aiv infeqcia/Sidsis da tuberkulozis koinfeqciis marTva...

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aiv infeqcia/Sidsis da tuberkulozis koinfeqciis marTva (klinikuri saxelmZRvanelo-rekomendacia gaidlaini) 2007 w. Tbilisi 1

Transcript of aiv infeqcia/Sidsis da tuberkulozis koinfeqciis marTva...

  • aiv infeqcia/Sidsis da tuberkulozis koinfeqciis marTva

    (klinikuri saxelmZRvanelo-rekomendacia gaidlaini)

    2007 w. Tbilisi

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  • klinikuri saxelmZRvanelo-rekomendaciebis zogadi mizani

    aiv infeqcia/Sidsis da tuberkulozis koinfeqciis klinikuri saxelmZRvanelo-rekomendaciebis mizans warmoadgens:

    samecniero mtkicebulebebze dafuZnebuli uaxlesi informaciis miwodeba aiv-infeqcia/Sidsis da tuberkulozis koinfeqciis Sesaxeb eqimi-fTiziatrebisTvis, eqim-infeqcionistebisTvis, ojaxis eqimebisTvis, jandacvis pirveladi rgolis muSakebisTvis, zemoT aRniSnul darSi momuSave saSualo samedicino personalisTvis da yvela dainteresebuli pirisTvis.

    ganxiluli klinikuri sakiTxebi

    mocemuli klinikuri rekomendaciebi ganixilaven aiv-infeqcia/Sidsis da tuberkulozis koinfeqciasTan dakavSirebul sakiTxebs, diagnostikis, profilaqtikis da mkurnalobis meTodebs, romlebic unda Catardes specializirebul dawesebulebaSi multidisciplinaruli jgufis mier.

    visTvis aris gankuTvnili mocemuli klinikuri rekomendacia

    mocemuli klinikuri rekomendaciebi gankuTvnilia fTiziatrebisTvis, infeqcionistebisTvis, ojaxis eqimebisTvis, socialuri muSakebisTvis da eqTnebisaTvis.

    mtkicebulebaTa doneebisa da rekomendaciebis xarisxi

    winamdebare saxelmZRvaneloSi yvela rekomendacias gaaCnia gradacia, romelic aRiniSneba laTinuri asoebiT A-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

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  • 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

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  • aabbrreevviiaattuurraa

    aaiivv adamianis imunodeficitis virusi

    aalltt alaninaminotransferaza

    anrti ara-nukleoziduri revers transkriftazas inhibitori

    aarrvv antiretrovirusuli

    aarrTT antiretrovirusuli Terapia

    aasstt aspartataminotransferaza

    iirrss imunuri rekonstituciis sindromi

    iiffaa imunofermentuli analizi

    mmaaaarrTT maRalaqtiuri antiretrovirusuli Terapia

    mmggbb mJavagamZle baqteria

    mmrrttbb multirezistentuli tuberkulozi

    nrti nukleoziduri revers transkriftazas inhibitori

    ppii proteazas inhibitorebi

    ppjjrr polimerizaciis jaWvuri reaqcia

    ttbb tuberkulozi

    SSiiddssii SeZenili imunodeficitis sindromi

    jjaannmmoo jandacvis msoflio organizacia

    AABBCC abakaviri ddddII didanosini 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 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. aaiivv iinnffeeqqcciiiiss kkllaassiiffiikkaacciiiiss ssiisstteemmaa (CDC)

    kklliinniikkuurrii kkaatteeggoorriiaa

    kklliinniikkuurrii

    kkaatteeggoorriiaa AA kklliinniikkuurrii

    kkaatteeggoorriiaa BB kklliinniikkuurrii

    kkaatteeggoorriiaa CC kkaatteeggoorriiaa CCDD44

    uujjrreeddeebbiiss rraaooddeennoobbiiss mmiixxeeddvviiTT A B C

    1) >500/mm3

    (≥29%) A1 B1 C1

    2) 200-500 mm3 (14-28%)

    A2 B2 C2

    3)

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    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 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 gamoyeneba 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 gamoixateba 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. tb infeqcia – mikobaqteria aris organizmSi. pacienti ar ainficirebs sxvebs. tb daavadeba – pacienti avadaa da SeuZlia daavadebis gavrceleba; aaxxaallii SSeemmTTxxvveevvaa –– aavvaaddmmyyooffii,, rroommeellssaacc wwaarrssuullSSii ttuubbeerrkkuulloozziissggaammoo mmkkuurrnnaalloobbaa aarr CCaattaarreebbiiaa aann ttuubbeerrkkuulloozziiss ssaawwiinnaaaaRRmmddeeggoopprreeppaarraatteebbii mmiiRReebbuullii aaqqvvss aarraa uummeetteess 44 kkvviirriissaa.. rreellaaffssii –– aavvaaddmmyyooffii,, rroommeellssaacc wwaarrssuullSSii CCaauuttaarrddaa ssttaannddaarrttuulliiTTeerraappiiiiss ssrruullii kkuurrssii ((WWHHOO//DDOOTTSS)),, eeqqiimmiiss mmiieerr mmkkuurrnnaalloobbiissggaammoossaavvaallii WWHHOO//IIUUAATTLLDD kkrriitteerriiuummeebbiiss mmiixxeeddvviiTT ggaanniissaazzRRvvrraa,,rrooggoorrcc ““ggaannkkuurrnneebbaa”” aann ““ddaassrruulleebbuullii mmkkuurrnnaalloobbaa”” ddaa kkvvllaavv,, iissee,,rrooggoorrcc wwaarrssuullSSii,, ddaauuddggiinnddaa bbaaqqtteerriioollooggiiuurraadd ddaaddaassttuurreebbuullii((nnaaxxvveelliiss nnaaccxxiiss mmiikkrroosskkooppiiaa ddaa//aann kkuullttuurraa)) aaqqttiiuurrii ttbb;;

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    mmkkuurrnnaalloobbaa SSeewwyyvveettiiss SSeemmddeegg –– aavvaaddmmyyooffii,, rroommlliissssttaannddaarrttiizzeebbuullii qqiimmiiooTTeerraappiiiiss kkuurrssii ((WWHHOO//DDOOTTSS)) SSeewwyyvveettiill iiqqnnaa 22TTvviiTT aann mmeettii xxnniiTT ddaa mmaass kkvvllaavv bbaaqqtteerriioollooggiiuurraadd ((nnaaxxvveelliissnnaaccxxiiss mmiikkrroosskkooppiiaa ddaa//aann kkuullttuurraa)) ddaa//aann kklliinniikkuurraadd ((kklliinniikkuurriissuurraaTTii ddaa gguullmmkkeerrddiiss rreennttggeennooggrraaffiiaa)) ddaauuddggiinnddaa aaqqttiiuurrii ttbb;; uuSSeeddeeggoo mmkkuurrnnaalloobbaa -- mmggbb ((++)) aavvaaddmmyyooffii,, rroommeelliicc

    ssttaannddaarrttiizzeebbuullii qqiimmiiooTTeerraappiiiiss ((WWHHOO//DDOOTTSS)) mmee--55 TTvveess aann SSeemmddeeggddaarrCCaa,, aann ggaaxxddaa bbaaqqtteerriiaaggaammoommyyooffii ((nnaaxxvveelliiss nnaaccxxiiss mmiikkrroosskkooppiiaaddaa//aann kkuullttuurraa));;

    2. epidemiologia

    2.1. tuberkulozis epidemiologia tuberkulozi (tb) msoflio jandacvis sistemis seriozuli problemaa. janmrTelobis msoflio organizaciis (janmo) bolo monacemebis Tanaxmad 2004 wels dafiqsirda tb 445 000 axali SemTxveva da 69 000-ze meti sikvdilis SemTxveva. evropis regionSi tuberkulozis axali SemTxvevebis saSualo maCvenebelia 50/100 000 mosaxleze, romelic meryeobs monakos 2 SemTxvevidan tajikeTis 177 SemTxvevamde. subregionul doneze saSualo maCvenebeli dasavleT evropisTvis aris 12/100 000 mosaxleze, centraluri evropisTvis -27/100 000 mosaxleze, xolo aRmosavleT evropisTvis - 96/100 000 mosaxleze. msoflioSi tuberkulozis yvelaze maRali gavrecelebis mqone 22 qveynidan me-12 adgili ukavia ruseTis federacias (AI) (1,2). tuberkulozis epidemiologiuri maCveneblebi maRalia qveynebSi(AI) (3,4):

    • romlebic ganicdian socialur-ekonomiur kriziss; • jandacvis finansireba arasakmarisia; • Camoyalibebulia aiv infeqcia/Sidsis da multirezistentuli

    tuberkulozisaTvis arakeTilsaimedo epidemiologiuri situacia;

    • sadac arasakmarisia profilaqtikuri RonisZiebebi maRali riskis mqone pirebisaTvis.

    msoflioSi multirezistentuli tuberkulozis (mrtb) yvelaze maRali prevalentoba fiqsirdeba evropis regionSi. evropis cxra qveynidan mrtb-s prevalentoba tuberkulozis axal SemTxvevebs Soris 7 qveyanaSi (estoneTi, israeli, yazaxeTi, latvia, litva, ruseTis federacia, uzbekeTi) 6,5%-ze metia; zemoT CamoTvlilTagan 5 qveyanaSi (estoneTi, yazaxeTi, litva, ruseTis federacia, uzbekeTi) ki warsulSi namkurnaleb SemTxvevaTa Soris analogiuri maCvenebeli 30%-s aRemateba (AI) (5). saerTo populaciasTan SedarebiT, tb-is gavrceleba ufro xSiria sasjelaRsrulebis dawesebulebebSi myof pirebSi. evropis regionSi sasjelaRsrulebis dawesebulebebSi myofi yoveli 100 000

  • adamianidan tb aReniSneba saSualod 100 pirs. gansakuTrebiT maRalia es maCvenebeli evropis aRmosavleT nawilSi da ruseTis federaciaSi. 2003 wels igi Seadgenda 600/100 000 patimarze (AI) (6). 2003 wels janmos evropis regionul ofisis monacemebiT, evropaSi tb-is axali SemTxvevebis 7% modioda patimrebze; es maCvenebeli qveynebis mixedviT meryeobda 0,1%-dan 30,4%-is farglebSi (AI) (7-10).

    2.2.aiv infeqcia/Sidsis epidemiologia 2.2.1. 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

  • 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 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.

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  • 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.

    2.2.2. aiv infeqcia/Sidsis gavrceleba saqarTveloSi

    2006 wlis 31 dekembris monacemebiT saqarTveloSi oficialuradregistrirebulia aiv infeqcia/Sidsis 1156 SemTxveva, maTgan 2006 wels gamovlinda 243 aiv inficirebuli adamiani. registrirebul SemTxveevaTa 79% saqarTvelos sazRvrebs garedanSemotanili infeqciaa. 18,5% Semotanili infeqciis lokalurigavrcelebis Sedegia aiv inficirebulis meuRleebsa da sqesobrivpartniorebze infeqciis gadacemis Sedegad.

    saqarTveloSi gamovlenili aiv inficirebulebis 64.3% daavaddanarkotikebis ineqciuri gziT moxmarebis Sedegad, 28.4% dainficirdaheteroseqsualuri kontaqtiT, 3,4% _ homo/biseqsualuri kontaqtiT, 1,1 %- daavadda virusis vertikalurad (dedidan bavSvze) gadacemisgziT, 1,6,%-Si inficirebis gza daudgenelia, 1,2 % dainficirdasisxlis gadasxmiT.

    aiv inficirebis yvelaze meti SemTxveva registrirebulia TbilisSi 306, Semdeg samegreloSi -129, aWarasa -121 da imereTSi -78. gamovlinda ucxoeTis 25 moqalaqe, maTgan 10 dabrunda TavianT qveyanaSi. saqarTveloSi SeiniSneba aiv infeqciis gavrcelebisaRmavali tempi. 2000 wels moxda aiv infeqciis registrirebuliSemTxvevebis 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, racaRemateba mTeli 2004 wlis manZilze gamovlenil SemTxvevaTaricxvs. saqarTveloSi aiv infeqciis gavrcelebis Taviseburebani iseTivea, rogorc aRmosavleT evropis qveynebSi. Sidsis gavrcelebis upirveles risk-jgufs aqac ineqciuri narkomanebi warmoadgenen. magram, rogorc sxva qveynebis gamocdileba gviCvenebs, Sidsis epidemia ar Semoifargleba mxolod narkomanTa wriT, Sidsis Semdegi msxverplni narkomanTa sqesobrivi partniorebi iqnebian.

