Page Comparison

What do you want to do?

🔘 Enrol a new client

🔘 Transfer in a client

🔘 Enrol a Mother into PMTCT program

🔘 Re-enrol a client

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Enrolment Date

␣␣-␣␣-␣␣␣␣ 📆

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Unique ID

__________________________________

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Entry Point

🔽 Voluntary male circumcision clinic

🔽 Private home-based care

🔽 Adolescent outreach program

🔽 Private company

🔽 Outreach program

🔽 Community-based organization

🔽 Outpatient department

🔽 Pediatric inpatient service

🔽 Voluntary counseling and testing program

🔽 Maternal and child health program

🔽 Vaccination service

🔽 Nutrition program

🔽 Sex worker outreach program

🔽 Intravenous venous drug user outreach program

🔽 Sexually transmitted infection program/clinic

🔽 Under five clinic

🔽 Tuberculosis treatment program

🔽 Adult inpatient service

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Population Category

🔘 General population

🔘 Key population

🔘 Priority population

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Key Population Type

🔘 Intravenous drug user

🔘 Male who has sex with men

🔘 Prisoners

🔘 Sex worker

🔘 Transgender Persons

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Priority Population Type

🔽 Adolescent Girls & Young Women

🔽 Client of sex worker

🔽 Fisher Folk

🔽 Long-distance truck driver

🔽 Migrant Workers

🔽 Non-intravenous drug user

🔽 Refugee

🔽 Uniformed Forces

🔽 Other

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Transfer-In

Transferring Facility

__________________________________

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Start ART Date

␣␣-␣␣-␣␣␣␣ 📆

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Current ART Regimen

🔽 d4T + 3TC + NVP

🔽 TDF + FTC + EFV

🔽 TDF + FTC + DTG

🔽 TDF + 3TC + NVP

🔽 TDF + 3TC + LPV/r

🔽 TDF + 3TC + EFV

🔽 TDF + 3TC + DTG + ETR + DRV + RTV

🔽 TDF + 3TC + DTG + DRV + RTV

🔽 TAF + 3TC + LPV/r

🔽 TAF + 3TC + DTG

🔽 TAF + 3TC + DRV/r

🔽 RAL + 3TC + DRV + RTV + TDF

🔽 RAL + 3TC + DRV + RTV + AZT

🔽 RAL + 3TC + DRV + RTV

🔽 ETV + 3TC + DRV + RTV

🔽 AZT + 3TC + RAL

🔽 AZT + 3TC + NVP

🔽 AZT + 3TC + LPV/r

🔽 AZT + 3TC + EFV

🔽 AZT + 3TC + DTG

🔽 AZT + 3TC + DRV + RTV + RAL

🔽 AZT + 3TC + ATV/r

🔽 ABC + 3TC + RAL

🔽 ABC + 3TC + NVP

🔽 ABC + 3TC + LPV/r

🔽 ABC + 3TC + EFV

🔽 ABC + 3TC + DTG

🔽 ABC + 3TC + DRVr

🔽 ABC + 3TC + DRV+RTV+RAL

🔽 ABC + 3TC + ATVr

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Transfer Documents

🔘 Mother enrolled in prevention of maternal to child transmission (PMTCT) program

🔘 Transfer-in with Records

🔘 Transfer-in without records

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Date of Enrolment into HIV Care

␣␣-␣␣-␣␣␣␣ 📆

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HIV Diagnosis

Date Confirmed HIV Positive

␣␣-␣␣-␣␣␣␣ 📆

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Test Type

🔘 Rapid test for HIV

🔘 HIV DNA polymerase chain reaction

🔘 Unknown

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Test Location

__________________________________

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Previous ARV/HAART Use

Use of Pre Exposure Prophylaxis (PrEP)

🔘 Yes

🔘 No

🔘 Unknown

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Date Last Used

␣␣-␣␣-␣␣␣␣ 📆

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Use of Post-exposure prophylaxis (PEP)

🔘 Yes

🔘 No

🔘 Unknown

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Date Last Used

␣␣-␣␣-␣␣␣␣ 📆

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ARV Use for Management of Hepatitis

🔘 Yes

🔘 No

🔘 Unknown

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Date Last Used

␣␣-␣␣-␣␣␣␣ 📆

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ART Use for Prevention of Mother to Child Transmission of HIV

🔘 Yes

🔘 No

🔘 Unknown

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Date Last Used

␣␣-␣␣-␣␣␣␣ 📆

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Nucleoside Reverse Transcriptase Inhibitors (NRTIS)

☑️ Zidovudine

☑️ Tenofovir

☑️ Lamivudine

☑️ Emtricitabine

☑️ Abacavir

☑️ Other antiretroviral drug

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Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIS)

☑️ Etravirine

☑️ Nevirapine

☑️ Efavirenz

☑️ Other antiretroviral drug

☑️ Unknown

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Protease Inhibitors (PIS)

☑️ Tipranavir

☑️ Saquinavir

☑️ Ritonavir

☑️ Fosamprenavir

☑️ Darunavir

☑️ Atazanavir

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Other HIV Drug Classes

☑️ Raltegravir

☑️ Dolutegravir

☑️ Maraviroc

☑️ Enfuvirtide

☑️ Other antiretroviral drug

☑️ Unknown

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Treatment Supporter

Treatment Supporter Available

🔘 Yes

🔘 No

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Treatment Supporter Name

__________________________________

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Treatment Supporter Phone Number

__________________________________

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Treatment Supporter Relationship

🔽 Sibling

🔽 Parent

🔽 Partner or spouse

🔽 Guardian

🔽 Grandparent

🔽 Other

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Re-enrollment

Date of Re-enrollment

␣␣-␣␣-␣␣␣␣ 📆

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Reason For Re-enrolment

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