ART Therapy Form
- Veronica Muthee
- Wamathaga Kamau
Questions | Concepts |
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What do you want to do? 🔘 Start ART 🔘 Substitute ART Regimen 🔘 Switch ART Regimen Line 🔘 Stop ART 🔘 Restart ART therapy | |
Start ART |
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Date of ART initiation ␣␣-␣␣-␣␣␣␣ 📆 | |
Regimen line 🔽 Adult 1st line ARV regimen 🔽 Child 1st line ARV regimen | |
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 + ATVrTC + NVP | 164432 ARV regimen/code for drugs collected
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Switch ART Regimen Line |
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Date regimen line switched ␣␣-␣␣-␣␣␣␣ 📆 | |
Reason for switching regimen line 🔘 Virologic failure 🔘 Immunologic failure | 160568 Reason antiretrovirals changed to second line therapy |
Regimen line 🔽 Adult 2nd line ARV regimen 🔽 Child 2nd line ARV regimen | |
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 + ATVrTC + NVP | 164432 ARV regimen/code for drugs collected
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Substitute ART Regimen |
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Date regimen substituted ␣␣-␣␣-␣␣␣␣ 📆 | |
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 |
Regimen line 🔽 Adult 1st line ARV regimen 🔽 Adult 2nd line ARV regimen 🔽 Child 1st line ARV regimen 🔽 Child 2nd line ARV regimen | |
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 + ATVrTC + NVP | 164432 ARV regimen/code for drugs collected
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Stop ART |
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Date patient Stopped care/treatment ␣␣-␣␣-␣␣␣␣ 📆 | |
Reason for discontinuing service 🔽 Cannot afford treatment | |
Restart ART |
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Date restarted ART ␣␣-␣␣-␣␣␣␣ 📆 | |
Regimen line 🔽 Adult 1st line ARV regimen 🔽 Adult 2nd line ARV regimen 🔽 Child 1st line ARV regimen 🔽 Child 2nd line ARV regimen | |
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 + ATVrTC + NVPP | 164432 ARV regimen/code for drugs collected
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Reason for restarting ART __________________________________ | |
Notes |
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Notes __________________________________ | |
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