21.3  WHO HIV clinical stages in adults and adolescents

The WHO HIV clinical staging system is a staging system developed for PLHIV to help healthcare providers, such as Health Extension Practitioners, estimate the degree of immune deficiency that an HIV patient presents. Staging means categorising the patient clinically into one of the four WHO HIV stages. It is useful to know these stages because it enables you clinically to identify patients with mild and severe diseases associated with HIV.

A PLHIV in WHO clinical stage 1 usually does not have a serious immune deficiency, and shows no signs of opportunistic infections (i.e. they are asymptomatic — no symptoms). A patient in WHO clinical stage 2 also does not have a serious immune deficiency, but usually shows signs of mild opportunistic infections. Patients in stage 3 or 4 usually have a severe immune deficiency, and show signs of moderate and severe opportunistic infections respectively. Stage 4 is considered to be AIDS.

  • Would you expect a person living with HIV in stage 2 to have a higher or lower CD4 cell count than a person living with HIV in stage 4 of the WHO clinical staging system? Why?

  • As the immune status of a person living with HIV becomes weaker, the HIV clinical stage gets higher. Therefore, stage 2 patients have stronger immunity than stage 4 patients, and the CD4 cell count is higher in stage 2 than in stage 4 patients.

We will discuss the WHO paediatric staging for children with HIV in Study Session 28.

Table 21.1 summarises the WHO HIV clinical staging for adults and adolescents adapted for the Ethiopian primary healthcare setting. Most opportunistic infections common in PLHIV will be explained in detail in Section 21.4, but for now you should use Table 21.1 as a reference to give you an idea of how clinical staging of PLHIV is implemented. Some opportunistic conditions may be diagnosed by a health worker in a health centre, whereas others need a diagnosis by doctors or health officers working at regional hospitals (marked with an asterisk in Table 21.1). These patients should be referred for appropriate diagnosis and treatment. Note that if the patient has clinical conditions that fall into more than one WHO clinical stage, the patient will be placed in the highest WHO clinical stage that fits the symptoms.

However, staging of a person living with HIV is not a permanent fixture. For example, a PLHIV who has been successfully treated for, and recovered from, Pneumocystis pneumonia may be downgraded from stage 4 to stage 3 if no other severe conditions are present.

Some opportunistic conditions may be easily identified by Health Extension Practitioners (HEPs), and these will be explained in detail in Section 21.4. For other opportunistic infections you may come across in PLHIV, a short description has been included in the table. You are not expected to memorise the details of these latter conditions. All conditions that require a diagnosis by doctors or health officers working at regional hospitals are marked with an asterisk.

Table 21.1  WHO adult and adolescent HIV clinical stages. (* requires diagnosis by a doctor or health officer)

Stage 1


Stage 2

Mild disease

No symptoms or only persistent generalised lymphadenopathy (PGL) (Section 21.4.1)

Weight loss 5–10%

Skin problems (Section 21.4.2):


prurigo (PPE)

herpes zoster

Mouth/throat problems (Section 21.4.3):

angular chelitis

recurrent mouth ulcers

Recurrent upper respiratory infections (repeated throat infections, sinusitis, or ear infections)

Stage 3

Moderate disease

Stage 4

Severe disease (AIDS)

Weight loss greater than 10%

Mouth/throat problems (Section 21.4.3):

oral thrush

oral hairy leukoplakia

    acute necrotising ulcerative gingivitis/periodontitis     (severe gum disease accompanied by ulcers)

Diarrhoea (for more than 1 month; sometimes intermittent)

Unexplained fever (for more than 1 month; sometimes intermittent)

Severe bacterial infections (e.g. pneumonia, muscle infection):

pulmonary TB (Section 21.4.4)

TB lymphadenopathy (chronic swelling of lymph nodes around the lungs)

HIV wasting syndrome (Section 21.4.5)

Oesophageal thrush (Section 21.4.3)

Herpes simplex ulcerations (large and chronic painful wounds on the genitals and/or anus for more than 1 month)

Lymphoma* (cancer of the immune system)

Kaposi’s sarcoma* (dark lesions on the skin and/or mouth, eye, lungs, intestines)

Invasive cervical cancer* (cancer of the female reproductive system)

Pneumocystis pneumonia* (severe pneumonia with shortness of breath on exertion and dry cough)

Extrapulmonary TB* (TB in tissues other than lungs, e.g. bone)

Cryptococcal meningitis* (meningitis caused by a fungus which can present without neck stiffness)

Toxoplasma brain abscess* (infection of the brain by a parasite)

Visceral leishmaniasis* (infection of internal organs by a protozoan)

HIV encephalopathy* (neurological impairment).

21.2  Why are opportunistic infections common in PLHIV?

21.4  Common opportunistic clinical manifestations in people with HIV