Hrev_master Healthcare in Low-resource Settings 2025; volume 13:14019 HIV knowledge level, social support, and risk perception on attitudes toward HIV testing among heterosexuals in Indonesia Alandia,1 Sri Yona,2 Chiyar Edison Sunarya2 1Faculty of Nursing, Universitas Indonesia, Depok, West Java; 2Department of Medical Surgical Nursing, Faculty of Nursing, Universitas Indonesia, Depok, West Java, Indonesia Abstract HIV/AIDS remains a major global health issue, particularly among heterosexual populations. The WHO and UNAIDS aim to end the epidemic by 2030 through the 95-95-95 strategy. In Indonesia, 81% of individuals knew their HIV status, 41% were on treatment, and 19% achieved viral suppression as of 2022. HIV test- ing is vital for identifying those infected. This research examines the relationships between HIV knowledge, social support, and risk per- ception with attitudes towards HIV testing among heterosexual individuals in Indonesia. Using a descriptive analytical design with a cross-sectional approach, 192 respondents from Bekasi Regional General Hospital, Class 1 Cipinang Prison, Class II A Cipinang Narcotics Prison, and Siloam Mampang Hospital were studied. Multivariate analysis showed that both knowledge (p=0.006, OR=2.205) and social support (p<0.001, OR=3.778) significantly influence attitudes towards HIV testing. Higher HIV knowledge and social support increase the likelihood of individuals supporting and participating in HIV testing, highlighting the importance of initia- tives to improve both areas to encourage testing. Introduction HIV/AIDS has become a global health challenge, with 39 mil- lion people infected by the end of 2022, 1.3 million new infec- tions, and 630,000 deaths related to HIV/AIDS.1 The highest HIV prevalence is recorded in Africa, Southeast Asia, and the Americas, while the Eastern Mediterranean has the lowest preva- lence.2 Indonesia faces significant challenges in controlling HIV/AIDS, with an increase in cases among women who are part- ners of key population groups.3,4 The HIV epidemic has persisted for more than three decades, with the primary mode of transmis- sion being heterosexual risk behaviors.3 In Indonesia, 68.1% of HIV cases are found in individuals aged 25-49 years.5 UNAIDS reports that 540,000 people are living with HIV in Indonesia, with 26,000 deaths due to AIDS.6 WHO and UNAIDS are committed to ending the HIV/AIDS epidemic by 2030 through the 95-95-95 approach, which aims for 95% of people living with HIV to know their status, 95% to be on ARV treatment, and 95% to achieve viral suppression by 2025.2 In Indonesia, progress toward the 95-95-95 targets is still lagging, with 81% of individu- als aware of their HIV status and 41% receiving ARV treatment.7 Efforts to increase HIV testing coverage are key to achieving these targets. HIV testing is a critical step in the effort to end the HIV/AIDS epidemic, as earlier testing can reduce transmission and improve treatment outcomes.8,9 Although HIV testing may generate anxiety and stigma, a positive test result enables timely referral for treatment and prevents further virus transmission, while a negative test result encourages individuals to reduce infec- tion risks.10,11 Good knowledge of HIV can reduce concerns about stigma related to HIV testing, as lack of knowledge often leads individu- als to avoid testing due to fear of social stigma or emotional con- sequences.12 Better knowledge increases risk awareness and moti- Correspondence: Sri Yona, Department of Medical Surgical Nursing, Faculty of Nursing, Universitas Indonesia, 16424 Depok, West Java, Indonesia. Tel.: +6281293912127 E-mail: sriyona@ui.ac.id Key words: attitudes toward HIV testing, HIV knowledge, social sup- port, risk perception Contributions: AA: contributed to design proposal and did data collec- tion, SY and CES contributed to the study conceptualization and design, analysis and interpretation of the data and writing of the article. SY, CES contributed to the manuscript. All authors have read and approved the submitted manuscript. Ethical approval: this study has received Institutional Review Board (IRB) approval from the Health Ethics Committee of the Faculty of Nursing, University of Indonesia (KET-194/UN2.F12.D1.2.1/ PPM.00.02/2024). Availability of data and material: the data presented in this study are available upon request from the corresponding author. Conflict of interest: None declared. Funding: this research was funded by the Indonesian Ministry of Education, Culture, Research, and Technology in 2024 (NKB- 830/UN2.RST/HKP.05.00/2024) Acknowledgments: the authors would like to express their sincere grati- tude to Bekasi Regional General Hospital, Class 1 Cipinang Prison, Class II A Cipinang Narcotics Prison, and Siloam Mampang Hospital for their valuable contribution to this research by granting permission to conduct the study within their institutions. Special thanks are extended to the respective heads of these facilities for their support and facilitation dur- ing the research process. Received: 20 May 2025. Accepted: 14 October 2025. Early access: 25 November 2025. