Vulnerabilidade ao HIV / Aids de pessoas heterossexuais casadas ou em união estável Vulnerability to HIV / AIDS in married heterosexual people or people in a common-law marriage

MÉTODOS: Estudo exploratório realizado no Distrito Federal, entre 2001 e 2002. Foram entrevistados 200 homens e mulheres heterossexuais (18 e 49 anos) em união civil ou estável, divididos em dois grupos: (I) 50 casais abordados em locais públicos, e (II) 100 usuários de Unidade Básica de Saúde, sendo 50 mulheres e 50 homens. O instrumento para coleta de dados consistiu de questionário semi-estruturado acerca de características demográfi cas, socioeconômicas e comportamentais dos entrevistados, com 38 perguntas, das quais duas eram abertas.


INTRODUCTION
In Brazil, although there is tendency for stability of AIDS incidence, cases of HIV infection in individuals over 35 is persistently growing. a The epidemic in the country is becoming female and heterosexual, associated with the increase in incidence among those with greater socioeconomic vulnerability. In the Brazilian Federal District (DF) 5,599 cases of AIDS have already been reported, with an incidence of 19.4 cases per 100,000 inhabitants in 2006, the fi fth largest in the country. a In the last two decades, HIV/AIDS has been characterized by a dynamics of continuous transformations, raising technical and ethical dilemmas to face it and to chose the best preventive strategies for its control. 2 Changes in epidemiological approaches (from "risk groups to risk behaviors" and, later to "vulnerability") allowed to pay closer attention to society as a whole and not only as isolated groups. However, this change in viewing society was not able to make an effective change regarding the stigma associate with the disease. 10 Maybe this is because AIDS was acknowledged as an "epidemic of the immorality", since initially it was associated with people and behaviors that were considered as deviant. "Immorality epidemics" is a concept developed by Guilhem 10 on the social perception of HIV/AIDS connected with metaphors such as "the gay plague" and with people initially suffering from the disease, such as prostitutes and drug users. In this sense, the moral history of AIDS enabled to build the idea that it was an "alien disease" belonging to "the others", belonging to those morally distant. However, the thin between "me" and "the other" arises when the infection goes beyond the limits of the public and the private, reaching up the sanctity of family and marriages. 12 Diffi culties regarding understanding the context of personal interactions still remain, especially of the factors that interfere in establishing and keeping a couple relationship and affective-sexual ties. 12 Therefore, to assess HIV/AIDS prevention among heterosexual in a stable relationship faces the obstacle of how much these people are attached to beliefs and moral values associated with marriage; in the Western idea, these values present attributes such as love, faithfulness, respect, trust, and sharing. 3,10 There is an assumption that when these values of the everyday life are taken upon, men and women are protected from the risk of being infected.
Diffi culties coming from the hierarchization of power in affective-sexual relationship, suppressing effective communication channels on sexuality between partners result in a justifi cation for having unsafe sex in stable relationships. 10 However, the current setting of AIDS epidemics confi rms that this behavior is failing and is preventing refl ection on the sexuality of men and women.
The different levels and nature of individual and collective vulnerability regarding infection, getting sick, and dying from HIV, require a broad questioning on the cultural standards traditionally accepted. 7 Vulnerability is understood as: "the situation resulting from a set of individual factors (biological, cognitive and behavioral), programmatic (prevention, education, control, and care programs, as well as political will), social (related to economic and social issues) and cultural (submitting to moral standards and beliefs, hierarchies, power relations, and gender issues), interdependent, and with mutual infl uence, taking up different weight and meanings over time and determining the level of susceptibility of individuals and groups regarding health issues". (Guilhem, Few are the studies on the perception and preventing attitudes towards HIV/AIDS of men and women in stable heterosexual relationship, its interface with moralities regarding marriage and roles taken up by partners. However, recent epidemiologic data show the need for an urgent approach on the heterosexual part of the population.
The objective of the present study was to assess the knowledge on prevention and perceptions regarding HIV/AIDS of men and women married or in a common-law marriage.

