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

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aiv infeqcia/SidsiT avadmyofTa

mkurnaloba da movla

(klinikuri saxelmZRvanelo rekomendacia –

gaidlaini)

2006 weli

Tbilisi

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

klinikuri saxelmZRvanelo – rekomendaciis avtorebi : Tengiz cercvaZe infeqciuri sneulebebis, Sidsis da klinikuri imunologiis s/p centris sameTvalyureo sabWos Tavmjdomare, Sidsis nacionaluri programis koordinatori, iv. javaxiSvilis sax. Tsu-s infeqciur daavadebaTa da klinikuri imunologiis departamentis sruli profesori fati gabunia infeqciuri sneulebebis, Sidsis da klinikuri imunologiis s/p centri, #2 boqsirebuli ganyofilebis gamgis m/S, medicinis mecierebaTa kandidati

nino goCitaSvili - infeqciuri paTologiis,Sidsis da klinikuri imunologiis s/p centri, Sidsis da imunodeficitebis dispanseruli ganyofilebis eqimi - infeqcionisti lali SarvaZe infeqciuri sneulebebis, Sidsis da klinikuri imunologiis s/p centri, Sidsis da imunodeficitebis ganyofilebis gamgis m/S, iv. javaxiSvilis sax. Tsu infeqciur daavadebaTa da klinikuri imunologiis departamentis asistent profesori

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sarCevi klinikuri saxelmZRvanelo-rekomendaciebis zogadi mizani

ganxiluli klinikuri sakiTxebi

visTvis aris gankuTvnili mocemuli klinikuri rekomendacia

mtkicebulebaTa doneebisa da rekomendaciebis gradaciis sqema abreviatura 1.daavadebis definicia klasifikacia terminologia 2.epidemiologia 3.etiopaTogenezi 4.klinikuri simptomatika 5.daavadebis diagnozi 6. gamokvlevis sqema

Tavi I. 1. aiv inficirebul pacientTa marTva 1.1. personaluri, ojaxis da samedicino istoria 1.2. fizikaluri gamokvleva 1.3. laboratoriuli da sxva gamokvlevebi 2. konsultireba aiv infeqciasTan asocirebuli problemebis Sesaxeb 3. oportunistuli da sxva infeqciebis profilaqtika 4. antirertovirusuli mkurnaloba 4.1. antiretrovirusuli mkurnalobis dawyeba 4.1.1. virusuli datvirTva 4.1.2. wamlisadmi rezistentobis testi 4.2. maRalaqtiuri antiretrovirusuli mkurnalobis pirveli rigis reJimebi 4.2.1. nukleozidis revers transkriftazas inhibitoris komponenti 4.2.2. aranukleozidis revers transkriftazas inhibitoris komponenti 4.3. antiretrovirusuli Terapiis reJimis dacva 4.3.1. antiretrovirusuli Terapiis reJimis dacvis barierebi da misi kontrolis strategiebi 4.4. uSedego mkurnaloba 4.4.1. virusuli araefeqturoba 4.4.2. imunologiuri araefeqturoba 4.4.3. klinikuri araefeqturoba 4.5. maRalaqtiuri antirerovirusuli mkurnalobis meore rigis reJimebi 4.5.1. nukleozidis revers transkriftazas inhibitoris komponenti 4.5.2. proteazas inhibitorebis komponenti 4.6. gadarCenis (Salvage) reJimebi 4.7. dagegmili Sewyvetili mkurnaloba (Sructured treatment interruption) 5. aiv inficirebul pacientTa klinikuri monitoringi 5.1. laboratoriuli indikatorebis monitoringi antiretrovirusuli Terapiis dawyebamde 5.2. laboratoriuli indikatorebis monitoringi antiretrovirusul Terapiaze myof pacientebSi 5.3. mkurnalobis reJimis dacvis monitoringi 5.4. antiretrovirusuli preparatebis toqsiurobis da gverdiTi efeqtebis marTva

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5.5. imunuri rekonstituciis sindromi 5.6. medikamentebis urTierTqmedeba

Tavi II. klinikur doneze Sesagrovebeli monacemebis minimumi damateba 1. aucilebeli informacia aiv infeqcia/Sidsis mkurnalobis da movlis personaluri istoriisTvis damateba 2. aiv infeqcia/Sidsis klinikuri klasifikacia Sesworebuli jandacvis msoflio organizaciis mier damateba 3. rezistentobis testi damateba 4. aucilebeli informacia antiretrovirusuli preparatebis Sesaxeb damateba 5. mkurnalobis reJimis dacvis monitoringis meTodebi damateba 6. antiretrovirusuli prepatarebis CamonaTvali damateba 7. leqsikoni damateba 8. horizonts miRma literaturis CamonaTvali

Tavi III. oportunistuli infeqcebis marTva 3.1. sasunTqi gzebis infeqciebi 3.1.1. baqteriuli respiratoruli infeqcebi 3.1.2. atipiuri mikobaqteriozebi 3.1.3. pnevmocisturi pnevmonia 3.1.4. sxva etiologiis pnevmoniebi imunodeficitis mqone pacientebSi 3.1.5. kuW-nawlavis traqtis infeqciebi 3.1.6. kandidozebi 3.1.7. kriptokokuli meningiti 3.1.8. histoplazmozi 3.1.9. kapoSis sarkoma 3.1.10. saSvilosnos yelis kibo 3.1.11. sxva avTisebiani warmoaqmnebi 3.1.11.1. arahojkinis limfoma 3.1.11.2. berkitis-tipis limfoma aiv inficirebulebSi 3.1.12. centraluri nervuli sistemis infeqciebi 3.1.13 toqsoplazmozi 3.1.14 martivi herpesiT gamowveuli infeqciebi 3.1.15 sartylisebuli liqeni 3.1.16 citomegalovirusuli infeqcia 3.1.17 epStein-baris virusiT gamowveuli infeqciebi 3.2. ZiriTadi simptomebi 3.2.1.persistuli generalizebuli limfadenopaTia mozrdil aiv inficirebulebSi

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3.2.2.cxeleba aiv inficirebulebSi 3.2.3. aiv inficirebul mozrdilebSi wonis umizezo kleba 3.2.4. mozrdilTa qronikuli diarea 3.2.5. piris Rrus dazinebebi 3.2.6. kanisa da frCxilebis dazianebebi 3.2.7. seboreuli dermatiti 3.2.8. muni 3.2.9. stafilokokuri folikuliti 3.2.10 kontagiozuri miluski gamoyenebuli literaturis CamonaTvali

Tavi IV aiv infeqcia/SidsiT daavadebulTa imunizaciis ZiriTadi principebi 4.1. vaqcinebisa da imunoglobulinebis gamoyeneba 4.2. cocxali atenuirebuli vaqcinebi 4.2.1 BCG vaqcina 4.2.2. qoleris vaqcina (CVD 103-HgR) 4.23. wiTelas, ybayurasa da wiTuras vaqcinebi (MMR, MR, M, R vaqcinebi6)

4.2.4. poliovirusis oraluri vaqcina (pov) 4.2.5. rotavirusis vaqcina 4.2.6. muclis tifis (Ty21a) vaqcina 4.2.7. Cutyvavilas vaqcina 4.2.8. yviTeli cxelebis vaqcina 4.3. daxocili da inaqtivirebuli vaqcinebi 4.3.1. qoleris vaqcina (WC/rBs) 4.2..2 difTeriis, tetanusisa da yivanaxvelas vaqcinebi (DTP, DTaP, DT, TT, Td9) 4.2.3. B tipis hemofilus influencas vaqcina (HiB) 4.2.4. A hepatitis vaqcina 4.2.5. B hepatitis vaqcina 3.2.5.1. B hepatitis vaqcinaciis reJimi aiv inficirebul pacientebSi 3.2.5.2. imunologiuri pasuxi B hepatitis vaqcinaciis mimarT 3.2.5.3. aiv inficirebul pacientTa B hepatitis vaqcinaciis Semdgomi monitoringi da strategia 4.3. gripis vaqcina

4.4. meningokokuri vaqcina 4.5. pnevmokokuri vaqcina 4.5..1. polisaqariduli pnevmokokuri vaqcina (ppv) 4.5.2. SekavSirebuli pnevmokokuri vaqcina (Spv) 4.6. inaqtivirebuli poliovirusis vaqcina (ipv) 4.7.cofis vaqcina 4.8. tkipismieri encefalitis vaqcina 4.9. tifis vaqcina (Vi polisaqaridi) 4.10. sxva daxocili antigenebi 4.1.1. imunoglobulinebis gamoyeneba 4.11.1. B hepatitis imunoglobulini (HBIg) 4.11.2. adamianis normaluri imunoglobulini 4.11.2.1. hepatiti A 4.11.2.2. wiTela

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4.11.2.3. cofis sawinaaRmdego imunoglobulini 4.11.2.4. tetanusis sawinaaRmdego imunoglobulini

4.11.2.5. Cutyvavila-zosteris sawinaaRmdego imunoglobulini danarTi 1. rekomendaciebi aiv infeqcia/SidsiT imunokompro-mitirebulTa imunizaciis Sesaxeb danarTi 2. aiv asocirebuli imunodeficitis klasifikacia danarTi 3. cofis vaqcina gamoyenebuli Lliteraturis CamonaTvali aiv infeqcia/Sidsis antiretrovirusuli Terapiis marTvis saxelmwifo standarti (protokoli) aiv infeqcia/SidsiT daavadebuli bavSvebis antiretrovirusuli mkurnalobis marTvis saxelmwifo standarti (protokoli) aiv infeqcia/Sidsis fonze ganviTarebuli baqteriuli pnevmoniis marTvis saxelmwifo standarti (protokoli) aiv infeqcia/Sidsis fonze ganviTarebuli atipiuri mikobaqteriozebis marTvis saxelmwifo standarti (protokoli) aiv infeqcia/Sidsis fonze ganviTarebuli pnevmocisturi pnevmoniis marTvis saxelmwifo standarti (protokoli) aiv infeqcia/Sidsis fonze ganviTarebuli kandidozebis marTvis saxelmwifo standarti (protokoli) aiv infeqcia/Sidsis fonze ganviTarebuli kriptokokuli meningitis marTvis saxelmwifo standarti (protokoli) aiv infeqcia/Sidsis fonze ganviTarebuli histoplazmozis marTvis saxelmwifo standarti (protokoli) aiv infeqcia/Sidsis fonze ganviTarebuli kapoSis sarkomis marTvis saxelmwifo standarti (protokoli)

aiv infeqcia/Sidsis fonze ganviTarebuli arahojkinis limfomebis marTvis saxelmwifo standarti (protokoli) aiv infeqcia/Sidsis fonze ganviTarebuli toqsoplazmozis marTvis saxelmwifo standarti (protokoli)

aiv infeqcia/Sidsis fonze ganviTarebuli martivi herpesiT gamowveuli infeqciebis marTvis saxelmwifo standarti (protokoli)

aiv infeqcia/Sidsis fonze ganviTarebuli martivi herpesiT gamowveuli infeqciebis marTvis saxelmwifo standarti (protokoli) aiv infeqcia/Sidsis fonze ganviTarebuli citomegalovirusuli infeqciis marTvis saxelmwifo standarti (protokoli)

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aiv infeqcia/Sidsis fonze ganviTarebuli dermatomikozebis marTvis saxelmwifo standarti (protokoli) aiv infeqcia/Sidsis fonze ganviTarebuli oniqomikozebis marTvis saxelmwifo standarti (protokoli) aiv infeqcia/Sidsis fonze ganviTarebuli seboreuli dermatitis marTvis saxelmwifo standarti (protokoli) aiv infeqcia/Sidsis fonze ganviTarebuli munis marTvis saxelmwifo standarti (protokoli) aiv infeqcia/Sidsis fonze ganviTarebuli stafilokokuri folikulitis marTvis saxelmwifo standarti (protokoli) aiv infeqcia/Sidsis fonze ganviTarebuli kontagiozuri moluskis marTvis saxelmwifo standarti (protokoli) aiv infeqcia/SidsiT avadmyofebSi B hepatitis virusiT ko-infeqciis marTvis saxelmwifo standarti (protokoli) aiv infeqcia/SidsiT avadmyofebSi C hepatitis virusiT ko-infeqciis marTvis saxelmwifo standarti (protokoli) aiv infeqcia/Sidsis da tuberkulozis koinfeqciis marTvis saxelmwifo standarti (protokoli)

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klinikuri saxelmZRvanelo-rekomendaciebis zogadi mizani

klinikuri saxelmZRvanelo-rekomendaciebis “aiv infeqcia/SidsiT avadmyofTa gamokvleva da mozardebisa da mozrdilTa antirertovirusuli mkurnaloba” mizans warmoadgens uaxles samecniero mtkicebulebebze dafuZnebuli informaciis miwodeba aiv-infeqcia/SidsiT avadmyofTa gamokvlevis, mkurnalobis, oportunistuli infeqciebis, vaqcinaciis, monitoringis Sesaxeb eqim - infeqcionistebisTvis, ojaxis eqimebisTvis, jandacvis pirveladi rgolis muSakebisTvis, zemoT aRniSnul dargSi momuSave saSualo samedicino personalisTvis da yvela dainteresebuli pirisTvis.

ganxiluli klinikuri sakiTxebi

mocemuli klinikuri rekomendaciebi ganixilaven aiv-infeqcia/Sidsis antiretrovirusul mkurnalobasTan dakavSirebul sakiTxebs, oportunistuli infeqciebis profilaqtikas, gamovlinebebs, diagnostikasa da mkurnalobas, vaqcinaciis ZiriTad principebs, avdmyofebis laboratorul-instrumentul gamokvlevebs mkurnalobamde da mkurnalobis dawyebis Semdeg, romlebic unda Catardes profilur dawesebulebaSi Sesabamisi kvalifikaciis mqone specialistis mier.

visTvis aris gankuTvnili mocemuli klinikuri rekomendacia

mocemuli klinikuri rekomendaciebi gankuTvnilia eqim infeqcionistebisTvis, nebismieri profilis eqimebisTvis, socialuri muSakebisTvis da eqTnebisaTvis.

mtkicebulebaTa doneebisa da rekomendaciebis xarisxi

winamdebare saxelmZRvaneloSi yvela rekomendacias gaaCnia gradacia, romelic aRiniSneba laTinuri asoebiT А- dan D- mde. amave dros yovel gradacias Seesabameba monacemTa mtkicebulebis garkveuli done. rac ufro maRalia rekomendaciis gradacia, miT ufro maRalia kvlevebis sizuste, romlebzec is aris dafuZnebuli

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done mtkicebulebis siZlieris done (Muir Gray)

xarisxi rekomendaciis xarisxi

(Cook et al) I

Zlieri mtkicebuleba, eyrdnoba minimum erT sistemur mimoxilvas, romelic efuZneba swori dizainis mqone randomizebul kontrolirebad kvlevas

A

eyrdnoba I donis mtkicebulebas da Sesabamisad mtkiced rekomendebulia

II

Zlieri mtkicebuleba, eyrdnoba minimum erTi swori dizainis mqone randomizebul kontrolirebad kvlevas

B

eyrdnoba I donis mtkicebulebas da Sesabamisad rekomendebulia

III

klinikuri kvleva randomizaciis gareSe, kohortuli da SemTxveva-kontrolis kvlevebi

C

eyrdnoba III donis mtkicebulebas SeiZleba CaiTvalos Sesabamisad

IV

araeqsperimentuli multicentruli kvlevebi

D

eyrdnoba IV da Vdonis mtkicebulebas saWiroebs konsesuss

Va

avtoritetul profesionalTa mosazreba

Vb

klinikuri gamocdileba, aRwerilobiTi kvlevebi an eqspertTa angariSi

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aabbrreevviiaattuurraa

aaiivv adamianis imunodeficitis virusi

aalltt alaninaminotransferaza

anrti ara-nukleoziduri revers transkriftazas inhibitori

aarrvv antiretrovirusuli

aarrTT antiretrovirusuli Terapia

aasstt aspartataminotransferaza

vvdd virusuli datvirTva

iirrss imunuri rekonstituciis sindromi

iiffaa imunofermentuli analizi

mmaaaarrTT maRalaqtiuri antiretrovirusuli Terapia

mmggbb mJavagamZle baqteria

mmrrttbb multirezistentuli tuberkulozi

nrti nukleoziduri revers transkriftazas inhibitori

ooii oportunistuli infeqciebi

ppii proteazas inhibitorebi

ppjjrr polimerizaciis jaWvuri reaqcia

ttbb tuberkulozi

SSiiddssii SeZenili imunodeficitis sindromi

jjaannmmoo jandacvis msoflio organizacia

AABBCC abakaviri

ddddII didanozini

EEFFVV efavirenzi

FFTTCC emtricitabini

LLPPVV//rr lopinavir/ritovaniri

NNFFVV nelfinaviri

ZZDDVV zidovudini

RRTTVV ritonaviri

SSQQVV seqvinaviri

TTDDFF tenofoviri

33TTCC lamivudini

UUNNAAIIDDSS gaeros aiv/Sidsis gaerTianebuli programa

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1.daavadebis definicia Sidsi abreviaturaa da iSifreba, rogorc SeZenili imunodeficitis sindromi. daavadeba Sidsis gamomwvevia adamianis imunodeficitis virusi (aiv-i). aiv infeqcia ewodeba daavadebas virusiT inficirebis momentidan sicocxlis bolomde. terminiT Sidsi aRiniSneba aiv infeqciis bolo stadia. aiv -i adamianis organizmSi SeWris Semdeg azianebs imunur sistemas, ris Sedegad inficirebul pirs SesaZloa ganuviTardes nebismieri infeqcia an/da simsivne, xSirad, sasikvdilo SedegiT.

aaiivv iinnffeeqqcciiiiss kkllaassiiffiikkaacciiiiss ssiisstteemmaa (CDC)

kklliinniikkuurrii kkaatteeggoorriiaa

kklliinniikkuurrii

kkaatteeggoorriiaa AA kklliinniikkuurrii

kkaatteeggoorriiaa BB kklliinniikkuurrii

kkaatteeggoorriiaa CC kkaatteeggoorriiaa CCDD44

uujjrreeddeebbiiss rraaooddeennoobbiiss mmiixxeeddvviiTT A B C

1) >500/mm3

(≥29%) A1 B1 C1

2) 200-500 mm3 (14-28%) A2 B2 C2

3) <200 (<14%) A3 B3 C3

* ruxi feriT moniSnul ujrebSi

miTiTebuli kategoriebi Seesabameba Sidss.

• asimptomuri aiv infeqcia;

• persistuli generali-zebuli limfade-nopaTia (pgl)*;

• mwvave (pirve-ladi) aiv daavadeba

* limfuri kvanZebi or an met midamoSi (sazardulis garda) diametriT > 1 sm-ze, 3 an meti Tvis ganmavlobaSi.

simptomuri, garda A da C kategoriebSi miTiTebuli mdgomareo-

bebisa

• baqteriuli angiomatozi;

• persistuli vulvova-ginaluri kandidozi, 1 Tveze meti xangrZli-vobis, romelic cudad eqvemdebareba mkurnalobas;

• saSvilosnos yelis mZime displazia an karcinoma insitu;

• konstitu-ciuri simptomebi, mag., cxeleba

(≥38,50C) an diarea 1 Tveze meti xnis ganmavlobaSi

• da sxva. -----------------------------

aRniSnuli mdgomareobebi ganpirobebuli unda iyos aiv infeqciiT.

ezofaguri da/an traqeo-bronquli kandidozi;

• eqstrapulmonuri koqcidiodomikozi;

• eqstrapulmonuri kriptokokozi;

• saSvilosnos yelis invaziuri kibo;

• qronikuli intestinuri kriptosporidiozi;

• citomegalovirusuli infeqcia: retiniti, an sxva lokalizaciis, garda RviZlis, elenTis, limfuri kvanZebisa;

• aiv encefalopaTia; martivi herpesi: kanis da lorwovanis wylulebiT 1 Tveze meti xnis ganmavlobaSi, bronqiti, pnevmonia;

• diseminirebuli, eqstrapulmonuri histoplazmozi;

• qronikuli izosporiazi;

• kapoSis sarkoma; • limfoma: berkitis, imunoblasturi, Tavis tvinis pirveladi;

• atipiuri mikobaqteriiT (M.avium an M.kansasii) infeqcia;

• pulmonuri an eqstrapulmonuri tuberkulozi;

• Pneumocystic carinii-iT gamowveuli pnevmonia;

• rekurentuli pnevmonia, (2 an meti epizodi weliwadSi);

• progresirebadi mravalkerovani leiko-encefalopaTia (pml);

• rekurentuli salmoneluri baqteriemia;

• cerebruli toqsoplazmozi;

• aiv-iT gamowveuli ganlevis sindromi.

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terminologia virusuli datvirTva – ewodeba adamianis imunodeficitis virusis (aiv-is) rnm-is raodenobas (koncentracias) plazmis 1 ml-Si; “fanjara” periodi – ewodeba periods adamianis imunodeficitis virusis organizmSi SeWridan aiv-antisxeulebis gamomuSavebamde; mwvave retrovirusuli sindromi – ewodeba aiv-is organizmSi SeWridan 2-3 kviris Semdeg ganviTarebul “infeqciuri mononukleozis msgavs sindroms”, romelic grZeldeba 2-3 kvira, mas mosdevs klinikuri gaumjobesebisa da serokonversiis periodi; klinikuri gaumjobeseba da serokonversia moicavs 2-4 kviras; am periodSi organizmSi gamomuSavdeba aiv-antisxeulebi; asimptomuri/qronikuli aiv infeqcia grZeldeba saSualod 8 weli; am periodis ganmavlobaSi TandaTan mcirdeba CD4+ limfocitebis absoluturi raodenoba SratSi da izrdeba virusuli datvirTva plzmaSi; oportunistuli infeqcia ewodeba iseT infeqciebs, romlis gamomwvevi (baqteria, virusi, paraziti Tu soko) Cveulebriv SeiZleba janmrTeli adamianis organizmSic binadrobdes da ar iwvevdes paTologias da mxolod imunokomprometirebul pirebSi gamoiwvios davaadeba. maRalaqtiuri antiretrovirusuli Terapia (maarT)- (HAART - High Activity antiretroviral Therapy) –3 an meti antiretrovirusuli preparatis kombinaciis xangrZlivad gamoyenebaa aiv infeqcia/SidsiT avadmyofebSi, romlis Sedegad: aRdgeba dazianebuli imunuri sistema, xangrZlivad iTrguneba Sidsis virusis replikacia, xangrZlivdeba avadmyofis sicocxle da umjobesdeba pacientis sicocxlis xarisxi. imunuri rekonstituciis sindromi (irs) – ewodeba paradoqsul reaqcias, romelic viTardeba antiretrovirusuli mkurnalobis dawyebis Semdeg da gamoxateba mdgomareobis gauaresebiT, rac dakavSirebulia latentur mdgomareobaSi myofi ama Tu im oportunistuli paTogenis gaaqtiurebasTan. imunuri rekonstituciis sindromi aixsneba antiretrovirusuli Terapiis Sedegad aRdgenili imunuri sistemis uCveulod mZlavri zemoqmedebiT mag: tuberkulozis mikobaqteriaze.

2. epidemiologia

aiv infeqcia/Sidsis gavrceleba msoflioSi

aiv/Sidsis epidemia kvlav rCeba dinamikur da mzardi xasiaTis epidemiad, romelmac saocari siswrafiT moicva msoflios praqtikulad yvela kontinenti, yvela qveyana da daamtkica, rom igi Tanabrad emuqreba yvelas rasis, sqesis, asakis, erovnebis, ganaTlebisa da sarwmunoebis miuxedavad. jandacvis msoflio organizaciis (janmo) monacemebiT Sidss msoflioSi sikvdilianobis mizezTa Soris meoTxe adgili ukavia. marTalia, antiretrovirusuli Terapiis (arT) xelmisawvdomobam da efeqturma profilaqtikurma programebma ganapirobes ganviTarebul qveynebSi mdgomareobis stabiluroba, magram mTlianad msoflioSi aiv inficirebulTa ricxvi mudmivad izrdeba.

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Sidsi registrirebulia msoflios 216 qveyanaSi. maTgan 41 qveyanaSi aqvs generalizebuli xasiaTi, xolo 85 – koncentrirebulia mxolod maRali riskis jgufebSi. gaeros Sidsis programis (UNAIDS) 2004 wlis monacemebiT msoflioSi: epidemiis dawyebidan dRemde inficirebulia 39.4 milioni adamiani maT Soris: mozrdilebi 37.2 mln qalebi 17,6 mln bavSvebi <15w 2.2 mln epidemiis dawyebidan dRemde gardaicvala 20 milionze meti adamiani. mxolod 2004 wels dainficirda 4,9 milioni adamiani maT Soris: mozrdilebi 4,3 mln bavSvebi <15w 640 000 2004 wels gardaicvala 3,1 milioni adamiani. maT Soris: mozrdilebi 2,6 mln bavSvebi <15w 510 000 aRsaniSnavia, rom msoflioSi inficirebis axali SemTxvevebis naxevari 15-dan 24 wlis asakze modis. amasTan, Tu epidemiis dasawyisSi aiv inficirebuli mamakacebis raodenoba mniSvnelovnad aRemateboda inficirebuli qalebis raodenobas, ukanasknel wlebSi proporcia dairRva da 2002 wlidan msoflioSi Sidsis virusiT inficirebulTa TiTqmis naxevari qalebma da gogonebma Seadgines. es tendencia gansakuTrebiT SesamCvevia msoflios im regionebSi, sadac dominirebs aiv-is gadacemis heteroseqsualuri gza. sayuradReboa aiv inficirebul orsul qalTa da axalSobilTa raodenobis mzardi dinamika. gamokvlevebiT dadginda, rom bavSvTa 90% aiv-iT inficirdeba vertikaluri (dedidan Svilze gadacemis) gziT. gansakuTrebuli msjelobis sagania Sidsis gamo daoblebuli bavSvebi. mxolod, sub-saharul afrikaSi Sidsis Sedegad daaxloebiT 12 milion bavSvs daeRupa erTi an orive mSobeli.

aiv infeqcia/Sidsis yvelaze meti SemTxveva oficialurad aRricxulia aSS-Si. Tumca realurad inficirebulTa raodenoba yvelaze metia afrikis kontinentze.

marTalia, sub-saharul afrikaSi dedamiwis populaciis mxolod 10% cxovrobs, magram msoflioSi yvela aiv inficirebulTa 2/3 swored am regionze modis. subsaharuli afrikis qveynebSi aiv infeqciis gadacemis ZiriTadi gza heteroseqsualuri kontaqtebia. amerikis kontinentze aRricxulia daaxloebiT 2,7 mln aiv inficirebuli (CrdiloeTi amerika – 1 mln SemTxveva, samxreTi amerika – 1,7 mln). kanadasa da aSS-Si aiv inficirebis SemTxvevaTa 25% gamowveulia narkotikebis ineqciuri moxmarebiT.

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amerikis kontinentze aiv infeqcia aSS-s Semdeg yvelaze farTod braziliasa da meqsikaSi aris gavrcelebuli. am qveynebSi dominirebs aiv infeqciis gavrceleba narkotikebis ineqciuri moxmarebiT an homoseqsualuri kontaqtebis Sedegad.

dasavleT evropaSi aiv/Sidsis yvelaze meti SemTxveva aRricxulia

inglisSi (≈ 62.000), Semdeg SveicariaSi, portugaliasa da germaniaSi. aiv/Sidsis gavrcelebis maRali maCveneblebi dafiqsirda holandiaSi, SvedeTSi, saberZneTSi, safrangeTsa da italiaSi. inficirebulTa 37% qalia, 29% _ axalgazrdebi 30 wlamde. am qveynebSi aiv inficirebis ZiriTadi mizezebia

• 50% _ heteroseqsualuri kontaqtebi

• 30% _ homo/biseqsualuri kontaqtebi

• 11% _ narkotikebis ineqciuri moxmareba centralur evropaSi kvlav SenarCunebulia aiv/Sidsis SemTxvevaTa dabali prevalentoba, Tumca am regionSi maRalia pediatriuli Sidsis maCveneblebi.

aziis kontinentze registrirebulia aiv infeqciis 7.4 mln. SemTxveva. es regioni didi xnis manZilze aiv infeqciisagan Tavisufal zonad iTvleboda, amJamad ki axali SemTxvevebis gamovlinebis mxriv azia erT-erT pirvel adgilze aRmoCnda. gansakuTrebiT SemaSfoTebeli statistikaa samxreT (pirvel rigSi CineTsa da indoeTSi) da samxreT aRmosavleT aziaSi.

epidemia Zalas ikrebs aRmosavleT evropis qveynebSi. ukanasknel wlebSi msoflioSi aiv infeqciis yvelaze swrafi aRmavloba swored am regionSi dafiqsirda. axali SemTxvevebis 76% modis ruseTis federaciaze, sadac yovelwliurad ormagdeba inficirebulTa raodenoba. aiv/Sidsis epidafeTqeba aRiniSneba ukrainasa da belorusiaSi. ukrainaSi mosaxleobis 1%-ia inficirebuli.

aRmosavleT evropis qveynebSi aiv inficirebis mizezebia

• 61% _ narkotikebis ineqciuri moxmareba

• 24% _ heteroseqsualuri kontaqtebi

• 0,3% _ homo/biseqsualuri kontaqtebi

aiv infeqcia/Sidsis gavrcelebis ZiriTadi gza am regionSi ineqciuri narkomaniaa, Tumca sul ufro izrdeba aiv-is heteroseqsualuri transmisiis SemTxvevebi. aRniSnulis gaTvaliswinebiT saxezea Sidsis virusis riskis jgufis pirebidan mosaxleobis farTo fenebSi gavrcelebis tendencia.

aiv infeqcia/Sidsis gavrceleba saqarTveloSi 2006 wlis 31 dekembris monacemebiT saqarTveloSi oficialurad registrirebulia aiv infeqcia/Sidsis 1800 SemTxveva, maTgan 2006 wels gamovlinda 243 aiv inficirebuli adamiani.

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registrirebul SemTxveevaTa 79% saqarTvelos sazRvrebs garedan Semotanili infeqciaa. 18,5% Semotanili infeqciis lokaluri gavrcelebis Sedegia aiv inficirebulis meuRleebsa da sqesobriv partniorebze infeqciis gadacemis Sedegad. gamovlenil inficirebulTagan 195 qalia, 643 mamakaci. 339 ganuviTarda Sidsi, 174 - gardaicvala.

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

aiv inficirebis yvelaze meti SemTxveva registrirebulia TbilisSi 306, Semdeg samegreloSi -129, aWarasa -121 da imereTSi -78. gamovlinda ucxoeTis 25 moqalaqe, maTgan 10 dabrunda TavianT qveyanaSi. saqarTveloSi SeiniSneba aiv infeqciis gavrcelebis aRmavali tempi. 2000 wels moxda aiv infeqciis registrirebuli SemTxvevebis gaormageba (1999 wlis 34 SemTxvevasTan SedarebiT 2000 wels gamovlinda 79 axali SemTxveva), Semdeg 2004 wels moxda 2003 welTan SedarebiT SemTxvevaTa 1,5-jer zrda. 2005 wlis 20 oqtombris monacemebiT gamovlinda 170 axali SemTxveva, rac aRemateba mTeli 2004 wlis manZilze gamovlenil SemTxvevaTa ricxvs. saqarTveloSi aiv infeqciis gavrcelebis Taviseburebani iseTivea, rogorc aRmosavleT evropis qveynebSi. Sidsis gavrcelebis upirveles risk-jgufs aqac ineqciuri narkomanebi warmoadgenen. magram, rogorc sxva qveynebis gamocdileba gviCvenebs, Sidsis epidemia ar Semoifargleba mxolod narkomanTa wriT, Sidsis Semdegi msxverplni narkomanTa sqesobrivi partniorebi iqnebian.

aiv infeqciis gadacemis gzebi

aiv infeqciis wyaros warmoadgens aiv inficirebuli an SidsiT daavadebuli adamiani, rogorc daavadebis usimptomo periodSi, aseve - klinikuri suraTis gaSlis Semdeg.

aiv aRmoCenilia adamianis mTel rig biologiur siTxeebSi. mas gansakuTrebiT maRali koncentraciiT Seicavs sisxli, sperma, vaginaluri sekreti, Tavzurgtvinis siTxe da dedis rZe.

Sidsis virusi gadaecema: • sqesobrivi kontaqtiT _ rogorc hetero, ise homoseqsualuri

kontaqtebiT (vaginaluri, analuri, oraluri);

• aiv inficirebuli sisxlis an misi calkeuli komponentebis gadasxmiT; aiv inficirebuli sisxliT dabinZurebuli Spricis, nemsis da sxva samedicino instrumentebis gamoyenebis SemTxvevaSi;

• inficirebuli dedisgan nayofze an axalSobilze mucladyofnis periodSi, mSobiarobis an ZuZuTi kvebis dros.

Sidsis virusi ar gadaecema:

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• haer-wveTovani gziT. Sesabamisad ar aris saSiSi aiv inficirebulTan saubari, virusi ar gadaecema daxvelebiT, daceminebiT an kocniT.

• sayofacxovrebo da socialuri kontaqtebiT. ar aris saSiSi xelis CamorTmeva, moxveva, daavadebulis mier gamoyenebuli WurWliT, TeTreuliT, saerTo tualetiT da abazaniT sargebloba. ar aris saSiSi aiv inficirebulTan erTad yofna sazogadoebrivi TavSeyris adgilebSi da mgzavroba transportiT.

• virusi ar gadaecema mwerebis an/da cxovelebis saSualebiT.

3. aiv infeqciis etiopaTogenezi

aiv miekuTvneba retrovirusebis ojaxs, lentivirusebis qveojaxs. lentivirusebi, Cveulebriv, nel infeqciebs iwveven. maTTvis damaxasiaTebelia daavadebis xangrZlivi latenturi periodi, paTologiur procesSi nervuli sistemis CarTva da susti imunuri pasuxi, rasac Tan sdevs persistuli viremia. ganasxvaveben aiv-1-sa da aiv-2-s. aiv-2 mogvianebiT aRmoaCines. igi aiv-1-sgan genetikuri Taviseburebebis mixedviT gansxvavdeba da ZiriTadad dasavleT afrikis zogierT qveyanaSia gavrcelebuli, Tumca sxva qveynebSic

gvxvdeba. aiv-2 aiv-1-Tan SedarebiT ufro Znelad gadaecema. iSvaTia misi vertikaluri gadacemis SemTxvevebic. aiv-2 infeqcia klinikurad aiv-1 infeqciis msgavsia, Tumca virusuli datvirTva, Cveulebriv, dabalia da daavadebis klinikuri progresireba ufro nelia.

aiv advilad inaqtivirdeba garemoSi. mSral pirobebSi virusi ramdenime saaTSi iRupeba, Tumca SesaZloa 1-3 dRe gaZlos. Qqsovilovan kulturaSi

virusi oTaxis temperaturaze 15 dRe Zlebs, xolo 370C-ze – 11 dRe. 56-600C-ze virusi 30 wT-Si iRupeba. virusi advilad eqvemdebareba qimiuri saSualebebiT sterilizacias. adamianis imunodeficitis virusi mdgradia

dabali temperaturisadmi -700C-ze ar inaqtivirdeba. aiv-is ZiriTadi samizne ujredebia CD4+ limfocitebi (T helper anu Th limfocitebi), garda amisa igi ainficirebs monocit/makrofagebs, cns-is mikroglias, folikulur-dendritul ujredebs da sxva. aiv-iT ujredis inficirebisas virusis garsis cila – gp120 uerTdeba samizne ujredis CD4 molekulas, rasac mohyveba virusis Sesvla ujredSi da misi genetikuri masalis integracia maspinZlis genomSi. Semdeg ki axali virionebis awyoba.

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adamianis imunodeficitis virusis sasicocxlo cikli

rogorc cnobilia, CD4+ limfocitebi aiv-is ZiriTadi samizne ujredebia. isini ZiriTad rols asruleben rogorc humoruli, ise – ujreduli imunuri pasuxis ganxorcielebaSi, ris gamoc maT imunuri orkestris diriJors uwodeben. aiv infeqciis imunopaTogenezSi wamyvani mniSvneloba eniWeba CD4+ limfocitebis raodenobis Semcirebas da maTi funqciis daTrgunvas, rasac Sedegad moyveba imunuri sistemis funqciis daTrgunva – imunosupresia. CD4+ limfocitebis ricxvi progresulad mcirdeba aiv infeqciis progresirebasTan erTad. igi virusul datvirTvasTan erTad mniSvnelovani markeria aiv daavadebis monitorirebisaTvis. aRsaniSnavia, rom virusis replikaciis TiToeul ciklSi warmoqmnili Stamebi erTmaneTisgan mniSvnelovnad gansxvavdeba ujreduli tropizmiT, antigenurobiT, wamlebis mimarT mgrZnobelobiT da sxva. aiv-is maRali mutagenoba mas saSualebas aZlevs efeqtianad aicilos Tavidan antivirusuli imunuri pasuxi, rac virusis persistencias uwyobs xels. garda amisa, aiv-is mutaciis amgvari unari dabrkolebebs qmnis vaqcinis SemuSavebisas da ganapirobebs wamlebis mimarT rezistentuli Stamebis warmoqmnas. aiv inficirebis gza, moxvedrili virusis raodenoba, aiv-is mocemuli Stamis paTogenuroba da maspinZlis genetikuri faqtorebi gavlenas axdens aiv specifikur imunur pasuxze. maneitralizebeli antisxeulebi gamomuSavdebian pirveladi infeqciidan 2-4 kviris Semdeg da maqsimums asimptomuri fazis dros aRweven. maTi gansazRvra sisxlSi rutinuli serologiuri testebiT SesaZlebelia inficirebidan 4-8 kviris Semdeg. Aantisxeulebis gaCenas sisxlSi serokonversia ewodeba. xolo periods inficirebidan serokonversiamde – e.w. window periodi. aiv antisxeulebis koncentracia mkveTrad ecema Sidsis ganviTarebasTan erTad. maneitralizebeli antisxeulebi aiv sawinaaRmdego citotoqsikur T limfocitebTan erTad imunuri pasuxis erT-erTi ZiriTadi komponentia, romelic dasawyisSi nawilobriv ablokirebs aiv-is replikacias. Tumca pirveladi infeeqciis dros ar xdeba aiv-is sruli eliminacia, rac infeqciis qronikul mimdinareobas ganapirobebs. provirus dnm-is integracia maspinZeli ujredis genetikur masalaSi da

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

4. klinikuri simptomatika

aiv infeqciis klinikuri speqtri aiv infeqciis bunebriv mimdinareobaSi (mkurnalobis gareSe) gamoyofen Semdeg stadiebs: virusis organizmSi SeWridan – 2-3 kviraSi viTardeba e.w. mwvave retrovirusuli sindromi – 2-3 kvira; klinikuri gaumjobeseba da serokonversia – 2-4 kvira; asimptomuri qronikuli aiv infeqcia – saSualod 8 weli; simptomuri aiv infeqcia/Sidsi – saSualod 1,3 weli; sikvdili. aiv infeqciis pirveladi gamovlinebaa mwvave retrovirusuli sindromi, romelsac Tan axlavs CD4+ limfocitebis ricxvis mkveTri daqveiTeba, plazmaSi maRali viremia.

cxrili #1 pirveladi aiv infeqcia: Civilebi da simptomebi (2002; US DHHS)

cxeleba – 96% mialgia – 54% hepatosplenomegalia –14%

adenopaTia - 74% diarea – 32% wonaSi kleba – 13% faringiti – 70% Tavis tkivili – 43% rZiana –12% gamonayari – 70% (eriTematozuli makulo-papuluri gamonayari saxesa da tanze, iSviaTad – xelisa da fexis gulebze, zogi aRniSnavs wylulovan gamonayars piris RruSi, saylapavisa da genitaluri organoebis lorwovanze)

sisuste da moTenTiloba – 27%

nevrologiuri gamovlinebebi – 12% (aseptiuri meningiti, meningoencefaliti, periferiuli neiropaTia, giien-bares sindromi, mxris nevriti, kognitiuri darRvevebi an fsiqozuri mdgomareoba)

klinikuri gaumjobesebis fazaSi aRiniSneba plazmaSi viremiis Semcireba, citotoqsiuri T limfocitebiT ganpirobebuli imunuri pasuxi. CD4+ limfocitebis ricxvis daqveiTeba kavSirSia virusuli datvirTvis matebasTan, rac Sidsis ganviTarebisa da avadmyofis sikvdilis mizezia. 2002 wels Catarebuli erT-erTi gamokvlevis SedegebiT CD4+ limfocitebis ricxvi aiv rnm-is koncentraciis yoveli log10-iT matebisas 1 ml-Si saSualod 4%-iT iklebs weliwadSi.

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aiv rnm-is koncentracia plazmaSi mkveTrad imatebs mwvave infeqciis periodSi da Semdeg iklebs, rac serokonversiisa da imunuri pasuxis Sedegia. daavadebis gviani stadia xasiaTdeba CD4+ limfocitebis ricxvis daqveiTebiT <200 ujredi/mm3 da oportunistuli infeqciebis, zogierTi simsivnis, ganlevis sindromis da nevrologiuri garTulebebis ganviTarebiT. aranamkurnaleb pacientebSi sicocxlis xangZlivoba mas Semdeg, rac CD4+ limfocitebis ricxvi 200 ujredi/mm3–mde daqveiTdeba, 3,7 welia; xolo Tu SidsTan asocirebuli pirveli klinikuri niSnebis gamovlenis momentisTvis CD4+ limfocitebis ricxvi udris an naklebia 60-70 ujr/mm3-Si, maSin avadmyofis sicocxlis xangrZlivoba saSualod 1,3 welia. daavadebis progresirebis tempi sxvadasxva pacientebSi variabeluria da mniSvnelovnad aris damokidebuli, erTis mxriv, maspinZlis e.w. dacviT faqtorebze da meores mxriv, virusis biologiur Taviseburebebze, aseve mniSvnelovnad icvleba igi mkurnalobisa da profilaqtikis fonze.

Sidsis klinikuri gamovlinebani metad mravalferovania. SidsiT daavadebuls Rrma imunodeficitis fonze SeiZleba ganuviTardes praqtikulad nebismieri infeqcia da simsivne, magram maTi ganviTarebis sixSire erTnairi ar aris. yvelaze xSirad uviTardebaT e.w. oportunistuli infeqciebi da is simsivneebi, romlebic, savaraudod, asocirebulia virusebTan.

oportunistuli ewodeba infeqcias, romlis gamomwvevi (baqteria, virusi, paraziti Tu soko) Cveulebriv SeiZleba janmrTeli adamianis organizmSic binadrobdes da ar iwvevdes paTologias da mxolod imunokomprometirebul pirebSi gamoiwvios daavadeba. SidsiT avadmyofebSi oportunustuli infeqciebi, rogorc wesi, Zalian mZimed mimdinareobs, cudad eqvemdebareba mkurnalobas da xSirad sikvdiliT mTavrdeba.

daavadebis progresirebis Sesafaseblad saukeTeso surogati markerebia virusuli datvirTva (anu virusis koncentracia 1 ml plazmaSi) da CD4+ limfocitebis absoluturi ricxvi 1 mm3 sisxlSi, romelTa saSualebiT SeasZlebelia daavadebis stadiisa da simZimis Sefaseba da mosalodneli progresirebis prognozireba Sidsis klinikuri niSnebis gamovlenamde 1,5-2 wliT adre. virusuli datvirTvis matebas, rogorc wesi, Tan sdevs CD4+ limfocitebis absoluturi ricxvis Semcireba. CD4+ pirdapirproporciul kavSirSia oportunistuli daavadebebis ganviTarebis riskTan. Uufro metic, CD4+ ujredebis garkveul maCvenebelze, ama Tu im konkretuli oportunistuli infeqciis da/an simsivneebis ganviTarebaa mosalodneli (ix. cxr. #2).

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cxrili #2 CD4+ limfocitebis ricxvis korelacia aiv infeqciis garTulebebTan

CD4+ limfocitebis ricxvi

infeqciuri garTulebebi arainfeqciuri garTulebebi

>500/mm3 -mwvave retrovirusuli sindromi

-vaginaluri kandidozi

-persistuli generalizebuli limfadenopaTia

-giien-bares sindromi -miopaTia

-aseptiuri meningiti 200-500/mm3 -pnevmokokuri da sxva

baqteriuli pnevmoniebi -filtvis tuberkulozi

- herpes zosteri -orofaringeuli

kandidozi - kriptosporidiozi, TviTgankurnebadi - kapoSis sarkoma

-Tmovani leikoplakia

- cervikaluri intraepiTeluri neoplazia

- cervikaluri simsivne (asocirebulia

adamiani papilomavirusTan) - B ujreduli simsivne

- anemia - idiopaTiuri

Trombocitopeniuli purpura

- hojkinis limfoma - limfocituri intersticiuli

pnevmonia

<200/mm3 - pnevmocisturi pnevmonia - diseminirebuli histoplazmozi da koqcidiomikozi

-miliaruli an filtvgareSe tuberkulozi

- progresirebadi multifokaluri

leikoencefalopaTia

- ganlevis sindromi - periferiuli neiropaTia - aiv asocirebuli demencia

- kardiomiopaTia - vakuoluri mielopaTia

- progresirebadi poliradikulopaTia

- arahojkinis limfoma

<100/mm3 -diseminirebuli martivi herpesi

- toqsoplazmozi - kriptokokozi

- kriptosporidiozi, qronikuli

- mikrosporidiozi - ezofaguri kandidozi

<50/mm3 - diseminirebuli citomegalovirusuli

infeqcia -atipiuri mikobaqteriis kompleqsiT gamowveuli diseminirebuli infeqcia

- centraluri nervuli sistemis limfoma

(asocirebulia epStein- baris

virusTan)

Sidsi erTi konkretuli virusiT gamowveuli daavadebaa, magram amave dros igi warmoadgens am virusiT gamowveuli imunodeficitis fonze ganviTarebul daavadebaTa speqtrs. Amis gamoc Sidsis klinikuri gamovlinebani imdenad mralavferovani SeiZleba iyos, rom Sidsis diagnozis dadgena mxolod klinikuri niSnebis safuZvelze praqtikulad

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SeuZlebelia da gadamwyveti misi diagnostikisTvis laboratoriuli gamokvlevaa. Sesabamisad, Sidsze saeWvo SemTxvevaSi diferenciuli diagnozi gatarebul unda iqnas yvela im daavadebasTan, romelic Sidsis dros SeiZleba Segvxvdes. marTalia, aiv infeqcias paTognomuri klinikuri niSnebi ar gaaCnia, magram mainc SeiZleba gamoiyos simptomebisa da daavadebebis jgufi, romelTa dros pirvel rigSi eWvi unda iqnas mitanili aiv infeqcia/Sidsze. Eesenia:

- aramotivirebuli (ucnobi etiologiis) cxeleba; - persistuli generalizebuli limfadenopaTia; - ganlevis sindromi (aiv kaxeqsia); - ucnobi etiologiis qronikuli diarea; - sxvadasxva saxis gamonayari kansa da lorwovanze; - gaxangrZlivebuli filtvebis anTeba, romelic cudad

eqvemdebareba Cveulebriv antibaqteriul Terapias; - nervuli sistemis sxvadasxva saxis dazianeba: -demencia, romlis erT-erTi mizezia Tavis tvinis atrofia, -kriptokokuli etiologiis meningiti, -toqsoplazmozuri encefaliti damaxasiaTebeli abscesebiT Tavis tvinSi, -progresuli multifokaluri leikoencefalopaTia.

SidsisTvis paTognomuria sami simsivnuri daavadeba:

• limfuri sistemis simsivne (hojkinis da ara-hojkinis simsivneebi) Tavis tvinis pirveladi limfoma, romelic gvxvdeba mxolod Sidsis an sxva imunokomrpomisis fonze

• saSvilosnos yelis invaziuri kibo da analuri invaziuri kibo homoseqsual mamkacebSi

• kapoSis sarkoma.

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sayuradReboa, rom samive zemoT CamoTvlili simsivne asocirebula virusebTan. limfuri sistemis kibo asocirebulia epStein-baris virusTsan; saSvilosnos yelisa da analuri invaziuri kibo asocirebulia papilomavirusTan, kapoSis sarkoma asocirebulia adamianis me-8 tipis herpesis virusTan. am simsivneebis arsebobis dros aucilebelia aiv intisxeulebze testireba. amasTan, aucileblad unda iqnes gaTvaliswinebuli epidemiologiuri monacemebi (maRali riskis jgufi, aiv inficirebulTan kontaqti da sxva), garda amisa, aiv infeqciaze gamokvleul unda iyvnen:

• sggd avadmyofebi: sifilisiT, gonoreiT, qlamidioziT, veneriuli limfogranulomiT, triqomoniaziT da a.S daavadebulebi

• B hepatitis virusiT inficirebulni

• C hepatitis virusiT inficirebulni,

• tuberkulozis nebismieri formiT daavadebulni (filtvis tuberkulozi, limfuri sistemis tuberkulozi, tuberkulozuri poliseroziti, tuberkulozuri meningiti) .

Aaramotivirebuli cxeleba (ucnobi etiologiis cxeleba)

ganmarteba: ucnobi etiologiis cxeleba ewodeba sami ZiriTadi

maxasiaTebelis Tanaarsebobas: 1) cxeleba 38.30C-ze an meti, 2)romelic grZeldeba 3 kviraze meti periodis ganmavlobaSi 3) da diagnozis garkveva ver moxerxda erTkviriani hospitalizaciis ganmavlobaSi. samkviriani periodi aucilebelia TviTgankurnebadi virusuli infeqciebis gamosaricxad.

persistuli generalizebuli limfadenopaTia

ganmarteba: persistuli generalizebuli limfadenopaTia ewodeba mdgomareobas, rodesac 3 kviraze meti periodis ganmavlobaSi hiperplazirebulia qvemoT CamoTvlili kanqveSa limfuri kvanZebidan 2-3 an meti : yuris wina, qvedaybisqveSa, kisris wina da ukana, kefisukana, laviwzeda, laviwqveSa, iRliis, idayvis, sazardulis horizontalur limfur kvanZTa jgufi, sazardulis vertikalur limfur kvanZTa jgufi. samkviriani periodi aucilebelia limfadenopaTiiT mimdinare TviTgankurnebadi virusuli infeqciebis gamosaricxad (ix. qvemoT).

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persistuli generalizebuli limfadenopaTiis mizezi garda aiv infeqciisa SeiZleba iyos

- simsivneebidan: limfomebi, leikemiebi, kapoSis sarkoma, metastazebi;

- infeqciebidan: brucelozi, katis nakawris daavadeba, veneriuli limfogranuloma, infeqciuri mononukleozi, wiTura, tuberkulozi, tularemia, tifoiduri cxeleba, sifilisi.

- autoimunuri daavadebebidan: sistemuri wiTeli mglura, revmatoiduli arTriti, dermatomioziti, Segrenis sindromi.

- iSviaTad: kavasakis daavadeba, sarkoidozi, medikamentebiT provocirebuli.

ganlevis sindromi ganmarteba: wonaSi umizezod kleba sawyis wonasTan SedarebiT 10%-ze meti erTi Tvis manZilze.

konstituciuri simptomebi (CDC-is klasifikaciiT) (aiv kaxeqsia –janmos klasifikaciiT)

ganmarteba:

- wonaSi umizezod kleba: sawyisi wonis 10%-ze meti, - an ucnobi etiologiis qronikuli diarea - 1 Tveze meti

xangrZlivobis, - an qronikuli sisuste SeuRlebuli xangrZliv (1 Tveze meti)

ucnobi etiologiis cxelebasTan

ucnobi etiologiis qronikuli diarea

ganmarteba: qronikuli ewodeba diareas, romelic meordeba TiTqmis yoveldRe 1 Tvis an meti drois manZilze. qronikuli diarea SeiZleba mimdinareobdes ganlevis sindromiT an mis gareSe, temperaturiT an mis gareSe. afebriluri qronikuli diareis gamomwvevi SeiZleba iyos kroptosporidia, izospora, mikrosporidia. temperaturuli reaqcia Tan axlavs qronikuli diareis Semdeg mizezebs: Jiardiozi, amebiazi, citomegalovirusiT gamowveuli diarea. garda zemoT CamoTvlili gamomwvevebisa qronikuli diareis mizezi Rrma imunodeficitis dros SeiZleba iyos: Mycobacteria Avium, Cyclospora cayetyaensis, Enteric virusis. zemoT CamoTvlili gamomwvevebis umravlesobis identifikacia Zalian rTulia da aucilebeblia an kvlevis kulturaluri meTodebis an nawlavis biofsiis gamoyeneba.

gamonayari kansa da lorwovanze

imunokomprometirebul pirebSi gvxvdeba kanisa da lorwovanis igive daavadebebi, rac imunokompetentur pirebSi, Tumca

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imunokomproometirebulebSi kanisa da lorwovanis banaluri daavadebebi mimdinareobs rTulad, aqvs persistuli xasiaTi da rTulia samkurnalod. qvemoT, mokled aris daxasiTebuli kanisa da lorwovanis is daavadebebi, romlebic ufro xSirad viTardeba aiv infeqcia/Sidsis fonze. Sesabamisad, klinicistma qvemoT aRwerili kanis da lorwovanis romelime daavadebis identifikaciisas avadmyofi unda gamoikvlios aiv antisxeulebze.

5. daavadebis diagnozi

laboratoriuli diagnostika

vinaidan aiv infeqcias paTognomuri klinikuri niSnebi ar gaaCnia, gadamwyveti mis diagnostikaSi laboratoriuli gamokvlevaa. aiv infeqciis laboratoriuli diagnostika sxvadasxva meTodiT xorcieldeba, virusis kultivireba Semdgomi idenTifikaciiT, sisxlsa da sxva biologiur siTxeebSi virusis antigenis da antisxeulebis gansazRvra, virusis genomis gamovlena da sxva. dReisaTvis aiv infeqciis laboratoriuli diagnostikis ZiriTadi saSualebebia sisxlSi aiv sawinaaRmdego antisxeulebis da virusis genetikuri masalis gansazRvra. aiv antisxeulebis gansazRvris meTodebi or jgufad iyofa – pirveladi anu skrininguli da damadasturebeli anu komfirmaciuli. skriningul meTodebs miekuTvneba: aiv antisxeulebis gamovlena imunofermentuli analizis (ifa), imunofluorescenciis, hemaglutinaciis, imunoqromatografiis, mikroprecipitaciis da sxva meTodebiT. gamokvlevis xangrZlivobis mixedviT es meTodebi iyofa Cveulebriv (xangrZlivoba 2-5 saaTi) da swraf/martiv (xangrZlivoba 5-30 wuTi) meTodebad. konfirmaciuli meTodebidan ZiriTadad gamoiyeneba imunoblotingi (Western blot). skriningul meTodebs Soris yvelaze farTod gamoiyeneba aiv antisxeulebis gamovlena ifa da swrafi/martivi meTodebiT, romlebic maRali mgrZnobelobiTa da specifikurobiT xasiaTdeba da amasTan, advilad xelmisawvdomia. maTi saSualebiT aiv antisxeulebi sisxlSi vlindeba inficirebidan 4-8 kviris Semdeg. dadebiTi Sedegis SemTxvevaSi kvleva grZeldeba damadasturebeli anu, konfirmaciuli meTodiT – imunoblotingiT (Western blot). imunoblotingis meTodi saSualebas iZleva ganisazRvros specifikuri antigenebis, anu virusis calkeuli cilebis sawinaaRmdego antisxeulebi. sadReisod yvelaze zusti da maRalmgrZnobiare meTodia virusis genomis (rnm, dnm) gamovlena polimerizaciis jaWvuri reaqciis (PCR) meTodiT. arsebobs virusis genomis gamovlenis alternatiuli meTodebic – bDNA (branched chain DNA) da NASBA (Nucleic Acid Sequence-Based Amplification). Tumca Tavisi mgrZnobelobiTa da specifikurobiT sadReisod isini PCR meTods CamorCeba. bDNA meTodiT xdeba virusis rnm-is moniSnuli monakveTidan

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signalis amplifikacia komplementuri dnm-iT hibridizaciis gziT. xolo PCR da NASBA meTodebis SemTxvevaSi xdeba virusis moniSnuli rnm-is amplifikacia fermentuli meTodebiT ise, rom gamravlebuli rnm ganisazRvros Cveulebrivi meTodebiT. PCR, romelic 80-ian wlebSi dainerga, didi win gadadgmuli nabijia zogadad infeqciuri daavadebis, maT Soris aiv infeqciis diagnostikaSic. misi saSualebiT xdeba infeqciuri agentis genetikuri masalis amplifikacia da gamovlena im SemTxvevaSic ki, roca misi koncentracia gamosakvlev masalaSi ukiduresad mcirea (1 virusi 100 000 ujredze).

PCR meTodi ori saxisaa: Tvisobrivi da raodenobrivi. Tvisobrivi gamoiyeneba aiv infeqciis diagnostikisaTvis adreul stadiaze – sisxlSi antisxeulebis gaCenamde, agreTve ifa da imunoblotingiT saWvo pasuxis miRebis SemTxvevaSi. gansakuTrebiT didia misi diagnostikuri Rirebuleba inficirebuli dedis axalSobilis aiv infeqciis diagnostirebisas. rogorc cnobilia, aiv inficirebuli dedis axalSobils SesaZloa arainficirebis SemTxvevaSic ki aReniSnos aiv antisxeulebis arseboba maTi transplacenturi barieris gavlis gamo. amitom gadamwyveti mniSvneloba axalSobilis aiv infeqciis diagnostikaSi swored PCR meTods eniWeba. raodenobrivi meTodi saSualebas iZleva ganisazRvros e.w. virusuli datvirTva, anu virusis raodenoba 1 ml plazmaSi. virusuli datvirTva saukeTeso markeria daavadebis prognozirebisa da mkurnalobis efeqtianobis Sesafaseblad.

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Tavi I. aiv inficirebul pacientTa marTva

1. pacientTa gamokvleva pirveli vizitisas

aiv inficirebuli pacientis gamokvleva pirveli vizitisas moicavs:

• detalur personalur, ojaxis da samedicino istorias;

• fizikalur gamokvlevas;

• laboratoriul da sxva gamokvlevebs;

• Sesabamisi specialistis gamokvlevas.

1.1. personaluri, ojaxis da samedicino istoria

cxrili 3. informacia, romelic aucileblad unda Sediodes samedicino istoriaSi pirveli vizitisas ZiriTadi informacia:

• pacientis saxeli

• dabadebis weli, Tve, ricxvi

• sqesi

• vizitis TariRi informacia testirebis Sesaxeb

• pirveli pozitiuri aiv testirebis TariRi

• mizezi, Tu ratom Caitara testireba

• bolo aiv negatiuri testirebis TariRi, Tu cnobilia aiv eqspoziciis riski da gadacemis kategoria (Tu cnobilia):

• saineqcio narkotikebis gamoyeneba

• sqesobrivi (sqesobrivi kontaqtis saxis miTiTebiT)

• sisxlis an misi produqtebis gadasxma, organos an qsovilis gadanergva

• dedidan bavSvze gadacema

• samsaxureobrivi eqspozicia (aRwerilobiT)

• ucnobi

• sqesobrivi partnior(eb)is aiv statusi (Tu cnobilia)

• sqesobrivi partnior(eb)is risk faqtorebi (Tu cnobilia)

aiv infeqciis gadadebis dro da adgili (qveyana), romelic yvelaze metad aris savaraudo an cnobili (a) aiv infeqciis mkurnalobis da movlis istoria: (ix. damateba 1)

• vizitamde aiv infeqciis mkurnalobis dro da adgili, mkurnalobis Sewyvetis miTiTebiT

• mkurnalobis reJimi

• gverdiTi efeqtebi

• reJimis dacva

• laboratoriuli monacemebi (CD4, virusuli datvirva, eleqtrolitebi, RviZlis funqciebi, Tirkmlis funqciebi, sisxlis saerTo analizi, didi xnis win inficirebuli pacientisTvis dalagebuli unda iyos qronologiurad) (7)

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• vizitamde rezistentobis testis dokumentirebuli Sedegi (Tu iyo gakeTebuli)

aiv asocirebuli daavadebebi da mdgomareobebi:

• tuberkulozi

• respiratoruli infeqciebi

• virusuli, baqteriuli da sokovani infeqciebi

• hepatiti B da C • neoplaziebi

• sxva sxva daavadebebi da mdgomareobebi:

• hospitalizacia

• qirurgiuli Careva

• sulieri mdgomareoba (depresia da a.S.)

• Tirkmlis an RviZlis daavadebebi

• endokrinologiuri daavadebebi

• sqesobrivi gziT gadamdebi daavadebebi (sggd)

• vaqcinaciebi

• alergiebi

• sxeulis cvlilebebi

• mimdinare medikamentebi ojaxis samedicino istoria (diabeti, arteriuli hipertenzia, kanis daavadebebi, simsivneebi da a.S.) gul-sisxlZarRvTa daavadebebi da daavadebis risk-faqtorebi (simsuqne, Tambaqos Warbad moxmareba, arteriuli hipertenzia da a.S.) eqspozicia tuberkulozTan (personaluri an ojaxuri kontaqtebi) b mimdinare medikamentebi (opioid CanacvlebiTi Terapiis CaTvliT) nivTierebaTa moxmareba:

• akrZaluli saineqcio narkotikebis moxmareba (warsulSi an awmyoSi)

• alkoholuri damokidebuleba reproduqciuli da sqesobrivi janmrTeloba

• kontracefciis meTodebi qalebSi

• orsuloba (wina, mimdinare, dagegmili)

• sqesobrivi praqtika socialuri istoria

• sacxovrebeli pirobebi (partnior(eb)i / meuRle / ojaxis wevrebi, bavSvebi da a.S.)

