{"id":26413,"date":"2023-03-06T13:32:50","date_gmt":"2023-03-06T10:32:50","guid":{"rendered":"https:\/\/www.klimikdergisi.org\/?p=26413"},"modified":"2023-03-21T14:17:42","modified_gmt":"2023-03-21T11:17:42","slug":"hiv-ile-infekte-hastalarin-zaman-icindeki-degisimi","status":"publish","type":"post","link":"https:\/\/www.klimikdergisi.org\/tr\/2023\/03\/06\/hiv-ile-infekte-hastalarin-zaman-icindeki-degisimi\/","title":{"rendered":"Ege \u00dcniversitesi HIV Kohortunda \u0130nfekte Hastalar\u0131n Bak\u0131m\u0131 ve \u0130zlemi: Zaman \u0130\u00e7indeki De\u011fi\u015fim"},"content":{"rendered":"<h2 class=\"p1\">G\u0130R\u0130\u015e<\/h2>\n<p class=\"p1\">Birle\u015fmi\u015f Milletler HIV\/AIDS Program\u0131 (Joint United Nations Programme on HIV\/AIDS \u2013 UNAIDS) 2014 y\u0131l\u0131nda, insan ba\u011f\u0131\u015f\u0131kl\u0131k yetmezlik virusu (human immunodeficiency virus \u2013HIV) infeksiyonunu kontrol alt\u0131na almak ve ihmal edilebilir d\u00fczeye indirmek amac\u0131yla 2020 y\u0131l\u0131 i\u00e7in 90-90-90 hedeflerini belirlemi\u015ftir. Bu hedefler uyar\u0131nca HIV ile ya\u015fayan bireylerin %90\u2019\u0131na tan\u0131 koyulmas\u0131, tan\u0131 alanlar\u0131n %90\u2019\u0131na ART ba\u015flanmas\u0131 ve tedavi ba\u015flananlar\u0131n %90\u2019\u0131nda virolojik bask\u0131lanman\u0131n sa\u011flanmas\u0131 ama\u00e7lanmaktad\u0131r (1). Bu hedeflere ula\u015f\u0131ld\u0131\u011f\u0131 takdirde, 2030 y\u0131l\u0131nda 95-95-95 hedefine eri\u015filebilece\u011fi ve HIV infeksiyonunun ihmal edilebilir d\u00fczeye inece\u011fi \u00f6ng\u00f6r\u00fclmektedir (2). 2019 y\u0131l\u0131 sonunda 90-90-90 hedeflerine ula\u015fman\u0131n m\u00fcmk\u00fcn olmad\u0131\u011f\u0131 belirtilmi\u015f ve 2020 y\u0131l\u0131nda ba\u015flayan COVID-19 pandemisi HIV alan\u0131nda yap\u0131lan \u00e7al\u0131\u015fmalar\u0131 \u00f6nemli \u00f6l\u00e7\u00fcde engellemi\u015ftir; ancak 2030 y\u0131l\u0131 i\u00e7in 95-95-95 hedefleri halen ge\u00e7erlili\u011fini korumaktad\u0131r (3).<span class=\"Apple-converted-space\">\u00a0<\/span><\/p>\n<p class=\"p1\">Son on y\u0131l i\u00e7inde k\u00fcresel anlamda yeni HIV infeksiyonlar\u0131n\u0131n say\u0131s\u0131nda dikkati \u00e7eken bir azalma olmu\u015ftur. Ancak halen belirli b\u00f6lgelerde, \u00f6zellikle de Do\u011fu Avrupa ve \u00fclkemizin de i\u00e7inde bulundu\u011fu Orta Avrupa \u00fclkelerinde yeni tan\u0131lar\u0131n say\u0131s\u0131 h\u0131zla artmaya devam etmektedir. T\u00fcrkiye\u2019de de son on y\u0131l i\u00e7inde yeni tan\u0131lar\u0131n say\u0131s\u0131nda dikkati \u00e7eken bir art\u0131\u015f olmu\u015ftur ve art\u0131\u015f ayn\u0131 h\u0131zla devam etmektedir (4,5). 2005-2014 y\u0131llar\u0131 aras\u0131nda Orta Avrupa i\u00e7in Avrupa Hastal\u0131k \u00d6nleme ve Kontrol Merkezi (European Centre for Disease Prevention and Control \u2013 ECDC)\u2019ne bildirilen yeni olgular\u0131n %70\u2019inden Polonya (%29), T\u00fcrkiye (%22) ve Romanya (%20)\u2019n\u0131n sorumlu oldu\u011fu tespit edilmi\u015ftir (6). ECDC 2021 raporunda da T\u00fcrkiye, Orta Avrupa b\u00f6lgesinde yeni tan\u0131lar\u0131n say\u0131s\u0131n\u0131n en h\u0131zl\u0131 art\u0131\u015f g\u00f6sterdi\u011fi \u00fclkeler aras\u0131nda yer alm\u0131\u015ft\u0131r (7). Avrupa b\u00f6lgesini ve dolay\u0131s\u0131yla \u00fclkemizi de ilgilendiren bir ba\u015fka \u00f6nemli sorun da olgular\u0131n yakla\u015f\u0131k yar\u0131s\u0131n\u0131n ge\u00e7 [CD4<sup>+<\/sup> T lenfosit say\u0131s\u0131 \u2264350 h\u00fccre\/mm<sup>3<\/sup> ve\/veya edinilmi\u015f ba\u011f\u0131\u015f\u0131k yetmezlik sendromu (acquired immune deficiency syndrome \u2013 AIDS) tan\u0131mlayan bir hastal\u0131k] tan\u0131 almas\u0131d\u0131r (4,7).<\/p>\n<p class=\"p3\">HIV ile infekte bireylerin erken tan\u0131mlanmas\u0131, tan\u0131 alanlar\u0131n sa\u011fl\u0131k sistemine hemen d\u00e2hil edilerek sistemin i\u00e7inde kalmas\u0131n\u0131n sa\u011flanmas\u0131 ve ART\u2019ye erken ba\u015flanmas\u0131, HIV ile ya\u015fayan bireylerin uzun ve kaliteli ya\u015famas\u0131n\u0131 sa\u011flarken di\u011fer yanda toplum i\u00e7inde bula\u015fmalar\u0131n da azalmas\u0131na \u00f6nemli \u00f6l\u00e7\u00fcde katk\u0131 sa\u011flamaktad\u0131r (8). \u00dclkemizde yap\u0131lan modelleme \u00e7al\u0131\u015fmalar\u0131, olgular\u0131n ancak %40-50\u2019sine tan\u0131 koyulabildi\u011fine i\u015faret etmektedir (9,10,11). Oysa tan\u0131 al\u0131p bir sa\u011fl\u0131k kurulu\u015funa y\u00f6nlendirilen olgularda, HIV kaskad\u0131n\u0131n ikinci ve \u00fc\u00e7\u00fcnc\u00fc 90 basamaklar\u0131nda ba\u015far\u0131 oranlar\u0131 hayli y\u00fcksektir (4,9,12).<\/p>\n<p class=\"p3\">\u00c7al\u0131\u015fman\u0131n \u00f6ncelikli amac\u0131, merkezimizde takip edilen HIV\/AIDS olgular\u0131nda tedavi ve izlem stratejilerini g\u00f6zden ge\u00e7irmek ve virolojik ba\u015far\u0131 oranlar\u0131n\u0131n y\u0131llar i\u00e7indeki seyrini g\u00f6zlemlemektir. Ayr\u0131ca, olgular\u0131n epidemiyolojik \u00f6zelliklerini, klinik ve laboratuvar bulgular\u0131n\u0131 ve sa\u011fkal\u0131m s\u00fcrelerini etkileyen fakt\u00f6rler de \u00e7al\u0131\u015fma kapsam\u0131nda irdelenmi\u015ftir.