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

N nino ruxaZe

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 12%-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 gamokvleva mSobiarobamde 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 mocemulia IV.2.3 qveTavSi. damokidebulebisa da abstinenciis Sefaseba

2 konsultacia pirveladi 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 0,91,3%-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 SesaZlo scenarebi da sakonsultacio centrebSi dbgp RonisZiebebis

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 orsulobamde 4. 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 saWiroeben arv Terapias janmrTelobis mdgoareobis gamo ar

gestaciuri periodi da CD4 raodenob a

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 zidovudins zidovudini gegmiuri nevirapinTa deda: gegmiuri 300mg 2jer sakeisro n erTad zidovudni sakeisro kveTa dReSi (32). kveTisas: mSobiarobis 300mg + 38-e kviraze an hemoglobinis zidovudiniT1 dros lamibudini fiziologiuri kontroliT monoTerapia. (saukeTeso 150mg 2jer mSobaroba4 kombinacia) dReSi 7dRis mSobiarobisas gan. zidovudini1 mSobiarobis 300mg yovel Semdgom2 3sT-Si mSobiarobam bavSvi: de zidovudini + (sirofi) Llamivudini 4mg/kg + 150mg 2jer lamivudini dReSi 2mg/kg 2jer + dReSi 7dRe3 Nnevirapini + 200mg nevirapini erTjeradad 2mg/kg mSobiarobis erjeradad dawyebisas mSobiarobis Semdgom. Nnevirapinis deda: gareSe movuxsnaT mSobiarobis zidovudini. dros bavSvi: zidovudini (sirofi) 4mg/kg 2jer dReSi 7dRe3 araugvianes sicocxlis pirveli 8sTsa. Tu ver vsazRvravT virusul datvirTvas an igi >10 000 asli/ml an adre Rebulobda zidovudins 5 zidovudini deda: Tu 36-38 300mg + mSobiarois Semdgom kviraze VL < lamivudini moixsnas samive 1000 asli/ml 150mg preparati. fiziologiuri +seqvinavir/ mSobiaroba8 6 ritonaviri bavSvi: zidovudini (sirofi) Tu 36-38 3 800/100mg 4mg/kg 2jer dReSi 7dRe kviraze VL 2jer dReSi 7 araugvianes sicocxis >1000 asli/ml, pirveli 8sT-sa. 38-e kviraze sakeisro kveTa. Tu ver vsazRvravT VL da ver vasrulebT

1. Tu SesaZlebelia zidovudinis i/v Seyvana, maSin sakeisro kveTamde 4sT-iT adre infuziis dawyeba (2mg/kg-ze pirveli saaTis ganmavlobaSi, Semdgom 1mg/kgze 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 gestaciis asaki da CD4 ricxvi Aaiv inficirebuli qalebi, romlebic janmrTelobis mdgomareobis gamo saWiroeben an SeiZleba saWiroebdnen arv Terapias Arv profilaqtika orsulobisa da mSobiarobis dros Arv profilaqtika mSobiarobis Semdgom mSobiarobis marTva

nebismieri gestaciuri asaki CD4 < 200mkl

nebismieri gestaciuri asaki CD4 200–350 mkl

zidovudini 300mg1 + lamivudini 150mg + nevirapini 200mg2 2jer dReSi SeniSvna: 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. zidovudini 300mg1 + lamivudini 150mg + seqvinavir/ritonaviri 800/100mg4 2jer dReSi

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 5 mSobiaroba . 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.

