Клинические аспекты ВИЧ-инфекции_Бартлетт2007 (1)

2007 i

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, , , , , (). , -, -. Copyright 2007, John G. Bartlett, M.D. . - , . . . - - , -, , 410-614-8488. ISBN: 0-978-0-9755326-3-8 10- ISBN: 0-9755326-3-4 : 2007 MMHIV

Johns Hopkins Medicine Health Publishing Business Group Suite 305, McAuley Bdg. 58101 Smith Avenue Baltimore, MD 21209

2007 iii

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2007 v

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2, , - 2007 . - : - ( , -), ( ), ( CD4), () ( - , - .). , - - -. CDC . , , 1364 . . , , , (110 ) 10 , FDA . - , - . 18 . , (Amplicor HIV-1 Monitor Test 1.5 Roche Versant HIV-1 RNA 3.0 Assay Bayer) . , Abbott, Real-Time PCR, - . -. , - FDA.

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5

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- 100000 / - CD4

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1. : /: 2007. , . http://data.unaids.org/pub/EPISlides/2007/2007_epiupdate_ru.pdf

2. : /: 2007. , . http://data.unaids.org/pub/EPISlides/2007/2007_epiupdate_ru.pdf

3. Ukraine. National Report on Monitoring Progress Towards the UNGASS declaration of Commitment on HIV/AIDS. 2008 (Draft).

4. .

5. Ukraine. National Report on Monitoring Progress Towards the UNGASS declaration of Commitment on HIV/AIDS. 2008 (Draft).

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2007 1

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1. -

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. 1.1. - : 1011 (. 1.2, . 3), - CD4 () (). , , T- (). CD4 - - (J Exp Med 2001; 194:1277). -, CD4 CD8 (Papagno L, PLoS Biol 2004; 2:E20). - CD4 ; CD4 4% log10 / (J Infect Dis 2002; 185:905). CD4 . -, ( ) . (J Infect Dis 1999; 180:1018). CD4

2 2007

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1.1. - CD4 (. Arch Intern Med 1995; 155:1537)

- - CD4*

>500 -1

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2007 3

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: >10 000 / + - (Ann Intern Med 2001; 134:25). , - 170 (J Acquir Immune Defic Syndr 2003; 33:625). - ; - , (N Engl J Med 2005; 352:1873). , - - 410% (N Engl J Med 2005; 352:1873; J Acquir Immune Defic Syndr 2006; 42:75).

1.2. - ( - - [DHHS] [Ann Intern Med 2002; 137:381])

96% 54% 14%

74% 32% 13%

70% 32% 12%

70% 27% 12%

* , , . , -.

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1.3. , 1993 .

*

CD4

, , -

- ( )

, - - (1987)

>500 -1 (29%) 1 1 1

200499 -1 (1428%) 2 2 2

4 2007

-

1.4. , 1997 .*

, , 3846 (16%)

, 144 (0,6%)

, 74 (0,3%)

, 1168 (5%)

, 314 (1,3%)

, , ; 1638 (7%)

: , , 1250 (5%)

, 208 (0,9%)

- (-): / - , 1196 (5%)

, -: >10% ( 2 30 ) ( ) 30 4212 (18%) >1 22 (0,1%)

60 ( 60 ) 1500 (7%)

: 162 (0,7%), 518 (2,3%), 170 (0,7%)

, M. kansasii Mycobacterium avium, 1124 (5%)

Mycobacterium tuberculosis: 1621 (7%), 491 (2%)

9145 (38%)

, (2 12 ) 1347 (5%)

213 (1%)

( Salmonella), 68 (0,3%)

1073 (4%)

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, 23 527 , - ( 1997 ). 36 643 (61% , 60 161 ) CD4 . -. , . , 100%.

. 1993 .

2007 5

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2. , - -, 2.16, . 4647.

- , , (Lancet 1996; 348:176). . - 2 : -1 -2, 40% 60% . - -1, , -2, . -1 , ( ) . - : CRF01_AE ( A E) CRF02_AG. 5570% . 1998 , N (new, ) (Nat Med 1998; 4:1032; Science 2000; 287:607). 98% -1- ; , (J Infect Dis 2000; 181:470); N . , 2005 -, 196 - 111 (55%) B, 54 (27%) A, 8 (4%) C (J Acquir Immune Defic Syndr 2006; 41:399). 2.1.

(J Acquir Immune Defic Syndr 2002; 29:184)

A* , , ,

B* , , , ,

C* , , , , ,

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* , ; 50% , 12% .

6 2007

-

-2 (. www.cdc.gov/hiv/pubs/facts/hiv2.htm)

-2 , CD4. .* -2-. -1, -2 -2- , , CD4 - (Lancet 1994; 344:1380; AIDS 1994; 8[suppl 1]:585; J Infect Dis 1999; 180:1116; J Acquir Immune Defic Syndr 2000; 24:257; Arch Intern Med 2000; 160:3286; AIDS 2000; 14:441; J Infect Dis 2002; 185:905). , - -1 -2, , (J Acquir Immune Defic Syndr 2005; 38:335). -2 -1 -, -1 (Nature 1987; 328:543), 2030% ( ) -2- . -2- - FDA (Ann Intern Med 1993; 118:211; JAMA 1992; 267:2775).

, -2, - , . 1) -1, -2 (AIDS 2002;

16:1775). 2) -2 6 , -1, -2- , (. . ) (JAMA 1993; 270:2083).

3) , - -2-; -, , - -1- (J Acquir Immun Defic Syndr 2005; 38:335).

4) -2 , - (J Clin Microbiol 2000; 38:1370; NEJM 2000; 342:1758; JAIDS 2000; 25:11; AIDS 2004; 18:495; Antivir Ther 2004; 9:57; J Clin Mi-crobiol 2005; 43:484).

5) -2- (. ).

6) - -2 -2 (Arch In-tern Med 2000; 160:3286), (J Virol Methods 2000;

* , -, -, -, , ,

, -, , , , , , -, , -, ; (MMWR 1992; 41[RR-12]:1).

2007 7

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88:81; Clin Infect Dis 2004; 38:1771; J Acquir Immun Defic Syndr 2000; 24:257; . - www.phls.co.uk).

-2. -2 FDA 1990 , 1992 - . -- -1 -2, CDC (MMWR 1992; 41[RR-12]:1). -, FDA, OraQuick -1 -2, Multispot -1 -2. - Reveal G2 Uni-Gold Recombigen - -1. - Multispot -1/-2 1-800-224-6723 - www.bio-rad.com.

. 1987 2005 -2- 76 , 52 - , , , (MMWR 1995; 44:603; JAMA 1992; 267:2775; - www.cdc.gov/hiv/pubs/ facts/hiv2.htm 1 2006 ). CDC , - -2 1) ; 2) , ; 3) -2- , ; 4) , -*; 5) , - -2. -2 CDC.

. -, : 1) , , , 1%; 2) ; 3) ; 4) ; 5) , (N Engl J Med 2006; 355:647; Clin Infect Dis 2004; 39:609). CDC - , :

1364 - -, , - , , ;

* , -, -, -, , ,

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8 2007

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; , - ;

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-, ;

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(), - . - . - -1, (p17, p24, p55), (gp41, gp120, gp160) - (p31, p51, p66). - , 2% - . (Am J Med 2000; 109:568): : ; : ,

gp120/160 + gp41, p24; : , -

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. (>3 ) - ( - ) 99,5% ( 9899,9%), 99,994% (N Engl J Med 2005; 352:570; JAMA 1991; 266:2861; Am J Med 2000; 109:568). .

. - . 0,3% (J Infect Dis 1993; 168:327)

2007 9

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6 (Am J Med 2000; 109:568).

. (JAMA 1993; 269:2786; Ann Intern Med 1988; 108:785). , , - ( 5 ) (N Engl J Med 1999; 340:1683; AIDS 2006; 20:460), , - (Clin Infect Dis 2006; 42:700).

, (AIDS 1995; 9:95; MMWR 1996; 45:181; Clin Infect Dis 1997; 25:98).

(N Engl J Med 2005; 353:1074). N O -2.

M ( AK) -1; -1 -2. - N (Lancet 1994; 343:1393; Lancet 1994; 344:1333; MMWR 1996; 45:561 J Clin Microbiol 2006; 44:1856; J Clin Microbiol 2006; 44:662). 2000 2 -, (MMWR 1996; 45:561; Emerg Infect Dis 1996; 2:209; AIDS 2002; 18:269). - N, -1, (Nat Med 1998; 4:1032). 2000 N (J Infect Dis 2000; 181:470). -- 2030% -2. - - -2. , -2, (. 67).

. . - ( ) 0,0004% 0,0007% (JAMA 1998; 280:1080; Arch Intern Med 2003; 163:1857; Arch Intern Med 2000; 160:2386). - , , CD4 (Arch Intern Med 2003; 163:1857). -, -. :

. - , - - (N Engl J Med 1993; 328:1281). - (N Engl J Med 1994; 331:881).

10 2007

-

. - . 266 , , 68% - 044% - , , (Ann Intern Med 1994; 121:584).

-. - , -, (Ann Intern Med 1994; 121:763). , , . - , - . , 2% 9% , (Ann Intern Med 1999; 130:37).

. - -1, (Am J Epidemiol 1995; 141:1089; N Engl J Med 2006; 354:1422; Cell 1997; 89:263).

(Ann Intern Med 2003; 163:1857).

. - 420% , , -1. : -

; 24. -,

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-2. (. ). . . - -1, -2, , - (N Engl J Med 1990; 322:217). , - ,

2007 11

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- . , , - . , - 1, 2 6 , - , (J Gen Intern Med 1992; 7:640; J Infect Dis 1991; 164:656; Arch Intern Med 2000; 160:2386; J Acquir Immune Defic Syndr 1998; 17:376).

