Prevention of HIV in people who live in a street situation : sharing experiences

Objective: to report the experience of university extension activities for HIV prevention and health promotion to homeless people. Method: a descriptive study, the type experience report, carried out at a referral center for specialized population living in the streets, in the period from May 2016 to August 2017. It was used the arc of Maguerez as the method. Held rapid testing for HIV and viral hepatitis, individual and collective guidelines for prevention and referral of cases required. Results: it was noted the consumption of alcohol and drugs, reports of various types of violence, social stigmas and HIV risk behaviors. Conclusion: homeless people are more exposed to various infections and is in a situation of greater vulnerability. There is urgent need for better inclusion of this population in different spaces that enable their participation in educational activities for health promotion and prevention of diseases that are exposed. Descriptors: Primary Prevention; HIV; Homeless Persons; Problem-Based Learning. RESUMÉN Objetivo: reportar la experiencia de las actividades de extensión universitaria para la prevención del VIH y la promoción de la salud en personas que viven en situación de calle. Método: se realizó un estudio descriptivo, la experiencia de tipo informe, realizado en un centro de referencia para la población especializados que viven en las calles, en el período comprendido entre mayo de 2016 a agosto de 2017. Se utilizó el arco de Maguerez como método. Celebradas las pruebas rápidas para el VIH y la hepatitis viral, individual y colectiva de las directrices para la prevención y la remisión de los expedientes necesarios. Resultados: señaló que el consumo de alcohol y drogas, los informes de los diversos tipos de violencia, los estigmas sociales y de comportamientos de riesgo para el VIH. Conclusión: la gente en las calles están más expuestos a diversas infecciones y se encuentra en una situación de mayor vulnerabilidad. Hay una necesidad urgente de mejorar la inclusión de esta población en diferentes espacios que permitirán su participación en las actividades de educación para la promoción de la salud y prevención de enfermedades que son expuestos. Descriptores: Prevención Primaria; VIH; Personas sin Hogar; Aprendizaje Basado en Problemas. Como citar este artigo: Brito GMI, Oliveira VMC, Borges BVS, Rocha SS, Avelino FVSD, Silva DCP et al. Prevention of HIV in people who live in a street situation: sharing experiences. Rev Pre Infec e Saúde[Internet]. 2018;4: 7740. Disponível em: http://www.ojs.ufpi.br/index.php/nupcis/article/view/7740 DOI: https://doi.org/10.26694/repis.v4i0.7740 Artigo Original Brito GMI, et al Prevenção do HIV em moradores de rua Rev Pre Infec e Saúde.2018;4:7285 2 INTRODUÇÃO A magnitude do Vírus da Imunodeficiência Humana (HIV) é motivo de preocupação, quando, aproximadamente 36,7 milhões de pessoas encontram-se infectadas no mundo e o número de adultos com essa infecção é de 34,9 milhões, com média de 2,1 milhões novos casos detectados ao ano. No Brasil, de acordo com o boletim epidemiológico, de 2007 até junho de 2016, foram notificados pelo Sistema de Informação de Agravos de Notificação (SINAN) 136.945 casos de infecção pelo HIV. Desse total, 92.142 em homens e 44.766 casos em mulheres. A prevalência de HIV no cenário nacional apresenta diferenças regionais, a saber: Sudeste (52,1%), Sul (21,1%), Nordeste (13,8%), Centro Oeste (6,7%) e na Região Norte (6,3%). Estudos mostram que a epidemia do HIV encontra-se com prevalência mais elevadas em populações de maior vulnerabilidade como pessoas que vivem em situação de rua, mulheres profissionais do sexo e Homens que fazem Sexo com Homens (HSH). No período de 2009 a 2013, a taxa de prevalência do HIV foi de 5,9% em usuários de drogas, 4,9% em profissionais do sexo e em HSH variou de 5,2 a 23,7%. Na