Perceptions about HIV/Aids and health inequalities among psychiatric patients in Brazil

Objectives: To describe perceptions about concept and modes of HIV/Aids transmission among psychiatric patients and to assess whether these perceptions differed according to sociodemographic characteristics and psychiatric conditions. We also investigated whether these characteristics were associated with the completely ignorance about the concept and the modes of transmission of HIV/Aids. Methods: Cross-sectional national multicenter study among 2,475 patients selected from 26 Brazilian mental health centers (11 hospitals, 15 outpatient). The perceptions emerged from the following open ended questions: What is Aids for you?; and, How do you think Aids is transmitted?. The textual material was analyzed using content analysis methods. Results were stratified according to sociodemographic variables and psychiatric conditions and analyzed using the chisquared test. Participants who did not know how to answer any of these questions were compared to the others by logistic regression. Results: Overall, perceptions were of disPerceptions about HIV/Aids and health inequalities among psychiatric patients in Brazil Lidyane do Valle Camelo1, Marina Celly Martins Ribeiro de Souza2, Maria Imaculada de Fátima Freitas3, Ana Paula Souto Melo4, Mark Drew Crosland Guimarães5 1 Enfermeira. Doutoranda do Programa de Pós-Graduação em Saúde Pública da Faculdade de Medicina da Universidade Federal de Minas Gerais – UFMG, membro do Grupo de Pesquisas em Epidemiologia e Avaliação em Saúde – GPEAS. Belo Horizonte, MG – Brasil. 2 Enfermeira. Doutoranda do Programa Pós-Graduação em Saúde e Enfermagem da Escola de Enfermagem da UFMG, membro GPEAS. Belo Horizonte, MG – Brasil. 3 Enfermeira. Doutora em Ciencias da Educação. Professora Titular do Departamento de Enfermagem Materno Infantil e Saúde Pública da Escola de Enfermagem da UFMG, membro GPEAS. Belo Horizonte, MG – Brasil. 4 Médica. Doutora em Saúde Pública pela UFMG. Professora Adjunta da Universidade Federal de São João Del-Rey, membro do GPEAS, Belo Horizonte, MG – Brasil. 5 Médico, Doutor em Epidemiologia. Professor Associado do Departamento de Medicina Preventiva e Social da Faculdade de Medicina da UFMG, coordenador do GPEAS. Belo Horizonte, MG – Brasil. Percepções sobre o HIV/Aids e desigualdades em saúde entre pacientes psiquiátricos no Brasil DOI: 10.5935/2238-3182.20130070


RESUMO
Objetivo: descrever as percepções sobre o conceito e formas de transmissão HIV/Aids em pacientes psiquiátricos e verificar se essas percepções são diferentes segundo características sociodemográficas e de condições psiquiátricas.Investigou-se também se essas características foram associadas ao desconhecimento sobre o conceito e as formas de transmissão do HIV/Aids.Métodos: estudo transversal multicêntrico realizado com 2.475 usuários de 26 serviços públicos de saúde mental (11 hospitais e 15 CAPS) no Brasil.As percepções emergiram das seguintes questões semiabertas: o que é Aids para você?; como você acha que a Aids é transmitida?O material textual foi analisado segundo a técnica de análise de conteúdo.Esses resultados foram estratificados segundo variáveis sociodemográficas e de condições psiquiátricas e analisados por meio do teste de qui-quadrado.Os participantes que não souberam responder sobre o conceito ou formas de transmissão do HIV/Aids foram comparados aos demais por meio de regressão logística.Resultados: em geral, as percepções foram de doença, transmissível (por via sexual e sanguínea), incurável e foram permeadas por aspec-Perceptions about HIV/Aids and health inequalities among psychiatric patients in Brazil gender, social status, ethnicity, generation and other social elements, since this action is sensitive to the socio-political, economic and cultural contexts. 13,14btaining information about people's perceptions about HIV/Aids has the potential to identify feelings, representations, evidence of lack of information and how these perceptions are distributed unequally in the socioeconomic and demographic groups, especially in vulnerable population such as psychiatric patients.This diagnosis contributes to construction of public health policies, since it has the potential to reveal aspects involved in comprehension and assimilation of the information as well as the consolidation of knowledge.Nevertheless, there are few studies that investigated perceptions about HIV/Aids in populations with mental illness, and to our knowledge, there is no study carried out in Brazil which used a population-based sample.This study aimed to describe perceptions about concept and modes of HIV/Aids transmission among a nationally representative sample of users of mental health services in Brazil and to assess whether these perceptions differed according to sociodemographic characteristics and psychiatric conditions.We also investigated whether these characteristics were associated with the complete ignorance about the concept and the modes of transmission of HIV/Aids.

