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Staging of HIV disease
Dr. Ira Shah
M.D, DNB, DCH(Gold Medalist), FCPS

There are 2 staging systems developed to determine the extent of HIV disease clinically. They are :
  1. CDC classification of HIV disease in children
  2. WHO staging system

CDC classification of HIV disease in children


Category N: Not symptomatic

Children who have no signs or symptoms considered to be the result of HIV infection or who have only one of the conditions listed in Category A.

Category A: Mildly symptomatic

Children with two or more of the conditions listed below but none of the conditions listed in Categories B and C.
  • Lymphadenopathy (>=0.5 cm at more than two sites; bilateral = one site)
  • Hepatomegaly
  • Splenomegaly
  • Dermatitis
  • Parotitis
  • Recurrent or persistent upper respiratory infection, sinusitis, or otitis media
Category B: Moderately symptomatic

Children who have symptomatic conditions other than those listed for Category A or C that are attributed to HIV infection. Examples of conditions in clinical Category B include but are not limited to:
  • Anemia (<8 g/dL), neutropenia (<1,000/mm³), or thrombocytopenia (<100,000/mm³) persisting for at least 30 days
  • Bacterial meningitis, pneumonia, or sepsis (single episode)
  • Candidiasis, oropharyngeal (thrush), persisting for more than 2 months in children over 6 months of age
  • Cardiomyopathy
  • Cytomegalovirus infection, with onset before 1 month of age
  • Diarrhea, recurrent or chronic
  • Hepatitis
  • Herpes simplex virus (HSV) stomatitis, recurrent (more than two episodes within 1 year)
  • HSV bronchitis, pneumonitis, or esophagitis with onset before 1 month of age
  • Herpes zoster (shingles) involving at least two distinct episodes or more than one dermatome
  • Leiomyosarcoma
  • Lymphoid interstitial pneumonia (LIP) or pulmonary lymphoid hyperplasia complex
  • Nephropathy
  • Nocardiosis
  • Persistent fever (lasting more than 1 month)
  • Toxoplasmosis, onset before 1 month of age
  • Varicella, disseminated (complicated chickenpox)
Category C: Severely symptomatic
  • Serious bacterial infections, multiple or recurrent (i.e., any combination of at least two culture-confirmed infections within a 2-year period), of the following types: septicemia, pneumonia, meningitis, bone or joint infection, or abscess of an internal organ or body cavity (excluding otitis media, superficial skin or mucosal abscesses, and indwelling catheter-related infections)
  • Candidiasis, esophageal or pulmonary (bronchi, trachea, lungs)
  • Coccidioidomycosis, disseminated (at site other than or in addition to lungs or cervical or hilar lymph nodes)
  • Cryptococcosis, extrapulmonary
  • Cryptosporidiosis or isosporiasis with diarrhea persisting more than 1 month
  • Cytomegalovirus disease with onset of symptoms at age over 1 month (at a site other than liver, spleen, or lymph nodes)
  • Encephalopathy (at least one of the following progressive findings present for at least 2 months in the absence of a concurrent illness other than HIV infection that could explain the findings): a) failure to attain or loss of developmental milestones or loss of intellectual ability, verified by standard developmental scale or neuropsychological tests; b) impaired brain growth or acquired microcephaly demonstrated by head circumference measurements or brain atrophy demonstrated by computerized tomography or magnetic resonance imaging (serial imaging is required for children under 2 years of age); c) acquired symmetric motor deficit manifested by two or more of the following: paresis, pathologic reflexes, ataxia, or gait disturbance
  • Herpes simplex virus infection causing a mucocutaneous ulcer that persists for more than 1 month; or bronchitis, pneumonitis, or esophagitis for any duration affecting a child over 1 month of age
  • Histoplasmosis, disseminated (at a site other than or in addition to lungs or cervical or hilar lymph nodes)
  • Kaposi's sarcoma
  • Lymphoma, primary, in brain
  • Lymphoma, small, noncleaved cell (Burkitt's), or immunoblastic or large cell lymphoma of B-cell or unknown immunologic phenotype
  • Mycobacterium tuberculosis, disseminated or extrapulmonary
  • Mycobacterium, other species or unidentified species, disseminated (at a site other than or in addition to lungs, skin, or cervical or hilar lymph nodes)
  • Mycobacterium avium complex or Mycobacterium kansasii, disseminated (at site other than or in addition to lungs, skin, or cervical or hilar lymph nodes)
  • Pneumocystis carinii pneumonia
  • Progressive multifocal leukoencephalopathy
  • Salmonella (nontyphoid) septicemia, recurrent
  • Toxoplasmosis of the brain with onset at greater than 1 month of age
  • Wasting syndrome in the absence of a concurrent illness other than HIV infection that could explain the following findings: a) persistent weight loss more than 10% of baseline OR b) downward crossing of at least two of the following percantile lines on the weight-for-age chart (e.g., 95th, 75th, 50th, 25th, 5th) in a child at least 1 year of age OR c) less than the 5th percentile on weight-for-height chart on two consecutive measurements at least 30 days apart PLUS a) chronic diarrhea (i.e., at least two loose stools per day for more than 30 days) OR b)documented fever (for at least 30 days, intermittent or constant)

