Training Toolkit HIV Care and Antiretroviral Treatment Recording and Reporting System
FORMS
2006
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Forms HIV Care and ART Recording and Reporting System
Patient Record Patient Booklet Pre-ART Register ART Register Drug Dispensing Register Drug Stock Register Monthly Report Cohort Report
Patient Record
9. Patient HIV care & Antiretroviral Treatment follow-up pregnancy (y/n) or FP method* opportunistic infections -code* Drugs prescribed for prophylaxis of Ols Antiretroviral drugs and dose prescribed adherence ART Side to ART* effects - code* - >95%, 80-95%, <80% lab results when available Condoms given y/n Referred to specialist or or hospital
Date of visit*
Date next visit
Weight (kg) & height for child
WHO stage
Performance scale*
*Instructions and codes: Date: Write the date of actual visit starting from the 1st visit for HIV care - ALL DATES: DD/MM/YY
Opportunistic infections: Enter one or more codes: Tuberculosis (TB); Candidiasis (C); Diarrhea (D); Cryptocococal meningitis (M); Pneumocystis Carinii Pneumonia (PCP); Cytomegalovirus disease (CMV); Penicilliosis (P); Herpes zoster (Z); Genital herpes (H); Toxoplasmosis (T); Other-specify Adherence: Check adherence by asking the patient if he/she has missed any doses. Also check the bottle/blister packet. Write the estimated level of adherence (e.g. >95% = < 3 doses missed in a period of 30 days; 80-95% = 3 to 12 doses missed in a period of 30 days; < 80% = >12 doses missed in a period of 30 days Side effects: Enter one or more codes: S=Skin rash; Nau-nausea; V=Vomiting; D=Diarrhoea; N=Neuropathy;J=Jaundice; A=Anemia; F=Fatigue; H=Headache; Fev=Fever; Hyp=Hypersensitivity; Dep=Depression; P=Pancreatitis; L=Lipodystrophy; Drows=Drowsiness; O=Other? Specify
Performance scale:
A- Normal activity; B- bedridden <50% of the day during last month; C- bedridden > 50% of the day during last month
FP:
family planning; 1 condoms, 2 oral contraceptive pills, 3 injectable/ implantable hormones, 4 diaphragm/cervical cap, 5 intrauterine device, 6 vasectomy/tubal ligation/hysterectomy
INFORMATION ABOUT ANTIRETROVIRAL DRUGS Dose ✦ ✦ ✦ ✦ ✦ ✦ ✦ ✦ ✦
Regimen d4T - related neuropathy or pancreatitis Substitute d4T to ZDV Substitute d4T to TDF or ABC Substitute NVP to EFV (except in pregnancy) Substitute NVP to EFV (except in pregnancy) Switch NVP to NFV Substitute ZDV to d4T ✦ ✦
Major Toxicity
Drug Substitution
D4T/3TC/NVP d4T -related lipoatrophy NVP -related severe hepatotoxicity NVP - related severe rash (but not life threatening) NVP -related life threatening rash (Stevens - Johnson syndrome) ZDV-related persistent GI intolerance or severe haemtological toxicity NVP-related severe hepatoxicity
✦
(Stavudine Lamuvidine Nevirapine)
d4T-3TC twice a day plus NVP 200 mg once a day for 2 weeks
✦
d4T-3TC-NVP Fixed dose combination twice a day if patient tolerates first 2 weeks of NVP ✦
✦
d4T: 30 mg twice daily if <60kg, 40mg twice daily if >60 kgg ✦ ✦
ZDV/3TC/NVP
✦
(Zidovudine Lamuvidine Nevirapine)
ZDV-3TC twice a day plus NVP 200 mg once a day for 2 weeks
✦ ✦ ✦
Substitute NVP to EFV (except in pregnancy. In this situation switch to NFV, LPV/r or ABC) ✦ ✦
ZDV-3TC-NVP Fixed dose combination twice a day if patient tolerates first 2 weeks of NVP NVP-related severe rash (but not life threatening)
Substitute NVP to EFV (except in pregnancy) Substitute NVP to NFV
NVP-related life threatening rash (Stevens - Johnson syndrome)
D4T/3TC/EFV ✦ ✦ ✦
✦
d4T-related neuropathy or pancreatitis d4T-related lipoatrophy EFV-related persistent CNS toxicity
✦ ✦ ✦
Substitute d4T to ZDV Substitute d4T to TDF or ABC Substitute EFV to NVP
(Stavudine Lamivudine Efavirenz)
d4T/3TC as twice daily fixed dose combination plus EFV (600 mg) once per day
✦
d4T: 30 mg twice daily if <60kg, 40mg twice daily if >60 kg ✦
ZDV/3TC/EFV ✦
✦
(Zidovudine Lamuvidine Efavirenz) EFV=Efavirenz; ZDV=Zidovudine;
ZDV-3TC twice a day as a fixed drug combination plus EFV (600 mg) once per day
ZDV-related persistent GI intolerance or severe hematological toxicity EFV-related persistent CNS toxicity LPV=Lopinavir; 3TC=Lamivudine NFV=Nelfinavir
✦
Substitute ZDV to d4T ✦
Substitute EFV to NVP
ABC= Abacavir; NVP= Nevirapine;
d4T= Stavudine; TDF=Tenofovir;
Patient Booklet
Antiretroviral Treatment Record (To retained by the patient) Name of treatment unit: District : State: Patient's name: Age: Complete Address: Village/town: District: ART Registration number: Date of enrollment for ART: dd Name of contact person/ guardian: Phone number of contact person/guardian: Address of contact person/guardian: mm yy State: Sex:
Patient’s photograph
Clinical Notes Date of visit: Chief Complaints: Investigations
Clinical examination:
Treatment
Remember ✦ ✦ ✦ ✦ ✦ ✦ ✦
Bring this booklet at each follow-up visit Take all medicines without missing any dose Take all medicines at the right time Take the full dose of medicines. DO NOT share medicines with family or friends Regular treatment can help you gain weight, feel better and resume normal activities Stick to a healthy and responsible life-style Bring empty blister packets/bottle at each follow-up visit
In case of emergency, contact : (Name, address and phone number of hospital/health worker): Come back on (Write date of next appointment) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.
