HIV Pregnant Women WItH more tHan one Pregnancy and tHe Use of antIretroVIral dUrIng Pre-natal care and cHIldbIrtH

Introduction: the increasing numbers of women infected by HIV resulted in the risk of a vertical transmission of the virus, and prevention has been conducted by means of prophylaxis and antiretroviral (ARV) interventions. Although medication in Brazil has been available since 1996, only 69% of HIV positive pregnant women used ARV methods properly during pre-natal care. Objective: to describe the socio-demographic and reproductive health profile of women who had more than one HIV positive pregnancy and identify the use of antiretroviral during pre-natal care and childbirth. Methods: we accessed 2.106 registers of HIV pregnant women at the SINAN, residing in São Paulo, from January 2007 to March 2011, and we selected 284 notifications of women with more than one pregnancy. Dependent variable: use of ARV; independent variables: age, race/color, education, occupation, pre-natal care, type of delivery, use of ARV in childbirth, pregnancy outcome, use of ARV prophylaxis in children. We conducted a Pearson Chi-square test, considering a confidence interval (CI) p < 0.05. Results: of the 284 pregnant women, 254 were HIV positive in their second childbirth and 30 in their third. The women were predominantly young, white, had a high school degree, and were housewives and workers in industries and services. 84.9% of them had pre-natal care, and of these, 82.6% used ARV during their term. During childbirth 77.3% received intravenous AZT. Over the course of the first 24 hours after birth, 91.5% of the infants received prophylaxis treatment. There was a significant statistical relation between the use of ARV during pre-natal care. Conclusion: the study revealed that, although these women were HIV positive in their second or third pregnancy, there is a lower percentage of HAART use than what is shown in present publications.


INTRODUCTION
The heterosexual transmission of HIV resulted in a larger number of infected women, and consequently, the vertical transmission of HIV became an important issue for collective health policies (1)(2)(3) .
It has been demonstrated that, during pregnancy, the risk of infecting the child, when there is no prophylaxis intervention, is estimated at 25 to 30%.During childbirth the risk increases to 65 to 70%, and during the lactating period the rate is of 7 to 39% (4) .
With the introduction of the ACTG Protocol 076, in 1996, and in 2001 of Highly Active Antiretroviral Therapy (HAART) for pregnant women, it has been possible to reduce this rate to less than 1% (5) .It is estimated that in Brazil, following the recommendation for vertical transmission prophylaxis, with the use of HAART, the risk of HIV infection for infants is 3% (6) .The country's prophylaxis recommendations, for preventing the vertical transmission of HIV, are as follows: provide anti--HIV testing, with pre and post-test counseling for all pregnant women in pre-natal care services; testing should be voluntary and confidential; administer Zidovudine (AZT) oral medication in HIV positive pregnant women, starting on the 14 th week of pregnancy, intravenous AZT during labor and childbirth, un-til the umbilical cord is clamped and oral AZT for the infant over the course of 6 weeks, according to the 076 Protocol of the ACTG.Preferably the delivery method should be a c-section, to avoid contact of the baby with the virus, but vaginal delivery is recommended when the viral load test is less than 1,000 copies/ mL or undetectable and the gestational age is over 34 weeks.Pregnant or postpartum women are advised to replace breastfeeding with artificial milk and other foods, according to the child's age, as long as it does not hinder the infant's proper growth and development (7) .
In Brazil there has been a progressive increase in the number of women diagnosed prior to their pregnancy, consequently the percentage of HIV positive pregnant women with antiretroviral (ARV) treatment during pre-natal care has increased (8) .
However, despite of all the investments made by public policies in the country to expand the access of HIV positive pregnant women to HAART, there is still a significant percentage of women who have not received the medication, either during their pregnancy or during childbirth.
In a study conducted by Nichiata (9) , it was possible to identify women who had more than one pregnancy, and were aware of the HIV positive diagnosis, where more than one child from the same mother was born with HIV.The study questioned if women in these conditions used ARV prophylaxis.

