Chapter Five Practical application of patient monitoring tools ......2005/03/30 · ART register...
92
Chapter Five Practical application of patient monitoring tools: country and project examples
Transcript of Chapter Five Practical application of patient monitoring tools ......2005/03/30 · ART register...
Chapter Five
Practical application of patient monitoring tools: country and
project examples
CHAPTER FIVE
PRACTICAL APPLICATION OF PATIENT MONITORING TOOLS: COUNTRY AND PROJECT EXAMPLES
Many countries and projects have created their own versions of the patient cards, registers and reporting forms. While in general the examples presented in this chapter contain the same basic elements outlined in these guidelines, they differ in how and how often data are collected and in the format of the forms used. This reflects the varied data collection needs and resources. There is obviously freedom to use different formats including a full patient chart; to collect additional data; and to adapt the forms to the country's clinical guidelines (for example, if no INH prophylaxis is routinely provided for HIV patients there should be no column on the card). It is important to standardize the system nationally with allowances for collecting more data or different formats for patient cards or charts. With the large resources available for some facilities, point-of-service flexibility is a good principle if a strong routine national system can still be built if there is standardization around collection and reporting based on the minimum data set and the internationally agreed indicators and definitions. In a simplified system, which limits paper and health worker time required for data recording, there is often a laminated form to assist the clinical review; the health worker then records key treatment data and relevant information on a card. Other details of an acute illness might be recorded in a patient-held card or exercise book. A more elaborate recording system would retain and record all positives and negatives of clinical review and detailed treatment data. This requires a full chart and space for chart storage with prompt retrieval for patient care. A review of various patient record systems showed a wide range in the number of pages per patient visit from 0.05 (multiple visits on a single card) to 8 pages. The following is a compilation of country and project examples of forms currently being used and adapted in the field, including a brief description of how these forms have been adapted.
Thyolo District, Malawi These are monitoring tools that have been piloted and used in Thyolo District, Malawi since April 2003 and have now been introduced in all district outpatient ART clinics. This simple system focuses on patient outcomes and is based on the TB model of reporting and evaluating. Patient master record card
Patients are issued personal identity cards and the facility keeps patient master cards, both carrying the same basic information. Regular follow-up of patients allows for monthly collection of information on the master cards monitoring weight, functional status, side-effects, adherence, and patient outcomes (alive, dead, defaulted, stopped, transfer out).
ART register While the system does not currently make use of a pre-ART register, a simple ART register has been developed. For now, master cards are filed by the quarter in which the patient started on ART.
Quarterly cohort analysis The system uses both cross-sectional and cohort analysis to monitor treatment outcomes: Quarterly ARV cohort analysis of patient master cards is carried out retrospectively. Treatment outcome, functional status and adherence rates are documented for the last month of the quarter as soon as the quarter ends. Outcome data for this cohort are analysed every three months.
Cumulative cohort analysis Cumulative ARV quarterly analysis is a cross-sectional analysis of all cohorts. This is also carried out quarterly, but allows for an analysis of all patients who have ever started on treatment and yields information on patient outcome totals (described above). However, as the programme continues and the number cohorts increases, the cumulative analysis of these cohorts, particularly if paper-based, may become problematic. This could be solved by carrying out the cumulative analysis at 6 or 12 months, or transitioning to an electronic system.1
1 Harries DH, Gomani P, Teck R, et al. Monitoring the response to antiretroviral therapy in resource-poor settings: the Malawi model. Transactions of the Royal Society of Tropical Medicine and Hygiene, 2004, 98: 695-701.
PA
TIE
NT
MA
STE
R R
EC
OR
D C
AR
D F
OR
AR
V:
Uni
que
AR
V N
umbe
r C
KW
/ AR
V/0
1___
_
Yea
r
200
4___
____
__
Nam
e_M
r Jos
hua
Phi
ri___
____
____
____
____
___
Age
34_
_
Sex
M__
_
In
itial
Wt (
Kg)
48_
___
Tr
ansf
er-In
(Y/N
) N
____
_
Add
ress
(phy
sica
l / P
O B
ox)
TA M
tem
ba, n
ear C
hikw
awa
Bom
a, C
hikw
awa
Dis
trict
____
____
____
____
____
____
____
____
____
____
____
____
Nam
e of
iden
tifia
ble
guar
dian
Mr J
ohn
Phi
ri___
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
Dat
e of
sta
rting
1st li
ne A
RV
regi
men
(spe
cify
d4t
/3TC
/NV
P fo
rmul
atio
n) J
ul 1
4 -d
4T-3
0mg_
R
easo
n fo
r AR
V:
Sta
ge II
I (P
neum
onia
)___
____
__
Dat
e of
sta
rting
alte
rnat
ive
1st li
ne A
RV
regi
men
(spe
cify
) ___
____
____
_
Dat
e of
sta
rting
2nd
line
AR
V re
gim
en (s
peci
fy)_
____
____
____
____
___
Out
com
e st
atus
O
f tho
se a
live
Am
bula
tory
W
ork/
scho
ol
Sid
e ef
fect
s A
RV
Giv
en
yr
mon
th
Dat
e W
t K
g
A
D
DF
Sto
p
TO
Sta
rt
Sbs
S
witc
h
Am
b B
ed
Yes
N
o Y
N
No.
Pill
s in
B
ottle
P
G
AR
V n
ot
give
n
200_
- ja
n
fe
b
m
ar
ap
r
mai
jun
20
04
jul
14
48
X
X
X
X
X
X
au
g
28
49
X
X
X
X
X
4
X
se
p 26
50
X
X
X
X
X
2 X
oct
24
51
X
X
X
X
PN
4 X
nov
de
c
An
nex C
1. M
ala
wi p
ati
en
t m
aste
r re
co
rd c
ard
Ou
tco
me s
tatu
s:
A=
aliv
e o
n A
RV
dru
gs; D
=dead -
whate
ver
the c
ause; D
F=
defa
ult -
not seen in thre
e m
onth
s; S
top=
sto
pped tre
atm
ent due
to s
ide e
ffects
/oth
er;
TO
=tr
ansfe
r-out to
anoth
er
AR
V tre
atm
ent unit
Of
tho
se a
live:
Sta
rt=
on first lin
e r
egim
en; S
bs=
substitu
te -
changed to a
ltern
ate
first lin
e r
egim
en; S
witch=
changed to s
econd lin
e r
egim
en
Am
bu
lato
ry:
Am
b=
able
to w
alk
to/a
t tr
eatm
ent unit a
nd w
alk
s a
t hom
e u
naid
ed; B
ed=
most of tim
e in b
ed a
t hom
e
Wo
rk/s
ch
oo
l:Y
es=
engaged in a
t pre
vio
us w
ork
/em
plo
ym
ent or
at school
Sid
e e
ffects
: If Y
es, specify –
YE
S-P
N=
periphera
l neuro
path
y; Y
ES
-HP
=hepatitis; Y
ES
-SK
=skin
rash
No
. P
ills
in
bo
ttle
: If p
atient com
es a
t 4 w
eeks c
ount num
ber
of pill
s in b
ottle
(8 p
ills o
r le
ss =
95%
adhere
nt)
AR
V g
iven
/no
t g
iven
: tick w
heth
er
AR
V thera
py g
iven in the a
ppro
priate
colu
mn P
=patient,
G=
guard
ian; if n
o A
RV
, th
en indic
ate
why
Annex E2. Malawi ART register
An
nex
B2
. M
ala
wi
AR
T r
egis
ter
AR
V
Reg
istr
ati
on
Nu
mb
er
Yea
rQ
ua
rter
Da
te o
f
reg
istr
ati
on
Na
me
Sex
Ag
eA
dd
ress
Da
te
firs
t
sta
rted
AR
V
dru
gs
Rea
son
for
sta
rtin
g
AR
V
dru
gs
Na
me/
Ad
dre
ss o
f
Gu
ard
ian
AR
V
Tre
atm
ent
Un
it
Rea
son
fo
r st
art
ing A
RV
Dru
g:
Sta
ge
III,
Sta
ge
IV, C
D4
co
un
t <
20
0/m
m3, S
tag
e II
wit
h T
LC
< 1
200
/mm
3, T
ub
ercu
losi
s, T
ran
sfer
-in
Qu
art
ers:
1 =
Jan
ua
ry t
o M
arc
h:
2 =
Apri
l to
Ju
ne:
3 =
Ju
ly t
o S
epte
mb
er:
4 =
Oct
ob
er t
o D
ecem
ber
An
nex
B2
. M
ala
wi
AR
T r
egis
ter
Ou
tco
me
(pro
vid
e d
ate
wh
en p
ati
ent
cha
ng
es
ou
tco
me
fro
m a
liv
e)
Of
tho
se a
liv
e (p
rov
ide
da
te
wh
en c
ha
ng
e fr
om
sta
rt)
Am
bu
lan
tA
t w
ork
or
(in
ch
ild
ren
at
sch
oo
l)
Dru
g a
dh
eren
ce
> 9
5%
Rem
ark
s
Ali
ve
Dea
dD
efa
ult
Sto
pT
ran
sfer
Sta
rtS
ub
stit
ute
Sw
itch
Yes
No
Yes
No
Yes
No
Ali
ve
- a
liv
e o
n A
RV
dru
gs:
Dea
d -
wh
ate
ver
th
e ca
use
: D
efa
ult
- n
ot
seen
in
th
ree
mo
nth
s: S
top
- s
top
ped
tre
atm
ent
du
e to
sid
e ef
fect
s/o
ther
: T
ran
sfer
- t
ran
sfer
-ou
t to
an
oth
er A
RV
tre
atm
ent
un
it
Sta
rt -
on
fir
st l
ine
reg
imen
: S
ub
stit
ute
- c
ha
ng
ed t
o a
lter
na
te f
irst
lin
e re
gim
en:
Sw
itch
- c
ha
ng
ed t
o s
eco
nd
lin
e re
gim
en
Am
bu
lan
t -
yes
/no
: A
t w
ork
or
sch
oo
l -
at
pre
vio
us
or
new
em
plo
ym
ent
for
ad
ult
s
Ad
her
ence
> 9
5%
- p
ill
cou
nts
of
8 t
ab
lets
or
less
wh
en p
ati
ent
com
es f
or
rev
iew
A
RV
QU
AR
TE
RL
Y
CO
HO
RT
AN
AL
YS
IS
FO
RM
*
NA
ME
OF
TR
EA
TM
EN
T U
NIT
__
__
__
__
__
__
_
T
hy
olo
DH
CO
HO
RT
[sp
ecif
y t
he
yea
r an
d t
he
quar
ter]
__________ 2003, Q
2
Tota
l num
ber
of
pat
ients
init
iall
y r
egis
tere
d f
or
AR
V i
n t
he
cohort
___116
Yea
r in
whic
h e
val
uat
ion i
s ta
kin
g p
lace
:_______________________2003
Dat
e at
whic
h e
val
uat
ion i
s ta
kin
g p
lace
_______________________ J
uly
10
th
Of
tota
l n
um
ber
reg
iste
red
in
th
e co
hort
:O
f to
tal
nu
mb
er r
egis
tere
d i
n t
he
coh
ort
:
Num
ber
Ali
ve
and o
n A
RV
ther
apy___________________106 (9
1%
)
[Ali
ve
and o
n F
irst
lin
e re
gim
en_______________101]
[Ali
ve
and o
n A
lter
nat
ive
firs
t li
ne
regim
en________5]
[Ali
ve
and o
n S
econd l
ine
regim
en_______________0]
Dea
d _
_____________________________________ 6
Def
ault
ed___________________________________ 0
Sto
pped
____________________________________ 4
Tra
nsf
erre
d o
ut
to a
noth
er t
reat
men
t unit
__________ 0
Of
those
Ali
ve:
Of
those
Ali
ve:
Num
ber
A
mbula
tory
___________106
At
work
___________ N
o i
nfo
rmat
ion
Wit
h s
ide
effe
cts
_
__________ 1
4
Wit
h P
ill
count
in b
ott
le 8
or
less
________ 6
3/6
3
N
ote
: P
ill
cou
nt
in b
ott
le 8
or
less
is
equ
ivale
nt
to 9
5%
adh
eren
ce N
ote
: P
ill
cou
nt
in b
ott
le 8
or
less
is
equ
ivale
nt
to 9
5%
adh
eren
ce
An
nex C
3. E
xam
ple
of
Mala
wi co
ho
rt a
naly
sis
*So
urc
e: H
arr
ies A
D. S
calin
g u
p A
RV
thera
py: In
tegra
tion o
f T
B a
nd H
IV. H
IV/A
IDS
Unit, M
inis
try o
f H
ealth, M
ala
wi.
Th
e cu
mu
lati
ve
an
aly
sis
nee
ded
of
ten
qu
art
ers
regis
tere
d f
or
AR
V t
her
ap
y b
etw
een
Ap
ril
2003 a
nd
Sep
tem
ber
2005*
Cohort
s
1+
2+
3+
4+
5+
6+
7+
8+
9+
10
Cohort
s
1+
2+
3+
4+
5+
6+
7+
8+
9
Cohort
s
1+
2+
3+
4+
5+
6+
7+
8
Cohort
s
1+
2+
3+
4+
5+
6+
7
Cohort
s
1+
2+
3+
4+
5+
6
Cohort
s
1+
2+
3+
4+
5
Cohort
s
1+
2+
3+
4
Cohort
s
1+
2+
3
Cohort
s
1+
2
Cohort
1
Cum
ula
tive
anal
ysi
s
Cohort
10
Cohort
9C
ohort
9
Cohort
8C
ohort
8C
ohort
8
Cohort
7C
ohort
7C
ohort
7C
ohort
7
Cohort
6C
ohort
6C
ohort
6C
ohort
6C
ohort
6
Cohort
5C
ohort
5C
ohort
5C
ohort
5C
ohort
5C
ohort
5
Cohort
4C
ohort
4C
ohort
4C
ohort
4C
ohort
4C
ohort
4C
ohort
4
Cohort
3C
ohort
3C
ohort
3C
ohort
3C
ohort
3C
ohort
3C
ohort
3C
ohort
3
Cohort
2C
ohort
2C
ohort
2C
ohort
2C
ohort
2C
ohort
2C
ohort
2C
ohort
2C
ohort
2
Cohort
1C
ohort
1C
ohort
1C
ohort
1C
ohort
1C
ohort
1C
ohort
1C
ohort
1C
ohort
1C
ohort
1
2005:
q4
2005:
q3
2005:
q2
2005:
q1
2004:
q4
2004:
q3
2004:
q2
2004:
q1
2003:
q4
2003:
q3
Yea
r an
d q
uart
er i
n w
hic
h e
ach
coh
ort
is
evalu
ate
d:
base
d o
n T
hyolo
Dis
tric
t H
osp
ital
pre
dic
tion
sC
ohort
s ar
e
num
ber
ed
from
1 t
o 1
0,
wit
h f
irst
cohort
bei
ng
all
pat
ients
regis
tere
d f
or
AR
V t
her
apy
bet
wee
n
Apri
l an
d
June
2003,
the
seco
nd
bei
ng p
atie
nts
regis
tere
d
bet
wee
n J
uly
and
Sep
tem
ber
,
and s
o o
n
An
ne
x C
4.
Ma
law
i c
um
ula
tiv
e c
oh
ort
an
aly
sis
*So
urc
e: H
arr
ies A
D, et al. C
ohort
analy
sis
for
monitoring the r
esponse to a
ntire
troviral th
era
py in r
esourc
e-p
oor
settin
gs: th
e M
ala
wi m
odel
2004. D
raft.
Western Cape Province, South Africa The system developed in the Western Cape, South Africa is based on three levels of information: individual patient management through clinical record-keeping using patient-held and facility-based patient cards; facility-based record-keeping through the use of registers; and cohort monitoring through quarterly treatment reports. For a complete list of monitoring tools and instructions, please refer to the Western Cape ART rollout resource website: http://www.epi.uct.ac.za/artrollout/. Patient card encounter form
The patient encounter form is a different presentation of the summary page in the WHO HIV care / ART card and is the most successful and well-validated component of the system.
Pre-ART and ART registers The pre-ART and ART registers are very similar to those presented in the WHO system, with the exception that the Western Cape pre-ART register also tracks CD4 count and the ART register tracks viral load and CD4 count.
Monthly report (including drug regimen breakdown) The monthly report is a more simplified version of the WHO quarterly report, and the treatment cohort report, like the ART register, includes viral load and CD4 count summaries.
Treatment cohort report and completed report The completed treatment cohort report form is based on pilot data collected from sites representing a 24-month history.
Patient transfer form The patient transfer form presents an example of information that may be collected to transfer a patient between facilities.
