Technical Guidance: Pediatric HIV Confidential Case Report Form

National HIV Surveillance System (NHSS)

Attachment 4(b)
Technical Guidance for HIV Surveillance Programs:
Pediatric HIV Confidential Case Report Form

Technical Guidance for HIV
Surveillance Programs
Pediatric HIV Confidential Case Report Form

HIV Surveillance Branch
Division of HIV Prevention
National Center for HIV, Viral Hepatitis, STD, and TB Prevention
Centers for Disease Control and Prevention
Atlanta, Georgia

Technical Guidance for HIV Surveillance Programs—Pediatric HIV Confidential Case Report Form

Acknowledgments
The Technical Guidance for HIV Surveillance Programs is a series of Technical Guidance files that are
part of a portfolio of resources to guide HIV surveillance programs at health departments in U.S. states,
cities, and territories on the implementation of HIV surveillance systems in accordance with state, local,
and territorial laws, regulations, and practices.
These files are living documents and the updates include adaptions and adjustments from previous
iterations. We acknowledge previous contributors from the Centers for Disease Control and Prevention
(CDC), other federal agencies, academic partners, and state, local, and territorial health departments.
The updates to these files were prepared by CDC in collaboration with the Council of State and
Territorial Epidemiologists (CSTE), with contributions from state, local, and territorial HIV surveillance
programs. The process of revising the Technical Guidance files included 2 phases: during February–
March 2023, CDC hosted 4 workshops in which HIV surveillance programs informed the revisions to the
Technical Guidance files; during May–June 2023, CDC hosted 3 workshops to discuss the recommended
revisions and gather feedback. HIV surveillance programs also provided input following the workshops.

Members of the CDC/CSTE HIV Subcommittee Leadership
CSTE: Elizabeth Daly, Lindsay Pierce, Symone Richardson
Health Departments: Analise Monterosso (TX), Betsey John (MA), Samantha Mathieson (TN)
CDC/HIV Surveillance Branch: Angela L. Hernandez, Nikiya Woodard, Azfar Siddiqi, Patricia Sweeney,
Alexandra Balaji, Tonia Gray, Anna Satcher Johnson, Patrick Minor, Anne Peruski
CDC/Detection and Response Branch: Alexandra M. Oster

Members of the CDC Division of HIV Prevention HIV Surveillance Technical
Guidance Workgroups
HIV Surveillance Branch: Anna Baker, Alexandra Balaji, Karin Bosh, Mi Chen, Scott Cope, André
Dailey, Fidel Desir Boya, Zanetta Gant, John Gerstle, Baskaran Govindarajan, Tonia Gray, Scott Grytdal,
Angela L. Hernandez, Kristen Hess, Shacara Johnson Lyons, Benjamin Laffoon, William Longdon,
Duane McKinley, Juliet Morales, Patrick Minor, Ndidi Nwangwu-Ike, Cheryl Ocfemia, Amanda Okello,
Anne Peruski, Shelly Ren, Samantha Retzloff, Sue Reynolds, Anna Satcher Johnson, Azfar Siddiqi, Sonia
Singh, Patricia Sweeney, Ashley Townes
Detection and Response Branch: Rachael Billock, Robert Bonacci, Nicoline Collins, Anne Marie France,
Camden Hallmark, Craig Hayes, Emily Holman, Irma Kocer, Laurie Linley, Alexandra M. Oster,
Nivedha Panneer, Meg Watson
Office of Science: Michael Friend
Programmatic Support Contractors: Sarah Baker, CAITTA, Inc.; Aubrey Gerber, DLH Corp.

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Technical Guidance for HIV Surveillance Programs—Pediatric HIV Confidential Case Report Form

Contents
Introduction ................................................................................................................................................... 4
Instructions for Completion .......................................................................................................................... 4
Purpose of Case Report Form .................................................................................................................. 4
The Case Report Form in the Context of Document-based Surveillance ................................................ 5
Patients for Whom Form is Indicated ...................................................................................................... 5
Definition of Variable Designators .......................................................................................................... 6
Disposition of Form ................................................................................................................................. 6
1. Patient Identification .......................................................................................................................... 6
2. Health Department Use Only ............................................................................................................. 8
3. Facility Providing Information ......................................................................................................... 10
4. Patient Demographics....................................................................................................................... 11
5. Residence at Diagnosis ..................................................................................................................... 16
6. Facility of Diagnosis ........................................................................................................................ 17
7. Patient History .................................................................................................................................. 18
8. Clinical: Opportunistic Illnesses ...................................................................................................... 23
9. Laboratory Data ................................................................................................................................ 25
10. Birth History (for patients exposed perinatally with or without consequent infection) ................... 32
11. Birthing Person History .................................................................................................................... 36
12. Treatment/Services Referrals ........................................................................................................... 44
13. Comments (Optional, applies to health department & health care providers) ................................. 46
14. Local/Optional Fields (Optional, applies to health department) ...................................................... 46
Appendix ..................................................................................................................................................... 47
Pediatric HIV Confidential Case Report Form (CDC 50.42B).............................................................. 47
Instructions for Completion .............................................................................................................. 47
Purpose ......................................................................................................................................... 47
Pediatric Cases of Public Health Importance (COPHI) ............................................................... 48

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Introduction
The goals of HIV surveillance are to describe the burden and epidemiology of HIV, monitor HIV trends,
identify HIV clusters and outbreaks, and guide public health action at the federal, state, local, and
territorial levels.
The Technical Guidance for HIV Surveillance Programs is a series of Technical Guidance files that are
part of a portfolio of resources to guide HIV surveillance programs at health departments on the
implementation of HIV surveillance systems in accordance with state, local, and territorial laws,
regulations, and practices. These files are prepared by the Centers for Disease Control and Prevention
(CDC) in collaboration with the Council of State and Territorial Epidemiologists (CSTE), with
contributions from state, local, and territorial HIV surveillance programs. These files are living
documents and the updates include adaptions and adjustments from previous iterations.
State, local, and territorial HIV surveillance programs at health departments are responsible for their HIV
surveillance system, which encompasses surveillance activities, reporting sources, surveillance
information systems (including the enhanced HIV/AIDS Reporting System [eHARS]), and other
supporting tools (like ATra Blackbox, Secure HIV-TRACE). All HIV surveillance systems together
contribute to the National HIV Surveillance System (NHSS).
CDC provides technical assistance and support to HIV surveillance programs to ensure that HIV
surveillance systems have complete, accurate, and timely data for public health action. The HIV
Surveillance Branch (HSB) of the Division of HIV Prevention (DHP), National Center for HIV, Viral
Hepatitis, STD, and TB Prevention (NCHHSTP) is responsible for NHSS.
The Technical Guidance files, periodically, will include examples of how eHARS can be used for
collecting and managing HIV surveillance data. Note that the same demonstrated concepts should also
apply if another surveillance information system is used by the HIV surveillance program.
Technical Guidance file Pediatric HIV Confidential Case Report Form (PCRF) describes the purpose and
indicators for use of the PCRF and instructions for completing the PCRF, which is designed to collect
information for persons less than 13 years of age who are perinatally exposed to HIV or diagnosed with
HIV. The PCRF Technical Guidance file supports standard data collection, which is important for
ensuring accurate HIV surveillance data that can guide public health action.
HIV surveillance programs should ensure that their policies and procedures include the activities
described in this Technical Guidance file and relevant public health actions; policies and procedures
should be reviewed at least annually and updated as needed. Ensure that staff are trained on the policies
and procedures with a focus on changes to procedures or areas needing improvement. Contact the HIV
surveillance program’s CDC surveillance project officer with any questions or feedback about this
Technical Guidance file. If needed, call the HSB main phone number at 404-639-2050 for assistance with
identifying the HIV surveillance program’s CDC surveillance project officer.

