Goal 4: Reduce child mortality

Target 4a: Reduce by two thirds the mortality rate among children under five

Goal 5: Improve maternal health

Target 5a: Reduce by three quarters the maternal mortality ratio
Target 5b: Achieve, by 2015, universal access to reproductive health

Goal 6: Combat HIV/AIDS, malaria and other diseases

Target 6a: Halt and begin to reverse the spread of HIV/AIDS
Target 6b: Achieve, by 2010, universal access to treatment for HIV/AIDS for
all those who need it
Target 6c: Halt and begin to reverse the incidence of malaria and other major
diseases

Multiple
medications/multiple doses
and ADHERENCE IS CRITICAL
resistances of ARV

HIV is a CHRONIC ILLNESS

that requires long term
treatment (for life)

Individuals with HIV disease

may be STIGMATIZED

CLINICAL AND LABORATORY

MONITORING are necessary
to demonstrate effectiveness
and identify side effects

Dampak epidemi HIV & AIDS di Indonesia

2006
2007
2008

60
50,82
50
40
29,36
30
20
8,5
10
0

0,72
'<1

1,03
'1-4

3,07

0,52
'5-14

'15-19

0,49

0,55
'20'29

Angka Harapan Hidup Bayi

dengan HIV 10 tahun
Angka Harapan Hidup
berkurang menjadi 67 tahun

'30-39

'40-49

'50-59

'> 60

Kehilangan Produktifitas
kerja 25 tahun
Kehilangan Harapan Hidup
37 tahun

Sumber: Ditjen PP&PL, Depkes RI, Laporan Triwulan IV 2008 (s/d 31 Desember 2008).
Modul 1,
Mazami Enterprise 2009

3,05

Halaman 4

Adults and children estimated to be living with HIV, 2008

Eastern Europe
Western &
Central Europe & Central Asia

850 000

North America

[710 000 970 000]

1.4 million

1.5 million

[1.4 1.7 million]

East Asia

850 000

[1.2 1.6 million]

Middle East & North Africa

Caribbean

240 000

310 000

[250 000 380 000]

[220 000 260 000]

[700 000 1.0 million]

South & South-East Asia

3.8 million

[3.4 4.3 million]

Sub-Saharan Africa
Latin America

2.0 million

[1.8 2.2 million]

22.4 million

[20.8 24.1 million]

Oceania

59 000

[51 000 68 000]

Total: 33.4 million (31.1 35.8 million)

December 2009

Kumulatif kasus AIDS di Indonesia dalam

10 tahun terakhir, sampai Maret 2010

24.482

30000
25000

24131 24482

20000

19973
16110

15000
11141

10000
8194

5000
0

5321
2873
2638
1195 2683
345 1172 316 1488
255
219
94
827
608
353

AIDS

4969
2947

3863

4158

KumAIDS

DIT J EN PP dan PL, KEMENTERIAN KESEHATAN RI, 2011

351

Kumulatif kasus HIV di Indonesia dalam

10 tahun terakhir, sampai Desember 2008
7000
6000

6.015

6066

6015

5230

5000
4244

4000
3369

3000

2720

2552

2000

1904

1172 732

1000
178

769

403

649

648

875

986

836

168

0
-51

-1000

HIV

KumHIV

Koreksi terhadap
duplikasi data

DIT J EN PP dan PL, KEMENTERIAN KESEHATAN RI, 2011

Persentase kumulatif cara penularan HIV

di Indonesia dalam 5 tahun terakhir
2006
2007
2008
2010

60
53,1
48

50

42,5

40

37,9

30
20
10
0

3,8
Homosex

0
0,2
Heterosex

IDU

Transfusi

2,2
2,6
Perinatal

2,5
3,2
?

DIT J EN PP dan PL, KEMENTERIAN KESEHATAN RI, 2011

4500
4000
3500
3000
2500
2000
1500
1000
500
0

3995

3775

3778

3712

1447

1125

1030
591

507

505

DIT J EN PP dan PL, KEMENTERIAN KESEHATAN RI, 2011

Kiat Ruxrungtham, Tim Brown, Praphan Phanuphak. HIV/AIDS in Asia. Lancet 2004; 364: 6982

Diagrammatic representation of risk groups in Asian HIV epidemics, demonstrating multiple

interlinked epidemics in higher risk populations (CSW, commercial sex worker, MSM, homosexual men, and
IDU, injecting drug user) and their relationship with low risk groups (their immediate sexual partners). (Used by Permission,
Tim Brown.)

