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ARTICLE INFORMATION
Received: August, 22, 2023
Revised: November, 11, 2023
Available online: November, 18, 2023
at : http://ejurnalmalahayati.ac.id/index.php/nursing/index
Abstract
Background: Human Immunodeficiency Virus (HIV), namely a virus that reduces the ability of the human
immune system, so that sufferers are susceptible to various diseases, the wider scope of ARV administration
certainly has a positive impact in reducing mortality and morbidity, improving the quality of life of patients with HIV
and AIDS.
Purpose: To determine the factors associated with delayed initiation of antiretroviral therapy in Human
Immunodeficiency Virus patients at the VCT (Voluntary Counseling and Testing) Clinic of Pringsewu Hospital in
2022.
Method: This type of quantitative research, using a cross sectional design. The population of this study were HIV
positive patients at the Pringsewu Regional General Hospital Clinic, Lampung for the year 2022, namely 174
patients, using the side total technique. Univariate data analysis, bivariate with chi square and multivariate with
multiple logistic regression tests.
Results: The result showed that the factors associated with delayed initiation of antiretroviral therapy in Human
Immunodeficiency Virus patients at the VCT Clinic at Pringsewu General Hospital in 2022 were Socioeconomic
Status (p value=0.009), education level (p value=0.001, opportunistic infections (p value= 0.001), HIV/AIDS
Stigma (p value=0.003), and Access (p value=0.018). The most dominant factor associated with delayed initiation
of antiretroviral therapy in patients with Human Immunodeficiency Virus infection was access (95% CI, p=0.027
and OR; 3.738).
Conclusion: Antiretroviral therapy (ARV) delays in PLWHA are strongly influenced by low socioeconomic status,
low education level, presence of opportunistic infections, positive stigma and remote access to healthcare
services.
Suggestion: Management at the hospital's VCT clinic is suggested to make guidelines or standardized services,
educate about the importance of ARVs, provide motivation, and carry out consistent control of ARV therapy. The
management always promotes the importance of awareness and adherence in carrying out ARV therapy which
will have many benefits in improving quality of life, healthy behavior, and extending life span.
INTRODUCTION
Human Immunodeficiency Virus (HIV) is a commonly found in AIDS patients in the United
retrovirus that belongs to the lentivirus family. There States, Europe, and Central Africa, while HIV-2 is
are two genetically different but antigenically related more common in West Africa (Kumar, Lodge, Trudel,
types of HIV, namely HIV-1 and HIV-2, which have Ouellet, Ouellette, & Tremblay, 2010). HIV-1 is more
been isolated from AIDS patients. HIV-1 is more easily transmitted than HIV-2. The period between
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Factors related to delayed initiation of antiretroviral therapy among patients with clinically eligible HIV-infected
the first infection and the onset of symptoms is day. Currently, AIDS is the leading cause of death in
longer, and the disease is milder in HIV-2 infections Africa and a quarter of the world (World Health
(World Health Organization, 2023). Organization, 2023).