• profesia da Tanamdeboba

• daxmarebis qseli (socialuri da samedicino dazRveva, sazogadoebrivi jgufi, vin icis pacientis aiv statusis Sesaxeb da a.S.)

a saWiroa epidemiologiisTvis, virusis subtipi da savaraudo rezistentuli Stamebis profili. b tuberkulozze Semdgomi gamokvlevis instuqciisTvis ix. aiv infeqciis da tuberkulozis koinfeqciis marTvis gaidlaini

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1.2. fizikaluri gamokvleva

fizikaluri gamokvlevisas unda dafiqsirdes arsebuli simptomebi da niSnebi, raTa ganisazRvros cvlilebebi statusSi. sasurvelia vixelmZRvaneloT standartuli istoriiT da gamokvlevis kiTxvariT; ix cxrili 2. cxrili 4. sawyisi fizikaluri gamokvleva garegnuli monacemebi:

• simaRle da wona

• lipodistrofia

• karnovskis indeqsi an zogadi mdgomareobis sxva standartuli Sefaseba

sasicocxlo niSnebi:

• arteriuli wneva

• temperatura

• pulsi Tavi

• garegnuli monacemebi

• kbilebis mdgomareoba

• oraluri kandidozi

• Tmovani leikoplakia

• pirveladi sifilisi

• saxis kani gul-mkerdi

• suTqva, xveleba, dispnoe

• gul-mkerdis forma

• emfizemis riskis kontroli sarZeve jirkvlis daTvaliereba (qalebsa da mamakacebSi) karcinomis riskis gasakontroleblad gulis mdgomareoba kardiovaskuluri riskis SefasebisTvis antiretrovirusul mkurnalobaze (8,9) (CIII) an endokarditis riski saineqcio narkomanebSi muclis Rrus da gastrointestinuri sistemis gamokvleva (sawyisi informacia antiretrovirusuli mkurnalobis gverdiTi efeqtebisTvis, gansakuTrebiT qronikuli hepatitis, alkoholuri intoqsikaciis da cirozis SemTxvevebSi)

• RviZlisa da elenTis konsistencia, zomebi da forma

• nawlavebis muSaoba

• muclis sirbile

• rigidoba

• sisuste, moTenTiloba, disfagia genitaluri da analuri regionis gamokvleva:

• martivi herpesi

• citomegalovirusi

• sifilisi

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• adamianis papilomavirusi (maxvilwvetiani kondilomebi, analuri karcinoma) (10) (BII), sxva sqesobrivi gziT gadamdebi daavadebebi(sggd)

qvemo kidurebi (moZraoba, mobiluroba, lipodistrofia) antiretrovirusuli mkurnalobis gverdiTi efeqtebis gasaTvaliswineblad kani (sxeulis):

• gadatanili herpes zosteri

• RviZlis daavadebebi

• kapoSis sarkoma

• seboreuli deramatiti

• narkotikis ineqciis adgilebi kanis dazianebebi mag: moyavisfro an muqi laqebi umjobesia avsaxoT fotoebSi, kanis sxva SesaZlo dazianebis gamiricxvis mizniT (moqaveba da gafxaWna) momavali gamokvlevisas limfuri kvanZebi nevrologiuri statusi (neiropaTiis niSnebi) gonebrivi statusi mxedveleobiTi da smeniTi funqcia

1.3. laboratoriuli da sxva gamokvlevebi cxrili 5. laboratoriuli testebi aiv infeqciasTan dakavSirebuli testireba:

• aiv serologiuri gamokvleva (tipurad ELISA an swrafi testi), romelsac mohyveba damadasturebeli testi (tipiurad vestern blotingi) (11) (AI);

• CD4 ujredebis ricxvi imunodeficitis xarisxis gansazRvrisTvis; orsul qalebSi CD4% (12,13) (AI)da

• virusuli datvirTvis testi polimerazuli jaWvuri reaqciis (pjr) meTodiT, virusis replikaciis donis gansazRvrisTvis (AI) a ;

testireba sxva infeqciebze (CIII)

• testi sifilisze (VDRL); • vaginaluri, asos an analuri Camonafxeki gonoreisa da Chlamydia

trachomatis identifikaciisTvis;

• testireba toqsoplazmis IgG serologiur testze da informacia infeqciis riskis Sesaxeb Tu serologiis Sedegi uaryofiTia

• kriptokokis antigenis titri rodesac CD4 limfocitebis ricxvi < 200 mm3 da saxezea kriptokokozis klinikuri niSnebi

• CMV antigenemia (pp65 adreuli antigeni) rodesac CD4 ujredebis ricxvi < 100 mm3 b

• serologiuri testi B,C hepatitis virusebze (anti HCV, HBsAg) g ZiriTadi laboratoriuli testebi:

o eleqtrolitebi (natriumi, kaliumi) N o RviZlis funqciuri sinjebi (ALT, AST, tute fosfataza,

saerTo da arapirdapiri bilirubini) o Tirkmlis funqciebi (Sardovana, kreatinini)

30

o laqtaddehidrogenaza (limfomebis dros ujredTa ZiriTadi brunva, filtvis infeqciebis niSnebi, miokardiumis infarqti, kunTebis dazianebani da a.S.)

o INR an proTrombinis dro o sisxlis saerTo analizi (formuliTa da Trombocitebis

ricxviT) o orsulobis testi arv Terapiis dawyebamde

Tu SesaZlebelia:

o glukoza o qolesterini (HDL, VLDL) o trigliceridebi o lipaza o C-reaqtiuli cila (CRP) o Tiroid-mastimulirebeli hormoni (TSH )

a. testebi umjobesia gakeTdes erTidaigive laboratoriaSi, raTa Tavidan aviciloT teqnikuri winaaRmdegobani b. CMV infeqciis adreuli deteqcia SesaZlebelia da pp65 adreuli antigeni kargi markeria CMV infeqciis mkurnalobis efeqturobis SefasebisTvis g. virusul hepatitebze testirebis Semdgomi informaciisTvis ix. C hepatitis da HIV koinfeqciis da B hepatitis da HIV koinfeqciis menejmentis protokolebi. cxrili 5. sxva gamokvlevebi

o tuberkulinis kanis testi a o naxvelis nacxis mikroskopia da gul-mkerdis rentgenologiuri

gamokvleva Tu saxezea tuberkulozis niSnebi o ekg (gamokvleva mkurnalobamde arT-ze myof pacientebSi gul-

sisxlZarRvovani daavadebis didi riskis gaTvaliswinebiT, SedarebisTvis) (14) (BII)

a. Semdgomi informaciisTvis tuberkulinis kanis testze gTxovT mimarToT tuberkulozis da HIV koinfeqciis menejmentis protokols sxva gamokvlevebis Catareba SesaZlebelia gaxdes saWiro Tanmxlebi daavadebebis gaTvaliswinebiT, magaliTad HCV/HIV an HBV/HIV koinfeqiebis dros: muclis Rrus organoebis eqoskopia limfuri kvanZebis, RviZlisa da elenTis zomebisa da formis Sesafaseblad an gastrointestinuri traqtis daavadebebis klinikuri niSnebis arsebobisas_ zemo an qvemo gastrointestinuri traqtis endoskopia. endoskopiuri monacemebi sasurvelia dokumentirebuli iyos fotoebiT. cxrili 7. specialistTa konsultaciebi

o nevrologiuri gamokvleva, rodesac HIV pirvelad aris diagnostirebuli (mag. periferiuli neiropaTiis identifikaciisTvis)

o ofTalmologiuri gamokvleva yovel sam TveSi erTxel CMV

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retinitis identifikaciisTvis, rodesac CD4 ujredebis ricxvi < 100mm3

o ginekologiuri gamokvleva PAP nacxis CaTvliT yovel 6 TveSi erTxel (adamianis papilomavirusiT gamowveuli karcinoma)

o sxva specialistebis konsultacia aucileblobis SemTxvevebSi

2. aiv infeqciasTan dakavSirebuli debulebebi

aiv infeqcia/SidsiT mcxovrebi pacientebis menejmenti moicavs: o pacientebis janmrTelobis monitorings; o arT-s dawyebas da mis xelSewyobas; o oportonistuli infeqciebis da sxva Tanmxlebi infeqciebisa da

daavadebebis profilaqtikasa da mkurnalobas; o fsiqologiur mxardaWeras; o mkurnalobis reJimis dacvis meTvalyureobas; o konsultirebas; o movlas.

pacientebis konsultireba unda daiwyos maTi socialuri mdgomareobis ganxilviT, romelic moicavs:

o megobrul ganwyobas; o samsaxureobriv statuss, samuSaos tips da mdgomareobas; o adamianebs, romlebic unda iyvnen informirebulni pacientis aiv

statusis Sesaxeb; o adamianebs, romlebTan erTadac jandacvis muSaks SeuZlia

ganixilos pacientis janmrTelobasTan dakavSirebuli sakiTxebi; o ojaxis wevrebs da naTesavebs; o medikamentebis Senaxvis reJimis dacvis SesaZleblobas; o cxovrebis stils, romelic SesaZloa zemoqmedebas axdendes

mkurnalobaze (15-17) (CIII). jandacvis muSakebma inficirebul pacientebTan erTad unda ganixilon mTeli rigi informaciisa, romelic unda esmodes pacients:

o avadmyofs unda aexsnas riskis Semcireba (daculi sqesobrivi kontaqti, ineqciis unar-Cvevebis gacnoba da sxva) romelic moicavs aiv pozitiur partniorTan daucveli sqesobrivi kontaqtis SemTxvevaSi aiv super infeqciis saSiSroebas rezistentuli StamiT. (18) (BII)

o toqsoplazmozis negatiuri serologiis SemTxvevaSi avadmyofs unda ganemartos misi gadacemis gzebi (maT Soris riski, romelic dakavSirebulia cxovelebTan) da profilaqtikis meTodebi (ix. protokoli 2 aiv/Sidsis ZiriTadi simtomebis da oportunistuli infeqciebis menejmenti)

o radgan HBV/HIV da HCV/HIV koinfeqcia xSiria da dakavSirebulia mTel rig sirTuleebTan, didi mniSvneloba eniWeba maT prevencias. Tanabrad mniSvnelovania RviZlis dazianebis da dedidan bavSvze infeqciebis gadacemis riskis Semcireba.

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o pacientebi saWiroa iyvnen informirebulni SesaZlo oportunistuli infeqciebis niSnebze (ix. protokoli 2 aiv/Sidsis ZiriTadi simtomebis da oportunistuli infeqciebis menejmenti)

o saineqcio narkotikebis momxmareblebTan unda ganvixiloT misi Sewyvetis mniSvneloba. Tu pacients ar surs an ar SeuZlia Sewyvitos saineqcio narkotikebis moxmareba maSin unda ganvumartoT zianis Semcirebis arsi;

o avadmyofs unda esmodes jansaRi cxovrebis wesis kerZod, Zilis, kvebis, varjiSis mniSvneloba.

o pacientebs, romelTac unda daiwyon antiretrovirusuli Terapia, unda ganemartoT Semdegi sakiTxebi:

o mkurnalobis reJimis dacvis mniSvneloba; o antiretrovirusuli medikamentebis SesaZlo toqsiuroba; o medikamentebis urTrierTqmedeba; o kontracefciis aucilebloba, rodesac pacienti imyofeba

efavirenzis Semcvel reJimze; o pacientebi informirebulni unda iyvnen maTi legaluri

pasugismgeblobebisa da uflebebis Sesaxeb; o pacientebi informirebulni unda iyvnen imunizaciis Sesaxeb da

samsaxureobrivi riskis Sesaxeb.

3. oportunistuli da sxva infeqciebis profilaqtika aiv infeqcia/SidsiT avadmyofebi imunizirebul unda iyvnen A da B hepatitis virusebisa da gripis virusis sawinaRmdegod. yvela aiv inficirebuli , romlis CD4 limfocitebis ricxvi naklebia 200 mm3 unda daewyoT profilaqtikuri mkurnaloba mTel rig infeqciebze, maT Soris pnevmocisturi pnevmoniis. ko-trimoqsazoliT profilaqtikuri Terapia unda gagrZeldes manamde, sanam CD4 ujredebis ricxvi ar gaxdeba 200 mm3 meti arv mkurnalobis dawyebidan 3 Tvis ganmavlobaSi stabilurad.

4. antiretrovirusuli Terapia 4.1. arT dawyeba arT dawyebis optimaluri dro ar aris dadasturebuli da igi ganxilvis sagania (19) (CIII). sxvadasxva kohortuli kvlevis da saxelmRvanelo rekomendaciebis mimoxilva aCvenebs farTod gavrcelebul Sexedulebas, rom am gadawyvetilebis misaRebad saukeTeso markeria CD4 ricxvi, xolo virusuli datvirTva meoradi markeria (20-30) (CIII). arT dawyebamde unda daiwyos avadmyofis mxardaWera reJimis maqsimaluri dacvis uzrunvelsayofad; janmo rekomendacias uwevs arT dawyebas klinikuri da imunologiuri kriteriumebis safuZvelze. rekomendaciebi arT dawyebis Sesaxeb Sejamebulia cxrilSi 8.

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cxrili 8 rekomendaciebi arT dawyebis Sesaxeb

janmo klinikuri stadia CD4 ricxvi rekomendacia

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

SesaZlebloba b, g < 200/mm3 umkurnaleT 2 200 - 350/mm3 ganixileT mkurnalobis

SesaZlebloba b, g 3 200 - 350/mm3 umkurnaleT 4 CD4 ricxvisgan

damoukideblad umkurnaleT

a. ix. danarTi 2 klinikuri stadiebis aRwerilobis Sesaxeb b. rodesac CD4 ricxvi 350/mm3-is midamoSia, daiwyeT msjeloba

pacientTan arT dawyebis saWiroebis moaxloebis da mkurnalobis sawyisi reJimis Sesaxeb.

g. virusuli datvirTva dakavSirebulia CD4 ricxvis klebasTan. rodesac virusuli datvirTva maRalia (> 100000 asli/ml), maRalia CD4 ricxvis swrafad klebis albaToba. Sesabamisad, Tu virusuli datvirTva maRalia da CD4 ricxvi 350/mm3-ia, rekomendebulia arT dawyeba.

arT dawyeba unda efuZnebodes CD4 ricxvis orjerad gansazRvras 14 – 28 dRis SualediT, raTa gamoiricxos laboratoriuli Secdoma an gadaxris sxva mizezi (magaliTad, Tanmxlebi daavadeba). 4.1.1. virusuli datvirTva virusuli datvirTva TavisTavad ar aris arT dawyebis markeri. Tumca, im SemTxvevaSi Tu virusuli datvirTva 100 000 asli/ml-ze maRalia (man SeiZleba 1 milion asli/ml-s miaRwios), SesaZloa adgili hqondes CD4 ricxvis swraf klebas. marTalia virusuli datvirTvis gansazRvra ZviradRirebulia, mniSvnelovania vicodeT misi mniSvneloba mkurnalobis dawyebamde, raTa SemdgomSi SevafasoT mkurnalobis efeqturoba. Tu virusuli datvirTva ar aris xelmisawvdomi, maSin CD4 ricxvi da klinikuri simptomebi sakmarisia mkurnalobis dawyebis gadawyvetilebis misaRebad. polimerizaciis jaWvuri reqciisa (pjr) da virusuli datvirTvis ar arseboba ar unda gaxdes mkurnalobis gadadebis kriteriumi. 4.1.2 rezistentobis testi mosazreba pirveli rigis mkurnalobamde rezistentobis testis Catarebis Sesaxeb gansxvavebulia. rezistentobaze testireba rekomendebulia im qveynebSi, sadac maRalia priveladi rezistentoba. evropaSi Catarda multicentruli kvleva axaldiagnozdasmul aiv inficirebulebSi 1996 da 2002 wlebSi. am jgufSi rezistentobis prevalentobam Seadgina 10% (31) (BII). aSS 40 qalaqSi Catarebul kvlevaSi rezistentobam 14% Seadgina (32)

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(BII). yvelaze maRali sixSire aRiniSna espaneTSi 26% (33) (BII) da san-franciskoSi 19% (34) (BII). sloveniis monacemebiT rezistentobis sixSire dabalia – 3,9% (35) (BII). eqspertebi rekomendacias uweven rezistentobis testirebas arT dawyebamde axaldiagnozdasmul pacientebSi (36-38) (BII), sadac igi xelmisawvdomia, xolo SezRuduli resursebis pirobebSi rezistentobaze sentineluri (saguSago) zedamxedvelobis dawesebas. arT dawyeba SesaZlebelia rezistentobaze testirebis gareSe. ixileT danarTi 3 rezistentobis testirebaze damatebiTi informaciisTvis. 4.2 pirveli rigis maarT reJimi rekomendebulia, rom pirveli rigis arT Seicavdes or nukleozid/nukleotidis analog revers transkriftazas inhibitors (nrti anu NRTI) da erT ara-nukleozidis analogis revers transkriptazas inhibitors (anrti anu NNRTI). rekomendebuli dozebisTvis ixileT danarTi 4. cxrili 9 rekomendaciebi pirveli rigis arT

Sesaxeb

arT reJimi medikamentebis kombinacia

2 NRTI-s + 1 NNRTI

ZDV + 3TC + (EFVa or NVP) an

TDF + FTC + (EFVa or NVP) an

ABC + 3TC + (EFVa or NVP)

a. EFV ganixileba, rogorc upiratesi anrti (AI) 4.2.1. nrti komponenti - pirveli rigis arT-s ZiriTadi Semadgeneli nawilia ori nrti-s kombinacia. erT-erTi unda iyos lamivudini (3TC) an emtricitabini (FTC) (39) (AI), xolo meore yvelaze xSirad zidovudinia (ZDV). vinaidan zidovudini pirveli rekomendebuli arv medikamenti iyo, masze uxvi monacemebia dagrovili. - sxva SesaZlo nrti-ebia tenofoviri (TDF) da abakaviri (ABC) 3TC–Tan an FTC–Tan kombinaciaSi. uaxlesi kvlevebi aCveneben TDF/FTC–is kombinaciis mcire upiratesobas ZDV/3TC–Tan SedarebiT, rodesac gamoiyeneba efavirenzTan (EFV) kombinaciaSi (40) (AI). aRniSnuli SesaZloa ganpirobebuli iyos TDF namkurnaleb pacientebSi gverdiTi movlenebis simciriT. saWiroa damatebiTi kvlevebi aRniSnulis dasadastureblad. unda aRiniSnos, rom ABC miRebis dros arsebobs saxifaTo hipersensitiurobis sindromis riski. - TDF da ABC upiratesobaa maTi rezistentobis kargi profili, romelic saSualebas iZleva momavalSi meti nrti-s kombinaciis gamoyenebas. Tumca maT aReniSnebaT seriozuli gverdiTi movlenebi da efeqturobis monacemebic mcirea zidovudinTan SedarebiT (41) (CIII).

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arv medikamentebi arseboben Semdegi fiqsirebuli dozis kombinaciebis saxiT (anu ori medikamenti 1 tabletSi):

- ZDV + 3TC - TDF + FTC - ABC + 3TC

- TDF/FTC kombinaciis ABC/3TC kombinaciasTan SedarebiT damatebiTi upiratesobaa dReSi erTxel misaRebi reJimis arseboba. - yvela sxva nrti kombinacias pirveli rigis reJimSi gamoyenebisTvis esaWiroeba safuZvliani mizezi. zogierTi kombinacia ar aris rekomendebuli (42), xolo sxvebs sWirdebaT gverdiTi movlenebis mWidro monitoringi. uaxlesi kvlevebi aCveneben gverdiTi movlenebis maRal sixSires stavudinis (d4T) gamoyenebis dros (40-47) (AI). amis gamo d4T gamoyenebul unda iqnes mxolod im SemTxvevaSi, Tu sxva arCevani ar aris an sxva nrti-ebi ukunaCvenebia. arsebobs nrti-ebis gamoyenebasTan dakavSirebuli ramdenime wesi: - ar gamoiyenoT d-medikamentebis kombinacia (ddI (didanozini), ddC (zalcitabini), d4T).

- ar daiwyoT mkurnaloba d-medikamentiT arsebuli neiropaTiis dros. - ar gamoiyenoT ZDV da d4T kombinacia. - ar gamoiyenoT 3TC da FTC kombinacia. 4.2.2. anrti komponenti - saukeTeso monacemebi arsebobs ZDV + 3TC + EFV Sesaxeb (48–50) (AI). aRniSnuli sami medikamentisgan Semdgari kombinacia dReSi orjer misaRebia. igi swrafadmoqmedia - EFV gamoyenebis dros virusuli datvirTva swrafad iklebs pirvel ori kviris ganmavlobaSi, CD4 ricxvis mateba sxva reJimebis dros aRniSnuli matebis msgavsia. Tumca aucilebelia mkurnalobis dawyebamde Tanmxlebi fsiqiatriuli daavadebebis gamoricxva. - nevirapini (NVP) kidev erTi rekomendebuli anrtia, romelic nrti-ebTan kombinaciaSi gamoiyeneba. RviZlis daavadebebis dros maRalia misi toqsiuroba (52) (AI). amis gamo misi gamoyeneba rekomendebulia qalebSi Tu CD4 ricxvi <250 ujrdi/mm3, xolo mamakacebSi - Tu CD4 ricxvi <400 ujrdi/mm3. ufro maRali CD4 ricxvis SemTxvevaSi nevirapinis gamoyeneba dakavSirebulia met hepatotoqsiurobasaTan. nevirapinis efeqturoba efavirenzis msgavsia (52) (BII). mkurnalobis dasawyisSi saWiroa nevirapinis 14-dRiani sawyisi doza - 200mg erTxel dReSi. 14 dRis Semdeg doza unda gaizardos - 200mg 2-jer dReSi. erTxel dReSi misaRebi doza gamokvlevis fazaSia. - delavirdini (DLV), mesame anrti, ar gamoiyeneba evropaSi. igi naklebefeqturia danarCen antri-ebTan SedarebiT, aqvs meti gverdiTi movlenebi da yoveldRiurad didi raodenobiT tabletis miRebaa saWiro. Tumca es ukanaskneli sadReisod gaumjobesda da gamoiyeneba 200mg tableti 3-jer dReSi. igi SesaZloa gamoyenebul iqnas im SemTxvevaSi, Tu

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sxva anrti-ebi ver aitaneba an arsebobs rezistentobis gansakuTrebuli forma. - ori nrti da erTi anrti-s alternativa SeiZleba iyos erTi klasisgan Sedgenili reJimi – “sammagi nukleozidi”3 an “oTxmagi nuklezidi”, romlebic mxolod sami an oTxi nrti-sgan Sedgeba. marTalia, am reJimze sawyisi pasuxi kargia, 24 kviris Semdeg rezistentobis ganviTarebis meti albaTobaa (48) (AI). Sesabamisad, sami nrti-s kombinacia unda gamoiyenebodes gansakuTrebul situaciebSi, magaliTad TB an HCV koinfeqciis SemTxvevaSi, rodesac erTdrouli mkurnalobaa saWiro, an alternativis saxiT, Tu antri ar aris xelmisawvdomi. - ori anrti-s da erTi nrti-s kombinacia ar aris rekomendebuli (53) (AI). - bustirebuli proteazas inhibitori (pi) or nrti-sTan erTad SesaZloa gamoyenebul iqnes pirveli rigis arT saxiT, Tu ukunaCvenebia anrti-ebi (anu verc efavirenzi da verc nevirapini ver iniSneba): - fsiqiatriuli daavadebebi da alt-s mateba 3-5-jer; - cirozi; - orsuloba, Tu CD4 ricxvia 250 - 350 ujrdi/mm3. - pi Semcveli pirveli rigis arT-s araefeqturobis dros naklebi arCevania Semdgomi reJimisTvis. zogadad rekomendebulia, rom pi Semonaxul iqnes meore rigis reJimisTvis. 3“sammagi nukleozidi”: fiqsirebuli dozis tableti, romelic Seicavs ZDV da 3TC da ABC. igi miiReba dReSi orjer (zidovudini ar aris rekomendebuli dReSi erTxel miRebisTvis). amJamad igi yvelaze martivi sammagi Terapiuli reJimia.

4.3. arT reJimis dacva mkurnalobis optimaluri Sedegis misaRebad saWiroa mkurnalobis reJimis dacva. kargad aris cnobili, rom arT reJimis maRal doneze dacva dakavSirebulia aiv asocirebuli avadobis da sikvdilianobis mkveTr SemcirebasTan (54) (AI), xolo reJimis arasaTanado dacva aiv-is wamlebis mimarT rezistentobis swraf ganviTarebas iwvevs (55) (AI). arT-sTvis ar aris gansazRvruli reJimis dacvis efeqturi done (arsebobs sxvaoba reJimebs Soris), Tumca reJimis dacva 95%-ze nakleb doneze dakavSirebulia cud virusologiur da imunologiur pasuxTan, xolo reJimis 100%-iT dacvas kidev ufro meti sargebeli moaqvs, vidre 95%-iT dacvas (56, 57) (AI). uaxlesi monacemebi aCveneben korelacias reJimis dacvasa da arv sxvadasxva klasis mimarT rezistentobas Soris (58) (AI). dabal an arasakmaris reJimis dacvas mohyveba arasaxarbielo Sedegebi pacientisTvis, sazogadoebrivi jandacvisTvis da qveynis ekonomikisTvis. kerZod, - pacientebi arian mniSvnelovani safrTxis winaSe rezistentobis ganviTarebis, mkurnalobis araefeqturobis da daavadebis progresirebis TvalsazrisiT (59, 60) (AI). axali kombinacia erTi reJimis araefeqturobis SemTxvevaSi umetesad ufro rTulia dacvis TvalsazrisiT (meti tabletebis ricxvi dReSi, gverdiT movlenebi, dieturi SezRudevebi, toqsiuroba da dozirebis sirTule). - rezistentuli virusis gavrceleba gamoiwvevs mis gadacemas axlad inficirebul pirebSi. aSS (61) (AI) da evropis (62) (AI) monacemebi

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aCveneben, rom pirveladi rezistentobis sixSire imatebs, da SeZenil rezistentobas uaryofiTi gavlena aqvs arT pasuxze. - rezistentuli Stamis arsebobas mohyveba meore rigis, mesame rigis da e.w. gadarCenis (salvage) reJimi, romlebic, Cveulebriv, ufro Zviria pirveli rigis reJimebTan SedarebiT. - reJimis arasakmarisi dacva, agreTve, moaswavebs daavadebis progresirebis maRal risks, rac met danaxarjebs moiTxovs oportunistuli infeqciebis samkurnalod (63) (AI). 4.3.1. barierebi reJimis dacvaSi da maTi sawinaaRmdego zomebi 4.3.1.1. pacientTan dakavSirebuli faqtorebi da strategiebi pacients ZiriTadi roli akisria reJimis dacvaSi. SeuZlebelia pacientis mier reJimis dacvis potencialis prognozireba. kvlevebma, romlebic Seiswavlidnen sqess, rasas, asaks, aiv gadacemis gzas da ganaTlebis dones, rogorc reJimis dacvis indikatorebs, gansxvavebuli Sedegebi aCvenes (64) (BII). individualuri reJimis dacvis donec SesaZloa sxvadasxva dros gansxvavdebodes (65) (BII). umravlesi aiv inficirebuli raRac dros gamoavlens reJimis dacvis dabal xarisxs. reJimis dacvis dabali donis SesaZlo mizezebia: - narkotikebis da alkoholis moxmareba - cudi kveba siRaribis gamo - religiuri mosazrebebi (66) (DIV) - aiv statusis gamJRavnebis SiSi medikamentebis rutinuli miRebisas - fsiqiatriuli mdgomarebebi (67) (DIV) - gverdiTi movlenebis SiSi da eWvi mkurnalobis saWiroebis Sesaxeb (68) (DIV). SesaZlo sawinaaRmdego strategiebi: - ganaTleba arT saWiroebis Sesaxeb - swrafi reagireba pacientis araswor Sexedulebaze - arT-s mimarT pacientis ganwyobis regularuli Sefaseba - “peer” (Tanasworis) Careva (pacientTa jgufebi) - fsiqiatriuli problemebis regularuli Sefaseba - reJimis dacvisTvis saWiro Cvevebis Sefaseba4 - specializirebuli socialuri samsaxuris an dawesebulebebis CarTva. 4es SesaZloa gaZlierdes im pirebis CarTviT, vinc kontaqtSia pacientTan (eqTani, farmacevti, ojaxi), agreTve, grafikis (cxrilebis), saaTiani tabletebis yuTebis gamoyenebiT, mogzaurobisas gegmis SemuSavebiT, Tu rogor miiRos medikamentebi garSemomyofebisTvis SeumCnevlad.

4.3.1.2. jandacvis muSakTan dakavSirebuli faqtorebi jandacvis muSakebi naTlad unda acnobierebdnen reJimis dacvis mniSvnelobas da mis rols rezistentobis ganviTarebaSi. aiv/Sidsis dargSi momuSave profesionali unda iRebdes mudmiv ganaTlebas reJimis dacvis sakiTxebSi. arsebobs ramdenime strategia, romelic unda gamoiyenos jandacvis muSakma reJimis dacvis xarisxis asamaRleblad.

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- TiToeul centrs, sadac tardeba aiv mkurnaloba, unda hqondes reJimis dacvis werilobiTi strategia, romelic gadaixedeba regularulad. - jandacvis muSakebi CarTulni unda iyvnen reJimis dacvis mxardasaWer programebSi (69) (CIII). - pacientTa survilis gaTvaliswinebam, CaerTos am programebSi SesaZloa gaaumjobesos reJimis dacva. - reJimis dacvaSi mxardaWera unda SeeTavazos yvela pacients imis gaTvaliswinebiT, Tu ra xarisxiT icavs esa Tu is pacienti reJims. - mxadaWera unda gagrZeldes meore rigis da “gadarCenis" reJimis drosac. mkurnalobis araefeqturoba unda iyos sakvanZo sakiTxi reJimis dacvis da mxardaWeris RonisZiebebis gaZlierebisTvis (70). - reJimis dacvis maRali xarisxi xangrZlivi procesia da ara erTjeradi movlena (71) (DIV), avadmyofs mxardaWera unda SevTavazos arT dawyebisas, Secvlisas da rutinuli meTvalyureobisas. - jandacvis muSakma unda uzrunvelyos, rom pacients hqondes adekvaturi codna aiv-is, reJimis dacvas da rezistentobas Soris kavSiris, gverdiTi movlenebis Sesaxeb. sityvieri informacia unda gamyardes werilobiTi informaciiT. - jandacvis muSakma SesaZloa rekomendacia gauwios tabletebis miRebis dRiurs, cxrilebs, medikamentebis konteinerebs, ojaxis wevrebis da megobrebis CarTvas “Semxseneblebad” (72) (DIV). - arT reJimis dacva umjobesdeba, Tu pacienti pozitiurad aRiqvams kavSirs eqimTan da jandacvis sxva muSakebTan (73) (DIV). - reJimis dacvaze adreuli meTvalyureoba unda ganxorcieldes reJimis dawyebidan an Secvlidan 2 dRis Semdeg imis gasarkvevad, esaWiroeba Tu ara pacients damatebiTi informacia an aqvs Tu ara raime gauTvaliswinebeli problema. 4.3.1.3. reJimTan dakavSirebuli faqtorebi da strategiebi - dozireba dReSi orjer metad dakavSirebulia reJimis dacvis ufro dabal donesTan (74) (CIII), xolo dReSi erTxel an orjer misaReb reJimebs Soris sxvaoba savaraudod ar aris (75) (CIII). dReSi erTxel an orjer misaRebi reJimis dros, dozaTa umravlesoba droulad miiReba. multivariaciuli analiziT dozis miReba daniSnulze gvian dakavSirebulia mkurnalobis araefeqturobasTan (76) (AI). - reJimis dacvis done ar aris dakavSirebuli arv klasTan. Tumca kvebiTi SezRudva sxvadasxva medikamentisTvis SesaZloa qmnides problemas (77) (BII). - tabletebis mcire ricxvis dros metia albaToba, rom 48 kviris Semdeg virusuli datvirTva iqneba < 50 asli/ml (75) (BII). - damazianebelma wamlebis urTierTqmedebam da gverdiTma movlenebma SesaZloa gavlena moaxdinos reJimis dacvis xarisxze. doza SesaZloa gamotovebul iqnes gulisrevis da diareis gamo, sisustis gamo CaZinebam, agreTve, SesaZloa gamoiwvios dozis gamotoveba (78) (DIV). SesaZlo sawinaaRmdego strategiebi: - Sefasdes cxovrebis wesi (kvebis, Zilis, samuSao reJimi) da moergos samkurnalo reJimi; - Sefasdes pirovnebis ganwyoba sxvadasxva reJimis mimarT (tabletis zoma, formulireba, raodenoba, dieturi SezRudva da a. S.).

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- tabletebis Cveneba pacientisTvis reJimis dawyebamde; - informaciis micema gverdiTi movlenebis da maTi marTvis Sesaxeb, mxardaWeris Sesaxeb. 4.4. uSedego mkurnaloba mkurnalobis araefeqturoba SesaZloa Sefasdes virusuli datvirTvis da CD4 ricxvis gansazRvriT, agreTve, klinikuri gamoklveviT. 4.4.1. virusologiuri araefeqturoba - virusuli datvirTva (vd) mkurnalobis warmatebis an araefeqturobis yvelaze adreuli indikatoria, romelsac mohyveba CD4 ricxvi daaxloebiT 1 Tvis Semdeg. iSviaTad viTardeba paradoqsuli reaqcia virusologiuri pasuxiT da imunologiuri araefeqturobiT. Sesabamisad, aucilebelia vd Sefasdes CD4 ricxvTan erTad kombinaciaSi. - virusologiur araefeqturobad miiCneva, Tu vd ar gaxda 400 asli/ml-ze naklebi mkurnalobis 24-e kviraze an 50 asli/ml-ze naklebi mkurnalobis 48-e kviraze. - Tu vd gaxda ganusazRvreli, magram Semdgomi ori gamokvlevisas 4-8 kviris intervaliT igi kvlav metia 400-1000 asli/ml-ze, aseT SemTxvevaSi virusologiuri araefeqturobis momatebuli riskia (79) (BII).. reJimis SenarCuneba zrdis Semdgomi mutaciebis da meti medikamentis mimarT ufro gamoxatuli rezistentobis ganviTarebis risks. - “Blips” (xanmokle mcire piki) aris vd-s msubuqi mateba ganusazRvreli donidan 50-200asli/ml-mde. mas SesaZloa adgili hqondes rezistentuli Stamis ganviTarebis gareSe (laboratoriuli Secdoma), Tumca igi aris indikatori reJimis dacvis msjelobisTvis (80) (BII). am situaciaSi SesaZloa, agreTve, damxmare roli Seasrulos medikamentebis Terapiulma monitoringma (TDM). TiToeuli “blifi” unda gakontroldes 4 kviraSi. - Tu virusulogiuri araefeqturobis mizezi ar vlindeba (reJimis araadeqvaturi dacva, wamlebis suboptimaluri done, wamlebis urTierTqmedeba da sxv.), unda ganxilul iqnes meore rigis Terapiis dawyebis SesaZlebloba5.

5 Tu cnobilia, rom qveyanaSi rezistentobis prevalentoba 7%-ze metia, rekomendebulia rezistentobis testi mkurnalobis araefeqturobis SemTxvevaSi wamlebis miRebisas an maTi Sewyvetidan 2-4 kviris ganmavlobaSi. mogvianebiT rezistentobis testi ver gamoavlens rezistentobas mkurnalobis Sewyvetis Semdeg veluri Stamis swrafi zrdis gamo.

4.4.2. imunologiuri araefeqturoba - Tu vd ar aris xelmisawvdomi, CD4 ricxvi gamoyenebul unda iqnes mkurnalobis warmatebis an araefeqturobis indikatorad. - imunologiuri araefeqturobaa, Tu CD4 ricxvma ar moimata 50 /mm3-ze metad arT pirveli wlis ganmavlobaSi. saSualod aranamkurnaleb

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pacientebSi mkurnalobis pirveli wlis ganmavlobaSi CD4 ricxvi imatebs 150 /mm3-iT (81, 82) (AI). - Tu CD4 ricxvi ar imatebs arT dawyebidan pirveli 9 Tvis ganmavlobaSi, ganxilul unda iqnes meore rigis arT SesaZlebloba. Tu vd aragansazRvradia, reJimi unda gagrZeldes. Tu igi > 400-1000 asli/ml-ze, unda verificirdes reJimis dacva da daiwyos meore rigis reJimi. - Tu CD4 ricxvi ar imatebs 6 Tvis ganmavlobaSi, xelaxla unda Sefasdes reJimis dacvis xarisxi. 4.4.3. klinikuri araefeqturoba arT dawyebis Semdeg, oportunistuli infeqciis (oi) an sxva aiv-asocirebuli daavadebis ganviTareba, klinikuri araefeqturobis indikatoria. Tumca es SeiZleba iyo imunuri rekonsitituciis sindromi (irs), gansakuTrebiT, arT-s dawyebidan pirveli 3 Tvis ganmavlobaSi, Tu igi dawyebul iqna CD4 ricxvi <50 ujredi/mm3-ze. am SemTxvevaSic vd gadamwyveti roli eniWeba meore rigis Terapiis dawyebis Sesafaseblad. cxrili 10 mkurnalobis araefeqturobis kriteriumebi

virusologiuri araefeqturoba

imunologiuri araefeqturoba

klinikuri araefeqturoba

markeri vd CD4 ricxvi

oi (aiv-Tan asocirebuli)

dro 24 kvira; 48 kvira 24-48 kvira

mkurnalobis dawyebidan 12 kviris Semdeg

zRvari >400asli/ml; >50asli/ml

50 ujredi/mm3-ze naklebi mateba

oi (gamoricxeT irs)

4.5. meore rigis arv reJimi (rekomendaciebi dozebis Sesaxeb ix. danarTi 4) - meore rigis Terapiad rekomendebulia pi-s Semcveli kombinacia. pi-ebs gaaCniaT maRali genetikuri barieri. - meore rigis arT rekomnedebulia mxolod pirveli rigis reJimis mimarT dadasturebuli araefeqturobis SemTxvevaSi. - meore rigis arT dawyebasTan erTad unda moxdes reJimis dacvis xelaxali Sefaseba da maqsimaluri mxardaWera. - meore rigis reJimis dros sul mcire ori nrti-s Secvlaa saWiro. arasodes SecvaloT mxolod erTi wamali saeWvo rezistentobis SemTxvevaSi. - efavirenzis da nevirapinis xangrZlivi naxevardaSlis periodis gamo, samive wamlis erTdrouli Sewyveta niSnavs, rom efavirenzi an nevirapini darCeba sisxlSi nrti-ebze xangrZlivad, rac maT mimarT rezistentobis gamomwvevi mutaciis ganviTarebis risks zrdis.

41

- aqedan gamomdinare, nrti+anrti reJimis Sewyvetisas SesaZloa Sewydes jer anrti da mogvianebiT, daaxloebiT 7 dRis Semdeg, nrti-ebi. Tumca am sakiTxTan dakavSirebiT sakmarisi monacemebi ar arsebobs. 4.5.1. nrti komponenti - Tu pirveli rigis arT Seicavda ZDV + 3TC, maSin meore rigSi SesaZloa gamoyenebul iqnas ABC ddI–Tan kombinaciaSi (an TDF da moxdes ddI dozis modifikacia da mWidro monitoringi) (83) (CIII). - Tu pacients pirveli rigis Terapia utardeboda TDF an ABC, maT mimarT rezistentobis maRali albaTobis gaTvaliswinebiT meore rigSi sasargeblo iqneba ZDV (84) (BII). K65R mutacia, romelsac iwves TDF da ABC, zrdis mgrZnobelobas ZDV–s mimarT (85, 86) (BII).. - 3TC agreTve sasargebloa mis mimarT rezistentobis dros, vinaidan mis mier gamowveuli 184V mutacia amcirebs virusis replikaciis unars da, agreTve, zrdis mgrZnobelobas ZDV mimarT. 4.5.2 pi komponenti - Tu pirveli rigis Terapia Seicavda anrti-s, meore rigSi gamoyenebul unda iqnes pi. - pi-ebis umravlesoba Zlierdeba (bustirdeba) ritonaviris (RTV an /r) dabali doziT - 100mg 2-jer dReSi. ritonaviri TavisTavad pi-ia. ritonaviriT ar bustirdeba nelfinaviri, romelic Zlierdeba ara qimiurad, aramed – sakvebiT. bustirebis meqanizmia ritonaviris mier citoqrom P450 (CYP) 3A4 izoenzimis inhibireba. Sedegad izrdeba pi medikamentebis done, garda nelfinavirisa (87) (BII).. ritonaviri gamoiyeneba mxolod sxva pi-ebis bustirebisTvis da ar aris efeqturi rogorc damoukidebeli arv medikamenti. - pi-ebs Soris gansxvaveba mdgomareobs maT mimarT rezistentobis ganviTarebisTvis saWiro mutaciebis ricxvSi da gverdiTi movlenebis profilSi. - yvelaze maRali barieri rezistentobis ganviTarebisTvis aReniSneba bustirebul lopinavirs (LPV/r) (88). - ritonaviriT bustirebuli atazanaviris (ATV/r), fosamprenviris (FPV/r), indinaviris (IDV/r) da seqvinaviris (SQV/r) rezistentobis profili umniSvnelod gansxvavdeba, risi klinikuri efeqtic mcirea an saerTod ar aris. - atazanaviri SesaZloa gamoyenebul iqnes ritonaviriT bustirebis gareSec (400 mg/dReSi). - nelfinaviri efeqturobiT naklebia sxva pi-ebTan SedarebiT. Tumca misi gamoyeneba kargad dokumentirebulia orsulebSi. misi araefeqturobis dros SeirCeva D30N mutacia, romelic ar iwvevs jvaredin rezistnetobas sxva pi-ebis mimarT (89, 90) (BII).. - arCevis pi-ia LPV/r misi kargad dokumentirebuli efeqturobis gamo (91). evropaSi registrirda LPV/r axali formulireba, romelic gamoiyeneba 2-jer dReSi da ar esaWiroeba macivari (92) (AI).

42

- ar warmoebulia LPV/r–is pirdapiri Sedareba amprenaviris axal forma fosamprenavirTan, dReSi erTxel misaReb atazanavirTan (93) (CIII) da seqvinaviris axal 500mg-ian formasTan, arsebobs mxolod arapirdapiri monacemebi (94) (DIV). saWiroa damatebiTi kvlevebi. - pi-s SerCevisas gaTvaliswinebul unda iqnas gverdiTi movlenebi, Tanmxlebi daavadebebi, wamlebTan urTierTqmedeba da pacientis individualuri ganwyoba. cxrili 11 rekomendebuli meore rigis arv reJimi mozardebis

mozrdilTaTvis pirveli rigis reJimi meore rigis reJimi ZDV + 3TC + (EFV an NVP)

LPV/ra (an ATV/r, SQV/r, FPV/r, IDV/r) + ddI + ABC an LPV/ra (an ATV/r, SQV/r, FPV/r, IDV/r) + TDF + ABC an LPV/ra (an ATV/r, SQV/r, FPV/r, IDV/r) + TDF + (ZDV + 3TC)b

TDF + FTC + (EFV an NVP)

LPV/ra (an ATV/r, SQV/r, FPV/r, IDV/r) + ddI + ABC an LPV/ra (an ATV/r, SQV/r, FPV/r, IDV/r) + ddI + ZDV

ABC + 3TC + (EFV an NVP)

LPV/ra (an ATV/r, SQV/r, FPV/r, IDV/r) + ddI + ZDV an LPV/ra (an ATV/r, SQV/r, FPV/r, IDV/r) + ZDV + TDF (+ 3TC)b

aLPV/r mocemulia rogorc upiratesi pi bustirebuli ritonaviriT, Tumca sxva pi-ebi SesaZloa gamoyenebul iqnas programis individualuri prioritetebis mixedviT. SesaZloa nebismieris gamoyeneba CamoTvlilTagan: ATV/r, SQV/r, FPV/r, da IDV/r. civi jaWvis ararsebobis SemTxvevaSi SesaZloa nelfinaviris gamoyeneba, Tumca igi ganixileba, rogorc naklebad potenturi, vidre bustirebuli pi-ebi. bZDV da 3TC gamoyeneba naCvenebia strategiuli mizniT, radgan pirveli rigis araefeqturobis SemTxvevaSi maT mimarT virusi rezistentuli iqneba. kerZod, ZDV SesaZloa Tavidan agvacilos an Seaferxos K65R mutaciis ganviTareba; xolo 3TC SeinarCunebs M184V mutacias, romelic amcirebis virusis replikaciis unars da garkveulwilad zrdis sensitiurobas ZDV mimarT. unda aRiniSnos, rom am strategiis klinikuri Rirebuleba ar aris dadasturebuli.

- Tu ganviTarda pi-s Semcveli pirveli rigis arT-s araefeqturoba, meore rigis reJimis SerCeva efuZneba rezistentobis profils. Tu rezistentobis profili ar aris xelmisawvdomi, navaraudebi unda iqnas rezistentoba pirveli rigis reJimSi Semavali pi-s mimarT. pi-s Semcveli pirveli rigis arT-s araefeqturobis dros SesaZlo arCevania:

- ZDV + 3TC + SQV/r (an ATV/r, FPV/r, IDV/r) ➔ ABC + ddI + LPV/r

- ZDV + 3TC + LPV/r ➔ ABC + ddI + anrti (darunaviri (TMC11)) an bustirebuli

tipranaviri (TPV/r) - kidev erTi arCevania ori pi-s kombinacia, magaliTad SQV + ATV/r (95). ar aris rekomendebuli ormagi pi-ebis kombniacaSi TPV/r gamoyeneba.

4.6. gadarCenis (Salvage) reJimebi dadasturebuli meore rigis araefeqturobis SemTxvevebSi (virusologiuri, imunologiuri, klinikuri araefeqturobis kriteriumebiT) ganixileba gadarCenis reJimebi. gadarCenis reJimebSi

43

igulisxmeba im medikamentebis kombinacia, romlebic SesaZloa muSaobdes an virusi maT mimarT iyos nawilobriv rezistentuli. yvela reJimi meore rigis Semdgom garTulebulia da moiTxovs arT-codnis maRal dones da unar-Cvevebs. genotipuri rezistentobis testis monacemebi am situaciaSi aucilebelia. zogierT SemTxvevebSi gadarCenis Terapiis dawyebamde umjobesia ramodenime TviT mocda, Tumca es strategia SesaZloa iyos saSiSi, kerZod, Tu CD4 ujredebis ricxvi dabalia.

o Tu SesaZlebelia, unda CaerTos ori medikamentis efeqturi kombinacia mag; SeWris inhibitori enfurvitidi (ENF) (96) (CIII), romelic iniSneba 2-jer dReSi kanqveSa aplikaciis saxiT da axali pi TPV (97,90) (CIII), an axali pi TCM114 (99,100) (CIII).

o TPV- genetikuri barieri ufro maRalia, vidre LPV/r da monacemebi gviCveneben mis efeqturobas am ukanasknelTan SedarebiT. dRevandel dRes TPV gamoiyeneba mxolod gadarCenis Terapiis reJimebSi.

o sxva SesaZleblobaa ori pi kombinacia (102-104) (CIII), gamonaklisia TPV, romelic ar unda gamoviyenoT sxva pi–sTan kombinaciaSi.

4.7. mkurnalobis dagegmili Sewyveta bevri ewinaaRmdegeba arT dagegmil Sewyvetas, Tumca dasabuTeba SesaZlebelia. mag. CD4>500 mm3 mudmivi done da virusis supresia mravali wlebis ganmavlobaSi abrkolebs oportunistuli infeqciebis ganviTarebas. mkurnalobis dagegmili Sewyveta, mkurnalobis reJimis araadeqvaturad dacvis SemTxvevaSi, Tavidan agvacilebs rezistentuli Stamebis ganviTarebas. mkurnalobis Sewyvetis Semdeg CD4 limfocitebis ricxvi Camodis pre-arv Terapiis donemde , amdenad aucilebelia pirveli sami Tvis ganmavlobaSi CD4 limfocitebis ricxvis monitoringi. zogierT pacientSi limfocitebis ricxvi >350 mm3 da dabali virusuli datvirTva (1000-5000 asli/ml) Tveebisa da wlebis ganmavlobaSia SenarCunebuli. mkurnalobis dagegmili Sewyvetis sargebelze arasakmao informaciis arsebobis gamo janmos mier igi ar aris rekomendebuli.

5.aiv inficirebul pacientTa klinikuri monitoringi

mas Semdeg rac adamians daesmeba aiv infeqciis diagnozi is uzrunvelyofili unda iyos monitoringiTa da movliT.

5.1. laboratoriuli indikatorebi arT dawyebamde CD4 ujredebis ricxvi

o gaimeoreT yovel 6 TveSi, Tu aris amouxsneli Sedegebi (CD4 ujredebis swrafi daqveiTeba an oportunistuli infeqciebis ganviTareba);

o Tu mimdinareobs msjeloba arT dawyebaze (CD4 ujredebi tolia an <350 mm3) gaimeoreT yovel 3 TveSi. statistikurad, erTi wlis ganmavlobaSi CD4 ujredebis ricxvi klebulobs 50 ujrediT, Tumca Tanmxlebi infeqciebis arsebobis dros SesaZloa daqveiTdes Zalian swrafad.

o virusuli datvirTva unda gakontroldes drois igive SualediT. dabali virusuli datvirTva (1000-5000 asli/ml)

44

maniSnebelia daavadebis duned progresirebis da piriqiT, maRali virusuli datvirTva (>100 000 asli /ml) miuTiTebs daavadebis swraf progresirebaze.

o ZiriTadi laboratoriuli testebi unda gakontroldes (cxr. 12) yovel 6 TveSi, Tu ar aris raime sxva mizezi, mag. orsuloba.

5.2. laboratoriuli maCvemeblebis monitoringi arv Terapiaze myof

pacientebSi arT-s warmatebis pirveli maCvenebelia virusuli datvirTva. imunuri pasuxi virusuli datvirTvis Sedegia da mogvianebiT viTardeba. arT monitoringisTvis saukeTesoa orives gakontroleba. virusuli datvirTva:

o virusuli datvirTva unda ganisazRvros mkurnalobis dawyebidan 4-8 kviraSi reJimis warmatebis SefasebisTvis. virusuli datvirTva aragansazRvradi unda gaxdes 16-24 kviraSi.

o virusuli datvirTvis monitoringisTvis sasurveli intervalia 3-4- Tve.

o Tu virusuli datvirTva gaxda aragansazRvradi (< 50 asli/ml) , is unda darCes aragansazRvradi.

o CD4 ujredebis ricxvi unda gakontroldes yovel 6 TveSi,

klinikuri warumateblobis SemTxvevebis garda. o ZiriTadi laboratoriuli testebi (cxr. 3 ) unda gakontroldes

yovel 6 TveSi, Tu ar aris raime cvlilebebli arv Terapiis reJimSi.

cxrili 12. laboratoriuli testebis sixSire ZiriTadad da specifikuri arv-s reJimis gaTvaliswinebiT

sawyisi 2

kvira 4

kvira8

kvira16

kvira 24

kvira 36

kvira48

kviravirusuli datvirTva

X

X X X X

CD4 ujredebis ricxvi

X X X (X) X

sisxlis saerTo analizi

X X X X (ZDV)

X (X) X

RviZlis funqciuri sinjebi

X X (NVP)

X X (NVP, ZDV, PI)

X (NVP, PI)

X (X) X

qolesterini triglice-ridebi

X (PI) X (PI)

X (PI)

Tirkmlis funqciebi

X X (TDF)

X (TDF, IDV)

X (X) X

X: testebi, romlebic unda Catardes arv Terapiisgan damoukideblad;

45

X (arv): testebi, romlebic unda Catardes mocemuli preparatis arsebobisas arT reJimSi; (X): araucilebeli testebi. 5.3. mkurnalobis reJimis dacvis monitoringi yvela pacienti, romelic imyofeba arT-ze mudmivad unda imyofebodnen meTvalyureobis qveS. sanam isini imyofebian mkurnalobis monitoringis qveS (ixileT damateba 5), miRebuli meTodia standartuli anketireba 14 dReSi an TveSi erTxel. virusuli datvirTvis cvlileba yovelTvis saWiroebs eqimis mier pacientTan erTad mkurnalobis reJimis ganxilvas. gamoiyeneba kiTxvari, romlis mixedviTac SeiZleba ganvsazRvroT damyoloba mkurnalobisadmi. mkurnalobis reJimis dacva 4-6 Tvis ganmavlobaSi saSualebas iZleva miRweul iqnas xangrZlivi imunovirusologiuri pasuxi (110) (AI). sxvadasxvagvari Careva SesaZlebelia, magram prioritetulia is reJimi, romelic adreul TveebSi iZleva arT-ze ukeTes pasuxs (110-114) (AI). mkurnalobis reJimis dacva SeiZleba iyos nawili rutinuli klinikuri dakvirvebisa, romelsac axorcielebs yvela profesionali eqimi. yoveli vizitis dros eqimi unda darwmundes, rom TiToeul pacients:

o aqvs emociuri da fizikuri mxardaWera o dRis ganmavlobaSi icavs wamlebis miRebis reJims o esmis, rom reJimis darRveva gamoiwvevs rezistentobis

ganviTarebas o gacnobierebuli unda hqondes, rom yvela doza droulad iqnas

miRebuli o wamlebis miRebis dros Tavs unda grZnobdes komfortulad. o daicvas daniSnuleba o esmodes arv-s moqmedeba da gverdiTi efeqtebi. o icodes Tu rodis mimarTos eqims.

sxva strategia moicavs:

o depresiis mkurnaloba, raTa amaRldes mkurnalobis reJimis dacva da miRweul iqnas xangrZlivi Sedegi

o wamlebis urTierTqmedebis da dozirebis menejmenti. o medikamentebis gacema mcire raodenobiT da xSiri intervalebiT,

romelic aiolebs: 1. problemebis droul gamovlenas, manam sanam ganviTardeba

rezistentoba 2. Semcirdes medikamentebis gacema da borotad gamoyeneba 3. gamoyenebuli iqnas dReSi erTxel misaRebi, erTdoziani

medikamentis kombinacia, rac xels Seuwyobs adreul etapze mkurnalobis damyolobas; da

46

4. mkurnalobaze uSualo zedamxedveloba, gansakuTrebiT hospitalSi

o fsiqosocialuri daxmareba o pacients miewodos saxelmZRvanelo da broSurebi o pacientebis monawileoba daxmarebis jgufebSi

5. 4. arv toqsiuroba da gverdiTi efeqtebis menejmenti gverdiTi efeqtebi xSiria arv Terapiis dros, gansakuTrebiT proteazas inhibitorebis miRebis dros (ix. cxrili 13).

o lopinavir/ritonavirs da nelfinavirs SeuZliaT gamoiwvion diarea o lopinaviri/ritonaviris miReba asocirebulia hiperlipidemiasTan

(gansakuTrebiT trigliceridebis momatebasTan) o cximebis metabolizmis darRvevebi SeiZleba gamoiwvios TiTqmis

yvela proteazas inhibitorebma o erTaderTi proteazas inhibitori, romelic gavlenas ar axdens

lipidur cvlaze aris atazanaviri da atazanavir/ritonaviri. zogierT qveyanaSi atazanaviri mowodebulia mkurnalobis meore rigis sqemaSi

o kardiovaskularuli garTulebebis riskis momateba saWiroebs Semdgom Seswavlas

cxrili 13 arv-s toqsiurobis dadastureba da menejmenti

ARV toqsiuroba menejmenti RviZlis nekrozi

nevirapini (NVP) o cxeleba, gamonayari (50%), gulisreva, Rebineba, eozinofilia, alt, ast-s donis momateba

o Cveulebriv pirvel 6-18 kviraSi, iSviaTad 48 kviris Semdeg

o nevirapinze myofi pacientebis 1-2%, qalebSi CD4 > 250 ; kacebSi CD4 > 400-ze

o RviZlis funqciuri sinjebis monitoringi 2, 4, 8, 16 kviraze da Semdeg yovel 3 TveSi

o simptomuri mkurnaloba o RviZlis nekrozis

mkurnaloba, calkeul klinikur SemTxvevebSi wamlebis Sewyveta

laqtat-acidozi maRlidan dabali riskisken:

o stavudini didanozinTan erTad

o didanozini o stavudini o zidovudini

o gulisreva, Rebineba, wonaSi dakleba, sisuste, pankreatiti, multiorganuli ukmarisoba, respiratoruli distres sindromi

o yoveli 1000 pacientidan 1-10 weliwadSi didanozini da stavudini

o laqtat-acidozis monitoringi Tu eWvia, inaxos adreuli indikatorebi (kreatinkinaza (CK) HCO3)

o acidozis samkurnalod mowodebulia bikarbonati

o abakaviriT, tenofoviriT, lamivudiniT, emtricitabiniT Secvla

47

maRali mgrZnobeloba

abakaviri (ABC )

o xSirad aris cxeleba, gamonayari, aseve sisuste da gulisreva

o 5%, iSviaTad 6 kviris Semdeg

o kanze dakvirveba, ar SeiZleba dawyeba gamonayris sawinaaRmdego wamlebTan erTad.

o Sewydes abakaviris miReba da ar ganaxldes Tu diagnozi saeWvoa

o Seicvalos zidovudiniT, tenofoviriT an stavudiniT

stivens-jonsis sindromi, epidermisis toqsiuri nekrozi

nevirapini (NVP) efavirenzis dabali doziT

o cxeleba, buStukovani gamonayari, mialgia

o nevirapini 1%-Si, efavirenzi 0,1%-Si

o kanze dakvirveba o antibiotikebis daniSvna

Wrilobis samkurnalod

pankreatiti maRlidan dabali riskisken:

o stavudini didanozinTan erTad

o didanozini o stavudini

o tkivili, lipazas maRali done

o didanozini 1-7%, dozis SemcirebiT

o lipazas donis monitoringi

o simptomuri mkurnaloba, parenteraluri kveba, wamlebis Sewyveta

o zidovudiniT an tenofoviriT an abakaviriT Secvla

48

ARV toqsiuroba menejmenti nefrotoqsiuroba

tenofoviri TDF

o Tirkmlis ukmarisoba da fankonis sindromi

o ufro xSirad pacientebSi Tirkmlis disfunqciiT

o kreatininis monitoringi, istoria Tirkmlis daavadebis Sesaxeb

o mkurnaloba simtomuria o tenofoviris dozis

koreqcia (saWiroa kreatininis klirensi: yovel meore dRes

o Seicvalos tenofoviri zidovudiniT, abakaviriT an stavudiniT

anemia

zidovudini ZDV

o anemia da neitropenia (sustad Semcireba iTvleba normad zidovudinTan)

o 1-4%, dozaze damokidebulebiT

o sisxlis saerTo analizis monitoringi 2, 4, 8, 12 kviraze. makrocitozi msubuqi anemiiT (hemoglobini 100 gr/l) xSiria

o mkurnaloba aris eriTropoetinis transfuzia (Zalze Zviria) an Seicvalos zidovudini sxva nrti (tenofoviri, abakaviri an stavudini)

periferiuli neiropaTia didanozini, stavudini, zalcitabini

o kidurebis tkivili, paresTezia

o 10-30% wlebis Semdeg

o periferiuli nervuli sistemis kontroli

o mkurnaloba tkivilis kupireba, Seicvalos arT. Sewydes wamlebi an Seicvalos nrti (zidovudini, tenofoviri, abakaviri)

cximovani atrofia stavudini, da sxva nrti

o loyisa da kidurebis cximis ganleva

o xangrZlivad gamoyenebis SemTxvevaSi xSiria (mitoqondriuli toqsiuroba)

o monitoringi da sawyis mdgom. Sedareba

o Seicvalos stavudini tenofoviriT an abakaviriT. Tu atrofia Seuqcevadia plastikuri qirurgia naCvenebia

cximovani akumulacia PI

o matulobs mucelze gacximovneba, mkerdis zoma,

o 20-80%

o Sefaseba da sawyis mdgom. Sedareba

o Seicvalos NNRTI-iT, Tu lipodistrofia/lipoatrofia ar aris tolerantuli, naCvenebia plastikuri qirurgia

nnrti>APV/fozamprenaviri FPV>abakaviriABC

o makulur-papuluri gamonayari

o 15% nnrti, APV 20%, abakaviri 5%

o cxelebis, RviZlis funqciuri sinjebis da kreatinkinazas monitoringi

o sxva alergenebis gamoricxva (sulfametoqsazol/trimetoprimi da sxva antibi.). gamonayari SeiZleba spontanurad gaqres arT-s

49

ARV toqsiuroba menejmenti PIs (all),zidovudini ZDV,didanizini ddI

o gulisreva da Rebineba, diarea

o xSiria

o gamoiricxos sxva mizezi (imunuri rekonstituciis anTebiTi sindromi CMV kolitiT, kriptosporidiozi, mikrosporidiozi, arT-s dawyebidan kvireebis Semdeg

o mkurnaloba aris loperamidiT Tu diareis sxva mizezi ar aris: metoklopramidi, zofrane gulisrevis da Rebinebis dros

centraluri nervuli sistemis (cns) toqsiuroba

efavirenzi EFV

o Ramis SfoTva, koncentraciis darRveva, depresia (suicidisken midrekileba)

o 50%

o pacientebis gafrTxileba, fsiqiatris konsultacia

o mkurnaloba Cveulebriv saWiro ar aris. aRniSnuli movlenebi gaivlis 5-21 dReSi

insulin rezistentoba

PIs (yvela magram ATV)

o glukozis tolerantoba matulobs, glukoza matulobs uzmoze

o 5%

o uzmoze glukozis monitoringi

o mkurnaloba dietiT da metforminis an glitazonis miReba

o Seicvalos pi nnrti-iT hiperlipidemia

stavudini (d4T)>PIs (all but ATV)

o lipidebis, qolesterolis, trigliceridebis momateba( am ukanasknelisTvis stavudini SeiZleba iyos wamyvani)

o 0%

o lipidebis donis monitoringi arT-s dawyebidan da Semdeg yovel eqvs TveSi

o mkurnaloba lipidebis, qolesterolis da trigliceridis gaidlainebiT

o sifrTxilea saWiro urTierTzemoqmedebisas (ar SeiZleba simvastatini da

Semdeg o Seicvalos nevirapini

efavirenziT an piriqiT. Tu ar aris gaumjobeseba scadeT sxva reJimi

transaminazebis elevacia

anrti (all) da PIs (all)

o auxsneli RviZlis funqciebis momateba

o 8-15% PI da nnrti o ufro xSirad

pacientebSi qronikuli HBV da HCV infeqciiT

o ALT monitoringi yovel eqvs TveSi, gaTvaliswinebuli iqnas sxva faqtorebi (mag. wamlismieri hepatiti.

o momateba xSirad Tan axlavs nnrti da pi ganuwyvetel miRebas

o Sewydes nnrti da pi miReba

50

lovastatini)

hiperbilirubinemia

atazanaviri (ATV) >indinaviri ( IDV)

o bilirubinis momateba (SesaZlebelia qavili, araprolongirebuli RviZlis dazianeba, Seqcevadi

o xSiria

o bilirubinis da klinikuri simtomebis monitoringi

o wamlebis Sewyveta Tu ar aris tolerantoba. Seicvalos pi.

nefroliTiazi

indinaviri (IDV)

o muclis tkivili, hematuria, Tirkmlis kolika

o 10-20%

o Sardis analizis da kreatininis monitoringi

o mkurnaloba igivea rac nefroliTiazis dros

51

ARV toqsiuroba menejmenti nefrotoqsiuroba

tenofoviri TDF

o Tirkmlis ukmarisoba da fankonis sindromi

o ufro xSirad pacientebSi Tirkmlis disfunqciiT

o kreatininis moni-toringi, istoria Tirkmlis daavadebis Sesaxeb

o mkurnaloba simto-muria o tenofoviris dozis

koreqcia (saWiroa kreatininis klirensi: yovel meore dRes

o Seicvalos tenofoviri zidovudiniT, abakaviri an stavudiniT

anemia

zidovudini ZDV

o anemia da neitropenia (sustad Semcireba iTvleba normad zidovudinTan)

o 1-4%, dozaze damokidebulebiT

o sisxlis saerTo analizis monitoringi 2, 4, 8, 12 kviraze. makrocitozi msubuqi anemiiT (hemoglobini 100 gr/l) xSiria

o mkurnaloba aris eroTropoetinis transfuzia (Zalze Zviria) an Seicvalos zidovudini sxva nrti (tenofoviri, abakaviri an stavudini)

periferiuli neiropaTia didanozini, stavudini, zalcitabini

o kidurebis tkivili, paresTezia

o 10-30% wlebis Semdeg

o periferiuli nervuli sistemis kontroli

o mkurnaloba tkivilis kupireba, Seicvalos arT. Sewydes wamlebi an Seicvalos nrti (zidovudini, tenofoviri, abakaviri)

cximovani atrofia stavudini, da sxva nrti

o o xSiria xangrZlivi

gamoyenebis SemTxvevaSi (mitoqondriuli toqsiuroba)

o monitoringi da sawyis mdgom. Sedareba

o Seicvalos stavudini tenofoviriT an abakaviriT. Tu atrofia Seuqcevadia plastikuri qirurgia naCvenebia

cximovani akumulacia PIs

o matulobs mucelze gacximovneba, mkerdis zoma,

o 20-80%

o Sefaseba da sawyis mdgom. Sedareba

o Seicvalos NNRTI-iT, Tu lipodistrofia/lipoatrofia ar aris tolerantuli, naCvenebia plastikuri qirurgia

nnrti>APV/fozamprenaviri FPV>abakaviriABC

o makulur-papuluri gamonayari

o 15% nnrti, APV 20%, abakaviri 5%

transaminazebis elevacia

anrti (all) da PIs (all)

o auxsneli RviZlis funqciebis momateba

o 8-15% PI da nnrti o ufro xSirad

pacientebSi qronikuli HBV da HCV infeqciiT

52

ARV toqsiuroba menejmenti PIs (all),zidovudini ZDV,didanizini ddI

o gulisreva da Rebineba, o diarea

centraluri nervuli sistemis (cns) toqsiuroba

efavirenzi EFV

o koncentracia depresia (suicidisken midrekileba)

o 50%

insulin rezistentoba

PIs (all but ATV)

o glukozis tolerantoba matulobs, glukoza matulobs

o 5%

hiperlipidemia

stavudini (d4T)>PIs (all but ATV)

o lipidebis qolesterini, trigliceridebi

o % meryeobs

hiperbilirubinemia

atazanaviri (ATV) >indinaviri ( IDV)

o bilirubinis momateba (SesaZloa qavili, ar grZeldeba RviZlis dazianeba, Seqcevadia)

o xSirad cvalebadobs

nefrolifiazi

indinaviri (IDV)

o muclis tkivili, hematuria, Tirkmlis kolika

o 10-20%

5.5 imunuri rekontituciis sindromi (irs) irs adgili aqvs arT sawyis etapze, ufro xSirad rodesac CD4<100mm3. Tu miZinebuli oportunistuli infeqcia ar diagnostirdeba klinikuri simtomebis ararsebobis gamo, maSin SesaZlebelia adgili hqondes irs arT sawyis etapze. saWiroa gamoswordes da gaaqtiurdes imunuri sistema, rac saSualebas mogvcems diagnostirdes oportunistuli infeqciebi (120-121) (CIII). oportunistuli infeqciebi sxvadasxvagvarad gamovlindeba, magaliTad abscesis dros gamomwvevia Mycobacterium avium-intracellulare (MAI) an gulmkerdis kuriozuli rentgenologiuri Sedegi Pneumocystis jirovecii pneumonia (PCP). irs gvxvdeba SemTxvevaTa 10%-Si. MAI da CMV yvelaze

53

xSiri oportonistuli infeqciebia, magram cudi mkurnalobis SemTxvevaSi SesaZlebelia PCP ganviTardes (122) (BII). irs ganviTarebis Semdeg arT unda gagrZeldes oportunistuli infeqciebis mkurnalobasTan erTad. SesaZlebelia prednizolonis dabali dozebi (20-60 mg dReSi). arT SesaZlebelia Sewydes Tu adgili aqvs oportunistuli infeqciebis mkurnalobis gverdiT efeqtebs an gamoxatulia ezofagiti (CMV, herpesuli infeqcia, kandidozi) tkiviliT. 5.6. wamlebis urTierTqmedeba wamlebis urTierTqmedeba warmoadgens calke problemas arT-s dros. aiv/SidsiT inficirebulebi iReben ramdenime saxis medikamentebs, imis gamo, rom aqvT manifestirebuli daavadeba da/an Tanmxlebi daavadebebi. medikamentebis urTierTqmedebis miuxedavad, maTi kombinaciis miReba SesaZlebelia kvlav gagrZeldes. miuxedavad amisa gverdiTi efeqtebis gamovlenis SesaZlebloba maRalia da saWiroebs monitorings. kontraceptivebis miReba sariskoa. cxrilSi 14 da 15 ilustrirebulia aranukleozidis revers transkriftazas inhibitorebis da proteazas inhibitorebis urTierTmoqmedeba. cxrili 14. anrtis zemoqmedeba

nnrti efeqti mniSvneloba

EFV NPV

+ ergotamini ++ (Tavidan acileba)

+ antiariTmulebi: lidokaini, amiodaroni da sxva

++ (SeniSvna)

+

+

antikonvulsurebi: karbamazepini, fenitoini, fenobarbitali

+ +

(+)c + itrakonazoli, ketokonazoli + + ciklosporini, takrolizmusi,

rapamicini + +

+ + + midazolami, alprazolami, triazolami

+ +

+ kalciumis arxis blokatorebi + + + + sildenafili, vardenafili,

tadalafili + +

+ fentanili + + + + metadoni + + + + kontraceptivebi + + + + rifampini, rifabutini + +

+ + stivens jonsis sindromi + + + + varfarini + +

54

cxrili 15. proteazas inhibitorebis zemoqmedeba proteazas inhibitorebi

APV ATV IDV LPV NFV RTV SQV efeqti mniSvneloba

+ fentanili, tramadoli, hidrokodoni

+

+ + kodeini, morfini, metadoni

+

+ + + + + + + amiodaroni, lidokaini, flekainidi

+

+ + + + + + karbamazepini, klonazepami, fenitoini, fenobarbitali

++ (Tavidan acileba)

+ + + + tricikluri antidepresantebi

+

+ + sxva antidepresantebi +

+ loratadini + +

+ atovaqvini +

+ + + ++ + + ++ benzodiazepini + +

+ beta blokatorebi +

+ + + + + + + kalciumis arxis blokatorebi

+ +

+ + + klaritromicini, eriTromicini, Tirkmlis

+ (SeniSvna)

+ + + + + klaritromicini, eriTromicini

+

+ + + + kontraceptivebi + +

+ + + + kortikosteroidebi +

+ + + + + + + ciklosporini +

+ + + + + + + ergot derivatebi ++ (Tavidan acileba)

+

++

+

+

+

+

+

protonuli dguSis inhibitorebi (PPIs)

+ (SeniSvna) (++, ATV- Tavidan acileba)

+ ++ + + + + + H2 antagonistebi ++ (SeniSvna) (++, ATV)

+ + + + + + + lovastatini, simvastatini

++ (Tavidan acileba)

+ irinotekani ++ (Tavidan acileba)

+ + + + + ketokonazoli, itrakonazoli

+

+ + + + + + + pimozidi ++ (Tavidan acileba)

+ + + + + + + rifampini ++ (Tavidan acileba)

+

+

+

+

+

+

+

rifabutini + (SeniSvna, doze

adjustment) + + + + + + + sildenafili + +

+ + + + + + + stiven jonsis sindromi ++ (Tavidan acileba)

+ tenofoviri + + (add RTV)

+ + + Teopilini +

+ + + + varfarini +

55

cxrilebis wakiTxvis magaliTi

1. cxrili 14 rigi 6: efavirenzi mkacrad zrdis dones: midazolamis, alfrazolamis da triazolamis, maSin roca nevirapinis doza amcirebs. zemoT xsenebuli faqtis klinikuri mniSvneloba mdgomreobs medikamentebis kvlav mowodebaSi.