Instructions for Completion
Purpose of Case Report Form
The PCRF (CDC 50.42B) is designed to collect information that promotes understanding of perinatal
HIV exposure and HIV infection morbidity and mortality among patients less than 13 years of age at time
of diagnosis. This form reflects data that are required to be collected and some that is recommended or
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optional. This guidance applies to all perinatal HIV exposure and HIV infection data collection even if an
HIV surveillance program uses a different form or medium for perinatal HIV exposure and HIV case
surveillance. See Appendix for further guidance.
Prior to 2023, CDC provided a separate Perinatal HIV Exposure Reporting (PHER) form to facilitate
collection of additional standardized data on HIV-exposed children. CDC revised the PCRF to include
some additional standardized data on HIV-exposed children and retired the separate PHER form in 2023.
The PCRF document in eHARS has been designed to generally align with the information collected on
the hardcopy PCRF described in this file.

The Case Report Form in the Context of Document-based Surveillance
Document-based data management allows all documents to be stored and retained electronically with
their original contents. 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 perinatal HIV exposure or HIV case to
enable traceability and provide a longitudinal view of data reported for a case.
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 jurisdiction, or their designee, should review all forms before the data are entered.
For additional information about conducting pediatric HIV surveillance activities, see Technical
Guidance file Pediatric HIV Surveillance.

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://ndc.services.cdc.gov/conditions/hiv-infection-aids-has-beenreclassified-as-hiv-stage-iii/).

•

For perinatal exposure HIV reporting, all children born to HIV-infected persons. This includes
only live births. The definition of a live birth as defined by the World Health Organization is:
“...the complete expulsion or extraction from its [birthing person] 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.” (see “Definition” at
https://www.who.int/data/gho/indicator-metadata-registry/imr-details/26).
Thus, if a birth certificate has been completed for the infant and the birthing person was HIVinfected, the form should be completed.

•

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 before 13 years of age.

•

Each child with HIV infection who has been reported but for whom updated information is
available such as new results from CD4 tests, viral load tests, or drug resistance tests (genotypic)
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reported from a medical provider, additional risk factor information, updated current address
information, or a change in vital status.
•

For each follow-up (typically every 6 months) of a child with perinatal HIV exposure whose
infection status has not been determined until the diagnostic status is known or up to 18 months of
age.

If the data are 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. Please note that for some of these
variables there must be a known value reported in order to meet the eligibility criteria for data
associated with the patient to be transmitted to the Centers for Disease Control and Prevention
(CDC) via eHARS. The eHARS Technical Reference Guide details the specific variables required
to meet the eligibility criteria at the beginning of Chapter 3. The eHARS Technical Reference
Guide can be accessed through the HSB SharePoint site:
https://cdcpartners.sharepoint.com/sites/NCHHSTP/HSB/default.aspx.

•

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 eHARS. Note. Some of these values
are unique identifiers.

Disposition of Form
•

The completed form is for health department use and is not to be sent to CDC. The Pacific Islands
are the only jurisdictions that submit forms to CDC for data entry in eHARS, and all patient
identifiers must be removed before submission.

•

Data obtained from these forms are entered in eHARS, which is provided by DHP, NCHHSTP,
CDC, and then transferred without identifiers to CDC by encrypted electronic transfer via a secure
access management service.

1. Patient Identification

•
•

Patient identifier information is for health department use only and is not transmitted to CDC
if marked with an asterisk (*) on the form.
Enter the data below for all children reported as perinatally exposed to HIV or reported with
HIV infection.
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1.1
1.2
1.3
1.4

1.5

1.6

1.7

1.8

1.9
1.10

1.11

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 in eHARS, the software automatically generates this
variable by using the patient’s last name. After the code is generated, HIV surveillance
program staff should fill this field on the form.
• This variable is a phonetic, alphanumeric code calculated by converting a surname to an
index letter and a 3-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/HSB/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)
• Enter patient’s alternate last name.
ADDRESS TYPE (Required, applies to health department & health care providers)
• Select one of the address types for the patient’s current address.
CURRENT ADDRESS, STREET (Required, applies to health department & health care
providers)
• Enter the patient’s current street address.
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. In eHARS, enter the address with the most recent address date
on a separate PCRF document on the “Identification” tab.
• Enter date in mm/dd/yyyy format; use “..” for unknown values (e.g., 03/../2011).

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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 perinatal HIV exposure, 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. In eHARS, enter the additional medical record
numbers on the “Identification” tab.
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 (available at
https://cdcpartners.sharepoint.com/sites/NCHHSTP/HSB/default.aspx).

2. Health Department Use Only

Enter the data below for all children reported as perinatally exposed to HIV or reported with
HIV infection.
2.1 DATE RECEIVED AT HEALTH DEPARTMENT (Recommended, applies to health
department)
• Enter date in mm/dd/yyyy format; use “..” for unknown values (e.g., 03/../2011).
2.2 eHARS DOCUMENT UID (System generated)
• Enter UID after eHARS generates this variable.
•

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2.3

2.4

2.5

2.6

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 infection
(including perinatal HIV exposure) in each state/jurisdiction where they are reported.
However, if the patient was a pediatric “Seroreverter” and was later infected with HIV,
the patient must be given 2 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.” HIV surveillance
programs must use the “Same as” field on the “Duplicate Review” tab in eHARS to link
the 2 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.
• Assigned numbers should not contain information that can be used to identify the person
(e.g., name, residence), the reporting health department, or the testing site.
• This variable is used, along with the state of report, to uniquely identify cases reported to
CDC and to merge 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.
• When CDC provides technical assistance and support for conducting HIV surveillance to
a city/county, each patient must have a unique city/county number assigned by the
city/county in which they are reported, an identifier associated with the patient
throughout the course of HIV infection (including perinatal HIV exposure). 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 2 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 HIV surveillance
program must use the “Same as” field on the “Duplicate Review” tab in eHARS to link
the 2 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.
• Assigned numbers should not contain information that can be used to identify the person
(e.g., name, residence), the reporting health department, or the testing site.
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 perinatal HIV exposure or HIV case
(all stages), use a separate case report form for each source.
• Refer to the eHARS Technical Reference Guide for a list of the document source codes
available in eHARS (available at
https://cdcpartners.sharepoint.com/sites/NCHHSTP/HSB/default.aspx).
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2.7

2.8

2.9

SURVEILLANCE METHOD (Required, applies to health department)
• Enter the method the case report was ascertained.
• For definitions of active, passive, follow up, and reabstraction, see Technical Guidance
file 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)
• Enter the medium in which the case report was submitted.
• Select “1-Field visit” if HIV surveillance program staff review medical records at
provider facilities or access the medical records remotely to elicit information for the
HIV case report forms.
• Select “2-Mailed” if the HIV case report form is received by U.S. mail.
• Select “3-Faxed” if the HIV case report form is received by fax.
• Select “4-Phone” if the telephone is used to elicit information to complete the HIV case
report form.
• Select “5-Electronic transfer” if electronic transfer of information is used to complete the
HIV case report form.
• Select “6-CD/disk” if information the HIV case report forms is received on CD/disk.

