Determinants of Oral Hygiene Status (OHI-S) in Adolescents Living with HIV/AIDS in Gorontalo City: The Role of Stigma, Discrimination, and Antiretroviral Therapy Adherence

1. Introduction

The development of oral health status (OHI-S) and human productivity currently faces major challenges, shown by high rates of HIV-related disease transmission. The World Health Organization (WHO) notes that AIDS remains a disease with rising prevalence and requires serious attention. HIV infects CD4+ T lymphocytes, weakening the immune system and progressing to AIDS (Pratiwi et al., 2022). HIV affects immune cells in several stages: initial infection (with or without acute syndrome), an asymptomatic stage, and later, advanced disease.

Factors increasing HIV transmission include having multiple sexual partners, engaging in anal sex, and not using condoms. Parenteral factors like blood transfusion and injectable drug use also contribute. Vertical transmission from an infected mother to a child can occur during pregnancy, birth, or after birth (Pratiwi et al., 2022). Among adolescents, peer influence, environmental factors, and psychological factors increase the transmission risk (Irwan et al., 2025).

The introduction of antiretroviral therapy (ART) in 1996 was a major breakthrough in treating people living with HIV (PLHIV) in developed countries. Though ART is not a cure and can cause side effects and drug resistance, it has reduced illness and death among PLHIV.

According to UNAIDS Global HIV & AIDS Statistics (2023), about 85.6 million people have been infected with HIV since the epidemic started, and 40.4 million have died from AIDS-related illnesses. In Indonesia, the Ministry of Health estimated 543,100 people living with HIV in 2020. Data from the Gorontalo Provincial Health Office from 2001 to June 2024 shows a total of 1,180 HIV/AIDS cases. Gorontalo City had the most cases, with 87 new cases in early 2024, bringing the total to 467.

Since the HIV/AIDS epidemic began, in adolescents living with HIV/AIDS have faced fear, rejection, stigma, and discrimination. Stigma is labeling people negatively, causing exclusion (Asrina et al., 2023). One common stigma is viewing HIV/AIDS as a “punishment” for moral or religious reasons. Discrimination is unfair treatment of stigmatized individuals, including rejection by family, peers, or the community.

Stigma and discrimination often lead people to withdraw from society, limiting daily activities. These issues reduce motivation to disclose HIV status and affect health outcomes, including oral health (OHI-S).

Adherence to antiretroviral therapy depends on biopsychosocial factors. Since ART is lifelong, it is essential to assess and improve adherence to support overall health, including oral health (OHI-S) for people living with HIV/AIDS.

The oral health status (OHI-S) of people living with HIV/AIDS in Gorontalo City shows considerable variability. Some individuals can perform daily activities similarly to healthy individuals without significant physical complaints. However, despite appearing physically stable, many still have concerns about health, daily life, social relationships, housing, and employment. This is reflected in their tendency to conceal their HIV status from the public. Additionally, some individuals experience negative emotions such as loneliness, hopelessness, anxiety, and depression, which in certain cases require support from healthcare professionals or peer support groups.

2. Materials and Methods

2.1. Study Design

This study applied using an analytical cross-sectional survey. Participants were selected through purposive sampling based on the following criteria: registered HIV/AIDS patients, residing in the study area, and willing to participate in the study.

2.2. Study Setting and Participants

This study was conducted in Gorontalo City, Indonesia, over a period of three months and involved 1 dentists and 390 respondent. The sample size was calculated using the single-population proportion formula with a 95% confidence level (Z = 1.96), an assumed proportion of 0.5, and a margin of error of 5%. The minimum required sample size was 384. To account for potential non-response and to increase statistical power, an additional 2–5% was added, resulting in a final sample size of 390 adolescents. The calculation was performed manually and can be verified using statistical software such as Open Epi or Epi Info.

2.3. Data Collection Instruments

Stigma was measured using the short version of the HIV Stigma Scale (Berger et al.), while discrimination was assessed using a questionnaire adapted from the People Living with HIV Stigma Index developed by UNAIDS. All instruments were tested for validity and reliability, with Cronbach’s alpha values exceeding 0.7, indicating acceptable internal consistency.

Oral hygiene status (OHI-S) was assessed through direct clinical examination conducted by a dentist. The OHI-S classification followed World Health Organization (WHO) criteria: good (0.0–1.2), fair (1.3–3.0), and poor (3.1–6.0).

2.4. Data Analysis

Data were analyzed using non-parametric statistical tests. Data analysis used an ordinal logistic regression test with a significance level of p < 0.05. All statistical analyses were performed using appropriate statistical software.

2.5. Ethical Considerations

This study received ethical approval from the Research Ethics Committee of the Gorontalo State University, Indonesia Approval No. 075/KEPK-UNG/B/XI/2025; 12 November 2025. This study was not registered as a clinical trial because it employed a analytical cross-sectional survey design and did not meet the criteria for mandatory clinical trial registration.

