Anti-HIV testing in gynecology services in the city of Rio de Janeiro

Abstracts

Objective:

The research proposes a study about the supply of anti-HIV services in primary health care in the city of Rio de Janeiro, in gynecology clinics. The objective of this study is to analyze the aspects involved in the expansion of access to HIV/AIDS diagnosis at the Primary Care Gynecology services in Rio de Janeiro.

Methods:

Descriptive qualitative study. Data was obtained through a semi-structured interview. For the analysis of qualitative data, we chose to use the Collective Subject Discourse. Results: In the field of gynecology, the supply of anti-HIV testing remains very limited, and in most cases happens on the occasion of prenatal care.

Conclusion:

In general,people do not feel vulnerable to HIV, and think they do not have risk behaviors, often because they are unaware of the form of disease transmission.

AIDS serodiagnosis; Primary care; Women's Health

Esta pesquisa propõe um estudo sobre a oferta do teste anti-HIV em serviços da Atenção Básica de Saúde do município do Rio de Janeiro, na clínica de ginecologia. O objetivo desse estudo foi analisar os aspectos que envolvem a ampliação do acesso ao diagnóstico do HIV/AIDS nos serviços de Ginecologia da Atenção Básica no município do Rio de Janeiro.

Métodos:

Estudo qualitativo descritivo. Os dados foram obtidos por meio de entrevista semiestruturada, e, para a análise dos dados qualitativos, optamos por utilizar o Discurso do Sujeito Coletivo. Como resultados, pudemos perceber que,na área de ginecologia, a oferta de testes anti-HIV ainda é muito baixa, acontecendo na maior parte dos casos devido ao pré-natal.

Conclusão:

De forma geral, as pessoas não se sentem vulneráveis ao HIV, e julgam não apresentar comportamentos de risco por muitas vezes desconhecerem a forma de transmissão da doença.

Sorodiagnóstico da AIDS; Atenção primária; Saúde da mulher

Objetivo:

La investigación propone un estudio sobre la prestación de servicios de pruebas de VIH en la Atención Primaria de Salud del municipio de Rio de Janeiro, en ginecología clínica. El objetivo es analizar los aspectos que involucran la expansión del acceso al diagnóstico del VIH/SIDA en la Atención Primaria de Ginecología en Rio de Janeiro.

Métodos:

Estudio cualitativo y descriptivo. Los datos fueron recolectados por medio de entrevistas semiestructuradas y análisis de datos cualitativos. Se optó por utilizar el Discurso del Sujeto Colectivo-DSC.

Resultados:

En el campo de la ginecología, la oferta de pruebas de VIH es todavía muy baja y sucede en la mayoría de los casos debido a la atención prenatal.

Conclusión:

En general, las personas no se sienten vulnerables al VIH y piensan no presentaren comportamientos de riesgo pues desconocen el modo de transmisión de la enfermedad.

Serodiagnóstico del SIDA; Atención primaria; Salud de la Mujer

INTRODUCTION

This research derived from the interest in gaining further knowledge about the theme HIV/AIDS, more specifically about the supply of anti-HIV testing at primary care gynecology services in the city of Rio de Janeiro. According to the Ministry of Health, the Brazilian sexually active population has limited access to counseling, diagnosis and treatment actions for Sexually Transmitted Diseases (STD), which increases their vulnerability to illnesses and HIV/AIDS.

The infection by HIV (Human Immunodeficiency Virus) expanded beyond the previously defined groups and is a reality for the general population today. Factors that represented safety now indicate exposure to the risk of contagion by HIV. Other phenomena are observed in the AIDS epidemic in Brazil, among which pauperization and feminization are highlighted. These represent population segments that were not prioritized in campaigns and public health policies at the start of the epidemic and which are often discriminated against by other population segments.

