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pdfAttachment 3(f)
Adult and Pediatric HIV/AIDS Confidential Case Reports
for National HIV/AIDS Surveillance OMB No. 0920-0573
Supplemental Surveillance Activity 3:
Enhanced Perinatal Surveillance (EPS) Data Collection Form
1
Form Approved
OMB No. 0920-0573
Expiration Date XX/XX/20XX
Adult and Pediatric HIV/AIDS Confidential Case Reports
for National HIV/AIDS Surveillance
Enhanced Perinatal Surveillance (EPS) Data Collection Form
Public reporting burden of this collection of information is
estimated to average 60 minutes per response, including the time
for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and
reviewing the collection of information. An agency may not
conduct or sponsor, and a person is not required to respond to a
collection of information unless it displays a currently valid
OMB control number. Send comments regarding this burden estimate
or any other aspect of this collection of information, including
suggestions for reducing this burden to CDC/ATSDR Reports
Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta,
Georgia 30333; Attn: OMB-PRA (0920-0573)
2
Infant State No. ____________________________
U.S. Department of Health
& Human Services
Centers for Disease Control
and Prevention
New
Form Approved OMB No. 0920-0573 Exp. Date XX/XX/20XX
Updated
Enhanced Perinatal Surveillance (EPS)
Initials of person completing the form (Print legibly.)
Information complete for analysis?
Yes No
Date form completed (eg. abstraction concluded)
Date form received by main facility
Date case was reported
__ __/__ __/__ __ __ __ (mm/dd/yyyy)
How was the infant first identified?
__ __/__ __/__ __ __ __ (mm/dd/yyyy)
__ __/__ __/__ __ __ __ (mm/dd/yyyy)
Routine case reporting—pediatric report
Routine case reporting—maternal report
Birth registry match
Active case finding for enhanced perinatal surveillance
Laboratory reporting
Other than routine surveillance activities (Specify.)
If information on the mother is not available, was the child adopted, in foster care, or abandoned?
Yes No Not applicable
1. Records abstracted (Required)
(1 = Abstracted, 2 = Attempted—record not available, 3 = Not abstracted, 4 = Attempted—will try again)
_____ Prenatal care records
_____ Pediatric medical records (non-HIV clinic or provider)
_____ Maternal HIV clinic records
_____ Birth certificate
_____ Labor and delivery records
_____ Death certificate
_____ Pediatric birth records
_____ Health department records
_____ Pediatric HIV medical records
_____ Other (Specify.) ________________________________________________________
Demographic Information
2. Infant
Reporting state (Required)
City No.
Date of birth (Required)
__ __/__ __/__ __ __ __ (mm/dd/yyyy)
State No. (Required)
Soundex code
Sex at birth
M F
Date of death
__ __/__ __/__ __ __ __ (mm/dd/yyyy)
3. Mother
Reporting state
City No.
Date of birth
__ __/__ __/__ __ __ __ (mm/dd/yyyy)
State No.
Soundex code
Date of death
__ __/__ __/__ __ __ __ (mm/dd/yyyy)
4. Mother’s country of birth
4a. If mother’s country of birth is not specified, list continent of birth if known.
5. Mother's Hispanic ethnicity
6. Mother's race (Mark all that apply.)
Yes
No
Unknown
7. Marital status (at time of delivery)
Single
American Indian/Alaska Native Hawaiian/Other Pacific Islander
Asian
White
Black/African American
Unknown
Other (Specify.)____________________________________________________
Divorced Married Separated Widowed Unknown
This report to the Centers for Disease Control and Prevention (CDC) is authorized by law (Sections 304 and 306 of the Public Health Service Act, 42 USC 242b and 242k). Response in this case is voluntary for federal
government purposes, but may be mandatory under state and local statutes. Your cooperation is necessary for the understanding and control of HIV/AIDS. Information in CDC’s HIV/AIDS surveillance system that would
permit identification of any individual on whom a record is maintained is collected with a guarantee that it will be held in confidence, will be used only for the purposes stated in the assurance on file at the local health
department, and will not otherwise be disclosed or released without the consent of the individual in accordance with Section 308(d) of the Public Health Service Act (42 USC 242m).
