Download Human Herpesvirus-8

Guidelines for Prevention and Treatment of Opportunistic
Infections in HIV-Infected Adults and Adolescents
Human Herpesvirus-8 Slide Set
Prepared by the AETC National Coordinating Resource Center based on
recommendations from the CDC, National Institutes of Health, and HIV
Medicine Association/Infectious Diseases Society of America
About This Presentation
These slides were developed using recommendations
published in July 2013. The intended audience is clinicians
involved in the care of patients with HIV. Certain sections
have been updated to reflect changes in the published
guidelines.
Users are cautioned that, because of the rapidly changing
field of HIV care, this information could become out of date
quickly. Finally, it is intended that these slides be used as
prepared, without changes in either content or attribution.
Users are asked to honor this intent.
– AETC National Coordinating Resource Center
http://www.aidsetc.org
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Human Herpesvirus-8 Disease
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Epidemiology
Clinical Manifestations
Diagnosis
Prevention
Treatment
Monitoring
Preventing Recurrence
Considerations in Pregnancy
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HHV-8 Disease: Epidemiology
 Associated with Kaposi sarcoma (KS) (all forms) and
certain neoplastic and lymphoproliferative disorders
(primary effusion lymphoma [PEL]), multicentric
Castleman disease)
 HHV-8 seroprevalence in United States: 1-5%
 Higher in MSM regardless of HIV serostatus (20-77%)
 Higher in some Mediterranean countries (10-20%) and parts
of sub-Saharan Africa (30-80%)
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HHV-8 Disease: Epidemiology (2)
 Pathogenesis of HHV-8 disease is unclear
 KS and PEL usually seen in advanced
immunosuppression (CD4 count <200 cells/µL), but can
occur at any CD4 count
 KS incidence up to 30% among AIDS patients in United
States before use of effective ART
 Dramatically lower incidence in recent years
 ART prevents and may regress KS lesions
 Ganciclovir, foscarnet, and cidofovir given for CMV
treatment may prevent or suppress KS
 Castleman disease and PEL remain rare
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HHV-8 Disease: Clinical
Manifestations
 Most with chronic HHV-8 infection are asymptomatic
 Acute infection may cause fever, rash, lymphadenopathy,
bone marrow failure, occasional rapid progression to KS
 Castleman disease: generalized adenopathy, fever; may
progress to multiorgan failure
 PEL: pleural, pericardial, or abdominal effusions; mass
lesions are less common
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HHV-8 Disease: Clinical
Manifestations (2)
 KS presentation varies
widely
 Most have nontender,
purplish, indurated skin
lesions
 Intraoral lesions are
common
 Visceral dissemination
may occur
Credit: P. Volberding, MD; UCSF Center
for HIV Information Image Library
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HHV-8 Disease: Diagnosis
 Routine screening for HHV-8 is not indicated
 Quantitation of HHV-8 by PCR has no established role in
diagnosis
 KS: biopsy
 Consult with specialist for diagnosis of other suspected
HHV-8 disease
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HHV-8 Disease: Prevention
 Preventing Exposure
 HHV-8 shedding in saliva and genital secretions may
transmit HHV-8 to uninfected partners
 Interventions to prevent exposure to HHV-8 not likely to be
highly effective, have not been validated; are not
recommended
 Preventing Disease
 Toxicity of anti-HHV-8 therapy outweighs potential benefits
 Early initiation of ART likely to be most
effective prevention measure
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HHV-8 Disease: Treatment
 ART for all: initiate or optimize
 Limited studies of HHV-8-specific agents
 KS:
 Ganciclovir, foscarnet may regress lesions; cidofovir ineffective in 1 study
 Chemotherapy if visceral KS; consider if widely disseminated cutaneous
KS
 Castleman disease:
 Preferred: valganciclovir 900 mg PO BID for 3 weeks or ganciclovir 5
mg/kg IV Q12H for 3 weeks or valganciclovir 900 mg PO BID + zidovudine
600 mg PO Q6H for 7-12 days
 Alternative: rituximab for 4-8 weeks (effective as alternative or adjunctive
therapy; associated with subsequent exacerbation or emergence of KS)
 PEL:
 Chemotherapy
 IV ganciclovir or PO valganciclovir may be useful adjunct
 Consult with specialist
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HHV-8 Disease: Starting ART
 Early ART initiation is likely to prevent KS and PEL
 ART should be given to all with KS, muticentric
Castleman disease, or PEL
 Insufficient evidence to support specific ARV regimens
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HHV-8 Disease: Monitoring and
Adverse Events
 IRIS reported in HHV-8-infected patients who initiate ART
 KS: new onset KS or exacerbations of previously stable
disease
 Castleman disease: clinical decompensation
 PEL: no data
 ART is key component of therapy and should not be
delayed
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HHV-8 Disease: Preventing
Recurrence
 ART recommended for all with HHV-8 disease
 May prevent KS progression or recurrence
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HHV-8 Disease: Considerations in
Pregnancy
 HHV-8 seropositivity does not appear to affect pregnancy
outcome; screening for HHV-8 not indicated
 Antiviral therapy for HHV-8 infection during pregnancy is
not recommended
 Diagnosis as in nonpregnant women
 For treatment, consult with specialist
 Perinatal transmission occurs infrequently, higher risk
with higher maternal antibody titer; may be associated
with increased infant mortality
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Websites to Access the Guidelines
 http://www.aidsetc.org
 http://aidsinfo.nih.gov
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About This Slide Set
 This presentation was prepared by Susa Coffey, MD,
for the AETC National Resource Center in July 2013.
 See the AETC NRC website for the most current
version of this presentation:
http://www.aidsetc.org
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July 2013
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