The epidemic of the HIV/AIDS infection represents a global, dynamic and unstable phenomenon, which results from the profound inequalities in the Brazilian society. In addition, it has gone through significant epidemiological transformations. It used to be restricted to large urban centers and predominantly to the male gender. Today, in Brazil, there is a clear heterosexualization, feminization and pauperization of the HIV/AIDS epidemic. According to the National STD/AIDS Program 2005, in the year 2000, the cases of heterosexual transmission already represented 30% of the cases, with a proportional reduction in homosexual transmission and injectable drugs use cases. In 2004, sexual transmission represented 95% of HIV causes among women and the case ratio between men and women dropped to 6.5 cases in men for every case in women since the start of the epidemic to less than two cases since 1999¹. This abrupt increase in transmissions causes by heterosexual contact implies a significant rise in the number of cases in women.

Social exclusion based on race/ethnic origin, nationality, gender, worsening of the economy and quality of life, among other factors, enhance the dissemination of the epidemic and should make us reconsider public policies that mix prevention with assistance, that are not only restricted to information, but that deal with the cultural characteristic and socioeconomic limits. In addition, intersectorial actions are needed as a more effective response in coping with the epidemic in Brazil². The healthcare model adopted by the National STD/AIDS Program (NP STD/AIDS) in the country establishes a policy of inclusion and universal access to prevention and care actions^1,3.

To give an example, investments are needed in the infrastructure established in health services and in the human resources that exist in the country's public health network, so that it is appropriately stimulated, organized, supported, with a view to the reversal of current STD/HIV/AIDS indicators in Brazil. In addition, in primary care, the population needs knowledge on STD/HIV, sensitizing the people with regards to their risks and safe sex, so as to reduce the incidence and prevalence of STD and HIV. Also, it is beyond doubt that expanded access to counseling, high-quality diagnosis and treatment possesses a high problem-solving ability with regard to the transmission of STD and HIV.

The supply and access of the population to HIV testing in the public health network has significantly increased. In 2005, 528 thousand tests were offered, increasing to 2.3 million in 2011 and this is due to the inclusion of the rapid test as routine for the detection of HIV⁴. Nevertheless, the qualitative indicators of the service are not part of daily praxis in health services, arousing reflections on these conditions^5,6.

With regard to HIV/AIDS, it is highlighted that, from 2000 till 2005, the state of Rio de Janeiro figured among the five states with the highest AIDS incidence levels in Brazil. In most cases, this figure is related to the late diagnosis and treatment access difficulties. Between 1980 and June 2010, 344,150 AIDS cases were notified in SINAN (Brazilian Case Registry Database) in the Southeast, corresponding to 58% of cases in Brazil in the same period⁷.

The health services available in the city of Rio de Janeiro include four Testing and Counseling Centers (TCC) and 43 Specialized Outpatient Services (SOS), besides hospital services for hospitalization care delivery to children and adults. Departing from the premise that the expansion of testing is a recommendation of the NP STD/AIDS, the aim in this study is to analyze the aspects involved in the expansion of access to the HIV/AIDS diagnosis in Primary Care Gynecology services in Rio de Janeiro.

LITERATURE REVIEW

For the literature review, the following descriptors were used: AIDS serodiagnosis; Primary health care and Woman's health. The search was undertaken in the databases available in the Virtual Health Library (VHL). Among the 1547 papers identified, none was directly related to the study object, but we identified different studies that relate anti-HIV testing with pregnant women.

HIV-testing supply policy in Brazil

To diagnose the HIV infection, the individual's blood sample needs to be tested. In general, the most used test is the Elisa and, if the result is reactive, a confirmatory test is carried out, which can be the indirect immunofluorescence test for HIV-1 or the western bloot. In addition, the rapid test permits the detection of anti-HIV antibodies within less than 30 minutes, based on the collection of a blood droplet from the finger tip, allowing the patient to find out the result of his test and, at the same time, receive pre- and post-test counseling.

The tests should be performed in accordance with the Ministry of Health standard, using products registered at the Brazilian Health Surveillance Agency (ANVISA). These tests can be undertaken at private and public health laboratories, at Primary Health Care Units (PHCU) or Testing and Counseling Centers (TCC), where the procedure can be done anonymously and free of charge, besides the counseling process before and after the test.

