Zubairi Art Sebagai Pencegahan
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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 ?
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
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
Summary of AIDS Epidemic in United States 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 HIV Prevalence, % United States NHANES,[2] NHANES,[2] Ages 18-39 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
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.
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)
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
December 2006 60,000 pts
December 2007 80,000 pts
December 2008 100,000 pts
December 2009 125,000 pts
As of April 2008, 100,517 patients on HAART (9514 in private sector)
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
Kapan 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 AntiretroviralTreated 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.
Background 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.
Summary of Study Design 2435 HIV-infected patients who initiated PI-containing HAART from 1997-1999 selected from 2 cohorts of the ANRS study: APROCOCOPILOTE 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
Lewden C, et al. J Acquir Immune Defic Syndr. 2007;46:72-77.
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.
What’s Next ?
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 Biomedik
1.
Obat Anti Retro Viral
PMTCT
Sunat, Sirkumsisi
Kondom
Pengobatan penyakit menular seksual Upaya Struktural
2.
3.
Ekonomi, Budaya, Pendidikan, Hukum
Kesetaraan gender 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
Kapan 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
Keputusan Presiden Menkes Menko Kesra
KESIMPULAN
See You in Bali ! 9th ICAAP 2009
Deadline Abstrak 15 Maret 2009
Masalah Jumlah odha meningkat terus Di Amerika maupun Indonesia Upaya Pencegahan Penularan berhasil ?
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
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
Summary of AIDS Epidemic in United States 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 HIV Prevalence, % United States NHANES,[2] NHANES,[2] Ages 18-39 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
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.
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)
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
December 2006 60,000 pts
December 2007 80,000 pts
December 2008 100,000 pts
December 2009 125,000 pts
As of April 2008, 100,517 patients on HAART (9514 in private sector)
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
Kapan 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 AntiretroviralTreated 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.
Background 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.
Summary of Study Design 2435 HIV-infected patients who initiated PI-containing HAART from 1997-1999 selected from 2 cohorts of the ANRS study: APROCOCOPILOTE 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
Lewden C, et al. J Acquir Immune Defic Syndr. 2007;46:72-77.
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.
What’s Next ?
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 Biomedik
1.
Obat Anti Retro Viral
PMTCT
Sunat, Sirkumsisi
Kondom
Pengobatan penyakit menular seksual Upaya Struktural
2.
3.
Ekonomi, Budaya, Pendidikan, Hukum
Kesetaraan gender 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
Kapan 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
Keputusan Presiden Menkes Menko Kesra
KESIMPULAN
See You in Bali ! 9th ICAAP 2009
Deadline Abstrak 15 Maret 2009
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