Public reporting burden of this collection of information is estimated to average 60 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data
needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB
control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR, Project Clearance Officer, 1600 Clifton
Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0573). Do not send completed form to this address.
06/19/2009
Page 1 of 8
Infant State No. ____________________________
8. Mother's HIV risk factor (Mark all that apply.)
Injection drug use
Heterosexual contact with
injection drug user
bisexual male
male with hemophilia with documented HIV
transfusion recipient with documented HIV infection
transplant recipient with documented HIV infection
HIV-infected male, risk factor not specified
Hemophilia with documented HIV
Receipt of transfusion
Receipt of transplant (tissue/organ or artificial insemination
Perinatal exposure (i.e. mother was perinatally infected)
Unknown
Other documented risk (Discuss with the NRR coordinator in your state.)
If Other, specify ______________________________________
Prenatal Care
9. Did mother receive any prenatal care for this pregnancy?
10. Date of first prenatal care visit
Yes No (Go to 15.) Not documented (Go to 15.) Unknown
__ __/__ __/__ __ __ __ (mm/dd/yyyy)
11. Month of pregnancy during which prenatal care began
12. Date of last prenatal care visit before delivery
_______ (mos) (99 = unknown) or _______ (in weeks if month is not noted in chart)
__ __/__ __/__ __ __ __ (mm/dd/yyyy)
13. Number of prenatal care visits __________ (99 = unknown)
14. In what type of facility was prenatal care primarily delivered? (Check only one box.)
OB/GYN clinic
Adult HIV specialty clinic
HMO clinic (for prenatal care)
Private care (OB/GYN, midwife)
Correctional facility
ACTG site
Other (Specify.) ______________________________
Not documented
Unknown
15. Was the mother screened for any of the following during pregnancy?
(Check test performed before birth, but closest to date of delivery or admission to labor and delivery.)
Yes
Group B strep
Hepatitis B (HBsAg)
Rubella
Syphilis
Date (mm/dd/yyyy)
__ __/__ __/__ __ __ __
__ __/__ __/__ __ __ __
__ __/__ __/__ __ __ __
__ __/__ __/__ __ __ __
No
Not documented
Record not available Unknown
16. Diagnosis (for the mother) of the following conditions during this pregnancy or at the time of labor and delivery
(See Instructions for Data Abstraction for definitions.)
Yes
Bacterial vaginosis
Chlamydia trachomatis infection
Genital herpes
Gonorrhea
Group B strep
Hepatitis B (HbsAg+)
Hepatitis C
PID
Syphilis
Trichomoniasis
Date of diagnosis
(mm/dd/yyyy)
__ __/__ __/__ __ __ __
__ __/__ __/__ __ __ __
__ __/__ __/__ __ __ __
__ __/__ __/__ __ __ __
__ __/_ __/__ __ __ __
__ __/__ __/__ __ __ __
__ __/__ __/__ __ __ __
__ __/__ __/__ __ __ __
__ __/__ __/__ __ __ __
__ __/__ __/__ __ __ __
No
Not documented Record not available Unknown
17. Mother's reproductive history
___________ No. of previous pregnancies
_________ No. of previous miscarriages or stillbirths
___________ No. of previous live births
_________ No. of previous induced abortions or ______ Total No. of previous abortions
06/19/2009
Page 2 of 8
Infant State No. ____________________________
18. Complete the chart for all siblings.
Date of birth
(mm/dd/yyyy)
Age
(yrs: mos as of mm/yyyy)
HIV serostatus
(See list.)
State No.
City No.
