HIV/AIDS UPDATE

ZUBAIRI DJOERBAN



Estimasi
Terlapor
Rawat Inap
Rawat Jalan
Yang mendapat ART
Prevalensi
Terima kasih
Besaran Masalah
o Estimasi di akhir tahun 2009 ada 333.200 odha
o Sekarang yang terdiagnosis < 100.000 odha (,30%)
o Berarti 200.000 + odha belum terdiagnosis
o Belum terdiagnosis berarti tidak mendapat ART
o Tidak mendapat pengobatan ART (anti retro viral therapy)
akan meninggal karena AIDS
o Jadi, kewajiban kita mendiagnosis dan mengobati

INDONESIA
Pusat Layanan HIV
RSUPN Cipto Mangunkusumo
Jumlah kumulatif Pasien yg
berobat di poliklinik Pokdi
UPT HIV RSCM, Juni 2011

5.414

1 Doktor selesai, 4 Doktor hampir selesai
69 Dokter spesialis (IPD, Anak, Obsgin,
Saraf, dll)
3 Post Doctoral
75
Publikasi Penelitian
150+ Sectio Caesaria
PMTCT

Layanan HIV di Lembaga
Permasyarakatan (Salemba,
Cipinang, Pondok Bambu,
Tangerang )

PROFIL UNIT PELAYANAN TERPADU HIV RSCM


Layanan
VCT


Layanan
Obat

30
49
62
64
89
88
97
92
75
105
87
89
92
99
79
91
98
87
69
78
92
108
95
82
106
0
20
40
60
80
100
120
KUNJUNGAN PASIEN TB HIV DI POLIKLIK POKDI UPT HIV PERIODE
MARET 2009 S/D MARET 2011
laki; 1218
laki; 1178
laki; 1494
laki; 1065
laki; 1350
laki; 1378
wnt,
418
Wnt,
403
wnt; 505
wnt; 461
wnt; 454
wanita, 494
0
200
400
600
800
1000
1200
1400
1600
Januari Februari Maret April Mei Juni
Pasien mendapat ARV menurut jenis kelamin
Semester I, 2010


Juni juli Agustus Sept Okt Nop Des
1.228
1.115
1.208
1.150
1.131
1.209 LAKI 1,206
459
467
514
476
488 484
PEREMP 495
Odha minum ART menurut menurut jenis
kelamin Bulan Juni sd Des 2011
L P
Juni juli Agustus Sept Okt Nop Des
1.450
1.384
1.498
1.403
1.410
1.477 DEWASA 1,485
237
198
224 223
209
216 ANAK-216
ART menurut Usia
Bulan Juni sd Des 2011
DW AN
-
5.000
10.000
15.000
20.000
25.000
30.000
thn 2008 thn 2009 thn 2010 thn 2011
12.673
20.804
24.719
27.473
Kunjungan pasien di Poli UPT HIV /POKDI
JUMLAH PASIEN BERDASARKAN PEMBAYARAN TH 2011
Tunai,
80.26%
askes,
0,26%
Jamkesmas
2.36%
SKTM,
11.66%
Gakin,
5.46%
Sumber: Laporan Rutin Depkes RI, 2007
HIV cummulative number in Indonesia
2000 2004 1987 2007
HIV INFECTION IN INDONESIA
INCREASE RAPIDLY
Jarum sunti narkotika
Seksual
Ibu ke bayi
Transfusi darah
Sarana Kesehatan ?
Terima kasih
Penularan
SEL
Limfosit CD4
Sel Dendrit
Makrofag
Limfosit CD8
Natural Killer Cells

Virus HIV ada dimana?
JARINGAN
Kelenjar getah bening
SSP: makrofag, glia,
cairan liquor
Saluran Genito urinaria:
limfosit T dan makrofag di
semen dan epitel ginjal
Justin Stebbing et al : NEJM 350;18, 29
April 2004

BASOFIL
EOSINOFIL
BATANG
SEGMEN
LIMFOSIT: T (CD4, CD8 dll), LIMFOSIT B
MONOSIT
Terima kasih
LEUKOSIT


Perjalanan Penyakit

Infeksi HIV seringkali tanpa gejala 2-7 tahun
Secara bertahap kondisi makin lemah
Kekebalan turun sesuai dg berkurangnya CD4
Mudah terserang berbagai penyakit: jamur candida,
toxoplasma, crypto, cytomegalovirus, kanker Kaposi,
tbc dll
Satu kali infeksi, infeksi seumur hidup
Tanpa ART, semua meninggal


Tanpa Gejala 2-7 tahun
Tahap lanjut:
Panas lama
Batuk Sesak
Diare
Berat badan turun
Sariawan
Kejang
Kesadaran menurun dll
Terima kasih
Gejala
Primary HIV Infection
Asymptomatic
Acute retroviral syndrome
Clinical Stage 1
Asymptomatic
Persistent generalized lymphadenopathy
Clinical Stage 2
Moderate unexplained weight loss (<10% of presumed or
measured body weight)
Recurrent respiratory infections (sinusitis, tonsillitis,
otitis media, and pharyngitis)
Herpes zoster, Angular cheilitis, Recurrent oral
ulceration, Papular pruritic eruptions, Seborrheic
dermatitis, Fungal nail infections
Terima kasih
STAGING
Clinical Stage 3
Unexplained severe weight loss (>10% of presumed or measured
body weight)
Unexplained chronic diarrhea for >1 month
Unexplained persistent fever for >1 month (>37.6C,
intermittent or constant)
Persistent oral candidiasis (thrush), Oral hairy
leukoplakia, Pulmonary tuberculosis (current)
Severe presumed bacterial infections (e.g., pneumonia,
empyema, pyomyositis, bone or joint infection,
meningitis, bacteremia), Acute necrotizing ulcerative
stomatitis, gingivitis, or periodontitis
Unexplained anemia (hemoglobin <8 g/dL),
Neutropenia (neutrophils <500 cells/L), Chronic
thrombocytopenia (platelets <50,000 cells/L)

