THE EFFECTIVENESS OF PEER GROUP SUPPORT MODEL BASED ON CHRONIC CARE MODEL ON ANTIRETROVIRAL COMPLIANCE, INCREASING IMMUNITY (CD4, VIRAL LOAD, OPPORTUNISTIC INFECTIONS), AND QUALITY OF LIFE OF PEOPLE WITH HIV (PLHIV)

Introduction: The role of peer groups is very important in the treatment process for HIV/AIDS patients which determines the health condition and quality of life of HIV/AIDS patients, however, peer group support has not been integrated with health services. Aim: This study aims to analyze the effectiveness of peer group support based on the chronic care model (CCM) on ARV treatment adherence, level of immunity, and quality of life for HIV/AIDS patients. Method: This research used a quasi-experimental design (pre-post test with control group design). The research population was patients with HIV/AIDS with a sample of 30 people in each control and intervention group. Data was collected using questionnaires and blood samples from PLHIV, then analyzed using the Chi-Square test, Wilcoxon Signed Rank Test, and Mann Whitney. Results: Effect test results show that there is a significant influence of chronic care model-based peer group support on ARV treatment adherence (0.000), CD4 count (0.000), Viral Load (0.000), Opportunistic Infections (0.000) and quality of life (0.000) in HIV patients /AIDS. Conclusion: Peer group support based on the chronic care model affects ARV treatment adherence, level of immunity, and quality of life for HIV/AIDS patients. Peer group support based on the chronic care model increases adherence to ARV treatment, increases CD4 counts, increases viral load, reduces the incidence of opportunistic infections, and improves quality of life in HIV/AIDS patients.


INTRODUCTION
The role of peer groups is very important in the treatment process for HIV/AIDS patients which determines the health condition and quality of life of HIV/AIDS patients, however, peer group support has not been integrated with health services (1).Peer group support is effective in forming positive behavior and new values in individuals who are members.Support from peer groups has been proven to increase sufferers' enthusiasm in the treatment process (2).
Many approaches can be used to increase antiretroviral adherence, but few are capable and effective in shaping positive behavior in sufferers in increasing their treatment adherence.So far, the peer group support approach has not been integrated with patient services in hospitals, so it is necessary to research the development of a peer group support model in increasing antiretroviral adherence, increasing immunity, reducing OI, and improving the quality of life of sufferers.
The number of HIV sufferers throughout the world is still increasing, in 2019 it reached 38 million sufferers and Indonesia is one of the countries in Southeast Asia with the highest number of HIV AIDS.In 2017 in Indonesia, there were 48,300 individuals living with HIV and AIDS.Of the large number of sufferers in the world, only 65% have access to antiretrovirals, whereas in Indonesia compliance with Antiretroviral Therapy (ART) is still a major problem, this is proven by the Lost follow-up (LFU) rate for treatment and antiretroviral therapy is still quite high.namely 21.87%.
According to a report on HIV care and antiretroviral therapy in 2017, there were approximately 214,819 people who were eligible for antiretrovirals, but only 180,843 people received antiretrovirals.Of the 180,843 people who had received antiretroviral therapy, 39,542 people (21.87%) lost LFU follow-up (21.87%) and 3,501 (1.93%) stopped taking antiretrovirals.This decrease in adherence to antiretroviral therapy ultimately makes sufferers prone to OI and have a poor quality of life due to stigma and hopelessness.The prevalence of HIV sufferers who did not take antiretrovirals out of 1,603 sufferers was 123 sufferers (7.7%) Human Immunodeficiency Virus (HIV) sufferers still show high rates and compliance with antiretroviral (ARV) treatment is still not 100% (5).Irregular compliance with antiretroviral use will cause the number of viruses in the sufferer's body to increase (6), as a result, the viral load will show high numbers and the CD4 count will decrease further, resulting in a progressive decrease in the body's immunity (7).The decrease in immunity that occurs has an impact on the worsening of the disease ( 8), the emergence of many opportunistic infections (OI) (UNAIDS, 2016) and will make the sufferer's quality of life even worse, thus affecting the sufferer's daily condition (10).
