Profile of adolescents and young adults with HIV/AIDS in the northeast region of Brazil between 2004 and 2016

Original Article

Vol. 16 nº 2 - Apr/Jun - 2019
Pages:72-
81

Profile of adolescents and young adults with HIV/AIDS in the northeast region of Brazil between 2004 and 2016

Authors: ^¹, ^², ^³, ^³, ^⁴

¹PhD in Dental Sciences from the Sao Leopoldo Mandic College (SLMANDIC). Master’s degree in Psychology from the University of Fortaleza (UNIFOR). Professor at the Fametro University Center (UNIFAMETRO). Fortaleza, CE, Brazil

²Master’s degree in Health and Environment from the Federal University of Maranhao (UFMA). Sao Luis, MA, Brazil

³Undergraduate in Medicine from the Federal University of Maranhao (UFMA). Sao Luis, MA, Brazil

⁴PhD in Dental Sciences from the Sao Leopoldo Mandic College (SLMANDIC). Master’s degree in Dentistry from the Cruzeiro do Sul University (UNICSUL). Pinheiro, MA, Brazil

Correspondence:

David de Alencar Correia Maia
FAMETRO Dental Complex
Filomeno Gomes Avenue, No. 184 – Jacarecanga
Fortaleza, CE, Brazil. Postal Code: 60010-281
( davidmaia42@gmail.com )

Submitted on 20/11/2018
Approved on 09/02/2019

Keywords: HIV infections; HIV Seroprevalence; Adolescent; Young Adult; Health Vulnerability.

Abstract

OBJECTIVE: To describe the characteristics of HIV/AIDS in adolescents and young adults between 2004 and 2016 in the nine states of the Brazilian Northeast region.
METHODS: This is a time series study, with data available in the Notifiable Diseases Information System (SINAN) between January 2004 and July 2016.
RESULTS: During the period, a total of 6,981 new cases were reported in the region. The majority were aged between 21 and 24 years (70.90%); male (60.74%); brown race (65.17%); heterosexual behavior (53.56%); with the highest concentration of cases in the state of Pernambuco (23.53%). From 2004 to 2008, there was an increase in the total number of cases, falling in 2009, increasing again from 2010 onwards, reaching its peak in 2013 (945 new cases), decreasing again from 2014 onwards. The highest incidence rates were observed in groups with lower levels of education.
CONCLUSION: AIDS in adolescents has shown an increasing trend in the last decade, with a higher incidence among heterosexual men, aged between 21 and 24 years, which justifies the creation of specific prevention campaigns for the adolescent and young adult population, aiming to combat the disease.

