HIVdanInfeksiOportunistik:

PilihanTerapidanPrognosis
YudiantoBudiSaroyo
FakultasKedokteranUniversitasIndonesia/
RSUPNdr.CiptoMangunkusumo

TopikPembicaraan
Epidemiologi
Patofisiologi
InfeksiOportunistik
ProfilaksisdanTerapi
Pencegahan
Kesimpulan

Epidemiologi

Sumber:HIV/AIDSReport,WHOSEARO,2010.In:PedomannasionalpencegahanpenularanHIV
dariibukeanak.Edisikedua.KementerianKesehatanRI,Jakarta,2011

Epidemiologi

JumlahHIVdanAIDSyang
DilaporkanperTahunsdMaret2013

Sumber:LaporanHIVAIDSTriwulan12013.DirektoratJenderalPengendalianPenyakitDanPenyehatanLingkungan(P2ML)
KementerianKesehatan,2014

Epidemiologi

SepuluhProvinsiyangMelaporkanJumlah
KumulatifAIDSTerbanyakTahun1987 2013

Sumber:LaporanHIVAIDSTriwulan12013.DirektoratJenderalPengendalianPenyakitDanPenyehatanLingkungan(P2ML)
KementerianKesehatan,2014

Epidemiologi

Sumber:PemodelanMatematikEpidemiHIV,Kemkes,2012.In:Pedomannasionalpencegahan
penularanHIVdariibukeanak.Edisikedua.KementerianKesehatanRI,Jakarta,2011

Patofisiologi

HIV1virionstructure

AtlasofSexuallyTransmittedDiseasesandAIDS4thEd,14HumanImmunodeficiencyVirusInfectionandtheAcquired
ImmunodeficiencySyndrome,StephenA.Morse,240255,2010

Patofisiologi

TheHIVreplicationcycle

Mandell,Douglas,andBennett'sPrinciplesandPracticeofInfectiousDiseases8thEd,130AntiretroviralTherapyforHumanImmunodeficiencyVirus
Infection,JohnE.Bennett,16221641.e6,2015

Patofisiologi

EffectofHIVonimmunesystem

AtlasofSexuallyTransmittedDiseasesandAIDS4thEd,14HumanImmunodeficiencyVirusInfectionandtheAcquiredImmunodeficiencySyndrome,
StephenA.Morse,240255,2010

Patofisiologi

HIVdiseaseprogressionandtheoccurrenceofselect
complication

Natural history of untreated HIV infection and relationship of specific opportunistic infections to CD4 count.
Hunter'sTropicalMedicineandEmergingInfectiousDisease9thEd,27HumanImmunodeficiencyVirusInfection,AlanJ.Magill, 217247,2013

Patofisiologi

Initialinfectionanddisseminationofhumanimmunodeficiency
virus(HIV)infection

Mandell,Douglas,andBennett'sPrinciplesandPracticeofInfectiousDiseases8thEd,123TheImmunologyofHumanImmunodeficiencyVirusInfection,JohnE.Bennett,1526
1540.e3,2015

Patofisiologi

Directandindirecteffectsofhumanimmunodeficiencyvirus
(HIV)infection

Mandell,Douglas,andBennett'sPrinciplesandPracticeofInfectiousDiseases8thEd,123TheImmunologyofHumanImmunodeficiencyVirusInfection,JohnE.Bennett,1526
1540.e3,2015

Apoptosis
Immuneattack
ofuninfected
cells

Patofisiologi

Directcellkilling
Mechanismsfor
CD4+Tcell
killing

lHIVinhibited
hematopoiesis
Indirect
Thymusdamage

Lymphnode
damage

Tcellanergy

AtlasofSexuallyTransmittedDiseasesandAIDS4thEd,14HumanImmunodeficiencyVirusInfectionandtheAcquiredImmunodeficiencySyndrome,
StephenA.Morse,240255,2010

EstimatedPerActRiskforAcquisitionofHIVby
ExposureRoute*
Riskper100exposurestoan
HIVinfectedsource
Bloodtransfusion
90.
Needlesharinginjectiondruguse
0.67
Percutaneousneedlestick
0.3
Receptiveanalintercourse
0.5
Receptivepenilevaginalintercourse
0.1
Insertiveanalintercourse
0.065
Insertivepenilevaginalintercourse
0.05
Receptiveoralintercourse
0.01
Insertiveoralintercourse
0.005
Mothertochildtransmission(withoutbreastfeeding)
30
Breastfeedingfor18months
15

