Post on 29-Dec-2019
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aiv infeqcia/SidsiT avadmyofTa
mkurnaloba da movla
klinikuri marTvis nacionaluri rekomendacia
(gaidlaini)
2
klinikuri praqtikis erovnuli rekomendacia (gaidlaini) `aiv
infeqcia/SidsiT avadmyofTa mkurnaloba da movla~ miRebulia klinikuri
praqtikis erovnuli rekomendaciebis (gaidlainebi) da daavadebaTa
marTvis saxelmwifo standartebis (protokolebi) SemuSavebis, Sefasebis
da danergvis erovnuli sabWos 2007 wlis 21 martis #1 sxdomaze da
damtkicebulia saqarTvelos Sromis, janmrTelobisa da socialuri
dacvis ministris 2008 wlis 26 ivlisis #176/o brZanebiT.
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aiv infeqcia/SidsiT avadmyofTa mkurnaloba da movla
klinikuri rekomendaciebis zogadi mizani
klinikuri saxelmZRvanelo-rekomendaciebis mizans warmoadgens uaxles
samecniero mtkicebulebebze dafuZnebuli informaciis miwodeba aiv-
infeqcia/SidsiT avadmyofTa gamokvlevis, mkurnalobis, oportunistuli
infeqciebis, vaqcinaciis, monitoringis Sesaxeb eqim -
infeqcionistebisTvis, ojaxis eqimebisTvis, jandacvis pirveladi rgolis
muSakebisTvis, zemoT aRniSnul dargSi momuSave saSualo samedicino
personalisTvis da yvela dainteresebuli pirisTvis.
ganxiluli klinikuri sakiTxebi
mocemuli klinikuri rekomendaciebi ganixilaven aiv-infeqcia/Sidsis
antiretrovirusul mkurnalobasTan dakavSirebul sakiTxebs,
oportunistuli infeqciebis profilaqtikas, gamovlinebebs,
diagnostikasa da mkurnalobas, vaqcinaciis ZiriTad principebs,
avdmyofebis laboratorul-instrumentul gamokvlevebs mkurnalobamde
da mkurnalobis dawyebis Semdeg, romlebic unda Catardes profilur
dawesebulebaSi Sesabamisi kvalifikaciis mqone specialistis mier.
gaidlaini gankuTvnilia
eqim-infeqcionistebisTvis, nebismieri profilis eqimebisTvis socialuri muSakebisTvis da eqTnebisaTvis.
mtkicebulebaTa doneebisa da rekomendaciebis xarisxi
winamdebare saxelmZRvaneloSi yvela rekomendacias gaaCnia gradacia,
romelic aRiniSneba laTinuri asoebiT А-dan D-mde. amave dros yovel gradacias Seesabameba monacemTa mtkicebulebis garkveuli done. rac ufro maRalia rekomendaciis gradacia, miT ufro maRalia kvlevebis
sizuste, romlebzec is aris dafuZnebuli
4
done mtkicebulebis siZlieris done
(Muir Gray) xarisxi rekomendaciis
xarisxi
(Cook et al) I
Zlieri mtkicebuleba, eyrdnoba
minimum erT sistemur
mimoxilvas, romelic efuZneba
swori dizainis mqone
randomizebul kontrolirebad
kvlevas
A
eyrdnoba I donis
mtkicebulebas da
Sesabamisad mtkiced
rekomendebulia
II
Zlieri mtkicebuleba, eyrdnoba
minimum erTi swori dizainis
mqone randomizebul
kontrolirebad kvlevas
B
eyrdnoba I donis
mtkicebulebas da
Sesabamisad
rekomendebulia
III
klinikuri kvleva
randomizaciis gareSe,
kohortuli da SemTxveva-
kontrolis kvlevebi
C
eyrdnoba III donis
mtkicebulebas
SeiZleba CaiTvalos
Sesabamisad
IV
araeqsperimentuli
multicentruli kvlevebi
D
eyrdnoba IV da
Vdonis
mtkicebulebas
saWiroebs konsesuss
Va
avtoritetul profesionalTa
mosazreba
Vb
klinikuri gamocdileba,
aRwerilobiTi kvlevebi an
eqspertTa angariSi
5
aabbrreevviiaattuurraa
aaiivv adamianis imunodeficitis virusi
aalltt alaninaminotransferaza
anrti
ara-nukleoziduri revers transkriftazas
inhibitori
aarrvv antiretrovirusuli
aarrTT antiretrovirusuli Terapia
aasstt aspartataminotransferaza
vvdd virusuli datvirTva
iirrss imunuri rekonstituciis sindromi
iiffaa imunofermentuli analizi
mmaaaarrTT maRalaqtiuri antiretrovirusuli Terapia
mmggbb mJavagamZle baqteria
mmrrttbb multirezistentuli tuberkulozi
nrti
nukleoziduri revers transkriftazas
inhibitori
ooii oportunistuli infeqciebi
ppii proteazas inhibitorebi
ppjjrr polimerizaciis jaWvuri reaqcia
ttbb tuberkulozi
SSiiddssii SeZenili imunodeficitis sindromi
jjaannmmoo jandacvis msoflio organizacia
AABBCC abakaviri ddddII didanozini EEFFVV efavirenzi FFTTCC emtricitabini LLPPVV//rr lopinavir/ritovaniri NNFFVV nelfinaviri ZZDDVV zidovudini RRTTVV ritonaviri SSQQVV seqvinaviri TTDDFF tenofoviri 33TTCC lamivudini UUNNAAIIDDSS gaeros aiv/Sidsis gaerTianebuli programa
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1. daavadebis definicia, klasifikacia da terminologia
Sidsi abreviaturaa da iSifreba, rogorc SeZenili imunodeficitis
sindromi. daavadeba Sidsis gamomwvevia adamianis imunodeficitis virusi
(aiv-i). aiv infeqcia ewodeba daavadebas virusiT inficirebis momentidan
sicocxlis bolomde. terminiT Sidsi aRiniSneba aiv infeqciis bolo
stadia. aiv -i adamianis organizmSi SeWris Semdeg azianebs imunur
sistemas, ris Sedegad inficirebul pirs SesaZloa ganuviTardes
nebismieri infeqcia an/da simsivne, xSirad, sasikvdilo SedegiT.
aiv infeqciis klasifikaciis sistema (CDC)
kkaatteeggoorriiaa CCDD44 uujjrreeddeebbiiss
rraaooddeennoobbiiss
mmiixxeeddvviiTT
kklliinniikkuurrii
kkaatteeggoorriiaa
kklliinniikkuurrii
kkaatteeggoorriiaa AAkklliinniikkuurrii
kkaatteeggoorriiaa BB kklliinniikkuurrii
kkaatteeggoorriiaa CC
A B C
• asimptomuri aiv infeqcia;
• persistuli generali-
zebuli
limfade-
nopaTia
(pgl)*;
simptomuri,
garda A da C kategoriebSi
miTiTebuli
mdgomareo-
bebisa
ezofaguri da/an traqeo-
bronquli kandidozi;
• eqstrapulmonuri koqcidiodomikozi;
• eqstrapulmonuri kriptokokozi;
• saSvilosnos yelis invaziuri kibo;
1) >500/mm3
(≥29%) A1 B1 C1
2) 200-500 mm3
(14-28%) A2 B2 C2
3)
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* ruxi feriT moniSnul ujrebSi
miTiTebuli kategoriebi
Seesabameba Sidss.
• mwvave (pirve-ladi) aiv
daavadeba
* limfuri
kvanZebi or an
met midamoSi
(sazardulis
garda)
diametriT
> 1 sm-ze,
3 an meti Tvis
ganmavlobaSi.
• baqteriuli angiomatozi;
• persistuli vulvova-
ginaluri
kandidozi, 1
Tveze meti
xangrZli-
vobis,
romelic
cudad
eqvemdebareba
mkurnalobas;
• saSvilosnos yelis mZime
displazia an
karcinoma
insitu; • konstitu-ciuri
simptomebi,
mag., cxeleba
(≥38,50C) an diarea 1
Tveze meti
xnis
ganmavlobaSi
• da sxva.
-----------------------------
aRniSnuli
mdgomareobebi
ganpirobebuli
unda iyos aiv
infeqciiT.
• qronikuli intestinuri kriptosporidiozi;
• citomegalovirusuli infeqcia: retiniti, an
sxva lokalizaciis,
garda RviZlis,
elenTis, limfuri
kvanZebisa;
• aiv encefalopaTia; martivi herpesi: kanis da
lorwovanis wylulebiT
1 Tveze meti xnis
ganmavlobaSi,
bronqiti, pnevmonia;
• diseminirebuli, eqstrapulmonuri
histoplazmozi;
• qronikuli izosporiazi;
• kapoSis sarkoma; • limfoma: berkitis, imunoblasturi, Tavis
tvinis pirveladi;
• atipiuri mikobaqteriiT (M.avium an M.kansasii) infeqcia;
• pulmonuri an eqstrapulmonuri
tuberkulozi;
• Pneumocystic carinii-iT gamowveuli pnevmonia;
• rekurentuli pnevmonia, (2 an meti epizodi
weliwadSi);
• progresirebadi mravalkerovani leiko-
encefalopaTia (pml);
• rekurentuli salmoneluri
baqteriemia;
• cerebruli toqsoplazmozi;
• aiv-iT gamowveuli ganlevis sindromi.
terminologia:
virusuli datvirTva – ewodeba adamianis imunodeficitis virusis (aiv-is)
rnm-is raodenobas (koncentracias) plazmis 1 ml-Si;
“fanjara” periodi – ewodeba periods adamianis imunodeficitis virusis
organizmSi SeWridan aiv-antisxeulebis gamomuSavebamde;
mwvave retrovirusuli sindromi – ewodeba aiv-is organizmSi SeWridan 2-
3 kviris Semdeg ganviTarebul “infeqciuri mononukleozis msgavs
sindroms”, romelic grZeldeba 2-3 kvira, mas mosdevs klinikuri
gaumjobesebisa da serokonversiis periodi;
klinikuri gaumjobeseba da serokonversia moicavs 2-4 kviras; am
periodSi organizmSi gamomuSavdeba aiv-antisxeulebi;
asimptomuri/qronikuli aiv infeqcia grZeldeba saSualod 8 weli; am
periodis ganmavlobaSi TandaTan mcirdeba CD4+ limfocitebis absoluturi raodenoba SratSi da izrdeba virusuli datvirTva
plzmaSi;
oportunistuli infeqcia ewodeba iseT infeqciebs, romlis gamomwvevi
(baqteria, virusi, paraziti Tu soko) Cveulebriv SeiZleba janmrTeli
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adamianis organizmSic binadrobdes da ar iwvevdes paTologias da
mxolod imunokomprometirebul pirebSi gamoiwvios davaadeba. maRalaqtiuri antiretrovirusuli Terapia (maarT)- (HAART - High Activity antiretroviral Therapy) –3 an meti antiretrovirusuli preparatis kombinaciis xangrZlivad gamoyenebaa aiv infeqcia/SidsiT avadmyofebSi, romlis
Sedegad: aRdgeba dazianebuli imunuri sistema, xangrZlivad iTrguneba
Sidsis virusis replikacia, xangrZlivdeba avadmyofis sicocxle da
umjobesdeba pacientis sicocxlis xarisxi.
imunuri rekonstituciis sindromi (irs) – ewodeba paradoqsul reaqcias,
romelic viTardeba antiretrovirusuli mkurnalobis dawyebis Semdeg
da gamoxateba mdgomareobis gauaresebiT, rac dakavSirebulia latentur
mdgomareobaSi myofi ama Tu im oportunistuli paTogenis
gaaqtiurebasTan. imunuri rekonstituciis sindromi aixsneba
antiretrovirusuli Terapiis Sedegad aRdgenili imunuri sistemis
uCveulod mZlavri zemoqmedebiT mag: tuberkulozis mikobaqteriaze.
2. epidemiologia aiv infeqcia/Sidsis gavrceleba msoflioSi
aiv/Sidsis epidemia kvlav rCeba dinamikur da mzardi xasiaTis epidemiad,
romelmac saocari siswrafiT moicva msoflios praqtikulad yvela
kontinenti, yvela qveyana da daamtkica, rom igi Tanabrad emuqreba yvelas
rasis, sqesis, asakis, erovnebis, ganaTlebisa da sarwmunoebis miuxedavad.
jandacvis msoflio organizaciis (janmo) monacemebiT Sidss msoflioSi
sikvdilianobis mizezTa Soris meoTxe adgili ukavia. marTalia,
antiretrovirusuli Terapiis (arT) xelmisawvdomobam da efeqturma
profilaqtikurma programebma ganapirobes ganviTarebul qveynebSi
mdgomareobis stabiluroba, magram mTlianad msoflioSi aiv
inficirebulTa ricxvi mudmivad izrdeba.
