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 According to a 2008 report from the
Black AIDS Institute:
Blacks 1.42 3.58
Select “A free-standing black America would rank 16th in
Comparator the world in the number of people living with HIV”
Countries[3]
Burkina Faso 1.6 “The number of black Americans living with HIV is
greater than the HIV population of
Ghana 1.9 7 of the 15 PEPFAR focus countries”
Rwanda 2.8
Haiti 2.2
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 December 2007 December 2008 December 2009

60,000 pts 80,000 pts 100,000 pts 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 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.

 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: 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

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
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

Keputusan Presiden
Menkes
Menko Kesra
KESIMPULAN
See You in Bali !
9th ICAAP 2009

Deadline Abstrak 15 Maret 2009