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Attachment 4b.
Pediatric HIV Confidential Case Report Form and Perinatal HIV Exposure Reporting Form
Technical Guidance
Technical Guidance for HIV
Surveillance Programs
Pediatric HIV Confidential Case Report Form and
Perinatal HIV Exposure Reporting Form
HIV Incidence and Case Surveillance Branch
Atlanta, Georgia
Contents
Pediatric HIV Confidential Case Report Form
Instructions for Completion ....................................................................................................................... 3
Purpose of Case Report Form ............................................................................................................ 3
The Case Report Form in the Context of Document-Based Surveillance ........................................... 3
Patients for Whom Form is Indicated ................................................................................................. 3
Definition of Variable Designators ..................................................................................................... 3
Disposition of Form ............................................................................................................................ 4
Patient Identification ........................................................................................................................... 4
Health Department Use Only .............................................................................................................. 6
Facility Providing Information ............................................................................................................ 7
Patient Demographics ......................................................................................................................... 8
Residence at Diagnosis ..................................................................................................................... 10
State/Local Use Only ........................................................................................................................ 11
Facility of Diagnosis ......................................................................................................................... 11
Patient History................................................................................................................................... 12
Clinical: Opportunistic Illnesses ....................................................................................................... 16
Laboratory Data ................................................................................................................................ 17
Birth History (for Perinatal Cases Only) ........................................................................................... 23
Treatment/Services Referrals ............................................................................................................ 26
Comments ......................................................................................................................................... 28
Local/Optional Fields ........................................................................................................................ 28
Appendix: Pediatric HIV Confidential Case Report ................................................................................ 28
Instructions for Completion .............................................................................................................. 28
Purpose .............................................................................................................................................. 28
Pediatric Cases of Public Health Importance (COPHI) .................................................................... 29
Patient Demographics ....................................................................................................................... 30
Residence of Diagnosis ..................................................................................................................... 34
Facility of Diagnosis ......................................................................................................................... 35
Patient History................................................................................................................................... 35
Clinical: Opportunistic Illnesses ....................................................................................................... 36
Birth History (for Perinatal Cases Only) ........................................................................................... 36
Treatment/Services Referrals ............................................................................................................ 38
Perinatal HIV Exposure Reporting (PHER) Form
Instructions for Completion ..................................................................................................................... 40
Purpose of Perinatal HIV Exposure Reporting (PHER) Form .......................................................... 40
The PHER Form in the Context of Document-Based Surveillance .................................................. 40
Definition of Variable Designators ................................................................................................... 40
Disposition of Form .......................................................................................................................... 40
Chart Abstraction Guidance .............................................................................................................. 40
Qualification of Abstractors .............................................................................................................. 41
Records to be Abstracted .................................................................................................................. 41
Abstraction of Mother’s Records ...................................................................................................... 41
Abstraction of Infant’s Records ........................................................................................................ 41
Follow-up Chart Review ................................................................................................................... 42
Indicating ‘Unknown’ ....................................................................................................................... 42
Not Documented ............................................................................................................................... 42
Dates.................................................................................................................................................. 42
Records that are ‘Not Available’ ....................................................................................................... 42
Conflicting Information .................................................................................................................... 42
Form Fields ....................................................................................................................................... 43
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National HIV Surveillance System Technical Guidance – PCRF and PHER Form, XXXX 2019
Technical Guidance for HIV Surveillance Programs —
Pediatric HIV Confidential Case Report Form
Instructions for Completion
Purpose of Case Report Form
The Pediatric HIV Confidential Case Report (CDC 50.42B) form (PCRF) is designed to collect
information that promotes understanding of HIV infection morbidity and mortality among patients less
than 13 years of age at time of diagnosis. This form reflects data that is required to be collected and some
that is recommended or optional. This guidance applies to all HIV infection data collection even if state
or local surveillance programs use a different form or medium for HIV case surveillance. See Appendix
for further guidance.
The Case Report Form in the Context of Document-Based Surveillance
Unlike case-based data management, document-based data management allows all documents to be stored
and retained electronically in their original formats. Instead of completing one form for a reported case,
fill out the applicable part of the form for each data source contributing information to that HIV case.
Patients for Whom Form is Indicated
Each child less than 13 years of age, who meets the HIV infection or stage 3 (AIDS) case
definition (available at https://www.cdc.gov/mmwr/preview/mmwrhtml/rr6303a1.htm).
In areas with perinatal exposure HIV reporting, all children born to HIV-infected mothers.
Includes each child whose infection status has not yet been determined, seroconverters, and
those exposed but determined not to be infected with HIV; inclusion of such patients is for
public health surveillance purposes only.
Each child with HIV infection progressing from an earlier or unknown stage to stage 3 (AIDS)
diagnosis.
Each child with HIV infection who has been reported but for whom updated information is
available such as new CD4 tests, viral load tests, or drug resistance tests (genotypic) reported
from a medical provider, additional risk factor information, updated current address
information, or a change in vital status.
If the data is collected electronically and can be imported, recording the information on a hardcopy form
is not necessary. A federal assurance of confidentiality applies to information on children exposed
perinatally with or without consequent infection.
Definition of Variable Designators
Required: Variables that must be collected by all programs.
Recommended: Variables that programs are strongly encouraged to collect but are not
absolutely required.
Optional: Variables that programs may or may not choose to collect.
System generated: Variables where the value is generated by the Centers for Disease Control
and Prevention (CDC)-supplied software.
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Disposition of Form
The completed form is for state or local health agency use and is not to be sent to the CDC.
The Pacific Islands are the only jurisdictions that send forms to CDC for data entry and all
patient identifiers must be removed before they are sent.
Data obtained from these forms are entered into standardized computer software provided by
the Division of HIV/AIDS Prevention, National Center for HIV, Viral Hepatitis, STD, and TB
Prevention, CDC, and then transferred without identifiers to CDC by encrypted electronic
transfer via a secure data network.
1. Patient Identification
1.1
1.2
1.3
1.4
1.5
1.6
1.7
1.8
*Information NOT transmitted to CDC
Patient identifier information is for state and local health department use only and is not
transmitted to CDC if marked with an * on the form. Enter the data below for all children
reported with HIV infection.
FIRST NAME (Required, applies to health department & health care providers)
Enter patient’s first name
MIDDLE NAME (Optional, applies to health department & health care providers)
Enter patient’s middle name.
LAST NAME (Required, applies to health department & health care providers)
Enter patient’s last name.
LAST NAME SOUNDEX (System generated)
After patient name is entered into CDC-supplied software, the software automatically
generates this variable by using the patient’s last name. After the code is generated, health
department staff should fill in this field on the form.
This variable is a phonetic, alphanumeric code calculated by converting a surname into an
index letter and a three-digit code. The index letter is the first letter of the surname. The
eHARS Technical Reference Guide describes exactly how the Last Name Soundex is
created.
You can access the eHARS Technical Reference Guide through SharePoint:
https://cdcpartners.sharepoint.com/sites/NCHHSTP/HICSB/default.aspx
ALTERNATE NAME TYPE (Optional, applies to health department & health care providers)
If available, write in the alternate name type (e.g., Alias, Birth Name)
ALTERNATE FIRST NAME (Optional, applies to health department & health care providers)
Enter patient’s alternate first name.
ALTERNATE MIDDLE NAME (Optional, applies to health department & health care
providers)
Enter patient’s alternate middle name.
ALTERNATE LAST NAME (Optional, applies to health department & health care providers)
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Enter patient’s alternate last name.
1.9 ADDRESS TYPE (Required, applies to health department & health care providers)
Select one of the address types for the patient’s current address.
1.10 CURRENT ADDRESS, STREET (Required, applies to health department & health care
providers)
Enter the patient’s current street address.
1.11 ADDRESS DATE (Required, applies to health department & health care providers)
Enter the earliest date that the patient was known to be residing at the current address
specified in 1.10. If the patient has resided at an address more than once (and has evidence
that they resided elsewhere in between), the address date captured should be the earliest date
that the patient moved to the address in the most recent instance.
You may enter the most recent date the patient was known to be residing at the address in
the Comments section.
Enter date in mm/dd/yyyy format using ‘..’ for unknown values (e.g., 03/../2011).
1.12 PHONE (Required if patient has a telephone, applies to health department & health care
providers)
Enter patient’s primary area code and telephone number associated with the current address
specified in 1.10.
1.13 CITY (Required, applies to health department & health care providers)
Enter patient’s current city.
1.14 COUNTY (Required, applies to health department & health care providers)
Enter patient’s current county.
1.15 STATE/COUNTRY (Required, applies to health department & health care providers)
Enter patient’s current state and country name.
1.16 ZIP CODE (Required, applies to health department & health care providers)
Enter patient’s current zip code.
1.17 MEDICAL RECORD NUMBER (Optional, applies to health department & health care
providers)
Enter medical record number of the patient if available.
This field may be left blank unless patient was hospitalized as an inpatient or treated as an
outpatient in a hospital, community health center, or health department clinic.
If the patient has more than one medical record number, enter the number of the primary
record that has HIV infection or stage 3 (AIDS) documentation. Additional numbers can be
noted in the Comments section annotating which facility is associated with which record
number.
1.18–1.19 OTHER ID TYPE and NUMBER (Optional, applies to health department & health care
providers)
Enter any additional patient identifier type (such as social security number) and the number
of the other identifier. For a list of ID types, please reference the eHARS Technical
Reference Guide.
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2. Health Department Use Only
2.1
2.2
2.3
2.4
2.5
2.6
DATE RECEIVED AT HEALTH DEPARTMENT (Recommended, applies to health
department)
Enter date in mm/dd/yyyy format using ‘..’ for unknown values (e.g., 03/../2011).
eHARS DOCUMENT UID (System generated)
Enter UID after CDC-supplied software generates this variable.
STATE NUMBER (Required, applies to health department)
Enter the assigned state number.
Each patient must have a unique state number throughout the course of HIV disease in each
state/jurisdiction where they are reported. If the patient was a pediatric “Seroreverter” and
was later infected with HIV, the patient must be given two different state numbers; one
associated with the “Seroreverter” and another associated with the HIV infection diagnosis.
Refer to Appendix 4.1.4 for the definition of a pediatric “Seroreverter”. Jurisdictions must
use the “Same as” field on the duplicate review tab in eHARS to link the two cases. Enter
the appropriate state number associated with the events being reported on the case report
form. For example, if providing information about the “Seroreverter”, enter the state number
associated with the “Seroreverter”.
Assigned numbers must not be reused, even if the case is later deleted.
This variable is used, along with the state of report, to uniquely identify cases
reported to CDC and to merge with state datasets without duplication.
REPORTING HEALTH DEPARTMENT -CITY/COUNTY (Required, applies to health
department)
Enter name of city and county of the health department that receives the report from
providers of surveillance data.
CITY/COUNTY NUMBER (Optional, applies to health department)
Enter the assigned city/county number.
Each patient must have a unique city/county number throughout the course of HIV disease
assigned by the separately funded city in which they are reported. If the city/county number
is the primary identifier and the patient was a pediatric “Seroreverter” and was later infected
with HIV, the patient must be given two different city/county numbers; one associated with
the “Seroreverter” and another associated with the HIV infection diagnosis. Refer to
Appendix 4.1.4 for the definition of a pediatric “Seroreverter”. If the city/county number is
the primary identifier, the jurisdiction must use the “Same as” field on the duplicate review
tab in eHARS to link the two cases. Enter the appropriate city/county number associated
with the events being reported on the case report form. For example, if providing
information about the “Seroreverter”, enter the city/county number associated with the
“Seroreverter”.
Assigned numbers must not be reused, even if the case is later deleted.
DOCUMENT SOURCE (Required, applies to health department)
Enter the code for the document source that provided the information for this report
(formerly report source).
To clearly identify multiple data sources for a given HIV case (all stages), use a separate
case report form for each source.
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2.7
2.8
2.9
Refer to the eHARS Technical Reference Guide for a list of the allowable document source
codes.
SURVEILLANCE METHOD (Required, applies to health department)
Enter the method the case report was ascertained.
For definitions of active, passive, follow up, re-abstraction refer to the file Source Data and
Completeness of Reporting.
DID THIS REPORT INITIATE A NEW INVESTIGATION? (Optional, applies to health
department)
Enter whether this case report initiated a new investigation by the health department.
REPORT MEDIUM (Optional, applies to health department)
Health department staff review medical records at provider facilities (i.e., field visits) or
receive information over the telephone, by fax, US mail, or other method, to establish an
HIV case and to elicit information for HIV case report forms. The health department can
also receive HIV case reports from physicians, laboratories, or other individuals or
institutions through electronic transfer or CD/disks. Enter the medium in which the case
report was submitted.
3. Facility Providing Information
3.1
FACILITY NAME (Recommended, applies to health department & health care providers)
Enter name of the facility providing the information.
If data was reported from different facilities, enter name of each on separate forms.
3.2 PHONE (Recommended, applies to health department & health care providers)
Enter facility’s current area code and telephone number.
3.3 STREET ADDRESS (Recommended, applies to health department & health care providers)
Enter facility’s street address.
3.4 CITY (Recommended, applies to health department & health care providers)
Enter city where facility providing information is located.
3.5 COUNTY (Recommended, applies to health department & health care providers)
Enter county where facility providing information is located.
3.6 STATE/COUNTRY (Recommended, applies to health department & health care providers)
Enter state and country name where facility providing information is located.
3.7 ZIP CODE (Recommended, applies to health department & health care providers)
Enter ZIP code where facility providing information is located.
3.8 FACILITY TYPE (Required, applies to health department & health care providers)
Select the type of facility providing information.
Refer to the eHARS Technical Reference Guide for additional information regarding
allowable facility types.
3.9 DATE FORM COMPLETED (Required, applies to health department & health care providers)
Enter date in mm/dd/yyyy format using ‘..’ for unknown values (e.g., 03/../2011).
3.10 PERSON COMPLETING FORM (Optional, applies to health department & health care
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providers)
Enter the name of the person completing the form who can be contacted to clarify entries
and supply additional information.
3.11 PHONE (Recommended, applies to health department & health care providers)
Enter the telephone number of the person completing the form.
4. Patient Demographics
4.1
4.2
DIAGNOSTIC STATUS AT REPORT (Optional, applies to health department & health care
providers)
Use one form to capture each event regardless of the interval between diagnostic status
dates, and where the same source of these data reported more than one event. Fill out
suitable number of case report forms:
o Fill out the first form completely for the first diagnosis.
o Fill out subsequent forms partially, capturing additional or updated data absent
from the first form.
Forms referred to in the preceding bulleted item must include at least the following data:
Diagnostic Status Report; Residence at Diagnosis (see Residence at Diagnosis below); and
Facility of Diagnosis (see Facility of Diagnosis below).
Status depends on child’s age, clinical profile, and laboratory findings. Refer to Appendix
4.1.1–4.1.4 for further guidance.
4.1.1
PERINATAL HIV EXPOSURE
o Select “Perinatal HIV Exposure” if the patient is less than 18 months of age, was
born to an HIV-infected mother, and does not meet the criteria for HIV infection or
the criteria for “Not Infected with HIV.”
o Refer to Appendix 4.1.1 for further guidance.
4.1.2
PEDIATRIC HIV
o Select “Pediatric HIV” if the patient meets the criteria specified in the Revised
Surveillance Case Definition for HIV Infection in children < 13 years of age and
does not meet the current CDC pediatric HIV infection stage 3 (AIDS) case
definition.
o Refer to Appendix 4.1.2 for further guidance.
4.1.3
PEDIATRIC AIDS
o Select “Pediatric AIDS” if patient meets the current HIV infection stage 3 case
definition for children < 13 years of age.
o Refer to Appendix 4.1.3 for further guidance.
4.1.4
PEDIATRIC SEROREVERTER
o Select “Seroreverter” if the perinatally exposed child initially has a positive HIV
test but is found NOT to be HIV-infected through criteria listed in Appendix 4.1.4.
o Of the four diagnostic status categories available on the case report form (CRF),
“Pediatric Seroreverter” is synonymous with “Not Infected with HIV.”
