Pencegahan HIV/AIDS Situasi di Indonesia

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Pencegahan HIV/AIDS

Situasi di Indonesia

Samsuridjal Djauzi

Pokdisus AIDS FKUI/RSCM

Divisi Alergi dan Imunologi Klinik Departemen Ilmu Penyakit Dalam FKUI/RSCM

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Pencegahan Melalui Perubahan Perilaku

 _{Biaya murah}

 _{Semula diharapkan bisa berjalan dengan berhasil}

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Survei Perubahan Perilaku di Indonesia (2008)

Belum terjadi perubahan perilaku yang nyata di

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HIV Infection In Indonesian Family



A husband admitted to hospital due to

cryptoccal meningitis, he is a worker in

electronic manufacture



His wife was pregnant and acquired HIV

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Upaya Pencegahan



_{Perubahan Perilaku}



_{Intervensi Biomedik: kondom, jarum suntik steril,}

Sirkumsisi, Obat Antiretroviral



_{Pemberdayaan : pendidikan, penanggulangan}

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Perubahan Perilaku

 _{Berhenti melakukan hubungan seksual tak aman}  _{Berhenti menggunakan narkoba}

 _{Menggunakan kondom 100% konsisten}

 _{Menggunakan jarum steril untuk satu orang}  _Mudahkah?

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Kelompok Risiko Tinggi dan Umum

 _{Pengguna narkoba (suntikan)}

 _{Pasangan seksualnya dan teman menyuntiknya}  _{Pekerja seks komersial}

 _Pelanggannya

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Penyuluhan dan Pencegahan Terutama

Ditujukan Kepada Riski

 _{Apa dampaknya bagi populasi umum}

 _{Kurangnya upaya penyuluhan secara umum}

 _{Persepsi hanya yang tertular HIV kelompok tertentu}

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Harm Reduction

 _{Sosialisasi lebih berhasil dibandingkan kondom}

 _{Refleksi untuk mencari strategi baru dalam}

mensosialisasikan kondom

 _{Kenapa viagra boleh kondom tidak?}

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Kesamaan Persepsi

 _{Kondom: masyarakat, petugas kesehatan, kalangan}

agama

 _{Jarum suntik: masyarakat, petugas kesehatan, penegak}

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Efficacy of HIV Prevention Strategies From

Randomized Clinical Trials

Abdool Karim SS, et al. Lancet. 2011;[Epub ahead of print].

Efficacy (%)

100

0 20 40 60 80

Study Effect Size, % (95% CI)

ART for prevention; HPTN 052, Africa, Asia, Americas

PrEP for discordant couples; Partners PrEP, Uganda, Kenya PrEP for heterosexual men and women; TDF2, Botswana

Medical male circumcision; Orange Farm, Rakai, Kisumu

PrEP for MSMs; iPrEX, Americas, Thailand, South Africa

Sexually transmitted diseases treatment; Mwanza, Tanzania Microbicide;

CAPRISA 004, South Africa HIV vaccine; RV144, Thailand 96 (73-99) 73 (49-85) 63 (21-84) 54 (38-66) 44 (15-63) 42 (21-58) 39 (6-60) 31 (1-51)

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Treatment as Prevention

 _{Meningkatkan tes HIV}

 _{Memberikan ARV secara dini}  _{Mempertahankan adherens}

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Gap Between Estimation and Reported

Cases on ART

 _{HIV Estimation 2013 : 600.000}  _{Reported : 120.000}  _{Start ART : >70.000}  _{On ART : 43.000}

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Cascade of Treatment

(March 2014)

1st_{line regimen: 96.76% (41,035 people)}

2nd_{line regimen: 13.24% (1,376 people)}

Only 50% PLWHA who are eligible for ART initiation still on ART 42411 79740 104483 150471 178631 0 50000 100000 150000 200000 Receiving ART Ever received ART Eligible to start ART Enrolled in HIV Care PLHIV who need to start ART (2012

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PLHIV Remain on ART

2005 until June 2014 2,381 4,552 6,068 10,616 16,063 19,572 24,013 31,002 39,418 43,104 - 5,000 10,000 15,000 20,000 25,000 30,000 35,000 40,000 45,000 50,000 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014*

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Tantangan Dalam Pemberian Obat ARV

 _{Infeksi Oportunistik}  _Adherens

 _{Ketersediaan obat ARV}

 _{Distyribusi layanan obat ARV}  _transportasi

 _{Kehadiran dalam tempat kerja}  _Mobilisasi

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Retensi Terhadap Obat ARV

 _Dharmais:

 _{6 bulan = 80%}

 _RSCM:

