This document revises the WHO clinical staging system for HIV/AIDS in adults and adolescents aged 15 years or more. It outlines 4 clinical stages based on severity of conditions: asymptomatic, mild conditions (stage 1-2), advanced conditions where presumptive diagnosis can be made (stage 3), and severe conditions where confirmatory testing is required (stage 4). The revisions aim to standardize definitions, harmonize pediatric and adult staging, and support ART scale-up by guiding decisions on when to initiate treatment. Annexes provide more details on recognizing conditions. The staging system is intended to facilitate clinical management and monitoring of patients, as well as surveillance efforts.
Slowdown of Urology residents' learning curve during COVID-19 EmergencyValentina Corona
This article discusses how the COVID-19 pandemic has significantly impacted urology resident training in Italy. Clinical activities and case discussions have been greatly reduced, limiting residents' surgical and clinical experience. To address this, the article proposes alternative smart learning methods like online video lessons, webinars, podcasts and virtual rounds to continue residents' education remotely. It acknowledges simulation training has also been impacted but preliminary home simulation experiences show promise if utility can be proven. The article concludes the pandemic presents both a current challenge and future opportunity to integrate smart learning more broadly into residency programs.
Pathways for urology patients during the COVID-19 pandemicValentina Corona
This document provides recommendations for pathways of care for urology patients during the COVID-19 pandemic. It suggests simplifying diagnostic pathways to reduce hospital visits and contagion risk. For urgent conditions like urinary obstruction or retention, it recommends ultrasound over CT initially and delaying further diagnosis if possible. For elective surgery, it advises telephone screening, limiting pre-op visits, and ideally testing all patients for COVID-19 to isolate any positive cases before admission. The goals are minimizing hospital access, resources used, and risk of contagion and readmission for patients.
Stepping Forward: Urologists' Effort During the COVID-19 Outbreak in SingaporeValentina Corona
Urologists in Singapore played an important role in responding to the COVID-19 outbreak. One quarter of the urology department staff were deployed to screen patients at the National Centre for Infectious Disease. This reduced urology services and impacted training. Lessons learned include maintaining emergency plans, effective administration, senior doctors leading by example, embracing technology, and remembering doctors' role in serving public health during crises.
The COVID-19 pandemic has significantly impacted urology services in northern Italy. In the province of Bergamo in Lombardy, over 50% of urologists are now infected with COVID-19. Urology departments have had to dedicate resources to treating COVID-19 patients, reducing operating capacity and outpatient services. Prioritizing and scheduling cancer surgeries is now difficult given limited resources. The long-term effects of delays in urology treatments are unknown, but could negatively impact patient outcomes.
The document provides recommendations from a panel of Italian urologists on managing urology practice during the COVID-19 pandemic. It distinguishes between urgent procedures that should still be performed, such as treating upper urinary tract obstruction or gross hematuria. It also separates urological cancer procedures into non-deferrable, semi-non-deferrable, deferrable and replaceable categories to help guide rescheduling of surgical activities. The panel aims to facilitate reorganization of urology departments while ensuring urgent and important cancer cases continue to be treated during the pandemic.
The document provides recommendations for surveillance of acute viral hepatitis. It defines clinical and laboratory criteria for diagnosing hepatitis A, B, and non-A/non-B. Surveillance is recommended to guide control measures like ensuring blood and injection safety and immunization programs. Countries should monitor cases of acute jaundice and increase in liver enzymes to detect hepatitis outbreaks and evaluate prevention programs. Standardized case definitions and laboratory tests are important for comparable surveillance data.
International classification of disease and International non-proprietary nam...JAYANTHBM
This slideshare give you a knowledge about international classification of diseases and international non-proprietary names of drugs. And also about the guidelines how they classify the disease and where we can find this type of classification and what is its primary use and who use this type of classification and use of non-proprietary names.
Slowdown of Urology residents' learning curve during COVID-19 EmergencyValentina Corona
This article discusses how the COVID-19 pandemic has significantly impacted urology resident training in Italy. Clinical activities and case discussions have been greatly reduced, limiting residents' surgical and clinical experience. To address this, the article proposes alternative smart learning methods like online video lessons, webinars, podcasts and virtual rounds to continue residents' education remotely. It acknowledges simulation training has also been impacted but preliminary home simulation experiences show promise if utility can be proven. The article concludes the pandemic presents both a current challenge and future opportunity to integrate smart learning more broadly into residency programs.
Pathways for urology patients during the COVID-19 pandemicValentina Corona
This document provides recommendations for pathways of care for urology patients during the COVID-19 pandemic. It suggests simplifying diagnostic pathways to reduce hospital visits and contagion risk. For urgent conditions like urinary obstruction or retention, it recommends ultrasound over CT initially and delaying further diagnosis if possible. For elective surgery, it advises telephone screening, limiting pre-op visits, and ideally testing all patients for COVID-19 to isolate any positive cases before admission. The goals are minimizing hospital access, resources used, and risk of contagion and readmission for patients.
Stepping Forward: Urologists' Effort During the COVID-19 Outbreak in SingaporeValentina Corona
Urologists in Singapore played an important role in responding to the COVID-19 outbreak. One quarter of the urology department staff were deployed to screen patients at the National Centre for Infectious Disease. This reduced urology services and impacted training. Lessons learned include maintaining emergency plans, effective administration, senior doctors leading by example, embracing technology, and remembering doctors' role in serving public health during crises.
The COVID-19 pandemic has significantly impacted urology services in northern Italy. In the province of Bergamo in Lombardy, over 50% of urologists are now infected with COVID-19. Urology departments have had to dedicate resources to treating COVID-19 patients, reducing operating capacity and outpatient services. Prioritizing and scheduling cancer surgeries is now difficult given limited resources. The long-term effects of delays in urology treatments are unknown, but could negatively impact patient outcomes.
The document provides recommendations from a panel of Italian urologists on managing urology practice during the COVID-19 pandemic. It distinguishes between urgent procedures that should still be performed, such as treating upper urinary tract obstruction or gross hematuria. It also separates urological cancer procedures into non-deferrable, semi-non-deferrable, deferrable and replaceable categories to help guide rescheduling of surgical activities. The panel aims to facilitate reorganization of urology departments while ensuring urgent and important cancer cases continue to be treated during the pandemic.
The document provides recommendations for surveillance of acute viral hepatitis. It defines clinical and laboratory criteria for diagnosing hepatitis A, B, and non-A/non-B. Surveillance is recommended to guide control measures like ensuring blood and injection safety and immunization programs. Countries should monitor cases of acute jaundice and increase in liver enzymes to detect hepatitis outbreaks and evaluate prevention programs. Standardized case definitions and laboratory tests are important for comparable surveillance data.
International classification of disease and International non-proprietary nam...JAYANTHBM
This slideshare give you a knowledge about international classification of diseases and international non-proprietary names of drugs. And also about the guidelines how they classify the disease and where we can find this type of classification and what is its primary use and who use this type of classification and use of non-proprietary names.
COVID-19 AND UROLOGY: A Comprehensive Review of the LiteratureValentina Corona
This article reviews the impact of the COVID-19 pandemic on the practice of urology. It discusses how the pandemic has led to the postponement of non-urgent surgeries and changes in residency training. It also examines the potential effects of COVID-19 on the urinary tract, noting that the kidneys and bladder may be at risk of viral invasion due to the presence of ACE2 receptors. The article reviews recommendations regarding kidney transplantation during the pandemic and reports limited cases of COVID-19 infection in renal transplant recipients.
The document discusses the International Classification of Diseases (ICD), which is maintained by the World Health Organization. The ICD provides a standardized system of diagnostic codes to classify diseases, injuries, symptoms, and causes of health issues. It allows for comparison of health data between locations and time periods. The classification system has been revised periodically to reflect advances in health science, with the current version being ICD-11 which will be implemented in 2022.
The document discusses international health regulations, specifically the International Health Regulations (IHR) from 2005. It provides background on the evolution of international health regulations from 1830 to 2005. It describes key aspects of IHR 2005, including its scope, objectives, structure with 10 parts and 9 annexures. Some important features of IHR 2005 are notification requirements, national IHR focal points, requirements for national core public health capacities, recommended measures, and procedures for determining public health emergencies of international concern.
The document discusses the classification of diseases. It begins by defining what a disease is and describing the main types. The most widely used system for classifying diseases is the World Health Organization's International Classification of Diseases (ICD). The ICD uses codes to map diseases and health conditions into broad diagnostic categories. It has gone through several revisions over time to ICD-10 to reflect advances in healthcare. The ICD classification system is used globally to facilitate disease tracking, epidemiology research, and clinical care.
This document outlines quality indicators proposed by the Indian Society of Critical Care Medicine to monitor performance in ICUs in India. It identifies parameters in several categories - mortality, morbidity, operational processes, errors/safety, infections, human resources, and customer focus. Specific metrics are defined for indicators like standardized mortality rate, incidence of complications, length of stay, compliance to protocols, fall rates, and patient satisfaction. Limitations are noted around applicability in the Indian context and challenges in monitoring some indicators consistently.
With the pandemic overclouding the whole world it has effected every strato of people including the Orthopaedic groups. This is to highlight the impact of COVID 19 on the orthopaedic in general.
This document discusses healthcare-associated infections (HAIs) and presents information from AdvaMed. It notes that HAIs occur worldwide and affect hundreds of millions annually, increasing morbidity, mortality, and costs. Up to 90% of HAI deaths in the US are caused by multi-drug resistant organisms. Surveillance shows HAI incidence is 3 times higher in developing economies compared to EU/US. HAIs lead to prolonged hospital stays and increased costs. Prevention through evidence-based interventions could reduce HAIs by 65-70% and save resources. Strong infection control including surveillance is needed to combat HAIs and antimicrobial resistance.
- The document discusses trauma centers and their role in providing care to seriously injured patients. It defines trauma centers and describes their classification levels from I to V, with Level I centers providing the highest level of surgical specialties and care.
- The roles and requirements of Levels I-V trauma centers are outlined, including necessary coverage of specialists, transfer agreements, and quality assessment programs. Level I centers provide leadership and research.
- Two levels of pediatric trauma centers (P-I and P-II) are also defined, with Level P-I centers requiring at least two pediatric surgeons and other pediatric specialists.
- The document then discusses components and resources needed for trauma centers in Indonesia, including minimum hospital
Impact of the COVID-19 pandemic on Urology Residency Training in ItalyValentina Corona
This study examines the impact of the COVID-19 pandemic on urology residency training in Italy through an online survey of 351 urology residents. Before the pandemic, most residents were routinely involved in clinical and surgical activities. During the pandemic, 41-81% of residents reported a severe or complete reduction in clinical activities, and 44-62% reported the same for surgical activities. Reductions were more pronounced for residents in their final training year. The study provides insights into how urology residency training has been impaired during the COVID-19 emergency period.
International classification of diseasesTharaniRam
The document discusses the classification of diseases and the International Classification of Diseases (ICD). It provides details on the history and development of the ICD, from early classifications in the 1700s to the current ICD-10 published in 1993. The ICD-10 aims to code diseases, injuries, and procedures numerically to facilitate data storage, retrieval and analysis. It contains three volumes organized into 21 chapters covering all disease and injury classifications.
This document provides guidance from the British Thoracic Society (BTS) on respiratory follow-up of patients diagnosed with COVID-19 pneumonia. It outlines two follow-up algorithms - one for more severe patients requiring ICU care, and one for mild-moderate cases not requiring ICU care.
For severe cases, it recommends an early virtual or in-person review at 4-6 weeks to assess symptoms, rehabilitation needs, etc. At 12 weeks, all severe cases should have an in-person review including chest x-ray to check for resolution.
For mild-moderate cases, it recommends a virtual chest x-ray review at 12 weeks. If clear, patients will be discharged with advice to seek care if new
The document summarizes the use of electronic health records (EHRs) for syndromic surveillance, using the example of Zika virus. It discusses how EHRs can help improve reporting of outbreaks by recording patient information. While EHRs provide advantages like improved reporting efficiency and criterion validity of data, they also have limitations like the need for diagnostic and demographic accuracy. The document reviews literature on different surveillance systems and their use in various healthcare settings. It concludes by discussing opportunities for further research, such as including new diseases in surveillance systems and improving collaboration between public and private health sectors.
Disease cost drivers hai apec hlm nusa dua 2013sandraduhrkopp
Healthcare-associated infections (HAIs) occur in hundreds of millions of patients each year globally, causing increased illness, death and costs. HAIs typically involve four types of infections and rates are usually higher in developing countries. HAIs prolong hospital stays by up to 3 weeks and increase costs by USD $4,888 to $11,591 per infection episode. It is estimated that 65-70% of HAIs are preventable. While preventing HAIs requires initial investment, it can free up hospital beds and resources in the long-run, improving outcomes and making more efficient use of limited healthcare funds.
1. The document provides guidelines for managing outbreaks of communicable diseases in Queensland health facilities.
2. It establishes an Outbreak Control Team to promptly recognize outbreaks, identify sources, stop spread, prevent recurrence, and ensure communication between stakeholders.
3. The Team is chaired by the Infection Control Committee Chair and includes managers, clinicians, public health experts, and others as needed. It investigates outbreaks and implements control measures.
International health regulaiton (IHR-2005) Afghanistan Dr. Islam SaeedIslam Saeed
The document provides an overview of the International Health Regulations (IHR) of 2005. The IHR are a legally binding framework that was established to help prevent the international spread of disease while avoiding unnecessary interference with international traffic and trade. The IHR require countries to strengthen their disease surveillance and response systems and to assess and report any public health events that may constitute a public health emergency of international concern within 24 hours. The document discusses Afghanistan's progress in implementing the IHR, including establishing an IHR focal point and conducting assessments, as well as ongoing challenges to fully meeting all IHR core capacity requirements.
