Краткая информация для выработки политики: антиретровирусная терапия и потребители инъекционных наркотиков

WHO/HIV/2005.01

Äàííûå äëÿ ïðîòèâîäåéñòâèÿ ÂÈ×/ÑÏÈÄó è óïîòðåáëåíèþ èíúåêöèîííûõ íàðêîòèêîâ

ÊÐÀÒÊÀß ÈÍÔÎÐÌÀÖÈß ÄËß ÂÛÐÀÁÎÒÊÈ ÏÎËÈÒÈÊÈ: ÀÍÒÈÐÅÒÐÎÂÈÐÓÑÍÀß ÒÅÐÀÏÈß È ÏÎÒÐÅÁÈÒÅËÈ ÈÍÚÅÊÖÈÎÍÍÛÕ ÍÀÐÊÎÒÈÊÎÂ

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èæå ïðîâîäèòñÿ àíàëèç äîñòóïíîé íà ñåãîäíÿøíèé äåíü èíôîðìàöèè î ïðåäîñòàâëåíèè àíòèðåòðîâèðóñíîé (ÀÐÂ) òåðàïèè ÂÈ×-èíôèöèðîâàííûì ïîòðåáèòåëÿì èíúåêöèîííûõ íàðêîòèêîâ.  äàííîì äîêóìåíòå òàêæå îáñóæäàåòñÿ ðÿä ìåäèöèíñêèõ, ïñèõîëîãè÷åñêèõ è ñîöèàëüíûõ âîïðîñîâ, êàñàþùèõñÿ ýòîé ïðîáëåìû – íàïðèìåð, íåîáõîäèìîñòü ó÷èòûâàòü âçàèìîäåéñòâèå ïðèìåíÿåìûõ ïðåïàðàòîâ è ïðåèìóùåñòâà ïðîãðàìì ñíèæåíèÿ âðåäà â îðãàíèçàöèè àäåêâàòíîãî óõîäà çà ÂÈ×-ïîëîæèòåëüíûì ïîòðåáèòåëÿìè íàðêîòèêîâ. Îñíîâíûå âîïðîñû, ñâÿçàííûå ñ ïðåäîñòàâëåíèåì ïîìîùè è óõîäà â îáëàñòè ÂÈ×, ðàññìàòðèâàþòñÿ â ïóáëèêàöèè Âñåìèðíîé îðãàíèçàöèè çäðàâîîõðàíåíèÿ (ÂÎÇ) “Ðàñøèðåíèå àíòèðåòðîâèðóñíîé òåðàïèè â óñëîâèÿõ îãðàíè÷åííûõ ðåñóðñî┠(WHO 2003) [1]; â äðóãèõ ïóáëèêàöèÿõ èç ñåðèè “Äàííûå äëÿ ïðîòèâîäåéñòâèÿ ÂÈ×/ÑÏÈÄó è óïîòðåáëåíèþ èíúåêöèîííûõ íàðêîòèêîâ”[2] ïðåäñòàâëåíà áîëåå ïîäðîáíàÿ èíôîðìàöèÿ ïî ñíèæåíèþ âðåäà.  äîêóìåíòå î ñîâìåñòíîé ïîçèöèè ÂÎÇ/ÓÎÎÍÍÏ/ ÞÍÝÉÄÑ ïî ïðèìåíåíèþ çàìåñòèòåëüíîé ïîääåðæèâàþùåé òåðàïèè â âåäåíèè ïàöèåíòîâ ñ îïèîèäíîé çàâèñèìîñòüþ è â ïðîôèëàêòèêå ÂÈ×-èíôåêöèè è ÑÏÈÄà[3] âêðàòöå èçëîæåíà ïîçèöèÿ ÎÎÍ â îòíîøåíèè çàìåñòèòåëüíîé òåðàïèè ñ ïðèìåíåíèåì îïèàòîâ.

ÑÏÐÀÂÎ×ÍÀß ÈÍÔÎÐÌÀÖÈß ×èñëåííîñòü ïîòðåáèòåëåé èíúåêöèîííûõ íàðêîòèêîâ â ìèðå îöåíèâàåòñÿ ïðèáëèçèòåëüíî â 13 ìèëëèîíîâ ÷åëîâåê (Aceijas et al. 2004); 5-10% âñåõ íîâûõ ñëó÷àåâ ÂÈ×èíôåêöèè â ìèðå ñâÿçàíû ñ óïîòðåáëåíèåì èíúåêöèîííûõ íàðêîòèêîâ (UNAIDS 2004). Ãëàâíîé äâèæóùåé ñèëîé ýïèäåìèè ÂÈ×-èíôåêöèè, îòíîñèòåëüíî íåäàâíî âñïûõíóâøåé âî ìíîãèõ ñòðàíàõ Âîñòî÷íîé Åâðîïû è Öåíòðàëüíîé Àçèè, ÿâëÿåòñÿ ïîòðåáëåíèå èíúåêöèîííûõ íàðêîòèêîâ (ÏÈÍ). Ðàñïðîñòðàíåííîñòü ÂÈ×-èíôåêöèè ñðåäè ïîòðåáèòåëåé òàêæå çíà÷èòåëüíî âîçðîñëà â Êèòàå, Èíäîíåçèè, Èðàíå, Ìüÿíìå, Ñåâåðíîé Àôðèêå, þæíîé ÷àñòè Ëàòèíñêîé Àìåðèêè è Âüåòíàìå (Aceijas et al. 2004; Rhodes T et al. 1999; Lai S et al. 2001; Hien et al. 2001; Panda et al. 2000). Ýïèäåìèÿ óïîòðåáëåíèÿ èíúåêöèîííûõ íàðêîòèêîâ, âñïûõíóâøàÿ íåñêîëüêî ðàíüøå, îñòàåòñÿ ôàêòîðîì, ñïîñîáñòâóþùèì ñîõðàíåíèþ âûñîêîé ðàñïðîñòðàíåííîñòè ÂÈ×-èíôåêöèè â Èòàëèè, Ïîðòóãàëèè, Èñïàíèè, Øâåéöàðèè è Íèäåðëàíäàõ, à òàêæå íåêîòîðûõ äðóãèõ çàïàäíîåâðîïåéñêèõ ñòðàíàõ (Hamers and Downs 2004 è EMCDDA 2004). Îäíîé èç õàðàêòåðíûõ îñîáåííîñòåé ýïèäåìèè ÂÈ×-èíôåêöèè, ðàñïðîñòðàíÿþùåéñÿ ÷åðåç ÏÈÍ, ÿâëÿåòñÿ âçðûâíîé õàðàêòåð åå ðàçâèòèÿ. Ñóùåñòâóþò äîêóìåíòàëüíî ïîäòâåðæäåííûå ïðèìåðû, êîãäà ðàñïðîñòðàíåííîñòü ÂÈ×-èíôåêöèè ñðåäè ïîòðåáèòåëåé èíúåêöèîííûõ íàðêîòèêîâ âñåãî çà íåñêîëüêî ëåò ïîäñêî÷èëà ñ 12% äî 60-70% (Grassly et al. 2003; De la .uente et al. 2003). Îáû÷íî òàêîãî ðîäà ýïèäåìèè âñïûõèâàþò ñðåäè ìîëîäûõ, ñåêñóàëüíî àêòèâíûõ ïîòðåáèòåëåé èíúåêöèîííûõ íàðêîòèêîâ-ìóæ÷èí, è