. , , - . , , , (MMWR 2002; 51:736; MMWR 2002; 57[RR-6]:7). : 0,001%, 0,04%, 0,52% ( ), - - 0,76% (Am J Epidemiol 1991; 134:1175; J Acquir Immune Defic Syndr 1993; 6:1049; Arch Intern Med 1995; 155:1305; Am J Public Health 1996; 86:642; Am J Public Health 2000; 90:352; MMWR 2001; 50:440).

. - , , . . . (Home Access Health Corp., Hoffman Estates, III; 800-HIV-TEST) , (1-800-448-8378) (www.homeaccess.com/04). 59,99 . , - . Home Access . 100%. - FDA, -. - , - , -. 174 316 , - 19961997 , 0,9% , 97% , . 60 000 , 2003 0,9%. 60% 49% - - (JAMA 1998; 280:1699).

12 2007

-

(N Engl J Med 1995; 332:1296), (N Engl J Med 2006; 354:437).

-. FDA - - (. 2.2), CLIA (www.cdc.gov/hiv/rapid_testing).

2.2. - , FDA

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% -

OraQuick OraSure Technologies www.orasure.com

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99,6

99,6

99,6

99,8

99,8

99,7

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20

20-40

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Trinity Biotech www.trinitybiotech.com/en/index.asp

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100

100

100

99,7

99,8

99,8

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10

Reveal G2 MedMira Inc. www.medmira.com

99,8

99,8

99,1

98,6

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5

Multispot HIV-1/HIV-2 HIV-2

Bio-Rad Labs 1-800-224-6723 www.bio-rad.com

100

100

99,9 -1 -2

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** CLIA (Clinical Laboratory Improvement Amendment , ) CLIA , . .

- CLIA ( , ) 1988 . - CLIA: . OraQuick Uni-Gold -; , , . , , , . . (Certificate of Waiver) - (. - www.phppo.cdc.gov/clia/regs/toc/aspx). Reveal Multispot HIV-1/HIV-2 - - ; - CLIA, ,

2007 13

-

, - , - . Reveal Multispot , , . , ,

; - ;

, ( 3 ), ;

- (-) . - - , - , - (MMWR 2004; 53:221);

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- 99% (J Acquir Immune Defic Syndr 1993; 6:115; Am J Emerg Med 1991; 9:416; Am Intern Med 1996; 125:471; J Human Virol 2001; 4:278; Internat J STD AIDS 2002; 13:171; J Clin Microbiol 2003; 41:3868; J Lab Med 2003; 27:288), - -; , - , 2.3. - - , , , , (MMWR 2001; 50[RR-11]:1; Infect Control Hosp Epidemiol 2001; 22:289), - (JAMA 2004; 292:219), - (MMWR 2006; 55:673), - , - , , (MMWR 1998; 47:215). ( CLIA) - - 45 (www.cdc.gov/hiv/rapid_testing).

2.3. - *

Ora-Quick Uni-Gold 10% 99% 97% 98% 2% 95% 87% 91%

1% 91% 77% 83% 0,5% 83% 63% 71% 0,1% 50% 25% 33%

99,9% 99,7% 99,8%

* Branson B, www.cdc.gov/hiv/topics/testing/rapid/index.htm

14 2007

-

. OraSure (OraSure Technologies, Inc.; , -; 800-672-7873; www.orasure.com) FDA - , IgG . - OraSure , -1 Vironostika bioMrieux - ; 24,15 . , , - -; , 800-Ora-Sure 800-672-7873. . -, , 20 . - 2040 . IgG, , , , 0,5 /, . - 26 066 , - 99,24%, - 99,89% ; 56 (0,22%) (AIDS 2006; 20:1661). 16 - 99% (AIDS 2006; 20:1655). , - . FDA - - (N Engl J Med 2006; 354:437).

. -1 Calypte (Calypte Biomedical Corp; , ; 877-225-9783; www.calypte.com) FDA . , - , . , 99% (88 89), 94% (49 52) (Lancet 1991; 337:183; Clin Chem 1999; 45:1602; Eur J Clin Micro-biol Infect Dis 2004; 23:831). - - , - . 192 - 816 . 480 1920 . , - 4 .

- - -1 -1 - (. 2.4, . 16). -1, 1 10 - , FDA.

2007 15

-

, , , - - , , -, , -, -. - - .

( ) (. 2.5, . 22) (Amplicor HIV-1 Monitor Test 1.5, -

Roche; 800-526-1247) (Versant HIV-1 RNA 3.0 Assay, -

Bayer; 800-434-2447)

(NASBA) (NucliSens HIV-1 QT, - bioMrieux, 800-682-2666)

. 2.5 . 22, - (J Clin Microbiol 1996; 34:3016; J Med Virol 1996; 50:293; J Clin Microbiol 1996; 34:1058; J Clin Microbiol 1998; 36:3392). (95% ) 0,30,5 log10 (. . 23 ) (J Infect Dis 1997; 175:247; AIDS 1999; 13:2269). , 95% - 10 000 / 3 100 32 000 -/. , - Amplicor 1.5 (Roche) (Versant 3.0), , (

16 2007

-

2.4. -1

.

99,7% . >99,7%, >99,9% (MMWR 1990; 38:380; N Engl J Med 1988; 319:961; JAMA1991; 266:2861).

- . . 1213 2.2

99,6% 20 . CLIA (Ora-Quick Uni-Gold Recombigen) , -, 20 . ; . 2.2 -, FDA (www.cdc.gov/hiv/rapid-testing). -, FDA (Int J STD AIDS 2006; 17:357; Vox Sang 1997; 72:11; J Clin Microbiol 2004; 42:3850).

(- OraSure)

99,6% IgG . : . (JAMA 1997; 227:254).

(Calypte HIV-1 Test)

>99% , - . . 4 .

-

95100%

28 - -2. . -. (, ). , , , : 2000/106 (N Engl J Med 1989; 321:1621).

-

>99% , - CD4 ( ) , . 5 106 (J Virol Methods 2005; 124:157). -; . FDA (Ann Intern Med 1996; 124:803), .

9598% 29% , - (10 000 / 100%.

24 3090% -. 100%, 90% , (Ann Intern Med2001; 134:25). (J Clin Micro 2005; 43:506).

2007 17

-

. 12 : -, 0,23 log10 / ( 2 ) , (J Acquir Immune Defic Syndr 2002; 31:11). - CD4

18 2007

-

, - (MACS). - - -, CD4 (Ann Intern Med 1995; 122:573; Science 1996; 272:1167; J Infect Dis 1996; 174:696; J Infect Dis 1996; 174:704; AIDS 1999; 13:1305; N Engl J Med 2001; 349:720; AIDS 2002; 16:2455; Lancet 2003; 362:679; J Acquir Immun Defic Syndr 2005; 38:289). , (AIDS 2006; 20:1197; Clin Infect Dis 2006; 42:136; J Infect Dis 2004; 190:280).

. , CD4

2007 19

-

CD4 (N Engl J Med 1996; 335:1091; Ann Intern Med 1996; 124:984; J Infect Dis 2002; 185:178). , 50 / (J Infect Dis 2004; 189:1452; J Infect Dis 2004; 189:1444). - .

. - , CD4 - ; -. , - 50 / (J Exp Med 2006; 203:1357). - , FDA - AG. , - -- , , - 1 log10 / Amplicor Monitor 1.5 3%, Versant 3.0 9%, NucliSens 15% (J Clin Microbiol 2005; 43:3860). - - -2 ( -2) .

. - , - - . - , . () , - CD4; (AIDS 2002; 16:39; J Clin Microbiol 2000; 38:1414).

(IAS-USA) (JAMA 2006; 296:827) (DHHS) (www.aidsinfo.nih.gov/guidelines). .

, 4 - , .

- . -, 34 (Clin Infect Dis 2001; 33:1060). - 14 (-), 1216 1624 . 0,751,0 log10 / 1 (Lancet 2001;

20 2007

-

358:1760; J Acquir Immune Defic Syndr 2002; 30:167), 1,52 log10 / (

2007 21

-

: - 5160 (J Immunol 1996; 157:1271); - 35 ;

, - Pneumovax ( Streptococcus pneumoniae) (Blood 1995; 86:1082; N Engl J Med 1996; 335:817; N Engl J Med 1996; 334:1222). 2 4 .

-. - Versant 3.0 - 75500 000 /. - Amplicor 50100 000 /. - - , (J Clin Microbiol 2000; 38:2837). NucliSens (1763 500 000 /), - , - , , , - , , (J Clin Microbiol 2000; 38:1414).

22 2007

-

2.5. FDA -,

Roche Bayer bioMrieux

800-526-1247 800-434-2447 800-682-2666

Amplicor HIV Monitor 1.5

Versant HIV-1 RNA 3.0

NucliSens HIV-1 QT

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, - , , - (Amplicor)

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, , . - .

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(Amplicor 1.5): 400750 000 -/ (Ultra-Direct 1.5): 50100 000 /

3.0: 75500 000 /*

NucliSens HIV-1 QT: 1763 500 000 /;

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Amplicor: 0,2 -: 0,5

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4 , - - 20 70.

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* , FDA, 75 /. 50 /.

2007 23

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CD4

CD4 , - , - (. . 1.1, . 2), . - - (Ann Intern Med 1997; 126:946; Lancet 2002; 360:119; Lancet 2003; 362:679). , CD8 (N Engl J Med 1990; 322:166), , - ( CD4/CD8) , - - (J Acquir Immune Defic Syndr 2006; 42:620). - CD8 ( CD38) , - (Science 1999; 283:857; J Acquir Immune Defic Syndr 2002; 29:346).

