aiv infeqcia/Sidsis dedidan bavSvze gadacemis profilaqtika

(saxelmZRvanelo-rekomendacia efuZneba janmos 2007 wlis klinikur protokols evropis regionisTvis adaptirebulia

saqarTvelosTvis)

2008 weli

P

protokolis redaqtori:

Tengiz cercvaZe - infeqciuri paTologiis, 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

Pprotokolis avtorebi:

Ffati gabunia infeqciuri paTologiis, Sidsis da klinikuri imunologiis s/p centri, #2 boqsirebuli ganyofilebis gamge, medicinis doqtori

Nnino ruxaZe infeqciuri paTologiis, Sidsis da klinikuri

imunologiis s/p centri, #2 boqsirebuli ganyofilebis eqimi infeqcionisti

koreqtura:

nino lanCava infeqciuri paTologiis, Sidsis da klinikuri imunologiis s/p centri, #2 boqsirebuli ganyofilebis eqimi infeqcionisti

I. ZiriTadi koncefcia

dedidan bavSvze adamianis imunodeficitis virusis (aiv) gadacemis klinikuri profilaqtika (dbgp) unda Seadgendes aiv-inficirebul dedaTa da bavSvTa pirveladi kompleqsuri daxmarebis nawils. dbgp samsaxuri unda TanamSromlobdes aiv-infeqcia/Sidsis mkurnalobisa da daxmarebis samTavrobo da arasamTavrobo organizaciebTan, reproduqciuli janmrTelobis dacvis, pediatriuli da narkologiuri daxmarebis, narkotikebis mavneblobis Semcirebis, fsiqologiuri da socialuri mxardaWeris, bavSvTaA dacvisa da sxva samsaxurebTan.

ineqciuri narkotikebis momxmarebeli orsuli qalebi diskriminaciis gareSe unda Rebulobdnen yovelgvar samedicino daxmarebas, antiretrovirusul Terapias (arT), reproduqciuli janmrTelobis SemanarCunebel da dbgp da sameano daxmarebas, iseve rogorc is qalebi, romlebic narkotikebs ar moixmaren.

yvela samedicino dokumentacia, miuxedavad imisa Seicavs Tu ara informacias aiv infeqciaze, unda inaxebodes saeqimo saidumlis Senaxvis Sesabamisad. es dokumentacia xelmisawvdomi unda iyos mxolod medmuSakisTvis, romelic uSualod aRmouCens daxmarebas pacients.

II. saerTo monacemebi aiv inficirebul qalTa umravlesobas unda orsulobis SenarCuneba; amasTan, maRalia riski axalSobilis inficirebisa intranatalurad, mSobiarobis dros da ZuZuTi kvebisas. Tu

ar miviRebT saTanado RonisZiebebs dedidan bavSvze gadacemis riski 15-30%-ia; ZuZuTi kvebisas ki riski matulobs 20-45%-mde (1).

dReisTvis arsebobs dbgp-s efeqturi meTodebi. iq sadac es meTodebi xelmisawvdomia da gamoiyeneba, dedidan bavSvze gadacemis riski klebulobs 1-2%-mde (1-3). am meTodebs miekuTvneba:

antiretrovirusuli profilaktika (arv-profilaktika), romelsac dedebs utareben osulobisa da mSobiarobis periodSi da bavSvebs sicocxlis pirvel kviraSi;

sameano Careva, sakeisro kveTis CaTvliT; ZuZuTi kvebaze uaris Tqma (4-6).

dReisaTvis janmo-s evropis regionSi dgas amocana Semcirdes aiv-infeqciis dedidan bavSvze gadacema, gansakuTrebiT im qveynebSi sadac aiv-infeqciis epidemia matulobs ineqciuri narkotikebis moxmarebis xarjze da gardamavali ekonomikuri mdgomareobis gamo jandacvis sistema dasustebulia. mSobiarobamde daxmarebis arseboba, ganviTarebuli jadacvis infrastruqtura, aiv infeqciis SedarebiT dabali gavrceleba da xelmisawvdomi da efeqturi dbgp, qmnis xelsayrel garemos regionSi bavSvTa aiv-infeqciis aRmosafxvrelad.

janmo wamogvidgens axalSobilebsa da bavSvebSi aiv-infeqciis profilaqtikis kompleqsur strategias, romelic wamodgenilia 4 mimarTulebiT:

1. aiv infeqciis pirveladi profilaqtika;2. aiv inficirebul qalebSi arasasurveli orsulobis Tavidan acileba;3. aiv-is dedidan bvSvze gadacemis profilaktika;4. aiv inficirebul dedebisa da maTi ojaxebisaTvis mkurnalobis, daxmarebisa da

daxmarebis aRmoCena (7).

Aam TavSi ganxilulia mesame mimarTuleba- aiv-is dedidan bavSvze gadacemis profilaqtika da Seesabameba axalSobilebSi aiv-infeqciis proflaqtikis regionalur mizans evropaSi (8): dagegmilia, rom 2010 wlisTvis axalSobilebSi aiv infeqciis sixSire Semcirdes <1 SemTxvevamde 100 000 cocxladSobilze da aiv inficirebuli bavSvebis ricxvi Semcirdes < 2%-mde.

evropis miznebi Seesabameba globalur miznebs, romelic dasmul iqna aiv infeqcia/Sidsisdmi miZRvnil gaeros generaluri ansambleis specialur sesiaze: 2001w. - 2010 wlisTvis aiv inficirebul baSvTa wili Semcirdes 50%-iT.

III. pirveladi gamokvleva

1. mSobiarobamde daxmarebis centrebSi orsulTa pirveladi gamokvlevamSobiarobamde konsultacia da aiv-ze testireba _ efeqturi samedicino Carevaa, romelic saSualebas gvaZlevs SevamciroT aiv-is dedidan bavSvze gadadebis sixSire. garda amisa, es xelsayreli momentia aiv-inficirebul qalebisa da bavSvebisTvis mkurnalobis dawyebisa da mxardaWerisTvis.

Aiv infeqciaze testirebis SeTavazeba saSualebas gvaZlevs orsulobis adreul stadiaze gamovavlinoT aiv infeqcia, gavataroT dbgp RonisZiebebi da SevamciroT aiv-is gadacemis riski orsulobis, mSobiarobisa da mSobiarobis Semdgom periodSi.

aiv-ze testireba nebayoflobiTia da tardeba Zaldatanebis gareSe. qalma aunda warmoadginos werilobiTi Tanxmoba da aseve ufleba aqvs uari ganacxados testirebaze. testirebasTan erTad saWiroa konsultaciis Catareba.

Aiv statusis gamovlenis pirveladi Sefaseba moicavs: testrebamde konsultacia; aiv antisxeuleze gamokvleva (Cveulebriv imunofermentuli analizi (ifa) an/da

eqspres testi) da ifa-s dadebiTi rezultatis dadastureba imunoblotiT; testis Semdgomi kosultacia;

Tu qali aiv inficirebulia, saWiroa gavagrZeloT gamokvleva aiv infeqciis specialistis monawileobiT, daavadebis klinikuri stadiis dasadgenad da dbgp-is gegmis Sesadgenad.testirebamde konsultaciis mizania gamovavlinoT nebismieri saxis narkotikebis momxmarebeli (maT Soris ineqciuri), aseve SevafasoT qalis seqsualuri partniorisgan inficirebis riski. narkotikebis gamoyeneba, gansakuTrebiT maTze damokidebleba, uaryofiTad moqmedebs orsulobis mimdinareobasa da nayofis ganviTarebaze da saWiroebs, rogorc dedis, aseve nayofis/bavSvis, specilizirebul daxmarebas orsulobis, mSobiarobisa da mSobiarobis Semdom periodSi.

Uufro dawvrilebiT narkotikuli damokidebulebisa da abstinenciis Sefaseba mocemulia IV.2.3 qveTavSi.

2 konsultaciapirveladi gamokvlevis Semdgom aiv inficirebul orsuls unda CavutaroT konsultacia Semdeg sakiTxebze, konkretuli situaciis Sesabamisad:

sqesobrivi kontaqtis dros prezervativis gaoyeneba aiv infeqciisa da sxva sqesobrivi gziT gadamdebi infeqciebis gadacemis profilaqtikis mizniT;

aiv-is nayofze/axalSobilze gadacemis riski da profilaqtikuri saSualebebi; arv profilaqtikis riski da sargebeli, romelic warmoadgens dbgp strategiis

nawils; vrusuli B da C hepatitebis perinataluri gadadebis riski da maTi Semcirebis

gzebi; sifilisis perinataluri gadadebis riski; sifilisis, gonoreas da qlamidiozis

mkurnalobis aucilebloba aiv-is gadadebis riskis Sesamcireblad; narkotikebis zegavlena nayofze, abstinenciis sindromisa da wamalTa

urTierTzemoqmedebis CaTvliT; narkotikebis mavneblobis Semcirebisa da damokidebulebis mkurnalobis

mizniT centrSi gagzavna da saWiroebis SemTxvevaSi CanacvlebiTi TerapiSi CarTva;

mSobiarobis marTvis gavlena aiv-is gadacemis riskze; sakeisro kveTis riski da sargebeli;

rekomendaciebi bavSvis kvebaze.

mas Semdeg, rac aiv inficirebul qals miewodeba sruli da zusti informacia SesaZlo riskisa da samedicino daxmarebis aRmoCenis Sesaxeb, man unda gadawyvitos SeinarCunos Tu ara nayofi. araviTar SemTxvevaSi ar unda vaiZuloT qali Sewyvitos orsuloba.

IV. mSobiarobamde daxmarebis centrsa da samSobiaro saxlebSi dbgp

RonisZiebebib gatareba

randomizirebulma kontrolirebulma kvlevebma, Ria cdebma da observaciulma kvlevebma daamtkica arv profilaqtikis (4,10-24) efeqtianoba. xolo sakeisro kveTa, aiv-is dedidan bavSvze gadacemis profilaqtikis erT-erTi gza.

aiv inficirebul qalebSi orsulobis adreul periodSi da mSobiarobis dros, aseve misi da bavSvis mSobiarobis Semdgom periodSi zidovudinis daniSvna amcirebs aiv-is vertikaluri gziT gadacemis sixSires axalSobilebSi, romlebic imyofebian xelovnur kvebaze 25,5%-dan 8,3%-mde (25-27).

dedis da bavSvis samkomponentiani sqemiT mkurnalobisas, romelSic Sedis proteazis inhibitori (pi), dedidan bavSvze gadacemis sixSires amcirebs 0,9-1,3%-mde (5, 28).

dbgp mizniT sakeisro kveTis efeqtianoba dadasturebulia meta-analiziT (28). magram observaciuli kvlevebis monacemebma gvaCvena, rom qalebSi Tu arv Terapiis fonze virusuli datvirTva aragansazRvradia, fiziologiuri mSobirobisas aiv-is gadacemis SemTxveva Zalian iSviaTia, amitom rekomendaciebi profilaqtikuri sakeisro kveTis Sesaxeb Secvlil iqna (30).

