HIV Care & Treatment Forms

HIV Enrollment Form

This form is used to enroll patients in HIV care, allowing them to access HIV-related clinical services. Details captured in this form include

• Client Profile: Population type, if they are new, transfer-in or re-enrolment after an interruption to treatment/ Stopping treatment, unique service identifier for the HIV clinic, and the service entry point.

• HIV Diagnosis/Linkage from HTS: When and where was the client confirmed HIV positive?

• Transfer-In details: Date the client started ART at the transferring facility, patient’s regimen at the time of referral, when the transfer-in client first enrolled into HIV care.

• Previous ARV/HAART Use: Previous use of PEP, PrEP, and HAART.

• Treatment Supporter details

ART Therapy Form

This form is used to capture detailed information about a patient's ART (Antiretroviral Therapy) treatment. It includes essential details such as

• ART Start date: The date when the patient was initiated on ART

• Regimen: A combination of HIV medicines used to manage HIV infection.

• Regimen Line: First line, Second line, Third line regimen.

• Reason for substitution, Change, or Stopping a regimen

• Documentation of treatment interruption.

Service Delivery Model Form

This form is used to capture detailed information on differentiated service delivery for HIV treatment, specifically for clients already on ART therapy. Based on clinical assessment, a healthcare provider can enroll or withdraw a client from differentiated service delivery. It includes essential details such as

• Date enrolled to DSD

• Type of DSD e.g Facility, Community

• Date disenrolled to DSD

• Reason for disenrolling from DSD

Transfer Out Form

This form is used to document the transfer of a client from one HIV clinic to another, ensuring continuity of care during the transition. It captures essential details such as

• Transfer-Out Date

• Receiving Facility

• Transfer-out Verification

Patient Tracing Form

This form is used to track and document efforts to trace a patient who has missed an appointment or medication pickup. It captures details about outreach attempts, reasons for the missed visit, and any follow-up actions taken to ensure the patient returns to care and continues their HIV treatment.

• Contact Date

• Contact Method

• Reasons for missing an appointment

• Tracing Outcome reached

Death Form

This form is used to document the cause of death of a patient with HIV. Key information captured include

• Date of death

• Cause of Death

Clinica Visit Form

This form is used to record patient findings during a clinical visit. It captures essential information such as presenting complaints, health assessments, observations, diagnoses, and treatment plans, facilitating comprehensive documentation of the patient's health status and ensuring continuity of care.

• Presenting Complaints

• Past Medical History

• Obstetrics and Gynecology (OBGYN) History

• Tuberculosis Screening, Prevention and Treatment

• Physical/Systemic Exam

• Management of OIs

Mental Health Assessment Form

This form is used for screening, diagnosing, monitoring, and assessing the severity of depression. Key information captured include

• Screening Date

• Patient’s Mental Health

• PHQ-9 Score

Disclosure Form

This form is used to record age-appropriate disclosure counseling for children and adolescents. It captures important information about the process, ensuring that the disclosure of an HIV diagnosis is conducted sensitively and tailored to the developmental stage of the child or adolescent.

• Date of Disclosure

• Stage of disclosure

Contact Tracing Form

This form is used to trace contacts of an index client, such as a child, sexual partner, or someone with whom they shared needles to encourage testing and access to HIV prevention or treatment services. It captures essential details about the contact, facilitating outreach and tracing efforts.

• Contact Date

• Contact Method

• Contact Tracing Outcome