aiv infeqcia/SidsiT avadmyofTa mkurnaloba da movla (klinikuri ...
aiv infeqcia/SidsiT avadmyofTa mkurnaloba da movla (klinikuri ...
aiv infeqcia/SidsiT avadmyofTa mkurnaloba da movla (klinikuri ...
You also want an ePaper? Increase the reach of your titles
YUMPU automatically turns print PDFs into web optimized ePapers that Google loves.
<strong>aiv</strong> <strong>infeqcia</strong>/<strong>SidsiT</strong> <strong>avadmyofTa</strong><br />
<strong>mkurnaloba</strong> <strong>da</strong> <strong>movla</strong><br />
(<strong>klinikuri</strong> saxelmZRvanelo<br />
rekomen<strong>da</strong>cia –<br />
gaidlaini)<br />
2006 weli<br />
Tbilisi<br />
1
<strong>klinikuri</strong> saxelmZRvanelo – rekomen<strong>da</strong>ciis re<strong>da</strong>qtori:<br />
Tengiz cercvaZe<br />
infeqciuri sneulebebis, Sidsis <strong>da</strong> <strong>klinikuri</strong><br />
imunologiis s/p centris sameTvalyureo<br />
sabWos Tavmjdomare, Sidsis nacionaluri<br />
programis koordinatori, iv. javaxiSvilis<br />
sax. Tsu-s infeqciur <strong>da</strong>avadebaTa <strong>da</strong><br />
<strong>klinikuri</strong> imunologiis departamentis sruli<br />
profesori<br />
<strong>klinikuri</strong> saxelmZRvanelo – rekomen<strong>da</strong>ciis avtorebi :<br />
Tengiz cercvaZe<br />
infeqciuri sneulebebis, Sidsis <strong>da</strong> <strong>klinikuri</strong><br />
imunologiis s/p centris sameTvalyureo<br />
sabWos Tavmjdomare, Sidsis nacionaluri<br />
programis koordinatori, iv. javaxiSvilis<br />
sax. Tsu-s infeqciur <strong>da</strong>avadebaTa <strong>da</strong><br />
<strong>klinikuri</strong> imunologiis departamentis sruli<br />
profesori<br />
fati gabunia<br />
infeqciuri sneulebebis, Sidsis <strong>da</strong> <strong>klinikuri</strong><br />
imunologiis s/p centri, #2 boqsirebuli<br />
ganyofilebis gamgis m/S, medicinis<br />
mecierebaTa kandi<strong>da</strong>ti<br />
nino goCitaSvili -<br />
infeqciuri paTologiis,Sidsis <strong>da</strong> <strong>klinikuri</strong><br />
imunologiis s/p centri, Sidsis <strong>da</strong><br />
imunodeficitebis dispanseruli<br />
ganyofilebis eqimi - infeqcionisti<br />
lali SarvaZe<br />
infeqciuri sneulebebis, Sidsis <strong>da</strong> <strong>klinikuri</strong><br />
imunologiis s/p centri, Sidsis <strong>da</strong><br />
imunodeficitebis ganyofilebis gamgis m/S,<br />
iv. javaxiSvilis sax. Tsu infeqciur<br />
<strong>da</strong>avadebaTa <strong>da</strong> <strong>klinikuri</strong> imunologiis<br />
departamentis asistent profesori<br />
2
sarCevi<br />
<strong>klinikuri</strong> saxelmZRvanelo-rekomen<strong>da</strong>ciebis zogadi mizani<br />
ganxiluli <strong>klinikuri</strong> sakiTxebi<br />
visTvis aris gankuTvnili mocemuli <strong>klinikuri</strong> rekomen<strong>da</strong>cia<br />
mtkicebulebaTa doneebisa <strong>da</strong> rekomen<strong>da</strong>ciebis gra<strong>da</strong>ciis sqema<br />
abreviatura<br />
1.<strong>da</strong>avadebis definicia<br />
klasifikacia<br />
terminologia<br />
2.epidemiologia<br />
3.etiopaTogenezi<br />
4.<strong>klinikuri</strong> simptomatika<br />
5.<strong>da</strong>avadebis diagnozi<br />
6. gamokvlevis sqema<br />
Tavi I.<br />
1. <strong>aiv</strong> inficirebul pacientTa marTva<br />
1.1. personaluri, ojaxis <strong>da</strong> samedicino istoria<br />
1.2. fizikaluri gamokvleva<br />
1.3. laboratoriuli <strong>da</strong> sxva gamokvlevebi<br />
2. konsultireba <strong>aiv</strong> <strong>infeqcia</strong>sTan asocirebuli problemebis Sesaxeb<br />
3. oportunistuli <strong>da</strong> sxva infeqciebis profilaqtika<br />
4. antirertovirusuli <strong>mkurnaloba</strong><br />
4.1. antiretrovirusuli mkurnalobis <strong>da</strong>wyeba<br />
4.1.1. virusuli <strong>da</strong>tvirTva<br />
4.1.2. wamlisadmi rezistentobis testi<br />
4.2. maRalaqtiuri antiretrovirusuli mkurnalobis pirveli rigis<br />
reJimebi<br />
4.2.1. nukleozidis revers transkriftazas inhibitoris komponenti<br />
4.2.2. aranukleozidis revers transkriftazas inhibitoris komponenti<br />
4.3. antiretrovirusuli Terapiis reJimis <strong>da</strong>cva<br />
4.3.1. antiretrovirusuli Terapiis reJimis <strong>da</strong>cvis barierebi <strong>da</strong> misi<br />
kontrolis strategiebi<br />
4.4. uSedego <strong>mkurnaloba</strong><br />
4.4.1. virusuli araefeqturoba<br />
4.4.2. imunologiuri araefeqturoba<br />
4.4.3. <strong>klinikuri</strong> araefeqturoba<br />
4.5. maRalaqtiuri antirerovirusuli mkurnalobis meore rigis reJimebi<br />
4.5.1. nukleozidis revers transkriftazas inhibitoris komponenti<br />
4.5.2. proteazas inhibitorebis komponenti<br />
4.6. ga<strong>da</strong>rCenis (Salvage) reJimebi<br />
4.7. <strong>da</strong>gegmili Sewyvetili <strong>mkurnaloba</strong> (Sructured treatment interruption)<br />
5. <strong>aiv</strong> inficirebul pacientTa <strong>klinikuri</strong> monitoringi<br />
5.1. laboratoriuli indikatorebis monitoringi antiretrovirusuli<br />
Terapiis <strong>da</strong>wyebamde<br />
5.2. laboratoriuli indikatorebis monitoringi antiretrovirusul<br />
Terapiaze myof pacientebSi<br />
5.3. mkurnalobis reJimis <strong>da</strong>cvis monitoringi<br />
5.4. antiretrovirusuli preparatebis toqsiurobis <strong>da</strong> gverdiTi<br />
efeqtebis marTva<br />
3
5.5. imunuri rekonstituciis sindromi<br />
5.6. medikamentebis urTierTqmedeba<br />
Tavi II. klinikur doneze Sesagrovebeli monacemebis minimumi<br />
<strong>da</strong>mateba 1. aucilebeli informacia <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis mkurnalobis <strong>da</strong><br />
movlis personaluri istoriisTvis<br />
<strong>da</strong>mateba 2. <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis <strong>klinikuri</strong> klasifikacia Sesworebuli<br />
jan<strong>da</strong>cvis msoflio organizaciis mier<br />
<strong>da</strong>mateba 3. rezistentobis testi<br />
<strong>da</strong>mateba 4. aucilebeli informacia antiretrovirusuli preparatebis<br />
Sesaxeb<br />
<strong>da</strong>mateba 5. mkurnalobis reJimis <strong>da</strong>cvis monitoringis meTodebi<br />
<strong>da</strong>mateba 6. antiretrovirusuli prepatarebis CamonaTvali<br />
<strong>da</strong>mateba 7. leqsikoni<br />
<strong>da</strong>mateba 8. horizonts miRma<br />
literaturis CamonaTvali<br />
Tavi III. oportunistuli infeqcebis marTva<br />
3.1. sasunTqi gzebis infeqciebi<br />
3.1.1. baqteriuli respiratoruli infeqcebi<br />
3.1.2. atipiuri mikobaqteriozebi<br />
3.1.3. pnevmocisturi pnevmonia<br />
3.1.4. sxva etiologiis pnevmoniebi imunodeficitis mqone pacientebSi<br />
3.1.5. kuW-nawlavis traqtis infeqciebi<br />
3.1.6. kandidozebi<br />
3.1.7. kriptokokuli meningiti<br />
3.1.8. histoplazmozi<br />
3.1.9. kapoSis sarkoma<br />
3.1.10. saSvilosnos yelis kibo<br />
3.1.11. sxva avTisebiani warmoaqmnebi<br />
3.1.11.1. arahojkinis limfoma<br />
3.1.11.2. berkitis-tipis limfoma <strong>aiv</strong> inficirebulebSi<br />
3.1.12. centraluri nervuli sistemis infeqciebi<br />
3.1.13 toqsoplazmozi<br />
3.1.14 martivi herpesiT gamowveuli infeqciebi<br />
3.1.15 sartylisebuli liqeni<br />
3.1.16 citomegalovirusuli <strong>infeqcia</strong><br />
3.1.17 epStein-baris virusiT gamowveuli infeqciebi<br />
3.2. ZiriTadi simptomebi<br />
3.2.1.persistuli generalizebuli limfadenopaTia mozrdil <strong>aiv</strong><br />
inficirebulebSi<br />
4
3.2.2.cxeleba <strong>aiv</strong> inficirebulebSi<br />
3.2.3. <strong>aiv</strong> inficirebul mozrdilebSi wonis umizezo kleba<br />
3.2.4. mozrdilTa qronikuli diarea<br />
3.2.5. piris Rrus <strong>da</strong>zinebebi<br />
3.2.6. kanisa <strong>da</strong> frCxilebis <strong>da</strong>zianebebi<br />
3.2.7. seboreuli dermatiti<br />
3.2.8. muni<br />
3.2.9. stafilokokuri folikuliti<br />
3.2.10 kontagiozuri miluski<br />
gamoyenebuli literaturis CamonaTvali<br />
Tavi IV <strong>aiv</strong> <strong>infeqcia</strong>/<strong>SidsiT</strong> <strong>da</strong>avadebulTa imunizaciis<br />
ZiriTadi principebi<br />
4.1. vaqcinebisa <strong>da</strong> imunoglobulinebis gamoyeneba<br />
4.2. cocxali atenuirebuli vaqcinebi<br />
4.2.1 BCG vaqcina<br />
4.2.2. qoleris vaqcina (CVD 103-HgR)<br />
4.23. wiTelas, ybayurasa <strong>da</strong> wiTuras vaqcinebi (MMR, MR, M, R vaqcinebi 6 )<br />
4.2.4. poliovirusis oraluri vaqcina (pov)<br />
4.2.5. rotavirusis vaqcina<br />
4.2.6. muclis tifis (Ty21a) vaqcina<br />
4.2.7. Cutyvavilas vaqcina<br />
4.2.8. yviTeli cxelebis vaqcina<br />
4.3. <strong>da</strong>xocili <strong>da</strong> inaqtivirebuli vaqcinebi<br />
4.3.1. qoleris vaqcina (WC/rBs)<br />
4.2..2 difTeriis, tetanusisa <strong>da</strong> yivanaxvelas vaqcinebi (DTP, DTaP, DT, TT,<br />
Td 9 )<br />
4.2.3. B tipis hemofilus influencas vaqcina (HiB)<br />
4.2.4. A hepatitis vaqcina<br />
4.2.5. B hepatitis vaqcina<br />
3.2.5.1. B hepatitis vaqcinaciis reJimi <strong>aiv</strong> inficirebul pacientebSi<br />
3.2.5.2. imunologiuri pasuxi B hepatitis vaqcinaciis mimarT<br />
3.2.5.3. <strong>aiv</strong> inficirebul pacientTa B hepatitis vaqcinaciis Semdgomi<br />
monitoringi <strong>da</strong> strategia<br />
4.3. gripis vaqcina<br />
4.4. meningokokuri vaqcina<br />
4.5. pnevmokokuri vaqcina<br />
4.5..1. polisaqariduli pnevmokokuri vaqcina (ppv)<br />
4.5.2. SekavSirebuli pnevmokokuri vaqcina (Spv)<br />
4.6. inaqtivirebuli poliovirusis vaqcina (ipv)<br />
4.7.cofis vaqcina<br />
4.8. tkipismieri encefalitis vaqcina<br />
4.9. tifis vaqcina (Vi polisaqaridi)<br />
4.10. sxva <strong>da</strong>xocili antigenebi<br />
4.1.1. imunoglobulinebis gamoyeneba<br />
4.11.1. B hepatitis imunoglobulini (HBIg)<br />
4.11.2. a<strong>da</strong>mianis normaluri imunoglobulini<br />
4.11.2.1. hepatiti A<br />
4.11.2.2. wiTela<br />
5
4.11.2.3. cofis sawinaaRmdego imunoglobulini<br />
4.11.2.4. tetanusis sawinaaRmdego imunoglobulini<br />
4.11.2.5. Cutyvavila-zosteris sawinaaRmdego imunoglobulini<br />
<strong>da</strong>narTi 1. rekomen<strong>da</strong>ciebi <strong>aiv</strong> <strong>infeqcia</strong>/<strong>SidsiT</strong> imunokompro-mitirebulTa<br />
imunizaciis Sesaxeb<br />
<strong>da</strong>narTi 2. <strong>aiv</strong> asocirebuli imunodeficitis klasifikacia<br />
<strong>da</strong>narTi 3. cofis vaqcina<br />
gamoyenebuli Lliteraturis CamonaTvali<br />
<strong>aiv</strong> <strong>infeqcia</strong>/Sidsis antiretrovirusuli Terapiis marTvis<br />
saxelmwifo stan<strong>da</strong>rti (protokoli)<br />
<strong>aiv</strong> <strong>infeqcia</strong>/<strong>SidsiT</strong> <strong>da</strong>avadebuli bavSvebis antiretrovirusuli<br />
mkurnalobis marTvis saxelmwifo stan<strong>da</strong>rti (protokoli)<br />
<strong>aiv</strong> <strong>infeqcia</strong>/Sidsis fonze ganviTarebuli<br />
marTvis saxelmwifo stan<strong>da</strong>rti (protokoli)<br />
baqteriuli pnevmoniis<br />
<strong>aiv</strong> <strong>infeqcia</strong>/Sidsis fonze ganviTarebuli atipiuri<br />
mikobaqteriozebis marTvis saxelmwifo stan<strong>da</strong>rti (protokoli)<br />
<strong>aiv</strong> <strong>infeqcia</strong>/Sidsis fonze ganviTarebuli pnevmocisturi pnevmoniis<br />
marTvis saxelmwifo stan<strong>da</strong>rti (protokoli)<br />
<strong>aiv</strong> <strong>infeqcia</strong>/Sidsis fonze ganviTarebuli<br />
saxelmwifo stan<strong>da</strong>rti (protokoli)<br />
kandidozebis marTvis<br />
<strong>aiv</strong> <strong>infeqcia</strong>/Sidsis fonze ganviTarebuli kriptokokuli meningitis<br />
marTvis saxelmwifo stan<strong>da</strong>rti (protokoli)<br />
<strong>aiv</strong> <strong>infeqcia</strong>/Sidsis fonze ganviTarebuli histoplazmozis marTvis<br />
saxelmwifo stan<strong>da</strong>rti (protokoli)<br />
<strong>aiv</strong> <strong>infeqcia</strong>/Sidsis fonze ganviTarebuli kapoSis sarkomis marTvis<br />
saxelmwifo stan<strong>da</strong>rti (protokoli)<br />
<strong>aiv</strong> <strong>infeqcia</strong>/Sidsis fonze ganviTarebuli arahojkinis limfomebis<br />
marTvis saxelmwifo stan<strong>da</strong>rti (protokoli)<br />
<strong>aiv</strong> <strong>infeqcia</strong>/Sidsis fonze ganviTarebuli toqsoplazmozis marTvis<br />
saxelmwifo stan<strong>da</strong>rti (protokoli)<br />
<strong>aiv</strong> <strong>infeqcia</strong>/Sidsis fonze ganviTarebuli martivi herpesiT<br />
gamowveuli infeqciebis marTvis saxelmwifo stan<strong>da</strong>rti<br />
(protokoli)<br />
<strong>aiv</strong> <strong>infeqcia</strong>/Sidsis fonze ganviTarebuli martivi herpesiT<br />
gamowveuli infeqciebis marTvis saxelmwifo stan<strong>da</strong>rti<br />
(protokoli)<br />
<strong>aiv</strong> <strong>infeqcia</strong>/Sidsis fonze ganviTarebuli citomegalovirusuli<br />
infeqciis marTvis saxelmwifo stan<strong>da</strong>rti (protokoli)<br />
6
<strong>aiv</strong> <strong>infeqcia</strong>/Sidsis fonze ganviTarebuli dermatomikozebis<br />
marTvis saxelmwifo stan<strong>da</strong>rti (protokoli)<br />
<strong>aiv</strong> <strong>infeqcia</strong>/Sidsis fonze ganviTarebuli oniqomikozebis marTvis<br />
saxelmwifo stan<strong>da</strong>rti (protokoli)<br />
<strong>aiv</strong> <strong>infeqcia</strong>/Sidsis fonze ganviTarebuli<br />
marTvis saxelmwifo stan<strong>da</strong>rti (protokoli)<br />
seboreuli dermatitis<br />
<strong>aiv</strong> <strong>infeqcia</strong>/Sidsis fonze ganviTarebuli munis marTvis<br />
saxelmwifo stan<strong>da</strong>rti (protokoli)<br />
<strong>aiv</strong> <strong>infeqcia</strong>/Sidsis fonze ganviTarebuli stafilokokuri<br />
folikulitis marTvis saxelmwifo stan<strong>da</strong>rti (protokoli)<br />
<strong>aiv</strong> <strong>infeqcia</strong>/Sidsis fonze ganviTarebuli kontagiozuri moluskis<br />
marTvis saxelmwifo stan<strong>da</strong>rti (protokoli)<br />
<strong>aiv</strong> <strong>infeqcia</strong>/<strong>SidsiT</strong> avadmyofebSi B hepatitis virusiT ko-infeqciis<br />
marTvis saxelmwifo stan<strong>da</strong>rti (protokoli)<br />
<strong>aiv</strong> <strong>infeqcia</strong>/<strong>SidsiT</strong> avadmyofebSi C hepatitis virusiT ko-infeqciis<br />
marTvis saxelmwifo stan<strong>da</strong>rti (protokoli)<br />
<strong>aiv</strong> <strong>infeqcia</strong>/Sidsis <strong>da</strong> tuberkulozis koinfeqciis marTvis<br />
saxelmwifo stan<strong>da</strong>rti (protokoli)<br />
7
<strong>klinikuri</strong> saxelmZRvanelo-rekomen<strong>da</strong>ciebis zogadi mizani<br />
<strong>klinikuri</strong> saxelmZRvanelo-rekomen<strong>da</strong>ciebis “<strong>aiv</strong> <strong>infeqcia</strong>/<strong>SidsiT</strong><br />
<strong>avadmyofTa</strong> gamokvleva <strong>da</strong> mozardebisa <strong>da</strong> mozrdilTa<br />
antirertovirusuli <strong>mkurnaloba</strong>” mizans warmoadgens uaxles samecniero<br />
mtkicebulebebze <strong>da</strong>fuZnebuli informaciis miwodeba <strong>aiv</strong>-<strong>infeqcia</strong>/<strong>SidsiT</strong><br />
<strong>avadmyofTa</strong> gamokvlevis, mkurnalobis, oportunistuli infeqciebis,<br />
vaqcinaciis, monitoringis Sesaxeb eqim - infeqcionistebisTvis, ojaxis<br />
eqimebisTvis, jan<strong>da</strong>cvis pirveladi rgolis muSakebisTvis, zemoT<br />
aRniSnul <strong>da</strong>rgSi momuSave saSualo samedicino personalisTvis <strong>da</strong> yvela<br />
<strong>da</strong>interesebuli pirisTvis.<br />
ganxiluli <strong>klinikuri</strong> sakiTxebi<br />
mocemuli <strong>klinikuri</strong> rekomen<strong>da</strong>ciebi ganixilaven <strong>aiv</strong>-<strong>infeqcia</strong>/Sidsis<br />
antiretrovirusul <strong>mkurnaloba</strong>sTan <strong>da</strong>kavSirebul sakiTxebs,<br />
oportunistuli infeqciebis profilaqtikas, gamovlinebebs,<br />
diagnostikasa <strong>da</strong> <strong>mkurnaloba</strong>s, vaqcinaciis ZiriTad principebs,<br />
avdmyofebis laboratorul-instrumentul gamokvlevebs <strong>mkurnaloba</strong>mde<br />
<strong>da</strong> mkurnalobis <strong>da</strong>wyebis Semdeg, romlebic un<strong>da</strong> Catardes profilur<br />
<strong>da</strong>wesebulebaSi Sesabamisi kvalifikaciis mqone specialistis mier.<br />
visTvis aris gankuTvnili mocemuli <strong>klinikuri</strong> rekomen<strong>da</strong>cia<br />
mocemuli <strong>klinikuri</strong> rekomen<strong>da</strong>ciebi gankuTvnilia eqim<br />
infeqcionistebisTvis, nebismieri profilis eqimebisTvis, socialuri<br />
muSakebisTvis <strong>da</strong> eqTnebisaTvis.<br />
mtkicebulebaTa doneebisa <strong>da</strong> rekomen<strong>da</strong>ciebis xarisxi<br />
winamdebare saxelmZRvaneloSi yvela rekomen<strong>da</strong>cias gaaCnia gra<strong>da</strong>cia,<br />
romelic aRiniSneba laTinuri asoebiT А- <strong>da</strong>n D- mde. amave dros<br />
yovel gra<strong>da</strong>cias Seesabameba monacemTa mtkicebulebis garkveuli<br />
done. rac ufro maRalia rekomen<strong>da</strong>ciis gra<strong>da</strong>cia, miT ufro maRalia<br />
kvlevebis sizuste, romlebzec is aris <strong>da</strong>fuZnebuli<br />
8
done<br />
mtkicebulebis siZlieris done<br />
(Muir Gray)<br />
xarisxi<br />
rekomen<strong>da</strong>ciis<br />
xarisxi<br />
(Cook et al)<br />
I<br />
Zlieri mtkicebuleba, eyrdnoba<br />
minimum erT sistemur<br />
mimoxilvas, romelic efuZneba<br />
swori dizainis mqone<br />
randomizebul kontrolirebad<br />
kvlevas<br />
A<br />
eyrdnoba I donis<br />
mtkicebulebas <strong>da</strong><br />
Sesabamisad mtkiced<br />
rekomendebulia<br />
II<br />
Zlieri mtkicebuleba, eyrdnoba<br />
minimum erTi swori dizainis<br />
mqone randomizebul<br />
kontrolirebad kvlevas<br />
B<br />
eyrdnoba I donis<br />
mtkicebulebas <strong>da</strong><br />
Sesabamisad<br />
rekomendebulia<br />
III<br />
<strong>klinikuri</strong> kvleva<br />
randomizaciis gareSe,<br />
kohortuli <strong>da</strong> SemTxvevakontrolis<br />
kvlevebi<br />
C<br />
eyrdnoba III donis<br />
mtkicebulebas<br />
SeiZleba CaiTvalos<br />
Sesabamisad<br />
IV<br />
araeqsperimentuli<br />
multicentruli kvlevebi<br />
D<br />
eyrdnoba IV <strong>da</strong><br />
Vdonis<br />
mtkicebulebas<br />
saWiroebs konsesuss<br />
Va<br />
avtoritetul profesionalTa<br />
mosazreba<br />
Vb<br />
<strong>klinikuri</strong> gamocdileba,<br />
aRwerilobiTi kvlevebi an<br />
eqspertTa angariSi<br />
9
abreviatura<br />
<strong>aiv</strong><br />
alt<br />
anrti<br />
arv<br />
arT<br />
ast<br />
vd<br />
irs<br />
ifa<br />
maarT<br />
mgb<br />
mrtb<br />
nrti<br />
oi<br />
pi<br />
pjr<br />
tb<br />
Sidsi<br />
janmo<br />
ABC<br />
ddI<br />
EFV<br />
FTC<br />
LPV/r<br />
NFV<br />
ZDV<br />
RTV<br />
SQV<br />
TDF<br />
3TC<br />
UNAIDS<br />
a<strong>da</strong>mianis imunodeficitis virusi<br />
alaninaminotransferaza<br />
ara-nukleoziduri revers transkriftazas<br />
inhibitori<br />
antiretrovirusuli<br />
antiretrovirusuli Terapia<br />
aspartataminotransferaza<br />
virusuli <strong>da</strong>tvirTva<br />
imunuri rekonstituciis sindromi<br />
imunofermentuli analizi<br />
maRalaqtiuri antiretrovirusuli Terapia<br />
mJavagamZle baqteria<br />
multirezistentuli tuberkulozi<br />
nukleoziduri revers transkriftazas<br />
inhibitori<br />
oportunistuli infeqciebi<br />
proteazas inhibitorebi<br />
polimerizaciis jaWvuri reaqcia<br />
tuberkulozi<br />
SeZenili imunodeficitis sindromi<br />
jan<strong>da</strong>cvis msoflio organizacia<br />
abakaviri<br />
di<strong>da</strong>nozini<br />
efavirenzi<br />
emtricitabini<br />
lopinavir/ritovaniri<br />
nelfinaviri<br />
zidovudini<br />
ritonaviri<br />
seqvinaviri<br />
tenofoviri<br />
lamivudini<br />
gaeros <strong>aiv</strong>/Sidsis gaerTianebuli programa<br />
10
1.<strong>da</strong>avadebis definicia<br />
Sidsi abreviaturaa <strong>da</strong> iSifreba, rogorc SeZenili imunodeficitis<br />
sindromi. <strong>da</strong>avadeba Sidsis gamomwvevia a<strong>da</strong>mianis imunodeficitis virusi<br />
(<strong>aiv</strong>-i). <strong>aiv</strong> <strong>infeqcia</strong> ewodeba <strong>da</strong>avadebas virusiT inficirebis momenti<strong>da</strong>n<br />
sicocxlis bolomde. terminiT Sidsi aRiniSneba <strong>aiv</strong> infeqciis bolo<br />
stadia. <strong>aiv</strong> -i a<strong>da</strong>mianis organizmSi SeWris Semdeg azianebs imunur<br />
sistemas, ris Sedegad inficirebul pirs SesaZloa ganuviTardes<br />
nebismieri <strong>infeqcia</strong> an/<strong>da</strong> simsivne, xSirad, sasikvdilo SedegiT.<br />
<strong>aiv</strong> infeqciis klasifikaciis sistema (CDC)<br />
kategoria CD4<br />
ujredebis<br />
<strong>klinikuri</strong><br />
kategoria<br />
raodenobis<br />
mixedviT A B C<br />
1) >500/mm 3<br />
(≥29%)<br />
2) 200-500 mm 3<br />
(14-28%)<br />
3)
terminologia<br />
virusuli <strong>da</strong>tvirTva – ewodeba a<strong>da</strong>mianis imunodeficitis virusis (<strong>aiv</strong>-is)<br />
rnm-is raodenobas (koncentracias) plazmis 1 ml-Si;<br />
“fanjara” periodi – ewodeba periods a<strong>da</strong>mianis imunodeficitis virusis<br />
organizmSi SeWri<strong>da</strong>n <strong>aiv</strong>-antisxeulebis gamomuSavebamde;<br />
mwvave retrovirusuli sindromi – ewodeba <strong>aiv</strong>-is organizmSi SeWri<strong>da</strong>n 2-<br />
3 kviris Semdeg ganviTarebul “infeqciuri mononukleozis msgavs<br />
sindroms”, romelic grZeldeba 2-3 kvira, mas mosdevs <strong>klinikuri</strong><br />
gaumjobesebisa <strong>da</strong> serokonversiis periodi;<br />
<strong>klinikuri</strong> gaumjobeseba <strong>da</strong> serokonversia moicavs 2-4 kviras; am<br />
periodSi organizmSi gamomuSavdeba <strong>aiv</strong>-antisxeulebi;<br />
asimptomuri/qronikuli <strong>aiv</strong> <strong>infeqcia</strong> grZeldeba saSualod 8 weli; am<br />
periodis ganmavlobaSi Tan<strong>da</strong>Tan mcirdeba CD4+ limfocitebis<br />
absoluturi raodenoba SratSi <strong>da</strong> izrdeba virusuli <strong>da</strong>tvirTva<br />
plzmaSi;<br />
oportunistuli <strong>infeqcia</strong> ewodeba iseT infeqciebs, romlis gamomwvevi<br />
(baqteria, virusi, paraziti Tu soko) Cveulebriv SeiZleba janmrTeli<br />
a<strong>da</strong>mianis organizmSic binadrobdes <strong>da</strong> ar iwvevdes paTologias <strong>da</strong><br />
mxolod imunokomprometirebul pirebSi gamoiwvios <strong>da</strong>vaadeba.<br />
maRalaqtiuri antiretrovirusuli Terapia (maarT)- (HAART - High Activity<br />
antiretroviral Therapy) –3 an meti antiretrovirusuli preparatis kombinaciis<br />
xangrZlivad gamoyenebaa <strong>aiv</strong> <strong>infeqcia</strong>/<strong>SidsiT</strong> avadmyofebSi, romlis<br />
Sedegad: aRdgeba <strong>da</strong>zianebuli imunuri sistema, xangrZlivad iTrguneba<br />
Sidsis virusis replikacia, xangrZlivdeba avadmyofis sicocxle <strong>da</strong><br />
umjobesdeba pacientis sicocxlis xarisxi.<br />
imunuri rekonstituciis sindromi (irs) – ewodeba paradoqsul reaqcias,<br />
romelic viTardeba antiretrovirusuli mkurnalobis <strong>da</strong>wyebis Semdeg<br />
<strong>da</strong> gamoxateba mdgomareobis gauaresebiT, rac <strong>da</strong>kavSirebulia latentur<br />
mdgomareobaSi myofi ama Tu im oportunistuli paTogenis<br />
gaaqtiurebasTan. imunuri rekonstituciis sindromi aixsneba<br />
antiretrovirusuli Terapiis Sedegad aRdgenili imunuri sistemis<br />
uCveulod mZlavri zemoqmedebiT mag: tuberkulozis mikobaqteriaze.<br />
2. epidemiologia<br />
<strong>aiv</strong> <strong>infeqcia</strong>/Sidsis gavrceleba msoflioSi<br />
<strong>aiv</strong>/Sidsis epidemia kvlav rCeba dinamikur <strong>da</strong> mzardi xasiaTis epidemiad,<br />
romelmac saocari siswrafiT moicva msoflios praqtikulad yvela<br />
kontinenti, yvela qveyana <strong>da</strong> <strong>da</strong>amtkica, rom igi Tanabrad emuqreba yvelas<br />
rasis, sqesis, asakis, erovnebis, ganaTlebisa <strong>da</strong> sarwmunoebis miuxe<strong>da</strong>vad.<br />
jan<strong>da</strong>cvis msoflio organizaciis (janmo) monacemebiT Sidss msoflioSi<br />
sikvdilianobis mizezTa Soris meoTxe adgili ukavia. marTalia,<br />
antiretrovirusuli Terapiis (arT) xelmisawvdomobam <strong>da</strong> efeqturma<br />
profilaqtikurma programebma ganapirobes ganviTarebul qveynebSi<br />
mdgomareobis stabiluroba, magram mTlianad msoflioSi <strong>aiv</strong><br />
inficirebulTa ricxvi mudmivad izrdeba.<br />
12
Sidsi registrirebulia msoflios 216 qveyanaSi. maTgan 41 qveyanaSi aqvs<br />
generalizebuli xasiaTi, xolo 85 – koncentrirebulia mxolod maRali<br />
riskis jgufebSi.<br />
gaeros Sidsis programis (UNAIDS) 2004 wlis monacemebiT msoflioSi:<br />
epidemiis <strong>da</strong>wyebi<strong>da</strong>n dRemde inficirebulia 39.4 milioni a<strong>da</strong>miani<br />
maT Soris: mozrdilebi 37.2 mln<br />
qalebi<br />
17,6 mln<br />
bavSvebi
amerikis kontinentze <strong>aiv</strong> <strong>infeqcia</strong> aSS-s Semdeg yvelaze farTod<br />
braziliasa <strong>da</strong> meqsikaSi aris gavrcelebuli. am qveynebSi dominirebs <strong>aiv</strong><br />
infeqciis gavrceleba narkotikebis ineqciuri moxmarebiT an<br />
homoseqsualuri kontaqtebis Sedegad.<br />
<strong>da</strong>savleT evropaSi <strong>aiv</strong>/Sidsis yvelaze meti SemTxveva aRricxulia<br />
inglisSi (≈ 62.000), Semdeg SveicariaSi, portugaliasa <strong>da</strong> germaniaSi.<br />
<strong>aiv</strong>/Sidsis gavrcelebis maRali maCveneblebi <strong>da</strong>fiqsir<strong>da</strong> holandiaSi,<br />
SvedeTSi, saberZneTSi, safrangeTsa <strong>da</strong> italiaSi. inficirebulTa 37%<br />
qalia, 29% _ axalgazrdebi 30 wlamde. am qveynebSi <strong>aiv</strong> inficirebis<br />
ZiriTadi mizezebia<br />
• 50% _ heteroseqsualuri kontaqtebi<br />
• 30% _ homo/biseqsualuri kontaqtebi<br />
• 11% _ narkotikebis ineqciuri moxmareba<br />
centralur evropaSi kvlav SenarCunebulia <strong>aiv</strong>/Sidsis SemTxvevaTa<br />
<strong>da</strong>bali prevalentoba, Tumca am regionSi maRalia pediatriuli Sidsis<br />
maCveneblebi.<br />
aziis kontinentze registrirebulia <strong>aiv</strong> infeqciis 7.4 mln. SemTxveva. es<br />
regioni didi xnis manZilze <strong>aiv</strong> infeqciisagan Tavisufal zonad<br />
iTvlebo<strong>da</strong>, amJamad ki axali SemTxvevebis gamovlinebis mxriv azia erTerT<br />
pirvel adgilze aRmoCn<strong>da</strong>. gansakuTrebiT SemaSfoTebeli<br />
statistikaa samxreT (pirvel rigSi CineTsa <strong>da</strong> indoeTSi) <strong>da</strong> samxreT<br />
aRmosavleT aziaSi.<br />
epidemia Zalas ikrebs aRmosavleT evropis qveynebSi. ukanasknel wlebSi<br />
msoflioSi <strong>aiv</strong> infeqciis yvelaze swrafi aRmavloba swored am regionSi<br />
<strong>da</strong>fiqsir<strong>da</strong>. axali SemTxvevebis 76% modis ruseTis federaciaze, sa<strong>da</strong>c<br />
yovelwliurad ormagdeba inficirebulTa raodenoba. <strong>aiv</strong>/Sidsis<br />
epi<strong>da</strong>feTqeba aRiniSneba ukrainasa <strong>da</strong> belorusiaSi. ukrainaSi<br />
mosaxleobis 1%-ia inficirebuli.<br />
aRmosavleT evropis qveynebSi <strong>aiv</strong> inficirebis mizezebia<br />
• 61% _ narkotikebis ineqciuri moxmareba<br />
• 24% _ heteroseqsualuri kontaqtebi<br />
• 0,3% _ homo/biseqsualuri kontaqtebi<br />
<strong>aiv</strong> <strong>infeqcia</strong>/Sidsis gavrcelebis ZiriTadi gza am regionSi ineqciuri<br />
narkomaniaa, Tumca sul ufro izrdeba <strong>aiv</strong>-is heteroseqsualuri<br />
transmisiis SemTxvevebi. aRniSnulis gaTvaliswinebiT saxezea Sidsis<br />
virusis riskis jgufis pirebi<strong>da</strong>n mosaxleobis farTo fenebSi<br />
gavrcelebis tendencia.<br />
<strong>aiv</strong> <strong>infeqcia</strong>/Sidsis gavrceleba saqarTveloSi<br />
2006 wlis 31 dekembris monacemebiT saqarTveloSi oficialurad<br />
registrirebulia <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis 1800 SemTxveva, maTgan 2006 wels<br />
gamovlin<strong>da</strong> 243 <strong>aiv</strong> inficirebuli a<strong>da</strong>miani.<br />
14
egistrirebul SemTxveevaTa 79% saqarTvelos sazRvrebs gare<strong>da</strong>n<br />
Semotanili <strong>infeqcia</strong>a. 18,5% Semotanili infeqciis lokaluri<br />
gavrcelebis Sedegia <strong>aiv</strong> inficirebulis meuRleebsa <strong>da</strong> sqesobriv<br />
partniorebze infeqciis ga<strong>da</strong>cemis Sedegad.<br />
gamovlenil inficirebulTagan 195 qalia, 643 mamakaci. 339 ganuviTar<strong>da</strong><br />
Sidsi, 174 - gar<strong>da</strong>icvala.<br />
saqarTveloSi gamovlenili <strong>aiv</strong> inficirebulebis 64.3% <strong>da</strong>avad<strong>da</strong><br />
narkotikebis ineqciuri gziT moxmarebis Sedegad, 28.4% <strong>da</strong>inficir<strong>da</strong><br />
heteroseqsualuri kontaqtiT, 3,4% _ homo/biseqsualuri kontaqtiT, 1,1 %-<br />
<strong>da</strong>avad<strong>da</strong> virusis vertikalurad (dedi<strong>da</strong>n bavSvze) ga<strong>da</strong>cemis gziT, 1,6,%-<br />
Si inficirebis gza <strong>da</strong>udgenelia, 1,2 % <strong>da</strong>inficir<strong>da</strong> sisxlis ga<strong>da</strong>sxmiT.<br />
<strong>aiv</strong> inficirebis yvelaze meti SemTxveva registrirebulia TbilisSi 306,<br />
Semdeg samegreloSi -129, aWarasa -121 <strong>da</strong> imereTSi -78. gamovlin<strong>da</strong><br />
ucxoeTis 25 moqalaqe, maTgan 10 <strong>da</strong>brun<strong>da</strong> TavianT qveyanaSi.<br />
saqarTveloSi SeiniSneba <strong>aiv</strong> infeqciis gavrcelebis aRmavali tempi. 2000<br />
wels mox<strong>da</strong> <strong>aiv</strong> infeqciis registrirebuli SemTxvevebis gaormageba (1999<br />
wlis 34 SemTxvevasTan Se<strong>da</strong>rebiT 2000 wels gamovlin<strong>da</strong> 79 axali<br />
SemTxveva), Semdeg 2004 wels mox<strong>da</strong> 2003 welTan Se<strong>da</strong>rebiT SemTxvevaTa<br />
1,5-jer zr<strong>da</strong>. 2005 wlis 20 oqtombris monacemebiT gamovlin<strong>da</strong> 170 axali<br />
SemTxveva, rac aRemateba mTeli 2004 wlis manZilze gamovlenil<br />
SemTxvevaTa ricxvs. saqarTveloSi <strong>aiv</strong> infeqciis gavrcelebis<br />
Taviseburebani iseTivea, rogorc aRmosavleT evropis qveynebSi. Sidsis<br />
gavrcelebis upirveles risk-jgufs aqac ineqciuri narkomanebi<br />
warmoadgenen. magram, rogorc sxva qveynebis gamocdileba gviCvenebs,<br />
Sidsis epidemia ar Semoifargleba mxolod narkomanTa wriT, Sidsis<br />
Semdegi msxverplni narkomanTa sqesobrivi partniorebi iqnebian.<br />
<strong>aiv</strong> infeqciis ga<strong>da</strong>cemis gzebi<br />
<strong>aiv</strong> infeqciis wyaros warmoadgens <strong>aiv</strong> inficirebuli an <strong>SidsiT</strong><br />
<strong>da</strong>avadebuli a<strong>da</strong>miani, rogorc <strong>da</strong>avadebis usimptomo periodSi, aseve -<br />
<strong>klinikuri</strong> suraTis gaSlis Semdeg.<br />
<strong>aiv</strong> aRmoCenilia a<strong>da</strong>mianis mTel rig biologiur siTxeebSi. mas<br />
gansakuTrebiT maRali koncentraciiT Seicavs sisxli, sperma, vaginaluri<br />
sekreti, Tavzurgtvinis siTxe <strong>da</strong> dedis rZe.<br />
Sidsis virusi ga<strong>da</strong>ecema:<br />
• sqesobrivi kontaqtiT _ rogorc hetero, ise homoseqsualuri<br />
kontaqtebiT (vaginaluri, analuri, oraluri);<br />
• <strong>aiv</strong> inficirebuli sisxlis an misi calkeuli komponentebis ga<strong>da</strong>sxmiT;<br />
<strong>aiv</strong> inficirebuli sisxliT <strong>da</strong>binZurebuli Spricis, nemsis <strong>da</strong> sxva<br />
samedicino instrumentebis gamoyenebis SemTxvevaSi;<br />
• inficirebuli dedisgan nayofze an axalSobilze mucladyofnis<br />
periodSi, mSobiarobis an ZuZuTi kvebis dros.<br />
Sidsis virusi ar ga<strong>da</strong>ecema:<br />
15
• haer-wveTovani gziT. Sesabamisad ar aris saSiSi <strong>aiv</strong><br />
inficirebulTan saubari, virusi ar ga<strong>da</strong>ecema <strong>da</strong>xvelebiT,<br />
<strong>da</strong>ceminebiT an kocniT.<br />
• sayofacxovrebo <strong>da</strong> socialuri kontaqtebiT. ar aris saSiSi xelis<br />
CamorTmeva, moxveva, <strong>da</strong>avadebulis mier gamoyenebuli WurWliT,<br />
TeTreuliT, saerTo tualetiT <strong>da</strong> abazaniT sargebloba. ar aris<br />
saSiSi <strong>aiv</strong> inficirebulTan erTad yofna sazogadoebrivi TavSeyris<br />
adgilebSi <strong>da</strong> mgzavroba transportiT.<br />
• virusi ar ga<strong>da</strong>ecema mwerebis an/<strong>da</strong> cxovelebis saSualebiT.<br />
3. <strong>aiv</strong> infeqciis etiopaTogenezi<br />
<strong>aiv</strong> miekuTvneba retrovirusebis ojaxs,<br />
lentivirusebis<br />
qveojaxs.<br />
lentivirusebi, Cveulebriv, nel<br />
infeqciebs iwveven. maTTvis<br />
<strong>da</strong>maxasiaTebelia<br />
<strong>da</strong>avadebis<br />
xangrZlivi latenturi periodi,<br />
paTologiur procesSi nervuli<br />
sistemis CarTva <strong>da</strong> susti imunuri<br />
pasuxi, rasac Tan sdevs persistuli<br />
viremia. ganasxvaveben <strong>aiv</strong>-1-sa <strong>da</strong> <strong>aiv</strong>-2-s.<br />
<strong>aiv</strong>-2 mogvianebiT aRmoaCines. igi <strong>aiv</strong>-1-<br />
sgan genetikuri Taviseburebebis<br />
mixedviT gansxvavdeba <strong>da</strong> ZiriTa<strong>da</strong>d<br />
<strong>da</strong>savleT afrikis zogierT qveyanaSia<br />
gavrcelebuli, Tumca sxva qveynebSic<br />
gvxvdeba. <strong>aiv</strong>-2 <strong>aiv</strong>-1-Tan Se<strong>da</strong>rebiT ufro Znelad ga<strong>da</strong>ecema. iSvaTia misi<br />
vertikaluri ga<strong>da</strong>cemis SemTxvevebic. <strong>aiv</strong>-2 <strong>infeqcia</strong> klinikurad <strong>aiv</strong>-1<br />
infeqciis msgavsia, Tumca virusuli <strong>da</strong>tvirTva, Cveulebriv, <strong>da</strong>balia <strong>da</strong><br />
<strong>da</strong>avadebis <strong>klinikuri</strong> progresireba ufro nelia.<br />
<strong>aiv</strong> advilad inaqtivirdeba garemoSi. mSral pirobebSi virusi ramdenime<br />
saaTSi iRupeba, Tumca SesaZloa 1-3 dRe gaZlos. Qqsovilovan kulturaSi<br />
virusi oTaxis temperaturaze 15 dRe Zlebs, xolo 37 0 C-ze – 11 dRe. 56-<br />
60 0 C-ze virusi 30 wT-Si iRupeba. virusi advilad eqvemdebareba qimiuri<br />
saSualebebiT sterilizacias. a<strong>da</strong>mianis imunodeficitis virusi mdgradia<br />
<strong>da</strong>bali temperaturisadmi -70 0 C-ze ar inaqtivirdeba.<br />
<strong>aiv</strong>-is ZiriTadi samizne ujredebia CD4+ limfocitebi (T helper anu Th<br />
limfocitebi), gar<strong>da</strong> amisa igi ainficirebs monocit/makrofagebs, cns-is<br />
mikroglias, folikulur-dendritul ujredebs <strong>da</strong> sxva.<br />
<strong>aiv</strong>-iT ujredis inficirebisas virusis garsis cila – gp120 uerTdeba<br />
samizne ujredis CD4 molekulas, rasac mohyveba virusis Sesvla ujredSi<br />
<strong>da</strong> misi genetikuri masalis integracia maspinZlis genomSi. Semdeg ki<br />
axali virionebis awyoba.<br />
16
a<strong>da</strong>mianis imunodeficitis virusis sasicocxlo cikli<br />
rogorc cnobilia, CD4+ limfocitebi <strong>aiv</strong>-is ZiriTadi samizne ujredebia.<br />
isini ZiriTad rols asruleben rogorc humoruli, ise – ujreduli<br />
imunuri pasuxis ganxorcielebaSi, ris gamoc maT imunuri orkestris<br />
diriJors uwodeben. <strong>aiv</strong> infeqciis imunopaTogenezSi wamyvani mniSvneloba<br />
eniWeba CD4+ limfocitebis raodenobis Semcirebas <strong>da</strong> maTi funqciis<br />
<strong>da</strong>Trgunvas, rasac Sedegad moyveba imunuri sistemis funqciis <strong>da</strong>Trgunva<br />
– imunosupresia. CD4+ limfocitebis ricxvi progresulad mcirdeba <strong>aiv</strong><br />
infeqciis progresirebasTan erTad. igi virusul <strong>da</strong>tvirTvasTan erTad<br />
mniSvnelovani markeria <strong>aiv</strong> <strong>da</strong>avadebis monitorirebisaTvis.<br />
aRsaniSnavia, rom virusis replikaciis TiToeul ciklSi warmoqmnili<br />
Stamebi erTmaneTisgan mniSvnelovnad gansxvavdeba ujreduli tropizmiT,<br />
antigenurobiT, wamlebis mimarT mgrZnobelobiT <strong>da</strong> sxva. <strong>aiv</strong>-is maRali<br />
mutagenoba mas saSualebas aZlevs efeqtianad aicilos Tavi<strong>da</strong>n<br />
antivirusuli imunuri pasuxi, rac virusis persistencias uwyobs xels.<br />
gar<strong>da</strong> amisa, <strong>aiv</strong>-is mutaciis amgvari unari <strong>da</strong>brkolebebs qmnis vaqcinis<br />
SemuSavebisas <strong>da</strong> ganapirobebs wamlebis mimarT rezistentuli Stamebis<br />
warmoqmnas.<br />
<strong>aiv</strong> inficirebis gza, moxvedrili virusis raodenoba, <strong>aiv</strong>-is mocemuli<br />
Stamis paTogenuroba <strong>da</strong> maspinZlis genetikuri faqtorebi gavlenas<br />
axdens <strong>aiv</strong> specifikur imunur pasuxze.<br />
maneitralizebeli antisxeulebi gamomuSavdebian pirveladi infeqcii<strong>da</strong>n<br />
2-4 kviris Semdeg <strong>da</strong> maqsimums asimptomuri fazis dros aRweven. maTi<br />
gansazRvra sisxlSi rutinuli serologiuri testebiT SesaZlebelia<br />
inficirebi<strong>da</strong>n 4-8 kviris Semdeg. Aantisxeulebis gaCenas sisxlSi<br />
serokonversia ewodeba. xolo periods inficirebi<strong>da</strong>n serokonversiamde –<br />
e.w. window periodi.<br />
<strong>aiv</strong> antisxeulebis koncentracia mkveTrad ecema Sidsis ganviTarebasTan<br />
erTad. maneitralizebeli antisxeulebi <strong>aiv</strong> sawinaaRmdego citotoqsikur<br />
T limfocitebTan erTad imunuri pasuxis erT-erTi ZiriTadi komponentia,<br />
romelic <strong>da</strong>sawyisSi nawilobriv ablokirebs <strong>aiv</strong>-is replikacias. Tumca<br />
pirveladi infeeqciis dros ar xdeba <strong>aiv</strong>-is sruli eliminacia, rac<br />
infeqciis qronikul mimdinareobas ganapirobebs. provirus dnm-is<br />
integracia maspinZeli ujredis genetikur masalaSi <strong>da</strong><br />
17
imunokompetenturi ujredebis, upiratesad, CD4+ limfocitebis<br />
destruqcia, imunuri sistemis funqciis moSlas <strong>da</strong> Rrma imunodeficitis<br />
ganviTarebas iwvevs.<br />
4. <strong>klinikuri</strong> simptomatika<br />
<strong>aiv</strong> infeqciis <strong>klinikuri</strong> speqtri<br />
<strong>aiv</strong> infeqciis bunebriv mimdinareobaSi (mkurnalobis gareSe) gamoyofen<br />
Semdeg stadiebs:<br />
virusis organizmSi SeWri<strong>da</strong>n – 2-3 kviraSi viTardeba e.w.<br />
mwvave retrovirusuli sindromi – 2-3 kvira;<br />
<strong>klinikuri</strong> gaumjobeseba <strong>da</strong> serokonversia – 2-4 kvira;<br />
asimptomuri qronikuli <strong>aiv</strong> <strong>infeqcia</strong> – saSualod 8 weli;<br />
simptomuri <strong>aiv</strong> <strong>infeqcia</strong>/Sidsi – saSualod 1,3 weli;<br />
sikvdili.<br />
<strong>aiv</strong> infeqciis pirveladi gamovlinebaa mwvave retrovirusuli sindromi,<br />
romelsac Tan axlavs CD4+ limfocitebis ricxvis mkveTri <strong>da</strong>qveiTeba,<br />
plazmaSi maRali viremia.<br />
cxrili #1<br />
pirveladi <strong>aiv</strong> <strong>infeqcia</strong>: Civilebi <strong>da</strong> simptomebi (2002; US DHHS)<br />
cxeleba – 96% mialgia – 54% hepatosplenomegalia –<br />
14%<br />
adenopaTia - 74% diarea – 32% wonaSi kleba – 13%<br />
faringiti – 70% Tavis tkivili – 43% rZiana –12%<br />
gamonayari – 70%<br />
(eriTematozuli makulopapuluri<br />
gamonayari<br />
saxesa <strong>da</strong> tanze,<br />
iSviaTad – xelisa <strong>da</strong><br />
fexis gulebze, zogi<br />
aRniSnavs wylulovan<br />
gamonayars piris RruSi,<br />
saylapavisa <strong>da</strong><br />
genitaluri organoebis<br />
lorwovanze)<br />
sisuste<br />
<strong>da</strong><br />
moTenTiloba – 27%<br />
nevrologiuri<br />
gamovlinebebi – 12%<br />
(aseptiuri meningiti,<br />
meningoencefaliti,<br />
periferiuli<br />
neiropaTia, giien-bares<br />
sindromi,<br />
nevriti,<br />
<strong>da</strong>rRvevebi<br />
fsiqozuri<br />
mdgomareoba)<br />
mxris<br />
kognitiuri<br />
an<br />
<strong>klinikuri</strong> gaumjobesebis fazaSi aRiniSneba plazmaSi viremiis Semcireba,<br />
citotoqsiuri T limfocitebiT ganpirobebuli imunuri pasuxi.<br />
CD4+ limfocitebis ricxvis <strong>da</strong>qveiTeba kavSirSia virusuli <strong>da</strong>tvirTvis<br />
matebasTan, rac Sidsis ganviTarebisa <strong>da</strong> avadmyofis sikvdilis mizezia.<br />
2002 wels Catarebuli erT-erTi gamokvlevis SedegebiT CD4+<br />
limfocitebis ricxvi <strong>aiv</strong> rnm-is koncentraciis yoveli log10-iT<br />
matebisas 1 ml-Si saSualod 4%-iT iklebs weliwadSi.<br />
18
<strong>aiv</strong> rnm-is koncentracia plazmaSi mkveTrad imatebs mwvave infeqciis<br />
periodSi <strong>da</strong> Semdeg iklebs, rac serokonversiisa <strong>da</strong> imunuri pasuxis<br />
Sedegia.<br />
<strong>da</strong>avadebis gviani stadia xasiaTdeba CD4+ limfocitebis ricxvis<br />
<strong>da</strong>qveiTebiT
cxrili #2 CD4+ limfocitebis ricxvis korelacia <strong>aiv</strong> infeqciis<br />
garTulebebTan<br />
CD4+<br />
limfociteb<br />
is ricxvi<br />
>500/mm3<br />
200-500/mm3<br />
SeuZlebelia <strong>da</strong> ga<strong>da</strong>mwyveti misi diagnostikisTvis laboratoriuli<br />
gamokvlevaa. Sesabamisad, Sidsze saeWvo SemTxvevaSi diferenciuli<br />
diagnozi gatarebul un<strong>da</strong> iqnas yvela im <strong>da</strong>avadebasTan, romelic Sidsis<br />
dros SeiZleba Segvxvdes.<br />
marTalia, <strong>aiv</strong> <strong>infeqcia</strong>s paTognomuri <strong>klinikuri</strong> niSnebi ar gaaCnia,<br />
magram mainc SeiZleba gamoiyos simptomebisa <strong>da</strong> <strong>da</strong>avadebebis jgufi,<br />
romelTa dros pirvel rigSi eWvi un<strong>da</strong> iqnas mitanili <strong>aiv</strong><br />
<strong>infeqcia</strong>/Sidsze. Eesenia:<br />
- aramotivirebuli (ucnobi etiologiis) cxeleba;<br />
- persistuli generalizebuli limfadenopaTia;<br />
- ganlevis sindromi (<strong>aiv</strong> kaxeqsia);<br />
- ucnobi etiologiis qronikuli diarea;<br />
- sxva<strong>da</strong>sxva saxis gamonayari kansa <strong>da</strong> lorwovanze;<br />
- gaxangrZlivebuli filtvebis anTeba, romelic cu<strong>da</strong>d<br />
eqvemdebareba Cveulebriv antibaqteriul Terapias;<br />
- nervuli sistemis sxva<strong>da</strong>sxva saxis <strong>da</strong>zianeba:<br />
-demencia, romlis erT-erTi mizezia Tavis tvinis atrofia,<br />
-kriptokokuli etiologiis meningiti,<br />
-toqsoplazmozuri encefaliti <strong>da</strong>maxasiaTebeli abscesebiT<br />
Tavis tvinSi,<br />
-progresuli multifokaluri leikoencefalopaTia.<br />
SidsisTvis paTognomuria sami simsivnuri <strong>da</strong>avadeba:<br />
• limfuri sistemis simsivne (hojkinis <strong>da</strong> ara-hojkinis simsivneebi)<br />
Tavis tvinis pirveladi limfoma, romelic gvxvdeba mxolod Sidsis an<br />
sxva imunokomrpomisis fonze<br />
• saSvilosnos yelis invaziuri kibo <strong>da</strong> analuri invaziuri kibo<br />
homoseqsual mamkacebSi<br />
• kapoSis sarkoma.<br />
21
sayuradReboa, rom samive zemoT CamoTvlili simsivne asocirebula<br />
virusebTan. limfuri sistemis kibo asocirebulia epStein-baris<br />
virusTsan; saSvilosnos yelisa <strong>da</strong> analuri invaziuri kibo<br />
asocirebulia papilomavirusTan, kapoSis sarkoma asocirebulia<br />
a<strong>da</strong>mianis me-8 tipis herpesis virusTan.<br />
am simsivneebis arsebobis dros aucilebelia <strong>aiv</strong> intisxeulebze<br />
testireba.<br />
amasTan, aucileblad un<strong>da</strong> iqnes gaTvaliswinebuli epidemiologiuri<br />
monacemebi (maRali riskis jgufi, <strong>aiv</strong> inficirebulTan kontaqti <strong>da</strong> sxva),<br />
gar<strong>da</strong> amisa, <strong>aiv</strong> <strong>infeqcia</strong>ze gamokvleul un<strong>da</strong> iyvnen:<br />
• sggd avadmyofebi:<br />
sifilisiT,<br />
gonoreiT,<br />
qlamidioziT,<br />
veneriuli limfogranulomiT,<br />
triqomoniaziT<br />
<strong>da</strong> a.S <strong>da</strong>avadebulebi<br />
• B hepatitis virusiT inficirebulni<br />
• C hepatitis virusiT inficirebulni,<br />
• tuberkulozis nebismieri formiT <strong>da</strong>avadebulni (filtvis<br />
tuberkulozi, limfuri sistemis tuberkulozi, tuberkulozuri<br />
poliseroziti, tuberkulozuri meningiti) .<br />
Aaramotivirebuli cxeleba<br />
(ucnobi etiologiis cxeleba)<br />
ganmarteba: ucnobi etiologiis cxeleba ewodeba sami ZiriTadi<br />
maxasiaTebelis Tanaarsebobas: 1) cxeleba 38.3 0 C-ze an meti, 2)romelic<br />
grZeldeba 3 kviraze meti periodis ganmavlobaSi 3) <strong>da</strong> diagnozis<br />
garkveva ver moxerx<strong>da</strong> erTkviriani hospitalizaciis ganmavlobaSi.<br />
samkviriani periodi aucilebelia TviTgankurnebadi virusuli<br />
infeqciebis gamosaricxad.<br />
persistuli generalizebuli limfadenopaTia<br />
ganmarteba: persistuli generalizebuli limfadenopaTia ewodeba<br />
mdgomareobas, rodesac 3 kviraze meti periodis ganmavlobaSi<br />
hiperplazirebulia qvemoT CamoTvlili kanqveSa limfuri kvanZebi<strong>da</strong>n 2-3<br />
an meti : yuris wina, qve<strong>da</strong>ybisqveSa, kisris wina <strong>da</strong> ukana, kefisukana,<br />
laviwze<strong>da</strong>, laviwqveSa, iRliis, i<strong>da</strong>yvis, sazardulis horizontalur<br />
limfur kvanZTa jgufi, sazardulis vertikalur limfur kvanZTa jgufi.<br />
samkviriani periodi aucilebelia limfadenopaTiiT mimdinare<br />
TviTgankurnebadi virusuli infeqciebis gamosaricxad (ix. qvemoT).<br />
22
persistuli generalizebuli limfadenopaTiis mizezi gar<strong>da</strong> <strong>aiv</strong><br />
infeqciisa SeiZleba iyos<br />
- simsivneebi<strong>da</strong>n: limfomebi, leikemiebi, kapoSis sarkoma,<br />
metastazebi;<br />
- infeqciebi<strong>da</strong>n: brucelozi, katis nakawris <strong>da</strong>avadeba, veneriuli<br />
limfogranuloma, infeqciuri mononukleozi, wiTura,<br />
tuberkulozi, tularemia, tifoiduri cxeleba, sifilisi.<br />
- autoimunuri <strong>da</strong>avadebebi<strong>da</strong>n: sistemuri wiTeli mglura,<br />
revmatoiduli arTriti, dermatomioziti, Segrenis sindromi.<br />
- iSviaTad: kavasakis <strong>da</strong>avadeba, sarkoidozi, medikamentebiT<br />
provocirebuli.<br />
ganlevis sindromi<br />
ganmarteba: wonaSi umizezod kleba sawyis wonasTan Se<strong>da</strong>rebiT 10%-ze<br />
meti erTi Tvis manZilze.<br />
konstituciuri simptomebi (CDC-is klasifikaciiT)<br />
(<strong>aiv</strong> kaxeqsia –janmos klasifikaciiT)<br />
ganmarteba:<br />
- wonaSi umizezod kleba: sawyisi wonis 10%-ze meti,<br />
- an ucnobi etiologiis qronikuli diarea - 1 Tveze meti<br />
xangrZlivobis,<br />
- an qronikuli sisuste SeuRlebuli xangrZliv (1 Tveze meti)<br />
ucnobi etiologiis cxelebasTan<br />
ucnobi etiologiis qronikuli diarea<br />
ganmarteba: qronikuli ewodeba diareas, romelic meordeba TiTqmis<br />
yoveldRe 1 Tvis an meti drois manZilze. qronikuli diarea SeiZleba<br />
mimdinareobdes ganlevis sindromiT an mis gareSe, temperaturiT an mis<br />
gareSe.<br />
afebriluri qronikuli diareis gamomwvevi SeiZleba iyos<br />
kroptosporidia, izospora, mikrosporidia.<br />
temperaturuli reaqcia Tan axlavs qronikuli diareis Semdeg mizezebs:<br />
Jiardiozi, amebiazi, citomegalovirusiT gamowveuli diarea.<br />
gar<strong>da</strong> zemoT CamoTvlili gamomwvevebisa qronikuli diareis mizezi Rrma<br />
imunodeficitis dros SeiZleba iyos: Mycobacteria Avium, Cyclospora<br />
cayetyaensis, Enteric virusis.<br />
zemoT CamoTvlili gamomwvevebis umravlesobis identifikacia Zalian<br />
rTulia <strong>da</strong> aucilebeblia an kvlevis kulturaluri meTodebis an<br />
nawlavis biofsiis gamoyeneba.<br />
gamonayari kansa <strong>da</strong> lorwovanze<br />
imunokomprometirebul pirebSi gvxvdeba kanisa <strong>da</strong> lorwovanis igive<br />
<strong>da</strong>avadebebi, rac imunokompetentur pirebSi, Tumca<br />
23
imunokomproometirebulebSi kanisa <strong>da</strong> lorwovanis banaluri <strong>da</strong>avadebebi<br />
mimdinareobs rTulad, aqvs persistuli xasiaTi <strong>da</strong> rTulia samkurnalod.<br />
qvemoT, mokled aris <strong>da</strong>xasiTebuli kanisa <strong>da</strong> lorwovanis is <strong>da</strong>avadebebi,<br />
romlebic ufro xSirad viTardeba <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis fonze.<br />
Sesabamisad, klinicistma qvemoT aRwerili kanis <strong>da</strong> lorwovanis<br />
romelime <strong>da</strong>avadebis identifikaciisas avadmyofi un<strong>da</strong> gamoikvlios <strong>aiv</strong><br />
antisxeulebze.<br />
5. <strong>da</strong>avadebis diagnozi<br />
laboratoriuli diagnostika<br />
vinai<strong>da</strong>n <strong>aiv</strong> <strong>infeqcia</strong>s paTognomuri <strong>klinikuri</strong> niSnebi ar gaaCnia,<br />
ga<strong>da</strong>mwyveti mis diagnostikaSi laboratoriuli gamokvlevaa.<br />
<strong>aiv</strong> infeqciis laboratoriuli diagnostika sxva<strong>da</strong>sxva meTodiT<br />
xorcieldeba, virusis kultivireba Semdgomi idenTifikaciiT, sisxlsa <strong>da</strong><br />
sxva biologiur siTxeebSi virusis antigenis <strong>da</strong> antisxeulebis<br />
gansazRvra, virusis genomis gamovlena <strong>da</strong> sxva.<br />
dReisaTvis <strong>aiv</strong> infeqciis laboratoriuli diagnostikis ZiriTadi<br />
saSualebebia sisxlSi <strong>aiv</strong> sawinaaRmdego antisxeulebis <strong>da</strong> virusis<br />
genetikuri masalis gansazRvra.<br />
<strong>aiv</strong> antisxeulebis gansazRvris meTodebi or jgufad iyofa – pirveladi<br />
anu skrininguli <strong>da</strong> <strong>da</strong>ma<strong>da</strong>sturebeli anu komfirmaciuli. skriningul<br />
meTodebs miekuTvneba: <strong>aiv</strong> antisxeulebis gamovlena imunofermentuli<br />
analizis (ifa), imunofluorescenciis, hemaglutinaciis,<br />
imunoqromatografiis, mikroprecipitaciis <strong>da</strong> sxva meTodebiT.<br />
gamokvlevis xangrZlivobis mixedviT es meTodebi iyofa Cveulebriv<br />
(xangrZlivoba 2-5 saaTi) <strong>da</strong> swraf/martiv (xangrZlivoba 5-30 wuTi)<br />
meTodebad. konfirmaciuli meTodebi<strong>da</strong>n ZiriTa<strong>da</strong>d gamoiyeneba<br />
imunoblotingi (Western blot).<br />
skriningul meTodebs Soris yvelaze farTod gamoiyeneba <strong>aiv</strong><br />
antisxeulebis gamovlena ifa <strong>da</strong> swrafi/martivi meTodebiT, romlebic<br />
maRali mgrZnobelobiTa <strong>da</strong> specifikurobiT xasiaTdeba <strong>da</strong> amasTan,<br />
advilad xelmisawvdomia. maTi saSualebiT <strong>aiv</strong> antisxeulebi sisxlSi<br />
vlindeba inficirebi<strong>da</strong>n 4-8 kviris Semdeg. <strong>da</strong>debiTi Sedegis SemTxvevaSi<br />
kvleva grZeldeba <strong>da</strong>ma<strong>da</strong>sturebeli anu, konfirmaciuli meTodiT –<br />
imunoblotingiT (Western blot). imunoblotingis meTodi saSualebas iZleva<br />
ganisazRvros specifikuri antigenebis, anu virusis calkeuli cilebis<br />
sawinaaRmdego antisxeulebi.<br />
sadReisod yvelaze zusti <strong>da</strong> maRalmgrZnobiare meTodia virusis genomis<br />
(rnm, dnm) gamovlena polimerizaciis jaWvuri reaqciis (PCR) meTodiT.<br />
arsebobs virusis genomis gamovlenis alternatiuli meTodebic – bDNA<br />
(branched chain DNA) <strong>da</strong> NASBA (Nucleic Acid Sequence-Based Amplification). Tumca<br />
Tavisi mgrZnobelobiTa <strong>da</strong> specifikurobiT sadReisod isini PCR meTods<br />
CamorCeba. bDNA meTodiT xdeba virusis rnm-is moniSnuli monakveTi<strong>da</strong>n<br />
24
signalis amplifikacia komplementuri dnm-iT hibridizaciis gziT. xolo<br />
PCR <strong>da</strong> NASBA meTodebis SemTxvevaSi xdeba virusis moniSnuli rnm-is<br />
amplifikacia fermentuli meTodebiT ise, rom gamravlebuli rnm<br />
ganisazRvros Cveulebrivi meTodebiT.<br />
PCR, romelic 80-ian wlebSi <strong>da</strong>inerga, didi win ga<strong>da</strong>dgmuli nabijia<br />
zoga<strong>da</strong>d infeqciuri <strong>da</strong>avadebis, maT Soris <strong>aiv</strong> infeqciis diagnostikaSic.<br />
misi saSualebiT xdeba infeqciuri agentis genetikuri masalis<br />
amplifikacia <strong>da</strong> gamovlena im SemTxvevaSic ki, roca misi koncentracia<br />
gamosakvlev masalaSi ukiduresad mcirea (1 virusi 100 000 ujredze).<br />
PCR meTodi ori saxisaa: Tvisobrivi <strong>da</strong> raodenobrivi. Tvisobrivi<br />
gamoiyeneba <strong>aiv</strong> infeqciis diagnostikisaTvis adreul stadiaze – sisxlSi<br />
antisxeulebis gaCenamde, agreTve ifa <strong>da</strong> imunoblotingiT saWvo pasuxis<br />
miRebis SemTxvevaSi. gansakuTrebiT didia misi diagnostikuri<br />
Rirebuleba inficirebuli dedis axalSobilis <strong>aiv</strong> infeqciis<br />
diagnostirebisas. rogorc cnobilia, <strong>aiv</strong> inficirebuli dedis<br />
axalSobils SesaZloa arainficirebis SemTxvevaSic ki aReniSnos <strong>aiv</strong><br />
antisxeulebis arseboba maTi transplacenturi barieris gavlis gamo.<br />
amitom ga<strong>da</strong>mwyveti mniSvneloba axalSobilis <strong>aiv</strong> infeqciis<br />
diagnostikaSi swored PCR meTods eniWeba.<br />
raodenobrivi meTodi saSualebas iZleva ganisazRvros e.w. virusuli<br />
<strong>da</strong>tvirTva, anu virusis raodenoba 1 ml plazmaSi. virusuli <strong>da</strong>tvirTva<br />
saukeTeso markeria <strong>da</strong>avadebis prognozirebisa <strong>da</strong> mkurnalobis<br />
efeqtianobis Sesafaseblad.<br />
25
Tavi I. <strong>aiv</strong> inficirebul pacientTa marTva<br />
1. pacientTa gamokvleva pirveli vizitisas<br />
<strong>aiv</strong> inficirebuli pacientis gamokvleva pirveli vizitisas moicavs:<br />
• detalur personalur, ojaxis <strong>da</strong> samedicino istorias;<br />
• fizikalur gamokvlevas;<br />
• laboratoriul <strong>da</strong> sxva gamokvlevebs;<br />
• Sesabamisi specialistis gamokvlevas.<br />
1.1. personaluri, ojaxis <strong>da</strong> samedicino istoria<br />
cxrili 3. informacia, romelic aucileblad un<strong>da</strong> Sediodes samedicino<br />
istoriaSi pirveli vizitisas<br />
ZiriTadi informacia:<br />
• pacientis saxeli<br />
• <strong>da</strong>badebis weli, Tve, ricxvi<br />
• sqesi<br />
• vizitis TariRi<br />
informacia testirebis Sesaxeb<br />
• pirveli pozitiuri <strong>aiv</strong> testirebis TariRi<br />
• mizezi, Tu ratom Caitara testireba<br />
• bolo <strong>aiv</strong> negatiuri testirebis TariRi, Tu cnobilia<br />
<strong>aiv</strong> eqspoziciis riski <strong>da</strong> ga<strong>da</strong>cemis kategoria (Tu cnobilia):<br />
• saineqcio narkotikebis gamoyeneba<br />
• sqesobrivi (sqesobrivi kontaqtis saxis miTiTebiT)<br />
• sisxlis an misi produqtebis ga<strong>da</strong>sxma, organos an qsovilis<br />
ga<strong>da</strong>nergva<br />
• dedi<strong>da</strong>n bavSvze ga<strong>da</strong>cema<br />
• samsaxureobrivi eqspozicia (aRwerilobiT)<br />
• ucnobi<br />
• sqesobrivi partnior(eb)is <strong>aiv</strong> statusi (Tu cnobilia)<br />
• sqesobrivi partnior(eb)is risk faqtorebi (Tu cnobilia)<br />
<strong>aiv</strong> infeqciis ga<strong>da</strong>debis dro <strong>da</strong> adgili (qveyana), romelic yvelaze metad<br />
aris savaraudo an cnobili (a)<br />
<strong>aiv</strong> infeqciis mkurnalobis <strong>da</strong> movlis istoria: (ix. <strong>da</strong>mateba 1)<br />
• vizitamde <strong>aiv</strong> infeqciis mkurnalobis dro <strong>da</strong> adgili, mkurnalobis<br />
Sewyvetis miTiTebiT<br />
• mkurnalobis reJimi<br />
• gverdiTi efeqtebi<br />
• reJimis <strong>da</strong>cva<br />
• laboratoriuli monacemebi (CD4, virusuli <strong>da</strong>tvirva,<br />
eleqtrolitebi, RviZlis funqciebi, Tirkmlis funqciebi, sisxlis<br />
saerTo analizi, didi xnis win inficirebuli pacientisTvis<br />
<strong>da</strong>lagebuli un<strong>da</strong> iyos qronologiurad) (7)<br />
26
• vizitamde rezistentobis testis dokumentirebuli Sedegi (Tu iyo<br />
gakeTebuli)<br />
<strong>aiv</strong> asocirebuli <strong>da</strong>avadebebi <strong>da</strong> mdgomareobebi:<br />
• tuberkulozi<br />
• respiratoruli infeqciebi<br />
• virusuli, baqteriuli <strong>da</strong> sokovani infeqciebi<br />
• hepatiti B <strong>da</strong> C<br />
• neoplaziebi<br />
• sxva<br />
sxva <strong>da</strong>avadebebi <strong>da</strong> mdgomareobebi:<br />
• hospitalizacia<br />
• qirurgiuli Careva<br />
• sulieri mdgomareoba (depresia <strong>da</strong> a.S.)<br />
• Tirkmlis an RviZlis <strong>da</strong>avadebebi<br />
• endokrinologiuri <strong>da</strong>avadebebi<br />
• sqesobrivi gziT ga<strong>da</strong>mdebi <strong>da</strong>avadebebi (sggd)<br />
• vaqcinaciebi<br />
• alergiebi<br />
• sxeulis cvlilebebi<br />
• mimdinare medikamentebi<br />
ojaxis samedicino istoria (diabeti, arteriuli hipertenzia, kanis<br />
<strong>da</strong>avadebebi, simsivneebi <strong>da</strong> a.S.)<br />
gul-sisxlZarRvTa <strong>da</strong>avadebebi <strong>da</strong> <strong>da</strong>avadebis risk-faqtorebi (simsuqne,<br />
Tambaqos Warbad moxmareba, arteriuli hipertenzia <strong>da</strong> a.S.)<br />
eqspozicia tuberkulozTan (personaluri an ojaxuri kontaqtebi) b<br />
mimdinare medikamentebi (opioid CanacvlebiTi Terapiis CaTvliT)<br />
nivTierebaTa moxmareba:<br />
• akrZaluli saineqcio narkotikebis moxmareba (warsulSi an awmyoSi)<br />
• alkoholuri <strong>da</strong>mokidebuleba<br />
reproduqciuli <strong>da</strong> sqesobrivi janmrTeloba<br />
• kontracefciis meTodebi qalebSi<br />
• orsuloba (wina, mimdinare, <strong>da</strong>gegmili)<br />
• sqesobrivi praqtika<br />
socialuri istoria<br />
• sacxovrebeli pirobebi (partnior(eb)i / meuRle / ojaxis wevrebi,<br />
bavSvebi <strong>da</strong> a.S.)<br />
• profesia <strong>da</strong> Tanamdeboba<br />
• <strong>da</strong>xmarebis qseli (socialuri <strong>da</strong> samedicino <strong>da</strong>zRveva,<br />
sazogadoebrivi jgufi, vin icis pacientis <strong>aiv</strong> statusis Sesaxeb <strong>da</strong><br />
a.S.)<br />
a saWiroa epidemiologiisTvis, virusis subtipi <strong>da</strong> savaraudo<br />
rezistentuli Stamebis profili.<br />
b tuberkulozze Semdgomi gamokvlevis instuqciisTvis ix. <strong>aiv</strong><br />
infeqciis <strong>da</strong> tuberkulozis koinfeqciis marTvis gaidlaini<br />
27
1.2. fizikaluri gamokvleva<br />
fizikaluri gamokvlevisas un<strong>da</strong> <strong>da</strong>fiqsirdes arsebuli simptomebi <strong>da</strong><br />
niSnebi, raTa ganisazRvros cvlilebebi statusSi. sasurvelia<br />
vixelmZRvaneloT stan<strong>da</strong>rtuli istoriiT <strong>da</strong> gamokvlevis kiTxvariT; ix<br />
cxrili 2.<br />
cxrili 4. sawyisi fizikaluri gamokvleva<br />
garegnuli monacemebi:<br />
• simaRle <strong>da</strong> wona<br />
• lipodistrofia<br />
• karnovskis indeqsi an zogadi mdgomareobis sxva stan<strong>da</strong>rtuli<br />
Sefaseba<br />
sasicocxlo niSnebi:<br />
• arteriuli wneva<br />
• temperatura<br />
• pulsi<br />
Tavi<br />
• garegnuli monacemebi<br />
• kbilebis mdgomareoba<br />
• oraluri kandidozi<br />
• Tmovani leikoplakia<br />
• pirveladi sifilisi<br />
• saxis kani<br />
gul-mkerdi<br />
• suTqva, xveleba, dispnoe<br />
• gul-mkerdis forma<br />
• emfizemis riskis kontroli<br />
sarZeve jirkvlis <strong>da</strong>Tvaliereba (qalebsa <strong>da</strong> mamakacebSi) karcinomis<br />
riskis gasakontroleblad<br />
gulis mdgomareoba kardiovaskuluri riskis SefasebisTvis<br />
antiretrovirusul <strong>mkurnaloba</strong>ze (8,9) (CIII) an endokarditis riski<br />
saineqcio narkomanebSi<br />
muclis Rrus <strong>da</strong> gastrointestinuri sistemis gamokvleva (sawyisi<br />
informacia antiretrovirusuli mkurnalobis gverdiTi efeqtebisTvis,<br />
gansakuTrebiT qronikuli hepatitis, alkoholuri intoqsikaciis <strong>da</strong><br />
cirozis SemTxvevebSi)<br />
• RviZlisa <strong>da</strong> elenTis konsistencia, zomebi <strong>da</strong> forma<br />
• nawlavebis muSaoba<br />
• muclis sirbile<br />
• rigidoba<br />
• sisuste, moTenTiloba, disfagia<br />
genitaluri <strong>da</strong> analuri regionis gamokvleva:<br />
• martivi herpesi<br />
• citomegalovirusi<br />
• sifilisi<br />
28
• a<strong>da</strong>mianis papilomavirusi (maxvilwvetiani kondilomebi, analuri<br />
karcinoma) (10) (BII), sxva sqesobrivi gziT ga<strong>da</strong>mdebi <strong>da</strong>avadebebi<br />
(sggd)<br />
qvemo kidurebi (moZraoba, mobiluroba, lipodistrofia)<br />
antiretrovirusuli mkurnalobis gverdiTi efeqtebis<br />
gasaTvaliswineblad<br />
kani (sxeulis):<br />
• ga<strong>da</strong>tanili herpes zosteri<br />
• RviZlis <strong>da</strong>avadebebi<br />
• kapoSis sarkoma<br />
• seboreuli deramatiti<br />
• narkotikis ineqciis adgilebi<br />
kanis <strong>da</strong>zianebebi mag: moyavisfro an muqi laqebi umjobesia avsaxoT<br />
fotoebSi, kanis sxva SesaZlo <strong>da</strong>zianebis gamiricxvis mizniT (moqaveba <strong>da</strong><br />
gafxaWna) momavali gamokvlevisas<br />
limfuri kvanZebi<br />
nevrologiuri statusi (neiropaTiis niSnebi)<br />
gonebrivi statusi<br />
mxedveleobiTi <strong>da</strong> smeniTi funqcia<br />
1.3. laboratoriuli <strong>da</strong> sxva gamokvlevebi<br />
cxrili 5. laboratoriuli testebi<br />
<strong>aiv</strong> <strong>infeqcia</strong>sTan <strong>da</strong>kavSirebuli testireba:<br />
• <strong>aiv</strong> serologiuri gamokvleva (tipurad ELISA an swrafi testi),<br />
romelsac mohyveba <strong>da</strong>ma<strong>da</strong>sturebeli testi (tipiurad vestern<br />
blotingi) (11) (AI);<br />
• CD4 ujredebis ricxvi imunodeficitis xarisxis gansazRvrisTvis;<br />
orsul qalebSi CD4% (12,13) (AI)<strong>da</strong><br />
• virusuli <strong>da</strong>tvirTvis testi polimerazuli jaWvuri reaqciis (pjr)<br />
meTodiT, virusis replikaciis donis gansazRvrisTvis (AI) a ;<br />
testireba sxva infeqciebze (CIII)<br />
• testi sifilisze (VDRL);<br />
• vaginaluri, asos an analuri Camonafxeki gonoreisa <strong>da</strong> Chlamydia<br />
trachomatis identifikaciisTvis;<br />
• testireba toqsoplazmis IgG serologiur testze <strong>da</strong> informacia<br />
infeqciis riskis Sesaxeb Tu serologiis Sedegi uaryofiTia<br />
• kriptokokis antigenis titri rodesac CD4 limfocitebis ricxvi <<br />
200 mm3 <strong>da</strong> saxezea kriptokokozis <strong>klinikuri</strong> niSnebi<br />
• CMV antigenemia (pp65 adreuli antigeni) rodesac CD4 ujredebis<br />
ricxvi < 100 mm3 b<br />
• serologiuri testi B,C hepatitis virusebze (anti HCV, HBsAg) g<br />
ZiriTadi laboratoriuli testebi:<br />
o eleqtrolitebi (natriumi, kaliumi) N<br />
o RviZlis funqciuri sinjebi (ALT, AST, tute fosfataza,<br />
saerTo <strong>da</strong> arapir<strong>da</strong>piri bilirubini)<br />
o Tirkmlis funqciebi (Sardovana, kreatinini)<br />
29
o laqtaddehidrogenaza (limfomebis dros ujredTa ZiriTadi<br />
brunva, filtvis infeqciebis niSnebi, miokardiumis infarqti,<br />
kunTebis <strong>da</strong>zianebani <strong>da</strong> a.S.)<br />
o INR an proTrombinis dro<br />
o sisxlis saerTo analizi (formuliTa <strong>da</strong> Trombocitebis<br />
ricxviT)<br />
o orsulobis testi arv Terapiis <strong>da</strong>wyebamde<br />
Tu SesaZlebelia:<br />
o glukoza<br />
o qolesterini (HDL, VLDL)<br />
o trigliceridebi<br />
o lipaza<br />
o C-reaqtiuli cila (CRP)<br />
o Tiroid-mastimulirebeli hormoni (TSH )<br />
a. testebi umjobesia gakeTdes erTi<strong>da</strong>igive laboratoriaSi, raTa Tavi<strong>da</strong>n<br />
aviciloT teqnikuri winaaRmdegobani<br />
b. CMV infeqciis adreuli deteqcia SesaZlebelia <strong>da</strong> pp65 adreuli<br />
antigeni kargi markeria CMV infeqciis mkurnalobis efeqturobis<br />
SefasebisTvis<br />
g. virusul hepatitebze testirebis Semdgomi informaciisTvis ix. C<br />
hepatitis <strong>da</strong> HIV koinfeqciis <strong>da</strong> B hepatitis <strong>da</strong> HIV koinfeqciis<br />
menejmentis protokolebi.<br />
cxrili 5. sxva gamokvlevebi<br />
o tuberkulinis kanis testi a<br />
o naxvelis nacxis mikroskopia <strong>da</strong> gul-mkerdis rentgenologiuri<br />
gamokvleva Tu saxezea tuberkulozis niSnebi<br />
o ekg (gamokvleva <strong>mkurnaloba</strong>mde arT-ze myof pacientebSi gulsisxlZarRvovani<br />
<strong>da</strong>avadebis didi riskis gaTvaliswinebiT,<br />
Se<strong>da</strong>rebisTvis) (14) (BII)<br />
a. Semdgomi informaciisTvis tuberkulinis kanis testze gTxovT<br />
mimarToT tuberkulozis <strong>da</strong> HIV koinfeqciis menejmentis protokols<br />
sxva gamokvlevebis Catareba SesaZlebelia gaxdes saWiro Tanmxlebi<br />
<strong>da</strong>avadebebis gaTvaliswinebiT, magaliTad HCV/HIV an HBV/HIV<br />
koinfeqiebis dros: muclis Rrus organoebis eqoskopia limfuri<br />
kvanZebis, RviZlisa <strong>da</strong> elenTis zomebisa <strong>da</strong> formis Sesafaseblad an<br />
gastrointestinuri traqtis <strong>da</strong>avadebebis <strong>klinikuri</strong> niSnebis<br />
arsebobisas_ zemo an qvemo gastrointestinuri traqtis endoskopia.<br />
endoskopiuri monacemebi sasurvelia dokumentirebuli iyos fotoebiT.<br />
cxrili 7. specialistTa konsultaciebi<br />
o nevrologiuri gamokvleva, rodesac HIV pirvelad aris<br />
diagnostirebuli (mag. periferiuli neiropaTiis<br />
identifikaciisTvis)<br />
o ofTalmologiuri gamokvleva yovel sam TveSi erTxel CMV<br />
30
etinitis identifikaciisTvis, rodesac CD4 ujredebis ricxvi <<br />
100mm3<br />
o ginekologiuri gamokvleva PAP nacxis CaTvliT yovel 6 TveSi<br />
erTxel (a<strong>da</strong>mianis papilomavirusiT gamowveuli karcinoma)<br />
o sxva specialistebis konsultacia aucileblobis SemTxvevebSi<br />
2. <strong>aiv</strong> <strong>infeqcia</strong>sTan <strong>da</strong>kavSirebuli debulebebi<br />
