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TB-HIV

TB-HIV. Reiva Wisdharilla Samuel Raymond Wahyu Permatasari Yohanes Edwin Budiman Stase Pulmonologi Fakultas Kedokteran Universitas Indonesia 2012. Human Immunodeficiency Virus (HIV). Epidemiologi dan permasalahan ko-infeksi TB pada HIV.

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TB-HIV

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  1. TB-HIV Reiva Wisdharilla Samuel Raymond WahyuPermatasari Yohanes Edwin Budiman StasePulmonologi FakultasKedokteranUniversitas Indonesia 2012

  2. Human Immunodeficiency Virus (HIV)

  3. Epidemiologidanpermasalahanko-infeksi TB pada HIV • Hingga2005, jumlah ODHA di seluruh dunia sebesar40,3 juta orang dan yang terinfeksi HIV sebesar 4,9 juta orang. • Pada 2008, 64 % dariseluruhkasus HIV terjadi di Afrikadan 15 % terjadi di Asia Tenggara. • Di Indonesia (2009)  18442 kasus di 32 Provinsi. • Koinfeksi TB-HIV: 24% - 45% kasus TB padainfeksi HIV asimptomatikdansebanyak 70 % padapasiendengan AIDS

  4. Etiologi Human Immunodeficiency Virus (HIV) http://static.ddmcdn.com/gif/aids-hiv-anatomy.gif

  5. Transmisi • TransmisiSeksual • Homoseksual • Heteroseksual • Transmisi Non Seksual • Parenteral • Transplasental Statistik Kasus HIV/AIDS di Indonesia dikaitkan dengan faktor resiko dilapor s/d Desember 2010 Laporan statistik HIV/AIDS di Indonesia. 2011. http://www.aidsindonesia.or.id

  6. Patogenesis http://www.niaid.nih.gov/SiteCollectionImages/topics/hivaids/hivReplicationCycle.gif

  7. Patofisiologi HIV / AIDS

  8. ManifestasiKlinis • Tumor • Sarkoma Kaposi • Limfomamaligna • ManifestasiOportunistik • Paru Pneumonia Pneumocystis (PCP), Cytomegalo Virus (CMV), Mycobacterium Avilum, Mycobacterium Tuberculosis • Gastrointestinal ↓nafsu makan, diare kronis, ↓ berat badan >10% /bulan • Manifestasi Neurologis ensefalitis, meningitis, demensia, mielopati, neuropati perifer.

  9. SkriningdanPemeriksaan • Skrining Semuapasienrisiko HIV tinggi • ELISA  (+)  Western Blot • CD4+ count • Normalnya 500-2000 sel/μL • Setelahserokonversi 700 sel/μL • AIDS  <200 sel/μL

  10. Viral Load (VL)  >30.000/μLbiasanyamanifestasi AIDS • Terapiadekuat bisatidakterdeteksi <20-75 kopi/ μL • Kultur virus danpemeriksaangenotipe menentukanmutasi/resistensi • Khususbayibarulahir  deteksi DNA proviral • PA  noduslimfarusak, hiperplasia, sel T multinuklearraksasa (khaspada HIV ensefalopati), mikrogliosis

  11. PemeriksaanInfeksiOportunistik • PPD (purified protein derivative) padaskin test  TB • Cytomegalovirus (CMV) dengantesserologi • Sifilisdengan RPR (rapid plasma reagent) • Tesamplifikasicepatuntukinfeksigonokokusdanklamidia • Serologi hepatitis A, B, danC • Antibodianti-toksoplasma • Pemeriksaanlain diare, angiomatosisbasiler, kandidiasisorofaring, kandidiasisvulvovaginal, pelvic inflammatory disease (PID), klamidia, GO, ataugardnerella, neoplasmaservikal, leukoplakia oral (EBV), purpuratrombositopenik, neuropatiperifer, herpes zoster.