Grécia, a prevalência estimada de HIV foi de 19,8%, e as probabilidades de infecção foram 2,3 vezes mais altas em sem-teto que injetam drogas. Uma pesquisa nacional, em que se teve 47,1% da população estudada pessoas que estiveram em situação de rua, a prevalência do HIV foi de 6,8% . Entende-se população de rua como "Grupo populacional heterogêneo que possui em comum a pobreza extrema, os vínculos familiares interrompidos ou fragilizados e a inexistência de moradia convencional regular, e que utiliza os logradouros públicos e as áreas degradadas como espaço de moradia e de sustento, de forma temporária ou permanente, bem como as unidades de acolhimento para pernoite temporário ou como moradia provisória”. Nesse sentido, a permanência na rua associada ao uso de drogas, e os diversos tipos de violência vivenciada por pessoas que vivem em situação de rua tornam-as mais vulneráveis a Infecções Sexualmente Transmissíveis (IST), além disso, a falta de conhecimento para adoção de medidas preventivas e de auto cuidado podem comprometer a saúde dessa população. Um estudo revelou que na maioria das vezes, o uso de álcool e crack estão presentes na vida de pessoas que vivem em situações de rua. E isso poderá ser um fator negativo para o uso do preservativo, que é a medida mais eficaz na prevenção das IST. Em Teresina, a população em situação de rua conta com o apoio do Centro de Referência Especializado para População em Situação de Rua denominado de Centro POP. O acesso ao Centro POP ocorre a partir da captação de pessoas que vivem em situação de rua, e posteriormente são cadastradas e passam a receber atendimento pelos profissionias psicólogos e assistentes sociais, especicamente, no que se refere aos direitos sociais. Considerando a Política do Centro POP, em Teresina, não existe assistencia á saúde e desde 2015 conta com o poio do projeto de extensão, para esse tivo de assistencia, que é uma atividade do Grupo de Estudo sobre Infecções e outros Agravos (GEDI) da Brito GMI, et al Prevenção do HIV em moradores de rua Rev Pre Infec e Saúde.2018;4:7285 3 Universidade Federal do Piauí que criou o projeto de extensão intitulado: Promoção da Saúde e estratégias para o enfrentamento da violência, do HIV e DST/Aids em moradores de rua da zona central de Teresina-PI. Diante dessa problemática surge a necessidade de buscar métódos e elementos essenciais para melhor compreensão da realidade. Assim, tendo como base a Metodologia da Problematização, optou-se pela observação da realidade por meio do Método do Arco de Maguerez, elaborado na década de 70 proposto por Bordenave e Pereira (1989). Essa aplicabilidade do Arco de Maguerez, permitiu o cumprimento das etapas para melhor construção do instrumento de coleta de dados. Com base nos fatos apresentados, objetivou-se relatar a experiência e relatar a experiência de atividades de extensão universitária para prevenção do HIV e promoção da saúde em pessoas que vivem em situação de rua.


INTRODUCTION
The magnitude of the Human Immunodeficiency Virus (HIV) is cause for concern, when approximately 36.7 million people are infected in the world and the number of adults with this infection is 34.9 million, with an average of 2.1 million new cases detected per year 1 .In Brazil, in accordance with the epidemiological bulletin from 2007 until June 2016, were notified by the Health Information Systems Programme (HISP) (Sistema de informação de agravos de notificação -SINAN in Portuguese) 136,945 cases of HIV infection.Among this number, 92,142 men and 44,766 cases in women.The prevalence of HIV in the national scenario presents regional differences, namely: Southeast (52.1%),Africa (21.1%),Northeast (13.8%),Center West (6.7%) and in the Northern Region (6.3%) 2 .
Studies show that the HIV epidemic is with higher prevalence in populations of greater vulnerability as homeless people, female sex workers and men who have sex with men (MSM).