2. cxrili 15 rigi 4: abakaviri, indinavir/lopinaviri, nelfinaviri, ritonaviri da seqvinaviri zrdian karbamazepinis, klonazepamis, fenitoinis da fenobartialis dones, maSin roca es wamlebi amcireben proteazas inhibitorebis dones. klinikuri Rirebuleba imaSia, rom aseT kombinacias Tavi unda avaridoT.

klinikur doneze Sesagrovebeli minimaluri monacemebis CamonaTvali klinikur doneze Sesagrovebeli minimaluri monacemebis CamonaTvali mniSvnelovania, rogorc mkurnalobis xelmisawvdomobisa da Sedegianobis indikatori. aseTi indikatorebi exmareba menejers SesTavazos es servisi yvelas, vinc saWiroebs. CamoTvlili monacemebi unda Segrovdes klinikur doneze, rogorc regularuli sabaziso: (TveSi erTxel, kvartalSi an eqvs TveSi erTxel)

o aiv pacientebis ricxvi, romelTac vxedavT weliwadSi erTxel o aiv pacientebis ricxvi, romlebic ganixilebian arT-s

kandidatebad (CD4<350 mm3) o aiv pacientebis ricxvi, romlebic arian arT-s sawyis etapze o aiv pacientebis ricxvi, romlebic Rebuloben arv-s o aiv pacientebis ricxvi, romlebic I rigis preparatebidan

gadavidnen II rigze. o aiv pacientebis ricxvi, romlebic II rigis preparatebidan

gadavidnen gadarCenis reJimze. o aiv pacientebis ricxvi, romlebmac Sewyvites arT, mizezis

aRniSvniT (magaliTad sikvdili, toqsiuroba-gverdiTi efeqtebi, orsuloba, arv ar aris xelmisawvdomi)

o aiv pacientebis ricxvi, romlebic mokvdnen arT-s dros, sikvdilis mizezis aRniSvniT (magaliTad aiv/SidsTan dakavSirebuli sikvdilianoba an misgan damoukidebeli, rogoricaa dozis gadaWarbeba, suicidi da sxva)

o aiv pacientebis ricxvi, romlebic mokvdnen arT-s dawyebidan 12 TveSi.

o gardacvlili aiv pacientebis ricxvi, sikvdilis mizezis aRniSvniT (magaliTad aiv/SidsTan dakavSirebuli sikvdilianoba an misgan damoukidebeli, rogoricaa dozis gadaWarbeba, suicidi da sxva).

56

Odamateba 1. ZiriTadi informacia aiv infeqcia/Sidsis mkurnalobis da movlis personaluri istoriisTvis

cxrili 16. ZiriTadi informacia aiv infeqcia/Sidsis mkurnalobis da movlis personaluri istoriisTvis

TariRi CD4 ujredebi/mm3

%

VL asli/ml

rezistentoba (genotipi an fenotipi)

57

damateba2. jandacvis msoflio organizaciis mier mowodebuli klinikuli stadia aiv/Sidsis mozardebsa da mozrdilebSi (Sua evropis regionis versia, adamianebisTvis romelTa asaki >15welze, aiv pozitiuria an saxezea aiv infeqciis sxva laboratoriuli testebi) mwvave aiv infeqcia

o asimtomuri o mwvave retrovirusuli sindromi

klinikuri stadia 1 o asimtomuri o persistuli generalizebuli limfadenopaTia

klinikuri stadia 2 o seboreuli dermatiti o angularuli heiliti o ganmeorebiTi oraluri ulceracia (ori an meti epizodi eqvsi

Tvis ganmavlobaSi) o herpes zosteri o respiratoruli traqtis ganmeorebiTi infeqcia (ori an meti

epizodi eqvsi Tvis ganmavlobaSi, sinusiti, Sua otiti, bronqiti, faringiti, traqeiti)

o frCxilebis sokovani infeqcia

klinikuri stadia 3 o piris Rrus Tmovani leikoplakia o umizezo qronikuli faRaraTi erT Tveze meti o ganmeorebiTi oraluri kandidozi (ori an meti epizodi eqvsi

Tvis ganmavlobaSi o sxva baqteriuli infeqcia (mag. pnevmonia, empiema, piomioziti,

Zvlebis an saxsrebis infeqcia, meningiti, baqteriemia) o mwvave, nekrozuli, ulcerogenuli stomatiti, gingiviti an

periodontiti)

klinikuri stadia 4

o filtvis tuberkulozi o eqstra pulmonuri tuberkulozi (limfadenopaTiis CaTvliT) o wonis umizezo dakargva (eqvsi Tvis ganmavlobaSi 10% meti) o aiv asocirebuli ganlevis sindromi o pnevmocisturi pnevmonia o ganmeorebiTi sxva an radiologiurad dadasturebuli

baqteriuli pnevmonia (ori an meti epizodi erT weliwadSi) o CMV retiniti (+koliti) o martivi herpes virusuli infeqcia (qronikuli an persistuli

bolo erTi Tvis ganmavlobaSi) o encefalopaTia o aiv-Tan asocirebuli kardiomiopaTia

58

o aiv-Tan asocirebuli nefropaTia o progresuli multifokaluri leikoencefalopaTia o kapoSis sarkoma da aiv_Tan dakavSirebuli avTvisebiani

daavadebebi: 1.toqsoplazmozi 2.diseminirebuli sokovani infeqcia (mag. kandidozi, kokcidomikozi, histoplazmozi) 3.kriptosporidozi 4.kriptokokuli meningiti 5.aratuberkulozuri mikobaqteriuli infeqcia

damateba 3. rezistentobis testi

rezistentobis testis Casatareblad saWiroa virusuli datvirTva minimum 500-1000 asli/ml. testis Catareba SeuZlebelia, rodesac aRiniSneba virusis sruli supresia. genotipis rezistentobis testi damyarebulia virusis rnm-is mutaciis analizze. mutacia damokidebulia virusis mgrZnobelobis cvlilebaze. es aris arapirdapiri mtkiceba wamlis rezistentobisa. rezistentuli virusis populacia ar aris maRali da Seadgens mTeli populaciis 20%-s. fenotipis rezistentobis testi msgavsad mikrobiologiuri rezistentobis testisa, ikvlevs virusis replikaciis unars ujredebis kulturaSi sxvadasxva agentis arsebobisas da adareben virusis veluri Stamis unarianobas. 50% inhibitoris koncentracia (IC50) aris wamlis potenciis markeri. testis Sedegi gviCvenebs mgrZnobelobis gansxvavebul xarisxs. rezistentobis romeli testi gamoviyenoT? amJamad arsebuli yvela testi aris Zviri. genotipis testis Rirebuleba Seadgens 400 E, fenotipis _ 800 E (2005w). drom nimuSis aRebidan Sedegis miRwevamde SeiZleba Seadginos ramdenime kvira. genotipis bazisuri testi saSualebas iZleva daigegmos mkurnalobis reJimi. pirveli da meore rigis mkurnalobis sqemebi ar saWiroebs Zvir fenotipis tests. rodesac gaurkvevelia arT-s istoria, sakmarisad cnobili mutacia, mkurnaloba ar aris Sedegiani, fenotipuri testis Catareba gamarTlebulia. yvela testis SemTxvevaSi unda gagrZeldes mkurnalobis arsebuli reJimi, sxva SemTxvevaSi swrafad ganviTardeba rezistentuli Stamebi. ar arsebobs standartuli rekomendaciebi romeli rezistentuli testebi ganiviyenoT, fenotipuri Tu genotipuri.

59

damateba 4. ZiriTadi informacia antiretrovirusuli mkurnalobis Sesaxeb cxrili 17. ZiriTadi informacia antiretrovirusuli mkurnalobis Sesaxeb arv abreviatura zoma dozebi SeniSvnebi gverdiTi efeqtebi rezistentobis profili

(didi da mcire)

nrti abakaviri ABC 300 mg 300 mg tab. orjer an

600 mg erTxel

ar aris monacemebi hipermgrZnobelobis reaqciisa

maRalmgrZnobiare reaqcia (cxeleba, gamonayari,gripismagvari simptomebi: GI da filtvis simptomi)

65R, 74V, 115F, 184V/I

didanoziri ddI 250 mg 400 mg

pacienti >60kg: 400 mg tab. erTxel pacienti <60kg: 250 mg tab. erTxel

Wamidan 2 sT-is Semdeg dozis koreqcia TDF, ara ribavirinTan kombinacia

periferiuli polineiropaTia, pankreatiti, laqtacidozi

65R, 74V

emtricitabini FTC 200 mg 200 mg kaps. erTxel igive, rac lamivudini 65R, 184V/I lamivudini 3TC 300 mg

150 mg 300 mg tab. erTxel an 150 mg tab. orjer

iSviaTi diarea 65R, 184V/I

stavudini d4T 30 mg 40 mg

pacienti >60kg: 40 mg kaps. orjer pacienti <60kg: 30 mg kaps. orjer

zidovudinTan ar SeiZleba

periferiuli neiropaTia, lipodistrofia, alt, ast-s donis momateba

41L, 67N, 70R, 75T/M/S/A, 210W, 215Y/F, 219Q/E

tenofoviri TDF 300 mg 300 mg tab. erTxel didanozinis dozis koreqcia, ar SeiZleba stavudinTan kombinacia; sifrTxile Tirkmlis ukmarisobis dros (dozis koreqcia)

Tirkmlis ukmarisoba 41L, 65R, 210W

zidovudini ZDV 300 mg 300 mg tab. orjer ar SeiZleba stavudinTan; mgrZno-biarea 65R da 184V

anemia, GI, Tavis tkivili 41L, 67N, 70R,210W, 215Y/F, 219Q/E

ABC + 3TC KVX 600 mg ABC 300 mg 3TC

1 tableti erTxel

TDF + FTC TVD 300 mg TDF 200 mg FTC

1 tableti erTxel

ZDV + 3TC ZDV + 3TC ABC

CBV TZV

300 mg TDF 150 mg 3TC 300 mg ZDV 150 mg 3TC 300 mg ABC

1 tableti orjer 1 tableti orjer

maRali doza zidovudinis maRalia riski (gverdiTi efeqtebis maRali riski) ara dReSi erTxel

anrti efavirenzi EFV 600 mg 600 mg tab. erTxel dawyeba saRamos Zilis darRveva, fsiqiuri darRvevebi

(depresia, suicidisken midrekileba, Tavbruxveva)

100I, 101E, 103N, 106A/M, 108I, 181C, 188L, 190A/S, 225H, 230L

60

arv abreviatura zoma dozebi SeniSvnebi gverdiTi efeqtebi

rezistentobis profili (didi da mcire)

nevirapini NVP 200 mg 200 mg tab. orjer pirveli 14 dRe 200 mg erTxel,Semdeg 200 mg orjer

gamonayari, RviZlis fermentebis momateba

100I, 101E, 103N, 106A/M, 108I, 179D/E, 181C/I, 188C/H, 190A/S, 230L

delavirdini DLV 200 mg 100 mg

200 mg x 2 tab. samjer an 100 mg x 4 tab. samjer

ar gamoiyeneba evropaSi gamonayari, gastro-intestinuri simptomebi, diarea

K103N/S, Y181C/I, P236L, G190A/S/E/Q/C, Y188L/H/C, V106A/M, K101E/P, M230L, K238T/N, F318L, V179D/E

pi

atazanaviri ATV 300 mg 300 mg erTxel + 100 mg RTV erTxel

iseTive dozireba, rogorc mkurnalobaze myofi pacientebis. gamoiyeneba ritonavirTan erTad

bilirubinis momateba

24I, 33F/I/V, 36I/L/V, 46I/L, 50L, 54V/L/M/T, 82A/F/T/S, 84V, 88S, 90M

fozamprenaviri FPV 700 mg 700 mg tab. orjer + 100 mg kaps. RTV orjer

iseTive dozireba, rogorc mkurnalobaze myofi pacientebis. gamoiyeneba ritonavirTan erTad

gamonayari, Tavis tkivili, diarea, dislipidemia

32I, 47V, 50V, 54L/M, 82A/F/T/S, 84V

indinaviri IDV 400 mg 400 mg kaps. orjer + 100 mg kaps. RTV orjer

gamoiyeneba ritonavirTan erTad

Tirkmlis kenWi, dislipidemia

24I, 32I, 36I, 46I/L, 54V, 82A/F/T/S, 84V, 90M

lopinaviri/ rito-naviri kombinacia

LPV/r 133 mg/33 mg 200 mg/50 mg

(133 mg/33 mg) x 3 kaps. orjer an (200 mg/50 mg) x 2 tab. orjer

Zveli monacemebiT saWiroa gayinva, axali monac. amis saWi-roeba ar aris; dReSi erTxel

diarea, meteorizmi, dislipidemia

10I/R/V, 20M/R, 24I, 32I, 33I/F/V, 46I/L, 53L, 54V/L, 63P, 71V, 82A/F/T, 84V, 90M

nelfinaviri NFV 250 mg 625 mg

625 mg x 2 tab. orjer an 250 mg x 5 tab orjer

saWmelTan erTad Sewova izrdeba 270%-iT; ar Zlierdeba ritonavirTan erTad

diarea, meteorizmi 30N, 36I, 46I/L, 54V/L/M/T, 82A/F/T/S, 84V, 88D/S, 90M

ritonaviri seqvinaviri

RTV SQV

100 mg 500 mg

500 mg x 2 kaps. orjer + 100 mg kaps. RTV orjer

axali 500 mg tab. 2004 wlamde iyo 200 mg. gamo-

iyeneba ritonavirTan erTad

dislipidemia, RviZlis funqciebis momateba, diarea diarea da sxva gastrointestinuri simpromebi, dislipidemia

48V, 53L, 54V/L, 82A/F/T, 84V, 90M

tipranaviri TPV 250 mg 250 mg x 2 kaps. orjer + 100 mg x 2 kaps. RTV orjer

iseTive dozireba, rogorc mkurnalobaze myofi pacientebis. ar gamoiyeneba pi-Tan erTad, gamoiyeneba ritonavirTan erTad

dislipidemia, RviZlis funqciebis momateba, diarea

13L/V, 20M/R/V, 33F/I, 35D/N, 36I, 45R, 46I/L, 47V, 54A/M/T/V, 58E, 66F 69K, 71I/K, 74P, 82F/L/T, 84C/V, 90M, 91S

ujredSi SeWris inhibitorebi

enfuvirtidi ENF 90 mg 90 mg/ml kanqveSa ineqcia orjer

ar aris recepri oraluri miRebisTvis

kanis mxriv reaqcia (qavili, SeSupeba, tkivili)

61

62

damateba 5. mkurnalobis reJimis dacvis monitoringis meTodebi TviT-angariSi kargi markeria mkurnalobis reJimisa, magram ara saukeTeso. igi gadaWarbebulad afasebs arT-s efeqturobas, vidre sxva meTodi (128). aucilebelia pacientma gaamJRavnos problemebi pirispir saubrisas. es meTodi SeiZleba iyos mniSvnelovani pacientis rolis gaZlierebisTvis mkurnalobis dagegmvaSi, sapirispirod mowodebuli kontrolirebadi meTodisa. momwodeblis Sefaseba mwiria (129) da ar aris sasurveli. wamlis donis monitoringi aris Zviri da SeuZlebelia yvela arT-ze myofi pacientisTvis. es ar aris rutinuli meTodi mkurnalobis efeqturobis kontrolisTvis. im SemTxvevaSi, rodesac plazmaSi wamlis Semcveloba dabalia, mkurnalobis efeqturoba ar ganixileba. plazmaSi wamlis done aris laboratoriuli markeri , romelic aCvenebs mag. zidovudinis miRebis reJimis dacvas. samedicino SemTxvevebis monitoringis sistema (MEMS) xSirad gamoiyeneba kvlevebis dros. tabletebis raodenoba da farmakologiuri dokumenti SeiZleba ganxilul iqnas, rogorc arasasurveli mcdeloba jandacvis muSakebis mxridan akontrolon mkurnalobaze damyoloba. amitom pacients unda movTxovoT, rom Tan hqondes darCenili medikamentebi. tabletebis identifikaciis testi (PIT) warmoadgens axal meTods, romelic korelaciaSia TviTangariSTan (132). pacientebs unda SeeZloT im tabletebis amocnoba, romlebsac Rebuloben (132). pacientebma unda amoarCion is tabletebi, romlebsac Rebuloben sxva msgavsi magram ara identuri arv “tyupi tabletebisgan”. surogati markerebis gamoyeneba realuria, magram dagvianebulia rodesac saxezea miRebis reJimis darRveva. pi-s Semcvel reJimebze ganviTarebuli virusuli araefeqturoba dakavSirebulia miRebis reJimis darRvevasTan da pi-ze genotipuri rezistentobis ararsebobasTan, rac miuTiTebs rom mkurnalobis araefeqturoba gamowveulia reJimis darRveviT (133,134). mimwodeblebi Zalian frTxilad unda iyvnen am markerebis interpretaciisas da gaiTvaliswinon medikamentebis sisxlSi dabali donis sxva SesaZlo mizezebi (131).

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damateba 6. antiretrovirusuli medikamentebis CamonaTvali cxrili 18 antiretrovirusuli medikamentebis CamonaTvali

saerTaSoriso saxeli (INN)

mwarmoeblis saxeli farmaceptuli kompania

nrti

epzikomi US, Kivexa United Kingdom (lamivudini/abakaviri) triziviri Europe, United Kingdom, US (zidovudini/lamivudini/abakaviri) ziageni United Kingdom, United States

GlaxoSmithKline

abaviri Genixpharma

abakaviri (ABC)

viroli viroli LZ (abkaviri/lamivudini/zidovudini)

Ranbaxy

videqsi, videqsi EC Bristol-Myers Squibb dineqsi EC odiviri Kit (didanozini/lamivudini/efavirenzi)

aviro-Z virozini viro-Z

Ranbaxy (India)

didanozini (ddI)

diviri Thai Government atripla (efavirenzi/emtricitabini/tenofoviri) Bristol-Myers Squibb emtricitabini

(FTC) emtriva truvada (tenofoviri/emtricitabini)

Cipla

kombiviri United Kingdom, United States (lamivudini/zidovuni) epiviri United Kingdom, United States, zefiqsi United Kingdom epzikomi United Kingdom, kiveqsa United Kingdom (lamivudini/abakaviri) triziviri United Kingdom, United States (zidovudini/lamivudini/abakaviri)

GlaxoSmithKline

lamivoqsi staveqsi-L (lamivudini/stavudini) staveqsi-LN (lamivudini/nevirapini/stavudini) zidoveqsi-L (lamivudini/zidovudini) zidoveqsi-LN (lamivudini/nevirapini/zidovudini)

Aurobindo

duoviri (lamivudini/zidovudini) duoviri-N (lamivudini/nevirapini/zidovudini) lamiviri odiviri Kit (didanozini/lamivudini/efavirenzi) triomuni (lamivudini/nevirapini/stavudini)

Cipla

heptaviri lamistari 30, lamistari 40 (lamivudini/stavudini) nevilasti (lamivudini/nevirapini/stavudini) zidolami (lamivudini/zidovudini)

Genixpharma

lamivudini (3TC)

virolami virokombi (lamivudini/zidovudini) virolansi (lamivudini/nevirapini/stavudini) virolisi (lamivudini/stavudini) virol LZ, abak-ALZ (abkaviri/lamivudini/zidovudini)

Ranbaxy

64

saerTaSoriso saxeli

mwarmoeblis saxeli farmaceptuli kompania

zeriti, zeriti XR Bristol-Myers Squibb staveqsi sraveqsi-L (lamivudini/stavudini) sraveqsi-LN (lamivudini/nevirapini/stavudini)

Aurobindo

staviri lamiviri-S (lamivudini/stavudini) triomuni (lamivudini/nevirapini/stavudini)

Cipla

lamistari (lamivudini/stavudini) nevilasti (lamivudini/nevirapini/stavudini) stagi

Genixpharma

staviri GPO (Thailand)

stavudini (d4T)

avostavi triviro-LNS (lamivudini/nevirapini/stavudini) virolansi (lamivudini/nevirapini/stavudini) virolisi, koviro (lamivudini/stavudini) virostavi

Ranbaxy

truvada (tenofoviri/emtricitabini) vireadi (tenofoviri)

Gilead Sciences tenofoviri (TDF)

atripla (efavirenzi/emtricitabini/tenofoviri) Bristol-Myers Squibb triple nuceozidi (TRZ)

triziviri United Kingdom, United States (zidovudini/lamivudini/abakaviri)

GlaxoSmithKline

kombiviri United Kingdom, United States (lamivudini /zidovudini) retroviri United Kingdom, United States triziviri United Kingdom, United States (zidovudini/lamivudini/abakaviri)

GlaxoSmithKline

zidoveqsi Aurobindo zidoviri duoviri (lamivudini /zidovudini)

Cipla

zido-H (zidovudini) Genixpharma antiviri GPO (Thailand)

zidovudini (ZDV or AZT)

aviro-Z virokombi (lamivudini /zidovudini) viroli LZ (abakaviri/lamivudini/zidovudini) viro-Z

Ranbaxy

nnrti delavirdini (DLV)

reskriptori Pfizer, Inc.

Sustiva Europe, United Kingdom, Stocrin Australia, Europe, Latin America, South Africa atripla (efavirenzi/emtricitabini/tenofoviri)

Bristol-Myers Squibb

viranzi Aurobindo efaviri Cipla estiva Genixpharma

efavirenzi (EFV)

efferveni Ranbaxy viramuni Boehringer Ingelheim nevireqsi staveqsi LN (lamivudini/nevirapini/stavudini)

Aurobindo

duoviri-N (lamivudini/nevirapini/zidovudini) nevimuni triomuni (lamivudini/nevirapini/stavudini)

Cipla

nevilasti (lamivudini/nevirapini/stavudini) Genixpharma

nevirapini (NVP)

gpoviri GPO (Thailand)

65

saerTaSoriso saxeli mwarmoeblis saxeli farmaceptuli

kompania nevipani

triviro LNS (lamivudini/nevirapini/stavudini) virolansi (lamivudini/nevirapini/stavudini) zidoveqsi-LN (lamivudini/nevirapini/zidovudini)

Ranbaxy

Fusion Inhibitors enfuvirtidi, T-20 fuzeoni Roche

Pharmaceuticals & Trimeris, Inc.

proteazas inhibitorebi

amprenaviri (APV) Agenerase United Kingdom, United States GlaxoSmithKline atazanaviri (ATV) Reyataz Europa, US, Zrevada Bristol-Myers Squibb fosamprenaviri (FPV) leqsiva US, telziri United Kingdom GlaxoSmithKline

and Vertex kriqsivani Merck & Co. indiveqsi Aurobinda indiviri Cipla indiviri Genixpharma

Indiraviri (IDV)

virodini Ranbaxy lopinaviri/ritonaviri kombinacia (LPV/r)

kaletra Abbott Laboratories

viracepti Pfizer, Inc., Roche Pharmaceuticals

nelveqsi Aurobinda nelviri Cipla nelfini Genixpharma

nelfinaviri (NFV)

nefaviri Ranbaxy norviri Abbott Laboratories ritonaviri (RTV) ritoviri Hetero/Genix

seqvinaviri (SQV) Fortovase europe, United Kingdom, United States Invirase United Kingdom, United States

Roche Pharmaceuticals

damateba 7. leqsikoni mkurnalobis reJimis dacva. rodesac wamlis dozis 95%-ia miRebuli saubaria mkurnalobisadmi damyolobaze. am maCveneblis qvemoT saubaria mkurnalobis reJimis darRvevaze. foni bazisuri nawilia arT mkurnalobisa, romelic Cveulebriv Seicavs or nrti-s, romelic Tavis mxriv fonia proteazas inhibitoris an pi-s da SeWris inhibitorisTvis. termini “optimaluri foni” gulisxmobs problemis regulirebas nrti-sTvis, romelic damyarebulia rezistentobis testis Sedegze. medegianoba aris mkurnalobis reJimis dacvis Zveli termini. genetikuri barieri gamoxatavs virusis mutaciis im raodenobas, romelic saWiroa wamlebis mimarT rezistentobis ganviTarebisTvis. rezistentoba erTi mutaciiT niSnavs dabal genetikur bariers. rezistentoba aTi mutaciiT niSnavs Zalian maRal genetikur bariers, Tumca aseTi daxasiaTeba SeiZleba Seicvalos. maRali mutacia warmoadgens cvlilebebs virusis rnm-Si, romelic ganapirobebs rezistentobas arT-s wamlebze an mTlian klasze.

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mcire mutacia muSaobs kombinaciaSi. igi SesaZloa gaxdes wamyvani rezistentobis ganviTarebaSi, an ewinaaRmdegebodes sxva araxelsayrel did an mcire mutacias. nukleozidis analogis mutacia (NAMs) mJRavndeba jvaredini rezistentobiT umetes nrti-sTvis. wertilovani mutacia warmoadgens erT cvlilebas rnm-is jaWvSi, risi Sedegic aris rezistentobis ganviTareba wamlis an wamlebis mTeli klasis mimarT. magaliTad: arT-s mkurnalobis dros 103 wertilovani mutacia niSnavs mutacias mTeli nrti-is mimarT. rezistentoba aris Sedegi rnm-is jaWvSi aminomJavebis Tanamimdevrobis cvlilebis, rac xdeba aiv-is “Raribi” replikaciis mizezi. cvlilebaTa umravlesoba ganapirobebs virusis sikvdils, zogierTi cvlilebis Sedegad ki virusi iZens unars gaumklavdes arT-s da gadarCes. mkurnalobis warmatebisTvis sasurvelia arT-s dawyebamde virusuli replikaciisa da rezistentobis testis Catareba. rezistentobis zogierTi Sedegi saboloo jamSi gamosadegia. Timidinis analogebis mutacia (TAMs) aris Sedegi zidovudiniT mkurnalobis. damateba 8. horizonts miRma arT-s kvleva grZeldeba. virusis axal mutacias da rezistentobas adgili aqvs regularulad _ rac qmnis axal warmodgenas wamlebisa da virusis urTierTobis Sesaxeb. qvemoT moyvanilia zogierTi ukanaskneli antiretrovirusuli preparatebi, romlebic mowonebulia an gadis gamocdas kombinaciaSi Zvel medikamentebTan.

o dReSi erTxel fiqsirebuli doza kombinaciiT _ tenifoviri + emtricitabini + efavirenzi ufro efeqturia, vidre standartuli kombinacia zidovudini + lamivudini + efavirenzi (40).

o etravirini warmoadgens axal nnrti, romelsac aqvs didi potenciali, miuxedavad mutaciisa, ramac SeiZleba ganapirobos nnrti-s klasis rezistentobis ganviTareba (135).

o darunaviri (TMC 114) axali proteazas inhibitoria, romelsac gaaCnia maRali genetikuri barieri, vidre lopinavir/ritonavirs, rezistentobis ganviTareba ufro nela xdeba, vidre nelfinaviris, APV, an lopinavir/ritonaviris SemTxvevaSi. darunaviri xelmisawvdomia farTod xelmisawvdomi programisTvis (EAP) (136). is axlaxan damtkicebul iqna FDA-s mier.

o kapravirini warmoadgens meore Taobis nnrti-s, romelic bevrad efeqturia miuxedavad nnrti-s klasikuri rezistentobisa.

o axali koreceptoris inhibitorebi kvlevis meore fazaSia. CXCR4 da CCR5, romlebic gamoxataven virusebs, brZoloben wamlebTan, romlebsac SeuZliaT gamiowvion erTis an orives inhibicia. axali testi koreceptorebis eqspresiisa saWiroa mkurnalobis dros. gverdiTi efeqtebi amJamad SezRudulia, Tumca sawyisi gamocdilebiT am axal klasisTvis aRmoCenilia kardiotoqsiuri efeqti. aRiareba SeiZleba moxdes 2007 wels.

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gamoyenebuli literaturis CamonaTvali: 1. Palella FJ Jr et al. Declining morbidity and mortality among patients with advanced human immunodeficiency virus infection. HIV Outpatient Study Investigators. The New England Journal of Medicine, 1998, 338(13):853–860. 2. Sterne JA et al. Long-term effectiveness of potent antiretroviral therapy in preventing AIDS and death: a prospective cohort study. The Lancet, 2005, 366(9483):378–384. 3. Lewden C. Responders to antiretroviral treatment over 500 CD4/mm³ reach same mortality rates as general population: APRICO and Aquitaine Cohorts. 10th European Aids Conference, Dublin, 17–20 November, 2005 (Abstract PE18.4/8). 4. Bartlett JG, Gallant JE. 2003 Medical Management of HIV Infection. Johns Hopkins University, Division of Infectious Disease and AIDS Service. Baltimore, 2003 (http://www.hopkins-aids.edu/publications/ book/03MMHIV1to3.pdf accessed 11 September 2006). 5. Wilson IB et al. Quality of HIV care provided by nurse practitioners, physician assistants and physicians. Annals of Internal Medicine, 2005, 143(10):729–736. 6. Aberg JA et al. Primary care guidelines for the management of persons infected with human immunodeficiency virus: recommendations of the HIV Medicine Association of the Infectious Diseases Society of America. Clinical Infectious Diseases, 2004, 39:609–629. 7. Mellors JW et al. Plasma viral load and CD4+ lymphocytes as prognostic markers of HIV-1 infection. Annals of Internal Medicine,1997, 126(12):946–954. 8. Savès M et al. Risk factors for coronary heart disease in patients treated for human immunodeficiency virus infection compared with the general population. Clinical Infectious Diseases, 2003, 37(2):292– 298. 9. Friis-Moller N et al. Combination antiretroviral therapy and the risk of myocardial infarction. The New England Journal of Medicine, 2003, 349(21):1993–2003. 10. Pragna Patel. Incidence of AIDS defining and non-AIDS defining malignancies among HIV-infected persons. 13th Annual Conference on Retroviruses and Opportunistic Infections (13th CROI), Denver, 5–8 February 2006 (Poster 813). 11. HIV testing methods. Geneva, Joint United Nations Programme on HIV/AIDS (UNAIDS), 1997 (UNAIDS Technical Update WC 503.1). 12. Mulcahy F et al. CD4 counts in pregnancy do not accurately reflect the need for long-term HAART. 13th Annual Conference on Retroviruses and Opportunistic Infections (CROI), Denver, 5–8 February 2006 (Abstract 704b). 13. Hawkins D et al. Guidelines for the management of HIV infection in pregnant women and the prevention of mother-to-child transmission of HIV. HIV Medicine, 2005, 6:107–148. 14. Friis-Moller N et al. Exposure to PI and NNRTI and risk of myocardial infarction: results from the D: A:D study. 13th Annual Conference on Retroviruses and Opportunistic Infections (CROI), Denver, 5–8 February 2006 (Abstract 144). 15. Markowity M et al. Infection with multidrug resistant, dual-tropic HIV-1 and rapid progression to AIDS: a case report. The Lancet, 2005, 365(9464):1031–1038. 16. Urbina A, Jones K. Crystal methamphetamine, its analogues, and HIV infection: medical and psychiatric aspects of a new epidemic. Clinical Infectious Diseases, 2004, 38(6):890–894. 17. Gregory M et al. Illicit drug use and HIV-1 disease progression: a longitudinal study in the era of highly active antiretroviral therapy. American Journal of Epidemiology, 2006, 163(5):412–420. 18. Markowitz M et al. Infection with multidrug resistant, dual-tropic HIV-1 and rapid progression to AIDS: a case report. The Lancet, 2005, 365(9464):1031–1038. 19. Kassutto S et al. Longitudinal analysis of clinical markers following antiretroviral therapy initiated during acute or early HIV type 1 infection. Clinical Infectious Diseases, 2006, 42:1024–1031. 20. The EACS Euroguidelines Group. European guidelines for the clinical management and treatment of HIV-infected adults in Europe. AIDS, 2003, 17(Suppl.):S3–S26. 21. British HIV Association guidelines for the treatment of HIV-infected adults with antiretroviral therapy. London, British HIV Association, 2003 (http://www.bhiva.org/guidelines/2003/hiv/index.html, accessed 30 May 2006). 22. Guidelines for the use of antiretroviral agents in HIV-1 infected adults and adolescents. Bethesda, United States Department of Health and Human Services (DHSS), 2004.1-35 patient evaluation and antiretroviral treatment for adults and adolescents 23. Salzberger B et al. German-Austrian recommendations for the antiretroviral therapy on HIV-infections. European Journal of Medical Research, 2004, 9:491–504 24. Egger M et al. Prognosis of HIV-1-infected patients starting highly active antiretroviral therapy: a collaborative analysis of prospective studies. The Lancet, 2002, 360(9327):119–129.

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25. Phillips AN et al. Viral load outcome of non-nucleoside reverse transcriptase inhibitor regimens for 2203 mainly antiretroviral-experienced patients. AIDS, 2001, 15(18):2385–2395. 26. Sterling TR et al. Improved outcomes with earlier initiation of highly active antiretroviral therapy among human immunodeficiency virus-infected patients who achieve durable virologic suppression: longer follow-up of an observational cohort study. Journal of Infectious Diseases, 2003, 188(11):1659–1665. 27. Opravil M et al. Clinical efficacy of early initiation of HAART in patients with asymptomatic HIV infection and CD4 cell count >350 x 10(6) /l. AIDS, 2002, 16(10):1371–1381. 28. Gras L et al. Predictors of changes in CD4 cell count seven years after starting HAART. 13th Annual Conference on Retroviruses and Opportunistic Infections (CROI), Denver, 5–8 February 2006 (Abstract 530). 29. Palella FJ Jr et al. Survival benefit of initiating antiretroviral therapy in HIV-infected persons in different CD4+ cell strata. Annals of Internal Medicine, 2003, 138(8):620–626. 30. Keruly J et al. Increases in CD4 cell count to five years in persons with sustained virologic suppression. 13th Annual Conference on Retroviruses and Opportunistic Infections (CROI), Denver, 5–8 February 2006 (Abstract 529). 31. Wensing AMJ, et al. Analysis from more than 1800 newly diagnosed patients with HIV from 17 European countries shows that 10% of the patients carry primary drug resistance: the CATCH study. The 2nd IAS Conference on HIV Pathogenesis and Treatment, International AIDS Society and ANRS, Paris, 13 July 2003 (Abstract LB1). 32. Ross L et al. Prevalence of antiretroviral drug resistance and resistance mutations in antiretroviral therapy (ART) naive HIV infected individuals from 40 US cities. 44th Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC), Washington, 30 October–2 November 2004 (Abstract H-173). 33. De Mendoza C et al. Evidence for a different transmission efficiency of viruses with distinct drug-reistance genotypes. 12th International Drug Resistance Workshop, Los Cabos, Mexico, 10–13 June 2003 (Abstract 130). 34. Grant GM et al. Declining nucleoside reverse transcriptase inhibitor primary resistance in San Francisco 2000–2002. 12th International Drug Resistance Workshop, Los Cabos, Mexico, 10–13 June 2003 (Abstract 120). 35. Babic DZ et al. Prevalence of antiretroviral drug resistance mutations and HIV-1 non-B subtypes in newly diagnosed drug-naive patients in Slovenia, 2000–2004. Virus Research, 2006, 118(1–2):156– 163. 36. Cane P et al. Time trends in primary resistance to HIV drugs in the United Kingdom: multicentre observational study. BMJ, 2005, 331(7529):1368. 37. de Mendoza C et al. Antiretroviral recommendations may influence the rate of transmission of drug resistant HIV type 1. Clinical Infectious Diseases, 2005, 41(2):227–232. 38. Daar ES, Richman DD. Confronting the emergence of drug-resistant HIV type 1: impact of antiretroviral therapy on individual and population resistance. AIDS Research and Human Retroviruses, 2005, 21(5):343–357. 39. McDoll et al. Emtricitabine and 3TC: interchangeable? A systemic review. 10th European AIDS Conference (EACS), Dublin, 17–20 November 2005 (Poster 7.3/17). 40. Gallant JE et al. Tenofovir DF, emtricitabine, and efavirenz vs. zidovudine, lamivudine, and efavirenz for HIV. The New England Journal of Medicine, 2006, 354(3):251–260. 41. DeJesus E et al. Abacavir versus zidovudine combined with lamivudine and efavirenz, for the treatment of antiretroviral-naive HIV-infected adults. Clinical Infectious Diseases, 2004, 39(7):1038–1046. 42. Barrios A et al. Paradoxical CD4+ T-cell decline in HIV-infected patients with complete virus suppression taking tenofovir and didanosine. AIDS, 2005, 19(6):569–575. 43. Saag MS et al. Efficacy and safety of emtricitabine vs stavudine in combination therapy in antiretroviral- naive patients: a randomized trial. JAMA, 2004, 292(2):180–189. 44. Bonnet F et al. Risk factors for hyperlactataemia in HIV-infected patients, Aquitaine Cohort, 1999– 2003. Antiviral Chemistry & Chemotherapy, 2005, 16(1):63–67. 1-36 HIV/AIDS TREATMENT AND CARE CLINICAL PROTOCOLS FOR THE WHO EUROPEAN REGION 45. Mallon PW et al. A prospective evaluation of the effects of antiretroviral therapy on body composition in HIV-1-infected men starting therapy. AIDS, 2003, 17(7):971–979. 46. Shah SS, Rodriguez T, McGowan JP. Miller Fisher variant of Guillain-Barré syndrome associated with lactic acidosis and stavudine therapy. Clinical Infectious Diseases, 2003, 36(10):131–133. 47. Bernasconi E et al. Abnormalities of body fat distribution in HIV-infected persons treated with antiretroviral drugs: The Swiss HIV Cohort Study. Journal of Acquired Immune Deficiency Syndromes, 1999, 31(1):50–55. 48. Gulick RM et al. Triple-nucleoside regimens versus efavirenz-containing regimens for the initial treatment

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of HIV-1 infection. The New England Journal of Medicine, 2004, 350(18):1850–1861. 49. Staszewski S et al. Efavirenz plus zidovudine and lamivudine, efavirenz plus indinavir, and indinavir plus zidovudine and lamivudine in the treatment of HIV-1 infection in adults. Study 006 Team. The New England Journal of Medicine, 1999, 341(25):1865–1873. 50. Bartlett JA et al. Abacavir/lamivudine in combination with efavirenz, amprenavir/ritonaviror stavudine: ESS40001 (CLASS) preliminary 48 weeks results. 14th International AIDS Conference, Barcelona, July 2002 (Abstract TuOrB1189). 51. van Leeuwen R et al. A randomized trial to study first-line combination therapy with or without a protease inhibitor in HIV-1–infected patients. AIDS, 2003, 17(7):987–999. 52. Calza L et al. Substitution of nevirapine or efavirenz for protease inhibitor versus lipid-lowering therapy for the management of dyslipidaemia. AIDS, 2005, 19(10):1051–1058. 53. Sheran M. The nonnucleoside reverse transcriptase inhibitors efavirenz and nevirapine in the treatment of HIV. HIV Clinical Trials, 2005, 6(3):158–168. 54. Palella FJ, Delaney KM, Moorman AC. Declining morbidity and mortality among patients with advanced human immunodeficiency virus infection. The New England Journal of Medicine, 1998, 338:853–860. 55. Perelson AS et al. HIV-1 dynamics in vivo: virion clearance rate, infected cell life-span, and viral generation time. Science, 1996, 271(5255):1582–1586. 56. Mannheimer S et al. The consistency of adherence to antiretroviral therapy predicts biologic outcomes for human immunodeficiency virus-infected persons in clinical trials. Clinical Infectious Diseases, 2002, 34(8):1115–1121. 57. Fischl M et al. Impact of directly observed therapy on long-term outcomes in HIV clinical trials. 8th Conference on Retroviruses and Opportunistic Infections (CROI), Chicago, 4–8 February 2001 (Abstract 528). 58. Bangsberg DR et al. Adherence-resistance relationships for protease and non-nucleoside reverse transcriptase inhibitors explained by virological fitness. AIDS, 2006, 20(2):223–231. 59. Maher K et al. Disease progression, adherence and response to protease inhibitor therapy for HIV infection in an Urban Veterans Affairs Medical Center. Journal of Acquired Immune Deficiency Syndromes, 1999, 22(4):358–363. 60. Vanhove GF et al. Patient compliance and drug failure in protease inhibitor monotherapy. JAMA, 1996, 276(24):1955–1956. 61. Little SJ et al. Antiretroviral-drug resistance among patients recently infected with HIV. The New England Journal of Medicine, 2002, 347(6):385–394. 62. UK Collaborative Group on Monitoring the Transmission of HIV. Drug resistance. Analysis of prevalence of HIV-1 drug resistance in primary infections in the United Kingdom. BMJ, 2001, 322(7294):1087– 1088. 63. Bangsberg DR, Perry S, Charlesbois ED. Adherence to HAART predicts progression to AIDS. 8th Conference on Retroviruses and Opportunistic Infections (CROI), Chicago, 4–8 February 2001 (Abstract 483). 64. Lerner BH, Gulick RM, Dubler NN. Rethinking nonadherence: historical perspectives on triple-drug therapy for HIV disease. Annals of Internal Medicine, 1998, 129(7):573–578. 65. Carrieri P et al. The dynamic of adherence to highly active antiretroviral therapy: results from the French National APROCO cohort. Journal of Acquired Immune Deficiency Syndromes, 2001, 28(3):232–239. 66. Walsh JC et al. Reasons for non-adherence to antiretroviral therapy: patients’ perspectives provide evidence of multiple causes. AIDS Care, 2001, 13(6):709–720. 67. Tuldra A et al. Prospective randomized two-arm controlled study to determine the efficacy of a specific intervention to improve long-term adherence to highly active antiretroviral therapy. Journal of Acquired Immune Deficiency Syndromes, 2000, 25(3):221–228.1-37 patient evaluation and antiretroviral treatment for adults and adolescents 68. Bamberger JD et al. Helping the urban poor stay with antiretroviral HIV drug therapy. American Journal of Public Health, 2000, 90(5):699–701. 69. Walsh JC et al. An assessment of current HIV treatment adherence services in the UK. AIDS Care, 2002, 14(3):329–334. 70. Cingolani A et al. Usefulness of monitoring HIV drug resistance and adherence in individuals failing highly active antiretroviral therapy: a randomized study (ARGENTA). AIDS, 2002, 16(3):369–379. 71. Mannheimer S et al. The consistency of adherence to antiretroviral therapy predicts biologic outcomes for human immunodeficiency virus-infected persons in clinical trials. Clinical Infectious Diseases, 2002, 34(8):1115–1121. 72. Chesney MA. Factors affecting adherence to antiretroviral therapy. Clinical Infectious Diseases, 2000,

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Suppl 2:S171–176. 73. Altice FL, Mostashari F, Friedland GH. Trust and the acceptance of and adherence to antiretroviral therapy. Journal of Acquired Immune Deficiency Syndromes, 2001, 28(1):47–58. 74. Claxton AJ, Cramer J, Pierce C. A systematic review of the associations between dose regimens and medication compliance. Clinical Therapeutics, 2001, 23(8):1296–1310. 75. Bartlett JA et al. Overview of the effectiveness of triple combination therapy in antiretroviral-naive HIV-1-infected adults. AIDS, 2001, 15(11):1369–1377. 76. Paterson DL et al. Adherence to protease inhibitor therapy and outcomes in patients with HIV infection. Annals of Internal Medicine, 2000, 133(1):21–30. 77. Fumaz CR et al. Quality of life, emotional status, and adherence of HIV-1-infected patients treated with efavirenz versus protease inhibitor-containing regimens. Journal of Acquired Immune Deficiency Syndromes, 2002, 29(3):244–253. 78. Bartlett JA. Addressing the challenges of adherence [review]. Journal of Acquired Immune Deficiency Syndromes, 2002, 29 Suppl. 1:S2–S10. 79. Moore AL et al. Raised viral load in patients with viral suppression on highly active antiretroviral therapy: transient increase or treatment failure? AIDS, 2002, 16(4):615–618. 80. Nettles RE et al. Intermittent HIV-1 viremia (Blips) and drug resistance in patients receiving HAART. JAMA, 2005, 293(7):817–829. 81. Le Moing V et al. Predictors of long-term increase in CD4(+) cell counts in human immunodeficiency virus-infected patients receiving a protease inhibitor-containing antiretroviral regimen. Journal of Infectious Diseases, 2002, 185(4):471–480. 82. Smith CJ et al. Factors influencing increases in CD4 cell counts of HIV-positive persons receiving longterm highly active antiretroviral therapy. Journal of Infectious Diseases, 2004, 190(10):1860–1868. 83. Barrios A et al. Paradoxical CD4+ T-cell decline in HIV-infected patients with complete virus suppression taking tenofovir and didanosine. AIDS, 2005, 19(6):569–575. 84. Gallant JE et al. Efficacy and safety of tenofovir DF vs stavudine in combination therapy in antiretroviral- naive patients: a 3-year randomized trial. JAMA, 2004, 292(2):191–201. 85. Miller MD et al. Decreased replication capacity of HIV-1 clinical isolates containing K65R or M184V RT mutations. 10th Conference on Retroviruses and Opportunistic Infections (CROI), Boston, 10–14 February 2003 (Abstract 616). 86. Parikh U et al. K65R: a multinucleoside resistance mutation of increasing prevalence exhibits bi-directional phenotypic antagonism with TAM. 11th Conference on Retroviruses and Opportunistic Infections (CROI), San Francisco, 8–11 February 2004 (Abstract 54). 87. Condra JH et al. Drug resistance and predicted virologic responses to human immunodeficiency virus type 1 protease inhibitor therapy. Journal of Infectious Diseases, 2000, 182(3):758–765. 88. Kempf DJ et al. Analysis of the virological response with respect to baseline viral phenotype and genotype in protease inhibitor-experienced HIV-1-infected patients receiving lopinavir/ritonavir therapy. Antiviral Therapy, 2002, 7(3):165–174. 89. Martinez-Picado J et al. Replicative fitness of protease inhibitor-resistant mutants of human immunodeficiency virus type 1. Journal of Virology, 1999, 73(5):3744–3752. 90. Albrecht MA et al. Nelfinavir, efavirenz, or both after the failure of nucleoside treatment of HIV infection. The New England Journal of Medicine, 2001, 345(6):398–407. 91. Kessler H et al. CD4 cell increases through more than 4 years in antiretroviral-naïve HIV+ patients treated with lopinavir/ritonavir-based therapy. The 2nd IAS Conference on HIV Pathogenesis and Treatment, International AIDS Society and ANRS, Paris, 13 July 2003 (Abstract 568). 1-38 HIV/AIDS TREATMENT AND CARE CLINICAL PROTOCOLS FOR THE WHO EUROPEAN REGION 92. Abbott’s new Kaletra tablet gets EMEA CHMP’s OK. Therapeutics Daily, 8 May 2006 (http://www. therapeuticsdaily.com/News/article.cfm?contenttype=sentryarticle&contentvalue=884529&channelID =31, accessed May 9, 2006). 93. Johnson M et al. 96-week comparison of once-daily atazanavir/ritonavir and twice-daily lopinavir/ritonavir in patients with multiple virologic failures. AIDS, 2006, 20(5):711–718. 94. Youle M et al. The final week 48 analysis of a phase IV randomised open label multicetre trial to evaluate safety and efficacy of lopinavir/ritonavir vs saquinavir/ritonavir in adult HIV-1 infection: the MaxCMin2 study. The 2nd IAS Conference on HIV Pathogenesis and Treatment, International AIDS Society and ANRS, Paris, 13 July 2003 (Abstract LB23). 95. Rottmann C et al: Atazanavir ritonavir saquinavir without any other antiretroviral drugs in protease inhibitor experienced patients with no reverse transcriptase options: a 24 week cohort analysis. 7th International Congress on Drug Therapy in HIV Infection, Glasgow, 14–18 November 2004 (Abstract P21). 96. Lazzarin A et al. Efficacy of enfuvirtide in patients infected with drug-resistant HIV-1 in Europe and

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Australia. The New England Journal of Medicine, 2003, 348(22):2186–2195. 97. Gonzalez-Lahoz J. The RESIST trials – superiority of tipranavir over other PIs. AIDS Reviews, 2004, 6(4):244–245. 98. Croom KF, Keam SJ. Tipranavir: a ritonavir-boosted protease inhibitor. Drugs, 2005, 65(12):1669– 1679. 99. Arasteh K et al. TMC114/ritonavir substitution for protease inhibitor(s) in a non-suppressive antiretroviral regimen: a 14-day proof-of-principle trial. AIDS, 2005, 19(9):943–947. 100. Kovalevsky AY et al. Effectiveness of nonpeptide clinical inhibitor TMC-114 on HIV-1 protease with highly drug resistant mutations D30N, I50V, and L90M. Journal of Medicinal Chemistry, 2006, 49(4):1379–1387. 101. Turner D et al. The influence of protease inhibitor resistance profiles on selection of HIV therapy in treatment-naive patients. Antiviral Therapy, 2004, 9(3):301–314. 102. Stephan C et al. Saquinavir drug exposure is not impaired by the boosted double protease inhibitor combination of lopinavir/ritonavir. AIDS, 2004, 18(3):503–508. 103. Eron JJ et al. A phase II trial of dual protease inhibitor therapy: amprenavir in combination with indinavir, nelfinavir, or saquinavir. Journal of Acquired Immune Deficiency Syndromes, 2001, 26(5):458–461. 104. Boffito M et al. Atazanavir enhances saquinavir hard-gel concentrations in a ritonavir-boosted oncedaily regimen. AIDS, 2004, 18(9):1291–1297. 105. Ananworanich J et al. CD4-guided scheduled treatments interruptions compared to continuous therapy: results of the Staccato trial. 13th Annual Conference on Retroviruses and Opportunistic Infections (CROI), Denver, 5–8 February 2006 (Abstract 102). 106. Skiest D et al. Predictors of HIV disease progression in patients who stop ART with CD4 cell counts >350 cells/mm3. 13th Annual Conference on Retroviruses and Opportunistic Infections (CROI), Denver, 5–8 February 2006 (Abstract 101). 107. Marchou B et al. Structured treatment interruptions in HIV-infected patients with high CD4 cell counts and virologic suppression: results of a prospective, randomized, open-label trial (Window - ANRS 106). 13th Annual Conference on Retroviruses and Opportunistic Infections (CROI), Denver, 5–8 February 2006 (Abstract 104). 108. Danel C et al. CD4-guided strategy arm stopped in a randomized structured treatment interruption trial in West African adults: ANRS 1269 Trivacan trial. 13th Annual Conference on Retroviruses and Opportunistic Infections (CROI), Denver, 5–8 February 2006 (Abstract 105LB). 109. El-Sadr W et al. Episodic CD4-guided use of art is inferior to continuous therapy: results of the SMART study. 13th Annual Conference on Retroviruses and Opportunistic Infections (CROI), Denver, 5–8 February 2006 (Abstract 106LB). 110. Carrieri MP et al. Impact of early versus late adherence to highly active antiretroviral therapy on immuno- virological response: a 3–year follow-up study. Antiviral Therapy, 2003, 8(6):585–594. 111. Safren SA et al. Two strategies to increase adherence to HIV antiretroviral medication: life-steps and medication monitoring. Behaviour Research and Therapy, 2001, (10):1151–1162. 112. Simoni JM et al. Antiretroviral adherence interventions: a review of current literature and ongoing studies.Topics in HIV Medicine, 2003, 11(6):185–198. 113. Golin CE, Smith SR, Reif S. Adherence counseling practices of generalist and specialist physicians caring for people living with HIV/AIDS in North Carolina. Journal of General Internal Medicine, 2004, 19(1):16–27.1-39 patient evaluation and antiretroviral treatment for adults and adolescents 114. Weber R et al. Effect of individual cognitive behaviour intervention on adherence to antiretroviral therapy: prospective randomized trial. Antiviral Therapy, 2004, 9(1):85–95. 115. Kerr T et al. Psychosocial determinants of adherence to highly active antiretroviral therapy among injection drug users in Vancouver. Antiviral Therapy, 2004, 9(3):407–414. 116. Tyndall MW et al. Attendance, drug use patterns, and referrals made from North America’s first supervised injection facility. Drug and Alcohol Dependence, 2005, December. 117. Yun LW et al. Antidepressant treatment improves adherence to antiretroviral therapy among depressed HIV-infected patients. Journal of Acquired Immune Deficiency Syndromes, 2005, 38(4):432–438. 118. Zimmermann AE et al. Tenofovir-associated acute and chronic kidney disease: a case of multiple drug interactions. Clinical Infectious Diseases, 2006, 42(2):283–290. 119. Bartlett JG. Pocket guide to adult HIV/AIDS treatment. Baltimore, John Hopkins University AIDS Service, 2006 (http://hopkins-aids.edu/publications/pocketguide/pocketgd0106.pdf, accessed 11 September 2006). 120. Jacobson MA et al. Cytomegalovirus retinitis after initiation of highly active antiretroviral therapy. The Lancet, 1997, 349(9063):1443–1445. 121. Race EM et al. Focal mycobacterial lymphadenitis following initiation of protease-inhibitor therapy in patients with advanced HIV-1 disease. The Lancet, 1998, 351(9098):252–255.

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122. Koval CE et al. Immune reconstitution syndrome after successful treatment of Pneumocystis carinii pneumonia in a man with human immunodeficiency virus type 1 infection. Clinical Infectious Diseases, 2002, 35(4):491–493. 123. Sande MA, Eliopoulos GM. The Sanford guide to HIV/AIDS therapy, 13th ed. Hyde Park, VT, Antimicrobial Therapy, 2004. 124. Gilbert DN, Moellering RC, Eliopoulos GM. The Sanford guide to antimicrobial therapy, 35th ed. Hyde Park, VT, Antimicrobial Therapy, 2005. 125. Antoniu T, Tseng AL. Interactions between recreational drugs and antiretroviral agents. The Annals of Pharmacotherapy, 2002, 36(10):1598–1613. 126. WHO/EURO report of the technical consultation on clinical staging of HIV/AIDS and HIV/AIDS case definition for surveillance. Copenhagen, WHO Regional Office for Europe, 2005 (http://www.euro. who.int/document/E87956.pdf, accessed 5 April 2006). 127. 2006 antiretroviral drug guide. IAPAC Monthly, 2006, 12 Suppl. 1 (http://www.iapac.org/home. asp?pid=7288, accessed 11 September 2006). 128. Liu H et al. A comparison study of multiple measures of adherence to HIV protease inhibitors. Annals of Internal Medicine, 2001, 134(10):968–977. 129. Bangsberg DR et al. Provider assessment of adherence to HIV antiretroviral therapy. Journal of Acquired Immune Deficiency Syndromes, 2001, 26(5):435–442. 130. Hugen PW et al. Assessment of adherence to HIV protease inhibitors: comparison and combination of various methods, including MEMS (electronic monitoring), patient and nurse report, and therapeutic drug monitoring. Journal of Acquired Immune Deficiency Syndromes, 2002, 30(3):324–334. 131. Paterson DL et al. Adherence to protease inhibitor therapy and outcomes in patients with HIV infection. Annals of Internal Medicine, 2000, 133(1):21–30. 132. Parienti JJ et al. The pills identification test: a tool to assess adherence to antiretroviral therapy. JAMA, 2001, 285(4):412. 133. Descamps D et al. Mechanisms of virologic failure in previously untreated HIV-infected patients from a trial of induction-maintenance therapy. JAMA, 2000, 283(2):205–11. 134. Havlir DV et al. Drug susceptibility in HIV infection after viral rebound in patients receiving indinavircontaining regimens. JAMA, 2000, 283(2):229–234. 135. Vingerhoets J et al. Effect of baseline resistance on the virologic response to a novel NNRTI, TMC 125, in patients with extensive NNRTI and PI resistance: analysis of study TMC 125–233. 13th Annual Conference on Retroviruses and Opportunistic Infections (CROI), Denver, 5–8 February 2006 (Abstract 154). 136. De Meyer et al. Effect of baseline susceptibility and on-treatment mutations on TMC 114 and control PI efficacy: preliminary analysis of data from PI-experienced patients from POWER 1 and POWER 2. 13th Annual Conference on Retroviruses and Opportunistic Infections (CROI), Denver, 5–8 February 2006 (Abstract 157).