ðàñïðîñòðàíÿþòñÿ ñåêñóàëüíûì ïóòåì ÷åðåç êîíòàêòû ñ ïàðòíåðàìè êàê ìóæñêîãî, òàê è æåíñêîãî ïîëà, à òàêæå ïóòåì âåðòèêàëüíîé ïåðåäà÷è âèðóñà îò ìàòåðè ê ðåáåíêó (ÏÌÐ). Ñåêñ-ðàáîòíèêè, ïðåäîñòàâëÿþùèå ñåêñóàëüíûå óñëóãè â îáìåí íà íàðêîòèêè èëè çà äåíüãè, íà êîòîðûå âïîñëåäñòâèè îíè ìîãóò êóïèòü íàðêîòèêè, ìîãóò ñòàòü ïðîìåæóòî÷íûì çâåíîì â ïåðåäà÷å âèðóñà îò ïîòðåáèòåëåé íàðêîòèêîâ â ñîîáùåñòâî ëþäåé, íå ïðèíèìàþùèõ íàðêîòèêè. Óïîòðåáëåíèå èíúåêöèîííûõ íàðêîòèêîâ òàêæå ìîæåò ïðèâåñòè ê çàðàæåíèþ ãåïàòèòîì B (ÂÃÂ), C (ÂÃÑ) è D è ïðèâîäèòü ê äðóãèì ìåäèöèíñêèì ïðîáëåìàì, íàïðèìåð, ê ïåðåäîçèðîâêå, òðîìáîçàì âåí è ñåðüåçíûì áàêòåðèàëüíûì èíôåêöèÿì. Êðîìå òîãî, â íåêîòîðûõ ñëó÷àÿõ ïîòðåáèòåëè íàðêîòèêîâ â òå÷åíèå äîëãîãî âðåìåíè ñòðàäàþò ñêðûòûìè ïñèõè÷åñêèìè ðàññòðîéñòâàìè, íå ïîëó÷àÿ íàäëåæàùåé äèàãíîñòèêè èëè ëå÷åíèÿ. Ìíîãèå ïîòðåáèòåëè èíúåêöèîííûõ íàðêîòèêîâ òàêæå ñòàëêèâàþòñÿ ñ ðÿäîì ñîöèàëüíûõ ïðîáëåì, òàêèõ êàê ñòèãìà è äèñêðèìèíàöèÿ, âûçâàííàÿ óïîòðåáëåíèåì íàðêîòèêîâ è íàëè÷èåì ó íèõ ÂÈ×-èíôåêöèè è/èëè ãåïàòèòà. Ìàòåðèàëüíûå ïðîáëåìû, âîçíèêàþùèå ó ïîòðåáèòåëåé

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http://www.who.int/hiv/pub/prev_care/en/ScalingUp_E.pdf http://www.who.int/hiv/pub/advocacy/idupolicybriefs/en/

World Health Organization, United Nations Office on Drugs and Crime and Joint United Nations Programme on HIV/AIDS (2004) Substitution maintenance therapy in the management of opioid dependence and HIV/AIDS prevention: position paper, Geneva: World Health Organization

íàðêîòèêîâ èç-çà íåîáõîäèìîñòè óäîâëåòâîðÿòü ïîòðåáíîñòü â ïñèõîàêòèâíîì âåùåñòâå è âåäóùèå ê âîâëå÷åíèþ â êðèìèíàëüíóþ äåÿòåëüíîñòü, à òàêæå çàêîíû, êðèìèíàëèçóþùèå õðàíåíèå íàðêîòèêîâ äëÿ ëè÷íîãî óïîòðåáëåíèÿ, ïðèâîäÿò ê òîìó, ÷òî â áîëüøèíñòâå ñòðàí áîëüøîé ïðîöåíò ïîòðåáèòåëåé íàðêîòèêîâ ïåðèîäè÷åñêè ïîäâåðãàåòñÿ òþðåìíîìó çàêëþ÷åíèþ. Ýòî âëå÷åò çà ñîáîé äîïîëíèòåëüíûå íåãàòèâíûå ñîöèàëüíûå è ìåäèöèíñêèå ïîñëåäñòâèÿ. .

ÂÈ×-èíôèöèðîâàííûõ ïîòðåáèòåëåé ñîîòâåòñòâóþò îáùèì ðåêîìåíäàöèÿì (WHO 2003): òåðàïèÿ ïðîâîäèòñÿ äëÿ ïàöèåíòîâ ñ êëèíè÷åñêè ðàçâåðíóòîé ñòàäèåé ÂÈ×èíôåêöèè, êîòîðàÿ îïðåäåëÿåòñÿ ñëåäóþùèì îáðàçîì: » Ñòàäèÿ IV ÂÈ×-èíôåêöèè ïî êëàññèôèêàöèè ÂÎÇ, íåçàâèñèìî îò ÷èñëà êëåòîê CD4; » Ñòàäèÿ III ÂÈ×-èíôåêöèè ïî êëàññèôèêàöèè ÂÎÇ (äëÿ ïðèíÿòèÿ îêîí÷àòåëüíîãî ðåøåíèÿ ìîæåò ó÷èòûâàòüñÿ ÷èñëî êëåòîê CD4 – ìåíåå 350/mm3); » Ñòàäèÿ I èëè II ÂÈ×-èíôåêöèè ïî êëàññèôèêàöèè ÂÎÇ ñ ÷èñëîì êëåòîê CD4 ìåíåå 200/mm3. Âñå ïðèìåíÿåìûå ñåãîäíÿ ÀÐÂ-ïðåïàðàòû èìåþò ñåðüåçíûå ïîáî÷íûå ýôôåêòû è îáëàäàþò òîêñè÷íûì äåéñòâèåì, íåêîòîðûå èç êîòîðûõ ìîãóò âûçûâàòü ñåðüåçíûå çàáîëåâàíèÿ è äàæå âåñòè ê ñìåðòåëüíîìó èñõîäó. Áîëåå ìÿãêèå ïîáî÷íûå ýôôåêòû ìîãóò íåãàòèâíî ñêàçàòüñÿ íà ñîáëþäåíèè ðåæèìà òåðàïèè, ÷òî ñíèçèò ýôôåêòèâíîñòü ëå÷åíèÿ è óâåëè÷èò ðèñê ðàçâèòèÿ è ïàöèåíòà óñòîé÷èâîñòè ê ïðåïàðàòàì (Dobkin 2005). Ïîòðåáèòåëè èíúåêöèîííûõ íàðêîòèêîâ ïðîäåìîíñòðèðîâàëè âûñîêèé óðîâåíü ïðèâåðæåííîñòè òåðàïèè (Open Society Institute 2004). Íåñìîòðÿ íà ýòî, èññëåäîâàíèÿ âñå ÷àùå ñîîáùàþò î òîì, ÷òî íàðêîïîòðåáèòåëè ñòàëêèâàþòñÿ ñî ñëîæíîñòÿìè, íå ïîçâîëÿþùèìè èì äîáèòüñÿ ïîëó÷åíèÿ ìåäèöèíñêîé ïîìîùè è óõîäà â îáëàñòè ÂÈ×-èíôåêöèè, ïðîäîëæèòü ëå÷åíèå è â ïîëíîé ìåðå âîñïîëüçîâàòüñÿ åãî ïðåèìóùåñòâàìè. Ýòè áàðüåðû ìîãóò áûòü ïðåîäîëåíû ñ ïîìîùüþ ïðîãðàìì ëå÷åíèÿ íàðêîçàâèñèìîñòè, àóòðè÷-ðàáîòû, ïðèåìà ïðåïàðàòîâ ïîä ìåäèöèíñêèì íàäçîðîì è ëå÷åíèåì ïîä íåïîñðåäñòâåííûì íàáëþäåíèåì (ÄÎÒ) (Bouhnik et al 2002; Carrieri et al. 1999; Palepu et al. 2003; Clarke et al. 2003; Palepu et al. 2001; Pach et al. 2003; Chen et al. 2003; Wood et al. 2003; Mockroft et al. 1999; McCance-Katz et al. 2002; Moatti et al. 2000; Carrieri et al. 2003; Lucas et al. 2004; Conway et al. 2004; McCance-Katz et al. 2002; Malta et al. 2003). Êàê ïîêàçûâàþò íàó÷íûå ôàêòû, äåÿòåëüíîñòü ïðîãðàìì, ïðåäîñòàâëÿþùèõ çàìåñòèòåëüíóþ ïîääåðæèâàþùóþ òåðàïèþ äëÿ ëþäåé ñ îïèîèäíîé çàâèñèìîñòüþ, ïîâûøàþùèõ äîñòóï ê ñòåðèëüíûì øïðèöàì è îêàçûâàþùèõ äðóãèå óñëóãè ïî ïðîôèëàêòèêå, ñïîñîáñòâóåò ñíèæåíèþ ÷èñëà íîâûõ ñëó÷àåâ ÂÈ×-èíôåêöèè ñðåäè ïîòðåáèòåëåé èíúåêöèîííûõ íàðêîòèêîâ (Wodak et al. 2005; Des Jarlais et al. 2005; .arrell et al. 2005). Èñïîëüçîâàíèå àóòðè÷ðàáîòíèêîâ è êîíñóëüòàíòîâ èç ÷èñëà ðàâíûõ – ïîòðåáèòåëåé íàðêîòèêîâ è ÂÈ×-èíôèöèðîâàííûõ – âî âñåì ìèðå îêàçàëîñü çàìå÷àòåëüíî ýôôåêòèâíûì ìåòîäîì âîâëå÷åíèÿ ïîòðåáèòåëåé èíúåêöèîííûõ íàðêîòèêîâ â ïðîãðàììû ïîìîùè â îáëàñòè ÂÈ×-èíôåêöèè, âêëþ÷àÿ ïðîãðàììû ïîääåðæêè äëÿ ïðîõîäÿùèõ ëå÷åíèå (Coyle et al. 1998; Needle et al. 2005). Ìåòàäîíîâàÿ èëè áóïðåíîðôèíîâàÿ çàìåñòèòåëüíàÿ ïîääåðæèâàþùàÿ òåðàïèÿ ïîçâîëÿåò íàðêîïîòðåáèòåëÿì,