The role of peer groups that have been implemented is the many HIV AIDS communities that have been formed and Non-Governmental Organizations (NGOs).
Communities and NGOs make efforts to monitor the level of patient compliance and provide positive activities to increase the actualization of PLHIV (11,12).The actualization of sufferers who are not formed will result in a poor self-assessment so the meaning of life decreases and results in a decrease in quality of life.The decreasing quality of life will cause sufferers to easily fall into a state of depression and get sick easily so they can easily fall into AIDS, critical condition, and even death (13).
The Chronic Care Model (CCM) identifies critical elements of the health care system that promote high-quality chronic disease care including community, health systems, selfmanagement support, delivery system design, decision support, and clinical information systems (14,15).The integration of treatment and the role of peer group support with elements of CCM is very important to strengthen fellow sufferers and assist health workers in providing integrated care between hospitals and the community.So it is hoped that peer group support combined with CCM can increase positive behavior such as motivation, support, and enthusiasm among sufferers and health workers which can increase compliance in treatment and improve the quality of life of sufferers which can be monitored and reminded by fellow PLWHA.
Peer group support is a support system for a group of people who suffer from the same disease, a practical place for a group of people to provide and receive emotional support and 7 Table 1 shows the characteristics of respondents.The distribution of characteristics of respondents in the intervention group shows that the most common age group is early adulthood and late adulthood, 11 (36.7%), and the most common gender is male, 83.3%.The marital status of 53.3% of PLHIV is unmarried, and the majority of ethnic groups are Javanese and religious (86.7%).The most common occupation was self-employment (43.3%) and their last education was high school or equivalent as much as 63.3% with a history of illness of 80.0% stating none.
The control group showed that the most common age was in late adulthood as much as 36.7% with males also showing more (73.3%).The marital status of 46.7% was married, the ethnic group of 83.3% was Javanese and 90.0% were Muslim.The most common occupation is selfemployment as much as 33.3% and their last education is high school or equivalent as much as 63.3%.86.7% of PLHIV's disease history stated that it was absent.The results of the Chi-square test for equality between the two groups of demographic characteristics show that the two groups are equivalent.The test results show that the p-value is > 0.05, so it can be said that the data on the demographic characteristics of PLHIV are equivalent.9 practical place for a group of people to give and receive emotional support and exchange information.The contribution of peer group support in improving chronic disease conditions has been widely proven.Increasing the abilities of PLHIV cannot be separated from the support system provided to PLHIV, one of which is social support.Social support is comfort, attention, appreciation, or assistance in other forms that individuals receive from other people or groups.
One way is by peer group support with a Chronic Care model approach, namely nursing intervention focused on a support system that will have an impact on the individual's confidence in his ability to process, plan, and modify behavior to achieve a better quality of life.The Chronic Care Model (CCM) identifies critical elements of the healthcare system that promote high-quality chronic disease care.These elements are community, health systems, selfmanagement support, delivery system design, decision support, and clinical information systems.The concepts of evidence-based change under each element, in combination, encourage productive interactions between informed sufferers who take an active part in their care and providers with resources and expertise (17,18).
Peer group support based on the Chronic Care Model (CCM) is a combination of theories that aims to increase antiretroviral adherence, reduce the incidence of opportunistic infections, and improve the quality of life of PLHIV.Peer group support based on the Chronic Care model is a system of providing and receiving assistance with care, shared responsibility, and mutual agreement, namely through support, friendship, empathy, mutual sharing, and mutual assistance by identifying important elements of the health care system that encourage disease treatment.HIV/AIDS encompasses communities, health systems, self-management support, delivery system design, decision support, and clinical information systems (19).
