Inconsistent condom use between serodifferent sexual partnerships to the human immunodeficiency virus*

Objective: to analyze predictors of inconsistent condom use among HIV-positive people with sexual immunodeficiency virus serodifferent sexual partnership. Method: cross-sectional, analytical study with a consecutive non-probabilistic sample consisting of people living with the human immunodeficiency virus with serodifferent sexual partnership and who were in outpatient clinical follow-up. Data were collected through individual interviews guided by a semi-structured questionnaire and subsequently analyzed with bivariate analysis and logistic regression. Results: Seven variables were independently associated with inconsistent condom use. Schooling less than 11 years of schooling (4.9 [2.4-10.1]), having multiple partnerships (5.0 [1.3-19.6]), using alcohol (2.1 [1.1 -4.4]) or other drugs (2.8 [1.2-6.3]), do not receive advice from a healthcare professional (2.0 [1.1-3.9]), have no knowledge of treatment as prevention (3.0 [1,2-6,9]) and not knowing that undetectable viral load reduces the risk of human immunodeficiency virus transmission (3.8 [1,1-13,7]) were predictors for inconsistent condom use. Conclusion: The study showed that psychosocial factors interfere with consistent condom use between serodifferent partnerships. Thus, it is highlighted that there is a need for comprehensive interventions that include the integration of clinical and psychosocial care.


Introduction
The scientific and technological advances regarding the health of people living with HIV (PLHIV), especially in the therapeutic field, with the advent of antiretroviral therapy (ART), caused changes in the life expectancy and perspective of these individuals (1)(2) .
Thus, the framing of human immunodeficiency virus (HIV) infection as a chronic disease, from access to ART, generated a new paradigm (3) with implications related to the integral health care of these people, since initially, the concern of health services was only to contain the infection.
These changes made it possible for PLHIV to reconstruct their life projects in various aspects, especially in the affective-sexual context, with the establishment of new relationships with sexual partnerships (4) , including HIV seronegative.
HIV serodifferent couples -when one partner is HIVpositive and the other HIV-negative (5) -have specific vulnerabilities and are at greater risk of becoming infected with HIV (6) .
In Brazil, despite efforts to interrupt the chain of transmission obtained through the provision of effective antiretroviral therapy, there is still a significant portion of PLHIV that has not reached undetectable viral load (VL), which is one of the factors considered most important for reducing sexual transmission of HIV (7) .
The UNAIDS Joint United Nations Program on HIV / AIDS "cascade" of care projects, by 2030, an ambitious target for the treatment of HIV / AIDS in which 90% of people are diagnosed with HIV; 90% of these people get treated and 90% of them reach viral suppression (8) .
Data related to the cascade of continuous HIV care in Brazil showed that by the end of 2015 there were 827,000 PLHIV in the country of which 715,000 (87%) were diagnosed; 95% of the diagnosed (677 thousand) had been linked to some health service and 83% of the linked (565 thousand) were retained in this service; 80% of those retained (455 thousand) were on ART and only 50% of those on ART (410 thousand) had suppressed VL (9) .
Thus, it is noteworthy that it is necessary to advance the fight against the AIDS epidemic in Brazil, because challenges still persist for the approach of sexuality and sexual behavior in the continuous care of PLHIV.
Historically, efforts to prevent infection have focused on reducing the risk of HIV transmission among seronegative individuals or those with unknown serological status and minimizing the needs and important role of PLHIV (10) as if the discovery of infection by itself would ensure changes in the preventive practices and behaviors and vulnerability they faced.
Measures and strategies to prevent sexual transmission of HIV have changed over the course of the epidemic mainly due to scientific advances in the world.
The findings defined new forms of prevention that were referred to in Brazil as "combined prevention" (10) .
It is the association of behavioral, biomedical and structural intervention strategies (10) focusing on reducing the transmission of HIV infection in various sectors, as it is known that a single prevention strategy is insufficient to control multiple HIV epidemics in the world and in Brazil (6) .
It is understood that, in the context of combined prevention, strategies aim to reduce the adherence gaps present in the use of classic preventive methods in isolation, such as the use of only male or female condoms as a preventive method.
To this end, the Ministry of Health has drafted the Combined Prevention Mandala, which outlines all possible strategies that may be effective for preventing HIV infection (11) . Thus, during consultations with Specialized Care Services (SCS), users are advised that no single method of prevention can reduce HIV infection (11) .
Condoms are considered an important component of the combined approach to HIV prevention and, when used consistently and correctly, are highly effective at preventing sexual transmission of the virus and other sexually transmitted infections (STIs) (11) .
In Brazil, condoms are freely distributed by the Unified Health System (UHS) and are a safe, low-cost barrier method with no adverse effects. It should be stimulated among PLHIV in combination with other methods such as treatment as prevention (TPT), pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) (11) , as inconsistent use increases the risk of HIV reinfection, just as exposure to STI increases the infectivity of the virus and therefore its transmissibility (12) .
In this sense, inconsistent male condom use has been described as prevalent among PLHIV with different types of sexual partnerships -both regular and casual, with negative HIV status or unknown HIV status, in different regions of the world (13)(14)(15)(16)(17)(18)(19) .
However, according to the World Health Organization (WHO), most studies on serodifferent couples have been conducted in sub-Saharan Africa, and knowledge gaps exist in other regions of the world (5) , resulting in insufficient emphasis on providing counseling for couples and supporting testing of HIV-positive partners.
In Brazil, some studies (20)(21) addressed the relationship of PLHIV in a serodifferent partnership and the use of the male condom, however, they were limited only to evaluate the use and not the factors associated with it. Reis RK, Melo ES, Fernandes NM, Antonini M, Neves LAS, Gir E. Therefore, the aim of this study was to analyze the predictors of inconsistent male condom use among HIVpositive people with HIV-negative sexual partnership.

