CDC Classification System for HIV Infection in Children

Due to the additional knowledge of the progression of HIV disease among children, a revised classification system for HIV infection in children was developed in 1994 that replaced the pediatric HIV classification system that was published in 1987. A child for the purposes of the CDC is an individual of less than 13 years of age. Standard anti-HIV IgG antibody tests cannot be used to reliably indicate a child's infection status before 18 months of age, so viral antigen tests are used.

In the new system, HIV-infected children are classified into mutually exclusive categories according to three parameters:

a) infection status

b) clinical status

c) immunologic status

This classification system reflects the stage of the child's disease, establishes mutually exclusive classification categories, and balances simplicity and medical accuracy in the classification process. This document also describes revised pediatric definitions for two acquired immunodeficiency syndrome-defining conditions.

When an infant is born to an HIV-infected mother, diagnosis of an HIV infection is complicated by the presence of maternal anti-HIV IgG antibody, which crosses the placenta to the fetus. Indeed, virtually all children born to HIV-infected mothers are HIV-antibody positive at birth, although only 15%-30% are actually infected.

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Category N: Not symptomatic

Children who have no signs or symptoms considered to be the result of HIV infection or who have only one of the conditions listed in Category A.

Category A: Mildly symptomatic

Children with two or more of the conditions listed below but none of the conditions listed in Categories B and C.

• Lymphadenopathy (>=0.5 cm at more than two sites; bilateral = one site)
• Hepatomegaly
• Splenomegaly
• Dermatitis
• Parotitis
• Recurrent or persistent upper respiratory infection, sinusitis, or otitis media

Category B: Moderately symptomatic

Children who have symptomatic conditions other than those listed for Category A or C that are attributed to HIV infection. Examples of conditions in clinical Category B include but are not limited to:

• Anemia (<8 g/dL), neutropenia (<1,000/mm³), or thrombocytopenia (<100,000/mm³) persisting for at least 30 days
• Bacterial meningitis, pneumonia, or sepsis (single episode)
• Candidiasis, oropharyngeal (thrush), persisting for more than 2 months in children over 6 months of age
• Cardiomyopathy
• Cytomegalovirus infection, with onset before 1 month of age
• Diarrhea, recurrent or chronic
• Hepatitis
• Herpes simplex virus (HSV) stomatitis, recurrent (more than two episodes within 1 year)
• HSV bronchitis, pneumonitis, or esophagitis with onset before 1 month of age
• Herpes zoster (shingles) involving at least two distinct episodes or more than one dermatome
• Leiomyosarcoma
• Lymphoid interstitial pneumonia (LIP) or pulmonary lymphoid hyperplasia complex
• Nephropathy
• Nocardiosis
• Persistent fever (lasting more than 1 month)
• Toxoplasmosis, onset before 1 month of age
• Varicella, disseminated (complicated chickenpox)

Category C: Severely symptomatic

• Serious bacterial infections, multiple or recurrent (i.e., any combination of at least two culture-confirmed infections within a 2-year period), of the following types: septicemia, pneumonia, meningitis, bone or joint infection, or abscess of an internal organ or body cavity (excluding otitis media, superficial skin or mucosal abscesses, and indwelling catheter-related infections)
• Candidiasis, esophageal or pulmonary (bronchi, trachea, lungs)
• Coccidioidomycosis, disseminated (at site other than or in addition to lungs or cervical or hilar lymph nodes)
• Cryptococcosis, extrapulmonary
• Cryptosporidiosis or isosporiasis with diarrhea persisting more than 1 month
• Cytomegalovirus disease with onset of symptoms at age over 1 month (at a site other than liver, spleen, or lymph nodes)
• Encephalopathy (at least one of the following progressive findings present for at least 2 months in the absence of a concurrent illness other than HIV infection that could explain the findings): a) failure to attain or loss of developmental milestones or loss of intellectual ability, verified by standard developmental scale or neuropsychological tests; b) impaired brain growth or acquired microcephaly demonstrated by head circumference measurements or brain atrophy demonstrated by computerized tomography or magnetic resonance imaging (serial imaging is required for children under 2 years of age); c) acquired symmetric motor deficit manifested by two or more of the following: paresis, pathologic reflexes, ataxia, or gait disturbance
• Herpes simplex virus infection causing a mucocutaneous ulcer that persists for more than 1 month; or bronchitis, pneumonitis, or esophagitis for any duration affecting a child over 1 month of age
• Histoplasmosis, disseminated (at a site other than or in addition to lungs or cervical or hilar lymph nodes)
• Kaposi's sarcoma
• Lymphoma, primary, in brain
• Lymphoma, small, noncleaved cell (Burkitt's), or immunoblastic or large cell lymphoma of B-cell or unknown immunologic phenotype
• Mycobacterium tuberculosis, disseminated or extrapulmonary
• Mycobacterium, other species or unidentified species, disseminated (at a site other than or in addition to lungs, skin, or cervical or hilar lymph nodes)
• Mycobacterium avium complex or Mycobacterium kansasii, disseminated (at site other than or in addition to lungs, skin, or cervical or hilar lymph nodes)
• Pneumocystis carinii pneumonia
• Progressive multifocal leukoencephalopathy
• Salmonella (nontyphoid) septicemia, recurrent
• Toxoplasmosis of the brain with onset at greater than 1 month of age
• Wasting syndrome in the absence of a concurrent illness other than HIV infection that could explain the following findings: a) persistent weight loss more than 10% of baseline OR b) downward crossing of at least two of the following percantile lines on the weight-for-age chart (e.g., 95th, 75th, 50th, 25th, 5th) in a child at least 1 year of age OR c) less than the 5th percentile on weight-for-height chart on two consecutive measurements at least 30 days apart PLUS a) chronic diarrhea (i.e., at least two loose stools per day for more than 30 days) OR b)documented fever (for at least 30 days, intermittent or constant)