Sidsi registrirebulia msoflios 216 qveyanaSi. maTgan 41 qveyanaSi aqvs
generalizebuli xasiaTi, xolo 85 – koncentrirebulia mxolod maRali
riskis jgufebSi.
gaeros Sidsis programis (UNAIDS) 2004 wlis monacemebiT msoflioSi epidemiis dawyebidan dRemde inficirebulia 39.4 milioni adamiani, maT
Soris:
mozrdilebi 37.2 mln
qalebi 17,6 mln
bavSvebi
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aRsaniSnavia, rom msoflioSi inficirebis axali SemTxvevebis naxevari 15-
dan 24 wlis asakze modis. amasTan, Tu epidemiis dasawyisSi aiv
inficirebuli mamakacebis raodenoba mniSvnelovnad aRemateboda
inficirebuli qalebis raodenobas, ukanasknel wlebSi proporcia
dairRva da 2002 wlidan msoflioSi Sidsis virusiT inficirebulTa
TiTqmis naxevari qalebma da gogonebma Seadgines. es tendencia
gansakuTrebiT SesamCvevia msoflios im regionebSi, sadac dominirebs aiv-
is gadacemis heteroseqsualuri gza.
sayuradReboa aiv inficirebul orsul qalTa da axalSobilTa
raodenobis mzardi dinamika. gamokvlevebiT dadginda, rom bavSvTa 90%
aiv-iT inficirdeba vertikaluri (dedidan Svilze gadacemis) gziT.
gansakuTrebuli msjelobis sagania Sidsis gamo daoblebuli bavSvebi.
mxolod, sub-saharul afrikaSi Sidsis Sedegad daaxloebiT 12 milion
bavSvs daeRupa erTi an orive mSobeli.
aiv infeqcia/Sidsis yvelaze meti SemTxveva oficialurad aRricxulia
aSS-Si. Tumca realurad inficirebulTa raodenoba yvelaze metia
afrikis kontinentze.
marTalia, sub-saharul afrikaSi dedamiwis populaciis mxolod 10%
cxovrobs, magram msoflioSi yvela aiv inficirebulTa 2/3 swored am
regionze modis. subsaharuli afrikis qveynebSi aiv infeqciis gadacemis
ZiriTadi gza heteroseqsualuri kontaqtebia.
amerikis kontinentze aRricxulia daaxloebiT 2,7 mln aiv inficirebuli
(CrdiloeTi amerika – 1 mln SemTxveva, samxreTi amerika – 1,7 mln).
kanadasa da aSS-Si aiv inficirebis SemTxvevaTa 25% gamowveulia
narkotikebis ineqciuri moxmarebiT.
amerikis kontinentze aiv infeqcia aSS-s Semdeg yvelaze farTod
braziliasa da meqsikaSi aris gavrcelebuli. am qveynebSi dominirebs aiv
infeqciis gavrceleba narkotikebis ineqciuri moxmarebiT an
homoseqsualuri kontaqtebis Sedegad.
dasavleT evropaSi aiv/Sidsis yvelaze meti SemTxveva aRricxulia
inglisSi (≈ 62.000), Semdeg SveicariaSi, portugaliasa da germaniaSi. aiv/Sidsis gavrcelebis maRali maCveneblebi dafiqsirda holandiaSi,
SvedeTSi, saberZneTSi, safrangeTsa da italiaSi. inficirebulTa 37%
qalia, 29% _ axalgazrdebi 30 wlamde. am qveynebSi aiv inficirebis
ZiriTadi mizezebia
• 50% _ heteroseqsualuri kontaqtebi • 30% _ homo/biseqsualuri kontaqtebi • 11% _ narkotikebis ineqciuri moxmareba
centralur evropaSi kvlav SenarCunebulia aiv/Sidsis SemTxvevaTa
dabali prevalentoba, Tumca am regionSi maRalia pediatriuli Sidsis
maCveneblebi.
aziis kontinentze registrirebulia aiv infeqciis 7.4 mln. SemTxveva. es
regioni didi xnis manZilze aiv infeqciisagan Tavisufal zonad
iTvleboda, amJamad ki axali SemTxvevebis gamovlinebis mxriv azia erT-
erT pirvel adgilze aRmoCnda. gansakuTrebiT SemaSfoTebeli
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statistikaa samxreT (pirvel rigSi CineTsa da indoeTSi) da samxreT
aRmosavleT aziaSi.
epidemia Zalas ikrebs aRmosavleT evropis qveynebSi. ukanasknel wlebSi
msoflioSi aiv infeqciis yvelaze swrafi aRmavloba swored am regionSi
dafiqsirda. axali SemTxvevebis 76% modis ruseTis federaciaze, sadac
yovelwliurad ormagdeba inficirebulTa raodenoba. aiv/Sidsis
epidafeTqeba aRiniSneba ukrainasa da belorusiaSi. ukrainaSi
mosaxleobis 1%-ia inficirebuli.
aRmosavleT evropis qveynebSi aiv inficirebis mizezebia:
• 61% _ narkotikebis ineqciuri moxmareba • 24% _ heteroseqsualuri kontaqtebi • 0,3% _ homo/biseqsualuri kontaqtebi
aiv infeqcia/Sidsis gavrcelebis ZiriTadi gza am regionSi ineqciuri
narkomaniaa, Tumca sul ufro izrdeba aiv-is heteroseqsualuri
transmisiis SemTxvevebi. aRniSnulis gaTvaliswinebiT saxezea Sidsis
virusis riskis jgufis pirebidan mosaxleobis farTo fenebSi
gavrcelebis tendencia.
aiv infeqcia/Sidsis gavrceleba saqarTveloSi 2006 wlis 31 dekembris monacemebiT saqarTveloSi oficialurad
registrirebulia aiv infeqcia/Sidsis 1800 SemTxveva, maTgan 2006 wels
gamovlinda 243 aiv inficirebuli adamiani.
registrirebul SemTxveevaTa 79% saqarTvelos sazRvrebs garedan
Semotanili infeqciaa. 18,5% Semotanili infeqciis lokaluri
gavrcelebis Sedegia aiv inficirebulis meuRleebsa da sqesobriv
partniorebze infeqciis gadacemis Sedegad.
gamovlenil inficirebulTagan 195 qalia, 643 mamakaci. 339 ganuviTarda
Sidsi, 174 - gardaicvala.
saqarTveloSi gamovlenili aiv inficirebulebis 64.3% daavadda
narkotikebis ineqciuri gziT moxmarebis Sedegad, 28.4% dainficirda
heteroseqsualuri kontaqtiT, 3,4% _ homo/biseqsualuri kontaqtiT, 1,1 %-
daavadda virusis vertikalurad (dedidan bavSvze) gadacemis gziT, 1,6,%-
Si inficirebis gza daudgenelia, 1,2 % dainficirda sisxlis gadasxmiT.
aiv inficirebis yvelaze meti SemTxveva registrirebulia TbilisSi 306,
Semdeg samegreloSi - 129, aWaraSi - 121 da imereTSi - 78. gamovlinda
ucxoeTis 25 moqalaqe, maTgan 10 dabrunda TavianT qveyanaSi.
saqarTveloSi SeiniSneba aiv infeqciis gavrcelebis aRmavali tempi. 2000
wels moxda aiv infeqciis registrirebuli SemTxvevebis gaormageba (1999
wlis 34 SemTxvevasTan SedarebiT 2000 wels gamovlinda 79 axali
SemTxveva), Semdeg 2004 wels moxda 2003 welTan SedarebiT SemTxvevaTa
1,5-jer zrda. 2005 wlis 20 oqtombris monacemebiT gamovlinda 170 axali
SemTxveva, rac aRemateba mTeli 2004 wlis manZilze gamovlenil
SemTxvevaTa ricxvs. saqarTveloSi aiv infeqciis gavrcelebis
Taviseburebani iseTivea, rogorc aRmosavleT evropis qveynebSi. Sidsis
gavrcelebis upirveles risk-jgufs aqac ineqciuri narkomanebi
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warmoadgenen. magram, rogorc sxva qveynebis gamocdileba gviCvenebs,
Sidsis epidemia ar Semoifargleba mxolod narkomanTa wriT, Sidsis
Semdegi msxverplni narkomanTa sqesobrivi partniorebi iqnebian.
aiv infeqciis gadacemis gzebi
aiv infeqciis wyaros warmoadgens aiv inficirebuli an SidsiT
daavadebuli adamiani, rogorc daavadebis usimptomo periodSi, aseve -
klinikuri suraTis gaSlis Semdeg.
aiv aRmoCenilia adamianis mTel rig biologiur siTxeebSi. mas
gansakuTrebiT maRali koncentraciiT Seicavs sisxli, sperma, vaginaluri
sekreti, Tavzurgtvinis siTxe da dedis rZe.
Sidsis virusi gadaecema
• sqesobrivi kontaqtiT _ rogorc hetero, ise homoseqsualuri kontaqtebiT (vaginaluri, analuri, oraluri);
• aiv inficirebuli sisxlis an misi calkeuli komponentebis gadasxmiT; aiv inficirebuli sisxliT dabinZurebuli Spricis, nemsis da sxva
samedicino instrumentebis gamoyenebis SemTxvevaSi;
• inficirebuli dedisgan nayofze an axalSobilze mucladyofnis periodSi, mSobiarobis an ZuZuTi kvebis dros.
Sidsis virusi ar gadaecema:
• haer-wveTovani gziT. Sesabamisad ar aris saSiSi aiv inficirebulTan saubari, virusi ar gadaecema daxvelebiT, daceminebiT an kocniT.
• sayofacxovrebo da socialuri kontaqtebiT. ar aris saSiSi xelis CamorTmeva, moxveva, daavadebulis mier gamoyenebuli WurWliT,
TeTreuliT, saerTo tualetiT da abazaniT sargebloba. ar aris
saSiSi aiv inficirebulTan erTad yofna sazogadoebrivi TavSeyris
adgilebSi da mgzavroba transportiT.
• virusi ar gadaecema mwerebis an/da cxovelebis saSualebiT. 3. aiv infeqciis etiopaTogenezi
aiv miekuTvneba retrovirusebis ojaxs,
lentivirusebis qveojaxs. lenti-
virusebi, Cveulebriv, nel infeqciebs
iwveven. maTTvis damaxasiaTebelia
daavadebis xangrZlivi latenturi
periodi, paTologiur procesSi
nervuli sistemis CarTva da susti
imunuri pasuxi, rasac Tan sdevs
persistuli viremia. ganasxvaveben aiv-1-
sa da aiv-2-s. aiv-2 mogvianebiT
aRmoaCines. igi aiv-1-sgan genetikuri
Taviseburebebis mixedviT gansxvavdeba
da ZiriTadad dasavleT afrikis
zogierT qveyanaSia gavrcelebuli,
Tumca sxva qveynebSic gvxvdeba. aiv-2
aiv-1-Tan SedarebiT ufro Znelad gadaecema. iSvaTia misi vertikaluri
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gadacemis SemTxvevebic. aiv-2 infeqcia klinikurad aiv-1 infeqciis
msgavsia, Tumca virusuli datvirTva, Cveulebriv, dabalia da
daavadebis klinikuri progresireba ufro nelia.
aiv advilad inaqtivirdeba garemoSi. mSral pirobebSi virusi ramdenime
saaTSi iRupeba, Tumca SesaZloa 1-3 dRe gaZlos. Qqsovilovan kulturaSi
virusi oTaxis temperaturaze 15 dRe Zlebs, xolo 370C-ze – 11 dRe. 56-600C-ze virusi 30 wT-Si iRupeba. virusi advilad eqvemdebareba qimiuri saSualebebiT sterilizacias. adamianis imunodeficitis virusi mdgradia
dabali temperaturisadmi -700C-ze ar inaqtivirdeba.
aiv-is ZiriTadi samizne ujredebia CD4+ limfocitebi (T helper anu Th limfocitebi), garda amisa igi ainficirebs monocit/makrofagebs, cns-is
mikroglias, folikulur-dendritul ujredebs da sxva.
aiv-iT ujredis inficirebisas virusis garsis cila – gp120 uerTdeba samizne ujredis CD4 molekulas, rasac mohyveba virusis Sesvla ujredSi da misi genetikuri masalis integracia maspinZlis genomSi. Semdeg ki
axali virionebis awyoba.
adamianis imunodeficitis virusis sasicocxlo cikli
rogorc cnobilia, CD4+ limfocitebi aiv-is ZiriTadi samizne ujredebia. isini ZiriTad rols asruleben rogorc humoruli, ise – ujreduli
imunuri pasuxis ganxorcielebaSi, ris gamoc maT imunuri orkestris
diriJors uwodeben. aiv infeqciis imunopaTogenezSi wamyvani mniSvneloba
eniWeba CD4+ limfocitebis raodenobis Semcirebas da maTi funqciis daTrgunvas, rasac Sedegad moyveba imunuri sistemis funqciis daTrgunva
– imunosupresia. CD4+ limfocitebis ricxvi progresulad mcirdeba aiv infeqciis progresirebasTan erTad. igi virusul datvirTvasTan erTad
mniSvnelovani markeria aiv daavadebis monitorirebisaTvis.
aRsaniSnavia, rom virusis replikaciis TiToeul ciklSi warmoqmnili
Stamebi erTmaneTisgan mniSvnelovnad gansxvavdeba ujreduli tropizmiT,
antigenurobiT, wamlebis mimarT mgrZnobelobiT da sxva. aiv-is maRali
mutagenoba mas saSualebas aZlevs efeqtianad aicilos Tavidan
antivirusuli imunuri pasuxi, rac virusis persistencias uwyobs xels.
garda amisa, aiv-is mutaciis amgvari unari dabrkolebebs qmnis vaqcinis
SemuSavebisas da ganapirobebs wamlebis mimarT rezistentuli Stamebis
warmoqmnas.