Sib 1
__ __/__ __/__ __ __ __
___:___ as of __ __/__ __ __ __
_______________
_____________________
_______________________
Sib 2
__ __/__ __/__ __ __ __
___:___ as of __ __/__ __ __ __
_______________
_____________________
_______________________
Sib 3
__ __/__ __/__ __ __ __
___:___ as of __ __/__ __ __ __
_______________
_____________________
_______________________
Sib 4
__ __/__ __/__ __ __ __
___:___ as of __ __/__ __ __ __
_______________
_____________________
_______________________
Sib 5
__ __/__ __/__ __ __ __
___:___ as of __ __/__ __ __ __
_______________
_____________________
_______________________
Sib 6
__ __/__ __/__ __ __ __
___:___ as of __ __/__ __ __ __
_______________
_____________________
_______________________
HIV serostatus: 1 = Infected, 2 = Not infected, 3 = Indeterminate, 9 = Not documented U=Unknown
Substance Use
19. Was substance use during pregnancy noted in the medical or social work records?
Yes No (Go to 20.) Record not available (Go to 20.)
Unknown
19a. If yes, indicate which substances were used during pregnancy. (Check all that apply.)
Alcohol
Amphetamines
Barbiturates
Benzodiazepines
Cocaine
Crack cocaine
Hallucinogens
Heroin
Marijuana (cannabis, THC, cannabinoids)
Methadone
Methamphetamines
Nicotine (any tobacco product)
Opiates
Other (Specify.)
______________________________
Specific drug(s) not documented
19b. If substances used, were any injected?
Yes No Not documented Unknown
Specify injected substance(s). __________________________________________
20. Was a toxicology screen done on the mother (either during pregnancy or at the time of delivery)?
Yes, positive result (Check all that apply.)
Alcohol
Amphetamines
Barbiturates
Benzodiazepines
Cocaine
Crack cocaine
Hallucinogens
Heroin
Marijuana (cannabis, THC, cannabinoids)
Methadone
Methamphetamines
Nicotine (any tobacco product)
Opiates
Other (Specify.)
____________________________
Specific drug(s) not documented
Yes, negative result No Toxicology screen not documented
21. Was a toxicology screen done on the infant at birth?
Yes, positive result (Check all that apply.)
Alcohol
Amphetamines
Barbiturates
Benzodiazepines
Cocaine
Crack cocaine
Hallucinogens
Heroin
Marijuana (cannabis, THC, cannabinoids)
Methadone
Methamphetamines
Nicotine (any tobacco product)
Opiates
Other (Specify.)
____________________________
Specific drug(s) not documented
Yes, negative result No Toxicology screen not documented
22. If the results of the toxocology screen indicated substance use, was the mother referred for treatment (during or after this
pregnancy)?
Yes No Not documented Unknown
06/19/2009
Page 3 of 8
Infant State No. ____________________________
Maternal Testing/Clinical Information
23. Mother’s HIV serostatus
Mother refused HIV testing
HIV-positive before this pregnancy
HIV-positive during this pregnancy
HIV-positive at time of delivery
HIV-positive before child's birth, date unknown
HIV-positive after child's birth
HIV-positive, date unknown
24. Date of mother's first positive result from confirmatory testing (WB or IFA)
__ __/__ __/__ __ __ __ (mm/dd/yyyy)
25. Results of mother’s HIV screening during pregnancy
Results
(See list in 26.)
Test
(See list in 26.)
_________________________________________________
______________________
Date
(mm/dd/yyyy)
25a. First screening
__ __/__ __/__ __ __ __
25b. Second screening (if result was negative, or mother refused first screening)
_________________________________________________
______________________
__ __/__ __/__ __ __ __
25c. Third screening (if result was negative, or mother refused second screening)
_________________________________________________
______________________
__ __/__ __/__ __ __ __
Results
(See list.)
Test
(See list.)
Date of results in
labor and delivery
(mm/dd/yyyy)
Time of results in
labor and delivery
(See military time.)