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2025 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2025; 13:14019 doi:10.4081/hls.2025.14019 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [Healthcare in Low-resource Settings 2025;13:14019] [page 245] vation to undergo testing.13 Stigma and discrimination can affect mental health and worsen reluctance to undergo HIV testing.14 Perceived risk also plays an important role in decision-making for testing, with higher perceived risks increasing motivation to test.14 Social support, including from family and peer groups, is crucial in reducing stigma and supporting the decision to get tested.15,16 Knowledge, social support, and risk perception are key factors in enhancing HIV testing and preventing HIV transmission. Materials and Methods This study employed a descriptive analytical method with a cross-sectional design, focusing on heterosexual individuals from two provinces in Indonesia: Special Capital Region of Jakarta Province and West Java. These locations were selected due to their high population density, diverse demographic characteristics, and reported prevalence of HIV cases. Both provinces are considered strategic regions for public health interventions, making them suit- able for studying factors influencing HIV testing attitudes. The research was conducted at four locations: Cipinang Class I Penitentiary, Jakarta Class II A Narcotics Prison, Siloam Hospital Mampang South Jakarta, and Bekasi District General Hospital (RSUD). Participants were recruited using a probability sampling technique with simple random sampling, giving all eligible indi- viduals an equal chance to be selected from each study site. The inclusion criteria for participants are being heterosexual, at least 18 years old, and residing in Special Capital Region of Jakarta Province or West Java, while individuals who identify as bisexual will be excluded from the study. The research will take place from August to October 2024. The sample size was deter- mined using the absolute precision method for population propor- tion estimation, based on HIV testing data in DKI Jakarta (2022), with a 95% confidence level and 5% margin of error, and an addi- tional 10% added to anticipate non-response. Data analysis will be conducted using SPSS software, and both proportions and bivariate relationships will be determined using chi-square tests and multivariate analysis. Potential confounders such as age, gender, education level, and marital status were con- trolled in the multivariate analysis to ensure the independent effect of each variable on attitudes toward HIV testing. The relationship between HIV knowledge, social support, risk perception, and atti- tudes toward HIV testing will be expressed as odds ratios (risk fac- tors) and calculated using multivariate logistic regression. The data collection of the respondents’ demographic characteristics consists of a checklist question using a demographic instrument, which includes age, gender, education, marital status, child ownership, employment status, and the province of residence (Special Capital Region of Jakarta Province and West Java). The instruments used include the Knowledge Questionnaire-18 (HIV-KQ-18), Perceived Social Support in HIV (PSS-HIV), HIV Risk Perception Questionnaire (HRPQ), and HIV-Antibody Testing Attitude Scale (HTAS). In this study, validity and reliability tests were conducted on the questionnaires with 40 respondents from West Java and Jakarta. Non-Indonesian questionnaires were translated by a certi- fied translator and validated by experts. The validity test showed all items were valid, except one item in the HIV testing attitude questionnaire (HTAS), which had an r-value of 0.314. This item was revised based on expert input. The reliability test showed all questionnaires had a Cronbach’s Alpha value above 0.6, indicating they were valid and reliable for use. To minimize bias, enumerators were trained in standardized data collection procedures, confiden- tiality, and