ÄÎÑÒÓÏ Ê ÀÍÒÈÐÅÒÐÎÂÈÐÓÑÍÎÌÓ ËÅ×ÅÍÈÞ

Àíòèðåòðîâèðóñíàÿ (ÀÐÂ) òåðàïèÿ äàåò âîçìîæíîñòü óëó÷øèòü ïðîãíîç òå÷åíèÿ çàáîëåâàíèÿ è ïîâûñèòü êà÷åñòâî æèçíè ëþäåé, æèâóùèõ ñ ÂÈ×/ÑÏÈÄîì. ÀÐÂòåðàïèÿ ìîæåò ïîñëóæèòü äëÿ ÂÈ×-èíôèöèðîâàííûõ ïîòðåáèòåëåé èíúåêöèîííûõ íàðêîòèêîâ ñòèìóëîì äëÿ âñòóïëåíèÿ â êîíòàêò ñî ñëóæáàìè çäðàâîîõðàíåíèÿ, îñóùåñòâëÿþùèìè ïðîôèëàêòèêó, êîíñóëüòèðîâàíèå è òåñòèðîâàíèå íà ÂÈ×, à òàêæå ïðåäîñòàâëÿþùèìè óñëóãè â îáëàñòè ëå÷åíèÿ, óõîäà è ïîääåðæêè ïàöèåíòîâ, æèâóùèõ ñ ÂÈ×/ÑÏÈÄîì. Îíà ìîæåò ñïîñîáñòâîâàòü ðåøåíèþ ïðîéòè ëå÷åíèå îò íàðêîçàâèñèìîñòè è ñî÷åòàííûõ çàáîëåâàíèé, òàêèõ êàê òóáåðêóëåç (TÁ), Âàè ÂÑÃ. Îäíàêî, õîòÿ ïðèìåíåíèå ÀÐÂ-òåðàïèè ðàñøèðÿåòñÿ, çà÷àñòóþ ïîòðåáèòåëè èíúåêöèîííûõ íàðêîòèêîâ íå èìåþò äîñòóïà ê ëå÷åíèþ. Íåñìîòðÿ íà ïåðå÷èñëåííûå ïîòåíöèàëüíûå ïðåèìóùåñòâà, øèðîêî ðàñïðîñòðàíåíî ìíåíèå, ÷òî ïîòðåáèòåëè èíúåêöèîííûõ íàðêîòèêîâ ÿâëÿþòñÿ ìàëîïîäõîäÿùèìè êàíäèäàòàìè äëÿ ïðîõîæäåíèÿ ÀÐÂ-òåðàïèè, òàê êàê çàâèñèìîñòü îò íàðêîòèêîâ ïîäðûâàåò èõ ñïîñîáíîñòü ñîáëþäàòü ðåæèì ëå÷åíèÿ, à ìåäèöèíñêèå îñëîæíåíèÿ è ñî÷åòàííûå çàáîëåâàíèÿ, òàêèå êàê ãåïàòèò Ñ, ñóùåñòâåííî óñëîæíÿþò ïðîöåññ ëå÷åíèÿ ïîòðåáèòåëåé è äåëàþò èõ ìåíåå âîñïðèèì÷èâûìè ê ÀÐÂ-òåðàïèè. Õîòÿ äëÿ ìíîãèõ ÂÈ×-èíôèöèðîâàííûõ ïîòðåáèòåëåé ýòè îãðàíè÷åíèÿ äåéñòâèòåëüíî ÿâëÿþòñÿ ïðîáëåìîé, îáøèðíûé îïûò ïîêàçûâàåò – à ìíîãî÷èñëåííûå èññëåäîâàíèÿ èìåþò òîìó äîêóìåíòàëüíûå äîêàçàòåëüñòâà, – ÷òî ïðåäîñòàâëåíèå ñïåöèàëèçèðîâàííîãî ìåäèöèíñêîãî óõîäà â îáëàñòè ÂÈ× ïîòðåáèòåëÿì èíúåêöèîííûõ íàðêîòèêîâ, êàê è âñåì ïðî÷èì ëþäÿì, æèâóùèì ñ ÂÈ×-èíôåêöèåé, ÷àñòî äàåò óñïåøíûå ðåçóëüòàòû.

ÎÑÍÎÂÍÛÅ ÔÀÊÒÛ Ïðîöåññ óõîäà çà ÂÈ×-èíôèöèðîâàííûìè ïîòðåáèòåëÿìè èíúåêöèîííûõ íàðêîòèêîâ íå ñëèøêîì ñèëüíî îòëè÷àåòñÿ îò óõîäà çà äðóãèìè ëþäüìè, æèâóùèìè ñ ÂÈ×/ÑÏÈÄîì. Îí ïðåäóñìàòðèâàåò îïðåäåëåíèå ñòàäèè èììóííîãî äåôèöèòà ïî êëèíè÷åñêèì è èììóíîëîãè÷åñêèì (CD4) ïðèçíàêàì, ïðîôèëàêòèêó è ëå÷åíèå îïïîðòóíèñòè÷åñêèõ èíôåêöèé è ÀÐÂ-òåðàïèþ. Êëèíè÷åñêèå è èììóíîëîãè÷åñêèå êðèòåðèè äëÿ íà÷àëà ÀÐÂ-òåðàïèè ñðåäè

