INTRODUCTION

The fight against the HIV/AIDS epidemic has a historic opportunity to attain the goal of zero new infections, discrimination, and AIDS-related deaths. This ambitious proposal is underpinned by technical and scientific advances especially in the areas of diagnosis and treatment, where scientific research has shown that the early initiation of antiretroviral therapy reduces complications of the infection and the risk of new transmissions^1)(2)(3.

Since 2014 the Joint United Nations Programme on HIV/AIDS (UNAIDS) established a global commitment that by 2020, 90% of all people living with HIV be aware of their serology, 90% of all people diagnosed with HIV infection initiate antiretroviral therapy uninterruptedly, and 90% of all people receiving antiretroviral therapy have viral suppression⁴.

The 90-90-90 goal provides for a cascade effect through the early identification of people living with HIV and timely initiation of health monitoring and antiretroviral treatment. There are several methodologies throughout the world to evaluate the cascade of care for people living with HIV, being a key component in the evaluation of treatment as prevention⁵. In Brazil, one of the indicators of evaluation of the cascade effect is the entry of people living with HIV/AIDS (PLWHA) with CD4 cell count equal to or greater than 200 cells/mm³, which means an early diagnosis⁶.

Although the cascade of care is an important strategy for achieving the 90-90-90 goal, the fight against the HIV epidemic must be grounded in the principles of human rights and combined with other prevention strategies. The use of coercive strategies, which not only violate the rights of the human person but also weaken the bond and distract people from the services they need, is inadmissible⁷.

The political and social scenarios should also be able to ensure universal access to health monitoring, testing and treatment, especially among key populations who are generally victims of stigma, discrimination and social exclusion. There is also a need to intensify programs for the provision of condoms, control of other sexually transmitted infections, use and access to antiretroviral prophylaxis before and after exposure, and harm reduction services for people who use drugs⁴⁾⁽⁸.

The HIV epidemic puts the entire population in a situation of vulnerability to infection. Much more than an individual problem of PLWHA, the infection reaches the collective range by putting all of us in a world where there is HIV/AIDS, bringing susceptibility to infection among everyone in the world. It is from this perspective of collective vulnerability and collective response that the epidemic that all must be engaged in prevention, harm reduction or treatment⁹.

There are about 34 million PLWHA in the world, with more than 2.2 million new infections and 1.7 million AIDS deaths taking place each year. In Brazil, it is estimated that there are 781,000 PLWHA, but only 649,000 (83%) are aware of their serological status. The national incidence rate is 19.7 cases per 100,000 inhabitants and the mortality rate is 5.7 cases per 100,000 inhabitants. In 2015, 405,000 PLWHA (52%) were using antiretroviral therapy and 356,000 (46%) had an undetecTable viral load, with an increase of 29.4% and 50.8%, respectively, in the last two years⁶⁾⁽¹⁰.

As far as serological testing for HIV is concerned, in Africa, the continent most affected by the epidemic, only 15% of adults were aware of their HIV serostatus in the last 12 months¹¹. In the United States of America, a report from the Centers for Disease Control and Prevention (CDC) indicated that only 45% of adults had been tested for HIV and only 10% to 12% of them had been tested in the last 12 months¹². In Brazil, 33.5% of the population between the ages of 15 and 64 in 2013 had been tested for HIV at least once in their lifetime and approximately 13% had been tested in the last 12 months. The highest rates of completion of the procedure occur among women in reproductive age, probably due to the mandatory prenatal test⁶.

Low access coverage for HIV diagnostic tests produces a domino effect, since late initiation of antiretroviral therapy increases the risk of prevenTable morbidity, AIDS mortality, and transmission of the virus¹¹⁾⁽¹³. In this sense, the present study raises the following research problem: to which extent have the participants of the Carnival in Rio de Janeiro participated in HIV testing and what factors could be associated with adherence to the test? The purpose of this research was to identify adherence to HIV testing and to describe factors of behavioral, social and programmatic nature associated with HIV testing among participants of the carnival in the Rio de Janeiro sambadrome.