. . , - CD4. - , FACSCount Becton Dickinson CyFlow Partec, - Guava PointCare Technolo-gies, , (Cytometry 2002; 50:69; BMJ 2001; 323:809; J Immunol Methods 1999; 222:209; J Clin Virol 2000; 17:101; J Acquir Immune Defic Syndr 2006; 41:607; J Transl Med 2006; 4:33; Clin Diagn Lab Immunol 2005; 12:1416; PLoS 2005; 2:e182).

. CD4 8001050 -1; 5001400 -1 (Ann Intern Med 1993; 119:55).

CD4. - CD4 ( ); CD4 ( DHHS 2006 , www.aidsinfo.nih.gov/guidelines). CD4 - 36 , , 34 . - , - . CD4 . , , CD4 4% log10 (/) (J Infect Dis 2002; 185:905).

24 2007

-

CD4. , - CD4, - , CD4 - , , - - . , - CD4 200 -1, 95% 118337 -1 (J Acquir Immune Defic Syndr 1993; 6:537). - , -. - CD4 30% CD4 3% ( DHHS 2006 , www.aidsinfo.nih.gov/guidelines).

, CD4. , - CD4, , , . - CD4, ( 5001400 -1). , CD4 : , - CD4. , CD4 (Clin Exp Immunol 1991; 86:349) : 12:30, 20:30 (J Acquir Im-mune Defic Syndr 1990; 3:144), . CD4 . - CD4 : - CD4 900 -1 300 -1 ; CD4 (Clin Immunol Im-munopathol 1983; 28:101). CD4, , , (lin Exp Immunol 1990; 80:460).

CD4 - HTLV-1, . HTLV-1 HTLV-2 , , CD4 HTLV-1. -, , HTLV-1/2- 712% 210% - (N Engl J Med 1990; 326:375; JAMA 1990; 263:60); 8090% HTLV-2. HTLV-1 (JAMA 1994; 271:353)

2007 25

-

(J Clin Microbiol 1995; 33:1735). HTLV-1 , - CD4 80180% CD4, , (JAMA 1994; 271:353). CD4 - . - CD4 (Clin Infect Dis 1995; 20:768; Arch Surg 1998; 133:25).

, ( ), , , CD4 (Ann Intern Med 1993; 119:55).

CD4. - CD4, (J Acquir Immune Defic Syndr 1989; 2:114). , ACTG ( , ), CD4 18%, CD4 25% (J Infect Dis 1994; 169:28). , CD4 (J Acquir Immune Defic Syndr 2004; 36:1028). , , , CD4, , -, - 350 -1 (J Infect Dis 2005; 192:950), - CD4 350 -1, , CD4 (J Infect Dis 2005; 192:945; J Acquir Immune Defic Syndr 2004; 36:1028). - CD4 .

2.6. CD4

CD4 CD4

>500 -1 >29%

200500 -1 1428%

26 2007

-

(J Infect Dis 2004; 190:1860). - , CD4 ; (JAMA 2002; 288:222). CD4 , - (Antivir Ther 1999; 4(Suppl 3):7; J Infect Dis 2001; 183:1328). , , - , , - (J Infect Dis 2004; 190:148). DHHS - ( ) - CD4 2550 -1 . CD4 ; 34 - 100150 -1 (Clin Infect Dis 2001; 33:344; Clin Infect Dis 2001; 32:1231; N Engl J Med 2003; 349:837). - CD4, , - - (N Engl J Med 2003; 349:837), - , - (J Infect Dis 2005; 192:1537).

. CD4 - (JAMA 1993; 269:622; Am J Med Sci 1992; 304:79). DHHS

2007 27

-

. CD4 CD4 . CD4 . , 12 , - (Nat Med 1997; 5:533; Science 1997; 277:112). 6 CD4. - , , , - - -. , , , , , CD4 300 -1 (J Infect Dis 2001; 183:1285).

CD4. CD4 , - CD4 - - -, . : 1) CD4 300 -1 - CD4 20% -; 2) ; 3) CD4, , , , , , - (N Engl J Med 1993; 328:373).. - CD4 (Chest 1994; 105:1335; Eur J Med 1993; 2:509; Am J Med Sci 1996; 312:240). , 430 - , , 62 (14%) CD4 (J Infect Dis 2000; 41:167). CDC CD4 ( . . ). , - CD4 (Int Arch Allergy Immunol 2005; 136:379). , CD4, : 1) -; 2) ; 3) CD4 - , ; 4) - , - ; , P. jiroveci, Candida, -8 ( ); 5) CD4, , , ; 6) -, CD4

28 2007

-

(Lancet 1992; 340:273; N Engl J Med 1993; 328:373; N Engl J Med 1993; 328:380; N Engl J Med 1993; 328:386; N Engl J Med 1993; 328:393; Clin Exp Immunol 1999; 116:322; Clin Infect Dis 2000; 3:E20; Clin Infect Dis 2001; 33: E125; Clin Infect Dis 2006; 42:e53). ( - ), CDC, .

(. N Engl J Med 2004; 350:1023)

, , 50% () (Lancet 2002; 359:49; Nature Med 2001; 7:1016). , 20002003 , - , , - 619%. , () - , , , - , (Clin Infect Dis 2005; 41:233; Antivir Ther 2006; 11:173). - (JAMA 2006; 296:827; DHHS 2006 , www.aidsinfo.nih.gov/guidelines). - - - . :

, - . , - 20% , , - (, CD4, ..), .

, 5001000 /. - , - , 0,1% , (J Acquir Immune Defic Syndr 2005; 40:24; J Infect Dis 2005; 192:1).

, - , - - (), .

, - . - , - ; .

2007 29

-

- , :

- , , , - .

- ( ), - , , . -, 4 , - , . 184V 20 (J Infect Dis 2005; 192:1537).

-, , , . , - , -. ACTG 398, - , , - , - . - , (Antivir Ther 2003; 8:S150).

- 5001000 /.

, , - . - . - - (. ).

- , - .

30 2007

-

DHHS (http://www.aidsinfo.nih.gov/guidelines, 12 2006 .) IAS-USA (http://www.iasusa.org; JAMA 2004; 292:251; Top HIVMed 2004; 12:119; Antivir Ther 2004; 9:829)

-

( . 2.7)

- , :

>0,50,7 log10 / 4 ;

>1 log10 / 8 ;

>1000 / 1624 .

2.7. - (J Acquir Immune Defic Syndr 2001; 26:551)

-

*

**

IAS-USA USA-DHHS

- ( 612 )

-

, -

* HIV Med 2003; 4 (Suppl.1):1

** AIDS 2001; 15:309 Antivir Ther 2004; 9:829 http://www.aidsinfo.nih.gov, 1 2006 .

. , - 2001 , - ( - 36 ), ,

2007 31

-

(HIV Clin Trials 2002; 3:1). - , -. , . , , , ( , ). 6 168 (39%) 432 , , 115 (29%) 400 , . - (AIDS 2002; 16:369). , - - TORO-1 TORO-2 (N Engl J Med 2003; 348:2175 2293). , ( ) - . IAS-USA : 1) -, , - - , ; 2) ; 3) -, (Clin Infect Dis 2003; 17:37). - B; - (Scand J Infect Dis 2003; 35[Suppl 106]:75).

- ( ). - , - -, - - . - 90- , -. . (S. Little) ., 377 -. 1995 2000 . ( ) (IC50 - /IC50 >10) 3,4% -, 1995 1998 , 12,4% , - 1999 2000 . - , 103, 118, 184

32 2007

-

215; 82 90 (N Engl J Med 2002; 347:385). 1,9% 7,1%. - (Antivir Ther 2002; 7:S188). , , - , 1012% . ; (. 2.8). - -. -, - , - , () . - , - (J Acquir Immune Defic Syndr 2006; 41:573; J Acquir Immune Defic Syndr 2004; 37:1665). -, -, . , -, , .

2.8. -

N

CPCRA-US1 19992001 491 11,6% 7,8% 3,0% 0,7%

2 20022003 1083 9,1% 5,4% 2,6% 3,0%

3 20002001 494 6,1% 3,1% 1,2% 1,2%

10 - 4 19952001 377 11,6% 7,8% 3,0% 0,7%

5 20022003 171 19,2% 12,4% 8,1% 6,6%

1. Clin Infect Dis 2005; 40:468; CPCRA-US (Community Programs for Clinical Research on AIDS) - .

2. Wensing, A. XVI , 2006 , TUAB 0101

3. J Acquir Immune Defic Syndr 2006; 42:86

4. N Engl J Med 2002; 347:385

5. BMJ 2005; 331:1368

. , - , - , (. 2.7).

2007 33

-

() : : . - 2.9 . 35 (J Antimicrob Chemother 2004; 53:555).

. , . (-) . - 98% (Antivir Ther 2000; 5 suppl 4:60; Antivir Ther 2000; suppl 3:53). -, 0,3%, 6,4% (Antivir Ther 2001; 6 suppl 1:1). , , . : 1) - () -; 2) , ( , 20% , ); 3) - --, , , , , . , 103N , 103 - (), , (N). 2.10 (. 36) , - . - , . , , http://www.iasusa.org http://www.hivdb.stanford.edu/. . 2.11 (. 3638), 2.12 (. 39), 2.13 (. 40), 2.14 (. 4142), 2.15 (. 43).

. - . ; , , () (Antivir Ther 2001; 6 suppl 1:129; Antivir Ther 2000; 5 suppl 3:49). , , - , , . - - (). - in vitro -, , . IC50 ( -, 50%) IC50 ( ). -

34 2007

-

, , , , ( ), - .

