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Volume 16, Issue 4 (2024)
3 2024, 16(4): 341-346 |
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Ethics code: 116/UN29.20.1/ETIK/2024
History
Received: 2024/10/27 | Accepted: 2024/11/29 | Published: 2024/12/5
Received: 2024/10/27 | Accepted: 2024/11/29 | Published: 2024/12/5
How to cite this article
Kusnan A, DP Sartiah, Majid R, Asriati A, Jumu L, Rahmawati R. Utilization of Voluntary Counselling and Testing Clinic in Elderly Male HIV/AIDS Patients. 3 2024; 16 (4) :341-346
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1- Department of Nursing, Faculty of Medical, Halu Oleo University, Kendari, Indonesia
2- Department of Public Health, Faculty of Public Health, Halu Oleo University, Kendari, Indonesia
3- Department of Medical Community, Faculty of Medical, Halu Oleo University, Kendari, Indonesia
4- Department of Nursing, Health Polytechnic of Ministry of Health Jayapura, Papua, Indonesia
2- Department of Public Health, Faculty of Public Health, Halu Oleo University, Kendari, Indonesia
3- Department of Medical Community, Faculty of Medical, Halu Oleo University, Kendari, Indonesia
4- Department of Nursing, Health Polytechnic of Ministry of Health Jayapura, Papua, Indonesia
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Introduction
Globalization has profoundly influenced Indonesian society, leading to a shift from traditional values to modern lifestyles often characterized by consumerism and high-risk behaviors [1, 2]. The surge in infectious diseases, particularly Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS), has emerged as a pressing global health issue. These illnesses have significantly affected Indonesia, with infection rates steadily climbing, including in rural regions. HIV compromises the immune system, increasing susceptibility to opportunistic infections, and is primarily spread through the exchange of infected bodily fluids such as blood, semen, and vaginal secretions [3-5].
The HIV epidemic continues to be a significant health issue globally. As of 2022, about 39 million people were living with HIV, with the African region experiencing the highest prevalence [6, 7]. In Southeast Asia, Indonesia stands out with one of the highest HIV rates among adults aged 15-49, at 0.5%, following Thailand and Myanmar. Despite ongoing efforts to curb the epidemic, the increasing number of new HIV/AIDS cases in Indonesia emphasizes the need for more effective interventions, especially for vulnerable groups like men who have sex with men (MSM) [8, 9].
MSM (Men who have sex with men) is a phenomenon that has existed for a long time and cannot be regarded as something new in society [10]. This group significantly contributes to the increasing proportion of HIV/AIDS cases worldwide, including in Indonesia. The causes of MSM behavior are highly complex and influenced by various factors, such as sexual orientation, social pressures, past trauma, social environments, and exposure to evolving cultural norms and values. Biological and psychosocial factors can also significantly shape a person's preferences or behaviors [11, 12].
According to the Indonesian Ministry of Health, cumulative HIV/AIDS cases in the country will surpass 540,000 by 2022, with an upward trend in annual incidence [10]. In Southeast Sulawesi Province, the number of HIV/AIDS cases has risen significantly, with Kendari City reporting the highest proportion of cases. In the last five years, Kendari City has seen a consistent rise in new HIV cases among men who have sex with men, with 173 reported cases in 2023 [13]. Factors such as stigma, discrimination, and limited access to healthcare services continue to drive the high transmission rates within this population [14].
Voluntary Counseling and Testing (VCT) services represent a strategic approach to addressing HIV/AIDS, offering individuals, particularly at-risk populations, the opportunity to voluntarily determine their HIV status [15-17]. These services encompass pre- and post-test counseling as well as treatment for individuals diagnosed with HIV. VCT seeks to promote awareness, foster preventive actions, and minimize the likelihood of HIV transmission, especially within high-risk groups such as men who have sex with men (MSM) [18-20].