<strong>aiv</strong> <strong>infeqcia</strong>/<strong>SidsiT</strong> mcxovrebi pacientebis menejmenti moicavs:<br />
o pacientebis janmrTelobis monitorings;<br />
o arT-s <strong>da</strong>wyebas <strong>da</strong> mis xelSewyobas;<br />
o oportonistuli infeqciebis <strong>da</strong> sxva Tanmxlebi infeqciebisa <strong>da</strong><br />
<strong>da</strong>avadebebis profilaqtikasa <strong>da</strong> <strong>mkurnaloba</strong>s;<br />
o fsiqologiur mxar<strong>da</strong>Weras;<br />
o mkurnalobis reJimis <strong>da</strong>cvis meTvalyureobas;<br />
o konsultirebas;<br />
o <strong>movla</strong>s.<br />
pacientebis konsultireba un<strong>da</strong> <strong>da</strong>iwyos maTi socialuri mdgomareobis<br />
ganxilviT, romelic moicavs:<br />
o megobrul ganwyobas;<br />
o samsaxureobriv statuss, samuSaos tips <strong>da</strong> mdgomareobas;<br />
o a<strong>da</strong>mianebs, romlebic un<strong>da</strong> iyvnen informirebulni pacientis <strong>aiv</strong><br />
statusis Sesaxeb;<br />
o a<strong>da</strong>mianebs, romlebTan erTa<strong>da</strong>c jan<strong>da</strong>cvis muSaks SeuZlia<br />
ganixilos pacientis janmrTelobasTan <strong>da</strong>kavSirebuli sakiTxebi;<br />
o ojaxis wevrebs <strong>da</strong> naTesavebs;<br />
o medikamentebis Senaxvis reJimis <strong>da</strong>cvis SesaZleblobas;<br />
o cxovrebis stils, romelic SesaZloa zemoqmedebas axdendes<br />
<strong>mkurnaloba</strong>ze (15-17) (CIII).<br />
jan<strong>da</strong>cvis muSakebma inficirebul pacientebTan erTad un<strong>da</strong> ganixilon<br />
mTeli rigi informaciisa, romelic un<strong>da</strong> esmodes pacients:<br />
o avadmyofs un<strong>da</strong> aexsnas riskis Semcireba (<strong>da</strong>culi sqesobrivi<br />
kontaqti, ineqciis unar-Cvevebis gacnoba <strong>da</strong> sxva) romelic moicavs<br />
<strong>aiv</strong> pozitiur partniorTan <strong>da</strong>ucveli sqesobrivi kontaqtis<br />
SemTxvevaSi <strong>aiv</strong> super infeqciis saSiSroebas rezistentuli StamiT.<br />
(18) (BII)<br />
o toqsoplazmozis negatiuri serologiis SemTxvevaSi avadmyofs<br />
un<strong>da</strong> ganemartos misi ga<strong>da</strong>cemis gzebi (maT Soris riski, romelic<br />
<strong>da</strong>kavSirebulia cxovelebTan) <strong>da</strong> profilaqtikis meTodebi (ix.<br />
protokoli 2 <strong>aiv</strong>/Sidsis ZiriTadi simtomebis <strong>da</strong> oportunistuli<br />
infeqciebis menejmenti)<br />
o radgan HBV/HIV <strong>da</strong> HCV/HIV ko<strong>infeqcia</strong> xSiria <strong>da</strong> <strong>da</strong>kavSirebulia<br />
mTel rig sirTuleebTan, didi mniSvneloba eniWeba maT prevencias.<br />
Tanabrad mniSvnelovania RviZlis <strong>da</strong>zianebis <strong>da</strong> dedi<strong>da</strong>n bavSvze<br />
infeqciebis ga<strong>da</strong>cemis riskis Semcireba.<br />
31
o pacientebi saWiroa iyvnen informirebulni SesaZlo<br />
oportunistuli infeqciebis niSnebze (ix. protokoli 2 <strong>aiv</strong>/Sidsis<br />
ZiriTadi simtomebis <strong>da</strong> oportunistuli infeqciebis menejmenti)<br />
o saineqcio narkotikebis momxmareblebTan un<strong>da</strong> ganvixiloT misi<br />
Sewyvetis mniSvneloba. Tu pacients ar surs an ar SeuZlia<br />
Sewyvitos saineqcio narkotikebis moxmareba maSin un<strong>da</strong><br />
ganvumartoT zianis Semcirebis arsi;<br />
o avadmyofs un<strong>da</strong> esmodes jansaRi cxovrebis wesis kerZod, Zilis,<br />
kvebis, varjiSis mniSvneloba.<br />
o pacientebs, romelTac un<strong>da</strong> <strong>da</strong>iwyon antiretrovirusuli Terapia,<br />
un<strong>da</strong> ganemartoT Semdegi sakiTxebi:<br />
o mkurnalobis reJimis <strong>da</strong>cvis mniSvneloba;<br />
o antiretrovirusuli medikamentebis SesaZlo toqsiuroba;<br />
o medikamentebis urTrierTqmedeba;<br />
o kontracefciis aucilebloba, rodesac pacienti imyofeba<br />
efavirenzis Semcvel reJimze;<br />
o pacientebi informirebulni un<strong>da</strong> iyvnen maTi legaluri<br />
pasugismgeblobebisa <strong>da</strong> uflebebis Sesaxeb;<br />
o pacientebi informirebulni un<strong>da</strong> iyvnen imunizaciis Sesaxeb <strong>da</strong><br />
samsaxureobrivi riskis Sesaxeb.<br />
3. oportunistuli <strong>da</strong> sxva infeqciebis profilaqtika<br />
<strong>aiv</strong> <strong>infeqcia</strong>/<strong>SidsiT</strong> avadmyofebi imunizirebul un<strong>da</strong> iyvnen A <strong>da</strong> B<br />
hepatitis virusebisa <strong>da</strong> gripis virusis sawinaRmdegod.<br />
yvela <strong>aiv</strong> inficirebuli , romlis CD4 limfocitebis ricxvi naklebia 200<br />
mm3 un<strong>da</strong> <strong>da</strong>ewyoT profilaqtikuri <strong>mkurnaloba</strong> mTel rig infeqciebze,<br />
maT Soris pnevmocisturi pnevmoniis. ko-trimoqsazoliT profilaqtikuri<br />
Terapia un<strong>da</strong> gagrZeldes manamde, sanam CD4 ujredebis ricxvi ar gaxdeba<br />
200 mm3 meti arv mkurnalobis <strong>da</strong>wyebi<strong>da</strong>n 3 Tvis ganmavlobaSi<br />
stabilurad.<br />
4. antiretrovirusuli Terapia<br />
4.1. arT <strong>da</strong>wyeba<br />
arT <strong>da</strong>wyebis optimaluri dro ar aris <strong>da</strong><strong>da</strong>sturebuli <strong>da</strong> igi ganxilvis<br />
sagania (19) (CIII). sxva<strong>da</strong>sxva kohortuli kvlevis <strong>da</strong> saxelmRvanelo<br />
rekomen<strong>da</strong>ciebis mimoxilva aCvenebs farTod gavrcelebul Sexedulebas,<br />
rom am ga<strong>da</strong>wyvetilebis misaRebad saukeTeso markeria CD4 ricxvi, xolo<br />
virusuli <strong>da</strong>tvirTva meoradi markeria (20-30) (CIII). arT <strong>da</strong>wyebamde un<strong>da</strong><br />
<strong>da</strong>iwyos avadmyofis mxar<strong>da</strong>Wera reJimis maqsimaluri <strong>da</strong>cvis<br />
uzrunvelsayofad;<br />
janmo rekomen<strong>da</strong>cias uwevs arT <strong>da</strong>wyebas <strong>klinikuri</strong> <strong>da</strong> imunologiuri<br />
kriteriumebis safuZvelze. rekomen<strong>da</strong>ciebi arT <strong>da</strong>wyebis Sesaxeb<br />
Sejamebulia cxrilSi 8.<br />
32
cxrili 8<br />
rekomen<strong>da</strong>ciebi arT <strong>da</strong>wyebis Sesaxeb<br />
janmo <strong>klinikuri</strong> stadia CD4 ricxvi<br />
rekomen<strong>da</strong>cia<br />
1<br />
< 200/mm 3 umkurnaleT<br />
200 - 350/mm 3 ganixileT mkurnalobis<br />
SesaZlebloba b, g<br />
2<br />
< 200/mm 3 umkurnaleT<br />
200 - 350/mm 3 ganixileT mkurnalobis<br />
SesaZlebloba b, g<br />
3 200 - 350/mm 3 umkurnaleT<br />
4 CD4 ricxvisgan<br />
umkurnaleT<br />
<strong>da</strong>moukideblad<br />
a. ix. <strong>da</strong>narTi 2 <strong>klinikuri</strong> stadiebis aRwerilobis Sesaxeb<br />
b. rodesac CD4 ricxvi 350/mm 3 -is mi<strong>da</strong>moSia, <strong>da</strong>iwyeT msjeloba<br />
pacientTan arT <strong>da</strong>wyebis saWiroebis moaxloebis <strong>da</strong> mkurnalobis<br />
sawyisi reJimis Sesaxeb.<br />
g. virusuli <strong>da</strong>tvirTva <strong>da</strong>kavSirebulia CD4 ricxvis klebasTan.<br />
rodesac virusuli <strong>da</strong>tvirTva maRalia (> 100000 asli/ml), maRalia<br />
CD4 ricxvis swrafad klebis albaToba. Sesabamisad, Tu virusuli<br />
<strong>da</strong>tvirTva maRalia <strong>da</strong> CD4 ricxvi 350/mm 3 -ia, rekomendebulia arT<br />
<strong>da</strong>wyeba.<br />
arT <strong>da</strong>wyeba un<strong>da</strong> efuZnebodes CD4 ricxvis orjerad gansazRvras 14 – 28<br />
dRis SualediT, raTa gamoiricxos laboratoriuli Secdoma an ga<strong>da</strong>xris<br />
sxva mizezi (magaliTad, Tanmxlebi <strong>da</strong>avadeba).<br />
4.1.1. virusuli <strong>da</strong>tvirTva<br />
virusuli <strong>da</strong>tvirTva TavisTavad ar aris arT <strong>da</strong>wyebis markeri. Tumca, im<br />
SemTxvevaSi Tu virusuli <strong>da</strong>tvirTva 100 000 asli/ml-ze maRalia (man<br />
SeiZleba 1 milion asli/ml-s miaRwios), SesaZloa adgili hqondes CD4<br />
ricxvis swraf klebas. marTalia virusuli <strong>da</strong>tvirTvis gansazRvra<br />
ZviradRirebulia, mniSvnelovania vicodeT misi mniSvneloba mkurnalobis<br />
<strong>da</strong>wyebamde, raTa SemdgomSi SevafasoT mkurnalobis efeqturoba. Tu<br />
virusuli <strong>da</strong>tvirTva ar aris xelmisawvdomi, maSin CD4 ricxvi <strong>da</strong><br />
<strong>klinikuri</strong> simptomebi sakmarisia mkurnalobis <strong>da</strong>wyebis ga<strong>da</strong>wyvetilebis<br />
misaRebad. polimerizaciis jaWvuri reqciisa (pjr) <strong>da</strong> virusuli<br />
<strong>da</strong>tvirTvis ar arseboba ar un<strong>da</strong> gaxdes mkurnalobis ga<strong>da</strong>debis<br />
kriteriumi.<br />
4.1.2 rezistentobis testi<br />
mosazreba pirveli rigis <strong>mkurnaloba</strong>mde rezistentobis testis Catarebis<br />
Sesaxeb gansxvavebulia. rezistentobaze testireba rekomendebulia im<br />
qveynebSi, sa<strong>da</strong>c maRalia priveladi rezistentoba. evropaSi Catar<strong>da</strong><br />
multicentruli kvleva axaldiagnoz<strong>da</strong>smul <strong>aiv</strong> inficirebulebSi 1996 <strong>da</strong><br />
2002 wlebSi. am jgufSi rezistentobis prevalentobam Seadgina 10% (31)<br />
(BII). aSS 40 qalaqSi Catarebul kvlevaSi rezistentobam 14% Seadgina (32)<br />
33
(BII). yvelaze maRali sixSire aRiniSna espaneTSi 26% (33) (BII) <strong>da</strong> sanfranciskoSi<br />
19% (34) (BII). sloveniis monacemebiT rezistentobis sixSire<br />
<strong>da</strong>balia – 3,9% (35) (BII). eqspertebi rekomen<strong>da</strong>cias uweven rezistentobis<br />
testirebas arT <strong>da</strong>wyebamde axaldiagnoz<strong>da</strong>smul pacientebSi (36-38) (BII),<br />
sa<strong>da</strong>c igi xelmisawvdomia, xolo SezRuduli resursebis pirobebSi<br />
rezistentobaze sentineluri (saguSago) ze<strong>da</strong>mxedvelobis <strong>da</strong>wesebas. arT<br />
<strong>da</strong>wyeba SesaZlebelia rezistentobaze testirebis gareSe. ixileT<br />
<strong>da</strong>narTi 3 rezistentobis testirebaze <strong>da</strong>matebiTi informaciisTvis.<br />
4.2 pirveli rigis maarT reJimi<br />
rekomendebulia, rom pirveli rigis arT Seicavdes or<br />
nukleozid/nukleotidis analog revers transkriftazas inhibitors<br />
(nrti anu NRTI) <strong>da</strong> erT ara-nukleozidis analogis revers<br />
transkriptazas inhibitors (anrti anu NNRTI). rekomendebuli<br />
dozebisTvis ixileT <strong>da</strong>narTi 4.<br />
cxrili 9<br />
rekomen<strong>da</strong>ciebi pirveli rigis arT<br />
Sesaxeb<br />
arT reJimi<br />
2 NRTI-s + 1 NNRTI<br />
medikamentebis kombinacia<br />
ZDV + 3TC + (EFV a or NVP)<br />
an<br />
TDF + FTC + (EFV a or NVP)<br />
an<br />
ABC + 3TC + (EFV a or NVP)<br />
a. EFV ganixileba, rogorc upiratesi anrti (AI)<br />
4.2.1. nrti komponenti<br />
- pirveli rigis arT-s ZiriTadi Semadgeneli nawilia ori nrti-s<br />
kombinacia. erT-erTi un<strong>da</strong> iyos lamivudini (3TC) an emtricitabini (FTC)<br />
(39) (AI), xolo meore yvelaze xSirad zidovudinia (ZDV). vinai<strong>da</strong>n<br />
zidovudini pirveli rekomendebuli arv medikamenti iyo, masze uxvi<br />
monacemebia <strong>da</strong>grovili.<br />
- sxva SesaZlo nrti-ebia tenofoviri (TDF) <strong>da</strong> abakaviri (ABC) 3TC–Tan an<br />
FTC–Tan kombinaciaSi. uaxlesi kvlevebi aCveneben TDF/FTC–is kombinaciis<br />
mcire upiratesobas ZDV/3TC–Tan Se<strong>da</strong>rebiT, rodesac gamoiyeneba<br />
efavirenzTan (EFV) kombinaciaSi (40) (AI). aRniSnuli SesaZloa<br />
ganpirobebuli iyos TDF namkurnaleb pacientebSi gverdiTi movlenebis<br />
simciriT. saWiroa <strong>da</strong>matebiTi kvlevebi aRniSnulis <strong>da</strong>sa<strong>da</strong>stureblad.<br />
un<strong>da</strong> aRiniSnos, rom ABC miRebis dros arsebobs saxifaTo<br />
hipersensitiurobis sindromis riski.<br />
- TDF <strong>da</strong> ABC upiratesobaa maTi rezistentobis kargi profili, romelic<br />
saSualebas iZleva momavalSi meti nrti-s kombinaciis gamoyenebas. Tumca<br />
maT aReniSnebaT seriozuli gverdiTi movlenebi <strong>da</strong> efeqturobis<br />
monacemebic mcirea zidovudinTan Se<strong>da</strong>rebiT (41) (CIII).<br />
34
arv medikamentebi arseboben Semdegi fiqsirebuli dozis kombinaciebis<br />
saxiT (anu ori medikamenti 1 tabletSi):<br />
- ZDV + 3TC<br />
- TDF + FTC<br />
- ABC + 3TC<br />
- TDF/FTC kombinaciis ABC/3TC kombinaciasTan Se<strong>da</strong>rebiT <strong>da</strong>matebiTi<br />
upiratesobaa dReSi erTxel misaRebi reJimis arseboba.<br />
- yvela sxva nrti kombinacias pirveli rigis reJimSi gamoyenebisTvis<br />
esaWiroeba safuZvliani mizezi. zogierTi kombinacia ar aris<br />
rekomendebuli (42), xolo sxvebs sWirdebaT gverdiTi movlenebis mWidro<br />
monitoringi. uaxlesi kvlevebi aCveneben gverdiTi movlenebis maRal<br />
sixSires stavudinis (d4T) gamoyenebis dros (40-47) (AI). amis gamo d4T<br />
gamoyenebul un<strong>da</strong> iqnes mxolod im SemTxvevaSi, Tu sxva arCevani ar aris<br />
an sxva nrti-ebi ukunaCvenebia.<br />
arsebobs nrti-ebis gamoyenebasTan <strong>da</strong>kavSirebuli ramdenime wesi:<br />
- ar gamoiyenoT d-medikamentebis kombinacia (ddI (di<strong>da</strong>nozini), ddC<br />
(zalcitabini), d4T).<br />
- ar <strong>da</strong>iwyoT <strong>mkurnaloba</strong> d-medikamentiT arsebuli neiropaTiis dros.<br />
- ar gamoiyenoT ZDV <strong>da</strong> d4T kombinacia.<br />
- ar gamoiyenoT 3TC <strong>da</strong> FTC kombinacia.<br />
4.2.2. anrti komponenti<br />
- saukeTeso monacemebi arsebobs ZDV + 3TC + EFV Sesaxeb (48–50) (AI).<br />
aRniSnuli sami medikamentisgan Semdgari kombinacia dReSi orjer<br />
misaRebia. igi swrafadmoqmedia - EFV gamoyenebis dros virusuli<br />
<strong>da</strong>tvirTva swrafad iklebs pirvel ori kviris ganmavlobaSi, CD4 ricxvis<br />
mateba sxva reJimebis dros aRniSnuli matebis msgavsia. Tumca<br />
aucilebelia mkurnalobis <strong>da</strong>wyebamde Tanmxlebi fsiqiatriuli<br />
<strong>da</strong>avadebebis gamoricxva.<br />
- nevirapini (NVP) kidev erTi rekomendebuli anrtia, romelic nrti-ebTan<br />
kombinaciaSi gamoiyeneba. RviZlis <strong>da</strong>avadebebis dros maRalia misi<br />
toqsiuroba (52) (AI). amis gamo misi gamoyeneba rekomendebulia qalebSi<br />
Tu CD4 ricxvi
sxva anrti-ebi ver aitaneba an arsebobs rezistentobis gansakuTrebuli<br />
forma.<br />
- ori nrti <strong>da</strong> erTi anrti-s alternativa SeiZleba iyos erTi klasisgan<br />
Sedgenili reJimi – “sammagi nukleozidi” 3 an “oTxmagi nuklezidi”,<br />
romlebic mxolod sami an oTxi nrti-sgan Sedgeba. marTalia, am reJimze<br />
sawyisi pasuxi kargia, 24 kviris Semdeg rezistentobis ganviTarebis meti<br />
albaTobaa (48) (AI). Sesabamisad, sami nrti-s kombinacia un<strong>da</strong><br />
gamoiyenebodes gansakuTrebul situaciebSi, magaliTad TB an HCV<br />
koinfeqciis SemTxvevaSi, rodesac erTdrouli <strong>mkurnaloba</strong>a saWiro, an<br />
alternativis saxiT, Tu antri ar aris xelmisawvdomi.<br />
- ori anrti-s <strong>da</strong> erTi nrti-s kombinacia ar aris rekomendebuli (53) (AI).<br />
- bustirebuli proteazas inhibitori (pi) or nrti-sTan erTad SesaZloa<br />
gamoyenebul iqnes pirveli rigis arT saxiT, Tu ukunaCvenebia anrti-ebi<br />
(anu verc efavirenzi <strong>da</strong> verc nevirapini ver iniSneba):<br />
- fsiqiatriuli <strong>da</strong>avadebebi <strong>da</strong> alt-s mateba 3-5-jer;<br />
- cirozi;<br />
- orsuloba, Tu CD4 ricxvia 250 - 350 ujrdi/mm 3 .<br />
- pi Semcveli pirveli rigis arT-s araefeqturobis dros naklebi<br />
arCevania Semdgomi reJimisTvis. zoga<strong>da</strong>d rekomendebulia, rom pi<br />
Semonaxul iqnes meore rigis reJimisTvis.<br />
3 “sammagi nukleozidi”: fiqsirebuli dozis tableti, romelic Seicavs ZDV <strong>da</strong> 3TC <strong>da</strong><br />
ABC. igi miiReba dReSi orjer (zidovudini ar aris rekomendebuli dReSi erTxel<br />
miRebisTvis). amJamad igi yvelaze martivi sammagi Terapiuli reJimia.<br />
4.3. arT reJimis <strong>da</strong>cva<br />
mkurnalobis optimaluri Sedegis misaRebad saWiroa mkurnalobis<br />
reJimis <strong>da</strong>cva. kargad aris cnobili, rom arT reJimis maRal doneze<br />
<strong>da</strong>cva <strong>da</strong>kavSirebulia <strong>aiv</strong> asocirebuli avadobis <strong>da</strong> sikvdilianobis<br />
mkveTr SemcirebasTan (54) (AI), xolo reJimis arasaTanado <strong>da</strong>cva <strong>aiv</strong>-is<br />
wamlebis mimarT rezistentobis swraf ganviTarebas iwvevs (55) (AI). arTsTvis<br />
ar aris gansazRvruli reJimis <strong>da</strong>cvis efeqturi done (arsebobs<br />
sxvaoba reJimebs Soris), Tumca reJimis <strong>da</strong>cva 95%-ze nakleb doneze<br />
<strong>da</strong>kavSirebulia cud virusologiur <strong>da</strong> imunologiur pasuxTan, xolo<br />
reJimis 100%-iT <strong>da</strong>cvas kidev ufro meti sargebeli moaqvs, vidre 95%-iT<br />
<strong>da</strong>cvas (56, 57) (AI). uaxlesi monacemebi aCveneben korelacias reJimis<br />
<strong>da</strong>cvasa <strong>da</strong> arv sxva<strong>da</strong>sxva klasis mimarT rezistentobas Soris (58) (AI).<br />
<strong>da</strong>bal an arasakmaris reJimis <strong>da</strong>cvas mohyveba arasaxarbielo Sedegebi<br />
pacientisTvis, sazogadoebrivi jan<strong>da</strong>cvisTvis <strong>da</strong> qveynis ekonomikisTvis.<br />
kerZod,<br />
- pacientebi arian mniSvnelovani safrTxis winaSe rezistentobis<br />
ganviTarebis, mkurnalobis araefeqturobis <strong>da</strong> <strong>da</strong>avadebis progresirebis<br />
TvalsazrisiT (59, 60) (AI). axali kombinacia erTi reJimis araefeqturobis<br />
SemTxvevaSi umetesad ufro rTulia <strong>da</strong>cvis TvalsazrisiT (meti<br />
tabletebis ricxvi dReSi, gverdiT movlenebi, dieturi SezRudevebi,<br />
toqsiuroba <strong>da</strong> dozirebis sirTule).<br />
- rezistentuli virusis gavrceleba gamoiwvevs mis ga<strong>da</strong>cemas axlad<br />
inficirebul pirebSi. aSS (61) (AI) <strong>da</strong> evropis (62) (AI) monacemebi<br />
36
aCveneben, rom pirveladi rezistentobis sixSire imatebs, <strong>da</strong> SeZenil<br />
rezistentobas uaryofiTi gavlena aqvs arT pasuxze.<br />
- rezistentuli Stamis arsebobas mohyveba meore rigis, mesame rigis <strong>da</strong><br />
e.w. ga<strong>da</strong>rCenis (salvage) reJimi, romlebic, Cveulebriv, ufro Zviria<br />
pirveli rigis reJimebTan Se<strong>da</strong>rebiT.<br />
- reJimis arasakmarisi <strong>da</strong>cva, agreTve, moaswavebs <strong>da</strong>avadebis<br />
progresirebis maRal risks, rac met <strong>da</strong>naxarjebs moiTxovs<br />
oportunistuli infeqciebis samkurnalod (63) (AI).<br />
4.3.1. barierebi reJimis <strong>da</strong>cvaSi <strong>da</strong> maTi sawinaaRmdego zomebi<br />
4.3.1.1. pacientTan <strong>da</strong>kavSirebuli faqtorebi <strong>da</strong> strategiebi<br />
pacients ZiriTadi roli akisria reJimis <strong>da</strong>cvaSi. SeuZlebelia pacientis<br />
mier reJimis <strong>da</strong>cvis potencialis prognozireba. kvlevebma, romlebic<br />
Seiswavlidnen sqess, rasas, asaks, <strong>aiv</strong> ga<strong>da</strong>cemis gzas <strong>da</strong> ganaTlebis<br />
dones, rogorc reJimis <strong>da</strong>cvis indikatorebs, gansxvavebuli Sedegebi<br />
aCvenes (64) (BII). individualuri reJimis <strong>da</strong>cvis donec SesaZloa<br />
sxva<strong>da</strong>sxva dros gansxvavdebodes (65) (BII). umravlesi <strong>aiv</strong> inficirebuli<br />
raRac dros gamoavlens reJimis <strong>da</strong>cvis <strong>da</strong>bal xarisxs.<br />
reJimis <strong>da</strong>cvis <strong>da</strong>bali donis SesaZlo mizezebia:<br />
- narkotikebis <strong>da</strong> alkoholis moxmareba<br />
- cudi kveba siRaribis gamo<br />
- religiuri mosazrebebi (66) (DIV)<br />
- <strong>aiv</strong> statusis gamJRavnebis SiSi medikamentebis rutinuli miRebisas<br />
- fsiqiatriuli mdgomarebebi (67) (DIV)<br />
- gverdiTi movlenebis SiSi <strong>da</strong> eWvi mkurnalobis saWiroebis Sesaxeb (68)<br />
(DIV).<br />
SesaZlo sawinaaRmdego strategiebi:<br />
- ganaTleba arT saWiroebis Sesaxeb<br />
- swrafi reagireba pacientis araswor Sexedulebaze<br />
- arT-s mimarT pacientis ganwyobis regularuli Sefaseba<br />
- “peer” (Tanasworis) Careva (pacientTa jgufebi)<br />
- fsiqiatriuli problemebis regularuli Sefaseba<br />
- reJimis <strong>da</strong>cvisTvis saWiro Cvevebis Sefaseba 4<br />
- specializirebuli socialuri samsaxuris an <strong>da</strong>wesebulebebis CarTva.<br />
4 es SesaZloa gaZlierdes im pirebis CarTviT, vinc kontaqtSia pacientTan (eqTani,<br />
farmacevti, ojaxi), agreTve, grafikis (cxrilebis), saaTiani tabletebis yuTebis<br />
gamoyenebiT, mogzaurobisas gegmis SemuSavebiT, Tu rogor miiRos medikamentebi<br />
garSemomyofebisTvis SeumCnevlad.<br />
4.3.1.2. jan<strong>da</strong>cvis muSakTan <strong>da</strong>kavSirebuli faqtorebi<br />
jan<strong>da</strong>cvis muSakebi naTlad un<strong>da</strong> acnobierebdnen reJimis <strong>da</strong>cvis<br />
mniSvnelobas <strong>da</strong> mis rols rezistentobis ganviTarebaSi. <strong>aiv</strong>/Sidsis<br />
<strong>da</strong>rgSi momuSave profesionali un<strong>da</strong> iRebdes mudmiv ganaTlebas reJimis<br />
<strong>da</strong>cvis sakiTxebSi. arsebobs ramdenime strategia, romelic un<strong>da</strong><br />
gamoiyenos jan<strong>da</strong>cvis muSakma reJimis <strong>da</strong>cvis xarisxis asamaRleblad.<br />
37
- TiToeul centrs, sa<strong>da</strong>c tardeba <strong>aiv</strong> <strong>mkurnaloba</strong>, un<strong>da</strong> hqondes reJimis<br />
<strong>da</strong>cvis werilobiTi strategia, romelic ga<strong>da</strong>ixedeba regularulad.<br />
- jan<strong>da</strong>cvis muSakebi CarTulni un<strong>da</strong> iyvnen reJimis <strong>da</strong>cvis mxar<strong>da</strong>saWer<br />
programebSi (69) (CIII).<br />
- pacientTa survilis gaTvaliswinebam, CaerTos am programebSi<br />
SesaZloa gaaumjobesos reJimis <strong>da</strong>cva.<br />
- reJimis <strong>da</strong>cvaSi mxar<strong>da</strong>Wera un<strong>da</strong> SeeTavazos yvela pacients imis<br />
gaTvaliswinebiT, Tu ra xarisxiT icavs esa Tu is pacienti reJims.<br />
- mxa<strong>da</strong>Wera un<strong>da</strong> gagrZeldes meore rigis <strong>da</strong> “ga<strong>da</strong>rCenis" reJimis<br />
drosac. mkurnalobis araefeqturoba un<strong>da</strong> iyos sakvanZo sakiTxi reJimis<br />
<strong>da</strong>cvis <strong>da</strong> mxar<strong>da</strong>Weris RonisZiebebis gaZlierebisTvis (70).<br />
- reJimis <strong>da</strong>cvis maRali xarisxi xangrZlivi procesia <strong>da</strong> ara erTjeradi<br />
movlena (71) (DIV), avadmyofs mxar<strong>da</strong>Wera un<strong>da</strong> SevTavazos arT <strong>da</strong>wyebisas,<br />
Secvlisas <strong>da</strong> rutinuli meTvalyureobisas.<br />
- jan<strong>da</strong>cvis muSakma un<strong>da</strong> uzrunvelyos, rom pacients hqondes adekvaturi<br />
codna <strong>aiv</strong>-is, reJimis <strong>da</strong>cvas <strong>da</strong> rezistentobas Soris kavSiris, gverdiTi<br />
movlenebis Sesaxeb. sityvieri informacia un<strong>da</strong> gamyardes werilobiTi<br />
informaciiT.<br />
- jan<strong>da</strong>cvis muSakma SesaZloa rekomen<strong>da</strong>cia gauwios tabletebis miRebis<br />
dRiurs, cxrilebs, medikamentebis konteinerebs, ojaxis wevrebis <strong>da</strong><br />
megobrebis CarTvas “Semxseneblebad” (72) (DIV).<br />
- arT reJimis <strong>da</strong>cva umjobesdeba, Tu pacienti pozitiurad aRiqvams<br />
kavSirs eqimTan <strong>da</strong> jan<strong>da</strong>cvis sxva muSakebTan (73) (DIV).<br />
- reJimis <strong>da</strong>cvaze adreuli meTvalyureoba un<strong>da</strong> ganxorcieldes reJimis<br />
<strong>da</strong>wyebi<strong>da</strong>n an Secvli<strong>da</strong>n 2 dRis Semdeg imis gasarkvevad, esaWiroeba Tu<br />
ara pacients <strong>da</strong>matebiTi informacia an aqvs Tu ara raime<br />
gauTvaliswinebeli problema.<br />
4.3.1.3. reJimTan <strong>da</strong>kavSirebuli faqtorebi <strong>da</strong> strategiebi<br />
- dozireba dReSi orjer metad <strong>da</strong>kavSirebulia reJimis <strong>da</strong>cvis ufro<br />
<strong>da</strong>bal donesTan (74) (CIII), xolo dReSi erTxel an orjer misaReb<br />
reJimebs Soris sxvaoba savaraudod ar aris (75) (CIII). dReSi erTxel an<br />
orjer misaRebi reJimis dros, dozaTa umravlesoba droulad miiReba.<br />
multivariaciuli analiziT dozis miReba <strong>da</strong>niSnulze gvian<br />
<strong>da</strong>kavSirebulia mkurnalobis araefeqturobasTan (76) (AI).<br />
- reJimis <strong>da</strong>cvis done ar aris <strong>da</strong>kavSirebuli arv klasTan. Tumca kvebiTi<br />
SezRudva sxva<strong>da</strong>sxva medikamentisTvis SesaZloa qmnides problemas (77)<br />
(BII).<br />
- tabletebis mcire ricxvis dros metia albaToba, rom 48 kviris Semdeg<br />
virusuli <strong>da</strong>tvirTva iqneba < 50 asli/ml (75) (BII).<br />
- <strong>da</strong>mazianebelma wamlebis urTierTqmedebam <strong>da</strong> gverdiTma movlenebma<br />
SesaZloa gavlena moaxdinos reJimis <strong>da</strong>cvis xarisxze. doza SesaZloa<br />
gamotovebul iqnes gulisrevis <strong>da</strong> diareis gamo, sisustis gamo CaZinebam,<br />
agreTve, SesaZloa gamoiwvios dozis gamotoveba (78) (DIV).<br />
SesaZlo sawinaaRmdego strategiebi:<br />
- Sefasdes cxovrebis wesi (kvebis, Zilis, samuSao reJimi) <strong>da</strong> moergos<br />
samkurnalo reJimi;<br />
- Sefasdes pirovnebis ganwyoba sxva<strong>da</strong>sxva reJimis mimarT (tabletis<br />
zoma, formulireba, raodenoba, dieturi SezRudva <strong>da</strong> a. S.).<br />
38
- tabletebis Cveneba pacientisTvis reJimis <strong>da</strong>wyebamde;<br />
- informaciis micema gverdiTi movlenebis <strong>da</strong> maTi marTvis Sesaxeb,<br />
mxar<strong>da</strong>Weris Sesaxeb.<br />
4.4. uSedego <strong>mkurnaloba</strong><br />
mkurnalobis araefeqturoba SesaZloa Sefasdes virusuli <strong>da</strong>tvirTvis <strong>da</strong><br />
CD4 ricxvis gansazRvriT, agreTve, <strong>klinikuri</strong> gamoklveviT.<br />
4.4.1. virusologiuri araefeqturoba<br />
- virusuli <strong>da</strong>tvirTva (vd) mkurnalobis warmatebis an araefeqturobis<br />
yvelaze adreuli indikatoria, romelsac mohyveba CD4 ricxvi<br />
<strong>da</strong>axloebiT 1 Tvis Semdeg. iSviaTad viTardeba paradoqsuli reaqcia<br />
virusologiuri pasuxiT <strong>da</strong> imunologiuri araefeqturobiT. Sesabamisad,<br />
aucilebelia vd Sefasdes CD4 ricxvTan erTad kombinaciaSi.<br />
- virusologiur araefeqturobad miiCneva, Tu vd ar gax<strong>da</strong> 400 asli/ml-ze<br />
naklebi mkurnalobis 24-e kviraze an 50 asli/ml-ze naklebi mkurnalobis<br />
48-e kviraze.<br />
- Tu vd gax<strong>da</strong> ganusazRvreli, magram Semdgomi ori gamokvlevisas 4-8<br />
kviris intervaliT igi kvlav metia 400-1000 asli/ml-ze, aseT SemTxvevaSi<br />
virusologiuri araefeqturobis momatebuli riskia (79) (BII).. reJimis<br />
SenarCuneba zrdis Semdgomi mutaciebis <strong>da</strong> meti medikamentis mimarT<br />
ufro gamoxatuli rezistentobis ganviTarebis risks.<br />
- “Blips” (xanmokle mcire piki) aris vd-s msubuqi mateba ganusazRvreli<br />
doni<strong>da</strong>n 50-200asli/ml-mde. mas SesaZloa adgili hqondes rezistentuli<br />
Stamis ganviTarebis gareSe (laboratoriuli Secdoma), Tumca igi aris<br />
indikatori reJimis <strong>da</strong>cvis msjelobisTvis (80) (BII). am situaciaSi<br />
SesaZloa, agreTve, <strong>da</strong>mxmare roli Seasrulos medikamentebis Terapiulma<br />
monitoringma (TDM). TiToeuli “blifi” un<strong>da</strong> gakontroldes 4 kviraSi.<br />
- Tu virusulogiuri araefeqturobis mizezi ar vlindeba (reJimis<br />
araadeqvaturi <strong>da</strong>cva, wamlebis suboptimaluri done, wamlebis<br />
urTierTqmedeba <strong>da</strong> sxv.), un<strong>da</strong> ganxilul iqnes meore rigis Terapiis<br />
<strong>da</strong>wyebis SesaZlebloba 5 .<br />
5 Tu cnobilia, rom qveyanaSi rezistentobis prevalentoba 7%-ze metia, rekomendebulia<br />
rezistentobis testi mkurnalobis araefeqturobis SemTxvevaSi wamlebis miRebisas an<br />
maTi Sewyveti<strong>da</strong>n 2-4 kviris ganmavlobaSi. mogvianebiT rezistentobis testi ver<br />
gamoavlens rezistentobas mkurnalobis Sewyvetis Semdeg veluri Stamis swrafi zrdis<br />
gamo.<br />
4.4.2. imunologiuri araefeqturoba<br />
- Tu vd ar aris xelmisawvdomi, CD4 ricxvi gamoyenebul un<strong>da</strong> iqnes<br />
mkurnalobis warmatebis an araefeqturobis indikatorad.<br />
- imunologiuri araefeqturobaa, Tu CD4 ricxvma ar moimata 50 /mm 3 -ze<br />
metad arT pirveli wlis ganmavlobaSi. saSualod aranamkurnaleb<br />
39
pacientebSi mkurnalobis pirveli wlis ganmavlobaSi CD4 ricxvi imatebs<br />
150 /mm 3 -iT (81, 82) (AI).<br />
- Tu CD4 ricxvi ar imatebs arT <strong>da</strong>wyebi<strong>da</strong>n pirveli 9 Tvis ganmavlobaSi,<br />
ganxilul un<strong>da</strong> iqnes meore rigis arT SesaZlebloba. Tu vd<br />
aragansazRvradia, reJimi un<strong>da</strong> gagrZeldes. Tu igi > 400-1000 asli/ml-ze,<br />
un<strong>da</strong> verificirdes reJimis <strong>da</strong>cva <strong>da</strong> <strong>da</strong>iwyos meore rigis reJimi.<br />
- Tu CD4 ricxvi ar imatebs 6 Tvis ganmavlobaSi, xelaxla un<strong>da</strong> Sefasdes<br />
reJimis <strong>da</strong>cvis xarisxi.<br />
4.4.3. <strong>klinikuri</strong> araefeqturoba<br />
arT <strong>da</strong>wyebis Semdeg, oportunistuli infeqciis (oi) an sxva <strong>aiv</strong>asocirebuli<br />
<strong>da</strong>avadebis ganviTareba, <strong>klinikuri</strong> araefeqturobis<br />
indikatoria. Tumca es SeiZleba iyo imunuri rekonsitituciis sindromi<br />
(irs), gansakuTrebiT, arT-s <strong>da</strong>wyebi<strong>da</strong>n pirveli 3 Tvis ganmavlobaSi, Tu<br />
igi <strong>da</strong>wyebul iqna CD4 ricxvi 400asli/ml;<br />
>50asli/ml<br />
50 ujredi/mm 3 -ze<br />
naklebi mateba<br />
<strong>klinikuri</strong><br />
araefeqturoba<br />
oi (<strong>aiv</strong>-Tan<br />
asocirebuli)<br />
mkurnalobis<br />
<strong>da</strong>wyebi<strong>da</strong>n 12<br />
kviris Semdeg<br />
oi (gamoricxeT<br />
irs)<br />
4.5. meore rigis arv reJimi<br />
(rekomen<strong>da</strong>ciebi dozebis Sesaxeb ix. <strong>da</strong>narTi 4)<br />
- meore rigis Terapiad rekomendebulia pi-s Semcveli kombinacia. pi-ebs<br />
gaaCniaT maRali genetikuri barieri.<br />
- meore rigis arT rekomnedebulia mxolod pirveli rigis reJimis mimarT<br />
<strong>da</strong><strong>da</strong>sturebuli araefeqturobis SemTxvevaSi.<br />
- meore rigis arT <strong>da</strong>wyebasTan erTad un<strong>da</strong> moxdes reJimis <strong>da</strong>cvis<br />
xelaxali Sefaseba <strong>da</strong> maqsimaluri mxar<strong>da</strong>Wera.<br />
- meore rigis reJimis dros sul mcire ori nrti-s Secvlaa saWiro.<br />
arasodes SecvaloT mxolod erTi wamali saeWvo rezistentobis<br />
SemTxvevaSi.<br />
- efavirenzis <strong>da</strong> nevirapinis xangrZlivi naxevar<strong>da</strong>Slis periodis gamo,<br />
samive wamlis erTdrouli Sewyveta niSnavs, rom efavirenzi an nevirapini<br />
<strong>da</strong>rCeba sisxlSi nrti-ebze xangrZlivad, rac maT mimarT rezistentobis<br />
gamomwvevi mutaciis ganviTarebis risks zrdis.<br />
40
- aqe<strong>da</strong>n gamomdinare, nrti+anrti reJimis Sewyvetisas SesaZloa Sewydes<br />
jer anrti <strong>da</strong> mogvianebiT, <strong>da</strong>axloebiT 7 dRis Semdeg, nrti-ebi. Tumca am<br />
sakiTxTan <strong>da</strong>kavSirebiT sakmarisi monacemebi ar arsebobs.<br />
4.5.1. nrti komponenti<br />
- Tu pirveli rigis arT Seicav<strong>da</strong> ZDV + 3TC, maSin meore rigSi SesaZloa<br />
gamoyenebul iqnas ABC ddI–Tan kombinaciaSi (an TDF <strong>da</strong> moxdes ddI dozis<br />
modifikacia <strong>da</strong> mWidro monitoringi) (83) (CIII).<br />
- Tu pacients pirveli rigis Terapia utardebo<strong>da</strong> TDF an ABC, maT mimarT<br />
rezistentobis maRali albaTobis gaTvaliswinebiT meore rigSi<br />
sasargeblo iqneba ZDV (84) (BII). K65R mutacia, romelsac iwves TDF <strong>da</strong><br />
ABC, zrdis mgrZnobelobas ZDV–s mimarT (85, 86) (BII)..<br />
- 3TC agreTve sasargebloa mis mimarT rezistentobis dros, vinai<strong>da</strong>n mis<br />
mier gamowveuli 184V mutacia amcirebs virusis replikaciis unars <strong>da</strong>,<br />
agreTve, zrdis mgrZnobelobas ZDV mimarT.<br />
4.5.2 pi komponenti<br />
- Tu pirveli rigis Terapia Seicav<strong>da</strong> anrti-s, meore rigSi gamoyenebul<br />
un<strong>da</strong> iqnes pi.<br />
- pi-ebis umravlesoba Zlierdeba (bustirdeba) ritonaviris (RTV an /r)<br />
<strong>da</strong>bali doziT - 100mg 2-jer dReSi. ritonaviri TavisTavad pi-ia.<br />
ritonaviriT ar bustirdeba nelfinaviri, romelic Zlierdeba ara<br />
qimiurad, aramed – sakvebiT. bustirebis meqanizmia ritonaviris mier<br />
citoqrom P450 (CYP) 3A4 izoenzimis inhibireba. Sedegad izrdeba pi<br />
medikamentebis done, gar<strong>da</strong> nelfinavirisa (87) (BII).. ritonaviri<br />
gamoiyeneba mxolod sxva pi-ebis bustirebisTvis <strong>da</strong> ar aris efeqturi<br />
rogorc <strong>da</strong>moukidebeli arv medikamenti.<br />
- pi-ebs Soris gansxvaveba mdgomareobs maT mimarT rezistentobis<br />
ganviTarebisTvis saWiro mutaciebis ricxvSi <strong>da</strong> gverdiTi movlenebis<br />
profilSi.<br />
- yvelaze maRali barieri rezistentobis ganviTarebisTvis aReniSneba<br />
bustirebul lopinavirs (LPV/r) (88).<br />
- ritonaviriT bustirebuli atazanaviris (ATV/r), fosamprenviris (FPV/r),<br />
indinaviris (IDV/r) <strong>da</strong> seqvinaviris (SQV/r) rezistentobis profili<br />
umniSvnelod gansxvavdeba, risi <strong>klinikuri</strong> efeqtic mcirea an saerTod ar<br />
aris.<br />
- atazanaviri SesaZloa gamoyenebul iqnes ritonaviriT bustirebis<br />
gareSec (400 mg/dReSi).<br />
- nelfinaviri efeqturobiT naklebia sxva pi-ebTan Se<strong>da</strong>rebiT. Tumca misi<br />
gamoyeneba kargad dokumentirebulia orsulebSi. misi araefeqturobis<br />
dros SeirCeva D30N mutacia, romelic ar iwvevs jvaredin rezistnetobas<br />
sxva pi-ebis mimarT (89, 90) (BII)..<br />
- arCevis pi-ia LPV/r misi kargad dokumentirebuli efeqturobis gamo (91).<br />
evropaSi registrir<strong>da</strong> LPV/r axali formulireba, romelic gamoiyeneba 2-<br />
jer dReSi <strong>da</strong> ar esaWiroeba macivari (92) (AI).<br />
41
- ar warmoebulia LPV/r–is pir<strong>da</strong>piri Se<strong>da</strong>reba amprenaviris axal forma<br />
fosamprenavirTan, dReSi erTxel misaReb atazanavirTan (93) (CIII) <strong>da</strong><br />
seqvinaviris axal 500mg-ian formasTan, arsebobs mxolod arapir<strong>da</strong>piri<br />
monacemebi (94) (DIV). saWiroa <strong>da</strong>matebiTi kvlevebi.<br />
- pi-s SerCevisas gaTvaliswinebul un<strong>da</strong> iqnas gverdiTi movlenebi,<br />
Tanmxlebi <strong>da</strong>avadebebi, wamlebTan urTierTqmedeba <strong>da</strong> pacientis<br />
individualuri ganwyoba.<br />
cxrili 11 rekomendebuli meore rigis arv reJimi mozardebis<br />
mozrdilTaTvis<br />
pirveli rigis reJimi meore rigis reJimi<br />
LPV/r a (an ATV/r, SQV/r, FPV/r, IDV/r) + ddI + ABC<br />
an<br />
ZDV + 3TC + (EFV an NVP) LPV/r a (an ATV/r, SQV/r, FPV/r, IDV/r) + TDF + ABC<br />
an<br />
LPV/r a (an ATV/r, SQV/r, FPV/r, IDV/r) + TDF + (ZDV + 3TC) b<br />
LPV/r a (an ATV/r, SQV/r, FPV/r, IDV/r) + ddI + ABC<br />
TDF + FTC + (EFV an NVP) an<br />
LPV/r a (an ATV/r, SQV/r, FPV/r, IDV/r) + ddI + ZDV<br />
LPV/r a (an ATV/r, SQV/r, FPV/r, IDV/r) + ddI + ZDV<br />
ABC + 3TC + (EFV an NVP) an<br />
LPV/r a (an ATV/r, SQV/r, FPV/r, IDV/r) + ZDV + TDF (+ 3TC) b<br />
a LPV/r mocemulia rogorc upiratesi pi bustirebuli ritonaviriT, Tumca sxva pi-ebi<br />
SesaZloa gamoyenebul iqnas programis individualuri prioritetebis mixedviT.<br />
SesaZloa nebismieris gamoyeneba CamoTvlilTagan: ATV/r, SQV/r, FPV/r, <strong>da</strong> IDV/r. civi<br />
jaWvis ararsebobis SemTxvevaSi SesaZloa nelfinaviris gamoyeneba, Tumca igi<br />
ganixileba, rogorc naklebad potenturi, vidre bustirebuli pi-ebi.<br />
b ZDV <strong>da</strong> 3TC gamoyeneba naCvenebia strategiuli mizniT, radgan pirveli rigis<br />
araefeqturobis SemTxvevaSi maT mimarT virusi rezistentuli iqneba. kerZod, ZDV<br />
SesaZloa Tavi<strong>da</strong>n agvacilos an Seaferxos K65R mutaciis ganviTareba; xolo 3TC<br />
SeinarCunebs M184V mutacias, romelic amcirebis virusis replikaciis unars <strong>da</strong><br />
garkveulwilad zrdis sensitiurobas ZDV mimarT. un<strong>da</strong> aRiniSnos, rom am strategiis<br />
<strong>klinikuri</strong> Rirebuleba ar aris <strong>da</strong><strong>da</strong>sturebuli.<br />
- Tu ganviTar<strong>da</strong> pi-s Semcveli pirveli rigis arT-s araefeqturoba, meore<br />
rigis reJimis SerCeva efuZneba rezistentobis profils. Tu<br />
rezistentobis profili ar aris xelmisawvdomi, navaraudebi un<strong>da</strong> iqnas<br />
rezistentoba pirveli rigis reJimSi Semavali pi-s mimarT.<br />
pi-s Semcveli pirveli rigis arT-s araefeqturobis dros SesaZlo<br />
arCevania:<br />
- ZDV + 3TC + SQV/r (an ATV/r, FPV/r, IDV/r) ➔ ABC + ddI + LPV/r<br />
- ZDV + 3TC + LPV/r ➔ ABC + ddI + anrti (<strong>da</strong>runaviri (TMC11)) an bustirebuli<br />
tipranaviri (TPV/r)<br />
- kidev erTi arCevania ori pi-s kombinacia, magaliTad SQV + ATV/r (95). ar<br />
aris rekomendebuli ormagi pi-ebis kombniacaSi TPV/r gamoyeneba.<br />
4.6. ga<strong>da</strong>rCenis (Salvage) reJimebi<br />
<strong>da</strong><strong>da</strong>sturebuli meore rigis araefeqturobis SemTxvevebSi<br />
(virusologiuri, imunologiuri, <strong>klinikuri</strong> araefeqturobis<br />
kriteriumebiT) ganixileba ga<strong>da</strong>rCenis reJimebi. ga<strong>da</strong>rCenis reJimebSi<br />
42
igulisxmeba im medikamentebis kombinacia, romlebic SesaZloa muSaobdes<br />
an virusi maT mimarT iyos nawilobriv rezistentuli. yvela reJimi meore<br />
rigis Semdgom garTulebulia <strong>da</strong> moiTxovs arT-codnis maRal dones <strong>da</strong><br />
unar-Cvevebs. genotipuri rezistentobis testis monacemebi am situaciaSi<br />
aucilebelia. zogierT SemTxvevebSi ga<strong>da</strong>rCenis Terapiis <strong>da</strong>wyebamde<br />
umjobesia ramodenime TviT moc<strong>da</strong>, Tumca es strategia SesaZloa iyos<br />
saSiSi, kerZod, Tu CD4 ujredebis ricxvi <strong>da</strong>balia.<br />
o Tu SesaZlebelia, un<strong>da</strong> CaerTos ori medikamentis efeqturi<br />
kombinacia mag; SeWris inhibitori enfurvitidi (ENF) (96) (CIII),<br />
romelic iniSneba 2-jer dReSi kanqveSa aplikaciis saxiT <strong>da</strong> axali<br />
pi TPV (97,90) (CIII), an axali pi TCM114 (99,100) (CIII).<br />
o TPV- genetikuri barieri ufro maRalia, vidre LPV/r <strong>da</strong> monacemebi<br />
gviCveneben mis efeqturobas am ukanasknelTan Se<strong>da</strong>rebiT. dRevandel<br />
dRes TPV gamoiyeneba mxolod ga<strong>da</strong>rCenis Terapiis reJimebSi.<br />
o sxva SesaZleblobaa ori pi kombinacia (102-104) (CIII), gamonaklisia<br />
TPV, romelic ar un<strong>da</strong> gamoviyenoT sxva pi–sTan kombinaciaSi.<br />
4.7. mkurnalobis <strong>da</strong>gegmili Sewyveta<br />
bevri ewinaaRmdegeba arT <strong>da</strong>gegmil Sewyvetas, Tumca <strong>da</strong>sabuTeba<br />
SesaZlebelia. mag. CD4>500 mm 3 mudmivi done <strong>da</strong> virusis supresia mravali<br />
wlebis ganmavlobaSi abrkolebs oportunistuli infeqciebis<br />
ganviTarebas. mkurnalobis <strong>da</strong>gegmili Sewyveta, mkurnalobis reJimis<br />
araadeqvaturad <strong>da</strong>cvis SemTxvevaSi, Tavi<strong>da</strong>n agvacilebs rezistentuli<br />
Stamebis ganviTarebas. mkurnalobis Sewyvetis Semdeg CD4 limfocitebis<br />
ricxvi Camodis pre-arv Terapiis donemde , amdenad aucilebelia pirveli<br />
sami Tvis ganmavlobaSi CD4 limfocitebis ricxvis monitoringi. zogierT<br />
pacientSi limfocitebis ricxvi >350 mm 3 <strong>da</strong> <strong>da</strong>bali virusuli <strong>da</strong>tvirTva<br />
(1000-5000 asli/ml) Tveebisa <strong>da</strong> wlebis ganmavlobaSia SenarCunebuli.<br />
mkurnalobis <strong>da</strong>gegmili Sewyvetis sargebelze arasakmao informaciis<br />
arsebobis gamo janmos mier igi ar aris rekomendebuli.<br />
5.<strong>aiv</strong> inficirebul pacientTa <strong>klinikuri</strong> monitoringi<br />
mas Semdeg rac a<strong>da</strong>mians <strong>da</strong>esmeba <strong>aiv</strong> infeqciis diagnozi is<br />
uzrunvelyofili un<strong>da</strong> iyos monitoringiTa <strong>da</strong> movliT.<br />
5.1. laboratoriuli indikatorebi arT <strong>da</strong>wyebamde<br />
CD4 ujredebis ricxvi<br />
o gaimeoreT yovel 6 TveSi, Tu aris amouxsneli Sedegebi (CD4<br />
ujredebis swrafi <strong>da</strong>qveiTeba an oportunistuli infeqciebis<br />
ganviTareba);<br />
o Tu mimdinareobs msjeloba arT <strong>da</strong>wyebaze (CD4 ujredebi tolia<br />
an
maniSnebelia <strong>da</strong>avadebis duned progresirebis <strong>da</strong> piriqiT,<br />
maRali virusuli <strong>da</strong>tvirTva (>100 000 asli /ml) miuTiTebs<br />
<strong>da</strong>avadebis swraf progresirebaze.<br />
o ZiriTadi laboratoriuli testebi un<strong>da</strong> gakontroldes (cxr.<br />
12) yovel 6 TveSi, Tu ar aris raime sxva mizezi, mag. orsuloba.<br />
5.2. laboratoriuli maCvemeblebis monitoringi arv Terapiaze myof<br />
pacientebSi<br />
arT-s warmatebis pirveli maCvenebelia virusuli <strong>da</strong>tvirTva. imunuri<br />
pasuxi virusuli <strong>da</strong>tvirTvis Sedegia <strong>da</strong> mogvianebiT viTardeba. arT<br />
monitoringisTvis saukeTesoa orives gakontroleba.<br />
virusuli <strong>da</strong>tvirTva:<br />
o virusuli <strong>da</strong>tvirTva un<strong>da</strong> ganisazRvros mkurnalobis <strong>da</strong>wyebi<strong>da</strong>n<br />
4-8 kviraSi reJimis warmatebis SefasebisTvis. virusuli <strong>da</strong>tvirTva<br />
aragansazRvradi un<strong>da</strong> gaxdes 16-24 kviraSi.<br />
o virusuli <strong>da</strong>tvirTvis monitoringisTvis sasurveli intervalia 3-4-<br />
Tve.<br />
o Tu virusuli <strong>da</strong>tvirTva gax<strong>da</strong> aragansazRvradi (< 50 asli/ml) , is<br />
un<strong>da</strong> <strong>da</strong>rCes aragansazRvradi.<br />
o CD4 ujredebis ricxvi un<strong>da</strong> gakontroldes yovel 6 TveSi,<br />
<strong>klinikuri</strong> warumateblobis SemTxvevebis gar<strong>da</strong>.<br />
o ZiriTadi laboratoriuli testebi (cxr. 3 ) un<strong>da</strong> gakontroldes<br />
yovel 6 TveSi, Tu ar aris raime cvlilebebli arv Terapiis<br />
reJimSi.<br />
cxrili 12. laboratoriuli testebis sixSire ZiriTa<strong>da</strong>d <strong>da</strong> specifikuri<br />
arv-s reJimis gaTvaliswinebiT<br />
virusuli<br />
<strong>da</strong>tvirTva<br />
2 4 8 16 24 36 48<br />
sawyisi<br />
kvira kvira kvira kvira kvira kvira kvira<br />
X X X X X<br />
CD4<br />
ujredebis<br />
ricxvi<br />
sisxlis saerTo<br />
analizi<br />
RviZlis<br />
funqciuri<br />
sinjebi<br />
qolesterini<br />
trigliceridebi<br />
Tirkmlis<br />
funqciebi<br />
X X X (X) X<br />
X X X X<br />
(ZDV)<br />
X X X<br />
(NVP)<br />
X (PI)<br />
X<br />
X<br />
(TDF)<br />
X<br />
(TDF,<br />
IDV)<br />
X<br />
(NVP,<br />
ZDV,<br />
PI)<br />
X<br />
(NVP,<br />
PI)<br />
X<br />
(PI)<br />
X (X) X<br />
X (X) X<br />
X (X) X<br />
X: testebi, romlebic un<strong>da</strong> Catardes arv Terapiisgan <strong>da</strong>moukideblad;<br />
X<br />
(PI)<br />
44
X (arv): testebi, romlebic un<strong>da</strong> Catardes mocemuli preparatis<br />
arsebobisas arT reJimSi;<br />
(X): araucilebeli testebi.<br />
5.3. mkurnalobis reJimis <strong>da</strong>cvis monitoringi<br />
yvela pacienti, romelic imyofeba arT-ze mudmivad un<strong>da</strong> imyofebodnen<br />
meTvalyureobis qveS. sanam isini imyofebian mkurnalobis monitoringis<br />
qveS (ixileT <strong>da</strong>mateba 5), miRebuli meTodia stan<strong>da</strong>rtuli anketireba 14<br />
dReSi an TveSi erTxel.<br />
virusuli <strong>da</strong>tvirTvis cvlileba yovelTvis saWiroebs eqimis mier<br />
pacientTan erTad mkurnalobis reJimis ganxilvas. gamoiyeneba kiTxvari,<br />
romlis mixedviTac SeiZleba ganvsazRvroT <strong>da</strong>myoloba mkurnalobisadmi.<br />
mkurnalobis reJimis <strong>da</strong>cva 4-6 Tvis ganmavlobaSi saSualebas iZleva<br />
miRweul iqnas xangrZlivi imunovirusologiuri pasuxi (110) (AI).<br />
sxva<strong>da</strong>sxvagvari Careva SesaZlebelia, magram prioritetulia is reJimi,<br />
romelic adreul TveebSi iZleva arT-ze ukeTes pasuxs (110-114) (AI).<br />
mkurnalobis reJimis <strong>da</strong>cva SeiZleba iyos nawili rutinuli <strong>klinikuri</strong><br />
<strong>da</strong>kvirvebisa, romelsac axorcielebs yvela profesionali eqimi. yoveli<br />
vizitis dros eqimi un<strong>da</strong> <strong>da</strong>rwmundes, rom TiToeul pacients:<br />
o aqvs emociuri <strong>da</strong> fizikuri mxar<strong>da</strong>Wera<br />
o dRis ganmavlobaSi icavs wamlebis miRebis reJims<br />
o esmis, rom reJimis <strong>da</strong>rRveva gamoiwvevs rezistentobis<br />
ganviTarebas<br />
o gacnobierebuli un<strong>da</strong> hqondes, rom yvela doza droulad iqnas<br />
miRebuli<br />
o wamlebis miRebis dros Tavs un<strong>da</strong> grZnobdes komfortulad.<br />
o <strong>da</strong>icvas <strong>da</strong>niSnuleba<br />
o esmodes arv-s moqmedeba <strong>da</strong> gverdiTi efeqtebi.<br />
o icodes Tu rodis mimarTos eqims.<br />
sxva strategia moicavs:<br />
o depresiis <strong>mkurnaloba</strong>, raTa amaRldes mkurnalobis reJimis <strong>da</strong>cva<br />
<strong>da</strong> miRweul iqnas xangrZlivi Sedegi<br />
o wamlebis urTierTqmedebis <strong>da</strong> dozirebis menejmenti.<br />
o medikamentebis gacema mcire raodenobiT <strong>da</strong> xSiri intervalebiT,<br />
romelic aiolebs:<br />
1. problemebis droul gamovlenas, manam sanam ganviTardeba<br />
rezistentoba<br />
2. Semcirdes medikamentebis gacema <strong>da</strong> borotad gamoyeneba<br />
3. gamoyenebuli iqnas dReSi erTxel misaRebi, erTdoziani<br />
medikamentis kombinacia, rac xels Seuwyobs adreul etapze<br />
mkurnalobis <strong>da</strong>myolobas; <strong>da</strong><br />
45
4. <strong>mkurnaloba</strong>ze uSualo ze<strong>da</strong>mxedveloba, gansakuTrebiT<br />
hospitalSi<br />
o fsiqosocialuri <strong>da</strong>xmareba<br />
o pacients miewodos saxelmZRvanelo <strong>da</strong> broSurebi<br />
o pacientebis monawileoba <strong>da</strong>xmarebis jgufebSi<br />
5. 4. arv toqsiuroba <strong>da</strong> gverdiTi efeqtebis menejmenti<br />
gverdiTi efeqtebi xSiria arv Terapiis dros, gansakuTrebiT proteazas<br />
inhibitorebis miRebis dros (ix. cxrili 13).<br />
o lopinavir/ritonavirs <strong>da</strong> nelfinavirs SeuZliaT gamoiwvion diarea<br />
o lopinaviri/ritonaviris miReba asocirebulia hiperlipidemiasTan<br />
(gansakuTrebiT trigliceridebis momatebasTan)<br />
o cximebis metabolizmis <strong>da</strong>rRvevebi SeiZleba gamoiwvios TiTqmis<br />
yvela proteazas inhibitorebma<br />
o erTaderTi proteazas inhibitori, romelic gavlenas ar axdens<br />
lipidur cvlaze aris atazanaviri <strong>da</strong> atazanavir/ritonaviri.<br />
zogierT qveyanaSi atazanaviri mowodebulia mkurnalobis meore<br />
rigis sqemaSi<br />
o kardiovaskularuli garTulebebis riskis momateba saWiroebs<br />
Semdgom Seswavlas<br />
cxrili 13<br />
arv-s toqsiurobis <strong>da</strong><strong>da</strong>stureba <strong>da</strong> menejmenti<br />
ARV toqsiuroba menejmenti<br />
RviZlis nekrozi<br />
nevirapini (NVP) o cxeleba, gamonayari (50%),<br />
gulisreva, Rebineba,<br />
eozinofilia, alt, ast-s<br />
donis momateba<br />
o<br />
o Cveulebriv pirvel 6-18<br />
kviraSi, iSviaTad 48<br />
kviris Semdeg<br />
o<br />
o<br />
laqtat-acidozi<br />
maRli<strong>da</strong>n <strong>da</strong>bali<br />
riskisken:<br />
o stavudini<br />
di<strong>da</strong>nozinTan<br />
erTad<br />
o di<strong>da</strong>nozini<br />
o stavudini<br />
o zidovudini<br />
o<br />
o<br />
o<br />
nevirapinze myofi<br />
pacientebis 1-2%, qalebSi<br />
CD4 > 250 ; kacebSi CD4 ><br />
400-ze<br />
gulisreva, Rebineba,<br />
wonaSi <strong>da</strong>kleba, sisuste,<br />
pankreatiti,<br />
multiorganuli<br />
ukmarisoba,<br />
respiratoruli distres<br />
sindromi<br />
yoveli 1000 pacienti<strong>da</strong>n<br />
1-10 weliwadSi<br />
di<strong>da</strong>nozini <strong>da</strong> stavudini<br />
46<br />
o<br />
o<br />
o<br />
RviZlis funqciuri<br />
sinjebis monitoringi 2,<br />
4, 8, 16 kviraze <strong>da</strong><br />
Semdeg yovel 3 TveSi<br />
simptomuri <strong>mkurnaloba</strong><br />
RviZlis nekrozis<br />
<strong>mkurnaloba</strong>, calkeul<br />
klinikur SemTxvevebSi<br />
wamlebis Sewyveta<br />
laqtat-acidozis<br />
monitoringi Tu eWvia,<br />
inaxos adreuli<br />
indikatorebi<br />
(kreatinkinaza (CK)<br />
HCO3)<br />
acidozis samkurnalod<br />
mowodebulia<br />
bikarbonati<br />
abakaviriT,<br />
tenofoviriT,<br />
lamivudiniT,<br />
emtricitabiniT Secvla
maRali mgrZnobeloba<br />
abakaviri (ABC ) o xSirad aris cxeleba,<br />
gamonayari, aseve sisuste<br />
<strong>da</strong> gulisreva<br />
o 5%, iSviaTad 6 kviris<br />
Semdeg<br />
stivens-jonsis sindromi, epidermisis toqsiuri nekrozi<br />
nevirapini (NVP)<br />
efavirenzis <strong>da</strong>bali<br />
o cxeleba, buStukovani<br />
gamonayari, mialgia<br />
doziT<br />
o nevirapini 1%-Si,<br />
efavirenzi 0,1%-Si<br />
o<br />
o<br />
o<br />
o<br />
o<br />
kanze <strong>da</strong>kvirveba, ar<br />
SeiZleba <strong>da</strong>wyeba<br />
gamonayris<br />
sawinaaRmdego<br />
wamlebTan erTad.<br />
Sewydes abakaviris<br />
miReba <strong>da</strong> ar ganaxldes<br />
Tu diagnozi saeWvoa<br />
Seicvalos<br />
zidovudiniT,<br />
tenofoviriT an<br />
stavudiniT<br />
kanze <strong>da</strong>kvirveba<br />
antibiotikebis <strong>da</strong>niSvna<br />
Wrilobis samkurnalod<br />
pankreatiti<br />
maRli<strong>da</strong>n <strong>da</strong>bali<br />
riskisken:<br />
o stavudini<br />
di<strong>da</strong>nozinTan<br />
erTad<br />
o di<strong>da</strong>nozini<br />
o stavudini<br />
o<br />
o<br />
tkivili, lipazas maRali<br />
done<br />
di<strong>da</strong>nozini 1-7%, dozis<br />
SemcirebiT<br />
o<br />
o<br />
o<br />
lipazas donis<br />
monitoringi<br />
simptomuri <strong>mkurnaloba</strong>,<br />
parenteraluri kveba,<br />
wamlebis Sewyveta<br />
zidovudiniT an<br />
tenofoviriT an<br />
abakaviriT Secvla<br />
47
ARV toqsiuroba menejmenti<br />
nefrotoqsiuroba<br />
tenofoviri TDF o Tirkmlis<br />
ukmarisoba <strong>da</strong><br />
o kreatininis monitoringi,<br />
istoria Tirkmlis<br />
o<br />
fankonis sindromi<br />
ufro xSirad<br />
pacientebSi<br />
Tirkmlis<br />
disfunqciiT<br />
anemia<br />
zidovudini ZDV o anemia <strong>da</strong><br />
neitropenia (sustad<br />
Semcireba iTvleba<br />
normad<br />
zidovudinTan)<br />
o 1-4%, dozaze<br />
<strong>da</strong>mokidebulebiT<br />
periferiuli neiropaTia<br />
di<strong>da</strong>nozini, stavudini,<br />
zalcitabini<br />
cximovani atrofia<br />
stavudini, <strong>da</strong> sxva nrti<br />
o<br />
o<br />
o<br />
o<br />
kidurebis tkivili,<br />
paresTezia<br />
10-30% wlebis<br />
Semdeg<br />
loyisa <strong>da</strong><br />
kidurebis cximis<br />
ganleva<br />
xangrZlivad<br />
gamoyenebis<br />
SemTxvevaSi xSiria<br />
(mitoqondriuli<br />
toqsiuroba)<br />
cximovani akumulacia<br />
PI o matulobs mucelze<br />
gacximovneba,<br />
mkerdis zoma,<br />
o 20-80%<br />
o<br />
o<br />
o<br />
o<br />
o<br />
o<br />
o<br />
o<br />
o<br />
o<br />
o<br />
<strong>da</strong>avadebis Sesaxeb<br />
<strong>mkurnaloba</strong> simtomuria<br />
tenofoviris dozis<br />
koreqcia (saWiroa<br />
kreatininis klirensi:<br />
yovel meore dRes<br />
Seicvalos tenofoviri<br />
zidovudiniT, abakaviriT<br />
an stavudiniT<br />
sisxlis saerTo analizis<br />
monitoringi 2, 4, 8, 12<br />
kviraze. makrocitozi<br />
msubuqi anemiiT<br />
(hemoglobini 100 gr/l)<br />
xSiria<br />
<strong>mkurnaloba</strong> aris<br />
eriTropoetinis<br />
transfuzia (Zalze<br />
Zviria) an Seicvalos<br />
zidovudini sxva nrti<br />
(tenofoviri, abakaviri an<br />
stavudini)<br />
periferiuli nervuli<br />
sistemis kontroli<br />
<strong>mkurnaloba</strong> tkivilis<br />
kupireba, Seicvalos arT.<br />
Sewydes wamlebi an<br />
Seicvalos nrti<br />
(zidovudini, tenofoviri,<br />
abakaviri)<br />
monitoringi <strong>da</strong> sawyis<br />
mdgom. Se<strong>da</strong>reba<br />
Seicvalos stavudini<br />
tenofoviriT an<br />
abakaviriT. Tu atrofia<br />
Seuqcevadia plastikuri<br />
qirurgia naCvenebia<br />
Sefaseba <strong>da</strong> sawyis mdgom.<br />
Se<strong>da</strong>reba<br />
Seicvalos NNRTI-iT, Tu<br />
lipodistrofia/lipoatr<br />
ofia ar aris<br />
tolerantuli, naCvenebia<br />
plastikuri qirurgia<br />
nnrti>APV/fozamprenaviri<br />
FPV>abakaviriABC<br />
o makulur-papuluri<br />
gamonayari<br />
o 15% nnrti, APV 20%,<br />
abakaviri 5%<br />
o<br />
o<br />
cxelebis, RviZlis<br />
funqciuri sinjebis <strong>da</strong><br />
kreatinkinazas<br />
monitoringi<br />
sxva alergenebis<br />
gamoricxva<br />
(sulfametoqsazol/trime<br />
toprimi <strong>da</strong> sxva antibi.).<br />
gamonayari SeiZleba<br />
spontanurad gaqres arT-s<br />
48
transaminazebis elevacia<br />
anrti (all) <strong>da</strong> PIs (all) o auxsneli RviZlis<br />
funqciebis momateba<br />
o<br />
o<br />
8-15% PI <strong>da</strong> nnrti<br />
ufro xSirad<br />
pacientebSi<br />
qronikuli HBV <strong>da</strong><br />
HCV infeqciiT<br />
o<br />
o<br />
o<br />
o<br />
Semdeg<br />
Seicvalos nevirapini<br />
efavirenziT an piriqiT.<br />
Tu ar aris gaumjobeseba<br />
scadeT sxva reJimi<br />
ALT monitoringi yovel<br />
eqvs TveSi,<br />
gaTvaliswinebuli iqnas<br />
sxva faqtorebi (mag.<br />
wamlismieri hepatiti.<br />
momateba xSirad Tan<br />
axlavs nnrti <strong>da</strong> pi<br />
ganuwyvetel miRebas<br />
Sewydes nnrti <strong>da</strong> pi<br />
miReba<br />
ARV toqsiuroba menejmenti<br />
PIs (all),zidovudini<br />
ZDV,di<strong>da</strong>nizini ddI<br />
o<br />
o<br />
gulisreva <strong>da</strong> Rebineba,<br />
diarea<br />
xSiria<br />
centraluri nervuli sistemis (cns) toqsiuroba<br />
efavirenzi EFV o Ramis SfoTva,<br />
koncentraciis <strong>da</strong>rRveva,<br />
depresia (suicidisken<br />
midrekileba)<br />
o 50%<br />
insulin rezistentoba<br />
PIs (yvela magram ATV) o glukozis tolerantoba<br />
matulobs, glukoza<br />
matulobs uzmoze<br />
o 5%<br />
hiperlipidemia<br />
stavudini (d4T)>PIs (all<br />
but ATV)<br />
o lipidebis, qolesterolis,<br />
trigliceridebis<br />
momateba( am<br />
ukanasknelisTvis<br />
stavudini SeiZleba iyos<br />
wamyvani)<br />
o 0%<br />
49<br />
o<br />
o<br />
o<br />
o<br />
o<br />
o<br />
o<br />
o<br />
o<br />
o<br />
gamoiricxos sxva<br />
mizezi (imunuri<br />
rekonstituciis<br />
anTebiTi sindromi CMV<br />
kolitiT,<br />
kriptosporidiozi,<br />
mikrosporidiozi, arT-s<br />
<strong>da</strong>wyebi<strong>da</strong>n kvireebis<br />
Semdeg<br />
<strong>mkurnaloba</strong> aris<br />
loperamidiT Tu<br />
diareis sxva mizezi ar<br />
aris: metoklopramidi,<br />
zofrane gulisrevis <strong>da</strong><br />
Rebinebis dros<br />
pacientebis<br />
gafrTxileba,<br />
fsiqiatris<br />
konsultacia<br />
<strong>mkurnaloba</strong> Cveulebriv<br />
saWiro ar aris.<br />
aRniSnuli movlenebi<br />
g<strong>aiv</strong>lis 5-21 dReSi<br />
uzmoze glukozis<br />
monitoringi<br />
<strong>mkurnaloba</strong> dietiT <strong>da</strong><br />
metforminis an<br />
glitazonis miReba<br />
Seicvalos pi nnrti-iT<br />
lipidebis donis<br />
monitoringi arT-s<br />
<strong>da</strong>wyebi<strong>da</strong>n <strong>da</strong> Semdeg<br />
yovel eqvs TveSi<br />
<strong>mkurnaloba</strong> lipidebis,<br />
qolesterolis <strong>da</strong><br />
trigliceridis<br />
gaidlainebiT<br />
sifrTxilea saWiro<br />
urTierTzemoqmedebisas<br />
(ar SeiZleba<br />
simvastatini <strong>da</strong>
hiperbilirubinemia<br />
atazanaviri (ATV)<br />
>indinaviri ( IDV)<br />
o<br />
o<br />
bilirubinis momateba<br />
(SesaZlebelia qavili,<br />
araprolongirebuli RviZlis<br />
<strong>da</strong>zianeba, Seqcevadi<br />
xSiria<br />
o<br />
o<br />
lovastatini)<br />
bilirubinis <strong>da</strong><br />
<strong>klinikuri</strong> simtomebis<br />
monitoringi<br />
wamlebis Sewyveta Tu<br />
ar aris tolerantoba.<br />
Seicvalos pi.<br />
nefroliTiazi<br />
indinaviri (IDV) o muclis tkivili,<br />
hematuria, Tirkmlis<br />
kolika<br />
o 10-20%<br />
o<br />
o<br />
Sardis analizis <strong>da</strong><br />
kreatininis<br />
monitoringi<br />
<strong>mkurnaloba</strong> igivea rac<br />
nefroliTiazis dros<br />
50
ARV toqsiuroba menejmenti<br />
nefrotoqsiuroba<br />
tenofoviri TDF o Tirkmlis ukmarisoba <strong>da</strong><br />
fankonis sindromi<br />
o<br />
o<br />
ufro xSirad<br />
pacientebSi Tirkmlis<br />
disfunqciiT<br />
anemia<br />
zidovudini ZDV o anemia <strong>da</strong> neitropenia<br />
(sustad Semcireba<br />
iTvleba normad<br />
zidovudinTan)<br />
o 1-4%, dozaze<br />
<strong>da</strong>mokidebulebiT<br />
periferiuli neiropaTia<br />
di<strong>da</strong>nozini, stavudini,<br />
zalcitabini<br />
cximovani atrofia<br />
stavudini, <strong>da</strong> sxva nrti<br />
o<br />
o<br />
o<br />
o<br />
kidurebis tkivili,<br />
paresTezia<br />
10-30% wlebis Semdeg<br />
xSiria xangrZlivi<br />
gamoyenebis SemTxvevaSi<br />
(mitoqondriuli<br />
toqsiuroba)<br />
cximovani akumulacia<br />
PIs o matulobs mucelze<br />
gacximovneba, mkerdis<br />
zoma,<br />
o 20-80%<br />
o<br />
o<br />
o<br />
o<br />
o<br />
o<br />
o<br />
o<br />
o<br />
o<br />
o<br />
kreatininis monitoringi,<br />
istoria<br />
Tirkmlis <strong>da</strong>avadebis<br />
Sesaxeb<br />
<strong>mkurnaloba</strong> simto-muria<br />
tenofoviris dozis<br />
koreqcia (saWiroa<br />
kreatininis klirensi:<br />
yovel meore dRes<br />
Seicvalos tenofoviri<br />
zidovudiniT, abakaviri<br />
an stavudiniT<br />
sisxlis saerTo<br />
analizis monitoringi<br />
2, 4, 8, 12 kviraze.<br />
makrocitozi msubuqi<br />
anemiiT (hemoglobini<br />
100 gr/l) xSiria<br />
<strong>mkurnaloba</strong> aris<br />
eroTropoetinis<br />
transfuzia (Zalze<br />
Zviria) an Seicvalos<br />
zidovudini sxva nrti<br />
(tenofoviri, abakaviri<br />
an stavudini)<br />
periferiuli nervuli<br />
sistemis kontroli<br />
<strong>mkurnaloba</strong> tkivilis<br />
kupireba, Seicvalos<br />
arT. Sewydes wamlebi an<br />
Seicvalos nrti<br />
(zidovudini,<br />
tenofoviri, abakaviri)<br />
monitoringi <strong>da</strong> sawyis<br />
mdgom. Se<strong>da</strong>reba<br />
Seicvalos stavudini<br />
tenofoviriT an<br />
abakaviriT. Tu atrofia<br />
Seuqcevadia plastikuri<br />
qirurgia naCvenebia<br />
Sefaseba <strong>da</strong> sawyis<br />
mdgom. Se<strong>da</strong>reba<br />
Seicvalos NNRTI-iT,<br />
Tu<br />
lipodistrofia/lipoat<br />
rofia ar aris<br />
tolerantuli,<br />
naCvenebia plastikuri<br />
qirurgia<br />
nnrti>APV/fozamprenaviri<br />
FPV>abakaviriABC<br />
o makulur-papuluri<br />
gamonayari<br />
o 15% nnrti, APV 20%,<br />
abakaviri 5%<br />
transaminazebis elevacia<br />
anrti (all) <strong>da</strong> PIs (all) o auxsneli RviZlis<br />
funqciebis momateba<br />
o<br />
o<br />
8-15% PI <strong>da</strong> nnrti<br />
ufro xSirad<br />
pacientebSi qronikuli<br />
HBV <strong>da</strong> HCV infeqciiT<br />
51
ARV toqsiuroba menejmenti<br />
PIs (all),zidovudini<br />
ZDV,di<strong>da</strong>nizini ddI<br />
o<br />
o<br />
gulisreva <strong>da</strong> Rebineba,<br />
diarea<br />
centraluri nervuli sistemis (cns) toqsiuroba<br />
efavirenzi EFV o koncentracia depresia<br />
(suicidisken midrekileba)<br />
o 50%<br />
insulin rezistentoba<br />
PIs (all but ATV) o glukozis tolerantoba<br />
matulobs, glukoza<br />
matulobs<br />
o 5%<br />
hiperlipidemia<br />
stavudini (d4T)>PIs (all<br />
but ATV)<br />
o lipidebis qolesterini,<br />
trigliceridebi<br />
o % meryeobs<br />
hiperbilirubinemia<br />
atazanaviri (ATV)<br />
>indinaviri ( IDV)<br />
o<br />
o<br />
bilirubinis momateba<br />
(SesaZloa qavili, ar<br />
grZeldeba RviZlis<br />
<strong>da</strong>zianeba, Seqcevadia)<br />
xSirad cvalebadobs<br />
nefrolifiazi<br />
indinaviri (IDV) o muclis tkivili,<br />
hematuria, Tirkmlis<br />
kolika<br />
o 10-20%<br />
5.5 imunuri rekontituciis sindromi (irs)<br />
irs adgili aqvs arT sawyis etapze, ufro xSirad rodesac CD4
xSiri oportonistuli infeqciebia, magram cudi mkurnalobis SemTxvevaSi<br />
SesaZlebelia PCP ganviTardes (122) (BII). irs ganviTarebis Semdeg arT<br />
un<strong>da</strong> gagrZeldes oportunistuli infeqciebis <strong>mkurnaloba</strong>sTan erTad.<br />
SesaZlebelia prednizolonis <strong>da</strong>bali dozebi (20-60 mg dReSi). arT<br />
SesaZlebelia Sewydes Tu adgili aqvs oportunistuli infeqciebis<br />
mkurnalobis gverdiT efeqtebs an gamoxatulia ezofagiti (CMV,<br />
herpesuli <strong>infeqcia</strong>, kandidozi) tkiviliT.<br />
5.6. wamlebis urTierTqmedeba<br />
wamlebis urTierTqmedeba warmoadgens calke problemas arT-s dros.<br />
<strong>aiv</strong>/<strong>SidsiT</strong> inficirebulebi iReben ramdenime saxis medikamentebs, imis<br />
gamo, rom aqvT manifestirebuli <strong>da</strong>avadeba <strong>da</strong>/an Tanmxlebi <strong>da</strong>avadebebi.<br />
medikamentebis urTierTqmedebis miuxe<strong>da</strong>vad, maTi kombinaciis miReba<br />
SesaZlebelia kvlav gagrZeldes. miuxe<strong>da</strong>vad amisa gverdiTi efeqtebis<br />
gamovlenis SesaZlebloba maRalia <strong>da</strong> saWiroebs monitorings.<br />
kontraceptivebis miReba sariskoa.<br />
cxrilSi 14 <strong>da</strong> 15 ilustrirebulia aranukleozidis revers<br />
transkriftazas inhibitorebis <strong>da</strong> proteazas inhibitorebis<br />
urTierTmoqmedeba.<br />
cxrili 14.<br />
anrtis zemoqmedeba<br />
nnrti efeqti mniSvneloba<br />
EFV NPV<br />
+ ergotamini ++ (Tavi<strong>da</strong>n<br />
acileba)<br />
+ antiariTmulebi: lidokaini,<br />
++ (SeniSvna)<br />
amio<strong>da</strong>roni <strong>da</strong> sxva<br />
antikonvulsurebi: karbamazepini,<br />
+ +<br />
+ + fenitoini, fenobarbitali<br />
(+)c + itrakonazoli, ketokonazoli +<br />
+ ciklosporini, takrolizmusi,<br />
+ +<br />
rapamicini<br />
+ + + mi<strong>da</strong>zolami, alprazolami,<br />
+ +<br />
triazolami<br />
+ kalciumis arxis blokatorebi + +<br />
+ + sildenafili, vardenafili,<br />
+ +<br />
ta<strong>da</strong>lafili<br />
+ fentanili + +<br />
+ + metadoni + +<br />
+ + kontraceptivebi + +<br />
+ + rifampini, rifabutini + +<br />
+ + stivens jonsis sindromi + +<br />
+ + varfarini + +<br />
53
cxrili 15.<br />
proteazas inhibitorebi<br />
APV ATV IDV LPV NFV RTV SQV<br />
proteazas inhibitorebis zemoqmedeba<br />
efeqti<br />
+ fentanili, tramadoli,<br />
hidrokodoni<br />
+ + kodeini, morfini,<br />
metadoni<br />
+ + + + + + + amio<strong>da</strong>roni, lidokaini,<br />
flekainidi<br />
+ + + + + + karbamazepini,<br />
klonazepami, fenitoini,<br />
fenobarbitali<br />
+ + + + tricikluri<br />
antidepresantebi<br />
mniSvneloba<br />
+<br />
+<br />
+<br />
++ (Tavi<strong>da</strong>n<br />
acileba)<br />
+ + sxva antidepresantebi +<br />
+ loratadini + +<br />
+ atovaqvini +<br />
+ + + ++ + + ++ benzodiazepini + +<br />
+ beta blokatorebi +<br />
+ + + + + + + kalciumis arxis<br />
blokatorebi<br />
+ + + klaritromicini,<br />
eriTromicini, Tirkmlis<br />
+ + + + + klaritromicini,<br />
eriTromicini<br />
+<br />
+ +<br />
+ (SeniSvna)<br />
+ + + + kontraceptivebi + +<br />
+ + + + kortikosteroidebi +<br />
+ + + + + + + ciklosporini +<br />
+ + + + + + + ergot derivatebi ++ (Tavi<strong>da</strong>n<br />
+ ++ + + + + +<br />
protonuli dguSis<br />
inhibitorebi (PPIs)<br />
+<br />
acileba)<br />
+ (SeniSvna)<br />
(++, ATV-<br />
Tavi<strong>da</strong>n<br />
acileba)<br />
+ ++ + + + + + H2 antagonistebi ++ (SeniSvna)<br />
(++, ATV)<br />
++ (Tavi<strong>da</strong>n<br />
acileba)<br />
+ irinotekani ++ (Tavi<strong>da</strong>n<br />
acileba)<br />
+<br />
+ + + + + + + lovastatini,<br />
simvastatini<br />
+ + + + + ketokonazoli,<br />
itrakonazoli<br />
+ + + + + + + pimozidi ++ (Tavi<strong>da</strong>n<br />
acileba)<br />
+ + + + + + + rifampini ++ (Tavi<strong>da</strong>n<br />
+ + + + + + +<br />
rifabutini<br />
acileba)<br />
+ (SeniSvna,<br />
doze<br />
adjustment)<br />
+ + + + + + + sildenafili + +<br />
+ + + + + + + stiven jonsis sindromi ++ (Tavi<strong>da</strong>n<br />
acileba)<br />
+ tenofoviri + + (add RTV)<br />
+ + + Teopilini +<br />
+ + + + varfarini +<br />
54
cxrilebis wakiTxvis magaliTi<br />
1. cxrili 14 rigi 6: efavirenzi mkacrad zrdis dones: mi<strong>da</strong>zolamis,<br />
alfrazolamis <strong>da</strong> triazolamis, maSin roca nevirapinis doza<br />
amcirebs. zemoT xsenebuli faqtis <strong>klinikuri</strong> mniSvneloba<br />
mdgomreobs medikamentebis kvlav mowodebaSi.<br />
2. cxrili 15 rigi 4: abakaviri, indinavir/lopinaviri, nelfinaviri,<br />
ritonaviri <strong>da</strong> seqvinaviri zrdian karbamazepinis, klonazepamis,<br />
