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პაპილომავირუსი და მისი მართვის თანამედროვე მიდგომები

თარიღი: 01 სექტემბერი, 2020

პაპილომავირუსი და მისი მართვის თანამედროვე მიდგომები

მაია ჯანელიძე - ექიმი მეან-გინეკოლოგი, რეპროდუქტოლოგი, მედიცინის მეცნიერებათა დოქტორი.

მადლენა ხვიჩია - მეან გინეკოლოგი.

ადამიანის პაპილომა ვირუსი (HPV) არის ერთ-ერთი ყველაზე გავრცელებული, უპირატესად, სქესობრივი გზით გადამდები ინფექცია. სექსუალურად აქტიური ქალების დაახლოებით 50% სიცოცხლეში ერთხელ მაინც ინფიცირდება ადამიანის პაპილომა ვირუსით, რომელსაც შეუძლია გამოიწვიოს საშვილოსნოს ყელის კიბო. ეს უკანასკნელი კი ერთ-ერთი ყველაზე გავრცელებული ონკოლოგიური დაავადებაა, როგორც მთელ მსოფლიოში, ისე საქართველოში. ძუძუს კიბოს შემდეგ ის მეორე ადგილს იკავებს ჩვენს რეგიონში. ვირუსის ბიოლოგია ფართოდ არის შესწავლილი და მკაფიოდაა გამოკვეთილი მათი კავშირი ავთვისებიან სიმსივნეებთან, განსაკუთრებით კი ანოგენიტალური ტრაქტის (საშვილოსნოს ყელი, საშო, ვულვა, ასო, ანუსი).

ადამიანის პაპილომავირუსით ინფიცირდება მხოლოდ ადამიანი. მისი გარცელების უპირატესი გზა დაუცველი სქესობრივი კავშირია, თუმცა ინფიცირება შეიძლება მოხდეს როგორც კანითკანთან კონტაქტით. ასევე დიგიტალურ/ანალური ან დიგიტალურ/ვაგინალური კონტაქტით. ასევე ვირუსით ინფიცირება შესაძლებელია მშორიარობის დროს, დაინფიცირებული სანაყოფე გზების გავლისას.

დაავადების რისკ-ფაქტორებია:

1. სქესობრივი ცხოვრების ადრეულ ასაკში დაწყება;

2. მრავალი სქესობრივი პარტნიორის ყოლა;

3. ნიკოტინის მოხმარება;

4. მშობიარობათა რაოდენობა (თუ აღემატება 5-ს);

5. გენიტალური ინფექციები, როგორიცაა მარტივი ჰერპესვირუსის ტიპი 2, ქლამიდიოზი, HIV (ადამიანის იმუნოდეფიციტის ვირუსი) ინფექცია.

ამჟამად პაპილომავირუსის 100-ზე მეტი ტიპია იდენტიფიცირებული. მათ შორის 30-მდე არის ტროპული (მგრძნობიარე) გენიტალური ტრაქტის მიმართ. საშვილოსნოს ყელის კიბოს შესაძლო განვითარების გათვალისწინებით, განასხვავებენ HPV ვირუსის მაღალი (ონკოგენური ანუ სიმსივნესთან ასოცირებული) და დაბალი (არაონკოგენური) რისკის ჯგუფებს.

პაპილომავირუსით ინფიცირებულთა 5-30%-ს შესაძლებელია ერთრდოულად ჰქონდეს ამ ვირუსის რამოდენიმე ტიპის კომბინაცია, რაც ცვლის პათოლოგიის მართვის პრინციპებს. ცერვიკალური სიმსივნის (საშვილოსნოს ყელის სიმსივნის) განვითარების მაღალი რისკის (ონკოგენური) გენოტიპებიდან განსაკუთრებით ონკო აგრესიულია 13 ტიპი - 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59 და 68, რომლებიც შესაძლოა იყოს საშვილოსნოს ყელის სხვადასხვა სიმძიმის დაზიანების (დისპლაზიის) და საშვილოსნოს ყელის კიბოს გამომწვევი. საშვილოსნოს ყელის სიმსივნეების გამოკვლევისას, ყველაზე ხშირად ვხვდებით HPV-16 და 18 გენოტიპს. შემთხვევათა 50% კი გამოწვეულია HPV-16 გენოტიპით. თუმცა უნდა აღვნიშნოთ ისიც, რომ ამ გენოტიპებით გამოწვეული ყველა დაზიანება არ განიცდის გადაგვარებას ავთვისებიან სიმსივნედ. რაც შეეხება დაბალი რისკის HPV ვირუსებს (6, 11, 40, 42, 43, 44, 53, 54, 61, 72, 73, და 81 ტიპი) ისინი ძირითადად, გენიტალურ კონდილომებს (მეჭეჭებს ) იწვევენ.