<\/p>\n<h2 class=\"p5\">Y\u00d6NTEMLER<\/h2>\n<p class=\"p3\">1996-2015 y\u0131llar\u0131 aras\u0131nda aras\u0131nda <span class=\"s1\">Ege \u00dcniversitesi T\u0131p Fak\u00fcltesi<\/span> \u0130nfeksiyon Hastal\u0131klar\u0131 ve Klinik Mikrobiyoloji Anabilim Dal\u0131\u2019na ba\u015fvuran HIV ile infekte olgular geriye d\u00f6n\u00fck olarak de\u011ferlendirildi. Hasta dosyalar\u0131na, HIV\/AIDS \u00f6zel takip formlar\u0131na ve hastane elektronik bilgi sistemindeki verilerine ula\u015f\u0131labilen HIV\/AIDS tan\u0131s\u0131 serolojik olarak do\u011frulanm\u0131\u015f 18 ya\u015f ve \u00fczeri olgular \u00e7al\u0131\u015fmaya al\u0131nd\u0131. Olgulara ili\u015fkin a\u015fa\u011f\u0131daki parametreler incelendi:<\/p>\n<ul>\n<li class=\"p6\">Demografik \u00f6zellikler (yas\u0327, cinsiyet, meslek, e\u011fitim ve ya\u015fad\u0131\u011f\u0131 yer),<\/li>\n<li class=\"p6\">Bulas\u0327ma yolu,<\/li>\n<li class=\"p6\">Klini\u011fe ilk ba\u015fvurusunda yeni tan\u0131\/sevk olmas\u0131, CD4<sup>+<\/sup> T lenfosit ve HIV RNA d\u00fczeyleri, klinik evresi,<\/li>\n<li class=\"p6\">F\u0131rsat\u00e7\u0131 infeksiyon ve kanserlerin varl\u0131\u011f\u0131 ve ortaya \u00e7\u0131kma zamanlar\u0131,<\/li>\n<li class=\"p6\">ART ba\u015flan\u0131p ba\u015flanmad\u0131\u011f\u0131,<\/li>\n<li class=\"p6\">Virolojik yan\u0131t olup olmad\u0131\u011f\u0131 ve olduysa zaman\u0131,<\/li>\n<li class=\"p6\">Ba\u015flang\u0131\u00e7taki CD4<sup>+<\/sup> T lenfosit &lt;200 h\u00fccre\/mm<sup>3<\/sup> olanlarda &gt;200 h\u00fccre\/mm<sup>3<\/sup> d\u00fczeyine \u00e7\u0131kana kadar ge\u00e7en s\u00fcre,<\/li>\n<li class=\"p6\">\u0130la\u00e7 de\u011fi\u015fikli\u011fi olup olmad\u0131\u011f\u0131 ve varsa nedenleri,<\/li>\n<li class=\"p6\">Virolojik ba\u015far\u0131s\u0131zl\u0131k geli\u015fme oran\u0131 ve nedenleri,<\/li>\n<li class=\"p6\">Tedavinin kesilmesi ve nedenleri,<\/li>\n<li class=\"p6\">Yan etkilerin s\u0131kl\u0131\u011f\u0131 ve niteli\u011fi ile ila\u00e7 de\u011fi\u015fikli\u011fine neden olup olmamas\u0131,<\/li>\n<li class=\"p6\">\u00d6l\u00fcm geli\u015fip geli\u015fmedi\u011fi, geli\u015ftiyse nedeni,<\/li>\n<li class=\"p6\">Sa\u011fkal\u0131m s\u00fcresi ve sa\u011fkal\u0131m ile ili\u015fkili fakt\u00f6rler.<\/li>\n<\/ul>\n<p class=\"p3\">Hastalar\u0131n HIV infeksiyonu evresi; ABD Hastal\u0131k Kontrol ve Korunma Merkezleri (Centers for Disease Control and Prevention \u2013 CDC) 2008 y\u0131l\u0131 k\u0131lavuzundaki s\u0131n\u0131flamaya g\u00f6re kategorize edilip kaydedildi (13). Ba\u015fvuru s\u0131ras\u0131nda CD4<sup>+<\/sup> T lenfosit say\u0131s\u0131 &lt;350 h\u00fccre\/mm<sup>3<\/sup> olan ve\/veya AIDS tan\u0131mlayan hastal\u0131\u011f\u0131 bulunanlar \u201cge\u00e7 ba\u015fvuru\u201d, CD4<sup>+<\/sup> T lenfosit say\u0131s\u0131 &lt;200 h\u00fccre\/mm<sup>3<\/sup> olan ve\/veya AIDS tan\u0131mlayan hastal\u0131\u011f\u0131 bulunanlar ise \u201cileri d\u00fczeyde ba\u015fvuru\u201d olarak de\u011ferlendirildi. HIV ile ilintili hastal\u0131klar i\u00e7in CDC taraf\u0131ndan yay\u0131mlanm\u0131\u015f olan AIDS tan\u0131mlayan hastal\u0131klar tablosu esas al\u0131nd\u0131 (13). Hastalar\u0131n g\u00fcn\u00fcm\u00fczde merkezimiz taraf\u0131ndan h\u00e2len takip edilip edilmedi\u011fine, en son poliklinik kontrol\u00fcnden sonra ge\u00e7en s\u00fcre temel al\u0131narak karar verildi; son bir y\u0131l i\u00e7erisinde HIV poliklini\u011fine bas\u0327vurmus\u0327 olan hastalar halen \u201ctakipli\u201d, bir y\u0131l\u0131 as\u0327k\u0131n s\u00fcredir<br \/>\npoliklinig\u0306e bas\u0327vurmayan hastalar \u201ctakip d\u0131s\u0327\u0131\u201d olarak kabul edildi. Hastalar\u0131n<br \/>\npoliklini\u011fimize ilk geldi\u011fi g\u00fcn bas\u0327vuru tarihi olarak kabul edildi.<\/p>\n<p class=\"p3\">ART alan hastalarda, alt\u0131 ay i\u00e7erisinde HIV RNA \u00f6l\u00e7\u00fcm\u00fcn\u00fcn saptanabilir d\u00fczeyin (50 kopya\/ml) alt\u0131na indirilememesi virolojik ba\u015far\u0131s\u0131zl\u0131k olarak de\u011ferlendirildi. Hastalara ili\u015fkin t\u00fcm demografik, klinik ve laboratuvar parametreleri hasta dosyalar\u0131ndan ve hastanenin elektronik bilgi sisteminden al\u0131nd\u0131; \u00f6l\u00fcm tarihleri hakk\u0131ndaki veriler ise hasta dosyalar\u0131na eklenen notlardan ve \u00f6l\u00fcm bildirim sisteminden elde edildi.<span class=\"Apple-converted-space\">\u00a0<\/span><\/p>\n<p class=\"p3\">\u00c7al\u0131\u015fma, <span class=\"s1\">Ege \u00dcniversitesi T\u0131p Fak\u00fcltesi<\/span> Klinik Aras\u0327t\u0131rmalar Etik Kurulu taraf\u0131ndan 18 Ekim 2017 tarih ve 16-12\/10 say\u0131l\u0131 karar numaras\u0131yla onayland\u0131.<span class=\"Apple-converted-space\">\u00a0<\/span><\/p>\n<h3 class=\"p8\">\u0130statistiksel Analiz<\/h3>\n<p class=\"p9\">Verilerin analizinde SPSS (\u201cStatistical Package for the Social Sciences\u201d) versiyon 18.0 program\u0131 (IBM Corp., Armonk, NY, ABD) kullan\u0131ld\u0131. Nicel de\u011fi\u015fkenler i\u00e7in ortalama, standart sapma, ortanca, minimum ve maksimum de\u011ferler kullan\u0131ld\u0131; s\u00fcrekli de\u011fi\u015fkenlerin normal da\u011f\u0131l\u0131ma uygunlu\u011fu ara\u015ft\u0131r\u0131ld\u0131 ve de\u011fi\u015fkenlerin t\u00fcm\u00fcn\u00fcn normal da\u011f\u0131l\u0131ma uymad\u0131\u011f\u0131na karar verildi. S\u00f6z konusu de\u011fi\u015fkenlerin kar\u015f\u0131la\u015ft\u0131rmalar\u0131nda parametrik olmayan y\u00f6ntemler kullan\u0131ld\u0131. Ba\u011f\u0131ms\u0131z gruplar Mann-Whitney U testi ile kar\u015f\u0131la\u015ft\u0131r\u0131ld\u0131. De\u011fi\u015fkenler aras\u0131ndaki ili\u015fki korelasyon y\u00f6ntemi ile ara\u015ft\u0131r\u0131ld\u0131. Nitel de\u011fi\u015fkenler \u00e7apraz tablolar halinde frekans ve y\u00fczdeler halinde sunuldu; da\u011f\u0131l\u0131mlar\u0131 <span class=\"s2\">\u03c7\u00b2\u00a0<\/span>testi ile kar\u015f\u0131la\u015ft\u0131r\u0131ld\u0131. Sa\u011fkal\u0131m ara\u015ft\u0131rmalar\u0131 i\u00e7in Kaplan-Meier y\u00f6ntemi kullan\u0131ld\u0131; ba\u011f\u0131ms\u0131z gruplar\u0131n sa\u011fkal\u0131m kar\u015f\u0131la\u015ft\u0131rmalar\u0131 Log-Rank testi ile yap\u0131ld\u0131. T\u00fcm testlerde tip-1 hata pay\u0131 i\u00e7in \u03b1=0.05 olarak kabul edilmi\u015f olup \u00e7ift y\u00f6nl\u00fc olarak test edildi; <i>p<\/i>&lt;0.05 oldu\u011fu durumlarda gruplar aras\u0131ndaki fark istatistiksel olarak anlaml\u0131 d\u00fczey olarak kabul edildi.<\/p>\n<h2 class=\"p5\">BULGULAR<\/h2>\n<p class=\"p1\">1996-2015 y\u0131llar\u0131 aras\u0131nda takip edilen 431 HIV\/AIDS olgusu \u00e7al\u0131\u015fmaya d\u00e2hil edildi. Veriler onar y\u0131ll\u0131k (1996-2005 ve 2006-2015) iki dilim kapsam\u0131nda de\u011ferlendirildi ve k\u0131yasland\u0131. T\u00fcm grup dikkate al\u0131nd\u0131\u011f\u0131nda, olgular\u0131n %79.1 (341\/431)\u2019i yeni tan\u0131, %20.9 (90\/431)\u2019u ise ba\u015fka merkezden sevk olarak klini\u011fe ba\u015fvurmu\u015ftu. Takip s\u00fcrecinde olgular\u0131n %77.3 (333\/431)\u2019\u00fcn\u00fcn takibinin s\u00fcrd\u00fcr\u00fclm\u00fc\u015f oldu\u011fu, %16.2 (70\/431)\u2019sinin ba\u015fka merkeze sevk edildi\u011fi veya takipten \u00e7\u0131kt\u0131\u011f\u0131, %6.5 (28\/431)\u2019inin ise \u00f6ld\u00fc\u011f\u00fc tespit edildi.