fenitoinis <strong>da</strong> fenobartialis dones, maSin roca es wamlebi<br />
amcireben proteazas inhibitorebis dones. <strong>klinikuri</strong> Rirebuleba<br />
imaSia, rom aseT kombinacias Tavi un<strong>da</strong> avaridoT.<br />
klinikur doneze Sesagrovebeli minimaluri monacemebis<br />
CamonaTvali<br />
klinikur doneze Sesagrovebeli minimaluri monacemebis CamonaTvali<br />
mniSvnelovania, rogorc mkurnalobis xelmisawvdomobisa <strong>da</strong><br />
Sedegianobis indikatori. aseTi indikatorebi exmareba menejers<br />
SesTavazos es servisi yvelas, vinc saWiroebs.<br />
CamoTvlili monacemebi un<strong>da</strong> Segrovdes klinikur doneze, rogorc<br />
regularuli sabaziso: (TveSi erTxel, kvartalSi an eqvs TveSi<br />
erTxel)<br />
o <strong>aiv</strong> pacientebis ricxvi, romelTac vxe<strong>da</strong>vT weliwadSi erTxel<br />
o <strong>aiv</strong> pacientebis ricxvi, romlebic ganixilebian arT-s<br />
kandi<strong>da</strong>tebad (CD4
O<strong>da</strong>mateba 1. ZiriTadi informacia <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis mkurnalobis<br />
<strong>da</strong> movlis personaluri istoriisTvis<br />
TariRi<br />
cxrili 16.<br />
CD4<br />
ujredebi/mm3 %<br />
ZiriTadi informacia <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis<br />
mkurnalobis <strong>da</strong> movlis personaluri istoriisTvis<br />
VL<br />
asli/ml<br />
rezistentoba<br />
(genotipi an<br />
fenotipi)<br />
56
<strong>da</strong>mateba2. jan<strong>da</strong>cvis msoflio organizaciis mier mowodebuli<br />
klinikuli stadia <strong>aiv</strong>/Sidsis mozardebsa <strong>da</strong> mozrdilebSi<br />
(Sua evropis regionis versia, a<strong>da</strong>mianebisTvis romelTa asaki<br />
>15welze, <strong>aiv</strong> pozitiuria an saxezea <strong>aiv</strong> infeqciis sxva<br />
laboratoriuli testebi)<br />
mwvave <strong>aiv</strong> <strong>infeqcia</strong><br />
o asimtomuri<br />
o mwvave retrovirusuli sindromi<br />
<strong>klinikuri</strong> stadia 1<br />
o asimtomuri<br />
o persistuli generalizebuli limfadenopaTia<br />
<strong>klinikuri</strong> stadia 2<br />
o seboreuli dermatiti<br />
o angularuli heiliti<br />
o ganmeorebiTi oraluri ulceracia (ori an meti epizodi eqvsi<br />
Tvis ganmavlobaSi)<br />
o herpes zosteri<br />
o respiratoruli traqtis ganmeorebiTi <strong>infeqcia</strong> (ori an meti<br />
epizodi eqvsi Tvis ganmavlobaSi, sinusiti, Sua otiti, bronqiti,<br />
faringiti, traqeiti)<br />
o frCxilebis sokovani <strong>infeqcia</strong><br />
<strong>klinikuri</strong> stadia 3<br />
o piris Rrus Tmovani leikoplakia<br />
o umizezo qronikuli faRaraTi erT Tveze meti<br />
o ganmeorebiTi oraluri kandidozi (ori an meti epizodi eqvsi<br />
Tvis ganmavlobaSi<br />
o sxva baqteriuli <strong>infeqcia</strong> (mag. pnevmonia, empiema, piomioziti,<br />
Zvlebis an saxsrebis <strong>infeqcia</strong>, meningiti, baqteriemia)<br />
o mwvave, nekrozuli, ulcerogenuli stomatiti, gingiviti an<br />
periodontiti)<br />
<strong>klinikuri</strong> stadia 4<br />
o filtvis tuberkulozi<br />
o eqstra pulmonuri tuberkulozi (limfadenopaTiis CaTvliT)<br />
o wonis umizezo <strong>da</strong>kargva (eqvsi Tvis ganmavlobaSi 10% meti)<br />
o <strong>aiv</strong> asocirebuli ganlevis sindromi<br />
o pnevmocisturi pnevmonia<br />
o ganmeorebiTi sxva an radiologiurad <strong>da</strong><strong>da</strong>sturebuli<br />
baqteriuli pnevmonia (ori an meti epizodi erT weliwadSi)<br />
o CMV retiniti (+koliti)<br />
o martivi herpes virusuli <strong>infeqcia</strong> (qronikuli an persistuli<br />
bolo erTi Tvis ganmavlobaSi)<br />
o encefalopaTia<br />
o <strong>aiv</strong>-Tan asocirebuli kardiomiopaTia<br />
57
o <strong>aiv</strong>-Tan asocirebuli nefropaTia<br />
o progresuli multifokaluri leikoencefalopaTia<br />
o kapoSis sarkoma <strong>da</strong> <strong>aiv</strong>_Tan <strong>da</strong>kavSirebuli avTvisebiani<br />
<strong>da</strong>avadebebi:<br />
1.toqsoplazmozi<br />
2.diseminirebuli sokovani <strong>infeqcia</strong> (mag. kandidozi,<br />
kokcidomikozi, histoplazmozi)<br />
3.kriptosporidozi<br />
4.kriptokokuli meningiti<br />
5.aratuberkulozuri mikobaqteriuli <strong>infeqcia</strong><br />
<strong>da</strong>mateba 3. rezistentobis testi<br />
rezistentobis testis Casatareblad saWiroa virusuli <strong>da</strong>tvirTva<br />
minimum 500-1000 asli/ml. testis Catareba SeuZlebelia, rodesac<br />
aRiniSneba virusis sruli supresia.<br />
genotipis rezistentobis testi <strong>da</strong>myarebulia virusis rnm-is mutaciis<br />
analizze. mutacia <strong>da</strong>mokidebulia virusis mgrZnobelobis cvlilebaze.<br />
es aris arapir<strong>da</strong>piri mtkiceba wamlis rezistentobisa. rezistentuli<br />
virusis populacia ar aris maRali <strong>da</strong> Seadgens mTeli populaciis 20%-s.<br />
fenotipis rezistentobis testi msgavsad mikrobiologiuri<br />
rezistentobis testisa, ikvlevs virusis replikaciis unars ujredebis<br />
kulturaSi sxva<strong>da</strong>sxva agentis arsebobisas <strong>da</strong> a<strong>da</strong>reben virusis veluri<br />
Stamis unarianobas. 50% inhibitoris koncentracia (IC50) aris wamlis<br />
potenciis markeri. testis Sedegi gviCvenebs mgrZnobelobis gansxvavebul<br />
xarisxs.<br />
rezistentobis romeli testi gamoviyenoT<br />
amJamad arsebuli yvela testi aris Zviri. genotipis testis Rirebuleba<br />
Seadgens 400 E, fenotipis _ 800 E (2005w). drom nimuSis aRebi<strong>da</strong>n Sedegis<br />
miRwevamde SeiZleba Seadginos ramdenime kvira. genotipis bazisuri testi<br />
saSualebas iZleva <strong>da</strong>igegmos mkurnalobis reJimi. pirveli <strong>da</strong> meore<br />
rigis mkurnalobis sqemebi ar saWiroebs Zvir fenotipis tests. rodesac<br />
gaurkvevelia arT-s istoria, sakmarisad cnobili mutacia, <strong>mkurnaloba</strong> ar<br />
aris Sedegiani, fenotipuri testis Catareba gamarTlebulia. yvela<br />
testis SemTxvevaSi un<strong>da</strong> gagrZeldes mkurnalobis arsebuli reJimi, sxva<br />
SemTxvevaSi swrafad ganviTardeba rezistentuli Stamebi. ar arsebobs<br />
stan<strong>da</strong>rtuli rekomen<strong>da</strong>ciebi romeli rezistentuli testebi ganiviyenoT,<br />
fenotipuri Tu genotipuri.<br />
58
<strong>da</strong>mateba 4. ZiriTadi informacia antiretrovirusuli mkurnalobis Sesaxeb<br />
cxrili 17. ZiriTadi informacia antiretrovirusuli mkurnalobis Sesaxeb<br />
arv abreviatura zoma dozebi SeniSvnebi gverdiTi efeqtebi rezistentobis profili<br />
(didi <strong>da</strong> mcire)<br />
nrti<br />
abakaviri ABC 300 mg 300 mg tab. orjer an<br />
600 mg erTxel<br />
di<strong>da</strong>noziri ddI 250 mg<br />
400 mg<br />
pacienti >60kg: 400 mg<br />
tab. erTxel<br />
pacienti 60kg: 40 mg<br />
kaps. orjer<br />
pacienti
arv abreviatura zoma dozebi SeniSvnebi gverdiTi<br />
efeqtebi<br />
nevirapini NVP 200 mg 200 mg tab. orjer pirveli 14 dRe 200 mg<br />
erTxel,Semdeg 200 mg<br />
orjer<br />
delavirdini DLV 200 mg<br />
100 mg<br />
200 mg x 2 tab. samjer an<br />
100 mg x 4 tab. samjer<br />
pi<br />
atazanaviri ATV 300 mg 300 mg erTxel<br />
+<br />
100 mg RTV erTxel<br />
fozamprenaviri FPV 700 mg 700 mg tab. orjer +<br />
100 mg kaps. RTV orjer<br />
indinaviri IDV 400 mg 400 mg kaps. orjer +<br />
100 mg kaps. RTV orjer<br />
lopinaviri/ LPV/r 133 mg/33 mg (133 mg/33 mg) x 3 kaps.<br />
rito-naviri<br />
200 mg/50 mg orjer an<br />
kombinacia<br />
(200 mg/50 mg) x 2 tab.<br />
nelfinaviri NFV 250 mg<br />
625 mg<br />
ritonaviri<br />
RTV<br />
100 mg<br />
orjer<br />
625 mg x 2 tab. orjer<br />
an 250 mg x 5 tab orjer<br />
seqvinaviri SQV<br />
500 mg 500 mg x 2 kaps. orjer<br />
+ 100 mg kaps. RTV orjer<br />
tipranaviri TPV 250 mg 250 mg x 2 kaps. orjer +<br />
100 mg x 2 kaps. RTV<br />
orjer<br />
ujredSi SeWris inhibitorebi<br />
enfuvirtidi ENF 90 mg 90 mg/ml kanqveSa<br />
ineqcia orjer<br />
60<br />
ar gamoiyeneba evropaSi<br />
iseTive dozireba, rogorc<br />
<strong>mkurnaloba</strong>ze myofi<br />
pacientebis. gamoiyeneba<br />
ritonavirTan erTad<br />
iseTive dozireba, rogorc<br />
<strong>mkurnaloba</strong>ze myofi<br />
pacientebis. gamoiyeneba<br />
ritonavirTan erTad<br />
gamoiyeneba ritonavirTan<br />
erTad<br />
Zveli monacemebiT<br />
saWiroa gayinva, axali<br />
monac. amis saWi-roeba ar<br />
aris; dReSi erTxel<br />
saWmelTan erTad Sewova<br />
izrdeba 270%-iT; ar<br />
Zlierdeba ritonavirTan<br />
erTad<br />
axali 500 mg tab. 2004<br />
wlamde iyo 200 mg. gamoiyeneba<br />
ritonavirTan erTad<br />
iseTive dozireba, rogorc<br />
<strong>mkurnaloba</strong>ze myofi<br />
pacientebis. ar gamoiyeneba<br />
pi-Tan erTad, gamoiyeneba<br />
ritonavirTan erTad<br />
ar aris recepri<br />
oraluri miRebisTvis<br />
gamonayari, RviZlis<br />
fermentebis<br />
momateba<br />
gamonayari, gastrointestinuri<br />
simptomebi, diarea<br />
bilirubinis<br />
momateba<br />
gamonayari, Tavis<br />
tkivili, diarea,<br />
dislipidemia<br />
Tirkmlis kenWi,<br />
dislipidemia<br />
diarea, meteorizmi,<br />
dislipidemia<br />
diarea, meteorizmi<br />
dislipidemia, RviZlis<br />
funqciebis momateba,<br />
diarea<br />
diarea <strong>da</strong> sxva<br />
gastrointestinuri<br />
simpromebi,<br />
dislipidemia<br />
dislipidemia,<br />
RviZlis funqciebis<br />
momateba, diarea<br />
kanis mxriv reaqcia<br />
(qavili, SeSupeba,<br />
tkivili)<br />
rezistentobis<br />
profili<br />
(didi <strong>da</strong> mcire)<br />
100I, 101E, 103N, 106A/M, 108I,<br />
179D/E, 181C/I, 188C/H,<br />
190A/S, 230L<br />
K103N/S, Y181C/I, P236L,<br />
G190A/S/E/Q/C, Y188L/H/C,<br />
V106A/M, K101E/P, M230L,<br />
K238T/N, F318L, V179D/E<br />
24I, 33F/I/V, 36I/L/V, 46I/L, 50L,<br />
54V/L/M/T, 82A/F/T/S, 84V, 88S,<br />
90M<br />
32I, 47V, 50V, 54L/M,<br />
82A/F/T/S, 84V<br />
24I, 32I, 36I, 46I/L, 54V,<br />
82A/F/T/S, 84V, 90M<br />
10I/R/V, 20M/R, 24I, 32I,<br />
33I/F/V, 46I/L, 53L, 54V/L, 63P,<br />
71V, 82A/F/T, 84V, 90M<br />
30N, 36I, 46I/L, 54V/L/M/T,<br />
82A/F/T/S, 84V, 88D/S, 90M<br />
48V, 53L, 54V/L, 82A/F/T, 84V,<br />
90M<br />
13L/V, 20M/R/V, 33F/I, 35D/N,<br />
36I, 45R, 46I/L, 47V, 54A/M/T/V,<br />
58E, 66F<br />
69K, 71I/K, 74P, 82F/L/T,<br />
84C/V, 90M, 91S
<strong>da</strong>mateba 5. mkurnalobis reJimis <strong>da</strong>cvis monitoringis meTodebi<br />
TviT-angariSi kargi markeria mkurnalobis reJimisa, magram ara<br />
saukeTeso. igi ga<strong>da</strong>Warbebulad afasebs arT-s efeqturobas, vidre sxva<br />
meTodi (128). aucilebelia pacientma gaamJRavnos problemebi pirispir<br />
saubrisas. es meTodi SeiZleba iyos mniSvnelovani pacientis rolis<br />
gaZlierebisTvis mkurnalobis <strong>da</strong>gegmvaSi, sapirispirod mowodebuli<br />
kontrolirebadi meTodisa.<br />
momwodeblis Sefaseba mwiria (129) <strong>da</strong> ar aris sasurveli.<br />
wamlis donis monitoringi aris Zviri <strong>da</strong> SeuZlebelia yvela arT-ze<br />
myofi pacientisTvis. es ar aris rutinuli meTodi mkurnalobis<br />
efeqturobis kontrolisTvis. im SemTxvevaSi, rodesac plazmaSi wamlis<br />
Semcveloba <strong>da</strong>balia, mkurnalobis efeqturoba ar ganixileba. plazmaSi<br />
wamlis done aris laboratoriuli markeri , romelic aCvenebs mag.<br />
zidovudinis miRebis reJimis <strong>da</strong>cvas.<br />
samedicino SemTxvevebis monitoringis sistema (MEMS) xSirad gamoiyeneba<br />
kvlevebis dros.<br />
tabletebis raodenoba <strong>da</strong> farmakologiuri dokumenti SeiZleba<br />
ganxilul iqnas, rogorc arasasurveli mcdeloba jan<strong>da</strong>cvis muSakebis<br />
mxri<strong>da</strong>n akontrolon <strong>mkurnaloba</strong>ze <strong>da</strong>myoloba. amitom pacients un<strong>da</strong><br />
movTxovoT, rom Tan hqondes <strong>da</strong>rCenili medikamentebi.<br />
tabletebis identifikaciis testi (PIT) warmoadgens axal meTods,<br />
romelic korelaciaSia TviTangariSTan (132). pacientebs un<strong>da</strong> SeeZloT im<br />
tabletebis amocnoba, romlebsac Rebuloben (132). pacientebma un<strong>da</strong><br />
amoarCion is tabletebi, romlebsac Rebuloben sxva msgavsi magram ara<br />
identuri arv “tyupi tabletebisgan”.<br />
surogati markerebis gamoyeneba realuria, magram <strong>da</strong>gvianebulia rodesac<br />
saxezea miRebis reJimis <strong>da</strong>rRveva. pi-s Semcvel reJimebze ganviTarebuli<br />
virusuli araefeqturoba <strong>da</strong>kavSirebulia miRebis reJimis <strong>da</strong>rRvevasTan<br />
<strong>da</strong> pi-ze genotipuri rezistentobis ararsebobasTan, rac miuTiTebs rom<br />
mkurnalobis araefeqturoba gamowveulia reJimis <strong>da</strong>rRveviT (133,134).<br />
mimwodeblebi Zalian frTxilad un<strong>da</strong> iyvnen am markerebis<br />
interpretaciisas <strong>da</strong> gaiTvaliswinon medikamentebis sisxlSi <strong>da</strong>bali<br />
donis sxva SesaZlo mizezebi (131).<br />
62
<strong>da</strong>mateba 6. antiretrovirusuli medikamentebis CamonaTvali<br />
cxrili 18<br />
antiretrovirusuli medikamentebis CamonaTvali<br />
saerTaSoriso<br />
saxeli (INN)<br />
nrti<br />
abakaviri (ABC)<br />
di<strong>da</strong>nozini (ddI)<br />
emtricitabini<br />
(FTC)<br />
lamivudini (3TC)<br />
mwarmoeblis saxeli<br />
epzikomi US, Kivexa United Kingdom<br />
(lamivudini/abakaviri)<br />
triziviri Europe, United Kingdom, US<br />
(zidovudini/lamivudini/abakaviri)<br />
ziageni United Kingdom, United States<br />
abaviri<br />
viroli<br />
viroli LZ (abkaviri/lamivudini/zidovudini)<br />
videqsi, videqsi EC<br />
dineqsi EC<br />
odiviri Kit (di<strong>da</strong>nozini/lamivudini/efavirenzi)<br />
aviro-Z<br />
virozini<br />
viro-Z<br />
diviri<br />
atripla (efavirenzi/emtricitabini/tenofoviri)<br />
emtriva<br />
truva<strong>da</strong> (tenofoviri/emtricitabini)<br />
kombiviri United Kingdom, United States<br />
(lamivudini/zidovuni)<br />
epiviri United Kingdom, United States, zefiqsi<br />
United Kingdom<br />
epzikomi United Kingdom, kiveqsa United Kingdom<br />
(lamivudini/abakaviri)<br />
triziviri United Kingdom, United States<br />
(zidovudini/lamivudini/abakaviri)<br />
lamivoqsi<br />
staveqsi-L (lamivudini/stavudini)<br />
staveqsi-LN (lamivudini/nevirapini/stavudini)<br />
zidoveqsi-L (lamivudini/zidovudini)<br />
zidoveqsi-LN (lamivudini/nevirapini/zidovudini)<br />
duoviri (lamivudini/zidovudini)<br />
duoviri-N (lamivudini/nevirapini/zidovudini)<br />
lamiviri<br />
odiviri Kit (di<strong>da</strong>nozini/lamivudini/efavirenzi)<br />
triomuni (lamivudini/nevirapini/stavudini)<br />
heptaviri<br />
lamistari 30, lamistari 40 (lamivudini/stavudini)<br />
nevilasti (lamivudini/nevirapini/stavudini)<br />
zidolami (lamivudini/zidovudini)<br />
virolami<br />
virokombi (lamivudini/zidovudini)<br />
virolansi (lamivudini/nevirapini/stavudini)<br />
virolisi (lamivudini/stavudini)<br />
virol LZ, abak-ALZ (abkaviri/lamivudini/zidovudini)<br />
farmaceptuli<br />
kompania<br />
GlaxoSmithKline<br />
Genixpharma<br />
Ranbaxy<br />
Bristol-Myers Squibb<br />
Ranbaxy (India)<br />
Thai Government<br />
Bristol-Myers Squibb<br />
Cipla<br />
GlaxoSmithKline<br />
Aurobindo<br />
Cipla<br />
Genixpharma<br />
Ranbaxy<br />
63
saerTaSoriso<br />
saxeli<br />
stavudini (d4T)<br />
tenofoviri (TDF)<br />
triple<br />
nuceozidi (TRZ)<br />
zidovudini (ZDV<br />
or AZT)<br />
nnrti<br />
delavirdini<br />
(DLV)<br />
efavirenzi (EFV)<br />
nevirapini (NVP)<br />
mwarmoeblis saxeli<br />
zeriti, zeriti XR<br />
staveqsi<br />
sraveqsi-L (lamivudini/stavudini)<br />
sraveqsi-LN (lamivudini/nevirapini/stavudini)<br />
staviri<br />
lamiviri-S (lamivudini/stavudini)<br />
triomuni (lamivudini/nevirapini/stavudini)<br />
lamistari (lamivudini/stavudini)<br />
nevilasti (lamivudini/nevirapini/stavudini)<br />
stagi<br />
staviri<br />
avostavi<br />
triviro-LNS (lamivudini/nevirapini/stavudini)<br />
virolansi (lamivudini/nevirapini/stavudini)<br />
virolisi, koviro (lamivudini/stavudini)<br />
virostavi<br />
truva<strong>da</strong> (tenofoviri/emtricitabini)<br />
vireadi (tenofoviri)<br />
atripla (efavirenzi/emtricitabini/tenofoviri)<br />
triziviri United Kingdom, United States<br />
(zidovudini/lamivudini/abakaviri)<br />
kombiviri United Kingdom, United States (lamivudini<br />
/zidovudini)<br />
retroviri United Kingdom, United States<br />
triziviri United Kingdom, United States<br />
(zidovudini/lamivudini/abakaviri)<br />
zidoveqsi<br />
zidoviri<br />
duoviri (lamivudini /zidovudini)<br />
zido-H (zidovudini)<br />
antiviri<br />
aviro-Z<br />
virokombi (lamivudini /zidovudini)<br />
viroli LZ (abakaviri/lamivudini/zidovudini)<br />
viro-Z<br />
reskriptori<br />
Sustiva Europe, United Kingdom, Stocrin Australia, Europe,<br />
Latin America, South Africa<br />
atripla (efavirenzi/emtricitabini/tenofoviri)<br />
viranzi<br />
efaviri<br />
estiva<br />
efferveni<br />
viramuni<br />
nevireqsi<br />
staveqsi LN (lamivudini/nevirapini/stavudini)<br />
duoviri-N (lamivudini/nevirapini/zidovudini)<br />
nevimuni<br />
triomuni (lamivudini/nevirapini/stavudini)<br />
nevilasti (lamivudini/nevirapini/stavudini)<br />
gpoviri<br />
farmaceptuli<br />
kompania<br />
Bristol-Myers Squibb<br />
Aurobindo<br />
Cipla<br />
Genixpharma<br />
GPO (Thailand)<br />
Ranbaxy<br />
Gilead Sciences<br />
Bristol-Myers Squibb<br />
GlaxoSmithKline<br />
GlaxoSmithKline<br />
Aurobindo<br />
Cipla<br />
Genixpharma<br />
GPO (Thailand)<br />
Ranbaxy<br />
Pfizer, Inc.<br />
Bristol-Myers Squibb<br />
Aurobindo<br />
Cipla<br />
Genixpharma<br />
Ranbaxy<br />
Boehringer Ingelheim<br />
Aurobindo<br />
Cipla<br />
Genixpharma<br />
GPO (Thailand)<br />
64
saerTaSoriso saxeli mwarmoeblis saxeli farmaceptuli<br />
kompania<br />
nevipani<br />
triviro LNS (lamivudini/nevirapini/stavudini)<br />
Ranbaxy<br />
virolansi (lamivudini/nevirapini/stavudini)<br />
zidoveqsi-LN (lamivudini/nevirapini/zidovudini)<br />
Fusion Inhibitors<br />
enfuvirtidi, T-20 fuzeoni Roche<br />
Pharmaceuticals &<br />
Trimeris, Inc.<br />
proteazas inhibitorebi<br />
amprenaviri (APV) Agenerase United Kingdom, United States GlaxoSmithKline<br />
atazanaviri (ATV) Reyataz Europa, US, Zreva<strong>da</strong> Bristol-Myers Squibb<br />
fosamprenaviri (FPV) leqsiva US, telziri United Kingdom GlaxoSmithKline<br />
and Vertex<br />
Indiraviri (IDV)<br />
kriqsivani<br />
Merck & Co.<br />
indiveqsi<br />
Aurobin<strong>da</strong><br />
indiviri<br />
Cipla<br />
indiviri<br />
Genixpharma<br />
virodini<br />
Ranbaxy<br />
lopinaviri/ritonaviri kaletra<br />
Abbott Laboratories<br />
kombinacia (LPV/r)<br />
nelfinaviri (NFV) viracepti<br />
Pfizer, Inc., Roche<br />
Pharmaceuticals<br />
nelveqsi<br />
Aurobin<strong>da</strong><br />
nelviri<br />
Cipla<br />
nelfini<br />
Genixpharma<br />
nefaviri<br />
Ranbaxy<br />
ritonaviri (RTV) norviri<br />
Abbott Laboratories<br />
ritoviri<br />
Hetero/Genix<br />
seqvinaviri (SQV)<br />
<strong>da</strong>mateba 7. leqsikoni<br />
Fortovase europe, United Kingdom, United States<br />
Invirase United Kingdom, United States<br />
65<br />
Roche<br />
Pharmaceuticals<br />
mkurnalobis reJimis <strong>da</strong>cva. rodesac wamlis dozis 95%-ia miRebuli<br />
saubaria mkurnalobisadmi <strong>da</strong>myolobaze. am maCveneblis qvemoT<br />
saubaria mkurnalobis reJimis <strong>da</strong>rRvevaze.<br />
foni bazisuri nawilia arT mkurnalobisa, romelic Cveulebriv<br />
Seicavs or nrti-s, romelic Tavis mxriv fonia proteazas inhibitoris<br />
an pi-s <strong>da</strong> SeWris inhibitorisTvis. termini “optimaluri foni”<br />
gulisxmobs problemis regulirebas nrti-sTvis, romelic<br />
<strong>da</strong>myarebulia rezistentobis testis Sedegze.<br />
medegianoba aris mkurnalobis reJimis <strong>da</strong>cvis Zveli termini.<br />
genetikuri barieri gamoxatavs virusis mutaciis im raodenobas,<br />
romelic saWiroa wamlebis mimarT rezistentobis ganviTarebisTvis.<br />
rezistentoba erTi mutaciiT niSnavs <strong>da</strong>bal genetikur bariers.<br />
rezistentoba aTi mutaciiT niSnavs Zalian maRal genetikur bariers,<br />
Tumca aseTi <strong>da</strong>xasiaTeba SeiZleba Seicvalos.<br />
maRali mutacia warmoadgens cvlilebebs virusis rnm-Si, romelic<br />
ganapirobebs rezistentobas arT-s wamlebze an mTlian klasze.
mcire mutacia muSaobs kombinaciaSi. igi SesaZloa gaxdes wamyvani<br />
rezistentobis ganviTarebaSi, an ewinaaRmdegebodes sxva araxelsayrel<br />
did an mcire mutacias.<br />
nukleozidis analogis mutacia (NAMs) mJRavndeba jvaredini<br />
rezistentobiT umetes nrti-sTvis.<br />
wertilovani mutacia warmoadgens erT cvlilebas rnm-is jaWvSi, risi<br />
Sedegic aris rezistentobis ganviTareba wamlis an wamlebis mTeli<br />
klasis mimarT. magaliTad: arT-s mkurnalobis dros 103 wertilovani<br />
mutacia niSnavs mutacias mTeli nrti-is mimarT.<br />
rezistentoba aris Sedegi rnm-is jaWvSi aminomJavebis Tanamimdevrobis<br />
cvlilebis, rac xdeba <strong>aiv</strong>-is “Raribi” replikaciis mizezi.<br />
cvlilebaTa umravlesoba ganapirobebs virusis sikvdils, zogierTi<br />
cvlilebis Sedegad ki virusi iZens unars gaumklavdes arT-s <strong>da</strong><br />
ga<strong>da</strong>rCes. mkurnalobis warmatebisTvis sasurvelia arT-s <strong>da</strong>wyebamde<br />
virusuli replikaciisa <strong>da</strong> rezistentobis testis Catareba.<br />
rezistentobis zogierTi Sedegi saboloo jamSi gamosadegia.<br />
Timidinis analogebis mutacia (TAMs) aris Sedegi zidovudiniT<br />
mkurnalobis.<br />
<strong>da</strong>mateba 8. horizonts miRma<br />
arT-s kvleva grZeldeba. virusis axal mutacias <strong>da</strong> rezistentobas<br />
adgili aqvs regularulad _ rac qmnis axal warmodgenas wamlebisa<br />
<strong>da</strong> virusis urTierTobis Sesaxeb.<br />
qvemoT moyvanilia zogierTi ukanaskneli antiretrovirusuli<br />
preparatebi, romlebic mowonebulia an gadis gamoc<strong>da</strong>s kombinaciaSi<br />
Zvel medikamentebTan.<br />
o dReSi erTxel fiqsirebuli doza kombinaciiT _ tenifoviri +<br />
emtricitabini + efavirenzi ufro efeqturia, vidre<br />
stan<strong>da</strong>rtuli kombinacia zidovudini + lamivudini + efavirenzi<br />
(40).<br />
o etravirini warmoadgens axal nnrti, romelsac aqvs didi<br />
potenciali, miuxe<strong>da</strong>vad mutaciisa, ramac SeiZleba ganapirobos<br />
nnrti-s klasis rezistentobis ganviTareba (135).<br />
o <strong>da</strong>runaviri (TMC 114) axali proteazas inhibitoria, romelsac<br />
gaaCnia maRali genetikuri barieri, vidre<br />
lopinavir/ritonavirs, rezistentobis ganviTareba ufro nela<br />
xdeba, vidre nelfinaviris, APV, an lopinavir/ritonaviris<br />
SemTxvevaSi. <strong>da</strong>runaviri xelmisawvdomia farTod xelmisawvdomi<br />
programisTvis (EAP) (136). is axlaxan <strong>da</strong>mtkicebul iqna FDA-s<br />
mier.<br />
o kapravirini warmoadgens meore Taobis nnrti-s, romelic bevrad<br />
efeqturia miuxe<strong>da</strong>vad nnrti-s klasikuri rezistentobisa.<br />
o axali koreceptoris inhibitorebi kvlevis meore fazaSia.<br />
CXCR4 <strong>da</strong> CCR5, romlebic gamoxataven virusebs, brZoloben<br />
wamlebTan, romlebsac SeuZliaT gamiowvion erTis an orives<br />
inhibicia. axali testi koreceptorebis eqspresiisa saWiroa<br />
mkurnalobis dros. gverdiTi efeqtebi amJamad SezRudulia,<br />
Tumca sawyisi gamocdilebiT am axal klasisTvis aRmoCenilia<br />
kardiotoqsiuri efeqti. aRiareba SeiZleba moxdes 2007 wels.<br />
66
gamoyenebuli literaturis CamonaTvali:<br />
1. Palella FJ Jr et al. Declining morbidity and mortality among patients with advanced human<br />
immunodeficiency virus infection. HIV Outpatient Study Investigators. The New England Journal of<br />
Medicine, 1998, 338(13):853–860.<br />
2. Sterne JA et al. Long-term effectiveness of potent antiretroviral therapy in preventing AIDS and death:<br />
a prospective cohort study. The Lancet, 2005, 366(9483):378–384.<br />
3. Lewden C. Responders to antiretroviral treatment over 500 CD4/mm³ reach same mortality rates as<br />
general population: APRICO and Aquitaine Cohorts. 10th European Aids Conference, Dublin, 17–20<br />
November, 2005 (Abstract PE18.4/8).<br />
4. Bartlett JG, Gallant JE. 2003 Medical Management of HIV Infection. Johns Hopkins University, Division<br />
of Infectious Disease and AIDS Service. Baltimore, 2003 (http://www.hopkins-aids.edu/publications/<br />
book/03MMHIV1to3.pdf accessed 11 September 2006).<br />
5. Wilson IB et al. Quality of HIV care provided by nurse practitioners, physician assistants and physicians.<br />
Annals of Internal Medicine, 2005, 143(10):729–736.<br />
6. Aberg JA et al. Primary care guidelines for the management of persons infected with human<br />
immunodeficiency virus: recommen<strong>da</strong>tions of the HIV Medicine Association of the Infectious Diseases<br />
Society of America. Clinical Infectious Diseases, 2004, 39:609–629.<br />
7. Mellors JW et al. Plasma viral load and CD4+ lymphocytes as prognostic markers of HIV-1 infection.<br />
Annals of Internal Medicine,1997, 126(12):946–954.<br />
8. Savès M et al. Risk factors for coronary heart disease in patients treated for human immunodeficiency<br />
virus infection compared with the general population. Clinical Infectious Diseases, 2003, 37(2):292–<br />
298.<br />
9. Friis-Moller N et al. Combination antiretroviral therapy and the risk of myocardial infarction. The New<br />
England Journal of Medicine, 2003, 349(21):1993–2003.<br />
10. Pragna Patel. Incidence of AIDS defining and non-AIDS defining malignancies among HIV-infected<br />
persons. 13th Annual Conference on Retroviruses and Opportunistic Infections (13th CROI), Denver,<br />
5–8 February 2006 (Poster 813).<br />
11. HIV testing methods. Geneva, Joint United Nations Programme on HIV/AIDS (UNAIDS), 1997 (UNAIDS<br />
Technical Up<strong>da</strong>te WC 503.1).<br />
12. Mulcahy F et al. CD4 counts in pregnancy do not accurately reflect the need for long-term HAART.<br />
13th Annual Conference on Retroviruses and Opportunistic Infections (CROI), Denver, 5–8 February<br />
2006 (Abstract 704b).<br />
13. Hawkins D et al. Guidelines for the management of HIV infection in pregnant women and the prevention<br />
of mother-to-child transmission of HIV. HIV Medicine, 2005, 6:107–148.<br />
14. Friis-Moller N et al. Exposure to PI and NNRTI and risk of myocardial infarction: results from the D:<br />
A:D study. 13th Annual Conference on Retroviruses and Opportunistic Infections (CROI), Denver, 5–8<br />
February 2006 (Abstract 144).<br />
15. Markowity M et al. Infection with multidrug resistant, dual-tropic HIV-1 and rapid progression to AIDS:<br />
a case report. The Lancet, 2005, 365(9464):1031–1038.<br />
16. Urbina A, Jones K. Crystal methamphetamine, its analogues, and HIV infection: medical and psychiatric<br />
aspects of a new epidemic. Clinical Infectious Diseases, 2004, 38(6):890–894.<br />
17. Gregory M et al. Illicit drug use and HIV-1 disease progression: a longitudinal study in the era of highly<br />
active antiretroviral therapy. American Journal of Epidemiology, 2006, 163(5):412–420.<br />
18. Markowitz M et al. Infection with multidrug resistant, dual-tropic HIV-1 and rapid progression to AIDS:<br />
a case report. The Lancet, 2005, 365(9464):1031–1038.<br />
19. Kassutto S et al. Longitudinal analysis of clinical markers following antiretroviral therapy initiated during<br />
acute or early HIV type 1 infection. Clinical Infectious Diseases, 2006, 42:1024–1031.<br />
20. The EACS Euroguidelines Group. European guidelines for the clinical management and treatment of<br />
HIV-infected adults in Europe. AIDS, 2003, 17(Suppl.):S3–S26.<br />
21. British HIV Association guidelines for the treatment of HIV-infected adults with antiretroviral therapy.<br />
London, British HIV Association, 2003 (http://www.bhiva.org/guidelines/2003/hiv/index.html, accessed<br />
30 May 2006).<br />
22. Guidelines for the use of antiretroviral agents in HIV-1 infected adults and adolescents. Bethes<strong>da</strong>,<br />
United States Department of Health and Human Services (DHSS), 2004.1-35 patient evaluation and antiretroviral<br />
treatment for adults and adolescents<br />
23. Salzberger B et al. German-Austrian recommen<strong>da</strong>tions for the antiretroviral therapy on HIV-infections.<br />
European Journal of Medical Research, 2004, 9:491–504<br />
24. Egger M et al. Prognosis of HIV-1-infected patients starting highly active antiretroviral therapy: a<br />
collaborative analysis of prospective studies. The Lancet, 2002, 360(9327):119–129.<br />
67
25. Phillips AN et al. Viral load outcome of non-nucleoside reverse transcriptase inhibitor regimens for<br />
2203 mainly antiretroviral-experienced patients. AIDS, 2001, 15(18):2385–2395.<br />
26. Sterling TR et al. Improved outcomes with earlier initiation of highly active antiretroviral therapy among<br />
human immunodeficiency virus-infected patients who achieve durable virologic suppression: longer<br />
follow-up of an observational cohort study. Journal of Infectious Diseases, 2003, 188(11):1659–1665.<br />
27. Opravil M et al. Clinical efficacy of early initiation of HAART in patients with asymptomatic HIV<br />
infection and CD4 cell count >350 x 10(6) /l. AIDS, 2002, 16(10):1371–1381.<br />
28. Gras L et al. Predictors of changes in CD4 cell count seven years after starting HAART. 13th Annual<br />
Conference on Retroviruses and Opportunistic Infections (CROI), Denver, 5–8 February 2006 (Abstract<br />
530).<br />
29. Palella FJ Jr et al. Survival benefit of initiating antiretroviral therapy in HIV-infected persons in different<br />
CD4+ cell strata. Annals of Internal Medicine, 2003, 138(8):620–626.<br />
30. Keruly J et al. Increases in CD4 cell count to five years in persons with sustained virologic suppression.<br />
13th Annual Conference on Retroviruses and Opportunistic Infections (CROI), Denver, 5–8 February<br />
2006 (Abstract 529).<br />
31. Wensing AMJ, et al. Analysis from more than 1800 newly diagnosed patients with HIV from 17 European<br />
countries shows that 10% of the patients carry primary drug resistance: the CATCH study. The 2nd<br />
IAS Conference on HIV Pathogenesis and Treatment, International AIDS Society and ANRS, Paris, 13<br />
July 2003 (Abstract LB1).<br />
32. Ross L et al. Prevalence of antiretroviral drug resistance and resistance mutations in antiretroviral therapy<br />
(ART) n<strong>aiv</strong>e HIV infected individuals from 40 US cities. 44th Interscience Conference on Antimicrobial<br />
Agents and Chemotherapy (ICAAC), Washington, 30 October–2 November 2004 (Abstract<br />
H-173).<br />
33. De Mendoza C et al. Evidence for a different transmission efficiency of viruses with distinct drug-reistance<br />
genotypes. 12th International Drug Resistance Workshop, Los Cabos, Mexico, 10–13 June 2003<br />
(Abstract 130).<br />
34. Grant GM et al. Declining nucleoside reverse transcriptase inhibitor primary resistance in San Francisco<br />
2000–2002. 12th International Drug Resistance Workshop, Los Cabos, Mexico, 10–13 June 2003<br />
(Abstract 120).<br />
35. Babic DZ et al. Prevalence of antiretroviral drug resistance mutations and HIV-1 non-B subtypes in<br />
newly diagnosed drug-n<strong>aiv</strong>e patients in Slovenia, 2000–2004. Virus Research, 2006, 118(1–2):156–<br />
163.<br />
36. Cane P et al. Time trends in primary resistance to HIV drugs in the United Kingdom: multicentre<br />
observational study. BMJ, 2005, 331(7529):1368.<br />
37. de Mendoza C et al. Antiretroviral recommen<strong>da</strong>tions may influence the rate of transmission of drug<br />
resistant HIV type 1. Clinical Infectious Diseases, 2005, 41(2):227–232.<br />
38. Daar ES, Richman DD. Confronting the emergence of drug-resistant HIV type 1: impact of antiretroviral<br />
therapy on individual and population resistance. AIDS Research and Human Retroviruses, 2005,<br />
21(5):343–357.<br />
39. McDoll et al. Emtricitabine and 3TC: interchangeable A systemic review. 10th European AIDS<br />
Conference (EACS), Dublin, 17–20 November 2005 (Poster 7.3/17).<br />
40. Gallant JE et al. Tenofovir DF, emtricitabine, and efavirenz vs. zidovudine, lamivudine, and efavirenz<br />
for HIV. The New England Journal of Medicine, 2006, 354(3):251–260.<br />
41. DeJesus E et al. Abacavir versus zidovudine combined with lamivudine and efavirenz, for the treatment<br />
of antiretroviral-n<strong>aiv</strong>e HIV-infected adults. Clinical Infectious Diseases, 2004, 39(7):1038–1046.<br />
42. Barrios A et al. Paradoxical CD4+ T-cell decline in HIV-infected patients with complete virus suppression<br />
taking tenofovir and di<strong>da</strong>nosine. AIDS, 2005, 19(6):569–575.<br />
43. Saag MS et al. Efficacy and safety of emtricitabine vs stavudine in combination therapy in antiretroviraln<strong>aiv</strong>e<br />
patients: a randomized trial. JAMA, 2004, 292(2):180–189.<br />
44. Bonnet F et al. Risk factors for hyperlactataemia in HIV-infected patients, Aquitaine Cohort, 1999–<br />
2003. Antiviral Chemistry & Chemotherapy, 2005, 16(1):63–67. 1-36 HIV/AIDS TREATMENT AND CARE CLINICAL<br />
PROTOCOLS FOR THE WHO EUROPEAN REGION<br />
45. Mallon PW et al. A prospective evaluation of the effects of antiretroviral therapy on body composition<br />
in HIV-1-infected men starting therapy. AIDS, 2003, 17(7):971–979.<br />
46. Shah SS, Rodriguez T, McGowan JP. Miller Fisher variant of Guillain-Barré syndrome associated with<br />
lactic acidosis and stavudine therapy. Clinical Infectious Diseases, 2003, 36(10):131–133.<br />
47. Bernasconi E et al. Abnormalities of body fat distribution in HIV-infected persons treated with<br />
antiretroviral drugs: The Swiss HIV Cohort Study. Journal of Acquired Immune Deficiency Syndromes,<br />
1999, 31(1):50–55.<br />
48. Gulick RM et al. Triple-nucleoside regimens versus efavirenz-containing regimens for the initial treatment<br />
68
of HIV-1 infection. The New England Journal of Medicine, 2004, 350(18):1850–1861.<br />
49. Staszewski S et al. Efavirenz plus zidovudine and lamivudine, efavirenz plus indinavir, and indinavir<br />
plus zidovudine and lamivudine in the treatment of HIV-1 infection in adults. Study 006 Team. The New<br />
England Journal of Medicine, 1999, 341(25):1865–1873.<br />
50. Bartlett JA et al. Abacavir/lamivudine in combination with efavirenz, amprenavir/ritonaviror stavudine:<br />
ESS40001 (CLASS) preliminary 48 weeks results. 14th International AIDS Conference, Barcelona,<br />
July 2002 (Abstract TuOrB1189).<br />
51. van Leeuwen R et al. A randomized trial to study first-line combination therapy with or without a protease<br />
inhibitor in HIV-1–infected patients. AIDS, 2003, 17(7):987–999.<br />
52. Calza L et al. Substitution of nevirapine or efavirenz for protease inhibitor versus lipid-lowering therapy<br />
for the management of dyslipi<strong>da</strong>emia. AIDS, 2005, 19(10):1051–1058.<br />
53. Sheran M. The nonnucleoside reverse transcriptase inhibitors efavirenz and nevirapine in the treatment<br />
of HIV. HIV Clinical Trials, 2005, 6(3):158–168.<br />
54. Palella FJ, Delaney KM, Moorman AC. Declining morbidity and mortality among patients with advanced<br />
human immunodeficiency virus infection. The New England Journal of Medicine, 1998,<br />
338:853–860.<br />
55. Perelson AS et al. HIV-1 dynamics in vivo: virion clearance rate, infected cell life-span, and viral<br />
generation time. Science, 1996, 271(5255):1582–1586.<br />
56. Mannheimer S et al. The consistency of adherence to antiretroviral therapy predicts biologic outcomes<br />
for human immunodeficiency virus-infected persons in clinical trials. Clinical Infectious Diseases,<br />
2002, 34(8):1115–1121.<br />
57. Fischl M et al. Impact of directly observed therapy on long-term outcomes in HIV clinical trials. 8th<br />
Conference on Retroviruses and Opportunistic Infections (CROI), Chicago, 4–8 February 2001 (Abstract<br />
528).<br />
58. Bangsberg DR et al. Adherence-resistance relationships for protease and non-nucleoside reverse<br />
transcriptase inhibitors explained by virological fitness. AIDS, 2006, 20(2):223–231.<br />
59. Maher K et al. Disease progression, adherence and response to protease inhibitor therapy for HIV infection<br />
in an Urban Veterans Affairs Medical Center. Journal of Acquired Immune Deficiency Syndromes,<br />
1999, 22(4):358–363.<br />
60. Vanhove GF et al. Patient compliance and drug failure in protease inhibitor monotherapy. JAMA, 1996,<br />
276(24):1955–1956.<br />
61. Little SJ et al. Antiretroviral-drug resistance among patients recently infected with HIV. The New England<br />
Journal of Medicine, 2002, 347(6):385–394.<br />
62. UK Collaborative Group on Monitoring the Transmission of HIV. Drug resistance. Analysis of prevalence<br />
of HIV-1 drug resistance in primary infections in the United Kingdom. BMJ, 2001, 322(7294):1087–<br />
1088.<br />
63. Bangsberg DR, Perry S, Charlesbois ED. Adherence to HAART predicts progression to AIDS. 8th<br />
Conference on Retroviruses and Opportunistic Infections (CROI), Chicago, 4–8 February 2001 (Abstract<br />
483).<br />
64. Lerner BH, Gulick RM, Dubler NN. Rethinking nonadherence: historical perspectives on triple-drug<br />
therapy for HIV disease. Annals of Internal Medicine, 1998, 129(7):573–578.<br />
65. Carrieri P et al. The dynamic of adherence to highly active antiretroviral therapy: results from the French<br />
National APROCO cohort. Journal of Acquired Immune Deficiency Syndromes, 2001, 28(3):232–239.<br />
66. Walsh JC et al. Reasons for non-adherence to antiretroviral therapy: patients’ perspectives provide<br />
evidence<br />
of multiple causes. AIDS Care, 2001, 13(6):709–720.<br />
67. Tuldra A et al. Prospective randomized two-arm controlled study to determine the efficacy of a specific<br />
intervention to improve long-term adherence to highly active antiretroviral therapy. Journal of Acquired<br />
Immune Deficiency Syndromes, 2000, 25(3):221–228.1-37 patient evaluation and antiretroviral treatment for adults and<br />
adolescents<br />
68. Bamberger JD et al. Helping the urban poor stay with antiretroviral HIV drug therapy. American Journal<br />
of Public Health, 2000, 90(5):699–701.<br />
69. Walsh JC et al. An assessment of current HIV treatment adherence services in the UK. AIDS Care,<br />
2002, 14(3):329–334.<br />
70. Cingolani A et al. Usefulness of monitoring HIV drug resistance and adherence in individuals failing<br />
highly active antiretroviral therapy: a randomized study (ARGENTA). AIDS, 2002, 16(3):369–379.<br />
71. Mannheimer S et al. The consistency of adherence to antiretroviral therapy predicts biologic<br />
outcomes for human immunodeficiency virus-infected persons in clinical trials.<br />
Clinical Infectious Diseases, 2002, 34(8):1115–1121.<br />
72. Chesney MA. Factors affecting adherence to antiretroviral therapy. Clinical Infectious Diseases, 2000,<br />
69
Suppl 2:S171–176.<br />
73. Altice FL, Mostashari F, Friedland GH. Trust and the acceptance of and adherence to antiretroviral<br />
therapy. Journal of Acquired Immune Deficiency Syndromes, 2001, 28(1):47–58.<br />
74. Claxton AJ, Cramer J, Pierce C. A systematic review of the associations between dose regimens and<br />
medication compliance. Clinical Therapeutics, 2001, 23(8):1296–1310.<br />
75. Bartlett JA et al. Overview of the effectiveness of triple combination therapy in antiretroviral-n<strong>aiv</strong>e<br />
HIV-1-infected adults. AIDS, 2001, 15(11):1369–1377.<br />
76. Paterson DL et al. Adherence to protease inhibitor therapy and outcomes in patients with HIV infection.<br />
Annals of Internal Medicine, 2000, 133(1):21–30.<br />
77. Fumaz CR et al. Quality of life, emotional status, and adherence of HIV-1-infected patients treated<br />
with efavirenz versus protease inhibitor-containing regimens. Journal of Acquired Immune Deficiency<br />
Syndromes, 2002, 29(3):244–253.<br />
78. Bartlett JA. Addressing the challenges of adherence [review]. Journal of Acquired Immune Deficiency<br />
Syndromes, 2002, 29 Suppl. 1:S2–S10.<br />
79. Moore AL et al. Raised viral load in patients with viral suppression on highly active antiretroviral<br />
therapy: transient increase or treatment failure AIDS, 2002, 16(4):615–618.<br />
80. Nettles RE et al. Intermittent HIV-1 viremia (Blips) and drug resistance in patients receiving HAART.<br />
JAMA, 2005, 293(7):817–829.<br />
81. Le Moing V et al. Predictors of long-term increase in CD4(+) cell counts in human immunodeficiency<br />
virus-infected patients receiving a protease inhibitor-containing antiretroviral regimen. Journal of Infectious<br />
Diseases, 2002, 185(4):471–480.<br />
82. Smith CJ et al. Factors influencing increases in CD4 cell counts of HIV-positive persons receiving<br />
longterm highly active antiretroviral therapy. Journal of Infectious Diseases, 2004, 190(10):1860–1868.<br />
83. Barrios A et al. Paradoxical CD4+ T-cell decline in HIV-infected patients with complete virus suppression<br />
taking tenofovir and di<strong>da</strong>nosine. AIDS, 2005, 19(6):569–575.<br />
84. Gallant JE et al. Efficacy and safety of tenofovir DF vs stavudine in combination therapy in antiretroviraln<strong>aiv</strong>e<br />
patients: a 3-year randomized trial. JAMA, 2004, 292(2):191–201.<br />
85. Miller MD et al. Decreased replication capacity of HIV-1 clinical isolates containing K65R or M184V<br />
RT mutations. 10th Conference on Retroviruses and Opportunistic Infections (CROI), Boston, 10–14<br />
February 2003 (Abstract 616).<br />
86. Parikh U et al. K65R: a multinucleoside resistance mutation of increasing prevalence exhibits bidirectional<br />
phenotypic antagonism with TAM. 11th Conference on Retroviruses and Opportunistic Infections<br />
(CROI), San Francisco, 8–11 February 2004 (Abstract 54).<br />
87. Condra JH et al. Drug resistance and predicted virologic responses to human immunodeficiency virus<br />
type 1 protease inhibitor therapy. Journal of Infectious Diseases, 2000, 182(3):758–765.<br />
88. Kempf DJ et al. Analysis of the virological response with respect to baseline viral phenotype and genotype<br />
in protease inhibitor-experienced HIV-1-infected patients receiving lopinavir/ritonavir therapy.<br />
Antiviral Therapy, 2002, 7(3):165–174.<br />
89. Martinez-Picado J et al. Replicative fitness of protease inhibitor-resistant mutants of human<br />
immunodeficiency<br />
virus type 1. Journal of Virology, 1999, 73(5):3744–3752.<br />
90. Albrecht MA et al. Nelfinavir, efavirenz, or both after the failure of nucleoside treatment of HIV infection.<br />
The New England Journal of Medicine, 2001, 345(6):398–407.<br />
91. Kessler H et al. CD4 cell increases through more than 4 years in antiretroviral-naïve HIV+ patients<br />
treated with lopinavir/ritonavir-based therapy. The 2nd IAS Conference on HIV Pathogenesis and Treatment,<br />
International AIDS Society and ANRS, Paris, 13 July 2003 (Abstract 568). 1-38 HIV/AIDS TREATMENT AND CARE<br />
CLINICAL PROTOCOLS FOR THE WHO EUROPEAN REGION<br />
92. Abbott’s new Kaletra tablet gets EMEA CHMP’s OK. Therapeutics Daily, 8 May 2006 (http://www.<br />
therapeutics<strong>da</strong>ily.com/News/article.cfmcontenttype=sentryarticle&contentvalue=884529&channelID<br />
=31, accessed May 9, 2006).<br />
93. Johnson M et al. 96-week comparison of once-<strong>da</strong>ily atazanavir/ritonavir and twice-<strong>da</strong>ily lopinavir/ritonavir<br />
in patients with multiple virologic failures. AIDS, 2006, 20(5):711–718.<br />
94. Youle M et al. The final week 48 analysis of a phase IV randomised open label multicetre trial to evaluate<br />
safety and efficacy of lopinavir/ritonavir vs saquinavir/ritonavir in adult HIV-1 infection: the MaxCMin2<br />
study. The 2nd IAS Conference on HIV Pathogenesis and Treatment, International AIDS Society<br />
and ANRS, Paris, 13 July 2003 (Abstract LB23).<br />
95. Rottmann C et al: Atazanavir ritonavir saquinavir without any other antiretroviral drugs in protease<br />
inhibitor experienced patients with no reverse transcriptase options: a 24 week cohort analysis. 7th<br />
International Congress on Drug Therapy in HIV Infection, Glasgow, 14–18 November 2004 (Abstract P21).<br />
96. Lazzarin A et al. Efficacy of enfuvirtide in patients infected with drug-resistant HIV-1 in Europe and<br />
70
Australia. The New England Journal of Medicine, 2003, 348(22):2186–2195.<br />
97. Gonzalez-Lahoz J. The RESIST trials – superiority of tipranavir over other PIs. AIDS Reviews, 2004,<br />
6(4):244–245.<br />
98. Croom KF, Keam SJ. Tipranavir: a ritonavir-boosted protease inhibitor. Drugs, 2005, 65(12):1669–<br />
1679.<br />
99. Arasteh K et al. TMC114/ritonavir substitution for protease inhibitor(s) in a non-suppressive antiretroviral<br />
regimen: a 14-<strong>da</strong>y proof-of-principle trial. AIDS, 2005, 19(9):943–947.<br />
100. Kovalevsky AY et al. Effectiveness of nonpeptide clinical inhibitor TMC-114 on HIV-1 protease<br />
with highly drug resistant mutations D30N, I50V, and L90M. Journal of Medicinal Chemistry, 2006,<br />
49(4):1379–1387.<br />
101. Turner D et al. The influence of protease inhibitor resistance profiles on selection of HIV therapy in<br />
treatment-n<strong>aiv</strong>e patients. Antiviral Therapy, 2004, 9(3):301–314.<br />
102. Stephan C et al. Saquinavir drug exposure is not impaired by the boosted double protease inhibitor<br />
combination of lopinavir/ritonavir. AIDS, 2004, 18(3):503–508.<br />
103. Eron JJ et al. A phase II trial of dual protease inhibitor therapy: amprenavir in combination with indinavir,<br />
nelfinavir, or saquinavir. Journal of Acquired Immune Deficiency Syndromes, 2001, 26(5):458–461.<br />
104. Boffito M et al. Atazanavir enhances saquinavir hard-gel concentrations in a ritonavir-boosted once<strong>da</strong>ily<br />
regimen. AIDS, 2004, 18(9):1291–1297.<br />
105. Ananworanich J et al. CD4-guided scheduled treatments interruptions compared to continuous therapy:<br />
results of the Staccato trial. 13th Annual Conference on Retroviruses and Opportunistic Infections<br />
(CROI), Denver, 5–8 February 2006 (Abstract 102).<br />
106. Skiest D et al. Predictors of HIV disease progression in patients who stop ART with CD4 cell counts<br />
>350 cells/mm3. 13th Annual Conference on Retroviruses and Opportunistic Infections (CROI), Denver,<br />
5–8 February 2006 (Abstract 101).<br />
107. Marchou B et al. Structured treatment interruptions in HIV-infected patients with high CD4 cell counts<br />
and virologic suppression: results of a prospective, randomized, open-label trial (Window - ANRS 106).<br />
13th Annual Conference on Retroviruses and Opportunistic Infections (CROI), Denver, 5–8 February<br />
2006 (Abstract 104).<br />
108. Danel C et al. CD4-guided strategy arm stopped in a randomized structured treatment interruption trial<br />
in West African adults: ANRS 1269 Trivacan trial. 13th Annual Conference on Retroviruses and Opportunistic<br />
Infections (CROI), Denver, 5–8 February 2006 (Abstract 105LB).<br />
109. El-Sadr W et al. Episodic CD4-guided use of art is inferior to continuous therapy: results of the SMART<br />
study. 13th Annual Conference on Retroviruses and Opportunistic Infections (CROI), Denver, 5–8 February<br />
2006 (Abstract 106LB).<br />
110. Carrieri MP et al. Impact of early versus late adherence to highly active antiretroviral therapy on immunovirological<br />
response: a 3–year follow-up study. Antiviral Therapy, 2003, 8(6):585–594.<br />
111. Safren SA et al. Two strategies to increase adherence to HIV antiretroviral medication: life-steps and<br />
medication monitoring. Behaviour Research and Therapy, 2001, (10):1151–1162.<br />
112. Simoni JM et al. Antiretroviral adherence interventions: a review of current literature and ongoing<br />
studies.Topics in HIV Medicine, 2003, 11(6):185–198.<br />
113. Golin CE, Smith SR, Reif S. Adherence counseling practices of generalist and specialist physicians caring<br />
for people living with HIV/AIDS in North Carolina. Journal of General Internal Medicine, 2004,<br />
19(1):16–27.1-39 patient evaluation and antiretroviral treatment for adults and adolescents<br />
114. Weber R et al. Effect of individual cognitive behaviour intervention on adherence to antiretroviral<br />
therapy: prospective randomized trial. Antiviral Therapy, 2004, 9(1):85–95.<br />
115. Kerr T et al. Psychosocial determinants of adherence to highly active antiretroviral therapy among<br />
injection drug users in Vancouver. Antiviral Therapy, 2004, 9(3):407–414.<br />
116. Tyn<strong>da</strong>ll MW et al. Atten<strong>da</strong>nce, drug use patterns, and referrals made from North America’s first<br />
supervised injection facility. Drug and Alcohol Dependence, 2005, December.<br />
117. Yun LW et al. Antidepressant treatment improves adherence to antiretroviral therapy among depressed<br />
HIV-infected patients. Journal of Acquired Immune Deficiency Syndromes, 2005, 38(4):432–438.<br />
118. Zimmermann AE et al. Tenofovir-associated acute and chronic kidney disease: a case of multiple drug<br />
interactions. Clinical Infectious Diseases, 2006, 42(2):283–290.<br />
119. Bartlett JG. Pocket guide to adult HIV/AIDS treatment. Baltimore, John Hopkins University AIDS<br />
Service, 2006 (http://hopkins-aids.edu/publications/pocketguide/pocketgd0106.pdf, accessed 11 September<br />
2006).<br />
120. Jacobson MA et al. Cytomegalovirus retinitis after initiation of highly active antiretroviral therapy. The<br />
Lancet, 1997, 349(9063):1443–1445.<br />
121. Race EM et al. Focal mycobacterial lymphadenitis following initiation of protease-inhibitor therapy in<br />
patients with advanced HIV-1 disease. The Lancet, 1998, 351(9098):252–255.<br />
71
122. Koval CE et al. Immune reconstitution syndrome after successful treatment of Pneumocystis carinii<br />
pneumonia in a man with human immunodeficiency virus type 1 infection. Clinical Infectious Diseases,<br />
2002, 35(4):491–493.<br />
123. Sande MA, Eliopoulos GM. The Sanford guide to HIV/AIDS therapy, 13th ed. Hyde Park, VT,<br />
Antimicrobial Therapy, 2004.<br />
124. Gilbert DN, Moellering RC, Eliopoulos GM. The Sanford guide to antimicrobial therapy, 35th ed.<br />
Hyde Park, VT, Antimicrobial Therapy, 2005.<br />
125. Antoniu T, Tseng AL. Interactions between recreational drugs and antiretroviral agents. The Annals of<br />
Pharmacotherapy, 2002, 36(10):1598–1613.<br />
126. WHO/EURO report of the technical consultation on clinical staging of HIV/AIDS and HIV/AIDS case<br />
definition for surveillance. Copenhagen, WHO Regional Office for Europe, 2005 (http://www.euro.<br />
who.int/document/E87956.pdf, accessed 5 April 2006).<br />
127. 2006 antiretroviral drug guide. IAPAC Monthly, 2006, 12 Suppl. 1 (http://www.iapac.org/home.<br />
asppid=7288, accessed 11 September 2006).<br />
128. Liu H et al. A comparison study of multiple measures of adherence to HIV protease inhibitors. Annals<br />
of Internal Medicine, 2001, 134(10):968–977.<br />
129. Bangsberg DR et al. Provider assessment of adherence to HIV antiretroviral therapy. Journal of Acquired<br />
Immune Deficiency Syndromes, 2001, 26(5):435–442.<br />
130. Hugen PW et al. Assessment of adherence to HIV protease inhibitors: comparison and combination of<br />
various methods, including MEMS (electronic monitoring), patient and nurse report, and therapeutic<br />
drug monitoring. Journal of Acquired Immune Deficiency Syndromes, 2002, 30(3):324–334.<br />
131. Paterson DL et al. Adherence to protease inhibitor therapy and outcomes in patients with HIV infection.<br />
Annals of Internal Medicine, 2000, 133(1):21–30.<br />
132. Parienti JJ et al. The pills identification test: a tool to assess adherence to antiretroviral therapy. JAMA,<br />
2001, 285(4):412.<br />
133. Descamps D et al. Mechanisms of virologic failure in previously untreated HIV-infected patients from<br />
a trial of induction-maintenance therapy. JAMA, 2000, 283(2):205–11.<br />
134. Havlir DV et al. Drug susceptibility in HIV infection after viral rebound in patients receiving<br />
indinavircontaining<br />
regimens. JAMA, 2000, 283(2):229–234.<br />
135. Vingerhoets J et al. Effect of baseline resistance on the virologic response to a novel NNRTI, TMC 125,<br />
in patients with extensive NNRTI and PI resistance: analysis of study TMC 125–233. 13th Annual Conference<br />
on Retroviruses and Opportunistic Infections (CROI), Denver, 5–8 February 2006 (Abstract<br />
154).<br />
136. De Meyer et al. Effect of baseline susceptibility and on-treatment mutations on TMC 114 and control<br />
PI efficacy: preliminary analysis of <strong>da</strong>ta from PI-experienced patients from POWER 1 and POWER 2.<br />
13th Annual Conference on Retroviruses and Opportunistic Infections (CROI), Denver, 5–8 February<br />
2006 (Abstract 157).<br />
72
Tavi II. oportunistuli infeqciebis marTva<br />
cxrili 19. oportunistuli infeqciebi <strong>da</strong> sxva <strong>da</strong>avadebebi, romlebic<br />
<strong>da</strong>kavSirebulia <strong>aiv</strong> <strong>infeqcia</strong>sTan<br />
baqteriuli<br />
infeqciebi<br />
• tuberkulozi<br />
• baqteriuli<br />
respiratoru<br />
li<br />
infeqciebi<br />
• nawlavTa<br />
baqteriuli<br />
infeqciebi<br />
• atipiuri<br />
mikobaqterio<br />
zebi<br />
• bartonelozi<br />
sokovani<br />
infeqciebi<br />
• ezofaguri<br />
kandidozi<br />
• kriptokokozi<br />
• histoplazmozi<br />
• pnevmocisturi<br />
pnevmonia<br />
• kokcidioidozi<br />
virusuli<br />
infeqciebi<br />
• infeqciebi,<br />
romelsac<br />
iwvevs:<br />
_martivi herpes<br />
virusi;<br />
-varicelazosteris<br />
virusi<br />
- citomegalovirusi<br />
_a<strong>da</strong>mianis<br />
herpes virusis 8<br />
tipi;<br />
_a<strong>da</strong>mianis<br />
papilomavirusi<br />
progresuli<br />
multifokaluri<br />
leikoencefalop<br />
aTia<br />
- hepatiti B <strong>da</strong><br />
C<br />
parazituli<br />
infeqciebi<br />
• toqsoplazmozi<br />
• kriptosporidiozi<br />
• mikrosporidiozi<br />
• izosporiazi<br />
• leiSmaniozi<br />
sxva<br />
<strong>da</strong>avadebebi<br />
• kapoSis<br />
sarkoma<br />
• arahojkinsis<br />
limfoma<br />
• saSvilosnos<br />
yelis simsivne<br />
• encefalopaTia<br />
• vakuoluri<br />
mielopaTia<br />
evropis regionisTvis yvelaze xSiri oportunistuli infeqciebia:<br />
o tuberkulozi<br />
o baqteriuli infeqciebi<br />
o pnevmocisturi pnevmonia<br />
o herpesuli infeqciebi (VZV, HSV 1 <strong>da</strong> 2, CMV)<br />
o kandidozuri ezofagiti<br />
o kriptokokuli meningiti<br />
o toqsoplazmozi<br />
SederebiT iSviaT oportonistul infeqciebs <strong>da</strong> simsivneebs miekuTvneba;<br />
o atipiuri mikobaqteriozebi<br />
o kapoSis sarkoma<br />
o arahojkinis limfoma<br />
o citomegalovirusuli infeqciebi (retina, kuW-nawlavis traqti,<br />
encefalitebi).<br />
cxrili 2. oportunistuli infeqciebis profilaqtika <strong>aiv</strong> inficirebul<br />
pacientebSi<br />
gamomwvevi maCveneblebi pirveli rigis<br />
preparatebi<br />
Pneumocystis CD4< 200mkl-1 ko-tromoqsazoli<br />
jirovecii<br />
an<br />
160/800 mg/dReSi yovel<br />
orofaringeuli<br />
Aalternatiuli<br />
sqemebi<br />
- ko-tromoqsazoli<br />
80-400 mg/dReSi<br />
73
kandidozi dRe yovel dRe<br />
- ko-trimoqsazoli<br />
160/800 mg/dReSi<br />
kviraSi samjer<br />
- <strong>da</strong>psoni 50 mg<br />
dReSi orjer<br />
- 100 mg dReSi<br />
erTxel (2)<br />
- pirimetamini 50 mg<br />
+ <strong>da</strong>psoni 50 mg<br />
+ foliumis mJava 15<br />
mg erTxel dReSi<br />
-pentamidis<br />
inhalaciebi 300 mg 3<br />
kviraSi erTxel (3)<br />
-aseve SesaZlebelia:<br />
klin<strong>da</strong>micini an<br />
M.tuberkunosis PPD reaqcia ><br />
5mm<br />
an<br />
kontaqti<br />
tuberkulozis<br />
aqtiuri<br />
formis mqone<br />
pacientTan<br />
Toxoplasma<br />
gondii, primary<br />
Toxoplasma<br />
gondii,<br />
secon<strong>da</strong>ry<br />
M. avium<br />
complex<br />
Criptococcus<br />
neoformans<br />
CD4< 100 mm3<br />
CD4< 100 mm3<br />
izoniazidi 300mg/dReSi<br />
+ piridoqsini 50<br />
mg/dReSi 6 Tvis<br />
ganmavlobaSi (6)<br />
ko-trimoqsazoli<br />
160/800 mg/dReSi yovel<br />
dRe<br />
ko-trimoqsazoli<br />
160/800 mg/dReSi yovel<br />
dRe<br />
CD4< 50mkl-1 azitromicini 1200 mg<br />
kviraSi erTxel<br />
CD4< 50mkl-1 flukonazoli 100-200<br />
mg/dReSi (11)<br />
atovaqvoni (4,5,)<br />
saWiroa <strong>da</strong>matebiTi<br />
kvlevebis Catareba<br />
alternatiuli<br />
profilaqtikuri<br />
mkurnalobis<br />
SemuSavebisTvis<br />
izoniazidze<br />
rezistentobis<br />
SemTxvevebSi<br />
- ko-trimoqsazoli,<br />
80-400 mg/dReSi<br />
yovel dRe (7,8)<br />
- <strong>da</strong>psoni 50 mg<br />
yovel dRe +<br />
pirimetamini 50 mg<br />
kviraSi erTxel +<br />
foliumis mJava 25<br />
mg kviraSi erTxel<br />
-<strong>da</strong>psoni 50 mg<br />
yovel dRe +<br />
pirimetamini 50 mg<br />
dReSi +<br />
foliumis mJava 15-<br />
25 mg dReSi<br />
klariTromicini<br />
500 mg orjer dReSi<br />
(9,10)<br />
74
3.1.sasunTqi gzebis infeqciebi<br />
filtvis morecidive infeqciur <strong>da</strong>avadebebs erT-erTi pirveli adgili<br />
uWiravs <strong>aiv</strong> inficirebulebSi <strong>da</strong> xSirad uqmnis safrTxes maT sicocxles.<br />
etiologiis mixedviT igi SeiZleba iyos baqteriuli, virusuli <strong>da</strong><br />
sokovani.<br />
<strong>aiv</strong> infeqciis adreul stadiaze viTardeba baqteriuli pnevmoniebi,<br />
romlebic advilad eqvemdeba antibaqteriul <strong>mkurnaloba</strong>s. <strong>aiv</strong><br />
inficirebulebSi xSiria inkafsulirebuli baqteriebiT mag. Streptococcus<br />
pneumoniae <strong>da</strong> Haemophilus influenzae-Ti gamowveuli infeqciebi. mogvianebiT,<br />
imunodeficitis fonze <strong>aiv</strong> inficirebulebs uviTardebaT filtvis<br />
oportunistuli infeqciebi, romelTa Soris yvelaze did problemas<br />
warmoadgens tuberkulozi. ujreduli imunitetis <strong>da</strong>qveiTebaTan erTad<br />
SeiZleba ganviTardes sicocxlisaTvis saSiSi oportunistuli<br />
infeqciebi, maT Soris pnevmocisturi, mikozuri <strong>da</strong> virusuli pnevmoniebi.<br />
me-20 cxrilSi CamoTvlilia filtvis <strong>da</strong>avadebebi, romlebic arTuleben<br />
<strong>aiv</strong> infeqciis mimdinareobas.<br />
cxrili 20. respiratoruli <strong>da</strong>avadebebi <strong>aiv</strong>/<strong>SidsiT</strong> <strong>da</strong>avadebul<br />
pacientebSi<br />
infeqciis tipi<br />
SesaZlo garTulebebi a<br />
baqteriuli<br />
pnevmokokuri pnevmonia empiema b, plevruli gamonaJoni,<br />
filtvis abscesi<br />
H. influenza pnevmonia plevruli gamonaJoni b , filtvis<br />
abscesi, empiema<br />
klebsielaTi gamowveuli pnevmonia empiema b , plevruli gamonaJoni<br />
stafilokokuri pnevmonia<br />
filtvis abscesi b , empiema , plevruli<br />
gamonaJoni<br />
M. tuberkulosis pnevmonia perikarduli gamonaJoni, filtvis<br />
abscesi, empiema, plevruli<br />
gamonaJoni<br />
MAC pnevmonia iSviaTi garTuleba: abscesi,<br />
gansakuTrebiT<br />
imunuri<br />
rekonstituciis sindromis dros<br />
virusuli<br />
citomegalovirusi<br />
pnevmoniti b (maRalia letaloba)<br />
martivi herpesis virusi<br />
pnevmoniti b (maRalia letaloba)<br />
sokovani<br />
pnevmocisturi pnevmonia<br />
pnevmoToraqsi<br />
kriptokokozi<br />
histoplazmozi<br />
aspergilozi<br />
filtvis abscesi<br />
sxva mdgomareobebi<br />
kapoSis sarkoma plevruli an perikardiuli<br />
gamonaJoni<br />
limfoma plevruli an perikardiuli<br />
gamonaJoni<br />
75
karcinoma (ara SidsTan perikardiuli gamonaJoni<br />
asocirebuli)<br />
a SesaZlo garTulebebi CamoTvlilia maTi ganviTarebis sixSiris<br />
mixedviT.<br />
b mdgomareobebi, romlebic yvelaze xSirad viTardeba<br />
3.1.1. baqteriuli respiratoruli infeqciebi<br />
<strong>aiv</strong> inficirebulebs imunodeficitis fonze xSirad uviTardebaT<br />
baqteriuli pnevmoniebi, romelTac axasiaTebT mZime mimdinareoba.<br />
yvelaze xSirad pnevmonias iwvevs Streptococcus pneumoniae. pnevmoniis sxva<br />
baqteriuli gamomwvevebi mocemulia Mme-21 cxrilSi. <strong>klinikuri</strong><br />
gamovlinebebia: xvela, cxeleba, tkivili gul-mkerdis areSi, qoSini <strong>da</strong><br />
taqipnoe. gulmkerdis rentgenogramaze SeiZleba gamoCndes wilovani<br />
pnevmoniis an bronqopnevmoniis klasikuri niSnebi, atipuri cvlilebebi an<br />
cvlilebebis ararseboba.<br />
diagnostikaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA<br />
diagnozi efuZneba klinikur gamovlinebebsa <strong>da</strong> rentgenologiur<br />
cvlilebebs. rentgenogramaze SeiZleba aRmoCndes:<br />
o filtvis parenqimis wilovani an kerovani <strong>da</strong>Crdilva<br />
o filtvis difuzuri infiltraciebi an<br />
o atipiuri cvlilebebi, kavernozuli <strong>da</strong>avadebis CaTvliT.<br />
<strong>mkurnaloba</strong>AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA<br />
Tu pacientis mdgomareoba saSualo simZimisaa, <strong>mkurnaloba</strong> SeiZleba<br />
Catardes binaze me-21 <strong>da</strong> me-22 cxrilebSi mocemuli sqemebis mixedviT.<br />
cxrili 21. baqteriuli pnevmoniis mkurnalobis pirveli rigis sqemebi<br />
antibiotiki doza MmiRebis<br />
sixSire<br />
amoqsicilini<br />
500-1000mg 3X<br />
(penicilinisa <strong>da</strong> ampicilinis<br />
mimarT SesaZlo<br />
dReSi<br />
rezistentobis<br />
SemTxvevaSi gamoiyeneT<br />
penicilini beta laqtamazas<br />
inhibitorebTan kombinaciaSi)<br />
76<br />
miRebis<br />
gza<br />
mkurnalobis<br />
xangrZlivoba<br />
PO 7 dRe an<br />
ufro<br />
xangrZlivad<br />
morCenamde<br />
Aan<br />
eriTromicini 500mg 4X dReSi PO 7 dRe<br />
an<br />
klaritromicini 500mg 2X dReSi PO 7 dRe<br />
Aan<br />
azitromicini 500mg erTxel<br />
dReSi<br />
qinoloni pnevmokokis sawinaaRmdego<br />
aqtivobiT (mag: moqsifloqsacini)<br />
an<br />
400 mg<br />
erTxel<br />
dReSi<br />
PO<br />
PO<br />
3-4 dRe<br />
7 dRe
doqsiciklini<br />
an<br />
100 mg<br />
2X dReSi<br />
PO<br />
7 dRe<br />
o Tu pirveli rigis sqemiT mkurnalobis fonze mdgomareoba 72 sT-Si<br />
ar gaumjobes<strong>da</strong> (cxelebis normalizeba, C reaqtiuli cilis<br />
matebis SeCereba, leikocitozis donis Semcireba), aucilebelia<br />
pacientis hospitalizacia <strong>da</strong> mkurnalobis Secvla II rigis sqemiT<br />
(cxrili 23), saWiroebis SemTxvevaSi _ JangbadiT inhalacia (am<br />
SemTxvevaSi un<strong>da</strong> vivaraudoT pnevmocisturi pnevmonia).<br />
o mZime mdgomareobaSi myofi avadmyofebis hospitalizacia un<strong>da</strong><br />
moxdes <strong>da</strong>uyonebliv.<br />
cxrili 23.<br />
sqemebi<br />
baqteriuli pnevmoniebis mkurnalobis meore rigis<br />
antibiotiki doza M miRebis<br />
sixSire<br />
MmiRebis<br />
gza<br />
mkurnalobis<br />
xangrZlivoba<br />
ceftriaqsoni 2g dReSi erTxel i/v<br />
+<br />
7 dRe<br />
eriTromicini 500mg 4X dReSi<br />
an<br />
ampicilin/<br />
1500mg 3X dReSi<br />
i/v<br />
sulbaqtami<br />
7 dRe<br />
+<br />
eriTromicini 500mg 4X dReSi<br />
an<br />
qinoloni<br />
400 mg erTxel dReSi IV/PO 7 dRe<br />
pnevmokokuri<br />
aqtivobiT<br />
(mag:<br />
moqsifloqsacini)<br />
an<br />
qloramfenikoli 12,5 mg/kg<br />
(mxolod sxva preparatebis<br />
ar arse-<br />
4X dReSi i/v 7 dRe<br />
bobis dros)<br />
o Tu mkurnalobis fonze mdgomareoba ar gaumjobes<strong>da</strong>, eWvi un<strong>da</strong><br />
mivitanoT pnevmocistur pnevmoniaze an tuberkulozze. antibiotikebiT<br />
mkurnalobis <strong>da</strong>wyebamde paTogenis identifikaciis oqros stan<strong>da</strong>rts<br />
miekuTvneba lavaJi bronqoskopiiT (14) (AI). <strong>da</strong>mxmare meTodia sisxlis<br />
kulturebi, romelsac aqvs maRali done pnevmokokis identifikaciisvis<br />
<strong>da</strong> SesaZloa Catardes swrafad.<br />
3.1.2. atipuri mikobaqteriozebi<br />
Mycobaqterium avium complex (MAC an MAI) gamowveuli infeqciebi ufro<br />
iSviaTad gvxvdeba, vidre sxva oportunistuli infeqciebi. <strong>klinikuri</strong><br />
gamovlinebebia:<br />
77
o cxeleba<br />
o wonaSi kleba<br />
o Ramis oflianoba<br />
o diarea<br />
o ganleva.<br />
o<br />
mikobaqteriebis aRmoCena SesaZlebelia avadmyofis sisxlsa <strong>da</strong><br />
eqskrementebSi.<br />
diagnostikaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA<br />
o sisxlis specialur nia<strong>da</strong>gze <strong>da</strong>Tesva.<br />
o pacientebs klinikurad gamovlinebuli infeqciiT<br />
mikobaqteriebis intensivoba imgvari aqvT, rom gamomwvevis<br />
aRmoCena SesaZlebelia <strong>da</strong>Tesili sisxlis TiTqmis yvela<br />
