HIV/AIDS UPDATE Janez Tomažič Klinika za infekcijske bolezni in vročinska stanja Katedra za infekcijske bolezni in epidemiologijo

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1 HIV/AIDS UPDATE 2017 Janez Tomažič Klinika za infekcijske bolezni in vročinska stanja Katedra za infekcijske bolezni in epidemiologijo

2 Patogeneza okužbe s HIV

3 1. Sesutje imunskega sistema

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5 KLINIČNE OPREDELITVE HIV OKUŽBE (CDC)

6 Patogeneza okužbe s HIV

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8 HIV and antiretroviral treatment (ART) might affect cardiovascular disease (CVD) through various pathophysiological pathways (together with environmental and genetic factors). Hemkens L G, and Bucher H C Eur Heart J 2014;eurheartj.eht528 Published on behalf of the European Society of Cardiology. All rights reserved. The Author For permissions please journals.permissions@oup.com

9 Kdo naj se odloči, da bolniku predlaga testiranje na HIV?

10 Katerikoli zdravnik

11 KDAJ POMISLITI NA OKUŽBO S HIV? epidemiološke okoliščine: MSM?, imel že SPO, hepatitis B/C, bivanje v tujini itd. indikatorske bolezni : AHS; oralna kandidoza; splošne težave, kot so hujšanje, utrujenost, vročina, driska; pasovec; okvara facialisa, ponavljajoče se okužbe, srbeča koža itd. bolezni, ki opredeljujejo aids: sindrom hujšanja, kandidoza požiralnika, PCP, ponavljajoče se bakterijske pljučnice itd.

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19 KDAJ POMISLITI NA OKUŽBO S HIV? epidemiološke okoliščine: MSM?, imel že SPO, hepatitis B/C, bivanje v tujini itd. indikatorske bolezni : AHS; oralna kandidoza; splošne težave, kot so hujšanje, utrujenost, vročina, driska; pasovec; okvara facialisa, ponavljajoče se okužbe, srbeča koža itd. bolezni, ki opredeljujejo aids: sindrom hujšanja, kandidoza požiralnika, PCP, ponavljajoče se bakterijske pljučnice itd.

20 Naravni potek okužbe (klinična slika) z virološkimi in imunološkimi spremembami pri nezdravljenem bolniku

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26 Naravni potek okužbe (klinična slika) z virološkimi in imunološkimi spremembami pri nezdravljenem bolniku

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37 Naravni potek okužbe (klinična slika) z virološkimi in imunološkimi spremembami pri nezdravljenem bolniku

38 Časovnica pojavljanja možnih»indikatorskih bolezni«(bolezni, pri katerih moramo pomisliti, da bi šlo lahko za okužbo s HIV) in bolezni, ki opredeljujejo aids pri bolniku, okuženem s HIV

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42 Bolnik KD, roj 1988; od 18. leta ima odnose z moškimi doma in v tujini (Nemčija, Portugalska, Dubaj); marca 2015 je bil sprejet zaradi dispneje ob naporu, vztrajajoče vročine, ni mogel globoko vdihniti zraka, nočno potenje; 157 CD4/mm3; kopij/ml PCP

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45 Bolnik s HAND, star 72 let, sprejet na Nevrologijo KIBVS (demenca, hemipareza, ataksija; ob HAART se je v 2 mesecih popravil do samostojnosti)

46 Bolnica KA roj. 1981; prišla avg. 2014: gl., vročina, bizarni zgibki d. roke likvor: pr 0.7; glu 3,8; sed: 3 limfociti; poz. PCR na toxoplazmozo Serum: poz. IgG na toxoplazmozo; preživela, boljša, obč. še zgibki

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48 ZDRAVLJENJE

49 Relevant treatmet guidelines

50 Življenjski krog HIV in mehanizmi delovanja zdravil

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54 ART

55 ART

56 NRTI: Descovy, Kivexa NNRTI: rilpivirin (Eviplera ) etravirin, efavirenz

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60 2 N(T)RTI + 3RD DRUG NNRTI INSTI PI

61 NNRTI: rilpivirin (Eviplera ) etravirin, efavirenz

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66 INSTI: dolutegravir (Tiumeq ), raltegravir, elvitegravir (Genvoya )

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71 darunavir/r atazanavir/r lopinavir/r (Kaletra )

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76 START: IMMEDIATE VS DEFERRED THERAPY FOR ASYMPTOMATIC, ART-NAIVE PTS International, randomized trial HIV-positive, ART-naive adults with CD4+ cell count > 500 cells/mm3 (N = 4685) Study closed by DSMB following interim analysis Immediate ART ART initiated immediately following randomization (n = 2326) Deferred ART Deferred until CD4+ cell count 350 cells/mm3, AIDS, or event requiring ART (n = 2359) Composite primary endpoint: any serious AIDS-related (AIDS-related death or AIDS-defining event) or non-aids related event (non-aids related death, CVD, end-stage renal disease, decompensated liver disease, non-aids defining cancer) Mean follow-up: 3 yrs; median baseline CD4+ cell count: 651 cells/mm3; median baseline HIV-1 RNA: 12,759 copies/ml Median CD4+ cell count at initiation of ART for deferred group: 408 cells/mm3 INSIGHT START Study Group. N Engl J Med. 2015;[Epub ahead of print]. Lundgren J, et al. IAS Abstract MOSY0302.

77 START: 57% REDUCED RISK OF SERIOUS EVENTS OR DEATH WITH IMMEDIATE ART 4.1% vs 1.8% in deferred vs immediate arms experienced serious AIDS or non-aids related event or death (HR: 0.43; 95% CI: ; P <.001) Cumulative Percent With Event 10 8 Deferred ART 6 4 Immediate ART Mo INSIGHT START Group. N Engl J Med. 2015;[Epub ahead of print]. Lundgren J, et al. IAS Abstract MOSY0302. Reproduced with permission.

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84 INTERDISCIPLINARY CARE FOR HIV POSITIVE PATIENTS - BEYOND UNDETECTABILITY Co- morbidities The involvement of other specialists into management/care of PLHIV

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98 HVALA ZA VAŠO POZORNOST VPRAŠANJA?

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