Blood
SexualContact
Others

Patofisiologi

ExposureRoute

Hunter'sTropicalMedicineandEmergingInfectiousDisease9thEd,27HumanImmunodeficiencyVirusInfection,AlanJ.Magill, 217247,2013

Patofisiologi

Positivepredictiverateofhumanimmunodeficiencyvirus(HIV)
confirmatoryassayisafunctionofdiseaseprevalence

Atverylowdiseaseprevalence(0.01%),thepositivepredictivevalueoftestingdeclinessharplywithanyfalsepositivetest
results.Astheprevalenceofinfectionincreases,thepositivepredictivevalueimprovesdespiteafewfalsepositivetestresults.As
HIVscreeningeliminatesthemajorityofHIVnegativeindividualsforfurtherconfirmation,theprevalenceofthepopulationof
samplesreferredforconfirmatoryassayincreasesdramaticallyandwillbeintherangeof90%.Thepositivepredictivevalue for
thesequentialstrategyremainshighdespiteanyfalsepositive
Mandell,Douglas,andBennett'sPrinciplesandPracticeofInfectiousDiseases8thEd,122DiagnosisofHumanImmunodeficiencyVirusInfection,
JohnE.Bennett,15031525.e7,2015

InfeksiOportunistik

WHOstagesofHumanImmunodeficiencyVirus(HIV)infection*
byCD4+Tlymphocytecountandpercentageoftotal
lymphocytes.
Stage1(HIVInfection)
Stage2(HIVInfection)
Stage3(AdvancedHIVdisease{AHD})
Stage4(AquiredImmunodeficiency
Syndrome{AIDs})

CD4+TLymphocytecountof500cells/L
CD4+TLymphocytecountof350499cells/L
CD4+TLymphocytecountof200349cells/L
CD4+TLymphocytecountof200cells/Lor
CD4+Tlymphocytepercentageof15

*Forreportingpurposesonly.
Amongadultsandchildrenaged5years.
Percentageapplicableforstage4only.
Amongadultsandadolescents(aged13years).CDCalsoincludesafourthstage.Stageunknown:
laboratoryconfirmationofHIVinfectionbutnoinformationonCD4+TLymphocytecountor
percentageandnoinformationonAIDsdefiningconditions.

AtlasofSexuallyTransmittedDiseasesandAIDS4thEd,13HumanImmunodeficiencyVirusInfectionandtheAcquiredImmunodeficiency
SyndromeEpidemiology,StephenA.Morse,230239,2010

InfeksiOportunistik

HIVRNAsetpointandriskofdiseaseprogression

AtlasofSexuallyTransmittedDiseasesandAIDS4thEd,14HumanImmunodeficiencyVirusInfectionandtheAcquiredImmunodeficiencySyndrome,
StephenA.Morse,240255,2010

AIDSDefiningConditions
Bacterialinfections,multipleorrecurrent*
Candidiasisofbronchi,trachea,orlungs

InfeksiOportunistik

Candidiasis,esophageal
Cervicalcancer,invasive
Coccidioidomycosis,disseminatedorextrapulmonary
Cryptococcosis,extrapulmonary

Lymphoidinterstitialpneumoniaand/orpulmonarylymphoid
hyperplasia*
Lymphoma,Burkitts(orequivalentterm)
Lymphoma,immunoblastic(orequivalentterm)
Lymphoma,primary,ofbrain
MycobacteriumaviumintracellularecomplexorMycobacterium
kansasii,disseminatedorextrapulmonary

Cryptosporidiosis,chronicintestinal(>1moduration)

Mycobacteriumtuberculosis,anysite(pulmonaryor
extrapulmonary)
Cytomegalovirusdisease(otherthanliver,spleen,ornodes)

Cytomegalovirusretinitis(withlossofvision)
Encephalopathy,HIVrelated

Mycobacterium,otherspeciesorunidentifiedspecies,
disseminatedorextrapulmonary

Pneumocystisjiroveciipneumonia
Herpessimplex,chroniculcer(s)(>1moduration);bronchitis,
Pneumonia,recurrent
pneumonitis,oresophagitis
Histoplasmosis,disseminatedorextrapulmonary

Progressivemultifocalleukoencephalopathy

Isosporiasis,chronicintestinal(>1moduration)

Salmonellasepticemia,recurrent

Kaposisarcoma

Toxoplasmosisofbrain
WastingsyndromeofHIVinfection

Mandell,Douglas,andBennett'sPrinciplesandPracticeofInfectiousDiseases8thEd,121EpidemiologyandPreventionofAIDSandHuman
ImmunodeficiencyVirusInfection,JohnE.Bennett

InfeksiOportunistik

LikelihoodfordevelopmentofAIDSwithin3years.