èñïûòûâàþùèì çàâèñèìîñòü îò îïèîèäîâ, ñòàáèëèçèðîâàòü ñâîþ æèçíü, èçáåæàòü èëè ïðåîäîëåòü ìíîæåñòâî ïðîáëåì, ñâÿçàííûõ ñ ÏÈÍ, è ÿâëÿåòñÿ íåîòúåìëåìîé ÷àñòüþ ñòðàòåãèè, íàïðàâëåííîé íà óäåðæàíèå àêòèâíûõ ïîòðåáèòåëåé èíúåêöèîííûõ íàðêîòèêîâ â ïðîãðàììàõ ëå÷åíèÿ (Mattick et al. 2002). Êðîìå òîãî, îíà ïðåäîñòàâëÿåò äîïîëèòåëüíûå âîçìîæíîñòè äëÿ ðàñøèðåíèÿ ÀÐÂ-òåðàïèè, ïîâûøàåò ñîáëþäåíèå ðåæèìà ëå÷åíèÿ è óâåëè÷èâàåò äîñòóïíîñòü ìåäèöèíñêîé ïîìîùè (Clarke et al. 2002; Moscatello et al. 2003; Lucas 2004, WHO et al. 2004; Open Society Institute 2004; .arrell et al. 2005). Âàæíî ïðåäóñìîòðåòü âçàèìîäåéñòâèå ìåæäó ìåòàäîíîì è áóïðåíîðôèíîì è ÀÐÂ-ïðåïàðàòàìè è ó÷èòûâàòü åãî ïðè îïðåäåëåíèè íåîáõîäèìîé äîçèðîâêè (Antoniou et al. 2002; Dobkin 2005). Âçàèìîäåéñòâèå ïðåïàðàòîâ, óñêîðÿþùåå âîçíèêíîâåíèå àáñòèíåíòíîãî ñèíäðîìà, ìîæåò ñïðîâîöèðîâàòü ðåöèäèâ óïîòðåáëåíèÿ ãåðîèíà, âîçáóäèòü íåäîâåðèå ê ñïåöèàëèñòàì, ïðåäîñòàâëÿþùèì óñëóãè, è âûçâàòü íåæåëàíèå ïðîäîëæàòü ÀÐÂ-òåðàïèþ (Dobkin 2005). Äëÿ îáëåã÷åíèÿ îñòðûõ èëè õðîíè÷åñêèõ áîëåé, ÂÈ×èíôèöèðîâàííûì ïîòðåáèòåëÿì ìîãóò ïîòðåáîâàòüñÿ äîïîëíèòåëüíûå àíàëüãåòèêè, ïîñêîëüêó â íåêîòîðûõ ñëó÷àÿõ îáû÷íàÿ äíåâíàÿ äîçà íå îêàçûâàåò íåîáõîäèìîãî áîëåóòîëÿþùåãî ýôôåêòà (Dobkin 2005). Òàêæå âàæíî ïðåäóñìîòðåòü ïîñëåäñòâèÿ âçàèìîäåéñòâèÿ ìåæäó àíàëüãåòèêàìè è íåêîòîðûìè ÀÐÂ-ïðåïàðàòàìè (ñìîòðèòå www.hiv-druginteractions.org è Dobkin 2005). Èíîãäà ïîòðåáèòåëè èíúåêöèîííûõ íàðêîòèêîâ îêàçûâàþòñÿ â áîëüíèöàõ, èñïðàâèòåëüíûõ ó÷ðåæäåíèÿõ èëè äðóãèõ çàâåäåíèÿõ, ãäå îíè ïîäâåðãàþòñÿ ïîâûøåííîìó ðèñêó àáñòèíåíòíîãî ñèíäðîìà èç-çà íàðóøåíèÿ ïðèâû÷íûõ ìîäåëåé óïîòðåáëåíèÿ îïèîèäîâ. Êóðñ äåòîêñèêàöèè áóïðåíîðôèíîì, ìåòàäîíîì èëè êëîíèäèíîì ìîæåò ñòàáèëèçèðîâàòü èõ ñîñòîÿíèå, îáëåã÷àÿ ïðîâåäåíèå ìåäèöèíñêîãî îñìîòðà è ëå÷åíèÿ (Umbricht et al. 2003). Ñîïóòñòâóþùàÿ èíôåêöèÿ Âàè/èëè ÂÃÑ è áîëåçíè ïå÷åíè, âûçâàííûå óïîòðåáëåíèåì àëêîãîëÿ, – ÷àñòîå ÿâëåíèå ñðåäè ÂÈ×-èíôèöèðîâàííûõ ïîòðåáèòåëåé èíúåêöèîííûõ íàðêîòèêîâ. Ýòè çàáîëåâàíèÿ ìîãóò ïîâûøàòü ðèñê òîêñè÷åñêîãî ïîðàæåíèÿ ïå÷åíè è çàòðóäíÿòü ìåòàáîëèçì íåêîòîðûõ ÀÐÂ-ïðåïàðàòîâ. Íåñìîòðÿ íà íàëè÷èå ñâÿçè ìåæäó ãåïàòîòîêñè÷íîñòüþ è ÀÐÂïðåïàðàòàìè, ïî÷òè 90% ëþäåé, æèâóùèõ ñ ÂÈ×/ÑÏÈÄîì, ïåðåíîñÿò ÀÐÂ-òåðàïèþ áåç ñåðüåçíûõ ïîðàæåíèé ïå÷åíè, íåçàâèñèìî îò òîãî, èíôèöèðîâàíû îíè ñîïóòñòâóþùèì ãåïàòèòîì èëè íåò (Sulkowski et al. 2000). Òàê èëè èíà÷å, âàæíî ïîìíèòü î ïîòåíöèàëüíûõ âçàèìîäåéñòâèÿõ ïðåïàðàòîâ, îñîáåííî ïðè ëå÷åíèè ÂÃÑ. Ëå÷åíèå ÒÁ ó ëþäåé, æèâóùèõ ñ ÂÈ×/ÑÏÈÄîì, â öåëîì ïðîâîäèòñÿ òàêæå, êàê â ÂÈ×-îòðèöàòåëüíûõ ïàöèåíòîâ; êðîìå òîãî, ïî äàííîé òåìå èìåþòñÿ ïîäðîáíûå âðà÷åáíûå èíñòðóêöèè (ñìîòðèòå, íàïðèìåð, American

Thoracic Society 2003). Çäåñü âàæíî ó÷èòûâàòü âçàèìîäåéñòâèå ìåæäó íåêîòîðûìè ïðîòèâîòóáåðêóëåçíûìè è ÀÐÂ-ïðåïàðàòàìè, ìåæäó íåêîòîðûìè ïðîòèâîòóáåðêóëåçíûìè ïðåïàðàòàìè è ìåòàäîíîì è, âîçìîæíî, áóïðåíîðôèíîì; òàêæå âàæíî òî÷íî âûáðàòü ìîìåíò äëÿ íà÷àëà ïðîâåäåíèÿ ÀÐÂ-òåðàïèè ó ïàöèåíòîâ ñ àêòèâíîé ôîðìîé òóáåðêóëåçà (Dobkin 2005).

