ARTICLE
A look at the factors of vulnerability of adolescents to HIV/AIDS

INTRODUCTION

Adolescence is the phase of a human being's life when many transformations happen in his/her organism and social environment. According to the Child and Adolescent Statute, adolescent is the subject aged 12 to 18 years; however, the World Health Organization states that adolescence is understood from 10 to 19 years old¹.

In this phase, the subject starts to have the ability of generating children, defines his/her ethical and moral values, and molds his/her social and sexual behaviors based on standards defined by society through relations of gender, race, and ethnicity².

For being in a learning process, the adolescent is able more easily to acquire new habits and behaviors, when compared to adults. Thus, health education actions should be performed so that they can acquire a healthy lifestyle³.

Lack of health education actions aimed at adolescents reflects directly on the increase of their vulnerability before situations like unplanned pregnancy, transmission of sexually transmitted diseases (STDs), use of illicit drugs, violence, among others. In this perspective, one may find the human immunodeficiency virus (HIV) infection: researches point out that even though adolescents know a lot about the Acquired Immune Deficiency Syndrome (AIDS), they have questionings regarding the forms of prevention, which therefore increases the cases of infected adolescents¹.

Recent data from the Brazilian Ministry of Health show that, in the period from 1980 to 2012, there was a total of 2,478 cases of HIV/AIDS infection in subjects aged 10 and 14 years, and 12,246 cases in people aged 15 and 19 years⁴.

In 2012, out of the 4,118 cases of AIDS in young people aged 15 to 24 years reported in Sinan, declared in SIM and registered in Siscel/Sisclon, 39.8% were from the Southeast region; 20.3% from the Northeast region; 19.0% from the South region; 12.4% from the North region; and 8.5% from the Central-West region⁵.

In addition, according to the Brazilian Ministry of Health, at Sinan, in the year of 2012, 16,464 cases of AIDS were reported for males aged 13 years or older, of whom 18.3% did not have information of the exposure category. Whereas, with regard to the female gender, out of 8,622 cases of AIDS reported at Sinan, in 2012, 91.2% provided the information of the exposure category⁵.

Epidemics advance in Brazil shows that there is a very wide need of implementing actions for health promotion, maintenance, and prevention in this population through means of the improvement of access to health services, as well as interaction between the professional and the adolescent⁶.

Considering the importance of this theme, sexual and reproductive health of adolescents needs to be further discussed and treated as a priority by health professionals. The principles of confidentiality and privacy must be respected since they are essential for an individualized service, and health education activities concerning contraceptive methods should be feasible. In addition, there is also the need of sexually transmitted infections (STI) prevention.

OBJECTIVE

To identify, based on an integrative review of the national literature, the vulnerability factors that make adolescents more subject to HIV/AIDS infection.

METHODS

This is an integrative review, a methodology that is based on researches of the health area clinical practice through the search of evidence delimited by a theme or question. Its main objective is to expand researcher's knowledge on the investigated theme, reunited and synthesized. This method presents six stages, namely: theme identification and creation of the question that will lead the study; data research and collection (databases choice, year of publication, inclusion and exclusion criteria); evaluation (definition of information to be extracted through the keywords); analysis (aims at elucidating different or conflicting results of the studies included in the research); interpretation of results (critical discussion and evaluation of results); and presentation of results (description of covered stages and exposure of the main research results)⁷.

Due to the increase of cases of adolescents infected with HIV/AIDS, the following questioning came into our minds: What are the vulnerability factors that make this group more vulnerable to HIV/AIDS infection?

Reference collection was performed through the Internet, consulting the Virtual Health Library (VHL), and the following databases: the Scientific Electronic Library Online (SciELO) and Latin American and Caribbean Literature on Health Sciences (LILACS). The study was carried out from March 2013 to January 2014. The research was done using the following keywords found in the Health Sciences Keywords (DeCS): acquired immune deficiency syndrome, vulnerability, and adolescent. Furthermore, as inclusion criteria we used: full texts available on-line and articles published in Portuguese from 2009 to 2014, aiming at contextualizing the study.

References were identified and chosen through three stages. Firstly, the keyword "acquired immune deficiency syndrome" was combined with "adolescent" and 952 titles were found. Then, we compared "acquired immune deficiency syndrome" and "vulnerability", and we found 302 titles, in these ones, some of them were already seen in the previous combination. Finally, we used the combination "acquired immune deficiency syndrome", "adolescent", and "vulnerability", where 76 titles were found, in which some of them had already been encountered in previous researches, therefore there were 1,330 texts.

Great part of these productions were excluded after reading their abstracts, since they did not associate with the thematic of this study, thus only 33 articles remained.

After analytical reading of these 33 texts, only 11 articles were chosen since the others did not fit the inclusion criteria that were established nor were they associated with the leading question of this study.

