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

Revised World Health Organization (WHO) Clinical Staging of HIV/AIDS For Adults and Adolescents (2005)

(This is the interim African Region version for persons aged 15 years or more who have had a positive HIV antibody test or other laboratory evidence of HIV infection) (The United Nations defines adolescents as persons aged 10−19 years but for surveillance purposes, the category of adults and adolescents comprises people aged 15 years and over)

Primary HIV infection

• Asymptomatic
• Acute retroviral syndrome

Clinical stage 1

• Asymptomatic
• Persistent generalized lymphadenopathy

Clinical stage 2

• Moderate and unexplained weight loss (
• Recurrent respiratory tract infections (such as sinusitis, bronchitis, otitis media, pharyngitis)
• Herpes zoster
• Recurrent oral ulcerations
• Papular pruritic eruptions
• Angular cheilitis
• Seborrhoeic dermatitis
• Onychomycosis (fungal nail infections)

Clinical stage 3

Conditions where a presumptive diagnosis can be made on the basis of clinical signs or simple investigations

• Unexplained chronic diarrhoea for longer than one month
• Unexplained persistent fever (intermittent or constant for longer than one month)
• Severe weight loss (10% of presumed or measured body weight)
• Oral candidiasis
• Oral hairy leukoplakia
• Pulmonary tuberculosis (TB) diagnosed in last two years
• Severe presumed bacterial infections (e.g. pneumonia, empyema, meningitis, bacteraemia, pyomyositis, bone or joint infection)
• Acute necrotizing ulcerative stomatitis, gingivitis or periodontitis

Conditions where confirmatory diagnostic testing is necessary

• Unexplained anaemia (

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)
• Esophageal candidiasis
• Extrapulmonary tuberculosis
• Kaposi's sarcoma
• Central nervous system toxoplasmosis
• HIV encephalopathy

Conditions where confirmatory diagnostic testing is necessary

• Extrapulmonary cryptococcosis including meningitis
• Disseminated non-tuberculous mycobacteria infection
• Progressive multifocal leukoencephalopathy
• Candida of trachea, bronchi or lungs
• Cryptosporidiosis
• Isosporiasis
• Visceral herpes simplex infection
• Cytomegalovirus (CMV) infection (retinitis or of an organ other than the liver, spleen or lymph nodes)
• Any disseminated mycosis (e.g. histoplasmosis, coccidioidomycosis, penicilliosis)
• Recurrent non-typhoidal salmonella sepsis
• Lymphoma (cerebral or B cell non-Hodgkin)
• Invasive cervical carcinoma
• Visceral leishmaniasis

Original proposal in 1990

Clinical Stage I

• Asymptomatic
• Generalised lymphadenopathy
• In some cases symptoms similar to those of cold flue would be manifested. Performance scale: 1: asymptomatic, normal activity.

Clinical Stage II

• Weight loss,
• Minor mucocutaneous manifestations (seborrheic dermatitis, prurigo, fungal nail infections, recurrent oral ulcerations, angular cheilitis)
• Herpes zoster within the last five years
• Recurrent upper respiratory tract infections (i.e. bacterial sinusitis)

And/or performance scale 2: symptomatic, normal activity.

Clinical Stage III

• Weight loss, 10% of body weight
• Unexplained chronic diarrhoea 1 month
• Unexplained prolonged fever (intermittent or constant), 1 month
• Oral [candidiasis] ([thrush])
• Oral hairy leucoplakia
• Pulmonary tuberculosis
• Severe bacterial infections (i.e. pneumonia, pyomyositis)

And/or performance scale 3: bedridden

Clinical Stage IV

The declaration of AIDS

• HIV wasting syndrome *
• Pneumocystis carinii pneumonia
• Toxoplasmosis of the brain
• Cryptosporidiosis with diarrhoea 1 month
• Cryptococcosis, extrapulmonary
• Cytomegalovirus disease of an organ other than liver, spleen or lymph node (ex: retinitis)
• Herpes simplex virus infection, mucocutaneous (1 month) or visceral
• Progressive multifocal leucoencephalopathy
• Any disseminated endemic mycosis
• Candidiasis of esophagus, trachea, bronchi
• Atypical mycobacteriosis, disseminated or lungs
• Non-typhoid Salmonella septicemia
• Extrapulmonary tuberculosis
• Lymphoma
• Kaposi's sarcoma
• HIV encephalopathy **

And/or performance scale 4: bedridden 50% of the day during last month.

(*) 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).

(**) 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.

References