Clinical Stage 4
HIV wasting syndrome, as defined by the CDC (see Table 1,
above), Pneumocystis pneumonia, Recurrent severe
bacterial pneumonia, Chronic herpes simplex infection
(orolabial, genital, or anorectal site for >1 month or
visceral herpes at any site), Esophageal candidiasis (or
candidiasis of trachea, bronchi, or lungs)
Extrapulmonary tuberculosis, Kaposi sarcoma,
Cytomegalovirus infection (retinitis or infection of other
organs), Central nervous system toxoplasmosis, HIV
encephalopathy, Cryptococcosis, extrapulmonary
(including meningitis), Disseminated nontuberculosis
mycobacteria infection, Progressive multifocal
leukoencephalopathy, Candida of the trachea, bronchi,
or lungs, Chronic cryptosporidiosis (with diarrhea)
Clinical Stage 4 (LANJUTAN)
Chronic isosporiasis
Disseminated mycosis (e.g., histoplasmosis,
coccidioidomycosis, penicilliosis)
Recurrent nontyphoidal Salmonella bacteremia
Lymphoma (cerebral or B-cell non-Hodgkin)
Invasive cervical carcinoma
Atypical disseminated leishmaniasis
Symptomatic HIV-associated nephropathy
Symptomatic HIV-associated cardiomyopathy
Reactivation of American trypanosomiasis
(meningoencephalitis or myocarditis)


Terima kasih
Infeksi Oportunistik

Data di RSCM Jakarta
Opportunistic Infection

Percentage (%)

Candidiasis oral 50
Pulmonary TB 37
Pneumonia 16.5
Extra pulmonary TB 13.8
Toxoplasma encephalitis 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
Pattern of opportunistic
infections of newly
diagnosed HIV-infected
patients in Cipto
Mangunkusumo hospital
2008-2009
Karjadi TH, Yunihastuti E

, Pramundita R,
Aziza S, Lie S, Imran D, et al. Presented
at 2010 PDPAI Clinical Research Meeting
Hepatitis coinfection in HIV patients
67,9
11,7
5,9
0
10
20
30
40
50
60
70
80
anti-HCV + HBsAg + anti-HCV and
HBsAg +
Percentage of coinfection
Pokdicare Database, 2004-2009
N=4551 HIV patients
Missing value= 938
Age = median 28 (16-77)
Anti Retroviral therapy
Infeksi Oportunistik
Transfusi, Infus, Antibiotika, anti jamur
Pengobatan Kecanduan
Dukungan psikologik
Dukungan sosial
Terima kasih
Pengobatan

Terima kasih
Pencegahan
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
3. Perubahan Perilaku, Positive Prevention


Segera mengobati odha dg ART/ARV
mengurangi angka penularan 92-96%

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
Bukti Hasil Penelitian 2010

The New York Times - February 23, 2007 :
Circumcision's Anti-AIDS Effect Found Greater
Than First Thought. Donald G. Mcneil Jr.



That decision, announced on Dec. 13, 2008, made
headlines around the world and led the two largest
funds for fighting AIDS to say they would consider
paying for circumcisions in high-risk countries. But
the final data from the trials, to be published today
in the British medical journal The Lancet, suggest
that circumcision reduces a man's risk by as
much as 65 %

+ +
ART Lini Pertama
Zidovudine
Stavudine*
Tenofovir
Lamivudine/
Emtricitabine
Nevirapine
Efavirenz
* Digunakan selama 6 bulan pertama hingga keadaan umum membaik
Dengan pemantauan efek samping
Penelitian HPTN 052, 0leh pemerintah Amerika. Dimulai
2005. 1.763 pasangan, 97% hetero seksual
PenelitianAmerika, Botswana, Brazil, India, Kenya,
Malawi n di n Amerika, Botswana, Brazil, India, Kenya,
Malawi, Africa 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
Bukti Hasil Penelitian Terbaru 2011

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
Hari AIDS Sedunia 1 Desember 2011
(1) Zero new HIV infections,
(2) Zero discrimination
(3) Zero AIDS-related deaths.

Terima kasih
Getting to Zero
Target 15 juta tes HIV
penduduk Afrika telah
tercapai
88% yang tes HIV telah
mendapat penjelasan
hasilnya, dan
ditemukan 2.200.000
orang yang positif HIV
(18%).
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.

Makin banyak odha di indonesia
Kemajuan pesat pengobatan, obat gratis
AIDS sudah ada obatnya
Minum ARV, mencegah kematian
Minum ARV, jarang sakit
Mengobati lebih dini lebih baik
Mengobati lebih dini mencegah penularan HIV
96%


Terima kasih