SEX ASSIGNED AT BIRTH (Required, applies to health department & health care providers)
Select patient’s sex assigned at birth.
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4.3
In addition to “Male” or “Female” sex at birth, CDC-supplied software includes a third
choice of “Unknown.”
COUNTRY OF BIRTH (Recommended, applies to health department & health care providers)
Select applicable response.
For patients born in US minor outlying areas, specify the name of the US dependency from
the following table:
US Dependencies
Baker Island
Howland Island
Jarvis Island
Johnston Atoll
Kingman Reef
Midway Islands
Navassa Island
Palmyra Atoll
Wake Island
For patients born in any other area outside of the US and US minor outlying areas, specify
the country/US dependency name.
4.4 DATE OF BIRTH (Required, applies to health department & health care providers)
Enter patient’s date of birth in mm/dd/yyyy format using ‘..’ for unknown values (e.g.,
03/../2011).
4.5 ALIAS DATE OF BIRTH (Optional, applies to health department & health care providers)
If available, enter the Alias date of birth in mm/dd/yyyy format using ‘..’ for unknown values
(e.g., 03/../2011).
4.6 VITAL STATUS (Required, applies to health department & health care providers)
Enter vital status at time of this report.
For further guidance on death ascertainment, see the file Death Ascertainment.
4.7 DATE OF DEATH (Required if applicable, applies to health department & health care
providers)
If patient is deceased, enter date of death in mm/dd/yyyy format using ‘..’ for unknown
values (e.g., 03/../2011).
For further guidance on death ascertainment, see the file Death Ascertainment.
4.8 STATE OF DEATH (Required, if applicable, applies to health department & health care
providers)
If patient is deceased, enter the state name where the death occurred. If the death occurred
outside of the US, enter “Foreign Country”.
4.9 DATE OF LAST MEDICAL EVALUATION (Optional, applies to health department & health
care providers)
Enter the date of the child’s last medical evaluation in mm/dd/yyyy format using ‘..’ for
unknown values (e.g., 03/../2011) regardless of reason for exam. This includes emergency
room visits.
4.10 DATE OF INITIAL EVALUATION FOR HIV INFECTION (Optional, applies to health
department & health care providers)
Enter the date of initial evaluation for HIV infection in mm/dd/yyyy format using ‘..’ for
unknown values (e.g., 03/../2011). This is the date when HIV infection was first considered,
either clinically or through laboratory evaluation.
For a child whose mother is known to be HIV infected at the time of birth and for whom
assessment of HIV is done at birth, use the date of birth. This assessment does not
necessarily include an order for an HIV test, although documentation of an HIV test is often
the earliest evidence that the diagnosis was considered.
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4.11
4.12
4.13
4.14
Evidence of HIV infection in a child must be obtained on or after the birth date.
ETHNICITY (Required, applies to health department & health care providers)
If search for this datum was completed and ethnicity could not be determined or if ethnicity
was documented to be unknown, select “Unknown”.
If no search for this datum was completed, leave this field blank.
Regardless of the availability of data on race, collect data on ethnicity.
As of January 2003, the US Office of Management and Budget (OMB) required that race
and ethnicity (Hispanic/Latino, Not Hispanic/Latino) for a person be collected as separate
variables.
A wide variety of ethnicities may be selected from values available in CDC-supplied
software. These ethnicities and codes are documented in the eHARS Technical Reference
Guide.
EXPANDED ETHNICITY (Optional if applicable, applies to health department & health care
providers)
Enter more specific ethnicity information for greater detail such as “Hispanic or Latino Cuban” or “Hispanic or Latino - Puerto Rican”.
Refer to the eHARS Technical Reference Guide for listing of expanded ethnicity.
RACE (Required, applies to health department & health care providers)
Select patient’s race even if information was submitted for ethnicity.
Select more than one race if applicable.
If no race information is available, select “Unknown”.
As of January 2003, the US Office of Management and Budget (OMB) required that systems
collect multiple races for a person (OMB Policy Directive 15 updated standards); at a
minimum, collect data on the following five categories: American Indian or Alaska Native,
Asian, Black or African American, Native Hawaiian or Other Pacific Islander, and White.
Refer to the eHARS Technical Reference Guide for further details.
EXPANDED RACE (Optional, if applicable, applies to health department & health care
providers)
Enter more specific race information for greater detail such as “American Indian or Alaska
Native.Navajo” or “White.Middle Eastern or North African”.
Refer to the eHARS Technical Reference Guide for listing of expanded race.
5. Residence at Diagnosis
5.1
5.2
Refer to Appendix 5.0 for further guidance.
If patient’s residence at HIV diagnosis and stage 3 (AIDS) diagnosis are different, enter the
address information associated with the stage 3 (AIDS) diagnosis in the Comments section.
ADDRESS EVENT TYPE (Required, applies to health department & health care providers)
Select the address event type for the patient’s residence at diagnosis.
If the patient’s residence at HIV diagnosis and stage 3 (AIDS) diagnosis was the same, you
may check both.
ADDRESS TYPE (Required, applies to health department & health care providers)
Select one address type for the patient’s address of residence at diagnosis.
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5.3
5.4
5.5
5.6
5.7
STREET ADDRESS (Required, applies to health department & health care providers)
Enter street address of residence at diagnosis.
CITY (Required, applies to health department & health care providers)
Enter city of residence at diagnosis.
COUNTY (Required, applies to health department & health care providers)
Enter county of residence at diagnosis.
STATE/COUNTRY (Required, applies to health department & health care providers)
Enter the state and country name of residence at diagnosis.
ZIP CODE (Required, applies to health department & health care providers)
Enter the ZIP code of residence at diagnosis.
6. State/Local Use Only
The information in this section is not transmitted to CDC and is meant only for state and
local health department use. State and local health departments should develop their own
policies for collecting the data elements within this section. Collection of information within
this section is Optional.
7. Facility of Diagnosis
7.1
7.2
7.3
7.4
7.5
7.6
7.7
7.8
If the patient’s HIV diagnosis and stage 3 (AIDS) diagnosis occurred at
different facilities, enter the stage 3 (AIDS) facility information in the
Comments section.
DIAGNOSIS TYPE (Recommended, applies to health department & health care providers)
Enter the diagnosis type that corresponds to the facility of diagnosis being
reported.
FACILITY NAME (Recommended, applies to health department & health care providers)
Enter name of the facility where patient was first diagnosed which
corresponds with the “Diagnosis Type” reported in 7.1.
Refer to Appendix 7.2 for further details.
PHONE (Recommended, applies to health department & health care providers)
Enter area code and telephone number of the facility of diagnosis.
STREET ADDRESS (Recommended, applies to health department & health care providers)
Enter street address of the facility of diagnosis.
CITY (Recommended, applies to health department & health care providers)
Enter city of the facility of diagnosis.
COUNTY (Recommended, applies to health department & health care providers)
Enter county of the facility of diagnosis.
STATE/COUNTRY (Recommended, applies to health department & health care providers)
Enter state and country name of the facility of diagnosis.
ZIP CODE (Recommended, applies to health department & health care providers)
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Enter ZIP code where the facility of diagnosis is located.
7.9 FACILITY TYPE (Required applies to health department & health care
providers)
Select the type of facility of diagnosis.
Refer to the eHARS Technical Reference Guide for listing of facility types.
7.10 PROVIDER NAME (Recommended, applies to health department & health care providers)
Enter provider’s name where the patient was first diagnosed which
corresponds with the “Diagnosis Type” reported in 7.1.
7.11 PROVIDER PHONE (Recommended, applies to health department & health care
providers)
Enter area code and telephone number for provider selected in 7.10.
7.12 SPECIALTY (Optional, applies to health department & health care providers)
Enter provider’s specialty for provider selected in 7.10.
8. Patient History
These data yield information about how patients may have acquired their infection.
Respond to each risk factor, selecting “Yes” for all factors that apply; “No” for those that do
not apply (only select “No” if medical record specifically states this is not a risk factor); and
“Unknown” for those for which investigation failed to yield an answer. If an investigation
for a particular item was not performed, then you should leave it blank. Collect data about
risk factors that occurred before the earliest known diagnosis of HIV infection. For further
guidance, see the file Risk Factor Ascertainment.
If the biological mother is known to be HIV infected and this is the only maternal risk, then
the case will initially be classified as “mother has HIV infection, risk not specified”.
Information on the child refers to circumstances or behaviors that were thought to have
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8.1
8.2
8.3
8.4
8.5
exposed the child to HIV, not to treatments since the child became HIV infected. For
example, if the child received a blood transfusion after the documentation of HIV infection,
do not enter that information on the form.
The state or local Cases of Public Health Importance (COPHI) coordinator should contact
the CDC COPHI coordinator as soon as possible if any unusual transmission circumstances
are suspected. For further guidance, see the file Risk Factor Ascertainment.
CHILD’S BIOLOGICAL MOTHER’S HIV INFECTION STATUS (Required, applies to
health department & health care providers)
If mother was diagnosed with HIV infection, select from boxes 3–8 (i.e., box “Known HIV+
before pregnancy” to box “HIV+, time of diagnosis unknown”), depending on information
available to determine the timing of her diagnosis. Where date of mother’s first positive HIV
confirmatory test is available, select the appropriate box by comparing the date of birth to
the date of the mother’s diagnosis.
Refer to Appendix 8.1 for further guidance.
DATE OF MOTHER’S FIRST POSITIVE HIV CONFIRMATORY TEST (Optional, applies
to health department & health care providers)
Where mother is known to be HIV infected, enter month, day, and year of the first positive
HIV confirmatory test in mm/dd/yyyy format using ‘..’ for unknown values (e.g., 03/../2011).
Refer to Appendix 8.2 for further guidance.
WAS THE BIOLOGICAL MOTHER COUNSELED ABOUT HIV TESTING DURING THIS
PREGNANCY, LABOR, OR DELIVERY? (Optional, applies to health department & health
care providers)
Complete this question for all mothers regardless of whether they were diagnosed with HIV
infection before this pregnancy.
Select “Yes” if mother was counseled at any time during this pregnancy, labor, or delivery
by a health care provider (private or public) about the risks of HIV in pregnancy and the
risks, benefits, and meaning of HIV testing.
If not, select “No.”
If no information in the medical chart is available regarding counseling, then select
“Unknown”.
AFTER 1977, AND BEFORE THE EARLIEST KNOWN DIAGNOSIS OF HIV INFECTION,
THIS CHILD’S BIOLOGICAL MOTHER HAD:
8.4.1
PERINATALLY ACQUIRED HIV INFECTION (Required, applies to health
department & health care providers)
o Select applicable response.
8.4.2
INJECTED NON-PRESCRIPTION DRUGS (Required, applies to health department
& health care providers)
o Select applicable response.
BIOLOGICAL MOTHER HAD HETEROSEXUAL RELATIONS WITH ANY OF THE
FOLLOWING:
This section relates to ascertainment of risk among heterosexual sex partners of the
biological mother of the case patient.
Verification of sex partner’s HIV infection status is not necessary.
8.5.1
INTRAVENOUS/INJECTION DRUG USER (Required, applies to health department
& health care providers)
o Select applicable response.
8.5.2
BISEXUAL MALE (Required, applies to health department & health care providers)
o Select applicable response.
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8.5.3
8.5.4
8.5.5
8.5.6
8.5.7
8.5.8
8.5.9
8.5.10
PERSON WITH HEMOPHILIA/COAGULATION DISORDER WITH
DOCUMENTED HIV INFECTION (Required, applies to health department & health
care providers)
o “Coagulation disorder” or “hemophilia” refers only to a disorder of a clotting
factor, which is any of the circulating proteins named Factor I, Factor II, Factor III,
etc., through Factor XII. These disorders include Hemophilia A and Von
Willebrand’s disease (Factor VIII disorders) and Hemophilia B (a Factor IX
disorder).
o Refer to Appendix 8.5.3 for further guidance.
o If yes, alert the state/local Cases of Public Health Importance (COPHI)
coordinator.
TRANSFUSION RECIPIENT WITH DOCUMENTED HIV INFECTION (Required,
applies to health department & health care providers)
o Consider documenting the reason for transfusion in the comments section.
o Refer to Appendix 8.5.4 for further guidance.
o If yes, alert the state/local Cases of Public Health Importance (COPHI)
coordinator.
TRANSPLANT RECIPIENT WITH DOCUMENTED HIV INFECTION (Required,
applies to health department & health care providers)
o Consider documenting the reason for transfusion/transplant in the Comments
section.
o If yes, alert the state/local Cases of Public Health Importance (COPHI)
coordinator.
PERSON WITH DOCUMENTED HIV INFECTION, RISK NOT SPECIFIED
(Required, applies to health department & health care providers)
o Select “Yes” only if male partner is known to be HIV-positive and that partner’s
risk for HIV is unknown.
RECEIVED TRANSFUSION OF BLOOD/BLOOD COMPONENTS (OTHER
THAN CLOTTING FACTOR) (Required, applies to health department & health care
providers)
o ‘Blood,’ is defined as a circulating tissue composed of a fluid portion (plasma) with
suspended formed elements (red blood cells, white blood cells, platelets).
o ‘Blood components’ that can be transfused, include erythrocytes, leukocytes,
platelets, and plasma.
o If “Yes,” specify the month, day, and year of the first and last transfusion before
the child’s biological mother received a diagnosis of HIV infection (stage 1,2,
unknown) or stage 3 (AIDS). Enter date in mm/dd/yyyy format using ‘..’ for
unknown values (e.g., 03/../2011).
o Consider documenting the reason for transfusion/transplant in the Comments
section.
o If the last transfusion was after March 1985, alert the state/local Cases of Public
Health Importance (COPHI) coordinator.
FIRST DATE RECEIVED (Required, applies to health department & health care
providers)
o Enter date in mm/dd/yyyy format using ‘..’ for unknown values (e.g., 03/../2011).
LAST DATE RECEIVED (Required, applies to health department & health care
providers)
o Enter date in mm/dd/yyyy format using ‘..’ for unknown values (e.g., 03/../2011).
RECEIVED TRANSPLANT OF TISSUES/ORGANS OR ARTIFICIAL
INSEMINATION (Required, applies to health department & health care providers)
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National HIV Surveillance System Technical Guidance – PCRF and PHER Form, XXXX 2019
o If this is the only risk factor present and the biological mother did not have a
diagnosis of HIV infection at the time of child’s birth, the transmission mode will
be initially classified as “risk not reported/identified” pending outcome of the
COPHI investigation.
o If yes, alert the state/local Cases of Public Health Importance (COPHI)
coordinator.
8.6 BEFORE THE DIAGNOSIS OF HIV INFECTION, THIS CHILD HAD
Alert state/local COPHI coordinator if the child had one or more of the risk factors
documented in this section.
8.6.1
INJECTED NON-PRESCRIPTION DRUGS (Required, applies to health department
& health care providers)
o Select applicable response.
8.6.2
RECEIVED CLOTTING FACTOR FOR HEMOPHILIA/COAGULATION
DISORDER (Required, applies to health department & health care providers)
o “Coagulation disorder” or “hemophilia” refers only to a disorder of a clotting
factor; factors are any of the circulating proteins named Factor I through Factor
XII. These disorders include Hemophilia A and Von Willebrand’s disease (Factor
VIII disorders) and Hemophilia B (a Factor IX disorder).
o This risk factor is generally documented in the history and physical section of the
patient’s medical chart.
o They do not include other bleeding disorders, such as thrombocytopenia, treatable
by platelet transfusion.
o If only a transfusion of platelets, other blood cells, or plasma was received by the
partner, then select “No.”
o Alert state/local COPHI coordinator if child was born after March 1998 and receipt
of clotting factor is the suspected mode of HIV transmission.
8.6.3
SPECIFY CLOTTING FACTOR (Required, applies to health department & health
care providers)
o If “Yes” to 8.6.2, above, then enter the specific clotting factor.
o Enter the date the clotting factor was received in mm/dd/yyyy format using ‘..’ for
unknown values (e.g., 03/../2011).
