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WHO Staging System for HIV/AIDS in Resource Limiting Settings Unit 5 HIV Basics: A Course for Physicians.

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Presentation on theme: "WHO Staging System for HIV/AIDS in Resource Limiting Settings Unit 5 HIV Basics: A Course for Physicians."— Presentation transcript:

1 WHO Staging System for HIV/AIDS in Resource Limiting Settings Unit 5 HIV Basics: A Course for Physicians

2 2 Learning Objectives  Describe how the WHO staging system is used to assist management of HIV/AIDS  List the clinical conditions that characterize each WHO stage of HIV/AIDS

3 3 Introductory Case: Lake  33 year old male presents to ART clinic for initial evaluation. He has a history of Zoster. He reports diarrhea, intermittent fever, and itching. He stopped working as a merchant one month ago due to fatigue.  What additional information is necessary for accurate WHO staging of this patient?

4 4 Introductory Case: Lake (2)  Diarrhea occurred daily, was non-bloody, and began 2 months ago  Fever began 2 months ago  Wt loss of 8 kg (50 ->42kg) over last 6 months  History of PTB treatment 1 year ago  No cough, night sweats  Exam revealed thrush and papular rash on trunk and extremities  CXR normal  Stool exam normal  HCT 9 g/dl

5 5 WHO Staging System for HIV/AIDS: Overview  Tool used to guide management of HIV patient in resource limited settings with limited laboratory access  Clinically based; CD4 count not required  Simple, flexible and widely used  Recently revised: Interim African version 2005  Utilizes 5 clinical stages based on the degree of immunocompromise and prognosis Primary HIV Infection, I,II, III, IV

6 6 WHO Staging System for HIV/AIDS: Overview (2)  Performed at each clinical visit Diagnosis Entry to clinical care (pre-ART) Follow-up  Stage assessment can be adjusted upwards or downwards over time according to response to ART and/or clinical progression

7 7 WHO Staging of HIV/AIDS  Primary HIV Infection  Stage I - asymptomatic  Stage II - mild disease  Stage III - moderate disease  Stage IV - advanced immunocompromise

8 8 WHO Stage I  Asymptomatic or  Persistent generalized lymphadenopathy (PGL)

9 9 Persistent Generalized Lymphadenopathy (PGL) Courtesy of Charles Steinberg MD

10 10 WHO Stage II  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

11 11 Pruritic Papular Eruption (PPE)  Epidemiology Substantial cause of HIV-related morbidity in sub- Saharan Africa Prevalence ranges from 12-46% Uncommon in HIV negative patients (PPV of 82-87%; may play role in diagnosing HIV) Probably related to hypersensitivity to arthropod bites

12 12 Pruritic Papular Eruption (2)  Clinical Manifestations Intensely pruritic, discrete, firm, papules; variable stages of development Excoriation results in pigmentation, scarring and nodules Predilection for extremities, but may involve trunk and face Severity of rash correlates with CD4 count  Treatment Topical steroid and oral antihistamines; however often refractory

13 13 Pruritic Papular Eruption Courtesy of Charles Steinberg MD

14 14 Pruritic Papular Eruption Courtesy of Charles Steinberg MD

15 15 Apthous Ulcer Source: Copyright © David Reznik, D.D.S.

16 16 Herpes Zoster Courtesy of Tom Thacher, MD Courtesy of the Public Health Image Library/CDC

17 17 Herpes Zoster Courtesy of Samuel Anderson, MD

18 18 Molluscum Contagiosum

19 19 WHO Stage III  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 diarrhea for > one month Unexplained persistent fever (intermittent or constant for > 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, bacteremia) Acute necrotizing ulcerative stomatitis, gingivitis or periodontitis

20 20 WHO Stage III (2)  Conditions where confirmatory diagnostic testing is necessary Unexplained anemia (<8 g/dl), and or neutropenia (<500/mm3) and or thrombocytopenia (<50 000/ mm3) for more than one month

21 21 Oral Candidiasis Courtesy of Samuel Anderson, MD Courtesy of Dr. R. Ojoh

22 22 Oral Candidiasis (2) Source:

23 23 Oral Hairy leukoplakia Courtesy of Dr. R. Ojoh

24 24 Pyomyositis  Large muscle groups, may be bilateral  Pathophysiology unclear  Tends to occur with advanced HIV infection  Diagnosis requires: High index of suspicion CT, ultrasonography  Staphylococcus aureus is the most commonly implicated organism  Treatment usually requires needle aspiration and/or surgical incision and drainage in addition to intravenous antibiotics

25 25 Pyomyositis Courtesy of Samuel Anderson, MD

26 26 WHO Stage IV  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

27 27 WHO Stage IV (2)  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

28 28 WHO Stage IV (3)  Conditions where confirmatory diagnostic testing is necessary: 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 septicemia Lymphoma (cerebral or B cell non-Hodgkin) Invasive cervical carcinoma Visceral leishmaniasis

29 29 Severe Chronic Herpes Simplex Ulcers © Slice of Life and Suzanne S. Stensaas

