Zubairi ART Sebagai Pencegahan

8/14/2019 Zubairi ART Sebagai Pencegahan

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Pengobatan ARV sebagaiUpaya Pencegahan

Zubairi Djoerban

Pusat Pelayanan Terpadu HIV

RS Cipto Mangunkusumo


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Masalah

Jumlah odha meningkat terus

Di Amerika maupun Indonesia

Upaya Pencegahan Penularan berhasil ?


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IndiaIndia 2.400.0002.400.000

ChinaChina 700.000700.000

ThailandThailand 610.000610.000

VietnamVietnam 290.000290.000

IndonesiaIndonesia 270.000270.000

BurmaBurma 240.000240.000

PakistanPakistan

96.00096.000

IranIran 86.00086.000

UNAIDS report on the global AIDS epidemic 2008 GenevUNAIDS report on the global AIDS epidemic 2008 Genev

Dikuti oleh The Lancet. HIV Prevention Au ust 200Dikutip oleh The Lancet. HIV Prevention August 200


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US CDC Center for Disease Control and PreventionUS CDC Center for Disease Control and Prevention

Estimasi jumlah kasus baru 2006: 40.000 orangEstimasi jumlah kasus baru 2006: 40.000 orang

Kenyataan 56.300 orangKenyataan 56.300 orang

73% laki, 53% MSM73% laki, 53% MSM

Blacks 83.7, Hispanics 29.3%, Whites 11.5%Blacks 83.7, Hispanics 29.3%, Whites 11.5%

Melebihi 40% dari estimasi semulaMelebihi 40% dari estimasi semula

African American MSM >African American MSM >

4% dana untuk prevention4% dana untuk prevention


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Summary of AIDS Epidemic inUnited States

Annual infection rate 40% higher than previously estimated due to newtechnology 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 theBlack AIDS Institute:

A free-standing black America would rank 16th ithe world in the number of people living with HIV

The number of black Americans living with HIV isgreater 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 40-49Whites 0.26 0.36

Blacks 1.42 3.58

SelectComparatorCountries[3]

Burkina Faso 1.6

Ghana 1.9Rwanda 2.8

Haiti 2.2


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Indonesia

Tahun 2002 2006 2008

Estimasi 108.000 193.000 270.000


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Pengobatan


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Data ARV Global akhir 200

Argentina 34.588Botswana 73.922

Brazilia 174.185

Cambodia 24.123

Cameroon 44.123

Cote dIvore 33.089

Etiopia 85.678

Afsel 339.671

Indonesia 17.000 (akhir 2008, yg pernah ARV

B t 6 Y St d


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Botswana 6-Year Study:HAART Roll-Out in Public Sector

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 secto

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


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ARV amat efektif untukpencegahan

Barreiro P, del Romero J, Leal M, et al. Natural pregnancies in HIVBarreiro P, del Romero J, Leal M, et al. Natural pregnancies in HIV

serodiscordant couples receiving successful antiretroviral therapy.serodiscordant couples receiving successful antiretroviral therapy.

J Acquir Immune Defic Syndr 2006; 43: 324-326J Acquir Immune Defic Syndr 2006; 43: 324-326

Kelompok yang minum ARV, tidak adaKelompok yang minum ARV, tidak ada

pasangannya yang tertular HIVpasangannya yang tertular HIV


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Quinn TC, Wawer MJ, Sewankambo N, et al. Viral load and heterosexua

transmission of human immunodeficiency virus type 1. Rakai Project Stu

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


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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%


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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 1318,

o Penularan lebih sering terjadi dari laki ke perempuan

o Penularan berbanding lurus dengan VL

o ARV mencegah penularan heteroseksual


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Meresepkan ARV tidak sukar

Obat ARV jumlahnya terbatas, limaObat ARV jumlahnya terbatas, lima

Pilih 3 dari 5Pilih 3 dari 5

Zidovudine, Lamivudine, Stavudine, nevirapine, EfavirenzZidovudine, Lamivudine, Stavudine, nevirapine, Efavirenz

Lamivudine selalu dipakaiLamivudine selalu dipakai

Duviral + NeviralDuviral + Neviral

Duviral + EfavirDuviral + Efavir

Stavir + Hiviral + NeviralStavir + Hiviral + Neviral

Stavir + Hiviral + EfavirStavir + Hiviral + Efavir

Efek samping bisa dipelajari, diobati, diantisipasiEfek samping bisa dipelajari, diobati, diantisipasi

Jumlah pasien banyakJumlah pasien banyak


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ARV harus diberikan sebagai paketARV harus diberikan sebagai paketpengobatan, bersama-sama denganpengobatan, bersama-sama dengan

# profilaksis co-trimoxazole# profilaksis co-trimoxazole

# managemen infeksi oportunistik# managemen infeksi oportunistik

# tatalaksana komorbiditas# tatalaksana komorbiditas

# pengobatan nutrisi# pengobatan nutrisi

# pengobatan paliatif# pengobatan paliatif


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Kapan Mulai ARV ?Kapan Mulai ARV ?

