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
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