ulufaSi.<br />
o vinai<strong>da</strong>n, diseminirebuli infeqciis dros xSirad ziandeba<br />
RviZli <strong>da</strong> Zvlis tvini, mikobaqteriebis aRmoCena SesaZlebelia<br />
mJavagamZle baqteriebze SeRebil preparatebSi, romlebic<br />
<strong>da</strong>mzadebulia am organoebi<strong>da</strong>n aRebuli bioptatebisgan.<br />
o RviZlis bioptatis mikroskopuli gamokvlebis gziT winaswari<br />
diagnozis <strong>da</strong>sma saSualebas iZleva <strong>mkurnaloba</strong> <strong>da</strong>viwyoT<br />
droulad.<br />
<strong>mkurnaloba</strong>AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA<br />
cxrili 24. atipuri mikobaqteriozebis <strong>mkurnaloba</strong> (AI)<br />
antibiotiki doza MmiRebis<br />
sixSire<br />
miRebis<br />
gza<br />
mkurnalobis<br />
xangrZlivoba<br />
pirveli rigis preparatebi (15,16)<br />
klariTromicini 500-1000 mg 2-jer dReSi PO 6 Tve ;<br />
<strong>da</strong>mokidebulia<br />
klinikur<br />
mdgomareobaze<br />
+<br />
etambutoli 15 mg/kg dReSi<br />
erTxel<br />
+<br />
rifabutini 300-450 mg dReSi<br />
erTxel<br />
PO 6 Tve ;<br />
<strong>da</strong>mokidebulia<br />
klinikur<br />
mdgomareobaze<br />
PO 6 Tve ;<br />
<strong>da</strong>mokidebulia<br />
klinikur<br />
mdgomareobaze<br />
sxva preparatebi, rimlebic moqmedeben atipiur mikobaqteriebze a<br />
azitromicini 500-1200 mg dReSi PO<br />
6 Tve<br />
erTxel<br />
ciprofloqsacini 500 mg 2-jer dReSi PO<br />
6 Tve<br />
amikacini 15 mg/kg/dR dReSi 1X i/v<br />
78
an 7,5<br />
mg/kg/dR<br />
2-jer dReSi i/v ara umetes 4<br />
kvirisa<br />
a rifampicini ar aris efeqturi atipiruri mokibaqteriis mimarT.<br />
o Tu atipiuri mikobaqteriozebis mkurnalobis fonze mdgomareoba<br />
gaumjobes<strong>da</strong> <strong>da</strong> preparatebi kargad ga<strong>da</strong>itaneba un<strong>da</strong> <strong>da</strong>iwyos arT.<br />
o atipiuri mikobaqteriozebis mkurnalobo<strong>da</strong>n 4-6- kviraSi iwyeba arT.<br />
6 Tvis Semdeg imunuri pasuxis gaumjobesebis Semdeg (CD4<br />
ricxvi>100mm3) Cerdeba atipiuri mikobaqteriozebis <strong>mkurnaloba</strong> <strong>da</strong><br />
gamoiyeneba meoradi profilaqtika.<br />
o meoradi profilaqtikis Sewyveta SesaZlebelia, rodesac imunuri<br />
sistema stabiluria 3-6- Tvis manZilze.<br />
o atipiuri mikobaqteriozebis <strong>mkurnaloba</strong> <strong>da</strong> meoradi profilaqtika<br />
grZeldeba 6 Tve, rac aris mkurnalobis warmatebis <strong>da</strong> relapsis<br />
Tavi<strong>da</strong>n acilebis sawin<strong>da</strong>ri.<br />
o didi mniSvneloba aqvs atipiuri mikobaqteriozebis mkurnalobis<br />
<strong>da</strong>wyebas arv Terapiis <strong>da</strong>wyebamde.<br />
o arsebobs albaToba imunuri rekonstituciis anTebiTi sindromis<br />
ganviTarebis arT-s <strong>da</strong>wyebis Semdeg.D<br />
3.1.3. pnevmocisturi pnevmonia<br />
o pnevmocisturi pnevmonia erT-erTi gavrcelebuli oportunistuli<br />
<strong>infeqcia</strong>a <strong>aiv</strong> inficirebulebSi. misi gamomwvevia Pneumocystis jiroveci<br />
(adre moixseniebdnen Pneumocystis carinii–is saxeliT).<br />
o tipiuri <strong>klinikuri</strong> gamovlinebebia: xvela, qoSini <strong>da</strong> cxeleba.<br />
o zogjer pnevmocisturi pnevmonia mimdinareobs filtvismieri<br />
gamovlinebebis gareSe.<br />
o xSirad aRiniSneba sunTqvis ukmarisobis niSnebi, qoSini <strong>da</strong> cianozi.<br />
o <strong>da</strong>avadebis mimdinareoba SeiZleba iyos mZime <strong>da</strong>, Tu droulad ar<br />
<strong>da</strong>iniSneba <strong>mkurnaloba</strong>, SeiZleba <strong>da</strong>mTavrdes sikvdiliT.<br />
diagnostikaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA<br />
o diagnozi ismeba <strong>klinikuri</strong> suraTis mixedviT. <strong>aiv</strong> inficirebul<br />
pacients uviTardeba respiratoruli distresi cianoziT an mis<br />
gareSe.<br />
o SesaZloa aRiniSnebodes mSrali xvela, Tumca ufro<br />
mniSvnelovania, rom filtvebSi fizikaluri gamokvlevebiTAD<br />
mciredi cvlilebebia an saerTod ar aris.<br />
o gul-mkerdis rentgenologiuri gamokvleva:<br />
o orive filtvis qvemo wilSi gamWvirvalobis Rrubliseburi<br />
<strong>da</strong>qveiTeba_yvela pacients ar aReniSneba.<br />
o SesaZlebelia orive filtvSi aRmoCndes kerovani <strong>da</strong>Crdilva,<br />
romelic waagavs baqteriuli pnevmoniis an tuberkulozis suraTs.<br />
o pacientebis umetesobas, romelTac <strong>da</strong>udgin<strong>da</strong> pnevmocisturi<br />
pnevmonia, rentgenologiuri cvlilebebi ar aReniSnebaT.<br />
o diagnozis oqros stan<strong>da</strong>rts warmoadgens bronquli lavaJi (14).<br />
diagnozi <strong>da</strong>sturdeba gamomwvevis cistis aRmoCeniT amonaxvelSi an<br />
bronquli lavaJis aspiratSi.<br />
o Tu bronqoskopiis Catareba SeuZlebelia, maSin pnevmocisturi<br />
pnevmoniis diagnozisTvis SesaZlebelia gamoyenebul iqnes rogorc<br />
79
indikatorebi filtvis <strong>da</strong>rRveuli funqciuri testebi an sisxlis<br />
airTa analizi.<br />
o diagnozis <strong>da</strong>smisTanave <strong>da</strong>wyebul un<strong>da</strong> iqnas <strong>mkurnaloba</strong>.<br />
<strong>mkurnaloba</strong>AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA<br />
pnevmocisturi pnevmoniis <strong>mkurnaloba</strong> tardeba stacionarSi.<br />
aucilebelia <strong>da</strong>mxmare Terapia JangbadiT inhalaciis CaTvliT.<br />
mkurnalobis detaluri sqema mocemulia cxrilSi N#25 <strong>da</strong> #26 qvemoT.<br />
cxrili 25.<br />
pnevmocisturi pnevmoniis pirveli rigis <strong>mkurnaloba</strong> (AI)<br />
antimikrobuli<br />
agenti<br />
timetoprimi/<br />
sulfametoqsazoli<br />
doza M miRebis M miRebis mkurnalobis<br />
sixSire gza xangrZlivoba<br />
400/80 mg 4X dReSi PO/IV 21 dRe<br />
cxrili 26. pnevmocisturi pnevmoniis meore rigis <strong>mkurnaloba</strong> (AI)<br />
Kklin<strong>da</strong>micini<br />
+<br />
primaqini<br />
600mg<br />
15 mg<br />
4X dReSi<br />
2X dReSi<br />
PO/IV<br />
PO<br />
21 dRe (17)<br />
an<br />
pentamidini (farTo 4 mg/kg IV<br />
speqtris<br />
dReSi. doza<br />
antibiotikTan mcir 2 mg/kg<br />
kombinaciaSi 5 dRis<br />
baqteriuli<br />
superinfeqciis<br />
mkurnalobis<br />
Semdeg (18)<br />
profilaqtikisTvis<br />
mag. ampicilin+<br />
sulbaqtami 10 dRe)<br />
dReSi<br />
erTxel<br />
IV<br />
21 dRe<br />
o mZime mdgomareobaSi myof avadmofebSi iniSneba prednizoloni, 80-<br />
250 mg PO/IV dReSi 1-2 kvira (amcirebs intersticiul SeSupebas).<br />
o mZime SemTxvevebSi ganixileba kombinirebuli <strong>mkurnaloba</strong>, mag. kotrimoqsazoli<br />
<strong>da</strong> pen<strong>da</strong>midini mxolod erTeuli Setyobinebuli<br />
SemTxvevebis mixedviT <strong>da</strong>kavSirebulia toqsiurobis maRal riskTan.<br />
pnevmocisturi pnevmoniis mZime SemTxvevebi moiTxovs xelovnur<br />
ventilacias an oqsigeniT saturacias (SO2)
o meoradi profilaqtikis mizniT <strong>aiv</strong> inficirebulma pacientebma un<strong>da</strong><br />
miiRon trimetoprim/sulfametoqsazoli 160/800 mg doziT erTxel<br />
dReSi xangrZlivad ;<br />
o aRniSnuli preparatebis miReba pacientma SeiZleba Sewyvitos Tu<br />
CD4 limfocitebis raodenoba stabilurad aRemateba 200 mm3-s sul<br />
mcire sami Tvis ganmavlobaSi.<br />
3.1.4. sxva etiologiis pnevmoniebi imunodeficitis mqone pacientebSi<br />
o pnevmoniebi SeiZleba iyos sokovani <strong>da</strong> virusuli etiologiis. aseT<br />
SemTxvevebSi Znelia diagnozis <strong>da</strong>zusteba rTuli laboratoriuli<br />
gamokvlevebis gareSe <strong>da</strong> rTulia maTi <strong>mkurnaloba</strong>.<br />
o pnevmoniis gamomwvev virusebs miekuTvneba: martivi herpesis virusi,<br />
varicela-zosteris virusi an citomegalovirusi.<br />
o sokovan pnevmoniebs Pneumocystis-jiroveci (Pneumocystis carinii) –is gar<strong>da</strong><br />
iwveven Histoplazma capsulatum, Cryptococcus neoformans <strong>da</strong> Aspergillus.<br />
diagnostikaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA<br />
o pnevmoniis mqone pacientebSi, romlebic Znelad eqvemdebarebian<br />
stan<strong>da</strong>rtul <strong>mkurnaloba</strong>s, un<strong>da</strong> vivaraudoT tuberkulozis an<br />
virusuli, sokovani an protozouli etiologiis pnevmoniis<br />
arseboba.<br />
o sokovani an sxva etiologiis pnevmoniebis specifikuri<br />
diagnostikisTvis auculebelia rTuli laboratoriuli<br />
gamokvlevebi:<br />
o pp65 adreuli CMV antigeni periferiuli sisxlSi an bronqul<br />
lavaJSi;<br />
o polimerazuli jaWvuri reaqcia (pjr) herpesis jgufis<br />
virusebisTvis (CMV, HSV 1/2/; VZV, EBV, HHV8, HHV6) ;<br />
o specialuri kulturebi nela-mzardi paTogenebisTvis mag: nokardia.<br />
o aucilebelia mWidri TanamSromloba eqimebsa <strong>da</strong> mikrobiologebs<br />
Soris.<br />
<strong>mkurnaloba</strong>AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA<br />
<strong>mkurnaloba</strong> <strong>da</strong>mokidebulia <strong>da</strong>avadebis etiologiaze mag: foskarneti CMV<br />
infeqciisTvis an xangrZlini antibiotikoTerapia (8 kvira) nokardiisTvis.<br />
3.1.5. kuW-nawlavis traqtis infeqciebi<br />
kuW-nawlavis traqtis <strong>da</strong>zianeba <strong>aiv</strong> inficirebulebSi SeiZleba iyos:<br />
o rogorc <strong>aiv</strong> infeqciis uSualo gamovlineba, aseve<br />
o baqteriuli,<br />
o virusuli,<br />
o sokovani<br />
o protozouli an<br />
o parazituli etiologiis.<br />
o zog SemTxvevaSi kuW-nawlavis aSliloba ganpirobebulia Sewovis<br />
unaris <strong>da</strong>rRveviT, rac nawlavTa xaoebis atrofiiTaa gamowveuli<br />
(malabsorbcia).<br />
81
o yvelaze xSirad viTardeba diarea, romelic SeiZleba iyos mwvave,<br />
qronikuli an qronikuli - gamwvavebebiT.<br />
o <strong>SidsiT</strong> avadmyofebSi diarea persistuli an qronikulia <strong>da</strong> xSirad<br />
aris maTi sikvdilis mizezi.<br />
o mwvave diarea saWiroebs dehir<strong>da</strong>tacias mkurnalobis Sedegis<br />
miRebamde.<br />
o ganavali sisxliani minarevebiT <strong>da</strong>maxasiaTebelia dizenteriis an<br />
nawlavTa amebiazisTvis.<br />
<strong>aiv</strong> inficirebulebs xSirad aReniSnebaT kuW-nawlavis traqtis <strong>da</strong>zianebis<br />
iseTi simptomebi, rogoricaa:<br />
o madis <strong>da</strong>kargva,<br />
o gulisreva<br />
o pirRebineba <strong>da</strong><br />
o wonaSi progresirebadi kleba.<br />
<strong>aiv</strong> inficirebulebSi yvelaze gavrcelebuli kuW-nawlavis infeqciebi <strong>da</strong><br />
maTi mkurnalobis Sesaxeb rekomen<strong>da</strong>ciebi mocemulia cxrilSi #27.<br />
cxrili 27. <strong>aiv</strong> inficirebulebSi gavrcelebuli kuW-nawlavis traqtis<br />
infeqciebi<br />
<strong>infeqcia</strong><br />
ara-tifoiduri<br />
salmonelozebi<br />
Sigelozebi<br />
<strong>klinikuri</strong><br />
gamovlinebebi <strong>da</strong><br />
diagnostika<br />
cxeleba, tkivili<br />
muclis areSi, diarea<br />
(SesaZlebelia<br />
ganavalSi sisxlis<br />
aRmoCena), wonaSi<br />
kleba, anoreqsia,<br />
hepatosplenomegalia.<br />
diagnostika _ sisxlis<br />
an ganavlis kultura<br />
cxeleba, tkivili<br />
muclis areSi,<br />
sisxliani diarea.<br />
diagnostika _ sisxlis<br />
an ganavlis kultura.<br />
kriptosporidozi wylisebri ganavali,<br />
madis <strong>da</strong>kargva,<br />
cxelebis ar arseboba.<br />
diagnostika _ ganavlis<br />
mikroskopulia.<br />
<strong>mkurnaloba</strong><br />
ciprofloqsacini,<br />
500mg 2-jer dReSi PO 2<br />
kviris ganmavlobaSi<br />
(19)<br />
ciprofloqsacini 500mg<br />
2-jer dReSi PO 7-10<br />
dRe<br />
an<br />
nalidiqsis mJava 500mg<br />
dReSi 4-jer PO 7-<br />
10DdRe<br />
an<br />
ko-trimoqsazoli<br />
160/800mg 2-jer dReSi<br />
PO 7-10 dRe<br />
paromomicini 1g 2-jer<br />
dReSi PO +<br />
azitromicini 600mg<br />
dReSi erTxel PO 4<br />
kviris ganmavlobaSi;<br />
Semdeg:<br />
mxolod paromomicini<br />
82
mikrosporidozi wylisebri ganavali,<br />
madis <strong>da</strong>kargva,<br />
cxelebis ararseboba.<br />
diagnostika _ ganavlis<br />
mikroskopulia.<br />
8 kvira (20,21).<br />
<strong>mkurnaloba</strong> xSirad<br />
warumatebelia (22).<br />
alben<strong>da</strong>zoli 400mg 2-<br />
jer dReSi PO 4kvira<br />
Tu es ar muSaobs<br />
scadeT:<br />
meben<strong>da</strong>zoni 500mg 3-jer<br />
dReSi PO<br />
(alben<strong>da</strong>zoli metad<br />
efeqturia) (23).<br />
3.1.6. kandidozebi<br />
o Candi<strong>da</strong> albicans pirvela<strong>da</strong>d kolonizdeba qalTa <strong>da</strong> mamakacTa kuWnawlavia<br />
traqtSi. Candi<strong>da</strong> albicans aRmoCndeba janmrTeli qalebis 1/3<br />
saSos mikrofloraSi.<br />
o qalebSi kandidozuri vulvovaginiti gamovlindeba saSo<strong>da</strong>n<br />
gamonadeniTa <strong>da</strong> vulvisa <strong>da</strong> saSos qaviliT.<br />
o mamakacebSi sasqeso organoebis kandidozi mimdinareobs, rogorc<br />
balaniti an balanopostiti, amasTan erTad aRniSnaven CuCi<strong>da</strong>n<br />
gamonadens <strong>da</strong> asosa <strong>da</strong> CuCis qavils.<br />
o piris Rrus kandidozi gamovlindeba lorwovani garsis anTebiTa <strong>da</strong><br />
mis ze<strong>da</strong>pirze TeTri balTebis warmoqmniT.<br />
o kandi<strong>da</strong> ainficirebs kansac <strong>da</strong> iwvevs qavana dermatits.<br />
o imunodeficitis gaRrmavebasTan erTad piris Rrus kandidozi<br />
SeiZleba gavrceldes saylapavze <strong>da</strong> gamoiwvios ezofagiti.<br />
o iSviaT SemTxvevebSi SeiZleba ganviTardes bronqebis <strong>da</strong>zianeba <strong>da</strong><br />
diseminirebuli kandidozi.<br />
simptomebiAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA<br />
piris Rrus kandidozi moicavs:<br />
o loyis lorwovan garss<br />
o enas<br />
o pir-xaxas<br />
o RrZilebs<br />
o rbil <strong>da</strong> magar sasas.<br />
avadmyofs SeiZleba ar hqondes Civilebi an aRniSnavdes Wamis dros wvis<br />
SegrZnebas.<br />
zogierTi avadmyofi uCivis pirSi TeTri nadebis arsebobas.<br />
roca kandidozi vrceldeba saylapavze pacienti uCivis:<br />
o tkivils ylapvis dros<br />
o retrosternalur tkivils<br />
o hipersalivacias.<br />
pacientebi, romlebSic kandidozi yvelaze xSirad viTardeba:<br />
o orsuloba <strong>da</strong> peroraluri kontraceptivebis miReba<br />
o axalSobilobis periodi, gansakuTrebiT dRenaklul<br />
bavSebSi<br />
o farTo speqtris antibiotikebis xangrZlivi miReba<br />
83
o glukokortikoidebis sistematiuri miReba<br />
o Saqriani diabeti<br />
o Tan<strong>da</strong>yolili an SeZenili imunodeficiti<br />
o mZime qronikuli <strong>da</strong>avadeba<br />
o gamofitva, kaxeqsia<br />
o onkologiuri <strong>da</strong>avadebebi, qimioTerapia an sxivuri Terapia.<br />
diagnostika<br />
o orofaringeuli kandidozis diagnostika efuZneba klinikur niSnebs,<br />
gasinjvas <strong>da</strong> <strong>da</strong>zianebuli ubnebi<strong>da</strong>n aRebuli masalis mikroskopul<br />
<strong>da</strong>Tvalierebas.<br />
o piris Rrus <strong>da</strong>Tvalierebisas vnaxulobT balTis formis TeTr<br />
nadebs SewiTlebul <strong>da</strong> anTebad lorwovan garsze.<br />
o anTeba SeiZleba gavrceldes sasaze, xaxaze, RrZilebze, enasa <strong>da</strong><br />
loyis lorwovanze. ena <strong>da</strong>zianebisas xdeba gluvi, wiTeli <strong>da</strong><br />
dvrilebi swordeba.<br />
o kandidozuri ezofagitis <strong>da</strong> filtvebis aspergilozis SemTxvevebSi<br />
diagnozis <strong>da</strong><strong>da</strong>sturebisTvis aucilebelia qsovilis bioftatis<br />
histologiuri gamokvleva.<br />
o <strong>aiv</strong> inficirebulebs erTxel mainc uviTardebaT piris Rrusa <strong>da</strong><br />
xaxis kandidozi. is sicocxlisTvis saSiSi ar aris, magram iwvevs<br />
ylapvis gaZnelebas<br />
o mkerdis tkivils, romelic Zlierdeba ylapvisas.<br />
o diseminirebuli kandidozis <strong>klinikuri</strong> gamovlinebebia: cxeleba <strong>da</strong><br />
<strong>da</strong>zianebul organoebTan <strong>da</strong>kavSirebuli simptomebi (mag: Tvalis<br />
<strong>da</strong>zianebisas_sibrmave).<br />
<strong>mkurnaloba</strong>AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA<br />
o piris Rrus kandidozisa <strong>da</strong> kandidozuri vulvovaginitis<br />
<strong>mkurnaloba</strong> iwyeba adgilobrivi araZviradRirebuli antimikozuri<br />
preparatebiT. mag.: nistatini, mikonazoli, klotrimazoli.<br />
o<br />
diseminirebuli kandidozisa <strong>da</strong> aseve, adgilobrivi mkurnalobis<br />
araefeqturobis dros, iniSneba sistemuri antimikozuri agentebi,<br />
mag:ketokonazoli, flukonazoli, itrakonazoli an amfotericin B.<br />
o im pacientebSi, romlebic imyofebian metadoniT, rogorc opioid-<br />
CanacvlebiT Terapiaze gasaTvaliswinebelia metadonis<br />
urTierTqmedeba flukonazolTan, itrakonazolTan an<br />
ketokonazilTan.<br />
o rekomen<strong>da</strong>ciebi kandidozis mkurnalobis Sesaxeb mocemulia me-28 _<br />
-29-30 cxrilebSi.<br />
cxrili 28. piris Rrus kandidozis <strong>mkurnaloba</strong> (AI)<br />
antimikozuri<br />
agenti<br />
doza<br />
M miRebis<br />
sixSire miRebis gza<br />
mkurnalobis<br />
xangrZlivoba<br />
mkurnalobis pirveli rigis sqemebi (24)<br />
mikonazoli tabletebi dReSi adgilobrivad 7 dRe<br />
gasawovad erTxel<br />
an<br />
flukonazoli 100 mg 2-jer dReSi PO 7 dRe<br />
84
3 dRe<br />
Semdeg<br />
erTxel<br />
dReSi 4 dRe<br />
mkurnalobis meore rigis sqemebi (25)<br />
itrakonazoli 200-400 mg dReSi<br />
erTxel<br />
PO<br />
7 dRe<br />
cxrili 29. vaginaluri kandidozis <strong>mkurnaloba</strong> (AI)<br />
antimikozuri<br />
agenti<br />
doza M miRebis<br />
sixSire<br />
miRebis<br />
gza<br />
mkurnalobis<br />
xangrZlivoba<br />
pirveli rigis sqemebi<br />
flukonazoli 100 mg erTjera<strong>da</strong>d PO erTjera<strong>da</strong>d<br />
klotrimazoli 500 mg erTjera<strong>da</strong>d vaginalurad erTjera<strong>da</strong>d<br />
meore rigis sqemebi<br />
ketokonazoli 200 mg 2-jer dReSi PO 3 dRe<br />
ketokonazoli 200 mg dReSi PO<br />
7 dRe<br />
erTxel<br />
SemanarCunebeli Terapia<br />
nistatini 2-4 mln IU 2-jer dReSi PO 10 dRe<br />
Aan<br />
flukonazoli 50-200 mg dReSi PO<br />
yoveldRe<br />
erTxel<br />
mesame rigis sqemebi<br />
ketokonazoli 200 mg dReSi<br />
erTxel<br />
itrakonazoli 100 mg dReSi<br />
erTxel<br />
PO<br />
PO<br />
<strong>da</strong>mokidebuli<br />
pasuxze,<br />
Cveulebriv 7-<br />
10 dRe<br />
<strong>da</strong>mokidebuli<br />
pasuxze,<br />
Cveulebriv 7-<br />
10 dRe<br />
cxrili 30. ezofaguri <strong>da</strong> diseminirebuli kandidozebis<br />
<strong>mkurnaloba</strong> (AI)<br />
antimikozuri<br />
agenti<br />
doza M miRebis<br />
sixSire<br />
miRebis<br />
gza<br />
mkurnalobis<br />
xangrZlivoba<br />
pirveli rigis sqemebi<br />
ketokonazoli 200-400 mg 2-jer dReSi PO 21 dRe<br />
Aan<br />
flukonazoli<br />
(ketokonazolze<br />
efeqturia)<br />
200-400 mg<br />
Semcirdes<br />
<strong>klinikuri</strong><br />
Sedegis<br />
mixedviT 3<br />
dRis Semdeg<br />
dReSi<br />
erTxel<br />
85<br />
PO/IV<br />
14 dRe
100 mg/dReSi<br />
meore rigis sqemebi<br />
amfotericini B 0,3-0,5 mg/kg IV 10-14 dRe<br />
Aan<br />
itrakonazoli 200-400 mg dReSi<br />
erTxel<br />
PO<br />
2 kvira<br />
o kandidozuri ezofagitis mkurnalobis Semdeg saWiroa xangrZlivi<br />
SemanarCunebeli Terapia flukonazoliT 50-100 mg/dReSi yoveldRe,<br />
an itrakonazoliT 100 mg/dReSi yoveldRe, an ketokonazoliT 200<br />
mg/dReSi yoveldRe.<br />
o Tu <strong>mkurnaloba</strong> araefeqturia un<strong>da</strong> gamoiricxos virusuli<br />
(citomegalovirusuli an herpesuli) ezofagiti ezofagoskopiiT.<br />
o Candi<strong>da</strong> glabrata. C. krusei <strong>da</strong> C. tropicalis rezistentulia flukonazolis<br />
mimarT zogierT SemTxvevebSi. saWiroa nimuSebis kulivireba,<br />
SesaZlebelia savaraudo testireba <strong>da</strong> amfotericin B <strong>da</strong>niSvna<br />
ufro efeqturia. vorikonazoli, posakonazoli <strong>da</strong> kaspofungini<br />
axali antimikozuri medikamentebia, romelTa mimarT arcerTi<br />
gamomwvevi ar aris rezistentuli, maT Soris Aspergillus; yvela<br />
maTgani ZviradRirebulia. vorikonazoli ar un<strong>da</strong> <strong>da</strong>iniSnos<br />
efavirenzTan <strong>da</strong> ritonavirTan erTad. pacientebi, romlebic<br />
Rebuloben proteazas inhibitorebs vorikonazolTan erTad<br />
saWiroeben gverTiTi efeqtebis mWidro monirtorings (26).<br />
3.1.7. kriptokokuli meningiti<br />
o kriptokokozi xSirad mimdinareobs meningitis formiT, ufro<br />
iSviaTad viTardeba pnevmonia <strong>da</strong> diseminirebuli <strong>infeqcia</strong>.<br />
o kriptokokuli meningiti erT-erTi gavrcelebuli sistemuri<br />
mikozia <strong>aiv</strong>/<strong>SidsiT</strong> <strong>da</strong>avadebulebSi.<br />
o <strong>avadmyofTa</strong> sicocxlis xangrZlivoba mkurnalobis gareSe Tveze<br />
naklebia.<br />
diagnostikaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA<br />
kriptokokozis diagnozireba Se<strong>da</strong>rebiT advilia. pacienti uCivisL Tavis<br />
tkivils, cxelebas, saxezea kefis kunTebis regidoba, Tavis qalis<br />
nervebis <strong>da</strong>zianeba, cnobierebis <strong>da</strong>rRveva, komatozuri mdgomareoba.<br />
meningitis niSnebi, maT Soris, cxeleba <strong>da</strong> kefis kunTebis rigidoba<br />
xSirad ar aRiniSneba. liqvors acentrifugireben, miRebul naleqs<br />
ikvleven mikroskopis qveS tuSis wveTis India ink <strong>da</strong>matebis Semdeg.<br />
o preparatSi naxuloben sqeli kafsuliT <strong>da</strong>farul safuaris<br />
ujredebs.<br />
o SesaZlebelia kriptokokis kulturis gamoyofa Tavzurgtvinis<br />
siTxi<strong>da</strong>n<br />
o gamoiyeneba Sratis <strong>da</strong> Tavzurgtvinis siTxis gamokvleva<br />
kriptokokul antigenze.<br />
<strong>mkurnaloba</strong>AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA<br />
86
ekomen<strong>da</strong>cibi kriptokokuli meningitis mkurnalobis Sesaxeb<br />
mocemulia me-31 cxrilSi.<br />
cxrili 31. kriptokokuli meningitis <strong>mkurnaloba</strong> (AI)<br />
antimikozuri doza<br />
agenti<br />
pirveli rigis sqemebi (27)<br />
amfotericini B 0,7-1,0 mg/kg<br />
+<br />
5-flucitozini 25 mg/kg<br />
M miRebis<br />
sixSire<br />
erTxel<br />
dReSi<br />
4X dReSi<br />
IV<br />
miRebis<br />
gza<br />
mkurnalobis<br />
xangrZlivoba<br />
14 dRe<br />
Semdeg<br />
flukonazoli 400 mg erTxel<br />
dReSi<br />
Semdeg<br />
flukonazoli 200mg erTxel<br />
dReSi<br />
meore rigis sqemebi<br />
amfotericini B 0,7-1,0 mg/kg<br />
+<br />
5-flucitozini 25 mg/kg<br />
erTxel<br />
dReSi<br />
4X dReSi<br />
PO sul mcire 10<br />
kvira<br />
PO<br />
IV<br />
mTeli<br />
cxovreba<br />
6-10 kvira<br />
an<br />
amfotericini B 0,7-1,0 mg/kg erTxel<br />
dReSi<br />
IV<br />
an (msubuq SemTxvevebSi)<br />
flukonazoli 400-800 mg erTxel PO<br />
dReSi<br />
Semdeg<br />
flukonazoli 200 mg erTxel PO<br />
dReSi<br />
6-10 kvira<br />
10-12 kvira<br />
mTeli<br />
cxovreba<br />
meoradiAqimioprofilaqtikaAan SemanarCunebeli Terapia<br />
o aucilebelia mTeli cxovrebis manZilze Catardes kriptokokozis<br />
meoradiAqimioprofilaqtika. am mizniT iniSneba flukonazoli 200<br />
mg/dReSiAyoveldRe.<br />
o itrakonazoli 200 mg/dReSiAyoveldRe.<br />
o SemanarCunebeli Terapiis aucilebloba pacientebSi, romelTa<br />
imunuri sistema aRdga (CD4 ricxvi >200 mm3) ar aris <strong>da</strong>mxmare <strong>da</strong> ar<br />
arsebobs raime sawinaaRmdego mosazreba am konkretuli<br />
SemTxvevisTvis.<br />
3.1.8. histoplazmozi<br />
am araxSiri mwvave an qronikuli infeqciis gamowvevia soko Hispoplasma<br />
capsulatum inhalaciuri sporebi.<br />
87
o eqspoziciis Sedegad <strong>da</strong>avadebis ganviTareba <strong>da</strong>mokidebulia<br />
rogorc maspinZlis imunur sistemaze aseve gamomwvevis<br />
raodenobaze.<br />
o diseminaciis aRkveTaze pasuxismgebelia intaqturi ujred<strong>da</strong>mokirebuli<br />
imuniteti. mwvave <strong>da</strong>avadeba gripismagvaria <strong>da</strong><br />
axasiaTebs:<br />
o cxeleba<br />
o anoreqsia<br />
o arTralgia<br />
o mialgia<br />
o mSrali xveleba<br />
o tkivili gul-mkerdis areSi.<br />
o diseminacia imunosupresiul avadmyofSi swarfad viTardeba <strong>da</strong><br />
axasiaTebs:<br />
o wonaSi <strong>da</strong>kleba<br />
o oraluri <strong>da</strong> kanis <strong>da</strong>zianebuli ubnebi<br />
o mkerdis niSnebi<br />
o RviZlis, elenTis <strong>da</strong> limfuri kvanZebis gadideba.<br />
o oraluri ubnebisTvis <strong>da</strong>maxasiaTebelia nekruzuli wylulebi.<br />
sesaZlebelia ganviTareds sasis perforacia <strong>da</strong> rbili qsovilis<br />
destruqcia.<br />
diagnostika<br />
diagnostika efuZneba klinikur suraTs <strong>da</strong> <strong>da</strong>sturdeba sokos kulturiT<br />
an qsovilis bioftatis histologiuri gamokvleviT.<br />
mwvave <strong>da</strong>avadebisas gul-mkerdis rentgenologiuri gamokvleva gviCvenebs:<br />
o Suasayaris limfadenopaTias<br />
o mravlobiT infiltratebs<br />
o qvemo wilis kvanZebs.<br />
o hispoplazmozis diagnostisTvis un<strong>da</strong> Catardes sisxlis <strong>da</strong> kanis<br />
testebi, Tumca isini ar aris farTod gamoyenebuli.<br />
<strong>mkurnaloba</strong><br />
imunokompetentur a<strong>da</strong>mianSi hispoplazmozi TviTgankurnebadia <strong>da</strong> ar<br />
sWirdeba <strong>mkurnaloba</strong>. imunosupresiis SemTxvebSi <strong>mkurnaloba</strong> un<strong>da</strong><br />
Catardes me-14 cxrilSi mocemuli sqemebis mixedviT.<br />
cxrili 32. histoplazmozis <strong>mkurnaloba</strong> (28) (AI)<br />
antifunfaluri<br />
agenti<br />
dozireba miRebis<br />
sixSire<br />
amfotericni B 0.7-1 mg/kg erTxel<br />
dReSi<br />
miRebis gza<br />
IV<br />
xangrZlivoba<br />
10 dRe<br />
sawyis <strong>mkurnaloba</strong>s mohyveba 3 Tviani <strong>mkurnaloba</strong> imunorekonstituciamde<br />
>100 CD4 ujrediT, Sedegi medikamentebiT:<br />
o itrakonazoli 200 mg 2X dReSi PO<br />
o flukonazoli 200 mg 2X dReSi PO<br />
o amfotericini B 1 mg/kg IV kviraSi erTxel.<br />
88
alternatiul reJims warmoadgens itrakonazoli 200 mg samjer dReSi - 3<br />
dRe, Semdeg 200 mg 2X dReSi 12 kvira (sakvebTan erTad).<br />
3.1.9. kapoSis sarkoma<br />
o kapoSis sarkomas iwvevs me-8 tipis herpes virusi (HHV8), romelic<br />
aseve cnobilia kapoSis sarkomasTan asocirebuli herpes virusis<br />
saxeliT (KSHV).<br />
o nebismieri pacienti kapoSis sarkomis savaraudi diagnioziT un<strong>da</strong><br />
gaigzavnos onkologTan.<br />
o imunodeficitis mqone <strong>aiv</strong> inficirebulebSi <strong>da</strong>avadeba mimdinareobs<br />
mZimed, diseminaciis tendenciiT <strong>da</strong> ufro male progresirebs, vidre<br />
<strong>da</strong>avadebis endemuri formis mqone arainficirebul a<strong>da</strong>mianebSi.<br />
diagnostikaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA<br />
kapoSis sarkomis winaswari diagnozi ismeba <strong>klinikuri</strong> suraTis<br />
safuZvelze <strong>da</strong> <strong>da</strong>sturdeba kanis <strong>da</strong>zianebuli ubnebi<strong>da</strong>n aRebuli<br />
bioptatis histologiuri gamokvleviT.<br />
<strong>klinikuri</strong> niSnebi moicavs Semdegs:<br />
o kapoSis sarkomis elementebi SeiZleba aRmovaCinoT kanisa <strong>da</strong><br />
lorwovanis nebismier areze. kanze elementebi warmodgenilia<br />
cisferi an mewamuli feris papulebiT an kvanZebiT, araiSviaTad<br />
garSemo arsebuli kanis limfuri SeSupebiT. xSirad ziandeba sasa,<br />
filtvebi kuW-nawlavis traqti <strong>da</strong> limfuri kvanZebi.<br />
o piris RruSi kapoSis sarkomis elementebi yvelaze xSirad<br />
ganlagebulia magar sasaze, iSviaTad enaze, xaxaze, nuSura<br />
jirkvlebsa <strong>da</strong> RrZilebze. isini warmoadgenen mewamuli feris<br />
papulebs, romlebic Cveulebriv ar aris mtkivneuli. xan<strong>da</strong>xan<br />
SeiZleba Segvxvdes msxvili elementebic <strong>da</strong> elementebi kanze.<br />
o filtvis parenqimis <strong>da</strong>zianeba atarebs infiltraciul xasiaTs.<br />
xSirad viTardeba sunTqvis ukmarisoba. filtvis infiltraciuli<br />
<strong>da</strong>zianebis mqone avadmyofebs arakeTilsaimedo prognozi aqvT <strong>da</strong><br />
maTSi maRalia sikvdilianoba.<br />
o aucilebelia ganvasxvavoT kapoSis sarkoma baqteriuli<br />
angiomatozisagan, romelic warmoadgens infeqciur <strong>da</strong>avadebas<br />
(gamomwvevi: Bartonella spp.) <strong>da</strong> aseve gvxvdeba <strong>aiv</strong> inficirebulebSi.<br />
<strong>mkurnaloba</strong>AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA<br />
o kapoSis sarkomis <strong>mkurnaloba</strong> tardeba onkologis mier.<br />
o kapoSis sarkoma avTvisebiani simsivnea. lokaluri formis<br />
samkurnalod gamoiyeneba sxivuri Terapia, generalizirebuli<br />
formis samkurnalod iniSneba citotoqsiuri qimioTerapia.<br />
o efeqturobis sxva<strong>da</strong>sxva xarisxiT gamoiyeneba simsivnis<br />
sawinaaRmdego preparatebis Semdegi kombinaciebi:<br />
o liposomuri doksorubiciniT monoTerapia (saukeTeso Sedegebi) (29-<br />
31) (BII)<br />
o bleomicini<br />
o vinkristini<br />
o <strong>da</strong>unorubicini<br />
o vinblastini<br />
o etopozidi.<br />
89
o remisiis miRweva Zalian Znelia <strong>da</strong> pacientebis umetesobas<br />
uviTardebaT recidivi.<br />
o calkeuli elementebi SeiZleba moSordes qirurgiulad an<br />
lazeris, Txevadi azotis (relapsis maRali done) <strong>da</strong> <strong>da</strong>sxivebis<br />
zemoqmedebiT. demonstrirebuli iyo uSualod kapoSis<br />
sarkomatozul kvanZSi bleomicinis Seyvanis efeqturoba.<br />
o kapoSis sarkoma SesaZloa <strong>da</strong>eqvemdebaros mxolod arT-s <strong>da</strong> nelnela<br />
alagdes.<br />
3.1.10. saSvilosnos yelis kibo<br />
o saSvilosnos yelis kibo erT-erTi xSiri saxea simsivneebis,<br />
romelic mizezia qalTa sikvdilianobis mTels msoflioSi.<br />
savaraudo ricxvi axali SemTxvevebisa msoflioSi Seadgens 500 000<br />
weliwadSi (32) (AI).<br />
o saSvilosnos yelisa <strong>da</strong> vulvis kiboswinare mdgomareobisa <strong>da</strong><br />
kibos ganviTarebaSi wamyvan etiologiur faqtors warmoadgens<br />
a<strong>da</strong>mianis papilomavirusi.<br />
o <strong>aiv</strong> inficirebul qalebSi cervikaluri intraepiTeluri neoplaziis<br />
(cin) riski 5-10-jer maRalia, maTi Pap nacxi paTologiuria<br />
SemTxvevaTa 20-40%-Si (33,34) (BII).<br />
diagnostika<br />
o <strong>aiv</strong> inficirebul qals un<strong>da</strong> Cautardes ginekologiuri gasinjva <strong>da</strong><br />
saSvilosnos yelis nacxis citologiuri gamokvleva Pap<br />
papanikolaus SeRebvis meTodiT. ginekologiuri <strong>da</strong> citologiuri<br />
gamokvleva un<strong>da</strong> ganmeordes eqvi Tvis Semdeg <strong>da</strong> yovelwliurad.<br />
o saSvilosnos yelis kiboze eWvis SemTxvevaSi pacienti un<strong>da</strong><br />
gasinjos ginekolog-onkologma <strong>da</strong> saWiroebis SemTxvevaSi<br />
gaigzavnos onkodispanseris ginekologiur ganyofilebaSi.<br />
3.1.11. sxva avTvisebiani warmonaqmnebi<br />
imunodeficitis mqone <strong>aiv</strong> inficirebul pacientebSi maRalia limfomiT<br />
avadoba, maT Soris arahojkinis, cns-is pirveladi <strong>da</strong> berkitis<br />
limfomebiT, aseve brtyelujredovani kiboTi. yvela <strong>aiv</strong> inficirebuli<br />
simsivneze eWvis SemTxvevaSi un<strong>da</strong> gaigzavnos onkologiur klinikaSi.<br />
3.1.11.1.arahojkinis limfoma<br />
imunodeficitis mqone <strong>aiv</strong> inficirebulebSi xSirad gvxvdeba arahojkinis<br />
limfomebi B ujredovani, ufro iSviaTad T ujredovani. misi ganviTareba<br />
ar aris <strong>da</strong>mokidebuli CD4 ujredebis ricxvze. varaudoben, rom am<br />
<strong>da</strong>avadebis paTogenezSi did rols TamaSobs epStein-baris an romelime<br />
sxva virusi.<br />
simsivnuri arahojkinis limfomis ujredebis deteqcia SesaZlebelia<br />
limfur kvanZebSi, kunTebSi, RviZlSi, elenTaSi, gulSi, TvinSi <strong>da</strong> kuWnawlavis<br />
traqtSi <strong>da</strong> Se<strong>da</strong>rebiT iSviaTad ZvlebSi.<br />
90
o simptomebi mravalferovania.<br />
o SeSupebuli limfuri kvanZebi SesaZlebelia palpirdebodes<br />
sxva<strong>da</strong>sxva adgilze.<br />
o cxeleba, wonaSi kleba <strong>da</strong> sisuste xSiria, Tumca ara aucilebeli.<br />
o <strong>da</strong>avadebis stadiis gansazRvrisTvis (I-IV) aucilebelia Semdegi<br />
gamokvlevebi – cerebruli, cervikaluri, Torakaluri <strong>da</strong><br />
abdominaluri kompiuteruli aqsialuri tomografia (CAT)<br />
skanireba, Zvlis tvinis <strong>da</strong> Tav-zurg-tvinis siTxis biofsia <strong>da</strong><br />
gastrodkopia. diagnozi <strong>da</strong>sturdeba hiperplazirebuli limfuri<br />
kvanZis bifsiiT, histologiuri gamokvleviT.<br />
3.1.11.2. berkitis-tipis limfoma <strong>aiv</strong> inficirebulebSi<br />
berkitis limfoma ara hojkinis limfomis erT-erTi subtipia. berkitis<br />
limfoma asocirebulia <strong>aiv</strong> infeqciiasTan <strong>da</strong> SeiZleba ganviTardes<br />
gamoxatuli imunodeficitis ganviTarebamde. <strong>da</strong>dgenilia kavSiri am<br />
<strong>da</strong>avadebasa <strong>da</strong> epStein-baris viruss Soris.<br />
diagnostika<br />
berkitis –tipis limfomis diagnozi ismeba limfuri kvanZis <strong>da</strong> simsivnis<br />
bioptatebis histologiuri gamokvleviT.<br />
ara hojkinis, berkitis-tipis <strong>da</strong> cns-is lomfomebis <strong>mkurnaloba</strong><br />
o ara-hojkinis limfomebis samkurnalod efeqturia CHOP reJimi, un<strong>da</strong><br />
Catardes 6 kursi (ganmeorebebi aucilebelia sruli remisiis<br />
misaRebad)<br />
o prednizoloni 100 mg/dReSi erTxel 5 dRe<br />
o vinkristini (onkovini) 1,4 mg/m2 (maqsimum 2 mg/dReSi) erTi doza<br />
mkurnalobis pirvel dRes<br />
o ciklofosfamidi 750 mg/m2/dReSi erTi doza mkurnalobis pirvel<br />
dRes<br />
o doqsorubicini (hidroqsi<strong>da</strong>unomicini) 50 mg/m2/dReSi erTi doza<br />
mkurnalobis pirvel dRes.<br />
meore cikli iwyeba yovel 21-e dRes (dRe 22-e mohyveba I dRes)<br />
o EPOCH reJimi, romelic moicavs etopozids, prednozolons,<br />
vinkristins, ciklofisfamids <strong>da</strong> <strong>da</strong>unorubicins an diqsirubicins<br />
efeqturia arT-sTan kombinaciaSi. igi efuZneba gagrZelebiT<br />
infuzias 96 saaTis ganmavlobaSi, romelc Semdegia:<br />
o etopozidi 50 mg/m2 dReSi (centraluri venuri xaziT)<br />
o doqsorubucuni 10 mg/m2/dReSi (centraluri venuri xaziT)<br />
o vinkristini 0,4 mg/m2/dReSi (maqs 2 mg/kviraSi) (centraluri venuri<br />
xaziT)<br />
o ciklofosfamidi 375 mg/m2 me-5 dRes mxolod, bolusiT<br />
(centraluri venuri xaziT)<br />
o prednizoloni 100 mg/dReSi pirveli 5 dRe erTxel dReSi.<br />
reJimi un<strong>da</strong> ganmeordes yovel 21 dReSi sanam ar Catardeba 6 cikli.<br />
o berkitis–tipis limfomis menejmenti ar gansxvavdeba sxva<br />
limfomebis mkurnalobisgan <strong>da</strong> poasuxobs CHOP <strong>da</strong> EPOCH reJimebs<br />
(BII). swrafad mzardi limfomis <strong>mkurnaloba</strong> ufro agresiuli<br />
91
qimioTerapiiT (mag : B-ALL reJimi) diskusiis Temas warmoadgens <strong>da</strong><br />
specifikuri rekomen<strong>da</strong>ciebi dRevandeli dRisTvis ar arsebobs<br />
(35,36) (Va).<br />
o berkitis–tipis limfomebis SemTxvevebSi qimioTerapias Tan un<strong>da</strong><br />
axldes <strong>da</strong>sxiveba savaraudo pirveladi keris.<br />
o SesaZlebelia ara hojkinis limfomebis <strong>mkurnaloba</strong> CD4 ujredebis<br />
ricxvisgan <strong>da</strong>moukideblad, Tumca mkurnalobis efeqturobisTvis<br />
arT un<strong>da</strong> <strong>da</strong>iniSnos ufro adre. qimioTerapiis ganmavlobaSi CD4<br />
ujredebis ricxvi >350 mm3 <strong>da</strong>kavSirebulia relapsis maRal<br />
maCveneblebTan arT gareSe (37) (BII).<br />
o intakranilauri limfomebis (metastazebi) sasurvelia Tavis<br />
<strong>da</strong>sxiveba, simsivnis sawinaaRmdego preparatebTan <strong>da</strong><br />
glukokortikoidebTan erTad (38) (BII).<br />
cns-is pirveladi limfomis dros erTaderTi efeqturi mtkicebulebaze<br />
<strong>da</strong>fuZnebuli Terapiaa sxivuri Terapia. <strong>da</strong>uyonebliv un<strong>da</strong> <strong>da</strong>iwyos arT<br />
(39,40) (AI).<br />
3.1.12. centraluri nervuli sistemis infeqciebi<br />
a<strong>da</strong>mianis imunodeficitis virusis nervul sistemaze pir<strong>da</strong>pir<br />
zemoqmedebas mivyavarT encefalopaTiis, mielopaTiis <strong>da</strong> periferiuli<br />
neiropaTiis ganviTarebamde. <strong>aiv</strong> <strong>infeqcia</strong>s ukavSireben iseT nevrologiur<br />
<strong>da</strong>rRvevebs, rogoricaa<br />
o Tavis tvinis nivTierebis atrofia <strong>da</strong> degeneracia,<br />
o Sids-demenciis kompleqsi,<br />
o naTxemis atrofia,<br />
o vakuoluri mielopaTia,<br />
o saxis nervis <strong>da</strong>mbla,<br />
o gien-baris sindromi <strong>da</strong><br />
o sensorul-motoruli periferiuli neiropaTia tkivilis sindromiT.<br />
cns-is <strong>da</strong>rRvevebi aseve SeiZleba mogvces baqteriulma, virusulma <strong>da</strong><br />
sokovanma oportunistulma infeqciebma (mag: kriptokokulma meningitma).<br />
3.1.13. toqsoplazmozi<br />
ganviTarebul qveynebSi toqsoplazmozi farTod aris gavrcelebuli.<br />
toqsoplazmozi iwvevs Tavis tvinSi mravlobiTi anTebadi ubnebis<br />
warmoqmnas. <strong>aiv</strong> inficirebulebSi toqsoplazmozi ZiriTa<strong>da</strong>d<br />
gamovlindeba encefalitis an diseminirebuli <strong>da</strong>avadebis saxiT.<br />
diagnostikaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA<br />
toqsoplazmozze eWvi SeiZleba gamoiTqvas <strong>klinikuri</strong> suraTis mixedviT:<br />
o cnobierebis <strong>da</strong>rRveva<br />
o cxeleba<br />
o krunCxvebi<br />
o Tavis tkivili<br />
o kerovani nevrologiuri simptomatika motoruli deficitis,<br />
kraniuli nervis parezis, moZraobis SezRudvis, dismetriis,<br />
mxedvelobis <strong>da</strong>kargvis <strong>da</strong> afaziis CaTvliT.<br />
92
o Tavis tvinis MAC an MRI skanirebiT aRmoCndeba mravlobiTi<br />
rgoliseburi kerebi.<br />
o Tu es meTodebi ar aris xelmisawvdomi diagnozis <strong>da</strong>dgenaSi<br />
gvexmareba serologiuri testebi toqsoplazmis sawinaaRmdegod<br />
gamomuSavebul antisxeulebze (IgG klasis).<br />
o cerebraluri toqsoplazmozis mqone pacientebis umravlesobas<br />
aReniSneba Toxoplasma gondii-iT gamowveuli infeqciis ga<strong>da</strong>tanis<br />
serologiuri niSnebi.<br />
o toqsoplazmozze eWvis dros iniSneba sacdeli <strong>mkurnaloba</strong><br />
o 2 kviris manZilze mkurnalobis araefeqturobis SemTxvevebSi dgeba<br />
sakiTxi Tavis tvinis biofsiis Sesaxeb.<br />
o diagnozs a<strong>da</strong>sturebs Tavis tvinis qsovilis histologiuri<br />
gamokvleva.<br />
<strong>mkurnaloba</strong>A<br />
AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA<br />
cxrili 15. toqsoplazmozis <strong>mkurnaloba</strong> (41-43) (AI)<br />
preparati doza M miRebis<br />
sixSire<br />
miRebis<br />
gza<br />
mkurnalobis<br />
xangrZlivoba<br />
<strong>mkurnaloba</strong><br />
pirimetamini 200 mg erTjera<strong>da</strong>d PO<br />
erTjera<strong>da</strong>d<br />
(gajerebiTi doza)<br />
Semdeg<br />
pirimetamini 25 mg<br />
3-jer dReSi PO<br />
6-8 kvira<br />
an 50 mg 2-jer dReSi<br />
+<br />
foliumis 15 mg dReSi PO<br />
6-8 kvira<br />
mJava<br />
erTxel<br />
+<br />
sulfadiazini 1 g 4-jer dReSi PO 6-8 kvira<br />
am sqemaSi sulfadiazini SeiZleba Seicvalos:<br />
• klin<strong>da</strong>miciniT 600 mg i/v an PO dReSi 4-jer 6 kvira<br />
• azitromiciniT 1200 mg PO dReSi erTxel 6 kvira<br />
• klariTromiciniT 1 g PO 2-jer dReSi 6 kvira<br />
• atovakvoniT 750 mg PO 4-jer dReSi 6 kvira.<br />
• zogierT pacients sWirdeba xangrZlivi <strong>mkurnaloba</strong><br />
toqsoplazmozis gamo. ga<strong>da</strong>wyvetileba efuZneba klinikur<br />
mdgomareobas <strong>da</strong> ganmeorebiT CAT skanirebas.<br />
• meoradi profilaqtika grZeldeba efeqturi reJimis ganaxevrebuli<br />
dozebiT manamde sanam CD4 ujredebs ricxvi sami Tvis ganmavlobaSi<br />
stabulurad ar moimatebs (200 ujredi <strong>da</strong> meti).<br />
3.1.14. martivi herpesiT gamowveuli infeqciebi<br />
• martivi herpesiT gamowveuli infeqciebi xSiria klinikur<br />
praqtikaSi.<br />
• herpesis pirvelad epizods xSirad axlavs recidivi.<br />
93
• imunodeficitis mqone pacientebSi <strong>da</strong>zianeba SeiZleba iyos vrceli<br />
<strong>da</strong> persistuli, aseve, SesaZlebelia moxdes infeqciis diseminacia.<br />
• martivi herpesi aris meningitisa <strong>da</strong> meningoencefalitis gamomwvevi.<br />
diagnostikaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA<br />
• diagnozi ZiriTa<strong>da</strong>d ismeba tipiuri <strong>klinikuri</strong> gamovlinebebiT.<br />
• herpesuli gamonayari Cveulebriv warmodgenilia vezikulebiTa <strong>da</strong><br />
mtkvneuli eroziebiT, romlebic ganlagebulia piris irgvliv,<br />
cxviris nestoebze, tuCebsa <strong>da</strong> sasqeso organoebze.<br />
• diseminirebuli martivi herpesiT gamowveuli infeqciis diagnozis<br />
<strong>da</strong>sma xSirad Znelia. amisaTvis saWiroa laboratoriuli kvlevebi,<br />
rogoricaa virusis kulturis gamoyofa, radio-imunoblotingis<br />
meTodi, imunofluoroescencia <strong>da</strong> monoklonuri antisxeulebiT<br />
testireba.<br />
• herpesul encefalits mivyavarT Tavis tvinSi <strong>da</strong>zianebis<br />
mravlobiTi kerebis ganviTarebamde, romelic TvalsaCinoa CAT<br />
skanirebiT.<br />
<strong>mkurnaloba</strong>AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA<br />
mkurnalobis sqemebi mocemulia me-33 – 34-e cxrilebSi.<br />
cxrili 16. martivi herpesvirusuli infeqciis msubuqi formis<br />
<strong>mkurnaloba</strong> (44-47(AI)<br />
antivirusuli<br />
agenti<br />
doza MmiRebis<br />
sixSire<br />
M miRebi<br />
gza<br />
mkurnalobis<br />
xangrZlivoba<br />
pirveli rigis sqemebi<br />
acikloviri 400 mg 3-jer dReSi PO 7-10 dRe<br />
an<br />
famcikloviri 250 mg 3-jer dReSi PO 7-10 dRe<br />
an<br />
valacikloviri 1 g 2-jer dReSi PO 7-10 dRe<br />
cxrili 17. martivi herpesvirusuli infeqciis recidivis<br />
<strong>mkurnaloba</strong> (44-47) (AI)<br />
antivirusuli<br />
agenti<br />
doza MmiRebis<br />
sixSire<br />
M miRebi<br />
gza<br />
mkurnalobis<br />
xangrZlivoba<br />
pirveli rigis sqemebi<br />
acikloviri 800 mg 5-jer dReSi PO 7-10 dRe<br />
an<br />
famcikloviri 500 mg 3-jer dReSi PO 7-10 dRe<br />
an<br />
valacikloviri 1 g 2-jer dReSi per os 7-10 dRe<br />
cxrili 18. martivi herpesvirusuli infeqciis mZime formis<br />
<strong>mkurnaloba</strong> (44-47) (AI)<br />
antivirusuli doza MmiRebis M miRebis mkurnalobis<br />
94
agenti sixSire gza xangrZlivoba<br />
pirveli rigis sqemebi<br />
acikloviri 10 mg/kg 3-jer dReSi IV 7-10 dRe<br />
an<br />
valacikloviri 1 g 2-jer dReSi PO 7-10 dRe<br />
cxrili 19. martivi herpesvirusuli infeqciis mZime visceraluri<br />
formebis <strong>mkurnaloba</strong> (44-47) (AI)<br />
antivirusuli<br />
agenti<br />
doza MmiRebis<br />
sixSire<br />
M miRebi<br />
gza<br />
mkurnalobis<br />
xangrZlivoba<br />
pirveli rigis sqemebi<br />
acikloviri 10 mg/kg 3-jer dReSi IV 14-21 dRe<br />
meore rigis sqema<br />
foskarneti<br />
(aciklovirze<br />
rezistentobis<br />
SemTxvevebSi)<br />
40-60 mg/kg 3-jer dReSi IV 14 dRe<br />
3.1.15. sartyliseburi liqeni (Herpes zoster) (48) (AI)<br />
• varicella-zoster-is virusiT gamowveuli pirveladi <strong>infeqcia</strong><br />
mimdinareobs diseminirebuli formiT.<br />
• bavSvebSi viTardeba Cutyvavilas <strong>klinikuri</strong> suraTi, Tumca<br />
a<strong>da</strong>mianTa umravlesobas es <strong>infeqcia</strong> ga<strong>da</strong>aqvs sub<strong>klinikuri</strong> formiT.<br />
• pirveladi infeqciis Semdeg virusi wlebis ganmavlobaSi latentur<br />
mdgomareobaSi inaxavs Tavs zurgis tvinis gangliebSi.<br />
• imunitetis <strong>da</strong>qveiTebasTan erTad virusi mravldeba <strong>da</strong> viTardeba<br />
kanis <strong>da</strong>zianebuli ubnebiT nervis an dermatomis gaswvriv.<br />
• SesaZloa moxdes infeqciis diseminacia kanis, nervuli sistemis,<br />
filtvebis <strong>da</strong> lorwovani garsebis CarTviT paTologiur procesSi.<br />
• imunodeficitis fonze zosteri multidermatomulia, persistirebs,<br />
axasiaTebs Zlieri tkivili <strong>da</strong> sisuste.<br />
diagnostikaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA<br />
diagnozi Cveulebriv ismeba <strong>klinikuri</strong> suraTis mixedviT.<br />
<strong>mkurnaloba</strong>AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA<br />
mkurnalobis sqemebi mocemulia 35-e <strong>da</strong> 36-e cxrilebSi.<br />
cxrili 20 sartyliseburi liqenis (kanis formis) <strong>mkurnaloba</strong> (AI)<br />
antivirusuli<br />
agenti<br />
doza MmiRebis<br />
sixSire<br />
M miRebi<br />
gza<br />
mkurnalobis<br />
xangrZlivoba<br />
pirveli rigis sqemebi<br />
acikloviri 800 mg 5-jer dReSi PO 7-10 dRe an<br />
vezikulis<br />
gaSrobamdeE<br />
95
an<br />
famcikloviri 500 mg 3-jer dReSi PO 7-10 dRe<br />
an<br />
valacikloviri 1 g 3-jer dReSi PO 7-10 dRe<br />
cxrili 21. Tvalis sartyliseburi liqenis, infeqciis diseminirebuli<br />
<strong>da</strong> visceruli formebis <strong>mkurnaloba</strong><br />
antivirusuli<br />
agenti<br />
doza MmiRebis<br />
sixSire<br />
M miRebi<br />
gza<br />
mkurnalobis<br />
xangrZlivoba<br />
pirveli rigis sqemebi<br />
acikloviri 10 mg/kg 3-jer dReSi IV 7-10 dRe<br />
an<br />
valacikloviri 1 gr 3-jer dReSi PO 7-10 dRe<br />
an<br />
famcikloviri 500 mg 3-jer dReSi PO 7-10 dRe<br />
meore rigis sqema<br />
foskarneti<br />
60 mg/kg<br />
an<br />
40 mg/kg<br />
2-jer dReSi<br />
an<br />
3-jer dReSi<br />
IV<br />
7-10 dRe<br />
• post-herpesuli nevralgia xSiri <strong>da</strong> seriozuli problemaa.<br />
<strong>da</strong>zianebul dermatomebSi viTardeba Zlieri tkivili.<br />
• tkivilis kontroli mniSvnelovania <strong>da</strong> tkivilis kupirebis mizniT<br />
niSnaven arasteroidul anTebis sawinaaRmdego preparatebi.<br />
• Tu tkivili gaxangrZliv<strong>da</strong> iniSneba amitriptilini, karbamazepini an<br />
fenitoini.<br />
3.1.16. citomegalovirusuli <strong>infeqcia</strong><br />
imunodeficitis fonze citomegalovirusma SeiZleba <strong>da</strong>azianos<br />
sxva<strong>da</strong>sxva organoebi <strong>da</strong> sistemebi. simptomebi moicavs:<br />
• cxeleba <strong>da</strong> diarea citomegalovirusuli kolitis Ddros<br />
• dispnoe- pnevmoniis dros<br />
• sibrmave - retinitis dros<br />
• citomegalovirusulma <strong>infeqcia</strong>m SeiZleba gamoiwvios piris Rrus<br />
lorwovanis mtkivneuli wylulebi, rac iwvevs kvebis reJimis<br />
<strong>da</strong>rRvevas.<br />
diagnostikaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA<br />
• pacientebs, romelTa CD4
cxrili 37. citomegalovirusuli infeqciiT gamowveuli kuW-nawlavis<br />
traqtisa <strong>da</strong> cns-is <strong>da</strong>zianebebis <strong>da</strong> retinitis <strong>mkurnaloba</strong> (49-53) (AI)<br />
antivirusuli<br />
agenti<br />
doza MmiRebis<br />
sixSire<br />
M miRebi<br />
gza<br />
mkurnalobis<br />
xangrZlivoba<br />
pirveli rigis sqema<br />
gancikloviri 5 mg/kg 2-jer dReSi IV 2-3 kvira<br />
meoradi profilaqtikisTvis aucilebelia gancikloviriT 5 mg/kg IV<br />
dReSi <strong>mkurnaloba</strong>.<br />
cxrili 38. citomegalovirusuli infeqciiT gamowveuli kuW-nawlavis<br />
traqtisa <strong>da</strong> cns-is <strong>da</strong>zianebebis <strong>mkurnaloba</strong> (49-53) (AI)<br />
antivirusuli<br />
agenti<br />
doza MmiRebis<br />
sixSire<br />
M miRebi<br />
gza<br />
mkurnalobis<br />
xangrZlivoba<br />
meore rigis sqemebi<br />
foskarneti 90 mg/kg 2-jer dReSi IV 3 kvira<br />
meoradi profialqtikisTvis aucilebelia foskarnetiT mkurnalobis<br />
xangrZlivi kursi doziT 90mg/kg IV erTxel dReSi.<br />
cxrili 39. citomegalovirusuli retinitis meoradi profilaqtika (49-53)<br />
(AI)<br />
antivirusuli<br />
agenti<br />
doza MmiRebis<br />
sixSire<br />
M miRebi<br />
gza<br />
meore rigis sqemebi<br />
Tvalis implantanti, romelic gamoyofs ganciklovirs<br />
+<br />
valgancikloviri 900 mg<br />
erTxel<br />
dReSi<br />
mkurnalobis<br />
xangrZlivoba<br />
PO manamde sanam CD4<br />
ujredebi ricxvi ar<br />
moimatebs 100-150 mm3<br />
minimum 3 Tvis<br />
ganmavlobaSi<br />
meoradi profilaqtikis Sewyveta SesaZlebelia 6 Tvis Semdeg <strong>da</strong><br />
imunorekonstituciisas - CD4 100-150 mm3.<br />
3.1.17. epStein-baris virusiT gamowveuli infeqciebi<br />
• epStein-baris virusi miekuTvneba herpesvirusebis ojaxs. am virusiT<br />
gamowveuli infeqciebi gavrcelebulia, rogorc <strong>aiv</strong> inficirebul,<br />
ise arainficirebul a<strong>da</strong>mianebSi.<br />
• <strong>aiv</strong> inficirebulebulTa orofaringealur sekretSi gvxvdeba<br />
virusuli nawilakebis momatebuli raodenoba <strong>da</strong> antisxeulebis<br />
ufro maRali titri, vidre arainficirebulebSi.<br />
• varaudoben, rom epStein-baris virusi iwvevs ramdenime <strong>da</strong>avadebas,<br />
maT Soris:<br />
• oraluri Tmovani leikoplakia;<br />
• limfoiduri intersticiuli pnevmoniti (LIP);<br />
• arahojkinis limfomebi;<br />
97
• berkitis-tipis limfoma;<br />
• nazofaringeuli karcinoma;<br />
oraluri Tmovani leikoplakia<br />
• oraluri Tmovani leikoplakia viTardeba, rogorc <strong>aiv</strong><br />
inficirebulebSi, aseve pacientebSi, romelTac utardebaT<br />
transplantaciis Semdgomi imunosupresiuli Terapia.<br />
• <strong>da</strong>zianebul kerebs aqvs ze<strong>da</strong>piri<strong>da</strong>n wamoweuli balTisiburi TeTri<br />
nadebis saxe, romelic ganlagebulia piris RruSi, upiratesad ki<br />
enis kideze. igi lorwovani garsis epiTelis keTilTvisebiani<br />
ga<strong>da</strong>gvarebaa.<br />
• rTulia diferencialuri diagnostika oralur Tmovan<br />
leikoplakiasa <strong>da</strong> piris Rrus kandidozs Soris; araiSviaTia am<br />
<strong>da</strong>avadebaTa erTdrouli arseboba.<br />
• specifikuri <strong>mkurnaloba</strong> ar arsebobs. pacientebisaTvis<br />
rekomendebulia piris Rrus higienis <strong>da</strong>cva.<br />
limfoiduri intersticiuli pnevmoniti<br />
• limfoiduri intersticiuli pnevmoniti upiratesad uviTardebaT<br />
<strong>aiv</strong> inficirebul bavSvebs, magram mozrdilebSic gvxvdeba.<br />
• <strong>da</strong>maxasiaTebelia difuzuri intersticiuli infiltratebis<br />
arseboba filtvebSi, romelic SeiZleba miviCnioT tuberkulozis<br />
an pnevmocisturi pnevmoniis gamovlinebad.<br />
• xSirad limfoiduri intersticiuli pnevmoniti mimdinareobs<br />
filtvis mZime paTologiis niSnebis gareSe.<br />
• specifikuri <strong>mkurnaloba</strong> ar arsebobs.<br />
3.2. ZiriTadi simptomebi<br />
3.2.1. persistuli generalizirebuli limfadenopaTia (pgl) mozrdil<br />
<strong>aiv</strong> inficirebulebSi<br />
• <strong>aiv</strong> infeqciis yvelaze adreul klinikur gamovlinebas warmoadgens<br />
limfuri kvanZebis simetriuli gadideba.<br />
• gadidebuli limfuri kvanZi, rogorc wesi umtkivneulo,<br />
elastiuri konsistenciis moZravi warmonaqmnia. yvelaze advilad<br />
isinjeba kisris, ybisqveSa, iRliisa <strong>da</strong> sazardulis limfuri<br />
kvanZebi.<br />
• persistuli generalizirebuli limfadenopaTia SeiZleba<br />
warmoadgendes <strong>aiv</strong> infeqciis erTaderT gamvlinebas<br />
• persistuli generalizirebuli limfadenopaTia _ es aris limfuri<br />
kvanZebis (1sm diametrze meti) or an meti jgufis gadideba<br />
(sazardulis gar<strong>da</strong>), romelic SenarCunebulia 1 Tveze met xans.<br />
• pgl–s dros limfuri kvanZis biofsiiT Ghistologiurad saxezea<br />
“reaqtiuli hiperplazia” an “folikuluri hiperplazia”.<br />
hiperplaziis mizezis gasarkvevad aucilebelia kimfuri kvanZis<br />
biofsia.<br />
98
diagnostika<br />
gamokvleva aucileblad un<strong>da</strong> moicavdes limfuri kvanZebis Semdegi<br />
jgufebis palpacias:<br />
• kisris wina <strong>da</strong> ukana<br />
• ybisqveSa<br />
• kefisukana<br />
• yuris irgvlivi (yuriswina <strong>da</strong> ukana)<br />
• iRliis orive<br />
• i<strong>da</strong>yvis are<br />
• sazardulis (am jgufis jirkvlebis gadideba janmrTel<br />
pirebSic gvxvdeba)<br />
persistuli generalizebuli limfadenopaTiis mqone <strong>aiv</strong><br />
inficirebulebSi SeiniSneba <strong>aiv</strong> infeqciis sxva gamovlinebebic. maT<br />
Soris:<br />
• piris Rrus kandidozi,<br />
• oraluri Tmovani leikoplakia,<br />
• qavana dermatiti,<br />
• frCxilebis gamuqeba,<br />
• oraluri <strong>da</strong> genitaluri herpesi,<br />
• umizezod wonaSi kleba,<br />
• ucnobi etiologiis cxeleba.<br />
generalizebuli limfadenopaTia <strong>da</strong>maxasiaTebelia sxva<br />
<strong>da</strong>avadebebisaTvisac, kerZod, tuberkulozis, leikozis, limfomis,<br />
kapoSis sarkomis, veneriuli limfogranulomis, sifilisis,<br />
citomegalovirusuli infeqciis, toqsoplazmozis, epStein-baris<br />
virusiT gamowveuli infeqciis, kriptokokozis, histoplazmozisa <strong>da</strong><br />
kanis Cirqovani infeqciebisaTvis, Savi Wirisa <strong>da</strong> B hepatitisaTvis.<br />
limfuri kvanZebis biofsiis Cvenebebi<br />
persistiuli generalizebuli limfadenopaTiis mqone pacientebi<br />
aucilebelia gagzavnil iqnas biofsiaze, Tu maT aReniSnebaT:<br />
• limfuri kvanZebis asimetriuli gadideba<br />
• limfuri kvanZebis gamoxatuli gadideba (3 sm diametris mqone erTi<br />
limfuri kvanZi mainc)<br />
• <strong>da</strong>kvirvebebis fonze limfuri kvanZebis gadideba<br />
• tuberkulozis raime niSnebi<br />
• gulmkerdis rentgenogramaze filtvis karis limfuri kvanZebis<br />
gadideba<br />
• nebismieri likalizaciis kapoSis sarkoma<br />
• cxeleba, Ramis oflianoba, wonaSi kleba erT kviraze xangZlivad.<br />
<strong>aiv</strong> asocirebuli limfadenopaTia ar aris seriozuli <strong>da</strong>avadebis, mag;<br />
lomfomis maniSnebeli. miuxe<strong>da</strong>vad amisa, mdgomareobis cvlilebisas, mag:<br />
persistuli cxelebis <strong>da</strong>matebisas sasurvelia limfadeneqtomia <strong>da</strong><br />
kvanZis histologiuri gamokvleva.<br />
99
3.2.2. cxeleba <strong>aiv</strong> inficirebulebSi<br />
• cxelebis mizezi SeiZleba iyos <strong>infeqcia</strong>, anTebiTi procesi an<br />
avTvisebiani simsivne. mozrdilebSi persistulad iTvleba cxeleba,<br />
Tu 38°C–ze maRali temperatura grZeldeba or kviraze gangrZlivad.<br />
• <strong>aiv</strong> inficirebul pacientebSi cxeleba SeiZleba iyos infeqciis<br />
erTaderTi <strong>klinikuri</strong> niSani. amitom persistuli cxelebis mqone<br />
avadmyofebis mkurnalobisas un<strong>da</strong> gvaxsovdes, rom misi mizezi<br />
SeiZleba iyos <strong>aiv</strong> <strong>infeqcia</strong>.<br />
• <strong>aiv</strong> /<strong>SidsiT</strong> pacientebSi persistul cxelebas SeiZleba Tan axldes<br />
misi gamomwvevi <strong>da</strong>avadebis simptomebi, magaliTad, pnevmoniis,<br />
tuberkulozis, kuW-nawlavis traqtis infeqciis an limfomis.<br />
persistuli cxelebis mqone mozrdil pacientebSi <strong>aiv</strong> <strong>infeqcia</strong>ze<br />
migviTiTebs Semdegi mdgomareobebi:<br />
• anamnezSi mravlobiTi <strong>da</strong>ucveli sqesobrivi kontaqtebi<br />
• <strong>aiv</strong> inficirebuli sqesobrivi partniori<br />
• <strong>aiv</strong> inficirebuli Svili<br />
• <strong>aiv</strong> infeqciisaTvis <strong>da</strong>maxasiaTebeli tipuri <strong>klinikuri</strong> niSnebis<br />
arseboba, rogoricaa:<br />
• persistuli generalizirebuli limfadenopaTia,<br />
• oraluri an genitaluri kandidozi <strong>da</strong>/an herpesi,<br />
• oraluri Tmovani leikoplakia,<br />
• qavana dermatiti,<br />
• wonaSi umizezod kleba,<br />
• frCxilebis gamuqeba (melanonixia),<br />
• tuCebis hipopigmentacia <strong>da</strong><br />
• Tmebis gaTxeleba <strong>da</strong> cvena.<br />
3.2.3. <strong>aiv</strong> inficirebul mozrdilebSi wonis umizezo kleba<br />
• mozrdilebSi wonaSi kleba xSirad <strong>da</strong>kavSirebulia <strong>aiv</strong><br />
<strong>infeqcia</strong>sTan.<br />
• wonis mniSvnelovan klebad iTvleba sxeulis sawyisi masis 10% -iT<br />
an metiT <strong>da</strong>qveiTeba umizezod.<br />
• gamoxatuli wonis kleba <strong>aiv</strong> inficirebulebSi atarebs “<strong>aiv</strong>kaxeqsiis”<br />
an ganlevis sindromis saxels.<br />
• ganlevis mizezi jer-jerobiT kargad ar aris Seswavlili.<br />
SesaZlebeli mizezebia:<br />
• qronikuli <strong>da</strong> morecidive infeqciebi,<br />
• qronikuli diarea,<br />
• Sewovis <strong>da</strong>rRveva (malabsorbcia),<br />
• <strong>aiv</strong> inducirebuli miopaTia <strong>da</strong><br />
<strong>aiv</strong> inducirebuli madis <strong>da</strong>qveiTeba.<br />
<strong>klinikuri</strong> niSnebiAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA<br />
• pacienti uCivis wonaSi umizezod klebas <strong>da</strong> madis <strong>da</strong>qveiTebas,<br />
rasac Tan axlavs an ar axlavs cxeleba <strong>da</strong> diarea.<br />
• <strong>aiv</strong> kaxeqsiis mqone pacientebi uCivian zogad saerTo diskomforts,<br />
gamofitvas, mousvenrobas, gauwyloebas.<br />
100
• aseT pacientebSi xSiria piris Rrus kandidozi,<br />
• aseT pacientebSi xSiria Sidsis sxva <strong>klinikuri</strong> gamovlinebebi, maT<br />
Soris nevrologiuri, mag. encefalopaTia <strong>da</strong> Sids-demenciis<br />
kompleqsi.<br />
3.2.4. mozrdilTa qronikuli diarea<br />
• qronikuli diarea ewodeba 28 dRis ganmavlobaSi arsebul xSir<br />
(sami an meti), Txier defekacias. qronikuli diareis fonze<br />
pacientebs SeiZleba ganuviTardeT mwvave diareis epizodebi.<br />
• Tu ar aris dizenteria ganavalSi sisxlis minarevebis arseboba<br />
iSviaTia.<br />
• avadmyofebs aReniSnebaT cudi ma<strong>da</strong> <strong>da</strong> ikleben wonaSi.<br />
• gamokvlevisas gamovlindeba gauwyloebis, anemiisa <strong>da</strong> gamofitvis<br />
niSnebi.<br />
qronikuli diareis mqone pacientebSi aRiniSneba:<br />
• kanisa <strong>da</strong> Tmebis distrofiuli cvlilebebi tipurad asocirebuli<br />
arasrulfasovan kvebasTan,<br />
• tuCebis gafermkrTaleba,<br />
• frCxilebis gamuqeba<br />
• piris Rrus kandidozi, oraluri Tmovani leikoplakia <strong>da</strong><br />
limfadenopaTia.<br />
3.2.5. piris Rrus <strong>da</strong>zianebebi<br />
kandidozis gar<strong>da</strong> <strong>aiv</strong> inficirebulebs xSirad aReniSnebaT piris Rrus<br />
sxva saxis <strong>da</strong>zianebebic. zogierTi maTgani ganxilulia me-40 cxrilSi.<br />
cxrili 40. piris Rrus yvelaze xSiri <strong>da</strong>zianebebi <strong>aiv</strong> inficirebulebSi<br />
mdgomareoba aRweriloba <strong>mkurnaloba</strong><br />
gingiviti hiperemia, SeSupeba <strong>da</strong> metroni<strong>da</strong>zoli 400 mg 2-jer<br />
sisxldena RrZilebi<strong>da</strong>n dReSi 7 dRe PO<br />
an<br />
eriTromicini 500 mg 4-jer<br />
piorea Cirqis <strong>da</strong>groveba<br />
kbilbudeSi<br />
periodontiti <strong>da</strong>maxasiaTebelia<br />
kbilebis garSemo<br />
Zvlebisa <strong>da</strong> rbili<br />
qsovilebis swrafi <strong>da</strong><br />
mtkivneuli rRveva.<br />
kbilebi iryeva <strong>da</strong><br />
Zvreba, RrZilebi<br />
sisxlmdenia.<br />
SesaZlebelia<br />
<strong>da</strong>wyluleba<br />
dReSi 7 dRe PO<br />
piris Rrus higiena: yoveli<br />
Wamis Semdeg pirSi Tbili<br />
marilwylis gamovleba <strong>da</strong><br />
kbilebis dReSi 2-jer gamoxexva<br />
infeqciis kerebis sanacia,<br />
pirSi qlorheqsidinis xsnaris<br />
gamovleba. aseve iniSneba<br />
amoqsicilini 500 mg 3-jer<br />
dReSi 5 dRis ganmavlobaSi PO<br />
an<br />
metroni<strong>da</strong>zoli 200 mg samjer<br />
dReSi 5 dRe PO.<br />
101
afTozuri<br />
wylulebi<br />
stomatiti<br />
qeiliti<br />
meoradi<br />
sifilisi<br />
lorwovanze aRiniSneba<br />
mtkivneuli wylulebi<br />
swori kideebiT.<br />
Cveulebriv <strong>da</strong>farulia<br />
Cirqovani nadebiT <strong>da</strong><br />
Sexebisas sisxlmdenia.<br />
piris Rrus lorwovanis<br />
anTeba. viTardeba piris<br />
Rrus cudi higienis<br />
pirobebSi; SeiZleba<br />
gamoiwvios anaerobebma.<br />
tuCebis SeSupeba <strong>da</strong><br />
SewiTleba, romelic<br />
icvleba sifermkrTaliT;<br />
xSirad aReniSnebaT<br />
gamaxatuli<br />
imunodeficitis mqone<br />
pirebs<br />
sifilidebi loyis<br />
lorwovanze (sveli<br />
papulebi <strong>da</strong> wylulebi,<br />
mogvagonebs lokokinis<br />
nakvalevs) <strong>da</strong> farTe<br />
kondilomebi tuCis<br />
kuTxeebsa <strong>da</strong> nestoebis<br />
garSemo. meoradi<br />
sifilisis dros yvela<br />
serologiuri testi<br />
<strong>da</strong>debiTia.<br />
piris Rrus higiena <strong>da</strong><br />
glukokortikoidebi<br />
adgilobrivad<br />
piris Rrus higiena: Wamis<br />
Semdeg marilwyalsnaris<br />
gamovleba <strong>da</strong> kbilebis dReSi<br />
2-jer gamoxexva.<br />
specifikuri <strong>mkurnaloba</strong> ar<br />
arsebobs. iniSneba A, B <strong>da</strong> C<br />
vitaminebi <strong>da</strong> piris Rrus<br />
higiena.<br />
pirveladi sifilisi:<br />
benzatinbenzilpenicilini 2,4<br />
mln. erT. kunTebSi erTjera<strong>da</strong>d<br />
meoreuli sifilisi:<br />
benzatinbenzilpenicilini 2,4<br />
mln. erT. kunTebSi kviraSi<br />
erTxel 3 kvira<br />
an<br />
doqsiciklini 100mg 2-jer<br />
dReSi 28 dRe PO<br />
an eriTromicini 500mg 4-jer<br />
dReSi 28 dRe PO.<br />
3.2.6. kanisa <strong>da</strong> frCxilebis <strong>da</strong>zianebebi<br />
dermatomikozebi<br />
• kanis sokovani <strong>da</strong>zianeba (dermatomikozebi) xSirad gvxvdeba<br />
rogorc <strong>aiv</strong> inficirebul, ise arainficirebul pacientebSi.<br />
• gamonayars xSirad Tan axlavs qavili, elementi mSralia <strong>da</strong><br />
aqercvladi.<br />
• <strong>da</strong>zianeba SeiZleba gaCndes sxeulis nebismier adgilze.<br />
diagnostikaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA<br />
gamomwvevi SeiZleba aRmovaCinoT <strong>da</strong>zianebuli kanis anafxekis<br />
mikroskopuli gamokvleviT.<br />
<strong>mkurnaloba</strong>AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA<br />
102
ogorc wesi efeqturia antimikozuri mazebisa <strong>da</strong> kremebis adgilobrivi<br />
aplikacia. rekomen<strong>da</strong>ciebi dermatomikozis mkurnalobis Sesaxeb<br />
mocemulia 41-e cxrilSi.<br />
cxrili 41. dermatomikozebis <strong>mkurnaloba</strong> (AI)<br />
antifungaluri doza<br />
preparati<br />
pirveli rigis sqemebi<br />
Mmikonazoli<br />
(adgilobrivad<br />
gamoyenebisTvis)<br />
klotrimazoli<br />
(adgilobrivad<br />
gamoyenebisTvis)<br />
MmiRebis<br />
sixSire<br />
3-jer dReSi<br />
meore rigis sqemebi<br />
ketokonazoli 200 mg dReSi<br />
erTxel<br />
an<br />
itrakonazoli 100 mg dReSi<br />
erTxel<br />
M miRebi<br />
gza<br />
Aadgilobrivad 21 dRe<br />
an<br />
3-jer dReSi adgilobrivad 21 dRe<br />
PO<br />
PO<br />
mkurnalobis<br />
xangrZlivoba<br />
1-3 Tve<br />
1-3 Tve<br />
oniqomikozebi<br />
frCxilebis sokovani <strong>da</strong>zianebebi (oniqomikozebi) iwveven frCxilis<br />
firfitebis deformaciasa <strong>da</strong> rRvevas.<br />
diagnostikaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA<br />
• diagnozi ismeba <strong>klinikuri</strong> suraTiT.<br />
• gamomwvevi SeiZleba aRmoCnes frCxilis firfitis qvevi<strong>da</strong>n aRebuli<br />
<strong>da</strong> kaliumis hidroqsidiT <strong>da</strong>muSavebuli masalis mikroskopuli<br />
gamokvleviT.<br />
<strong>mkurnaloba</strong>AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA<br />
cxrili 42. oniqomikozebis <strong>mkurnaloba</strong> (AI)<br />
pirveli rigis sqemebi<br />
antifungaluri<br />
preparati<br />
doza MmiRebis<br />
sixSire<br />
MmiRebi<br />
gza<br />
terbinafini 250 mg dReSi PO<br />
erTxel<br />
mkurnalobis<br />
xangrZlivoba<br />
6 kvira xelis<br />
TiTebis<br />
<strong>da</strong>zianebisas an<br />
12 kvira fexis<br />
TiTebis<br />
<strong>da</strong>zianebisas<br />
an<br />
itrakonazoli 200 mg 2-jer dReSi PO yoveli Tvis I<br />
kviris<br />
103
ganmavlobaSi 2<br />
Tvis manZilze<br />
(xelis TiTebis<br />
<strong>da</strong>zianebisas),<br />
3-4 Tve (fexis<br />
TiTebi<br />
<strong>da</strong>zianebisas)<br />
3.2.7. seboreuli dermatiti<br />
• <strong>aiv</strong> inficirebulebs xSirad uviTardebaT seboreuli dermatiti.<br />
varaudoben, rom mas iwvevs soko Pityrosporum ovale (aseva cnobilia,<br />
rogorc Malassezia furfur).<br />
• elementi warmoadgens wiTeli feris laqas, romelic iqercleba. <strong>aiv</strong><br />
inficirebulebSi <strong>da</strong>zianeba vrcelia, elementebi xangrZlivad rCeba<br />
<strong>da</strong> xSirad iZleva recidivs.<br />
diagnostikaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA<br />
diagnozi ismeba <strong>klinikuri</strong> suraTiT. Cveulebriv gamonayari gvxvdeba:<br />
o saxeze<br />
o cxviris nestoebis irgvliv<br />
o cxvir-tuCis naoWze,<br />
o warbebze,<br />
o Tavis Tmian nawilze,<br />
o gul-mkerdis areSi<br />
o iRliebSi,<br />
o tanis ze<strong>da</strong> nawilsa <strong>da</strong><br />
o sazardulis areSi.<br />
diagnozi <strong>da</strong>sturdeba sokos aRmoCeniT kanis <strong>da</strong>zianebuli ubni<strong>da</strong>n<br />
anafxeki masalis mikroskopuli gamokvlevisas.<br />