13
aiv inficirebis gza, moxvedrili virusis raodenoba, aiv-is mocemuli
Stamis paTogenuroba da maspinZlis genetikuri faqtorebi gavlenas
axdens aiv specifikur imunur pasuxze.
maneitralizebeli antisxeulebi gamomuSavdebian pirveladi infeqciidan
2-4 kviris Semdeg da maqsimums asimptomuri fazis dros aRweven. maTi
gansazRvra sisxlSi rutinuli serologiuri testebiT SesaZlebelia
inficirebidan 4-8 kviris Semdeg. Aantisxeulebis gaCenas sisxlSi
serokonversia ewodeba. xolo periods inficirebidan serokonversiamde –
e.w. window periodi.
aiv antisxeulebis koncentracia mkveTrad ecema Sidsis ganviTarebasTan
erTad. maneitralizebeli antisxeulebi aiv sawinaaRmdego citotoqsikur
T limfocitebTan erTad imunuri pasuxis erT-erTi ZiriTadi komponentia, romelic dasawyisSi nawilobriv ablokirebs aiv-is replikacias. Tumca
pirveladi infeeqciis dros ar xdeba aiv-is sruli eliminacia, rac
infeqciis qronikul mimdinareobas ganapirobebs. provirus dnm-is
integracia maspinZeli ujredis genetikur masalaSi da
imunokompetenturi ujredebis, upiratesad, CD4+ limfocitebis destruqcia, imunuri sistemis funqciis moSlas da Rrma imunodeficitis
ganviTarebas iwvevs.
4. klinikuri simptomatika
aiv infeqciis klinikuri speqtri
aiv infeqciis bunebriv mimdinareobaSi (mkurnalobis gareSe) gamoyofen
Semdeg stadiebs:
virusis organizmSi SeWridan – 2-3 kviraSi viTardeba e.w. mwvave retrovirusuli sindromi – 2-3 kvira; klinikuri gaumjobeseba da serokonversia – 2-4 kvira; asimptomuri qronikuli aiv infeqcia – saSualod 8 weli; simptomuri aiv infeqcia/Sidsi – saSualod 1-3 weli; sikvdili.
aiv infeqciis pirveladi gamovlinebaa mwvave retrovirusuli sindromi,
romelsac Tan axlavs CD4+ limfocitebis ricxvis mkveTri daqveiTeba, plazmaSi maRali viremia.
cxrili #1
pirveladi aiv infeqcia: Civilebi da simptomebi (2002; US DHHS)
cxeleba – 96% mialgia – 54% hepatosplenomegalia –
14%
adenopaTia - 74% diarea – 32% wonaSi kleba – 13%
faringiti – 70% Tavis tkivili – 43% rZiana –12%
gamonayari – 70%
(eriTematozuli makulo-
papuluri gamonayari
sisuste da
moTenTiloba – 27%
nevrologiuri
gamovlinebebi – 12%
(aseptiuri meningiti,
14
saxesa da tanze,
iSviaTad – xelisa da
fexis gulebze, zogi
aRniSnavs wylulovan
gamonayars piris RruSi,
saylapavisa da
genitaluri organoebis
lorwovanze)
meningoencefaliti,
periferiuli
neiropaTia, gien-bares
sindromi, mxris
nevriti, kognitiuri
darRvevebi an
fsiqozuri
mdgomareoba)
klinikuri gaumjobesebis fazaSi aRiniSneba plazmaSi viremiis Semcireba,
citotoqsiuri T limfocitebiT ganpirobebuli imunuri pasuxi.
CD4+ limfocitebis ricxvis daqveiTeba kavSirSia virusuli datvirTvis matebasTan, rac Sidsis ganviTarebisa da avadmyofis sikvdilis mizezia.
2002 wels Catarebuli erT-erTi gamokvlevis SedegebiT CD4+ limfocitebis ricxvi aiv rnm-is koncentraciis yoveli log10-iT matebisas 1 ml-Si saSualod 4%-iT iklebs weliwadSi.
aiv rnm-is koncentracia plazmaSi mkveTrad imatebs mwvave infeqciis
periodSi da Semdeg iklebs, rac serokonversiisa da imunuri pasuxis
Sedegia.
daavadebis gviani stadia xasiaTdeba CD4+ limfocitebis ricxvis daqveiTebiT
15
limfocitebis absoluturi ricxvi 1 mm3 sisxlSi, romelTa saSualebiT
SeasZlebelia daavadebis stadiisa da simZimis Sefaseba da mosalodneli
progresirebis prognozireba Sidsis klinikuri niSnebis gamovlenamde 1,5-
2 wliT adre. virusuli datvirTvis matebas, rogorc wesi, Tan sdevs CD4+ limfocitebis absoluturi ricxvis Semcireba. CD4+ pirdapirproporciul kavSirSia oportunistuli daavadebebis
ganviTarebis riskTan. Uufro metic, CD4+ ujredebis garkveul maCvenebelze, ama Tu im konkretuli oportunistuli infeqciis da/an
simsivneebis ganviTarebaa mosalodneli (ix. cxr. #2).
cxrili #2
CD4+ limfocitebis ricxvis korelacia aiv infeqciis garTulebebTan
CD4+ limfocitebis
ricxvi
infeqciuri garTulebebi arainfeqciuri
garTulebebi
>500/mm3 - mwvave retrovirusuli
sindromi
- vaginaluri kandidozi
- persistuli generalizebuli
limfadenopaTia;
- gien-bares sindromi;
- miopaTia;
- aseptiuri meningiti.
200-500/mm3 - pnevmokokuri da sxva
baqteriuli pnevmoniebi;
- filtvis tuberkulozi;
- herpes zosteri;
- orofaringeuli kandi-
dozi;
- kriptosporidiozi,
TviTgankurnebadi;
- kapoSis sarkoma;
- Tmovani leikoplakia.
- cervikaluri
intraepiTeluri neoplazia;
- cervikaluri simsivne
(asocirebulia adamianis
papilomavirusTan);
- ujreduli simsivne;
- anemia;
- idiopaTiuri
Trombocitopeniuli purpura;
- hojkinis limfoma;
- limfocituri
intersticiuli pnevmonia.
16
17
• saSvilosnos yelis invaziuri kibo da analuri invaziuri kibo homoseqsual mamkacebSi;
• kapoSis sarkoma.
sayuradReboa, rom samive zemoT CamoTvlili simsivne asocirebula
virusebTan. limfuri sistemis kibo asocirebulia epStein-baris
virusTsan; saSvilosnos yelisa da analuri invaziuri kibo
asocirebulia papilomavirusTan, kapoSis sarkoma asocirebulia
adamianis me-8 tipis herpesis virusTan.
am simsivneebis arsebobis dros aucilebelia aiv intisxeulebze
testireba.
amasTan, aucileblad unda iqnes gaTvaliswinebuli epidemiologiuri
monacemebi (maRali riskis jgufi, aiv inficirebulTan kontaqti da sxva),
garda amisa, aiv infeqciaze gamokvleul unda iyvnen:
• sggd avadmyofebi: sifilisiT; gonoreiT; qlamidioziT; veneriuli limfogranulomiT; triqomoniaziT da a.S daavadebulebi.
• B hepatitis virusiT inficirebulni; • C hepatitis virusiT inficirebulni; • tuberkulozis nebismieri formiT daavadebulni (filtvis
tuberkulozi, limfuri sistemis tuberkulozi, tuberkulozuri
poliseroziti, tuberkulozuri meningiti).
aramotivirebuli cxeleba (ucnobi etiologiis cxeleba)
ganmarteba: ucnobi etiologiis cxeleba ewodeba sami ZiriTadi
maxasiaTebelis Tanaarsebobas: 1) cxeleba 38.30C-ze an meti, 2)romelic
18
grZeldeba 3 kviraze meti periodis ganmavlobaSi 3) da diagnozis
garkveva ver moxerxda erTkviriani hospitalizaciis ganmavlobaSi.
samkviriani periodi aucilebelia TviTgankurnebadi virusuli
infeqciebis gamosaricxad.
persistuli generalizebuli limfadenopaTia
ganmarteba: persistuli generalizebuli limfadenopaTia ewodeba
mdgomareobas, rodesac 3 kviraze meti periodis ganmavlobaSi
hiperplazirebulia qvemoT CamoTvlili kanqveSa limfuri kvanZebidan 2-3
an meti: yuris wina, qvedaybisqveSa, kisris wina da ukana, kefisukana,
laviwzeda, laviwqveSa, iRliis, idayvis, sazardulis horizontalur
limfur kvanZTa jgufi, sazardulis vertikalur limfur kvanZTa jgufi.
samkviriani periodi aucilebelia limfadenopaTiiT mimdinare
TviTgankurnebadi virusuli infeqciebis gamosaricxad (ix. qvemoT).
persistuli generalizebuli limfadenopaTiis mizezi garda aiv
infeqciisa SeiZleba iyos:
- simsivneebidan: limfomebi, leikemiebi, kapoSis sarkoma, metastazebi;
- infeqciebidan: brucelozi, katis nakawris daavadeba, veneriuli limfogranuloma, infeqciuri mononukleozi, wiTura,
tuberkulozi, tularemia, tifoiduri cxeleba, sifilisi.
- autoimunuri daavadebebidan: sistemuri wiTeli mglura, revmatoiduli arTriti, dermatomioziti, Segrenis sindromi.
- iSviaTad: kavasakis daavadeba, sarkoidozi, medikamentebiT provocirebuli.
ganlevis sindromi
ganmarteba: wonaSi umizezod kleba sawyis wonasTan SedarebiT 10%-ze
meti erTi Tvis manZilze.
konstituciuri simptomebi (CDC-is klasifikaciiT) (aiv kaxeqsia – janmos klasifikaciiT)
ganmarteba:
- wonaSi umizezod kleba: sawyisi wonis 10%-ze meti, - an ucnobi etiologiis qronikuli diarea - 1 Tveze meti
xangrZlivobis,
- an qronikuli sisuste SeuRlebuli xangrZliv (1 Tveze meti) ucnobi etiologiis cxelebasTan
ucnobi etiologiis qronikuli diarea
ganmarteba: qronikuli ewodeba diareas, romelic meordeba TiTqmis
yoveldRe 1 Tvis an meti drois manZilze. qronikuli diarea SeiZleba
mimdinareobdes ganlevis sindromiT an mis gareSe, temperaturiT an mis
gareSe.
afebriluri qronikuli diareis gamomwvevi SeiZleba iyos
kroptosporidia, izospora, mikrosporidia.
temperaturuli reaqcia Tan axlavs qronikuli diareis Semdeg mizezebs:
Jiardiozi, amebiazi, citomegalovirusiT gamowveuli diarea.
19
garda zemoT CamoTvlili gamomwvevebisa qronikuli diareis mizezi Rrma
imunodeficitis dros SeiZleba iyos: Mycobacteria Avium, Cyclospora cayetyaensis, Enteric virusis. zemoT CamoTvlili gamomwvevebis umravlesobis identifikacia Zalian
rTulia da aucilebelia an kvlevis kulturaluri meTodebis an
nawlavis biofsiis gamoyeneba.
gamonayari kansa da lorwovanze
imunokomprometirebul pirebSi gvxvdeba kanisa da lorwovanis igive
daavadebebi, rac imunokompetentur pirebSi, Tumca imunokom-
prometirebulebSi kanisa da lorwovanis banaluri daavadebebi
mimdinareobs rTulad, aqvs persistuli xasiaTi da rTulia samkurnalod.
qvemoT, mokled aris daxasiTebuli kanisa da lorwovanis is daavadebebi,
romlebic ufro xSirad viTardeba aiv infeqcia/Sidsis fonze.
Sesabamisad, klinicistma qvemoT aRwerili kanis da lorwovanis
romelime daavadebis identifikaciisas avadmyofi unda gamoikvlios aiv
antisxeulebze.
5. daavadebis diagnozi
laboratoriuli diagnostika
vinaidan aiv infeqcias paTognomuri klinikuri niSnebi ar gaaCnia,
gadamwyveti mis diagnostikaSi laboratoriuli gamokvlevaa.
aiv infeqciis laboratoriuli diagnostika sxvadasxva meTodiT
xorcieldeba, virusis kultivireba Semdgomi identifikaciiT, sisxlsa da
sxva biologiur siTxeebSi virusis antigenis da antisxeulebis
gansazRvra, virusis genomis gamovlena da sxva.
dReisaTvis aiv infeqciis laboratoriuli diagnostikis ZiriTadi
saSualebebia sisxlSi aiv sawinaaRmdego antisxeulebis da virusis
genetikuri masalis gansazRvra.
aiv antisxeulebis gansazRvris meTodebi or jgufad iyofa – pirveladi
anu skrininguli da damadasturebeli anu komfirmaciuli. skriningul
meTodebs miekuTvneba: aiv antisxeulebis gamovlena imunofermentuli
analizis (ifa), imunofluorescenciis, hemaglutinaciis,
imunoqromatografiis, mikroprecipitaciis da sxva meTodebiT.
gamokvlevis xangrZlivobis mixedviT es meTodebi iyofa Cveulebriv
(xangrZlivoba 2-5 saaTi) da swraf/martiv (xangrZlivoba 5-30 wuTi)
meTodebad. konfirmaciuli meTodebidan ZiriTadad gamoiyeneba
imunoblotingi (Western blot).
skriningul meTodebs Soris yvelaze farTod gamoiyeneba aiv
antisxeulebis gamovlena ifa da swrafi/martivi meTodebiT, romlebic
maRali mgrZnobelobiTa da specifikurobiT xasiaTdeba da amasTan,
advilad xelmisawvdomia. maTi saSualebiT aiv antisxeulebi sisxlSi
vlindeba inficirebidan 4-8 kviris Semdeg. dadebiTi Sedegis SemTxvevaSi
20
kvleva grZeldeba damadasturebeli anu, konfirmaciuli meTodiT –
imunoblotingiT (Western blot). imunoblotingis meTodi saSualebas iZleva ganisazRvros specifikuri antigenebis, anu virusis calkeuli cilebis
sawinaaRmdego antisxeulebi.
sadReisod yvelaze zusti da maRalmgrZnobiare meTodia virusis genomis
(rnm, dnm) gamovlena polimerizaciis jaWvuri reaqciis (PCR) meTodiT. arsebobs virusis genomis gamovlenis alternatiuli meTodebic – bDNA (branched chain DNA) da NASBA (Nucleic Acid Sequence-Based Amplification). Tumca Tavisi mgrZnobelobiTa da specifikurobiT sadReisod isini PCR meTods CamorCeba. bDNA meTodiT xdeba virusis rnm-is moniSnuli monakveTidan signalis amplifikacia komplementuri dnm-iT hibridizaciis gziT. xolo
PCR da NASBA meTodebis SemTxvevaSi xdeba virusis moniSnuli rnm-is amplifikacia fermentuli meTodebiT ise, rom gamravlebuli rnm
ganisazRvros Cveulebrivi meTodebiT.