_________________________________________________
______________________
__ __/__ __/__ __ __ __
__ __:__ __
______________________
__ __/__ __/__ __ __ __
__ __:__ __
______________________
__ __/__ __/__ __ __ __
__ __:__ __
26. Mother’s HIV screening at time of labor and delivery
26a. First screening
26b. Second screening (if applicable)
_________________________________________________
26c. Confirmatory test
_________________________________________________
Results
Positive
Negative
Indeterminate
Results not available
Not tested
Not tested but known to be infected
Refused
Unknown
06/19/2009
Tests
Rapid
Expedited EIA
EIA
Not documented
Military time
noon
=
4:30 pm =
midnight =
12:30 am =
12:00
16:30
00:00
00:30
Page 4 of 8
Infant State No. ____________________________
27. Were CD4 counts determined during pregnancy or within 6 months before pregnancy?
Yes No (Go to 28.) Not documented (Go to 28.) Record not available (Go to 28.) Unknown
27a. If yes, list below. (If more than 3 counts in record, prioritize the CD4 counts, starting with the count closest to delivery. If CD4
counts were not determined during pregnancy, record CD4 counts within 6 months before pregnancy if possible.)
Example: CD4 count of 174 cells/µL, 12%, August 12, 2000, would be recorded as
CD4 result
Unit
Date blood drawn
(mm/dd/yyyy)
__ __ __ __
cells/µL
__ __/__ __/__ __ __ __
__ __ __ __
%
__ __/__ __/__ __ __ __
__ __
__ __
CD4 result
174
cells/µL
08/12/2000
12
%
08/12/2000
Unit
Date blood drawn
(mm/dd/yyyy)
CD4 result
Unit
Date blood drawn
(mm/dd/yyyy)
cells/µL
__ __/__ __/__ __ __ __
__ __ __ __
cells/µL
__ __/__ __/__ __ __ __
%
__ __/__ __/__ __ __ __
__ __
%
__ __/__ __/__ __ __ __
28. Were viral quantification tests (ie, viral load) performed on the mother during pregnancy or within 6 months before pregnancy?
Yes No (Go to 29.) Not documented (Go to 29.) Record not available (Go to 29.) Unknown
28a. If yes, list all results below. (If more than 3 in record, prioritize the results of viral load tests, starting with the result closest to
delivery. If viral load tests were not performed during pregnancy, record viral loads within 6 months of pregnancy if possible.)
Result in No. of copies/mL
Result in logs
Date blood drawn
(mm/dd/yyyy)
____________________________
_______________
__ __/__ __/__ __ __ __
____________________________
_______________
__ __/__ __/__ __ __ __
____________________________
_______________
__ __/__ __/__ __ __ __
29. What was the mother's most advanced HIV serostatus during pregnancy?
HIV infection, not AIDS
HIV-negative
AIDS, CD4 criteria only
Not documented
AIDS, indicator condition
Record not available
Unknown
30. Was the mother's HIV serostatus noted in her prenatal care medical records?
Yes, HIV-positive Yes, HIV-negative No No prenatal care Record not available Unknown
Antiretroviral Therapy
31. Were antiretroviral drugs prescribed for the mother during this pregnancy?
Yes (Complete table.)
No (Go to 31a.)
Not documented (Go to 32.)
Record not available (Go to 32.) Unknown
Date stopped
(if yes in preceding column)
(mm/dd/yyyy)
Stop codes
(See list on
p. 8.)
__ __/__ __/__ __ __ __
________
_____________
__ __/__ __/__ __ __ __
________
__ __/__ __/__ __ __ __
_____________
__ __/__ __/__ __ __ __
________
__ __/__ __/__ __ __ __
_____________
__ __/__ __/__ __ __ __
________
__________
__ __/__ __/__ __ __ __
_____________
__ __/__ __/__ __ __ __
________
__________
__ __/__ __/__ __ __ __
_____________
__ __/__ __/__ __ __ __
________
vii.________________ __________
__ __/__ __/__ __ __ __
_____________
__ __/__ __/__ __ __ __
________
viii._______________ __________
__ __/__ __/__ __ __ __
_____________
__ __/__ __/__ __ __ __
________
Drug name
(See list on p. 8.)
Other
(specify)
Drug
refused
Date drug started
(mm/dd/yyyy)
Gestational age
drug started
(weeks; round down)
i. _______________ ___________
__ __/__ __/__ __ __ __
_____________
ii. _______________
__________
__ __/__ __/__ __ __ __
iii.________________
__________
iv.________________
__________
v.________________
vi.________________
Drug stopped
Yes No ND
(After completing table, go to 32.)
