If CD4 Testing Available

WHO Stage IV disease irrespective of CD4 cell count· WHO Stage III disease (including but not restricted to HIV wasting, chronic diarrhoea of unknown etiology, prolonged fever of unknown etiology, pulmonary tuberculosis, recurrent invasive Bacterial infections, or recurrent/persistent mucosal candidiasis) with consideration of using CD4 cell counts < 350/mm3 to assist decision making WHO Stage I or II disease with CD4 cell counts = 200/mm3

If CD4 Testing Unavailable

WHO Stage IV disease irrespective of total lymphocyte count· WHO Stage III disease (including but not restricted to HIV wasting, chronic diarrhoea of unknown etiology, prolonged fever of unknown etiology, pulmonary tuberculosis, recurrent invasive bacterial infections, or recurrent/persistent mucosal candidiasis) irrespective of total lymphocyte count·

WHO Stage II disease with a total lymphocyte count = 1200/mm3

1. CD4 count advisable to assist with determining need for immediate therapy. For example, pulmonary TB may occur at any CD4 level and other conditions may be mimicked by non-HIV etiologies (e.g., chronic diarrhoea, prolonged fever).
2. The precise CD4 level above 200/mm3 at which ARV treatment to start has not been established.
3. A total lymphocyte count of = 1200/mm3 can be substituted for the CD4 count when the latter is unavailable and HIVrelated symptoms (Stage II or III) exist. It is not useful in the asymptomatic patient. Thus, in the absence of CD4 cell testing, asymptomatic HIV infected patients (WHO Stage I) should not be treated because there is currently no other reliable marker available in severely resource constrained settings.

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

Clinical Stage I:
1. Asymptomatic
2. Generalized lymphadenopathy Performance scale: 1: asymptomatic, normal activity
   Clinical Stage II:
3. Weight loss, < 10% of body weight
4. Minor mucocutaneous manifestations (seborrheic dermatitis, prurigo, fungal nail infections, recurrent oral ulcerations, angular cheilitis)
5. Herpes zoster within the last five years
6. Recurrent upper respiratory tract infections (i.e. bacterial sinusitis) And/or performance scale 2: symptomatic , normal activity
   Clinical Stage III:
7. Weight loss, > 10% of body weight
8. Unexplained chronic diarrhoea, > 1 month
9. Unexplained prolonged fever (intermittent or constant) , > 1 month
10. Oral candidiasis (thrush)
11. Oral hairy leucoplakia
12. Pulmonary tuberculosis
13. Severe bacterial infections (i.e. pneumonia, pyomyositis) And/or performance scale 3: bedridden < 50% of the day during last month.
    WHO – Scaling up antiretroviral therapy in resource-limited settings – 2003 Revision ( DRAFT VERSION )
    Clinical Stage IV:
14. HIV wasting syndrome (1)
15. Pneumocystis carinii pneumonia
16. Toxoplasmosis of the brain
17. Cryptosporidiosis with diarrhoea > 1 month
18. Cryptococcosis, extrapulmonary
19. Cytomegalovirus disease of an organ other than liver, spleen or lymph node (ex: retinitis)
20. Herpes simplex virus infection, mucocutaneous (>1month) or visceral
21. Progressive multifocal leucoencephalopathy
22. Any disseminated endemic mycosis
23. Candidiasis of esophagus, trachea, bronchi
24. Atypical mycobacteriosis, disseminated or lungs
25. Non-typhoid Salmonella septicemia
26. Extrapulmonary tuberculosis
27. Lymphoma
28. Kaposi’s sarcoma
29. HIV encephalopathy (2) And/or performance scale 4: bedridden > 50% of the day during last month.
    1. HIV wasting syndrome: weight loss of > 10% of body weight, plus either unexplained chronic diarrhoea (> 1 month) or chronic weakness and unexplained prolonged fever (> 1 month).
    2. HIV encephalopathy: clinical findings of disabling cognitive and/or motor dysfunction interfering with activities of daily living, progressing over weeks to months, in the absence of a concurrent illness or condition other than HIV infection which could explain the findings.
    WHO – Scaling up antiretroviral therapy in resource-limited settings – 2003 Revision ( DRAFT VERSION )

Clinical Stage I:
1. Asymptomatic
2. Generalized lymphadenopathy
   Clinical Stage II:
3. Chronic diarrhoea >30 days duration in absence of known etiology
4. Severe persistent or recurrent candidiasis outside the neonatal period
5. Weight loss or failure to thrive in the absence of known etiology
6. Persistent fever >30 days duration n the absence of known etiology
7. Recurrent severe bacterial infections other than septicemia or meningitis (e.g., osteomyelitis, bacterial (non-TB) pneumonia, abscesses)
   Clinical Stage III:
8. AIDS defining opportunistic infections
9. Severe failure to thrive (“wasting”) in the absence of known etiology (*)
10. Progressive encephalopathy
11. Malignancy
12. Recurrent septicemia or meningitis

(*) persistent weight loss > 10% of baseline, or less than 5th percentile on weight for height chart on 2 consecutive measurements more than 1 month apart in the absence of another etiology or concurrent illness)