8.6.4
RECEIVED TRANSFUSION OF BLOOD/BLOOD COMPONENTS (OTHER
THAN CLOTTING FACTOR) (Required, applies to health department & health care
providers)
o If child received a transfusion of blood cells (red cells, white cells, and platelets) or
plasma, specify month, day, and year of first and last transfusion before the patient
was infected with HIV or received a diagnosis of stage 3 or AIDS. Enter date in
mm/dd/yyyy format using ‘..’ for unknown values (e.g., 03/../2011).
o It is often helpful to document the reason for the transfusion in the Comments
section.
8.6.5
RECEIVED TRANSPLANT OF TISSUE/ORGANS (Required, applies to health
department & health care providers)
o The case will be initially classified as “risk not reported/identified” pending
outcome of the no identified risk (NIR) investigation.
o If yes, alert the state/local Cases of Public Health Importance (COPHI)
coordinator.
8.6.6
SEXUAL CONTACT WITH A MALE (Required, applies to health department &
health care providers)
o If child is known to have had sexual contact/abuse, mark the appropriate box.
o If this is the only risk history, the case will be initially classified as “risk not
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8.6.7
8.6.8
reported/identified” pending outcome of NIR investigation.
o Alert state/local COPHI coordinator.
SEXUAL CONTACT WITH A FEMALE (Required, applies to health department &
health care providers)
o If the child is known to have had sexual contact/abuse, mark the appropriate box.
o If this is the only risk history, the case will be initially classified as
“risk not reported/identified” pending outcome of NIR investigation.
o Alert state/local COPHI coordinator.
OTHER DOCUMENTED RISK (Alert State/Local NIR Coordinator) (Required,
applies to health department & health care providers)
o Include detail in Comments section.
9. Clinical: Opportunistic Illnesses
9.1
CLINICAL: OPPORTUNISTIC ILLNESSES
9.1.1–9.1.27 (Optional, applies to health department & health care providers)
o Select all that apply and enter diagnosis dates. Enter date in mm/dd/yyyy format
using ‘..’ for unknown values (e.g., 03/../2011).
o For additional information, refer to the most recent case definition for HIV
infection (available at http://wwwn.cdc.gov/nndss/conditions/hiv-infection/).
9.1.28 RVCT CASE NUMBER (Optional, applies to health department & health care
providers)
o If this patient has a verified case of tuberculosis (TB), health department staff enter
the nine-digit alphanumeric code from the TB case report or TB data management
system. Providers in the private and public sectors diagnosing tuberculosis in their
stage 3 (AIDS) patients may get this number from TB surveillance staff.
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National HIV Surveillance System Technical Guidance – PCRF and PHER Form, XXXX 2019
10. Laboratory Data
Throughout this section, “Collection Date” refers to the date when the specimen was
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10.1
collected or drawn. Enter collection dates in mm/dd/yyyy format using ‘..’ for unknown
values (e.g., 03/../2011).
Record all laboratory tests. Include all diagnostic tests, viral load tests, CD4 tests, and drug
resistance tests (genotypic) where possible. Where the number of tests exceeds the number
of fields available on the form, record such results in the Comments section. In eHARS,
enter the additional test results on the lab data tab with the applicable test type.
Include tests with negative or indeterminate results that are part of a diagnostic testing
algorithm whose overall interpretation is positive (that the patient is HIV-infected).
In the absence of lab tests, record HIV infection or stage 3 (AIDS) diagnostic evidence
documented in the chart by a physician.
HIV IMMUNOASSAYS (NON-DIFFERENTIATING)
Assuming active case finding, review patient’s chart and lab reports for the earliest date of
documented HIV positivity. “Indeterminate” refers to Indeterminate HIV antibody test
results.
Enter the brand name of the test and/or its manufacturer, lab name, facility name and
provider name. (Optional, applies to health department & health care providers)
Enter results and collection dates for all tests (including negative or indeterminate test
results) that are part of a diagnostic testing algorithm whose overall interpretation is
positive (that the patient is HIV-infected). (Required, applies to health department &
health care providers)
o Enter specimen collection date in mm/dd/yyyy format using ‘..’ for unknown values
(e.g., 03/../2011).
Check the Point-of-care rapid test box if the test is a CLIA waived point-of-care rapid test.
(Optional, applies to health department & health care providers)
10.1.1 HIV-1 IA
o Enter result and collection date of first HIV-1 IA. (Required, applies to health
department & health care providers)
o “Positive IA” means repeatedly reactive tests on a single sample.
10.1.2 HIV-1/2 IA
o Enter result and collection date of first HIV-1/2 combination IA test. (Required,
applies to health department & health care providers)
10.1.3 HIV-1/2 AG/AB
o Enter result and collection date of combined p24 antigen and anti HIV1/2 antibody
screening assay. (Required, applies to health department & health care providers)
10.1.4 HIV-1 WESTERN BLOT
o Enter the result and collection date of first HIV-1 Western blot. (Required, applies
to health department & health care providers)
o Western blot banding patterns should be interpreted according to the
CDC/Association of State and Territorial Public Health Laboratory Directors
(ASTPHLD) recommendations “Interpretation and Use of the Western Blot Assay
for Serodiagnosis of Human Immunodeficiency Virus Type 1 Infections ”
(MMWR, 1989:38:No.S-7).
10.1.5 HIV-1 IFA
o Enter the result and collection date of first HIV-1 IFA. (Required, applies to health
department & health care providers)
10.1.6 HIV-2 IA
o Enter result and date of first HIV-2 IA. (Required, applies to health department &
health care providers)
o “Positive IA” means repeatedly reactive tests on a single sample.
10.1.7 HIV-2 WESTERN BLOT
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10.2
10.3
o Enter the result and collection date of first HIV-2 Western blot. (Required, applies
to health department & health care providers)
HIV IMMUNOASSAYS (DIFFERENTIATING)
Assuming active case finding, review patient’s chart and lab reports for the earliest date of
documented HIV positivity.
Enter the brand name of the test and/or its manufacturer, lab name, facility name and
provider name. (Optional, applies to health department & health care providers)
Enter results and collection dates for all tests (including negative or indeterminate test
results) that are part of a diagnostic testing algorithm whose overall interpretation is
positive (that the patient is HIV-infected). (Required, applies to health department &
health care providers)
o Enter specimen collection date in mm/dd/yyyy format using ‘..’ for unknown values
(e.g., 03/../2011).
10.2.1 HIV-1/2 TYPE-DIFFERENTIATING IMMUNOASSAY
o Enter collection date of first HIV-1/2 Type-Differentiating IA. (Required, applies
to health department & health care providers)
o Enter the role of the test in the diagnostic algorithm, “screening/initial” or
“confirmatory/supplemental”. That is, was the test used as a screening/initial test in
the recommend diagnostic algorithm or was the test used as a
confirmatory/supplemental test in the recommended diagnostic algorithm.
o Enter the overall interpretation of the test (Required, applies to health department
& health care providers)
o Record the result for each analyte (HIV-1Ab and HIV-2 Ab). That is, one result
should be recorded for HIV-1 Ab and one result should be recorded for HIV-2 Ab.
(Required, applies to health department & health care providers).
o Check the Point-of-care rapid test box if the test is a CLIA waived point-of-care
rapid test. (Optional, applies to health department & health care providers)
10.2.2 HIV-1/2 AG/AB-DIFFERENTIATING IMMUNOASSAY
o Enter result and collection date of first HIV-1/2 Ag/Ab-Differentiating IA.
(Required, applies to health department & health care providers)
o If the result is HIV Ab reactive or HIV Ag reactive and HIV Ab reactive, check the
box for “Ab positive” or “Both (Ag and Ab reactive)”, respectively, on the ACRF.
These indicate that antibodies to HIV-1 or HIV-2 were detected.
10.2.3 HIV-1/2 AG/AB AND TYPE-DIFFERENTIATING IMMUNOASSAY
o Enter collection date of first HIV-1/2 Ag/Ab and Type-Differentiating IA.
(Required, applies to health department & health care providers)
o Enter the Overall interpretation of the test. (Required, applies to health department
& health care providers)
o If provided enter index value for the overall interpretation.(Optional, applies to
health department & health care providers)
o Record the result for each analyte (HIV-1 Ag and HIV-1 Ab and HIV-2 Ab). That
is, one result should be recorded for HIV-1 Ag, one result for HIV-1 Ab and one
result should be recorded for HIV-2 Ab. (Required, applies to health department &
health care providers)
o Enter the index value for each analyte.(Optional, applies to health department &
health care providers)
HIV DETECTION TESTS (QUALITATIVE)
All varieties of such tests establish the presence of the pathogen, HIV. By contrast, HIV
tests such as the IA or Western blot establish the presence of the immune system’s
response to the pathogen (i.e., HIV antibodies).
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10.4
10.5
Assuming active case finding, review patient’s chart and lab reports for the earliest date of
documented HIV positivity.
Enter the brand name of the test and/or its manufacturer, lab name, facility name and
provider name. (Optional, applies to health department & health care providers)
Enter results and collection dates for all tests (including negative or indeterminate test
results) that are part of a diagnostic testing algorithm whose overall interpretation is
positive (that the patient is HIV-infected). (Required, applies to health department &
health care providers)
o Enter specimen collection date in mm/dd/yyyy format using ‘..’ for unknown values
(e.g., 03/../2011).
10.3.1 HIV-1 RNA/DNA NAAT (QUALITATIVE)
o Enter result and collection date of earliest NAAT. (Required, applies to health
department & health care providers)
10.3.2 HIV-1 CULTURE
o Enter result and collection date of earliest test by culture. (Required, applies to
health department & health care providers)
10.3.3 HIV-2 RNA/DNA NAAT (QUALITATIVE)
o Enter result and collection date of earliest NAAT. (Required, applies to health
department & health care providers)
10.3.4 HIV-2 CULTURE
o Enter result and collection date of earliest test by culture. (Required, applies to
health department & health care providers)
HIV DETECTION TESTS (QUANTITATIVE VIRAL LOAD)
o Enter the brand name of the test and/or its manufacturer, lab name, facility name and
provider name. (Optional, applies to health department & health care providers)
o Indicate if results are “Detectable” or “Undetectable”. Viral load tests with undetectable
results should also be entered. (Optional, applies to health department & health care
providers)
o Enter results in units of viral copies per milliliter (mL) and Log. (Required, applies to
health department & health care providers)
o Where results are reported above the limit of quantification (LOQ), select
“Detectable” then enter “greater than detection limits for this assay” and the
result value in the copies/mL field.
o Where the results reported are below the LOQ, select “Undetectable” then enter
“fewer than detectable by this assay” and the result value in the copies/mL field.
For example, a result of “<48 cp/mL detected” should be entered into the
copies/ml field as “fewer than detectable by this assay - 48 cp/mL”.
o Enter specimen collection date in mm/dd/yyyy format using ‘..’ for unknown values (e.g.,
03/../2011).
10.4.1 HIV-1 RNA/DNA NAAT (QUANTITATIVE VIRAL LOAD)
o Enter result and collection date of earliest test. (Required, applies to health
department & health care providers)
10.4.2 HIV-2 RNA/DNA NAAT (QUANTITATIVE VIRAL LOAD)
o Enter result and collection date of earliest test. (Required, applies to health
department & health care providers)
DRUG RESISTANCE TESTS (GENOTYPIC)
This section should be completed if there is evidence of a drug resistance test
(genotypic), regardless of the type of drug resistance test, in the patient’s medical or
other record.
Enter the brand name of the test and/or its manufacturer, lab name, facility name and
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10.6
provider name. (Optional, applies to health department & health care providers)
Enter the collection date of the earliest test. (Required, applies to health department &
health care providers)
When entering this information in eHARS, you should use the lab data tab and choose
“HIV-1 Genotype (Unspecified)” as the test type. You will not be able to enter a
genotype sequence since this test type only captures evidence of a drug resistance test
(genotypic). If a corresponding genotype sequence is subsequently received, you should
import this information as a separate laboratory document using the test type that reflects
the type of drug resistance test that was conducted (e.g., HIV-1 Genotype (PR/RT
Nucleotide Sequence)).
IMMUNOLOGIC TESTS (CD4 COUNT AND PERCENTAGE)
Enter the brand name of the test and/or its manufacturer, lab name, facility name and
provider name. (Optional, applies to health department & health care providers)
Whenever CD4 count and percentage are both available for the same specimen
collection date, record both.
Enter specimen collection date in mm/dd/yyyy format using ‘..’ for unknown values (e.g.,
03/../2011). (Required, applies to health department & health care providers)
10.6.1 CD4 AT OR CLOSEST TO DIAGNOSIS
o This is the first CD4 result closest to the date of initial HIV infection diagnosis,
regardless of stage of disease at diagnosis.
10.6.1.1 CD4 COUNT
Record the CD4 count closest to the time when the patient was determined
to be HIV infected. If this information is not available when the initial case
report is completed, it may be entered later.
Enter result and specimen collection date of first CD4 count. (Required,
applies to health department & health care providers)
10.6.1.2 CD4 PERCENTAGE
Record the CD4 percentage closest to the time when the patient was
determined to be HIV infected. If this information is not available when the
initial case report is completed, it may be entered later.
Record result and specimen collection date of first CD4 percentage.
(Required, applies to health department & health care providers)
10.6.2 FIRST CD4 RESULT < 200 cells/μL or < 14%
o This is the first CD4 result indicative of stage 3 (AIDS). The stage is based
primarily on the CD4 count; the CD4 count takes precedence over the CD4
percentage, and the percentage is considered only if the count is missing.
10.6.2.1 CD4 COUNT
Record results and specimen collection date of first CD4 indicative of stage
3 (i.e., < 200 cells/μL). (Required, applies to health department & health
care providers)
10.6.2.2 CD4 PERCENTAGE
Record results and specimen collection date if: (Required, applies to health
department & health care providers)
o The CD4 percentage was from a specimen collected on the same
date as the first CD4 count indicative of stage 3 (see section 9.5.2.1
above) or
o The first CD4 percentage indicative of stage 3 (i.e., <14%) was from
a specimen collected on an earlier date than the first CD4 count
indicative of stage 3 and was not accompanied by a CD4 count for
the same date.
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10.7
10.6.3 Other CD4 RESULT
10.6.3.1 CD4 COUNT
Enter results and specimen collection date of other CD4 count. (Required,
applies to health department & health care providers)
10.6.3.2 CD4 PERCENTAGE
Record results and specimen collection date of other CD4 percentage.
(Required, applies to health department & health care providers)
DOCUMENTATION OF TESTS
10.7.1 DID DOCUMENTED LABORATORY TEST RESULTS MEET APPROVED HIV
DIAGNOSTIC ALGORITHM CRITERIA? (Required if applicable, applies to health
department & health care providers)
o This section captures diagnoses through novel algorithms, and should only be
completed if none of the following were positive for HIV-1: Western blot, IFA,
culture, viral load, qualitative NAAT (RNA or DNA), HIV-1/2 type-differentiating
immunoassay (supplemental test), stand-alone p24 antigen test, or nucleotide
sequence.
o HIV-1 antigen analyte results from combination antigen/antibody tests in which the
antigen result can be differentiated from the antibody result, such as an “HIV-1/2
Ag/Ab differentiating immunoassay” or an “HIV-1/2 Ag/Ab and typedifferentiating immunoassay”, are not considered stand-alone p24 antigen tests.
Refer to sections 10.2.2 and 10.2.3 for more information regarding these
combination Ag/Ab immunoassays.
o “Approved HIV diagnostic algorithm criteria” means any criteria that satisfy the
HIV surveillance case definition, regardless of whether approved for other
purposes such as laboratory-based HIV testing or point-of-care HIV screening.
o If “Yes”, enter date of earliest positive test for this algorithm in mm/dd/yyyy format
using ‘..’ for unknown values (e.g., 03/../2011). (Required if applicable, applies to
health department & health care providers)
10.7.2 IF LABORATORY TESTS WERE NOT DOCUMENTED, IS PATIENT
CONFIRMED BY A PHYSICIAN AS (HIV-INFECTED or NOT HIV-INFECTED)
(Required if applicable, applies to health department & health care providers)
o If laboratory evidence of an HIV test is unavailable or was insufficient to meet
surveillance case definition in the patient’s medical or other record and written
documentation of lab evidence of HIV infection consistent with the HIV case
definition is noted by the physician, enter “Yes”; otherwise enter “No” or
“Unknown.”