Pre-ART Register
ART Register
Drug Dispensing Register
Antiretroviral Drug Dispensing Register (Maintain a separate page for each day)
Date: ______ /______ /______ Number of tablets dispensed (list to be adapted according to the drugs available) D4T 30mg/3TC/NVP D4T 40mg/3TC/NVP D4T 30mg/3TC D4T 40mg/3TC Other specify Other specify Other specify
Nevirapine
Reg. No.
Efavirenz
ZDV/3TC
Patient’s name
Patient’s signature
Total tablets dispensed Signature of the pharmacist/drug dispenser: ____________________________________
Drug Stock Register
Antiretroviral Drug Stock Register (Maintain a separate page for each drug)
Name of the drug Date Opening Stock Stock received Stock dispensed Stock expired/ discarded Balance stock
Total tablets dispensed Stock at the start of the month (A): Stock received during the month (B): Stock at the end of the month (A+B) — (C+D): Stock dispensed during the month (C): Stock expired/discarded during the month (D):
Monthly Report
Monthly HIV care/Antiretroviral treatment (ART) Centre Report 1. Name of the Treatment Unit 2. Name of the District 3. Name of the State/province 4. Name of the Treatment Unit incharge 5. Report for the period month A- MEDICAL CARE 6. Enrollment in HIV care (PLWHA seeking care at the treatment center) 6.1 Cumulative no. of patients ever enrolled in HIV care at beginning of this month 6.2 New patients enrolled in HIV care during this month 6.3 Cumulative no. of patients ever enrolled in HIV care at the end of this month 7. Medical eligibility for ART* 7.1 No. of patients medically eligible for ART but have not been started on ART at the end of this month 8. Enrollment on ART 8.1 Cumulative no. of patients ever started on ARTat the beginning of this month 8.2 New patients started on ART during this month 8.3 No. of patients on ART transferred in this month 8.4 Cumulative no. of patients ever started on ARTat the end of this month 9. outcomes on ART 9.1 Cumulative no. of death reported at the end of this month 9.2 Cumulative no. of patients transferred out under ARV at the end of this month 9.3 No. of patients missing/lost to follow-up at the end of this month 9.4 No. of patients stopping ART at the end of this month 9.5 No. of patients on ART at the end of this month ✦ ✦ ✦
year
adult male
adult female child.<14 yo
total
adult male
adult female child.<14 yo
total
adult male
adult female child.<14 yo
total
adult male
adult female child.<14 yo
total
9.5.1 Among them, no. on original 1st line regimen 9.5.2 No. on substituted 1st line regimen 9.5.3 No. switched on 2nd line regimen
* refers to the medical elligibility on clinical and/or laboratory criteriae, whether or not the patient is ready for ART
10. TREATMENT ADHERENCE 10.1. No. of patients assessed for adherence during this month 10.2. Of those assessed for adherence, level of adherence in the last month 10.2.1. < 3 doses missed in a period of 30 days 10.2.2 =3 to 12 doses missed in a period of 30 days 10.2.3. >12 doses missed in a period of 30 days > 95% 80-95% <80%
Total
B - PHARMACY 11. REGIMEN AT THE END OF THE MONTH Regimen D4T30/3TC/NEV D4T40/3TC/NEV ZDV/3TC/NEV ZDV/3TC/EFV D4T30/3TC/EFV D4T40/3TC/EFV No. of patients on ART
Total= No. of patients on ART at the end of this month (=9.5)
12. DRUG STOCKS Was there a stock-out of antiretroviral drugs this month? Was there a stock-out of drugs for opportunistic infection this month? Stock dispensed during the month ( C) Yes Yes Stock expired/ discarded during the month (D) No No Stock at the end of the month (A+B)-(C+D)
Name of the drug (list ARV and OI drugs)
Stock at the start of the month (A)
Stock received during the month (B)
Amount requested
Cohort Report