INTRODUCTION

The Brazilian and global history of the human immunodeficiency virus (HIV) epidemic is marked by profound epidemiological, social, and political transformations^1,2. These transformations are perceived from the ways of presenting concepts and images to attitudes about the virus, which made it a sensitive social phenomenon and, therefore, susceptible to social representations^3,4.

The most recent concerns about the epidemic are the increasing number of new cases in specific populations, the compromised quality of life and social relationships due to the normalization of HIV as a chronic health condition, and the economic impact on health systems after the expansion of testing and treatment in the health care network^{2)(4)(5)(6)(7)(8)(9}.

About the Health Care Network (HCN), it is defined as polyarchic organizational arrangements that contemplate various technological densities, called health care levels of actions and health care and support services, centralized and coordinated by the Primary Health Care (PHC), which must respond quickly to acute situations and manage chronic health conditions^10,12.

In HCN, health communication related to HIV diagnosis is carried out through the provision of testing, counseling, and treatment addressing issues and elements of social interaction with an impact on people's health status and health work relationships involving motivation, opportunity, and capacity. And it happens with different theoretical, technical, and methodological contributions, as shown in studies conducted in sub-Saharan African countries, the region most affected by HIV in recent years¹, and other Asian and European countries on the subject^6)(7)(8)(9.

This study aimed to analyze the representational contents of health care professionals about HIV in counseling.

MATERIALS AND METHOD

This is a qualitative, descriptive-exploratory study, guided by the process approach of the Theory of Social Representations (TSR)¹³. It is in accordance with the COREQ guide. Developed in the municipalities of Recife and Jaboatão dos Guararapes, Pernambuco, Brazil, selected due to the annual number of new HIV cases per residence in relation to other municipalities in the state, in the period from June 2017 to February 2018.

As for technological density, the scenarios included were eight Basic Health Units (BHU), two Emergency Care Units (ECU), two polyclinics, two Counseling and Testing Centers, three hospitals, being two high-risk maternity hospitals and a general hospital, totaling 17 points in the health care network.

The sample was intentional, non-probabilistic, and consisted of 30 participants, included based on the following criteria: being a graduate health professional; being qualified for HIV testing and counseling; and acting as a counselor for six months or more. Those on leave of absence for more than six months and in exclusively administrative or managerial activities were excluded.

As for the instruments used for data collection, a semi-structured interview script was developed with guiding questions about HIV representations in counseling. Sociodemographic questionnaire with the variables age, sex, religion, profession, and length of professional experience as a counselor. And script for recording non-participant observation sessions in a field diary, with description of the environment in order to differentiate the situations in the levels of care and relationships between people involved, users, family members, partners and counseling professionals.

The data were collected by a doctoral student and two undergraduate nursing students trained and under supervision of the main researcher, leader of the research group, in rooms reserved in the participants' workplaces. All ethical aspects inherent to research with human beings were complied with. The researchers introduced themselves, explained the research objectives, and invited the professionals to sign two copies of the Informed Consent Form. There were seven refusals among the invited counseling professionals. After the pilot test, no need to modify the data collection instruments was identified.

As for the methods and techniques used to analyze the data, descriptive statistics with support from the Statistical Package for the Social Science (SPSS) version 22.0 were used for the quantitative data from the sociodemographic questionnaire.

As for the qualitative data, we obtained individual audio records of the interviews by digital recording in .mp3 format, with an average duration of 21 minutes. The participants could listen to the audios and decide on the exclusion of excerpts or the entire interview. Next, we transcribed the data, which underwent thematic-categorical content analysis, consisting of three stages¹⁴.

In the first of them, called pre-analysis, the corpus obtained from the transcriptions was organized and defined. This resulted in 56 pages of files in .docx format according to the requirements of the ATLAS.ti 8.0® software such as the adequacy of the text to the standard norm; verification of the concordance between the transcriptions and the recorded audios; and standardization of the nomination of the audio and text files with the professional category, attention point and Arabic numeral in order of interview, as in the example: Nurse BHU 14, saved in a specific folder for the inclusion of the project through the creation of the hermeneutic unit¹⁵.

