evAluAtion oF selF-esteem in people livinG WitH Hiv / Aids in tHe citY oF RibeiRão pReto , stAte oF são pAulo , bRAZil

This cross-sectional study aimed evaluate self-esteem individuals with HIV/AIDS and relate it to sociodemographic and clinical factors. 331 people with HIV/AIDS, who were assisted at two referral centers in a city of the interior of São Paulo state between 2007 and 2010, participated of the study. Data were collected through individual interviews, using self-esteem scale of Rosenberg. 167 (50.5%) of the respondents were male, mostly between 30 and 39 years old (42.0%). Considering the variables related to sexuality, 82.2% reported being heterosexual and 84.6% referred to have been infected by sexual intercourse. Regarding the evaluation of self-esteem, the avarage score was 25.25. The negative impacts whether physical, social or emotional of HIV infection revealed the need for health services prepared to offer comprehensive care for people with HIV/AIDS, valuing the psychosocial factors. descRiptoRs: Acquired Immunodeficiency Syndrome. Self-esteem. Self-image. evAluAciÓn de lA AutoestimA en peRsonAs Que viven con el viH/sidA en el municipio de RibeiRão pReto, estAdo de são pAulo, bRAsil Resumen: Este estudio transversal objetivó evaluar autoestima individuos con VIH/SIDA y relacionarla con factores sociodemográficos y clínicos. 331 personas con VIH/SIDA, asistidas en dos centros de referencia en una ciudad del estado de São Paulo entre 2007 y 2010, participaron del estudio. Datos fueron recolectados a través de entrevistas individuales, utilizándose la escala de autoestima de Rosenberg. De los encuestados, 167 (50,5%) eran hombres, en su mayoría entre 30 y 39 años (42,0%). Con referencia a variables relacionadas con sexualidad, 82,2% reportaron ser heterosexual y 84,6% informaron de que habían sido infectados por relaciones sexuales. En cuanto a la evaluación de autoestima, la pontuación media fue de 25,25. Impactos negativos sea físicos, sociales o emocionales de la infección por el VIH revelaron la necesidad de servicios de salud preparados para ofrecer una atención integral para personas con VIH/SIDA, valorizando factores psicosociales. descRiptoRes: Síndrome de Inmunodeficiencia Adquirida. Autoestima. Autoimagen. 1049


INTRODUCTION
After the introduction of the Highly Active Anti-Retroviral Therapy (HAART), infection by the Acquired Immunodeficiency Virus (HIV)/ AIDS became a chronic condition.Currently, people living with HIV/AIDS have the opportunity to live with the disease rather than for the disease as in the 1980's, which enables, among other aspects, transforming the syndrome, culturally perceived as an outcome of an announced death, into a disease with a chronicity perspective, allowing for changes in values, beliefs, habits and individual and collective knowledge. 1his situation implicates a challenge in the delivery of comprehensive health care to these individuals, as the possibility of deconstructing the idea of imminent death emerges when the diagnosis of the HIV/AIDS infection is received.The change must also occur among health professionals, in order to remove their focus from death, aimed at dealing with the disease and comprising social and emotional aspects of those living with HIV/AIDS in the care provided. 2espite the great benefits resulting from the use of HAART, mostly prolonging survival and the chronicity of the infection, treatment deeply marks the individuals, affecting their physical, social and mental well-being and involving negative feelings such as depression, distress and fear of dying, which interfere in their self-esteem and identity. 3lthough the progress of the medication therapy has contributed to reduce mortality rates, it is known that in the HIV positive context, important psychosocial consequences are observed, such as depression, low self-esteem and prejudice. 4elf-esteem refers to the degree of consideration or respect an individual has for oneself and a way to measure the values attributed to his/her own judgments and capabilities.It is related to the concept of oneself and influenced by the way he/ she is seen by loved ones. 5ue to the chronicity of the HIV infection, important changes may occur in the life of these carriers, emerging new needs to be understood and dealt with, enhancing the already existing ones.Understanding the self-esteem of people living with HIV/AIDS is essential.Increased self-esteem makes the individual living with HIV perceive him/herself in a positive way; on the other hand, those with affected self-esteem may see themselves as more limited and discouraged, 4 with great implications to mental health.Given the circumstances, the present study had the aim to evaluate the self-esteem in people with HIV/ AIDS and to relate it to sociodemographic and clinical factors.