. . , 55 000 , , . 20% - -, - (Antivir Therapy 2003; 8:S103). . 2.15 . 43.

. - - -, -, , , , . , , , , , (GART [AIDS 2000; 14:F83], VIRADAPT [Lancet 1999; 353:2195]; HAVANA [AIDS 2002; 16:209]), , (REALVIRFEN [Antivir Ther 2003; 8:577]; NARVAL [Antivir Ther 2003; 8:427]). , -, - (Ann Intern Med 2001; 134:440; J Acquir Immune Defic Syndr 2000; 24:227). , -, - , ( CERT [Clin Infect Dis 2004; 38:723] TORO [N Engl J Med 2003; 348:2175]). , . - , , - , -, .

2007 35

-

2.9. -

(300480 . )

12 -

*

( - )

, - - -

(>20%)

, -

-

- 5001000 /

--

, (- - )

-

( 8001000 .)

,

, - , - ; , ,

, -

(>20%)

5001000 /

* , , ; , - .

36 2007

-

2.10. * A I R C K S

D L T

E M V

F N W G P Y H Q

* , .

2.11. ( IAS-USA, ) (Top HIV Med 2006; 14:125130). . http://www.iasusa.org - , http://hivdb.stanford.edu

- *

()

AZT 41L, 67N, 70R, 210W, 215Y/F, 219Q/E

(); . - 65R. 41L, 210W 215Y, . 67N, 70R 219Q/E , . 184V, 65R 74V AZT. . 44D 118I - .

d4T 41L, 67N, 70R, 210W, 215Y/F, 219Q/E, 75T/M/A

d4T (. AZT). 75T/M/A, d4T, .

3TC 65R, M184V/I 184V/I 3TC AZT, d4T TDF, . ddl ABC, M184V/I . 3TC 44D 118I, 3TC.

FTC 65R, M184V/I .

ddI 65R, 74V ddI. 74V 65R , 184V/I ddI ABC (74V, 65R) TDF (65R).

ABC 65R, 74V, 115F, 184V

. 184V/I ABC, -, ABC.

* IAS-USA; , () ().

2007 37

-

2.11. ()

*

()

TDF 65R, 70E 65R 3 , 41L 210W. 184V/I TDF, 65R . 70E, TDF, .

- Q151M

151M 62V, 75I, 77L, 116Y,

, 3TC FTC. . 151M AZT, d4T, ABC, ddI, TDF 3TC FTC.

- T69

69

, 3TC FTC. , , TDF.

- -

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

. AZT d4T. 44D 118I - . .

()

NVP 100I, 103N, 106A/M, 108I, 181C/I, 188C/L/H, 190A

( ) 181C; 103N. 103N, 106M, 188L/C NVP . 188H NVP .

DLV 103N, 106M, 181C, 188L, 236L

(190A/S, 225) NVP EFV, DLV (. 2.13); - .

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

103N, . 188L 106M EFV . 181C ( ) EFV , , - .

* IAS-USA; , () ().

38 2007

-

2.11. ()

()

()

()

IDV/r

46IL, 82A/F/T, 84V

10I/R/V, 20M/R, 24I, 32I, 35I, 54V, 71V/T, 73S/A, 77I, 90M

IDV (. 4 ) 3 .

NFV 30N, 90M 10F/I, 36I, 46I/L, 71V/T, 77I, 82A/F/T/S, 84V, 88D/S

30N ; . ( -- ) 90M, .

SQV/r 48V, 90M 10I/R/V, 24I, 54L/V, 62V, 71V/T, 73S, 77I, 82A/F/T/S, 84V

90M, 48V. 48V , 90M - . , , , .

FPV/r 50V, 84V 10F/I/R/V, 32I, 46I/L, 47V, 54L/V/M, 73S, 82A/F/T/S, 90M

56V - LPV. 50V, 84V, 32I, 54L/M 47V DRV. 10V, 47V, 54M 84V TPV. FPV/r ( FPV) , .

LPV/r 32I, 47V/A, 82A/F/T/S

10F/I/R/V, 20M/R, 24I, 33F, 46I/L, 50V, 53L, 54V/L/A/M/T/S, 63P, 71V/T, 73S, 84V, 90M

LPV/r- , - , -. 47A - LPV .

TPV/r 33F, 82L/T, 84V 10V, 13V, 20M/R, 35G, 36I, 43T, 46L, 47V, 54A/M/V, 58E, 69K, 74P, 83D, 90M

- 01 TPV. 27 .

DRV/r 50V, 54M/L, 76V, 84V

11I, 32I, 33F, 47V, 50V, 73S, 89V

DRV; - .

ATV ATV/r

50L, 84V, 88S 10I/F/V/C, 16E, 20R/M/I/T/V, 24I, 32I, 33I/F/V, 36I/L/V, 46I/L, 48V, 53L/Y, 54L/V/M/T/A, 60E, 62V, 64I/M/V, 71V/I/T/L, 73C/S/T/A, 82A/T/F/I, 85V, 90M, 93L/M

50L - ; , - . in vivo 3 : 10F/V/I, 16E, 33F/I/V, 46I/L, 60E, 84V, 85V.

(20)

36D/S, 37V, 38A/M/E, 39R, 40H, 42T, 43D

, .

() ; .

() - .

2007 39

-

2.12. -

()

M41L, D67N/G, K70R, L210W, T215F/Y, K219E/Q/N

(AZT, d4T), . - 41L/210W/215Y , - 67N/70R/219. T215C/D/E/S/I/V, , , , , . , .

E44D, V118I

- .

,

K65R

TDF, ABC, ddI. 3TC/FTC, - AZT. , AZT, . - d4T , d4T . TDF/FTC , TDF/3TC.

,

L74V

ABC ddI. ( , ABC/3TC, L74V , K65R.) ABC ddI, AZT TDF. , AZT, .

3TC/FTC

M184V/I

3TC FTC. - - ABC ddI ( ). AZT, d4T, TDF. , .

- - -

T69

, 3TC FTC; . , TDF.

- - -

Q151M

, 3TC FTC; . V75I, F77L, F116Y. TDF .

d4T

V75T/M/A d4T in vitro d4T, d4T.

ABC

Y115F ABC; ABC 3 .

40 2007

-

2.13. - ()

A98G NVP (); NVP.

L100I K103N; , EFV DLV. AZT TDF.

K101E/P K101E NVP EFV (); - , NVP. K101P .

K103N/S/R

K103N ; . K103S ; - DLV EFV NVP. K103R , , V179D.

V106M/A

V106M NVP ( C); NVP/EFV DLV. V106A NVP (); NVP, DLV EFV. V106I , .

V108I NVP EFV (); .

V179D/E (); - . V179D + K103R.

Y181C/I

NVP DLV, . EFV , EFV , , - EFV. AZT .

Y188L/H/C

Y188L NVP, DLV EFV (), NVP EFV DLV. Y188C NVP; NVP EFV DLV. Y188H .

G190S/A/E/Q

G190A NVP EFV; NVP EFV. G190A/S - DLV. G190E/Q EFV NVP DLV. - DLV ; .

P225H K103N; . DLV.

F227L V106A; NVP.

M230L (); .

P236L DLV (); DLV NVP.

K238T/N (), K103N ; , NVP.

Y318F (); DLV .

2007 41

-

2.14. ()

L10I/F/R/V () , . L10V - TPV TPV.

I13V TPV TPV.

K20R/I/M/T/V (), . K20M/R/V TPV TPV.

L23I ; NFV .

L24I/F L24I , IDV, . L24F , - .

D30N () , NFV, - B; NFV ; N88D/S.

V32I , IDV, RTV, APV, LPV.

L33F/I/V L33F RTV, APV, LPV, ATV TPV . L33I/V , , , .

E35G TPV TPV.

M36I/V/L M36I/V , - . M36I TPV TPV. M36L: .

K43T TPV TPV.

M46I/L/V

M46I/L , - . M46L TPV TPV. M46V .

I47A/V I47V - APV, IDV, RTV, LPV, TPV. I47A LPV .

G48V/M G48V SQV; SQV . G48M: .

I50V/L

I50V APV , ; APV ; RTV, LPV . I50L ATV , ; ATV ; .

F53L .

42 2007

-

2.14. () ()

I54V/M/L/T/S/A I54V - . I54M/L APV FPV; . I54T/S/A: . I54A/M/V TPV TPV.

Q58E TPV - TPV.

L63A/C/E/H/P/ Q/R/S/T/V/I

L63P ; . : .

H69K TPV - TPV.

A71V/T/I A71V/T . A71I: .

G73S/C/T/A G73S/C/T NFV, IDV, SQV ATV . G73A .

T74P TPV - TPV.

L76V LPV .

V77I , NFV.

V82A/T/F/S/ I/G/L

V82A/T/F/S , LPV, IDV RTV, NFV, SQV, APV ATV . V82I , . V82M G, IDV. V82L/T TPV TPV.

N83D TPV - TPV.

I84V/A/C I84V : APV, NFV SQV, LPV. TPV TPV. I84A/C: I84V, .

N88S/D N88D NFV - SQV ATV. N88S NFV ATV, IDV APV.

L90M SQV NFV , TPV.

T91S LPV in vitro; .

I93L/M I93L , . I93M , , - .