Visit date
Visit type
Date next visit
Stage
Weight
Height / BSA (child) | | | | | Bloods taken
CD4 (CD4%)
Viral Load
HB
PLT
Neut
TLC x 1000
Triglycerides
Cholesterol
Glucose
ALT
RPR
Chest X-ray
Referred / hospitalised
FP / Condoms / Pap FP CON PAP FP CON PAP FP CON PAP FP CON PAP FP CON PAP
1
2
3
4
5
6
TB symptoms
Months on TB Rx
TB M / C / S
Months on ART
Months on regimen
Pill count In Out In Out In Out In Out In Out
ARV1
ARV2
ARV3
ARV4 or other
ARV5 or other
ARV6 or other
other
other
INH
Cotrimoxazole
Fluconazole
Adverse event / grade
Adverse event / grade
Captured Date Date Date Date DateART 4
/ /
/ / Nurse Doctor
/ / / / / / / / Nurse Doctor Nurse Doctor Nurse Doctor Nurse Doctor
/ / / / / / / /
HIV
con
ditio
ns /
OI's
/ TB
Oth
er
resu
ltsM
edic
atio
n, in
cl. A
RVs
and
pro
phyl
axis
CD4
CD4
CD4
CD4
CD4
CD4
Page
Out
com
e __
____
_D
ied/
Lost
/
TFO
/
ART
____
___
Dat
e
Adult FemaleAdult Male
Child < 14yo FemChild < 14yo Male
Valu
e
D
D/M
M/Y
YVa
lue
DD
/MM
/YY
Valu
e
D
D/M
M/Y
YVa
lue
DD
/MM
/YY
Valu
e
D
D/M
M/Y
YVa
lue
DD
/MM
/YY
Fold
er #
ID/
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er #
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/
/
/
Fold
er #
ID/
/
/
/
/
/
/
/
/
/
/
/
/
/
Fold
er #
ID/
/
/
/
/
/
/
/
/
/
/
/
/
/
Fold
er #
ID/
/
/
/
/
/
/
/
/
/
/
/
/
/
Fold
er #
ID/
/
/
/
/
/
/
/
/
/
/
/
/
/
Fold
er #
ID/
/
/
/
/
/
/
/
/
/
/
/
/
/
Fold
er #
ID/
/
/
/
/
/
/
/
/
/
/
/
/
/
1818 19 20
Patie
nt's
Nam
e, S
urna
me,
fold
er n
umbe
r and
ID n
umbe
r
171698 145 15121
1514131211108 9 16 171 2 3 4 5 6 7
201943 1311106 72
BD
DOB
------
-D
D/M
M/
YY
Date
VC
T---
----
DD
/MM
/ YY
AC
E
Mon
th a
rriv
ing
at th
e cl
inic
Date
st
arte
d in
car
e at
clin
ic
(DD
/MM
)
Age
& G
ende
r
TOTA
LS
Com
men
ts
12
45
78
910
11
Page
Died
/ Lo
st/ T
FO
____
___
Date
Adult FemaleAdult Male
Child < 14yo FemChild < 14yo Male
Regimen
Outcome (R)IP/(L)TF/(T)FO
Transfer In
Regimen
Outcome (R)IP/(L)TF/(T)FO
Transfer In
Regimen
Outcome (R)IP/(L)TF/(T)FO
Transfer In
Fold
er #
IDY
YM
MD
D/
/
Fold
er #
IDY
YM
MD
D/
/
Fold
er #
IDY
YM
MD
D/
/
Fold
er #
IDY
YM
MD
D/
/
Fold
er #
IDY
YM
MD
D/
/
Fold
er #
IDY
YM
MD
D/
/
Fold
er #
IDY
YM
MD
D/
/
Fold
er #
IDY
YM
MD
D/
/
Fold
er #
IDY
YM
MD
D/
/
Fold
er #
IDY
YM
MD
D/
/
Fold
er #
IDY
YM
MD
D/
/
Fold
er #
IDY
YM
MD
D/
/
Fold
er #
IDY
YM
MD
D/
/
Fold
er #
IDY
YM
MD
D/
/
Fold
er #
IDY
YM
MD
D/
/
Fold
er #
IDY
YM
MD
D/
/
Fold
er #
IDY
YM
MD
D/
/
Fold
er #
IDY
YM
MD
D/
/
Fold
er #
IDY
YM
MD
D/
/
Fold
er #
IDY
YM
MD
D/
/
TOT
EXP
FLR
VLD
VLS
RIP
TFI
FLR
VLD
VLS
CD
DC
DA
RIP
TFI
FLR
VLD
VLS
CD
DC
DA
RIP
TFI
SLR
LTF
SLR
LTF
SLR
LTF
STO
TFO
STO
TFO
STO
TFO
Out
com
e
TOTA
LS
Coho
rt Date
st
arte
d (D
D/M
M)
Age
& G
ende
r
Prior ART (P)MTCT/ (H)AART
Funding source: (S)tate / (O)ther
Pregnant when starting ART
Starting regimen
WHO stage
Viral Load
At 1
2m
onth
s:(R
epor
t on
even
ts b
etw
een
6 &
12
mon
ths)
At 3
mon
ths:
(Rep
ort o
n ev
ents
bet
wee
n st
artin
g AR
V's
& 3
mon
ths)
CD 4 Count
At 6
mon
ths:
(Rep
ort o
n ev
ents
bet
wee
n 3
& 6
Mon
ths)
CD4
Viral load
Viral load
Viral load
CD4
1
2 43 1311106 7 19
2
20
3 4 5 6 7 8 12 13 16 19189 10 1711 14 15
Patie
nt's
Nam
e, S
urna
me,
fold
er n
umbe
r and
ID n
umbe
r
171698 145 15121 ART 5a18
20
Adu
lt 1s
t Lin
e R
egim
ens
Adu
lt 2n
d Li
ne R
egim
ens
Paed
. 1st
Lin
e R
egim
ens
Paed
. 2nd
Lin
e R
egim
ens
Stop
cod
es
1a(3
0) =
d4t
(30)
-3TC
-EFV
1a
(40)
= d
4t(4
0)-3
TC-E
FV
1b(3
0) =
d4t
(30)
-3TC
-NVP
1b
(40)
= d
4t(4
0)-3
TC-N
VP
1c
= AZ
T-3T
C-N
VP
1d
= AZ
T-3T
C-E
FV
1e
= 1N
=
non-
stan
dard
regi
men
2a =
AZT
-ddI
-LPV
/r (<
60kg
) 2a
2 = A
ZT-d
dI-L
PV/r
(>=6
0kg)
2b
=
2c =
2d
=
2N =
non
-sta
ndar
d re
gim
en n
oted
in
com
men
ts
P1a
= d4
t-3TC
-EFV
P1
b =
d4t-3
TC-N
VP
P1c
= AZ
T-3T
C-N
VP
P1d
= AZ
T-3T
C-E
FV
P1e
= d4
T-3T
C-L
PV/r
P1f
= AZ
T-3T
C-L
PV/r
P1g
= d4
T-3T
C-R
TV
P1h
= AZ
T-3T
C-R
TV
P1i
=
P1N
= n
on-s
tand
ard
P2a
= AZ
T-dd
I-LPV
/r
P2b
= AZ
T-dd
I-NVP
P2
c =
AZT-
ddI-E
FV
P2d
= AB
C-d
dI-L
PV/r
P2
e =
ABC
-ddI
-NVP
P2
f =
ABC
-ddI
-EFV
P2
g =
P2
N =
non
-sta
ndar
d
S1
Toxi
city
/ sid
e ef
fect
s S2
C
ontra
indi
catio
n - p
regn
ancy
S3
Tr
eatm
ent f
ailu
re
S4
Poor
adh
eren
ce
S5
Hos
pita
lisat
ion
/ too
ill
S6
Dru
g ou
t of s
tock
S7
Pa
tient
reas
on
S8
Oth
er p
atie
nt d
ecis
ion
S9
Plan
ned
inte
rrupt
ion
S10
Oth
er
1314
1516
1719
2021
2223
2526
2728
2931
3233
3435
36
Regimen
Outcome (R)IP/(L)TF/(T)FO
Transfer In
Regimen
Outcome (R)IP/(L)TF/(T)FO
Transfer In
Regimen
Outcome (R)IP/(L)TF/(T)FO
Transfer InFL
RVL
DVL
SC
DD
CD
AR
IPTF
IFL
RVL
DVL
SC
DD
CD
AR
IPTF
IFL
RVL
DVL
SC
DD
CD
AR
IPTF
I
SLR
LTF
SLR
LTF
SLR
LTF
STO
TFO
STO
TFO
STO
TFO
Com
men
tsR
egim
en c
hang
es
TO
TALS
/
//
/
/
//
/
/
//
/
/
/
/
/
Transfer to the follow-on register
/
//
/
/
//
/
New
regi
men
/
Reas
on fo
r sw
itch
__
____
__Da
te
New
regi
men
/
Reas
on fo
r sw
itch
__
____
__Da
te
/
/
/
//
/
/
//
/
/
//
/
At 2
4 m
onth
s:(R
epor
t on
even
ts b
etw
een
18 &
24
mon
ths)
At 1
8 m
onth
s:(R
epor
t on
even
ts b
etw
een
12 &
18
mon
ths)
CD4
Viral load
1Viral load
Viral load
At 3
0 m
onth
s:(R
epor
t on
even
ts b
etw
een
24 &
30
Mon
ths)
CD4
CD4
2 3 4 5 6
/
//
/
/
/
7
/
/
/
/
8/
/
/
/
/
//
/
12
/
//
/
/
/
/
//
/
16
/
/
1918
16 171 2 3 4 5 6 7 108 99 10 17
/
//
/
/
/
1111 12
/
/
1313
/
/
1414
1515
/
/
ART 5b
18 19 2020
Rea
sons
for
regi
men
cha
nges
(s
ubst
itutio
ns a
nd s
witc
hes)
1
Toxi
city
2
Pre
gnan
cy
3 R
isk
of p
regn
ancy
4
New
TB
5
Cha
nge
in p
roto
col
6 D
rug
out o
f sto
ck
7 O
ther
pat
ient
reas
on
8C
linic
al T
reat
men
t Fai
lu9
Imm
unol
ogic
al T
reat
me
10V
irolo
gica
l Tre
atm
ent F
a
Year District
Month Facility
Date Reported Completed by
On ART Due to start On ART Due to start
d4T (30) / 3TC / EFV - 1a(30)
d4T (40) / 3TC / EFV - 1a(40)
AZT / 3TC / NVP - 1c P1c
AZT / 3TC / EFV - 1d P1d
Other first line ( )
Other first line ( )
AZT / ddI / LPV/r (<60kg) - 2a1
AZT / ddI / LPV/r (>=60kg) - 2a2
Total remaining in care
Past month Cumulative Past month Cumulative
Cross-sectional % remaining in careTotal remaining in care / Cummulative number started on ART x 100
Notes relating to drug availability and need for emergency procurement
ART 1
Other second line ( )
Started on ART
d4T (30) / 3TC / NVP - 1b(30)
d4T (40) / 3TC / NVP - 1b(40)
General notes
Other second line ( )
Monthly ART reporting form with regimen details
ChildrenAdults
P2a
% %
At end of monthAt end of month
P1a
P1b
Annex D5. Western Cape quarterly treatment cohort report form
Facility: Adults or children:
Treatment Cohort Q1 '04 Q2 '04 Q3 '04 Q4 '04 2004 Q1 '05 Q2 '05 Q3 '05 Q4 '05 2005 Q1 '06 Q2 '06 Q3 '06 Q4 '06 2006
Number non-naive commenced (EXP)
Number of ART-naive patients commenced (TOT)
Number of ART-naïve male
Number of ART-naïve female
Number with CD4 below 50/ul or 20% TLC
Continuing first-line regimen (FLR)
On second line regimen (SLR)
Treatment discontinued (STO)
Viral load done (some projects) (VLD)
Viral load < 400 copies/mL (if applicable) (VLS)
Died (RIP)
Lost to follow-up (LTF)
Transferred out (TFO)
Transferred in (TFI)
Continuing first-line regimen (FLR)
On second line regimen (SLR)
Treatment discontinued (STO)
CD4 counts done (CDD)
CD4 counts above 200 cells/�l or 20% TLC (CDA)
Viral load done (some projects) (VLD)
Viral load < 400 copies/mL (if applicable) (VLS)
Died between 3 and 6 months (RIP)
Lost to follow-up between 3 and 6 months (LTF)
Transferred out between 3 and 6 months (TFO)
Transferred in between 3 and 6 months (TFI)
Continuing first-line regimen (FLR)
On second line regimen (SLR)
Treatment discontinued (STO)
CD4 counts done (CDD)
CD4 counts above 200 cells/�l or 20% TLC (CDA)
Viral load done (some projects) (VLD)
Viral load < 400 copies/mL (if applicable) (VLS)
Died between 6 and 12 months (RIP)
Lost to follow-up between 6 and 12 months (LTF)
Transferred out between 6 and 12 months (TFO)
Transferred in between 6 and 12 months (TFI)
Continuing first-line regimen (FLR)
On second line regimen (SLR)
Treatment discontinued (STO)
CD4 counts done (CDD)
CD4 counts above 200 cells/�l or 20% TLC (CDA)
Viral load done (some projects) (VLD)
Viral load < 400 copies/mL (if applicable) (VLS)
Died between 12 and 18 months (RIP)
Lost to follow-up between 12 and 18 months (LTF)
Transferred out between 12 and 18 months (TFO)
Transferred in between 12 and 18 months (TFI)
Continuing first-line regimen (FLR)
On second line regimen (SLR)
Treatment discontinued (STO)
CD4 counts done (CDD)
CD4 counts above 200 cells/�l or 20% TLC (CDA)
Viral load done (some projects) (VLD)
Viral load < 400 copies/mL (if applicable) (VLS)
Died between 18 and 24 months (RIP)
Lost to follow-up between 18 and 24 months (LTF)
Transferred out between 18 and 24 months (TFO)
Transferred in between 18 and 24 months (TFI)
Quarterly ART cohort reporting form
Aft
er
3 m
on
ths
Aft
er
6 m
on
ths
District:
Sta
rtin
g A
RT
Aft
er
12 m
on
ths
Aft
er
18 m
on
ths
Aft
er
24 m
on
ths
Year
Qua
rter
2001
2001
Tot
al20
0220
02 T
otal
2003
2003
Tot
al20
0420
04 T
otal
Cat
egor
yD
ata
01_Q
201
_Q3
01_Q
402
_Q1
02_Q
202
_Q3
02_Q
403
_Q1
03_Q
203
_Q3
03_Q
404
_Q1
04_Q
204
_Q3
Bas
eTo
tal
3128
2685
5866
6548
237
7410
510
313
641
822
996
9C
DD
3128
2483
5865
6548
236
7410
110
313
241
021
7%
CD
4<50
64.5
%42
.9%
50.0
%53
.0%
53.4
%40
.0%
44.6
%58
.3%
48.3
%45
.9%
43.6
%29
.1%
34.8
%37
.6%
39.6
%M
ale%
32.3
%32
.1%
26.9
%30
.6%
31.0
%36
.4%
32.3
%33
.3%
33.3
%29
.7%
31.4
%33
.0%
35.3
%32
.8%
29.7
%A
IDS
%51
.6%
35.7
%50
.0%
45.9
%51
.7%
37.9
%49
.2%
52.1
%47
.3%
39.2
%54
.3%
39.8
%47
.8%
45.9
%50
.7%
Year
Qua
rter
2001
2001
Tot
al20
0220
02 T
otal
2003
2003
Tot
alC
ateg
ory
Dat
a01
_Q2
01_Q
301
_Q4
02_Q
102
_Q2
02_Q
302
_Q4
03_Q
103
_Q2
03_Q
303
_Q4
3 m
onth
FLR
2725
2274
5555
5944
213
7191
9012
237
4S
LR0
00
00
00
00
00
00
0S
TO1
00
11
00
12
12
21
6V
LD25
2422
7145
4949
3818
158
7574
108
315
VLS
2121
1860
4144
4630
161
4470
6986
269
CD
D0
00
00
00
00
00
00
0C
DA
00
00
00
00
00
00
00
RIP
32
49
29
63
202
108
1131
LTF
00
00
01
00
10
12
25
TFO
01
01
01
00
10
01
01
Per
c di
ed9.
7%7.
4%15
.4%
10.7
%3.
4%14
.1%
9.2%
6.3%
8.5%
2.7%
9.7%
8.0%
8.2%
7.5%
Per
c ltf
0.0%
0.0%
0.0%
0.0%
0.0%
1.8%
0.0%
0.0%
0.5%
0.0%
1.1%
2.1%
1.6%
1.3%
Per
c rip
or l
tf9.
7%7.
4%15
.4%
10.7
%3.
4%15
.4%
9.2%
6.3%
8.9%
2.7%
10.6
%9.
8%9.
6%8.
7%R
emai
ning
in c
are
90.3
%89
.3%
84.6
%88
.2%
96.6
%83
.3%
90.8
%93
.8%
90.7
%97
.3%
88.6
%89
.3%
89.8
%90
.7%
Per
c st
oppe
d3.
6%0.
0%0.
0%1.
3%1.
8%0.
0%0.
0%2.
2%0.
9%1.
4%2.
2%2.
2%0.
8%1.
6%P
erc
on S
LR0.
0%0.
0%0.
0%0.
0%0.
0%0.
0%0.
0%0.
0%0.
0%0.
0%0.
0%0.
0%0.
0%0.
0%V
L C
ompl
etio
n92
.6%
96.0
%10
0.0%
95.9
%81
.8%
89.1
%83
.1%
86.4
%85
.0%
81.7
%82
.4%
82.2
%88
.5%
84.2
%V
LS%
84.0
%87
.5%
81.8
%84
.5%
91.1
%89
.8%
93.9
%78
.9%
89.0
%75
.9%
93.3
%93
.2%
79.6
%85
.4%
ITT
VL
< 40
077
.8%
84.0
%81
.8%
81.1
%74
.5%
80.0
%78
.0%
68.2
%75
.6%
62.0
%76
.9%
76.7
%70
.5%
71.9
%
6 m
onth
FLR
2623
2271
5453
5943
209
6887
90S
LR0
00
00
00
00
00
0S
TO2
00
20
00
11
14
2V
LD25
2321
6953
4954
3619
259
7483
VLS
2222
1761
4744
4832
171
5669
69C
DD
2523
2068
5049
5434
187
5972
88C
DA
915
1135
2322
2816
8928
4147
RIP
02
02
22
01
53
30
LTF
00
00
00
00
00
00
TFO
00
00
00
00
00
00
Per
c di
ed0.
0%8.
0%0.
0%2.
7%3.
6%3.
6%0.
0%2.
2%2.
3%4.
2%3.
2%0.
0%P
erc
ltf0.
0%0.
0%0.
0%0.
0%0.
0%0.
0%0.
0%0.
0%0.
0%0.
0%0.
0%0.
0%P
erc
rip o
r ltf
0.0%
8.0%
0.0%
2.7%
3.6%
3.6%
0.0%
2.2%
2.3%
4.2%
3.2%
0.0%
Rem
aini
ng in
car
e90
.3%
82.1
%84
.6%
85.9
%93
.1%
80.3
%90
.8%
91.7
%88
.6%
93.2
%86
.7%
89.3
%P
erc
stop
ped
7.1%
0.0%
0.0%
2.7%
0.0%
0.0%
0.0%
2.3%
0.5%
1.4%
4.4%
2.2%
Per
c on
SLR
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
VL
Com
plet
ion
96.2
%10
0.0%
95.5
%97
.2%
98.1
%92
.5%
91.5
%83
.7%
91.9
%86
.8%
85.1
%92
.2%
VLS
%88
.0%
95.7
%81
.0%
88.4
%88
.7%
89.8
%88
.9%
88.9
%89
.1%
94.9
%93
.2%
83.1
%IT
T V
L <
400
84.6
%95
.7%
77.3
%85
.9%
87.0
%83
.0%
81.4
%74
.4%
81.8
%82
.4%
79.3
%76
.7%
CD
4 C
ompl
etio
n89
.3%
100.
0%90
.9%
93.2
%92
.6%
92.5
%91
.5%
77.3
%89
.0%
85.5
%79
.1%
95.7
%C
D4
> 20
036
.0%
65.2
%55
.0%
51.5
%46
.0%
44.9
%51
.9%
47.1
%47
.6%
47.5
%56
.9%
53.4
%IT
T C
D4
> 20
032
.1%
65.2
%50
.0%
47.9
%42
.6%
41.5
%47
.5%
36.4
%42
.4%
40.6
%45
.1%
51.1
%
FLR
On
first
line
regi
men
Perc
die
dP
erce
ntag
e of
pat
ient
s dy
ing
in th
e pe
riod
SLR
On
seco
nd li
ne re
gim
enPe
rc lt
fP
erce
ntag
e of
pat
ient
s lo
st to
follo
w-u
p in
the
perio
dST
OS
topp
ed A
RT
but s
till i
n ca
rePe
rc ri
p or
ltf
Per
cent
age
of p
atie
nt w
ho h
ave
eith
er d
ied
or b
een
lost
to fo
llow
-up
VLD
Vira
l loa
ds d
one
Rem
aini
ng in
car
eC
umul
ativ
e pe
rcen
tage
of p
atie
nts
rem
aini
ng in
car
eVL
SV
iral l
oad
resu
lts u
nder
400
cps
/mL
Perc
sto
pped
Per
cent
age
of p
atie
nts
who
hav
e st
oppe
d th
erap
y at
this
dur
atio
n on
AR
TC
DD
CD
4 co
unts
don
ePe
rc o
n SL
RP
erce
ntag
e of
pat
ient
s on
sec
ond-
line
ther
apy
at th
is d
urat
ion
on A
RT
CD
AC
D4
coun
ts a
bove
200
/ul
VL C
ompl
etio
nP
erce
ntag
e of
vira
l loa
ds d
one
that
sho
uld
have
bee
n do
neR
IPN
ew d
eath
sVL
S%O
f the
vira
l loa
ds d
one,
the
perc
enta
ge b
elow
400
cps
/mL
LTF
New
loss
es to
follo
wup
ITT
VL <
400
Inte
ntio
n to
test
vira
l loa
d be
low
400
cps
/mL
- i.e
. not
don
e is
cla
ssifi
ed a
s be
ing
abov
e 40
0 cp
s/m
LTF
OTr
ansf
ers
out
CD
4 C
ompl
etio
nP
erce
ntag
e of
CD
4 co
unts
don
e th
at s
houl
d ha
ve b
een
done
CD
4 >
200
Of t
hose
CD
4 co
unts
don
e, th
e pe
rcen
tage
abo
ve 2
00/u
lIT
T C
D4
> 20
0In
tent
ion
to te
st C
D4
coun
t abo
ve 2
00/u
l, i.e
. not
don
e cl
assi
fied
as b
eing
bel
ow 2
00/u
l
Gra
nd
Tota
l
Year
Qua
rter
2001
2001
Tot
al20
0220
02 T
otal
2003
2003
Tot
alC
ateg
ory
Dat
a01
_Q2
01_Q
301
_Q4
02_Q
102
_Q2
02_Q
302
_Q4
03_Q
103
_Q2
03_Q
303
_Q4
12 m
onth
FLR
2523
2068
5350
5638
197
67S
LR1
00
10
03
25
0S
TO1
00
10
00
11
1V
LD25
2318
6651
4757
3519
059
VLS
2120
1455
4137
4330
151
51C
DD
2522
1764
5243
5736
188
61C
DA
1514
1342
2928
3923
119
44R
IP1
02
31
20
25
0LT
F0
00
00
00
11
1TF
O0
00
00
10
01
0P
erc
died
3.6%
0.0%
9.1%
4.1%
1.9%
3.8%
0.0%
4.7%
2.4%
0.0%
Per
c ltf
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
2.4%
0.5%
1.4%
Per
c rip
or l
tf3.
6%0.
0%9.
1%4.
1%1.
9%3.
8%0.
0%6.
8%2.
9%1.
4%R
emai
ning
in c
are
87.1
%82
.1%
76.9
%82
.4%
91.4
%75
.8%
90.8
%85
.4%
85.7
%91
.9%
Per
c st
oppe
d3.
7%0.
0%0.
0%1.
4%0.
0%0.
0%0.
0%2.
4%0.
5%1.
5%P
erc
on S
LR3.
8%0.
0%0.
0%1.
4%0.
0%0.
0%5.
1%5.
0%2.
5%0.
0%V
L C
ompl
etio
n96
.2%
100.
0%90
.0%
95.7
%96
.2%
94.0
%96
.6%
87.5
%94
.1%
88.1
%V
LS%
84.0
%87
.0%
77.8
%83
.3%
80.4
%78
.7%
75.4
%85
.7%
79.5
%86
.4%
ITT
VL
< 40
080
.8%
87.0
%70
.0%
79.7
%77
.4%
74.0
%72
.9%
75.0
%74
.8%
76.1
%C
D4
Com
plet
ion
92.6
%95
.7%
85.0
%91
.4%
98.1
%86
.0%
96.6
%87
.8%
92.6
%89
.7%
CD
4 >
200
60.0
%63
.6%
76.5
%65
.6%
55.8
%65
.1%
68.4
%63
.9%
63.3
%72
.1%
ITT
CD
4 >
200
55.6
%60
.9%
65.0
%60
.0%
54.7
%56
.0%
66.1
%56
.1%
58.6
%64
.7%
18 m
onth
FLR
2322
1863
4848
55S
LR2
10
35
23
STO
10
01
00
1V
LD22
2216
6049
4747
VLS
1618
1246
3843
29C
DD
2120
1657
4846
43C
DA
1516
1344
3832
29R
IP0
00
00
00
LTF
00
22
00
0TF
O0
00
00
00
Per
c di
ed0.
0%0.
0%0.
0%0.
0%0.
0%0.
0%0.
0%P
erc
ltf0.
0%0.
0%10
.0%
2.9%
0.0%
0.0%
0.0%
Per
c rip
or l
tf0.
0%0.
0%10
.0%
2.9%
0.0%
0.0%
0.0%
Rem
aini
ng in
car
e83
.9%
82.1
%69
.2%
78.8
%91
.4%
75.8
%90
.8%
Per
c st
oppe
d3.
8%0.
0%0.
0%1.
5%0.
0%0.
0%1.
7%P
erc
on S
LR8.
0%4.
3%0.
0%4.
5%9.
4%4.
0%5.
2%V
L C
ompl
etio
n88
.0%
95.7
%88
.9%
90.9
%92
.5%
94.0
%81
.0%
VLS
%72
.7%
81.8
%75
.0%
76.7
%77
.6%
91.5
%61
.7%
ITT
VL
< 40
064
.0%
78.3
%66
.7%
69.7
%71
.7%
86.0
%50
.0%
CD
4 C
ompl
etio
n80
.8%
87.0
%88
.9%
85.1
%90
.6%
92.0
%72
.9%
CD
4 >
200
71.4
%80
.0%
81.3
%77
.2%
79.2
%69
.6%
67.4
%IT
T C
D4
> 20
057
.7%
69.6
%72
.2%
65.7
%71
.7%
64.0
%49
.2%
24 m
onth
FLR
2321
1660
43S
LR2
20
46
STO
10
23
2V
LD24
2216
6244
VLS
1618
1246
34C
DD
2221
1659
43C
DA
2017
1451
39R
IP0
00
01
LTF
00
00
0TF
O0
00
01
Per
c di
ed0.
0%0.