Goldman'sCecilMedicine24thEd,396TreatmentofHumanImmunodeficiencyVirusInfectionandAcquiredImmunodeficiencySyndrome,Lee
Goldman,21852196,2012

ProfilaksisdanTerapi

Terapi

Mandell,Douglas,andBennett'sPrinciplesandPracticeofInfectiousDiseases8thEd,131ManagementofOpportunisticInfectionsAssociatedwithHPV
Infection,JohnE.Bennett,16421665.e5,

ProfilaksisdanTerapi

Terapi

Mandell,Douglas,andBennett'sPrinciplesandPracticeofInfectiousDiseases8thEd,131ManagementofOpportunisticInfectionsAssociatedwithHPV
Infection,JohnE.Bennett,16421665.e5,

ProfilaksisdanTerapi

Terapi

Mandell,Douglas,andBennett'sPrinciplesandPracticeofInfectiousDiseases8thEd,131ManagementofOpportunisticInfectionsAssociatedwithHPV
Infection,JohnE.Bennett,16421665.e5,

ProfilaksisdanTerapi

Terapi

Mandell,Douglas,andBennett'sPrinciplesandPracticeofInfectiousDiseases8thEd,131ManagementofOpportunisticInfectionsAssociatedwithHPV
Infection,JohnE.Bennett,16421665.e5,

ProfilaksisdanTerapi

ProphylaxistoPreventFirstEpisodeof
OpportunisticDisease

Mandell,Douglas,andBennett'sPrinciplesandPracticeofInfectiousDiseases8thEd,131ManagementofOpportunisticInfectionsAssociatedwithHPV
Infection,JohnE.Bennett,16421665.e5,

ProfilaksisdanTerapi

Profilaksis

Goldman'sCecilMedicine24thEd,396TreatmentofHumanImmunodeficiencyVirusInfectionandAcquiredImmunodeficiencySyndrome,LeeGoldman,
21852196,2012

Opportunisticinfectionprophylaxisandtreatmentin
adolescentsandadults
ProfilaksisdanTerapi

Riskfactor

Agent
Pneumocystisjiroveci

CD4cellcount<200cells/mL

Coccidioidomycosis
Toxoplasmagondii
CD4Tcellcount<100cells/mL
CD4Tcellcount<50cells/mL

Histoplasmosis
Mycobacteriumavium
complex(MAC)
Cryptococcosis

Prophylacticmedication
Trimethoprimsulfamethoxazole(TMP
SMX)ordapsoneplusorminus
pyrimethamineandleucovorinor
aerosolizedpentamidineoratovaquone
Inendemicareas:fluconazoleor
Itraconazole
TMPSMXordapsone+pyrimethamine
plusleucovorinoratovaquone+
pyrimethamine+leucovorin
Inendemicareas:Itraconazole
Macrolide(clarithromycinor
azithromycin)orrifabutin
Inendemicareas:fluconazoleor
itraconazole

Goldman'sCecilMedicine24thEd,396TreatmentofHumanImmunodeficiencyVirusInfectionandAcquiredImmunodeficiencySyndrome,LeeGoldman,
21852196,2012

ProfilaksisdanTerapi

Opportunisticinfectionprophylaxisandtreatmentin
adolescentsandadults
Riskfactor
Agent
Prophylacticmedication
PPD>5mmindurationorrecent Mycobacterium
INHpyridoxinefor9months;if
TBcontactmonthbutnoactiveTBtuberculosis
unlikelytocomplete9courseandon
andnohistoryoftreatmentfor
HAART:rifabutinpluspyrizinamide
activeorlatentTB
for2months
Varicellazoster
Varicellazosterimmunoglobulins
Contactwithchickenpoxor
(VZIG)
shinglesinvaricellazostersero
negativeindividuals
Streptococcuspneumoniae Pneumovax
HIVinfected
Meningococcus foryouthMenactra
attendingthemilitaryor
collegeandconsiderFor
unvaccinatedadults
RecombivaxHBorEnergerixB
Negativeanti HBcandpreviously HepatitisB
unimmunizedorunderimmunized
tohepatitisB
Havrix
Negativeanti hepatitisAserology HepatitisA
Goldman'sCecilMedicine24thEd,396TreatmentofHumanImmunodeficiencyVirusInfectionandAcquiredImmunodeficiencySyndrome,Lee
Goldman,21852196,2012

