Status at enrolment: □ HIV exposed Infant
□ TB Rx
□ Pregnancy
□ Postpartum
□ other
Unique No. □□□□□□□□□
Prior ARVs
Y()
Prior ART
None
PMTCT only
Earlier ARV
not transfer in
District _________ Health unit __________ District clinician/team __________
Name _________________________ Patient clinic No. ____________________
Sex M □ F □
Age ____
DOB _________
Marital status ______________
Date
_ _/_ _/_ _
_ _/_ _/_ _
Where __________ ARVs ______
Where __________ ARVs ______
Address ___________________________________________________________
ART
Telephone (whose) __________________________________________________
Cohort (month/year) _______/______
Date
_/_/_
ART transfer in from_____________ ARVs _________
_/_/_
Start ART 1st -line initital regimen _________________
At start
ART
Wt _____ Cl.stage ______ CD4 ______ Preg ______
Treatment supporter/medication pick-up if ill ____________________________
1st - line
Address ___________________________________________________________
Telephone (whose) __________________________________________________
Home based care provided by ________________________________________
Name of
family
members
and
partners
Age
HIV
P/N
HIV
care
Y/N
_ /_ /_
_ /_ /_
Exposed infant follow-up
Exposed
Infant
Name/
No.
Unique
No.
DOB
Infant
feeding
practice
at 3
mos.
CTX
started
by
2mos.
HIV
test
type/
resul
t
Final
statu
s
(If
confirm
+)
Unique
ID
2nd -line
Family status
Substitute within 1stt-line
New regimen ________________ Why ____________
New regimen ________________ Why ____________
Switch to 2nd-line (or substitution within 2nd-line)
_ /_ / _
New regimen ________________ Why ____________
_/_/_
New regimen ________________ Why ____________
ART treatment interruption - Stop or missed drug pick-up
HIV care
Date
Confirmed HIV + test
HIV enrolled
Medically eligible for ART
Drug allergies
HIV 1 2 Ab/virologic test
Where_______________
□ HIV care transfer in from__________
Clinical stage ______ CD4 ________
□ Presumptive clinical diagnosis of
severe HIV infection in infants
Relevant medical conditions
Stop or
Lost
Date
Why
Date if
restart
Stop
Lost
Stop
Lost
Stop
Lost
Stop
Lost
Status
Date
Dead
Transferd out
Lost to follow-up (drop)
Where _____________
Unique No. □□□□□□□□□
Date
Check if
scheduled.
Write in
alternate
pick-up if ill
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
Followup date
Duration
in months
since first
starting
ART/since
starting
current
regimen
Wt
Ht
at first
visit
If child
record
+/Oedema
HIV care/ART card
Pregnancy
/RH-FP
choices
If child
record
MUAC
Write age in
mos. if ≤59
mos.
TB
status
(if TBRX
record
month/
year
started
and TB
reg No.)
Potential
side
effects
New OI,
Other
problems
If child,
include
nutritional
problems
WHO
clinical
stage
Name _____________________
Cotrimoxazole
Adhere
INH
Dose/
days
No. pills
dispensed
Other
meds
dispensed
ARV drugs(incl.
prophylaxis)
Investigations
Refer or
consult or
link/provide
(including
nutritional
supplements)
Adher
e/why
CD4
if <5,
record
CD4%
(including
nutritional
support and
infant feeding)
If hospitalized,
No. of days
Regimen/
Dose/No.
days
dispensed
Hgb,RPR,
CXR,
TB sputum.
Infant
Ab/HIV
virologic
test, other
HIV transmission
prevention for key
population
(Check)
□ Discordant
couple
□ MSM
□ IDU
□ SW
□ Clients of SW
Codes for pregnancy/RH-FP choices
P= pregnant. List EDD and ANC No.. If referred for
PMTCT, note in last column.
AB= recent induced abortion. Note when.
MC= recent miscarriage. Note when
Wants P= wants to become pregnant now or
considering; not using FP
Has FP= already using condoms/other
FP. Note method(s)
Wants FP= note method(s) provided or
referred for. Record referral in last
column.
