Ethiopia HIV Case Report Form for Newly Diagnosed HIV

Positive Individual

Instruction:
- The CRF will be completed only for clients who tested HIV positive for the first time.
- Repeat HIV positive testers should not be reported
- All dates need to be recorded consistently as DD/MM/YYYY (In Ethiopian Calendar)
- Section with asterisk “*” sign should be inquired from client, before the client leaves POC
- CRF will be archived securely once data entry has been performed
Verbal consent/assent (Section E&H will be completed after the client provides informed verbal consent or assent)
Provided by (Initials): _____________ Date: ________________ Provider Signature: _______
HIV CS ID----------------------
*Section A: Client Identifier (Information from this section will be used to uniquely identify a person and link their health information
(sentinel events from medical record system, or laboratory data system) overtime. Individual identifiers like name, Kebele ID, and
phone number will be removed from the analysis.)
1. Full Name: Name: ______________Father’s Name: ______________ Grand Father’s Name: ____________
2. Mother’s Name: _________________ Mother’s Father’s Name: ___________________
3. Place of birth: Region: ________ Zone/SC________ Woreda: ________ Town: _______ Kebele: __________
other country, specify ____________________
4. DOB : DD : __ MM : __ YYYY : ____ Age : ___ year(s), if under-five years, month (s) : ___
5. Sex : M F
6. Kebele identification number : _______ Not available
7. Medical record number (MRN) : _____________ Not available
8. Mobile phone number : _______________ Not available
Section B: Facility Information *Section C: Index Testing
1. Region: ___________Zone/SC________ Woreda_______ 1. Is this client contact of known
2. Facility Name: ______________ HIV positive person (index case)?
3. Facility code: _____________ Yes , No , If yes, Index
4. Point of HIV testing service where the case was diagnosed case unique ART
VCT ART ANC L&D PMTCT number:__________ Not
TB VMMC OPD Under-five OPD available (If client aged <5
IPD KP Clinic Others Specify: _____ years & identified through PMTCT:
Other HTS only HF Unique ART # of biological
Public Private Community DIC mother should be used)
*Section D : Demographic Information (Question # 5 & 6 are applicable for 15 years and above persons only)
1. Current Residence: 3. Type of Current Residence: 6. Current Marital Status
a. Region: _______ Rural Urban a. Never Married
b. Zone/SC________ 4. Housing Type b. Married
c. Woreda: ______ a. House/apartment/flat c. Living together
d. Town: _______ b. Prison d. Widow/widower
e. Kebele: ______ c. Homeless (not living in shelter) e. Divorced/separated
f. Other (specify) _________ d. Shelter (refugee or IDP centers)
2. Permanent Residence (if 5. Primary Occupation:
different from current): a. Govt/Non-govt org. 7. Education
a. Region: _______ b. Long Distance Drivers a. Not Applicable (<7
b. Zone/SC________ c. Drivers/ Driver Assistants (City Bus, years old)
c. Woreda: ______ Minibus, Bajaj, Motorcycle) b. No formal education
d. Town: _______ d. Student c. Primary
e. Kebele: ______ e. Daily Laborers d. Secondary
f. Other (specify) __________ f. Farmers e. Higher
g. Housewife
h. Female sex worker
i. Housemaid
j. Self-employed/private business
k. Wait staff/bartender
l. Unemployed/jobless
m. Other, specify _________
*Section E: Assessment for Potential Risk of Acquiring HIV
(if the age of the client is < 13 years, proceed to Q#9)
1. In the last 12 months, have you had sex ? If the response is other than yes, go to question # 8
Yes No Refused
2. With how many different people have you had sex within the last 12 months?
One Two or More Refused
3. Did you use a condom the last time you had sex?
Yes No Refused
4. In the last 12 months, have you ever received money, gifts, or other benefits from someone in exchange for sex?
Yes No Refused
5. If yes to Q4, in the last 12 months, was exchanging sex for money or other benefits ever your main weekly or
monthly source of income?
Yes No Refused
6. In the last 12 months, have you ever paid money or gifts (other benefits/favors) someone for sex?
 Yes No Refused
7. In the last 12 months, did you have sex with someone you know to be an HIV-positive person?
Yes No Refused Don’t know
8. In the last 12 months, have you injected any illicit drugs (for example, drugs not prescribed to you, such as heroin,
cocaine, morphine, or others) Yes No Refused
9. In the last 12 months, did you receive any blood transfusion, or invasive medical procedure?
Yes No Refused Not applicable
10. If the child is aged <5 years: Was client’s biological mother HIV-positive while she was pregnant or breastfeeding
the client/child? Yes No Don’t know
if Yes,
Known HIV+ before pregnancy Known HIV+ during pregnancy Known HIV+ sometime during labor
Known HIV+ after child’s birth HIV+ Time of diagnosis unknown
11. If the child is aged <5 years: Was this child breastfed? Yes No Unknown
12. If the child is aged <5 years: Has s/he ever taken ARV prophylaxis?
Yes No Don’t know