3. Facility Providing Information

Facility information is not transmitted to CDC if marked with an * on the form.
Enter the data below for all children reported as perinatally exposed to HIV or reported with
HIV infection.
3.1 FACILITY NAME (Recommended, applies to health department & health care providers)
• Enter name of the facility providing the information.
• If data were 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.
•
•

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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
facility types available in eHARS (available at
https://cdcpartners.sharepoint.com/sites/NCHHSTP/HSB/default.aspx).
3.9 DATE FORM COMPLETED (Required, applies to health department & health care
providers)
• Enter date in mm/dd/yyyy format; use “..” for unknown values (e.g., 03/../2011).
3.10 PERSON COMPLETING FORM (Optional, applies to health department & health care
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

Enter the data below for all children reported as perinatally exposed to HIV or reported with
HIV infection.
4.1 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 event.
o Fill out subsequent forms partially, capturing additional or updated data absent from
the first form.
•

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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 person, and has an undetermined HIV infection
status.
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 4 diagnostic status categories available on the case report form,
“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.
• If search for this datum was completed and sex assigned at birth could not be assigned as
“Male” or “Female,” select “Unknown.” Also, select “Unknown” if the patient’s sex
assigned at birth is listed as a value other than “Male” or “Female” (e.g., intersex, X
[non-binary marker]). You may enter the specific value for sex assigned at birth in the
Comments section. In eHARS, enter the specific value for sex assigned at birth in the
“Comments” tab. Patient’s with an “Unknown” value for sex assigned at birth will not
be transmitted to CDC and select variables in eHARS will not be calculated.
COUNTRY OF BIRTH (Recommended, applies to health department & health care
providers)
• Select applicable response.
• For patients born in U.S. minor outlying areas, specify the name of the U.S. dependency
from the following table:
U.S. Dependencies
Baker Island
Johnston Atoll
Navassa Island
Howland Island
Kingman Reef
Palmyra Atoll
Jarvis Island
Midway Islands
Wake Island

•

4.2

4.3

•

For patients born in any other area outside of the United States and U.S. minor outlying
areas, specify the country/U.S. dependency name.

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4.4

DATE OF BIRTH (Required, applies to health department & health care providers)
• Enter patient’s date of birth in mm/dd/yyyy format; use “..” 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; use “..” 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 Technical Guidance 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; use “..” for unknown
values (e.g., 03/../2011).
• For further guidance on death ascertainment, see Technical Guidance 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 United States, 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; use “..” 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; use “..” 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 birthing person 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.
• Evidence of HIV infection in a child must be obtained on or after the birth date.
4.11 GENDER IDENTITY and DATE IDENTIFIED (Required if not perinatal exposure or
perinatal transmission, applies to health department & health care providers)
• Enter the gender identity of the patient. Gender identity refers to a person’s internal
understanding of their own gender, or gender with which a person identifies. (See CDC’s
web page, HIV and Transgender People: Terminology, available at HIV Terms and Definitions
| HIV | CDC for more information.)
• For an individual who identifies as a boy or girl and does not have a gender identity that is
discrepant from their sex at birth, enter “Boy” or “Girl.”
• For an individual who identifies as a gender opposite of their sex at birth, enter
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“Transgender Boy” or “Transgender Girl.” Ex: For a person who is male sex at birth, who
identifies as a girl, record the person as a Transgender Girl. For a person who is female sex
at birth, who identifies as a boy, record the person as a Transgender Boy.
• If the patient’s stated gender identity differs from the selections provided or the patient’s
stated gender identity at a point in time includes more than one of the selections
provided, select “Additional gender identity” and specify the gender identity or gender
identities.
• If documented that the patient declined to provide their gender identity, select “Declined
to answer.”
• If search for this datum was completed and gender identity could not be determined or if
gender identity was documented to be unknown, select “Unknown.”
• Refer to the lookup codes in the eHARS Technical Reference Guide for gender identity
values available in eHARS (available at
https://cdcpartners.sharepoint.com/sites/NCHHSTP/HSB/default.aspx).
• For date identified, please enter the date the patient indicated identifying as the selected
gender identity, if documented. If this date is unknown or the selected response option
for gender identity was “Declined to answer” or “Unknown,” enter the date of service
(e.g., medical appointment, partner services interview) for when the information on
gender identity was obtained. If that date is unknown, enter the most recent date of
service. You may also enter the most recent date associated with the patient’s gender
identity in the Comments section. In eHARS, enter the gender identity value associated
with the most recent date on a separate PCRF document on the “Demographics” tab.
Record the date in mm/dd/yyyy format; use “..” for unknown values (e.g., 03/../2011).
• If the patient’s gender identity has changed over time, record the other gender identities
and associated dates identified in the Comments section. In eHARS, enter each
additional value on separate PCRF documents on the “Demographics” tab.
4.12 SEXUAL ORIENTATION and DATE IDENTIFIED (Required if not perinatal exposure
or perinatal transmission, applies to health department & health care providers)
• Enter sexual orientation of the patient. Sexual orientation should not be assigned based
on review of other recorded information (e.g., responses to questions about gender of
sexual partners); use only information where sexual orientation is explicitly indicated.
• If the patient’s stated sexual orientation differs from the selections provided or the
patient’s stated sexual orientation at a point in time includes more than one of the
selections provided, select “Additional sexual orientation” and specify the sexual
orientation or sexual orientations.
• If documented that the patient declined to provide their sexual orientation, select
“Declined to answer.”
• If search for this datum was completed and sexual orientation could not be determined or
if the sexual orientation was documented to be unknown, select “Unknown.”
• Refer to the lookup codes in the eHARS Technical Reference Guide for sexual
orientation values available in eHARS (available at
https://cdcpartners.sharepoint.com/sites/NCHHSTP/HSB/default.aspx).
• For date identified, please enter the date the patient indicated identifying as the selected
sexual orientation, if documented. If this date is unknown or the selected response option
for sexual orientation was “Declined to answer” or “Unknown,” enter the date of service
for when the information on sexual orientation was obtained. If that date is unknown,
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4.13

4.14

4.15

4.16

enter the most recent date of service. You may also enter the most recent date associated
with the patient’s sexual orientation in the Comments section. In eHARS, enter the
sexual orientation value associated with the most recent date on a separate PCRF
document on the “Demographics” tab. Record it in mm/dd/yyyy format; use “..” for
unknown values (e.g., 03/../2011).
• If the patient’s sexual orientation has changed over time, record other sexual orientations
and associated dates identified in the Comments section. In eHARS, enter each
additional value on separate PCRF documents on the “Demographics” tab.
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 U.S. 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 eHARS. These
ethnicities and codes are documented in the eHARS Technical Reference Guide
(available at https://cdcpartners.sharepoint.com/sites/NCHHSTP/HSB/default.aspx).
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
(available at https://cdcpartners.sharepoint.com/sites/NCHHSTP/HSB/default.aspx).
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 U.S. 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 5 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 (available at
https://cdcpartners.sharepoint.com/sites/NCHHSTP/HSB/default.aspx).
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 (available at
https://cdcpartners.sharepoint.com/sites/NCHHSTP/HSB/default.aspx).