HIV patient outcomes have been shown to improve with appropriate support by case management. HIV case managers need to have a working understanding of clinical management issues to improve on the great work that they do for their patients. This presentation attempts to provide case managers with this information.
HIV AIDS - Risk factor, Clinical feature & ComplicationHafiz Mohd Razak
HIV can be transmitted sexually, through blood or blood products, or from mother to child. It progresses through acute infection, asymptomatic latency, and AIDS if untreated. Complications include opportunistic infections like tuberculosis, cancers like Kaposi's sarcoma, neurological issues, and wasting syndrome due to immune system damage. Common infections are candidiasis, cryptococcal meningitis, toxoplasmosis, and cryptosporidiosis. Cancers include Kaposi's sarcoma and lymphomas. Other complications are wasting syndrome, neurological symptoms, and kidney disease like HIVAN.
This case involves a 36-year-old Indian woman (DK) newly diagnosed with HIV who presented with fever and progressively worsening back pain. Imaging showed sacroiliitis and she was ultimately diagnosed with disseminated coccidioidomycosis after multiple negative tests. Her symptoms improved with antifungal treatment. The second case involves a 41-year-old transgender woman (Terry) who presented with dysphagia, abdominal pain, and chest pain. Imaging revealed cardiac masses and she was diagnosed with Burkitt's lymphoma involving the heart.
Is a condition seen in some cases of AIDS or immunosuppression, in which the immune system begins to recover, but then responds to a previously acquired opportunistic infection with an overwhelming inflammatory response that paradoxically makes the symptoms of infection worse.
Staging and clinical manifestation of HIVvijay dihora
The document outlines the classification system and clinical staging of HIV in pediatric patients. It describes two parameters used for classification - clinical status and degree of immunologic impairment. It then lists specific clinical conditions and symptoms that are used to stage pediatric HIV infection from asymptomatic to severe, including conditions where presumptive or confirmatory diagnosis is needed. It also provides a table staging immune status based on CD4+ T-cell percentages and counts by age.
COVID-19 AND UROLOGY: A Comprehensive Review of the LiteratureValentina Corona
This article reviews the impact of the COVID-19 pandemic on the practice of urology. It discusses how the pandemic has led to the postponement of non-urgent surgeries and changes in residency training. It also examines the potential effects of COVID-19 on the urinary tract, noting that the kidneys and bladder may be at risk of viral invasion due to the presence of ACE2 receptors. The article reviews recommendations regarding kidney transplantation during the pandemic and reports limited cases of COVID-19 infection in renal transplant recipients.
The document discusses the International Classification of Diseases (ICD), which is maintained by the World Health Organization. The ICD provides a standardized system of diagnostic codes to classify diseases, injuries, symptoms, and causes of health issues. It allows for comparison of health data between locations and time periods. The classification system has been revised periodically to reflect advances in health science, with the current version being ICD-11 which will be implemented in 2022.
The document discusses international health regulations, specifically the International Health Regulations (IHR) from 2005. It provides background on the evolution of international health regulations from 1830 to 2005. It describes key aspects of IHR 2005, including its scope, objectives, structure with 10 parts and 9 annexures. Some important features of IHR 2005 are notification requirements, national IHR focal points, requirements for national core public health capacities, recommended measures, and procedures for determining public health emergencies of international concern.
The document discusses the classification of diseases. It begins by defining what a disease is and describing the main types. The most widely used system for classifying diseases is the World Health Organization's International Classification of Diseases (ICD). The ICD uses codes to map diseases and health conditions into broad diagnostic categories. It has gone through several revisions over time to ICD-10 to reflect advances in healthcare. The ICD classification system is used globally to facilitate disease tracking, epidemiology research, and clinical care.
This document outlines quality indicators proposed by the Indian Society of Critical Care Medicine to monitor performance in ICUs in India. It identifies parameters in several categories - mortality, morbidity, operational processes, errors/safety, infections, human resources, and customer focus. Specific metrics are defined for indicators like standardized mortality rate, incidence of complications, length of stay, compliance to protocols, fall rates, and patient satisfaction. Limitations are noted around applicability in the Indian context and challenges in monitoring some indicators consistently.
With the pandemic overclouding the whole world it has effected every strato of people including the Orthopaedic groups. This is to highlight the impact of COVID 19 on the orthopaedic in general.
This document discusses healthcare-associated infections (HAIs) and presents information from AdvaMed. It notes that HAIs occur worldwide and affect hundreds of millions annually, increasing morbidity, mortality, and costs. Up to 90% of HAI deaths in the US are caused by multi-drug resistant organisms. Surveillance shows HAI incidence is 3 times higher in developing economies compared to EU/US. HAIs lead to prolonged hospital stays and increased costs. Prevention through evidence-based interventions could reduce HAIs by 65-70% and save resources. Strong infection control including surveillance is needed to combat HAIs and antimicrobial resistance.
- The document discusses trauma centers and their role in providing care to seriously injured patients. It defines trauma centers and describes their classification levels from I to V, with Level I centers providing the highest level of surgical specialties and care.
- The roles and requirements of Levels I-V trauma centers are outlined, including necessary coverage of specialists, transfer agreements, and quality assessment programs. Level I centers provide leadership and research.
- Two levels of pediatric trauma centers (P-I and P-II) are also defined, with Level P-I centers requiring at least two pediatric surgeons and other pediatric specialists.
- The document then discusses components and resources needed for trauma centers in Indonesia, including minimum hospital
Impact of the COVID-19 pandemic on Urology Residency Training in ItalyValentina Corona
This study examines the impact of the COVID-19 pandemic on urology residency training in Italy through an online survey of 351 urology residents. Before the pandemic, most residents were routinely involved in clinical and surgical activities. During the pandemic, 41-81% of residents reported a severe or complete reduction in clinical activities, and 44-62% reported the same for surgical activities. Reductions were more pronounced for residents in their final training year. The study provides insights into how urology residency training has been impaired during the COVID-19 emergency period.
International classification of diseasesTharaniRam
The document discusses the classification of diseases and the International Classification of Diseases (ICD). It provides details on the history and development of the ICD, from early classifications in the 1700s to the current ICD-10 published in 1993. The ICD-10 aims to code diseases, injuries, and procedures numerically to facilitate data storage, retrieval and analysis. It contains three volumes organized into 21 chapters covering all disease and injury classifications.
This document provides guidance from the British Thoracic Society (BTS) on respiratory follow-up of patients diagnosed with COVID-19 pneumonia. It outlines two follow-up algorithms - one for more severe patients requiring ICU care, and one for mild-moderate cases not requiring ICU care.
For severe cases, it recommends an early virtual or in-person review at 4-6 weeks to assess symptoms, rehabilitation needs, etc. At 12 weeks, all severe cases should have an in-person review including chest x-ray to check for resolution.
For mild-moderate cases, it recommends a virtual chest x-ray review at 12 weeks. If clear, patients will be discharged with advice to seek care if new
The document summarizes the use of electronic health records (EHRs) for syndromic surveillance, using the example of Zika virus. It discusses how EHRs can help improve reporting of outbreaks by recording patient information. While EHRs provide advantages like improved reporting efficiency and criterion validity of data, they also have limitations like the need for diagnostic and demographic accuracy. The document reviews literature on different surveillance systems and their use in various healthcare settings. It concludes by discussing opportunities for further research, such as including new diseases in surveillance systems and improving collaboration between public and private health sectors.
Disease cost drivers hai apec hlm nusa dua 2013sandraduhrkopp
Healthcare-associated infections (HAIs) occur in hundreds of millions of patients each year globally, causing increased illness, death and costs. HAIs typically involve four types of infections and rates are usually higher in developing countries. HAIs prolong hospital stays by up to 3 weeks and increase costs by USD $4,888 to $11,591 per infection episode. It is estimated that 65-70% of HAIs are preventable. While preventing HAIs requires initial investment, it can free up hospital beds and resources in the long-run, improving outcomes and making more efficient use of limited healthcare funds.
1. The document provides guidelines for managing outbreaks of communicable diseases in Queensland health facilities.
2. It establishes an Outbreak Control Team to promptly recognize outbreaks, identify sources, stop spread, prevent recurrence, and ensure communication between stakeholders.
3. The Team is chaired by the Infection Control Committee Chair and includes managers, clinicians, public health experts, and others as needed. It investigates outbreaks and implements control measures.
International health regulaiton (IHR-2005) Afghanistan Dr. Islam SaeedIslam Saeed
The document provides an overview of the International Health Regulations (IHR) of 2005. The IHR are a legally binding framework that was established to help prevent the international spread of disease while avoiding unnecessary interference with international traffic and trade. The IHR require countries to strengthen their disease surveillance and response systems and to assess and report any public health events that may constitute a public health emergency of international concern within 24 hours. The document discusses Afghanistan's progress in implementing the IHR, including establishing an IHR focal point and conducting assessments, as well as ongoing challenges to fully meeting all IHR core capacity requirements.
HIV patient outcomes have been shown to improve with appropriate support by case management. HIV case managers need to have a working understanding of clinical management issues to improve on the great work that they do for their patients. This presentation attempts to provide case managers with this information.
HIV AIDS - Risk factor, Clinical feature & ComplicationHafiz Mohd Razak
HIV can be transmitted sexually, through blood or blood products, or from mother to child. It progresses through acute infection, asymptomatic latency, and AIDS if untreated. Complications include opportunistic infections like tuberculosis, cancers like Kaposi's sarcoma, neurological issues, and wasting syndrome due to immune system damage. Common infections are candidiasis, cryptococcal meningitis, toxoplasmosis, and cryptosporidiosis. Cancers include Kaposi's sarcoma and lymphomas. Other complications are wasting syndrome, neurological symptoms, and kidney disease like HIVAN.
This case involves a 36-year-old Indian woman (DK) newly diagnosed with HIV who presented with fever and progressively worsening back pain. Imaging showed sacroiliitis and she was ultimately diagnosed with disseminated coccidioidomycosis after multiple negative tests. Her symptoms improved with antifungal treatment. The second case involves a 41-year-old transgender woman (Terry) who presented with dysphagia, abdominal pain, and chest pain. Imaging revealed cardiac masses and she was diagnosed with Burkitt's lymphoma involving the heart.
Is a condition seen in some cases of AIDS or immunosuppression, in which the immune system begins to recover, but then responds to a previously acquired opportunistic infection with an overwhelming inflammatory response that paradoxically makes the symptoms of infection worse.
Staging and clinical manifestation of HIVvijay dihora
The document outlines the classification system and clinical staging of HIV in pediatric patients. It describes two parameters used for classification - clinical status and degree of immunologic impairment. It then lists specific clinical conditions and symptoms that are used to stage pediatric HIV infection from asymptomatic to severe, including conditions where presumptive or confirmatory diagnosis is needed. It also provides a table staging immune status based on CD4+ T-cell percentages and counts by age.
The document discusses iris biometrics and an iris recognition system. It provides details on iris anatomy, image acquisition, preprocessing, iris localization including pupil and iris detection, iris normalization, feature extraction using Haar wavelets, and matching. It evaluates the system on three databases achieving over 94% accuracy with low false acceptance and rejection rates. Further work is proposed on fusion, dual extraction approaches, indexing large databases, and using local descriptors.
This document discusses the presenting problems in HIV infection. It describes the stages of infection from acute to asymptomatic to symptomatic disease. Common respiratory infections associated with HIV include pneumonia, Pneumocystis jiroveci pneumonia, tuberculosis, and atypical mycobacterial infections. Other organ systems affected by opportunistic infections in HIV patients with low CD4 counts include the cardiovascular and gastrointestinal systems. Mucocutaneous manifestations are also common.
2 natural history of hiv and who clinical staging naco lac mDrShruthi Pradeep
This document summarizes the natural history and clinical staging of HIV infection in 3 paragraphs. It describes the typical progression of untreated HIV infection from initial viral transmission and acute retroviral syndrome, to asymptomatic chronic infection lasting an average of 8 years, to symptomatic HIV infection and AIDS occurring on average 1.3 years later without treatment. It also outlines the WHO clinical staging system for classifying HIV patients based on their symptoms and disease progression into 4 stages, with stage 1 being asymptomatic and stage 4 involving advanced AIDS-defining illnesses. The document provides an overview of the modes of HIV transmission, pathogenesis, typical clinical course, and classification approach for monitoring HIV disease progression.
This document discusses multidrug-resistant tuberculosis (MDR-TB) and extensively drug-resistant tuberculosis (XDR-TB). It defines MDR-TB as tuberculosis resistant to at least isoniazid and rifampicin, and defines XDR-TB as MDR-TB additionally resistant to fluoroquinolones and injectable second-line drugs. It also discusses mechanisms of drug resistance development, clinical factors promoting resistance, testing methods, categories of antituberculosis drugs, and public health responsibilities regarding treatment and prevention of drug-resistant tuberculosis.
1. The document provides guidelines for categorizing TB cases and treatment regimens under the Revised National Tuberculosis Control Programme (RNTCP) in India. It describes 5 categories of TB cases and their standard treatment regimens.
2. The document also summarizes various adverse drug reactions associated with anti-TB medications, their causative agents, clinical presentations, and management guidelines. It provides treatment guidelines for special groups including children, pregnant women, HIV patients, and those with comorbidities.
