Analysis of Psychological Problems in People with HIV/AIDS

HIV/AIDS is a disease that attacks the immune system, which causes opportunistic infections. In addition to physical problems, many experience psychological disorders which further reduce the quality of life of PLWHA. This study aims to analyze psychological problems in PLWHA. The design of this research was an observational descriptive study with a population of PLWHA who visited VCT polyclinic at M.Djamil Hospital, Padang. A sample of 50 respondents was selected using a purposive sampling technique. The inclusion criteria were HIV patients who were willing to participate and the exclusion criteria were patients who had opportunistic infections and severe drug side effects. Data collection was carried out by interviewing and using a questionnaire. The results of this study found that the most negative experience that occurred were receiving stigma and negative behavior from society (62%), having experienced violence (54%) and being MSM (52%). The most common negative thoughts are fear of social stigma (84%), fear of dying in severe AIDS (70%)


INTRODUCTION
Adressing public health issues such as the infectious disease HIV/AIDS is a challenge for all countries (Aini et al., 2021).An estimated 38 million people worldwide are HIV positive.An estimated 690.000 people died from HIV and 1.7 million people were newly infected in 2019 (Awopegba et al., 2020;Ilmiatun et al., 2021).In China, estimations indicated that the number of HIV/AIDS cases would be >1 million by the end of 2018 and continue to grow in the next few years.The early epidemic stage of HIV/AIDS in China was closely associated with intravenous drug use (IDU) and sharing syringes and concentrated among intravenous drug users and men who have sex with men (MSM) (Yuan et al., 2021).Indonesia is a country ranked 5 th most at risk of contracting HIV in Asia (Aini et al., 2021).Report on the development of HIV/AIDS and sexually transmitted infections in March counted 274,875 HIV positive people with West Sumatra ranked 14th in the province with the highest number of HIV patients with 14,918 people (Kemenkes, 2022).
Human Immunodeficiency Virus (HIV) is a virus that attacks the human body's immune system such as CD4 lymphocytes.Acquired Immune Deficiency Syndrome (AIDS) is a collection of symptoms of decreased self-defense abilities (Sustrasno et al., 2021).HIV patients will experience a decrease in their CD4 count, which is less than 200 cells/mm3, indicating that the human immune system is very weak.When the immune system is weakened, the body is unable to fight various causes of disease that can cause opportunistic infections such as weight loss, prolonged fever, enlarged lymph nodes, diarrhea, tuberculosis, fungal infections, herpes, and others (Roza et al., 2022;Sustrasno et al., 2021).
Most people infected with HIV experience difficult times in their lives resulting in psychological disorders.Psychological disorders occur when the patient first receives information that the patient is infected with HIV.most people go into severe shock.Many questions arise for PLWHA about how their life will be in the future, how long PLWHA can survive, and how this disease will affect those close to them.This is because there is no correct response to this disease in society.Each patient sees this disease differently.Many are consumed by anger, depression, hopelessness, and fear for themselves and loved ones and even contemplate suicide.Other patients are just the opposite, very calm (Muzaffar, 2022) These psychological disorders are increasing when they learn that PLWHA has to take drugs throughout their lives, as well as the side effects of physical disorders experienced by patients.Most patients with HIV infection are young people who have no prior experience with everyday medication.Some of them are afraid to think about the inability of their immune system to fight this deadly virus, the difficulty in taking medication, and the possible side effects of taking ARVs (Aini et al., 2021;Roza et al., 2022;Muzaffar., 2022).Psychological disorders apart from being caused by physical problems can occur due to the emergence of stigma and anxiety in the community experienced by PLWHA (Defiaroza, 2018).Fear, shame, and rejection cause PLWHA to experience severe depression which will have an impact on reducing the immune system of people with HIV, causing a decrease in the quality of life of HIV patients (Meo et al., 2021;Roza et al., 2020).
The emergence of negative stigma toward PLWHA as a result of factors connected to this disease such as multiple partner sexual activity, homosexuality, addiction to psychotropic narcotics and other addictive substances (drugs), ignorance of HIV transmission and immoral behavior that is unacceptable to society (Al Fatih et al., 2021).According to Noerliani's research, 57.4% of the respondents from the Madiun district community believed that PLWHA were associated with persons in a bad environtment.58.8% of respondents stated that PLWHA are sexual customers.55.3% of respondents stated that PLWHA are adherents of free sex and 51.8% of respondents stated that PLWHA are drug users (Noerliani, 2022).
The forms of stigma and rejection that PLWHA receive include family rejection, exclusion and disposal of PLWHA to remote places, separation of cutlery at home, divorce disputes from spouses, access to public services and moral enforcement are limited because they are considered immoral, do not want PLWHA to be in groups or organizations, and hostility both verbal and physical (Al Fatih et al., 2021).It is estimated that around 50% of men and women experience stigma and treatment related to their status as HIV patients in 35% of countries in the world (Aryastuti et al., 2020).In a survey conducted by Asia Pacific Network of People Living with HIV/AIDS in India, the Philippines and Thailand, 50% of 726 HIV positive individuals reported warnings from the healthcare system, care denial from medical facillities, and even physical violence and expulsion from their homes by their own families (Suswani et al., 2022).
Stigma and treatment do not only occur in PLWHA but also occur in PLWHA families, namely 14% stigma and hatred from neighbors, stigma from co-workers by 7%, stigma from the work environment by 5%, stigma from the school environment by 3%, and the worship environment.by 3% (Noerliani, 2022).In other words, psychological disorders in PLWHA occur not only due to past experiences, but due to the emergence of ongoing problems caused by internal (somatic) and external (stigma) factors related to the patient's present and future life (Rzeszutek et al., 2021).All crisis situations associated with these psychological disorders cause PLWHA to feel hopeless, guilty, anxious, and afraid of loss.Many PLWHA are very aware of their own mortality and are afraid of losing their physical strength, health, and independence, or losing friends and loved ones, coupled with the emergence of stigma and surveillance from society (Muzaffar, 2020).This of course creates negative thoughts, events, and behaviors that interfere with PLHIV's adherence to their illness as well as psychologically disturbing PLHIV such as irritability, self-closure, suicide, and others.Therefore this study was conducted to analyze negative events, thoughts, and behaviors that interfere with the psychology of HIV/AIDS patients or people living with HIV.