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5. Residence at Diagnosis

Residence information is not transmitted to CDC if marked with an * on the form.
Enter the data below for all children reported as perinatally exposed to HIV or reported with
HIV infection.
• Refer to Appendix (5) 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. In
eHARS, enter the address information associated with stage 3 (AIDS) diagnosis on the
“Demographics” tab with the applicable address event type.
5.1 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.
5.2 ADDRESS TYPE (Required, applies to health department & health care providers)
• Select one of the address types for the patient’s address of residence at diagnosis.
5.3 STREET ADDRESS (Required, applies to health department & health care providers)
• Enter street address of residence at diagnosis.
5.4 CITY (Required, applies to health department & health care providers)
• Enter city of residence at diagnosis.
5.5 COUNTY (Required, applies to health department & health care providers)
• Enter county of residence at diagnosis.
5.6 STATE/COUNTRY (Required, applies to health department & health care providers)
• Enter the state and country name of residence at diagnosis.
5.7 ZIP CODE (Required, applies to health department & health care providers)
• Enter the ZIP code of residence at diagnosis.
•
•

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6. Facility of Diagnosis

Facility information is not transmitted to CDC if marked with an * on the form.
Enter the data below for all children reported as perinatally exposed to HIV or reported with
HIV infection.
• 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. In eHARS, enter the
facility information associated with stage 3 (AIDS) diagnosis on the “Facility” tab with the
applicable diagnosis type.
• For details about documenting the information for a telemedicine facility, refer to Appendix
(6).
6.1 DIAGNOSIS TYPE (Recommended, applies to health department & health care providers)
• Enter the diagnosis type that corresponds to the facility of diagnosis being reported.
6.2 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 6.1.
• Refer to Appendix (6.2) for further details.
6.3 PHONE (Recommended, applies to health department & health care providers)
• Enter area code and telephone number of the facility of diagnosis.
6.4 STREET ADDRESS (Recommended, applies to health department & health care providers)
• Enter street address of the facility of diagnosis.
6.5 CITY (Recommended, applies to health department & health care providers)
• Enter city of the facility of diagnosis.
6.6 COUNTY (Recommended, applies to health department & health care providers)
• Enter county of the facility of diagnosis.
6.7 STATE/COUNTRY (Recommended, applies to health department & health care providers)
• Enter state and country name of the facility of diagnosis.
6.8 ZIP CODE (Recommended, applies to health department & health care providers)
• Enter ZIP code where the facility of diagnosis is located.
6.9 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 (available at
https://cdcpartners.sharepoint.com/sites/NCHHSTP/HSB/default.aspx).
6.10 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 6.1.
•
•

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6.11 PROVIDER PHONE (Recommended, applies to health department & health care
providers)
• Enter area code and telephone number for provider selected in 6.10.
6.12 SPECIALTY (Optional, applies to health department & health care providers)
• Enter provider’s specialty for provider selected in 6.10.

7. Patient History

•

•
•

•

Enter all data below for children reported with HIV infection. For children reported as
perinatally exposed to HIV, enter data below through 7.9.4; do not enter data under the
heading “Before the diagnosis of HIV infection, this child had:”
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 Technical Guidance file Risk Factor Ascertainment.
Information on the child refers to circumstances or behaviors that were thought to have
exposed the child to HIV, not to treatments since the child became HIV infected. For example,
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if the child received a blood transfusion after the documentation of HIV infection, do not enter
that information on the form.
• The state, local, or territorial Cases of Public Health Importance (COPHI) coordinator should
contact the CDC COPHI coordinator (Scott Grytdal, [email protected]) as soon as possible if
any unusual transmission circumstances are suspected. For further guidance, see Technical
Guidance file Cases of Public Health Importance (COPHI).
7.1 BIRTHING PERSON’S HIV INFECTION STATUS (Required, applies to health
department & health care providers)
• For the birthing person, if HIV infection was diagnosed then 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 diagnosis. Where date of
the birthing person’s first positive test result to confirm HIV infection is available, select
the appropriate box by comparing the date of birth of the child to the date of HIV
infection diagnosis of the birthing person.
• Refer to Appendix (7.1) for further guidance.
7.2 DATE OF BIRTHING PERSON’S FIRST POSITIVE TEST RESULT TO CONFIRM
INFECTION (Optional, applies to health department & health care providers)
• Where the birthing person is known to be HIV infected, enter month, day, and year of
the specimen collection date of the first positive test result to confirm HIV infection in
mm/dd/yyyy format; use “..” for unknown values (e.g., 03/../2011).
7.3 CHILD BREASTFED/CHESTFED BY BIRTHING PERSON (Required, applies to health
department and health care providers)
• Select applicable response.
• Select “Yes” if there is evidence that the patient was fed milk produced from the birthing
person’s chest or documentation indicates that the patient was breastfed/chestfed milk by
the birthing person.
• When the birthing person was known to be not HIV infected at the time of child’s birth
an investigation should be initiated and the state, local, or territorial Cases of Public
Health Importance (COPHI) coordinator should be alerted. In all other situations,
investigation is not required, but the CDC COPHI coordinator can be consulted if
interested in further investigating breastfeeding/chestfeeding as the mode of
transmission.
7.4 START DATE (Required, applies to health department and health care providers)
• If the child was breastfed/chestfed by the birthing person, enter the date the child
initiated breastfeeding/chestfeeding in mm/dd/yyyy format; use “..” for unknown values
(e.g., 03/../2011).
7.5

STOP DATE (Required, applies to health department and health care providers)
• If the child was breastfed/chestfed by the birthing person, enter the date the child
stopped breastfeeding/chestfeeding in mm/dd/yyyy format; use “..” for unknown values
(e.g., 03/../2011).
• The stop date for breastfeeding/chestfeeding should represent the last time the child was
exposed to breastfeeding/chestfeeding by the birthing person.

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7.6

7.7

7.8

CHILD RECEIVED PREMASTICATED/PRE-CHEWED FOOD FROM BIRTHING
PERSON (Required, applies to health department and health care providers)
• Select applicable response.
• When the birthing person was known to be not HIV infected at the time of child’s birth
an investigation should be initiated and the state, local, or territorial COPHI coordinator
should be alerted. In all other situations, investigation is not required, but the CDC
COPHI coordinator can be consulted (Scott Grytdal, [email protected]) if interested in
further investigating premastication/pre-chewing as the mode of transmission.
AFTER 1977 AND BEFORE THE EARLIEST KNOWN DIAGNOSIS OF HIV
INFECTION, THE BIRTHING PERSON HAD:
7.7.1 PERINATALLY ACQUIRED HIV INFECTION (Required, applies to health
department & health care providers)
o Select applicable response.
7.7.2 INJECTED NONPRESCRIPTION DRUGS (Required, applies to health
department & health care providers)
o Select applicable response.
o Select “Yes” if the birthing person injected nonprescription drugs at any time
in the past or if a drug prescribed to the birthing person was injected when
there is evidence that injection equipment was shared (e.g., syringes, needles,
cookers).
BIRTHING PERSON HAD HETEROSEXUAL RELATIONS WITH ANY OF THE
FOLLOWING:
• This section relates to ascertainment of risk factors among heterosexual sex partners of
the birthing person of the case patient.
• Heterosexual contact is defined as the birthing person having sexual contact with a
partner whose sex assigned at birth is different from the patient’s sex assigned at birth.
• Verification of sex partner’s HIV infection status is not necessary.
7.8.1 PERSON WHO INJECTED DRUGS (Required, applies to health department &
health care providers)
o Select applicable response. Select “Yes” if the partner injected illicit or
nonprescription drugs at any time in the past or if a drug prescribed to the
partner was injected when there is evidence that injection equipment was
shared (e.g., syringes, needles, cookers).
7.8.2 BISEXUAL MALE (Required, applies to health department & health care
providers)
o Select applicable response. “Yes” should be selected only if the partner’s sex
assigned at birth is male and there is evidence that the partner also had sex with
another person whose sex assigned at birth was male.
7.8.3 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).
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7.9