Despite its potential, several barriers hinder the utilization of VCT services, including limited knowledge, stigma, fear of test results, and restricted access. At Kendari City General Hospital (RSUD Kendari), the treatment adherence rate among patients reached 95.6%. However, the proportion of MSM accessing VCT services remains a point for improvement. Preliminary observations indicate that 428 MSM visited the VCT Clinic at RSUD Kendari in 2023, reflecting a significant increase in recent years. The present study intends to explore the factors that affect the use of Voluntary Counseling and Testing (VCT) services by HIV-positive men who have sex with men (MSM) at Kendari City Hospital. The results are expected to contribute to shaping health policies and strategies aimed at preventing HIV/AIDS transmission, both locally and nationally.
Instrument and Methods
Design & Samples
This study adopted an observational analytic design with a cross-sectional approach, a method used in research to collect data at a particular moment rather than over a period of time [21]. The research focused on men who have sex with men (MSM) living with HIV/AIDS who had visited the VCT Clinic at Kendari City Hospital by March 2024, with a total population of 428 individuals. Using the Slovin formula, a sample of 82 participants was selected with a 90% confidence level (α=0.1) through simple random sampling. Eligibility criteria included being at least 45 years old, having a confirmed or temporary HIV/AIDS diagnosis, being fluent in Indonesian, and having visited the VCT Clinic within the specified timeframe. Respondents with critical or unstable health conditions that prevented them from participating in interviews were excluded from the study.
Instrument
The research utilized validated structured questionnaires, including Guttman scales to assess knowledge, family support, peer support, and Likert scales for measuring attitude and action. The utilization of the VCT Clinic was determined based on the number of visits in the past year, with visits categorized as "good" if they occurred six times or more and "less" if fewer than six were made. Data for the study were gathered through interviews conducted with structured questionnaires, while secondary data were obtained from the records at Kendari City Hospital and pertinent literature. The research instrument was tested for validity through correlation analysis between individual question items and the total variable score. All items had correlation values greater than 0.3, confirming their validity. To assess reliability, Cronbach’s Alpha was applied, resulting in a coefficient of 0.87, above the acceptable minimum of 0.7, demonstrating that the instrument has high internal consistency.
Procedure
The first step involved obtaining informed consent from the respondents. Before beginning data collection, the researcher provided an overview of the study's objectives, explained the steps involved, and informed participants about their rights, including confidentiality of their responses and the option to join or withdraw from the study at any point without any repercussions. Following the acquisition of written consent, data collection commenced with structured interviews. These interviews were conducted using a validated questionnaire and covered key research variables, including knowledge, attitude, family support, peer support, and utilization of the VCT Clinic. The researcher personally conducted the interviews, ensuring respondents fully understood the questions and their responses were accurately recorded. Additionally, secondary data were collected from Kendari City Hospital’s documentation, which provided information on the number of visits made by HIV/AIDS patients to the VCT Clinic over the past year. This data was used to categorize service utilization as “good” or “less”.
Three trained enumerators supported the researchers in facilitating the data collection process. These enumerators played a crucial role in conducting direct interviews with respondents, recording their answers, and completing questionnaires according to established procedures. With the enumerators' assistance, the researchers ensured that the data collection process was conducted effectively, resulting in more accurate and representative data.
Data analysis
For data analysis, the researcher followed a stepwise approach. The analysis began with univariate analysis to describe the frequency distribution of each variable. Next, a bivariate analysis was conducted using the Chi-Square test to explore the associations between independent variables (such as knowledge, family support, peer support, and attitude) and the dependent variable (use of the VCT Clinic). A multivariate analysis with logistic regression was performed to identify significant factors impacting VCT Clinic utilization. The findings are reported as Adjusted Odds Ratios (aOR) with 95% Confidence Intervals (CI), reflecting the probability of independent variables affecting the dependent variable after accounting for other factors. Additionally, a Crude Odds Ratio (cOR) was calculated in the initial phase to examine the unadjusted relationships between the variables.
Findings
Most participants (76.8%) fell within the 45-59 age group, had completed high school (50.0%), and were single (22.0%; Table 1).