2007 43

-

2.15. , - (VircoTYPE)

Monogram PhoneSense

Virco Antivirogram

Virco VircoTYPE -

/

ABC 4,5 6,5 2,1 0,7 1,9

ddI 1,3 2,2 2,3 0,9 2,6

FTC 3,5 3,7 3,5

3TC 3,5 2,1 1,0 3,4

d4T 1,7 2,4 0,9 2,0

TDF 1,4 4,0 2,5 0,9 2,1

AZT 1,9 2,7 1,2 9,6

DLV 6,2

NVP 3,0 3,4 3,4

EFV 4,5 5,5 5,5

APV 0,9 2,0

APV/r 1,2 9,6

ATV 2,2 2,4 2,4

ATV/r 5,2

DRV/r 10,0 40,0 2,4

FPV 2,0 2,2 2,2

FPV/r 4,0 11,0

IDV 2,1 2,4 0,9 4,5

IDV/r 10,0 10,6 40,1

LPV/r 9,0 55,0 1,7 9,7 56,1

NFV 3,6 2,2 1,3 7,3

RTV 2,5

SQV 1,7 1,8

SQV/r 2,3 12,0 7,1 26,5

TPV/r 2,0 8,0 1,8 1,2 5,4

=

=

=

=

=

=

=

=

44 2007

-

, - -, - 2.16 . 4647 ( IDSA -, Clin Infect Dis 2004; 39:609).

. , , -, , - , (J Acquir Immune Defic Syndr 1994; 7:1134; J Acquir Immune Defic Syndr 2001; 28:221). 36 ; ( , ), , (, -), , , .

. - - (J Infect Dis 2002; 186:231), -, , , - - . 75% , 20% (J Acquir Immune Defic Syndr 1994; 7:1134).

(MMWR 2006; 55[RR-1]:22). , - (VDRL RPR) . 6% - - . - , - (Clin Infect Dis 1994; 19:1040; J Infect Dis 1992; 165:1124; J Acquir Immune Defic Syndr 1994; 7:1134; Am J Med 1995; 99:55). - 300 000 VDRL- - - 2,1%, 0,24% (Int J STD AIDS 2005; 16:722). , . : - (FTA-ABS) - (TP-PA). , VDRL RPR , - . - - ,

2007 45

-

, - - - (MMWR 2002; 51[RR-6]:19). . . 464467.

, . - N. gonorrhoeae () C. trachomatis (AIDS 2000; 14:297), , (Sex Transm Dis 2001; 28:33; Clin Infect Dis 2002; 35:1010). , 1) , , 2) , 3) (Sex Transm Infect 1999; 75:3; Lancet 1995; 346:530). N. gonorrhoeae C. trachomatis , (). -, -. (MMWR 2002; 51[RR-15]:1). 60 100 . N. gonorrhoeae C. trachomatis - , , - , . CDC (- ), - , , , (MMWR 2003; 52[RR-12]:6).

, - . CDC - (2003 .), (MMWR 2003; 52[RR-12]:6): RPR VDRL . N. gonorrhoeae / C. tra-

chomatis () - (), , 1030 .

( - ).

, : N. gonorrhoeae C. trachomatis ( - ).

, : N. gonorrhoeae ( -).

46 2007

-

2.16.

*

IgG **

1015 . ( ); 5060% ; 90% . , , - , .

**

2030 . A.

HBcAg HBsAg**

1015 . : HBcAg HBsAg . , HBsAg.

HBsAg** 2025 . B. - , HBsAg, - .

**

25 .

IgG ; 150 . - , CD4 200 -1 - .

6080 . : IgM , , HBsAg IgM HBcAg.

(. . 7) 3060 . - .

(VDRL RPR)**

516 . , , . FTA-ABS.

IgG Toxoplasma**

1215 . ; , CD4 100 -1, - . - IgG. IgM .

IgG varicella-zoster *

, , , : / / , - varicella-zoster.

* . ** IDSA (Clin Infect Dis 2004;

39:609).

2007 47

-

2.16. ()

-*

**

1015 .

. - .

-6- 1420 .

: 1) : - -6- ( - ) , , , -- ; 2) , - (. . 54). -6- , - , .

()**

2040 .

, - . 36 , .**

-

68 .

36 . .

- - - CD4

60150 .

36 . , , , . , CD4

48 2007

-

. , , ; 36 . - , , , -, , - .

. - - (Am Rev Respir Crit Care Med 2001; 164:21; Chest 2001; 120:1888). CDC - - (MMWR 1986; 35:448) . () , 1065 - -, 3, 6 12 (Arch Intern Med 1996; 156:191), 123 (2%) 5263. -, 82 . , - - - . DHHS (MMWR 1998; 47[RR-1]:38). - , , - , - , , 563 - , - , , (0,02%) - - (Lancet 2003; 362:1551). , . . CDC - ( ) 5 (PPD) - , . , - (, -, ), . - , CD4 >200 -1 ( USPHS/IDSA - 2002 (MMWR 2002; 51[RR-6])). , 4872 5 . -

2007 49

-

. , -, QuantiFERON-TB, -, , (Curr Opin Infect Dis 2006; 19:189; Am J Respir Crit Care Med 2005; 172:631). - QFT-Gold FDA.

. CDC , -, , 6 (MMWR 2002; 517[RR-6]:59; JAMA 1994; 271:1866; MMWR 1999; 48[RR-10]:31); 2.17 . 49 . - - (SIL) (3345% - 714% - ) 09 (Arch Pediatr Adolesc Med 2000; 154:127; Obstet Gynecol Clin N Am 1996; 23:861; J Acquir Immune Defic Syndr 2003; 32:527; J Acquir Immun Defic Syndr 2004; 36:978). - . - - -, , (16, 18, 31, 33 35); (Clin Infect Dis 1995; 25 [suppl 1]:S121; N Engl J Med 1997; 337:1343; J Infect Dis 2001; 184:682). 2.17.

(MMWR 2002; 51[RR-6]:58; JAMA 1989; 262:931; JAMA 2002; 287:2114)

; , 23 .

, (ASCUS) ASC-US ( ) ASC-H ( -

). ASC-H - ASCUS HSIL ( - )

: (16, 18, 31, 33 35 ) . . 46 2 , . ASCUS, .

(LSIL)

46 , , , - .*

(HSIL) ( in situ)

; .

* - - .

50 2007

-

. , -; . ; - 95% 95% . 7 . , : . ,

. -

, , - .

.

, .

- , - .

, , , . - 25 - , .

, , - , . ( ), -, , , - ASCUS. : ( 16, 18, 31, 33 35) -, (CIN 3 ) (JAMA 2002; 288:1749). , (91% 61%), (73% 82%).

2007 51

-

, , (). , , ; , - (Am J Med 2000; 108:674). 60% 75% - (J Infect Dis 1998; 177:361), - 80 , (Lancet 1998; 351:1833), , - CD4

52 2007

-

HBcAg HBsAg (MMWR 2002; 51[RR-6]:63). 3550% , 6080% , 520% , , 314% . - HBsAg, , , , - , , (Ann Intern Med 2005; 142:333). - HBsAg , - (J Med Virol 2006; 51:556). CDC - - HBsAg 12 - , - (MMWR 1999; 48:33). , HBsAg 10 / (MMWR 2001; 50[RR-1]). , (Ann Intern Med 1982; 97:362; MMWR 2002; 51[RR-6]:64). -. 30 (Clin Infect Dis 2002; 35:1368) -, CD4 (Addiction 2002; 97:985; Scand J Infect Dis 2004; 36:131).

. HBsAg . - HBsAg - . - 0,21,0% 67% , .

HBsAg (HBeAg ), - () . - - - , , .

(MMWR 2004; 53[RR-15]:1). 1,8% , 46% 7090% . - C - - , . - 99%, -, , CD4

2007 53

-

- C , , , . 50100 /. , - ; . ( ) 500 / . . . 2.18 . 53. . , - - . C - (. . 496).

2.18.

2545 .

. - - >99%. ; - . - - .

(-)

160200 .

- ; - . 50 /. .

160225 .

- . - , . 500 /; 105107 /. , - . - . - -, - .

200250 .

6 ; 1 (70%), . , 2 3, .

. ( IgG) - , (Ann Intern Med 1992; 117:163)

54 2007

-

. IgG , IgM , - , . - 1030% ; - 1%. 9597%. - , 2047% CD4

2007 55

-

, . Gdmed, , . , GdA-, -, , . . . . -6- , - . : 1) - -6- ; 2) -6- -6-; 3) - -. , , . (). -6- , - , 30 , . , -/ ; , ; .

- , , , ( ), (. . 128 4.30).

56 2007

-

3. : USPHS/IDSA 2002 - , - (MMWR 2002; 51[RR-8]:1; www.aidsinfo.nih.gov)

3.1. ,

,

, . .

, . - .

; , ( , ) - , . .

D . .

. - .

,

I -

II , - - (, -), .

III , , - .

2007 57

-

( )

Pneumocystis jiroveci (P. carinii)

. - Pneumocystis carinii Pneumocystis jiroveci (Stringer et al., Emerg Infect Dis 2002; 8:891). (Pneu-mocystis Carinii Pneumonia) , , Pneumoystis jiroveci Pneumonia.

: CD4

58 2007

-

.

. , , 2550% , -, 2540% , , 24% , (N Engl J Med 1995; 332:693). - , ( - ). , - - , - , , (. . 387388). (J Acquir Immune Defic Syndr 2000; 24:337). , , - . , , -6-, . -/ () - .

. , CD4 3 200 -1, (AI) (N Engl J Med 1999; 340:1301; Lancet 1999; 353:1293; Lancet 1999; 353:201; J Infect Dis 2000; 181:1635), (BII) (N Engl J Med 2001; 344:159; N Engl J Med 2001; 344:168). - CD4 200 -1 (III). 14 , , , - , , - CD4 200 -1 (Clin Infect Dis 2001; 33:1901). 19,1 18,2 1000 - 43,5 41,9 1000 - . 34,5 8,6 1000 -, . - 96 , 42 , (AIDS 2004; 18:2047). : 78 , 40 ( ), (AIDS 2004; 18:2047).