ProfilaksisdanTerapi

Profilaksis

Goldman'sCecilMedicine24thEd,396TreatmentofHumanImmunodeficiencyVirusInfectionandAcquiredImmunodeficiencySyndrome,LeeGoldman,
21852196,2012

TopikPembicaraan
Epidemiologi
Patofisiologi
InfeksiOportunistik
ProfilaksisdanTerapi
Pencegahan
Kesimpulan

Pencegahan

PotentialFactorsInfluencingMothertoChildTransmissionofHIV
MaternalFactors
AdvancedHIVdisease,asmeasuredby:
Clinicalstaging
LowCD4+lymphocytecount
Higherviralloads
p24antigenemia
PrimaryHIVinfection
Viralphenotype:syncytiuminducing
Viralgenotype:virulentmutantstrainofHIV
Coinfectionwithothersexuallytransmitteddiseases
Firstborntwins
Obstetricevents
Vaginaldelivery
Invasiveproceduresorfetalmonitoringduringlabor
Prolongedprematureruptureofmembranes(>4hr)
Oldermaternalage
Cigarettesmokingandillicitdruguseduringpregnancy
Breastfeeding
Unprotectedsexualintercoursewithmultiplepartners
weight

LabororBirthCanalFactors
Cervicovaginalviralload
LocalHIVspecificimmuneresponse
Maternalfetaltransfusionofblood
ImmuneFactors
Humoral
Neutralizingantibody
Antibodydependentcellularcytotoxicity
gp120V3loopantibody
MHCconcordanceandhomozygosity
MaternalhumanleukocyteantigenA*2301
CellMediated
CytotoxicTlymphocytes

CD8suppression

Mucosalimmunity
FetalorPlacentalFactors
Chorioamnionitis
Prematurity
Lowbirth

Other

Mandell,Douglas,andBennett'sPrinciplesandPracticeofInfectiousDiseases8thEd,128HumanImmunodeficiencyVirusInfectioninWomen,JohnE.
Bennett,15901615.e8,2015

Relativesensitivitiesofvariousvirologicalassaysfortheearlydiagnosisof
HIV1infectionininfantsfrombirthto6monthsofage
HIV1assay
Pencegahan

Meansensitivity(%)*
Culture
DNAPCR
p24antigen
ICDp24antigen
RNAPCR

114days

Timetodetection
14months

41
40
27
32
32

89
80
40
97
91

6months
91
97
56
87
100

PCR,polymerasechainreaction;ICD,immunecomplexdissociated.
*Dataisbasedonninepublishedstudies.

AtlasofSexuallyTransmittedDiseasesandAIDS4thEd,14HumanImmunodeficiencyVirusInfectionandtheAcquiredImmunodeficiency
Syndrome,StephenA.Morse,240255,2010

Pencegahan

FactorsAssociatedwithFertilityDesiresandIntentionsin
WomenLivingwithHIVInfection
POSITIVE INFLUENCES
Younger age
No children
Antiretroviral therapy
Interventions to preventmother
tochild transmission

NEGATIVE INFLUENCES
Personal health concerns
Having had one or more children
Concerns about infecting partner
Concerns about infecting child

Negative or judgmental attitudes of

Partners/family members wishfor
healthcare workers, family, and
children
community
HIVrelated stigma
HIVrelated stigma
Newmale partner
Fear of disclosure
Mandell,Douglas,andBennett'sPrinciplesandPracticeofInfectiousDiseases8thEd,128HumanImmunodeficiencyVirusInfectioninWomen,JohnE.
Bennett,15901615.e8,2015

Kesimpulan
Deteksidini
ARVsedinimungkin
MonitorCD4dankemungkinanIO(InfeksiOportunistik)
Pencegahan:BerbasisCD4,imunisasi

TERIMAKASIH