HIV (e) EDUCATION MARCH ,30 2011
Femmy Tambajong CST - RATUMBUYSANG HOSPITAL MANADO-NORTH SULAWESI
INTRODUCTION TRANSMISSION DIAGNOSE
MANAGEMENT CASE
Problems in HIV:
Estimated number of births per year 4.386.000*
Estimated number of HIV+ pregnant women : 3.300**
:
Vertical mother-to-child transmission during pregnancy, labour and breastfeeding
*UNICEF, UNAIDS and WHO, Children and AIDS: Country Fact Sheets 2008. Indonesia: UN Population Division 2007
**UNICEF, UNAIDS and WHO, Children and AIDS: Country Fact Sheet 2008.Indonesia:UNAIDS/WHO, 2008
Vertikal ◦ Kehamilan ◦ Persalinan ◦ Laktasi Horisontal ◦ Sama seperti penularan pada orang dewasa
HIV disease and clinical staging of HIV infection in infants and children
WHO Clinical Staging of HIV for infants and children with established HIV infection (2007) Clinical Stage 1 Asymptomatic Persistent generalized lymphadenopathy
Clinical Stage 2 Unexplained persistent hepatomegaly Papular pruritic eruptions Fungal nail infections Angular cheilitis Lineal gingival erythema Extensive wart virus infection Extensive molluscum contagiosum Recurrent oral ulceration Unexplained persistent parotid enlargement Herpes zoster Recurrent or chronic upper respiratory tract infections
WHO Clinical Staging of HIV for infants and children with established HIV infection (2007) Clinical Stage 3 Unexplained moderate malnutrition or wasting not adequately responding to standard therapy Unexplained persistent diarhoea (14 days or more) Unexplained persistent fever (>37.6oC, intermitent or constant >1mo) Persistent oral candidiasis (after first 6-8 weeks of life) Oral hairy leukoplakia Acute necrotizing ulcerative gingivitis or periodontitis Lymph nodes tuberculosis Pulmonary tuberculosis Severe recurrent bacterial pnuemonia Symptomatic lymphoid interstitial pneumonia Chronic HIV-associated lung disease, including bronchiectasis Unexplained anemia (<8 g/dL, neutropneia (<0,5x109/L), and or chronic thrombocytopenia (<50x109/L)
WHO Clinical Staging of HIV for infants and children with established HIV infection (2007) Clinical Stage 4 Unexplained severe wasting, stunting, or severe malnutrition not responding to standard therapy Pneumocystis jerovicii Recurrent severe bacterial infections (empyema, pyomyositis, bone or joint infection, meningitis, but excluding pneumonia) Chronic herpes simplex infection infection (orolabial or cutaneous >1 month,or visceral at any site) Extrapulmonary tuberculosis Kaposi sarcoma Oesophageal candidiasis (or trachea, bronchi, or lungs) Cytomegalovirus infection, retinitis or affecting any other organ, with onset at age >1 month Central nervous system toxoplamosis (after neonatal period) Extrapulmonary cryptococcus, including meningitis HIV encephalopathy Disseminated endemic mycosis (extrapulmonary histoplasmosis, coccidiomycosis) Chronic cryptosporidiosis (with diarrhoe) Chronic isosporiasis
Virus masuk
PCR, kultur
Respons antibodi
Serologi: rapid, ELISA, EIA
Kerusakan sel
TLC, CD4
Tatalaksana awal Penilaian indikasi ARV Penilaian adherence Memulai pengobatan ARV Pemantauan awal Pemantauan jangka panjang
Umur
Bayi < 12 bln
12 – 35 bln
36 – 59 bln
> 5 thn
%CD4
Obati semua
< 20
< 20
< 15
< 750
< 350
= dewasa
CD4 absolut
WHO 2008
Jenis, dosis, interaksi dengan makanan Kalau menggunakan NVP memerlukan “leading dose” selama 2 minggu (alergi, fungsi hati) Pemantauan dan kontrol: ◦ 2 minggu sebanyak 2 kali ◦ Setiap bulan hingga bulan ke 6 ◦ Bergantung kondisi (setiap bulan/setiap 2 bulan)