Horizontally

Sexual contact
Mucous membranes, non-intact skin, bloodstream
Vertically
Mother To Child Transmission

Vagina mempunyai
luas permukaan
paparan lebih luas

HIV lebih mudah

hidup di vagina

Kadar HIV lebih

tinggi dalam mani

Wanita mempunyai risiko lebih tinggi

tertular pada kontak seksual heteroseksual.

Volberding, 1998; WHO, 2000

Josefina J Card, Angela Amarillas, Alana Conner, Alana Conner, Diana Dull Akers, Julie Solomon, Ralph J DiClemente. The
Complete HIV/AIDS Teaching Kit. Springer Publishing Co, NY, 2008

Pria TIDAK SIRKUMSISI berisiko lebih besar tertular ataupun

menularkan HIV.
kontak seksual anal
homoseksual pria
yang terpenetrasi
mempunyai risiko
lebih besar daripada
penetran

Permukaan dalam kulup

penis mengandung sel
Langerhans yang
mudah dipenetrasi HIV
cara masuk HIV.

Sirkumsisi
menghilangkan kulup
penis risiko menurun
untuk tertular maupun
menularkan HIV juga IMS

Transmisi
HIV
Josefina J Card, Angela Amarillas, Alana Conner, Alana Conner, Diana Dull Akers, Julie Solomon, Ralph J DiClemente. The
Complete HIV/AIDS Teaching Kit. Springer Publishing Co, NY, 2008

Vertical transmission (95%)

Transplacental [in utero] ( 10%)
Peripartum [in utero or birth
canal] ( 60%)
Breast-feeding ( 30%)

Sexual abuse

Blood product transfusion

Extremely rare because of
excellent screening

Unexplained
Mix-up in nursery ?
Surrogate breast-feeding
Nosocomial infection with
contaminated equipment
Occult sexual abuse

Mechanisms of Mother-Infant HIV Transmission

Transplacental infection "Ascending infection"
Direct contact by infant
Microtransfusion

Sources of infection
Maternal blood
Placenta
Amniotic fluid
Cervicovaginal secretions
Breastmilk

Routes of Entry

Umbilical circulation
Skin
Mucous membranes
GI tract
Respiratory tract

Growth of HIV epidemics in populations with different percentages of men visiting sex
workers according to injecting drug use.
Condoms were used in 30% of commercial sex acts for all percentages.
Kiat Ruxrungtham, Tim Brown, Praphan Phanuphak. HIV/AIDS in Asia. Lancet 2004; 364: 6982

HIV prevalence
compared with expected
HIV prevalence in the
absence of behavior
change in (A) Thailand
and (B) Cambodia. The
behavior changes were a
reduction by 50% in the
number of men visiting
CSW, and an increase to
90% or higher of
condom use in sex work
Kiat Ruxrungtham, Tim Brown, Praphan Phanuphak. HIV/AIDS in Asia. Lancet 2004; 364: 6982

Dapat, bila.
Terdeteksi
Terkendali : Perilaku, Obat, ANC ,PI

Pemilihan rute persalinan

Pemilihan ASI/PASI
Pemantauan Bayi-Balita
Dukungan & Perhatian

3 jenis pemeriksaan ELISA

Untuk darah yang sama

Kepastian diagnostik

Perlu pemeriksaan lanjut

Four FDA-approved Rapid HIV Tests

Sensitivity
(95% C.I.)

Specificity
(95% C.I.)

OraQuick Advance
- whole blood
- oral fluid
- plasma

99.6 (98.5 - 99.9)

99.3 (98.4 - 99.7)
99.6 (98.5 - 99.9)

100 (99.7-100)
99.8 (99.6 99.9)
99.9 (99.6 99.9)

Uni-Gold Recombigen
- whole blood
- serum/plasma

100 (99.5 100)

100 (99.5 100)

99.7 (99.0 100)

99.8 (99.3 100)

Vial

Stand

Reactive
Control

Loop
Positive
HIV-1/2
Device
Positive

Negative

(+)

(-)

OraQuick

Read results in 20 Minutes

Developed World
10 20% progress to AIDS in < 1 year
50% may reach 10 years with no ARV
Resource poor settings
80% mortality by 2 years

Developing World
If symptomatic in 1st year of life
Survival generally 3 years

100

15

98

95

80

75

Early
Late
Labor &
Early
antenatal antenatal Delivery postpartum
36 wks

Uninfected

70
Late
postpartum

6 mos

Infected

 Kontrasepsi
Pilih pasangan ? / Pencegahan primer

Pemberian Anti Retro Virus

Hidup sehat (Tobat)
Jika suami + Gunakan kondom

SC atau minimalkan obstetrik operatif

PASI ?

