Getting to Zero:

Zero AIDS-related death

Rudi Wisaksana
Divisi Penyakit Tropik dan Infeksi
RS Dr. Hasan Sadikin
Target: UNAIDS 2015
Zero new infection
Sexual transmission reduced by half
Vertical transmission eliminated
Infeksi baru pada IDU dicegah
Zero AIDS-related death
Universal access to ART for PLHIV who eligible
TB related death reduced by half
Zero discrimination
Countries with punitive laws reduced by half
HIV related travel restriction eliminated in half of countries
HIV-women specific need addressed in half of nations
Zero tolerance for gender-based violence



Treatment Cascade
Outreach
Testing
Treatment
Initiation
ART
Success
Linkage
to Care
Testing
Treatment

Strategies
Adequate resources (financial & manpower)
Earlier HIV detection (routine HIV testing)
Earlier linkage to care (CD4, Dx, Co-infection
Rx)
Earlier ART initation criteria (test and treat)
Safe, effective & inexpensive ARV
Better retention to care
Praphan, 2013
Strategy: Early Detection
Symptom based
approach
Use clinical symptoms to identify HIV
patients
HIV Screening in
Methadon Clinic and
Prison
Integrated approach of HIV testing
and care in high risk group
Partner notification Routine screening of sexual partners
of HIV patients
PITC (Provider intiated
testing and counseling)
HIV test propose and consent by
physicians, counseled afterward
Rudi Wisaksana, 2009
Active case finding: through targeted
testing
Partners testing Routine testing
Total so far 118 512
Age 27 (25 30) 29 (26 32)
IDU 25.3% 67.0%
Female 51.3% 24.3%
WHO stage IV 0% 48.3%
CD4 338 (265 460) 59 (15 231)
Hinta Meijerink, 2009
Clinic Number
of VCT
VCT
Unit
Cost
($)
Travel
Time
Time in
the Clinic
HIV (+) CD 4
(median)
Enrolled
in HIV
care (%)
hospital 568 71 45 min 94 min 37% 129 88%
community 28 84 39 min n/a 14% n/a 0%
Sex worker
clinic
784 68 20 min 38 min 3% 292 8%
Prison 574 23 - n/a 7% 290 100%
HIV testingwhere?
Adi Siregar, 2010
Diagnosing HIV:
one, two or three test ?
Retrospective data : 2006 2008
4727 test
HIV-positive :
37% in 2006; 25% in 2007; 24% in 2008

After 1
st
HIV test:
No single false-positive found
Indrati, 2009
Time gain from earlier testing

Hinta, 2009
Symptom-based approach
Hinduan, 2008

Clinical Indications HIV (+) HIV (-)
Weight loss 87% 76%
Chronic diarrhea > 2 weeks 58% 21%
Prolonged fever 61% 66%
Chronic coughs > 3 weeks 19% 42%
Skin disorder 13% 11%
Oral thrush 61% 11%
Genital infections 3% 3%
Algorithm to predict CD4 350

12
Oral Candidiasis?
NO
Hb, BMI
Hb<12 AND BMI<18,5
Start ART
Other
TLC
Female
TLC < 1700
Start ART
TLC 1700
No ART
Male
TLC <1800
Start ART
TLC 1800
No ART
YES
Start ART
Sensitivity: 89%
Specificity: 79%
Oedenhouven, 2011
TLC sebagai monitoring ARV
Hanya berguna setelah 1 tahun ARV

CD4 > 200 sel/mm
3
Pria: TLC > 2300 sel/mm
3
Wanita: TLC > 1400 sel/mm
3

Immunological Failure
TLC menurun > 5% per bulan

Immunological VS virological failure
Virological
failure (+)
Virological
failure (-)
Total
Immunological
failure (+)
23 28 51
Immunological
failure (-)
11 244 255
Total
34 272 306
Sensitivity 58 %; Specificity 89 %
Y Hartantri, 2009
Viral load = Mahal?
Kirim ke: Teratai Clinic RS HS Bandung
In house assay
Sensitifity 92.8%
Specificity 98.8%
Limit of detection 450 copies/ml
Price 60 US$/test
Fibriani, 2011
Adherence counseling and ARV response
2%
98%
Receive
adherence counseling
n=750
treatment
failure
no treatment
failure
10%
90%
Did not receive
adherence counseling
n=265
Kesumah, 2011
TB-HIV management


2012 Triwulan 1 Triwulan 2
Jumlah pasien 295 250
Jumlah PITC/VCT 17 61
Jumlah HIV (+) 3 4
Prevalensi HIV > 1%
Suyanto, 2012
Survival in EPTB
Early Death in TBM Patients
0 10 20 30
0
50
100
HIV-positive
HIV-negative
days
P
e
r
c
e
n
t

s
u
r
v
i
v
a
l
Rizal, 2008
TB-HIV in RSHS
Symptoms
Low sensitivity
TB diagnostic from Chest X-ray
Only sensitive for outpatients
Not sensitive nor specific for inpatients
FAB stain
Can produce sputum: 29%
Sensitivity : ZN 59%; FM 72%

Rahmadi, 2008; Wisaksana 2010
TB diagnostic (April-August 2012)
n
Symptoms (+) 68
Sputum available 49
BTA (+) 8
Gen Xpert (+) 9
Chest X-ray (+) 12
Teratai, April-August 2012
BTA (+) BTA (-)
GenXpert
(+)
7 2
GenXpert
(-)
1 38
GenXpert vs BTA
Teratai, April-August 2012
Isoniazide Prophylactic Therapy (IPT)
Dianjurkan WHO
Reduksi risiko TB: 33-64%
Terutama untuk TST (+)
INH 300 mg selama 6 bulan, FU 3 tahun

Hambatan:
Kesulitan menyingkirkan TB aktif pada CD4 rendah

Summary
Zero AIDS-related death could be reach
Examine cascade of treatment
Early test is the most important
Develop own (local) strategy
Working with community
Budget: cost efective - priority


Thank you