HIV Incidence Surveillance Data Elements

Attachment 3 (d)

Adult and Pediatric HIV/AIDS Confidential Case Reports

for National HIV/AIDS Surveillance OMB No. 0920-0573

Supplemental Surveillance Activity 1: HIV Incidence Surveillance –

Standard HIV Incidence Surveillance Data Elements

Form Approved

OMB No. 0920-0573

Expiration Date XX/XX/20XX

Adult and Pediatric HIV/AIDS Confidential Case Reports

for National HIV/AIDS Surveillance

Standard HIV Incidence Surveillance Data Elements

Public reporting burden of this collection of information is estimated to average 10 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 persons 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)

Variable Description	Valid Value	Required/Optional
Number of HIV tests in 2 years prior to the first positive (For people who previously tested positive)	1 - 99 R=refused D=don't know	Optional
Anonymous HIV test at first positive test	0=no 1=yes 7=refused 9=don't know	Optional
Antiretroviral medications within the last 6 months	0=no 1=yes 7=refused 9=don't know	Required
ARV meds taken	22=Agenerase 30=Aptivus 24=Combivir 06 =Crixivan 11=Emtriva 03=Epivir 28=Epzicom 25=Fortovase 10=Fuzeon 19=Hepsera 02=Hivid 23=Hydroxyurea 18=Invirase 16=Kaletra 31=Lexiva 07=Norvir 88=Other 09=Rescriptor 26=Retrovir 15=Reyataz 08=Saquinavir	Required
CLIA code for source lab where specimen originated	text	Required
Currently taking antiretroviral medications	0=no 1=yes 7=refused 9=don't know	Optional
Date HAART use began	yyyymmdd	Required
Date HAART use ended	yyyymmdd	Required
Date information is extracted	yyyymmdd	Required
Date of first HIV test ever	yyyymmdd	Optional
Date of first positive HIV test	yyyymmdd	Required
Date of STARHS test	yyyymmdd	Required
Date of the HIV test that resulted in a case report	yyyymmdd	Optional
Date specimen was obtained	yyyymmdd	Required
Has specimen been approved for STARHS?	0=no 1=yes 2=pending	Required
Laboratory ID	33D0654341=NYST 33D0654341=CDCSTARHS 33D0654341=NY 33D0654341=CDCSTAR 21D0649758=MARY01 50D0661430=WASH	Required
Date of last HIV negative test before first positive	yyyymmdd	Required
Date of last HIV negative test before first positive (or before test that resulted in a case report if never previously tested positive)	yyyymmdd	Optional
Name of site where first tested positive for HIV	text	Optional
Name of site where last tested negative for HIV	text	Optional
Ever tested for HIV	0=no 1=yes 7=refused 9=don't know	Optional
Ever tested negative	0=no 1=yes 7=refused 9=don't know	Required
Number of HIV tests in last 2 years before first positive (including first positive test)	1 - 99 R=refused D=don't know	Required
Number of HIV tests in last 2 years before first positive (People who never had previous positive)	1 - 99 R=refused D=don't know	Optional
Optical density	text	Required
Ever tested positive	0=no 1=yes 7=refused 9=don't know	Optional
Reason for first positive HIV test*	text	Optional
Reason for testing at first positive - exposure to HIV within the last 6 months*	0=no 1=yes 7=refused 9=don't know	Optional
Reason for testing at first positive - just checking to make sure you are HIV negative*	0=no 1=yes 7=refused 9=don't know	Optional
Reason for testing at first positive - other reason*	0=no 1=yes 7=refused 9=don't know	Optional
Reason for testing at first positive - regular tester; time for routine HIV test*	0=no 1=yes 7=refused 9=don't know	Optional
Reason for testing at first positive - required by either insurance, military, court order, or for some other required reason*	0=no 1=yes 7=refused 9=don't know	Optional
Reason for the test that led to the case report - exposure to HIV within the last 6 months*	0=no 1=yes 7=refused 9=don't know	Optional
Reason for the test that led to the case report- just checking to make sure you are HIV negative*	0=no 1=yes 7=refused 9=don't know	Optional
Reason for the test that led to the case report- other reason*	0=no 1=yes 7=refused 9=don't know	Optional
Reason for the test that led to the case report- regular tester; time for routine HIV test*	0=no 1=yes 7=refused 9=don't know	Optional
Reason for the test that led to the case report - required by either insurance, military, court order, or for some other required reason*	0=no 1=yes 7=refused 9=don't know	Optional
Reason STARHS not performed	1=QNS 2=specimen never received at public lab 3=broken in transit 4=other	Required
Results received	0=no 1=yes	Required
Specify other reason for testing at fist positive*	text	Optional
Specify other reason for the test that led to the case report*	text	Optional
Specimen ID number from source lab	text	Required
STARHS ID	text	Required
STARHS regional lab specimen ID number (same as STARHS lab imported variable SPECIMEN ID)	text	Required
STARHS test result	01=long term 02=recent 91=QNS 92=not rec’d by STARHS lab 93=broken 94=other	Required
State lab CLIA code	text	Required
State lab specimen ID number	text	Required
State of site where first tested positive for HIV	text	Optional
State of site where last tested negative for HIV	text	Optional
Test assay	BED=BED BVLS=BVLS (Vironostika LS) OTLS=OTLS (Vironostika LS) OTV=OTV (Vironostika LS) AVID=AVID	Required
Type of site where first tested positive for HIV	F01=inpatient facility F01.01=inpatient facility/hospital F01.04=inpatient facility/long term care F01.50=inpatient facility/drug treatment F01.OTH=inpatient facility/other F01.UNK=inpatient facility unknown F.OTH=facility/other F.UNK=facility/unknown	Optional
Type of site where participant last tested negative for HIV	F01=inpatient facility F01.01=inpatient facility/hospital F01.04=inpatient facility/long term care F01.50=inpatient facility/drug treatment F01.OTH=inpatient facility/other F01.UNK=inpatient facility unknown F.OTH=facility/other F.UNK=facility/unknown	Optional
Type of test performed on specimen (LOINC)	5220-9=EIA / Elisa 21009-6=Western Blot 5472-6=CD4 25835-0=Viral Load (NASBA) 5017-9=Viral Load (bDAN) 25836-8=Viral Load (RT-PCR)	Required
What type of specimen was obtained	1=blood finger stick 2=blood venipuncture 3=blood spot 4=oral mucosal transudate 5=urine 8=other 9=unknown	Required

* The reason for testing for first positive test or for the test that led to the case report will no longer be part of the standard HIV Incidence Surveillance data elements beginning January 1, 2007.