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HIV-infecties wereldwijd Clemens Richter. Overzicht Besmetting, natuurlijk beloop Epidemiologie Behandeling Preventie Risico voor reiziger.

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Presentatie over: "HIV-infecties wereldwijd Clemens Richter. Overzicht Besmetting, natuurlijk beloop Epidemiologie Behandeling Preventie Risico voor reiziger."— Transcript van de presentatie:

1 HIV-infecties wereldwijd Clemens Richter

2 Overzicht Besmetting, natuurlijk beloop Epidemiologie Behandeling Preventie Risico voor reiziger

3 Hoe raak je besmet? Sexuele transmissie Bloed- bloed (BT, i.v.drug gebruik, prik-accident) Perinatale transmissie

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5 Gemiddeld risico op HIV besmetting bij incidenten Percutaan0,3% (HBV 30%, HCV 3%) Slijmvlies0.1% Niet intacte huid<0.1%

6 Sexuele transmissie van HIV Bij eenmalig contact —Receptief anaal: 0.8 - 3% —Vaginaal: M to V = 0.05 - 0.15%, V to M = 0.03 - 0.09% —Oraal ~ 10x lager dan vaginaal Cofactor : STDs, geen circumcisie, menstruatie, viral load

7 Studie uit Uganda Virale loadTransmissie rate elk jaar <4000 400-34994.5% 3500-999912.5% 10,000-49,99914% 50,000+23% Quinn et al, NEJM 2000:342:921-929. Virale load en transmissie risiko

8 HIV interaction with CD4 cell Fusion Complete CD4 Attachment HR1-HR2 Interaction CXCR4 CCR5 HIV gp120 Anchorage CD4 Co-receptor Interaction Cell HIV gp41

9 HIV-RNA, Steady State Replic. HIV-1 RNA Slow (<10 4 ) Rapid (>10 5 ) Intermediate Stabilization over 2-3 mos Acute infection

10 Rol van het intestinale immuun system destructieve fase in darm mucosa vroeg na infectie gevolgd door microbiële translocatie, immuun activatie en uitgebreid verlies van CD4 cellen

11 Acute HIV infection is characterized by a rapid and massive loss of the body’s CD4+ T cells Plasma viremia Blood CD4+ T cells Body CD4+ T cells Primary infection ±Acute HIV syndrome Wide dissemination of virus Seeding of lymphoid organs Relative magnitude Time after initial infection Weeks Death Opportunistic diseases Clinical latency Constitutional symptoms Years 0369121245781011+369

12 HIV-epidemie 1990 – 2008

13 35.0 million [33.1 million – 37.2 million] 31.8 million [30.1 million – 33.7 million] 16.0 million [15.2 million – 16.9 million] 3.2 million [2.9 million – 3.5 million] 2.1 million [1.9 million – 2.4 million] 1.9 million [1.7 million – 2.1 million] 240 000 [210 000 – 280 000] 1.5 million [1.4 million – 1.7 million] 1.3 million [1.2 million – 1.5 million] 190 000 [170 000 – 220 000] Number of people living with HIV in 2013 People newly infected with HIV in 2013 AIDS deaths in 2013 Total Adults Women Children (<15 years) Total Adults Children (<15 years) Total Adults Children (<15 years) Global summary of the AIDS epidemic  2013

14 Total dec 2013: 35.0 million [33.2 million – 37.2 million] Middle East & North Africa 230 000 [160 000 – 330 000] Sub-Saharan Africa 24.7 million [23.5 million – 26.1 million] Eastern Europe & Central Asia 1.1 million [980 000– 1.3 million] Asia and the Pacific 4.8 million [4.1 million – 5.5 million] North America and Western and Central Europe 2.3 million [2.0 million – 3.0 million] Latin America 1.6 million [1.4 million – 2.1 million] Caribbean 250 000 [230 000 – 280 000] Adults and children estimated to be living with HIV  2013

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16 Tot 2015: 78 miljoen mensen geïnfecteerd, 40 miljoen overleden, situatie 2015: 1. Zuid Afrika 6.300.000 2. Nigeria 3.200.000 3. India2.100.000 4. Kenya, Mozambique, Uganda 1.600.000 7. Tanzania, Zimbabwe1.400.000 9. Zambia1.100.000

17 CDC definitie Stage A: asymptomatic Stage B: minor complications Stage C: AIDS indicator diseases 1: >500 CD4 cells 2: 200-500 CD4 cells 3: <200 CD4 cells

18 Viral load en CD4 bepalen de uitkomst

19 Behandeling Grote doorbraak 1996!, in arme landen pas zeer geleidelijk vanaf 2001

20 Mortality in patients with CD4<100 of antiretroviral (ARV) therapy including a protease inhibitor among those patients, USA, 1994–1997 0 10 20 30 40 1994199519961997 Deaths per 100 person years 0 20 40 60 80 100 ARV therapy including proteaseinhibitors (% of patient days) Deaths ARV Source: Palella et al., New England Journal of Medicine, 1998 Mar, 26: 338–60 98036-E-35 – 15 July 1998

