PHER (mondfied)

Perinatal HIV Exposure Report (PHER) Form

U.S. Department of Health
& Human Services
State Number

Centers for Disease Control
and Prevention

Form Approved OMB No. 0920-0573 Exp. 02/29/2016
Xx/Date02/29/2016

1. If information on the mother is not available, was the child adopted, or in foster care?

□ Yes □ No □ Not applicable

2. Records abstracted
(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.)

3. Weeks’ gestation at first prenatal care visit
weeks

4. 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.)

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Yes

Group B strep
Hepatitis B (HBsAg)
Rubella
Syphilis

Date (mm/dd/yyyy)

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No

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Not documented

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Record not available

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Unknown

5. 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.)

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Yes
Bacterial vaginosis
Chlamydia trachomatis infection
Genital herpes
Gonorrhea
Group B strep
Hepatitis B (HbsAg+)
Hepatitis C
PID
Syphilis
Trichomoniasis

Date (mm/dd/yyyy)

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No

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Not documented

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Record not available

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Unknown

6. 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

7. Complete the chart for all siblings.
Date of birth
(mm/dd/yyyy)

Age
(yrs: mos as of mm/yyyy)

Sib 1

/

/

:

as of

/

Sib 2

/

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:

as of

/

Sib 3

/

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:

as of

/

Sib 4

/

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:

as of

/

HIV serostatus
(See list.)

State No.

City No.

HIV serostatus: 1 = Infected, 2 = Not infected, 3 = Indeterminate, 9 = Not documented, U = Unknown
Public reporting burden of this collection of information is estimated to average 18 to 30 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, Project Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, GA
30333, ATTN: PRA (0920-0573). Do not send completed form to this address.

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. Information in CDC’s National HIV 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).

8. Was substance use during pregnancy noted in the medical or social work records?

□ Yes □ No (Go to 10.) □ Record not available (Go to 9.)

□ Unknown

8a. 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

8b. If substances used, were any injected?

□ Yes □ No □ Not documented □ Unknown □ Specify injected substance(s).

9. 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
□ Cocaine
□ Marijuana (cannabis, THC, cannabinoids)
□ Amphetamines
□ Crack cocaine □ Methadone
□ Barbiturates
□ Hallucinogens □ Methamphetamines
□ Benzodiazepines □ Heroin
□ Nicotine (any tobacco product)
□ Yes, negative result □ No □ Toxicology screen not documented

□ Opiates
□ Other (Specify.)
□ Specific drug(s) not documented

10. Was a toxicology screen done on the infant at birth?

□ Yes, positive result (Check all that apply.)
□ Alcohol
□ Cocaine
□ Marijuana (cannabis, THC, cannabinoids)
□ Amphetamines
□ Crack cocaine □ Methadone
□ Barbiturates
□ Hallucinogens □ Methamphetamines
□ Benzodiazepines □ Heroin
□ Nicotine (any tobacco product)
□ Yes, negative result □ No □ Toxicology screen not documented

□ Opiates
□ Other (Specify.)
□ Specific drug(s) not documented

11. 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

12. Were antiretroviral drugs prescribed for the mother during this pregnancy?

□ Yes (Complete table.) □ No (Go to 12a.) □ Not documented (Go to 13.) □ Record not available (Go to 13.) □ Unknown

Drug name
(See list on p. 8.)

Other
(specify)

Drug
refused

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i.
ii.
iii.
iv.
v.
vi.

Date drug started
(mm/dd/yyyy)
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Gestational age
drug started
(weeks; round down)

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Drug stopped
Yes No ND

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Date stopped
(if yes in preceding
column) (mm/dd/yyyy)
/
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/

Stop codes
(See list on
p. 8.)

/
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/

(After completing table, go to 13.)

12a. If no antiretroviral drug was prescribed during pregnancy, check reason.

□ No prenatal care
□ Mother known to be HIV-negative during pregnancy
□ HIV serostatus of mother unknown
□ Mother refused

□ Not documented
□ Other (Specify.)

□ Unknown

13. Was mother’s HIV serostatus noted in her labor and delivery records?

□ Yes, HIV-positive

□ Yes, HIV-negative

□ No

□ Record not available □ Unknown

14. Did mother receive antiretroviral drugs during labor and delivery?

□ Yes (Complete table.)

Drug name
(See list.)

Other
(specify)

□ No (Go to 14a.)
Drug
refused

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i.
ii.
iii.
iv.
v.
vi.
(After completing table, go to 15.)

□ Not documented (Go to 15.)
Date received
(mm/dd/yyyy)
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□ Record not available

Time received
(See military time.)
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:

(Go to 15.)