<strong>mkurnaloba</strong>AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA<br />
o rekomendebulia <strong>da</strong>zianebuli ubnebis xSirad <strong>da</strong>bana qerclis<br />
mosaSoreblad,<br />
o karg Sedegs iZleva selenis sulfidis Semcveli samkurnalo<br />
Sampunebis gamoyeneba.<br />
o SesaZloa yvelaze efeqturi aRmoCndes hidrokortizonis 1%-ani<br />
mazis aplikaciebi. aseve karg Sedegs iZleva ketokonazolis 2%-ani<br />
kremi.<br />
3.2.8. muni<br />
muns iwvevs tkipa Sarcoptes scabiei. mdedr tkipas kanSi gahyavs gasasvleli,<br />
romelsac aqvs ramodenime sm sigrZis ze<strong>da</strong>piri<strong>da</strong>n wamoweuli wiTeli<br />
nawiburis Sesaxe<strong>da</strong>oba. mdedri tkipa gayvanil gasasvlelSi debs<br />
kvercxebs <strong>da</strong> Semdeg ga<strong>da</strong>adgildeba sxeulis sxva nawilSi. kvercxebi<strong>da</strong>n<br />
gamodis tkipebis axali Taoba, romlebic izrdebian, jvardebian, gahyavT<br />
axali gasasvlelebi <strong>da</strong> deben axal kvercxebs.<br />
o parazitis pirveladi SeWri<strong>da</strong>n <strong>da</strong>axloebiT erT Tvis ganmavlobaSi<br />
(2-6 kvira) simptomebi TiTqmis ar aRiniSneba.<br />
104
o ganmeorebiTi invaziis Semdeg ki viTardeba alergiuli reaqcia <strong>da</strong><br />
simptomebi gamovlindeba 1-4 dRis ganmavlobaSi.<br />
o kanqveSa gasasvlelis gayvanisas viTardeba gamonayari, romelic<br />
xSirad gvxvdeba:<br />
o xelebze - mtevnebze (gansakuTrebiT TiTebs Soris),<br />
o majis, i<strong>da</strong>yvis, muxlismomxrel ze<strong>da</strong>pirebze,<br />
o winamxris i<strong>da</strong>yviskena ze<strong>da</strong>pirze,<br />
o sasqeso asoze,<br />
o sarZeve jirkvlebsa <strong>da</strong><br />
o beWebze.<br />
o tkipebi <strong>da</strong> maT mier gayvanili gasasvlelebi SeiZleba iyos Zalian<br />
mcire raodenobiT <strong>da</strong> gagviWirdes maTi <strong>da</strong>naxva.<br />
o avadmyofs ZiriTa<strong>da</strong>d awuxebs tanis Zlieri qavili, gansakuTrebiT<br />
RamiT.<br />
o imunodeficitis mqone pacientebs xSirad uviTardebaT munis mZime<br />
forma, romelsac uwodeben norvegiuls. misTvis <strong>da</strong>maxasiaTebelia<br />
vezikuluri gamonayari <strong>da</strong> sqeli fufxebis warmoqmna mTel<br />
sxeulze. munis am formis dros qavili ar aris gamoxatuli.<br />
o qavilis gamo muni xSirad rTuldeba meoradi infeqciebiT.<br />
diagnostikaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA<br />
o diagnozi ismeba <strong>klinikuri</strong> gamovlinebebisa <strong>da</strong> <strong>da</strong>zianebuli keris<br />
anafxekis mikroskopuli gamokvlevis safuZvelze.<br />
o mikroskopiisas aRmoCndeba tkipebi an/<strong>da</strong> maTi kvercxebi.<br />
<strong>mkurnaloba</strong>AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA<br />
o SerCevis preparats warmoadgens adgilobrivad gamosayenebeli 1%-<br />
ani gamabenzen heqsaqloridi, romelic ismeba mTels tanze, Tavis<br />
gar<strong>da</strong>, mozrdilebSi Camoibaneba 24 sT-Si , xolo bavSvebSi_8sT-Si.<br />
sakmarisia erTjeradi <strong>da</strong>muSaveba.<br />
o aseve SesaZlebelia kanis <strong>da</strong>muSaveba 1%-ani permetriniT an 1%-ani<br />
lin<strong>da</strong>niT; es preparatebic ismeba mTels tanze <strong>da</strong> Camoibaneba 8 sT-<br />
Si. permetrinisa <strong>da</strong> lin<strong>da</strong>nis gamoyeneba ar SeiZleba<br />
orsulebisaTvis, meZuZuri dedebisa <strong>da</strong> bavSvebisaTvis.<br />
o norvegiuli munis samkurnalod, imunodeficitis mqone pacientebSi,<br />
efeqturia ivermeqtini, 200 mg/kg PO erTjera<strong>da</strong>d.<br />
o tansacmeli, TeTreuli <strong>da</strong> pirsaxocebi un<strong>da</strong> gamoixarSos <strong>da</strong><br />
<strong>da</strong>uTovdes gaSrobis Semdeg.<br />
o munis <strong>mkurnaloba</strong> un<strong>da</strong> Cautardes sqesobriv partniors <strong>da</strong> yvelas<br />
vinc sayofacxovrebo kontaqtSi iyo <strong>avadmyofTa</strong>n.<br />
3.2.9. stafilokokuri folikuliti<br />
o folikuliti _ kanis <strong>infeqcia</strong>a, romlis drosac procesi Tmis<br />
folikulSia lokalizebuli.<br />
o <strong>aiv</strong> inficirebulebs xSirad uviTardebaT pustularuli<br />
perifolikuliti.<br />
o folikulits, rogorc wesi, iwvevs Staphylococcus aureus, magram sxva<br />
mikroorganizmebsac SeuZlia misi gamowveva.<br />
diagnostikaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA<br />
o diagnozi ismeba <strong>klinikuri</strong> gamovlinebebis safuZvelze.<br />
105
o gamonayari warmodgenilia mravlobiTi wvrili (5 mm diametris),<br />
hiperemiuli folikulebiT, romlebic centrSi <strong>da</strong>Cirqebulia.<br />
o xSirad elementebs aqvT midrekileba gaerTianebisaken. kanis<br />
<strong>da</strong>zianebas Tan axlavs qavili.<br />
<strong>mkurnaloba</strong>AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA<br />
iniSneba antibiotiki, magaliTad cefaleqsini an kloksacilini 500 mg PO<br />
4-jer dReSi 7-21 dRe.<br />
3.2.10. kontagiozuri moluski<br />
o kontagiozuri moluski _ kanis ze<strong>da</strong>piruli <strong>infeqcia</strong>a, romelsac<br />
iwvevs kontagiozuri moluskis virusi.<br />
o <strong>infeqcia</strong> ga<strong>da</strong>dis <strong>avadmyofTa</strong>n mWidro kontaqtiT an saerTo<br />
moxmarebis nivTebiT <strong>da</strong> sqesobrivi gziT.<br />
o inkubaciuri periodi meryeobs 1-2 kviri<strong>da</strong>n ramodenime Tvemde.<br />
o elementebis mocilebam an moqavebam SeiZleba gamoiwvios axali<br />
gamonayrebis ganviTareba.<br />
o kontagiozuri moluski ufro xSiria imunodeficitis mqone <strong>aiv</strong><br />
inficirebulebSi.<br />
o <strong>aiv</strong> inficirebulebSi <strong>aiv</strong> negatiurebisgan gansxvavebiT:<br />
o elementebi raodenobrivad bevria,<br />
o xangrZlivad persistirebs,<br />
o ufro msxvilia <strong>da</strong><br />
o Znelad eqvemdebareba <strong>mkurnaloba</strong>s.<br />
diagnostikaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA<br />
o diagnozi ismeba <strong>da</strong>maxasiaTebeli elementis aRmoCenisas.<br />
o kanSi SeRwevisas virusi iwvevs 2-5 mm diametris kanisferi mkvrivi<br />
papulebis ganviTarebas. papulebi Seicavs TeTr cximovan sekrets.<br />
o gamonayaris elementebi SeiZleba ganviTardes sxeulis nebismier<br />
adgilas, xSirad iyos ucvlelad mravali Tvis manZilze <strong>da</strong>/an<br />
gaqres <strong>da</strong> Semdeg kvlav gaCndes.<br />
o specifikuri diagnostikuri testi virusis aRmosaCenad ar arsebobs.<br />
<strong>mkurnaloba</strong>AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA<br />
<strong>mkurnaloba</strong> mdgomareobs papulis rbili SigTavsis mocilebaSi, romlis<br />
Semdeg papula qreba. mkurnalobis taqtika yvela SemTxvevaSi<br />
individualuria. arsebobs kanis <strong>da</strong>zianebuli ubnis <strong>da</strong>muSavebis<br />
sxva<strong>da</strong>sxva meTodi. elementebs <strong>da</strong>muSaveba SesaZlebelia Semdegi<br />
meTodebis gamoyenebiT:<br />
_ kiuretaJi<br />
_ qimiuri destruqcia fenolis koncentrirebuli xsnariT<br />
_ krioTerapia<br />
_ eleqtrokoagulacia<br />
cnobilia, rom <strong>aiv</strong> inficirebulebSi arT-s <strong>da</strong>wyeba xels uwyobs<br />
kontagiozuri moluskis eliminacias. naCvenebi iyo, rom antivirusuli<br />
preparati – cidofoviri, romelsac aqvs Zlieri antiretrovirusuli<br />
moqmedeba, aseve efeqturia kontagiozuri moluskis samkurnalod.<br />
106
gamoyenebuli literaturis CamonaTvali:<br />
1. El-Sadr WM et al. A randomized trial of <strong>da</strong>ily and thrice-weekly trimethoprim-sulfamethoxazole for<br />
the prevention of Pneumocystis carinii pneumonia in human immunodeficiency virus-infected persons.<br />
Terry Beirn Community Programs for Clinical Research on AIDS (CPCRA). Clinical Infectious Diseases,<br />
1999, 29(4):775–783.<br />
2. Bozzette SA et al. A randomized trial of three antipneumocystis agents in patients with advanced human<br />
immunodeficiency virus infection. NIAID AIDS Clinical Trials Group. The New England Journal of<br />
Medicine, 1995, 332(11):693–699.<br />
3. Bucher HC et al. Meta-analysis of prophylactic treatments against Pneumocystis carinii pneumonia and<br />
toxoplasma encephalitis in HIV-infected patients. Journal of Acquired Immune Deficiency Syndromes<br />
and Human Retrovirology, 1997, 15(2):104–114.<br />
4. El-Sadr WM et al. Atovaquone compared with <strong>da</strong>psone for the prevention of Pneumocystis carinii<br />
pneumonia in patients with HIV infection who cannot tolerate trimethoprim, sulfonamides, or both.<br />
Community Program for Clinical Research on AIDS and the AIDS Clinical Trials Group. The New England<br />
Journal of Medicine, 1998, 339(26):1889–1895.<br />
5. Chan C et al. Atovaquone suspension compared with aerosolized pentamidine for prevention of<br />
Pneumocystis carinii pneumonia in human immunodeficiency virus-infected subjects intolerant of<br />
trimethoprim or sulfonamides. Journal of Infectious Diseases, 1999, 180(2):369–376.<br />
6. Bucher HC et al. Isoniazid prophylaxis for tuberculosis in HIV infection: a meta-analysis of randomized<br />
controlled trials. AIDS, 1999, 13(4):501–507.<br />
7. Podzamczer D et al. Thrice-weekly sulfadiazine-pyrimethamine for maintenance therapy of toxoplasmic<br />
encephalitis in HIV-infected patients. Spanish Toxoplasmosis Study Group. AIDS, 2000, 14(3):331–<br />
332.<br />
8. Gallant JE, Moore D, Chaisson RE. Prophylaxis for opportunistic infections. Annals of Internal Medicine,<br />
1995, 122(9):730–731.<br />
9. Havlir DV et al. Prophylaxis against disseminated Mycobacterium avium complex with weekly<br />
azithromycin, <strong>da</strong>ily rifabutin, or both. California Collaborative Treatment Group. The New England Journal of<br />
Medicine, 1996, 335(6):392–398.<br />
10. Nightingale SD et al. Incidence of Mycobacterium avium-intracellulare complex bacteremia in human<br />
immunodeficiency virus-positive patients. Journal of Infectious Diseases, 1992, 165(6):1082–1085.<br />
11. Saag MS et al. A comparison of itraconazole versus fluconazole as maintenance therapy for AIDSassociated<br />
cryptococcal meningitis. National Institute of Allergy and Infectious Diseases Mycoses Study<br />
Group. Clinical Infectious Diseases, 1999, 28(2):291–296.<br />
12. Gant V, Parton S. Community-acquired pneumonia. Current Opinion in Pulmonary Medicine, 2000,<br />
6:226–233.<br />
13. Cordero E et al. Usefulness of sputum culture for diagnosis of bacterial pneumonia in HIV-infected<br />
patients. European Journal of Clinical Microbiology and Infectious Diseases, 2002, 21(5):362–367.<br />
14. Cruciani M et al. Meta-analysis of diagnostic procedures for Pneumocystis carinii pneumonia in HIV-1-<br />
infected patients. European Respiratory Journal, 2002, 20(4):982–989.<br />
15. Shafran SD et al.A comparison of two regimens for the treatment of Mycobacterium avium complex<br />
bacteremia in AIDS: rifabutin, ethambutol, and clarithromycin versus rifampin, ethambutol, clofazimine,<br />
and ciprofloxacin. Canadian HIV Trials Network Protocol 010 Study Group. The New England Journal<br />
of Medicine, 1996, 335(6):377–383.<br />
16. Benson CA et al. A prospective, randomized trial examining the efficacy and safety of clarithromycin in<br />
combination with ethambutol, rifabutin, or both for the treatment of disseminated Mycobacterium avium<br />
complex disease in persons with acquired immunodeficiency syndrome. Clinical Infectious Diseases,<br />
2003, 37(9):1234–1243.<br />
17. Toma E et al.Clin<strong>da</strong>mycin with primaquine vs. Trimethoprim-sulfamethoxazole therapy for mild and<br />
moderately severe Pneumocystis carinii pneumonia in patients with AIDS: a multicenter, double-blind,<br />
randomized trial (CTN 004). CTN-PCP Study Group. Clinical Infectious Diseases, 1998, 27(3):524–<br />
530.<br />
18. Vohringer HF et al. Pharmacologic studies with pentamidine aerosol in HIV patients [in German].<br />
Medizinische Klinik, 1990, 85 Suppl. 2:248–250, 291.<br />
19. Jacobson MA et al. Ciprofloxacin for Salmonella bacteremia in the acquired immunodeficiency syndrome<br />
(AIDS). Annals of Internal Medicine, 1989, 110(12):1027–1029. 9-31 management of opportunistic infections and<br />
general symptoms of hiv/aids<br />
107
20. Chen XM et al. Cryptosporidiosis. The New England Journal of Medicine, 2002, 346(22):1723–1731.<br />
21. Smith NH et al. Combination drug therapy for cryptosporidiosis in AIDS. Clinical Infectious Diseases,<br />
1998, 178(3):900–903.<br />
22. Carr A et al.Treatment of HIV-1-associated microsporidiosis and cryptosporidiosis with combination<br />
antiretroviral therapy. The Lancet, 1998, 351:256–261.<br />
23. Miao YM, Gazzard BG. Management of protozoal diarrhoea in HIV disease. HIV Medicine, 2000,<br />
1(4):194–199.<br />
24. Sangeorzan JA et al. Epidemiology of oral candidiasis in HIV-infected patients: colonization, infection,<br />
treatment, and emergence of fluconazole resistance. American Journal of Medicine, 1994, 97(4):339–<br />
346.<br />
25. Saag MS et al. Treatment of fluconazole-refractory oropharyngeal candidiasis with itraconazole oral<br />
solution in HIV-positive patients. AIDS Research and Human Retroviruses, 1999, 15(16):1413–1417.<br />
26. VFEND side effects, and drug interactions: voriconazole [web page]. Rancho Sante Fe, CA, RxList,<br />
2006 (http://www.rxlist.com/cgi/generic/vfend_ad.htm accessed, 12 June 2006).<br />
27. Saag MS et al. Practice guidelines for the management of cryptococcal disease. Infectious Diseases Society<br />
of America. Clinical Infectious Diseases, 2000, 30(4):710–718.<br />
28. Johnson PC et al. Safety and efficacy of liposomal amphotericin B compared with conventional<br />
amphotericin B for induction therapy of histoplasmosis in patients with AIDS. Annals of Internal Medicine,<br />
2002, 137(2):105–109.<br />
29. Rosenthal E et al. DNX Study Group Phase IV study of liposomal <strong>da</strong>unorubicin (DaunoXome) in<br />
AIDSrelated Kaposi sarcoma. American Journal of Clinical Oncology, 2002, 25(1): 57–59.<br />
30. Osoba D et al. Effect of treatment on health-related quality of life in acquired immunodeficiency syndrome<br />
(AIDS)-related Kaposi’s sarcoma: a randomized trial of pegylated-liposomal doxorubicin versus<br />
doxorubicin, bleomycin, and vincristine. Cancer Investigation, 2001, 19(6):573–580.<br />
31. Cheung TW et al. AIDS-related Kaposi’s sarcoma: a phase II study of liposomal doxorubicin. The TLC<br />
D-99 Study Group. Clinical Cancer Research, 1999, 5(11):3432–3437.<br />
32. Shanta V et al. Epidemiology of cancer of the cervix: global and national perspective. Journal of the<br />
Indian Medical Association, 2000, 98(2):49–52.<br />
33. Wright TC Jr et al. Cervical intraepithelial neoplasia in women infected with human immunodeficiency<br />
virus: prevalence, risk factors, and validity of Papanicolaou smears. New York Cervical Disease Study.<br />
Obstetrics and Gynecology, 1994, 84(4):591–597.<br />
34. Sun XW et al. Human papillomavirus infection in human immunodeficiency virus-seropositive women.<br />
Obstetrics and Gynecology, 1995, 85(5 Pt 1):680–686.<br />
35. Hoffmann C, et al. The short and intensive B-ALL protocol is a highly effective regimen in patients with<br />
AIDS-associated Burkitt or Burkitt-like lymphoma. 11th Conference on Retroviruses and Opportunistic<br />
Infections Feb. 8-11 2004 San Francisco, CA (Abstract 787).<br />
36. Hoffmann C et al. Successful autologous stem cell transplantation in a severely immunocompromised<br />
patient with relapsed AIDS-related B-cell lymphoma. European Journal of Medical Research, 2006,<br />
11(2):73–76.<br />
37. Hoffmann C et al. Response to highly active antiretroviral therapy strongly predicts outcome in patients<br />
with AIDS-related lymphoma. AIDS, 2003, 17(10):1521–1529.<br />
38. Fine HA, Mayer RJ. Primary central nervous system lymphoma. Annals of Internal Medicine, 1993,<br />
119(11):1093–1104.<br />
39. Hoffmann C et al. Survival of AIDS patients with primary central nervous system lymphoma is<br />
dramatically improved by HAART-induced immune recovery. AIDS, 2001, 15(16):2119–2127.<br />
40. McGowan JP, Shah S. Long-term remission of AIDS-related primary central nervous system lymphoma<br />
associated with highly active antiretroviral therapy. AIDS, 1998, 12(8):952–954.<br />
41. Katlama C et al. Pyrimethamine-clin<strong>da</strong>mycin vs. pyrimethamine-sulfadiazine as acute and longterm<br />
therapy for toxoplasmic encephalitis in patients with AIDS. Clinical Infectious Diseases, 1996,<br />
22(2):268–275.<br />
42. Dannemann B et al. Treatment of toxoplasmic encephalitis in patients with AIDS. A randomized trial<br />
comparing pyrimethamine plus clin<strong>da</strong>mycin to pyrimethamine plus sulfadiazine. The California Collaborative<br />
Treatment Group. Annals of Internal Medicine, 1992, 116(1):33–43.<br />
43. Chirgwin K et al. Randomized phase II trial of atovaquone with pyrimethamine or sulfadiazine for<br />
treatment of toxoplasmic encephalitis in patients with acquired immunodeficiency syndrome: ACTG 237/<br />
9-32 HIV/AIDS TREATMENT AND CARE CLINICAL PROTOCOLS FOR THE WHO EUROPEAN REGION<br />
ANRS 039 Study. AIDS Clinical Trials Group 237/Agence Nationale de Recherche sur le SIDA, Essai<br />
039. Clinical Infectious Diseases, 2002, 34(9):1243–1250.<br />
44. Conant MA et al. Valaciclovir versus aciclovir for herpes simplex virus infection in HIV-infected<br />
individuals: two randomized trials. International Journal of STD and AIDS, 2002, 13(1):12–21.<br />
108
45. Ioannidis JP et al. Clinical efficacy of high-dose acyclovir in patients with human immunodeficiency<br />
virus infection: a meta-analysis of randomized individual patient <strong>da</strong>ta. Journal of Infectious Diseases,<br />
1998, 178(2):349–359.<br />
46. Chang E, Absar N, Beall G. Prevention of recurrent herpes simplex virus (HSV) infections in HIV-infected<br />
persons. AIDS Patient Care, 1995, 9(5):252–255.<br />
47. Safrin S. Treatment of acyclovir-resistant herpes simplex virus infections in patients with AIDS. Journal<br />
of Acquired Immune Deficiency Syndrome, 1992,.5 Suppl. 1:S29–S32.<br />
48. Gnann JW Jr, Whitley RJ. Clinical practice: herpes zoster. The New England Journal of Medicine, 2002,<br />
347(5):340–346.<br />
49. Whitley RJ et al. Guidelines for the treatment of cytomegalovirus diseases in patients with AIDS in the<br />
era of potent antiretroviral therapy: recommen<strong>da</strong>tions of an international panel. International AIDS Society-<br />
USA. Archives of Internal Medicine, 1998, 158(9):957–969.<br />
50. Foscarnet-Ganciclovir Cytomegalovirus Retinitis Trial: 5. Clinical features of cytomegalovirus retinitis<br />
at diagnosis: studies of ocular complications of AIDS Research Group in collaboration with the AIDS<br />
Clinical Trials Group. American Journal of Ophthalmology, 1997, 124(2):141–157.<br />
51. Martin DF et al. A controlled trial of valganciclovir as induction therapy for cytomegalovirus retinitis.<br />
The New England Journal of Medicine, 2002, 346(15):1119–1126.<br />
52. Jacobson MA et al. Phase I study of combination therapy with intravenous cidofovir and oral ganciclovir<br />
for cytomegalovirus retinitis in patients with AIDS. Clinical Infectious Diseases, 1999, 28(3):528–533.<br />
53. Martin DF et al. Oral ganciclovir for patients with cytomegalovirus retinitis treated with a ganciclovir<br />
implant. Roche Ganciclovir Study Group. The New England Journal of Medicine, 1999, 340(14):1063–<br />
1070.<br />
109
Tavi IV. <strong>aiv</strong> <strong>infeqcia</strong>/<strong>SidsiT</strong> <strong>da</strong>avadebulTa imunizaciis<br />
ZiriTadi principebi<br />
ramdena<strong>da</strong>c <strong>aiv</strong> <strong>infeqcia</strong> iwvevs imunuri sistemis progresirebad<br />
<strong>da</strong>zianebas, SesaZloa <strong>aiv</strong> inficirebul pirebSi zogierTi vaqcina gaxdes<br />
mniSvnelovani gverdiTi reaqciis mizezi.<br />
imunobiologiuri produqti ar aris sruliad usafrTxo; amis<br />
gaTvaliswinebiT, axalSobilTa, bavSvTa <strong>da</strong> mozrdilTa vaqcinaciis<br />
ZiriTadi principebi efuZneba Semdegs:<br />
• imunobiologiuri produqtis maxasiaTeblebi;<br />
• aqtiuri <strong>da</strong> pasiuri imunizaciis principebis mecnieruli codna;<br />
• infeqciis epidemiologia;<br />
• infeqciis sawinaaRmdego proteqciis miRwevis <strong>da</strong>debiTi <strong>da</strong> uaryofiTi<br />
mxareebi.<br />
aRniSnuli <strong>da</strong>debiTi <strong>da</strong> uaryofiTi mxareebis zust Sefasebamde, rasac<br />
Semdgomi kvlevebi gviCvenebs, <strong>aiv</strong> <strong>infeqcia</strong> <strong>SidsiT</strong> <strong>da</strong>avadebul pirebSi<br />
nebismieri vaqcinacia un<strong>da</strong> tardebodes sifrTxiliT <strong>klinikuri</strong> <strong>da</strong><br />
prevenciuli medicinis eqspertebis SefasebiT.<br />
terminebi – vaqcinacia <strong>da</strong> imunizacia xSirad moiazreba sinonimebad.<br />
vaqcinacia es aris procesi, rodesac a<strong>da</strong>mianis organizmSi Segvyavs<br />
imunobiologiuri produqti (vaqcina an anatoqsini) <strong>da</strong> gulisxmobs<br />
aqtiur imunizacias. imunizacia ufro farTo mcnebaa <strong>da</strong> gulisxmobs<br />
imunitetis xelovnur induqcias, romelic SeiZleba iyos pasiuri an<br />
aqtiuri.<br />
<strong>aiv</strong> <strong>infeqcia</strong>/<strong>SidsiT</strong> <strong>da</strong>avadebulTa vaqcinaciis ZiriTadi principebia.<br />
• <strong>da</strong>xocili an inaqtivirebuli vaqcina ar warmoadgens safrTxes<br />
imunokompromitirebulTaTvis <strong>da</strong> ZiriTa<strong>da</strong>d gamoiyeneba iseve, rogorc<br />
janmrTel populaciaSi.<br />
• rac Seexeba cocxali virusis an baqteriis Semcvel vaqcinebs,<br />
rogoric aris BCG, oraluri poliovirusis, tifis(Ty21a), Cutyvavilas<br />
<strong>da</strong> yviTeli cxelebis vaqcinebi, maTi gamoyeneba <strong>aiv</strong> inficirebul<br />
pirebSi SesaZloa <strong>da</strong>kavSirebuli iyos garkveul riskTan <strong>da</strong>, amitom,<br />
un<strong>da</strong> tardebodes <strong>da</strong>debiTi <strong>da</strong> uaryofiTi mxareebis zedmiwevniT<br />
SefasebiT, <strong>aiv</strong> infeqciis stadiisa <strong>da</strong> imunuri sistemis supresiis<br />
xarisxis gaTvaliswinebiT.<br />
4.1. vaqcinebisa <strong>da</strong> imunoglobulinebis gamoyeneba<br />
<strong>aiv</strong> <strong>infeqcia</strong>/<strong>SidsiT</strong> <strong>da</strong>avadebulTa imunizaciisas gaTvaliswinebuli un<strong>da</strong><br />
iyos aRniSnuli vaqcinebis imunogenurobis ZiriTadi aspeqtebi.<br />
• miuxe<strong>da</strong>vad imisa, rom <strong>aiv</strong> inficirebul axalSobilebSi ujreduli <strong>da</strong><br />
humoruli imunitetis <strong>da</strong>qveiTeba iwyeba <strong>da</strong>badebisTanave, maT<br />
umravlesobaSi imunuri pasuxis unari sicocxlis pirveli 2 wlis<br />
ganmavlobaSi SenarCunebulia. rekomendebuli vaqcinebis 1 imunogenurobis<br />
Seswavlam gamoavlina serokonversiis <strong>da</strong>makmayofilebeli<br />
xarisxi <strong>aiv</strong> infeqciis adreul stadiaze. aRsaniSnavia, rom TiToeuli<br />
110
vaqcina xasiaTdeba serokonversiis gansazRvruli doniT. vaqcinaciaze<br />
mopasuxeTa wili <strong>aiv</strong> infeqciis Sidsis stadiaSi progresirebasTan<br />
erTad mcirdeba.<br />
• <strong>aiv</strong> inficirebul simptomur bavSvebsa <strong>da</strong> mozrdilebSi vaqcinaciaze<br />
aRiniSneba suboptimaluri imunologiuri pasuxi. imunuri pasuxi<br />
cocxal <strong>da</strong> <strong>da</strong>xocil antigenebze mcirdeba, ramdena<strong>da</strong>c <strong>aiv</strong> <strong>infeqcia</strong><br />
progresirebs. Tumca, maRali doziT vaqcinaciis SemTxvevaSi imunuri<br />
pasuxi <strong>da</strong> antisxeulebis persistencia <strong>aiv</strong> inficirebul pirebSi<br />
sistemurad Seswavlili ar aris. aRniSnul kontigentSi, SesaZlebelia<br />
gamoyenebul iqnas vaqcinaciis gazrdili doza, an xSiri bustireba.<br />
Tumca am etapze myari rekomen<strong>da</strong>ciebi ar arsebobs.<br />
konkretuli vaqcinisa <strong>da</strong> imunoglobulinis usafrTxoebisa 2 <strong>da</strong><br />
efeqfturobis Sefaseba moicavs aRniSnuli <strong>da</strong>avadebis epidemiologiisa<br />
<strong>da</strong> recipientis imunosupresiis xarisxis gansazRvras. es ukanaskneli<br />
un<strong>da</strong> Sefasdes eqimis mier jan<strong>da</strong>cvis msoflio organizaciis <strong>klinikuri</strong><br />
stadiebis sistemis 3 <strong>da</strong>/an asakobrivi jgufisTvis <strong>da</strong>maxasiaTebeli CD4+<br />
ujredebis ricxvisa <strong>da</strong> procentis mixedviT.<br />
1 BCG vaqcina; difTeriis, tetanusisa <strong>da</strong> yivanaxvelas vaqcina (DTP); OPV; MMR vaqcina;<br />
B hepatitis vaqcina; HiB vaqcina.<br />
2 <strong>aiv</strong> <strong>infeqcia</strong>/<strong>SidsiT</strong> <strong>da</strong>avadebulTa vaqcinirebis usafrTxoebis Sesaxeb informacia<br />
mcirea (Va); vaqcinaciasTan <strong>da</strong>kavSirebuli nebismieri gverdiTi reaqciis Sesaxeb<br />
informacia un<strong>da</strong> miewodoT Sesabamis samsaxurebs; gasaTvaliswinebelia, rom zogierTi<br />
gverdiTi movlena SesaZlebelia gamovlindes xangrZlivi latenturi periodis Semdeg<br />
(DIV).<br />
3 <strong>klinikuri</strong> stadiis Sefasebisas SeiZleba ixelmZRvaneloT antiretrovirusuli<br />
mkurnalobis protokolebiT mozrdilebisa <strong>da</strong> bavSvebisaTvis.<br />
4.2. cocxali atenuirebuli vaqcinebi<br />
4.2.1 BCG vaqcina<br />
BCG vaqcina icavs 2 wlamde asakis bavSvebs diseminirebuli <strong>da</strong> mZime<br />
formis tuberkulozisgan, maT Soris tuberkulozuri meningitisa <strong>da</strong><br />
miliaruli tuberkulozisgan (AI). filtvis tuberkulozis sixSiris<br />
Semcirebis TvalsazrisiT zr<strong>da</strong>srul populaciaSi BCG vaqcinacia<br />
araefeqturia an xasiaTdeba mcire efeqtiT (AI).<br />
ar aris cnobili mcirdeba Tu ara vaqcinis efeqturoba <strong>aiv</strong> inficirebul<br />
bavSvebSi. arsebobs garkveuli monacemebi, rom BCG vaqcinaciis Semdgom<br />
tuberkulinis <strong>da</strong>debiTi testi naklebad xSiria <strong>aiv</strong> inficirebul<br />
bavSvebSi. Tumca aRniSnuli mtkicebulebis sarwmunoeba naTeli ar aris<br />
(Vb). aRwerilia lokaluri garTulebebisa <strong>da</strong> diseminirebuli BCG<br />
infeqciis SemTxvevebi <strong>aiv</strong> inficirebuli bavSvebis vaqcinacii<strong>da</strong>n<br />
ramdenime wlis Semdegac. Tumca prospeqtuli kvlevebiT <strong>aiv</strong> inficirebul<br />
<strong>da</strong> janmrTel axalSobilebSi BCG imunizaciis Semdgomi garTulebebis<br />
riskis mxriv gansxvaveba ar gamovlin<strong>da</strong> (CIII). BCG infeqciis<br />
tubrekulozuri infeqciisagan gansasxvaveblad saWiroa gverdiTi<br />
reaqciebis mWidro monitoringi <strong>aiv</strong> infeqciis maRali prevalentobis<br />
areebSi. Semdgomi kvlevebiT <strong>da</strong>debiTi <strong>da</strong> uaryofiTi mxareebis zust<br />
Sefasebamde BCG vaqcinacia un<strong>da</strong> Catardes mxolod asimptomur <strong>aiv</strong><br />
111
inficirebul bavSvebSi (ramdena<strong>da</strong>c arsebobs disiminirebuli <strong>da</strong>avadebis<br />
albaToba). romelTac aqvT tuberkulozuri infeqciis ganviTarebis<br />
maRali riski, rac Tavis mxriv <strong>da</strong>mokidebulia tuberkulozis lokalur<br />
gavrcelebaze. 4 maRali riskis SemTxvevaSi sasurvelia BCG imunizacia<br />
(CIII).<br />
rekomen<strong>da</strong>ciebi<br />
• tuberkulozis <strong>da</strong>bali gavrcelebis arealSi 5 <strong>aiv</strong> inficirebul<br />
bavSvebSi, miuxe<strong>da</strong>vad <strong>klinikuri</strong> stadiisa <strong>da</strong> imunodeficitis<br />
xarisxisa, ar un<strong>da</strong> Catardes BCG vaqcinacia. infeqciis maRali<br />
gavrcelebis arealSi BCG vaqcinacia un<strong>da</strong> Catardes mxolod <strong>aiv</strong><br />
<strong>da</strong>debiT asimptomur bavSvebSi. bavSvebi <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis<br />
simptomebiT ar un<strong>da</strong> iyvnen BCG vaqcinirebuli (BII).<br />
• BCG vaqcina rekomendirebuli ar aris mozardebsa <strong>da</strong> mozrdilebSi,<br />
maT Soris <strong>aiv</strong> inficirebul pirebSi. ramdena<strong>da</strong>c is araefeqturia an<br />
umniSvnelod amcirebs mozrdilTa filtvis tuberkulozis<br />
SemTxvevebs.<br />
• prevenciuli antituberkulozuri <strong>mkurnaloba</strong> mkacrad<br />
rekomendirebulia im <strong>aiv</strong> <strong>infeqcia</strong>/<strong>SidsiT</strong> <strong>da</strong>avadebulebisaTvis,<br />
romlebic savaraudod inficirebulebi arian tuberkulozis<br />
mikobaqteriiT an imyofebian tuberkulozis ganviTarebis riskis qveS<br />
(AI).<br />
4 aRsaniSnavia, rom im qveynebSic ki, sa<strong>da</strong>c tuberkulozis gavrceleba <strong>da</strong>balia,<br />
zogierTi subpopulacia SeiZleba gamoirCeodes <strong>da</strong>avadebis maRali prevalentobiT. 5<br />
janmos evropis regionis qveynebi, sa<strong>da</strong>c SemTxvevaTa raodenoba 100 000 mosaxleze 20-<br />
ze naklebia.<br />
5 janmos evropis regionis qveynebi, sa<strong>da</strong>c SemTxvevaTa raodenoba 100 000 mosaxleze 20-<br />
ze naklebia.<br />
4.2.2. qoleris vaqcina (CVD 103-HgR)<br />
miuxe<strong>da</strong>vad imisa, rom cocxali atenuirebuli oraluri vaqcina farTod<br />
gamoiyenebo<strong>da</strong> <strong>aiv</strong> infeqciis endemur kerebSi <strong>da</strong> seriozuli gverdiTi<br />
reaqciebi ar <strong>da</strong>fiqsirebula, usafrTxoebis Sesaxeb sakmarisi monacemebis<br />
ar arsebobis gamo is ukunaCvenebia <strong>aiv</strong> inficirebul pirebSi (CIII).<br />
<strong>da</strong>xocili WC/rBs vaqcina rekomendebulia <strong>aiv</strong> inficirebulTaTvis (BII).<br />
4..2.3. wiTelas, ybayurasa <strong>da</strong> wiTuras vaqcinebi (MMR, MR, M, R<br />
vaqcinebi 6 )<br />
<strong>aiv</strong> inficirebul asimptomur bavSvebs, aseve bavSvebs zomieri<br />
imunosupresiiT arainficirebuli bavSvebis msgavsad rutinulad un<strong>da</strong><br />
CautardeT MMR <strong>da</strong> wiTelas Semcveli sxva vaqcinaciebi (AI).<br />
mniSvnelovania gvaxsovdes, rom wiTelas vaqcinis imunogenuroba<br />
mcirdeba, Tu vaqcinacia Catardeba a<strong>da</strong>mianis normaluri<br />
imunoglobulinis gamoyenebi<strong>da</strong>n 6 Tveze nakleb periodSi. miuxe<strong>da</strong>vad<br />
imisa, rom <strong>aiv</strong> inficirebul asimptomur <strong>da</strong> simptomur pirebSi MMR-sa<br />
<strong>da</strong> wiTelas Semcveli sxva vaqcinebis gamoyenebisas Catarebuli<br />
kvlevebiT mniSvnelovani gverdiTi reaqciebi ar <strong>da</strong>fiqsirebula, es<br />
vaqcinebi rekomendebuli araa mniSvnelovani imunosupresiis mqone <strong>aiv</strong><br />
inficirebulTaTvis. rekomen<strong>da</strong>ciis ar arsebobis mizezebia:<br />
112
• wiTelas vaqcinaciis Semdgomi pnevmoniis SemTxveva mZime<br />
imunosupresiis mqone recipientSi;<br />
• monacemebi wiTelas vaqcinaciaze gansxvavebuli imunuri pasuxis<br />
Sesaxeb mZime imunosupresiis mqone pirebSi;<br />
• monacemebi wiTelas vaqcinaciis Semdgomi virusuli infeqciiT<br />
gamowveuli letalobis Sesaxeb sul mcire 6 imunokompromitirebul<br />
pirSi.<br />
rekomen<strong>da</strong>ciebi<br />
• MMR <strong>da</strong> wiTelas Semcveli sxva vaqcinebi saSualo an mkveTri<br />
imunosupresiis mqone bavSvebsa <strong>da</strong> mozrdilebSi ar gamoiyeneba (13<br />
wlamde CD4+
8 igulisxmeba piri, romelsac aReniSneba poliomielitis vaqcinis virusis ga<strong>da</strong>cemis<br />
riski <strong>aiv</strong> inficirebul pirze fekaluri an oraluri gziT.<br />
rekomen<strong>da</strong>cia<br />
• pov ar un<strong>da</strong> iqnas gamoyenebuli <strong>aiv</strong> inficirebul/<strong>SidsiT</strong> <strong>da</strong>avadebulebSi,<br />
rogorc bavSvebSi, aseve zr<strong>da</strong>srulebSi, imunodeficitis<br />
statusis miuxe<strong>da</strong>vad; aseve maTi ojaxis wevrebsa <strong>da</strong> maTTan mWidro<br />
kontaqtSi myof sxva pirebSi (AI).<br />
4.2.5. rotavirusis vaqcina<br />
rekomen<strong>da</strong>cia<br />
• Semdgomi samecniero mtkicebulebebiT <strong>aiv</strong> inficirebul bavSvebSi<br />
vaqcinis usafrTxoebisa <strong>da</strong> imunogenurobis profilis <strong>da</strong><strong>da</strong>sturebamde<br />
aRniSnul kategoriaSi rotavirusis vaqcina ar un<strong>da</strong> iqnas gamoyenebuli<br />
<strong>da</strong>moukideblad imunodeficitis statusisa (CIII).<br />
4.2.6. muclis tifis (Ty21a) vaqcina<br />
miuxe<strong>da</strong>vad imisa, rom asimptomur <strong>aiv</strong> inficirebul pirebs 200/mm 3 -ze<br />
maRali CD4+ limfocitebis absoluturi ricxviT SesaZlebelia<br />
CautardeT vaqcinacia muclis tifis cocxali atenuirebuli vaqciniT<br />
(Ty21a jaWvis gamoyenebiT), parenteraluri inaqtivirebuli vaqcina<br />
Teoriulad ufro usafrTxo alternativaa (DIV).<br />
rekomen<strong>da</strong>cia<br />
• Ty21a vaqcina ar un<strong>da</strong> iqnas gamoyenebuli <strong>aiv</strong> inficirebul/<strong>SidsiT</strong><br />
<strong>da</strong>avadebulebSi, rogorc bavSvebSi, aseve zr<strong>da</strong>srulebSi,<br />
imunodeficitis statusis miuxe<strong>da</strong>vad.<br />
4.2.7. Cutyvavilas vaqcina<br />
miuxe<strong>da</strong>vad imisa, rom mcire zomis axalma kvlevam ar gamoavlina<br />
mniSvnelovani gverdiTi reaqciebi 10 <strong>aiv</strong> inficirebul bavSvSi, <strong>aiv</strong><br />
<strong>infeqcia</strong>/<strong>SidsiT</strong> gamowveuli zomieri an mZime imunodeficitis mqone<br />
pirebs Cutyvavilas vaqciniT vaqcinacia ar un<strong>da</strong> CautardeT. Tumca<br />
asimptomur <strong>da</strong> msubuqad gamoxatuli simptomatikis mqone <strong>aiv</strong><br />
inficirebul bavSvebs, romelTa CD4 ujredebis ricxvi 25% an metia<br />
pirveli vaqcinacia un<strong>da</strong> CautardeT 12-15 Tvis asakSi, xolo ganmeorebiTi<br />
4-8 kviris Semdeg. virusuli infeqciis SesaZlo diseminaciis gamo<br />
Cutyvavilas vaqcina ar un<strong>da</strong> iqnas gamoyenebuli im <strong>aiv</strong> inficirebul<br />
bavSvebSi, romelTa CD4 ujredebis ricxvi 25%-ze naklebia.<br />
<strong>aiv</strong> inficirebuli bavSvebi <strong>da</strong> mozrdilebi, romlebic gamoirCevian<br />
maRali mimReblobiT Cutyvavila-zosteris virusis mimarT _ pirebi,<br />
114
omlebsac ar ga<strong>da</strong>utaniaT Cutyvavila (pirveladi <strong>infeqcia</strong>), aReniSnebaT<br />
zosteri (rekurentuli <strong>infeqcia</strong>) an arian seronegatiurni _ sasurvelia<br />
moeridon eqspozicias CutyvaviliT an zosteriT <strong>da</strong>avadebul pirebTan.<br />
<strong>aiv</strong> inficirebul/<strong>SidsiT</strong> <strong>da</strong>avadebulebTan mWidro kontaqtSi myof pirebs<br />
(gansakuTrebiT bavSvebs), romlebsac ar ga<strong>da</strong>utaniaT Cutyvavila <strong>da</strong> arian<br />
<strong>aiv</strong> seronegatiurebi, un<strong>da</strong> CautardeT Cutyvavilas vaqcinacia, raTa ar<br />
moxdes virusis transmisia am pirebi<strong>da</strong>n im <strong>aiv</strong> inficirebulebze,<br />
romlebic Cutyvavila-zosteris virusis mimarT maRali mimReblobiT<br />
gamoirCevian.<br />
rekomen<strong>da</strong>ciebi<br />
• Cutyvavilas vaqcina ar un<strong>da</strong> iqnas gamoyenebuli <strong>aiv</strong> inficirebul<br />
mozrdilebSi imunodeficitis statusis miuxe<strong>da</strong>vad, aseve <strong>aiv</strong><br />
inficirebul bavSvebSi zomieri an mZime imunosupresiiT.<br />
• Cutyvavilas vaqcina un<strong>da</strong> gamoviyenoT mxolod asimptomur <strong>da</strong> msubuqad<br />
gamoxatuli simptomatikis mqone <strong>aiv</strong> inficirebul bavSvebSi (CD4>=25%)<br />
(BII).<br />
• <strong>aiv</strong> inficirebul/<strong>SidsiT</strong> <strong>da</strong>avadebulebTan mWidro kontaqtSi myof<br />
pirebs, romlebic gamoirCevian virusis mimarT maRali mimReblobiT,<br />
un<strong>da</strong> CautardeT vaqcinacia Cutyvavila-zosteris virusis SesaZlo<br />
transmisiis prevenciis mizniT.<br />
4.2.8. yviTeli cxelebis vaqcina<br />
yviTeli cxelebis vaqcinis virusi Teoriulad warmoadgens encefalitis<br />
ganviTarebis risk-faqtors <strong>aiv</strong> inficirebul pirebSi, ris gamoc is<br />
aRniSnul kategoriaSi ar gamoiyeneba. yviTeli cxeleba endemuri<br />
<strong>da</strong>avadebaa ekvatoruli afrikis 33 <strong>da</strong> samxreT amerikis 11 qveyanaSi.<br />
aRniSnul teriatoriaze mogzaurobisas mkurnalma eqimma pacients un<strong>da</strong><br />
miawodos informacia arsebuli riskisa <strong>da</strong> moskitebisagan Tav<strong>da</strong>cvis<br />
meTodebis Sesaxeb. zogierTi klinika pirovnebis CD4+ ujredebis ricxvis<br />
gaTvaliswinebiT iRebs vaqcinaciis ga<strong>da</strong>wyvetilebas.<br />
Tu <strong>aiv</strong> inficirebuli piri ver aridebs Tavs yviTeli cxelebis virusTan<br />
potenciur eqspozicias mas un<strong>da</strong> SevTavazoT vaqcinacia. saWiroa<br />
vaqcinaciasTan <strong>da</strong>kavSirebuli SesaZlo gverdiTi reaqciebis monitoringi.<br />
ramdena<strong>da</strong>c <strong>aiv</strong> negatiur pirebTan Se<strong>da</strong>rebiT <strong>aiv</strong> pozitiur a<strong>da</strong>mianebSi<br />
vaqcinacia SesaZloa iyos naklebad efeqturi, sasurvelia<br />
maneitralizebeli antisxeulebis titris gansazRvra endemur keraSi<br />
mogzaurobamde. yviTeli cxelebis sawinaaRmdego vaqcinacia un<strong>da</strong><br />
CautardeT imunosupresirebuli pirebis ojaxis wevrebsac, Tu maT ar<br />
aReniSnebaT winaaRmdegCvenebebi.<br />
rekomen<strong>da</strong>cia<br />
• yviTeli cxelebis vaqcina ar un<strong>da</strong> iqnas gamoyenebuli <strong>aiv</strong><br />
inficirebulebSi, rogorc bavSvebSi, aseve zr<strong>da</strong>srulebSi,<br />
imunodeficitis statusis miuxe<strong>da</strong>vad, gar<strong>da</strong> im SemTxvevebisa, rodesac<br />
mosalodneli <strong>da</strong>debiTi Sedegi aWarbebs arsebul risks (DIV).<br />
115
4.3. <strong>da</strong>xocili <strong>da</strong> inaqtivirebuli vaqcinebi<br />
<strong>da</strong>xocili <strong>da</strong> inaqtivirebuli vaqcinebi ar warmoadgens safrTxes<br />
imunokompromitirebuli pirebisaTvis <strong>da</strong>, ZiriTa<strong>da</strong>d, gamoiyeneba iseve,<br />
rogorc janmrTel populaciaSi. xSirad imunokompromitirebul<br />
pacientebSi <strong>da</strong>xocili <strong>da</strong> inaqtivirebuli vaqcinis antigenis Sesabamisi<br />
imunuri pasuxi imunokompetentur pirebTan Se<strong>da</strong>rebiT naklebad<br />
srulyofilia; SesaZloa saWiro gaxdes vaqcinaciis maRali doza an<br />
xSiri bustireba, Tumca aRniSnuli modifikaciebis SemTxvevaSic<br />
SesaZloa imunuri pasuxi optimalurze susti iyos (DIV).<br />
4.3.1. qoleris vaqcina (WC/rBs)<br />
Zveli parenteraluri vaqcina (fenoliT inaqtivirebuli <strong>da</strong>xocili<br />
srulujredovani qoleris vibrioni 01) <strong>da</strong>bali efeqturobisa <strong>da</strong><br />
xanmokle <strong>da</strong>cviTi periodis gamo rekomendebuli ar aris, Tumca zogierT<br />
qveyanaSi mainc iwarmoeba.<br />
<strong>da</strong>xocili srulujredovani qoleris vibrionisa <strong>da</strong> qoleris toqsinis<br />
rekombinantuli B fraqciis kombinaciis Semcveli vaqcina (WC/rBs)<br />
usafrTxoa orsulobisa <strong>da</strong> ZuZuTi kvebis periodSic, aseve <strong>aiv</strong> pozitiur<br />
pirebSic.<br />
oraluri vaqcinis 2 doza 10-14 dRis SualediT ainducirebs sawyis<br />
proteqcias vaqcinirebulTa 86%-Si. saSualod vaqcinacia efeqturia 50-<br />
60%-Si sul mcire 3 wlis ganmavlobaSi.<br />
<strong>aiv</strong> pozitiur pirebSi kombinirebuli vaqcinis (WC/rBs) efeqturobis<br />
<strong>da</strong>ma<strong>da</strong>sturebeli specifikuri monacemebi dRemde cnobili ar iyo, Tumca<br />
im populaciis magaliTze, romlis 25%-s <strong>aiv</strong> pozitiuri pirebi<br />
warmoadgendnen, mozambikSi Catarebulma uaxlesma kvlevam gamoavlina<br />
<strong>da</strong>maimedebeli Sedegebi. imunitetis xangrZlivoba <strong>aiv</strong> inficirebulebSi<br />
cnobili ar aris. <strong>aiv</strong> inficirebul mozrdilebSi 100mm 3 -ze naklebi CD4+<br />
ujredebis ricxviT imunizaciis Semdgomi pasuxi SesaZloa iyos susti,<br />
xolo im pirebSi, romelTa CD4+ ujredebis ricxvi 100mm 3 -ze metia<br />
imunuri pasuxi umjobesdeba ori dozis Semdeg. aRniSnuli monacemebi<br />
gviCvenebs vaqcinaciis efeqturobas adreuli an Sualeduri <strong>aiv</strong><br />
<strong>da</strong>avadebisas (DIV).<br />
vaqcinacia seleqtiurad un<strong>da</strong> CautardeT im <strong>aiv</strong> inficirebulebs,<br />
romelTac uwevT mogzauroba endemur kerebSi an miekuTvnebian erT-erT<br />
risk-jgufs (isini vinc xangrZlivi periodiT mogzauroben, iReben<br />
Seumowmebel wyals an arasaTanadod momzadebul sakvebs an cxovroben<br />
arasanitarul pirobebSi <strong>da</strong>avadebis endemur keraSi) (DIV).<br />
116
4.2..2 difTeriis, tetanusisa <strong>da</strong> yivanaxvelas vaqcinebi (DTP,<br />
DTaP, DT, TT, Td 9 )<br />
<strong>aiv</strong> inficirebul bavSvebSi imunuri statusis miuxe<strong>da</strong>vad DTP <strong>da</strong> DT<br />
vaqcinebi rekomendebulia janmrTeli populaciisaTvis gankuTvnili<br />
reJimiT, maT Soris yivanaxvelas araujreduli formis (DTaP) gamoyenebis<br />
SemTxvevaSic rogorc bustirebis, aseve pirveli dozirebisaTvis (AI).<br />
TT <strong>da</strong> Td vaqcinebi imunuri statusis miuxe<strong>da</strong>vad SesaZloa gamoyenebul<br />
iqnas <strong>aiv</strong> inficirebul mozrdilebSi janmrTeli populaciisaTvis<br />
gankuTvnili reJimiTa <strong>da</strong> dozirebiT(BII). gansakuTrebuli mniSvneloba<br />
un<strong>da</strong> mieniWos narkotikebis ineqciuri gziT momxmarebelTa vaqcinacias<br />
TT <strong>da</strong> Td vaqcinebiT, raTa nemsebis gacvlis programebis ararsebobis<br />
SemTxvevaSi SevZloT tetanusis prevencia.<br />
4.2.3. B tipis hemofilus influencas vaqcina (HiB)<br />
5 wlis asakis zeviT bavSvebs <strong>da</strong>avadebisadmi asakobrivad ganpirobebuli<br />
mgrZnobelobis gaTvaliswinebiT HiB vaqcinacia ar esaWiroebaT. zogierT<br />
a<strong>da</strong>mianSi gamomwvevi iwvevs invaziur <strong>infeqcia</strong>s. mikroorganizmis sisxlis<br />
nakadSi moxvedris zusti gza ucnobia, Tumca ganmsazRvreli faqtori<br />
SeiZleba iyos zemo sasunTqi gzebis winmswrebi virusuli an<br />
mikoplazmuri <strong>infeqcia</strong>. sisxlis nakadis gziT baqteria ga<strong>da</strong>inacvlebs<br />
sxeulis sxva<strong>da</strong>sxva nawilebisaken, ZiriTa<strong>da</strong>d ki tvinis garsebisaken. <strong>aiv</strong><br />
inficirebuli bavSvebi <strong>da</strong> mozrdilebi imunosupresiis gamowarmoadgenen<br />
HiB <strong>da</strong>avadebis ganviTarebis maRal risk-jgufs <strong>da</strong> SesaZloa CautardeT<br />
vaqcinacia. 5 wlis asakis zeviT <strong>aiv</strong> inficirebulebma, romlebic<br />
imyofebian HiB <strong>da</strong>avadebis ganviTarebis riskis qveS, un<strong>da</strong> miiRon vaqcinis<br />
sul mcire erTi doza. imunokompromitirebuli bavSvebis vaqcinacia un<strong>da</strong><br />
Catardes janmrTeli populaciisaTvis gankuTvnili dozirebiTa <strong>da</strong><br />
reJimiT.<br />
TiToeuli pacientis magaliTze individualurad un<strong>da</strong> Sefasdes<br />
<strong>da</strong>avadebis ganviTarebis riski <strong>da</strong> vaqcinaciis mosalodneli efeqturoba,<br />
ris mixedviTac ga<strong>da</strong>wydeba imunizaciis sakiTxi. zogierTi monacemis<br />
mixedviT <strong>aiv</strong> negatiur pirebTan Se<strong>da</strong>rebiT <strong>aiv</strong> inficirebulebSi HiB<br />
<strong>da</strong>avadebis ganviTarebis riski ufro maRalia.<br />
9 DTP: difTeriisa <strong>da</strong> tetanusis anatoqsini <strong>da</strong> yivanaxvelas vaqcina; DTaP: difTeriisa<br />
<strong>da</strong> tetanusis anatoqsini <strong>da</strong> yivanaxvelas araujreduli vaqcina; DT:difTeriisa <strong>da</strong><br />
tetanusis anatoqsini (pediatriuli gamoyenebisaTvis); TT: tetanusis anatoqsini; Td:<br />
tetanusisa <strong>da</strong> difTeriis anatoqsini (mozrdilebisaTvis).<br />
4.2.4. A hepatitis vaqcina<br />
A hepatitis virusiT gamowveuli simptomuri <strong>da</strong>avadebis ganviTarebis<br />
riski pir<strong>da</strong>pir korelaciaSia asakTan. 6 wlamde asakis bavSvebSi A<br />
hepatitis virusiT <strong>infeqcia</strong> Cveulebriv asimptomuria, simptomuri<br />
<strong>da</strong>avadeba ki ZiriTa<strong>da</strong>d gvxvdeba mozrdilebSi. <strong>da</strong>avadebis ga<strong>da</strong>tanis<br />
Semdeg imuniteti mTeli sicocxlis manZilze narCundeba. <strong>da</strong>bal-endemur<br />
117
kerebSi A hepatiti erTeuli an mcire jgufuri SemTxvevebis saxiT<br />
gvxvdeba. maRal-endemur kerebSi <strong>da</strong>avadeba ZiriTa<strong>da</strong>d gvxvdeba<br />
asimptomuri formiT bavSvTa asakSi. <strong>da</strong>bali an saSualo donis endemur<br />
areebSi mozrdilTa <strong>da</strong>avadeba Se<strong>da</strong>rebiT xSiria <strong>da</strong> A hepatiti SesaZloa<br />
warmoadgendes samedicino <strong>da</strong> ekonomikur tvirTs.<br />
A hepatitis vaqcinacia (erTjeradi doza 6-12 Tvis Semdgomi bustirebiT)<br />
mkacrad rekomendebulia aRniSnuli <strong>da</strong>avadebis an misi garTulebebis<br />
ganviTarebis riskis mqone pirebSi miuxe<strong>da</strong>vad imunuri <strong>da</strong> <strong>aiv</strong> statusisa<br />
(AI).<br />
risk-jgufs miekuTvnebian:<br />
• pirebi RviZlis qronikuli <strong>da</strong>avadebiT; 10<br />
• homoseqsuali mamakacebi (MSM);<br />
•<br />
narkotikebis momxmareblebi; 11<br />
• Sededebis faqtorTan <strong>da</strong>kavSirebuli <strong>da</strong>rRvevebis mqone pirebi;<br />
• <strong>da</strong>avadebis profesiuli riskis mqone pirebi (mag: laboratoriis<br />
muSakebi);<br />
• 1 wlis an ufrosi asakis pirebi araendemuri qveynebi<strong>da</strong>n, romlebic<br />
gegmaven mogzaurobas A hepatitis virusiT gamowveuli infeqciis<br />
maRali an saSualo endemurobis keraSi 12.<br />
A hepatitis vaqcina gamoirCeva maRali imunogenurobiT. mozrdilTa 95%-<br />
ze mets pirveli vaqcinacii<strong>da</strong>n 4 kviraSi ganuviTardeba proteqtoruli<br />
antisxeulebi. rac Seexeba bavSvebsa <strong>da</strong> mozardebs, pirveli vaqcinacii<strong>da</strong>n<br />
1 TveSi seropozitiuri aRmoCndeba 97%-ze meti. klinikur kvlevebSi<br />
vaqcinaciis ori dozis yvela recipients ganesazRvra antisxeulebis<br />
proteqtoruli done. aRniSnulis gamo, vaqcinaciis Semdgomi testireba<br />
naCvenebi ar aris. A hepatitis virusis sawinaaRmdego antisxeulebis<br />
<strong>da</strong>bali koncentraciis ganmsazRvreli testirebis meTodebi rutinuli<br />
diagnostikisaTvis vaqcinaciis Semdgom periodSi rekomendebuli ar aris<br />
(AI).<br />
monacemebi antisxeulebis persistenciisa <strong>da</strong> imunuri mexsierebis<br />
xangrZlivobis Sesaxeb mcirea, ramdena<strong>da</strong>c dReisaTvis xelmisawvdom<br />
vaqcinebze <strong>da</strong>kvirveba warmoebs 12 welze naklebi periodis ganmavlobaSi.<br />
busteruli dozis <strong>da</strong>matebis saWiroebas gansazRvravs Semdgomi kvlevebi.<br />
10 RviZlis qronikuli <strong>da</strong>avadebis mqone pirebi inficirebis SemTxvevaSi arian<br />
fulminanturi A hepatitis ganviTarebis gazrdili riskis qveS. <strong>aiv</strong> inficirebul pirebs<br />
Tanmxlebi qronikuli hepatitiT B an C, un<strong>da</strong> CautardeT vaqcinacia A hepatitis vaqciniT.<br />
11 A hepatitis virusi <strong>da</strong>avadebis sawyis stadiaze aRmoCndeba avadmyofis sisxlSi <strong>da</strong><br />
iSviaTad transmisia SesaZloa moxdes transfuziis gziT; virusi advilad vrceldeba<br />
antisanitariisa <strong>da</strong> personaluri higienis <strong>da</strong>bali donis pirobebSi, rac xSirad<br />
aRiniSneba narkotikebis momxmarebelTa Soris.<br />
12 vaqcinacia un<strong>da</strong> Catardes gamgzavrebamde 2-4 kviriT adre. maRali an saSualo<br />
endemurobis keras miekuTvneba msoflios yvela qveyana gar<strong>da</strong> kanadis, aSS-s, <strong>da</strong>savleT<br />
evropisa, skandinaviis, iaponiis, axali zelandiis <strong>da</strong> avstraliisa.<br />
118
4.2.5. B hepatitis vaqcina<br />
B hepatitis vaqcina rekomendebulia B virusiT gamowveuli infeqciis<br />
maRali riskis mozrdilebisTvis miuxe<strong>da</strong>vad imunuri <strong>da</strong> <strong>aiv</strong> statusisa<br />
(AI). maRali riskis jgufebia:<br />
• homoseqsuali mamakacebi (MSM);<br />
• mravlobiTi heteroseqsualuri sqesobrivi kontaqtebis mqone pirebi;<br />
• sqesobrivi gziT ga<strong>da</strong>mdebi infeqciebiT pacientebi;<br />
• komerciuli seqs-muSakebi;<br />
• B hepatitis virusis mtarebelTa sqesobrivi partniorebi <strong>da</strong> ojaxis<br />
wevrebi;<br />
• narkotikebis ineqciuri gziT momxmareblebi;<br />
• patimrebi, rogorc mamakacebi, aseve qalebi;<br />
• hemodializze myofi pirebi (miuxe<strong>da</strong>vad imisa, rom B hepatitis vaqcina<br />
aRniSnul kategoriaSi naklebad efeqturia, is mainc rekomendebulia);<br />
• jan<strong>da</strong>cvis muSakebi. 13<br />
B hepatitis vaqcina rekomendebulia yvela axalSobilisTvis<br />
<strong>da</strong>badebisTanave <strong>da</strong> 18 wlamde asakis bavSvebSi, miuxe<strong>da</strong>vad imunuri <strong>da</strong> <strong>aiv</strong><br />
statusisa (AI). miuxe<strong>da</strong>vad imisa iTvaliswinebs Tu ara vaqcinaciis reJimi<br />
erT Tvemde asakis bavSvTa vaqcinacias, maTi efeqturoba erTnairia.<br />
<strong>aiv</strong> inficirebul bavSvebSi vaqcinaciis Semdgomi proteqciis<br />
xangrZlivoba cnobili ar aris, rac Seexeba arainficirebul bavSvebs,<br />
<strong>da</strong>dgenilia, rom vaqcinaciiT ganpirobebuli antisxeulebis done droTa<br />
ganmavlobaSi mcirdeba, Tumca bavSvebSic <strong>da</strong> mozrdilebSic imunuri<br />
mexsiereba srulyofilad narCundeba vaqcinacii<strong>da</strong>n 15 wlis manZilze.<br />
normaluri imunuri sistemis mqone bavSvebsa <strong>da</strong> mozrdilebs ar<br />
esaWiroebaT <strong>da</strong>matebiTi dozebi bustirebisaTvis, arc rutinuli<br />
serologiuri testirebaa naCvenebi. gamonaklisia bavSvebi, romelTa<br />
dedebic HBsAg pozitiurebi arian. isini gamokvleul un<strong>da</strong> iqnen HBsAg-sa<br />
<strong>da</strong> mis sawinaaRmdego antisxeulebze vaqcinaciis mesame dozis Semdeg. Tu<br />
ze<strong>da</strong>piruli antisxeulebis titri 10mIU/ml-ze naklebia, naCvenebia<br />
vaqcinaciis sruli kursis gameoreba. aRniSnul kategoriaSi pasiurad<br />
gadmocemuli dediseuli core antisxeulebi SeiZleba ganisazRvros 24<br />
Tveze maRal asakSic, ris gamoc aRniSnuli testireba ukunaCvenebia.<br />
SesaZlebelia xangrZlivi periodis Semdeg saWiro gaxdes <strong>da</strong>matebiTi<br />
dozebis gamoyeneba bustirebisaTvis (BII). 14<br />
4.2.5.1. B hepatitis vaqcinaciis reJimi <strong>aiv</strong> inficirebul pacientebSi (AI)<br />
<strong>aiv</strong> inficirebuli pacientebs, romelTac ar aReniSnebaT HBV infeqciis<br />
markerebi an arian HBsAg negatiurebi,un<strong>da</strong> CautardeT vaqcinacia.<br />
• B hepatitis vaqcinacia un<strong>da</strong> <strong>da</strong>iwyos gansazRvruli doziT (20µg 0, 1, 2 <strong>da</strong><br />
12 Tveze an 0, 1 <strong>da</strong> 6 Tveze) im pacientebisaTvis, romelTa CD4+<br />
limfocitebis ricxvi >500/mm 3 .<br />
• B hepatitis vaqcinis pediatriuli dozaa 10µg.<br />
• pacientebisaTvis 200-500/mm 3 CD4+ ujredebis ricxviT rekomendebulia<br />
intensiuri reJimi (20µg 0, 1, 2 <strong>da</strong> 12 Tveze).<br />
119
13<br />
riski maRalia staJirebis periodSi; vaqcinacia un<strong>da</strong> Catardes staJirebaze myofi<br />
medicinis, stomatologiis, saeqTno saqmis, laboratoriuli teqnologiebisa <strong>da</strong><br />
jan<strong>da</strong>cvis sxva profesiebis <strong>da</strong>rgSi.<br />
14 hemodializze myof pacientebSi yovelwliurad un<strong>da</strong> ganisazRvros antisxeulebis<br />
titri, ris mixedviTac Sefasdeba vaqcinaciis <strong>da</strong>matebiTi dozis saWiroeba<br />
bustirebisaTvis; <strong>da</strong>matebiTi doza saWiroa, Tu antisxeulebis titri < 10 mIU/ml.<br />
• armopasuxe pacientebSi rekomendebulia <strong>da</strong>matebiTi dozebi<br />
bustirebisaTvis an vaqcinaciis axali kursi 40µg doziT.<br />
• pacientebs 200/mm 3 -ze naklebi CD4+ limfocitebis ricxviT jer un<strong>da</strong><br />
<strong>da</strong>ewyoT arv <strong>mkurnaloba</strong>; vaqcinacia un<strong>da</strong> ga<strong>da</strong>vdoT klinikurad<br />
SesamCnevi imunuri rekonstituciis miRwevamde, sasurvelia CD4<br />
ujredebis 200/mm 3 -ze metad momatebamde (BII).<br />
4.2.5.2. imunologiuri pasuxi B hepatitis vaqcinaciis mimarT<br />
• pasuxi vaqcinaze <strong>da</strong>mokidebulia vaqcinaciis periodSi CD4+ ujredebis<br />
ricxvze; pasuxi SeiZleba <strong>da</strong>qveiTdes pacientebSi CD4+ ujredebis<br />
500mm 3 -ze naklebi ricxviT.<br />
• B hepatitis vaqcinaciis sruli kursis Catarebisas imunologiuri<br />
pasuxis albaToba <strong>aiv</strong> inficirebul pacientebSi 500/mm 3 -ze maRali CD4+<br />
ujredebis ricxviT 87%-ia, xolo 200-500mm 3 CD4+ ujredebis ricxviT _<br />
mxolod 33%.<br />
• C hepatitisa <strong>da</strong> a<strong>da</strong>mianis imunodeficitis virusebiT ko<strong>infeqcia</strong>m<br />
SesaZloa gamoiwvios B hepatitis vaqcinaciis Semdgomi imunologiuri<br />
pasuxis <strong>da</strong>qveiTeba, aseve B virusis ze<strong>da</strong>piruli antigenis<br />
sawinaaRmdego antisxeulebis titris Semcireba <strong>aiv</strong> monoinfeqciiT<br />
pacientebTan Se<strong>da</strong>rebiT.<br />
4.2.5.3. <strong>aiv</strong> inficirebul pacientTa B hepatitis vaqcinaciis Semdgomi<br />
monitoringi <strong>da</strong> strategia<br />
• B virusis ze<strong>da</strong>piruli antigenis sawinaaRmdego antisxeulebis titri<br />
un<strong>da</strong> ganisazRvros vaqcinaciis <strong>da</strong>mTavrebi<strong>da</strong>n 4 kviraSi.<br />
proteqtoruli antisxeulebis ganuviTareblobis SemTxvevaSi<br />
(HBsas
parenteraluri Tu sqesobrivi eqspoziciis SemTxvevaSi B hepatitis<br />
sawinaaRmdego imunoglobuliniT (HBIg) profilaqtikis Sesaxeb.<br />
4.3. gripis vaqcina 15<br />
gripi SeiZleba gaxdes seriozuli avadmyofobisa <strong>da</strong> garTulebebis<br />
15 mas Semdeg, rac gripis cocxali vaqcina <strong>aiv</strong> <strong>infeqcia</strong>/<strong>SidsiT</strong> <strong>da</strong>avadebulebSi<br />
ukunaCvenebia, aRniSnul kategoriaSi gamoiyeneba gripis inaqtivirebuli vaqcina<br />
mizezi imunokompromitirebul pirebSi. aseTi pirebis did nawilSi<br />
vaqcinacia uzrunvelyofs proteqtoruli antisxeulebis gamomuSavebas.<br />
miuxe<strong>da</strong>vad imisa, rom <strong>aiv</strong> <strong>infeqcia</strong>/<strong>SidsiT</strong> <strong>da</strong>avadebulebSi informacia<br />
gripiT avadobis sixSirisa <strong>da</strong> simZimis Sesaxeb dReisaTvis mwiria, gripis<br />
sezonis <strong>da</strong>wyebis win rekomendebulia yvela <strong>aiv</strong> inficirebulis<br />
vaqcinacia. vaqcinaciis sapasuxo antisxeulebis titri <strong>aiv</strong> infeqciis<br />
Sorswasul stadiaze SeiZleba iyos <strong>da</strong>bali, Tumca imunuri pasuxis<br />
gasaZliereblad <strong>da</strong>matebiTi dozis efeqturoba <strong>da</strong>dgenili ar aris (CIII).<br />
4.4. meningokokuri vaqcina<br />
gansazRvruli serotipebis 16 Semcveli meningokokuri vaqciniT rutinuli<br />
imunizacia rekomendebulia meningokokuri <strong>da</strong>avadebis epidemiis arealSi<br />
wamsvlelTaTvis <strong>aiv</strong> statusis miuxe<strong>da</strong>vad, aseve risk-jgufebisaTvis,<br />
magaliTad pirebisaTvis anatomiuri an funqciuri aspleniiT (AI).<br />
4.5. pnevmokokuri vaqcina<br />
pnevmokokuri vaqcina rekomendebulia iseTi qronikuli <strong>da</strong>avadebis mqone<br />
pirebSi, romlebic asocirebulia pnevmokokuri <strong>da</strong>avadebis an misi<br />
garTulebebis gazrdil riskTan (BII). aseTi qronikuli <strong>da</strong>avadebebia<br />
imunosupresiasTan asocirebuli mdgomareobebi, maT Soris <strong>aiv</strong> <strong>infeqcia</strong>.<br />
arsebobs pnevmokokuri vaqcinis ori tipi: polisaqariduli pnevmokokuri<br />
vaqcina (ppv) <strong>da</strong> SekavSirebuli pnevmokokuri vaqcina (Spv).<br />
4.5..1. polisaqariduli pnevmokokuri vaqcina (ppv)<br />
ppv-s erTi doza gamoyenebul un<strong>da</strong> iqnas rutinulad 65 wlis asakis<br />
zeviT pirebSi imunuri <strong>da</strong> <strong>aiv</strong> statusis miuxe<strong>da</strong>vad (AI); 2 wlis asakis<br />
zeviT 17 qronikuli <strong>da</strong>avadebis mqone (kardiovaskularuli <strong>da</strong>avadeba,<br />
filtvis paTologia, diabeti, alkoholizmi, cirozi, cerebrospinaluri<br />
siTxis siWarbe) imunokompetentur pirebSi; 2 wlis asakis zeviT<br />
imunokomprometirebul (maT Soris <strong>aiv</strong> <strong>infeqcia</strong>/<strong>SidsiT</strong> <strong>da</strong>avadebulebi) 18<br />
pirebSi, romlebic imyofebian pnevmokokuri <strong>da</strong>avadebis ganviTarebis<br />
riskis qveS. pacientebs simptomuri an asimptomuri <strong>aiv</strong> infeqciiT<br />
vaqcinacia un<strong>da</strong> CautardeT diagnozis <strong>da</strong><strong>da</strong>sturebisTanave. Tu <strong>aiv</strong><br />
inficirebuli an zoga<strong>da</strong>d imunosupresirebuli (magaliTad,<br />
kortikosteroidebis xangrZivi kursis recipientebi) piris vaqcinaciis<br />
statusi ucnobia, aseT SemTxvevaSi vaqcinacia tardeba (BII).<br />
janmrTel mozrdilTa 80%-ze mets ppv-s miRebi<strong>da</strong>n 2-3 kviraSi<br />
ganuviTardeba antisxeulebi vaqcinis serotipebis mimarT. antisxeulebis<br />
maRali titri janmrTel mozrdilebSi narCundeba sul mcire 5 wlis<br />
121
ganmavlobaSi, xolo Se<strong>da</strong>rebiT ufro swrafad qveiTdeba fonuri<br />
<strong>da</strong>avadebebis mqone, maT Soris <strong>aiv</strong> inficirebul pirebSi.<br />
16 meningokokuri vaqcina un<strong>da</strong> moicavdes Sesabamis geografiul arealSi <strong>da</strong>avadebis<br />
epidemiis gamomwvev serotipebs. meningokokuri serojgufebi A, B <strong>da</strong> C aRmoCenila mTel<br />
msoflioSi; serojgufi Y aRmoCenilia aSS-is zogierT nawilSi; serojgufi A<br />
<strong>da</strong>fiqsirebulia “meningitis sartyelSi” senegali<strong>da</strong>n eTiopiamde; serojgufi W125<br />
nanaxia saudis arabeTSi.<br />
17 2 wlamde asakis bavSvebSi ppv-s umetesi serotipebis sapasuxo antisxeulebis titri<br />
<strong>da</strong>balia.<br />
18 <strong>aiv</strong> <strong>infeqcia</strong>/<strong>SidsiT</strong> <strong>da</strong>avadebulebTa gar<strong>da</strong> pirebi anatomiuri an funqciuri<br />
aspleniiT (romelime <strong>da</strong>avadebis arsebobisas an qirurgiuli gziT mocilebisas),<br />
hojkinis <strong>da</strong>avadebiT, limfomiT, mravlobiTi mielomiT, Tirkmlis qronikuli<br />
ukmarisobiT, an imunosupresiasTan asocirebuli sxva mdgomareobiT (mag.: organos<br />
transplantaciisas).<br />
65 wlamde asakis imunokompetenturi pirebis rutinuli revaqcinacia<br />
rekomendebuli araa.<br />
65 wlis pirebsa <strong>da</strong> ufro xan<strong>da</strong>zmulebs ganmeorebiTi doza un<strong>da</strong> mieceT<br />
im SemTxvevaSi Tu pirveli dozis gamoyenebi<strong>da</strong>n gasulia 5 weliwadze<br />
meti <strong>da</strong> im periodisTvis maTi asaki iyo 65 welze naklebi. <strong>aiv</strong><br />
<strong>infeqcia</strong>/<strong>SidsiT</strong> <strong>da</strong>avadebulebsa <strong>da</strong> sxva imunokompromitirebul pirebs,<br />
romlebic miekuTvnebian maRali riskis jgufs ganmeorebiTi vaqcinacia<br />
un<strong>da</strong> CautardeT 5 wlis Semdeg.<br />
revaqcinacia aseve rekomendebulia 2 wlisa <strong>da</strong> Semdgomi asakis bavSvebSi,<br />
romlebic imyofebian infeqciis ganviTarebis maRali riskis qveS; aseve im<br />
pirebSi, romlebSic fonuri <strong>da</strong>avadebis gamo mosalodnelia pnevmokokuri<br />
antisxeulebis titris swrafi Semcireba. revaqcinacia un<strong>da</strong> Catardes<br />
pirveli dozis gamoyenebi<strong>da</strong>n 3-5 wlis Semdeg.<br />
4.5.2. SekavSirebuli pnevmokokuri vaqcina (Spv)<br />
Spv imunogenuria Cvilebsa <strong>da</strong> bavSvebSi, maT Soris <strong>aiv</strong> inficirebulebSi<br />
imunuri statusis miuxe<strong>da</strong>vad. Spv-s oTxi dozis Semdeg yvela janmrTel<br />
axalSobils uviTardeba vaqcinis TiToeuli serotipis sawinaaRmdego<br />
antisxeulebi (AI). 19<br />
• vaqcinacia rutinulad tardeba 2, 4 <strong>da</strong> 6 Tvis asakSi, <strong>da</strong>matebiTi doza<br />
bustirebisaTvis rekomendebulia 12-15 Tvis asakSi.<br />
• aravaqcinirebul 7-11 Tvis asakis bavSvebs, maT Soris <strong>aiv</strong><br />
inficirebulebs, Spv-s pirveli ori doza un<strong>da</strong> mieceT 6-8 kviris<br />
intervaliT, <strong>da</strong>matebiTi doza bustirebisaTvis rekomendebulia 12-15<br />
Tvis asakSi.<br />
• aravaqcinirebul 12-23 Tvis asakis bavSvebs un<strong>da</strong> mieceT Spv-s ori doza<br />
6-8 kviris intervaliT.<br />
• aravaqcinirebul 24-59 Tvis asakis janmrTel bavSvebs un<strong>da</strong> mieceT Spv-s<br />
erTjeradi doza.<br />
• 24-59 Tvis asakis bavSvebs <strong>aiv</strong> infeqciiT, namglisebrujredovani anemiiT,<br />
aspleniiT, qronikuli <strong>da</strong>avadebebiTa <strong>da</strong> imunomakompromitirebuli<br />
mdgomareobebiT un<strong>da</strong> mieceT Spv-s ori doza 6-8 kviris intervaliT.<br />
122
efeqtis bustirebisTvis rekomendebulia Spv-s <strong>da</strong>matebiTi doza meore<br />
vaqcinacii<strong>da</strong>n 6-8 kviris Semdeg.<br />
• rutinuli Spv vaqcinacia 5 wlis asakis zeviT bavSvebSi<br />
rekomendebuli araa <strong>aiv</strong> statusis miuxe<strong>da</strong>vad.<br />
Spv-s pirveladi kursis Semdeg revaqcinacia dReisaTvis rekomendebuli<br />
araa. Tumca 2 wlisa <strong>da</strong> Semdgomi asakis bavSvebSi, Spv-s pirveladi<br />
kursis bolo vaqcinacii<strong>da</strong>n 6-8 kviris Semdeg rekomendebulia <strong>da</strong>matebiTi<br />
doza efeqtis bustirebisTvis.<br />
19 dReisaTvis <strong>aiv</strong> <strong>infeqcia</strong>/<strong>SidsiT</strong> <strong>da</strong>avadebulebSi Spv-s gamoyenebis Sesaxeb monacemebi<br />
mcirea, Catarebulia kvlevebi mxolod samxreT afrikaSi, aseve mcire gamokvlevebi aSS-<br />
Si.<br />
4.6. inaqtivirebuli poliovirusis vaqcina (ipv)<br />
Tu polioimunizacia naCvenebia, ipv gamoyenebul un<strong>da</strong> iqnas <strong>aiv</strong><br />
inficirebul Cvilebsa <strong>da</strong> bavSvebSi imunuri statusis miuxe<strong>da</strong>vad, aseve<br />
momvlel personalsa <strong>da</strong> ojaxis im wevrebSi, romlebic mWidro kontaqtSi<br />
arian <strong>aiv</strong> inficirebul/<strong>SidsiT</strong> <strong>da</strong>avadebulebTan, raTa moxdes vaccine an<br />
vaccine-derived poliovirusis transmisiis prevencia am ukanasknelebSi (AI).<br />
aravaqcinirebuli <strong>aiv</strong> inficirebuli mozrdilebisaTvis, romelTac<br />
aReniSnebaT poliovirusTan eqspoziciis maRali riski, rekomendebulia<br />
ipv-s pirveladi kursi.<br />
4.7.cofis vaqcina<br />
gamoiyeneba cofis sawinaaRmdego ori tipis vaqcina: nervuli qsovilis<br />
vaqcina (Semple-type) <strong>da</strong> axali ujredi<strong>da</strong>n miRebuli vaqcina (modern cellderived<br />
vaccine). cofis sawinaaRmdego vaqcinebi gamoiyeneba eqspoziciis<br />
Semdgomi proteqciisa <strong>da</strong> eqspoziciamde imunogenurobisaTvis. cofis<br />
sawinaaRmdego vaqcinebi ar aris ukunaCvenebi <strong>aiv</strong> inficirebulTaTvis <strong>da</strong><br />
saWiroebisas un<strong>da</strong> gamoviyenoT (AI).<br />
imunokompromitirebul <strong>aiv</strong> inficirebulebSi SesaZloa ar ganviTardes<br />
efeqturi imunologiuri pasuxi, ramdena<strong>da</strong>c imuniteti <strong>da</strong>mokidebulia<br />
CD4+ ujredebiT ganpirobebuli maneitralizebeli antisxeulebis titrze<br />
G proteinis mimarT. amrigad, rodesac imunokompromitirebul <strong>aiv</strong><br />
inficirebuls utardeba eqspoziciis Semdgomi <strong>mkurnaloba</strong>,<br />
savaldebuloa intramuskularuli vaqcinisa <strong>da</strong> cofis sawinaaRmdego<br />
imunoglobulinis gamoyeneba sapasuxo antisxeulebis serologiuri<br />
monitoringiT.<br />
proteqciisaTvis saWiroa cofis sawinaaRmdego antisxeulebis titri<br />
>0.5IU/ml. Tu cofis sawinaaRmdego vaqcinis 4-5 dozis gamoyenebis Semdeg<br />
maneitralizebeli antisxeulebis titri
4.8. tkipismieri encefalitis vaqcina<br />
tkipismieri encefalitis virusiT gamowveuli <strong>infeqcia</strong> gvxvdeba evropis<br />
did nawilSi (avstria, germania, samxreT <strong>da</strong> centaluri SvedeTi, ungreTi,<br />
safrangeTi, Sveicaria, norvegia, <strong>da</strong>nia, poloneTi, xorvatia, albaneTi,<br />
estoneTi, latvia, litva, CexeTi, slovakeTi, ruseTi). <strong>da</strong>avadeba cnobilia<br />
ramdenime saxeliT, rogoricaa rusuli gazafxul-zafxulis encefaliti<br />
(RSSE), Soreuli aRmosavleTis encefaliti <strong>da</strong> centaluri evropis<br />
encefaliti (CEE).<br />
aRniSnul qveynebSi mogzaurobisas inficirebis riski <strong>da</strong>balia.<br />