10.7.2.1 HIV-INFECTED (Required if applicable, applies to health department &
health care providers)
IF “YES” TO 10.7.2.1, PROVIDE DATE OF DIAGNOSIS BY
PHYSICIAN (Required in the absence of lab results, applies to health
department & health care providers)
Date of diagnosis is defined as the date (at least the year) of diagnosis
reported in the content of the medical record. If the diagnosis date was not
reported in the note, the date when the note was written can be used as a
proxy. For example, if a health care provider writes a note in a medical
chart on 4/10/2010 stating the patient had positive HIV EIA and WB on
2/11/2010, this should be recorded as 2/11/2010 as the date of diagnosis by
the physician.
10.7.2.2 NOT HIV-INFECTED (Required if applicable, applies to health department
& health care providers)
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National HIV Surveillance System Technical Guidance – PCRF and PHER Form, XXXX 2019
IF “YES” TO 10.7.2.2, PROVIDE DATE OF DIAGNOSIS BY
PHYSICIAN (Required in the absence of lab results, applies to health
department & health care providers)
Date of diagnosis is defined as the date (at least the year) when the patient
was determined to be “not HIV-infected”.
11. Birth History (for Perinatal Cases only)
11.1 BIRTH HISTORY AVAILABLE (Optional, applies to health department & health care
providers)
If birth history is not available, proceed to next section.
11.2 RESIDENCE AT BIRTH (Required, applies to health department & health care providers)
Select one of the address types for the patient’s residence at time of birth.
Enter the street address, city, county, state, country name, and zip code of the patient’s
residence at time of birth
11.3 FACILITY OF BIRTH (Optional, applies to health department & health care providers)
Check if same as facility providing information.
Enter name, address, phone, city, county, state/country and zip code of the hospital/clinic of
birth.
Sites should uniformly record hospital names, including abbreviations.
If this child was born at home, enter “home birth”.
11.4 BIRTH HISTORY
11.4.1 BIRTH WEIGHT (Optional, applies to health department & health care providers)
o Enter the birth weight in pounds and ounces, or grams.
o If recorded only in pounds and ounces, convert to grams.
11.4.2 TYPE (Optional, applies to health department & health care providers)
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National HIV Surveillance System Technical Guidance – PCRF and PHER Form, XXXX 2019
11.4.3
11.4.4
11.4.5
11.4.6
11.4.7
11.4.8
11.4.9
o Select applicable response. If unknown, select “9.”
DELIVERY (Optional, applies to health department & health care providers)
o Elective cesarean section refers to a cesarean section that occurs before rupture of
membranes and before the onset of labor.
o Elective cesarean section has been demonstrated to reduce perinatal transmission of
HIV, if performed before the onset of labor.
o It will be important to monitor the trends in the use of elective cesarean section for
the prevention of perinatal HIV.
o Notes in the child’s records are acceptable even if no birth records are available.
BIRTH DEFECTS (Optional, applies to health department & health care providers)
o If “Yes,” specify type.
o Refer to Appendix 11.4.4 for further guidance and an abbreviated list of birth
defects.
NEONATAL STATUS (Optional, applies to health department & health care
providers)
o Select applicable response and record the child’s gestational age, if known, in the
boxes provided.
o “Full term” is defined as gestational age greater than or equal to 37 weeks.
o “Premature” is defined as gestational age less than 37 weeks.
o If search for gestational age was unsuccessful, then enter “99” for unknown
number of weeks.
o Post mature neonatal status (after 40 weeks) should be recorded as full term.
11.3.5.1 NEONATAL GESTATIONAL AGE IN WEEKS
Enter weeks of gestation.
PRENATAL CARE (Optional, applies to health department & health care providers)
o Prenatal care is defined as any care for the pregnancy beyond pregnancy testing
and before delivery, even if no regular follow-up ensued.
MONTH OF PREGNANCY PRENATAL CARE BEGAN (Optional, applies to
health department & health care providers)
o Record the gestational month of pregnancy (01 to 09) that the mother began her
prenatal care.
o If any fraction of a month is reported, round to the next whole month.
o In the absence of prenatal care, enter “00.”
o If search for this datum was unsuccessful, then enter “99” for month of first visit.
o Refer to Appendix 11.4.7 for further guidance.
TOTAL NUMBER OF PRENATAL CARE VISITS (Optional, applies to health
department & health care providers)
o Record the total number of times the mother went to the clinic or doctor for her
prenatal care; exclude visits unrelated to prenatal care.
o In the absence of prenatal care visits, enter “00”.
o In the presence of prenatal care and search for this datum was unsuccessful, then
enter “99” for number of prenatal visits.
o Where data source reports a range of visits (e.g., “10–13”), enter the lowest number
(e.g., “10”).
DID MOTHER RECEIVE ANTIRETROVIRALS (ARVs) PRIOR TO THIS
PREGNANCY? (Recommended, applies to health department & health care
providers)
o ‘Pregnancy’ is defined as: The condition of having a developing embryo or fetus in
the body after union of an ovum and spermatozoon. Labor and delivery occur after
this interval, so they are not considered part of the ‘pregnancy’.
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National HIV Surveillance System Technical Guidance – PCRF and PHER Form, XXXX 2019
o Select “Yes” if information is available that states that the mother used ARVs prior
to this pregnancy. If “Yes”, record the date ARV treatment began and the date of
last use. Enter date in mm/dd/yyyy format using ‘..’ for unknown values (e.g.,
03/../2011).
o Select “No” if mother did not use ARVs prior to this pregnancy.
o If a woman did not receive ARVs, do not assume it was because she refused. Select
“Refused” only if explicit documentation in the medical record indicates that the
patient was offered the drug, but the patient declined.
o Select “Unknown” after an unsuccessful search for this datum.
11.3.9.1 IF “YES,” PLEASE SPECIFY ALL
11.4.10 DID MOTHER RECEIVE ARVs DURING PREGNANCY? (Recommended, applies
to health department & health care providers)
o Select “Yes” if information is available that states that the mother used ARVs any
time during pregnancy. If “Yes”, record the date ARV treatment began and the date
of last use. Enter date in mm/dd/yyyy format using ‘..’ for unknown values (e.g.,
03/../2011).
o Select “No” if mother did not use ARVs during pregnancy.
o Select “Refused” only if explicit documentation in the medical record indicates that
the patient was offered the drug, but the patient declined.
o Select “Unknown” if it is unknown whether the mother ever used ARVs during
pregnancy.
o 11.3.10.1 IF “YES,” PLEASE SPECIFY ALL
For a list of antiretroviral therapies currently available and link to
treatment guidelines, refer to Appendix 11.4.10.
11.4.11 DID MOTHER RECEIVE ARVs DURING LABOR/DELIVERY? (Recommended,
applies to health department & health care providers)
o Select “Yes” if information is available that states that the mother used ARVs any
time during labor/delivery. If “Yes”, record the date ARV treatment began and the
date of last use. Enter date in mm/dd/yyyy format using ‘..’ for unknown values
(e.g., 03/../2011).
o Select “No” if mother did not use ARVs during labor/delivery.
o Select “Refused” only if explicit documentation in the medical record indicates that
the patient was offered the drug, but the patient declined.
o Select “Unknown” if it is unknown whether the mother ever used ARVs during
labor/delivery.
11.3.11.1 IF “YES,” PLEASE SPECIFY ALL
11.5 MATERNAL INFORMATION
11.5.1 MATERNAL DATE OF BIRTH (DOB) (Optional, applies to health department &
health care providers)
o Enter the biological mother’s date of birth in mm/dd/yyyy format using ‘..’ for
unknown values (e.g., 03/../2011).
11.5.2 MATERNAL LAST NAME SOUNDEX (Optional, applies to health department)
o Enter maternal soundex here.
o After patient name is entered into CDC-supplied software, the software
automatically generates this variable by using the patient’s last name. After the
code is generated, health department staff should fill in this field on the form.
o This variable is a phonetic, alphanumeric code calculated by converting a surname
into an index letter and a three-digit code. The index letter is the first letter of the
surname. The eHARS Technical Reference Guide describes exactly how the Last
Name Soundex is created. You can access the eHARS Technical Reference Guide
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National HIV Surveillance System Technical Guidance – PCRF and PHER Form, XXXX 2019
11.5.3
11.5.4
11.5.5
through SharePoint:
https://cdcpartners.sharepoint.com/sites/NCHHSTP/HICSB/default.aspx
o Refer to Appendix 11.5.2 for further guidance.
MATERNAL STATE ID NUMBER (Optional, applies to health department)
o Enter assigned state number if the biological mother is known to be HIV infected.
o State numbers should not be reused.
MATERNAL COUNTRY OF BIRTH (Optional, applies to health department &
health care providers)
o Select applicable response.
o For mothers born in US minor outlying areas, specify the name of the US
dependency from the following table:
US Dependencies
Baker Island
Midway Islands
Howland Island
Navassa Island
Jarvis Island
Palmyra Atoll
Johnston Atoll
Wake Island
Kingman Reef
o For mothers born in any other area outside of the US and US minor outlying areas,
specify the country name.
o If this information is not available in the child’s records, it can be left blank and
updated on follow-up.
OTHER MATERNAL ID (Optional, applies to health department & health care
providers).
o Enter any other maternal ID type (such as social security number) and the number
of the other ID.
12. Treatment/Services Referrals
This section should be completed by the person initially notifying the health department of
the HIV case. Where health department staff populated fields in the Treatment/Services
Referrals section through chart abstraction, providers of surveillance data may defer this
task to public health workers.
This information should be updated for each child when there is a change in diagnostic
status, whenever possible.
12.1 THIS CHILD EVER TAKEN ANY ARVS (Required, applies to health department & health
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National HIV Surveillance System Technical Guidance – PCRF and PHER Form, XXXX 2019
12.2
12.3
12.4
12.5
12.6
care providers)
This variable indicates whether the patient has ever taken any antiretroviral medication.
“Yes” indicates there is evidence that the person has taken ARVs, including self-report.
If “Yes”, it is important to enter the dates when use began and, if appropriate, ended. Enter
date in mm/dd/yyyy format using ‘..’ for unknown values (e.g., 03/../2011).
“No” indicates there is evidence that the patient has never taken ARVs.
“Unknown” should be used when the person completing the form does not know whether
or not the patient has ever taken ARVs, after searching for the information or asking the
patient.
Leave the field blank if there was no attempt to find the information.
IF YES, REASON FOR ARV USE (Required, applies to health department & health care
providers)
Select all that apply.
“HIV Tx” indicates that the patient used ARVs to treat HIV infection.
“PrEP” indicates that the patient used ARVs prior to HIV diagnosis for HIV preexposure
prophylaxis (PrEP).
“PEP” indicates that the patient used ARVs as postexposure prophylaxis (PEP).
“PMTCT” indicates that the patient used ARVs to prevent HIV mother-to-childtransmission during pregnancy.
“HBV Tx” indicates that the patient used ARVs to treat hepatitis B virus infection.
“Other” indicates that the patients used ARVs for a reason other than those indicated
above.
ARV MEDICATIONS (Recommended, applies to health department & health care providers)
For each ARV use reason indicated in 12.2, list the medications taken.
This variable is used to verify that the medication taken was actually an antiretroviral.
It is not necessary to list every drug combination that may have been used; record at least
one ARV. Enter “unspecified” if an ARV was taken but the name is not known.
Refer to Appendix 12.3 for further guidance.
DATE BEGAN (Required, applies to health department & health care providers)
For each ARV use reason indicated in 12.2, enter the earliest date that the patient took the
ARVs, even if ARV use was sporadic.
If the first time ARVs were taken occurred after HIV diagnosis, it is very important to
enter a date, even an estimated date, later than the date of HIV diagnosis.
Enter date in mm/dd/yyyy format using ‘..’ for unknown values (e.g., 03/../2011).
DATE OF LAST USE (Required, applies to health department & health care providers)
For each ARV use reason indicated in 12.2, enter the most recent date of ARV use.
For patients currently on ARVs, record the date of the most recent prescription or known
usage. If the information was collected during a patient interview, the date would be the
interview date. If the information was collected as part of a medical record review, record
the date of the most recent prescription or date of the most recent physician’s note.
Enter date in mm/dd/yyyy format using ‘..’ for unknown values (e.g., 03/../2011).
HAS THIS CHILD EVER TAKE PCP PROPHYLAXIS? (Optional, applies to health
department & health care providers)
If nothing in the medical chart indicates the use of any of these drugs or refers to the
prophylactic treatment of PCP, then select “No.”
If “Yes,” enter the date the child was started on therapy to prevent the occurrence of PCP
and the date of last use in mm/dd/yyyy format using ‘..’ for unknown values (e.g.,
03/../2011).
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National HIV Surveillance System Technical Guidance – PCRF and PHER Form, XXXX 2019
“Unknown” is used if treatment information in the medical chart is unclear or was
unavailable.
Refer to Appendix 12.6 for further guidance.
WAS THIS CHILD BREASTFED? (Optional, applies to health department & health care
providers)
If there is suspicion that the child’s only exposure to HIV was through breast milk, the
local/state NIR coordinator should be alerted.
Refer to Appendix 12.7 for further guidance.
THIS CHILD’S PRIMARY CARETAKER IS (Optional, applies to health department &
health care providers)
Select the person who provides the majority of care for the child.
Refer to Appendix 12.8 for further guidance.
12.7
12.8
13.
Comments (Optional, applies to health department & health care providers)
14.
This section can be used for information not requested on the form or for information
requested but where there might not be room in the space provided.
As appropriate, information collected in this section can be entered in existing fields on the
PCRF of the CDC-supplied software.
Information entered into the “Comments” tab on the PCRF of the CDC-supplied software
will not be transmitted to CDC.
Local/Optional Fields (Optional, applies to health department)
This section is for collection of data that is not on the form at the state and local level.
This information is not sent to CDC.
Appendix. Pediatric HIV Confidential Case Report Form (CDC 50.42B)
Instructions for Completion
Purpose
Information captured on the Pediatric HIV Confidential Case Report Form (PCRF) provides
population-based data on diagnostic testing and initiation of prophylaxis and treatment, as well
as HIV-related morbidity and mortality among children (CARE Amendments [Section 2626])
to support states with prevention activities.
CDC’s Division of HIV/AIDS Prevention (DHAP) needs initial reports and updates to reflect
the earliest dates that children meet each reporting criteria (i.e., perinatal exposure, HIV
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infection, stage 3 or AIDS, seroreverter), as well as changes in diagnostic or vital status.
When a child who was previously reported as HIV infected has progressed to stage 3 (AIDS)
or has died, state/reporting area personnel update the National HIV Surveillance System
(NHSS) accordingly.
After programs receive initial reports of evidence of HIV exposure or infection among
children, surveillance staff follow up to determine whether diagnostic status of the child
changes. For example, staff updates reports of children with perinatal exposure after 6 months
of age to confirm or refute HIV infection and again at 18 months of age.
The PCRF can accommodate updated information including immunologic markers and
diagnoses of opportunistic infections.
CDC updated the PCRF and related software in 2000 to: evaluate the implementation and
impact of the Public Health Service (PHS) recommendations on the prevention of transmission
of HIV from mother to child; accommodate surveillance requirements of the Ryan White
CARE Act Amendments of 1996; and accommodate the revised 2000 HIV case definition for
perinatal HIV exposure, pediatric infection, and those perinatally exposed but not infected
with HIV.
In 1995, CDC added variables on receipt of maternal ARVs during pregnancy and
labor/delivery and neonatal ARV.
Maternal HIV counseling and testing, prenatal care, and refusal of ARV treatment were added
in 1996.
Viral load tests, receipt of additional antiretroviral (ARV) therapy during labor/delivery for the
newborn and elective cesarean were added to the pediatric reporting form in 1999.
These additions enable reporting areas to identify possible reasons for failures in preventing
HIV transmission related to childbirth (i.e., receipt of maternal HIV testing, prenatal care, and
antiretroviral treatment).