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 arvTerapia. cxrili 3 gestaciuri asaki yvela asakis Aaiv inficirebuli orsuli qalebi, romlebmac orsulobamde daiwyes arv Terapia Aarv profilaqtika Aarv profilaqtika mSobiarobis orsulobisa da mSobiarobis marTva mSobiarobis dros Semdgom gavagrZeloT arsebuli deda: Tu 36-38 kviraze sqema, Tu masSi ar mSobiarobis VL < 1000asl/ml, Sedis efavirenzi Semdgom fiziologiuri gziT gagrZeldes mSobiaroba4. Tu sqemaSi Sedis mkurnaloba igive 1, efavirenzi orsulobis sqemiT. Tu 36-38 kviraze pirvel trimestrSi VL > 1000asl/ml, efavirenzi SegviZlia bavSvi: 38-e kviraze SevcvaloT zidovudini(sirofi) sakeisro kveTa. seqvinavir/ritonaviriT 4mg/kg 2jer dReSi 7 800/1002 an abakaviriT. dRe. davwyoT Tu ver Tu <250mkl SegviZlia mSobiarobidan vsazRvravT VL davniSnoT nevirapini3. pirvel 8sT-Si. da maarT-is reJimis dacva < meore rigis sqemebis dRenaklul bavSvebs 95%, 38-e upiratesoba faravs zidovudini kviraze sakeisro masTan dakavSirebul eniSnebaT doziT kveTa. risks. gagrZeldes am 1,5mg/kg i/v an sqemiT mkurnaloba 2,0mg/kg per os Tu ver orsulobis da vsazRvravT VL mSobiarobis periodSi da maarT-is da Semdgom. 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 klnikaSi moxvedris dro mSobiarobis procesSi Aaiv inficirebuli qalebi, romlebic pirvelad mSobiarobis dros mimarTaven daxmarebisTvis samedicino dawesebulebas (orsulobis dros ar Rebulobdnen arv Terapias) Aarv profilaqtika Aarv profilaqtika mSobirobis marTva mSobiarobis dros mSobiarobis Semdeg zidovudini 300mg yovel deda: fiziologiuri 3sT-Si bavSvis zidovudni 300mg + mSobiaroba5 dabadebamde lamivudini 150mg + 2jer dReSi 7dRis lamivudini 150mg gan. mSobiarobis mSobiarobis Semdgom2 unda moveridoT dasawyisSi, Semdeg ki invaziur Carevebs, yovel 12sT-Si bavSvis bavSvi2: rogoricaa 3 dabadbmde zidovudini (sirofi) monitoringis mizniT + 4mg/kg 2jer dRei Tavze eleqtrodebis nevirapini 200mg 4kv. dadeba da erTjeradad mSobiarobis + epiziotomia. dasawyisSi lamivudini 2mg/kg 2jer dReSi 4kv. + nevirapini 2mg/kg erjeradad

mSobiarobis Semdgom 48-72sTSi4 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 812sT_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 nivTiereba alkoholi delta-9-tetrahidrokanabinoli (kanafi: marixuana, haSiSi) Tambaqo abstinenciuri sindromis niSnebi/simptomebi konkretuli fsiqoaqtiuri nivTierebebis gamoyenebisas aiv-inficirebul orsul qalebSi niSnebi/simptomebi agzneba, tremori, , taqikardia, Zilis darRveva, arteriuli wnevis momateba, gulisreva, midriazi, krunCxviTi Setevebi. SfoTva, gaRizianebadoba, zomieri agzneba, uZiloba, gulisreva, spazmebi. gaRizianebadoba, SfoTva, yuradRebis koncentraciis darRveva, siZneleebi davalebis Sesrulebisas, SimSilis grZnoba, wonaSi momateba, Zilis darRveva, Zilianoba, mowevis moTxovnileba. tremori, uZiloba, xSiri xamxami, agzneba, intoqsikaciuri fsiqozi, krunCxviTi Setevebi, mSfoTva,mousvenroba, kunTovani spazmebi, Zilis darRveva, arteriuli wnevis momateba, cxeleba, madis daqveiTeba. mialgia, tkivili muclis areSi, SimSilis grZnoba, Zilianoba, suicidaluri azrebi, bradikardia, wamlismieri damikidebuleba, depresia. gripismagvari sindromi, agzneba, midriazi,

trankvilizatorebi da saZile saSualebebi: alprazolami, barbituratebi, qlordiazepoqsidi,diazepami, flurazepami, gluTetimidi, meprobamati,fenciklidini. fsiqostimulatorebi: metamfetamini, kokaini, meTilfenidati, fenmetrazini, dimeTiltriftamini, fenciklidini. opoidebi: kodein/oqsikodoni,

heroini, hidromorfoni, tripelenamidi.