The integration of treatment and the role of peer group support with elements of CCM is very important to strengthen fellow sufferers and assist health workers in providing integrated care between hospitals and the community.So it is hoped that peer group support combined with CCM can increase positive behavior such as motivation, support, and enthusiasm among sufferers and health workers which can increase compliance in treatment and improve the quality of life of sufferers who can be monitored and reminded of each other by PLHIV.
The experience of an illness will give rise to various feelings and reactions of stress, frustration, anxiety, anger, denial, shame, sadness, and uncertainty that lead to adaptation to the illness.There is no quick or correct way to go through the grieving process.The role of the peer 10 group is to get an overview of grief behavior, recognize the influence of grief on behavior, and provide support in the form of empathy.So the peer group has good benefits in controlling the loss stage well.
Peer group support can also have an impact on PLWHA's motivation to engage in physical activity and sports.Physical exercise and the number of CD4 T cells are also very important for PLWHA if they want to improve their quality of life.Regular physical exercise or exercise has been proven to have a strengthening effect on the body, including increasing immunity.The more people with HIV/AIDS who are active in physical activity, the better their quality of life.Likewise, the number of CD4 T cells is an indicator of the strength of the body's immune system.Good body defenses support general health conditions and in turn, improve quality of life (20).
People with HIV/AIDS (PLWHA) also often experience psychological problems due to the stigma given by society.If a person suffering from HIV/AIDS experiences or receives stigma from the people around them, this bad label is inserted or internalized in their thoughts and feelings, which can cause heavy emotional and physical burdens.The stigmatization that is considered commonplace in society makes HIV/AIDS patients increasingly marginalized and has a broad impact on all aspects of their lives.Not only that, this stigma has also been proven to be the initiator of the initial idea of suicide.Suicidal behavior in HIV/AIDS patients occurs frequently and is significantly associated with mental disorders and lower quality of life (21).
The role of a good peer support group for PLWHA can improve the quality of life of PLWHA, for example, the role of a good peer support group in monitoring their treatment, especially ARVs, and can be a forum for counseling and education about good nutrition for PLWHA so that nutrition can be met optimally for PLWHA.In this way, PLWHA can work without worrying about their physical condition and PLWHA are more productive.Apart from that, with the role of a good peer support group, PLWHA is allowed to meet and make friends with other people so that PLWHA feel they have friends to share with, think about the same fate so that a sense of mutual support will emerge between PLWHA.PLWHA do not feel alone so if they continue to think about their illness, PLWHA will fall into a state of stress which will worsen their health condition (22).
The application of peer group support based on the Chronic Care model can increase the ability of PLHIV to have a significant relationship with ARV treatment adherence.This can be so because PLHIV whose abilities improve also show a positive response in themselves, so they will be more compliant with ARV treatment because PLHIV wants to stay healthy.11 Increasing the abilities of PLHIV will also improve in terms of carrying out daily activities, carrying out their beliefs in worship, determining abilities in coping mechanisms, carrying out social interactions, worship activities, self-confidence, social acceptance, self-care, and managing feelings.If all of these things can be managed well, the lives of PLHIV will always be positive and will have an impact on compliance with ARV treatment, including accuracy in schedules, accuracy in quantity, accuracy in type, management of side effects, acceptance of information and motivation within PLHIV (23).
Increasing the ability of PLHIV has a significant relationship with the level of immunity of PLHIV.The incidence of opportunistic infections will increase if the immune condition of PLHIV decreases, which is not proportional to the large viral load.Opportunistic infections are infections caused by a decrease in the body's immune system.These opportunistic infections occur due to microorganisms entering the body such as bacteria, fungi, and viruses.Normally CD4 cells are 500 but in HIV/AIDS sufferers it can be less than 500.To predict whether infection is likely to occur based on the level of CD4 cells per microliter.CD4 cells will decrease with increasing exposure to HIV infection.If CD4 cells reach 350 then the possibility that a person has an infection is a skin infection and then varicella zoster.Then, if the CD4 cells decrease by 250, there is a possibility that a person will experience oral candidiasis, and pneumonia, then if the CD4 level decreases, a person can experience bacteriococcal meningitis.