Pemberian Anti Retro Virus

Pemantauan Baby at risk

Maternal
- Viral load yang tinggi
(>5.000 copies/mL misal
saat terjadi serokonversi)
- Karateristik Virus
- CD4<200/ T limfosit count)
- Defisiensi imun
- Infeksi virus, bakteri,
parasit
- Defisiensi vitamin A
- IDUs
- Banyak pasangan seksual

Obstetrik
- Kelahiran per vaginam vs SC
- KPD yang terbengkalai
- Pendarahan intrapartum
(Kala II)
- Chorioamnionitis
- Prosedur invasif (misal epis,
EF/EV
Bayi
- Preterm (BBLR) < 34 mg
- ASI/Mastitis
- Luka di mulut bayi

Bangkok: Transmission Rates by

Delivery Plasma Viral Load
Transmission Rate

50%
40%
30%

20%
10%

0%
<6,573
RNA

6,57313,177

13,17833,759

33,76093,126

0.054
0.143
0.273
0.316
Mother's Viral Load at Delivery (copies/mL)

Source: Shaffer et al., J Infect Dis 1999

>93,126

0.429

Fusion Inhibitor

Entry Inhibitor
Attachment Inhibitor,
Co-receptor Antagonist

NNRTI
Mazami Enterprise 2009

NRTI. NtRTI

Reverse
Transcriptase
Inhibitor

Integrase
Inhibitor
Modul 3a,

PI

Protease
Inhibitor

Maturation
Inhibitor
Halaman 32

Therapy% Transmisi

Maternal Plasma HIV-1 RNA Copy/mL

Table 3: Estimated Rates of Mother-Infant

HIV Transmission by Intervention

30

No intervention

23

Exclusive breast-feeding and early

20
20

Replacement feeding only

Short regimen ZDV only

15

Breast-feeding + short regimen ZDV

10
9,4
9
7,6
6,4

EBF+short regimen ZDV+ baby ZDV+

Short regimen ZDV+RF
Nevirapine+RF
Long regimen ZDV
Short regimen ZDV+Nevirapine+RF
Long regimen ZDV+CS

2
Transmission Rate (%)

Impact of Infant Feeding

A randomized trial in Kenya, 1992-98
197 in breast feeding arm
204 in formula feeding arm
Of note: less compliant in the formula feeding arm (70% vs 96%)

Infant age
Birth
6 weeks
14 weeks
6 months
12 months
24 months

Cumulative
infection rate
BF
FF
7.0
3.1
19.9
9.7
24.5
13.2
28.0
15.9
32.3
18.2
36.7
20.5

Difference in
cumulative rate

P value

3.9
10.2
11.3
12.1
14.1
16.2

0.35
0.005
0.007
0.009
0.003
0.001

Randomized trial of breast feeding vs formula feeding

Infants with negative HIV PCR at 6 wk of age were followed.
Probability of breast milk transmission of HIV-1

Measure of breast
milk infectivity

Prenatal maternal plasma HIV

RNA

Maternal CD4
count

43120

< 43120

< 400 400

Per liter ingested

.0010*

.0003

.0010*

.0004

Per day of exposure

.0004*

.0001

.0004*

.0002

Probability of breast milk transmission was 0.0003 per day of

breast feeding. Similar to probability of heterosexual
transmission per unprotected sex act.

Richardson BA. J Infect Dis 2003;187:736

 When replacement feeding is affordable,

feasible, acceptable, sustainable and safe,
avoidance of all breastfeeding is recommended.
Where breastfeeding is the only option, this
should be exclusive breastfeeding for 4-6
months
At 4-6 months, cessation of breastfeeding
should be as rapid as possible

The provision of breastmilk only

No other form of milk, water or food

Oral antibiotics are allowed

Oral vaccines are allowed

Transmission rate
7.6
FF
9.5
6.5
4.7
1.9

ACTG 076
Thai/CDC
PHPT LL
PHPT LS
PHPT

15
17
8
12
19
12
10
16
15

Retro-CI
DITRAME
PETRA-A
PETRA-B
PETRA-C
HIVNET012
SAINT
MALAWI
NVAZ
AZT

AZT+3TC

BF

NVP

Bayi usia < 18 bulan:

