pengobatan arv sebagai upaya pencegahan - arc...

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


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


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%


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

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