METHODS
An exploratory study was conducted in a population of men and women from 18 to 49 years old, living in the Brazilian Federal District, between 2001 and 2002 that were either married or in a stable relationship. A convenience sample was used, made up by 200 individuals divided into two groups: Group I was formed by heterosexual couples approached in public places (malls, clubs and fairs) using the snowball technique, totaling 50 pairs. The technique was to ask those surveyed names of couples, friends, and relatives to take part in the study, minimizing difficulties regarding recruiting and approaching people for interviews. 11 Group II was formed by 100 unrelated users (50 men and 50 women) from a Basic Health Unit.
The instrument for data collection was a semi-structured questionnaire with 38 questions, two of which were open. There were three blocks of questions regarding demographic, socioeconomic and behavioral features of the interviewees. On the two open questions, respondents were asked to report if they used condoms, the reasons for that and the self-perception of HIV/AIDS risk accepted in a stable relationship. Closed questions were validated in previous surveys. 10,b There was no standard regarding the number of answer options in each question. Questions were grouped in intervals or simple categories. Univariate statistical analysis was performed using chi-square test and Fisher's exact test, with a 5% signifi cance level using EpiInfo 6.0 program. Answers to the open questions were used to exemplify some data.
This study has been approved by the Ethical Research Committee of the Health Secretariat of the Brazilian Federal District (CEP-SES/DF). All participants gave their written consent. Table 1 presents sociodemographic characteristics and length of affective-sexual relationship of individuals according to the group.

RESULTS
Regarding knowledge on HIV/AIDS transmission, sexual relationship was identifi ed as a source of infection for almost all individuals ( Table 2). Transfusion and using non-disposable syringe/needles were reported in greater proportion by group I than group II (p<0.001 and p=0.046, respectively). Living with people with HIV and kissing on the lips were also mentioned as ways for transmitting the virus (Table 3), this last one was more signifi cantly mentioned by Group II (p=0.005).
The use of condoms was equally reported as a preventive measure by both groups (95%). Caution regarding blood transfusion and use of disposable syringe/needles were proportionally more commonly reported by Group I than Group II (p<0.001 and p=0.002, respectively) ( Table 2). In the open questions, most men (20 from group I and 10 from group II) reported not using condoms with their partners because it would be incompatible with having a fi xed sexual partner, as illustrated by this report: "I see no need. I only have one partner". Among women, the most frequent justifi cation (24%) was trust in their partners, as shown by this report "We have a relationship based on trust and love. I am taking the risk". Only one woman reported the use of condoms to prevent sexually transmitted diseases, such as AIDS. Other arguments included: use of another contraceptive method, the partner dislike for using condoms, and previous HIV test, which made the relationship safe.
About the self-perception on the risk of getting HIV, because they were in a stable affective-sexual partnership, 71% of women answered affi rmatively, compared to 44% of men. The following reports show this

