Paradigma Baru Konseling Tes HIV untuk “Getting to Zero” Zubairi Djoerban Pusat Layanan HIV FKUI RS Cipto Mangunkusumo empati

Pra dan Pasca Tes VCT PITC Informed Consent Tes Rutin Konseling Tes HIV Pra dan Pasca Tes VCT PITC Informed Consent Tes Rutin

Pokok Bahasan Getting to Zero. Tema Hari AIDS Sedunia Konseling Data Lapangan Kesimpulan

Zero New HIV Infections Zero Discrimination Zero AIDS-related deaths Getting to Zero Zero New HIV Infections Zero Discrimination Zero AIDS-related deaths

Zero HIV Infections Deborah Donells et al di Lancet 12 June 2010 Odha minum ART mengurangi penularan HIV 92% Perlu memperluas, meningkatkan jumlah tes HIV

Heterosexual HIV-1 transmission after initiation of antiretroviral therapy: a prospective cohort analysis The Lancet, 375:2092 - 98, 12 June 2010, Deborah Donnell et al A peer-reviewed study showed that placing people living with HIV on antiretroviral treatment created a 12-fold reduction in transmission to their HIV-negative partner. This 92% decrease in the likelihood of transmission confirms the importance of scaling up widespread testing and reaching universal access (at least 80% coverage) to AIDS treatment

Penelitian HPTN 052 oleh US National Inst Penelitian HPTN 052 oleh US National Inst. of Allergy and Infectious Diseases 1.763 pasangan dari 9 negara Amerika, Botswana Brazil, India, Kenya, Malawi, AfrikaSelatan, Thailand, dan Zimbabwe Kelompok I: minum ARV segera setelah tes HIV + Kelompok II: ditunda sampai CD4 turun < 250 Hasil: kelompok I yg tertular 1 orang, Kelp-II: 27 ARV dini mengurangi penularan 96% Amat signifikan, shg penelitian yang dijadualkan sp 2015 dihentikan awal 2011 agar semua odha segera dapat ARV

Mengobati odha dg ARV mengurangi angka penularan 96%

25 Maret 2010. Afrika Selatan mulai tes HIV masal, 15 juta orang dalam waktu 1 tahun. Jumlah penduduk 50 juta Tujuan meningkatkan cakupan pengobatan ARV agar mortalitas dan morbiditas turun, bagi odha yang jumlahnya amat besar dan memperbaiki manajemen tb Penularan HIV di Afsel terutama melalui heterosexual, disusul penularan ibu ke bayi

Universal Access: Tes HIV sebanyak mungkin # Afrika Selatan: tes HIV 15/50 juta penduduk # Botswana: semua penduduk # Amerika: semua pasien di layanan kesehatan # Indonesia: ratusan ribu saja # Dites HIV untuk diobati # Diobati ARV: menjadi tidak sakit, tetap sehat, panjang umur dan tidak menularkan lagi! # HAM, hak azasi odha untuk mendapat ARV

Terima kasih Countdown to Zero UNAIDS 2011 Michel Sidibé (UNAIDS Executive Director) Eric Goosby (United States Global AIDS Coordinator) Di negara2 maju, sekarang ini penularan ibu ke bayi praktis sudah zero. Juga kematian bayi dan anak dg HIV bisa dicegah total. Di tahun 2015, bayi2 yg dilahirkan dimanapun dapat lahir tanpa tertular HIV, dan ibunya tetap hidup normal produktif

Gel Tenofovir Penelitian di Af Sel membuktikan, pemakaian gel tenofovir di vagina menekan penularan HIV 50% , amat signifikan, setelah dipakai 1 tahun. Gel mengurangi penularan sebesar 39% stlh 2.5 tahun. Bermanfaat ketika pasangan menolak pakai kondom.