The advancement of the epidemic required testing as an important form of control. Therefore, the Testing and Counseling Centers were created, characterized by the supply of the anti-HIV serology test accompanied by pre and post-test counseling, free and charge, on a voluntary and confidential base⁸.

At the start of 1998, there were three health services acknowledged as TCC by the Ministry of Health in the city of Rio de Janeiro: TCC São Francisco, TCC Rocha Maia, and TCC Madureira. In the year 2000, more than 150 TCC were functioning in Brazil, 11 of which in the State of Rio de Janeiro. The impact of TCC actions to reduce the incidence of HIV is directly related to the ability of the counseling services to provide support and facilitate behavioral changes in risk situations for HIV patients and others⁸.

Besides the TCC, anti-HIV tests can and should be available at the Primary Health Care Units (PHCU) as, according to the basic principles of the Unified Health System(SUS), i.e. universalization, integrality, decentralization, hierarchization and popular participation, these units are the individual's entry door into the public health system, which should offer welcoming, early diagnosis and treatment and forwarding to referral units.

At the PHCU, the test should always be offered, from the perspective of universality and accessibility, and undertaken with the patient's consent through appropriate pre and post-test counseling. In prenatal care, the pregnant woman is advised to get tested in order to protect her health and prevent the transmission of diseases to her infant. These diseases include syphilis, Hepatitis B, HTLV and HIV. Anti-HIV testing should be authorized by the pregnant woman after counseling by a health professional who has been trained for this activity. Any health professional with specific training and in accordance with the responsibilities of his/her professional category can provide the counseling. To permit this, the professionals should recognize their own limits, reconsider their concepts and prejudices and know that they cannot answer everything they are asked⁹.

Service access for anti-HIV testing

The public policies are clearly interested in investing in woman's health prevention and promotion, as exemplified by Prenatal and Woman's Health policies (colon and breast cancer screening), but some barriers exist that hamper the woman's relation with the health services, including lack of knowledge or denial of their vulnerability or even the detection of their vulnerability by health professionals, leading to a late diagnosis and treatment³. The early detection of the virus is extremely important for a successful treatment of the infected patient. Therefore, however, new testing access opportunities need to be created without changes in the diagnostic quality.

Access means the act of arriving or entering and, what HIV testing is concerned, any and all persons are entitled to get tested when they find this necessary and to receive pre and post-test counseling. The easier access and the individual's preferred entry door to health is through primary care, which should offer services like educative actions for health promotion and disease prevention, counseling for HIV diagnostic tests and adherence to treatment and care recommendations, early diagnosis of the HIV infection, appropriate treatment, forwarding of cases that go beyond this care level, joint monitoring and prevention of vertical HIV transmission.

Primary care is an important form of access and should be used and valued, considering that, if it provides its services and activities appropriately, its problem-solving ability will be high in contributing to the reduction in the number of HIV infection cases. It is fundamental for the organization of health services to promote better access to the patients visiting the service and for each professional to incorporate the concern with identifying the most vulnerable patients into his/her routine, guaranteeing humanized and problem-solving care. Also, actions are needed in the community to further the risk perception for these conditions, besides stimulating the adoption of safe practices for health⁸.

Some populations are extremely stigmatized and have been historically excluded from health services, such as transvestites, male and female sex professionals, drugs users, homosexuals and young people in street situations. It is important to promote and expand the access to health services, to prevention materials and to diagnosis with counseling.

According to the Ministry of Health, in the last decade, one of the main advances in terms of programs for the female population in Brazil was the articulation with the Woman's Health program area between the central and state and municipal levels. This articulation permitted the implementation of STD/AIDS actions in woman's health services, promoting joint actions with programs like the Prenatal and Birth Humanization Program and HIV Prophylaxis in Sexual Violence Situations¹⁰.

Gynecology care: an opportunity for prevention

Women represent a majority in Brazil and are the most frequent health service users, for themselves as well as for their children, family members, neighbors and friends they accompany. They are also caregivers, for their family members and neighbors, and therefore deserve special attention.