Method
This is a cross-sectional and analytical study that was conducted in the five Specialized Care Services (SCS) in a city in the interior of São Paulo. The sampling plan adopted was by simple random sampling in which prevalence parameters were selected by estimating that 62% of people living with HIV have an active sex life after diagnosis, as described in another study conducted in the municipality (22) , relative error of 10% and significance level of 5% and a very large total population (N = 10,000, for example), which indicated the need for a sample size of 235. However, to reach this Inconsistent condom use was defined as "yes" for those participants who reported that they never or sometimes used condoms (versus "no", ie "always used condoms") for the past six months.
Data was statistically analyzed using IBM® Statistical Package for Social Sciences (SPSS) software, version 23, and R (R Core Team software, version 3.4.1) software.
Descriptive statistics were performed to characterize the participants and analytical to verify the association between the study variables through the chi-square test. To assess the influence of independent variables on inconsistent condom use (yes / no), logistic regression analysis was used. The category "yes" was adopted as a reference in all cases. For the analysis, a significance level of 5% (α = 0.05) was adopted.
The study was submitted and appreciated by the

Results
The study included 286 PLHIV who had a serodifferent sexual partnership, with an average age of 41.2 years, ranging from 18 to 73 years. Table 1 shows that the sample consisted predominantly of men (68.6%) and of these 37.8% were men who have sex with men (MSM). It was found that the majority (51.4%) of respondents had elementary education and about 67.1% were in the formal or informal job market.    for inconsistent condom use, as shown in Table 5.