INTRODUCTION In the 1980s, a new disease emerged that was initially identified as a syndrome and was later recognized as a clinical entity of viral etiology, called Acquired Immunodeficiency Syndrome (AIDS). Between 1980 and 1985, the first cases of the disease appeared in the United States, Haiti and Central Africa, and the first case was discovered in Brazil in 1980. In that same year, knowledge of the possible transmission factor through sexual contact, drug use or exposure to blood and blood products was reinforced. The first cases of AIDS reported in Brazil appeared in the so-called risk groups, which included male homosexuals, injectable drug users and prostitutes ¹ . However, the evolution of the epidemic revealed the capacity to reach all people who adopted risk behaviors, such as, for example, having sexual relations without a condom or sharing syringes ² . This syndrome was responsible for significant changes in the field of health and in other areas because it involves aspects related to health and behavior. And, despite having brought challenges to the scientific field and given greater visibility to issues related to sexuality, prevention through campaigns and awareness of health problems has been an important measure for Public Health, ensuring the quality of life of the population ³ . Epidemiological developments have made it possible to target the disease not only to isolated groups (homosexuals, prostitutes and injectable drug users), but to society as a whole. This targeting has shown the growth of infection by the Human Immunodeficiency Virus (HIV) in women of childbearing age. Even so, there has been no change in the stigma regarding the disease ² . The concept of risk or risk behavior has fallen into disuse, being replaced today by social vulnerability, where structural factors have led to the spread of the epidemic, such as material conditions of existence, sexuality, citizenship, race/color, among others, requiring the State to implement policies and/or actions to combat HIV/AIDS from a social perspective and not merely from a health perspective ^2,4 . In addition, the naturalization of HIV/AIDS infection as a disease that can be controlled by medication, the belief that HIV transmission is impossible due to an undetectable viral load, the feeling of invincibility that arises with time spent together as a couple, and its influence on maintaining safe sex are vulnerability factors that contribute to the increase in the number of cases ^5-6 . Today, HIV/AIDS affects several groups, regardless of sex, gender or sexual orientation, and in recent years, the number of cases has increased among adolescents and young adults ⁶. The Health Sciences Descriptors (DECs) ⁷ classify an individual between the ages of 13 and 18 as an adolescent, and a young adult as someone between the ages of 19 and 24. However, the World Health Organization ⁸ (WHO) considers adolescence to be the period from 10 to 19 years, further distinguishing between early adolescence from 10 to 14 years and late adolescence from 15 to 25 years. The concern with the late adolescence age group described by the WHO ⁸ arises from the fact that vulnerability is greater in this age group, as it is a stage of life where social, psychological and physical conflicts are common, and where pleasure is discovered ⁹ . Therefore, health education actions are needed to provide guidance on the risks of sexually transmitted diseases (STDs) in general and AIDS ^6,10 . This phase involves many biological, cognitive, emotional and social changes, and is the time when “new practices and behaviors are adopted, autonomy is gained, and exposure to various situations and risks that may lead to infection” is taken on ¹⁰ . In addition, there has been an annual increase in the number of young people infected with HIV/AIDS, this increase being due to the vulnerability of adolescents, who become sexually active before the age of 15 ¹¹ . A survey conducted by the Ministry of Health on the sexual behavior of the population in 2008 confirms this information, where the data reveal that among Brazilian males aged 16-24, 36.9% had sexual intercourse before the age of 15 and among females, the percentage was 17% ¹² . Early sexual initiation is associated with a high incidence of sexually transmitted diseases (STDs), considered one of the most frequent health problems ^6,13-14 . In Brazil, every year, a contingent of 4 million young people become sexually active, where the median age of first sexual intercourse is 14 years for men and 15 years for women. Early sexual initiation can be considered an aggravating factor for risky behavior in relation to HIV/AIDS, and unprotected sexual intercourse is also an aggravating factor for teenage pregnancy ^6,10,14 . The factors that have contributed to the increased incidence of sexual intercourse among adolescents are multiple and complex, and it is difficult to assess the importance of each of them ¹⁴ . However, the consequences of the young age of female menarche can be observed in the rejuvenation of the reproductive process in Brazil, where the fertility rate among younger women has increased