PCR, romelic 80-ian wlebSi dainerga, didi win gadadgmuli nabijia zogadad infeqciuri daavadebis, maT Soris aiv infeqciis diagnostikaSic.
misi saSualebiT xdeba infeqciuri agentis genetikuri masalis
amplifikacia da gamovlena im SemTxvevaSic ki, roca misi koncentracia
gamosakvlev masalaSi ukiduresad mcirea (1 virusi 100 000 ujredze).
PCR meTodi ori saxisaa: Tvisobrivi da raodenobrivi. Tvisobrivi gamoiyeneba aiv infeqciis diagnostikisaTvis adreul stadiaze – sisxlSi
antisxeulebis gaCenamde, agreTve ifa da imunoblotingiT saWvo pasuxis
miRebis SemTxvevaSi. gansakuTrebiT didia misi diagnostikuri
Rirebuleba inficirebuli dedis axalSobilis aiv infeqciis
diagnostirebisas. rogorc cnobilia, aiv inficirebuli dedis
axalSobils SesaZloa arainficirebis SemTxvevaSic ki aReniSnos aiv
antisxeulebis arseboba maTi transplacenturi barieris gavlis gamo.
amitom gadamwyveti mniSvneloba axalSobilis aiv infeqciis
diagnostikaSi swored PCR meTods eniWeba.
raodenobrivi meTodi saSualebas iZleva ganisazRvros e.w. virusuli
datvirTva, anu virusis raodenoba 1 ml plazmaSi. virusuli datvirTva
saukeTeso markeria daavadebis prognozirebisa da mkurnalobis
efeqtianobis Sesafaseblad.
21
I. aiv inficirebul pacientTa marTva
1. pacientTa gamokvleva pirveli vizitisas aiv inficirebuli pacientis gamokvleva pirveli vizitisas moicavs:
• detalur personalur, ojaxis da samedicino istorias; • fizikalur gamokvlevas; • laboratoriul da sxva gamokvlevebs; • Sesabamisi specialistis gamokvlevas.
personaluri, ojaxis da samedicino istoria cxrili 3.
informacia, romelic aucileblad unda Sediodes samedicino istoriaSi
pirveli vizitisas
ZiriTadi informacia:
• pacientis saxeli; • dabadebis weli, Tve, ricxvi; • sqesi; • vizitis TariRi.
informacia testirebis Sesaxeb:
• pirveli pozitiuri aiv testirebis TariRi; • mizezi, Tu ratom Caitara testireba; • bolo aiv negatiuri testirebis TariRi, Tu cnobilia.
aiv eqspoziciis riski da gadacemis kategoria (Tu cnobilia):
• saineqcio narkotikebis gamoyeneba; • sqesobrivi (sqesobrivi kontaqtis saxis miTiTebiT); • sisxlis an misi produqtebis gadasxma, organos an qsovilis
gadanergva;
• dedidan bavSvze gadacema; • samsaxureobrivi eqspozicia (aRwerilobiT); • ucnobi; • sqesobrivi partnior(eb)is aiv statusi (Tu cnobilia); • sqesobrivi partnior(eb)is risk-faqtorebi (Tu cnobilia).
aiv infeqciis gadadebis dro da adgili (qveyana), romelic yvelaze metad
aris savaraudo an cnobili (a)
aiv infeqciis mkurnalobis da movlis istoria: (ix. damateba 1)
• vizitamde aiv infeqciis mkurnalobis dro da adgili, mkurnalobis Sewyvetis miTiTebiT;
• mkurnalobis reJimi; • gverdiTi efeqtebi; • reJimis dacva; • laboratoriuli monacemebi (CD4, virusuli datvirva,
eleqtrolitebi, RviZlis funqciebi, Tirkmlis funqciebi,
sisxlis saerTo analizi, didi xnis win inficirebuli
pacientisTvis dalagebuli unda iyos qronologiurad) (7);
• vizitamde rezistentobis testis dokumentirebuli Sedegi (Tu iyo gakeTebuli).
22
aiv asocirebuli daavadebebi da mdgomareobebi:
• tuberkulozi; • respiratoruli infeqciebi; • virusuli, baqteriuli da sokovani infeqciebi; • hepatiti B da C; • neoplaziebi; • sxva.
sxva daavadebebi da mdgomareobebi:
• hospitalizacia; • qirurgiuli Careva; • sulieri mdgomareoba (depresia da a.S.); • Tirkmlis an RviZlis daavadebebi; • endokrinologiuri daavadebebi; • sqesobrivi gziT gadamdebi daavadebebi (sggd); • vaqcinaciebi; • alergiebi; • sxeulis cvlilebebi; • mimdinare medikamentebi.
ojaxis samedicino istoria (diabeti, arteriuli hipertenzia, kanis
daavadebebi, simsivneebi da a.S.)
gul-sisxlZarRvTa daavadebebi da daavadebis risk-faqtorebi (simsuqne,
Tambaqos Warbad moxmareba, arteriuli hipertenzia da a.S.)
eqspozicia tuberkulozTan (personaluri an ojaxuri kontaqtebi) b
mimdinare medikamentebi (opioid CanacvlebiTi Terapiis CaTvliT)
nivTierebaTa moxmareba:
• akrZaluli saineqcio narkotikebis moxmareba (warsulSi an awmyoSi);
• alkoholuri damokidebuleba.
reproduqciuli da sqesobrivi janmrTeloba
• kontracefciis meTodebi qalebSi; • orsuloba (wina, mimdinare, dagegmili); • sqesobrivi praqtika.
socialuri istoria
• sacxovrebeli pirobebi (partnior(eb)i / meuRle / ojaxis wevrebi, bavSvebi da a.S.);
• profesia da Tanamdeboba; • daxmarebis qseli (socialuri da samedicino dazRveva,
sazogadoebrivi jgufi, vin icis pacientis aiv statusis Sesaxeb
da a.S.).
a. saWiroa epidemiologiisTvis, virusis subtipi da savaraudo
rezistentuli Stamebis profili. b tuberkulozze Semdgomi gamokvlevis instuqciisTvis ix. aiv
infeqciis da tuberkulozis koinfeqciis marTvis gaidlaini
23
fizikaluri gamokvleva
fizikaluri gamokvlevisas unda dafiqsirdes arsebuli simptomebi da
niSnebi, raTa ganisazRvros cvlilebebi statusSi. sasurvelia
vixelmZRvaneloT standartuli istoriiT da gamokvlevis kiTxvariT; ix
cxrili 2.
cxrili 4.
sawyisi fizikaluri gamokvleva
garegnuli monacemebi:
• simaRle da wona; • lipodistrofia; • karnovskis indeqsi an zogadi mdgomareobis sxva standartuli
Sefaseba;
sasicocxlo niSnebi:
• arteriuli wneva; • temperatura; • pulsi.
Tavi
• garegnuli monacemebi; • kbilebis mdgomareoba; • oraluri kandidozi; • Tmovani leikoplakia; • pirveladi sifilisi; • saxis kani.
gul-mkerdi
• suTqva, xveleba, dispnoe; • gul-mkerdis forma; • emfizemis riskis kontroli.
sarZeve jirkvlis daTvaliereba (qalebsa da mamakacebSi) karcinomis
riskis gasakontroleblad
gulis mdgomareoba kardiovaskuluri riskis SefasebisTvis
antiretrovirusul mkurnalobaze (8,9) (CIII) an endokarditis riski saineqcio narkomanebSi
muclis Rrus da gastrointestinuri sistemis gamokvleva (sawyisi
informacia antiretrovirusuli mkurnalobis gverdiTi efeqtebisTvis,
gansakuTrebiT qronikuli hepatitis, alkoholuri intoqsikaciis da
cirozis SemTxvevebSi)
• RviZlisa da elenTis konsistencia, zomebi da forma; • nawlavebis muSaoba; • muclis sirbile; • rigidoba; • sisuste, moTenTiloba, disfagia.
genitaluri da analuri regionis gamokvleva:
• martivi herpesi. • citomegalovirusi;
24
• sifilisi; • adamianis papilomavirusi (maxvilwvetiani kondilomebi, analuri
karcinoma) (10) (BII), sxva sqesobrivi gziT gadamdebi daavadebebi(sggd).
qvemo kidurebi (moZraoba, mobiluroba, lipodistrofia)
antiretrovirusuli mkurnalobis gverdiTi efeqtebis
gasaTvaliswineblad
kani (sxeulis):
• gadatanili herpes zosteri; • RviZlis daavadebebi; • kapoSis sarkoma; • seboreuli deramatiti; • narkotikis ineqciis adgilebi.
kanis dazianebebi mag: moyavisfro an muqi laqebi umjobesia avsaxoT
fotoebSi, kanis sxva SesaZlo dazianebis gamiricxvis mizniT (moqaveba da
gafxaWna) momavali gamokvlevisas
limfuri kvanZebi
nevrologiuri statusi (neiropaTiis niSnebi)
gonebrivi statusi
mxedveleobiTi da smeniTi funqcia
laboratoriuli da sxva gamokvlevebi
cxrili 5.
laboratoriuli testebi
aiv infeqciasTan dakavSirebuli testireba:
• aiv serologiuri gamokvleva (tipurad ELISA an swrafi testi), romelsac mohyveba damadasturebeli testi (tipiurad vestern
blotingi) (11) (AI); • CD4 ujredebis ricxvi imunodeficitis xarisxis gansazRvrisTvis;
orsul qalebSi CD4% (12,13) (AI) da • virusuli datvirTvis testi polimerazuli jaWvuri reaqciis (pjr)
meTodiT, virusis replikaciis donis gansazRvrisTvis (AI) a ; testireba sxva infeqciebze (CIII)
• testi sifilisze (VDRL); • vaginaluri, asos an analuri Camonafxeki gonoreisa da Chlamydia
trachomatis identifikaciisTvis; • testireba toqsoplazmis IgG serologiur testze da informacia
infeqciis riskis Sesaxeb Tu serologiis Sedegi uaryofiTia;
• kriptokokis antigenis titri rodesac CD4 limfocitebis ricxvi < 200 mm3 da saxezea kriptokokozis klinikuri niSnebi;
• CMV antigenemia (pp65 adreuli antigeni), rodesac CD4 ujredebis ricxvi < 100 mm3 b;
• serologiuri testi B,C hepatitis virusebze (anti HCV, HBsAg) g
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ZiriTadi laboratoriuli testebi:
• eleqtrolitebi (natriumi, kaliumi); N • RviZlis funqciuri sinjebi (ALT, AST, tute fosfataza,
saerTo da arapirdapiri bilirubini);
• Tirkmlis funqciebi (Sardovana, kreatinini); • laqtaddehidrogenaza (limfomebis dros ujredTa ZiriTadi
brunva, filtvis infeqciebis niSnebi, miokardiumis infarqti,
kunTebis dazianebani da a.S.);
• INR an proTrombinis dro; • sisxlis saerTo analizi (formuliTa da Trombocitebis
ricxviT);
• orsulobis testi arv Terapiis dawyebamde.
Tu SesaZlebelia:
• glukoza; • qolesterini (HDL, VLDL); • trigliceridebi; • lipaza; • C-reaqtiuli cila (CRP); • Tiroid-mastimulirebeli hormoni (TSH ).
a. testebi umjobesia gakeTdes erTidaigive laboratoriaSi, raTa Tavidan
aviciloT teqnikuri winaaRmdegobani; b. CMV infeqciis adreuli deteqcia SesaZlebelia da pp65 adreuli antigeni kargi markeria CMV infeqciis mkurnalobis efeqturobis SefasebisTvis; g. virusul hepatitebze testirebis Semdgomi informaciisTvis ix. C hepatitis da HIV koinfeqciis da B hepatitis da HIV koinfeqciis menejmentis protokolebi.
cxrili 6.
sxva gamokvlevebi
• tuberkulinis kanis testi; a • naxvelis nacxis mikroskopia da gul-mkerdis rentgenologiuri
gamokvleva Tu saxezea tuberkulozis niSnebi;
• ekg (gamokvleva mkurnalobamde arT-ze myof pacientebSi gul-sisxlZarRvovani daavadebis didi riskis gaTvaliswinebiT,
SedarebisTvis) (14) (BII).
a. Semdgomi informaciisTvis tuberkulinis kanis testze gTxovT
mimarToT tuberkulozis da HIV koinfeqciis menejmentis protokols
sxva gamokvlevebis Catareba SesaZlebelia gaxdes saWiro Tanmxlebi
daavadebebis gaTvaliswinebiT, magaliTad HCV/HIV an HBV/HIV koinfeqiebis dros: muclis Rrus organoebis eqoskopia limfuri
kvanZebis, RviZlisa da elenTis zomebisa da formis Sesafaseblad an
26
gastrointestinuri traqtis daavadebebis klinikuri niSnebis arsebobisas
_ zemo an qvemo gastrointestinuri traqtis endoskopia. endoskopiuri
monacemebi sasurvelia dokumentirebuli iyos fotoebiT.
cxrili 7.