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Adiksi

 _{Akibat fisiologis dari penggunaan narkoba}

 _{Tak mudah diatasi; perlu perjuangan panjang dan}

melelahkan

 _{Rehabilitasi dapat mengurangi adiksi namun mudah}

relaps kembali

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Limitation and Continuation to The Methadone Service

(

N

of Methadone clinics in Jakarta =

18 clinics)

• MMT has been adopted as national program since 2006 (scaled up to 17 provinces)

• Provision of methadone HCl is fully supported by GoI

• Administration cost paid by patients except for particular sites (supported by local government). Most clinics ask patients to pay at min. cost (0.5 USD at primary health care (PHC); 1.2 USD at hospital)

• Non-supportive client-therapist relationship

Program

factors

• Lack of support from the family (most of them are abstinence-oriented)

• Lots of stigma and discrimination

• MAT is not favorable treatment for law enforcement sector

Social

factors

• Faulty belief system that they can be abstinent whenever they need

• Myths of MAT (difficult to get off methadone; severe withdrawal symptoms)

• Limited proper knowledge on recovery (highly demand on THD regardless continuing mixing with depressant substances)

Individua

l factors

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PMTCT

until June 2014

2011 2012 2013 2014

 Pregnant women went for

HIV test 21,103 43,624 100,926 137,000

 HIV-infected pregnant

women 534 1,329 3,135 1,182

% positive 2.5% 3% 3.1% 0.9%

 Pregnant women on ART 601 1,070 1,544 1,456

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PPIA dan

Profilaksis

Bayi

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Pencegahan Pasca Pajanan (PPP)

 _{Pemberian ARV dalam waktu singkat untuk mengurangi}

kemungkinan didapatnya infeksi HIV setelah terpapar ketika bekerja atau setelah kekerasan seksual.

 _{Ditawarkan pada kedua kelompok pajanan tersebut dan} diberikan sesegera mungkin dalam waktu 72 jam setelah paparan.

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Opportunistic Infection Percentage (%) Candidiasis oral 50 Pulmonary TB 37 Pneumonia 16.5 Extra pulmonary TB 13.8 Toxoplasmosis 12.1 Chronic Diarrhea 11.2 Seborrheic dermatitis. 5.3 CMV retinitis 3.4 Candidiasis esophageal 3.3 Persistent Fever 3.2 Herpes zoster 3.2 EPP 1.6 Wasting syndrome 1.2 Herpes simplex 0.6 Cryptococcal Meningitis 0.4 ITP 0.2 Toxocariasis 0.1 PCP 0

OIs Distribution

among HIV Patients

at Pokdisus RSCM

2008/2009

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HIV and Hepatitis Co-infection

Data from Pokdisus HIV Clinic, Jakarta, 2004-2011 (N=5544)

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% anti-HCV (+) HBsAg (+) 74.7% 11.9% 22.5% 5.9% 63.9% 10.5% male female all Anti-HCV tested = 46.4% HBsAg tested = 40.5%

Yunihastuti, et al. 2012. Decrease seroprevalence of HCV and HBV co-infection … in press

• HIV and hepatitis B:

access to free TDF based ART

• HIV and hepatitis C: most HCV untreated

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Immunization in PLWHA

 _{Hepatitis B}  _{Hepatitis A}  _HPV  _Influenza  _Pneumococcal  _Varicella

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Concern about HIV in MSM

 _{Increasing prevalence of HIV among MSM}  _{MSM-friendly service is needed}

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Persentase Infeksi HIV yang Dilaporkan

Menurut Faktor Risiko Tahun 2010- September

2013

19.5% _15.3% 11.3% 10.4% 46.4% 49.5% 49.9% _49.8% 3.5% 4.8% 7.0% 9.7% 30.6% 30.4% _31.8% 30.1% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 2010 2011 2012 2013* Lain-lain LSL Heteroseksual Penasun

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HIV risk factor among newly diagnosed HIV-infected

male in RSCM

UPT HIV RSCM/Pokdisus AIDS FKUI 2.3 _5.7 8.7 17.9 27.4 0% 20% 40% 60% 80% 100% 2009 2010.0 2011 2012 2013 MSM IDU + MSM hetero IDU + hetero IDU only MSM sensitivity training

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Empowerment

Continuing the case earlier…

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Fortunately the husband could survive with high

dose fluconazole treatment. However he lost his job



Family income should be part of Care Support and

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Conclusion

 _{Biomedical intervention becomes prominent}  _{The coverage of ART provision needs scaling up}  _Adherence

 _PMTCT

 _{Post-Exposure Prophylaxis}

 _{Prevention of Hepatitis B, Hepatitis A, HPV}  _{Psychological support towards PWID}

 _{Concern on HIV transmission among MSM}  _{The need of empowerment}

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