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  • 2.2.3. 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. masgansakuTrebiT 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 komponentebisgadasxmiT; aiv inficirebuli sisxliT dabinZurebuli Spricis, nemsis da sxva samedicino instrumentebis gamoyenebisSemTxvevaSi;

    • inficirebuli dedisgan nayofze an axalSobilze mucladyofnisperiodSi, 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.

    2.3. aiv infeqcia/Sidsis da tuberkulozis koinfeqciis epidemiologia

    tb-is maRali prevalentobis qveynebSi tuberkuloziT daavadebis riski sakmaod maRalia pozitiuri aiv statusis mqone pirebSi. aRmosavleT evropaSi saxezea tb-is da aiv infeqcia/Sidsis damoukidebeli epidemiebi da adamianTa umetesoba tb-iT avaddeba aiv infeqciasTan dakavSirebuli imunosupresiis gareSe. amis miuxedavad aiv inficirebul pirebs Soris tb-iT daavadebis riski sakmaod maRalia. 2004 wels dasavleT da aRmosavleT evropis qveynebis SetyobinebaTa mixedviT, tb Sidsis indikatorul daavadebaTa Soris yvelaze xSiria da masze modis Sidsis axali SemTxvevebis 24%-dan 56%-mde (AI) (11,12). arasakmarisia epidkvlevebi gamo, tb/aiv koinfeqciis Sesaxeb codna mwiria. aRmosavleT evropaSi aiv infeqcia/Sidsis prevalentobis dramatuli mateba, aseve tbmaRali prevalentoba mosalodnels xdis tb/aiv koinficirebuli pacientebis ricxvis dramatul zrdas momaval 5 weliwadSi (CIII)

    11

  • (12-14). 2000 wels evropaSi Catarebuli epidemiologiuri monacemebis analizebma gviCvena, rom tuberkuloziT avadmyofebis 2,6% aiv inficirebulia. ruseTis federaciaSi tuberkuloziT daavadebulTa 1% aiv inficirebulia; ukrainaSi aiv inficirebulebi Seadgenen tuberkuloziT daavadebulTa 5%-s. msoflioSi aiv infeqcia/SidsiT mcxovrebi 42 mln adamianis 1/3 koinficirebulia tuberkuloziT. 70% koinficirebuli pirebisa cxovrobs sub-saharul afrikaSi, 20% - samxreT-aRmosavleT aziaSi da 4% laTinur amerikasa da karibis zRvis regionSi. patimrebi yvelaze metad arian tb da aiv infeqciiT inficirebis riskis qveS. cixe Tavisi daxuruli sivrciT, cudi ventilaciiT, araadeqvaturi ganaTebiT da tb daavadebul pacientebTan eqspoziciiT xels uwyobs tb-s gavrcelebas. cixisTvis damaxasiaTebeli qcevis stereotipi, arasteriluri saineqcio instrumentebis gamoyeneba, tatuireba da daucveli sqesobrivi kontaqtebi, xels uwyobs eqspozicias aiv infeqciasTan, aseve B da C virusul hepatitebTan (BII) (15).

    2.4. aiv infeqcia/Sidsis gavlena aqtiuri tuberkulozis ganviTarebaze

    latenturi formis Mycobacterium tuberculosis infeqciis mqone

    adamianebSi aiv infeqcia warmoadgens tuberkulozis aqtiuri formis ganviTarebisaTvis erT-erT yvelaze seriozul xelSemwyob faqtors. aiv infeqcia zrdis tuberkulozis recidivis albaTobas, rogorc gamomwvevis endogenuri reaqtivaciis, ise egzogenuri reinfeqciis Sedegad. aiv infeqcia zrdis tuberkulozis mikobaqteriis mimReblobas. pirveladi tuberkulozi aiv infeqciis fonze xSiria da gvxveba SemTxvevaTa 1/3-Si (BII) (16,17). aiv inficirebulTa 40% avaddeba tuberkuloziT Tavisi cxovrebis ganmavlobaSi. aqtiuri tb daavadebis ganviTarebis riski aiv koinficireblebSi yovelwliurad Seadgens 10%, maSin roca ara aiv inficirebulebSi es riski sicocxlis ganmavlobaSi Seadgens 10%-s. tuberkulozis fataluri SemTxvevebi 4-5-jer metia aiv pozitiurebSi aiv negatiurebTan SedarebiT.

    2.5. aiv infeqcia/Sidsis gavlena tuberkulozis gavrcelebaze tb aiv maRali prevalentobis qveynebSi erT-erTi yvelaze xSiri oportunistuli infeqciaa. aiv infeqcia mniSvnelovnad zrdis tb-iT daavadebuli pacientebis ricxvs, rac amaRlebs avadmyofobis gadacemis albaTobas ojaxis (tb-is gadacemis maRali riski ojaxuri kontaqtebiT aseve, bavSvebze da aiv pozitiur partniorebze) da sazogadoebis wevrebze (samsaxurSi kontaqtisas, skolebSi, saavadmyofoebSi da a.S.).

    12

  • mrtb riski maRalia aiv inficirebulebSi miuxedavad geografiuli mdebareobisa, adre Catarebuli Terapiisa, asakisa, rasisa da sxva..mrtb-s ganviTarebisa da Sesabamisad gavrcelebis riski izrdeba arastandartizebuli, araadeqvaturi da wyvetili mkurnalobis SemTxvevebSi (AI) (18-20), aseve mrtb SesaZloa dakavSirebuli iyos antituberkulozuri preparatebis malabsorbciasTan aiv inficirebulebSi.

    3. etiopaTogenezi

    3.1. aiv infeqcia/Sidsis etiopaTogenezi

    aiv miekuTvneba retrovirusebis ojaxs, lentivirusebis qveojaxs. lentivirusebi, 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 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 – gp120uerTdeba samizne ujredis CD4 molekulas, rasac mohyveba virusis Sesvla ujredSi da misi genetikuri masalis integracia maspinZlis genomSi. Semdeg ki axali virionebis awyoba.

    13

  • 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 datvirTvasTanerTad 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. 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

    14

  • ujredebis, upiratesad, CD4+ limfocitebis destruqcia, imunuri sistemis funqciis moSlas da Rrma imunodeficitis ganviTarebas iwvevs.

    3.2 tuberkulozis etiopaTogenezi

    tuberkulozis gamomwvevi miekuTvneba mikobaqteriebis jgufs, romelic genetikurad enaTesaveba umartivesebs – sxivur sokoebs anu aqtinomicetebs. tuberkulozis gamomwvevs uwodeben koxis bacilas, koxis Cxirs da a.S. daavadebis gamomwvevis pirveli aRmomCenis pativsacemad (24 marti, 1882w).

    adamianebSi daavadebis yvelaze xSiri gamomwvevia M. tuberculosis, Semdeg M. bovis, M.africanum da sxva. atipuri mikobaqteriebi (M. avium, M. muris, M. Kansaci da sxva) adamianisaTvis pirobiT paTogenuria. maT mier gamowveuli tuberkulozis sixSire da mniSvneloba dabalia zogad populaciaSi, Tumca SedarebiT did mniSvnelobas iZens imunokomprometirebul pirebSi, mag. aiv infeqciis dros. M. tuberculosis iwvevs daavadebas ZiriTadad bronqopulmonuri infeqciis saxiT, xolo M. bovis ki ufro rbili qsovilebisa da gastrointestinuri traqtis dazianebas.

    mikobaqteria mJava gamZle baqteriaa. is inarCunebs Seferilobas mJaveebiT, tuteebiT da spirtiT damuSavebisas. mikobaqteriis ganmasxvavebeli niSania ujredis Txeli kedeli, romelic Seicavs mikolis mJavas, virulentobis faqtoris komponents – trehalozis sulfats da proteinebsa da peptidebs (romlebic warmoadgenen mikobaqteriis mTavar antigenur substrats). tuberkulozismikobaqteria mkacri aerobia da damokidebulia Jangbadis Semcvelobaze. pirvel rigSi igi azianebs organoebs, romelSic Jangbadis koncentracia da sisxlis nakadis siCqare maRalia: filtvi da Tirkmeli. mikobaqterias aqvs Cxiris forma, arismoxrili an swori formis, 1,5-6 mkm zomis da 0,2-0,5 mkm sisqis, uZravi. erTsa da imave kulturaSi SeiZleba Segvxvdes sxvadasxva zomis mikobaqtriebi: mcire kokiseburi formebidan – Zalian did gantotvil formebamde. ÛSeRebil nacxSi SeiZleba ganlagebuli iyos rogorc calkeul Cxirebad, ise erTmaneTis paralelurad an grovebad. tuberkulozis mikobaqterias axasiaTebs mdgradoba sxvadasxva fizikuri da qimiuri agentebis mimarT. Txevad naxvelSi rCeba sicocxlisunariani da virulenturi 5-6 Tvis ganmavlobaSi, xolo gamomSral mdgomareobaSi ramodenime Tvis ganmavlobaSi inarCuneben TavianT Tvisebebs d xelsayrel garemo pirobebSi moxvedrisas SeuZliaT gamoavlinon paTogenuri aqtivoba. sakveb niadagze izrdeba Zalian nela. erTi replikaciisaTvis saWiroa daaxloebiT 18 saaTi. sul daaxloebiT 2-6 kviraa saWiro, raTa miviRoT mniSvnelovani zomis kolonia. bacila ar warmoqmnis pigments, romelic SesaZloa mikrobis diferencirebisaTvis gamodges sxva atipuri mikobaqteriebisagan.

    M. tuberculosis gadaecema haerwveTovani gziT. bacila imyofeba wveTovan infeqciuri birTvSi ( 1-5 mkm diametris) da amoxvelebis dros vrceldeba garemomcvel haerSi, rac inhalirdeba sxva

    15

  • adamianis mier da iolad aRwevs alveolebamde. aseTi “infeqciuri birTvebi fizikuri Tvisebebis gamo saaTobiT rCebian Sewonil mdgomareobaSi haerSi.

    infeqciis gamowvevisaTvis M. tuberculosis inhalirdeba da CaaRwevs filtvis alveolebamde, sadac ganicdis fagocitozs makrofagebis mier. maspinZlis Tavdacvis pirveli meqanizmi moicavs SEsabamisi qsovilebis polimorfonuklearuli leikocitebiT da monocitebiT infiltracias, rac qmnis granulomas. es ujredebi Tavis mxriv

    warmoqmnian β-qemokinebs (mag. RANTES, MIP-1a, MCP-1 da sxva) Tujredebis qemoatraqciisaTvis, aseve citokinebs (mag. IL-1, IL-12) T ujredebis aqtivacisaTvis M tuberculosis antigenis sawinaaRmdegod. Tujredebisa da IFN-g-s makrofagebis Semdgomi aqtivaciisaTvis Tujredebi asinTezeben IL-2. es faqtorebi mniSvnelovania granulomis formirebisaTvis da baqteriis Semosafarglad. garda amisa, Tujredebi inficirebuli monocitebisa da makrofagebis lizisSi monawileoben.

    M tuberculosis-iT pirveladi inficirebis Semdeg pacientTa umravlesobas uviTardeba imunuri pasuxi, rac sakmarisia mikobaqteriis eliminaciis an Semosafarglad. IL-12 sekrecia uzrunvelyofs Th1 - T ujredovan pasuxs, rac zrdis makrofagebis aqtivaciisaTvis saWiro IFN-g sekrecias . imunitetis formirebaSi mTavari momentia tuberkulozuri granulomis Camoyalibeba, romelic formirdeba makrofagebis diferencirebiT da multinuklearuli giganturi ujredebis warmoqmniT. infeqciis Semofargvlis unaris daqveiTeba am ujredebis mier ganapirobebs granulomis kazeozuri centris gaTxevadebas, rac xels uwyobs baqteriis ujredgare replikaciasa da Rrus formirebas. inficirebuli pacietebis 5%-s ar SeuZlia mikobaqteriis Semofargvla da maT uviTardebaT pirveladi tb inficirebidan pirvel 3 weliwadSi, maSin roca sxva 5%-Si tb reaqtivdeba pirveli 3 wlis Semdeg.

