UPDATE HIV/AIDS ZUBAIRI DJOERBAN

(1)

UPDATE HIV/AIDS

ZUBAIRI DJOERBAN

(2)

CONSOLIDATED GUIDELINES ON

HIV TESTING SERVICES

JULY 2015

HIV TESTING

SERVICES

5Cs: CONSENT, CONFIDENTIALITY,

COUNSELLING,

(3)

Definition: HIV testing services

Throughout these guidelines the term HIV testing services (HTS) is used to embrace the full range of services that should be provided together with HIV testing – counselling (pre-test information and

post-test counselling); linkage to appropriate HIV prevention, treatment and care services and other clinical and support services; and coordination with laboratory services to support quality assurance and the delivery of correct results. The WHO 5 Cs are

principles that apply to all models of HTS and in all circumstances

(4)

(5)

W.H.O. CONSOLIDATED GUIDELINES

ON THE USE OF ANTIRETROVIRAL

DRUGS FOR TREATING AND

PREVENTING HIV INFECTION

2015

POLICY BRIEF

WHAT’S NEW

(6)

 The review of evidence in 2015 concludes that:

 _{Earlier initiation of ART is better}

 TENOFOVIR alone or in combination with emtricitabine, is efficacious as PrEP to prevent HIV acquisition .

 Safer and more efficacious ARV are becoming available

 _{Innovative approaches to HIV testing being implemented}

(home testing, community-based testing and selftesting).

 _{Many countries now provide lifelong ART to all pregnant}

and breastfeeding women.

 _{Many countries are implementing VL testing as the}

preferred monitoring technology for people taking ART.

 New point-of-care viral load testing technologies have the potential to expand access to viral load testing.

(7)

BPJS JKN



Tes Elisa



CD4

(8)

Perkembangan Pesat Pengobatan HIV AIDS

SEJARAH KAPAN MULAI ARV/ART

 AIDS tahap lanjut .. 1981-1990

 Walaupun belum ada gejala, bila CD4<200 1996 HAART

 CD4 <350

 CD4 < 500

 CD4 berapapun

(9)

QoL People Living with HIV/AIDS

Yvonne Handayani , Zubairi Djoerban, Hendry Irawan

PUBMED Acta Medica Indonesiana 2012 Oct;44(4):310-6

 Kramat 128 Hospital, Nov 2010 – Jan 2011

 88 patients with HIV/AIDS, 70 male

 50 IDU (56.8%), 38 sexual transmission

 Age 23-60 ys (x 34.1 ys), Married 67%

 CD4 >500: 78.3% after 2 ys treatment

(10)

Keberhasilan pemberian ARV

 Klinis: berat badan meningkat, infeksi berkurang

 Imunologis: peningkatan CD4 (Amir Fauzan, Pokdisus 2005)

 _{Tercapai pada 85% pasien memulai lini-1}

 Virologis: jumlah HIV (viral load) mencapai < 400 kopi/mL (tidak

terdeteksi) dalam 6 bulan setelah pengobatan:

 Tercapai pada 93,5% pasien memulai lini-1

(11)



District of Columbia, Amerika

Terima kasih

Sejak 2009, Semua Bayi yang

dilahirkan odha, tidak ada yang

(12)

(13)

NRTI / NtRTI

NNRTI

PI

NRTI AZT (Zidovudine) 3TC (Lamivudine) FTC (Emtricitabine) d4T (Stavudine) ddI (Didanosine) ABC (Abacavir) NtRTI TDF (Tenofovir) NVP (Nevirapine) EFV (Efavirenz) LPV/r (Lopinavir/Ritonavir booster)

Jenis dan golongan antiretroviral

yang ada di Indonesia

(14)

Hari AIDS Sedunia 1 Desember 2011



(1) Zero new HIV infections,



(2) Zero discrimination



(3) Zero AIDS-related deaths.

Terima kasih

(15)

Surat Edaran Menkes 129 th 2013

 Tes Kepada Semua

 Ibu Hamil  IMS  TB  Pasangan Odha Binaan  Hepatitis

(16)

Surat Edaran Menkes RI No 129

Tahun 2013 tentang Pelaksanaan

Pengendalian HIV-AIDS dan Infeksi

(17)

Inisiasi dini ART tanpa melihat CD4

dapat diberikan kpd HIV +:

 Ibu hamil

 Koinfeksi TB

 LSL / MSM

 Koinfeksi hepatitis B dan C

 Wanita Pekerja Seks

 Pengguna narkotika suntik

 Odha yang pasangan tetapnya HIV – ve, dan tidak menggunakan kondom konsisten

(18)

TEST and TREAT



Botswana



South Africa



China



_US



Indonesia

(19)

(20)

BOTSWANA 2006 Toronto AIDS Conference

Sheila Tlou menkes Botswana sedi. Setiap hari, selalu saja ada rakyatnya yang meninggal.