Upaya pencegahan penularan Upaya Biomedik Obat Anti Retro Viral 96% PMTCT 60% Sunat, Sirkumsisi 60% Gel Intravaginal 40%, Kondom , (vaksin 30%, Thailand) Pengobatan penyakit menular seksual Upaya Struktural Ekonomi, Budaya, Pendidikan, Hukum, Gender HAM Perubahan Perilaku

Zero AIDS-related deaths Makin dini mengobati makin baik Dahulu menunggu kondisi buruk tuk ARV Asimptomatik, CD4 < 200 CD4< 350 CD4< 500 CD4>500 kemudian Test and Treat

Pengobatan ARV dini, CD4 < 350 mengurangi angka kematian 75%. Menekan angka kematian 75%, angka kejadian tbc 50% Duviral dan Efavirenz. Penelitian 816 odha Haiti, 2005 – 08 Kelompok pengobatan dini, CD4 antara 200 -350, tanpa riwayat gejala AIDS, sewaktu odha masih sehat, berat badannya belum turun, tanpa sariawan maupun diare, tanpa panas batuk, tanpa gejala. Kelompok standar lama, dengan CD4 kurang dari 200 N Engl J Med. 2010;363:257-65

Pengobatan ARV amat dini, CD4<500, jg terbukti mengurangi angka kematian Penelitian kohor Europa, Australia dan Kanada, 9.455 odha yang diteliti 1996 - 2009. Manfaat ARV nyata bila mulai ketika CD4: 0 - 49 cells/mm3, mengurangi angka kematian 70% Untuk CD4: 200 - 349 cells/mm3 mengurangi 40% CD4 350 - 499 cells/mm3:  25% Jonsson Funk M et al. HAART initiation and clinical outcomes. Abstract THLBB201, 2010

Botswana : Tes HIV rutin ! 48% penduduk Botswana tes HIV MTCT turun dari 30% ke 6% VCT gagal, kurang cepat dan kurang efisien Panelis menekankan bahwa masalah Kesehatan Masyarakat dan HAM tidak harus dan tidak perlu dipertentangkan Konpertensi Internasional AIDS Toronto 2006. Sheila D Tlou, Menkes Botswana

Amerika: Tes HIV rutin CDC mengeluarkan rekomendasi baru tes HIV rutin, pada remaja, dewasa dan ibu hamil. Alasannya karena 25% odha Amerika, tidak waspada akan status HIVnya, dan 40% odha terlambat diagnosis CDC, TELAH merekomendasi tes rutin HIV untuk kelompok risiko tinggi dan di lingkungan dengan prevalensi tinggi 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

CDC Recommendations for Routine HIV Testing Routine, voluntary HIV screening in healthcare settings recommended for all patients 13-64 yrs of age Except in populations with documented prevalence of undiagnosed HIV infection < 0.1% Without prevalence data, voluntary HIV screening appropriate until diagnostic yield < 1/1000 patients screened is established Separate written consent not recommended Pre- or post-test prevention counseling should not be required with testing or screening programs Branson BM, et al. MMWR Recomm Rep. 2006;55:1-17.

USPSTF HIV Testing Recommendations Screening strongly recommended for all adolescents and adults at increased risk for HIV and all pregnant women Increased risk defined as individuals with ≥ 1 risk individual factor or individuals receiving healthcare in a high-prevalence or high-risk clinical setting Individual Risk Factors High-Prevalence or High-Risk Settings Men who have had sex with men after 1975 Men and women having unprotected sex with multiple partners Past or present IDUs Men and women who exchange sex for money or drugs or have sex partners who do Individuals whose past or present sex partners were HIV infected, bisexual, or IDUs Persons being treated for STDs Persons with a history of blood transfusion between 1978 and 1985 Persons who request an HIV test despite reporting no individual risk factors may be considered at increased risk STD clinics Correctional facilities Homeless shelters Tuberculosis clinics Clinics serving men who have sex with men Adolescent health clinics with a high prevalence of STDs Any clinical setting with a known HIV prevalence ≥ 1% among the patient population being served For more information on the USPSTF Screening for HIV recommendations, go to: http://www.uspreventiveservicestaskforce.org/uspstf/uspshivi.htm. USPSTF recommendations. July 2005.

Zero Discrimination Kebijakan , UU terkendala oleh Praduga, stigma dan diskriminasi terhadap populasi kunci Kriminalisasi pengguna narkotika Masalah kesetaraan gender, kekerasan perempuan KEMAJUAN 18 negara Asia Pasifik memp UU perlindungan odha Bbrp negara tlh mencabut aturan perundangan yg negatif

4067-ON-AB-B Realisasi Uu. No 4067-ON-AB-B Realisasi Uu.No.35 Tahun 2009 Tentang Narkotika (Pecandu Adalah Korban) Dikota Bekasi Adalah Omong Kosong Mohammad Iwan Ikhsan SH, LSM Grapiks Bekasi Dari ke 14 penangkapan yang dilakukan oleh polisi dikota Bekasi rata-rata semuanya mendapatkan pasal 112/114. Di kedua pasal tersebut tertulis ancaman pidana penjara sedangkan jadi realita pecandu adalah korban dikota Bekasi adalah omong kosong.