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Tavi II. oportunistuli infeqciebis marTva

cxrili 19. oportunistuli infeqciebi da sxva daavadebebi, romlebic dakavSirebulia aiv infeqciasTan

baqteriuli infeqciebi

sokovani infeqciebi

virusuli infeqciebi

parazituli infeqciebi

sxva daavadebebi

tuberkulozi baqteriuli

respiratoruli infeqciebi

nawlavTa baqteriuli infeqciebi

atipiuri mikobaqteriozebi

bartonelozi

ezofaguri kandidozi

kriptokokozi histoplazmozi pnevmocisturi

pnevmonia kokcidioidozi

infeqciebi, romelsac iwvevs:

_martivi herpes virusi; -varicela-zosteris virusi - citomegalo-virusi _adamianis herpes virusis 8 tipi; _adamianis papilomavirusi progresuli multifokaluri leikoencefalopaTia - hepatiti B da C

toqsoplazmozi kriptospori-diozi

mikrospori-diozi

izosporiazi leiSmaniozi

kapoSis sarkoma

arahojkinsis limfoma

saSvilosnos yelis simsivne

encefalopaTia

vakuoluri mielopaTia

evropis regionisTvis yvelaze xSiri oportunistuli infeqciebia: o tuberkulozi o baqteriuli infeqciebi o pnevmocisturi pnevmonia o herpesuli infeqciebi (VZV, HSV 1 da 2, CMV) o kandidozuri ezofagiti o kriptokokuli meningiti o toqsoplazmozi

SederebiT iSviaT oportonistul infeqciebs da simsivneebs miekuTvneba;

o atipiuri mikobaqteriozebi o kapoSis sarkoma o arahojkinis limfoma o citomegalovirusuli infeqciebi (retina, kuW-nawlavis traqti,

encefalitebi). cxrili 2. oportunistuli infeqciebis profilaqtika aiv inficirebul pacientebSi gamomwvevi maCveneblebi pirveli rigis

preparatebi Aalternatiuli sqemebi

Pneumocystis jirovecii

CD4< 200mkl-1 an orofaringeuli

ko-tromoqsazoli 160/800 mg/dReSi yovel

- ko-tromoqsazoli80-400 mg/dReSi

74

kandidozi dRe yovel dRe - ko-trimoqsazoli160/800 mg/dReSi kviraSi samjer - dapsoni 50 mg dReSi orjer - 100 mg dReSi erTxel (2) - pirimetamini 50 mg + dapsoni 50 mg + foliumis mJava 15 mg erTxel dReSi -pentamidis inhalaciebi 300 mg 3 kviraSi erTxel (3) -aseve SesaZlebelia: klindamicini an atovaqvoni (4,5,)

M.tuberkunosis PPD reaqcia >5mm an kontaqti tuberkulozis aqtiuri formis mqone pacientTan

izoniazidi 300mg/dReSi + piridoqsini 50 mg/dReSi 6 Tvis ganmavlobaSi (6)

saWiroa damatebiTi kvlevebis Catareba alternatiuli profilaqtikuri mkurnalobis SemuSavebisTvis izoniazidze rezistentobis SemTxvevebSi

Toxoplasma gondii, primary

CD4< 100 mm3 ko-trimoqsazoli 160/800 mg/dReSi yovel dRe

- ko-trimoqsazoli, 80-400 mg/dReSi yovel dRe (7,8) - dapsoni 50 mg yovel dRe + pirimetamini 50 mg kviraSi erTxel + foliumis mJava 25 mg kviraSi erTxel

Toxoplasma gondii, secondary

CD4< 100 mm3 ko-trimoqsazoli 160/800 mg/dReSi yovel dRe

-dapsoni 50 mg yovel dRe + pirimetamini 50 mg dReSi + foliumis mJava 15-25 mg dReSi

M. avium complex

CD4< 50mkl-1 azitromicini 1200 mg kviraSi erTxel

klariTromicini 500 mg orjer dReSi (9,10)

Criptococcus neoformans

CD4< 50mkl-1 flukonazoli 100-200 mg/dReSi (11)

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3.1.sasunTqi gzebis infeqciebi filtvis morecidive infeqciur daavadebebs erT-erTi pirveli adgili uWiravs aiv inficirebulebSi da xSirad uqmnis safrTxes maT sicocxles. etiologiis mixedviT igi SeiZleba iyos baqteriuli, virusuli da sokovani. aiv infeqciis adreul stadiaze viTardeba baqteriuli pnevmoniebi, romlebic advilad eqvemdeba antibaqteriul mkurnalobas. aiv inficirebulebSi xSiria inkafsulirebuli baqteriebiT mag. Streptococcus pneumoniae da Haemophilus influenzae-Ti gamowveuli infeqciebi. mogvianebiT, imunodeficitis fonze aiv inficirebulebs uviTardebaT filtvis oportunistuli infeqciebi, romelTa Soris yvelaze did problemas warmoadgens tuberkulozi. ujreduli imunitetis daqveiTebaTan erTad SeiZleba ganviTardes sicocxlisaTvis saSiSi oportunistuli infeqciebi, maT Soris pnevmocisturi, mikozuri da virusuli pnevmoniebi. me-20 cxrilSi CamoTvlilia filtvis daavadebebi, romlebic arTuleben aiv infeqciis mimdinareobas. cxrili 20. respiratoruli daavadebebi aiv/SidsiT daavadebul pacientebSi infeqciis tipi SesaZlo garTulebebi a baqteriuli pnevmokokuri pnevmonia empiema b, plevruli gamonaJoni,

filtvis abscesi H. influenza pnevmonia plevruli gamonaJoni b, filtvis

abscesi, empiema klebsielaTi gamowveuli pnevmonia empiema b, plevruli gamonaJoni stafilokokuri pnevmonia filtvis abscesib, empiema, plevruli

gamonaJoni M. tuberkulosis pnevmonia perikarduli gamonaJoni, filtvis

abscesi, empiema, plevruli gamonaJoni

MAC pnevmonia iSviaTi garTuleba: abscesi, gansakuTrebiT imunuri rekonstituciis sindromis dros

virusuli citomegalovirusi pnevmoniti b (maRalia letaloba) martivi herpesis virusi pnevmoniti b (maRalia letaloba) sokovani pnevmocisturi pnevmonia pnevmoToraqsi kriptokokozi histoplazmozi aspergilozi filtvis abscesi sxva mdgomareobebi kapoSis sarkoma plevruli an perikardiuli

gamonaJoni limfoma plevruli an perikardiuli

gamonaJoni

76

karcinoma (ara SidsTan asocirebuli)

perikardiuli gamonaJoni

a SesaZlo garTulebebi CamoTvlilia maTi ganviTarebis sixSiris mixedviT. b mdgomareobebi, romlebic yvelaze xSirad viTardeba 3.1.1. baqteriuli respiratoruli infeqciebi aiv inficirebulebs imunodeficitis fonze xSirad uviTardebaT baqteriuli pnevmoniebi, romelTac axasiaTebT mZime mimdinareoba. yvelaze xSirad pnevmonias iwvevs Streptococcus pneumoniae. pnevmoniis sxva baqteriuli gamomwvevebi mocemulia Mme-21 cxrilSi. klinikuri gamovlinebebia: xvela, cxeleba, tkivili gul-mkerdis areSi, qoSini da taqipnoe. gulmkerdis rentgenogramaze SeiZleba gamoCndes wilovani pnevmoniis an bronqopnevmoniis klasikuri niSnebi, atipuri cvlilebebi an cvlilebebis ararseboba. diagnostikaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA diagnozi efuZneba klinikur gamovlinebebsa da rentgenologiur cvlilebebs. rentgenogramaze SeiZleba aRmoCndes:

o filtvis parenqimis wilovani an kerovani daCrdilva o filtvis difuzuri infiltraciebi an o atipiuri cvlilebebi, kavernozuli daavadebis CaTvliT.

mkurnalobaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA Tu pacientis mdgomareoba saSualo simZimisaa, mkurnaloba SeiZleba Catardes binaze me-21 da me-22 cxrilebSi mocemuli sqemebis mixedviT. cxrili 21. baqteriuli pnevmoniis mkurnalobis pirveli rigis sqemebi

antibiotiki doza MmiRebis

sixSire miRebis gza

mkurnalobis xangrZlivoba

amoqsicilini (penicilinisa da ampicilinis mimarT SesaZlo rezistentobis SemTxvevaSi gamoiyeneT penicilini beta laqtamazas inhibitorebTan kombinaciaSi)

500-1000mg 3X dReSi

PO 7 dRe an ufro xangrZlivad morCenamde

Aan eriTromicini 500mg 4X dReSi PO 7 dRe an klaritromicini 500mg 2X dReSi PO 7 dRe Aan azitromicini 500mg erTxel

dReSi PO 3-4 dRe

an qinoloni pnevmokokis sawinaaRmdegoaqtivobiT (mag: moqsifloqsacini)

400 mg erTxel dReSi

PO 7 dRe

77

an doqsiciklini 100 mg

2X dReSi PO 7 dRe

o Tu pirveli rigis sqemiT mkurnalobis fonze mdgomareoba 72 sT-Si ar gaumjobesda (cxelebis normalizeba, C reaqtiuli cilis matebis SeCereba, leikocitozis donis Semcireba), aucilebelia pacientis hospitalizacia da mkurnalobis Secvla II rigis sqemiT (cxrili 23), saWiroebis SemTxvevaSi _ JangbadiT inhalacia (am SemTxvevaSi unda vivaraudoT pnevmocisturi pnevmonia).

o mZime mdgomareobaSi myofi avadmyofebis hospitalizacia unda moxdes dauyonebliv.

cxrili 23. baqteriuli pnevmoniebis mkurnalobis meore rigis sqemebi antibiotiki doza M miRebis

sixSire MmiRebis gza


ceftriaqsoni + eriTromicini

2g 500mg

dReSi erTxel 4X dReSi

i/v 7 dRe

an

ampicilin/ sulbaqtami + eriTromicini

1500mg 500mg

3X dReSi 4X dReSi

i/v 7 dRe

an

qinoloni pnevmokokuri aqtivobiT (mag: moqsifloqsacini)

400 mg erTxel dReSi IV/PO 7 dRe

an

qloramfenikoli (mxolod sxva pre-paratebis ar arse-bobis dros)

12,5 mg/kg

4X dReSi

i/v

7 dRe

o Tu mkurnalobis fonze mdgomareoba ar gaumjobesda, eWvi unda

mivitanoT pnevmocistur pnevmoniaze an tuberkulozze. antibiotikebiT mkurnalobis dawyebamde paTogenis identifikaciis oqros standarts miekuTvneba lavaJi bronqoskopiiT (14) (AI). damxmare meTodia sisxlis kulturebi, romelsac aqvs maRali done pnevmokokis identifikaciisvis da SesaZloa Catardes swrafad.

3.1.2. atipuri mikobaqteriozebi Mycobaqterium avium complex (MAC an MAI) gamowveuli infeqciebi ufro

iSviaTad gvxvdeba, vidre sxva oportunistuli infeqciebi. klinikuri gamovlinebebia:

78

o cxeleba o wonaSi kleba o Ramis oflianoba o diarea o ganleva. o mikobaqteriebis aRmoCena SesaZlebelia avadmyofis sisxlsa da eqskrementebSi.

diagnostikaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA

o sisxlis specialur niadagze daTesva. o pacientebs klinikurad gamovlinebuli infeqciiT

mikobaqteriebis intensivoba imgvari aqvT, rom gamomwvevis aRmoCena SesaZlebelia daTesili sisxlis TiTqmis yvela ulufaSi.

o vinaidan, diseminirebuli infeqciis dros xSirad ziandeba RviZli da Zvlis tvini, mikobaqteriebis aRmoCena SesaZlebelia mJavagamZle baqteriebze SeRebil preparatebSi, romlebic damzadebulia am organoebidan aRebuli bioptatebisgan.

o RviZlis bioptatis mikroskopuli gamokvlebis gziT winaswari diagnozis dasma saSualebas iZleva mkurnaloba daviwyoT droulad.

mkurnalobaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA

cxrili 24. atipuri mikobaqteriozebis mkurnaloba (AI) antibiotiki doza MmiRebis

sixSire miRebis gza


pirveli rigis preparatebi (15,16)

klariTromicini 500-1000 mg 2-jer dReSi PO 6 Tve ; damokidebulia

klinikur mdgomareobaze

+ etambutoli 15 mg/kg dReSi

erTxel PO 6 Tve ;

damokidebulia klinikur

mdgomareobaze +

rifabutini 300-450 mg dReSi erTxel

PO 6 Tve ; damokidebulia


sxva preparatebi, rimlebic moqmedeben atipiur mikobaqteriebze a

azitromicini 500-1200 mg dReSi erTxel

PO

ciprofloqsacini 500 mg 2-jer dReSi PO amikacini 15 mg/kg/dR dReSi 1X i/v

6 Tve

6 Tve

79

an 7,5mg/kg/dR

2-jer dReSi i/v ara umetes 4 kvirisa

a rifampicini ar aris efeqturi atipiruri mokibaqteriis mimarT.

o Tu atipiuri mikobaqteriozebis mkurnalobis fonze mdgomareoba gaumjobesda da preparatebi kargad gadaitaneba unda daiwyos arT.

o atipiuri mikobaqteriozebis mkurnalobodan 4-6- kviraSi iwyeba arT. 6 Tvis Semdeg imunuri pasuxis gaumjobesebis Semdeg (CD4 ricxvi>100mm3) Cerdeba atipiuri mikobaqteriozebis mkurnaloba da gamoiyeneba meoradi profilaqtika.

o meoradi profilaqtikis Sewyveta SesaZlebelia, rodesac imunuri sistema stabiluria 3-6- Tvis manZilze.

o atipiuri mikobaqteriozebis mkurnaloba da meoradi profilaqtika grZeldeba 6 Tve, rac aris mkurnalobis warmatebis da relapsis Tavidan acilebis sawindari.

o didi mniSvneloba aqvs atipiuri mikobaqteriozebis mkurnalobis dawyebas arv Terapiis dawyebamde.

o arsebobs albaToba imunuri rekonstituciis anTebiTi sindromis ganviTarebis arT-s dawyebis Semdeg.D

3.1.3. pnevmocisturi pnevmonia

o pnevmocisturi pnevmonia erT-erTi gavrcelebuli oportunistuli

infeqciaa aiv inficirebulebSi. misi gamomwvevia Pneumocystis jiroveci (adre moixseniebdnen Pneumocystis carinii–is saxeliT).

o tipiuri klinikuri gamovlinebebia: xvela, qoSini da cxeleba. o zogjer pnevmocisturi pnevmonia mimdinareobs filtvismieri

gamovlinebebis gareSe. o xSirad aRiniSneba sunTqvis ukmarisobis niSnebi, qoSini da cianozi. o daavadebis mimdinareoba SeiZleba iyos mZime da, Tu droulad ar

dainiSneba mkurnaloba, SeiZleba damTavrdes sikvdiliT.

diagnostikaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA o diagnozi ismeba klinikuri suraTis mixedviT. aiv inficirebul

pacients uviTardeba respiratoruli distresi cianoziT an mis gareSe.

o SesaZloa aRiniSnebodes mSrali xvela, Tumca ufro mniSvnelovania, rom filtvebSi fizikaluri gamokvlevebiTAD mciredi cvlilebebia an saerTod ar aris.

o gul-mkerdis rentgenologiuri gamokvleva: o orive filtvis qvemo wilSi gamWvirvalobis Rrubliseburi

daqveiTeba_yvela pacients ar aReniSneba. o SesaZlebelia orive filtvSi aRmoCndes kerovani daCrdilva,

romelic waagavs baqteriuli pnevmoniis an tuberkulozis suraTs. o pacientebis umetesobas, romelTac daudginda pnevmocisturi

pnevmonia, rentgenologiuri cvlilebebi ar aReniSnebaT. o diagnozis oqros standarts warmoadgens bronquli lavaJi (14).

diagnozi dasturdeba gamomwvevis cistis aRmoCeniT amonaxvelSi an bronquli lavaJis aspiratSi.

o Tu bronqoskopiis Catareba SeuZlebelia, maSin pnevmocisturi pnevmoniis diagnozisTvis SesaZlebelia gamoyenebul iqnes rogorc

80

indikatorebi filtvis darRveuli funqciuri testebi an sisxlis airTa analizi.

o diagnozis dasmisTanave dawyebul unda iqnas mkurnaloba. mkurnalobaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA pnevmocisturi pnevmoniis mkurnaloba tardeba stacionarSi.

aucilebelia damxmare Terapia JangbadiT inhalaciis CaTvliT. mkurnalobis detaluri sqema mocemulia cxrilSi N#25 da #26 qvemoT.

cxrili 25. pnevmocisturi pnevmoniis pirveli rigis mkurnaloba (AI) antimikrobuli agenti

doza M miRebis sixSire

M miRebis gza


timetoprimi/ sulfametoqsazoli

400/80 mg 4X dReSi PO/IV

21 dRe

cxrili 26. pnevmocisturi pnevmoniis meore rigis mkurnaloba (AI) Kklindamicini + primaqini

600mg 15 mg

4X dReSi 2X dReSi

PO/IV PO

21 dRe (17)

an

pentamidini (farTo speqtris antibiotikTan kombinaciaSi baqteriuli superinfeqciis profilaqtikisTvis mag. ampicilin+ sulbaqtami 10 dRe)

4 mg/kg IV dReSi. doza mcir 2 mg/kg 5 dRis mkurnalobis Semdeg (18)

dReSi erTxel

IV 21 dRe

o mZime mdgomareobaSi myof avadmofebSi iniSneba prednizoloni, 80-

250 mg PO/IV dReSi 1-2 kvira (amcirebs intersticiul SeSupebas). o mZime SemTxvevebSi ganixileba kombinirebuli mkurnaloba, mag. ko-

trimoqsazoli da pendamidini mxolod erTeuli Setyobinebuli SemTxvevebis mixedviT dakavSirebulia toqsiurobis maRal riskTan. pnevmocisturi pnevmoniis mZime SemTxvevebi moiTxovs xelovnur ventilacias an oqsigeniT saturacias (SO2)<92%.

unda moxdes gverdiTi efeqtebis monitoringi, gansakuTrebiT Tirkmlebis, parkreasis (pendamidiniT mkurnalobisas), Zvlis tvinis (ko-trimoqsazoliT mkurnalobisas). laboratoriuli gamokvlevebi aucilebelia 2 kviraSi erTxel. pnevmocisturi pnevmoniis mwvave SemTxvevis warmatebiT mkurnalobis Semged :

81

o meoradi profilaqtikis mizniT aiv inficirebulma pacientebma unda miiRon trimetoprim/sulfametoqsazoli 160/800 mg doziT erTxel dReSi xangrZlivad ;

o aRniSnuli preparatebis miReba pacientma SeiZleba Sewyvitos Tu CD4 limfocitebis raodenoba stabilurad aRemateba 200 mm3-s sul mcire sami Tvis ganmavlobaSi.

3.1.4. sxva etiologiis pnevmoniebi imunodeficitis mqone pacientebSi o pnevmoniebi SeiZleba iyos sokovani da virusuli etiologiis. aseT

SemTxvevebSi Znelia diagnozis dazusteba rTuli laboratoriuli gamokvlevebis gareSe da rTulia maTi mkurnaloba.

o pnevmoniis gamomwvev virusebs miekuTvneba: martivi herpesis virusi, varicela-zosteris virusi an citomegalovirusi.

o sokovan pnevmoniebs Pneumocystis-jiroveci (Pneumocystis carinii) –is garda iwveven Histoplazma capsulatum, Cryptococcus neoformans da Aspergillus.

diagnostikaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA o pnevmoniis mqone pacientebSi, romlebic Znelad eqvemdebarebian

standartul mkurnalobas, unda vivaraudoT tuberkulozis an virusuli, sokovani an protozouli etiologiis pnevmoniis arseboba.

o sokovani an sxva etiologiis pnevmoniebis specifikuri diagnostikisTvis auculebelia rTuli laboratoriuli gamokvlevebi:

o pp65 adreuli CMV antigeni periferiuli sisxlSi an bronqul lavaJSi;

o polimerazuli jaWvuri reaqcia (pjr) herpesis jgufis virusebisTvis (CMV, HSV 1/2/; VZV, EBV, HHV8, HHV6) ;

o specialuri kulturebi nela-mzardi paTogenebisTvis mag: nokardia. o aucilebelia mWidri TanamSromloba eqimebsa da mikrobiologebs

Soris.

mkurnalobaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA mkurnaloba damokidebulia daavadebis etiologiaze mag: foskarneti CMV infeqciisTvis an xangrZlini antibiotikoTerapia (8 kvira) nokardiisTvis.

3.1.5. kuW-nawlavis traqtis infeqciebi

kuW-nawlavis traqtis dazianeba aiv inficirebulebSi SeiZleba iyos: o rogorc aiv infeqciis uSualo gamovlineba, aseve o baqteriuli, o virusuli, o sokovani o protozouli an o parazituli etiologiis. o zog SemTxvevaSi kuW-nawlavis aSliloba ganpirobebulia Sewovis

unaris darRveviT, rac nawlavTa xaoebis atrofiiTaa gamowveuli (malabsorbcia).

82

o yvelaze xSirad viTardeba diarea, romelic SeiZleba iyos mwvave, qronikuli an qronikuli - gamwvavebebiT.

o SidsiT avadmyofebSi diarea persistuli an qronikulia da xSirad aris maTi sikvdilis mizezi.

o mwvave diarea saWiroebs dehirdatacias mkurnalobis Sedegis miRebamde.

o ganavali sisxliani minarevebiT damaxasiaTebelia dizenteriis an nawlavTa amebiazisTvis.

aiv inficirebulebs xSirad aReniSnebaT kuW-nawlavis traqtis dazianebis iseTi simptomebi, rogoricaa:

o madis dakargva, o gulisreva o pirRebineba da o wonaSi progresirebadi kleba.

aiv inficirebulebSi yvelaze gavrcelebuli kuW-nawlavis infeqciebi da maTi mkurnalobis Sesaxeb rekomendaciebi mocemulia cxrilSi #27. cxrili 27. aiv inficirebulebSi gavrcelebuli kuW-nawlavis traqtis infeqciebi infeqcia klinikuri

gamovlinebebi da diagnostika

mkurnaloba

ara-tifoiduri salmonelozebi

cxeleba, tkivili muclis areSi, diarea (SesaZlebelia ganavalSi sisxlis aRmoCena), wonaSi kleba, anoreqsia, hepatosplenomegalia. diagnostika _ sisxlis an ganavlis kultura

ciprofloqsacini, 500mg 2-jer dReSi PO 2 kviris ganmavlobaSi(19)

Sigelozebi cxeleba, tkivili muclis areSi, sisxliani diarea. diagnostika _ sisxlis an ganavlis kultura.

ciprofloqsacini 500mg 2-jer dReSi PO 7-10 dRe an nalidiqsis mJava 500mg dReSi 4-jer PO 7-10DdRe an ko-trimoqsazoli 160/800mg 2-jer dReSiPO 7-10 dRe

kriptosporidozi wylisebri ganavali, madis dakargva, cxelebis ar arseboba. diagnostika _ ganavlis mikroskopulia.

paromomicini 1g 2-jer dReSi PO + azitromicini 600mg dReSi erTxel PO 4 kviris ganmavlobaSi; Semdeg: mxolod paromomicini

83

8 kvira (20,21). mkurnaloba xSirad warumatebelia (22).

mikrosporidozi wylisebri ganavali, madis dakargva, cxelebis ararseboba. diagnostika _ ganavlis mikroskopulia.

albendazoli 400mg 2-jer dReSi PO 4kvira Tu es ar muSaobs scadeT: mebendazoni 500mg 3-jer dReSi PO (albendazoli metad efeqturia) (23).

3.1.6. kandidozebi

o Candida albicans pirveladad kolonizdeba qalTa da mamakacTa kuW-nawlavia traqtSi. Candida albicans aRmoCndeba janmrTeli qalebis 1/3 saSos mikrofloraSi.

o qalebSi kandidozuri vulvovaginiti gamovlindeba saSodan gamonadeniTa da vulvisa da saSos qaviliT.

o mamakacebSi sasqeso organoebis kandidozi mimdinareobs, rogorc balaniti an balanopostiti, amasTan erTad aRniSnaven CuCidan gamonadens da asosa da CuCis qavils.

o piris Rrus kandidozi gamovlindeba lorwovani garsis anTebiTa da mis zedapirze TeTri balTebis warmoqmniT.

o kandida ainficirebs kansac da iwvevs qavana dermatits. o imunodeficitis gaRrmavebasTan erTad piris Rrus kandidozi

SeiZleba gavrceldes saylapavze da gamoiwvios ezofagiti. o iSviaT SemTxvevebSi SeiZleba ganviTardes bronqebis dazianeba da

diseminirebuli kandidozi. simptomebiAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA piris Rrus kandidozi moicavs:

o loyis lorwovan garss o enas o pir-xaxas o RrZilebs o rbil da magar sasas.

avadmyofs SeiZleba ar hqondes Civilebi an aRniSnavdes Wamis dros wvis SegrZnebas. zogierTi avadmyofi uCivis pirSi TeTri nadebis arsebobas. roca kandidozi vrceldeba saylapavze pacienti uCivis:

o tkivils ylapvis dros o retrosternalur tkivils o hipersalivacias.

pacientebi, romlebSic kandidozi yvelaze xSirad viTardeba:

o orsuloba da peroraluri kontraceptivebis miReba o axalSobilobis periodi, gansakuTrebiT dRenaklul

bavSebSi o farTo speqtris antibiotikebis xangrZlivi miReba

84

o glukokortikoidebis sistematiuri miReba o Saqriani diabeti o Tandayolili an SeZenili imunodeficiti o mZime qronikuli daavadeba o gamofitva, kaxeqsia o onkologiuri daavadebebi, qimioTerapia an sxivuri Terapia. diagnostika o orofaringeuli kandidozis diagnostika efuZneba klinikur niSnebs,

gasinjvas da dazianebuli ubnebidan aRebuli masalis mikroskopul daTvalierebas.

o piris Rrus daTvalierebisas vnaxulobT balTis formis TeTr nadebs SewiTlebul da anTebad lorwovan garsze.

o anTeba SeiZleba gavrceldes sasaze, xaxaze, RrZilebze, enasa da loyis lorwovanze. ena dazianebisas xdeba gluvi, wiTeli da dvrilebi swordeba.

o kandidozuri ezofagitis da filtvebis aspergilozis SemTxvevebSi diagnozis dadasturebisTvis aucilebelia qsovilis bioftatis histologiuri gamokvleva.

o aiv inficirebulebs erTxel mainc uviTardebaT piris Rrusa da xaxis kandidozi. is sicocxlisTvis saSiSi ar aris, magram iwvevs

ylapvis gaZnelebas o mkerdis tkivils, romelic Zlierdeba ylapvisas. o diseminirebuli kandidozis klinikuri gamovlinebebia: cxeleba da

dazianebul organoebTan dakavSirebuli simptomebi (mag: Tvalis dazianebisas_sibrmave).

mkurnalobaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA

o piris Rrus kandidozisa da kandidozuri vulvovaginitis mkurnaloba iwyeba adgilobrivi araZviradRirebuli antimikozuri preparatebiT. mag.: nistatini, mikonazoli, klotrimazoli.

o diseminirebuli kandidozisa da aseve, adgilobrivi mkurnalobis araefeqturobis dros, iniSneba sistemuri antimikozuri agentebi, mag:ketokonazoli, flukonazoli, itrakonazoli an amfotericin B.

o im pacientebSi, romlebic imyofebian metadoniT, rogorc opioid- CanacvlebiT Terapiaze gasaTvaliswinebelia metadonis urTierTqmedeba flukonazolTan, itrakonazolTan an ketokonazilTan.

o rekomendaciebi kandidozis mkurnalobis Sesaxeb mocemulia me-28 _ -29-30 cxrilebSi.

cxrili 28. piris Rrus kandidozis mkurnaloba (AI) antimikozuri

agenti doza

M miRebis sixSire

miRebis gza


mkurnalobis pirveli rigis sqemebi (24) mikonazoli tabletebi

gasawovad dReSi erTxel

adgilobrivad 7 dRe

an flukonazoli 100 mg 2-jer dReSi PO 7 dRe

85

3 dRe Semdeg erTxel dReSi 4 dRe

mkurnalobis meore rigis sqemebi (25) itrakonazoli 200-400 mg dReSi

erTxel PO 7 dRe

cxrili 29. vaginaluri kandidozis mkurnaloba (AI) antimikozuri

agenti doza M miRebis

sixSire miRebis gza


pirveli rigis sqemebi flukonazoli 100 mg erTjeradad PO erTjeradad klotrimazoli 500 mg erTjeradad vaginalurad erTjeradad meore rigis sqemebi ketokonazoli 200 mg 2-jer dReSi PO 3 dRe ketokonazoli 200 mg dReSi

erTxel PO 7 dRe

SemanarCunebeli Terapia nistatini 2-4 mln IU 2-jer dReSi PO 10 dRe

Aan flukonazoli 50-200 mg dReSi

erTxel PO yoveldRe

mesame rigis sqemebi ketokonazoli 200 mg dReSi

erTxel PO damokidebuli

pasuxze, Cveulebriv 7-

10 dRe itrakonazoli 100 mg dReSi


pasuxze, Cveulebriv 7-10 dRe

cxrili 30. ezofaguri da diseminirebuli kandidozebis mkurnaloba (AI) antimikozuri


sixSire miRebis gza


pirveli rigis sqemebi

ketokonazoli 200-400 mg 2-jer dReSi PO 21 dRe Aan flukonazoli

(ketokonazolze efeqturia)

200-400 mg Semcirdes klinikuri Sedegis mixedviT 3 dRis Semdeg

dReSi erTxel

PO/IV

14 dRe

86

100 mg/dReSi meore rigis sqemebi

amfotericini B 0,3-0,5 mg/kg IV 10-14 dRe

Aan itrakonazoli 200-400 mg dReSi

erTxel PO 2 kvira

o kandidozuri ezofagitis mkurnalobis Semdeg saWiroa xangrZlivi

SemanarCunebeli Terapia flukonazoliT 50-100 mg/dReSi yoveldRe, an itrakonazoliT 100 mg/dReSi yoveldRe, an ketokonazoliT 200 mg/dReSi yoveldRe.

o Tu mkurnaloba araefeqturia unda gamoiricxos virusuli (citomegalovirusuli an herpesuli) ezofagiti ezofagoskopiiT.

o Candida glabrata. C. krusei da C. tropicalis rezistentulia flukonazolis mimarT zogierT SemTxvevebSi. saWiroa nimuSebis kulivireba, SesaZlebelia savaraudo testireba da amfotericin B daniSvna ufro efeqturia. vorikonazoli, posakonazoli da kaspofungini axali antimikozuri medikamentebia, romelTa mimarT arcerTi gamomwvevi ar aris rezistentuli, maT Soris Aspergillus; yvela maTgani ZviradRirebulia. vorikonazoli ar unda dainiSnos efavirenzTan da ritonavirTan erTad. pacientebi, romlebic Rebuloben proteazas inhibitorebs vorikonazolTan erTad saWiroeben gverTiTi efeqtebis mWidro monirtorings (26).

3.1.7. kriptokokuli meningiti

o kriptokokozi xSirad mimdinareobs meningitis formiT, ufro iSviaTad viTardeba pnevmonia da diseminirebuli infeqcia.

o kriptokokuli meningiti erT-erTi gavrcelebuli sistemuri mikozia aiv/SidsiT daavadebulebSi.

o avadmyofTa sicocxlis xangrZlivoba mkurnalobis gareSe Tveze naklebia.

diagnostikaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA

kriptokokozis diagnozireba SedarebiT advilia. pacienti uCivisL Tavis tkivils, cxelebas, saxezea kefis kunTebis regidoba, Tavis qalis nervebis dazianeba, cnobierebis darRveva, komatozuri mdgomareoba. meningitis niSnebi, maT Soris, cxeleba da kefis kunTebis rigidoba xSirad ar aRiniSneba. liqvors acentrifugireben, miRebul naleqs ikvleven mikroskopis qveS tuSis wveTis India ink damatebis Semdeg.

o preparatSi naxuloben sqeli kafsuliT dafarul safuaris ujredebs.

o SesaZlebelia kriptokokis kulturis gamoyofa Tavzurgtvinis siTxidan

o gamoiyeneba Sratis da Tavzurgtvinis siTxis gamokvleva kriptokokul antigenze.

mkurnalobaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA

87

rekomendacibi kriptokokuli meningitis mkurnalobis Sesaxeb mocemulia me-31 cxrilSi. cxrili 31. kriptokokuli meningitis mkurnaloba (AI) antimikozuri


sixSire miRebis gza


pirveli rigis sqemebi (27)

amfotericini B + 5-flucitozini

0,7-1,0 mg/kg 25 mg/kg

erTxel dReSi 4X dReSi

IV

14 dRe

Semdeg flukonazoli 400 mg erTxel

dReSi PO sul mcire 10

kvira Semdeg flukonazoli 200mg erTxel

dReSi PO mTeli

cxovreba meore rigis sqemebi amfotericini B + 5-flucitozini

0,7-1,0 mg/kg 25 mg/kg


IV 6-10 kvira

an

amfotericini B 0,7-1,0 mg/kg erTxel dReSi

IV 6-10 kvira

an (msubuq SemTxvevebSi) flukonazoli 400-800 mg erTxel

dReSi PO 10-12 kvira


dReSi PO mTeli

cxovreba meoradiAqimioprofilaqtikaAan SemanarCunebeli Terapia

o aucilebelia mTeli cxovrebis manZilze Catardes kriptokokozis meoradiAqimioprofilaqtika. am mizniT iniSneba flukonazoli 200 mg/dReSiAyoveldRe.

o itrakonazoli 200 mg/dReSiAyoveldRe. o SemanarCunebeli Terapiis aucilebloba pacientebSi, romelTa

imunuri sistema aRdga (CD4 ricxvi >200 mm3) ar aris damxmare da ar arsebobs raime sawinaaRmdego mosazreba am konkretuli SemTxvevisTvis.

3.1.8. histoplazmozi

am araxSiri mwvave an qronikuli infeqciis gamowvevia soko Hispoplasma capsulatum inhalaciuri sporebi.

88

o eqspoziciis Sedegad daavadebis ganviTareba damokidebulia rogorc maspinZlis imunur sistemaze aseve gamomwvevis raodenobaze.

o diseminaciis aRkveTaze pasuxismgebelia intaqturi ujred-damokirebuli imuniteti. mwvave daavadeba gripismagvaria da axasiaTebs:

o cxeleba o anoreqsia o arTralgia o mialgia o mSrali xveleba o tkivili gul-mkerdis areSi. o diseminacia imunosupresiul avadmyofSi swarfad viTardeba da

axasiaTebs: o wonaSi dakleba o oraluri da kanis dazianebuli ubnebi o mkerdis niSnebi o RviZlis, elenTis da limfuri kvanZebis gadideba. o oraluri ubnebisTvis damaxasiaTebelia nekruzuli wylulebi.

sesaZlebelia ganviTareds sasis perforacia da rbili qsovilis destruqcia.

diagnostika diagnostika efuZneba klinikur suraTs da dasturdeba sokos kulturiT an qsovilis bioftatis histologiuri gamokvleviT. mwvave daavadebisas gul-mkerdis rentgenologiuri gamokvleva gviCvenebs:

o Suasayaris limfadenopaTias o mravlobiT infiltratebs o qvemo wilis kvanZebs. o hispoplazmozis diagnostisTvis unda Catardes sisxlis da kanis

testebi, Tumca isini ar aris farTod gamoyenebuli. mkurnaloba imunokompetentur adamianSi hispoplazmozi TviTgankurnebadia da ar sWirdeba mkurnaloba. imunosupresiis SemTxvebSi mkurnaloba unda Catardes me-14 cxrilSi mocemuli sqemebis mixedviT. cxrili 32. histoplazmozis mkurnaloba (28) (AI) antifunfaluri

agenti dozireba miRebis

sixSire miRebis gza xangrZlivoba

amfotericni B 0.7-1 mg/kg erTxel dReSi

IV 10 dRe

sawyis mkurnalobas mohyveba 3 Tviani mkurnaloba imunorekonstituciamde >100 CD4 ujrediT, Sedegi medikamentebiT:

o itrakonazoli 200 mg 2X dReSi PO o flukonazoli 200 mg 2X dReSi PO o amfotericini B 1 mg/kg IV kviraSi erTxel.

89

alternatiul reJims warmoadgens itrakonazoli 200 mg samjer dReSi - 3 dRe, Semdeg 200 mg 2X dReSi 12 kvira (sakvebTan erTad). 3.1.9. kapoSis sarkoma

o kapoSis sarkomas iwvevs me-8 tipis herpes virusi (HHV8), romelic aseve cnobilia kapoSis sarkomasTan asocirebuli herpes virusis saxeliT (KSHV).

o nebismieri pacienti kapoSis sarkomis savaraudi diagnioziT unda gaigzavnos onkologTan.

o imunodeficitis mqone aiv inficirebulebSi daavadeba mimdinareobs mZimed, diseminaciis tendenciiT da ufro male progresirebs, vidre daavadebis endemuri formis mqone arainficirebul adamianebSi.

diagnostikaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA kapoSis sarkomis winaswari diagnozi ismeba klinikuri suraTis safuZvelze da dasturdeba kanis dazianebuli ubnebidan aRebuli bioptatis histologiuri gamokvleviT. klinikuri niSnebi moicavs Semdegs:

o kapoSis sarkomis elementebi SeiZleba aRmovaCinoT kanisa da lorwovanis nebismier areze. kanze elementebi warmodgenilia cisferi an mewamuli feris papulebiT an kvanZebiT, araiSviaTad garSemo arsebuli kanis limfuri SeSupebiT. xSirad ziandeba sasa, filtvebi kuW-nawlavis traqti da limfuri kvanZebi.

o piris RruSi kapoSis sarkomis elementebi yvelaze xSirad ganlagebulia magar sasaze, iSviaTad enaze, xaxaze, nuSura jirkvlebsa da RrZilebze. isini warmoadgenen mewamuli feris papulebs, romlebic Cveulebriv ar aris mtkivneuli. xandaxan SeiZleba Segvxvdes msxvili elementebic da elementebi kanze.

o filtvis parenqimis dazianeba atarebs infiltraciul xasiaTs. xSirad viTardeba sunTqvis ukmarisoba. filtvis infiltraciuli dazianebis mqone avadmyofebs arakeTilsaimedo prognozi aqvT da maTSi maRalia sikvdilianoba.

o aucilebelia ganvasxvavoT kapoSis sarkoma baqteriuli angiomatozisagan, romelic warmoadgens infeqciur daavadebas (gamomwvevi: Bartonella spp.) da aseve gvxvdeba aiv inficirebulebSi.

mkurnalobaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA o kapoSis sarkomis mkurnaloba tardeba onkologis mier. o kapoSis sarkoma avTvisebiani simsivnea. lokaluri formis

samkurnalod gamoiyeneba sxivuri Terapia, generalizirebuli formis samkurnalod iniSneba citotoqsiuri qimioTerapia.

o efeqturobis sxvadasxva xarisxiT gamoiyeneba simsivnis sawinaaRmdego preparatebis Semdegi kombinaciebi:

o liposomuri doksorubiciniT monoTerapia (saukeTeso Sedegebi) (29-31) (BII)

o bleomicini o vinkristini o daunorubicini o vinblastini o etopozidi.

90

o remisiis miRweva Zalian Znelia da pacientebis umetesobas uviTardebaT recidivi.

o calkeuli elementebi SeiZleba moSordes qirurgiulad an lazeris, Txevadi azotis (relapsis maRali done) da dasxivebis zemoqmedebiT. demonstrirebuli iyo uSualod kapoSis sarkomatozul kvanZSi bleomicinis Seyvanis efeqturoba.

o kapoSis sarkoma SesaZloa daeqvemdebaros mxolod arT-s da nel-nela alagdes.

3.1.10. saSvilosnos yelis kibo o saSvilosnos yelis kibo erT-erTi xSiri saxea simsivneebis,

romelic mizezia qalTa sikvdilianobis mTels msoflioSi. savaraudo ricxvi axali SemTxvevebisa msoflioSi Seadgens 500 000 weliwadSi (32) (AI).

o saSvilosnos yelisa da vulvis kiboswinare mdgomareobisa da kibos ganviTarebaSi wamyvan etiologiur faqtors warmoadgens adamianis papilomavirusi.

o aiv inficirebul qalebSi cervikaluri intraepiTeluri neoplaziis (cin) riski 5-10-jer maRalia, maTi Pap nacxi paTologiuria SemTxvevaTa 20-40%-Si (33,34) (BII).

diagnostika

o aiv inficirebul qals unda Cautardes ginekologiuri gasinjva da saSvilosnos yelis nacxis citologiuri gamokvleva Pap papanikolaus SeRebvis meTodiT. ginekologiuri da citologiuri gamokvleva unda ganmeordes eqvi Tvis Semdeg da yovelwliurad.

o saSvilosnos yelis kiboze eWvis SemTxvevaSi pacienti unda gasinjos ginekolog-onkologma da saWiroebis SemTxvevaSi gaigzavnos onkodispanseris ginekologiur ganyofilebaSi.

3.1.11. sxva avTvisebiani warmonaqmnebi

imunodeficitis mqone aiv inficirebul pacientebSi maRalia limfomiT avadoba, maT Soris arahojkinis, cns-is pirveladi da berkitis limfomebiT, aseve brtyelujredovani kiboTi. yvela aiv inficirebuli simsivneze eWvis SemTxvevaSi unda gaigzavnos onkologiur klinikaSi.

3.1.11.1.arahojkinis limfoma

imunodeficitis mqone aiv inficirebulebSi xSirad gvxvdeba arahojkinis limfomebi B ujredovani, ufro iSviaTad T ujredovani. misi ganviTareba ar aris damokidebuli CD4 ujredebis ricxvze. varaudoben, rom am daavadebis paTogenezSi did rols TamaSobs epStein-baris an romelime sxva virusi. simsivnuri arahojkinis limfomis ujredebis deteqcia SesaZlebelia limfur kvanZebSi, kunTebSi, RviZlSi, elenTaSi, gulSi, TvinSi da kuW-nawlavis traqtSi da SedarebiT iSviaTad ZvlebSi.

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o simptomebi mravalferovania. o SeSupebuli limfuri kvanZebi SesaZlebelia palpirdebodes

sxvadasxva adgilze. o cxeleba, wonaSi kleba da sisuste xSiria, Tumca ara aucilebeli. o daavadebis stadiis gansazRvrisTvis (I-IV) aucilebelia Semdegi

gamokvlevebi – cerebruli, cervikaluri, Torakaluri da abdominaluri kompiuteruli aqsialuri tomografia (CAT) skanireba, Zvlis tvinis da Tav-zurg-tvinis siTxis biofsia da gastrodkopia. diagnozi dasturdeba hiperplazirebuli limfuri kvanZis bifsiiT, histologiuri gamokvleviT.

3.1.11.2. berkitis-tipis limfoma aiv inficirebulebSi

berkitis limfoma ara hojkinis limfomis erT-erTi subtipia. berkitis limfoma asocirebulia aiv infeqciiasTan da SeiZleba ganviTardes gamoxatuli imunodeficitis ganviTarebamde. dadgenilia kavSiri am daavadebasa da epStein-baris viruss Soris. diagnostika berkitis –tipis limfomis diagnozi ismeba limfuri kvanZis da simsivnis bioptatebis histologiuri gamokvleviT. ara hojkinis, berkitis-tipis da cns-is lomfomebis mkurnaloba

o ara-hojkinis limfomebis samkurnalod efeqturia CHOP reJimi, unda Catardes 6 kursi (ganmeorebebi aucilebelia sruli remisiis misaRebad)

o prednizoloni 100 mg/dReSi erTxel 5 dRe o vinkristini (onkovini) 1,4 mg/m2 (maqsimum 2 mg/dReSi) erTi doza

mkurnalobis pirvel dRes o ciklofosfamidi 750 mg/m2/dReSi erTi doza mkurnalobis pirvel

dRes o doqsorubicini (hidroqsidaunomicini) 50 mg/m2/dReSi erTi doza

mkurnalobis pirvel dRes. meore cikli iwyeba yovel 21-e dRes (dRe 22-e mohyveba I dRes)

o EPOCH reJimi, romelic moicavs etopozids, prednozolons, vinkristins, ciklofisfamids da daunorubicins an diqsirubicins efeqturia arT-sTan kombinaciaSi. igi efuZneba gagrZelebiT infuzias 96 saaTis ganmavlobaSi, romelc Semdegia:

o etopozidi 50 mg/m2 dReSi (centraluri venuri xaziT) o doqsorubucuni 10 mg/m2/dReSi (centraluri venuri xaziT) o vinkristini 0,4 mg/m2/dReSi (maqs 2 mg/kviraSi) (centraluri venuri

xaziT) o ciklofosfamidi 375 mg/m2 me-5 dRes mxolod, bolusiT

(centraluri venuri xaziT) o prednizoloni 100 mg/dReSi pirveli 5 dRe erTxel dReSi.

reJimi unda ganmeordes yovel 21 dReSi sanam ar Catardeba 6 cikli.

o berkitis–tipis limfomis menejmenti ar gansxvavdeba sxva limfomebis mkurnalobisgan da poasuxobs CHOP da EPOCH reJimebs (BII). swrafad mzardi limfomis mkurnaloba ufro agresiuli

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qimioTerapiiT (mag : B-ALL reJimi) diskusiis Temas warmoadgens da specifikuri rekomendaciebi dRevandeli dRisTvis ar arsebobs (35,36) (Va).

o berkitis–tipis limfomebis SemTxvevebSi qimioTerapias Tan unda axldes dasxiveba savaraudo pirveladi keris.

o SesaZlebelia ara hojkinis limfomebis mkurnaloba CD4 ujredebis ricxvisgan damoukideblad, Tumca mkurnalobis efeqturobisTvis arT unda dainiSnos ufro adre. qimioTerapiis ganmavlobaSi CD4 ujredebis ricxvi >350 mm3 dakavSirebulia relapsis maRal maCveneblebTan arT gareSe (37) (BII).

o intakranilauri limfomebis (metastazebi) sasurvelia Tavis dasxiveba, simsivnis sawinaaRmdego preparatebTan da glukokortikoidebTan erTad (38) (BII).

cns-is pirveladi limfomis dros erTaderTi efeqturi mtkicebulebaze dafuZnebuli Terapiaa sxivuri Terapia. dauyonebliv unda daiwyos arT (39,40) (AI).

3.1.12. centraluri nervuli sistemis infeqciebi

adamianis imunodeficitis virusis nervul sistemaze pirdapir zemoqmedebas mivyavarT encefalopaTiis, mielopaTiis da periferiuli neiropaTiis ganviTarebamde. aiv infeqcias ukavSireben iseT nevrologiur darRvevebs, rogoricaa

o Tavis tvinis nivTierebis atrofia da degeneracia, o Sids-demenciis kompleqsi, o naTxemis atrofia, o vakuoluri mielopaTia, o saxis nervis dambla, o gien-baris sindromi da o sensorul-motoruli periferiuli neiropaTia tkivilis sindromiT.

cns-is darRvevebi aseve SeiZleba mogvces baqteriulma, virusulma da sokovanma oportunistulma infeqciebma (mag: kriptokokulma meningitma).

3.1.13. toqsoplazmozi

ganviTarebul qveynebSi toqsoplazmozi farTod aris gavrcelebuli. toqsoplazmozi iwvevs Tavis tvinSi mravlobiTi anTebadi ubnebis warmoqmnas. aiv inficirebulebSi toqsoplazmozi ZiriTadad gamovlindeba encefalitis an diseminirebuli daavadebis saxiT.

diagnostikaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA

toqsoplazmozze eWvi SeiZleba gamoiTqvas klinikuri suraTis mixedviT: o cnobierebis darRveva o cxeleba o krunCxvebi o Tavis tkivili o kerovani nevrologiuri simptomatika motoruli deficitis,

kraniuli nervis parezis, moZraobis SezRudvis, dismetriis, mxedvelobis dakargvis da afaziis CaTvliT.

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o Tavis tvinis MAC an MRI skanirebiT aRmoCndeba mravlobiTi rgoliseburi kerebi.

o Tu es meTodebi ar aris xelmisawvdomi diagnozis dadgenaSi gvexmareba serologiuri testebi toqsoplazmis sawinaaRmdegod gamomuSavebul antisxeulebze (IgG klasis).

o cerebraluri toqsoplazmozis mqone pacientebis umravlesobas aReniSneba Toxoplasma gondii-iT gamowveuli infeqciis gadatanis serologiuri niSnebi.

o toqsoplazmozze eWvis dros iniSneba sacdeli mkurnaloba o 2 kviris manZilze mkurnalobis araefeqturobis SemTxvevebSi dgeba

sakiTxi Tavis tvinis biofsiis Sesaxeb. o diagnozs adasturebs Tavis tvinis qsovilis histologiuri

gamokvleva. mkurnalobaA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA

cxrili 15. toqsoplazmozis mkurnaloba (41-43) (AI) preparati doza M miRebis

sixSire miRebis gza


mkurnaloba pirimetamini 200 mg erTjeradad

(gajerebiTi doza) PO erTjeradad

Semdeg pirimetamini 25 mg

an 50 mg 3-jer dReSi 2-jer dReSi

PO 6-8 kvira

+ foliumis mJava

15 mg dReSi erTxel

PO 6-8 kvira

+

sulfadiazini 1 g 4-jer dReSi PO 6-8 kvira am sqemaSi sulfadiazini SeiZleba Seicvalos:

klindamiciniT 600 mg i/v an PO dReSi 4-jer 6 kvira azitromiciniT 1200 mg PO dReSi erTxel 6 kvira klariTromiciniT 1 g PO 2-jer dReSi 6 kvira atovakvoniT 750 mg PO 4-jer dReSi 6 kvira. zogierT pacients sWirdeba xangrZlivi mkurnaloba

toqsoplazmozis gamo. gadawyvetileba efuZneba klinikur mdgomareobas da ganmeorebiT CAT skanirebas.

meoradi profilaqtika grZeldeba efeqturi reJimis ganaxevrebuli dozebiT manamde sanam CD4 ujredebs ricxvi sami Tvis ganmavlobaSi stabulurad ar moimatebs (200 ujredi da meti).

3.1.14. martivi herpesiT gamowveuli infeqciebi

martivi herpesiT gamowveuli infeqciebi xSiria klinikur praqtikaSi.

herpesis pirvelad epizods xSirad axlavs recidivi.

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imunodeficitis mqone pacientebSi dazianeba SeiZleba iyos vrceli da persistuli, aseve, SesaZlebelia moxdes infeqciis diseminacia.

martivi herpesi aris meningitisa da meningoencefalitis gamomwvevi. diagnostikaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA diagnozi ZiriTadad ismeba tipiuri klinikuri gamovlinebebiT. herpesuli gamonayari Cveulebriv warmodgenilia vezikulebiTa da

mtkvneuli eroziebiT, romlebic ganlagebulia piris irgvliv, cxviris nestoebze, tuCebsa da sasqeso organoebze.

diseminirebuli martivi herpesiT gamowveuli infeqciis diagnozis dasma xSirad Znelia. amisaTvis saWiroa laboratoriuli kvlevebi, rogoricaa virusis kulturis gamoyofa, radio-imunoblotingis meTodi, imunofluoroescencia da monoklonuri antisxeulebiT testireba.

herpesul encefalits mivyavarT Tavis tvinSi dazianebis mravlobiTi kerebis ganviTarebamde, romelic TvalsaCinoa CAT skanirebiT.

mkurnalobaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA mkurnalobis sqemebi mocemulia me-33 – 34-e cxrilebSi. cxrili 16. martivi herpesvirusuli infeqciis msubuqi formis mkurnaloba (44-47(AI) antivirusuli agenti

doza MmiRebis sixSire

M miRebi gza


pirveli rigis sqemebi acikloviri 400 mg 3-jer dReSi PO 7-10 dRe an famcikloviri 250 mg 3-jer dReSi PO 7-10 dRe an valacikloviri 1 g 2-jer dReSi PO 7-10 dRe cxrili 17. martivi herpesvirusuli infeqciis recidivis mkurnaloba (44-47) (AI) antivirusuli agenti


M miRebi gza


pirveli rigis sqemebi acikloviri 800 mg 5-jer dReSi PO 7-10 dRe an famcikloviri 500 mg 3-jer dReSi PO 7-10 dRe an valacikloviri 1 g 2-jer dReSi per os 7-10 dRe cxrili 18. martivi herpesvirusuli infeqciis mZime formis mkurnaloba (44-47) (AI) antivirusuli doza MmiRebis M miRebis mkurnalobis

95

agenti sixSire gza xangrZlivoba pirveli rigis sqemebi acikloviri 10 mg/kg 3-jer dReSi IV 7-10 dRe

an valacikloviri 1 g 2-jer dReSi PO 7-10 dRe cxrili 19. martivi herpesvirusuli infeqciis mZime visceraluri formebis mkurnaloba (44-47) (AI) antivirusuli agenti


M miRebi gza


pirveli rigis sqemebi acikloviri 10 mg/kg 3-jer dReSi IV 14-21 dRe meore rigis sqema

foskarneti (aciklovirze rezistentobis SemTxvevebSi)

40-60 mg/kg 3-jer dReSi IV 14 dRe

3.1.15. sartyliseburi liqeni (Herpes zoster) (48) (AI)

varicella-zoster-is virusiT gamowveuli pirveladi infeqcia mimdinareobs diseminirebuli formiT.

bavSvebSi viTardeba Cutyvavilas klinikuri suraTi, Tumca adamianTa umravlesobas es infeqcia gadaaqvs subklinikuri formiT.

pirveladi infeqciis Semdeg virusi wlebis ganmavlobaSi latentur mdgomareobaSi inaxavs Tavs zurgis tvinis gangliebSi.

imunitetis daqveiTebasTan erTad virusi mravldeba da viTardeba kanis dazianebuli ubnebiT nervis an dermatomis gaswvriv.

SesaZloa moxdes infeqciis diseminacia kanis, nervuli sistemis, filtvebis da lorwovani garsebis CarTviT paTologiur procesSi.

imunodeficitis fonze zosteri multidermatomulia, persistirebs, axasiaTebs Zlieri tkivili da sisuste.

diagnostikaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA

diagnozi Cveulebriv ismeba klinikuri suraTis mixedviT. mkurnalobaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA mkurnalobis sqemebi mocemulia 35-e da 36-e cxrilebSi.

cxrili 20 sartyliseburi liqenis (kanis formis) mkurnaloba (AI) antivirusuli agenti


M miRebi gza


pirveli rigis sqemebi acikloviri 800 mg 5-jer dReSi PO 7-10 dRe an

vezikulis gaSrobamdeE

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an famcikloviri 500 mg 3-jer dReSi PO 7-10 dRe

an valacikloviri 1 g 3-jer dReSi PO 7-10 dRe cxrili 21. Tvalis sartyliseburi liqenis, infeqciis diseminirebuli da visceruli formebis mkurnaloba antivirusuli agenti


M miRebi gza


pirveli rigis sqemebi acikloviri 10 mg/kg 3-jer dReSi IV 7-10 dRe an valacikloviri 1 gr 3-jer dReSi PO 7-10 dRe

an famcikloviri 500 mg 3-jer dReSi PO 7-10 dRe meore rigis sqema foskarneti 60 mg/kg

an 40 mg/kg

2-jer dReSi an 3-jer dReSi

IV 7-10 dRe

post-herpesuli nevralgia xSiri da seriozuli problemaa.

dazianebul dermatomebSi viTardeba Zlieri tkivili. tkivilis kontroli mniSvnelovania da tkivilis kupirebis mizniT

niSnaven arasteroidul anTebis sawinaaRmdego preparatebi. Tu tkivili gaxangrZlivda iniSneba amitriptilini, karbamazepini an

fenitoini. 3.1.16. citomegalovirusuli infeqcia imunodeficitis fonze citomegalovirusma SeiZleba daazianos sxvadasxva organoebi da sistemebi. simptomebi moicavs:

cxeleba da diarea citomegalovirusuli kolitis Ddros dispnoe- pnevmoniis dros sibrmave - retinitis dros citomegalovirusulma infeqciam SeiZleba gamoiwvios piris Rrus

lorwovanis mtkivneuli wylulebi, rac iwvevs kvebis reJimis darRvevas.

diagnostikaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA pacientebs, romelTa CD4<100 mm3 yovel 3 TveSi unda CautardeT

ofTalmoskopia, raTa droulad gamovlindes citomegalovirusuli retiniti.

citomegalovirusuli infeqciis sxva lokalizaciis SemTxvevbSi diagnozis dasadgenad saWiroa ZviradRirebuli gamokvlevebis Catareba, maT Soris dazianebuli organoebis bioptatis gamokvleva, dnm-is hibridizaciis meTodis gamoyeneba.

mkurnalobaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA rekomendaciebi citomegalovirusuli infeqciis mkurnalobis Sesaxeb

mocemulia 37-e, 38-e cxrilebSi.

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cxrili 37. citomegalovirusuli infeqciiT gamowveuli kuW-nawlavis traqtisa da cns-is dazianebebis da retinitis mkurnaloba (49-53) (AI) antivirusuli agenti


M miRebi gza


pirveli rigis sqema gancikloviri 5 mg/kg 2-jer dReSi IV 2-3 kvira meoradi profilaqtikisTvis aucilebelia gancikloviriT 5 mg/kg IV dReSi mkurnaloba. cxrili 38. citomegalovirusuli infeqciiT gamowveuli kuW-nawlavis traqtisa da cns-is dazianebebis mkurnaloba (49-53) (AI) antivirusuli agenti


M miRebi gza


meore rigis sqemebi foskarneti 90 mg/kg 2-jer dReSi IV 3 kvira meoradi profialqtikisTvis aucilebelia foskarnetiT mkurnalobis xangrZlivi kursi doziT 90mg/kg IV erTxel dReSi. cxrili 39. citomegalovirusuli retinitis meoradi profilaqtika (49-53) (AI) antivirusuli agenti


M miRebi gza


meore rigis sqemebi Tvalis implantanti, romelic gamoyofs ganciklovirs + valgancikloviri 900 mg erTxel

dReSi PO manamde sanam CD4

ujredebi ricxvi ar moimatebs 100-150 mm3 minimum 3 Tvis ganmavlobaSi

meoradi profilaqtikis Sewyveta SesaZlebelia 6 Tvis Semdeg da imunorekonstituciisas - CD4 100-150 mm3. 3.1.17. epStein-baris virusiT gamowveuli infeqciebi

epStein-baris virusi miekuTvneba herpesvirusebis ojaxs. am virusiT gamowveuli infeqciebi gavrcelebulia, rogorc aiv inficirebul, ise arainficirebul adamianebSi.

aiv inficirebulebulTa orofaringealur sekretSi gvxvdeba virusuli nawilakebis momatebuli raodenoba da antisxeulebis ufro maRali titri, vidre arainficirebulebSi.

varaudoben, rom epStein-baris virusi iwvevs ramdenime daavadebas, maT Soris:

oraluri Tmovani leikoplakia; limfoiduri intersticiuli pnevmoniti (LIP); arahojkinis limfomebi;

98

berkitis-tipis limfoma; nazofaringeuli karcinoma;

oraluri Tmovani leikoplakia

oraluri Tmovani leikoplakia viTardeba, rogorc aiv inficirebulebSi, aseve pacientebSi, romelTac utardebaT transplantaciis Semdgomi imunosupresiuli Terapia.

dazianebul kerebs aqvs zedapiridan wamoweuli balTisiburi TeTri nadebis saxe, romelic ganlagebulia piris RruSi, upiratesad ki enis kideze. igi lorwovani garsis epiTelis keTilTvisebiani gadagvarebaa.

rTulia diferencialuri diagnostika oralur Tmovan leikoplakiasa da piris Rrus kandidozs Soris; araiSviaTia am daavadebaTa erTdrouli arseboba.

specifikuri mkurnaloba ar arsebobs. pacientebisaTvis rekomendebulia piris Rrus higienis dacva.

limfoiduri intersticiuli pnevmoniti

limfoiduri intersticiuli pnevmoniti upiratesad uviTardebaT aiv inficirebul bavSvebs, magram mozrdilebSic gvxvdeba.

damaxasiaTebelia difuzuri intersticiuli infiltratebis arseboba filtvebSi, romelic SeiZleba miviCnioT tuberkulozis an pnevmocisturi pnevmoniis gamovlinebad.

xSirad limfoiduri intersticiuli pnevmoniti mimdinareobs filtvis mZime paTologiis niSnebis gareSe.

specifikuri mkurnaloba ar arsebobs. 3.2. ZiriTadi simptomebi

3.2.1. persistuli generalizirebuli limfadenopaTia (pgl) mozrdil aiv inficirebulebSi

aiv infeqciis yvelaze adreul klinikur gamovlinebas warmoadgens limfuri kvanZebis simetriuli gadideba.

gadidebuli limfuri kvanZi, rogorc wesi umtkivneulo, elastiuri konsistenciis moZravi warmonaqmnia. yvelaze advilad isinjeba kisris, ybisqveSa, iRliisa da sazardulis limfuri kvanZebi.

persistuli generalizirebuli limfadenopaTia SeiZleba warmoadgendes aiv infeqciis erTaderT gamvlinebas

persistuli generalizirebuli limfadenopaTia _ es aris limfuri kvanZebis (1sm diametrze meti) or an meti jgufis gadideba (sazardulis garda), romelic SenarCunebulia 1 Tveze met xans.

pgl–s dros limfuri kvanZis biofsiiT Ghistologiurad saxezea “reaqtiuli hiperplazia” an “folikuluri hiperplazia”. hiperplaziis mizezis gasarkvevad aucilebelia kimfuri kvanZis biofsia.

99

diagnostika gamokvleva aucileblad unda moicavdes limfuri kvanZebis Semdegi jgufebis palpacias:

kisris wina da ukana ybisqveSa kefisukana yuris irgvlivi (yuriswina da ukana) iRliis orive idayvis are sazardulis (am jgufis jirkvlebis gadideba janmrTel

pirebSic gvxvdeba)

persistuli generalizebuli limfadenopaTiis mqone aiv inficirebulebSi SeiniSneba aiv infeqciis sxva gamovlinebebic. maT Soris:

piris Rrus kandidozi,

oraluri Tmovani leikoplakia,

qavana dermatiti,

frCxilebis gamuqeba,

oraluri da genitaluri herpesi,

umizezod wonaSi kleba,

ucnobi etiologiis cxeleba.

generalizebuli limfadenopaTia damaxasiaTebelia sxva daavadebebisaTvisac, kerZod, tuberkulozis, leikozis, limfomis, kapoSis sarkomis, veneriuli limfogranulomis, sifilisis, citomegalovirusuli infeqciis, toqsoplazmozis, epStein-baris virusiT gamowveuli infeqciis, kriptokokozis, histoplazmozisa da kanis Cirqovani infeqciebisaTvis, Savi Wirisa da B hepatitisaTvis. limfuri kvanZebis biofsiis Cvenebebi

persistiuli generalizebuli limfadenopaTiis mqone pacientebi aucilebelia gagzavnil iqnas biofsiaze, Tu maT aReniSnebaT:

limfuri kvanZebis asimetriuli gadideba limfuri kvanZebis gamoxatuli gadideba (3 sm diametris mqone erTi

limfuri kvanZi mainc) dakvirvebebis fonze limfuri kvanZebis gadideba tuberkulozis raime niSnebi gulmkerdis rentgenogramaze filtvis karis limfuri kvanZebis

gadideba nebismieri likalizaciis kapoSis sarkoma cxeleba, Ramis oflianoba, wonaSi kleba erT kviraze xangZlivad.

aiv asocirebuli limfadenopaTia ar aris seriozuli daavadebis, mag; lomfomis maniSnebeli. miuxedavad amisa, mdgomareobis cvlilebisas, mag: persistuli cxelebis damatebisas sasurvelia limfadeneqtomia da kvanZis histologiuri gamokvleva.

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3.2.2. cxeleba aiv inficirebulebSi cxelebis mizezi SeiZleba iyos infeqcia, anTebiTi procesi an

avTvisebiani simsivne. mozrdilebSi persistulad iTvleba cxeleba,

Tu 38°C–ze maRali temperatura grZeldeba or kviraze gangrZlivad. aiv inficirebul pacientebSi cxeleba SeiZleba iyos infeqciis

erTaderTi klinikuri niSani. amitom persistuli cxelebis mqone avadmyofebis mkurnalobisas unda gvaxsovdes, rom misi mizezi SeiZleba iyos aiv infeqcia.

aiv /SidsiT pacientebSi persistul cxelebas SeiZleba Tan axldes misi gamomwvevi daavadebis simptomebi, magaliTad, pnevmoniis, tuberkulozis, kuW-nawlavis traqtis infeqciis an limfomis. persistuli cxelebis mqone mozrdil pacientebSi aiv infeqciaze migviTiTebs Semdegi mdgomareobebi:

• anamnezSi mravlobiTi daucveli sqesobrivi kontaqtebi

• aiv inficirebuli sqesobrivi partniori

• aiv inficirebuli Svili

• aiv infeqciisaTvis damaxasiaTebeli tipuri klinikuri niSnebis arseboba, rogoricaa:

• persistuli generalizirebuli limfadenopaTia,

• oraluri an genitaluri kandidozi da/an herpesi,

• oraluri Tmovani leikoplakia,

• qavana dermatiti,

• wonaSi umizezod kleba,

• frCxilebis gamuqeba (melanonixia),

• tuCebis hipopigmentacia da

• Tmebis gaTxeleba da cvena. 3.2.3. aiv inficirebul mozrdilebSi wonis umizezo kleba

mozrdilebSi wonaSi kleba xSirad dakavSirebulia aiv infeqciasTan.

wonis mniSvnelovan klebad iTvleba sxeulis sawyisi masis 10% -iT an metiT daqveiTeba umizezod.

gamoxatuli wonis kleba aiv inficirebulebSi atarebs “aiv-kaxeqsiis” an ganlevis sindromis saxels.

ganlevis mizezi jer-jerobiT kargad ar aris Seswavlili. SesaZlebeli mizezebia:

qronikuli da morecidive infeqciebi, qronikuli diarea, Sewovis darRveva (malabsorbcia), aiv inducirebuli miopaTia da aiv inducirebuli madis daqveiTeba. klinikuri niSnebiAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA pacienti uCivis wonaSi umizezod klebas da madis daqveiTebas,

rasac Tan axlavs an ar axlavs cxeleba da diarea. aiv kaxeqsiis mqone pacientebi uCivian zogad saerTo diskomforts,

gamofitvas, mousvenrobas, gauwyloebas.

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aseT pacientebSi xSiria piris Rrus kandidozi, aseT pacientebSi xSiria Sidsis sxva klinikuri gamovlinebebi, maT

Soris nevrologiuri, mag. encefalopaTia da Sids-demenciis kompleqsi.

3.2.4. mozrdilTa qronikuli diarea

qronikuli diarea ewodeba 28 dRis ganmavlobaSi arsebul xSir (sami an meti), Txier defekacias. qronikuli diareis fonze pacientebs SeiZleba ganuviTardeT mwvave diareis epizodebi.

Tu ar aris dizenteria ganavalSi sisxlis minarevebis arseboba iSviaTia.

avadmyofebs aReniSnebaT cudi mada da ikleben wonaSi. gamokvlevisas gamovlindeba gauwyloebis, anemiisa da gamofitvis

niSnebi. qronikuli diareis mqone pacientebSi aRiniSneba: kanisa da Tmebis distrofiuli cvlilebebi tipurad asocirebuli

arasrulfasovan kvebasTan, tuCebis gafermkrTaleba, frCxilebis gamuqeba piris Rrus kandidozi, oraluri Tmovani leikoplakia da

limfadenopaTia.

3.2.5. piris Rrus dazianebebi kandidozis garda aiv inficirebulebs xSirad aReniSnebaT piris Rrus sxva saxis dazianebebic. zogierTi maTgani ganxilulia me-40 cxrilSi. cxrili 40. piris Rrus yvelaze xSiri dazianebebi aiv inficirebulebSi mdgomareoba aRweriloba mkurnaloba gingiviti hiperemia, SeSupeba da

sisxldena RrZilebidan metronidazoli 400 mg 2-jer dReSi 7 dRe PO an eriTromicini 500 mg 4-jer dReSi 7 dRe PO

piorea Cirqis dagroveba kbilbudeSi

piris Rrus higiena: yoveli Wamis Semdeg pirSi Tbili marilwylis gamovleba da kbilebis dReSi 2-jer gamoxexva

periodontiti damaxasiaTebelia kbilebis garSemo Zvlebisa da rbili qsovilebis swrafi da mtkivneuli rRveva. kbilebi iryeva da Zvreba, RrZilebi sisxlmdenia. SesaZlebelia dawyluleba

infeqciis kerebis sanacia, pirSi qlorheqsidinis xsnaris gamovleba. aseve iniSneba amoqsicilini 500 mg 3-jer dReSi 5 dRis ganmavlobaSi PO an metronidazoli 200 mg samjer dReSi 5 dRe PO.

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afTozuri wylulebi

lorwovanze aRiniSneba mtkivneuli wylulebi swori kideebiT. Cveulebriv dafarulia Cirqovani nadebiT da Sexebisas sisxlmdenia.

piris Rrus higiena da glukokortikoidebi adgilobrivad

stomatiti piris Rrus lorwovanis anTeba. viTardeba piris Rrus cudi higienis pirobebSi; SeiZleba gamoiwvios anaerobebma.

piris Rrus higiena: Wamis Semdeg marilwyalsnaris gamovleba da kbilebis dReSi 2-jer gamoxexva.

qeiliti tuCebis SeSupeba da SewiTleba, romelic icvleba sifermkrTaliT; xSirad aReniSnebaT gamaxatuli imunodeficitis mqone pirebs

specifikuri mkurnaloba ar arsebobs. iniSneba A, B da C vitaminebi da piris Rrus higiena.

meoradi sifilisi

sifilidebi loyis lorwovanze (sveli papulebi da wylulebi,mogvagonebs lokokinis nakvalevs) da farTe kondilomebi tuCis kuTxeebsa da nestoebis garSemo. meoradi sifilisis dros yvela serologiuri testi dadebiTia.

pirveladi sifilisi: benzatinbenzilpenicilini 2,4 mln. erT. kunTebSi erTjeradad meoreuli sifilisi: benzatinbenzilpenicilini 2,4 mln. erT. kunTebSi kviraSi erTxel 3 kvira an doqsiciklini 100mg 2-jer dReSi 28 dRe PO an eriTromicini 500mg 4-jer dReSi 28 dRe PO.

