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 | 166937 Care management plan |
Enrolment Date ␣␣-␣␣-␣␣␣␣ 📆 | 160555 Date enrolled in HIV care |
Unique ID __________________________________ | 162576 New patient identifier |
Other Unique ID __________________________________ | 162727 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 service | 160540 Method of enrollment |
Entry Point - Other __________________________________ | 61011 Free text comment |
Population Category 🔘 General population 🔘 Key population 🔘 Priority population | 166432 Study population type |
Key Population Type 🔘 Intravenous drug user 🔘 Male who has sex with men 🔘 Prisoners 🔘 Sex worker 🔘 Transgender Persons | 166433 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 🔽 Other5682506 Priority Population Types | 166433 Target population type |
Transfer-In |
Transferring Facility __________________________________ | 160535 Transferred from location |
Start ART Date ␣␣-␣␣-␣␣␣␣ 📆 | 159599 Antiretroviral treatment start date |
Current ART Regimen*** 🔽 d4T ABC + 3TC + NVPDTG
🔽 TDF ABC + FTC 3TC + EFV
🔽 TDF ABC + FTC 3TC + DTGLPV/r
🔽 TDF ABC + 3TC + NVP
🔽 TDF AZT + 3TC + LPVATV/r
🔽 TDF + 3TC + EFV🔽 TDF AZT + 3TC + DTG + ETR + DRV + RTV
🔽 TDF AZT + 3TC + DTG + DRV + RTVEFV
🔽 TAF AZT + 3TC + LPV/r
🔽 TAF AZT + 3TC + DTGNVP
🔽 TAF + 3TC + DRV/r 🔽 RAL + 3TC DTG + DRV ABC + RTV + TDF3TC
🔽 RAL + 3TC + DRV/r + RTV DTG + AZT 🔽 RAL + 3TC + DRV + RTV
🔽 ETV DRV/r + 3TC DTG + DRV TDF + RTV3TC
🔽 AZT DRV/r + 3TC RAL + RAL🔽 AZT + 3TC + NVP
🔽 AZT + 3TC + LPVDRV/r 🔽 AZT + 3TC + EFV🔽 AZT RAL + ABC + 3TC + DTG
🔽 AZT DRV/r + 3TC RAL + DRV TDF + RTV + RAL3TC
🔽 AZT TDF + 3TC + ATV/r
🔽 ABC TDF + 3TC + RALDTG
🔽 ABC TDF + 3TC + NVPEFV
🔽 ABC TDF + 3TC + LPV/r
🔽 ABC TDF + 3TC + EFV 🔽 ABC + 3TC + DTG 🔽 ABC + 3TC + DRVr 🔽 ABC + 3TC + DRV+RTV+RAL 🔽 ABC + 3TC + ATVr | HIV_Transfer_In_RegimenPatients Regimen | Transfer Documents
🔘 Mother enrolled in prevention of maternal to child transmission (PMTCT) program
🔘 Transfer-in with Records
🔘 Transfer-in without records
| 7962d0ed-0fb5-4580-8e46-6fd318091154NVP
| 164432 ARV regimen/code for drugs collected |
Date of Enrolment into HIV Care ␣␣-␣␣-␣␣␣␣ 📆 | 163260 Date of first visit |
HIV Diagnosis |
Date Confirmed HIV Positive ␣␣-␣␣-␣␣␣␣ 📆 | 60554 160554 Date of HIV diagnosis |
Test Type*** 🔘 Rapid test for HIV 🔘 HIV DNA polymerase chain reaction 🔘 Unknown | 164401 HIV test performed | Test Location
__________________________________
| c4768674-0c26-4353-8a3f-608e7b40ac57 |
Previous ARV/HAART Use | |
Indication/intent of therapy ☑️ Pre Exposure Prophylaxis (PrEP) ☑️ Prevention of Mother to Child Transmission (PMTCT) ☑️ Post-exposure prophylaxis (PEP) | 160846 Indication/intent of therapy |
Use of Pre Exposure Prophylaxis (PrEP)
🔘 Yes