Getting to Zero Terima kasih Prioritaskan Upaya Pencegahan yang high-impact Pengobatan mengurangi penularan 96% Tingkatkan odha yang mendapat ARV, tes 15 juta Menjaga kelangsungan pengobatan ARV HAM dan Gender

Prasarat Sukses Komitmen Kepemimpinan Politik Partnership dg LSM dan odha Akses ARV. Minimalkan ketergntungan Manfaatkan ARV produk dalam negeri Tes HIV sebanyak mungkin Akses tes HIV, CD4 dan VL yang murah Hapus UU dan kebijakan yang memicu diskriminasi

Unit Pelayanan Terpadu HIV/AIDS RS Cipto Mangunusumo 7 Juni 2011: 5 Unit Pelayanan Terpadu HIV/AIDS RS Cipto Mangunusumo 7 Juni 2011: 5.414 odha yang pernah mendapat ARV

5.414 PMTCT 75 UNIT PELAYANAN TERPADU HIV RSCM Layanan VCT Layanan Jumlah kumulatif Pasien yg pernah berobat di poliklinik Pokdi UPT HIV RSCM 75 Publikasi Penelitian 1 Doktor selesai, 4 Doktor hampir selesai 69 Dokter spesialis (IPD, Anak, Obsgin, Saraf, dll) 1 Post Doctoral PMTCT 211 Ibu ( thn 2008 s/d awal 2010 ) 150 Sectio Caesaria Layanan HIV di Lembaga Permasyarakatan (Salemba, Cipinang, Pondok Bambu, Tangerang ) Layanan VCT Layanan Obat

JUMLAH PASIEN 31 JAN. 2010: 4.590 odha 27 Oktober 2010: 5.082

UPT HIV SEMESTER I - 2010

Opportunistic Infection Percentage (%) Candidiasis oral 50 Pulmonary TB 37 Pneumonia 16.5 Extra pulmonary TB 13.8 Toxoplasma encephalitis 12.1 Chronic Diarrhea 11.2 Seborrheic dermatitis. 5.3 CMV retinitis 3.4 Candidiasis esophageal 3.3 Persistent Fever 3.2 Herpes zoster EPP 1.6 Wasting syndrome 1.2 Herpes simplex 0.6 Cryptococcal Meningitis 0.4 ITP 0.2 Toxocariasis 0.1 PCP Pattern of opportunistic infections of newly diagnosed HIV-infected patients in Cipto Mangunkusumo hospital 2008-2009 Karjadi TH, Yunihastuti E , Pramundita R, Aziza S, Lie S, Imran D, et al. Presented at 2010 PDPAI Clinical Research Meeting

Hepatitis coinfection in HIV patients Missing value= 938 Age = median 28 (16-77) Pokdicare Database, 2004-2009

Update Terpenting Lebih dini mengobati lebih baik Angka kematian HIV/AIDS turun drastis, 75% Mengobati ARV = mencegah penularan 92% Test and Treat 5.2 juta orang mendapat ARV Gel intravagina Tenofovir efektif cegah penularan 54% Deklarasi Wina

Kapan Mulai ARV?

DHHS 2009: When to Start CD4+ Cell Count Recommendation < 350 cells/mm³ Start HAART 350-500 cells/mm³ Start HAART* > 500 cells/mm³ Panel divided† Regardless of CD4+ Cell Count History of AIDS-defining illness Certain acute opportunistic infections Pregnancy HIVAN HBV coinfection when HBV treatment is indicated CD4+ count decline > 100 cells/mm3 per yr HIV-1 RNA > 100,000 copies/mL DHHS, US Department of Health and Human Services; HBV, hepatitis B virus; HIVAN, HIV-associated nephropathy.   This slide lists the DHHS guidelines released on World AIDS Day, December 1, 2009. The guidelines state that HAART should be initiated at CD4+ cell counts between 350 and 500 cells/mm^3. The asterisk indicates that 55% of panel members strongly recommended initiation at these CD4+ cell counts and 45% moderately recommended it. Essentially, all members of the panel at least moderately recommended initiating therapy when the CD4+ count is ≤ 500 cells/mm^3. The final category is CD4+ cell counts > 500 cells/mm^3, and on this issue, the panel was equally divided. One half of the members favored initiating therapy regardless of CD4+ cell count—that is, even in those patients with CD4+ cell counts > 500 cells/mm^3—whereas the remaining one half thought that the recommendations should view this number as an optional threshold for initiation of therapy. There are some conditions listed that favor initiation of antiretroviral therapy regardless of the CD4+ cell count, including history of an AIDS-defining illness, certain opportunistic infections, pregnancy, HIV-associated nephropathy, hepatitis B coinfection when hepatitis B treatment is indicated, rapid CD4+ cell count decline, and a high HIV-1 RNA level. The trend clearly is toward increased numbers of people falling into the category for which recommendations to start therapy are positive. *Panel divided: 55% strongly recommend and 45% moderately recommend. †50% favor initiating therapy at this stage; 50% view initiating therapy at this stage as optional. http://aidsinfo.nih.gov/contentfiles/AdultandAdolescentGL.pdf. 38