Tu aiv-is profilaqtikis mizniT gadawyda sakeisro kveTa, operacia unda Catardes gestaciis 38-e kviraze, moveridoT amniocentezs (31).

dbgp-is mizniT arv-profilaqtikis danSvnis Sesaxeb gadawyvetileba unda miiRos mSobiarobamde daxmarebis centris med. personalma da aiv infeqciis specialistma. orsul qalebSi profilaqtikur RonisZiebebs Soris mniSvnelovania:

arT-s Cveneba momarTvisas gestaciis vada samedicino dawesebulebis done (pirveladi samedicino daxmarebis centri,

specializirebuli klinika). warsulSi arv preparatebis gamoyeneba Tanmxlebi daavadebebi arv preparatebis xelmisawvdomoba.

aiv-inficirebul orsul qalebs saprofilaqtiko RonisZiebebi unda CautardeT, miuxedavad imisa, arian Tu ara isini saineqcio narkotikebis momxmarebeli.

orsul qalebSi arv Terapiis saWiroeba unda efuZnebodes aiv-infeqciis stadias, romelic SemuSavebulia janmo-s mier da imunologiur kriteriumebs.

1. samSobiaroebsa da sakonsultacio centrebSi dbgp RonisZiebebis SesaZlo scenarebi

xSir SemTxvevaSi aiv-inficirebuli qalebi SegviZlia mivaniWoT erT-erT am kategorias:

1. isini vinc janmrTelobis mdgomareobis gamo ar saWiroeben arv Terapias;2. isini vinc janmrTelobis mdgomareobis gamo saWiroeben an SeiZleba

saWiroebdnen arv Terapias;3. vinc arv Terapia daiwyo orsulobamde4. isini vinc ar mimarTven Sesabamis dawesebulebebs mSobiarobamde;

1.1 aiv-inficirebuli orsuli qalebi, romlebic janmrTelobis mdgomareobis gamo ar saWiroeben arv Terapias

cxrili 1. aiv-inficirebuli qalebi, romlebic janmrTelobis mdgoareobis gamo ar saWiroeben arv Terapias

gestaciuri periodi da CD4 raodenoba

Aarv profilaqtika orsulobis periodSi

Aarv profilaqtika mSobiarobs dros

arv profilaqtika mSobiarobis Semdeg

mSobiarobis marTva

24-28 kvira

CD4 >350/mkl

Tu SesaZlebelia virusuli datvirTvis gansazRvra da igi <10 000 asli/ml da pacienti adre ar Rebulobda zidovudinszidovudini 300mg 2jer dReSi (32). hemoglobinis kontroliT

gegmiuri sakeisro kveTisas: zidovudiniT1 monoTerapia.

mSobiarobisas zidovudini1

300mg yovel 3sT-Si mSobiarobamde+Llamivudini 150mg 2jer dReSi+Nnevirapini 200mg erTjeradad mSobiarobis dawyebisas

nevirapinTan erTad mSobiarobis dros (saukeTeso kombinacia)

deda:zidovudni 300mg + lamibudini 150mg 2jer dReSi 7dRis gan. mSobiarobis Semdgom2

bavSvi: zidovudini (sirofi) 4mg/kg + lamivudini 2mg/kg 2jer dReSi 7dRe3

+nevirapini 2mg/kg erjeradad mSobiarobis Semdgom.

gegmiuri sakeisro kveTa 38-e kviraze an fiziologiuri mSobaroba4

Nnevirapinis gareSe mSobiarobis dros

deda:movuxsnaT zidovudini.

bavSvi:zidovudini (sirofi) 4mg/kg 2jer dReSi 7dRe3

araugvianes sicocxlis pirveli 8sT-sa.

Tu ver vsazRvravT virusul datvirTvas an igi >10 000 asli/ml an adre Rebulobda zidovudins 5

zidovudini 300mg + lamivudini 150mg +seqvinavir/ ritonaviri 6

800/100mg

deda:mSobiarois Semdgom moixsnas samive preparati.

bavSvi: zidovudini (sirofi) 4mg/kg 2jer dReSi 7dRe3

Tu 36-38 kviraze VL < 1000 asli/ml fiziologiuri mSobiaroba8

Tu 36-38 kviraze VL

2jer dReSi 7 araugvianes sicocxis pirveli 8sT-sa.

>1000 asli/ml, 38-e kviraze sakeisro kveTa.Tu ver vsazRvravT VL da ver vasrulebT maarT <95%, 38-e kviraze sakeisro kveTa.Tu ver vsazRvravT VL da ver vasrulebT maarT >95%, fiziologiuri mSobiaroba8

1. Tu SesaZlebelia zidovudinis i/v Seyvana, maSin sakeisro kveTamde 4sT-iT adre infuziis dawyeba (2mg/kg-ze pirveli saaTis ganmavlobaSi, Semdgom 1mg/kg-ze Wiplaris gadaWramde).

2. zidovudini + lamivudinis kombinacia eniSneba dedas mSobiarbis dros da 7 dRe mis Semdeg, nevirapinis mimarT rezictentobis ganviTarebis Sesamcireblad. Tu deda ar Rebulobda nevirapins, moexnas arT sakesros kveTis Semdgom.

3. Tu deda orsulobis periodSi Rebulobda arv-Terapias 4 kviraze naklebi periodiT, bavSvma zidovudini unda miiRos 4 kvira. dRenaklul bavSvebs zidovudin miecema 1.5 mg/kg i/v an 2.0 mg/kg per os.

4. saboloo gadawyvtileba mSobiarois marTvis Sesaxeb unda miviRoT sakeisro kveTisa da fiziologiuri mSobiarobis riskisa da upiratesobis ganxilvis Semdgom. fiziologiuri mSobiarobisas unda moveridoT invaziur Carevebs, rogoricaa monitoringis mizniT Tavze eleqtrodebis dadeba da epiziotomia.

5. Tu deda adre Rebulobda arv Terapias an/da arsebobs riski rom infeqcia gamowveulia aiv-is rezistentuli StamiT, arT-s SerCevamde saWiroa testi rezistentobaze.

6. alternatiuli Terapiis saxiT SegviZlia gamoviyenoT lopinavir/ritonaviri 400/100mg an nelfinaviri 1250mg 2-jer dReSi.

7. orsulobis garTulebis gamo SesaZlebelia ver moxerxdes arT reJimis dacva.8. ar unda davuSvaT invaziuri sameano Carevebi, rogoricaa monitoringis mizniT

Tavze eleqtrodebis dadeba da epiziotomia. epiziotomia dasaSvebia mxolod gadaudebeli CvenebiT (33).

1.2 aiv inficirebuli orsuli qalebi, romlebic janmrTelobis mdgomareobis gamo saWiroeben arv Terapias.

Tu aiv inficirebul orsuls esaWiroeba arv Terapia janmrTelobis mdgomareobis gamo, magram aqamde ar dauwyia mkurnaloba, saWiroa daviwyoT pirveli rigis maRalaqtiuri antiretrovirusuli Terapia (maarT). Terapiisa da profilaqtikis mizniT rekomendebulia Semdegi kombinacia: zidovudini, lamivudini da nevirapini

(19,34,35). janmrTelobis SenarCunebis mizniT aiv-inficirebul qalebSi aucilebelia arv Terapiis gagrZeleba mSobiarobis Semdgomac.

cxrili 2 Aaiv inficirebuli qalebi, romlebic janmrTelobis mdgomareobis gamo saWiroeben an SeiZleba saWiroebdnen arv Terapias

gestaciis asaki da CD4 ricxvi

Arv profilaqtika orsulobisa da mSobiarobis dros

Arv profilaqtika mSobiarobis Semdgom

mSobiarobis marTva

nebismieri gestaciuri asaki

CD4 < 200mkl

zidovudini 300mg1 + lamivudini 150mg + nevirapini 200mg2 2jer dReSiSeniSvna:nevirapinis sawyisi doza 200mg 1jer dReSi, ori kviris Semdgom 200mg 2jer dReSi.RviZlis fermentaciuli aqtivobis Sefaseba mkurnalobis dawyebamde, 2-4 kviraSi, mkurnalobis dawyeidan da Semdgom 4 kviraSi erTxel.

deda: gavagrZeloT mkurnaloba igive sqemiT.

bavSvi:zidovudini (sirofi) 4mg/kg 2jer dReSi 7 dRe3, mkurmalobas viwyebT mSoiarobidan pirvel 8 sT-Si

Tu 36-38 kviraze VL < 1000asl/ml, fiziologiuri gziT mSobiaroba5.

Tu 36-38 kviraze VL > 1000asl/ml, 38-e kviraze sakeisro kveTa.

Tu ver vsazRvravT VL da maarT-is reJimis dacva < 95%, 38-e kviraze sakeisro kveTa.

Tu ver vsazRvravT VL da maarT-is reJimis dacva > 95%, fiziologiuri gziT mSobiaroba.

nebismieri gestaciuri asaki

CD4 200–350 mkl

zidovudini 300mg1 +lamivudini 150mg +seqvinavir/ritonaviri 800/100mg4 2jer dReSi

deda:arv-Terapiis gagrZelebis saWiroeba unda daefuZnos klinikuri da imunologiur monacemebs, aseve unda gaviTvaliswinoT orsulobis dros mimdinare fiziologiuri cvlilebebi (mocirkulile plazmis moculobis momateba _ hemodilucia), CD4 limfocitebis droebiTi daqveiTeba, romelic mSobiarobis Semdgom aRdgeba.

bavSvi:zidovudini (sirofi) 4mg/kg 2jer dReSi 7 dRe3, mkurnalobas viwyebT mSoiarobidan pirvel 8 sT-Si

1. hemoglobinis mkacri kontroli. anemiis an preparatis autanlobisas zidovudini Seicvalos tenofoviriT an abakaviriT.

2. CD4> 250mkl sagrZnoblad matulobs nevirapinis hepatotoqsiurobis riski (36). 3. Tu deda orslobis priodSi arv-Terapias Rebulobda 4 kviraze naklebi periodiT,

bavSvi Rebulobs zidovudins 4 kvira. dRenaklul bavSvebs zidovudini eniSnebaT doziT 1,5mg/kg i/v an 2,0mg/kg per oss.

4. saboloo gadawyvtileba mSobiarois marTvis Sesaxeb unda miviRoT sakeisro kveTisa da fiziologiuri mSobiarobis riskisa da upiratesobis ganxilvis Semdgom. fiziologiuri mSobiarobisas unda moveridoT invaziur Carevebs, rogoricaa monitoringis mizniT Tavze eleqtrodebis dadeba da epiziotomia.

5. seqvinavir/ritonavris magivrad SegviZlia davniSnoT lopinavir/ritonaviri (400/100mg 2jer dReSi) an telfinaviri (1250mg 2jer dReSi). Tu es preparatebi ar gvaqvs, SegviZlia davniSnoT efavirenzi, mxolod meore trimestridan, raTa Tavidan aviciloT ganviTarebis mankebi.