Human Immunodeficiency Virus (HIV) is a virus In Indonesia, the number of new HIV-positive
that weakens the immune system of humans, cases increased in 2021, amounting 456,453
making patients susceptible to various diseases individuals, consisting of 320,963 with HIV and
(Wibowo, 2015). HIV (Human Immunodeficiency 135,490 with AIDS. Among the HIV-positive cases,
Virus) is an RNA retrovirus that specifically attacks 9,675 individuals tested positive out of 1,030,793
the immune system of the human body. The tested. Among the detected 7,650 HIV-positive
weakened immune system in HIV-infected cases, 8,232 individuals received antiretroviral
individuals makes them susceptible to various treatment (ARV). ARV medication is not meant to
infections, which can lead to the development of eliminate the HIV virus from the body but to suppress
AIDS (Nuraisyah, Matahari, Isni, & Utami, 2021). its growth, maintaining the health of those who are
Human Immunodeficiency Virus (HIV) belongs to HIV-positive. Based on age groups, 69.7% of HIV-
the lentivirus family. The HIV virus is a group of positive cases found from January to December
retroviruses that can utilize its own RNA and host cell 2021 were in the 25-49 age group, 16.9% in the 20-
DNA to form viral DNA. HIV uses the DNA from 24 age group, and 8.1% in the ≥50 age group. HIV-
CD4+ T cells and lymphocytes to replicate. After positive cases among infants ≤18 months were 7 out
formation, the genetic code of the DNA in the form of of 287 babies who underwent HIV testing with PCR
a double strand enters the cell nucleus. Then, with DNA (EID). In terms of gender, 70% of HIV-positive
the help of the enzyme integrase, the viral DNA copy cases were detected in males and 30% in females
is inserted into the patient's DNA. HIV viruses that (Ministry of Health of the Republic of Indonesia,
successfully enter the patient's body also infect 2021).
various types of cells, especially monocytes, Risk factors for HIV-positive cases detected from
macrophages, microglia cells in the brain, placental January to December 2021 showed that 28% were
Hofbauer cells, dendritic cells in lymph nodes, homosexual, 14.4% heterosexual, 10.3% shared
epithelial cells in the intestines, and Langerhans cells needles, and 40.7% were unknown. Among the
in the skin (Nuraisyah, Matahari, Isni, & Utami, 7,650 HIV-positive cases, 2.4% were prostitutes,
2021). 26.5% were Gay, 1.1% were transgender individuals,
Clinical symptoms resulting from HIV infection 0.6% were drug users, 1.2% were inmates, 10.0%
are usually realized by patients after some time due were pregnant women, 13.0% were TB patients, and
to the lack of recovery. HIV-infected patients can 0.8% were sexually transmitted infection (STI)
remain asymptomatic for years. During the course of patients. The number of AIDS cases (HIV-positive
the disease, CD4+ T cells decrease in number from detected already in the AIDS stage, accompanied by
1000/μl before infection to about 200-300/μl after infections related to HIV/AIDS) was 1,677 cases.
infection within 2-10 years (Kurniawati, 2022). The provinces with the highest number of AIDS
Transmission of HIV infection include sexual cases in Indonesia were Central Java, North
contact, intravenous drug injection, blood and blood Sumatra, East Java, West Java, East Kalimantan,
products, and mother-to-child transmission (Ministry and Papua (Ministry of Health of the Republic of
of Health of the Republic of Indonesia, 2015). Indonesia, 2021).
At the end of the 20th century, the World Health In Lampung Province, Indonesia, in the year
Organization (WHO) reported an epidemic caused by 2017, there were 276 HIV/AIDS cases, increasing to
the Human Immunodeficiency Virus (HIV), namely 317 cases in 2018, and further rising to 323 cases in
Acquired Immunodeficiency Syndrome (AIDS). Its 2019. In the period of January to March 2021, there
spread was rapid worldwide. During the period from was an additional increase of 124 cases (Health
1983 to 2011, HIV had infected over 60 million office of Lampung Province, 2021).
people, with nearly 20 million people suffering from Active use of antiretroviral drugs (ARV) has a
AIDS. This led to over 14,000 new infections every positive impact on reducing mortality and morbidity,
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Factors related to delayed initiation of antiretroviral therapy among patients with clinically eligible HIV-infected
and improving the quality of life of people living with experienced delayed ARV initiation, while 337
HIV and AIDS (PLWHA) (Buchacz, Baker, Moorman, patients (75.9%) did not experience delay. Among
Richardson, Wood, Holmberg, & HIV Outpatient the statistically significant variables were
Study (HOPS) Investigators, 2008). opportunistic infection (Sutini, Cahyarti, Rahayu,
Antiretroviral (ARV) drugs are used to suppress Sofro, Fahanah, Pramudo, & Riyadi, 2020). Risk
the development of HIV in the body. Some factors associated with delayed ARV initiation were
commonly used ARV drugs in Indonesia include age > 30 years (pooled OR = 1.46, 95% CI 1.09-
Lamivudine and Zidovudine. The use of ARV serves 1.94), male gender (pooled OR = 1.22, 95% CI 1.01-
to suppress the replication of HIV, not to eliminate it. 1.48), long distance to the clinic (pooled OR = 2.02,
ARV therapy should be administered to individuals 95% CI 1.20-3.40), and fear of confidentiality breach
infected with HIV. If not done, HIV will develop and (pooled OR = 2.72, 95% CI 1.00-7.44) (Sari, Jannah,
its levels will increase in the blood. Discontinuing Tahlil, & Susanti, 2022).
