This tab describes the data that may be collected during care and treatment clinical visit for HIV workflow (HIV.D)

Whether visit was scheduled or unscheduled, clinical only, or for ARV drug pick-up

Is this is a scheduled visit?

Temperature of the client in Celsius

The number of breaths per minute

The number of heartbeats per minute

The client's height in centimetres

The client's current weight in kilograms

Systolic blood pressure (SBP) in mmHg

Diastolic blood pressure (DBP) in mmHg

If the client's blood pressure cannot be taken, this should be indicated here. Otherwise, blood pressure should be measured.

Signs that may indicate the client has a serious illness and needs triage or an emergency referral

Client is exhibiting another sign of a serious illness (specify)

Client is currently pregnant

Client is giving infant breast milk

Total number of times the woman has been pregnant (gravida)

Total number of pregnancies lost/ended due to miscarriages and/or abortions before 22 weeks/5 months

Total number of live births after 22 weeks

Calculated parity is the total number of live and stillbirths

Client's HIV status is different from a current partner's HIV status

Client is currently taking ART

The date on which the client started or restarted ART

Client stopped taking ART

Date on which client stopped ART

Is the client successfully established on ART?

Whether the client is ART naive or is restarting ART

The date on which the client was first initiated on ART

Time the client has been on ART since starting or restarting it in years and months

Date(s) client restarted ART after stopping (intentionally interrupting) for any number of reasons (see 'Reason ART stopped')

Month and year client originally started ART (documented) at a health facility in the system. The cohort is a group of patients who started ART in the same month (or quarter) and year, whose status is followed over time, using the ART register.

Client is transferring in with records or known ART drugs and ART start date

Date client presented at facility (with transfer/referral slip) from another facility (and on ART) within the system

Name of health facility client was transferred from

Date client first enrols in HIV care at the facility. Begins when a person with a confirmed HIV diagnosis presents to a facility where HIV care is provided and a medical record, patient card, file or chart is opened for the first time. This could be at an HIV care/ART, MNCH or TB clinic.

Client's age when the client was enrolled in ART care

Facility where the client first enrolled in HIV care

Whether or not the client received ARV drugs prior to enrolling into HIV care

Date ARV drugs were started prior to enrolment into HIV care/ART

Health facility (or other location) where ARV drugs were received prior to enrolment into HIV care/ART

ARV drug regimen received prior to enrolment into HIV care/ART

Does the client have any current chronic health conditions or problems?

Other health conditions not included in the list (specify)

Original full, first-line ARV drug regimen patient started on at this facility

The current ART regimen the client is taking

The date on which the client started taking the current ART regimen

The preferred first-line ART regimen for the client according to WHO (or national) guidelines

The alternative first-line ART regimen for the client according to WHO (or national) guidelines

The first-line ART regimen for the client under special circumstances according to WHO (or national) guidelines

The preferred second-line ART regimen for the client according to WHO (or national) guidelines

The alternative second-line ART regimen for the client according to WHO (or national) guidelines

The optimal regimen for transition to DTG-based regimens for children established on ART

ART regimen for treating clients living with HIV, based on national guidance

List of ART regimens

Other regimen based upon WHO recommendations (specify)

Drug composition of client's current ART regimen

Drug class of current ART regimen

Offer or refer for prevention services

Offer or refer to sexual and reproductive health services

Date client was tested for hepatitis B virus (HBV)

Hepatitis B virus test result (HBsAg)

Date HBV test result (HBsAG) was returned to client

Date when client started treatment (TDF) for hepatitis B virus (HBV)

Hepatitis B virus treatment regimen prescribed

Date client was tested for hepatitis C virus (HCV antibody, HCV RNA or HCV core antigen)

Hepatitis C virus test result (HCV antibody, HCV RNA or HCV core antigen)

Date HCV test result was returned to client

Date when client started treatment for hepatitis C virus (HCV)

Date when client completed treatment for hepatitis C virus (HCV)

Hepatitis C virus treatment regimen prescribed

Hepatitis C viral load test date

Hepatitis C viral load test result (qualitative)

Type of medicine client is prescribed

Client is currently on TDF-based ART regimen

WHO clinical stage of client based on signs and symptoms. WHO clinical staging is a way to categorize HIV disease severity based on new or recurrent clinical events. There are 4 WHO clinical stages that range from mild symptoms (WHO clinical stage 1) to severe symptoms (WHO clinical stage 4).