□ Unknown

Type of administration
Oral
IV
Not documented

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Military time: noon = 12:00; midnight = 00:00

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14a. If no antiretroviral drug was received during labor and delivery, check reason.

□ Precipitous delivery/STAT
□

□ HIV serostatus of mother

Cesarean delivery
Prescribed but not administered

□

□

15. Was mother referred for HIV care after delivery?

□ Yes

□ No (Go to 18.)

□ Mother tested HIV- □ Other (Specify.)

unknown
Birth not in hospital

□ Not documented (Go to 17.)

negative during
pregnancy
Mother refused

□ Not documented
□ Unknown

□ Record not available (Go to 17.) □ Unknown

16. If yes, indicate first CD4 result or first viral load after discharge from hospital (up to 6 months after discharge).
16a. CD4 result

□ Not done

Result

□ Not available

Unit
cells/µL
%

17. Birth information

16b. Viral load

Date blood drawn
(mm/dd/yyyy)
/
/

□ Not done □ Not available

Result in copies/mL

Result in logs

Date blood drawn
(mm/dd/yyyy)

/
/

□ Birth not in hospital

/

/

□ Record not available

Time (See
military
time.)

Date
(mm/dd/yyyy)

Date
(mm/dd/yyyy)

Time (See
military
time.)

Onset of labor

:

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Rupture of membranes

:

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Admission to labor
and delivery

:

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Delivery

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Military time: noon = 12:00; midnight = 00:00

18. If Cesarean delivery, mark all the following indications that apply.

□ 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 (e.g., herpes, disproportion)
(Specify)

□ Not specified

□ Not applicable

19. Was mother’s HIV serostatus noted on the child’s birth record?

□ No □ Yes, HIV-positive □ Yes, HIV-negative □ Record not available □ Unknown

20. Were antiretroviral drugs prescribed for the child?

□ Yes (Complete table.) □ No (Go to 20a.) □ Not documented □ Record not available □ Unknown

Drug name
(See list.)

i.
ii.
iii.
iv.
v.
vi.

Other
(specify)

Drug
refused

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Date drug started
(mm/dd/yyyy)
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/

Time started
(See military
time.)

Drug stopped
Yes No ND UNK

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Stop date
Stop codes
(if therapy not completed) (See list on
(mm/dd/yyyy)
p. 8.)
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Military time: noon = 12:00; midnight = 00:00

20a. If no antiretroviral drug was prescribed, indicate reason.

□ HIV serostatus of mother unknown
□ Mother known to be HIV-negative during pregnancy
□ Mother refused

□ Other (Specify.)
□ Not documented

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
NNRTI

NRTI

Protease inhibitor

Protease inhibitor

Delavirdine (Rescriptor)
Efavirenz (Sustiva)
Nevirapine (Viramune, NVP)

Abacavir (Ziagen, ABC)
Combivir (AZT & 3TC)
Didanosine (ddI, Videx)
Emtriva (Emtricitabine or FTC)
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)

Amprenavir (Agenerase)
Darunavir (Prezista)
Indinavir (Crixivan)
Kaletra (Lopinavir, Ritonavir)
Lexiva (Fosamprenavir)
Nelfinavir (Viracept)
Reyataz (Atazanavir or ATV)
Ritonavir (Norvir)
Saquinavir (Fortavase, Invirase)
Tipranavir (Aptivus)

Amprenavir (Agenerase)
Darunavir (Prezista)
Indinavir (Crixivan)
Kaletra (Lopinavir, Ritonavir)
Lexiva (Fosamprenavir)
Nelfinavir (Viracept)
Reyataz (Atazanavir or ATV)
Ritonavir (Norvir)
Saquinavir (Fortavase, Invirase)
Tipranavir (Aptivus)

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
AIDS Clinical Trials Group
ART
antiretroviral therapy EIA
enzyme immunoassay HARS
HIV/AIDS Reporting System
HMO
health maintenance organization
ICD-9
International Classification of Diseases, Ninth Revision
ICD -10
International Classification of Diseases, Tenth Revision
IFA
immunofluorescent assay
ND
not documented
NNRTI
nonnucleoside reverse transcriptase inhibitor
NRTI
nucleoside reverse transcriptase inhibitor
NRR
no risk factor reported
OB-GYN obstetric-gynecologic or obstetrician-gynecologist
PCP
Pneumocystis jirovecii pneumonia [jirovecii is now preferred to carinii; abbreviation is the same]
PI
protease inhibitor
PID
pelvic inflammatory disease
STAT
immediately (statim)
WB
Western blot