ARV consumption for PLWHA risks the development Research conducted at Amertha Bali Clinic
of resistance to the drug (Mathebula, 2019). concluded that factors influencing PLWHA to initiate
The initiation timing of ARV therapy in HIV ARV therapy include gender (PR = 1.21), education
patients is closely related to the reduction in mortality (PR = 1.22), marital status, insurance ownership (PR
and morbidity among PLWHA (Rahayu, Karjadi, & = 1.17), knowledge (PR = 1.55), perceived barriers
Nelwan, 2016) During the period of 2009 in the (PR = 1.33), guideline-based counseling (PR = 1.42),
United States and South Africa, lower mortality rates and social support (PR = 1.24) (Yuliyatni, 2015).
and lower HIV infection progression were reported in In Indonesia, a total of 49,217 PLWHA received
patients who initiated ARV therapy early after ARV therapy from all 34 provinces. In Lampung
opportunistic infection. Among 283 patients, a higher Province, 319 PLWHA received ARV therapy,
death rate was found in patients with delayed ARV individuals with Human Immunodeficiency Virus
initiation (24%) compared to those without delay infection.
(14%). Some studies also indicated that early Ministry of Health Decree No.
initiation of ARV treatment showed a lower death 451/MENKES/SK/XII states that there are 358
rate (around 1%) compared to those who delayed referral hospitals for PLWHA. These designated
ARV initiation (5%) (Rahayu, Karjadi, & Nelwan, hospitals are required to provide comprehensive
2016). health services to PLWHA, including services related
According to the Minister of Health of the to HIV/AIDS, such as Voluntary Counseling and
Republic of Indonesia Decree No. Testing (VCT), ARV, Prevention of Mother-to-Child
HK.01.07/Menkes/90/2019 on the National Transmission (PMTCT), treatment for opportunistic
Guidelines for HIV Medical Services, ARV therapy infections, and support services (Ministry of Health of
must be provided to all individuals with HIV/AIDS the Republic of Indonesia, 2021).
regardless of clinical stage and CD4 count. For In 2016, there were a total of 3,771 HIV testing
asymptomatic PLWHA, ARV therapy should start services in operation, yet there remained a
within 7 days after a positive HIV diagnosis and significant gap between the number of individuals
clinical examination (Alen, Agresa, & Yuliandra, who needed testing and the number of tests
2017). conducted. Additionally, nearly half of those who
In 2009, research in Nigeria, which has the ever received ARV treatment couldn't maintain it due
second highest number of HIV/AIDS patients after to death or loss to follow-up. The under-utilization of
South Africa, found a proportion of 26% delayed available HIV/AIDS healthcare services may result in
ARV therapy initiation. Delayed initiation of ARV program failure to prevent HIV/AIDS transmission,
therapy in PLWHA could be related to factors such leading to increased HIV rates and higher morbidity
as high CD4 count, low functional status, and low and mortality rates for affected individuals (World
body mass index (BMI) (Arisudhana, & Artati, 2022). Health Organization, 2023).