3. Guidelines are given for diagnosis and treatment of MDR-TB and XDR-TB cases. Standardized treatment regimens are recommended depending on drug susceptibility testing results and previous treatment history. Strict treatment
This document provides information about HIV/AIDS, including how it is transmitted and prevented. It defines HIV as the virus that compromises the immune system, and AIDS as the final stage when the immune system is severely damaged. Some key statistics are presented, such as over 1.7 million people in the US being infected since 1981, with 1 in 5 unaware. Common symptoms during HIV emergence from latency are also listed. The document stresses that while there is no cure for HIV, antiretroviral drugs can suppress it and transmission is preventable through condom use and clean needles.
Ebola clinical care guidelines en2 2014-10-28[1]cbrneccteam
This document provides updated clinical care guidelines for treating patients with Ebola Virus Disease (EVD) in Canada. It was organized by the Public Health Agency of Canada, Canadian Critical Care Society, Canadian Association of Emergency Physicians, and Association of Medical Microbiology & Infectious Diseases Canada. The guidelines focus on managing isolated EVD cases in individuals traveling to or from West Africa. They incorporate recent experiences treating EVD patients in Western hospitals and lessons learned from hospitals developing EVD plans.
This document provides updated guidelines for primary care providers on the management of patients infected with HIV. Key changes from the 2004 guidelines include:
1) The guidelines have a new format to more clearly identify recommendations.
2) Tables have been added on immunizations and routine health care maintenance.
3) Guidelines on many HIV-related topics have been updated, including new antiretroviral drugs, diagnostic HIV tests, and screening and management recommendations.
4) The guidelines address the long-term care of HIV patients, including non-AIDS related health issues, as improved treatment has increased patient lifespan.
The document is a global policy report on viral hepatitis prevention and control by the World Health Organization. It finds that viral hepatitis is a widespread and growing disease burden globally that causes liver damage and cancer. While tools exist to prevent and treat hepatitis, more action is needed as many infections are asymptomatic until serious liver damage occurs. The report analyzes data from a WHO survey of member states on their hepatitis policies and programs. It identifies gaps in prevention, screening, and treatment efforts and areas where WHO can provide assistance to member states in developing more effective national and localized response strategies.
This document provides guidelines for conducting population-based surveys to measure national HIV prevalence. It outlines how to plan and implement a new national survey, incorporate HIV testing into existing surveys, and calculate a national HIV prevalence estimate by combining data from surveys and sentinel surveillance. Population-based surveys can provide more representative HIV prevalence data than sentinel surveillance alone. The guidelines aim to help countries obtain accurate national estimates by adjusting prevalence measures from different data sources and accounting for biases.
The document provides the National Consolidated Guidelines for Comprehensive HIV Prevention, Care and Treatment in Ethiopia. It outlines recommendations for HIV testing strategies, linkage to care, ART initiation, management of treatment and co-infections. Key changes from previous guidelines include refined criteria for targeted HIV testing, a revised testing algorithm, recommendations for retesting and linkage interventions to improve engagement in care following diagnosis. The guidelines aim to ensure standardized, quality HIV services are accessible nationwide based on recent evidence.
This chapter discusses key considerations for developing a protocol for population-based surveys measuring HIV. It recommends that surveys be designed based on the epidemic context and objectives of monitoring the impact of HIV. Surveys should return HIV and other biomarker results to participants and measure HIV prevalence among children when adult female HIV prevalence is over 5%. HIV incidence should only be included when adult prevalence is over 5% and incidence over 0.3%. Developing the protocol takes about two years to cover planning, implementation, and release of results.
SYSTEMS-LEVEL QUALITY IMPROVEMENTFrom Cues to Nudge A Knolisandrai1k
SYSTEMS-LEVEL QUALITY IMPROVEMENT
From Cues to Nudge: A Knowledge-Based Framework
for Surveillance of Healthcare-Associated Infections
Arash Shaban-Nejad1,2 & Hiroshi Mamiya2 & Alexandre Riazanov3 & Alan J. Forster4 &
Christopher J. O. Baker2,5 & Robyn Tamblyn2 & David L. Buckeridge2
Received: 3 June 2015 /Accepted: 30 September 2015 /Published online: 4 November 2015
# Springer Science+Business Media New York 2015
Abstract We propose an integrated semantic web framework
consisting of formal ontologies, web services, a reasoner and a
rule engine that together recommend appropriate level of
patient-care based on the defined semantic rules and guide-
lines. The classification of healthcare-associated infections
within the HAIKU (Hospital Acquired Infections – Knowl-
edge in Use) framework enables hospitals to consistently fol-
low the standards along with their routine clinical practice and
diagnosis coding to improve quality of care and patient safety.
The HAI ontology (HAIO) groups over thousands of codes
into a consistent hierarchy of concepts, along with relation-
ships and axioms to capture knowledge on hospital-associated
infections and complications with focus on the big four types,
surgical site infections (SSIs), catheter-associated urinary tract
infection (CAUTI); hospital-acquired pneumonia, and blood
stream infection. By employing statistical inferencing in our
study we use a set of heuristics to define the rule axioms to
improve the SSI case detection. We also demonstrate how the
occurrence of an SSI is identified using semantic e-triggers.
The e-triggers will be used to improve our risk assessment of
post-operative surgical site infections (SSIs) for patients un-
dergoing certain type of surgeries (e.g., coronary artery bypass
graft surgery (CABG)).
Keywords Ontologies . Knowledge modeling .
Healthcare-associated infections . Surveillance . Semantic
framework . Surgical site infections
Introduction
Healthcare-associated Infections (HAIs) affect millions of
patients around the world, killing hundreds of thousands
and imposing, directly or indirectly, a significant socio-
economic burden on healthcare systems [1]. According
to the Centers for Disease Control (CDC) [2], hospital-
acquired infections in the U.S., where the point preva-
lence of HAIs among hospitalized patients is 4 %, result
in an estimated 1.7 million infections, which lead to as
many as 99,000 deaths and cost up to $45 billion annually
[3, 4]. Similar or higher rates of HAI occur in other coun-
tries as well with an estimated 10.5 % of patients in Ca-
nadian hospitals having an HAI [5]. Clinical assessment
and laboratory testing are generally used to detect and
confirm an infection, identify its origin, and determine
appropriate infection control methods to stop the infection
from spreading within a healthcare institution. Failure to
monitor, and detect HAI in timely manner can delay di-
agnosis, leading to complications (e.g., sepsis), and
allowing an epid ...
Role of In Vitro Diagnostics in Saudi ArabiaSolidiance
Saudi Arabia’s healthcare system currently relies heavily on government funding, which accounts for 65% healthcare spending in the country. Healthcare trends in Saudi Arabia's, e.g. demographic shifts, high incidence rates of lifestyle related diseases, growing demand for private healthcare services, and strategic investments made by the government have driven demands for in vitro diagnostic (IVD) devices. Solidiance co-developed this exclusive white paper with Kind Abdulaziz Medical City and Abbott Diagnostics, highlighting the contribution, value and future of in vitro diagnostics in Saudi Arabia’s healthcare system. According to the report, the future looks bright for IVD in Saudi Arabia, however it depends on how fast it can be adopted and implemented in order to benefit the government, healthcare players seeking to improve and invest on the sector, and also the people.
This report provides the first global assessment of progress toward universal health coverage. It finds that while access to essential health services has increased globally, significant gaps remain. Coverage of key services like antiretroviral therapy and tuberculosis treatment is below 80%, and inequities exist both between and within countries. The report establishes a core set of tracer indicators to monitor coverage of reproductive, maternal, child, and infectious disease services. It highlights both successes in expanding coverage and the ongoing need to address remaining gaps to achieve universal access to quality health care.
SYSTEMS-LEVEL QUALITY IMPROVEMENTFrom Cues to Nudge A Kno.docxdeanmtaylor1545
The document proposes a knowledge-based framework called HAIKU that uses ontologies, web services, and rules to improve surveillance of healthcare-associated infections. The framework focuses on consistently classifying infections like surgical site infections according to standards and guidelines. It uses the HAI ontology to group thousands of codes into a hierarchy of infection concepts and relationships. Statistical analysis and heuristics are used to define rules to improve detection of surgical site infection cases. The framework aims to use "e-triggers" identified through the ontology to better assess risk of postoperative infections for certain surgeries.
The document describes the evolution and components of India's National AIDS Control Program (NACP). It began in 1992 and is now in its fourth phase (NACP-IV) from 2012-2017. Key aspects include:
- Integrated Counselling and Testing Centers (ICTCs) were established in 2006 by integrating earlier Voluntary Counselling and Testing Centers (VCTCs) and Prevention of Parent-to-Child Transmission centers.
- NACP-IV has 5 components: prevention services, expanding information/education, comprehensive care/support/treatment, strengthening institutional capacities, and a strategic information management system.
- Targeted interventions provide prevention, care, and treatment services focused on high-
This document provides background information on a WHO consultation regarding guidance on viral hepatitis prevention, surveillance, and treatment. It summarizes statistics on hepatitis B and C infections globally and among people who inject drugs. It also describes the negative impact of HIV co-infection on hepatitis disease progression. To inform the guidance, interviews were conducted with community members and healthcare providers affected by or working on viral hepatitis across various world regions. Their perspectives will provide insights into the individual challenges faced by those impacted by the guidance.
This document provides information on ongoing research projects within the Biostatistics, Epidemiology and Scientific Computing department at King Faisal Specialist Hospital & Research Centre. It describes two ongoing registry projects - the Thromboembolic Disorders Registry established in 2001 to study thromboembolic episodes and bleeding disorders during anticoagulation therapy, and the Cleft Lip and Palate Registry established in 1999 to determine the type and prevalence of cleft lip and palate in the hospital's patient population and contribute to reporting. The document gives background and objectives for each registry.
The document discusses metrics for monitoring the cascade of HIV services across the continuum of care. It presents a conceptual framework showing the cascade from diagnosis to viral suppression. Key metrics are identified to measure progress at each stage, including the percentage of people living with HIV who know their status, are linked to care, initiated on antiretroviral therapy, and have achieved viral suppression. The metrics were field tested in two countries and found useful for program assessment. Challenges include data quality and capacity at the local level. Guidelines will be published in early 2014 to help countries use these metrics to identify gaps and improve program performance.
Sustaining the HIV and AIDS Response in the Countries of the OECS: Regional I...HFG Project
In 2014, the six countries of the Organization of Eastern Caribbean States (OECS) of Antigua and Barbuda, Dominica, Grenada, St. Kitts and Nevis, St. Lucia and St. Vincent and the Grenadines developed HIV and AIDS Investment Case Briefs, with the support of USAID’s Health Finance and Governance (HFG) and Strengthening Health Outcomes through the Private Sector (SHOPS) projects. This document provides a summary of the findings of these briefs, which includes an analysis of the costs of HIV and AIDS programs that respond to the disease in the six countries, the resources that are available, the funding gaps, and the potential impact of different levels of investment in programming on the progression of the disease in the region.
2021 HIV HEALTH SECTOR ANNUAL REPORT.pdfMercy Morka
The document provides an overview of Nigeria's national HIV/AIDS monitoring and evaluation systems, which utilize both paper-based and electronic tools like monthly summary forms, electronic medical records, and the National Data Repository to collect and report HIV program data. It notes challenges with timely and comprehensive reporting of data from states. NASCP is working to improve reporting through expanding the National Data Repository and integrating HIV data more fully into the national DHIS2 platform.
This document provides an outline and instructions for an education session on hand hygiene for trainers, observers, and healthcare workers. The session aims to raise awareness of key hand hygiene messages and teach the WHO guidelines. It will cover topics like the impact of healthcare-associated infections, transmission risks, and the WHO's hand hygiene implementation strategy. Practical sessions are recommended to demonstrate hand hygiene procedures during patient care.
1. Health care-associated infections (HCAIs) are a major global problem that impact patient safety. They prolong hospital stays, increase costs, and often result in disability or death.
2. In developed countries, 5-15% of hospitalized patients acquire HCAIs, and rates are even higher in intensive care units, sometimes affecting up to 37% of patients. European studies show HCAI prevalence rates of 4.6-9.3% among hospitalized patients.