Ringkasanofrekomendasi WHO WHO summary recommended preffered untuk ARV lini pertama pada bayi dan first-line ARV regiments for infants and anak children
_________________________________________________
Rejimen 1 NNRTI + 2 NRTI
Strength Regimen of Recommendation, Level of Evidence A (II)(A of 2 NRTI plus 1 NNRTI
AZT + 3TC + NVP/EFV AZT + 3TC + NVP/EFV d4T + 3TC + NVP/EFV d4T + 3TC + NVP/EFV ABC + 3TC + NVP/EFV ABC + 3TC + NVP/EFV
II)
_________________________________________________ Sumber: WHO 2007. AZT=Zidovudin
3TC=Lamivudin
ABC=Abakavir
NVP=Nevirapin
EFV=Efavirenz
ART
WHO recommended alternative ARV regiments or infants and children to simplify managemen of toxicity, comorbidity, and drug interaction _________________________________________________
Rejimen 1 NNRTI + 2 NRTI
Strength of Recommendation, Level of Evidence A (II)
Regimen of triple NRTI (C III) AZT + 3TC + NVP/EFV AZT/d4T + 3TC + ABC d4T + 3TC + NVP/EFV ABC + 3TC + NVP/EFV
_________________________________________________
Sumber: WHO 2007. AZT=Zidovudin
3TC=Lamivudin
ABC=Abakavir
NVP=Nevirapin
EFV=Efavirenz
Sediaan ARV untuk anak di Indonesia NRTI
NNRTI
Didanosine ddI, Efavirenz dideoxyinosin e
VIDEX Lamivudine 3TC
EPIVIR EPIVIR HBV Stavudine
d4T
Zerit Zidovudine ZDV, AZT
RETROVIR
EFV
SUSTIVA Nevirapin e
NVP
VIRAMUN
PI
Lopinavir/ LPV/RTV Ritonavir ABT 378
KALETRA Lopinavir/ LPV/RTV Ritonavir 200/50
ALUVIA
Sediaan ARV untuk anak di Indonesia FDC Fixed drug combination TRIOMUNE (Cipla, India) Lamivudine, stavudine, nevirapine dispersible tablets TRIOMUNE baby
TRIOMUNE junior
30 mg
60 mg
Stavudine
6 mg
12 mg
Nevirapine
50 mg
100 mg
Lamivudine
Cotrimoxazole (TMP-SMZ) was given to all infants born to HIV-infected mothers until HIV is ruled out Dose: 5 mg/kg body weight TMP, once daily
Analisa kasus
Seorang anak perempuan, 5 tahun dirawat karena pneumonia yang berat. Dokter meminta tes HIV. Tes pada anak positif, pada kedua orangtua negatif Pertanyaan: ◦ Apa kemungkinan yang terjadi? ◦ Bila hasil tes benar dan dapat dipercaya, bagaimana menjelaskan situasi pada anak?
Kasus 2/1 NJ, tgl.lahir 18-09-2002 (datang ke RSCM usia 6 bulan) Dikirim SpA (RS H) dengan diare berulang Lahir SC, BBL 2400 g, PBL 46 cm, diberi ASI Riwayat penyakit • diare berulang sejak usia 1 minggu, dirawat di RS berbeda 3x dengan GED • Bengkak di leher kanan dan ketiak kanan sejak usia 2 bulan, berobat ke SpA di RS H
TELAAH KLINIS ?
Kasus 2/2
TELAAH KLINIS
1. Anamnesis Morbiditas Faktor risiko 2. Pemeriksaan fisis 3. Pemeriksaan penunjang
Kasus 2/3
Pemeriksaan penunjang, 1. Uji tuberkulin (-) 2. Serologi antiHIV ibu (+) 3. Serologi ayah (-)
Kasus 2/4
TELAAH KLINIS LANJUT 1. Ibu pernah punya partner seksual multipel 2. Ibu membawa hasil laboratorium PCR RNA HIV dengan viral load 700.996 kopi/mL, sudah berobat
Kasus 2/5
Konfirmasi diagnosis dan staging Infeksi HIV o Hasil pemeriksaan laboratorium anak • Hb 11,4 leuko 3800 trombo 306.000 Dif. -/-/-/62/35/3 LED 50 • VL 262.162 kopi/mL CD4 33% o Klasifikasi klinis o Defisiensi imun Limfadenitis tuberkulosis
Kasus 2/6
Klasifikasi klinis dan staging Infeksi HIV o Kelas 3 • TB kelenjar • Diare berulang • Moniliasis kronis Defisiensi imun o WHO: ringan (CD4 30-35%) o CDC: tidak ada supresi (>23%)
Kasus 2/7
Rencana ART dan dosing • Jenis ARV • Dosis
OAT RHE
Kasus 2/8
Rencana ART dan dosing ARV Lini pertama: AZT, 3TC, NVP Dosis AZT 160 mg/m2 3x/h, untuk meningkatkan adherensi diberikan 2x/h (180-240 mg/m2 2x/h) walaupun tidak disetujui FDA 3TC 4 mg/kgBB (max. 150 mg) 2x/h NVP dosis inisial 150 mg/m2(max.200 mg) 1x/h 14h, kemudian 2x/h (max. 2x200 mg/h)