3.2.6. kanisa da frCxilebis dazianebebi dermatomikozebi

kanis sokovani dazianeba (dermatomikozebi) xSirad gvxvdeba rogorc aiv inficirebul, ise arainficirebul pacientebSi.

gamonayars xSirad Tan axlavs qavili, elementi mSralia da aqercvladi.

dazianeba SeiZleba gaCndes sxeulis nebismier adgilze. diagnostikaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA gamomwvevi SeiZleba aRmovaCinoT dazianebuli kanis anafxekis mikroskopuli gamokvleviT. mkurnalobaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA

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rogorc wesi efeqturia antimikozuri mazebisa da kremebis adgilobrivi aplikacia. rekomendaciebi dermatomikozis mkurnalobis Sesaxeb mocemulia 41-e cxrilSi. cxrili 41. dermatomikozebis mkurnaloba (AI) antifungaluri preparati


M miRebi gza


pirveli rigis sqemebi Mmikonazoli (adgilobrivad gamoyenebisTvis)

3-jer dReSi Aadgilobrivad 21 dRe

an klotrimazoli (adgilobrivad gamoyenebisTvis)

3-jer dReSi adgilobrivad 21 dRe

meore rigis sqemebi ketokonazoli 200 mg dReSi

erTxel PO 1-3 Tve

an itrakonazoli 100 mg dReSi

erTxel PO 1-3 Tve

oniqomikozebi frCxilebis sokovani dazianebebi (oniqomikozebi) iwveven frCxilis firfitebis deformaciasa da rRvevas. diagnostikaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA

diagnozi ismeba klinikuri suraTiT. gamomwvevi SeiZleba aRmoCnes frCxilis firfitis qvevidan aRebuli

da kaliumis hidroqsidiT damuSavebuli masalis mikroskopuli gamokvleviT.

mkurnalobaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA cxrili 42. oniqomikozebis mkurnaloba (AI) pirveli rigis sqemebi antifungaluri preparati


MmiRebi gza


terbinafini 250 mg dReSi erTxel

PO 6 kvira xelis TiTebis dazianebisas an 12 kvira fexis TiTebis dazianebisas

an itrakonazoli 200 mg 2-jer dReSi PO yoveli Tvis I

kviris

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ganmavlobaSi 2 Tvis manZilze (xelis TiTebis dazianebisas), 3-4 Tve (fexis TiTebi dazianebisas)

3.2.7. seboreuli dermatiti

aiv inficirebulebs xSirad uviTardebaT seboreuli dermatiti. varaudoben, rom mas iwvevs soko Pityrosporum ovale (aseva cnobilia, rogorc Malassezia furfur).

elementi warmoadgens wiTeli feris laqas, romelic iqercleba. aiv inficirebulebSi dazianeba vrcelia, elementebi xangrZlivad rCeba da xSirad iZleva recidivs.

diagnostikaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA diagnozi ismeba klinikuri suraTiT. Cveulebriv gamonayari gvxvdeba:

o saxeze o cxviris nestoebis irgvliv o cxvir-tuCis naoWze, o warbebze, o Tavis Tmian nawilze, o gul-mkerdis areSi o iRliebSi, o tanis zeda nawilsa da o sazardulis areSi.

diagnozi dasturdeba sokos aRmoCeniT kanis dazianebuli ubnidan anafxeki masalis mikroskopuli gamokvlevisas. mkurnalobaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA

o rekomendebulia dazianebuli ubnebis xSirad dabana qerclis mosaSoreblad,

o karg Sedegs iZleva selenis sulfidis Semcveli samkurnalo Sampunebis gamoyeneba.

o SesaZloa yvelaze efeqturi aRmoCndes hidrokortizonis 1%-ani mazis aplikaciebi. aseve karg Sedegs iZleva ketokonazolis 2%-ani kremi.

3.2.8. muni muns iwvevs tkipa Sarcoptes scabiei. mdedr tkipas kanSi gahyavs gasasvleli, romelsac aqvs ramodenime sm sigrZis zedapiridan wamoweuli wiTeli nawiburis Sesaxedaoba. mdedri tkipa gayvanil gasasvlelSi debs kvercxebs da Semdeg gadaadgildeba sxeulis sxva nawilSi. kvercxebidan gamodis tkipebis axali Taoba, romlebic izrdebian, jvardebian, gahyavT axali gasasvlelebi da deben axal kvercxebs.

o parazitis pirveladi SeWridan daaxloebiT erT Tvis ganmavlobaSi (2-6 kvira) simptomebi TiTqmis ar aRiniSneba.

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o ganmeorebiTi invaziis Semdeg ki viTardeba alergiuli reaqcia da simptomebi gamovlindeba 1-4 dRis ganmavlobaSi.

o kanqveSa gasasvlelis gayvanisas viTardeba gamonayari, romelic xSirad gvxvdeba:

o xelebze - mtevnebze (gansakuTrebiT TiTebs Soris), o majis, idayvis, muxlismomxrel zedapirebze, o winamxris idayviskena zedapirze, o sasqeso asoze, o sarZeve jirkvlebsa da o beWebze. o tkipebi da maT mier gayvanili gasasvlelebi SeiZleba iyos Zalian

mcire raodenobiT da gagviWirdes maTi danaxva. o avadmyofs ZiriTadad awuxebs tanis Zlieri qavili, gansakuTrebiT

RamiT. o imunodeficitis mqone pacientebs xSirad uviTardebaT munis mZime

forma, romelsac uwodeben norvegiuls. misTvis damaxasiaTebelia vezikuluri gamonayari da sqeli fufxebis warmoqmna mTel sxeulze. munis am formis dros qavili ar aris gamoxatuli.

o qavilis gamo muni xSirad rTuldeba meoradi infeqciebiT. diagnostikaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA

o diagnozi ismeba klinikuri gamovlinebebisa da dazianebuli keris anafxekis mikroskopuli gamokvlevis safuZvelze.

o mikroskopiisas aRmoCndeba tkipebi an/da maTi kvercxebi. mkurnalobaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA

o SerCevis preparats warmoadgens adgilobrivad gamosayenebeli 1%-ani gamabenzen heqsaqloridi, romelic ismeba mTels tanze, Tavis garda, mozrdilebSi Camoibaneba 24 sT-Si , xolo bavSvebSi_8sT-Si. sakmarisia erTjeradi damuSaveba.

o aseve SesaZlebelia kanis damuSaveba 1%-ani permetriniT an 1%-ani lindaniT; es preparatebic ismeba mTels tanze da Camoibaneba 8 sT-Si. permetrinisa da lindanis gamoyeneba ar SeiZleba orsulebisaTvis, meZuZuri dedebisa da bavSvebisaTvis.

o norvegiuli munis samkurnalod, imunodeficitis mqone pacientebSi, efeqturia ivermeqtini, 200 mg/kg PO erTjeradad.

o tansacmeli, TeTreuli da pirsaxocebi unda gamoixarSos da dauTovdes gaSrobis Semdeg.

o munis mkurnaloba unda Cautardes sqesobriv partniors da yvelas vinc sayofacxovrebo kontaqtSi iyo avadmyofTan.

3.2.9. stafilokokuri folikuliti

o folikuliti _ kanis infeqciaa, romlis drosac procesi Tmis folikulSia lokalizebuli.

o aiv inficirebulebs xSirad uviTardebaT pustularuli perifolikuliti.

o folikulits, rogorc wesi, iwvevs Staphylococcus aureus, magram sxva mikroorganizmebsac SeuZlia misi gamowveva.

diagnostikaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA o diagnozi ismeba klinikuri gamovlinebebis safuZvelze.

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o gamonayari warmodgenilia mravlobiTi wvrili (5 mm diametris), hiperemiuli folikulebiT, romlebic centrSi daCirqebulia.

o xSirad elementebs aqvT midrekileba gaerTianebisaken. kanis dazianebas Tan axlavs qavili.

mkurnalobaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA iniSneba antibiotiki, magaliTad cefaleqsini an kloksacilini 500 mg PO 4-jer dReSi 7-21 dRe. 3.2.10. kontagiozuri moluski

o kontagiozuri moluski _ kanis zedapiruli infeqciaa, romelsac iwvevs kontagiozuri moluskis virusi.

o infeqcia gadadis avadmyofTan mWidro kontaqtiT an saerTo moxmarebis nivTebiT da sqesobrivi gziT.

o inkubaciuri periodi meryeobs 1-2 kviridan ramodenime Tvemde. o elementebis mocilebam an moqavebam SeiZleba gamoiwvios axali

gamonayrebis ganviTareba. o kontagiozuri moluski ufro xSiria imunodeficitis mqone aiv

inficirebulebSi. o aiv inficirebulebSi aiv negatiurebisgan gansxvavebiT: o elementebi raodenobrivad bevria, o xangrZlivad persistirebs, o ufro msxvilia da o Znelad eqvemdebareba mkurnalobas.

diagnostikaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA o diagnozi ismeba damaxasiaTebeli elementis aRmoCenisas. o kanSi SeRwevisas virusi iwvevs 2-5 mm diametris kanisferi mkvrivi

papulebis ganviTarebas. papulebi Seicavs TeTr cximovan sekrets. o gamonayaris elementebi SeiZleba ganviTardes sxeulis nebismier

adgilas, xSirad iyos ucvlelad mravali Tvis manZilze da/an gaqres da Semdeg kvlav gaCndes.

o specifikuri diagnostikuri testi virusis aRmosaCenad ar arsebobs.

mkurnalobaAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA mkurnaloba mdgomareobs papulis rbili SigTavsis mocilebaSi, romlis Semdeg papula qreba. mkurnalobis taqtika yvela SemTxvevaSi individualuria. arsebobs kanis dazianebuli ubnis damuSavebis sxvadasxva meTodi. elementebs damuSaveba SesaZlebelia Semdegi meTodebis gamoyenebiT: _ kiuretaJi _ qimiuri destruqcia fenolis koncentrirebuli xsnariT _ krioTerapia _ eleqtrokoagulacia cnobilia, rom aiv inficirebulebSi arT-s dawyeba xels uwyobs kontagiozuri moluskis eliminacias. naCvenebi iyo, rom antivirusuli preparati – cidofoviri, romelsac aqvs Zlieri antiretrovirusuli moqmedeba, aseve efeqturia kontagiozuri moluskis samkurnalod.

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gamoyenebuli literaturis CamonaTvali: 1. El-Sadr WM et al. A randomized trial of daily and thrice-weekly trimethoprim-sulfamethoxazole for the prevention of Pneumocystis carinii pneumonia in human immunodeficiency virus-infected persons. Terry Beirn Community Programs for Clinical Research on AIDS (CPCRA). Clinical Infectious Diseases, 1999, 29(4):775–783. 2. Bozzette SA et al. A randomized trial of three antipneumocystis agents in patients with advanced human immunodeficiency virus infection. NIAID AIDS Clinical Trials Group. The New England Journal of Medicine, 1995, 332(11):693–699. 3. Bucher HC et al. Meta-analysis of prophylactic treatments against Pneumocystis carinii pneumonia and toxoplasma encephalitis in HIV-infected patients. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology, 1997, 15(2):104–114. 4. El-Sadr WM et al. Atovaquone compared with dapsone for the prevention of Pneumocystis carinii pneumonia in patients with HIV infection who cannot tolerate trimethoprim, sulfonamides, or both. Community Program for Clinical Research on AIDS and the AIDS Clinical Trials Group. The New England Journal of Medicine, 1998, 339(26):1889–1895. 5. Chan C et al. Atovaquone suspension compared with aerosolized pentamidine for prevention of Pneumocystis carinii pneumonia in human immunodeficiency virus-infected subjects intolerant of trimethoprim or sulfonamides. Journal of Infectious Diseases, 1999, 180(2):369–376. 6. Bucher HC et al. Isoniazid prophylaxis for tuberculosis in HIV infection: a meta-analysis of randomized controlled trials. AIDS, 1999, 13(4):501–507. 7. Podzamczer D et al. Thrice-weekly sulfadiazine-pyrimethamine for maintenance therapy of toxoplasmic encephalitis in HIV-infected patients. Spanish Toxoplasmosis Study Group. AIDS, 2000, 14(3):331– 332. 8. Gallant JE, Moore D, Chaisson RE. Prophylaxis for opportunistic infections. Annals of Internal Medicine, 1995, 122(9):730–731. 9. Havlir DV et al. Prophylaxis against disseminated Mycobacterium avium complex with weekly azithromycin, daily rifabutin, or both. California Collaborative Treatment Group. The New England Journal of Medicine, 1996, 335(6):392–398. 10. Nightingale SD et al. Incidence of Mycobacterium avium-intracellulare complex bacteremia in human immunodeficiency virus-positive patients. Journal of Infectious Diseases, 1992, 165(6):1082–1085. 11. Saag MS et al. A comparison of itraconazole versus fluconazole as maintenance therapy for AIDS-associated cryptococcal meningitis. National Institute of Allergy and Infectious Diseases Mycoses Study Group. Clinical Infectious Diseases, 1999, 28(2):291–296. 12. Gant V, Parton S. Community-acquired pneumonia. Current Opinion in Pulmonary Medicine, 2000, 6:226–233. 13. Cordero E et al. Usefulness of sputum culture for diagnosis of bacterial pneumonia in HIV-infected patients. European Journal of Clinical Microbiology and Infectious Diseases, 2002, 21(5):362–367. 14. Cruciani M et al. Meta-analysis of diagnostic procedures for Pneumocystis carinii pneumonia in HIV-1- infected patients. European Respiratory Journal, 2002, 20(4):982–989. 15. Shafran SD et al.A comparison of two regimens for the treatment of Mycobacterium avium complex bacteremia in AIDS: rifabutin, ethambutol, and clarithromycin versus rifampin, ethambutol, clofazimine, and ciprofloxacin. Canadian HIV Trials Network Protocol 010 Study Group. The New England Journal of Medicine, 1996, 335(6):377–383. 16. Benson CA et al. A prospective, randomized trial examining the efficacy and safety of clarithromycin in combination with ethambutol, rifabutin, or both for the treatment of disseminated Mycobacterium avium complex disease in persons with acquired immunodeficiency syndrome. Clinical Infectious Diseases, 2003, 37(9):1234–1243. 17. Toma E et al.Clindamycin with primaquine vs. Trimethoprim-sulfamethoxazole therapy for mild and moderately severe Pneumocystis carinii pneumonia in patients with AIDS: a multicenter, double-blind, randomized trial (CTN 004). CTN-PCP Study Group. Clinical Infectious Diseases, 1998, 27(3):524– 530. 18. Vohringer HF et al. Pharmacologic studies with pentamidine aerosol in HIV patients [in German]. Medizinische Klinik, 1990, 85 Suppl. 2:248–250, 291. 19. Jacobson MA et al. Ciprofloxacin for Salmonella bacteremia in the acquired immunodeficiency syndrome (AIDS). Annals of Internal Medicine, 1989, 110(12):1027–1029. 9-31 management of opportunistic infections and general symptoms of hiv/aids

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20. Chen XM et al. Cryptosporidiosis. The New England Journal of Medicine, 2002, 346(22):1723–1731. 21. Smith NH et al. Combination drug therapy for cryptosporidiosis in AIDS. Clinical Infectious Diseases, 1998, 178(3):900–903. 22. Carr A et al.Treatment of HIV-1-associated microsporidiosis and cryptosporidiosis with combination antiretroviral therapy. The Lancet, 1998, 351:256–261. 23. Miao YM, Gazzard BG. Management of protozoal diarrhoea in HIV disease. HIV Medicine, 2000, 1(4):194–199. 24. Sangeorzan JA et al. Epidemiology of oral candidiasis in HIV-infected patients: colonization, infection, treatment, and emergence of fluconazole resistance. American Journal of Medicine, 1994, 97(4):339– 346. 25. Saag MS et al. Treatment of fluconazole-refractory oropharyngeal candidiasis with itraconazole oral solution in HIV-positive patients. AIDS Research and Human Retroviruses, 1999, 15(16):1413–1417. 26. VFEND side effects, and drug interactions: voriconazole [web page]. Rancho Sante Fe, CA, RxList, 2006 (http://www.rxlist.com/cgi/generic/vfend_ad.htm accessed, 12 June 2006). 27. Saag MS et al. Practice guidelines for the management of cryptococcal disease. Infectious Diseases Society of America. Clinical Infectious Diseases, 2000, 30(4):710–718. 28. Johnson PC et al. Safety and efficacy of liposomal amphotericin B compared with conventional amphotericin B for induction therapy of histoplasmosis in patients with AIDS. Annals of Internal Medicine, 2002, 137(2):105–109. 29. Rosenthal E et al. DNX Study Group Phase IV study of liposomal daunorubicin (DaunoXome) in AIDSrelated Kaposi sarcoma. American Journal of Clinical Oncology, 2002, 25(1): 57–59. 30. Osoba D et al. Effect of treatment on health-related quality of life in acquired immunodeficiency syndrome (AIDS)-related Kaposi’s sarcoma: a randomized trial of pegylated-liposomal doxorubicin versus doxorubicin, bleomycin, and vincristine. Cancer Investigation, 2001, 19(6):573–580. 31. Cheung TW et al. AIDS-related Kaposi’s sarcoma: a phase II study of liposomal doxorubicin. The TLC D-99 Study Group. Clinical Cancer Research, 1999, 5(11):3432–3437. 32. Shanta V et al. Epidemiology of cancer of the cervix: global and national perspective. Journal of the Indian Medical Association, 2000, 98(2):49–52. 33. Wright TC Jr et al. Cervical intraepithelial neoplasia in women infected with human immunodeficiency virus: prevalence, risk factors, and validity of Papanicolaou smears. New York Cervical Disease Study. Obstetrics and Gynecology, 1994, 84(4):591–597. 34. Sun XW et al. Human papillomavirus infection in human immunodeficiency virus-seropositive women. Obstetrics and Gynecology, 1995, 85(5 Pt 1):680–686. 35. Hoffmann C, et al. The short and intensive B-ALL protocol is a highly effective regimen in patients with AIDS-associated Burkitt or Burkitt-like lymphoma. 11th Conference on Retroviruses and Opportunistic Infections Feb. 8-11 2004 San Francisco, CA (Abstract 787). 36. Hoffmann C et al. Successful autologous stem cell transplantation in a severely immunocompromised patient with relapsed AIDS-related B-cell lymphoma. European Journal of Medical Research, 2006, 11(2):73–76. 37. Hoffmann C et al. Response to highly active antiretroviral therapy strongly predicts outcome in patients with AIDS-related lymphoma. AIDS, 2003, 17(10):1521–1529. 38. Fine HA, Mayer RJ. Primary central nervous system lymphoma. Annals of Internal Medicine, 1993, 119(11):1093–1104. 39. Hoffmann C et al. Survival of AIDS patients with primary central nervous system lymphoma is dramatically improved by HAART-induced immune recovery. AIDS, 2001, 15(16):2119–2127. 40. McGowan JP, Shah S. Long-term remission of AIDS-related primary central nervous system lymphoma associated with highly active antiretroviral therapy. AIDS, 1998, 12(8):952–954. 41. Katlama C et al. Pyrimethamine-clindamycin vs. pyrimethamine-sulfadiazine as acute and longterm therapy for toxoplasmic encephalitis in patients with AIDS. Clinical Infectious Diseases, 1996, 22(2):268–275. 42. Dannemann B et al. Treatment of toxoplasmic encephalitis in patients with AIDS. A randomized trial comparing pyrimethamine plus clindamycin to pyrimethamine plus sulfadiazine. The California Collaborative Treatment Group. Annals of Internal Medicine, 1992, 116(1):33–43. 43. Chirgwin K et al. Randomized phase II trial of atovaquone with pyrimethamine or sulfadiazine for treatment of toxoplasmic encephalitis in patients with acquired immunodeficiency syndrome: ACTG 237/ 9-32 HIV/AIDS TREATMENT AND CARE CLINICAL PROTOCOLS FOR THE WHO EUROPEAN REGION ANRS 039 Study. AIDS Clinical Trials Group 237/Agence Nationale de Recherche sur le SIDA, Essai 039. Clinical Infectious Diseases, 2002, 34(9):1243–1250. 44. Conant MA et al. Valaciclovir versus aciclovir for herpes simplex virus infection in HIV-infected individuals: two randomized trials. International Journal of STD and AIDS, 2002, 13(1):12–21.

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45. Ioannidis JP et al. Clinical efficacy of high-dose acyclovir in patients with human immunodeficiency virus infection: a meta-analysis of randomized individual patient data. Journal of Infectious Diseases, 1998, 178(2):349–359. 46. Chang E, Absar N, Beall G. Prevention of recurrent herpes simplex virus (HSV) infections in HIV-infected persons. AIDS Patient Care, 1995, 9(5):252–255. 47. Safrin S. Treatment of acyclovir-resistant herpes simplex virus infections in patients with AIDS. Journal of Acquired Immune Deficiency Syndrome, 1992,.5 Suppl. 1:S29–S32. 48. Gnann JW Jr, Whitley RJ. Clinical practice: herpes zoster. The New England Journal of Medicine, 2002, 347(5):340–346. 49. Whitley RJ et al. Guidelines for the treatment of cytomegalovirus diseases in patients with AIDS in the era of potent antiretroviral therapy: recommendations of an international panel. International AIDS Society- USA. Archives of Internal Medicine, 1998, 158(9):957–969. 50. Foscarnet-Ganciclovir Cytomegalovirus Retinitis Trial: 5. Clinical features of cytomegalovirus retinitis at diagnosis: studies of ocular complications of AIDS Research Group in collaboration with the AIDS Clinical Trials Group. American Journal of Ophthalmology, 1997, 124(2):141–157. 51. Martin DF et al. A controlled trial of valganciclovir as induction therapy for cytomegalovirus retinitis. The New England Journal of Medicine, 2002, 346(15):1119–1126. 52. Jacobson MA et al. Phase I study of combination therapy with intravenous cidofovir and oral ganciclovir for cytomegalovirus retinitis in patients with AIDS. Clinical Infectious Diseases, 1999, 28(3):528–533. 53. Martin DF et al. Oral ganciclovir for patients with cytomegalovirus retinitis treated with a ganciclovir implant. Roche Ganciclovir Study Group. The New England Journal of Medicine, 1999, 340(14):1063– 1070.

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Tavi IV. aiv infeqcia/SidsiT daavadebulTa imunizaciis ZiriTadi principebi ramdenadac aiv infeqcia iwvevs imunuri sistemis progresirebad dazianebas, SesaZloa aiv inficirebul pirebSi zogierTi vaqcina gaxdes mniSvnelovani gverdiTi reaqciis mizezi. imunobiologiuri produqti ar aris sruliad usafrTxo; amis gaTvaliswinebiT, axalSobilTa, bavSvTa da mozrdilTa vaqcinaciis ZiriTadi principebi efuZneba Semdegs:

• imunobiologiuri produqtis maxasiaTeblebi;

• aqtiuri da pasiuri imunizaciis principebis mecnieruli codna;

• infeqciis epidemiologia;

• infeqciis sawinaaRmdego proteqciis miRwevis dadebiTi da uaryofiTi mxareebi.

aRniSnuli dadebiTi da uaryofiTi mxareebis zust Sefasebamde, rasac Semdgomi kvlevebi gviCvenebs, aiv infeqcia SidsiT daavadebul pirebSi nebismieri vaqcinacia unda tardebodes sifrTxiliT klinikuri da prevenciuli medicinis eqspertebis SefasebiT. terminebi – vaqcinacia da imunizacia xSirad moiazreba sinonimebad. vaqcinacia es aris procesi, rodesac adamianis organizmSi Segvyavs imunobiologiuri produqti (vaqcina an anatoqsini) da gulisxmobs aqtiur imunizacias. imunizacia ufro farTo mcnebaa da gulisxmobs imunitetis xelovnur induqcias, romelic SeiZleba iyos pasiuri an aqtiuri. aiv infeqcia/SidsiT daavadebulTa vaqcinaciis ZiriTadi principebia.

• daxocili an inaqtivirebuli vaqcina ar warmoadgens safrTxes imunokompromitirebulTaTvis da ZiriTadad gamoiyeneba iseve, rogorc janmrTel populaciaSi.

• rac Seexeba cocxali virusis an baqteriis Semcvel vaqcinebs, rogoric aris BCG, oraluri poliovirusis, tifis(Ty21a), Cutyvavilas da yviTeli cxelebis vaqcinebi, maTi gamoyeneba aiv inficirebul pirebSi SesaZloa dakavSirebuli iyos garkveul riskTan da, amitom, unda tardebodes dadebiTi da uaryofiTi mxareebis zedmiwevniT SefasebiT, aiv infeqciis stadiisa da imunuri sistemis supresiis xarisxis gaTvaliswinebiT.

4.1. vaqcinebisa da imunoglobulinebis gamoyeneba aiv infeqcia/SidsiT daavadebulTa imunizaciisas gaTvaliswinebuli unda iyos aRniSnuli vaqcinebis imunogenurobis ZiriTadi aspeqtebi.

• miuxedavad imisa, rom aiv inficirebul axalSobilebSi ujreduli da humoruli imunitetis daqveiTeba iwyeba dabadebisTanave, maT umravlesobaSi imunuri pasuxis unari sicocxlis pirveli 2 wlis ganmavlobaSi SenarCunebulia. rekomendebuli vaqcinebis1 imunogenu-robis Seswavlam gamoavlina serokonversiis damakmayofilebeli xarisxi aiv infeqciis adreul stadiaze. aRsaniSnavia, rom TiToeuli

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vaqcina xasiaTdeba serokonversiis gansazRvruli doniT. vaqcinaciaze mopasuxeTa wili aiv infeqciis Sidsis stadiaSi progresirebasTan erTad mcirdeba.

• aiv inficirebul simptomur bavSvebsa da mozrdilebSi vaqcinaciaze aRiniSneba suboptimaluri imunologiuri pasuxi. imunuri pasuxi cocxal da daxocil antigenebze mcirdeba, ramdenadac aiv infeqcia progresirebs. Tumca, maRali doziT vaqcinaciis SemTxvevaSi imunuri pasuxi da antisxeulebis persistencia aiv inficirebul pirebSi sistemurad Seswavlili ar aris. aRniSnul kontigentSi, SesaZlebelia gamoyenebul iqnas vaqcinaciis gazrdili doza, an xSiri bustireba. Tumca am etapze myari rekomendaciebi ar arsebobs.

konkretuli vaqcinisa da imunoglobulinis usafrTxoebisa2 da efeqfturobis Sefaseba moicavs aRniSnuli daavadebis epidemiologiisa da recipientis imunosupresiis xarisxis gansazRvras. es ukanaskneli unda Sefasdes eqimis mier jandacvis msoflio organizaciis klinikuri stadiebis sistemis3 da/an asakobrivi jgufisTvis damaxasiaTebeli CD4+ ujredebis ricxvisa da procentis mixedviT. 1 BCG vaqcina; difTeriis, tetanusisa da yivanaxvelas vaqcina (DTP); OPV; MMR vaqcina; B hepatitis vaqcina; HiB vaqcina. 2aiv infeqcia/SidsiT daavadebulTa vaqcinirebis usafrTxoebis Sesaxeb informacia

mcirea (Va); vaqcinaciasTan dakavSirebuli nebismieri gverdiTi reaqciis Sesaxeb informacia unda miewodoT Sesabamis samsaxurebs; gasaTvaliswinebelia, rom zogierTi gverdiTi movlena SesaZlebelia gamovlindes xangrZlivi latenturi periodis Semdeg

(DIV). 3klinikuri stadiis Sefasebisas SeiZleba ixelmZRvaneloT antiretrovirusuli mkurnalobis protokolebiT mozrdilebisa da bavSvebisaTvis.

4.2. cocxali atenuirebuli vaqcinebi 4.2.1 BCG vaqcina BCG vaqcina icavs 2 wlamde asakis bavSvebs diseminirebuli da mZime formis tuberkulozisgan, maT Soris tuberkulozuri meningitisa da miliaruli tuberkulozisgan (AI). filtvis tuberkulozis sixSiris Semcirebis TvalsazrisiT zrdasrul populaciaSi BCG vaqcinacia araefeqturia an xasiaTdeba mcire efeqtiT (AI). ar aris cnobili mcirdeba Tu ara vaqcinis efeqturoba aiv inficirebul bavSvebSi. arsebobs garkveuli monacemebi, rom BCG vaqcinaciis Semdgom tuberkulinis dadebiTi testi naklebad xSiria aiv inficirebul bavSvebSi. Tumca aRniSnuli mtkicebulebis sarwmunoeba naTeli ar aris (Vb). aRwerilia lokaluri garTulebebisa da diseminirebuli BCG infeqciis SemTxvevebi aiv inficirebuli bavSvebis vaqcinaciidan ramdenime wlis Semdegac. Tumca prospeqtuli kvlevebiT aiv inficirebul da janmrTel axalSobilebSi BCG imunizaciis Semdgomi garTulebebis riskis mxriv gansxvaveba ar gamovlinda (CIII). BCG infeqciis tubrekulozuri infeqciisagan gansasxvaveblad saWiroa gverdiTi reaqciebis mWidro monitoringi aiv infeqciis maRali prevalentobis areebSi. Semdgomi kvlevebiT dadebiTi da uaryofiTi mxareebis zust Sefasebamde BCG vaqcinacia unda Catardes mxolod asimptomur aiv

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inficirebul bavSvebSi (ramdenadac arsebobs disiminirebuli daavadebis albaToba). romelTac aqvT tuberkulozuri infeqciis ganviTarebis maRali riski, rac Tavis mxriv damokidebulia tuberkulozis lokalur gavrcelebaze.4 maRali riskis SemTxvevaSi sasurvelia BCG imunizacia (CIII). rekomendaciebi • tuberkulozis dabali gavrcelebis arealSi5 aiv inficirebul

bavSvebSi, miuxedavad klinikuri stadiisa da imunodeficitis xarisxisa, ar unda Catardes BCG vaqcinacia. infeqciis maRali gavrcelebis arealSi BCG vaqcinacia unda Catardes mxolod aiv dadebiT asimptomur bavSvebSi. bavSvebi aiv infeqcia/Sidsis simptomebiT ar unda iyvnen BCG vaqcinirebuli (BII).

• BCG vaqcina rekomendirebuli ar aris mozardebsa da mozrdilebSi, maT Soris aiv inficirebul pirebSi. ramdenadac is araefeqturia an umniSvnelod amcirebs mozrdilTa filtvis tuberkulozis SemTxvevebs.

• prevenciuli antituberkulozuri mkurnaloba mkacrad rekomendirebulia im aiv infeqcia/SidsiT daavadebulebisaTvis, romlebic savaraudod inficirebulebi arian tuberkulozis mikobaqteriiT an imyofebian tuberkulozis ganviTarebis riskis qveS (AI).

4aRsaniSnavia, rom im qveynebSic ki, sadac tuberkulozis gavrceleba dabalia, zogierTi subpopulacia SeiZleba gamoirCeodes daavadebis maRali prevalentobiT. 5 janmos evropis regionis qveynebi, sadac SemTxvevaTa raodenoba 100 000 mosaxleze 20-ze naklebia. 5 janmos evropis regionis qveynebi, sadac SemTxvevaTa raodenoba 100 000 mosaxleze 20-ze naklebia.

4.2.2. qoleris vaqcina (CVD 103-HgR) miuxedavad imisa, rom cocxali atenuirebuli oraluri vaqcina farTod gamoiyeneboda aiv infeqciis endemur kerebSi da seriozuli gverdiTi reaqciebi ar dafiqsirebula, usafrTxoebis Sesaxeb sakmarisi monacemebis ar arsebobis gamo is ukunaCvenebia aiv inficirebul pirebSi (CIII). daxocili WC/rBs vaqcina rekomendebulia aiv inficirebulTaTvis (BII). 4..2.3. wiTelas, ybayurasa da wiTuras vaqcinebi (MMR, MR, M, R vaqcinebi6) aiv inficirebul asimptomur bavSvebs, aseve bavSvebs zomieri imunosupresiiT arainficirebuli bavSvebis msgavsad rutinulad unda CautardeT MMR da wiTelas Semcveli sxva vaqcinaciebi (AI). mniSvnelovania gvaxsovdes, rom wiTelas vaqcinis imunogenuroba mcirdeba, Tu vaqcinacia Catardeba adamianis normaluri imunoglobulinis gamoyenebidan 6 Tveze nakleb periodSi. miuxedavad imisa, rom aiv inficirebul asimptomur da simptomur pirebSi MMR-sa da wiTelas Semcveli sxva vaqcinebis gamoyenebisas Catarebuli kvlevebiT mniSvnelovani gverdiTi reaqciebi ar dafiqsirebula, es vaqcinebi rekomendebuli araa mniSvnelovani imunosupresiis mqone aiv inficirebulTaTvis. rekomendaciis ar arsebobis mizezebia:

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• wiTelas vaqcinaciis Semdgomi pnevmoniis SemTxveva mZime imunosupresiis mqone recipientSi;

• monacemebi wiTelas vaqcinaciaze gansxvavebuli imunuri pasuxis Sesaxeb mZime imunosupresiis mqone pirebSi;

• monacemebi wiTelas vaqcinaciis Semdgomi virusuli infeqciiT gamowveuli letalobis Sesaxeb sul mcire 6 imunokompromitirebul pirSi.

rekomendaciebi • MMR da wiTelas Semcveli sxva vaqcinebi saSualo an mkveTri

imunosupresiis mqone bavSvebsa da mozrdilebSi ar gamoiyeneba (13 wlamde CD4+ <15%, 13 wlis asakis zeviT CD4+ <14%7);

• MMR da wiTelas Semcveli sxva vaqcinebi unda gamoviyenoT asimptomer an zomierad imunosupresirebul aiv inficirebulebSi;

• axalSobilebSi, romlebic gamoirCevian wiTelas virusTan eqspoziciis maRali riskiT rekomendebulia wiTelas antigenis damatebiTi doziT vaqcinacia 6-11 Tvis asakSi, ris Semdegac rutinulad Catardeba MMR an wiTelas Semcveli sxva vaqcinacia 12 Tvis asakSi an mogvianebiT (vaqcinaciebs Soris intervali sul mcire 1 Tvea);

• aiv inficirebul simptomur pacientebs, romelTac aReniSnaT eqspozocia wiTelas virusTan, unda mieceT adamianis imunoglobulini miuxedavad vaqcinaciis imunostatusisa (AI);

• imunokompromitirebulebTan mWidro kontaqtSi myof pirebs aseve unda CautardeT vaqcinacia (AI).

6MMR:wiTela, wiTura, ybayura; MR:wiTela da wiTura; M:wiTela; R:wiTura. 7bavSvebs zomieri an Zlieri imunosupresiiT aReniSnebaT CD4+ ujredebis Semdegi maCveneblebi:

• <750 ujredi/mm3, rodesac asaki<12w.

• <500 ujredi/mm3, rodesac asaki 1-5w.

• <200 ujredi/mm3, rodesac asaki 6w. an metia

4.2.4. poliovirusis oraluri vaqcina (pov) miuxedavad imisa, rom SesaZlebelia aiv inficirebuli asimptomuri bavSvebis vaqcinacia poliovirusis oraluri vaqciniT, rogorc simptomuri, aseve asimptomuri aiv inficirebuli bavSvebisaTvis rekomendebulia inaqtivirebuli poliovirusis vaqcina (ipv) (BII). aiv inficirebulebs ar unda CautardeT vaqcinacia pov-iT, radgan aRniSnul pirebSi vaqcinis virusis replikacia SesaZlebelia ver daiTrgunos efeqturad. Tandayolili imunodeficitis mqone bavSvebSi pov-is gamoyeneba iwvevs progresirebad nevrologiur darRvevebs (paralizur daavadebas) (AI). Tu pov gamoyenebul iqna aiv inficirebulis ojaxis wevrTan an aiv inficirebulTan mWidro kontaqtSi myof sxva pirTan8, mas da aiv inficirebuls unda aekrZaloT mWidro kontaqti vaqcinaciidan erTi Tvis ganmavlobaSi, rac vaqcinis virusis maqsimaluri eqskreciis periodia.

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8 igulisxmeba piri, romelsac aReniSneba poliomielitis vaqcinis virusis gadacemis riski aiv inficirebul pirze fekaluri an oraluri gziT.

rekomendacia • pov ar unda iqnas gamoyenebuli aiv inficirebul/SidsiT daavadebu-

lebSi, rogorc bavSvebSi, aseve zrdasrulebSi, imunodeficitis statusis miuxedavad; aseve maTi ojaxis wevrebsa da maTTan mWidro kontaqtSi myof sxva pirebSi (AI).

4.2.5. rotavirusis vaqcina rekomendacia • Semdgomi samecniero mtkicebulebebiT aiv inficirebul bavSvebSi

vaqcinis usafrTxoebisa da imunogenurobis profilis dadasturebamde aRniSnul kategoriaSi rotavirusis vaqcina ar unda iqnas gamoye-nebuli damoukideblad imunodeficitis statusisa (CIII).

4.2.6. muclis tifis (Ty21a) vaqcina miuxedavad imisa, rom asimptomur aiv inficirebul pirebs 200/mm3-ze maRali CD4+ limfocitebis absoluturi ricxviT SesaZlebelia CautardeT vaqcinacia muclis tifis cocxali atenuirebuli vaqciniT (Ty21a jaWvis gamoyenebiT), parenteraluri inaqtivirebuli vaqcina Teoriulad ufro usafrTxo alternativaa (DIV).

rekomendacia • Ty21a vaqcina ar unda iqnas gamoyenebuli aiv inficirebul/SidsiT

daavadebulebSi, rogorc bavSvebSi, aseve zrdasrulebSi, imunodeficitis statusis miuxedavad.

4.2.7. Cutyvavilas vaqcina miuxedavad imisa, rom mcire zomis axalma kvlevam ar gamoavlina mniSvnelovani gverdiTi reaqciebi 10 aiv inficirebul bavSvSi, aiv infeqcia/SidsiT gamowveuli zomieri an mZime imunodeficitis mqone pirebs Cutyvavilas vaqciniT vaqcinacia ar unda CautardeT. Tumca asimptomur da msubuqad gamoxatuli simptomatikis mqone aiv inficirebul bavSvebs, romelTa CD4 ujredebis ricxvi 25% an metia pirveli vaqcinacia unda CautardeT 12-15 Tvis asakSi, xolo ganmeorebiTi 4-8 kviris Semdeg. virusuli infeqciis SesaZlo diseminaciis gamo Cutyvavilas vaqcina ar unda iqnas gamoyenebuli im aiv inficirebul bavSvebSi, romelTa CD4 ujredebis ricxvi 25%-ze naklebia. aiv inficirebuli bavSvebi da mozrdilebi, romlebic gamoirCevian maRali mimReblobiT Cutyvavila-zosteris virusis mimarT _ pirebi,

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romlebsac ar gadautaniaT Cutyvavila (pirveladi infeqcia), aReniSnebaT zosteri (rekurentuli infeqcia) an arian seronegatiurni _ sasurvelia moeridon eqspozicias CutyvaviliT an zosteriT daavadebul pirebTan. aiv inficirebul/SidsiT daavadebulebTan mWidro kontaqtSi myof pirebs (gansakuTrebiT bavSvebs), romlebsac ar gadautaniaT Cutyvavila da arian aiv seronegatiurebi, unda CautardeT Cutyvavilas vaqcinacia, raTa ar moxdes virusis transmisia am pirebidan im aiv inficirebulebze, romlebic Cutyvavila-zosteris virusis mimarT maRali mimReblobiT gamoirCevian.

rekomendaciebi

• Cutyvavilas vaqcina ar unda iqnas gamoyenebuli aiv inficirebul mozrdilebSi imunodeficitis statusis miuxedavad, aseve aiv inficirebul bavSvebSi zomieri an mZime imunosupresiiT.

• Cutyvavilas vaqcina unda gamoviyenoT mxolod asimptomur da msubuqad gamoxatuli simptomatikis mqone aiv inficirebul bavSvebSi (CD4>=25%) (BII).

• aiv inficirebul/SidsiT daavadebulebTan mWidro kontaqtSi myof pirebs, romlebic gamoirCevian virusis mimarT maRali mimReblobiT, unda CautardeT vaqcinacia Cutyvavila-zosteris virusis SesaZlo transmisiis prevenciis mizniT.

4.2.8. yviTeli cxelebis vaqcina yviTeli cxelebis vaqcinis virusi Teoriulad warmoadgens encefalitis ganviTarebis risk-faqtors aiv inficirebul pirebSi, ris gamoc is aRniSnul kategoriaSi ar gamoiyeneba. yviTeli cxeleba endemuri daavadebaa ekvatoruli afrikis 33 da samxreT amerikis 11 qveyanaSi. aRniSnul teriatoriaze mogzaurobisas mkurnalma eqimma pacients unda miawodos informacia arsebuli riskisa da moskitebisagan Tavdacvis meTodebis Sesaxeb. zogierTi klinika pirovnebis CD4+ ujredebis ricxvis gaTvaliswinebiT iRebs vaqcinaciis gadawyvetilebas. Tu aiv inficirebuli piri ver aridebs Tavs yviTeli cxelebis virusTan potenciur eqspozicias mas unda SevTavazoT vaqcinacia. saWiroa vaqcinaciasTan dakavSirebuli SesaZlo gverdiTi reaqciebis monitoringi. ramdenadac aiv negatiur pirebTan SedarebiT aiv pozitiur adamianebSi vaqcinacia SesaZloa iyos naklebad efeqturi, sasurvelia maneitralizebeli antisxeulebis titris gansazRvra endemur keraSi mogzaurobamde. yviTeli cxelebis sawinaaRmdego vaqcinacia unda CautardeT imunosupresirebuli pirebis ojaxis wevrebsac, Tu maT ar aReniSnebaT winaaRmdegCvenebebi.

rekomendacia • yviTeli cxelebis vaqcina ar unda iqnas gamoyenebuli aiv

inficirebulebSi, rogorc bavSvebSi, aseve zrdasrulebSi, imunodeficitis statusis miuxedavad, garda im SemTxvevebisa, rodesac mosalodneli dadebiTi Sedegi aWarbebs arsebul risks (DIV).

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4.3. daxocili da inaqtivirebuli vaqcinebi daxocili da inaqtivirebuli vaqcinebi ar warmoadgens safrTxes imunokompromitirebuli pirebisaTvis da, ZiriTadad, gamoiyeneba iseve, rogorc janmrTel populaciaSi. xSirad imunokompromitirebul pacientebSi daxocili da inaqtivirebuli vaqcinis antigenis Sesabamisi imunuri pasuxi imunokompetentur pirebTan SedarebiT naklebad srulyofilia; SesaZloa saWiro gaxdes vaqcinaciis maRali doza an xSiri bustireba, Tumca aRniSnuli modifikaciebis SemTxvevaSic SesaZloa imunuri pasuxi optimalurze susti iyos (DIV).

4.3.1. qoleris vaqcina (WC/rBs) Zveli parenteraluri vaqcina (fenoliT inaqtivirebuli daxocili srulujredovani qoleris vibrioni 01) dabali efeqturobisa da xanmokle dacviTi periodis gamo rekomendebuli ar aris, Tumca zogierT qveyanaSi mainc iwarmoeba. daxocili srulujredovani qoleris vibrionisa da qoleris toqsinis rekombinantuli B fraqciis kombinaciis Semcveli vaqcina (WC/rBs) usafrTxoa orsulobisa da ZuZuTi kvebis periodSic, aseve aiv pozitiur pirebSic. oraluri vaqcinis 2 doza 10-14 dRis SualediT ainducirebs sawyis proteqcias vaqcinirebulTa 86%-Si. saSualod vaqcinacia efeqturia 50-60%-Si sul mcire 3 wlis ganmavlobaSi. aiv pozitiur pirebSi kombinirebuli vaqcinis (WC/rBs) efeqturobis damadasturebeli specifikuri monacemebi dRemde cnobili ar iyo, Tumca im populaciis magaliTze, romlis 25%-s aiv pozitiuri pirebi warmoadgendnen, mozambikSi Catarebulma uaxlesma kvlevam gamoavlina damaimedebeli Sedegebi. imunitetis xangrZlivoba aiv inficirebulebSi cnobili ar aris. aiv inficirebul mozrdilebSi 100mm3-ze naklebi CD4+ ujredebis ricxviT imunizaciis Semdgomi pasuxi SesaZloa iyos susti, xolo im pirebSi, romelTa CD4+ ujredebis ricxvi 100mm3-ze metia imunuri pasuxi umjobesdeba ori dozis Semdeg. aRniSnuli monacemebi gviCvenebs vaqcinaciis efeqturobas adreuli an Sualeduri aiv daavadebisas (DIV). vaqcinacia seleqtiurad unda CautardeT im aiv inficirebulebs, romelTac uwevT mogzauroba endemur kerebSi an miekuTvnebian erT-erT risk-jgufs (isini vinc xangrZlivi periodiT mogzauroben, iReben Seumowmebel wyals an arasaTanadod momzadebul sakvebs an cxovroben arasanitarul pirobebSi daavadebis endemur keraSi) (DIV).

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4.2..2 difTeriis, tetanusisa da yivanaxvelas vaqcinebi (DTP, DTaP, DT, TT, Td9) aiv inficirebul bavSvebSi imunuri statusis miuxedavad DTP da DT vaqcinebi rekomendebulia janmrTeli populaciisaTvis gankuTvnili reJimiT, maT Soris yivanaxvelas araujreduli formis (DTaP) gamoyenebis SemTxvevaSic rogorc bustirebis, aseve pirveli dozirebisaTvis (AI). TT da Td vaqcinebi imunuri statusis miuxedavad SesaZloa gamoyenebul iqnas aiv inficirebul mozrdilebSi janmrTeli populaciisaTvis gankuTvnili reJimiTa da dozirebiT(BII). gansakuTrebuli mniSvneloba unda mieniWos narkotikebis ineqciuri gziT momxmarebelTa vaqcinacias TT da Td vaqcinebiT, raTa nemsebis gacvlis programebis ararsebobis SemTxvevaSi SevZloT tetanusis prevencia.

4.2.3. B tipis hemofilus influencas vaqcina (HiB) 5 wlis asakis zeviT bavSvebs daavadebisadmi asakobrivad ganpirobebuli mgrZnobelobis gaTvaliswinebiT HiB vaqcinacia ar esaWiroebaT. zogierT adamianSi gamomwvevi iwvevs invaziur infeqcias. mikroorganizmis sisxlis nakadSi moxvedris zusti gza ucnobia, Tumca ganmsazRvreli faqtori SeiZleba iyos zemo sasunTqi gzebis winmswrebi virusuli an mikoplazmuri infeqcia. sisxlis nakadis gziT baqteria gadainacvlebs sxeulis sxvadasxva nawilebisaken, ZiriTadad ki tvinis garsebisaken. aiv inficirebuli bavSvebi da mozrdilebi imunosupresiis gamowarmoadgenen HiB daavadebis ganviTarebis maRal risk-jgufs da SesaZloa CautardeT vaqcinacia. 5 wlis asakis zeviT aiv inficirebulebma, romlebic imyofebian HiB daavadebis ganviTarebis riskis qveS, unda miiRon vaqcinis sul mcire erTi doza. imunokompromitirebuli bavSvebis vaqcinacia unda Catardes janmrTeli populaciisaTvis gankuTvnili dozirebiTa da reJimiT. TiToeuli pacientis magaliTze individualurad unda Sefasdes daavadebis ganviTarebis riski da vaqcinaciis mosalodneli efeqturoba, ris mixedviTac gadawydeba imunizaciis sakiTxi. zogierTi monacemis mixedviT aiv negatiur pirebTan SedarebiT aiv inficirebulebSi HiB daavadebis ganviTarebis riski ufro maRalia. 9 DTP: difTeriisa da tetanusis anatoqsini da yivanaxvelas vaqcina; DTaP: difTeriisa da tetanusis anatoqsini da yivanaxvelas araujreduli vaqcina; DT:difTeriisa da tetanusis anatoqsini (pediatriuli gamoyenebisaTvis); TT: tetanusis anatoqsini; Td: tetanusisa da difTeriis anatoqsini (mozrdilebisaTvis).

4.2.4. A hepatitis vaqcina A hepatitis virusiT gamowveuli simptomuri daavadebis ganviTarebis riski pirdapir korelaciaSia asakTan. 6 wlamde asakis bavSvebSi A hepatitis virusiT infeqcia Cveulebriv asimptomuria, simptomuri daavadeba ki ZiriTadad gvxvdeba mozrdilebSi. daavadebis gadatanis Semdeg imuniteti mTeli sicocxlis manZilze narCundeba. dabal-endemur

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kerebSi A hepatiti erTeuli an mcire jgufuri SemTxvevebis saxiT gvxvdeba. maRal-endemur kerebSi daavadeba ZiriTadad gvxvdeba asimptomuri formiT bavSvTa asakSi. dabali an saSualo donis endemur areebSi mozrdilTa daavadeba SedarebiT xSiria da A hepatiti SesaZloa warmoadgendes samedicino da ekonomikur tvirTs. A hepatitis vaqcinacia (erTjeradi doza 6-12 Tvis Semdgomi bustirebiT) mkacrad rekomendebulia aRniSnuli daavadebis an misi garTulebebis ganviTarebis riskis mqone pirebSi miuxedavad imunuri da aiv statusisa (AI). risk-jgufs miekuTvnebian:

• pirebi RviZlis qronikuli daavadebiT;10

• homoseqsuali mamakacebi (MSM); • narkotikebis momxmareblebi;11

• Sededebis faqtorTan dakavSirebuli darRvevebis mqone pirebi;

• daavadebis profesiuli riskis mqone pirebi (mag: laboratoriis muSakebi);

• 1 wlis an ufrosi asakis pirebi araendemuri qveynebidan, romlebic gegmaven mogzaurobas A hepatitis virusiT gamowveuli infeqciis maRali an saSualo endemurobis keraSi12.

A hepatitis vaqcina gamoirCeva maRali imunogenurobiT. mozrdilTa 95%-ze mets pirveli vaqcinaciidan 4 kviraSi ganuviTardeba proteqtoruli antisxeulebi. rac Seexeba bavSvebsa da mozardebs, pirveli vaqcinaciidan 1 TveSi seropozitiuri aRmoCndeba 97%-ze meti. klinikur kvlevebSi vaqcinaciis ori dozis yvela recipients ganesazRvra antisxeulebis proteqtoruli done. aRniSnulis gamo, vaqcinaciis Semdgomi testireba naCvenebi ar aris. A hepatitis virusis sawinaaRmdego antisxeulebis dabali koncentraciis ganmsazRvreli testirebis meTodebi rutinuli diagnostikisaTvis vaqcinaciis Semdgom periodSi rekomendebuli ar aris (AI). monacemebi antisxeulebis persistenciisa da imunuri mexsierebis xangrZlivobis Sesaxeb mcirea, ramdenadac dReisaTvis xelmisawvdom vaqcinebze dakvirveba warmoebs 12 welze naklebi periodis ganmavlobaSi. busteruli dozis damatebis saWiroebas gansazRvravs Semdgomi kvlevebi.

10 RviZlis qronikuli daavadebis mqone pirebi inficirebis SemTxvevaSi arian fulminanturi A hepatitis ganviTarebis gazrdili riskis qveS. aiv inficirebul pirebs Tanmxlebi qronikuli hepatitiT B an C, unda CautardeT vaqcinacia A hepatitis vaqciniT. 11 A hepatitis virusi daavadebis sawyis stadiaze aRmoCndeba avadmyofis sisxlSi da iSviaTad transmisia SesaZloa moxdes transfuziis gziT; virusi advilad vrceldeba antisanitariisa da personaluri higienis dabali donis pirobebSi, rac xSirad aRiniSneba narkotikebis momxmarebelTa Soris. 12 vaqcinacia unda Catardes gamgzavrebamde 2-4 kviriT adre. maRali an saSualo endemurobis keras miekuTvneba msoflios yvela qveyana garda kanadis, aSS-s, dasavleT evropisa, skandinaviis, iaponiis, axali zelandiis da avstraliisa.

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4.2.5. B hepatitis vaqcina B hepatitis vaqcina rekomendebulia B virusiT gamowveuli infeqciis maRali riskis mozrdilebisTvis miuxedavad imunuri da aiv statusisa (AI). maRali riskis jgufebia:

• homoseqsuali mamakacebi (MSM);

• mravlobiTi heteroseqsualuri sqesobrivi kontaqtebis mqone pirebi;

• sqesobrivi gziT gadamdebi infeqciebiT pacientebi;

• komerciuli seqs-muSakebi;

• B hepatitis virusis mtarebelTa sqesobrivi partniorebi da ojaxis wevrebi;

• narkotikebis ineqciuri gziT momxmareblebi; • patimrebi, rogorc mamakacebi, aseve qalebi; • hemodializze myofi pirebi (miuxedavad imisa, rom B hepatitis vaqcina

aRniSnul kategoriaSi naklebad efeqturia, is mainc rekomendebulia);

• jandacvis muSakebi.13 B hepatitis vaqcina rekomendebulia yvela axalSobilisTvis dabadebisTanave da 18 wlamde asakis bavSvebSi, miuxedavad imunuri da aiv statusisa (AI). miuxedavad imisa iTvaliswinebs Tu ara vaqcinaciis reJimi erT Tvemde asakis bavSvTa vaqcinacias, maTi efeqturoba erTnairia. aiv inficirebul bavSvebSi vaqcinaciis Semdgomi proteqciis xangrZlivoba cnobili ar aris, rac Seexeba arainficirebul bavSvebs, dadgenilia, rom vaqcinaciiT ganpirobebuli antisxeulebis done droTa ganmavlobaSi mcirdeba, Tumca bavSvebSic da mozrdilebSic imunuri mexsiereba srulyofilad narCundeba vaqcinaciidan 15 wlis manZilze. normaluri imunuri sistemis mqone bavSvebsa da mozrdilebs ar esaWiroebaT damatebiTi dozebi bustirebisaTvis, arc rutinuli serologiuri testirebaa naCvenebi. gamonaklisia bavSvebi, romelTa dedebic HBsAg pozitiurebi arian. isini gamokvleul unda iqnen HBsAg-sa da mis sawinaaRmdego antisxeulebze vaqcinaciis mesame dozis Semdeg. Tu zedapiruli antisxeulebis titri 10mIU/ml-ze naklebia, naCvenebia vaqcinaciis sruli kursis gameoreba. aRniSnul kategoriaSi pasiurad gadmocemuli dediseuli core antisxeulebi SeiZleba ganisazRvros 24 Tveze maRal asakSic, ris gamoc aRniSnuli testireba ukunaCvenebia. SesaZlebelia xangrZlivi periodis Semdeg saWiro gaxdes damatebiTi dozebis gamoyeneba bustirebisaTvis (BII).14 4.2.5.1. B hepatitis vaqcinaciis reJimi aiv inficirebul pacientebSi (AI) aiv inficirebuli pacientebs, romelTac ar aReniSnebaT HBV infeqciis markerebi an arian HBsAg negatiurebi,unda CautardeT vaqcinacia. • B hepatitis vaqcinacia unda daiwyos gansazRvruli doziT (20µg 0, 1, 2 da

12 Tveze an 0, 1 da 6 Tveze) im pacientebisaTvis, romelTa CD4+ limfocitebis ricxvi >500/mm3.

• B hepatitis vaqcinis pediatriuli dozaa 10µg. • pacientebisaTvis 200-500/mm3 CD4+ ujredebis ricxviT rekomendebulia

intensiuri reJimi (20µg 0, 1, 2 da 12 Tveze).

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13 riski maRalia staJirebis periodSi; vaqcinacia unda Catardes staJirebaze myofi medicinis, stomatologiis, saeqTno saqmis, laboratoriuli teqnologiebisa da jandacvis sxva profesiebis dargSi. 14 hemodializze myof pacientebSi yovelwliurad unda ganisazRvros antisxeulebis titri, ris mixedviTac Sefasdeba vaqcinaciis damatebiTi dozis saWiroeba bustirebisaTvis; damatebiTi doza saWiroa, Tu antisxeulebis titri < 10 mIU/ml.

• armopasuxe pacientebSi rekomendebulia damatebiTi dozebi bustirebisaTvis an vaqcinaciis axali kursi 40µg doziT.

• pacientebs 200/mm3-ze naklebi CD4+ limfocitebis ricxviT jer unda daewyoT arv mkurnaloba; vaqcinacia unda gadavdoT klinikurad SesamCnevi imunuri rekonstituciis miRwevamde, sasurvelia CD4 ujredebis 200/mm3-ze metad momatebamde (BII).

4.2.5.2. imunologiuri pasuxi B hepatitis vaqcinaciis mimarT • pasuxi vaqcinaze damokidebulia vaqcinaciis periodSi CD4+ ujredebis

ricxvze; pasuxi SeiZleba daqveiTdes pacientebSi CD4+ ujredebis 500mm3-ze naklebi ricxviT.

• B hepatitis vaqcinaciis sruli kursis Catarebisas imunologiuri pasuxis albaToba aiv inficirebul pacientebSi 500/mm3-ze maRali CD4+ ujredebis ricxviT 87%-ia, xolo 200-500mm3 CD4+ ujredebis ricxviT _ mxolod 33%.

• C hepatitisa da adamianis imunodeficitis virusebiT koinfeqciam SesaZloa gamoiwvios B hepatitis vaqcinaciis Semdgomi imunologiuri pasuxis daqveiTeba, aseve B virusis zedapiruli antigenis sawinaaRmdego antisxeulebis titris Semcireba aiv monoinfeqciiT pacientebTan SedarebiT.

4.2.5.3. aiv inficirebul pacientTa B hepatitis vaqcinaciis Semdgomi monitoringi da strategia • B virusis zedapiruli antigenis sawinaaRmdego antisxeulebis titri

unda ganisazRvros vaqcinaciis damTavrebidan 4 kviraSi. proteqtoruli antisxeulebis ganuviTareblobis SemTxvevaSi (HBsas<10mIU/ml) unda Catardes damatebiTi vaqcinacia bustirebisaTvis an revaqcinacia (1-3 damatebiTi doza). Tumca maRali dozebiT vaqcinaciis imunogenuroba cnobili ar aris da dozirebis Sesaxeb myari rekomendaciebis gacema am etapze SeuZlebelia.

• vaqcinaciaze armopasuxe pirebi rCebian B hepatitis virusiT inficirebis riskis qveS da maT yovelwliurad unda CautardeT gamokvleva aRniSnuli infeqciis serologiur markerebze (HBsAg da HBcTotal).

• pirebi, romelTac vaqcinaciis 6 dozis Semdeg ar ganuviTardaT anti-HBs antisxeulebis deteqtabeluri titri, gamokvleul unda iqnen HBsAg -ze.

• HBsAg pozitiur pirebs unda CautardeT konsultacia.

• vaqcinaciaze armopasuxe HBsAg negatiur pirebi ganixileba B hepatitis virusiT infeqciis mimarT mgrZnobiare jgufad da isini konsultirebuli unda iqnen prevenciuli RonisZiebebisa da

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parenteraluri Tu sqesobrivi eqspoziciis SemTxvevaSi B hepatitis sawinaaRmdego imunoglobuliniT (HBIg) profilaqtikis Sesaxeb.

4.3. gripis vaqcina15 gripi SeiZleba gaxdes seriozuli avadmyofobisa da garTulebebis 15 mas Semdeg, rac gripis cocxali vaqcina aiv infeqcia/SidsiT daavadebulebSi ukunaCvenebia, aRniSnul kategoriaSi gamoiyeneba gripis inaqtivirebuli vaqcina

mizezi imunokompromitirebul pirebSi. aseTi pirebis did nawilSi vaqcinacia uzrunvelyofs proteqtoruli antisxeulebis gamomuSavebas. miuxedavad imisa, rom aiv infeqcia/SidsiT daavadebulebSi informacia gripiT avadobis sixSirisa da simZimis Sesaxeb dReisaTvis mwiria, gripis sezonis dawyebis win rekomendebulia yvela aiv inficirebulis vaqcinacia. vaqcinaciis sapasuxo antisxeulebis titri aiv infeqciis Sorswasul stadiaze SeiZleba iyos dabali, Tumca imunuri pasuxis gasaZliereblad damatebiTi dozis efeqturoba dadgenili ar aris (CIII).

4.4. meningokokuri vaqcina gansazRvruli serotipebis16 Semcveli meningokokuri vaqciniT rutinuli imunizacia rekomendebulia meningokokuri daavadebis epidemiis arealSi wamsvlelTaTvis aiv statusis miuxedavad, aseve risk-jgufebisaTvis, magaliTad pirebisaTvis anatomiuri an funqciuri aspleniiT (AI).

4.5. pnevmokokuri vaqcina pnevmokokuri vaqcina rekomendebulia iseTi qronikuli daavadebis mqone pirebSi, romlebic asocirebulia pnevmokokuri daavadebis an misi garTulebebis gazrdil riskTan (BII). aseTi qronikuli daavadebebia imunosupresiasTan asocirebuli mdgomareobebi, maT Soris aiv infeqcia. arsebobs pnevmokokuri vaqcinis ori tipi: polisaqariduli pnevmokokuri vaqcina (ppv) da SekavSirebuli pnevmokokuri vaqcina (Spv). 4.5..1. polisaqariduli pnevmokokuri vaqcina (ppv) ppv-s erTi doza gamoyenebul unda iqnas rutinulad 65 wlis asakis zeviT pirebSi imunuri da aiv statusis miuxedavad (AI); 2 wlis asakis zeviT17 qronikuli daavadebis mqone (kardiovaskularuli daavadeba, filtvis paTologia, diabeti, alkoholizmi, cirozi, cerebrospinaluri siTxis siWarbe) imunokompetentur pirebSi; 2 wlis asakis zeviT imunokomprometirebul (maT Soris aiv infeqcia/SidsiT daavadebulebi)18 pirebSi, romlebic imyofebian pnevmokokuri daavadebis ganviTarebis riskis qveS. pacientebs simptomuri an asimptomuri aiv infeqciiT vaqcinacia unda CautardeT diagnozis dadasturebisTanave. Tu aiv inficirebuli an zogadad imunosupresirebuli (magaliTad, kortikosteroidebis xangrZivi kursis recipientebi) piris vaqcinaciis statusi ucnobia, aseT SemTxvevaSi vaqcinacia tardeba (BII). janmrTel mozrdilTa 80%-ze mets ppv-s miRebidan 2-3 kviraSi ganuviTardeba antisxeulebi vaqcinis serotipebis mimarT. antisxeulebis maRali titri janmrTel mozrdilebSi narCundeba sul mcire 5 wlis

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ganmavlobaSi, xolo SedarebiT ufro swrafad qveiTdeba fonuri daavadebebis mqone, maT Soris aiv inficirebul pirebSi.

16 meningokokuri vaqcina unda moicavdes Sesabamis geografiul arealSi daavadebis epidemiis gamomwvev serotipebs. meningokokuri serojgufebi A, B da C aRmoCenila mTel msoflioSi; serojgufi Y aRmoCenilia aSS-is zogierT nawilSi; serojgufi A dafiqsirebulia “meningitis sartyelSi” senegalidan eTiopiamde; serojgufi W125 nanaxia saudis arabeTSi. 17 2 wlamde asakis bavSvebSi ppv-s umetesi serotipebis sapasuxo antisxeulebis titri dabalia. 18 aiv infeqcia/SidsiT daavadebulebTa garda pirebi anatomiuri an funqciuri aspleniiT (romelime daavadebis arsebobisas an qirurgiuli gziT mocilebisas), hojkinis daavadebiT, limfomiT, mravlobiTi mielomiT, Tirkmlis qronikuli ukmarisobiT, an imunosupresiasTan asocirebuli sxva mdgomareobiT (mag.: organos transplantaciisas).

65 wlamde asakis imunokompetenturi pirebis rutinuli revaqcinacia rekomendebuli araa. 65 wlis pirebsa da ufro xandazmulebs ganmeorebiTi doza unda mieceT im SemTxvevaSi Tu pirveli dozis gamoyenebidan gasulia 5 weliwadze meti da im periodisTvis maTi asaki iyo 65 welze naklebi. aiv infeqcia/SidsiT daavadebulebsa da sxva imunokompromitirebul pirebs, romlebic miekuTvnebian maRali riskis jgufs ganmeorebiTi vaqcinacia unda CautardeT 5 wlis Semdeg. revaqcinacia aseve rekomendebulia 2 wlisa da Semdgomi asakis bavSvebSi, romlebic imyofebian infeqciis ganviTarebis maRali riskis qveS; aseve im pirebSi, romlebSic fonuri daavadebis gamo mosalodnelia pnevmokokuri antisxeulebis titris swrafi Semcireba. revaqcinacia unda Catardes pirveli dozis gamoyenebidan 3-5 wlis Semdeg. 4.5.2. SekavSirebuli pnevmokokuri vaqcina (Spv) Spv imunogenuria Cvilebsa da bavSvebSi, maT Soris aiv inficirebulebSi imunuri statusis miuxedavad. Spv-s oTxi dozis Semdeg yvela janmrTel axalSobils uviTardeba vaqcinis TiToeuli serotipis sawinaaRmdego antisxeulebi (AI).19 • vaqcinacia rutinulad tardeba 2, 4 da 6 Tvis asakSi, damatebiTi doza

bustirebisaTvis rekomendebulia 12-15 Tvis asakSi.