ethical considerations. The questionnaires were pre- tested to ensure clarity and consistency across study sites. The data collection for respondents’ demographic characteris- tics involved a checklist question using a demographic instrument, which includes age, gender, education, marital status, child owner- ship, employment status, and province of residence (Special Capital Region of Jakarta Province and West Java). Results Table 1 shows the characteristics of the respondents. Most were male (60.4%), with the majority having a high school educa- tion (47.9%). Most were unmarried (54.7%), and 77.9% had chil- dren. Most respondents were employed (81.8%), with 56.7% in the formal sector. Regarding HIV risk, 67.2% were classified as high risk, with 35.9% having one risk factor and 1% having more than three risk factors. Table 2 shows the frequency distribution of respondents based on HIV knowledge, social support, risk perception, and attitudes toward HIV testing. The average HIV knowledge score was mod- erate, with a median of 10. Social support also had a moderate score, with a median of 44. The average risk perception was high (57.74), and 72.9% had a positive attitude toward HIV testing. Table 3 presents the analysis of factors affecting attitudes toward HIV testing. The young adult group showed higher support for HIV testing, but no significant difference was found in the Odds Ratio (OR). Other factors, like gender, education, and employment, did not show significant results, except for HIV risk status, where high-risk individuals were more likely to support HIV testing (OR=0.391, p=0.015). Table 4 presents the candidate selection for the study. Variables with a p-value < 0.25 were included in the multivariate analysis. These included knowledge, social support, risk perception, age, education, marital status, and HIV high-risk status. Variables with p-values > 0.25, like gender and employment, were excluded, though gender was kept for theoretical reasons. Table 5 presents the final multivariate analysis. It shows that knowledge and social support significantly affect attitudes toward HIV testing. Higher knowledge (OR=2.205) and higher social sup- port (OR=3.778) were associated with more favorable attitudes toward HIV testing. Social support had the strongest influence, with a p-value < 0.001. Discussion The analysis results show a significant relationship between knowledge about HIV and attitudes towards HIV testing in hetero- sexual groups in Indonesia. The P value of <0.001 indicates that the relationship between knowledge level and attitudes towards HIV testing is statistically significant. The better a person’s knowl- edge about HIV, the more likely they are to have a positive attitude towards HIV testing. Knowledge plays a crucial role in reducing the stigma associated with HIV testing. Individuals with limited understanding of HIV may mistakenly believe that an HIV diagno- sis is a death sentence or that they will face severe social stigma if the test results are positive. Concerns about the social and emotion- al consequences of a positive test result often lead individuals to Advancing Nursing Education and Practice for Future Global Health [page 246] [Healthcare in Low-resource Settings 2025;13:14019] Advancing Nursing Education and Practice for Future Global Health Table 1. Characteristics of respondents based on age category, gender, education, marital status, child ownership status, employment sta- tus, and type of occupation. Variable Category Number % Age Young adulthood (18-39 years) 155 80.7 Middle adulthood (40+ years) 37 19.3 Total 192 100 Gender Male 116 60.4 Female 76 39.6 Total 192 100 Education No Schooling 3 1.6 Primary School 14 7.3 Junior High School 24 12.5 High School 92 47.9 University or Higher Education 59 30.7 Total 192 100 Marital status Single 105 54.7 Married 59 30.7 Divorced 28 14.6 Total 192 100 Child ownership Has Children 60 77.9 No Children 17 22.1 Total 77 100 Employment Unemployed 35 18.2 Employed 157 81.8 Total 192 100 Type of occupation Formal employment 89 56.7 Informal employment 68 43.3 Total 157 100 Belongs to high-risk group for HIV? Not at risk 63 32.8 At risk 129 67.2 Total 192 100 Type of high-risk group Unprotected sexual intercourse 49 38.0 Intravenous Drug User (IDU) 5 3.9 Having more than one sexual partner 14 10.9 Excessive alcohol and drug use in the context of sexual behavior 18 14.0 Commercial Sex Worker (CSW) 1 0.8 Unprotected sexual intercourse and excessive alcohol and drug 7 5.4 use in the context of sexual behavior