Study design and population
For this analysis we used data obtained from the PESSOAS Project, a cross-sectional study conducted in a nationally representative sample of 26 users of public mental health services (11 psychiatric hospitals and 15 public mental health outpatient clinics -CAPS), whose main objective was to determine the prevalence HIV infection, syphilis and hepatitis C. We obtained a random sample (n = 2475) of patients older than 18 years, able to provide informed consent and to answer a questionnaire, weighted proportionally by the type of service (Hospital or CAPS). 15he project was approved by the participating services, by the Ethics Committee of the Universidade Federal de Minas Gerais (COEP/ UFMG, 125/05) and by the National Research Ethics (CONEP 592/2006).Further details about the methodology of this study were described by Guimarães et al. 15 tos negativos.Estas percepções apresentaram diferenças significativas segundo características sociodemográficas e de condições psiquiátricas por 18,6% não souberam indicar o conceito ou forma de transmissão do HIV/Aids e esse grupo teve mais chances de ter acima de 40 anos, menos de oito anos de estudo, não ter renda individual e estar recebendo tratamento em hospitais psiquiátricos.Conclusões: os resultados reforçam a necessidade de medidas macrossociais para minimizar as desigualdades e políticas de prevenção do HIV direcionadas para pacientes com transtornos mentais no Brasil.

INTRODUCTION
There is significant evidence that individuals with mental illness have an increased risk of infection with human immunodeficiency virus (HIV) 1 .3][4][5] This low perception of risk causes a higher vulnerable to HIV in this population, since the perceived risk influences the adoption of protective practices. 6][9][10][11] All these factors can render these patients more exposed to unprotected sex with unknown partners.Additionally, the social isolation, experienced by people with mental disorder, impedes access to information.This contributes to the lack of elementary factors about HIV transmission and prevention, and provides construction of inadequate perceptions, substantially increasing the vulnerability of this population to HIV. 12 The availability of information about the concept and modes of transmission of HIV/Aids is an important aspect to the prevention.However, the comprehension and the ability to assimilate this information that are responsible to the construction of knowledge, and this process is not only influenced by the availability of information, but also by life trajectories, values, feelings, individual and collective social representations and beliefs.The adoption of protective practices from established knowledge is also influenced by Perceptions about HIV/Aids and health inequalities among psychiatric patients in Brazil

RESULTS
Among the 2,475 participants from the PESSOAS Project, the majority were female (51.6%), older than 40 years (51.7%),whites (51.4%), single (67.1%), with less than eight years of education (70.6%), had individual income in the month prior to the interview(59.2%),and had a diagnosis of SMD (56.6%).There was a predominance of patients recruited in CAPS (63.7%).
A total of 5,138 evocations were generated from the question What is Aids for you?. From the analysis of the textual material arising from this question, it was created ten categories that covered 84.3% of evocations (Table 1).Among all participants, 12.9% did not know how to define Aids.The participants defined Aids as a disease (67.9%), transmissible (22.5%), which leads to death (18.5%) and it is incurable (16.8%).Terms indicative of negative perceptions of the disease as a threat, bad and suffering were cited by 25.1% of participants.The perception about Aids was also permeated by its transmission mechanism and etiology, since relative terms sexual act, blood and virus were also present.Expressions related to prevention appeared in only 1.8% of participants' speech (Table 1).

Event and explanatory variables
All participants were submitted to a standardized semi-structured face to face interview, to obtain sociodemographic, clinical and behavioral data.The event of interest was the perception about HIV/Aids and its modes of transmission obtained by the following open-ended questions: What is Aids for you?; and, How do you think Aids is transmitted?.Additionally, participants who did not know how to answer at least one of these two questions were grouped and compared to the others.We assessed the following demographic characteristics: gender, age (≤ 40; >40 years), marital status (married; unmarried), self-reported skin color (white; nonwhite), education (< 8 years of schooling; ≥ 8 years of schooling) and individual income in the month prior to the interview (had no income; had income), local treatment (hospital; CAPS) and main psychiatric diagnosis.Participants who declared to be separated and widowed were grouped as single.Psychiatric diagnoses were obtained through medical records and classified by ICD-10 and were categorized as severe mental disorders -SMD (diagnoses of schizophrenia, bipolar disorder and depression with psychotic symptoms), and other diagnoses were considered mental disorders not severe (MDNS).

