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

🔽 Adult 1st line ARV regimen

🔽 Child 1st line ARV regimen

164855 ARV regimen or code patient is switched to

• 164506 Adult 1st line ARV regimen

• 164507Child 1st line ARV regimen

Regimen

🔽 ABC + 3TC + DTG
🔽 ABC + 3TC + EFV
🔽 ABC + 3TC + LPV/r
🔽 ABC + 3TC + NVP
🔽 AZT + 3TC + ATV/r
🔽 AZT + 3TC + DTG
🔽 AZT + 3TC + EFV
🔽 AZT + 3TC + LPV/r
🔽 AZT + 3TC + NVP
🔽 DRV/r + DTG + ABC + 3TC
🔽 DRV/r + DTG + AZT + 3TC
🔽 DRV/r + DTG + TDF + 3TC
🔽 DRV/r + RAL + AZT + 3TC
🔽 DRV/r + RAL + ABC + 3TC
🔽 DRV/r + RAL + TDF + 3TC
🔽 TDF + 3TC + ATV/r 164
🔽 TDF + 3TC + DTG
🔽 TDF + 3TC + EFV
🔽 TDF + 3TC + LPV/r
🔽 TDF + 3TC + NVP

164432 ARV regimen/code for drugs collected

167756 Abacavir / Dolutegravir / Lamivudine
162563 Abacavir / Efavirenz / Lamivudine
162200 Abacavir / Lamivudine / Lopinavir / Ritonavir
162199 Abacavir / Nevirapine / Lamivudine
164511 Atazanavir / Lamivudine / Ritonavir / Zidovudine
166087 Dolutegravir / Lamivudine / Zidovudine
160124 Efavirenz / Lamivudine / Zidovudine
162561 Lamivudine / Lopinavir / Ritonavir / Zidovudine
167740 Lamivudine / nevirapine / zidovudine
167444 Abacavir / Darunavir / Dolutegravir / Lamivudine / Ritonavir
167442 Darunavir / Dolutegravir / Lamivudine / Ritonavir / Zidovudine
166521 Darunavir / Dolutegravir / Lamivudine / Ritonavir / Tenofovir
166685 Darunavir / Lamivudine / Raltegravir / Ritonavir / Zidovudine
166683 Abacavir / Darunavir / Lamivudine / Raltegravir / Ritonavir
166522 Darunavir / Lamivudine / Raltegravir / Ritonavir / Tenofovir
164512 Atazanavir / Lamivudine / Ritonavir / Tenofovir
165086 Dolutegravir / Lamivudine / Tenofovir
164505 Lamivudine / Efavirenz / Tenofovir
162201 Lamivudine / Lopinavir / Ritonavir / Tenofovir
162565 Lamivudine / Nevirapine / Tenofovir

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

🔽 ABC + 3TC + DTG
🔽 ABC + 3TC + EFV
🔽 ABC + 3TC + LPV/r
🔽 ABC + 3TC + NVP
🔽 AZT + 3TC + ATV/r
🔽 AZT + 3TC + DTG
🔽 AZT + 3TC + EFV
🔽 AZT + 3TC + LPV/r
🔽 AZT + 3TC + NVP
🔽 DRV/r + DTG + ABC + 3TC
🔽 DRV/r + DTG + AZT + 3TC
🔽 DRV/r + DTG + TDF + 3TC
🔽 DRV/r + RAL + AZT + 3TC
🔽 DRV/r + RAL + ABC + 3TC
🔽 DRV/r + RAL + TDF + 3TC
🔽 TDF + 3TC + ATV/r 164
🔽 TDF + 3TC + DTG
🔽 TDF + 3TC + EFV
🔽 TDF + 3TC + LPV/r
🔽 TDF + 3TC + NVP

164432 ARV regimen/code for drugs collected

167756 Abacavir / Dolutegravir / Lamivudine
162563 Abacavir / Efavirenz / Lamivudine
162200 Abacavir / Lamivudine / Lopinavir / Ritonavir
162199 Abacavir / Nevirapine / Lamivudine
164511 Atazanavir / Lamivudine / Ritonavir / Zidovudine
166087 Dolutegravir / Lamivudine / Zidovudine
160124 Efavirenz / Lamivudine / Zidovudine
162561 Lamivudine / Lopinavir / Ritonavir / Zidovudine
167740 Lamivudine / nevirapine / zidovudine
167444 Abacavir / Darunavir / Dolutegravir / Lamivudine / Ritonavir
167442 Darunavir / Dolutegravir / Lamivudine / Ritonavir / Zidovudine
166521 Darunavir / Dolutegravir / Lamivudine / Ritonavir / Tenofovir
166685 Darunavir / Lamivudine / Raltegravir / Ritonavir / Zidovudine
166683 Abacavir / Darunavir / Lamivudine / Raltegravir / Ritonavir
166522 Darunavir / Lamivudine / Raltegravir / Ritonavir / Tenofovir
164512 Atazanavir / Lamivudine / Ritonavir / Tenofovir
165086 Dolutegravir / Lamivudine / Tenofovir
164505 Lamivudine / Efavirenz / Tenofovir
162201 Lamivudine / Lopinavir / Ritonavir / Tenofovir
162565 Lamivudine / Nevirapine / Tenofovir

