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Observations will seek to generate data in order to inform the proposed study’s guiding questions (a) (b) (c) (d) and (e).
The proposed research study will operate these data collections as a tool to fully experience the ambiance of these two spaces. Furthermore the researcher will use these data methods to full operate the experience and interactions between the residents, the buildings and its surrounding environment. By using the Reflective Journaling Method and Field Notes, will allow the researcher to capture the interacting moments in DTES and Gas town, while mobilizing from one block to the next. These methods and observation cycles will generate abundance of information that the researcher will experience. Thus, providing enough data to critically answer the questions. These methods and constructs will allow the researcher to understand the space and the ambiance within it.
The data will be simplified and categorized into the three sections of the literature review themes. Moreover, the final phase is of the data display will be used and implemented into the theoretical research essay. Furthermore, the proposed study will be executed in research essay format.
Suicidal behavior is a prevalent psychiatric emergency in HIV-infected adults. Detection of suicidal ideation is important in planning early psychiatric intervention and optimizing HIV/AIDS management. Characterization of suicidal ideation among HIV-infected adults is crucial; however, practically there is no data in Indonesia, the country with the second largest burden of HIV/AIDS epidemic in Asia. This study aims to identify suicidal ideation and analyze the associated psychopathology and determining factors among HIV-infected adults in Indonesia.
An observational cross-sectional study was conducted among HIV-infected adults aged 18–65 years old receiving antiretroviral therapy (ART). Measurement using Symptom Checklist-90 (SCL-90) was performed to assess the existing psychopathology. Firth’s penalized logistic regression analysis was performed to identify factors associated with suicidal ideation.
A total of 86 subjects were recruited. Most subjects were male (65.1%), median age was 35 years, and median latest CD4 count was 463 cells/μl. Lifetime suicidal ideation was identified in 20 subjects (23.3%). Mean SCL-90 T-score for depressive and anxiety symptoms were both significantly higher among subjects with suicidal ideation (M = 60.75, SD = 12.0, p = 0.000 and M = 57.9, SD = 2.8, p = 0.001, respectively) compared to those without. Bivariate analyses showed that lifetime suicidal ideation was associated with depressive and anxiety symptoms, non-marital status, CD4 count < 500 cells/μl, and efavirenz use. Multivariate analysis identified that a single-point increase in SCL-90 depression symptoms score (AOR 1.16, 95% CI 4.5–123.6, p = 0.000) and efavirenz use (AOR 5.00, 95% CI 1.02–24.6, p = 0.048) were significant independent factors related to suicidal ideation.
Suicide is one of the leading causes of death worldwide. In 2018, World Health Organization (WHO) estimated that almost 800,000 people die due to suicide annually, 79% of which occurred in low- and middle-income countries (LMICs) [1, 2]. Phases of suicidal behavior can be divided into suicidal ideation, plans, and attempt [3, 4]. Centers for Disease Control and Prevention (CDC) defines suicide as death caused by self-directed harmful behavior with an intention of dying as a result, while suicidal ideation is defined as having a thought of or considering suicide [3, 5, 6]. WHO surveyed 21 countries in 2001–2007 and reported lifetime prevalence of suicidal ideation as 2.0 to 2.1% [7, 8]. The majority of individuals (60%) who made a suicidal plan or attempt proceeded to do so within one year since the ideation onset [3, 7].
Suicidal behavior has been well characterized as a pervasive comorbidity among people living with HIV (PLHIV), which may represent the prevalence of mental disorders among PLHIV [9]. HIV infection may either directly disrupt central nervous system (CNS), associated with CNS-related opportunistic infections that defines acquired immune deficiency syndrome (AIDS), or might be accompanied by environmental issues negatively affecting mental health (e.g. substance use, socioeconomic burden, and stigma) [10,11,12]. All of these may lead to increased risk of psychopathology. Indeed, a 2018 study in UK showed that a higher proportion of PLHIV presented with depressive symptoms (27.0% versus 10.5%) and anxiety (21.6% versus 9.6%) compared to demographically-matched HIV-negative group [13, 14]. Almost double of those numbers were reported in Asian countries, such as China (50.8% of PLHIV showing depressive symptoms) and India (50% and 25–36% of PLHIV showing depressive and anxiety symptoms, respectively) [15,16,17]. Prevalence in LMICs was similarly high, but resource limitation further added difficulties to the situation, due to underdiagnosis of mental disorders, suboptimal access to treatment, and limited research-based knowledge [18, 19]. Subsequently, suicidal behavior was reported at an alarmingly high rate among PLHIV: 22.5% of PLHIV in Ethiopia showed suicidal ideation [20], increase in suicide rate due to HIV seropositive status was reported in South Africa (13.3 to 18.9%) [21], and suicidal ideation was reported in as many as 45% of HIV-positive men who have sex with men (MSM) in India [22]. High suicidal burden among PLHIV has been consistently reported across countries, highlighting the urgency to monitor associated factors to suicidal ideation [23].