Unprotected sexual intercourse and IDU 1 0.8 Unprotected sexual intercourse and having more than one sexual partner 23 17.8 Having more than one sexual partner and CSW 3 2.3 Unprotected sexual intercourse, having more than one sexual partner, 7 5.4 and alcohol/drug abuse 4 3.1 Unprotected sexual intercourse, IDU, and having more than one sexual partner 2 1.6 Unprotected sexual intercourse, IDU, having more than one sexual partner, 1 0.8 and excessive alcohol/drug use Unprotected sexual intercourse, IDU, having more than one sexual partner, 1 0.8 excessive alcohol/drug use, and CSW Total 129 100 Table 2. Frequency distribution of respondents based on HIV knowledge, social support, risk perception, and attitudes towards HIV testing Variable Median SD Min-Maks CI 95% HIV Knowledge Level 10.00 3.881 0-16 8.73-9.84 Social Support 44.00 9.668 12-60 40.83-42.47 Variable Mean SD Min-Maks CI 95% Risk Perception 57.74 11.105 26-93 56.16-59.33 Variable Category Number Percentage Attitudes toward HIV testing Unfavorable 52 27.1% Favorable 140 72.9% Total 192 100% [Healthcare in Low-resource Settings 2025;13:14019] [page 247] Advancing Nursing Education and Practice for Future Global Health Table 3. Analysis of the relationship between potential confounding variables and attitudes towards HIV testing. Variable Attitudes Towards HIV Testing p Unfavorable Favorable Total n % n % n % Age Young adulthood 38 19.8 113 60.9 155 80.7 0.101 Middle adulthood 14 7.3 23 12.0 37 19.3 Gender Male 33 17.2 83 43.2 116 60.4 0.599 Female 19 9.9 57 29.7 76 39.6 Education Low (primary and secondary) 41 21.4 92 47.9 133 69.3 0.080 High 11 5.7 48 25.0 59 30.7 Employment status Not working 8 4.2 27 14.1 35 18.2 0.534 Working 44 22.9 113 58.9 157 81.8 Marital Status Single 26 13.5 79 41.1 105 54.7 0.426 Married 26 13.5 61 21.8 87 45.3 Having children No 28 14.6 94 49.0 122 63.5 0.089 Yes 24 12.5 46 24.0 70 36.5 High-Risk Group for HIV? Not at Risk 10 5.2 53 27.6 63 32.8 0.015* At Risk 42 21.9 87 45.3 129 67.2 Reason for high-risk group 1 Reason 30 23.3 57 44.2 87 67.4 0.502 >1 Reason 12 9.3 30 23.3.6 34 32.6 Table 4. Candidate selection results. No Variable p Description 1. Knowledge <0.001 Included 2. Social support 0.003 Included 3. Risk perception <0.001 Included 4. Age 0.043 Included 5. Gender 0.599* Included 6. Education 0.083 Included 7. Employment status 0.535 Not included 8. Type of work 0.289 Not included 9. Marital Status 0.194 Included 10. Having children 0.091 Included 11. High-risk group for HIV 0.017 Included 12. Reason for high-risk group 0.479 Not included *Significant if p< p0.25 Table 5. Results of the final multivariate modeling. Variable B Wald p OR CI 95% Knowledge 0.791 7.610 0.006 2.205 (1.257-3.866) Social support 1.329 12.869 <0.001 3.778 (1.719-8.029) Constant -0.559 2.425 0.119 0.572 [page 248] [Healthcare in Low-resource Settings 2025;13:14019] avoid HIV testing.17 Moreover, inadequate knowledge about HIV transmission, early symptoms, and the long-term impact of the dis- ease may result in the perception that testing is unnecessary.18 This lack of understanding can contribute to the spread of HIV, as indi- viduals may not be aware of the risks they face. Low knowledge about HIV transmission often leads individuals to be unaware of their risk status, ultimately affecting their motivation to get test- ed.19 Comprehensive knowledge of HIV, including a correct under- standing of transmission and prevention strategies, is critical in preventing HIV transmission.20 A significant association between HIV knowledge and HIV testing behavior among women has also been reported, with women possessing good HIV knowledge being 3.75 times more likely to undergo testing compared to those with lower knowledge levels.21 These findings highlight the essential role of knowledge in encouraging HIV testing uptake. Additionally, the analysis demonstrates a significant relationship between risk perception and attitudes towards HIV testing among heterosexual respondents in Indonesia (p<0.001). Higher levels of perceived risk are associated with a more positive attitude towards HIV testing. Risk perception plays a vital role in the acceptance of HIV prevention strategies and is an integral component of the deci- sion-making process for undergoing HIV testing. Studies have shown that individuals who perceive themselves to be at high risk for HIV are more likely to engage in preventive behaviors, including HIV testing.14,22 However, a significant gap often exists between risk awareness and action, with many individ- uals who acknowledge high-risk