THE CORRELATION OF ANTIRETROVIRAL CONSUMPTION ADHERENCE ON THE QUALITY OF LIFE OF HIV PATIENTS: A SYSTEMATIC REVIEW

Introduction: The use of antiretroviral therapy (ARV) occupies a major role in maintaining the immune system of patients with HIV / AIDS. Nowadays, there are still many cases of disobedient behavior in taking medication that affects the health condition and Quality of Life (QoL) of patients. This study aimed to conduct a systematic review of previous journals discussing the correlation of antiretroviral (ARV) consuming adherence to the Quality of Life (QoL) of HIV patients.


INTRODUCTION
The existence of the human immunodeficiency virus (HIV) in the human body will disrupt the immune system, which makes the body is susceptible to various disorders existing around it (Oliveira et al., 2018). As a result, the body is susceptible to various diseases so that it contributes to the decrease in productivity. The use of antiretroviral therapy (ARV) plays a major role in maintaining the immune system of people with HIV / AIDS. The recommended combination of antiretroviral drugs is capable to aggressively suppress the development of the virus in the body. Therefore, it results in preventing HIV progression to AIDS to enhance the improvement of patient survival and quality of life (Desta et al., 2020). One of the formidable challenges faced by HIV patients is the impaired quality of life due to the negative impact on their physical and mental health (Xiao et al., 2019). Efforts to maintain the quality of life and productivity of HIV patients are not merely taking ARV drugs regularly but also how to maintain the adherencein running therapy for years.
According to UNAIDS data, at the end of 2019, there were about 38 million people in the world lived with HIV / AIDS, 25.4 million of whom were accessing antiretroviral therapy, where 88% of patients wereexperiencedviral suppression (Ajayi et al., 2020). The procurement of ARV drugs in health services that are easily available is a very supportive factor for the success of therapy. The availability of ARV drugs is not the only solution. Patients with HIV / AIDS need lifelong treatment so that commitment and persistence are needed in carrying out therapy.
Research conducted in Brazil by Primeira et al. (2020), showed that strict adherence inhibits virus progression, decreasing the likelihood of viral load, CD4, and higher lymphocytes compared to patients with lower adherence levels which resulted in to detain the decrease of the body's defense cells (Primeira et al., 2020). The quality of life globally was increased, this is supported by a research of Reis (2020) explaining someone who was adherent to ARV therapy would improve health and could easily continue their daily activities (Reis et al., 2019), (Xiao et al., 2019). The quality of life is influenced by many different factors such as physical condition, environment, and support from family and close relatives. The best way to achieve a quality of life associated with strict adherence suggested that the higher the quality of life for people with HIV, the higher their adherence to treatment (Primeira et al., 2020). This systematic review aims to discussing the correlation of antiretroviral (ARV) consuming adherence to the Quality of Life (QoL) of HIV patients.

METHOD
The types of study conducted were cross-sectional studies focused on the adherence of ARV drugs consumption to the quality of life of HIV AIDS patients. The literature searching process was specified on the five years latest research (2016)(2017)(2018)(2019)(2020) in the English version and selected from several indexed electronic databases such as EBSCO, Science Direct, PubMed, Scopus, Proquest, Sage. Wiley, and DOAJ. The writing of article search results was made according to the principals of Preferred Reporting Items for Systematic Review (PRISMA) checklist and flow diagrams.
The feasibility of this study was assessed using the PECOT framework. Population: the study population was all categories of patients with HIV / AIDS. Exposure: the exposure was ARV drugs consumption adherence. Comparison: No comparison, effect of ARV drugs consuming adherence on the quality of life for HIV / AIDS patients. Output: was seen from the changing / improving quality of life of the patients. Time period: 2016-2020. Article was identified with the keywords ("Adherence AND Antiretroviral OR ARV OR highly active antiretroviral therapy") AND ("Quality of Life OR QoL") AND ("HIV AIDS OR AIDS Virus OR Acquired Immune Deficiency Syndrome Virus OR Acquired Immunodeficiency Syndrome Virus OR HTLV-III OR Human Immunodeficiency OR Human Immunodeficiency Viruses ").
Risk of bias could be diminished by using critical appraisal tools. Reviewers was used Joanna Briggs Institute (JBI) critical appraisal tools. JBI critical appraisal tools was checklist questionnaire with list of items requires, things had to be done, and points to be considered. Every study design has different question. Declared to have escaped the risk of bias if the value is more than 75%. Two reviewers (BS and MN) had scoring articles that had been chosen. Result of scoring were from low risk, mild risk, high risk or unclear risk.
Data extraction this study was using a structured form to extract articles from title, year/time study research (2016)(2017)(2018)(2019)(2020), study design, sample size, variable, intervention, analysis, the outcome measures used to evaluate intervention and results.

