HIV AIDS classification

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Ammu Susheela, M.D. [2]

Overview

Many definitions have been developed for epidemiological surveillance of HIV/AIDS such as the Bangui definition and the 1994 Expanded World Health Organization AIDS Case Definition. However, clinical staging of patients was not an intended use for these systems as they are neither sensitive, nor specific for that purpose. In developing countries, the World Health Organization staging system for HIV infection and disease that uses clinical and laboratory data is widely employed. The Centers for Disease Control (CDC) Classification System for HIV/AIDS is another primary system used.

Classification

WHO Staging System for HIV Infection and Disease in Adults and Adolescents

Clinical stage	Features
Clinical stage 1	Asymptomatic Generalized lymphadenopathy
Clinical stage 2	Weight loss of less than 10% body weight Minor mucocutaneous manifestations Herpes Zooster within the last five years Recurrent respiratory tract infections (such as sinusitis, bronchitis, otitis media, pharyngitis) Recurrent oral ulcerations Papular pruritic eruptions Angular cheilitis Seborrhoeic dermatitis Fungal finger nail infections
Clinical stage 3	Conditions where a presumptive diagnosis can be made on the basis of clinical signs or simple investigations Unexplained chronic diarrhoea for longer than one month Unexplained persistent fever (intermittent or constant for longer than one month) Severe weight loss (>10% of presumed or measured body weight) Oral candidiasis Oral hairy leukoplakia Pulmonary tuberculosis (TB) diagnosed in last two years Severe presumed bacterial infections (e.g. pneumonia, empyema, meningitis, bacteraemia, pyomyositis, bone or joint infection) Acute necrotizing ulcerative stomatitis, gingivitis or periodontitis Conditions where confirmatory diagnostic testing is necessary Unexplained anaemia (< 80 g/l), and or neutropenia(<500/µl) and or thrombocytopenia (<50 000/ µl) for more than one month
Clinical stage 4	Conditions where a presumptive diagnosis can be made on the basis of clinical signs or simple investigations HIV wasting syndrome Pneumocystis pneumonia Recurrent severe or radiological bacterial pneumonia Chronic herpes simplex infection (orolabial, genital or anorectal of more than one month’s duration) Oesophageal candidiasis Extrapulmonary Tuberculosis Kaposi sarcoma Central nervous system toxoplasmosis HIV encephalopathy Conditions where confirmatory diagnostic testing is necessary Extrapulmonary cryptococcosis including meningitis Disseminated non-tuberculous mycobacteria infection Progressive multifocal leukoencephalopathy Candida of trachea, bronchi or lungs Cryptosporidiosis Isosporiasis Visceral herpes simplex infection Cytomegalovirus (CMV) infection (retinitis or of an organ other than liver, spleen or lymph nodes) Any disseminated mycosis (e.g. histoplasmosis, coccidiomycosis, penicilliosis) Recurrent non-typhoidal salmonella septicaemia Lymphoma (cerebral or B cell non-Hodgkin) Invasive cervical carcinoma Visceral leishmaniasis

WHO Staging System for HIV Infection and Disease in Children

Clinical stage	Features
Clinical stage 1	Asymptomatic Generalized lymphadenopathy
Clinical stage 2	Hepatosplenomegaly Papular pruritic eruptions Seborrhoeic dermatitis Extensive human papilloma virus infection Extensive molluscum contagiosum Fungal nail infections Recurrent oral ulcerations Linear gingival erythema (LGE) Angular cheilitis Parotid enlargement Herpes zoster Recurrent or chronic RTIs (otitis media, otorrhoea, sinusitis) Chronic diarrhoea lasting for more than 30 days in the absence of known etiology Severe persistent or recurrent candidiasis outside the neonatal period Weight loss or failure to thrive in the absence of known etiology Persistent fever lasting for more than 30 days in the absence of known etiology. Recurrent severe bacterial infections other than septicemia or meningitis like osteomyelitis, bacterial pneumonia or abscesses
Clinical stage 3	Conditions where a presumptive diagnosis can be made on the basis of clinical signs or simple investigations Moderate unexplained malnutrition not adequately responding to standard therapy Unexplained persistent diarrhoea (14 days or more ) Unexplained persistent fever (intermittent or constant, for longer than one month) Oral candidiasis (outside neonatal period ) Oral hairy leukoplakia Acute necrotizing ulcerative gingivitis/periodontitis Pulmonary TB Severe recurrent presumed bacterial pneumonia Conditions where confirmatory diagnostic testing is necessary Chronic HIV-associated lung disease including brochiectasis Lymphoid interstitial pneumonitis (LIP) Unexplained anaemia (<80g/l), and or neutropenia (<1000/µl) and or thrombocytopenia (<50 000/µl) for more than one month
Clinical stage 4	Conditions where a presumptive diagnosis can be made on the basis of clinical signs or simple investigations Unexplained severe wasting or severe malnutrition not adequately 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) Extrapulmonary Tuberculosis Kaposi’s sarcoma Oesophageal candidiasis Central nervous system toxoplasmosis (outside the neonatal period) HIV encephalopathy Conditions where confirmatory diagnostic testing is necessary CMV infection (CMV retinitis or infection of organs other than liver, spleen or lymph nodes; onset at age one month or more) Extrapulmonary cryptococcosis including meningitis Any disseminated endemic mycosis (e.g. extrapulmonary histoplasmosis, coccidiomycosis, penicilliosis) Cryptosporidiosis Isosporiasis Disseminated non-tuberculous mycobacteria infection Candida of trachea, bronchi or lungs Visceral herpes simplex infection Acquired HIV associated rectal fistula Cerebral or B cell non-Hodgkin lymphoma Progressive multifocal leukoencephalopathy (PML) HIV-associated cardiomyopathy or HIV-associated nephropathy