As states move toward pediatric HIV exposure reporting, information on receipt of prenatal,
intrapartum, and neonatal ARV and receipt of other antiretroviral therapy can be collected for
all children born to HIV-infected women. Timely follow-up of these children to determine
infection status will aid in evaluating the impact of these recommendations most effectively.
For evolution of the pediatric case definition, please refer to the 1987 pediatric AIDS case
definition (MMWR 1987;36(suppl):1–15S), the 1994 revised classification system for HIV
infection in children less than 13 years of age (MMWR 1994;43:(No. RR-12):1–10), and the
2000 HIV case definition in the CDC Guidelines for National Human Immunodeficiency
Virus Case Surveillance, Including Monitoring for Human Immunodeficiency Virus Infection
and Acquired Immunodeficiency Syndrome (MMWR 1999;48(RR-13):1–31), available at
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr4813a1.htm, the 2008 case definition
(MMWR 2008; 57 (RR-10) 1-12 at
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5710a1.htm, and the Revised Surveillance
Case Definition for HIV Infection — United States, 2014 (MMWR 2014;63 (RR03);1-10 at
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6303a1.htm?s_cid=rr6303a1_e.
Pediatric Cases of Public Health Importance (COPHI)
Reporting area staff should continue to discuss certain priority cases directly with CDC
surveillance staff. These include HIV infection in a health care setting, HIV-2 infection, HIV
infection attributed to tissue or organ transplantation, suspected transmission due to sexual
contact, mother-to-infant transmission due to breast feeding, transfusions after March 1985, or
any other unusual transmission circumstances. This direct communication will ensure the
timeliest technical support. For further guidance, see the file Risk Factor Ascertainment.
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National HIV Surveillance System Technical Guidance – PCRF and PHER Form, XXXX 2019
4. Patient Demographics
4.1
DIAGNOSTIC STATUS AT REPORT
4.1.1
PERINATAL HIV EXPOSURE
o The “Perinatal HIV Exposure” category is composed of “Presumptively Not
Infected,” “Definitively Not Infected,” and “Indeterminate.”
o A child aged less than 18 months born to an HIV-infected mother will be
categorized as having perinatal exposure to HIV infection if the child does not
meet the criteria for HIV infection or the criteria for “not infected with HIV.”
4.1.2
PEDIATRIC HIV
o Among children <18 months old whose mothers were not infected and all children
aged ≥18 months, a reportable case of HIV infection must meet at least one of the
following criteria:
1.1: Persons Aged ≥18 Months and Children Aged <18 Months whose Mothers
were Not Infected
1.1.1: Laboratory Evidence
Laboratory criteria require reporting of the date of the specimen collection for
positive test results in multitest algorithms or stand-alone virologic tests and enough
information about the tests to determine that they meet any of the following criteria:
A multitest algorithm consisting of
o A positive (reactive) result from an initial HIV antibody or
combination antigen/antibody test, and
o An accompanying or subsequent positive result from a supplemental
HIV test different from the initial test.
The initial HIV antibody or antigen/antibody test and the supplemental HIV
test that is used to verify the result from the initial test can be of any type used
as an aid to diagnose HIV infection. For surveillance purposes, supplemental
tests can include some not approved by the Food and Drug Administration
(FDA) for diagnosis (e.g., HIV-1 viral load test, HIV-2 Western
blot/immunoblot antibody test, and HIV-2 NAT). However, the initial and
supplemental tests must be "orthogonal" (i.e., have different antigenic
constituents or use different principles) to minimize the possibility of
concurrent nonspecific reactivity. Because the antigenic constituents and test
principles are proprietary information that might not be publicly available for
some tests, tests will be assumed to be orthogonal if they are of different
types. For example:
o One test is a combination antigen/antibody test and the other an antibodyonly test.
o One test is an antibody test and the other a NAT.
o One test is a rapid immunoassay (a single-use analytical device that
produces results in <30 minutes) and the other a conventional
immunoassay.
o One test is able to differentiate between HIV-1 and HIV-2 antibodies and
the other is not.
Tests also will be assumed to be orthogonal if they are of the same type (e.g., two
conventional immunoassays) but made by different manufacturers. The type of
HIV antibody test that verifies the initial test might be one formerly used only as
an initial test (e.g., conventional or rapid immunoassay, HIV-1/2 typedifferentiating immunoassay), or it might be one traditionally used as a
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National HIV Surveillance System Technical Guidance – PCRF and PHER Form, XXXX 2019
supplemental test for confirmation (e.g., Western blot, immunofluorescence
assay).
A positive result of a multitest HIV antibody algorithm from which only the
final result was reported, including a single positive result on a test used only
as a supplemental test (e.g., HIV Western blot, immunofluorescence assay) or
on a test that might be used as either an initial test or a supplemental test (e.g.,
HIV-1/2 type-differentiating rapid antibody immunoassay) when it might
reasonably be assumed to have been used as a supplemental test (e.g., because
the algorithm customarily used by the reporting laboratory is known).
A positive result or report of a detectable quantity (i.e., within the established
limits of the laboratory test) from any of the following HIV virologic (i.e.,
non-antibody) tests:
o Qualitative HIV NAT (DNA or RNA)
o Quantitative HIV NAT (viral load assay)
o HIV-1 p24 antigen test
o HIV isolation (viral culture) or
o HIV nucleotide sequence (genotype).
1.1.2: Clinical (Non-Laboratory) Evidence
Clinical criteria for a confirmed case (i.e., a "physician-documented" diagnosis for
which the surveillance staff have not found sufficient laboratory evidence described
above) are met by the combination of:
A note in a medical record by a physician or other qualified medical-care
provider that states that the patient has HIV infection, and
One or both of the following:
o The laboratory criteria for a case were met based on tests done after the
physician's note was written (validating the note retrospectively).
o Presumptive evidence of HIV infection (e.g., receipt of HIV antiretroviral
therapy or prophylaxis for an opportunistic infection), an otherwise
unexplained low CD4+ T-lymphocyte count, or an otherwise unexplained
diagnosis of an opportunistic illness.
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o Among children aged less than 18 months whose mothers have an unknown
infection status or were known to be infected, a reportable case of HIV infection
must meet at least one of the following criteria:
1.2: Children Aged <18 Months Born to Mothers Who Have an Unknown
Infection Status or were Known to be Infected
1.2.1: Laboratory Evidence
A child aged <18 months is categorized for surveillance purposes as HIV infected if
all of the following criteria are met:
Positive results on at least one specimen (not including cord blood) from any
of following HIV virologic tests:
o HIV-1 NAT (DNA or RNA)
o HIV-1 p24 antigen test, including neutralization assay for a child aged >1
month
o HIV isolation (viral culture) or
o HIV nucleotide sequence (genotype).
The test date (at least the month and year) is known.
One or both of the following:
o Confirmation of the first positive result by another positive result on one
of the above virologic tests from a specimen obtained on a different date
or
o Both of the following:
No subsequent negative result on an HIV antibody test, and no
subsequent negative result on an HIV NAT before age 18 months.
1.2.2: Clinical Evidence
The same criteria as for section 1.1.2 above (1.1.2 Clinical [Non-Laboratory]
Evidence for Persons Aged ≥18 Months and Children Aged <18 Months
whose Mothers were Not Infected) or
All three of the following alternative criteria:
o Evidence of perinatal exposure to HIV infection before 18 months of age:
A mother with documented HIV infection or
A confirmed positive test for HIV antibody (e.g., a positive initial
antibody test confirmed by a supplemental antibody test) and a mother
whose infection status is unknown or undocumented.
o Diagnosis of a stage-3-indicative opportunistic illness.
o No subsequent negative result on an HIV antibody test.
4.1.3
PEDIATRIC AIDS
o Children who are HIV infected and exhibit any of the following AIDS-defining
clinical conditions should be reported as Stage 3 (AIDS) cases; although most of
these conditions appear among adult AIDS diagnostic criteria, asterisked
conditions apply only to aged <6 years, and conditions with a dagger footnote
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National HIV Surveillance System Technical Guidance – PCRF and PHER Form, XXXX 2019
symbol apply only to children aged ≥6 years and adults.
Bacterial infections, multiple or recurrent*
Candidiasis of bronchi, trachea, or lungs
Candidiasis of esophagus
Cervical cancer, invasive†
Coccidioidomycosis, disseminated or extrapulmonary
Cryptococcosis, extrapulmonary
Cryptosporidiosis, chronic intestinal (>1 month’s duration)
Cytomegalovirus disease (other than liver, spleen, or nodes), onset at age >1 month
Cytomegalovirus retinitis (with loss of vision)
Encephalopathy, HIV related
Herpes simplex: chronic ulcer(s) (>1 month’s duration); or bronchitis, pneumonitis, or
esophagitis (onset at age >1 month)
o Histoplasmosis, disseminated or extrapulmonary
o Isosporiasis, chronic intestinal (>1 month’s duration)
o Kaposi’s sarcoma
o Lymphoma, Burkitt (or equivalent term)
o Lymphoma, immunoblastic (or equivalent term)
o Lymphoma, primary, of brain
o Mycobacterium avium complex or M. kansasii, disseminated or extrapulmonary
o Mycobacterium tuberculosis of any site, pulmonary†, disseminated, or extrapulmonary
o Mycobacterium, other species or unidentified species, disseminated or extrapulmonary
o Pneumocystis jirovecii (previously known as “Pneumocystis carinii”) pneumonia
o Pneumonia, recurrent†
o Progressive multifocal leukoencephalopathy
o Salmonella septicemia, recurrent
o Toxoplasmosis of brain, onset at age >1 month
o Wasting syndrome due to HIV
†
Only among adults and children aged ≥6 years.
* Only among children aged <6 years.
o
o
o
o
o
o
o
o
o
o
o
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National HIV Surveillance System Technical Guidance – PCRF and PHER Form, XXXX 2019
4.1.4
PEDIATRIC SEROREVERTER
o Virtually all children less than 18 months of age born to HIV-infected mothers are
antibody positive at birth.
o A child aged < 18 months born to an HIV-infected mother will be categorized for
surveillance purposes as “not infected with HIV” if the child does not meet the
criteria for HIV infection but meets the following criteria:
3.1: Uninfected
A child aged <18 months who was born to an HIV-infected mother or had a
positive HIV antibody test result is classified for surveillance purposes as not
infected with HIV if the following criteria are met:
Laboratory criteria for HIV infection are not met (see section 1.2.1)
No diagnosis of a stage-3-defining opportunistic illness attributed to
HIV infection and
Either laboratory or clinical evidence as described below.
3.1.1: Laboratory Evidence
Definitively Uninfected
No positive HIV NAT (RNA or DNA) and
At least one of the following two criteria:
o At least two negative HIV NATs from specimens obtained on
different dates, both of which were at age ≥ 1 month and one of
which was at age ≥ 4 months.
o At least two negative HIV antibody tests from specimens obtained
on different dates at age ≥ 6 months.
Presumptively Uninfected
Criteria for definitively uninfected with HIV are not met
At least one of the following four laboratory criteria are met:
o At least two negative NATs from specimens obtained on different
dates, both of which were at age ≥2 weeks and one of which was at
age ≥4 weeks.
o One negative NAT (RNA or DNA) from a specimen obtained at age
≥8 weeks.
o One negative HIV antibody test from a specimen obtained at age ≥6
months.
o If criteria for HIV infection had initially been met by one positive
HIV NAT test then it must have been followed by at least two
negative test results from specimens obtained on different dates, one
of which is:
A NAT test from a specimen obtained at age ≥ 8 weeks, or
An HIV antibody test from a specimen obtained at age ≥ 6
months.
No subsequent positive NAT
3.1.2: Clinical Evidence
A note in a medical record by a physician or other qualified medical-care
provider states that the patient is not infected with HIV.
5. Residence at Diagnosis
For reports of HIV infection or perinatal HIV exposure, enter the patient’s city, county,
state/country, and ZIP code of residence at the time of the first confirmatory test for HIV
infection or when HIV infection was first considered, either clinically or through laboratory
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National HIV Surveillance System Technical Guidance – PCRF and PHER Form, XXXX 2019
evaluation.
Documentation of an HIV test is often the earliest evidence that HIV diagnosis was
considered, however, an HIV test may not have been ordered at that time.
If the patient’s residence changes between diagnosis of perinatal HIV exposure and
confirmed HIV infection, record new address.
If laboratory slips are not available, enter the patient’s residence at the date of physician
diagnosis of HIV infection. For HIV, stage 3 (AIDS) case reports, enter patient’s residence
at the date of the first stage 3 (AIDS) diagnosis based on the applicable case definition.
For further guidance about residency assignment, see the file Date and Place of Residence.
7. Facility of Diagnosis
7.2
FACILITY NAME
For reports of perinatal HIV exposure, enter the name of the facility where child was first
evaluated for HIV infection, either clinically or through laboratory evaluation.
The hospital where the mother obtained prenatal care should not be used to answer this
question unless it was also the facility where the child was born and HIV infection was
considered as a diagnosis at the time of the child’s birth or at the time of subsequent
physician/clinic visits.
For reports of confirmed HIV infection, enter the name of the facility where the child was
confirmed to be HIV-infected.
If test results were not in the medical record, enter the name of the facility where the child’s
HIV infection was diagnosed and documented by the health care provider. Enter facility
uniformly to prevent the occurrence of multiple names for a given facility.
For HIV, stage 3 (AIDS) case reports, enter the name of the facility where the patient was
first diagnosed with stage 3 (AIDS) based on the applicable case definition.
These fields strictly apply to facility where HIV or HIV infection stage 3 (AIDS) was
diagnosed. Where chart abstraction is conducted at a facility other than the Facility of
Diagnosis (Section 4), document report source.
8. Patient History
8.1
This information is often found in the mother’s chart in the discharge summary, history and
physical, social service notes, counseling and testing notes, and STD diagnosis notes.
Where not explicitly annotated, contact the child’s provider about maternal/child risk factor
information.
See the file Risk Factor Ascertainment for further guidance on risk factor data collection.
This information can be difficult to find, particularly if the patient has not been interviewed.
States should have risk factor ascertainment procedures tailored to their jurisdictions.
CHILD’S BIOLOGICAL MOTHER’S HIV INFECTION STATUS
“Refused HIV testing” should be selected if mother’s refusal is documented in the medical
chart.
If the biological mother has been tested for HIV and found to be uninfected at or after the
child’s birth, then perinatal transmission is not the presumed mode of exposure to HIV
infection.
If mother-to-infant transmission through breast-feeding is considered to be the only mode of
transmission, please alert the state or local NIR coordinator, check “Yes” in the “Other
documented Risk”, and provide detail in the Comments section.
If dates are not available, please review medical charts to determine when maternal HIV
diagnosis occurred in relationship to the child’s birth and select:
Known HIV+ before pregnancy;
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National HIV Surveillance System Technical Guidance – PCRF and PHER Form, XXXX 2019
8.2
8.5
Known HIV+ during pregnancy;
Known HIV+ sometime before birth;
Known HIV+ at delivery;
Known HIV+ after child’s birth; or
HIV+, time of diagnosis unknown.
If no information is available regarding maternal HIV status, please select:
HIV status unknown.
DATE OF MOTHER’S FIRST POSITIVE HIV CONFIRMATORY TEST
Enter the date of the mother’s first positive test that confirmed HIV infection in mm/dd/yyyy
format using ‘..’ for unknown values (e.g., 03/../2011).
BIOLOGICAL MOTHER HAD HETEROSEXUAL RELATIONS WITH ANY OF THE
FOLLOWING
8.5.3
PERSON WITH HEMOPHILIA/COAGULATION DISORDER WITH
DOCUMENTED HIV INFECTION
o Do not include other bleeding disorders, such as thrombocytopenia, treatable by
platelet transfusion.
o If a transfusion of only platelets, other blood cells, or plasma was received by the
partner, then code “No” and see question 8.5.4 below.
8.5.4 TRANSFUSION RECIPIENT WITH DOCUMENTED HIV INFECTION
o Refers to someone with documented HIV infection who received a transfusion of
blood cells (red cells, white cells, platelets) or plasma.
