Questions | Concepts | ||
|---|---|---|---|
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**CC 🔽 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***CC 🔽 d4T ABC + 3TC + NVPDTG HIV_Transfer_In_RegimenPatients Regimen 166521 DarunavirNVP | 164432 ARV regimen/code for drugs collected
| ||
Date of Enrolment into HIV Care ␣␣-␣␣-␣␣␣␣ 📆 | |||
HIV Diagnosis | |||
Date Confirmed HIV Positive ␣␣-␣␣-␣␣␣␣ 📆 | |||
Test Type 🔘 Rapid test for HIV 🔘 HIV DNA polymerase chain reaction 🔘 Unknown | |||
Previous ARV/HAART Use | |||
Use of Indication/intent of therapy ☑️ Pre Exposure Prophylaxis (PrEP) 🔘 Yes 🔘 No 🔘 Unknown | Use of ☑️ Prevention of Mother to Child Transmission (PMTCT) ☑️ Post-exposure prophylaxis (PEP)***CC 🔘 Yes 🔘 No 🔘 Unknown | 164845 Eligible for post-exposure prophylaxis
| |
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
| ||
Nucleoside Reverse Transcriptase Inhibitors (NRTIS)***CC | |||
Antiretroviral drugs used ☑️ Zidovudine ☑️ Tenofovir ☑️ Lamivudine ☑️ Emtricitabine ☑️ Abacavir ☑️ Other antiretroviral drug NRTIS Nucleoside Reverse Transcriptase Inhibitors (NRTIS) ARVs Other antiretroviral drug Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIS)***CC ☑️ Etravirine ☑️ Nevirapine ☑️ Efavirenz ☑️ Other antiretroviral drug ☑️ Unknown NNRTIS Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIS) ARVs Unknown Protease Inhibitors (PIS)***CC ☑️ Tipranavir ☑️ Saquinavir ☑️ Ritonavir ☑️ Fosamprenavir ☑️ Darunavir ☑️ Atazanavir ProteaseInhibitorsProtease Inhibitors (PIS) ARVs Atazanavir Other HIV Drug Classes ☑️ Raltegravir ☑️ Dolutegravir ☑️ Maraviroc ☑️ Enfuvirtide ☑️ Other antiretroviral drug ☑️ Unknown | 1193 Current drugs used1085 Antiretroviral drugs | ||
Treatment Supporter | |||
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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