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

🔽 ABC + 3TC + DTG
🔽 ABC + 3TC + EFV
🔽 ABC + 3TC + LPV/r
🔽 ABC + 3TC + NVP
🔽 AZT + 3TC + ATV/r
🔽 AZT + 3TC + DTG
🔽 AZT + 3TC + EFV
🔽 AZT + 3TC + LPV/r
🔽 AZT + 3TC + NVP
🔽 DRV/r + DTG + ABC + 3TC
🔽 DRV/r + DTG + AZT + 3TC
🔽 DRV/r + DTG + TDF + 3TC
🔽 DRV/r + RAL + AZT + 3TC
🔽 DRV/r + RAL + ABC + 3TC
🔽 DRV/r + RAL + TDF + 3TC
🔽 TDF + 3TC + ATV/r 164
🔽 TDF + 3TC + DTG
🔽 TDF + 3TC + EFV
🔽 TDF + 3TC + LPV/r
🔽 TDF + 3TC + NVP

164432 ARV regimen/code for drugs collected

167756 Abacavir / Dolutegravir / Lamivudine
162563 Abacavir / Efavirenz / Lamivudine
162200 Abacavir / Lamivudine / Lopinavir / Ritonavir
162199 Abacavir / Nevirapine / Lamivudine
164511 Atazanavir / Lamivudine / Ritonavir / Zidovudine
166087 Dolutegravir / Lamivudine / Zidovudine
160124 Efavirenz / Lamivudine / Zidovudine
162561 Lamivudine / Lopinavir / Ritonavir / Zidovudine
167740 Lamivudine / nevirapine / zidovudine
167444 Abacavir / Darunavir / Dolutegravir / Lamivudine / Ritonavir
167442 Darunavir / Dolutegravir / Lamivudine / Ritonavir / Zidovudine
166521 Darunavir / Dolutegravir / Lamivudine / Ritonavir / Tenofovir
166685 Darunavir / Lamivudine / Raltegravir / Ritonavir / Zidovudine
166683 Abacavir / Darunavir / Lamivudine / Raltegravir / Ritonavir
166522 Darunavir / Lamivudine / Raltegravir / Ritonavir / Tenofovir
164512 Atazanavir / Lamivudine / Ritonavir / Tenofovir
165086 Dolutegravir / Lamivudine / Tenofovir
164505 Lamivudine / Efavirenz / Tenofovir
162201 Lamivudine / Lopinavir / Ritonavir / Tenofovir
162565 Lamivudine / Nevirapine / Tenofovir

Stop ART

Date patient Stopped care/treatment

␣␣-␣␣-␣␣␣␣ 📆

162572 Date patient refused HIV care/treatment

Reason for discontinuing service

🔽 Cannot afford treatment
🔽 Change formulation
🔽 Completed total PMTCT
🔽 Currently pregnant
🔽 Inpatient care or hospitalization
🔽 Medications unavailable
🔽 Non-compliance with treatment or therapy
🔽 Other
🔽 Other patient decision
🔽 Planned treatment interruption
🔽 Refusal of treatment by patient
🔽 Regimen failure
🔽 "Toxicity drug"
🔽 Treatment never started - patient refused
🔽 Tuberculosis treatment started
🔽 Unknown

1252Reason antiretrovirals stopped

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

🔽 ABC + 3TC + DTG
🔽 ABC + 3TC + EFV
🔽 ABC + 3TC + LPV/r
🔽 ABC + 3TC + NVP
🔽 AZT + 3TC + ATV/r
🔽 AZT + 3TC + DTG
🔽 AZT + 3TC + EFV
🔽 AZT + 3TC + LPV/r
🔽 AZT + 3TC + NVP
🔽 DRV/r + DTG + ABC + 3TC
🔽 DRV/r + DTG + AZT + 3TC
🔽 DRV/r + DTG + TDF + 3TC
🔽 DRV/r + RAL + AZT + 3TC
🔽 DRV/r + RAL + ABC + 3TC
🔽 DRV/r + RAL + TDF + 3TC
🔽 TDF + 3TC + ATV/r 164
🔽 TDF + 3TC + DTG
🔽 TDF + 3TC + EFV
🔽 TDF + 3TC + LPV/r
🔽 TDF + 3TC + NVP

164432 ARV regimen/code for drugs collected

167756 Abacavir / Dolutegravir / Lamivudine
162563 Abacavir / Efavirenz / Lamivudine
162200 Abacavir / Lamivudine / Lopinavir / Ritonavir
162199 Abacavir / Nevirapine / Lamivudine
164511 Atazanavir / Lamivudine / Ritonavir / Zidovudine
166087 Dolutegravir / Lamivudine / Zidovudine
160124 Efavirenz / Lamivudine / Zidovudine
162561 Lamivudine / Lopinavir / Ritonavir / Zidovudine
167740 Lamivudine / nevirapine / zidovudine
167444 Abacavir / Darunavir / Dolutegravir / Lamivudine / Ritonavir
167442 Darunavir / Dolutegravir / Lamivudine / Ritonavir / Zidovudine
166521 Darunavir / Dolutegravir / Lamivudine / Ritonavir / Tenofovir
166685 Darunavir / Lamivudine / Raltegravir / Ritonavir / Zidovudine
166683 Abacavir / Darunavir / Lamivudine / Raltegravir / Ritonavir
166522 Darunavir / Lamivudine / Raltegravir / Ritonavir / Tenofovir
164512 Atazanavir / Lamivudine / Ritonavir / Tenofovir
165086 Dolutegravir / Lamivudine / Tenofovir
164505 Lamivudine / Efavirenz / Tenofovir
162201 Lamivudine / Lopinavir / Ritonavir / Tenofovir
162565 Lamivudine / Nevirapine / Tenofovir

Reason for restarting ART

__________________________________

161011 Free text comment

Notes

Notes

__________________________________

160632 Free text general