Table 1. Distribution of respondent characteristics by frequency
Sufficient knowledge was associated with 7.386 times higher odds of utilizing the VCT Clinic than insufficient knowledge (p=0.001). A positive attitude was identified as a significant factor in the univariate (p=0.001) and multivariate analyses (p=0.005). Engaging in positive actions also had a significant impact, with odds 16.562 times higher in the univariate analysis (p=0.001), and it remained significant in the multivariate analysis (p=0.009). Adequate family support significantly correlated with VCT Clinic utilization in the univariate analysis (p=0.001). Sufficient peer support had a notable effect on the univariate analysis (p=0.001; Table 2).
Table 2. Binary logistic regression analysis of VCT Clinic utilization
Discussion
The findings of this study show that a significant proportion of male sex workers (MSM) in Kendari City, specifically 74.4%, make optimal use of Voluntary Counseling and Testing (VCT) services. This strong utilization rate may reflect the success of HIV/AIDS education and prevention programs, although challenges remain in ensuring equal access across all key populations. Knowledge about HIV/AIDS and VCT services is a crucial first step in promoting positive health behaviors. Individuals with a good understanding of HIV risks, the benefits of VCT, and the safe process of counseling and testing are more likely to feel confident in utilizing these services. Knowledge helps reduce fear or anxiety often caused by a lack of accurate information while also dispelling myths and stigma associated with HIV. By increasing knowledge, individuals are more encouraged to be aware of their health status and take the necessary preventive measures [22-24].
While knowledge demonstrated a meaningful relationship in the preliminary analysis, it did not emerge as a significant factor in the multivariate analysis. This suggests that sufficient knowledge does not necessarily lead to behavior change, particularly in contexts with social stigma. To address this, a more contextualized educational approach is needed to provide information and emphasize how that knowledge can be applied in practical actions [25, 26].
A positive attitude emerged as a key factor in increasing the use of VCT services. A positive attitude toward the importance of knowing one's HIV status, the belief in the benefits of VCT services, and trust in healthcare providers can encourage individuals to utilize these services voluntarily. The multivariate analysis revealed that respondents with a positive attitude were 10.78 times more likely to use the service than those with a negative attitude. This result supports earlier research highlighting the critical role of cultivating positive views toward health services in encouraging proactive health behaviors [27, 28]. Consequently, campaigns that emphasize the benefits of VCT and address stigma within the community are essential [28].
Positive action was another significant factor influencing VCT utilization. Respondents who took proactive steps to maintain their health were 8.63 times more likely to use the service. This highlights the crucial role of individual awareness and the willingness to take concrete actions, such as regular visits to VCT clinics, in preventing and controlling the spread of HIV/AIDS. Reinforcing positive behaviors should be a priority in public health programs [29].
Peer support plays an important role in encouraging individuals to access VCT services. Peers can provide moral encouragement, share positive experiences related to VCT, and serve as trusted sources of information. In the MSM community, peer support can also help overcome fear and anxiety caused by the stigma attached to HIV [30]. Family support also contributes to increased utilization of VCT services. Supportive families tend to provide emotional encouragement, help reduce fear of diagnosis, and motivate individuals to get tested. Family support can create a safe and comfortable environment for individuals, ultimately increasing their willingness to use VCT services [28, 31]. However, this effect became insignificant in the multivariate analysis. This may be due to the influence of other more dominant variables, such as individual attitudes and actions. Nevertheless, social support remains an essential factor in helping individuals navigate the stigma and discrimination often faced by MSM. Community-based programs that strengthen the role of family and peers in providing moral and emotional support could be beneficial [32].
Several other factors may influence an individual's decision not to visit VCT services regularly despite having adequate knowledge. Although they understand the importance of an HIV test to know their health status, fear of a positive test result remains a major barrier. A positive result can trigger anxiety about their future, including social, psychological, and medical consequences. The fear of these consequences, such as concerns about long-term treatment or its impact on social and work life, can prevent them from returning to VCT services, even though they are aware of the importance of the test. Additionally, individuals may have good knowledge, but without sustained social support from family, peers, or the community, they may feel less motivated to visit VCT services regularly [33, 34].