9. Clinical: Opportunistic Illnesses
9.1
CLINICAL: OPPORTUNISTIC ILLNESSES
9.1.1–9.1.27 (Optional, applies to health department & health care providers)
o Select all that apply and enter diagnosis dates. Enter date in mm/dd/yyyy format
using ‘..’ for unknown values (e.g., 03/../2011).
o For additional information, refer to the most recent case definition for HIV
infection (available at
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6303a1.htm?s_cid=rr6303a1_e.).
11. Birth History (For Perinatal Cases only)
11.4 BIRTH HISTORY
11.4.4 BIRTH DEFECTS
o Data collected will be used to evaluate changes in incidence or other unusual
patterns of serious birth defects among children exposed to zidovudine in utero
compared with those who were not exposed and with the general population.
o Approximately 3%–4% of all babies will have serious birth defects (e.g., neural
tube defects, congenital heart defects, esophageal atresia, and cleft lip/palate).
o The methods and definitions used were developed by the CDC National Center on
Birth Defects and Developmental Disabilities and are currently used in the
Metropolitan Atlanta Congenital Defects Program, an active surveillance system
for birth defects in the Atlanta metropolitan area.
o Select “Yes” if the child meets the case definition for birth defects as defined by
the CDC National Center on Birth Defects and Developmental Disabilities as listed
below.
Criteria for Inclusion as Reportable Birth Defect:
The child must have a structural or genetic birth defect or other specified
birth outcome that can adversely affect his or her health and development;
The structural or genetic birth defect must be diagnosed or its signs or
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National HIV Surveillance System Technical Guidance – PCRF and PHER Form, XXXX 2019
symptoms recognized within the first year of life;
The infant must have a gestational age of at least 20 weeks or a birth
weight of at least 500 grams; and
A case must be abstracted by the child’s sixth birthday.
Criteria for Exclusion:
Defects such as normal variants or minor anomalies are considered
excludable. Diagnoses that may be normal variants or minor anomalies
may be included only if associated with another reportable defect.
Imprecise diagnoses (probable, possible, compatible with, consistent
with, suspected, questionable, suggestive of, etc.) should be abstracted
and coded as such and follow-up conducted to ascertain true status.
For children with possible birth defects, please review newborn and
hospital records including the face sheet; history and physical; discharge
summary; operative, laboratory, x-ray, cardiac catheterization, and
autopsy reports; and notes and consultations by physicians, nurses, and
social and psychological services.
In addition, birth defect (i.e., congenital anomalies) information is also
collected on the standard US birth certificate.
Hospital records should be reviewed to determine if a reportable defect is
present. Each reportable condition is coded separately according to the
birth defect code (see below). These codes are based on ICD-9 codes but
provide more specific diagnostic information.
If reportable birth defects are diagnosed, select “Yes” and abstract all
diagnoses onto the case report form.
Include discrepant diagnoses. Also include diagnoses appearing in the
chart that have not been ruled out by an expert or lab test.
If the infant is diagnosed with a syndrome, record the name and code of
the syndrome as well as the individual defects.
If there is a question about whether a diagnosis is reportable or how to
code any diagnosis, please call the CDC HIV Incidence and Case
Surveillance Branch (HICSB) at (404) 639-2050.
BIRTH DEFECTS CODE
The 6-digit defect codes are based on 3- to 5-digit ICD-9-CM or ICD-10CM codes from a birth certificates or medical records (or ICD-9 or ICD10 codes from death certificates). The shorter codes may be used in place
of the 6-digit codes. Enter the code for the birth defect given in the birth
certificate, medical record, or death certificate. If the code is not available
in those places, but the birth defect is described using medical
terminology, then look up the corresponding code in the ICD-9-CMbased list (downloadable from
http://www.cdc.gov/ncbddd/birthdefects/macdp.html) if the record was
from before October 1, 2014, or in the ICD-10-CM-based list
(downloadable from http://www.cdc.gov/nchs/icd/icd10cm.htm) if the
record was from October 1, 2014 or later.
If defects exist, list all on the case report form and enter in the Comments
section.
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National HIV Surveillance System Technical Guidance – PCRF and PHER Form, XXXX 2019
11.4.7
MONTH OF PREGNANCY PRENATAL CARE BEGAN
o Enter “09” if care began in the ninth month or later.
o If entry is reported in weeks, convert to appropriate months as follows:
Weeks
Months
Weeks
Months
1–4
1
23–26
6
5–9
2
27–30
7
10–13
3
31–35
8
14–17
4
36+
9
18–22
5
11.4.10 DID MOTHER RECEIVE ARVs DURING PREGNANCY?
Clinicians initiating antiretroviral regimens in the HIV-1-infected pregnant patient
should refer to Recommendations for Use of Antiretroviral Drugs in Pregnant HIV1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV1 Transmission in the United States at
https://aidsinfo.nih.gov/guidelines/html/3/perinatal-guidelines/0.
11.5 MATERNAL INFORMATION
11.5.2 MATERNAL LAST NAME SOUNDEX
o If not already complete, enter the name and date of birth of the patient’s biological
mother in the CDC-supplied software. The SOUNDEX CODE will automatically
be generated based on the biological mother’s surname.
o Retrieve the soundex code from the database and enter here.
12. Treatment/Services Referrals
12.3 ARV MEDICATIONS
Please refer to the Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection
https://aidsinfo.nih.gov/guidelines/html/2/pediatric-treatment-guidelines/0/#.
12.6 HAS THIS CHILD EVER TAKE PCP PROPHYLAXIS?
Please refer to MMWR 1995;44(RR-4):1–11 for the 1995 Revised Guidelines for
Prophylaxis Against Pneumocystis carinii Pneumonia (PCP) for Children Infected with or
Perinatally Exposed to HIV. Examples of PCP prophylaxis include
Trimethoprim/sulfamethoxazole (TMP/SMX, Bactrim, Septra), Pentamidine, and Dapsone.
TMP/SMX (Bactrim, Septra) can be used to treat infections other than HIV but is usually
used for a shorter period. For example, TMP/SMX is used for 2–3 weeks to treat otitis media
and would NOT be recorded as “Yes” in this field.
Include as PCP prophylaxis if it is clearly noted as such in the medical chart or given for a
period of 2 weeks or longer.
12.7 WAS THIS CHILD BREASTFED?
Avoidance of breast-feeding to prevent postpartum transmission of HIV has been
recommended for HIV-infected mothers in the United States.
12.8 THIS CHILD’S PRIMARY CARETAKER IS
“Other relative” refers to children living with an aunt, grandmother, etc. in an informal
arrangement, and the relative does not receive a stipend for providing care.
If a child lives with a relative and that relative is paid a stipend for caring for the child,
“Foster/Adoptive parent, relative” should be selected.
A child is in “foster/adoptive parent, unrelated” if living with someone other than a relative.
“Adoptive parent, relative” refers to child who has been legally adopted by a relative. This
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National HIV Surveillance System Technical Guidance – PCRF and PHER Form, XXXX 2019
includes children with deceased parents whose legal custody has been transferred to a
relative.
If the adoptive parent is unrelated please select “foster/adoptive parent, unrelated.” This
includes children with deceased parents whose legal custody has been transferred to a person
who is unrelated to the child.
“Social service agency” refers to children whose primary caretaker is a social service
agency, which usually refers to children living in group home situations.
For children being cared for in situations not described above, select “other” and specify in
this section.
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National HIV Surveillance System Technical Guidance – PCRF and PHER Form, XXXX 2019
Technical Guidance for HIV Surveillance Programs — Perinatal
HIV Exposure Reporting (PHER) Form
Instructions for Completion
Purpose of Perinatal HIV Exposure Reporting (PHER) Form
The Perinatal HIV Exposure Reporting (PHER) form is used to collect information on perinatal exposure
cases. The form facilitates collection of additional standardized data on HIV-exposed children. This
guidance applies to data collection even if surveillance sites use a different form or medium for HIV case
surveillance. Information on children who are perinatally exposed to HIV or who have HIV stage 3
(AIDS) is protected under a federal assurance of confidentiality.
The PHER Form in the Context of Document-Based Surveillance
Unlike case-based data management, document-based data management allows all documents to be
stored and retained electronically in their original formats. Instead of completing one form for a given
reported case, fill out the applicable part of the form for each data source contributing to that case.
Definition of Variable Designators
Required: Variables that must be collected by all programs.
Recommended: Variables that programs are strongly encouraged to collect but are not
absolutely required.
Optional: Variables that programs may or may not choose to collect.
Disposition of Form
The completed PHER form is for state or local health agency use and is not to be sent to the
Centers for Disease Control and Prevention (CDC). The Pacific Islands are the only
jurisdictions that send forms to CDC for data entry and all patient identifiers must be
removed before they are sent.
Data obtained from these forms are entered into standardized computer software provided by
the Division of HIV/AIDS Prevention, National Center for HIV, Viral Hepatitis, STD, and
TB Prevention, CDC (or other compatible software), linked to maternal records, and then
transferred without identifiers to CDC. Electronic transfers are encrypted via secure data
network.
Chart Abstraction Guidance
Accurate data abstraction is critical. For example, the dates of receipt of prenatal care should be before
the infant’s date of birth. If inconsistent information is found in medical records indicate that in the
Comments section on the data abstraction form. This will serve as documentation that the inconsistency
was in the medical record and is not an error in abstraction, notation, or data entry. The HIV Surveillance
Coordinator in each project area, or their designee, should review all data abstraction forms before the
data are entered.
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National HIV Surveillance System Technical Guidance – PCRF and PHER Form, XXXX 2019
Qualifications of Abstractors
Abstractors should be familiar with the components of a medical record (e.g.,
demographic/financial information, doctor’s progress notes, prenatal care records, labor and
delivery records, nurse’s notes, operative notes, lab results, discharge summaries, problem
lists, drug lists, etc.).
Abstractors should be familiar with medical abbreviations and terminology, especially as
related to HIV.
Abstractors should be familiar with the procedures required to abstract records from various
providers and facilities.
Abstractors must be trained in security and confidentiality (S&C) requirements and sign a
statement of compliance. Health departments and academic institutions should have S&C
training requirements and methods in place to document completion of this training.
Records to be Abstracted
At a minimum the following records should be reviewed. Additional records may be
reviewed if available (e.g., STD records, Health Department records).
Mother
Infant
Maternal prenatal records
Maternal labor and delivery records
Maternal HIV clinic records
Pediatric birth records (hospital records)
Birth certificate
Pediatric medical records (HIV clinic, nonHIV clinic, or other medical records)
Death certificate
Abstraction of Mother’s Records
All maternal variables refer to information on the infant’s biologic mother.
If it is not possible to obtain a medical chart for the mother, the PHER form should still be
completed to the extent possible.
If information on the mother is available in the infant’s chart and also in the mother’s chart,
use the mother’s chart as the primary record for questions related to the mother’s care.
Abstraction of Infant’s Records
Complete this form only for live births. The definition of a live birth as defined by the World
Health Organization is:
‘...the complete expulsion or extraction from its mother of a product of
conception, irrespective of the duration of the pregnancy, which, after
such separation, breathes or shows any other evidence of life, such as
beating of the heart, pulsation of the umbilical cord, or definite movement
of voluntary muscles, whether or not the umbilical cord has been cut or
the placenta is attached; each product of such a birth is considered live
born.’
Thus, if a birth certificate has been completed for the infant, the record should be abstracted.
If a woman has had several pregnancies during the project period, each pregnancy should be
considered a separate event and should be abstracted separately.
If the outcome of a pregnancy is multiple births (e.g., twins, triplets), a separate eHARS and
supplemental exposure reporting form should be completed for each infant, however the
maternal information need only be abstracted once.
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National HIV Surveillance System Technical Guidance – PCRF and PHER Form, XXXX 2019
Follow-up Chart Review
Review the pediatric chart at 6 months, 12 months, and 18 months (and at 6 month intervals thereafter if
the child’s infection status is still undetermined). When reviewing the pediatric chart, abstract all data
needed for eHARS updates (e.g., HIV diagnostic tests, CD4 counts, treatment, prophylaxis, AIDSdefining conditions, birthweight, vital status, and birth defects). A new pediatric form should be
completed documenting the updates. On the additional form the demographics section for both the mother
and the infant should be completed as well as those portions of the form that need to be newly completed
or updated. The updated infant’s HIV diagnostic tests, CD4 counts, and viral load test results should be
entered directly into eHARS.
Indicating ‘Unknown’
A ‘99’ should be checked or written to indicate an unknown value for any question. Type of response is
indicated on the form. Unknown should only be checked if the source records are not available.
Not Documented
Responses of ‘Not documented’ should only be checked if the source records are available but there is no
indication in the affirmative or negative for the question being asked.
Dates
All dates on this abstraction form should be written as month/day/year (mm/dd/yyyy) or Month/Year
(mm/yyyy) as indicated on the form. If all or part of a date is unknown, ‘..’ should be entered into the
appropriate space (e.g., 02/../2005). No not use ‘99” to indicate unknown/missing dates. Be sure that the
infant’s date of birth is consistent with the date of delivery and that the dates of receipt of prenatal care,
CD4 and viral load testing, receipt of antiretrovirals, and other data are based on this date of birth.
Records That Are ‘Not Available’
Records will be considered ‘not available’ after two attempts, separated in time, have been made to
review the record. Before a chart is considered ‘not available’, attempt to locate other sites of care where
the chart may be located. Record not available should only be selected if the information cannot be
obtained from any record source.
Conflicting Information
The medical chart from which a specific question should be answered depends on the question itself. For
example, a maternal obstetrical chart and the HIV chart may have different dates for receipt of prenatal
care. We recommend using information from the obstetrical chart. Similarly, if there are different start
dates for administration of ARV, use the HIV infectious disease (HIV/ID) chart unless the obstetrical
chart documents a good reason to the contrary (e.g., the OB/GYN physician may have also managed the
patient’s antiretroviral therapy). In general, obstetrical information should be pulled from the obstetrical
prenatal or postnatal chart and HIV/ID information should be pulled from the HIV/ID chart.
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National HIV Surveillance System Technical Guidance – PCRF and PHER Form, XXXX 2019
Form Fields
The state/city number fields for the mother and infant at the top of the PHER Form are required.
1. Child adopted or in foster care (Recommended, if applicable, applies to health department &
health care providers).
Select ‘Yes’ only if the maternal information is not available due to child being adopted, in
foster care or abandoned.
If the maternal information is not available for other reasons, check ‘No’. Else, check ‘Not
applicable’.
2. Records abstracted (Optional, if applicable, applies to health department & health care providers).
For each type of record, code whether it was: (1) abstracted; (2) attempted but record was
not available; (3) not abstracted; or (4) attempted, will try again.
Do not simply indicate an X or √ for each record abstracted, rather, use the appropriate
number code.
3. Week’s gestation at first prenatal care visit (Required, if applicable, applies to health department
& health care providers).
Enter value in weeks.
A prenatal care visit is the first visit where intake information is obtained. Normally a
woman knows she is pregnant at the time of this first prenatal care visit. A visit to a doctor
to confirm pregnancy status would not be considered the first prenatal care visit unless
intake data and other services typical of the first prenatal care visit are obtained at the time
of that confirmation. Such services would include intake prenatal blood tests, for example. If
the woman had been seen by more than one prenatal care provider, then the date of the visit
to the first prenatal care provider seen should be documented.
4. Screening of mother for disease during pregnancy (Recommended, if applicable, applies to health
department & health care providers).
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National HIV Surveillance System Technical Guidance – PCRF and PHER Form, XXXX 2019
4.1
4.2
4.3
4.4
Use test done prior to birth but closest to delivery date or at admission for labor and
delivery.