    3.3 tuberkulozis mimdinareoba aiv inficirebulebSi

    tb pacientebSi, romlebic koinficirebulia aiv-1 infeqciiT, M. tuberculosis infeqcia gansxvavebulia. aiv-1 inficirebul pacientebSi aqtiuri tb ganviTarebis Sansi 20-jer maRalia, rac ZiriTadad ganpirobebulia axali inficirebis daavadebisaken progresirebiT. amasTan erTad, aiv inficirebul pacintebs maRali riski aqvT latenturi tuberkulozis aqtivaciis da eqstrapulmonuri tb (mag plevriti) CamoyalibebisaTvis. ase, rom tb daavadebis klinikuri kursi xSirad ramodenime wlidan ramodenime Tvemde mcirdeba. tb paTologiuri maxasiaTeblebi aiv inficirebul pacientebSi damokidebulia imunosupresiis xarisxze. pacientebSi imunuri sistemis naklebi supresiiT aRiniSneba kazeozuri granulomebi momwifebuli epiTeloduri ujredebiTa da multinuklearuli giganturi ujredebiT. CD4 raodenobis daqveiTebas axlavs qsovilebis difuzuri dazianebani nekroziT, mcire raodenobis

    16

  • epiTeloiduri ujredebiT da didi raodenobiT mikobaqteriebiT. terminalur pacientebs filtvebSi aReniSnebaT fibrozuli da gakiruli tb dazianebani aqtiur mikobaqteriebis Semcvel da gamomyof dazianebebTan erTad. imunologiuri kvlevebi miuTiTebs, rom aiv-1 - tb koinficirebul pacientebs araefeqturi imunuri pasuxi aReniSnebaT filtvebSi, rasac gamoixateba infeqciis ubanSi zogadad limfocitebis simwiriTa da maT Soris CD4 limfocitebis dabali wiliT. aseve daqveiTebulia interferon-γ−s i-rnm done, rasac axlavs interferon-γ−s produqciis daqveiTeba, rac Tavis mxriv makrofagebis aqtivaciis faqtors warmoadgens. rodesac aiv –tb koinficirebuli pacientebis periferiuli sisxlis mononuklearuli ujredebi gamohyofdnen da axdendnen mis eqspozicias M. tuberculosis-iT in vitro, ujredebi gamohyofdnen naklebi raodenobiT interferon-γ−s, magram imave raodenobiT Th-2citokinebs, rasac aiv negatiuri tb inficirebuli pacientebis analogiuri ujredebi. es yovelive miuTiTebs, rom aiv inficirebuli pacientebis makrofagebi naklebi intensivobiT aqtivdeba M. tuberculosis –ze, Tumca am pacientebs humoruli imunitetis gamomuSaveba jer kidev SeuZliaT. aseTi imunologiuri maxasiaTeblebi ver uzrunvelyofs granulomis efeqtur warmoqmnas, da xels uwyobs daavadebis xSir progresirebas tb aqtivacias.

    3.4. tuberkulozis zegavlena aiv infeqcis progresirebaze garda imisa, rom aiv infeqcia aCqarebs tb progresirebas, TviTon tb infeqciac axdens arasasurvel zegavlenas aiv infeqciis mimdinareobaze. retrospeqtuli kvlevebi miuTiTebs, rom tb infeqcia zrdis Sidsis progresirebis tempsa da letalobas. izoniazidiT profilaqtika PPD+ pacientebSi aqveiTebda ara mxolod tb avadobas, aramed aiv asocirebuli daavadebebis sixSires am pacientebSi. Catarebul kvlevebSi aqtiuri tb dakavSirebuli iyo letaluri gamosavlis sixSiris matebasTan, rodesac CD4 ricxvi aRemateboda 200/mm3. erT-erTi xelis Semwyobi faqtori, rac zrdida tb-s uaryofiT zegavlenas aiv daavadebaze, iyo maRali virusuli datvirTva. aseTi zegavlena gansakuTrebiT CD4 maRal maCveneblebze SeiniSneboda ( CD4>500/mm3). es imaze miuTiTebs, rom tb zrdis aiv replikacias in vivo. tb asev asocirebuli iyo aiv replikaciis Seqcevad matebasTan aqtivirebul ujredebSi. tb dainficirebuli filtvebis segmentebSi aivinficirebul pacientebSi virusuli replikacia iyo ufro maRali, vidre aiv inficirebuli pacientebis filtvis qsovilebSi tb infeqciis gareSe. in vitro kvlevebSi M. tuberculosis zrdis aiv replikacias transkripciisada virusuli SeWris aqtivaciiT. M. tuberculosis ganpirobebuli aivreplikaciis stimulireba rogorc Cans dakavSirebulia specifiuricitokinebis (rogoricaa TNF-α) da qemokinebis ( mag. MCP-1, magram ara RANTES an MIP-1α) donis matebasTan tb dros da maspinZlis imunuri sistemis aqtivaciasTan. amasTan erTad M. tuberculosis

    17

  • pirdapir zrdis aiv replikacias koinficirebul sisxlis monocitebsa da mononuklearul ujredebSi. es SesaZloa dakavSirebuli iyos ujredis mgrZnobelobis gazrdasTan aivvirusis mimarT. tb inficirebuli pacientebis monocitebi ufro iolad inficirdeba virusiT, vidre janmrTeli donoris sisxlis monocitebi. sisxlis monovitebis inficireba virusiT ufro efeqturs xdis aiv transmisias T-ujredebze. imunuri sistemis araspecifiuri antigenuri stimulacia aseve axdens zegavlenas aiv-1 replikaciasa da heterogenurobaze. magaliTad aiv-1 inficirebulebis vaqcinacia tetanusiT iwvevs virusuli datvirTvis matebas da droebiT virusuli kvazisaxeobebis Semadgenlobisa da ganawilebis Secvlas. magram tb iwvevs qronikul infeqcias, riTic xangrZlivi drois ganmavlobaSi zrdis virusis replikaciasa da heterogenurobas. tb zrdis aivreplikaciasa da heterogenurobas pirvel rigSi infeqciis areSi. aman SeiZleba gamoiwvos aiv kvazisaxeobebis swrafi evolucia filtvebSi, rac Secvlis sistemur heterogenurobasac.

    4. klinikuri simptomatika:

    4.1. aiv infeqcia/Sidsis gavlena tuberkulozis klinikur

    prezentaciaze

    aiv infeqciis progresirebasTan erTad Rrmavdeba imunosupresia. CD4 limfocitebis ricxvi klebulobs 50-80 ujrediT/mm3 weliwadSi. imunuri sistema veRar axerxebs tuberkulozis mikobaqteriis aqtivaciisa an gamravlebis procesebis daTrgunvas. tuberkulozis klinikuri gamovlinebis Taviseburebani damokidebulia CD4 limfocitebis raodenobaze. Tu CD4limfocitebis ricxvi metia 350 /mm3, maSin ufro xSiria filtvis tuberkulozuri dazianeba (post-pirveladi anu meoradi filtvis tuberkulozi); klinikuri mimdinareoba, mikobaqteriagamoyofis sixSire, rentgenologiuri cvlilebebi (filtvis zemo wilebis infiltracia + kavitacia) aiv negatiuri pirebis analogiuria. gviani aiv infeqciis dros ki daavadebis klinikuri prezentacia pirvelad tuberkulozis msgavsia: naxvelis nacxi xSirad mgb negatiuria da gulmkerdis rentgenologiuri gamokvleviT upiratesad gvxvdeba qvemo da/an Sua wilebis dazianeba xSirad destruqciebis gareSe, miliarizacia (BII) (21-23). Rrma imunodeficitis dros ( CD4 limfocitebis ricxvi

  • 4.2. tuberkulozis gavlena aiv inficirebulTa avadobasa da sikvdilobaze

    aiv negatiur pirebSi aqtiuri tb asocirebulia saSualo imunur deficitTan. im qveynebSi sadac aris tb-is da aiv infeqciis damoukidebeli epidemiebi, tb yovelTvis ar miuTiTebs imunuri sistemis Zlier dazianebaze aiv inficirebul pirebSi. tb SesaZloa ganviTardes aiv inficirebamde an mis adreul stadiaze, manamde sanam imunuri sistema daziandeba. aiv inficirebulebSi aqtiuri tuberkulozis fonze imunodeficiti Rrmavdeba, rac xels uwyobs sxva oportunistuli infeqciebis (saylapavis kandidozi, kriptokokuli meningiti, pnevmocisturi pnevmonia da a.S.) ganviTarebas. aseT SemTxvevebSi, oportunistuli infeqciebidan nebismierma SesaZloa gamoiwvios pacientis sikvdili da letaluri gamosavali ar iyos dakavSirebuli uSualod tb-Tan (AI) (24). Aaqve unda aRiniSnos, rom aiv infeqcia/SidsiT gardacvlilTa 30%-Si sikvdilis mizezs tuberkulozi warmoadgens (BII) (22, 23, 25). es monacemebi miuTiTebs tb diagnostikisa da mkurnalobis aucileblobaze aiv inficirebuli pirebSi, gansakuTrebiT Rrma imunodeficitis dros.

    5. daavadebis diagnozi

    5.1. tuberkulozis riskis Sefaseba da diagnostika aiv inficirebul pirebSi

    yvela aiv inficirebuli piri imyofeba aqtiuri tb-is ganviTarebis riskis qveS da meores mxriv, yvela tb-iT daavadebuli piri konsultirebuli da testirebuli unda iyos aiv antisxeulebze.

    • aiv pozitiuri pirebi imyofebian tb-is ganviTarebis maRali riskis qveS;

    • tb warmoadgens yvelaze xSir oportunistul infeqcias; • tb aris aiv inficirebuli pirebis sikvdilobis yvelaze xSiri

    mizezi; aiv infeqcia/Sidsi ganapirobebs:

    • tb-is progresirebas latenturi formidan daavadebaSi; • tb-is klinikuri mimdinareobis Taviseburebebs; • tb-is mkurnalobis Taviseburebebs; aqtiuri tuberkulozi ganapirobebs:

    • aiv infeqcia/Sidsis klinikur progresirebas da gavlenas axdens mis mkurnalobaze;

    • tb Sidsis indikatoruli daavadebaa. aiv inficirebul pirebSi tb-ze eWvi unda gaCndes Semdeg SemTxvevebSi:

    • respiratoruli simptomebis (mag: 2 kviraze meti xangrZlivobis xvela) arsebobisas;

    19

  • • kontaqtisas filtvis aqtiuri tb-iT daavadebul pirTan; • zogadi intoqsikaciis sindromis fonze ganviTarebul

    sxvadasxva organoebis dazianebisaTvis damaxasiaTebali lokaluri simptomebis arsebobisas.

    Tu aiv inficirebuli pirs ar aReniSneba tuberkuloziT daavadebisaTvis damaxasiaTebeli niSnebi, (aseve, eqspozicia an klinikuri simptomebi), unda gakeTdes mantus alergiuli sinji latenturi tuberkulozis identifikaciisTvis, romelic momavalSi SesaZloa gadaizardos tb daavadebaSi aiv asocirebuli imunosupresiis gamo. tuberkulinodiagnostikas safuZvlad udevs tuberkulozis gamomwvevis antigenisadmi (tuberkulini - tuberkulozis bacilisgan gamoyofili gasufTavebuli cila) ganviTarebuli dayovnebuli tipis zemgrZnobeloba, romelic vlindeba diagnostikumis Seyvanis adgilze ganviTarebuli adgilobrivi anTebiTi reaqciis saxiT. tuberkulin - PPD-RT23-is 0,1 ml Seyvanil unda iqnas winamxarze, kanqveS ise, rom warmoiqmnas 5 – 6 mm diametris papula. Mmantus sinjis Sefaseba xdeba 48-72 sT-is Semdeg; izomeba induraciis diametri. aiv inficirebul pirebSi testi iTvleba pozitiurad Tu induracia aRemateba 5 mm-s. reaqcia gviCvenebs mxolod pirovnebis dainficirebas tuberkulozis mikobaqteriiT (BII) (15,17). tuberkulinis testis pozitiuri Sedegi miuTiTebs profilaqtikuri mkurnalobis dawyebis aucileblobaze; negatiuri pasuxis arseboba ki aiv inficirebuli pirebSi gamoricxavs SemdgomSi tb-iT daavadebis risks (gamonaklisia Rrma imunodeficituri mdgomareoba). aqtiuri tuberkulozis diagnostika emyareba klinikuri, baqteriologiuri (naxvelis mikroskopia da daTesva specialur niadagebze) da rentgenologiuri gamokvlevebis Sedegebs. klinikurad da rentgenologiurad filtvis tuberkulozze saeWvo mgb(-) uaryofiT SemTxvevebSi, daavadebis araspecifikuri da tuberkulozuri etiologiis diferencirebisTvis, mizanSewonilia sacdeli Terapia farTo speqtris antibiotikebiT. aqtiuri tbgamoricxvis SemTxvevaSi, keTdeba mantus sinji latenturi tuberkulozis arsebobis dasadgenad.