In the period from 2009 to 2013, the rate of HIV prevalence was 5.9% in drug users, 4.9% in sex workers and MSM varied from 5.2 to 23.7% [3][4] .In Greece, the estimated prevalence of HIV was 19.8%, and the probabilities of infection were 2.3 times higher in homeless people who inject drugs 5 .A national survey with 47.1% people who were in the streets, the HIV prevalence was 6.8%

Second moment
In October 2016 the activities were initiated at the POP Center.To compose the sample table of Based on this, during the period of extension people in a homeless situation reported drug use, involvement by IST, various types of violence, social stigmas, and stated that the difficulty of family life was the main reason to live on the streets.Furthermore, it was observed difficulty in interpersonal relationship among their peers and also with the work team.
Homeless people often have limited access to health services and healthcare.The lack of activities of prevention and health promotion, coupled with the increase in the prevalence of chronic health conditions contributes to the worsening of preventable diseases.
There is urgent need of prevention programs based on vaccination against hepatitis B, early diagnosis of these infections, as well as greater integration of people living in situations of street in the network of health services so that they can receive full assistance.
Attention to the health of this population should be based on priority actions for assistance, regarding the vulnerability and precarious health, the difficulty of access to health services, stigma and prejudice reported by the participants.
Inter-sectoral and integrated actions that focus on the social inclusion of the people living in the streets, are important for the rescue of citizenship.Moreover, the care for the homeless population through the nursing care must come before the installation of diseases, and/or aggravating, in this way, it is necessary to sharpen these professionals, the development of skills, aimed at better therapeutic approach, listening, empathy, and scientific knowledge.The difficulty in establishing the interpersonal relationship that homeless people demonstrated is possible to be developed.For this, it is necessary to the detachment and empathy, the ability to understand without judging and respect, establishing limits 16 .
People with housing instability that also have long-term illnesses, such as HIV, have a greater risk of negative results of health compared with people housed in a stable way with the same health conditions 17 .
A study conducted in the southeast region of Brazil found a prevalence of 4.9% and 12.5% for HIV and syphilis in homeless people8.Surveys conducted in the world scenario, as in Costa Rica and in Iran also found high prevalence of HIV (7% and 3.4%), hepatitis B (32% and 2.58%) and hepatitis C (4% and 23.3%) [18][19] .
Without knowing the history of the person who lives in the streets, with their adversities, complaints, adversity and their natural universe, become impractical or difficult to investigate their real needs and desires while humans 14 .
The activity has contributed to applying academic knowledge which can arise the interest for assistance in vulnerable populations in future projects.The Theorization, a planning and implementation of educational actions allowed list key points important for construction of instrument and best approach related measures for the prevention of HIV and the promotion of health with a view to increasing access to health services through referrals.
The study presented as the main limitation not being able to count on the population universe of people in a situation of street.It stands out: because this population is of difficult access and approach, some participants did not continue with the receipt of activities regarding:

6 .