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 7.6.4 below.
o If yes, alert the state, local, or territorial COPHI coordinator.
7.8.4 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. In
eHARS, enter on the “Comments” tab.
o Refers to someone with documented HIV infection who received a transfusion
of blood cells (red cells, white cells, platelets) or plasma.
o If yes, alert the state, local, or territorial COPHI coordinator.
7.8.5 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. In eHARS, enter on the “Comments” tab.
o If yes, alert the state, local, or territorial COPHI coordinator.
7.8.6 PERSON WITH DOCUMENTED HIV INFECTION, RISK NOT SPECIFIED
(Required, applies to health department & health care providers)
o Select “Yes” only if partner is known to be HIV-positive and that partner’s risk
factor for HIV is unknown.
BIRTHING PERSON HAD:
7.9.1–7.9.3 RECEIVED TRANSFUSION OF BLOOD/BLOOD COMPONENTS
(OTHER THAN CLOTTING FACTOR), FIRST DATE RECEIVED, and LAST
DATE RECEIVED (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 birthing person received a diagnosis of HIV infection (stage 1,2,
unknown) or stage 3 (AIDS). Enter date in mm/dd/yyyy format; use “..” for
unknown values (e.g., 03/../2011).
o Consider documenting the reason for transfusion/transplant in the Comments
section. In eHARS, enter on the “Comments” tab.
o If the last transfusion was after March 1985, alert the state, local, or territorial
COPHI coordinator.
7.9.4 RECEIVED TRANSPLANT OF TISSUES/ORGANS OR ARTIFICIAL
INSEMINATION (Required, applies to health department & health care
providers)
o If this is the only risk factor present and the birthing person did not have HIV
infection diagnosed 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, or territorial COPHI coordinator.
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7.10 BEFORE THE DIAGNOSIS OF HIV INFECTION, THIS CHILD HAD
• Alert state, local, or territorial COPHI coordinator if the child had one or more of the risk
factors documented in this section.
7.10.1
INJECTED NONPRESCRIPTION DRUGS (Required, applies to health
department & health care providers)
o Select applicable response.
o Select “Yes” if the patient injected illicit or nonprescription drugs at any time
in the past or if a drug prescribed to the patient was injected when there is
evidence that injection equipment was shared (e.g., syringes, needles, cookers).
7.10.2–7.10.4
RECEIVED CLOTTING FACTOR FOR
HEMOPHILIA/COAGULATION DISORDER, SPECIFY CLOTTING FACTOR,
and DATE RECEIVED (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, or territorial COPHI coordinator if child was born after
March 1998 and receipt of clotting factor is the suspected mode of HIV
transmission.
o If “Yes,” then enter the specific clotting factor and the date the clotting factor
was received in mm/dd/yyyy format; use “..” for unknown values (e.g.,
03/../2011).
7.10.5
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
(AIDS). Enter date in mm/dd/yyyy format; use “..” for unknown values (e.g.,
03/../2011).
o It is often helpful to document the reason for the transfusion in the Comments
section. In eHARS, enter on the “Comments” tab.
7.10.6
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 COPHI investigation.
7.10.7
SEXUAL CONTACT WITH A MALE (Required, applies to health
department & health care providers)

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o If child is known to have had sexual contact/abuse, mark the appropriate box
based on the partner’s sex assigned at birth. If search for this datum was
completed and the partner’s sex assigned at birth cannot be determined, select
“Unknown.”
o If this is the only risk history, the case will be initially classified as “risk not
reported/identified” pending outcome of COPHI investigation.
7.10.8
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 based on the partner’s sex assigned at birth. If search for this datum was
completed and the partner’s sex assigned at birth cannot be determined, select
“Unknown.”
o If this is the only risk history, the case will be initially classified as
“risk not reported/identified” pending outcome of COPHI investigation.
7.10.9
BEEN BREASTFED/CHESTFED BY NON-BIRTHING PERSON
(Required, applies to health department & health care providers)
o Select applicable response.
o Select “Yes” if there is evidence that the patient was fed milk produced from
the chest of a non-birthing person or documentation indicates that the patient
was breastfed/chestfed by a non-birthing person. This includes evidence of the
receipt of donor milk.
7.10.10
RECEIVED PREMASTICATED/PRE-CHEWED FOOD FROM NONBIRTHING PERSON (Required, applies to health department & health care
providers)
o Select applicable response.
7.10.11
OTHER DOCUMENTED RISK (Required, applies to health department
& health care providers)
o Include detail in Comments section. In eHARS, enter on the “Comments” tab.

8. Clinical: Opportunistic Illnesses

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8.1

CLINICAL: OPPORTUNISTIC ILLNESSES
8.1.1–8.1.27 (Optional, applies to health department & health care providers)
o Select all that apply and enter diagnosis dates. Enter date in mm/dd/yyyy
format; use “..” for unknown values (e.g., 03/../2011).
o For additional information, refer to the most recent case definition for HIV
infection (available at https://ndc.services.cdc.gov/conditions/hiv-infectionaids-has-been-reclassified-as-hiv-stage-iii/).
8.1.28 RVCT CASE NUMBER (Optional, applies to health department & health care
providers)
o If this patient has a verified case of tuberculosis (TB), HIV surveillance
program staff enter the 9-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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9. Laboratory Data

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Throughout this section, “Collection Date” refers to the date when the specimen was collected
or drawn. Enter collection dates in mm/dd/yyyy format; use “..” for unknown values (e.g.,
03/../2011).
• Record all laboratory test results. Include results of all diagnostic tests, viral load tests, CD4
tests, and drug resistance tests (genotypic) where possible. Where the number of test results
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). For
information on the current HIV diagnostic testing algorithm, please refer to the 2018 Quick
reference guide, available at https://stacks.cdc.gov/view/cdc/50872.
• In the absence of laboratory tests, record HIV infection or stage 3 (AIDS) diagnostic evidence
documented in the chart by a physician.
• For children reported as perinatally exposed to HIV, record all test results of tests performed
to determine the diagnostic status of the child.
9.1 HIV IMMUNOASSAYS (IA)
• Assuming active case finding, review patient’s chart and laboratory reports for the
earliest date of documented HIV positivity.
• Enter the brand name of the test and/or its manufacturer, laboratory 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; use “..” for unknown values
(e.g., 03/../2011).
• Enter testing option for all tests. (Optional, applies to health department & health care
providers)
o Enter “Point-of-care test by provider” if the test was performed by the provider either
in a healthcare setting or other testing venue.
o Enter “Self-test, result directly observed by provider” if the test was performed by
the patient but directly observed by a provider (including via a telemedicine
appointment).
o Enter “Lab-test, self-collected sample” if the patient collected the sample (blood or
oral fluid) and sent it to the laboratory for testing.
9.1.1 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 a repeatedly reactive result on a single sample.
9.1.2 HIV-1/2 IA
o Enter result and date of first HIV-1/2 IA. (Required, applies to health
department & health care providers)
o “Positive IA” means a repeatedly reactive result on a single sample.
•