In the local context, this study offers valuable insights into the unique challenges MSM faces in Kendari City. Stigma, limited access to services, and fear of diagnosis are significant barriers that must be addressed through a multisectoral approach. To increase their effectiveness, efforts to improve VCT programs should focus on engaging key stakeholders, including government bodies, NGOs, and local communities.
Conclusion
The use of Voluntary Counseling and Testing services by male workers living with HIV/AIDS in Kendari City is largely driven by their positive attitudes and behaviors, while social support and knowledge act as contributing factors. While most respondents utilized the service effectively, barriers such as stigma, fear of diagnosis, and limited access continue to impact certain groups.
Acknowledgments: The author expresses heartfelt thanks to the Dean of the Faculty of Medicine at the University of Halu Oleo (UHO) for their continuous support, mentorship, and provision of resources throughout the research. This support played a crucial role in the study's success. Additionally, the author is deeply grateful to the Head of the Research and Community Service Institute at Halu Oleo University for their insightful guidance and assistance during the research process.
Ethical Permissions: The Research Ethics Committee of the Faculty of Medicine at Halu Oleo University granted ethical approval for this study under approval number 116/UN29.20.1/ETIK/2024. Before the study commenced, all procedures were thoroughly evaluated and approved, adhering to the ethical standards for health research outlined in the Declaration of Helsinki.
Conflicts of Interests: The authors reported no conflict of interest.
Authors' Contribution: Kusnan A (First Author), Introduction Writer/Methodologist/Original or Assistant Researcher/Discussion Writer/Statistical Analyst (35%); DP S (Second Author), Introduction Writer/Methodologist/Original or Assistant Researcher/Discussion Writer/Statistical Analyst (10%); Majid R (Third Author), Introduction Writer/Methodologist/Original or Assistant Researcher/Discussion Writer/Statistical Analyst (10%); Asriati A (Fourth Author), Introduction Writer/Methodologist/Original or Assistant Researcher/Discussion Writer/Statistical Analyst (10%); Jumu L (Fifth Author), Introduction Writer/Methodologist/Original or Assistant Researcher/Discussion Writer/Statistical Analyst (10%); Rachmawati R (Sixth Author), Introduction Writer/Methodologist/Original or Assistant Researcher/Discussion Writer/Statistical Analyst (25%)
Funding/Support: This research was not funded; no financial support was received from any government, private, or non-profit organizations.
Globalization has profoundly influenced Indonesian society, leading to a shift from traditional values to modern lifestyles often characterized by consumerism and high-risk behaviors [1, 2]. The surge in infectious diseases, particularly Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS), has emerged as a pressing global health issue. These illnesses have significantly affected Indonesia, with infection rates steadily climbing, including in rural regions. HIV compromises the immune system, increasing susceptibility to opportunistic infections, and is primarily spread through the exchange of infected bodily fluids such as blood, semen, and vaginal secretions [3-5].
The HIV epidemic continues to be a significant health issue globally. As of 2022, about 39 million people were living with HIV, with the African region experiencing the highest prevalence [6, 7]. In Southeast Asia, Indonesia stands out with one of the highest HIV rates among adults aged 15-49, at 0.5%, following Thailand and Myanmar. Despite ongoing efforts to curb the epidemic, the increasing number of new HIV/AIDS cases in Indonesia emphasizes the need for more effective interventions, especially for vulnerable groups like men who have sex with men (MSM) [8, 9].
MSM (Men who have sex with men) is a phenomenon that has existed for a long time and cannot be regarded as something new in society [10]. This group significantly contributes to the increasing proportion of HIV/AIDS cases worldwide, including in Indonesia. The causes of MSM behavior are highly complex and influenced by various factors, such as sexual orientation, social pressures, past trauma, social environments, and exposure to evolving cultural norms and values. Biological and psychosocial factors can also significantly shape a person's preferences or behaviors [11, 12].