3. Proper hand hygiene is one of the most important measures to reduce HCAI transmission and burden. However, hand hygiene compliance among health workers is low worldwide. Improving practices can significantly decrease infection rates
5. INTERIM WHO CLINICAL STAGING OF HIV/AIDS AND HIV/AIDS CASE DEFINITIONS FOR SURVEILLANCE AFRICAN REGIONIV
CONTENTS
Acronyms and Abbreviations __________________________________________________ V
Executive summary __________________________________________________________1
Background________________________________________________________________2
Revised WHO clinical staging of HIV/AIDS for adults and adolescents _____________________5
Revised WHO clinical staging of HIV/AIDS for infants and children _______________________11
Recommendations for implementation ___________________________________________18
Annex 1. WHO clinical staging for adults and adolescents: presumptive and definitive criteria for
recognizing HIV/AIDS-related clinical events _______________________________________20
Annex 2. WHO clinical staging for infants and children: presumptive and definitive criteria for
recognizing HIV/AIDS-related clinical events _______________________________________30
Key References ____________________________________________________________42
9
16
29
41
6. V
ACRONYMS AND ABBREVIATIONS
AFB acid-fast bacilli
AIDS acquired immunodeficiency syndrome
ART antiretroviral therapy
ARV antiretroviral medicine
BAL bronchoalveolar lavage
CD4 human T helper cells expressing CD4 antigen (T helper cell)
CDC Centers for Disease Control and Prevention (USA)
CMV cytomegalovirus
CNS central nervous system
CRAG cryptococcal antigen
CSF cerebrospinal fluid
CT computed tomography
CXR chest X-ray
DNA deoxyribonucleic acid
HIV human immunodeficiency virus
HSV herpes simplex virus
IMCI integrated management of childhood illness
IRS immune restoration syndrome
JC Jacob Creutzfeldt (Virus)
LGE linear gingival erythema
LIP lymphoid interstitial pneumonitis
LP lumbar puncture
LRTI lower respiratory tract infection
LTB laryngotracheal bronchitis
MOT mycobacteria other than tuberculosis
MRI magnetic resonance imaging
NAT nucleic acid testing
P24 a soluble antigen produced by HIV
PCP pneumocystis pneumonia
PCR polymerase chain reaction
PGL persistent generalized lymphadenopathy
PLWHA people living with HIV/AIDS
PML progressive multifocal leukoencephalopathy
RF rectal fistula
RVF rectovaginal fistula
RNA ribonucleic acid
SD standard deviation
TB tuberculosis
TLC total lymphocyte count
URTI upper respiratory tract infection
WHO World Health Organization
ZN Ziehl-Neelsen (staining method)
7. EXECUTIVE SUMMARY
W
ith a view to facilitating the scale-up of access to antiretroviral therapy
(ART) in the African Region the present document outlines recent
revisions made by WHO to the clinical staging of HIV/AIDS and to
case definitions for HIV/AIDS disease surveillance. These interim guidelines are
based on an international drafting meeting held in Saas Fee in June 2004 and
on recommendations made by experts from African countries at a meeting held
in Nairobi in December of the same year.
The revisions to the clinical staging target professionals ranging from senior
consultants in teaching and referral hospitals to surveillance officers and first-
level health care providers, all of whom have important roles in caring for
people living with HIV and AIDS (PLWHA), including children. It is proposed that
countries review, adapt and repackage the guidelines as appropriate for specific
tasks at different levels of health service delivery. It is hoped that national HIV/
AIDS programmes in African countries will thus be assisted to develop, revise or
strengthen their ART guidelines, patient monitoring and surveillance efforts.
The interim clinical staging and revised definitions for surveillance are currently
being reviewed in the other WHO regions and will be finalized at a global
meeting to be held in September 2005.
INTERIM WHO CLINICAL STAGING OF HIV/AIDS AND HIV/AIDS CASE DEFINITIONS FOR SURVEILLANCE AFRICAN REGION1
8. 2
BACKGROUND
H
IV/AIDS surveillance is useful for monitoring temporal, geographical and
risk-group trends and for estimating the burden of HIV/AIDS-related
disease. Surveillance definitions were introduced in 1982, and many
different definitions have been used for national and international reporting (1).
The clinical case definitions recommended by WHO in 1985 and revised in 1994
are designed for use in resource-limited settings. They require confirmation of
HIV infection by means of serological testing. The surveillance definitions were
introduced before the widespread use of antiretroviral therapy (ART), which
can restore many patients with severe disease to health, and reverse disease
progression. Surveillance now needs to capture those patients in need of ART.
The WHO clinical staging system for HIV/AIDS, as developed in 1990,
emphasized the use of clinical parameters to guide clinical decision-making for
the management of HIV/AIDS patients. It was designed for use in resource-
limited settings where there was limited access to laboratory services. The WHO
clinical staging system has been widely used in resource-limited countries,
particularly in the African Region, and has proved pragmatic and useful in
facilities at both the first level and the referral level. It was originally hierarchal
in recognition of the relentless progression of HIV infection, with no reversal or
improvement allowed. Unfortunately confusion has occurred with clinical case
definitions for surveillance being used for clinical purposes. The clinical disease
classification system of the Centers for Disease Control and Prevention (CDC)
in the USA which is based on immunological parameters (CD4 counts) clinical
parameters and virological parameters and requires laboratory confirmation of
many clinical events is designed for surveillance purposes, but is frequently used
for clinical management purposes.
In response to the changing landscape of HIV/AIDS, particularly in resource-
limited settings, and specifically to support scale up of anti-retroviral treatment,
revisions and harmonization of the clinical staging and case definitions for
surveillance are required. For this reason, WHO in collaboration with CDC, held
two expert consultative meetings, in June 2004 in Saas Fe, Switzerland and in
December 2004 in Nairobi, Kenya to review and revise the 1994 WHO clinical
staging system and AIDS case definitions. The revisions made were based upon
the best available evidence or, where evidence was inconclusive or unavailable,
on the balance of expert opinion. This present document describes the interim
WHO clinical staging system and case definitions as agreed during the second
meeting, held in Nairobi.
9. INTERIM WHO CLINICAL STAGING OF HIV/AIDS AND HIV/AIDS CASE DEFINITIONS FOR SURVEILLANCE AFRICAN REGION3
The revisions are also designed to reflect that with the use of ART HIV is a
chronic disease. ART changes the prognosis and can reverse the inevitable
progression through the clinical stages.
The revisions were designed to strengthen clinical staging and the AIDS case
definitions for both adults and children, and to simplify and standardize
definitions for use by a cross-section of health providers, programme managers
and surveillance officers. They were also intended to harmonize paediatric
and adult clinical staging and AIDS case definitions so as to improve patient
management, patient monitoring and surveillance efforts.
The aims of the proposed revisions were to:
◗ provide greater consistency between the adult and paediatric staging
systems;
◗ harmonize clinical case definitions and surveillance definitions;
◗ provide clinical and immunological staging for adults and children
based upon the degree of immunocompromise and prognosis, but that
facilitates follow up care;
◗ provide guidance on the care of children aged under 18 months, in
whom persisting maternal antibodies make it difficult to definitively
diagnose HIV infection if virological or P24 antigen testing is not readily
available;
◗ facilitate the use of the clinical staging system and HIV/AIDS case
definitions by non-specialist and non-paediatric health care workers at
the basic level and in peripheral health care facilities;
◗ assist with clinical decision-making, including decisions on starting,
substituting, switching and stopping ART, and with routine follow up
of patients on treatment;
◗ permit the inclusion of laboratory testing, especially CD4 count, where
available, so as to guide prognosis and assist in determining the need
for ART and other therapies;
◗ provide surveillance definitions for advanced stages of HIV infection
which reflect disease requiring ART either immediately or in the near
future.
The clinical staging is presented in two summary tables (1 and 4). Table 1 is to
be is used for those who are 15a years and above for whom there is confirmed
laboratory evidence of HIV infection. Table 4 concerns infants and children
aged under 15 years with confirmed laboratory evidence of HIV infection. An
a The cut off age of 15 years is applied as this is the usual cut off for surveillance definitions.
10. 4
additional classification for presumptive diagnosis of clinical stage 4 (severe HIV
infection) in infants under 18 months is also available for use in situations where
definitive diagnosis of HIV infection is not readily available.
Clinical events are categorized as those where a presumptive clinical
diagnosis may be made (conditions that can be diagnosed clinically or with basic
laboratory tests) and those where a definitive diagnosis may be made (for
conditions requiring more complex and sophisticated laboratory investigations).
Also given are explanatory notes, proposed immunological staging categories,
implications for criteria to initiate ART and proposed harmonized definitions of
advanced HIV/AIDS for the purposes of surveillance. Clinical staging needs to
be performed at determination or confirmation of HIV infection, and on entry to
clinical care (pre-ART) to help guide ART and care related decisions. Assessment
of clinical stage at each clinical visit also provides useful information on current
clinical status, and can guide clinical decision making. National guidelines for
the clinical management of HIV/AIDS can be modified on this basis.
Annex 1 addresses issues related to the recognition and diagnosis of clinical
events in adults and adolescents, and key decisions related to clinical events
pre-ART and while on ART; Annex 2 does the same for infants and children.
11. INTERIM WHO CLINICAL STAGING OF HIV/AIDS AND HIV/AIDS CASE DEFINITIONS FOR SURVEILLANCE AFRICAN REGION5
REVISED WHO CLINICAL STAGING OF HIV/AIDS
FOR ADULTS AND ADOLESCENTS
(Interim African Region version for persons aged 15 years or more with positive HIV antibody test or
other laboratory evidence of HIV infection)b
TABLE 1. REVISED WHO CLINICAL STAGING OF HIV/AIDS FOR ADULTS AND ADOLESCENTS
Primary HIV infection
Asymptomatic
Acute retroviral syndrome
Clinical stage 1
Asymptomatic
Persistent generalized lymphadenopathy (PGL)
Clinical stage 2
Moderate unexplained weight loss (<10% of presumed or measured body weight)
Recurrent respiratory tract infections (RTIs, sinusitis, bronchitis, otitis media, pharyngitis)
Herpes zoster
Angular cheilitis
Recurrent oral ulcerations
Papular pruritic eruptions
Seborrhoeic dermatitis
Fungal nail infections of fingers
Clinical stage 3
Conditions where a presumptive diagnosis can be made on the basis of clinical
signs or simple investigations
Severe weight loss (>10% of presumed or measured body weight)
Unexplained chronic diarrhoea for longer than one month
Unexplained persistent fever (intermittent or constant for longer than one month)
Oral candidiasis
Oral hairy leukoplakia
Pulmonary tuberculosis (TB) diagnosed in last two years
Severe presumed bacterial infections (e.g. pneumonia, empyema, pyomyositis, bone or
joint infection, meningitis, bacteraemia)
Acute necrotizing ulcerative stomatitis, gingivitis or periodontitis
Conditions where confirmatory diagnostic testing is necessary
Unexplained anaemia (<8 g/dl), and or neutropenia (<500/mm3) and or
thrombocytopenia (<50 000/ mm3) for more than one month
b All clinical events or conditions referred to are described in the Annexes. The UN defines
adolescents as persons aged 10−19 years but, in the present document, the category of
adults and adolescents comprises people aged 15 years and over for surveillance purposes.
12. 6
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 TB
Kaposi’s sarcoma
Central nervous system (CNS) toxoplasmosis
HIV encephalopathy
Conditions where confirmatory diagnostic testing is necessary:
Extrapulmonary cryptococcosis including meningitis
Disseminated non-tuberculous mycobacteria infection
Progressive multifocal leukoencephalopathy (PML)
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
13. INTERIM WHO CLINICAL STAGING OF HIV/AIDS AND HIV/AIDS CASE DEFINITIONS FOR SURVEILLANCE AFRICAN REGION7
EXPLANATORY NOTES
The 2005 revised clinical staging system for adults and adolescents is designed to:
◗ be used where HIV infection is confirmed by HIV antibody or virological
testing;
◗ harmonize with newly proposed immunological criteria
◗ harmonize with revised HIV/AIDS surveillance definitions
For clinical management purposes it is designed to:
◗ be used for assessment at baseline or entry into HIV care to guide
decisions on when to start cotrimoxazole prophylaxis, start ART and
other HIV related interventions;
◗ provide simple guidance to assist clinical care providers on when to start,
substitute, switch or stop ART in HIV-infected adults and adolescents,
or to trigger referral as outlined in the WHO ART guidelines for a public
health approach(2);
◗ be used to assess current clinical status of individuals in HIV care, either
on or off ART;
◗ encourage clinical care providers to offer diagnostic testing for HIV in
adults and adolescents exhibiting the clinical events suggestive of HIV
disease;
◗ prompt urgent offer of HIV diagnostic testing for stage 3 or stage
4 events either on site, or by referral for testing to a site where
immediate assessment by HIV care providers able to initiate ART can be
performed;
◗ be used to guide clinicians in assessing the response to ART, particularly
where viral load and/or CD4 counts or percentages are not widely or
easily available (new or recurrent stage 4 events may suggest failure
of response to treatment; new or recurrent stage 2 or stage 3 events
may suggest an inadequate response to treatment, potentially because
of poor adherence; however further evidence is required in order to
determine the significance of staging events once ART has commenced.
Clinical events in the first three months after ART has begun may be
caused by immune restoration syndrome (IRS) rather than a poor
response to ART).
Note: Total lymphocyte count (TLC) is not currently recommended for
monitoring therapy.
14. 8
Annex 1 provides further descriptions of each clinical event and their diagnosis
clinically or with basic laboratory or radiological investigations (presumptive
diagnosis) and on requirements for more sophisticated investigations (definitive
diagnosis).
For surveillance purposes it is designed to:
◗ classify disease in a progressive sequence from least to most severe and
remains hierarchical (with only the first stage 3 or stage 4 clinical event
requiring notification);
◗ be used with reference to current clinical events, meaning those that
have been diagnosed or are currently being managed;
◗ be considered in relation to previous clinical events, such as reported
TB, severe pneumonia, PCP or other conditions; this is retrospective
clinical staging for surveillance.
IMMUNOLOGICAL STAGING OF HIV INFECTION
Clinical staging can be used effectively without access to CD4 or other
laboratory testing. However, CD4 testing is useful for determining the degree
of immunocompromise, and where CD4 facilities are available they should be
used to support and reinforce clinical decision-making. Data on CD4 levels are
not a prerequisite for starting ART and should only be used in conjunction with
consideration of the clinical stage. Table 2 presents CD4 levels in relation to the
severity of immunosuppression.
For clinical purposes long term prognosis has been shown to be related to the
nadir or lowest-ever value of CD4. It should be noted that the immunological
staging of disease reverses with successful ART.