METHOD
The research design was descriptive observational with a sample of 50 respondents to analyze negative events, thoughts, and behaviors that interfere with the psychology of HIV patients.The population is HIV/AIDS patients who visit to the VCT polyclinic at RSUP Dr.M.Jamil Padang.The sampling technique used was purposive sampling technique.Inclusion criteria viz HIV patients who agreed to participate in the study.Exclusion criteria were patients who were experiencing severe opportunistic infections and were experiencing severe drug side effects.Prior to data collection, patients were asked to fill out informed consent.The data collection technique was an interview using a questionnaire which contained negative events, negative thoughts and negative behaviors experienced by HIV patients.
The questionnaire in this study was obtained from the results of Focus Group Discussions and interviews with HIV patients and has been tested for validity and reliability.Data analyzed with distribution frequency.This research has pass ethichal clearance test by committee ethics at RSUP Dr. M. Jamil Padang on July 2022.Out of a total of 50 respondents who were willing to take part in the study, 94 % were male, 50 % had a senior high school as the last education, 78% were employed, 70% were single, 62% had a bad relations with their families, 78% were known by their families that the patient was a PLWHA, 50% homosexual, 64% did not experience opportunistic infections, 62% did not experience side effects while taking ARVs, 32% suffering from HIV 10 years (Table 1).Unpleasant events that have occurred to PLWHA are shown in table 2. The most frequent incidents were having received stigma and negative treatment from society 62%, having experienced violence 54%, being MSM (male sex men) 52%, HIV-infected friends died 46% and were afraid of not getting a partner 44%.The negative thoughts that had occurred in PLWHA showed in table 3. The highest negative thoughts experienced by PLWHA were fear of stigma and negative treatment from society if other people know their HIV status, which is 84%.70% of people living with HIV were afraid of dying in severe AIDS, 66% were afraid of not being able to please their parents and 64% were afraid of death and the grave .Table 4 showed that the negative behavior most often carried out by PLWHA was depression by 66%, then the behavior of staying away from other people was 64%, being lazy to go to college/school was 54%, daydream 50% and wanting to commit suicide was 46% .

RESULTS AND DISCUSSION
The results of this study indicated that 62% of PLWHA had a negative experience of stigma and negative treatment from society.Stigma and negative treatment against PLWHA were strongly attached because people still adhere to moral, religious and cultural values or customs (Munthe et al., 2022).Stigma and threats against PLWHA were not only carried out by ordinary people who do not have sufficient knowledge about HIV, but also by educated people who were familiar with HIV disease.The community considers PLWHA as community waste that must be avoided in the community or ostracized.This happens because the risk factors for this disease were associated with negative events in the form of sexual deviations such as MSM (Male Sex Male), drug use, and sexual customers (Noerliani, 2022).These people are often disapproved by the general public, and they are seen as individuals who are immoral and have bad character (Ornek O et al., 2020).This was in accordance with the results of this study namely of 50 samples there were 47 samples is man with 54% of them being MSM (Male Sex Male) and 18% being drug addicts .This change has also brought great challenges to the traditional HIV/AIDS prevention and control strategy (Yuan et al., 2021).