• aravaqcinirebul 7-11 Tvis asakis bavSvebs, maT Soris aiv inficirebulebs, Spv-s pirveli ori doza unda mieceT 6-8 kviris intervaliT, damatebiTi doza bustirebisaTvis rekomendebulia 12-15 Tvis asakSi.

• aravaqcinirebul 12-23 Tvis asakis bavSvebs unda mieceT Spv-s ori doza 6-8 kviris intervaliT.

• aravaqcinirebul 24-59 Tvis asakis janmrTel bavSvebs unda mieceT Spv-s erTjeradi doza.

• 24-59 Tvis asakis bavSvebs aiv infeqciiT, namglisebrujredovani anemiiT, aspleniiT, qronikuli daavadebebiTa da imunomakompromitirebuli mdgomareobebiT unda mieceT Spv-s ori doza 6-8 kviris intervaliT.

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efeqtis bustirebisTvis rekomendebulia Spv-s damatebiTi doza meore vaqcinaciidan 6-8 kviris Semdeg.

• rutinuli Spv vaqcinacia 5 wlis asakis zeviT bavSvebSi rekomendebuli araa aiv statusis miuxedavad.

Spv-s pirveladi kursis Semdeg revaqcinacia dReisaTvis rekomendebuli araa. Tumca 2 wlisa da Semdgomi asakis bavSvebSi, Spv-s pirveladi kursis bolo vaqcinaciidan 6-8 kviris Semdeg rekomendebulia damatebiTi doza efeqtis bustirebisTvis.

19 dReisaTvis aiv infeqcia/SidsiT daavadebulebSi Spv-s gamoyenebis Sesaxeb monacemebi mcirea, Catarebulia kvlevebi mxolod samxreT afrikaSi, aseve mcire gamokvlevebi aSS-Si.

4.6. inaqtivirebuli poliovirusis vaqcina (ipv) Tu polioimunizacia naCvenebia, ipv gamoyenebul unda iqnas aiv inficirebul Cvilebsa da bavSvebSi imunuri statusis miuxedavad, aseve momvlel personalsa da ojaxis im wevrebSi, romlebic mWidro kontaqtSi arian aiv inficirebul/SidsiT daavadebulebTan, raTa moxdes vaccine an vaccine-derived poliovirusis transmisiis prevencia am ukanasknelebSi (AI). aravaqcinirebuli aiv inficirebuli mozrdilebisaTvis, romelTac aReniSnebaT poliovirusTan eqspoziciis maRali riski, rekomendebulia ipv-s pirveladi kursi.

4.7.cofis vaqcina gamoiyeneba cofis sawinaaRmdego ori tipis vaqcina: nervuli qsovilis vaqcina (Semple-type) da axali ujredidan miRebuli vaqcina (modern cell-derived vaccine). cofis sawinaaRmdego vaqcinebi gamoiyeneba eqspoziciis Semdgomi proteqciisa da eqspoziciamde imunogenurobisaTvis. cofis sawinaaRmdego vaqcinebi ar aris ukunaCvenebi aiv inficirebulTaTvis da saWiroebisas unda gamoviyenoT (AI). imunokompromitirebul aiv inficirebulebSi SesaZloa ar ganviTardes efeqturi imunologiuri pasuxi, ramdenadac imuniteti damokidebulia CD4+ ujredebiT ganpirobebuli maneitralizebeli antisxeulebis titrze G proteinis mimarT. amrigad, rodesac imunokompromitirebul aiv inficirebuls utardeba eqspoziciis Semdgomi mkurnaloba, savaldebuloa intramuskularuli vaqcinisa da cofis sawinaaRmdego imunoglobulinis gamoyeneba sapasuxo antisxeulebis serologiuri monitoringiT. proteqciisaTvis saWiroa cofis sawinaaRmdego antisxeulebis titri >0.5IU/ml. Tu cofis sawinaaRmdego vaqcinis 4-5 dozis gamoyenebis Semdeg maneitralizebeli antisxeulebis titri<0.5IU/ml-ze, 4 kviris Semdeg rekomendebulia damatebiTi dozebis gamoyeneba (AI).

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4.8. tkipismieri encefalitis vaqcina tkipismieri encefalitis virusiT gamowveuli infeqcia gvxvdeba evropis did nawilSi (avstria, germania, samxreT da centaluri SvedeTi, ungreTi, safrangeTi, Sveicaria, norvegia, dania, poloneTi, xorvatia, albaneTi, estoneTi, latvia, litva, CexeTi, slovakeTi, ruseTi). daavadeba cnobilia ramdenime saxeliT, rogoricaa rusuli gazafxul-zafxulis encefaliti (RSSE), Soreuli aRmosavleTis encefaliti da centaluri evropis encefaliti (CEE). aRniSnul qveynebSi mogzaurobisas inficirebis riski dabalia. inficireba ZiriTadad dakavSirebulia iseT aqtivobebTan, rogoricaa soflis meurneoba da metyeveoba, seirnoba da nadiroba endemuri regionebis Tbil da tyian arealSi. inficirebis maRali riski aqvT metyeveebs, xis mWrelebs, fermerebs, meomrebs, laboratoriis muSakebsa da turistebs, romelTac uwevT nadiroba, aseve savele pirobebSi muSaoba da cxovreba. preeqspoziciuri profilaqtika SesaZlebelia inaqtivirebuli vaqciniT. vaqcinaciis standartuli reJimi moicavs or dozas 4-12 kviris intervaliT da mesame dozas 9-12 Tvis Semdeg. imunokompetentur pirebSi serokonversiis sixSire 3 dozis Semdeg 85-100%-ia. riskis qveS myofi pirebisaTvis rekomendebulia bustireba yovel 3 weliwadSi. swrafi reJimebi20 janmrTel pirebSi xasiaTdeba imave efeqturobiT da praqtikulia mogzaurebisTvis (AI). swrafi reJimis vaqcinaciis efeqturoba aiv inficirebulebSi ucnobia. aiv inficirebulebSi vaqcinaciis imunogenurobis Sesaswavlad Catarebulia mxolod ori kvleva. aRniSnuli kvlevebi gviCvenebs, rom vaqcina janmrTel pirebTan SedarebiT aiv inficirebulebSi, ZiriTadad ki im pirebSi, romelTa CD4+ ujredebis ricxvi 500/mm3-ze mcirea, naklebad efeqturia. Tumca 4 dozis Semcvelma vaqcinaciam 0, 1, 2 da 9-12 Tveze SeiZleba gaaumjobesos imunuri pasuxi aiv inficirebulebSi. amave dros unda aRiniSnos, rom zemoTaRwerili strategiis Sesaxeb informacia mcirea (CIII). imunizacia unda CautardeT aiv inficirebulebs, romlebic gegmaven endemuri regionis qveynebis tyian arealSi mogzaurobasa an muSaobas gvian gazafxulze an zafxulSi, rodesac tkipebi gansakuTrebiT aqtiuria. vaqcina aseve rekomendebulia im emigrantebisaTvis, romelTac cxovreba uwevT tkipismieri encefalitis endemur arealSi. aiv inficirebulebSi, romelTa CD4+ ujredebis ricxvi 400/mm3-ze metia vaqcinacia SeiZleba CautardeT standartuli an swrafi reJimiT. aiv inficirebulebs, romelTa CD4+ ujredebis ricxvi 400/mm3-ze naklebia vaqcinaciis meore dozidan erT TveSi sasurvelia CautardeT serologiuri testireba. araadeqvaturi imunuri pasuxis SemTxvevaSi pirs unda mieces vaqcinis ori damatebiTi doza, pirveli-dauyovnebeli, xolo meore- 9-12 Tvis Semdeg. Tu serologiuri testireba araxelmisawvdomia vaqcinacias vatarebT 4 dozis Semcveli reJimiT (0, 1, 2 da 9-12 Tveze).

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imunokompromitirebul aiv inficirebulebSi vaqvinaciis Semdgomi imunuri pasuxis daqveiTebis albaTobis gamo aucilebelia dacviTi RonisZiebebis mniSvnelobis xazgasma. busteruli rekomendaciebi aiv inficirebuli da imunokompetenturi pirebisaTvis erTnairia.

4.9. tifis vaqcina (Vi polisaqaridi) dabali efeqturobisa da gverdiTi reaqciebis sixSiris gamo Zveli inaqtivirebuli vaqcina rekomendebuli ar aris, Tumca ekonomikur mizezTa gamo zogierT qveyanaSi is mainc iwarmoeba. parenteruli daxocili vaqcina, romelic Seicavs Vi polisaqarids kanqveS an kunTSi erTjeradi dozirebisas zomierad efeqturia (50-80%). vaqcina ineqciidan 7 dReSi uzrunvelyofs proteqcias, romelic narCundeba sul mcire ori weli. riskis qveS myofi pirebisTvis rekomendebulia bustireba yovel sam weliwadSi. aiv inficirebul pirebs salmonelas StamiT inficirebis maRali riski aqvT. garda amisa imunodeficiti ganapirobebs baqteriemias antibiotikebis mimarT rezistentobas, daavadebis relafss da persistul infeqcias. miuxedavad imisa, rom zogadad saerTaSoriso mogzaurobisas

20 FSME: pirveladi kursis saxiT gamoiyeneba 2 doza 14 dRis intervaliT, xolo mesame doza 9-12 Tvis Semdeg; Encepur: sami doza 0, 7 da 21 dReze pirveladi kursis saxiT, meoTxe doza 12-18 Tvis Semdeg.

saWiro ar aris, Vi polisaqaridis Semcveli vaqcina rekomendebulia yvela aiv inficirebulisaTvis, romelic gegmavs mogzaurobas eqspoziciis maRali riskis arealSi. mosalodnel eqspoziciamde sul mcire ori kviriT adre unda Catardes erTjeradi vaqcinacia. tifis vaqcina ar uzrunvelyofs proteqcias 100%-Si da pasuxi SiZleba kidev ufro Semcirdes aiv infeqcia/SidsiT daavadebulebSi. zogadad bustireba rekomendebulia yovel sam weliwadSi. maTTvis ki, romelTa CD4+ ujredebis ricxvi 200/mm3-ze naklebia. es intervali SeiZleba Semcirdes or wlamde. mogzaurebs unda mieceT rekomendaciebi sakvebTan da sasmelTan dakavSirebuli akrZalvebis Sesaxeb.

4.10. sxva daxocili antigenebi daxocili antigenebis Semcveli sxva vaqcinebi, rogoricaa iaponuri encefalitis, Savi Wirisa da jilexis vaqcinebi ar warmoadgens safrTxes aiv /SidsiT daavadebulTTavis, miuxedavad maTi imunologiuri statusisa. es vaqcinebi gamoiyeneba iseve, rogorc ara aiv inficirebul pirebSi.

4.1.1. imunoglobulinebis gamoyeneba 4.11.1. B hepatitis imunoglobulini (HBIg) imunokompromitirebul pirebSi, maT Soris aiv infeqcia/SidsiT daavadebulebSi, B hepatitis imunoglobulini gamoiyeneba igive

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CvenebebiTa da doziT, rogorc imunokompetentur adamianebSi (AI). B hepatitis imunoglobuliniT eqspoziciis Semdgomma profilaqtikam SeiZleba ganapirobos droebiTi imunitetis ganviTareba. B hepatitis imunoglobulini gamoiyeneba pasiuri imunizaciisTvis:

• HBsAg pozitiuri dedebis axalSobilebSi; • pirebSi, romelTac aReniSnaT HBsAg pozitiur sisxlTan an sxeulis

sxva siTxesTan kanismieri, lorwovanismieri an sqesobrivi eqspozicia; • pacientebSi RviZlis transplantaciiT. rogorc wesi B hepatitis imunoglobulini gamoiyeneba B hepatitis vaqcinasTan kombinaciaSi. nebismieri piri, romelsac esaWiroeba B hepatitis imunoglobulini miekuTvneba maRali riskis jgufs, rac imas niSnavs, rom mas unda Cautardes B hepatitis vaqcinis kursi. B hepatitis imunoglobulini naCvenebia:

• axalSobilebSi, romelTaA dedebic HBsAg pozitiurni an ucnobi HBsAg statusis arian; B hepatitis imunoglobulini21, aseve, SeiZleba gamoviyenoT B hepatitis vaqciniT imunoprofilaqtikisas dabadebisTanave an dabadebidan mcire periodSi.

• HBsAg pozitiur dedaTa axalSobilebSi, sasurvelia pirveli 12 saaTis ganmavlobaSi; amasTanave, B hepatitis imunoglobulinisa da vaqcinis ineqciis wertilebi ar unda emTxveodes erTmaneTs.

• B hepatitis vaqcinaze armopasuxe HBsAg negatiur pirebSi; aRniSnuli kategoria konsultirebul unda iqnas HBV infeqciis prevenciisa da B hepatitis imunoglobulinis saWiroebis Sesaxeb HBsAg pozitiur sisxlTan parenteraluri eqspoziciisas.

21 perinetaluri gziT SeZenili infeqciisgan B hepatitis dauyovnebeli vaqcinaciiT (24 sT-is ganmavlobaSi) uzrunvelyofili dacva B hepatitis imunoglobulinis damatebiTi gamoyenebisas mniSvnelovnad ar umjobesdeba.

• savaraudo sqesobrivi kontaqti mwvave B hepatitiT daavadebul pacientTan ukanaskneli sqesobrivi kontaqtidan 14 dRis ganmavlobaSi22.

• aravaqcinirebul axalSobilebSi, romelTa dedebs an momvlel pirebs aqvT mwvave HBV infeqcia, aseT SemTxvevaSi axalSobils unda mieces B hepatitis vaqcinaciis kursis pirveli dozac23.

• pirebSi, romelTac aqvT mWidro kontaqti mwvave HBV infeqciiT pacientTan, an aReniSnaT eqspozicia inficirebuli adamianis sisxlTan (mag. makratlis, saparsis an sxva gziT), aseT SemTxvevaSi unda mieces B hepatitis vaqcinaciis kursis pirveli dozac24.

4.11.2. adamianis normaluri imunoglobulini 4.11.2.1. hepatiti A A hepatitis prevenciisTvis25 adamianis normaluri imunoglobulinis gamoyenebis Cvenebebi da wesebi msgavsia imunokompetenturi da imunokompromitirebuli pirebisTvis. adamianis normaluri imunoglobu-linis da A hepatitis vaqcinis erTdrouli gamoyeneba proteqtoruli antisxeulebis formaciaze mniSvnelovan zegavlenas ar axdens.

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A hepatitis prevenciis mizniT adamianis normaluri imunoglobulinis gamoyeneba naCvenebia Semdeg jgufebSi:

• pirebi, romlebic A hepatitis vaqcinaciidan 4 kviraze nakleb periodSi gegmaven mogzaurobas maRali riskis arealSi (vaqcinisa da imunoglobulinis ineqciis wertilebi unda iyos daSorebuli)

• 1 wlamde asakis bavSvebi. ramdenadac maT A hepatitis vaqcinacia ar utardebaT, maRali riskis arealSi mogzaurobisas mogzaurobis xangrZlivobis gaTvaliswinebiT unda gamoviyenoT 0.02-0.06ml/kg imunoglobulini.

• A hepatitis virusTan eqspozirebuli aravaqcinirebuli pirebi. imunoglobulini unda gamoviyenoT eqspoziciidan 2 kviris ganmavlobaSi.

• A hepatitiT daavadebulTan mWidro kontaqtSi myofi pirebi.

• bavSvebi da momuSave personali bavSvTa centrebSi A hepatitis diagnostirebisas.

• transmisiis maRali riskis mqone pirebi (mag.,kvebiT dawesebulebebSi inficirebul sakvebTan kontaqtisas).

Tu A hepatitis vaqcinaciidan gasulia 1 Tve an meti adamianis normaluri imunoglobulini ar gamoiyeneba. 22Tu ukanaskneli sqesobrivi kontaqtidan gasulia 14 dReze meti, miuxedavad imisa, rom eqspoziciis Semdgomi profilaqtikis efeqturobis xarisxi cnobili ar aris, unda Catardes B hepatitis vaqcinacia, xolo B hepatitis sawinaaRmdego imunoglobulini rekomendebuli ar aris. 23 B hepatitis sawinaaRmdego imunoglobulini rekomendebuli ar aris CvilebisTvis, romelTac miiRes an unda miiRon vaqcinis meore doza. 24B hepatitis vaqcinacia rutinulad unda Catardes aseve sisxlismieri eqspoziciis gareSe mWidro arasqesobrivi kontaqtisas, gansakuTrebiT bavSvebsa da mozardebSi. 25HAV infeqciis prevenciisTvis rekomendebulia adamianis normaluri imunoglobulini eqspoziciamde an eqspoziciidan 2 kviris manZilze. adamianis normaluri imunoglobulinis mogvianebiTi gamoyeneba xSirad mxolod amcirebs HAV infeqciis klinikur gamovlinebebs.

4.11.2.2. wiTela imunokompromitirebul pirebSi, maT Soris aiv inficirebulebSi, adamianis normaluri imunoglobulini naCvenebia wiTelas virusTan eqspoziciis SemTxvevaSi prevenciis mizniT. wiTelas vaqcinaciis ukuCvenebis SemTxvevaSi, imunokompromitirebul pirebSi, maT Soris 1 wlamde asakis bavSvebSi, naCvenebia adamianis normaluri imunoglobulinis 0.5ml/kg (maqsimaluri doza - 15ml) intramuskularuli gamoyeneba eqspoziciisTanave. wiTelas virusTan eqspozirebul simptomur aiv inficirebulebSi adamianis normaluri imunoglobulini unda gamoviyenoT vaqcinaciis statusis miuxedavad, ramdenadac am SemTxvevaSi vaqcinacia SeiZleba iyos araefeqturi da ganviTardes daavadeba. imunokompromitirebul pirebSi wiTelas profilaqtikis mizniT adamianis normaluri imunoglobulinis gamoyenebisas, 6 Tvis ganmavlobaSi vaqcinacia ar tardeba.

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4.11.2.3. cofis sawinaaRmdego imunoglobulini imunokompromitirebul pacientebSi, maT Soris aiv inficirebulebSi, cofis sawinaaRmdego imunoglobulini, gamoiyeneba igive CvenebebiTa da dozirebiT, rogorc imunokompetentur pirebSi (AI). cofis sawinaaRmdego imunoglobulini naCvenebia III kategoriis kontaqtisas (transdermaluri nakbeni an nakawri, lorwovani membranis kontaminacia nerwyviT) vaqcinaciis kursis pirvel dozasTan erTad. cofis sawinaaRmdego imunoglobulini ar aris naCvenebi vaqcinirebuli pirebisaTvis maneitralizebeli antisxeulebis titriT 0.5se/ml an meti. Tu aiv inficirebul imunokompromitirebul pirs utardeba eqspoziciis Semdgomi mkurnaloba, cofis sawinaaRmdego imunoglobulini auculebelia vaqcinaciis kursis pirvel dozasTan erTad. amasTan, sasurvelia antisxeulebis serologiuri monitoringi. 4.11.2.4. tetanusis sawinaaRmdego imunoglobulini imunokompromitirebul pacientebSi, maT Soris aiv inficirebulebSi, tetanusis sawinaaRmdego imunoglobulini, gamoiyeneba igive CvenebebiTa da dozirebiT, rogorc imunokompetentur pirebSi. tetanusis imunoglobulini rekomendebulia tetanusiT avadmyofebSi, aseve araadeqvaturi imunizaciisas pirebSi WrilobebiT an tetanusis ganviTarebis riskTan asocirebuli sxva mdgomareobebiT. tetanusis imunoglobulini axdens tetanusis mocirkulire toqsinis neitrali-zacias. is ar moqmedebs nervul sistemaSi moxvedril toqsinze. tetanusis mkurnalobisaTvis bavSvebsa da mozrdilebSi rekomendebulia erTjeradi intramuskularuli doza 3000-5000 erTeuli. tetanusis sawinaaRmdego imunoglobulinis gamoyenebis Cvenebebia:

• mniSvenelovani zomis dabinZurebuli Wriloba, imunizaciis gaurkveveli statusis an mxolod 2 dozis gamoyenebisas. aseT SemTxvevaSi damatebiT sasurvelia anatoqsinis gamoyeneba.26

26 anatoqsinis sawyisi dozebi ar axdens imunitetis inducirebas. tetanusis sawinaaRndego imunoglobulini uzrunvelyofs antitoqsinis proteqtorul dones imunuri pasuxis ganviTarebamde.

• mniSvenelovani zomis dabinZurebuli Wriloba tetanusis anatoqsinis gamoyenebis winaaRmdegCvenebiT.

• tetanusis simptomebis arseboba.

intravenuri imunoglobulini Seicavs tetanusis antitoqsins da SesaZloa gamoyenebul iqnas, Tu tetanusis sawinaaRmdego imunoglobulini xelmisawvdomi ar aris. 4.11.2.5. Cutyvavila-zosteris sawinaaRmdego imunoglobulini

Cutyvavila-zosteris sawinaaRmdego imunoglobulini ZiriTadad gamoiyeneba axalSobilTa da mniSvnelovnad imunikompromitirebul pirTa, maT Soris aiv inficirebulTa pasiuri imunizaciisaTvis

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CutyvavilasTan an zosterTan eqspoziciis SemTxvevaSi (BII). CutyvavilasTan eqspozirebul imunikompromitirebul pirebSi Cutyvavila-zosteris sawinaaRmdego imunoglobulinis gamoyenebam SesaZloa Seamciros inficirebisa da garTulebebis riski. aiv inficirebul bavSvebSi Cutyvavilas profilaqtikisaTvis (bavSvebi, romelTac ar gadautaniaT Cutyvavila an zosteri an ar aReniSnebaT Cutyvavila-zosteris sawinaaRmdego antisxeulebis deteqtabeluri done) sasurvelia Cutyvavila-zosteris sawinaaRmdego imunoglobulinis gamoyeneba eqspoziciidan 96 saaTis ganmavlobaSi. Cutyvavila-zosteris sawinaaRmdego imunoglobulini aseve rekomendebulia aiv inficirebul orsulTaTvis Cutyvavila-zosteris virusTan eqspoziciidan 96 saaTis ganmavlobaSi. Tu gamoiyeneba acikloviri, sasurvelia Cutyvavila-zosteris sawinaaRmdego antisxeulebis kontroli. seropozitiur SemTxvevaSi medikamenti SesaZlebelia Sewydes.

danarTi 1. rekomendaciebi aiv infeqcia/SidsiT imunokompro-mitirebulTa imunizaciis Sesaxeb rekomendaciebi aiv infeqcia/SidsiT imunokompromiti-

rebulTa imunizaciis Sesaxeb vaqcina Cvilebi da bavSvebi zrdasrulebi ararutinuli

imunizacia

jilexi _ _ gamoiyeneT Cvenebisas

BCG ukunaCvenebia/gansaxilvelia _ ukunaCvenebia

qolera(CVD103HgR) _ _ ukunaCvenebia

qolera (WC/rBs) _ _ gamoiyeneT Cvenebisas

DTP/DTaP/DT rekomendebulia _ _

hepatiti A _ _ gamoiyeneT Cvenebisas

hepatiti B rekomendebulia gamoiyeneT Cvenebisas

_

HiBB rekomendebulia gansaxilvelia _

gripi _ _ gamoiyeneT Cvenebisas ipv rekomendebulia _ gamoiyeneT Cvenebisas iaponuri enc. _ _ gamoiyeneT Cvenebisas meningokoki _ _ gamoiyeneT Cvenebisas MMR/MR/M/R rekomendebulia/gansaxilvelia gansaxilvelia _ opv ukunaCvenebia _ ukunaCvenebia Savi Wiri _ _ gamoiyeneT Cvenebisas pnevmokoki _ _ gamoiyeneT Cvenebisas cofi _ _ gamoiyeneT Cvenebisas rotavirusi _ _ ukunaCvenebia tkipismieri enc. _ _ gamoiyeneT Cvenebisas TT/Td rekomendebulia rekomendebulia _

tifi(Ty21a) _ _ ukunaCvenebia

tifi, inaqt. _ _ gamoiyeneT Cvenebisas Cutyvavila _ _ ukunaCvenebia/gansaxilvelia

yviTeli cxeleba _ _ ukunaCvenebia

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rekomendebulia: vaqcina rekomendebulia rutinuli reJimis mixedviT an naCvenebia aiv imunosupresirebulTaTvis. gamoiyeneT Cvenebisas: imunosupresia ukuCvenebis mizezi ar aris; SeiZleba arsebobdes ukuCvenebis sxva mizezi ukunaCvenebia: aiv imunosupresia absoluturi an SedarebiTi ukuCvenebaa vaqcinis gamoyenebisTvis gansaxilvelia: gadawyvetileba vaqcinaciis Sesaxeb damokidebulia konkretul pacientTan daavadebis risksa da vaqcinis efeqturobaze,

danarTi 2. aiv asocirebuli imunodeficitis klasifikacia bavSvebSi aiv asocirebuli imunodeficitis klasifikacia

CD4 ujredebis maCvenebeli asakis mixedviT klasifikacia

<11 Tve (%)

12-35 Tve (%)

36-59 Tve (%)

5w. da meti (ujredi/mm3)

umniSvnelo >35 >30 >25 >500 saSualo 30-35 25-30 20-25 350-499 Sors wasuli 25-30 20-25 15-20 200-349 mZime <25 <20 <15 <200

an <15% aRniSnuli exeba mozardebsa da mozrdilebsac wyaro: jandacvis msoflio organizacia, 2006w.

danarTi 3. cofis vaqcina eqspoziciamdeli vaqcinacia SesaZlebelia Catardes nebismier ujredul vaqcinasTan kombinaciaSi da rekomendebulia cofis virusTan eqspoziciis riskis mqone yvela pirisTvis. ZiriTadad es rekomendaciebi exeba:

• laboratoriis muSakebs

• veterinarebs

• cxovelTa mwvrTnelebs

• potenciurad inficirebul cxovelebTan xSiri eqspoziciis mqone pirebs

• maRalendemuri arealis27 vizitorebs, romelTac SesaZloa aReniSnoT eqspozicia cofis virusis maspinZelTan.28

eqspoziciamdeli reJimi iTvaliswinebs vaqcinis 1 ml an 0.5ml-is gamoyenebas 0, 7 da 28 dReze.29 aRniSnuli vaqcinebiT eqspoziciis Semdgomi vaqcinaciis (cofis sawinaaRmdego imunoglobulinis gamoyenebiT an mis gareSe) saWiroeba damokidebulia cofiT daavadebul cxovelTan kontaqtis tipze. vaqcinis tipis gaTvaliswinebiT eqspoziciis Semdgomi profilaqtikisTvis gamoiyeneba 1ml an 0.5 ml 4-5 doza 4 kviris ganmavlobaSi. cofis virusTan eqspozirebul pacientebSi, romelTac Catarebuli aqvT eqspoziciamdeli vaqcinaciis sruli kursi an eqspoziciis Semdgomi mkurnaloba cofis ujreduli vaqciniT, sakmarisia cofis ujreduli vaqcinis ori intramuskularuli doza 3 dRis

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intervaliT. aseT SemTxvevaSi cofis sawinaaRmdego imunoglobulinis gamoyeneba saWiro ar aris. igive wesebi vrceldeba vaqcinirebul pirebze, romelTa maneitralizebeli antisxeulebis titri 0.5 se/ml-Si an metia.

adamianis diploidur-ujreduli vaqcina miCneulia oqros standartad. jandacvis msoflio organizaciis mixedviT aucilebelia ujreduli vaqcinis minimum 2.5se-s gamoyeneba TiToeuli dozirebisas. miuxedavad maRali efeqturobisa ujreduli vaqciniT eqspoziciis Semdgom Catarebuli milioni mkurnalobidan erTi SeiZleba aRmoCndes uSedego. analizi gviCvenebs, rom uSedego mkurnaloba, rogorc wesi, dakavSirebulia mniSvnelovan dazianebasTan Tavis an mezobel midamoSi, an arasworad Catarebul mkurnalobasTan. eqspoziciis Semdgomi mkurnalobis sruli kursi nervuli qsovilis vaqcinis gamoyenebiT gulisxmobs 23 ineqciisgan Semdgari imunizaciis gaxangrZlivebul da mtkivneul kurss. amasTan nervuli qsovilis vaqcinebi ujredul vaqcinebTan SedarebiT neklebad efeqturia. amrigad, aRniSnuli vaqcina eqspoziciis Semdgomi imunizaciisaTvis rekomendebuli ar aris.

27 2.5 mlrd adamianze meti cxovrobs cofis endemur arealSi(afrika, azia, samxreT amerika).yovelwliurad saSualod 50 000 adamiani iRupeba cofiT da 10 mln-ze met adamians utardeba eqspoziciis Semdgomi profilaqtika. 5-15 wlis asakis bavsvebi imyofebian maRali riskis qveS. 28 calkeul asakobriv jgufebSi Catarebuli kvlevebis mixedviT daavadebis maRali riski aqvT ganviTarebadi qveynebis cofis endemur areebSi mcxovreb bavSvebs. 29 ZiriTadad rekomendebulia 1 wlis Semdeg damatebiti doza bustirebisTvis; vaqcinacia yovel 5 weliwadSi maRali riskis pirebisTvis; cofis virusis sawinaaRmdego antisxeulebis perioduli gamokvleva (proteqciisaTvis aucilebeli titria >0.5se/ml)

gamoyenebuli litraturis CamonaTvali: 1. Onorato IM, Markowitz LE, Oxtoby MJ. Childhood immunization, vaccine-preventable diseases and infection with human immunodeficiency virus. The Pediatric Infectious Disease Journal, 1988, 6:588– 595. 2. Opravil M et al. Poor antibody response after tetanus and pneumococcal vaccination in immunocompromised, HIV-infected patients. Clinical and Experimental Immunology, 1991, 84(2):185–189. 3. Borkowsky W et al. Antibody responses to bacterial toxoids in children infected with human immunodeficiency virus. The Journal of Pediatrics, 1987, 110:563–566. 4. Huang KL et al. Antibody responses after influenza and pneumococcal immunization in HIV-infected homosexual men. JAMA, 1987, 257:2047–2050. 5. Klein RS et al. Responses to pneumococcal vaccine among asymptomatic heterosexual partners of persons with AIDS and intravenous drug users infected with human immunodeficiency virus. Journal of Infectious Diseases, 1989, 160:826–831. 6. TB/HIV: a clinical manual, 2nd ed. Geneva, WHO, 2004. 7. Global Advisory Committee on Vaccine Safety. Safety of BCG vaccination in immunocompromised individuals. Weekly Epidemiological Record, 2003, 32(8):283 (http://www.who.int/wer/2003/en/wer7832. pdf, accessed 25 June 2006).

132

8. United States Centers for Disease Control. Disseminated Mycobacterium bovis infection from BCG vaccination of a patient with acquired immunodeficiency syndrome. MMWR, 1985, 34:227–228. 9. Ninane J et al. Disseminated BCG in HIV infection. Archives of Disease in Childhood, 1988, 63:1268– 1269. 10. Broekmans JF et al. European framework for turberculosis control and elimination in countries with low incidence. The European Respiratory Journal, 2002, 19(4):765–775. 11. British HIV Association immunization guidelines for HIV-infected adults. London, British HIV Association, First edition April 2006. (http://www.bhiva.org, accessed 16 November 2006). 12. Centers for Disease Control. Measles pneumonitis following measles-mumps-rubella vaccination of a patient with HIV infection, 1993. MMWR, 1996, 45(28):603–606. 13. Palumbo P et al. Population-based study of measles and measles immunization in human immunodeficiency virus-infected children. The Pediatric Infectious Disease Journal, 1992, 11(12):1008–1014. 14. Atkinson W, Hamborsky J, Wolfe S, eds. Epidemiology and prevention of vaccine-preventable diseases, 8th ed. Washington, DC, Public Health Foundation, 2005. 15. Centers for Disease Control. 1993 revised classification system for HIV infection and expanded surveillance case definition for AIDS among adolescents and adults. MMWR: Recommendations and Reports, 1992, 41(RR-17):1–19. 16. Centers for Disease Control. 1994 revised classification system for human immonodeficiency virus infection in children less than 13 years of age. MMWR: Recommendations and Reports, 1994, 43(RR- 12):1–10. 17. Atkinson WL et al. General recommendations on immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP) and the American Academy of Family Physicians (AAFP). MMWR: Recommendations and Reports, 2002, 51(RR-2):1–35. 18. EPI vaccines in HIV-infected individuals: the safety of EPI-recommended vaccines in HIV-infected individuals. Geneva, WHO, 2001 (http://www.who.int/vaccines-diseases/diseases/HIV. shtml, accessed 6 December 2004). 19. Sixbey JW. Routine immunization and the immunosuppressed child. Advances in Pediatric Infectious Diseases, 1987, 2:79–114. 20. Wright PF et al. Vaccine-associated poliomyelitis in a child with sex-linked agammaglobulinemia. The Journal of Pediatrics, 1977, 91:408–412. 21. Wyatt HV. Poliomyelitis in hypogammaglobulinemics. Journal of Infectious Diseases, 1973, 128(6):802– 806. 22. Davis LE et al. Chronic progressive poliomyelitis secondary to vaccination of an immunodeficient child. The New England Journal of Medicine, 1977, 297(5):241–245. 23. Core information for the development of immunization policy: 2002 update: Expanded Programme on Immunization of the Department of Vaccines and Biologicals. Geneva, WHO, 2003 (http://www.who. int/vaccines-documents/DocsPDF02/www557.pdf, accessed on 29 June 2006). 12-22 HIV/AIDS TREATMENT AND CARE CLINICAL PROTOCOLS FOR THE WHO EUROPEAN REGION 24. Armenian SH et al. Safety and immunogenicity of live varicella virus vaccine in children with human immunodeficiency virus type 1. The Pediatric Infectious Disease Journal, 2006, 25(4):368–370. 25. Centers for Disease Control. Recommendations of the Advisory Committee on Immunization Practices (ACIP): use of vaccines and immuno globulins in persons with altered immunocompetence. MMWR: Recommended Reports, 1993, 42(RR-4):1–18. 26. WHO. WHO position paper. Weekly Epidemiological Record. 20 April 2001. No. 16, 2001, 76, 117-124. (http://www.who.int/topics/cholera/vacccines/en/index.html, accessed 21 September 2006). 27. Lewis DJ et al. Immune response following oral administration of cholera toxin B subunit to HIV-1-infected UK and Kenyan subjects. AIDS 1994;8:779-785. 28. Sanchez JL et al. Protective efficacy of oral whole-cell/recombinant-B-subunit cholera vaccine in Peruvian military recruits. Lancet 1994;344:1273-1276. 29. Farly MM et al. Invasive Haemophilus influenzae disease in adults: a prospective, population-based surveillance. Annals of Internal Medicine, 1992, 116:806–812. 30. Steinhart R et al. Invasive Haemophilus influezae infections in men with HIV infection. JAMA, 1992, 268(23):3350–3352. 31. Frequently asked questions about hepatitis A. Atlanta, Centers for Disease Control and Prevention, 2006 (http://www.cdc.gov/ncidod/diseases/hepatitis/a/faqa.htm, accessed on 22 June 2006). 32. Vaccine-preventable diseases, vaccines and vaccination. In: Nuttall I, ed. International travel and health: situation as on 1 January 2005. Geneva, WHO, 2005:103–104 (http://whqlibdoc.who.int/publications/ 2005/9241580364_chap6.pdf accessed on 29 June 2006). 33. Van Damme P et al. Hepatitis A booster vaccination: is there a need? The Lancet, 2003, 362(9389):1065–

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1071. 34. Tedaldi E et al. Hepatitis A and B vaccination practices for ambulatory patients infected with HIV. Clinical Infectious Diseases, 2004; 38:1478–1484. 35. Welch K, Morse A. Improving screening and vaccination for hepatitis B in patients coinfected with HIV and hepatitis C. American Journal of Gastroenterology, 2002, 97:2928–2929. 36. Hodges GR et al. Response to influenza A vaccine among high-risk patients. Southern Medical Journal, 1979, 72(1):29–32. 37. Safrin S, Rush JD, Mill J. Influenza in patients with human immunodeficiency virus infection. Chest, 1990, 98:33–37. 38. Gross PA et al. Influenza immunization in immunosuppressed children. Journal of Pediatrics, 1978, 92(1):30–35. 39. Advisory Committee on Immunization Practices (ACIP). Vaccine side-effects, adverse reactions, contraindications and precautions. Atlanta, Centers for Disease Control, 1996. 40. Landesman SH, Schiffman G. Assessment of the antibody response to pneumococcal vaccine in highrisk populations. Reviews of Infectious Diseases, 1981, 3(Suppl.):S184–S197. 41. Centers for Disease Control. Prevention of pneumococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR: Recommended Reports, 1997, 46(RR-08):1–24 (http://www.cdc.gov/mmwr/PDF/rr/rr4608.pdf accessed 14 November 2006). 42. Requirements for tick-borne encephalitis vaccine (inactivated) 2. In: WHO Expert Committee on Biological Standardization. WHO Expert Committee on Biological Standardization: forty-eighth report. Geneva, WHO, 1999:4463 (WHO Technical Report Series 889; http://www.who.int/biologicals/publications/ trs/areas/vaccines/tick_encephalitis/WHO_TRS_889_A2.pdf, accessed 16 November 2006). 43. WHO. WHO position paper. Weekly Epidemiological Record. 11 August 2000. No. 32, 2000, 75, 257- 264. (http://www.who.int/wer, accessed 21 September 2006). 44. WHO position on the use of hepatitis B vaccines. Weekly Epidemiological Record, 2004, 28(79):255– 263 (http://www.who.int/wer/2004/en/wer7928.pdf accessed 25 June 2006). 45. Antiretroviral therapy of HIV infection in infants and children in resource-limited settings: towards universal access: recommendations for a public health approach: 2006. Geneva, WHO, 2006 (http://www. who.int/hiv/pub/guidelines/WHOpaediatric.pdf, accessed 21 August 2006).

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aiv infeqcia/Sidsis antiretrovirusuli Terapiis marTvis saxelmwifo standarti (protokoli)

1. daavadebis/nozologiis/sindromis mokle ganmarteba _ aiv infeqcia/Sidsi ewodeba adamianis imunodeficitis virusiT gamowveul infeqciur daavadebas.

2. kriteriumebi _ a. damadasturebeli _ aiv infeqcia/Sidsis damadasturebeli

kriteriumebia: aiv antisxeulebis arseboba sisxlis SratSi imunoblotingis meTodiT, aiv rnm-is raodenobrivad da/an aiv provirus dnm-is Tvisobrivad aRmoCena sisxlSi polimerizaciis jaWvuri reaqciis meTodiT.

b. gamomricxavi _ aiv infeqcia Sidsis gamomricxavi kriteriumebia: aiv antisxeulebis ar arseboba sisxlis SratSi imunofermentuli meTodiT, raodenobrivad aiv rnm-is da/an Tvisobrivad aiv provirus dnm-is ar arseboba sisxlSi polimerizaciis jaWvuri reaqciis meTodiT.

3. simptomebi da niSnebi _

a. damadasturebeli _ aiv infeqcia/Sidss paTognomuri klinikuri niSnebi ar gaaCnia. igi miekuTvneba laboratoriulad sadiagnozo daavadebebs. simptomebidan SeiZleba gamovyoT: gaxangrZlivebuli cxeleba, gaxangrZlivebuli faRaraTi, limfadenopaTia, aramotivirebuli profuzuli oflianoba, Zlieri saerTo sisuste, aramotivirebuli wonaSi kleba (erTi Tvis ganmavlobaSi sxeulis wonis 10% da meti), sxvadasxva gamonayari kansa da lorwovanze, kandidozuri ezofagiti, cns-is atipiuri dazianebebi da sxva. atipiuri mikobaqteriebiT gamowveuli infeqciebis damadasturebel simptomebs ganekuTvneba cxeleba, Ramis oflianoba, diarea, abdominaluri tkivili, wonaSi kleba da kaxeqsia

b. gamomricxavi _ aiv infeqcia/Sidsis gamomricxavi simptomebi ar arsebobs, aiv inficirebuli wlebis ganmavlobaSi SeiZleba Civilebs ar warmoadgendes.

4. diagnostikur _ laboratoriuli testebi da specialistTa

konsultaciebi laboratoriuli testebi aiv infeqciasTan dakavSirebuli testireba:

• aiv serologiuri gamokvleva (tipurad ELISA an swrafi testi), romelsac mohyveba damadasturebeli testi (tipiurad vestern blotingi) (11);

• CD4 ujredebis ricxvi imunodeficitis xarisxis gansazRvrisTvis; orsul qalebSi CD4% (12,13) da

• virusuli datvirTvis testi polimerazuli jaWvuri reaqciis (pjr) meTodiT, virusis replikaciis donis gansazRvrisTvis ;

testireba sxva infeqciebze

• testi sifilisze (VDRL); • vaginaluri, asos an analuri Camonafxeki gonoreisa da Chlamydia

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trachomatis identifikaciisTvis;

• testireba toqsoplazmis IgG serologiur testze da informacia infeqciis riskis Sesaxeb Tu serologiis Sedegi uaryofiTia

• kriptokokis antigenis titri rodesac CD4 limfocitebis ricxvi < 200 mm3 da saxezea kriptokokozis klinikuri niSnebi

• CMV antigenemia (pp65 adreuli antigeni) rodesac CD4 ujredebis ricxvi < 100 mm3

• serologiuri testi B,C hepatitis virusebze (anti HCV, HBsAg) ZiriTadi laboratoriuli testebi:

o eleqtrolitebi (natriumi, kaliumi) N o RviZlis funqciuri sinjebi (ALT, AST, tute fosfataza,

saerTo da arapirdapiri bilirubini) o Tirkmlis funqciebi (Sardovana, kreatinini) o laqtaddehidrogenaza (limfomebis dros ujredTa ZiriTadi

brunva, filtvis infeqciebis niSnebi, miokardiumis infarqti, kunTebis dazianebani da a.S.)

o INR an proTrombinis dro o sisxlis saerTo analizi (formuliTa da Trombocitebis

ricxviT) o orsulobis testi arv Terapiis dawyebamde

saWiroebis SemTxvevebSi:

o glukoza o qolesterini (HDL, VLDL) o trigliceridebi o lipaza o C-reaqtiuli cila (CRP) o Tiroid-mastimulirebeli hormoni (TSH )

sxva gamokvlevebi

o tuberkulinis kanis testi o naxvelis nacxis mikroskopia da gul-mkerdis rentgenologiuri

gamokvleva Tu saxezea tuberkulozis niSnebi o ekg (gamokvleva mkurnalobamde arT-ze myof pacientebSi gul-

sisxlZarRvovani daavadebis didi riskis gaTvaliswinebiT, SedarebisTvis) (14)

specialistTa konsultaciebi

o nevrologiuri gamokvleva, rodesac HIV pirvelad aris diagnostirebuli (mag. periferiuli neiropaTiis identifikaciisTvis)

o ofTalmologiuri gamokvleva yovel sam TveSi erTxel CMVretinitis identifikaciisTvis, rodesac CD4 ujredebis ricxvi < 100mm3

o ginekologiuri gamokvleva PAP nacxis CaTvliT yovel 6 TveSi erTxel (adamianis papilomavirusiT gamowveuli karcinoma)

o sxva specialistebis konsultacia aucileblobis SemTxvevebSi

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5. mkurnaloba a) rekomendebuli pirveli rigis arT

arT reJimi medikamentebis kombinacia

2 NRTI-s + 1 NNRTI

ZDV + 3TC + (EFVa or NVP) an

TDF + FTC + (EFVa or NVP) an

ABC + 3TC + (EFVa or NVP)

b)

rekomendebuli meore rigis arv reJimi mozardebisa da mozrdilTaTvis

pirveli rigis reJimi meore rigis reJimi ZDV + 3TC + (EFV an NVP)

LPV/ra (an ATV/r, SQV/r, FPV/r, IDV/r) + ddI + ABC an LPV/ra (an ATV/r, SQV/r, FPV/r, IDV/r) + TDF + ABC an LPV/ra (an ATV/r, SQV/r, FPV/r, IDV/r) + TDF + (ZDV + 3TC)b

TDF + FTC + (EFV an NVP)

LPV/ra (an ATV/r, SQV/r, FPV/r, IDV/r) + ddI + ABC an LPV/ra (an ATV/r, SQV/r, FPV/r, IDV/r) + ddI + ZDV

ABC + 3TC + (EFV an NVP)

LPV/ra (an ATV/r, SQV/r, FPV/r, IDV/r) + ddI + ZDV an LPV/ra (an ATV/r, SQV/r, FPV/r, IDV/r) + ZDV + TDF (+ 3TC)b

6. reabilitacia da dakvirveba

monitoringis samizneebs warmoadgens laboratoriuli testebi antiretrovirusuli mkurnalobis efeqturobis gasakontroleblad

sawyisi 2

kvira 4

kvira8

kvira16

kvira 24

kvira 36

kvira48

kviravirusuli datvirTva

X

X X X X

CD4 ujredebis ricxvi

X X X (X) X

sisxlis saerTo analizi

X X X X (ZDV)

X (X) X

RviZlis funqciuri sinjebi

X X (NVP)

X X (NVP, ZDV, PI)

X (NVP, PI)

X (X) X

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qolesterini triglice-ridebi

X (PI) X (PI)

X (PI)

Tirkmlis funqciebi

X X (TDF)

X (TDF, IDV)

X (X) X

7. gaidlaini, romelsac eyrdnoba aRniSnuli protokoli

aRniSnuli protokoli eyrdnoba jandacvis msoflio organizaciis 2006 wlis gaidlains: “aiv/SidsiT daavadebuli mozrdili da mozardi pirebis gamokvleva da antiretrovirusuli mkurnaloba”, aseve protokoli Sejerebulia DHHS da EACS 2005 wlis antirtrovirusuli mkurnalobis gaidlainebTan.

138

aiv infeqcia/SidsiT daavadebuli bavSvebis antiretrovirusuli mkurnalobis marTvis saxelmwifo standarti (protokoli) 1. daavadebis/nozologiis/sindromis mokle ganmarteba - aiv

infeqcia/Sidsi warmoadgens adamianis imunodeficitis virusiT (aiv) gamowveul infeqciur daavadebas.

2 . kriteriumebi

a. damadasturebeli _ 18 Tvis Semdeg aiv infeqcia/Sidsis damadasturebeli kriteriumebia: aiv antisxeulebis arseboba sisxlis SratSi imunoblotingis meTodiT, aiv rnm-is raodenobrivad da/an aiv provirus dnm-is Tvisobrivad aRmoCena sisxlSi polimerizaciis jaWvuri reaqciis meTodiT.

b. gamomricxavi _ 18 Tvis Semdeg aiv infeqcia Sidsis gamomricxavi kriteriumebia: aiv antisxeulebis ar arseboba sisxlis SratSi imunofermentuli meTodiT, raodenobrivad aiv rnm-is da/an Tvisobrivad aiv provirus dnm-is ar arseboba sisxlSi polimerizaciis jaWvuri reaqciis meTodiT.

18 wlamde asakis bavSvebSi aiv infeqciis diagnostikaSemdegi sqemiT xorcieldeba

• aiv-is pirveladi diagnostika xorcieldeba dabadebidan 48 sT-is Semdeg. gamoiyeneba pjr meTodiT aiv dnm gansazRvra axalSobilis sisxlSi, romelic ar aris aRebuli Wiplaris venidan, vinaidan is SeiZleba dabinZurebuli iyos dedis sisxliT. am dros kvlevis substrats warmoadgens periferiuli sisxlis mononuklearebSi arsebuli provirusuli dnm. dabadebidan 48 saaTSi inficirebuli bavSvebis 38% aCvenebs dadebiT pasuxs aiv dnm pjr-ze. testis mgrZnobeloba ar icvleba mniSvnelovnad pirveli 1 kviris ganmavlobaSi, magram mkveTrad matulobs sicocxlis meore kviridan, rodesac daavadebuli bavSvebis 93% gamovlindeba. 28 dRis asakSi aiv dnm pjr-s ukve aqvs 96% mgrZnobeloba da 99% specifiuroba. aiv dnm pjr gamokvlevaze uaryofiTi pasuxis miRebis SemTxvevaSi bavSvs ganmeorebiTi gamokvleva imave meTodiT utardeba 3 Tvis asakSi. miRebuli dadebiTi Sedegi safuZvelia aiv infeqciis winaswari diagnozisa. saboloo diagnozi dgindeba ganmeorebiTi pjr-iT aiv –is dnm-ze sisxlis axal porciaSi.

• 2-3 Tvis asakSi aiv dnm pjr meTodis alternatiul meTodad SesaZloa CaiTvalos aiv rnm pjr diagnostikis meTodi, romlis mgrZnobeloba am asakSi 90-100%-s aRwevs, xolo specifiuroba aiv dnm pjr specifiurobis msgavsia, Tumca aiv rnm dabali doniT deteqtireba (<10 000 asli/ml) SesaZloa ar iyos dasayrdnobi da interpretacia unda moxdes sifrTxiliT.

• Tu pjr ar aris xelmisawvdomi, 15-18 Tvis asakSi tardeba bavSvis sisxlis analizi aiv antisxeulebze. dedis antisxeulebi IgG (maT Soris aiv infeqciis sawinaaRmdego) transplacenturi gziT xvdeba bavSvis organizmSi. is mTlianad iSleba 18 Tvis asakisaTvis. amdenad am asakis Semdeg aiv sawinaaRmdego

139

antisxeulebze dadebiTi Sedegi miuTiTebs, rom bavSvi aiv inficirebulia.

• Tu bavSvi ikvebeba dedis rZiT, maSin aiv antisxeulebze gamokvlevas azri aqvs ZuZuTi kvebis Sewyvetidan 6 Tvis Semdeg, vinaidan manamde bavSvi SeiZleba e.w. “fanjara periodSi” imyofebodes.

3.simptomebi da niSnebi _ a) damadasturebeli _ aiv infeqcia/Sidss paTognomuri klinikuri niSnebi ar gaaCnia. igi miekuTvneba laboratoriulad sadiagnozo daavadebebs. saSvilosnosSida inficirebis SemTxvevaSi aRwerilia Taviseburi simptomokompleqsi, rac xasiaTdeba zrda-ganviTarebis SeferxebiT, SesaZloa gamoxatuli iyos mravlobiTi darRvevebi qala-saxisa da tvinis nawilebSi. aiv inficirebul axalSobilebs SesaZloa gamoxatuli hqondeT gamoweuli Subli, brtyeli cxviri, egzofTalmi mocisfro sklerebi, mikrocefalia, Tumca unda aRiniSnos, rom ganviTarebis anomaliebi ar aris mkafiod damaxasiaTebeli niSani aiv infeqciisaTvis. aiv inficirebul bavSvebSi simptomebidan SeiZleba gamovyoT: zrda- ganviTarebaSi CamorCena, aramotivirebuli cxeleba, qronikuli/morecidive yuris infeqciebi, qronikuli pnevmonia an diarea, qronikuli dermatiti, parotiduli jirkvlebis SeSupeba, sistemuri limfadenopaTia, hepatomegalia, splenomegalia. limfocituri disfunqcia safuZvlad udevs morecidive sokovan infeqciebs, rogoricaa kandidozi, rac Cveulebriv Terapias ar emorCileba. bavSvebSi yvelaze gavrcelebuli oportunistuli infeqciebia: pnevmocisturi pnevmonia (PCP) da sistemuri kandidozi, xSiria ezofagiti. pediatriuli pnevmocisturi pnevmoniis didi wili Zalian adreul asakSi iCens Tavs, rasac Tan axlavs maRali letaloba. es ki am daavadebis proflaqtikis farTod Catarebis aucileblobis safuZvels iZleva. adreuli PCP profilaqtikis Catarebis SesaZlebloba 4-6 kviris asakidan dedis aiv statusis adreul dadgenas did mniSnelobas sZens. sxva oportunistuli infeqciebidan aRsaniSnavia: citomegalovirusuli infeqcia, romelic iwvevs filtvebisa da gastroenteraluri traqtis dazianebas da iSviaTad iwvevs retinits. (rac xSiria mozrdilebSi), qronikuli diarea, gamowveuli kriptosporidioziT, lamblioziT, izosporaTi an iseTi virusiT, rogoricaa, adenovirusi. meningiti SesaZloa gamowveul iyos kriptokokiT, rac klinikurad naklebi simwvaviT vlindeba baqteriul meningitTan SedarebiT. aratuberkulozuri mikobaqteria (Mycobacterium avium intracelulare) daavadebas iwvevs mogvianebiT etapebze imunitetis mZime supresiisas. is iwvevs cxelebas wonaSi klebiT an mis gareSe an SesaZloa gamovlindes malabsorbciuli diareis saxiT. oportunistuli infeqciis garda sicocxlis pirveli wlis ganmavlobaSi aiv inficrebul bavSvebs SesaZloa gamouvlindeT limfoiduri intersticiuli pnevmonia. es nela moprogresire da xSirad asimptomuri daavadebaa. is Cveulebriv vlindeba sicocxlis pirveli wlis Tavze da piks ori wlis asakisaTvis aRwevs. xSiradaa asocirebuli parotiduli jirkvlebis SeSupebasTan da hipergamaglobulinemiasTan. bavSvs SesaZloa hqondes mxolod es gamovlinebani filtvebis dazianebis gamovlinebamde didi xniT adre. Semdgom vlindeba daqveiTebul oqsigenaciasTan dakavSirebuli gamovlinebani, maT Soris dolis

140

joxiseburi TiTebi. Tumca wlebis manZilze gamovlinebani SesaZloa Zalze mwiri iyos. xSiria morecidive baqteriuli infeqciebi, rac gamowveulia: Hemophilius influenzae, Streptococcus pyogenes, Staphylococcus epidermidis, pneumococcus, salmonellas. yvelaze xSirad morecidive baqteriul infeqcias pnevmonia miekuTvneba, romlis xSir mizezsac S. pneumoniae warrmoadgens. mwvave pnevmoniis xSiri mizezia pnevmocisturi pnevmoniac, rac mxedvelobaSi unda gvqondes miuxedavad pacientis imunuri statusisa da CD4 raodenobisa. tuberkulozi aiv inficirebuli bavSvebis erT-erT seriozul problemas warmoadgens. diagnostikisaTvis gamoiyeneba kanis tuberkulinuri testi da naxvelSi mJavagamZle baqteriis aRmoCena mikroskopiisa da kulturis miRebis gziT. bavSvebSi naxvelis ararsebobis dros mimarTaven kuWis amonarecxis kvlevas. aiv inficirebul bavSvebSi xSiria cns dazianeba, rac gamoixateba fsiqo-fizikuri ganviTarebis SeferxebiT, encefalopaTiiT, cerebruli dambliT an/da spastiuri tetraplegiis saxiT. adgili aqvs Tavis garSemowerilobis zrdis SeCerebas. kompiuteruli tomograma kortiklur atrofias an kalcifikacias uCevnebs (gansakuTrebiT bazalur gangliebSi simetriulad). aiv inficirebuli bavSvebis daaxloebiT 20%-Si viTardeba Trombocitebis imunuri destruqcia. anemia ganpirobebuli SeiZleba iyos aiv-is mier, iatrogenuli faqtorebiT an virusuli infeqciebis (magaliTad, parvovirus B19) supresiuli zegavleniT Zvlis tvinze, aseve SratSi eriTroepoetinis donis daqveiTebiTa da Zvlis tvinis daqveiTebuli reagirebiT eriTroepoetinze. anemias iwvevs neoplaziuri agentebic. neitropenia xSiria Rrma imunosupresiis dros da kavSirSia baqteriuli infeqciebis darTvis maRal riskTan. neitropenia SesaZloa gamowveuli iyos medikamentebiT, romelsac bavSvi iRebs mkurnalobis procesSi. aiv azianebs gulsa da Tirkmelebs. es garTulebebi gansakuTrebiT xSiria mozrdil bavSvebSi 2-3 wlis asakis zemoT. Cveulebriv gamoxatulia qronikuli kardiomiopaTia. Tirkmlis dazianeba vlindeba nefrozuli sindromis an glomerulonefritis saxiT. 4. diagnostikur-laboratoriuli testebi da specialistTa konsultaciebi

a) pirvel 4 saaTSi

• konsultacia stacionaruli

• sisxlis klinikuri analizi (sisxlis saerTo analizi, sisxlis jgufis da rezusis gansazRvra, transaminazebis, bilirubinis, laqtatdehidrogenazas, Sardovanas, kreatininis, glukozis, saerTo cilis da cilis fraqciebis, rkinis da rkinis gajerebis unaris, proTrombinis da Trombinis drois gansazRvra)

• imunologiuri analizi (CD4+, CD8+ limfocitebis CaTvliT)

• Sardis saerTo analizi

• liqvoris saerTo analizi

• liqvoris baqterologiuri gamokvleva

141

• naxvelis baqterioskopuli gamokvleva

• sisxlSi Toxo IgG diagnostika

• mantus sinji

b) pirvel 24 saaTSi

• gulmkerdis rentgenograma (erTi proeqcia)

• rentgenologis konsultacia

• ekg

• kardiologis konsultacia

• sisxlis bioqimiuri analizi (saerTo cila, albumini, ALT, AST, bilirubini, da misi fraqciebi, CD4, CD8)

• Sardis analizi

• ganavlis analizi

• sisxlis baqteriologiuri gamokvleva

• naxvelis baqteriologiuri gamokvleva

g) pirvel 3 dReSi

• nevropaTologis konsultacia

• ftiziatris konsultacia

• antibiotikebisadmi mgrZnobelobis gansazRvra

• aiv virusuli datvirTvis gansazRvra

• virusuli hepatitebis (B, C, D) diagnostika • aTaSangis diagnostika (TPHA, RPR meTodebiT)

• serologiuri gamokvlevebi sxva mikroorganizmebisaTvis 5. mkurnaloba

ppiirrvveellii rriiggiiss aarrTT ssqqeemmaa aaiivv iinnffiicciirreebbuull bbaavvSSvveebbSSii

aarrTT--ss aannaammnneezzii ((mmaaTT SSoorriiss ddeeddiiss mmiieerr aarrvv pprreeppaarraatteebbiiss mmiiRReebbaa oorrssuulloobbiissaa ddaa mmSSoobbiiaarroobbiiss ddrrooss)),, TTaannmmxxlleebbii ddaaaavvaaddeebbeebbii

ppiirrvveellii rriiggiiss aarrTT ssqqeemmaa**

bavSvebSi, romlebic ar Rebulobdnen arv preparatebs, ar aris riski preparatebis urTierTqmedebisa da wamlismieri mdgradobis

zidovudini** + lamivudini + nevirapini an

zidovudini** + lamivudini + efavirenzi***

bavSvebi, romlebic imyofebodnen nevirapinis zemoqmedebis qveS, dedidan bavSvze aiv infeqciis gadadebis profilaqtikis mizniT.

zidovudini** + lamivudini + lopinaviri/ritonaviri

an zidovudini** + lamivudini + nelfinaviri

tuberkuloziT daavadebulebi**** zidovudini** + lamivudini + abakaviri an

zidovudini** + lamivudini + efavirenzi***

142

* saWiroa arv preparatebis bavSvebisaTvis misaReb samkurnalwamlo formebSi miwodeba (Txevad formaSi, 6 welze patara bavSvebSi), romelic uzrunvelyofs zust dozirebas.

** anemiis mqone bavSvebSi ukunaCvenebia zidovudinis Semcveli arT sqemebi. *** 3 welze didi asakis bavSvebSi **** arT unda daviwyoT 2 Tviani intensiuri antituberkulozuri Terepiis

Semdeg. Tu situacia saSualebas gavaZlevs arT umjobesia daviwyoT antituberkulozuri Terapiis kursis damTavrebisas. es Tavidan agvacilebs rifampicinisa da arv preparatis negatiuri urTierTqmedebis Sedegebs. garda amisa arT da antituberkulozuri preparatebis erTdrouli daniSvna zrdis Terapiis reJimis darRvevis risks. arT-s adreuli daniSvna gamarTlebulia, Tu tuberkuloziT daavadebul aiv inficirebul bavSvs aReniSneba aiv infeqciis gamoxatuli gamovlinebebi an/da mZime imunodeficiti.

arT sqemis Secvlis aucilebloba ganpirobebulia an Terapiis araefeqturobiT, an SeuTavsebeli gverdiTi movlenebiT. sqema unda Secvalos im eqimma, romelmac daniSna pirveladi mkurnaloba. vidre axal sqemas davniSnavT unda davrwmundeT, rom bavSvi preparatebs Rebulobda mkacrad daniSnulebis mixedviT. Tu arT-s sqemis gamocvla ganpirobebulia Terapiis araefeqturobiT, saWiroa samive preparatis erTdrouli Secvla

mmeeoorree rriiggiiss aarrTT ssqqeemmaa

aarrTT--ss ssaawwyyiissii ssqqeemmaa mmeeoorree rriiggiiss rreekkoommeennddeebbuullii ssqqeemmaa

zidovudini + lamivudini + nevirapinian

zidovudini + lamivudini + ifavirenci

abakaviri + didanozini + lopinaviri/ritonaviri

an abakaviri + didanozini +

nelfinaviri

zidovudini + lamivudini + nelfinaviri

an zidovudini + lamivudini +

lopinaviri/ritonaviri

abakaviri + didanozini + nevirapini

an abakaviri + didanozini +

efavirenzi

* Tu bavSvs SeuZlia kafsulis gadaylapva, xolo preparatis erTjerad doza (romelic gaTvlilia wonaze an sxeulis farTobze) Seadgens ramodenime kafsulas erTad, mas aseve SegviZlia davuniSnoT seqvinavir/ritonaviri an indinavir/ritonaviri

66..rreeaabbiilliittaacciiaa ddaa ddaakkvviirrvveebbaa mmoonniittoorriinnggii ssaammiizznneeeebbii

SSeemmoowwmmeebbiiss

vvaaddaa

aannTTrrooppoommee--ttrruullii

mmoonnaacceemmeebbii SSeemmoowwmmeebbaa

llaabboorraattoorriiuullii ggaammookkvvlleevveebbii

143

pirveli Semowmeba

arT-s dawyebidan 2 kviraSi + +

sisxlis klinikuri analizi, RviZlis fermentebis aqtivoba; Sardis saerTo analizi

meore Semowmeba

pirveli Semowmebidan erT TveSi + +

sisxlis klinikuri analizi, RviZlis fermentebis aqtivoba; Sardis saerTo analizi

momdevno Semowmebebi

yovel 3 TveSi, Tu saWiro ar aris ufro xSiri vizitebi

+ +

sisxlis klinikuri analizi, RviZlis fermentebis aqtivoba. CD4-is dones sazRvraven yovel 3-4 TveSi, Tu ar aris Cveneba ufro xSiri gamokvlevisaTvis

1 Tu sqema Seicavs nevirapins, 18 Tvis ganmavlobaSi, yovel 4 TveSiunda ganvsazRvroT RviZlis funqciuri maCveneblebi.

aarrTT--ss eeffeeqqttuurroobbiiss kkoonnttrroollii

kklliinniikkuurrii mmaaCCvveenneebblleebbiiss kkoonnttrroollii ((ssiiggrrZZee,, wwoonnaa,, ssaaeerrTToo mmddggoommaarreeoobbaa)) janmrTeli bavSvis fizikuri ganviTareba mudmivad mimdinareobs da

wonisa da simaRlis matebiT gamovlindeba. imunodeficitis mqone aiv inficirebul bavSvebSi igi Seferxebulia da arT-s dawyebis fonze mkveTrad matulobs. qvemoT mocemulia ZiriTadi klinikuri maCvenebebi, romlebic saSualebas mogvcems vimsjelod arT-s efeqtianobaze.

• “wona/simaRlis” diagrama (rodesac SeuZlebelia CD4-is donis gansazRvra, mkurnalobis efeqtianobis Sesafaseblad gamoiyeneba fizikur ganviTarebis diagramebi). Tu im bavSvebis ganviTarebis fizikuri maCveneblebi, romlebsac utardebaT arT, ar Seesabameba diagramebze mocemul maCveneblebs, unda veZeboT ganviTarebis Seferxebis mizezebi. ZiriTadi mizezi oria:

− oportunistuli infeqcia (am SemTxvevaSi diagramis mrudi mkveTrad ecema).

− Terapiis reJimis darRveva (am SemTxvevaSi diagramis mrudi ecema TandaTanobiT).

• fsiqomotoruli ganviTareba

• nevrologiuri darRvevebi, maT Soris encefalopaTiis simptomebi.

• infeqciuri daavadebebi: saxe da sixSire.