METHOD

Research with a cross-sectional design, product of the outreach project of the State University of Rio de Janeiro "Only Joy will Infect The Samba of Prevention will Take Over in this Carnival!". Since its creation in 1991, the project has continued to work in an uninterrupted manner, promoting health education and prevention of sexually transmitted infections/AIDS in the carnival of Rio de Janeiro.

The scenario of the study was the Sambadrome of Rio de Janeiro, place where the apogee of the carioca carnival occurs with the parades of samba schools in the samba street professor Darcy Ribeiro. The population was made up of more than 600 thousand visitors, among carnival dancers, spectators and workers who share in this cultural festival, one of the biggest events in the world. The inclusion criterion for participation in the study was to be aged 18 years or older, and illiterate or visual impaired people were excluded due to the inability to read the questionnaire, as well as people who had not practiced penetrative sexual intercourse (anal, oral or vaginal) in the last 12 months.

The sample size was calculated using formulas for finite populations, considering a sampling error of 5% and a confidence level of 95%. Five hundred and fifty-seven people were selected for convenience, met the established eligibility criteria, and thus participated in the study.

Data collection occurred on the days of the parades of the Samba Schools of the Access and Special Group in February 2016. Seven scholarship holders of the outreach project participated in the collection of data. They were distributed in the popular stands, in the odd and even sectors of circulation, and in the concentrations of people by the "Mail post" and "Balança, mas não cai". Considering that the research was to take place in a festive, competitive and cost-conscious environment, the positioning of the researchers aimed to guarantee the involvement and participation of the interviewees without disturbing the event. Therefore, the research began at 4:00 p.m., one hour before the opening of the gates to access the bleachers (time needed to gather information from the workers), and ended at 9:00 pm, due to the start of the parades.

The data collection instrument used was a questionnaire, containing variables on social aspects (sex, age, schooling, religious belief, work and conjugality), behavioral aspects (extramarital relationships, homossexual practices, sex with multiple partners, drug use, and condom use), programmatic (access to health services), and HIV testing. The preparation of the instrument took into account the objectives of the study, data obtained in previous researches carried out by the project coordinator, as well as the social and epidemiological dynamics of STI/HIV/AIDS. The instrument was subjected to a pre-test in the technical rehearsals that preceded the carnival.

The data collected were organized in a spreadsheet on theExcel Softwareversion 2013, and later imported into the programStatistical Package for the Social Science(SPSS), version 18.0. Data analyses were performed through descriptive statistics, and measures of central tendency and dispersion were calculated for the quantitative variables. APearsonchi-square test was carried out in order to verify the association between variables, with a significance level of 95%.

The development of the study met the ethical recommendations for research involving human beings as described in Resolution 466/2012 of the National Health Council, Brazil. The project obtained a favorable Opinion through protocol 223,405/2013 and CAAE 12602113.9.0000.5291 of the Research Ethics Committee of the Veiga de Almeida University.

RESULTS

Five hundred and fifty-seven people participated in the study, more than half corresponding to females (58.7%), with a mean age of 38.5 years and a standard deviation of 13.4. Regarding the serological test for HIV detection, thegraph 1shows that 369 (66.2%) of the participants had been tested at least once in their life, 302 (54.2%) had been tested in the last 12 months, and only 83 (14.9%) already done the rapid test. Among the people who had been tested in the last 12 months, 178 did so only once, 79 did it twice, and 45 had been tested three times or more.

Figure 1- Realization of diagnostic HIV testing among participants of the carnival in the Sambadrome of the city of Rio de Janeiro. Rio de Janeiro, RJ, Brazil, 2016. (n = 557). 

Table 1presents the analysis of the association between the realization of HIV diagnostic testing and independent variables covering social, behavioral and programmatic aspects. The results showed significant associations (p < 0.05) in the following variables: gender, age group, sTable relationship, being registered in a Basic Health Unit or in the Family Health Strategy (FHS), and being aware of the service that performs free diagnostic HIV testing.

