
HIV/AIDS: Neredeyiz?
İlk olarak 1981 yılında tanımlanan Edinsel İmmün Yetmezlik Sendromu(AIDS), bir pandemi haline gelmiş ve halen pandemi olarak devam etmektedir. 1984 yılında ise bu hastalık tablosuna neden olan etkenin bir virus olduğu gösterilmiş ve bu virusa insan immün yetmezlik virusu (HIV) adı verilmiştir.
HIV infeksiyonu en sık olarak cinsel temas (erkek-kadın, erkek-erkek) ve damar içi uyuşturucu kullananlarda aynı enjektörün paylaşılması ile bulaşmaktadır. Bunun yanı sıra kan transfüzyonu, organ transplantasyonu, HIV ile yaşayan anneden bebeğe ve sağlık çalışanlarında mesleki maruziyet sonrası bulaşma olabilir.
HIV infeksiyonu ile AIDS aynı değildir. HIV’in vücuda girdikten sonra genellikle viral bir üst solunum yolu infeksiyonu gibi seyreden akut dönemini, kronik infeksiyon (asemptomatik dönem) dönemi izler. Bu dönemde de HIV infeksiyonundan şüphelenebileceğimiz ağızda tekrarlayan mantar infeksiyonları, gece yanığı (zona) gibi hastalıklar oluşabilir. HIV vücuda girdikten sonra bağışıklık sisteminin hücrelerini (CD4+ T-lenfositleri) zaman içinde doğrudan ve dolaylı olarak hasara uğratır, azaltır ve bağışıklık sistemini zayıflatır. Bu bağışıklık sistemi hücrelerinin sayısının 200/mm3’ün altına düşmesi ile AIDS dönemi başlar. HIV infeksiyonu eğer zamanında tanınarak tedavi edilmezse, yaklaşık 8-10 yıllık süre içerisinde bu döneme ulaşılır. Bağışıklık sisteminin iyice zayıfladığı bu dönemde, bağışıklık sisteminin normal olduğu kişilerde hastalık yapmayan ya da sık görülmeyen mikroorganizmaların yaptığı infeksiyonlar (fırsatçı infeksiyonlar) ve kaposi sarkomu, lenfoma gibi kanserler gelişir.
2021 sonu itibariyle Dünya’da 38.4 milyon HIV infeksiyonu ile yaşayan kişi olduğu tahmin edilmektedir. Günümüze kadar yaklaşık 40 milyon kişi AIDS ya da AIDS ile ilişkili fırsatçı infeksiyon ya da kanserlerden kaybedilmiştir. 2021 yılında 1.5 milyon yeni HIV infeksiyonu saptanmış olup, AIDS ve AIDS ile ilişkili komplikasyonlar nedeniyle 650.000 kişi yaşamını yitirmiştir.
Ülkemizde ise 2021 yılı sonu itibariyle T.C. Sağlık Bakanlığı resmi kayıtlarında 32376(26000’i erkek) kişi HIV ile yaşıyor olarak raporlanmıştır. Hastalığını bilmeyen kişilerin olma olasılığının yüksek olması nedeniyle ülkemizde HIV ile yaşayanların sayısının 65000-70000 arasında olduğu tahmin edilmektedir ve Dünya Sağlık Örgütü’nün tahmini de bu yöndedir.
Ülkemizdeki en önemli bulaş yolu cinsel yol iledir. Resmi kayıtlarda bulaş yollarının sadece yarısı tam olarak raporlanabilmiştir. Bulaş açısından durumu bilinen kişilerin %97.1’inde bulaş yolu cinsel yol iledir. Cinsel yol ile bulaşın da yaklaşık %67’sini heteroseksüel (kadın-erkek) ilişki, %33’ünü ise erkek-erkek ilişkisi ve biseksüel ilişki oluşturmaktadır. Ülkemizde HIV ile yaşayanların en yoğun oldukları yaş aralığı 20-45 arasıdır. Bununla birlikte 15-19 yaş aralığında (adölesanlar) son yıllarda dikkati çeken bir artış mevcuttur.
Ülkemizde 2000 yılının başından 2018 yılına kadar %400’lere ulaşan bir artış mevcuttur. Bu artışta rol oynayan önemli faktörler olarak HIV prevalansı yüksek olan bazı komşu ülkelerle yakın turistik ilişkilerimiz, toplumda HIV infeksiyonu hakkında farkındalığın yeterince gelişmemiş olması, HIV infeksiyonu açısından riski daha yüksek olan hassas(kilit) gruplara yeterince ulaşılamaması, damgalama, ayrımcılık ve orta öğretimde cinsel yol ile bulaşan infeksiyonlardan korunma eğitiminin yeterli olmaması gibi nedenler sayılabilir.
Son yıllarda resmi kayıtlara girenlerin azalması, COVID-19 pandemisinin getirdiği karantina ve kapanma ya da konu ile ilgili bakım veren kliniklerin tamamen COVID-19 hastalarına yönelmesi gibi kısıtlamalarla test yaptırma olanaklarının pandemiden olumsuz etkilenmesine bağlanmaktadır. 2023 yılında bu artış ivmesinin normale dönmesi beklenmektedir.