1.3. aiv inficirebuli orsuli qalebi, romelTac orsulobamde daiwyes arv-Terapia.

cxrili 3 Aaiv inficirebuli orsuli qalebi, romlebmac orsulobamde daiwyes arv Terapia

gestaciuri asaki Aarv profilaqtika orsulobisa da mSobiarobis dros

Aarv profilaqtika mSobiarobis Semdgom

mSobiarobis marTva

yvela asakis gavagrZeloT arsebuli sqema, Tu masSi ar Sedis efavirenzi

Tu sqemaSi Sedis efavirenzi1, orsulobis pirvel trimestrSi efavirenzi SegviZlia SevcvaloT seqvinavir/ritonaviriT 800/1002 an abakaviriT. Tu <250mkl SegviZlia davniSnoT nevirapini3.

meore rigis sqemebis upiratesoba faravs masTan dakavSirebul

deda: mSobiarobis SemdgomgagrZeldes mkurnaloba igive sqemiT.

bavSvi:zidovudini(sirofi) 4mg/kg 2jer dReSi 7 dRe. davwyoT mSobiarobidan pirvel 8sT-Si.

dRenaklul bavSvebs zidovudini eniSnebaT doziT

Tu 36-38 kviraze VL < 1000asl/ml, fiziologiuri gziT mSobiaroba4.

Tu 36-38 kviraze VL > 1000asl/ml, 38-e kviraze sakeisro kveTa.

Tu ver vsazRvravT VL da maarT-is reJimis dacva < 95%, 38-e kviraze sakeisro kveTa.

risks. gagrZeldes am sqemiT mkurnaloba orsulobis da mSobiarobis periodSi da Semdgom.

1,5mg/kg i/v an 2,0mg/kg per os

Tu ver vsazRvravT VL da maarT-is reJimis dacva > 95%, fiziologiuri gziT mSobiaroba4.

1. aRwerilia erTeuli SemTxvevebi nervuli Reros defeqtisa pirvel trimestrSi efavirenzis miRebisas. mniSvnelivania efavirenzis miRebis Sewyveta Casaxvamde. nervuli Reros formireba mTavrdeba gestaciis meeqvse kviraze, xolo preparatis Secvlam SeiZleba gamoiwvios virusuli datvirTvis momateba. dasavleT evropis bevr klinikebSi aiv infeqciis specialistebi agrZeleben efavirenziT mkurnalobas Tu orsulma pirvelad mimarTa konsultaciur centrs orsulobis me-8 kviras an ufro gvian. Tu miiReba gadawyvetileba efavirenzis moxsnis Sesaxeb, mkurnaloba ar unda Sewydes, is unda Canacvldes sxva arv preparatiT, raTa Tavidan aviciloT rezistentobis ganviTareba.

2. seqvnavir/ritonavris magivrad SegviZlia davniSnoT lopinavir/ritonaviri (400/100mg 2jer dReSi) an nelfinaviri (1250mg 2jer dReSi).

3. CD4 > 250mkl sagrZnoblad matulobs nevirapinis hepatotoqsiurobis riski (36). dozireba ix. cxrili 2.

4. saboloo gadawyvetileba mSobiarois marTvis Sesaxeb unda miviRoT sakeisro kveTis da fiziologiuri mSobiarobis riskisa da upiratesobis ganxilvis Semdgom. fiziologiuri mSobiarobisas unda moveridoT invaziur Carevebs, rogoricaa monitoringis mizniT Tavze eleqtrodebis dadeba da epiziotomia.

1.4 aiv inficirebuli qalebi, romlebic pirvelad mSobiarobis dros mimarTaven daxmarebisTvis .

qalebi, romelTac irsulobis periodSi ar miiRes daxmareba, xSirad miekuTvnebian komerciuli seqs muSakebs da/an ineqciuri narkotikebis momxmareblebs. aseT orsulebSi aiv infeqciis maRali riskis gamo mniSvnelovania droulad davadginoT maTi aiv statusi. aseT SemTxvevaSi orsulebs sTavazoben eqspres-testirebis Catarebas samSobiaroSi. dadebiTi Sedegisas diagnozi dasturdeba imunoblotingiT da fasdeba arv Terapiis dawyebis aucilebloba.

cxrili 4 Aaiv inficirebuli qalebi, romlebic pirvelad mSobiarobis dros mimarTaven daxmarebisTvis samedicino dawesebulebas (orsulobis dros ar Rebulobdnen arv Terapias)

klnikaSi moxvedris dro

Aarv profilaqtika mSobiarobis dros

Aarv profilaqtika mSobiarobis Semdeg

mSobirobis marTva

mSobiarobis procesSi

zidovudini 300mg yovel 3sT-Si bavSvis dabadebamde+lamivudini 150mg mSobiarobis dasawyisSi, Semdeg ki

deda:zidovudni 300mg + lamivudini 150mg 2jer dReSi 7dRis gan. mSobiarobis Semdgom2

fiziologiuri mSobiaroba5

unda moveridoT invaziur Carevebs,

yovel 12sT-Si bavSvis dabadbmde +nevirapini 200mg erTjeradad mSobiarobis dasawyisSi

bavSvi2: zidovudini (sirofi)3

4mg/kg 2jer dRei 4kv.+ lamivudini 2mg/kg 2jer dReSi 4kv.+nevirapini 2mg/kg erjeradad mSobiarobis Semdgom 48-72sT-Si4

rogoricaa monitoringis mizniT Tavze eleqtrodebis dadeba da epiziotomia.

1. arv Terapiis Semdgomi taqtika, im qalebSi, romelTac aiv infeqcia aRmoaCndaT mSobarobis dros, damokideulia CD4, VL da klinikur kvlevebze, romelic rac SeiZleba male unda CavataroT mSobiarobis Semdgom.

2. Tu deda Rebulobda zidovudin-lamivudinis profilqtikas, bavSvs dabadebidan 8-12sT_Si unda mivceT zidovudinisa da lamivudinis kombinacia.

3. dRenaklul bavSvebs zidovudini eniSnebaT doziT 1,5mg/kg i/v an 2,0mg/kg per os.

4. Tu deda ar Rebulobda nevirapins an misi miRebidan, bavSvis gaCenamde, gavida araumcires 2 saaTisa, nevirapinis erTi doza axalSobils unda mivceT dabadebisas da meore ki 72sT-Si.

5. Tu aqtiuri samSobiaro moqmedeba ar dawyebula da sanayofe garsebic mTelia, SegviZlia SevTavaziT sakeisro kveTa.

1.5 dbgp aqtiuri tuberkulozis mqone aiv inficirebul orsul qalebSi

aqtiuri tuberkulozis mqone aiv inficirebul orsul qalebSi, pirvel rigSi vmkurnalobT tuberkulozs (ixileT me-4 Tavi “tuberkulozi da aiv infeqcia”).

pirveli rigis antituberkulozuri preparatebis umetesoba usafrTxoa orsulobis dros, garda streptomicinisa, romelic ototiqsiurobiT gamoirCeva.

Tu antituberkulozuri mkurnaloba xangrZlivia, xolo pacients esaWiroeba arv Terapia dbgp mizniT, mkurnalobas viwyebT mis fonze.

Tu arv kombinaciaSi Sedis nevirapini an aragaZlierebuli proteazis inhibitori, ar unda dainiSnos rifampicinTan kombinaciaSi wamlebis urTierTzemoqmedebis gamo (37-41).

Tu aiv inficirebuli orsuli qali Rebulobs rifampicins dbgp mizniT rekomendebulia gamoviyenoT sqema zidovudini + lamivudini + seqvinavir/ritonaviri (dozireba ixileT pirvel TavSi). unda vakontroloT RviZlis fermentaciuli aqtivoba. Tu seqvinavir/ritonaviri ar aris, SegviZlia davniSnoT abakaviri. magram misi orsulebSi gamoyeneba saWiroebs Semdgom dakvirvebas.

arsebobs zidovudin/lamivudin/abakaviris kombinirebuli preparati fiqsirebuli dozirebiT. sqemebi sami nukleoziduri transkriptazas inhibitoriT nakleb efeqturia vidre ori nukleoziduri transkriptazas inhibitori aranukleoziduri SebrunebiTi transkriptazas inhibitorTan an gaZlierebul proteazas inhibitorTan erTad.

Tu rifampicinis magivrad gamoiyeneba rifabutini, arv Terapiis sqema ar icvleba da iseTivea, rogorc zeviT aris aRwerili. lopinavir/ritonaviris fonze rifabutinis done matulobs, amitom xandaxan saWiroa misi dozis dakleba.

2. ineqciuri narkotikebis momxmarebel aiv inficirebul orsulTa marTva

orsulebSi, romlebic moixmaren ineqciur narkotikebs, xSiria garTulebebis ricxvi. aseTi pacientebis marTvisas unda gaviTvaliswinoT narkotikuli damokidebulebis mosalodneli garTulebebi orsulsa da nayofze (ix. cxrili 6) (43). aqedan gamomdinare, ZiriTadi mizania _ aralegaluri narkotikebis miRebis stabilizacia an dozis Semcireba.

2.1 daxmarebis organizeba ineqciuri narkotikebis momxmarebeli (inm) aiv inficirebuli orsulebis efeqturi marTvisaTvis, saWiroa orsulobis adreul stadiaze CavrToT samedicino daxmarebis samsaxurSi. ZiriTad strategias warmoadgens kompleqsuri midgoma, sadac mTavari roli uWiravs mSobiarobamde, mSobiarobisa da mSobiarobis Semdgom daxmarebas. am samsaxurebTan unda iTanamSromlon:

narkotikebis mavneblobis Semcirebis samsaxuri, romelic agzavnis inm orsulebs mSobiarobamde daxmarebis centrSi;

specialistebi narkotikuli damokidebulebis samkurnalod; aiv/Sidsis mkurnalobis samsaxuri; fsiqologiuri da socialuri mxardaWeris samsaxuri;

2.2 narkotikuli damokidebulebisa da abstinenciuri sindromis Sefaseba orsulebSi

xSirad pacientebi malaven aralegaluri narkotikebis moxmarebis faqts. qalebi, romlebic aRiareben inm da isini vinc uaryofen, magram aqvT ineqciis kvali an saeWvo simptomebi, saWiroeben damatebiT gamokvlevas.

qalebi, romlebic moixmaren narkotikebs, xSirad aReniSnebaT ramdenime fsiqoaqtiuri nivTierebis mimarT damokidebuleba (nikotini, alkoholi, opoidebi, kokaini, “eqstazi”, sxva amfetaminebi, benzodiazepinebi) (44). xandaxan fsiqoaqtiuro nivTierebebis gamoyenebis niSnebis/simptomebis da abstinenciuri sindromis gamovlena Znelia. mniSvnelovania gamovyoT orsulobis klinikuri da garTulebuli orsulobis niSnebi, narkotikebis gamoyenebis da abstinenciuri sindromis simptomebisagan.

cxrili 5 abstinenciuri sindromis niSnebi/simptomebi konkretuli fsiqoaqtiuri nivTierebebis gamoyenebisas aiv-inficirebul orsul qalebSi

nivTiereba niSnebi/simptomebialkoholi agzneba, tremori, , taqikardia, Zilis darRveva,

arteriuli wnevis momateba, gulisreva, midriazi, krunCxviTi Setevebi.

delta-9-tetrahidrokanabinoli (kanafi: marixuana, haSiSi)

SfoTva, gaRizianebadoba, zomieri agzneba, uZiloba, gulisreva, spazmebi.