It has been found that many HIV/AIDS sufferers experience tuberculosis and other opportunistic infections (24).
The implementation of peer support groups improves the psychological condition of respondents, from bargaining to acceptance.The acceptance stage is the second stage after bargaining and depression.At this stage, the respondent feels pain because the pain is reduced and moves towards identification as someone who has limitations due to the illness they suffer from.Respondents are willing to accept help from other people to deal with their illness and will carry out treatment according to what the respondent can do.Meanwhile, in the control group, in the second measurement, respondents were only in the depression phase.This also increases from bargaining to depression.In this phase, respondents admit to feeling sad and put aside feelings of anger.Respondents try new behaviors consistent with new limitations.
Respondents had a high emotional level in this phase, including deep sadness and regret, helplessness, no hope of life, feeling guilt for their illness, and loneliness, and many respondents chose to cry (Rose, 1974).12 The support needed by respondents so that they can improve social conditions is as follows (Kesrepro, 2007): 1. Support for PLWHA and their families.PLWHA experiences a difficult process related to psychology, a process that should lead to acceptance of the condition.However, society and institutions sometimes still provide negative opinions so that PLWHA and their families are discriminated against, this causes a weakening of the quality of life of PLWHA.
2. Health service premises.Often, institutions that are expected to provide care and support are the first place where people experience stigma and discrimination.For example, providing poor quality medical care and even refusing to provide treatment, isolation measures, breaches of confidentiality, and the use of negative words and body language by health workers.
3. Education.The right to education is sometimes still undermined through refusals to enroll students in school.Rejection occurs in negative treatment from peers and exclusion in class.
4. Media.Some journalists do not have sufficient knowledge or basic information when reporting on situations involving vulnerable groups and PLWHA.Misinformation can encourage inappropriate comments and the use of negative terms.Reports whose truth has not been clarified hurt increasingly cornering PLWHA.
5. Workplace.The ability to pay for living and to be employed is a basic human right.
Issues related to HIV AIDS concern hiring and dismissal, safety of other employees, health insurance, absence from work for health purposes, and treatment of superiors and co-workers.Often the thinking behind these related issues is the belief that there is no point in investing money in someone who will eventually die.The absence of a recruitment policy is a complicated condition that is often overlooked.

CONCLUSION
Peer group support based on the chronic care model (CCM) influences ARV treatment adherence, immunity level, and quality of life for HIV/AIDS patients.Peer group support based on the chronic care model increases adherence to ARV treatment, increases CD4 counts, increases viral load, reduces the incidence of opportunistic infections, and improves quality of life in HIV/AIDS patients.

Table 1
The Effectiveness of Peer Group Support Model Based on Chronic Care Model on Antiretroviral Compliance, Increasing Immunity (CD4, Viral Load, Opportunistic Infections), and Quality of Life of People with HIV (PLHIV) The contribution of peer group support in improving chronic disease conditions has been widely proven.Based on several studies that have been carried out and the description of the problem above, it is very possible to carry out research on the development of a peer group support model based on the chronic care model for antiretroviral adherence, Characteristics of PLHIV Research Intervention Group and Control Group ___________________________________________________________________________ Rev. Gest.Soc.Ambient.