21 Nieuw richtlijnen voor gebruikl ARVs voor behandeling en preventie HIV-infectie “rijke landen”: c-ART should be offered to all patients with HIV-infection, even with CD4 > 500 “Resource limited countries”: new WHO guideline from June 2013 is getting close to that of high income countries

22 Verandering WHO richtlijnen tussen 2006 en 2013: gebaseerd op CD4 2006: < 200 2010: < 350 2013: < 500(prioriteit < 350 en stadium 3 / 4)

23 Verandering richtlijnen voor zwangere vrouwen en tijdens borstvoeding 2010:start ART with CD4 < 350 or stage 3 / 4 disease 2013:initiate ART regardless of CD4 and clinical stage

24 2013 –initiate ART regardless of WHO clinical stage and CD4 cell count adults and adolescents> 10 years Active TB disease HBV coinfection with severe chronic liver disease Pregnant and breastfeeding women with HIV HIV-positive individual in a serodiscordant partnership

25 Behandeling is ook preventie! Een van de belangrijkste studies van de laatste 10 jaar 1763 “disconcordant” couples from US, Africa, India, Brazil 886 start c-ART immediately (CD4 350-550) 870 delayed arm: <250 CD4 and/or complaints In early arm: 4 transmissions In delayed arm: 35 transmissions Early c-ART: 96% reduction of transmissions!! Cohen, NEJM 2011; 365: 493-505

26 Preventie Preventie moeder-kind overdracht: alle zwangere vrouwen behandelen met volledige HIV- behandeling Vroege start HIV-behandeling Sexuele overdracht - condoom - circumcisie - systemisch Prep ? Verschil man/vrouw - vaginale gel met tenofovir?

27 Aandachtspunten voor reizigers naar de tropen Vermijd onbeschermde seks in HIV- endemische landen Gezondheidswerkers werkend in HIV- endemische landen: wees alert voor prikaccidenten en vraag advies betr. PEP (HIV-remmers mee) indien locaal niet aanwezig Hoog risico groep: MSM Waarschuw voor last minute reis zonder vaccinatie en zonder malaria profylaxe

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30 WHO – HIV department | March 21, 2015 Middle East & North Africa 16 000 [11 000 – 22 000] Sub-Saharan Africa 2.9 million [2.6 million – 3.2 million] Eastern Europe & Central Asia 14 000 [13 000 – 14 000] Latin America 35 000 [27 000 – 54 000] Caribbean 17 000 [14 000 – 20 000] Children (<15 years) estimated to be living with HIV  2013 Total: 3.2 million [2.9 million – 3.5 million] Asia and the Pacific 210 000 [190 000– 270 000] North America and Western and Central Europe 2800 [2300 – 3600]

31 WHO – HIV department | March 21, 2015 Estimated adult and child deaths from AIDS  2013 Middle East & North Africa 15 000 [10 000 – 21 000] Sub-Saharan Africa 1.1 million [1.0 million – 1.3 million] Eastern Europe & Central Asia 53 000 [43 000 – 69 000] Latin America 47 000 [39 000 – 75 000] Caribbean 11 000 [8300 – 14 000] Total: 1.5 million [1.4 million – 1.7 million] Asia and the Pacific 250 000 [210 000– 290 000] North America and Western and Central Europe 27 000 [23 000 – 34 000]

32 WHO – HIV department | March 21, 2015 Estimated number of adults and children newly infected with HIV  2013 Middle East & North Africa 25 000 [14 000 – 41 000] Sub-Saharan Africa 1.5 million [1.3 million – 1.6 million] Eastern Europe & Central Asia 110 000 [86 000 – 130 000] Latin America 94 000 [71 000 – 170 000] Caribbean 12 000 [9400 – 14 000] Total: 2.1 million [1.9 million – 2.4 million] Asia and the Pacific 350 000 [250 000 – 510 000] North America and Western and Central Europe 88 000 [44 000 – 160 000]

33 WHO – HIV department | March 21, 2015 About 6 000 new HIV infections a day in 2013  About 68% are in Sub Saharan Africa  About 700 are in children under 15 years of age  About 5 200 are in adults aged 15 years and older, of whom: ─ almost 47% are among women ─ about 33% are among young people (15-24)

34 WHO – HIV department | March 21, 2015 2013 global HIV and AIDS estimates Children (<15 years) Children living with HIV3.2 million [2.9 million – 3.5 million] New HIV infections in 2013 240 000 [210 000 – 280 000] Deaths due to AIDS in 2013190 000 [170 000 – 220 000]

35 WHO – HIV department | March 21, 2015 2 million people newly enrolled on antiretroviral treatment in 2013 – the largest ever annual increase

36 WHO – HIV department | March 21, 2015

37 23% of children in need received treatment in 2013 as compared to 37% for adults, pointing to a larger gap between services for adults and children living with HIV


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