HIV infeksiyonu tedavisinde ilk antiretroviral (ART) ilaç olan zidovudin 1987 yılında kullanıma girmiş, bunu üç ilaçlı kombinasyonlar takip etmiştir. 1996 yılından itibaren etkili kombinasyonların tedaviye girmesi ile yeni infeksiyon sayılarında ve AIDS’e bağlı ölüm oranlarında belirgin azalma meydana gelmiştir. Tedavisini düzenli kullananlarda yaşam süresi beklentisi HIV ile yaşamayanlara göre neredeyse aynı seviyeye gelmiştir. Bu tedaviler HIV’i vücuttan tamamen eradike etmemektedir ve tedavinin ömür boyu düzenli olarak alınması gerekmektedir. Yapılan çalışmalarda tedavisini düzenli olarak alan ve HIV’in kandaki seviyesi en az 6 ay ölçülemeyecek düzeyde seyredenlerin (belirlenemeyenlerin) bulaştırıcı olmadığı gösterilmiş ve bu sonuçlar belirlenemeyen (B)=bulaştırmayan (B) yaklaşımını getirmiştir (B=B).
Birleşmiş Millletler AIDS Örgütü (UNAIDS) 2014 yılında HIV ile yaşayanların , 2020 yılında %90’ının tanı alması, tanı alanların %90’ının tedaviye ulaşması ve tedaviye ulaşanların %90’ında tedaviyle virusun kanda ölçülemeyecek düzeylere gelmesini hedefleyen 90-90-90 hedeflerini koymuştur. 2020 yılı itibariyle bu hedeflere ulaşılamamıştır ve küresel olarak bu hedeflerdeki durum UNAIDS tarafından sırasıyla 81-67-59 olarak bildirilmiştir. Ayrıca daha sonra bu hedeflere HIV ile yaşayanların sağlıklı ve kaliteli bir yaşam sürdürmesi ile ilgili dördüncü 90 hedefi eklenmiştir. Ülkemizde ise bu oranlar 50-86-90 olarak tahmin edilmektedir. Bu hedeflere ulaşmada ülkemizdeki temel sorun HIV ile yaşayanların yaklaşık olarak sadece %50’sinin tanı almış olmasıdır. Tanı alanların tedaviye ulaşmasında ve tedavinin başarılı gitmesinde hedeflere ulaşılmış görünmektedir. Ülkemizdeki diğer bir sorun ise tanı alanların neredeyse yarısının tanı aldıkları anda bağışıklık sisteminde belirgin bir hasar oluşmuş olmasıdır (sağlıklı kişilerde 500-1500/mm3 olan CD4+ T-lenfositlerinin 350/mm3’ün altına düşmesi), yani geç tanı alanlardır.
UNAIDS 2030 hedeflerini 95-95-95 olarak güncellemiştir. Bunun anlamı HIV ile yaşayanların %95’inin tanı alması, tanı alanların %95’inin ART’ye ulaşması ve ART’ye ulaşanların %95’inde tedavinin başarılı olarak devam etmesidir. Bunun önündeki en büyük engellerden biri de HIV ile yaşayanların damgalanması ve ayrımcılıktır. Damgalama ve ayrımcılık hak ihlallerini beraberinde getirmektedir. Tüm toplum olarak damgalama ve ayrımcılık ile savaşmamız gerekmektedir.
HIV infeksiyonundan korunmak için davranış modifikasyonu (kondom kullanımı ve güvenli seks) büyük önem taşımaktadır. Ayrıca damar içi uyuşturucu kullanımından uzak durmak, güvenli kan transfüzyonu, HIV ile yaşayan anneden bebeğe geçişin önlenmesi için gerekli önlemlerin alınması, HIV ile yaşayan annenin bebeğini emzirmemesi ve sağlık çalışanlarının standart önlemlere uyması da korunma önlemleri içindedir.
Stratejik olarak korunmada önemli olan bir diğer nokta ise infeksiyon riski yüksek olan seks işçileri, erkek ile seks yapan erkekler gibi popülasyonlara ulaşarak (kilit ya da hassas popülasyon) hem HIV ile yaşayanların erken tanı alması hem de antiretroviral tedaviye erişebilmelerinin sağlanmasıdır. Yapılan çalışmalarda kilit popülasyonlarda temas öncesi profilaksinin (TEP) yararlı olduğu gösterilmiş ve birçok ülkede korunmadaki ana stratejilerden biri olarak kabul edilmiştir.
Komşu olduğumuz Doğu Avrupa ve Orta Asya bölgesindeki ülkelerde olduğu gibi ülkemizde de HIV infeksiyonlarında ciddi bir artış devam etmektedir. Ülkemizde bu artışın önüne geçebilmek için cinsel yol ile bulaşan infeksiyonlardan korunma konusunda bilincin artırılması ve bunun için ortaöğretimde eğitim programlarının geliştirilmesi ve uygulanması, toplumda farkındalığın artırılmasına yönelik programların basında ve medyada sadece 1 Aralık günlerinde değil sürekli olarak yıl boyunca yer alması, eğitim çalışmalarının sürekli olması, gönüllü danışmanlık ve test merkezlerinin (GDTM) sayılarının artırılarak daha da yaygınlaştırılması büyük önem taşımaktadır. Ülkemizde tanı aldıktan sonra tüm HIV ile yaşayanlar ülkemizin bu konudaki güçlü yanlarından biri olan sosyal güvence ile tedaviye ulaşabilmekte ve tedavi başarısının devamı yüksek oranlarda sağlanabilmektedir.
UNAIDS tarafından ilk olarak 1988 yılında (1 Aralık 1988) ilan edilen “Dünya AIDS Günü”nden bu yana farkındalığın artırılması ve hedeflere ulaşılabilmesi için her yıl bir tema seçilmektedir. 2022 yılının teması ”Eşitsizlikleri sona erdir, AIDS’i sona erdir, Pandemiyi sona erdir” olarak kabul edilmiştir.
Prof. Dr. Halis AKALIN
Türk Klinik Mikrobiyoloji ve İnfeksiyon Hastalıkları Derneği
HIV/AIDS Çalışma Grubu Başkanı
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