Sociodemographic, maternal and clinical conditions of children exposed to the human immunodeficiency virus

This was a quantitative, descriptive cross-sectional study aiming to identify the sociodemographic, maternal and clinical conditions of children exposed to the Human Immunodeficiency Virus, who were treated in a reference hospital for infectious diseases in Fortaleza-Ceara. The sample consisted of 117 mothers who brought their children for consultation between July and December 2009. Data were collected through a semi-structured interview form. There was a higher percentage of mothers aged 20-29 years (53.8%), married (73.5%) and unemployed (68.3%). Most children were less than 12 months old (39.4%), did not receive governmental assistance (66.6%), and did not attend the health service on the scheduled date (77.0%). Some mothers did not use Zidovudine during pregnancy (15.4%), and eight children did not use it after birth (6.8%). Nineteen children did not use prophylaxic Trimethoprim-Sulfametaxazol in the first year of life. It was concluded that most children had socioeconomic difficulties that negatively influenced their health conditions.


Introduction
Described as a complex issue, infection with the Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS) can occur in any individual, regardless of gender, social class, race, religion, among others, leading to changes in biological, social and psychological aspects of the people affected and those people close to them (1)(2) .
Studies evidence that the number of women with HIV has been increasing and most women are infected during the childbearing age, leading to a significant rate of pregnant women in this situation and therefore, a large number of children born who have been exposed to or infected with HIV. Thereby, the tendency of mother-to-child transmission or vertical transmission (VT) increases (3)(4) .
The and psychologically to deliver their infants (1,5) .
At the beginning of the AIDS epidemic, due to the lack of efficient therapeutic methods, expectations of survival for infected children were restricted. With the advent of antiretroviral drugs and the greater interest of the authorities regarding the health and well-being of these children and their families, the situation was changed, and there was increased survival and better quality of life for this population (3)(4) .
As demonstrated by Protocol 076 Pediatric AIDS clinical trial group (PACTG), in order to reduce VT of HIV, the use of azidothymidine (AZT) is recommended after 14 weeks of pregnancy; intravenous AZT in pregnant women is given during labor and childbirth until umbilical cord clamping (5) . For newborns exposed to HIV, substitution of breastfeeding by formula  (5)(6) . Children born exposed to HIV are considered to be at risk. Therefore, it is of great importance to monitor the care of children in consultations scheduled in the specialized care service and ensure that those responsible are receiving free infant milk formula, so that they are not breastfed (6) . Periodic monitoring in specialized services with trained pediatricians should be maintained at least until establishment of the diagnosis. Consultations should be monthly for the first six months and quarterly from the second half of life. If HIV infection is confirmed, treatment will continue in those services. Children without a seropositive diagnosis can be monitored in primary health care (7) .
In Brazil, most individuals living with HIV/ AIDS have unfavorable living conditions, with low education and low income (3) . This fact undermines the access to population health services, and increases financial difficulties due to unemployment and illness. Health conditions are directly associated with the individuals' social conditions. Therefore, health promotion, prevention, rehabilitation and recovery are linked to the conditions presented by the individual, in this case, the child (8) .
Coping, vulnerability and the conditions established to manage living with HIV are problems faced by the children's mothers -both those with the disease and those exposed to the virus -and sometimes by the children themselves. Because mothers constantly encourage their children, take them to regular hospital consultations, assist them with necessary medications, accompany them to exams, they assume a vital role in promoting health and taking care of the child. Antiretroviral treatment of the mother during pregnancy and childbirth, as well as during postpartum follow-up, is a decisive initiative.
In addition to care by specialized professionals and other family members, whose measures are essential to achieving a healthy social, psychological and physical life.
Considering the above, the present study aimed to characterize the sociodemographic, maternal and clinical conditions of children born exposed to HIV who are treated in a reference service for infectious diseases in Fortaleza-Ceará. This study is important for better understanding of the characteristics of these children and can subsidize holistic nursing care directed to existing needs.

