Post on 03-Feb-2018
Pengobatan ARV sebagai
Upaya Pencegahan
Zubairi Djoerban
Pusat Pelayanan Terpadu HIV
RS Cipto Mangunkusumo
Masalah
Jumlah odha meningkat terus
Di Amerika maupun Indonesia
Upaya Pencegahan Penularan berhasil ?
Epidemiologi
India 2.400.000
China 700.000
Thailand 610.000
Vietnam 290.000
Indonesia 270.000
Burma 240.000
Pakistan 96.000
Iran 86.000
UNAIDS report on the global AIDS epidemic 2008 Geneve
Dikutip oleh The Lancet. HIV Prevention August 2008
Peningkatan HIV baru di US, 40% melebihi estimasi
US CDC Center for Disease Control and Prevention
Estimasi jumlah kasus baru 2006: 40.000 orang
Kenyataan 56.300 orang
73% laki, 53% MSM
Blacks 83.7, Hispanics 29.3%, Whites 11.5%
Melebihi 40% dari estimasi semula
African American MSM >
4% dana untuk prevention
Annual infection rate 40% higher than previously estimated due to new technology and new methodology, according to Centers for Disease Control[1]
Estimates rose from 40,000 to 56,300 in 2006
Blacks disproportionately infected with HIV in United States
According to a 2008 report from the Black AIDS Institute:
“A free-standing black America would rank 16th in the world in the number of people living with HIV”
“The number of black Americans living with HIV is greater than the HIV population of
7 of the 15 PEPFAR focus countries”
1. Hall HI, et al. JAMA. 2008;300:520-529. 2. McQuillan GM, et al. J Acquir Immune Defic Syndr. 2006;41:651-656. 3. UNAIDS, 2008. Available at: http://www.unaids.org.
HIV Prevalence, %
United States NHANES,[2]
Ages 18-39NHANES,[2]
Ages 40-49
Whites 0.26 0.36
Blacks 1.42 3.58
Select Comparator Countries[3]
Burkina Faso 1.6
Ghana 1.9
Rwanda 2.8
Haiti 2.2
Indonesia
Tahun 2002 2006 2008
Estimasi 108.000 193.000 270.000
Pengobatan
Data ARV Global akhir 2007
Argentina 34.588
Botswana 73.922
Brazilia 174.185
Cambodia 24.123
Cameroon 44.123
Cote d’Ivore 33.089
Etiopia 85.678
Afsel 339.671
Indonesia 17.000 (akhir 2008, yg pernah ARV)
Estimation by end 2008: 113,000 adults infected with HIV
Roll-out program established in 2001, with specific goals
Program run primarily by nurses
As of April 2008, 100,517 patients on HAART (9514 in private sector)
60,000 pts 80,000 pts 100,000 pts 125,000 pts
December 2006 December 2007 December 2008 December 2009
Puvimanasinghe J, et al. IAC 2008. Abstract MOAB0204.
ARV amat efektif untuk pencegahan
Barreiro P, del Romero J, Leal M, et al. Natural pregnancies in HIV
serodiscordant couples receiving successful antiretroviral therapy.
J Acquir Immune Defic Syndr 2006; 43: 324-326
Kelompok yang minum ARV, tidak ada
pasangannya yang tertular HIV
ARV amat efektif untuk pencegahan
Quinn TC, Wawer MJ, Sewankambo N, et al. Viral load and heterosexual
transmission of human immunodeficiency virus type 1. Rakai Project Study
Group. N Engl J Med 2000; 342: 921- 929
Jumlah Virus (Viral Load) merupakan faktor prediksi
utama penularan HIV
Untuk odha dengan VL < 1500 copies of HIV-1RNA/ml,
amat sedikit kemungkinannya bisa menularkan HIV
ARV amat efektif untuk pencegahan
Castilla J, Del Romero J, Hernando V, Marincovich B, Garcia S,
Rodriguez C. Effectiv eness of highly active antiretroviral therapy in
reducing heterosexual transmission of HIV. J Acquir Immune Defic
Syndr 2005; 40: 96-101
Dengan ARV: Prevalensi HIV pasangan turun dari 10.3%
(1991-1995) menjadi 1.9% (1999-2003; P = 0.0061).
Odha yang minum ARV, Penularan HIV turun 80%
ARV amat efektif untuk pencegahan
Melo M, Varella I, Nielsen K, Turella L, Santos B. Demographic
characteristics, sexual transmission and CD4 progression among
heterosexual HIV-1 serodiscordant couples followed in Porto Alegre, Brazil.