Number of doses of antiretroviral therapy (ART) the client missed since the last visit, used for monitoring adherence

Client received results from viral load test

The date on which the client received results from viral load test

Date and time when the sample was collected to test the client's HIV viral load

Expected date when client's viral load test results will be returned and reviewed

Date of client's ART interruption (ART stop or missed drug pick-up)

Reason why client was not adherent

Client reported not being adherent because of other reason for nonadherence (specify)

Reason client intentionally stopped ART

Client stopped ART because of other reason (specify)

ART treatment failure

General care activities to be performed during the care visit

Coinfection prevention and treatment activities performed during the care visit

Signs and symptoms of opportunistic infections or other comorbidities experienced by client

Other comorbidities or coinfection signs or symptoms (specify)

New or recurrent clinical events used to categorize HIV disease severity based at baseline and follow up

WHO clinical stage of client based on signs and symptoms at start of ART

Date on which the client's WHO HIV clinical stage changed, including the date when the client's stage is first determined

CD4 cell count in cells/mm^3

CD4 cell percentage

Date and time when CD4 count test was conducted

CD4 count performed at HIV diagnosis

Date and time when baseline CD4 count test was conducted

Client had late ART initiation. That is, the client's first CD4 count from baseline CD4 test performed (such as at HIV diagnosis) was a count of <200 cells/mm3

Reason why ART was not initiated at diagnosis or within 7 days of diagnosis

Client did not initiate ART at diagnosis or within 7 days of diagnosis because of other reason (specify)

Client initiated ART within 7 days of diagnosis

Time from HIV diagnosis to when client started ART

Result from the viral load test in number of copies/mL

The client is virally suppressed for HIV, based on the client's most recent viral load test result being less than 1000 copies/mL

Date the viral load test result was received from the lab or completed in the facility

Date on which the client tested as becoming virally suppressed, as indicated by a viral load test result under 1000 copies/mL

Whether the viral load is being tested for routine monitoring on a set schedule or for targeted monitoring for suspected treatment failure

Hepatitis B test is required

Hepatitis C test is recommended or should be considered

Syphilis test is required

Name of examinations, test and results for any relevant investigations carried out for client

Date of scheduled monitoring examination

Hepatitis C test has been ordered

Syphilis test has been ordered

Client received results from viral load test

The date on which the client received results from a viral load test

Reason why a substitution was made to the antiretroviral (ARV) drug regimen

A substitution was made for another reason (specify)

A switch to second-line ART regimen is recommended

A switch to third-line ART regimen is recommended

Provider has made a regimen switch

Reason why a switch to a second- or third-line regimen was made

A switch was made to the regimen for another reason (specify)

A drug substitution is recommended

A dosage change is recommended

Provider has made a regimen substitution

Date co-trimoxazole prophylaxis prescribed to client

Completion date of co-trimoxazole prophylaxis prescribed to client

Dose of co-trimoxazole prophylaxis prescribed to client

Number of days of co-trimoxazole prophylaxis prescribed to client

Client has been on ART, but has stopped taking it or a treatment failure is suspected

INCLUDE VALUE SETS OF REGIMENS

Client is experiencing antiretroviral drug (ARV) toxicity

Clients status of coinfections at the time when ART was initiated

ART status of women to prevent mother-to-child transmission

Date of delivery/birth of infant if breastfeeding at ART start

Client living with HIV was in an ongoing sexual relationship with an HIV-negative partner when ART was started

The date on which the client started taking the current ART regimen

Name or regimen code of all other medications prescribed during the visit

Date the medications were prescribed

Number of doses (quantity taken at a single point in time) of drugs prescribed/dispensed

Number of days supply of each medication or regimen prescribed during the visit

Any other medications that were dispensed to client, including preventive treatment

Number of days supply of each medication or regimen dispensed during the visit

Prescribed dosage of the medication

Prescribed frequency for taking the medication

Counselling was carried out during visit

Type of treatment-limiting toxicity experienced by client. Treatment-limiting toxicity is defined as a serious adverse drug reaction that results in drug discontinuation or substitution. In addition, any reaction that leads to treatment interruption or requires changing the drug or regimen because of an adverse drug reaction is also considered a serious adverse drug reaction.