Notwithstanding the scarcity of studies in LMICs, distinct factors predictive of suicidal behavior have been well described [7, 18, 19]. HIV positive status, together with socioeconomic burden, poor social support, and perceived stigma, were found to be predictive of suicide attempt in South Africa [21]. In high-income countries (HICs), socioeconomic factors are associated less strongly compared to the progression of HIV disease itself. In Switzerland, for example, lower cluster-of-differentiation-4-expressing T cells (CD4 T cells) and advanced HIV/AIDS stage were related to higher suicide rate among PLHIV [24]. In particular, antiretroviral therapy (ART) containing efavirenz as a non-nucleoside reverse transcriptase inhibitor (NNRTI), was linked to significant adverse effects on the CNS which may induce psychiatric symptoms, such as severe depression and suicidal ideation [25]. PLHIV receiving efavirenz were approximately twice as likely to experience suicidal thoughts or attempt suicide compared to those receiving other medications [26]. On the other hand, non-HIV-related risk factors did not vary between countries, which included female gender, young adult (18–34 years old), low educational level (secondary education or lower), married, and having a mental disorder [7]. While diagnosable mental disorders prior to suicidal behavior are more prevalent in HICs (> 90% versus 60%), psychopathologies are as predictive of suicidal ideation in LMICs as they are in HICs [2, 27, 28]. Ultimately, psychopathology in PLHIV was found to affect the clinical outcome and mortality, adherence to ART, HIV risk behaviors, and quality of life (QOL) poorly [11, 17, 29, 30]. Psychological interventions (e.g. cognitive behavioral therapy and group psychotherapy) in HICs are effective in improving depressive symptoms among PLHIV, as evidently shown by clinical trials [31,32,33]. Such studies also highlighted the importance of early detection of suicidal behavior in order to enable timely intervention to improve mental health and HIV/AIDS-related treatment outcomes [34]. Nevertheless, more data are urgently needed in LMICs, including Indonesia.
Indonesia is the third most populous LMICs in the world and known to have the second largest burden of PLHIV in Asia [35, 36]. Although the suicide rate among general population in Indonesia (3.4 per 100,000 people) is lower than the crude suicide rate in both South-East Asia and worldwide (13.2 and 10.6 per 100,000 people, respectively), suicide is regarded as a major concern in Indonesia [1]. Suicidal ideation was reported in 4.75% of Indonesian adolescents [37], while a 2019 survey of 1018 adults in the general population reported that 1 of 4 subjects experienced suicidal thoughts [38]. With regard to PLHIV in Indonesia, however, the characteristic of suicidal ideation is practically unknown. In this study, we aim to identify suicidal ideation and psychopathology among PLHIV in Indonesia and the associated factors. Prior evidences in other countries signified depression as a major factor to the emergence of suicidal ideation among PLHIV [20, 39,40,41]. Thus, we hypothesize that Indonesian PLHIV who have experienced suicidal ideation will show significantly higher depression symptoms score. It is hoped that the result of this study is beneficial to optimize early psychological intervention, prevent suicide, and improve the overall HIV/AIDS treatment outcome in Indonesia.
A cross-sectional study was conducted among subjects who met inclusion criteria, which were adult PLHIV aged 18–65 years old receiving antiretroviral therapy (ART) and fluent in Indonesian language. Subjects were excluded if severe mental disorders, including psychotic disorders as well as intellectual and developmental disabilities, were revealed during psychiatric examination. Power analysis with medium effect size (d = 0.50) and an alpha of 0.05 showed that a minimum size of 86 subjects was necessary to achieve a power of 0.90. Subject recruitment was done by consecutive sampling