TABLE 2. CD4 LEVELS IN RELATION TO THE SEVERITY OF IMMUNOSUPPRESSION
Not significant immunosuppression >500/mm3
Mild immunosuppression 350 −499/mm3
Advanced immunosuppression 200−349/mm3
Severe immunosuppression <200/mm3
15. INTERIM WHO CLINICAL STAGING OF HIV/AIDS AND HIV/AIDS CASE DEFINITIONS FOR SURVEILLANCE AFRICAN REGION9
IMPLICATIONS FOR CLINICAL AND IMMUNOLOGICAL CRITERIA FOR
INITIATING ART IN ADULTS AND ADOLESCENTS
There is strong evidence for the clinical benefit of ART in adults with advanced
HIV/AIDS as determined clinically or immunologically. The precise clinical and
or immunological criteria for initiating ART is usually outlined in national
treatment guidelines. Existing WHO recommendations are provided on a
WHO web site (2).
TABLE 3. CLINICAL AND IMMUNOLOGICAL CRITERIA FOR INITIATING ART IN ADULTS
AND ADOLESCENTS
Clinical stage ART
4 Treat.
3
Consider treatment: CD4, if available, can guide
the urgency with which ART should be started.
1 or 2 Only if CD4 <200/mm3.
CD4 can be used to monitor responses to treatment, although they are not
essential. Absolute CD4 values also fluctuate with intercurrent illness and
with physiological and test variability, so the trend over two or three repeated
measurements is usually more informative than individual values. Note: that
during the course of acute HIV infection the CD4 count may reach very low
levels and then recover.
16. 10
PROPOSED HARMONIZED DEFINITIONS OF ADVANCED
HIV/AIDS DISEASE FOR SURVEILLANCE IN
ADULTS AND ADOLESCENTS
AIDS case definitions first developed in 1982 were primarily designed as an
epidemiological tool for surveillance purposes. Various revisions over the next
two decades led to inclusion of clinical and laboratory criteria to the surveillance
definitions. WHO introduced a clinical case definition for surveillance in 1985,
and revised this in 1986 and 1994 to include serological testing for HIV.
‘AIDS’ as a term has also been used to describe the various clinical syndromes,
specific opportunistic infections or malignancies that occur with HIV infection
and signal those in whom advanced HIV infection has occurred. There has been
confusion between surveillance definitions and clinical staging definitions. These
guidelines seek to harmonize both. In the present context of scaling up ART the
purpose of surveillance is to monitor the burden of advanced HIV disease and
allow estimates of the number of people who require or may shortly require
ART.
Including a CD4 threshold in surveillance definitions specifies the level at which
advanced HIV related immunosuppression is deemed to have occurred and from
which intervention with ART is immediately or soon needed to offset disease
progression. For surveillance purposes once the clinical OR immunological trigger
event has occurred the patient should be captured only once in surveillance
data, regardless of ART or other treatment interventions or outcomes.
BOX 1. ADVANCED HIV/AIDS DISEASE DEFINITIONS FOR SURVEILLANCE
Any clinical stage 3 or stage 4 disease
or,
where CD4 is availablec, any clinical stage and CD4 <350/mm3.
c CD4 based reporting remains optional
17. INTERIM WHO CLINICAL STAGING OF HIV/AIDS AND HIV/AIDS CASE DEFINITIONS FOR SURVEILLANCE AFRICAN REGION11
REVISED WHO CLINICAL STAGING OF HIV/AIDS FOR
INFANTS AND CHILDREN
(INTE RIM AFRICAN RE GION VE RSION FOR P E RSONS AGE D UNDE R 15 YE ARS W ITH
CONfiRM E D LAB ORATORY E VIDE NCE OF HIV INFE CTION: HIV ANTIB ODY IF AGE D 18 M ONTHS AND
AB OVE ; VIROLOGICAL OR P24 ANTIGE N TE STING IF AGE D UNDE R 18 M ONTHS)D
TABLE 4. REVISED WHO CLINICAL STAGING OF HIV/AIDS FOR INFANTS AND CHILDREN
Clinical Stage 1
Asymptomatic
PGL
Clinical Stage 2
Hepatosplenomegaly
Papular pruritic eruptions
Seborrhoeic dermatitis
Extensive human papilloma virus infection
Extensive molluscum contagiosum
Fungal nail infections
Recurrent oral ulcerations
Lineal gingival erythema (LGE)
Angular cheilitis
Parotid enlargement
Herpes zoster
Recurrent or chronic RTIs (otitis media, otorrhoea, sinusitis)
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
d All clinical events or conditions referred to are described in the Annexes.
18. 12
Conditions where confirmatory diagnostic testing is necessary
Chronic HIV-associated lung disease including brochiectasis
Lymphoid interstitial pneumonitis (LIP)
Unexplained anaemia (<8g/dl), and or neutropenia (<1000/mm3) and or
thrombocytopenia (<50 000/ mm3) 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 TB
Kaposi’s sarcoma
Oesophageal candidiasis
CNS 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
19. PRESUMPTIVE DIAGNOSIS OF CLINICAL STAGE 4 HIV IN
CHILDREN AGED UNDER 18 MONTHS
The presumptive diagnosis is designed for use where access to confirmatory
diagnostic testing for HIV infection by means of virological testing (usually nucleic
acid testing, NAT) or P24 antigen testing for infants and children aged under 18
months is not readily available. It is not recommended for use by clinical care
providers who are not trained in ART or experienced in HIV care. It should
be accompanied by immediate efforts to confirm the HIV diagnosis with the best
nationally or locally available test for age. Presumptive diagnosis of clinical stage 4
disease suggests severe immunosuppression, and ART is indicated.
BOX 2. PRESUMPTIVE CLINICAL STAGE 4 IN INFANTS AND CHILDREN AGED UNDER
18 MONTHS WHERE VIROLOGICAL CONFIRMATION OF HIV INFECTION IS NOT AVAILABLE
A presumptive diagnosis of stage 4 clinical disease
should be made if:
An infant is HIV-antibody positive (ELISA or rapid test), aged under 18 months
and symptomatic with two or more of the following:
+/– oral thrush;
+/– severe pneumoniae
+/– severe wasting/malnutrition
+/– severe sepsisf
CD4 values, where available, may be used to guide decision-making; CD4
percentages below 25% require ART
Other factors that support the diagnosis of clinical stage 4 HIV infection in an
HIV-seropositive infant are:
• recent HIV related maternal death
• advanced HIV disease in the mother.
Confirmation of the diagnosis of HIV infection should be sought as soon as
possible.
EXPLANATORY NOTES
The 2005 revised clinical staging system for infants and children is designed to:
◗ be used where HIV infection is confirmed by HIV antibody or virological
testing;
◗ harmonize with newly proposed immunological criteria
◗ harmonize with revised HIV/AIDS surveillance definitions
e Pneumonia requiring oxygen.
f Requiring intravenous therapy.
INTERIM WHO CLINICAL STAGING OF HIV/AIDS AND HIV/AIDS CASE DEFINITIONS FOR SURVEILLANCE AFRICAN REGION13
20. For clinical management purposes it is designed to:
◗ be used for assessment at baseline or entry into HIV care to guide
decisions on when to start cotrimoxazole prophylaxis, start ART and
other HIV related interventions;
◗ provide simple guidance to assist clinical care providers on when to
start, substitute, switch or stop ART in HIV-infected children, or to
trigger referral as outlined in the WHO ART guidelines for a public
health approach(2);
◗ be used to assess current clinical status of children in HIV care, either on
or off ART;
◗ encourage clinical care providers to offer HIV diagnostic testing in infants
and children exhibiting clinical events suggestive of HIV disease;
◗ prompt urgent referral for diagnostic HIV testing and assessment for all
Stage 3 or stage 4 events in children where HIV status is unknown or a
child is known to be HIV exposed;
◗ be used to guide clinicians in assessing the response to ART, particularly
where viral load and/or CD4 counts or percentages are not widely
or easily available (however, further evidence is required in order to
determine the significance of staging events once ART has been started;
new or recurrent stage 4 events may suggest a failure of response to
treatment; new or recurrent stage 2 or stage 3 events may suggest
an inadequate response to treatment, potentially attributable to poor
adherence); note that clinical events in the first three months after
starting ART may be attributable to IRS rather than a poor response to
ART; this is reported less commonly in children;
Note: Total lymphocyte count (TLC) is not currently recommended for
monitoring therapy.
Annex 2 provides further descriptions of each clinical event and their diagnosis
clinically or with basic laboratory or radiological investigations (presumptive
diagnosis) and on requirements for more sophisticated investigations (definitive
diagnosis).
For surveillance purposes it is designed to;
◗ classify disease in a progressive sequence from least to most severe and
remains hierarchical (with only the first stage 3 or stage 4 clinical event
requiring notification);
◗ be used with reference to current clinical events, meaning those that
have been diagnosed or are currently being managed;
14
21. INTERIM WHO CLINICAL STAGING OF HIV/AIDS AND HIV/AIDS CASE DEFINITIONS FOR SURVEILLANCE AFRICAN REGION15
◗ be considered in relation to previous clinical events, such as reported
TB, severe pneumonia, PCP or other conditions; this is retrospective
clinical staging for surveillance.
IMMUNOLOGICAL CATEGORIES FOR PAEDIATRIC
HIV INFECTION
Immunological staging for children is also possible. The absolute CD4 count
and the percentage values in healthy infants who are not infected with HIV
are considerably higher than those observed in uninfected adults, and slowly
decline to adult values by the age of 6 years. In considering absolute counts
or percentages, therefore, age must be taken into account as a variable. The
absolute CD4 count associated with a specific level of immunosuppression tend
to change with age, whereas the CD4 percentage related to immunological
damage does not vary as much. Currently, therefore, the measurement of
the CD4 percentage is recommended in younger children. CD4 testing is not
essential for the initiation of ART, and should only be used in conjunction with
the clinical stage. As for adults, immunological staging assists clinical decision-
making and provides a link with monitoring and surveillance definitions. It is
usually reversed by successful ART.
TABLE 5. CD4 LEVELS IN RELATION TO THE SEVERITY OF IMMUNOSUPPRESSION
Immune status
Age
Up to 12
months
13-59
months
5 years or
over
Not significant immunosuppression >35% >25% >500/mm3
Mild immunosuppression 25−34% 20−24% 350−499/mm3
Advanced immunosuppression 20−24% 15−19% 200−349/mm3
Severe immunosuppression <20% <15% <200/mm3
22. 16
IMPLICATIONS FOR CLINICAL AND IMMUNOLOGICAL
CRITERIA FOR INITIATING ART
Although there are concerns about the early use of ART in asymptomatic infants,
all children with stage 3 or stage 4 disease (advanced HIV defined clinically)
should start ART following discussion with their families. There is very strong
evidence for the clinical benefit of ART in children with advanced HIV/AIDS. For
older children some clinical conditions, e.g. LIP, appear to have a more stable
clinical course, although there are few data on cohorts from African settings.
Because of the revisions in clinical staging these recommendations should
replace those provided in the 2003 WHO reference guide (2).
TABLE 6. CLINICAL AND IMMUNOLOGICAL CRITERIA FOR INITIATING ART IN
INFANTS AND CHILDREN
Clinical stages ART
4 Treat.
Presumptive stage 4 Treat.
3
Consider treatment for all ages. Children aged
under 2 years usually require ART.
CD4 %, if available should be used to guide
decisions on ART.
1 and 2
Usually only where CD4 available.
Under 12 months: CD4 % <20
13-59 months : CD4 % <15
5 years or over CD4 <200/mm3
Note: co-trimoxazole prophylaxis should be given to all HIV-exposed infants
and children until HIV infection is excluded and to all HIV-infected infants and
children
CD4 can be used to monitor responses to treatment, although it is not essential.
Absolute CD4 values also fluctuate with intercurrent illness and with physiological
and test variability, so the trend over two or three repeated measurements is
usually more informative than individual values.
23. INTERIM WHO CLINICAL STAGING OF HIV/AIDS AND HIV/AIDS CASE DEFINITIONS FOR SURVEILLANCE AFRICAN REGION17
PROPOSED HARMONIZED DEFINITIONS OF ADVANCED
HIV/AIDS DISEASE FOR SURVEILLANCE IN
CHILDREN AGED UNDER 15 YEARS
The surveillance of paediatric HIV/AIDS can provide estimates of the number
of infants and children who require or may shortly require ART. AIDS case
definitions for surveillance have until recently only been provided by CDC and
include laboratory criteria. There has been confusion between surveillance
definitions and clinical staging definitions.
These guidelines propose age-related clinical and immunological case definitions
of advanced HIV/AIDS disease in infants and children for surveillance purposes.
Age-related definitions are required because of the age-related changes in
immunological markers. Advanced HIV disease for surveillance purposes should
be reported only once for each individual.
BOX 3. ADVANCED HIV/AIDS DISEASE DEFINITIONS FOR SURVEILLANCE FOR
INFANTS AND CHILDREN
Clinical stage 3 or stage 4 disease at any age
or
where CD4 is availableg, any clinical stage with
• CD4 % <25% in children aged under 12 months
• CD4 % <20% in children aged 12 -59 months
• CD4 <350/mm3 in children aged 5 years and above
g CD4 based reporting remains optional
24. 18
RECOMMENDATIONS FOR IMPLEMENTATION
The following recommendations concern the use of the revised clinical staging
and HIV/AIDS case definitions for clinical management and case-reporting.
◗ The revised clinical staging should be used to update and strengthen
national guidelines so as to ensure that they provide clear guidance on
which clinical and immunological stages require or are eligible for co-
trimoxazole prophylaxis and ART treatment and support patient follow up.