CDC Classification System for HIV Infection

• In the beginning, the Centers for Disease Control and Prevention (CDC) did not have an official name for the disease, often referring to it by way of the diseases that were associated with it, for example, lymphadenopathy, the disease after which the discoverers of HIV originally named the virus.
• They also used Kaposi's Sarcoma and Opportunistic Infections, the name by which a task force had been set up in 1981.
• In the general press, the term GRID, which stood for Gay-related immune deficiency, had been coined.
• However, after determining that AIDS was not isolated to the homosexual community, the term GRID became misleading and AIDS was introduced at a meeting in July 1982.
• By September 1982 the CDC started using the name AIDS, and properly defined the illness.
• In 1993, the CDC expanded their definition of AIDS to include all HIV positive people with a CD4⁺ T cell count below 200 per µL of blood or 14% of all lymphocytes.
• The majority of new AIDS cases in developed countries use either this definition or the pre-1993 CDC definition. The AIDS diagnosis still stands even if, after treatment, the CD4⁺ T cell count rises to above 200 per µL of blood or other AIDS-defining illnesses are cured.

CDC Classification System for HIV Infection in Adults and Adolescents

According to the US CDC definition, one has AIDS if he/she is infected with HIV and present with one of the following:

• A CD4+ T-cell count below 200 cells/µl (or a CD4+ T-cell percentage of total lymphocytes of less than 14%).

or he/she has one of the following defining illnesses

CDC Classification System for HIV Infection in Adults and Adolescents
Defining illness
Candidiasis of bronchi, trachea, or lungs Candidiasis esophageal Cervical cancer (invasive) Coccidioidomycosis, disseminated or extrapulmonary Cryptococcosis, extrapulmonary Cryptosporidiosis, chronic intestinal for longer than 1 month Cytomegalovirus disease (other than liver, spleen or lymph nodes) Encephalopathy (HIV-related) Herpes simplex: chronic ulcer(s) (for more than 1 month); or bronchitis, pneumonitis, or esophagitis Histoplasmosis, disseminated or extrapulmonary Isosporiasis, chronic intestinal (for more than 1 month) Kaposi's sarcoma Lymphoma Burkitt's, immunoblastic or primary brain Mycobacterium avium complex Mycobacterium, other species, disseminated or extrapulmonary Pneumocystis carinii pneumonia Pneumonia (recurrent) Progressive multifocal leukoencephalopathy Salmonella septicemia (recurrent) Toxoplasmosis of the brain Tuberculosis Wasting syndrome due to HIV

People who are not infected with HIV may also develop these conditions; this does not mean they have AIDS. However, when an individual presents laboratory evidence against HIV infection, a diagnosis of AIDS is ruled out unless the patient has not:

• undergone high-dose corticoid therapy or other immunosuppressive/cytotoxic therapy in the three months before the onset of the indicator disease
• OR been diagnosed with Hodgkin's disease, non-Hodgkin's lymphoma, lymphocytic leukemia, multiple myeloma, or any cancer of lymphoreticular or histiocytic tissue, or angioimmunoblastic lymphoadenopathy
• OR a genetic immunodeficiency syndrome atypical of HIV infection, such as one involving hypogamma globulinemia

AND

• the individual has had Pneumocystis carinii pneumonia
• OR one of the above defining illnesses AND a CD4+ T-cell count below 200 cells/µl (or a CD4+ T-cell percentage of total lymphocytes of less than 14%).

CDC Classification System for HIV Infection in Children

In the new system, HIV-infected children are classified into mutually exclusive categories according to three parameters:

a) infection status

b) clinical status

c) immunologic status

This classification system reflects the stage of the child's disease, establishes mutually exclusive classification categories, and balances simplicity and medical accuracy in the classification process. This document also describes revised pediatric definitions for two acquired immunodeficiency syndrome-defining conditions.

When an infant is born to an HIV-infected mother, diagnosis of an HIV infection is complicated by the presence of maternal anti-HIV IgG antibody, which crosses the placenta to the fetus. Indeed, virtually all children born to HIV-infected mothers are HIV-antibody positive at birth, although only 15%-30% are actually infected.

Clinical stage	Features
Category N	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)

Further information: [[:CDC Classification System for HIV Infection in Adults and Adolescents]]

Further information: [[:CDC Classification System for HIV Infection in Children]]