ART Therapy Form

Questions	Concept
What do you want to do? 🔘 Start ART 🔘 Substitute ART Regimen 🔘 Switch ART Regimen Line 🔘 Stop ART 🔘 Restart ART therapy	7557d77c-172b-4673-9335-67a38657dd01
Start ART
Date of ART initiation ␣␣-␣␣-␣␣␣␣ 📆	159599AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA
Regimen line 🔽 Adult 1st line ARV regimen 🔽 Child 1st line ARV regimen	164515AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA
Regimen 🔽 ABC + 3TC + ATVr 🔽 🔽 🔽	dfbe256e-30ba-4033-837a-2e8477f2e7cd
Switch ART Regimen Line
Date regimen line switched ␣␣-␣␣-␣␣␣␣ 📆	164516AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA
Reason for switching regimen line 🔘 Virologic failure 🔘 Immunologic failure	160568AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA
Regimen line 🔽 Adult 2nd line ARV regimen 🔽 Child 2nd line ARV regimen	164431AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA
Regimen 🔽 🔽 🔽 🔽
Substitute ART Regimen
Date regimen substituted ␣␣-␣␣-␣␣␣␣ 📆	164431AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA
Reason for substituting regimen 🔽 New diagnosis of Tuberculosis 🔽 Currently pregnant 🔽 Medications unavailable 🔽 Toxicity, drug 🔽 Other non-coded	160562AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA
Regimen line 🔽 Adult 1st line ARV regimen 🔽 Adult 2nd line ARV regimen 🔽 Child 1st line ARV regimen 🔽 Child 2nd line ARV regimen
Regimen 🔽 🔽 🔽 🔽
Stop ART - Refused treatment
Date patient refused HIV care/treatment ␣␣-␣␣-␣␣␣␣ 📆	162572AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA
Reason for discontinuing service (text) __________________________________	163513AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA
Restart ART
Date restarted ART ␣␣-␣␣-␣␣␣␣ 📆	160738AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA
Regimen line 🔽 Adult 1st line ARV regimen 🔽 Adult 2nd line ARV regimen 🔽 Child 1st line ARV regimen 🔽 Child 2nd line ARV regimen
Regimen 🔽 🔽 🔽 🔽
Reason for restarting ART __________________________________
Notes
Notes __________________________________