Data Analysis
The textual material that emerged from the two open-ended questions was analyzed using content analysis. 16Firstly, it was performed an examination of the discourses through the lexical and semantic analysis.Subsequently, the words evoked were grouped into semantically close categories and analyzed descriptively second frequency of evocation.The proportion of each category that emerged from the content analysis was compared separately according to sociodemographic and psychiatric conditions using the Pearson chi-square test.
Participants who did not know what Aids is or how it is transmitted were compared to others by means of Pearson's chi-square test.Afterwards, it was proceeded to univariate analysis to obtain the odds ratio (OR) and its confidence interval of 95 %, by using logistic regression.Only remained in the final model those variables with p <0.05.Analyses were performed in Epi-Info 3.5.1).Citation of appropriate terms to define Aids as a disease, incurable and transmitted was statistically higher among female participants, aged less than 40 years, with 8 years or more of education, owners of individual income, who were being treated in CAPS and had no diagnosis of SMD (Table 2).Negative perceptions as a threat, bad and suffering or leads to death were cited in a proportion statistically higher among females, and among participants with higher education, that had individual income and that were married (Table 2).
Regarding to the question How do you think Aids is transmitted?, a total of 4,104 evocations were generated, and from the lexical and semantic proximity, we created five categories, which contemplated 91% of the total of all evocations (Table 1).Among all participants, 13.4% were unable to identify the modes of transmission of HIV/Aids.Most respondents indicated that the modes of transmission was through sexual practice (77.7%), followed by the transmission through blood (52.2%) (Table 1).Misperceptions about the disease transmission, such as the idea that HIV/Aids is transmitted through shared use of personal objects, social con-

DISCUSSION
The present study indicated a worrying situation with respect the perceptions about HIV/Aids concept and its modes of transmission in a nationally representative sample of users of mental health services in Brazil.Our results indicate that in general the perceptions about HIV/Aids were disease, transmissible (by sex and blood), incurable and it was permeated by negative aspects.We found that adequate perceptions were most frequently cited among younger participants, with higher socioeconomic status, who were being treated in CAPS and had no diagnosis of SMD.Furthermore, we found that participants who did not know how to describe the concept or form of transmission of HIV/Aids had more chances to be older, to be in socioeconomic disadvantage, and receiving treatment in psychiatric hospitals.
Our results are in agreement with the process of social construction of AIDS, historically guided by ideas of death, promiscuity, the existence of risk groups, innocent victims (eg.newborn, hemophiliacs) and guilty (sex workers, homosexuals and drug addicts). 16tation of appropriate terms to indicate the modes of transmission of HIV, such as through sexual practice and the through blood were significantly higher among male participants with less than 40 years, with 8 years or more of education, owners of individual income, that were married, whites, who were receiving treatment at CAPS and who had no diagnosis of SMD (Table 3).Misperceptions about how disease transmission, such as through shared personal objects, social contact and kissing were cited in a proportion statistically higher among males (Table 3).
The proportion of participants who did not know how to answer at least one of the open-ended questions (18.6%) was higher among women, older participants, with low education, who did not have income, single, and who were hospitalized (Table 4).In multivariate analysis, having age over 40 years old, less than eight years of education, have no individual income and be under treatment in hospital remained associated with did not know how to answer at least one of the two questions about concept and modes of transmission of HIV/Aids (Table 4).(1) The proportions are relative to n total of each category of sociodemographic variables and psychiatric conditions.
Perceptions about HIV/Aids and health inequalities among psychiatric patients in Brazil leads to death".These representations of HIV/Aids are described since the beginning of the epidemic, with a few variations of some elements that appear sometimes stronger, sometimes not.8][19][20][21][22] However, more recently, other factors such as "condom", "preservative", "prevention", "irresponsible" and "neglect" have been found as important elements of representations of Aids in These representations and perceptions allowed a false idea of security or "immunity" of people not classified in risk groups against the HIV virus 16 .Furthermore, the early years of the Aids epidemic in Brazil were characterized by alarmist and sensationalist manner adopted by the media in its divulgation, reinforcing conceptions of disease "risk group", "gay disease" and "disease of others". 17he perceptions that we find in this study may have their origin in the stigma and representation in the imagination of people that Aids is a "disease that Perceptions about HIV/Aids and health inequalities among psychiatric patients in Brazil confirm a previous study that evaluated the knowledge about HIV/Aids in an objective and quantitative analysis in the PESSOAS Project. 28Using a knowledge score, obtained by means of rights and wrongs to ten statements about HIV/Aids and its modes of transmission and prevention, it was found that to be older and having less education were also independently associated with lower knowledge about Aids. 28hile in the general population, single people are more well-informed about HIV/Aids 25 , in this study, single participants had a higher difficulty to develop appropriate perceptions about Aids.Being single was also associated with less knowledge about HIV/Aids in patients with mental illness in other studies. 24Psychiatric patients without company tend to become even more socially isolated, which contributes to less access to prevention information and it becomes difficult to construct appropriate representations about HIV/Aids. 28e have found a higher proportion of adequate perceptions about conception of Aids among females, which could be explained by the potential expansion of the risks of HIV infection among women in the current course of the HIV epidemic in Brazil.However, as in other studies 25 men were more wellinformed about the modes of HIV transmission.Women value more affective relationship, love and fidelity, and they have difficulties to negotiate sexual practices and they have little options of preventive methods under your control. 29,30This may lead the women to seek less information about the modes of transmission of HIV, despite having knowledge of the disease, since it could have the idea that this is not necessary because the partner is faithful and that this activity is man's role.
Participants who were being treated in a psychiatric hospital and had been diagnosed with SMD had more problems to report appropriate perceptions about HIV/Aids.Moreover, hospitalized patients presented more chances to not know how to describe the concept and modes of transmission of the disease.These findings illustrate the need for greater institutional space utilization of psychiatric care, regardless of their nature, to provide access to information, as well as HIV testing and referral.
Our results show that the availability of information is only one aspect that should be considered to the prevention of HIV/Aids, especially in vulnerable populations such as psychiatric patients.9][20][21] But, this situation was not found in the present study, considering that the quotation of elements related to prevention was very small.
The proportion of participants that did not know how to describe the concept or modes of transmission of HIV/Aids was high.This result is worrying, given the high investment in public policies aiming to disseminate information about HIV/Aids.This illustrates that the comprehension and the ability to assimilate information does not only depend on information availability, but it involves the operation of structural determinants and factors related to life course of individuals.These characteristics need to be taken into account in the construction of public policies more efficient, especially in vulnerable populations such as users of mental health services.
Participants with more than 40 years old had more difficulties to construct appropriate perceptions about HIV/Aids and they were more likely to not know how to describe the concept and modes of transmission of the disease.Older individuals probably not had guidance focused on preventive sexual attitudes, as the young people have nowadays.Moreover, they still have a strong representation that Aids is a "disease of others", thus, they would not be susceptible to contamination. 23In addition, patients with mental disorders with more advanced age tend to be more socially isolated, with limited access to information and other elements that can contribute to the consolidation of proper representations. 24National survey that assessed knowledge about modes of HIV transmission in general population also found that older people have less knowledge about HIV/Aids. 25atients with mental illness with less than 8 years of education and who had no personal income also had lower proportions of appropriate perceptions about HIV/Aids and they had more chances to not know how to describe the concept and modes of transmission of the disease.Socioeconomic status have been associated with a lower degree of information about HIV/Aids in studies of the general population [25][26][27] and with psychiatric population. 24,28he differential access to updated information and prevention services added with the strong contextual factors that difficult the adoption of protective behaviors are some of the reasons that may explain this relationship. 29Regarding the education in particular, the lack of ability to read can be a major barrier that limits access to information and the consolidation of appropriate representations. 24,29These results social status, marital status, psychiatric diagnosis, and characteristics of the treatment institution.In addition, contextual factors of family, treatment institution, as well as the socio-political, economic and cultural, which were not analyzed in this work, should also be taken into consideration.
This study has some limitations.We used only two open-ended questions to describe perceptions about HIV/Aids and its transmission.Thus, it was not possible to know the perceptions in depth as in other qualitative research methods, including in-depth interviews or focus groups.However, the sample size, typical of a cross-sectional study, allowed a dialogue between different methodologies, enabling the construction of stratified analyzes to identify statistically significant differences between groups.

