Kebijakan Pengendalian HIV-AIDS
dengan Penggunaan Strategis ARV
Dr. Siti Nadia Tarmizi, M.Epid
591.823
ESTIMASI JUMLAH ODHA 2012
591.823
JUMLAH HIV DAN AIDS YANG DILAPORKAN
PER TAHUN SD NOVEMBER 2013
859
7.195
6.048
10.362 9.793
21.591 21.031 21.511
28.215
4.987
3.514
4.425 4.943
5.483
6.845 7.004
5.686 5.529
- 5.000 10.000 15.000 20.000 25.000 30.000 s.d. 2005 2006 2007 2008 2009 2010 2011 2012 2013* Jumlah HIV Jumlah AIDSKumulatif HIV = 126.605
Kumulatif AIDS = 48.416
JUMLAH INFEKSI HIV MENURUT KELOMPOK UMUR
TAHUN 2010-SEPT 2013
390
405
827
547
242
683
541
208
697
526
221
701
3.480
3.113
2.964
3.079
15.648
15.490
15.133
14.904
841 956 1.968 982-
2.000
4.000
6.000
8.000
10.000
12.000
14.000
16.000
18.000
2010
2011
2012
2013
≤4
5-14
15-19
20-24
25-49
≥50
CASCADE OF TREATMENT
SD
SEPTEMBER 2013
Prevalensi HIV Berdasarkan Populasi Berisiko, STBP 2007-2013
*2007 & 2011 di kota yang sama
**2009 & 2013 di kota yang sama
9,8
4,0
0,1
24,3
5,3
52,4
9,3
3,1
0,7
23,2
12,4
42,4
6,5
2,6
0,4
9,1
7,0
27,0
7,4
1,5
0,2
7,4
12,8
39,5
1,2
0
20
40
60
80
WPSL
WPSTL
Pria Risti
Waria
LSL
Penasun
WBP
%
7
JUMLAH INFEKSI HIV BARU
PERTAHUN,
PER SUBPOPULASI
(PEMODELAN MATEMATIKA 2012)
JUMLAH INFEKSI HIV BARU PERTAHUN,
PER SUBPOPULASI
Layanan Terkait HIV-AIDS dan IMS
LAYANAN
JUMLAH
Konseling dan Tes HIV
899
(RS, PKM, LSM, Rutan/Lapas)
Perawatan, Dukungan dan
Pengobatan
380 (266 RS Pengampu dan
114 Satelit)
Program Terapi Rumatan
Metadon
85 (RS, PKM, Rutan/Lapas)
Layanan Jarum dan Alat Suntik
Steril
194 PKM
IMS
866 (RS dan PKM)
GETTING THREE ZEROES
•
Menurunkan jumlah kasus baru HIV
•
Menurunkan angka kematian
•
Menurunkan stigma dan
diskriminasi
•
Meningkatkan kualitas hidup ODHA
Pengertian (1)
Layanan Komprehensif
upaya yang meliputi upaya
promotif, preventif,
kuratif, dan rehabilitatif
bagi masyarakat yang
membutuhkan (yang belum terinfeksi agar tidak
tertular, yang sudah terinfeksi agar kualitas hidup
meningkat)
melibatkan seluruh sektor terkait, masyarakat
termasuk
swasta
,
kader,
LSM,
kelompok
dampingan sebaya, ODHA, keluarga, PKK, tokoh adat,
tokoh
agama
dan
tokoh
masyarakat
serta
Layanan Berkesinambungan
pemberian
layanan
komprehensif
HIV
atau
paripurna sejak dari rumah atau komunitas,
hingga ke fasyankes
(puskesmas, klinik dan rumah
sakit) selama perjalanan infeksi HIV
dimaksudkan
sebagai
layanan
terpadu
dan
berkesinambungan untuk memberikan dukungan baik
aspek manajerial, medis, psikologis maupun
sosial
untuk ODHA selama perawatan dan
pengobatan untuk mengurangi atau menyelesaikan
permasalahan yang dihadapinya.