specialistTa konsultaciebi
• nevrologiuri gamokvleva, rodesac HIV pirvelad aris diagnostirebuli (mag. periferiuli neiropaTiis identifikaciisTvis)
• ofTalmologiuri gamokvleva yovel sam TveSi erTxel CMVretinitis identifikaciisTvis, rodesac CD4 ujredebis ricxvi < 100mm3
• ginekologiuri gamokvleva PAP nacxis CaTvliT yovel 6 TveSi erTxel (adamianis papilomavirusiT gamowveuli karcinoma)
• sxva specialistebis konsultacia aucileblobis SemTxvevebSi
2. aiv infeqciasTan dakavSirebuli debulebebi
aiv infeqcia/SidsiT mcxovrebi pacientebis menejmenti moicavs:
pacientebis janmrTelobis monitorings; arT-s dawyebas da mis xelSewyobas; oportonistuli infeqciebis da sxva Tanmxlebi infeqciebisa da daavadebebis profilaqtikasa da mkurnalobas;
fsiqologiur mxardaWeras; mkurnalobis reJimis dacvis meTvalyureobas; konsultirebas; movlas.
pacientebis konsultireba unda daiwyos maTi socialuri mdgomareobis
ganxilviT, romelic moicavs:
megobrul ganwyobas; samsaxureobriv statuss, samuSaos tips da mdgomareobas; adamianebs, romlebic unda iyvnen informirebulni pacientis aiv statusis Sesaxeb;
adamianebs, romlebTan erTadac jandacvis muSaks SeuZlia ganixilos pacientis janmrTelobasTan dakavSirebuli sakiTxebi;
ojaxis wevrebs da naTesavebs; medikamentebis Senaxvis reJimis dacvis SesaZleblobas; cxovrebis stils, romelic SesaZloa zemoqmedebas axdendes mkurnalobaze (15-17) (CIII).
jandacvis muSakebma inficirebul pacientebTan erTad unda ganixilon
mTeli rigi informaciisa, romelic unda esmodes pacients:
avadmyofs unda aexsnas riskis Semcireba (daculi sqesobrivi kontaqti, ineqciis unar-Cvevebis gacnoba da sxva) romelic moicavs
aiv pozitiur partniorTan daucveli sqesobrivi kontaqtis
27
SemTxvevaSi aiv super infeqciis saSiSroebas rezistentuli StamiT. (18) (BII)
toqsoplazmozis negatiuri serologiis SemTxvevaSi avadmyofs unda ganemartos misi gadacemis gzebi (maT Soris riski, romelic
dakavSirebulia cxovelebTan) da profilaqtikis meTodebi (ix.
protokoli 2 aiv/Sidsis ZiriTadi simtomebis da oportunistuli
infeqciebis menejmenti);
radgan HBV/HIV da HCV/HIV koinfeqcia xSiria da dakavSirebulia mTel rig sirTuleebTan, didi mniSvneloba eniWeba maT prevencias.
Tanabrad mniSvnelovania RviZlis dazianebis da dedidan bavSvze
infeqciebis gadacemis riskis Semcireba.;
pacientebi saWiroa iyvnen informirebulni SesaZlo oportunistuli infeqciebis niSnebze (ix. protokoli 2 aiv/Sidsis
ZiriTadi simtomebis da oportunistuli infeqciebis menejmenti)
saineqcio narkotikebis momxmareblebTan unda ganvixiloT misi Sewyvetis mniSvneloba. Tu pacients ar surs an ar SeuZlia
Sewyvitos saineqcio narkotikebis moxmareba maSin unda
ganvumartoT zianis Semcirebis arsi;
avadmyofs unda esmodes jansaRi cxovrebis wesis kerZod, Zilis, kvebis, varjiSis mniSvneloba;
pacientebs, romelTac unda daiwyon antiretrovirusuli Terapia, unda ganemartoT Semdegi sakiTxebi:
• mkurnalobis reJimis dacvis mniSvneloba; • antiretrovirusuli medikamentebis SesaZlo toqsiuroba; • medikamentebis urTrierTqmedeba; • kontracefciis aucilebloba, rodesac pacienti imyofeba
efavirenzis Semcvel reJimze;
pacientebi informirebulni unda iyvnen maTi legaluri pasugismgeblobebisa da uflebebis Sesaxeb;
pacientebi informirebulni unda iyvnen imunizaciis Sesaxeb da samsaxureobrivi riskis Sesaxeb.
3. oportunistuli da sxva infeqciebis profilaqtika aiv infeqcia/SidsiT avadmyofebi imunizirebul unda iyvnen A da B hepatitis virusebisa da gripis virusis sawinaRmdegod.
yvela aiv inficirebuli, romlis CD4 limfocitebis ricxvi naklebia 200 mm3 unda daewyoT profilaqtikuri mkurnaloba mTel rig infeqciebze,
maT Soris pnevmocisturi pnevmoniaze. ko-trimoqsazoliT
profilaqtikuri Terapia unda gagrZeldes manamde, sanam CD4 ujredebis ricxvi ar gaxdeba 200 mm3 meti arv mkurnalobis dawyebidan 3 Tvis
ganmavlobaSi stabilurad.
4. antiretrovirusuli Terapia
4.1. arT dawyeba
arT dawyebis optimaluri dro ar aris dadasturebuli da igi ganxilvis
sagania (19) (CIII). sxvadasxva kohortuli kvlevis da saxelmRvanelo
28
rekomendaciebis mimoxilva aCvenebs farTod gavrcelebul Sexedulebas,
rom am gadawyvetilebis misaRebad saukeTeso markeria CD4 ricxvi, xolo virusuli datvirTva meoradi markeria (20-30) (CIII). arT dawyebamde unda daiwyos avadmyofis mxardaWera reJimis maqsimaluri dacvis
uzrunvelsayofad;
janmo rekomendacias uwevs arT dawyebas klinikuri da imunologiuri
kriteriumebis safuZvelze. rekomendaciebi arT dawyebis Sesaxeb
Sejamebulia cxrilSi 8.
cxrili 8
rekomendaciebi arT dawyebis Sesaxeb
janmo klinikuri stadia a CD4 ricxvi rekomendacia 1 < 200/mm3 umkurnaleT
200 - 350/mm3 ganixileT mkurnalobis
SesaZlebloba b, g
2 < 200/mm3 umkurnaleT
200 - 350/mm3 ganixileT mkurnalobis
SesaZlebloba b, g
3 200 - 350/mm3 umkurnaleT
4 CD4 ricxvisgan damoukideblad
umkurnaleT
a) ix. damateba 2 klinikuri stadiebis aRwerilobis Sesaxeb b) rodesac CD4 ricxvi 350/mm3-is midamoSia, daiwyeT msjeloba pacientTan
arT dawyebis saWiroebis moaxloebis da mkurnalobis sawyisi reJimis
Sesaxeb.
c) virusuli datvirTva dakavSirebulia CD4 ricxvis klebasTan. rodesac virusuli datvirTva maRalia (> 100000 asli/ml), maRalia CD4 ricxvis swrafad klebis albaToba. Sesabamisad, Tu virusuli datvirTva
maRalia da CD4 ricxvi 350/mm3-ia, rekomendebulia arT dawyeba.
arT dawyeba unda efuZnebodes CD4 ricxvis orjerad gansazRvras 14 – 28 dRis SualediT, raTa gamoiricxos laboratoriuli Secdoma an gadaxris
sxva mizezi (magaliTad, Tanmxlebi daavadeba).
4.1.1. virusuli datvirTva
virusuli datvirTva TavisTavad ar aris arT dawyebis markeri. Tumca, im
SemTxvevaSi Tu virusuli datvirTva 100 000 asli/ml-ze maRalia (man
SeiZleba 1 milion asli/ml-s miaRwios), SesaZloa adgili hqondes CD4 ricxvis swraf klebas. marTalia virusuli datvirTvis gansazRvra
ZviradRirebulia, mniSvnelovania vicodeT misi mniSvneloba mkurnalobis
dawyebamde, raTa SemdgomSi SevafasoT mkurnalobis efeqturoba. Tu
virusuli datvirTva ar aris xelmisawvdomi, maSin CD4 ricxvi da klinikuri simptomebi sakmarisia mkurnalobis dawyebis gadawyvetilebis
misaRebad. polimerizaciis jaWvuri reqciisa (pjr) da virusuli
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datvirTvis ar arseboba ar unda gaxdes mkurnalobis gadadebis
kriteriumi.
4.1.2 rezistentobis testi
mosazreba pirveli rigis mkurnalobamde rezistentobis testis Catarebis
Sesaxeb gansxvavebulia. rezistentobaze testireba rekomendebulia im
qveynebSi, sadac maRalia priveladi rezistentoba. evropaSi Catarda
multicentruli kvleva axaldiagnozdasmul aiv inficirebulebSi 1996 da
2002 wlebSi. am jgufSi rezistentobis prevalentobam Seadgina 10% (31)
(BII). aSS 40 qalaqSi Catarebul kvlevaSi rezistentobam 14% Seadgina (32) (BII). yvelaze maRali sixSire aRiniSna espaneTSi 26% (33) (BII) da san-franciskoSi 19% (34) (BII). sloveniis monacemebiT rezistentobis sixSire dabalia – 3,9% (35) (BII). eqspertebi rekomendacias uweven rezistentobis testirebas arT dawyebamde axaldiagnozdasmul pacientebSi (36-38) (BII), sadac igi xelmisawvdomia, xolo SezRuduli resursebis pirobebSi
rezistentobaze sentineluri (saguSago) zedamxedvelobis dawesebas. arT
dawyeba SesaZlebelia rezistentobaze testirebis gareSe. ixileT
damateba 3 rezistentobis testirebaze damatebiTi informaciisTvis.
4.2 pirveli rigis maarT reJimi
rekomendebulia, rom pirveli rigis arT Seicavdes or
nukleozid/nukleotidis analog revers transkriftazas inhibitors
(nrti anu NRTI) da erT ara-nukleozidis analogis revers transkriptazas inhibitors (anrti anu NNRTI). rekomendebuli dozebisTvis ixileT damateba 4.
cxrili 9
rekomendaciebi pirveli rigis arT Sesaxeb
arT reJimi medikamentebis kombinacia
2 NRTI-s + 1 NNRTI
ZDV + 3TC + (EFVa or NVP) an
TDF + FTC + (EFVa or NVP) an
ABC + 3TC + (EFVa or NVP)
a. EFV ganixileba, rogorc upiratesi anrti (AI) 4.2.1. nrti komponenti
• pirveli rigis arT-s ZiriTadi Semadgeneli nawilia ori nrti-s kombinacia. erT-erTi unda iyos lamivudini (3TC) an emtricitabini (FTC) (39) (AI), xolo meore yvelaze xSirad zidovudinia (ZDV).
30
vinaidan zidovudini pirveli rekomendebuli arv medikamenti iyo,
masze uxvi monacemebia dagrovili.
• sxva SesaZlo nrti-ebia tenofoviri (TDF) da abakaviri (ABC) 3TC–Tan an FTC–Tan kombinaciaSi. uaxlesi kvlevebi aCveneben TDF/FTC–is kombinaciis mcire upiratesobas ZDV/3TC–Tan SedarebiT, rodesac gamoiyeneba efavirenzTan (EFV) kombinaciaSi (40) (AI). aRniSnuli SesaZloa ganpirobebuli iyos TDF namkurnaleb pacientebSi gverdiTi movlenebis simciriT. saWiroa damatebiTi kvlevebi aRniSnulis
dasadastureblad. unda aRiniSnos, rom ABC miRebis dros arsebobs saxifaTo hipersensitiurobis sindromis riski.
• TDF da ABC upiratesobaa maTi rezistentobis kargi profili, romelic saSualebas iZleva momavalSi meti nrti-s kombinaciis
gamoyenebas. Tumca maT aReniSnebaT seriozuli gverdiTi movlenebi da
efeqturobis monacemebic mcirea zidovudinTan SedarebiT (41) (CIII). arv medikamentebi arseboben Semdegi fiqsirebuli dozis kombinaciebis
saxiT (anu ori medikamenti 1 tabletSi):
- ZDV + 3TC - TDF + FTC - ABC + 3TC
• TDF/FTC kombinaciis ABC/3TC kombinaciasTan SedarebiT damatebiTi upiratesobaa dReSi erTxel misaRebi reJimis arseboba.
• yvela sxva nrti kombinacias pirveli rigis reJimSi gamoyenebisTvis esaWiroeba safuZvliani mizezi. zogierTi kombinacia ar aris
rekomendebuli (42), xolo sxvebs sWirdebaT gverdiTi movlenebis
mWidro monitoringi. uaxlesi kvlevebi aCveneben gverdiTi movlenebis
maRal sixSires stavudinis (d4T) gamoyenebis dros (40-47) (AI). amis gamo d4T gamoyenebul unda iqnes mxolod im SemTxvevaSi, Tu sxva
arCevani ar aris an sxva nrti-ebi ukunaCvenebia.
arsebobs nrti-ebis gamoyenebasTan dakavSirebuli ramdenime wesi:
- ar gamoiyenoT d-medikamentebis kombinacia (ddI (didanozini), ddC (zalcitabini), d4T).
- ar daiwyoT mkurnaloba d-medikamentiT arsebuli neiropaTiis dros. - ar gamoiyenoT ZDV da d4T kombinacia. - ar gamoiyenoT 3TC da FTC kombinacia.
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4.2.2. anrti komponenti
• saukeTeso monacemebi arsebobs ZDV + 3TC + EFV Sesaxeb (48–50) (AI). aRniSnuli sami medikamentisgan Semdgari kombinacia dReSi orjer
misaRebia. igi swrafadmoqmedia - EFV gamoyenebis dros virusuli datvirTva swrafad iklebs pirvel ori kviris ganmavlobaSi, CD4 ricxvis mateba sxva reJimebis dros aRniSnuli matebis msgavsia. Tumca
aucilebelia mkurnalobis dawyebamde Tanmxlebi fsiqiatriuli
daavadebebis gamoricxva.