. , (N Engl J Med 2000; 342:1416; Am J Respir Crit Care Med 2000; 162:167; Emerg Infect Dis 2004; 10:1713). - - (JAMA 2001; 286:2450).

2007 59

-

M. tuberculosis (MMWR 1998; 47:[RR-20]). ( 5 ) - (I), (AII), - (AII) (MMWR 2000; 49[RR-6]). 780 - (Lancet 2000; 356:470; MMWR 2000; 49[RR-6]). , -, - (J Acquir Immune Defic Syndr 1998; 19:361; BMJ 1995; 311:1468; J Infect Dis 2004; 190:869). -, , .

. , - 0,38. 11 -, 8130 . (Cochrane Database Syst Rev 2004, CD000171).

, 9- (MMWR 2000; 49[RR-6]; MMWR 2001; 50:773)

300 + 50 1 9 (AII)

900 + 100 2 - 9 (BII).

, , 9- 600 1 + 1520 / 1 2 (AI). . . 347, 348, 448. - , - (. ).

: 600 / 4 (BII). -; - .

M. TUBERCULOSIS, : + 2 ( ) (AI). : + - ( 2 ) (BIII);

60 2007

-

300 / 4 (CIII). . - - , - (. . 347, 348, 448).

M. TUBERCULOSIS, , - : + - + . 500 (Arch Chest Dis 2002; 57:39). - (Antim-icrob Agents Chemother 1999; 43:85).

: .

, (). , - , 40 , 7 - (MMWR 2001; 50:733; MMWR 2002; 51:998; Am Rev Respir Crit Care Med 2001; 164:1319). , - - ; 3 . , 15 721 - , , 250 /. , , (12 745). , - -, , - (Clin Infect Dis 2004; 39:561). -, - , , , 9- - , - - . , 2, 4, 6 8 ; - , 2, 4 6 . 5 , , - , , - (MMWR 2002; 51:998). - CDC 404-639-8116.

, . . , , , 3 - . : , , , , , 3 . , 5 -

2007 61

-

3 .

Toxoplasma gondii

: CD4

62 2007

-

: 300 / (BI) 1200 1 300 / (CI) (. . 448). - , (J Infect Dis 2000; 181:1289).

. - - (CII) (N Engl J Med 1998; 338:853; N Engl J Med 2000; 342:1085; Ann Intern Med 2000; 133:493; J Infect Dis 1998; 178:1446; HIV Med 2004; 5:278).

: -, CD4 100 -1 (AI); - CD4 6 , - (CIII). - - - . - CD4 40 500 -

2007 63

-

3.2. -

-

FluMist

/

MMR/MR/M/R*

- CD4 >200 -1

(Varivax)

* MMR = , ; MR = ; M = ; R =

S. pneumoniae

: -. - 50100 , (Ann Intern Med 2000; 132:182; J Infect Dis 1996; 173:857; J Acquir Immune Defic Syndr 2001; 27:35; AM J Respir Crit Care Med 2000; 162:2063).

. (Pneumovax) 0,5 ( CD4 >200 -1 BII; CD4 200 -1, CD4

64 2007

-

(Lancet 2000; 355:2106). (Vaccine 2006; 24:2563). , - ( ) 1,6 , - (AIDS 2004; 18:1210). - , - (J Infect Dis 2004; 190:707). - , , (CIII), - (Clin Infect Dis 2000; 30:51).

: HBcAg HBsAg.

: Recombivax HB 10 3 ( 016 ) (BII) Engerix-B 20 3 (BII).

. . : 0,5 , (BIII). , 20022003 ., CD4 (J Acquir Immune Defic Syndr 2005; 39:167). 6 , 27 78% (BMC Infect Dis 2006; 11:138).

. - - 100 (CIII) 100 (CIII), , 20052006 90% - (JAMA 2006;295:891). (, 10 , -) (, 75 /) - B , FDA .

2007 65

-

: 1) , 2) ( ), 3) , (MMWR 2002; 51[RR-6]:61). - , 33% . ( - ).

: 0,5 2 (BIII).

;

: CD4

66 2007

-

4.

- (DHHS) 10 2006 (http://www.aidsinfo.nih.gov) (IAS-USA) (JAMA 2006; 296:827).

: .

: - (

2007 67

-

Dis 2004; 190:1043; Lancet 2002; 360:119; Lancet 2003; 362:679; AIDS 2002; 16:2455; JAMA 2001; 286:2568).

200350 -1 , CD4, , CD4 200 -1, - (. . ), (, ). ( www.art-cohort-collaboration.org -, ; 13 , 9000 .) , , 350 -1. -: 1) (AIDS 2003; 17:1863; Lancet 2003; 360:119; J Infect Dis 2004; 190:1046); 2) , ( CD4 190250 -1; AIDS 2006; 20:2051; DHHS 2006 ); 3) , ; 4) , .

: 1) , - ; 2) ; 3) - (Med Care 2006; 44:990); 4) , - ; 5) -, , . - - CD4 , .

- - 4.1, 4.2.

68 2007

-

4.1. , , , , - CD4 . MACS ( ) (Ann Intern Med 1997; 126:946; 2002 . [A. Muoz])

(-)*, / , , %

CD4 55 000 70 84 98 100

CD4 201350 -1 N 3 6 9

1 5007 000 27 0 20 37

7 00020 000 44 7 44 66

20 00055 000 53 36 72 85

>55 000 104 64 89 93

CD4 >350 -1 N 3 6 9

55 000 262 40 72 85

* (/), -.

4.2. , , - -, *

CD4

100 000 /

>100 000 /

350 3% 4%

* 40 000 ; , 50 20% 27%, 30% (www.art-cohort-collaboration.org; 15 2006 ).

2007 69

-

DHHS

4.3. : DHHS 10 2006 . (http://www.aidsinfo.nih.gov)

CD4

( - -)*

( )

100 000 / .

* >24 ., >10% .

IAS-USA

4.4. : IAS-USA 2006 . (JAMA 2006; 296:827)

-

- ( )

:

CD4 100 000 /, CD4 (>100 -1 )

CD4 350500 -1 , >100 000 / CD4 (>100 -1 )

CD4 >500 -1

70 2007

-

. , 2003 . ( , http://www.who.int/hiv/pub/prev_care/en/WHO_ARV_Guidelines_Update.pdf)

- , CD4. - CD4 , - . CD4 200 -1 . 4.5. :

2006 (www.who.int/hiv/pub/guidelines/arvguidelines2006.pdf)

* -

CD4

- CD4

I II - CD4

2007 71

-

, , . - , , , 20% , -. - , - - - (J Infect Dis 2005; 192:24). , , (. . 133), (. . 440), - (. . 490), -2 (. . 67).

4.6. : DHHS 10 2006 . (http://www.aidsinfo.nih.gov)

(

) ( )

: EFV*

: ATV/r FPV/r 2 / LPV/r 2 /

TDF/FTC AZT/3TC

NVP**

ATV ( RTV) FPV ( RTV) FPV/r 1 / LPV/r 1 /

+ ABC/3TC ddI/3TC

* , . ** CD4 >250 -1

CD4 >400 -1.

AZT/3TC/ABC: , . SQV/r: , . d4T/3TC: , .

: DLV : DRV, IDV, IDV/r, RTV ( ), SQV ( ), TPV

: TDF/ddI, AZT/d4T, ddI/d4T, ddC, , AZT/3TC/ABC TDF/AZT/3TC.

72 2007

-

4.7. : IAS-USA (JAMA 2006; 296:827)

-

TDF/FTC : EFV NVP

AZT/3TC /r: LPV/r, ATV/r, FPV/r SQV/r

ABC/3TC

4.8.

: 2006 . (www.who.int/hiv/pub/guidelines/arvguidelines2006)

(AZT TDF) + (3TC FTC) + (EFV NVP)

(ABC d4T) + (3TC FTC) + (EFV NVP)

: CD4 >250 -1, , - , -2-

: AZT/3TC/ABC AZT/3TC/TDF

( ); d4T/AZT, d4T/ddI, 3TC/FTC, TDF/3TC/ABC, TDF/3TC/ddI, TDF/ddI/

2007 73

-

4.9. ,

2 + 1 , *

+

, -

/ AUC (- ATV/r 300/100 1 )

QTc ( - - , H2-)

- -

+

( FDA , )

KLEAN, FPV/r LPV/r ( )

DRV ( I50V)

, , -

- -

+ *

- ,

, ,

IDV/r: 400/400 2

800/100 2 -

+

>100 000 / , -

, LPV/r

FDA

- ( ) - (ACTG 5142)

DHHS -

, , - (ACTG 5142)

, -

* , , (-, , ). . , , .

74 2007

-

4.9. , ()

2 + 1 , *

D30N

-, -

,

, , ( )

>100 000 / / CD4

L90M

2

() + *

Gemini ( 24 - ) , , , LPV/r

,

, .

2 +

3

>100 000 / -,

TDF/FTC

, EFV

;

* , , (-, , ). . , , .

2007 75

-

4.9. , ()

2 +

-

, , - CD4 >250 -1 () >400 -1 ()

,

-

-,

3

AZT/3TC/ ABC

()

-

- , -

-

(. ) 2

2 ( )

AZT/3TC AZT/FTC

()

(AZT/3TC)

M184V

: , ,

, -

,

2

TDF/3TC TDF/FTC

()

(TDF/FTC TDF/FTC/EFV)

- AZT/3TC (N Engl J Med 2006; 354:251)

184V - TDF

(K65R)

TDF ATV ( ATV/r)

76 2007

-

4.9. , ()

2 ( )

ABC/3TC ABC/FTC

()

(ABC/3TC)

- ddI (L74V) TDF ddI (K65R)

ddI/3TC ddI/FTC

: , , ,

()

K65R,

d4T/3TC d4T/FTC

M184V ( -) -

: , , , (),

, -

2

ddI/d4T ( -)

()

-

ddI/d4T: , , ,

(ddI) , , -

2

AZT/ddI ( -)

()

AZT + ddI , -

( , - )

(AZT ddI),

2

TDF/ddI ( -)

-

- CD4

, - ddI

,

2007 77

-

4.10.