behaviors still choosing not to undergo testing. For example, although only 3.4% of men and 2.5% of women perceived themselves to be at high risk for HIV, they did not get tested in the past year.23 Low risk perception remains a major barrier to HIV testing, even among individuals with adequate knowledge about the disease.23 This phenomenon is frequently driven by misconceptions about risky behaviors or the absence of visible symptoms, leading individuals to underestimate their vulnerability and feel no need for testing.12 Therefore, increasing awareness of HIV risk behaviors can encourage individ- uals to undergo testing and better understand their health status. Psychological factors, such as anxiety about potential positive results, also play a role in shaping individual perceptions of HIV risk. Uncertainty about the social and emotional impacts of a pos- itive test result can strengthen risk perception.24,25 Individuals at high risk, such as drug users or those engaging in unprotected sex with partners of unknown HIV status, are expected to have high- risk perceptions.26 A deeper understanding of behaviors that increase HIV transmission risk has been associated with a greater likelihood of adopting proactive measures, including voluntary HIV testing.27 This study also demonstrated a significant relationship between social support and attitudes towards HIV testing among heterosexual respondents in Indonesia. Individuals with higher levels of social support were more likely to exhibit supportive atti- tudes towards HIV testing. Conversely, respondents with low social support tended to have negative attitudes. This relationship was statistically significant, with a P value of 0.003. Social support provides emotional, practical, and informational assistance needed to overcome the fear and stigma associated with HIV testing.15 It can enhance individuals’ courage to undergo testing, reduce anxi- ety, and improve their understanding of the importance of HIV testing.28,29 Furthermore, higher levels of social support have been associated with increased HIV testing behaviors and intentions. Respondents with greater social support were found to be 1.48 times more likely to have ever undergone HIV testing [aOR=1.48; p<0.001], and 1.22 times more likely to have been tested in the past six months [aOR=1.22; p<0.01].30 Additionally, social support was shown to positively influence HIV-related knowledge, further enhancing individuals’ intentions to undergo HIV testing. Social support also plays a critical role in addressing the stig- ma associated with HIV. Individuals living with HIV often experi- ence stigma, which can significantly affect their decision to under- go testing. Without strong social support, they may fear discrimi- nation and thus avoid seeking testing.13 Conversely, strong social support encourages individuals to share experiences and seek information, thereby reducing fear and increasing their confidence in maintaining their health. Based on the analysis, it can be con- cluded that social support plays a significant role in shaping posi- tive attitudes towards HIV testing among heterosexual individuals in Indonesia. Social support not only provides emotional encour- agement but also enhances knowledge and reduces stigma, thereby making individuals more likely to undergo HIV testing. Multivariate analysis revealed that both knowledge and social support significantly influenced attitudes towards HIV testing. Social support had the greatest impact, with an odds ratio (OR of 3.778, while knowledge had an OR of 2.205. These findings high- light the importance of both knowledge and social support in encouraging HIV testing. Social support, in particular, plays a cru- cial role in reducing stigma and fear, making it a key factor in pro- moting HIV testing behavior in Indonesia. This study was a cross-sectional design, so the findings are limited to two provinces (DKI Jakarta and West Java). Conclusions Social support is the most significant factor compared to other variables influencing an individual’s decision to undergo HIV test- ing. This is because social support provides essential emotional, practical, and informational encouragement in overcoming fear and stigma often associated with HIV testing. Research shows that individuals who receive strong social support are more likely to undergo HIV testing, participate in prevention programs, and access HIV-related healthcare services. References 1. Delaney KP, Johnson CV, Bowles KE, DiNenno EA. 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