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Clinical and Immunological Staging in HIV-infected Children HAIVN Harvard Medical School AIDS Initiative in Vietnam 1 Learning Objectives By the end of this session, participants should be able to: Explain the purposes of clinical and immunological staging, and their applications Determine the clinical stage of an HIV patient Identify the severely immunosuppressed category for each age group 2 Clinical Staging 3 Clinical Staging Based on classification developed by WHO Purposes: • To determine severity of clinical disease • To determine when to start antiretroviral therapy • After ART started, to monitor for response to treatment Clinical staging ranges from stage 1 (mildest), to stage 4 (most severe) 4 Application of Clinical Staging in Relation to ARV Treatment Before ARV: Identify highest clinical stage patient has reached Purpose: Determine eligibility for ARV treatment After Starting ARV: Re-evaluate current clinical status of patient Purpose: Assess clinical improvement in response to ARV treatment 5 Remember The purpose of giving the highest clinical stage is to ensure patient receives ART timely The purpose of clinical staging after ART is to monitor for treatment response All of HIV-infected children should have clinical stage identified at every visit 6 WHO Pediatric Stages: Stage 1 Asymptomatic Persistent generalized lymphadenopathy 7 WHO Pediatric Stages: Stage 2 Most frequently seen: Hepatosplenomegaly Papular pruritic eruption Recurrent or chronic upper respiratory tract infections Herpes zoster (zona) Angular cheilitis Recurrent oral ulceration 8 Stage 2 Diseases (1) Linear gingival erythema Zona 9 Stage 2 Diseases (2) Herpes varicella zoster (zona) 10 Stage 2 Diseases (3) PPE: lower arms and legs, leaves scars after resolution 11 Stage 2 Diseases (4) Bilateral parotid enlargement 12 WHO Pediatric Stages: Stage 3 Most frequently seen: Moderate malnutrition or wasting Diarrhea >14 days Fever for >1 month Oral candidiasis Pulmonary, lymph node TB Severe recurrent bacterial pneumonia Anemia, neutropenia or chronic thrombocytopenia 13 Stage 3 Diseases (3) Lymphocytic interstitial pneumonitis: 14 Typical nodular infiltrates mainly at the hilar areas WHO Pediatric Stages: Stage 4 Most frequently seen: Severe wasting/malnutrition PCP (pneumocystis pneumonia) Recurrent severe bacterial infection* Extrapulmonary TB (except lymph node TB) Systemic fungal infections CMV Herpes simplex infections > 1 month HIV encephalopathy 15 Stage 4 Diseases (1) Herpes Simplex chronic infection (>1 month) 16 Stage 4 Diseases (2) Penicillium Marneffei skin lesions: Flesh-color, umbilicated papules concentrated mainly on 17 face, back, arms, and legs Case Study 18 Case Study: Binh (1) Binh is a five-month old baby, presented with severe wasting, pulmonary TB, and oral thrush. He is also anemic with HgB of 6.5g/dL. List his clinical conditions and assign staging What stage is Binh at now? 19 Case Study: Binh (2) Binh was treated for TB and placed on ART. 6 months later, had significant weight gain, asymptomatic, tolerated ARV well. What stage is Binh at now? 20 Case Study: Tin Tin, a 9-month old infant was recently diagnosed with HIV. On questioning about past medical history, you found that he has had multiple admissions for pneumonia On exam he had small (<1cm) lymph nodes on his neck, axilla, and inguinal areas, and splenomegaly List his clinical conditions and assign staging What stage is Tin at now? 21 Immunological Staging 22 CD4 Percentage/Count Children •Absolute CD4 count is generally not <5 used due to: high fluctuation between measurements age-related decline •CD4 percentage (%) is preferred because it is more constant Children •CD4 count is used because its pattern >5 is similar to that of adults 23 Immunological Staging (1) CD4 percentage and CD4 count reflect the severity of immunosuppression in the HIVinfected patient Purpose of immunological staging is to: • • • • • • Classify severity of disease Anticipate what OI’s are most likely Know when to start prophylactic therapy Know when to start ART Monitor for immune recovery on treatment Prognosticate 24 Immunological Staging (2) <11 months 12-35 months 36-59 months ≥ 5 yrs Not > 35% significant > 30% > 25% > 500 cells Mild 25 – 30% 20 – 25% 350−499 cells 20−24% 15−20% 200−349 cells 30 – 35% Advanced 25 – 29% Severe <25% <20% <1500 cells <750 cells <15% <350 cells <15% <200 cells Key Points WHO clinical staging classifies patient into 4 categories based on clinical manifestations Both clinical staging and CD4 count/percentage are used to: • determine eligibility for OI prophylaxis and ART • assess patient’s response to ART 26 Thank you! Questions? 27