31a. If no antiretroviral drug was prescribed during pregnancy, check reason.
No prenatal care
HIV serostatus of mother unknown
06/19/2009
Mother known to be HIV-negative during pregnancy Not documented Unknown
Mother refused
Other (Specify.) __________________
Page 5 of 8
Infant State No. ____________________________
32. Was mother's HIV serostatus noted in her labor and delivery records?
Yes, HIV-positive
Yes, HIV-negative
No
Record not available Unknown
33. Did mother receive antiretroviral drugs during labor and delivery?
Yes (Complete table.)
No (Go to 33a.)
Drug Name
(See list.)
Other
(specify)
Not documented (Go to 34.)
Drug
refused
Record not available
Unknown
(Go to 34.)
Date received
(mm/dd/yyyy)
Time received
(See military time.)
Oral
Type of administration
IV
Not documented
i. ___________________
____________
__ __/__ __/__ __ __ __
__ __:__ __
ii. __________________
____________
__ __/__ __/__ __ __ __
__ __:__ __
iii. __________________
____________
__ __/__ __/__ __ __ __
__ __:__ __
iv. __________________
____________
__ __/__ __/__ __ __ __
__ __:__ __
v. __________________
____________
__ __/__ __/__ __ __ __
__ __:__ __
vi. __________________
____________
__ __/__ __/__ __ __ __
__ __:__ __
vii. __________________
____________
__ __/__ __/__ __ __ __
__ __:__ __
(After completing table, go to 34.)
Military time: noon = 12:00; midnight = 00:00
33a. If no antiretroviral drug was received during labor and delivery, check reason.
HIV serostatus of mother
Precipitous delivery/STAT
Cesarean delivery
Prescribed but not administered
during pregnancy
No (Go to 36.)
________________________
Mother refused
34. Was mother referred for HIV care after delivery?
Yes
Mother tested HIV-negative Other (Specify.)
unknown
Birth not in hospital
Not documented (Go to 36.)
Not documented
Unknown
Record not available (Go to 36.) Unknown
35. If yes, indicate first CD4 result or first viral load after discharge from hospital (up to 6 months after discharge).
35a. CD4 result
Not done Not available
35b. Viral load
Not done Not available
Result
Unit
Date blood drawn
(mm/dd/yyyy)
Result in copies/mL
__ __ __ __
cells/µL
__ __/__ __/__ __ __ __
_________________
%
__ __/__ __/__ __ __ __
__ __
Result in logs
____________
Date blood drawn
(mm/dd/yyyy)
__ __/__ __/__ __ __ __
Birth History
Single Twin >3 Record not available Unknown
37. Birth information Birth not in hospital
Record not available
36. Type of birth
Time
Date (mm/dd/yyyy)
Time
(See military time.)
Date (mm/dd/yyyy)
(See military time.)
Onset of labor
__ __:__ __
__ __/__ __/__ __ __ __
Rupture of membranes
__ __:__ __
__ __/__ __/__ __ __ __
Admission to labor and delivery
__ __:__ __
__ __/__ __/__ __ __ __
Delivery
__ __:__ __
__ __/__ __/__ __ __ __
Military time: noon = 12:00; midnight = 00:00
38. Gestational age at time of delivery ______________________ (in weeks; round down to nearest whole week)
39a. If Cesarean delivery, mark all the following indications that apply.
39. Mode of delivery
Vaginal (Go to 40.) Unknown
Elective Cesarean delivery
Non-elective Cesarean delivery
Cesarean delivery, unknown type
Record not available (Go to 41.)
