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HIV Clinical Staging

HAIVNHarvard Medical School AIDS

Initiative in Vietnam

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Learning Objectives

By the end of this session, participants should be able to:

Determine the clinical stage of an HIV patient

Explain when to evaluate the clinical stage of the patient

Explain how to apply clinical staging before and after ARV treatment

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WHO Clinical Staging System

WHO Clinical Stage can be used to: Estimate degree of damage done to a

patient’s immune system Follow progression of HIV disease Determine when to start:• prophylactic treatment with cotrimoxazole • antiretroviral therapy (ART)

Follow patient’s response to ART

WHO Clinical Stage should be evaluated at every clinic visit

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Application of Clinical Staging in Relation to ARV Treatment

Before ARV: Identify highest

clinical stage patient has reached

Reason: Determine eligibility for ARV treatment

After Starting ARV: Re-evaluate

current clinical status of patient

Reason: Assess the improvement of clinical status and the response to ARV treatment

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WHO Clinical Stages

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Stage 1: Asymptomatic

Most typical/common syndromes: Asymptomatic Persistent generalized

lymphadenophathy

Performance Scale: Normal activity

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Stage 2: Mildly Symptomatic

Most typical/common syndromes: Moderate unexplained weight loss (<

10% of body weight) Recurrent respiratory infections Zona (Herpes zoster) Papular pruritic eruption (PPE)

Performance Scale: symptomatic but normal activity

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Stage 3: Progressively Symptomatic

Most typical/common syndromes: Unexplained:• severe weight loss (> 10% of body weight)• chronic diarrhea for > 1 month• persistent fever for > 1 month

Recurrent oral candidiasis Pulmonary tuberculosis Severe bacterial infections Unexplained anemia, neutropenia, or

thrombocytopenia

Performance Scale: symptomatic, in bed < 50% of the time

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Stage 4: Severely Symptomatic

Most typical/common syndromes: Extrapulmonary tuberculosis Pneumocystis jiroveci Pneumonia (PCP) Esophageal candidiasis CNS Toxoplasmosis Cryptococcal meningitis Penicilliosis CMV retinitis

Performance Scale: bedridden > 50% of the time

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What is her Clinical Stage?

Nguyet was treated for lymph node TB from January to September 2009. Currently she has no fever or other symptoms of an OI. She lost 12 kg before TB treatment and gained 6 kg after treatment. She is not yet on ARV.

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What is her Clinical Stage?

6 months after starting ARV Nguyet has gained another 3 kg. She feels well but now has herpes zoster (zona) on her left side.

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Immunological Staging

Severity CD4 mm3

Normal or unremarkable deficiency

> 500

Mild deficiency 350 - 499

Progressive deficiency 200 - 349

Severe deficiency < 200

Immune status is evaluated by CD4 cell count

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Criteria for Diagnosis of Advanced HIV Infection (Including AIDS)

Advanced HIV Infection:

Having any clinical stage 3 or 4 condition (presumptive or definitive diagnosis)

and/or CD4 cell count <

350 cells/mm3

AIDS: Having any clinical

stage 4 condition (presumptive or definitive diagnosis)

or CD4 cell count <

200 cells/mm3

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Key Points

WHO clinical staging classifies patient into 4 categories based on clinical symptoms

Perform clinical staging at each visit to:• determine eligibility for ART• assess patient’s response to ART

CD4 count, clinical staging are used to:• evaluate status of patient’s immune

system• decide when to start OI prophylaxis and

ART

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Thank you!

Questions?