GROUP B STREP (GBS) - Group B streptococci. A major cause of perinatal bacterial
infections and systemic and focal infections in infants. Invasive disease categorized into early
onset (1st week of life) and late-onset (usually at 3-4 weeks of life). Colonization late in
pregnant women and newborns ranges from 5% to 35%. Intrapartum chemoprophylaxis is IV
Penicillin G. Two types of prevention strategies may be used:
Screening all pregnant women at 35 to 37 weeks for vaginal and rectal GBS colonization
and offering intrapartum chemoprophylaxis to those identified as GBS carriers; or
Risk factor based strategy - prophylaxis given to women with intrapartum risk factors
including gestation < 37 weeks, ≥ 18 hours since rupture of membrane, or temperature of
38 C or greater.
HEPATITIS B (Hepatitis B surface antigen, HBsAg) - Detects acutely or chronically infected
persons. Prenatal HbsAg screening of all pregnant women is recommended. Babies of mothers
who are HbsAg (+) must have HBIG and HBV vaccine within 12 hours of birth to prevent
perinatal HBV infection. Be sure the test result is for the surface antigen rather than the antibody
(anti-HBs), core antigen (HbcAg), or antibody (anti-HBc); or Hepatitis B e antigen (HbeAg) or
antibody (anti-HBe). This test is usually done at the initial prenatal visit or at the time of labor
and delivery for high risk women and women whose status is unknown.
RUBELLA - Screening is usually done at the initial prenatal visit. If ‘negative’ the mother
should be immunized.
SYPHILIS - All pregnant women should receive serologic screening for syphilis early in
pregnancy with a nontreponemal test (e.g., VDRL and RPR). In addition, screening is
recommended in the third trimester for those in high risk prevalence areas or for women at high
risk. Nontreponemal antibody tests are used for screening purposes and presumptive diagnosis:
VDRL (venereal disease research laboratory); RPR (rapid plasma reagin test; STS serologic test
for syphilis, syphilis screening test); ART (automated reagin test). The nontreponemal antibody
test should be confirmed with a treponemal antibody test (e.g., FTA-ABS, MHA-TP). If a
pregnant woman has a reactive nontreponemal test and a persistently negative treponemal test, a
false positive test is inferred.
(Reference: Red Book 2000- American Academy of Pediatrics).
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National HIV Surveillance System Technical Guidance – PCRF and PHER Form, XXXX 2019
5. Diagnosis (for the mother) during this pregnancy or at time of labor and delivery
(Recommended, if applicable, applies to health department & health care providers).
5.1
5.2
5.3
5.4
For this question, “diagnosed” refers to newly diagnosed, a recurrence of, or a chronic
infection with any of the following conditions. Screening for syphilis, gonorrhea, and
chlamydia is typically done during prenatal care. Generally, diagnosis of an STD/STI will be
documented in multiple places in the chart including progress notes, a prenatal clinic visit
summary sheet (which should include summary of lab tests for various sexually transmitted
diseases), lab results section, or in sexually transmitted disease summary sheets (typical in
public health clinics).
Diagnoses may be presumptive or definitive depending on symptoms and lab tests. If a
diagnosis is made either presumptively or definitively, note the answer as ‘Yes’. Specific
criteria for answering ‘Yes’ to this question are outlined below.
All dates on this abstraction form should be written as month/day/year (mm/dd/yyyy) or
Month/Year (mm/yyyy) as indicated on the form. If all or part of a date is unknown, ‘..’
should be entered into the appropriate space (e.g., 03/../2011). No not use ‘99” to indicate
unknown/missing dates.
BACTERIAL VAGINOSIS - Clinician diagnosis of bacterial vaginosis. Sometimes abbreviated
BV.
CHLAMYDIA (Chlamydia trachomatis) - Record positive test for chlamydia (a positive
culture, positive EIA, or detection of chlamydial antigen or nucleic acid).
Name of lab tests - Chlamydia cell culture (TRIC Agent Culture); direct fluorescent
antibody (DFA) tests; enzyme immunoassay (EIA) tests; nucleic hybridization (DNA probe)
tests; and PCR and LCR.
GENITAL HERPES - Active (herpes genitalis) - Primary herpes (first episode of herpes) or
recurrence of herpes during pregnancy or at labor and delivery.
Name of lab tests - herpes virus culture; herpes cytology (herpetic inclusion bodies,
cytology, inclusion body stain, Tzanck smear, Giemsa stain viral study); rapid diagnostic
tests- direct immunofluorescent AB or EIA; HSV Ag; or polymerase chain reaction (PCR).
GONORRHEA (Neisseria gonorrhea) - Record if culture positive.
Name of lab tests - Neisseria gonorrhea culture (GC Culture, Gonorrhea Culture); ThayerMartin medium; chocolate agar; detection of nucleic acid.
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National HIV Surveillance System Technical Guidance – PCRF and PHER Form, XXXX 2019
5.5
5.6
5.7
5.8
5.9
GROUP B STREP - Group B streptococci. A major cause of perinatal bacterial infections and
systemic and focal infections in infants. Invasive disease categorized as early onset (1st week of
life) and late-onset (usually at 3-4 weeks of life). Colonization late in pregnant women and
newborns ranges from 5% to 35%. Intrapartum chemoprophylaxis is IV Penicillin G. Two types
of prevention strategies may be used:
Screening all pregnant women at 35 to 37 weeks for vaginal & rectal GBS colonization,
offering intrapartum chemoprophylaxis to those identified as GBS carriers; or
Risk factor based strategy in which prophylaxis is given to women with intrapartum risk
factors: gestation < 37 weeks, ≥ 18 hours since rupture of membrane, or temperature 38 C
or greater.
HEPATITIS B (Hepatitis B surface antigen, HbsAg) - Detects acutely or chronically infected
persons. Prenatal HbsAg screening of all pregnant women is recommended. Babies of mothers
who are HbsAg (+) must have HBIG & HBV vaccine within 12 hours of birth to prevent
perinatal HBV infection.
Be sure the test result is for the surface antigen rather than the antibody (anti-HBs), core
antigen (HbcAg) or antibody (anti-HBc); or Hepatitis B e antigen (HbeAg) or antibody (antiHBe). Tests are usually done at the initial prenatal visit or at the time of labor and delivery
for high risk women and women whose status is unknown.
HEPATITIS C - Tests do not distinguish between acute, chronic, or resolved infection.
Diagnosis by antibody assays involves initial screening EIA. Repeatedly positive results are
confirmed by a recombinant immunoblot assay (RIBA). Highly sensitive PCR assays for
detection of HCV RNA are also available.
Name of lab test - EIA (Enzyme immunoassay) screen, confirmed by recombinant
immunoblot assay (RIBA).
PELVIC INFLAMMATORY DISEASE (PID) - Look for documentation of a clinical diagnosis
of PID. A note stating ‘rule out PID’ does not indicate the woman had PID.
SYPHILIS (Treponema pallidum) - All pregnant woman should receive a serologic screen for
syphilis early in pregnancy with a nontreponemal test (e.g., VDRL, RPR, STS, and ART) and
preferably again at delivery. In addition, screening is recommended in the third trimester for
those in high prevalence areas or those at high risk.
Nontreponemal antibody tests are used for screening. Any reactive nontreponemal test must
be confirmed by a specific treponemal test (FTA-ABS and MHA-TP) to exclude false
positive results which can be caused by a viral infection (e.g., infectious mononucleosis,
hepatitis, varicella and measles), lymphoma, TB, malaria, endocarditis, connective tissue
disease, pregnancy, or abuse of injection drugs. If a pregnant woman has a reactive
nontreponemal test and a persistently negative treponemal test, a false positive test is
inferred. A positive FTA-ABS or MHA-TP usually remains reactive for life, even after
successful therapy. Also, look for evidence of treatment for syphilis - receipt of penicillin
(bicillin) 2.4 million units is the standard treatment for syphilis in the mother. Check
whether the child was diagnosed with or treated for congenital syphilis with penicillin for 10
days. A physician diagnosis will be clearly documented in the infant's birth chart. Also
check the congenital syphilis registry to confirm congenital syphilis, with consideration for
confidentiality and security of an individual’s HIV or stage 3 or AIDS status.
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National HIV Surveillance System Technical Guidance – PCRF and PHER Form, XXXX 2019
Name of lab tests - Presumptive diagnosis: nontreponemal tests (for screening purposes)
VDRL (venereal disease research laboratory); RPR (rapid plasma reagin test, serologic test
for syphilis, STS, syphilis screening test, ART-automated reagin test). Definitive diagnosis:
treponemal tests (for diagnostic purposes) Darkfield examination (Darkfield microscopy,
syphilis; Treponema Pallidum Darkfield examination); FTA-ABS (Fluorescent Treponemal
Antibody Absorbed Test, Fluorescent Treponemal Antibody Adsorption); MHA-TP
(Microhemagglutination assay for Antibody to Treponema Pallidum;
Microhemagglutination, Treponema Pallidum.
5.10 TRICHOMONAS (Trichomonas vaginalis) - Record clinician diagnosis of trichomonas.
Trichomonas is diagnosed by finding trichomonas on a wet mount.
Name of lab tests - Trichomonas preparation (Hanging Drop Mount for Trichomonas,
Trichomonas vaginalis wet preparation; Trich Prep; wet preparation for Trichomonas
vaginalis.
6. Mother’s reproductive history (Optional, if applicable, applies to health department & health care
providers).
6.1
6.2
6.3
6.4
An obstetrical history should be documented at the first prenatal visit in the progress notes
section or the prenatal care flow sheet. The obstetrical history should list the outcome of all
the woman’s past pregnancies.
NUMBER OF PREVIOUS PREGNANCIES: This number should include all pregnancies,
regardless of outcome (e.g., including abortions and miscarriages) up to but EXCLUDING the
pregnancy that is being abstracted.
NUMBER OF PREVIOUS LIVE BIRTHS: The number of live births is the total preterm and
term births (excluding abortions, miscarriages, and stillbirths). Note that parity (commonly
reported in medical charts) refers to the number of viable pregnancies, that is, the number of
pregnancies carried to 20 weeks. Parity excludes miscarriages and elective abortions but
includes stillbirths. Parity cannot be used for this answer.
NUMBER OF PREVIOUS MISCARRIAGES: A miscarriage is an abortion which occurs
naturally and may also be referred to as a ‘spontaneous abortion’ (SAB). A spontaneous
abortion is a fetal death that occurs before 20 weeks (a stillbirth is a fetal death that occurs at or
after 20 weeks). Record the number of miscarriages.
NUMBER OF PREVIOUS INDUCED ABORTIONS: An ‘induced’ abortion is brought on
purposely and may also be known as an ‘artificial’ or ‘therapeutic’ abortion (TAB), or referred
to as a ‘termination of pregnancy’ (TOP). In cases where the woman has had an abortion, the
chart may abbreviate this as ‘A’ or ‘Ab’ or ‘TAB’ or ‘TOP’ followed by a number designating
the number of abortions prior to this pregnancy. Record the number of induced abortions.
The medical record does not always differentiate spontaneous from elective abortions. In
those cases the only data available is ‘total’. Number of total abortions: spontaneous
abortion + elective abortion = total. The total number of abortions is usually noted at intake
at the time of the first prenatal care visit in the obstetrical history. If the provider
documented parity as a four-digit number, the third digit (number of pregnancies ending in
abortion) can be used to answer this question. Remember to record the number of previous
induced abortions (above) AND the number of previous miscarriages (above) OR (if the
chart does not break these two categories out) the total number of abortions, but not both.
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National HIV Surveillance System Technical Guidance – PCRF and PHER Form, XXXX 2019
Note on G_P_ Abbreviations In the Medical Record: This information is often written in the
following format: G _ P_, as in G5 P3 or it may be written as G5P3A1. The ‘G’ (gravida) refers to the
total number of pregnancies (including current pregnancy), the ‘P’ (para) to the number of live births
(at least 20 weeks gestation) and the ‘A’ to the number of induced and spontaneous abortions.
Information on gravida status is usually noted at intake at the time of the first prenatal care visit. Also
note that ‘multigravida’ refers to a woman who has been pregnant more than once, ‘primigravida’
refers to a woman who is pregnant for the first time (by definition, has no prior pregnancies), and a
‘grand multiparous’ woman refers to a woman who has had more than 5 pregnancies.
G = gravida, the number of pregnancies including the current pregnancy;
P = parity, the number of pregnancies > 20 weeks gestation (excludes miscarriages and 1st
trimester abortions); and
A = Abortion, the number of abortions (both spontaneous and induced abortions).
For example, a woman who is G5 P3A1 has been pregnant 5 times (including the current pregnancy), 3
of those pregnancies were carried to at least 20 weeks gestation, and she had 1 spontaneous or
induced abortion.
Parity may also be documented as a four digit number. The first digit represents the number of
pregnancies delivered at full-term (at least 37 weeks gestation). The second digit represents the
number of pregnancies delivered pre-term (20-37 weeks). The third digit represents the number of
abortions including spontaneous or therapeutic abortions; and the last digit represents the number of
living children the woman currently has.
P = parity may be documented as a 4 digit number:
1st digit = term pregnancies (>37 weeks);
2nd digit = preterm pregnancies (20-37 weeks);
3rd digit = abortions (includes both spontaneous and induced abortions); and
4th digit = living children
For example, a woman’s record may read G5 P2113. This woman has delivered 2 infants who were fullterm, delivered one infant pre-term, had one abortion and has 3 living children. This patient is
currently pregnant (total number of pregnancies=5) and she has had four previous pregnancies.
If you are using G_P_ notation to complete Q.6, remember that you will have to subtract the current
pregnancy from the gravida (G) notation.
This format is not always followed exactly as described here. When possible, it will be useful to ask
clinic nurses what their standard notation is.
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National HIV Surveillance System Technical Guidance – PCRF and PHER Form, XXXX 2019
7. Complete the chart for all siblings (Recommended, if applicable, applies to health department &
health care providers).
If possible, record the dates of birth and/or age in years and months of live born siblings.
Indicate the current serostatus of the sibling and the STATENO and the CITYNO. This
information is not always available on prenatal care charts or labor and delivery records.
8. Substance use during pregnancy (Recommended, if applicable, applies to health department &
health care providers).
This section provides information on whether substance use occurred during the mother’s
pregnancy.
This information is typically found in the progress notes, social worker notes, lab results
summary section, or in the summary sheet listing all prenatal care visits, lab results,
gestational ages, and other information.
8.1
WAS SUBSTANCE USED DURING PREGNANCY?
Indicate whether substances were used during pregnancy by selecting “Yes”, “No”, “Record
not available”, or “Unknown”.
If ‘Yes’, indicate which substances were used. The drugs listed here are in alphabetical order
and may be checked if there is evidence of a toxicology screen or a notation in records not
based on a toxicology screen (e.g., patient self-report).
Heroin is a semisynthetic narcotic and opiate and should be listed as heroin, opiate, or opioid
on the urine toxicology lab results sheet.
Marijuana may be listed on the urine toxicology results as cannabis, a cannabinoid, THC or
simply marijuana.
Methadone is a synthetic narcotic and should be listed as methadone. Any methadone use,
whether legal or illegal, should be included as ‘Yes’ to this question.
If ‘Other’, be sure to specify the name of the drug(s) used.
8.2
IF SUBSTANCE USED, WERE ANY INJECTED?
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National HIV Surveillance System Technical Guidance – PCRF and PHER Form, XXXX 2019
If ‘Yes’, write the name of the drug in the space provided.
9. Was toxicology screen done on mother? (Recommended, if applicable, applies to health
department & health care providers).
Check ‘Yes, positive result’ for any drug testing positive and indicate the drug resulting in
the positive test.
Check ‘Yes, negative result’ if a screen was conducted and all drugs tested for were
negative.
Check ‘No’ if it is known that a screen was not conducted.
Otherwise check ‘Toxicology screen not documented’ if no testing or results are
documented in any records.
The toxicology testing must have been completed during pregnancy, not before pregnancy.
Toxicology screens are usually done using urine or serum and are usually listed as ‘positive’
if there is evidence of the drug in the urine or blood serum.
Heroin is a semisynthetic narcotic and opiate and should be listed as heroin, opiate, or opioid
on the urine toxicology lab results sheet.
Marijuana may be listed on the urine toxicology results as cannabis, a cannabinoid, THC or
simply marijuana.
Methadone is a totally synthetic narcotic and should be listed as methadone. Any methadone
use, whether legal or illegal, should be included as ‘Yes’ to this question.
If ‘Other’, be sure to specify the name of the drug(s) used.
Select the appropriate response(s) from given legal values. If screening for ‘Other’ drug was
done, be sure to indicate what the drug was in the space provided.
