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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: % —Vaginaal: M to V = %, V to M = % —Oraal ~ 10x lager dan vaginaal Cofactor : STDs, geen circumcisie, menstruatie, viral load

7 Studie uit Uganda Virale loadTransmissie rate elk jaar < % % 10,000-49,99914% 50,000+23% Quinn et al, NEJM 2000:342: 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

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] [ – ] 1.5 million [1.4 million – 1.7 million] 1.3 million [1.2 million – 1.5 million] [ – ] 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 [ – ] Sub-Saharan Africa 24.7 million [23.5 million – 26.1 million] Eastern Europe & Central Asia 1.1 million [ – 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 [ – ] 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 Nigeria India Kenya, Mozambique, Uganda Tanzania, Zimbabwe Zambia

17 CDC definitie Stage A: asymptomatic Stage B: minor complications Stage C: AIDS indicator diseases 1: >500 CD4 cells 2: 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– Deaths per 100 person years ARV therapy including proteaseinhibitors (% of patient days) Deaths ARV Source: Palella et al., New England Journal of Medicine, 1998 Mar, 26: 338– 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: < : < : < 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 (CD ) 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:

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 [ – ] Sub-Saharan Africa 2.9 million [2.6 million – 3.2 million] Eastern Europe & Central Asia [ – ] Latin America [ – ] Caribbean [ – ] Children (<15 years) estimated to be living with HIV  2013 Total: 3.2 million [2.9 million – 3.5 million] Asia and the Pacific [ – ] 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 [ – ] Sub-Saharan Africa 1.1 million [1.0 million – 1.3 million] Eastern Europe & Central Asia [ – ] Latin America [ – ] Caribbean [8300 – ] Total: 1.5 million [1.4 million – 1.7 million] Asia and the Pacific [ – ] North America and Western and Central Europe [ – ]

32 WHO – HIV department | March 21, 2015 Estimated number of adults and children newly infected with HIV  2013 Middle East & North Africa [ – ] Sub-Saharan Africa 1.5 million [1.3 million – 1.6 million] Eastern Europe & Central Asia [ – ] Latin America [ – ] Caribbean [9400 – ] Total: 2.1 million [1.9 million – 2.4 million] Asia and the Pacific [ – ] North America and Western and Central Europe [ – ]

33 WHO – HIV department | March 21, 2015 About 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 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, global HIV and AIDS estimates Children (<15 years) Children living with HIV3.2 million [2.9 million – 3.5 million] New HIV infections in [ – ] Deaths due to AIDS in [ – ]

35 WHO – HIV department | March 21, 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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