CONCLUSION
The results suggest that there are health inequalities evident in this population, since social, demographic and psychiatric conditions appear to be involved in comprehension and assimilation of information by patients with mental disorders.Macro-social and economic actions, directed to addressing social inequalities, and public health interventions, targeting the most vulnerable groups, are needed to address the epidemic of infection by HIV and constitute a challenge to formulators and policymakers in Brazil.

Table 1 -
Perceptions about the concept and the modes of Aids transmission among users of mental health services.PESSOAS Project, 2007 Perceptions about HIV/Aids and health inequalities among psychiatric patients in Brazil tact and by kissing were cited by about 10% of the participants (Table

Table 2 -
Proportions of participants1 who conceptualized the Aids in each category created by content analysis of textual material arising from the question What is AIDS for you?, according to sociodemographic variables and psychiatric conditions.PESSOAS Project, 2007 Notes:(1)The proportions are relative to n total of each category of sociodemographic variables and psychiatric conditions.(2)*indicates p <0.05.Perceptions about HIV/Aids and health inequalities among psychiatric patients in Brazil

Table 3 -
Proportions of participants1 who identified the modes of Aids transmission of in each category created by content analysis of textual material arising from the question How do you think Aids is transmitted?, according to sociodemographic variables and psychiatric conditions.PESSOAS Project, 2007

Table 4 -
Factors associated with ignorance about the concept and/or modes of transmission Aids.PESSOAS Project.2007(N=2.475)