EPIDEMIOLOGI HIV/AIDS

W A F I N U R M U S L I H AT U N 1
WHY DO YOU WANT TO LEARN ABOUT
HIV/AIDS?

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 TOPICS OF DISCUSSIONS

Definition Epidemiology

HIV/AIDS

Mode of
Management
transmission

Stages

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 WHAT IS HIV?

• HUMAN (Manusia)
• IMMUNODEFICIENCY (Penurunan Daya
Tahan Tubuh)
• VIRUS

HIV adalah virus yang hidup, berkembang

dalam tubuh manusia dan melemahkan
sistem kekebalan tubuh
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 AIDS?
• ACQUIRED IMMUNE DEFICIENCY SYNDROM
• Kumpulan gejala penyakit yang di dapat akibat
menurunnya sistem kekebalan tubuh akibat infeksi HIV
• Kekebalan tubuh dapat turun oleh sebab lain, misal
obat-obatan steroid pasca transplantasi

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 KASUS PERTAMA AIDS

• Kasus I AIDS dilaporkan di Los Angeles oleh Dr. Gottlib

Æ MMWR, Juni 1981:
• Lima remaja homoseksual
• Semuanya aktif seksual
• Gejala yang sama: penurunan imunitas dan infeksi Pneumocystis
carinii pneumonia (PCP)
• Kasus I di Indonesia 1987 dilaporkan di Bali oleh Dr.Tuti
Parwati
• Turis asing
• Homoseksual
• Didiagnosis dua tahun sebelumnya

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 GLOBAL HIV/AIDS SITUATION

• There are about 42 million people living with HIV today

• In 2003:
• troughly 4.8 million people became infected with HIV
• around 2.9 million people died from HIV
• Tren kasus menurun, Indonesia justru meningkat >25%
pada usia 15-29 tahun

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GLOBAL SITUATION AT END 2003

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 GLOBAL HIV/AIDS SITUATION

• The majority of new infections occur in young people 15-24 years of

age
• Since 1981 over 20 million people have died from HIV
• No country in the world remains unaffected by HIV
• The HIV epidemic can vary between countries and even within a
country
• Different areas may have
• Different modes of transmission
• Different levels of infection
• Most new infections occur in resource limited countries where
access to treatments is poor

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 HIV/AIDS CASES IN INDONESIA (AS OF
MARCH 2006)
7000

6000 5823
5321

5000

4000

3000 2682 2638

2000
1487 1195
1171
607 826
1000 198 258 352 502
345 316
60 255 219
44 94
0
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

AIDS Kumulatif

5000
4500 4333
4000 4244

3500
3368
3000
2500 2552 2720
1904
2000
1500 1172
769 732 875
1000 648 649
465 591 403
500 178 168 89
83 126
0
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

HIV Kumulatif 11
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 SITUASI HIV DI INDONESIA,
JANUARI-MARET 2016
• Persentase infeksi HIV tertinggi pada kelompok umur
25-49 tahun (69.7%), diikuti kelompok umur 20-24 tahun
(16.6%), dan kelompok umur >= 50 tahun (7.2%).
• Rasio HIV antara laki-laki dan perempuan= 2:1.
• Persentase faktor risiko HIV tertinggi adalah hubungan
seks berisiko pada heteroseksual (47%), LSL (25%),
lain-lain (25%) dan penggunaan jarum suntik tidak steril
pada penasun (3%).

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HOW IS HIV TRANSMITTED?

Body fluid that can spread HIV

Blood
Seminal fluid
Vagina fluid
Breast milk

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 TRANSMISSION - BLOOD

1. Transfusion of blood and other blood products

2. Non-sterile syringe and other Medical equipmens,
particularly in IDUs

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TRANSMISSION - BLOOD

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 Risk behaviour in IDUs

(BSS data)

Bandung 90%

Surabaya 90%

Jakarta 88%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Shares needles Only shares water No injecting risk

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 Alasan berbagi jarum
Percent explaining why they are not currently

100

90
90%
80
carrying a needle

70

60
60%
50

40
45%
30

20

10

0
Jakarta Surabaya Bandun
g
Jarum teman Takut ditangkap Guna jarum dari tempat khusus

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 SEXUAL TRANSMISSION

• Sexual activities which are risky for transmission (from

highest to lowest risks):
1. Anal intercourse
2. Vaginal intercourse
3. Oral
4. Intercourse with condom