According to the Indonesian Ministry of Health, cumulative HIV/AIDS cases in the country will surpass 540,000 by 2022, with an upward trend in annual incidence [10]. In Southeast Sulawesi Province, the number of HIV/AIDS cases has risen significantly, with Kendari City reporting the highest proportion of cases. In the last five years, Kendari City has seen a consistent rise in new HIV cases among men who have sex with men, with 173 reported cases in 2023 [13]. Factors such as stigma, discrimination, and limited access to healthcare services continue to drive the high transmission rates within this population [14].
Voluntary Counseling and Testing (VCT) services represent a strategic approach to addressing HIV/AIDS, offering individuals, particularly at-risk populations, the opportunity to voluntarily determine their HIV status [15-17]. These services encompass pre- and post-test counseling as well as treatment for individuals diagnosed with HIV. VCT seeks to promote awareness, foster preventive actions, and minimize the likelihood of HIV transmission, especially within high-risk groups such as men who have sex with men (MSM) [18-20].
Despite its potential, several barriers hinder the utilization of VCT services, including limited knowledge, stigma, fear of test results, and restricted access. At Kendari City General Hospital (RSUD Kendari), the treatment adherence rate among patients reached 95.6%. However, the proportion of MSM accessing VCT services remains a point for improvement. Preliminary observations indicate that 428 MSM visited the VCT Clinic at RSUD Kendari in 2023, reflecting a significant increase in recent years. The present study intends to explore the factors that affect the use of Voluntary Counseling and Testing (VCT) services by HIV-positive men who have sex with men (MSM) at Kendari City Hospital. The results are expected to contribute to shaping health policies and strategies aimed at preventing HIV/AIDS transmission, both locally and nationally.
Instrument and Methods
Design & Samples
This study adopted an observational analytic design with a cross-sectional approach, a method used in research to collect data at a particular moment rather than over a period of time [21]. The research focused on men who have sex with men (MSM) living with HIV/AIDS who had visited the VCT Clinic at Kendari City Hospital by March 2024, with a total population of 428 individuals. Using the Slovin formula, a sample of 82 participants was selected with a 90% confidence level (α=0.1) through simple random sampling. Eligibility criteria included being at least 45 years old, having a confirmed or temporary HIV/AIDS diagnosis, being fluent in Indonesian, and having visited the VCT Clinic within the specified timeframe. Respondents with critical or unstable health conditions that prevented them from participating in interviews were excluded from the study.
Instrument
The research utilized validated structured questionnaires, including Guttman scales to assess knowledge, family support, peer support, and Likert scales for measuring attitude and action. The utilization of the VCT Clinic was determined based on the number of visits in the past year, with visits categorized as "good" if they occurred six times or more and "less" if fewer than six were made. Data for the study were gathered through interviews conducted with structured questionnaires, while secondary data were obtained from the records at Kendari City Hospital and pertinent literature. The research instrument was tested for validity through correlation analysis between individual question items and the total variable score. All items had correlation values greater than 0.3, confirming their validity. To assess reliability, Cronbach’s Alpha was applied, resulting in a coefficient of 0.87, above the acceptable minimum of 0.7, demonstrating that the instrument has high internal consistency.
Procedure
The first step involved obtaining informed consent from the respondents. Before beginning data collection, the researcher provided an overview of the study's objectives, explained the steps involved, and informed participants about their rights, including confidentiality of their responses and the option to join or withdraw from the study at any point without any repercussions. Following the acquisition of written consent, data collection commenced with structured interviews. These interviews were conducted using a validated questionnaire and covered key research variables, including knowledge, attitude, family support, peer support, and utilization of the VCT Clinic. The researcher personally conducted the interviews, ensuring respondents fully understood the questions and their responses were accurately recorded. Additionally, secondary data were collected from Kendari City Hospital’s documentation, which provided information on the number of visits made by HIV/AIDS patients to the VCT Clinic over the past year. This data was used to categorize service utilization as “good” or “less”.