inficireba ZiriTa<strong>da</strong>d <strong>da</strong>kavSirebulia iseT aqtivobebTan, rogoricaa<br />
soflis meurneoba <strong>da</strong> metyeveoba, seirnoba <strong>da</strong> nadiroba endemuri<br />
regionebis Tbil <strong>da</strong> tyian arealSi. inficirebis maRali riski aqvT<br />
metyeveebs, xis mWrelebs, fermerebs, meomrebs, laboratoriis muSakebsa<br />
<strong>da</strong> turistebs, romelTac uwevT nadiroba, aseve savele pirobebSi muSaoba<br />
<strong>da</strong> cxovreba.<br />
preeqspoziciuri profilaqtika SesaZlebelia inaqtivirebuli vaqciniT.<br />
vaqcinaciis stan<strong>da</strong>rtuli reJimi moicavs or dozas 4-12 kviris<br />
intervaliT <strong>da</strong> mesame dozas 9-12 Tvis Semdeg. imunokompetentur pirebSi<br />
serokonversiis sixSire 3 dozis Semdeg 85-100%-ia. riskis qveS myofi<br />
pirebisaTvis rekomendebulia bustireba yovel 3 weliwadSi. swrafi<br />
reJimebi 20 janmrTel pirebSi xasiaTdeba imave efeqturobiT <strong>da</strong><br />
praqtikulia mogzaurebisTvis (AI). swrafi reJimis vaqcinaciis<br />
efeqturoba <strong>aiv</strong> inficirebulebSi ucnobia.<br />
<strong>aiv</strong> inficirebulebSi vaqcinaciis imunogenurobis Sesaswavlad<br />
Catarebulia mxolod ori kvleva. aRniSnuli kvlevebi gviCvenebs, rom<br />
vaqcina janmrTel pirebTan Se<strong>da</strong>rebiT <strong>aiv</strong> inficirebulebSi, ZiriTa<strong>da</strong>d ki<br />
im pirebSi, romelTa CD4+ ujredebis ricxvi 500/mm 3 -ze mcirea, naklebad<br />
efeqturia. Tumca 4 dozis Semcvelma vaqcinaciam 0, 1, 2 <strong>da</strong> 9-12 Tveze<br />
SeiZleba gaaumjobesos imunuri pasuxi <strong>aiv</strong> inficirebulebSi. amave dros<br />
un<strong>da</strong> aRiniSnos, rom zemoTaRwerili strategiis Sesaxeb informacia<br />
mcirea (CIII).<br />
imunizacia un<strong>da</strong> CautardeT <strong>aiv</strong> inficirebulebs, romlebic gegmaven<br />
endemuri regionis qveynebis tyian arealSi mogzaurobasa an muSaobas<br />
gvian gazafxulze an zafxulSi, rodesac tkipebi gansakuTrebiT<br />
aqtiuria. vaqcina aseve rekomendebulia im emigrantebisaTvis, romelTac<br />
cxovreba uwevT tkipismieri encefalitis endemur arealSi.<br />
<strong>aiv</strong> inficirebulebSi, romelTa CD4+ ujredebis ricxvi 400/mm 3 -ze metia<br />
vaqcinacia SeiZleba CautardeT stan<strong>da</strong>rtuli an swrafi reJimiT. <strong>aiv</strong><br />
inficirebulebs, romelTa CD4+ ujredebis ricxvi 400/mm 3 -ze naklebia<br />
vaqcinaciis meore dozi<strong>da</strong>n erT TveSi sasurvelia CautardeT<br />
serologiuri testireba. araadeqvaturi imunuri pasuxis SemTxvevaSi pirs<br />
un<strong>da</strong> mieces vaqcinis ori <strong>da</strong>matebiTi doza, pirveli-<strong>da</strong>uyovnebeli, xolo<br />
meore- 9-12 Tvis Semdeg. Tu serologiuri testireba araxelmisawvdomia<br />
vaqcinacias vatarebT 4 dozis Semcveli reJimiT (0, 1, 2 <strong>da</strong> 9-12 Tveze).<br />
124
imunokompromitirebul <strong>aiv</strong> inficirebulebSi vaqvinaciis Semdgomi<br />
imunuri pasuxis <strong>da</strong>qveiTebis albaTobis gamo aucilebelia <strong>da</strong>cviTi<br />
RonisZiebebis mniSvnelobis xazgasma. busteruli rekomen<strong>da</strong>ciebi <strong>aiv</strong><br />
inficirebuli <strong>da</strong> imunokompetenturi pirebisaTvis erTnairia.<br />
4.9. tifis vaqcina (Vi polisaqaridi)<br />
<strong>da</strong>bali efeqturobisa <strong>da</strong> gverdiTi reaqciebis sixSiris gamo Zveli<br />
inaqtivirebuli vaqcina rekomendebuli ar aris, Tumca ekonomikur<br />
mizezTa gamo zogierT qveyanaSi is mainc iwarmoeba.<br />
parenteruli <strong>da</strong>xocili vaqcina, romelic Seicavs Vi polisaqarids<br />
kanqveS an kunTSi erTjeradi dozirebisas zomierad efeqturia (50-80%).<br />
vaqcina ineqcii<strong>da</strong>n 7 dReSi uzrunvelyofs proteqcias, romelic<br />
narCundeba sul mcire ori weli. riskis qveS myofi pirebisTvis<br />
rekomendebulia bustireba yovel sam weliwadSi.<br />
<strong>aiv</strong> inficirebul pirebs salmonelas StamiT inficirebis maRali riski<br />
aqvT. gar<strong>da</strong> amisa imunodeficiti ganapirobebs baqteriemias<br />
antibiotikebis mimarT rezistentobas, <strong>da</strong>avadebis relafss <strong>da</strong> persistul<br />
<strong>infeqcia</strong>s. miuxe<strong>da</strong>vad imisa, rom zoga<strong>da</strong>d saerTaSoriso mogzaurobisas<br />
20 FSME: pirveladi kursis saxiT gamoiyeneba 2 doza 14 dRis intervaliT, xolo mesame<br />
doza 9-12 Tvis Semdeg; Encepur: sami doza 0, 7 <strong>da</strong> 21 dReze pirveladi kursis saxiT,<br />
meoTxe doza 12-18 Tvis Semdeg.<br />
saWiro ar aris, Vi polisaqaridis Semcveli vaqcina rekomendebulia<br />
yvela <strong>aiv</strong> inficirebulisaTvis, romelic gegmavs mogzaurobas<br />
eqspoziciis maRali riskis arealSi. mosalodnel eqspoziciamde sul<br />
mcire ori kviriT adre un<strong>da</strong> Catardes erTjeradi vaqcinacia. tifis<br />
vaqcina ar uzrunvelyofs proteqcias 100%-Si <strong>da</strong> pasuxi SiZleba kidev<br />
ufro Semcirdes <strong>aiv</strong> <strong>infeqcia</strong>/<strong>SidsiT</strong> <strong>da</strong>avadebulebSi. zoga<strong>da</strong>d bustireba<br />
rekomendebulia yovel sam weliwadSi. maTTvis ki, romelTa CD4+<br />
ujredebis ricxvi 200/mm 3 -ze naklebia. es intervali SeiZleba Semcirdes<br />
or wlamde. mogzaurebs un<strong>da</strong> mieceT rekomen<strong>da</strong>ciebi sakvebTan <strong>da</strong><br />
sasmelTan <strong>da</strong>kavSirebuli akrZalvebis Sesaxeb.<br />
4.10. sxva <strong>da</strong>xocili antigenebi<br />
<strong>da</strong>xocili antigenebis Semcveli sxva vaqcinebi, rogoricaa iaponuri<br />
encefalitis, Savi Wirisa <strong>da</strong> jilexis vaqcinebi ar warmoadgens safrTxes<br />
<strong>aiv</strong> /<strong>SidsiT</strong> <strong>da</strong>avadebulTTavis, miuxe<strong>da</strong>vad maTi imunologiuri statusisa.<br />
es vaqcinebi gamoiyeneba iseve, rogorc ara <strong>aiv</strong> inficirebul pirebSi.<br />
4.1.1. imunoglobulinebis gamoyeneba<br />
4.11.1. B hepatitis imunoglobulini (HBIg)<br />
imunokompromitirebul pirebSi, maT Soris <strong>aiv</strong> <strong>infeqcia</strong>/<strong>SidsiT</strong><br />
<strong>da</strong>avadebulebSi, B hepatitis imunoglobulini gamoiyeneba igive<br />
125
CvenebebiTa <strong>da</strong> doziT, rogorc imunokompetentur a<strong>da</strong>mianebSi (AI). B<br />
hepatitis imunoglobuliniT eqspoziciis Semdgomma profilaqtikam<br />
SeiZleba ganapirobos droebiTi imunitetis ganviTareba. B hepatitis<br />
imunoglobulini gamoiyeneba pasiuri imunizaciisTvis:<br />
• HBsAg pozitiuri dedebis axalSobilebSi;<br />
• pirebSi, romelTac aReniSnaT HBsAg pozitiur sisxlTan an sxeulis<br />
sxva siTxesTan kanismieri, lorwovanismieri an sqesobrivi eqspozicia;<br />
• pacientebSi RviZlis transplantaciiT.<br />
rogorc wesi B hepatitis imunoglobulini gamoiyeneba B hepatitis<br />
vaqcinasTan kombinaciaSi. nebismieri piri, romelsac esaWiroeba B<br />
hepatitis imunoglobulini miekuTvneba maRali riskis jgufs, rac imas<br />
niSnavs, rom mas un<strong>da</strong> Cautardes B hepatitis vaqcinis kursi. B hepatitis<br />
imunoglobulini naCvenebia:<br />
• axalSobilebSi, romelTaA dedebic HBsAg pozitiurni an ucnobi HBsAg<br />
statusis arian; B hepatitis imunoglobulini 21 , aseve, SeiZleba<br />
gamoviyenoT B hepatitis vaqciniT imunoprofilaqtikisas<br />
<strong>da</strong>badebisTanave an <strong>da</strong>badebi<strong>da</strong>n mcire periodSi.<br />
• HBsAg pozitiur de<strong>da</strong>Ta axalSobilebSi, sasurvelia pirveli 12 saaTis<br />
ganmavlobaSi; amasTanave, B hepatitis imunoglobulinisa <strong>da</strong> vaqcinis<br />
ineqciis wertilebi ar un<strong>da</strong> emTxveodes erTmaneTs.<br />
• B hepatitis vaqcinaze armopasuxe HBsAg negatiur pirebSi; aRniSnuli<br />
kategoria konsultirebul un<strong>da</strong> iqnas HBV infeqciis prevenciisa <strong>da</strong> B<br />
hepatitis imunoglobulinis saWiroebis Sesaxeb HBsAg pozitiur<br />
sisxlTan parenteraluri eqspoziciisas.<br />
21 perinetaluri gziT SeZenili infeqciisgan B hepatitis <strong>da</strong>uyovnebeli vaqcinaciiT (24<br />
sT-is ganmavlobaSi) uzrunvelyofili <strong>da</strong>cva B hepatitis imunoglobulinis <strong>da</strong>matebiTi<br />
gamoyenebisas mniSvnelovnad ar umjobesdeba.<br />
• savaraudo sqesobrivi kontaqti mwvave B hepatitiT <strong>da</strong>avadebul<br />
pacientTan ukanaskneli sqesobrivi kontaqti<strong>da</strong>n 14 dRis ganmavlobaSi 22 .<br />
• aravaqcinirebul axalSobilebSi, romelTa dedebs an momvlel pirebs<br />
aqvT mwvave HBV <strong>infeqcia</strong>, aseT SemTxvevaSi axalSobils un<strong>da</strong> mieces B<br />
hepatitis vaqcinaciis kursis pirveli dozac 23 .<br />
• pirebSi, romelTac aqvT mWidro kontaqti mwvave HBV infeqciiT<br />
pacientTan, an aReniSnaT eqspozicia inficirebuli a<strong>da</strong>mianis sisxlTan<br />
(mag. makratlis, saparsis an sxva gziT), aseT SemTxvevaSi un<strong>da</strong> mieces B<br />
hepatitis vaqcinaciis kursis pirveli dozac 24 .<br />
4.11.2. a<strong>da</strong>mianis normaluri imunoglobulini<br />
4.11.2.1. hepatiti A<br />
A hepatitis prevenciisTvis 25 a<strong>da</strong>mianis normaluri imunoglobulinis<br />
gamoyenebis Cvenebebi <strong>da</strong> wesebi msgavsia imunokompetenturi <strong>da</strong><br />
imunokompromitirebuli pirebisTvis. a<strong>da</strong>mianis normaluri imunoglobulinis<br />
<strong>da</strong> A hepatitis vaqcinis erTdrouli gamoyeneba proteqtoruli<br />
antisxeulebis formaciaze mniSvnelovan zegavlenas ar axdens.<br />
126
A hepatitis prevenciis mizniT a<strong>da</strong>mianis normaluri imunoglobulinis<br />
gamoyeneba naCvenebia Semdeg jgufebSi:<br />
• pirebi, romlebic A hepatitis vaqcinacii<strong>da</strong>n 4 kviraze nakleb<br />
periodSi gegmaven mogzaurobas maRali riskis arealSi (vaqcinisa<br />
<strong>da</strong> imunoglobulinis ineqciis wertilebi un<strong>da</strong> iyos <strong>da</strong>Sorebuli)<br />
• 1 wlamde asakis bavSvebi. ramdena<strong>da</strong>c maT A hepatitis vaqcinacia ar<br />
utardebaT, maRali riskis arealSi mogzaurobisas mogzaurobis<br />
xangrZlivobis gaTvaliswinebiT un<strong>da</strong> gamoviyenoT 0.02-0.06ml/kg<br />
imunoglobulini.<br />
• A hepatitis virusTan eqspozirebuli aravaqcinirebuli pirebi.<br />
imunoglobulini un<strong>da</strong> gamoviyenoT eqspozicii<strong>da</strong>n 2 kviris<br />
ganmavlobaSi.<br />
• A hepatitiT <strong>da</strong>avadebulTan mWidro kontaqtSi myofi pirebi.<br />
• bavSvebi <strong>da</strong> momuSave personali bavSvTa centrebSi A hepatitis<br />
diagnostirebisas.<br />
• transmisiis maRali riskis mqone pirebi (mag.,kvebiT <strong>da</strong>wesebulebebSi<br />
inficirebul sakvebTan kontaqtisas).<br />
Tu A hepatitis vaqcinacii<strong>da</strong>n gasulia 1 Tve an meti a<strong>da</strong>mianis normaluri<br />
imunoglobulini ar gamoiyeneba.<br />
22 Tu ukanaskneli sqesobrivi kontaqti<strong>da</strong>n gasulia 14 dReze meti, miuxe<strong>da</strong>vad imisa, rom<br />
eqspoziciis Semdgomi profilaqtikis efeqturobis xarisxi cnobili ar aris, un<strong>da</strong><br />
Catardes B hepatitis vaqcinacia, xolo B hepatitis sawinaaRmdego imunoglobulini<br />
rekomendebuli ar aris.<br />
23 B hepatitis sawinaaRmdego imunoglobulini rekomendebuli ar aris CvilebisTvis,<br />
romelTac miiRes an un<strong>da</strong> miiRon vaqcinis meore doza.<br />
24 B hepatitis vaqcinacia rutinulad un<strong>da</strong> Catardes aseve sisxlismieri eqspoziciis<br />
gareSe mWidro arasqesobrivi kontaqtisas, gansakuTrebiT bavSvebsa <strong>da</strong> mozardebSi.<br />
25 HAV infeqciis prevenciisTvis rekomendebulia a<strong>da</strong>mianis normaluri imunoglobulini<br />
eqspoziciamde an eqspozicii<strong>da</strong>n 2 kviris manZilze. a<strong>da</strong>mianis normaluri<br />
imunoglobulinis mogvianebiTi gamoyeneba xSirad mxolod amcirebs HAV infeqciis<br />
klinikur gamovlinebebs.<br />
4.11.2.2. wiTela<br />
imunokompromitirebul pirebSi, maT Soris <strong>aiv</strong> inficirebulebSi,<br />
a<strong>da</strong>mianis normaluri imunoglobulini naCvenebia wiTelas virusTan<br />
eqspoziciis SemTxvevaSi prevenciis mizniT. wiTelas vaqcinaciis<br />
ukuCvenebis SemTxvevaSi, imunokompromitirebul pirebSi, maT Soris 1<br />
wlamde asakis bavSvebSi, naCvenebia a<strong>da</strong>mianis normaluri<br />
imunoglobulinis 0.5ml/kg (maqsimaluri doza - 15ml) intramuskularuli<br />
gamoyeneba eqspoziciisTanave. wiTelas virusTan eqspozirebul simptomur<br />
<strong>aiv</strong> inficirebulebSi a<strong>da</strong>mianis normaluri imunoglobulini un<strong>da</strong><br />
gamoviyenoT vaqcinaciis statusis miuxe<strong>da</strong>vad, ramdena<strong>da</strong>c am SemTxvevaSi<br />
vaqcinacia SeiZleba iyos araefeqturi <strong>da</strong> ganviTardes <strong>da</strong>avadeba.<br />
imunokompromitirebul pirebSi wiTelas profilaqtikis mizniT a<strong>da</strong>mianis<br />
normaluri imunoglobulinis gamoyenebisas, 6 Tvis ganmavlobaSi<br />
vaqcinacia ar tardeba.<br />
127
4.11.2.3. cofis sawinaaRmdego imunoglobulini<br />
imunokompromitirebul pacientebSi, maT Soris <strong>aiv</strong> inficirebulebSi,<br />
cofis sawinaaRmdego imunoglobulini, gamoiyeneba igive CvenebebiTa <strong>da</strong><br />
dozirebiT, rogorc imunokompetentur pirebSi (AI). cofis sawinaaRmdego<br />
imunoglobulini naCvenebia III kategoriis kontaqtisas (transdermaluri<br />
nakbeni an nakawri, lorwovani membranis kontaminacia nerwyviT)<br />
vaqcinaciis kursis pirvel dozasTan erTad. cofis sawinaaRmdego<br />
imunoglobulini ar aris naCvenebi vaqcinirebuli pirebisaTvis<br />
maneitralizebeli antisxeulebis titriT 0.5se/ml an meti.<br />
Tu <strong>aiv</strong> inficirebul imunokompromitirebul pirs utardeba eqspoziciis<br />
Semdgomi <strong>mkurnaloba</strong>, cofis sawinaaRmdego imunoglobulini<br />
auculebelia vaqcinaciis kursis pirvel dozasTan erTad. amasTan,<br />
sasurvelia antisxeulebis serologiuri monitoringi.<br />
4.11.2.4. tetanusis sawinaaRmdego imunoglobulini<br />
imunokompromitirebul pacientebSi, maT Soris <strong>aiv</strong> inficirebulebSi,<br />
tetanusis sawinaaRmdego imunoglobulini, gamoiyeneba igive CvenebebiTa<br />
<strong>da</strong> dozirebiT, rogorc imunokompetentur pirebSi. tetanusis<br />
imunoglobulini rekomendebulia tetanusiT avadmyofebSi, aseve<br />
araadeqvaturi imunizaciisas pirebSi WrilobebiT an tetanusis<br />
ganviTarebis riskTan asocirebuli sxva mdgomareobebiT. tetanusis<br />
imunoglobulini axdens tetanusis mocirkulire toqsinis neitralizacias.<br />
is ar moqmedebs nervul sistemaSi moxvedril toqsinze.<br />
tetanusis mkurnalobisaTvis bavSvebsa <strong>da</strong> mozrdilebSi rekomendebulia<br />
erTjeradi intramuskularuli doza 3000-5000 erTeuli. tetanusis<br />
sawinaaRmdego imunoglobulinis gamoyenebis Cvenebebia:<br />
• mniSvenelovani zomis <strong>da</strong>binZurebuli Wriloba, imunizaciis<br />
gaurkveveli statusis an mxolod 2 dozis gamoyenebisas. aseT<br />
SemTxvevaSi <strong>da</strong>matebiT sasurvelia anatoqsinis gamoyeneba. 26<br />
26 anatoqsinis sawyisi dozebi ar axdens imunitetis inducirebas. tetanusis<br />
sawinaaRndego imunoglobulini uzrunvelyofs antitoqsinis proteqtorul dones<br />
imunuri pasuxis ganviTarebamde.<br />
•<br />
mniSvenelovani zomis <strong>da</strong>binZurebuli Wriloba tetanusis<br />
anatoqsinis gamoyenebis winaaRmdegCvenebiT.<br />
•<br />
tetanusis simptomebis arseboba.<br />
intravenuri imunoglobulini Seicavs tetanusis antitoqsins <strong>da</strong><br />
SesaZloa gamoyenebul iqnas, Tu tetanusis sawinaaRmdego<br />
imunoglobulini xelmisawvdomi ar aris.<br />
4.11.2.5. Cutyvavila-zosteris sawinaaRmdego imunoglobulini<br />
Cutyvavila-zosteris sawinaaRmdego imunoglobulini ZiriTa<strong>da</strong>d<br />
gamoiyeneba axalSobilTa <strong>da</strong> mniSvnelovnad imunikompromitirebul<br />
pirTa, maT Soris <strong>aiv</strong> inficirebulTa pasiuri imunizaciisaTvis<br />
128
CutyvavilasTan an zosterTan eqspoziciis SemTxvevaSi (BII).<br />
CutyvavilasTan eqspozirebul imunikompromitirebul pirebSi<br />
Cutyvavila-zosteris sawinaaRmdego imunoglobulinis gamoyenebam<br />
SesaZloa Seamciros inficirebisa <strong>da</strong> garTulebebis riski.<br />
<strong>aiv</strong> inficirebul bavSvebSi Cutyvavilas profilaqtikisaTvis (bavSvebi,<br />
romelTac ar ga<strong>da</strong>utaniaT Cutyvavila an zosteri an ar aReniSnebaT<br />
Cutyvavila-zosteris sawinaaRmdego antisxeulebis deteqtabeluri done)<br />
sasurvelia Cutyvavila-zosteris sawinaaRmdego imunoglobulinis<br />
gamoyeneba eqspozicii<strong>da</strong>n 96 saaTis ganmavlobaSi.<br />
Cutyvavila-zosteris sawinaaRmdego imunoglobulini aseve<br />
rekomendebulia <strong>aiv</strong> inficirebul orsulTaTvis Cutyvavila-zosteris<br />
virusTan eqspozicii<strong>da</strong>n 96 saaTis ganmavlobaSi. Tu gamoiyeneba<br />
acikloviri, sasurvelia Cutyvavila-zosteris sawinaaRmdego<br />
antisxeulebis kontroli. seropozitiur SemTxvevaSi medikamenti<br />
SesaZlebelia Sewydes.<br />
<strong>da</strong>narTi 1. rekomen<strong>da</strong>ciebi <strong>aiv</strong> <strong>infeqcia</strong>/<strong>SidsiT</strong> imunokompromitirebulTa<br />
imunizaciis Sesaxeb<br />
rekomen<strong>da</strong>ciebi <strong>aiv</strong> <strong>infeqcia</strong>/<strong>SidsiT</strong> imunokompromitirebulTa<br />
imunizaciis Sesaxeb<br />
vaqcina Cvilebi <strong>da</strong> bavSvebi zr<strong>da</strong>srulebi ararutinuli<br />
imunizacia<br />
jilexi _ _ gamoiyeneT Cvenebisas<br />
BCG ukunaCvenebia/gansaxilvelia _ ukunaCvenebia<br />
qolera(CVD103HgR) _ _ ukunaCvenebia<br />
qolera (WC/rBs) _ _ gamoiyeneT Cvenebisas<br />
DTP/DTaP/DT rekomendebulia _ _<br />
hepatiti A _ _ gamoiyeneT Cvenebisas<br />
hepatiti B rekomendebulia gamoiyeneT _<br />
Cvenebisas<br />
HiBB rekomendebulia gansaxilvelia _<br />
gripi _ _ gamoiyeneT Cvenebisas<br />
ipv rekomendebulia _ gamoiyeneT Cvenebisas<br />
iaponuri enc. _ _ gamoiyeneT Cvenebisas<br />
meningokoki _ _ gamoiyeneT Cvenebisas<br />
MMR/MR/M/R rekomendebulia/gansaxilvelia gansaxilvelia _<br />
opv ukunaCvenebia _ ukunaCvenebia<br />
Savi Wiri _ _ gamoiyeneT Cvenebisas<br />
pnevmokoki _ _ gamoiyeneT Cvenebisas<br />
cofi _ _ gamoiyeneT Cvenebisas<br />
rotavirusi _ _ ukunaCvenebia<br />
tkipismieri enc. _ _ gamoiyeneT Cvenebisas<br />
TT/Td rekomendebulia rekomendebulia _<br />
tifi(Ty21a) _ _ ukunaCvenebia<br />
tifi, inaqt. _ _ gamoiyeneT Cvenebisas<br />
Cutyvavila _ _ ukunaCvenebia/gansaxilvelia<br />
yviTeli cxeleba _ _ ukunaCvenebia<br />
129
ekomendebulia: vaqcina rekomendebulia rutinuli reJimis mixedviT an naCvenebia <strong>aiv</strong><br />
imunosupresirebulTaTvis.<br />
gamoiyeneT Cvenebisas: imunosupresia ukuCvenebis mizezi ar aris; SeiZleba arsebobdes<br />
ukuCvenebis sxva mizezi<br />
ukunaCvenebia: <strong>aiv</strong> imunosupresia absoluturi an Se<strong>da</strong>rebiTi ukuCvenebaa vaqcinis<br />
gamoyenebisTvis<br />
gansaxilvelia: ga<strong>da</strong>wyvetileba vaqcinaciis Sesaxeb <strong>da</strong>mokidebulia konkretul<br />
pacientTan <strong>da</strong>avadebis risksa <strong>da</strong> vaqcinis efeqturobaze,<br />
<strong>da</strong>narTi 2. <strong>aiv</strong> asocirebuli imunodeficitis klasifikacia<br />
bavSvebSi<br />
<strong>aiv</strong> asocirebuli imunodeficitis klasifikacia<br />
klasifikacia CD4 ujredebis maCvenebeli asakis mixedviT<br />
35 >30 >25 >500<br />
saSualo 30-35 25-30 20-25 350-499<br />
Sors wasuli 25-30 20-25 15-20 200-349<br />
mZime
intervaliT. aseT SemTxvevaSi cofis sawinaaRmdego imunoglobulinis<br />
gamoyeneba saWiro ar aris. igive wesebi vrceldeba vaqcinirebul pirebze,<br />
romelTa maneitralizebeli antisxeulebis titri 0.5 se/ml-Si an metia.<br />
a<strong>da</strong>mianis diploidur-ujreduli vaqcina miCneulia oqros stan<strong>da</strong>rtad.<br />
jan<strong>da</strong>cvis msoflio organizaciis mixedviT aucilebelia ujreduli<br />
vaqcinis minimum 2.5se-s gamoyeneba TiToeuli dozirebisas. miuxe<strong>da</strong>vad<br />
maRali efeqturobisa ujreduli vaqciniT eqspoziciis Semdgom<br />
Catarebuli milioni mkurnalobi<strong>da</strong>n erTi SeiZleba aRmoCndes uSedego.<br />
analizi gviCvenebs, rom uSedego <strong>mkurnaloba</strong>, rogorc wesi,<br />
<strong>da</strong>kavSirebulia mniSvnelovan <strong>da</strong>zianebasTan Tavis an mezobel mi<strong>da</strong>moSi,<br />
an arasworad Catarebul <strong>mkurnaloba</strong>sTan.<br />
eqspoziciis Semdgomi mkurnalobis sruli kursi nervuli qsovilis<br />
vaqcinis gamoyenebiT gulisxmobs 23 ineqciisgan Semdgari imunizaciis<br />
gaxangrZlivebul <strong>da</strong> mtkivneul kurss. amasTan nervuli qsovilis<br />
vaqcinebi ujredul vaqcinebTan Se<strong>da</strong>rebiT neklebad efeqturia. amrigad,<br />
aRniSnuli vaqcina eqspoziciis Semdgomi imunizaciisaTvis rekomendebuli<br />
ar aris.<br />
27 2.5 mlrd a<strong>da</strong>mianze meti cxovrobs cofis endemur arealSi(afrika, azia, samxreT<br />
amerika).yovelwliurad saSualod 50 000 a<strong>da</strong>miani iRupeba cofiT <strong>da</strong> 10 mln-ze met<br />
a<strong>da</strong>mians utardeba eqspoziciis Semdgomi profilaqtika. 5-15 wlis asakis bavsvebi<br />
imyofebian maRali riskis qveS.<br />
28 calkeul asakobriv jgufebSi Catarebuli kvlevebis mixedviT <strong>da</strong>avadebis maRali<br />
riski aqvT ganviTarebadi qveynebis cofis endemur areebSi mcxovreb bavSvebs.<br />
29 ZiriTa<strong>da</strong>d rekomendebulia 1 wlis Semdeg <strong>da</strong>matebiti doza bustirebisTvis;<br />
vaqcinacia yovel 5 weliwadSi maRali riskis pirebisTvis; cofis virusis sawinaaRmdego<br />
antisxeulebis perioduli gamokvleva (proteqciisaTvis aucilebeli titria >0.5se/ml)<br />
gamoyenebuli litraturis CamonaTvali:<br />
1. Onorato IM, Markowitz LE, Oxtoby MJ. Childhood immunization, vaccine-preventable diseases and<br />
infection with human immunodeficiency virus. The Pediatric Infectious Disease Journal, 1988, 6:588–<br />
595.<br />
2. Opravil M et al. Poor antibody response after tetanus and pneumococcal vaccination in<br />
immunocompromised, HIV-infected patients. Clinical and Experimental Immunology, 1991, 84(2):185–189.<br />
3. Borkowsky W et al. Antibody responses to bacterial toxoids in children infected with human<br />
immunodeficiency virus. The Journal of Pediatrics, 1987, 110:563–566.<br />
4. Huang KL et al. Antibody responses after influenza and pneumococcal immunization in HIV-infected<br />
homosexual men. JAMA, 1987, 257:2047–2050.<br />
5. Klein RS et al. Responses to pneumococcal vaccine among asymptomatic heterosexual partners of persons<br />
with AIDS and intravenous drug users infected with human immunodeficiency virus. Journal of<br />
Infectious Diseases, 1989, 160:826–831.<br />
6. TB/HIV: a clinical manual, 2nd ed. Geneva, WHO, 2004.<br />
7. Global Advisory Committee on Vaccine Safety. Safety of BCG vaccination in immunocompromised<br />
individuals. Weekly Epidemiological Record, 2003, 32(8):283 (http://www.who.int/wer/2003/en/wer7832.<br />
pdf, accessed 25 June 2006).<br />
131
8. United States Centers for Disease Control. Disseminated Mycobacterium bovis infection from BCG<br />
vaccination of a patient with acquired immunodeficiency syndrome. MMWR, 1985, 34:227–228.<br />
9. Ninane J et al. Disseminated BCG in HIV infection. Archives of Disease in Childhood, 1988, 63:1268–<br />
1269.<br />
10. Broekmans JF et al. European framework for turberculosis control and elimination in countries with low<br />
incidence. The European Respiratory Journal, 2002, 19(4):765–775.<br />
11. British HIV Association immunization guidelines for HIV-infected adults. London, British HIV<br />
Association, First edition April 2006. (http://www.bhiva.org, accessed 16 November 2006).<br />
12. Centers for Disease Control. Measles pneumonitis following measles-mumps-rubella vaccination of a<br />
patient with HIV infection, 1993. MMWR, 1996, 45(28):603–606.<br />
13. Palumbo P et al. Population-based study of measles and measles immunization in human<br />
immunodeficiency<br />
virus-infected children. The Pediatric Infectious Disease Journal, 1992, 11(12):1008–1014.<br />
14. Atkinson W, Hamborsky J, Wolfe S, eds. Epidemiology and prevention of vaccine-preventable diseases,<br />
8th ed. Washington, DC, Public Health Foun<strong>da</strong>tion, 2005.<br />
15. Centers for Disease Control. 1993 revised classification system for HIV infection and expanded<br />
surveillance case definition for AIDS among adolescents and adults. MMWR: Recommen<strong>da</strong>tions and Reports,<br />
1992, 41(RR-17):1–19.<br />
16. Centers for Disease Control. 1994 revised classification system for human immonodeficiency virus<br />
infection in children less than 13 years of age. MMWR: Recommen<strong>da</strong>tions and Reports, 1994, 43(RR-<br />
12):1–10.<br />
17. Atkinson WL et al. General recommen<strong>da</strong>tions on immunization: recommen<strong>da</strong>tions of the Advisory<br />
Committee on Immunization Practices (ACIP) and the American Academy of Family Physicians (AAFP).<br />
MMWR: Recommen<strong>da</strong>tions and Reports, 2002, 51(RR-2):1–35.<br />
18. EPI vaccines in HIV-infected individuals: the safety of EPI-recommended vaccines in<br />
HIV-infected individuals. Geneva, WHO, 2001 (http://www.who.int/vaccines-diseases/diseases/HIV.<br />
shtml, accessed 6 December 2004).<br />
19. Sixbey JW. Routine immunization and the immunosuppressed child. Advances in Pediatric Infectious<br />
Diseases, 1987, 2:79–114.<br />
20. Wright PF et al. Vaccine-associated poliomyelitis in a child with sex-linked agammaglobulinemia. The<br />
Journal of Pediatrics, 1977, 91:408–412.<br />
21. Wyatt HV. Poliomyelitis in hypogammaglobulinemics. Journal of Infectious Diseases, 1973, 128(6):802–<br />
806.<br />
22. Davis LE et al. Chronic progressive poliomyelitis secon<strong>da</strong>ry to vaccination of an immunodeficient child.<br />
The New England Journal of Medicine, 1977, 297(5):241–245.<br />
23. Core information for the development of immunization policy: 2002 up<strong>da</strong>te: Expanded Programme on<br />
Immunization of the Department of Vaccines and Biologicals. Geneva, WHO, 2003 (http://www.who.<br />
int/vaccines-documents/DocsPDF02/www557.pdf, accessed on 29 June 2006). 12-22 HIV/AIDS TREATMENT AND<br />
CARE CLINICAL PROTOCOLS FOR THE WHO EUROPEAN REGION<br />
24. Armenian SH et al. Safety and immunogenicity of live varicella virus vaccine in children with human<br />
immunodeficiency virus type 1. The Pediatric Infectious Disease Journal, 2006, 25(4):368–370.<br />
25. Centers for Disease Control. Recommen<strong>da</strong>tions of the Advisory Committee on Immunization Practices<br />
(ACIP): use of vaccines and immuno globulins in persons with altered immunocompetence. MMWR:<br />
Recommended Reports, 1993, 42(RR-4):1–18.<br />
26. WHO. WHO position paper. Weekly Epidemiological Record. 20 April 2001. No. 16, 2001, 76, 117-124.<br />
(http://www.who.int/topics/cholera/vacccines/en/index.html, accessed 21 September 2006).<br />
27. Lewis DJ et al. Immune response following oral administration of cholera toxin B subunit to HIV-1-<br />
infected UK and Kenyan subjects. AIDS 1994;8:779-785.<br />
28. Sanchez JL et al. Protective efficacy of oral whole-cell/recombinant-B-subunit cholera vaccine in Peruvian<br />
military recruits. Lancet 1994;344:1273-1276.<br />
29. Farly MM et al. Invasive Haemophilus influenzae disease in adults: a prospective, population-based<br />
surveillance. Annals of Internal Medicine, 1992, 116:806–812.<br />
30. Steinhart R et al. Invasive Haemophilus influezae infections in men with HIV infection. JAMA, 1992,<br />
268(23):3350–3352.<br />
31. Frequently asked questions about hepatitis A. Atlanta, Centers for Disease Control and Prevention, 2006<br />
(http://www.cdc.gov/ncidod/diseases/hepatitis/a/faqa.htm, accessed on 22 June 2006).<br />
32. Vaccine-preventable diseases, vaccines and vaccination. In: Nuttall I, ed. International travel and health:<br />
situation as on 1 January 2005. Geneva, WHO, 2005:103–104 (http://whqlibdoc.who.int/publications/<br />
2005/9241580364_chap6.pdf accessed on 29 June 2006).<br />
33. Van Damme P et al. Hepatitis A booster vaccination: is there a need The Lancet, 2003, 362(9389):1065–<br />
132
1071.<br />
34. Te<strong>da</strong>ldi E et al. Hepatitis A and B vaccination practices for ambulatory patients infected with HIV. Clinical<br />
Infectious Diseases, 2004; 38:1478–1484.<br />
35. Welch K, Morse A. Improving screening and vaccination for hepatitis B in patients coinfected with HIV<br />
and hepatitis C. American Journal of Gastroenterology, 2002, 97:2928–2929.<br />
36. Hodges GR et al. Response to influenza A vaccine among high-risk patients. Southern Medical Journal,<br />
1979, 72(1):29–32.<br />
37. Safrin S, Rush JD, Mill J. Influenza in patients with human immunodeficiency virus infection. Chest,<br />
1990, 98:33–37.<br />
38. Gross PA et al. Influenza immunization in immunosuppressed children. Journal of Pediatrics, 1978,<br />
92(1):30–35.<br />
39. Advisory Committee on Immunization Practices (ACIP). Vaccine side-effects, adverse reactions,<br />
contraindications and precautions. Atlanta, Centers for Disease Control, 1996.<br />
40. Landesman SH, Schiffman G. Assessment of the antibody response to pneumococcal vaccine in highrisk<br />
populations. Reviews of Infectious Diseases, 1981, 3(Suppl.):S184–S197.<br />
41. Centers for Disease Control. Prevention of pneumococcal disease: recommen<strong>da</strong>tions of the Advisory<br />
Committee on Immunization Practices (ACIP). MMWR: Recommended Reports, 1997, 46(RR-08):1–24<br />
(http://www.cdc.gov/mmwr/PDF/rr/rr4608.pdf accessed 14 November 2006).<br />
42. Requirements for tick-borne encephalitis vaccine (inactivated) 2. In: WHO Expert Committee on<br />
Biological Stan<strong>da</strong>rdization. WHO Expert Committee on Biological Stan<strong>da</strong>rdization: forty-eighth report.<br />
Geneva, WHO, 1999:4463 (WHO Technical Report Series 889; http://www.who.int/biologicals/publications/<br />
trs/areas/vaccines/tick_encephalitis/WHO_TRS_889_A2.pdf, accessed 16 November 2006).<br />
43. WHO. WHO position paper. Weekly Epidemiological Record. 11 August 2000. No. 32, 2000, 75, 257-<br />
264. (http://www.who.int/wer, accessed 21 September 2006).<br />
44. WHO position on the use of hepatitis B vaccines. Weekly Epidemiological Record, 2004, 28(79):255–<br />
263 (http://www.who.int/wer/2004/en/wer7928.pdf accessed 25 June 2006).<br />
45. Antiretroviral therapy of HIV infection in infants and children in resource-limited settings: towards<br />
universal access: recommen<strong>da</strong>tions for a public health approach: 2006. Geneva, WHO, 2006 (http://www.<br />
who.int/hiv/pub/guidelines/WHOpaediatric.pdf, accessed 21 August 2006).<br />
133
<strong>aiv</strong> <strong>infeqcia</strong>/Sidsis antiretrovirusuli Terapiis marTvis<br />
saxelmwifo stan<strong>da</strong>rti (protokoli)<br />
1. <strong>da</strong>avadebis/nozologiis/sindromis mokle ganmarteba _ <strong>aiv</strong><br />
<strong>infeqcia</strong>/Sidsi ewodeba a<strong>da</strong>mianis imunodeficitis virusiT<br />
gamowveul infeqciur <strong>da</strong>avadebas.<br />
2. kriteriumebi _<br />
a. <strong>da</strong>ma<strong>da</strong>sturebeli _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis <strong>da</strong>ma<strong>da</strong>sturebeli<br />
kriteriumebia: <strong>aiv</strong> antisxeulebis arseboba sisxlis SratSi<br />
imunoblotingis meTodiT, <strong>aiv</strong> rnm-is raodenobrivad <strong>da</strong>/an <strong>aiv</strong><br />
provirus dnm-is Tvisobrivad aRmoCena sisxlSi<br />
polimerizaciis jaWvuri reaqciis meTodiT.<br />
b. gamomricxavi _ <strong>aiv</strong> <strong>infeqcia</strong> Sidsis gamomricxavi<br />
kriteriumebia: <strong>aiv</strong> antisxeulebis ar arseboba sisxlis SratSi<br />
imunofermentuli meTodiT, raodenobrivad <strong>aiv</strong> rnm-is <strong>da</strong>/an<br />
Tvisobrivad <strong>aiv</strong> provirus dnm-is ar arseboba sisxlSi<br />
polimerizaciis jaWvuri reaqciis meTodiT.<br />
3. simptomebi <strong>da</strong> niSnebi _<br />
a. <strong>da</strong>ma<strong>da</strong>sturebeli _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidss paTognomuri<br />
<strong>klinikuri</strong> niSnebi ar gaaCnia. igi miekuTvneba<br />
laboratoriulad sadiagnozo <strong>da</strong>avadebebs. simptomebi<strong>da</strong>n<br />
SeiZleba gamovyoT: gaxangrZlivebuli cxeleba,<br />
gaxangrZlivebuli faRaraTi, limfadenopaTia,<br />
aramotivirebuli profuzuli oflianoba, Zlieri saerTo<br />
sisuste, aramotivirebuli wonaSi kleba (erTi Tvis<br />
ganmavlobaSi sxeulis wonis 10% <strong>da</strong> meti), sxva<strong>da</strong>sxva<br />
gamonayari kansa <strong>da</strong> lorwovanze, kandidozuri ezofagiti,<br />
cns-is atipiuri <strong>da</strong>zianebebi <strong>da</strong> sxva. atipiuri mikobaqteriebiT<br />
gamowveuli infeqciebis <strong>da</strong>ma<strong>da</strong>sturebel simptomebs<br />
ganekuTvneba cxeleba, Ramis oflianoba, diarea, abdominaluri<br />
tkivili, wonaSi kleba <strong>da</strong> kaxeqsia<br />
b. gamomricxavi _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis gamomricxavi simptomebi<br />
ar arsebobs, <strong>aiv</strong> inficirebuli wlebis ganmavlobaSi SeiZleba<br />
Civilebs ar warmoadgendes.<br />
4. diagnostikur _ laboratoriuli testebi <strong>da</strong> specialistTa<br />
konsultaciebi<br />
laboratoriuli testebi<br />
<strong>aiv</strong> <strong>infeqcia</strong>sTan <strong>da</strong>kavSirebuli testireba:<br />
• <strong>aiv</strong> serologiuri gamokvleva (tipurad ELISA an swrafi testi),<br />
romelsac mohyveba <strong>da</strong>ma<strong>da</strong>sturebeli testi (tipiurad vestern<br />
blotingi) (11);<br />
• CD4 ujredebis ricxvi imunodeficitis xarisxis gansazRvrisTvis;<br />
orsul qalebSi CD4% (12,13) <strong>da</strong><br />
• virusuli <strong>da</strong>tvirTvis testi polimerazuli jaWvuri reaqciis (pjr)<br />
meTodiT, virusis replikaciis donis gansazRvrisTvis ;<br />
testireba sxva infeqciebze<br />
• testi sifilisze (VDRL);<br />
• vaginaluri, asos an analuri Camonafxeki gonoreisa <strong>da</strong> Chlamydia<br />
134
trachomatis identifikaciisTvis;<br />
• testireba toqsoplazmis IgG serologiur testze <strong>da</strong> informacia<br />
infeqciis riskis Sesaxeb Tu serologiis Sedegi uaryofiTia<br />
• kriptokokis antigenis titri rodesac CD4 limfocitebis ricxvi <<br />
200 mm3 <strong>da</strong> saxezea kriptokokozis <strong>klinikuri</strong> niSnebi<br />
• CMV antigenemia (pp65 adreuli antigeni) rodesac CD4 ujredebis<br />
ricxvi < 100 mm3<br />
• serologiuri testi B,C hepatitis virusebze (anti HCV, HBsAg)<br />
ZiriTadi laboratoriuli testebi:<br />
o eleqtrolitebi (natriumi, kaliumi) N<br />
o RviZlis funqciuri sinjebi (ALT, AST, tute fosfataza,<br />
saerTo <strong>da</strong> arapir<strong>da</strong>piri bilirubini)<br />
o Tirkmlis funqciebi (Sardovana, kreatinini)<br />
o laqtaddehidrogenaza (limfomebis dros ujredTa ZiriTadi<br />
brunva, filtvis infeqciebis niSnebi, miokardiumis infarqti,<br />
kunTebis <strong>da</strong>zianebani <strong>da</strong> a.S.)<br />
o INR an proTrombinis dro<br />
o sisxlis saerTo analizi (formuliTa <strong>da</strong> Trombocitebis<br />
ricxviT)<br />
o orsulobis testi arv Terapiis <strong>da</strong>wyebamde<br />
saWiroebis SemTxvevebSi:<br />
o glukoza<br />
o qolesterini (HDL, VLDL)<br />
o trigliceridebi<br />
o lipaza<br />
o C-reaqtiuli cila (CRP)<br />
o Tiroid-mastimulirebeli hormoni (TSH )<br />
sxva gamokvlevebi<br />
o tuberkulinis kanis testi<br />
o naxvelis nacxis mikroskopia <strong>da</strong> gul-mkerdis rentgenologiuri<br />
gamokvleva Tu saxezea tuberkulozis niSnebi<br />
o ekg (gamokvleva <strong>mkurnaloba</strong>mde arT-ze myof pacientebSi gulsisxlZarRvovani<br />
<strong>da</strong>avadebis didi riskis gaTvaliswinebiT,<br />
Se<strong>da</strong>rebisTvis) (14)<br />
specialistTa konsultaciebi<br />
o nevrologiuri gamokvleva, rodesac HIV pirvelad aris<br />
diagnostirebuli (mag. periferiuli neiropaTiis<br />
identifikaciisTvis)<br />
o ofTalmologiuri gamokvleva yovel sam TveSi erTxel CMV<br />
retinitis identifikaciisTvis, rodesac CD4 ujredebis ricxvi <<br />
100mm3<br />
o ginekologiuri gamokvleva PAP nacxis CaTvliT yovel 6 TveSi<br />
erTxel (a<strong>da</strong>mianis papilomavirusiT gamowveuli karcinoma)<br />
o sxva specialistebis konsultacia aucileblobis SemTxvevebSi<br />
135
5. <strong>mkurnaloba</strong><br />
a) rekomendebuli pirveli rigis arT<br />
arT reJimi<br />
2 NRTI-s + 1 NNRTI<br />
medikamentebis kombinacia<br />
ZDV + 3TC + (EFV a or NVP)<br />
an<br />
TDF + FTC + (EFV a or NVP)<br />
an<br />
ABC + 3TC + (EFV a or NVP)<br />
b) rekomendebuli meore rigis arv reJimi mozardebisa <strong>da</strong><br />
mozrdilTaTvis<br />
pirveli rigis reJimi meore rigis reJimi<br />
LPV/r a (an ATV/r, SQV/r, FPV/r, IDV/r) + ddI + ABC<br />
an<br />
ZDV + 3TC + (EFV an NVP) LPV/r a (an ATV/r, SQV/r, FPV/r, IDV/r) + TDF + ABC<br />
an<br />
LPV/r a (an ATV/r, SQV/r, FPV/r, IDV/r) + TDF + (ZDV + 3TC) b<br />
LPV/r a (an ATV/r, SQV/r, FPV/r, IDV/r) + ddI + ABC<br />
TDF + FTC + (EFV an NVP) an<br />
LPV/r a (an ATV/r, SQV/r, FPV/r, IDV/r) + ddI + ZDV<br />
LPV/r a (an ATV/r, SQV/r, FPV/r, IDV/r) + ddI + ZDV<br />
ABC + 3TC + (EFV an NVP) an<br />
LPV/r a (an ATV/r, SQV/r, FPV/r, IDV/r) + ZDV + TDF (+ 3TC) b<br />
6. reabilitacia <strong>da</strong> <strong>da</strong>kvirveba<br />
monitoringis samizneebs warmoadgens laboratoriuli testebi<br />
antiretrovirusuli mkurnalobis efeqturobis gasakontroleblad<br />
virusuli<br />
<strong>da</strong>tvirTva<br />
CD4<br />
ujredebis<br />
ricxvi<br />
sisxlis saerTo<br />
analizi<br />
RviZlis<br />
funqciuri<br />
sinjebi<br />
2 4 8 16 24 36 48<br />
sawyisi<br />
kvira kvira kvira kvira kvira kvira kvira<br />
X X X X X<br />
X X X (X) X<br />
X X X X<br />
(ZDV)<br />
X X X<br />
(NVP)<br />
X<br />
(NVP,<br />
ZDV,<br />
PI)<br />
X<br />
(NVP,<br />
PI)<br />
X (X) X<br />
X (X) X<br />
136
qolesterini<br />
trigliceridebi<br />
Tirkmlis<br />
funqciebi<br />
X (PI)<br />
X<br />
X<br />
(TDF)<br />
X<br />
(TDF,<br />
IDV)<br />
X<br />
(PI)<br />
X (X) X<br />
X<br />
(PI)<br />
7. gaidlaini, romelsac eyrdnoba aRniSnuli protokoli<br />
aRniSnuli protokoli eyrdnoba jan<strong>da</strong>cvis msoflio organizaciis 2006<br />
wlis gaidlains: “<strong>aiv</strong>/<strong>SidsiT</strong> <strong>da</strong>avadebuli mozrdili <strong>da</strong> mozardi pirebis<br />
gamokvleva <strong>da</strong> antiretrovirusuli <strong>mkurnaloba</strong>”, aseve protokoli<br />
Sejerebulia DHHS <strong>da</strong> EACS 2005 wlis antirtrovirusuli mkurnalobis<br />
gaidlainebTan.<br />
137
<strong>aiv</strong> <strong>infeqcia</strong>/<strong>SidsiT</strong> <strong>da</strong>avadebuli bavSvebis antiretrovirusuli<br />
mkurnalobis marTvis saxelmwifo stan<strong>da</strong>rti (protokoli)<br />
1. <strong>da</strong>avadebis/nozologiis/sindromis mokle ganmarteba - <strong>aiv</strong><br />
<strong>infeqcia</strong>/Sidsi warmoadgens a<strong>da</strong>mianis imunodeficitis virusiT (<strong>aiv</strong>)<br />
gamowveul infeqciur <strong>da</strong>avadebas.<br />
2 . kriteriumebi<br />
a. <strong>da</strong>ma<strong>da</strong>sturebeli _ 18 Tvis Semdeg <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis<br />
<strong>da</strong>ma<strong>da</strong>sturebeli kriteriumebia: <strong>aiv</strong> antisxeulebis arseboba<br />
sisxlis SratSi imunoblotingis meTodiT, <strong>aiv</strong> rnm-is<br />
raodenobrivad <strong>da</strong>/an <strong>aiv</strong> provirus dnm-is Tvisobrivad<br />
aRmoCena sisxlSi polimerizaciis jaWvuri reaqciis meTodiT.<br />
b. gamomricxavi _ 18 Tvis Semdeg <strong>aiv</strong> <strong>infeqcia</strong> Sidsis<br />
gamomricxavi kriteriumebia: <strong>aiv</strong> antisxeulebis ar arseboba<br />
sisxlis SratSi imunofermentuli meTodiT, raodenobrivad<br />
<strong>aiv</strong> rnm-is <strong>da</strong>/an Tvisobrivad <strong>aiv</strong> provirus dnm-is ar arseboba<br />
sisxlSi polimerizaciis jaWvuri reaqciis meTodiT.<br />
18 wlamde asakis bavSvebSi <strong>aiv</strong> infeqciis diagnostikaSemdegi sqemiT<br />
xorcieldeba<br />
• <strong>aiv</strong>-is pirveladi diagnostika xorcieldeba <strong>da</strong>badebi<strong>da</strong>n 48 sT-is<br />
Semdeg. gamoiyeneba pjr meTodiT <strong>aiv</strong> dnm gansazRvra<br />
axalSobilis sisxlSi, romelic ar aris aRebuli Wiplaris<br />
veni<strong>da</strong>n, vinai<strong>da</strong>n is SeiZleba <strong>da</strong>binZurebuli iyos dedis<br />
sisxliT. am dros kvlevis substrats warmoadgens periferiuli<br />
sisxlis mononuklearebSi arsebuli provirusuli dnm.<br />
<strong>da</strong>badebi<strong>da</strong>n 48 saaTSi inficirebuli bavSvebis 38% aCvenebs<br />
<strong>da</strong>debiT pasuxs <strong>aiv</strong> dnm pjr-ze. testis mgrZnobeloba ar icvleba<br />
mniSvnelovnad pirveli 1 kviris ganmavlobaSi, magram mkveTrad<br />
matulobs sicocxlis meore kviri<strong>da</strong>n, rodesac <strong>da</strong>avadebuli<br />
bavSvebis 93% gamovlindeba. 28 dRis asakSi <strong>aiv</strong> dnm pjr-s ukve<br />
aqvs 96% mgrZnobeloba <strong>da</strong> 99% specifiuroba. <strong>aiv</strong> dnm pjr<br />
gamokvlevaze uaryofiTi pasuxis miRebis SemTxvevaSi bavSvs<br />
ganmeorebiTi gamokvleva imave meTodiT utardeba 3 Tvis asakSi.<br />
miRebuli <strong>da</strong>debiTi Sedegi safuZvelia <strong>aiv</strong> infeqciis winaswari<br />
diagnozisa. saboloo diagnozi dgindeba ganmeorebiTi pjr-iT <strong>aiv</strong><br />
–is dnm-ze sisxlis axal porciaSi.<br />
• 2-3 Tvis asakSi <strong>aiv</strong> dnm pjr meTodis alternatiul meTo<strong>da</strong>d<br />
SesaZloa CaiTvalos <strong>aiv</strong> rnm pjr diagnostikis meTodi, romlis<br />
mgrZnobeloba am asakSi 90-100%-s aRwevs, xolo specifiuroba <strong>aiv</strong><br />
dnm pjr specifiurobis msgavsia, Tumca <strong>aiv</strong> rnm <strong>da</strong>bali doniT<br />
deteqtireba (
antisxeulebze <strong>da</strong>debiTi Sedegi miuTiTebs, rom bavSvi <strong>aiv</strong><br />
inficirebulia.<br />
• Tu bavSvi ikvebeba dedis rZiT, maSin <strong>aiv</strong> antisxeulebze<br />
gamokvlevas azri aqvs ZuZuTi kvebis Sewyveti<strong>da</strong>n 6 Tvis Semdeg,<br />
vinai<strong>da</strong>n manamde bavSvi SeiZleba e.w. “fanjara periodSi”<br />
imyofebodes.<br />
3.simptomebi <strong>da</strong> niSnebi _<br />
a) <strong>da</strong>ma<strong>da</strong>sturebeli _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidss paTognomuri <strong>klinikuri</strong> niSnebi<br />
ar gaaCnia. igi miekuTvneba laboratoriulad sadiagnozo <strong>da</strong>avadebebs.<br />
saSvilosnosSi<strong>da</strong> inficirebis SemTxvevaSi aRwerilia Taviseburi<br />
simptomokompleqsi, rac xasiaTdeba zr<strong>da</strong>-ganviTarebis SeferxebiT,<br />
SesaZloa gamoxatuli iyos mravlobiTi <strong>da</strong>rRvevebi qala-saxisa <strong>da</strong> tvinis<br />
nawilebSi. <strong>aiv</strong> inficirebul axalSobilebs SesaZloa gamoxatuli<br />
hqondeT gamoweuli Subli, brtyeli cxviri, egzofTalmi mocisfro<br />
sklerebi, mikrocefalia, Tumca un<strong>da</strong> aRiniSnos, rom ganviTarebis<br />
anomaliebi ar aris mkafiod <strong>da</strong>maxasiaTebeli niSani <strong>aiv</strong> infeqciisaTvis.<br />
<strong>aiv</strong> inficirebul bavSvebSi simptomebi<strong>da</strong>n SeiZleba gamovyoT: zr<strong>da</strong>ganviTarebaSi<br />
CamorCena, aramotivirebuli cxeleba,<br />
qronikuli/morecidive yuris infeqciebi, qronikuli pnevmonia an diarea,<br />
qronikuli dermatiti, parotiduli jirkvlebis SeSupeba, sistemuri<br />
limfadenopaTia, hepatomegalia, splenomegalia. limfocituri disfunqcia<br />
safuZvlad udevs morecidive sokovan infeqciebs, rogoricaa kandidozi,<br />
rac Cveulebriv Terapias ar emorCileba. bavSvebSi yvelaze<br />
gavrcelebuli oportunistuli infeqciebia: pnevmocisturi pnevmonia (PCP)<br />
<strong>da</strong> sistemuri kandidozi, xSiria ezofagiti. pediatriuli pnevmocisturi<br />
pnevmoniis didi wili Zalian adreul asakSi iCens Tavs, rasac Tan<br />
axlavs maRali letaloba. es ki am <strong>da</strong>avadebis proflaqtikis farTod<br />
Catarebis aucileblobis safuZvels iZleva. adreuli PCP profilaqtikis<br />
Catarebis SesaZlebloba 4-6 kviris asaki<strong>da</strong>n dedis <strong>aiv</strong> statusis adreul<br />
<strong>da</strong>dgenas did mniSnelobas sZens. sxva oportunistuli infeqciebi<strong>da</strong>n<br />
aRsaniSnavia: citomegalovirusuli <strong>infeqcia</strong>, romelic iwvevs<br />
filtvebisa <strong>da</strong> gastroenteraluri traqtis <strong>da</strong>zianebas <strong>da</strong> iSviaTad<br />
iwvevs retinits. (rac xSiria mozrdilebSi), qronikuli diarea,<br />
gamowveuli kriptosporidioziT, lamblioziT, izosporaTi an iseTi<br />
virusiT, rogoricaa, adenovirusi. meningiti SesaZloa gamowveul iyos<br />
kriptokokiT, rac klinikurad naklebi simwvaviT vlindeba baqteriul<br />
meningitTan Se<strong>da</strong>rebiT. aratuberkulozuri mikobaqteria (Mycobacterium<br />
avium intracelulare) <strong>da</strong>avadebas iwvevs mogvianebiT etapebze imunitetis mZime<br />
supresiisas. is iwvevs cxelebas wonaSi klebiT an mis gareSe an SesaZloa<br />
gamovlindes malabsorbciuli diareis saxiT.<br />
oportunistuli infeqciis gar<strong>da</strong> sicocxlis pirveli wlis<br />
ganmavlobaSi <strong>aiv</strong> inficrebul bavSvebs SesaZloa gamouvlindeT<br />
limfoiduri intersticiuli pnevmonia. es nela moprogresire <strong>da</strong> xSirad<br />
asimptomuri <strong>da</strong>avadebaa. is Cveulebriv vlindeba sicocxlis pirveli<br />
wlis Tavze <strong>da</strong> piks ori wlis asakisaTvis aRwevs. xSira<strong>da</strong>a asocirebuli<br />
parotiduli jirkvlebis SeSupebasTan <strong>da</strong> hipergamaglobulinemiasTan.<br />
bavSvs SesaZloa hqondes mxolod es gamovlinebani filtvebis <strong>da</strong>zianebis<br />
gamovlinebamde didi xniT adre. Semdgom vlindeba <strong>da</strong>qveiTebul<br />
oqsigenaciasTan <strong>da</strong>kavSirebuli gamovlinebani, maT Soris dolis<br />
139
joxiseburi TiTebi. Tumca wlebis manZilze gamovlinebani SesaZloa<br />
Zalze mwiri iyos.<br />
xSiria morecidive baqteriuli infeqciebi, rac gamowveulia:<br />
Hemophilius influenzae, Streptococcus pyogenes, Staphylococcus epidermidis, pneumococcus,<br />
salmonellas. yvelaze xSirad morecidive baqteriul <strong>infeqcia</strong>s pnevmonia<br />
miekuTvneba, romlis xSir mizezsac S. pneumoniae warrmoadgens. mwvave<br />
pnevmoniis xSiri mizezia pnevmocisturi pnevmoniac, rac mxedvelobaSi<br />
un<strong>da</strong> gvqondes miuxe<strong>da</strong>vad pacientis imunuri statusisa <strong>da</strong> CD4<br />
raodenobisa.<br />
tuberkulozi <strong>aiv</strong> inficirebuli bavSvebis erT-erT seriozul<br />
problemas warmoadgens. diagnostikisaTvis gamoiyeneba kanis<br />
tuberkulinuri testi <strong>da</strong> naxvelSi mJavagamZle baqteriis aRmoCena<br />
mikroskopiisa <strong>da</strong> kulturis miRebis gziT. bavSvebSi naxvelis<br />
ararsebobis dros mimarTaven kuWis amonarecxis kvlevas. <strong>aiv</strong><br />
inficirebul bavSvebSi xSiria cns <strong>da</strong>zianeba, rac gamoixateba fsiqofizikuri<br />
ganviTarebis SeferxebiT, encefalopaTiiT, cerebruli <strong>da</strong>mbliT<br />
an/<strong>da</strong> spastiuri tetraplegiis saxiT. adgili aqvs Tavis<br />
garSemowerilobis zrdis SeCerebas. kompiuteruli tomograma kortiklur<br />
atrofias an kalcifikacias uCevnebs (gansakuTrebiT bazalur gangliebSi<br />
simetriulad).<br />
<strong>aiv</strong> inficirebuli bavSvebis <strong>da</strong>axloebiT 20%-Si viTardeba Trombocitebis<br />
imunuri destruqcia. anemia ganpirobebuli SeiZleba iyos <strong>aiv</strong>-is mier,<br />
iatrogenuli faqtorebiT an virusuli infeqciebis (magaliTad,<br />
parvovirus B19) supresiuli zegavleniT Zvlis tvinze, aseve SratSi<br />
eriTroepoetinis donis <strong>da</strong>qveiTebiTa <strong>da</strong> Zvlis tvinis <strong>da</strong>qveiTebuli<br />
reagirebiT eriTroepoetinze. anemias iwvevs neoplaziuri agentebic.<br />
neitropenia xSiria Rrma imunosupresiis dros <strong>da</strong> kavSirSia<br />
baqteriuli infeqciebis <strong>da</strong>rTvis maRal riskTan. neitropenia SesaZloa<br />
gamowveuli iyos medikamentebiT, romelsac bavSvi iRebs mkurnalobis<br />
procesSi.<br />
<strong>aiv</strong> azianebs gulsa <strong>da</strong> Tirkmelebs. es garTulebebi gansakuTrebiT xSiria<br />
mozrdil bavSvebSi 2-3 wlis asakis zemoT. Cveulebriv gamoxatulia<br />
qronikuli kardiomiopaTia. Tirkmlis <strong>da</strong>zianeba vlindeba nefrozuli<br />
sindromis an glomerulonefritis saxiT.<br />
4. diagnostikur-laboratoriuli testebi <strong>da</strong> specialistTa<br />
konsultaciebi<br />
a) pirvel 4 saaTSi<br />
• konsultacia stacionaruli<br />
• sisxlis <strong>klinikuri</strong> analizi (sisxlis saerTo analizi,<br />
sisxlis jgufis <strong>da</strong> rezusis gansazRvra, transaminazebis,<br />
bilirubinis, laqtatdehidrogenazas, Sardovanas, kreatininis,<br />
glukozis, saerTo cilis <strong>da</strong> cilis fraqciebis, rkinis <strong>da</strong><br />
rkinis gajerebis unaris, proTrombinis <strong>da</strong> Trombinis drois<br />
gansazRvra)<br />
• imunologiuri analizi (CD4+, CD8+ limfocitebis CaTvliT)<br />
• Sardis saerTo analizi<br />
• liqvoris saerTo analizi<br />
• liqvoris baqterologiuri gamokvleva<br />
140
• naxvelis baqterioskopuli gamokvleva<br />
• sisxlSi Toxo IgG diagnostika<br />
• mantus sinji<br />
b) pirvel 24 saaTSi<br />
• gulmkerdis rentgenograma (erTi proeqcia)<br />
• rentgenologis konsultacia<br />
• ekg<br />
• kardiologis konsultacia<br />
• sisxlis bioqimiuri analizi (saerTo cila, albumini, ALT,<br />
AST, bilirubini, <strong>da</strong> misi fraqciebi, CD4, CD8)<br />
• Sardis analizi<br />
• ganavlis analizi<br />
• sisxlis baqteriologiuri gamokvleva<br />
• naxvelis baqteriologiuri gamokvleva<br />
g) pirvel 3 dReSi<br />
• nevropaTologis konsultacia<br />
• ftiziatris konsultacia<br />
• antibiotikebisadmi mgrZnobelobis gansazRvra<br />
• <strong>aiv</strong> virusuli <strong>da</strong>tvirTvis gansazRvra<br />
• virusuli hepatitebis (B, C, D) diagnostika<br />
• aTaSangis diagnostika (TPHA, RPR meTodebiT)<br />
• serologiuri gamokvlevebi sxva mikroorganizmebisaTvis<br />
5. <strong>mkurnaloba</strong><br />
pirveli rigis arT sqema <strong>aiv</strong> inficirebul bavSvebSi<br />
arT-s anamnezi (maT Soris dedis<br />
mier arv preparatebis miReba<br />
orsulobisa <strong>da</strong> mSobiarobis<br />
dros), Tanmxlebi <strong>da</strong>avadebebi<br />
bavSvebSi, romlebic ar<br />
Rebulobdnen arv preparatebs, ar<br />
aris riski preparatebis<br />
urTierTqmedebisa <strong>da</strong> wamlismieri<br />
mdgradobis<br />
bavSvebi, romlebic imyofebodnen<br />
nevirapinis zemoqmedebis qveS,<br />
dedi<strong>da</strong>n bavSvze <strong>aiv</strong> infeqciis<br />
ga<strong>da</strong>debis profilaqtikis mizniT.<br />
tuberkuloziT <strong>da</strong>avadebulebi****<br />
pirveli rigis arT sqema*<br />
zidovudini** + lamivudini + nevirapini<br />
an<br />
zidovudini** + lamivudini + efavirenzi***<br />
zidovudini** + lamivudini +<br />
lopinaviri/ritonaviri<br />
an<br />
zidovudini** + lamivudini + nelfinaviri<br />
zidovudini** + lamivudini + abakaviri<br />
an<br />
zidovudini** + lamivudini + efavirenzi***<br />
141
* saWiroa arv preparatebis bavSvebisaTvis misaReb samkurnalwamlo<br />
formebSi miwodeba (Txevad formaSi, 6 welze patara bavSvebSi),<br />
romelic uzrunvelyofs zust dozirebas.<br />
** anemiis mqone bavSvebSi ukunaCvenebia zidovudinis Semcveli arT sqemebi.<br />
*** 3 welze didi asakis bavSvebSi<br />
**** arT un<strong>da</strong> <strong>da</strong>viwyoT 2 Tviani intensiuri antituberkulozuri Terepiis<br />
Semdeg. Tu situacia saSualebas gavaZlevs arT umjobesia <strong>da</strong>viwyoT<br />
antituberkulozuri Terapiis kursis <strong>da</strong>mTavrebisas. es Tavi<strong>da</strong>n<br />
agvacilebs rifampicinisa <strong>da</strong> arv preparatis negatiuri urTierTqmedebis<br />
Sedegebs. gar<strong>da</strong> amisa arT <strong>da</strong> antituberkulozuri preparatebis<br />
erTdrouli <strong>da</strong>niSvna zrdis Terapiis reJimis <strong>da</strong>rRvevis risks. arT-s<br />
adreuli <strong>da</strong>niSvna gamarTlebulia, Tu tuberkuloziT <strong>da</strong>avadebul <strong>aiv</strong><br />
inficirebul bavSvs aReniSneba <strong>aiv</strong> infeqciis gamoxatuli gamovlinebebi<br />
an/<strong>da</strong> mZime imunodeficiti.<br />
arT sqemis Secvlis aucilebloba ganpirobebulia an Terapiis araefeqturobiT,<br />
an SeuTavsebeli gverdiTi movlenebiT. sqema un<strong>da</strong> Secvalos im eqimma,<br />
romelmac <strong>da</strong>niSna pirveladi <strong>mkurnaloba</strong>. vidre axal sqemas <strong>da</strong>vniSnavT<br />
un<strong>da</strong> <strong>da</strong>vrwmundeT, rom bavSvi preparatebs Rebulob<strong>da</strong> mkacrad<br />
<strong>da</strong>niSnulebis mixedviT. Tu arT-s sqemis gamocvla ganpirobebulia Terapiis<br />
araefeqturobiT, saWiroa samive preparatis erTdrouli Secvla<br />
meore rigis arT sqema<br />
arT-s sawyisi sqema<br />
meore rigis rekomendebuli sqema<br />
zidovudini + lamivudini + nevirapini<br />
an<br />
zidovudini + lamivudini +<br />
ifavirenci<br />
zidovudini + lamivudini +<br />
nelfinaviri<br />
an<br />
zidovudini + lamivudini +<br />
lopinaviri/ritonaviri<br />
abakaviri + di<strong>da</strong>nozini +<br />
lopinaviri/ritonaviri<br />
an<br />
abakaviri + di<strong>da</strong>nozini +<br />
nelfinaviri<br />
abakaviri + di<strong>da</strong>nozini +<br />
nevirapini<br />
an<br />
abakaviri + di<strong>da</strong>nozini +<br />
efavirenzi<br />
* Tu bavSvs SeuZlia kafsulis ga<strong>da</strong>ylapva, xolo preparatis<br />
erTjerad doza (romelic gaTvlilia wonaze an sxeulis farTobze)<br />
Seadgens ramodenime kafsulas erTad, mas aseve SegviZlia<br />
<strong>da</strong>vuniSnoT seqvinavir/ritonaviri an indinavir/ritonaviri<br />
6.reabilitacia <strong>da</strong> <strong>da</strong>kvirveba<br />
monitoringi samizneebi<br />
Semowmebis<br />
va<strong>da</strong><br />
anTropometruli<br />
monacemebi<br />
Semowmeba<br />
laboratoriuli<br />
gamokvlevebi<br />
142
pirveli<br />
Semowmeba<br />
meore<br />
Semowmeba<br />
momdevno<br />
Semowmebebi<br />
arT-s<br />
<strong>da</strong>wyebi<strong>da</strong>n 2<br />
kviraSi + +<br />
pirveli<br />
Semowmebi<strong>da</strong>n<br />
erT TveSi + +<br />
yovel 3<br />
TveSi, Tu<br />
saWiro ar<br />
aris ufro<br />
xSiri<br />
vizitebi<br />
+ +<br />
sisxlis <strong>klinikuri</strong><br />
analizi, RviZlis<br />
fermentebis aqtivoba;<br />
Sardis saerTo<br />
analizi<br />
sisxlis <strong>klinikuri</strong><br />
analizi, RviZlis<br />
fermentebis aqtivoba;<br />
Sardis saerTo<br />
analizi<br />
sisxlis <strong>klinikuri</strong><br />
analizi, RviZlis<br />
fermentebis aqtivoba.<br />
CD4-is dones<br />
sazRvraven yovel 3-4<br />
TveSi, Tu ar aris<br />
Cveneba ufro xSiri<br />
gamokvlevisaTvis<br />
1 Tu sqema Seicavs nevirapins, 18 Tvis ganmavlobaSi, yovel 4 TveSi<br />
un<strong>da</strong> ganvsazRvroT RviZlis funqciuri maCveneblebi.<br />
arT-s efeqturobis kontroli<br />
<strong>klinikuri</strong> maCveneblebis kontroli (sigrZe, wona, saerTo mdgomareoba)<br />
janmrTeli bavSvis fizikuri ganviTareba mudmivad mimdinareobs <strong>da</strong><br />
wonisa <strong>da</strong> simaRlis matebiT gamovlindeba. imunodeficitis mqone <strong>aiv</strong><br />
inficirebul bavSvebSi igi Seferxebulia <strong>da</strong> arT-s <strong>da</strong>wyebis fonze<br />
mkveTrad matulobs. qvemoT mocemulia ZiriTadi <strong>klinikuri</strong> maCvenebebi,<br />
romlebic saSualebas mogvcems vimsjelod arT-s efeqtianobaze.<br />
• “wona/simaRlis” diagrama (rodesac SeuZlebelia CD4-is donis<br />
gansazRvra, mkurnalobis efeqtianobis Sesafaseblad gamoiyeneba<br />
fizikur ganviTarebis diagramebi). Tu im bavSvebis ganviTarebis<br />
fizikuri maCveneblebi, romlebsac utardebaT arT, ar Seesabameba<br />
diagramebze mocemul maCveneblebs, un<strong>da</strong> veZeboT ganviTarebis<br />
Seferxebis mizezebi. ZiriTadi mizezi oria:<br />
− oportunistuli <strong>infeqcia</strong> (am SemTxvevaSi diagramis mrudi<br />
mkveTrad ecema).<br />
− Terapiis reJimis <strong>da</strong>rRveva (am SemTxvevaSi diagramis mrudi<br />
ecema Tan<strong>da</strong>TanobiT).<br />
• fsiqomotoruli ganviTareba<br />
• nevrologiuri <strong>da</strong>rRvevebi, maT Soris encefalopaTiis simptomebi.<br />
• infeqciuri <strong>da</strong>avadebebi: saxe <strong>da</strong> sixSire.<br />
143
laboratoriuli monacemebis kontroli<br />
• CD4-is done (Tu SesaZlebelia)<br />
• sisxlis <strong>klinikuri</strong> analizi<br />
• RviZlis fermentebis aqtivoba (alt, ast)<br />
• <strong>da</strong>matebiTi gamokvlevebi: arT-s sqemisa <strong>da</strong> preparatebis gverdiTi<br />
efeqtebis mixedviT.<br />
7.gaidlaini, romelsac eyrdnoba aRniSnuli protokoli<br />
aRniSnuli protokoli eyrdnoba jan<strong>da</strong>cvis msoflio organizaciis 2006<br />
wlis gaidlains: “<strong>aiv</strong>/<strong>SidsiT</strong> <strong>da</strong>avadebuli bavSvebis gamokvleva <strong>da</strong><br />
antiretrovirusuli <strong>mkurnaloba</strong>”, aseve protokoli Sejerebulia DHHS,<br />
USA-IAS <strong>da</strong> EACS 2005 wlis bavSvTaAantirtrovirusuli mkurnalobis<br />
gaidlainebTan.<br />
144
<strong>aiv</strong> <strong>infeqcia</strong>/Sidsis fonze ganviTarebuli baqteriuli pnevmoniebis<br />
marTvis saxelmwifo stan<strong>da</strong>rti (protokoli)<br />
1. <strong>da</strong>avadebis/nozologiis/sindromis mokle ganmarteba _ <strong>aiv</strong><br />
<strong>infeqcia</strong>/Sidsi ewodeba a<strong>da</strong>miani imunodeficitis virusiT gamowveul<br />
infeqciur <strong>da</strong>avadebas. baqteriuli pnevmoniss yvelaze xSiri<br />
gamomwvevia Streptococcus pneumoniae. sxva gamomwvevbia: Haemophilus influenzae,<br />
Klebsiella spp., Staphylococcus spp., Mycobacterium tuberculosis, Micobacterium aviumintracellulare.<br />
2. kriteriumebi _<br />
a) <strong>da</strong>ma<strong>da</strong>sturebeli _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis <strong>da</strong>ma<strong>da</strong>sturebeli<br />
kriteriumebia: <strong>aiv</strong> antisxeulebis arseboba sisxlis SratSi<br />
imunoblotingis meTodiT, <strong>aiv</strong> rnm-is raodenobrivad <strong>da</strong>/an <strong>aiv</strong><br />
provirus dnm-is Tvisobrivad aRmoCena sisxlSi polimerizaciis<br />
jaWvuri reaqciis meTodiT. ze<strong>da</strong> sasunTqi gzebis baqteriuli<br />
infeqciebis diagnozi efuZneba klinikur gamovlinebebsa <strong>da</strong><br />
rentgenologiur cvlilebebs. rentgenogramaze SeiZleba<br />
aRmoCndes filtvis parenqimis wilovani, kerovani an difuzuri<br />
<strong>da</strong>Crdilva an gamovlindes atipuri cvlilebebi.<br />
b) gamomricxavi _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis gamomricxavi kriteriumebia:<br />
<strong>aiv</strong> antisxeulebis ar arseboba sisxlis SratSi<br />
imunofermentuli meTodiT, raodenobrivad <strong>aiv</strong> rnm-is <strong>da</strong>/an<br />
Tvisobrivad <strong>aiv</strong> provirus dnm-is ar arseboba sisxlSi<br />
polimerizaciis jaWvuri reaqciis meTodiT. ze<strong>da</strong> sasunTqi<br />
gzebis baqteriuli infeqciebis gamomricxavi kriteriumebia<br />
<strong>klinikuri</strong> gamovlinebebisa <strong>da</strong> rentgenologiuri cvlilebebis<br />
ar arseboba.<br />
3. simptomebi <strong>da</strong> niSnebi _<br />
a) <strong>da</strong>ma<strong>da</strong>sturebeli _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidss paTognomuri <strong>klinikuri</strong><br />
niSnebi ar gaaCnia. igi miekuTvneba laboratoriulad sadiagnozo<br />
<strong>da</strong>avadebebs. simptomebi<strong>da</strong>n SeiZleba gamovyoT: gaxangrZlivebuli<br />
cxeleba, gaxangrZlivebuli faRaraTi, limfadenopaTia,<br />
aramotivirebuli profuzuli oflianoba, Zlieri saerTo<br />
sisuste, aramotivirebuli wonaSi kleba (erTi Tvis ganmavlobaSi<br />
sxeulis wonis 10% <strong>da</strong> meti), sxva<strong>da</strong>sxva gamonayari kansa <strong>da</strong><br />
lorwovanze, kandidozuri ezofagiti, cns-is atipiuri<br />
<strong>da</strong>zianebebi <strong>da</strong> sxva. ze<strong>da</strong> sasunTqi gzebis baqteriuli<br />
infeqciebis <strong>da</strong>ma<strong>da</strong>sturebel simptomebs ganekuTvneba cxeleba,<br />
advilad <strong>da</strong>Rla, xveleba, qoSini, tkivili gulmkerdis areSi,<br />
taqipnoe.<br />
b) gamomricxavi _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis gamomricxavi simptomebi ar<br />
arsebobs, <strong>aiv</strong> inficirebuli wlebis ganmavlobaSi SeiZleba<br />
Civilebs ar warmoadgendes. ze<strong>da</strong> sasunTqi gzebis baqteriuli<br />
infeqciebis gamomricxavi faqtoria Sesabamisi Civilebisa <strong>da</strong><br />
simptomebis ar arseboba.<br />
4. diagnostikur _ laboratoriuli testebi <strong>da</strong> specialistTa<br />
konsultaciebi<br />
CD3, CD4, CD8 limfocitebis absoluturi ricxvis gansazRvra, <strong>aiv</strong><br />
virusuli <strong>da</strong>tvirTvis gansazRvra polimerizaciis jaWvuri reaqciis<br />
meTodiT, sisxlis saerTo analizi, RviZlis funqciuri sinjebi,<br />
145
Tirkmlis funqciuri sinjebi, gulmkerdis rentgenologiuri gamokvleva,<br />
eqim-pulmonologis konsultacia.<br />
5. <strong>mkurnaloba</strong> AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA<br />
baqteriuli pnevmoniis mkurnalobis pirveli rigis sqemebi<br />
antibiotiki doza MmiRebis<br />
sixSire<br />
amoqsicilini<br />
500-1000mg 3X<br />
(penicilinisa <strong>da</strong> ampicilinis<br />
mimarT SesaZlo<br />
dReSi<br />
rezistentobis<br />
SemTxvevaSi gamoiyeneT<br />
penicilini beta laqtamazas<br />
inhibitorebTan kombinaciaSi)<br />
miRebis<br />
gza<br />
mkurnalobis<br />
xangrZlivoba<br />
PO 7 dRe an<br />
ufro<br />
xangrZlivad<br />
morCenamde<br />
Aan<br />
eriTromicini 500mg 4X dReSi PO 7 dRe<br />
an<br />
klaritromicini 500mg 2X dReSi PO 7 dRe<br />
Aan<br />
azitromicini 500mg erTxel<br />
dReSi<br />
qinoloni pnevmokokuri aqtivobiT<br />
(mag: moqsifloqsacini)<br />
doqsiciklini<br />
an<br />
an<br />
400 mg<br />
erTxel<br />
dReSi<br />
100 mg<br />
2X dReSi<br />
PO<br />
PO<br />
PO<br />
3-4 dRe<br />
7 dRe<br />
7 dRe<br />
o Tu pirveli rigis sqemiT mkurnalobis fonze mdgomareoba 72 sT-Si<br />
ar gaumjobes<strong>da</strong> (cxelebis normalizeba, leikocitozis donis<br />
Semcireba), aucilebelia pacientis hospitalizacia <strong>da</strong> mkurnalobis<br />
Secvla II rigis sqemiT,. saWiroebis SemTxvevaSi _ JangbadiT<br />
inhalacia.<br />
baqteriuli pnevmoniebis mkurnalobis meore rigis sqemebi<br />
antibiotiki doza M miRebis<br />
sixSire<br />
ceftriaqsoni 2g dReSi erTxel<br />
+<br />
eriTromicini 500mg 4X dReSi<br />
an<br />
ampicilin/<br />
1500mg 3X dReSi<br />
sulbaqtami<br />
+<br />
eriTromicini 500mg 4X dReSi<br />
an<br />
MmiRebis<br />
gza<br />
IV<br />
IV<br />
mkurnalobis<br />
xangrZlivoba<br />
7 dRe<br />
7 dRe<br />
146
qinoloni<br />
pnevmokokuri<br />
aqtivobiT<br />
(mag:<br />
moqsifloqsacini)<br />
qloramfenikoli<br />
(mxolod sxva preparatebis<br />
ar arsebobis<br />
dros)<br />
400 mg erTxel dReSi IV/PO 7 dRe<br />
an<br />
12,5 mg/kg<br />
4X dReSi IV 7 dRe<br />
7.gaidlaini, romelsac eyrdnoba aRniSnuli protokoli<br />
aRniSnuli protokoli eyrdnoba jan<strong>da</strong>cvis msoflio organizaciis 2006<br />
wlis gaidlains: “<strong>aiv</strong>/<strong>SidsiT</strong> <strong>da</strong>avadebul mozrdil <strong>da</strong> mozard pirebSi<br />
oportunistuli infeqciebis profilaqtika <strong>da</strong> <strong>mkurnaloba</strong>”, aseve<br />
protokoli Sejerebulia DHHS, USA-AIS <strong>da</strong> EACS 2005 wlis oportunistuli<br />
infeqciebis mkurnalobis gaidlainebTan.<br />
147
<strong>aiv</strong> <strong>infeqcia</strong>/Sidsis fonze ganviTarebuli atipiuri<br />
mikobaqteriozebis marTvis saxelmwifo stan<strong>da</strong>rti (protokoli)<br />
1. <strong>da</strong>avadebis/nozologiis/sindromis mokle ganmarteba _ <strong>aiv</strong><br />
<strong>infeqcia</strong>/Sidsi ewodeba a<strong>da</strong>mianis imunodeficitis virusiT gamowveul<br />
infeqciur <strong>da</strong>avadebas. atipiuri mikobaqteriozebi ewodeba Mycobacterium<br />
avium complex gamowveul infeqciebs.<br />
2.kriteriumebi _<br />
a)<strong>da</strong>ma<strong>da</strong>sturebeli _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis <strong>da</strong>ma<strong>da</strong>sturebeli kriteriumebia:<br />
