ART Therapy Form

What do you want to do?

🔘 Start ART

🔘 Substitute ART Regimen

🔘 Switch ART Regimen Line

🔘 Stop ART

🔘 Restart ART therapy

1255 Antiretroviral plan

• 1256 Start drugs

• 1258 Change formulation

• 1259 Change regimen

• 1260 Stop all

• 162904 Restart medication

Start ART

Date of ART initiation

␣␣-␣␣-␣␣␣␣ 📆

159599 Antiretroviral treatment start date

Regimen line***164855 instead of 164515

🔽 Adult 1st line ARV regimen

🔽 Child 1st line ARV regimen

164515 ARV regimen or code patient is switched to

• 164506 Adult 1st line ARV regimen

• 164507Child 1st line ARV regimen

Regimen***CC

🔽 ABC + 3TC + ATVr

🔽 ABC + 3TC + DRV+RTV+RAL

🔽 ABC + 3TC + DRVr

🔽 ABC + 3TC + DTG

🔽 ABC + 3TC + EFV

🔽 ABC + 3TC + LPV/r

🔽 ABC + 3TC + NVP

🔽 ABC + 3TC + RAL

🔽 AZT + 3TC + ATV/r

🔽 AZT + 3TC + DRV + RTV + RAL

🔽 AZT + 3TC + DTG

🔽 AZT + 3TC + EFV

🔽 AZT + 3TC + LPV/r

🔽 AZT + 3TC + NVP

🔽 AZT + 3TC + RAL

🔽 d4T + 3TC + EFV

🔽 d4T + 3TC + LPV/r

🔽 d4T + 3TC + NVP

🔽 ETV + 3TC + DRV + RTV

🔽 RAL + 3TC + DRV + RTV

🔽 RAL + 3TC + DRV + RTV + ABC

🔽 RAL + 3TC + DRV + RTV + AZT

🔽 RAL + 3TC + DRV + RTV + TDF

🔽 TAF + 3TC + DRV/r

🔽 TAF + 3TC + DTG

🔽 TAF + 3TC + LPV/r

🔽 TDF + 3TC + DTG + DRV + RTV

🔽 TDF + 3TC + DTG + ETR + DRV + RTV

🔽 TDF + 3TC + EFV

🔽 TDF + 3TC + LPV/r

🔽 TDF + 3TC + NVP

🔽 TDF + FTC + DTG

🔽 TDF + FTC + EFV

164432 ARV regimen/code for drugs collected

• ABC_3TC_ATVr

• 166683 Abacavir / Darunavir / Lamivudine / Raltegravir / Ritonavir

• ABC_3TC_DRVr

• ABC_3TC_DTG

• 162563 Abacavir / Efavirenz / Lamivudine

• 162200Abacavir / Lamivudine / Lopinavir / Ritonavir

• 162199 Abacavir / Nevirapine / Lamivudine

• 166686 Abacavir / Lamivudine / Raltegravir

• 164511 Atazanavir / Lamivudine / Ritonavir / Zidovudine

• 166685 Darunavir / Lamivudine / Raltegravir / Ritonavir / Zidovudine

• 166087 Dolutegravir / Lamivudine / Zidovudine

• 160124 Efavirenz / Lamivudine / Zidovudine

• 162561 Lamivudine / Lopinavir / Ritonavir / Zidovudine

• AZT_3TC_NVP

• AZT_3TC_RAL

• 160104 Efavirenz / Lamivudine / Stavudine

• 162560 Lamivudine / Lopinavir / Ritonavir / Stavudine

• d4T_3TC_NVP

• ETV_3TC_DRV_RTV

• RAL_3TC_DRV_RTV

• 166683 Abacavir / Darunavir / Lamivudine / Raltegravir / Ritonavir