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9.1.3 HIV-1/2 AG/AB
o Enter result and collection date of first HIV-1/2 combination IA test.
(Required, applies to health department & health care providers)
o “Positive IA” means a repeatedly reactive result on a single sample.
9.1.4 HIV-2 IA
o Enter result and collection date of first HIV-2 IA. (Required, applies to health
department & health care providers)
o “Positive IA” means a repeatedly reactive result on a single sample.
9.1.5 HIV-1/2 AG/AB-DIFFERENTIATING IMMUNOASSAY
o Enter collection date of first HIV-1/2 Ag/Ab-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 Record the result for each analyte (HIV-1 Ag and HIV-1/2 Ab). That is, one
result should be recorded for HIV-1 Ag, one result for HIV-1/2 Ab result.
(Required, applies to health department & health care providers)
9.1.6 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)
9.1.7 HIV-1/2 TYPE-DIFFERENTIATING IMMUNOASSAY (supplemental)
o Enter collection date of first HIV-1/2 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 Record the result for each analyte (HIV-1 Ab 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)
9.1.8 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 in Interpretation and use of the western blot
assay for serodiagnosis of human immunodeficiency virus type 1 infections. In
MMWR;38(7):1–7, available at
https://www.cdc.gov/mmwr/preview/mmwrhtml/00001431.htm.
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9.2

9.1.9 HIV-1 IFA
o Enter the result and collection date of first HIV-1 IFA. (Required, applies to
health department & health care providers)
9.1.10 HIV-2 WESTERN BLOT
o Enter the result and collection date of first HIV-2 western blot. (Required,
applies to health department & health care providers)
HIV DETECTION TESTS
• All varieties of such tests establish the presence of the pathogen, HIV. By contrast, HIV
tests such as an immunoassay or western blot establish the presence of the immune
system’s response to the pathogen (i.e., HIV antibodies).
• Assuming active case finding, review patient’s chart and laboratory reports for the
earliest date of documented HIV positivity.
• Enter the brand name of the test and/or its manufacturer, laboratory 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; use “..” for unknown values
(e.g., 03/../2011).
• Enter testing option for all tests. (Optional, applies to health department & health care
providers)
o Enter “Point-of-care test by provider” if the test was performed by the provider either
in a healthcare setting or other testing venue.
o Enter “Self-test, result directly observed by provider” if the test was performed by
the patient but directly observed by a provider (including via a telemedicine
appointment).
o Enter “Lab-test, self-collected sample” if the patient collected the sample (blood or
oral fluid) and sent it to the laboratory for testing.
9.2.1 HIV-1/2 RNA NAAT (QUALITATIVE)
o Enter result and collection date of earliest nucleic acid amplification test
(NAAT). (Required, applies to health department & health care providers)
9.2.2 HIV-1 RNA NAAT (QUALITATIVE and QUANTITATIVE)
o Enter the collection date of earliest NAAT. (Required, applies to health
department & health care providers)
o Enter the qualitative result of the test. (Required, applies to health department
& health care providers)
o For all reactive qualitative results, record the result for the analyte (quantitative
result). (Required, applies to health department & health care providers)
 Where results are reported as “Detected” above the limit of quantification
(LOQ), select “Detectable above limit” and the result value in the
copies/mL field. For example, a result of “>10,000,000 cp/mL detected”
should be entered in the copies/mL field as “greater than detectable by this
assay - 10,000,000 cp/mL.”

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Where results are reported as “Detected,” select “Detectable within limits”
and the result value in the copies/mL field.
 Where results are reported as “Detected” below the LOQ, select
“Detectable below limit” and the result value in the copies/mL field. For
example, a result of “<20 cp/mL detected” should be entered in the
copies/mL field as “fewer than detectable by this assay - 20 cp/mL.”
HIV-1 RNA/DNA NAAT (QUALITATIVE)
o Enter result and collection date of earliest NAAT. (Required, applies to health
department & health care providers)
HIV-1 Culture
o Enter result and collection date of earliest culture result. (Required, applies to
health department & health care providers)
HIV-2 RNA/DNA NAAT (QUALITATIVE)
o Enter result and collection date of earliest NAAT. (Required, applies to health
department & health care providers)
HIV-2 Culture
o Enter result and collection date of earliest culture result. (Required, applies to
health department & health care providers)
HIV-1 RNA/DNA NAAT (QUANTITATIVE)
o Enter date of earliest NAAT. (Required, applies to health department & health
care providers)
o Enter the result of the test. (Required, applies to health department & health
care providers)
 Where results are reported as “Detected” above the limit of quantification
(LOQ), select “Detectable above limit” and the result value in the
copies/mL field. For example, a result of “>10,000,000 cp/mL detected”
should be entered in the copies/mL field as “greater than detectable by this
assay - 10,000,000 cp/mL.”
 Where results are reported as “Detected,” select “Detectable within limits”
and the result value in the copies/mL field.
 Where results are reported as “Detected” below the LOQ, select
“Detectable below limit” and the result value in the copies/mL field. For
example, a result of “<20 cp/mL detected” should be entered in the
copies/mL field as “fewer than detectable by this assay - 20 cp/mL.”
 Where results are reported as “Not detected,” select “Not detected.”
HIV-2 RNA/DNA NAAT (QUANTITATIVE)
o Enter date of earliest NAAT. (Required, applies to health department & health
care providers)
o Enter the result of the test. (Required, applies to health department & health
care providers)
 Where results are reported as “Detected” above the limit of quantification
(LOQ), select “Detectable above limit” and the result value in the
copies/mL field. For example, a result of “>10,000,000 cp/mL detected”
should be entered in the copies/mL field as “greater than detectable by this
assay - 10,000,000 cp/mL.”


9.2.3

9.2.4

9.2.5

9.2.6

9.2.7

9.2.8

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Where results are reported as “Detected,” select “Detectable within limits”
and the result value in the copies/mL field.
 Where results are reported as “Detected” below the LOQ, select
“Detectable below limit” and the result value in the copies/mL field. For
example, a result of “<20 cp/mL detected” should be entered in the
copies/mL field as “fewer than detectable by this assay - 20 cp/mL.”
 Where results are reported as “Not detected,” select “Not detected.”
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, laboratory name, facility name
and 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 by using the test type that
reflects the type of drug resistance test that was conducted (e.g., HIV-1 Genotype
[PR/RT RNA Nucleotide Sequence-Sanger method]).
IMMUNOLOGIC TESTS (CD4 COUNT AND PERCENTAGE)
• Enter the results of all HIV-related CD4 tests that are available from the source where
information is being collected to complete the form. At minimum, the first CD4 results
closest to the date of initial HIV infection diagnosis should be reported and the first CD4
results indicative of stage 3 (AIDS) should be reported if available.
• Enter the brand name of the test and/or its manufacturer, laboratory 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; use “..” for unknown values (e.g.,
03/../2011). (Required, applies to health department & health care providers)
9.4.1 CD4 COUNT
o Enter result and specimen collection date of all CD4 counts. (Required,
applies to health department & health care providers)
9.4.2 CD4 PERCENTAGE
o Record result and specimen collection date of all CD4 percentages. (Required,
applies to health department & health care providers)
DOCUMENTATION OF TESTS
9.5.1 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,