ÏÎËÈÒÈÊÀ È ÄÅßÒÅËÜÍÎÑÒÜ ÏÎ ÏÐÎÂÅÄÅÍÈÞ ÏÐÎÃÐÀÌÌ ÂÈ×-èíôèöèðîâàííûå ïîòðåáèòåëè èíúåêèîííûõ íàðêîòèêîâ äîëæíû èìåòü ðàâíûé è âñåîáùèé äîñòóï ê ÀÐÂ-òåðàïèè – êàê èñõîäÿ èç ïðèíöèïîâ îõðàíû îáùåñòâåííîãî çäîðîâüÿ, òàê è ñ òî÷êè çðåíèÿ ñîáëþäåíèÿ ïðàâ ÷åëîâåêà. Çäåñü âàæíóþ ðîëü èãðàþò ëèöà, ôîðìèðóþùèå ïîëèòèêó â äàííîé îáëàñòè, âûñòóïàÿ çà ëå÷åíèå ÂÈ×-ïîçèòèâíûõ ïîòðåâèòåëåé èíúåêöèîííûõ íàðêîòèêîâ â ñâîèõ ñòðàíàõ. Âñåñòîðîííÿÿ äåÿòåëüíîñòü ïî áîðüáå ñ ÂÈ×-èíôåêöèåé ñðåäè ïîòðåáèòåëåé èíúåêöèîííûõ íàðêîòèêîâ äîëæíà ñî÷åòàòü â ñåáå ïðîôèëàêòèêó, ëå÷åíèå, óõîä è ïîääåðæêó, ÷òîáû îáåñïå÷èòü ìàêñèìàëüíîå èñïîëüçîâàíèå ïðåäîñòàâëÿåìûõ óñëóã íà ñàìûõ ðàííèõ ýòàïàõ èíôåêöèè. Ïîìèìî ÂÈ×èíôåêöèè, ñðåäè ïîòðåáèòåëåé èíúåêöèîííûõ íàðêîòèêîâ îòìå÷àåòñÿ âûñîêèé óðîâåíü íàðêîçàâèñèìîñòè, íàëè÷èå äðóãèõ èíôåêöèé, ïåðåäàþùèõñÿ ÷åðåç êðîâü, è ìåäèöèíñêèõ ïðîáëåì, ñâÿçàííûõ ñ èíúåêöèÿìè. Ïðîôèëàêòèêà è ëå÷åíèå ýòèõ ñîñòîÿíèé ñíèæàþò óðîâíè çàáîëåâàåìîñòè è ñìåðòíîñòè è ñïîñîáñòâóþò ïðèâëå÷åíèþ ïîòðåáèòåëåé èíúåêöèîííûõ íàðêîòèêîâ â ïðîãðàììû êîìïëåêñíîé ïîìîùè â îáëàñòè ÂÈ×èíôåêöèè. Çàëîãîì ýôôåêòèâíîñòè ÀÐÂ-òåðàïèè è ëå÷åíèÿ ëþáûõ ñî÷åòàííûõ çàáîëåâàíèé ÿâëÿåòñÿ òùàòåëüíîå èññëåäîâàíèå è êîíñóëüòèðîâàíèå ïàöèåíòà, íà îñíîâå êîòîðûõ ïðîâîäèòñÿ ðàçðàáîòêà èíäèâèäóàëüíîãî ïëàíà ëå÷åíèÿ, ïîçâîëÿþùåãî îáåñïå÷èòü åãî ìàêñèìàëüíóþ ýôôåêòèâíîñòü. Ñîöèàëüíàÿ ïîìîùü, ïðåäîñòàâëåíèå èíôîðìàöèè, ïîääåðæêà â ñîáëþäåíèè ðåæèìà ëå÷åíèÿ (ïðèâåðæåííîñòè), çàìåñòèòåëüíàÿ òåðàïèÿ è äðóãèå ôîðìû ëå÷åíèÿ íàðêîçàâèñèìîñòè ÿâëÿþòñÿ èñêëþ÷èòåëüíî âàæíûìè ýëåìåíòàìè ýôôåêòèâíîé ïðîãðàììû ïîìîùè â îáëàñòè ÂÈ×-èíôåêöèè. Åñëè ïîòðåáèòåëè íàðêîòèêîâ ñìîãóò ñëåäîâàòü ìåäèöèíñêèì íàçíà÷åíèÿì è ñîáëþäàòü ðåæèì ïðèåìà ïðåïàðàòîâ, âåðîÿòíåå âñåãî, îíè áóäóò èìåòü òàêîé æå õîðîøèé ýôôåêò îò ÀÐÂòåðàïèè, êàê è äðóãèå ëþäè, æèâóùèå ñ ÂÈ×. Êîãäà ê ïîòðåáèòåëÿì îòíîñÿòñÿ áåç îñóæäåíèÿ, ðåöèäèâ èëè ïðîäîëæåíèå óïîòðåáëåíèÿ íàðêîòèêîâ ìîãóò ðàññìàòðèâàòüñÿ ïðîñòî êàê ìåäèöèíñêàÿ ïðîáëåìà, òðåáóþùàÿ äîïîëíèòåëüíîãî âíèìàíèÿ, äëÿ óñòðàíåíèÿ êîòîðîé, êàê è â ñëó÷àå ñ äðóãèìè ñî÷åòàííûìè çàáîëåâàíèÿìè, íåîáõîäèìû äîïîëíèòåëüíûå ìåðû.

Ïðèíöèïû ïðîâåäåíèÿ óñïåøíûõ ïðîãðàìì äëÿ ïîòðåáèòåëåé èíúåêöèîííûõ íàðêîòèêîâ Ñåðüåçíîé ïðîáëåìîé ïðè îñóùåñòâëåíèè óõîäà çà ÂÈ×ïîçèòèâíûìè ïîòðåáèòåëÿìè èíúåêöèîííûõ íàðêîòèêîâ ÿâëÿåòñÿ íåîáõîäèìîñòü îäíîâðåìåííîãî ïðåäîñòàâëåíèÿ ðàçëè÷íûõ óñëóã. Óñïåøíûå ïðîãðàììû ìåäèöèíñêîé ïîìîùè, íàöåëåííûå íà àêòèâíûõ ïîòðåáèòåëåé íàðêîòèêîâ, âûÿâèëè ñëåäóþùèå âàæíûå ïðèíöèïû: » Ìåäèöèíñêàÿ ïîìîùü äîëæíà áûòü äîñòóïíîé äëÿ êëèåíòîâ, îíà äîëæíà îñóùåñòâëÿòüñÿ â ó÷ðåæäåíèÿõ, ÿâëÿþùèõñÿ ÷àñòüþ îáùåé ñèñòåìû çäðàâîîõðàíåíèÿ. Óñëóãè äîëæíû áûòü áåñïëàòíûìè è îðèåíòèðîâàííûìè íà ïîòðåáèòåëÿ; îíè äîëæíû ïðåäîñòàâëÿòüñÿ íà ðàâíîïðàâíîé îñíîâå, ñïåöèàëèñòàìè, îòíîñÿùèìèñÿ ê ïîòðåáèòåëÿì íàðêîòèêîâ áåç îñóæäåíèÿ. » Ìåäèöèíñêàÿ ïîìîùü äîëæíà áûòü âñåñòîðîííåé è âêëþ÷àòü ìàêñèìàëüíîå ÷èñëî íàèáîëåå íåîáõîäèìûõ óñëóã, êîòîðûå ìîãóò áûòü ïðåäîñòàâëåíû â ñòåíàõ îäíîãî ó÷ðåæäåíèÿ. » Ìåäèöèíñêàÿ ïîìîùü äîëæíà ïðåäîñòàâëÿòüñÿ ïîòðåáèòåëÿì èíúåêöèîííûõ íàðêîòèêîâ â òîì îáúåìå, â êîòîðîì îíè ãîòîâû åå ïðèíÿòü; èíà÷å ïîòðåáèòåëè ìîãóò îòêàçàòüñÿ ïîëüçîâàòüñÿ ïðåäîñòàâëÿåìûìè óñëóãàìè. » Ñòðàòåãèè àóòðè÷-ðàáîòû ÿâëÿþòñÿ ïðèíöèïèàëüíî âàæíûì êîìïîíåíòîì ïîìîùè â îáëàñòè ÂÈ×-èíôåêöèè; íàèáîëåå ýôôåêòèâíûå ïðîãðàììû íàëàæèâàþò êðåïêèå ñâÿçè ñ îðãàíèçàöèÿìè íà óðîâíå ñîîáùåñòâà, ïðåäñòàâëÿþùèìè èíòåðåñû ãðóïï, çàòðîíóòûõ ýïèäåìèåé, è èñïîëüçóþò îáó÷àþùèõ è êîíñóëüòàíòîâ, íàáðàííûõ èç ýòèõ ãðóïï, äëÿ ðàáîòû ïî ïðèíöèïó “ðàâíûéðàâíîìó”. » Ïðè ðàçðàáîòêå ìåäèöèíñêèõ óñëóã ñëåäóåò óäåëÿòü áîëüøîå âíèìàíèå âîïðîñó íåïðåðûâíîñòè è ïðååìñòâåííîñòè óõîäà, ÷òîáû îáåñïå÷èòü óäåðæàíèå ïàöèåíòîâ íà ëå÷åíèè. ×òîáû äàòü ÂÈ×-èíôèöèðîâàííûì ïîòðåáèòåëÿì èíúåêöèîííûõ íàðêîòèêîâ âîçìîæíîñòü óñïåøíî èñïîëüçîâàòü ÀÐÂ-òåðàïèþ, âàæíî ó÷èòûâàòü èõ ñïåöèôè÷åñêèå ïîòðåáíîñòè; â ïåðâóþ î÷åðåäü, ýòî îòíîñèòñÿ ê ñîáëþäåíèþ ðåæèìà ïðèåìà ïðåïàðàòîâ. Êðîìå òîãî, íåîáõîäèìî óäåëÿòü ïðèñòàëüíîå âíèìàíèå äèàãíîñòèêå è ëå÷åíèþ ñî÷åòàííûõ çàáîëåâàíèé, òàêèõ êàê ÒÁ, Âàè ÂÃÑ, à òàêæå âçàèìîäåéñòâèþ ïðåïàðàòîâ, îñîáåííî â ñëó÷àÿõ, êîãäà ïàöèåíò ïðîõîäèò íåñêîëüêî êóðñîâ ëå÷åíèÿ è çàìåñòèòåëüíóþ ïîääåðæèâàþùóþ òåðàïèþ íàðêîçàâèñèìîñòè. Âîïðîñîì ïðèíöèïèàëüíîé âàæíîñòè äëÿ ïîòðåáèòåëåé èíúåêöèîííûõ íàðêîòèêîâ ÿâëÿåòñÿ ïðàâèëüíûé âûáîð âðåìåíè íà÷àëà ÀÐÂ-òåðàïèè. Êðàéíå âàæíî óáåäèòüñÿ, ÷òî ïîòðåáèòåëè ðàñïîëàãàþò âñåé íåîáõîäèìîé èíôîðìàöèåé è ìîòèâàöèåé ê ëå÷åíèþ, à ïîòåíöèàëüíûå