Subsequently, the second stage began, material exploration or coding, in which excerpts from the interviews were grouped by selecting the text read and activating the command create quotes to identify units of meaning, registration and context. In the third stage, called results processing, inference, and interpretation, the categorization process was carried out, that is, the classification of the meaning units into certain categories. For this, readings of the data were done in order to identify patterns, which were incorporated into the descriptions of the thematic categories built, named, and presented using as a guide the theoretical reference of the study, the TSR^{13)(15)(16)(17}. We tried to compose and associate for each verbal record, interview, action or practice the correspondence from the observations recorded in the field diaries^13,15.

The study was conducted in compliance with the ethical aspects provided for in Resolution 466/2012 of the National Health Council (NHC). Evaluated and approved by the Research Ethics Committee (REC) of the University of Pernambuco, Hospital Complex - Hospital Universitário Oswaldo Cruz (HUOC)/ Pronto Socorro Cardiológico Universitário de Pernambuco - prof. Luiz Tavares (PROCAPE), Pernambuco, Brazil, CAAE 79852217.6.0000.5192 and opinion no. 2,431,472.

RESULTS

The participants of this study have a mean age of 48 years, ranging from 26 to 67 years; 80.70% are female; 46.88% are nurses, 28.12% physicians, 15.62% social workers and 9.38% psychologists. Regarding the time they have been working in HIV counseling, it was from 9 months to 24 years, with an average of 12 years as counselors. From the analysis supported by the ATLAS.ti 8.0^® software, it was possible to select 519 RU (Registration Unit) from the 30 interviews, called primary documents, from which three thematic categories emerged, presented below.

DISCUSSION

In this study, it was found that nurses were the most present counseling professionals

of the multiprofessional team in the comprehensive HIV care line, which leads to the need to explore the practices of welcoming, testing, and counseling performed by nurses in the health care network, in order to support the work process or practices of these professionals.

Evidenciou-se a ampla experiência dos profissionais participantes do estudo no aconselhamento, o que permitiu conhecimento sobre relações entre as representações e práticas perante as constantes mudanças e transformações epidemiológicas, sociais e políticas.

As for the representational contents, it was identified that the first category revealed that PHC professionals present HIV as a phenomenon linked to social prejudices rooted in the social imaginary related to death. It is affirmed that these representations are in transformation of the resistant type, when even in contradiction with the previous representation, until then of the hegemonic type, it finds mechanisms to maintain some of its characteristics in the new representation^16,18) that reveal not the fear of biological death, but of social death in the face of prejudice¹⁹.

In a study on the construction and transformation of social representations of AIDS and implications for health care, it was shown that over the decades the introduction of the possibility of living with the virus and the lessening of the importance of death have gained increasing prominence as a result of access to antiretroviral therapy¹⁶, a process called normalization of disease.

Among the findings of the present study, it is noteworthy that prejudice compromises confidentiality and privacy in the reception process, which are assured even in a perspective of reorientation towards PHC, of testing and counseling practices⁵. This is because these efforts were understood as a way to expand the offer only to specific populations, such as women in the gravid-puerperium cycle and patients under investigation for tuberculosis^20,21.

The studies on the social representations of health professionals about HIV are loaded with conceptual dualities that interrelate common sense knowledge and reified knowledge¹⁷. When establishing the health communication process, the professionals project their beliefs, values, and opinions, even if unconsciously, revealing difficulties in dealing with the other's subjectivity, but they recognize that they must consider the user's beliefs and values to be effective in their attempt to promote an encounter and communicate, revealing the intersubjective aspect of health communication^12,22.

Thus, in the second thematic category, the representational contents of HIV of SSA professionals reveal considerations related to vulnerabilities. These representations are considered as emancipated or in emancipation¹⁶, because they are produced in inter-group relations, by divergent groups, professionals, and users, and acquire autonomy when shared and appropriated by both, but can also be understood as intersubjective, i.e., dealing with the encounter between people²³.

A interdependência, ou dependência mútua, afirmada neste estudo, entre os conteúdos representacionais e as práticas, permitiu compor outras considerações sobre a organização das práticas de aconselhamento. Admite-se a identificação de dificuldades entre os profissionais da PHC em garantir o sigilo e a privacidade, levando os usuários à procura de serviços com ênfase no anonimato durante o acolhimento, testagem e aconselhamento enquanto práticas dos THC.

