Antiretroviral Therapy (ART): ART Assessment

Learning Objectives:

  • Clinically stage HIV-infected adolescents and adults using the WHO Staging system
  • Assess eligibility for starting ART using clinical/immunological criteria
  • Assess client readiness for ART (conduct pre-ART counselling)

  • Quiz

    Tell your mentee you would like to assess their knowledge related to ART assessment with the following questions.

    • How many WHO clinical stages are there?

      [note text]

      4 stages

    • What are the names of the stages?

      [note text]
      Stage 1 Asymptomatic/persistent generalized lymphadenopathy
      Stage 2 Mild
      Stage 3 Moderate severity
      Stage 4 Severe

    • Why is WHO clinical staging important?

      [note text]
      WHO clinical staging is important because it:
      • Helps the health care workers to categorise clients into the 4 stages in order to clinically identify those in need of lifelong treatment
      • Helps the health workers to identify clients who need intervention such as cotrimoxazole prophylaxis to prevent OIs
      • Enables baseline clinical assessment which helps to monitor response to treatment and identify treatment failure
      • Helps to determine the prognosis
      • Strengthens the clinical diagnosis when laboratory testing is unavailable or delayed
      • Guides decisions regarding the initiation, success or failure of ART

      The WHO staging system is based on the clinical status as well as past medical history. It is important to note that the accuracy may be limited if the past medical history is unavailable. Comprehensive history taking and good clinical examination are essential to accurate staging, and staging should be conducted at every clinical visit in order to identify disease progression or treatment failure.

    • When do you start ART in adults and adolescents?

      [note text]

      ART should be provided to all eligible people with confirmed HIV diagnosis and with a CD4 count of ≤500 cells/mm³ or in WHO clinical stage 3 and 4, regardless of their CD4 count

    • What clients should be initiated on ART regardless of CD4 count?

      [note text]
      As a priority, initiate ART in all individuals with severe /advanced HIV disease (WHO clinical stage 3 or 4) or CD4 count ≤350 cells/mm³. It is also recommended to initiate ART in the following categories of clients:
      • HIV+ with active TB disease
      • HIV+ pregnant and breast-feeding women
      • HIV+ in sero-discordant relationships
      • HBV co-infection with severe chronic liver disease
      • All HIV + children below 5 years of age

    • Maria is a 22-year-old woman. She is HIV-positive. She thinks she got HIV when having sex with a teacher while she was in school. The teacher was very thin and died three years later. Her husband left her when she disclosed her HIV status. Now she lives alone. She has repeated ear infections, and lost some weight, but not a lot. She has no other clinical signs.

      In what WHO clinical stage is Maria?

      [note text]

      Stage 2 (weight loss < 10% of body weight and recurrent URTI- Otitis media)

    • Kuda is 27 years old and used to sell small household materials on the street. But now he is too sick to work. He is very weak and has to stay in bed most of the time. He is very thin and has had a constant fever for several months. He was worried about "having AIDS" for a long time, but never got "the courage" to do the HIV test. After hearing about free ART, he finally did the test, which revealed that he is HIV-positive.

      In what WHO clinical stage is Kuda?

      [note text]

      Stage 3

    • An extremely thin HIV-positive client who has had chronic diarrhoea for the past month.

      What is this client’s WHO clinical stage?

      [note text]

      Stage 3

    • An HIV-positive client with pulmonary tuberculosis and purple lesions on the skin of the left leg, with oedema of the leg.

      What is this client’s WHO clinical stage?

      [note text]

      Stage 4 (Kaposi sarcoma which is an AIDS-defining condition)

    • An HIV-positive client who has had oral thrush and intermittent diarrhoea for one month.

      What is this client’s WHO clinical stage?

      [note text]

      Stage 3

    • An HIV-positive client with tuberculosis of the cervical lymph nodes.

      What is this client’s WHO clinical stage?

