Diare pada Orang dengan HIV/AIDS

UPDATE HIV/AIDS
ZUBAIRI DJOERBAN
CONSOLIDATED GUIDELINES ON
HIV TESTING SERVICES
JULY 2015
HIV TESTING
SERVICES
5Cs: CONSENT, CONFIDENTIALITY,
COUNSELLING,
CORRECT RESULTS AND CONNECTION
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
QUALITY CONTROL
W.H.O. CONSOLIDATED GUIDELINES
ON THE USE OF ANTIRETROVIRAL
DRUGS FOR TREATING AND
PREVENTING HIV INFECTION
2015
POLICY BRIEF
WHAT’S NEW
 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.
BPJS JKN
 Tes Elisa
 CD4
 VL-HIV
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
 Test n Treat
VCT
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
 Undetectable Viral Load: 74.4% after 2 ys
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
(Yunihastuti, Pokdisus 2010)
Sejak 2009, Semua Bayi yang
dilahirkanTerima
odha, kasih
tidak ada yang
tertular HIV

District of Columbia, Amerika
TERAPI ANTIRETROVIRAL
Jenis dan golongan antiretroviral
yang ada di Indonesia
NRTI / NtRTI
NRTI
AZT (Zidovudine)
3TC (Lamivudine)
FTC (Emtricitabine)
d4T (Stavudine)
ddI (Didanosine)
ABC (Abacavir)
NtRTI
TDF (Tenofovir)
NNRTI
NVP (Nevirapine)
EFV (Efavirenz)
PI
LPV/r
(Lopinavir/Ritonavir
booster)
Getting
to Zero
Terima kasih
Hari AIDS Sedunia 1 Desember 2011
 (1) Zero new HIV infections,
 (2) Zero discrimination
 (3) Zero AIDS-related deaths.
Surat Edaran Menkes 129 th 2013
 Tes Kepada Semua
 Ibu Hamil
 IMS
 TB
 Pasangan Odha
 Binaan
 Hepatitis
Surat Edaran Menkes RI No 129
Tahun 2013 tentang Pelaksanaan
Pengendalian HIV-AIDS dan Infeksi
Menular Seksual (IMS)
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
TEST and TREAT
 Botswana
 South Africa
 China
 US
 Indonesia
BOTSWANA
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
penyebab kematian rakyatnya adalah AIDS.
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
Domestic Product 10.900 dolar per kapita per tahun
SOUTH AFRICA
Target 15 juta
penduduk Afrika telah
tercapai
 88% yang tes HIV
telah mendapat
penjelasan hasilnya
 ditemukan
2.200.000 orang yang
positif HIV (18%)
.
CHINA
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
 http://sciencespeaksblog.org/2012/04/25/treatment-as-prevention-action-in-
china/#ixzz2HOHUuWIQ
US
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.”
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
Terima kasih
Pencegahan
1. Upaya Biomedik
Efektifitas Upaya
pencegahan penularan HIV

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
3. Perubahan Perilaku, Positive Prevention
Bukti Hasil
Penelitian
2010
Terima
kasih
 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.
Segera mengobati odha dg ART/ARV
mengurangi angka penularan 92-96%
Bukti Hasil Terima
Penelitian
kasihTerbaru 2011
 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
 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%
 Treatment is Prevention
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
also weakening our economies”
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.
Prinsip penatalaksanaan HIV
Suportif
Infeksi
oportunistik
HIV Clinical Mentoring, PIT PDUI March 2011
Anti retro
viral (ARV)
Jenis dan golongan antiretroviral
yang ada di Indonesia
NRTI / NtRTI
NRTI
AZT (Zidovudine)
3TC (Lamivudine)
FTC (Emtricitabine)
d4T (Stavudine)
ddI (Didanosine)
ABC (Abacavir)
NtRTI
TDF (Tenofovir)
NNRTI
NVP (Nevirapine)
EFV (Efavirenz)
PI
LPV/r
(Lopinavir/Ritonavir
booster)
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)
• HIV/hepatitis B virus (HBV) coinfection (AII)
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
Infeksi menular seksual lain
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
 Komunikasi dengan petugas kesehatan
Panduan
kombinasi ARV
Lini PERTAMA
Zidovudine
Nevirapine
Stavudine*
+
Lamivudine/
Emtricitabine
+
Efavirenz
Tenofovir
* Digunakan selama 6 bulan pertama hingga keadaan umum membaik
Dengan pemantauan efek samping
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
 < 50 kopi virus/cc darah
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)
Pedoman nasional pencegahan penularan HIV dari ibu ke bayi, 2011
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
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
Regimen lini 2 (Indonesia saat ini)
tenofovir
+ Emtricitabine +
Lopinavir
/ritonavir
1 x 1 tablet
2 x 2 tab
Pencegahan transmisi pada pasangan
(HTPN042) di 9 negara selama 5 tahun
1763
pasangan HIV
diskordan
Early ART
Delayed ART
(CD4 <350)
1 orang
tertular HIV
27 orang
tertular HIV
Risiko penularan berkurang
Cohen MS, et al. N Eng J Med, July 2011
ARV sebagai pencegahan paparan
 Pencegahan
 Pencegahan setelah
sebelum paparan:
paparan: PostExposure
PreExposure
Prophylaxis (PEP):
Prophylaxis (PrEP)
 Occupational PEP
 Non-occupational PEP
Getting
to Zero
Terima kasih
Hari AIDS Sedunia 1 Desember 2011
 (1) Zero new HIV infections,
 (2) Zero discrimination
 (3) Zero AIDS-related deaths.
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
 adherence to ART
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
US CDC
 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
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 metaanalysis. 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.
INDONESIA
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
 Test and Treat
HPTN 074
(HIV Prevention Trials Network)
Bukti Hasil Terima
Penelitian
kasihTerbaru 2011
 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
Integrated treatment and prevention for
people who inject drugs.
A vanguard study for a network-based
Terima
kasih
randomized HIV prevention trial comparing
an integrated intervention including
supported antiretroviral therapy to the
standard of care.
SPONSORED BY
US government
 Division of AIDS, US National Institute of Allergy
and Infectious Diseases
 US National Institute of Drug Abuse
 US National Institutes of Health
Budget $ 2,140,143
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
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 HIVinfected 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.
KENDALA ?
KESIMPULAN
 Makin Dini Mengobati Makin Baik
 Tes HIV Sebanyak Mungkin (30 JT?)
 TEST and TREAT
 Perlu Kerja Keras ... Kerja, kerja, kerja
dan saling mendukung
Terima kasih
T
B
#g
# HIV
CDC
 The
#g