METHODS
This is a cross-sectional study performed in two outpatient clinics specialized in the care of individuals with HIV/AIDS in a city in the interior of the state of São Paulo, Brazil.Individuals who participated in this study were carriers of HIV/ AIDS, clients of the public health system, registered in the studied service, who received care in the period between 2007 and 2010 and met the inclusion criteria: being aware of the HIV/AIDS diagnosis, older than 18 years, assisted at the outpatient clinics in the study location, coming to medical appointments booked during the study period, with physical and emotional conditions to participate in the interview.
Data were collected by means of individual interviews and the Rosenberg Scale was used to evaluate self-esteem, in a version translated and adapted to Portuguese.This instrument consists of Likert scale (1=strongly agree, 2=agree, 3=disagree, 4=strongly disagree) with 10 questions, of which five evaluate positive feelings regarding him/herself (In general, I am satisfied with myself; I feel I have a few good qualities; I can do things as well as most people, as long as they are taught to me; I feel I am a valuable person, at least to the same rate as other people; I have a positive attitude about myself).The other five items evaluate negative feelings (Sometimes I feel useless; I feel no satisfaction for the things I have accomplished; I feel I have not much to be proud of; Sometimes, I feel really useless, incapable of doing things; I wish I had more respect for myself; Most of the time I tend to feel I am a looser).
The interval may vary from 10 (ten items multiplied by 1) to 40 (ten items multiplied by 4).As per this instrument, higher scores indicate higher self-esteem. 7ociodemographic and clinical data were collected using a specific questionnaire for this study.

RESULTS
From the 650 registered individuals, 331 (50.9%) individuals who sought for treatment in the period between 2007 and 2010 were interviewed.From these, 167 (50.5%) were male, with a predominant age range between 30 and 39 years (42.0%),134 (40.5%) were single and 212 (64.0%) had been educated up to primary school (Table 1).Regarding the self-esteem evaluation performed in the study population, the mean was 25.25 with a minimum of 17 and maximum of 37.
Table 2 presents the mean and the standard deviation found in the employment of the Selfesteem Scale of Rosenberg in the participants of this study.3 presents the mean, minimum and maximum values of self-esteem and the standard deviation found in the population studied according to the variables considered.Individuals who affirmed being separated/divorced, who could not report their exposure category and had no comorbidity presented higher self-esteem means, with statistically significant differences.