Tambaqo gaRizianebadoba, SfoTva, yuradRebis koncentraciis darRveva, siZneleebi davalebis Sesrulebisas, SimSilis grZnoba, wonaSi momateba, Zilis

darRveva, Zilianoba, mowevis moTxovnileba.trankvilizatorebi da saZile saSualebebi: alprazolami, barbituratebi, qlordiazepoqsidi,diazepami, flurazepami, gluTetimidi, meprobamati,fenciklidini.

tremori, uZiloba, xSiri xamxami, agzneba, intoqsikaciuri fsiqozi, krunCxviTi Setevebi, mSfoTva,mousvenroba, kunTovani spazmebi, Zilis darRveva, arteriuli wnevis momateba, cxeleba, madis daqveiTeba.

fsiqostimulatorebi: metamfetamini, kokaini, meTilfenidati, fenmetrazini, dimeTiltriftamini, fenciklidini.

mialgia, tkivili muclis areSi, SimSilis grZnoba, Zilianoba, suicidaluri azrebi, bradikardia, wamlismieri damikidebuleba, depresia.

opoidebi: kodein/oqsikodoni, heroini, hidromorfoni, tripelenamidi.

gripismagvari sindromi, agzneba, midriazi, spazmebi mucelSi, uZiliba, SfoTva, wamlismieri damokidebuleba, arteriuli wnevis momateba, taqikardia.

wyaro: adaptirebulia Rayburn and Bogenschutz, 2004 (45).

yvela qals, romelic moixmars narkotikebs ar uviTardeba damokidebuleba. vinaidan narkodamokidebuleba cvlis pacientebis marTvis strategias, mniSvnelovania misi gamovlena da Sefaseba. mSobiarobamde mxardaWeris samsaxuris personals advilad SeuZlia Seafasos damokidebulebis xarisxi kiTxvarebis saSualebiT (ix. Tavi 5 “aiv-infeqcia/SidsiT daavadebuli narkotikebis ineqciuri momxmareblebis mkurnaloba da movla”, danarTi 3). arsebobs sxva standartizirebuli meTodebi narkologiuri damokidebulebis gamosavlenad da Sesafaseblad, maT Soris damokidebilebis simZimis indeqsi (ASI) [evropuli versia 6 ( EuroASI6) romelic mocemulia danarTi 1, Tavi 5] (44). magram simZimis Semdgomi Sefaseba unda moxdes narkologis mier.

2.3 fsiqoaqtiuri nivTierebebis zemoqmedeba da abstinenciuri sindromi orsulobis dros.

abstinenciuri simptomebi Rwerilia me-5 cxrilSi, orsulze, nayofze da axalSobilze fsiqoaqtiuri nivTierebebis zemoqmedeba me-6 cxrilSi.

cxrili 6 orsulze, nayofze da axalSobilze fsiqoaqtiuri nivTierebebis zemoqmedeba

nivTiereba zegavlenaalkoholi TviTneburi aborti, mikrocefalia, zrdis Seferxeba, cns

darRvevebi, fsiqikuri ganviTarebisa da qceviTi darRvevebis CaTvliT, qala-saxis anomaliebi ( Tvalis kuTxeebSi quTuToebis Sezrda, zeda tuCis hipoplazia, zeda ybis hipoplazia).

Tambaqo ar iwvevs ganviTarebis mankebs, intranataluri zrdis SeCereba (dabadebisas wonis deficiti 200gr), naadrevi mSobiaroba, placentis winmdebareoiba, placentis nadrevi aSreveba.

delta-9-tetrahidrokanabinoli (kanafi: marixuana, haSiSi)

ar iwvevs ganviTarebis mankebs, naadrevi mSobiaroba, Sesabamisad nayofis wonis deficiti, umniSvnelo qceviTi darRvevebi.

fsiqostimulatorebi: metamfetamini, kokaini, meTilfenidati, fenmetrazini,

TviTneburi aborti, nayofis hiperaqtiuroba, ganviTarebis mankebi (gulis mankebi, sanaRvle gzebis atrezia), qceviTi darRvevebi, saSarde gzebis

dimeTiltriftamini, fenciklidini. anomaliebi, ganviTarebis Seferxebis asimetriuli forma, placentis naadrevi aSreveba, Tavis tvinis infarqti an sxva dazianebebi, nayofis intranataluri sikvdili, axalSobilis nekrozuli koliti.

opoidebi: kodein/oqsikodoni, heroini, hidromorfoni, tripelenamidi.

intranataluri gaviTarebis Seferxeba ganviTarebis mankebis gareSe, nayofis abstinenciuri sindromi momatebuli aqtivobiT, sunTqvis daqveiTeba sanayofe wylebis adreuli daRvra, naadrevi mSobiaroba, sanayofe wylebis mekoniumiT SemRvreva, perinataluri sikvdili.E

wyaro: adaptirebulia Rayburn and Bogenschutz, 2004 (45).

2.4 konsultireba da mkurnaloba narkotikuli damokidebulebisas

konsultireba – narkotikuli damokidebulebis mqone, aiv inficirebuli orsulebis samedicino daxmarebis umTavresi nawilia. is moicavs yvela im sakiTxis ganxilvas, romelic mocemulia IV.1 nawilSi. gansakuTrebiT sayuradReboa:

narkotikebis mavnebloba nayofisa da axalSobilisTvis opoidebiT CanacvlebiTi Terapiis mniSvneloba dedisa da nayofis

janmrTelobisTvis TviTneburad narkotikebisgan Tavis Sekavebam, samedicino da fsiqologiuri

mxardaWeris gareSe, SeiZleba gamoiwvios nayofSi stresi. opoidebiT CanacvlebiTi Terapiis (oCT) dros, orsulobis gavlena

SemanarCunebel dozaze da dozis momatebis saWiroeba. CanacvlebiTi opoidebisa da arv-preparatebis urTierT zemoqmedeba arv da opoidebiT CanacvlebiTi Terapiis reJimis dacva.

2.5 opoidebiT CanacvlebiTi Terapia orsulobis dros

Tu orsuli qali moixmars narkotikebs da mas aReniSneba damokidebulebis niSnebi (ix. me-4 danarTi me-5 TavSi “aiv/Sidsi ineqciuri narkotikebis momxmareblebSi: mkurnaloba da daxmareba”), saWiroa CavutaroT konsultacia oCT riskisa da sargebelis Sesaxeb. aseve miviRiT Tanxmoba mkurnalobasa da reJimis dacvaze (44,46,47). orsul qalebSi narkotikuli damokidebulebis samkurnalod gamoyenebuli preparatebi mocemulia mocemuli Tavis #1 danarTSi.

2.5.1 meTadoniT CanacvlebiTi Terapia dResdReobiT meTadoni warmoadgens oCT ZiriTad preparats orsul qalebSi. oCT Tavidan gvacilebs aralegaluri narkotikebis gamoyenebis recidivs, abstinenciuri sindromis ganviTarebasa da amcirebs orsulobis garTulebis risks (44,46). igi unda moicavdes, rogorc mSobiarobamde daxmarebas, aseve fsiqosocialur konsultaciebs (mxardaWeris mSjgufebi, socialuri mxardaWera, gauTvaliswinebeli situaciebis marTva, qceviTi Cvevebis swavleba, motivirebuli da ojaxuri qcevis fsiqoTerapia).

faqtebi gvaCveneben, rom opoiduri damokidebulebis mqone orsulebSi narotikebis miRebaze Tavis Sekaveba (imaTi CaTvliTac, vinc Rebulobs), matulobs riski nayofis intranataluri sikvdilisa (46). damtkicebulia, rom meTadoniT CanacvlebiTi Terapia mSobiarobamde daxmarebasTan kombinaciaSi aumjobesebs nayofis ganviTarebas,

xolo heroinis moxmarebis gagrZelebam SeiZleba migviyvanos nayofis sikvdilamde (46).

cxrili 7 orsulebSi meTadoniT CanacvlebiTi Terapiis upiratesoba da nakli

upiratesoba naklisaSulebas gvaZlevs Tavi avaridoT nayofze narkotikebSi Semavali minarevebis zemoqmedebas. arsebuli monacemebiT, sufTa meTadoni da heroini ar iwvevs ganviTarebis mankebs.

daregulirebis Sedegad cnibili dozis miReba.

saSualebas gvaZlevs Tavi avaridoT narkotikebis miReabisgan Tavis Sekavebas, rasac orsulobis adreul periodSi mivyavarT TviTnebur abotramde, gvian periodSi – intranataluri ganviTarebis Seferxebamde da mkvdradSobadobamde.

naadrevi mSobiarobis riskis Semcireba

intranataluri ganviTarebis Seferxeba riskis Semcireba.

axalSobilebSi abstinenciuri sindromi mimdinareobs ufro mZimed da xangrZlivad, im bavSvebisgan gansxvavebiT, romelTa dedebi ar Rebulobdnen oCT.

xangrZlivdeba axalSobilis hospitalizaciisa da mkurnalobis periodi.

axalSobilebSi wonis klebis mateba

mcirdeba bavSvis sakvebze moTxovnileba.

wyaro: Brown et ai., 1998 (46).

meTadoni _ xangrZlivi moqmedebis preparatia, romlis adeqvaturi doziT daniSvnisas iqmneba nayofis ganviTarebis xelsayreli pirobebi. orsulebSi rac SeiZleba male unda daviwyoT meTadoniT CamacvlebiTi Terapia. mkurnalobis pirvel trimestrSi dawyeba optimaluria rogorc dedisTvis, aseve nayofisTvis.

dozirebameTadonis doza yovelTvis irCeva individualurad; is unda iyos sakmarisi abstinenciuri sindromis subieqturi da obieqturi simptomebis mosaxsnelad da moTxovnilebis Sesamcireblad. mizanSewonilia gamoviyenoT minimaluri efeqtiuri doza. 60mg/dReze naklebi doza araefeqturia; orsul qalebSi dabali dozebis daniSvnas xSirad mivyavarT aralegaluri narkotikebis moxmarebamde an Terapaze uaris Tqmamde (46). mcire raodenibiT pacientebs, nivTierebaTa cvlis Taviseburebis gamo daCqarebuli aqvT RiZlSi meTadonis metabolizmi. ris gamoc misi doza 120mg –ze meti iyos.

