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The clinical events used to categorize HIV disease among infants, children, adolescents or adults living with HIV are divided into those for which a presumptive clinical diagnosis may be made (where syndromes or conditions can be diagnosed clinically or with basic ancillary investigations) and those requiring a definitive diagnosis (generally conditions described according to causation requiring more complex or sophisticated laboratory confirmation). Table 1 provides the clinical stage in simplified terms describing the spectrum of HIV related symptomatology, asymptomatic, mild symptoms, advanced symptoms and severe symptoms. We can summarize the clinical staging events, and further details of the specific events and the criteria for recognizing them. The clinical stage is useful for assessment at baseline (first diagnosis of HIV infection) or entry into long-term HIV care and in the follow-up of patients in care and treatment programs. It should be used to guide decisions on when to start co-trimoxazole prophylaxis and other HIV related interventions, including when to start antiretroviral therapy. The clinical stages have been shown to be related to survival, prognosis and progression of clinical disease without antiretroviral therapy in adults and children.
Clinical assessment of people receiving antiretroviral therapy Treatment with potent and effective antiretroviral therapy regimens can reverse and improve clinical status in keeping with immune recovery and suppression of viral load. New or recurrent clinical staging events once people are receiving antiretroviral therapy for more than 24 weeks may be used to guide decision-making, particularly when the CD4 count is not available. It is assumed that the clinical staging events remain significant among people receiving antiretroviral therapy as they are among children and adults before the start of antiretroviral therapy. In the first 24 weeks of starting an antiretroviral therapy regimen, clinical events appear largely due to immune reconstitution (or the toxicity of antiretroviral therapy); after 24 weeks, clinical events usually reflect immune deterioration. However, the monitoring of disease progression and response to therapy using clinical staging events urgently needs to be validated. Immunological assessment The pathogenesis of HIV infection is largely attributable to the decrease in the number of T cells (a specific type of lymphocyte) that bear the CD4 receptor (CD4+). The immune status of a child or adult living with HIV can be assessed by measuring the absolute number (per mm3 ) or percentage of CD4+ cells, and this is regarded as the standard way to assess and characterize the severity of HIV-related immunodeficiency. Progressive depletion of CD4+ T cells is associated with progression of HIV disease and an increased likelihood of opportunistic infections and other clinical events associated with HIV, including wasting and death.
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