<strong>aiv</strong> antisxeulebis arseboba sisxlis SratSi imunoblotingis meTodiT,<br />
<strong>aiv</strong> rnm-is raodenobrivad <strong>da</strong>/an <strong>aiv</strong> provirus dnm-is Tvisobrivad aRmoCena<br />
sisxlSi polimerizaciis jaWvuri reaqciis meTodiT. atipiuri<br />
mikobaqteriebiT gamowveuli infeqciebis diagnozi ismeba <strong>klinikuri</strong><br />
suraTisa <strong>da</strong> laboratoriuli gamokvlevebis mixedviT. misi<br />
<strong>da</strong>ma<strong>da</strong>sturebeli kriteriumia Mycobacterium avium complex -is aRmoCena<br />
specialur nia<strong>da</strong>gze <strong>da</strong>Tesil sisxlSi, ganavalSi, RviZlisa <strong>da</strong> Zvlis<br />
tvinis bioptatSi.<br />
b)gamomricxavi _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis gamomricxavi kriteriumebia: <strong>aiv</strong><br />
antisxeulebis ar arseboba sisxlis SratSi imunofermentuli meTodiT,<br />
raodenobrivad <strong>aiv</strong> rnm-is <strong>da</strong>/an Tvisobrivad <strong>aiv</strong> provirus dnm-is ar<br />
arseboba sisxlSi polimerizaciis jaWvuri reaqciis meTodiT. atipiuri<br />
mikobaqteriebiT gamowveul infeqciebis gamomricxavi kriteriumia<br />
<strong>klinikuri</strong> suraTisa <strong>da</strong> Mycobacterium avium complex -is ar arseboba<br />
specialur nia<strong>da</strong>gze <strong>da</strong>Tesil sisxlSi, ganavalSi, RviZlisa <strong>da</strong> Zvlis<br />
tvinis bioptatSi.<br />
3.simptomebi <strong>da</strong> niSnebi _<br />
a. <strong>da</strong>ma<strong>da</strong>sturebeli _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidss paTognomuri <strong>klinikuri</strong> niSnebi<br />
ar gaaCnia. igi miekuTvneba laboratoriulad sadiagnozo <strong>da</strong>avadebebs.<br />
simptomebi<strong>da</strong>n SeiZleba gamovyoT: gaxangrZlivebuli cxeleba,<br />
gaxangrZlivebuli faRaraTi, limfadenopaTia, aramotivirebuli<br />
profuzuli oflianoba, Zlieri saerTo sisuste, aramotivirebuli wonaSi<br />
kleba (erTi Tvis ganmavlobaSi sxeulis wonis 10% <strong>da</strong> meti), sxva<strong>da</strong>sxva<br />
gamonayari kansa <strong>da</strong> lorwovanze, kandidozuri ezofagiti, cns-is<br />
atipiuri <strong>da</strong>zianebebi <strong>da</strong> sxva. atipiuri mikobaqteriebiT gamowveuli<br />
infeqciebis <strong>da</strong>ma<strong>da</strong>sturebel simptomebs ganekuTvneba cxeleba, wonaSi<br />
kleba, Ramis oflianoba, diarea, ganleva.<br />
b. gamomricxavi _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis gamomricxavi simptomebi ar<br />
arsebobs, <strong>aiv</strong> inficirebuli wlebis ganmavlobaSi SeiZleba Civilebs ar<br />
warmoadgendes. atipiuri mikobaqteriebiT gamowveuli infeqciebis<br />
gamomricxavi faqtoria Sesabamisi Civilebisa <strong>da</strong> simptomebis ar arseboba.<br />
4. diagnostikur _ laboratoriuli testebi <strong>da</strong> specialistTa<br />
konsultaciebi<br />
CD3, CD4, CD8 limfocitebis absoluturi ricxvis gansazRvra, <strong>aiv</strong><br />
virusuli <strong>da</strong>tvirTvis gansazRvra polimerizaciis jaWvuri reaqciis<br />
meTodiT, sisxlis saerTo analizi, RviZlis funqciuri sinjebi,<br />
Tirkmlis funqciuri sinjebi, gulmkerdis rentgenologiuri gamokvleva,<br />
Mycobacterium avium complex-is aRmoCena specialur nia<strong>da</strong>gze <strong>da</strong>Tesil<br />
sisxlSi, ganavalSi, RviZlsa <strong>da</strong> Zvlis tvinis bioptatSi.<br />
5. atipuri mikobaqteriozebis <strong>mkurnaloba</strong><br />
antibiotiki doza MmiRebis miRebis mkurnalobis<br />
148
sixSire gza xangrZlivoba<br />
pirveli rigis preparatebi<br />
klariTromicini 500-1000 mg 2-jer dReSi PO 6 Tve ;<br />
<strong>da</strong>mokidebulia<br />
klinikur<br />
mdgomareobaze<br />
+<br />
etambutoli 15 mg/kg dReSi<br />
erTxel<br />
+<br />
rifabutini 300-450 mg dReSi<br />
erTxel<br />
PO 6 Tve ;<br />
<strong>da</strong>mokidebulia<br />
klinikur<br />
mdgomareobaze<br />
PO 6 Tve ;<br />
<strong>da</strong>mokidebulia<br />
klinikur<br />
mdgomareobaze<br />
sxva preparatebi, rimlebic moqmedeben atipiur mikobaqteriebze<br />
azitromicini 500-1200 mg dReSi PO<br />
6 Tve<br />
erTxel<br />
ciprofloqsacini 500 mg 2-jer dReSi PO<br />
6 Tve<br />
amikacini<br />
15 mg/kg/dR dReSi 1X i/v<br />
an 7,5 2-jer dReSi i/v<br />
mg/kg/dR<br />
ara umetes 4<br />
kvirisa<br />
6. reabilitacia <strong>da</strong> <strong>da</strong>kvirveba<br />
o Tu atipiuri mikobaqteriozebis mkurnalobis fonze mdgomareoba<br />
gaumjobes<strong>da</strong> <strong>da</strong> preparatebi kargad ga<strong>da</strong>itaneba un<strong>da</strong> <strong>da</strong>iwyos arT.<br />
o atipiuri mikobaqteriozebis mkurnalobo<strong>da</strong>n 4-6- kviraSi iwyeba arT.<br />
6 Tvis Semdeg imunuri pasuxis gaumjobesebis Semdeg (CD4<br />
ricxvi>100mm3) Cerdeba atipiuri mikobaqteriozebis <strong>mkurnaloba</strong> <strong>da</strong><br />
gamoiyeneba meoradi profilaqtika.<br />
o meoradi profilaqtikis Sewyveta SesaZlebelia, rodesac imunuri<br />
sistema stabiluria 3-6- Tvis manZilze.<br />
o atipiuri mikobaqteriozebis <strong>mkurnaloba</strong> <strong>da</strong> meoradi profilaqtika<br />
grZeldeba 6 Tve, rac aris mkurnalobis warmatebis <strong>da</strong> relapsis<br />
Tavi<strong>da</strong>n acilebis sawin<strong>da</strong>ri.<br />
o didi mniSvneloba aqvs atipiuri mikobaqteriozebis mkurnalobis<br />
<strong>da</strong>wyebas arv Terapiis <strong>da</strong>wyebamde.<br />
o arsebobs albaToba imunuri rekonstituciis anTebiTi sindromis<br />
ganviTarebis arT-s <strong>da</strong>wyebis Semdeg.D<br />
7.gaidlaini, romelsac eyrdnoba aRniSnuli protokoli<br />
aRniSnuli protokoli eyrdnoba jan<strong>da</strong>cvis msoflio organizaciis 2006<br />
wlis gaidlains: “<strong>aiv</strong>/<strong>SidsiT</strong> <strong>da</strong>avadebul mozrdil <strong>da</strong> mozard pirebSi<br />
oportunistuli infeqciebis profilaqtika <strong>da</strong> <strong>mkurnaloba</strong>”, aseve<br />
protokoli Sejerebulia DHHS, USA-AIS <strong>da</strong> EACS 2005 wlis oportunistuli<br />
infeqciebis mkurnalobis gaidlainebTan.<br />
149
<strong>aiv</strong> <strong>infeqcia</strong>/Sidsis fonze ganviTarebuli pnevmocisturi pnevmoniis<br />
marTvis saxelmwifo stan<strong>da</strong>rti (protokoli)<br />
1. <strong>da</strong>avadebis/nozologiis/sindromis mokle ganmarteba _ <strong>aiv</strong><br />
<strong>infeqcia</strong>/Sidsi ewodeba a<strong>da</strong>mianis imunodeficitis virusiT<br />
gamowveul infeqciur <strong>da</strong>avadebas. pnevmocisturi pnevmoniis<br />
gamomwvevia Pneumocystis jiroveci.<br />
2. kriteriumebi _<br />
a. <strong>da</strong>ma<strong>da</strong>sturebeli _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis <strong>da</strong>ma<strong>da</strong>sturebeli<br />
kriteriumebia: <strong>aiv</strong> antisxeulebis arseboba sisxlis SratSi<br />
imunoblotingis meTodiT, <strong>aiv</strong> rnm-is raodenobrivad <strong>da</strong>/an <strong>aiv</strong><br />
provirus dnm-is Tvisobrivad aRmoCena sisxlSi<br />
polimerizaciis jaWvuri reaqciis meTodiT. pnevmocisturi<br />
pnevmoniis diagnozi ismeba <strong>klinikuri</strong> suraTisa <strong>da</strong><br />
rentgenologiuri cvlilebebis mixedviT. pnevmocisturi<br />
pnevmoniis <strong>klinikuri</strong> gamovlinebebia: xvela, qoSini, cxeleba,<br />
respiratoruli distresi – cianoziT. rentgenologiuri<br />
niSani - orive filtvis qvemo wilSi gamWvirvalobis<br />
Rrubliseburi <strong>da</strong>qveiTeba - yvela pacients ar aReniSneba.<br />
pnevmocisturi pnevmoniis <strong>da</strong>ma<strong>da</strong>sturebeli kriteriumia<br />
Pneumocystis jiroveci-is cistis aRmoCena naxvelSi an<br />
bronqoalveolaruli lavaJiT miRebul siTxeSi.<br />
b. gamomricxavi _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis gamomricxavi<br />
kriteriumebia: <strong>aiv</strong> antisxeulebis ar arseboba sisxlis SratSi<br />
imunofermentuli meTodiT, raodenobrivad <strong>aiv</strong> rnm-is <strong>da</strong>/an<br />
Tvisobrivad <strong>aiv</strong> provirus dnm-is ar arseboba sisxlSi<br />
polimerizaciis jaWvuri reaqciis meTodiT. pnevmocisturi<br />
pnevmoniis gamomricxavi kriteriumebia <strong>klinikuri</strong><br />
gamovlinebebisa <strong>da</strong> Pneumocystis jiroveci-is cistis ar arseboba<br />
naxvelSi an bronqoalveolaruli lavaJiT miRebul siTxeSi.<br />
3. simptomebi <strong>da</strong> niSnebi _<br />
a. <strong>da</strong>ma<strong>da</strong>sturebeli _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidss paTognomuri<br />
<strong>klinikuri</strong> niSnebi ar gaaCnia. igi miekuTvneba<br />
laboratoriulad sadiagnozo <strong>da</strong>avadebebs. simptomebi<strong>da</strong>n<br />
SeiZleba gamovyoT: gaxangrZlivebuli cxeleba,<br />
gaxangrZlivebuli faRaraTi, limfadenopaTia,<br />
aramotivirebuli profuzuli oflianoba, Zlieri saerTo<br />
sisuste, aramotivirebuli wonaSi kleba (erTi Tvis<br />
ganmavlobaSi sxeulis wonis 10% <strong>da</strong> meti), sxva<strong>da</strong>sxva<br />
gamonayari kansa <strong>da</strong> lorwovanze, kandidozuri ezofagiti,<br />
cns-is atipiuri <strong>da</strong>zianebebi <strong>da</strong> sxva. pnevmocisturi pnevmoniis<br />
<strong>da</strong>ma<strong>da</strong>sturebel simptomebs ganekuTvneba xvela, qoSini,<br />
cxeleba, respiratoruli distresi – cianoziT.<br />
b. gamomricxavi _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis gamomricxavi simptomebi<br />
ar arsebobs, <strong>aiv</strong> inficirebuli wlebis ganmavlobaSi SeiZleba<br />
Civilebs ar warmoadgendes. pnevmocisturi pnevmoniis<br />
gamomricxavi faqtoria Sesabamisi Civilebisa <strong>da</strong> simptomebis<br />
ar arseboba.<br />
150
4. diagnostikur _ laboratoriuli testebi <strong>da</strong> specialistTa<br />
konsultaciebi<br />
CD3, CD4, CD8 limfocitebis absoluturi ricxvis gansazRvra, <strong>aiv</strong><br />
virusuli <strong>da</strong>tvirTvis gansazRvra polimerizaciis jaWvuri reaqciis<br />
meTodiT, sisxlis saerTo analizi, RviZlis funqciuri sinjebi,<br />
Tirkmlis funqciuri sinjebi, gulmkerdis rentgenologiuri gamokvleva,<br />
Pneumocystis jiroveci-is cistis aRmoCena naxvelSi an bronqoalveolaruli<br />
lavaJiT miRebul siTxeSi, eqim-pulmonologis konsultacia.<br />
5. pnevmocisturi pnevmoniis <strong>mkurnaloba</strong> tardeba stacionarSi.<br />
aucilebelia <strong>da</strong>mxmare Terapia JangbadiT inhalaciis CaTvliT.<br />
pnevmocisturi pnevmoniis pirveli rigis <strong>mkurnaloba</strong><br />
antimikrobuli<br />
agenti<br />
timetoprimi/<br />
sulfametoqsazoli<br />
doza M miRebis M miRebis mkurnalobis<br />
sixSire gza xangrZlivoba<br />
400/80 mg 4X dReSi PO/IV 21 dRe<br />
pnevmocisturi pnevmoniis meore rigis <strong>mkurnaloba</strong><br />
Kklin<strong>da</strong>micini<br />
+<br />
primaqini<br />
600mg<br />
15 mg<br />
4X dReSi<br />
2X dReSi<br />
PO/IV<br />
PO<br />
21 dRe<br />
an<br />
pentamidini (farTo 4 mg/kg IV<br />
speqtris<br />
dReSi. doza<br />
antibiotikTan mcir 2 mg/kg<br />
kombinaciaSi 5 dRis<br />
baqteriuli<br />
superinfeqciis<br />
mkurnalobis<br />
Semdeg (18)<br />
profilaqtikisTvis<br />
mag. ampicilin+<br />
sulbaqtami 10 dRe)<br />
dReSi<br />
erTxel<br />
IV<br />
21 dRe<br />
o mZime mdgomareobaSi myof avadmofebSi iniSneba prednizoloni, 80-<br />
250 mg PO/IV dReSi 1-2 kvira (amcirebs intersticiul SeSupebas).<br />
o mZime SemTxvevebSi ganixileba kombinirebuli <strong>mkurnaloba</strong>, mag. kotrimoqsazoli<br />
<strong>da</strong> pen<strong>da</strong>midini mxolod erTeuli Setyobinebuli<br />
SemTxvevebis mixedviT <strong>da</strong>kavSirebulia toqsiurobis maRal riskTan.<br />
pnevmocisturi pnevmoniis mZime SemTxvevebi moiTxovs xelovnur<br />
ventilacias an oqsigeniT saturacias (SO2)
6. reabilitacia <strong>da</strong> <strong>da</strong>kvirveba<br />
monitoringis samizneebs warmoadgens Tirkmlebis, parkreasis<br />
(pen<strong>da</strong>midiniT mkurnalobisas), Zvlis tvinis (ko-trimoqsazoliT<br />
mkurnalobisas) laboratoriuli gamokvlevebi 2 kviraSi erTxel.<br />
pnevmocisturi pnevmoniis mwvave SemTxvevis warmatebiT mkurnalobis<br />
Semged :<br />
o meoradi profilaqtikis mizniT <strong>aiv</strong> inficirebulma pacientebma un<strong>da</strong><br />
miiRon trimetoprim/sulfametoqsazoli 160/800 mg doziT erTxel<br />
dReSi xangrZlivad ;<br />
o aRniSnuli preparatebis miReba pacientma SeiZleba Sewyvitos Tu<br />
CD4 limfocitebis raodenoba stabilurad aRemateba 200 mm3-s sul<br />
mcire sami Tvis ganmavlobaSi.<br />
7.gaidlaini, romelsac eyrdnoba aRniSnuli protokoli<br />
aRniSnuli protokoli eyrdnoba jan<strong>da</strong>cvis msoflio organizaciis 2006<br />
wlis gaidlains: “<strong>aiv</strong>/<strong>SidsiT</strong> <strong>da</strong>avadebul mozrdil <strong>da</strong> mozard pirebSi<br />
oportunistuli infeqciebis profilaqtika <strong>da</strong> <strong>mkurnaloba</strong>”, aseve<br />
protokoli Sejerebulia DHHS, USA-AIS <strong>da</strong> EACS 2005 wlis oportunistuli<br />
infeqciebis mkurnalobis gaidlainebTan.<br />
152
<strong>aiv</strong> <strong>infeqcia</strong>/Sidsis fonze ganviTarebuli<br />
saxelmwifo stan<strong>da</strong>rti (protokoli)<br />
kandidozebis marTvis<br />
1. <strong>da</strong>avadebis/nozologiis/sindromis mokle ganmarteba _ <strong>aiv</strong><br />
<strong>infeqcia</strong>/Sidsi ewodeba a<strong>da</strong>mianis imunodeficitis virusiT gamowveul<br />
infeqciur <strong>da</strong>avadebas. kandidozebis gamomwvevia Candi<strong>da</strong> albicans.<br />
2.kriteriumebi _<br />
a)<strong>da</strong>ma<strong>da</strong>sturebeli _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis <strong>da</strong>ma<strong>da</strong>sturebeli<br />
kriteriumebia: <strong>aiv</strong> antisxeulebis arseboba sisxlis SratSi<br />
imunoblotingis meTodiT, <strong>aiv</strong> rnm-is raodenobrivad <strong>da</strong>/an <strong>aiv</strong> provirus<br />
dnm-is Tvisobrivad aRmoCena sisxlSi polimerizaciis jaWvuri reaqciis<br />
meTodiT. orofaringeuli kandidozis diagnostika efuZneba klinikur<br />
niSnebs, gasinjvas <strong>da</strong> <strong>da</strong>zianebuli ubnebi<strong>da</strong>n aRebuli masalis<br />
mikroskopul <strong>da</strong>Tvalierebas. piris Rrus <strong>da</strong>Tvalierebisas vnaxulobT<br />
balTis formis TeTr nadebs SewiTlebul <strong>da</strong> anTebad lorwovan garsze.<br />
anTeba SeiZleba gavrceldes sasaze, xaxaze, RrZilebze, enasa <strong>da</strong> loyis<br />
lorwovanze. ena <strong>da</strong>zianebisas xdeba gluvi, wiTeli <strong>da</strong> dvrilebi<br />
swordeba. kandidozuri ezofagitis SemTxvevebSi diagnozis<br />
<strong>da</strong><strong>da</strong>sturebisTvis aucilebelia qsovilis bioptatis histologiuri<br />
gamokvleva.<br />
b)gamomricxavi _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis gamomricxavi kriteriumebia: <strong>aiv</strong><br />
antisxeulebis ar arseboba sisxlis SratSi imunofermentuli meTodiT,<br />
raodenobrivad <strong>aiv</strong> rnm-is <strong>da</strong>/an Tvisobrivad <strong>aiv</strong> provirus dnm-is ar<br />
arseboba sisxlSi polimerizaciis jaWvuri reaqciis meTodiT.<br />
kandidozebis gamomricxavi kriteriumebia Sesabamisi <strong>klinikuri</strong><br />
gamovlinebebis ar arseboba.<br />
simptomebi <strong>da</strong> niSnebi _<br />
a)<strong>da</strong>ma<strong>da</strong>sturebeli _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidss paTognomuri <strong>klinikuri</strong><br />
niSnebi ar gaaCnia. igi miekuTvneba laboratoriulad sadiagnozo<br />
<strong>da</strong>avadebebs. simptomebi<strong>da</strong>n SeiZleba gamovyoT: gaxangrZlivebuli<br />
cxeleba, gaxangrZlivebuli faRaraTi, limfadenopaTia,<br />
aramotivirebuli profuzuli oflianoba, Zlieri saerTo sisuste,<br />
aramotivirebuli wonaSi kleba (erTi Tvis ganmavlobaSi sxeulis<br />
wonis 10% <strong>da</strong> meti), sxva<strong>da</strong>sxva gamonayari kansa <strong>da</strong> lorwovanze,<br />
kandidozuri ezofagiti, cns-is atipiuri <strong>da</strong>zianebebi <strong>da</strong> sxva. piris<br />
Rrus kandidozi moicavs: loyis lorwovan garss, enas, pir-xaxas,<br />
RrZilebs, rbil <strong>da</strong> magar sasas. avadmyofs SeiZleba ar hqondes<br />
Civilebi an aRniSnavdes Wamis dros wvis SegrZnebas. zogierTi<br />
avadmyofi uCivis pirSi TeTri nadebis arsebobas. roca kandidozi<br />
vrceldeba saylapavze pacienti uCivis: tkivils ylapvis dros,<br />
retrosternalur tkivils, hipersalivacias.<br />
b)gamomricxavi _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis gamomricxavi simptomebi ar<br />
arsebobs, <strong>aiv</strong> inficirebuli wlebis ganmavlobaSi SeiZleba<br />
Civilebs ar warmoadgendes. kandidozebis gamomricxavi faqtoria<br />
Sesabamisi Civilebisa <strong>da</strong> simptomebis ar arseboba.<br />
4.diagnostikur _ laboratoriuli testebi <strong>da</strong> specialistTa<br />
konsultaciebi<br />
CD3, CD4, CD8 limfocitebis absoluturi ricxvis gansazRvra, <strong>aiv</strong><br />
virusuli <strong>da</strong>tvirTvis gansazRvra polimerizaciis jaWvuri reaqciis<br />
meTodiT, sisxlis saerTo analizi, RviZlis funqciuri sinjebi,<br />
Tirkmlis funqciuri sinjebi, gulmkerdis rentgenologiuri gamokvleva,<br />
153
kandidozuri ezofagitis SemTxvevebSi diagnozis <strong>da</strong><strong>da</strong>sturebisTvis<br />
aucilebelia qsovilis bioptatis histologiuri gamokvleva.<br />
5.kandidozebis <strong>mkurnaloba</strong><br />
piris Rrus kandidozis <strong>mkurnaloba</strong><br />
antimikozuri<br />
agenti<br />
doza<br />
M miRebis<br />
sixSire<br />
mkurnalobis pirveli rigis sqemebi<br />
mikonazoli tabletebi dReSi<br />
gasawovad erTxel<br />
an<br />
flukonazoli 100 mg 2-jer dReSi<br />
3 dRe<br />
Semdeg<br />
erTxel<br />
dReSi 4 dRe<br />
mkurnalobis meore rigis sqemebi<br />
itrakonazoli 200-400 mg dReSi<br />
erTxel<br />
miRebis gza<br />
adgilobrivad<br />
PO<br />
PO<br />
mkurnalobis<br />
xangrZlivoba<br />
7 dRe<br />
7 dRe<br />
7 dRe<br />
vaginaluri kandidozis <strong>mkurnaloba</strong><br />
antimikozuri<br />
agenti<br />
doza M miRebis<br />
sixSire<br />
miRebis<br />
gza<br />
mkurnalobis<br />
xangrZlivoba<br />
pirveli rigis sqemebi<br />
flukonazoli 100 mg erTjera<strong>da</strong>d PO erTjera<strong>da</strong>d<br />
klotrimazoli 500 mg erTjera<strong>da</strong>d vaginalurad erTjera<strong>da</strong>d<br />
meore rigis sqemebi<br />
ketokonazoli 200 mg 2-jer dReSi PO 3 dRe<br />
ketokonazoli 200 mg dReSi PO<br />
7 dRe<br />
erTxel<br />
SemanarCunebeli Terapia<br />
nistatini 2-4 mln IU 2-jer dReSi PO 10 dRe<br />
Aan<br />
flukonazoli 50-200 mg dReSi PO<br />
yoveldRe<br />
erTxel<br />
mesame rigis sqemebi<br />
ketokonazoli 200 mg dReSi<br />
erTxel<br />
itrakonazoli 100 mg dReSi<br />
erTxel<br />
PO<br />
PO<br />
<strong>da</strong>mokidebuli<br />
pasuxze,<br />
Cveulebriv 7-<br />
10 dRe<br />
<strong>da</strong>mokidebuli<br />
pasuxze,<br />
Cveulebriv 7-<br />
10 dRe<br />
154
ezofaguri <strong>da</strong> diseminirebuli kandidozebis <strong>mkurnaloba</strong><br />
antimikozuri<br />
agenti<br />
doza M miRebis<br />
sixSire<br />
miRebis<br />
gza<br />
mkurnalobis<br />
xangrZlivoba<br />
pirveli rigis sqemebi<br />
ketokonazoli 200-400 mg 2-jer dReSi PO 21 dRe<br />
Aan<br />
flukonazoli<br />
(ketokonazolze<br />
efeqturia)<br />
200-400 mg<br />
Semcirdes<br />
<strong>klinikuri</strong><br />
Sedegis<br />
mixedviT 3<br />
dRis Semdeg<br />
100 mg/dReSi<br />
dReSi<br />
erTxel<br />
PO/IV<br />
14 dRe<br />
meore rigis sqemebi<br />
amfotericini B 0,3-0,5 mg/kg IV 10-14 dRe<br />
Aan<br />
itrakonazoli 200-400 mg dReSi<br />
erTxel<br />
PO<br />
2 kvira<br />
6.reabilitacia <strong>da</strong> <strong>da</strong>kvirveba<br />
kandidozuri ezofagitis mkurnalobis Semdeg saWiroa xangrZlivi<br />
SemanarCunebeli Terapia flukonazoliT 50-100 mg/dReSi yoveldRe, an<br />
itrakonazoliT 100 mg/dReSi yoveldRe, an ketokonazoliT 200<br />
mg/dReSi yoveldRe.<br />
7.gaidlaini, romelsac eyrdnoba aRniSnuli protokoli<br />
aRniSnuli protokoli eyrdnoba jan<strong>da</strong>cvis msoflio organizaciis 2006<br />
wlis gaidlains: “<strong>aiv</strong>/<strong>SidsiT</strong> <strong>da</strong>avadebul mozrdil <strong>da</strong> mozard pirebSi<br />
oportunistuli infeqciebis profilaqtika <strong>da</strong> <strong>mkurnaloba</strong>”, aseve<br />
protokoli Sejerebulia DHHS, USA-AIS <strong>da</strong> EACS 2005 wlis oportunistuli<br />
infeqciebis mkurnalobis gaidlainebTan.<br />
155
<strong>aiv</strong> <strong>infeqcia</strong>/Sidsis fonze ganviTarebuli kriptokokuli meningitis<br />
marTvis saxelmwifo stan<strong>da</strong>rti (protokoli)<br />
1.<strong>da</strong>avadebis /nozologiis / sindromis mokle ganmarteba _ <strong>aiv</strong><br />
<strong>infeqcia</strong>/Sidsi ewodeba a<strong>da</strong>mianis imunodeficitis virusiT gamowveul<br />
infeqciur <strong>da</strong>avadebas. kriptokokuli meningitis gamomwvevia soko<br />
Criptococcus neoformans.<br />
2.kriteriumebi _<br />
a)<strong>da</strong>ma<strong>da</strong>sturebeli _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis <strong>da</strong>ma<strong>da</strong>sturebeli kriteriumebia:<br />
<strong>aiv</strong> antisxeulebis arseboba sisxlis SratSi imunoblotingis meTodiT,<br />
<strong>aiv</strong> rnm-is raodenobrivad <strong>da</strong>/an <strong>aiv</strong> provirus dnm-is Tvisobrivad aRmoCena<br />
sisxlSi polimerizaciis jaWvuri reaqciis meTodiT. kriptokokozis<br />
diagnozis <strong>da</strong><strong>da</strong>sturebisTvis liqvors acentrifugireben, miRebul naleqs<br />
ikvleven mikroskopis qveS tuSis wveTis India ink <strong>da</strong>matebis Semdeg.<br />
preparatSi naxuloben sqeli kafsuliT <strong>da</strong>farul safuaris ujredebs.<br />
SesaZlebelia kriptokokis kulturis gamoyofa Tavzurgtvinis<br />
siTxi<strong>da</strong>n.gamoiyeneba Sratis <strong>da</strong> Tavzurgtvinis siTxis gamokvleva<br />
kriptokokul antigenze.<br />
b)gamomricxavi _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis gamomricxavi kriteriumebia: <strong>aiv</strong><br />
antisxeulebis ar arseboba sisxlis SratSi imunofermentuli meTodiT,<br />
raodenobrivad <strong>aiv</strong> rnm-is <strong>da</strong>/an Tvisobrivad <strong>aiv</strong> provirus dnm-is ar<br />
arseboba sisxlSi polimerizaciis jaWvuri reaqciis meTodiT.<br />
kriptokokozis gamomricxavi kriteriumebia liqvorSi sqeli kafsuliT<br />
<strong>da</strong>faruli safuaris ujredebis ar arseboba.<br />
3.simptomebi <strong>da</strong> niSnebi<br />
a)<strong>da</strong>ma<strong>da</strong>sturebeli _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidss paTognomuri <strong>klinikuri</strong> niSnebi<br />
ar gaaCnia. igi miekuTvneba laboratoriulad sadiagnozo <strong>da</strong>avadebebs.<br />
simptomebi<strong>da</strong>n SeiZleba gamovyoT: gaxangrZlivebuli cxeleba,<br />
gaxangrZlivebuli faRaraTi, limfadenopaTia, aramotivirebuli<br />
profuzuli oflianoba, Zlieri saerTo sisuste, aramotivirebuli wonaSi<br />
kleba (erTi Tvis ganmavlobaSi sxeulis wonis 10% <strong>da</strong> meti), sxva<strong>da</strong>sxva<br />
gamonayari kansa <strong>da</strong> lorwovanze, kandidozuri ezofagiti, cns-is<br />
atipiuri <strong>da</strong>zianebebi <strong>da</strong> sxva. kriptokokuli meningitis dros pacienti<br />
uCivisL Tavis tkivils, cxelebas, saxezea kefis kunTebis regidoba, Tavis<br />
qalis nervebis <strong>da</strong>zianeba, cnobierebis <strong>da</strong>rRveva, komatozuri<br />
mdgomareoba. xSirad SesaZlebelia ar aRiniSnos meningitis niSnebi, maT<br />
Soris, cxeleba <strong>da</strong> kefis kunTebis rigidoba.<br />
b)gamomricxavi _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis gamomricxavi simptomebi ar<br />
arsebobs, <strong>aiv</strong> inficirebuli wlebis ganmavlobaSi SeiZleba Civilebs ar<br />
warmoadgendes. kriptokokuli meningitis gamomricxavi faqtoria<br />
Sesabamisi Civilebisa <strong>da</strong> simptomebis ar arseboba.<br />
4.diagnostikur _ laboratoriuli testebi <strong>da</strong> specialistTa<br />
konsultaciebi<br />
CD3, CD4, CD8 limfocitebis absoluturi ricxvis gansazRvra, <strong>aiv</strong><br />
virusuli <strong>da</strong>tvirTvis gansazRvra polimerizaciis jaWvuri reaqciis<br />
meTodiT, sisxlis saerTo analizi, RviZlis funqciuri sinjebi,<br />
Tirkmlis funqciuri sinjebi, Tavzurgtvinis siTxis aReba <strong>da</strong> naleqis<br />
gamokvleva mikroskopis qveS tuSis wveTis India ink <strong>da</strong>matebis Semdeg an,<br />
156
kriptokokis kulturis gamoyofa Tavzurgtvinis siTxi<strong>da</strong>n an, Sratsa<br />
<strong>da</strong>/an Tavzurgtvinis siTxeSi kriptokokuli antigenis aRmoCena.<br />
5.kriptokokuli meningitis <strong>mkurnaloba</strong><br />
antimikozuri doza<br />
agenti<br />
pirveli rigis sqemebi (27)<br />
amfotericini B 0,7-1,0 mg/kg<br />
+<br />
5-flucitozini 25 mg/kg<br />
M miRebis<br />
sixSire<br />
erTxel<br />
dReSi<br />
4X dReSi<br />
IV<br />
miRebis<br />
gza<br />
mkurnalobis<br />
xangrZlivoba<br />
14 dRe<br />
Semdeg<br />
flukonazoli 400 mg erTxel<br />
dReSi<br />
Semdeg<br />
flukonazoli 200mg erTxel<br />
dReSi<br />
meore rigis sqemebi<br />
amfotericini B 0,7-1,0 mg/kg<br />
+<br />
5-flucitozini 25 mg/kg<br />
erTxel<br />
dReSi<br />
4X dReSi<br />
PO sul mcire 10<br />
kvira<br />
PO<br />
IV<br />
mTeli<br />
cxovreba<br />
6-10 kvira<br />
an<br />
amfotericini B 0,7-1,0 mg/kg erTxel<br />
dReSi<br />
IV<br />
an (msubuq SemTxvevebSi)<br />
flukonazoli 400-800 mg erTxel PO<br />
dReSi<br />
Semdeg<br />
flukonazoli 200 mg erTxel PO<br />
dReSi<br />
6-10 kvira<br />
10-12 kvira<br />
mTeli<br />
cxovreba<br />
6.reabilitacia <strong>da</strong> <strong>da</strong>kvirveba<br />
aucilebelia mTeli cxovrebis manZilze Catardes kriptokokozis<br />
meoradiAqimioprofilaqtika. am mizniT iniSneba flukonazoli 200<br />
mg/dReSiAyoveldRe. alternativas warmoadgens itrakonazoli 200<br />
mg/dReSiAyoveldRe. SemanarCunebeli Terapiis aucilebloba pacientebSi,<br />
romelTa imunuri sistema aRdga (CD4 ricxvi >200 mm3) ar aris <strong>da</strong>mxmare<br />
<strong>da</strong> ar arsebobs raime sawinaaRmdego mosazreba am konkretuli<br />
SemTxvevisTvis.<br />
7.gaidlaini, romelsac eyrdnoba aRniSnuli protokoli<br />
aRniSnuli protokoli eyrdnoba jan<strong>da</strong>cvis msoflio organizaciis 2006<br />
wlis gaidlains: “<strong>aiv</strong>/<strong>SidsiT</strong> <strong>da</strong>avadebul mozrdil <strong>da</strong> mozard pirebSi<br />
oportunistuli infeqciebis profilaqtika <strong>da</strong> <strong>mkurnaloba</strong>”, aseve<br />
protokoli Sejerebulia DHHS, USA-AIS <strong>da</strong> EACS 2005 wlis oportunistuli<br />
infeqciebis mkurnalobis gaidlainebTan.<br />
157
<strong>aiv</strong> <strong>infeqcia</strong>/Sidsis fonze ganviTarebuli histoplazmozis marTvis<br />
saxelmwifo stan<strong>da</strong>rti (protokoli)<br />
1.<strong>da</strong>avadebis /nozologiis / sindromis mokle ganmarteba _ <strong>aiv</strong><br />
<strong>infeqcia</strong>/Sidsi ewodeba a<strong>da</strong>mianis imunodeficitis virusiT gamowveul<br />
infeqciur <strong>da</strong>avadebas. hispoplazmozis gamomwvevia soko Histoplazma<br />
capsulatum inhalaciuri sporebi.<br />
2.kriteriumebi _<br />
o a)<strong>da</strong>ma<strong>da</strong>sturebeli _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis <strong>da</strong>ma<strong>da</strong>sturebeli<br />
kriteriumebia: <strong>aiv</strong> antisxeulebis arseboba sisxlis SratSi<br />
imunoblotingis meTodiT, <strong>aiv</strong> rnm-is raodenobrivad <strong>da</strong>/an <strong>aiv</strong><br />
provirus dnm-is Tvisobrivad aRmoCena sisxlSi polimerizaciis<br />
jaWvuri reaqciis meTodiT. histoplazmozis diagnostika<br />
<strong>da</strong>sturdeba sokos kulturiT an qsovilis bioptatis<br />
histologiuri gamokvleviT. hispoplazmozis diagnostisTvis un<strong>da</strong><br />
Catardes sisxlis <strong>da</strong> kanis testebi, Tumca isini ar aris farTod<br />
gamoyenebuli.<br />
b)gamomricxavi _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis gamomricxavi kriteriumebia: <strong>aiv</strong><br />
antisxeulebis ar arseboba sisxlis SratSi imunofermentuli meTodiT,<br />
raodenobrivad <strong>aiv</strong> rnm-is <strong>da</strong>/an Tvisobrivad <strong>aiv</strong> provirus dnm-is ar<br />
arseboba sisxlSi polimerizaciis jaWvuri reaqciis meTodiT.<br />
histoplazmozis gamomricxavi kriteriumebia sokos ar arseboba qsovilis<br />
bioptatis histologiuri gamokvleviT.<br />
3.simptomebi <strong>da</strong> niSnebi<br />
a)<strong>da</strong>ma<strong>da</strong>sturebeli _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidss paTognomuri <strong>klinikuri</strong><br />
niSnebi ar gaaCnia. igi miekuTvneba laboratoriulad sadiagnozo<br />
<strong>da</strong>avadebebs. simptomebi<strong>da</strong>n SeiZleba gamovyoT: gaxangrZlivebuli<br />
cxeleba, gaxangrZlivebuli faRaraTi, limfadenopaTia,<br />
aramotivirebuli profuzuli oflianoba, Zlieri saerTo sisuste,<br />
aramotivirebuli wonaSi kleba (erTi Tvis ganmavlobaSi sxeulis<br />
wonis 10% <strong>da</strong> meti), sxva<strong>da</strong>sxva gamonayari kansa <strong>da</strong> lorwovanze,<br />
kandidozuri ezofagiti, cns-is atipiuri <strong>da</strong>zianebebi <strong>da</strong> sxva.<br />
histoplazmiT gamowveuli mwvave <strong>da</strong>avadeba gripismagvaria <strong>da</strong><br />
axasiaTebs: cxeleba, anoreqsia, arTralgia, mialgia, mSrali xveleba,<br />
tkivili gul-mkerdis areSi. diseminacia imunosupresiul avadmyofSi<br />
swrafad viTardeba <strong>da</strong> axasiaTebs: wonaSi <strong>da</strong>kleba, oraluri <strong>da</strong> kanis<br />
<strong>da</strong>zianebuli ubnebi, RviZlis, elenTis <strong>da</strong> limfuri kvanZebis gadideba.<br />
oraluri ubnebisTvis <strong>da</strong>maxasiaTebelia nekrozuli wylulebi.<br />
SesaZlebelia ganviTareds sasis perforacia <strong>da</strong> rbili qsovilis<br />
destruqcia.<br />
b)gamomricxavi _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis gamomricxavi simptomebi ar<br />
arsebobs, <strong>aiv</strong> inficirebuli wlebis ganmavlobaSi SeiZleba Civilebs ar<br />
warmoadgendes. histoplazmozis gamomricxavi faqtoria Sesabamisi<br />
Civilebisa <strong>da</strong> simptomebis ar arseboba.<br />
158
4.diagnostikur _ laboratoriuli testebi <strong>da</strong> specialistTa<br />
konsultaciebi<br />
o CD3, CD4, CD8 limfocitebis absoluturi ricxvis gansazRvra, <strong>aiv</strong><br />
virusuli <strong>da</strong>tvirTvis gansazRvra polimerizaciis jaWvuri reaqciis<br />
meTodiT, sisxlis saerTo analizi, RviZlis funqciuri sinjebi,<br />
Tirkmlis funqciuri sinjebi, qsovilis bioptatis histologiuri<br />
gamokvleva histoplazmozis diagnostikisTvis.<br />
5. histoplazmozis <strong>mkurnaloba</strong><br />
antifungaluri<br />
agenti<br />
dozireba miRebis<br />
sixSire<br />
amfotericni B 0.7-1 mg/kg erTxel<br />
dReSi<br />
miRebis gza<br />
IV<br />
xangrZlivoba<br />
10 dRe<br />
sawyis <strong>mkurnaloba</strong>s mohyveba 3 Tviani <strong>mkurnaloba</strong> imunorekonstituciamde<br />
>100 CD4 ujrediT, Sedegi medikamentebiT:<br />
o itrakonazoli 200 mg 2X dReSi PO<br />
o flukonazoli 200 mg 2X dReSi PO<br />
o amfotericini B 1 mg/kg IV kviraSi erTxel.<br />
alternatiul reJims warmoadgens itrakonazoli 200 mg samjer dReSi - 3<br />
dRe, Semdeg 200 mg 2X dReSi 12 kvira (sakvebTan erTad).<br />
7.gaidlaini, romelsac eyrdnoba aRniSnuli protokoli<br />
aRniSnuli protokoli eyrdnoba jan<strong>da</strong>cvis msoflio organizaciis 2006<br />
wlis gaidlains: “<strong>aiv</strong>/<strong>SidsiT</strong> <strong>da</strong>avadebul mozrdil <strong>da</strong> mozard pirebSi<br />
oportunistuli infeqciebis profilaqtika <strong>da</strong> <strong>mkurnaloba</strong>”, aseve<br />
protokoli Sejerebulia DHHS, USA-AIS <strong>da</strong> EACS 2005 wlis oportunistuli<br />
infeqciebis mkurnalobis gaidlainebTan.<br />
159
<strong>aiv</strong> <strong>infeqcia</strong>/Sidsis fonze ganviTarebuli kapoSis sarkomis marTvis<br />
saxelmwifo stan<strong>da</strong>rti (protokoli)<br />
1.<strong>da</strong>avadebis /nozologiis / sindromis mokle ganmarteba _ <strong>aiv</strong><br />
<strong>infeqcia</strong>/Sidsi ewodeba a<strong>da</strong>mianis imunodeficitis virusiT gamowveul<br />
infeqciur <strong>da</strong>avadebas. kapoSis sarkoma avTvisebiani simsivnea, romlis<br />
gamomwvevia gamomwvevia me-8 tipis herpes virusi (HHV8 an KSHV).<br />
2.kriteriumebi _<br />
a)<strong>da</strong>ma<strong>da</strong>sturebeli _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis <strong>da</strong>ma<strong>da</strong>sturebeli kriteriumebia:<br />
<strong>aiv</strong> antisxeulebis arseboba sisxlis SratSi imunoblotingis meTodiT,<br />
<strong>aiv</strong> rnm-is raodenobrivad <strong>da</strong>/an <strong>aiv</strong> provirus dnm-is Tvisobrivad aRmoCena<br />
sisxlSi polimerizaciis jaWvuri reaqciis meTodiT. kapoSis sarkomis<br />
diagnozi <strong>da</strong>sturdeba kanis <strong>da</strong>zianebuli ubnebi<strong>da</strong>n aRebuli bioptatis<br />
histologiuri gamokvleviT.<br />
b)gamomricxavi _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis gamomricxavi kriteriumebia: <strong>aiv</strong><br />
antisxeulebis ar arseboba sisxlis SratSi imunofermentuli meTodiT,<br />
raodenobrivad <strong>aiv</strong> rnm-is <strong>da</strong>/an Tvisobrivad <strong>aiv</strong> provirus dnm-is ar<br />
arseboba sisxlSi polimerizaciis jaWvuri reaqciis meTodiT. kapoSis<br />
sarkomis gamomricxavi kriteriumebia kanis <strong>da</strong>zianebuli ubnebi<strong>da</strong>n<br />
aRebul bioptatSi <strong>da</strong>ignozis histologiurad ar <strong>da</strong><strong>da</strong>stureba.<br />
3.simptomebi <strong>da</strong> niSnebi<br />
a)<strong>da</strong>ma<strong>da</strong>sturebeli _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidss paTognomuri <strong>klinikuri</strong><br />
niSnebi ar gaaCnia. igi miekuTvneba laboratoriulad sadiagnozo<br />
<strong>da</strong>avadebebs. simptomebi<strong>da</strong>n SeiZleba gamovyoT: gaxangrZlivebuli<br />
cxeleba, gaxangrZlivebuli faRaraTi, limfadenopaTia,<br />
aramotivirebuli profuzuli oflianoba, Zlieri saerTo sisuste,<br />
aramotivirebuli wonaSi kleba (erTi Tvis ganmavlobaSi sxeulis<br />
wonis 10% <strong>da</strong> meti), sxva<strong>da</strong>sxva gamonayari kansa <strong>da</strong> lorwovanze,<br />
kandidozuri ezofagiti, cns-is atipiuri <strong>da</strong>zianebebi <strong>da</strong> sxva. kanze<br />
elementebi warmodgenilia cisferi an mewamuli feris papulebiT an<br />
kvanZebiT, araiSviaTad garSemo arsebuli kanis limfuri SeSupebiT.<br />
xSirad ziandeba sasa, filtvebi kuW-nawlavis traqti <strong>da</strong> limfuri<br />
kvanZebi. piris RruSi kapoSis sarkomis elementebi yvelaze xSirad<br />
ganlagebulia magar sasaze, iSviaTad enaze, xaxaze, nuSura<br />
jirkvlebsa <strong>da</strong> RrZilebze. isini warmoadgenen mewamuli feris<br />
papulebs, romlebic Cveulebriv ar aris mtkivneuli. xan<strong>da</strong>xan SeiZleba<br />
Segvxvdes msxvili elementebic <strong>da</strong> elementebi kanze. filtvis<br />
parenqimis <strong>da</strong>zianeba atarebs infiltraciul xasiaTs. xSirad<br />
viTardeba sunTqvis ukmarisoba. filtvis infiltraciuli <strong>da</strong>zianebis<br />
mqone avadmyofebs arakeTilsaimedo prognozi aqvT <strong>da</strong> maTSi maRalia<br />
sikvdilianoba.<br />
b)gamomricxavi _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis gamomricxavi simptomebi ar<br />
arsebobs, <strong>aiv</strong> inficirebuli wlebis ganmavlobaSi SeiZleba Civilebs ar<br />
warmoadgendes. kapoSis sarkomis gamomricxavi faqtoria Sesabamisi<br />
Civilebisa <strong>da</strong> simptomebis ar arseboba.<br />
160
4.diagnostikur _ laboratoriuli testebi <strong>da</strong> specialistTa<br />
konsultaciebi<br />
CD3, CD4, CD8 limfocitebis absoluturi ricxvis gansazRvra, <strong>aiv</strong><br />
virusuli <strong>da</strong>tvirTvis gansazRvra polimerizaciis jaWvuri reaqciis<br />
meTodiT, sisxlis saerTo analizi, RviZlis funqciuri sinjebi,<br />
Tirkmlis funqciuri sinjebi, kapoSis sarkomiT <strong>da</strong>zianebuli kanis<br />
ubnebis biopsia <strong>da</strong> histologiuri gamokvleva.<br />
5.kapoSis sarkomis <strong>mkurnaloba</strong><br />
kapoSis sarkomis <strong>mkurnaloba</strong> tardeba onkologis mier. lokaluri<br />
formis samkurnalod gamoiyeneba sxivuri Terapia. generalizirebuli<br />
formis samkurnalod iniSneba citotoqsiuri qimioTerapia. efeqturobis<br />
sxva<strong>da</strong>sxva xarisxiT gamoiyeneba simsivnis sawinaaRmdego preparatebis<br />
Semdegi kombinaciebi: liposomuri doksorubiciniT monoTerapia,<br />
bleomicini, vinkristini, <strong>da</strong>unorubicini, vinblastini, etopozidi.<br />
calkeuli elementebi SeiZleba moSordes qirurgiulad an lazeris,<br />
Txevadi azotis <strong>da</strong> <strong>da</strong>sxivebis zemoqmedebiT. demonstrirebuli iyo<br />
uSualod kapoSis sarkomatozul kvanZSi bleomicinis Seyvanis<br />
efeqturoba. kapoSis sarkoma SesaZloa <strong>da</strong>eqvemdebaros mxolod arT-s <strong>da</strong><br />
nel-nela alagdes.<br />
7.gaidlaini, rimelsac eyrdnoba aRniSnuli protokoli<br />
aRniSnuli protokoli eyrdnoba jan<strong>da</strong>cvis msoflio organizaciis 2006<br />
wlis gaidlains: “<strong>aiv</strong>/<strong>SidsiT</strong> <strong>da</strong>avadebul mozrdil <strong>da</strong> mozard pirebSi<br />
oportunistuli infeqciebis profilaqtika <strong>da</strong> <strong>mkurnaloba</strong>”, aseve<br />
protokoli Sejerebulia DHHS, USA-AIS <strong>da</strong> EACS 2005 wlis oportunistuli<br />
infeqciebis mkurnalobis gaidlainebTan.<br />
161
<strong>aiv</strong> <strong>infeqcia</strong>/Sidsis fonze ganviTarebuli arahojkinis limfomebis<br />
marTvis saxelmwifo stan<strong>da</strong>rti (protokoli)<br />
1.<strong>da</strong>avadebis /nozologiis / sindromis mokle ganmarteba _ <strong>aiv</strong><br />
<strong>infeqcia</strong>/Sidsi ewodeba a<strong>da</strong>mianis imunodeficitis virusiT gamowveul<br />
infeqciur <strong>da</strong>avadebas. arahojkinis lomfomebi limfuri sistemis<br />
avTvisebiani simsivneebia, romlebic Sidsis fonze xSir SemTxvevaSi<br />
asocirebulia epStein-baris virusTan (EBV).<br />
2.kriteriumebi _<br />
a)<strong>da</strong>ma<strong>da</strong>sturebeli _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis <strong>da</strong>ma<strong>da</strong>sturebeli kriteriumebia:<br />
<strong>aiv</strong> antisxeulebis arseboba sisxlis SratSi imunoblotingis meTodiT,<br />
<strong>aiv</strong> rnm-is raodenobrivad <strong>da</strong>/an <strong>aiv</strong> provirus dnm-is Tvisobrivad aRmoCena<br />
sisxlSi polimerizaciis jaWvuri reaqciis meTodiT. arahojkinis<br />
limfomebis diagnozi <strong>da</strong>sturdeba hipereplazirebuli limfuri kvanZis<br />
biofsiiT, histologiuri gamokvleviT.<br />
b)gamomricxavi _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis gamomricxavi kriteriumebia: <strong>aiv</strong><br />
antisxeulebis ar arseboba sisxlis SratSi imunofermentuli meTodiT,<br />
raodenobrivad <strong>aiv</strong> rnm-is <strong>da</strong>/an Tvisobrivad <strong>aiv</strong> provirus dnm-is ar<br />
arseboba sisxlSi polimerizaciis jaWvuri reaqciis meTodiT.<br />
arahojkinis limfomis gamomricxavi kriteriumebia simsivnis<br />
morfologiuri substratis ar arseboba hiperplazirebuli limfuri<br />
kvanZis bioptatSi.<br />
3.simptomebi <strong>da</strong> niSnebi<br />
a)<strong>da</strong>ma<strong>da</strong>sturebeli _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidss paTognomuri <strong>klinikuri</strong> niSnebi<br />
ar gaaCnia. igi miekuTvneba laboratoriulad sadiagnozo <strong>da</strong>avadebebs.<br />
simptomebi<strong>da</strong>n SeiZleba gamovyoT: gaxangrZlivebuli cxeleba,<br />
gaxangrZlivebuli faRaraTi, limfadenopaTia, aramotivirebuli<br />
profuzuli oflianoba, Zlieri saerTo sisuste, aramotivirebuli wonaSi<br />
kleba (erTi Tvis ganmavlobaSi sxeulis wonis 10% <strong>da</strong> meti), sxva<strong>da</strong>sxva<br />
gamonayari kansa <strong>da</strong> lorwovanze, kandidozuri ezofagiti, cns-is<br />
atipiuri <strong>da</strong>zianebebi <strong>da</strong> sxva. arahojkinis limfomebis dros simptomebi<br />
mravalferovania: hiperplazirebuli limfuri kvanZebi SesaZlebelia<br />
palpirdebodes sxva<strong>da</strong>sxva adgilze; cxeleba, wonaSi kleba <strong>da</strong> sisuste<br />
xSiria, Tumca ara aucilebeli; <strong>da</strong>avadebis stadiis gansazRvrisTvis (I-IV)<br />
aucilebelia Semdegi gamokvlevebi: cerebruli, cervikaluri,<br />
Torakaluri <strong>da</strong> abdominaluri kompiuterul-aqsialuri tomografiuli<br />
(CAT) skanireba, Zvlis tvinis <strong>da</strong> Tav-zurg-tvinis siTxis aspiracia <strong>da</strong><br />
gastroskopia.<br />
b)gamomricxavi _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis gamomricxavi simptomebi ar<br />
arsebobs, <strong>aiv</strong> inficirebuli wlebis ganmavlobaSi SeiZleba Civilebs ar<br />
warmoadgendes. arahojkinis limfomis gamomricxavi faqtoria Sesabamisi<br />
Civilebisa <strong>da</strong> simptomebis ar arseboba.<br />
4.diagnostikur _ laboratoriuli testebi <strong>da</strong> specialistTa<br />
konsultaciebi<br />
CD3, CD4, CD8 limfocitebis absoluturi ricxvis gansazRvra, <strong>aiv</strong><br />
virusuli <strong>da</strong>tvirTvis gansazRvra polimerizaciis jaWvuri reaqciis<br />
meTodiT, sisxlis saerTo analizi, RviZlis funqciuri sinjebi,<br />
Tirkmlis funqciuri sinjebi, hiperplazirebuli limfuri kvanZis<br />
biofsia <strong>da</strong> histologiuri gamokvleviT simsivnis morfologiuri<br />
substratis aRmoCena.<br />
162
5.arahojkinis limfomebis (maT Soris berkitis tipis <strong>da</strong> cns-is<br />
limfomebis) <strong>mkurnaloba</strong><br />
ara-hojkinis limfomebis samkurnalod efeqturia CHOP reJimi, un<strong>da</strong><br />
Catardes 6 kursi (ganmeorebebi aucilebelia sruli remisiis misaRebad):<br />
o prednizoloni 100 mg/dReSi erTxel 5 dRe<br />
o vinkristini (onkovini) 1,4 mg/m2 (maqsimum 2 mg/dReSi) erTi doza<br />
mkurnalobis pirvel dRes<br />
o ciklofosfamidi 750 mg/m2/dReSi erTi doza mkurnalobis pirvel<br />
dRes<br />
o doqsorubicini (hidroqsi<strong>da</strong>unomicini) 50 mg/m2/dReSi erTi doza<br />
mkurnalobis pirvel dRes.<br />
meore cikli iwyeba yovel 21-e dRes (dRe 22-e mohyveba I dRes)<br />
o EPOCH reJimi, romelic moicavs etopozids, prednozolons,<br />
vinkristins, ciklofisfamids <strong>da</strong> <strong>da</strong>unorubicins an doqsirubicins<br />
efeqturia arT-sTan kombinaciaSi. igi efuZneba gagrZelebiT<br />
infuzias 96 saaTis ganmavlobaSi, romelic Semdegia:<br />
o etopozidi 50 mg/m2 dReSi (centraluri venuri xaziT)<br />
o doqsorubucuni 10 mg/m2/dReSi (centraluri venuri xaziT)<br />
o vinkristini 0,4 mg/m2/dReSi (maqs 2 mg/kviraSi) (centraluri venuri<br />
xaziT)<br />
o ciklofosfamidi 375 mg/m2 me-5 dRes mxolod, bolusiT<br />
(centraluri venuri xaziT)<br />
o prednizoloni 100 mg/dReSi pirveli 5 dRe erTxel dReSi.<br />
reJimi un<strong>da</strong> ganmeordes yovel 21 dReSi sanam ar Catardeba 6 cikli.<br />
o berkitis–tipis limfomis menejmenti ar gansxvavdeba sxva<br />
limfomebis mkurnalobisgan <strong>da</strong> pasuxobs CHOP <strong>da</strong> EPOCH reJimebs.<br />
swrafad mzardi limfomis <strong>mkurnaloba</strong> ufro agresiuli<br />
qimioTerapiiT (mag : B-ALL reJimi) diskusiis Temas warmoadgens <strong>da</strong><br />
specifikuri rekomen<strong>da</strong>ciebi dRevandeli dRisTvis ar arsebobs.<br />
o berkitis–tipis limfomebis SemTxvevebSi qimioTerapias Tan un<strong>da</strong><br />
axldes savaraudo pirveladi keris <strong>da</strong>sxiveba.<br />
o arahojkinis limfomebis <strong>mkurnaloba</strong> SesaZlebelia CD4 ujredebis<br />
ricxvisgan <strong>da</strong>moukideblad, Tumca mkurnalobis efeqturobisTvis<br />
arT un<strong>da</strong> <strong>da</strong>iniSnos ufro adre. qimioTerapiis ganmavlobaSi CD4<br />
ujredebis ricxvi >350 mm3 <strong>da</strong>kavSirebulia relapsis maRal<br />
maCveneblebTan arT gareSe (37).<br />
o intakranialuri limfomebis (metastazebi) arsebobisas sasurvelia<br />
Tavis <strong>da</strong>sxiveba, simsivnis sawinaaRmdego preparatebTan <strong>da</strong><br />
glukokortikoidebTan erTad (38).<br />
cns-is pirveladi limfomis dros erTaderTi efeqturi mtkicebulebaze<br />
<strong>da</strong>fuZnebuli Terapiaa sxivuri Terapia. <strong>da</strong>uyonebliv un<strong>da</strong> <strong>da</strong>iwyos arT<br />
(39,40).<br />
7.gaidlaini, romelsac eyrdnoba aRniSnuli protokoli<br />
aRniSnuli protokoli eyrdnoba jan<strong>da</strong>cvis msoflio organizaciis 2006<br />
wlis gaidlains: “<strong>aiv</strong>/<strong>SidsiT</strong> <strong>da</strong>avadebul mozrdil <strong>da</strong> mozard pirebSi<br />
oportunistuli infeqciebis profilaqtika <strong>da</strong> <strong>mkurnaloba</strong>”, aseve<br />
protokoli Sejerebulia DHHS, USA-AIS <strong>da</strong> EACS 2005 wlis oportunistuli<br />
infeqciebis mkurnalobis gaidlainebTan.<br />
163
<strong>aiv</strong> <strong>infeqcia</strong>/Sidsis fonze ganviTarebuli toqsoplazmozis marTvis<br />
saxelmwifo stan<strong>da</strong>rti (protokoli)<br />
1.<strong>da</strong>avadebis /nozologiis / sindromis mokle ganmarteba _ <strong>aiv</strong><br />
<strong>infeqcia</strong>/Sidsi ewodeba a<strong>da</strong>mianis imunodeficitis virusiT gamowveul<br />
infeqciur <strong>da</strong>avadebas. <strong>da</strong>avadeba toqsoplazmozis gamomwvevia paraziti<br />
Toxoplasma gondii. <strong>SidsiT</strong> avadmyofebSi toqsoplazma iwvevs Tavis tvinSi<br />
mravlobiTi anTebadi ubnebis warmoqmnas <strong>da</strong> gamovlindeba<br />
encefalitis an diseminirebuli <strong>da</strong>avadebis saxiT.<br />
2.kriteriumebi _<br />
a)<strong>da</strong>ma<strong>da</strong>sturebeli _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis <strong>da</strong>ma<strong>da</strong>sturebeli<br />
kriteriumebia: <strong>aiv</strong> antisxeulebis arseboba sisxlis SratSi<br />
imunoblotingis meTodiT, <strong>aiv</strong> rnm-is raodenobrivad <strong>da</strong>/an <strong>aiv</strong><br />
provirus dnm-is Tvisobrivad aRmoCena sisxlSi polimerizaciis<br />
jaWvuri reaqciis meTodiT. toqsoplazmozis dros Tavis tvinis<br />
MAC an MRI skanirebiT aRmoCndeba mravlobiTi rgoliseburi kerebi.<br />
Tu es meTodebi ar aris xelmisawvdomi diagnozis <strong>da</strong>dgenaSi<br />
gvexmareba serologiuri testebi toqsoplazmis sawinaaRmdegod<br />
gamomuSavebul antisxeulebze (IgG klasis). cerebraluri<br />
toqsoplazmozis mqone pacientebis umravlesobas aReniSneba<br />
Toxoplasma gondii-iT gamowveuli infeqciis ga<strong>da</strong>tanis serologiuri<br />
niSnebi. diagnozs a<strong>da</strong>sturebs Tavis tvinis qsovilis histologiuri<br />
gamokvleva.<br />
b)gamomricxavi _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis gamomricxavi kriteriumebia: <strong>aiv</strong><br />
antisxeulebis ar arseboba sisxlis SratSi imunofermentuli<br />
meTodiT, raodenobrivad <strong>aiv</strong> rnm-is <strong>da</strong>/an Tvisobrivad <strong>aiv</strong> provirus<br />
dnm-is ar arseboba sisxlSi polimerizaciis jaWvuri reaqciis<br />
meTodiT. toqsoplazmozis gamomricxavi kriteriumebia Tavis tvinis<br />
MAC an MRI skanirebiT aRmoCndeba mravlobiTi rgoliseburi kerebis<br />
ar arseboba, negatiuri serologiuri testebi toqsoplazmis<br />
sawinaaRmdegod gamomuSavebul antisxeulebze (IgG klasis).<br />
3.simptomebi <strong>da</strong> niSnebi<br />
a)<strong>da</strong>ma<strong>da</strong>sturebeli _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidss paTognomuri <strong>klinikuri</strong> niSnebi<br />
ar gaaCnia. igi miekuTvneba laboratoriulad sadiagnozo <strong>da</strong>avadebebs.<br />
simptomebi<strong>da</strong>n SeiZleba gamovyoT: gaxangrZlivebuli cxeleba,<br />
gaxangrZlivebuli faRaraTi, limfadenopaTia, aramotivirebuli<br />
profuzuli oflianoba, Zlieri saerTo sisuste, aramotivirebuli wonaSi<br />
kleba (erTi Tvis ganmavlobaSi sxeulis wonis 10% <strong>da</strong> meti), sxva<strong>da</strong>sxva<br />
gamonayari kansa <strong>da</strong> lorwovanze, kandidozuri ezofagiti, cns-is<br />
atipiuri <strong>da</strong>zianebebi <strong>da</strong> sxva. toqsoplazmozis dros saxezea Semdegi<br />
<strong>klinikuri</strong> suraTi: cnobierebis <strong>da</strong>rRveva, cxeleba, krunCxvebi, Tavis<br />
tkivili, kerovani nevrologiuri simptomatika motoruli deficitis,<br />
kraniuli nervis parezis, moZraobis SezRudvis, dismetriis, mxedvelobis<br />
<strong>da</strong>kargvis <strong>da</strong> afaziis CaTvliT.<br />
b)gamomricxavi _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis gamomricxavi simptomebi ar<br />
arsebobs, <strong>aiv</strong> inficirebuli wlebis ganmavlobaSi SeiZleba Civilebs ar<br />
warmoadgendes. toqsoplazmozis gamomricxavi faqtoria Sesabamisi<br />
Civilebisa <strong>da</strong> simptomebis ar arseboba.<br />
164
4.diagnostikur _ laboratoriuli testebi <strong>da</strong> specialistTa<br />
konsultaciebi<br />
CD3, CD4, CD8 limfocitebis absoluturi ricxvis gansazRvra, <strong>aiv</strong><br />
virusuli <strong>da</strong>tvirTvis gansazRvra polimerizaciis jaWvuri reaqciis<br />
meTodiT, sisxlis saerTo analizi, RviZlis funqciuri sinjebi,<br />
Tirkmlis funqciuri sinjebi, Tavis tvinis MAC an MRI skanireba,<br />
serologiuri testebi toqsoplazmis sawinaaRmdegod gamomuSavebul<br />
antisxeulebze (IgG klasis), Tavis tvinis biofsia <strong>da</strong> qsovilis<br />
histologiuri gamokvleva.<br />
5. toqsoplazmozis <strong>mkurnaloba</strong><br />
preparati doza M miRebis<br />
sixSire<br />
miRebis<br />
gza<br />
mkurnalobis<br />
xangrZlivoba<br />
<strong>mkurnaloba</strong><br />
pirimetamini 200 mg erTjera<strong>da</strong>d PO<br />
erTjera<strong>da</strong>d<br />
(gajerebiTi doza)<br />
Semdeg<br />
pirimetamini 25 mg<br />
3-jer dReSi PO<br />
6-8 kvira<br />
an 50 mg 2-jer dReSi<br />
+<br />
foliumis 15 mg dReSi PO<br />
6-8 kvira<br />
mJava<br />
erTxel<br />
+<br />
sulfadiazini 1 g 4-jer dReSi PO 6-8 kvira<br />
am sqemaSi sulfadiazini SeiZleba Seicvalos:<br />
• klin<strong>da</strong>miciniT 600 mg i/v an PO dReSi 4-jer 6 kvira<br />
• azitromiciniT 1200 mg PO dReSi erTxel 6 kvira<br />
• klariTromiciniT 1 g PO 2-jer dReSi 6 kvira<br />
• atovakvoniT 750 mg PO 4-jer dReSi 6 kvira.<br />
6.reabilitacia <strong>da</strong> <strong>da</strong>kvirveba<br />
zogierT pacients sWirdeba xangrZlivi <strong>mkurnaloba</strong> toqsoplazmozis<br />
gamo. ga<strong>da</strong>wyvetileba efuZneba klinikur mdgomareobas <strong>da</strong> ganmeorebiT<br />
CAT skanirebas.<br />
meoradi profilaqtika grZeldeba efeqturi reJimis ganaxevrebuli<br />
dozebiT manamde sanam CD4 ujredebs ricxvi sami Tvis ganmavlobaSi<br />
stabilurad ar moimatebs (200 ujredi <strong>da</strong> meti).<br />
7.gaidlaini, rimelsac eyrdnoba aRniSnuli protokoli<br />
aRniSnuli protokoli eyrdnoba jan<strong>da</strong>cvis msoflio organizaciis 2006<br />
wlis gaidlains: “<strong>aiv</strong>/<strong>SidsiT</strong> <strong>da</strong>avadebul mozrdil <strong>da</strong> mozard pirebSi<br />
oportunistuli infeqciebis profilaqtika <strong>da</strong> <strong>mkurnaloba</strong>”, aseve<br />
protokoli Sejerebulia DHHS, USA-AIS <strong>da</strong> EACS 2005 wlis oportunistuli<br />
infeqciebis mkurnalobis gaidlainebTan.<br />
165
<strong>aiv</strong> <strong>infeqcia</strong>/Sidsis fonze ganviTarebuli martivi herpesiT<br />
gamowveuli infeqciebis marTvis saxelmwifo stan<strong>da</strong>rti<br />
(protokoli)<br />
1.<strong>da</strong>avadebis /nozologiis / sindromis mokle ganmarteba _ <strong>aiv</strong><br />
<strong>infeqcia</strong>/Sidsi ewodeba a<strong>da</strong>mianis imunodeficitis virusiT gamowveul<br />
infeqciur <strong>da</strong>avadebas. <strong>SidsiT</strong> avadmyofebSi martivi herpesis virusi<br />
HSV I <strong>da</strong> II tipis iwvevs vrcel, persistul an diseminirebul<br />
<strong>infeqcia</strong>s, meningitsa <strong>da</strong> meningoencefalits.<br />
2.kriteriumebi _<br />
a)<strong>da</strong>ma<strong>da</strong>sturebeli _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis <strong>da</strong>ma<strong>da</strong>sturebeli<br />
kriteriumebia: <strong>aiv</strong> antisxeulebis arseboba sisxlis SratSi<br />
imunoblotingis meTodiT, <strong>aiv</strong> rnm-is raodenobrivad <strong>da</strong>/an <strong>aiv</strong><br />
provirus dnm-is Tvisobrivad aRmoCena sisxlSi polimerizaciis<br />
jaWvuri reaqciis meTodiT. lokaluri martivi herpesis disgnozi<br />
ismeba klinikurad, xolo diseminirebuli martivi herpesiT<br />
gamowveuli infeqciis diagnostikisTvis aucilebelia virusis<br />
kulturis gamoyofa, radio-imunoblotingis meTodi,<br />
imunofluoroescencia <strong>da</strong> monoklonuri antisxeulebiT testireba.<br />
herpesul encefalits mivyavarT Tavis tvinSi <strong>da</strong>zianebis mravlobiTi<br />
kerebis ganviTarebamde, romelic TvalsaCinoa CAT skanirebiT; aseve<br />
martivi herpesiT gamowveuli cns-is diagnostikisTvis gamoiyeneba Tavzurg-tvinis<br />
siTxeSi dnm-is aRmoCena pjr meodiT.<br />
b)gamomricxavi _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis gamomricxavi kriteriumebia: <strong>aiv</strong><br />
antisxeulebis ar arseboba sisxlis SratSi imunofermentuli<br />
meTodiT, raodenobrivad <strong>aiv</strong> rnm-is <strong>da</strong>/an Tvisobrivad <strong>aiv</strong> provirus<br />
dnm-is ar arseboba sisxlSi polimerizaciis jaWvuri reaqciis<br />
meTodiT. martivi herpesiT gamowveuli diseminirebuli infeqciis<br />
gamomricxavi kriteriumebia martivi herpesis virusis kulturis,<br />
radio-imunoblotingis meTodis, imunofluoroescenciis <strong>da</strong><br />
monoklonuri antisxeulebiT, Tav-zurg-tvinis siTxeSi martivi<br />
herpesis virusis dnm-ze pjr testirebis negatiuri Sedegi.<br />
3.simptomebi <strong>da</strong> niSnebi<br />
a)<strong>da</strong>ma<strong>da</strong>sturebeli _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidss paTognomuri <strong>klinikuri</strong><br />
niSnebi ar gaaCnia. igi miekuTvneba laboratoriulad sadiagnozo<br />
<strong>da</strong>avadebebs. simptomebi<strong>da</strong>n SeiZleba gamovyoT: gaxangrZlivebuli<br />
cxeleba, gaxangrZlivebuli faRaraTi, limfadenopaTia,<br />
aramotivirebuli profuzuli oflianoba, Zlieri saerTo sisuste,<br />
aramotivirebuli wonaSi kleba (erTi Tvis ganmavlobaSi sxeulis<br />
wonis 10% <strong>da</strong> meti), sxva<strong>da</strong>sxva gamonayari kansa <strong>da</strong> lorwovanze,<br />
kandidozuri ezofagiti, cns-is atipiuri <strong>da</strong>zianebebi <strong>da</strong> sxva.<br />
herpesuli gamonayari Cveulebriv warmodgenilia vezikulebiTa <strong>da</strong><br />
mtkvneuli eroziebiT, romlebic ganlagebulia piris irgvliv, cxviris<br />
nestoebze, tuCebsa <strong>da</strong> sasqeso organoebze. diseminirebuli martivi<br />
herpesiT gamowveuli infeqciis diagnozis <strong>da</strong>sma xSirad Znelia.<br />
saxezea meningitisa an/<strong>da</strong> meningoencefalitis suraTi, Sesabamisi<br />
cvlilebebiT CAT skanirebisas.<br />
b)gamomricxavi _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis gamomricxavi simptomebi ar<br />
arsebobs, <strong>aiv</strong> inficirebuli wlebis ganmavlobaSi SeiZleba Civilebs<br />
ar warmoadgendes. lokaluri <strong>da</strong> diseminirebuli martivi herpesiT<br />
166
gamowveuli infeqciis gamomricxavi faqtoria Sesabamisi Civilebisa <strong>da</strong><br />
simptomebis ar arseboba.<br />
4.diagnostikur _ laboratoriuli testebi <strong>da</strong> specialistTa<br />
konsultaciebi<br />
o CD3, CD4, CD8 limfocitebis absoluturi ricxvis gansazRvra, <strong>aiv</strong><br />
virusuli <strong>da</strong>tvirTvis gansazRvra polimerizaciis jaWvuri<br />
reaqciis meTodiT, sisxlis saerTo analizi, RviZlis funqciuri<br />
sinjebi, Tirkmlis funqciuri sinjebi, martivi herpesis virusis<br />
kulturis gamoyofa, martivi herpesis deteqcia radioimunoblotingis<br />
meTodi, imunofluoroescenciis an/<strong>da</strong><br />
monoklonuri antisxeulebiT testirebis meTodebiT, herpesul<br />
encefalitze eWvis SemTxvevebSi - Tavis tvinis MAC an MRI<br />
skanireba <strong>da</strong> Tav-zurg-tvinis siTxeSi martivi herpesis dnm-is<br />
aRmoCena pjr meTodiT.<br />
5. martivi herpesvirusuli infeqciis msubuqi formis<br />
<strong>mkurnaloba</strong><br />
antivirusuli<br />
agenti<br />
doza MmiRebis<br />
sixSire<br />
M miRebi<br />
gza<br />
mkurnalobis<br />
xangrZlivoba<br />
pirveli rigis sqemebi<br />
acikloviri 400 mg 3-jer dReSi PO 7-10 dRe<br />
an<br />
famcikloviri 250 mg 3-jer dReSi PO 7-10 dRe<br />
an<br />
valacikloviri 1 g 2-jer dReSi PO 7-10 dRe<br />
martivi herpesvirusuli infeqciis recidivis<br />
<strong>mkurnaloba</strong><br />
antivirusuli<br />
agenti<br />
doza MmiRebis<br />
sixSire<br />
M miRebi<br />
gza<br />
mkurnalobis<br />
xangrZlivoba<br />
pirveli rigis sqemebi<br />
acikloviri 800 mg 5-jer dReSi PO 7-10 dRe<br />
an<br />
famcikloviri 500 mg 3-jer dReSi PO 7-10 dRe<br />
an<br />
valacikloviri 1 g 2-jer dReSi per os 7-10 dRe<br />
martivi herpesvirusuli infeqciis mZime formis<br />
<strong>mkurnaloba</strong><br />
antivirusuli<br />
agenti<br />
doza MmiRebis<br />
sixSire<br />
M miRebis<br />
gza<br />
mkurnalobis<br />
xangrZlivoba<br />
pirveli rigis sqemebi<br />
acikloviri 10 mg/kg 3-jer dReSi IV 7-10 dRe<br />
an<br />
valacikloviri 1 g 2-jer dReSi PO 7-10 dRe<br />
167
martivi herpesvirusuli infeqciis mZime visceraluri formebis<br />
<strong>mkurnaloba</strong><br />
antivirusuli<br />
agenti<br />
doza MmiRebis<br />
sixSire<br />
M miRebi<br />
gza<br />
mkurnalobis<br />
xangrZlivoba<br />
pirveli rigis sqemebi<br />
acikloviri 10 mg/kg 3-jer dReSi IV 14-21 dRe<br />
meore rigis sqema<br />
foskarneti<br />
(aciklovirze<br />
rezistentobis<br />
SemTxvevebSi)<br />
40-60 mg/kg 3-jer dReSi IV 14 dRe<br />
7.gaidlaini, romelsac eyrdnoba aRniSnuli protokoli<br />
aRniSnuli protokoli eyrdnoba jan<strong>da</strong>cvis msoflio organizaciis 2006<br />
wlis gaidlains: “<strong>aiv</strong>/<strong>SidsiT</strong> <strong>da</strong>avadebul mozrdil <strong>da</strong> mozard pirebSi<br />
oportunistuli infeqciebis profilaqtika <strong>da</strong> <strong>mkurnaloba</strong>”, aseve<br />
protokoli Sejerebulia DHHS, USA-AIS <strong>da</strong> EACS 2005 wlis oportunistuli<br />
infeqciebis mkurnalobis gaidlainebTan.<br />
168
<strong>aiv</strong> <strong>infeqcia</strong>/Sidsis fonze ganviTarebuli<br />
marTvis saxelmwifo stan<strong>da</strong>rti (protokoli)<br />
sartyliseburi liqenis<br />
1.<strong>da</strong>avadebis /nozologiis / sindromis mokle ganmarteba _ <strong>aiv</strong><br />
<strong>infeqcia</strong>/Sidsi ewodeba a<strong>da</strong>mianis imunodeficitis virusiT gamowveul<br />
infeqciur <strong>da</strong>avadebas. <strong>da</strong>avadeba sartyliseburi liqenis gamomwvevia<br />
herpesis jgufis mesame tipis virusi Variccela zoster virus (VZV) . <strong>SidsiT</strong><br />
avadmyofebSi sartyliseburi liqeni multidermatomulia, persistirebs,<br />
axasiaTebs Zlieri tkivili <strong>da</strong> sisuste; SesaZloa moxdes infeqciis<br />
diseminacia kanis, nervuli sistemis, filtvebis, lorwovani garsebis<br />
CarTviT paTologiur procesSi.<br />
2.kriteriumebi _<br />
a)<strong>da</strong>ma<strong>da</strong>sturebeli _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis <strong>da</strong>ma<strong>da</strong>sturebeli kriteriumebia:<br />
<strong>aiv</strong> antisxeulebis arseboba sisxlis SratSi imunoblotingis meTodiT,<br />
<strong>aiv</strong> rnm-is raodenobrivad <strong>da</strong>/an <strong>aiv</strong> provirus dnm-is Tvisobrivad aRmoCena<br />
sisxlSi polimerizaciis jaWvuri reaqciis (pjr) meTodiT.<br />
sartylisebuli liqenis <strong>da</strong>ma<strong>da</strong>sturebeli kriteriumia <strong>da</strong>maxasiaTebeli<br />
vezikuluri gamonayaris arseboba dermatomis gaswvriv; cns-is<br />
<strong>da</strong>zianebisas Tav-zurg-tvinis siTxeSi VZV dnm-is aRmoCena pjr<br />
meTodiT.<br />
b)gamomricxavi _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis gamomricxavi kriteriumebia: <strong>aiv</strong><br />
antisxeulebis ar arseboba sisxlis SratSi imunofermentuli meTodiT,<br />
raodenobrivad <strong>aiv</strong> rnm-is <strong>da</strong>/an Tvisobrivad <strong>aiv</strong> provirus dnm-is ar<br />
arseboba sisxlSi polimerizaciis jaWvuri reaqciis meTodiT.<br />
sartyliseburi liqenis gamomricxavi kriteriumebia <strong>da</strong>maxasiaTebeli<br />
vezikuluri gamonayaris ar arseboba kanze.<br />
3.simptomebi <strong>da</strong> niSnebi<br />
a)<strong>da</strong>ma<strong>da</strong>sturebeli _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidss paTognomuri <strong>klinikuri</strong> niSnebi<br />
ar gaaCnia. igi miekuTvneba laboratoriulad sadiagnozo <strong>da</strong>avadebebs.<br />
simptomebi<strong>da</strong>n SeiZleba gamovyoT: gaxangrZlivebuli cxeleba,<br />
gaxangrZlivebuli faRaraTi, limfadenopaTia, aramotivirebuli<br />
profuzuli oflianoba, Zlieri saerTo sisuste, aramotivirebuli wonaSi<br />
kleba (erTi Tvis ganmavlobaSi sxeulis wonis 10% <strong>da</strong> meti), sxva<strong>da</strong>sxva<br />
gamonayari kansa <strong>da</strong> lorwovanze, kandidozuri ezofagiti, cns-is<br />
atipiuri <strong>da</strong>zianebebi <strong>da</strong> sxva. sartyliseburi liqenis dros saxezea<br />
vezikuluri gamonayari dermatomis gaswvriv, romelsac Tan axlavs<br />
Zlieri mtkivneuloba, zogjer cxeleba, regionuli limfadenopaTia,<br />
Zlieri sisuste; SesaZloa moxdes infeqciis diseminacia<br />
multidermatomuli formis ganviTarebiT, nervuli sistemis, filtvebis<br />
<strong>da</strong> lorwovani garsebis CarTviT paTologiur procesSi.<br />
b)gamomricxavi _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis gamomricxavi simptomebi ar<br />
arsebobs, <strong>aiv</strong> inficirebuli wlebis ganmavlobaSi SeiZleba Civilebs ar<br />
warmoadgendes. sartyliseburi liqenis gamomricxavi faqtoria Sesabamisi<br />
Civilebisa <strong>da</strong> simptomebis ar arseboba.<br />
4.diagnostikur _ laboratoriuli testebi <strong>da</strong> specialistTa<br />
konsultaciebi<br />
CD3, CD4, CD8 limfocitebis absoluturi ricxvis gansazRvra, <strong>aiv</strong><br />
virusuli <strong>da</strong>tvirTvis gansazRvra polimerizaciis jaWvuri reaqciis<br />
169
meTodiT, sisxlis saerTo analizi, RviZlis funqciuri sinjebi,<br />
Tirkmlis funqciuri sinjebi, VZV sawinaaRmdego antisxeulebis<br />
gansazRvra sisxlSi (IgM <strong>da</strong> IgG klasis), cns-is <strong>da</strong>zianebisas VZV dnm-is<br />
aRmoCena Tav-zurg-tvinis siTxeSi pjr meTodiT.<br />
5.sartyliseburi liqenis sxva<strong>da</strong>sxva formebis <strong>mkurnaloba</strong><br />
sartyliseburi liqenis (kanis formis) <strong>mkurnaloba</strong><br />
antivirusuli<br />
agenti<br />
doza MmiRebis<br />
sixSire<br />
M miRebi<br />
gza<br />
mkurnalobis<br />
xangrZlivoba<br />
pirveli rigis sqemebi<br />
acikloviri 800 mg 5-jer dReSi PO 7-10 dRe an<br />
vezikulis<br />
gaSrobamdeE<br />
an<br />
famcikloviri 500 mg 3-jer dReSi PO 7-10 dRe<br />
an<br />
valacikloviri 1 g 3-jer dReSi PO 7-10 dRe<br />
Tvalis sartyliseburi liqenis, infeqciis diseminirebuli <strong>da</strong> visceruli<br />
formebis <strong>mkurnaloba</strong><br />
antivirusuli<br />
agenti<br />
doza MmiRebis<br />
sixSire<br />
M miRebi<br />
gza<br />
mkurnalobis<br />
xangrZlivoba<br />
pirveli rigis sqemebi<br />
acikloviri 10 mg/kg 3-jer dReSi IV 7-10 dRe<br />
an<br />
valacikloviri 1 gr 3-jer dReSi PO 7-10 dRe<br />
an<br />
famcikloviri 500 mg 3-jer dReSi PO 7-10 dRe<br />
meore rigis sqema<br />
foskarneti<br />
60 mg/kg<br />
an<br />
40 mg/kg<br />
2-jer dReSi<br />
an<br />
3-jer dReSi<br />
170<br />
IV<br />
7-10 dRe<br />
6.reabilitacia <strong>da</strong> <strong>da</strong>kvirveba<br />
post-herpesuli nevralgia xSiri <strong>da</strong> seriozuli problemaa. <strong>da</strong>zianebul<br />
dermatomebSi viTardeba Zlieri tkivili.<br />
tkivilis kontroli mniSvnelovania <strong>da</strong> tkivilis kupirebis mizniT<br />
iniSneba arasteroidul anTebis sawinaaRmdego preparatebi.<br />
Tu tkivili gaxangrZliv<strong>da</strong> iniSneba amitriptilini, karbamazepini an<br />
fenitoini.<br />
7.gaidlaini, romelsac eyrdnoba aRniSnuli protokoli<br />
aRniSnuli protokoli eyrdnoba jan<strong>da</strong>cvis msoflio organizaciis 2006<br />
wlis gaidlains: “<strong>aiv</strong>/<strong>SidsiT</strong> <strong>da</strong>avadebul mozrdil <strong>da</strong> mozard pirebSi<br />
oportunistuli infeqciebis profilaqtika <strong>da</strong> <strong>mkurnaloba</strong>”, aseve<br />
protokoli Sejerebulia DHHS, USA-AIS <strong>da</strong> EACS 2005 wlis oportunistuli<br />
infeqciebis mkurnalobis gaidlainebTan.
