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Microsoft word - hivqual_u_paper_abstract_form_v4

HIVQUAL-U Manual Data Collection Form (version 4)
Adult/Adolescent
Start Date: XX/ XX/ XXXX
End Date: XX/XX/XXXX


Patient Profile

Patient Data Entry Screen 1: “Monitoring HIV Status and Continuity of Care”
1.1 Did the patient have any CD4 counts during the review period? … Yes … No … Not stated
If no, go to 1.1.2
1.1.1 (If yes in 1.1) Record CD4 counts from tests during the review period only:

1.1.2
(If No in 1.1) Are Total lymphocyte counts available for this patient during review period? … Yes … No … Not stated
If yes, go to 1.1.2.1,
if no or “not stated”, go to 1.2
1.1.2.1 (If yes in 1.1) Record TLC results from tests during the review period only:
1.2 Did the patient visit for medical care in the past 6 months? … Yes … No … Not stated
1.2.1 Record visit dates and WHO Clinical staging at each visit in the past 12 months:
Patient Data Entry Screen 2: Prevention Education and Prophylaxis
2.1 Was HIV prevention discussed in the last 3 months? … Yes … No … Not stated
Prevention education includes talks on
Abstinence, Faithfulness, Condom use VCT – Child’s blood tests and Testing partners 2.2. Was cotrimoxazole prescribed to the patient in the last 6 months? … Yes … No … Not stated
Patient Data Entry Screen 3: “Anti-retroviral Therapy and Adherence”

3.1 Was the patient on ARV therapy (other than PMTCT) during the review period? … Yes … No … Not
stated
If yes, go to 3.1.1
If no or “not stated,”, stop
3.1.1 Is the patient still on ARV therapy at the end of the review period? … Yes … No … Not

3.1.2 Report all ARV regimens received during the review period, with starting date and ending
date (if applicable). Each line should include a complete regimen (not just a new single drug). Do not include ARV taken solely to prevent mother-to-child transmission of HIV. Select drug regimens or individual drugs from the pop-up menu • Trimune (d4T+3TC+NVP)
Combivir (AZT+3TC), also known as Zarlivir
Trivada (TDF+3TC+EMC)
Trizivir (AZT+3TC+NVP)
SQV Saquinavir, Invirase, Fortovase
RTV Ritonavir, Norvir
NFV Nelfinavir, Viracept
3TC Lamivudine, Lamivir, Epivir
Kaletra
TDF Tenofovir, Viread (used in clinical boosted Lopinavir
trials only)
NVP Nevirapine, Viramune
Specified other drug
“Specify______________________________”
3.2. Was patient adherence to ARV therapy assessed in the last 2 quarters during the review period? • If no or “not stated,” go to 4.1
3.3. What was the score at the last adherence assessment in the review period? … Good … Fair … Poor SCORE GUIDE
SCORE PERCENTAGE
Good

Patient Data Entry Screen 4: “TB”

4.1 Was the patient assessed for clinical symptoms or risk factor for TB during the review period? … Yes … No … Not stated • If yes go to 4.1.1
Clinical Symptoms
Risk factors
Contact with individuals with active TB 4.1.1 (If yes) was the patient screened for TB? … Yes … No … Not stated 4.1.1.1 Was the patient screened by chest x-ray? … Yes 4. 1.1.2 Was the patient screened by sputum AFB? … Yes 4. 1.1.3 Did the patient diagnosed TB disease? … Yes 4.2 Was the patient treated for active TB? … Yes … No … Not stated

Source: http://nationalqualitycenter.org/hivqualtest/files/7312/HIVQUAL_U_paper_abstract_form_V4.pdf

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