• nevirapini (NVP) kidev erTi rekomendebuli anrtia, romelic nrti-ebTan kombinaciaSi gamoiyeneba. RviZlis daavadebebis dros maRalia
misi toqsiuroba (52) (AI). amis gamo misi gamoyeneba rekomendebulia qalebSi Tu CD4 ricxvi
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4.3. arT reJimis dacva
mkurnalobis optimaluri Sedegis misaRebad saWiroa mkurnalobis
reJimis dacva. kargad aris cnobili, rom arT reJimis maRal doneze
dacva dakavSirebulia aiv asocirebuli avadobis da sikvdilianobis
mkveTr SemcirebasTan (54) (AI), xolo reJimis arasaTanado dacva aiv-is wamlebis mimarT rezistentobis swraf ganviTarebas iwvevs (55) (AI). arT-sTvis ar aris gansazRvruli reJimis dacvis efeqturi done (arsebobs
sxvaoba reJimebs Soris), Tumca reJimis dacva 95%-ze nakleb doneze
dakavSirebulia cud virusologiur da imunologiur pasuxTan, xolo
reJimis 100%-iT dacvas kidev ufro meti sargebeli moaqvs, vidre 95%-iT
dacvas (56, 57) (AI). uaxlesi monacemebi aCveneben korelacias reJimis dacvasa da arv sxvadasxva klasis mimarT rezistentobas Soris (58) (AI).
dabal an arasakmaris reJimis dacvas mohyveba arasaxarbielo Sedegebi
pacientisTvis, sazogadoebrivi jandacvisTvis da qveynis ekonomikisTvis.
kerZod,
• pacientebi arian mniSvnelovani safrTxis winaSe rezistentobis ganviTarebis, mkurnalobis araefeqturobis da daavadebis
progresirebis TvalsazrisiT (59, 60) (AI). axali kombinacia erTi reJimis araefeqturobis SemTxvevaSi umetesad ufro rTulia dacvis
TvalsazrisiT (meti tabletebis ricxvi dReSi, gverdiT movlenebi,
dieturi SezRudevebi, toqsiuroba da dozirebis sirTule).
• rezistentuli virusis gavrceleba gamoiwvevs mis gadacemas axlad inficirebul pirebSi. aSS (61) (AI) da evropis (62) (AI) monacemebi aCveneben, rom pirveladi rezistentobis sixSire imatebs, da SeZenil
rezistentobas uaryofiTi gavlena aqvs arT pasuxze.
• rezistentuli Stamis arsebobas mohyveba meore rigis, mesame rigis da e.w. gadarCenis (salvage) reJimi, romlebic, Cveulebriv, ufro Zviria pirveli rigis reJimebTan SedarebiT.
• reJimis arasakmarisi dacva, agreTve, moaswavebs daavadebis progresirebis maRal risks, rac met danaxarjebs moiTxovs
oportunistuli infeqciebis samkurnalod (63) (AI).
4.3.1. barierebi reJimis dacvaSi da maTi sawinaaRmdego zomebi
4.3.1.1. pacientTan dakavSirebuli faqtorebi da strategiebi
pacients ZiriTadi roli akisria reJimis dacvaSi. SeuZlebelia pacientis
mier reJimis dacvis potencialis prognozireba. kvlevebma, romlebic
Seiswavlidnen sqess, rasas, asaks, aiv gadacemis gzas da ganaTlebis
dones, rogorc reJimis dacvis indikatorebs, gansxvavebuli Sedegebi
aCvenes (64) (BII). individualuri reJimis dacvis donec SesaZloa sxvadasxva dros gansxvavdebodes (65) (BII). umravlesi aiv inficirebuli raRac dros gamoavlens reJimis dacvis dabal xarisxs.
reJimis dacvis dabali donis SesaZlo mizezebia:
- narkotikebis da alkoholis moxmareba;
- cudi kveba siRaribis gamo;
- religiuri mosazrebebi (66) (DIV); - aiv statusis gamJRavnebis SiSi medikamentebis rutinuli miRebisas;
- fsiqiatriuli mdgomarebebi (67) (DIV);
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- gverdiTi movlenebis SiSi da eWvi mkurnalobis saWiroebis Sesaxeb (68)
(DIV).
SesaZlo sawinaaRmdego strategiebi:
- ganaTleba arT saWiroebis Sesaxeb;
- swrafi reagireba pacientis araswor Sexedulebaze;
- arT-s mimarT pacientis ganwyobis regularuli Sefaseba;
- “peer” (Tanasworis) Careva (pacientTa jgufebi); - fsiqiatriuli problemebis regularuli Sefaseba;
- reJimis dacvisTvis saWiro Cvevebis Sefaseba4
- specializirebuli socialuri samsaxuris an dawesebulebebis CarTva.
4.3.1.2. jandacvis muSakTan dakavSirebuli faqtorebi
jandacvis muSakebi naTlad unda acnobierebdnen reJimis dacvis
mniSvnelobas da mis rols rezistentobis ganviTarebaSi. aiv/Sidsis
dargSi momuSave profesionali unda iRebdes mudmiv ganaTlebas reJimis
dacvis sakiTxebSi. arsebobs ramdenime strategia, romelic unda
gamoiyenos jandacvis muSakma reJimis dacvis xarisxis asamaRleblad.
• TiToeul centrs, sadac tardeba aiv mkurnaloba, unda hqondes reJimis dacvis werilobiTi strategia, romelic gadaixedeba
regularulad.
• jandacvis muSakebi CarTulni unda iyvnen reJimis dacvis mxardasaWer programebSi (69) (CIII).
• pacientTa survilis gaTvaliswinebam, CaerTos am programebSi SesaZloa gaaumjobesos reJimis dacva.
• reJimis dacvaSi mxardaWera unda SevTavazoT yvela pacients imis gaTvaliswinebiT, Tu ra xarisxiT icavs esa Tu is pacienti reJims.
• mxadaWera unda gagrZeldes meore rigis da “gadarCenis" reJimis drosac. mkurnalobis araefeqturoba unda iyos sakvanZo sakiTxi
reJimis dacvis da mxardaWeris RonisZiebebis gaZlierebisTvis (70).
• reJimis dacvis maRali xarisxi xangrZlivi procesia da ara erTjeradi movlena (71) (DIV), avadmyofs mxardaWera unda SevTavazoT
arT dawyebisas, Secvlisas da rutinuli meTvalyureobisas.
• jandacvis muSakma unda uzrunvelyos, rom pacients hqondes adekvaturi codna aiv-is, reJimis dacvas da rezistentobas Soris
kavSiris, gverdiTi movlenebis Sesaxeb. sityvieri informacia unda
gamyardes werilobiTi informaciiT.
• jandacvis muSakma SesaZloa rekomendacia gauwios tabletebis miRebis dRiurs, cxrilebs, medikamentebis konteinerebs, ojaxis wevrebis da
megobrebis CarTvas “Semxseneblebad” (72) (DIV).
• arT reJimis dacva umjobesdeba, Tu pacienti pozitiurad aRiqvams kavSirs eqimTan da jandacvis sxva muSakebTan (73) (DIV).
4es SesaZloa gaZlierdes im pirebis CarTviT, vinc kontaqtSia pacientTan (eqTani,
farmacevti, ojaxi), agreTve, grafikis (cxrilebis), saaTiani tabletebis yuTebis
gamoyenebiT, mogzaurobisas gegmis SemuSavebiT, Tu rogor miiRos medikamentebi
garSemomyofebisTvis SeumCnevlad.
34
• reJimis dacvaze adreuli meTvalyureoba unda ganxorcieldes reJimis dawyebidan an Secvlidan 2 dRis Semdeg imis gasarkvevad, esaWiroeba
Tu ara pacients damatebiTi informacia, an aqvs Tu ara raime
gauTvaliswinebeli problema.
4.3.1.3. reJimTan dakavSirebuli faqtorebi da strategiebi
dozireba dReSi orze metjer dakavSirebulia reJimis dacvis ufro
dabal donesTan (74) (CIII), xolo dReSi erTxel an orjer misaReb reJimebs Soris sxvaoba savaraudod ar aris (75) (CIII). dReSi erTxel an orjer misaRebi reJimis dros, dozaTa umravlesoba droulad miiReba.
multivariaciuli analiziT dozis miReba daniSnulze gvian
dakavSirebulia mkurnalobis araefeqturobasTan (76) (AI).
• reJimis dacvis done ar aris dakavSirebuli arv klasTan. Tumca kvebiTi SezRudva sxvadasxva medikamentisTvis SesaZloa qmnides
problemas (77) (BII). • tabletebis mcire ricxvis dros metia albaToba, rom 48 kviris Semdeg
virusuli datvirTva iqneba < 50 asli/ml (75) (BII). • damazianebelma wamlebis urTierTqmedebam da gverdiTma movlenebma
SesaZloa gavlena moaxdinos reJimis dacvis xarisxze. doza SesaZloa
gamotovebul iqnes gulisrevis da diareis gamo, sisustis gamo
CaZinebam, agreTve, SesaZloa gamoiwvios dozis gamotoveba (78) (DIV).
SesaZlo sawinaaRmdego strategiebi:
• Sefasdes cxovrebis wesi (kvebis, Zilis, samuSao reJimi) da moergos samkurnalo reJimi;
• Sefasdes pirovnebis ganwyoba sxvadasxva reJimis mimarT (tabletis zoma, formulireba, raodenoba, dieturi SezRudva da a. S.).
• tabletebis Cveneba pacientisTvis reJimis dawyebamde; • informaciis micema gverdiTi movlenebis da maTi marTvis Sesaxeb,
mxardaWeris Sesaxeb.
4.4. uSedego mkurnaloba
mkurnalobis araefeqturoba SesaZloa Sefasdes virusuli datvirTvis da
CD4 ricxvis gansazRvriT, agreTve, klinikuri gamoklveviT.
4.4.1. virusologiuri araefeqturoba
• virusuli datvirTva (vd) mkurnalobis warmatebis an araefeqturobis yvelaze adreuli indikatoria, romelsac mohyveba CD4 ricxvi daaxloebiT 1 Tvis Semdeg. iSviaTad viTardeba paradoqsuli reaqcia
virusologiuri pasuxiT da imunologiuri araefeqturobiT.
Sesabamisad, aucilebelia vd Sefasdes CD4 ricxvTan erTad kombinaciaSi.
• virusologiur araefeqturobad miiCneva, Tu vd ar gaxda 400 asli/ml-ze naklebi mkurnalobis 24-e kviraze an 50 asli/ml-ze naklebi
mkurnalobis 48-e kviraze.
35
• Tu vd gaxda ganusazRvreli, magram Semdgomi ori gamokvlevisas 4-8 kviris intervaliT igi kvlav metia 400-1000 asli/ml-ze, aseT
SemTxvevaSi virusologiuri araefeqturobis momatebuli riskia (79)
(BII).. reJimis SenarCuneba zrdis Semdgomi mutaciebis da meti medikamentis mimarT ufro gamoxatuli rezistentobis ganviTarebis
risks.
• “Blips” (xanmokle mcire piki) aris vd-s msubuqi mateba ganusazRvreli donidan 50-200 asli/ml-mde. mas SesaZloa adgili hqondes
rezistentuli Stamis ganviTarebis gareSe (laboratoriuli Secdoma),
Tumca igi aris indikatori reJimis dacvis msjelobisTvis (80) (BII). am situaciaSi SesaZloa, agreTve, damxmare roli Seasrulos
medikamentebis Terapiulma monitoringma (TDM). TiToeuli “blifi” unda gakontroldes 4 kviraSi.
• Tu virusulogiuri araefeqturobis mizezi ar vlindeba (reJimis araadeqvaturi dacva, wamlebis suboptimaluri done, wamlebis
urTierTqmedeba da sxv.), unda ganxilul iqnes meore rigis Terapiis
dawyebis SesaZlebloba5.
4.4.2. imunologiuri araefeqturoba
• Tu vd ar aris xelmisawvdomi, CD4 ricxvi gamoyenebul unda iqnes mkurnalobis warmatebis an araefeqturobis indikatorad.
• imunologiuri araefeqturobaa, Tu CD4 ricxvma ar moimata 50 /mm3-ze metad arT pirveli wlis ganmavlobaSi. saSualod aranamkurnaleb
pacientebSi mkurnalobis pirveli wlis ganmavlobaSi CD4 ricxvi imatebs 150 /mm3-iT (81, 82) (AI).
• Tu CD4 ricxvi ar imatebs arT dawyebidan pirveli 9 Tvis ganmavlobaSi, ganxilul unda iqnes meore rigis arT SesaZlebloba.
Tu vd aragansazRvradia, reJimi unda gagrZeldes. Tu igi > 400-1000
asli/ml-ze, unda verificirdes reJimis dacva da daiwyos meore rigis
reJimi.
• Tu CD4 ricxvi ar imatebs 6 Tvis ganmavlobaSi, xelaxla unda Sefasdes reJimis dacvis xarisxi.