dozis kleba (detoqsikacia) rogorc ki stabilizirdeba pacientis mdgomareoba, romelic Rebulobs meTadons, saWiroa ganvixiloT masTan erTad SeZlebs Tu ara dozis TandaTanobiT daklebasa da Semdgom moxsnas, Tu gagrZeldes SemanarCunebeli Terapia. dozis kleba SesaZlebelia mxolod meore trimestridan da Tu orsuloba mimdinareobs garTulebis gareSe. dozis kviraSi 2,5-5 mg kleba iTvleba usabrTxod (46). unda gakeTdes

yvelaferi, raTa Tavidan aviciloT abstinenciuri sindromi, vinaidan is iwvevs gamoxatul distress nayofSi.

dozis matebaorsulobis gvian vadebze, SeiZleba saWiro gaxdes meTadonis dozis mateba an orad gayofa (miReba dilas da saRamos), raTa mocirkulire plazmis moculobis momatebam, plazmis cilebis mier meTadonis SeboWvis zrdam da Tirkmelebis sisxlmomaragebis gaZlierebam ar gamoiwvios meTadonis koncentraciis daqveiTeba. xandaxan dozis mateba saWiroa abstinenciisa da narkotikebis miRebis recidivis Tavidan asacileblad. unda avRniSnoT, rom Tu arv Terapiis sqema Seicavs nevirapins an efavirenzs, saWiroa meTadonis dozis momateba.

meTadonisa da arv-preparatebis urTierTzemoqmedebameTadonisa da arv-preparatebis urTierTzemoqmedeba orsulebSi iseTivea, rogorc sxva pacientebSi (ix. me-5 Tavi “aiv/Sidsi ineqciuri narkotikebis momxmareblebSi: mkurnaloba da daxmareba”). Tu arv Terapiis sqema Seicavs nevirapins an efavirenzs, saWiroa meTadonis dozis momateba, vinaidan isini sagrZnoblad amcireben meTadonis koncentracias, ramac SeiZleba gamoiwvios abstinenciuri sindromi.

rig SemTxvevebze dakvirvebam gvaCvena, rom pacientebSi, romlebic xangrZlivad Rebuloben meTadons, nevirapinis daniSvnisas abstinenciis mosaxsnelad saWiro iyo yoveldRiurad meTadonis dozis 50-100% zrda. abstinenciuri sindromi viTardeba nevirapinis miRebidan me-4 – me-8 dRes.

meTadoni sagrZnoblad zrdis zidovudinis koncentrecias (43% -mde), rac zrdis gverdiTi movlenebis ganviTarebis risks. ris gamoc saWiroa pacientze dakvirvba.

seqvinavir/ritonaviri umniSvnelod aqveiTbs meTadonis koncentracias. dozis Secvlas ar saWiroebs, magram saWiroa dakvirveba.

2.5.2. buprenorfiniT CanacvlebiTi Terapia vinaidan buprenorfini miekuTvneba wamlebis usafrTxoebis klasifikaciis C kategorias, orsulebSi is sifrTxiliT unda gamoviyenoT (49-51). Tumca kvlevebiT buprenorfinis mavne zemoqmedeba nayofze ar dadginda, umjobesia Tavi avaridoT mis daniSvnas orsulebsa da meZuZur dedebSi. misi daniSvna SenaZlebelia maSin, Tu daniSvnis saWiroeba aRemateba nayofze zemoqmedebis risks (52); mag.: meTdonis arqona an preparatis autanloba. pacienti unda gavafrTxilod SesaZlo riskis Sesaxeb. es preparati iniSneba individualuri SerCeviT da sifrTxiliT, rogorc orsulebSi aseve daorsulebis saSiSroebis dros. evropidan da avstraliidan calkeuli Setyobinebebi adasturebs, rom buprenorfinis 0,4-dan 24mg/dReSi dozirebiT miRebisas orsuliba normalurad mimdinareobs (50).

2.6 mSobiarobisas Semosuli, narkotiuli damokidebulebis mqone, aiv-inficirebuli qalebis marTva, romelTac mSobiarobamde ar miuRiaT daxmareba.

orsulTa umetesoba, romlebic Rebuloben narkotikebs, ar mimarTaven mSobiarobamde daxmarebas da Semodian samSobiaro saxlebSi mSobiarobamde an uSualod mSobiarobisas. aseT SemTxvevaSi medpersonali mzad unda iyos gaataros Semdegi RonisZiebebi:

Sefasdes narkotikuli damokidebulebis done (ix. danarTi 1 me-5 TavSi “aiv/Sidsi ineqciuri narkotikebis momxmareblebSi: mkurnaloba da daxmareba”) da Seatyobinos neonatologs;

Tu meloginis aiv-statusi ucnobia an orsulobis periodSi uaryofiTi iyo, CavataroT aiv-ze eqspres-testireba;

daeniSnos abstinenciuri sindromis mkurnaloba; saWiroebis SemTxvevaSi daewyos opoidebiT CanacvlebiTi Terapia; CavutaroT konsultacia orsulebsa da nayofze narkotikebis mavne zegavlenisa

da mkurnalobis Sesaxeb.

opoiduri damokidebulebis mqone, aiv-inficirebuli qalebSi dbgp tardeba igive wesebiT, rogorc sxva qalebSi (aiv-inficirebuli qalebi romlebic ar Rebulobdnen arv-profilaqtikas orsulobis dros. ix. cxrili 4). wamlismieri damokidebulebis mqone orsulebi, romelTac arv-preparetebi daeniSnaT mSobiarobamde an mSobiarobisas, esaWiroebaT meTadonis sakmarisi doz, raTa Tavidan aviciloT abstinenciuri sindromi.

2.6.1. gautkivarebagautkivarebas eniWeba mniSvnelovani adgili mSobiarobisa da mSobiarobis Semdgom periodSi, gansakuTrebiT sakeisro kveTisas. opoiduri damokidebulebis mqone qalebSi iseve xdeba, rogorc sxva mSobiareebSi. tkivilis kupirebisaTvis SesaZloa saWiro gaxdes analgetikebis ufro maRali dozebi (53).

Tu SesaZlebelia, epiduraluri anesTezia unda gakeTdes mSobiarobis adreul etapze; misi gameoreba SeiZleba mSobiarobis Semdgom adreul periodze, gansakuTrebiT sakeisro kveTis Semdgom.

3. mSobiarobis Semdgom periodSi qalebis marTva

mSobiarobis Semdgom periodSi dbgp medikamentebis sqemebi mocemulia cxrilSi 1-4. samSobiarodan gaweramd yvela aiv-inficirebul qali konsultirebul iyos bavSvis kvebasa da kontracefciaze. 3.1 bavSvis kveba

miuxedavad imisa Rebulobda Tu ara deda perinatalur periodSi arv-proflaqtikas, ZuZuTi kvebisas bavSvis inficrebis riski sakmaod maRalia. kvlevebis mixedviT dadginda, rom risk-jgufis baSvebSi ZuZuTi kvebisas gadacemis riski 14% (54-56). janmo-s rekomendaciiT aiv-inficirebulma qalebma uari unda Tqvas ZuZuTi kvebaze, Tu xelovnuri sakvebi akmayofilebs Semdeg moTxovnebs: unda iyos misaRebi, finansurad xelmisawvdomi, stabiluri da usabrTxo (ganmartebebi ix. danarTi 2). sxva SemTxvevaSi rekomenddebulia pirvel TveebSi ZuZuTi kveba, xolo rogorc ki iqneba SesaZlebloba dakmayofildes zemoT CamoTvlili pirobebi, gadagvyavs xelovnur kvebaze. arsebobs monacmebi, rom mxolod ZuZuTi kvebisas pirveli sami Tvis ganmavlobaSi aiv-is gadacemis riski dabalia, vidre Sereuli kvebisas, amitom am ukanasknelisgan Tavi unda SevikavoT.

yuradReba unda gavamaxvilod ZuZuTi kvebisas aiv-infeqciis gadacemis riskze da rekomendacia gavuwioT xelovnur kvebas. aseve xazgasmiT unda avRniSnoT, rom xelovnuri kvebisas ar SeiZleba bavSvis mkerdze miwvena da avuxsnaT swored rogor movamzadoT da mivceT dedis rZis Semcvleli. mSobiarobidan ori kviris Sendeg deda unda gamocxaddes bavSvTa poliklinikaSi, raTa SevamowmoT sworad kvebavs Tu ara bavSvs da gadavwyvitoT arsebuli problemebi.

3.2 mSobiarobis Semdgomi kontracefciaprezervativi rCeba upirates saSualebad arasasurveli orsulobis Tavidan asacileblad da aiv-is gadacemis saprofilaqtikod. ar unda gamoiyenon kontracefciisaTvis laqtaciuri amenorea, vinaidan ar aris rekomenddebuli ZuZuTi kveba (ufro zustad ix. Tavi 9 “aiv-inficirebul qalebSi seqsualuri da reproduqciuli janmrTelobis mxardaWera”, QqveTavi “laqtaciuri amenoreis meTodi”).

4. samSobiaro saxlSi axalSobilebis marTva 4.1 axalSobilebSi aiv infeqciis laboratoriuli daignostikapirveli PCR diagnostika aiv dnm-ze an aiv rnm-ze unda CavataroT mSobiarobidan pirvel 48sT-Si. Wiplaridan aRebuli sisxli ar gamodgeba, vinaidan SeiZleba Seerios dedis sisxli. dadebiTi rezultati xSir SemTxvevaSi miuTiTebs imas rom bavSvi inficirebulia. meore PCR kvleva tardeba 6-8 kviraze, pirveladi rezultatis miuxedavad. Tu PCR ver vakeTebT, maSin vikvlevT sisxls antisxeulebze 15-18 Tvis asakSi, Semdgomi damadasturebeli kvleviT – imunoblotiT.

bavSvis gamokvlevis paralelurad, momvlel pirs unda ganumartoT testirebis rezultati da bavSvis aiv statusis saboloo dadasturebis saWiroeba.

adreuli asakis bavSvebSi aiv-infeqciis diagnostirebis algoriTmi mocemulia me-11 TavSi “aiv/Sidsis mqone bavSvebis mkurnaloba da daxmareba”, qveTavi “aiv-infeqciis laboratoriuli diagnostika”.

4.2 narkotikuli damokidebulebisa da abstinenciuri sindromis mqone bavSvebis marTva

4.2.1 klinikuri kvlevaaxalSobilebi, romlebic intranatalurad imyofebodnen opoidebis zemoqmedebis qveS, 50-80% aReniSnebaT abstinenciuri sindromi (xSirad pirvel 24-72sT-Si). mZime gamovlinebebi, romlebic saWiroeben samedicino Carevas, aseT bavSvebSi mxolod 5-20% gvxvdeba. axalSobilebSi, romelTa dedebi Rebulobdnen buprenorfins, abstinenciuri sindrmi gansakuTrbiT gamoxatulia dabadebidan me-3 – me-4 dRes da 5-7 dRe grZeldeba. meTadoniT gamowveuli abstinenciuri sindromi grZeldeba araumetes 4 dRisa (60).

axalSobilTa abstinenciuri sindromis simptomebi gansxvavdeba simZimiTa da xangrZlivobiT:

tremori, kunTovani hipertonusi, mousvenroba, Zilis darRveva, gaxangrZlivebuli tirili, hiperrefleqsia;

xSiri boyini, Rebineba, diarea; taqipnoe; mcire simptomebi: cxeleba, cemineba, oflianoba, mTqnareba, cxviris

gaWedva;

axalSobilebSi, romelTa dedebi iyeneben narkotikebs an eWvia maT gamoyenebaze, abstinenciuri sindromis simZime unda Sefasdes yovel 4 sT-Si. simZimis Sefaseba unda moxdes erTidaigive sistemiT (ix. danarTi 3 axalSibilebSi abstinenciuri sindromis simZimis Sefaseba niSnebisa da simptomebis mixedviT). am Sefasebis safuZvlze abstinenciuri sindromis samkurnalod irCeva prepaatebis dozebi (ix. cxrili 8).