  12. KlasifikasiHasilPemeriksaan • Kategori A  infeksiHIV asimtomatik • Kategori B  adagejalaterkait HIV: diare, angiomatosisbasiler, kandidiasisorofaring, kandidiasisvulvovaginal, pelvic inflammatory disease/PID (klamidia, GO, gardnerella), neoplasmaservikal, leukoplakia oral (EBV), purpuratrombositopenik, neuropatiperifer, herpes zoster. • Kategori C  infeksiHIV dengan AIDS. • Kategori A1, B1, dan C1  CD4 >500/ µL. • Kategori A2, B2, dan C2  CD4 200-400/ µL. • Kategori A3, B3, dan C3  CD4 <200/ µL.

  13. MulaiTerapiFarmakologi • JikatidaktersediatesCD4  pemantauanklinis. • Jikatersediates CD4: • Mulaiterapi ARV padasemuapasien HIV jikaCD4 <350 sel/mm3tanpamemandang stadium klinis. • TerapiARV  semuapasien HIV dengan TB aktif, ibuhamil, dankoinfeksi Hepatitis B tanpamemandangjumlah CD4.

  14. Obat Antiretroviral Kombinasi • NRTI (Nucleoside Reverse Transcriptase Inhibitor) → zidovudin, didanosin, zalsitabin, stavudin, lamivudin, emtrisitabin, abakavir. • NtRTI (Nucleotide reverse Transcriptase Inhibitor) → Tenofovir disoproksil • NNRTI  penghambat enzim RT  cara berikatan di dekat tempataktif enzim  perubahan konformasi situs aktif. • PI (Protease Inhibitor) → sakuinavir, ritonavir, indinavir, nelfinavir, amprenavir, lopinavir, atazanavir. • Viral Entry Inhibitor → enfuvirtid

  15. Kombinasi 2 NRTI + 1 PI  kuat dan lama menekan replikasi virus. • Kombinasi 2 NRTI + 1 NNRTI  menekan virus + meningkatkan perbaikan imunologis (+ direkomendasikandi Indonesia).

  16. GagalTerapi

  17. LanjutanTatalaksana • Kriteriagagalterapiutama (prioritas)  kriteriavirologis  imunologis  klinis • Jikaterbuktigagalterapi  perbaikikepatuhan  masihbelumberhasiljuga?  lanjutke LINI KEDUA • Linikedua  2 NRTI + boosted-PI (bPI) • yang disediakansecaragratis olehpemerintah TDF/AZT + 3TC + Lopinavir/Ritonavir (LPV/RTV).

  18. HIV and TB – An Interdisciplinary and Multisectoral Approach General Practitioners, Internists, Pulmonologists, Laboratory Experts, Pharmacy, Healthcare System, us.

  19. TB-HIV(Koinfeksi)

  20. TB-HIV • Kemungkinan 20-37 kali lipat • 400.000 dari 1,7 jutaorang yang meninggaldari TB adalah TB-HIV • 1,2 jutadari 9,4 jutakasus TB baruadalah TB-HIV • PrevalensiTB-HIV berkorelasidenganprevalensi HIV

  21. Pemeriksaan • Padadaerahdenganangkaprevalensiinfeksi HIV tinggi, pemeriksaan HIV rutindilakukanuntuksemuapasien TB • Padadaerahdenganprevalensi HIV rendah, pemeriksaan HIV diindikasikanuntukpasien TB denganrisikotinggi HIV • Di Indonesia, pasien TB yang memerlukanuji HIV : • Adariwayatperilakurisikotinggitertular HIV (pekerjaan) • Hasilpengobatan OAT tidakmemuaskan • MDR TB/TB kronik

