Questions | Concepts | |
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What do you want to do? 🔘 Enrol a new client 🔘 Transfer in a client 🔘 Enrol a Mother into PMTCT program 🔘 Re-enrol a client | ||
Enrolment Date ␣␣-␣␣-␣␣␣␣ 📆 | 160555AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA | |
Unique ID __________________________________ | ||
Other Unique ID __________________________________ | 162576AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA162727 Other facility patient identifier | |
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 service160540AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA | ||
Entry Point - Other __________________________________ | ||
Population Category*** 🔘 General population 🔘 Key population 🔘 Priority population746737c0 | -4201-4d7f-b580-816e36dc425a166432 Study population type | |
Key Population Type*** 🔘 Intravenous drug user 🔘 Male who has sex with men 🔘 Prisoners 🔘 Sex worker 🔘 Transgender Personsd3d4ae96 | -8c8a-43db-a9dc-dac951f5dcb3166433 Target population type | |
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 | 2bf14240-b2b2-42b2-8cf3-b5f8a0cb7764 | |
Transfer-In | ||
Transferring Facility __________________________________ | 160535AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA160535 Transferred from location | |
Start ART Date ␣␣-␣␣-␣␣␣␣ 📆 | 159599AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA159599 Antiretroviral treatment start date | |
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 | dfbe256e-30ba-4033-837a-2e8477f2e7cd | |
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Date of Enrolment into HIV Care ␣␣-␣␣-␣␣␣␣ 📆 | 163260AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA163260 Date of first visit | |
HIV Diagnosis | ||
Date Confirmed HIV Positive ␣␣-␣␣-␣␣␣␣ 📆 | 160554AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA60554 Date of HIV diagnosis | |
Test Type*** 🔘 Rapid test for HIV 🔘 HIV DNA polymerase chain reaction 🔘 Unknownca4953af-9ad4-4514-b54a-6832acd7cae9 | ||
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Previous ARV/HAART Use | ||
Use of Pre Exposure Prophylaxis (PrEP) 🔘 Yes 🔘 No 🔘 Unknown5d397775 | -0155-4033-95dc-edcec98e8190166655 Pre-exposure prophylaxis (PrEP) regimen | |
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Use of Post-exposure prophylaxis (PEP)**** 🔘 Yes 🔘 No 🔘 Unknown8bfdc328-1970-446c-9d7b-97d62703801b | ||
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ART Use for Prevention of Mother to Child Transmission of HIV 🔘 Yes 🔘 No 🔘 Unknown163532AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA | 163532 Mother enrolled in prevention of maternal to child transmission (PMTCT) program | |
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Nucleoside Reverse Transcriptase Inhibitors (NRTIS) ☑️ Zidovudine ☑️ Tenofovir ☑️ Lamivudine ☑️ Emtricitabine ☑️ Abacavir ☑️ Other antiretroviral drug | 54e7ff9b-4d93-41ba-ad0b-cb5f565785f2 NRTIS Nucleoside Reverse Transcriptase Inhibitors (NRTIS) ARVs | |
Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIS) ☑️ Etravirine ☑️ Nevirapine ☑️ Efavirenz ☑️ Other antiretroviral drug ☑️ Unknown | 9064043b-5b18-4228-97ff-f0e20aaf9448 NNRTIS Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIS) ARVs | |
Protease Inhibitors (PIS) ☑️ Tipranavir ☑️ Saquinavir ☑️ Ritonavir ☑️ Fosamprenavir ☑️ Darunavir ☑️ Atazanavir | 77eed025-0f5c-4173-bf45-36e05a175aaf | |
Other HIV Drug Classes*** ☑️ Raltegravir ☑️ Dolutegravir ☑️ Maraviroc ☑️ Enfuvirtide ☑️ Other antiretroviral drug ☑️ Unknown |
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Treatment Supporter | ||
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Treatment Supporter Name __________________________________ | 160638AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA160638 Name of treatment supporter | |
Treatment Supporter Phone Number __________________________________ | 160642AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA160642 Telephone number of treatment supporter | |
Treatment Supporter Relationship 🔽 Sibling 🔽 Parent 🔽 Partner or spouse 🔽 Guardian 🔽 Grandparent 🔽 Other160640AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA | ||
Re-enrollment | ||
Date of Re-enrollment ␣␣-␣␣-␣␣␣␣ 📆20efadf9-86d3-4498-b3ab-7da4dad9c429 | ||
Reason For Re-enrolment __________________________________ | 14ae2dc9-5964-425a-87e8-9ca525cf055e162169 Text of encounter note | |
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