1. 1 HIV Clinical Staging HAIVN Harvard Medical School AIDS Initiative in Vietnam

2. 2 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

3. 3 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

4. 4 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

5. 5 WHO Clinical Stages

6. 6 Stage 1: Asymptomatic Most typical/common syndromes: Asymptomatic Persistent generalized lymphadenophathy Performance Scale: Normal activity

7. 7 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

8. 8 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

9. 9 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

10. 10 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.

11. 11 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.

12. 12 Immunological Staging SeverityCD4 mm 3 Normal or unremarkable deficiency > 500 Mild deficiency 350 - 499 Progressive deficiency 200 - 349 Severe deficiency < 200 Immune status is evaluated by CD4 cell count 12

13. 13 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

14. 14 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

15. 15 Thank you! Questions?