Peristiwa ini benar benar terjadi, baru 14 tahun yang lalu. Harapan hidup rakyat Sheila turun drastis, bahkan yang perempuan tidak mencapai 50 tahun. Beberapa orang yang meninggal sempat tes darah HIV, ternyata

(21)

BOTSWANA

 Bagaimana mungkin!!. Laporan di mejanya selalu

menyebutkan jumlah odha di negaranya, Botswana, -utara Afrika Selatan-, hanya 5.000 orang

 Jumlah penduduk 1,815,508 orang.

 Bekas protektorat Inggris ini merdeka th 1966

 Negara penghasil intan berlian dengan Gross

(22)

(23)

Target 15 juta

penduduk Afrika telah tercapai

 88% yang tes HIV

telah mendapat penjelasan hasilnya  ditemukan 2.200.000 orang yang positif HIV (18%) .

(24)

(25)

China: In 2011, 74,517 individuals were

identified as HIV infected



_{In 2011, > 84 million Chinese received HIV TEST}



_{74,517 individuals were identified as HIV infected}



_{Of those, 45,843 were enrolled in ART}



_{27.6 percent had late stage AIDS}



(26)

(27)

Professor Myron Cohen of the University

of North Carolina at Chapel Hill



_{“If we were doing a good job with prevention in}

the US, the average CD4 count at diagnosis would

be rising,” he said. “It’s not. We’re doing a bad job

at finding these people.”

(28)

US: TES HIV TIDAK PERLU CONSENT TERTULIS

Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings 2006 CDC. These recommendations

support routine testing and differ from previous recommendations

“ Separate written consent for HIV testing is not

recommended”. Prevention counseling—defined as an interactive process of assessing risk of infection, recognizing specific behaviors that increase this risk, and developing a plan to reduce risk—should not be required with HIV testing

(29)

Terima kasih

(30)

Efektifitas Upaya

pencegahan penularan HIV

1. Upaya Biomedik

 Anti Retro Viral: 92-96%

 PMTCT: mendekati 100%

 Sunat, Sirkumsisi: 65%

 Gel Tenofovir Intravaginal 39%

 Kondom

 Pengobatan penyakit menular seksual

2. Upaya Struktural

 Ekonomi, Budaya, Pendidikan, Hukum, Gender

 HAM

(31)



_{Deborah Donell dkk, Lancet 12 Juni 2010,}

“Heterosexual HIV

-1 transmission after initiation

of

ART: a prospective cohort analysis”.



_{Odha yang minum ARV akan mengurangi penularan}

ke pasangan heterokseksualnya sebanyak 92%



_{Treatment is Prevention}

_.

Terima kasih

(32)

Segera mengobati odha dg ART/ARV

mengurangi angka penularan 92-96%

(33)

 Penelitian HPTN 052, 0leh pemerintah Amerika.

Dimulai 2005. 1.763 pasangan, 97% hetero seksual

 Amerika, Botswana, Brazil, India, Kenya, Malawi n di Afrika Selatan, Thailand, dan Zimbabwe.

 2 Kelompok, (I) segera ARV setelah diketahui

terinfeksi HIV, kelompok (II) ARV ketika CD4 sudah turun < 250 sel/mm3

Terima kasih

(34)

 Hasil Penelitian: Hanya 1 orang yang tertular HIV untuk pasangan odha yang segera diobati setelah diketahui terinfeksi.

 Sedangkan pd kelompok II yang mulai ARV ketika CD4 < 250 penularan HIV terjadi pd 27 orang

 ARV segera setelah diagnosis mengurangi penularan 96%

(35)

5 million people in ART, what do you have to say about the 10 million people who are still waiting?

 JULIO MONTANER (2010 Vienna: Head of International

AIDS Society and Chair of International AIDS Conference) : “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}

(36)

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.