A study of 444 patients starting ARV therapy for Pringsewu Regional General Hospital is a
the first time showed that 107 patients (24.1%) designated HIV/AIDS referral hospital until
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Factors related to delayed initiation of antiretroviral therapy among patients with clinically eligible HIV-infected
September 2022. In the VCT Clinic section that experts, and existing health policies, the
administers ARV therapy, there are 174 individuals. phenomenon of delayed ARV initiation in PLWHA at
Based on preliminary surveys conducted in October the VCT Clinic of Pringsewu Regional General
2021, among the seven PLWHA utilizing healthcare Hospital is assumed to be related to individual
services at the VCT Clinic, some had higher characteristics (age, gender, education, marital
education but did not adhere well to ARV therapy status, opportunistic infection status, perception of
(experienced loss to follow-up), four out of seven HIV stigma, experience of discrimination, knowledge,
PLWHA, or 57.1%. Among these seven PLWHA, five family support, and social environment support) and
of them, or 71.4%, had good family support, and organizational characteristics (healthcare worker
their knowledge of HIV/AIDS was good. From an behavior, healthcare worker human resources, and
organizational perspective, feedback showed that service facilities).
five individuals, or 71.4%, rated healthcare worker
behavior as friendly and responsive, six individuals, RESEARCH METHOD
or 85.7%, rated the facilities as adequate, but data This research is of a quantitative nature and
indicated that service utilization was not yet optimal. employs a Cross-Sectional approach. The subjects of
There are factors related to delayed ARV this study are HIV-positive patients (UPT HIV) at the
VCT Clinic of Pringsewu Regional General Hospital,
initiation in PLWHA at the VCT Clinic of Pringsewu
Lampung Province in the year 2022, totaling 174
Regional General Hospital that are causing the
patients.
therapy program to not function as intended. This The object of this research is the delay in initiating
study aims to examine the factors related to delayed antiretroviral therapy in patients diagnosed with HIV,
ARV initiation in PLWHA. The basic concept of this where patients who should have received immediate
behavior refers to the health belief model (HBM) treatment experience delays in their therapeutic
theory (Setiyaningsih, Tamtomo, & Suryani, 2016). process. This study is divided into two groups: less than
Each individual has an assessment of belief in their 7 days and more than 7 days. The factors include
vulnerability and severity levels, which influences socioeconomic status, education level, opportunistic
preventive efforts against diseases (Glanz, Rimer, & infection, HIV stigma, and access to facility.
Viswanath, 2008; Rosenstock, 1974). The health Socioeconomic status is divided into high income (>IDR
belief model concept can provide insight into healthy 1,581,000) and low income (<IDR 1,581,000).
behavior for ARV therapy at an individual level. Education level is divided into high school graduate or
Thus, factors related to belief and motivation for ARV above (>senior high school) and less than high school
therapy can be obtained. graduate (˂senior high school). Opportunistic infection
This study seeks to describe the components of factors categorize those infected and those not
HBM, which include beliefs that represent an infected, including ARI, Diarrhea, Candidiasis, and TB.
individual's perception of a condition. Thus far, the The factors influencing stigma HIV/AIDS are divided
Health Belief Model is the most commonly used into positive and negative groups, based on a
theory in health education and promotion (Glanz, questionnaire consisting of five statements. Each
Rimer, & Viswanath, 2008). This theory was chosen statement is scored from 1 to 3, with the total score
ranging from 5 to 15. Stigma is considered positive if
because HBM is a cognition-based theory that
the total score is above the mean and negative if it is
combines knowledge, opinions, and actions taken by
below the mean.
individuals related to their health condition. There is The access to facility factor is divided based on the
a close relationship between beliefs and healthy distance to the clinic: far (>4km) and close (≤4km). The
behavior. research was conducted from March to October 2023.
The situational presence of a pandemic poses a The study obtained ethical approval from the University
threat (perceived threat of injury or illness) as well as of Malahayati's Research Ethics Commission with
advantages and disadvantages (benefits and costs). ethical certificate no. 3405/EC/KEP-UNIMAL/V/2023,
This basic concept guides behavior to initiate a dated May 3, 2023.
process.