  22. Gambaranklinis HIV

  23. ManifestasiKlinis TB padapasien HIV

  24. DaftarPustaka • DjoerbanZ, Djauzi S. HIV/AIDS di Indonesia. In: Sudoyo AW, Setiyohadi B, Alwi I, Simadibrata MK, Setiati S, eds. Buku ajar ilmupenyakitdalam. 4th ed. Jakarta: PusatPenerbitanDepartemenIlmuPenyakitDalam FKUI 2006 • DjuandaA., PenyakitKelamin AIDS (AqcuiredImmunoDeficincy Syndrome) DalamIlmuPenyakitKulitdanKelamin, Edisi ke-4. Jakarta : FakultaskedokteranUniversitas Indonesia : 2005 • DjauziS, Djoerban Z. Penatalaksanaan HIV/AIDS dipelayanankesehatandasar. Jakarta: BalaiPenerbit FKUI 2002. • FauciAS, Lane HC. Human Immunodeficiency Virus Disease: AIDS and related disorders. In: Kasper DL, Fauci AS, Longo DL, Braunwald E, Hause SL, Jameson JL. editors. Harrison’s Principles of Internal Medicine. 17th ed. The United States of America: McGraw-Hill • UNAIDS-WHO. Report on the global HIV/AIDS epidemic 2010: executive summary. Geneva. 2010. • DitjenPP & PL Depkes RI. StatistikKasus HIV/AIDS di Indonesia. 2009

  25. Daftar Pustaka • Louisa M, Setiabudy R. Antivirus. Dalam: Gunawan SG, Setiabudy R, Nafrialdi, Elysabeth, editor. Farmakologi dan Terapi. Edisi V. Jakarta: Balai Penerbit Fakultas Kedokteran Universitas Indonesia; 1995. • DirektoratJenderalPengendalianPenyakitdanPenyehatanLingkungan. PedomanNasionalTatalaksanaKlinisInfeksi HIV danTerapi Antiretroviral PadaOrangDewasadanRemaja. KementrianKesehatanRepublik Indonesia, 2011. • KonsorsiumUpayaKesehatanKemenkes RI. PedomanNasionalPelayananKedokteran: Tatalaksana HIV/AIDS. KementrianKesehatanRepublik Indonesia, 2011. • Spector SA, McKinley GF, Lalezari JP, Samo T, Andruczk R, Follansbee S, et al. Oral ganciclovir for the prevention of cytomegalovirus disease in persons with AIDS. Roche Cooperative Oral Ganciclovir Study Group. N Engl J Med. Jun 6 1996;334(23):1491-7. • Impact of antiretroviral therapy on tuberculosis incidence among HIV-positive patients in high-income countries. Clin Infect Dis. May 2012;54(9):1364-72.

  26. U.S. Preventive Services Task Force. Screening for HIV. Available at http://www.uspreventiveservicestaskforce.org/uspstf/uspshivi.htm. Accessed June 16, 2011. • [Guideline] Qaseem A, Snow V, Shekelle P, Hopkins R Jr, Owens DK. Screening for HIV in health care settings: a guidance statement from the American College of Physicians and HIV Medicine Association. Ann Intern Med. Jan 20 2009;150(2):125-31. • Hull MW, Rollet K, Odueyungbo A, Saeed S, Potter M, Cox J, et al. Factors Associated With Discordance Between Absolute CD4 Cell Count and CD4 Cell Percentage in Patients Coinfected With HIV and Hepatitis C Virus. Clin Infect Dis. Jun 2012;54(12):1798-1805 • Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Services. January 10, 2011; 1-174. Accessed June 16, 2011. Available at http://aidsinfo.nih.gov/contentfiles/ AdultandAdolescentGL.pdf. • Hoffmann CJ, Brown TT. Thyroid function abnormalities in HIV-infected patients. Clin Infect Dis. Aug 15 2007;45(4):488-94. • Lee PL, Yiannoutsos CT, Ernst T, Chang L, Marra CM, Jarvik JG, et al. A multi-center 1H MRS study of the AIDS dementia complex: validation and preliminary analysis. J MagnReson Imaging. Jun 2003;17(6):625-33.

  27. Thank you.

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