4.2.2 axalSoblebSi abstnenciuri sindromis mkurnalobaaxalSoblebSi abstnenciuri sindromis mkurnalobis ZiriTadi mizani _ uzrunvelyoT srulyofili ZiliT, kvebiTa da simSvidiT; mkurnaloba ar xsnis yvela simptomebs. mkurnaloba tardeba etapobrivad.

pirveli etapi – SemanarCunebeli Terapia : mSvidi garemo (aramkveTri ganaTeba, mWidrod gadaxveva, xelSi an loginSi rweva, matyuara), xSiri kveba mcire ulufebiT, garemoSi mkveTri cvlilebebisagan Tavis Sekaveba. Tu simptomebi Zlierdeba, gadavdivarT meore etabze.

meore etapi – medikamentozuri mkurnaloba: SerCevis preparati – fenobarbitalis xsnari. Tu es preparati araefeqturia an viTardeba krunCxvebi, mis magivrad iniSneba morfinis xsnari. samkurnalo dozebi varireben abstinenciuri sindromis Sefasebis qulebis mixedviT (ix. cxrili 8 da danarTi 3). iSviaTad SeiZleba ganviTardes Zlieri Rebineba; am SemTxvevaSi saWiroa preparatis droebiT Secvla qlorpromaziniT (2-3 mg/kg/dReSi 3-4jer i/m).

cxrili 8 axalSobilebSi abstinenciuri sindromis samkurnalo preparatebis Terapiuli doza

abstinenciuri sindromis simZimis xarisxi (qulebi)

dozafenobarbitali morfini

8 - 10 6 mg/kg/dReSi 3 miReba 0,32 mg/kg/dReSi 4 miReba

11 - 13 8 mg/kg/dReSi 3 miReba 0,48 mg/kg/dReSi 4 miReba

14 -16 10 mg/kg/dReSi 3 miReba 0,64 mg/kg/dReSi 4 miReba

17 + 12 mg/kg/dReSi 3 miReba 0,80 mg/kg/dReSi 4 miReba

wyaro: Finnegan et al., 1975 (51).

axalSobilebSi arv-preparatebisa da abstinenciuri sindromis samkurnalo preparatebs Soris urTierTdamokidebuleba jerjerobiT Seswavlili ar aris.

4.3 imunizaciaim qveynebSi, sadac tuberkulozis SemTxvevaTa ricxvi aRemateba 20 - 100 000 mosaxleze (61), yvela axalSobili, romelic intranatalurad imyofeboda aiv-is zemoqmedebis qveS, aucileblad unda aicras (bcJ vaqcina) samSobiaro saxlSi, iseve rogorc sxva axalSobilebi.

im qveynebSi, sadac tuberkulozis SemTxvevaTa ricxvi dabalia, aiv-inficirebul bavSvebs tuberkulozis sawinaaRmdeo vaqcinacia ar utardebaT, aiv-is klinikuri gamovlinebisa da gamoxatuli imunodeficitis miuxedavad. sxva acrebi utardebaT imunizaciis nacionaluri progrmis Tanaxmad. rekomendaciebi vaqcinaciis Sesaxeb ix. me-12 TavSi “aiv infcirebulTa da aiv-is maRali riskis mqone pirTa vaqcinacia”.

5. mimarTva Semdgomi daxmarebis misaRebadaiv-inficirebuli qalebi, axalSobilebi da maTi ojaxebi mudmivad unda Rebulobden mravalprofilur daxmarebas, kerZod:

axalSobilebis pediatriuli daxmareba, maT Soris maarT, oportunistuli infeqciebis profilaqtikis mizniT, sicocxlis pirvel wels (Cvenebis mixedviT);

dedebisaTvis mSobiarobis Semdgomi kontracefcia;

aiv/Sidsis dros mkurnaloba da daxmareba; narkotikebis mavneblobis Semcirebis programis farglebSi daxmareba da

narkotikuli damokidebulebis mkurnaloba; saTanado meTvalyureobis da daxmarebis uzrunvelsayofad, samSoiaro saxlidan gawerisas unda mieces dawvrilebiTi amonaweri dedisa da bavSvis mdgomareibisa da arv-s Sesaxeb. es amonaweri unda gadaeces pacientisa da axalSobilis mkurnal eqims (dawvrilebiT ix. Tavi 1 “mozrdilTa da mozardebSi g) mokvleva da antiretrovirusuli Terapia” da Tavi 11 “aiv/Sidsis mqone bavSvebis mkurnaloba da daxmareba”).

V. samedicino dawesebulebebSi Segrovebeli monacemebis minimaluri CamonaTvali monacemebi, romlebic unda Segrovdes metad mniSvnelivania raTa SemuSavdes dbgp momsaxurebis xelmisawvdomi da efeqturi forma. aseTi indikatorebi xels uwyoben jandacvis sistemas SeimuSaon RonisZiebebi, raTa Sesabamisi samsaxurebi gafarTovdes da ganmtkicdes da xelmisawvdomi gaxdes yvela qalisTvis.

yovel samedicino dawesebulebaSi regularulad unda Segrovdes Semdegi monacamebi (mag.: TveSi, kvartalSi, 6 TveSi erTxel).

mSobiarobamde daxmarebis centrebSi: orsulTa raodenoba; orsulTa raodenoba, romlebmac Caitares testireba aiv-infeqciaze; aiv infeqciaze testirebis dadebiTi rezultatis mqne orsulTa ricxvi aiv inficirebul orsulTa raodenoba, romelTac gaukeTda samedicini aborti; aiv inficirebul orsulTa raodenoba, romelTac CautardaT arv-profilaqtika; aiv inficirebul orsulTa raodenoba, romlebic moixmaren ineqciur narkotikebs; aiv inficirebul orsulTa raodenoba, romlebic Rebuloben opoidebiT CanacvlebiT

Terapias; aiv inficirebul orsulTa raodenoba, romlebic Rebuloben opoidebiT CanacvlebiT

Terapias (oCT) da arv-profilaqtikas;

samSobiaro saxlSi: Semosul aiv inficirebul orsulTa raodenoba; Semosul orsulTa raodenoba, romlebmac orsulobis dros ar Caitares testireba

aiv infeqciaze; - ramden maTgans Cautarda eqspres-restireba aiv-ze; - ramden maTgans hqonda dadebiTi pasuxi; Aaiv inficirebul orsulTa raodenoba, romlebic orsulobisas ar Rebulobdnen arv-

profilaqtikas; Aaiv inficirebul orsulTa raodenoba, romlebic moixmaren ineqciur narkotikebs

da aReniSnebaT opoiduri damokidebuleba; - orsulobis dros ramdeni maTgani Rebulobda oCT; Aaiv inficirebul orsulTa raodenoba, romlebmac imSobiares fiziologiuri gziT; Aaiv inficirebul orsulTa raodenoba, romlebsac gaukeTdaT sakeisro kveTa Aaiv inficirebuli dedebis mier gaCenil axalSobilTa raodenoba;

- ramdeni maTgani Rebulobda arv-profilaqtikas; - ramdeni maTgani iyo xelovnur kvebaze; - ramdeni maTgani Rebulobda ZuZuTi kvebas;

Aaiv inficirebul dedaTa da axalSobilTa raodenoba, romelTac diagnozi daesvaT PCR meTodiT;

opoiduri damokidebulebis mier mqone gaCenil axalSobilTa raodenoba; axalSobilTa raodenoba, romlebic Rebulobdnen abstinenciuri sindromis

mkurnalobas;

danarTi 1. preparatebi, romlebic gamoiyeneba orsulebSi fsiqoaqtiur nivTierebebze damokidebulebis samkurnalod

cxrili 9 preparatebi, romlebic gamoiyeneba orsulebSi fsiqoaqtiur nivTierebebze damokidebulebis samkurnalod

preparati doza gverdiTi novlemnebi SeniSvnaopoiduri damokidebulebaklonidini 0.1-0.2mg yovel

6-8sT-Si, davakvirdeT abstinenciis sindroms

arteriuli hipotonia, Zilianoba

bevrad efeqturia somaturi simptomebisas, vidre fsiqikuris; esaWiroeba damatebiTi preparatebi

naltreqsoni 50mg/dReSi, an 100mg orSabaTi, oTxSabaTi da 150mg paraskevs

muclis areSi tkivili, 40wlis asakis zemoT RviZlis fermentebis aqtivobis momateba

abstinenciuri sindromis mkurnaloba da SemanarCunebeli Terapia ; iniSneba opoidebis bolo gamoyenebidan araumcires erTi kviris Semdeg

buprenorfini dasawyisSi 2-4mg, pirvel dReRameSi doza SegviZlia gavzardoT 8mg-mde ; meore dRes, simptomebis mixedviT, 16mg-mde; Semdgom 8mg-iT yovel meore dRes ; xSirad ufro efeqturia doza > 60mg

msubuqi abstinenciuri sindromi, Sekruloba, Zilianoba

abstinenciuri sindromis mkurnaloba da SemanarCunebeli Terapia; gamoiyeneba mxolod klinikis farglebSi; iniSneba opoidebis bolo gamoyenebidan araumcires 24sT-sa

meTadoni ufro efeqturia Tu doza > 60mg

Zilianoba, Sekruloba, libidos daqveiTeba, mtevnebis SeSupeba

opoiduri damikidebulebis CamacvlebiTi Terapia; gamoiyeneba mxolod licenzirebuli narkologiuri mkurnalobis programis farglebSi

nikotinuri damokidebulebanikotinis plastirebi 21mg/dReSi 4kv.,

14mg/dReSi 2kv., 7mg/dReSi 2kv. (nikodermi CQ); an 15mg/16sT (nikotroli) 8kv.