Three trained enumerators supported the researchers in facilitating the data collection process. These enumerators played a crucial role in conducting direct interviews with respondents, recording their answers, and completing questionnaires according to established procedures. With the enumerators' assistance, the researchers ensured that the data collection process was conducted effectively, resulting in more accurate and representative data.
Data analysis
For data analysis, the researcher followed a stepwise approach. The analysis began with univariate analysis to describe the frequency distribution of each variable. Next, a bivariate analysis was conducted using the Chi-Square test to explore the associations between independent variables (such as knowledge, family support, peer support, and attitude) and the dependent variable (use of the VCT Clinic). A multivariate analysis with logistic regression was performed to identify significant factors impacting VCT Clinic utilization. The findings are reported as Adjusted Odds Ratios (aOR) with 95% Confidence Intervals (CI), reflecting the probability of independent variables affecting the dependent variable after accounting for other factors. Additionally, a Crude Odds Ratio (cOR) was calculated in the initial phase to examine the unadjusted relationships between the variables.
Findings
Most participants (76.8%) fell within the 45-59 age group, had completed high school (50.0%), and were single (22.0%; Table 1).
Table 1. Distribution of respondent characteristics by frequency
Sufficient knowledge was associated with 7.386 times higher odds of utilizing the VCT Clinic than insufficient knowledge (p=0.001). A positive attitude was identified as a significant factor in the univariate (p=0.001) and multivariate analyses (p=0.005). Engaging in positive actions also had a significant impact, with odds 16.562 times higher in the univariate analysis (p=0.001), and it remained significant in the multivariate analysis (p=0.009). Adequate family support significantly correlated with VCT Clinic utilization in the univariate analysis (p=0.001). Sufficient peer support had a notable effect on the univariate analysis (p=0.001; Table 2).
Table 2. Binary logistic regression analysis of VCT Clinic utilization
Discussion
The findings of this study show that a significant proportion of male sex workers (MSM) in Kendari City, specifically 74.4%, make optimal use of Voluntary Counseling and Testing (VCT) services. This strong utilization rate may reflect the success of HIV/AIDS education and prevention programs, although challenges remain in ensuring equal access across all key populations. Knowledge about HIV/AIDS and VCT services is a crucial first step in promoting positive health behaviors. Individuals with a good understanding of HIV risks, the benefits of VCT, and the safe process of counseling and testing are more likely to feel confident in utilizing these services. Knowledge helps reduce fear or anxiety often caused by a lack of accurate information while also dispelling myths and stigma associated with HIV. By increasing knowledge, individuals are more encouraged to be aware of their health status and take the necessary preventive measures [22-24].
While knowledge demonstrated a meaningful relationship in the preliminary analysis, it did not emerge as a significant factor in the multivariate analysis. This suggests that sufficient knowledge does not necessarily lead to behavior change, particularly in contexts with social stigma. To address this, a more contextualized educational approach is needed to provide information and emphasize how that knowledge can be applied in practical actions [25, 26].
A positive attitude emerged as a key factor in increasing the use of VCT services. A positive attitude toward the importance of knowing one's HIV status, the belief in the benefits of VCT services, and trust in healthcare providers can encourage individuals to utilize these services voluntarily. The multivariate analysis revealed that respondents with a positive attitude were 10.78 times more likely to use the service than those with a negative attitude. This result supports earlier research highlighting the critical role of cultivating positive views toward health services in encouraging proactive health behaviors [27, 28]. Consequently, campaigns that emphasize the benefits of VCT and address stigma within the community are essential [28].
Positive action was another significant factor influencing VCT utilization. Respondents who took proactive steps to maintain their health were 8.63 times more likely to use the service. This highlights the crucial role of individual awareness and the willingness to take concrete actions, such as regular visits to VCT clinics, in preventing and controlling the spread of HIV/AIDS. Reinforcing positive behaviors should be a priority in public health programs [29].