0%0.
0%0.
0%1.
9%P
erc
ltf0.
0%0.
0%0.
0%0.
0%0.
0%P
erc
rip o
r ltf
0.0%
0.0%
0.0%
0.0 %
1.9%
Rem
aini
ng in
car
e83
.9%
82.1
%69
.2%
78.8
%87
.9%
Per
c st
oppe
d3.
8%0.
0%11
.1%
4.5%
3.9%
Per
c on
SLR
8.0%
8.7%
0.0%
6.3%
12.2
%V
L C
ompl
etio
n96
.0%
95.7
%10
0.0%
96.9
%89
.8%
VLS
%66
.7%
81.8
%75
.0%
74.2
%77
.3%
ITT
VL
< 40
064
.0%
78.3
%75
.0%
71.9
%69
.4%
CD
4 C
ompl
etio
n84
.6%
91.3
%88
.9%
88.1
%84
.3%
CD
4 >
200
90.9
%81
.0%
87.5
%86
.4%
90.7
%IT
T C
D4
> 20
076
.9%
73.9
%77
.8%
76.1
%76
.5%
NATIONAL COMPREHENSIVE HIV AND AIDS PROGRAMME
TRANSFER OF ART PATIENT TO OTHER ART SERVICE POINT
ART Service Point:
District/Metro:
Province:
Tel: Fax:
DC No.:
Parent/guardian: (if applicable) First Name: ______________________ Surname: _________________________ Tel:________________
PATIENT HISTORY
ART start date
Baseline ART
dd mm yy
Baseline Lab (at start of ART) Baseline clinical status (at start of ART)
Regimen 1aRegimen 1b
Any child regimen
Weight (kg)
Height (cm)
WHO Clinical Stage Adult
WHO Performance Scale
WHO Clinical Stage Child
(if different to 1a or 1b)
Current regimen since
Current ART Most recent Lab Current clinical status
Weight (kg)
WHO Clinical Stage Adult
WHO Performance Scale
WHO Clinical Stage Child
Regimen 1a Regimen 2
copies/ml
mm yymm yy
Regimen 1b Any child regimen(if different to 1a/b or 2)
Specify baseline ART regimen if not 1a or 1b:
mm yyVL________________
No YesNo Yes
CotrimoxazoleFluconazole
Current prophylaxis:
dd mm yy dd mm yy
REASON FOR TRANSFER / other relevant details:
ACKNOWLEDGEMENT OF TRANSFER (to be completed by receiving ART service point)
dd mm yyWe have received the transfer notice. Received date:
Please fax mail to us: ART Assessment and Baseline formART Patient Follow Up forms/details
Patient has attended his/her first visit at
Date of visit:
our ART service point.
Fax/send back copy of whole form to transferring ART service point immediately after receiving it!Fax/send back copy of whole form to transferringART service point immediately after first visit!
dd mm yy
Clinician’s name_____________________ Clinician’s name____________________
Clinician’s name_____________________ Signature_______________________
Tel________________Fax_______________
Tel_________________Fax_________________
Specify current ART regimen if not 1a/b or 2:
ART drugs issuedwill last until
Prophylaxis issuedwill last until
First appointment made atNo Yesreceiving service point Appointment date
dd mm yyTransfer date
dd mm yy
CD4____________ %
CD4__________________ %
CD4_________cells/mm3
CD4______________ cells/mm3
ALT____________U/l x1012/lEry __________
Leuc__________ Lymph_________x109/l x109/l
Neut__________ Platlet__________x109/l x109/l
Hb_____________g/dl HCT______________l/l
Gluc__________ mmol/lCholest________mmol/l
M F
PATIENT IDENTIFIER
Sex Current file No: _______________________
dd mm yyDate of birth
Tel:_________________ ID
First Name: ________________________ Surname: ____________________________
Other non-publicTransfer from:
Patient’s contact details:
Facility Name:
GP
District/Metro:
Province:
Tel: Fax:
DC No.:
Mail address
Transfer to: Public sectorNGO/FBO/CBO
Any previous Transfer forms
Uganda Monthly reporting form
Uganda has used the WHO forms described in these guidelines, with small modifications to adapt to country needs. The monthly reporting forms are bound and carbon-copied in triplicate to allow a copy to remain in the facility.
WHO South-East Asia Regional Office (SEARO) SEARO has developed a training toolkit for HIV care and ART recording and reporting. The following forms are part of this package which also contains ARV drug registers and a cohort analysis report form. Patient booklet
This is an example of a patient-held record that contains basic demographic information, the unique patient ID number, 12 pages of clinical notes (only 2 are shown), and the date of the next appointment.
The patient card, registers and monthly report forms are variations of the generic WHO tools. Patient ART card Pre-ART register ART register Monthly report form
Ant
iretr
ovira
l Tre
atm
ent R
ecor
d (T
o re
tain
ed b
y th
e pa
tient
) N
ame
of tr
eatm
ent u
nit:
Dis
trict
:
S
tate
: P
atie
nt’s
nam
e:
A
ge:
S
ex:
Com
plet
e A
ddre
ss:
Vill
age/
tow
n:
Dis
trict
:
S
tate
:
AR
T R
egis
tratio
n nu
mbe
r:
Dat
e of
enr
ollm
ent
for A
RT:
Nam
e of
con
tact
per
son/
gua
rdia
n:
Pho
ne n
umbe
r of c
onta
ct p
erso
n/gu
ardi
an:
Add
ress
of c
onta
ct p
erso
n/gu
ardi
an:
P
atie
nt’s
ph
otog
raph
d
d
m m
y y
Clin
ical
Not
es
Dat
e of
vis
it:
Chi
ef C
ompl
aint
s:
In
vest
igat
ions
Clin
ical
exa
min
atio
n:
Trea
tmen
t
Clin
ical
Not
es
Dat
e of
vis
it:
Chi
ef C
ompl
aint
s:
In
vest
igat
ions
Clin
ical
exa
min
atio
n:
Tr
eatm
ent
Rem
embe
r •
Brin
g th
is b
ookl
et a
t eac
h fo
llow
-up
visi
t •
Take
all
med
icin
es w
ithou
t mis
sing
any
dos
e •
Take
all
med
icin
es a
t the
righ
t tim
e •
Take
the
full
dose
of m
edic
ines
. DO
NO
T sh
are
med
icin
es
with
fam
ily o
r frie
nds
• R
egul
ar tr
eatm
ent c
an h
elp
you
gain
wei
ght,
feel
bet
ter
and
resu
me
norm
al a
ctiv
ities
•
Stic
k to
a h
ealth
y an
d re
spon
sibl
e lif
e-st
yle
• B
ring
empt
y bl
iste
r pac
kets
/bot
tle a
t eac
h fo
llow
-up
visi
t In
cas
e of
em
erge
ncy,
con
tact
:
____
____
____
____
____
___
____
(Nam
e, a
ddre
ss a
nd p
hone
num
ber
of h
ospi
tal/h
ealth
wor
ker)
:
____
____
____
____
____
___
____
Com
e ba
ck o
n
(Writ
e da
te o
f nex
t app
oint
men
t)
1.
6.
2.
7.
3.
8.
4.
9.
5.
10
.
PATI
ENT
HIV
CA
RE
and
AN
TIR
ETR
OVI
RA
L TR
EATM
ENT
(AR
T) R
ECO
RD
(T
o be
sto
red
in a
lock
ed c
abin
et a
t the
hea
lth c
entr
e an
d ar
rang
ed s
eria
lly b
y re
gist
ratio
n nu
mbe
r)
1. P
atie
nt Id
entif
icat
ion
Dat
a (W
rite
com
plet
e in
form
atio
n)
Reg
istr
atio
n N
umbe
r :
code
clin
ic (2
#)-c
ode
patie
nt (4
#)
Nam
e of
Tre
atm
ent U
nit:
City
:
D
istri
ct:
Sta
te/p
rovi
nce:
Nam
e of
pat
ient
:
A
ge:
(d
ate
of b
irth:
/
/
dd
/
mm
/
yy
Sex
: M
ale
F
emal
e
Pat
ient
’s p
hone
num
ber:
Add
ress
:
City
/vill
age:
Dis
trict
:
Sta
te/p
rovi
nce:
D
ista
nce
from
resi
denc
e to
clin
ic (k
m)
Trea
tmen
t sup
porte
r’s n
ame
(if a
pplic
able
)
Trea
tmen
t sup
porte
r’s a
ddre
ss:
Trea
tmen
t sup
porte
r’s p
hone
num
ber:
D
ate
conf
irmed
HIV
+ te
st:
//
dd
/
mm
/
yy
Plac
e:
Entr
y po
int (
serv
ices
refe
rrin
g th
e pa
tient
for H
IV c
are)
: 1
-VC
T 2
-TB
3
-Out
patie
nt
4-In
patie
nt
5-P
aedi
atric
6
-PM
TCT
7-S
TI
8-P
rivat
e
9-N
GO
1
0-S
elf r
efer
red
11-
IDU
out
reac
h
12-
CS
W o
utre
ach
1
3-ot
her_
____
____
____
____
____
____
____
pat
ient
tran
sfer
red
in o
n A
RT
from
ano
ther
HIV
car
e/A
RT
clin
ic fr
om th
e na
tiona
l pro
gram
Nam
e pr
evio
us c
linic
:
Dat
e tra
nsfe
rred
in :
2. P
erso
nal H
isto
ry (
Tick
one
cho
ice)
3.
Fam
ily H
isto
ry (
Tick
one
cho
ice)
M
arita
l sta
tus:
S
ingl
e
Mar
ried
D
ivor
ce/s
epar
ate
Wid
owed
N
ot a
pplic
able
Est
imat
ed m
onth
ly
hous
ehol
d in
com
e:
Fam
ily m
embe
rs:
partn
er/c
hild
ren
Age
/ se
x H
IV
+/-/u
nkno
wn
ART
Y/N
R
egis
t. N
o if
in c
are
Mod
e of
HIV
tra
ns-
mis
sio
n
1 C
omm
erci
al s
ex w
orke
r (C
SW)
2 O
ther
het
eros
exua
l rou
te
3 M
en h
avin
g se
x w
ith m
en (M
SM)
4 In
ject
ing
drug
use
(ID
U)
5 B
lood
tran
sfus
ion
6 M
othe
r to
child
7
Unk
now
n
For I
DU
s
Sub
stitu
tion
ther
apy
Y
N
If ye
s, ty
pe:
Lite
rate
Yes
N
o
Em
ploy
ed
Yes
N
o
Alc
ohol
ism
H
abitu
al
Soc
ial
N
o us
e
4. A
ntire
trov
iral t
reat
men
t his
tory
If
yes
PM
TCT
E
arlie
r AR
T P
lace
: P
rivat
e G
ovt
Was
AR
T re
ceiv
ed
befo
re?
Yes
N
o D
rugs
and
dur
atio
n:
5. C
linic
al a
nd L
abor
ator
y In
vest
igat
ions
D
ate
(dd/
mm
/yy)
W
HO
st
age
Wei
ght
(kg)
H
eigh
t (c
m)
Perf
or-
man
ce
A/B
/C*
Tota
l ly
mph
ocyt
e co
unt
CD
4 co
unt
(or %
in
child
ren)
At 1
st v
isit
in c
linic
At A
RT
med
ical
elig
ibilit
y
ch
ild
At s
tart
of A
RT
child
A
t 6 m
onth
s A
RT
child
A
t 12
mon
ths
AR
T
ch
ild
At 2
4 m
onth
s A
RT
child
6. A
ntire
trov
iral T
reat
men
t Tr
eatm
ent S
tart
ed
SUB
STIT
UTI
ON
with
in 1
st li
ne, S
WIT
CH
to 2
nd li
ne, S
TOP,
RES
TAR
T
Dat
e S
ubst
itutio
n,
switc
h or
sto
p R
easo
n (c
ode)
D
ate
rest
art
New
regi
men
D4T
30+3
TC+N
VP
D
4T40
+3TC
+NV
P
D4T
30+3
TC+E
FV
D4T
40+3
TC+E
FV
ZD
V+3
TC+N
VP
Z
DV
+3TC
+EFV
Rea
sons
SU
BST
ITU
TE: 1
toxi
city
sid
e ef
fect
s, 2
pre
gnan
cy, 3
risk
of p
regn
ancy
, 4 n
ewly
dia
gnos
ed T
B, 5
ne
w d
rug
avai
labl
e, 6
dru
g ou
t of s
tock
, 7 o
ther
reas
on (s
peci
fy)
Rea
sons
for S
WIT
CH
: 1 c
linic
al tr
eatm
ent f
ailu
re, 2
imm
unol
ogic
al fa
ilure
, 3 v
irolo
gic
failu
re
Rea
sons
STO
P: 1
toxi
city
sid
e ef
fect
s, 2
pre
gnan
cy, 3
trea
tmen
t fai
lure
, 4 p
oor a
dher
ence
, 5 il
lnes
s ho
spita
lizat
ion,
6 d
rug
out o
f sto
ck, 7
pat
ient
lack
of f
inan
ce, 8
pat
ient
dec
isio
n, 9
pla
nned
trea
tmen
t in
terr
uptio
n, 1
0 ot
hers
7. T
uber
culo
sis
trea
tmen
t dur
ing
HIV
car
e TB
regi
stra
tion
Dis
trict
:
H
ealth
Cen
tre:
TB n
umbe
r:
Dis
ease
cla
ss (t
ick)
P
ulm
onar
y TB
Sm
ear-
posi
tive
S
mea
r-ne
gativ
e E
xtra
pulm
onar
y si
te: _
____
____
____
TB R
egim
en (t
ick)
C
ateg
ory
I C
ateg
ory
II O
ther
spe
cify
: D
ate
star
t TB
Rx:
/
/
d
d /
mm
/
yy
Trea
tmen
t out
com
e:
Cur
e
Rx
com
plet
ed
Rx
failu
re
Die
d
Def
ault
T
rans
fer o
ut
Dat
e:
//
)
d
d /
mm
/
yy
8. E
nd o
f Fol
low
-up
Dea
th
Dat
e of
dea
th:
//
Los
t to
follo
w-u
p (>
3 m
onth
s)
Dat
e la
st v
isit:
/
/
Tra
nsfe
rred
out
D
ate:
/
/
d
d /
mm
/
yy
New
clin
ic:
*
Per
form
ance
sca
le: A
- Nor
mal
act
ivity
; B- b
edrid
den
<50%
of t
he d
ay d
urin
g la
st m
onth
; C- b
edrid
den
> 50
% o
f the
day
dur
ing
last
mon
th
9. P
ATI
ENT
HIV
CA
RE
& A
NTI
RET
RO
VIR
AL
TREA
TMEN
T FO
LLO
W-U
P
Dat
e of
vi
sit*
Dat
e ne
xt v
isit
Wei
ght
(kg)
&
hei
ght
for c
hild
WH
O
stag
e
Per
for-
man
ce
scal
e*
preg
nanc
y(y
/n)
or F
P m
etho
d*
oppo
rtuni
stic
in
fect
ions
- c
ode*
Dru
gs p
resc
ribed
fo
r pro
phyl
axis
of
OIs
Ant
iretro
vira
l dru
gs a
nd d
ose
pres
crib
ed
adhe
renc
e to
AR
T* -
>95%
, 80-
95%
, <80
%
AR
T S
ide
effe
cts
- cod
e*
lab
resu
lts
whe
n av
aila
ble
Con
d-om
s gi
ven
y/n
Ref
erre
d to
spe
cial
ist
or h
ospi
t.
*Inst
ruct
ions
and
cod
es:
Dat
e: W
rite
the
date
of a
ctua
l vis
it st
artin
g fro
m th
e 1st
vis
it fo
r HIV
car
e –
ALL
DAT
ES
: DD
/MM
/YY
Perf
orm
ance
sca
le: A
- Nor
mal
act
ivity
; B- b
edrid
den
<50%
of t
he d
ay d
urin
g la
st m
onth
; C- b
edrid
den
> 50
% o
f the
day
dur
ing
last
mon
thj
FP: f
amily
pla
nnin
g; 1
con
dom
s, 2
ora
l con
trace
ptiv
e pi
lls, 3
inje
ctab
le/im
plan
tabl
e ho
rmon
es, 4
dia
phra
gm/c
ervi
cal c
ap, 5
in
traut
erin
e de
vice
, 6 v
asec
tom
y/tu
bal
ligat
ion/
hyst
erec
tom
y
Opp
ortu
nist
ic in
fect
ions
: Ent
er o
ne o
r mor
e co
des −
Tube
rcul
osis
(TB
); C
andi
dias
is (C
); D
iarr
hea
(D);
Cry
ptoc
ococ
al m
enin
gitis
(M);
Pne
umoc
ystis
Car
inii
Pne
umon
ia (P
CP
); C
ytom
egal
oviru
s di
seas
e (C
MV
); P
enic
illios
is (P
); H
erpe
s zo
ster
(Z);
Gen
ital h
erpe
s (H
); To
xopl
asm
osis
(T);
Oth
er-s
peci
fy
Adh
eren
ce: C
heck
adh
eren
ce b
y as
king
the
patie
nt if
he/
she
has
mis
sed
any
dose
s. A
lso
chec
k th
e bo
ttle/
blis
ter p
acke
t. W
rite
the
estim
ated
leve
l of
adhe
renc
e (e
.g. >
95%
= <
3 d
oses
mis
sed
in a
per
iod
of 3
0 da
ys; 8
0-95
% =
3 to
12
dose
s m
isse
d in
a p
erio
d of
30
days
; < 8
0% =
>12
dos
es m
isse
d in
a
perio
d of
30
days
Si
de e
ffect
s: E
nter
one
or m
ore
code
s −
S=S
kin
rash
; Nau
-nau
sea;
V=V
omiti
ng; D
=Dia
rrho
ea; N
=Neu
ropa
thy;
J=Ja
undi
ce; A
=Ane
mia
; F=F
atig
ue;
H=H
eada
che;
Fev
=Fev
er; H
yp=H
yper
sens
itivi
ty; D
ep=D
epre
ssio
n; P
=Pan
crea
titis
; L=L
ipod
ystro
phy;
Dro
ws=
Dro
wsi
ness
; O=O
ther−
Spec
ify
INFO
RM
ATI
ON
AB
OU
T A
NTI
RET
RO
VIR
AL
DR
UG
S
Reg
imen
D
ose
Maj
or T
oxic
ity
Dru
g Su
bstit
utio
n
D4T
/3TC
/NVP
(Sta
vudi
ne
Lam
uvid
ine
Nev
irapi
ne)
• d4
T-3T
C tw
ice
a da
y pl
us N
VP 2
00 m
g on
ce
a da
y fo
r 2 w
eeks
• d4
T-3T
C-N
VP F
ixed
dos
e co
mbi
natio
n tw
ice
a da
y if
patie
nt to
lera
tes
first
2 w
eeks
of N
VP
• d4
T: 3
0 m
g tw
ice
daily
if <
60kg
, 40m
g tw
ice
daily
if >
60 k
gg
• d4
T –
rela
ted
neur
opat
hy o
r pan
crea
titis
• d4
T –r
elat
ed li
poat
roph
y
• N
VP
–re
late
d se
vere
hep
atot
oxic
ity
• N
VP
– re
late
d se
vere
rash
(but
not
life
thre
aten
ing)
• N
VP
–re
late
d lif
e th
reat
enin
g ra
sh (S
teve
ns –
Joh
nson
sy
ndro
me)
• S
ubst
itute
d4T
to Z
DV
• S
ubst
itute
d4T
to T
DF
or A
BC
• S
ubst
itute
NV
P to
EFV
(exc
ept i
n pr
egna
ncy)
• S
ubst
itute
NV
P to
EFV
(exc
ept i
n pr
egna
ncy)
• S
witc
h N
VP
to N
FV
ZDV/
3TC
/NVP
(Zid
ovud
ine
Lam
uvid
ine
Nev
irapi
ne)
• ZD
V-3T
C tw
ice
a da
y pl
us N
VP 2
00 m
g on
ce
a da
y fo
r 2 w
eeks
• ZD
V-3T
C-N
VP F
ixed
dos
e co
mbi
natio
n tw
ice
a da
y if
patie
nt to
lera
tes
firs
t 2 w
eeks
of N
VP
• ZD
V–r
elat
ed p
ersi
sten
t GI i
ntol
eran
ce o
r sev
ere
haem
tolo
gica
l to
xici
ty
• N
VP
–rel
ated
sev
ere
hepa
toxi
city
• N
VP
–rel
ated
sev
ere
rash
(but
not
life
thre
aten
ing)
• N
VP
–rel
ated
life
thre
aten
ing
rash
(Ste
vens
– J
ohns
on
synd
rom
e)
• S
ubst
itute
ZD
V to
d4T
•
Subs
titut
e N
VP
to E
FV (
exce
pt in
pre
gnan
cy.