For information analysis and description, the articles were separated in a table (Table 1). The variables identified after reading the full texts were: author(s), journal, year of publication, methodology, objectives, and factors that make adolescents vulnerable to HIV/AIDS infection (these are emphatically approached in the topic "Results and Discussion").

Table 1:

Variables included in the study sample

RESULTS AND DISCUSSION

When researchers started focusing on the critical analysis of the selected productions, they proved that all of them were published in different journals from the health area; therefore, they are in a simple and determined numeric proportion of 1:1.

After investigating the quantity of published productions per year in the sample, it was seen that in 2011 more articles were found for the study, which may have some association with the Carnival campaign of the Brazilian Ministry of Health. This was released on February 25, 2011, and its slogan was: "Without condom, it will not be possible". This campaign had as its focus adolescents aged 15 to 24 years, and it was carried out in two stages: at the first, adolescents were emotionally moved as to the importance of condom and encouraged to enjoy the festivity using the preservative; at the second, those who did not have intercourse with protection were stimulated to go through HIV testing⁸.

This emphasis on the bigger number of publications in 2011 can also be associated with the II Meeting of the Formation Program of Young Leaders living with HIV/AIDS, performed by the United Nations Children's Fund (UNICEF) from April 15 to 18, in 2011. Around 20 adolescents from all Brazilian regions participated of this event, which had as its objective the exchange of experiences about the disease and discussion regarding prevention, assistance, and rights of teenagers and young subjects with HIV/AIDS⁹.

After observing the methodologies of the chosen publications, it was seen the predominance of descriptive articles represented by 5 articles (45.4%). Furthermore, 4 articles (36.3%) are classified with the quantitative approach.

With regard to the objectives proposed by the investigations identified in scientific journals, it was seen that in 7 of them (63.6%), the authors directed their study towards adolescents' knowledge on HIV/AIDS (what is AIDS, preventive measures, transmissibility, vulnerability, sexual behaviors, among others).

Therefore, the most recurring vulnerability factor to HIV/AIDS infection in the readings performed referred to the insufficient or erroneous knowledge of teenagers about this disease. This is an information that could justify the concern of professionals about the knowledge acquired by adolescents about the epidemics, which directly reflects on the increase of amount of individuals that, by chance, may be exposed and/or infected.

Due to the social existent representations, many adolescents believe that they cannot be infected by HIV/AIDS, naming the infection as "other people's disease", "adult's disease", "of older people" or of specific groups, as prostitutes, homosexual, and drug users¹⁰. However, this belief in immunity¹¹ is dangerous, because the infected adolescent may have some difficulties regarding acceptance and fighting the disease.

Researchers also observed that there is a tendency of epidemics feminization due to gender inequality, lack of information and physiological characteristics, according the following discussion.

Many adolescents do not negotiate the preservative use by several reasons, such as: partner does not like; fear of losing the partner, which makes her passive and dependent of sexist convictions; and fear of not being valued or stigmatized because she suggested the use or for having a condom, even when the sexual intercourse was not planned^12,13.

Some adolescents only make use of the birth control pill, so we can assume that they may not know that this method only prevents an unplanned pregnancy or maybe that pregnancy prevention overcomes STDs¹⁴.

Other important factor in the gender issues concerns violence, evidenced and strengthened by sexual abuse report; lower control about the sexual intercourses and use of preservatives; relationships with older partners; and lower acquisitive power¹⁵.

It is also seen inhibition or even adolescents' unawareness on questions concerning sexuality, which is motivated by society and family's super-masculinity, who many times demands prudence and conservatism - a fact that was not seen in male gender adolescents, who, in general, are treated more liberally¹².

With regard to physiological aspects, we can see that adolescents present higher risk of contracting the infection due to more exposure of his/her uterine epithelium¹⁵.

As to the general knowledge about HIV/AIDS, this theme seems controversial: some studies report their knowledge as unsatisfactory; others, however, declared that adolescents present a good knowledge concerning the causes, symptoms, and treatment. Nevertheless, it is important to highlight that the fact of adolescents mentioning infection as a sexually transmitted infection does not ensure that he/she knows or wants to protect him/herself from the contagion¹⁶.

Studies developed by Brêtas et al. and Nader et al. point that girls have more knowledge concerning STI/AIDS than boys (a fact that maybe happens by the development of each gender). However, one must know that adolescents represent a group with higher risk to exposure and/or infection, since they sometimes feel unable of requesting the use of preservatives during a sexual intercourse^17,18.

Some behaviors mean absence of relevant information regarding the subject and corroborate such information, namely: unawareness of HIV/AIDS transmission by doing anal/oral sex and during menstruation or pregnancy/post-partum; practice of interrupted sexual intercourse; and antibiotic and vitamin intake and, even, washing of the genital areas after sexual practice as a preventive measure^10,17.