Method
This is a quantitative, descriptive-exploratory, In order to meet the study's aim, the following maternal variables were analyzed: age, self-reported race, education, marital status, occupational status, religion, and economic status. In order to meet and clarify the purpose of the study the following maternal variables were analyzed. For the socioeconomic classification, the Brazil Economic Classification Criterion (BECC) was used, which examines families in categories according to consumption patterns or potentials using a socioeconomic scale, through assignment of weights to a set of items, such as domestic comfort and level of education of the head of household (9) . The BECC is presented through five classes, designated A, B, C, D and E. Class A is the one possessing optimum conditions, therefore Class E has negligible conditions for survival.
For the children, the variables adopted were: age (in months), gender, race, result of last anti-HIV serology testing, governmental assistance, use of other health services, attendance at follow-up appointments on the date scheduled, submission to required exams, age of the first consultation of the child in the specialized service, start of AZT use by the mother during pregnancy, start of AZT use by the child, person responsible for the administration of AZT to the child, use of Trimethoprim-Sulfametaxazol during the first year of life, maternal perception of the child's health status.
All mothers were invited to participate in the study while they waited for their children to be attended. The interviews had a mean duration of 60 minutes and were conducted in a private room in order to ensure the confidentiality of information and maintain privacy and spontaneity of the mothers.
Data obtained were tabulated in Excel.
Descriptive statistics and analysis of the associations between the variables, "Brazil Economic Classification Criterion" and "mother's education" with "children's attendance to follow-up appointment on the date scheduled" and "children's submission to required exams", using the Fisher's exact test, were calculated.
For such analyses, a 0.05 (5%) probability of type I error (significance level) was established. A p-value <0.05 was considered statistically significant.