PCR-RNA HIV (viral load) pertama pada usia 1 bulan
viral load kedua pada usia 4-6 bulan

Diagnosis positif: 2 x pemeriksaan didapatkan positif (terdapat virus HIV > 400 kopi)

Diagnosis negatif: 2 x pemeriksaan didapatkan viral load undetectable dan

dikonfirmasi dengan pemeriksaan anti-HIV ELISA 3 kali dengan reagen yang berbeda
pada usia 18 bulan.

Bayi usia > 18 bulan: pemeriksaan anti-HIV ELISA 3 kali dengan reagen yang berbeda
seperti pada ibu

RECOMMEND
During Labor and Delivery
Provide optimal routine care during all
births to minimize OB complications
Use of partograph to monitor and avoid
prolonged labor
Provide supportive nursing care .-ambulate,
feed, rehydrate .
Facilitate optimum social support .
Avoid unnecessary obstetric procedures
Maintain intact perineum if possible
Maintain universal precautions
Identify and address potential accidental
exposure of client or provider to HIV virus
Perform C-section prior to onset of labor
when feasible
Use extreme care during late or emergency
C-section

AVOID
During Labor and Delivery
Avoid/reduce artificial rupture of
membranes
Avoid unnecessary episiotomy
Avoid repeated vaginal examination
Avoid or reduce unnecessary
instrumentation during delivery (forceps,
etc.)
Avoid or reduce use of vacuum extraction .
Avoid C-section after onset of labor except
in emergencies
Avoid/decrease Premature Rupture of
Membranes (PROM)/Prolonged Labor (longer
than 4 hours) (Rate of transmission increases
by 2% each hour after 4 hours)
Prevent/treat intrapartum haemorrhage

Mona Moore. A Behavior Change Perspective on Integrating PMTCT and Safe Motherhood Programs. The CHANGE Project
AED/The Manoff Group Washington, 2003

RECOMMEND
AVOID
After Delivery
After Delivery
Maternal
Newborn
Maternal
Careful handling of Careful drying to
placenta, cord, lochia, remove remaining
etc.
maternal blood and
fluids
Prevent/treat
cracked nipples and Gentle removal of
mastitis
vernix
Clamp umbilical cord Gentle newborn
after it stops pulsing resuscitation when
to avoid blood spray required
Careful disposal of Prompt treatment of
bed clothes and other newborn thrush
soiled birth materials
Offer proper
contraception

Newborn
Avoid invasive procedures
Avoid vigorous suction
Avoid unnecessary
newborn procedures

Mona Moore. A Behavior Change Perspective on Integrating PMTCT and Safe Motherhood Programs. The CHANGE Project
AED/The Manoff Group Washington, 2003

ABSTINENCE

Tidak melakukan hubungan seks bagi orang

yang belum menikah

BE FAITHFUL

Bersikap saling setia hanya pada satu

pasangan seks (tidak berganti-ganti pasangan)

CONDOM

Cegah penularan HIV yang terjadi melalui

hubungan seksual dengan menggunakan
kondom (bila salah satu dari pasangan
tersebut diketahui terinfeksi HIV)

DRUG NO

Dilarang menggunakan narkoba yang dapat

menjadi alur transmisi HIV

ELIMINATION
OF STD

Mengurangi PHS

 HIV mudah dimatikan

Dipanaskan 560 C selama 30
Alkohol
Klorin 0,5%
Di luar tubuh (suhu ruangan): mati
dalam 24 jam

HBV
Di luar tubuh (suhu ruangan) : tetap
hidup minimal 1 minggu

Terluka dalam (hingga otot), OR

15 (6,0-41, 95% CI)
Darah terlihat pada alat
penyebab luka, OR 6,2 (2,2-21,
95% CI)
Alat penyebab luka berasal dari
vena atau arteri pasien sumber,
OR 4,3 (1,7-12, 95% CI)

Petugas kesehatan
meminum zidovudine
(profilaksis diperkirakan
memberikan 80%
perlindungan), OR 0,19
(0,06-0,52, 95% CI)

Pasien sumber meninggal dalam

waktu 60 hari sejak paparan, OR
5,6 (2,0-16, 95% CI)
Source: CDC case control study 2003. Cardo et al., New Engl J Med 1997;337:1485-90.

