TUGAS EVIDENCE BASED MEDICINE

Skenario

Seorang anak perempuan 6 bulan , datang ke rumah sakit di temanin oleh ibunya , ia mengeluh
diare yang hilang timbul sejak 4 bulan yang lalu , selain itu pasien juga mengeluh sering
sariawan , tenggorokan sakit, sering sekali demam, serta berat badan berkurang 8 kg 3 bulan
terakhir, dari riwayatnya di katakan bahwa orang tua pasien dulu seorang pekerja seks komersial
yang sudah taubat dan ayahnya positif menderita HIV. Pada pemeriksaan fisik pasien terlihat
kaheksia, dan pada pemeriksaan darah rutin LED 45mm/jam. Pada pemeriksaan screening
antibodi HIV di dapatkan hasil (+) kemudian dokter melakukan pemeriksaan limfosit T CD4 dan
CD8, Dokter menyimpulkan bahwa pasien menderita HIV. Ibu anak ini menanyakan , bagaimana
harapan hidup anaknya, lalu dokter menjelaskan prognosis dari penyakit anak ibu tersebut.

Pertanyaan (foreground question)

Bagaimanakah prognosis yang dapat terjadi dilihat dari segi umur ?

PICO
Population : Seorang anak perempuan 6 bulan datang bersama ibunya mengeluh diare sejak 4
bulan yang lalu.
Intervention : Menilai harapan hidup pasien anak yang tidak terkena HIV.
Comparison : Menilai harapan hidup pasien anak yang terkena HIV.
Outcomes : Bagaimana harapan hidup pasien anak yang menderita HIV dengan yang tidak
menderita HIV ?

Pencarian bukti ilmiah

Alamat website : http://www.ncbi.nlm.nih.gov
Kata kunci : HIV AND survival AND child AND adult
Limitasi : Januari 2009 Maret 2014
Hasil Pencarian : 79

Dipilih artikel berjudul

Survival rate of AIDS disease and mortality in HIV-infected patients in Hamadan, Iran: a
registry-based retrospective cohort study (19972011)

HIV AND survival AND child AND adult AND Prognosis 2009-20014 years
HIV AND Child AND adult AND Qualiti of life

Apakah pada pasien dewasa lebih cenderung berisiko terkena HIV dibandingan anak-anak , pada
pasien anak yang menderita HIV prognosis lebih buruk daripada penderita dewasa.
Review Jurnal
Pendahuluan
The human immunodeficiency virus (HIV) and the acquired immunodeficiency syndrome
(AIDS) epidemic are now considered the worlds most serious public health threat. 1 There is no
cure for AIDS at this time. However, HIV-related mortality has decreased since the inception of
combination antiretroviral therapy (ART).2 Several treatments are available that can delay the
progression of disease for many years and improve the quality of life of HIV/AIDS patients.
With the advent of antiretroviral medications, HIV- positive patients can now stay healthy, live
longer and have hope after their diagnosis.3 ART has increased the life expectancy of patients
who are infected with HIV and has reduced the incidence of illnesses associated with the AIDS. 4
It is estimated that ART has prevented 2.5 million deaths in low- and middle-income countries
globally since 1995.5

Treatment can be complex with several prognostic factors including chronic pathologies
associated with immunodeficiency, chronic viral and bacterial infections. 6 There is good
evidence that if the levels of HIV remain suppressed and the CD4 count remains high (above
200), that life and quality of life can be significantly prolonged and improved.3 On the other hand,
co-infection of HIV with other infections such as hepatitis C virus infection 7 and tuberculosis
(TB)8,9 may increase the risk of mortality.

Metoda
children of high-risk parents, especially pregnant or lactating women, are screened for relevant
infections. This innovative model, which was first established in 2000, is being replicated
through the country, including the establishment of TCs within prisons and most provinces.

Two different outcomes were investigated in this study. The first outcome of interest was
estimating the duration of time between diagnosis of HIV infection and progress to AIDS. The
second outcome of interest was estimating the duration of time between diagnosis of AIDS and
occurrence of death from AIDS-related causes. The patients who were lost to follow-up or died
from a condition other than AIDS were considered as censored. The effect of several prognostic
factors on the survival time to AIDS was investigated including gender, age, marital status, mode
of HIV transmission and co-infection with TB, which means a patient with HIV who had a
definitive TB disease. Furthermore, the effect of cART on survival time was also investigated.

The cumulative AIDS rate among HIV-positive subjects and cumulative death rate in patients
with AIDS were investigated and plotted using the KaplanMeier method. The cumulative AIDS
and death rates across subgroups were compared using the log-rank test. In addition, we also
calculated both unadjusted and adjusted hazards ratios of progression to AIDS using the Cox
proportional hazard model. We also checked the two-way interactions between the variables in
the model using a backward stepwise approach. All analyses were performed at 0.05 significance
levels using the statistical software, Stata 11 (StataCorp, College Station, TX, USA).
Hasil
Of the 585 HIV-positive subjects, 521 (89.1%) were men and 29 (5.0%) were primarily
diagnosed with AIDS. Of the 137 patients with AIDS, 98 were diagnosed with CD4 less than 350
per mm3 irrespective of other clinical sign and symptoms, 11 were diagnosed with total
lymphocyte count less than 1200 and 28 were diagnosed from their clinical manifestations. The
mean age at diagnosis was 32.5 years, ranging from birth to 66 years. Additional characteristics
of the subjects including gender, age, marital status, mode of HIV transmission and co-infection
with TB are shown in Table 1. According to the findings, the frequency of HIV/AIDS was higher
among men, age group of 2534 years, single individuals and IDUs. Co-infection with TB was
rare. There were significant differences in the proportion of HIV-positive subjects who
progressed to AIDS in terms of age groups (p 0.037), mode of HIV transmission (p 0.010)
and co-infection with TB (p 0.001). However, the proportion of progression from HIV to
AIDS was not statistically significant between the two genders (p 0.060) and different marital
status (p 0.348).

The survival rates for from HIV infection to AIDS, from diagnosis of AIDS to death and from
HIV infection to death are shown in Table 2. Based on these results, one-year, five-year and 10-
year survival rates from HIV to AIDS were 89%, 69% and 30%, respectively. One-year and five-
year survival rates from AIDS to death were 76% and 46%, respectively. One-year, five-year and
10-year survival rates from HIV infection to death were 87%, 67% and 40%, respectively. In
addition, the survival rates for progression from HIV to AIDS, from diagnosis of AIDS to death
and from HIV to death by gender are shown in Figure 1, Figure 2 and Figure 3, respectively. The
survival rate from HIV to AIDS was longer in men than in women while the survival rates from
AIDS to death and from HIV to death were longer in women than in men.

Of the 137 patients with AIDS, 123 (89.8%) received cART, 34 (27.6%) of whom eventually
died from AIDS and 14 (10.2%) did not receive cART, all of whom (100%) died from AIDS (p<
0.001). These patients did not receive cART because they were either unsatisfied with or
ineligible to receive cART. Hazard ratio of death was 4.77 (95% CI: 2.54, 8.96) in patients who
did not receive cART compared to those who did (p< 0.001).

Kesimpulan
This study focused on the most common and important prognostic factors that affect the duration
of time from HIV infection to AIDS and the duration of time from AIDS to death. We
demonstrated that co-infection with TB was among the most important prognostic factors of
progression to AIDS and ART was found to be an effective measure that can contribute
substantially in suppressing HIV viral replication and improving the survival of patients living
with HIV.