      [note text]

      Stage 4 (Extra pulmonary TB)

    • An HIV-positive client with big abscesses of the skin that extend to the muscle, with yellow pus coming out of some of them.

      What is this client’s WHO clinical stage?

      [note text]

      Stage 3

    • [activity type]

      Tell your mentee that you are going to engage in a role play to help him or her with ART assessment skills. He or she will play the role of health care provider, and you will be the client.

      Show the mentee the instructions below for the health worker. Then, tap on the box for the client (mentor) instructions. Do not show this to the mentee.


      Rejoice is a 38-year-old woman on ART, who is looking after her late sister’s child. The sister died a year ago and left 3 children. The firstborn is 15 years old and is well, the second is 13 years old and is also well, but the 11 year old has been getting weaker and is coughing. She did not go to school last month because she was too weak to walk the 2km distance. Rejoice is worried that the 11 year old might have TB or HIV.

      • You are a 38-year-old woman who is on ART and looking after your late sister’s child. Your sister died a year ago and left 3 children. You are worried that the youngest child might have TB or HIV, as you think her mother was infected.

        Questions to ask as the health care worker:

        • "What are the signs of HIV in children? I always thought that children die very young if they have the virus."
        • "If my sister was HIV positive, wouldn’t all of her children also be positive?"
        • "Is it possible that my sister’s 11 year old daughter could have been HIV infected as a result of sexual abuse?"
        • "If my niece has TB, are we all infected? None of the other children are sick, just her."

        If you are asked, respond with the following answers.

        • You are afraid to tell the healthcare worker that you suspected that your sister was HIV positive since she was sick all the time and in and out of the hospital. Your sister refused to talk to anyone in the family about her illness and just kept telling you that "she was going to be fine."
        • You are tired and under a lot of stress with having to raise these children. You barely have enough food for everyone. You have been missing some of your doses of HIV medicine lately since you fall asleep as soon as the children are in bed and don’t wake up until the next morning.

        Check off which of the following items the mentee does during the course of the role play.

    • [activity type]

      Tell your mentee that you will review a case study and ask some questions to help him/her improve skills in ART assessment.

      Itai is a 33-year-old male presenting to the ART clinic for initial evaluation. He has a history of Herpes Zoster and reports diarrhoea, intermittent fever, and itching. He stopped working as a vendor one month ago due to fatigue.

      1. What additional information is necessary for accurate WHO staging of this client?


        Physical exam, More information on symptoms

      More information about Itai:

      • Diarrhoea occurred daily, was non-bloody, and began 2 months ago
      • Fever began 2 months ago
      • Weight loss of 8 kg (50 -> 42kg) over last 6 months
      • History of PTB treatment 1 year ago
      • No cough, night sweats
      • Exam revealed oral thrush and papular rash on trunk and extremities
      • CXR normal
      • Stool exam normal
      • Hb 9 g/dl
      1. Based on these findings, in what clinical stage is Itai?


        Stage 3

      2. Why do you place him in that stage?

        • PTB 1 year ago
        • Unexplained persistent diarrhoea 14 days or more
        • Unexplained persistent fever for longer than 1 month
        • Oral thrush
        • Weight loss of more than 10% of body weight
        • Unexplained anaemia- Hb 9g/dl for a man

    • [activity type]

      Have the mentee look at the following photos and identify which stage the person is and why. Tap the image to reveal correct answers. Tap again for answer to disappear before moving to the next image.

      1.
      2.
      3.
      4.
      5.
      6.
      7.
      8.

    • [activity type]

      Ask mentee to assess ART readiness assessment with a client. Observe the mentee performing ART initiation/ART readiness counselling for one of the stages in the checklist below. After the client leaves, discuss what went well, what was challenging for the mentee, and any questions the mentee has.

      Client education on HIV and AIDS and introduction to ART including:

      Stage 1 Pre-ART initiation

      Stage 2 ART initiation

      Stage 3 Support for ART initiation

      Stage 4 Maintenance

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