Based on the initial survey results, support from
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Factors related to delayed initiation of antiretroviral therapy among patients with clinically eligible HIV-infected
RESEARCH RESULT
Variables Results
Age (Mean ±SD) (Range) (Year) (33.39±0.677) (18-56)
Gender (n/%)
Male 154/88.5
Female 20/11.5
Socioeconomic (n/%)
High 40/23.0
Low 134/77.0
In Table 1, the average age of 174 respondents majority have an education level less than high
shows a mean of 33.39 with a standard deviation of school graduate (˂senior high school), at 66.1%.
0.677 with an age range of 18 to 56 years. Additionally, the majority of respondents have
Meanwhile, based on gender, the majority are male, opportunistic infections, totaling 67.2%. Negative
namely 88.5%. stigma is prevalent among the majority of
Based on the table above, the majority of respondents, accounting for 56.9%, and most
respondents have delayed initiation of antiretroviral respondents have access to clinics nearby,
therapy for more than 7 days, amounting to 72.4%. constituting 78.7%.
Furthermore, the majority of respondents have a low
socioeconomic status, comprising 77.0%, while the
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Factors related to delayed initiation of antiretroviral therapy among patients with clinically eligible HIV-infected
Stigma (n/%)
0,003 3,00 (1,50-5,97)
Positive 30/62.5 45/35.7
Negative 18/37.5 81/64.3
Access to Healthcare
Services (n/%) 0,018 3,90 (1,30-11,7)
Far 4/8.3 33/26.2
Near 44/91.7 93/73.8
Based on the table above, the results of bivariate above high school (˃senior high school) are 26.2%,
analysis reveal relationships with p-values as follows: while those with an education level below high school
socioeconomic status shows a p-value of 0.009, (˂senior high school) are 73.8%.
education p-value of 0.001, opportunistic infection p- For the factor of opportunistic infection,
value of 0.000, HIV stigma p-value of 0.003, and respondents with an opportunistic infection make up
access to facility p-value of 0.018, in relation to the 41.7%, while those without an opportunistic infection
delay in initiating antiretroviral therapy in Human account for 58.3%. Among the 126 respondents who
Immunodeficiency Virus patients. initiated antiretroviral therapy after 7 days, those with
Bivariate analysis results indicate that out of the 48 an opportunistic infection are 77.0%, while those
respondents who initiated antiretroviral therapy within 7 without an opportunistic infection are 23.0%.
days, those with a high socioeconomic status comprise Regarding the stigma factor, respondents with a
37.5%, while those with a low socioeconomic status positive stigma are 62.5%, while those with a negative
constitute 62.5%. Additionally, among the 126 stigma are 37.5%. Among the 126 respondents who
respondents who initiated antiretroviral therapy after 7 initiated antiretroviral therapy after 7 days, those with a
days, those with a high socioeconomic status make up positive stigma are 35.7%, while those with a negative
17.5%, while those with a low socioeconomic status stigma are 64.3%.
account for 82.5%. Finally, for the access to facility factor, respondents
Regarding the factor of education level, those with with distant access to facility are 8.3%, while those with
an education level above high school (˃senior high close access to facility are 91.7%. Among the 126
school) are 54.2%, while those with an education level respondents who initiated antiretroviral therapy after 7
below high school (˂senior high school) are 45.8%. days, those with distant access to facility are 26.2%,
Among the 126 respondents who initiated antiretroviral while those with close access to facility are 73.8%.
therapy after 7 days, those with an education level
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Factors related to delayed initiation of antiretroviral therapy among patients with clinically eligible HIV-infected
Based on the table above, after removing the opportunistic infection, stigma, and access to the
interaction variable, the four variables above have p- service facilities. The final multivariate results
values ≤ 0.05, and no more variables are eliminated, indicate that out of these four factors related to the
thus considered the final model, concluding the delay in initiating antiretroviral therapy, the access to
multivariate modeling. In the final stage, there are the service facilities variable is the most dominant
four variables significantly related to the delay in factor (p=0.027 and OR; 3.738).