(37)

Prinsip penatalaksanaan HIV

Suportif _Infeksi

oportunistik _{viral (ARV)}Anti retro

(38)

NRTI / NtRTI

NNRTI

PI

NRTI AZT (Zidovudine) 3TC (Lamivudine) FTC (Emtricitabine) d4T (Stavudine) ddI (Didanosine) ABC (Abacavir) NtRTI TDF (Tenofovir) NVP (Nevirapine) EFV (Efavirenz) LPV/r (Lopinavir/Ritonavir booster)

Jenis dan golongan antiretroviral

yang ada di Indonesia

(39)

AMERIKA: ART untuk semua infeksi HIV

• CD4 count <350 cells/mm3 (AI)

• CD4 count 350 to 500 cells/mm3 (AII) • CD4 count >500 cells/mm3 (BIII)

ART segera mulai pada • Hamil (AI)

• Riwayat AIDS (AI)

• Nefropati HIV (HIVAN) (AII)

(40)

Penilaian klinis dan

laboratorium

Keadaan umum – Anemia – Diare – Kehamilan – Demam Laboratorium: – Hemoglobin – Fungsi hati – Tes kehamilan – CD4 – VIRAL LOAD Ronsen dada Penyakit penyerta

TB dan penyakit infeksi oportunistik lain

Penyakit akibat HIV lainnya Hepatitis

(41)

Persiapan sebelum ARV

Konseling pra-ARV:

 Kesiapan meminum obat seumur hidup

 Efektivitas terapi ARV tergantung adherens

 Pengetahuan mengenai efek samping yang dapat timbul, bagaimana menghadapi

 Jadwal pemantauan efek samping dan efektivitas obat

 Mekanisme pengambilan obat dan ketersediaan di masing-masing tempat

(42)

Panduan

(43)

+

Lini PERTAMA

Zidovudine Stavudine* Tenofovir Lamivudine/ Emtricitabine Nevirapine Efavirenz

* Digunakan selama 6 bulan pertama hingga keadaan umum membaik Dengan pemantauan efek samping

(44)

Perlu ditekankan

 Tanpa pengobatan ARV, semua odha meninggal

 ARV menekan angka kematian dan morbiditas

 Banyak odha yang tetap bekerja normal, produktif

 Ada odha Yang tetap baik dan produktif > 17 tahun

 ARV menekan angka penularan 96%

 Jangan menghentikan minum ARV

 Takut efek samping ARV, hubungi dokter / konselor

 VL kurang dari 400 kopi = undetectable

 Arti viral load undetectable:

 < 400 kopi virus/cc darah

(45)

ARV profilaksis pada ibu hamil



3 kombinasi ARV profilaksis yang dimulai dini



Sejak kehamilan 14 minggu, dilanjutkan sampai

persalinan, atau, jika menyusui, diteruskan sampai

1 minggu setelah semua bayi yang mengkonsumsi

ASI selesai.

Rekomendasi regimen

AZT + 3TC + LPV/r atau AZT + 3TC + EFV* atau

TDF + 3TC (or FTC) + EFV* atau AZT + 3TC + ABC

Pada pemakaian kombinasi dengan EFV, setelah penghentian EFV, kedua obat lainnya AZT+3TC atau TDF+3TC/FTC diteruskan selama 14 hari (tail off)

*

(46)

Kriteria switch (ganti lini-2)

Kriteria Definisi

Virologis VL >5000 kopi/mL Optimal VL belum diketahui Imunologis -CD4 kembali ke awal

-< 50% nilai tertinggi -Persisten <100

sel/mL

Tanpa infeksi yang dapat menyebabkan penurunan CD4

Klinis Infeksi oportunistik stadium 4 baru atau kambuh

Bukan sindrom pulih imun (IRIS/IRD)

Beberapa kondisi stadium 3 (TB, infeksi bakterial berat) dapat merupakan indikasi kegagalan terapi

(47)

Ganti ke lini-2

 Jika tersedia:

 Gunakan viral load (VL) untuk konfirmasi kegagalan terapi

 Pemeriksaan VL tiap 6 bulan untuk mendeteksi replikasi virus

 VL persisten >5000 kopi/mL mengkonfirmasi kegagalan terapi

 Jika tidak tersedia VL, gunakan kriteria imunologis

(48)

Regimen lini 2 (Indonesia saat ini)

tenofovir

+

_{Emtricitabine}

+

_/ritonavirLopinavir

1 x 1 tablet

(49)

