aiv infeqcia/SidsiT avadmyofTa mkurnaloba da movla...• 24% _ heteroseqsualuri kontaqtebi • 0,3%...

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1 aiv infeqcia/SidsiT avadmyofTa mkurnaloba da movla klinikuri marTvis nacionaluri rekomendacia (gaidlaini)

Transcript of aiv infeqcia/SidsiT avadmyofTa mkurnaloba da movla...• 24% _ heteroseqsualuri kontaqtebi • 0,3%...

  • 1

    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.

  • 3

    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

  • 9

    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

  • 10

    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

  • 12

    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

  • 25

    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

  • 29

    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.

  • 31

    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

  • 32

    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);

  • 33

    - 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


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