We noticed that most adolescents report using condom as HIV/AIDS prevention, however its use is renounced when the partner is well-known, when there is only one partner, and/or when the person trusts his/her partner^11,16. In addition, it was seen the report of male adolescents stating that they do not use the preservative because this method messes pleasure during the sexual act due to sensitivity decrease (which is a myth infused in society from trivial beliefs, capable of resulting in several risks)¹⁴.

Sexual abstinence as prevention, although it is known, is not considered an usual practice and therefore is not seen as a preventive measure¹⁸.

Other vulnerability factor found in the readings concerns "hooking up". This behavior is common among adolescents and is the representation of affection, caress and many times sporadic sex, which favors the increase of STI cases¹⁹.

However, when religion is present in the lives of adolescents, "hooking up" and sexual existences are less frequent, which makes us believe that the religious practice interferes in their lives¹⁹.

It is important to emphasize the homoaffective relationships among adolescents. Hiding the first sexual experiences from family and/or friends, internal conflicts (causes of psychic suffering), social isolation, and low self-esteem (that makes them susceptible to inequality relations of power, in which there is also difficulty in negotiating the use of preservative) are risk factors pointed as constituents for HIV/AIDS infection¹⁵.

With regard to information sources about STI/AIDS, adolescents look for knowledge in means like school, media (Internet, television, radio, magazines, newspapers), health services, teachers, parents, and friends. The media, although a great information provider, is not considered efficient in the transmission of information about HIV/AIDS to adolescents, because it may cause confusions in their mentality and even value distortion^17,18.

On the other hand, family, besides an important connection link, many times cannot have bounds with teenagers to talk about living a healthy sexuality, therefore they are not part of a sexual education context of these subjects^17,18.

As to health services, adolescents who go to such facilities are few, and usually they are girls. This scenario happens due to several factors, among them: absence of actions directed to adolescents; absence of adhesion to the Adolescent Health Attention Policy, preconized by the Brazilian Ministry of Health; and inexistence of bound between professionals from the health services with teenagers. This is the reason why adolescents do not consider the place efficient to care, reception, and health promotion¹².

Hence, workshops and lectures regarding adolescents' sexuality, not only on health services, where the adolescent will hardly be present, but also in schools and in other living spaces, has been an effective and efficient prevention strategy for it stimulates change of habits and behaviors to avoid HIV/AIDS, as well as other sexually transmitted infections^16,20.

The recent increase of alcohol and drug abuse by teenagers is also a point to be emphasized; this behavior consists on a direct factor of risk to infection by the virus since it does not permit that the adolescent takes sensate and preventive attitudes towards the possibility of contracting the virus¹⁹.

Education was also pointed as a vulnerability risk, since the low educational level difficults adolescents' access to relevant information about STI/HIV/AIDS, making them susceptible. However, it is suggested that the real factor of lack of concern as to the STI prevention is the adolescent's behavior¹³.

Finally, it is important to emphasize the vulnerability to which the afro-descendant adolescents are exposed. In Brazil, social and race inequalities have been happening for several years. In addition, it is seen that, summed to the abovementioned vulnerabilities, there are the economical, social, and cultural difficulties from the lowest classes (composed predominantly by black subjects). Thus, it is necessary to create normative and humanitarian policies for the lowest classes, as well as to deepen their knowledge about poverty, ethnicity, equity, discrimination and the connection to risks that adolescents have of becoming infected with the virus¹⁹.

CONCLUSION

In order to meet the strong desire of investigating the vulnerability factors of adolescents before HIV/AIDS, this study enabled fruitful moments with rise of ideas, because through it, we could identify evidence in the national scientific literature of the risks the adolescents are exposed to, as well as to reflect proposals that may decrease the infection.

The used methodology provided the investigation of these factors and the theoretical study about questions concerning the theme, therefore it seems efficient for the objective achievement.

Since remote times, adolescents have been passible of contracting STI. Each period of the Brazilian history brings sexual experiences of adolescents in several ways, depending on their social contexts.

During the Brazilian-colony period until Republic, patriarchalism was the main model of power in the family organization, and sexuality was directed only towards reproduction, with social rules that accepted sexual practice in the marriage and upon men's control. Only from the 1950s, after the appearance of beat and hippie movements, adolescents started to retort the social model under study, which converged in disentail of formerly sexual paradigms and, with this, the right of pleasure, diversification in the way of speaking and acting, use of birth control pills by women and production of pornography²¹.

Contemporaneity, still with reflexes of such revolution, brought to the eyes of society the visualization of subjects that, in the splendor of adolescence, lived sexuality in an active manner and many times inconsequent, hiding such fact from parents, guardians, and friends.

This reality, associated with scarcity of policies directed to adolescents' care, has provided an increase in the number of their cases of infection by HIV/AIDS in Brazil.

Thus, knowing adolescents' susceptibility to this infection allows that actions aimed at this audience be developed, integrating family to school, health services, and other environments in which the adolescent is inserted so that risks be identified and decreased through the determination of adequate strategies.