Pencegahan transmisi pada pasangan (HTPN042) di 9 negara selama 5 tahun

1763 pasangan HIV diskordan Early ART 1 orang tertular HIV Delayed ART (CD4 <350) 27 orang tertular HIV

Cohen MS, et al. N Eng J Med, July 2011

Risiko penularan berkurang 96%

(50)

ARV sebagai pencegahan paparan

 Pencegahan sebelum paparan: PreExposure Prophylaxis (PrEP)  Pencegahan setelah paparan: PostExposure Prophylaxis (PEP):  Occupational PEP  Non-occupational PEP

(51)

Hari AIDS Sedunia 1 Desember 2011



_{(1) Zero new HIV infections,}



_{(2) Zero discrimination}



_{(3) Zero AIDS-related deaths.}

Terima kasih

(52)

Prevention benefit of

treating HIV infection

 HIV testing is the foundation for prevention and care

 Early identification of infection empowers individuals to act that benefits their own and the public health

 Early treatment substantially reduces transmitting HIV

 The prevention benefit can only be realized with effective treatment, which requires

 linkage to care

 retention in care

(53)

Persons at risk for HIV

 Knowing their HIV status through routine testing

 Getting into care soon after diagnosis n starting ART

 Remaining in care and staying on HIV treatment

 Modifying behaviors that reduce of getting or spreading HIV, such as:

@ using condoms properly and consistently, @ reducing numbers of partners

@ avoiding sharing needles and syringes

(54)

 _{Only 50% of persons in the US with HIV remain in care,}15,16

and about 18% do not know they are infected; these persons may contribute to the onward transmission of HIV

In addition to expanding testing and treating HIV infection earlier, overcoming the challenges of undiagnosed infection and poor

engagement in care will result in better care of HIV-infected populations and reduced numbers of new HIV infections.17, 18

(55)

US data: retention in care among PLHIV

 Marks G, Gardner LI, Craw J, Crepaz N. Entry and retention in medical care among HIV-diagnosed persons: a

meta-analysis. AIDS 2010;24:2665-2678. CDC. Vital signs: HIV

prevention through care and treatment—United States. MMWR

2011;60:1618-1623.

 CDC. Vital signs: HIV prevention through care and treatment—United States. MMWR 2011;60:1618-1623.

(56)

(57)

WHAT’S NEXT



Test 30 juta tahun 2013? (baca 2016)



Mulai dari mana ? Dimana ?



PSK, MSM, Daerah Prevalensi Tinggi



_{Semua ibu hamil}



Masyarakat Umum



Populasi kunci saja, terbukti tak cukup

(58)

HPTN 074

(59)

 Penelitian HPTN 052, 0leh pemerintah Amerika.

Dimulai 2005. 1.763 pasangan, 97% hetero seksual

 Amerika, Botswana, Brazil, India, Kenya, Malawi n di Afrika Selatan, Thailand, dan Zimbabwe.

 2 Kelompok, (I) segera ARV setelah diketahui

terinfeksi HIV, kelompok (II) ARV ketika CD4 sudah turun < 250 sel/mm3

Terima kasih

(60)

Terima kasih

Integrated treatment and prevention for

people who inject drugs.

A vanguard study for a network-based

randomized HIV prevention trial comparing

an integrated intervention including

supported antiretroviral therapy to the

standard of care.

(61)

US government



_{Division of AIDS, US National Institute of Allergy}

and Infectious Diseases



_{US National Institute of Drug Abuse}



_{US National Institutes of Health}

(62)

The HPTN 074 Site Selection Committee (SSC) selected

only 3 sites based on subjective criteria focused on site

experience, capacity and population suitability:

1. Kiev, Ukraine

2. Thai Ngyuen, Vietnam

3. Jakarta, Indonesia

(63)

PURPOSE

 _{The purpose of this study is to determine the feasibility of}

a future trial that will assess whether an integrated intervention combining psychosocial counseling and

supported referrals for antiretroviral therapy (ART) at any CD4 cell count and substance use treatment for

HIV-infected people who inject drugs (PWID) will reduce HIV transmission to HIV-uninfected injection partners, as

compared to routine care dictated by national guidelines for HIV-infected PWID.

(64)

(65)

KESIMPULAN



Makin Dini Mengobati Makin Baik



Tes HIV Sebanyak Mungkin (30 JT?)



TEST and TREAT



Perlu Kerja Keras ... Kerja, kerja, kerja

(66)

(67)

T



B

(68)

(69)

(70)

CDC

(71)