,

EFV 600 ddI 400 ABC 600 TDF 300 3TC 300 FTC 200

ATV 400 ATV/r 300/100 FPV/r 1400/200 LPV/r 800/200 * SQV/r 2000/100

* LPV/r 1 FDA . SQV/r 1 FDA. , EFV/TDF/FTC 1 EFV/3TC/ABC* 2 NVP + (TDF/FTC 3TC/ABC)* 3 ATV/r + (TDF/FTC 3TC/ABC)* 3 LPV/r + (TDF/FTC 3TC/ABC)* 5 FPV/r + (TDF/FTC 3TC/ABC)* 5 SQV/r + (TDF/FTC 3TC/ABC)* 7 _____________________________ * , AZT/3TC, . -2- (Clin Infect Dis 2004; 38:1771) -2 , - - - (. . 6).

-2, - , .

-2 , -1-.

. -2. , -, -2 -1. , , -, -1, -2.

, , . 53 14 264 , 1994 2006 . , , 48 50 /, : 1998 41%, 19992000 50%, 20012002 56%, 20032004 64%. - 4.11 (AIDS 2006; 20:251).

78 2007

-

4.11. ,

, : , 48 50 / CD4 48 - (AIDS 2006; 20:251)

2007 79

-

. - , - , (Pater-son) . (Ann Intern Med 2000; 133:21). , 95% 80- 400 / 24 , 9095% - 400 / - 50%. - (AIDS 2001; 15:2109; Clin Infect Dis 2001; 33:386; Clin Infect Dis 2002; 34:115; AIDS 2004; 35:S35). , , , 95% , , , (AIDS 2006; 20:223; Clin Infect Dis 2006; 43:939), - . , - NFV 56 , EFV 36100 . - 400 / 95100% , , 54100% , (Clin Infect Dis 2006; 43:939).

. - - , - . , - - - (J Acquir Immune Defic Syndr 2002; 30:278; AIDS 2000; 14:357; AIDS 2001; 15:1701). , 23% , - , - 92100% ( - ) (AIDS 2003; 17:1925). , 88% , - -, >70% (Clin Infect Dis 2003; 37:1112). ,

80 2007

-

. , - ACTG 5142 250 -, LPV/r, 96 , - 23% (Riddler SA, XVI , -, 2006 .; THLB-0204). -

1. - .

.

, , .

- , .

.

-, 612 (Topics HIV Med 2003; 11:185).

- , ( [HRSA] - [DHHS]).

, , - .

: - () , , , - (), .

2. , -: , -, , (, ), - , (, - ), - , (Topics HIV Med 2003; 11:185; American Public Health Association, Recommendations for Best Practices [ -, ], www.apha.org/ppp/hiv).

2007 81

-

3. , , - (http://www.bhiva.org/guidelines/2004/adherence/index.html) . 53 , 14 264 , - (AIDS 2006; 20:2051). - -, , (JAMA 2002; 288:2868); , .

. - (J Acquir Immune Defic Syndr 2003; 34:191; Patient Educ Couns 2003; 50:187). , - , - (J Acquir Immune Defic Syndr 2003; 34:174; J Assoc Nurses AIDS Care 2003; 14:52).

, , . , , - , - , - (XV , 2004 ., LbOrB15).

. , 5- (AIDS 2006; 20:1295).

. , (Clin Infect Dis 2004; 38[suppl 5]:S409; Clin Infect Dis 2004; 38[suppl 5]:S414; Clin Infect Dis 2006; 42:1628).

, . ( FDA) >89% (N Engl J Med 2003; 348:2186).

- 1. , ,

; , , - .

82 2007

-

2. -.

3. , - .

4. , , .

. -

2007 83

-

. - , , , , - . ,

84 2007

-

. - IAS-USA 2006 . (JAMA 2006; 296:827), DHHS 2006 . (http://AIDSinfo.nih.gov) - - (http://www.bhiva.org/guidelines/2006/hiv/hivfs06.html), - , 50 /. . -, , - 0,71,0 log10 / , 1,52,0 log10 / 4 50 /, 50 / - .

. 12 , 1197 , , 24 62% 50 / (Clin In-fect Dis 2004; 38:614). 14 264 - , - 1994 2004 , , 45% 48 50 /, 20032004 36% (AIDS 2006; 20:2051).

, 50 /. , - 50 /, (JAMA 2005; 293:817; J Infect Dis 2004; 189:1444; J Infect Dis 2004; 189:1452). , (50400 /), - 9/21 , - 11 (Clin Infect Dis 2004; 39:1030). , - 50 / ; -,

2007 85

-

, - CD4. 50 / , -, -.

DHHS CD4 2550 -1 (DHHS, http://AIDSinfo.nih.gov, 10 2006 .). - CD4 ; : 50120 -1 , - 27 -1 (J Infect Dis 2006; 94:29; JAMA 2002; 288:222; J Infect Dis 2002; 185:471; JAMA 2004; 292:1911). , - . 596 -, 2,5 , - , CD4 5,2 -1 10% , 400 /, (J Infect Dis 2004; 190:1860). , - , , - CD4 5% (JAMA 2006; 296:1498). - , CD4, -. - , - , (J Infect Dis 2001; 183:1328; Clin Infect Dis 2002; 35:1005). , CD4 CD8 (J Infect Dis 2006; 194:29). - , , , - , - CD4 . -, , - 200300 -1. , CD4

86 2007

-

, .

(. 4.13), (. - 4.14) (. 4.15)

4.13. -

, - (Clin Infect Dis 2004; 39:609)

14 ; , ,

0,71,0 log10 / 1,52,0 log10 -/ 4

34 400 / , , , , >1000 /, - -

CD4

34 - CD4 3070 -1 4 , 100150 -1 .

CD4 300400 -1

CD4

1, 2 3

- CD4 3080 -1 - , ; , - .

2007 87

-

4.14. : Cmin - ( DHHS 12 2006 ., )

(: -, . , , , - , (Clin Infect Dis 2006; 42:1189)

(/)

150

* 400

1000

100

1000

800

3400

100250

* Cmin 1200 /. Cmin 4000 /.

4000 /. .

88 2007

-

4.15. (Clin Infect Dis 2006; 43:645)

: d4T, AZT, ddI

, , : - .

. . 120. (Clin Infect Dis 2002; 34:838): d4T, ( ATV), EFV>NVP

, , - , 36 , ( , , , )

NCEP.

, ( ). , - d4T, EFV.

ATV.

. . 123. : ( ATV) ATV/r -

+ 36 (IAS-USA), 13 - + 34 (DHHS)

( ATV).

, - -, , - , , ATV.

. . 122. -: d4T, AZT (-), ( )

:

: ; - -

: .

: - .

, ( - - d4T AZT TDF ABC ).

. . 117. : NVP ( ), EFV, NVP, ( - 3 ), d4T, AZT, ddI ( )

34 ( )

NVP TPV: - (. - )

NVP: , 2, 4, 8, 12 16 , - 3 ( - DHHS FDA).

TPV/r: - ,

. . 128.

2007 89

-

. , 1 log10 / (90%) 14

90 2007

-

4.16b.

(. 4.5)

I II III IV

- - CD4 (. )

- - CD4 (. ) + >10 000 / 6

4.17. (, 2006 .)

(NVP EFV) + - ,

/r LPV/r*, ATV/r, FPV/r, IDV/r, SQV/r ( NFV*, )

(AZT d4T) + 3TC ddI/ABC TDF/ABC TDF/3TC (AZT)

TDF + 3TC ddI/ABC or ddI/3TC (AZT)

ABC + 3TC ddI/3TC (AZT) TDF/3TC (AZT)

(AZT d4T) + 3TC+ (TDF ABC) EFV + ddI

* NFV ( LPV/r , ) .

3TC FTC . 3TC

, M184V, AZT TDF. AZT K65R.

2007 91

-

( DHHS, 2006 ., IAS-USA 2006 ., ) : , , , - , - ( , () , ), - , -, (. . 79).

(. 4.10, . 77). (): - EFV/TDF/FTC () . , NVP, ATV, LPV/r, FPV 2 5 . : . .

. - , - , -, . , , -, ddI IDV - .

: ddI, IDV , , EFV ( 23 -); ATV, TPV/r, NFV SQV.

(. 4.22, . 108112): TDF EFV ATV, d4T/AZT, TDF/ddI ( ).

. - , - . , 4 . , - , , , ; - . , 215 - , M184V , . - , (

92 2007

-

, , , , , -. , , - - , - , , - ( -; 3TC, FTC ). , - , , - , , - (Antimicrob Agents Chemother 2004; 48:644). 4 , , 4 - -. , , , K103N, - 912 (J Clin Lab Anal 2002; 16:76); , , - (J Med Virol 2003; 69:1). M184V - (Antimicrob Agents Chemo-ther 2003; 47:3377) 520 (Antimicrob Agents Chemother 2002; 46:2255; Antimicrob Agents Chemother 2004; 48:644).

- , - , - , , - .

, - (. . 117132).

2007 93

-

, , , , . , , , : , . () . - , , - - , - - , - - . 2 , -, ( DHHS 10 2006 ; IAS-USA 2006 ; JAMA 2006; 296:827).