    5.2. aiv infeqcia/Sidsis riskis Sefaseba da diagnostika tuberkuloziT avadmyofebSi

    aiv infeqciaze konsultireba da testireba rutinulad unda mimdinareobdes im dawesebulebebSi sadac zedamxedveloben aqtiuri tb-iT daavadebul pacientebs. medicinis muSakebma garkveviT unda ganumarton pacientebs testirebis mniSvneloba daavadebis swori menejmentis TvalsazrisiT. pacientTa aiv inficirebis Sefaseba moicavs:

    20

  • • aiv infeqciaze pretest konsultacias; • serologiur gamokvlevas aiv antisxeulebze ( swrafi/

    martivi an imunofermentuli MmeTodebiT), romelsac saeWvo SemTxvevaSi mohyveba damadasturebeli gamokvleva imunoblitingis meTodiT;

    • posttest konsultacia, testirebis Sedegebis ganmartebiT. aiv inficirebuli pacientebi gadadian Sesabamisi profilis eqimis meTvalyureobis qveS. bavSvebis dainficireba tuberkulozis mokobaqteriiT ZiriTadad xdeba mgb pozitiuri naxvelis mqone mozrdilTan (ufro xSirad ojaxis wevrTan) kontaqtis Sedegad. tubsawinaaRmdego qimioprofilaqtikis gareSe, aiv pozitiuri Cvili asakis bavSvebis 40-50%-s, aseve mozrdili asakis aiv inficirebuli bavSvebis daaxloebiT 15%-s tuberkulozisTvis damaxasiaTebeli simptomebi uvlindebaT inficirebidan 1 an 2 weliwadSi. aiv inficirebul CvilebSi tuberkulozis mikobaqteriiT inficirebidan daavadebis ganviTarebamde saWiroa sul mcire 6-8 kvira. gansakuTrebuli yuradReba unda mieqces im aiv pozitiuri qalebis axalSobilebs, romelTac tuberkulozis sawinaaRmdego mkurnaloba daewyoT mSobiarobamde 2 Tveze naklebi drois periodSi. es Cvilebi gamokvleul unda iyvnen Tandayolili tuberkulozis simptomebis arsebobaze da daeniSnoT Sesabamisi mkurnaloba. 7 welze meti asakis bavSvebsa da mozardebisaTvis damaxasiaTebelia tuberkulozis tipiuri klinikuri simptomatika; 4 wlamde asakis bavSvebSi ki xSiria atipuri mimdinareoba procesis filtvgareSe diseminaciiT, hepatomegaliiT, gaxangrZlivebuli cxelebiT, limfadenopaTiiT, anemiiTa da wonaSi klebiT.

    5.3. tuberkulozis identifikacia aiv inficirebuli bavSvebSi tuberkulozis diagnozis dasma bavSvebsa da CvilebSi imis miuxedavad arian Tu ara isini aiv inficirebuli, garkveul siZneleebTan aris dakavSirebuli. bavSvebSi sasunTqi sistemis tuberkulozis dros iSviaTia naxvelis gamoyofa, rac tuberkulozis baqteriologiuri identificirebisaTvis aris saWiro. Ddaavadebis verifikaciis sxva meTodebi, rogoricaa magaliTad, gastraluri lavaJi arapraqtikulia farTod gamoyenebis TvalsazrisiT. Sesabamisad, rTuldeba daavadebis, gansakuTrebiT ki filtvis tuberkulozis baqteriologiuri dadastureba. aiv inficirebul bavSvebSi tuberkulozis diagnozis dasma kidev ufro rTulia, vinaidan aiv asocirebuli bevr daavadebas axasiaTebs tuberkulozis msgavsi klinikuri mimdinareoba da simptomatika. amasTan kanis tuberkulinuri sinjis pasuxi nakleb sarwmunoa. amitom tuberkulozis diagnozi xSirad efuZneba epidemiologiur anamnezs, tuberkulozisaTvis damaxasiaTebeli niSnebisa da simptomebis arsebobas da gamokvlevebis Sedegebs (ix. cxrili 1).

    21

  • cxrili 1 mdgomareobebi dakavSirebuli aqtiur

    tuberkulozTan bavSvebSi

    tuberkulozi saeWvoa, rodesac adgili aqvs

    • anamnezSi kontaqts filtvis tuberkulozis dadasturebul SemTxvevasTan;

    • wiTelas gadatanis Semdeg imunosupresiul mdgomareobas; • wonaSi klebas, xvelas, paTologiur auskultaciur monacemebs

    filtvebSi, romelic ar daeqvemdebara farTo speqtris antibiortikoTerapias;

    • zedapiruli limfuri kvanZebis umtkivneulo SeSupebas. tuberkulozi savaraudoa, roca adgili aqvs saeWvo tuberkulozis SemTxevevas da erT-erT niSans qvemoT CamoTvlilTagan

    • tuberkulozis kanis testi 5 mm-ze meti induraciiT • Sesabamisi cvlilebebi gulmkerdis rentgenogramaze • Sesabamisi histologiuri cvlilebebi biofsiur masalaSi • dadebiTi Sedegi antituberkulozur mkurnalobaze tuberkulozi dadasturebulia, roca

    • tuberkulozis mikobaqteria identificirebulia biologiur sekretebSi an qsovilebSi

    • naxvelis nacxis samjeradi pirdapiri mikroskopiiT minimum or preparatSi aRmoCenilia mJavagamZle mikobaqteria

    5. 4. aiv infeqcia/Sidsis identifikacia aqtiuri tuberkuloziT

    daavadebul Cvilebsa da bavSvebSi aiv infeqciaze eWvis mitanis SemTxvevaSi, 18 Tvemde asakis bavSvebSi aiv infeqciis diagnostikisTvis gamoiyeneba aiv provirus dnm-is Tvisobrivi aRmoCena polimerazis jaWvuri reaqciis meTodiT (pjr kvleva); 18 Tveze meti asakis bavSvebisaTvis ki -imunofermentuli analizi (ELISA) – serologiuri kvleva aiv sawinaaRmdego antisxeulebis aRmosaCenad.

    22

  • 6. gamokvlevebis sqema

    sqema1. aiv inficirebul pirebSi tuberkulozis riskis da daavadebis Sesafasebeli algoriTmi

    @@@@@

    diax

    aqtiuri tb gamoiricxa

    aqtiuri tb dadasturda

    tb-is mkurnaloba

    tb-is mkurnaloba ar tardeba

    tuberkulinis kanis testi

    pozitiuri negatiuri

    tb-s profilaqtikuri mkurnaloba

    aqtiuri tb-is dadastureba an gamorcxva (klinikuri, baqteriologiuri, rentgenologiuri gamokvleva; sacdeli mkurnaloba farTo speqtris antibiotikebiT)

    ara

    axali kontaqti tb daavadebulTan an

    tb simptomebi

    23

  • 7. mkurnalobis sqema

    7.1. koinficirebuli pacientebis menejmenti aiv infeqcia/SidsiT da tuberkuloziT koinficirebis SemTxvevaSi Zalian didi mniSvneloba eniWeba mkurnalobis dawyebis vadebs. vinaidan tuberkulozis sxvadasxva SemTxveva saWiroebs gansxvavebul klinikur marTvas, tuberkulozisa da aiv infeqciis statusis sawyisi Sefasebis Semdeg, unda dadgindes Tu ra aReniSneba pacients: 1. tuberkulozis mikobaqteriiT inficireba (Sefasebis kriteriumi: tuberkulinuri testis dadebiTi Sedegi); Tu 2. tuberkulozuri daavadeba; aqtiuri tuberkulozis diagnozis dasmis SemTxvevaSi -baqteriagamoyofis arsebobis, dazianebis gavrcelebisa da farmako-anamnezis mixedviT, unda ganisazRvros romel kategorias (pirveli, meore, meoTxe) miekuTvneba avadmyofi.

    7.2. koinficirebuli aqtiuri tuberkuloziT daavadebuli pacientebis menejmenti

    pozitiuri aiv statusis mqone pacientebi, romlebic inficirebulni arian tuberkulozis mikobaqteriiT da aqvT aqtiuri tuberkulozis ganviTarebis maRali riski, daavadebis prevenciis mizniT saWiroeben tubsawinaaRmdego qimioprofilaqtikas izoniazidiT (5 mg/kg – maqsimaluri dRiuri doza 300 mg erTxel dReSi 6 Tvis ganmavlobaSi). izoniazidis gverdiTi movlenebis (neiropaTia da sxva) Tavidan asacileblad damatebiT iniSneba 25 mg piridoqsini dReSi, gansakuTrebiT orsulebSi, alkoholis Warb momxmareblebSi da malnutriciis SemTxvevebSi. M qveynebSi, sadac aRiniSneba izoniazidis mimarT rezistentoba(CIII) (26-28) mowodebulia qimioprofilaqtikis alternatiuli sqemebi, magram maTi efeqturobis dasadastureblad Semdgomi kvlevebis Catarebaa saWiro. Semdgomi kvlevebia aseve Casatarebeli latenturi tuberkulozis axali sadiagnostiko testebis SesamuSaveblad. janmo rekomendacias uwevs arT dawyebas klinikuri da imunologiuri kriteriumebis safuZvelze. rekomendaciebi arT dawyebis Sesaxeb Sejamebulia cxrilSi 2. cxrili 2 rekomendaciebi arT dawyebis Sesaxeb

    janmo klinikuri stadia CD4 ricxvi rekomendacia

    < 200/mm3 umkurnaleT 1 200 - 350/mm3 ganixileT mkurnalobis

    SesaZlebloba a,b

    < 200/mm3 umkurnaleT 2 200 - 350/mm3 ganixileT mkurnalobis

    SesaZlebloba a,b

    3 200 - 350/mm3 umkurnaleT

    4 CD4 ricxvisgan damoukideblad

    umkurnaleT

    24

  • a. rodesac CD4 ricxvi 350/mm3-is midamoSia, daiwyeT msjeloba pacientTan arT dawyebis saWiroebis moaxloebis da mkurnalobis sawyisi reJimis Sesaxeb.

    b. 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.

    antiretrovirusuli mkurnalobis dawyebisTanave avadmyofs eniSneba tuberkulozis qimioprofilaqtika. aucilebelia CD4limfocitebis im zeda zRvaris identifikacia, romlis zemoT tuberkulozis qimioprofilaqtika naklebad aris saWiro.

    7.3. tuberkulozis mkurnaloba tuberkulozis mkurnalobas aiv inficirebul pacientebSi prioritetuli mniSvneloba eniWeba da is unda daiwyos aqtiuri tuberkulozis diagnozis dadasturebidan rac SeiZleba male. tuberkulozis mkurnaloba swrafad aqveiTebs am daavadebasTan dakavSirebul sikvdilobas da misi transmisiis Sanss (BII) (15, 29, 30). tuberkulozis mkurnaloba miuxedavad misi Tanxlebisa arT-sTan unda efuZnebodes im preparatebis gamoyenebas, romelTa bioSeRwevadoba cnobilia. tuberkulozis mkurnaloba moicavs or fazas: intensiursa da gagrZelebis. tuberkulozis mkurnalobis xangrZlivoba damokidebulia avadmyofTa kategoriaze da saSualod 6-9 Tves moicavs; aqedan intensiuri fazis xangrZlivobaa 2-3 Tve, gagrZelebis fazisa ki - 4-5 Tve. Tanamedrove monacemebiT, aiv inficirebul pacientebSi rifampicinis Semcveli qimioTerapiis reJimebis gamoyeneba minimumamde amcirebs relafsis ganviTarebis SesaZleblobas. cxrili 3 aqtiuri tuberkulozis mkurnalobisTvis

    rekomendirebuli reJimebi aiv inficirebul pacientebSi

    tuberkulozis mkurnalobis reJimebi1

    tuberkulozis SemTxvevis tipi

    intensiuri faza2 gagrZelebis faza

    axali tbB pacienti HRZE 2 Tvis ganmavlobaSi 3

    HR 4 Tvis ganmavlobaSi

    adre tb-namkurnalebi pacienti, maT Soris

    • recidivi • mkurnaloba misi Sewyvetis

    Semdeg

    • uSedego mkurnaloba 4 • sxva SemTxveva

    HRZES 2 Tvis ganmavlobaSi + HRZE 1 Tvis ganmavlobaSi

    HRE 5 Tvis ganmavlobaSi

    25

  • qronikuli (zedamxedvelobis qveS Catarebuli ganmeorebiTi mkurnalobis Semdeg naxveli isev mgb pozitiuria) mrtb (aRiniSneba rezistentoba minimum H da R)

    specialuri reJimi

    H –izoniazidi, R – rifampicini, Z – pirazinamidi, E – etambutoli, S- streptomicini.