3. Results

3.1. Analysis of Univariat in Stiqma, Discrimination, Therapi ARV and Oral Hygiene Indeks (OHIS)

Distribution of Respondents by Stigma, Discrimination, Antiretroviral Therapy Adherence, and Oral Health Status (OHI-S).

Based on Table 1, the stigma variable shows that the majority of respondents (57; 82.6%) experienced high levels of stigma, while 12 respondents (17.4%) experienced low levels of stigma. Similarly, the discrimination variable indicates that most respondents (51, 73.9%) experienced low levels of discrimination, whereas 18 (26.1%) reported high levels.

Regarding antiretroviral therapy (ART) adherence, the majority of respondents demonstrated high adherence, totaling 25 individuals (36.2%). Regarding oral health status (OHI-S), most respondents (37, 53.6%) were categorized as having a fair level of oral hygiene, while only 4 (5.8%) were classified as having poor oral hygiene.

3.2. Analysis of Validty Instrument Reseacrh

The magnitude of the coefficient of determination indicates how well the independent variables (stigma, discrimination, and ARV therapy adherence) explain the dependent variable (oral and dental health quality (OHIS)). The results of the determination coefficient calculation above show that the R-Square value using the Nagelkerke method is 0.456. Thus, it can be inferred that the variables of stigma, discrimination, and ARV therapy adherence can explain the oral and dental health quality (OHIS) variable by 45.6%.

Table 2. Model Fit – Coefficient of Determination.

Model	Pseudo R-Square
Nagelkerke	0.456

Table 2. Model Fit – Coefficient of Determination.

Model	Pseudo R-Square
Nagelkerke	0.456

Table 3. Association Between Independent Variables and Oral Hygiene.

Status (OHI-S)
Variables	OHI-S (Good) n (%)	(Fair) n (%)	(Poor) n (%)	Total n (%)	P-value	OR
Stigma					0.000	0.028
Low	23 (33.3)	35 (50.7)	11 (15.9)	69 (17.7)
High	134 (41.7)	175 (54.5)	12 (3.7)	321 (82.3)
Discrimination					0.006	7.32
Low	159 (54.6)	120 (41.2)	12 (4.1)	291 (74.6)
High	2 (2.0)	90 (90.9)	11 (11.1)	99 (25.4)
ART Adherence					0.708	0.761
High	90 (63.8)	51 (36.2)	0 (0)	141 (36.2)
Moderate	28 (20.6)	86 (63.2)	23 (16.9)	136 (34.9)
Low	39 (34.5)	73 (64.6)	0 (0)	113 (29.0)

Table 3. Association Between Independent Variables and Oral Hygiene.

Status (OHI-S)
Variables	OHI-S (Good) n (%)	(Fair) n (%)	(Poor) n (%)	Total n (%)	P-value	OR
Stigma					0.000	0.028
Low	23 (33.3)	35 (50.7)	11 (15.9)	69 (17.7)
High	134 (41.7)	175 (54.5)	12 (3.7)	321 (82.3)
Discrimination					0.006	7.32
Low	159 (54.6)	120 (41.2)	12 (4.1)	291 (74.6)
High	2 (2.0)	90 (90.9)	11 (11.1)	99 (25.4)
ART Adherence					0.708	0.761
High	90 (63.8)	51 (36.2)	0 (0)	141 (36.2)
Moderate	28 (20.6)	86 (63.2)	23 (16.9)	136 (34.9)
Low	39 (34.5)	73 (64.6)	0 (0)	113 (29.0)

Based on the bivariate analysis using ordinal logistic regression, the stigma variable showed a p-value of 0.000 (< 0.05), indicating a statistically significant association between stigma and oral hygiene status among people living with HIV/AIDS in Gorontalo City. Individuals with high levels of stigma had 0.028 times the odds of having better oral health status (OHI-S) compared to those with low stigma.

Similarly, the discrimination variable demonstrated a significant association (p-value = 0.006; < 0.05). Individuals experiencing high levels of discrimination had 7.32 times higher odds of having better oral hygiene status (OHI-S) compared to those with low discrimination.

In contrast, antiretroviral therapy (ART) adherence was not significantly associated with oral hygiene status (p = 0.708;> 0.05). This suggests that ART adherence does not have a significant effect on oral health status among in adolescents living with HIV/AIDS in Gorontalo City.

4. Discussion

4.1. The Effect of Stigma on Oral Hygiene Status (OHI-S) Among in Adolescents Living with HIV/AIDS

The results of this study indicate that individuals with high levels of stigma tend to have a fair level of oral hygiene (54.5%), while the proportion with poor OHI-S is lower than among those with low stigma.

Stigma was found to have a statistically significant effect on oral hygiene status (OHI-S) among in adolescents living with HIV/AIDS, with a p-value of 0.000 (p < 0.05) and an odds ratio (OR) of 0.028. This indicates that individuals with high stigma had 0.028 times the odds of having better oral hygiene status compared to those with low stigma. Among the 69 respondents, the majority (82.6%) experienced high stigma, while 17.4% experienced low stigma.