Results
Regarding the sociodemographic characteristics of the 117 mothers with children born exposed to HIV, it was found that the age ranged from 18 to 42 years, with a mean age of 28 years. About race, 71.0% reported being of mixed race (brown). Regarding education, 29.0% were illiterate. Most were married or had a stable union (73.5%), and were unemployed at the time of the study (68.3%). As for religion, 75.2% were Catholic, and 68.3% of families were in Classes "D" and "E", therefore most children lived in environments with minimal access to consumer goods and economic resources. These data are presented in Table 1.    Table 3.    Table 4 provides this data. Table 5 shows the frequency with which mothers brought their children who were born It was also observed that illiterate mothers took their children for the follow-up consultations less frequently than literate mothers (p=0.0005).
Moreover, submission to the exams required for the child was significantly lower (p<0.0001) among illiterate mothers than among literate mothers.
Similar to other studies, this study found that most individuals with HIV/AIDS live in a situation of poverty, low education and unemployment, factors that can negatively influence growth and development of children born exposed to HIV (3)(4)10,12) . It was also observed that some mothers to the advent of antiretroviral drugs (4,13) .
It should be noted that the lack of parental resources, as well as the lack of government assistance, interfere directly and negatively in the treatment and monitoring of children born exposed to HIV. Although Brazil has a very organized national program for sexually transmitted diseases and AIDS in the three levels of care within the Unified Health system (SUS) -federal, state and local, which is internationally recognized and an example for the world for having a program that offers good responses to the HIV/AIDS epidemic, it is worth questioning the future sustainability and the extent to which Brazil has control over an epidemic that grows invisibly in its poor interior. An important indicator is access to antiretroviral drugs, because even if the treatment is offered for free, in many regions, the fact that people do not have enough to eat makes them unable to respond to therapy (10) .
Among the governmental initiatives directed which are directed at follow-up of children born exposed to HIV. These manuals are considered national benchmarks for the care of children and adolescents and have been periodically updated in accordance with the progress of science. Thereby, they offer professionals updates on treatment and management of various other aspects related to infection (3,(5)(6) . These documents also emphasize the need for bonding between the child, parents, caregivers and health professionals.
As noticed in this study, not all children born exposed to HIV made the first appointment at the reference service before the 30 th day of life.
Different reasons may be involved in this absence or irregularity in the follow up of the child. Among them, maternal fear of revealing their serological condition or that of their children is emphasized, because one of the dilemmas experienced by women is disclosure of the diagnosis. They hide it due to the fear of being stigmatized and rejected. They often avoid reporting it to their own family, in order not to be victims of their prejudice (12,14) . Moreover, after the child's birth, When the third test result is negative, the sample is considered "HIV negative" (5)(6) .
In the social and health contexts, family plays a key role as a provider of child care, because the infant depends on others to survive. In this family context, mothers play the role of provider and are responsible for effective communication with health professionals. They seek the best assistance and care, so that a greater health potential can be reached (15)(16) .
It is therefore essential that the survival and health of children and their caregivers, i.e., mothers, are maintained and ensured. It is necessary to improve the conditions of care and access to health services, monitoring of treatment and support offering to those infected in order to ensure adequate assistance.
These mentioned measures are essential to improving the quality of life of children. Associated with that, antiretroviral therapy has benefits for HIV-infected children and mothers' health (5)(6) .
Over the last 10 years there has been a 11.1% decrease in AIDS mortality in Brazil, but according to regions, mortality has increased in the North, Northeast and South (3) . The reduction in morbidity and mortality has occurred due to the advent of antiretroviral drugs in 1996. Brazil was the first developing country to adopt a policy of public access to antiretroviral treatment, and internationally recognized as such by having a program that provides good responses against HIV/AIDS (17) .
The birth of children exposed to HIV is strongly associated with lack of prenatal care and the high rate of HIV in low-income areas. Several factors influence adherence to antiretroviral treatment, so that treatment regimens need to be well assessed for each individual. There is the need to observe the physiological, pathological, social and environmental characteristics of each person, especially related to the child, a fragile and vulnerable being, with greater limitations and dependent on care (5)(6) .
Therefore, treatment and more detailed, specific follow-up must be provided to them, strengthened by greater attention from health professionals and caregiver mothers. The importance of multidisciplinary healthcare teams is highlighted, which can provide adequate treatment and followup for the patient, i.e., the child. This is a complex treatment in which the role of health professionals and healthcare services are crucial to the well-being of children exposed or already infected with HIV (18) . The importance of knowing and demystifying the subject related to children born exposed to HIV is revealed, in order to provide them better quality of life.
Furthermore, adverse life circumstances jeopardize the process of structuring personality, the construction of sociability and psychological maturity. As some authors warn, the experiences that occur in childhood are weighted differently in the human life (12,16,(18)(19) . This fact justifies the expansion of research, with the aim of investigating the contexts and quality of life of children, especially those who face unfavorable everyday life situations, to their full and healthy development, such as children exposed to HIV.

Conclusion
The By knowing the conditions in which children born exposed to HIV live, the significance of these aspects in their lives is understood. Therefore, the attention of family members and health professionals is critical to the physical and emotional well-being of children. Thus, the importance of studies that expose these issues is evidenced, seeking individual effectiveness of health and wellness as well as improvement in public health and well-being of the society, which is constantly exposed and vulnerable to various diseases.
AIDS is confirmed as a stigmatizing disease, which brings a great challenge to family members, health professionals and society. The family becomes obliged to live with many atypical events, like assimilating the fact of having an incurable virus, transmitted to the child, or taking care of a child of a family member who died of AIDS, in addition to often dealing with social prejudice related to the illness.
Thus, for the limitations caused by this condition to be addressed in the best possible way, caregivers need to feel safe and supported by health professionals.
There were difficulties in the development of this study, mainly due to the complexity of the subject, which is childhood AIDS. As a limitation, we emphasize the fact that the interview was held on the same day of consultation, so participants were excessively concerned about missing their consultation because of the interview.
Finally, the aspects related to sociodemographic, maternal and clinical conditions of children born exposed to HIV were observed, and most had socioeconomic difficulties that could negatively influence their health conditions. Studies of this nature are important to recognize the profile of those affected, so that nursing care directed to existing needs and the resources that these individuals have to live can be determined. Further studies about HIV infection and AIDS in pediatric patients are needed, so that care can be performed according to the unique needs of this group of individuals.