◗ All infants, children, adolescents and adults with clinical stage 3 or stage
4 disease should be reported as having advanced HIV/AIDS disease. Such
case reports can be used to calculate the burden of HIV/AIDS which
immediately requires or will soon require ART. HIV/AIDS reporting for
surveillance should preserve patient confidentiality in accordance with
existing national or international recommendations.
◗ National HIV/AIDS programmes should be encouraged to support
CD4-based HIV/AIDS case-reporting for surveillance.
The following additional recommendations concern actions facilitating the
use of the interim clinical staging system and HIV/AIDS case definitions for
surveillance.
Actions at the global and regional level:
◗ At the global level, WHO should publish details of the new HIV/AIDS
clinical staging.
◗ At the global level, WHO should develop and disseminate guidelines
on the use of the revised HIV clinical staging system and of the revised
case definitions.
◗ At the regional level, WHO should organize intercountry meetings in
order to introduce the revisions and to encourage rapid implementation
in countries.
◗ WHO and CDC should incorporate the proposed revisions to
surveillance definitions into surveillance training materials that are
under development.
◗ WHO and CDC should provide technical support for the adoption and
scaling-up for implementation of these revisions in countries.
◗ WHO and CDC should provide technical support for the development
of systems for reporting AIDS-related deaths.
◗ WHO and CDC will hold a meeting during the fourth quarter of 2006
in order to review and update the clinical staging system and case
definitions.
25. INTERIM WHO CLINICAL STAGING OF HIV/AIDS AND HIV/AIDS CASE DEFINITIONS FOR SURVEILLANCE AFRICAN REGION19
Actions at the national level
◗ Ministries of health and their partners should organize national
consensus meetings on the proposed revisions, and should adapt and
repackage the regional guidelines in accordance with existing national
specifications in a way that is appropriate for use at different levels of
health service delivery.
◗ Ministries of health should integrate the proposed revisions into
existing guidelines and procedures for HIV/AIDS clinical management
and HIV/AIDS case-reporting.
◗ Ministries of health should organize in-country training in order to build
capacity for the implementation of the revisions, including integration
into the curricula of relevant professional and non-professional training
institutions.
◗ Ministries of health should produce simplified wall charts, laminated
desk-top guides, pocket guides and other materials facilitating the use
of the recommended revisions.
◗ Ministries of health should establish systems for HIV/AIDS reporting in
children at a few sentinel sites where children are seen to improve and
strengthen the provision of information on children with HIV/AIDS.
◗ Ministries of health should ensure that reliable systems are in place for
reporting AIDS-related deaths.
26. 20
ANNEX 1.
WHO CLINICAL STAGING FOR ADULTS AND ADOLESCENTS:
PRESUMPTIVE AND DEFINITIVE CRITERIA FOR RECOGNIZING
HIV/AIDS-RELATED CLINICAL EVENTS
(For use in adults and adolescents aged 15 years and above with laboratory evidence of HIV infection.)
Clinical event Presumptive diagnosis Definitive diagnosis
Primary HIV infection
Asymptomatic Detectable core P24
antigen and high blood HIV
RNA, profound temporary
lymphopenia and other
transient blood abnormalities
may occur. Not usually HIV
antibody-positive until after
symptoms.
Seroconversion from HIV Ab-
negative to Ab-positive.
Acute retroviral syndrome Acute febrile illness 2−4 weeks
post-exposure, often with
lymphadenopathy, pharyngitis
and skin manifestations.
Clinical Stage 1
Asymptomatic No symptoms reported and no
signs on examination.
Not required.
Persistent generalized
lymphadenopathy
(PGL)
Swollen or enlarged lymph
nodes >1 cm, in two or more
non-contiguous sites, excluding
inguinal nodes, in absence of
known cause.
Not required but can be
confirmed by histology
(germinal centre hyperplasia,
lymph node structure
preserved).
Clinical Stage 2
Moderate unexplained weight
loss (<10% of presumed or
measured body weight)
Reported weight loss but no
obvious thinning of face or
body.
Confirmed by documented
weight loss.
Recurrent presumed bacterial
RTI
(two or more in any six-month
period)
Symptom complex, e.g.
unilateral face pain with
nasal discharge (sinusitis) or
painful swollen eardrum (otitis
media), cough with purulent
sputum (bronchitis), sore throat
(pharyngitis). Two or more
documented occurrences of
antibiotic- responsive URTI.
Not required but may be
confirmed by laboratory studies
where available, e.g. culture of
suitable body fluid.
27. INTERIM WHO CLINICAL STAGING OF HIV/AIDS AND HIV/AIDS CASE DEFINITIONS FOR SURVEILLANCE AFRICAN REGION21
Clinical event Presumptive diagnosis Definitive diagnosis
Herpes zoster Painful rash of small fluid-
filled blisters in distribution
of a nerve supply, can be
haemorrhagic on erythematous
background, and does not
cross midline. Current or in
the last two years. Severe or
frequently recurrent herpes
zoster is usually associated
with more advanced HIV
disease.
Not required.
Angular cheilitis Splits or cracks on lips at
the angle of the mouth with
depigmentation, usually
responds to antifungal
treatment but may recur.
Also common in nutritional
deficiency, e.g. of B vitamins.
Not required.
Recurrent oral ulcerations
occurring twice or more in six
months
Aphthous ulceration,
typically with a halo of
inflammation and a yellow-grey
pseudomembrane.
Not required.
Papular pruritic eruptions Papular pruritic vesicular
lesions. Also common in
uninfected adults.
Note: scabies and obvious
insect bites should be excluded.
Not required.
Seborrhoeic dermatitis Itchy scaly skin condition,
particularly affecting scalp,
face, upper trunk and
perineum. Also common in
uninfected adults.
Not required.
Fungal nail infections of fingers Fungal paronychia (painful
red and swollen nail bed) or
onycholysis (separation of the
nail from the nail bed) of the
fingernails. Also common in
uninfected adults. Proximal
white subungual onchomycosis
is uncommon without
immunodeficiency.
Not required but confirmed by
culture of nail scrapings.
28. 22
Clinical Stage 3
Clinical event Presumptive diagnosis Definitive diagnosis
Severe unexplained weight loss
(more than 10% of presumed
or measured body weight)
Reported weight loss without
trying, and noticeable thinning
of face, waist and extremities.
Documented loss of more than
10% of body weight.
Unexplained chronic diarrhoea
for longer than one month
Chronic diarrhoea (loose or
watery stools three or more
times daily) reported for longer
than one month.
Not required but confirmed if
three or more stools observed
and documented as unformed,
and two or more stool tests
reveal no pathogens on
microscopy and culture and no
faecal leukocytes.
Unexplained persistent fever
(intermittent or constant and
for longer than one month)
Reports of fever or night
sweats for more than one
month, either intermittent or
constant with reported lack
of response to antibiotics or
antimalarials. No other obvious
foci of disease reported or
found on examination. Malaria
must be excluded in malarious
areas.
Not required but confirmed if
documented fever >37.5 °C
with negative blood culture,
negative Ziehl-Nielsen (ZN)
stain, negative malaria slide,
normal or unchanged chest X-
ray (CXR) and no other obvious
foci of disease.
Oral candidiasis Persistant creamy white
to yellow soft small
plaques on red or normally
coloured mucosa which
can often be scraped off
(pseudomembranous), or red
patches on tongue, palate or
lining of mouth, usually painful
or tender (erythematous
form), not responding to local
antifungal treatment.
Not required.
Oral hairy leukoplakia Fine small linear patches on
lateral borders of the tongue,
generally bilaterally, which do
not scrape off.
Not required.
29. INTERIM WHO CLINICAL STAGING OF HIV/AIDS AND HIV/AIDS CASE DEFINITIONS FOR SURVEILLANCE AFRICAN REGION23
Clinical event Presumptive diagnosis Definitive diagnosis
Pulmonary TB
(current or in last two years)
Chronic (symptoms lasting
three or more weeks)
productive cough, haemoptysis,
shortness of breath, weight
loss, fever, night sweats
and fatigue, no resolution
of symptoms with standard
broad-spectrum antibiotics,
positive ZN stain.
Response to standard anti-TB
treatment in one month.
Note: TB diagnosis and
treatment should follow
national or international
guidelines.
CD4 should be used where
possible to guide therapy; very
low CD4 may require urgent
ART.
Not required but confirmed by
positive sputum culture.
Severe presumed bacterial
infection (e.g. pneumonia,
meningitis, empyema,
pyomyositis, bone or joint
infection, bacteraemia )
Fever accompanied by specific
symptoms or signs that localize
infection, and response to
antibiotic.
Not required but confirmed
by bacteria isolated from
appropriate clinical specimens.
Acute necrotizing ulcerative
gingivitis or necrotizing
ulcerative periodontitis
Severe pain, ulcerated gingival
papillae, loosening of teeth,
spontaneous bleeding, bad
odour, and rapid loss of bone
and/or soft tissue.
Not required.
Unexplained anaemia (<8g/dl),
neutropenia (<1000/mm3) or
thrombocytopenia(<50000/mm3)
for more than one month
No presumptive clinical
diagnosis.
Diagnosed on laboratory
testing and not explained by
other non-HIV conditions. Not
responding to standard therapy
with haematinics, antimalarials
or anthelmintics as outlined
in relevant national treatment
guidelines, WHO guidelines or
other relevant guidelines.
Clinical Stage 4
30. 24
Clinical event Presumptive diagnosis Definitive diagnosis
HIV wasting syndrome Unexplained weight loss
greater than 10% of body
weight and visible thinning of
face, waist and extremities;
plus
either unexplained chronic
diarrhoea (lasting more than
one month)
or
unexplained prolonged or
intermittent fever for one
month or more.
Confirmed by documented
weight loss without trying;
plus
documented unformed stools
negative for pathogens;
negative for modified ZN;
or
Documented temperature of
37.5 °C or more on occasions
with no obvious foci of disease,
negative blood culture, negative
malaria slide and normal or
unchanged CXR.
Pneumocystis pneumonia Dry cough, progressive
shortness of breath, especially
on exertion, with cyanosis,
tachypnoea and fever,
response to high-dose co-
trimoxazole +/– prednisolone.
Bilateral crepitations on
auscultation with or without
reduced air entry.
CXR may show typical bilateral
interstitial infiltrate with bat
wing appearance.
Not required but confirmed by:
microscopy of induced sputum
or bronchoalveolar lavage
(BAL), or histology of lung
tissue.
Recurrent severe or radiological
bacterial pneumonia (two or
more episodes within one year)
Two episodes of fever, wet
cough, fast and difficult
breathing and chest pain.
Consolidation on clinical
examination and CXR.
Response to antibiotics.
Not required but confirmed
by culture or antigen test from
appropriate specimen.
Chronic herpes simplex virus
(HSV) infection (orolabial,
genital or anorectal of more
than one month, or visceral of
any duration)
Severe and progressive painful
orolabial, genital, or anorectal
lesions caused by recurrent
HSV infection reported for
more than one month. History
of previous episodes. Scarring
from previous episodes may be
evident.
Not required for mucocutanoues
HSV but required for visceral
HSV. Suggestive symptoms of
organ damage, e.g. bronchitis,
pneumonitis, oesophagitis,
colitis, encephalitis, supported
by histology or culture.
31. INTERIM WHO CLINICAL STAGING OF HIV/AIDS AND HIV/AIDS CASE DEFINITIONS FOR SURVEILLANCE AFRICAN REGION25
Clinical event Presumptive diagnosis Definitive diagnosis
Oesophageal candidiasis Chest pain and dysphagia
(difficulty in swallowing),
odynophagia (pain on
swallowing food and fluids),
or retrosternal pain worse on
swallowing (food and fluids)
+/– oral Candida. Responds
to antifungal treatment.
Not required but confirmed by
macroscopic appearance at
endoscopy or bronchoscopy,
microscopy or histology.
Extrapulmonary/disseminated
TB
Systemic illness usually with
prolonged fever, night sweats,
weakness and weight loss.
Clinical features of organs
involved, e.g. focal
lymphadenopathy, cold
abscess, sterile pyuria,
pericarditis, ascites, pleural
effusion, meningitis, arthritis,
orchitis, lupus vulgaris.
CXR may reveal diffuse
uniformly distributed small
miliary shadows
Response to standard anti-TB
treatment in one month.
Not required but confirmed by
acid-fast bacilli (AFBs) seen in
microscopy of cerebrospinal
fluid (CSF), effusion, lymph
node aspirate, urine, etc.
Mycobacteria TB isolated from
blood culture or any appropriate
specimen except sputum or
BAL.
Histology (e.g. pleural or
pericardial biopsy).
CXR may show interstitial
infiltrates.
Lymphocytic CSF with
typical abnormalities, no
bacterial growth and negative
cryptococcal antigen (CRAG).
Kaposi’s sarcoma Typical appearance in skin
or oropharynx of persistent,
initially flat, patches with a
pink or blood-bruise colour,
skin lesions that usually
develop into nodules. Can
be confused clinically with
bacillary angiomatosis, non-
Hodgkin lymphoma and
cutaneous fungal or bacterial
infections.
Not required but may be
confirmed by :
• typical red-purple lesions
seen on bronchoscopy or
endoscopy;
• dense masses in lymph nodes,
viscera or lungs by palpation
or radiology;
• histology.
32. 26
Clinical event Presumptive diagnosis Definitive diagnosis
CMV (retinitis or CMV infection
of an organ other than liver,
spleen or lymph nodes)
Retinitis only.
CMV retinitis may be diagnosed
by experienced clinicians.
Progressive floaters in field
of vision, light flashes and
scotoma.