<strong>aiv</strong> <strong>infeqcia</strong>/Sidsis fonze ganviTarebuli citomegalovirusuli<br />
infeqciis marTvis saxelmwifo stan<strong>da</strong>rti (protokoli)<br />
1.<strong>da</strong>avadebis /nozologiis / sindromis mokle ganmarteba _ <strong>aiv</strong><br />
<strong>infeqcia</strong>/Sidsi ewodeba a<strong>da</strong>mianis imunodeficitis virusiT gamowveul<br />
infeqciur <strong>da</strong>avadebas. citomegalovirusuli <strong>da</strong>avadebis gamomwvevia<br />
herpesis jgufis me-4 tipis virusi CMV. <strong>SidsiT</strong> avadmyofebSi<br />
citomegalovirusma Sieleba <strong>da</strong>azaianos sxva<strong>da</strong>sxa organoebi <strong>da</strong><br />
sistemebi.<br />
2.kriteriumebi _<br />
a)<strong>da</strong>ma<strong>da</strong>sturebeli _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis <strong>da</strong>ma<strong>da</strong>sturebeli kriteriumebia:<br />
<strong>aiv</strong> antisxeulebis arseboba sisxlis SratSi imunoblotingis meTodiT,<br />
<strong>aiv</strong> rnm-is raodenobrivad <strong>da</strong>/an <strong>aiv</strong> provirus dnm-is Tvisobrivad aRmoCena<br />
sisxlSi polimerizaciis jaWvuri reaqciis meTodiT. citomegalovirusis<br />
deteqciisTvis gamoiyeneba misi adreuli antigenis pp65 aRmoCena sisxlSi;<br />
pacientebs, romelTa CD4
)gamomricxavi _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis gamomricxavi simptomebi ar<br />
arsebobs, <strong>aiv</strong> inficirebuli wlebis ganmavlobaSi SeiZleba Civilebs ar<br />
warmoadgendes. citomegalovirusuli infeqciis gamomricxavi faqtoria<br />
Sesabamisi Civilebisa <strong>da</strong> simptomebis ar arseboba.<br />
4.diagnostikur _ laboratoriuli testebi <strong>da</strong> specialistTa<br />
konsultaciebi<br />
CD3, CD4, CD8 limfocitebis absoluturi ricxvis gansazRvra, <strong>aiv</strong><br />
virusuli <strong>da</strong>tvirTvis gansazRvra polimerizaciis jaWvuri reaqciis<br />
meTodiT, sisxlis saerTo analizi, RviZlis funqciuri sinjebi,<br />
Tirkmlis funqciuri sinjebi, CMV pp65 adreuli antigenis aRmoCena<br />
sisxlSi, <strong>da</strong>zianebuli organoebis bioptatis gamokvleva, CMV dnm-is<br />
aRmoCena pjr meTodiT, ofTalmologis konsultacia,<br />
gastroenterologis konsultacia, nevropaTologis konsultacia.<br />
5.citomegalovirusuli infeqciebis sxva<strong>da</strong>sxva formebis <strong>mkurnaloba</strong><br />
citomegalovirusuli infeqciiT gamowveuli kuW-nawlavis traqtisa <strong>da</strong><br />
cns-is <strong>da</strong>zianebebis <strong>da</strong> retinitis <strong>mkurnaloba</strong><br />
antivirusuli<br />
agenti<br />
doza MmiRebis<br />
sixSire<br />
M miRebi<br />
gza<br />
mkurnalobis<br />
xangrZlivoba<br />
pirveli rigis sqema<br />
gancikloviri 5 mg/kg 2-jer dReSi IV 2-3 kvira<br />
meoradi profilaqtikisTvis aucilebelia gancikloviriT 5 mg/kg IV<br />
dReSi <strong>mkurnaloba</strong>.<br />
citomegalovirusuli infeqciiT gamowveuli kuW-nawlavis traqtisa <strong>da</strong><br />
cns-is <strong>da</strong>zianebebis <strong>mkurnaloba</strong><br />
antivirusuli<br />
agenti<br />
doza MmiRebis<br />
sixSire<br />
M miRebi<br />
gza<br />
mkurnalobis<br />
xangrZlivoba<br />
meore rigis sqemebi<br />
foskarneti 90 mg/kg 2-jer dReSi IV 3 kvira<br />
meoradi profialqtikisTvis aucilebelia foskarnetiT mkurnalobis<br />
xangrZlivi kursi doziT 90mg/kg IV erTxel dReSi.<br />
172
6.reabilitacia <strong>da</strong> <strong>da</strong>kvirveba<br />
citomegalovirusuli retinitis meoradi profilaqtika<br />
antivirusuli<br />
agenti<br />
doza MmiRebis<br />
sixSire<br />
M miRebi<br />
gza<br />
meore rigis sqemebi<br />
Tvalis implantanti, romelic gamoyofs ganciklovirs<br />
+<br />
valgancikloviri 900 mg<br />
erTxel<br />
dReSi<br />
mkurnalobis<br />
xangrZlivoba<br />
PO manamde sanam CD4<br />
ujredebi ricxvi ar<br />
moimatebs 100-150 mm3<br />
minimum 3 Tvis<br />
ganmavlobaSi<br />
meoradi profilaqtikis Sewyveta SesaZlebelia 6 Tvis Semdeg <strong>da</strong><br />
imunorekonstituciisas - CD4 100-150 mm3.<br />
7.gaidlaini, romelsac eyrdnoba aRniSnuli protokoli<br />
aRniSnuli protokoli eyrdnoba jan<strong>da</strong>cvis msoflio organizaciis 2006<br />
wlis gaidlains: “<strong>aiv</strong>/<strong>SidsiT</strong> <strong>da</strong>avadebul mozrdil <strong>da</strong> mozard pirebSi<br />
oportunistuli infeqciebis profilaqtika <strong>da</strong> <strong>mkurnaloba</strong>”, aseve<br />
protokoli Sejerebulia DHHS, USA-AIS <strong>da</strong> EACS 2005 wlis oportunistuli<br />
infeqciebis mkurnalobis gaidlainebTan.<br />
\<br />
173
<strong>aiv</strong> <strong>infeqcia</strong>/Sidsis fonze ganviTarebuli dermatomikozebis marTvis<br />
saxelmwifo stan<strong>da</strong>rti (protokoli)<br />
1.<strong>da</strong>avadebis /nozologiis / sindromis mokle ganmarteba _ <strong>aiv</strong><br />
<strong>infeqcia</strong>/Sidsi ewodeba a<strong>da</strong>mianis imunodeficitis virusiT gamowveul<br />
infeqciur <strong>da</strong>avadebas. dermatomikozebi ewodeba kanis sokovan <strong>da</strong>zianebas,<br />
romelic SeiZleba gaCndes sxeulis nebismier adgilze, gamonayari<br />
mSralia, aqercvladi, Tan axlavs qavili.<br />
2.kriteriumebi _<br />
a)<strong>da</strong>ma<strong>da</strong>sturebeli _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis <strong>da</strong>ma<strong>da</strong>sturebeli kriteriumebia:<br />
<strong>aiv</strong> antisxeulebis arseboba sisxlis ratSi imunoblotingis meTodiT, <strong>aiv</strong><br />
rnm-is raodenobrivad <strong>da</strong>/an <strong>aiv</strong> provirus dnm-is Tvisobrivad aRmoCena<br />
sisxlSi polimerizaciis jaWvuri reaqciis meTodiT. dermatomikozebis<br />
<strong>da</strong><strong>da</strong>sturebisTvis aucilebelia <strong>da</strong>zianebuli kanis anafxekis<br />
mikroskopuli gamokvleva.<br />
b)gamomricxavi _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis gamomricxavi kriteriumebia: <strong>aiv</strong><br />
antisxeulebis ar arseboba sisxlis SratSi imunofermentuli meTodiT,<br />
raodenobrivad <strong>aiv</strong> rnm-is <strong>da</strong>/an Tvisobrivad <strong>aiv</strong> provirus dnm-is ar<br />
arseboba sisxlSi polimerizaciis jaWvuri reaqciis meTodiT.<br />
dermatomikozis gamomricxavi kriteriumia <strong>da</strong>zianebuli kanis anafxekis<br />
mikroskopiiT gamomnvevis ar arseboba.<br />
3.simptomebi <strong>da</strong> niSnebi<br />
a)<strong>da</strong>ma<strong>da</strong>sturebeli _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidss paTognomuri <strong>klinikuri</strong> niSnebi<br />
ar gaaCnia. igi miekuTvneba laboratoriulad sadiagnozo <strong>da</strong>avadebebs.<br />
simptomebi<strong>da</strong>n SeiZleba gamovyoT: gaxangrZlivebuli cxeleba,<br />
gaxangrZlivebuli faRaraTi, limfadenopaTia, aramotivirebuli<br />
profuzuli oflianoba, Zlieri saerTo sisuste, aramotivirebuli wonaSi<br />
kleba (erTi Tvis ganmavlobaSi sxeulis wonis 10% <strong>da</strong> meti), sxva<strong>da</strong>sxva<br />
gamonayari kansa <strong>da</strong> lorwovanze, kandidozuri ezofagiti, cns-is<br />
atipiuri <strong>da</strong>zianebebi <strong>da</strong> sxva. dermatomikozebis dros saxezea sxeulis<br />
nebismier adgilze ganviTarebuli mSrali <strong>da</strong> aqercvladi ubani,<br />
romelsac Tan axlavs qavili.<br />
b)gamomricxavi _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis gamomricxavi simptomebi ar<br />
arsebobs, <strong>aiv</strong> inficirebuli wlebis ganmavlobaSi SeiZleba Civilebs ar<br />
warmoadgendes. dermatomikozis gamomricxavi faqtoria Sesabamisi<br />
gamonayaris ar arseboba kanze.<br />
4.diagnostikur _ laboratoriuli testebi <strong>da</strong> specialistTa<br />
konsultaciebi<br />
CD3, CD4, CD8 limfocitebis absoluturi ricxvis gansazRvra, <strong>aiv</strong><br />
virusuli <strong>da</strong>tvirTvis gansazRvra polimerizaciis jaWvuri reaqciis<br />
meTodiT, sisxlis saerTo analizi, RviZlis funqciuri sinjebi,<br />
Tirkmlis funqciuri sinjebi, virusli hepatitebis diagnostika, kanis<br />
174
<strong>da</strong>zianebuli ubnis anafxekis mikroskopuli <strong>da</strong>Tvaliereba, dermatologis<br />
konsultacia.<br />
5. dermatomikozebis <strong>mkurnaloba</strong><br />
antifungaluri doza<br />
preparati<br />
pirveli rigis sqemebi<br />
Mmikonazoli<br />
(adgilobrivad<br />
gamoyenebisTvis)<br />
klotrimazoli<br />
(adgilobrivad<br />
gamoyenebisTvis)<br />
MmiRebis<br />
sixSire<br />
3-jer dReSi<br />
meore rigis sqemebi<br />
ketokonazoli 200 mg dReSi<br />
erTxel<br />
an<br />
itrakonazoli 100 mg dReSi<br />
erTxel<br />
M miRebi<br />
gza<br />
Aadgilobrivad 21 dRe<br />
an<br />
3-jer dReSi adgilobrivad 21 dRe<br />
PO<br />
PO<br />
mkurnalobis<br />
xangrZlivoba<br />
1-3 Tve<br />
1-3 Tve<br />
7.gaidlaini, romelsac eyrdnoba aRniSnuli protokoli<br />
aRniSnuli protokoli eyrdnoba jan<strong>da</strong>cvis msoflio organizaciis 2006<br />
wlis gaidlains: “<strong>aiv</strong>/<strong>SidsiT</strong> <strong>da</strong>avadebul mozrdil <strong>da</strong> mozard pirebSi<br />
oportunistuli infeqciebis profilaqtika <strong>da</strong> <strong>mkurnaloba</strong>”, aseve<br />
protokoli Sejerebulia DHHS, USA-AIS <strong>da</strong> EACS 2005 wlis oportunistuli<br />
infeqciebis mkurnalobis gaidlainebTan.<br />
175
<strong>aiv</strong> <strong>infeqcia</strong>/Sidsis fonze ganviTarebuli oniqomikozebis marTvis<br />
saxelmwifo stan<strong>da</strong>rti (protokoli)<br />
1.<strong>da</strong>avadebis /nozologiis / sindromis mokle ganmarteba _ <strong>aiv</strong><br />
<strong>infeqcia</strong>/Sidsi ewodeba a<strong>da</strong>mianis imunodeficitis virusiT gamowveul<br />
infeqciur <strong>da</strong>avadebas. oniqomikozebi warmoadgens frCxilis sokovan<br />
<strong>da</strong>zianebebs, romlebic iwveven frCxilis firfitebis deformaciasa <strong>da</strong><br />
rRvevas.<br />
kriteriumebi _<br />
a)<strong>da</strong>ma<strong>da</strong>sturebeli _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis <strong>da</strong>ma<strong>da</strong>sturebeli<br />
kriteriumebia: <strong>aiv</strong> antisxeulebis arseboba sisxlis SratSi<br />
imunoblotingis meTodiT, <strong>aiv</strong> rnm-is raodenobrivad <strong>da</strong>/an <strong>aiv</strong><br />
provirus dnm-is Tvisobrivad aRmoCena sisxlSi polimerizaciis<br />
jaWvuri reaqciis meTodiT. oniqomikozebis <strong>da</strong>ma<strong>da</strong>sturebeli<br />
kriteriumia gamomwvevis aRmoCena frCxilis firfitis qvevi<strong>da</strong>n<br />
aRebul <strong>da</strong> kaliumis hidroqsidiT <strong>da</strong>muSavebul masalaSi<br />
mikroskopuli gamokvleviT.<br />
b)gamomricxavi _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis gamomricxavi kriteriumebia: <strong>aiv</strong><br />
antisxeulebis ar arseboba sisxlis SratSi imunofermentuli<br />
meTodiT, raodenobrivad <strong>aiv</strong> rnm-is <strong>da</strong>/an Tvisobrivad <strong>aiv</strong> provirus<br />
dnm-is ar arseboba sisxlSi polimerizaciis jaWvuri reaqciis<br />
meTodiT. oniqomikozebis gamomricxavi kriteriumia <strong>da</strong>zianebuli<br />
frCxilis firfitis qvevi<strong>da</strong>n aRebul <strong>da</strong> kaliumis hidroqsidiT<br />
<strong>da</strong>muSavebul masalaSi gamomwvevis ar arseboba mikroskopuli<br />
<strong>da</strong>TvalierebiT.<br />
3.simptomebi <strong>da</strong> niSnebi<br />
a)<strong>da</strong>ma<strong>da</strong>sturebeli _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidss paTognomuri <strong>klinikuri</strong> niSnebi<br />
ar gaaCnia. igi miekuTvneba laboratoriulad sadiagnozo <strong>da</strong>avadebebs.<br />
simptomebi<strong>da</strong>n SeiZleba gamovyoT: gaxangrZlivebuli cxeleba,<br />
gaxangrZlivebuli faRaraTi, limfadenopaTia, aramotivirebuli<br />
profuzuli oflianoba, Zlieri saerTo sisuste, aramotivirebuli wonaSi<br />
kleba (erTi Tvis ganmavlobaSi sxeulis wonis 10% <strong>da</strong> meti), sxva<strong>da</strong>sxva<br />
gamonayari kansa <strong>da</strong> lorwovanze, kandidozuri ezofagiti, cns-is<br />
atipiuri <strong>da</strong>zianebebi <strong>da</strong> sxva. oniqomikozebi iwveven frCxilis<br />
firfitebis deformaciasa <strong>da</strong> rRvevas.<br />
b)gamomricxavi _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis gamomricxavi simptomebi ar<br />
arsebobs, <strong>aiv</strong> inficirebuli wlebis ganmavlobaSi SeiZleba Civilebs ar<br />
warmoadgendes. oniqomikozebis gamomricxavi faqtoria Sesabamisi<br />
Civilebisa <strong>da</strong> simptomebis ar arseboba.<br />
4.diagnostikur _ laboratoriuli testebi <strong>da</strong> specialistTa<br />
konsultaciebi<br />
CD3, CD4, CD8 limfocitebis absoluturi ricxvis gansazRvra, <strong>aiv</strong><br />
virusuli <strong>da</strong>tvirTvis gansazRvra polimerizaciis jaWvuri reaqciis<br />
176
meTodiT, sisxlis saerTo analizi, RviZlis funqciuri sinjebi,<br />
Tirkmlis funqciuri sinjebi, virusuli hepatitis markerebi, masalis<br />
aReba <strong>da</strong>zianebuli frCxilis firfitis qvevi<strong>da</strong>n, kaliumis hidroqsidiT<br />
<strong>da</strong>muSaveba <strong>da</strong> mikroskopuli <strong>da</strong>Tvaliereba, dermatologis konultacia.<br />
5. oniqomikozebis <strong>mkurnaloba</strong><br />
pirveli rigis sqemebi<br />
antifungaluri<br />
preparati<br />
doza MmiRebis<br />
sixSire<br />
MmiRebi<br />
gza<br />
terbinafini 250 mg dReSi PO<br />
erTxel<br />
mkurnalobis<br />
xangrZlivoba<br />
6 kvira xelis<br />
TiTebis<br />
<strong>da</strong>zianebisas an<br />
12 kvira fexis<br />
TiTebis<br />
<strong>da</strong>zianebisas<br />
an<br />
itrakonazoli 200 mg 2-jer dReSi PO yoveli Tvis I<br />
kviris<br />
ganmavlobaSi 2<br />
Tvis manZilze<br />
(xelis TiTebis<br />
<strong>da</strong>zianebisas),<br />
3-4 Tve (fexis<br />
TiTebi<br />
<strong>da</strong>zianebisas)<br />
7.gaidlaini, romelsac eyrdnoba aRniSnuli protokoli<br />
aRniSnuli protokoli eyrdnoba jan<strong>da</strong>cvis msoflio organizaciis 2006<br />
wlis gaidlains: “<strong>aiv</strong>/<strong>SidsiT</strong> <strong>da</strong>avadebul mozrdil <strong>da</strong> mozard pirebSi<br />
oportunistuli infeqciebis profilaqtika <strong>da</strong> <strong>mkurnaloba</strong>”, aseve<br />
protokoli Sejerebulia DHHS, USA-AIS <strong>da</strong> EACS 2005 wlis oportunistuli<br />
infeqciebis mkurnalobis gaidlainebTan.<br />
177
<strong>aiv</strong> <strong>infeqcia</strong>/Sidsis fonze ganviTarebuli<br />
marTvis saxelmwifo stan<strong>da</strong>rti (protokoli)<br />
seboreuli dermatitis<br />
1.<strong>da</strong>avadebis /nozologiis / sindromis mokle ganmarteba _ <strong>aiv</strong><br />
<strong>infeqcia</strong>/Sidsi ewodeba a<strong>da</strong>mianis imunodeficitis virusiT gamowveul<br />
infeqciur <strong>da</strong>avadebas. varaudoben, rom seboreuli dermatitis<br />
gamomwvevia soko Pitysporu ovale (aseve cnobilia rogorc Malassezia furfur).<br />
elementi warmoadgens wiTeli feris laqas, romelic iqercleba.<br />
2.kriteriumebi _<br />
a)<strong>da</strong>ma<strong>da</strong>sturebeli _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis <strong>da</strong>ma<strong>da</strong>sturebeli kriteriumebia:<br />
<strong>aiv</strong> antisxeulebis arseboba sisxlis SratSi imunoblotingis meTodiT,<br />
<strong>aiv</strong> rnm-is raodenobrivad <strong>da</strong>/an <strong>aiv</strong> provirus dnm-is Tvisobrivad aRmoCena<br />
sisxlSi polimerizaciis jaWvuri reaqciis meTodiT. seboreuli<br />
dermatitis diagnozi <strong>da</strong>sturdeba sokos aRmoCeniT kanis <strong>da</strong>zianebuli<br />
ubni<strong>da</strong>n anafxeki masalis mikroskopuli gamokvlevisas.<br />
b)gamomricxavi _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis gamomricxavi kriteriumebia: <strong>aiv</strong><br />
antisxeulebis ar arseboba sisxlis SratSi imunofermentuli meTodiT,<br />
raodenobrivad <strong>aiv</strong> rnm-is <strong>da</strong>/an Tvisobrivad <strong>aiv</strong> provirus dnm-is ar<br />
arseboba sisxlSi polimerizaciis jaWvuri reaqciis meTodiT. seboreuli<br />
dermatitis diagnozi gamoiricxeba, Tu kanis <strong>da</strong>zianebuli ubni<strong>da</strong>n<br />
anafxeki masalis mikroskopuli gamokvlevisas gamomwvevi ar aRmoCndeba.<br />
3.simptomebi <strong>da</strong> niSnebi<br />
a)<strong>da</strong>ma<strong>da</strong>sturebeli _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidss paTognomuri <strong>klinikuri</strong> niSnebi<br />
ar gaaCnia. igi miekuTvneba laboratoriulad sadiagnozo <strong>da</strong>avadebebs.<br />
simptomebi<strong>da</strong>n SeiZleba gamovyoT: gaxangrZlivebuli cxeleba,<br />
gaxangrZlivebuli faRaraTi, limfadenopaTia, aramotivirebuli<br />
profuzuli oflianoba, Zlieri saerTo sisuste, aramotivirebuli wonaSi<br />
kleba (erTi Tvis ganmavlobaSi sxeulis wonis 10% <strong>da</strong> meti), sxva<strong>da</strong>sxva<br />
gamonayari kansa <strong>da</strong> lorwovanze, kandidozuri ezofagiti, cns-is<br />
atipiuri <strong>da</strong>zianebebi <strong>da</strong> sxva. seboreuli dermatitis dros saxezea<br />
aqerclili wiTeli feris laqa saxeze, cxviris nestoebis irgvliv,<br />
cxvir-tuCis naoWze, warbebze, Tavis Tmian nawilze, gul-mkerdis areSi<br />
iRliebSi, tanis ze<strong>da</strong> nawilsa <strong>da</strong> sazardulis areSi.<br />
b)gamomricxavi _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis gamomricxavi simptomebi ar<br />
arsebobs, <strong>aiv</strong> inficirebuli wlebis ganmavlobaSi SeiZleba Civilebs ar<br />
warmoadgendes. seboreuli dermatitis gamomricxavi faqtoria Sesabamisi<br />
Civilebisa <strong>da</strong> simptomebis ar arseboba.<br />
4.diagnostikur _ laboratoriuli testebi <strong>da</strong> specialistTa<br />
konsultaciebi<br />
CD3, CD4, CD8 limfocitebis absoluturi ricxvis gansazRvra, <strong>aiv</strong><br />
virusuli <strong>da</strong>tvirTvis gansazRvra polimerizaciis jaWvuri reaqciis<br />
meTodiT, sisxlis saerTo analizi, RviZlis funqciuri sinjebi,<br />
178
Tirkmlis funqciuri sinjebi, virusuli hepatitis markerebi, <strong>da</strong>zianebuli<br />
kanis anafxekis mikroskopuli gamokvleva, dermatologis konsultacia.<br />
5.seboreuli dermatitis <strong>mkurnaloba</strong><br />
rekomendebulia <strong>da</strong>zianebuli ubnebis xSirad <strong>da</strong>bana qerclis<br />
mosaSoreblad,<br />
karg Sedegs iZleva selenis sulfidis Semcveli samkurnalo Sampunebis<br />
gamoyeneba.<br />
SesaZloa yvelaze efeqturi aRmoCndes hidrokortizonis 1%-ani mazis<br />
aplikaciebi. aseve karg Sedegs iZleva ketokonazolis 2%-ani kremi.<br />
7.gaidlaini, romelsac eyrdnoba aRniSnuli protokoli<br />
aRniSnuli protokoli eyrdnoba jan<strong>da</strong>cvis msoflio organizaciis 2006<br />
wlis gaidlains: “<strong>aiv</strong>/<strong>SidsiT</strong> <strong>da</strong>avadebul mozrdil <strong>da</strong> mozard pirebSi<br />
oportunistuli infeqciebis profilaqtika <strong>da</strong> <strong>mkurnaloba</strong>”, aseve<br />
protokoli Sejerebulia DHHS, USA-AIS <strong>da</strong> EACS 2005 wlis oportunistuli<br />
infeqciebis mkurnalobis gaidlainebTan.<br />
179
<strong>aiv</strong> <strong>infeqcia</strong>/Sidsis fonze ganviTarebuli munis marTvis<br />
saxelmwifo stan<strong>da</strong>rti (protokoli)<br />
1.<strong>da</strong>avadebis /nozologiis / sindromis mokle ganmarteba _ <strong>aiv</strong><br />
<strong>infeqcia</strong>/Sidsi ewodeba a<strong>da</strong>mianis imunodeficitis virusiT gamowveul<br />
infeqciur <strong>da</strong>avadebas. <strong>da</strong>avadeba munis gamomwvevia tkipa Sarkoptes scabiei.<br />
mdedr tkipas kanSi gahyavs gasasvleli, romelsac aqvs ramodenime sm<br />
sigrZis ze<strong>da</strong>piri<strong>da</strong>n wamoweuli wiTeli nawiburis Sesaxe<strong>da</strong>oba. mdedri<br />
tkipa gayvanil gasasvlelSi debs kvercxebs <strong>da</strong> Semdeg ga<strong>da</strong>adgildeba<br />
sxeulis sxva nawilSi. kvercxebi<strong>da</strong>n gamodis tkipebis axali Taoba,<br />
romlebic izrdebian, jvardebian, gahyavT axali gasasvlelebi <strong>da</strong> deben<br />
axal kvercxebs.<br />
2.kriteriumebi _<br />
a)<strong>da</strong>ma<strong>da</strong>sturebeli _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis <strong>da</strong>ma<strong>da</strong>sturebeli<br />
kriteriumebia: <strong>aiv</strong> antisxeulebis arseboba sisxlis SratSi<br />
imunoblotingis meTodiT, <strong>aiv</strong> rnm-is raodenobrivad <strong>da</strong>/an <strong>aiv</strong><br />
provirus dnm-is Tvisobrivad aRmoCena sisxlSi polimerizaciis<br />
jaWvuri reaqciis meTodiT. munis diagnozi diagnozi ismeba<br />
<strong>klinikuri</strong> gamovlinebebisa <strong>da</strong> <strong>da</strong>zianebuli keris anafxekis<br />
mikroskopuli gamokvlevis safuZvelze. mikroskopiisas aRmoCndeba<br />
tkipebi an/<strong>da</strong> maTi kvercxebi.<br />
b)gamomricxavi _ <strong>aiv</strong> <strong>infeqcia</strong> /Sidsis gamomricxavi kriteriumebia: <strong>aiv</strong><br />
antisxeulebis ar arseboba sisxlis SratSi imunofermentuli<br />
meTodiT, raodenobrivad <strong>aiv</strong> rnm-is <strong>da</strong>/an Tvisobrivad <strong>aiv</strong> provirus<br />
dnm-is ar arseboba sisxlSi polimerizaciis jaWvuri reaqciis<br />
meTodiT. munis gamomricxavi kriteriumebia anafxekis mikroskopisas<br />
tkipebis an/<strong>da</strong> maTi kvercxebis ar arseboba.<br />
3.simptomebi <strong>da</strong> niSnebi<br />
a)<strong>da</strong>ma<strong>da</strong>sturebeli _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidss paTognomuri <strong>klinikuri</strong><br />
niSnebi ar gaaCnia. igi miekuTvneba laboratoriulad sadiagnozo<br />
<strong>da</strong>avadebebs. simptomebi<strong>da</strong>n SeiZleba gamovyoT: gaxangrZlivebuli<br />
cxeleba, gaxangrZlivebuli faRaraTi, limfadenopaTia,<br />
aramotivirebuli profuzuli oflianoba, Zlieri saerTo sisuste,<br />
aramotivirebuli wonaSi kleba (erTi Tvis ganmavlobaSi sxeulis<br />
wonis 10% <strong>da</strong> meti), sxva<strong>da</strong>sxva gamonayari kansa <strong>da</strong> lorwovanze,<br />
kandidozuri ezofagiti, cns-is atipiuri <strong>da</strong>zianebebi <strong>da</strong> sxva. munis<br />
dros kanqveSa gasasvlelis adgilze viTardeba gamonayari, romelic<br />
xSirad gvxvdeba:<br />
o xelebze - mtevnebze (gansakuTrebiT TiTebs Soris),<br />
o majis, i<strong>da</strong>yvis, muxlismomxrel ze<strong>da</strong>pirebze,<br />
o winamxris i<strong>da</strong>yviskena ze<strong>da</strong>pirze,<br />
o sasqeso asoze,<br />
o sarZeve jirkvlebsa <strong>da</strong><br />
o beWebze.<br />
o avadmyofs ZiriTa<strong>da</strong>d awuxebs tanis Zlieri qavili, gansakuTrebiT<br />
RamiT.<br />
180
o imunodeficitis mqone pacientebs xSirad uviTardebaT munis mZime<br />
forma, romelsac uwodeben norvegiuls. misTvis <strong>da</strong>maxasiaTebelia<br />
vezikuluri gamonayari <strong>da</strong> sqeli fufxebis warmoqmna mTel<br />
sxeulze. munis am formis dros qavili ar aris gamoxatuli.<br />
o qavilis gamo muni xSirad rTuldeba meoradi infeqciebiT.<br />
b)gamomricxavi _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis gamomricxavi simptomebi ar<br />
arsebobs, <strong>aiv</strong> inficirebuli wlebis ganmavlobaSi SeiZleba Civilebs ar<br />
warmoadgendes. munis gamomricxavi faqtoria Sesabamisi Civilebisa <strong>da</strong><br />
simptomebis ar arseboba.<br />
4.diagnostikur _ laboratoriuli testebi <strong>da</strong> specialistTa<br />
konsultaciebi<br />
CD3, CD4, CD8 limfocitebis absoluturi ricxvis gansazRvra, <strong>aiv</strong><br />
virusuli <strong>da</strong>tvirTvis gansazRvra polimerizaciis jaWvuri reaqciis<br />
meTodiT, sisxlis saerTo analizi, RviZlis funqciuri sinjebi,<br />
Tirkmlis funqciuri sinjebi, virusuli hepatitis markerebi, <strong>da</strong>zianebuli<br />
keris anafxekis mikroskopuli Seswavla, dermatologis konsultacia.<br />
A5.munis <strong>mkurnaloba</strong>A<br />
AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA<br />
SerCevis preparats warmoadgens adgilobrivad gamosayenebeli 1%-ani<br />
gamabenzen heqsaqloridi, romelic ismeba mTels tanze, Tavis gar<strong>da</strong>,<br />
mozrdilebSi Camoibaneba 24 sT-Si , xolo bavSvebSi_8sT-Si. sakmarisia<br />
erTjeradi <strong>da</strong>muSaveba.<br />
aseve SesaZlebelia kanis <strong>da</strong>muSaveba 1%-ani permetriniT an 1%-ani<br />
lin<strong>da</strong>niT; es preparatebic ismeba mTels tanze <strong>da</strong> Camoibaneba 8 sT-Si.<br />
permetrinisa <strong>da</strong> lin<strong>da</strong>nis gamoyeneba ar SeiZleba orsulebisaTvis,<br />
meZuZuri dedebisa <strong>da</strong> bavSvebisaTvis.<br />
norvegiuli munis samkurnalod, imunodeficitis mqone pacientebSi,<br />
efeqturia ivermeqtini, 200 mg/kg PO erTjera<strong>da</strong>d.<br />
tansacmeli, TeTreuli <strong>da</strong> pirsaxocebi un<strong>da</strong> gamoixarSos <strong>da</strong> <strong>da</strong>uTovdes<br />
gaSrobis Semdeg.<br />
munis <strong>mkurnaloba</strong> un<strong>da</strong> Cautardes sqesobriv partniors <strong>da</strong> yvelas vinc<br />
sayofacxovrebo kontaqtSi iyo <strong>avadmyofTa</strong>n.<br />
7.gaidlaini, romelsac eyrdnoba aRniSnuli protokoli<br />
aRniSnuli protokoli eyrdnoba jan<strong>da</strong>cvis msoflio organizaciis 2006<br />
wlis gaidlains: “<strong>aiv</strong>/<strong>SidsiT</strong> <strong>da</strong>avadebul mozrdil <strong>da</strong> mozard pirebSi<br />
oportunistuli infeqciebis profilaqtika <strong>da</strong> <strong>mkurnaloba</strong>”, aseve<br />
protokoli Sejerebulia DHHS, USA-AIS <strong>da</strong> EACS 2005 wlis oportunistuli<br />
infeqciebis mkurnalobis gaidlainebTan.<br />
181
<strong>aiv</strong> <strong>infeqcia</strong>/Sidsis fonze ganviTarebuli stafilokokuri<br />
folikulitis marTvis saxelmwifo stan<strong>da</strong>rti (protokoli)<br />
1.<strong>da</strong>avadebis /nozologiis / sindromis mokle ganmarteba _ <strong>aiv</strong><br />
<strong>infeqcia</strong>/Sidsi ewodeba a<strong>da</strong>mianis imunodeficitis virusiT gamowveul<br />
infeqciur <strong>da</strong>avadebas. folikuliti _ kanis <strong>infeqcia</strong>a, romlis drosac<br />
procesi Tmis folikulSia lokalizebuli. <strong>aiv</strong> inficirebulebs<br />
xSirad uviTardebaT pustularuli perifolikuliti. folikulits,<br />
rogorc wesi, iwvevs Staphylococcus aureus, magram sxva<br />
mikroorganizmebsac SeuZlia misi gamowveva.<br />
2.kriteriumebi _<br />
a)<strong>da</strong>ma<strong>da</strong>sturebeli _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis <strong>da</strong>ma<strong>da</strong>sturebeli<br />
kriteriumebia: <strong>aiv</strong> antisxeulebis arseboba sisxlis SratSi<br />
imunoblotingis meTodiT, <strong>aiv</strong> rnm-is raodenobrivad <strong>da</strong>/an <strong>aiv</strong><br />
provirus dnm-is Tvisobrivad aRmoCena sisxlSi polimerizaciis<br />
jaWvuri reaqciis meTodiT. stafilokokuri folikulitis diagnozi<br />
ismeba <strong>klinikuri</strong> gamovlinebebis safuZvelze. gamonayari<br />
warmodgenilia mravlobiTi wvrili (5 mm diametris), hiperemiuli<br />
folikulebiT, romlebic centrSi <strong>da</strong>Cirqebulia. xSirad elementebs<br />
aqvT midrekileba gaerTianebisaken. kanis <strong>da</strong>zianebas Tan axlavs<br />
qavili.<br />
b)gamomricxavi _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis gamomricxavi kriteriumebia: <strong>aiv</strong><br />
antisxeulebis ar arseboba sisxlis SratSi imunofermentuli<br />
meTodiT, raodenobrivad <strong>aiv</strong> rnm-is <strong>da</strong>/an Tvisobrivad <strong>aiv</strong> provirus<br />
dnm-is ar arseboba sisxlSi polimerizaciis jaWvuri reaqciis<br />
meTodiT. stafilokokuri folikulitis gamomricxavi kriteriumia<br />
Sesabamisi <strong>klinikuri</strong> suraTis ar arseboba.<br />
3.simptomebi <strong>da</strong> niSnebi<br />
a)<strong>da</strong>ma<strong>da</strong>sturebeli _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidss paTognomuri <strong>klinikuri</strong> niSnebi<br />
ar gaaCnia. igi miekuTvneba laboratoriulad sadiagnozo <strong>da</strong>avadebebs.<br />
simptomebi<strong>da</strong>n SeiZleba gamovyoT: gaxangrZlivebuli cxeleba,<br />
gaxangrZlivebuli faRaraTi, limfadenopaTia, aramotivirebuli<br />
profuzuli oflianoba, Zlieri saerTo sisuste, aramotivirebuli wonaSi<br />
kleba (erTi Tvis ganmavlobaSi sxeulis wonis 10% <strong>da</strong> meti), sxva<strong>da</strong>sxva<br />
gamonayari kansa <strong>da</strong> lorwovanze, kandidozuri ezofagiti, cns-is<br />
atipiuri <strong>da</strong>zianebebi <strong>da</strong> sxva. stafilokokuri folikulitis dros<br />
gamonayari warmodgenilia mravlobiTi wvrili (5 mm diametris),<br />
hiperemiuli folikulebiT, romlebic centrSi <strong>da</strong>Cirqebulia. xSirad<br />
elementebs aqvT midrekileba gaerTianebisaken. kanis <strong>da</strong>zianebas Tan<br />
axlavs qavili.<br />
b)gamomricxavi _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis gamomricxavi simptomebi ar<br />
arsebobs, <strong>aiv</strong> inficirebuli wlebis ganmavlobaSi SeiZleba Civilebs ar<br />
warmoadgendes. stafilokokuri folikulitis gamomricxavi faqtoria<br />
Sesabamisi gamonayaris ar arseboba.<br />
182
4.diagnostikur _ laboratoriuli testebi <strong>da</strong> specialistTa<br />
konsultaciebi<br />
CD3, CD4, CD8 limfocitebis absoluturi ricxvis gansazRvra, <strong>aiv</strong><br />
virusuli <strong>da</strong>tvirTvis gansazRvra polimerizaciis jaWvuri reaqciis<br />
meTodiT, sisxlis saerTo analizi, RviZlis funqciuri sinjebi,<br />
Tirkmlis funqciuri sinjebi, virusuli hepatitis markerebi, pustulis<br />
SigTavsis baqteriologiuri gamokvleva, dermatologis konsultacia.<br />
5. stafilokokuri folikulitis <strong>mkurnaloba</strong><br />
I rigis preparati<br />
cefaleqsini 500 mg PO 4-jer dReSi 7-21 dRe.<br />
alternatiuli preparati<br />
kloksacilini 500 mg PO 4-jer dReSi 7-21 dRe.<br />
7.gaidlaini, romelsac eyrdnoba aRniSnuli protokoli<br />
aRniSnuli protokoli eyrdnoba jan<strong>da</strong>cvis msoflio organizaciis 2006<br />
wlis gaidlains: “<strong>aiv</strong>/<strong>SidsiT</strong> <strong>da</strong>avadebul mozrdil <strong>da</strong> mozard pirebSi<br />
oportunistuli infeqciebis profilaqtika <strong>da</strong> <strong>mkurnaloba</strong>”, aseve<br />
protokoli Sejerebulia DHHS, USA-AIS <strong>da</strong> EACS 2005 wlis oportunistuli<br />
infeqciebis mkurnalobis gaidlainebTan.<br />
183
<strong>aiv</strong> <strong>infeqcia</strong>/Sidsis fonze ganviTarebuli kontagiozuri moluskis<br />
marTvis saxelmwifo stan<strong>da</strong>rti (protokoli)<br />
1.<strong>da</strong>avadebis /nozologiis / sindromis mokle ganmarteba _ <strong>aiv</strong><br />
<strong>infeqcia</strong>/Sidsi ewodeba a<strong>da</strong>mianis imunodeficitis virusiT gamowveul<br />
infeqciur <strong>da</strong>avadebas. kontagiozuri moluski _ kanis ze<strong>da</strong>piruli<br />
<strong>infeqcia</strong>a, romelsac iwvevs kontagiozuri moluskis virusi. <strong>aiv</strong><br />
inficirebulebSi <strong>aiv</strong> negatiurebisgan gansxvavebiT: elementebi<br />
raodenobrivad bevria, xangrZlivad persistirebs, ufro msxvilia <strong>da</strong><br />
Znelad eqvemdebareba <strong>mkurnaloba</strong>s.<br />
2.kriteriumebi _<br />
a)<strong>da</strong>ma<strong>da</strong>sturebeli _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis <strong>da</strong>ma<strong>da</strong>sturebeli<br />
kriteriumebia: <strong>aiv</strong> antisxeulebis arseboba sisxlis SratSi<br />
imunoblotingis meTodiT, <strong>aiv</strong> rnm-is raodenobrivad <strong>da</strong>/an <strong>aiv</strong><br />
provirus dnm-is Tvisobrivad aRmoCena sisxlSi polimerizaciis<br />
jaWvuri reaqciis meTodiT. kontagiozuri moluskis diagnozi ismeba<br />
<strong>da</strong>maxasiaTebeli elementis aRmoCenisas. specifikuri diagnostikuri<br />
testi virusis aRmosaCenad ar arsebobs.<br />
b)gamomricxavi _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis gamomricxavi kriteriumebia: <strong>aiv</strong><br />
antisxeulebis ar arseboba sisxlis SratSi imunofermentuli<br />
meTodiT, raodenobrivad <strong>aiv</strong> rnm-is <strong>da</strong>/an Tvisobrivad <strong>aiv</strong> provirus<br />
dnm-is ar arseboba sisxlSi polimerizaciis jaWvuri reaqciis<br />
meTodiT. kontagiozuri moluski gamomricxavi kriteriumia Sesabamisi<br />
gamonayaris ar arseboba.<br />
3.simptomebi <strong>da</strong> niSnebi<br />
a)<strong>da</strong>ma<strong>da</strong>sturebeli _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidss paTognomuri <strong>klinikuri</strong><br />
niSnebi ar gaaCnia. igi miekuTvneba laboratoriulad sadiagnozo<br />
<strong>da</strong>avadebebs. simptomebi<strong>da</strong>n SeiZleba gamovyoT: gaxangrZlivebuli<br />
cxeleba, gaxangrZlivebuli faRaraTi, limfadenopaTia,<br />
aramotivirebuli profuzuli oflianoba, Zlieri saerTo sisuste,<br />
aramotivirebuli wonaSi kleba (erTi Tvis ganmavlobaSi sxeulis<br />
wonis 10% <strong>da</strong> meti), sxva<strong>da</strong>sxva gamonayari kansa <strong>da</strong> lorwovanze,<br />
kandidozuri ezofagiti, cns-is atipiuri <strong>da</strong>zianebebi <strong>da</strong> sxva.<br />
kontagiozuri moluskis gamomwvevi kanSi SeRwevisas iwvevs 2-5 mm<br />
diametris kanisferi mkvrivi papulebis ganviTarebas. papulebi Seicavs<br />
TeTr cximovan sekrets. gamonayaris elementebi SeiZleba ganviTardes<br />
sxeulis nebismier adgilas, xSirad iyos ucvlelad mravali Tvis<br />
manZilze <strong>da</strong>/an gaqres <strong>da</strong> Semdeg kvlav gaCndes.<br />
b)gamomricxavi _ <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis gamomricxavi simptomebi ar<br />
arsebobs, <strong>aiv</strong> inficirebuli wlebis ganmavlobaSi SeiZleba Civilebs ar<br />
warmoadgendes. kontagiozuri moluskis gamomricxavi faqtoria<br />
Sesabamisi gamonayaris ar arseboba.<br />
184
4.diagnostikur _ laboratoriuli testebi <strong>da</strong> specialistTa<br />
konsultaciebi<br />
CD3, CD4, CD8 limfocitebis absoluturi ricxvis gansazRvra, <strong>aiv</strong><br />
virusuli <strong>da</strong>tvirTvis gansazRvra polimerizaciis jaWvuri reaqciis<br />
meTodiT, sisxlis saerTo analizi, RviZlis funqciuri sinjebi,<br />
Tirkmlis funqciuri sinjebi, virusuli hepatitis markerebi, eqim<br />
dermatologis konultacia.<br />
5.kontagiozuri moluskis <strong>mkurnaloba</strong><br />
kontagiozuri moluski <strong>mkurnaloba</strong> mdgomareobs papulis rbili<br />
SigTavsis mocilebaSi, romlis Semdeg papula qreba. mkurnalobis taqtika<br />
yvela SemTxvevaSi individualuria. arsebobs kanis <strong>da</strong>zianebuli ubnis<br />
<strong>da</strong>muSavebis sxva<strong>da</strong>sxva meTodi. elementebs <strong>da</strong>muSaveba SesaZlebelia<br />
Semdegi meTodebis gamoyenebiT:<br />
_ kiuretaJi<br />
_ qimiuri destruqcia fenolis koncentrirebuli xsnariT<br />
_ krioTerapia<br />
_ eleqtrokoagulacia<br />
cnobilia, rom <strong>aiv</strong> inficirebulebSi arT-s <strong>da</strong>wyeba xels uwyobs<br />
kontagiozuri moluskis eliminacias. naCvenebi iyo, rom antivirusuli<br />
preparati – cidofoviri, romelsac aqvs Zlieri antiretrovirusuli<br />
moqmedeba, aseve efeqturia kontagiozuri moluskis samkurnalod<br />
7.gaidlaini, romelsac eyrdnoba aRniSnuli protokoli<br />
aRniSnuli protokoli eyrdnoba jan<strong>da</strong>cvis msoflio organizaciis 2006<br />
wlis gaidlains: “<strong>aiv</strong>/<strong>SidsiT</strong> <strong>da</strong>avadebul mozrdil <strong>da</strong> mozard pirebSi<br />
oportunistuli infeqciebis profilaqtika <strong>da</strong> <strong>mkurnaloba</strong>”, aseve<br />
protokoli Sejerebulia DHHS, USA-AIS <strong>da</strong> EACS 2005 wlis oportunistuli<br />
infeqciebis mkurnalobis gaidlainebTan.<br />
185
<strong>aiv</strong> <strong>infeqcia</strong>/<strong>SidsiT</strong> avadmyofebSi B hepatitis virusiT ko-infeqciis<br />
marTvis saxelmwifo stan<strong>da</strong>rti (protokoli)<br />
1. <strong>da</strong>avadebis /nozologiis/sindromis mokle ganmarteba – B hepatiti<br />
a<strong>da</strong>mianis B hepatitis virusiT gamowveuli infeqciuri <strong>da</strong>avadebaa. <strong>aiv</strong><br />
<strong>infeqcia</strong>/Sidsi ewodeba a<strong>da</strong>mianis imunodeficitis virusiT gamowveul<br />
infeqciur <strong>da</strong>avadebas. orive paTogeniT erTdroulad <strong>da</strong>avadebisas<br />
saubaria <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis <strong>da</strong> B hepatitis virusiT ko<strong>infeqcia</strong>ze.<br />
2.kriteriumebi –<br />
a) <strong>da</strong>ma<strong>da</strong>sturebeli – <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis <strong>da</strong>ma<strong>da</strong>sturebeli<br />
kriteriumebia: <strong>aiv</strong> antisxeulebis arseboba sisxlis SratSi<br />
imunoblotingis meTodiT, <strong>aiv</strong> rnm-is <strong>da</strong>/an <strong>aiv</strong> provirusis<br />
dnm-is aRmoCena sisxlSi polimerizaciis jaWvuri reaqciis<br />
meTodiT; BB hepatitis virusiT <strong>da</strong>avadebis <strong>da</strong>ma<strong>da</strong>sturebeli<br />
kriteriumia HBsAg-is arseboba sisxlis SratSi.<br />
imunofermentuli analizis meTodiT. HBsAg-is arseboba > 6<br />
Tveze meti xangrZlivobiT qronikuli HBV infeqciis<br />
maCvenebelia. qronikuli HBV infeqciis sxva<strong>da</strong>sxva variantis<br />
sadiagnostiko markerebia: HBeAg, Anti-HBe <strong>da</strong> HBV DNA.<br />
b) gamomricxavi – <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis gamomricxavi<br />
kriteriumebia: A<strong>aiv</strong> antisxeulebis ararseboba sisxlis<br />
SratSi imunofermentuli analizis meTodiT, <strong>aiv</strong> rnm-is<br />
<strong>da</strong>/an <strong>aiv</strong> provirus dnm-is ararseboba sisxlSi<br />
polimerizaciis jaWvuri reaqciis meTodiT. B hepatitis<br />
virusiT infeqciis gamomricxavi kriteriumebia: H HBsAg-is <strong>da</strong><br />
Anti-HBc antisxeulebis ararseboba sisxlis SratSi.<br />
3.simptomebi <strong>da</strong> niSnebi<br />
a)<strong>da</strong>ma<strong>da</strong>sturebeli - <strong>aiv</strong> <strong>infeqcia</strong>/Sidss paTognomuri <strong>klinikuri</strong><br />
niSnebi ar gaaCnia, igi miekuTvneba laboratoriulad sadiagnozo<br />
<strong>da</strong>avadebebs. simptomebi<strong>da</strong>n SesaZloa gamovyoT: gaxangrZlivebuli<br />
cxeleba, gaxangrZlivebuli faRaraTi, limfadenopaTia,<br />
aramotivirebuli profuzuli oflianoba, Zlieri saerTo<br />
sisuste, aramotivirebuli wonaSi kleba (1 Tvis ganmavlobaSi<br />
sxeulis wonis 10% an meti), sxva<strong>da</strong>sxva gamonayari kansa <strong>da</strong><br />
lorwovanze, kandidozuri ezofagiti, cns-is atipiuri<br />
<strong>da</strong>zianebebi. B hepatiti mwvave stadiaze SesaZloa usimptomod<br />
mimdinareobs, umetes SemTxvevaSi mwvave B hepatitis dros<br />
avadmyofs aReniSneba zoga<strong>da</strong>d hepatitis niSnebi, rogoricaa:<br />
siyviTle, saerTo sisuste, Sardis gamuqeba, ganavlis gaRiaveba,<br />
zogjer sxeulis temperatutis momateba, diskomforti muclis<br />
RruSi, gulisrevis SegrZneba, Rebineba <strong>da</strong> sxva intoqsikaciis<br />
movlenebi. <strong>da</strong>avadebam 1.4%-Si SesaZloa miiRos fulminanturi<br />
mimdinareoba. <strong>avadmyofTa</strong> 10-15%-Si <strong>da</strong>avadeba qronikul<br />
mimdinareobas Rebulobs <strong>da</strong> qronikuli B hepatiti praqtikulad<br />
xasiaTdeba usimptomo mimdinareobiT, SesaZlebelia gamoxatuli<br />
iyos mxolod zogadi saerTo sisuste.<br />
b) gamomricxavi - qronikul B hepatitis iseve rogorc <strong>aiv</strong><br />
<strong>infeqcia</strong>/Sidsis gamomricxavi simptomebi ar arsebobs, qronikul B<br />
186
hepatitiTa <strong>da</strong> <strong>aiv</strong>-iT koinficirebuli pacienti wlebis ganmavlobaSi<br />
SeiZleba Civilebs ar warmoadgendes.<br />
4.diagnostikur-laboratoriuli testebi<br />
yvela HIV <strong>da</strong>debiT avadmyofs un<strong>da</strong> Cautardes gamokvleva HBsAg-ze <strong>da</strong><br />
anti-HBc antisxeulebze(AII). im SemTxvevaSi, Tu HBsAg uaryofiTia <strong>da</strong> anti-<br />
HBc <strong>da</strong>debiTi, maSin avadmyofs un<strong>da</strong> Cautardes gamokvleva anti-HBs-ze(AII)<br />
<strong>da</strong> ga<strong>da</strong>wydes esaWiroeba Tu ara avadmyofs HBV vaqcinacia.<br />
yvela avadmyofs, romelsac aqvs <strong>da</strong>debiTi HBsAg un<strong>da</strong> Cautardes<br />
gamokvleva anti-HDV-ze(AII).<br />
yvela avadmyofs, romelsac aqvs <strong>da</strong>debiTi HBsAg un<strong>da</strong><br />
un<strong>da</strong> Cautardes Semdegi gamokvlevebi:<br />
HBeAg <strong>da</strong> anti-HBe, HBV dnm-is gansazRvra, RviZlis ultrabgeriTi<br />
gamokvleva, RviZlis biofsia an fibrozis arainvaziuri markerebis<br />
gansazRvra RviZlis <strong>da</strong>avadebis simZimis Sesafaseblad, ALT-is gansazRvra<br />
(seriuli), CD3, CD4, CD8 limfocitebis absoluturi ricxvis gansazRvra,<br />
<strong>aiv</strong> virusuli <strong>da</strong>tvirTvis gansazRvra, sisxlis saerTo analizi.<br />
5.<strong>mkurnaloba</strong><br />
HBV infeqciis mkurnalobis SemTxvevaSi HIV koinfeqciT avadmyofebSi<br />
gaTvaliswinebul un<strong>da</strong> iqnas 2 ZiriTadi varianti:<br />
1. HBV mkurnalobis algoriTmi HIV koinfeqciiT avadmyofebisTvis,<br />
romelTac ar esaWiroebaT arv <strong>mkurnaloba</strong>. H<br />
HBV/HIV koinfeqciiT<br />
avadmyofebi HAART-is<br />
Cvenebis gareSeE.<br />
HBV DNA, ALT,<br />
HBeAg<br />
ALT-is normaluri<br />
done, HBV DNA-is<br />
<strong>da</strong>bali done<br />
HBVaqtiuri<br />
<strong>da</strong>avadeba, maRali<br />
HBV DNA.*<br />
dinamikaSi<br />
<strong>da</strong>kvirveba<br />
RviZlis <strong>da</strong>avadebis<br />
statusi<br />
RviZlis araaqtiuri<br />
an msubuqi <strong>da</strong>avadeba**<br />
aqtiuri <strong>da</strong>/an<br />
progresirebadi <strong>da</strong>avadeba***<br />
187
dinamikaSi<br />
<strong>da</strong>kvirveba<br />
CD4≥500/mm 3 CD420000IU/ml HBeAg(+) pozitiurisTvis, HBV DNA>2000IU/ml HBeAg(-) negatiurisTvis.<br />
** Metavir _F2<br />
HBV/HIV koinfeqciiT avadmyofebisTvis, romelTac ar esaWiroebaT arv<br />
<strong>mkurnaloba</strong> HBV infeqciis samkurnalod SerCevis preparati aris<br />
interferoni.<br />
mkurnalobis reJimebi aris Semdegi:<br />
1. HBeAg (+) pozitiuri avadmyofebisTvis.<br />
stan<strong>da</strong>rtuli INF 5-6 MU/dReSi an 10 MU 3-jer kviraSi 4-6 Tve.<br />
2. HBeAg (-) negatiuri avadmyofebisTvis.<br />
stan<strong>da</strong>rtuli INF 3-6 MU 3-jer kviraSi 12 Tve.<br />
an<br />
3. PEG-INF 2a 180mkg 1- jer kviraSi 12 Tve. HBeAg/ anti-HBe statusisgan<br />
<strong>da</strong>moukideblad.<br />
4. im SemTxvevaSi Tu interferoni ukunaCvenebia gamoyenebul un<strong>da</strong> iqnas<br />
adefoviri 10mg dReSi.<br />
2. HBV mkurnalobis algoriTmi HIV koinfeqciiT avadmyofebisTvis,<br />
romelTac WirdebaT arv <strong>mkurnaloba</strong>. H<br />
HBV/HIV koinfeqciiT<br />
avadmyofebi romelTac<br />
WirdebaT HAART .<br />
maRali HBV DNA<br />
<strong>da</strong>bali HBV DNA<br />
avadmyofebi<br />
ciroziT<br />
lamivudin rezistentuli<br />
avadmyofebi<br />
HAART SerCevis reJimi<br />
188<br />
HAART romelSic<br />
Sedis tenofoviri +<br />
lamivudini an<br />
emtricitabini
avadmyofebi<br />
lamivudinis mimarT<br />
rezistentobis<br />
gareSi<br />
HAART romelSic<br />
Sedis tenofoviri<br />
+ lamivudini an<br />
emtricitabini<br />
un<strong>da</strong> Canacvldes erTi<br />
NRTI tenofoviriT an<br />
<strong>da</strong>ematos tenofoviri<br />
HBV/HIV koinfeqciiT avadmyofebisTvis, romelTac esaWiroebaT arv<br />
<strong>mkurnaloba</strong> <strong>da</strong> HBV <strong>mkurnaloba</strong> gaTvaliswinebul un<strong>da</strong> iqnas Semdegi:<br />
a) Tu HBV DNA aris maRali koncentraciiT, maSin HAART aucileblad<br />
un<strong>da</strong> Seicavdes or medikaments romelsac gaaCnia ormagi aqtivoba<br />
rogorc HBV aseve HIV mimarT.<br />
b) lamivudinis mimarT rezistentobis SemTxvevaSi, roca HIV <strong>infeqcia</strong><br />
kontrolirebadia, erT-erTi NRTI un<strong>da</strong> Seicvalos tenofoviriT.<br />
g) lamivudinis mimarT rezistentobis SemTxvevaSi, roca HIV <strong>infeqcia</strong><br />
kargad ar kontrolirdeba, pirvel rigSi yuradreba un<strong>da</strong> mieqces<br />
HHAART-s, romelic kargad gaakontrolebs <strong>aiv</strong> <strong>infeqcia</strong>s <strong>da</strong> <strong>da</strong>ematos<br />
tenofoviri.<br />
d) avadmyofebSi romelTac aqvT cirozi HBV mkurnalobis sakiTxi un<strong>da</strong><br />
ga<strong>da</strong>wydes HBV DNA-s <strong>da</strong>bali maCveneblis dros. (HBV DNA>200IU/ml). aseT<br />
avadmyofebSi interferoni ukunaCvenebia.<br />
D<br />
fulminanturi mwvave B hepatitis <strong>mkurnaloba</strong> HIV koinfeqciiT<br />
avadmyofebSi<br />
Cveulebriv mwvave B hepatiti SemTxvevaTa maRal procentSi mTavrdeba<br />
gamojanmrTelebiT <strong>da</strong> amitom <strong>mkurnaloba</strong>s ar saWiroebs.<br />
fulminanturi mwvave B hepatitis SemTxvevaSi lamivudiniT <strong>mkurnaloba</strong><br />
un<strong>da</strong> iqnas ganxiluli, miuxe<strong>da</strong>vad <strong>aiv</strong>-is mimarT rezistentobis<br />
ganviTarebis riskisa.<br />
tenofoviris <strong>da</strong> adefoviris <strong>da</strong>niSvnisgan Tavi un<strong>da</strong> iqnas Sekavebuli am<br />
medikamentebis gamoxatuli nefrotoqsiurobis gamo.<br />
6.reabilitacia <strong>da</strong> <strong>da</strong>kvirveba<br />
189
HBV mkurnalobis efeqturoba HBeAg (+) pozitiur avadmyofebSi fasdeba<br />
anti-HBe-is myari serokonversiiT, xolo HBeAg (-) negatiur avadmyofebSi<br />
ALT-s myari normalizebiT <strong>da</strong> HBV dnm-is myari supresiiT(
<strong>aiv</strong> <strong>infeqcia</strong>/<strong>SidsiT</strong> avadmyofebSi C hepatitis virusiT ko-infeqciis<br />
marTvis saxelmwifo stan<strong>da</strong>rti (protokoli)<br />
1.ganmarteba – C hepatiti a<strong>da</strong>mianis C hepatitis virusiT gamowveuli<br />
infeqciuri <strong>da</strong>avadebaa. <strong>aiv</strong> <strong>infeqcia</strong>/Sidsi ewodeba a<strong>da</strong>mianis<br />
imunodeficitis virusiT gamowveul infeqciur <strong>da</strong>avadebas. orive<br />
paTogeniT erTdroulad <strong>da</strong>avadebisas saubaria <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis <strong>da</strong><br />
C hepatitis virusiT ko<strong>infeqcia</strong>ze.<br />
2. kriteriumebi –<br />
a) <strong>da</strong>ma<strong>da</strong>sturebeli – <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis <strong>da</strong>ma<strong>da</strong>sturebeli<br />
kriteriumebia: <strong>aiv</strong> antisxeulebis arseboba sisxlis SratSi<br />
imunoblotingis meTodiT, <strong>aiv</strong> rnm-is <strong>da</strong>/an <strong>aiv</strong> provirusis<br />
dnm-is aRmoCena sisxlSi polimerizaciis jaWvuri reaqciis<br />
meTodiT; C hepatitis virusiT <strong>da</strong>avadebis <strong>da</strong>ma<strong>da</strong>sturebeli<br />
kriteriumebia: C hepatitis virusis sawinaaRmdego<br />
antisxeulebis arseboba sisxlis SratSi imunofermentuli<br />
analizis meTodiT <strong>da</strong>/an C hepatitis virusis rnm-is aRmoCena<br />
sisxlSi polimerizaciis jaWvuri reaqciis meTodiT.<br />
b) gamomricxavi – <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis gamomricxavi<br />
kriteriumebia: A<strong>aiv</strong> antisxeulebis ararseboba sisxlis<br />
SratSi imunofermentuli analizis meTodiT, <strong>aiv</strong> rnm-is<br />
<strong>da</strong>/an <strong>aiv</strong> provirus dnm-is ararseboba sisxlSi<br />
polimerizaciis jaWvuri reaqciis meTodiT. C hepatitis<br />
virusiT infeqciis gamomricxavi kriteriumebia: C hepatitis<br />
virusis sawinaaRmdego antisxeulebis ararseboba, <strong>da</strong>/an C<br />
hepatitis virusis rnm-is ararseboba sisxlSi<br />
polimerizaciis jaWvuri reaqciis meTodiT.<br />
3. simptomebi <strong>da</strong> niSnebi<br />
a) <strong>da</strong>ma<strong>da</strong>sturebeli - <strong>aiv</strong> <strong>infeqcia</strong>/Sidss paTognomuri<br />
<strong>klinikuri</strong> niSnebi ar gaaCnia, igi miekuTvneba<br />
laboratoriulad sadiagnozo <strong>da</strong>avadebebs. simptomebi<strong>da</strong>n<br />
SesaZloa gamovyoT: gaxangrZlivebuli cxeleba,<br />
gaxangrZlivebuli faRaraTi, limfadenopaTia,<br />
aramotivirebuli profuzuli oflianoba, Zlieri saerTo<br />
sisuste, aramotivirebuli wonaSi kleba (1 Tvis<br />
ganmavlobaSi sxeulis wonis 10% an meti), sxva<strong>da</strong>sxva<br />
gamonayari kansa <strong>da</strong> lorwovanze, kandidozuri ezofagiti,<br />
cns-is atipiuri <strong>da</strong>zianebebi; C hepatiti mwvave stadiaze<br />
ZiriTa<strong>da</strong>d usimptomod mimdinareobs, mxolod SemTxvevaTa<br />
25%-Si SeasaZloa gamovlindes simptomebi: siyviTle, saerTo<br />
sisuste, Sardis gamuqeba, ganavlis gaRiaveba, zogjer<br />
sxeulis temperatutis momateba, diskomforti muclis<br />
RruSi, gulisrevis SegrZneba, Rebineba <strong>da</strong> sxva intoqsikaciis<br />
movlenebi. <strong>da</strong>avadeba SemTxvevaTa 80%-Si qronikul<br />
mimdinareobas Rebulobs <strong>da</strong> qronikuli C hepatiti<br />
praqtikulad xasiaTdeba usimptomo mimdinareobiT,<br />
SesaZlebelia gamoxatuli iyos mxolod zogadi saerTo<br />
sisuste. aqe<strong>da</strong>n gamomdinare C hepatitic miekuTvneba<br />
laboratiriulad <strong>da</strong>siagnostiko <strong>da</strong>avadebebs.<br />
191
) gamomricxavi - <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis gamomricxavi simptomebi<br />
<strong>da</strong> niSnebi ar arsebobs, <strong>aiv</strong> inficirebuls wlebis<br />
ganmavlobaSi SesaZloa simptomebi ar aReniSnebodes; C<br />
hepatitis virusiT infeqciis simptomebi <strong>da</strong> niSnebi aseve ar<br />
arsebobs <strong>da</strong> avadmyofs wlebis ganmavlobaSi SesaZloa ar<br />
aReniSnebodes araviTari simptomi.<br />
4. diagnostikur-laboratoriuli testebi.<br />
yvela HIV <strong>da</strong>debiT avadmyofs udna Cautardes gamokvleva<br />
anti-HCV antisxeulebze(AII). Anti-HCV (+) pozitiuri Sedegis<br />
SemTxvevaSi un<strong>da</strong> Catardes HCV RNA-s gansazRvra.<br />
yvela avadmyofs, romelsac aqvs HCV RNA (+) pozitiuri un<strong>da</strong><br />
Catardes Semdegi gamokvlevebi:<br />
1. ΗCV genotipis gansazRvra .<br />
2. HCV virusuli <strong>da</strong>tvirTvis gansazRvra.<br />
3. sisxlis saerTo analizi, ALT, AST, G-GT, kreatinini.<br />
4. RviZlis ultrabgeriTi gamokvleva.<br />
5. RviZlis biofsia an fibrozis arainvaziuri markerebis<br />
gansazRvra RviZlis <strong>da</strong>avadebis simZimis Sesafaseblad<br />
6 CD3, CD4, CD8 limfocitebis absoluturi ricxvis gansazRvra,<br />
<strong>aiv</strong> virusuli <strong>da</strong>tvirTvis gansazRvra.<br />
5. <strong>mkurnaloba</strong><br />
HCV infeqciis samkurnalod HCV/HIV ko-infeqciiT avadmyofbSi gamoiyeneba<br />
kombinirebuli antivirusuli <strong>mkurnaloba</strong> pegilirebuli alfa<br />
interferoniT <strong>da</strong> ribaviriniT.<br />
mwvave C hepatitis mkurnalobis sakiTxi ko_infeqciiT avadmyofebSi jerjerobiT<br />
sabolood ga<strong>da</strong>Wrili ar aris.<br />
qronikuli C hepatitis <strong>mkurnaloba</strong>: Tu qronikuli C hepatitis diagnozi<br />
ganisazRvra <strong>aiv</strong> infeqciis adreul stadiaze (manamde, sanam avadmyofs ar<br />
Wirdeba HAART <strong>mkurnaloba</strong>) HCV infeqciis <strong>mkurnaloba</strong> <strong>da</strong>wyebul un<strong>da</strong><br />
iqnas. (AIII).<br />
Tu ko-infeqciT avadmyofebs aqvT Rrma imunodeficiti, jer <strong>da</strong>wyebul<br />
un<strong>da</strong> iqnas HAART <strong>da</strong> HCV mkurnalobis sakiTxi ganxilul un<strong>da</strong> iqnas<br />
mxolod CD4 ujredebis raodenobis momatebis Semdeg.(AII).<br />
HCV infeqciis mkurnalobis rejimi HIV koinfeqciiT avadmyofebSi<br />
interferoni:<br />
- PEG-IFN alpha 2α- 180 mkg 1 Xjer kviraSi an PEG-IFN alpha 2b 1.5 mkg/kg<br />
kviraSi erTxel.<br />
ribavirini<br />
- HCV 1 <strong>da</strong> HCV 4 genotipiT avadmyofebisTvis maRali virusuli<br />
<strong>da</strong>tvirTviT ribavirini 1000-1200 mg dReSi 1-jer (mkurnalobis<br />
<strong>da</strong>wyeba)(BIII)<br />
192
- yvela sxva SemTxvevaSi (maT Soris HCV 1 <strong>da</strong> HCV 4 genotipiT<br />
avadmyofebisTvis <strong>da</strong>bali virusuli <strong>da</strong>tvirTviT) ribavirini 800 mg<br />
dReSi 1-jer (AII).<br />
HIV/HCV ko-infeqciiT avadmyofebSi, genotipisgan <strong>da</strong>moukideblad<br />
mkurnalobis xangrZlivoba Seadgens 48 kviras (BI).<br />
HCV infeqciis mkurnalobis algoriTmi HCV/HIV koinfeqciiT<br />
avadmyofebSi<br />
HCV/HIV ko<strong>infeqcia</strong><br />
HCV RNA (+) <strong>da</strong>debiTi<br />
CD4+ >200/mm 3<br />
( 200-350 mm 3 )<br />
CD4+ 800, 000 IU/ml)<br />
HCV 1 genotipi<br />
virsuli <strong>da</strong>tvirTva<br />
(
pegilirebuli interferonis <strong>da</strong> ribavirinis dozis cvlilebebi<br />
mkurnalobis dros ganviTarebuli hematologiuri cvlilebebis dros<br />
ribavirinis Semcireba<br />
600 mg -mde<br />
medikamentebis dozis cvlilebebi<br />
ribavirin<br />
is<br />
Sewyveta<br />
PEG-IFN-is<br />
Semcireba<br />
70%,50%, 25%-iT<br />
PEG-IFN<br />
Sewyveta<br />
neitrofilebi
menejmenti<br />
gverdiTi movlenebi<br />
antidepresantebi<br />
(seleqtiuri serotoninis<br />
ukumitacebis inhibitori)<br />
Tireoiduli hormoni<br />
klinikurad gamoxatuli depresiis SemTxvevaSi(ΑΙΙ)<br />
hipoTireozis dros (AII).<br />
β-blokatorebi<br />
hiperTireozis dros (CIII).<br />
• Tanmxlebi antiretrovirusuli medikamentebis<br />
gamoyeneba.<br />
PEG- intrferoniT <strong>da</strong> ribaviriniT kombinirebuli mkurnalobis dros<br />
cirozian avadmyofebSi di<strong>da</strong>nozini (ddI) ukunaCvenebia(EI) <strong>da</strong> aseve<br />
sasurvelia ar iqnas gamoyenebuli RviZlis naklebad mZime <strong>da</strong>zianebis<br />
dros.(EII).<br />
PEG- intrferoniT <strong>da</strong> ribaviriniT kombinirebuli mkurnalobis dros<br />
stavudini (d4T) gansakuTrebiT di<strong>da</strong>nozinTan(ddI) kombinaciaSi ar un<strong>da</strong><br />
iqnas gamoyenebuli, radgan am dros izrdeba laqtat acidozis<br />
ganviTarebis riski.(EII).<br />
aseve HCV –s kombinirebuli antivirusuli mkurnalobis dros HIV koinfeqciiT<br />
avadmyofebSi zidovudinis gamoyenebisgan Tavi un<strong>da</strong> iqnas<br />
Sekavebuli, radgan zidovudini zrdis anemiis <strong>da</strong> neitropeniis<br />
ganviTarebis risks(DII).<br />
PI –s gamoyeneba amcirebs myari virusuli pasuxis(SVR) ganviTarebis<br />
albaTobas HIV/HCV ko-infeqciiT avadmyofebSi, Tumca jer-jerobiT<br />
kategoriuli uaryofiTi rekomen<strong>da</strong>ciebi PI –s gamoyenebis mimarT ar aris.<br />
NVP (nevirapini) sifrTxiliT un<strong>da</strong> iqnas gamoyenebuli(AII).<br />
6. reabilitacia <strong>da</strong> <strong>da</strong>kvirveba<br />
HCV antivirusul <strong>mkurnaloba</strong>ze myofi avadmyofebis<br />
monitoringi, mkurnalobis tolerantobis <strong>da</strong> mkurnalobis<br />
efeqturobis Sefasebis mizniT<br />
maCveneblebi<br />
1,2 4 8 12 16 20 24 28 32 34 36 48 72<br />
mkurnalobis<br />
tolerantoba<br />
sisxlis<br />
saerTo<br />
Trombocite X X<br />
X X X X X X X X X X X<br />
195
i<br />
CD4 X X X X X X X X X<br />
TSH X X X<br />
HCV RNA<br />
raodenobri<br />
vi (VL)<br />
X<br />
mkurnalobis<br />
efeqturoba<br />
HCV RNA<br />
Tvisobrivi X X X<br />
‣ antivirusuli mkurnalobis <strong>da</strong>wyebi<strong>da</strong>n 12 kviraze Tu HCV virusuli<br />
<strong>da</strong>tvirTva gax<strong>da</strong> aragansazRvradi an Semcir<strong>da</strong> sul cota 2 log 10 -iT, es<br />
niSnavs, rom <strong>mkurnaloba</strong>ze adreuli virusuli pasuxi(EVR) miRebulia<br />
<strong>da</strong> <strong>mkurnaloba</strong> un<strong>da</strong> gagrZeldes.<br />
‣ Tu HCV virusuli <strong>da</strong>tvirTva ar Semcir<strong>da</strong> sul cota 2 log 10 -iT,<br />
<strong>mkurnaloba</strong> un<strong>da</strong> Sewydes, radgan aseT SemTxvevaSi myari virusuli<br />
pasuxis(SVR) ar miReba mosalodnelia <strong>da</strong>axloebiT 99-100%-Si.(AII).<br />
‣ zemoT aRniSnuli vrceldeba HCV nebismieri genotipiT avadmyofze.<br />
‣ amis Semdeg mkurnalobis <strong>da</strong>wyebi<strong>da</strong>n 24 kviraze rekomendebulia HCV<br />
RNA –is (Tvisobrivi) gansazRvra <strong>da</strong> im avadmyofebSi, romlebic am<br />
etapze rCebian HCV RNA (+) pozitiuri, <strong>mkurnaloba</strong> un<strong>da</strong> Sewydes.<br />
(radgan aseT SemTxvevaSi myari virusuli pasuxis(SVR) ar miiReba<br />
mosalodnelia <strong>da</strong>axloebiT 99-100%-Si.)<br />
‣ mkurnalobis <strong>da</strong>wyebi<strong>da</strong>n 48 kviraze un<strong>da</strong> ganisazRvros HCV RNA<br />
(Tvisobrivi) <strong>da</strong> miRebuli Sedegi <strong>da</strong>afiqsirebs mkurnalobis bolo<br />
pasuxs. (EOT)<br />
‣ mkurnalobis <strong>da</strong>mTavrebi<strong>da</strong>n 6 Tvis Semdeg kvlav un<strong>da</strong> ganisazRvros<br />
HCV RNA (Tvisobrivi). negatiuri HCV RNA mianiSnebs myari virusuli<br />
pasuxis (SVR) miRebaze, ris Semdegac <strong>da</strong>avadebis recidivis ganviTareba<br />
Zalian iSviaTia.<br />
‣ Semdgomi gamokvleva SesaZloa Catardes 12-24 Tvis Semdeg mkurnalobis<br />
<strong>da</strong>mTavrebi<strong>da</strong>n.<br />
7. gaidlaini romelsac eyrdnoba aRniSnuli protokoli<br />
aRniSnuli protokoli eyrdnoba 2006 wels janmo-s mier evropis<br />
regionisTvis gamocemul gaidlains <strong>da</strong> klinikur protokolebs<br />
“ C hepatitis <strong>da</strong> <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis koinfeqciis marTva” <strong>da</strong> evropis I<br />
konsensus konferenciis: “HBV <strong>da</strong> HCV infeqciebis marTva HIV koinfeqciiT<br />
avadmyofebSi.” (1-2, marti, 2005. parizi, safrangeTi) konsensus<br />
<strong>da</strong>dgenilebas.<br />
196
<strong>aiv</strong> <strong>infeqcia</strong>/Sidsis <strong>da</strong> tuberkulozis koinfeqciis marTvis<br />
saxelmwifo stan<strong>da</strong>rti (protokoli)<br />
1.ganmarteba – <strong>aiv</strong> <strong>infeqcia</strong>/Sidsi ewodeba a<strong>da</strong>mianis imunodeficitis<br />
virusiT gamowveul infeqciur <strong>da</strong>avadebas. tuberkulozis gamomwvevia<br />
tuberkulozis mikobaqteria. orive paTogeniT erTdroulad<br />
<strong>da</strong>avadebisas saubaria <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis <strong>da</strong> tuberkuloziT<br />
ko<strong>infeqcia</strong>ze.<br />
2.kriteriumebi –<br />
a) <strong>da</strong>ma<strong>da</strong>sturebeli – <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis <strong>da</strong>ma<strong>da</strong>sturebeli<br />
kriteriumebia: <strong>aiv</strong> antisxeulebis arseboba sisxlis SratSi<br />
imunoblotingis meTodiT, <strong>aiv</strong> rnm-is raodenobrivad <strong>da</strong>/an<br />
<strong>aiv</strong> provirusis dnm-is Tvisobrivad aRmoCena sisxlSi<br />
polimerizaciis jaWvuri reaqciis meTodiT; tuberkuloziT<br />
<strong>da</strong>avadebis <strong>da</strong>ma<strong>da</strong>sturebeli kriteriumia: avadmyofis<br />
biologiur masalaSi (maT Soris naxvelis nacxSi)<br />
mJavagamZle baqteriebis (mgb) arseboba, biologiur masalaSi<br />
kulturaluri meTodiT tuberkulozis mikobaqteriis<br />
aRmoCena.<br />
b) gamomricxavi – <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis gamomricxavi<br />
kriteriumebia: A<strong>aiv</strong> antisxeulebis ararseboba sisxlis<br />
SratSi imunofermentuli meTodiT, raodenobrivad <strong>aiv</strong> rnm-is<br />
<strong>da</strong>/an Tvisobrivad <strong>aiv</strong> provirus dnm-is ararseboba sisxlSi<br />
polimerizaciis jaWvuri reaqciis meTodiT; tuberkulozis<br />
gamomricxavi kriteriumebia: tuberkulozis <strong>da</strong>maxasiaTebeli<br />
<strong>klinikuri</strong> niSnebisa <strong>da</strong> simptomebis ar arseboba, biologiur<br />
masalaSi (maT Soris naxvelis nacxSi) baqterioskopiiT mgbsa<br />
<strong>da</strong> kulturaluri gamokvleviT tub.mikobaqteriis ar<br />
arseboba.<br />
3.simptomebi <strong>da</strong> niSnebi<br />
a)<strong>da</strong>ma<strong>da</strong>sturebeli - <strong>aiv</strong> <strong>infeqcia</strong>/Sidss paTognomuri <strong>klinikuri</strong><br />
niSnebi ar gaaCnia, igi miekuTvneba laboratoriulad sadiagnozo<br />
<strong>da</strong>avadebebs. simptomebi<strong>da</strong>n SesaZloa gamovyoT: gaxangrZlivebuli<br />
cxeleba, gaxangrZlivebuli faRaraTi, limfadenopaTia,<br />
aramotivirebuli profuzuli oflianoba, Zlieri saerTo sisuste,<br />
aramotivirebuli wonaSi kleba (1 Tvis ganmavlobaSi sxeulis wonis<br />
10% an meti), sxva<strong>da</strong>sxva gamonayari kansa <strong>da</strong> lorwovanze, kandidozuri<br />
ezofagiti, cns-is atipiuri <strong>da</strong>zianebebi; tuberkulozis<br />
<strong>da</strong>ma<strong>da</strong>sturebel simptomebs miekuTvneba: zogadi niSnebi:<br />
subfebriliteti, Ramis oflianoba, advilad <strong>da</strong>Rla, saerTo sisuste,<br />
Sromis unaris <strong>da</strong>qveiTeba, taqikardia. tuberkulozis filtvis formis<br />
dros zogad simptomatikas emateba: 2 kviris an meti xangrZlivobis<br />
xveleba (produqtiuli, mSrali an sisxliani), haeris ukmarisoba,<br />
usiamovno SegrZneba an tkivili gulmkerdSi; tuberkulozis<br />
filtvgareSe formebis dros ki zogado intoqsikaciis niSnebs emateba<br />
ama Tu im organos <strong>da</strong>zianebisaTvis <strong>da</strong>maxasiaTebeli lokaluri<br />
simptomatika.<br />
197
)gamomricxavi - <strong>aiv</strong> <strong>infeqcia</strong>/Sidsis gamomricxavi simptomebi <strong>da</strong> niSnebi<br />
ar arsebobs, <strong>aiv</strong> inficirebuls wlebis ganmavlobaSi SesaZloa simptomebi<br />
ar aReniSnebodes; tuberkulozis gamomricxavi niSnebi <strong>da</strong> simptobebia<br />
Civilebis ararseboba, kontaqtis ar arseboba aqtiuri tuberkuloziT<br />
<strong>da</strong>avadebulTan;<br />
mdgomareobebi <strong>da</strong>kavSirebuli aqtiur tuberkulozTan bavSvebSi<br />
tuberkulozi saeWvoa, rodesac adgili aqvs<br />
• anamnezSi kontaqts filtvis tuberkulozis <strong>da</strong><strong>da</strong>sturebul<br />
SemTxvevasTan<br />
• wiTelas ga<strong>da</strong>tanis Semdeg imunosupresiul mdgomareobas<br />
• wonaSi klebas, xvelas, paTologiur auskultaciur monacemebs<br />
filtvebSi, romelic ar <strong>da</strong>eqvemdebara farTo speqtris<br />
antibiortikoTerapias<br />
• ze<strong>da</strong>piruli limfuri kvanZebis umtkivneulo SeSupebas<br />
tuberkulozi savaraudoa, roca adgili aqvs saeWvo tuberkulozis<br />
SemTxevevas <strong>da</strong> erT-erT niSans qvemoT CamoTvlilTagan<br />
• tuberkulozis kanis testi 5 mm-ze meti induraciiT<br />
• Sesabamisi cvlilebebi gulmkerdis rentgenogramaze<br />
• Sesabamisi histologiuri cvlilebebi biofsiur masalaSi<br />
• <strong>da</strong>debiTi Sedegi antituberkulozur <strong>mkurnaloba</strong>ze<br />
tuberkulozi <strong>da</strong><strong>da</strong>sturebulia, roca<br />
• tuberkulozis mikobaqteria identificirebulia biologiur<br />
sekretebSi an qsovilebSi<br />
• naxvelis nacxis samjeradi pir<strong>da</strong>piri mikroskopiiT minimum or<br />
preparatSi aRmoCenilia mJavagamZle mikobaqteria<br />
4.diagnostikur-laboratoriuli testebi <strong>da</strong> specialistTa konsultaciebi<br />
CD3, CD4, CD8 limfocitebis absoluturi ricxvis gansazRvra, <strong>aiv</strong><br />
virusuli <strong>da</strong>tvirTvis gansazRvra, sisxlis saerTo analizi, RviZlis<br />
funqciuri sinjebi, Tirkmlis funqciuri sinjebi, virusuli hepatitis<br />
markerebis gansazRvra, naxvelis nacxis gamokvleva mgb-ze, gul-mkerdis<br />
rentgenologiuri gamokvleva, muclis Rrus eqoskopia; eqininfeqcionistis<br />
konsultacia, eqim-fTiziatris konsultacia;<br />
198
5.<strong>mkurnaloba</strong><br />
tuberkulozis <strong>mkurnaloba</strong> <strong>aiv</strong> inficirebul pacientebSi un<strong>da</strong> <strong>da</strong>iwyos<br />
aqtiuri tuberkulozis diagnozis <strong>da</strong><strong>da</strong>sturebi<strong>da</strong>n rac SeiZleba male.<br />
aqtiuri tuberkulozis mkurnalobisTvis rekomendirebuli reJimebi <strong>aiv</strong><br />
inficirebul pacientebSi<br />
tuberkulozis SemTxvevis tipi<br />
axali tbB pacienti<br />
adre tb-namkurnalebi pacienti, maT<br />
Soris<br />
• relafsi<br />
• <strong>mkurnaloba</strong> misi Sewyvetis<br />
Semdeg<br />
• sxva SemTxveva<br />
• uSedego <strong>mkurnaloba</strong> 4<br />
qronikuli (ze<strong>da</strong>mxedvelobis qveS<br />
Catarebuli ganmeorebiTi mkurnalobis<br />
Semdeg naxveli isev mgb pozitiuria)<br />
mrtb (aRiniSneba rezistentoba minimum H <strong>da</strong> R)<br />
tuberkulozis mkurnalobis<br />
reJimebi 1<br />
intensiuri faza 2 gagrZelebis<br />
faza<br />
HRZE 2 Tvis HR 4 Tvis<br />
ganmavlobaSi 3 ganmavlobaSi<br />
HRZES 2 Tvis HRE 5 Tvis<br />
ganmavlobaSi ganmavlobaSi<br />
an<br />
HRZE 1 Tvis<br />
ganmavlobaSi<br />
specialuri reJimi<br />
H –izoniazidi, R – rifampicini, Z – pirazinamidi, E – etambutoli, S- streptomicini.<br />
1 – <strong>aiv</strong> inficirebuli pacientebisaTvis aqtiuri tuberkuloziT mkurnalobis<br />
yoveldRiuri reJimia rekomendirebuli;<br />
2 - rekomendebulia <strong>mkurnaloba</strong> uSualo ze<strong>da</strong>mxedvelobis qveS Catarebuli<br />
qimioTerapiis mTeli kursis ganmavlobaSi.<br />
3 – streptomicini SesaZloa gamoyenebul iqnes etambutolis nacvlad. tuberkulozuri<br />
meningitisas etambutoli un<strong>da</strong> Seicvalos streptomiciniT.<br />
4- yvela SemTxvevaSi un<strong>da</strong> Catardes wamlebis mimarT mikroorganizmis mgrZnobelobis<br />
Seswavla mkurnalobis reJimis individualuri wesiT SesarCevad.<br />
tuberkulozis mkurnalobisTvis <strong>aiv</strong> inficirebul bavSvebSi<br />
rekomendirebulia igive reJimebi, rac mozrdilebSi. preparatebis<br />
dozireba xdeba sxeulis masis Sesabamisad.<br />
199
pirveli rigis antituberkulozuri medikamentebis rekomendebuli dozebi<br />
medikamentebi dRiuri dozebi 1<br />
(Cveuli doza an<br />
zRvruli)<br />
izoniazidi<br />
rifampicini<br />
pirazinamidi<br />
etambutoli<br />
streptomicini<br />
5 mg/kg<br />
(Cveulebriv 300 mg)<br />
10 mg/kg<br />
(450 mg TuU 50 kg)<br />
25 mg/kg<br />
(20-30 mg/kg)<br />
15 mg/kg<br />
(15-20 mg/kg)<br />
15 mg/kg<br />
(12-18 mg/kg)<br />
kviraSi samjer<br />
miRebisTvis<br />
gaTvaliswinebuli<br />
dozebi<br />
(Cveuli doza an<br />
zRvruli)<br />
10 mg/kg<br />
(Cveulebriv 900 mg)<br />
10 mg/kg<br />
(450 mg TuU 50 kg)<br />
35 mg/kg<br />
(30-40 mg/kg)<br />
30 mg/kg<br />
(20-35 mg/kg)<br />
15 mg/kg<br />
(12-18 mg/kg)<br />
1. rodesac rifampicini gamoiyeneba antiretrovirusul<br />
medikamentebTan erTad, rekomendebulia yoveldRiuri reJimiT<br />
<strong>mkurnaloba</strong><br />
rekomendirebuli pirveli rigis maarT reJimi tb<br />
pacientebisaTvis, romlebsac eZlevaT rifampicini 1<br />
maarT<br />
arv preparatebis<br />
sasurvelia 2 nrti<br />
(nukleoziduri revers<br />
transkriftazas inhibitori)<br />
+<br />
1 antri (aranukleoziduri<br />
revers trankriftazas<br />
inhibitori)<br />
alternatiuli 3 nrti<br />
kombinacia<br />
ZDV (an TDF)+ 3TC (an<br />
FTC) + EFV 2<br />
ZDV+ 3TC + ABC(an TDF)<br />
1 – dozireba ix me-2 <strong>da</strong>matebaSi<br />
2 - rekomendirebulia efavirenzis dozireba 600 mg/dR gansakuTrebiT 60kg<br />
pacientebSi, Tumca es debuleba saWiroebs Semdgom kvlevas.<br />
nevirapini SesaZloa gamoyenebul iqnas (200 mg erTxel 2 kviris<br />
ganmavlobaSi, Semdeg 200 mg orjer), RviZlis funqciuri testebis <strong>da</strong><br />
wamlis toqsiurobis kontroliT.<br />
200
ekomendirebuli meore rigis maarT reJimi tb pacientebisaTvis<br />
maarT<br />
sasurvelia 2 nrti<br />
+<br />
2 pi (maT Soris erTi<br />
bustirebuli)<br />
alternatiuli 2 nrti<br />
+<br />
2 pi<br />
arv preparatebis<br />
kombinacia<br />
ABC+ ddI + LPV/r +RTV<br />
an<br />
TDF+ ddI + LPV/r +RTV<br />
ABC+ ddI + SQV +RTV<br />
an<br />
TDF+ ddI + SQV +RTV<br />
rekomendebuli tb reJimebi Tirkmlis <strong>da</strong>avadebis mqone pacientebisTvis 1<br />
intensiuri faza gagrZelebis faza<br />
SerCevis preparati HRZ 2 Tve HR 4 Tve<br />
alternatiuli HRZE 2 Tve HR 4 Tve<br />
1. zemoT aRniSnuli rekomen<strong>da</strong>ciebi un<strong>da</strong> iqnes gaTvaliswinebuli,<br />
rodesac kreatininis done miaRwevs 130-160 mkm/l.<br />
rekomendebuli tb reJimebi pacientebSi RviZlis <strong>da</strong>avadebebiT 1<br />
intensiuri faza gagrZelebis faza<br />
SerCevis preparati SHRE 2 Tve HR 6 Tve<br />
I alternativa SHE 2 Tve HE 10 Tve<br />
II alternativa<br />
RE 9 Tve<br />
1. RviZlis <strong>da</strong>avadebad iwodeba mdgomareoba, rodesac<br />
alaninaminotransferaza samjer aRemateba normis maCvenebels an Tu<br />
saxezea qronikuli hepatiti an cirozi.<br />
6.reabilitacia <strong>da</strong> <strong>da</strong>kvirveba<br />
arv <strong>da</strong> tb <strong>mkurnaloba</strong>ze myofi pacientebis monitoringi<br />
Sefaseba kvira Tve<br />
0 2 4 8 3 4 5 6 7 8 9 10 11 12<br />
tb/ <strong>aiv</strong> <strong>da</strong>avadebebis istoria X X<br />
fizikaluri gamokvleva X X X X X X X<br />
komorbiduli <strong>da</strong>avadebebi X X X X<br />
ginekologiuri gamokvleva X X X X X<br />
rutinuli laboratoriuli X X X X<br />
201
testebi:<br />
• sisxlis saerTo analizi<br />
• RviZlis funqciuri sinjebi<br />
(alt, ast, bilirubinebi)<br />
• kreatinini<br />
• Sardovana<br />
CD4 ujredebi X X X X<br />
virusuli <strong>da</strong>tvirTva X X X X<br />
gul-mkerdis rentgenologiuri X X<br />
gamokvleva<br />
orsulobis testi X X<br />
naxvelis-nacxis gamokvleva 1 X X X X X X<br />
mkurnalobis reJimis <strong>da</strong>cvis X X X X X X X X X X X X X X<br />
Sefaseba (orive <strong>da</strong>avadebis: tb <strong>da</strong><br />
<strong>aiv</strong> infeqciis)<br />
7.gaidlaini, romelsac eyrdnoba aRniSnuli protokoli<br />
aRniSnuli protokoli eyrdnoba janmo-s mier evropis regionisTvis 2006<br />
wels gamocemul gaidlains ”tuberkulozisa <strong>da</strong> <strong>aiv</strong> <strong>infeqcia</strong>/DSidsis<br />
koinfeqciis marTva”, aseve, Sejerebulia DHHS, USA-IAS <strong>da</strong> EACS 2005 wlis<br />
”tb/<strong>aiv</strong> koinfeqciis” marTvis gaidlainebTan.<br />
202
Change language