10. Toxicology screen on infant at birth (Recommended, if applicable, applies to health department &
health care providers).
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National HIV Surveillance System Technical Guidance – PCRF and PHER Form, XXXX 2019
Most toxicology screens on infants are done using urine. A positive screen at birth indicates
illicit maternal drug use before delivery. This information should be noted in the infant's
birth chart.
See toxicology report interpretation in section 9 above.
Select all drugs identified on screening, including methadone.
If screening for ‘Other’ drug was done, specify the drug metabolites in the space provided.
11. Mother’s HIV serostatus (Required, if applicable, applies to health department & health care
providers).
This information may be found in the history or progress notes, or on a lab report.
Select “No” if there is evidence of prenatal care but no indication that an HIV test was
conducted.
If no prenatal care was received, indicate “No prenatal care”.
12. Antiretroviral drugs prescribed for mother (Required, if applicable, applies to health
department & health care providers).
12.1 WERE ANTIRETROVIRAL DRUGS PRESCRIBED FOR THE MOTHER DURING THIS
PREGNANCY?
‘During this pregnancy’ refers to the time up to, but not including, labor and delivery.
Select ‘yes’ if the mother was previously taking, began taking, or restarted antiretroviral
medications after interruption during the 1st trimester. See section 12.2 for instructions on
coding individual drugs.
Select ‘no’ if no ARV was prescribed during this pregnancy. See section 12.3 for
instructions on coding why no ARV was prescribed.
12.2 IF ‘YES’, ANTIRETROVIRAL DRUGS PRESCRIBED FOR THE MOTHER DURING THIS
PREGNANCY.
DRUG NAME - Note all antiretrovirals either used or refused during the pregnancy.
COMBIVIR is a combination of ZDV (AZT) and 3TC. If combivir is discontinued during
pregnancy but either ZDV (AZT) or 3TC (lamivudine) is continued, code Combivir as
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National HIV Surveillance System Technical Guidance – PCRF and PHER Form, XXXX 2019
stopped and indicate that ZDV or 3TC was begun (as a single drug) and the date this change
was made. If the woman received drug therapy as part of ACTG 316, receipt of
NEVIRAPINE should not be indicated on the antiretroviral drug chart since it is not known
whether the mother received the drug or the placebo. If the specific drugs she received or
refused are unknown, complete the grid and write ‘Unknown” in the ‘Drug Name’ column.
Also, enter the receipt of ARVs during pregnancy in eHARS.
DRUG REFUSED - If any antiretroviral drug was refused, write the name of the drug in the
grid and check the column labeled ‘Drug Refused’. Do not assume that a woman who did
not receive antiretroviral drugs refused the drugs; she may not have been offered ARV
medications. Only code ‘refused’ if refusal is documented. This is asked to distinguish
between women who were not prescribed drugs because they were not offered and those
who were not prescribed drugs because they refused them.
DATE DRUG STARTED - Enter the date the drug was started in mm/dd/yyyy format using
‘..’ for unknown values (i.e., 03/../2011). In the case of a woman having interrupted
antiretroviral medications due to pregnancy, the column ‘Date Started’ refers to the date
when the mother initially started the antiretroviral drugs.
GESTATIONAL AGE STARTED - Enter week of gestation antiretrovirals were started.
Round down to the nearest completed week of gestation (e.g., if the medical chart indicates
37 4/7 weeks then round to 37 weeks). In the case of a woman having interrupted
antiretroviral medications due to pregnancy, the column ‘Gestational Age Started’ refers to
the gestational age when the mother initially started the antiretroviral drugs. If the week is
unknown then indicate ‘99’ for Unknown.
DRUG STOPPED - If the drug was stopped (discontinued) prior to the birth of the infant but
administered sometime during the pregnancy, indicate ‘Yes’, the drug was stopped. Enter
‘ND’ if it is not documented.
DATE STOPPED - Enter date the antiretrovirals were stopped (if completely discontinued)
in mm/dd/yyyy format using ‘..’ for unknown values (i.e., 03/../2011).
DRUG STOP CODE - To answer this question, use the stop codes found at the end of the
abstraction form. Up to two codes are allowed. If there are more than two reasons why a
drug is stopped, indicate the two most important reasons. Code the reasons as they are
written in the physician’s notes. Do not attempt to provide reasons if they are not clearly
documented in the chart. If a woman interrupts use only temporarily, for example while she
is in the first 3 months of pregnancy and then restarts, do not code as stopped.
Enter ‘Unknown’ in the ‘Drug Name’ column if the specific drugs she received are
unknown.
12.3 IF NO ARV WAS PRESCRIBED IN PREGNANCY, INDICATE REASON:
NO PRENATAL CARE - The mother did not receive any prenatal care during her
pregnancy.
HIV STATUS OF MOTHER UNKNOWN - The physician may not have known the HIV
status of mother because she refused testing or the physician did not offer testing.
Sometimes the mother is not identified as being HIV positive until after delivery.
MOTHER KNOWN TO BE HIV NEGATIVE DURING PREGNANCY - If the mother
tested HIV negative during pregnancy (with no further testing to indicate HIV
seroconversion), she would not receive ARV for prevention of perinatal transmission. There
must be evidence of a negative test during pregnancy in the chart; do not use patient report.
MOTHER REFUSED - Mother refused ARV during pregnancy.
OTHER - If ‘Other’ is indicated, be sure to specify why ARV was not prescribed.
NOT DOCUMENTED - Indicate ‘Not Documented’ if the woman was not prescribed ARV
but the reason why is not known.
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National HIV Surveillance System Technical Guidance – PCRF and PHER Form, XXXX 2019
13. Was mother’s HIV serostatus noted in her labor and delivery records? (Required, if applicable,
applies to health department & health care providers).
Select ‘Yes, HIV-Positive’ if there is explicit reference to her positive HIV status in the
chart (including receipt of ARV). For the majority of women tested before or during
pregnancy, the answer here is ‘Yes, Positive’. For some patients the HIV test date may not
be documented at all. The chart should indicate, however, she was known to be HIVinfected during her pregnancy. In such cases, check ‘Yes, HIV-positive’.
Select ‘Yes, HIV-negative’ if there is explicit reference to her negative HIV status in the
chart. This must be evident by the presence of a negative test result.
Select ‘No’ if:
o The progress notes in the prenatal records state that this is a woman at risk for HIV
infection but that her HIV infection status is unknown.
o The woman may have been tested before delivery, but appears not to be known to
be HIV-infected by medical staff include: being tested so late in pregnancy that
results are not available before delivery, failure of physicians to inquire about HIV
status, failure to be offered a test during prenatal care, and failure of patient to
disclose.
14. Did mother receive antiretroviral drugs during labor and delivery? (Required, if applicable,
applies to health department & health care providers).
The labor and delivery period is also termed the intrapartum period and refers to the time
from which the woman was admitted to the hospital for labor to the time of delivery.
14.1 Select appropriate response from given values of “Yes”, “No”, “Not documented”, “Record not
available”, and “Unknown”.
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National HIV Surveillance System Technical Guidance – PCRF and PHER Form, XXXX 2019
Select ‘Yes’ if ARVs received during the intrapartum period, and complete the table for all
drugs received during labor and delivery. Enter “Unknown” in the ‘Drug Name’ column if
the specific drugs received are unknown.
o Enter the date the drug was started in mm/dd/yyyy format using ‘..’ for unknown
values (e.g., 03/../2011). Write time in military hours (e.g., 9:15 a.m. is 09:15, 1:00
p.m. is 13:00). Midnight is 00:00 and noon is 12:00. To calculate military time
count the number of hours and minutes past midnight or 00:00 hours. Indicate if
the drug was administered orally, through IV, or not documented.
Select “No” if no ARV was received during labor & delivery, and indicate reason from the
following given legal values:
o Precipitous delivery/STAT C-section - In some cases an eminent delivery of an
infant may preclude prescription and/or administration of ARV.
o Prescribed but not administered - There are instances where a physician has
ordered the medication, but the mother never received it. Possible reasons would
include not having the specific ARV in the hospital pharmacy. If the ARV was
prescribed but not administered because the women delivered prior to
administration, check the previous box for ‘Precipitous delivery/STAT c-section’.
o HIV serostatus of mother unknown - The physician may not have known the HIV
status of mother either because she refused testing or the physician did not offer
testing. Sometimes the mother is not identified as being HIV positive until after
delivery.
o Birth not in hospital - If the birth occurred outside a hospital, in all likelihood ARV
would not have been administered.
o Mother tested HIV negative during pregnancy - Some women may become HIV
positive during pregnancy. The mother may have tested HIV negative at some
point during pregnancy and was never retested and determined to be HIV positive.
In this case she may not have been prescribed ARV during labor and delivery
because she was believed to be HIV negative. There must be evidence of a
negative test during pregnancy or at labor and delivery in the chart; do not use
patient report.
o Mother Refused - Mother refused ARV at labor and delivery.
o Other - If ‘Other’ is indicated, be sure to specify why ARV was not prescribed.
Select “Not Documented” if the woman was not prescribed ARV but the reason why is not
known.
Drug Refused - If any antiretroviral drug was refused, write the name of the drug in the grid
and check ‘Yes’ in the column labeled ‘Was Drug Refused’. Do not assume that a woman
who did not receive antiretroviral drugs refused the drugs - they may not have been offered.
Only code ‘refused’ if refusal is documented. Our goal is to sort out women who did not
receive drugs because it was not offered to them, and those who did not receive it because
they refused it.
15. Was mother referred for HIV care after delivery? (Recommended, if applicable, applies to health
department & health care providers).
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National HIV Surveillance System Technical Guidance – PCRF and PHER Form, XXXX 2019
Indicate if the mother was referred for HIV care after delivery. An indicator for this could be
a CD4 or viral load test after the mother’s discharge from the hospital following delivery of
the infant. This information is usually found in the mother’s chart. If not, indicate ‘Not
documented’.
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National HIV Surveillance System Technical Guidance – PCRF and PHER Form, XXXX 2019
16. If yes, indicate first CD4 or first viral load result after discharge from the hospital (up to 6
months after discharge). (Required, if applicable, applies to health department & health care
providers).
This question is most relevant for those project areas that have laboratory reporting of CD4
counts and viral loads. If the mother receives CD4 or viral load testing this information can
be used as a marker that the mother has received care after delivery.
Indicate the first CD4 count and percentage and the first viral load result following the
mother’s discharge from the hospital (after delivery of the infant). This information will
most likely be found in the mother’s clinic chart. If there is no indication of a subsequent
CD4 or viral load result, mark ‘Not done’.
See the PCRF, Section 9 above, for instructions on coding CD4 and viral load results.
17. Birth information (Required, if applicable, applies to health department & health care providers).
This information may be listed in the labor and delivery record or in a dictated/transcribed
labor and delivery summary by the physician. Write time in military hours (e.g., 9:15 a.m. is
09:15, 1:00 p.m. is 13:00). Midnight is 00:00 and noon is 12:00. To calculate military time
count the number of hours and minutes after midnight or 00:00 hours. Enter the date in
mm/dd/yyyy format using ‘..’ for unknown values (e.g., 03/../2011).
Onset of labor - This should be found on the labor and delivery summary sheet. The onset
of labor is defined as the time when contractions are 3-5 minutes apart. The date and time
are necessary to calculate the duration of ruptured membranes, and duration of labor. In an
‘elective cesarean section’ there will not be onset contractions, because by definition, an
elective cesarean occurs prior to onset of labor. In this case, write ‘none’ in the space
provided.
Admission to Labor and Delivery - Time of admission should be available on the face
sheet (likely stamped on this sheet). If possible, record the time of admission to Labor and
Delivery (L&D), rather than to hospital. A short time between admission and delivery
(‘precipitous delivery’) may be a reason for not receiving ARVs. You should make sure that
the date and time of admission to L&D is for the admission associated with delivery. The
woman may have been admitted on another date and/or time for false labor or some other
reason and sent home, then readmitted for delivery.
Rupture of membranes - This should be found on the labor and delivery summary sheet.
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National HIV Surveillance System Technical Guidance – PCRF and PHER Form, XXXX 2019
The date and time are necessary to calculate the duration of ruptured membranes and
duration of labor. Rupture of membranes refers to the time when the amniotic sac is either
purposely broken or ruptures on its own. When a physician/health care provider ruptures the
membranes this is referred to as artificial rupture of membranes--often abbreviated as
AROM. When membranes rupture on their own, spontaneously, this is referred to as
spontaneous rupture of membranes (SROM). Premature rupture of membranes is referred to
as PROM. In the case of cesarean section, the rupture of membranes may be almost
concurrent with time of delivery.
Delivery - This should be found on the labor and delivery summary sheet. The date and time
are necessary to calculate the duration of ruptured membranes and duration of labor. If the
time of delivery is unknown because of a home or out-of-hospital delivery, enter ‘..:..’.
Verify that the delivery date is the same as the date of birth noted on the first page of the
abstraction form. If there is an inconsistency, verify the correct date of birth and update
eHARS if necessary.
18. If Cesarean delivery, mark all the following indications that apply (Required, if applicable,
applies to health department & health care providers).
Mode of delivery information should be noted in the delivery summary sheet, nurse’s notes,
anesthesiologist’s notes, or physician’s progress notes. Often there is a standard check off
list of procedures that may have been performed in the course of labor and delivery. A
cesarean delivery may be noted there.
Elective cesarean section refers to a cesarean section that occurs before rupture of
membranes and before the onset of labor. If a cesarean section was planned but then
performed ahead of schedule due to unexpected circumstances, it should still be coded as
‘Elective.’ Non-elective (or emergent) C-sections are usually done because the fetus has
shown signs of distress during labor. Elective C-sections are planned, done for a variety of
reason (e.g., previous C-section, breech position, HIV prevention) and usually occur before
the onset of labor. C-sections that are done in the middle of the night are usually not
elective. Review the chart for clarification if summary sheet indicates ‘elective’. Whether a
C-section was elective or emergent may not be noted in the delivery summary sheet, but the
dictated discharge summary will make this clear. The reason(s) for a C-section are given in
the labor and delivery medical record. Notes in the child’s records are acceptable even if no
birth records are available.
If not documented, select ‘Not specified’.
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National HIV Surveillance System Technical Guidance – PCRF and PHER Form, XXXX 2019
19. Was the mother’s HIV serostatus noted on the child’s birth record? (Recommended, if
applicable, applies to health department & health care providers).
Select appropriate response from given values.
20. Were antiretroviral drugs prescribed for the child? (Required, if applicable, applies to health
department & health care providers).
Select “Yes” if any ARVs were prescribed for the child, and complete the grid.
o Enter the dates in mm/dd/yyyy format using ‘..’ for unknown values (e.g.,
03/../2011). Write time in military hours (e.g., 9:15 a.m. is 09:15, 1:00 p.m. is
13:00). Midnight is 00:00 and noon is 12:00. To calculate military time count the
number of hours and minutes after midnight or 00:00 hours.
Enter all ARVs for the child
If no ARV prescribed, indicate reason
o HIV serostatus of mother unknown - The physician may not have known the HIV
status of mother either because she refused testing or the physician did not offer
testing. Sometimes the mother is not identified as being HIV positive until after
delivery.
o Mother known to be HIV negative during pregnancy - If the mother tested HIV
negative during pregnancy (with no further testing to indicate HIV
seroconversion), she would not receive ARV for prevention of perinatal
transmission. There must be evidence of a negative test during pregnancy or at
labor and delivery in the chart; do not use patient report.
o Mother Refused - Mother refused ARV for infant during first six weeks of life.
o Other - If ‘Other’ is indicated, be sure to specify why ARV was not prescribed.
o Not Documented - Indicate ‘Not Documented’ if the infant was not prescribed
ARV but the reason why is not known.
Select “Unknown” if the specific drugs prescribed are unknown, complete the grid, and
write “Unknown” in the “Drug name” column.
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National HIV Surveillance System Technical Guidance – PCRF and PHER Form, XXXX 2019
| File Type | application/pdf |
| File Title | Technical_Guidance_vol2.book |
| Author | bnk5 |
| File Modified | 2019-05-31 |
| File Created | 2019-05-22 |