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 PERINATAL TRANSMISSION
(MOTHER TO CHILD TRANSMISSION)
• During delivery
• Through breast-feeding

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 PERINATAL TRANSMISSION
(MOTHER TO CHILD TRANSMISSION)

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 FAKTOR RESIKO DAN PENULARAN
INDIVIDU YANG BERESIKO TERKENA INFEKSI
HIV
Risiko tinggi
• Homoseksual dan biseksual
• Pengguna narkoba suntik (IDU) yang berbagi jarum
• Pasangan seks orang dengan resiko tinggi
• Bayi yg lahir dari ibu HIV, terutama yang tanpa terapi
• Penerima transfusi darah terutama di negara yang tidak ada alat skrining

Risiko Rendah
• Pekerja kesehatan termasuk bidan, perawat, dokter, dokter gigi dan pekerja
laboratorium

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 FACTORS CONTRIBUTING TO
GROWTH OF HIV EPIDEMICS
• Poor and delayed public health response in
early stages particularly in groups with high risk
behaviours e.g. sharing injecting equipment,
unprotected sex with multiple partners
• Limited access to health and welfare services
• Ineffective intervention programs for sex workers

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 FACTORS CONTRIBUTING TO
GROWTH OF HIV EPIDEMICS
• Ineffective intervention programs for intravenous
drug use
• Increased levels of inter-region and country
migration
• Economic restructuring particularly in poor
countries
• War and civil unrest

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TRANSMISSION OF HIV IN INDONESIA

Kutipan Grafik: Pandu (2002) 29

 ROAD TO DIAGNOSIS

Risky behaviours:

1. IDU HIV tests and others

2. Sex workers VCT diagnosis
3. Unsafe sex
4. others

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 LABORATORY DIAGNOSIS

• Serological
• Seroconversion (3-4 weeks post infection)
• RT-PCR
• Screening of HIV
• ELISA (sensitivity >99%; specificity >99%)
• Confirmatory test
• Western blot (detects specific antibodies directed
against the various HIV proteins)

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 OTHER LABORATORY PARAMETER

• Viral load testing

• To determine the start and monitor of therapy
• CD4+ T cell counts
• FACS, dyna beads
• To determine the start and monitor of therapy

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 CHARACTERISTICS OF HIV

• As CD4 cell count decreases:

• the immune defenses are weakened
• the patient becomes vulnerable to opportunistic
infections
• Without treatment, most HIV-infected individuals
progress to symptomatic disease and AIDS

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INFEKSI HIV DAN JUMLAH CD4+

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IMMUNE RESPONSE IN HIV

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EVOLUTION OF HIV-AIDS

: CD4 cells
: HIV

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 VIRAL LOAD AND CD4

CD4+ T-cell count

800-1200
Viral load

200

Days Years
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 WHO STADIUM OF HIV
Stadium klinis I:
• Tanpa gejala (asimtomatis)
• Limfadenopati generalisata yang persisten
• Skala penampilan 1: tanpa gejala, kegiatan normal

Stadium klinis II:

• Kehilangan berat badan, <10% BB
• Gambaran mukokutan minor
• Herpes zoster
• Infeksi saluran napas bagian atas yang berulang
• Dan/atau skala penampilan 2: simtomatis, kegiatan normal

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 WHO STADIUM HIV
• Stadium klinis III:
• Kehilangan berat badan, >10% BB
• Diare kronis yang tidak dapat dijelaskan, >1 bulan
• Demam berkepanjangan yang tidak dapat dijelaskan (hilang
timbul atau menetap), >1 bulan
• Kandidiasis mulut
• Tuberkulosis paru
• Infeksi bakteri yang parah
• Dan/atau skala penampilan 3: terbaring di tempat tidur <50%
hari selama bulan terakhir

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 STADIUM INFEKSI HIV
• Stadium Klinis IV:
• Sindroma wasting HIV
• PCP
• Toksoplasmosis di otak
• CMV pada organ selain hati, lmpa atau kelenjar getah bening
• Infeksi virus hespes simplex (HSV) mukokutan >1 bulan
• Kandidiasis esofagus, trakea, bronki atau paru
• Mikobakteriosis
• Septikemi
• Tuberkulosis di luar paru
• Limfoma
• Sarkoma kaposi
• Ensefalopati HIV
Dan/atau skala penampilan 4: terbaring di tempat tidur >50%
hari selama bulan terakhir

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 WHAT IS ANTIRETROVIRAL THERAPY?