MSM (Male
In this study, 78% of the sample still had a job.However, as a results of the HIV disease, the sample frequently faces stigma and discrimination at work.Stigma and discrimination exist not only at work but in almost all sectors, including the health sector (54%), community (32%), family (18%), and workplace (18%), with women experiencing more stigma and discrimination from family and society.Stigma and discrimination are high in the health sector because health workers tend to think they have the right to refuse treatment for various reasons.For example, for the safety of other patients, the convenience of other staff members, feeling uncomfortable, and the obligation to protect themselves (Suswani et al., 2022).This is in line with Aryastuti's research, which states that stigma and discrimination are forms of expression to protect oneself from being infected when providing health services (Aryastuti et al., 2020).As a reluts of this stigma, many PLWHA are hesitant to disclose their infection to neighbors or even their family members.In addition, they deny some individuals access to clinical, psychological, and community services (Tomar et al., 2021).
Noerliani 2022 in Krebet Village, Madiun Regency, stated that 117 out of 340 respondents protected themselves and their families from the spread of HIV by staying away from PLWHA, and 64% of respondents did not agree if PLWHA were made friends.The form of stigma that appears is that PLWHA must be shunned because it transmits deadly diseases 30.3% and PLWHA are people who are no longer able to work so they don't need to be involved in community activities 36.76%(Noerliani, 2022).PLHWA are often potrayed negatively in news coverage, and are often categorized as "dangerous people" (Chan et al., 2022).The community still considers the stigma and their actions right because they think that PLWHA deserve their fate and must be responsible for the HIV virus they get (Suswani et al., 2022).As a result of their thinking patterns and public attitudes, PLWHA find it difficult to find friends and patterns.It can be seen that 70% of the sample does not yet have a married/owned couple.
Forms of suffering due to social stigma, for example, include being ostracized from the community and family environment, looked down upon and judged, not receiving proper health care, and not having the opportunity to make a proper living.There are 78% of the sample who choose to open up about suffering from HIV disease to later family raises attitude discrimination in family.The forms of stigma and rejection that PLWHA receive in the family environment are in the form of ostracism and disposal of PLWHA to remote places, separation of cutlery at home, and divorce disputes from spouses (Al fatih dkk 2021).As a result of this, PLWHA experience anxiety, stress, and depression, which are indirectly related to the occurrence of significant changes in the quality of life, especially in the mental or psychological quality of PLWHA (Dewi et al., 2020;Murwani, 2020;Munthe et al., 2022).One study found that 31% of people living with HIV in Sub Saharan Africa had depressive symptoms, with 18% reporting symptoms of major depression.Furthermore, out of 336 PLWHA from Southwestern Uganda, 45.8% of PLHWA were found to have symptoms of depression (Kemigisha et al., 2019;Okumu et al., 2021).
As a result of the negative events experienced by PLWHA, negative thoughts emerged which were grouped into 3 groups of thoughts, namely views about oneself in the form of feeling worthless, damaged, and a presence that was not considered anymore.Negative views about the world and its environment in the form of seeing the world and its surroundings as an insensitive group, punishing and cornering the existence of PLWHA and a negative view of the future where PLWHA considers the future as futile and does not give the slightest hope (Beirao et al., 2023;Lawal et al., 2023;Moonti, 2022;Singh et al., 2019).
The negative thought that happened in PLWHA in this research was feeling afraid of being stigmatized and anxious in society, which was found in 42 samples (84%) of the 50 samples.Other PLWHA negative thoughts that are quite significant relate to the spiritual level of God thoughts of fear of dying in severe AIDS conditions (70%) and thoughts of fear of the last day or grave (64%) (Murwani, 2020).Most PLWHA have a low spiritual level because some of them cannot accept the fact that they are infected with the virus and still consider it a punishment from God due to their own actions.As an expression of regret for their actions, when stressed, PLWHA will seek support from their religious beliefs (Munthe et al., 2022).PLWHA are starting to think about increasing the frequency of praying, reading holy books, and other religious practises as a form of expression of regret (Murwani, 2020).Therefore PLWHA feel afraid of the torment of the last day or the grave because the spiritual growth of PLWHA has begun.
According to PLWHA, thought negative others that arise as a result of psychological disturbance form thought feel sad 42%, mind feel pessimistic 28%, mind feel self fail or not usefull 24%, and mind feel inferior or low self 30%.Supported by study Moonti, 2022 namely PLWHA has diverse showing reaction exists disturbance psychological form feeling anxiety, stress, and depression shown with feeling sad, hopeless, pessimistic, feeling self failed, no satisfied in live, feel more bad compared to with others, judgment low to body and helpless (Marbaninag et al., 2020;Moonti, 2022 ;Muzaffar, 2022;Senthilkumar et al., 2021).
Negative experience and thoughts that disturb the psychology of PLWHA cause sensitive feelings which are then expressed through negative behaviors such as denial, indifference, frustration, loss of patience, poor concentration, selfisolation, hiding the status of their illness, even considering this as the law of karma.which causes PLWHA's desire to end their life.Furthermore, some HIV/AIDS patients will show a feeling of anger which often appears during the process of adaptation to their condition.The emergence feelings of hopelessness, sadness, and depression (Aini et al., 2021).Dessauvagie 2020, found that 30-50% of PLWHA show emotional difficulties which lead to negative behavior (Dessauvagie et al., 2020).This is in accordance with the results of this study which stated that people living with HIV often behaved negatively such as depression (66%), wanting to kill themselves (46%), staying away from other people (64%), daydreaming (50%), lazy to go to college or school (54%).
Psychological disorders such as depression and anxiety are among the most common co-morbidities among PLHIV worldwide.PLWHA are two to three times more likely to experience mental disorders than HIV-negative people and have a poor quality of life (Ncitakalo et al., 2021).Based on the results of a 2022 Munthe study, 73.3% of PLHIV respondents had a poor quality of life (Munthe et al., 2022).HIV patients who are depressed have twice the risk of developing the disease than HIV patients who are not depressed.If this depressive phase escalates into major depression, of course it will exacerbate the condition of PLHIV including having a tendency to end their life.Other psychological impacts of negative treatment from society can also change the personality of PLWHA.PLHIV have a personality that is not open and closed.Apart from that, this feeling of fear of social discrimination will make PLWHA afraid to get tested yourself and go to therapy (Afridah et al., 2022).
Psychological disorders in PLWHA were also associated with various health behaviors and health service seeking such as non-adherence to treatment and low retention rates in HIV care (Ncitakalo et al., 2021).In this situation, support from various parties, including family support, peer support, social support, and especially spiritual support, is needed so that the quality of life of PLWHA is increasing.(Murwani, 2020).The main sources of instrumental social support were relatives not living in the same household (67%), this is followed by spouses/partners (47%), relatives living in the same household (41%), friends offered 31%, the boss/coworker, neighbours and health professionals offered very minimal instrumental social support of 4%, 5% and 9% respectively.Social support enhances quality of life and provides a buffer against adverse life events.Research reveals that social support is an important variable in the prevention of diseases, promotion of health, therapeutic compliance and in the process of recovery from illness13.It has a protective effect during crisis, such as mourning, retirement, unemployment, illness recovery, and hospitalization, as well as the HIV infection (Adimora et al., 2021).

