Pengobatan ARV sebagai Upaya Pencegahan Zubairi Djoerban Pusat Pelayanan Terpadu HIV RS Cipto Mangunkusumo.

Presentasi berjudul: "Pengobatan ARV sebagai Upaya Pencegahan Zubairi Djoerban Pusat Pelayanan Terpadu HIV RS Cipto Mangunkusumo."— Transcript presentasi:

1 Pengobatan ARV sebagai Upaya Pencegahan Zubairi Djoerban Pusat Pelayanan Terpadu HIV RS Cipto Mangunkusumo

2 Masalah  Jumlah odha meningkat terus  Di Amerika maupun Indonesia  Upaya Pencegahan Penularan berhasil ?

3 India2.400.000 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  Merson MH et al: The History and Chalenge of HIV Prevention.  The Lancet, August 2008

4 US CDC Center for Disease Control and Prevention Estimasi jumlah kasus baru 2006: 40.000 orang 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

5 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 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 StatesNHANES, [2] Ages 18-39 NHANES, [2] Ages 40-49 Whites0.260.36 Blacks1.423.58 Select Comparator Countries [3] Burkina Faso1.6 Ghana1.9 Rwanda2.8 Haiti2.2

6 Indonesia Tahun 200220062008 Estimasi108.000193.000270.000

7 Pengobatan

8 Data ARV Global akhir 2007 Argentina34.588 Botswana73.922 Brazilia174.185 Cambodia 24.123 Cameroon 44.123 Cote d’Ivore 33.089 Etiopia 85.678 Afsel339.671 Indonesia 17.000 (akhir 2008, yg pernah ARV)‏

9 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 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.

10 ARV amat efektif untuk pencegahan Barreiro 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: 324-326  Kelompok yang minum ARV, tidak ada pasangannya yang tertular HIV

11 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

12 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%

13 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

14 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

15 ARV harus diberikan sebagai paket pengobatan, bersama-sama dengan # profilaksis co-trimoxazole # managemen infeksi oportunistik # tatalaksana komorbiditas # pengobatan nutrisi # pengobatan paliatif ARV harus diberikan sebagai paket pengobatan, bersama-sama dengan # profilaksis co-trimoxazole # managemen infeksi oportunistik # tatalaksana komorbiditas # pengobatan nutrisi # pengobatan paliatif

16 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

17 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/mm 3 on long-term combination antiretroviral therapy reach same mortality rates as the general population. J Acquir Immune Defic Syndr. 2007;46:72-77.

18 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.

19 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 4-6 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

20 Summary of Key Conclusions  Subgroup of patients with CD4+ cell counts ≥ 500 cells/mm 3 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.

21 What’s Next ?

22 Dampak pada pasangan serodiscordant

23 VCT, PITC, RUTIN ?

24 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

25 1. 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

26 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

27 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

28 Mulai ARV lebih dini

29 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  VL > 100.000 aidsinfo.nih.gov

30 Keputusan Presiden Menkes Menko Kesra

31 KESIMPULAN

32 See You in Bali ! 9 th ICAAP 2009 Deadline Abstrak 15 Maret 2009