    1. aiv inficirebuli pacientebisaTvis aqtiuri tuberkuloziT mkurnalobis yoveldRiuri reJimia rekomendirebuli;

    uSualo zedamxedvelobis qveS Catarebuli mkurnaloba rekomendebulia mkurnalobis mTeli kursis ganmavlobaSi;

    2. streptomicini SesaZloa gamoyenebul iqnes etambutolis nacvlad;

    3. tuberkulozuri meningitisas etambutoli unda Seicvalos streptomiciniT.

    4. sasurvelia unda Catardes wamlebis mimarT mikroorganizmis mgrZnobelobis Seswavla mkurnalobis reJimis individualuri wesiT SesarCevad.

    7.4. antiretrovirusuli mkurnalobis dawyeba aqtiuri tuberkuloziT daavadebul pacientTa umetesobas Rrma imunodeficiti aqvT da amdenad isini saWiroeben arT-s. aseT pacientebSi sasurvelia ar moxdes arT da tuberkulozis sawinaaRmdego mkurnalobis erTdrouli dawyeba da dayovndes arT (ix. cxrili 4) (BII) (31-34). zemoT aRniSnuli strategia:

    • amartivebs pacientis marTvas; • Tavidan agvaSorebs arT da tuberkulozis sawinaaRmdego

    preparatebis urTierTqmedebas;

    • Tavidan agvaSorebs maT erTobliv toqsiurobas; • amcirebs imunuri rekonstituciis sindromis (irs) risks; • amcirebs pacientis gaugebrobas da dabneulobas, Tu romeli

    daavadebis wamali rodis miiRos ;

    • aumjobesebs reJimis dacvas. cxrili 4 aqtiuri tuberkulozis sawinaaRmdego

    mkurnalobis dawyebis strategia aiv inficirebul pacientebSi

    kriteriumebi tb mkurnaloba arT filtvgareSe tuberkulozi (miuxedavad CD4 ricxvisa)

    daiwyeT dauyovnebliv

    filtvis tuberkulozi daiwyeT dauyovnebliv

    daiwyeT rac SeiZleba swrafad, antituberkulozuri preparatebis kargad atanisTanave (2 kviridan – 2 Tvis

    26

  • (CD4 < 200 /mm3) farglebSi) 1

    filtvis tuberkulozi (CD4 = 200-350 /mm3)

    daiwyeT dauyovnebliv daiwyeT antituberkulozuri mkurnalobis intensiuri fazis damTavrebisTanave (daiwyeT ufro adre

    mZime SemTxvevebSi) filtvis tuberkulozi (CD4 >350 /mm3)

    daiwyeT dauyovnebliv akontroleT CD4 ricxvi (ganixileT arT Tu CD4 daiwevs 350/mm3 qvemoT)

    1 – arT dawyebis Sesaxeb gadawyvetileba unda efuZnebodes aseve klinikur gamokvlevebsa da imunodeficitis sxva niSnebs. pirveli rigis maRalaqtiuri antiretrovirusuli Terapia (maarT) maarT - maRalaqtiuri antiretrovirusuli Terapia standartulad rekomendirebuli arT-ia. is moicavs sam an met arv preparats. saukeTeso arT reJimis SesarCevad tuberkuloziT inficirebuli pacientebSi gaTvaliswinebuli unda iqnas Semdegi faqtorebi:

    • preparatebis potenciuroba • gverdiTi efeqtebi da toqsiuroba • miRebis simartive, raTa ukeTesad iyos daculi mkurnalobis

    reJimi. arT tuberkuloziT inficirebuli pacientebSi saWiroebs Semdegi faqtorebis gaTvaliswinebas :

    • urTierTzegavlena rifampicinsa da zogierT arv preparats Soris

    • tabletebis raodenoba • reJimis dacvis didi mniSvneloba • preparatebis toqsiuroba • imunuri rekonstituciis sindromis ganviTarebis riski cxrili 5 rekomendirebuli pirveli rigis mmaaaarrTT reJimi tb

    pacientebisaTvis, romlebsac eZlevaT rifampicini1

    maarT arv preparatebis kombinacia

    sasurvelia

    2 nnrrttii (nukleoziduri revers transkriftazas inhibitori) ++ 1 aannrrttii (ara-nukleoziduri revers transkriftazas inhibitori)

    ZDV (an TDF)+ 3TC (an FTC) + EFV 2

    27

  • alternatiuli

    3 nnrrttii ZDV+ 3TC + ABC(an TDF)

    1 – dozireba ix me-2 damatebaSi 2 - rekomendirebulia efavirenzis dozireba 600 mg/dR gansakuTrebiT 60kg pacientebSi, Tumca es debuleba saWiroebs Semdgom kvlevas. nevirapini SesaZloa gamoyenebul iqnas (200 mg erTxel dReSi 2 kviris ganmavlobaSi, Semdeg 200 mg orjer dReSi), RviZlis funqciuri testebis da wamlis toqsiurobis kontroliT. ZiriTadi mosazrebani pirveli rigis maarT reJimis gamoyenebisas ZDV (an TDF)+ 3TC (an FTC) + EFV • ar aris saWiro rifampicinis dozis koreqcia • EFV aqveiTebs mniSvnelovnad metadonis dones. ZDV+ 3TC + ABC(an TDF) • ar aris saWiro rifampicinis dozis SerCeva • tuberkuloziT inficirebul qals ufro usafrTxoa daeniSnos

    ZDV+ 3TC + ABC uSedego mkurnaloba (Treatment Failure)

    antiretroviruli mkurnalobis araefeqturobis sami

    kriteriumi arsebobs, romlTa mixedviT SeiZleba msjeloba mkurnalobis warumateblobaze:

    1. virusolofiuri; 2. imunologiuri; 3. klinikuri;

    1. arT-s araefeqturobis virusologiuri kriteriumebi:

    a) arasruli virusologiuri pasuxi: mag., Tu ar miiRweva virusuli datvirTva < 400 asli/ml mkurnalobis dawyebidan 24 kviris Semdeg;

    b) arasruli virusologiuri pasuxi: mag., Tu ar miiRweva virusuli datvirTva < 50 asli/ml 48 kviris Semdeg.

    c) virusis replikaciis ganaxleba (rebound) – viremiis ganaxleba virusis replikaciis daTrgunvis Semdeg, ganmeorebiTi kvlevisas.

    2. arT-s araefeqturobis imunologiuri kriteriumebi::

    a) CD4 ricxvis im donemde Semcireba, ra donezec iyo arT dawyebis dros an ufro dabla, im SemTxvevaSi, Tu gamoricxulia sxva infeqciuri daavadebebi, romelTac SeiZleba gamoewviaT es;

    b) CD4 ricxvis mkurnalobis ganmavlobaSi arsebuli pikuri donidan 50% Semcireba Tu gamoricxulia sxva

    28

  • infeqciuri daavadebebi, romelTac SeiZleba gamoewviaT es. 33.. arT-s araefeqturobis klinikuri kriteriumebi:

    a) axali oportunistuli infeqciebis an avTvisebiani simsivneebis ganviTareba, romlebic migviTiTeben daavadebis klinikur progresirebaze. Ees mdgomareobebi unda ganvasxvavoT imunuri sistemis aRdgenis (rekonstituciis) sindromisgan, romelic SesaZlebelia arT-s dawyebidan pirveli 3 Tvis ganmavlobaSi da ar niSnavs mkurnalobis araefeqturobas. oportunistul infeqciebs mkurnaloben Cveulebrivad, arT-s sqema ar icvleba.

    b) adre gadatanili oportunistuli infeqciebis recidivi (tuberkulozi ar aris mkurnalobis araefeqturobis kriteriumi, vinaidan SesaZloa adgili hqondes egzogenur reinfeqcias. aqtiuri tuberkulozis SemTxvevaSi pacienti ar gadadis meore rigis reJimze).

    mkurnalobis virusologiuri araefeqturobis SemTxvevaSi tardeba adamianis imunodeficitis virusis genotipuri rezistentobis testida aiv inficirebuli piri genotipuri rezistentobis testis Sedegebis mixedviT mkurnalobis pirveli rigis reJimidan gadadis meore rigis reJimze. pacientebisaTvis, romlebic iReben meore rigis reJims saWiroa moxdes proteazis inhibitorebis (pi) dozis SerCeva. meore rigis maRalaqtiuri antiretrovirusuli reJimi cxrili 6 rekomendirebuli meore rigis mmaaaarrTT reJimi tb

    pacientebisaTvis maarT arv preparatebis

    kombinacia sasurvelia

    2 nnrrttii ++ 2 ppii (maT Soris erTi bustirebuli)

    ABC+ ddI + LPV/r +RTV an TDF+ ddI + LPV/r +RTV

    alternatiuli

    2 nnrrttii ++ 2 ppii

    ABC+ ddI + SQV +RTV an TDF+ ddI + SQV +RTV

    ZiriTadi mosazrebani meore rigis maarT reJimisTvis ABC (an TDF) + ddI + LPV/r + RTV

    29

  • • Tuki iniSneba ddI da TDF, dozis koreqcia saWiroa pankreasze toqsiuri zegavlenisa da negatiuri imunuri efeqtebis gamo. ddI-is rekomendirebuli doza TDF-Tan (300 mg erTxel) erTad daniSnvisas Seadgens:

    o 250 mg erTxel dReSi pacientebisaTvis woniT >60kg o 125 – 200 mg erTxel dReSi pacientebisaTvis woniT <

    60kg (38, 39).

    • rodesac iniSneba LPV/r 400/100 mg orjer dReSi, unda daematos RTV 300 mg orjer dReSi, RviZlis funqciebisa da lipidebis donis mWidro monitoringiT.

    ABC (an TDF) + ddI + SQV +RT

    • rodesac iniSneba SQV rekomendebuli dRiuri doza SQV-sTvis da RTV-sTvis aris 400 mg , aucilebelia RviZlis fermentebis mWidro monitoringi.

    • rifampicinis dozis modifikacia ar aris saWiro am reJimisas. antiretrovirusuli da antituberkulozuri medikamentebis urTierTqmedeba da menejmenti

    • rifampicini iwvevs RviZlis citoqrom P450 (CYP) fermentTa sistemis aqtiurobis stimulacias, romelic axdensaranukleozidis analogebisa da proteazas inhibitorebis metabolizebas. es meqanizmi safuZvlad udevs sisxlSi maTi koncentraciis daqveiTebas da Sesabamisad aiv-is replikaciis arasrul daTrgunvas, rac qmnis rezistentobis ganviTarebis saSiSroebas. rifampicini 75%-iT amcirebs proteazas inhibitorebis koncentracias sisxlSi, rac aucilebels xdis dozis modifikacias.

    • aranukleozidis analogebi da proteazas inhibitorebi Tavis mxriv cvlian rifampicinis koncentracias sisxlSi, amitom upiratesoba eniWeba rifampicinis yoveldRiur reJims (40 - 42);

    • rifampicini ar zemoqmedebs nukleozidis analogis ukutranskriftazas inhibitorebze, amdenad dozis modifikacia ar aris saWiro;

    • pacientebSi, meore rigis antiretrovirusul reJimebze, usafrTxod SegviZlia gamoviyenoT rifabutini 150 mg dRegamoSvebiT an 3X kviraSi rifampicinis nacvlad, rogorc alternatiuli preparati.

    • rifabutini ar unda dainiSnos arabustirebul seqvinavirTan, magram SesaZloa gamoviyenoT kombinaciaSi SQV da RTV.

    koinfeqciis klinikuri menejmenti specialuri mdgomareobisas Tirkmlis daavadebebi

    • izoniazids, rifampicinsa da pirazinamids ar sWirdebaT dozis modifikacia TirkmliT daavadebul pacientebSi;

    30

  • • periferiuli neiropaTiis profilaqtikisTvis avadmyofebma unda miiRon piridoqsini;

    • streptomicini da etambutoli gamoiyofa Tirkmlis gziT, amdenad aucilebelia dozis Semcireba da kreatininis monitoringi yovelTviurad;

    • tenofoviri ar unda dainiSnos nefrotoqsiurobis gamo; cxrili 7. rekomendebuli tb reJimebi Tirkmlis daavadebi mqone pacientebisTvis 1

    intensiuri faza gagrZelebis faza SerCevis preparati HRZ 2 Tve HR 4 Tve alternatiuli HRZE 2 Tve HR 4 Tve

    1. zemoT aRniSnuli rekomendaciebi unda iqnes gaTvaliswinebuli, rodesac kreatininis done miaRwevs 130-160 mkm/l.