<span class=\"Apple-converted-space\">\u00a0<\/span><\/p>\n<p class=\"p3\"><span class=\"s3\">\u00c7al\u0131\u015fmaya al\u0131nan olgular\u0131n 345 (%80)\u2019i erkek, 86 (%20)\u2019s\u0131 kad\u0131nd\u0131; 278 (%64.5)\u2019inin \u0130zmir\u2019de ikamet etti\u011fi g\u00f6r\u00fcld\u00fc. Kat\u0131l\u0131mc\u0131lar\u0131n ba\u015fvuru an\u0131ndaki ortanca ya\u015f de\u011feri 36.43 (17-77) y\u0131l olarak bulundu. \u00c7al\u0131\u015fman\u0131n ilk zaman diliminde erkek ve kad\u0131n olgular\u0131n say\u0131s\u0131 s\u0131ras\u0131yla 24 (%63.2) ve 14 (%36.8) idi; ikinci zaman diliminde say\u0131lar \u00f6nemli \u00f6l\u00e7\u00fcde artm\u0131\u015f olup s\u0131ras\u0131yla 321 (%81.7) ve 72 (%18.3) olarak tespit edildi (<i>p<\/i>=0.012) (Tablo 1). Ancak ya\u015f da\u011f\u0131l\u0131mlar\u0131 a\u00e7\u0131s\u0131ndan iki d\u00f6nem aras\u0131nda anlaml\u0131 bir fark olmad\u0131\u011f\u0131 g\u00f6zlendi; ortanca ya\u015f s\u0131ras\u0131yla 33 (22-74) ve 33 (17-77) idi (<i>p<\/i>=0.93).<\/span><\/p>\n<p class=\"p3\">HIV\u2019in olas\u0131 bula\u015fma yollar\u0131na ili\u015fkin 386 (%89.6) olgunun verilerine ula\u015f\u0131labildi. Heteroseks\u00fcel bula\u015fma tespit edilen olgu say\u0131s\u0131 224 (%52), erkek erke\u011fe seks veya iki cinsle seks yapan olgu say\u0131s\u0131 147 (%34.1), kan yolu ile bula\u015fma say\u0131s\u0131 12 (%2.8), vertikal bula\u015fma say\u0131s\u0131 3 (%0.7) olarak saptand\u0131. Kalan 45 (%10.4) olgunun olas\u0131 bula\u015fma yolu \u201cbilinmeyen\u201d olarak s\u0131n\u0131fland\u0131r\u0131ld\u0131. \u0130ki zaman dilimi aras\u0131nda bula\u015fma yollar\u0131nda g\u00f6zlenen fark istatistiksel a\u00e7\u0131dan anlaml\u0131 d\u00fczeydeydi (Tablo 1) (<i>p<\/i>=0.001).<\/p>\n<div id=\"attachment_26531\" style=\"width: 2190px\" class=\"wp-caption alignright\"><a href=\"https:\/\/www.klimikdergisi.org\/wp-content\/uploads\/2023\/03\/KD.C36.S1_4248_Tablo.1.png\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-26531\" class=\"size-full wp-image-26531\" src=\"https:\/\/www.klimikdergisi.org\/wp-content\/uploads\/2023\/03\/KD.C36.S1_4248_Tablo.1.png\" alt=\"\" width=\"2180\" height=\"1299\" srcset=\"https:\/\/www.klimikdergisi.org\/wp-content\/uploads\/2023\/03\/KD.C36.S1_4248_Tablo.1.png 2180w, https:\/\/www.klimikdergisi.org\/wp-content\/uploads\/2023\/03\/KD.C36.S1_4248_Tablo.1-390x232.png 390w, https:\/\/www.klimikdergisi.org\/wp-content\/uploads\/2023\/03\/KD.C36.S1_4248_Tablo.1-810x483.png 810w, https:\/\/www.klimikdergisi.org\/wp-content\/uploads\/2023\/03\/KD.C36.S1_4248_Tablo.1-768x458.png 768w\" sizes=\"auto, (max-width: 2180px) 100vw, 2180px\" \/><\/a><p id=\"caption-attachment-26531\" class=\"wp-caption-text\"><strong>Tablo 1.<\/strong> HIV Kohortunun \u0130ki D\u00f6neminin Farkl\u0131 De\u011fi\u015fkenler A\u00e7\u0131s\u0131ndan K\u0131yaslamas\u0131<\/p><\/div>\n<p class=\"p3\">Yirmi y\u0131l\u0131 kapsayan izlem s\u00fcrecinin ilk zaman diliminde olgular\u0131n %28.9\u2019unun takipte kald\u0131\u011f\u0131, %44.7\u2019sinin takipten \u00e7\u0131kt\u0131\u011f\u0131, %26.3\u2019\u00fcn\u00fcn \u00f6ld\u00fc\u011f\u00fc tespit edildi; ikinci zaman diliminde ise bu oranlar s\u0131ras\u0131yla %81.9, %13.5 ve %4.6 olarak bulundu. Takipte kalan olgular\u0131n say\u0131s\u0131n\u0131n ikinci on y\u0131ll\u0131k dilimde anlaml\u0131 d\u00fczeyde artt\u0131\u011f\u0131, takipten \u00e7\u0131kanlar\u0131n ve \u00f6lenlerin say\u0131lar\u0131n\u0131n ise anlaml\u0131 d\u00fczeyde azald\u0131\u011f\u0131 g\u00f6r\u00fcld\u00fc (<i>p<\/i>=0.00) (Tablo 1).<\/p>\n<div id=\"attachment_26534\" style=\"width: 907px\" class=\"wp-caption alignright\"><a href=\"https:\/\/www.klimikdergisi.org\/wp-content\/uploads\/2023\/03\/KD.C36.S1_4248_Sekil.1.png\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-26534\" class=\"wp-image-26534 size-full\" src=\"https:\/\/www.klimikdergisi.org\/wp-content\/uploads\/2023\/03\/KD.C36.S1_4248_Sekil.1.png\" alt=\"\" width=\"897\" height=\"1082\" srcset=\"https:\/\/www.klimikdergisi.org\/wp-content\/uploads\/2023\/03\/KD.C36.S1_4248_Sekil.1.png 897w, https:\/\/www.klimikdergisi.org\/wp-content\/uploads\/2023\/03\/KD.C36.S1_4248_Sekil.1-216x260.png 216w, https:\/\/www.klimikdergisi.org\/wp-content\/uploads\/2023\/03\/KD.C36.S1_4248_Sekil.1-448x540.png 448w, https:\/\/www.klimikdergisi.org\/wp-content\/uploads\/2023\/03\/KD.C36.S1_4248_Sekil.1-768x926.png 768w\" sizes=\"auto, (max-width: 897px) 100vw, 897px\" \/><\/a><p id=\"caption-attachment-26534\" class=\"wp-caption-text\"><strong>\u015eekil 1.<\/strong> Ba\u015fvuru An\u0131ndaki CD4+ T Lenfosit Say\u0131s\u0131n\u0131n Y\u0131llar \u0130\u00e7indeki De\u011fi\u015fimi<\/p><\/div>\n<p class=\"p3\">CDC\u2019nin k\u0131lavuzuna uygun olarak kay\u0131tl\u0131 431 olgunun 422\u2019sinin bas\u0327vuru an\u0131ndaki HIV infeksiyonu evresinin s\u0131n\u0131flamas\u0131 yap\u0131ld\u0131; olgular\u0131n 113 (%26.8)\u2019\u00fc evre-1, 181 (%42.9)\u2019i evre-2 ve 128 (%30.3)\u2019i evre-3 olarak de\u011ferlendirildi. AIDS a\u015famas\u0131 olan evre-3\u2019te ba\u015fvuran olgular\u0131n say\u0131s\u0131n\u0131n ikinci on y\u0131lda azald\u0131\u011f\u0131 ve ilk ba\u015fvurular\u0131n \u00e7o\u011funlukla evre-1 veya evre-2\u2019de oldu\u011fu g\u00f6r\u00fcld\u00fc (<i>p<\/i>=0.00) (Tablo 1).