|
String
|
Linea di divisione
|
1
|
|
0
|
|
|
|
|
Psychosocial/Knowledge Criteria (applies to patients and caregivers)
|
|
|
|
|
|
| | | |
|
Boolan (Yes/No)
|
Select
|
2
|
vb1
|
0
|
|
|
|
|
1. Understands the nature of HIV infection and benefits of ART
|
|
|
|
|
|
| | | |
|
Boolan (Yes/No)
|
Select
|
3
|
vb2
|
0
|
|
|
|
|
2. Has screened negative for alcohol or other drug use disorder, or is established on treatment
|
|
|
|
|
|
| | | |
|
Boolan (Yes/No)
|
Select
|
4
|
vb3
|
0
|
|
|
|
|
3. Has screened negative for depression or other psychiatric illness, or is established on treatment
|
|
|
|
|
|
| | | |
|
Boolan (Yes/No)
|
Select
|
5
|
vb4
|
0
|
|
|
|
|
4. Is willing to disclose/has disclosed HIV status, ideally to a family member or close friend?
|
|
|
|
|
|
| | | |
|
Boolan (Yes/No)
|
Select
|
6
|
vb5
|
0
|
|
|
|
|
5. Has received demonstration of how to take/administer ART and other prescribed medication?
|
|
|
|
|
|
| | | |
|
Boolan (Yes/No)
|
Select
|
7
|
vb6
|
0
|
|
|
|
|
6. Has received information on predictable side effects of ART and understands what steps to take in case of these side effects?
|
|
|
|
|
|
| | | |
|
Boolan (Yes/No)
|
Select
|
8
|
vb7
|
0
|
|
|
|
|
7. For patients dependent on a caregiver: caregiver is committed to long-term support of the patient, daily administration of ART, and meets the criteria above?
|
|
|
|
|
|
| | | |
|
Boolan (Yes/No)
|
Select
|
9
|
vb8
|
0
|
|
|
|
|
8. Other likely barriers to adherence have been identified and there is a plan in place to address them (e.g. frequent travel for work, plan to deal with unexpected travel, distance from clinic, etc)?
|
|
|
|
|
|
| | | |
|
Boolan (Yes/No)
|
Select
|
10
|
vb9
|
0
|
|
|
|
|
9. Patient/caregiver has provided accurate locator information and contact details?
|
|
|
|
|
|
| | | |
|
Boolan (Yes/No)
|
Select
|
11
|
vb10
|
0
|
|
|
|
|
10. Patient/caregiver feels ready to start ART today?
|
|
|
|
|
|
| | | |
|
String
|
Linea di divisione
|
12
|
|
0
|
|
|
|
|
Support Systems Criteria (applies to patients and caregivers)
|
|
|
|
|
|
| | | |
|
Boolan (Yes/No)
|
Select
|
13
|
vb11
|
0
|
|
|
|
|
1. Has identified convenient time/s of day for taking ART, and/or associated dose/s with daily event/s
|
|
|
|
|
|
| | | |
|
Boolan (Yes/No)
|
Select
|
14
|
vb12
|
0
|
|
|
|
|
2. Treatment supporter has been identified and engaged in HIV education, or will attend next counselling session?
|
|
|
|
|
|
| | | |
|
Boolan (Yes/No)
|
Select
|
15
|
vb13
|
0
|
|
|
|
|
3. Is aware of support group meeting time/s?
|
|
|
|
|
|
| | | |
|
Boolan (Yes/No)
|
Select
|
16
|
vb14
|
0
|
|
|
|
|
4. If facility has SMS reminder system: Has enrolled into SMS reminder system?
|
|
|
|
|
|
| | | |
|
Boolan (Yes/No)
|
Select
|
17
|
vb15
|
0
|
|
|
|
|
5. Other support systems are in place or planned (e.g. setting phone alarm, pill box)?
|
|
|
|
|
|
| | | |
|
String
|
Linea di divisione
|
18
|
|
0
|
|
|
|
|
Medical Criteria (applies to patients)
|
|
|
|
|
|
| | | |
|
Boolan (Yes/No)
|
Select
|
19
|
vb16
|
0
|
|
|
|
|
1. Newly diagnosed with TB:defer ART until patient tolerates anti-TB medication; initiate ART as soon as possible preferably within 2 weeks; for TB meningitis delay ART for 4 to 8 weeks); monitor closely for IRIS
|
|
|
|
|
|
| | | |
|
Boolan (Yes/No)
|
Select
|
20
|
vb17
|
0
|
|
|
|
|
2. Newly diagnosed cryptococcal meningitis (CM), or symptoms consistent with CM (progressive headache, fever, malaise, neck pain, confusion): defer ART until completed 5 weeks of CM treatment, or until ruling out CM as the cause of symptoms; monitor closely for IRIS
|
|
|
|
|
|
| | | |
|
String
|
Linea di divisione
|
21
|
|
0
|
|
|
|
|
*If the response to any of the psychosocial criteria or support systems criteria is "No”: develop a strategy to address the issue as quickly as possible and consider assigning a case manager. ART may be initiated with adequate adherence support while the criteria is being addressed, on a case-by-case basis
|
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| | | |