Table 1- Behavioral, social and programmatic factors associated with the realization of HIV diagnostic testing among participants of the carnival in the Sambadrome of the city of Rio de Janeiro. Rio de Janeiro, RJ, Brazil, 2016. (n = 557) 

Source: Prepared by the authors, 2016.

Legend:^*-Pearson Chi-square test.

Table 2shows the analysis of the association between the realization of diagnostic HIV testing in the last 12 months with the independent variables. The results showed significant associations (p < 0.05) in the following variables: gender, age group, sTable relationship, being registered in a Basic Health Unit or in the Family Health Strategy (FHS), and being aware of the service that performs free diagnostic HIV testing.

Table 2- Behavioral, social and programmatic factors associated with the realization of HIV diagnostic testing in the last 12 months among participants of the carnival in the Sambadrome of the city of Rio de Janeiro. Rio de Janeiro, RJ, Brazil, 2016. (n = 557) 

Source: Prepared by the authors, 2016.

Legend:^*-Pearson Chi-square test.

Table 3shows the association between the realization of the rapid HIV testing and the independent variables. The results show that significant associations (p < 0.05) were observed in the following variables: sex, age group, long-term relationship, having had sexual relationship with same-sex person in the last 12 months, having had sexual relationship with five sexual partners or more in the last 12 months, being registered in a basic health unit or in the FHS and being aware of the service that performs HIV diagnostic testing for free.

Table 3- Behavioral, social and programmatic factors associated with the realization of rapid HIV diagnostic testing among participants of the carnival in the Sambadrome of the city of Rio de Janeiro. Rio de Janeiro, RJ, Brazil, 2016. (n = 557) 

Source: Prepared by the authors, 2016.

Legend:^*- Pearson Chi-square test.

The Tables converge to demonstrate that being registered in a basic health unit or in the FHS and knowing the service that performs HIV diagnostic testing for free are the factors that had a significant association (p < 0.05) with the realization of the test at least once in life, in the last 12 months, and with the realization of the rapid test.

DISCUSSION

Brazil has taken on the global commitment proposed by UNAIDS to achieve the goal of 90% of people living with HIV/AIDS by 2020 to be aware of their serology, with the main interventionist measure being the access to diagnostic methods⁴. The present study indicates that only 66.2% of the participants had already undergone the serological exam ever in their lives and 54.2% did so in the last 12 months. Research conducted in Brazil in 2013 shows that 33.5% of the population had at least one HIV test in their lives, 13% in the last 12 months. Among women, the percentage of HIV testing was 40%, 56% higher than that found among men, where only 26% reported having undergone HIV testing at least once in life⁶. Regarding men who have sex with men, a survey conducted in Salvador (Brazil) found that 44.1% of the interviewees had already been tested for HIV, a result higher than that found among men in general¹⁴.

In Spain, a study conducted in 2011 found that about 55% of the Spanish population had previously undergone HIV testing, mainly immigrants. Among those who had never been tested for HIV before, the main barriers mentioned were: low perception of risk and concern about the loss of anonymity¹⁵.

In the United States of America, a research conducted between 2011 and 2013 found that 19% of people aged 15-44 had been tested for HIV in the last 12 months, among which 22% were women and 16% men. Higher percentages of HIV testing were seen in people aged 15-34, non-Hispanic blacks, people with same-sex partners, and people with multiple partners¹⁶.

It is noTable that gender issues still permeate the conduct of HIV testing. Investigations suggest that the greater participation of women in the test is associated with the indication of the test during prenatal care and the strong public policy framework directed at women, while the first comprehensive health policy targeting men in Brazil was launched in the year of 2008. Notwithstanding the programmatic aspects, masculine cultural issues make them believe that they are strong, providers and virile and, therefore, they deny the presence of diseases, considering that care is associated with feminine issues⁷⁾⁽¹⁷.