<\/p>\n<div id=\"attachment_26536\" style=\"width: 1251px\" class=\"wp-caption alignright\"><a href=\"https:\/\/www.klimikdergisi.org\/wp-content\/uploads\/2023\/03\/KD.C36.S1_4248_Sekil.2.png\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-26536\" class=\"size-full wp-image-26536\" src=\"https:\/\/www.klimikdergisi.org\/wp-content\/uploads\/2023\/03\/KD.C36.S1_4248_Sekil.2.png\" alt=\"\" width=\"1241\" height=\"1078\" srcset=\"https:\/\/www.klimikdergisi.org\/wp-content\/uploads\/2023\/03\/KD.C36.S1_4248_Sekil.2.png 1241w, https:\/\/www.klimikdergisi.org\/wp-content\/uploads\/2023\/03\/KD.C36.S1_4248_Sekil.2-299x260.png 299w, https:\/\/www.klimikdergisi.org\/wp-content\/uploads\/2023\/03\/KD.C36.S1_4248_Sekil.2-622x540.png 622w, https:\/\/www.klimikdergisi.org\/wp-content\/uploads\/2023\/03\/KD.C36.S1_4248_Sekil.2-768x667.png 768w\" sizes=\"auto, (max-width: 1241px) 100vw, 1241px\" \/><\/a><p id=\"caption-attachment-26536\" class=\"wp-caption-text\"><strong>\u015eekil 2.<\/strong> CD4+ T Lenfosit Say\u0131s\u0131 ile HIV RNA D\u00fczeyi Aras\u0131ndaki Korelasyon<\/p><\/div>\n<p class=\"p3\">\u00c7al\u0131\u015fman\u0131n ilk on y\u0131ll\u0131k diliminde, ba\u015fvuru an\u0131ndaki CD4<sup>+<\/sup> T lenfositlerinin ortanca de\u011feri 160 (3-650) h\u00fccre\/mm<sup>3<\/sup> iken, 2006-2015 y\u0131llar\u0131 aras\u0131nda bu de\u011fer 355 (0-1800) h\u00fccre\/mm<sup>3<\/sup> bulundu (<i>p<\/i>=0.00). Ba\u015fvuru an\u0131ndaki ortanca HIV-RNA de\u011feri; 1996-2005 y\u0131llar\u0131 aras\u0131nda 75 000 (200- 1 000 001) kopya\/ml ve 2006-2015 y\u0131llar\u0131 aras\u0131nda 39 685 (0-19 000 000) kopya\/ml olarak tespit edildi (<i>p<\/i>=0.169) (\u015eekil 1). CD4<sup>+<\/sup> T lenfositlerinin say\u0131s\u0131 ile HIV RNA d\u00fczeyi aras\u0131nda negatif bir korelasyon (r=-0.396) oldu\u011fu saptand\u0131 (\u015eekil 2).<\/p>\n<p class=\"p3\">\u00c7al\u0131\u015fman\u0131n ilk 10 y\u0131l\u0131nda olgular\u0131n 28 (%75.8)\u2019inin ve ikinci on y\u0131lda ise 194 (%49.5)\u2019\u00fcn\u00fcn ge\u00e7 d\u00f6nemde ba\u015fvurdu\u011fu g\u00f6r\u00fcld\u00fc. \u0130leri evrede ba\u015fvuran olgular\u0131n oranlar\u0131 ise ilk on y\u0131lda %65.5 ve ikinci on y\u0131lda %22.7 idi (<i>p<\/i>=0.00).<\/p>\n<p class=\"p3\">Olgular\u0131n 406 (%94.2)\u2019s\u0131na tedavi ba\u015flan\u0131rken, 25 (%5.8)\u2019inin tedavisiz izlendi\u011fi g\u00f6r\u00fcld\u00fc. Tedavi ba\u015flanan 406 olgudan 344 (%84.7)\u2019\u00fc tedavi ba\u015fland\u0131ktan sonra 6. ayda virolojik yan\u0131t a\u00e7\u0131s\u0131ndan de\u011ferlendirilmi\u015f olup 241 (%70.1)\u2019inde virolojik yan\u0131t\u0131n elde edildi\u011fi, 103 (%29.9)\u2019\u00fcnde virolojik yan\u0131t\u0131n sa\u011flanamad\u0131\u011f\u0131 anla\u015f\u0131ld\u0131. Olgular\u0131n 38 (%9.4)\u2019inde klini\u011fe ba\u015fvuru an\u0131nda HIV RNA negatifti; bu olgular d\u0131\u015far\u0131da tutularak yap\u0131lan istatistiksel analizde, iki zaman dilimi aras\u0131nda 6. ayda virolojik yan\u0131t elde etme a\u00e7\u0131s\u0131ndan anlaml\u0131 d\u00fczeyde bir fark oldu\u011fu tespit edildi (<i>p<\/i>=0.00) (Tablo 1). ART ba\u015flanan 406 olgu, toplam takip s\u00fcresince HIV RNA \u00f6l\u00e7\u00fcm\u00fcn\u00fcn negatifle\u015fmesi a\u00e7\u0131s\u0131ndan da de\u011ferlendirildi; olgular\u0131n 317 (%78.1)\u2019sinde HIV RNA \u00f6l\u00e7\u00fcm\u00fcn\u00fcn saptanabilir d\u00fczeyin alt\u0131na indi\u011fi, 27 (%6.6)\u2019sinde negatifle\u015fme sa\u011flanamad\u0131\u011f\u0131, 24 (%5.9)\u2019\u00fcnde de HIV RNA \u00f6l\u00e7\u00fcm\u00fcne ili\u015fkin bilgi olmad\u0131\u011f\u0131 anla\u015f\u0131ld\u0131. \u0130ki zaman dilimi aras\u0131nda HIV RNA \u00f6l\u00e7\u00fcm\u00fcn\u00fcn saptanabilir d\u00fczeyin alt\u0131na inmesi a\u00e7\u0131s\u0131ndan istatistiksel a\u00e7\u0131dan anlaml\u0131 d\u00fczeyde fark tespit edildi (<i>p<\/i>=0.004) (Tablo 1).<\/p>\n<p class=\"p3\">Takip s\u00fcrecinde, 406 olgunun 158 (%38.9)\u2019inde tedavi de\u011fi\u015fikli\u011fi yap\u0131ld\u0131\u011f\u0131 g\u00f6r\u00fcld\u00fc. Tedavi de\u011fi\u015fikli\u011fi nedenleri; 76 olguda (%48.1) yan etki, 18 (%11.4) olguda viral y\u00fck\u00fcn bask\u0131lanamamas\u0131, 16 (%10.1) olguda bilinmeyen nedenler, 12 (%7.6) olguda rejimin basitle\u015ftirilmesi, 9 (%5.7) olguda d\u00fczensiz kullan\u0131m, 8 (%5) olguda olas\u0131 diren\u00e7, 5 (%3.2) olguda ilac\u0131n temin edilememesi, 5 (%3.2) olguda kullan\u0131m zorlu\u011fu, 4 (%2.5) olguda ila\u00e7 etkile\u015fimi ve 5 (%2.2) olguda gebelik (n=5; %2.2) olarak tespit edildi.<\/p>\n<p class=\"p3\">AIDS tan\u0131mlayan hastal\u0131k a\u00e7\u0131s\u0131ndan 410 olgunun verilerine ula\u015f\u0131ld\u0131; 53 (%12.9) olguda AIDS tan\u0131mlayan hastal\u0131k geli\u015fti\u011fi ve bunlar\u0131n 44 (%83)\u2019\u00fcn\u00fcn bu nedenle hastaneye yat\u0131r\u0131ld\u0131\u011f\u0131 anla\u015f\u0131ld\u0131. \u00c7al\u0131\u015fman\u0131n ilk ve ikinci on y\u0131ll\u0131k diliminde AIDS tan\u0131mlayan hastal\u0131\u011f\u0131 olan olgular\u0131n oranlar\u0131 s\u0131ras\u0131yla %52.6 ve %11 olarak saptand\u0131 (<i>p<\/i>=0.01) (Tablo 1). Olgularda tespit edilen AIDS tan\u0131mlayan hastal\u0131klar\u0131n da\u011f\u0131l\u0131m\u0131; t\u00fcberk\u00fcloz (%38), Kaposi sarkomu (%11), sitomegalovirus (CMV) infeksiyonu (%10), <i>Toksoplazma gondii<\/i> ansefaliti (%8), non-Hodgkin lenfoma (%8), <i>Cryptosporidium<\/i> spp. infeksiyonu (%6), <i>Pneumocystis jirovecii<\/i> pn\u00f6monisi (%5), JC virusuna (JCV) ba\u011fl\u0131 progresif multifokal ansefalopati (%5), yayg\u0131n varisella zoster virusu (VZV) infeksiyonu (%5), yayg\u0131n <i>Candida<\/i> spp. infeksiyonu (%2), <i>Mycobacterium avium<\/i> kompleksi infeksiyonu (%2) ve herpes simpleks virusu (HSV) infeksiyonu (%2) \u015feklindedir.<span class=\"Apple-converted-space\">\u00a0<\/span><\/p>\n<p class=\"p3\">Klini\u011fe ba\u015fvuran olgular\u0131n 104 (%24.1)\u2019\u00fcn\u00fcn CD4<sup>+<\/sup> T lenfosit say\u0131s\u0131 &lt;200 h\u00fccre\/mm<sup>3<\/sup> olarak tespit edildi. Olgular\u0131n 90 (%86.5)\u2019\u0131nda takip s\u00fcrecinde CD4<sup>+<\/sup> T lenfosit say\u0131s\u0131 &gt;200 h\u00fccre\/mm<sup>3<\/sup> d\u00fczeyine ula\u015f\u0131rken, 14 (%13.5)\u2019\u00fcnde say\u0131 bu d\u00fczeyin alt\u0131nda kalm\u0131\u015ft\u0131. CD4<sup>+<\/sup> T lenfosit say\u0131lar\u0131 &lt;200 h\u00fccre\/mm<sup>3<\/sup> olup takip s\u00fcrecinde &gt;200 h\u00fccre\/mm<sup>3<\/sup> d\u00fczeyine y\u00fckselenlerin oran\u0131 ilk ve ikinci zaman diliminde s\u0131ras\u0131yla %57.1 ve %91.1 olarak bulundu (<i>p<\/i>=0.003).