30 30 Disseminated Cutaneous Cryptococcosis Courtesy of Samuel Anderson, MD

31 31 Disseminated cutaneous cryptococcosis (2) Courtesy of Samuel Anderson, MD

32 32 HIV wasting syndrome  Weight loss >10% body weight plus  Unexplained chronic diarrhea (>1 mo) or  Unexplained fever (>1 mo) plus chronic weakness

33 33 HIV encephalopathy (AIDS dementia complex)  Dementia - persistent cognitive decline with preserved alertness  Complex - concomitantly altered motor performance and, at times, behavior; myelopathy may be prominent  Disabling condition that interferes with activities of daily living  Progresses over weeks to months  Absence of concurrent illness or condition that could explain findings  Limited treatment options; ART may be helpful

34 34 Kaposi’s sarcoma  Epidemiology Human herpesvirus-8 (HHV-8) necessary but not sufficient for KS to develop most common AIDS-associated neoplasm increased frequency in all HIV transmission groups compared to the general population  Clinical manifestations Variable, from an indolent process to a disseminated, aggressive disease skin lesions oral lesions others sites

35 35 Kaposi’s Sarcoma: Management  ART: an essential component of KS management; lesions may regress  Local irradiation: bulky/obstructive lesions (e.g. oropharyngeal)  Systemic IFN-alfa: slow progressive disease  Systemic chemotherapy: rapid, life threatening disease including pulmonary or severe lymphedema

36 36 Kaposi’s Sarcoma Courtesy of Tom Thacher, MD

37 37 Kaposi’s Sarcoma Courtesy of Samuel Anderson, MD

38 38 Introductory Case: Lake (3)  The patient was counseled and started on NVP/3TC/d4T. At his 6 month f/u visit, he states that his symptoms have resolved and he has returned to work.  Examination reveals wt of 47kg and a persistent papular lesions with evidence of recent excoriations.  What additional information is necessary for current WHO staging of this patient?

39 39 Introductory Case: Lake (4)  The patient returns again after 12 months of ART. He has developed head ache, anorexia, cough, and unilateral weakness.  What additional information is needed for current WHO staging of this patient?

40 40 Introductory Case: Lake (5)  Wt is now 40kg  Thrush is present  Spastic left hemiparesis is confirmed  CXR normal  Sputum negative for AFB  Any additional information necessary for staging this patient?

41 Case Studies

42 42 Case Study: Betrukan  Betrukan, 19, meets a man she likes very much who lives in the same town. Solomon, handsome, funny and a few years older, has his own butchery. Solomon is unaware that he has been living with HIV for 3 years. Solomon and Bertukan become a couple. They have unprotected sex as Bertukan, a secretary for a medical office, has been on OCPs (oral contraceptive pills) for a year.

43 43 Case Study: Betrukan (2)  Ten days later, Bertukan misses work due to a flu-like illness. She has fever, her joints ache and her glands are swollen.  2 months later, Bertukan decides to be tested for HIV, but Solomon declines. Bertukan feels well. Bertukan gets tested, and is seroreactive.

44 44 Case Study: Betrukan (3) 1.What are some reasons people might not get their test results? 2.What is Bertukan’s WHO classification? 3.What is Solomon’s WHO classification?

45 45 Case Study: Betrukan (4)  Eighteen months later Bertukan and Solomon are expecting their first baby. Her antenatal clinic has been providing HIV information and PMTCT for some time. Group education regarding HIV and safe motherhood includes HIV testing as routine pre-natal care.  She discloses her status to Solomon who has not been feeling well – he has lost 4 kg in the past few weeks and has been having diarrhea. He agrees to HIV testing and his test is positive.

46 46 Case Study: Betrukan (5) 4.What WHO stage is Solomon now? 5.What should happen next at the clinic?

47 47 Case Study: Rahel  37yo Ethiopian woman presents w/1 yr history of oral candidiasis. HIV Elisa negative 1 yr ago. Repeat Elisa was positive and she is referred to your clinic.  PMH: non contributory  SH: lives alone, earns 500 birr/mo, no ETOH, has no current sex partner and no prior use of condoms or birth control  ROS: non-contributory.

48 48 Case Study: Rahel (2)  Tearful woman  T37, Wt 55kg,Ht 5’5”  HEENT: white plaques / pseudomembranes on posterior pharynx, no OHL, no adenopathy  Heart, Lungs, Abd: normal  Skin: seborrheic dermatitis of face  Pelvic: thick, white discharge, KOH+

49 49 Case Study: Rahel (3) 1.What is her current WHO stage? 2.Is she a candidate for ART? 3.What are the immediate health care issues to be addressed at initial visit? 4.What other issues need to be addressed before ART is considered?

50 50 Key Points  WHO Staging of HIV/AIDS is an important tool used for management of HIV in resource limited settings  Staging is based on clinical conditions that correlate with the degree of immunocompromise and prognosis  Staging should be assessed at time of HIV diagnosis, prior to starting ART, and with each follow-up visit to assess response to ART


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