Women's vulnerability to AIDS is closely linked to a cultural logic of sexuality, which can be explained by women's sexual submission to men and by the sexual repression that permeates girls' education, constituted based on myths and prejudices, delimited by gender, sex, sexual orientation, class and race¹¹.

In Brazil, woman's health was incorporated into national health policies in the first decades of the 20^th century but, at that time, it was limited to demands related to pregnancy and delivery. Maternal-infant programs translated a restricted view on women, based on their biological specificity and on their social role as mothers and housewives, responsible for child raising, education and care for the health of their children and other family members¹².

After many changes in public health policies, woman's health turns into a priority for the government and, in 2003, the National Comprehensive Woman's Health Policy - Principles and Guidelines started to be constructed which, according to the Ministry of Health, incorporates comprehensiveness and health promotion as guiding principles and aims to consolidate the advances in the field of sexual and reproductive rights, emphasizing the improvement of obstetric care, family planning, care delivery to unsafe abortion and the fight against domestic and sexual violence. It also adds the prevention and treatment of women living with HIV/AIDS and patients with non-transmissible chronic conditions and gynecological cancer.

From the biological viewpoint, Sexually Transmitted Diseases (STD) are great facilitators of the HIV infection, and are more frequently asymptomatic in women than in men, but the fact that they have no clear clinical dimension does not mean that they have no weakness in the barriers against HIV infection.

The policy also discusses maternal mortality, the precariousness of obstetric care, breastfeeding, family planning, the precariousness of contraceptive care, domestic and sexual violence, adolescent woman's health, woman's health in the climacteric period/menopause, health of African-American women, health of women who live and work in rural areas, woman's health in prison situations and mental health and gender. Primary Health Care Units with high problem-solving ability and easy access are capable of causing a strong impact on the HIV/AIDS epidemic and on the incidence of STD in the country, and the health professionals who deliver care to women should always heed each woman's risks and vulnerabilities.

Effective STD prevention and control are considered a priority for reproductive health promotion, especially among women. Besides being the main facilitating factor for HIV infection, STD cause a strong psychological impact on their patients, as well as social impacts. If the woman is pregnant, the large majority of the STD can be transmitted to the fetus and some, if not diagnosed timely, can cause severe complications and even death. The risk concept means the exposure of an individual or group of people to situations that somehow make them susceptible to infections and illness. This concept, however, has become insufficient to explain the determinants of the HIV epidemic. Therefore, in view of the dynamic nature of personal behaviors and their interaction with several dimensions, the vulnerability concept was incorporated¹³.

About the vulnerability concept:

It can be summarized exactly as this movement of considering the chance of people's exposure to disease as a result of a set of not only individual, but also collective, contextual aspects, which entail greater susceptibility to the infection and the disease and, inseparably linked, greater or lesser availability of all kinds of resources to protect themselves from both^14:117-139.

Until today, the large majority of women receive the diagnosis of HIV infection in a late stage (illness of their partner or their vertically infected child), as an important part of health professionals use an outdated "risk group' concept, without situating these women in a vulnerability context¹².

For many pregnant women, taking the HIV test during antenatal care is a demonstration of love and care towards their child as, based on the diagnostic result, actions to prevent the vertical transmission are taken to protect the child from the infection. These women should be sensitized though, not only to protect their child, but also to their own health, focusing on self-care, prevention and the accomplishment of the test to permit an early diagnosis¹⁴.

In view of this situation, Primary Care, as one of the entry doors to the health service, should guarantee access to the HIV test during prenatal care¹⁵. Antenatal care is fundamental to prepare for motherhood. It should not be considered as mere medical care, but as work to prevention clinical-obstetric problems and as emotional assistance.

To increase the number of pregnant women tested for HIV, greater adherence (of health professionals and users) to actions aimed at detecting this infection is fundamental. In that sense, the incorporation of these actions by the BHU will promote a strong impact on the control of the epidemic in Brazil.