    RviZlis daavadebebi

    • izoniazidi, rifampicini da pirazinamidi asocirebuli arian wamlismier hepatitTan;

    • pirazinamidi yvelaze hepatotoqsiuria, meore adgili uWiravs rifampicins. rifampicini asocirdeba qolestazur siyviTlesTan da ara hepatocelulur dazianebasTan;

    • pacientebma RviZlis daavadebiT ar unda miiRon pirazinamidi. alternatiuli tb preparati mowodebulia cxrilSi 6;

    • klinikuri da RviZlis fermentebis laboratoriuli monitoringi aucilebelia regularulad. sixSire ganisazRvreba pacientis mdgomareobiT.

    cxrili 8. rekomendebuli tb reJimebi pacientebSi RviZlis daavadebebiT 1

    intensiuri faza gagrZelebis faza SerCevis preparati SHRE 2 Tve HR 6 Tve I alternativa SHE 2 Tve HE 10 Tve II alternativa RE 9 Tve 1. RviZlis daavadebad iwodeba mdgomareoba, rodesac alaninaminotranferaza samjer aRemateba normis maCvenebels an Tu saxezea qronikuli hepatiti an cirozi. Svilosnobis asakis qalebi rifampicinsa da zogierT antiretrovirusul reJims (proteazas inhibitorebs) SeuZlia daTrgunos estrogenebis done da estrogenis Semcveli oraluri kontraceptivebi ar iqneba efeqturi. orsuli qalebi

    • tb-is da arv mkurnalobis dawyebis strategia orsulebSi igivea, rac araorsul qalebSi an mamakacebSi (ix. cxrili 2);

    31

  • • rekomendebulia prezervativebis gamoyeneba tb/aiv koinficirebul qalebSi iseve, rogorc yvela aiv monoinficirebul qalebSi, raTa Semcirdes aiv superinfeqciis (damatebiTi inficireba aiv-is imave an sxva qvetipiT) an sxva sqesobrivi gziT gadamdebi infeqciebis gadacemis riski;

    • pirvelis rigis tb-is preparatebis umravlesoba usafrTxoa orsulTaTvis. gamonakliss warmoadgens streptomicini, romelic ototoqsiuria da ar gamoiyeneba orsulebSi (garda meningealuri infeqciebisa) an meZuZur qalebSi;

    • Tu tb/aiv inficirebuli qali gadawyvets daorsulobas mas gestaciis 28-e kviridan unda daewyos arv Terapia aiv vertikaluri transmisiis Sesamcireblad;

    • tb/aiv mkurnalobis monitoringi unda Catardes sxva mozrdili pacientebis menejmentis msgavsad.

    saineqcio narkotikebis momxmareblebi tb/aiv koinfeqciis klinikuri menejmenti saineqcio narkotikebis momxmareblebSi rTulia da saWiroebs met Zalisxmevas Semdegi faqtorebis gamo:

    • urTierTqmedeba tb, aiv preparatebsa da akrZalul narkotikebs Soris zrdis hepatotoqsiurobas maTSi, vinc iRebs opioid CanacvlebiT Terapias;

    • metadonis done mcirdeba (33-68%-iT) rifampicinis gamo (mizanSewonilia metadonis dozis gazrda).

    • B da C hepatitebiT koinficirebis maRali albaToba da hepatitis sawinaaRmdego preparatebis urTierTqmedebis albaToba arv da tb preparatebTan;

    • preparatebis miRebis reJimi ufro xSirad darRveulia; • naklebia mimarTvianoba jandacvis dawesebulebebSi. TanamSromloba zianis emcirebis programebTan (44, 45) SesaZloa saWiro gaxdes am kategoriis pacientebis efeqturi marTvisaTvis ganaTlebis, skriningis, tb prevenciuli mkrnalobis, DOT startegiis da sxv gzebiT. saWiroa gaTvaliswinebuli iqnas, rom

    • rifampicini ar iniSneba LPV/r, NFV, SQV-Tan im pacientebSi, romlebic iReben metadoniT CanacvlebiT Terapias. arCevanis preparatia rifabutini 150 mg 3-jer kviraSiL LPV/r-Tan an 300 mg 3-jer kviraSi NFV-Tan.

    • rifabutini ar unda iqnas gamoyenebuli SQV-Tan erTad. tuberkulozis mkurnaloba bavSvebSi aiv inficirebul bavSvebSi tuberkulozis mkurnalobas udidesi mniSvneloba eniWeba da unda daiwyos tuberkulozis diagnozis dasmisTanave. tuberkulozis mkurnalobisaTvis rekomendirebulia mozrdilebis analogiuri qimioTerapiuli sqemebi preparatebis dozireba xdeba sxeulis masis gaTvaliswinebiT (ix. damateba I).

    32

  • aiv infeqcia/Sidsis mkurnaloba bavSvebSi

    aiv inficirebul bavSvebs, romelTac daudasturdebaT tuberkulozis diagnozi, pirvel rigSi unda CautardeT tuberkulozis sawinaaRmdego Terapia. arv Terapia unda daviwyoT rac SeiZleba male, amasTan gaTvaliswinebuli unda iyos #9 cxrilSi moyvanili klinikuri da imunologiuri kriteriumebi.

    cxrili 9 aqtiuri tuberkuloziT daavadebul aiv inficirebul bavSvebSi arv Terapiis dawyebis strategia

    kriteriumebi tuberkulozis sawinaaRmdego mkurnaloba

    arv Terapia

    pediatriuli klinikuri stadia 4

    mZime

    imuno

    def

    icit

    i

    daiwyeT dauyovnebliv

    daiwyeT rac SeiZleba male tuberkulozis sawinaaRmdego mkurnalobis dawyebidan (2-8 kviris Semdeg)

    pediatriuli klinikuri stadia 3

    msubuqi

    imuno

    def

    icit

    i an

    imuno

    def

    icit

    is

    gar

    eSe

    daiwyeT dauyovnebliv

    arT SesaZloa dayovndes da misi saWiroeba isev Sefasdes tuberkulozis sawinaaRmdego mkurnalobis CaTavebis Semdeg. saWiroa tuberkulozis sawinaaRmdego mkurnalobis efeqturobis monitorireba. Tuki ar aRiniSneba gaumjobeseba, SesaZloa dadges sakiTxi arv Terapiaze.

    mZime imunodeficiti gulisxmobs mdgomareobas, rodesac CD4 + ujredebis raodenoba aRemateba Zalian mZime imunodeficitisaTvis Sesabamis asakobriv maCvenebels 5%-iT, an rodesac CD4+ ujredebis ricxvi 5 wlamde asakis bavSvebisaTvis Seadgens 200-350 ujreds/mm3.

    maRalaqtiuri antiretrovirusuli

    Terapiis rekomendebuli reJimebi tb/aiv koinficirebul bavSvebSi

    aarrTT rreeJJiimmeebbii tb/aiv koinficirebuli bavSvebSi garkveulwilad gansxvavdeba aiv monoinficirebuli bavSvebis arT reJimebisagan. arT reJimis SerCeva am kategoriis bavSvebSi garTulebulia pediatriuli arT preparatebis SezRuduli arCevanis an dozirebis Sesaxeb arsebuli mwiri monacemebis gamo

    33

  • (gansakuTerebiT 3 wlamde asakis bavSvebSi).

    mTavari miTiTebani antiretrovirusuli preparatebisaTvis

    • AZT toqsiurobisas an autanlobisas SesaZlebelia misi Secvla stavudiniT;

    • Tuki rifampicinTan erTad iniSneba NVP, saWiroa RviZlis potenciuri toqsiurobis monitoringi klinikurad da RviZlis funqciuri testebis gamoyenebiT;

    • EFV dReisaTvis ar gamoiyeneba 3 wlamde asakis bavSvebisaTvis. misi micema ar SeiZleba sqesobrivad momwifebuli gogonebisaTvis adeqvaturi kontracefciis gamoyenebis gareSe an orsulobis pirvel trimestrSi;

    • tuberkulozis mkurnalobis dasrulebis DSemdeg sasurvelia me-10 cxrilSi miTiTebuli arT reJimis SenarCuneba;

    cxrili 10 maarT reJimebi tuberkulozi/aiv koinficirebul bavSebSi, romlebsac eZlevaT rifampicini

    bavSvis asaki

    arT klasi arT kombinacia

    sasurvelia 3 nnrrttii (nukleoziduri revers transkriftazas inhibitori)

    ZDV+ 3TC + ABC < 3 welze

    alternatiuli 2 nnrrttii ++NNVVPP

    ZDV+ 3TC + NNVVPP

    sasurvelia 2 nnrrttii ++ 1 aannrrttii (aranukleoziduri reverstranskriftazas inhibitori)

    ZDV+ 3TC + EFV > 3 welze

    alternatiuli 3 nnrrttii

    ZDV+ 3TC + ABC

    8. reabilitacia /meTvalyureoba

    8.1. pirveladi profilaqtika kotrimoqsazoliT

    tb/aiv koinificrebul pacientebSi, mkurnalobis dawyebis Semdgom, tuberkulozis Sorswasuli formebis dros SesaZloa dafiqsirdes letaluri gamosavali. letaluri gamosavali SesaZloa gamowveuli iyos rogorc sakuTriv tuberkulozuri procesis progresirebiT, aseve sxva oportunistuli infeqciebis (mag. pnevmocisturi pnevmoniis an toqsoplazmozuri encefalitis) TandarTviT (32). amitom kotrimoqsazoliT pirveladi

    34

  • profilaqtika aucilebelia am ori daavadebisgan dasacavad.

    • pacientebSi CD4-is ricxviT < 200/mm3 aucilebelia kotrimoqsazolis daniSvna tb-is mkurnalobasTan erTad 4-6 Tvis ganmavlobaSi CD4 limfocitebis ricxvis stabilur matebamde sul mcire 3 Tvis ganmavlobaSi >200 ujredi/mm3.

    • rekomendebuli profilaqtikuri doza mozrdilebisTvis Seadgens kotrimoqsazolis erT ormag dozian tablets: 160/800 mg erTxel dReSi;

    • aucilebelia preparatis miRebaze meTvalyureoba tuberkulozis preparatebis msgavsad , gansakuTrebiT mZime avadyofebSi.

    pirveladi profilaqtika kotrimoqsazoliT bavSvebSi

    tb/aiv koinficirebuli bavSvebs unda daeniSnoT pnevmocisturi infeqciis profilaqtikuri Terapia kotrimoqsazoliT tuberkulozis mkurnalobis mTeli periodis ganmavlobaSi miuxedavad maTi imunuri supresiis xarisxisa.

    8.2. tb/aiv koinficirebuli pacientebis monitoringi

    tuberkulozis mkurnalobis monitoringi pacientTa did umravlesobaSi (gamonaklisia mrtb) antituberkulozuri mkurnaloba efeqturia da pacientebis Tavs ukeT grZnoben mkurnalobis dawyebidan 2-3- kviraSi. pacientebSi, romelTac tb/aiv koinfeqciis diagnozi daesviT gvian stadiaze SesaZloa adgili hqondes klinikuri an radiologiuri monacemebis gauaresebas. aiv infeqciis gvian stadiaze Cveulebriv efeqtur antituberkulozur preparatebs ar SeuZliT radikalurad Semoabrunon klinikuri mdgomareoba. anituberkulozuri mkurnalobis intensiuri fazis pirveli 2-4 kviris ganmavlobaSi mizanSewonilia pacientis hospitalizacia da sruli klinikuri gamokvleva yovel kviraSi. aucilebelia alt-s kontroli mkurnalobis ganmavlobaSi. hepatotoqsiuroba SesaZloa ganviTardes koinficirebuli pacientebis 5-10%-Si. pacientTa mkurnaloba sasurvelia mimdinareobdes uSualo meTvalyureobis qveS. mZime diarea SesaZloa gaxdes mizezi wamalTa malabsorbciis da mkurnalobis araefeqturobis. am mdgomareobaSi aucilebelia saineqcio tb preparatebis gamoyeneba. diareis gareSec SesaZlos adgili hqondes rifampicinis aradeqvatul absorbcias, rac gvxvdeba aiv inficirebulTa 10%-Si. pioritetulia tb mkurnalobis gagrZeleba da arv Terapiis Sewyveta gastrointestinuri simptomebis alagebamde. jer-jerobiT sabolood gansazRvruli ar aris, ra RonisZiebebi unda Catardes recidivis Tavidan asacileblad tubsawinaaRmdego qimioTerapiis sruli kursis damTavrebis Semdeg. pacientebisTvis vinc icavs tb mkurnalobis reJims, tb-is prognozi keTilsaimedia. gamonakliss warmoadgens:

