, the score ranged from 0 to 12 points, and the higher the score, the greater the selfcare. The Health Deviation Self-Care Score was also elaborated, ranging from 0 to 4 points. The higher the score, the greater the self-care. Developmental Self-  Table 1  Few people had residence with garbage collection (3%), running water (4.5%) and sewage network (4.5%). However, 34.9% did not have a health service close to their home.  The mean time of diagnosis was 8.3 years (standard deviation (SD) = 7.1) and the mean duration of treatment was 7.3 years (SD = 6.7).

Results
Alencar RA, Parenti ABH, Lopes CC, Ramos FT, Ciosak SI.   The Self-Care Score was calculated considering 12 items and each item received the value of one point.
The mean self-care score was 6.3 points (SD = 1.8), minimum of 1 point and maximum of 10 points.      to the maintenance of their health (2,9) , leading the individual to understand that self-care is something that must be learned for their own benefit (14) .
A study conducted in Iran has shown that providing adequate support and services, as well as a positive attitude of society towards HIV-positive women, can contribute to adherence to self-care in young women with HIV (1) .
In contrast, HIV stigma can have numerous repercussions, such as loss of friendships and family ties, dismissal from school and occupation, and denial of health care (15)(16) . HIV stigma is a process of devaluation of people living with or who are associated with HIV infection and may be related to the non-disclosure of their HIV status (4) .
As found in the present study, concealing the diagnosis leads PLWHA to perform less self-care. This fact can be justified by the stigma of HIV that leads many PLWHA not to seek a health service to perform the treatment (17) . In the world, due to the stigma, one third of PLWHA do not reveal their positive serology for HIV to others (15) .
It was also demonstrated in this study that age was a variable that negatively influenced the performance of self-care. Study shows that elderly people living with HIV/AIDS for almost 30 years and are part of the preantiretroviral therapy group have developed their own strategies for increasing resilience, including self-care behaviors, such as dedication to health and involvement in medical care. In contrast, the group of elderly people living in the post-antiretroviral therapy era understood self-care as remaining adherent to the therapy and thus abstained from good health behaviors (15) .
However, considering that adherence to antiretroviral therapy is a part of actions that demonstrate self-care, a study in Tanzania found that non-adherence to antiretroviral therapy was associated with younger age and unemployment (12) .  (18) .
After the logistic regression, the present study revealed that PLWHA who present a change in sexual life after HIV diagnosis has a greater chance of making changes in their lifestyle. However, a study shows that HIV diagnosis leads PLWHA to have sexual dissatisfaction (19) . The persistence of HIV-related stigma and discrimination may be a barrier to the sexual life of PLWHA, which has a greater effect on the desire and frequency of sexual activity than on the discontinuation thereof, a fact influenced by HIV/AIDS stigma, and moral and religious values (20) .
However, it is believed that knowing aspects that may influence the performance of self-care contributes to the performance of the professionals who assist PLWHA.
The importance of self-care measuring instruments is emphasized and can be used as a methodological tool that assists in the evaluation of patients' responses to the performance of their self-care.
The study has as limitations the fact that the participants were recruited in an specialized outpatient service, which tends to present samples of PLWHA that already perform better their self-care, since the recruitment occurred during the patients' attendance to nursing consultations, which demonstrates that these patients care about their health. Therefore, the presence of the patient in the follow-up visit shows a greater performance of self-care by these subjects. The results should not be generalized to other populations and regions of the country.

Conclusion
This study evidenced aspects related to the increase or decrease of self-care in PLWHA, which are attended in a specialized outpatient service. Among these aspects, it should be noted that PLWHA who needed to hide the diagnosis of HIV/AIDS had less selfcare. The chance of self-care decreased with increasing age. On the other hand, it was found that PLWHA that have a permanent partner have a greater chance of performing self-care.
The use of Orem's Theory made it possible to identify the increase or decrease of self-care of PLWHA.
However, other studies are necessary to emphasize the analytical character of the self-care performance of these patients.