3TC FTC. - , 3TC FTC, 184V - . 3TC FTC, 3TC FTC , AZT, d4T TDF. 3TC FTC - , , .

. , - -, , , , - . . , - .

- , 1000 /: - . - 23 (Antimicrob Agents Chemother 2002; 46:3907). >1000 / - .

: -

94 2007

-

.

- , , -; - . : 1) - , , 24 ; 2) ; 3) - ( - ), 4) - , -.

- -, - - . - : 1. - , , .

2. , , (, LPV/r/SQV LPV/r/ATV), , - , (AIDS 2004; 18:503). - , -.

3. , -, , - . , EFV NVP , - , NFV. LPV/r 533/133 ( ) 2 + EFV (Antimicrob Agents Chemother 2003; 47:350; Antiviral Ther 2002; 17:165) IDV/r/EFV (N Engl J Med 1999; 341:1865). ( ) - ACTG 5142, 83% 96 50 -/. - - EFV LPV -. - LPV/r (3 [600/150 ] 2 ) EFV, - .

2007 95

-

4. DRV/r, LPV/r, ATV/r TPV/r. LPV/r ATV/r -, - , - (Clin Infect Dis 2004; 38:1599). - TPV/r, , - (. . 375). 2006 DRV/r, -, , - (. 206). RESIST (TPV/r) POWER (DRV/r) - - ; . 50 / 46% , DRV/r, 23% , - TPV/r (Hill A. M., XLVI ICAAC, -, 2006 ., - H1386). (RESIST POWER) - , - (. 4.18, . 99). POWER -

96 2007

-

, (TMC 125), - .

, - . - ; , , , , (N Engl J Med 1999; 341:1865; N Engl J Med 2003; 349:2293). , EFV/LPV/r, EFV + 2 LPV/r + 2 . ACTG 5142, (Riddler S. A., XVI , , 2006 ., - JHLB-0204). - , 184V, , ( - , 184V, -), 184V AZT, TDF d4T (J Infect Dis 2005; 192:1537; AIDS 2006; 20:795; Antimicrob Agents Chemother 2003; 47:3478). (, AZT/d4T, ddI/d4T, ddI/TDF).

, . . - , . - ENF (T-20), DRV TPV, . - , (ETV), , EFV NVP, -: CCR5 ( ), - (MK-0518 GS-9137), (-), TNX-355 CD4. - , 2008 . , , - , .

2007 97

-

1. 2 , -

. 2. 3TC FTC , -

. 3. -

. 4. (ENF, TPV/r, DRV/r) -

, , - .

5. - , .

6. , , , -: (a) , () - CD4, () , () , - , - . , (POWER, TORO, RESIST) - 8590%, - - CD4 (. 5.13, 5.55).

, , -, CD4. , -, , , , -. . -

98 2007

-

- (J Infect Dis 2003; 188:1001). -, -. CD4 50 -1 - , -, CD4 200 -1. , - - - . , , 3TC (, , FTC), 184V, - (J Infect Dis 2005; 192:1537). , - , , . (AIDS 2006; 201:799). 6 - 184V 0,5 log10 -/. , , 8-14 184V, 10 (Clin Infect Dis 2005; 41:236). , , 3TC , - - CD4 - CD4. CD4, - .

. 2006 FDA , (T-20, ENF), (DRV) (TPV). (TORO-1 TORO-2), - , - 995 , -, - . - TPV/r (RESIST 1 2) DRV/r (POWER 1 2), , - . 48 4.18.

2007 99

-

4.18. RESIST POWER 48

5000 /, , . 2 : 16- , (N Engl J Med 2003; 349:837). , , CD4 ( 85 -1 4 ) , - (17 5 ). - - (Clin Infect Dis 2004; 39:569).

- . : - , - CD4 CD8, - , - . - - - (Swiss-Spanish Intermittent Treatment Trial, SSITT),

100 2007

-

-, . - , , () -, CD4 CD8, - -, - (Nature 2000; 407:523). - , - - 11 14 (XI CROI, 2003, 24). ; - , - (PLoS Med 2004; 1:e36).

. , - . NIH - , -. - , , (Proc Natl Acad Sci 2001; 98:15161; J Infect Dis 2004; 189:174). 48 - . . - STACCATO ( - WOWO week-on, week-off [ - ]); - 53% , WOWO, 5% , (Lancet 2006; 368:459). - - WOWO (Clin Infect Dis 2005; 40:728). DART - 8 -, 8 ; - (XVI , , 2006 ., THLB-0207). FOTO five [days] on, two off [5 , 2 -]. , - - . - 20 - FOTO , - 19 20 , - - ( IAS, --, 2005 ., WePe 12.4.C10). , .

CD4. : >350 -1, , -

2007 101

-

CD4 -, , - . - , - SMART -. SMART 5472 - CD4 >350 -1

102 2007

-

50 /, LPV/r (XVI - , , 2006 ., THLB-0203). ; - - , (. 4.19). - - ATV/r: 3 36 1220 - ATV/r (JAMA 2006; 296:806). , EFV/AZT/3TC/ABC, - AZT/3TC/ABC. 96 50 / (77% 79% , ), - 16 141 (11%) , , 8 141 (5%) , (J Acquir Immune Defic Syndr 2005; 39:257). , EFV, LPV/r ATV/r , 50 /, , , , . .

4.19. LPV/r

2007 103

-

DHHS (. 4.14, . 87).

: , - , - ;

, , ;

-;

(. - www.hivpharmacology.com; , -);

-.

, - , . , 40 , 44% 25% (Clin Infect Dis 2006; 42:1189).

. - () 50800 /. - 3 4 (JAMA 2005; 293:817). 24 714 (3,1%). - 50200 / , - , , . - - , - (PPT plasma preparation tubes), (J Clin Virol 2006; 35:420). , , , . , , -, . , , - (J Infect Dis 2005; 51:195).

104 2007

-

- . , -, , - CD4 ( ), , , . , -, EFV NVP (Clin Infect Dis 2006; 42:401). - , - . , 6080% , K103N (J Infect Dis 2005; 192:24). , , - :

EFV NVP 57 ( IAS-USA, JAMA 2006; 296:827); DHHS ( 7 2006 ) 37 (J Infect Dis 2006; 193:482).

, , - ( - -, 2005 .). (Moore Clinic) - 34 , - - (36100 ) (2530 ).

2007 105

-

, FDA 4.20. , FDA

-

(-)

-

FDA

(AZT, AZT) GlaxoSmithKline 1987 .

(ddI) Bristol Myers-Squibb 1991 .

(ddC)* Hoffmann-La Roche 1992 .

(d4T) Bristol Myers-Squibb 1994 .

(3TC) GlaxoSmithKline 1995 .

(SQV-hgc) Hoffmann-La Roche 1995 .

(RTV) Abbott Laboratories 1996 .

(IDV) Merck & Co., Inc. 1996 .

(NVP) Boehringer Ingelheim 1996 .

(NFV) Pfizer 1997 .

(DLV) Pfizer 1997 .

/ (AZT/3TC)

GlaxoSmithKline 1997 .

(SQV-sgc)*

Hoffmann-La Roche 1997 .

(EFV) DuPont Pharmaceuti-cals 1998 .

(ABC) GlaxoSmithKline 1999 .

(APV)* GlaxoSmithKline 1999 .

/ (LPV/r)

Abbott Laboratories 2000 .

// (AZT/3TC/ABC) GlaxoSmithKline 2000 .

(TDF)

Gilead Sciences 2001 .

(ENF) Roche 2003 .

(FTC) Bristol Myers-Squibb 2003 .

(FTC) Gilead Sciences 2003 .

(FPV) GlaxoSmithKline 2003 .

/ (3TC/ABC) GlaxoSmithKline 2004 .

/ (TDF/FTC) Gilead Sciences 2004 .

(TPV) Boehringer Ingelheim 2005 .

(DRV) Tibotec 2006 .

// (EFV/TDF/FTC)

Gilead Sciences Bristol Myers-Squibb

2006 .

* ; .

106 2007

-

4.21. ,

,

-

LPV/r,

* *

DLV DLV

, EFV

, NVP , NVP

DLV

, EFV DLV , EFV DLV DLV

, NVP

ATV, NFV , NVP

-

RTV ( ), EFV, NVP

, DHHS, / , .

* : ,

: , , .

: , .

: , , , .

2007 107

-

(. . 128)

(J Infect Dis 2005; 40:174) : - , - , - , . - ; : A - 200 2 , B C . - .

: - EFV NVP .

: - ; . NFV: ; . IDV: 600 8 ; - IDV/r 200/100 2 . .

SQV/r: ; . LPV/r: ; . ATV: B -

300 1 ; C ; 300400 1 : . .

DRV/r: . FPV FPV/r: . 58 - FPV 700 2 ; 912 - .

TPV TPV/r: TPV/r B C -; TPV .

ENF: -.

-: . 56 = - A; 79 = - B, >9 C.

1 2 3 * I-II IIIIV (/) >3,5 2,83,5

108 2007

-

4.22. ,

IDV SQV NFV FPV LPV/r

IDV 68%

: IDV 600 3

SQV 3 : -

44%, APV 31%

- 400 200 FPV/r

- 3 LPV 13%

200

- -

IDV/r: . RTV

-;

. RTV

; -

;

- , . RTV

200

>400 /

>400 /

200

IDV 89%

SQV 84%

NFV 82%

APV 82%

AUC LPV 75%

IDV 32% 2

150 300 3 ; IDV 1000 3

IDV/RTV: . RTV

40%

SQV + RTV: . RTV

NFV: 1250 2 ,

2 - 150 300 3

NFV: 1250 2

APV 15% 193%

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Клинические аспекты ВИЧ-инфекции_Бартлетт2007 (1)