Fasyankes
Sekunder
RS Kab/Kota
Fasyankes
Tersier
RS Provinsi
Masyarakat
Kelompok
Dukungan
KADER
COMMUNITY
ORGANIZER
COMMUNITY
ORGANIZER
Fasyankes
Primer
PUSKESMAS
PBM:
LSM, Ormas, Orsos, RelawanPBR:
Keluarga ODHAKerangka Kerja Layanan Komprehensif
Berkesinambungan
KOMISI PENANGGULANGAN
AIDS (KPA)
•
Koordinasi dan kemitraan dg semua
pemangku kepentingan di setiap lini
PILAR
1
•
Peran Aktif ODHA dan Keluarga
PILAR 2
•
Pelayanan terintegrasi dan terdesentralisasi
sesuai kondisi epidemiologi setempat
PILAR 3
•
Paket layanan HIV komprehensif yang
berkesinambungan
PILAR 4
•
Sistem rujukan dan jejaring kerja
PILAR 5
•
Akses layanan terjamin
PILAR 6
Rajal
IMS
KTIP
TB
KTIP
KIA/KB
KTIP
LKB
KDS
KTS
Ranap
KTIP
PTRM/LASS
KTIP
LAB/Rad
KTIP
Paket Pelayanan HIV/AIDS dan IMS yang
Terintegrasi dan Rujukan Internal
Penjangkauan/
Outreach
Paket Pelayanan HIV/AIDS dan IMS yang
Terintegrasi dan Rujukan Internal
TIPK
TIPK
TIPK
TIPK
TIPK
TIPK
LASS/PTRM
TIPK75 Kab/Kota LKB (2012-2013)
1. Kota Denpasar
2. Kab Badung
3. Kota Jakarta Barat
4. Kota Surabaya
5. Kota Makassar
6. Kota Bandung
7. Kota Manado
8. Kota Medan
9. Kab Sorong
10.Kab Jayapura
11.Kota Tanjung Pinang
12.Kota Pekanbaru
13.Kota Padang
14.Kota Jambi
15.Kota Palembang
16.Kota Bandar
Lampung
17.Kab Tangerang
18.Kota Cilegon
19.Jakpus
20.Jakut
21. Jaktim
22. Jaksel
23. Kota Bogor
24. Kota Semarang
25. Kota Surakarta
26. Kota Yogyakarta
27. Kota Malang
28. Kab Malang
29. Kota Mataram
30. Kota Pontianak
31. Kota Singkawang
32. Kota Jayapura
33. Merauke
34. Kota Sorong
35. Manokwari
36. Kota Timika
37. Kab Deliserdang
38. Kota Batam
39. Kab Karawang
40. Kota Cirebon
41. Kab Indramayu
42. Kab Semarang
43. Kab Buleleng
44. Kab Jayawijaya
45. Kab Fak-fak
46. Kota Bekasi
47. Kab Bekasi
48. Kab Cirebon
49. Kab Bandung
50. Kota Depok
51. Kab Bogor
52. Kota Tasikmalaya
53. Kab Subang
54. Kab Sumedang
55. Kab Banyumas
56. Kab. Batang
57. Kab Cilacap
58. Kab Banyuwangi
59. Kab Sidoarjo
60. Kota Kediri
61. Kab Garut
62. Kab
Tasikmalaya
63. Kab Ciamis
64. Kab Kuningan
65. Kab Kendal
66. Kab Tegal
67. Kota Tegal
68. Kab Kediri
69. Kab Paniai
70. Kab Nabire
71. Kota
Banjarmasin
72. Kab Pare-Pare
73. Kab Jember
74. Kab
Majalengka
75. Kab. Jombang
18 Kab/Kota LKB (2014)
1.
Kota Banda Aceh
2.
Kab. Simalungun
3.
Kota Bukittinggi
4.
Kota Dumai
5.
Kota Bengkulu
6.
Kota Pangkal Pinang
7.
Kab. Karimun
8.
Kab. Sleman
9.
Kab. Sikka
10.
Kota Kupang
11.
Kota Palangkaraya
12.
Kota Balikpapan
13.
Kota Samarinda
14.
Kota Palu
15.
Kota Kendari
16.
Kab. Gorontalo
17.
Kota Ambon
18.
Kota Ternate
Terapi Anti Retroviral
Tujuan Terapi ARV
Memperbaiki kualitas hidup
Mencegah infeksi oportunistik
Mencegah progresi penyakit
Strategic Use of ART/Pengggunaan Strategi
ARV sebagai Pencegahan & Pengobatan
models, but has been about 33% in actual programmes [ 29] .
Rather than 0% refusal of uptake of treatment, as assumed in the
models, some settings have seen 20% refusal [ 30] . Finally, the
dropout rate from programmes was 1.7% per year in the most
optimistic model simulations presented in Eaton et al., compared
with around 10% over the first year in the I eDEA network of
clinics
[31–33].
T hese
inconsistencies
between
modelling
assumptions
and
projects and real world situations do not mean that treatment
cannot be used to generate greater reductions in incidence, but
rather that major advances in programme coverage and delivery
will be required to fully exploit the potential prevention benefits of
treatment. T hese are operational barriers that could be improved
without the development of new scientific prevention technologies,
but which will nevertheless require substantial investment in health
services.