from 17% to 23% in the last 10 years ¹⁵and the feminization of AIDS, which is more intense between the ages of 13 and 19, where there has been an inversion of the proportion of cases between males and females ¹⁶ . This vulnerability of the group included in late adolescence makes this study relevant in describing the incidence of HIV/AIDS in these age groups, alerting for greater care and attention in education and specific health programs for these groups. More than half of the new HIV infections that occur today affect the population aged 15 to 24. However, the needs of millions of young people around the world continue to be systematically unmet when HIV/AIDS strategies are developed or policies are established. It is estimated that 11.8 million young people aged 15 to 24 are living with HIV/AIDS today worldwide. Every day, approximately 6,000 young people in this age group become infected with HIV ¹¹ . Of the 4,500 new HIV infections in 2016, 35% occurred among young people aged 15 to 24, and annually one in ten sexually active people acquires an STD ¹⁷ . The total number of AIDS cases among young people aged 15 to 24, from 1982 to June 2011, corresponds to 66,698. In 2010, the region with the highest incidence rate was the South (14.3 cases per 100,000 inhabitants), followed by the North (12.8), Southeast (9.2), Central-West (7.9) and Northeast (6.9). The sex ratio among young people aged 15 to 24 is currently 1.4, that is, for every 14 men with HIV/AIDS, there are 10 women in the same situation ¹⁸ . Considering the official data on the clinical and epidemiological characteristics of adolescents aged 15 to 24 with HIV/AIDS in the Northeast Region between 2004 and June 2016, it is important to analyze this context in order to describe the profile of the infected population in this age group. In this way, it is possible to suggest the creation of public policies for prevention and treatment in order to guide new research and guide health professionals interested in the subject. OBJECTIVE To describe the profile of the adolescent population with HIV/AIDS in the Northeast region between 2004 and 2016. METHODS To characterize the profile of adolescents aged 15 to 24 with AIDS/HIV in the Brazilian Northeast, the cross-sectional, analytical, descriptive and exploratory method was used. Data collection was performed in SINAN (Notifiable Diseases Information System), SISCEL (Laboratory Test Control System of the National Network for CD4+/CD8 Lymphocyte Count and Viral Load) and SIM (Mortality Information System), made available by the Department of Information Technology of the Unified Health System (DATASUS), at the electronic address ( http://www.datasus.gov.br), considering the period from 01/01/2004 to 06/30/2016. This database is freely accessible to the public. The cases of HIV/AIDS reported in the system, by year of diagnosis, between January 1, 2004 and June 30, 2016 (latest period available) were considered and studied. The population chosen for the present study was adolescents aged 15 to 24 years old with HIV/AIDS, reported by the SINAN, SIM, SISCEL systems. All 6,981 cases reported by the system in the period were studied, this number corresponded to 100%, in this age group in the Northeast region of Brazil. The variables addressed in this study were the following: age, gender, education (years of study), sexual orientation and race. Data on these variables were collected by state and always cross-referenced with the age group, divided into: 15 to 20 years and 21 to 24 years. A link was established between the SINAN, SISCEL and SIM databases. The data were presented in the form of tables and graphs. The data were entered into an Excel spreadsheet where the initial compilation was performed. The results were analyzed using frequency distribution tables and graphs in Excel 2007. The analyses were performed using the SAS program (SAS Institute Inc., Cary, NC, USA, Release 9.2, 2010). The process adopted in the data analysis involved measures in relation to the incidence coefficient according to gender, age group, education, race and sexual orientation. The incidence coefficients were measures of the risk and severity of the disease in these groups. This study complies with the standards of Resolution 466/12 of the National Health Council, and does not require the approval of the Research Ethics Committee, since it uses a database with free public access. RESULTS The majority of adolescents reported with HIV/AIDS in the Northeast region during the period analyzed were between 21 and 24 years old (70.90%), were male (60.74%) and of mixed race (65.17%). A large number of individuals (23.32%) did not report their level of education, but the majority of those who did (32.95%) had incomplete elementary school, and the minority was at the extremes (illiterate, 2.25%; or completed higher education, 2.87%). Regarding the year of notification, a greater number of cases were observed in males throughout the period studied (Figure 1). Among these, the age group of 21 to 24 years prevails, with a higher incidence in the brown race, and with incomplete elementary education (Figure 2).