144

llaabboorraattoorriiuullii mmoonnaacceemmeebbiiss kkoonnttrroollii

• CD4-is done (Tu SesaZlebelia)

• sisxlis klinikuri analizi

• RviZlis fermentebis aqtivoba (alt, ast)

• damatebiTi gamokvlevebi: arT-s sqemisa da preparatebis gverdiTi efeqtebis mixedviT.

7.gaidlaini, romelsac eyrdnoba aRniSnuli protokoli

aRniSnuli protokoli eyrdnoba jandacvis msoflio organizaciis 2006 wlis gaidlains: “aiv/SidsiT daavadebuli bavSvebis gamokvleva da antiretrovirusuli mkurnaloba”, aseve protokoli Sejerebulia DHHS, USA-IAS da EACS 2005 wlis bavSvTaAantirtrovirusuli mkurnalobis gaidlainebTan.

145

aiv infeqcia/Sidsis fonze ganviTarebuli baqteriuli pnevmoniebis marTvis saxelmwifo standarti (protokoli) 1. daavadebis/nozologiis/sindromis mokle ganmarteba _ aiv

infeqcia/Sidsi ewodeba adamiani imunodeficitis virusiT gamowveul infeqciur daavadebas. baqteriuli pnevmoniss yvelaze xSiri gamomwvevia Streptococcus pneumoniae. sxva gamomwvevbia: Haemophilus influenzae, Klebsiella spp., Staphylococcus spp., Mycobacterium tuberculosis, Micobacterium avium-intracellulare.

2. kriteriumebi _ a) damadasturebeli _ aiv infeqcia/Sidsis damadasturebeli

kriteriumebia: aiv antisxeulebis arseboba sisxlis SratSi imunoblotingis meTodiT, aiv rnm-is raodenobrivad da/an aiv provirus dnm-is Tvisobrivad aRmoCena sisxlSi polimerizaciis jaWvuri reaqciis meTodiT. zeda sasunTqi gzebis baqteriuli infeqciebis diagnozi efuZneba klinikur gamovlinebebsa da rentgenologiur cvlilebebs. rentgenogramaze SeiZleba aRmoCndes filtvis parenqimis wilovani, kerovani an difuzuri daCrdilva an gamovlindes atipuri cvlilebebi.

b) gamomricxavi _ aiv infeqcia/Sidsis gamomricxavi kriteriumebia: aiv antisxeulebis ar arseboba sisxlis SratSi imunofermentuli meTodiT, raodenobrivad aiv rnm-is da/an Tvisobrivad aiv provirus dnm-is ar arseboba sisxlSi polimerizaciis jaWvuri reaqciis meTodiT. zeda sasunTqi gzebis baqteriuli infeqciebis gamomricxavi kriteriumebia klinikuri gamovlinebebisa da rentgenologiuri cvlilebebis ar arseboba.

3. simptomebi da niSnebi _ a) damadasturebeli _ aiv infeqcia/Sidss paTognomuri klinikuri

niSnebi ar gaaCnia. igi miekuTvneba laboratoriulad sadiagnozo daavadebebs. simptomebidan SeiZleba gamovyoT: gaxangrZlivebuli cxeleba, gaxangrZlivebuli faRaraTi, limfadenopaTia, aramotivirebuli profuzuli oflianoba, Zlieri saerTo sisuste, aramotivirebuli wonaSi kleba (erTi Tvis ganmavlobaSi sxeulis wonis 10% da meti), sxvadasxva gamonayari kansa da lorwovanze, kandidozuri ezofagiti, cns-is atipiuri dazianebebi da sxva. zeda sasunTqi gzebis baqteriuli infeqciebis damadasturebel simptomebs ganekuTvneba cxeleba, advilad daRla, xveleba, qoSini, tkivili gulmkerdis areSi, taqipnoe.

b) gamomricxavi _ aiv infeqcia/Sidsis gamomricxavi simptomebi ar arsebobs, aiv inficirebuli wlebis ganmavlobaSi SeiZleba Civilebs ar warmoadgendes. zeda sasunTqi gzebis baqteriuli infeqciebis gamomricxavi faqtoria Sesabamisi Civilebisa da simptomebis ar arseboba.

4. diagnostikur _ laboratoriuli testebi da specialistTa konsultaciebi

CD3, CD4, CD8 limfocitebis absoluturi ricxvis gansazRvra, aiv virusuli datvirTvis gansazRvra polimerizaciis jaWvuri reaqciis meTodiT, sisxlis saerTo analizi, RviZlis funqciuri sinjebi,

146

Tirkmlis funqciuri sinjebi, gulmkerdis rentgenologiuri gamokvleva, eqim-pulmonologis konsultacia.

5. mkurnaloba AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA baqteriuli pnevmoniis mkurnalobis pirveli rigis sqemebi

antibiotiki doza MmiRebis

sixSire miRebis gza


amoqsicilini (penicilinisa da ampicilinis mimarT SesaZlo rezistentobis SemTxvevaSi gamoiyeneT penicilini beta laqtamazas inhibitorebTan kombinaciaSi)

500-1000mg 3X dReSi

PO 7 dRe an ufro xangrZlivad morCenamde

Aan eriTromicini 500mg 4X dReSi PO 7 dRe an klaritromicini 500mg 2X dReSi PO 7 dRe Aan azitromicini 500mg erTxel

dReSi PO 3-4 dRe

an qinoloni pnevmokokuri aqtivobiT (mag: moqsifloqsacini)

400 mg erTxel dReSi

PO 7 dRe

an doqsiciklini 100 mg

2X dReSi PO 7 dRe

o Tu pirveli rigis sqemiT mkurnalobis fonze mdgomareoba 72 sT-Si ar gaumjobesda (cxelebis normalizeba, leikocitozis donis Semcireba), aucilebelia pacientis hospitalizacia da mkurnalobis Secvla II rigis sqemiT,. saWiroebis SemTxvevaSi _ JangbadiT inhalacia.

baqteriuli pnevmoniebis mkurnalobis meore rigis sqemebi antibiotiki doza M miRebis

sixSire MmiRebis gza


ceftriaqsoni + eriTromicini

2g 500mg

dReSi erTxel 4X dReSi

IV 7 dRe

an

ampicilin/ sulbaqtami + eriTromicini

1500mg 500mg

3X dReSi 4X dReSi

IV 7 dRe

an

147

qinoloni pnevmokokuri aqtivobiT (mag: moqsifloqsacini)

400 mg erTxel dReSi IV/PO 7 dRe

an

qloramfenikoli (mxolod sxva pre-paratebis ar arse-bobis dros)

12,5 mg/kg

4X dReSi

IV

7 dRe


aRniSnuli protokoli eyrdnoba jandacvis msoflio organizaciis 2006 wlis gaidlains: “aiv/SidsiT daavadebul mozrdil da mozard pirebSi oportunistuli infeqciebis profilaqtika da mkurnaloba”, aseve protokoli Sejerebulia DHHS, USA-AIS da EACS 2005 wlis oportunistuli infeqciebis mkurnalobis gaidlainebTan.

148

aiv infeqcia/Sidsis fonze ganviTarebuli atipiuri mikobaqteriozebis marTvis saxelmwifo standarti (protokoli) 1. daavadebis/nozologiis/sindromis mokle ganmarteba _ aiv infeqcia/Sidsi ewodeba adamianis imunodeficitis virusiT gamowveul infeqciur daavadebas. atipiuri mikobaqteriozebi ewodeba Mycobacterium avium complex gamowveul infeqciebs. 2.kriteriumebi _ a)damadasturebeli _ aiv infeqcia/Sidsis damadasturebeli kriteriumebia: aiv antisxeulebis arseboba sisxlis SratSi imunoblotingis meTodiT, aiv rnm-is raodenobrivad da/an aiv provirus dnm-is Tvisobrivad aRmoCena sisxlSi polimerizaciis jaWvuri reaqciis meTodiT. atipiuri mikobaqteriebiT gamowveuli infeqciebis diagnozi ismeba klinikuri suraTisa da laboratoriuli gamokvlevebis mixedviT. misi damadasturebeli kriteriumia Mycobacterium avium complex -is aRmoCena specialur niadagze daTesil sisxlSi, ganavalSi, RviZlisa da Zvlis tvinis bioptatSi. b)gamomricxavi _ aiv infeqcia/Sidsis gamomricxavi kriteriumebia: aiv antisxeulebis ar arseboba sisxlis SratSi imunofermentuli meTodiT, raodenobrivad aiv rnm-is da/an Tvisobrivad aiv provirus dnm-is ar arseboba sisxlSi polimerizaciis jaWvuri reaqciis meTodiT. atipiuri mikobaqteriebiT gamowveul infeqciebis gamomricxavi kriteriumia klinikuri suraTisa da Mycobacterium avium complex -is ar arseboba specialur niadagze daTesil sisxlSi, ganavalSi, RviZlisa da Zvlis tvinis bioptatSi. 3.simptomebi da niSnebi _ a. damadasturebeli _ aiv infeqcia/Sidss paTognomuri klinikuri niSnebi ar gaaCnia. igi miekuTvneba laboratoriulad sadiagnozo daavadebebs. simptomebidan SeiZleba gamovyoT: gaxangrZlivebuli cxeleba, gaxangrZlivebuli faRaraTi, limfadenopaTia, aramotivirebuli profuzuli oflianoba, Zlieri saerTo sisuste, aramotivirebuli wonaSi kleba (erTi Tvis ganmavlobaSi sxeulis wonis 10% da meti), sxvadasxva gamonayari kansa da lorwovanze, kandidozuri ezofagiti, cns-is atipiuri dazianebebi da sxva. atipiuri mikobaqteriebiT gamowveuli infeqciebis damadasturebel simptomebs ganekuTvneba cxeleba, wonaSi kleba, Ramis oflianoba, diarea, ganleva. b. gamomricxavi _ aiv infeqcia/Sidsis gamomricxavi simptomebi ar arsebobs, aiv inficirebuli wlebis ganmavlobaSi SeiZleba Civilebs ar warmoadgendes. atipiuri mikobaqteriebiT gamowveuli infeqciebis gamomricxavi faqtoria Sesabamisi Civilebisa da simptomebis ar arseboba. 4. diagnostikur _ laboratoriuli testebi da specialistTa konsultaciebi CD3, CD4, CD8 limfocitebis absoluturi ricxvis gansazRvra, aiv virusuli datvirTvis gansazRvra polimerizaciis jaWvuri reaqciis meTodiT, sisxlis saerTo analizi, RviZlis funqciuri sinjebi, Tirkmlis funqciuri sinjebi, gulmkerdis rentgenologiuri gamokvleva, Mycobacterium avium complex-is aRmoCena specialur niadagze daTesil sisxlSi, ganavalSi, RviZlsa da Zvlis tvinis bioptatSi.

5. atipuri mikobaqteriozebis mkurnaloba antibiotiki doza MmiRebis miRebis mkurnalobis

149

sixSire gza xangrZlivoba pirveli rigis preparatebi

klariTromicini 500-1000 mg 2-jer dReSi PO 6 Tve ; damokidebulia


+ etambutoli 15 mg/kg dReSi

erTxel PO 6 Tve ;

damokidebulia klinikur

mdgomareobaze +

rifabutini 300-450 mg dReSi erTxel

PO 6 Tve ; damokidebulia


sxva preparatebi, rimlebic moqmedeben atipiur mikobaqteriebze

azitromicini 500-1200 mg dReSi erTxel

PO

ciprofloqsacini 500 mg 2-jer dReSi PO 15 mg/kg/dR dReSi 1X i/v amikacini an 7,5 mg/kg/dR

2-jer dReSi i/v

6 Tve

6 Tve

ara umetes 4 kvirisa

6. reabilitacia da dakvirveba o Tu atipiuri mikobaqteriozebis mkurnalobis fonze mdgomareoba

gaumjobesda da preparatebi kargad gadaitaneba unda daiwyos arT. o atipiuri mikobaqteriozebis mkurnalobodan 4-6- kviraSi iwyeba arT.

6 Tvis Semdeg imunuri pasuxis gaumjobesebis Semdeg (CD4 ricxvi>100mm3) Cerdeba atipiuri mikobaqteriozebis mkurnaloba da gamoiyeneba meoradi profilaqtika.

o meoradi profilaqtikis Sewyveta SesaZlebelia, rodesac imunuri sistema stabiluria 3-6- Tvis manZilze.

o atipiuri mikobaqteriozebis mkurnaloba da meoradi profilaqtika grZeldeba 6 Tve, rac aris mkurnalobis warmatebis da relapsis Tavidan acilebis sawindari.

o didi mniSvneloba aqvs atipiuri mikobaqteriozebis mkurnalobis dawyebas arv Terapiis dawyebamde.

o arsebobs albaToba imunuri rekonstituciis anTebiTi sindromis ganviTarebis arT-s dawyebis Semdeg.D



150

aiv infeqcia/Sidsis fonze ganviTarebuli pnevmocisturi pnevmoniis marTvis saxelmwifo standarti (protokoli)

1. daavadebis/nozologiis/sindromis mokle ganmarteba _ aiv infeqcia/Sidsi ewodeba adamianis imunodeficitis virusiT gamowveul infeqciur daavadebas. pnevmocisturi pnevmoniis gamomwvevia Pneumocystis jiroveci.

2. kriteriumebi _ a. damadasturebeli _ aiv infeqcia/Sidsis damadasturebeli

kriteriumebia: aiv antisxeulebis arseboba sisxlis SratSi imunoblotingis meTodiT, aiv rnm-is raodenobrivad da/an aiv provirus dnm-is Tvisobrivad aRmoCena sisxlSi polimerizaciis jaWvuri reaqciis meTodiT. pnevmocisturi pnevmoniis diagnozi ismeba klinikuri suraTisa da rentgenologiuri cvlilebebis mixedviT. pnevmocisturi pnevmoniis klinikuri gamovlinebebia: xvela, qoSini, cxeleba, respiratoruli distresi – cianoziT. rentgenologiuri niSani - orive filtvis qvemo wilSi gamWvirvalobis Rrubliseburi daqveiTeba - yvela pacients ar aReniSneba. pnevmocisturi pnevmoniis damadasturebeli kriteriumia Pneumocystis jiroveci-is cistis aRmoCena naxvelSi an bronqoalveolaruli lavaJiT miRebul siTxeSi.

b. gamomricxavi _ aiv infeqcia/Sidsis gamomricxavi kriteriumebia: aiv antisxeulebis ar arseboba sisxlis SratSi imunofermentuli meTodiT, raodenobrivad aiv rnm-is da/an Tvisobrivad aiv provirus dnm-is ar arseboba sisxlSi polimerizaciis jaWvuri reaqciis meTodiT. pnevmocisturi pnevmoniis gamomricxavi kriteriumebia klinikuri gamovlinebebisa da Pneumocystis jiroveci-is cistis ar arseboba naxvelSi an bronqoalveolaruli lavaJiT miRebul siTxeSi.

3. simptomebi da niSnebi _ a. damadasturebeli _ aiv infeqcia/Sidss paTognomuri

klinikuri niSnebi ar gaaCnia. igi miekuTvneba laboratoriulad sadiagnozo daavadebebs. simptomebidan SeiZleba gamovyoT: gaxangrZlivebuli cxeleba, gaxangrZlivebuli faRaraTi, limfadenopaTia, aramotivirebuli profuzuli oflianoba, Zlieri saerTo sisuste, aramotivirebuli wonaSi kleba (erTi Tvis ganmavlobaSi sxeulis wonis 10% da meti), sxvadasxva gamonayari kansa da lorwovanze, kandidozuri ezofagiti, cns-is atipiuri dazianebebi da sxva. pnevmocisturi pnevmoniis damadasturebel simptomebs ganekuTvneba xvela, qoSini, cxeleba, respiratoruli distresi – cianoziT.

b. gamomricxavi _ aiv infeqcia/Sidsis gamomricxavi simptomebi ar arsebobs, aiv inficirebuli wlebis ganmavlobaSi SeiZleba Civilebs ar warmoadgendes. pnevmocisturi pnevmoniis gamomricxavi faqtoria Sesabamisi Civilebisa da simptomebis ar arseboba.

151

4. diagnostikur _ laboratoriuli testebi da specialistTa konsultaciebi

CD3, CD4, CD8 limfocitebis absoluturi ricxvis gansazRvra, aiv virusuli datvirTvis gansazRvra polimerizaciis jaWvuri reaqciis meTodiT, sisxlis saerTo analizi, RviZlis funqciuri sinjebi, Tirkmlis funqciuri sinjebi, gulmkerdis rentgenologiuri gamokvleva, Pneumocystis jiroveci-is cistis aRmoCena naxvelSi an bronqoalveolaruli lavaJiT miRebul siTxeSi, eqim-pulmonologis konsultacia.

5. pnevmocisturi pnevmoniis mkurnaloba tardeba stacionarSi.

aucilebelia damxmare Terapia JangbadiT inhalaciis CaTvliT.

pnevmocisturi pnevmoniis pirveli rigis mkurnaloba antimikrobuli agenti

doza M miRebis sixSire

M miRebis gza


timetoprimi/ sulfametoqsazoli

400/80 mg 4X dReSi PO/IV

21 dRe

pnevmocisturi pnevmoniis meore rigis mkurnaloba Kklindamicini + primaqini

600mg 15 mg

4X dReSi 2X dReSi

PO/IV PO

21 dRe

an

pentamidini (farTo speqtris antibiotikTan kombinaciaSi baqteriuli superinfeqciis profilaqtikisTvis mag. ampicilin+ sulbaqtami 10 dRe)

4 mg/kg IVdReSi. dozamcir 2 mg/kg5 dRismkurnalobis Semdeg (18)

dReSi erTxel

IV 21 dRe

o mZime mdgomareobaSi myof avadmofebSi iniSneba prednizoloni, 80-

250 mg PO/IV dReSi 1-2 kvira (amcirebs intersticiul SeSupebas). o mZime SemTxvevebSi ganixileba kombinirebuli mkurnaloba, mag. ko-

trimoqsazoli da pendamidini mxolod erTeuli Setyobinebuli SemTxvevebis mixedviT dakavSirebulia toqsiurobis maRal riskTan. pnevmocisturi pnevmoniis mZime SemTxvevebi moiTxovs xelovnur ventilacias an oqsigeniT saturacias (SO2)<92%.

152


monitoringis samizneebs warmoadgens Tirkmlebis, parkreasis (pendamidiniT mkurnalobisas), Zvlis tvinis (ko-trimoqsazoliT mkurnalobisas) laboratoriuli gamokvlevebi 2 kviraSi erTxel. pnevmocisturi pnevmoniis mwvave SemTxvevis warmatebiT mkurnalobis Semged :

o meoradi profilaqtikis mizniT aiv inficirebulma pacientebma unda miiRon trimetoprim/sulfametoqsazoli 160/800 mg doziT erTxel dReSi xangrZlivad ;

o aRniSnuli preparatebis miReba pacientma SeiZleba Sewyvitos Tu CD4 limfocitebis raodenoba stabilurad aRemateba 200 mm3-s sul mcire sami Tvis ganmavlobaSi.



153

aiv infeqcia/Sidsis fonze ganviTarebuli kandidozebis marTvis saxelmwifo standarti (protokoli)

1. daavadebis/nozologiis/sindromis mokle ganmarteba _ aiv infeqcia/Sidsi ewodeba adamianis imunodeficitis virusiT gamowveul infeqciur daavadebas. kandidozebis gamomwvevia Candida albicans. 2.kriteriumebi _ a)damadasturebeli _ aiv infeqcia/Sidsis damadasturebeli

kriteriumebia: aiv antisxeulebis arseboba sisxlis SratSi imunoblotingis meTodiT, aiv rnm-is raodenobrivad da/an aiv provirus dnm-is Tvisobrivad aRmoCena sisxlSi polimerizaciis jaWvuri reaqciis meTodiT. orofaringeuli kandidozis diagnostika efuZneba klinikur niSnebs, gasinjvas da dazianebuli ubnebidan aRebuli masalis mikroskopul daTvalierebas. piris Rrus daTvalierebisas vnaxulobT balTis formis TeTr nadebs SewiTlebul da anTebad lorwovan garsze. anTeba SeiZleba gavrceldes sasaze, xaxaze, RrZilebze, enasa da loyis lorwovanze. ena dazianebisas xdeba gluvi, wiTeli da dvrilebi swordeba. kandidozuri ezofagitis SemTxvevebSi diagnozis dadasturebisTvis aucilebelia qsovilis bioptatis histologiuri gamokvleva. b)gamomricxavi _ aiv infeqcia/Sidsis gamomricxavi kriteriumebia: aiv antisxeulebis ar arseboba sisxlis SratSi imunofermentuli meTodiT, raodenobrivad aiv rnm-is da/an Tvisobrivad aiv provirus dnm-is ar arseboba sisxlSi polimerizaciis jaWvuri reaqciis meTodiT. kandidozebis gamomricxavi kriteriumebia Sesabamisi klinikuri gamovlinebebis ar arseboba. simptomebi da niSnebi _

a)damadasturebeli _ aiv infeqcia/Sidss paTognomuri klinikuri niSnebi ar gaaCnia. igi miekuTvneba laboratoriulad sadiagnozo daavadebebs. simptomebidan SeiZleba gamovyoT: gaxangrZlivebuli cxeleba, gaxangrZlivebuli faRaraTi, limfadenopaTia, aramotivirebuli profuzuli oflianoba, Zlieri saerTo sisuste, aramotivirebuli wonaSi kleba (erTi Tvis ganmavlobaSi sxeulis wonis 10% da meti), sxvadasxva gamonayari kansa da lorwovanze, kandidozuri ezofagiti, cns-is atipiuri dazianebebi da sxva. piris Rrus kandidozi moicavs: loyis lorwovan garss, enas, pir-xaxas, RrZilebs, rbil da magar sasas. avadmyofs SeiZleba ar hqondes Civilebi an aRniSnavdes Wamis dros wvis SegrZnebas. zogierTi avadmyofi uCivis pirSi TeTri nadebis arsebobas. roca kandidozi vrceldeba saylapavze pacienti uCivis: tkivils ylapvis dros, retrosternalur tkivils, hipersalivacias.

b)gamomricxavi _ aiv infeqcia/Sidsis gamomricxavi simptomebi ar arsebobs, aiv inficirebuli wlebis ganmavlobaSi SeiZleba Civilebs ar warmoadgendes. kandidozebis gamomricxavi faqtoria Sesabamisi Civilebisa da simptomebis ar arseboba.

4.diagnostikur _ laboratoriuli testebi da specialistTa konsultaciebi

CD3, CD4, CD8 limfocitebis absoluturi ricxvis gansazRvra, aiv virusuli datvirTvis gansazRvra polimerizaciis jaWvuri reaqciis meTodiT, sisxlis saerTo analizi, RviZlis funqciuri sinjebi, Tirkmlis funqciuri sinjebi, gulmkerdis rentgenologiuri gamokvleva,

154

kandidozuri ezofagitis SemTxvevebSi diagnozis dadasturebisTvis aucilebelia qsovilis bioptatis histologiuri gamokvleva.

5.kandidozebis mkurnaloba piris Rrus kandidozis mkurnaloba antimikozuri

agenti doza

M miRebis sixSire

miRebis gza


mkurnalobis pirveli rigis sqemebi mikonazoli tabletebi

gasawovad dReSi erTxel

adgilobrivad 7 dRe

an flukonazoli 100 mg 2-jer dReSi

3 dRe Semdeg erTxel dReSi 4 dRe

PO 7 dRe

mkurnalobis meore rigis sqemebi itrakonazoli 200-400 mg dReSi

erTxel PO 7 dRe

vaginaluri kandidozis mkurnaloba antimikozuri


sixSire miRebis gza


pirveli rigis sqemebi flukonazoli 100 mg erTjeradad PO erTjeradad klotrimazoli 500 mg erTjeradad vaginalurad erTjeradad meore rigis sqemebi ketokonazoli 200 mg 2-jer dReSi PO 3 dRe ketokonazoli 200 mg dReSi

erTxel PO 7 dRe

SemanarCunebeli Terapia nistatini 2-4 mln IU 2-jer dReSi PO 10 dRe

Aan flukonazoli 50-200 mg dReSi

erTxel PO yoveldRe

mesame rigis sqemebi ketokonazoli 200 mg dReSi


pasuxze, Cveulebriv 7-

10 dRe itrakonazoli 100 mg dReSi


pasuxze, Cveulebriv 7-10 dRe

155

ezofaguri da diseminirebuli kandidozebis mkurnaloba antimikozuri


sixSire miRebis gza


pirveli rigis sqemebi

ketokonazoli 200-400 mg 2-jer dReSi PO 21 dRe Aan flukonazoli

(ketokonazolze efeqturia)

200-400 mg Semcirdes klinikuri Sedegis mixedviT 3 dRis Semdeg 100 mg/dReSi

dReSi erTxel

PO/IV

14 dRe

meore rigis sqemebi

amfotericini B 0,3-0,5 mg/kg IV 10-14 dRe

Aan itrakonazoli 200-400 mg dReSi

erTxel PO 2 kvira

6.reabilitacia da dakvirveba kandidozuri ezofagitis mkurnalobis Semdeg saWiroa xangrZlivi SemanarCunebeli Terapia flukonazoliT 50-100 mg/dReSi yoveldRe, an itrakonazoliT 100 mg/dReSi yoveldRe, an ketokonazoliT 200 mg/dReSi yoveldRe. 7.gaidlaini, romelsac eyrdnoba aRniSnuli protokoli


156

aiv infeqcia/Sidsis fonze ganviTarebuli kriptokokuli meningitis marTvis saxelmwifo standarti (protokoli)

1.daavadebis /nozologiis / sindromis mokle ganmarteba _ aiv infeqcia/Sidsi ewodeba adamianis imunodeficitis virusiT gamowveul infeqciur daavadebas. kriptokokuli meningitis gamomwvevia soko Criptococcus neoformans. 2.kriteriumebi _

a)damadasturebeli _ aiv infeqcia/Sidsis damadasturebeli kriteriumebia: aiv antisxeulebis arseboba sisxlis SratSi imunoblotingis meTodiT, aiv rnm-is raodenobrivad da/an aiv provirus dnm-is Tvisobrivad aRmoCena sisxlSi polimerizaciis jaWvuri reaqciis meTodiT. kriptokokozis diagnozis dadasturebisTvis liqvors acentrifugireben, miRebul naleqs ikvleven mikroskopis qveS tuSis wveTis India ink damatebis Semdeg. preparatSi naxuloben sqeli kafsuliT dafarul safuaris ujredebs. SesaZlebelia kriptokokis kulturis gamoyofa Tavzurgtvinis siTxidan.gamoiyeneba Sratis da Tavzurgtvinis siTxis gamokvleva kriptokokul antigenze. b)gamomricxavi _ aiv infeqcia/Sidsis gamomricxavi kriteriumebia: aiv antisxeulebis ar arseboba sisxlis SratSi imunofermentuli meTodiT, raodenobrivad aiv rnm-is da/an Tvisobrivad aiv provirus dnm-is ar arseboba sisxlSi polimerizaciis jaWvuri reaqciis meTodiT. kriptokokozis gamomricxavi kriteriumebia liqvorSi sqeli kafsuliT dafaruli safuaris ujredebis ar arseboba. 3.simptomebi da niSnebi a)damadasturebeli _ aiv infeqcia/Sidss paTognomuri klinikuri niSnebi ar gaaCnia. igi miekuTvneba laboratoriulad sadiagnozo daavadebebs. simptomebidan SeiZleba gamovyoT: gaxangrZlivebuli cxeleba, gaxangrZlivebuli faRaraTi, limfadenopaTia, aramotivirebuli profuzuli oflianoba, Zlieri saerTo sisuste, aramotivirebuli wonaSi kleba (erTi Tvis ganmavlobaSi sxeulis wonis 10% da meti), sxvadasxva gamonayari kansa da lorwovanze, kandidozuri ezofagiti, cns-is atipiuri dazianebebi da sxva. kriptokokuli meningitis dros pacienti uCivisL Tavis tkivils, cxelebas, saxezea kefis kunTebis regidoba, Tavis qalis nervebis dazianeba, cnobierebis darRveva, komatozuri mdgomareoba. xSirad SesaZlebelia ar aRiniSnos meningitis niSnebi, maT Soris, cxeleba da kefis kunTebis rigidoba. b)gamomricxavi _ aiv infeqcia/Sidsis gamomricxavi simptomebi ar arsebobs, aiv inficirebuli wlebis ganmavlobaSi SeiZleba Civilebs ar warmoadgendes. kriptokokuli meningitis gamomricxavi faqtoria Sesabamisi Civilebisa da simptomebis ar arseboba.


CD3, CD4, CD8 limfocitebis absoluturi ricxvis gansazRvra, aiv virusuli datvirTvis gansazRvra polimerizaciis jaWvuri reaqciis meTodiT, sisxlis saerTo analizi, RviZlis funqciuri sinjebi, Tirkmlis funqciuri sinjebi, Tavzurgtvinis siTxis aReba da naleqis gamokvleva mikroskopis qveS tuSis wveTis India ink damatebis Semdeg an,

157

kriptokokis kulturis gamoyofa Tavzurgtvinis siTxidan an, Sratsa da/an Tavzurgtvinis siTxeSi kriptokokuli antigenis aRmoCena. 5.kriptokokuli meningitis mkurnaloba antimikozuri


sixSire miRebis gza


pirveli rigis sqemebi (27)


0,7-1,0 mg/kg 25 mg/kg


IV

14 dRe


dReSi PO sul mcire 10

kvira Semdeg flukonazoli 200mg erTxel

dReSi PO mTeli

cxovreba meore rigis sqemebi


0,7-1,0 mg/kg 25 mg/kg


IV 6-10 kvira

an

amfotericini B 0,7-1,0 mg/kg erTxel dReSi

IV 6-10 kvira

an (msubuq SemTxvevebSi) flukonazoli 400-800 mg erTxel

dReSi PO 10-12 kvira


dReSi PO mTeli

cxovreba

6.reabilitacia da dakvirveba aucilebelia mTeli cxovrebis manZilze Catardes kriptokokozis meoradiAqimioprofilaqtika. am mizniT iniSneba flukonazoli 200 mg/dReSiAyoveldRe. alternativas warmoadgens itrakonazoli 200 mg/dReSiAyoveldRe. SemanarCunebeli Terapiis aucilebloba pacientebSi, romelTa imunuri sistema aRdga (CD4 ricxvi >200 mm3) ar aris damxmare da ar arsebobs raime sawinaaRmdego mosazreba am konkretuli SemTxvevisTvis.



158

aiv infeqcia/Sidsis fonze ganviTarebuli histoplazmozis marTvis saxelmwifo standarti (protokoli)

1.daavadebis /nozologiis / sindromis mokle ganmarteba _ aiv infeqcia/Sidsi ewodeba adamianis imunodeficitis virusiT gamowveul infeqciur daavadebas. hispoplazmozis gamomwvevia soko Histoplazma capsulatum inhalaciuri sporebi. 2.kriteriumebi _ o a)damadasturebeli _ aiv infeqcia/Sidsis damadasturebeli

kriteriumebia: aiv antisxeulebis arseboba sisxlis SratSi imunoblotingis meTodiT, aiv rnm-is raodenobrivad da/an aiv provirus dnm-is Tvisobrivad aRmoCena sisxlSi polimerizaciis jaWvuri reaqciis meTodiT. histoplazmozis diagnostika dasturdeba sokos kulturiT an qsovilis bioptatis histologiuri gamokvleviT. hispoplazmozis diagnostisTvis unda Catardes sisxlis da kanis testebi, Tumca isini ar aris farTod gamoyenebuli.

b)gamomricxavi _ aiv infeqcia/Sidsis gamomricxavi kriteriumebia: aiv antisxeulebis ar arseboba sisxlis SratSi imunofermentuli meTodiT, raodenobrivad aiv rnm-is da/an Tvisobrivad aiv provirus dnm-is ar arseboba sisxlSi polimerizaciis jaWvuri reaqciis meTodiT. histoplazmozis gamomricxavi kriteriumebia sokos ar arseboba qsovilis bioptatis histologiuri gamokvleviT. 3.simptomebi da niSnebi

a)damadasturebeli _ aiv infeqcia/Sidss paTognomuri klinikuri niSnebi ar gaaCnia. igi miekuTvneba laboratoriulad sadiagnozo daavadebebs. simptomebidan SeiZleba gamovyoT: gaxangrZlivebuli cxeleba, gaxangrZlivebuli faRaraTi, limfadenopaTia, aramotivirebuli profuzuli oflianoba, Zlieri saerTo sisuste, aramotivirebuli wonaSi kleba (erTi Tvis ganmavlobaSi sxeulis wonis 10% da meti), sxvadasxva gamonayari kansa da lorwovanze, kandidozuri ezofagiti, cns-is atipiuri dazianebebi da sxva. histoplazmiT gamowveuli mwvave daavadeba gripismagvaria da axasiaTebs: cxeleba, anoreqsia, arTralgia, mialgia, mSrali xveleba, tkivili gul-mkerdis areSi. diseminacia imunosupresiul avadmyofSi swrafad viTardeba da axasiaTebs: wonaSi dakleba, oraluri da kanis dazianebuli ubnebi, RviZlis, elenTis da limfuri kvanZebis gadideba. oraluri ubnebisTvis damaxasiaTebelia nekrozuli wylulebi. SesaZlebelia ganviTareds sasis perforacia da rbili qsovilis destruqcia.

b)gamomricxavi _ aiv infeqcia/Sidsis gamomricxavi simptomebi ar arsebobs, aiv inficirebuli wlebis ganmavlobaSi SeiZleba Civilebs ar warmoadgendes. histoplazmozis gamomricxavi faqtoria Sesabamisi Civilebisa da simptomebis ar arseboba.

159


o CD3, CD4, CD8 limfocitebis absoluturi ricxvis gansazRvra, aiv virusuli datvirTvis gansazRvra polimerizaciis jaWvuri reaqciis meTodiT, sisxlis saerTo analizi, RviZlis funqciuri sinjebi, Tirkmlis funqciuri sinjebi, qsovilis bioptatis histologiuri gamokvleva histoplazmozis diagnostikisTvis.

5. histoplazmozis mkurnaloba antifungaluri

agenti dozireba miRebis

sixSire miRebis gza xangrZlivoba

amfotericni B 0.7-1 mg/kg erTxel dReSi

IV 10 dRe

sawyis mkurnalobas mohyveba 3 Tviani mkurnaloba imunorekonstituciamde >100 CD4 ujrediT, Sedegi medikamentebiT:

o itrakonazoli 200 mg 2X dReSi PO o flukonazoli 200 mg 2X dReSi PO o amfotericini B 1 mg/kg IV kviraSi erTxel.

alternatiul reJims warmoadgens itrakonazoli 200 mg samjer dReSi - 3 dRe, Semdeg 200 mg 2X dReSi 12 kvira (sakvebTan erTad).



160

aiv infeqcia/Sidsis fonze ganviTarebuli kapoSis sarkomis marTvis saxelmwifo standarti (protokoli)

1.daavadebis /nozologiis / sindromis mokle ganmarteba _ aiv infeqcia/Sidsi ewodeba adamianis imunodeficitis virusiT gamowveul infeqciur daavadebas. kapoSis sarkoma avTvisebiani simsivnea, romlis gamomwvevia gamomwvevia me-8 tipis herpes virusi (HHV8 an KSHV). 2.kriteriumebi _

a)damadasturebeli _ aiv infeqcia/Sidsis damadasturebeli kriteriumebia: aiv antisxeulebis arseboba sisxlis SratSi imunoblotingis meTodiT, aiv rnm-is raodenobrivad da/an aiv provirus dnm-is Tvisobrivad aRmoCena sisxlSi polimerizaciis jaWvuri reaqciis meTodiT. kapoSis sarkomis diagnozi dasturdeba kanis dazianebuli ubnebidan aRebuli bioptatis histologiuri gamokvleviT. b)gamomricxavi _ aiv infeqcia/Sidsis gamomricxavi kriteriumebia: aiv antisxeulebis ar arseboba sisxlis SratSi imunofermentuli meTodiT, raodenobrivad aiv rnm-is da/an Tvisobrivad aiv provirus dnm-is ar arseboba sisxlSi polimerizaciis jaWvuri reaqciis meTodiT. kapoSis sarkomis gamomricxavi kriteriumebia kanis dazianebuli ubnebidan aRebul bioptatSi daignozis histologiurad ar dadastureba. 3.simptomebi da niSnebi

a)damadasturebeli _ aiv infeqcia/Sidss paTognomuri klinikuri niSnebi ar gaaCnia. igi miekuTvneba laboratoriulad sadiagnozo daavadebebs. simptomebidan SeiZleba gamovyoT: gaxangrZlivebuli cxeleba, gaxangrZlivebuli faRaraTi, limfadenopaTia, aramotivirebuli profuzuli oflianoba, Zlieri saerTo sisuste, aramotivirebuli wonaSi kleba (erTi Tvis ganmavlobaSi sxeulis wonis 10% da meti), sxvadasxva gamonayari kansa da lorwovanze, kandidozuri ezofagiti, cns-is atipiuri dazianebebi da sxva. kanze elementebi warmodgenilia cisferi an mewamuli feris papulebiT an kvanZebiT, araiSviaTad garSemo arsebuli kanis limfuri SeSupebiT. xSirad ziandeba sasa, filtvebi kuW-nawlavis traqti da limfuri kvanZebi. piris RruSi kapoSis sarkomis elementebi yvelaze xSirad ganlagebulia magar sasaze, iSviaTad enaze, xaxaze, nuSura jirkvlebsa da RrZilebze. isini warmoadgenen mewamuli feris papulebs, romlebic Cveulebriv ar aris mtkivneuli. xandaxan SeiZleba Segvxvdes msxvili elementebic da elementebi kanze. filtvis parenqimis dazianeba atarebs infiltraciul xasiaTs. xSirad viTardeba sunTqvis ukmarisoba. filtvis infiltraciuli dazianebis mqone avadmyofebs arakeTilsaimedo prognozi aqvT da maTSi maRalia sikvdilianoba.

b)gamomricxavi _ aiv infeqcia/Sidsis gamomricxavi simptomebi ar arsebobs, aiv inficirebuli wlebis ganmavlobaSi SeiZleba Civilebs ar warmoadgendes. kapoSis sarkomis gamomricxavi faqtoria Sesabamisi Civilebisa da simptomebis ar arseboba.

161


CD3, CD4, CD8 limfocitebis absoluturi ricxvis gansazRvra, aiv virusuli datvirTvis gansazRvra polimerizaciis jaWvuri reaqciis meTodiT, sisxlis saerTo analizi, RviZlis funqciuri sinjebi, Tirkmlis funqciuri sinjebi, kapoSis sarkomiT dazianebuli kanis ubnebis biopsia da histologiuri gamokvleva. 5.kapoSis sarkomis mkurnaloba kapoSis sarkomis mkurnaloba tardeba onkologis mier. lokaluri formis samkurnalod gamoiyeneba sxivuri Terapia. generalizirebuli formis samkurnalod iniSneba citotoqsiuri qimioTerapia. efeqturobis sxvadasxva xarisxiT gamoiyeneba simsivnis sawinaaRmdego preparatebis Semdegi kombinaciebi: liposomuri doksorubiciniT monoTerapia, bleomicini, vinkristini, daunorubicini, vinblastini, etopozidi. calkeuli elementebi SeiZleba moSordes qirurgiulad an lazeris, Txevadi azotis da dasxivebis zemoqmedebiT. demonstrirebuli iyo uSualod kapoSis sarkomatozul kvanZSi bleomicinis Seyvanis efeqturoba. kapoSis sarkoma SesaZloa daeqvemdebaros mxolod arT-s da nel-nela alagdes.

7.gaidlaini, rimelsac eyrdnoba aRniSnuli protokoli


162

aiv infeqcia/Sidsis fonze ganviTarebuli arahojkinis limfomebis marTvis saxelmwifo standarti (protokoli) 1.daavadebis /nozologiis / sindromis mokle ganmarteba _ aiv infeqcia/Sidsi ewodeba adamianis imunodeficitis virusiT gamowveul infeqciur daavadebas. arahojkinis lomfomebi limfuri sistemis avTvisebiani simsivneebia, romlebic Sidsis fonze xSir SemTxvevaSi asocirebulia epStein-baris virusTan (EBV). 2.kriteriumebi _ a)damadasturebeli _ aiv infeqcia/Sidsis damadasturebeli kriteriumebia: aiv antisxeulebis arseboba sisxlis SratSi imunoblotingis meTodiT, aiv rnm-is raodenobrivad da/an aiv provirus dnm-is Tvisobrivad aRmoCena sisxlSi polimerizaciis jaWvuri reaqciis meTodiT. arahojkinis limfomebis diagnozi dasturdeba hipereplazirebuli limfuri kvanZis biofsiiT, histologiuri gamokvleviT. b)gamomricxavi _ aiv infeqcia/Sidsis gamomricxavi kriteriumebia: aiv antisxeulebis ar arseboba sisxlis SratSi imunofermentuli meTodiT, raodenobrivad aiv rnm-is da/an Tvisobrivad aiv provirus dnm-is ar arseboba sisxlSi polimerizaciis jaWvuri reaqciis meTodiT. arahojkinis limfomis gamomricxavi kriteriumebia simsivnis morfologiuri substratis ar arseboba hiperplazirebuli limfuri kvanZis bioptatSi. 3.simptomebi da niSnebi a)damadasturebeli _ aiv infeqcia/Sidss paTognomuri klinikuri niSnebi ar gaaCnia. igi miekuTvneba laboratoriulad sadiagnozo daavadebebs. simptomebidan SeiZleba gamovyoT: gaxangrZlivebuli cxeleba, gaxangrZlivebuli faRaraTi, limfadenopaTia, aramotivirebuli profuzuli oflianoba, Zlieri saerTo sisuste, aramotivirebuli wonaSi kleba (erTi Tvis ganmavlobaSi sxeulis wonis 10% da meti), sxvadasxva gamonayari kansa da lorwovanze, kandidozuri ezofagiti, cns-is atipiuri dazianebebi da sxva. arahojkinis limfomebis dros simptomebi mravalferovania: hiperplazirebuli limfuri kvanZebi SesaZlebelia palpirdebodes sxvadasxva adgilze; cxeleba, wonaSi kleba da sisuste xSiria, Tumca ara aucilebeli; daavadebis stadiis gansazRvrisTvis (I-IV) aucilebelia Semdegi gamokvlevebi: cerebruli, cervikaluri, Torakaluri da abdominaluri kompiuterul-aqsialuri tomografiuli (CAT) skanireba, Zvlis tvinis da Tav-zurg-tvinis siTxis aspiracia da gastroskopia. b)gamomricxavi _ aiv infeqcia/Sidsis gamomricxavi simptomebi ar arsebobs, aiv inficirebuli wlebis ganmavlobaSi SeiZleba Civilebs ar warmoadgendes. arahojkinis limfomis gamomricxavi faqtoria Sesabamisi Civilebisa da simptomebis ar arseboba. 4.diagnostikur _ laboratoriuli testebi da specialistTa konsultaciebi CD3, CD4, CD8 limfocitebis absoluturi ricxvis gansazRvra, aiv virusuli datvirTvis gansazRvra polimerizaciis jaWvuri reaqciis meTodiT, sisxlis saerTo analizi, RviZlis funqciuri sinjebi, Tirkmlis funqciuri sinjebi, hiperplazirebuli limfuri kvanZis biofsia da histologiuri gamokvleviT simsivnis morfologiuri substratis aRmoCena.

163

5.arahojkinis limfomebis (maT Soris berkitis tipis da cns-is limfomebis) mkurnaloba ara-hojkinis limfomebis samkurnalod efeqturia CHOP reJimi, unda Catardes 6 kursi (ganmeorebebi aucilebelia sruli remisiis misaRebad):

o prednizoloni 100 mg/dReSi erTxel 5 dRe o vinkristini (onkovini) 1,4 mg/m2 (maqsimum 2 mg/dReSi) erTi doza

mkurnalobis pirvel dRes o ciklofosfamidi 750 mg/m2/dReSi erTi doza mkurnalobis pirvel

dRes o doqsorubicini (hidroqsidaunomicini) 50 mg/m2/dReSi erTi doza

mkurnalobis pirvel dRes. meore cikli iwyeba yovel 21-e dRes (dRe 22-e mohyveba I dRes)

o EPOCH reJimi, romelic moicavs etopozids, prednozolons, vinkristins, ciklofisfamids da daunorubicins an doqsirubicins efeqturia arT-sTan kombinaciaSi. igi efuZneba gagrZelebiT infuzias 96 saaTis ganmavlobaSi, romelic Semdegia:

o etopozidi 50 mg/m2 dReSi (centraluri venuri xaziT) o doqsorubucuni 10 mg/m2/dReSi (centraluri venuri xaziT) o vinkristini 0,4 mg/m2/dReSi (maqs 2 mg/kviraSi) (centraluri venuri

xaziT) o ciklofosfamidi 375 mg/m2 me-5 dRes mxolod, bolusiT

(centraluri venuri xaziT) o prednizoloni 100 mg/dReSi pirveli 5 dRe erTxel dReSi.

reJimi unda ganmeordes yovel 21 dReSi sanam ar Catardeba 6 cikli. o berkitis–tipis limfomis menejmenti ar gansxvavdeba sxva

limfomebis mkurnalobisgan da pasuxobs CHOP da EPOCH reJimebs. swrafad mzardi limfomis mkurnaloba ufro agresiuli qimioTerapiiT (mag : B-ALL reJimi) diskusiis Temas warmoadgens da specifikuri rekomendaciebi dRevandeli dRisTvis ar arsebobs.

o berkitis–tipis limfomebis SemTxvevebSi qimioTerapias Tan unda axldes savaraudo pirveladi keris dasxiveba.

o arahojkinis limfomebis mkurnaloba SesaZlebelia CD4 ujredebis ricxvisgan damoukideblad, Tumca mkurnalobis efeqturobisTvis arT unda dainiSnos ufro adre. qimioTerapiis ganmavlobaSi CD4 ujredebis ricxvi >350 mm3 dakavSirebulia relapsis maRal maCveneblebTan arT gareSe (37).

o intakranialuri limfomebis (metastazebi) arsebobisas sasurvelia Tavis dasxiveba, simsivnis sawinaaRmdego preparatebTan da glukokortikoidebTan erTad (38).

cns-is pirveladi limfomis dros erTaderTi efeqturi mtkicebulebaze dafuZnebuli Terapiaa sxivuri Terapia. dauyonebliv unda daiwyos arT (39,40).



164

aiv infeqcia/Sidsis fonze ganviTarebuli toqsoplazmozis marTvis saxelmwifo standarti (protokoli)

1.daavadebis /nozologiis / sindromis mokle ganmarteba _ aiv infeqcia/Sidsi ewodeba adamianis imunodeficitis virusiT gamowveul infeqciur daavadebas. daavadeba toqsoplazmozis gamomwvevia paraziti Toxoplasma gondii. SidsiT avadmyofebSi toqsoplazma iwvevs Tavis tvinSi mravlobiTi anTebadi ubnebis warmoqmnas da gamovlindeba encefalitis an diseminirebuli daavadebis saxiT. 2.kriteriumebi _ a)damadasturebeli _ aiv infeqcia/Sidsis damadasturebeli kriteriumebia: aiv antisxeulebis arseboba sisxlis SratSi imunoblotingis meTodiT, aiv rnm-is raodenobrivad da/an aiv provirus dnm-is Tvisobrivad aRmoCena sisxlSi polimerizaciis jaWvuri reaqciis meTodiT. toqsoplazmozis dros Tavis tvinis MAC an MRI skanirebiT aRmoCndeba mravlobiTi rgoliseburi kerebi. Tu es meTodebi ar aris xelmisawvdomi diagnozis dadgenaSi gvexmareba serologiuri testebi toqsoplazmis sawinaaRmdegod gamomuSavebul antisxeulebze (IgG klasis). cerebraluri toqsoplazmozis mqone pacientebis umravlesobas aReniSneba Toxoplasma gondii-iT gamowveuli infeqciis gadatanis serologiuri niSnebi. diagnozs adasturebs Tavis tvinis qsovilis histologiuri gamokvleva.

b)gamomricxavi _ aiv infeqcia/Sidsis gamomricxavi kriteriumebia: aiv antisxeulebis ar arseboba sisxlis SratSi imunofermentuli meTodiT, raodenobrivad aiv rnm-is da/an Tvisobrivad aiv provirus dnm-is ar arseboba sisxlSi polimerizaciis jaWvuri reaqciis meTodiT. toqsoplazmozis gamomricxavi kriteriumebia Tavis tvinis MAC an MRI skanirebiT aRmoCndeba mravlobiTi rgoliseburi kerebis ar arseboba, negatiuri serologiuri testebi toqsoplazmis sawinaaRmdegod gamomuSavebul antisxeulebze (IgG klasis).

3.simptomebi da niSnebi a)damadasturebeli _ aiv infeqcia/Sidss paTognomuri klinikuri niSnebi ar gaaCnia. igi miekuTvneba laboratoriulad sadiagnozo daavadebebs. simptomebidan SeiZleba gamovyoT: gaxangrZlivebuli cxeleba, gaxangrZlivebuli faRaraTi, limfadenopaTia, aramotivirebuli profuzuli oflianoba, Zlieri saerTo sisuste, aramotivirebuli wonaSi kleba (erTi Tvis ganmavlobaSi sxeulis wonis 10% da meti), sxvadasxva gamonayari kansa da lorwovanze, kandidozuri ezofagiti, cns-is atipiuri dazianebebi da sxva. toqsoplazmozis dros saxezea Semdegi klinikuri suraTi: cnobierebis darRveva, cxeleba, krunCxvebi, Tavis tkivili, kerovani nevrologiuri simptomatika motoruli deficitis, kraniuli nervis parezis, moZraobis SezRudvis, dismetriis, mxedvelobis dakargvis da afaziis CaTvliT. b)gamomricxavi _ aiv infeqcia/Sidsis gamomricxavi simptomebi ar arsebobs, aiv inficirebuli wlebis ganmavlobaSi SeiZleba Civilebs ar warmoadgendes. toqsoplazmozis gamomricxavi faqtoria Sesabamisi Civilebisa da simptomebis ar arseboba.

165

4.diagnostikur _ laboratoriuli testebi da specialistTa konsultaciebi CD3, CD4, CD8 limfocitebis absoluturi ricxvis gansazRvra, aiv virusuli datvirTvis gansazRvra polimerizaciis jaWvuri reaqciis meTodiT, sisxlis saerTo analizi, RviZlis funqciuri sinjebi, Tirkmlis funqciuri sinjebi, Tavis tvinis MAC an MRI skanireba, serologiuri testebi toqsoplazmis sawinaaRmdegod gamomuSavebul antisxeulebze (IgG klasis), Tavis tvinis biofsia da qsovilis histologiuri gamokvleva. 5. toqsoplazmozis mkurnaloba preparati doza M miRebis

sixSire miRebis gza


mkurnaloba pirimetamini 200 mg erTjeradad

(gajerebiTi doza) PO erTjeradad

Semdeg pirimetamini 25 mg

an 50 mg 3-jer dReSi 2-jer dReSi

PO 6-8 kvira

+ foliumis mJava

15 mg dReSi erTxel

PO 6-8 kvira

+

sulfadiazini 1 g 4-jer dReSi PO 6-8 kvira am sqemaSi sulfadiazini SeiZleba Seicvalos:

klindamiciniT 600 mg i/v an PO dReSi 4-jer 6 kvira azitromiciniT 1200 mg PO dReSi erTxel 6 kvira klariTromiciniT 1 g PO 2-jer dReSi 6 kvira atovakvoniT 750 mg PO 4-jer dReSi 6 kvira.

6.reabilitacia da dakvirveba zogierT pacients sWirdeba xangrZlivi mkurnaloba toqsoplazmozis gamo. gadawyvetileba efuZneba klinikur mdgomareobas da ganmeorebiT CAT skanirebas. meoradi profilaqtika grZeldeba efeqturi reJimis ganaxevrebuli dozebiT manamde sanam CD4 ujredebs ricxvi sami Tvis ganmavlobaSi stabilurad ar moimatebs (200 ujredi da meti). 7.gaidlaini, rimelsac eyrdnoba aRniSnuli protokoli


166

aiv infeqcia/Sidsis fonze ganviTarebuli martivi herpesiT gamowveuli infeqciebis marTvis saxelmwifo standarti (protokoli)

1.daavadebis /nozologiis / sindromis mokle ganmarteba _ aiv infeqcia/Sidsi ewodeba adamianis imunodeficitis virusiT gamowveul infeqciur daavadebas. SidsiT avadmyofebSi martivi herpesis virusi HSV I da II tipis iwvevs vrcel, persistul an diseminirebul infeqcias, meningitsa da meningoencefalits. 2.kriteriumebi _ a)damadasturebeli _ aiv infeqcia/Sidsis damadasturebeli kriteriumebia: aiv antisxeulebis arseboba sisxlis SratSi imunoblotingis meTodiT, aiv rnm-is raodenobrivad da/an aiv provirus dnm-is Tvisobrivad aRmoCena sisxlSi polimerizaciis jaWvuri reaqciis meTodiT. lokaluri martivi herpesis disgnozi ismeba klinikurad, xolo diseminirebuli martivi herpesiT gamowveuli infeqciis diagnostikisTvis aucilebelia virusis kulturis gamoyofa, radio-imunoblotingis meTodi, imunofluoroescencia da monoklonuri antisxeulebiT testireba. herpesul encefalits mivyavarT Tavis tvinSi dazianebis mravlobiTi kerebis ganviTarebamde, romelic TvalsaCinoa CAT skanirebiT; aseve martivi herpesiT gamowveuli cns-is diagnostikisTvis gamoiyeneba Tav-zurg-tvinis siTxeSi dnm-is aRmoCena pjr meodiT. b)gamomricxavi _ aiv infeqcia/Sidsis gamomricxavi kriteriumebia: aiv antisxeulebis ar arseboba sisxlis SratSi imunofermentuli meTodiT, raodenobrivad aiv rnm-is da/an Tvisobrivad aiv provirus dnm-is ar arseboba sisxlSi polimerizaciis jaWvuri reaqciis meTodiT. martivi herpesiT gamowveuli diseminirebuli infeqciis gamomricxavi kriteriumebia martivi herpesis virusis kulturis, radio-imunoblotingis meTodis, imunofluoroescenciis da monoklonuri antisxeulebiT, Tav-zurg-tvinis siTxeSi martivi herpesis virusis dnm-ze pjr testirebis negatiuri Sedegi. 3.simptomebi da niSnebi a)damadasturebeli _ aiv infeqcia/Sidss paTognomuri klinikuri niSnebi ar gaaCnia. igi miekuTvneba laboratoriulad sadiagnozo daavadebebs. simptomebidan SeiZleba gamovyoT: gaxangrZlivebuli cxeleba, gaxangrZlivebuli faRaraTi, limfadenopaTia, aramotivirebuli profuzuli oflianoba, Zlieri saerTo sisuste, aramotivirebuli wonaSi kleba (erTi Tvis ganmavlobaSi sxeulis wonis 10% da meti), sxvadasxva gamonayari kansa da lorwovanze, kandidozuri ezofagiti, cns-is atipiuri dazianebebi da sxva. herpesuli gamonayari Cveulebriv warmodgenilia vezikulebiTa da mtkvneuli eroziebiT, romlebic ganlagebulia piris irgvliv, cxviris nestoebze, tuCebsa da sasqeso organoebze. diseminirebuli martivi herpesiT gamowveuli infeqciis diagnozis dasma xSirad Znelia. saxezea meningitisa an/da meningoencefalitis suraTi, Sesabamisi cvlilebebiT CAT skanirebisas. b)gamomricxavi _ aiv infeqcia/Sidsis gamomricxavi simptomebi ar arsebobs, aiv inficirebuli wlebis ganmavlobaSi SeiZleba Civilebs ar warmoadgendes. lokaluri da diseminirebuli martivi herpesiT

167

gamowveuli infeqciis gamomricxavi faqtoria Sesabamisi Civilebisa da simptomebis ar arseboba.

4.diagnostikur _ laboratoriuli testebi da specialistTa konsultaciebi o CD3, CD4, CD8 limfocitebis absoluturi ricxvis gansazRvra, aiv

virusuli datvirTvis gansazRvra polimerizaciis jaWvuri reaqciis meTodiT, sisxlis saerTo analizi, RviZlis funqciuri sinjebi, Tirkmlis funqciuri sinjebi, martivi herpesis virusis kulturis gamoyofa, martivi herpesis deteqcia radio-imunoblotingis meTodi, imunofluoroescenciis an/da monoklonuri antisxeulebiT testirebis meTodebiT, herpesul encefalitze eWvis SemTxvevebSi - Tavis tvinis MAC an MRI skanireba da Tav-zurg-tvinis siTxeSi martivi herpesis dnm-is aRmoCena pjr meTodiT.

5. martivi herpesvirusuli infeqciis msubuqi formis mkurnaloba antivirusuli agenti


M miRebi gza


pirveli rigis sqemebi acikloviri 400 mg 3-jer dReSi PO 7-10 dRe an famcikloviri 250 mg 3-jer dReSi PO 7-10 dRe an valacikloviri 1 g 2-jer dReSi PO 7-10 dRe martivi herpesvirusuli infeqciis recidivis mkurnaloba antivirusuli agenti


M miRebi gza


pirveli rigis sqemebi acikloviri 800 mg 5-jer dReSi PO 7-10 dRe an famcikloviri 500 mg 3-jer dReSi PO 7-10 dRe an valacikloviri 1 g 2-jer dReSi per os 7-10 dRe martivi herpesvirusuli infeqciis mZime formis mkurnaloba antivirusuli agenti


M miRebis gza


pirveli rigis sqemebi acikloviri 10 mg/kg 3-jer dReSi IV 7-10 dRe

an valacikloviri 1 g 2-jer dReSi PO 7-10 dRe

168

martivi herpesvirusuli infeqciis mZime visceraluri formebis mkurnaloba antivirusuli agenti


M miRebi gza


pirveli rigis sqemebi acikloviri 10 mg/kg 3-jer dReSi IV 14-21 dRe meore rigis sqema

foskarneti (aciklovirze rezistentobis SemTxvevebSi)

40-60 mg/kg 3-jer dReSi IV 14 dRe



169

aiv infeqcia/Sidsis fonze ganviTarebuli sartyliseburi liqenis marTvis saxelmwifo standarti (protokoli) 1.daavadebis /nozologiis / sindromis mokle ganmarteba _ aiv infeqcia/Sidsi ewodeba adamianis imunodeficitis virusiT gamowveul infeqciur daavadebas. daavadeba sartyliseburi liqenis gamomwvevia herpesis jgufis mesame tipis virusi Variccela zoster virus (VZV) . SidsiT avadmyofebSi sartyliseburi liqeni multidermatomulia, persistirebs, axasiaTebs Zlieri tkivili da sisuste; SesaZloa moxdes infeqciis diseminacia kanis, nervuli sistemis, filtvebis, lorwovani garsebis CarTviT paTologiur procesSi.

2.kriteriumebi _ a)damadasturebeli _ aiv infeqcia/Sidsis damadasturebeli kriteriumebia: aiv antisxeulebis arseboba sisxlis SratSi imunoblotingis meTodiT, aiv rnm-is raodenobrivad da/an aiv provirus dnm-is Tvisobrivad aRmoCena sisxlSi polimerizaciis jaWvuri reaqciis (pjr) meTodiT. sartylisebuli liqenis damadasturebeli kriteriumia damaxasiaTebeli vezikuluri gamonayaris arseboba dermatomis gaswvriv; cns-is dazianebisas Tav-zurg-tvinis siTxeSi VZV dnm-is aRmoCena pjr meTodiT. b)gamomricxavi _ aiv infeqcia/Sidsis gamomricxavi kriteriumebia: aiv antisxeulebis ar arseboba sisxlis SratSi imunofermentuli meTodiT, raodenobrivad aiv rnm-is da/an Tvisobrivad aiv provirus dnm-is ar arseboba sisxlSi polimerizaciis jaWvuri reaqciis meTodiT. sartyliseburi liqenis gamomricxavi kriteriumebia damaxasiaTebeli vezikuluri gamonayaris ar arseboba kanze. 3.simptomebi da niSnebi a)damadasturebeli _ aiv infeqcia/Sidss paTognomuri klinikuri niSnebi ar gaaCnia. igi miekuTvneba laboratoriulad sadiagnozo daavadebebs. simptomebidan SeiZleba gamovyoT: gaxangrZlivebuli cxeleba, gaxangrZlivebuli faRaraTi, limfadenopaTia, aramotivirebuli profuzuli oflianoba, Zlieri saerTo sisuste, aramotivirebuli wonaSi kleba (erTi Tvis ganmavlobaSi sxeulis wonis 10% da meti), sxvadasxva gamonayari kansa da lorwovanze, kandidozuri ezofagiti, cns-is atipiuri dazianebebi da sxva. sartyliseburi liqenis dros saxezea vezikuluri gamonayari dermatomis gaswvriv, romelsac Tan axlavs Zlieri mtkivneuloba, zogjer cxeleba, regionuli limfadenopaTia, Zlieri sisuste; SesaZloa moxdes infeqciis diseminacia multidermatomuli formis ganviTarebiT, nervuli sistemis, filtvebis da lorwovani garsebis CarTviT paTologiur procesSi. b)gamomricxavi _ aiv infeqcia/Sidsis gamomricxavi simptomebi ar arsebobs, aiv inficirebuli wlebis ganmavlobaSi SeiZleba Civilebs ar warmoadgendes. sartyliseburi liqenis gamomricxavi faqtoria Sesabamisi Civilebisa da simptomebis ar arseboba. 4.diagnostikur _ laboratoriuli testebi da specialistTa konsultaciebi CD3, CD4, CD8 limfocitebis absoluturi ricxvis gansazRvra, aiv virusuli datvirTvis gansazRvra polimerizaciis jaWvuri reaqciis

170

meTodiT, sisxlis saerTo analizi, RviZlis funqciuri sinjebi, Tirkmlis funqciuri sinjebi, VZV sawinaaRmdego antisxeulebis gansazRvra sisxlSi (IgM da IgG klasis), cns-is dazianebisas VZV dnm-is aRmoCena Tav-zurg-tvinis siTxeSi pjr meTodiT.

5.sartyliseburi liqenis sxvadasxva formebis mkurnaloba sartyliseburi liqenis (kanis formis) mkurnaloba antivirusuli agenti


M miRebi gza


pirveli rigis sqemebi acikloviri 800 mg 5-jer dReSi PO 7-10 dRe an

vezikulis gaSrobamdeE

an famcikloviri 500 mg 3-jer dReSi PO 7-10 dRe

an valacikloviri 1 g 3-jer dReSi PO 7-10 dRe Tvalis sartyliseburi liqenis, infeqciis diseminirebuli da visceruli formebis mkurnaloba antivirusuli agenti


M miRebi gza


pirveli rigis sqemebi acikloviri 10 mg/kg 3-jer dReSi IV 7-10 dRe an valacikloviri 1 gr 3-jer dReSi PO 7-10 dRe

an famcikloviri 500 mg 3-jer dReSi PO 7-10 dRe meore rigis sqema foskarneti 60 mg/kg

an 40 mg/kg

2-jer dReSi an 3-jer dReSi

IV 7-10 dRe

6.reabilitacia da dakvirveba post-herpesuli nevralgia xSiri da seriozuli problemaa. dazianebul dermatomebSi viTardeba Zlieri tkivili. tkivilis kontroli mniSvnelovania da tkivilis kupirebis mizniT iniSneba arasteroidul anTebis sawinaaRmdego preparatebi. Tu tkivili gaxangrZlivda iniSneba amitriptilini, karbamazepini an fenitoini.