4.4.3. klinikuri araefeqturoba
arT dawyebis Semdeg, oportunistuli infeqciis (oi) an sxva aiv-
asocirebuli daavadebis ganviTareba, klinikuri araefeqturobis
indikatoria. Tumca es SeiZleba iyos imunuri rekonsitituciis sindromi
(irs), gansakuTrebiT, arT-s dawyebidan pirveli 3 Tvis ganmavlobaSi, Tu
igi dawyebul iqna CD4 ricxvi
36
cxrili 10
mkurnalobis araefeqturobis kriteriumebi
virusologiuri
araefeqturoba
imunologiuri
araefeqturoba
klinikuri
araefeqturoba
markeri vd CD4 ricxvi oi (aiv-Tan asocirebuli)
dro 24 kvira; 48 kvira 24-48 kvira
mkurnalobis
dawyebidan 12
kviris Semdeg
zRvari >400asli/ml;
>50asli/ml
50 ujredi/mm3-ze
naklebi mateba
oi (gamoricxeT
irs)
4.5. meore rigis arv reJimi
(rekomendaciebi dozebis Sesaxeb ix. damateba 4)
• meore rigis Terapiad rekomendebulia pi-s Semcveli kombinacia. pi-ebs gaaCniaT maRali genetikuri barieri.
• meore rigis arT rekomnedebulia mxolod pirveli rigis reJimis mimarT dadasturebuli araefeqturobis SemTxvevaSi.
• meore rigis arT dawyebasTan erTad unda moxdes reJimis dacvis xelaxali Sefaseba da maqsimaluri mxardaWera.
• meore rigis reJimis dros sul mcire ori nrti-s Secvlaa saWiro. arasodes SecvaloT mxolod erTi wamali saeWvo rezistentobis
SemTxvevaSi.
• efavirenzis da nevirapinis xangrZlivi naxevardaSlis periodis gamo, samive wamlis erTdrouli Sewyveta niSnavs, rom efavirenzi an
nevirapini darCeba sisxlSi nrti-ebze xangrZlivad, rac maT mimarT
rezistentobis gamomwvevi mutaciis ganviTarebis risks zrdis.
• aqedan gamomdinare, nrti+anrti reJimis Sewyvetisas SesaZloa Sewydes jer anrti da mogvianebiT, daaxloebiT 7 dRis Semdeg, nrti-ebi. Tumca,
am sakiTxTan dakavSirebiT sakmarisi monacemebi ar arsebobs.
4.5.1. nrti komponenti
• Tu pirveli rigis arT Seicavda ZDV + 3TC, maSin meore rigSi SesaZloa gamoyenebul iqnas ABC ddI–Tan kombinaciaSi (an TDF da moxdes ddI dozis modifikacia da mWidro monitoringi) (83) (CIII).
• Tu pacients pirveli rigis Terapia utardeboda TDF an ABC, maT mimarT rezistentobis maRali albaTobis gaTvaliswinebiT meore
rigSi sasargeblo iqneba ZDV (84) (BII). K65R mutacia, romelsac iwves TDF da ABC, zrdis mgrZnobelobas ZDV–s mimarT (85, 86) (BII)..
37
• 3TC agreTve sasargebloa mis mimarT rezistentobis dros, vinaidan mis mier gamowveuli 184V mutacia amcirebs virusis replikaciis unars da, agreTve, zrdis mgrZnobelobas ZDV mimarT.
4.5.2 pi komponenti
• Tu pirveli rigis Terapia Seicavda anrti-s, meore rigSi gamoyenebul unda iqnes pi.
• pi-ebis umravlesoba Zlierdeba (bustirdeba) ritonaviris (RTV an /r) dabali doziT - 100mg 2-jer dReSi. ritonaviri TavisTavad pi-ia.
ritonaviriT ar bustirdeba nelfinaviri, romelic Zlierdeba ara
qimiurad, aramed – sakvebiT. bustirebis meqanizmia ritonaviris mier
citoqrom P450 (CYP) 3A4 izoenzimis inhibireba. Sedegad izrdeba pi medikamentebis done, garda nelfinavirisa (87) (BII).. ritonaviri gamoiyeneba mxolod sxva pi-ebis bustirebisTvis da ar aris efeqturi
rogorc damoukidebeli arv medikamenti.
• pi-ebs Soris gansxvaveba mdgomareobs maT mimarT rezistentobis ganviTarebisTvis saWiro mutaciebis ricxvSi da gverdiTi movlenebis
profilSi.
• yvelaze maRali barieri rezistentobis ganviTarebisTvis aReniSneba bustirebul lopinavirs (LPV/r) (88).
• ritonaviriT bustirebuli atazanaviris (ATV/r), fosamprenviris (FPV/r), indinaviris (IDV/r) da seqvinaviris (SQV/r) rezistentobis profili umniSvnelod gansxvavdeba, risi klinikuri efeqtic mcirea an saerTod
ar aris.
• atazanaviri SesaZloa gamoyenebul iqnes ritonaviriT bustirebis gareSec (400 mg/dReSi).
• nelfinaviri efeqturobiT naklebia sxva pi-ebTan SedarebiT. Tumca misi gamoyeneba kargad dokumentirebulia orsulebSi. misi
araefeqturobis dros SeirCeva D30N mutacia, romelic ar iwvevs jvaredin rezistnetobas sxva pi-ebis mimarT (89, 90) (BII)..
• arCevis pi-ia LPV/r misi kargad dokumentirebuli efeqturobis gamo (91). evropaSi registrirda LPV/r axali formulireba, romelic gamoiyeneba 2-jer dReSi da ar esaWiroeba macivari (92) (AI).
• ar aris warmoebuli LPV/r–is pirdapiri Sedareba amprenaviris axal forma fosamprenavirTan, dReSi erTxel misaReb atazanavirTan (93)
(CIII) da seqvinaviris axal 500mg-ian formasTan, arsebobs mxolod arapirdapiri monacemebi (94) (DIV). saWiroa damatebiTi kvlevebi.
• pi-s SerCevisas gaTvaliswinebul unda iqnas gverdiTi movlenebi, Tanmxlebi daavadebebi, wamlebTan urTierTqmedeba da pacientis
individualuri ganwyoba.
38
cxrili 11
rekomendebuli meore rigis arv reJimi mozardebis mozrdilTaTvis
pirveli rigis reJimi meore rigis reJimi
ZDV + 3TC + (EFV an NVP)
LPV/ra (an ATV/r, SQV/r, FPV/r, IDV/r) + ddI + ABC an LPV/ra (an ATV/r, SQV/r, FPV/r, IDV/r) + TDF + ABC an LPV/ra (an ATV/r, SQV/r, FPV/r, IDV/r) + TDF + (ZDV + 3TC)b
TDF + FTC + (EFV an NVP)
LPV/ra (an ATV/r, SQV/r, FPV/r, IDV/r) + ddI + ABC an LPV/ra (an ATV/r, SQV/r, FPV/r, IDV/r) + ddI + ZDV
ABC + 3TC + (EFV an NVP)
LPV/ra (an ATV/r, SQV/r, FPV/r, IDV/r) + ddI + ZDV an LPV/ra (an ATV/r, SQV/r, FPV/r, IDV/r) + ZDV + TDF (+ 3TC)b
aLPV/r mocemulia rogorc upiratesi pi bustirebuli ritonaviriT, Tumca sxva pi-ebi SesaZloa gamoyenebul iqnas programis individualuri prioritetebis mixedviT.
SesaZloa nebismieris gamoyeneba CamoTvlilTagan: ATV/r, SQV/r, FPV/r, da IDV/r. civi jaWvis ararsebobis SemTxvevaSi SesaZloa nelfinaviris gamoyeneba, Tumca igi
ganixileba, rogorc naklebad potenturi, vidre bustirebuli pi-ebi. bZDV da 3TC gamoyeneba naCvenebia strategiuli mizniT, radgan pirveli rigis araefeqturobis SemTxvevaSi maT mimarT virusi rezistentuli iqneba. kerZod, ZDV SesaZloa Tavidan agvacilos an Seaferxos K65R mutaciis ganviTareba; xolo 3TC SeinarCunebs M184V mutacias, romelic amcirebis virusis replikaciis unars da garkveulwilad zrdis sensitiurobas ZDV mimarT. unda aRiniSnos, rom am strategiis klinikuri Rirebuleba ar aris dadasturebuli.
• Tu ganviTarda pi-s Semcveli pirveli rigis arT-s araefeqturoba, meore rigis reJimis SerCeva efuZneba rezistentobis profils. Tu
rezistentobis profili ar aris xelmisawvdomi, navaraudevi unda
iqnas rezistentoba pirveli rigis reJimSi Semavali pi-s mimarT.
pi-s Semcveli pirveli rigis arT-s araefeqturobis dros SesaZlo
arCevania:
ZDV + 3TC + SQV/r (an ATV/r, FPV/r, IDV/r) ➔ ABC + ddI + LPV/r ZDV + 3TC + LPV/r ➔ ABC + ddI + anrti (darunaviri (TMC11)) an bustirebuli tipranaviri (TPV/r)
kidev erTi arCevania ori pi-s kombinacia, magaliTad SQV + ATV/r (95). ar aris rekomendebuli ormagi pi-ebis kombniacaSi TPV/r gamoyeneba.
4.6. gadarCenis (Salvage) reJimebi
dadasturebuli meore rigis araefeqturobis SemTxvevebSi
(virusologiuri, imunologiuri, klinikuri araefeqturobis
kriteriumebiT) ganixileba gadarCenis reJimebi. gadarCenis reJimebSi
igulisxmeba im medikamentebis kombinacia, romlebic SesaZloa muSaobdes
an virusi maT mimarT iyos nawilobriv rezistentuli. yvela reJimi meore
rigis Semdgom garTulebulia da moiTxovs arT-codnis maRal dones da
unar-Cvevebs. genotipuri rezistentobis testis monacemebi am situaciaSi
aucilebelia. zogierT SemTxvevebSi gadarCenis Terapiis dawyebamde
39
umjobesia ramodenime TviT mocda, Tumca es strategia SesaZloa iyos
saSiSi, kerZod, Tu CD4 ujredebis ricxvi dabalia. • Tu SesaZlebelia, unda CaerTos ori medikamentis efeqturi kombinacia
mag; SeWris inhibitori enfurvitidi (ENF) (96) (CIII), romelic iniSneba 2-jer dReSi kanqveSa aplikaciis saxiT da axali pi TPV (97,90) (CIII), an axali pi TCM114 (99,100) (CIII).
• TPV - genetikuri barieri ufro maRalia, vidre LPV/r da monacemebi gviCveneben mis efeqturobas am ukanasknelTan SedarebiT. dRevandel
dRes TPV gamoiyeneba mxolod gadarCenis Terapiis reJimebSi. • sxva SesaZleblobaa ori pi kombinacia (102-104) (CIII), gamonaklisia
TPV, romelic ar unda gamoviyenoT sxva pi–sTan kombinaciaSi.
4.7. mkurnalobis dagegmili Sewyveta
bevri ewinaaRmdegeba arT dagegmil Sewyvetas, Tumca dasabuTeba
SesaZlebelia. mag. CD4>500 mm3 mudmivi done da virusis supresia mravali wlebis ganmavlobaSi abrkolebs oportunistuli infeqciebis
ganviTarebas. mkurnalobis dagegmili Sewyveta, mkurnalobis reJimis
araadeqvaturad dacvis SemTxvevaSi, Tavidan agvacilebs rezistentuli
Stamebis ganviTarebas. mkurnalobis Sewyvetis Semdeg CD4 limfocitebis ricxvi Camodis pre-arv Terapiis donemde, amdenad aucilebelia pirveli
sami Tvis ganmavlobaSi CD4 limfocitebis ricxvis monitoringi. zogierT pacientSi limfocitebis ricxvi >350 mm3 da dabali virusuli datvirTva
(1000-5000 asli/ml) Tveebisa da wlebis ganmavlobaSia SenarCunebuli.
mkurnalobis dagegmili Sewyvetis sargebelze arasakmao informaciis
arsebobis gamo janmos mier igi ar aris rekomendebuli.
5. aiv inficirebul pacientTa klinikuri monitoringi
mas Semdeg rac adamians daesmeba aiv infeqciis diagnozi is
uzrunvelyofili unda iyos monitoringiTa da movliT.
5.1. laboratoriuli indikatorebi arT dawyebamde
CD4 ujredebis ricxvi:
• gaimeoreT yovel 6 TveSi, Tu aris amouxsneli Sedegebi (CD4 ujredebis swrafi daqveiTeba an oportunistuli infeqciebis ganviTareba);
• Tu mimdinareobs msjeloba arT dawyebaze (CD4 ujredebi tolia an 100 000 asli /ml) miuTiTebs daavadebis swraf
progresirebaze.
40
• ZiriTadi laboratoriuli testebi unda gakontroldes (cxr. 12) yovel 6 TveSi, Tu ar aris raime sxva mizezi, mag. orsuloba.
5.2. laboratoriuli maCvemeblebis monitoringi arv Terapiaze myof
pacientebSi
arT-s warmatebis pirveli maCvenebelia virusuli datvirTva. imunuri
pasuxi virusuli datvirTvis Sedegia da mogvianebiT viTardeba. arT
monitoringisTvis saukeTesoa orives gakontroleba.
virusuli datvirTva:
• virusuli datvirTva unda ganisazRvros mkurnalobis dawyebidan 4-8 kviraSi reJimis warmatebis SefasebisTvis. virusuli datvirTva
aragansazRvradi unda gaxdes 16-24 kviraSi.
• virusuli datvirTvis monitoringisTvis sasurveli intervalia 3-4- Tve.
• Tu virusuli datvirTva gaxda aragansazRvradi (< 50 asli/ml), is unda darCes aragansazRvradi.
• CD4 ujredebis ricxvi unda gakontroldes yovel 6 TveSi, klinikuri warumateblobis SemTxvevebis garda.