kanis organuli gaRizianeba, uZiloba

vinc 10 Rerze naklebs eweva dozas ukleben; plastiris dakvris adgili yoveldRe icvleba

nikotiniani saReWi rezini

vinc eweva < 25 Rers dReSi – 2mg, > 25 Rers dReSi – 4mg

tkivili piris RruSi da ReWvisas, slokini, dispepsia

saReWi rezinis saaTobrivad ReWva (yovel 1-2 saaTSi), da ara saWiroebis dros; 15 wT-iT adre ar SeiZleba sakvebisa da siTxis miReba

bupropioni (amfebutamoni) Senelebuli gamoTavisuflebiT

viwyebT 150mg diliT 3 dRemowevaze Tavis danebebamde 1 kv. adre; 150mg 2jer dReSi 7-12 kv.; kursi SegviZlia gavagrZeloT 6 Tvemde

uZiloba da piris simSrale; ukuCvenebebi: gulyriTi Setevebi, saWmlis monelebis darRvevebi, anamnezSi Tavis qalis tramva; preparati ar eniSnebaT pacientebs, romlebic bolo2 kviris ganmavlobaSi Rebulobdnen monoaminoqsidazis inhibitorebs; wamlebis usafrTxoebis klasifikaciis mixedviT miekuTvneba BBkategorias

gaicema receptiT; damatebiTi varianti pacientebisaTvis, romlebic uars acxadeben nikotiniT CanacvlebiT Terapiaze

alkoholuri abstinenciis sindromiqlordiazepoqsidi erTjeradi doza 25-

100mgZilianoba, Tavbru, ataqsia, gonebis dabindva

xangrZlivi naxevrad daSlis periodi; SegviZlia mivceT dartymiTi doza simptomebis Sesamcireblad da Semdeg movxsnaT preparati

diazepami erTjeradi doza 15-60mg

igivea rac qlordiazepoqsidis

xanmokle naxevardaSlis periodi, ar aqvs aqtiuri metabolitebi da damokidebulia RviZlis funqciaze; xSirad iniSneba yovel 4-6 sT-Si

karbamazepini dartymiTi doza 400mg, Semdgom 200mg 3jer dReSi,

Zilianoba, Tavbru, ataqsia, gonebis dabindva, gulisreva-

efeqturia saSualo simZimis abstinenciuri

moxna TandaTanobiT 5 dRis ganmavlobaSi

Rebineba, sisxlwarmoqmnis daTrgunva

sindromisas; mZimed mimdinare abstinenciuri sindromisas Sescavleli ar aris;

alkoholuri damokidebulebadisulfirami 250-500mg

yoveldRiudad an dRegamoSvebiT

hepatiti, nevriti, periferiuli neiropaTia, disulfiramiduli reaqcia alkoholis miRebisas

efeqturoba matulobs daniSnulebis kontrolisas; aseve efeqturia kokainuri damokidebulebis dros

naltreqsoni iseTive, rogorc opoiduri damokidebulebisas

iseTive, rogorc opoiduri damokidebulebisas

gamoiricxos faruli opoiduri damokidebuleba, raTa aviciloT abstinenciuri sindromis gaZliereba;ukunaCvenebia pacientebisaTvis, romlebic gegmaven operacias da saWiroeben narkotikul analgetikebs

danarTi 2. xelovnuri sakvebi unda akmayofilebdes Semdeg moTxovnebs: misaRebi, ganxorcielebadoba, finansurad xelmisawvdomi, stabiluri da usabrTxo

es terminebi SegviZlia gamoviyenoT safuZvlis saxi. isini saWiroeben adaptacias pirobebisa da mimdinare kvlevebis mixedviT.

mimRebloba. dedas ar eqmneba problemebi xelovnur sakvebTan dakavSirebiT, rogoricaa kulturuli tradiciebi an socialuri pirobebi, stigmisadmi SiSi an diskrimainacia. mimRebloba niSnavs, rom qali an ar ganicdis socialur da kulturalur zewolas, romelic ara aris mimarTuli xelovnuri kvebis sawinaaRmdegod da mis gadawyetilebas mxars uWers ojaxi da axloblebi, an/da mas SeuZlia winaaRmdegoba gauwios ojaxs da megobrebs, romlebic moiTxoven ZuZuTi kvbas.

Ganxorcielebadoba. dedas (da misi ojaxs) sakmarisi dro, Cvevebi da sxva pirobebi aqvT dedis rZis Semcvlelis mosamzadeblad da bavSvis dR-eRameSi 12-jer sakvebad. dedas unda SeeZlos instruqciiT sakvebis momzadeba; mas mxars uWeren axloblebi, rac saSualebas aZlevs moamzados sakvebi da gamokvebos bavSvi, imis gaTvaliswinebiT rom mas uwevs ojaxSi sxva samuSaos Sesrulebac.

finansuri xelmisawvdomoba. dadas (da mis ojaxs) sazogadoebrivi

organizaciebisa an jandacvis sistemis (Tu saWiroa) mxardaWeriT SeuZlia dafaros xelovnur sakvebTan dakavSirebuli da aseve sxva finansuri danaxarjebi (sawvavi,sufTa wyali, saponi, sxva saWiro nivTebi) janmrTelobisa da ojaxis zaralis gareSe. Sexeduleba finansuri xelmisaswvdomobis Sesaxeb aseve gulisxmobs (saWiroebis SemTxvevaSi) samedicino daxmarebas bavSvebSi diareis dros, mkurnalobis xarjebs.

Stabiluroba. mudmivi da uwyveti momarageba. ingredientebisa da produqtebis gadanawilebis sando sistema, romelic saWiroa xelovnuri kvebisTvis; is unda iyos xelmisawvdomi mTeli im drois manZilze, vidre esaWiroeba bavSvs – erT wlamde asaksa da mozrdilebSi.

usafrTxoeba. xelovnuri sakvebi unda momzaddes higienuri wesebis dacviT da sworad unda inaxebodes; bavSvi unda Rebulobdes sakvebs sakmarisi raodenobiTa da higienuri moTxovnilebis dakmayofilebiT (xelebis dabana, sufTa boTli an Wiqa). usafrTxoeba niSnavs, rom deda an sxva piri zrunavs bavSvze:

xeli miuwvdeba sufTa wylis wyarosTan; amzadebs srulyofil sakvebs, romelic ar Seicavs infeqciis gamomwvevebs; saSualeba aqvs daibanos xelebi da garecxos WurWeli, regularulad

gaasterilon sakvebis mosamzadeblad saWiro nivTebi; hqondeT wylis aduRebis saSualeba sakvebis yoveli momzadebis win; hqondeT sakvebis mSral adgilas Senaxvis saSualeba, sufTa, mSral

konteinerSi, mwerebisagan, mRrRnelebisa da sxva cxovelebisagan dasacavad.

Tu am pirobebs ver akmayofileben, maSin rekomendebulia sicocxlis pirvel TveebSi mxolod ZuZuTi kveba da pirvelive SesaZleblobisas xelovnur kvebaze gadayvana. Aaiv inficirebul dedebs unda davexmaroT swori gadawyvetilebis miRebaSi, romelic saukeTesod Seewyoba misi cxovrebis wess, da Semdgom ganvaxorcieliT igi. kvebis ra saxec ar unda airCios dedam, Cven unda davexmarod mas sworad da usafrTxod gaakeTos es.

danarTi 3. axalSobilebSi abstinenciis sindromis simZimis Sefaseba qulebSi

cxrili 10 axalSobilebSi abstinenciuri sindromis simZimis SefasebaniSnebi da simptomebi qulebidarRvevebi cns mxrivSeuCerebeli tirili 2SeuCerebeli xangrZlivi tirili 31 sT-ze naklebi Zili Wamis Semdeg 32 sT-ze naklebi Zili Wamis Semdeg 23sT-ze naklebi Zili Wamis Semdeg 1moros refleqsis momateba 2moros refleqsis mkveTri momateba 3agznebisas msubuqi tremori 1agznebisas zomieri an Zlieri tremori 2msubuqi tremori mSvid mdgomareobaSi 3zomieri an Zlieri tremori mSvid mdgomareobaSi 4kunTebis hipertonusi 2eqskoriaciebi (specifiur adgilebSi) 1

mioklonia 3generalizirebuli krunCxvebi 5metaboluri vazomotoruli sunTqviTi darRvevebioflianoba 1cxeleba 37,2 – 38,20 C 1cxeleba 38,40 C 2xSiri mTqnareba (> 3-4 jer) 1marmarilosebri kani 1cxviris gaWedva 1cemineba > 3-4 jer 1cxviris nestoebis daberva 2sunTqviTi sixSire > 60 wT-Si 1sunTqviTi sixSire > 60 wT-Si gul-mkerdis damyoli ubnebis monawileobiT

2

kuW-nawlavis darRvevebixarbi wova 1susti wova da male danayreba 2xSiri boyini 2profuzuli Rebineba 3Txieri ganavali 2wylisebri ganavali 3

Bbibliografia:

1.De Cock KM et al. Prevention of mother-to-child HIV transmission in resource-poor countries: translating research intopolicy and practice. JAMA, 2000, 283(9):1175—1182.2. European Centre for the Epidemiological Monitoring of AIDS (EuroHIV). HIV/AIDS surveillance in Europe: end-yearreport 2004. Saint-Maurice, Institut de Veille Sanitaire, 2005 (No. 71;http://www.eurohiv.org/reports/index_reports_eng.htm, accessed 24 July 2006).3. 2004 report on the global AIDS epidemic. Geneva, Joint United Nations Programme on HIV/AIDS (UNAIDS), 2004(http://www.unaids.org/bangkok2004/GAR2004_html/GAR2004_00_en.htm, accessed 24 July 2006).4. Dorenbaum A et al. Two-dose intrapartum/newborn nevirapine and standard antiretroviral therapy to reduce perinatalHIV transmission: a randomized trial. JAMA, 2002, 288:189—198.5. Cooper ER et al. Combination antiretroviral strategies for the treatment of pregnant HIV-1-infected women and prevention of perinatal HIV-1 transmission. Journal of Acquired Immune Deficiency Syndromes, 2002, 29:484—494.6. Thorne C, Newell ML. Are girls more at risk of intrauterine-acquired HIV infection than boys? AIDS, 2004,18(2):344—347.7. Strategic approaches to the prevention of HIV infection in infants: report of a WHO meeting, Morges, Switzerland, 20—22 March 2002. Geneva, WHO, 2003 (www.who.int/hiv/pub/mtct/en/StrategicApproachesE.pdf, accessed 7 June 2004).8. Strategic framework for the prevention of HIV infection in infants in Europe. Copenhagen, WHO Regional Office forEurope, 2004 (www.euro.who.int/childhealtdev/manuals/manualstop, accessed 06 October 2006).9. Declaration of Commitment on HIV/AIDS. New York, United Nations General Assembly Special Session (UNGASS)on HIV/AIDS, 25—27 June 2001

