HIV in adults

World Health Organization staging[89]World Health Organization. WHO case definitions of HIV for surveillance and revised clinical staging and immunological classification of HIV-related disease in adults and children. Geneva, Switzerland: WHO Press; 2007 [internet publication]. https://apps.who.int/iris/handle/10665/43699

Stage 1

• Acute seroconversion syndrome: there is no current case definition for acute seroconversion illness, although an acute viral syndrome in the early stages of HIV is well recognised. Primary infection usually presents within the first month of exposure to HIV and commonly presents with a fever and lymphadenopathy. Other clinical symptoms and signs might include pharyngitis, maculopapular rash, orogenital ulcers, or meningoencephalitis. Other opportunistic infections may occur, due to the transient lymphopenia. The CD4 count may drop profoundly. Diagnosis is made by observing the appearance of an HIV antibody (serial rapid tests or enzyme-linked immunosorbent assay [ELISA] or by noting the presence of HIV, using HIV-RNA or HIV-DNA and/or ultra-sensitive HIV p24 antigen with an absent HIV antibody).[4]Wilson D, Naidoo S, Bekker LG, et al. Handbook of HIV medicine. South Africa: Oxford University Press; 2002.[20]Morris L, Cilliers T. Viral structure, replication, tropism, pathogenesis and natural history. In: Abdool Karim SS, Abdool Karim Q, eds. HIV/AIDS in South Africa. Cambridge University Press; 2005:79-89.

• Persistent generalised lymphadenopathy (painless enlarged nodes, in two or more non-contiguous sites of >1 cm for >3 months).

• Asymptomatic, that is, no symptoms reported that might be related to HIV/AIDS.

• Performance status 1 (fully active and asymptomatic).

Stage 2

• Weight loss of less than 10% of body weight

• Herpes zoster (shingles)

• Minor mucocutaneous manifestations

• Recurrent upper respiratory tract infections

• Performance status 2 (symptomatic but near fully active).

Stage 3

• Weight loss of more than 10% of body weight

• Chronic diarrhoea for more than 1 month

• Prolonged fever for more than 1 month

• Oral candida, chronic vaginal candidiasis

• Oral hairy leukoplakia

• Severe bacterial infections

• Pulmonary tuberculosis (TB)

• Performance status 3 (in bed less than 50% of past month).

Stage 4

• Extrapulmonary TB

• Pneumocystis jirovecii pneumonia

• Cryptococcal meningitis

• Herpes simplex virus ulcer for more than 1 month

• Oesophageal or pulmonary candidiasis

• Toxoplasmosis

• Cryptosporidiosis

• Isosporiasis

• Cytomegalovirus

• HIV wasting syndrome

• HIV encephalopathy

• Kaposi's sarcoma

• Progressive multi-focal leukoencephalopathy

• Disseminated mycosis

• Atypical mycobacteriosis

• Non-typhoid salmonella bacteraemia

• Lymphoma

• Recurrent pneumonia

• Invasive cervical carcinoma

• Performance status 4 (confined to bed more than 50% of the time).

Advanced HIV​[97]World Health Organization. Guidelines for managing advanced HIV disease and rapid initiation of antiretroviral therapy. Jul 2017 [internet publication]. https://iris.who.int/bitstream/handle/10665/255884/9789241550062-eng.pdf?sequence=1

• CD4 count <200 cells/microlitre, or stage 3 or 4 event at presentation in adults, adolescents, and children ≥5 years of age. All children <5 years of age should be considered as having advanced disease at presentation.

• Seriously ill adult or adolescent: respiratory rate ≥30 breaths per minute, heart rate ≥120 bpm, unable to walk unaided, or body temperature ≥39°C.

• Seriously ill child: lethargy or unconsciousness, convulsions, unable to drink/breastfeed, repeated vomiting, tachycardia or tachypnoea, or body temperature ≥39°C.

• Severely immunosuppressed: CD4 count <50 cells/microlitre.

US Centers for Disease Control and Prevention case severity[88]Centers for Disease Control and Prevention. Revised surveillance case definition for HIV infection: United States, 2014. MMWR Recomm Rep. 2014;63(RR-03):1-10. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6303a1.htm http://www.ncbi.nlm.nih.gov/pubmed/24717910?tool=bestpractice.com

Note that the CD4+ T-lymphocyte count takes precedence over the CD4+ T-lymphocyte percentage in HIV stages 1, 2, and 3. The CD4+ T-lymphocyte percentage should only be considered if the count is missing.

HIV, stage 0

• Indicates early infection, inferred from a negative or indeterminate HIV test result within 180 days of a positive result. The criteria for stage 0 supersede and are independent of criteria used for other stages.

HIV, stage 1 (≥6 years)

• Laboratory confirmation of HIV with no AIDS-defining condition, and

  • CD4+ T-lymphocyte count of ≥500 cells/microlitre, or

  • CD4+ T-lymphocyte percentage of total lymphocytes of ≥26%.

HIV, stage 2 (≥6 years)

• Laboratory confirmation of HIV with no AIDS-defining condition, and

  • CD4+ T-lymphocyte count of 200 to 499 cells/microlitre, or

  • CD4+ T-lymphocyte percentage of total lymphocytes of 14% to 25%.

HIV, stage 3 (AIDS; ≥6 years)

• Laboratory confirmation of HIV, and

  • CD4+ T-lymphocyte count of <200 cells/microlitre, or

  • CD4+ T-lymphocyte percentage of total lymphocytes of <14% or

  • Documentation of an AIDS-defining condition.

  Documentation of an AIDS-defining condition supersedes a CD4+ T-lymphocyte count of >200 cells/microlitre and a CD4+ T-lymphocyte percentage of total lymphocytes of >14%.

HIV, stage unknown

• Laboratory confirmation of HIV, and

  • No information on CD4+ T-lymphocyte count or percentage, and

  • No information on presence of AIDS-defining conditions.

Stage-3-defining opportunistic illnesses in HIV

• Bacterial infections, multiple or recurrent (only among children aged <6 years)

• Candidiasis of bronchi, trachea, or lungs

• Candidiasis of oesophagus

• Cervical cancer, invasive (only among adults, adolescents, and children aged ≥6 years)

• Coccidioidomycosis, disseminated, or extrapulmonary

• Cryptococcosis, extrapulmonary

• Cryptosporidiosis, chronic intestinal (>1 month's duration)

• Cytomegalovirus disease (other than liver, spleen, or nodes), onset at age >1 month

• Cytomegalovirus retinitis (with loss of vision)

• Encephalopathy, HIV-related

• Herpes simplex: chronic ulcers (>1 month's duration) or bronchitis, pneumonitis, or oesophagitis (onset at age >1 month)

• Histoplasmosis, disseminated or extrapulmonary

• Isosporiasis, chronic intestinal (>1 month's duration)

• Kaposi's sarcoma

• Lymphoma, Burkitt's (or equivalent term)

• Lymphoma, immunoblastic (or equivalent term)

• Lymphoma, primary, of brain

• Mycobacterium avium complex or Mycobacterium kansasii, disseminated or extrapulmonary

• Mycobacterium tuberculosis of any site, pulmonary (only among adults, adolescents, and children aged ≥6 years), disseminated, or extrapulmonary

• Mycobacterium, other species or unidentified species, disseminated or extrapulmonary

• Pneumocystis jirovecii pneumonia

• Pneumonia, recurrent (only among adults, adolescents, and children aged ≥6 years)

• Progressive multifocal leukoencephalopathy

• Salmonella septicaemia, recurrent

• Toxoplasmosis of brain, onset at age >1 month

• Wasting syndrome attributed to HIV.