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 zegavlena alkoholi 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 ar iwvevs ganviTarebis mankebs, naadrevi (kanafi: marixuana, haSiSi) mSobiaroba, Sesabamisad nayofis wonis deficiti, umniSvnelo qceviTi darRvevebi. fsiqostimulatorebi: TviTneburi aborti, nayofis hiperaqtiuroba, metamfetamini, kokaini, ganviTarebis mankebi (gulis mankebi, sanaRvle meTilfenidati, fenmetrazini, 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, intranataluri gaviTarebis Seferxeba ganviTarebis heroini, hidromorfoni, mankebis gareSe, nayofis abstinenciuri sindromi tripelenamidi. 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 upiratesoba saSulebas gvaZlevs Tavi avaridoT nayofze narkotikebSi Semavali minarevebis zemoqmedebas. arsebuli monacemebiT, sufTa meTadoni da heroini ar iwvevs ganviTarebis orsulebSi meTadoniT CanacvlebiTi Terapiis upiratesoba da nakli nakli axalSobilebSi abstinenciuri sindromi mimdinareobs ufro mZimed da xangrZlivad, im bavSvebisgan gansxvavebiT, romelTa dedebi ar Rebulobdnen oCT.

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. 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. dozireba meTadonis 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 mateba orsulobis 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. xangrZlivdeba axalSobilis hospitalizaciisa da mkurnalobis periodi. axalSobilebSi wonis klebis mateba mcirdeba bavSvis sakvebze moTxovnileba.

meTadonisa da arv-preparatebis urTierTzemoqmedeba meTadonisa 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, aivinficirebuli 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. gautkivareba gautkivarebas 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 kontracefcia prezervativi 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 daignostika pirveli 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 bavSvebis marTva abstinenciuri sindromis mqone

4.2.1 klinikuri kvleva axalSobilebi, 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 mkurnaloba axalSoblebSi 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 doza simZimis xarisxi (qulebi) fenobarbitali morfini 8 - 10 6 mg/kg/dReSi 3 miReba 0,32 mg/kg/dReSi miReba 11 - 13 8 mg/kg/dReSi 3 miReba 0,48 mg/kg/dReSi miReba 14 -16 10 mg/kg/dReSi 3 miReba 0,64 mg/kg/dReSi miReba 17 + 12 mg/kg/dReSi 3 miReba 0,80 mg/kg/dReSi miReba wyaro: Finnegan et al., 1975 (51).

4 4 4 4

axalSobilebSi arv-preparatebisa da abstinenciuri sindromis samkurnalo preparatebs Soris urTierTdamokidebuleba jerjerobiT Seswavlili ar aris. 4.3 imunizacia im 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 misaRebad aiv-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 monacamebi (mag.: TveSi, kvartalSi, 6 TveSi erTxel). Segrovdes Semdegi

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 arvprofilaqtikas; • 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 SeniSvna opoiduri damokidebuleba klonidini 0.1-0.2mg yovel arteriuli hipotonia, bevrad efeqturia 6-8sT-Si, Zilianoba somaturi davakvirdeT simptomebisas, abstinenciis vidre fsiqikuris; sindroms esaWiroeba damatebiTi preparatebi naltreqsoni 50mg/dReSi, an muclis areSi tkivili, abstinenciuri 100mg orSabaTi, 40wlis asakis zemoT sindromis oTxSabaTi da RviZlis fermentebis mkurnaloba da 150mg paraskevs aqtivobis momateba SemanarCunebeli Terapia ; iniSneba opoidebis bolo gamoyenebidan araumcires erTi kviris Semdeg buprenorfini dasawyisSi 2-4mg, msubuqi abstinenciuri abstinenciuri pirvel dReRameSi sindromi, Sekruloba, sindromis doza SegviZlia Zilianoba mkurnaloba da gavzardoT 8mgSemanarCunebeli mde ; meore dRes, Terapia; simptomebis gamoiyeneba mixedviT, 16mgmxolod klinikis mde; Semdgom farglebSi; iniSneba 8mg-iT yovel meore opoidebis bolo dRes ; xSirad ufro gamoyenebidan efeqturia doza > araumcires 24sT60mg sa meTadoni ufro efeqturia Tu Zilianoba, Sekruloba, opoiduri doza > 60mg libidos daqveiTeba, damikidebulebis mtevnebis SeSupeba CamacvlebiTi Terapia; gamoiyeneba mxolod licenzirebuli narkologiuri mkurnalobis programis farglebSi nikotinuri damokidebuleba nikotinis plastirebi 21mg/dReSi 4kv., kanis organuli vinc 10 Rerze 14mg/dReSi 2kv., gaRizianeba, uZiloba naklebs eweva 7mg/dReSi 2kv. dozas ukleben; plastiris dakvris (nikodermi CQ); an adgili yoveldRe 15mg/16sT icvleba (nikotroli) 8kv. nikotiniani saReWi vinc eweva < 25 tkivili piris RruSi da saReWi rezinis rezini Rers dReSi – 2mg, ReWvisas, slokini, saaTobrivad