The recruitment of people for HIV counseling and testing remains low, mainly due to the stigma directed at people living with the virus. A study carried out in a South African community sought to improve attitudes and acceptance of voluntary counseling and testing services through an educational intervention. After the intervention, it was observed that the knowledge of the population about HIV/AIDS increased, the stigma against people living with HIV decreased, and the proportion of HIV testing increased from 40% in 2014 to 70% in 2008¹⁸. Furthermore, a study conducted in Uganda also identified that an educational activity and the approximation of the health services with the local population, with respect to HIV counseling and testing, led to the reduction of risk behaviors, stigma and discrimination associated with the infection and increased testing from 18.6% to 62%¹.

The studies reinforce the need for investments to reduce the programmatic vulnerabilities through the provision of educational activities and the approximation of health services to the population. The data of this research corroborate the cited studies with the finding that participants who were aware of the health services that perform HIV testing free of charge and who were registered in Basic Health Units or Family Health Teams had performed HIV testing more often than those who did otherwise.

The diagnosis of people living with HIV/AIDS is a global commitment to tackle the epidemic. The search for new technologies is imperative for factual effective responses. The advent of rapid testing has revolutionized the access to diagnosis. Besides the immediate result, the test is easy to perform and does not require a laboratory structure, presenting the possibility of testing populations in regions of difficult access or temporary populations. To achieve the ambitious goal of making 80% of the population aware of their HIV status by 2010, the Kenyan government has invested heavily in the provision of rapid testing, either at health facilities, or out of the units through community bases, door-to-door testing and self-testing. Qualitative analyses showed that the population that accepted the door-to-door test had fear of the stigma and emotional vulnerability associated with receiving the result in public facilities. This explains that about 60% of people were tested for the first time through this new methodology of HIV testing³.

The low demand for health institutions or the refusal to go to those places due to fear of stigma and discrimination was also addressed in a meta-analysis. The results indicate that some strategies that have been adopted to ensure a better coverage of HIV testing include: mobile unit testing, door-to-door testing, community testing, self-testing, and testing at workplaces and schools. Tests performed outside health institutions increase the chance of diagnosis of people with elevated CD4 levels, but have a lower positivity rate among those seeking health units¹⁰.

A study conducted with twenty-three health workers from a reference hospital in infectious diseases in Florianópolis (Brazil) identified that HIV/AIDS prevention strategies have been rethought. As condom use is not a constant reality in the life of the population, preventive actions should include a wide set of strategies that range from sex education to early diagnosis¹⁹.

Although the result of the present investigation does not portray the multiple forms of the offer of diagnostic methods for HIV, it is noTable that we can still advance the offer of rapid tests. Although basic health units and the Family Health Strategy (FHS) are associated with a more frequent HIV testing, yet many people may not be covered with screening for fear of attending institutions because of the stigma and discrimination still surrounds the HIV epidemic.

In this sense, the study invites other researchers to analyze the supply and adherence to HIV testing, especially the effectiveness of the multiple ways of offering the test (door-to-door, self-test, mobile units, etc.) and prioritizing the meeting with the most vulnerable and non-affiliated populations.

The limitation of this study is the use of a questionnaire as data collection instrument in a dynamic and festive environment, which may have influenced the inattention of people in the moment of responding to the research questions, considering that the information on testing is self-reported. However, the results show congruence with the literature, demonstrating an increase in the number of tests over the years, probably due to the massive investment in the expansion of rapid testing in Brazil, besides campaigns of the Ministry of Health and the expansion of the FHS, especially in Rio de Janeiro.

CONCLUSION

The present study sought to identify the adherence to HIV testing among carnival participants in the Rio de Janeiro sambadrome. The results showed that 66.2% of the participants had undergone testing at least once in their lives, 54.2% had been tested in the last 12 months and 14.9% had already undergone rapid HIV testing. Among the analyzed variables, age group, having knowledge about places that offer free HIV testing, and being registered in a BHU or in the FHS were statistically significant factors for HIV testing once in life, in the past 12 months, and for the rapid testing.

Data showed that more than half of the population had already been tested for HIV, but we have not yet reached the goal of making 90% of the PLWHA aware of their HIV status. Efforts are therefore still needed to increase the coverage of testing and to maintain a periodicity, especially among the most vulnerable populations.