9.3

9.4

9.5

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culture, quantitative NAAT (RNA or DNA), qualitative NAAT (RNA or
DNA), HIV-1/2 type-differentiating immunoassay (supplemental test),
standalone 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
type-differentiating immunoassay,” are not considered standalone p24 antigen
tests. Refer to sections 9.1.5 and 9.1.6 for more information regarding
combination Ag/Ab IA.
o “Yes” indicates that the test results were determined to be part of a diagnostic
testing algorithm that satisfies the HIV surveillance case definition for HIV-1
or HIV-2 (refer to the most recent case definition for HIV infection available at
https://ndc.services.cdc.gov/conditions/hiv-infection-aids-has-beenreclassified-as-hiv-stage-iii/), regardless of whether the tests were approved for
other purposes such as laboratory-based HIV testing or point-of-care HIV
screening.
 If “Yes,” enter date of earliest positive test result for this algorithm in
mm/dd/yyyy format; use “..” for unknown values (e.g., 03/../2011).
(Required if applicable, applies to health department & health care
providers).
o “No” indicates that the test results were determined to not be a part of a
diagnostic testing algorithm that satisfies the HIV surveillance case definition
for HIV-1 or HIV-2.
o “Unknown” indicates that you are unable to determine whether the test results
were part of a diagnostic testing algorithm that satisfies the HIV surveillance
case definition for HIV-1 or HIV-2.
o Values of “No” and “Unknown” should generally not be selected. This form is
intended to be used to ascertain that 2 tests are part of an algorithm that meet
the HIV surveillance case definition. Carefully review all “No” and
“Unknown” responses before entering in eHARS.
9.5.2 IS EARLIEST EVIDENCE OF DIAGNOSIS DOCUMENTED BY A
PHYSICIAN RATHER THAN BY LABORATORY TEST RESULTS?
(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 laboratory evidence of HIV infection consistent with the
HIV case definition is noted by the physician, enter “Yes”; otherwise enter
“No” or “Unknown.”
9.5.2.1 HIV-INFECTED (Required if applicable, applies to health department
& health care providers)
 IF “YES” TO 9.5.2.1, PROVIDE DATE OF DIAGNOSIS BY
PHYSICIAN (Required in the absence of laboratory 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
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patient had received a diagnosis of HIV infection on 2/11/2010,
then 2/11/2010 should be recorded as the date of diagnosis by the
physician.
9.5.2.2 NOT HIV-INFECTED (Required if applicable, applies to health
department & health care providers)
 IF “YES” TO 9.5.2.2, PROVIDE DATE OF DIAGNOSIS BY
PHYSICIAN (Required in the absence of laboratory 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.”

10. Birth History (for patients exposed perinatally with or without consequent infection)

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Birth history information is not transmitted to CDC if marked with an * on the form.
Enter the data below for all children reported as perinatally exposed with or without
consequent HIV infection.
10.1 BIRTH HISTORY AVAILABLE (Optional, applies to health department & health care
providers)
• If none of the birth history elements in the section are available, proceed to next section,
Birthing Person History.
10.2 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.
10.3 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.”
10.4 BIRTH HISTORY
10.4.1 BIRTH WEIGHT (Optional, applies to health department & health care
providers)
o Enter the birth weight in pounds and ounces, or grams.
10.4.2 TYPE (Optional, applies to health department & health care providers)
o Select applicable response. If unknown, select “9.”
10.4.3 DELIVERY (Required, applies to health department & health care providers)
o Select the applicable response.
o Notes in the child’s records are acceptable even if no birth records are
available.
o If search for this datum was completed and the delivery method could not be
determined or if the delivery method was documented to be unknown, select
“Unknown.”
10.4.4 IF CESAREAN DELIVERY, MARK ALL THE FOLLOWING INDICATIONS
THAT APPLY (Required, if applicable, applies to health department & health
care providers)
o Select the appliable indications.
o The reason(s) for a cesarean delivery should be documented in the labor and
delivery medical record. Notes in the child’s records are acceptable even if no
birth records are available.
o If search for this datum was completed and the indications could not be
determined, select “Not specified.”
10.4.5 BIRTH INFORMATION (Required, if applicable, applies to health department
& health care providers)
o 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
•
•

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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; use “..” for unknown values (e.g., 03/../2011).
 Rupture of membranes information 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. 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 information 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.
10.4.6–10.4.7 CONGENTIAL DISORDERS and IF YES, SPECIFY TYPES (Optional,
applies to health department & health care providers)
o If “Yes,” specify type.
o Refer to Appendix (10.4.6) for further guidance.
10.4.8 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.
o If search for this datum was completed and the gestational age cannot be
determined, select “Unknown.”
10.4.8.1 NEONATAL GESTATIONAL AGE IN WEEKS
 Enter weeks of gestation.
 If search for gestational age was unsuccessful, then enter “99” for
unknown number of weeks.
10.4.9 WAS A TOXICOLOGY SCREEN DONE ON THE INFANT AFTER BIRTH
(Recommended, if applicable, applies to health department & health care
providers)
o Select applicable response. Include any toxicology screen with a specimen
collection date on the child’s date of birth or within the 6 days following the
child’s date of birth.
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o If search for this datum was completed but a response of “Yes” or “No” cannot
be determined, select “Unknown.”
o Most toxicology screens on infants are done using urine. A positive screen at
birth indicates drug use by the birthing person before delivery. This
information should be noted in the infant’s birth chart.
o If the specimen for any toxicology screen was collected for the infant on the
date of birth or the following 6 days after birth, complete the following
information for each substance.
 If the substance was not included in any toxicology screen in the 7 days on
or after the child’s date of birth, select “Not screened” for the particular
substance.
 If the substance was included in any toxicology screen in the 7 days on or
after the child’s date of birth, enter the date of screen for the substance in
mm/dd/yyyy format; use “..” for unknown values (e.g., 03/../2011) and
select the applicable result; select “Unknown” if a search for the result was
completed but the result was not documented.
 If the same substance was screened more than 1 time during the 7 days on
or after the child’s date of birth, enter the subsequent date of screen and
result values in the Comments section. In eHARS, enter the additional
information on the PCRF on the “Birth History” tab.
 If screening for ‘Other’ substance was done, specify the substance in the
space provided.

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11. Birthing Person History

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Enter the data below regarding the birthing person for all children reported as perinatally
exposed with or without consequent HIV infection. If information for the birthing person is
not available (e.g., because child is adopted), proceed to the next section, Treatment/Services
Referrals.
11.1 BIRTHING PERSON DATE OF BIRTH (Optional, applies to health department & health
care providers)
• Enter the birthing person’s date of birth in mm/dd/yyyy format; use “..” for unknown
values (e.g., 03/../2011).
11.2 BIRTHING PERSON LAST NAME SOUNDEX (Optional, applies to health department)
• After the birthing person’s last name is entered in eHARS, the software automatically
generates this variable by using the birthing person’s last name. After the code is
generated, HIV surveillance program staff should fill in this field on the form.
• This variable is a phonetic, alphanumeric code calculated by converting a surname to an
index letter and a 3-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/HSB/default.aspx
11.3 BIRTHING PERSON COUNTRY OF BIRTH (Optional, applies to health department &
health care providers)
• Select applicable response.
• For birthing persons born in U.S. minor outlying areas, specify the name of the U.S.
dependency from the following table:
U.S. Dependencies
Baker Island
Johnston Atoll
Navassa Island
Howland Island
Kingman Reef
Palmyra Atoll
Jarvis Island
Midway Islands
Wake Island
•

For birthing persons born in any other area outside of the United States and U.S. minor
outlying areas, specify the country name.
• If this information is not available in the child’s records, it can be left blank and updated
on follow-up.
11.4 BIRTHING PERSON STATE ID NUMBER ( Required, applies to health department)
• Enter assigned state number if the birthing person is known to be HIV infected.
• State numbers should not be reused.
11.5 BIRTHING PERSON CITY/COUNTY ID NUMBER (Optional, applies to health
department)
• Enter the assigned city/county number if the birthing person is known to be HIV
infected.
• City/County numbers should not be reused.
11.6 OTHER BIRTHING PERSON ID (Optional, applies to health department & health care
providers).
• Enter any other ID type (such as social security number) for the birthing person and the
number of the other ID.
•