áàðüåðû, ïðåïÿòñòâóþùèå ñîáëþäåíèþ ðåæèìà, îöåíåíû è ïðåîäîëåíû. Åñëè ðå÷ü íå èäåò î áîëüíûõ â êðèòè÷åñêîì ñîñòîÿíèè, ëó÷øå íåìíîãî îòëîæèòü íà÷àëî òåðàïèè, ÷òîáû ïðèíÿòü âñå íåîáõîäèìûå ìåðû, ÷åì ïîäâåðãíóòü ïàöèåíòà ðèñêó íåóäà÷íîãî èñõîäà òåðàïèè èëè ðàçâèòèÿ ó íåãî ðåçèñòåíòíîñòè ê ïðåïàðàòàì. Ìíîãèå ñòðàíû ïðèíÿëè äëÿ ñåáÿ ïîäõîä ÂÎÇ ê ÀÐÂòåðàïèè, ïðåäóñìàòðèâàþùèé ñòàíäàðòíûå ñõåìû ïåðâîãî è âòîðîãî ðÿäà òåðàïèè. Åñëè ïðåïàðàò ïåðâîãî ðÿäà âûçûâàåò ó ïàöèåíòà òîêñè÷åñêèå ïîðàæåíèÿ, îí ìîæåò áûòü çàìåíåí äðóãèì ÀÐÂ-ïðåïàðàòîì, îòíîñÿùèìñÿ ê òîìó æå êëàññó.  ñëó÷àå íåóäà÷è (êîòîðàÿ îïðåäåëÿåòñÿ êëèíè÷åñêèìè è èììóíîëîãè÷åñêèìè ïðèçíàêàìè) ïàöèåíò ïåðåâîäèòñÿ íà òåðàïèþ âòîðîãî ðÿäà. Óïðîùåííûå ñõåìû, â îñîáåííîñòè òå, êîòîðûå ïðåäóàòðèâàþò ôèêñèðîâàííûå íèçêîäîçîâûå êîìáèíàöèè, èìåþò çíà÷èòåëüíûå ïðåèìóùåñòâà, ïîñêîëüêó òðåáóþò ïðèåìà ìåíüøåãî ÷èñëà ïðåïàðàòîâ. Îäíàêî â ñëó÷àå ñî÷åòàííûõ çàáîëåâàíèé, çàìåñòèòåëüíîé ïîääåðæèâàþùåé òåðàïèè èëè ëå÷åíèÿ îïïîðòóíèñòè÷åñêèõ èíôåêöèé ïðîñòûå ñõåìû ìîãóò áûòü èñêëþ÷åíû, è ÀÐÂ-òåðàïèÿ ìîæåò íóæäàòüñÿ â ìîäèôèêàöèÿõ (Dobkin 2005). Äëÿ ïîääåðæêè ñîáëþäåíèÿ ïàöèåíòîì ðåæèìà ëå÷åíèÿ è âûÿâëåíèÿ ïðîáëåì â ýòîé îáëàñòè, ìîæåò áûòü âåñüìà ïîëåçåí ïîñòîÿííûé íàäçîð çà õîäîì òåðàïèè. Åñëè âîçìîæíî, òåðàïèþ ñëåäóåò ïðîâîäèòü â ó÷ðåæäåíèè, îñóùåñòâëÿþùåì îáùèé ìåäèöèíñêèé óõîä, ïîñêîëüêó ýòî îáåñïå÷èò ñïåöèàëèñòàì äîñòóï ê íàèáîëåå ïîëíîé èíôîðìàöèè î ñîáëþäåíèè ðåæèìà òåðàïèè è êëèíè÷åñêîé ðåàêöèè. Êàê ïðàâèëî, íà íà÷àëüíîì ýòàïå ïàöèåíò ïîëó÷àåò ïðåïàðàòû â íåáîëüøèõ äîçèðîâêàõ ñ êîðîòêèìè èíòåðâàëàìè. Êîãäà åãî ñîñòîÿíèå ñòàáèëèçèðóåòñÿ, èíòåðâàëû ìåæäó ïðåäîñòàâëåíèåì ïðåïàðàòîâ ìîãóò óâåëè÷èâàòüñÿ. È íàïðîòèâ, åñëè ïîâåäåíèå ïîòðåáèòåëåé èíúåêöèîííûõ íàðêîòèêîâ ñòàíîâèòñÿ áåñïîðÿäî÷íûì, èì âíîâü ìîæåò áûòü íàçíà÷åíà ñõåìà, ïðåäóñìàòðèâàþùàÿ ÷àñòûé ïðèåì ïðåïàðàòîâ, êîòîðàÿ ïîçâîëÿåò âåñòè áîëåå ïðèñòàëüíûé íàäçîð è îêàçûâàòü ïàöèåíòó íåîáõîäèìóþ ïîääåðæêó.