In th
is s
ituat
ion
switc
h to
NFV
, LP
V/r
or A
BC
)
• S
ubst
itute
NV
P to
EFV
(exc
ept i
n pr
egna
ncy)
• S
ubst
itute
NV
P to
NFV
D4T
/3TC
/EFV
(Sta
vudi
ne
Lam
ivud
ine
E
favi
renz
)
• d4
T/3T
C a
s tw
ice
daily
fixe
d do
se c
ombi
natio
n pl
us E
FV (6
00 m
g) o
nce
per d
ay
• d4
T: 3
0 m
g tw
ice
daily
if <
60kg
, 40m
g tw
ice
daily
if >
60 k
g
• d4
T–re
late
d ne
urop
athy
or p
ancr
eatit
is
• d4
T–re
late
d lip
oatro
phy
• E
FV–r
elat
ed p
ersi
sten
t CN
S to
xici
ty
• S
ubst
itute
d4T
to Z
DV
• S
ubst
itute
d4T
to T
DF
or A
BC
• S
ubst
itute
EFV
to N
VP
ZDV
/3TC
/EFV
(Zid
ovud
ine
Lam
uvid
ine
Efa
vire
nz)
• ZD
V-3T
C tw
ice
a da
y as
a fi
xed
drug
co
mbi
natio
n pl
us E
FV (6
00 m
g) o
nce
per d
ay
• ZD
V–r
elat
ed p
ersi
sten
t GI i
ntol
eran
ce o
r sev
ere
hem
atol
ogic
al
toxi
city
• E
FV–r
elat
ed p
ersi
sten
t CN
S to
xici
ty
• S
ubst
itute
ZD
V to
d4T
• S
ubst
itute
EFV
to N
VP
AB
C=
Aba
cavi
r; d4
T= S
tavu
dine
; E
FV=E
favi
renz
; LP
V=L
opin
avir;
N
FV=N
elfin
avir
NV
P=
Nev
irapi
ne;
TDF=
Teno
fovi
r; ZD
V=Z
idov
udin
e;
3TC
=Lam
ivud
ine
HIV
CA
RE-
PR
E A
RT
REG
ISTE
R: F
ill a
t firs
t vis
it co
lum
n 1
to 1
0Fi
ll w
hen
appl
icab
le c
olum
n 11
to 1
61
23
45
67
89
1011
1213
1415
16D
ATE
1st
vi
sit a
t the
cl
inic
Reg
istr
atio
n nu
mbe
rPa
tient
's n
ame
and
addr
ess
Age
Sex
M/ F
Con
firm
ed H
IV+
test
En
try
poin
t -co
de
1 to
13*
risk factor -code 1 to 7**
Literate
Employed
CPT
D
ate
of
Star
t
TB tr
eatm
ent
Cla
ss/R
egim
en
Dat
e of
sta
rt
DA
TE
med
ical
ly
ellig
ible
for
AR
T
Why
med
ical
ly
ellig
ible
?D
ATE
A
RT
star
ted
End
of fo
llow
-up
befo
re s
tart
ing
Dat
e of
de
ath
Dat
e lo
st
to F
U (l
ast
visi
t)
Dat
e tr
ansf
erre
d ou
t D
ate
Plac
e
1
□Y □
N□Y
□N
WH
O s
tage
CD
4 #/
%
TLC
#
2
□Y □
N□Y
□N
WH
O s
tage
CD
4 #/
%
TLC
#
3
□Y □
N□Y
□N
WH
O s
tage
CD
4 #/
%
TLC
#
4
□Y □
N□Y
□N
WH
O s
tage
CD
4 #/
%
TLC
#
5
□Y □
N□Y
□N
WH
O s
tage
CD
4 #/
%
TLC
#
6
□Y □
N□Y
□N
WH
O s
tage
CD
4 #/
%
TLC
#
7
□Y □
N□Y
□N
WH
O s
tage
CD
4 #/
%
TLC
#
8
□Y □
N□Y
□N
WH
O s
tage
CD
4 #/
%
TLC
#
9
□Y □
N□Y
□N
WH
O s
tage
CD
4 #/
%
TLC
#
10
□Y □
N□Y
□N
WH
O s
tage
CD
4 #/
%
TLC
#
11
□Y □
N□Y
□N
WH
O s
tage
CD
4 #/
%
TLC
#
12
□Y □
N□Y
□N
WH
O s
tage
CD
4 #/
%
TLC
#
13
□Y □
N□Y
□N
WH
O s
tage
CD
4 #/
%
TLC
#
14
□Y □
N□Y
□N
WH
O s
tage
CD
4 #/
%
TLC
#
15
□Y □
N□Y
□N
WH
O s
tage
CD
4 #/
%
TLC
#
*Ent
ry p
oint
: 1-V
CT;
2-T
B; 3
-Out
patie
nt; 4
-Inpa
tient
; 5-P
aedi
atric
; 6-P
MTC
T; 7
-STI
; 8-P
rivat
e; 9
-NG
O; 1
0-S
elf r
efer
red;
11-
IDU
out
reac
h; 1
2- C
SW
out
reac
h; 1
3-ot
her -
Writ
e co
de T
R if
the
patie
nt w
as tr
ansf
erre
d in
on
AR
T**
Mod
e of
HIV
tran
smis
sion
: 1-C
omm
erci
al s
ex w
orke
r (C
SW
), 2
-Oth
er h
eter
osex
ual r
oute
, 3-
Men
hav
ing
sex
with
men
(MS
M),
4-In
ject
ing
drug
use
(ID
U),
5-B
lood
tran
sfus
ion,
6-M
othe
r to
child
, 7-
Unk
now
nC
PT:
Cot
rimox
azol
e pr
even
tive
ther
apy
AR
T R
EGIS
TER
Mon
th:
Year
:
DA
TE o
f sta
rt o
f A
RT
Reg
istr
atio
n nu
mbe
rPa
tient
's fi
rst n
ame
and
surn
ame
Age
Sex
M/ F
Patie
nt’s
add
ress
and
co
ntac
t num
ber
Trea
tmen
t sup
port
er’s
na
me
and
cont
act
num
ber
Prior ARV history
WH
O
stag
e at
st
art
of R
x
Perf
orm
ance
sca
leA
-nor
mal
act
ivity
; B
-bed
ridde
n<50
%;
C-B
edrid
den>
50%
Wei
ght (
kg)
at s
tart
, 6, 1
2,24
m
onth
s of
AR
T
CD
4 co
unt
at s
tart
, 6, 1
2,24
m
onth
s of
AR
T (a
bsol
ute
num
ber f
or a
dults
an
d %
for c
hild
ren)
TB tr
eatm
ent
durin
g A
RT
AR
T re
gim
en s
tart
edD
isea
se, C
ateg
ory
Reg
imen
Dat
e R
x st
art
1
……
……
……
.…
……
……
…□
YA
t sta
rt of
Rx
At 6
mon
ths
At s
tart
of R
xA
t 6 m
onth
sA
t sta
rt of
Rx
At 6
mon
ths
……
……
……
.…
……
……
…□
NA
t 12
mon
ths
At 2
4 m
onth
sA
t 12
mon
ths
At 2
4 m
onth
sA
t 12
mon
ths
At 2
4 m
onth
s
2
……
……
……
.…
……
……
…□
YA
t sta
rt of
Rx
At 6
mon
ths
At s
tart
of R
xA
t 6 m
onth
sA
t sta
rt of
Rx
At 6
mon
ths
……
……
……
.…
……
……
…□
NA
t 12
mon
ths
At 2
4 m
onth
sA
t 12
mon
ths
At 2
4 m
onth
sA
t 12
mon
ths
At 2
4 m
onth
s
3
……
……
……
.…
……
……
…□
YA
t sta
rt of
Rx
At 6
mon
ths
At s
tart
of R
xA
t 6 m
onth
sA
t sta
rt of
Rx
At 6
mon
ths
……
……
……
.…
……
……
…□
NA
t 12
mon
ths
At 2
4 m
onth
sA
t 12
mon
ths
At 2
4 m
onth
sA
t 12
mon
ths
At 2
4 m
onth
s
4
……
……
……
.…
……
……
…□
YA
t sta
rt of
Rx
At 6
mon
ths
At s
tart
of R
xA
t 6 m
onth
sA
t sta
rt of
Rx
At 6
mon
ths
……
……
……
.…
……
……
…□
NA
t 12
mon
ths
At 2
4 m
onth
sA
t 12
mon
ths
At 2
4 m
onth
sA
t 12
mon
ths
At 2
4 m
onth
s
5
……
……
……
.…
……
……
…□
YA
t sta
rt of
Rx
At 6
mon
ths
At s
tart
of R
xA
t 6 m
onth
sA
t sta
rt of
Rx
At 6
mon
ths
……
……
……
.…
……
……
…□
NA
t 12
mon
ths
At 2
4 m
onth
sA
t 12
mon
ths
At 2
4 m
onth
sA
t 12
mon
ths
At 2
4 m
onth
s
6
……
……
……
.…
……
……
…□
YA
t sta
rt of
Rx
At 6
mon
ths
At s
tart
of R
xA
t 6 m
onth
sA
t sta
rt of
Rx
At 6
mon
ths
……
……
……
.…
……
……
…□
NA
t 12
mon
ths
At 2
4 m
onth
sA
t 12
mon
ths
At 2
4 m
onth
sA
t 12
mon
ths
At 2
4 m
onth
s
7
……
……
……
.…
……
……
…□
YA
t sta
rt of
Rx
At 6
mon
ths
At s
tart
of R
xA
t 6 m
onth
sA
t sta
rt of
Rx
At 6
mon
ths
……
……
……
.…
……
……
…□
NA
t 12
mon
ths
At 2
4 m
onth
sA
t 12
mon
ths
At 2
4 m
onth
sA
t 12
mon
ths
At 2
4 m
onth
s
8
……
……
……
.…
……
……
…□
YA
t sta
rt of
Rx
At 6
mon
ths
At s
tart
of R
xA
t 6 m
onth
sA
t sta
rt of
Rx
At 6
mon
ths
……
……
……
.…
……
……
…□
NA
t 12
mon
ths
At 2
4 m
onth
sA
t 12
mon
ths
At 2
4 m
onth
sA
t 12
mon
ths
At 2
4 m
onth
s
9
……
……
……
.…
……
……
…□
YA
t sta
rt of
Rx
At 6
mon
ths
At s
tart
of R
xA
t 6 m
onth
sA
t sta
rt of
Rx
At 6
mon
ths
……
……
……
.…
……
……
…□
NA
t 12
mon
ths
At 2
4 m
onth
sA
t 12
mon
ths
At 2
4 m
onth
sA
t 12
mon
ths
At 2
4 m
onth
s
1 0
……
……
……
.…
……
……
…□
YA
t sta
rt of
Rx
At 6
mon
ths
At s
tart
of R
xA
t 6 m
onth
sA
t sta
rt of
Rx
At 6
mon
ths
……
……
……
.…
……
……
…□
NA
t 12
mon
ths
At 2
4 m
onth
sA
t 12
mon
ths
At 2
4 m
onth
sA
t 12
mon
ths
At 2
4 m
onth
s
AR
T R
EGIS
TER
Mon
th:
Year
: Tr
eatm
ent s
ubst
itute
d w
ithin
1st
line
dr
ugs
Trea
tmen
t sw
itche
d to
2nd
line
End
of fo
llow
-up
on A
RT
Mon
thly
vis
its: ●
1st r
ow, w
rite
patie
nt o
utco
me:
on
treat
men
t (O
T) if
pat
ient
pic
ked
up A
RT
drug
s; s
topp
ed (
ST) i
f AR
T w
as s
topp
ed b
y th
e do
ctor
; mis
sing
(M
IS) i
f the
pat
ient
mis
sed
the
sche
dule
d vi
sit;
lost
to fo
llow
-up
(LFU
) if t
he p
atie
nt is
mis
sing
for ≥3
mon
ths;
rest
art (
RS)
if A
RT
was
rest
arte
d af
ter a
n in
terr
uptio
n; t
rans
ferr
ed o
ut (
TR);
dead
(D);
(NA
) if t
he p
atie
nt w
as n
ot s
ched
uled
to v
isit
this
m
onth
● 2
nd ro
w: w
rite
adhe
renc
e fo
r the
pat
ient
s on
trea
tmen
t ( A
=>95
%, B
=80-
95%
, C=<
80%
)
Dat
e su
bstit
ute
dR
easo
n*N
ew R
egim
enD
ate
switc
hed
Rea
son*
*N
ew R
egim
enD
ate
of
deat
h
Dat
e lo
st
to F
U
(last
vi
sit)
Dat
e tr
ansf
ered
O
ut o
n A
RT
Wee
k2
Mon
th 1
mo.
2m
o.3
mo.
4m
o.5
mo.
6m
o.7
mo.
8m
o.9
mo.
10
mo.
11
mo.
12m
o.
13m
o.
14m
o.
15m
o.
16m
o.
17m
o.
18m
o.
19m
o.
20m
o.
21m
o.
22m
o.
23m
o.24
* Rea
sons
for s
ubsi
tutio
n w
ithin
firs
t lin
e tr
eatm
ent:1
-toxi
city
or s
ide
effe
cts;
2-p
regn
ancy
;3-r
isk
of p
regn
ancy
; 4-n
ewly
dia
gnos
ed T
B; 5
-new
dru
g av
aila
ble;
6-d
rug
out o
f sto
ck; 7
-oth
er re
ason
.* R
easo
ns fo
r sw
itchi
ng to
sec
ond
line
trea
tmen
t:1-to
xici
ty o
r sid
e ef
fect
s; 2
-pre
gnan
cy; 3
-ris
k of
pre
gnan
cy; 4
-new
ly d
iagn
osed
TB
; 5-n
ew d
rug
avai
labl
e; 6
-dru
g ou
t of s
tock
; 7-o
ther
reas
on; 8
-clin
ical
trea
tmen
t fai
lure
; 9-im
mun
olog
ical
failu
re; 1
0 -v
irolo
gica
l fai
lure
.R
easo
ns fo
r sto
ppin
g A
RT:
1- t
oxic
ity s
ide
effe
cts;
2-p
regn
ancy
; 3-tr
eatm
ent f
ailu
re; 4
-poo
r adh
eren
ce; 5
-illn
ess
hosp
italis
atio
n; 6
-dru
g ou
t of s
tock
; 7-la
ck o
f fin
ance
; 8-p
atie
nt's
dec
isio
n to
sto
p; 9
oth
er re
ason
.
Monthly HIV care/ Antiretroviral treatment (ART) Centre Report1. Name of the Treatment Unit2. Name of the District3. Name of the State/province4. Name of the Treatment Unit incharge
5. Report for the periodmonth year
A- MEDICAL CARE
6. Enrollment in HIV care (PLWHA seeking care at the treatment center) adult male adult female child.<14 yo total
6.1 Cumulative no. of patients ever enrolled in HIV care at beginning of this month6.2 New patients enrolled in HIV care during this month6.3 Cumulative no. of patients ever enrolled in HIV care at the end of this month
7. Medical eligibility for ART* adult male adult female child.<14 yo total
7.1 No. of patients medically eligible for ART but have not been started on ART at the end of this month
8. Enrollment on ART adult male adult female child.<14 yo total
8.1 Cumulative no. of patients ever started on ARTat the beginning of this month8.2 New patients started on ART during this month
8.3 No. of patients on ART transferred in this month
8.4 Cumulative no. of patients ever started on ARTat the end of this month
9. outcomes on ART adult male adult female child.<14 yo total
9.1 Cumulative no. of death reported at the end of this month 9.2 Cumulative no. of patients transferred out under ARV at the end of this month9.3 No. of patients missing/lost to follow-up at the end of this month9.4 No. of patients stopping ART at the end of this month
9.5 No. of patients on ART at the end of this month
● 9.5.1 Among them, no. on original 1st line regimen
● 9.5.2 No. on substituted 1st line regimen
● 9.5.3 No. switched on 2nd line regimen
* refers to the medical elligibility on clinical and/or laboratory criteriae, whether or not the patient is ready for ART
10. TREATMENT ADHERENCETotal
10.1. No. of patients assessed for adherence during this month
10.2. Of those assessed for adherence, level of adherence in the last month
10.2.1. < 3 doses missed in a period of 30 days > 95%
10.2.2 =3 to 12 doses missed in a period of 30 days 80-95%
10.2.3. >12 doses missed in a period of 30 days <80%
Monthly HIV care/ Antiretroviral treatment (ART) Centre Report
B- PHARMACY
11. REGIMEN AT THE END OF THE MONTH
Regimen No. of patients on ART
D4T30/3TC/NEVD4T40/3TC/NEVZDV/3TC/NEVZDV/3TC/EFVD4T30/3TC/EFVD4T40/3TC/EFV
Total= No. of patients on ART at the end of this month (=9.5)
12. DRUG STOCKS Was there a stock-out of antiretroviral drugs this month? Yes No Was there a stock-out of drugs for opportunistic infection this m Yes No
Name of the drug (list ARV and OI drugs)
Stock at the start of the month (A)
Stock received during the month
(B)
Stock dispensed during the month ( C)
Stock expired/
discarded during the month (D)
Stock at the end of the
month (A+B)-(C+D)
Amount requested
Kenya Quarterly integrated monitoring and evaluation report form
Kenya's MTCT+ programme is an example of one that links PMTCT to ART. Many of the same indicators and data can be collected in addition to PMTCT-specific information and should ideally be integrated and tracked on the same forms. The quarterly integrated monitoring form that is used in Kenya is a good example of how the linkage between PMTCT and ART may be accomplished.
US President's Emergency Plan Track 1.0 partners Quarterly report form
The CDC has adapted the WHO quarterly report form for Track 1.0 partner organizations (grantees of centrally funded cooperative agreements and contracts through the Emergency Plan to implement HIV/AIDS programmes in 14 priority countries) to be able to collect indicators required by the US President's Emergency Plan. These include several cohort indicators collected at 6 and 12 months.
At the time of development, Track 1.0 reporting requirements included a definition of NEW that differed slightly from the one defined in Table B. In partner programmes, NEW referred to patients who initiated ART during the reporting period. This may include non-naïve patients such as those previously in PMTCT, or who may have received treatment in the past but not currently on ART when enrolling in the ART programme.
Qua
rter b
egin
ning
(mm
/dd/
yy):
Gra
ntee
:Lo
catio
n:
1. M
ales
(0-1
4 ye
ars)
a.f.
k.0
oo.
2. M
ales
(>14
year
s)b.
g.l.
0pp
.3.
Fem
ales
(0-1
4 ye
ars)
c.h.
m.
0qq
.4.
Fem
ales
(>14
yea
rs)
d.i.
n.0
rr.
Tota
le.
0j.
0o.
0uu
.0
vv.
1. M
ales
(0-1
4 ye
ars)
a.g.
m.
0aa
.gg
.m
m.
2. M
ales
(>14
year
s)b.
h.n.
0bb
.hh
.nn
.3.
Fem
ales
(0-1
4 ye
ars)
c.i.
o.0
cc.
ii.oo
.4.
Fem
ales
(>14
yea
rs)
d.j.
p.0
dd.
jj.pp
.To
tal
e.0
k.0
q.0
ee.
0kk
.0
qq.
0
5. P
regn
ant f
emal
es (s
ubse
t of t
otal
)f.
l.r.
0ff.
ll.rr
.
Pag
e 1
7-A
pr-0
5
Cum
ulat
ive
num
ber e
nrol
led
in
HIV
car
e by
the
end
of th
e qu
arte
r
Num
ber o
n A
RT
who
TR
AN
SFE
RR
ED
in
du
ring
the
quar
ter
(sub
set o
f 2h-
2n)
Num
ber N
EW
on
AR
T du
ring
the
quar
ter
(s
ubse
t of 2
h-2n
)
Num
ber i
n H
IV c
are
durin
g th
e qu
arte
r & e
ligib
le fo
r AR
T, b
ut
NO
T st
arte
d A
RT
by th
e en
d of
the
quar
ter
(s
ubse
t of
1uu
.)
Num
ber s
tarte
d on
AR
T in
pr
ogra
m d
urin
g th
e qu
arte
r (in
clud
es N
EW
and
TR
AN
SFE
RS
)
Qua
rter
ly, F
acili
ty-B
ased
HIV
Car
e/A
RT
Rep
ortin
g Fo
rm
1. H
IV P
allia
tive
Car
e (n
on-A
RT
and
AR
T ca
re)
Cum
ulat
ive
num
ber s
tarte
d on
A
RT
by th
e en
d of
the
quar
ter
NE
W e
nrol
lees
in H
IV c
are
durin
g th
e qu
arte
r
Qua
rter e
ndin
g (m
m/d
d/yy
):Fa
cilit
y:C
ount
ry:
2. A
RT
Car
e
Cum
ulat
ive
num
ber s
tarte
d on
A
RT
by th
e be
ginn
ing
of th
e qu
arte
r
Cum
ulat
ive
num
ber e
nrol
led
in
HIV
car
e by
the
begi
nnin
g of
qu
arte
r
Tota
l num
ber w
ho re
ceiv
ed
HIV
car
e du
ring
the
quar
ter
No.
of p
erso
ns o
n A
RT
at th
e en
d of
the
quar
ter w
ho w
ere
treat
ed w
ith U
SG
-fund
ed A
RT
(sub
set o
f 2qq
.)ss
.
Tota
l num
ber o
n A
RT
at th
e en
d of
the
quar
ter
3. T
rain
ing
in A
RT
and
HIV
Car
e*1.
Num
ber o
f per
sons
trai
ned
in A
RT
ca
re d
urin
g th
e qu
arte
ra.
b.c.
d.0
2. N
o. tr
aine
d in
(non
-AR
T) H
IV p
allia
tive
care
dur
ing
the
quar
ter
e.
4.1
Cha
nge
in C
D4+ c
ount
and
adh
eren
ce to
AR
T fo
r 6-m
onth
coh
ort (
>6 y
ears
old
)
Mon
ths
whe
n co
hort
star
ted
AR
Ta.
a.N
umbe
r of p
erso
ns in
coh
ort
b.e.
b.e.
No.
in c
ohor
t who
hav
e C
D4+ c
ount
s c.
f.c.
f.M
edia
n C
D4+ c
ount
for c
ohor
td.
g.d.
g.N
o. in
coh
ort w
ho re
ceiv
ed A
RV
s fo
r 6
out o
f 6 m
onth
sh.
h.
5. N
umbe
r of p
atie
nts
on e
ach
regi
men
at t
he e
nd o
f the
qua
rter
d4T-
3TC
-NV
P
a.
aa.
d4T-
3TC
-EFV
b.bb
.d4
T-3T
C-L
PV
/rc.
cc.
ZDV
-3TC
-NV
P
d.
dd,
ZDV
-3TC
-EFV
e.ee
.Fe
b, M
ar, A
prZD
V-3
TC-L
PV
/rf.
ff.M
ay, J
une,
Jul
yZD
V-d
dI-N
VP
g.gg
.A
ug, S
ept,
Oct
ZDV
-ddI
-EFV
h.hh
.N
ov, D
ec, J
anZD
V-d
dI-L
PV
/r i.
iid4
T-dd
I-NV
Pj.
jj.d4
T-dd
I-EFV
k.kk
.d4
T-dd
I-LP
V/r
l.ll.
m.
mm
.n.
nn.
o.oo
.p.
pp.
q.qq
.r.
rr.
s.ss
.t.
tt.u.
uu.
v.vv
.w
.w
w.