<\/p>\n<p class=\"p3\">CD4<sup>+<\/sup> T lenfosit &lt;200 h\u00fccre\/mm<sup>3<\/sup> olan olgular\u0131n CD4<sup>+<\/sup> T lenfosit say\u0131lar\u0131n\u0131n &gt;200 h\u00fccre\/mm<sup>3<\/sup> olmas\u0131na kadar ge\u00e7en s\u00fcre 1996-2005 y\u0131llar\u0131 aras\u0131nda ortanca 9 (1-24) ay, 2006-2015 y\u0131llar\u0131 aras\u0131nda ise 3 (1-50) ay bulundu.<span class=\"Apple-converted-space\">\u00a0<\/span><\/p>\n<p class=\"p3\">ART kullanan 406 olgunun \u00fc\u00e7\u00fcnde ilk on y\u0131lda, 28\u2019inde ise ikinci on y\u0131lda olmak \u00fczere toplam 31(%7.6) olguda virolojik ba\u015far\u0131s\u0131zl\u0131k geli\u015fti\u011fi g\u00f6r\u00fcld\u00fc. Say\u0131lar\u0131n az olmas\u0131 nedeniyle iki grup aras\u0131nda istatistiksel kar\u015f\u0131la\u015ft\u0131rma yap\u0131lamad\u0131. Virolojik ba\u015far\u0131s\u0131zl\u0131\u011f\u0131n nedeni; olgular\u0131n 18 (%58)\u2019inde ART\u2019nin d\u00fczensiz kullan\u0131lmas\u0131, 6 (%19.3)\u2019s\u0131nda antiretroviral ila\u00e7lara diren\u00e7, 1(%3.2)\u2019inde ise hem antiviral tedavinin d\u00fczensiz kullan\u0131m\u0131 hem de ila\u00e7lara diren\u00e7 olarak belirlendi; olgular\u0131n 6 (%19.3)\u2019s\u0131nda ba\u015far\u0131s\u0131zl\u0131\u011f\u0131n nedeni bilinmemektedir.<span class=\"Apple-converted-space\">\u00a0<\/span><\/p>\n<p class=\"p3\">\u0130zlem s\u00fcrecinde, verilerine ula\u015f\u0131labilen 384 olgunun 262 (%60.8)\u2019sinde yan etki geli\u015fti\u011fi tespit edildi. Olgular\u0131n 231 (%60.2)\u2019inde hiperlipidemi, 39 (%10.2)\u2019unda kemik metabolizmas\u0131nda bozukluk, 30 (%7.8)\u2019unda psikiyatrik bozukluk, 17 (%4.4)\u2019sinde anemi, 14 (%3.6)\u2019\u00fcnde karaci\u011fer fonksiyon testlerinde bozukluk, 14 (%3.6)\u2019\u00fcnde b\u00f6brek fonksiyon testlerinde bozukluk, 10 (%2.6)\u2019unda gastrointestinal sistem (G\u0130S) bozuklu\u011fu, 2 (%0.5)\u2019sinde kas enzimlerinde bozukluk ve cilt lezyonlar\u0131 ve 1 (%0.3)\u2019inde n\u00f6rolojik yan etkiler g\u00f6r\u00fcld\u00fc. En s\u0131k g\u00f6r\u00fclen yan etki olan hiperlipideminin ilk on y\u0131ll\u0131k d\u00f6nemde oran\u0131 %93.3 olup ikinci on y\u0131ll\u0131k dilimde bu oran %67.2\u2019ye d\u00fc\u015f\u00fcyordu; bu fark istatistiksel olarak anlaml\u0131 bir d\u00fczeyde de\u011fildi (<i>p<\/i>=0.44). S\u00f6z konusu yan etkilerin kullan\u0131lan antiretroviral ila\u00e7larla ili\u015fkisi bilinmemektedir.<\/p>\n<p class=\"p3\">Takip s\u00fcrecinde olgular\u0131n 32 (%7.4)\u2019sinde tedaviye ara verildi\u011fi g\u00f6zlendi. Bunun nedeni 24 (%78.1) olguda uyumsuzluk, 3 (%9.4) olguda ila\u00e7 yan etkisi, 2 (%6.3) olguda ilac\u0131n bulunamamas\u0131, 1 (%3.1) olguda akut hepatit B geli\u015fmesi ve 1 (%3.1) olguda ilac\u0131n yanl\u0131\u015f kullan\u0131lmas\u0131 idi.<\/p>\n<p class=\"p3\">Olgular\u0131n 28 (%6.5)\u2019i hayat\u0131n\u0131 kaybetmi\u015fti. \u00d6l\u00fcmlerin %35.7\u2019si 1996-2005 y\u0131llar\u0131 aras\u0131nda, %64.3\u2019\u00fc ise 2006-2015 y\u0131llar\u0131 aras\u0131nda ger\u00e7ekle\u015fmi\u015f olup 11 (%39.2) olgunun \u00f6l\u00fcm nedeni tespit edilemedi. \u00d6l\u00fcm nedeni bilinenlerin 2 (%14.3)\u2019sinin lenfoma, 3 (%10.9)\u2019\u00fcn\u00fcn t\u00fcberk\u00fcloz, 2 (%7.1)\u2019sinin AIDS t\u00fckenmi\u015flik sendromu, 2 (%7.1\u2019sinin) \u00e7oklu organ yetmezli\u011fi, 2 (%7.1)\u2019sinin konjestif kalp yetmezli\u011fi, 1 (%3.8)\u2019inin l\u00f6semi, 1(%3.8)\u2019inin diyabetik ketoasidoz, 1 (%3.8)\u2019inin aspirasyon ve 1 (%3.8)\u2019inin de ate\u015fli silahla vurulma sonucu hayat\u0131n\u0131 kaybetti\u011fi tespit edildi.<\/p>\n<p class=\"p3\">\u00d6l\u00fcm nedeni bilinen 17 olgunun 2 (%11.8)\u2019si ilk on y\u0131ll\u0131k dilimde, 15 (%88.2)\u2019i ikinci on y\u0131ll\u0131k dilimde hayat\u0131n\u0131 kaybetmi\u015fti. Bunlar\u0131n 9 (%52.9)\u2019u AIDS ile ili\u015fkili olarak, 8 (%47.1)\u2019i AIDS d\u0131\u015f\u0131 nedenlerden dolay\u0131 \u00f6lm\u00fc\u015ft\u00fc. \u0130lk d\u00f6nemde \u00f6l\u00fcm nedeni bilinen iki hasta AIDS ile ili\u015fkili nedenlerden hayat\u0131n\u0131 kaybederken, ikinci d\u00f6nemdeki15 hastan\u0131n 7 (%46.7)\u2019si AIDS ile ili\u015fkili olarak, 8 (%53.3)\u2019i AIDS d\u0131\u015f\u0131 nedenlerden dolay\u0131 \u00f6lm\u00fc\u015ft\u00fc. \u00d6l\u00fcm nedenleri a\u00e7\u0131s\u0131ndan iki grup aras\u0131nda istatistiksel a\u00e7\u0131dan anlaml\u0131 d\u00fczeyde fark saptanmad\u0131 (<i>p<\/i>=0.471).<\/p>\n<p class=\"p3\">\u00c7al\u0131\u015fma s\u00fcresi boyunca takip edilen ve verilerine ula\u015f\u0131labilen 431 olgudan 411\u2019nin tahmini sa\u011fkal\u0131m ortalamas\u0131 272 (%95 GA=225-320) ay olarak tespit edildi. HIV RNA de\u011ferlerine ula\u015f\u0131labilen 379 olgudan, HIV RNA \u00f6l\u00e7\u00fcm\u00fc saptanabilir d\u00fczeyin alt\u0131na inenlerin tahmini sa\u011fkal\u0131m ortalamas\u0131 325 (%95 GA=302-348) ay iken, HIV RNA d\u00fczeyi negatifle\u015fmeyenlerin ortalamas\u0131 ise 107 ay (%95 GA=66-148) idi (<i>p<\/i>=0.00).<\/p>\n<p class=\"p3\">AIDS tan\u0131mlayan hastal\u0131\u011f\u0131n sa\u011fkal\u0131m s\u00fcresine etkisi a\u00e7\u0131s\u0131ndan 410 olgu de\u011ferlendirildi. AIDS tan\u0131mlayan hastal\u0131\u011f\u0131 olanlar\u0131n tahmini sa\u011fkal\u0131m ortalamas\u0131 175 (%95 GA=146-203) ay ve AIDS tan\u0131mlayan hastal\u0131\u011f\u0131 olmayanlar\u0131n tahmini sa\u011fkal\u0131m ortalamas\u0131 295 (%95 GA=244-346) ay olarak bulundu (<i>p<\/i>=0.00).<\/p>\n<p class=\"p3\"><span class=\"s3\">Klinik evreleri belirlenen 407 olgu, klinik evrenin sa\u011fkal\u0131m s\u00fcresine etkisi a\u00e7\u0131s\u0131ndan de\u011ferlendirildi. CD4<sup>+<\/sup> T lenfosit say\u0131lar\u0131 &gt;200 h\u00fccre\/mm<sup>3<\/sup> olan olgularda tahmini sa\u011fkal\u0131m s\u00fcresi 314 (%95 GA=260-367) ay, &lt;200 h\u00fccre\/mm<sup>3<\/sup> olanlarda ise 184 (%95 GA=163-204) olarak tespit edildi (<i>p<\/i>=0.00).