OBJECTIVE
To describe the demographic and reproductive health profile of women who had more than one HIV positive pregnancy and identify the use of antiretroviral during pre-natal care and childbirth.

METHODS
It is an exploratory, descriptive, cross-sectional and quantitative study, using a secondary database.
Data collection was made by means of the Sistema de Informação de Agravos de Notificação (SINAN), where we accessed the registrations of HIV positive pregnant women in the city of São Paulo, over the course of January 2007 and March 2011.Of a total of 2,106 registrations in the original database, we elaborated a specific spreadsheet containing the total of HIV positive pregnant women who had more than one pregnancy, and we identified 284 registrations.
Dependent variables were: the use of ARV interventions during pre-natal care, during delivery and by the child.Independent variables were: age, race/color, education, pre-natal care, and evolution of the pregnancy.
The results underwent a Pearson Chi-square test, in order to verify the connection between the study's variables, with a confidence interval of 95%, or in other words, there is a 5% acceptable probability of error for the connection, p < 0.05.Over the course of the test, for the use of ARV interventions during delivery and evolution of the delivery, we used as criteria the factor of women who had their pregnancy outcome during the notification period of the SINAN.
The research was approved by the Comitê de Ética em Pesquisa da Secretária Municipal da Saúde (Ethics Research Committee of the Municipal Secretariat of Health) of the city of São Paulo, with the protocol n o 255.0.162.000-10.

RESULTS
Of the 284 pregnant women identified as being HIV positive, 254 (89.4%) were in their second pregnancy and 30 (10.6%) were in their third pregnancy.They were mainly young, white, had a high school degree, and were housewives and workers in industries and services.
Their age ranged from 20 to 39 years old (87.0%), 13 were teenagers, with ages ranging from 17 to 19, and one of them was HIV positive and was in her third pregnancy.(Table 1).
The majority of women, 136 (47.9%) had 8 or more years of education.As for their jobs (10) , they were mainly classified as "undefined" (48.2%), and this category includes housewives, unemployed and students (Table 1).
The majority of women 241(84.9%)had pre-natal care.And 107 of them (37.7%) were in the first quarter of their pregnancy when they started pre-natal care (Table 2).
Of the 241 women who had pre-natal care, 30 (12.4%) did not use ARV treatment during this period.Of the women that gave birth, (216), 41 (19%) of them did not receive prophylactic ARV treatment during pre-natal care.The majority of the women, 119 (55.0%) gave birth with a c-section (Table 2).
The use of ARV during pre-natal care was associated to the pregnant women's education (p < 0.05), and it showed that the women that used ARV during pre-natal care were, for the most part, the ones with 5 to 8 years of education (Table 3).