Typical eye lesions on serial
fundoscopic examination;
discrete patches of retinal
whitening with distinct borders,
spreading centrifugally, often
following blood vessels,
associated with retinal
vasculitis, haemorrhage and
necrosis.
Definitive diagnosis required for
other sites. Symptoms and signs
of other organ involvement,
e.g. pneumonitis, pancreatitis,
colitis, cholecystitis, not
responding to co-trimoxazole
or antibiotics. Histology. CSF
polymerase chain reaction
(PCR).
CNS toxoplasmosis Fever, headache, focal
neurological signs, convulsions.
Rapid response (within 10
days) to high-dose
co-trimoxazole, or
pyrimethamine and
sulphadiazine or clindamycin.
Not required but confirmed by
computed tomography (CT)
scan showing single/multiple
lesions with mass effect/
enhancing with contrast.
If lumbar puncture (LP)
performed, CSF nonspecific or
normal. Resolution of findings
after treatment if patient
survives.
Cryptococcal meningitis
or other extrapulmonary
Cryptococcus infection
Meningitis: usually subacute,
fever with increasing severe
headache, meningism,
confusion, behavioural changes.
Responds to antifungal
therapy.
Confirmed by CSF microscopy
(India ink or Gram stain).
Serum or CSF CRAG-positive or
culture-positive.
HIV encephalopathy Clinical finding of disabling
cognitive and/or motor
dysfunction interfering with
activities of daily living,
progressing over weeks or
months in the absence of a
concurrent illness or condition
other than HIV infection which
might explain the findings.
LP should be conducted to
exclude other infectious causes.
Recommended to confirm
clinical features and exclude
other causes including
neurosyphilis:
• brain scan by means of
CT or magnetic resonance
imaging (MRI) with
• LP.
33. INTERIM WHO CLINICAL STAGING OF HIV/AIDS AND HIV/AIDS CASE DEFINITIONS FOR SURVEILLANCE AFRICAN REGION27
Clinical event Presumptive diagnosis Definitive diagnosis
Disseminated non-tuberculous
mycobacteria infection
No presumptive diagnosis. Nonspecific clinical symptoms
including progressive weight
loss, fever, anaemia, night
sweats, fatigue or diarrhoea.
Severe anaemia and/or elevated
alkaline phosphatase and/or
(in case of diarrhoea) persisting
AFB in the stool in spite of TB
therapy.
Plus:
Culture of atypical mycobacteria
species from stool, blood,
body fluid or other body tissue,
excluding lung.
PML No presumptive diagnosis. Progressive focal neurological
signs without headache or
fever, cortical blindness,
cerebellar signs, dementia.
Confirmed by consistent MRI
or CT scan, and biopsy. Viral
PCR for Jacob Creutzfeldt virus.
Candidiasis of trachea, bronchi,
lungs
No presumptive diagnosis. Confirmed by symptoms,
clinical signs suggestive of
organ involvement and/or
macroscopic appearance at
bronchoscopy. Histology or
cytology, or microscopy of
specimen from tissue.
Cryptosporidiosis (with
diarrhoea lasting more than one
month)
No presumptive diagnosis. Chronic diarrhoea, often profuse
and watery, with weight loss,
± abdominal pain, nausea,
vomiting; confirmed by modified
ZN microscopic examination
of stool. Stools observed to
be unformed with organism
visualized in stool sample.
Isosporiasis No presumptive diagnosis. Watery diarrhoea, cramps and
weight loss. Symptoms usually
indistinguishable from those of
cryptosporidiosis.
Isosporiaisis responds to high-
dose cotrimoxazole.
34. 28
Clinical event Presumptive diagnosis Definitive diagnosis
Any disseminated mycosis (e.g.
coccidiomycosis, histoplasmosis,
penicilliosis)
No presumptive diagnosis. Clinical symptoms nonspecific,
e.g. skin rash, cough, shortness
of breath, fever, anaemia,
weight loss.
CXR: infiltrates or nodules.
Confirmed by direct microscopy.
Histology: usually granuloma
formation. Isolation: antigen
detection from affected
tissue. Skin lesion culture or
microscopy positive.
Recurrent non-typhoidal
salmonella septicaemia (two or
more episodes in last year )
No presumptive diagnosis. Nonspecific symptoms: fever,
sweats, headaches, weight
loss, diarrhoea and anorexia.
Confirmed by blood culture.
Lymphoma (cerebral or B cell
non-Hodgkin)
No presumptive diagnosis. Symptoms consistent with
lymphoma: lymphadenopathy,
splenomegaly, pancytopenia,
testicular or lung mass lesions;
no response clinically to
antitoxoplasma or anti-TB
treatment.
CNS imaging: at least one
lesion with mass effect on brain
scan; histology.
Invasive cervical carcinoma No presumptive diagnosis. Persistent vaginal discharge,
postcoital or intermenstrual
bleeding unresponsive to
appropriate antibacterial or
antifungal treatment; cervical
lesions visualized. Histology.
Cytology, but not carcinoma
in situ.
Visceral leishmaniasis No presumptive diagnosis. Suggestive symptoms:
malaise, chronic fever,
hepatosplenomegaly,
pancytopenia . Amastigotes
visualized or cultured from any
appropriate clinical specimen.
35. INTERIM WHO CLINICAL STAGING OF HIV/AIDS AND HIV/AIDS CASE DEFINITIONS FOR SURVEILLANCE AFRICAN REGION29
CLINICAL STAGING EVENTS AS A TOOL TO GUIDE
CLINICAL MANAGEMENT IN ADULTS AND ADOLESCENTS
(PRE-ART AND ART FOLLOW-UP CARE)
The same criteria for presumptive and definitive diagnosis apply
Clinical events pre-ART Action
Stage 1 No action required
Stage 2 Requires cotrimoxazole
Stage 3
Or
Stage 4
Requires cotrimoxazole if not already started
Consider ART
First ever occurrence of a stage 3 or 4 event requires notification
for surveillance purposes
Clinical events on ART Action
Stage 1 Consider interruption of cotrimoxazole if stable on ART for
6 months or more.
New or recurrent :
Stage 2
or
stage 3
Check adherence
Treat and manage condition
Restart cotrimoxazole
Should alert the provider to the possibility of poor adherence or
failing response to treatment.
New or recurrent
Stage 4
Check adherence
Treat and manage condition
Restart cotrimoxazole
Consider regimen switch
Suggest failure to respond to ART, possibly because of true failure
of the regimen and/or poor adherence.
36. 30
ANNEX 2.
WHO CLINICAL STAGING FOR INFANTS AND CHILDREN:
PRESUMPTIVE AND DEFINITIVE CRITERIA FOR RECOGNIZING
HIV/AIDS-RELATED CLINICAL EVENTS
(For use in infants and children aged under 15 years with laboratory evidence of HIV infection: HIV
antibody in those aged 18 months and above, DNA or RNA virological testing or P24 antigen testing
for those aged under 18 months.)
Highlighted events are still awaiting further data for clarification of definitions
Clinical event Clinical diagnosis Definitive diagnosis
Clinical Stage 1
Asymptomatic No symptoms reported and no
signs on examination.
Not required.
PGL Swollen or enlarged lymph
nodes >1 cm at two or more
non-contiguous sites, without
known cause.
Not required.
(Histology; germinal centre
hyperplasia, lymph node
structure preserved.)
Clinical Stage 2
Hepatosplenomegaly Unexplained enlarged liver or
spleen.
Not required.
Papular pruritic eruptions Persistent papular pruritic
vesicular lesions; scabies
should be excluded.
Not required.
Seborrhoeic dermatitis Itchy scaly skin condition
particularly affecting scalp, face,
upper trunk and perineum. Also
common in uninfected children
and in babies.
Not required.
Fungal nail infections Fungal paronychia (painful,
red and swollen nail bed)
or onycholysis (painless
separation of the nail from
the nail bed). Proximal white
subungual onchomycosis
is uncommon without
immunodeficiency.
Culture of nail scrape.
37. INTERIM WHO CLINICAL STAGING OF HIV/AIDS AND HIV/AIDS CASE DEFINITIONS FOR SURVEILLANCE AFRICAN REGION31
Clinical event Clinical diagnosis Definitive diagnosis
Angular cheilitis Splits or cracks on lips at
the angle of the mouth with
depigmentation, usually
responding to antifungal
treatment but may recur.
Also common in nutritional
deficiency, e.g. of B vitamins.
Not required.
LGE Erythematous band that
follows the contour of the
free gingival line; may be
associated with spontaneous
bleeding.
Uncommon in HIV-uninfected
children.
Not required.
Human papilloma virus infection
(extensive facial, more than 5%
of body area or disfiguring)
Characteristic skin lesions;
warts; small fleshy grainy
bumps, often rough, on sole of
feet are flat (plantar warts).
Also common in uninfected
children.
Not required.
Molluscum contagiosum
infection
(extensive facial, more than 5%
of body area or disfiguring)
Characteristic skin lesions:
small flesh-coloured, pearly
or pink, dome-shaped or
umbilicated growths, may be
inflamed or red.
Also common in uninfected
children.
Not required.
Recurrent oral ulcerations
(two or more in six months)
Aphthous ulceration,
typically with a halo of
inflammation and a yellow-grey
pseudomembrane.
Not required.
Parotid enlargement Asymptomatic bilateral swelling
that may spontaneously resolve
and recur, in absence of other
known cause, usually painless.
Uncommon in HIV-uninfected
children.
Not required.
38. 32
Clinical event Clinical diagnosis Definitive diagnosis
Herpes zoster Painful rash with fluid-
filled blisters, dermatomal
distribution, can be
haemorrhagic on erythematous
background, and can become
large and confluent. Does not
cross the midlines. Note: severe
persistent herpes zoster may
have worse prognosis.
Viral culture, histology, EM of
lesion fluid.
Recurrent RTI
(twice or more in any six-month
period)
Symptom complex, e.g. fever
with unilateral face pain and
nasal discharge (sinusitis)
or painful swollen eardrum
(otitis media), sore throat with
productive cough ( bronchitis),
sore throat (pharyngitis) and
barking croup-like cough (LTB).
Persistent or recurrent ear
discharge.
Not required but may be
confirmed by laboratory or
X-ray studies where available,
especially for sinus, and culture
or appropriate specimens.
Clinical Stage 3
Unexplained moderate
malnutrition (very low weight-
for-age: up to −2 standard
deviations (SDs) (3, 4); not
responding adequately to
standard therapy,
Unexplained weight loss
or failure to gain weight
not explained by poor or
inadequate feeding or other
infections , and not adequately
responding within two weeks
to standard management ,
Documented loss of body
weight, failure to gain weight
on standard management and
no other cause identified during
investigation.
Unexplained persistent
diarrhoea
(14 days and above)
Unexplained persistent
diarrhoea (loose or watery
stool, three or more times
daily), not responding to
standard treatment.
Not required, but confirmed
if stools observed and
documented as unformed.
Culture and microscopy reveal
no pathogens.
Unexplained persistent fever
(intermittent or constant and
for longer than one month)
Reports of fever or night
sweats for longer than one
month, either intermittent or
constant, with reported lack
of response to antibiotics or
antimalarials.
No other obvious foci of
disease reported or found on
examination. Malaria must be
excluded in malarious areas.
Not required but confirmed if
documented fever of >37.5 °C
with negative blood culture,
negative malaria slide and
normal or unchanged CXR,
and no other obvious foci of
disease.
39. INTERIM WHO CLINICAL STAGING OF HIV/AIDS AND HIV/AIDS CASE DEFINITIONS FOR SURVEILLANCE AFRICAN REGION33
Clinical event Clinical diagnosis Definitive diagnosis
Oral candidiasis
(outside first 6 weeks of live)
Persistent creamy white to
yellow soft small plaques
on red or normally coloured
mucosa, easily scraped off
(pseudomembranous), or red
patches on tongue, palate
or lining of mouth, usually
painful or tender, responding to
antifungal treatment.
Microscopy or culture.
Oral hairy leukoplakia Fine small linear patches on
lateral borders of tongue,
generally bilaterally, which do
not scrape off.
Not required.
Pulmonary TB Nonspecific symptoms,
e.g. chronic cough, fever,
night sweats, anorexia and
weight loss. In the older child
also productive cough and
haemoptysis. Response to
standard anti-TB treatment in
one month.
Note: diagnosis should be
made in accordance with
national guidelines.
Abnormal CXR plus positive
sputum smear, or culture.
Severe recurrent presumed
bacterial pneumonia
Cough with fast breathing,
chest indrawing, nasal flaring,
wheezing, and grunting.
Crackles or consolidation on
auscultation. Responds to
course of antibiotics.
Not required but confirmed by
isolation of bacteria from
appropriate
clinical specimens.
Acute necrotizing ulcerative
gingivitis or stomatitis, or
acute necrotizing ulcerative
periodontitis
Severe pain, ulcerated gingival
papillae, loosening of teeth,
spontaneous bleeding, bad
odour, and rapid loss of bone
and/or soft tissue.
Not required.
40. 34
Clinical event Clinical diagnosis Definitive diagnosis
Symptomatic LIP No presumptive clinical
diagnosis.
CXR: bilateral reticulonodular
interstitial pulmonary infiltrates
present for more than two
months with no response
to antibiotic treatment and
no other pathogen found.
Oxygen saturation persistently
<90%. May present with
cor pulmonale and may have
increased exercise-induced
fatigue.
Frequently confused with
miliary TB.
Chronic HIV-associated
lung disease (including
brochiectasis)
No presumptive clinical
diagnosis.