<\/span><\/p>\n<h2 class=\"p5\">\u0130RDELEME<\/h2>\n<p class=\"p3\">Bu \u00e7al\u0131\u015fma, <span class=\"s1\">Ege \u00dcniversitesi<\/span> HIV kohortunda, karma antiretroviral tedavinin kullan\u0131ma girdi\u011fi 1996 y\u0131l\u0131ndan itibaren yap\u0131lan izlem ve tedavinin, bunlar\u0131n sonu\u00e7lar\u0131n\u0131n ve olgular\u0131n epidemiyolojik \u00f6zelliklerinin onar y\u0131ll\u0131k iki zaman dilimde \u00f6nemli farkl\u0131l\u0131klar sergiledi\u011fini ortaya koymaktad\u0131r. T\u00fcm d\u00fcnyada yeni HIV olgular\u0131n\u0131n say\u0131s\u0131 azalma e\u011filimi g\u00f6stermekteyken (14, 15), art\u0131\u015f e\u011filiminin s\u00fcrd\u00fc\u011f\u00fc Orta ve Do\u011fu Avrupa b\u00f6lgesinde, T\u00fcrkiye art\u0131\u015f\u0131n en y\u00fcksek oldu\u011fu \u00fc\u00e7 \u00fclkeden biri durumundad\u0131r (6). Son 10 y\u0131l i\u00e7inde T.C. Sa\u011fl\u0131k Bakanl\u0131\u011f\u0131\u2019na bildirimi yap\u0131lan yeni olgu say\u0131lar\u0131, dikkati \u00e7ekecek d\u00fczeyde artm\u0131\u015ft\u0131r ve artmaya devam etmektedir (5). Yap\u0131lan \u00e7al\u0131\u015fmalar, mevcut durumun s\u00fcrmesi halinde 2040 y\u0131l\u0131nda y\u0131ll\u0131k yeni olgu say\u0131s\u0131n\u0131n 150 000, toplam olgu say\u0131s\u0131n\u0131n da 400 000 civar\u0131na yakla\u015faca\u011f\u0131n\u0131 \u00f6ng\u00f6rmektedir (9). Bu ba\u011flamda, HIV ile ya\u015fayan bireylerin tan\u0131mlanmas\u0131 ve en k\u0131sa zamanda ART\u2019ye ba\u015flanmas\u0131, virolojik a\u00e7\u0131dan bask\u0131lanmas\u0131 ve sa\u011fl\u0131k sisteminin i\u00e7inde tutulmas\u0131 son derece \u00f6nemlidir. Dolay\u0131s\u0131yla HIV ile ya\u015fayan bireylerin izlendi\u011fi sa\u011fl\u0131k kurumlar\u0131n\u0131n, kendi hasta profillerini tan\u0131mas\u0131, izlemde g\u00fc\u00e7l\u00fc ve zay\u0131f y\u00f6nlerini bilmesi, ba\u015far\u0131 oranlar\u0131n\u0131 izlemesi, zaman i\u00e7indeki de\u011fi\u015fimi g\u00f6rmesi ve eksik kalan y\u00f6nlerini tamamlamas\u0131 kritik \u00f6neme sahiptir. Bu \u00e7al\u0131\u015fma, <span class=\"s1\">Ege \u00dcniversitesi<\/span> kohortunun y\u0131llar i\u00e7indeki performans\u0131n\u0131 g\u00f6stermektedir ve bildi\u011fimiz kadar\u0131yla, \u00fclkemizde iki farkl\u0131 d\u00f6nemi k\u0131yaslayan ilk kohort \u00e7al\u0131\u015fmas\u0131d\u0131r.<span class=\"Apple-converted-space\">\u00a0<\/span><\/p>\n<p class=\"p3\">\u00dclkemizde yeni tan\u0131 alan olgular\u0131n profillerinin y\u0131llar i\u00e7inde ciddi de\u011fi\u015fiklikler g\u00f6sterdi\u011fi daha \u00f6nce ba\u015fka \u00e7al\u0131\u015fmalarda da bildirilmi\u015ftir. T.C Sa\u011fl\u0131k Bakanl\u0131\u011f\u0131 istatistiklerinde de bu de\u011fi\u015fimi g\u00f6rmek m\u00fcmk\u00fcnd\u00fcr (5). Ancak kohortlarda bildirilen de\u011fi\u015fimin, bakanl\u0131\u011fa yap\u0131lan bildirimlerdekine k\u0131yasla \u00e7ok daha b\u00fcy\u00fck oranda oldu\u011fu bilinmektedir. \u00d6rne\u011fin, 2011-2016 y\u0131llar\u0131n\u0131 kapsayan bir \u00e7al\u0131\u015fmada heteroseks\u00fcel bula\u015fma oran\u0131 %69\u2019dan %50\u2019ye d\u00fc\u015ferken, erkek erke\u011fe seks yoluyla bula\u015fma oranlar\u0131 iki kat artarak %16\u2019dan %31\u2019e y\u00fckselmi\u015ftir; T.C. Sa\u011fl\u0131k Bakanl\u0131\u011f\u0131\u2019n\u0131n ayn\u0131 d\u00f6nemi kapsayan istatistiklerinde ise bu oranlar s\u0131ras\u0131yla %42 ve %11.4 \u015feklinde bildirilmi\u015ftir (4). Bula\u015fma yolu bilinmeyenlerin oranlar\u0131 aras\u0131nda da ciddi farkl\u0131l\u0131klar g\u00f6r\u00fclmektedir; T.C. Sa\u011fl\u0131k Bakanl\u0131\u011f\u0131 verilerine g\u00f6re %42.7 olan bu oran, belirtilen \u00e7al\u0131\u015fmada %12.5 bulunmu\u015ftur (4). <span class=\"s1\">\u00c7al\u0131\u015fmam\u0131z\u0131n<\/span> verileri de erkeklerle seks yapan erkekler aras\u0131nda bula\u015fma oranlar\u0131n\u0131n y\u0131llar i\u00e7inde dikkati \u00e7ekecek d\u00fczeyde y\u00fckseldi\u011fini ve bula\u015fma yolu bilinmeyenlerin oran\u0131n\u0131n, di\u011fer bir\u00e7ok kohortta oldu\u011fu gibi, T.C. Sa\u011fl\u0131k Bakanl\u0131\u011f\u0131\u2019n\u0131n verilerinin aksine, hayli d\u00fc\u015f\u00fck d\u00fczeyde oldu\u011funu ortaya koymaktad\u0131r. Bunun temel nedeni, \u00f6zellikle erkeklerle seks yapan erkeklerin ilk ba\u015fvuru an\u0131nda kurumlara ve hekimlere duydu\u011fu g\u00fcvensizlik nedeniyle bula\u015fma yolunu s\u00f6ylemekten ka\u00e7\u0131nmas\u0131d\u0131r. Zaman i\u00e7inde hekim ve hasta aras\u0131ndaki g\u00fcvenin tesis edilmesi sonucu do\u011fru bula\u015fma yolu dosyaya kaydedilmekle birlikte bakanl\u0131\u011fa bu d\u00fczeltme bildirilmemektedir.<span class=\"Apple-converted-space\">\u00a0<\/span><\/p>\n<p class=\"p3\">Ge\u00e7 tan\u0131 alan olgu say\u0131lar\u0131, t\u00fcm Avrupa\u2019da oldu\u011fu gibi, \u00fclkemizde de y\u00fcksek oranlardad\u0131r. D\u00fcnya Sa\u011fl\u0131k \u00d6rg\u00fct\u00fc, Avrupa b\u00f6lgesinde 2020 y\u0131l\u0131nda ge\u00e7 tan\u0131 alanlar\u0131n oran\u0131 halen %50 olarak bildirilmektedir (7). \u00dclkemizde yap\u0131lan \u00e7al\u0131\u015fmalarda da bu oran\u0131n benzer oldu\u011fu g\u00f6r\u00fclmektedir (4, 16). \u00c7al\u0131\u015fmam\u0131zda ilk ve ikinci on y\u0131ll\u0131k dilimler k\u0131yasland\u0131\u011f\u0131nda, ikinci zaman diliminde ge\u00e7 tan\u0131 alan olgu say\u0131s\u0131nda anlaml\u0131 bir azalma olmas\u0131na kar\u015f\u0131n, yine de olgular\u0131n neredeyse yar\u0131s\u0131n\u0131n ge\u00e7 tan\u0131 alm\u0131\u015f oldu\u011fu tespit edildi. Benzer \u015fekilde, CDC k\u0131lavuzunda yer alan tan\u0131ma g\u00f6re ileri evrede tan\u0131 alanlar\u0131n da say\u0131s\u0131, ikinci zaman diliminde dikkati \u00e7ekecek \u00f6l\u00e7\u00fcde azalm\u0131\u015ft\u0131r; ancak yine de olgular\u0131n d\u00f6rtte birinden fazlas\u0131n\u0131 olu\u015fturmaktad\u0131r. \u00dclkemizdeki ger\u00e7ekle\u015ftirilen y\u0131ll\u0131k HIV test say\u0131s\u0131 7-8 milyon d\u00fczeyine ula\u015fm\u0131\u015ft\u0131r; bu rakamlar fazla y\u00fcksek gibi g\u00f6r\u00fcnmekle birlikte ger\u00e7ekle\u015ftirilen testler HIV infeksiyonu a\u00e7\u0131s\u0131ndan riski daha y\u00fcksek hassas (kilit) gruplar i\u00e7in bir test stratejisinin sonucu de\u011fil genel toplumun taranmas\u0131 kaynakl\u0131d\u0131r.