Penularan selain perkutan: lebih banyak

Risiko penularan : tergantung HBeAg pasien, paparan
Perkutan: kejadian tidak terlalu banyak

Risiko

Hepatitis

Pengidap

HBsAg +, HBeAg

1-6%

23-37%

HBsAg +, HBeAg +

22-31%

37-62%

Sumber
Penularan
Luka di Kulit
(tertusuk jarum)

Mukokutan

Gerberding 1995; Seelf 1978.

HBV (%)

HIV (%)

27 - 37

0,3 0,4

Mudah

< 0,1

Protect patientsprotect healthcare personnel

promote quality healthcare!

 Mulai secepat mungkin

< 36 jam
Dalam hitungan jam, bukan hari
Interval antara paparan dengan PEP yang masih
efektif pada manusia? Tidak diketahui
Pada paparan berat dan risiko tinggi dapat
dipertimbangkan setelah lewat waktu
Reevaluasi sumber penularan:

Dalam 72 jam

Kode paparan

KS HIV

Rekomendasi profilaksis
pascapaparan
1
1
Mungkin tidak diperlukan
1
2
Pertimbangkan regimen
standar
2
1
Dianjurkan regimen standar
2
2
Dianjurkan regimen tambahan
3
1 atau 2
Dianjurkan regimen tambahan
Tidak diketahui Tidak diketahui Jika dicurigai kode paparan 2
atau 3, regimen standar
dianjurkan
Regimen standar: AZT 300 mg + 3TC 150 mg (Duviral) selama 4 minggu.
Regimen tambahan: regimen standar ditambah Indinavir 3x800mg, atau Nelfinavir
3x750mg.

Source: MoPH, Thailand, 2000

Contoh Alur Pelayanan PMTCT 1

Untuk Ibu Hamil

Tempat pelayanan

Posyandu

Klinik ANC

Klinik KB

Klinik VCT

Klinik IMS

Klinik PTRM

Ibu Hamil dengan risiko terinfeksi HIV

VCT
Pasangan

Positif

Negatif

VCT/ PICT

Konseling
ARV Profilaksis

Persalinan

Konseling
Asuhan Antenatal

Asuhan Antenatal

Persalinan

Persalinan

Asuhan Pasca Natal

Asuhan Pasca Natal

Perawatan lanjutan Odha

RS Rujukan ARV

Puskesmas

Contoh Alur Pelayanan PMTCT 2

Untuk PUS & WUS

Tempat pelayanan

Posyandu

Klinik ANC

VCT
Pasangan

Klinik KB

Klinik VCT

Klinik IMS

PUS/ WUS dengan risiko terinfeksi HIV

Positif

Negatif

VCT/ PICT

Konseling
Ya
ARV
sesuai
protokol

Klinik PTRM

Konseling

Ya
Indikasi ARV

Ingin Hamil
Tidak

Tidak

Tidak

Ya
Memenuhi syarat

Perawatan
lanjutan Odha
RS Rujukan ARV

Ya

Hamil
Asuhan Ante Natal
Persalinan
Asuhan Pasca Natal

Tidak

Hamil
Ikuti Alur 1
Modul 10,

Kontrasepsi
Halaman 55
Puskesmas

Deteksi Dini
Wajib menawarkan pemeriksan HIV
Mulai 14 minggu
SC

ARV

Lanjutkan ARV

Persalinan

Pervaginam

Profilaksis
ARV 1 bulan

ASI

Nutrisi
PASI syarat AFASS

1. Menyebarkan informasi tentang HIV terutama pada wanita usia

reproduksi, termasuk penyuluhan bekerja sama dengan institusi
pendidikan (topik : kesehatan reproduksi dan pencegahan
penularan).
2. Mengurangi stigma di kalangan petugas kesehatan maupun pada
masyarakat.
3. Memperluas cakupan pemeriksaan penapis HIV.
4. Membentuk jejaring multi disiplin yang kompak (pediatri,
keperawatan, penyakit dalam, kesehatan komunitas, pemerintah
dan organisasi profesi rumah sakit, Komisi Penanggulangan AIDS
daerah maupun pusat, dan lembaga swadaya masyarakat).
5. Mendukung rujukan mulai dari Puskesmas hingga rumah sakit
rujukan (ARV maupun tempat bersalin)
6. Menjaga kesinambungan data maternal dan bayi.