• ZiriTadi laboratoriuli testebi (cxr. 3) unda gakontroldes yovel 6 TveSi, Tu ar aris raime cvlilebebli arv Terapiis reJimSi.
cxrili 12.
laboratoriuli testebis sixSire ZiriTadad da specifikuri arv-s
reJimis gaTvaliswinebiT
sawyisi
2
kvira
4
kvira 8
kvira 16
kvira 24
kvira 36
kvira 48
kvira virusuli
datvirTva
X
X X X X
CD4 ujredebis ricxvi
X X X (X) X
sisxlis saerTo
analizi
X X X X
(ZDV) X (X) X
RviZlis
funqciuri
sinjebi
X X
(NVP) X X
(NVP, ZDV, PI)
X
(NVP, PI)
X (X) X
qolesterini
triglice-ridebi
X (PI) X (PI) X (PI)
Tirkmlis
funqciebi
X X
(TDF) X
(TDF, IDV)
X (X) X
X: testebi, romlebic unda Catardes arv Terapiisgan damoukideblad;
X (arv): testebi, romlebic unda Catardes mocemuli preparatis arsebobisas
arT reJimSi;
(X): araucilebeli testebi.
41
5.3. mkurnalobis reJimis dacvis monitoringi
yvela pacienti, romelic imyofeba arT-ze mudmivad unda imyofebodnen
meTvalyureobis qveS. sanam isini imyofebian mkurnalobis monitoringis
qveS (ixileT damateba 5), miRebuli meTodia standartuli anketireba 14
dReSi an TveSi erTxel.
virusuli datvirTvis cvlileba yovelTvis saWiroebs eqimis mier
pacientTan erTad mkurnalobis reJimis ganxilvas. gamoiyeneba kiTxvari,
romlis mixedviTac SeiZleba ganvsazRvroT damyoloba mkurnalobisadmi.
mkurnalobis reJimis dacva 4-6 Tvis ganmavlobaSi saSualebas iZleva
miRweul iqnas xangrZlivi imunovirusologiuri pasuxi (110) (AI). sxvadasxvagvari Careva SesaZlebelia, magram prioritetulia is reJimi,
romelic adreul TveebSi iZleva arT-ze ukeTes pasuxs (110-114) (AI).
mkurnalobis reJimis dacva SeiZleba iyos nawili rutinuli klinikuri
dakvirvebisa, romelsac axorcielebs yvela profesionali eqimi. yoveli
vizitis dros eqimi unda darwmundes, rom TiToeul pacients:
aqvs emociuri da fizikuri mxardaWera; dRis ganmavlobaSi icavs wamlebis miRebis reJims; esmis, rom reJimis darRveva gamoiwvevs rezistentobis ganviTarebas; gacnobierebuli unda hqondes, rom yvela doza droulad iqnas miRebuli;
wamlebis miRebis dros Tavs unda grZnobdes komfortulad; daicvas daniSnuleba; esmodes arv-s moqmedeba da gverdiTi efeqtebi; icodes, Tu rodis mimarTos eqims.
sxva strategia moicavs:
depresiis mkurnalobas, raTa amaRldes mkurnalobis reJimis dacva da miRweul iqnas xangrZlivi Sedegi;
wamlebis urTierTqmedebis da dozirebis menejments; medikamentebis gacemas mcire raodenobiT da xSiri intervalebiT, romelic aiolebs:
1. problemebis droul gamovlenas, manam sanam ganviTardeba rezistentoba;
2. Semcirdes medikamentebis gacema da borotad gamoyeneba; 3. gamoyenebuli iqnas dReSi erTxel misaRebi, erTdoziani
medikamentis kombinacia, rac xels Seuwyobs adreul etapze
mkurnalobis damyolobas;
4. mkurnalobaze uSualo zedamxedveloba, gansakuTrebiT hospitalSi.
fsiqosocialur daxmarebas; pacients miewodos saxelmZRvanelo da broSurebi; pacientebis monawileobas daxmarebis jgufebSi.
5.4. arv toqsiuroba da gverdiTi efeqtebis menejmenti
gverdiTi efeqtebi xSiria arv Terapiis dros, gansakuTrebiT proteazas
inhibitorebis miRebis dros (ix. cxrili 13).
lopinavir/ritonavirs da nelfinavirs SeuZliaT gamoiwvion diarea;
42
lopinaviri/ritonaviris miReba asocirebulia hiperlipidemiasTan (gansakuTrebiT trigliceridebis momatebasTan);
cximebis metabolizmis darRvevebi SeiZleba gamoiwvios TiTqmis yvela proteazas inhibitorebma;
erTaderTi proteazas inhibitori, romelic gavlenas ar axdens lipidur cvlaze aris atazanaviri da atazanavir/ritonaviri. zogierT
qveyanaSi atazanaviri mowodebulia mkurnalobis meore rigis sqemaSi;
kardiovaskularuli garTulebebis riskis momateba saWiroebs Semdgom Seswavlas.
cxrili 13
arv-s toqsiurobis dadastureba da menejmenti
ARV toqsiuroba menejmenti RviZlis nekrozi
nevirapini (NVP) o cxeleba, gamonayari (50%), gulisreva, Rebineba,
eozinofilia, alt, ast-s
donis momateba
o Cveulebriv pirvel 6-18 kviraSi, iSviaTad 48
kviris Semdeg
o nevirapinze myofi pacientebis 1-2%, qalebSi
CD4 > 250 ; kacebSi CD4 > 400-ze
o RviZlis funqciuri sinjebis monitoringi 2,
4, 8, 16 kviraze da
Semdeg yovel 3 TveSi
o simptomuri mkurnaloba o RviZlis nekrozis
mkurnaloba, calkeul
klinikur SemTxvevebSi
wamlebis Sewyveta
laqtat-acidozi
maRlidan dabali
riskisken:
o stavudini didanozinTan
erTad
o didanozini o stavudini o zidovudini
o gulisreva, Rebineba, wonaSi dakleba, sisuste,
pankreatiti,
multiorganuli
ukmarisoba,
respiratoruli distres
sindromi
o yoveli 1000 pacientidan 1-10 weliwadSi
didanozini da stavudini
o laqtat-acidozis monitoringi Tu eWvia,
inaxos adreuli
indikatorebi
(kreatinkinaza (CK) HCO3)
o acidozis samkurnalod mowodebulia
bikarbonati
o abakaviriT, tenofoviriT,
lamivudiniT,
emtricitabiniT Secvla
maRali mgrZnobeloba
abakaviri (ABC )
o xSirad aris cxeleba, gamonayari, aseve sisuste
da gulisreva
o 5%, iSviaTad 6 kviris Semdeg
o kanze dakvirveba, ar SeiZleba dawyeba
gamonayris
sawinaaRmdego
wamlebTan erTad.
o Sewydes abakaviris miReba da ar ganaxldes
Tu diagnozi saeWvoa
o Seicvalos zidovudiniT,
tenofoviriT an
stavudiniT
o
43
stivens-jonsis sindromi, epidermisis toqsiuri nekrozi
nevirapini (NVP) efavirenzis dabali
doziT
o cxeleba, buStukovani gamonayari, mialgia
o nevirapini 1%-Si, efavirenzi 0,1%-Si
o kanze dakvirveba o antibiotikebis daniSvna
Wrilobis samkurnalod
pankreatiti
maRlidan dabali
riskisken:
o stavudini didanozinTan
erTad
o didanozini o stavudini
o tkivili, lipazas maRali done
o didanozini 1-7%, dozis SemcirebiT
o lipazas donis monitoringi
o simptomuri mkurnaloba, parenteraluri kveba,
wamlebis Sewyveta
o zidovudiniT an tenofoviriT an
abakaviriT Secvla
ARV toqsiuroba menejmentinefrotoqsiuroba
tenofoviri TDF
o Tirkmlis ukmarisoba da fankonis sindromi
o ufro xSirad pacientebSi Tirkmlis
disfunqciiT
o kreatininis monitoringi, istoria Tirkmlis
daavadebis Sesaxeb
o mkurnaloba simtomuria o tenofoviris dozis
koreqcia (saWiroa
kreatininis klirensi:
yovel meore dRes
o Seicvalos tenofoviri zidovudiniT, abakaviriT
an stavudiniT
anemia
zidovudini ZDV
o anemia da neitropenia (sustad Semcireba
iTvleba normad
zidovudinTan)
o 1-4%, dozaze damokidebulebiT
o sisxlis saerTo analizis monitoringi 2, 4, 8, 12
kviraze. makrocitozi
msubuqi anemiiT
(hemoglobini 100 gr/l)
xSiria o mkurnaloba aris
eriTropoetinis
transfuzia (Zalze
Zviria) an Seicvalos
zidovudini sxva nrti
(tenofoviri, abakaviri an
stavudini)
periferiuli neiropaTia
didanozini, stavudini,
zalcitabini
o kidurebis tkivili,
paresTezia
o 10-30% wlebis Semdeg
o periferiuli nervuli sistemis kontroli
o mkurnaloba tkivilis kupireba, Seicvalos arT.
Sewydes wamlebi an
Seicvalos nrti
(zidovudini, tenofoviri,
abakaviri)
cximovani atrofia
stavudini, da sxva nrti
o loyisa da o kidurebis cximis
ganleva
o xangrZlivad gamoyenebis
o monitoringi da sawyis o mdgom. Sedareba o Seicvalos stavudini
tenofoviriT an
abakaviriT. Tu atrofia
44
SemTxvevaSi
xSiria
(mitoqondriuli
toqsiuroba)
Seuqcevadia plastikuri
qirurgia naCvenebia
cximovani akumulacia
PI
o matulobs mucelze
gacximovneba,
mkerdis zoma,
o 20-80%
o Sefaseba da sawyis mdgom. Sedareba
o Seicvalos NNRTI-iT, Tu lipodistrofia/lipoatr
ofia ar aris
tolerantuli, naCvenebia
plastikuri qirurgia
nrti fosamprenaviri
FPV>abakaviri ABC o makulur-papuluri
gamonayari
o 15% nnrti, APV 20%, abakaviri 5%
o cxelebis, RviZlis funqciuri sinjebis da
kreatinkinazas
monitoringi
o sxva alergenebis gamoricxva
(sulfametoqsazol/trim
etoprimi da sxva
antibi.). gamonayari
SeiZleba spontanurad
gaqres arT-s Semdeg
o Seicvalos nevirapini efavirenziT an piriqiT.
Tu ar aris
gaumjobeseba scadeT
sxva reJimi
transaminazebis elevacia
anrti (all) da PIs (all)
o auxsneli RviZlis funqciebis momateba
o 8-15% PI da nnrti o ufro xSirad
pacientebSi
qronikuli HBV da HCV infeqciiT
o ALT monitoringi yovel eqvs TveSi,
gaTvaliswinebuli iqnas
sxva faqtorebi (mag.
wamlismieri hepatiti. o momateba xSirad Tan
axlavs nnrti da pi
ganuwyvetel miRebas
o Sewydes nnrti da pi miReba
45
ARV toqsiuroba menejmenti PIs (all),zidovudini ZDV,didanizini ddI
o gulisreva da Rebineba, diarea
o xSiria
o gamoiricxos sxva mizezi (imunuri rekonstituciis
anTebiTi sindromi CMV kolitiT,
kriptosporidiozi,
mikrosporidiozi, arT-s
dawyebidan kvireebis Semdeg
o mkurnaloba aris loperamidiT Tu diareis
sxva mizezi ar aris:
metoklopramidi, zofrane
gulisrevis da Rebinebis
dros
centraluri nervuli sistemis (cns) toqsiuroba
efavirenzi EFV
o Ramis SfoTva, koncentraciis darRveva,
depresia (suicidisken
midrekileba)
o 50%
o pacientebis gafrTxileba, fsiqiatris konsultacia
o mkurnaloba Cveulebriv saWiro ar aris. aRniSnuli
movlenebi gaivlis 5-21
dReSi
insulin rezistentoba
PIs (yvela magram ATV)
o glukozis tolerantoba matulobs, glukoza
matulobs uzmoze
o 5%
o uzmoze glukozis monitoringi
o mkurnaloba dietiT da metforminis an glitazonis
miReba o Seicvalos pi nnrti-iT
hiperlipidemia
stavudini (d4T)>PIs (all but ATV)
o lipidebis, qolesterolis, trigliceridebis
momateba( am
ukanasknelisTvis
stavudini SeiZleba iyos
wamyvani)
o 0%
o lipidebis donis monitoringi arT-s
dawyebidan da Semdeg yovel
eqvs TveSi
o mkurnaloba lipidebis, qolesterolis da
trigliceridis
gaidlainebiT
o sifrTxilea saWiro urTierTzemoqmedebisas (ar
SeiZleba simvastatini da
lovastatini)
hiperbilirubinemia
atazanaviri (ATV) >indinaviri ( IDV)
o bilirubinis momateba (SesaZlebelia qavili, araprolongirebuli RviZlis
dazianeba, Seqcevadi
o xSiria
o bilirubinis da klinikuri simtomebis monitoringi
o wamlebis Sewyveta Tu ar aris tolerantoba.
Seicvalos pi.
nefroliTiazi
indinaviri (IDV)
o muclis tkivili, hematuria, Tirkmlis
kolika
o 10-20%
o Sardis analizis da kreatininis monitoringi
o mkurnaloba igivea rac nefroliTiazis dros
46
ARV toqsiuroba menejmentinefrotoqsiuroba
tenofoviri TDF
o Tirkmlis ukmarisoba da fankonis sindromi
o ufro xSirad pacientebSi Tirkmlis
disfunqciiT
o kreatininis moni-toringi, istoria
Tirkmlis daavadebis
Sesaxeb
o mkurnaloba simto-muria o tenofoviris dozis
koreqcia (saWiroa
kreatininis klirensi:
yovel meore dRes
o Seicvalos tenofoviri zidovudiniT, abakaviri
an stavudiniT
anem