<span class=\"Apple-converted-space\">\u00a0<\/span><\/p>\n<p class=\"p3\">UNAIDS, 2014 y\u0131l\u0131nda HIV infeksiyonunu kontrol alt\u0131na almak ve ihmal edilebilir d\u00fczeye indirmek amac\u0131yla 2020 y\u0131l\u0131 i\u00e7in 90-90-90 hedeflerini belirlemi\u015ftir. Orta Avrupa \u00fclkeleri aras\u0131nda 2018 y\u0131l\u0131nda dahi bu hedefe ula\u015fan hi\u00e7bir \u00fclke olmamas\u0131na kar\u015f\u0131n, <span class=\"s1\">kohortumuzda<\/span> ART ba\u015flama oranlar\u0131, 90-90-90 hedeflerinde \u00f6ng\u00f6r\u00fclenin \u00e7ok \u00fczerinde olup Bat\u0131 Avrupa \u00fclkelerindeki oranlara e\u015fde\u011ferdir (17). \u00dclkemizde yap\u0131lm\u0131\u015f di\u011fer \u00e7al\u0131\u015fmalarda da bu d\u00fczeyde olmasa da bir\u00e7ok Avrupa \u00fclkesinden bildirilenlerden daha y\u00fcksek oranlar elde edilmi\u015ftir (4,12,18,19,20). Bunun temel nedenlerinden biri, 2012 y\u0131l\u0131nda Amerika Birle\u015fik Devletleri HIV ile Ya\u015fayan Eri\u015fkin ve Ergenlerde Antiretroviral \u0130la\u00e7lar\u0131n Kullan\u0131m\u0131 K\u0131lavuzu\u2019na, \u201c<i>CD4<sup>+<\/sup> T lenfosit say\u0131s\u0131na bak\u0131lmaks\u0131z\u0131n herkese ART ba\u015flanmas\u0131\u201d<\/i> \u00f6nerisinin BIII kan\u0131t d\u00fczeyi ile d\u00e2hil edilmesinin ard\u0131ndan (21), 2013 y\u0131l\u0131nda yay\u0131mlanm\u0131\u015f olan T.C. Sa\u011fl\u0131k Bakanl\u0131\u011f\u0131 HIV\/AIDS Tan\u0131 Tedavi Rehberi\u2019nde (22) de yer almas\u0131 ve ayn\u0131 tarihte Avrupa\u2019da kabul g\u00f6rmese de T\u00fcrk hekimleri taraf\u0131ndan uygulanmaya ba\u015flanm\u0131\u015f olmas\u0131d\u0131r. Bunun yan\u0131 s\u0131ra, genel sa\u011fl\u0131k sigortas\u0131 sistemine ge\u00e7ildikten sonra ART\u2019ye eri\u015fimin \u00f6n\u00fcnde ciddi bir engel ve k\u0131s\u0131tlama kalmamas\u0131 ve HIV ile ya\u015fayan bireylerin izleminin \u00f6zenle ve yak\u0131n ilgi ile yap\u0131lmas\u0131 da bu sonuca katk\u0131da bulunmu\u015f olabilir.<span class=\"Apple-converted-space\">\u00a0<\/span><\/p>\n<p class=\"p3\"><span class=\"s3\">Benzer \u015fekilde, <\/span><span class=\"s4\">kohortumuzda<\/span><span class=\"s3\"> \u00fc\u00e7\u00fcnc\u00fc 90\u2019\u0131 ifade eden virolojik ba\u015far\u0131 elde etme basama\u011f\u0131nda da seviyenin hayli y\u00fcksek oldu\u011fu tespit edildi. T\u00fcm grup dikkate al\u0131nd\u0131\u011f\u0131nda, ilk 6 ayda ve toplam izlem s\u00fcresinde virolojik bask\u0131lanma oranlar\u0131 hedefin alt\u0131nda g\u00f6r\u00fcnse de iki zaman dilimi kar\u015f\u0131la\u015ft\u0131r\u0131ld\u0131\u011f\u0131nda, birinci zaman diliminde %25 ve %66.7 oranlar\u0131yla \u00e7ok daha d\u00fc\u015f\u00fck olmas\u0131na kar\u015f\u0131n, ikinci zaman diliminde ayn\u0131 oranlar\u0131n %73.3 ve %93.3\u2019e y\u00fckseldi\u011fi g\u00f6zlendi. Bu ko\u015fullarda, ikinci zaman diliminde, UNAIDS\u2019in virolojik bask\u0131lanma i\u00e7in hedefledi\u011fi %90 hedefinin \u00fczerine \u00e7\u0131k\u0131ld\u0131\u011f\u0131 s\u00f6ylenebilir. Bu \u00f6nemli farkl\u0131l\u0131\u011f\u0131n olas\u0131 nedenleri olarak; yeni antiretroviral ila\u00e7lar\u0131n kullan\u0131m\u0131n\u0131n daha kolay olmas\u0131, yan etki profillerinin daha tolere edilebilir olmas\u0131 nedeniyle hasta uyumunun ge\u00e7mi\u015fe g\u00f6re daha y\u00fcksek olmas\u0131 ve \u00fclkemizde 2012 y\u0131l\u0131nda ilk kez ruhsatland\u0131r\u0131lm\u0131\u015f olan entegraz inhibit\u00f6r\u00fc grubuna ait ila\u00e7lar\u0131n HIV RNA d\u00fczeyini di\u011fer ila\u00e7 gruplar\u0131na g\u00f6re daha h\u0131zla bask\u0131lamalar\u0131 \u015feklinde s\u0131ralanabilir (23-26).<\/span><\/p>\n<p class=\"p3\">\u00c7al\u0131\u015fmadaki virolojik ba\u015far\u0131s\u0131zl\u0131k oranlar\u0131n\u0131n son derece d\u00fc\u015f\u00fck olmas\u0131 sevindiricidir. Di\u011fer bir\u00e7ok \u00e7al\u0131\u015fmada belirtildi\u011fi ve beklendi\u011fi \u00fczere, her iki zaman diliminde de virolojik ba\u015far\u0131s\u0131zl\u0131\u011f\u0131n, tedaviyi uyumsuz kullananlarda ve\/veya antiretroviral ila\u00e7lara direnci bulunanlarda geli\u015fti\u011fi g\u00f6r\u00fclmektedir (19,27,28). Ancak bu olgularda tedavi de\u011fi\u015fikli\u011fi yap\u0131larak virolojik ba\u015far\u0131 sa\u011flan\u0131p sa\u011flanmad\u0131\u011f\u0131 konusunda veri toplanmad\u0131.<span class=\"Apple-converted-space\">\u00a0<\/span><\/p>\n<p class=\"p3\">Olgular\u0131n \u00f6nemli bir b\u00f6l\u00fcm\u00fcnde yan etki geli\u015fti\u011fi g\u00f6zlendi. \u00d6zellikle hiperlipideminin en s\u0131k g\u00f6r\u00fclen yan etki olmas\u0131 ve \u00e7al\u0131\u015fman\u0131n ilk 16 y\u0131l\u0131nda g\u00f6zlenen yan etki oranlar\u0131 g\u00fcn\u00fcm\u00fczde kullan\u0131lan ila\u00e7lar yerine daha fazla olan proteaz ve nonn\u00fckleozid revers transkriptaz inhibit\u00f6rlerinin kullan\u0131lm\u0131\u015f olmas\u0131na ba\u011flanabilir (29-31). Nitekim \u00e7al\u0131\u015fman\u0131n iki zaman dilimi kar\u015f\u0131la\u015ft\u0131r\u0131ld\u0131\u011f\u0131nda, hiperlipidemi oranlar\u0131n\u0131n ikinci dilimde azald\u0131\u011f\u0131 g\u00f6r\u00fclmektedir.