Health professionals, particularly nurses, need to invest in sensitization strategies, as health education is part of their professional vocation. These strategies can be based on workshops and group counseling, considering the users' different cultural levels and degrees of understanding, granting opportunities for reflection on risk practices and forms of prevention to adopt¹⁶.

The Brazilian policy has well-established guidelines, based on actions that reduce the risks of intra-uterine/intra-delivery transmission and eliminate the risk of transmission through breastfeeding. To permit vertical HIV transmission reduction actions, any and all prenatal care service should: Offer the anti-HIV test to all pregnant women during the first prenatal care consultation, as this is a routine test, including pre and post-test counseling, independently of the woman's risk situation for HIV infection. The test should always be taken on a voluntary and confidential base though¹².

METHOD

This research is focused on the supply of anti HIV-testing at gynecology clinics in primary healthcare units in Rio de Janeiro. The qualitative method was chosen. The units for the quantitative data collection were selected in view of the following characteristics: location, number of attendances, services offered, number of professionals and accessibility of the clinical analysis laboratory. After this survey, considering the program area, the clinics with the largest number of attendances and services offered were selected for the study.

Data were collected through a semistructured interview with women who use the gynecology service at Primary Health Care Units, using a script with questions related to the study objectives. The interview script consisted of three parts: the first was focused on the subjects' characteristics; in the second part, it was verified how the anti-HIV testing was expanded and how the diagnosis and treatment of HIV/AIDS increased; and the third investigated the factors that facilitate and/or hamper this process, as well as suggestions to improve the access to these services.

The women were interviewed after receiving orientations and signing the Informed Consent Form, in compliance with National Health Council Resolution196/96. The interviews were tape-recorded. The interviewees' anonymity and confidentiality was guaranteed. The duration of the interviews was approximately 20 minutes. Approval for the research was obtained from the Research Ethics Committee of the Rio de Janeiro Municipal Secretary of Health and Civil Defense, under protocol 106/09.

In total, 33 women were interviewed. These users were attended by medical professionals. For data analysis, the technique proposed by Lefrevre was used¹⁷, called the Collective Subject Discourse (CSD), in which categories of thinking (Core Ideas) are described that are present in the interviewees' reality, as well as the discursive content (Key Expressions) of each category. In addition, at the same time as collective thinking is qualified, it needs to be quantified. As an analytic tool, the software Qualiquantisoft was used.

As a study limitation, the difficulty to get authorization from the services for data collection is highlighted, as the managers considered it as an assessment. In addition, the results presented here related to the contexts in which the Primary Care services are offered in Rio de Janeiro.

RESULTS AND DISCUSSION

The research subjects were women who were interviewed at the gynecology clinics of five Primary Health Care Units (PHCU) in Rio de Janeiro. Most of these women were between 21 and 50 years of age, has not finished primary education, were mulatto, heterosexual and married.

After the characterization, the first interview question the users at the gynecology clinic were asked questioned the reason that made them take the anti-HIV test, and most of them attributed it to the prevention of vertical transmission of the virus during antenatal care. In this case, the physician requests the test in accordance with Ministry of Health recommendations, during the first consultation and in the final pregnancy term. Although pre and post-test counseling is recommended, the sensitization and counseling strategy was not used with any of the interviewees, to the extent that one woman only found out she was being tested for HIV when the blood sample was collected.

I did it because I was pregnant so I had to do it. It was my gynecologist who requested it. Each time I got pregnant I had to do it. The nurse collected the blood, I asked what it was for and he explained that it was for the HIV test and that it was compulsory. During prenatal care only. That it was part of the tests. The doctor said that it was compulsory to do the prenatal care. I had to sign the form to do it. The doctor said it was better to do it to see if I had something. (CSD1)

In 65 % of the cases of HIV-positive pregnant women, the virus is transmitted close to or during the delivery¹¹. In many cases, the compulsory nature of the test during pregnancy was mentioned, without guaranteeing the decision to choose between doing it or not. Only one interviewee mentioned the signing of the consent form.