• 166685 Darunavir / Lamivudine / Raltegravir / Ritonavir / Zidovudine

• RAL_3TC_DRV_RTV_TDF

• TAF_3TC_DRVr

• TAF_3TC_DTG

• TAF_3TC_LPVr

• TDF_3TC_DTG_DRV_RTV

• TDF_3TC_DTG_ETR_DRV_RTV

• 164505 Lamivudine / Efavirenz / Tenofovir

• 162201 Lamivudine / Lopinavir / Ritonavir / Tenofovir

• 162565 Lamivudine / Nevirapine / Tenofovir

• TDF_FTC_DTG

• TDF_FTC_EFV

Switch ART Regimen Line

Date regimen line switched

␣␣-␣␣-␣␣␣␣ 📆

164516 Date of switching to 2nd line ARV regimen

Reason for switching regimen line

🔘 Virologic failure

🔘 Immunologic failure

160568 Reason antiretrovirals changed to second line therapy

• 160569 Virologic failure

• 160566 Immunologic failure

Regimen line

🔽 Adult 2nd line ARV regimen

🔽 Child 2nd line ARV regimen

164515 ARV regimen or code patient is switched to

• 164513 Adult 2nd line ARV regimen

• 164514 Child 2nd line ARV regimen

Regimen***CC

🔽 ABC + 3TC + ATVr

🔽 ABC + 3TC + DRV+RTV+RAL

🔽 ABC + 3TC + DRVr

🔽 ABC + 3TC + DTG

🔽 ABC + 3TC + EFV

🔽 ABC + 3TC + LPV/r

🔽 ABC + 3TC + NVP

🔽 ABC + 3TC + RAL

🔽 AZT + 3TC + ATV/r

🔽 AZT + 3TC + DRV + RTV + RAL

🔽 AZT + 3TC + DTG

🔽 AZT + 3TC + EFV

🔽 AZT + 3TC + LPV/r

🔽 AZT + 3TC + NVP

🔽 AZT + 3TC + RAL

🔽 d4T + 3TC + EFV

🔽 d4T + 3TC + LPV/r

🔽 d4T + 3TC + NVP

🔽 ETV + 3TC + DRV + RTV

🔽 RAL + 3TC + DRV + RTV

🔽 RAL + 3TC + DRV + RTV + ABC

🔽 RAL + 3TC + DRV + RTV + AZT

🔽 RAL + 3TC + DRV + RTV + TDF

🔽 TAF + 3TC + DRV/r

🔽 TAF + 3TC + DTG

🔽 TAF + 3TC + LPV/r

🔽 TDF + 3TC + DTG + DRV + RTV

🔽 TDF + 3TC + DTG + ETR + DRV + RTV

🔽 TDF + 3TC + EFV

🔽 TDF + 3TC + LPV/r

🔽 TDF + 3TC + NVP

🔽 TDF + FTC + DTG

🔽 TDF + FTC + EFV

164432 ARV regimen/code for drugs collected

• ABC_3TC_ATVr

• ABC_3TC_DRV_RTV_RAL

• ABC_3TC_DRVr

• ABC_3TC_DTG

• ABC_3TC_EFV

• ABC_3TC_LPVr

• ABC_3TC_NVP

• ABC_3TC_RAL

• AZT_3TC_ATVr

• AZT_3TC_DRV_RTV_RAL

• AZT_3TC_DTG

• AZT_3TC_EFV

• AZT_3TC_LPVr

• AZT_3TC_NVP

• AZT_3TC_RAL

• d4T_3TC_EFV

• d4T_3TC_LPVr

• d4T_3TC_NVP

• ETV_3TC_DRV_RTV

• RAL_3TC_DRV_RTV

• RAL_3TC_DRV_RTV_ABC

• RAL_3TC_DRV_RTV_AZT

• RAL_3TC_DRV_RTV_TDF

• TAF_3TC_DRVr

• TAF_3TC_DTG

• TAF_3TC_LPVr

• TDF_3TC_DTG_DRV_RTV

• TDF_3TC_DTG_ETR_DRV_RTV

• TDF_3TC_EFV

• TDF_3TC_LPVr

