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 ␣␣-␣␣-␣␣␣␣ 📆 | |||
Unique ID __________________________________ | |||
Other Unique ID __________________________________ | |||
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 | |||
Entry Point - Other __________________________________ | |||
Population Category 🔘 General population 🔘 Key population 🔘 Priority population | |||
Key Population Type 🔘 Intravenous drug user 🔘 Male who has sex with men 🔘 Prisoners 🔘 Sex worker 🔘 Transgender Persons | |||
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 | |||
Transfer-In | |||
Transferring Facility __________________________________ | |||
Start ART Date ␣␣-␣␣-␣␣␣␣ 📆 | |||
Current ART Regimen* **(Custom C) 🔽 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 | HIV_Transfer_In_RegimenPatients Regimen | ||
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Date of Enrolment into HIV Care ␣␣-␣␣-␣␣␣␣ 📆 | |||
HIV Diagnosis | |||
Date Confirmed HIV Positive ␣␣-␣␣-␣␣␣␣ 📆 | |||
Test Type 🔘 Rapid test for HIV 🔘 HIV DNA polymerase chain reaction 🔘 Unknown |
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Previous ARV/HAART Use | |||
Use of Pre Exposure Prophylaxis (PrEP) 🔘 Yes 🔘 No 🔘 Unknown | |||
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Use of Post-exposure prophylaxis (PEP)****CC 🔘 Yes 🔘 No 🔘 Unknown | 164845 Eligible for post-exposure prophylaxis
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ART Use for Prevention of Mother to Child Transmission of HIV***CC 🔘 Yes 🔘 No 🔘 Unknown | 163532 Mother enrolled in prevention of maternal to child transmission (PMTCT) program
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Nucleoside Reverse Transcriptase Inhibitors (NRTIS)***CC ☑️ 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)***CC ☑️ Etravirine ☑️ Nevirapine ☑️ Efavirenz ☑️ Other antiretroviral drug ☑️ Unknown | 9064043b-5b18-4228-97ff-f0e20aaf9448 NNRTIS Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIS) ARVs | ||
Protease Inhibitors (PIS)***CC ☑️ Tipranavir ☑️ Saquinavir ☑️ Ritonavir ☑️ Fosamprenavir ☑️ Darunavir ☑️ Atazanavir | 77eed025-0f5c-4173-bf45-36e05a175aaf | ||
Other HIV Drug Classes ☑️ Raltegravir ☑️ Dolutegravir ☑️ Maraviroc ☑️ Enfuvirtide ☑️ Other antiretroviral drug ☑️ Unknown | Treatment Supporter | ||
Treatment Supporter | Available|||
Treatment Supporter Name __________________________________ | |||
Treatment Supporter Phone Number __________________________________ | |||
Treatment Supporter Relationship 🔽 Sibling 🔽 Parent 🔽 Partner or spouse 🔽 Guardian 🔽 Grandparent 🔽 Other | |||
Re-enrollment | |||
Date of Re-enrollment ␣␣-␣␣-␣␣␣␣ 📆 | |||
Reason For Re-enrolment __________________________________ | |||
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