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 China Thailand Vietnam Indonesia Burma Pakistan Iran  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

US CDC Center for Disease Control and Prevention Estimasi jumlah kasus baru 2006: orang Estimasi jumlah kasus baru 2006: orang Kenyataan 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 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: McQuillan GM, et al. J Acquir Immune Defic Syndr. 2006;41: UNAIDS, Available at: HIV Prevalence, % United StatesNHANES, [2] Ages NHANES, [2] Ages Whites Blacks Select Comparator Countries [3] Burkina Faso1.6 Ghana1.9 Rwanda2.8 Haiti2.2

Indonesia Tahun Estimasi

Pengobatan

Data ARV Global akhir 2007 Argentina Botswana Brazilia Cambodia Cameroon Cote d’Ivore Etiopia Afsel Indonesia (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  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 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. serodiscordant couples receiving successful antiretroviral therapy. J Acquir Immune Defic Syndr 2006; 43:  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:  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:  Dengan ARV: Prevalensi HIV pasangan turun dari 10.3% ( ) menjadi 1.9% ( ; P = ).  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 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 > 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/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.

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: Lewden C, et al. J Acquir Immune Defic Syndr. 2007;46:72-77.

Summary of Study Design Lewden C, et al. J Acquir Immune Defic Syndr. 2007;46:  2435 HIV-infected patients who initiated PI-containing HAART from 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

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.

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

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

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  VL > aidsinfo.nih.gov

Keputusan Presiden Menkes Menko Kesra

KESIMPULAN

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