(http://data.unaids.org/publications/irc-pub03/aidsdeclaration_en.pdf, accessed 24July 2006).10. Jackson JB et al. Intrapartum and neonatal single-dose nevirapine compared with zidovudine for prevention of motherto-child transmission of HIV-1 in Kampala, Uganda: 18-month follow-up of the HIVNET 012 randomized trial. TheLancet, 2003, 362(9387):859—868.11. Guay LA et al. Intrapartum and neonatal single-dose nevirapine compared with zidovudine for prevention of mother-tochild transmission of HIV-1 in Kampala, Uganda: HIVNET 012 randomized trial. The Lancet, 1999, 354(9181):795—802.12. The Petra study team. Efficacy of three short-course regimens of zidovudine and lamivudine in preventing early and late transmission of HIV-1 from mother to child in Tanzania, South Africa, and Uganda (Petra study): a randomized, doubleblind,placebo-controlled trial. The Lancet, 2002, 359(9313):1178—1186.13. Shaffer N et al. Short-course zidovudine for perinatal HIV-1 transmission in Bangkok, Thailand: a randomized controlled trial: Bangkok Collaborative Perinatal HIV Transmission Study Group. The Lancet, 1999, 353(9155):773—780.14. Dabis F et al. 6-month efficacy, tolerance, and acceptability of a short regimen of oral zidovudine to reduce vertical transmission of HIV in breastfed children in Cote d’Ivoire and Burkina Faso: a double-blind placebo controlled multicentre trial. The Lancet, 1999, 353(9155):786—792.15. Leroy V et al. Twenty-four month efficacy of a maternal short-course zidovudine regimen to prevent mother-to-child transmission of HIV-1 in West Africa. AIDS, 2002, 16(4):631—641.16. Wiktor SZ et al. Short-course oral zidovudine for prevention of mother-to-child transmission of HIV-1 in Abidjan, Cote d’Ivoire: a randomized trial. The Lancet, 1999, 353(9155):781—785.17. Moodley D et al. A multicentre randomized controlled trial of nevirapine versus a combination of zidovudine and lamivudine to reduce intrapartum and early postpartum mother-to-child transmission of human immunodeficiency virus type 1. Journal of Infectious Diseases, 2003, 187(5):725—735.18. Lallemant M et al. A trial of shortened zidovudine regimens to prevent mother-to-child transmission of human immunodeficiency virus type 1. Perinatal HIV Prevention Trial (Thailand) Investigators. The New England Journal of Medicine, 2000, 343(14):982—991.19. Mandelbrot L et al. Lamivudine-zidovudine combination for prevention of maternal-infant transmission of HIV-1.JAMA, 2001, 285(16):2083—2093.20. Chaisilwattana P et al. Short-course therapy with zidovudine plus lamivudine for prevention of mother-to-child transmission of human immunodeficiency virus type 1 in Thailand. Clinical and Infectious Diseases, 2002,35(11):1405—1413.21. Dabis F et al. A short course of zidovudine + peripartum nevirapine is highly efficacious in preventing mother-to-child transmission of HIV-1: the ARNS 1201DITRAME Plus study. 10th Conference on Retroviruses and Opportunistic Infections, Boston, 10—14 February 2003 (Abstract 854).22. Dabis F et al. Effectiveness of a short course of zidovudine + lamivudine and peripartum nevirapine to prevent HIV-1 mother-to-child transmission: the ANRS DITRAME Plus trial, Abidjan, Cote d’Ivoire. Antiviral Therapy, 2003, 8 (Suppl. 1):S236—S237.23. Taha TE et al. Short post-exposure prophylaxis in newborn babies to reduce mother-to-child transmission of HIV-1: NVAZ randomized clinical trial. The Lancet, 2003, 362(9391):1171—1177.24. Vyankandondera J et al. Reducing risk of HIV-1 transmission from mother to infant through breastfeeding using antiretroviral prophylaxis in infants (SIMBA). 2nd

IAS Conference on HIV Pathogenesis and Treatment, Paris, 13—16 July 2003 (Abstract LB7).25. Therapeutic and other interventions to reduce the risk of mother-to-child transmission of HIV-1 in Europe: the European Collaborative Study. British Journal of Obstetrics and Gynaecology, 2000, 105:704—709.26. Cooper ER et al. After AIDS Clinical Trial 076: the changing pattern of zidovudine use during pregnancy, and subsequent reduction in the vertical transmission of human immunodeficiency virus in a cohort of infected women and their infants. Journal of Infectious Diseases 1996, 174:1207—1211.10-3027. Mayaux MJ et al. Acceptability and impact of zidovudine for prevention of mother-to-child human immunodeficiency virus type -1 transmission in France. The Journal of Pediatrics, 1997, 131:857—862.28. The International Perinatal HIV Group. The mode of delivery and the risk of vertical transmission of human immunodeficiency virus type 1 — a meta-analysis of 15 prospective cohort studies. The New England Journal of Medicine, 1999, 340:977—987.29. The European Mode of Delivery Collaboration. Prelabour caesarean-section versus vaginal delivery in prevention of vertical HIV-1 transmission: a randomized clinical trial. The Lancet, 1999, 353:1035—1039.30. Browne R et al. Outcomes of planned vaginal delivery of HIV-positive women managed in a multi-disciplinary setting. British HIV Association/British Association for Sexual Health and HIV, Dublin, 20-23 April 2005.31. Scheduled Caesarean delivery and the prevention of vertical transmission of HIV infection. International Journal of Gynaecology and Obstetrics, 2001, 73(3):279—281.32. Read P et al. Does zidovudine monotherapy in pregnancy predispose to the emergence of resistance? HIV Medicine, 2006, 7(Suppl. 1).33. Pregnancy, childbirth, postpartum and newborn care: a guide for essential practice. Geneva, World Health Organization, 2003.34. Giuliano M et al. Selection of resistance mutations in pregnant women receiving zidovudine and lamivudine to prevent HIV perinatal transmission. AIDS, 2003, 17(10):1570—1572.35. Eshleman et al. Characterization of nevirapine resistance mutations in women with subtype A vs. D HIV-1 6—8 weeks after single-dose nevirapine (HIVNET 012). Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology, 2004, 35(2):126—130.36. Stern JO et al. A comprehensive hepatic safety analysis of nevirapine in different populations of HIV infected patients. Journal of Acquired Immune Deficiency Syndromes, 2003, 34:S21—S33.37. United States Centers for Disease Control. Updated guidelines for the use of rifabutin or rifampin for the treatment and prevention of tuberculosis among HIV-infected patients taking protease inhibitors or nonnucleoside reverse transcriptase inhibitors. Morbidity and Mortality Weekly Report, 2000, 49(9):185—189.38. Patel A et al. To study the safety and antiretroviral efficacy of rifampicin and efavirenz in antiretroviral naïve tuberculosis coinfected HIV-1 patients in India. 10th Conference on Retroviruses and Opportunistic Infections, Boston,10—14 February 2003 (Abstract 138).39. Pedral-Samapio D et al. Efficacy of efavirenz 600 mg dose in the ARV therapy regimen for HIV patients receiving rifampicin in the treatment of tuberculosis. 10th Conference on Retroviruses and Opportunistic Infections, Boston, 10—14 February 2003 (Abstract 784).

40. Ribera A, Azuaje C, Montero F. Saquinavir, ritonavir, didanosine, and lamivudine in a once daily regimen for HIV infection in patients with rifampicin-containing anti-tuberculosis treatment. XIV International AIDS Conference, Barcelona, 7—12 July 2002 (Abstract ThPeB 7280).41. La Porte C et al. Pharmacokinetics of two adjusted dose regimens of lopinavir/ritonavir in combination with rifampicin in healthy volunteers. 42nd Interscience Conference on Antimicrobial Agents and Chemotherapy, San Diego, 27—30 September 2002 (Abstract A-1823).42. Bartlett JA et al. An updated systematic overview of triple combination therapy in antiretroviral-naive HIV-infected adults. 12th Conference on Retroviruses and Opportunistic Infections, Boston, 22—25 February 2005 (www.thebody.com/confs/retro2005/pdfs/croi_586.pdf, accessed 19 June 2006).43. Medication-assisted treatment for opioid addiction in opioid treatment programs. Rockville, MD, United States Center for Substance Abuse Treatment, 2005 (Treatment Improvement Protocol Series, No. 43; www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.chapter.82676, accessed 1 June 2006).44. Chasnoff IJ et al. Screening for substance use in pregnancy: a practical approach for the primary care physician. American Journal of Obstetrics and Genecology, 2001, 184(4):752—758.45. Rayburn WF, Bogenschutz MP. Pharmacotherapy for pregnant women with addictions. American Journal of Obstetrics and Gynecology, 2004, 191(6):1885—1897.46. Brown HL et al. Methadone maintenance in pregnancy: a reappraisal. American Journal of Obstetrics and Gynecology, 1998, 179(2):459—463.47. Department of Health Scottish Office, Department of Health Welsh Office, Department of Health and Social Services of Northern Ireland. Drug misuse and dependence — guidelines on clinical management. London, Her Majesty’s Stationery Office, 1999 (http://www.atforum.com/SiteRoot/pages/addiction_resources/UK%20Methadone%20Guidelines.pdf, accessed 19 June 2006).48. Pregnancy categories (web page). U.S. Food and Drug Administration, FDA Consumer magazine, Rockville, MD, United States, May-June 2001 (www.fda.gov/fdac/features/2001/301_preg.html, 06 October 2006).49. Kandall SR. Improving treatment for drug-exposed infants. Rockville, MD, United States Center for Substance Abuse Treatment, 1993 (Treatment Improvement Protocol Series, No. 5;http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.chapter.24127, accessed 1 June 2006).50. Fisher G et al. Treatment of opioid dependent pregnant women with buprenorphine. Addiction, 2000, 95(2):239—244.51. Finnegan et al. Neonatal abstinence syndrome: assessment and management. Addictive Diseases International Journal, 1975, 2(1):141—158.52. Clinical guidelines for the use of buprenorphine in the treatment of opioid addiction. Rockville, MD, United States Center for Substance Abuse Treatment, 2004.53. Co-operation Group to Combat Drug Abuse and Illicit Trafficking in Drugs (Pompidou Group). Pregnancy and drug misuse update 2000: proceedings: seminar organized by the Co-operation Group to Combat Drug Abuse and Illicit Trafficking in Drugs (Pompidou Group), Strasbourg, France, 29—30 May 2000. Strasbourg, Council of Europe, 2000.54. Dunn DT et al. Risk of human immunodeficiency virus type 1 transmission through breastfeeding. The Lancet, 1992, 340:585—588. 1 0-31

55. Leroy V et al. International multicentre polled analysis of late postnatal mother-to-child transmission of HIV-1 infection. The Lancet, 1998, 352:597—600.56. Miotti PG et al. HIV transmission through breastfeeding: a study in Malawi. JAMA, 1999, 282(8):744—749.57. Coutsoudis A et al. Influence of infant-feeding patterns on early mother-to-child transmission of HIV-1 in Durban, South Africa: a prospective cohort study. The Lancet, 1999, 354(9177):471—476.58. HIV and infant feeding: a guide for health-care managers and supervisors. Geneva, WHO, 2003.59. Nair P. Pharmacological management of neonatal opioid abstinence syndrome. CNS Drugs, 1997, 8(6):448—456.60. Johnson RE, Jones HE, Fischer G. Use of buprenorphine in pregnancy: patient management and effects on the neonate. Drug and Alcohol Dependence, 2003, 70(2 Suppl.):S87—S101.61. Broekmans JF et al. European framework for tuberculosis control and elimination in countries with low incidence. The European Respiratory Journal, 2002, 19(4):765—775. 10