Tota
l x.
0xx
.0
a.g.
m.
06.
2 R
easo
n1.
Sto
pped
AR
Tb.
h.n.
0
2. T
rans
ferr
ed o
utc.
i.o.
0
3. D
eath
d.j.
p.0
4. L
ost t
o fo
llow
-up
e.k.
q.0
5. U
nkno
wn
f.l.
r.0
Pag
e 2
7-A
pr-0
5
Oct
ober
1 -
Dec
embe
r 31
4.2
Cha
nge
in C
D4+ c
ount
and
adh
eren
ce to
AR
T fo
r 12-
mon
th c
ohor
t (>6
yea
rs o
ld)
6-m
onth
coh
orts
pa
tient
s w
ho s
tarte
d on
A
RT
in th
e pr
eced
ing
mon
ths
of:
Oth
er h
ealth
care
wor
kers
Mon
ths
whe
n co
hort
star
ted
AR
T B
asel
ine
Tota
l
Med
ian
CD
4+ cou
nt fo
r coh
ort
No.
of p
erso
ns in
coh
ort w
ho re
ceiv
ed A
RV
s fo
r 12
out o
f 12
mon
ths
Adu
lts
6.1
Num
ber o
f per
sons
who
sta
rted
on
AR
T at
the
faci
lity
in th
e EP
pr
ogra
m w
ho w
ere
NO
T on
AR
T at
the
end
of th
e qu
arte
r
12 m
onth
s
Janu
ary
1 - M
arch
31
Tota
l
Num
ber o
f per
sons
in c
ohor
tN
o. in
coh
ort w
ho h
ave
CD
4+ c
ount
s
LEG
END
for T
able
4
Aug
, Sep
t, O
ct
Apr
il 1
- Jun
e 30
July
1 -
Sep
tem
ber 3
0
Mal
eFe
mal
e
Bas
elin
e
Phy
sici
ans
Nov
, Dec
, Jan
Feb,
Mar
, Apr
ilM
ay, J
une,
Jul
y
Nur
ses
6 m
onth
s
12-m
onth
coh
orts
pa
tient
s w
ho s
tarte
d on
AR
Tin
the
prev
ious
yea
r, du
ring
the
mon
ths
of:
Chi
ldre
n (<
14 y
ears
)
Rep
ortin
g Pe
riod
pa
tient
s be
ing
repo
rted
durin
g th
e tim
e qu
arte
r:
*Ple
ase
prov
ide
train
ing
num
bers
by
coun
try, n
ot b
y fa
cilit
y, fo
r eac
h gr
ante
e
Multi-country Columbia Antiretroviral Programme (MCAP) Columbia University Mailman School of Public Health is a Track 1.0 partner under the first phase of the US President's Emergency Plan. It is implementing HIV care and treatment at sites in Kenya, Mozambique, Rwanda, South Africa, and Tanzania, and must aggregate data using the Track 1.0 quarterly report form. Adult enrolment and follow-up forms
These forms contain many of the same data elements on the Patient HIV care / ART cards presented previously; however, the information is collected over eight pages (four each) in a more user-friendly format. While check boxes and bubbles may reduce the incidence of reporting error, it ultimately results in a much larger volume of paper being used and stored. The storage of paper charts involves a more complex filing system, and the use of limited space and resources. The advantage of the card system is that it is a self-contained unit that can be filed, referenced, and transported relatively easily. Each programme must make its own decision, weighing the costs and benefits of each system.
Adult patient care flowsheet
This form functions in the same way as the summary sheet of the Patient HIV care / ART card shown in Annex D. Key information is transferred from the follow-up forms to allow providers a brief overview of a patient’s clinical status.
Paediatric patient care flowsheet
This form is similar to the adult patient counterpart with two main differences: function has been replaced by milestones; and tuberculin skin test results and pregnancy status have been replaced by HIV test type and results (HIV status is more difficult to determine in infants who have been exposed to the virus in the womb and requires several tests to confirm positivity).
Annex M1. MCAP adult enrolment and follow-up forms
MCAP ADULT ENROLLMENT FORM
MCAP Adult Enrollment Form – Version 1.0 – page 1 of 4 International Center for AIDSCare and Treatment Programs (ICAP)
Patient Name: Patient ID Number:
Enrollment Date: Site/Facility Code: Family Code:
day month year optional optional
1. Date of birth: 1a. Age at last birthday day month year
(Enter 99 if information is not known) (Enter 99 if information is not known)
2. Sex: O Female O Male
3.
4.
Referred by: O VCT site O pMTCT site O family member enrolled in MCAP O self-referral O TB clinic O STI clinic O inpatient hospital ward O outpatient clinic O other O traditional healer O other HIV/AIDS treatment program (specify) :
Does the patient have a household member enrolled in MCAP? O Yes O No Index Patient’s MCAP ID #:
5. Is the patient a member of MCAP staff (health care worker) or family of MCAP staff? O Yes O No
6. Is the patient currently pregnant? O Yes O No Expected Date of Delivery:
7. Does the patient have a spouse, partner, household member(s) or child(ren) who might be eligible for MCAP? (e.g. known to be HIV-infected or at risk of HIV-infection?) O Yes O No
O Done8. Is the patient employed outside the home? O Yes O No
Provide referrals for VCT and/orMCAP enrollment as appropriate
9. Does the patient have electricity inside the home? O Yes O No 10. Does the patient have running (piped) water inside the home? O Yes O No
11. Within the last month, has the patient experienced any of the following symptoms? O Yes O NoIf yes, fill in the 'o' to the right of each condition. If no, proceed to question 12.
Symptom Yes Symptom YesCough O Pain - Abdominal ODepression O Pain - Muscles ODiarrhea O Pain - Legs/feet ODifficulty breathing O Poor appetite OFatigue O Rash OFever O Thrush OHeadache O Weakness OMemory problems O Weight gain ONausea and/or vomiting O Weight loss ONew visual problems O Other 1 (specify): ONight sweats O Other 2 (specify): ONumbness or tingling in legs and/or feet O Other 3 (specify): O
12. Functional status (please select one):O Working (able to perform usual work in or out of the house)O Ambulatory (unable to work, but able to perform activities of daily living – e.g eating, bathing – without assistance) O Bedridden (unable to perform activities of daily living – e.g. eating, bathing – without assistance)
Columbia UniversityMailman School of Public Health
Annex M1. MCAP adult enrolment and follow-up forms
MCAP Adult Enrollment Form – Version 1.0 – page 2 of 4 International Center for AIDSCare and Treatment Programs (ICAP)
Columbia UniversityMailman School of Public Health
13. Are the patient and/or his/her partner currently using any form of family planning? O Yes O No If yes, fill in ‘o’ for all that apply:
O Condoms O Oral Contraceptive Pills O Injectable/ implanted hormones (e.g. Depo-provera, Norplant) O Diaphragm / Cervical Cap O Intrauterine Device O Vasectomy/ tubal ligation/ hysterectomy O Other:
14. Physical examination
Temperature oC Height cm Weight kg
Examinations Normal Abnormal Not Done Comments / DescriptionsEars, nose, throat O O OHead and neck O O OCardiovascular O O OLungs O O OAbdomen O O OLymph nodes O O OSkin O O OUrogenital O O OMusculoskeletal O O ONeurological O O OOther 1 (specify): O O OOther 2 (specify): O O O
15. Has the patient ever had, or does the patient currently have, any of the following conditions? Fill in the 'o' to the right of each indicator condition
WHO Stage 1 WHO Stage 4 Asymptomatic HIV Infection O Candidiasis (esophageal, bronchi, trachea, or lungs) O Persistent generalized lymphadenopathy O Cryptococcosis, extrapulmonary O
WHO Stage 2 Cryptosporidiosis with diarrhea (> 1 month duration) O Herpes zoster (within last 5 years) O Cytomegalovirus disease (other than liver, spleen, lymph nodes) O Minor mucocutaneous manifestations O Herpes simplex (mucocutaneous >1month, or visceral any duration) O Recurrent upper respiratory tract infections O HIV encephalopathy O Weight loss � 10% of body weight O HIV wasting syndrome O
WHO Stage 3 Kaposi's sarcoma (KS) O Lymphoma O Severe bacterial infections
(i.e., pneumonia, pyomyositis)O
Atypical mycobacteriosis, disseminated O Oral candidiasis (thrush) O Unexplained chronic diarrhea (> 1 month) O
Mycosis, disseminated endemic (i.e., Histoplasmosis,Coccidiodomycosis)
O
Tuberculosis, extrapulmonary O Unexplained prolonged fever (intermittent or constant, > 1 month)
OPneumocystis carinii pneumonia (PCP) O
Oral hairy leukoplakia O Progressive multifocal leukoencephalopathy (PML) O Tuberculosis, pulmonary (within previous year) O Salmonella septicemia, non-typhoid O Weight loss > 10% of body weight O Toxoplasmosis, CNS O
16. Based on the table above, what is the highest WHO staging indicator condition the patient has experienced to date?O WHO Stage 1 O WHO Stage 2 O WHO Stage 3 O WHO Stage 4
17. What is the patient’s most recent CD4 count? Date specimen collected
/mm3 %
Annex M1. MCAP adult enrolment and follow-up forms
MCAP Adult Enrollment Form – Version 1.0 – page 3 of 4 International Center for AIDSCare and Treatment Programs (ICAP)
Columbia UniversityMailman School of Public Health
18. What medications is the patient currently taking? O Isoniazid (INH) preventive therapy O Cotrimoxazole prophylaxis O Treatment for active TB disease O Antiretroviral treatment (ART): please specify O Other (please list all prescription, nonprescription, herbal, complementary, and traditional agents):
19. Has the patient previously been treated for tuberculosis? O Yes O No
20, Has the patient previously taken antiretroviral medication? O No O Yes, but only to prevent mother-to-child-transmission (pMTCT) O Yes, patient was previously treated with antiretroviral medication (ART)
21. If not on OI prophylaxis, indicate eligibility for OI prophylaxis as of this visit:
O Not yet determined/ awaiting other information
O Ineligible
O Eligible
22. If not on antiretroviral treatment (ART), indicate eligibility for ART as of this visit:
O Not yet determined/ awaiting other information
O Ineligible
O Eligible
If the answer to Q 19 and/or Q 20 is yes, specify medications used and when treated:
O Newly eligible for prophylaxis by CD4 count CD4 count =
O Newly eligible for prophylaxis by WHO Stage WHO Stage =
O Previously eligible for prophylaxis (specify):
O Newly eligible for ART by CD4 count CD4 count =
O Newly eligible for ART by WHO Stage WHO Stage =
O Previously eligible for ART (specify):
23. List all medications being started, stopped, or continued (chart continues on next page):
Medication RecommendationStart Stop Continue
Reasons forDiscontinuation*
Dose and Comments
Cotrimoxazole O O ODapsone O O O
Zidovudine (AZT) O O OLamivudine (3TC) O O OStavudine (D4T) O O ODidanosine (DDI) O O OAbacavir (ABC) O O ONevirapine (NVP) O O OEfavirenz (EFV) O O ONelfinavir (NFV) O O OLopinavir/ritonavir (LPV/r) O O OTenofovir (TDF) O O O
continued on next page…
Annex M1. MCAP adult enrolment and follow-up forms
MCAP Adult Enrollment Form – Version 1.0 – page 4 of 4 International Center for AIDSCare and Treatment Programs (ICAP)
Columbia UniversityMailman School of Public Health
Medication chart, continued…
Medication Recommendation start stop continue
Reasons forDiscontinuation*
Dose and Comments
Isoniazid (INH): O O ORifampin (RIF): O O OEthambutol (ETH): O O OPyrazinamide (PZA): O O OStreptomycin (STREP): O O O
Other (specify): O O OOther (specify): O O O
* Reasons for Discontinuation:1 = Side Effect / Toxicity / Drug interaction 3 = Patient non-adherence 5 = pMTCT prophylaxis complete 7 = Other, specify2 = Disruption in Drug Supply / Stock out 4 = Treatment failure 6 = Patient refused
25. Patient Plan:
26. What tests will be ordered for the patient?Fill in ‘o’ for all that apply:O None O Electrolytes
O Complete Blood Count O Tuberculin skin test (TST using PPD)
O CD4 Count O Sputum for AFB
O ALT (Alanine Aminotransferase) O Pregnancy test
O AST (Aspartate Aminotransferase) O Radiology test (specify):
O Creatinine O Other (specify):
27. What referrals will be made for the patient?Fill in ‘o’ for all that apply:ONone O TB treatment / DOT program O Social support services
OFamily planning services O Adherence counseling O Other referral (specify):
ONutritional support O Mental health services
O In-patient care / Hospitalization O Psychosocial counseling
28. When is the patient's next appointment?O 1 week O 3 months Appointment Date:
O 1 month O 6 months
O 2 months O Other (specify): day month year
Form Completed By: Provider Initials:
Annex M1. MCAP adult enrolment and follow-up forms
MCAP ADULT FOLLOW-UP FORM
MCAP Adult Follow-Up Form – Version 1.0 – Page 1 of 4 International Center for AIDSCare and Treatment Programs (ICAP)
Patient Name: Patient ID Number:
Visit Date:
day month year
1. Does the patient have a new medical problem, physical symptom, or concern today? O Yes O No If yes, please describe:
2. Within the last month, has the patient experienced any of the following symptoms? O Yes O No If yes, fill in the 'o' to the right of each condition. If no, proceed to question 3.
Symptom Yes Symptom YesCough O Pain - abdominal ODepression O Pain - muscles ODiarrhea O Pain - legs/feet ODifficulty breathing O Poor appetite OFatigue O Rash OFever O Thrush OHeadache O Weakness OMemory problems O Weight gain ONausea and/or vomiting O Weight loss ONew visual problems O Other 1 (specify): ONight sweats O Other 2 (specify): ONumbness or tingling in legs and/or feet O Other 3 (specify): O
3. Physical examination
Temperature oC Height cm Weight kg Change in weightsince last visit:
Examinations Normal Abnormal Not Done Comments / DescriptionsEars, nose, throat O O OHead and neck O O OCardiovascular O O OLungs O O OAbdomen O O OLymph nodes O O OSkin O O OUrogenital O O OMusculoskeletal O O ONeurological O O OOther 1 (specify): O O OOther 2 (specify): O O O
4. Functional status (please select one):O Working (able to perform usual work in or out of the house)O Ambulatory (unable to work, but able to perform activities of daily living – e.g eating, bathing – without assistance) O Bedridden (unable to perform activities of daily living – e.g. eating, bathing – without assistance)
Columbia UniversityMailman School of Public Health
Annex M1. MCAP adult enrolment and follow-up forms
5. Are the patient and/or his/her partner currently using any form of family planning? O Yes O No If yes, fill in ‘o’ for all that apply:
O Condoms O Oral Contraceptive Pills O Injectable/ implanted hormones (e.g. Depo-provera, Norplant) O Diaphragm / Cervical Cap O Intrauterine Device O Vasectomy/ tubal ligation/ hysterectomy O Other:
6. If the patient is female, is she pregnant?
O Yes, the patient is known to be pregnant. The expected date of delivery isO No, the patient is not known to be pregnant. day month yearO The patient was pregnant; the pregnancy has ended since her last visit.
O Live birth O Pregnancy loss/ still birth O Pregnancy termination
7. Since the last visit, has the patient been hospitalized for HIV-related reasons? O Yes O No If so, briefly describe the reason for hospitalization:
Enrolled in MCAP? O Yes O No - if no, why not? (specify):
8. What is the highest WHO staging indicator condition the patient has experienced to date?O WHO Stage 1 O WHO Stage 2 O WHO Stage 3 O WHO Stage 4
9. What is the patient’s most recent CD4 count? Date specimen collected
/mm3 % day month year
10. Since the last visit, has the patient had any other significant clinical or laboratory findings that will change his/ her medical management? If so, please detail here :
11. If the patient is not on OI prophylaxis, indicate eligibility for OI prophylaxis as of this visit: O Not yet determined/ awaiting other information
O Ineligible
O Eligible O Newly eligible for prophylaxis by CD4 count CD4 count =
O Newly eligible for prophylaxis by WHO Stage WHO Stage =
O Previously eligible for prophylaxis (specify):
International Center for AIDSCare and Treatment Programs (ICAP)
Columbia UniversityMailman School of Public Health
MCAP Adult Follow-Up Form – Version 1.0 – Page 2 of 4
Annex M1. MCAP adult enrolment and follow-up forms
12. If the patient is not on antiretroviral treatment (ART), indicate ART eligibility as of this visit:
O Not yet determined/ awaiting other information
O Ineligible
O Eligible
13. If the patient is taking ARVs, during the last seven days, how many of her/his pills did the patient take? (If not taking ARVs, skip to question 15)
Read list to patient, fill in only one 'o'O None of her/his pills O Very few of her/his pills O About half of her/his pills
O Most of her/his pills O All of her/his pills every day
14.If the patient missed any pills in the last seven days, what reason(s) did s/he provide?Read list to patient, fill in 'o' for all that applyO Forgot O Clinic ran out of medication O Patient ran out of pills O Felt too ill O Lost her/his medication O Other reason:
O Side effects O Disclosure or privacy issues
O Newly eligible for ART by CD4 count CD4 count =
O Newly eligible for ART by WHO Stage WHO Stage =
O Previously eligible for ART (specify):
If all taken, skip to Question 15
15. List all medications being started, stopped, or continued:
Medication RecommendationStart Stop Continue
Reasons forStopping Med*
Dose and Comments
Cotrimoxazole O O ODapsone O O O
Zidovudine (AZT) O O OLamivudine (3TC) O O OStavudine (D4T) O O ODidanosine (DDI) O O OAbacavir (ABC) O O ONevirapine (NVP) O O OEfavirenz (EFV) O O ONelfinavir (NFV) O O OLopinavir/ritonavir (LPV/r) O O OTenofovir (TDF) O O O
Isoniazid (INH): O O ORifampin (RIF): O O OEthambutol (ETH): O O OPyrazinamide (PZA): O O OStreptomycin (STREP): O O O
Other (specify): O O OOther (specify): O O O
* Reasons for Stopping Medication:1 = Side Effect / Toxicity / Drug interaction 3 = Patient non-adherence 5 = pMTCT prophylaxis complete 7 = Other, specify:2 = Disruption in Drug Supply / Stock out 4 = Treatment failure 6 = Patient refused
International Center for AIDSCare and Treatment Programs (ICAP)
Columbia UniversityMailman School of Public Health
MCAP Adult Follow-Up Form – Version 1.0 – Page 3 of 4
Annex M1. MCAP adult enrolment and follow-up forms
16. Patient Plan
17.What tests will be ordered for the patient? Fill in ‘o’ for all that apply:O None O Electrolytes
O Complete Blood Count O Tuberculin skin test (TST using PPD)
O CD4 Count Assay O Sputum for AFB
O ALT (Alanine Aminotransferase) O Pregnancy test
O AST (Aspartate Aminotransferase) O Radiology test (specify):
O Creatinine O Other (specify):
18. What referrals will be made for the patient? Fill in ‘o’ for all that apply:ONone O TB treatment / DOT program O Social support services
OFamily planning services O Adherence counseling O Other referral (specify):
ONutritional support O Mental health services
O In-patient care / Hospitalization O Psychosocial counseling
19. When is the patient's next appointment?O 1 week O 3 months Appointment Date:
O 1 month O 6 months
O 2 months O Other (specify): day month year
Form Completed By: Provider Initials:
International Center for AIDSCare and Treatment Programs (ICAP)
Columbia UniversityMailman School of Public Health
MCAP Adult Follow-Up Form – Version 1.0 – Page 4 of 4
Annex M2. MCAP adult patient care flowsheet
MCAP Adult Patient Care Flowsheet
Patient Name: Patient ID Number:
Date Function(W, A, or B)
Wt(kgs)
WHOstage
CD4 TST(-/+)
Pregnant?(Y/N/NA)
INH?(Y/N)
CTX?(Y/N)
ART?(Y/N)
If on ARVs, list regimen
* W = able to work, A = ambulatory, B = bedbound
MCAP Adult Patient Care FlowsheetInternational Center for AIDSCare and Treatment Programs (ICAP)
Columbia UniversityMailman School of Public Health
Annex M3. MCAP paediatric patient care flowsheet
MCAP Pediatric Patient Care Flowsheet
Patient Name: Patient ID Number:
CD4Date Milestones(Y/N)
Wt(kgs)
WHOstage
# %
HIV test (type & results )
INH?(Y/N)
CTX?(Y/N)
ART?(Y/N)
If on ARVs, list regimen
* Y = meeting developmental milestones, N = not meeting developmental milestones
MCAP Pediatric Patient Care Flowsheet – Version 1.0International Center for AIDSCare and Treatment Programs (ICAP)
Columbia UniversityMailman School of Public Health
Annex M3. MCAP paediatric patient care flowsheet
MCAP Pediatric Patient Care Flowsheet
Patient Name: Patient ID Number:
HIV test results:
Test #1: Type of test O HIV DNA PCR O HIV RNA PCR O Antibody test
Date of specimen: / / Age of child on date of test:
MCAP Patient Patient Care Flowsheet – Version 1.0 International Center for AIDSCare and Treatment Programs (ICAP)
Columbia UniversityMailman School of Public Health
O years O months
Test result:
Test #2: Type of test O HIV DNA PCR O HIV RNA PCR O Antibody test
Date of specimen: / / Age of child on date of test: O years O months
Test result:
Test #3: Type of test O HIV DNA PCR O HIV RNA PCR O Antibody test
Date of specimen: / / Age of child on date of test: O years O months
Test result:
CD4Date Milestones(Y/N)
Wt(kgs)
WHOstage
# %
HIV test (type & results )
INH?(Y/N)
CTX?(Y/N)
ART?(Y/N)
If on ARVs, list regimen
* Y = meeting developmental milestones, N = not meeting developmental milestones
AIDSRelief Project (partners include: Catholic Relief Services, Catholic Medical Mission Board, Interchurch Medical Assistance, Futures Group, and University of Maryland) The AIDSRelief Project is another Track 1.0 partner which has developed optional template forms for its project sites to use in the field. Some or all of the sites in Guyana, Haiti, Nigeria, South Africa, Tanzania, Uganda and Zambia have adapted or are in the process of adapting the forms. Medical data card
The medical data form is another presentation of the HIV care / ART patient card presented in Annex D using bubbles rather than codes.
