The World Health Organisation (WHO) clinical staging system for HIV/Aids was developed in 1990 using clinical parameters to guide clinical decision making for management of HIV/Aids. It is used for limited resource settings where there is limited access to laboratory service.
Stages of infection
Although HIV infection can theoretically be divided into 4 different phases, it is important to note that HIV-infection cannot in practice be precisely demarcated into separate and distinct phases with easily identifiable boundaries. The health of the HIV positive person will depend on the health of his or her immune system, on CD4 cell count and viral load in the blood, as well as on the exposure to infections and diseases in the environment.
HIV/Aids is seen as a chronic disease nowadays, because HIV-positive people can live with the infection for many years if they look after their immune systems. Especially antiretroviral medication made it possible for many individuals who have been very sick with HIV/Aids, to become fully functioning again - with a low, or even undetectable viral load.
It is also not possible to say exactly what symptoms and diseases will be associated with HIV-infection in a specific person. Because of the unique way in which HIV attacks and disarms the immune system, all kinds of bacteria, fungi, protozoa, viruses and cancers are able to invade the body. That is the reason why we talk about Aids as a syndrome - a collection of many illnesses and infections.
HIV-infection can, however, theoretically be divided into the following phases or stages:
Stage 1: The primary HIV infection phase (or acute sero-conversion illness)
Stage 2: The asymptomatic latent phase. The minor symptomatic phase
Stage 3: The major symptomatic phase and opportunistic diseases
Stage 4: AIDS-defining conditions: the severe symptomatic phase
Read: How HIV is transmitted
Stage 1: The primary HIV infection phase
The acute phase of HIV infection (also called acute sero-conversion illness) begins as soon as sero-conversion has taken place. Sero-conversion means the point in time when a person’s HIV status converts or changes from being HIV negative to HIV positive. This also usually coincides with the time when an HIV test will show that a person is HIV positive. Sero conversion is preceded by a Window period. This period is between the onset of the HIV infection and the appearance of detectable antibodies to the virus. The window period is about 3 to 4 weeks and may be longer with other individuals
Sero-conversion usually occurs four to eight weeks after an individual has been infected with the HI virus. About 30%-60% of people infected with HIV develop flu-like symptoms such as sore throat, headache, mild fever, fatigue, muscle and joint pains, swelling of the lymph nodes, rash, and (occasionally) oral ulcers. These symptoms usually last from between one and two weeks.
Because of the rapid replication of the virus, the viral load is usually very high during the acute phase. Immediate and aggressive treatment with anti-retroviral therapy (ART) at this stage may be effective in reducing the viral load to undetectable levels.
Stage 2: The asymptomatic latent phase
The second phase of HIV infection is the asymptomatic latent or silent phase. In this stage, an infected person displays no symptoms. Infected individuals are often not even aware that they are carrying the HI virus, and may therefore unwittingly infect new sex partners.
Even though the infected person may be ignorant of its presence, the virus nevertheless remains active in the body during this stage and it continues to damage and undermine its victim’s immune system. A positive HIV test is often the only indication of HIV infection during this latent phase.
HIV-infected people can remain healthy for a long time, show no symptoms and carry on with their work in a normal way. Some people remain HIV positive for many years without any manifestation of clinical disease while others may deteriorate rapidly, develop AIDS and die within months. In some cases the only symptom during this phase is swollen glands.
Read: HIV transmission through sexual acts
Stage 3: The minor symptomatic phase of HIV disease
In the third phase of infection, minor and early symptoms of HIV disease usually begin to manifest. At this stage the viral load is high and the immune system is not coping and manifests itself by the occurrence of opportunistic infections.
This phase usually starts when people with HIV antibodies begin to present with one or more of the following symptoms:
- Mild to moderate swelling of the lymph nodes in the neck, armpits and groin
- Occasional fevers
- Oral candidiasis (thrush)
- Pulmonary tuberculosis
- Oral hairy leukoplakia
- Shingles (or Herpes zoster)
- Skin rashes and nail infections
- Sores in the mouth that come and go
- Recurrent upper respiratory tract infections
- Weight loss up to 10% of the person’s usual body weight
- General feelings of tiredness and non-feeling-well
What is shingles?
Shingles (or herpes zoster) is a viral infection that is caused by the same virus that causes chicken pox. In the days before the HIV/Aids pandemic, shingles used to be seen only in older people or in those who had weakened immune systems.
Nowadays shingles is very common in people with HIV infection and Aids, and it is even often seen in young people. Shingles affects nerve and surrounding skin surface, and it is characterised by an extremely painful skin rash or tiny blisters on the face, limbs or body. Blisters are usually on one side of the trunk and clustered on one side of the face. It is confined to one side of the body and does not cross the midline. The severe pain may continue for months even if the lesions are healed. It can also affect the eyes, causing pain and blurred vision. Shingles can be very severe in people with depressed immune systems.
Read: Shingles vaccine is safe
Stage 4: AIDS (major symptomatic phase of HIV infection and opportunistic diseases)
The fourth stage is known as Aids. Major symptoms and opportunistic diseases begin to appear as the immune system continues to deteriorate. At this point, the CD4 cell count becomes very low while the viral load becomes very high.
The following symptoms are usually an indication of advanced immune deficiency:
- Oral and vaginal thrush infections which are very persistent and recurrent (Candida)
- Oesophageal candida (thrush in the food pipe)
- Extra pulmonary Tuberculosis (TB affecting other parts of the body besides the lungs)
- Recurrent herpes infections such as cold sores (herpes simplex)
- Recurrent herpes zoster (or shingles)
- Bacterial skin infections and skin rashes
- Bacterial pneumonia
- Kaposi’s sarcoma, or a rare form of skin cancer (painless reddish-brown or bluish-purple patches or swelling on the skin and mucous membranes such as in the mouth). Kaposi’s sarcoma can also occur in the lungs and gastro-intestinal tract. It reacts well to chemotherapy or to alpha-interferon, but it can develop invasive open lesions and cause death if not promptly treated. Kaposi’s sarcoma is less common in black Africans
- Pneumocystis Carinii Pneumonia (PCP)
- Fever for more than a month
- Persistent diarrhoea for more than a month leading to wasting syndrome
- Weight loss (more than 10 percent of the usual body weight)
- Generalised lymphadenopathy (or, in some cases, the shrinking of previously enlarged lymph nodes)
- Toxoplasmosis of brain
- Cryptococcal meningitis
- Peripheral neuropathy (Nervous system problems - often complain of pains, numbness or “pins and needles” in the hands and feet
- Abdominal discomfort, headaches
- Oral hairy leucoplakia (thickened white patches on the side of the tongue)
- Persistent cough and reactivation of tuberculosis
Read: How to prevent Aids
HIV and malaria
HIV-infected individuals are more prone to severe malaria than non-infected individuals. Malaria also causes a seven-fold increase in the HIV viral load of people with HIV infection. People with HIV infection should therefore take extra precautions when visiting malarial areas.
Reviewed by Lulu Mtwisha, Programme Manager and Trainer at the Desmond Tutu HIV Foundation (December 2014)