WHO CLINICAL STAGING OF HIV/AIDS FOR INFANTS AND CHILDREN


Primary HIV infection
Asymptomatic
Acute retroviral syndrome
Clinical Stage 1
Asymptomatic
Persistent generalized lymphadenopathy
Clinical Stage 2
Unexplained persistent hepatosplenomegaly
Papular pruritic eruptions
Extensive wart virus infection
Extensive molluscum contagiosum
Recurrent oral ulcerations
Unexplained persistent parotid enlargement
Lineal gingival erythema
Herpes zoster
Recurrent or chronic respiratory tract infections (otitis media, otorrhoea, sinusitis, tonsillitis )
Fungal nail infections
Clinical Stage 3
Moderate unexplained malnutrition not adequately responding to standard therapy
Unexplained persistent diarrhea (14 days or more )
Unexplained persistent fever (above 37.5 intermittent or constant, for longer than one month)
Persistent oral candida (outside first 6- 8 weeks of life)Oral hairy leukoplakia
Acute necrotizing ulcerative gingivitis/periodontitis
TB lymphadenitis
Pulmonary tuberculosis
Severe recurrent presumed bacterial pneumonia
Symptomatic lymphoid interstitial pneumonitis
Chronic HIV-associated lung disease including bronchiectasis
Unexplained anemia (<8g/dl ), neutropenia (<500/mm3) or chronic thrombocytopenia (<50 000/ mm3)
HIV-associated cardiomyopathy or HIV-associated nephropathy
Clinical Stage 4
Unexplained severe wasting, stunting or severe malnutrition not responding to standard therapy
Pneumocystis pneumonia
Recurrent severe presumed bacterial infections (e.g. empyema, pyomyositis, bone or joint infection,     meningitis, but excluding pneumonia)
Chronic herpes simplex infection; (orolabial or cutaneous of more than one month's duration or     visceral at any site)
Extrapulmonary tuberculosis
Kaposi sarcoma
Oesophageal candidiasis (or candida of trachea, bronchi or lungs)
Central nervous system toxoplasmosis (outside the neonatal period)
HIV encephalopathy
Cytomegalovirus (CMV) infection; retinitis or CMV infection affecting another organ, with onset at age over 1 month .
Extrapulmonary cryptococcosis including meningitis
Disseminated endemic mycosis (extrapulmonary histoplasmosis, coccidiomycosis, penicilliosis)
Chronic Cryptosporidiosis
Chronic Isosporiasis
Disseminated non-tuberculous mycobacteria infection
    Acquired HIV-associated rectal fistula
Cerebral or B cell non-Hodgkin lymphoma
    Progressive multifocal leukoencephalopathy

Reference:


  1. 1994 Revised Classification System for Human Immunodeficiency Virus Infection in Children Less Than 13 Years of Age. CDC MMWR. 1994 / 43(RR-12);1-10
  2. WHO Clinical Staging of HIV/AIDS and HIV/AIDS Case Definitions for Surveillance. Published by WHO, 2006.
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