| Miami | v.18.n.1 | p.1-14 | e06327 | 2024.5 exchange information.Indonesian, and cooperative in complying with agreed activity rules.This research used data instruments on respondent characteristics, CCM-based peer group support, ARV treatment record sheets, sufferer immunity instruments, and sufferer quality of life.Data collection begins with consent from PLHIV.PLHIV was divided into two groups, the intervention group and the control group.Patients who are willing to become respondents are asked to sign an informed consent sheet.Next, a pre-test was carried out on the treatment group and control group.The perpetrator group was given CCM-based peer group support intervention in 4 sessions over 6 weeks: Session 1 was carried out by the agreement with the peer group support members, session 2 was carried out 2 weeks after session 1, session 3 was carried out 2 weeks after session 2, and session 4 was carried out 2 weeks after session 2. weeks after session 3.In the control group, it was implemented by HIV/AIDS management procedures at the UPIPI Polyclinic, Dr. Hospital.Soetomo Surabaya.Researchers conducted a post-test on respondents by measuring the level of adherence to ARV treatment, body immunity level (CD4 count, viral load, opportunistic infections), and quality of life.After the data was collected it was analyzed using the Wilcoxon Signed Test and Mann Whitney Test.This research has The Effectiveness of Peer Group Support Model Based on Chronic Care Model on Antiretroviral Compliance, Increasing Immunity (CD4, Viral Load, Opportunistic Infections), and Quality of Life of People with HIV (PLHIV) ___________________________________________________________________________ Rev. Gest.Soc.Ambient.| Miami | v.18.n.1 | p.1-14 | e06327 | 2024.6 received ethical permission from the Ethics Committee of the Faculty of Nursing, Airlangga University with number 2582-KEPK 3 RESULT The Effectiveness of Peer Group Support Model Based on Chronic Care Model on Antiretroviral Compliance, Increasing Immunity (CD4, Viral Load, Opportunistic Infections), and Quality of Life of People with HIV (PLHIV) ___________________________________________________________________________ Rev. Gest.Soc.Ambient.| Miami | v.18.n.1 | p.1-14 | e06327 | 2024.

Table 2
TestThe Effectiveness of Peer Group Support Model Based on Chronic Care Model on Antiretroviral Compliance, Increasing Immunity (CD4, Viral Load, Opportunistic Infections), and Quality of Life of People with HIV (PLHIV) of the Effect of Peer Group Support Based on the Chronic Care Model (CCM) on ARV treatment adherence, level of immunity, and quality of life for HIV/AIDS patients ___________________________________________________________________________ Rev. Gest.Soc.Ambient.|Miami | v.18.n.1 | p.1-14 | e06327 | 2024.8

Table 2
shows the results of the analysis of the influence of Peer Group Support based on the chronic care model (CCM) on ARV treatment compliance, level of immunity, and quality of life for HIV/AIDS patients.The results of the Wilcoxon test in the treatment group showed that there was a significant difference between ARV adherence, body immunity (CD4, viral load, opportunistic infections, and quality of life before and after giving Peer Group Support based on the chronic care model (CCM) with a value of p<0.05.The results of the difference test between the treatment and control groups, there were significant differences in adherence to ARV treatment (p=0.000),CD4(p=0.000),viralload(p=0.000),opportunisticinfections(p=0.000), and quality of life ( p = 0.000).The Mann-Whitney test shows the post-test comparison of ARV treatment adherence (p = 0.001), CD4 (p = 0.011), viral load (p = 0.010), opportunistic infections (p = 0.034), and quality of life (p =0.000) shows (p<0.05)meaning that the post-test of the perpetrator group and the control group has a significant difference.4DISCUSSIONTheapplication of peer group support based on the Chronic Care model shows a significant influence on ARV treatment compliance, level of immunity, and quality of life for HIV/AIDS patients.This is based on research results showing that the intervention group increased adherence to ARV treatment, increased CD4 counts, increased viral load, reduced the incidence of opportunistic infections, and improved quality of life in HIV/AIDS patients.Peer group support interventions show an increase in Quality of Life (QoL).Treatment and the role of peer group support are very important to strengthen fellow sufferers and assist health workers in providing integrated services between hospitals and the community.Peer group support is a support system for a group of people suffering from the same illness, a The Effectiveness of Peer Group Support Model Based on Chronic Care Model on Antiretroviral Compliance, Increasing Immunity (CD4, Viral Load, Opportunistic Infections), and Quality of Life of People with HIV (PLHIV) ___________________________________________________________________________ Rev. Gest.Soc.Ambient.| Miami | v.18.n.1 | p.1-14 | e06327 | 2024.