initiating antiretroviral therapy: education,
DISCUSSION
Socioeconomic status addressing issues according to ARV therapy
Based on this explanation, individuals with a procedures.
lower socioeconomic status tend to have lower levels
of compliance with ARV therapy. This is due to Opportunistic infection
limited financial resources, which are associated with The statistical test results yielded a p-value of
treatment costs, transportation, healthcare facility 0.000, indicating a relationship between opportunistic
accommodations, and social support.. infections and the delay in initiating antiretroviral
therapy in patients with HIV infection. The OR value
Education level of 4.68 indicates that respondents without
The statistical test results yielded a p-value of opportunistic infections are 4.68 times more likely to
0.001, indicating a relationship between education initiate antiretroviral therapy within 7 days compared
level and the delay in initiating antiretroviral therapy to respondents with opportunistic infections.
in patients with HIV infection. The OR value of 3.33 Based on this explanation, opportunistic
indicates that respondents with an education level infections can hinder ARV therapy in HIV/AIDS
above high school (˃senior high school) are 3.33 patients. Several factors contribute to this, such as
times more likely to initiate antiretroviral therapy treatment complexity. The treatment process for
within 7 days compared to respondents with an PLWHA patients with opportunistic infections
education level below high school (˂senior high becomes complex and intensive, especially when
school). involving additional medications with strict
Based on this explanation, the education factor schedules. This can complicate the management
influences the delay in ARV therapy initiation. There and adherence to the ARV therapy process.
are several ways to address the impact of education Additionally, drug interactions for treating
on the delay of ARV therapy, such as providing opportunistic infections can interact with ARV drugs.
comprehensive and easily accessible knowledge to Drug interactions may affect the effectiveness of
all PLWHA. Additionally, involving social workers, ARV or increase the risk of unwanted side effects..
counselors, and trained medical teams is necessary
to assist low-educated PLWHA individuals in
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Factors related to delayed initiation of antiretroviral therapy among patients with clinically eligible HIV-infected
Sutini, S., Cahyarti, W., Rahayu, S., Sofro, M., World Health Organization (2023). HIV and AIDS.
Fahanah, N., Pramudo, S., & Riyadi, S. (2020, Diakses dari: https://www.who.int/news-
September). Socio-Demografic Characteristics room/fact-sheets/detail/hiv-
Associated with Loss to Follow-up of aids?gclid=CjwKCAjw8symBhAqEiwAaTA__HS6
Antiretroviral Therapy Among HIV and AIDS ngZtTUBdl88YQSlvhjpskKVEjuDqF9jz9Muf3Cxh
Patients in Semarang City, Central Java SgpIUb-1iBoCS04QAvD_BwE
Province: A Case Control Study. In Proceedings
of the 5th International Seminar of Public Health Yuliyatni, P. C. D. (2015) Faktor Determinan Orang
and Education, ISPHE 2020, 22 July 2020, Dengan Hiv/Aids (PLWHA) Memulai Terapi ARV
Universitas Negeri Semarang, Semarang, Pada Program Test And Treat Di Klinik Amertha
Indonesia. Denpasar Bali, jurnal Publikasi Program Pasca
Sarjana Universitas Gadjah Mada Yogyakarta.
Wibowo, A (2015) Kesehatan Masyarakat di Accessed from:
Indonesia Konsep, Aplikasi,dan Tantangan Raja http://erepo.unud.ac.id/id/eprint/5968/1/62479e47
Grafindo Persada Jakarta. Accessed from: 2dd021f2328025602e51f874.pdf
DOI: https://doi.org/10.33024/minh.v6i4.11752
329