It is understood street population as"Heterogeneous population group that has in common extreme poverty, family bonds interrupted or weakened and the lack of regular conventional housing, and that uses the public places and the degraded areas as living space and sustenance, temporarily or permanently, as well as the units for temporary accommodation or as provisional housing"7 .In this sense, the sojourn on the street associated with drug use, and the various types of violence experienced by people living in the streets make them more vulnerable to sexually transmitted infections (STIS), moreover, the lack of knowledge to adopt preventive measures and self-care can compromise the health of this population.A study revealed that in the majority of cases, the use of alcohol and crack are present in their lives.And this may be a negative factor for condom use, which is the most effective measure in the prevention of STIS8 .InTeresina, the homeless population counts with the support of specialized Reference Center for Homeless Population called POP Center.Access to the Wellness POP Center occurs from the abstraction of people living in the streets, and subsequently are registered and receiving care from professional psychologists and social workers regarding social rights.Whereas the POP Center's Policy, in Teresina, there is assistance to health and since 2015 has the extension project support, for this type of assistance, which is an activity of the Study Group about infections and other ailments (GEDI) at the Federal University of Piauí which created the extension project entitled: Health Promotion and strategies for coping with violence, HIV and STD/Aids in street dwellers of the central zone of Teresina-PI.Due to this problem arises the need to seek methods and essential elements for a better understanding of reality.So, taking as a basis the Problematization Methodology, it was Brito GMI, et al Prevention of HIV in people who live in a street Rev Pre Infec e Saúde.2018;4:7285 3 decided the observation of reality by means of the method of the arc of Maguerez, drawn up in the decade of 70 proposed by Bordenave and Pereira (1989)9.This applicability of the arc of Maguerez, enabled the completion of the steps to better construction of a data collection instrument.Based on the facts presented, this study aimed to report the experience and reporting the experience of university extension activities for HIV prevention and health promotion for homeless people.METHOD It is a descriptive study, experience report type, drawn up during the activities of an extension project entitled: "Health Promotion and strategies for coping with violence, HIV and STD/Aids in street dwellers of the central zone of Teresina-PI" developed by the Federal University of Piauí, which happened in two moments: the first occurred in May to August 2016 which corresponded to the planning of activities; the second, developed in October 2016 to August 2017 was characterized by the site recognition and implementation of proposed activities.Firts moment In this planning phase was the selection of students considering the better academic performance, the identification and affinity with the work and knowledge about the topic.In this sense, were selected four students to integrate the extension project.Initially, a meeting was held with the staff of the POP Center to explain the objectives and goals, request support for implementation of the project in relation to the appropriate physical space, security of the team and define inclusion criteria (age greater than or equal to 18 years and live on the streets for more than three months) and did not present aggressive behavior at the time of the activities.Subsequently, the fellows were oriented to the development of activities with people in the streets by active methodology of the arc of Maguerez, following the steps: reflect on the reality found, define Key Points, Theorization, Hypotheses of Solution and Application to Reality 9 .In the stage of observation of reality it was noted: predominantly male population, lack of housing, drug use, difficulty of approach and devaluation of self-care.Afterwards, emerged the following question: measures related to HIV prevention and health promotion are developed for people living in the street?It was defined as key points: little information regarding the prevention measures for HIV and health promotion, consumption of alcohol and other drugs, violence, and difficulty of access to health services.In step Theorization were listed: health behaviors among young people in the streets showed their vulnerability to HIV infection as a result of their high levels of high-risk sexual behavior, i.e., multiple sexual partners, involvement in survival sex and inconsistent use of condoms in contexts of considerable consumption of alcohol and drugs.Besides, many factors make young women vulnerable to HIV infection, such as the lack of power to negotiate safer sex, sex trade, be victims of forced sex 10 .Brito GMI, et al Prevention of HIV in people who live in a street Rev Pre Infec e Saúde.2018;4:7285 4 The high consumption of alcohol increases the risk of a number of communicable diseases and non-communicable diseases, including HIV.The link between the consumption of alcohol by men, and the increase of sexual risk behavior with the acquisition of HIV was documented in a variety of subpopulations and settings, including Angolan soldiers, migrants from central region and migrant workers in Kazakhstan and male homosexuals in India.Excessive alcohol consumption showed that can increase the progression of the disease in people living with HIV 11 .On this basis were listed the following issues: carrying out educational interventions to expand the knowledge of homeless people in relation to preventive measures contributes to the reduction of risk behaviors, and thus helps to prevent HIV and promote health?Based on the findings was built an instrument type form that has been validated on the form and content by three judges with experience in the subject matter.This form contained questions relating to sociodemographic and behavioral aspects.Yet, in this phase of the project scholars empowered to carry out rapid tests for detection of HIV and viral hepatitis.During these activities, was the advice in the pre and post test, and all participants were instructed to individually and collectively about the preventive measures for the reduction of HIV infections.