40. Instrument used
06/19/2009
HIV indication (high viral load)
Previous Cesarean (repeat)
Malpresentation (breech, transverse)
Prolonged labor or failure to progress
Mother’s or physician’s preference
Fetal distress
Placenta abruptia or p. previa
Other (eg, herpes, disproportion)
Specify ________________________________
Not specified
None Forceps Vacuum Forceps and vacuum Not specified
Page 6 of 8
Infant State No. ____________________________
41. Child's birth weight (lbs/oz or grams)
_______ lbs ________ oz
42. Was mother's HIV serostatus noted on the child's birth record?
or _________ grams
No
Yes, HIV-positive Yes, HIV-negative Record not available Unknown
Pediatric History
43. Were antiretroviral drugs prescribed for the child during the first 6 weeks of life?
Yes (Complete table.) No (Go to 43a.) Not documented (Go to 44.) Record not available (Go to 44.) Unknown
Drug
refused
Date drug started
(mm/dd/yyyy)
Time started
(See military
time.)
ART
Completed?
Yes No ND UNK
Stop date
(if therapy not completed)
(mm/dd/yyyy)
Stop codes
(See list on
p. 8.)
i._________________ ____________
__ __/__ __/__ __ __ __
__ __:__ __
__ __/__ __/__ __ __ __
_______
ii.________________ _____________
__ __/__ __/__ __ __ __
__ __:__ __
__ __/__ __/__ __ __ __
_______
iii.________________ ____________
__ __/__ __/__ __ __ __
__ __:__ __
__ __/__ __/__ __ __ __
_______
iv.________________ ____________
__ __/__ __/__ __ __ __
__ __:__ __
__ __/__ __/__ __ __ __
_______
v.________________ _____________
__ __/__ __/__ __ __ __
__ __:__ __
__ __/__ __/__ __ __ __
_______
vi.________________ ____________
__ __/__ __/__ __ __ __
__ __:__ __
__ __/__ __/__ __ __ __
_______
vii.________________ ____________
__ __/__ __/__ __ __ __
__ __:__ __
__ __/__ __/__ __ __ __
_______
viii._______________ ____________
__ __/__ __/__ __ __ __
__ __:__ __
__ __/__ __/__ __ __ __
_______
Drug name
(See list on p. 8.)
Other
(specify)
Military time: noon = 12:00; midnight = 00:00
43a. If no antiretroviral drug was prescribed during the first 6 weeks of life, indicate reason.
HIV serostatus of mother unknown
Mother known to be HIV-negative during pregnancy
Mother refused
44. Infant’s HIV antibody testing
Results
(See list.)
Other (Specify.) ____________________________________________
Not documented
45. Results of DNA/RNA screening
Test
(See list.)
Date blood drawn
(mm/dd/yyyy)
Results
(See list in 44.)
i. ________________
______________
__ __/__ __/__ __ __ __
i. ________________
__ __/__ __/__ __ __ __
ii. _______________
______________
__ __/__ __/__ __ __ __
ii. ________________
__ __/__ __/__ __ __ __
iii. _______________
______________
__ __/__ __/__ __ __ __
iii. ________________
__ __/__ __/__ __ __ __
iv. ________________
__ __/__ __/__ __ __ __
v. ________________
__ __/__ __/__ __ __ __
Results
Positive
Negative
Indeterminate
Results not available
Infant not tested
Mother refused
Unknown
Tests
Rapid
Expedited EIA
EIA
Not
documented
46. What is the child's current HIV infection status?
AIDS
HIV-negative
Confirmed HIV infected (not AIDS)
Indeterminate as of
__ __/__ __/__ __ __ __ (mm/dd/yyyy)
48. Was PCP prophylaxis prescribed during the first year of life?
Yes Date received __ __/__ __/__ __ __ __
No Not documented Record not available Unknown
06/19/2009
Test
DNA
RNA
Date blood drawn
(mm/dd/yyyy)
47. If child's HIV serostatus is indeterminate, indicate reason.
Moved from state
Provider out of state
Child <18 months of age
Lost to follow-up
Died before serostatus determined
Not documented
49. Was child breastfed?
Yes
Duration _______ days _____ weeks
No
Duration not documented
Not documented Record not available Unknown
Page 7 of 8
Infant State No. ____________________________
50. Were birth defects noted during the first year of life?
Yes No (Go to 51.) Record not available (Go to 51.)