*Section F : History of HIV Testing and related Clinical Information

1. Have you ever been tested for HIV before your current visit? Yes No
2. If yes, date of most recent HIV-negative test in the last 12 Months: ____months ago
3. Ever been on Pre-exposure prophylaxis (PrEP) Yes No Refused Unknown
4. Ever been on ART Yes No Refused Unknown
5. If the client is a girl/woman ≥13 years of age, ask the pregnancy/breastfeeding status:
a. Not pregnant b. Pregnant c. Breastfeeding
Section G: HIV Diagnosis Information
HIV positive Test Date: DD____MM: ____ YYYY: ______ Test Type: Rapid PCR
Section H: HIV-1 Recent Infection Testing Algorithm (RITA) (15 years and above only)
Rapid test for recent infection (RTRI) Result:
Done: Test name: Test date: DD___MM: ___ YYYY: _____ Recent
Long-term
Not done: Reasons: Refused No test kit Other , specify ______ Inconclusive
Viral Load Testing (for RTRI recent cases only) VL Test Result (Copies/ml):
Done: Sample collection date: DD___MM: ___ YYYY: _____ ___________
VL result receiving date: DD___MM: ___ YYYY: _____ VL Result Other: ___________
Not done: Reason: Refused RTRI kit supply shortage specify ______
Section I: Clinical Information at the time of HIV diagnosis (To be completed by ART service provider)
WHO Stage: 1st CD4 count: Done: Not done: Presence of Opportunistic Infections:
I II If done, Sample Collection Date:
III IV DD____MM: ___YYYY: ____ Yes No Not Assessed
Count/l: ________
Not done:
Section J: Individual level response provided within 15 days of new HIV diagnosis (To be completed by ART service provider)
Linked to Care Index Case Testing (ICT)/Partner Notification Service (PNS):
Yes No ICT/PNS offered: Yes No
ART initiation Client Accepted: Yes No
Yes Date ICT/PNS accepted: DD____MM: ____ YYYY: _____
Unique ART number: ___________ # of Contacts (by age in years): ≥ 15 < 15
Initiation date: # of Contacts Elicited
DD____MM: ____ YYYY: ____ #Tested for HIV
Regimen: ___________ # HIV positive
No why? # HIV negative
In counselling
# Known positive
Referred
# All new and known positives linked to care
Deferred
If referred, to which HF_________ # All new and known positives started ART
# Eligible for PrEP ( i.e. FSW, sero-discordant couple)
# Started on PrEP
Section K: Data Management Information (to be completed by the Case Surveillance focal person (CS FP))
Date the completed form checked & approved: DD____MM: ____ YYYY: _____
Name of CS FP Checked and approved the completed form_______________
Phone number of facilities CS FP Approved the completed form____________
Date data entered to REDCap at HF: DD_______MM: _______ YYYY: __________
Name of the Data Clerk : ____________