Literature Search and Study Design
The first stage of literature search with the specified keywords on several databases obtained a total of 723 articles consisting of 176 Science Direct articles, 50 Pubmed articles, 214 Scopus articles, 62 Proquest articles, 43 Sage articles, 30 EBSCO articles, 115 Wiley articles, and 33 DOAJ articles. Those articles were identified based on author duplication, title, and by selecting "exclude". The second stage was selecting the manuscript by examining the journal abstract based on the agreed conditions. The third stage was reviewing the complete article and the eligibility criteria. The complete articles were reviewed with the PECOT framework to minimize the risk of bias in this study, the selection of data was carried out independently by 2 authors covering the same design, methods, interventions, and outcomes to be assessed. In this study, the data extraction tool was designed to guide information from notes following the research objectives. The extracted data in each of the included studies included: author, year, country, population and setting, study design, study objectives, methods and interventions, instruments used follow-up time, and the outcome of each study. The result selected 30 full-text articles and the quality were rated andeventually found 15 articles based on criteria and constituted a cross-sectional as the research design.

Partisipant Characteristic
A total of 15 articles selected in the line review published between 2016 and 2020 are international journals originating from the country (Brazil = 2); (Betancur et al., 2017), (Sabino et al., 2021) (Lahai et al., 2020), (Reis et al., 2019), (Primeira et al., 2020). The total number of respondents in this review were 5,416 respondents, with a total population involved between 83 and 1395 participants. The highest number of population was 1,395 participants. Participants involved were limited by several criteria such as being HIV positive, adhering to the use of ARV drugs consumption, and having experience related to medical treatment. All studies were conducted on children to adults (10-60 years old).\

Outcomes Measures
The Systematic Review results from the 15 articles were attached to the Matrix table in Appendix 1, found 10 journals with good quality, and 5 journals with moderate quality. Most of the studies used the Cross-Sectional Study design. Measuring instruments used in all studies were observation sheets, interviews, questionnaires using WHOQOL-BREF arranged in four domains: physical, psychological, social relations, environmental and consisted of 26 questions, two of which referred to the quality of life. Questionnaire on ART adherence using CEAT-HIV consisted of 20 items, the standard Morisky Drug Adherence Predictor Scale (MMAPS-8), and another similar questionnaire. The results of a review of 15 articles, therefore showed the effect of antiretroviral (ARV) consumption adherence on the quality of life (QoL) of HIV patients.  Table 1. Results of the review, the correlation of antiretroviral (ARV) adherence to the quality of life of HIV AIDS patients; physical health was increased, global quality of life was increased, sexual function was increased, viral suppression was decreased, viral load was decreased, CD 4 and lymphocytes were increased, disease progression was decreased, opportunistic infections were decreased, body immunity was increased. Table 2, Results of review, factors influencing adherence to antiretroviral (ARV) drugs consumption in HIV patients; depression / major depressive disorder, marital status, work status, type of ARV, family support, environment, emotional, less supportive ARV service places, gender, age, selfefficacy, concentration, forgetfulness, fear or shame, discomfort, the stigma known as HIV patient, and toxic ARV.