DISCUSSION
Limitations of the present study are: different selection processes, use of convenience sample, that is, which is not representative of the general population. However, because it was an exploratory survey, the study aimed at making more explicit the problem, favoring understanding of the issue.
Group I presented greater schooling and income. The form of sexual transmission of HIV is equally known by the two groups, whereas the other aspects demonstrated that the group with lower schooling had less information.
Parker & Camargo 18 (2000) highlighted that AIDS has been directed to the less favored segments of society, and to Fernandes, 4 (1998) that fact that the disease reached more and more people with lower schooling, is due to the reduced access to information. The same ways of transmission and prevention among women in the present study were observed by Grimberg 9 (2001). Vieira et al 20 (2000) observe that men had knowledge on AIDS transmission, and 97% said that sexual relation is a way of transmitting HIV.
The infl uence of the environment in which individuals were submitted to questionnaires can be noticed by the answers on the use of condoms. Individuals of the survey approached in the health unit (group II) may have mentioned the use of condoms more frequently because of the doctor's power, 6 as a way to meet the interviewers' expectations.
Restricted use of condoms was common to the groups, both in marital and extramarital relationships. Historically, the use of condoms was associated with prostitution, promiscuity, and extramarital relations, Care with blood transfusion 50 9 Use disposable syring/needles 59 38 Regarding sources of information on HIV/AIDS, there is the need for the effective participation of the media in education intervention regarding HIV/AIDS prevention, because they have a signifi cant role on the construction of social and individual values. 19 Meyer et al 15 (2004) considered that television adds on HIV/ AIDS reproduce or broadcast multiple gender representations, unstable and confl icting, excluding those who are not identifi ed in these descriptions. Gonçalves & Varandas 8 (2005) propose a bioethical agreement with the media so that moral dilemma related to AIDS can be suitably dealt with.
Schools and teachers appear as important channels to spread information. According to data of the Ministry of Education and Culture 16 (2005), 60.2% of the schools in the country have actions to prevent sexually transmitted diseases and AIDS. However, it is disturbing that only 29.3% of the teachers are skilled for it. 16 The increased number of individuals from Group II that acquired knowledge on the disease in health units is due to the fact that interviews with these subjects were performed in a Basic Health Unit, becoming, therefore, a selection bias.
For Berquó, 1 (2000) the difference between one night stand among genders is a result of different views on the need of sexual-affective relations. Female sexuality is still seen as limited to its reproductive function, and male sexuality is undisciplined and incoherent. a For Macklin 14 (2003), women are more vulnerable to AIDS due to their social and economical place in society, hindering them to negotiate the use of condoms, discuss about fi delity, and leave relationships that put them at risk. Feelings of helplessness are noticed and also dilemma reported by women that express a fatal conception of the disease, against which nothing can be done.
Vieira et al 20 (2000) pointed out the risks to which men are exposed to, since many have several partners and do no use condoms. As previously described in a report, there is still the idea that AIDS is limited to certain groups, being a disease outside their context. Thus, preventive measures are not adopted by these individuals that do not see themselves as risk group.
Additionally, men only feel they are in risk of getting HIV outside the household environment.
HIV/AIDS is still seen as "street disease" or "disease of the others". 10 Therefore, there is little discussion on the issue among couples. Gender representations are observed on the speech of the interviewees, as well as cultural values regarding love and fi delity, expressed, for example by the "myth of the romantic love" 3 as an essential attribute of happiness. This romantic and eternal view of love may make couples stop using condoms and believe that they are really protected against HIV/AIDS.
Heterosexual men and women interviewed in the present study, married or in common-law marriage, have important knowledge on HIV/AIDS transmission, however, their marital perceptions express the culture they are inserted in regarding gender roles and hierarchization of the affective-sexual relationship. This may explain restriction to the adoption of preventive behavior, making them vulnerable to HIV infection.
There are categories of vulnerability to HIV infection in the present study. Preventive behaviors, even those known by individuals, are not practiced in most situations (individual vulnerability). Income and gender inequalities interfere both for acquiring information and for decision making in AIDS prevention (social vulnerability). Culturally established male and female role interfere considerably on the decision about HIV/AIDS prevention by individuals (cultural vulnerability).
Therefore, there is need for empowering couples, understood as the expansion of freedom of choice and ability to act on the resources affecting their lives. 13 Empowering is an essential tool for overcoming gender inequality. 13 Prevention policies towards HIV/AIDS must take into account that the epidemics lies on inequalities, affecting populations heterogeneously. 5 Stigmas, taboos, and prejudice regarding the disease establish a family and social organization in which speeches of power, especially in marital relations, infl uence collective answers to the epidemics. Campaigns geared to couples in stable relationships are necessary and must consider social values that hinder the adoption of preventive practices of individuals. It is imperative, therefore, that those in charge of health area use the media consciously to control the epidemics, enlarging the individual, social, cultural, and political dimension of the subjects.