I n many models, including several of those in the modelling
comparison [ 15] , several significant simplifying assumptions about
other factors that might influence success were made, because the
exercise was focussed on the impact of a simple and stylized
treatment
programme on H I V
incidence. I n particular,
most
models
did
not
explicitly
include
the
relationship
between
adherence to ART
regimens and degree of viral suppression,
which would affect the therapeutic benefit, the prevention effect,
and the potential for emergence of drug-resistant
virus. Drug
resistance is an important issue, especially over the long timescales
considered here, because it effectively weakens the impact of
existing first-line regimens and could cause greater reliance on
second- and third-line treatment regimens, which are currently
more expensive. T here are many other considerations that the
modelling comparison by Eaton et al. did not address, such as the
interaction of ART with behavioural interventions and the best
C
um
ul
at
ive
p
er
ce
nt
ag
e
of
H
IV
tr
an
sm
is
si
on
s
0%
50%
100%
0
4
8
12
Years since HIV infection
CD4 < 350
CD4 < 200
CD4 < 350
CD4 < 200
Fig u r e 1. A f r am ew o r k f o r u n d er st an d in g t h e ep id em io lo g ical im p act o f HIV t r eat m en t . The published results of models[38,53–55] that have estimated the contribution of different stages of HIV infection to onward transmission are compiled in a median cumulative distribution of infections generated by one infected person over the course of his/her infection in the absence of treatment (red line). The horizontal axis shows time from the time of infection to 12 years, which is the mean survival time for those with untreated HIV infection [56]. The vertical axis shows the cumulative transmission, from 0% (no new infections generated yet) to 100% (all onward transmission completed). (Note that the uncertainty in this distribution is not indicated.) The shading indicates the approximate CD4 cell count category at each time point [25,26]. Current ly, treatment tends to be initiated well below a CD4 cell count of 200 cells/ ml [32], meaning that the contribution of treatment to prevention is minimal because most of the transmission from that person has already occurred before treatment starts. If increased testing and improved linkages to care enabled individuals to start treatment at a CD4 cell count very close to 200 cells/ ml, this could result in a substantial reduction in HIV incidence, because , 25%–30% of transmission normally arises from individuals after that point. The prevention impact would be expected to be even greater with initiation close to a CD4 cell count of 350 cells/ ml. If the average number of new infections arising from an infected person in a susceptib le population exceeds one before treatment could be feasibility initiated, then treatment could not eliminate the HIV epidemic. In this framework, the influence of other forms of prevention will be to change the shape of the graph. For instance, if many men are circumcised or individuals have fewer new sexual partners per time unit, then new infections arising from an infected person will grow more slowly over time, so that on average one new infection might be generated only after the point at which a feasible programme could have initiated treatment.
doi:10.1371/journal.pmed.1001259.g001
PLoS Medicine | www.plosmedici ne.org 33 July 2012 | Volume 9 | Issue 7 | e1001259
Rasional Penggunaan ART
Dampak Potensial
Strategic Use of
ART
Perluasan
signifikan
cakupan
ART
dapat
menghasilkan
pengurangan jumlah infeksi baru HIV menjadi setengahnya.
Secara kumulatif akan menurunkan jumlah infeksi baru HIV di
Indonesia sebesar 432.000 – 482.000 pada tahun 2020, dan antara
1.563.000 sampai 1.715.000 pada tahun 2030.
Biaya pengobatan tambahan untuk mencegah satu infeksi HIV baru
berkisar antara $ 4200 - $ 9400, bergantung pada efektivitas ART.
Biaya ini kurang dari setengah biaya yang diperkirakan mengobati
seseorang yang sudah terinfeksi (sekitar $ 15,000).
Berarti, memperluas program pengobatan tidak hanya akan
mengendalikan epidemi HIV tetapi juga akan menghemat biaya
dalam jangka panjang.
STRATEGIC USE OF ARV-SUFA
•
ibu hamil
▫
pasien IMS
▫
pasangan ODHA
▫
pasien TB
▫
pasien Hepatitis
▫
Populasi Kunci :
WPS, LSL, TG,
Penasun, LBT
▫
WBP
•
Ibu Hamil HIV
•
Co Infeksi TB HIV
•
Co Infeksi Hepatitis
•
Sero – Discordant
•
Populasi Kunci
Konseling Lanjutan
•
Konseling Pasca Tes
•
Konseling Pasangan
•
Konseling Keluarga
•
Pengungkapan Hasil Tes Pasangan
•
Konseling Memulai Terapi
ko
1. Konseling dan Tes
HIV
2. IMS
3. TB HIV
4. PPIA
5. LASS/PTRM
6. Satelit ARV
7. Lab. Sederhana
(RDT/ jejaring lab
dan IMS)
(PKM, Klinik, Lapas,
DPS,)
1. Konseling dan Tes
HIV
2. IMS
3. TB HIV
4. PPIA
5. LASS *
6. PDBN *
7. PDP
8. Lab. Lengkap (CD
4/jejaring lab)
(RS Kab/kota, PKM )
1. Konseling dan Tes
HIV
2. IMS
3. TB HIV
4. PPIA
5. PDP
6. LASS *
7. PDBN *
8. Penunjang
Diagnostik (VL +
CD4) dan Lab.
lengkap
JEJARING MINIMUM PELAYANAN
RS RUJUKAN prop dan
kab/kota (pemerintah
/swasta)
RS Kab/kota (kswasta dan pemerintah) dan PKM LKB
LAYANAN SATELIT / Fasyankes