Âçàèìîäåéñòâèå ìåæäó ïðîãðàììàìè ñíèæåíèÿ âðåäà è ïðîãðàììàìè ëå÷åíèÿ Îáåñïå÷åíèå ñâÿçåé ìåæäó ïðîãðàììàìè ñíèæåíèÿ âðåäà è ëå÷åíèÿ ÂÈ× ïîçâîëÿåò áûñòðî íàïðàâëÿòü ïîòðåáèòåëåé èíúåêöèîííûõ íàðêîòèêîâ ñ ïîëîæèòåëüíûìè ðåçóëüòàòàìè òåñòèðîâàíèÿ íà ÂÈ× â ïðîãðàììû îêàçàíèÿ ìåäèöèíñêîé ïîìîùè. Òàêèå ñâÿçè ñïîñîáñòâóþò áîëåå êà÷åñòâåííîìó ìîíèòîðèíãó è ðåãóëèðîâàíèþ âçàèìîäåéñòâèÿ ïðåïàðàòîâ. Êðîìå òîãî, îíè ïîìîãàþò óñèëèòü ïðîôèëàêòè÷åñêóþ ðàáîòó ñðåäè êëèåíòîâ ñ îòðèöàòåëüíûìè òåñòàìè íà ÂÈ×. Ïðîãðàììû ñíèæåíèÿ âðåäà, äîáèâøèåñÿ äîâåðèÿ è ïîëüçóþùèåñÿ àâòîðèòåòîì, èìåþò çíà÷èòåëüíûé îïûò â óñòàíîâêå êîíòàêòà è ñâÿçåé ñ ïîòðåáèòåëÿìè èíúåêöèîííûõ íàðêîòèêîâ, ÷òî äàåò èì âîçìîæíîñòü ñìÿã÷èòü ìåäèöèíñêèå è ïñèõîëîãè÷åñêèå ïîñëåäñòâèÿ óïîòðåáëåíèÿ íàðêîòèêîâ è îáëåã÷èòü ïðåäî-

ñòàâëåíèå ïîìîùè â îáëàñòè ÂÈ×. Ýòè ïðîãðàììû äîëæíû ïðèíèìàòü ó÷àñòèå â ïëàíèðîâàíèè ëå÷åíèÿ ÂÈ× äëÿ ïîòðåáèòåëåé íàðêîòèêîâ, ïðîâåäåíèè àóòðè÷-ðàáîòû, íàïðàâëåííîé íà ïðèâëå÷åíèå ïîòðåáèòåëåé â ïðîãðàììû òåñòèðîâàíèÿ, êîíñóëüòèðîâàíèÿ è ëå÷åíèÿ â îáëàñòè ÂÈ×, à òàêæå â ïîñëåäóþùèõ íàáëþäåíèÿõ çà ïîòðåáèòåëÿìè, âûáûâøèìè èç ïðîãðàìì ìåäèöèíñêîé ïîìîùè. Àóòðè÷-ïðîãðàììû, îñíîâàííûå íà ïðèíöèïå ïîääåðæêè ðàâíûõ ðàâíûìè, îêàçàëèñü ýôôåêòèâíûì ñðåäñòâîì ïðîñâåùåíèÿ àêòèâíûõ ïîòðåáèòåëåé è èõ ìîòèâèðîâàíèÿ ê ïîïûòêàì äîáèòüñÿ âîçìîæíîñòè ïîëó÷åíèÿ ýôôåêòèâíîé ïîìîùè. Íåîáõîäèìî ñîçäàâàòü èëè âêëþ÷àòü â îáùóþ ïðîãðàììó ëå÷åíèÿ ÂÈ×-èíôåêöèè ãðóïïû ïîääåðæêè è îáó÷àþùèå ïðîãðàììû äëÿ ïîòðåáèòåëåé èíúåêöèîííûõ íàðêîòèêîâ, â ïåðâóþ î÷åðåäü äëÿ òîãî, ÷òîáû ïîäãîòîâèòü ÂÈ×-ïîçèòèâíûõ ïîòðåáèòåëåé íàðêîòèêîâ ê âîçìîæíûì ïîáî÷íûì ýôôåêòàì ÀÐÂòåðàïèè è ÷òîáû îêàçàòü èì ïîääåðæêó â ñîáëþäåíèè ðåæèìà ëå÷åíèÿ.

Îñîáûå ìåðû â îòíîøåíèè æåíùèí è ñåêñ-ðàáîòíèêîâ Çíà÷èòåëüíóþ ÷àñòü ÂÈ×-èíôèöèðîâàííûõ ïîòðåáèòåëåé èíúåêöèîííûõ íàðêîòèêîâ ñîñòàâëÿþò æåíùèíû ðåïðîäóêòèâíîãî âîçðàñòà; äîñòóï ê óñëóãàì ïî ïëàíèðîâàíèþ ñåìüè è ïðîôèëàêòèêå ïåðåäà÷è ÂÈ× îò ìàòåðè ê ðåáåíêó (ÏÌÒ) – âêëþ÷àÿ, ïðè íåîáõîäèìîñòè, óõîä è ëå÷åíèå äëÿ ñàìèõ æåíùèí – äîëæåí ñòàòü íåîòúåìëåìîé ÷àñòüþ êîìïëåêñíîé ñòðàòåãèè óõîäà. Ìíîãèå ÂÈ×-ïîçèòèâíûå æåíùèíû íå ïîëüçóþòñÿ óñëóãàìè ïî äîðîäîâîé ïîìîùè è âõîäÿò â êîíòàêò ñ ìåäèöèíñêèìè ó÷ðåæäåíèÿìè òîëüêî âî âðåìÿ ðîäîâ. ×òîáû ïðåäîòâðàòèòü ÏÌÐ, ïåðñîíàë ðîäèëüíûõ äîìîâ äîëæåí èìåòü äîñòóï ê êà÷åñòâåííûì ñðåäñòâàì ýêñïðåññòåñòèðîâàíèÿ è íåîòëîæíîé ìåäèêàìåíòîçíîé òåðàïèè íà îñíîâå íåâèðàïèíà[ 4]. Ðåêîìåíäóåòñÿ ñäåëàòü òåñòèðîâàíèå íà ÂÈ× óñëóãîé, ïðåäëàãàåìîé âñåì ïàöèåíòêàì ðîääîìîâ[5]. Êàê ìóæ÷èíû, òàê è æåíùèíû, óïîòðåáëÿþùèå èíúåêöèîííûå íàðêîòèêè è çàíèìàþùèåñÿ ñåêñîì çà äåíüãè èëè â îáìåí íà íàðêîòèêè, íóæäàþòñÿ â äîïîëíèòåëüíîé ìåäèöèíñêîé è ñîöèàëüíîé ïîìîùè. Ýòî ïîìîãëî áû ñíèçèòü óðîâåíü ñåêñóàëüíîé ïåðåäà÷è ÂÈ× è îáëåã÷èòü äëÿ íèõ äîñòóï ê ëå÷åíèþ. Àóòðè÷-ðàáîòà è ïîääåðæêà ëå÷åíèq, îñóùåñòâëÿåìûå ðàâíûìè ñðåäè ðàâíûõ, äîëæíû áûòü îðãàíèçîâàíû òàêèì îáðàçîì, ÷òîáû îõâàòûâàòü òåõ, êòî ïîäâåðãàåòñÿ äâîéíîìó ðèñêó â ñâÿçè ñ óïîòðåáëåíèåì èíúåêöèîííûõ íàðêîòèêîâ è ñåêñ-ðàáîòîé.