• TDF_3TC_NVP

• TDF_FTC_DTG

• TDF_FTC_EFV

Substitute ART Regimen

Date regimen substituted

␣␣-␣␣-␣␣␣␣ 📆

164431 Date of ARV substitution

Reason for substituting regimen

🔽 New diagnosis of Tuberculosis

🔽 Currently pregnant

🔽 Medications unavailable

🔽 Toxicity, drug

🔽 Other non-coded

160562 Reason antiretrovirals changed for first line therapy

• 160567 New diagnosis of Tuberculosis

• 1434 Currently pregnant

• 1754 Medications unavailable

• 102 Toxicity, drug

• 5622 Other

Regimen line

🔽 Adult 1st line ARV regimen

🔽 Adult 2nd line ARV regimen

🔽 Child 1st line ARV regimen

🔽 Child 2nd line ARV regimen

164515 ARV regimen or code patient is switched to

• 164506 Adult 1st line ARV regimen

• 164513 Adult 2nd line ARV regimen

• 164507 Child 1st line ARV regimen

• 164514 Child 2nd line ARV regimen

Regimen***CC

🔽 ABC + 3TC + ATVr

🔽 ABC + 3TC + DRV+RTV+RAL

🔽 ABC + 3TC + DRVr

🔽 ABC + 3TC + DTG

🔽 ABC + 3TC + EFV

🔽 ABC + 3TC + LPV/r

🔽 ABC + 3TC + NVP

🔽 ABC + 3TC + RAL

🔽 AZT + 3TC + ATV/r

🔽 AZT + 3TC + DRV + RTV + RAL

🔽 AZT + 3TC + DTG

🔽 AZT + 3TC + EFV

🔽 AZT + 3TC + LPV/r

🔽 AZT + 3TC + NVP

🔽 AZT + 3TC + RAL

🔽 d4T + 3TC + EFV

🔽 d4T + 3TC + LPV/r

🔽 d4T + 3TC + NVP

🔽 ETV + 3TC + DRV + RTV

🔽 RAL + 3TC + DRV + RTV

🔽 RAL + 3TC + DRV + RTV + ABC

🔽 RAL + 3TC + DRV + RTV + AZT

🔽 RAL + 3TC + DRV + RTV + TDF

🔽 TAF + 3TC + DRV/r

🔽 TAF + 3TC + DTG

🔽 TAF + 3TC + LPV/r

🔽 TDF + 3TC + DTG + DRV + RTV

🔽 TDF + 3TC + DTG + ETR + DRV + RTV

🔽 TDF + 3TC + EFV

🔽 TDF + 3TC + LPV/r

🔽 TDF + 3TC + NVP

🔽 TDF + FTC + DTG

🔽 TDF + FTC + EFV

164432 ARV regimen/code for drugs collected

• ABC_3TC_ATVr

• ABC_3TC_DRV_RTV_RAL

• ABC_3TC_DRVr

• ABC_3TC_DTG

• ABC_3TC_EFV

• ABC_3TC_LPVr

• ABC_3TC_NVP

• ABC_3TC_RAL

• AZT_3TC_ATVr

• AZT_3TC_DRV_RTV_RAL

• AZT_3TC_DTG

• AZT_3TC_EFV

• AZT_3TC_LPVr

• AZT_3TC_NVP

• AZT_3TC_RAL

• d4T_3TC_EFV

• d4T_3TC_LPVr

• d4T_3TC_NVP

• ETV_3TC_DRV_RTV

• RAL_3TC_DRV_RTV

• RAL_3TC_DRV_RTV_ABC

• RAL_3TC_DRV_RTV_AZT

• RAL_3TC_DRV_RTV_TDF

• TAF_3TC_DRVr

• TAF_3TC_DTG

• TAF_3TC_LPVr

• TDF_3TC_DTG_DRV_RTV

• TDF_3TC_DTG_ETR_DRV_RTV

• TDF_3TC_EFV

• TDF_3TC_LPVr

• TDF_3TC_NVP

• TDF_FTC_DTG

• TDF_FTC_EFV

Stop ART

Date patient Stopped care/treatment