Home visit form The home-based care forms were created at the request of project sites that wanted to capture basic information from established home-based care and adherence programmes.
Annex N1. AIDSRelief Project medical data card
M
ED
ICA
L D
AT
A C
AR
D
1.P
ati
ent
Nam
e 2
. Gu
ard
ian
's N
am
e _____________________
3. C
on
tact
Tel
eph
on
e N
um
ber
_______________________
4. I
D
--
-5
.H
osp
No.
6.P
rovid
er's
Nam
e _____________________
Countr
y
OP
OS
#S
atel
lite
#
7. E
stim
ate
d D
ate
of
Bir
th_______/_
______/_
______
8. D
ate
of
HIV
dia
gn
osi
s ______/_
_____
9. D
ate
En
roll
ed i
n A
IDS
Rel
ief
____/_
__/_
__
10
. Dis
close
d S
tatu
sY
es1
1. T
reatm
ent
Pre
para
tion
(dat
e) _____/_
____
12
. Da
te I
nit
iate
d H
AA
RT
__
_/_
__
/__
_
13
. 1st
Reg
imen
_______/_
______/_
______/_
______
2n
d R
egim
en_______/_
______/_
______/_
______
3rd
Reg
imen
_______/_
______/_
______/_
______
Dat
e st
arte
d_____/_
____
Dat
e st
opped
_____/_
____
Dat
e st
arte
d_____/_
_____
Dat
e st
opped
_____/_
____
Dat
e st
arte
d_____/_
_____
Dat
e st
opped
_____/_
____
14
.R
easo
ns
for
Ch
an
ge
of
Reg
imen
Rea
son
s fo
r C
han
ge
of
Reg
imen
Rea
son
s fo
r C
han
ge
of
Reg
imen
15
. AR
V M
uta
tion
s
Toxic
ity
Toxic
ity
Toxic
ity
NR
TI:
Tre
atm
ent
Fai
lure
Tre
atm
ent
Fai
lure
Tre
atm
ent
Fai
lure
Non-a
dher
ence
Non-a
dher
ence
Non-a
dher
ence
Dru
g i
nte
ract
ion
Dru
g i
nte
ract
ion
Dru
g i
nte
ract
ion
Pre
gnan
cyP
regnan
cyP
regnan
cyN
NR
TI:
Pat
ient
Pre
fere
nce
Pat
ient
Pre
fere
nce
Pat
ient
Pre
fere
nce
Dru
gs
not
avai
lable
Dru
gs
not
avai
lable
Dru
gs
not
avai
lable
PI:
Mig
rato
ry p
atie
nt,
no f
oll
ow
up a
vai
lable
Mig
rato
ry p
atie
nt,
no f
oll
ow
up a
vai
lable
Mig
rato
ry p
atie
nt,
no f
oll
ow
up a
vai
lable
Tra
nsf
er t
o a
noth
er p
rogra
mT
ransf
er t
o a
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er p
rogra
mT
ransf
er t
o a
noth
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rogra
m
Inab
ilit
y t
o p
ayIn
abil
ity t
o p
ayIn
abil
ity t
o p
ay
Oth
erO
ther
Oth
er
16
. Past
Med
ical
His
tory
/Pro
ble
m L
ist
17
.O
BG
YN
His
tory
1___________________
4___________________
Del
iver
y d
ate
Pap
Sm
ear
S
tage
2___________________
5___________________
___/_
__
NV
PH
AA
RT
___/_
__
______
3___________________
6___________________
___/_
__
NV
PH
AA
RT
___/_
__
______
18
. Op
port
un
isti
c In
fect
ion
s
Date
of:
Init
ial
Dx
Confi
rmed
R
ecurr
ence
Confi
rmed
Init
ial
Dx
Confi
rmed
R
ecurr
ence
Confi
rmed
P
ulm
onar
y T
B___/_
__
___/_
__
G
enit
al u
lcer
ativ
e dis
ease
___/_
__
___/_
__
Sm
ear
+S
mea
r -
U
reth
itis
/cer
vic
itis
___/_
__
___/_
__
C
D4 N
ad
ir
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xtr
apulm
onar
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B___/_
__
___/_
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P
ID___/_
__
___/_
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M
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teri
a oth
er___/_
__
___/_
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oxo, P
ML
, ly
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___/_
__
___/_
__
19
.W
HO
sta
ge
P
CP
___/_
__
___/_
__
E
nce
phal
opat
hy
___/_
__
___/_
__
At
enro
llm
ent
C
rypto
cocc
al m
enin
git
is___/_
__
___/_
__
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uta
neo
us
KS
___/_
__
___/_
__
O
ral
Can
did
iasi
s___/_
__
___/_
__
V
isce
ral
KS
___/_
__
___/_
__
At
init
iati
on
C
andid
ial
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phogit
is___/_
__
___/_
__
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ym
phom
a___/_
__
___/_
__
of
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V
P
neu
monia
___/_
__
___/_
__
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epsi
s___/_
__
___/_
__
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er___/_
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___/_
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__
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sim
ple
x___/_
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___/_
__
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/was
ting
___/_
__
___/_
__
Pat
ient
Enro
lmen
t #
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SR
elie
f F
orm
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rd;
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ge
1 o
f 2
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ve
mb
er
20
04
Annex N2. AIDSRelief Project home visit form7. D
isp
ensi
ng
Fre
qu
ency
:
Dir
ectl
y o
bse
rved
th
erap
y (
DO
T)
1. P
ati
ent
Na
me
3. H
osp
/Fa
cili
ty #
Wee
kl y
ref
ills
Bi
Mo
nth
ly
2. I
D-
-M
on
thly
Co
un
try
PO
S #
Sat
elli
te #
Pat
ien
t en
roll
men
t#O
ther
(p
leas
e sp
ecif
y)
4. C
are
tak
er/G
ua
rdia
n_
__
__
__
__
__
__
__
__
__
__
5. C
HW
/CH
V/N
urs
e T
eam
__
__
__
__
__
__
__
__
__
__
__
__
__
__
__
5a. A
lter
na
tiv
e C
HW
/CH
V T
eam
#_
__
__
__
__
__
__
__
__
__
__
__
__
Ad
her
ence
co
des
:
1
F
org
ot
7
Del
iver
y/
trav
el p
rob
lem
s
S
ub
loca
tio
n
2
Sid
e ef
fect
s8
D
isp
ensa
ry o
ut
of
sto
ck
N
eare
st C
hu
rch
3
F
eeli
ng
Sic
k9
P
rog
ram
sto
pp
ed
P
rim
ary
Sch
oo
l
4
Ill
nes
s in
fam
ily
10
Un
able
to
pay
fo
r m
eds
C
hie
f /
Su
bch
ief
5
P
erce
ived
lac
k o
f n
eed
11
Wo
rk c
on
flic
t
T
elep
ho
ne
#
6
Sh
arin
g m
edic
atio
n1
2 O
ther
WE
EK
1 _
_/_
_/_
_W
EE
K 2
__
/__
/__
WE
EK
3 _
_/_
_/_
_W
EE
K 4
__
/__/_
_
MT
WT
hF
SS
MT
WT
hF
SS
MT
WT
hF
SS
MT
WT
hF
SS
8N
um
ber
of
Tim
es Y
ou S
aw T
he
Pat
ient
(1-3
)
9N
um
ber
of
Tim
es Y
ou D
irec
tly O
bse
rved
Ther
a py
(1
-3)
10
Num
ber
of
Tim
es C
aret
aker
Dir
ectl
y O
bse
rved
Ther
a py
(1
-3)
11
Num
ber
of
Mis
sed d
ose
s per
da y
(1-3
)
12
Why D
id P
atie
nt
mis
s dose
s?(F
ill
in A
dh
eren
ce R
easo
ns
Co
de)
13
Was
Adher
ence
Expla
ined
And E
nco
ura
ged
? (Y
or
N)
14
Dru
gs
Wer
e D
eliv
ered
To P
atie
nt
(indic
ate
wit
h a
tic
k m
ark)
15
Could
Not
Fin
d (
tick
if
un
able
to
fin
d p
atie
nt/
pat
ien
t n
ot
ho
me)
16
SY
MP
TO
MS
TH
IS W
EE
K:
O
ther
Fev
er
Y
ello
w e
yes
Ras
h
H
eadac
he
Du
rati
on
:H
om
e V
isit
Form
6.H
ow
to
Lo
cate
Pa
tien
t:
C
ough
Dia
rrhea
N
ause
a/vom
itti
ng
A
dm
itte
d t
o H
osp
ital
L
oss
of
appet
ite/
abdom
inal
pai
n
Hom
e V
isit F
orm
1 o
f 1
Form
8
Octo
ber
4, 2004
Annex N2. AIDSRelief Project home visit formP
ati
ent'
s n
ext
clin
ic a
pp
oin
tmen
t/
//
//
//
/
17
Act
ion
s T
ak
en:
Urg
ent
Med
ical
Ref
erri
ng C
onta
ct #
___________________________
Super
vis
or
Mad
e A
war
e___________________________ D
ate
_____/_
_____/_
_____
Dail
y C
om
men
tsD
ail
y C
om
men
ts
Date
Date
Wee
k 1
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k 3
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k 2
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k 4
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_________________________________________
________________________________________
Hom
e V
isit F
orm
1 o
f 1
Form
8O
cto
ber
4, 2004
KwaZulu Natal province, South Africa Adult visit summary form
KwaZulu Natal province in South Africa has developed a set of forms for both adults and children for its ARV rollout programme that may be accessed at: http://www.kznhealth.gov.za/arv/forms.htm. The adult visit summary form is an alternative presentation of a patient encounter form that is filled out at each patient visit.
Annex P1. KwaZulu Natal adult visit summary form
/ / / / /
CD4 Count
Viral Load
Hb
WCC
Plts
ALT
GGT
Alk Phos
Cholestrol
Test Type
Result
1
2
3
4
Event / Grade
Event / Grade
Event / Grade
Event / Grade
Cotrimoxazole
Fluconazole
In Out In Out In Out In Out In Out
Social Work
Counselling
TB Clinic
Inpatient/Hospital
Antenatal
Dietician
Specialist Clinic
Other (specify)
/ /
/ /
/ /
/ / / / / /
/ / / /
Temperature
/ /
/ /
WHO Performance
Height (metres)
Weight (kgs)
BMI
Treatment Regimen
Months on Treatment
Blood Pressure (systolic/diastolic)
Bloods Taken (X=No; Tick=Yes)
Blo
od R
esul
tsO
ther
Tes
ts
Visit Date
Scheduled (X=No; Tick=Yes)
Date of Next Visit
WHO Staging
Months on Regimen
Change in Treatment Regimen
No. of Missed Doses
TB Symptoms (Tick=Yes)
Substitutions
Action
Comments
Captured By
SA ID Number
Hospital File Number
Months on TB Treatment
Adv
erse
Eve
nts/
Sid
e E
ffect
s
Opp
ortu
nist
icIn
fect
ions
OI
Pro
phy-
laxi
s
Ref
erra
ls(T
ick=
Yes
)
ADULT VISIT SUMMARY FORM
KwaZulu Natal Department of HealthComprehensive Care Programme
Ethiopia ARV clinic patient record
Ethiopia has recently adapted the WHO forms to distribute nationally as it prepares to scale up ART. While the registers and aggregated data forms are almost identical for reporting reasons, the country has opted to include a set of clinical intake forms. The clinical form has the advantage of taking a clinician through the intake process, ensuring coverage of the major parts of a patient's clinical history and provides a comprehensive overview of the patient, including his or her social and economic circumstances. All but the two sections (E and F) of the form are filled out only once, at the initial visit (section G is filled out at the second visit). Section F gives an example of an adherence assessment form (to be filled out at each visit), which provides an estimate of self-reported adherence and reasons for poor or non-adherence.
HIV care / ART follow-up form
The follow-up form is similar to WHO's patient card encounter form. However, due to the lack of a patient summary form, it also incorporates information from clinical intake forms to facilitate data transfer to the pre-ART register. In addition the codes are more descriptive and provide users with a quick assessment of adherence.
Cohort analysis form
Ethiopia's cohort analysis form is a good example of a country-adapted form. While it is almost an exact replica of the generic WHO form, it has added mean CD4 % for children and replaced the months and years with those from the Ethiopian calendar. In addition to the regular A3 size presentation of the form, Ethiopia has created poster-size laminated cohort forms to be filled out and displayed at facilities to show progress of patients on treatment.
FEDERAL MINISTRY OF HEALTH OF ETHIOPIA
ARV CLINIC PATIENT RECORD A. PATIENT REGISTRATION FORM
Health Facility Name:_________________________________________________________________ Date:______/______/___________
PATIENT IDENTIFICATION
Name: ________ __ Father’s Name: _____ ____ __ _ Grandfather’s Name: ________
Date of Birth:______/______/_____ Age:_______ Gender: ○ Male ○ Female
ART Unique ID No.: Patient Card No.: __________/__________
MARITAL STATUS: LEVEL OF EDUCATION: RELIGION:
○ Never Married ○ No education ○ Muslim
○ Married (incl. de facto) ○ Primary ○ Orthodox
○ Separated ○ Secondary ○ Protestant
○ Divorced ○ Tertiary ○ Catholic
○ Widow/Widower ○ Other
Occupation: ____________________________________________________________
HUSBAND / WIFE AND DEPENDENT CHILDREN AT HOME ○ Husband/Wife Children ○ Yes ○ No
If Yes: Age _____,______,______,______,______,______,
PATIENT ADDRESS Region: ________________________ Woreda/Kifle Ketema: ______________________ __
Kebele/Peasant Association: ___________________________________________________________ House No.:____________
Telephone Number: Home ____ Mobile: ______ Work: ____________________
PATIENT REFERRAL INFORMATION
From with-in the hospital
○ In-patient ○ Medical Outpatient ○ TB Clinic ○ STI Clinic
○ PMTCT ○ General VCT ○ Pediatric Outpatient ○ Other Outpatient
Outside the Hospital
○ Health Centers ○ Public Hospital ○ Private Hospital ○ NGO/FBO Hospital
○ Private Clinic ○ Self-referred ○ Community Referred ○ Others ○ Unknown
CARE GIVER/EMERGENCY CONTACT INFORMATION:
Full Name: _______________________________________________________________________________ Age: _____________
Gender: ○ Male ○ Female
Relation: _____________________________________ ○ Other (Specify) __________________________________________
Address: ○ Same as patient’s address
Region: ________________________ Woreda/Kifle Ketema: ______________________ __
Kebele/Peasant Association: ___________________________________________________________ House No.:____________
Telephone Number: Home ____ Mobile: ______ Work: ____________________
INSTRUCTIONS: A. PATIENT REGISTRATION FORM
Note: All fields must be filled in Health Facility Name – Health Facility name as registered at the Ministry of Health Date: - Use Ethiopian calendar and a format of DD/MM/YYYY Name: - Enter patient’s name. Father’s Name: - Enter patient’s father’s name. If not known enter NA. Grandfather’s Name: - Enter patient’s grandfather’s name. If not known enter NA Patient Card Number- 6 digit number followed by year found on patient card to be issued to patient by ART Unique ID No. –Patients should be assigned Unique ART number. This will be (region number/ woreda / facility /patient assigned 5 digit number). The first patient to start ART in the clinic will be given 00001. Date of Birth: - Use Ethiopian calendar and a format of DD/MM/YYYY. If only month and year are known then enter 00 for day, if only year is known than enter 00 for day and 00 for month. Age: - Enter patient’s current age in years. If patient is less than 5 years old, enter age in months. Gender: - fill in the appropriate circle Marital Status: - fill in appropriate circle Level of Education: - fill in appropriate circle Religion: - fill in appropriate circle Occupation: Please fill in patient’s job Husband/Wife and dependent children at home: Please fill the appropriate circle (Husband or Wife). Fill in the appropriate circle for children. If there are children, please list all the ages in ascending order (eg 2, 5, 7 …) Patient Address: - Enter address at which patient normally lives
a. Region – Enter one of the following number codes 1. Tigray (TG) 6. Benshangul .Gumuz (BG) 2. Afar (AF) 7. SNNPR (SN) 3. Amhara (AM) 12. Gambella (GA) 4. Oromia (OR) 13. Harar (HA) 5. Somali (SO) 14. Addis Ababa (AA)
15. Dire Dawa (DD) b. Woreda/Kifle Ketema – For Addis Ababa enter patient’s Kifle ketema. For other regions enter patient’s Woreda #. c. Kebele – Enter patient’s Kebele number d. House No. – Enter patient’s house number e. Home Telephone – Enter patient’s telephone number. If patient does not have a telephone enter NA. f. Mobile – Enter patient’s mobile (cell) telephone number. If patient does not have a mobile enter NA. g. Work – Enter patient’s work telephone number. If patient does not have a work telephone enter NA
Patient Referred From: - fill in appropriate circle. If patient is referred from Outside Clinic/Health Facility fill in the name of the Clinic/ Health Facility. If patient is referred from other fill in name of the other facility. Care giving Relative Information: Enter the name of family member that is aware of patient’s serostatus to avoid unintended disclosure a. Name – Enter name of next of kin
b. Father’s name – Enter the father’s name of next of kin c. Age – Enter the age, in years, of the next of kin d. Relation – fill in the appropriate circle that best describes the relationship between the patient e. and the relative.
Care giving Relative Address: - If the relative’s address is the same as the patient, fill in the appropriate circle. If it is different then fill in the spaces using the same codes as listed above for Patient Address fields.
a. Region – Enter one of the region number codes listed above under Patient Address Region field. b. Woreda/Kifle Ketema – For Addis Ababa enter the Kifle ketema. For other regions enter the Woreda #. c. Kebele/Peasant Association – Enter relative’s Kebele//Peasant Association Number d. House No. – Enter relative’s house number e. Home Telephone – Enter relative telephone number. If they do not have a telephone number enter NA. f. Mobile – Enter relative’s mobile (cell) telephone number. If they do not have a mobile enter NA.
Work – Enter relative’s work telephone number. If they do not have a work telephone number enter NA.
FEDERAL MINISTRY OF HEALTH OF ETHIOPIA
ARV CLINIC PATIENT RECORD B. PAST MEDICAL /TREATMENT HISTORY FORM Health Facility Name:_________________________________________________________________ Date:______/______/__________
PATIENT IDENTIFICATION Name: ___________ __ Father’s Name: _____ ______ __ _ Grandfather’s Name: __________ ART Unique ID No.: __ ________ Patient Card No.: ______________/_____________
PAST OPPORTUNISTIC ILLNESS (MARK ALL THAT APPLY) ○ Candidiasis ○ Encephalopathy ○ PneumocystisCarinii Pneumonia
○ Candidiasis (Oropharyngeal) ○ Fever (>1 month; unexplained) ○ Pneumonia (recurrent)
○ CMV ○ Herpes Simplex (>1 month) ○ Recurrent URTIs
○ Cryptococcal Infection ○ Kaposi sarcoma ○ Salmonella Septicemia
○ Cryptococcal Meningitis ○ Minor Mucocutaneous Manifestations ○ TB-Extrapulmonary
○ Cryptosporidiosis ○ Mycosis ○ Toxoplasmosis (brain)
○ Diarrhea (>1 month) ○ PGL ○ Wasting Syndrome
○ Disseminated Atypical Mycobacteriosis ○ PML
Other (specify) ________________________________________________
PAST TESTS/TREATMENT TB ○ TB Smear Date: _____/______/_____ Site/Health facility:_______________________________________________________
Result: ○ Not Determined ○ Negative ○ Positive ○ Pos +1 ○ Pos +2 ○ Pos +3 ○ Unknown
TB Tx ○ Yes ○ No Completed Tx ○ Yes ○ No
Date Tx started _________/_____/_____ Date completed _________/______/_____
Regimen: ○ Not Determined ○ 2SRHZ/6EH ○ 2HRZES/1HRZE/5HRE ○ 2HRZE/6HE
Post Treatment smear: ○ Sputum smear + Date ____/___ /_____ Smear negative Date _____/______/____
HIV
HIV Test ○ Yes ○ No, if yes Date: ____/___ /_____ Site/Health facility:________________________________________________
ARV Rx ○ Yes ○ No if yes Start: ____/___ /_____ Length (weeks) ○ Still on Treatment
Regimen: ○ d4t (30)-3TC-NVP ○ d4t (40)-3TC-NVP ○ d4t (30)-3TC-EFV
○ d4t (40)-3TC-EFV ○ AZT-3TC-NVP ○ 2nd line
○ PMTCT ○ Yes ○ No If Yes Site/Health facility:___________________________________________________
Regimen: ○ Nevirapine ○ Non-Nevirapine Baby Treated: ___________
CD4
○ CD4+ ○ Yes ○ No, if yes Date: ____/___ /_____ Site Health facility: ________Result ____ ____/mm3
MEDICATIONS: Cotrimoxazole ○ Yes ○ No INH ○ Yes ○ No Fluconazole ○ Yes ○ No
Other Medication/s (Specify): ________________________________________________________________________________ Known Drug-related Allergies
○ Penicillium ○ Cephalosporin ○ Sulfonamides (Cotrimoxazole, etc.)