Discussion
In Brazil, there is a lack of official epidemiological and behavioral data on HIV serodifferent couples, in varied contexts of the relationship, either with fixed and / or casual partnerships. This fact highlights its invisibility in services, health policies, as well as between social movements and researchers (23)(24) .
In this study, it was found that few people (29%) reported inconsistent condom use with negative or unknown HIV status, which may be corroborated by other investigations that found rates of 28.7% respectively (22) and 20.7% (25) of inconsistent condom use among PLHIV.
In fact, although the prevalence of risky sexual behavior decreases after the discovery of HIV infection (17) , Studies conducted among PLHIV reported inconsistent condom use with HIV-negative or unknown sex partners in different regions of the world (15)(16)(17)(18)(26)(27)(28) .
In this sense, it is noteworthy that, in clinical practice, in addition to all the assistance already provided, one should also pay attention to the investigation of behaviors and practices beyond the inconsistent use of condoms, as this is fundamental for the identification of individuals in risk of nonadherence or suboptimal adherence to effective preventive strategies. Other studies have also investigated this issue that may contribute to the risk of HIV transmission to HIV-negative sexual partnership and also reinfection by HIV or acquisition of another STI by HIV-positive partners (27)(28)(29)(30) .
The results indicate that having a lower educational level was a predictor for inconsistent condom use in the individuals who were part of the study. These results resemble those of other studies, which revealed that a higher level of education is associated with regular condom use (31)(32) . In addition, another study showed that as the level of education increases, the chance of engaging in risky sexual practices decreases (4) .
Low education conditions access to information and the ability to assimilate and understand the guidance received in health services and directly interfere with health behavior and the possibility of adopting protective practices for themselves and others (33) .
Better access to information, understanding and awareness about preventing sexual transmission of HIV can foster sexual negotiation and increased condom adherence.
In this study, it was observed that having a casual partner was associated with inconsistent condom use (p = <0.001). And PLHIV who have both fixed and casual partnerships simultaneously are 5.0 times more likely (CI = 95%, 1.3-19.6, p = 0.019) to engage in unprotected sex compared to those who have only single and fixed partnerships. This may be related to the fact that those who have had multiple sexual partners may not disclose their status to their partners, which was also described in a study in Ethiopia (34) . Thus, the type of bond and the affective- A multicenter study of both heterosexual and homosexual serodifferent couples identified 11 cases of HIV transmission among people who had casual partnerships outside of a fixed partnership relationship (35) .
Thus, observing HIV transmission outside the relationship with fixed partnerships increases the importance of counseling nurses assessing types of partnerships and inconsistent condom use (13) .
Including information about sexual partnerships in risk management and counseling will help to better understand individual risk profiles and to plan appropriate intervention strategies for HIV prevention.
Another predictor found in this study was that using alcohol during sexual intercourse is 2.1 more likely to have unprotected sex with an HIV-serodifferent sexual partnership. This result is in line with several other studies in the literature that have shown the association between alcohol use and risky sexual behavior among PLHIV (36)(37) . Among serodifferent partnerships, this behavior is particularly worrying, mainly because it exposes seronegative partners to HIV exposure.
Alcohol has been associated with disinhibition in which people may be more likely to engage in riskier sexual behaviors (38) . In fact, alcohol use is considered a risk factor for HIV infection because of its interference with adherence to prevention methods such as condoms, impaired ability or willingness to be assertive when negotiating condom use with a resistant partner and decreased perceptions of possible negative consequences of condomless sex (38) .
Systematic review investigating the effects of alcohol consumption on unprotected sexual intentions showed that participants who consumed alcohol were less likely to perform communication and sexual negotiation skills (39) .
In addition, alcohol and other drug use is also associated with poor adherence to ART, which may lead to a higher risk of therapeutic failure and, consequently, to sustained non-suppression of viral load (40)(41)(42) .
Therefore, interventions directed at the association between alcohol and sexual behavior should highlight the negative influence of alcohol on decision making for protected sex, particularly with occasional partners (43) .
For this, health services should offer prevention programs that address coprevalent conditions (44) , transmission (46) .
In Brazil, a study conducted in the Federal District, which described the perceptions of PLHIV in the  (13) . Reducing condom use increases the risk of exposure to STIs and HIV infectivity and, therefore, their transmissibility (14) .
In the context of combined prevention, the male condom remains a method of protection against STI and HIV infection, and it remains critical to expand its access to the entire population as a priority action (11) , especially for people at risk of exposure to HIV and those who are in HIV serodifferent partnership (6) .
To this end, it is necessary to overcome the exclusively rational logic of prevention work, which is reflected in a purely prescriptive attitude of condom use, also called "latex fundamentalism", in which it is imposed without the necessary dialogue and reflection for overcoming the difficulties of its use (21) .
More innovative approaches that dialogue with the autonomy of PLHIV and their sexual partnerships are needed.
Therefore, considering that prevention options for HIV-serodifferent couples are expanding and becoming more widely available, educational interventions can be a potentially useful tool to help them explore options, make decisions, and identify prevention methods that are best suited to fit their reality and life context (49) and can help PLHIV not only recognize the importance of the male condom, but also to be informed about the existence of other methods that can be combined with the same, enabling them to manage their own risks (11) .
Finally, it is noteworthy that this study had some limitations, such as the non-random sample and the fact that information on sexual behavior and condom use was obtained through the patient's report, which may lead to a bias of answer, since it seeks to report what is considered "more correct" than it is actually practiced, which may lead to an underestimation of the risk.