␣␣-␣␣-␣␣␣␣ 📆

162572 Date patient refused HIV care/treatment

Reason for discontinuing service (text)***why not 1252

__________________________________

163513 Reason for discontinuing service (text)

Restart ART

Date restarted ART

␣␣-␣␣-␣␣␣␣ 📆

160738 Date drug restarted

Regimen line

🔽 Adult 1st line ARV regimen

🔽 Adult 2nd line ARV regimen

🔽 Child 1st line ARV regimen

🔽 Child 2nd line ARV regimen

164515 ARV regimen or code patient is switched to

• 164506 Adult 1st line ARV regimen

• 164513 Adult 2nd line ARV regimen

• 164507 Child 1st line ARV regimen

• 164514 Child 2nd line ARV regimen

Regimen***CC

🔽 ABC + 3TC + ATVr

🔽 ABC + 3TC + DRV+RTV+RAL

🔽 ABC + 3TC + DRVr

🔽 ABC + 3TC + DTG <> 165606

🔽 ABC + 3TC + EFV <> 162563

🔽 ABC + 3TC + LPV/r <> 162200

🔽 ABC + 3TC + NVP <> 162199

🔽 ABC + 3TC + RAL <> 166686

🔽 AZT + 3TC + ATV/r

🔽 AZT + 3TC + DRV + RTV + RAL

🔽 AZT + 3TC + DTG

🔽 AZT + 3TC + EFV

🔽 AZT + 3TC + LPV/r

🔽 AZT + 3TC + NVP

🔽 AZT + 3TC + RAL

🔽 d4T + 3TC + EFV

🔽 d4T + 3TC + LPV/r

🔽 d4T + 3TC + NVP

🔽 ETV + 3TC + DRV + RTV

🔽 RAL + 3TC + DRV + RTV

🔽 RAL + 3TC + DRV + RTV + ABC

🔽 RAL + 3TC + DRV + RTV + AZT

🔽 RAL + 3TC + DRV + RTV + TDF

🔽 TAF + 3TC + DRV/r

🔽 TAF + 3TC + DTG

🔽 TAF + 3TC + LPV/r

🔽 TDF + 3TC + DTG + DRV + RTV

🔽 TDF + 3TC + DTG + ETR + DRV + RTV

🔽 TDF + 3TC + EFV <> 164505

🔽 TDF + 3TC + LPV/r

🔽 TDF + 3TC + NVP <> 162565

🔽 TDF + FTC + DTG <>

🔽 TDF + FTC + EFV

164432 ARV regimen/code for drugs collected

• ABC_3TC_ATVr

• ABC_3TC_DRV_RTV_RAL

• ABC_3TC_DRVr

• ABC_3TC_DTG

• ABC_3TC_EFV

• ABC_3TC_LPVr

• ABC_3TC_NVP

• ABC_3TC_RAL

• AZT_3TC_ATVr

• AZT_3TC_DRV_RTV_RAL

• AZT_3TC_DTG

• AZT_3TC_EFV

• AZT_3TC_LPVr

• AZT_3TC_NVP

• AZT_3TC_RAL

• d4T_3TC_EFV

• d4T_3TC_LPVr

• d4T_3TC_NVP

• ETV_3TC_DRV_RTV

• RAL_3TC_DRV_RTV

• RAL_3TC_DRV_RTV_ABC

• RAL_3TC_DRV_RTV_AZT

• RAL_3TC_DRV_RTV_TDF

• TAF_3TC_DRVr

• TAF_3TC_DTG

• TAF_3TC_LPVr

• TDF_3TC_DTG_DRV_RTV

• TDF_3TC_DTG_ETR_DRV_RTV

• TDF_3TC_EFV

• TDF_3TC_LPVr

• TDF_3TC_NVP

• TDF_FTC_DTG

• TDF_FTC_EFV

Reason for restarting ART

__________________________________

161011 Free text comment

Notes

Notes

__________________________________

160632 Free text general