DISCUSSION
The correlation of antiretroviral (ARV) adherence to quality of life for HIV AIDS patients; physical health has improved, supported by the study of Lahai (2020) found empirical evidence on the level of adherence and quality of life as well as the determinant correlation among children living with HIV / AIDS in Sierra Leone so that physical health had improved (Lahai et al., 2020). Besides, the quality of life globally was increased, this is supported by a research of Reis (2020) explaining someone who was adherent to ARV therapy would improve health and could easily continue their daily activities (Reis et al., 2019), (Xiao et al., 2019). Besides, sexual function was good, viral suppression was good, viral load was decreased, CD 4, lymphocytes were increased, disease progression was decreased, body immunity was increased and opportunistic infections was decreased (Kagee et al., 2016). Findings that affecting equilibrium were predictors of all Quality of Life (QOL) domains. Treatment adherence was a predictor of all QOL domains with the exclusion of social relationships. A study from Desta (2020) revealed that more than half of participants adhering to ARVs were related to having better global scoresfrom life quality (Desta et (Lahai et al., 2020), (Primeira et al., 2020), (Xiao et al., 2019), (Nyongesa et al., 2018), (Reis et al., 2020), (Sabino et al., 2020). Quality of life globally (Reis et al., 2020), (Xiao et al., 2019), (Desta et al., 2020), (Bulali et al., 2018) Sexual function / sex (Sabino et al., 2020), (Primeira et al., 2020) Virus suppression (Kagee et al., 2016), (Tran et al., 2018) Viral load was decreased, CD 4, lymphocytewere increased, disease progression was decreased, the opportunistic infection was decreased, body immune was increased. (Kagee et al., 2016), (Primeira et al., 2020), (Xiao et al., 2019), (Reis et al., 2020).
Besides, the increasing effects of antiretroviral (ARV) drugs consumption adherence to the quality of life of HIV AIDS patients,there are several factors influencing ARV consumption adherence itself. ARV consumption adherence greatly affects the health status of HIV AIDS patients (Chukwuorji et al., 2020). One of the factors affecting adherence to antiretroviral (ARV) therapy in HIV patients isdepression / major depressive disorder. In the study of Sabino (2020), suggested that younger HIV patients with depression should receive special attention in clinical settings for the lower potential treatment adherence and quality of life (Sabino et al., 2021). Supported by Asrat's (2020) study, found that Major depressive disorder (MDD) affected adherence in taking medication for HIV patients so that it affected the quality of life of the patients (Asrat et al., 2020). Besides, the factors affecting the regularity of taking medication were also supported by marital status, employment status, type of ARV, family support, environment, emotional, unsupportive places for ARV services, gender, age, self-efficacy, concentration/forgetfulness, fear or embarrassment, discomfort, the stigma of being identified as HIV patients, and toxic antiretroviral (Chukwuorji et al., 2020).
Apart from ARV adherence, it turns out that other factors were affecting the Quality of Life (QoL) in HIV patients, namely; physical health, emotional condition (sadness, shame, loss of hope), family support, environment, gender, age, economic condition, education, socio-culture. A person with hopelessness and depression had no interest in selfcare, especially when they aresupposed to be adherent in taking antiretroviral drugs (ARVs) which can improve the quality of life of a patient with HIV AIDS (Asrat et al., 2020). In additionto supporting from the environment, family and friends, as health workers, nurses also play an active role in motivating patients who experience hopelessness and health problems, especially negative stigmatization related to HIV conditions. Therefore, the quality of life or health status could improve by the support of strong will within the patients themselves and supported by a good environment. The main factor contributing to the recovery was the regularity in consuming antiretroviral drugs (ARV) in HIV patients.

CONCLUSION
The study result showed that there was an correlation of adherence to taking antiretroviral drugs (ARV) on the Quality of Life (QoL) of HIV patients, including; increased physical health, increased quality of life globally, improved sexual function, viral suppression, decreased viral load, CD 4, increased lymphocytes, decreased disease progression, decreased opportunistic infections, and increased body immunity.