🔘 No
🔘 Unknown | 166655 Pre-exposure prophylaxis (PrEP) regimen
| Date Last Used
␣␣-␣␣-␣␣␣␣ 📆
| 5af829e9-2427-4ed7-bb55-de43816103641065 Yes
1066 No 1067 Unknown |
Use of Post-exposure prophylaxis (PEP)****CC
🔘 Yes
🔘 No
🔘 Unknown | 164845 Eligible for post-exposure prophylaxis
|
Date Last Used
␣␣-␣␣-␣␣␣␣ 📆
| fbe937b6-a4ad-4ce5-9c43-002222fbabfb
|
ARV Use for Management of Hepatitis
🔘 Yes
🔘 No
🔘 Unknown
| 906ed69c-949b-47b5-b469-2205f0da473a
|
Date Last Used
␣␣-␣␣-␣␣␣␣ 📆
| 6a6cbda5-b155-4144-9ff9-ec3d1d1cd5091065 Yes
1066 No 1067 Unknown |
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
| Date Last Used
␣␣-␣␣-␣␣␣␣ 📆
| 163782AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA1065 Yes
1066 No 1067 Unknown |
Nucleoside Reverse Transcriptase Inhibitors (NRTIS)***CC
☑️ Zidovudine
☑️ Tenofovir
☑️ Lamivudine
☑️ Emtricitabine
☑️ Abacavir
☑️ Other antiretroviral drug54e7ff9b-4d93-41ba-ad0b-cb5f565785f2 | NRTIS Nucleoside Reverse Transcriptase Inhibitors (NRTIS) ARVs
86663 Zidovudine 84796 Tenofovir disoproxil 78643 Lamivudine 75628 Emtricitabine 70056 Abacavir 5424 Other antiretroviral drug |
Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIS)***CC
☑️ Etravirine
☑️ Nevirapine
☑️ Efavirenz
☑️ Other antiretroviral drug
☑️ Unknown9064043b-5b18-4228-97ff-f0e20aaf9448 | NNRTIS Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIS) ARVs
159810 Etravirine 80586 Nevirapine 75523 Efavirenz 5424 Other antiretroviral drug 1067 Unknown |
Protease Inhibitors (PIS)***CC
☑️ Tipranavir
☑️ Saquinavir
☑️ Ritonavir
☑️ Fosamprenavir
☑️ Darunavir
☑️ Atazanavir77eed025-0f5c-4173-bf45-36e05a175aaf | ProteaseInhibitorsProtease Inhibitors (PIS) ARVs
85160 Tipranavir 83690 Saquinavir 83412 Ritonavir 76658 Fosamprenavir 74258 Darunavir 71647 Atazanavir |
Other HIV Drug Classes***
☑️ Raltegravir
☑️ Dolutegravir
☑️ Maraviroc
☑️ Enfuvirtide
☑️ Other antiretroviral drug
☑️ Unknown3509e1d9-93d0-4a6b-b5cb-90259699b01a | 1193 Current drugs used *** | Treatment Supporter | Treatment Supporter Available
🔘 Yes
🔘 No
| 0a540601-8cc4-4d18-9360-d760780f3eb1
154378 Raltegravir
165085 Dolutegravir 154376 Maraviroc 75676 Enfuvirtide 5424 Other antiretroviral drug 1067 Unknown |
Treatment Supporter | |
Treatment Supporter Name __________________________________ | 160638 Name of treatment supporter |
Treatment Supporter Phone Number __________________________________ | 160642 Telephone number of treatment supporter |
Treatment Supporter Relationship 🔽 Sibling 🔽 Parent 🔽 Partner or spouse 🔽 Guardian 🔽 Grandparent 🔽 Other | 160640 Treatment supporter relationship to patient |
Re-enrollment | |
Date of Re-enrollment ␣␣-␣␣-␣␣␣␣ 📆 | 160753 Date of event |
Reason For Re-enrolment __________________________________ | 162169 Text of encounter note160632 Free text general |