Field observations suggest that stigma is generally associated with negative impacts on various aspects of life, potentially leading to poorer oral health outcomes. However, this study’s findings show that stigma does not always directly determine oral hygiene status. Some individuals with low stigma still exhibited poor oral health, while some individuals with high stigma maintained good oral hygiene.

This phenomenon can be explained by psychosocial factors. Respondents with low stigma but poor oral health tended to experience psychological distress, limited social relationships, and a lack of environmental support. The absence of overt stigma does not necessarily imply adequate social support. Individuals may not be stigmatized but still lack emotional and practical support.

Conversely, individuals with high stigma may develop coping mechanisms and resilience, supported by strong social networks and self-acceptance. These factors enable them to maintain better oral hygiene. Respondents reported satisfaction with their social relationships, supportive environments, and positive self-perception, which facilitated access to oral healthcare services.

These findings are consistent with observations that people living with HIV/AIDS often establish supportive relationships through peer networks and community organizations, such as the AIDS Commission, which regularly conducts group discussions and support activities. This study is consistent with previous research (Rao et al., 2017), which demonstrated that social support mediates the relationship between stigma and health outcomes. Strong social support can mitigate the negative effects of stigma on both oral health and mental well-being

4.2. The Effect of Discrimination on Oral Hygiene Status (OHI-S)

The findings indicate that respondents experiencing high discrimination were predominantly classified as having fair OHI-S (90.9%) and had a higher proportion of poor OHI-S (11.1%). Discrimination showed a statistically significant association with oral hygiene status (p = 0.006), indicating that it plays an important role in determining oral health outcomes among in adolescents living with HIV/AIDS. Furthermore, individuals experiencing high discrimination had 7.32 times higher odds of poor oral hygiene status compared to those with low discrimination.

The study also revealed that respondents who experienced low discrimination had better oral health, whereas none of those who experienced high discrimination had good oral hygiene. This suggests that lower levels of discrimination are associated with better oral health outcomes.

Discrimination is a significant social determinant of oral health. Individuals experiencing low discrimination tend to have higher self-confidence, better social acceptance, and stronger support from family and community, enabling them to maintain their health and engage actively in social life.

In contrast, individuals experiencing high discrimination often face psychological distress, social isolation, and limited access to healthcare services. This leads to reduced utilization of oral healthcare services and poorer oral hygiene, characterized by increased plaque and calculus accumulation.

Field observations also indicate that discrimination can lead to fear, shame, low self-esteem, and anxiety, which negatively influence health-seeking behavior. Individuals may avoid healthcare facilities due to fear of negative treatment, resulting in delayed or inadequate oral care.

These findings are consistent with previous studies (Xu et al., 2017), which highlight the importance of family support and reduced discrimination in improving health outcomes. Interventions aimed at reducing discrimination and strengthening social support can significantly improve oral health among people living with HIV/AIDS

4.3. The Effect of Antiretroviral Therapy Adherence on Oral Hygiene Status (OHI-S)

The results indicate that respondents with high adherence tended to have better OHI-S (63.8%); however, this association was not statistically significant (p = 0.708 > 0.05). This suggests that ART adherence does not have a direct effect on oral hygiene status among people living with HIV/AIDS in Gorontalo City.

This finding may be explained by the fact that most patients, regardless of adherence level, did not perceive significant physical health problems. As a result, physical health status may not be the dominant factor influencing perceptions of oral hygiene.

Although ART improves systemic health and reduces disease progression, it does not directly influence oral hygiene behaviors. Therefore, individuals who perceive themselves as physically stable may not prioritize oral health practices.

These findings indicate that improving oral health among people living with HIV/AIDS requires a comprehensive approach that includes psychosocial and behavioral interventions, rather than focusing solely on ART adherence.

This study is consistent with previous research (Monasel et al., 2022; Rahmawati et al., 2020), which reported that ART adherence is not a primary determinant of oral health outcomes. Although ART improves physical health and reduces hospitalization costs, it does not necessarily enhance psychological well-being or social relationships, which are critical factors influencing oral hygiene.

5. Conclusions

Stigma and discrimination were found to have a significant influence on oral hygiene status (OHI-S) among in adolescents living with HIV/AIDS, with discrimination identified as the most dominant determinant. In contrast, antiretroviral therapy adherence was not significantly associated with oral hygiene status.

Although ART improves overall health outcomes, it does not directly affect oral hygiene status. These findings suggest that oral health among in adolescents living with HIV/AIDS is more strongly influenced by behavioral and psychosocial factors than by clinical stability

Study Limitations: This study has several limitations that should be considered when interpreting the findings. First, although oral hygiene status (OHI-S) was assessed clinically, this study did not include other comprehensive oral health indicators such as DMFT index, periodontal status, or oral opportunistic infections, which could provide a more complete picture of oral health conditions among in adolescents living with HIV/AIDS.

Second, The ART adherence was measured as a behavioral variable without incorporating clinical parameters such as CD4 count or viral load, which may provide a more comprehensive understanding of the relationship between clinical status and oral health outcomes.