History of cough productive of
copious amounts of purulent
sputum, with or without
clubbing, halitosis, and
crepitations and/or wheezes
on auscultation; CXR may
show honeycomb appearance
(small cysts) and/or persistent
areas of opacification and/or
widespread lung destruction,
with fibrosis and loss of
volume. CT scan of chest may
be used to confirm.
Unexplained anaemia (<8g/dl),
and or neutropenia (<500/
mm3) and or thrombocytopenia
(<50 000/ mm3) for longer
than one month
No presumptive clinical
diagnosis.
Diagnosed on laboratory
testing, not explained by other
non-HIV conditions, or not
responding to standard therapy
with haematinics, antimalarials
or anthelmintics as outlined in
IMCI.
41. INTERIM WHO CLINICAL STAGING OF HIV/AIDS AND HIV/AIDS CASE DEFINITIONS FOR SURVEILLANCE AFRICAN REGION35
Clinical Stage 4
Clinical event Clinical diagnosis Definitive diagnosis
Unexplained severe wasting
or severe malnutrition not
adequately responding to
standard therapy
Persistent weight loss not
explained by poor or inadequate
feeding, other infections and
not adequately responding in
two weeks to standard therapy.
Characterized by:
visible severe wasting of
muscles, with or without
oedema of both feet, and/or
weight-for-height of –3 SDs, as
defined by WHO IMCI guidelines.
Documented loss of weight or
failure to gain weight.
Pneumocystis pneumonia (PCP) Dry cough, progressive
shortness of breath, cyanosis,
tachypnoea and fever; chest
indrawing or stridor. Response
to high-dose co-trimoxazole
+/– prednisolone.
(Severe or very severe
pneumonia as in IMCI). Usually
of sudden onset and very
severe in infants under six
months of age .
Microscopy of induced sputum
or BAL, or histology of lung
tissue.
CXR shows typical bilateral
perihilar diffuse infiltrates.
Recurrent severe presumed
bacterial infection (two or
more episodes in one year),
e.g. meningitis, empyema,
pyomyositis, bone or joint
infection, bacteraemia
Fever accompanied by specific
symptoms or signs that
localize infection. Responds to
antibiotics.
Not required but confirmed
by bacteria isolated from
appropriate clinical specimens
and includes recurrent
non-typhoidal salmonella
septicaemia.
Chronic herpes simplex virus
infection (chronic orolabial or
intraoral lesions of more than
one month or visceral of any
duration)
Severe and progressive painful
orolabial or skin lesions
attributable to recurrent HSV
reported for more than one
month. History of previous
episodes. Scarring from
previous episodes may be
evident.
Visceral HSV requires
confirmation. Suggestive
symptoms of organ damage,
e.g. bronchitis, pneumonitis,
oesophagitis, colitis,
encephalitis, supported by
histology or culture.
42. 36
Clinical event Clinical diagnosis Definitive diagnosis
Oesophageal candidiasis Chest pain and dysphagia
(difficulty in swallowing),
odynophagia (pain on
swallowing food and fluids),
or retrosternal pain worse on
swallowing (food and fluids)
+/– oral Candida. Responds
to antifungal treatment.
May be difficult to detect in
young children. Suspect if oral
Candida observed and if refusal
occurs or if there are difficulties
or crying when feeding.
Not required but confirmed
by macroscopic appearance
at endoscopy, microscopy
of specimen from tissue or
macroscopic appearance at
bronchoscopy or histology.
Extrapulmonary TB TB not limited to lungs.
Systemic illness usually with
prolonged fever, night sweats,
weight loss.
Clinical features of organs
involved, e.g. focal
lymphadenopathy, cold
abscess, sterile pyuria,
pericarditis, ascites, pleural
effusion, meningitis, arthritis,
orchitis, lupus vulgaris.
Responds to standard anti-TB
therapy.
Note: simple lymph gland
extrapulmonary TB may have a
better prognosis.
Mycobacterium TB isolated
form blood culture or other
specimen except sputum
or BAL. Positive AFB on
microscopy or culture on
relevant specimens.
Biopsy and histology. X-ray.
Kaposi’s sarcoma Typical appearance in skin or
oropharynx, initially flat patches
with a pink or blood-bruise
colour, usually developing into
nodules.
Typical red-purple lesions seen
on bronchoscopy or endoscopy.
Biopsy.
43. INTERIM WHO CLINICAL STAGING OF HIV/AIDS AND HIV/AIDS CASE DEFINITIONS FOR SURVEILLANCE AFRICAN REGION37
Clinical event Clinical diagnosis Definitive diagnosis
CMV retinitis and CMV
infection of organs other than
liver, spleen or lymph nodes,
with onset at age over 1 month
No presumptive clinical
diagnosis.
Clinically, disease suspected if
there are typical eye lesions on
serial fundoscopic examination;
discrete patches of retinal
whitening with distinct borders,
spreading centrifugally, often
following blood vessels,
associated with retinal vasculitis,
haemorrhage and necrosis.
Symptoms and signs of organ
involvement, e.g. typical eye
lesions on fundoscopy or
pneumonitis not responding to
co-trimoxazole or antibiotics.
Histology or detection of
antigen from affected tissue.
CNS toxoplasmosis
(outside the neonatal period )
Fever, headache, focal
neurological signs, convulsions.
Response to high-dose co-
trimoxazole or pyrimethamine
and sulphadiazine or
clindamycin.
CT scan showing single/
multiple lesions with mass
effect/enhancing with
contrast. CSF results normal or
nonspecific.
Resolution of findings after
treatment if patient survives.
Cryptococcal meningitis Meningitis: usually subacute,
fever with increasing severe
headache, irritability,
meningism, confusion,
behavioural changes. Responds
to antifungal therapy
CSF: microscopy (India ink or
Gram stain)
Positive serum CRAG test.
HIV encephalopathy At least one of the following,
progressing over at least two
months in the absence of
another illness:
• gross discrepancy between
the actual and developmental
age, failure to attain, or loss
of, developmental milestones,
loss of intellectual ability;
or
• progressive impaired brain
growth demonstrated
by stagnation of head
circumference;
or
• acquired symmetric motor
deficit accompanied by two
or more of the following:
paresis, pathological reflexes,
ataxia, gait disturbances.
Brain CT scan or MRI to exclude
other causes.
44. 38
Clinical event Clinical diagnosis Definitive diagnosis
Any disseminated mycosis
(e.g. histoplasmosis,
coccidiomycosis, penicilliosis)
No presumptive clinical
diagnosis.
Organ-specific and nonspecific
symptoms, e.g. may cause skin
rash, or cough, shortness of
breath, fever, anaemia, weight
loss.
Diagnosis confirmed by direct
microscopy, histology or antigen
detection in relevant specimens.
CXR may show infiltrates or
nodules.
Candidiasis of the trachea,
bronchi or lungs
No presumptive clinical
diagnosis.
Macroscopic appearance at
endoscopy.
Microscopy and culture of
specimen from endoscopic
tissue.
Disseminated mycobacteriosis,
other than TB
No presumptive clinical
diagnosis.
Nonspecific clinical symptoms
including progressive weight
loss, fever, anaemia, night
sweats, fatigue or diarrhoea;
plus
culture of atypical mycobacteria
species from stool, blood,
body fluid or other body tissue,
excluding lung.
Cryptosporidiosis
(with diarrhoea lasting more
than one month)
No presumptive clinical
diagnosis.
Chronic diarrhoea, often
profuse and watery, with
weight loss, ± abdominal pain,
nausea, vomiting, but usually
mild or no fever. Confirmed by
microscopic examination on
modified ZN stain.
Isosporiasis No presumptive clinical
diagnosis.
Chronic diarrhoea, often
profuse and watery, with
weight loss, ± abdominal pain,
nausea, vomiting. Isosporiasis
responds to high-dose co-
trimoxazole.
45. INTERIM WHO CLINICAL STAGING OF HIV/AIDS AND HIV/AIDS CASE DEFINITIONS FOR SURVEILLANCE AFRICAN REGION39
Clinical event Clinical diagnosis Definitive diagnosis
Cerebral or B cell non-Hodgkin
lymphoma
No presumptive clinical
diagnosis.
Symptoms consistent with
lymphoma: lymphadenopathy,
hepatosplenomegaly,
pancytopenia, besides other
nonspecific or organ-specific
symptoms. No response
clinically to antitoxoplasma or
anti-TB treatment.
CNS imaging: at least one
lesion with mass effect on
brain scan, and no response
to antitoxoplasma and anti-TB
treatment. Cytology. Histology.
Response to chemotherapy.
PML No presumptive clinical
diagnosis.
Progressive focal neurological
signs without headache or
fever. Cortical blindness and
cerebellar signs. Convulsions
are rare. MRI or CT scan
Acquired HIV-associated rectal
fistula, including rectovaginal
fistula
Further information and
evidence relating to this
condition and its definition are
being sought. Case reports from
African countries suggest that it
is highly specific to HIV and that
the prognosis is poor. Clinical
features suggestive, exclusion of
other causes, faecal discharge
through the vagina or urethra,
or urine discharge through the
rectum in an HIV-infected child
usually following an episode of
diarrhoea.
46. 40
Clinical event Clinical diagnosis Definitive diagnosis
HIV-associated nephropathy No presumptive clinical
diagnosis.
Further information and
evidence relating to this
condition and its definition
are being sought. Symptoms
and signs suggestive of renal
disease, with no other obvious
cause identified. Early morning
urine protein/creatinine ratio
of >200mg/mmol in absence
of a urinary tract infection
and absence of an axillary
temperature of 38.0 ºC. Renal
biopsy and histology.
HIV-associated cardiomyopathy No presumptive clinical
diagnosis.
Further information and
evidence relating to this
condition and its definition are
being sought. Exclusion of other
causes of congestive cardiac
failure. The left ventricle and
right ventricle are enlarged. The
end-diastolic and end-systolic
dimensions of the left or right
ventricle are increased (2 SDs
from the mean for body surface
area), with a reduced fractional
shortening and ejection
fraction (2 SDs from the mean).
Echocardiography check.
47. INTERIM WHO CLINICAL STAGING OF HIV/AIDS AND HIV/AIDS CASE DEFINITIONS FOR SURVEILLANCE AFRICAN REGION41
CLINICAL STAGING EVENTS AS A TOOL TO GUIDE
CLINICAL MANAGEMENT FOR INFANTS AND CHILDREN
(PRE-ART AND ART FOLLOW-UP CARE)
The same criteria for presumptive and definitive diagnosis apply
Clinical events pre-ART Action
Stage 1 May require cotrimoxazole
Stage 2 Requires cotrimoxazole
Stage 3
Or
stage 4
Requires cotrimoxazole if not already started
Consider ART
Notification for surveillance purposes of first ever occurrence of
a stage 3 or 4 event.
Clinical events on ART Action
Stage 1 Currently not advised to discontinue cotrimoxazole in children
under 5 years.
New or recurrent :
Stage 2
or
stage 3
Check adherence, provide support
Treat and manage condition
Should alert the provider to the possibility of poor adherence or
failing response to treatment.
New or recurrent
Stage 4
Check adherence, provide support
Treat and manage condition
Consider ART regimen switch
Suggests failure to respond to ART, possibly because of true
failure of the regimen and/or poor adherence.
48. 42
KEY REFERENCES
1. http://www.who.int/hiv/strategic/surveillance/definitions/en/
2. http://www.who.int/3by5/publications/documents/arv_guidelines/en/
3. http://www.who.int/child-adolescent-health/publications/child_health/who_fch_
cah_00.1.htm
4. http://www.who.int/nut/documents/manage_severe_malnutrition_eng.pdf
5. Oral Manifestations of HIV in the Developing and Developed World. Proceedings
and abstracts of the 4th International Workshop on Oral Manifestations of HIV
Infection. Oral Dis. 2002; 8 Suppl 2:6-8.
6. Mortality of infected and uninfected infants born to HIV-infected mothers in Africa:
a pooled analysis. The Lancet 2004; 364:1236-1243. Marie Louise Newell, Hoosen
Coovadia, Marjo Cortina-Borja, Nigel Rollins, Philippe Gaillard & Francois Dabis.
Available at :
http://www.thelancet.com/journals/lancet/article/PIIS0140673604171407/fulltext
7. Co-trimoxazole as prophylaxis against opportunistic infections in HIV-infected
Zambian children (CHAP): a double-blind randomized placebo-controlled trial
C Chintu b, GJ Bhat b, AS Walker a, V Mulenga b, F Sinyinza b, K Lishimpi b, L
Farrelly , N Kaganson , A Zumla , SH Gillespie , AJ Nunn and DM Gibb on behalf of
the CHAP trial team. Available at:
http://www.thelancet.com/journals/lancet/article/PIIS0140673604174424/fulltext
8. PENTA guidelines for the use of antiretroviral therapy, 2004 M Sharland,
S Blanche, G Castelli, J Ramos and DM Gibb on behalf of the PENTA Steering
Committee. Available at http://www.ctu.mrc.ac.uk/penta/guidelin.pdf
9. US The Working Group on Antiretroviral Therapy and Medical Management of
HIV-Infected Children.Guidelines for the Use of Antiretroviral Agents in Pediatric
HIV Infection .March 24, 2005. Available at: http://aidsinfo.nih.gov/guidelines/
default_db2.asp?id=51
49. For more information, contact:
WORLD HEALTH ORGANIZATION
Department of HIV/AIDS
20, avenue Appia
CH-1211 Geneva 27
Switzerland
E-mail: hiv-aids@who.int
http://www.who.int/hiv/en