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 ␣␣-␣␣-␣␣␣␣ 📆 | 160555AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA |
Unique ID __________________________________ | 162576AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA |
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 | 160540AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA |
Population Category 🔘 General population 🔘 Key population 🔘 Priority population | 746737c0-4201-4d7f-b580-816e36dc425a |
Key Population Type 🔘 Intravenous drug user 🔘 Male who has sex with men 🔘 Prisoners 🔘 Sex worker 🔘 Transgender Persons | d3d4ae96-8c8a-43db-a9dc-dac951f5dcb3 |
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 __________________________________ | 160535AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA |
Start ART Date ␣␣-␣␣-␣␣␣␣ 📆 | 159599AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA |
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 |
Transfer Documents 🔘 Mother enrolled in prevention of maternal to child transmission (PMTCT) program 🔘 Transfer-in with Records 🔘 Transfer-in without records | 7962d0ed-0fb5-4580-8e46-6fd318091154 |
Date of Enrolment into HIV Care ␣␣-␣␣-␣␣␣␣ 📆 | 163260AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA |
HIV Diagnosis | |
Date Confirmed HIV Positive ␣␣-␣␣-␣␣␣␣ 📆 | 160554AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA |
Test Type 🔘 Rapid test for HIV 🔘 HIV DNA polymerase chain reaction 🔘 Unknown | ca4953af-9ad4-4514-b54a-6832acd7cae9 |
Test Location __________________________________ | c4768674-0c26-4353-8a3f-608e7b40ac57 |
Previous ARV/HAART Use | |
Use of Pre Exposure Prophylaxis (PrEP) 🔘 Yes 🔘 No 🔘 Unknown | 5d397775-0155-4033-95dc-edcec98e8190 |
Date Last Used ␣␣-␣␣-␣␣␣␣ 📆 | 5af829e9-2427-4ed7-bb55-de4381610364 |
Use of Post-exposure prophylaxis (PEP) 🔘 Yes 🔘 No 🔘 Unknown | 8bfdc328-1970-446c-9d7b-97d62703801b |
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-ec3d1d1cd509 |
ART Use for Prevention of Mother to Child Transmission of HIV 🔘 Yes 🔘 No 🔘 Unknown | 163532AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA |
Date Last Used ␣␣-␣␣-␣␣␣␣ 📆 | 163782AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA |
Nucleoside Reverse Transcriptase Inhibitors (NRTIS) ☑️ Zidovudine ☑️ Tenofovir ☑️ Lamivudine ☑️ Emtricitabine ☑️ Abacavir ☑️ Other antiretroviral drug | 54e7ff9b-4d93-41ba-ad0b-cb5f565785f2 |
Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIS) ☑️ Etravirine ☑️ Nevirapine ☑️ Efavirenz ☑️ Other antiretroviral drug ☑️ Unknown | 9064043b-5b18-4228-97ff-f0e20aaf9448 |
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 | 3509e1d9-93d0-4a6b-b5cb-90259699b01a |
Treatment Supporter | |
Treatment Supporter Available 🔘 Yes 🔘 No | 0a540601-8cc4-4d18-9360-d760780f3eb1 |
Treatment Supporter Name __________________________________ | 160638AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA |
Treatment Supporter Phone Number __________________________________ | 160642AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA |
Treatment Supporter Relationship 🔽 Sibling 🔽 Parent 🔽 Partner or spouse 🔽 Guardian 🔽 Grandparent 🔽 Other | 160640AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA |
Re-enrollment | |
Date of Re-enrollment ␣␣-␣␣-␣␣␣␣ 📆 | 20efadf9-86d3-4498-b3ab-7da4dad9c429 |
Reason For Re-enrolment __________________________________ | 14ae2dc9-5964-425a-87e8-9ca525cf055e |
General
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