DEBATE
It is known that pre-natal care during the pregnancy is a crucial factor for the health of the mother and the child, especially for HIV positive pregnant women, and that the sooner it begins it increases the chances of intervening in the transmission of the virus from mother to child (6) .
The women in the study were notified as pregnant and HIV positive for the second and third time and had, therefore, knowledge about their condition since their first pregnancy.As for the use of ARV during delivery there was a significant connection between the variables: pre-natal care, type and evolution of the delivery (p < 0.05).The use of ARV during delivery was higher among women who attended pre-natal care and opted for a c-section (Table 4).
Although the majority of women in the study had pre-natal care, we expected a higher percentage of antiretroviral use during pre--natal care and during delivery, given that they knew about their HIV positive condition.According to reports from HIV positive women who had seronegative children, we found that they were encouraged to seek assistance during their pregnancy (11) .
The study found a percentage of approximately 85% compliance with pre-natal care, lower than what is found in Brazil (12,13) and in the world, with a variation of 90 to 100% (14,15).As for compliance with pre-natal care and childbirth ARV treatment, 82.6% and 77.3% pregnant women had prophylaxis treatment, respectively.
In a study conducted in Porto Alegre, without taking into account the number of pregnancies, a higher percentage was found of women who had pre-natal care (97.7%), with the use of ARV for 86.6% of them and a 92.8% use of prophylaxis during delivery.At the same time there were a percentage of women who were previously diagnosed as HIV positive who didn't use ARV during their pregnancy (16) .
There are doubts about why women who are seropositive, and know about their condition and about the risk of vertical transmission, do not have pre-natal care or use ARV during their second and third pregnancies.
In this instance, the determinant factor to be considered is the quality of pre-natal care.According to reports from seropositive women, the challenges they face for this kind of health service are numerous: too much bureaucracy for pre-natal care, high turnaround of professionals, lack of educational practices and laboratorial resources within the health units, lack of communication and clarity by the professionals (17,18) .Even though Brazil has 97.1% coverage of pre-natal care for pregnant women in general, only 26.5% of pre-natal care is considered adequate, according to the PHPN (Programa de Humanização do Pré-natal e Nascimento) parameters (19) .
Being HIV positive makes it even more difficult to access treatment, given the complexity of HAART, side effects, forgetfulness, and the incompatibility between the treatment and the routines of life and self-esteem (20) .
Prevention during the intra-delivery period is another crucial factor in reducing vertical transmission of the virus, given the increased risk of transmission during this period.In the study, 19.0% of women did not have prophylaxis during delivery.National studies showed variations between 10 and 23% (21,22) , and a lower value when the women knew about their condition during the pregnancy (22,23) .Analyzing the quality of pre-natal assistance and the deliveries in public maternities provided for pregnant women, we identified a reality that is far from what is recommended by the Ministry of Health, showing how fragile the Programa Brasileiro de Redução da TV do HIV (Brazilian Program to Reduce the Transmission of HIV), regarding its organization, management and health service assessment (24) .
There were a higher percentage of women who had a normal delivery (39.80%) than in other studies (20.5% to 27.3%) (15,25) .The definition of normal delivery is based on the results of the maternal viral load (less than 1.000 copies/mL), conducted after the 34 th week of pregnancy, and in association with an obstetric evaluation (6) .It is possible that women who had more than one pregnancy are in this condition, ensuring a safe vaginal delivery.There was a connection between the use of ARV during delivery and pre--natal care and a c-section delivery.We expected that, knowing about their HIV positive condition, there would be a greater probability that these women would seek pre-natal care, use HAART prophylaxis and opt for a c-section, in order to prevent the vertical transmission of HIV.
Of the 200 live born, 5% did not receive prophylaxis during the first 24 hours after birth.A higher value than what has been found in some studies (2.1 to 2.2%) (25,26) .
In this study, despite the norms and measures to prevent the vertical transmission of HIV, a part of the country's health policy, with a clear definition of the commitment to these actions by health organizations, the institutionalization process of these recommendations in practice is limited.
Missed opportunities to perform preventive interventions, in pre-natal care, during delivery or for the newborn, show the vulnerability of women and children in the program to HIV, regarding the prevention of vertical transmission.
One of the study's limitations was the incorrect filling of reports, the inconsistence of some data and incomplete information that were important for the analysis.Our suggestion is that the database can be improved by adding information related to the reasons why women do not attend pre-natal care and do not go through HAART intervention.

CONCLUSION
The study showed that, although they were notified as second or third pregnancies with a previous HIV+ diagnosis since their first pregnancy, there weren't a higher percentage of pregnant women in the program than what other studies showed.It is necessary to verify the reasons for the non-adherence to prophylactic treatment and the type of health care provided to these women, since they are HIV positive since their first pregnancy, particularly as to the quality and accountability of these services.

Total 284 100.00 Ocupation (CBO, 2002) 10
Professor and Doctor of the Department of Collective Health Nursing at the Nursing School of the University of São Paulo, São Paulo, SP, Brazil.

Table 1 -
Socio-demographic profile of HIV positive pregnant women in the city of São Paulo, São Paulo, from 2007 to 2011* * Data from March 2011.** The cases considered were the ones that resulted in delivery.Source: SINAN.

Table 3 -
Number and percentage, according to the use of ARV during pre-natal care and education, from 2007 to 2011*

Table 4 -
Number and percentage, according to the use of ARV during delivery, type and evolution of the delivery with pre-natal care, form 2007 to 2011*