Figure 1. Number of reported cases of HIV/AIDS in the Brazilian Northeast among adolescents aged 15-24 years, by year and gender. Figure 2. Number of reported cases of HIV/AIDS in the Brazilian Northeast among adolescents aged 15-24 years, by year and level of education.

Due to the Hierarchical Exposure Category, 16.28% of the cases surveyed did not include information on the category of exposure to HIV/AIDS, representing a total of 1,137 notifications (Table 1). Among those in which the information was available, there was a higher incidence in heterosexual individuals, according to notifications from all years.

Regarding the Brazilian state in the Northeast region, Pernambuco had the highest number of reported cases in the period analyzed (23.53%), followed by Bahia (18.94%), Ceará (17.64%) and Maranhao (11.58%), with the lowest number occurring in Sergipe (4.55%) (Table 2). When analyzed by gender, the same states are ranked in the same position in the ranking of notifications, with eight of the nine northeastern states showing a predominance of males, with the exception of Bahia (Figure 3).

Figure 3. Number of reported cases of HIV/AIDS in the Brazilian Northeast in adolescents between 15 and 24 years old according to the notified State, from January 2004 to June 2016.

DISCUSSION The results obtained in the research demonstrate that the incidence of HIV in adolescent individuals aged 15 to 24 years in the studied period has been decreasing. In Brazil, according to data from UNAIDS ¹⁷ , “from 2006 to 2015 the detection rate of AIDS cases among young males aged 15 to 19 years almost tripled (from 2.4 to 6.9 cases per 100,000 inhabitants) and among young people aged 20 to 24 years, the rate more than doubled (from 15.9 to 33.1 cases per 100,000 inhabitants)” ¹⁷ . The research indicated 95.02 cases per 100,000 inhabitants in this geographic region, whose population of young people between 15 and 24 years of age is 7,346,838 inhabitants, according to the IBGE ¹⁹ . The Ministry of Health ²⁰ provides data on the epidemic by geographic region, and the latest publication, in 2016, shows that in the period from 2001 to 2011, the incidence rate fell in the Southeast from 23 to 21 cases per 100,000 inhabitants. In the other regions, this incidence rate increased: from 27 to 31 in the South; from 9 to 20 in the North; from 14 to 17 in the Central-West; and from 7 to 14 in the Northeast ²⁰ . However, when analyzing the data observed in this research, it is noted that cases in the Northeast decreased, and that, when analyzed year by year, there is an oscillation: there was a small increase in the number of cases between 2004 and 2005; in 2006 it decreased and increased again year by year until 2013; but in 2014 there was a significant drop, going from 945 cases in 2013 to 416 in 2014. The results of this research indicated the prevalence of HIV/AIDS in males, in the age group of 15 to 24 years. However, for the Ministry of Health ²⁰ , this difference has been decreasing over the years in the Brazilian context. However, in the Northeast region, this research shows a small difference in the number of cases by gender between the years 2004 to 2009. However, from 2010 to 2014, the ratio between the number of cases in the male gender and the female gender increased: in 2004, the ratio was 1.01 cases of the former in relation to the latter; in 2016 it reached 1.54 cases in the male gender for every 1 in the female gender. Despite this, the ratio of cases between the male and female population remains stable, in line with national data ²⁰ . As for the age group affected by HIV/AIDS, every 14 seconds, a young person between the ages of 15 and 24 is infected with HIV/AIDS. And of all new infections, about half occur in this age group ( ^10-14) . Worldwide, more than seven thousand young people are infected with HIV/AIDS every day, for a total of 2.6 million per year ¹⁷ . In Brazil, data from the Ministry of Health ²⁰indicate that 12,046 cases of HIV/AIDS were recorded among young people aged 10 to 19 years from the beginning of the epidemic in the 1980s to 2012, representing 1.8% of the cases reported in the country. In our research, we noted a higher incidence in young people aged 21 to 24 years (70.90%). This result is related to the notifications that occur in an older age group, but the contamination occurs in an earlier period, with a significant increase in cases in the groups aged 10 to 14 and 15 to 19 years. It should be considered that the infections that led to the cases reported in early adulthood (between 20 and 24 years) most likely occurred during adolescence ^{10, 12} . One of the reasons for HIV/AIDS infection is the lack of access to information, and the lower the level of education, the lower the percentage of knowledge about ways to prevent and transmit HIV ^4,6,10,12,15 . In the data collected in this study, there is an increase in the proportion of the disease in the less educated population and a decrease in the more educated levels of education. This fact leads to a reflection on prevention strategies and educational campaigns, which must be clear and adapted to the level of understanding of people with less formal education, and understanding the vulnerabilities of young Brazilians and their social determinants is fundamental for strengthening public programs and policies ⁶ . Regarding the mode of transmission, the Ministry of Health ²⁰ recorded, in 2012, a percentage of 86.8% of cases (all age groups) due to heterosexual relations. Our research corroborates national data, in which the majority of those who reported their sexual orientation declared themselves heterosexual (3,739 individuals or 53.56%) in all years analyzed. In 2012, 336 cases were reported in adolescents aged 15 to 24, which is equivalent to 37% of the cases reported that year in this age group. The predominance of cases in heterosexuals found in this study can be attributed to several factors, such as difficulty in negotiating between partners to adopt preventive measures; doubts about the effectiveness and use of condoms; lack of knowledge about transmission routes; complete trust in the partner; taboo about immunity; and the absence of strategies to prevent the risks of HIV/AIDS infection ^{2,10,12,14,15} . When analyzed by state (Figure 3), Pernambuco has the highest number of reported cases among the population and period studied, which corroborates other data that indicate that the highest incidence of HIV/AIDS in the Northeast is in coastal cities, due to the greater tourism and sexual exploitation in this region ¹⁸ . CONCLUSION The incidence of HIV/AIDS among adolescents aged 15 to 24 in the Brazilian Northeast from 2004 to 2016 increased until 2013, with divergent behavior between the sexes from that year onwards, having declined in females and having had slight overall growth until 2015. After more than three decades since the beginning of the HIV/AIDS epidemic, it is possible to observe a significant change in the epidemiological characteristics of the disease and the affected populations, denoting the decline of the precepts that entitled specific groups as more predisposed to HIV infection and development of AIDS. According to the research, it is possible to observe this change more directly in adolescents, where heterosexualization is a striking characteristic. With the onset of sexual activity at an increasingly early age, the chances of contracting HIV/AIDS increase. Therefore, it is necessary to plan and implement actions aimed at reducing new infections, as well as measures that seek to improve early detection rates of cases, since the adolescent population does not recognize itself as vulnerable, even after unprotected sexual intercourse. Furthermore, the data collected in this research emphasize the importance of establishing HIV/AIDS prevention and care programs for young people in the Northeast. It is necessary to understand the importance of surveying and consolidating indicators in order to support effective policies and practices for the prevention and control of the main exposure factors, thus contributing to changes in the epidemiological picture of HIV/AIDS in adolescence.