XVI International AIDS Conference; Toronto, ON, Canada; Aug 13–18,
o Penularan lebih sering terjadi dari laki ke perempuan
o Penularan berbanding lurus dengan VL
o ARV mencegah penularan heteroseksual
Meresepkan ARV tidak sukar
Obat ARV jumlahnya terbatas, lima
Pilih 3 dari 5
Zidovudine, Lamivudine, Stavudine, nevirapine, Efavirenz
Lamivudine selalu dipakai
Duviral + Neviral
Duviral + Efavir
Stavir + Hiviral + Neviral
Stavir + Hiviral + Efavir
Efek samping bisa dipelajari, diobati, diantisipasi
Jumlah pasien banyak
ARV harus diberikan sebagai paket
pengobatan, bersama-sama dengan
# profilaksis co-trimoxazole
# managemen infeksi oportunistik
# tatalaksana komorbiditas
# pengobatan nutrisi
# pengobatan paliatif
Guideline Baru 2008, DHHSKapan Mulai ARV ?
Riwayat Diagnosis AIDS
CD4 < 350
CD4 > 350 (tergantung comorbid n pilihan pasien) bila:
Ibu Hamil
Nefropati
CD4 < 17%
Penurunan CD4 per tahun > 100
Ko infeksi hepatitis B
VL > 100.000 aidsinfo.nih.gov
Long-term Antiretroviral-Treated
HIV-Infected Adults With High
CD4+ Cell Counts Have Similar
Mortality to General Population
Lewden C, Chêne G, Morlat P, et al. HIV-infected adults with a CD4 cell count
greater than 500 cells/mm3 on long-term combination antiretroviral therapy reach
same mortality rates as the general population.
J Acquir Immune Defic Syndr. 2007;46:72-77.
Dramatic decrease in AIDS-related deaths associated with HAART
Early virologic and immunologic responses on HAART correlated with longer survival[1]
Higher CD4+ cell counts linked with fewer AIDS-defining clinical events
Current study compared mortality of HIV-infected individuals receiving HAART with those of the general population[2]
1. Chệne G, et al. Lancet. 2003;362:679-686. 2. Lewden C, et al. J Acquir Immune Defic Syndr. 2007;46:72-77.
Lewden C, et al. J Acquir Immune Defic Syndr. 2007;46:72-77.
2435 HIV-infected patients who initiated PI-containing HAART from
1997-1999 selected from 2 cohorts of the ANRS study: APROCO-
COPILOTE cohort (n = 1281) and AQUITAINE cohort (n = 1154)
Standard clinical and biologic data collected at baseline and every 4-6
months
CD4+ cell counts estimated for a median follow-up time of 6.8 years
HIV-infected patient mortality compared with 2002 French population
statistics
Subgroup of patients with CD4+ cell counts
≥ 500 cells/mm3 for 6 years after initiation of
combination antiretroviral therapy attained mortality
similar to the general population
Lewden C, et al. J Acquir Immune Defic Syndr. 2007;46:72-77.
Dampak pada pasangan
serodiscordant
VCT, PITC, RUTIN ?
Paradigma Baru Tes HIV
Dasar rekomendasi: 25% odha Amerika, tidak
waspada akan status HIVnya, dan sekitar 40%
odha yang di diagnosis AIDS, ternyata baru
diketahui terinfeksi kurang dari 1 tahun
Bayer R, Fairchild AL: Changing the Paradigm for HIV Testing The End of Exceptionalism.
New England J Med, 17 Agustus 2006
Malave MH et al Making HIV testing a routine part of medical care. City Health Information. Vol. 25. No. 2. February 2006:9-12. New York
Upaya pencegahanpenularan1. Upaya Biomedik
Obat Anti Retro Viral
PMTCT
Sunat, Sirkumsisi
Kondom
Pengobatan penyakit menular seksual
2. Upaya Struktural
Ekonomi, Budaya, Pendidikan, Hukum
Kesetaraan gender
3. Perubahan Perilaku, Positive Prevention
Padian NS: The Lancet. HIV Prevention, 21-35, August 2008
Tes HIV rutin untuk semua pasien
Screening for HIV Infection in Health Care
Settings: A Guidance Statement from the
American College of Physicians and HIV
Medicine Association
1 Dec 2008
Tes HIV rutin untuk semua pasien
Guidance Statement 1: ACP merekomendasikan agar
klinisi menerapkan skrining rutin HIV dan menganjurkan
kepada pasien untuk dites darahnya
Guidance Statement 2: ACP merekomendasikan klinisi
menekankan perlunya tes HIV ulangan, secara individual
Mulai ARV lebih dini
Guideline Baru 2008, DHHSKapan Mulai ARV ?
Riwayat Diagnosis AIDS
CD4 < 350
CD4 > 350 (tergantung comorbid n pilihan pasien) bila:
Ibu Hamil
Nefropati
CD4 < 17%
Penurunan CD4
Penurunan CD4 per tahun > 100
Ko infeksi hepatitis B
VL > 100.000 aidsinfo.nih.gov
Keputusan PresidenMenkes
Menko Kesra
KESIMPULAN
See You in Bali !9th ICAAP 2009
Deadline Abstrak 15 Maret 2009