Âçàèìîäåéñòâèå ìåæäó ïðåïàðàòàì çàìåñòèòåëüíîé ïîääåðæèâàþùåé òåðàïèè è ÀÐÂ-ïðåïàðàòàìè  ñâÿçè ñ ïîòåíöèàëüíûì âçàèìîäåéñòâèåì ìåæäó ïðåïàðàòàìè çàìåñòèòåëüíîé òåðàïèåé äëÿ ëèö ñ íàðêîçàâèñèìîñòüþ è ÀÐÂ-ïðåïàðàòàìè, öåëåñîîáðàçíî áûëî áû îáåñïå÷èòü íà íà÷àëüíîì ýòàïå ÀÐÂ-òåðàïèè ðåãóëÿðíûå êîíòàêòû è îòêðûòîå îáùåíèå ìåæäó ñïåöèàëèñòàìè ïî ëå÷åíèþ ÂÈ×, ÂÈ×-èíôèöèðîâàííûìè ïîòðåáèòåëÿìè èíúåêöèîííûõ íàðêîòèêîâ è ïåðñîíàëîì ïðîãðàììû çàìåñòèòåëüíîé ïîääåðæèâàþùåé òåðàïèè.  öåëîì, íåîáõîäèìî âíèìàòåëüíî ñëåäèòü çà ñîñòîÿíèåì ïàöèåíòîâ, ïðîõîäÿùèõ çàìåñòèòåëüíóþ ïîääåðæèâàþùóþ òåðàïèþ, â ñëó÷àÿõ, êîãäà âíîñÿòñÿ êàêèå-ëèáî èçìåíåíèÿ â íàçíà÷åííûå èì ïðåïàðàòû â ðàìêàõ äðóãèõ êóðñîâ ëå÷åíèÿ, à òàêæå ó÷èòûâàòü âîçìîæíîñòü âçàèìîäåéñòâèÿ ïðèíèìàåìûõ ïðåïàðàòîâ ñ “óëè÷íûìè” íàðêîòèêàìè. Ñóùåñòâóåò íåñêîëüêî ìîäåëåé, ïîçâîëÿþùèõ óñïåøíî ñî÷åòàòü ìåäèöèíñêóþ ïîìîùü ïðè ÂÈ× ñ ëå÷åíèåì íàðêîçàâèñèìîñòè.  èõ ÷èñëî âõîäèò: » ïðåäîñòàâëåíèå ìåäèöèíñêîé ïîìîùè ïóòåì íàïðàâëåíèÿ ïàöèåíòà â áëèæàéøóþ êëèíèêó ëå÷åíèÿ ÂÈ×; » îðãàíèçàöèÿ ëå÷åíèÿ íàðêîçàâèñèìîñòè â ìåäèöèíñêîì ó÷ðåæäåíèè, îêàçûâàþùåì íåîáõîäèìóþ ìåäèöèíñêóþ ïîìîùü ïðè ÂÈ×èíôåêöèè; » ïðåäîñòàâëåíèå íåîáõîäèìîé ïåðâè÷íîé ìåäèöèíñêîé ïîìîùè äëÿ ÂÈ×-èíôèöèðîâàííûõ ïîòðåáèòåëåé èíúåêöèîííûõ íàðêîòèêîâ â ó÷ðåæäåíèè, îñóùåñòâëÿþùåì ëå÷åíèå íàðêîçàâèñèìîñòè.

Èñïðàâèòåëüíûå ó÷ðåæäåíèÿ Çàêðûòûå óñëîâèÿ òþðåì äîëæíû ðàññìàòðèâàòüñÿ êàê äîïîëíèòåëüíàÿ âîçìîæíîñòü äëÿ ïðîôèëàêòèêè è ìåäèöèíñêîé ïîìîùè â îáëàñòè ÂÈ×. Êîìïëåêñíàÿ è íåïðåðûâíàÿ ïîìîùü äîëæíà ïðåäîñòàâëÿòüñÿ êàê â ñîîáùåñòâå, òàê è çà åãî ïðåäåëàìè, ïîñêîëüêó ëþäè ïåðåìåùàþòñÿ èç ñîîáùåñòâà â ìåñòàõ çàäåðæàíèÿ è íàîáîðîò. Äåòîêñèêàöèÿ â çàêðûòûõ ó÷ðåæäåíèÿõ äîëæíà ïðîâîäèòüñÿ íà îñíîâå èíäèâèäóàëüíîãî ïîäõîäà, à îòìåíà íàðêîòèêà èëè íàðêîòèêîâ, îò êîòîðûõ ó ïàöèåíòà ñóùåñòâóåò çàâèñèìîñòü, äîëæíà ïðîèñõîäèòü ïîä ìåäèöèíñêèì íàáëþäåíèåì, ÷òîáû ñìÿã÷èòü ñèìïòîìû àáñòèíåíòíîãî ñèíäðîìà è ìèíèìèçèðîâàòü âåðîÿòíîñòü íåáëàãîïðèÿòíûõ ìåäèöèíñêèõ îñëîæíåíèé. Íåîáõîäèìî ðàçðàáîòàòü ìåòîäû è ìîäåëè, êîòîðûå áóäóò ñïîñîáñòâîâàòü ñîòðóäíè÷åñòâó ìåæäó ðàáîòíèêàìè çäðàâîîõðàíåíèÿ è ïåðñîíàëîì èñïðàâèòåëüíûõ ó÷ðåæäåíèé èëè ïðàâîîõðàíèòåëüíûõ îðãàíîâ.

ñìîòðèòå äîêóìåíòû ÂÎÇ ïî ÏÌÐ íà http://www.who.int/hiv/pub/ mtct/en/ 4

ñìîòðèòå ðóêîâîäÿùèå ïðèíöèïû ÂÎÇ/ÞÍÝÉÄÑ ïî ðóòèííûì óñëóãàì íà http://www.unaids.org/Unaids/EN/In+focus/Topic+areas/ HIV+diagnostic+tests.asp 5

ÂÛÂÎÄÛ Ëèöàì, ôîðìèðóþùèì ïîëèòèêó, ñëåäóåò çàäóìàòüñÿ î ñåðüåçíûõ ñîöèàëüíûõ è ìåäèöèíñêèõ çàòðàò, ñâÿçàííûõ óïîòðåáëåíèåì èíúåêöèîííûõ íàðêîòèêîâ, î òàêæå î âåðîÿòíîñòè ïîâûøåíèÿ ðàñïðîñòðàíåííîñòè ãåïàòèòîâ B è C, ÂÈ×-èíôåêöèè è óðîâíÿ ñìåðòíîñòè, åñëè ïðîãðàììû ÀÐÂ-òåðàïèè è ñíèæåíèÿ âðåäà îñòàíóòñÿ íåäîñòóïíûìè äëÿ ïîòðåáèòåëåé èíúåêöèîííûõ íàðêîòèêîâ.  áîðüáå ñ ÂÈ×-èíôåêöèåé â ñðåäå ïîòðåáèòåëåé èíúåêöèîííûõ íàðêîòèêîâ ïî-ïðåæíåìó îñòàþòñÿ íåðåøåííûìè ñåðüåçíûå ïðîáëåìû. Äëÿ òîãî, ÷òîáû îáåñïå÷èòü ýôôåêòèâíûé êîíòðîëü íàä ýïèäåìèåé è ïðåäîñòàâèòü ïîìîùü òåì, êòî óæå ïîñòðàäàë îò íåå, íåîáõîäèìî óñòðàíèòü âñå ñóùåñòâóþùèå ñîöèàëüíûå, ýêîíîìè÷åñêèå è ïðàâîâûå áàðüåðû, è ðåøèòü âñå ôèçè÷åñêèå è ïñèõîëîãè÷åñêèå ïðîáëåìû.

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Ïåðåâîä äàííîé ïóáëèêàöèè íà ðóññêèé ÿçûê îñóùåñòâëåí Ñåòüþ ñíèæåíèÿ âðåäà Öåíòðàëüíîé è Âîñòî÷íîé Åâðîïû (Central and Eastern European Harm Reduction Network).

Áîëåå ïîäðîáíóþ èíôîðìàöèþ ìîæíî ïîëó÷èòü âî Âñåìèðíîé îðãàíèçàöèè çäðàâîîõðàíåíèÿ ïî àäðåñó: World Health Organization Department of HIV/AIDS 20, avenue Appia CH-1211 Geneva 27 Switzerland Ý÷. ïî÷òà: hiv-aids@who.int Âåá-ñàéò: http://www.who.int/hiv/en