LIMITATION OF THE STUDY
The limitation of this research are difficult to find samples that are willing to be respondent in this reasearch because in general PLWHA isolate themselves from social life.Furthermore, most of the samples are male, so it is difficult to find psychological problems that are felt in women

CONCLUSIONS AND SUGGESTIONS
The most negative and unpleasant events that happened to PLWHA were receiving negative stigma and treatment from society 62%, having experienced violence 54%, and being MSM (male sex men) 52%.The highest negative thoughts experienced by PLWHA were thoughts of fear of being stigmatized and negatively treated by society if other people find out their HIV status by 84%, then PLWHA were afraid of dying in a severe AIDS condition by 70%, they were afraid of not being able to please their parents by 66% and they were afraid of death and the grave by 64%.The negative behavior that was mostly carried out by PLWHA was depression by 66%, then the behavior of staying away from other people by 64%, being lazy to go to college/school by 54%, wanting to commit suicide by 46%.It is expected that health workers can overcome the psychological problems that occur in HIV AIDS patients as well as possible.To future researchers to be able to conduct research on how to overcome the psychological problems of HIV patients, so that the quality of life of HIV patients becomes better.
Sex Male) has increased because sexual relationships are changing under the influence of social and economic development.There are dramatic technological advances and extensive socioeconomic reforms, transportation, communication, and sexual activity have changed fastly over the last decade.Internet and smartphones have provided a convenient tool for finding sexual services, and new sexual relationships have been established online.