დღეს აქტიურად განიხილება ანუ სიმსივნესა და პაპილომავირუსს შორისკავშირი. დადგინდა, რომ მამაკაცებში ანუსისა და ასოს თავის სიმსივნის ხშირი გამომწვევია HPV-16, რომელიც ყველაზე ონკოაგრესიული გენოტიპია. ჯანდაცვისმსოფლიოორგანიზაციის (WHO) მონაცემებით, არსებობს საშვილოსნოს ყელის კიბოს თავიდან აცილების ორი გზა: პროფილაქტიკა ვაქცინაციის სახით და კიბოს წინარე დაავადებების დროული დიაგნოსტიკა (პაპ-ტესტი, კოლპოსკოპია და HPV გენოტიპირება).

დღეისათვის შემუშავებულია 3 ტიპის ვაქცინა: ბივალენტური ვაქცინა (Cervarix), ქვადრივალენტური (Gardasil) და 9 ვალენტური (Gardasil 9), რომლებიც შესაბამისად იცავს 16,18; 6,11,16,18;6,11,16,18,31,33,45,52,58 ტიპის HPV ვირუსებისგან.

ჯანდაცვის მსოფლიო ორგანიზაციის (WHO), ამერიკის მეან-გინეკოლოგთა კოლეჯის (ACOG) და ამერიკის სიმსივნის ასოციაციის (ACS) რეკომენდაციით, სასურველია ვაქცინაციის ჩატარება გოგონებში 9-დან 13 წლამდე და ბიჭებში 9-დან 16-წლამდე. თუმცა, უნდა აღინიშნოს ისიც, რომ იმუნიზაცია ეფექტურია ნებისმიერ ასაკში სქესობრივი ცხოვრების დაწყებამდე.

საშვილოსნოს ყელის პათოლოგიის დიაგნოსტიკის საწყისი ეტაპია :

1. სწორად აღებული პაპ-ტესტის ჩატარება;

2. კოლპოსკოპიური კვლევა და საჭიროების დროს დამიზნებითი ბიოფსია;

3. HPV- გენოტიპირება. გარკვეულ ქვეყნებში HPV- გენოტიპირება არის ქალთა სკრინინგ პროგრამის ნაწილი. ის გვაძლევს საშუალებას დავადგინოთ პაპილომავირუსის რომელი გენოტიპით არის პაციენტი ინფიცირებული, რის შემდეგაც ინდივიდუალური მიდგომით შეგვიძლია პრობლემის მართვა.

საქართველოში კი საშვილოსნოს ყელის კიბოს სკრინინგი დაფუძნებულია პაპ-ტესტზე. დაგროვილი მასალა მიუთითებს, რომ სკრინინგს შეუძლია შეამციროს ავადობისა და სიკვდილობის მაჩვენებლები (Hakama, 1982; Hakama et al., 1986). საშვილოსნოს ყელის კიბოს მაჩვენებელი ასევე შემცირდა მას შემდეგ, რაც პრაქტიკაში ფართოდ დაინერგა ინტერფერონის ინდუქტორი პრეპარატები. განსაკუთრებით მაღალი ანტივირუსული და იმუნომოდულატორული ეფექტით გამოირჩევა ენდოგენური ინტერფერონისინდუქტორი-ლარიფანი. ეგზოგენური ინტერფერონის ინდუქტორებისგან განსხვავებით მას არ გააჩნია ანტიგენური თვისებები; არ იწვევს აუტოიმუნურ რეაქციებს; არ იწვევს ინტერფერონის ჭარბი რაოდენობით დაგროვებას; აქვს ნაკლები გვერდითი ეფექტი და რაც ყველაზე მთავარია არ საჭიროებს მრავალჯერად გამოყენებას, ვინაიდან ის სისხლში ხანგრძლივად ცირკულირებს.