> 25 Rers dReSi – 4mg

dispepsia

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 Zilianoba, Tavbru, ataqsia, gonebis dabindva

ReWva (yovel 1-2 saaTSi), da ara saWiroebis dros; 15 wT-iT adre ar SeiZleba sakvebisa da siTxis miReba gaicema receptiT; damatebiTi varianti pacientebisaTvis, romlebic uars acxadeben nikotiniT CanacvlebiT Terapiaze

alkoholuri abstinenciis sindromi qlordiazepoqsidi erTjeradi doza 25100mg

diazepami

erTjeradi doza 1560mg

igivea rac qlordiazepoqsidis

karbamazepini

dartymiTi doza 400mg, Semdgom 200mg 3jer dReSi, moxna TandaTanobiT 5 dRis ganmavlobaSi

Zilianoba, Tavbru, ataqsia, gonebis dabindva, gulisrevaRebineba, sisxlwarmoqmnis daTrgunva

xangrZlivi naxevrad daSlis periodi; SegviZlia mivceT dartymiTi doza simptomebis Sesamcireblad da Semdeg movxsnaT preparati xanmokle naxevardaSlis periodi, ar aqvs aqtiuri metabolitebi da damokidebulia RviZlis funqciaze; xSirad iniSneba yovel 4-6 sT-Si efeqturia saSualo simZimis abstinenciuri sindromisas; mZimed mimdinare abstinenciuri sindromisas Sescavleli ar aris; efeqturoba matulobs daniSnulebis

alkoholuri damokidebuleba disulfirami 250-500mg yoveldRiudad an dRegamoSvebiT

hepatiti, nevriti, periferiuli neiropaTia, disulfiramiduli reaqcia

alkoholis miRebisas

naltreqsoni

iseTive, rogorc opoiduri damokidebulebisas

iseTive, rogorc opoiduri damokidebulebisas

kontrolisas; aseve efeqturia kokainuri damokidebulebis dros 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 Sefaseba niSnebi da simptomebi qulebi darRvevebi cns mxriv SeuCerebeli tirili 2 SeuCerebeli xangrZlivi tirili 3 1 sT-ze naklebi Zili Wamis Semdeg 3 2 sT-ze naklebi Zili Wamis Semdeg 2 3sT-ze naklebi Zili Wamis Semdeg 1 moros refleqsis momateba 2 moros refleqsis mkveTri momateba 3 agznebisas msubuqi tremori 1 agznebisas zomieri an Zlieri tremori 2 msubuqi tremori mSvid mdgomareobaSi 3 zomieri an Zlieri tremori mSvid mdgomareobaSi 4 kunTebis hipertonusi 2 eqskoriaciebi (specifiur adgilebSi) 1 mioklonia 3 generalizirebuli krunCxvebi 5 metaboluri vazomotoruli sunTqviTi darRvevebi oflianoba 1 cxeleba 37,2 – 38,20 C 1 0 cxeleba 38,4 C 2 xSiri mTqnareba (> 3-4 jer) 1 marmarilosebri kani 1 cxviris gaWedva 1

cemineba > 3-4 jer 1 cxviris nestoebis daberva 2 sunTqviTi sixSire > 60 wT-Si 1 sunTqviTi sixSire > 60 wT-Si gul-mkerdis damyoli ubnebis 2 monawileobiT kuW-nawlavis darRvevebi xarbi wova 1 susti wova da male danayreba 2 xSiri boyini 2 profuzuli Rebineba 3 Txieri ganavali 2 wylisebri ganavali 3 Bbibliografia:

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