DISCUSSION
The individuals interviewed in this study were young, with primary education and most claimed being infected by sexual contact, revealing the need for population awareness regarding prevention methods against HIV.These findings were also seen in a study that suggested people living with aids have lower education and are young. 8mong the 331 individuals with HIV/ AIDS participating in this study, 164 (49.5%) were women.HIV/AIDS infection in women has progressively increased, representing approximately 50% of the cases worldwide and 30% of the cases in Latin America. 9In Brazil, between 1980 and 2011, 608,230 cases of aids were identified, 397,662 in men and 210,538 in women.This ratio between genders, in Brazil, has decreased throughout the years, demonstrating a female feature in the epidemics. 10 this study, the predominant sexual orientation was heterosexual, in 82.2% of the HIV/AIDS cases.In a study performed in the city of São Paulo, the heterosexual relation was found to contribute to the epidemics among women. 11esults related to education are consistent with the social profile of the epidemics in Brazil, which reaches people with lower education, 12 with 161 (48.6%) individuals presenting only incomplete primary education in this study.In addition, 13 (3.9%)individuals claimed to be illiterate and only 16 (4.8%)had a college degree.
Regarding the poverty in the epidemics, education is used as an indirect variable of the socio-economic situation, influencing the increase of the epidemics among people with lower education. 13Universal education is one of the goals of this millennium to the United Nations.For the UN, education is a way to cope with the aids epidemics, as there is a relation between low education and increased risk for infection. 14omparing the results of this study to a sample of people living with HIV/AIDS in the state of Minas Gerais, some variables were observed to be similar, for instance: low education, the most affected age range, transmission by sexual contact and the marital status of the individuals studied.Nevertheless, there were different data, such as most of the sample being female.
Among the interviewees, 176 (53.2%) presented comorbidities related to the HIV infection or to HAART, information also found in another study. 12The advent of this therapy brought benefits such as the reduction of opportunistic infections and an increase in life expectancy due to the chronicity of the disease, 12 however, its use must be considered a risk factor for cardiovascular and metabolic disorders, requiring guidance to a healthy lifestyle. 16mong the individuals in this study, 133 (40.2%) demonstrated good clinical parameters and markers of the infection by HIV, observed by the high CD4 cell count.Ever since the beginning of the HIV epidemics, monitoring CD4 lymphocytes has been used as a predictive laboratorial parameter of the HIV infection prognosis and also as an indicator of risk for opportunistic infections. 12n this study, the mean score for self-esteem was 25.25.In other Brazilian studies, 17,18 the mean for self-esteem was higher, suggesting that people living with HIV/AIDS present worse self-esteem when compared to individuals living with other chronic diseases.Self-esteem levels influence self-confidence and valuing, and may lead the individual not to care for his/her health, for per-sonal care, not to believe in him/herself and not to search for treatment. 12he low self-esteem found in people living with HIV/aids in this study may be related to the negative consequences of dealing with the HIV/ AIDS infection, broadly reported in literature as depression, and social and emotional isolation. 12,19elf-esteem is an essential aspect in the creation and maintenance of health, hope and quality of life.People living with HIV/AIDS may have their self-esteem damaged due to the social impact the infection may cause in their lives, associated to the stigma of the disease, as potentially fatal.Nevertheless, the infection also causes physical and social limitations in the life of the individuals, such as the loss of a life project, the need for restructuring habits, dealing with new limitations at work and family relations. 12egarding the items in the Rosenberg Self-Esteem Scale, the highest mean (2.98) observed was related to question 9, in which individuals agreed with the statement "Most of the time I tend to feel I am a looser" and the one presenting the lowest mean was question 10 (2. 19), in which participants agreed with "I have a positive attitude (thoughts, actions and positive feelings) about myself", diverging from another study 15 that found the highest mean in question 4 and the lowest in item 8.
Increased self-esteem favors individuals with HIV/AIDS in having positive feelings about themselves; on the other hand low self-esteem makes them feel more limited and discouraged. 4elf-esteem may be predisposed by social features such as gender, age, marital status as well as by the disease affecting oneself. 20In the present study, there was a statistically significant difference between the means in self-esteem and in marital status (p<0.001).Single individuals present the worst mean compared to married, separated/ divorced and widowed individuals.These findings may suggest single individuals have less family support and, therefore, less support for coping with life with HIV/AIDS and worse self-esteem.
A study performed in Brazil demonstrated family support is important in coping with the disease, 15 and in the quality of life. 21A study performed with children living with HIV/AIDS in Ruanda, Africa, showed that both self-esteem and family support are important for their resilience in coping with the disease. 22he variable category of exposure also identified statistically significant differences (p<0.001)among the means, as individuals who were exposed by blood had worse self-esteem.Such findings were also seen in another study 15 and they can be related to the fact that most individuals included in this category were infected by sharing syringes and needles when using injectable drugs and that this is a vulnerable population under the individual, social and pragmatic point of view.
In addition, individuals who had no comorbidities had better self-esteem means (p=0.022).The presence of comorbidities or co-infections may implicate in larger physical 23 and psychological 24 symptoms, among people living with HIV/aids with reduced self-esteem.
Hence, strategies must be adopted in health services to offer comprehensive care to the health of this population, such as physical activities, individual therapy and group activities.Physical exercises have been an influencing factor in self-esteem as demonstrated in an investigation performed with a group of aged individuals. 25In another study, the physical activity helped achieve a better perception in the satisfaction of the participants in life. 26oreover, the implementation of group activities among health professionals and people living with HIV/AIDS generates familiarity and the perception of needs, feelings and afflictions, 27 in addition to building a setting for emotional support, exchange of experiences and understanding the psychosocial aspects of living with HIV/ AIDS, 28 and constituting an important strategy for the education and promotion of health.

CONCLUSION
The present study identified that people living with HIV/AIDS have lower self-esteem when compared to individuals living with other chronic diseases.A significant relation was found between self-esteem and the variables marital status, category of exposure and presence of comorbidities.
Few studies which evaluated self-esteem in people living with HIV/AIDS were found in the national and international literature, although it is an important theme for this population.Hence, more investigations regarding the variables that may influence the self-esteem of these individuals are necessary, in addition to the relation of self-esteem to health, quality of life and therapy compliance.
Negative impacts whether physical, social or emotional of the infection by HIV/AIDS require attention and engagement from health services to work on interventions that favor self-esteem, for instance physical exercise, individual therapy and group activities, since they may influence the way to deal with the disease.The self-esteem evaluation may help reveal individuals who may demonstrate difficulties in committing to treatment and to selfcare.Nurses, as the fundamental professionals in the health team, must be prepared to deliver comprehensive care to individuals with HIV/ AIDS, given their emotional and clinical features.
A database was constructed, organized into Excel spreadsheets and processed and analyzed in the Statistical Package for Social Sciences (SPSS) software, version 15.0.Descriptive statistics was employed in data analysis.Participants were informed regarding the objectives of the study, data confidentiality and the assurance of anonymity.Data collection was initiated after the signature of the Free and Informed Consent Form.The research proposal was approved by the Research Ethics Committee of the University of São Paulo at Ribeirão Preto College of Nursing, protocol No.0699/2006, according to the recommendations on resolution 196/96 of the National Health Council.