171

aiv infeqcia/Sidsis fonze ganviTarebuli citomegalovirusuli infeqciis marTvis saxelmwifo standarti (protokoli) 1.daavadebis /nozologiis / sindromis mokle ganmarteba _ aiv infeqcia/Sidsi ewodeba adamianis imunodeficitis virusiT gamowveul infeqciur daavadebas. citomegalovirusuli daavadebis gamomwvevia herpesis jgufis me-4 tipis virusi CMV. SidsiT avadmyofebSi citomegalovirusma Sieleba daazaianos sxvadasxa organoebi da sistemebi. 2.kriteriumebi _ a)damadasturebeli _ aiv infeqcia/Sidsis damadasturebeli kriteriumebia: aiv antisxeulebis arseboba sisxlis SratSi imunoblotingis meTodiT, aiv rnm-is raodenobrivad da/an aiv provirus dnm-is Tvisobrivad aRmoCena sisxlSi polimerizaciis jaWvuri reaqciis meTodiT. citomegalovirusis deteqciisTvis gamoiyeneba misi adreuli antigenis pp65 aRmoCena sisxlSi; pacientebs, romelTa CD4<100 mm3 yovel 3 TveSi unda CautardeT ofTalmoskopia, raTa droulad gamovlindes citomegalovirusuli retiniti. citomegalovirusuli infeqciis sxva lokalizaciis SemTxvevebSi diagnozis dasadgenad saWiroa ZviradRirebuli gamokvlevebis Catareba, maT Soris dazianebuli organoebis bioptatis gamokvleva, dnm-is hibridizaciis meTodis gamoyeneba.

b)gamomricxavi _ aiv infeqcia/Sidsis gamomricxavi kriteriumebia: aiv antisxeulebis ar arseboba sisxlis SratSi imunofermentuli meTodiT, raodenobrivad aiv rnm-is da/an Tvisobrivad aiv provirus dnm-is ar arseboba sisxlSi polimerizaciis jaWvuri reaqciis meTodiT. citomegalovirusuli infeqcia gamoricxulia, rodesac CD4 ujredebis ricxvi metia 200 mm3. 3.simptomebi da niSnebi a)damadasturebeli _ aiv infeqcia/Sidss paTognomuri klinikuri niSnebi ar gaaCnia. igi miekuTvneba laboratoriulad sadiagnozo daavadebebs. simptomebidan SeiZleba gamovyoT: gaxangrZlivebuli cxeleba, gaxangrZlivebuli faRaraTi, limfadenopaTia, aramotivirebuli profuzuli oflianoba, Zlieri saerTo sisuste, aramotivirebuli wonaSi kleba (erTi Tvis ganmavlobaSi sxeulis wonis 10% da meti), sxvadasxva gamonayari kansa da lorwovanze, kandidozuri ezofagiti, cns-is atipiuri dazianebebi da sxva. citomegalovirusuli infeqciis dros simptomebi moicavs:

• cxeleba da diarea - citomegalovirusuli kolitis Ddros dispnoe- pnevmoniis dros sibrmave - retinitis dros citomegalovirusulma infeqciam SeiZleba gamoiwvios piris Rrus

lorwovanis mtkivneuli wylulebi, rac iwvevs kvebis reJimis darRvevas.

172

b)gamomricxavi _ aiv infeqcia/Sidsis gamomricxavi simptomebi ar arsebobs, aiv inficirebuli wlebis ganmavlobaSi SeiZleba Civilebs ar warmoadgendes. citomegalovirusuli infeqciis gamomricxavi faqtoria Sesabamisi Civilebisa da simptomebis ar arseboba. 4.diagnostikur _ laboratoriuli testebi da specialistTa konsultaciebi CD3, CD4, CD8 limfocitebis absoluturi ricxvis gansazRvra, aiv virusuli datvirTvis gansazRvra polimerizaciis jaWvuri reaqciis meTodiT, sisxlis saerTo analizi, RviZlis funqciuri sinjebi, Tirkmlis funqciuri sinjebi, CMV pp65 adreuli antigenis aRmoCena sisxlSi, dazianebuli organoebis bioptatis gamokvleva, CMV dnm-is aRmoCena pjr meTodiT, ofTalmologis konsultacia, gastroenterologis konsultacia, nevropaTologis konsultacia. 5.citomegalovirusuli infeqciebis sxvadasxva formebis mkurnaloba citomegalovirusuli infeqciiT gamowveuli kuW-nawlavis traqtisa da cns-is dazianebebis da retinitis mkurnaloba antivirusuli agenti


M miRebi gza


pirveli rigis sqema gancikloviri 5 mg/kg 2-jer dReSi IV 2-3 kvira meoradi profilaqtikisTvis aucilebelia gancikloviriT 5 mg/kg IV dReSi mkurnaloba. citomegalovirusuli infeqciiT gamowveuli kuW-nawlavis traqtisa da cns-is dazianebebis mkurnaloba antivirusuli agenti


M miRebi gza


meore rigis sqemebi foskarneti 90 mg/kg 2-jer dReSi IV 3 kvira meoradi profialqtikisTvis aucilebelia foskarnetiT mkurnalobis xangrZlivi kursi doziT 90mg/kg IV erTxel dReSi.

173

6.reabilitacia da dakvirveba

citomegalovirusuli retinitis meoradi profilaqtika antivirusuli agenti


M miRebi gza


meore rigis sqemebi Tvalis implantanti, romelic gamoyofs ganciklovirs + valgancikloviri 900 mg erTxel

dReSi PO manamde sanam CD4

ujredebi ricxvi ar moimatebs 100-150 mm3 minimum 3 Tvis ganmavlobaSi

meoradi profilaqtikis Sewyveta SesaZlebelia 6 Tvis Semdeg da imunorekonstituciisas - CD4 100-150 mm3.


aRniSnuli protokoli eyrdnoba jandacvis msoflio organizaciis 2006 wlis gaidlains: “aiv/SidsiT daavadebul mozrdil da mozard pirebSi oportunistuli infeqciebis profilaqtika da mkurnaloba”, aseve protokoli Sejerebulia DHHS, USA-AIS da EACS 2005 wlis oportunistuli infeqciebis mkurnalobis gaidlainebTan. \

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aiv infeqcia/Sidsis fonze ganviTarebuli dermatomikozebis marTvis saxelmwifo standarti (protokoli) 1.daavadebis /nozologiis / sindromis mokle ganmarteba _ aiv infeqcia/Sidsi ewodeba adamianis imunodeficitis virusiT gamowveul infeqciur daavadebas. dermatomikozebi ewodeba kanis sokovan dazianebas, romelic SeiZleba gaCndes sxeulis nebismier adgilze, gamonayari mSralia, aqercvladi, Tan axlavs qavili. 2.kriteriumebi _ a)damadasturebeli _ aiv infeqcia/Sidsis damadasturebeli kriteriumebia: aiv antisxeulebis arseboba sisxlis ratSi imunoblotingis meTodiT, aiv rnm-is raodenobrivad da/an aiv provirus dnm-is Tvisobrivad aRmoCena sisxlSi polimerizaciis jaWvuri reaqciis meTodiT. dermatomikozebis dadasturebisTvis aucilebelia dazianebuli kanis anafxekis mikroskopuli gamokvleva. b)gamomricxavi _ aiv infeqcia/Sidsis gamomricxavi kriteriumebia: aiv antisxeulebis ar arseboba sisxlis SratSi imunofermentuli meTodiT, raodenobrivad aiv rnm-is da/an Tvisobrivad aiv provirus dnm-is ar arseboba sisxlSi polimerizaciis jaWvuri reaqciis meTodiT. dermatomikozis gamomricxavi kriteriumia dazianebuli kanis anafxekis mikroskopiiT gamomnvevis ar arseboba. 3.simptomebi da niSnebi a)damadasturebeli _ aiv infeqcia/Sidss paTognomuri klinikuri niSnebi ar gaaCnia. igi miekuTvneba laboratoriulad sadiagnozo daavadebebs. simptomebidan SeiZleba gamovyoT: gaxangrZlivebuli cxeleba, gaxangrZlivebuli faRaraTi, limfadenopaTia, aramotivirebuli profuzuli oflianoba, Zlieri saerTo sisuste, aramotivirebuli wonaSi kleba (erTi Tvis ganmavlobaSi sxeulis wonis 10% da meti), sxvadasxva gamonayari kansa da lorwovanze, kandidozuri ezofagiti, cns-is atipiuri dazianebebi da sxva. dermatomikozebis dros saxezea sxeulis nebismier adgilze ganviTarebuli mSrali da aqercvladi ubani, romelsac Tan axlavs qavili. b)gamomricxavi _ aiv infeqcia/Sidsis gamomricxavi simptomebi ar arsebobs, aiv inficirebuli wlebis ganmavlobaSi SeiZleba Civilebs ar warmoadgendes. dermatomikozis gamomricxavi faqtoria Sesabamisi gamonayaris ar arseboba kanze. 4.diagnostikur _ laboratoriuli testebi da specialistTa konsultaciebi CD3, CD4, CD8 limfocitebis absoluturi ricxvis gansazRvra, aiv virusuli datvirTvis gansazRvra polimerizaciis jaWvuri reaqciis meTodiT, sisxlis saerTo analizi, RviZlis funqciuri sinjebi, Tirkmlis funqciuri sinjebi, virusli hepatitebis diagnostika, kanis

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dazianebuli ubnis anafxekis mikroskopuli daTvaliereba, dermatologis konsultacia. 5. dermatomikozebis mkurnaloba antifungaluri preparati


M miRebi gza


pirveli rigis sqemebi Mmikonazoli (adgilobrivad gamoyenebisTvis)

3-jer dReSi Aadgilobrivad 21 dRe

an klotrimazoli (adgilobrivad gamoyenebisTvis)

3-jer dReSi adgilobrivad 21 dRe

meore rigis sqemebi ketokonazoli 200 mg dReSi

erTxel PO 1-3 Tve

an itrakonazoli 100 mg dReSi

erTxel PO 1-3 Tve



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aiv infeqcia/Sidsis fonze ganviTarebuli oniqomikozebis marTvis saxelmwifo standarti (protokoli)

1.daavadebis /nozologiis / sindromis mokle ganmarteba _ aiv infeqcia/Sidsi ewodeba adamianis imunodeficitis virusiT gamowveul infeqciur daavadebas. oniqomikozebi warmoadgens frCxilis sokovan dazianebebs, romlebic iwveven frCxilis firfitebis deformaciasa da rRvevas. kriteriumebi _ a)damadasturebeli _ aiv infeqcia/Sidsis damadasturebeli kriteriumebia: aiv antisxeulebis arseboba sisxlis SratSi imunoblotingis meTodiT, aiv rnm-is raodenobrivad da/an aiv provirus dnm-is Tvisobrivad aRmoCena sisxlSi polimerizaciis jaWvuri reaqciis meTodiT. oniqomikozebis damadasturebeli kriteriumia gamomwvevis aRmoCena frCxilis firfitis qvevidan aRebul da kaliumis hidroqsidiT damuSavebul masalaSi mikroskopuli gamokvleviT.

b)gamomricxavi _ aiv infeqcia/Sidsis gamomricxavi kriteriumebia: aiv antisxeulebis ar arseboba sisxlis SratSi imunofermentuli meTodiT, raodenobrivad aiv rnm-is da/an Tvisobrivad aiv provirus dnm-is ar arseboba sisxlSi polimerizaciis jaWvuri reaqciis meTodiT. oniqomikozebis gamomricxavi kriteriumia dazianebuli frCxilis firfitis qvevidan aRebul da kaliumis hidroqsidiT damuSavebul masalaSi gamomwvevis ar arseboba mikroskopuli daTvalierebiT.

3.simptomebi da niSnebi a)damadasturebeli _ aiv infeqcia/Sidss paTognomuri klinikuri niSnebi ar gaaCnia. igi miekuTvneba laboratoriulad sadiagnozo daavadebebs. simptomebidan SeiZleba gamovyoT: gaxangrZlivebuli cxeleba, gaxangrZlivebuli faRaraTi, limfadenopaTia, aramotivirebuli profuzuli oflianoba, Zlieri saerTo sisuste, aramotivirebuli wonaSi kleba (erTi Tvis ganmavlobaSi sxeulis wonis 10% da meti), sxvadasxva gamonayari kansa da lorwovanze, kandidozuri ezofagiti, cns-is atipiuri dazianebebi da sxva. oniqomikozebi iwveven frCxilis firfitebis deformaciasa da rRvevas. b)gamomricxavi _ aiv infeqcia/Sidsis gamomricxavi simptomebi ar arsebobs, aiv inficirebuli wlebis ganmavlobaSi SeiZleba Civilebs ar warmoadgendes. oniqomikozebis gamomricxavi faqtoria Sesabamisi Civilebisa da simptomebis ar arseboba. 4.diagnostikur _ laboratoriuli testebi da specialistTa konsultaciebi CD3, CD4, CD8 limfocitebis absoluturi ricxvis gansazRvra, aiv virusuli datvirTvis gansazRvra polimerizaciis jaWvuri reaqciis

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meTodiT, sisxlis saerTo analizi, RviZlis funqciuri sinjebi, Tirkmlis funqciuri sinjebi, virusuli hepatitis markerebi, masalis aReba dazianebuli frCxilis firfitis qvevidan, kaliumis hidroqsidiT damuSaveba da mikroskopuli daTvaliereba, dermatologis konultacia. 5. oniqomikozebis mkurnaloba pirveli rigis sqemebi antifungaluri preparati


MmiRebi gza


terbinafini 250 mg dReSi erTxel

PO 6 kvira xelis TiTebis dazianebisas an 12 kvira fexis TiTebis dazianebisas

an itrakonazoli 200 mg 2-jer dReSi PO yoveli Tvis I

kviris ganmavlobaSi 2 Tvis manZilze (xelis TiTebis dazianebisas), 3-4 Tve (fexis TiTebi dazianebisas)



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aiv infeqcia/Sidsis fonze ganviTarebuli seboreuli dermatitis marTvis saxelmwifo standarti (protokoli)

1.daavadebis /nozologiis / sindromis mokle ganmarteba _ aiv infeqcia/Sidsi ewodeba adamianis imunodeficitis virusiT gamowveul infeqciur daavadebas. varaudoben, rom seboreuli dermatitis gamomwvevia soko Pitysporu ovale (aseve cnobilia rogorc Malassezia furfur). elementi warmoadgens wiTeli feris laqas, romelic iqercleba. 2.kriteriumebi _

a)damadasturebeli _ aiv infeqcia/Sidsis damadasturebeli kriteriumebia: aiv antisxeulebis arseboba sisxlis SratSi imunoblotingis meTodiT, aiv rnm-is raodenobrivad da/an aiv provirus dnm-is Tvisobrivad aRmoCena sisxlSi polimerizaciis jaWvuri reaqciis meTodiT. seboreuli dermatitis diagnozi dasturdeba sokos aRmoCeniT kanis dazianebuli ubnidan anafxeki masalis mikroskopuli gamokvlevisas.

b)gamomricxavi _ aiv infeqcia/Sidsis gamomricxavi kriteriumebia: aiv antisxeulebis ar arseboba sisxlis SratSi imunofermentuli meTodiT, raodenobrivad aiv rnm-is da/an Tvisobrivad aiv provirus dnm-is ar arseboba sisxlSi polimerizaciis jaWvuri reaqciis meTodiT. seboreuli dermatitis diagnozi gamoiricxeba, Tu kanis dazianebuli ubnidan anafxeki masalis mikroskopuli gamokvlevisas gamomwvevi ar aRmoCndeba. 3.simptomebi da niSnebi a)damadasturebeli _ aiv infeqcia/Sidss paTognomuri klinikuri niSnebi ar gaaCnia. igi miekuTvneba laboratoriulad sadiagnozo daavadebebs. simptomebidan SeiZleba gamovyoT: gaxangrZlivebuli cxeleba, gaxangrZlivebuli faRaraTi, limfadenopaTia, aramotivirebuli profuzuli oflianoba, Zlieri saerTo sisuste, aramotivirebuli wonaSi kleba (erTi Tvis ganmavlobaSi sxeulis wonis 10% da meti), sxvadasxva gamonayari kansa da lorwovanze, kandidozuri ezofagiti, cns-is atipiuri dazianebebi da sxva. seboreuli dermatitis dros saxezea aqerclili wiTeli feris laqa saxeze, cxviris nestoebis irgvliv, cxvir-tuCis naoWze, warbebze, Tavis Tmian nawilze, gul-mkerdis areSi iRliebSi, tanis zeda nawilsa da sazardulis areSi. b)gamomricxavi _ aiv infeqcia/Sidsis gamomricxavi simptomebi ar arsebobs, aiv inficirebuli wlebis ganmavlobaSi SeiZleba Civilebs ar warmoadgendes. seboreuli dermatitis gamomricxavi faqtoria Sesabamisi Civilebisa da simptomebis ar arseboba. 4.diagnostikur _ laboratoriuli testebi da specialistTa konsultaciebi CD3, CD4, CD8 limfocitebis absoluturi ricxvis gansazRvra, aiv virusuli datvirTvis gansazRvra polimerizaciis jaWvuri reaqciis meTodiT, sisxlis saerTo analizi, RviZlis funqciuri sinjebi,

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Tirkmlis funqciuri sinjebi, virusuli hepatitis markerebi, dazianebuli kanis anafxekis mikroskopuli gamokvleva, dermatologis konsultacia. 5.seboreuli dermatitis mkurnaloba

rekomendebulia dazianebuli ubnebis xSirad dabana qerclis mosaSoreblad, karg Sedegs iZleva selenis sulfidis Semcveli samkurnalo Sampunebis gamoyeneba. SesaZloa yvelaze efeqturi aRmoCndes hidrokortizonis 1%-ani mazis aplikaciebi. aseve karg Sedegs iZleva ketokonazolis 2%-ani kremi.



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aiv infeqcia/Sidsis fonze ganviTarebuli munis marTvis saxelmwifo standarti (protokoli) 1.daavadebis /nozologiis / sindromis mokle ganmarteba _ aiv infeqcia/Sidsi ewodeba adamianis imunodeficitis virusiT gamowveul infeqciur daavadebas. daavadeba munis gamomwvevia tkipa Sarkoptes scabiei. mdedr tkipas kanSi gahyavs gasasvleli, romelsac aqvs ramodenime sm sigrZis zedapiridan wamoweuli wiTeli nawiburis Sesaxedaoba. mdedri tkipa gayvanil gasasvlelSi debs kvercxebs da Semdeg gadaadgildeba sxeulis sxva nawilSi. kvercxebidan gamodis tkipebis axali Taoba, romlebic izrdebian, jvardebian, gahyavT axali gasasvlelebi da deben axal kvercxebs.

2.kriteriumebi _ a)damadasturebeli _ aiv infeqcia/Sidsis damadasturebeli kriteriumebia: aiv antisxeulebis arseboba sisxlis SratSi imunoblotingis meTodiT, aiv rnm-is raodenobrivad da/an aiv provirus dnm-is Tvisobrivad aRmoCena sisxlSi polimerizaciis jaWvuri reaqciis meTodiT. munis diagnozi diagnozi ismeba klinikuri gamovlinebebisa da dazianebuli keris anafxekis mikroskopuli gamokvlevis safuZvelze. mikroskopiisas aRmoCndeba tkipebi an/da maTi kvercxebi. b)gamomricxavi _ aiv infeqcia /Sidsis gamomricxavi kriteriumebia: aiv antisxeulebis ar arseboba sisxlis SratSi imunofermentuli meTodiT, raodenobrivad aiv rnm-is da/an Tvisobrivad aiv provirus dnm-is ar arseboba sisxlSi polimerizaciis jaWvuri reaqciis meTodiT. munis gamomricxavi kriteriumebia anafxekis mikroskopisas tkipebis an/da maTi kvercxebis ar arseboba.

3.simptomebi da niSnebi

a)damadasturebeli _ aiv infeqcia/Sidss paTognomuri klinikuri niSnebi ar gaaCnia. igi miekuTvneba laboratoriulad sadiagnozo daavadebebs. simptomebidan SeiZleba gamovyoT: gaxangrZlivebuli cxeleba, gaxangrZlivebuli faRaraTi, limfadenopaTia, aramotivirebuli profuzuli oflianoba, Zlieri saerTo sisuste, aramotivirebuli wonaSi kleba (erTi Tvis ganmavlobaSi sxeulis wonis 10% da meti), sxvadasxva gamonayari kansa da lorwovanze, kandidozuri ezofagiti, cns-is atipiuri dazianebebi da sxva. munis dros kanqveSa gasasvlelis adgilze viTardeba gamonayari, romelic xSirad gvxvdeba: o xelebze - mtevnebze (gansakuTrebiT TiTebs Soris), o majis, idayvis, muxlismomxrel zedapirebze, o winamxris idayviskena zedapirze, o sasqeso asoze, o sarZeve jirkvlebsa da o beWebze. o avadmyofs ZiriTadad awuxebs tanis Zlieri qavili, gansakuTrebiT

RamiT.

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o imunodeficitis mqone pacientebs xSirad uviTardebaT munis mZime forma, romelsac uwodeben norvegiuls. misTvis damaxasiaTebelia vezikuluri gamonayari da sqeli fufxebis warmoqmna mTel sxeulze. munis am formis dros qavili ar aris gamoxatuli.

o qavilis gamo muni xSirad rTuldeba meoradi infeqciebiT.

b)gamomricxavi _ aiv infeqcia/Sidsis gamomricxavi simptomebi ar arsebobs, aiv inficirebuli wlebis ganmavlobaSi SeiZleba Civilebs ar warmoadgendes. munis gamomricxavi faqtoria Sesabamisi Civilebisa da simptomebis ar arseboba. 4.diagnostikur _ laboratoriuli testebi da specialistTa konsultaciebi CD3, CD4, CD8 limfocitebis absoluturi ricxvis gansazRvra, aiv virusuli datvirTvis gansazRvra polimerizaciis jaWvuri reaqciis meTodiT, sisxlis saerTo analizi, RviZlis funqciuri sinjebi, Tirkmlis funqciuri sinjebi, virusuli hepatitis markerebi, dazianebuli keris anafxekis mikroskopuli Seswavla, dermatologis konsultacia. A5.munis mkurnalobaA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA SerCevis preparats warmoadgens adgilobrivad gamosayenebeli 1%-ani gamabenzen heqsaqloridi, romelic ismeba mTels tanze, Tavis garda, mozrdilebSi Camoibaneba 24 sT-Si , xolo bavSvebSi_8sT-Si. sakmarisia erTjeradi damuSaveba. aseve SesaZlebelia kanis damuSaveba 1%-ani permetriniT an 1%-ani lindaniT; es preparatebic ismeba mTels tanze da Camoibaneba 8 sT-Si. permetrinisa da lindanis gamoyeneba ar SeiZleba orsulebisaTvis, meZuZuri dedebisa da bavSvebisaTvis. norvegiuli munis samkurnalod, imunodeficitis mqone pacientebSi, efeqturia ivermeqtini, 200 mg/kg PO erTjeradad. tansacmeli, TeTreuli da pirsaxocebi unda gamoixarSos da dauTovdes gaSrobis Semdeg. munis mkurnaloba unda Cautardes sqesobriv partniors da yvelas vinc sayofacxovrebo kontaqtSi iyo avadmyofTan.



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aiv infeqcia/Sidsis fonze ganviTarebuli stafilokokuri folikulitis marTvis saxelmwifo standarti (protokoli)

1.daavadebis /nozologiis / sindromis mokle ganmarteba _ aiv infeqcia/Sidsi ewodeba adamianis imunodeficitis virusiT gamowveul infeqciur daavadebas. folikuliti _ kanis infeqciaa, romlis drosac procesi Tmis folikulSia lokalizebuli. aiv inficirebulebs xSirad uviTardebaT pustularuli perifolikuliti. folikulits, rogorc wesi, iwvevs Staphylococcus aureus, magram sxva mikroorganizmebsac SeuZlia misi gamowveva. 2.kriteriumebi _ a)damadasturebeli _ aiv infeqcia/Sidsis damadasturebeli kriteriumebia: aiv antisxeulebis arseboba sisxlis SratSi imunoblotingis meTodiT, aiv rnm-is raodenobrivad da/an aiv provirus dnm-is Tvisobrivad aRmoCena sisxlSi polimerizaciis jaWvuri reaqciis meTodiT. stafilokokuri folikulitis diagnozi ismeba klinikuri gamovlinebebis safuZvelze. gamonayari warmodgenilia mravlobiTi wvrili (5 mm diametris), hiperemiuli folikulebiT, romlebic centrSi daCirqebulia. xSirad elementebs aqvT midrekileba gaerTianebisaken. kanis dazianebas Tan axlavs qavili. b)gamomricxavi _ aiv infeqcia/Sidsis gamomricxavi kriteriumebia: aiv antisxeulebis ar arseboba sisxlis SratSi imunofermentuli meTodiT, raodenobrivad aiv rnm-is da/an Tvisobrivad aiv provirus dnm-is ar arseboba sisxlSi polimerizaciis jaWvuri reaqciis meTodiT. stafilokokuri folikulitis gamomricxavi kriteriumia Sesabamisi klinikuri suraTis ar arseboba.

3.simptomebi da niSnebi a)damadasturebeli _ aiv infeqcia/Sidss paTognomuri klinikuri niSnebi ar gaaCnia. igi miekuTvneba laboratoriulad sadiagnozo daavadebebs. simptomebidan SeiZleba gamovyoT: gaxangrZlivebuli cxeleba, gaxangrZlivebuli faRaraTi, limfadenopaTia, aramotivirebuli profuzuli oflianoba, Zlieri saerTo sisuste, aramotivirebuli wonaSi kleba (erTi Tvis ganmavlobaSi sxeulis wonis 10% da meti), sxvadasxva gamonayari kansa da lorwovanze, kandidozuri ezofagiti, cns-is atipiuri dazianebebi da sxva. stafilokokuri folikulitis dros gamonayari warmodgenilia mravlobiTi wvrili (5 mm diametris), hiperemiuli folikulebiT, romlebic centrSi daCirqebulia. xSirad elementebs aqvT midrekileba gaerTianebisaken. kanis dazianebas Tan axlavs qavili. b)gamomricxavi _ aiv infeqcia/Sidsis gamomricxavi simptomebi ar arsebobs, aiv inficirebuli wlebis ganmavlobaSi SeiZleba Civilebs ar warmoadgendes. stafilokokuri folikulitis gamomricxavi faqtoria Sesabamisi gamonayaris ar arseboba.

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4.diagnostikur _ laboratoriuli testebi da specialistTa konsultaciebi CD3, CD4, CD8 limfocitebis absoluturi ricxvis gansazRvra, aiv virusuli datvirTvis gansazRvra polimerizaciis jaWvuri reaqciis meTodiT, sisxlis saerTo analizi, RviZlis funqciuri sinjebi, Tirkmlis funqciuri sinjebi, virusuli hepatitis markerebi, pustulis SigTavsis baqteriologiuri gamokvleva, dermatologis konsultacia. 5. stafilokokuri folikulitis mkurnaloba I rigis preparati cefaleqsini 500 mg PO 4-jer dReSi 7-21 dRe. alternatiuli preparati kloksacilini 500 mg PO 4-jer dReSi 7-21 dRe. 7.gaidlaini, romelsac eyrdnoba aRniSnuli protokoli


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aiv infeqcia/Sidsis fonze ganviTarebuli kontagiozuri moluskis marTvis saxelmwifo standarti (protokoli)

1.daavadebis /nozologiis / sindromis mokle ganmarteba _ aiv infeqcia/Sidsi ewodeba adamianis imunodeficitis virusiT gamowveul infeqciur daavadebas. kontagiozuri moluski _ kanis zedapiruli infeqciaa, romelsac iwvevs kontagiozuri moluskis virusi. aiv inficirebulebSi aiv negatiurebisgan gansxvavebiT: elementebi raodenobrivad bevria, xangrZlivad persistirebs, ufro msxvilia da Znelad eqvemdebareba mkurnalobas. 2.kriteriumebi _ a)damadasturebeli _ aiv infeqcia/Sidsis damadasturebeli kriteriumebia: aiv antisxeulebis arseboba sisxlis SratSi imunoblotingis meTodiT, aiv rnm-is raodenobrivad da/an aiv provirus dnm-is Tvisobrivad aRmoCena sisxlSi polimerizaciis jaWvuri reaqciis meTodiT. kontagiozuri moluskis diagnozi ismeba damaxasiaTebeli elementis aRmoCenisas. specifikuri diagnostikuri testi virusis aRmosaCenad ar arsebobs. b)gamomricxavi _ aiv infeqcia/Sidsis gamomricxavi kriteriumebia: aiv antisxeulebis ar arseboba sisxlis SratSi imunofermentuli meTodiT, raodenobrivad aiv rnm-is da/an Tvisobrivad aiv provirus dnm-is ar arseboba sisxlSi polimerizaciis jaWvuri reaqciis meTodiT. kontagiozuri moluski gamomricxavi kriteriumia Sesabamisi gamonayaris ar arseboba.


a)damadasturebeli _ aiv infeqcia/Sidss paTognomuri klinikuri niSnebi ar gaaCnia. igi miekuTvneba laboratoriulad sadiagnozo daavadebebs. simptomebidan SeiZleba gamovyoT: gaxangrZlivebuli cxeleba, gaxangrZlivebuli faRaraTi, limfadenopaTia, aramotivirebuli profuzuli oflianoba, Zlieri saerTo sisuste, aramotivirebuli wonaSi kleba (erTi Tvis ganmavlobaSi sxeulis wonis 10% da meti), sxvadasxva gamonayari kansa da lorwovanze, kandidozuri ezofagiti, cns-is atipiuri dazianebebi da sxva. kontagiozuri moluskis gamomwvevi kanSi SeRwevisas iwvevs 2-5 mm diametris kanisferi mkvrivi papulebis ganviTarebas. papulebi Seicavs TeTr cximovan sekrets. gamonayaris elementebi SeiZleba ganviTardes sxeulis nebismier adgilas, xSirad iyos ucvlelad mravali Tvis manZilze da/an gaqres da Semdeg kvlav gaCndes.

b)gamomricxavi _ aiv infeqcia/Sidsis gamomricxavi simptomebi ar arsebobs, aiv inficirebuli wlebis ganmavlobaSi SeiZleba Civilebs ar warmoadgendes. kontagiozuri moluskis gamomricxavi faqtoria Sesabamisi gamonayaris ar arseboba.

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4.diagnostikur _ laboratoriuli testebi da specialistTa konsultaciebi CD3, CD4, CD8 limfocitebis absoluturi ricxvis gansazRvra, aiv virusuli datvirTvis gansazRvra polimerizaciis jaWvuri reaqciis meTodiT, sisxlis saerTo analizi, RviZlis funqciuri sinjebi, Tirkmlis funqciuri sinjebi, virusuli hepatitis markerebi, eqim dermatologis konultacia. 5.kontagiozuri moluskis mkurnaloba kontagiozuri moluski mkurnaloba mdgomareobs papulis rbili SigTavsis mocilebaSi, romlis Semdeg papula qreba. mkurnalobis taqtika yvela SemTxvevaSi individualuria. arsebobs kanis dazianebuli ubnis damuSavebis sxvadasxva meTodi. elementebs damuSaveba SesaZlebelia Semdegi meTodebis gamoyenebiT: _ kiuretaJi _ qimiuri destruqcia fenolis koncentrirebuli xsnariT _ krioTerapia _ eleqtrokoagulacia cnobilia, rom aiv inficirebulebSi arT-s dawyeba xels uwyobs kontagiozuri moluskis eliminacias. naCvenebi iyo, rom antivirusuli preparati – cidofoviri, romelsac aqvs Zlieri antiretrovirusuli moqmedeba, aseve efeqturia kontagiozuri moluskis samkurnalod



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aiv infeqcia/SidsiT avadmyofebSi B hepatitis virusiT ko-infeqciis marTvis saxelmwifo standarti (protokoli) 1. daavadebis /nozologiis/sindromis mokle ganmarteba – B hepatiti adamianis B hepatitis virusiT gamowveuli infeqciuri daavadebaa. aiv infeqcia/Sidsi ewodeba adamianis imunodeficitis virusiT gamowveul infeqciur daavadebas. orive paTogeniT erTdroulad daavadebisas saubaria aiv infeqcia/Sidsis da B hepatitis virusiT koinfeqciaze. 2.kriteriumebi –

a) damadasturebeli – aiv infeqcia/Sidsis damadasturebeli kriteriumebia: aiv antisxeulebis arseboba sisxlis SratSi imunoblotingis meTodiT, aiv rnm-is da/an aiv provirusis dnm-is aRmoCena sisxlSi polimerizaciis jaWvuri reaqciis meTodiT; BB hepatitis virusiT daavadebis damadasturebeli kriteriumia HBsAg-is arseboba sisxlis SratSi. imunofermentuli analizis meTodiT. HBsAg-is arseboba > 6 Tveze meti xangrZlivobiT qronikuli HBV infeqciis maCvenebelia. qronikuli HBV infeqciis sxvadasxva variantis sadiagnostiko markerebia: HBeAg, Anti-HBe da HBV DNA.

b) gamomricxavi – aiv infeqcia/Sidsis gamomricxavi kriteriumebia: Aaiv antisxeulebis ararseboba sisxlis SratSi imunofermentuli analizis meTodiT, aiv rnm-is da/an aiv provirus dnm-is ararseboba sisxlSi polimerizaciis jaWvuri reaqciis meTodiT. B hepatitis virusiT infeqciis gamomricxavi kriteriumebia: H HBsAg-is da Anti-HBc antisxeulebis ararseboba sisxlis SratSi.


a)damadasturebeli - aiv infeqcia/Sidss paTognomuri klinikuri niSnebi ar gaaCnia, igi miekuTvneba laboratoriulad sadiagnozo daavadebebs. simptomebidan SesaZloa gamovyoT: gaxangrZlivebuli cxeleba, gaxangrZlivebuli faRaraTi, limfadenopaTia, aramotivirebuli profuzuli oflianoba, Zlieri saerTo sisuste, aramotivirebuli wonaSi kleba (1 Tvis ganmavlobaSi sxeulis wonis 10% an meti), sxvadasxva gamonayari kansa da lorwovanze, kandidozuri ezofagiti, cns-is atipiuri dazianebebi. B hepatiti mwvave stadiaze SesaZloa usimptomod mimdinareobs, umetes SemTxvevaSi mwvave B hepatitis dros avadmyofs aReniSneba zogadad hepatitis niSnebi, rogoricaa: siyviTle, saerTo sisuste, Sardis gamuqeba, ganavlis gaRiaveba, zogjer sxeulis temperatutis momateba, diskomforti muclis RruSi, gulisrevis SegrZneba, Rebineba da sxva intoqsikaciis movlenebi. daavadebam 1.4%-Si SesaZloa miiRos fulminanturi mimdinareoba. avadmyofTa 10-15%-Si daavadeba qronikul mimdinareobas Rebulobs da qronikuli B hepatiti praqtikulad xasiaTdeba usimptomo mimdinareobiT, SesaZlebelia gamoxatuli iyos mxolod zogadi saerTo sisuste.

b) gamomricxavi - qronikul B hepatitis iseve rogorc aiv infeqcia/Sidsis gamomricxavi simptomebi ar arsebobs, qronikul B

187

hepatitiTa da aiv-iT koinficirebuli pacienti wlebis ganmavlobaSi SeiZleba Civilebs ar warmoadgendes.

4.diagnostikur-laboratoriuli testebi yvela HIV dadebiT avadmyofs unda Cautardes gamokvleva HBsAg-ze da anti-HBc antisxeulebze(AII). im SemTxvevaSi, Tu HBsAg uaryofiTia da anti-HBc dadebiTi, maSin avadmyofs unda Cautardes gamokvleva anti-HBs-ze(AII) da gadawydes esaWiroeba Tu ara avadmyofs HBV vaqcinacia. yvela avadmyofs, romelsac aqvs dadebiTi HBsAg unda Cautardes gamokvleva anti-HDV-ze(AII). yvela avadmyofs, romelsac aqvs dadebiTi HBsAg unda unda Cautardes Semdegi gamokvlevebi: HBeAg da anti-HBe, HBV dnm-is gansazRvra, RviZlis ultrabgeriTi gamokvleva, RviZlis biofsia an fibrozis arainvaziuri markerebis gansazRvra RviZlis daavadebis simZimis Sesafaseblad, ALT-is gansazRvra (seriuli), CD3, CD4, CD8 limfocitebis absoluturi ricxvis gansazRvra, aiv virusuli datvirTvis gansazRvra, sisxlis saerTo analizi.

5.mkurnaloba HBV infeqciis mkurnalobis SemTxvevaSi HIV koinfeqciT avadmyofebSi

gaTvaliswinebul unda iqnas 2 ZiriTadi varianti:

1. HBV mkurnalobis algoriTmi HIV koinfeqciiT avadmyofebisTvis, romelTac ar esaWiroebaT arv mkurnaloba. H

HBV/HIV koinfeqciiT avadmyofebi HAART-is

Cvenebis gareSeE.

HBV DNA, ALT, HBeAg

ALT-is normaluri done, HBV DNA-is dabali done

RviZlis araaqtiuri an msubuqi daavadeba**

aqtiuri da/an progresirebadi daavadeba***

RviZlis daavadebis statusi

HBVaqtiuri daavadeba, maRali HBV DNA.*

dinamikaSi dakvirveba

188

*HBV DNA>20000IU/ml HBeAg(+) pozitiurisTvis, HBV DNA>2000IU/ml HBeAg(-) negatiurisTvis. ** Metavir <A2 da/an<F2 *** Metavir >_A2 da/an>_F2 HBV/HIV koinfeqciiT avadmyofebisTvis, romelTac ar esaWiroebaT arv mkurnaloba HBV infeqciis samkurnalod SerCevis preparati aris interferoni. mkurnalobis reJimebi aris Semdegi: 1. HBeAg (+) pozitiuri avadmyofebisTvis. standartuli INF 5-6 MU/dReSi an 10 MU 3-jer kviraSi 4-6 Tve.

2. HBeAg (-) negatiuri avadmyofebisTvis. standartuli INF 3-6 MU 3-jer kviraSi 12 Tve. an 3. PEG-INF 2a 180mkg 1- jer kviraSi 12 Tve. HBeAg/ anti-HBe statusisgan damoukideblad. 4. im SemTxvevaSi Tu interferoni ukunaCvenebia gamoyenebul unda iqnas adefoviri 10mg dReSi.

2. HBV mkurnalobis algoriTmi HIV koinfeqciiT avadmyofebisTvis, romelTac WirdebaT arv mkurnaloba. H

CD4≥500/mm3 CD4<500/mm3

IFN/Peg IFN/ adefoviri HAART romelSic Sedis

tenofoviri+lamivudini an emtricitabini

dinamikaSi dakvirveba

HBV/HIV koinfeqciiT avadmyofebi romelTac

WirdebaT HAART .

maRali HBV DNA dabali HBV DNA

HAART SerCevis reJimi HAART romelSic Sedis tenofoviri + lamivudini an emtricitabini

avadmyofebi ciroziT

lamivudin rezistentuli avadmyofebi

189

HBV/HIV koinfeqciiT avadmyofebisTvis, romelTac esaWiroebaT arv mkurnaloba da HBV mkurnaloba gaTvaliswinebul unda iqnas Semdegi: a) Tu HBV DNA aris maRali koncentraciiT, maSin HAART aucileblad

unda Seicavdes or medikaments romelsac gaaCnia ormagi aqtivoba rogorc HBV aseve HIV mimarT.

b) lamivudinis mimarT rezistentobis SemTxvevaSi, roca HIV infeqcia

kontrolirebadia, erT-erTi NRTI unda Seicvalos tenofoviriT. g) lamivudinis mimarT rezistentobis SemTxvevaSi, roca HIV infeqcia kargad ar kontrolirdeba, pirvel rigSi yuradreba unda mieqces HHAART-s, romelic kargad gaakontrolebs aiv infeqcias da daematos tenofoviri. d) avadmyofebSi romelTac aqvT cirozi HBV mkurnalobis sakiTxi unda gadawydes HBV DNA-s dabali maCveneblis dros. (HBV DNA>200IU/ml). aseT avadmyofebSi interferoni ukunaCvenebia. D fulminanturi mwvave B hepatitis mkurnaloba HIV koinfeqciiT avadmyofebSi Cveulebriv mwvave B hepatiti SemTxvevaTa maRal procentSi mTavrdeba gamojanmrTelebiT da amitom mkurnalobas ar saWiroebs. fulminanturi mwvave B hepatitis SemTxvevaSi lamivudiniT mkurnaloba unda iqnas ganxiluli, miuxedavad aiv-is mimarT rezistentobis ganviTarebis riskisa. tenofoviris da adefoviris daniSvnisgan Tavi unda iqnas Sekavebuli am medikamentebis gamoxatuli nefrotoqsiurobis gamo.


avadmyofebi lamivudinis mimarT rezistentobis gareSi

HAART romelSic Sedis tenofoviri + lamivudini an emtricitabini

unda Canacvldes erTi NRTI tenofoviriT an daematos tenofoviri

190

HBV mkurnalobis efeqturoba HBeAg (+) pozitiur avadmyofebSi fasdeba anti-HBe-is myari serokonversiiT, xolo HBeAg (-) negatiur avadmyofebSi ALT-s myari normalizebiT da HBV dnm-is myari supresiiT(<2000 IU/ml). nukleotidis da nukleozidis analogebiT mkunalobis SemTxvevaSi sawyisi pasuxi mkurnalobaze ganisazRvreba rogorc HBV dnm-is 1 log10-iT SemcirebiT 1-3 Tvis ganmavlobaSi. amis Semdeg HBV dnm-s gansazRvra unda xdebodes yoves 3 TveSi erTjer. mkurnaloba efeqturia Tu HBV dnm aragansazRvradia. rac Seexeba mkurnalobis Sewyvetis sakiTxs (nukleozidis da nkleotidis analogebiT mkurnalobisas) jer-jerobiT amis Taobaze azrTa sxvadasxvaobaa. mkurnaloba sasurvelia gagrZeldes rac SeiZleba didxans, radganac Sewyvetam SesaZloa gamoiwvios RviZlis fataluri daavadeba.

7.gaidlaini romelsac eyrdnoba aRniSnuli protokoli

aRniSnuli protokoli eyrdnoba 2006 wels janmo-s mier evropis regionisTvis gamocemul gaidlains da klinikur protokolebs “ B hepatitis da aiv infeqcia/Sidsis koinfeqciis marTva” da evropis I konsensus konferenciis: “HBV da HCV infeqciebis marTva HIV ko-infeqciiT avadmyofebSi.” (1-2, marti, 2005. parizi, safrangeTi) konsensus dadgenilebas.

191

aiv infeqcia/SidsiT avadmyofebSi C hepatitis virusiT ko-infeqciis marTvis saxelmwifo standarti (protokoli)

1.ganmarteba – C hepatiti adamianis C hepatitis virusiT gamowveuli infeqciuri daavadebaa. aiv infeqcia/Sidsi ewodeba adamianis imunodeficitis virusiT gamowveul infeqciur daavadebas. orive paTogeniT erTdroulad daavadebisas saubaria aiv infeqcia/Sidsis da C hepatitis virusiT koinfeqciaze. 2. kriteriumebi –

a) damadasturebeli – aiv infeqcia/Sidsis damadasturebeli kriteriumebia: aiv antisxeulebis arseboba sisxlis SratSi imunoblotingis meTodiT, aiv rnm-is da/an aiv provirusis dnm-is aRmoCena sisxlSi polimerizaciis jaWvuri reaqciis meTodiT; C hepatitis virusiT daavadebis damadasturebeli kriteriumebia: C hepatitis virusis sawinaaRmdego antisxeulebis arseboba sisxlis SratSi imunofermentuli analizis meTodiT da/an C hepatitis virusis rnm-is aRmoCena sisxlSi polimerizaciis jaWvuri reaqciis meTodiT.

b) gamomricxavi – aiv infeqcia/Sidsis gamomricxavi kriteriumebia: Aaiv antisxeulebis ararseboba sisxlis SratSi imunofermentuli analizis meTodiT, aiv rnm-is da/an aiv provirus dnm-is ararseboba sisxlSi polimerizaciis jaWvuri reaqciis meTodiT. C hepatitis virusiT infeqciis gamomricxavi kriteriumebia: C hepatitis virusis sawinaaRmdego antisxeulebis ararseboba, da/an C hepatitis virusis rnm-is ararseboba sisxlSi polimerizaciis jaWvuri reaqciis meTodiT.

3. simptomebi da niSnebi

a) damadasturebeli - aiv infeqcia/Sidss paTognomuri

klinikuri niSnebi ar gaaCnia, igi miekuTvneba laboratoriulad sadiagnozo daavadebebs. simptomebidan SesaZloa gamovyoT: gaxangrZlivebuli cxeleba, gaxangrZlivebuli faRaraTi, limfadenopaTia, aramotivirebuli profuzuli oflianoba, Zlieri saerTo sisuste, aramotivirebuli wonaSi kleba (1 Tvis ganmavlobaSi sxeulis wonis 10% an meti), sxvadasxva gamonayari kansa da lorwovanze, kandidozuri ezofagiti, cns-is atipiuri dazianebebi; C hepatiti mwvave stadiaze ZiriTadad usimptomod mimdinareobs, mxolod SemTxvevaTa 25%-Si SeasaZloa gamovlindes simptomebi: siyviTle, saerTo sisuste, Sardis gamuqeba, ganavlis gaRiaveba, zogjer sxeulis temperatutis momateba, diskomforti muclis RruSi, gulisrevis SegrZneba, Rebineba da sxva intoqsikaciis movlenebi. daavadeba SemTxvevaTa 80%-Si qronikul mimdinareobas Rebulobs da qronikuli C hepatiti praqtikulad xasiaTdeba usimptomo mimdinareobiT, SesaZlebelia gamoxatuli iyos mxolod zogadi saerTo sisuste. aqedan gamomdinare C hepatitic miekuTvneba laboratiriulad dasiagnostiko daavadebebs.

192

b) gamomricxavi - aiv infeqcia/Sidsis gamomricxavi simptomebi da niSnebi ar arsebobs, aiv inficirebuls wlebis ganmavlobaSi SesaZloa simptomebi ar aReniSnebodes; C hepatitis virusiT infeqciis simptomebi da niSnebi aseve ar arsebobs da avadmyofs wlebis ganmavlobaSi SesaZloa ar aReniSnebodes araviTari simptomi.

4. diagnostikur-laboratoriuli testebi.

yvela HIV dadebiT avadmyofs udna Cautardes gamokvleva anti-HCV antisxeulebze(AII). Anti-HCV (+) pozitiuri Sedegis SemTxvevaSi unda Catardes HCV RNA-s gansazRvra. yvela avadmyofs, romelsac aqvs HCV RNA (+) pozitiuri unda Catardes Semdegi gamokvlevebi:

1. ΗCV genotipis gansazRvra . 2. HCV virusuli datvirTvis gansazRvra. 3. sisxlis saerTo analizi, ALT, AST, G-GT, kreatinini. 4. RviZlis ultrabgeriTi gamokvleva. 5. RviZlis biofsia an fibrozis arainvaziuri markerebis

gansazRvra RviZlis daavadebis simZimis Sesafaseblad 6 CD3, CD4, CD8 limfocitebis absoluturi ricxvis gansazRvra, aiv virusuli datvirTvis gansazRvra.

5. mkurnaloba

HCV infeqciis samkurnalod HCV/HIV ko-infeqciiT avadmyofbSi gamoiyeneba kombinirebuli antivirusuli mkurnaloba pegilirebuli alfa interferoniT da ribaviriniT.

mwvave C hepatitis mkurnalobis sakiTxi ko_infeqciiT avadmyofebSi jer-jerobiT sabolood gadaWrili ar aris. qronikuli C hepatitis mkurnaloba: Tu qronikuli C hepatitis diagnozi ganisazRvra aiv infeqciis adreul stadiaze (manamde, sanam avadmyofs ar Wirdeba HAART mkurnaloba) HCV infeqciis mkurnaloba dawyebul unda iqnas. (AIII).

Tu ko-infeqciT avadmyofebs aqvT Rrma imunodeficiti, jer dawyebul unda iqnas HAART da HCV mkurnalobis sakiTxi ganxilul unda iqnas mxolod CD4 ujredebis raodenobis momatebis Semdeg.(AII).

HCV infeqciis mkurnalobis rejimi HIV koinfeqciiT avadmyofebSi interferoni:

- PEG-IFN alpha 2α- 180 mkg 1 Xjer kviraSi an PEG-IFN alpha 2b 1.5 mkg/kg kviraSi erTxel.

ribavirini - HCV 1 da HCV 4 genotipiT avadmyofebisTvis maRali virusuli

datvirTviT ribavirini 1000-1200 mg dReSi 1-jer (mkurnalobis dawyeba)(BIII)

193

- yvela sxva SemTxvevaSi (maT Soris HCV 1 da HCV 4 genotipiT avadmyofebisTvis dabali virusuli datvirTviT) ribavirini 800 mg dReSi 1-jer (AII).

HIV/HCV ko-infeqciiT avadmyofebSi, genotipisgan damoukideblad mkurnalobis xangrZlivoba Seadgens 48 kviras (BI). HCV infeqciis mkurnalobis algoriTmi HCV/HIV koinfeqciiT avadmyofebSi

HCV/HIV koinfeqcia

CD4+ <200/mm3

HCV RNA (+) dadebiTi

HCV 1an 4 genotipi virusuli datvirTva (>800, 000 IU/ml)

HCV 1 genotipi virsuli datvirTva (<800, 000 IU/ml)

HCV 2,3 genotipi virusuli datvirTva maRali/dabali

HAARTCD4+ >200/mm3

( 200-350 mm3)

HCV mkurnaloba

HCV mkurnalboba naCvenebia

daavadebis simZimis Sefaseba: RviZlis biofsia, fibro testi da sxva,

msubuqi daavadeba

F0-F1 saSualo simZimis da mZime

F2-F4

dakvirveba dinamikaSi

mkurnalobis xangrZlivoba 48 kvira

194

pegilirebuli interferonis da ribavirinis dozis cvlilebebi mkurnalobis dros ganviTarebuli hematologiuri cvlilebebis dros

medikamentebis dozis cvlilebebi

ribavirinis Semcireba 600 mg -mde

ribavirinis

Sewyveta

PEG-IFN-is Semcireba

70%,50%, 25%-iT

PEG-IFN Sewyveta

kombinirebuli mkurnalobis Sewyveta

neitrofilebi <750/mm3 <500/mm3

Trombocitebi 25 000– 50 000/mm3 <25 000/mm3

hemoglobini (gulis daavadebis gareSe)

8.5–10.0 g/dl <8.5 g/dl

gulis stabiluri daavadeba

≥2 g/dl –iT daqveiTeba nebismieri 4 kviris ganmavl-Si

<12 g/dl

HIV ko infeqciiT avadmyofebSi HCV mkurnalobis ukuCvenebebi: • orsuloba • kardiopaTia, rogoricaa gulis ukmarisoba da iSemiuri daavadeba. • fsiqiuri sferos darRvevebi • alkoholis aqtiuri moxmareba (>50 g/dRe) • dekompensirebuli cirozi (Child-Pugh C) HCV infeqciis mkurnalobis dros ganviTarebuli gverdiTi movlenebis marTva

avadmyofebSiPPEG-INF + ribavirinis kombinaciiT mkurnalobisas ganviTarebuli gverdiTi movlenebis marTvisTvis rekomendebulia Semdegi saSualebebi.

mmeenneejjmmeennttii ggvveerrddiiTTii mmoovvlleenneebbii

paracetamoli

(SesaZlebelia kombinacia anTebis sawinaaRmnego arasteroidebTan) eriTropoetini zrdis faqtori

gripismagvari sindromisTvis (AII).

mZime anemiis SemTxevaSi (BI). mZime neitropeniis SemTxvevaSi (CIII).

195

mmeenneejjmmeennttii ggvveerrddiiTTii mmoovvlleenneebbii

antidepresantebi (seleqtiuri serotoninis ukumitacebis inhibitori) Tireoiduli hormoni β-blokatorebi

klinikurad gamoxatuli depresiis SemTxvevaSi(ΑΙΙ)

hipoTireozis dros (AII).

hiperTireozis dros (CIII).

• Tanmxlebi antiretrovirusuli medikamentebis gamoyeneba.

PEG- intrferoniT da ribaviriniT kombinirebuli mkurnalobis dros cirozian avadmyofebSi didanozini (ddI) ukunaCvenebia(EI) da aseve sasurvelia ar iqnas gamoyenebuli RviZlis naklebad mZime dazianebis dros.(EII). PEG- intrferoniT da ribaviriniT kombinirebuli mkurnalobis dros stavudini (d4T) gansakuTrebiT didanozinTan(ddI) kombinaciaSi ar unda iqnas gamoyenebuli, radgan am dros izrdeba laqtat acidozis ganviTarebis riski.(EII). aseve HCV –s kombinirebuli antivirusuli mkurnalobis dros HIV ko-infeqciiT avadmyofebSi zidovudinis gamoyenebisgan Tavi unda iqnas Sekavebuli, radgan zidovudini zrdis anemiis da neitropeniis ganviTarebis risks(DII). PI –s gamoyeneba amcirebs myari virusuli pasuxis(SVR) ganviTarebis albaTobas HIV/HCV ko-infeqciiT avadmyofebSi, Tumca jer-jerobiT kategoriuli uaryofiTi rekomendaciebi PI –s gamoyenebis mimarT ar aris. NVP (nevirapini) sifrTxiliT unda iqnas gamoyenebuli(AII).


HCV antivirusul mkurnalobaze myofi avadmyofebis monitoringi, mkurnalobis tolerantobis da mkurnalobis efeqturobis Sefasebis mizniT

maCveneblebi 1,2

4

8

12

16

20

24

28

32

34

36

48

72

mkurnalobis tolerantoba

sisxlis saerTo Trombocite

X

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

196

bi

CD4 X X X X X X X X X

TSH X X X HCV RNA

raodenobrivi (VL)

X

mkurnalobis efeqturoba

HCV RNA Tvisobrivi

X

X X

antivirusuli mkurnalobis dawyebidan 12 kviraze Tu HCV virusuli datvirTva gaxda aragansazRvradi an Semcirda sul cota 2 log10-iT, es niSnavs, rom mkurnalobaze adreuli virusuli pasuxi(EVR) miRebulia da mkurnaloba unda gagrZeldes.

Tu HCV virusuli datvirTva ar Semcirda sul cota 2 log10-iT, mkurnaloba unda Sewydes, radgan aseT SemTxvevaSi myari virusuli pasuxis(SVR) ar miReba mosalodnelia daaxloebiT 99-100%-Si.(AII).

zemoT aRniSnuli vrceldeba HCV nebismieri genotipiT avadmyofze. amis Semdeg mkurnalobis dawyebidan 24 kviraze rekomendebulia HCV

RNA –is (Tvisobrivi) gansazRvra da im avadmyofebSi, romlebic am etapze rCebian HCV RNA (+) pozitiuri, mkurnaloba unda Sewydes. (radgan aseT SemTxvevaSi myari virusuli pasuxis(SVR) ar miiReba mosalodnelia daaxloebiT 99-100%-Si.)

mkurnalobis dawyebidan 48 kviraze unda ganisazRvros HCV RNA (Tvisobrivi) da miRebuli Sedegi daafiqsirebs mkurnalobis bolo pasuxs. (EOT)

mkurnalobis damTavrebidan 6 Tvis Semdeg kvlav unda ganisazRvros HCV RNA (Tvisobrivi). negatiuri HCV RNA mianiSnebs myari virusuli pasuxis (SVR) miRebaze, ris Semdegac daavadebis recidivis ganviTareba Zalian iSviaTia.

Semdgomi gamokvleva SesaZloa Catardes 12-24 Tvis Semdeg mkurnalobis damTavrebidan.

7. gaidlaini romelsac eyrdnoba aRniSnuli protokoli

aRniSnuli protokoli eyrdnoba 2006 wels janmo-s mier evropis regionisTvis gamocemul gaidlains da klinikur protokolebs “ C hepatitis da aiv infeqcia/Sidsis koinfeqciis marTva” da evropis I konsensus konferenciis: “HBV da HCV infeqciebis marTva HIV ko-infeqciiT avadmyofebSi.” (1-2, marti, 2005. parizi, safrangeTi) konsensus dadgenilebas.

197

aiv infeqcia/Sidsis da tuberkulozis koinfeqciis marTvis saxelmwifo standarti (protokoli)

1.ganmarteba – aiv infeqcia/Sidsi ewodeba adamianis imunodeficitis virusiT gamowveul infeqciur daavadebas. tuberkulozis gamomwvevia tuberkulozis mikobaqteria. orive paTogeniT erTdroulad daavadebisas saubaria aiv infeqcia/Sidsis da tuberkuloziT koinfeqciaze. 2.kriteriumebi –

a) damadasturebeli – aiv infeqcia/Sidsis damadasturebeli kriteriumebia: aiv antisxeulebis arseboba sisxlis SratSi imunoblotingis meTodiT, aiv rnm-is raodenobrivad da/an aiv provirusis dnm-is Tvisobrivad aRmoCena sisxlSi polimerizaciis jaWvuri reaqciis meTodiT; tuberkuloziT daavadebis damadasturebeli kriteriumia: avadmyofis biologiur masalaSi (maT Soris naxvelis nacxSi) mJavagamZle baqteriebis (mgb) arseboba, biologiur masalaSi kulturaluri meTodiT tuberkulozis mikobaqteriis aRmoCena.

b) gamomricxavi – aiv infeqcia/Sidsis gamomricxavi kriteriumebia: Aaiv antisxeulebis ararseboba sisxlis SratSi imunofermentuli meTodiT, raodenobrivad aiv rnm-is da/an Tvisobrivad aiv provirus dnm-is ararseboba sisxlSi polimerizaciis jaWvuri reaqciis meTodiT; tuberkulozis gamomricxavi kriteriumebia: tuberkulozis damaxasiaTebeli klinikuri niSnebisa da simptomebis ar arseboba, biologiur masalaSi (maT Soris naxvelis nacxSi) baqterioskopiiT mgb-sa da kulturaluri gamokvleviT tub.mikobaqteriis ar arseboba.


a)damadasturebeli - aiv infeqcia/Sidss paTognomuri klinikuri niSnebi ar gaaCnia, igi miekuTvneba laboratoriulad sadiagnozo daavadebebs. simptomebidan SesaZloa gamovyoT: gaxangrZlivebuli cxeleba, gaxangrZlivebuli faRaraTi, limfadenopaTia, aramotivirebuli profuzuli oflianoba, Zlieri saerTo sisuste, aramotivirebuli wonaSi kleba (1 Tvis ganmavlobaSi sxeulis wonis 10% an meti), sxvadasxva gamonayari kansa da lorwovanze, kandidozuri ezofagiti, cns-is atipiuri dazianebebi; tuberkulozis damadasturebel simptomebs miekuTvneba: zogadi niSnebi: subfebriliteti, Ramis oflianoba, advilad daRla, saerTo sisuste, Sromis unaris daqveiTeba, taqikardia. tuberkulozis filtvis formis dros zogad simptomatikas emateba: 2 kviris an meti xangrZlivobis xveleba (produqtiuli, mSrali an sisxliani), haeris ukmarisoba, usiamovno SegrZneba an tkivili gulmkerdSi; tuberkulozis filtvgareSe formebis dros ki zogado intoqsikaciis niSnebs emateba ama Tu im organos dazianebisaTvis damaxasiaTebeli lokaluri simptomatika.

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b)gamomricxavi - aiv infeqcia/Sidsis gamomricxavi simptomebi da niSnebi ar arsebobs, aiv inficirebuls wlebis ganmavlobaSi SesaZloa simptomebi ar aReniSnebodes; tuberkulozis gamomricxavi niSnebi da simptobebia Civilebis ararseboba, kontaqtis ar arseboba aqtiuri tuberkuloziT daavadebulTan; mdgomareobebi dakavSirebuli aqtiur tuberkulozTan bavSvebSi tuberkulozi saeWvoa, rodesac adgili aqvs

• anamnezSi kontaqts filtvis tuberkulozis dadasturebul SemTxvevasTan

• wiTelas gadatanis Semdeg imunosupresiul mdgomareobas

• wonaSi klebas, xvelas, paTologiur auskultaciur monacemebs filtvebSi, romelic ar daeqvemdebara farTo speqtris antibiortikoTerapias

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

• tuberkulozis kanis testi 5 mm-ze meti induraciiT

• Sesabamisi cvlilebebi gulmkerdis rentgenogramaze

• Sesabamisi histologiuri cvlilebebi biofsiur masalaSi

• dadebiTi Sedegi antituberkulozur mkurnalobaze tuberkulozi dadasturebulia, roca

• tuberkulozis mikobaqteria identificirebulia biologiur sekretebSi an qsovilebSi

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

4.diagnostikur-laboratoriuli testebi da specialistTa konsultaciebi CD3, CD4, CD8 limfocitebis absoluturi ricxvis gansazRvra, aiv virusuli datvirTvis gansazRvra, sisxlis saerTo analizi, RviZlis funqciuri sinjebi, Tirkmlis funqciuri sinjebi, virusuli hepatitis markerebis gansazRvra, naxvelis nacxis gamokvleva mgb-ze, gul-mkerdis rentgenologiuri gamokvleva, muclis Rrus eqoskopia; eqin-infeqcionistis konsultacia, eqim-fTiziatris konsultacia;

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5.mkurnaloba

tuberkulozis mkurnaloba aiv inficirebul pacientebSi unda daiwyos aqtiuri tuberkulozis diagnozis dadasturebidan rac SeiZleba male. aqtiuri tuberkulozis mkurnalobisTvis rekomendirebuli reJimebi aiv inficirebul pacientebSi

tuberkulozis mkurnalobis reJimebi1

tuberkulozis SemTxvevis tipi

intensiuri faza2 gagrZelebis faza

axali tbB pacienti HRZE 2 Tvis ganmavlobaSi 3

HR 4 Tvis ganmavlobaSi

adre tb-namkurnalebi pacienti, maT Soris

• relafsi

• mkurnaloba misi Sewyvetis Semdeg

• sxva SemTxveva

• uSedego mkurnaloba 4

HRZES 2 Tvis ganmavlobaSi an HRZE 1 Tvis ganmavlobaSi

HRE 5 Tvis ganmavlobaSi

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

specialuri reJimi

H –izoniazidi, R – rifampicini, Z – pirazinamidi, E – etambutoli, S- streptomicini. 1 – aiv inficirebuli pacientebisaTvis aqtiuri tuberkuloziT mkurnalobis yoveldRiuri reJimia rekomendirebuli; 2 - rekomendebulia mkurnaloba uSualo zedamxedvelobis qveS Catarebuli qimioTerapiis mTeli kursis ganmavlobaSi. 3 – streptomicini SesaZloa gamoyenebul iqnes etambutolis nacvlad. tuberkulozuri meningitisas etambutoli unda Seicvalos streptomiciniT. 4- yvela SemTxvevaSi unda Catardes wamlebis mimarT mikroorganizmis mgrZnobelobis Seswavla mkurnalobis reJimis individualuri wesiT SesarCevad.

tuberkulozis mkurnalobisTvis aiv inficirebul bavSvebSi rekomendirebulia igive reJimebi, rac mozrdilebSi. preparatebis dozireba xdeba sxeulis masis Sesabamisad.

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pirveli rigis antituberkulozuri medikamentebis rekomendebuli dozebi medikamentebi dRiuri dozebi 1

(Cveuli doza an zRvruli)

kviraSi samjer miRebisTvis

gaTvaliswinebuli dozebi

(Cveuli doza an zRvruli)

izoniazidi 5 mg/kg (Cveulebriv 300 mg)

10 mg/kg (Cveulebriv 900 mg)

rifampicini 10 mg/kg (450 mg TuU <50 kg 600 mg Tu >50 kg)

10 mg/kg (450 mg TuU <50 kg 600 mg Tu >50 kg)

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

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

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

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

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

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

1. rodesac rifampicini gamoiyeneba antiretrovirusul

medikamentebTan erTad, rekomendebulia yoveldRiuri reJimiT mkurnaloba

rekomendirebuli pirveli rigis mmaaaarrTT reJimi tb

pacientebisaTvis, romlebsac eZlevaT rifampicini1 maarT arv preparatebis

kombinacia sasurvelia

2 nrti (nukleoziduri revers transkriftazas inhibitori) ++ 1 aannttrrii (aranukleoziduri revers trankriftazas inhibitori)

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

alternatiuli

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

1 – dozireba ix me-2 damatebaSi 2 - rekomendirebulia efavirenzis dozireba 600 mg/dR gansakuTrebiT <60 kg wonis pacientebSi. dozis gazrda 800 mg/ dReSi saWiroa >60kg pacientebSi, Tumca es debuleba saWiroebs Semdgom kvlevas. nevirapini SesaZloa gamoyenebul iqnas (200 mg erTxel 2 kviris ganmavlobaSi, Semdeg 200 mg orjer), RviZlis funqciuri testebis da wamlis toqsiurobis kontroliT.

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rekomendirebuli meore rigis mmaaaarrTT reJimi tb pacientebisaTvis maarT arv preparatebis

kombinacia sasurvelia

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

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

alternatiuli

2 nnrrttii ++ 2 ppii

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

rekomendebuli tb reJimebi Tirkmlis daavadebis mqone pacientebisTvis 1

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

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

rekomendebuli tb reJimebi pacientebSi RviZlis daavadebebiT 1

intensiuri faza gagrZelebis faza SerCevis preparati SHRE 2 Tve HR 6 Tve I alternativa SHE 2 Tve HE 10 Tve II alternativa RE 9 Tve

1. RviZlis daavadebad iwodeba mdgomareoba, rodesac alaninaminotransferaza samjer aRemateba normis maCvenebels an Tu saxezea qronikuli hepatiti an cirozi.


arv da tb mkurnalobaze myofi pacientebis monitoringi

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

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

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testebi:

• sisxlis saerTo analizi

• RviZlis funqciuri sinjebi (alt, ast, bilirubinebi)

• kreatinini

• Sardovana

CD4 ujredebi X X X X

virusuli datvirTva X X X Xgul-mkerdis rentgenologiuri gamokvleva

X X

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

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


aRniSnuli protokoli eyrdnoba janmo-s mier evropis regionisTvis 2006 wels gamocemul gaidlains ”tuberkulozisa da aiv infeqcia/DSidsis koinfeqciis marTva”, aseve, Sejerebulia DHHS, USA-IAS da EACS 2005 wlis ”tb/aiv koinfeqciis” marTvis gaidlainebTan.

Documents

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