Riwayat Diagnosis AIDSRiwayat Diagnosis AIDS

CD4 < 350CD4 < 350

CD4 > 350 (tergantung comorbid n pilihan pasien) bila:CD4 > 350 (tergantung comorbid n pilihan pasien) bila:

Ibu HamilIbu Hamil

NefropatiNefropati

CD4 < 17%CD4 < 17%

PPeennuurruunnaann CCDD44 per tahun > 100per tahun > 100

Ko infeksi hepatitis BKo infeksi hepatitis B

VL > 100.000VL > 100.000 aidsinfo.nih.aidsinfo.nih.


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Long-term Antiretroviral-

Treated HIV-Infected Adults

With High CD4+ Cell Counts

Have Similar Mortality to

General Population

Lewden C, Chne 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.


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Background

Dramatic decrease in AIDS-related deaths associatedwith HAART

Early virologic and immunologic responses onHAART correlated with longer survival[1]

Higher CD4+ cell counts linked with fewer AIDS-definingclinical events

Current study compared mortality of HIV-infectedindividuals receiving HAART with those of the

general population[2]

1. Chne G, et al. Lancet. 2003;362:679-686.2. Lewden C, et al. J Acquir Immune Defic Syndr. 2007;46:72-77.


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Summary of Study Design

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

months

CD4+ cell counts estimated for a median follow-up time of 6.8 years

HIV-infected patient mortality compared with 2002 French populatio

statistics


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Summary of Key Conclusions

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.


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Whats Next ?Whats Next ?


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Dampak padaDampak padapasanganpasangan

serodiscordantserodiscordant


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VCT, PITC, RUTIN ?VCT, PITC, RUTIN ?


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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


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1.1. Upaya BiomedikUpaya Biomedik

Obat Anti Retro ViralObat Anti Retro Viral

PMTCTPMTCT

Sunat, SirkumsisiSunat, Sirkumsisi

KondomKondom

Pengobatan penyakit menular seksualPengobatan penyakit menular seksual

2.2. Upaya StrukturalUpaya Struktural

Ekonomi, Budaya, Pendidikan, HukumEkonomi, Budaya, Pendidikan, Hukum

Kesetaraan genderKesetaraan gender

3.3. Perubahan Perilaku, Positive PreventionPerubahan Perilaku, Positive Prevention

Padian NS: The Lancet. HIV Prevention 21-35 Au ust 200Padian NS: The Lancet. HIV Prevention 21-35 Au ust 200


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Tes HIV rutin untuk semua pasien

Screening for HIV Infection in Health Care

Settings: A Guidance Statement from the

American College of Physicians and HIVMedicine Association

1 Dec 2008

Tes HIV rutin untuk semuaTes HIV rutin untuk semua


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Tes HIV rutin untuk semuaTes HIV rutin untuk semua

pasienpasien

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


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Mulai ARV lebih diniMulai ARV lebih dini


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Kapan Mulai ARV ?Kapan Mulai ARV ?

Riwayat Diagnosis AIDSRiwayat Diagnosis AIDS

CD4 < 350CD4 < 350

CD4 > 350 (tergantung comorbid n pilihan pasien) bila:CD4 > 350 (tergantung comorbid n pilihan pasien) bila:

Ibu HamilIbu Hamil

NefropatiNefropati

CD4 < 17%CD4 < 17%

Penurunan CD4Penurunan CD4

PPeennuurruunnaann CCDD44 per tahun > 100per tahun > 100

Ko infeksi hepatitis BKo infeksi hepatitis B


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Keputusan PresidenKeputusan PresidenMenkesMenkes

Menko KesraMenko Kesra


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KESIMPULANKESIMPULAN


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See You in Bali !See You in Bali !

99thth ICAAP 2009ICAAP 2009

Deadline Abstrak 15 Maret 2009Deadline Abstrak 15 Maret 2009

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Zubairi ART Sebagai Pencegahan