It is known that diagnosing HIV at the start of pregnancy is very important to reduce the vertical transmission and control the mother's disease. Therefore, anti-HIV testing should be offered to all pregnant women during the first prenatal consultation, as it is a routine test, with pre and post-test counseling, independently of the woman's risk situation for HIV infection. The test should always be taken on a voluntary and confidential base though.

Among the interviewees, the compulsory nature of the test was identified as a meaning of undergoing the test, as they had no other choice and probably did not decide this.

At that moment, I was practically obliged because they ask it there, it is compulsory. Anyone getting a surgery has to take this test. (CSD2)

When asked if they want to repeat the test, many women said they would repeat the test if they were asked to. This question was asked to the women who had already undergone the anti-HIV test. They indicated they would like to repeat it for different reasons, including: Distrust in their partner, independently of whether he was their fixed partner or not; The fact that the last test was taken a long time ago. In other words, it is unknown whether these people take the test regularly because they know that they have been exposed to risks, and many people still use the blood donation to discover their health condition. A minority of the women related the test with HIV prevention.

Well, I would like that. Just to make sure because, as I witnessed it closely, my husband died from this problem, so I had everything to catch it. I'm going to repeat it. Because it has been a long time, more than six or seven years. If the doctor asks it I will definitely do it because I have nothing against undergoing this test. Yes, I would repeat it. I donate blood every three months. Because I believe I haven't got that anymore. The life we lead, I don't trust anyone. I am always taking the test, I even have several HIV test results at home. We're married, but sometimes it's good to get rid of the doubt so that you don't have to worry. I would like to, justto know, because you live with the person and you can't fully trust your partner. Men! Men even more, men are relative. (CSD3)

Some people have no specific reason for repeating the test but report that it is not a problem for them to do it so, if it is possible, if the physician requests it, they would repeat it without any problem. Some people would take the test again for the sake of safety and relief to know that they have not been infected by HIV.

Hence, the large majority would repeat the test, independently of the reason. Some people would even like the physicians to offer it more, as they still believe that they cannot ask to be tested or visit a testing center and be tested voluntarily and anonymously. Therefore, the health professionals can and should expand the supply of the test, always aiming for an early diagnosis with appropriate pre and post-test counseling and the rupture of the transmission chain, with a consequent drop in the number of new cases of HIV infection.

When asked about the initiative to undergo the test, few women were offered the anti-HIV test during gynecological care. Most of the women who had already undergone the test did this during prenatal care.

Only during prenatal care really. It was the gynecologist at Vila Isabel who offered it. They only asked it when I was pregnant, otherwise no. Only during prenatal care. (CSD4)

The test supply needs to be expanded beyond the prenatal care routine¹⁸. Whenever possible, the health professional should use the opportunity and offer the test to the client, as it is only by enhancing serology testing for HIV that early diagnosis will be effect and that the number of late discoveries of the infection will drop. This fact can strongly interfere in the patients' quality of life^11,14.

It was verified that some interviewees do not recognize the risky nature of their sexual practices and said they would not like being tested for HIV; not even if the health professional requested it.

No, because I think there's no need. Well, I think not because I'm not in this risk group thing. I have never taken the test, I have never needed to, I have never received a transfusion, and I don't have these diseases. (CSD5)

In the discourse, some interviewees indicated that they find it important that only informed persons undergo the test. This perception reveals a mistake as, nowadays, any person is subject to catching HIV in case of unprotected sexual practices.

When asked about why they would undergo the test, many women indicated that they would due to the mere acknowledgement of having gone through risk situations. Therefore, they would undergo the test if the health professional asked them to.

Because I have a partner, but I don't know what he's doing. I don't trust my husband, he may cheat on me and I don't know, so it's important to take the test. The doubt: If I have it or not. The virus or HIV really. Do the test to be really sure. The fear makes many people not want to do it out of fear of a positive response. If I hadn't gone through any problem I think I wouldn't. Only if I were a virgin, then I wouldn't need to but, when you start having intercourse with a man, you always have to try and protect yourself. (CSD6)

The fear of an HIV-reactive result is highlighted here as one of the limiting factors for taking the test. Despite acknowledging the exposure to risk situations and despite not using preventive measures, they believe that they are not infected by HIV.