+ + Zidovudine r Stavudine Lamivudine Nevirapine r Efavirenz Pilihan kombinasi: Duviral + Neviral Staviral + Hiviral + Neviral Duviral + Efavir Staviral + Hiviral + Efavir 39

Towards a Paradigm Shift in HIV Treatment and Prevention July 18, 2010 UN Under Secretary General Michel Sidibe Head of International AIDS Society and Chair of International AIDS Conference, Julio Montaner.

MICHEL SIDIBE, direktur eksekutif UNAIDS 1 MICHEL SIDIBE, direktur eksekutif UNAIDS 1. Universal access is about social justice 2. Universal access will never happen, if we don’t bring innovation, if we don’t have prevention revolution 3. We have circumcisions, which are being accepted today socially, which were not. We could continue to use condoms, preservatives which are made available to young people. So, that is the revolution, ….

Towards a Paradigm Shift in HIV Treatment and Prevention, Vienna, July 18, 2010 Treatment is Prevention: But certainly what is important for me is Treatment 2.0. … We need to have drugs which can be administered easily. We need to make it owned by communities. We need to make sure that we can have the which are more costly, and we will work with our colleagues from WHO... We will work to make people understanding that this treatment for prevention is not just a dream. It is possible

5 million people in ARV, what do you have to say about the 10 million people who are still waiting? JULIO MONTANER: “I think it is a crime. It is a crime. We cannot wait. People infected with HIV who have a medical indication to be on treatment, they are dying because they are not being treated. Not only they are dying, their families are suffering. They are also weakening our economies so this is bad for the people, this is bad for their people. This is bad for society”

People who are not treated are more likely, dramatically more likely to transmit infection. We have to stop this. This is nonsense. We have to stop it. We have got to stop it now!

Pra dan Pasca Tes VCT PITC Informed Consent Tes Rutin Tahap Peralihan Konseling Tes HIV Pra dan Pasca Tes VCT PITC Informed Consent Tes Rutin Tahap Peralihan

Expanding HIV Testing n Counseling Parameter Program HTC (HIV Testing and Couseling yang efektif adalah: jumlah besar orang dengan HIV/AIDS yang mendapat pengobatan ARV tahap dini memenuhi kebutuhan klien dan provider Pendekatan ke klien yang baik

Pelatihan Konselor Modul Inti: VCT dan PITC Modul Inti + Populasi Khusus Modul Inti + Aderens + Disclosure Modul Inti + Antenatal

Tujuan Konseling Untuk mengurangi penularan Untuk meningkatkan aderens pengobatan Untuk mengurangi masalah psikologi HIV Untuk memperbaiki kualitas hidup

Terima kasih 440 konselor ikut lokakarya 3 hari V. Isakov, P. Smyrnov: VCT dg rapid test sbg intervensi utama ke akses universal ke pencegahan, pengobatan dan dukungan untuk pengguna narkotika TUPE371 Konp IAS 2011, Juli 2011, Roma 440 konselor ikut lokakarya 3 hari Selama th 2010 ada 70.580 IDUs menerima VCT dg rapid test, 4 903 positif HIV 76% IDUs ke dokter untuk memastikan hasil tes HIV 97% puas dg layanan VCT, 46% klien memakai kondom, 36% klien hentikan pakai jarum saling pinjam Mendapat pengobatan ARV

Kesimpulan Getting to Zero Zero New HIV Infections Zero Discrimination Zero AIDS-related deaths KONSELING

Zero Maturnuwun

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