Unknown
50a. If yes, specify type(s). _______________________________
Code _____._____
Code _____._____
Code _____._____
51. If child is deceased, please obtain the following from the death certificate. (Print legibly. Include ICD-9 or ICD-10 codes only if code
appears on death certificate.)
Cause of death
ICD-9 code
or
ICD-10 code
Immediate___________________________________________________________________________________
___________
___________
Underlying __________________________________________________________________________________
___________
___________
Underlying __________________________________________________________________________________
___________
___________
Underlying __________________________________________________________________________________
___________
___________
Contributing _________________________________________________________________________________
___________
___________
Note. Please be sure that a date of death has been entered on page 1, under Demographic Information (2. Infant).
Please include comments or clinical information you consider relevant to the overall understanding of this child's HIV exposure
or infection status. State the date and source of the information.
Antiretroviral drugs and stop codes
NNRTI
Delavirdine (Rescriptor)
Efavirenz (Sustiva)
Nevirapine (Viramune, NVP)
NRTI
Abacavir (Ziagen, ABC)
Combivir (AZT & 3TC)
Didanosine (ddI, Videx)
Emtriva (Emtricitabine or FTC)
NRTI (cont)
Epzicom (Abacavir/3TC, Kivexa)
Lamivudine (3TC, Epivir)
Stavudine (d4T, Zerit)
Trizivir (AZT & 3TC & Abacavir)
Truvada (Tenofovir DF/Emtricitabine)
®
Videx EC (Didanosine)
Viread (Tenofovir)
Zalcitabine (ddC, Hivid)
Zidovudine (AZT, Retrovir)
Protease inhibitor
Amprenavir (Agenerase)
Darunavir (Prezista)
Indinavir (Crixivan)
Kaletra (Lopinavir, Ritonavir)
Lexiva (Fosamprenavir)
Nelfinavir (Viracept)
Reyataz (Atazanavir or ATV)
Ritonavir (Norvir)
Saquinavir (Fortavase, Invirase)
Tipranavir (Aptivus)
Other
Adefovir dipivoxil (bis-POM,
PMEA, Preveon)
Atripla (Efavirenz & Tenofovir &
Emtricitabine)
Fuzeon (Enfuvirtide or T20)
Hydroxyurea (Droxia, Hydrea)
Intelence
Selzentry
Isentress
If an antiretroviral drug not
on this list, call CDC
Stop codes (2 codes allowed; if more, choose the 2 most important)
S1 = Adverse events (toxicity, lack of tolerance)
S2 = ART completed
S3 = Drug resistance detected
S4 = Poor adherence
S5 = Inadequate effectiveness
S6 = Strategic treatment interruption (planned drug holiday)
S7 = Drug interactions
S8 = Mother’s choice
S9 = Pregnancy
S10 = Child determined not to be HIV infected
S11 = Improving effectiveness
S12 = Improving convenience
S13 = Reason not indicated; unknown
S14 = Mother couldn’t afford drugs
Sxx = Other reason
List of abbreviations
ACTG
ART
EIA
HARS
HMO
ICD-9
ICD -10
IFA
ND
NNRTI
AIDS Clinical Trials Group
antiretroviral therapy
enzyme immunoassay
HIV/AIDS Reporting System
health maintenance organization
International Classification of Diseases, Ninth Revision
International Classification of Diseases, Tenth Revision
immunofluorescent assay
not documented
nonnucleoside reverse transcriptase inhibitor
06/19/2009
NRTI
NRR
OB-GYN
PCP
PI
PID
STAT
WB
nucleoside reverse transcriptase inhibitor
no risk factor reported
obstetric-gynecologic or obstetrician-gynecologist
Pneumocystis jirovecii pneumonia [jirovecii is now preferred to carinii;
abbreviation is the same]
protease inhibitor
pelvic inflammatory disease
immediately (statim)
Western blot
Page 8 of 8
File Type | application/pdf |
File Title | Microsoft Word - EPS_Data_Collection _draftburden_with_cover.doc |
Author | bnk5 |
File Modified | 2009-11-02 |
File Created | 2009-06-22 |