Unable P= thinks she cannot get
pregnant
No sex= not sexually active no
Codes for FP methods
C = condoms
OC = oral contraceptive pills
IMP = implant
LAM = Lactational Amenorrhea Method
FA = fertility awareness method/periodic abstinence
V = vasectomy (partner’s)
ECP = emergency contraceptive pills
dispensed
INJ = Injectable
IUD = intrauterine device
D = diaphragm/cervical cap
TL = tubal ligation/female sterilization
UND = undecided
Codes for TB status (check on each visit)
No signs = no signs or symptoms of TB
Suspect = TB refer or sputums sent (Record sputum sent & results in lab column; record referral in
Refer col)
Not done (ND) = not assessed for whatever reason
TB Rx = currently on TB treatment. Record month/year started and TB reg No.
(Record INH in INH col. and TB treatment regimen in Other meds col)
Why SUBSTITUTE or SWITCH codes
Codes for HIV -exposed infant final status
1. Toxicity/side effects
DEAD if dead (write in date of death if known)
2. Pregnancy
P if positive N if negative and no longer breast feeding
3. Risk of pregnancy
N/BF if negative and still breast feeding
4. Due to new TB
5. New drug available
6. Drug out of stock
7. Other reason (specify)
Reasons for SWITCH to 2nd-line regimen only:
8. Clinical treatment failure
9.Immunologic failure
10. Virologic failure
U if status unknown
Codes for HIV prevention interventions for key
population
CC- couple counselling
RR- targeted risk reduction
C- Condom promotion/provision
NSP- Needle and syringe programmes
NSP code is checked for all with access to NSP or
have access to sterile injection equipment.
OST- Opioid Substitution Therapy
OST is checked for Opioid substitution therapy or
other drug dependence treatment.
Why STOP codes
1 Toxicity/side effects
2 Pregnancy
3 Treatment failure
4 Poor adherence
5 Illness, hospitalization
6 Drugs out of stock
7 Patient lacks finances
8 Other patient decision
9 Planned Rx interruption
10 Other (specify)
11 Excluded HIV infection in infant
Codes for CTX/ART adherence
Codes for potential side effects or other problems
Nausea
Anaemia
Diarrhoea
ABdominal pain
Fatigue
Headache
BN burning/numb/tingling
Jaundice
CNS: dizzy, anxiety, nightmare, depression
FAT changes
Rash
Codes for new OI or other problems
Zoster
GUD genital ulcer disease
COUGH*
Severe Complicated Malnutrition
FEVER*
Poor Weight Gain
Thrush- oral/vaginal
Weight loss*
UD urethral discharge
DB difficult breathing
PID pelvic inflammatory disease
DEmentia/Enceph
Ulcers - mouth or other ___
Pneumonia
IRIS Immune reconstitution inflammatory syndrome
Symptoms with * are suggestive of TB
Adherence
G(Good)
F(Fair)
P(Poor)
%
≥ 95%
85-94%
< 85%
Missed doses per month
1x daily dosing
<2 doses
2-4 doses
≥ 5 doses
2x daily dosing
≤ 3 doses
4-8 doses
≥ 9 doses
Codes for why poor/ fair adherence
1. Toxicity/side effects
2. Share with others
3. Forgot
4. Felt better
5. Too ill
6. Stigma, disclosure or
privacy issues
7. Drug stock out—
dispensary
8. Patient lost/ran out of pills
9. Delivery/travel problems
10. Inability to pay
11. Alcohol
12. Depression
13. Pill burden
14. Other (specify)
Follow-up education, support and preparation for ARV therapy [to be revised]
Date/comments
Educate on basics, prevention,
disclosure
Basic HIV and TB education, transmission
Prevention: abstinence, safer sex, condoms
Prevention: household precautions, what is safe
Post-test counselling: implications of results
Positive living
Testing partners
Disclosure, to whom disclosed (list)
Family/living situation
Shared confidentiality
Reproductive choices, prevention of MTCT
Child's blood test
Progression of disease
Progression, Rx
Available treatment/prophylaxis
CTX, INH prophylaxis
Malaria prevention, IPT, ITN
Follow-up appointments, clinical team
ART preparation, initiation. support, monitor,
Rx
ART -- educate on essentials (locally adapted)
Why complete adherence needed
Adherence preparation, indicate visits
Indicate when READY for ART: DATE/result clinical team discussion
Explain dose, when to take
What can occur, how to manage side effects
What to do if one forgets dose
What to do when travelling
Adherence plan (schedule, aids, explain diary)
Treatment supporter preparation
Which doses, why missed
ARV support group
How to contact clinic
Home-based care,
support
Symptom management/palliative care at home
Caregiver booklet
Home-based care -- specify
Support groups
Community support
Date/comments
Date/comments
Date/comments