○ Amino glycosides (Streptomycin, etc) ○ Other______________________________________________________(specify)
INSTRUCTIONS: B. PAST MEDICAL /TREATMENT HISTORY FORM Note: All fields must be filled in
Health Facility name – Health Facility name as registered at the Ministry of Health Date: - Use Ethiopian calendar and a format of DD/MM/YYYY ART Unique ID No. –Patients should be assigned Unique ART number. This will be.(region number/ woreda /facility / patient assigned 5 digit number ). The first patient to start ART in the clinic will be given 00001. Patient Card No. - 6 digit number followed by year found on patient card to be issued to patient by facility. Past Opportunistic Illness – fill in all applicable circles. Note that this information can be obtained from both the patient and any available medical/lab records. Past Tests/Treatment – If a patient has had more than one of these tests in the past, list only the most recent ones. Indicate the test date using Ethiopian calendar and a format of DD/MM/YYYY. The site refers to the facility at which the test was performed. If unknown enter NA in space. For CD4 test, if result is not available/unknown enter NA in result space.
a. TB – Enter date upon which patient initiated TB treatment and completed treatment using Ethiopian calendar and DD/MM/YYYY format. b. ARV – Enter date on which patient initiated ARV treatment using Ethiopian calendar and DD/MM/YYYY format. Enter the length of treatment (in number of weeks) calculated from the start date to date the treatment ended. If patient is currently on ARV treatment, calculate length of treatment from start date to today. Fill in the appropriate circle for regimen and for outcome. c. PMTCT – Same as with ARV
Prophylaxis – Same general instructions as Past Treatment fields. Current Medications – Fill in all applicable circles. If ‘Other’ write in medications.
Known Drug Allergies – Fill in all applicable circles. If ‘Other’ write in drug name/class
FEDERAL MINISTRY OF HEALTH OF ETHIOPIA
ARV CLINIC PATIENT RECORD C. GENERAL CONDITION/PHYSICAL EXAM
Health Facility Name:_________________________________________________________________ Date:______/______/_______
PATIENT IDENTIFICATION Name: ____________________________ Father’s Name: _____________________________ Grandfather’s Name: __________________________ ART Unique ID No.: __________________________________________ Patient Card No.: ______________/_____________
VITAL SIGNS AND FUNCTIONAL LEVEL Height (cm) Weight (kg) Temp (oC) HR (b/m) BP (s/d mmHg) RR (R/m) __ __ __ __ __ __ __ __ __ __ __ __ __ __ / __ __ __ __ __ SYMPTOM SCREEN ○ Chronic Cough ○ Night Sweats ○ Numbness/Tingling ○ Dyspnea ○ Fever > 1 month ○ Persistent Headaches ○ Hemoptysis ○ Dysphagia and/or Odynophagia ○ Mental Confusion ○ Chronic Fatigue ○ Nausea and/or Vomiting ○ Chronic Diarrhea ○ Weight Loss ○ __% body wt ○ Abdominal Pain ○ STI Symptoms ○ Flu-like (URTI) PATIENT’S PREGNANCY STATUS ○ Pregnant EDD ____/____/____ ○ Not Pregnant ○ Not Applicable (male) GENERAL APPEARANCE OF PATIENT AT PRESENTATION: _________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
PHYSICAL EXAM
Physical Exam Normal Abnormal Specify Abnormal Finding
HEENT
Lymph nodes
Chest
Heart
Abdomen
Genitourinary System
Musculo-skeletal system
Skin
Nervous System
Other findings:
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
INSTRUCTIONS: C. GENERAL CONDITION/PHYSICAL EXAM Note: All fields must be filled in
Health Facility Name – Health Facility name as registered at the Ministry of Health
Date: - Use Ethiopian calendar and a format of DD/MM/YYYY.
ART Unique ID No. –Patients should be assigned Unique ART number. This will be (region number/ woreda /facility
/patient assigned 5 digit number ). The first patient to start ART in the clinic will be given 00001.
Patient Card No. - 6 digit number followed by year found on patient card to be issued to patient by facility
Functional status – W or Work = working, A or Amb= ambulatory, B or Bed= bedridden (Working=able to perform usual
work in or out of the house, harvest, go to school. Ambulatory=ambulatory but not able to work. Able to perform
activities of daily living. Bedridden=not able to perform activities of daily living.
Vital Signs - Enter all the indicated vital signs.
Symptoms – Fill in all applicable circles. Note the following:
a. For ‘Cough’ you can fill in duration and whether it is productive if applicable
b. For ‘Fever’ you can fill in duration if applicable
c. For ‘Weight Loss’ you can fill in if > than 10% of body weight
d. For ‘Amenorrhea’ you should enter the date of LMP using Ethiopian calendar and DD/MM/YYYY format
e. For ‘Diarrhea’ you can enter duration and if there is blood present
Patient’s Pregnancy Status – fill in appropriate circle. If patient is currently pregnant indicate the Expected Delivery Date
using Ethiopian calendar and a format of DD/MM/YYYY
Physical and Mental Examination – fill in all applicable circles. Note that the left-hand column should be filled in if
findings are normal. If findings are abnormal for any system, fill in applicable circles or spaces to the right.
FEDERAL MINISTRY OF HEALTH OF ETHIOPIA
ARV CLINIC PATIENT RECORD D. CLINICAL REVIEW Health Facility Name:_________________________________________________________________ Date:______/______/__________
PATIENT IDENTIFICATION
Name: ___________ __ Father’s Name: _____ ______ __ _ Grandfather’s Name: __________ ART Unique ID No.: __ ________ Patient Card No.: ______________/_____________
WHO STAGING
WHO Stage 1 Conditions
○ Persistent Generalized Lymphadenopathy (PGL)
WHO Stage 2 Conditions
○ Minor Mucocutaneous Manifestations ○ Herpes Zoster
○ Weight Loss <10% of Body Weight ○ Recurrent Upper Respiratory Tract Infections
WHO Stage 3 Conditions
○ Oral Candidiasis ○ Weight Loss >10% of Body Weight
○ Oral Hairy Leukoplakia ○ Bacterial Pneumonia
○ Unexplained Chronic Diarrhea (>1 month) ○ Other Severe Bacterial Infections (i.e. pyomyositis)
○ Unexplained Prolonged Fever (>1 month) ○ Pulmonary Tuberculosis
WHO Stage 4 Conditions
○ Extrapulmonary Tuberculosis ○ HIV Wasting Syndrome
○ Atypical Mycobacteriosis ○ Candidiasis (Esophagus, Trachea, Bronchi or Lungs)
○ Crytococcosis Extrapulmonary ○ Cryptosporidiosis with Diarrhea (>1 month duration)
○ Herpes Simplex (mucocutaneous >1 month, or visceral ○ CMV Disease (other than liver, spleen, lymph nodes)
○ HIV Encephalopathy ○ Karposi’s Sarcoma
○ Lymphoma ○ PML
○ Mycosis, Disseminated (i.e. Histoplasma, Coccidioides) ○ Pneumocystis Carinii Pneumonia (PCP)
○ Salmonella Septicemia, Non-typhoid ○ Toxoplasmosis of the CNS
CLINICAL REVIEW
Does the Patient need evaluation for cough or TB?
○ No ○ Yes if Yes, Order: ○ TB sputum smear ○ Empiric Antibiotics ○ Chest X-Ray
Does the Patient need evaluation for diarrhea?
○ No ○ Yes Order: ○ Stool Examination ○ Empiric Antibiotics ○ Empiric Antiparasitics
Does the Patient need evaluation for fever?
○ No ○ Yes Order: ○ Urine Analysis ○ Malaria Slide ○ Hb, WBC, Diff
○ Blood Culture ○ Empiric Antibiotics ○ other (specify __________________________)
Does the Patient need prophylactic medication? ○ No ○ Yes
Does the Patient need evaluation for ARV treatment? ○ No ○ Yes
○ Start Education Sessions If Yes: ○ Hgb, WBC with differential ○ Liver function test (ALT) ○ CD4 count
INSTRUCTIONS: D. CLINICAL REVIEW Note: All fields must be filled in
Health Facility name – Health Facility name as registered to the facility by the Ministry of Health
Date: - Use Ethiopian calendar and a format of DD/MM/YYYY
ART Unique ID No. –Patients should be assigned Unique ART number. This will be (region number/ Woreda /facility
/patient assigned 5 digit number ). The first patient to start ART in the clinic will be given 00001.
Patient Card No. - 6 digit number followed by year found on patient card to be issued to patient by facility.
WHO Staging – fill in all applicable circles in each level. Note that a patient’s WHO stage is the highest stage that has at
least one circle filled in.
Clinical Review – The purpose of this section is to help the clinical provider develop an appropriate plan of care based
on HIV/AIDS treatment guidelines. Any ‘Order’ circles filled in should be followed up with the appropriate laboratory/X-
ray request form.
FEDERAL MINISTRY OF HEALTH OF ETHIOPIA
ARV CLINIC PATIENT RECORD E. SOCIAL ASSESSMENT Health Facility Name:_________________________________________________________________ Date:______/______/__________
PATIENT IDENTIFICATION Name: ___________ __ Father’s Name: _____ ______ __ _ Grandfather’s Name: __________ ART Unique ID No.: __ ________ Patient Card No.: ______________/_____________
EMPLOYMENT Current employment: ○ Working full time ○ Working part-time ○ Not working/Studying due to ill health ○ Unemployed Other (Specify):______________________________________________ Employer’s Name __________________________________ Department ____________________ Position _____________________ Does/Did illness affect ability to carry out this employment/study? ○ Yes ○ No If yes how often_____________________
If No is there any impact due to illness?__________________________________________
LIVING CONDITIONS
Home: Number of rooms ___ ___ ○ Running water ○ Electricity
Number of people in the household
RELIGIOUS/SUPPORTIVE CARE Religious conviction ○ Muslim ○ Orthodox ○ Protestant ○ Catholic ○ Other
Spiritual caregiver_________________________________________
Community Support/HIV support groups ○ Yes ○ No
DISCLOSURE Does anyone else know about your HIV Status? Family ○ Wife/Husband ○ Own Child (ren) ○ Parent(s) ○ Brother(s)/Sister(s) Others ○ Relatives ○ Friends
FAMILY MEMBERS – SPOUSE Condition of wife/husband: ○ Healthy ○ Chronic Ill ○ Dead ○ Unknown HIV tested Result ○ Not Asked ○ Negative ○ Positive ○ Unknown TB Result ○ Not Asked ○ Negative ○ Positive ○ Unknown Was/Is on ARV treatment Yes ○ No ○ Was/Is on TB treatment Yes ○ No ○
FAMILY MEMBERS – CHILDREN
Number of children alive Number HIV tested Number positive Number chronically ill
Number of children died Number HIV tested Number positive Number were chronically ill
ISSUES/CONCERNS IDENTIFIED General
○ Concerns about financial issue within the family ○ Bereavement/grief ○ Other concerns ○ Concerns about the children ○ HIV status disclosure concerns ○ Concerns regarding marital relationship ○ Adherence to treatment concerns
○ Concerns regarding family relations ○ Dietary problems
INSTRUCTIONS: E. SOCIAL ASSESSMENT
Health Facility name – Health Facility name as registered at the Ministry of Health
Date: - Use Ethiopian calendar and a format of DD/MM/YYYY
ART Unique ID No. –Patients should be assigned Unique ART number. This will be.(region number/ woreda /
facility /patient assigned 5 digit number ). The first patient to start ART in the clinic will be given 00001.
Employment Details (especially important if the clinic is workplace clinic) Company – Fill in the name of the company where the patient words. If the patient is not working at this
time enter NA. Department – Fill in the department in which the patient works. If not known or not applicable enter NA
Employer’s Working/Study: -
a. Working full time – If the patient is full time employee
b. Working part-time – If the patient works on part time base. c. Not Working/studying due to ill health. – If the patient couldn’t work/or study due to HIV/AIDS related problems d. Unemployed – If the patient doesn’t work due to not HIV/AIDS related problems but other factors e. Other (specify)–Include students, housewives and other employment categories.
Disclosure: if any one knows the status of the patient/ child at work place, school, family and other
community members Family Members:
a. Family : Spouse and/or children aware of the patient’s serostatus b. Others: other relatives, friends etc who are aware of the patient’s serostatus
Family Member: spouse: please fill in the appropriate circle to indicate the health status of the spouse
Family Member: children: please fill in the appropriate circle to indicate the health status of the child
Issues/Concerns Identified: please fill in the appropriate circle to indicate the Issues/Concerns identified
Social assessment should be conducted whenever the patient comes to the Health facility by counselors or ART nurse
FEDERAL MINISTRY OF HEALTH OF ETHIOPIA
ARV CLINIC PATIENT RECORD F. ART ADHERENCE COUNSELING Health Facility Name:_________________________________________________________________ Date:______/______/__________
PATIENT IDENTIFICATION Name: ___________ __ Father’s Name: _____ ______ __ _ Grandfather’s Name: __________ ART Unique ID No.: __ ________ Patient Card No.: ______________/_____________
HEALTH EDUCATION & KNOWLEDGE ○ Attended HIV related health education session(s) in the past
○ Attended HIV related counseling session(s) in the past
Understanding of HIV disease: ○ NA ○ - ○ + ○ ++ ○ +++
Understanding of HIV transmission: ○ NA ○ - ○ + ○ ++ ○ +++
Understanding of prophylaxis and treatment of OI: ○ NA ○ - ○ + ○ ++ ○ +++
Understanding of ART medication adherence: ○ NA ○ - ○ + ○ ++ ○ +++
RISK-BEHAVIOR ○ Has regular sexual partner
○ Has casual sexual partner(s) – Number of casual partners in last 3 months ○ 1 ○ 2 ○ 3 ○ >3
Condom use ○ NA ○ Never ○ Rarely ○ Sometimes ○ Mostly ○ Always ○ No response
Addictions:
Tobacco ○ NA ○ - ○ + ○ ++ ○ +++
Alcohol ○ NA ○ - ○ + ○ ++ ○ +++
Soft Drugs ○ NA ○ - ○ + ○ ++ ○ +++ e.g., Khat, Shisha, pills, etc.
Hard Drugs ○ NA ○ - ○ + ○ ++ ○ +++ e.g., cocaine, morphine, i.v.-drugs, etc.
Adherence: Concerns/barriers to ART:
○ Stigma (family and friends will find out) ○ Depressed/anxious
○ Afraid of medications (side effects; “poison”) ○ Will forget to take medications
○ Doubt that medications will work ○ Other _______________________________________________
GENERAL FEELING Since your last visit , have you had any problems or complaints? Have you been hospitalized?
○ No ○ Yes ○ No ○ Yes
How has your appetite been since your last visit? ○ Not Asked ○ Good ○ OK ○ Poor
How has your strength been since your last visit?
○ Normal ○ Weak, but not in bed ○ Very weak, often in bed ○ Extremely weak, mostly in bed
How many days have you been too sick to work? ____ ○ Lost job due to current illness
Evaluator’s impression about mental condition
○ At ease ○ Confused ○ Depressed ○ Anxious ○ Suicidal
APPROPRIATE REFERRAL ○ Physician ○ Pharmacy ○ Social Services ○ Laboratory ○ Community Based Organizations
INSTRUCTIONS: F. ART ADHERENCE COUNSELING Note: All fields must be filled in This form must be completed each time a patient is seen at the ART clinic
Health Facility Name:- Health Facility name as registered at the Ministry of Health
Date: - Use Ethiopian calendar and a format of DD/MM/YYYY
ART Unique ID No. –Patients should be assigned Unique ART number. This will be. (Region number/ Woreda /
Facility /patient assigned 5 digit numbers). The first patient to start ART in the clinic will be given 00001.
Patient Card No. – 6 digit number followed by year found on patient card to be issued to patient by facility.
Health Education & Knowledge – fill in appropriate circles. Scale is from ‘- None’ to ‘+++ A great deal’
Life Style – fill in appropriate circles. Scale is from ‘- No Use’ to ‘+++ A great deal of use’
Issues Identified – fill all applicable circles, counsel and refer when necessary.
Adherence questions – fill in appropriate circle for each question. Educate patient re adherence at every visit.
General Feeling questions – fill in appropriate circles. Some questions may be more appropriate at follow-up.
Counsel patient accordingly
Appropriate referral: fill in appropriate circles and refer patient according to identified needs discovered
during counseling
The Adherence counseling form need to be filled by the counselor or nurse every time the patient comes to clinic. This form should be copied.
FEDERAL MINISTRY OF HEALTH OF ETHIOPIA
ARV CLINIC PATIENT RECORD G. ART ASSESSMENT AND PLAN Health Facility Name:_________________________________________________________________ Date:______/______/__________
PATIENT IDENTIFICATION
Name: ___________ __ Father’s Name: _____ ______ __ _ Grandfather’s Name: __________ ART Unique ID No.: __ ________ Patient Card No.: ______________/_____________
ARV ELIGIBILITY CRITERIA
Clinical Criteria:
CD4 below 200 ○ Yes ○ No
WHO Stage IV ○ Yes ○ No
WHO Stage II and III with TLC ≤ 1200 ○ Yes ○ No
Social Criteria:
Resident of catchments area ○ Yes ○ No
No identified barriers for adherence ○ Yes ○ No
PLAN
1. OI Prophylaxis (dd/mm/yy)
Cotrimoxazole: Start _____/______/______Continue ______/______/______Discontinue ______/______/______Start at a later date______/______/______
INH: Start _____/______/______Continue ______/______/______Discontinue ______/______/______Start at a later date______/______/______
Fluconazole: Start _____/______/______Continue ______/______/______Discontinue ______/______/______Start at a later date______/______/______
2. Treatment for other conditions: ○ Yes ______ ○ No ______ If Yes: Diagnosis: ______________ Treatment: ____________________
If Yes: Diagnosis: ______________ Treatment: ____________________
3. Recommend ART:
○ Yes _____________ ○ No _____________○ Deferred (State reason) _____________________________
If yes, specify regimen:
○ 1a(30) = d4t (30)-3TC-NVP
○ 1a(40) = d4t (40)-3TC-NVP
○ 1b(30) = d4t (30)-3TC-EFV
○ 1b(40) = d4t (40)-3TC-EFV
○ 1c = AZT-3TC-NVP
○ 1d = AZT-3TC-EFV
INSTRUCTIONS : G. ART ASSESSMENT AND PLAN Note: All fields must be filled in
Form G is to be completed at the second visit by the treating physician. Health Facility Name:- Name as registered at the Ministry of Health
Date: - Use Ethiopian calendar and a format of DD/MM/YYYY
ART Unique ID No. –Patients should be assigned Unique ART number. This will be. (Region number/ Woreda /
Facility /patient assigned 5 digit numbers). The first patient to start ART in the clinic will be given 00001.
Patient Card No. – 6 digit number followed by year found on patient card to be issued to patient by facility.
ARV Eligibility Criteria- Clinical Criteria: fill in the appropriate circle to indicate the ARV Eligibility Clinical Criteria ARV Eligibility Criteria- Social Criteria: fill in the appropriate circle to indicate the ARV Eligibility Social Criteria
Plan- OI Prophylaxis: please use the appropriate blank space to fill the appropriate date (dd/mm/yy)
Plan- Treatment for other conditions: fill in the appropriate circle Plan- Recommend ART: please fill in the appropriate circle
Follo
w-u
p da
te
Mon
ths
on A
RT
Preg
nanc
y/Fa
mily
Pla
nnin
g Fu
nctio
nal s
tatu
s TB
sta
tus
S=S
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U
S=U
nsch
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F=
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Dur
atio
n in
mon
ths
sinc
e in
itiat
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of
AR
T If
Pre
AR
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blan
k 0
= A
RT
initi
atio
n 1
wee
k =
1 w
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2 w
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= 2
wee
ks
3 w
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= 3
wee
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1 =
1 m
onth
…
If
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hang
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gim
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tal n
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of w
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tart
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T =
Ref
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FP=
Not
pre
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fam
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If on
FP
, not
e m
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ds (n
ote:
mor
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m
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1= c
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2= o
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pills
3=
inje
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plan
tabl
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rmon
es (e
.g.
depo
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Dia
phra
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5=In
traut
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vice
6=
Vas
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W=W
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ble
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rm
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k in
or o
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f the
ho
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vest
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to s
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for c
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not a
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=Bed
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rm a
ctiv
ities
of d
aily
livi
ng)
No
sign
s =
no s
igns
or s
ympt
oms
of T
B
TB re
fer =
TB
sus
pect
ed a
nd re
ferre
d fo
r ev
alua
tion
INH
= c
urre
ntly
on
INH
pro
phyl
axis
(IP
T).