    35

  • • multirezistentuli tuberkulozi; • pacientebi, romelTac axali dawyebuli aqvT tb mkurnaloba

    aiv infeqciis gvian stadiaze;.

    antiretrovirusuli mkurnalobis monitoringi BA arv Terapiaze myofi pacientebis monitoringi moicavs klinikur, imunologiur da virusologiur maCveneblebs , aseve, arv preparatebis toqsiurobisa da gverdiTi efeqtebis Sefasebas. arT-s dawyebis Semdeg SesaZloa imunuri rekonstituciis sindromis (irs) ganviTareba, gansakuTrebiT, Rrmad imunokomprometirebul pirebSi. msgavsi gauareseba gvxvdeba tuberkuloziT koinficirebul pacientTa 1/3-Si, romelTac daiwyes arT. irs SesaZloa ganviTardes mkurnalobis dawyebidan 2 TveSi, SesaZloa Zalian adre, mag. 5 dReSi. irs ufro metad viTardeba, rodesac arv Terapiis dawyeba win uswrebs antutuberkulozuri mkurnalobis dawyebas, an Tu arv Terapia daiwyo CD4 limfocitebis Zalian dabali ricxvis dros . irs-is niSnebi da simptomebi moicavs:

    • maRal cxelebas; • periferiul da Suasayaris limfadenopaTias; • movlenebs cns-is mxriv; • filtvis rentgenologiuri suraTis gauaresebas.

    irs-is diagnostika xdeba im SemTxvevaSi Tu gauaresebis sxva mizezebi gamoiricxa, mag: tb-is mkurnalobis araefeqturoba. zogierT SemTxvevaSi simptomebi alagdeba Carevis gareSe da arv Terapia grZeldeba. seriozuli reaqciebi, mag; saylapavis kompresia Suasayaris limfadenopaTiis gamo, saWiroebs steroidebis xanmokle kurss. prednozoloni SeiZleba dainiSnos 20-60 mg/dReSi 2-3 kviris ganmavlobaSi, dozis klebiT sul mcire erTi Tvis ganmavlobaSi(DIV) (48, 49). koinficirebuli pacientebi romlebic imyofebian mkurnalobaze unda gadiodnen regularul klinikur gasinjvas, laboratoriul monitorings, toqsiurobisa da gverdiTi efeqtebis kontrols da a.S. yovelive zemoT aRniSnuli dajamebulia cxrilSi 11. cxrili 11 arv da tb mkurnalobaze myofi pacientebis

    monitoringi Sefaseba kvira Tve

    0 2 4 8 3 4 5 6 7 8 9 10 11 12

    tb/ aiv daavadebebis istoria X Xfizikaluri gamokvleva X X X X X X Xkomorbiduli daavadebebi X X X Xginekologiuri gamokvleva X X X X Xrutinuli laboratoriuli testebi:

    • sisxlis saerTo analizi • RviZlis funqciuri sinjebi

    X X X X

    36

  • (alt, ast, bilirubinebi)

    • kreatinini • Sardovana

    CD4 ujredebi X X X Xvirusuli datvirTva X X X Xgul-mkerdis rentgenologiuri gamokvleva

    X X

    orsulobis testi X Xnaxvelis-nacxis gamokvleva 1 X X X X X X mkurnalobis reJimis dacvis Sefaseba (orive daavadebis: tb da aiv infeqciis)

    X X X X X X X X X X X X X X

    1 aucilebelia me-3, me-5 da me-8 Tveebze, mxolod im SemTxvevebSi, rodesac tardeba 8 Tviani tubsawinaaRmdego qimioTerapia, xolo tuberkulozis axali SemTxvevebis dros (6 Tviani reJimi) –intensiuri fazis bolos, gagrZelebis fazis SuaSi da dasasruls.

    8.3. antituberkulozuri da antiretrovirusuli mkurnalobis reJimis dacva

    tb-is da aiv infeqciis mkurnalobis warmatebisTvis gadamwyvetia mkurnalobis reJimis dacva. Tu pacienti ar icavs medikamentebis miRebis reJims, tuberkulozis mikobaqteriisa da adamianis imunodeficitis virusis mimarT rezistentobis ganviTarebis anu wamalmdgradi Stamebis Camoyalibebis maRali albaToba iqmneba. tb-is dros rekomendebulia uSualo meTvalyureobis qveS mkurnaloba (AI) (50); arT-s SemTxvevaSi aucilebelia preparatebis miRebis reJimis dacva 95%-iT optimaluri virusuli supresiisa da mkurnalobis efeqturobisTvis (BII) (51). mkurnalobis dawyebamde pacients unda ganvumartoT mkurnalobis reJimis dacvis aucilebloba da misi Sedegebi. aucilebelia mkurnalobis periodSi preparatebis miRebis kontroli da gverdiTi efeqtebis swori menejmenti, rac xels Seuwyobs mkurnalobis reJimis dacvas.

    8.4. koinficirebuli bavSvebis monitoringi tb/aiv koinficirebuli bavSvebis rutinuli monitoringi da mkurnalobis efeqturobis Sefaseba unda moicavdes klinikur niSnebsa da simptomebs, laboratoriul monacemebs, reJimis dacvis kontrolsa da zrda-ganviTarebis (nutriciuli statusi) Sefasebas. naxvelis nacxis Sefaseba unda Catardes me-6, me-8 da me-12 Tveze tuberkulozis mkurnalobis dawyebidan.

    37

  • 8.5. klinikaSi Sesakrebi monacemebis minimumi

    regularulad (TveSi, kvartalSi an 6 TveSi erTxel) unda Sefasdes Semdegi monacemebi, raTa gaumjobesdes tb/aiv koinficirebuli pacientebis marTva da ganxorcieldes erToblivi RonisZiebebi:

    • tuberkuloziT inficirebul registrirebul pacientTa ricxvi; • tuberkuloziT inficirebul registrirebul pacientTa ricxvi,

    romelTac CautardaT testireba aiv infeqciaze;

    • tuberkuloziT inficirebul registrirebul pacientTa ricxvi, romelTac daudgindaT aiv infeqcia;

    • aiv inficirebul pacientTa ricxvi, romlebsac CautardaT skriningi tuberkulozur infeqciaze;

    • aiv inficirebul pacientTa ricxvi, romlebsac daudgindaT tuberkulozuri infeqcia;

    o aiv inficirebul pacientTa ricxvi, romelTac daudgindaT tuberkulozuri infeqcia da romelTac Catarebuli aqvT prevenciuli mkurnaloba izoniazidiT;

    • aiv inficirebul pacientTa ricxvi, romlebsac pirvelad daudgindaT tuberkulozuri infeqcia;

    o aiv inficirebul pacientTa ricxvi, pirvelad dadgenili da daregistrirebuli tuberkulozuri infeqciiT, romelTa CD4 > an= 350/mm3;

    o aiv inficirebul pacientTa ricxvi, pirvelad dadgenili da daregistrirebuli tuberkulozuri infeqciiT, romelTa CD4 < 350/mm3;

    o aiv inficirebul pacientTa ricxvi, pirvelad dadgenili tuberkulozuri infeqciiT, romelTac Catarebuli aqvT prevenciuli Terapia kotrimoqsazoliT 1;.

    • tb/aiv koinficirebul pacientTa ricxvi, romlebic iReben tuberkulozis sawinaaRmdego mkurnalobas;

    • tb/aiv koinficirebul pacientTa ricxvi, romlebic iReben tuberkulozis sawinaaRmdego mkurnalobas da arT-s 2;

    • tb/aiv koinficirebul pacientTa ricxvi tuberkulozis sawinaaRmdego mkurnalobis gamosavlis yovel kategoriaSi 3 ;

    • tb/aiv koinficirebul pacientTa ricxvi, romlebic gardaicvalnen, sikvdilis mizezis miTiTebiT (mag. tuberkulozTan asocirebuli sikvdili, sxva aiv infeqcia/SidsTan asocirebuli sikvdili an sxva ara aiv ineqcia/SidsTan asocirebuli sikvdili, rogoricaa ubeduri SemTxveva, dozis gadaWarbeba an suicidi). 1. igulisxmeba sul mcire erTi dozis miReba tuberkulozis

    sawinaaRmdego mkurnalobis periodSi; 2. im pacientebis CaTvliT, romelTac daiwyes arT an agrZeleben

    adre dawyebul arT-s tuberkulozis sawinaaRmdego mkurnalobis periodSi an Semdeg;

    3. es indikatori unda gamoiTvalos yoveli qvemoT CamoTvlili SesaZlo gamosavlisaTvis: gankurneba, dasrulebuli mkurnaloba, uSedego mkurnaloba, sikvdili, Sewyvetili mkurnaloba an sxva dawesebulebaSi gadayvana.

    38

  • damateba I. antituberkulozuri medikamentebi (mozrdilebi, mozardebi da bavSvebi) cxrili 11. pirveli rigis antituberkulozuri medikamentebis rekomendebuli dozebi medikamentebi dRiuri dozebi 1

    (Cveuli doza an diapazoni) kviraSi samjer miRebisTvis

    gaTvaliswinebuli dozebi

    (Cveuli doza an diapazoni)

    izoniazidi 5 mg/kg (Cveulebriv 300 mg)

    10 mg/kg (Cveulebriv 900 mg)

    rifampicini 10 mg/kg (450 mg TuU 50 kg)

    10 mg/kg (450 mg TuU 50 kg)

    pirazinamidi 25 mg/kg (20-30 mg/kg)

    35 mg/kg (30-40 mg/kg)

    etambutoli 15 mg/kg (15-20 mg/kg)

    30 mg/kg (20-35 mg/kg)

    streptomicini 15 mg/kg (12-18 mg/kg)

    15 mg/kg (12-18 mg/kg)

    1. rodesac rifampicini gamoiyeneba antiretrovirusul

    medikamentebTan erTad, rekomendebulia yoveldRiuri reJimiT mkurnaloba

    9. eTikur-samarTlebrivi rekomendaciebi*

    10. praqtikaSi adaptaciis da protokolebis SemuSavebis rekomendaciebi*

    11. gaidlainis gadasinjvis da ganaxlebis vada (Tu sxvagvarad araa dasabuTebuli pirvelwyaroSi, sasurvelia – 2 weli)

    yovel 2 weliwadSi erTxel

    12. gaidlainis miRebis xerxi/wyaro

    (pirdapiri Targmani, adaptacia, Tu sxvadasxva gaidlainebis Sejereba)

    arsebuli gaidlaini efuZneba janmrTelobis msoflio organizaciis mier evropis regionisTvis 2006 wels mowodebul gaidlains da dawerilia sxvadasxva gaidlainebis (DHHS, IAS-USA, BHIVA da a.S.)Sejerebisa da adaptaciis Sedegad.

    39

  • 13. alternatiuli gaidlainis miTiTeba (Tu arsebobs)

    alternatiuli gaidlaini saqarTveloSi amJamad ar arsebobs.