Changes in the way of perceiving and integrating critical conditions and elements of vulnerability, such as gender, race, ethnicity, sexuality, social class, age group, and the effects they produce on interpersonal or intersubjective relationships²³ in professional practice are aimed at improving health care^19-24.

Studies from sub-Saharan African and Asian countries marked by vulnerabilities that threaten women and children, who are daily victims of sexual abuse and violence, argue that testing and counseling needs to address the different realities of people^19,25. A study conducted in Mexico includes violence and immigration as critical elements²⁶. And other studies from Latin America present data that reinforce the increased vulnerability to HIV among some specific populations, called key and priority populations²⁷.

There is criticism of the bio medicalized actions between testing and treatment, demonstrating the increase in supply and diversity of tests and the reduction in importance of counseling^28,29, revealing counseling in some other points of the attention network, characteristics of irreversible situations, those that are present in norms or rules of institutions and that pressure those involved to transform their representations due to the new proposed or even imposed practice²⁸.

In another sense, in the third thematic category, the social representations of HIV refer to the normality of the epidemic in its only biomedical contexts, that is, serological. In this way, the practices converging in a relationship of interdependence with the representations in the HTA reveal the urgency in testing for confirmation of the serological condition, referral, and initiation of antiretroviral treatment in a situation of serious illness or worsening of the health condition or risk for vertical transmission,²⁹ so that the immediate situation can be resolved.

This is because technological advances, both for detection and treatment, mark changes in health practices and policies, and relate to the transformation of representations of the resistant type²⁸, those that are life-threatening to progressive transformation²⁹, or those of the hope for normality based on pharmacological treatment. In other words, at this level of attention, the antiretroviral treatment is presented by the professionals as a possibility to revert the imbalance of the imminent health situation and only then can it be thought of under an educational perspective of adherence²⁵.

It is worth noting that in African countries, in order to expand the diagnosis of HIV, testing is employed as a public health strategy without counseling. In this context, the test is not understood as a professional practice, lay people such as community leaders and volunteers trained for this purpose perform it during health actions and there is also the encouragement of self-testing for specific population groups³⁰.

As a contribution to the advancement of scientific knowledge on the subject, the results may support the development of continuing education strategies for professional qualification and updating, aimed at implementing favorable conditions for HIV-related health communication, especially among nurses, considering that they are the professionals most integrated into the actions, strategies, and programs for testing and counseling in Brazil.

This should be performed from the perspective of health promotion and education, valuing the practices of welcoming, testing, pre-test and post-test counseling, observing the individual and social vulnerabilities, integrating all the potentialities of the health care network in a comprehensive HIV care line guided by the guarantee of privacy and confidentiality.

As for the limits of the study, these stem from the qualitative methodological approach, due to the fact that it does not allow generalizations of results. However, these limitations were circumvented by the possibility of comparability of results with other studies using the theoretical framework of social representations to understand a complex phenomenon of importance to health promotion.

CONCLUSION

The study analyzed the representational contents of health care professionals about HIV in counseling and showed that the circumstances of the situation differ according to the contexts and levels of health care. Furthermore, practices are also influenced and transformed by these representations, as much as the reverse is also true. Even in institutionalized settings, intersubjectivity also seemed to have a relationship with their representations and practices, and therefore can interfere with the way health communication happens.

Health communication practices related to HIV diagnosis in PHC are convergent and did not vary much in each point of care of the same type, the BHU. However, the relationships between social representations of HIV and practices are divergent and subjective. As for SHC, although convergence and clear intersubjectivity are evident in the HCP and a little less obvious in the polyclinic, it is considered that there are divergences between representations and practices, this because, at this level, the points of care are diverse, highlighting the BHU that acts more closely to the practices of the THC in which there is convergence between practices and representations of counseling professionals from maternity hospitals and general hospital.

It is considered that health communication related to the diagnosis of HIV should be guided by the perspectives of health promotion and network health care, so that its intersubjective aspects, i.e., the encounter between subjects in different contexts, denote a possible challenge for health professionals and nursing, so that it is expected with this study to subsidize the professional practice by promoting favorable conditions for health communication. As for the implications for nursing, the study provides directions and actions that enhance the appropriate professional performance, consequently improving the assistance to people. In order that the understanding of intersubjective aspects may subsidize favorable conditions in counseling at all points of the health care network.