As suggested, a large part of the interviewees acknowledge the importance of undergoing the test and suggest the expansion of serology testing for HIV, with a view to enhancing actions for prevention and encouragement of an early diagnosis and appropriate treatment of the infection.

I hope these tests will be offered me because there's a very big lack of health care. Always offer it to young people, elderly people and women. They should really offer this thing, without us asking for it. It should be offered to everyone, it would be something to tranquilize everyone. The anti-HIV test should be offered in all health services because, this way, people will be less afraid of undergoing the test. (CSD7)

Expanding the access to the anti-HIV test involves the distance between the health service and where the patient lives, the transportation time and means used, difficulties faced to receive care (queues, waiting place and time) and the treatment the user receives^16:27-34.

CONCLUSIONS

Based on the results obtained, it is concluded that much remains to be considered and reflected about the expansion of HIV serology testing in the primary care network in the city of Rio de Janeiro. Since the emergence of the first case of the AIDS infection in 1980 until today, the epidemic has completely changed its characteristics, which at first included the predominance of homosexual men, injectable drugs users and individuals who received blood and blood product transfusions.

At the end of the 1980's and early 1990's, then, the epidemic started to gain a different profile and heterosexual transmission became the main transmission route, which has continued until today, including a large female participation in the dynamics of the epidemic. In view of this profile, it is verified that little is mentioned about the expansion of HIV testing, even by health professionals, despite the importance of the test for the early detection of the virus and the appropriate treatment of the infection, with a view to a better quality of life for people living with HIV.

At the gynecology clinic, the supply of anti-HIV testing for women is limited. In general, access levels to the test were very low, despite the interest in taking the test the women demonstrated. Hence, we do not identify that HIV testing has expanded at the gynecology clinics of the investigated health services.

According to the interviewees, few factors facilitated the HIV testing. The factors the women highlighted as relevant for taking the test are emphasized here: the perceived importance for vertical prevention, acknowledgement of risk situations and the offering of the test by the health professional at the institution where the women are monitored.

During the study, we identified different factors that hamper the women's access to anti-HIV testing. The most mentioned factor was that the health professionals do not offer the test, in addition to the compulsory test request and the fear of an HIV seropositive result. These factors represent barriers to undergo the anti-HIV test. Other limiting factors are the lack of dissemination and information about how and where to get tested as limiting factors for the access to and expansion of HIV testing.

Among the suggestions offered by the primary health services users themselves in the city of Rio de Janeiro, the expanded supply of anti-HIV testing by health professionals is highlighted, as well as the improved quality of health services, more specifically of treatment and user welcoming, the expansion of access to the diagnosis and the enhancement of actions to prevent and encourage the early diagnosis and appropriate treatment of the infection, testing as a right and a preventive action that needs further dissemination and campaigns about the anti-HIV test and possibilities to get tested.

Thus, this study was important to make health services and professionals reflect on the importance and definition of guidelines for the development of public policy implementation strategies focused on the expansion of HIV serology testing.

As regards research, these study results provide support for the development of other studies aimed at strategies to monitor the national HIV testing expansion policy. Access to health technologies is a civil right, as well as access to high-quality public health services with a view to early diagnosis and appropriate treatment, so as to minimize the development of opportunistic diseases.

This study contributed to the knowledge about the perspective of women who use Primary Health Care Services on anti-HIV testing and allowed them to express themselves on the theme. Therefore, we consider that it is important to acknowledge women as protagonists of the health system and the relation between this acknowledgement and the improvement of health service quality, also contributing for the professionals to know how the women assess the services, as this knowledge will lead to the reconsideration of professional and organizational practices at gynecology services.

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Publication Dates

• Publication in this collection
  Jan-Mar 2014

History

• Received
  19 July 2012
• Reviewed
  16 May 2013
• Accepted
  13 June 2013