Religion, Faith, and Spirituality as Barriers and Facilitators to Antiretroviral Therapy Initiation Among People with HIV in Indonesia

Indonesia is a country deeply rooted in religion, faith, and spirituality. These aspects significantly determine individuals' decision-making and behavior, including health care decisions. Given the suboptimal attainment of the HIV-cascade targets in the country, we conducted a study to explore the role of religion, faith, and spirituality on antiretroviral therapy (ART) initiation. Our study involved individual interviews with 67 participants recruited from community health centers, public hospitals, and private clinics, predominantly Muslim, including 17 untreated people with HIV (ART-naïve), 30 people with HIV on treatment (ART-experienced), and 20 HIV service providers. Findings revealed that many individuals perceived HIV as a godly punishment related to individual failure (prior risk-prone behaviors), generating shame, guilt, and stigma. Perceiving religion as punitive and unforgiving and holding fatalistic beliefs was linked to postponed ART initiation. Conversely, perceiving religion as loving and forgiving, seeking forgiveness through religious practices, viewing ART intake as a "collaborative" effort with God, and engaging in righteous deeds facilitated ART initiation. These findings indicated that religion, faith, and spirituality can serve as both barriers and facilitators to ART initiation, depending on individuals' faith-based practices and perceptions of religion, whether punishing or forgiving. We recommend that people with HIV and health care providers better recognize the role of religion, faith, and spirituality in coping with shame, guilt, and stigma after an HIV diagnosis. This recognition can facilitate informed decisions regarding ART initiation, ultimately improving health outcomes for individuals with HIV in Indonesia.