• ART is a combination of at least 3 drugs which stop HIV

replicating
• Highly Active Antiretroviral Therapy (HAART)

• Drugs are called antiretrovirals (ARV) because HIV is a

retrovirus

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Dosis: 2 x sehari Dosis: 1 x sehari

Dosis: 2 x sehari
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 ANTI-RETROVIRAL

• Reverse transcriptase inhibitors

• Nucleoside reverse transcriptase inhibitors (NsRTIs)
• AZT, d4T, 3TC, ddI, abacavir
• Nucleotide reverse transcriptase inhibitors (NtRTIs)
• Tenofovir
• Non-nucleoside reverse transcriptase inhibitors (NNRTIs)
• efavirenz, nevirapine

• Protease inhibitors (PIs)

• indinavir, nelfinavir

• Fusion inhibitors
• T20

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 ANTIRETROVIRAL DRUGS – 2004

Nucleoside RTIs Non nucleoside RTIs Protease inhibitors

zidovudine (ZDV) nevirapine (NVP) saquinavir (SQV)

didanosine (ddI) efavirenz (EFV) ritonavir (RTV)
zalcitabine (ddC) delavirdine (DLV) indinavir (IDV)
stavudine (d4T) Nucleotide RTIs nelfinavir (NFV)
lamivudine (3TC) Tenofovir (TDF) amprenavir (APV)
abacavir (ABC) Fusion inhibitors lopinavir/r (LPV/r)
emtricitabine (FTC) Enfuvirtide (T20) atazanavir (ATZ)

Triple therapy (HAART) for all fosamprenavir

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WHO ESSENTIAL MEDICINES LIST ARVS

• Abacavir • Indinavir
• Didanosine • Ritonavir
• Lamivudine • Lopinavir + Ritonavir (Kaletra)
• Stavudine • Nelfinavir
• Zidovudine • Saquinavir SGC
• Efavirenz
• Nevirapine

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 GOALS OF THERAPY

• Control of HIV replication

• Viral load undetectable
• Restore immunologic function
• stabilise or increase in CD4 cell count
• Stop disease progression (new infections)
• Improve of quality of life
• Increase survival

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 GOALS OF THERAPY
Plasma HIV-RNA CD4 count
(copies/ml) (cells/mm3)
Viral load CD4
1.000.000 370 400
350
100.000 Goal is 300
10.000 undetectable 250
viral load 200
1.000 150
100
100
VL <50 7 50
10 0
M1 M2 M3 M6 M12 M18 M24
Months on triple therapy
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 WHY ALWAYS USE THREE DRUGS
1987–1991: Single
nucleoside
1991–1995: Dual
nucleoside
Log change in HIV RNA
from baseline

1996–today
HAART

HAART + good adherenc

Time
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 WHEN TO START?
1000

800

600
CD4 + Early Opportunistic Infections
Cells Late Opportunistic Infections
400
350
200
Trigger
0 points to
1 2 3 4 5 6 7 8 9 10 11 12 13 14 start
ART?

Infection Time in Years

Mostly ART recommended at CD4 200 or less 53

KAPAN MULAI ARTDEWASA & REMAJA

Rekomendasi WHO:

WHO Stage IV disease: Tanpa menghiraukan Jumlah Sel CD4 atau

limfosit total

WHO Stage III disease: dgn pertimbangan jumlah sel CD4 <
350/mm3, u/ mendukung pengambilan keputusan

WHO Stage I atau II: dgn jumlah sel CD4  200/mm3 atau limfosit
<1200/mmk

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DAMPAK HAART PADA CD4 DAN VIRAL LOAD

CD4+ T cell
count
800-1200 Viral load

50,000

200

Tak terdeteksi

Hari Tahun Mulai pengobatan

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 WHEN TO START ARV (WHO DEC. 2003)

• Three main ways to

decide
WHO STAGING OF HIV
• CD4 count
DISEASE
• Clinical disease stage
• Total lymphocyte count Stage 1 Asymptomatic

Stage 2 Minor
• Viral load symptoms
• Not needed to start
Stage 3 More severe
• Useful for monitoring
symptoms
• Usually not available
Stage 4 AIDS

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