TB R
x =
curr
ently
on
DO
TS
Sput
um =
TB
sus
pect
ed a
nd s
putu
m s
ampl
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nt
--, +
, ++,
or +
++ =
spu
tum
resu
lts
Pot
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l sid
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s
OIs
or o
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pro
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s (a
lso
use
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teria
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umon
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, Pul
mon
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Tube
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B, E
xtra
pul
mon
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tube
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Th
rush
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l, va
gina
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s-m
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, gen
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C o
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, Dia
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Oth
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Est
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here
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belo
w:
A
dher
ence
%M
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ddo
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G(g
ood)
>
95%
≤
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ses
F(fa
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85-9
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8 do
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P(po
or)
< 85
%
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dose
s ST
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= S
topp
ed A
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If S
TOP
, In
why
col
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not
e re
ason
why
sto
pped
: 1
Toxi
city
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s
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ancy
3
Trea
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4
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r adh
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5
Illne
ss, h
ospi
taliz
atio
n
6 D
rugs
out
of s
tock
7
Pat
ient
lack
fina
nces
8
Oth
er p
atie
nt d
ecis
ion
9 P
lann
ed tr
eatm
ent i
nter
rupt
ion
10 O
ther
1 To
xici
ty/s
ide
effe
cts
2 S
hare
with
oth
ers
3 Fo
rgot
4
Felt
bette
r 5
Too
ill
6 S
tigm
a, d
iscl
osur
e or
priv
acy
issu
es
7 D
rug
stoc
k ou
t – d
ispe
nsar
y 8
Pat
ient
lost
/ ran
out
of p
ills
9 D
eliv
ery/
trave
l pro
blem
s 10
Inab
ility
to p
ay
11 A
lcoh
ol
12 D
epre
ssio
n 13
Oth
er
____
____
____
____
___
Adu
lt 1st
Lin
e R
egim
ens:
1a
(30)
=d4t
(30)
-3TC
-NVP
1a
(40)
=d4t
(40)
-3TC
-NVP
1b
(30)
=d4t
(30)
-3TC
-EFV
1b
(40)
=d4t
(40)
-3TC
-EFV
1c
= A
ZT-3
TC-N
VP
1d
=
AZT
-3TC
-EFV
A
dult
2nd L
ine
Reg
imen
s:
2a =
ABC
-ddI
-LP
V/r
2b =
ABC
-ddI
-NFV
2c
= TD
F-dd
I-LPV
/r 2d
= TD
F- d
dI-N
FV
Chi
ld 1
st L
ine
Reg
imen
s 4a
=d4
T-3T
C-N
VP
4b
= d
4T-3
TC-E
FV
4c =
AZT
-3TC
-NVP
4d
= A
ZT-3
TC-E
FV
Chi
ld 2
nd L
ine
Reg
imen
s 5a
= A
BC-d
dI-L
PV
/r 5b
= A
BC-d
dI-N
FV
5c =
TD
F-dd
I-LP
V/r
5d =
TD
F-dd
I-NFV
Elig
ible
C
heck
whe
n pa
tient
is
med
ical
ly e
ligib
le fo
r AR
T
Why
Elig
ible
1
Clin
ical
onl
y
3
TLC
2
CD
4
4
Tra
nsfe
r In
(TI)
Elig
ible
and
read
y C
heck
whe
n pt
is m
edic
ally
elig
ible
AN
D
read
y (c
ouns
elle
d fo
r adh
eren
ce) f
or A
RT
Follo
w-u
p st
atus
Afte
r fol
low
-up
date
, in
seco
nd c
olum
n, w
rite:
TO
= tr
ansf
erre
d ou
t
LO
ST =
not
see
n si
nce
…
D
EAD
= d
ied
D
RO
P =
lost
to fo
llow
-up,
dro
pped
from
dru
g su
pply
FO
LAR
T - V
r1/9
7
Rep
ort o
n Tr
eatm
ent S
tatu
s/O
utco
mes
for C
ohor
ts o
n A
RT
Coh
orts
are
def
ined
by
mon
th/y
ear t
hey
star
ted
AR
T.
Faci
lity
Nam
e:__
____
____
____
____
____
____
____
____
____
____
___
For c
ohor
t sta
rting
AR
T by
mon
th/y
ear:
at b
asel
ine
th
en re
sults
at 6
mon
ths
on A
RT,
12
mon
ths
on A
RT,
24
mon
ths
on A
RT
Coh
ort
Tire
97
6 m
o-H
amle
97
12 m
o-Ti
re
98
24 m
o-Ti
re
99
Coh
ort
Yek
atit
97
6 m
o-N
ehas
e 97
12 m
oY
ekat
it 98
24 m
o-Y
ekat
it 99
Coh
ort
Meg
abit
97
6 m
o-M
eskr
em
97
12 m
oM
egab
it 98
24 m
o-M
egab
it 99
Coh
ort
Mia
zia
97
6 m
o-Ti
kim
ete
98
12 m
oM
iazi
a
98
24 m
o-m
iazi
a
99
Coh
ort
Gin
bote
97
6 m
o-H
idar
e 98
12 m
o-G
inbo
te
98
24 m
o-G
inbo
te
99
Coh
ort
Sen
e
97
6 m
o-Ta
hesa
s 98
12 m
oS
ene
98
24 m
o-S
ene
99
ASt
arte
d on
AR
T in
this
clin
ic- o
rigin
al c
ohor
t
BTr
ansf
ers
In
A
dd +
xx
xx
xx
CTr
ansf
ers
Out
Su
btra
ct
-x
xx
xx
xD
Net
cur
rent
coh
ort
EO
n O
rigin
al 1
st L
ine
Reg
imen
F
On
Alte
rnat
e 1s
t Lin
e R
egim
en (S
ubst
itute
d)
GO
n 2n
d Li
ne R
egim
en (S
witc
hed)
HSt
oppe
d
ID
ied
JTr
ansf
erre
d O
ut
K
Lost
to
Follo
w-u
p (D
RO
P)
Perc
ent o
f coh
ort a
live
and
on A
RT
[ (E
+ F+
G) /
D *
100
]
CD
4 %
(for
chi
ldre
n)
CD
4 m
edia
n or
pro
port
ion
> 20
0 (o
ptio
nal)
Func
tiona
l Sta
tus
Pro
porti
on W
orki
ng
Pro
porti
on A
mbu
lato
ry
Pro
porti
on B
edrid
den
Num
ber o
f per
sons
who
pic
ked
up A
RVs
eac
hm
onth
for 6
mon
ths
x
xx
xx
xx
xx
xx
xx
x
xx
xx
Num
ber o
f per
sons
who
pic
ked
up A
RVs
eac
hm
onth
for 1
2 m
onth
s x
x
xx
xx
xx
xx
xx
x x
x
xx
x
For c
ohor
t sta
rting
AR
T by
mon
th/y
ear:
at b
asel
ine
th
en re
sults
at 6
mon
ths
on A
RT,
12
mon
ths
on A
RT,
24
mon
ths
on A
RT
Coh
ort
Ham
le
97
6 m
o-Ti
re
98
12 m
oH
amle
98
24 m
o-H
amle
99
Coh
ort
Neh
ase
97
6 m
o-Y
ekat
it 98
12 m
oN
ehas
e 98
24 m
o-N
ehas
e 99
Coh
ort
Mes
kere
m
98
6 m
o-M
egab
it 98
12 m
o-M
eske
rem
99
24 m
o-M
eske
rem
00
Coh
ort
Tiki
mte
98
6 m
o-M
iazi
a 98
12 m
oTi
kim
te
99
24 m
o-Ti
kim
te
00
Coh
ort
Hid
are
98
6 m
o-G
inbo
t 98
12 m
oH
idar
e 99
24 m
o-H
idar
e 00
Coh
ort
Tahi
sas
98
6 m
o-S
ene
98
12 m
oTa
hisa
s 99
24 m
o-Ta
hisa
s 00
ASt
arte
d on
AR
T in
this
clin
ic- o
rigin
al c
ohor
t
BTr
ansf
ers
In
A
dd +
xx
xx
xx
CTr
ansf
ers
Out
Su
btra
ct
-x
xx
xx
xD
Net
cur
rent
coh
ort
EO
n O
rigin
al 1
st L
ine
Reg
imen
F
On
Alte
rnat
e 1s
t Lin
e R
egim
en (S
ubst
itute
d)
GO
n 2n
d Li
ne R
egim
en (S
witc
hed)
H
Stop
ped
ID
ied
JTr
ansf
erre
d O
ut
KLo
st t
o Fo
llow
-up
(DR
OP)
Perc
ent o
f coh
ort a
live
and
on A
RT
[ (E
+ F+
G) /
D *
100
]
CD
4 %
(for
chi
ldre
n)
CD
4 m
edia
n or
pro
port
ion
> 20
0 (o
ptio
nal)
Func
tiona
l Sta
tus
Pro
porti
on W
orki
ng
Pro
porti
on A
mbu
lato
ry
Pro
porti
on B
edrid
den
Num
ber o
f per
sons
who
pic
ked
up A
RVs
eac
hm
onth
for 6
mon
ths
x
xx
xx
xx
x
xx
xx
xx
xx
xx
Num
ber o
f per
sons
who
pic
ked
up A
RVs
eac
hm
onth
for 1
2 m
onth
s x
xx
xx
xx
x
xx
xx
xx
xx
xx
WHO European Regional Office (EURO) Patient ART Card and Monthly report form
The EURO office has adapted the WHO forms to suit the specific characteristics of its target population. In many Eastern European countries, where these forms will be used, intravenous drug use (IDU) plays a role in HIV transmission. Hepatitis B and C and TB are also prevalent in this region and have accordingly been included on the monitoring forms. Identification of hepatitis is important as it may impact the adverse reactions from ART (on the liver). The EURO forms are currently being field-tested in Moldova and soon Ukraine.
Uni
que
#
HIV
CA
RE
/AR
T C
AR
D__
__
Dis
tric
t___
____
____
___
Hea
lth u
nit_
___
Dis
tric
t phy
sici
an/te
am__
____
__N
ame_
____
____
____
____
____
__
Pt c
linic
no_
____
____
___
Sex:
M
F
D
ate
of b
irth
____
___
Mar
ital s
tatu
s___
____
A
ddre
ss__
____
____
____
____
____
____
____
____
____
____
____
__
____
____
____
____
____
____
____
____
____
____
____
____
____
___
Pho
ne (w
hose
) Pr
ior
AR
T:
Tran
sfer
in w
ith re
cord
s P
MTC
T on
ly
E
arlie
r AR
V, n
ot tr
ansf
er in
N
one
H
ospi
tal,
TB c
linic
, STI
clin
ic, I
DU
clin
ic, O
ut-p
atie
nt c
linic
, H
R p
rogr
am,
Car
e en
try p
oint
: (c
ircle
) A
IDS
Cen
ter,
Wom
en c
onsu
ltatio
n C
ente
r, O
ther
(spe
cify
): __
____
____
____
_ Tr
eatm
ent s
uppo
rter
/med
pic
k-up
if il
l:___
____
____
____
____
_ A
ddre
ss__
____
____
____
____
____
____
____
____
____
____
____
____
___
Phon
e:
Hom
e-ba
sed
care
pro
vide
d by
:
AR
T tr
eatm
ent i
nter
rupt
ions
N
ames
of f
amily
m
embe
rs o
r pa
rtne
rs
also
in H
IV c
are
Age
H
IV
stat
us
Dat
e
Uni
que
No
Sto
p Lo
st
(circ
le)
Dat
e
Why
(use
cod
es
A-J
)
Dat
e if
Res
tart:
Stop
Lo
st
Stop
Lo
st
Stop
Lo
st
St
op
Lo
st
D
ate
____
___
Con
firm
ed H
IV +
test
W
here
____
__
HIV
1 2
(c
ircle
) __
____
_ En
rolle
d in
HIV
car
e
Ab/
PCR
If <
18 m
o
AR
T __
____
_ M
edic
ally
elig
ible
Clin
ical
sta
ge
____
___
W
hy
elig
ible
: C
linic
al o
nly
CD
4#/%
____
VL
___
CO
HO
RT:
____
___
Med
ical
ly e
ligib
le a
nd re
ady
for A
RT
____
___
Tran
sfer
red
in
from
:___
____
A
RT
star
ted:
____
____
____
St
art A
RT
first
-line
initi
al re
gim
en:_
____
____
____
____
____
____
____
____
__
____
_ * TB
sta
tus_
__
****
**
Hep
B__
_ **
***
Hep
C__
ID
U s
tatu
s**_
_Wei
ght_
__
____
___
Subs
titut
e w
ithin
1st
line
:___
____
____
____
____
____
____
____
____
___
____
___
New
regi
men
____
____
____
____
____
____
____
____
____
____
W
hy__
_
1st line
____
___
New
____
____
____
____
____
____
____
____
____
____
____
___
W
hy__
_
(u
se c
odes
1-7
)
Sw
itch
to 2
nd lin
e (o
r Sub
stitu
te w
ithin
2nd
line
):___
____
____
____
__
____
_ N
ew re
gim
en__
____
____
____
____
____
____
____
____
____
__
Why
___
____
___
New
____
____
____
____
____
____
____
____
____
____
____
___
W
hy__
___
____
_ N
ew__
____
____
____
____
____
____
____
____
____
____
____
_
Why
___
2nd
line
____
___
Dea
d
(u
se c
odes
8-1
0)
__
____
_ Tr
ansf
erre
d ou
t To
whe
re:_
____
____
____
____
____
____
____
W
hy S
TOP
code
s:
Why
SU
BST
ITU
TE o
r SW
ITC
H c
odes
: A
T
oxic
ity/s
ide
effe
cts*
**
1
Toxi
city
/sid
e ef
fect
s B
P
regn
ancy
2
P
regn
ancy
/risk
of p
regn
ancy
C
T
reat
men
t fai
lure
3
D
ue to
iden
tifie
d H
epat
itis
D
Poo
r adh
eren
ce**
**
4
Due
to n
ew T
B
E
Illn
ess,
hos
pita
lizat
ion
5
New
dru
g av
aila
ble
F
Dru
gs o
ut o
f sto
ck
6
Dru
g ou
t of S
tock
G
P
atie
nt la
cks
finan
ces
7
Oth
er re
ason
(spe
cify
)___
____
___
H
Oth
er p
atie
nt d
ecis
ion
Rea
sons
for S
WIT
CH
to 2
nd li
ne re
gim
en o
nly
I
Pla
nned
Rx
inte
rrup
tion
8
Clin
ical
trea
tmen
t fai
lure
J
O
ther
____
____
____
____
____
9
Im
mun
olog
ic fa
ilure
10 V
irolo
gic
failu
re
* Cod
es fo
r TB
sta
tus
(che
ck o
n ea
ch v
isit)
:
**ID
U s
tatu
s
***C
odes
for p
oten
tial
Side
Effe
cts
or O
ther
Pr
oble
ms
****
Cod
es fo
r Why
if
poor
/fair
adhe
renc
e
****
*Cod
es fo
r new
OI o
r ot
her d
isea
ses
****
** C
odes
for
Hep
atiti
s B
, H
epat
itis
C s
tatu
s
1. N
o TB
tre
atm
ent/p
reve
ntio
n 1.
Nev
er in
ject
ed d
ugs
1.N
ause
a 1.
To
xici
ty/s
ide
effe
cts
1. G
ener
alis
ed
lym
phoa
deno
path
y
1. U
nkno
wn
2. U
nder
TB
pre
vent
ativ
e tre
atm
ent
2. In
ject
ed d
rugs
2.
Dia
rrho
ea
2.
Sha
re w
ith o
ther
s 2.
Her
pes
Zost
er
2. N
ot in
fect
ed
3. U
nder
TB
trea
tmen
t 2a
. las
t tim
e in
ject
ed d
rugs
(d
ate)
3.
Fat
igue
3.
Fo
rgot
3.
Pne
umon
ia
3. In
fect
ed (n
o ne
ed fo
r tre
atm
ent)
Plea
se re
cord
the
info
rmat
ion
belo
w:
3. In
ject
dru
gs c
urre
ntly
4.
Hea
dach
e 4.
Fe
lt be
tter
4. C
andi
dias
is
4. U
nder
trea
tmen
t of
H
ep C
A
). S
kin
test
Dat
e___
__
R
esul
t +/
-
3a. E
very
day
5. B
N b
urni
ng/n
umb/
tingl
ing
5.
Too
ill
5. R
ecur
rent
bac
teria
l in
fect
ions
5. U
nder
trea
tmen
t of
Hep
B
B).B
acte
riolo
gy
D
ate_
____
_
Res
ult_
____
3b. A
few
tim
es a
wee
k 6.
Ras
h 6.
S
tigm
a, d
iscl
osur
e or
pr
ivac
y is
sues
6.
Ora
l hai
ry le
ukop
laki
a
C).
X-R
ay
D
ate_
____
_
Res
ult_
____
3c. L
ess
than
onc
e a
wee
k 7.
Ana
emia
7.
D
rug
out o
f st
ock
disp
ensa
ry
7. P
ersi
sten
t fev
er
D).
Pre
vent
ativ
e tre
atm
ent
Med
icat
ion_
____
__
Sta
rt da
te__
____
_
S
top
date
____
___
3d. L
ess
than
onc
e a
mon
th
8. A
bdom
inal
pai
n 8.
P
atie
nt lo
st/ra
n ou
t of
pills
8.
Une
xpla
ined
chr
onic
di
arrh
oea
E).
TB tr
eatm
ent
Sta
rt at
e___
____
S
top
date
____
___
4. U
nder
sub
stitu
tion
treat
men
t 9.
Jau
ndic
e 9.
D
eliv
ery/
trave
l pr
oble
ms
9. W
eigh
t los
s
10
.Fat
chan
ges
10.
Inab
ility
to p
ay
10.
Cyt
omeg
alov
irus
retin
itis
11. C
NS
: di
zzy,
anx
iety
, ni
ghtm
are,
dep
ress
ion
11.
Alc
ohol
11
. Lym
phom
a
12
. D
epre
ssio
n 12
. Kap
osi s
arco
ma
13.
Inje
ctin
g dr
ugs_
____
____
____
_ 13
. HIV
enc
epha
lopa
thy
14
. O
ther
____
____
____
__
14. O
ther
(spe
cify
)
Uni
que
# H
IV C
AR
E/A
RT
CA
RD
___
_ N
ame
____
____
____
____
____
____
____
Preg
nant
PM
TCT?
D
ue d
ate
or F
P
no
FP/y
es:
Met
hods
Ref
er o
r co
nsul
t on
link
/ pr
ovid
e
Dat
e C
heck
if
sche
dule
d.(S
) U
nsch
edul
ed (U
) W
rite
in
alte
rnat
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Follow-up Education, Support and Preparation for ARV therapy Date/Comments Date/Comments Date/CommentsBasic HIV education, transmission Prevention: abstinence, safer sex, condoms, Harm Reduction
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 MTCT
Child's blood test Progression of disease Available treatment/prophylaxis Follow-up appointments, clinical team
CTX, INH prophylaxis ARTeducate 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 Symptom management/palliative care at home
Caregiver Booklet Home-based carespecify Support groups Community support
Educate on basics, prevention, disclosure Educate on basics, prevention, disclosure
Progression, Rx
Progression, Rx
AR
T preparation…......initiation…
.......support, monitor…
……
.
Hom
e-based care, support H
ome-based care, support
Cumulative number of persons ever enrolled in HIV
care at this facility at beginning of month
New persons enrolled in HIV care at this facility during the
month
Cumulative number of persons ever enrolled in HIV care at this facility at end of
month
1. Males (>14 years) a. g. m.1a. Males IDUs (IDU code 3)
1b. Males with active TB (TB code 3)
1c. Males with active Hepatitis (codes for Hep 4 or 5)
2. Non-pregnant females (>14 years) b. h. n.
2a. Females IDUs (IDU code 3)
2b. Females with active TB (TB code 3)2c. Females with active Hepatitis (codes for Hep 4 or 5)
3. Pregnant females c. i. o.
3a. Pregnant IDUs
4. Boys (0-14 years) d. j. p.
5. Girls (0-14 years) e. k. q.
Total f. l. r.
s.
t.
Cumulative number of persons ever started on ART at this facility at beginning of
month
New persons started on ART at this facility during the
month
Cumulative number of persons ever started on ART
at this facility at end of month
1. Males (>14 years) a. g. m.1a. Males IDUs (IDU code 3)
1b. Males with active TB (TB code 3)
1c. Males with active Hepatitis (codes for Hep 4 or 5)
2. Non-pregnant females (>14 years) b. h. n.
2a. Females IDUs (IDU code 3)
2b. Females with active TB (TB code 3)2c. Females with active Hepatitis (codes for Hep 4 or 5)
3. Pregnant females c. i. o.
3a. Pregnant IDUs
4. Boys (0-14 years) d. j. p.
5. Girls (0-14 years) e. k. q.
Total f. l. r.
s.
t.
u.
v.
Page 1
Median baseline CD4+ count for persons who started ART in the last month (optional)
City/oblast/Country:
Number of baseline CD4+ counts for persons who started ART in the last month (optional)
Total number of persons who are enrolled and eligible for ART but have not been started on ART
2. ART care - new and cumulative number of persons started
No.of persons on ART and already enrolled in program who transferred into facility in last month
No. of persons already enrolled for HIV care who transferred in from another facility
Number of persons who restarted ART during the last month, after stopping ART for at least 1 month
Monthly, Facility-Based HIV Care/ART Reporting FormMonth: MOH or Project or Grantee:
Year:Facility:
1. HIV care (non-ART and ART) - new and cumulative number of persons enrolled
Location:
4. ARV regimen at end of month Male FemaleOn 1st-line ARV regimen4.1 Adults (>14 years)
AZT-3TC-EFV a. j.AZT-3TC-NVP b. k.d4T-3TC-EFV c. l.d4T-3TC-NVP d. m.
e. n.f. o.g. p.h. q.
Adults on 1st-line regimens i. r. s.4.2 Children (0-14 years)
AZT-3TC-EFV a. k.AZT-3TC-NVP b. l.d4T-3TC-EFV c. m.d4T-3TC-NVP d. n.
e. o.f. p.g. q.h. r.
Children on 1st-line regimens i. s. u.
Adults and children on 1st-line regimensj. t. v.
Total adults and children on 1st-line regimens
On 2nd-Line ARV regimen4.3 Adults (>14 years)
ABC-ddI-LPV/r a. i.TDF-ddI-LPV/r b. j.ABC-ddI-SQV/r c. k.TDF-ddI-SQVr d. l.
e. m.Another regimen (specify) f. n.
g. o.Adults on 2nd-line regimens h. p. q.
4.4 Children (0-14 years)ABC-ddI-LPV/r a. k.ABC-ddI-NFV b. l.
ABC-ddI-SQV/r c. m.d. n.
Another regimen (specify) e. o.f. p.g. q.
Children on 2nd-line regimens h. r. u.
Adults and children on 2nd-line regimensi. s. v.
Total adults and children on 2ndline regimens
Adults and children on 1st- and 2nd-line regimensj. t. w.
Total adults and children on 1st-and 2nd-line regimens
5.1 Number of persons who did not pick up their ARV regimens Male Female1. For last 1 month (only) a. e.2. For last 2 months (only) b. f. 1. Lost to follow-up a.3. For last 3 or more months c. g. 2. Who died b.
Subtotal d. h. 3. Who stopped ART c.i. 4. Who transferred out d.
6. Number of personnel trained in HIV care during the month Physicians Nurses Other staff Subtotal1. ART clinical care a. e. i. m.2. Non-ART clinical care b. f. j. n.3. Adherence counseling/support c. g. k. o.4. Other types of training d. h. l. p.
q.
Total number of persons who did not pick up their ART regimens
Total personnel trained
5.2 Of those who did not pick up regimen in last 1 month (optional)
Total number of adults and children
Total number of children on 2nd-line regimen
Total number of adults on 1st-line regimen
Total number of adults on 2nd-line regimen
Total number of children on 1st-line regimen