    14. gamoyenebuli literatura

    1. Global tuberculosis control: surveillance, planning, financing. Geneva, WHO, 2006 (WHO/HTM/2006.326 (AI) 2. EuroTB. Surveillance of tuberculosis in Europe: report on tuberculosis cases notified in 2003. Saint-Maurice, Institut de Veille Sanitaire, 2005 http://www.eurotb.org/rapports/2003/report_2003.htm, accessed 7 August 2006) (AI). 3. Salt J. Current trends in international migration in Europe. Strasbourg, Council of Europe, 2002(CDMG/2002/26) (AI). 4. Hayward AC et al. Epidemiology and control of tuberculosis in western European cities. InternationalJournal of Tuberculosis and Lung Diseases, 2003, 7:751–757(AI). 5. WHO/IUATLD global project on anti-tuberculosis drug resistance surveillance. Anti-tuberculosis drugresistance in the world: report no. 3. Geneva, WHO, 2004 (WHO/HTM/TB/2004.343) (AI). 6. Aebi MF. Space 1 (Council of Europe Annual Penal Statistics) Survey 2004. Strasbourg, Council ofEurope, 2005(AI). 7. Drobniewski F. Tuberculosis in prisons – forgotten plague. The Lancet, 1995, 346:948–949(AI). 8. Bone A et al. Tuberculosis control in prisons: a manual for programme managers. Geneva, WHO, 2000(WHO/CDS/TB/2000.281) (AI). 9. Drobniewski FA et al. Tuberculosis, HIV seroprevalence and intravenous drugs abuse in prisoners. TheEuropean Respiratory Journal, 2005, 26:298–304. (AI) 10. de Colombani P. Overview of the tuberculosis situation in the European Region with a focus on prisons.11th Annual Meeting and Conference of the WHO European Network for Prison and Health: the Next10 Years, London, 17–18 October 200(AI)5. 11. European Centre for the Epidemiological Monitoring of AIDS (EuroHIV). HIV/AIDS surveillance inEurope: end-year report 2004. Saint-Maurice, Institut de Veille Sanitaire, 2005 (No. 71; http://www(AI). eurohiv.org/reports/report_71/pdf/report_eurohiv_71.pdf, accessed 29 September 2006). 12. Corbett EL et al. The growing burden of tuberculosis: global trends and interactions with the HIV epidemic.Archives of Internal Medicine, 2003, 163:1009–102(AI)1. 13. Interim policy on collaborative TB/HIV activities. Geneva, WHO, 2004 (WHO/HTM/HIV/2004.1) (CIII). 14. de Colombani P et al. European framework to decrease the burden of TB/HIV. Copenhagen, WHORegional Office for Europe, 2003 (WHO/EURO/03/5037600) (CIII). 15. TB/HIV: a clinical manual, 2nd ed. Geneva, WHO, 2004 (WHO/HTM/TB/2004.329) (BII). 16. Lienhardt C, Rodriques LC. Estimation of the impact of the human immunodeficiency virus infectionon tuberculosis: tuberculosis risks revised? International Journal of Tuberculosis and Lung Diseases,1997, 1(3):196–204(BII).. 17. Hopewell PC, Chaisson RE. Tuberculosis and human immunodeficiency virus infection. In: ReichmanLB, Hershfield ES, eds. Tuberculosis: a comprehensive international approach. New York, Marcel, Dekker, 2000:525–547 (Lung Biology in Health and Disease Series, Vol. 144(BII).). 18. Girardi E et al. Impact of the HIV epidemic on the spread of other diseases: the case of tuberculosis. AIDS, 2000, 14(Suppl. 3):S47–S56(AI). 19. Cruciani M et al. The impact of HIV1 on infectiousness of tuberculosis: a metaanalysis. Clinical InfectiousDiseases, 2001, 33:1922–1930(AI).

    40

  • 20. Castro KG, Dooley SW, Curran JW. Transmission of HIV-associated tuberculosis to health-care workers.The Lancet, 1992, 340(8826):1043–1044(AI). 21. Ackah AN et al. Response to treatment, mortality and CD4 lymphocyte counts in HIV-infected persons with tuberculosis in Abidjan. AIDS, 1995, 9:1251–1254(BIII). 22. Harries AD et al. Deaths from tuberculosis in Sub-Saharan African countries with a high prevalence of HIV-1. The Lancet, 2001, 357(9267):1519–1529) (BIII). 23. Elliott AM et al. The impact of human immunodeficiency virus on mortality of patients treated for tuberculosis in a cohort study in Zambia. Transactions of the Royal Society of Tropical Medicine and Hygiene, 1995, 89:78–82(BIII). 24. Badri M et al. Association between tuberculosis and HIV disease progression in a high tuberculosis prevalence area. The International Journal of Tuberculosis and Lung Disease, 2001, 5:225–232(AI). 25. Drobniewski F et al. Increasing trends in HIV and TB rates in Odessa and the Ukraine. International Journal of STD & AIDS, 2005, 16:374–378(BII). 26. ManageMent of tuberculosis and HiV coinfection 26. WHO, Joint United Nations Programme on HIV/AIDS (UNAIDS). Policy statement on preventivetherapy against tuberculosis in people living with HIV: report of a meeting held in Geneva, 18–20 February 1998. Geneva, WHO, 1998 (WHO/TB/98.255; UNAIDS/98.34) (CIII). 27. Fitzgerald DW et al. Active tuberculosis in individuals infected with human immunodeficiency virus after isoniazid prophylaxis. Clinical Infectious Diseases, 2000, 31:1495–1497(CIII).. 28. TB/HIV research priorities in resource-limited settings: report of an expert consultation. Geneva, WHO,2005 (WHO/HIV/2005.03) (CIII).. 29. Treatment of tuberculosis: guidelines for national programmes, 3rd ed. Geneva, WHO, 2003 (http://whqlibdoc.who.int/hq/2003/WHO_CDS_TB_2003.313_eng.pdf, accessed 4 April 2006) (BII). 30. Dean GL et al. Treatment of tuberculosis in HIV-infected persons in the area of highly active antiretroviral therapy. AIDS, 2002, 16(1):75–83(BII). 31. Scaling up antiretroviral therapy in resource-limited settings: treatment guidelines for a public healthapproach, 2003 rev. Geneva, WHO, 2004(BII). 32. Benson CA et al. Treating opportunistic infections among HIV-infected adults and adolescents: recommendations from CDC, the National Institutes of Health and the HIV Medicine Association/Infectious Disease Society of America. Morbidity and Mortality Weekly Report, 2004, 53(RR-15):S131–S235. (BII) 33. Fujiwara PI, Clevenbergh P, Dlodlo RA. Management of adults living with HIV/AIDS in low-income, high-burden settings with special reference to persons with tuberculosis. International Journal of Tuberculosis and Lung Diseases, 2005, 9(9):946–958(BII). 34. Pozniak AL et al. BHIVA treatment guidelines for TB/HIV infection. The British HIV Association, London, 2005 (http://www.bhiva.org/guidelines/2005/tbhiv.html, accessed 8 June 2006) (BII). 35. Almond L et al. A retrospective survey of the Liverpool TDM Service: factors influencing efavirenz concentrations in patients taking rifampicin. 6th International Workshop on Clinical Pharmacology of HIV Therapy, Quebec, April 2005 (Poster 2.12). 36. Manosuthi W et al. A randomized controlled trial of efavirenz 600 mg/day versus 800 mg/day in HIV-infected patients with tuberculosis to study plasma efavirenz level, virological and immunological outcomes: a preliminary result. In: XV International AIDS Conference. Bangkok, 2004 (Abstract MoOrB1013). 37. Sheehan NL, Richter C. Efavirenz 600 mg is not associated with subtherapeutic efavirenz concentrations when given concomitantly with rifampin. 6th International Workshop on Clinical Pharmacology of HIV Therapy, Quebec, 28–30 April 2005. 38. Kearney BP et al. Didanosine and tenofovir DF drug-drug interaction: assessment of

    41

  • didanosine dose reduction. Tenth Conference on Retroviruses and Opportunistic Infections, Boston, Feb 10-14 (Abstract 533). 39. Kaul S et al. Pharmacokinetic evaluation of reduced doses of didanosine enteric coated capsules (ddI EC) in combination with tenofovir disoproxil fumarate (TDF) and food for a once daily antiretroviral regimen. Fourth International Workshop on Clinical Pharmacology of HIV therapy, Cannes, March 27-29 2003 (Abstract 54). 40. Centers for Disease Control. Updated guidelines for the use of rifabutin or rifampin for the treatment and prevention of tuberculosis among HIV-infected patients taking protease inhibitors. Morbidity andMortality Weekly Report, 2000, 49:185–189. 41. Ribera A, Azuaje C, Montero F. Saquinavir, ritonavir, didanosine, and lamivudine in a once daily regimenfor HIV infection in patients with rifampicin-containing antituberculosis treatment. In: XVI International AIDS Conference. Barcelona, 2002 (Abstract ThPeB 7280). 42. Ribera E et al. Pharmacokinetic interaction between nevirapine and rifampicin in HIV-infected patients with tuberculosis. Journal of Acquired Immune Deficiency Syndrome, 2001, 28:450–453. 43. WHO HIV/AIDS. Evidence for action: effectiveness of community-based outreach in preventing HIV/ AIDS among injecting drug users. Geneva, WHO, 2004. 44. Purcell DW et al. Interventions for seropositive injectors research and evaluation: an integrated behavioural intervention with HIV-positive injection drug users to address medical care, adherence and risk reduction. Journal of Acquired Immune Deficiency Syndrome, 2004, 37:S110–S118. 45. Verwell G et al. Treatment with highly active antiretroviral therapy in human immunodeficiency virus type 1-infected children is associated with a sustained effect on growth. Pediatrics, 2002, 109(2) (http:/www.pediatrics.org/cgi/content/full/109/2/e25, accessed 4 April 2006). 46. Furrer H, Malinverni R. Systemic inflammatory reaction after starting highly active antiretroviral therapy in AIDS patients treated for extrapulmonary tuberculosis. American Journal of Medicine, 1999, 106:371–372.Narita M et al. Paradoxical worsening of tuberculosis following antiretroviral therapy in patients with AIDS. American Journal of Respiratory and Critical Care Medicine, 1998, 158(1):157–161. 48. Kumarasamy N et al. Incidence of immune reconstitution syndrome in HIV/tuberculosis-coinfected patients after initiation of generic antiretroviral therapy in India. Journal of Acquired Immune Deficiency Syndrome, 2004, 37(5):1574–1576(DIV). 49. Lawn SD, Bekker L, Miller RF. Immune reconstitution disease associated with mycobacterial infections in HIV-infected individuals receiving antiretrovirals. The Lancet Infectious Diseases, 2005, 5(6):361–373 (DIV). 50. Bartlett JA. Addressing the challenges of adherence. Journal of Acquired Immune Deficiency Syndrome, 2002, 29:S2–S10 (AI). 51. Lange JMA et al. What policymakers should know about drug resistance and adherence in the context of scaling-up treatment of HIV infection. AIDS, 2004, 18(suppl 3):S69–S74(BII). 52. A guide to monitoring and evaluation for collaborative TB/HIV activities. Field test version. Geneva, WHO, 2004 (WHO/HIV/2004.09). 53. Treatment of tuberculosis: guidelines for national programmes, 3rd ed. Geneva, WHO, 2003:55 (http://whqlibdoc.who.int/hq/2003/WHO_CDS_TB_2003.313_eng.pdf, accessed 4 April 2006).

    42

  • 15. avtorTa jgufi (redaqtori, koleqtivi, recenzentebi/eqspertebi)

    klinikuri saxelmZRvanelo – rekomendaciis redaqtori: Tengiz cercvaZe infeqciuri sneulebebis, Sidsis da klinikuri imunologiis s/p centris sameTvalyureo sabWos Tavmjdomare, Sidsis nacionaluri programis koordinatori, iv. javaxiSvilis sax. Tsu-s infeqciur daavadebaTa da klinikuri imunologiis departamentis sruli profesori klinikuri saxelmZRvanelo – rekomendaciis avtorebi : Tengiz cercvaZe infeqciuri sneulebebis, Sidsis da klinikuri imunologiis s/p centris sameTvalyureo sabWos Tavmjdomare, Sidsis nacionaluri programis koordinatori, iv. javaxiSvilis sax. Tsu-s infeqciur daavadebaTa da klinikuri imunologiis departamentis sruli profesor


NEDERLAND EN DE ARABISCHE REGIO - Eerste Kamer · 2015. 3. 13. · 5 Woord vooraf De AIV ontving op 16 juni 2014 de adviesaanvraag van de regering inzake een derde AIV-advies over

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AIV Katalog mobile gsm 2012

AIV Katalog mobile gsm 2012

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FPI review process & AIV&T plan of FPIA

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aiv.2012 ) · 2 instruqcia davalebebisaTvis 1 _ 54 davalebaSi dasmulia SekiTxva da mocemulia oTxi savaraudo pasuxi, romelTagan mxolod erTia swori. …

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aiv infeqcia/SidsiT avadmyofTa mkurnaloba da movla ...medportal.ge/guideline/SHIDSI/ART-gaidlaini.pdf · 1 aiv infeqcia/SidsiT avadmyofTa mkurnaloba da movla (klinikuri saxelmZRvanelo

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epStein – baris virusiT infeqcia infeqciuri mononukleozi · `epStein-baris virusiT infeqcia – infeqciuri mononukleozi~ ... baris virusiT infeqcia infeqciuri mononukleozi ... (LP)

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AIV Katalog car

AIV Katalog car

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ZogierTi meore rigis preparatis mimarT tuberkulozis gamomwvevis rezistentobis gansazRvra saqarTveloSi kvlevis dagegmva, mimdinareoba, Sedegebi zogierTi.

ZogierTi meore rigis preparatis mimarT tuberkulozis gamomwvevis rezistentobis gansazRvra saqarTveloSi kvlevis dagegmva, mimdinareoba, Sedegebi zogierTi.

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AIV Katalog car connect 2013

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