References

1. Garcia S, Souza FM. Vulnerabilities to HIV/AIDS in the Brazilian Context: gender, race and generation inequities. Saúde Soc. 2010 Dec; 19(Suppl 2): 9-20. 2. Villela WV, Monteiro S. Gender, stigma and health: reflections based on prostitution, abortion and HIV/AIDS among women. Epidemiol. Serv. Health 2015 Sep; 24(3): 531-40. 3. Cézar VM, Draganov PB. The History and Public Policies of HIV in Brazil under a Bioethical Perspective. Ensaios Cienc., Cienc. Biol. Agrar. Health 2014; 18 (3):151-6. 4. Schaurich D, Freitas HMB. The HIV/AIDS vulnerability framework applied to families: a reflective exercise. Rev. Esc. Enferm. USP 2011;45(4): 989-95. 5. Reis RK, Gir E. Vulnerability to HIV/AIDS and prevention of sexual transmission among serodiscordant couples. Rev. Esc. Enferm. USP 2009; 43(3):662-9. 6. Fontes MB, Crivelaro RC, Scartezini AM, Lima DD, Garcia AA, Fujioka RF. Determining factors of knowledge, attitudes and practices in STD/AIDS and viral hepatitis, among young people aged 18 to 29, in Brazil. Ciência & Saúde Coletiva 2017; 22(4):1343-52. 7. Descriptors in Health Sciences: DeCS. ed. rev. and ampl. Sao Paulo: BIREME / PAHO / WHO, 2017. [Accessed on April 15, 2018]. Available at:http://decs.bvsalud.org . 8. WHO. World Health Organization. Adolescents: health risks and solutions. May 2017. [Accessed on April 15, 2018]. Available at: http://www.who.int/mediacentre/factsheets/fs345/en/ . 9. Cavalcante MB, Alves MD, Barroso MG. Adolescence, alcohol and drugs: a reflection in the health promotion perspective. Esc Anna Nery 2008; 12:555-9. 10. Câmara SC. Adolescents’ vulnerabilities to sexual transmission of HIV/AIDS: an analysis in the context of the school health program. [Dissertation] Fortaleza: Universidade Estadual do Ceará, Ceará, 2012. 11. Brazil. Ministry of Health. Secretariat of Health Surveillance. National Program for the Control and Prevention of STD/AIDS. Epidemiological Bulletin of AIDS and STDs. Brasília, 2006a. 12. Brazil. Ministry of Health. Sexual behavior of the Brazilian population and perceptions of HIV/AIDS. Brasília, 2009. 13. Linhares IM, Duarte G, Giraldo PC, Bagnoli VR. STDs/AIDS: FEBRASCO Guidance Manual. 10th ed. Sao Paulo: Ponto, 2004. 14. Andalaft JN. Sexual behavior in adolescence. The role of emergency contraception. Journal of SOGIA BR. 2013; 4 (6):8-10. 15. Brazil. Ministry of Health. Secretariat of Health Care. Department of Strategic Programmatic Actions. Theoretical and referential framework: sexual health and reproductive health of adolescents and young people. Brasília, 2006b. 16. Brazil. Ministry of Health. Secretariat of Health Surveillance. National Program for STD/AIDS Control and Prevention. AIDS and STD Epidemiological Bulletin. Brasília, 2008. 17. UNAIDS. Statistics. Global Summary of the AIDS Epidemic. Accessed on April 15, 2018. Available at: https://unaids.org.br/estatisticas/ . 18. Brazil. Ministry of Health. Health Surveillance Secretariat. National Program for STD/AIDS Control and Prevention. AIDS and STD Epidemiological Bulletin. Brasília, 2011. 19. Brazil. Brazilian Institute of Geography and Statistics (IBGE). Population estimates. 2012. [Accessed on April 15, 2018]. Available at: http://www.ibge.gov.br/home/estatistica/populacao/estimativa2012/POP_2012_TCU.pdf . 20. Brazil. Ministry of Health. Health Surveillance Secretariat. Department of STD, AIDS and Viral Hepatitis. Epidemiological Bulletin – AIDS and STD. Brasília, 2016. [Accessed on April 15, 2018]. Available at: http://www.aids.gov.br/pt-br/pub/2016/boletim-epidemiologico-de-aids-2016 .