participants was used non-probabilistic sampling, of the convenience type; thus, the people in the streets that existed at the time of data collection were invited to participate in the research.In the end, it was told with a total of 250 interviewed.In this way, the data collection occurred through the applicability of the instrument, implementation of rapid testing and individual and collective guidance for HIV prevention and improvement of self-care and referral of cases required.This is a population of difficult approach and for greater adherence to the project by this population the team attended an average of four participants per day, taking into account the individual characteristics, such as the level of understanding and time availability.After applying the instrument was offered the rapid test for HIV, hepatitis B and C. For all who agreed to perform the examination was requested signing the Informed Consent Form (ICF) and was carried out pre and post-test counseling.In addition to this advice, people in the streets were oriented about preventive measures for the reduction of risks to Sexually Transmissible Infections, namely: the use and distribution of male and female condoms and gel lubricant; not sharing of sharp and piercing objects; clarification on the increased risk of contracting HIV by the use of drugs, lack of housing, and high-risk sexual behavior; incentive to routine and regular testing; strengthening the HIV-positive serum or discordant couples on the importance of the use of antiretroviral treatment is associated with the use of condoms to minimize the risk of HIV infection, as well as adherence to pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP).Brito GMI, et al Prevention of HIV in people who live in a street Rev Pre Infec e Saúde.2018;4:7285 5 TAll participants with results reagents for HIV and hepatitis were referred to the Outpatient Care (Serviço de Assistência Ambulatorial -SAE in Portuguese).All the participants forwarded were instructed to return to the POP Center, in the face of any difficulty of access to health services.This proposal has met all the ethical requirements nº 1.755.893 12.RESULTS Understanding Vulnerabilities of Homeless People Extension activity is an opportunity to share scientific knowledge with society promoting health promotion and prevention of disease.It is through the realization of projects of extension that is possible the interference and social change in the life of a subject 13 .Homeless people have different characteristics, related to age ranging from youth to the elderly, and also in relation to schooling may be low level high.The majority are men from Teresina and other states of Brazil.These people are more exposed to various infections and is in a situation of social vulnerability, when resources and skills are insufficient or inadequate to deal with the opportunities offered by society 14 .
services it must improved the reception to people living in the streets taking as a basis the National Policy for homeless population, in order to respect the dignity of the human person, the right to family and community life, appreciation and respect for life and citizenship, the humanized and universalized and respect to social conditions Brito GMI, et al Prevention of HIV in people who live in a street Rev Pre Infec e Saúde.2018;4:7285 6 and differences of origin, race, age, nationality, gender, sexual orientation and religion, and disabled persons 7 .DISCUSSION It is characterized as a population living in the streets, the group of people who have in common the extreme poverty, family bonds interrupted, experiences of a social process of disaffiliation by absence of wage labor and the protections derived or dependent on this form of work, without regular conventional housing and the street as the living space and sustenance 15 .
aggressiveness and change of address or hospitalization in institutions of rehabilitation.Highlights the importance of the partnership of a multiprofessional team of POP Center for best initial approach and support of security guards during the whole period of implementation of the activities.CONCLUSION People who live in the street are more exposed to HIV infections, considering the consumption of alcohol and other drugs, reports of violence and difficulties of access to health services.Reporting the experience gained with the use of the methodology of problematization awakened in the participants of the extension activity new perspectives on strategies for the prevention of HIV and other infections, and health promotion in people in a situation of street.Moreover, the study revealed that problems experienced by the community, Brito GMI, et al Prevention of HIV in people who live in a street Rev Pre Infec e Saúde.2018;4:72857 especially in vulnerable populations has little visibility to students and the general population, in this way, it is necessary the discussion of these issues, to draw up effective interventions for health care, disease prevention and reducing the grievances.Therefore, university extensions are considered essential activities when favoring the reflection and construction of critical thinking, guided in action-reflection-action and in relations further university.