Specify the type of unexpected adverse drug reaction the client experienced

Date on which ARV drug regimen (one or more drugs) for client was changed within the first-line regimen (substitution)

Reason(s) why one ore more drugs in client's first-line ARV drug regimen was changed (substituted)

New antiretroviral (ARV) drugs after client changed regimen within the first-line regimen

Date client was changed from a first-line to second-line ARV drug regimen (switch)

New ART regimen after switch to second-line ART regimen

Reason why client was switched from first- to second-line ARV drug regimen (see 'Reason for regimen switch' for levels)

Date on which ARV drug regimen for client was changed within the second-line regimen (substitution)

Reason(s) why client changed drug regimen (within the second-line)

New ARV drugs after client changed regimen within the second- line regimen

Date client was changed from a second- to third-line ARV drug regimen (switch)

New ART regimen after switch to third-line ART regimen

Reason why client was switched from second- to third-line ARV drug regimen (see 'Reason for regimen switch' for levels)

Date on which ARV drug regimen for client was changed within the third-line (substitution)

Reason(s) why client changed drug regimen (within the third-line)

New ARV drugs after client changed regimen within the third-line regimen

Enhanced adherence counselling was provided to the client during the visit

A first enhanced adherence counselling was provided to the client during the visit

The date on which the first enhanced adherence counselling was provided to the client

A second enhanced adherence counselling was provided to the client during the visit

The date on which the second enhanced adherence counselling was provided to the client

A third enhanced adherence counselling was provided to the client during the visit

The date on which the third enhanced adherence counselling was provided to the client

Full name of person providing support to client for adherence, care, treatment and other needs (e.g. ARV pick-up if ill)

Full address or description of home of treatment supporter

Telephone number if available, or else telephone number of neighbour/friend

Name of individual or organization that provides home-based care to client

Counselling provided on diagnoses

Whether counselling was provided to a client who has been diagnosed with hepatitis B

Whether counselling was provided to a client who has been diagnosed with hepatitis C

Whether counselling and treatment was provided to a client who has been diagnosed with syphilis

Whether counselling and treatment was provided to a client who has been diagnosed with syphilis. Additional testing (RPR test) recommended.

Client accepted offer for partner services

Offer voluntary testing for all partners and biological children of positive cases (includes partner services and index case testing), as well as partners and social contacts of people from key populations, where appropriate

HIV status of each family member at time of patient's enrolment, including partner (for mothers)

Unique ID number of each family member if enrolled in HIV care according to national guidelines (see unique ID number)

Date of death for each family member as appropriate

Whether the client was offered voluntary partner services or family services

Offer or refer for support for disclosure and partner services

Offer or refer for other support services

Date the client is to return for monitoring, re-supply or any other reason

Whether the visit will be clinical only, ARV drug pick-up or other. Client may have multiple follow-ups scheduled.

Other reason for the follow-up appointment (specify)

A test or screening recommended for the client's care plan at a future date

Reason why test was not performed

Other reason blood pressure can not be taken (specify)

List of all of the medications the client is currently taking

Other medications or supplements that are not listed above (specify)

Does the client have any allergies?

Client has other allergies not listed here (specify)

Method the client reports currently using at intake

Current state of the client's taking of the medication

Hepatitis B negative counselling conducted

The brand or trade name used to refer to the vaccine received

Type of vaccine received (such as IPV, OPV)

Represents the visit/encounter date, which is the date and time when the vaccine was administered to the client

The service delivery location where the vaccine adminstration occurred

Vaccine dose number within series

The quantity of vaccine product that was administered

The recommended number of vaccine doses for immunity according to national protocol

Vaccine preventable disease being targeted by vaccine administered

Reason the vaccine dose was not given

Other reason why the immunization was not provided (specify)

Whether malaria prophylaxis was given

IPTp-SP dose number that was provided

Date on which the IPTp-SP dose was provided

Reason why the treatment was not given

Other reason why the prophylaxis was not provided

More than 28 days have passed since client's last missed appointment

Death of client was AIDS-related

Date of client's first AIDS diagnosis

Client's age at date received final HPV vaccination dose

Date of cervical cancer screening test

Client's lifetime number of screenings for cervical cancer

Type of cervical cancer screening test used in primary screening

Screened for cervical cancer using other method (specify)

HPV-DNA cervical cancer screening test result