Peer support plays an important role in encouraging individuals to access VCT services. Peers can provide moral encouragement, share positive experiences related to VCT, and serve as trusted sources of information. In the MSM community, peer support can also help overcome fear and anxiety caused by the stigma attached to HIV [30]. Family support also contributes to increased utilization of VCT services. Supportive families tend to provide emotional encouragement, help reduce fear of diagnosis, and motivate individuals to get tested. Family support can create a safe and comfortable environment for individuals, ultimately increasing their willingness to use VCT services [28, 31]. However, this effect became insignificant in the multivariate analysis. This may be due to the influence of other more dominant variables, such as individual attitudes and actions. Nevertheless, social support remains an essential factor in helping individuals navigate the stigma and discrimination often faced by MSM. Community-based programs that strengthen the role of family and peers in providing moral and emotional support could be beneficial [32].
Several other factors may influence an individual's decision not to visit VCT services regularly despite having adequate knowledge. Although they understand the importance of an HIV test to know their health status, fear of a positive test result remains a major barrier. A positive result can trigger anxiety about their future, including social, psychological, and medical consequences. The fear of these consequences, such as concerns about long-term treatment or its impact on social and work life, can prevent them from returning to VCT services, even though they are aware of the importance of the test. Additionally, individuals may have good knowledge, but without sustained social support from family, peers, or the community, they may feel less motivated to visit VCT services regularly [33, 34].
In the local context, this study offers valuable insights into the unique challenges MSM faces in Kendari City. Stigma, limited access to services, and fear of diagnosis are significant barriers that must be addressed through a multisectoral approach. To increase their effectiveness, efforts to improve VCT programs should focus on engaging key stakeholders, including government bodies, NGOs, and local communities.
Conclusion
The use of Voluntary Counseling and Testing services by male workers living with HIV/AIDS in Kendari City is largely driven by their positive attitudes and behaviors, while social support and knowledge act as contributing factors. While most respondents utilized the service effectively, barriers such as stigma, fear of diagnosis, and limited access continue to impact certain groups.
Acknowledgments: The author expresses heartfelt thanks to the Dean of the Faculty of Medicine at the University of Halu Oleo (UHO) for their continuous support, mentorship, and provision of resources throughout the research. This support played a crucial role in the study's success. Additionally, the author is deeply grateful to the Head of the Research and Community Service Institute at Halu Oleo University for their insightful guidance and assistance during the research process.
Ethical Permissions: The Research Ethics Committee of the Faculty of Medicine at Halu Oleo University granted ethical approval for this study under approval number 116/UN29.20.1/ETIK/2024. Before the study commenced, all procedures were thoroughly evaluated and approved, adhering to the ethical standards for health research outlined in the Declaration of Helsinki.
Conflicts of Interests: The authors reported no conflict of interest.
Authors' Contribution: Kusnan A (First Author), Introduction Writer/Methodologist/Original or Assistant Researcher/Discussion Writer/Statistical Analyst (35%); DP S (Second Author), Introduction Writer/Methodologist/Original or Assistant Researcher/Discussion Writer/Statistical Analyst (10%); Majid R (Third Author), Introduction Writer/Methodologist/Original or Assistant Researcher/Discussion Writer/Statistical Analyst (10%); Asriati A (Fourth Author), Introduction Writer/Methodologist/Original or Assistant Researcher/Discussion Writer/Statistical Analyst (10%); Jumu L (Fifth Author), Introduction Writer/Methodologist/Original or Assistant Researcher/Discussion Writer/Statistical Analyst (10%); Rachmawati R (Sixth Author), Introduction Writer/Methodologist/Original or Assistant Researcher/Discussion Writer/Statistical Analyst (25%)
Funding/Support: This research was not funded; no financial support was received from any government, private, or non-profit organizations.
Keywords: