Padjadjaran Nursing Journal (Jurnal Keperawatan Padjadjaran)

ISSN 2338-5324 (print)

ISSN 2442-7276 (online)
Online di http://jkp.fkep.unpad.ac.id
DOI : 10.24198/jkp

The Effect of the E-Patuh Application on HIV/Aids Patients’ Adherence in

Consuming Antiretroviral

Alfian, Kusman Ibrahim, Imas Rafiyah

Faculty of Nursing Universitas Padjadjaran
Email: alfianthyan@gmail.com

Submitted: 29-06-2018 Accepted: 10-04-2019 Published: 28-04-2019

Abstract

Medication adherence is behavior that refers to client obeys in following a medication, and makes lifestyle
changes in accordance of recommendations from health care providers. Antiretroviral adherence is paramount
for HIV/AIDS patients. The effects were often a problem in antiretroviral treatment and toxicity and often
be the reason for replacing or stopping antiretroviral treatment. This study aimed to determine the “E-Patuh”
Applications effect on antiretroviral adherence in patients Of HIV/AIDS In West Java. The research design
was a quasi-experimental with nonequivalent control group design. The location of this research was in RSUD
Kota Bandung and in RSUD Kota Banjar. The respondents was selected without randomization and used
purposive sampling technique. Respondents in this study were 30 respondents. Data were obtained using self-
report questionnaires. The intervention group was monitored a 30-day android-based E-Patuh application and
monitored on an E-Patuh website and then measured adherence value with self-report. Data were analyzed
using SPSS 22 with chi-square test. The results showed a significant difference between adherence value
before and after application of E-Patuh in the intervention group with (p <0.05) with obtained p value = 0,006.
The results of this study prove a positive effect on the using of E-Patuh applications against ARV medication
adherence in the intervention group with the support system of the E-Patuh application. The used of E-Patuh
is helpful in improving ARV adherence in HIV/AIDS patients. The features contained in E-Patuh were directly
reminiscent of the timing of taking medication for PWLH. E-Patuh should be consideration for PLHIV and
health care providers in hospitals to improve ARV adherence to reduce mortality rates in people living with HIV.

Keywords: Adherence, Antiretroviral, E-Patuh Applications.

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 Alfian: The Effect of the E-patuh application on HIV/AIDS Patients Adherence in Consuming Antiretroviral

Introduction the treatment of antiretroviral medication

has a significant impact on patients who
Human Immunodeficiency Virus (HIV) is a live it, such as the onset of symptoms
virus that attacks leukocyte (lymphocytes) in that aggravate the state of the patient.
human body and causing acquired immune Technology developments on ARV
deficiency syndrome (AIDS) (Kemenkes, adherence interventions have been used in
2014). HIV/AIDS is a complex chronic PLHIV including of pager, smartphone,
disease. The number of HIV in Indonesia SMS, video, computer-based programs and
in the fourth quarter of 2017 was 14,640 and the development of behavioral intervention
AIDS was 4,725 people . The highest AIDS technology intervention technology (BITs)
percentage at 30–39 years (35.2%), followed to improve ARV compliance (Pellowski
by 20–29 years your (29.5%) and 40–49 & Kalichman 2012). Along with the
years (17.7%). West Java is the third highest development of existing interventions,
number of HIV infections in Indonesia in the nurses should play a role to increase ARVs
period of March 2016 amounted to 28,964 adherence. Dayer et al. (2013) and Whellan
people and the number of AIDS in West Java et al. (2013) explained that their study focus
was ranked sixth in Indonesia with 6,502 on improving to ARVs adherence, providing
people. educational information on ARV medication
The development of using antiretroviral treatment and HIV/AIDS information based
therapy as a treatment of choice in HIV/ on electronic monitoring system.
AIDS has significantly improved the health In this study The E-Patuh application
condition of HIV people. Palella et al. is developed from the existing electronic
(1998) explains that ARVs have illustrated monitoring system applications based on
that HIV/AIDS patients can be treated, to Android and website system with Google
reduce the morbidity, mortality and improve servers to store patient’s data. The features
quality of life. Hypersensitivity reactions are improving of medication adherence and
to antiretroviral drugs are more common in document medical history, CD4 history, and
HIV patients than in other general disease symptoms experienced by PLWHA during
populations. The reasons why people with medication treatment. The forms of the
HIV experience hypersensitivity reactions report are immediately sent and documented
to antiretroviral medications are more often in the “E-Patuh” website application system.
multi-factor, such as immune hyperactivity E-Patuh Supported with reminders and
factors, changes in medication metabolism, notifications to remind people living with
profilesocytes, oxidative stress, and genetic HIV to take medication on time.
predisposition (Nursalam, 2007).
The medication effects should not be an
obstacle to starting antiretroviral therapy. Not Method
all patients have effects of arising from the
ARV treatment. ARV treatment is beneficial This study used quasi experimental with
when compared to the risk of morbidity and nonequivalent control group design approach
death that would occur if the patient did not with experimental group (A) and control group
get ARV therapy (Kemenkes, 2011). (B). The value of ARV medication adherence
The level of antiretroviral adherence in was measured in pretest and posttest. The
Indonesia is low, with a range of 40–70% still experimental group was given intervention
below the national target of adherence > 95% by using E-Patuh android application as
(Latif, Maria, & Syafar, 2014). Kemenkes user and then readied for respondent’s
(2017) showed the number of people living smartphone. The Experimental group was
with HIV who were getting ARVs in the conducted in Ujung Berung Hospital. For the
fourth quarter of 2017 was 91,369 people. control group were not given intervention in
The total of 88,386 people used first-line the form of E-Patuh android application and
regimens, 2,983 people receiving second line was conducted in Banjar Hospital. This study
and 2,983 people was drop out of medication. would evaluate the treatment of E-Patuh in a
Cohen et al. (2011) said Disobedience in month.

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 Alfian: The Effect of the E-patuh application on HIV/AIDS Patients Adherence in Consuming Antiretroviral

The sample technique in this research with additional items that discussed the
used nonprobability sampling with purposive circumstances surrounding compliance
sampling. The numbers of experimental group behavior. The questions were measured by 4
were 15 respondents and 15 respondents for items, namely 1. Are you sometimes having
control group without any randomization in difficulty remembering the time to take
each group. The data were tested statistically medicine?, 2. When you feel good, do you
to determine the difference of scores in the sometimes stop taking medicine?, 3. Think
intervention group and control group on pre- four days back, have you missed it Taking
test and post-test using chi square test of SPSS medicine?, 4. At times when your condition
program to measure the pairs of nominal data feels worse, do you stop taking medicine?.
or dichotomy (Dahlan, 2015). The question category was responded to yes/
This study used indirect measurement no for each item with a response dichotomy
methods in the form of self-report using (Morisky, Ang, Krousel-Wood, & Ward,
the Morisky Medication Adherence Scale 2008).
(MMAS) questionnaire. Measurement of
ARV medication adherence used the self-
report questionnaire was developed with a Result
four-item scale of questions and supplemented
Table 1 The Respondent’s Characteristics
Characteristic Group p
Intervention Control
f % f %
Age (Old): 0.247
17–20 years 6 40 3 20
21–40 years 5 33.3 8 53.3
40–60 years 4 26.7 4 26.7
Gender: 0.000
Male 14 93.3 7 46.7
Female 1 6.7 8 53.3
Married Status: 0.161
Married 3 20 6 40
Single 10 66.7 7 46.7
Divorce 2 13.3 2 13.3
Education: 0.638
Elementary 1 6.7 - -
Middle 3 20 3 20
High 9 60 6 40
University 2 13.3 6 40
Work: 0.593
Private employees 7 46.7 9 60
Entrepreneurship 3 20 1 6.7
Unemployment 3 20 1 6.7
Laborer 1 6.7 1 6.7
IRT 1 6.7 3 20
Duration of ARVs: 0.091
15 years 10 66.7 3 20

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 Alfian: The Effect of the E-patuh application on HIV/AIDS Patients Adherence in Consuming Antiretroviral

6 – 12 months 5 33.3 6 40
5 – 10 years - - 6 40
Type of ARV 0.036
3FDC 10 66.7 11 73.3
Lamipudin, Tenopovir, Evafiren 1 6.7
Duviral dan evafiren 2 13.3
Lamifudin, neviral, TDF 1 6.7
Duviral dan neviral 5 33.3
Side Effects of Treatment: 0.521
No complaints 7 46.7 1 6.7
Nausea 2 13.3 8 53.3
Dizziness, nausea - - 6 40
Rash 1 6.7 - -
Dizzy and limp 5 33.3 - -
p < 0.005 (homogeneity test)

Table 2 Pretest Score the ARV adherence in Intervention and Control Group
Group Adherence Level x2 p
High Medium Low
f (%) f (%) f (%)
Pre- test intervention group 6 (40.0) 5 (33.5) 4 (26.5) 2.812 0.245*
Pre-test control group 12 (80.0) 3 (20.0) -
* chi square test p < 0.05

Table 3 Posttest Score the ARV adherence in Intervention and Control Group (n = 30)
Group Adherence Level x2 p
High Medium Low
f (%) f (%) f (%)
Pre- test intervention group 8 (53.3) 7 (46.7) - 6.234 0.013*
Pre-test control group 11 (73.3) 4 (26.7) -
* chi square test p < 0.05

Table 4 Pretest and Posttest Score an ARV Adherence in Intervention Group (n = 15)
Group Adherence Level x2 p
High Medium Low
f (%) f (%) f (%)
Pre- test intervention group 6 (40.0) 5 (33.5) 4 (26.5) 10.179 0.006
Pre-test control group 8 (53.3) 7 (46.7) -
* chi square test p < 0.05

Table 5 Pretest and Postest Score an ARV adherence in Control Group (n = 15)
Group Adherence Level x2 p
High Medium Low
f (%) f (%) f (%)
Pre- test intervention group 12 (80.0) 3 (20) - 3.068 0.080
Pre-test control group 11 (73.3) 4 (26.7) -
* chi square test p < 0.05

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The table 1 describes the characteristics Between pre-test in intervention group

of respondents between the intervention and got small part of adherence value 4 (26%) of
control groups. The study showed the most respondent with low compliance category at
respondents were range of aged 21–40 years pre-test and at post-test there is no value of
(53.3%) and almost all respondents in the compliance of respondent in low adherence
intervention group were male (93.3%). The category. The result of statistic test with
marital status data most of the respondents chi square test in table was obtained p
were single on intervention group 66.7% value = 0.006, because p value <0.05 then
and 46.7% for control group. Most of the statistically there is a significant difference
respondent was senior high school with 9 between antiretroviral drug adherence level
people (60%), private employment amounted score before and after giving of E-Patuh
to 9 people (60%). Most of the respondents application in intervention group.
suffered from HIV-positive people and In the test of difference between pretest and
underwent ARVs within 1–5 years at 10 posttest in control group using chi square test
(60.7%) in the intervention group. Most of in table 5 obtained p value = 0.080, because
the 3FDC ARVs consumed by all respondents p value <0.05 hence statistically there is no
were 21 respondents. 1 person (6.7%) of the significant difference between antiretroviral
control group did not have antiretroviral side medication adherence level scores in group
effects but in the intervention group. a small control before and after application of
percentage of 1 (6.7%) of the respondents E-Patuh to the intervention group.
had side-effect rash on the skin.
Pretest intervention and control group
using chi square test showed on the table Discussion
3 and the result obtained p value = 0.245.
Since p value 0.05 hence statistically there This study prove a positive effect of E-Patuh
is no significant difference of pretest score applications against ARV medication
of ARV adherence medication level between adherence on the intervention group. The
group intervention and control groups. Pre- features provide reminder of taking the
test adherence levels in the control arm medicine for respondents in real time, enlarge
were almost 12 (80%) in high adherence. the knowledge’s, to guide the patient for
Meanwhile, in the intervention group there health care provider in West Java and changes
are still respondents with compliance of less the patient behavior in ARV medication.
4 (26.5%) of respondents. Several methods have been developed
Posttest in intervention and control group to improve ARV adherence by building up
using chi square test on table 3 obtained p the android and website monitoring system.
value = 0.013, because p value <0.05 then Study of Dayer’s et al. (2013) shows the
statistically there was significant difference methods of changing patient behavior
in post test score of adherence medication using reminders, counseling, strengthening,
intervention group antiretroviral drug and education, simplifying the dosage, or
control groups. The post-test adherence level combining those methods. In general, the
in the control group of 11 (73.3%) was in compliance interventions are categorized as
high adherence level and the intervention behavioral, educational, or organizational
group had respondents with high adherence based on modifying the environment or
of 8 (53.3%) respondents. patient, delivering information, or reducing
In the test to know the difference of pretest the risks that impede treatment and establish
and posttest in intervention and control group communication with health care providers.
using categorical comparative analysis not A similar study Zia’s (2014) on the
paired by using chi square. Differences implementation of ARV antiretroviral
of ARV preoperative and posttest test monitoring system by smartphone-based
compliance scores in the intervention group client server method shows three respondents
will be presented in table and the control stated strongly agree that the reminder helps
group will be presented in table below: to remind ARV medication. The respondent
agree that the message feature can facilitate

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 Alfian: The Effect of the E-patuh application on HIV/AIDS Patients Adherence in Consuming Antiretroviral

for communicating with the clinic staff or alarm to take medication so that they can
while on ARV therapy, to help the officer in directly change their behavior by providing
the process of collecting the results of CD4 health promotion through APP, providing
examination, determines the consumption information on medication schedule,
schedule and facilitates communication education delivery, and health service
between the officer and the patient during information. All information and education
the ARV therapy. Dayer’s et al. (2013) again provided can be known by the notification
illustrates the potential benefits of smartphone that goes into android system of PLWHA.
technology to increase effectiveness in The descriptive result indicates the
compliance programs, refine financing, as level of adherence to taking antiretroviral
a real-time tool for evaluating medication drugs before and after the administration
adherence. of the E-Patuh Application in the control
The study of electronic monitoring system group. From the table shows almost all the
became good opportunity in the modernizing respondents have high adherence with the
of information and telecommunication tools amount of 12 (80%) in the control group
in health community. The expansion of pre-test. After the provision of E-Patuh
information and technology should be in line application in the intervention group showed
with utilization in the field of health specially that there was a decrease in compliance rate of
in monitoring the system for ARV medication PLHIV as evidenced by the compliance level
adherence to patients who living with HIV. in the control group with the high adherence
After giving for a month of E-Patuh category amounted to 11 (73.4%). The level
application to the intervention group on 15 of education in the control group was partially
respondents and remain active using E-Patuh educated at university level with 6 (40%)
application the respondent still get the respondents and SMA 6 (40%) respondents.
medication adherence intervention in the form The level of education in the control group
of reminder with alarm and notification time tends to be better so it has better pre-test and
of taking the medicine on time. While using post-test compliance percentage.
the E-Patuh application researchers have The effects of antiretroviral treatment in
submitted articles on HIV/AIDS to be able the control group were mostly 8 (53.3%)
to provide information and education about respondents felt nauseated. As a result of side
the importance of medication adherence and effects of ARV treatment one of the factors
educate the respondents’ understanding of that inhibited adherence to the control group
HIV/AIDS. said 2 respondents discontinued treatment
After using E-Patuh during the treatment when physically felt better. This research is
package program, it was found that 5 supported by research of Sugiharti, Yuniar,
respondents still had difficulty remembering and Lestary (2014) which get nausea, fever,
the time to take medication but on the other rash made ODHA cannot stand side effect so
hand there were increasing of adherence to decided to stop treatment.
6 respondents who before using E-Patuh had Marital status in the control group
trouble often skipping medication within married one of the social support factors to
four days. This compliance improvement the support system of respondents in ARV
is evidenced by no respondents claiming adherence with 6 (40%) of respondents. In
to have a problem with taking time to take line with Galistiani and Lia (2013) say social
medication time during the use of E-Patuh. support especially in the context of intimate
The E-Patuh application is an android- relationships or the quality of marriage and
based smartphone app and website that is family relationships is the most important
connected with internet network that can source of social support. Social support from
access communication, information and as people around the patient can be a boost to
remainder. This technology provides the HIV treatment adherence.
principle of benefit to PLWHA to improve In this study, the extent of ARV adherence
the behavior of obedient to ARV. The features in general is quieted <95% below the national
contained in the E-Patuh application can target. It will have an impact on the spread or
enhance compliance by providing remainder suppression of HIV virus to PLHIV. With the

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 Alfian: The Effect of the E-patuh application on HIV/AIDS Patients Adherence in Consuming Antiretroviral

issue, WHO and the Ministry of Health through and even individual characteristics. A
a system of curing with this prevention, similar opinion is supported by the theory
care and treatment program emphasize that of Acceptance Technology Model (TAM)
ongoing care and with attention to ARV by Davis (1989) is a model for predicting
adherence can suppress the virus in the body, individual acceptance of a new technology.
reduce the risk of transmission to others, help TAM is actually adopted from the theory of
people living with HIV and help keep long reasoned action model (TRA) by Ajzen and
life (Kemenkes, 2017). Fishbein (1975), the theory of action with
Given that antiretroviral therapy is a one premise that reactions and perceptions of
lifelong therapy, then the problem of treatment a person to something that will determine the
adherence was a common problem. Various attitude and behavior of the person.
studies show obstacles to obstacles such as Differences in adherence levels of PLHIV
fear of side effects, forgetfulness, unhealthy pretest and posttest in both groups tended to
lifestyles, poor health conditions, missing better control group. This can be influenced by
medicine boxes, lack of personal awareness, some external and internal support factors in
opportunistic infections, daily activities, the patient so as to perceive and behave toward
economic problems insufficient income for something that can improve compliance.
ARV treatment, unemployment, and fear of External support factors are employment,
stigma. While adherence supporters, among most respondents work as private employees
others, have a regular schedule of taking in the control group of 9 (60%) of respondents
medication, understanding the importance of and intervention groups 7 (46.7%) with
adherence, getting good treatment results and varying salary. A minority of 3 (20%) of the
confidence in the treatment process (Yuniar, respondents in the intervention group were
Handayani, & Arsyastami, 2012). unemployed so that the work factor could
Technological developments cannot be be a factor in the intervention group had less
denied so quickly and rapidly in all aspects compliance than the control group because
of human life. This becomes an opportunity the work would affect income to meet the
and a challenge for us especially in the field needs of antiretroviral treatment. Although
of health. The demand of technological ARV programs are free but access to ARVs
development with the internet network in requires financing. This study was supported
the health world leads the health service by Wulandari (2015) study which stated that
system in paying attention to the compliance insufficient income made respondents did not
of antiretroviral programs for PLHIV. routinely come to take the medicine, and vice
Utilization of technology in the field of health versa respondents with middle to high income
services in hospitals or in the community, and work become private employees tend to
especially for PLWHA will assist PLWHA in always actively come to take antiretroviral
undergoing a life-long antiretroviral regimen drugs.
program, facilitate access to health services,
delivery of information and education, time
efficient and financing in various aspects of Conclusion
service. Acceptance of technology based on
android and website in it the use of E-Patuh The growth of technology becomes good
application to PLWHA will guide some change for people living with HIV to be
aspects of knowledge, attitude of PLWHA more effective in ARV medication program.
in antiretroviral treatment program so that PWLH needs the program for monitoring
ODHA become know, understand and able their ARV medication. The implementation
to change behavior in taking decision during E-Patuh based android and website system
undergoing ARV treatment program. had positive outcome for increasing ARVs
Taiwo and Downe (2013) said that medication adherence.
in Technology Acceptance Models And After using E-Patuh during the treatment
Theories argue that interaction between package program, it was found that 5
humans and technology will affect the social respondents still had difficulty remembering
and psychological factors of individuals the time to take medication but on the other

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 Alfian: The Effect of the E-patuh application on HIV/AIDS Patients Adherence in Consuming Antiretroviral

hand there were increasing of adherence to Smartphone medication adherence apps:

6 respondents who before using E-Patuh had Potential benefits to patients and providers.
trouble often skipping medication within J Am Pharm Assoc, 53(2), 172–181. https://
four days. This compliance improvement d o i. o rg /1 0 . 1 3 3 1 / J A P h A . 2 0 1 3 . 1 2 2 0 2 .
is evidenced by no respondents claiming Smartphone.
to have a problem with taking time to take
medication time during the use of E-Patuh. . Galistiani, G.F. & Lia, M. (2013). Kepatuhan
The ARVs adherence medication score in pengobatan antiretroviral pada pasien HIV/
control group were relatively better at the AIDS di RSUD Prof. Dr. Margono Soekarjo
beginning. Although in the control group Purwokerto. Media Farmasi, 10(2), 94–103.
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expressed difficulties remembering the time Kemenkes RI. (2011). Pedoman tata laksana
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Jakarta: Kemenkes RI.
 
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