<span class=\"Apple-converted-space\">\u00a0<\/span><\/p>\n<p class=\"p3\">\u00c7al\u0131\u015fmam\u0131zda, %7.4 olan tedaviye ara verme oran\u0131, T\u00fcrkiye\u2019de yak\u0131n tarihte yap\u0131lm\u0131\u015f geni\u015f \u00e7apl\u0131 bir kohort (HIV-TR kohortu) \u00e7al\u0131\u015fmas\u0131nda bildirilen %11.6 oran\u0131na yak\u0131n bulundu (18). Ancak iki \u00e7al\u0131\u015fma aras\u0131nda tedavinin kesilme nedenleri a\u00e7\u0131s\u0131ndan \u00f6nemli farkl\u0131l\u0131klar bulunmaktad\u0131r. <span class=\"s1\">\u00c7al\u0131\u015fmam\u0131z\u0131n kohortunda,<\/span> olgular\u0131n %78.1\u2019inde ila\u00e7, tedaviye uyumsuzluk nedeniyle kesilirken, yan etki nedeniyle tedavinin kesilme oran\u0131 %9.4\u2019t\u00fcr. Buna kar\u015f\u0131l\u0131k HIV-TR kohortunda olgular\u0131n %45\u2019inde toksisite\/intolerans nedeniyle tedaviye ara verilmi\u015ftir (18). Bu fark\u0131n en olas\u0131 nedeni; tedaviye ara verme gerek\u00e7esi olarak hasta dosyas\u0131nda uyumsuzluk bildirilmekle birlikte, s\u00f6z konusu uyumsuzlu\u011fun muhtemel nedeni ila\u00e7 yan etkisi\/intolerans\u0131 olmas\u0131d\u0131r. Ayr\u0131ca, HIV-TR kohortu, tedavi se\u00e7eneklerinin bol oldu\u011fu 2011-2017 y\u0131llar\u0131n\u0131 kapsarken, <span class=\"s1\">\u00e7al\u0131\u015fmam\u0131zda <\/span>ila\u00e7 se\u00e7eneklerinin son derece s\u0131n\u0131rl\u0131 oldu\u011fu bir zaman diliminde izlenen hastalar da kohorta d\u00e2hil edildi. Se\u00e7eneklerin s\u0131n\u0131rl\u0131 oldu\u011fu durumlarda ciddi bir yan etki olmad\u0131\u011f\u0131 takdirde ila\u00e7 de\u011fi\u015fikli\u011fi yerine yan etkinin semptomatik yakla\u015f\u0131m ile giderilmesi yolu se\u00e7ilmi\u015f olabilir.<span class=\"Apple-converted-space\">\u00a0<\/span><\/p>\n<p class=\"p3\">AIDS tan\u0131mlayan hastal\u0131\u011f\u0131 olan ve\/veya CD4<sup>+<\/sup> T lenfosit say\u0131s\u0131 &lt;200 h\u00fccre\/mm<sup>3<\/sup> olan bireylerde klinik tablonun a\u011f\u0131r seyirli ve \u00f6l\u00fcmle sonu\u00e7lanma ihtimalinin y\u00fcksek oldu\u011fu, \u00f6te yandan HIV RNA d\u00fczeyinin h\u0131zla bask\u0131lanmas\u0131n\u0131n, ba\u011f\u0131\u015f\u0131kl\u0131\u011f\u0131n yeniden yap\u0131lanmas\u0131n\u0131 sa\u011flayaca\u011f\u0131ndan, morbidite ve mortaliteyi azaltaca\u011f\u0131 g\u00f6sterilmi\u015ftir (32). S\u00f6z konusu \u00e7al\u0131\u015fmalarda elde edilen sonu\u00e7lar uyar\u0131nca, 2015 y\u0131l\u0131ndan bu yana CD4<sup>+ <\/sup>T lenfosit say\u0131s\u0131ndan ve HIV RNA d\u00fczeyinden ba\u011f\u0131ms\u0131z olarak yeni tan\u0131 alan her olguya en k\u0131sa zamanda ART ba\u015flanmas\u0131 \u00f6nerilmektedir (21,33,34). Nitekim \u00e7al\u0131\u015fmam\u0131zda da ba\u015flang\u0131\u00e7taki CD4<sup>+<\/sup> d\u00fczeyi &gt;200 h\u00fccre\/mm<sup>3<\/sup> olan, AIDS tan\u0131mlay\u0131c\u0131 hastal\u0131\u011f\u0131 bulunmayan ve virolojik ba\u015far\u0131 sa\u011flanm\u0131\u015f bireylerde sa\u011fkal\u0131m s\u00fcresi, di\u011ferlerine g\u00f6rece anlaml\u0131 \u00f6l\u00e7\u00fcde daha y\u00fcksek bulundu ve \u00f6l\u00fcm say\u0131lar\u0131 da daha az tespit edildi. Bu bulgu, \u00e7al\u0131\u015fman\u0131n ilk zaman dilimi ile k\u0131yasland\u0131\u011f\u0131nda ikinci zaman diliminde ileri evre hastal\u0131kla ba\u015fvuran hasta say\u0131s\u0131n\u0131n az olmas\u0131na, 2012 y\u0131l\u0131ndan itibaren t\u00fcm olgulara CD4<sup>+<\/sup> T lenfosit say\u0131s\u0131ndan ve HIV RNA d\u00fczeyinden ba\u011f\u0131ms\u0131z olarak ART ba\u015flanmas\u0131na, dolay\u0131s\u0131yla virolojik bask\u0131lanman\u0131n daha y\u00fcksek oranda elde edilmesine ve CD4<sup>+<\/sup> T lenfosit say\u0131s\u0131n\u0131n daha h\u0131zl\u0131 y\u00fckselmesine ba\u011flanabilir.<span class=\"Apple-converted-space\">\u00a0<\/span><\/p>\n<p class=\"p3\">Sonu\u00e7 olarak; t\u00fcm d\u00fcnyadaki geli\u015fmelerle paralel olarak, <span class=\"s1\">Ege \u00dcniversitesi<\/span> HIV kohortunda da HIV infeksiyonunun tedavi ve izleminde zaman i\u00e7inde olumlu geli\u015fmeler ya\u015fanm\u0131\u015ft\u0131r. Kohortta, \u00f6zellikle de ikinci on y\u0131ll\u0131k zaman diliminde UNAIDS hedeflerinin ikinci ve \u00fc\u00e7\u00fcnc\u00fc basamaklar\u0131ndaki hedefler \u00fczerine \u00e7\u0131k\u0131lm\u0131\u015f olmas\u0131 sevindiricidir. Bu sonucun elde edilmesinde, antiretroviral tedavide elde edilen geli\u015fme ve yenilikler \u00f6nemli rol oynarken, uzun y\u0131llard\u0131r HIV izlemi yapan <span class=\"s1\">Ege \u00dcniversitesi T\u0131p Fak\u00fcltesi<\/span> sa\u011fl\u0131k hizmeti ekibinin t\u00fcm elemanlar\u0131n\u0131n katk\u0131s\u0131 da yads\u0131namaz.<span class=\"Apple-converted-space\">\u00a0<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"<p>G\u0130R\u0130\u015e Birle\u015fmi\u015f Milletler HIV\/AIDS Program\u0131 (Joint United Nations Programme on HIV\/AIDS \u2013 UNAIDS) 2014 y\u0131l\u0131nda, insan ba\u011f\u0131\u015f\u0131kl\u0131k yetmezlik virusu (human immunodeficiency virus \u2013HIV) infeksiyonunu kontrol alt\u0131na almak ve ihmal edilebilir d\u00fczeye indirmek amac\u0131yla 2020 y\u0131l\u0131 i\u00e7in 90-90-90 hedeflerini belirlemi\u015ftir. Bu hedefler uyar\u0131nca HIV ile ya\u015fayan bireylerin %90\u2019\u0131na tan\u0131 koyulmas\u0131, tan\u0131 alanlar\u0131n %90\u2019\u0131na ART ba\u015flanmas\u0131 ve [&hellip;]<\/p>\n","protected":false},"author":4,"featured_media":26856,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"footnotes":""},"categories":[5129],"tags":[5109,5163,5657,5658],"class_list":["post-26413","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-ozgun-arastirma","tag-antiretroviral-tedavi","tag-hiv-2","tag-izlem","tag-sagkalim"],"acf":[],"_links":{"self":[{"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/posts\/26413","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/users\/4"}],"replies":[{"embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/comments?post=26413"}],"version-history":[{"count":4,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/posts\/26413\/revisions"}],"predecessor-version":[{"id":26459,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/posts\/26413\/revisions\/26459"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/media\/26856"}],"wp:attachment":[{"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/media?parent=26413"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/categories?post=26413"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.klimikdergisi.org\/tr\/wp-json\/wp\/v2\/tags?post=26413"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}