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11.7 PRENATAL CARE
• Prenatal care is defined as any care for the pregnancy beyond pregnancy testing and
before delivery, even if no regular follow-up ensued.
11.7.1 MONTH OF PREGNANCY PRENATAL CARE BEGAN (Required, applies to
health department & health care providers)
o Record the gestational month of pregnancy (01 to 09) that the birthing person
began prenatal care. A prenatal care visit is the first visit where intake
information is obtained. Normally a birthing person knows they 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 birthing person 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.
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 If entry is reported in weeks, convert to appropriate months as follows:
Weeks
Months
Weeks
Months
1–4

1

22–26

6

5–8

2

27–30

7

9–13

3

31–35

8

14–17

4

36–40

9

18–21

5

41+

10

o Abstractors should use the gestational age value available in the record. The
method (LMP, ultrasound, infant exam) for assigning gestational age in the
medical record might vary.
11.7.2 TOTAL NUMBER OF PRENATAL CARE VISITS (Optional, applies to health
department & health care providers)
o Record the total number of times the birthing person went to the clinic or
doctor for 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”).
11.8 HAS THE BIRTHING PERSON EVER BEEN PREGNANT BEFORE THIS
PREGNANCY (Optional, if applicable, applies to health department & health care
providers)
• Select applicable response. If search for this datum was completed but a response of
“Yes” or “No” cannot be determined, select “Unknown.”
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11.8.1 IF YES, NUMBER OF PREVIOUS PREGNANCIES (Optional, if applicable,
applies to health department & health care providers)
o 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.
11.8.2. PREGNANCY OUTCOME (Optional, if applicable, applies to health
department & health care providers)
o For each previous pregnancy where the pregnancy outcome is known, select
the applicable response.
o Live birth includes preterm and term births.
o Miscarriage or stillbirth includes spontaneous abortions/fetal deaths that occur
before 20 weeks (miscarriage) or after 20 weeks (stillbirth).
o Induced abortion includes abortions brought on purposely and may also be
known as an ‘artificial’ or ‘therapeutic’ abortion (TAB) or referred to as a
‘termination of pregnancy’ (TOP). 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.
o If there are more than 5 previous pregnancies, record the additional
information in the Comments section. In eHARS, record additional
pregnancies on the PCRF on the “Birthing Person History” tab.
11.8.3 YEAR OUTCOME OCCURRED (Optional, if applicable, applies to health
department & health care providers)
o For each previous pregnancy where the pregnancy outcome is known, record
the 4-digit year associated with the pregnancy outcome.
o If the year of the pregnancy outcome is unknown, enter “9999”
o If there are more than 5 previous pregnancies, record the additional
information in the Comments section. In eHARS, record additional
pregnancies on the PCRF on the “Birthing Person History” tab.
11.9 WAS A TEST RESULT (WITH A SPECIMEN COLLECTION DATE WITHIN THE 6
WEEKS ON OR BEFORE DELIVERY) DOCUMENTED IN THE BIRTHING PERSON’S
LABOR/DELIVERY RECORD (Optional, applies to health department and health care
providers)
• Select applicable response for both the CD4 and quantitative NAAT (RNA or DNA) test
types.
• Limited to test results with specimens collected within the 6 weeks on or before delivery.
• If a search for this datum was completed but a response of “Yes” or “No” cannot be
determined, select “Unknown”
11.10 DID BIRTHING PERSON RECEIVE ANTIRETROVIRALS (ARVs) PRIOR TO THIS
PREGNANCY? (Recommended, applies to health department & health care providers)
• ‘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’.
• Select “Yes” if information is available that states that the birthing person used ARV
drugs prior to this pregnancy. If “Yes,” record the date ARV drug use began and the date
of last use. Enter date in mm/dd/yyyy format; use “..” for unknown values (e.g.,
03/../2011).
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Select “No” if the birthing person did not use ARV drugs prior to this pregnancy.
If a birthing person did not receive ARV drugs, do not assume it was because they
refused. Select “Refused” only if explicit documentation in the medical record indicates
that the birthing person was offered the drug, but the birthing person declined.
• Select “Unknown” after an unsuccessful search for this datum.
11.10.1 IF “YES,” PLEASE SPECIFY ALL
o Record all ARV drugs received prior to this pregnancy.
11.11 DID BIRTHING PERSON RECEIVE ARVs DURING PREGNANCY? (Required,
applies to health department & health care providers)
• Select “Yes” if information is available that states that the birthing person used ARV
drugs any time during pregnancy. If “Yes,” record the date ARV drug use began and the
date of last use. Enter date in mm/dd/yyyy format; use “..” for unknown values (e.g.,
03/../2011).
• Select “No” if the birthing person did not use ARV drugs during pregnancy.
• Select “Refused” only if explicit documentation in the medical record indicates that the
birthing person was offered the drug, but the birthing person declined.
• Select “Unknown” if it is unknown whether the birthing person ever used ARV drugs
during pregnancy.
11.11.1 IF “YES,” PLEASE SPECIFY ALL
o Record all ARV drugs received during pregnancy.
o For additional information about ARV drug regimens for pregnant patients
with HIV infection, refer to Recommendations for the Use of Antiretroviral
Drugs During Pregnancy and Interventions to Reduce Perinatal HIV
Transmission in the United States at
https://clinicalinfo.hiv.gov/en/guidelines/perinatal/recommendations-arvdrugs-pregnancy-situation-specific-conceive.
11.11.2 IF NO, SELECT REASON
o Select “No prenatal care” if the birthing person did not receive any prenatal
care during pregnancy.
o Select “Birthing person known to be HIV-negative during pregnancy” if the
birthing person tested HIV negative during pregnancy and no further testing
was documented. There must be evidence of a negative test during
pregnancy in the chart; do not use patient report.
o Select “HIV serostatus of birthing person unknown” if the physician did not
know the HIV status of the birthing person because the birthing person
refused testing or the physician did not offer testing during pregnancy.
o Select “Other” if another reason for not receiving ARV drugs was
documented. If “Other” is selected specify the specific reason.
o Select “Unknown” after an unsuccessful search for this datum.
o If more than one reason applies, enter the additional reason(s) in the
Comments section. In eHARS, enter each reason on a separate PCRF
document.
•
•

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11.12 DID BIRTHING PERSON RECEIVE ARVs DURING LABOR/DELIVERY? (Required,
applies to health department & health care providers)
• Select “Yes” if information is available that states that the birthing person used ARV
drugs any time during labor/delivery. Labor and delivery period is also termed the
intrapartum period and refers to the time from which the person was admitted to the
hospital for labor to the time of delivery. If “Yes,” record the date ARV drug use began
and the date of last use. Enter date in mm/dd/yyyy format; use “..” for unknown values
(e.g., 03/../2011).
• Select “No” if the birthing person did not use ARV drugs during labor/delivery.
• Select “Refused” only if explicit documentation in the medical record indicates that the
birthing person was offered the drug, but the birthing person declined.
• Select “Unknown” if it is unknown whether the birthing person ever used ARV drugs
during labor/delivery.
11.12.1 IF “YES,” PLEASE SPECIFY ALL
o Record all ARV drugs received during labor/delivery.
o For additional information about ARV drug regimens during the
intrapartum period, refer to Recommendations for the Use of Antiretroviral
Drugs During Pregnancy and Interventions to Reduce Perinatal HIV
Transmission in the United States at
https://clinicalinfo.hiv.gov/en/guidelines/perinatal/intrapartum-care.
11.12.2 IF NO, SELECT REASON
o Select “Precipitous delivery/STAT Cesarean delivery” if an eminent
delivery of an infant may preclude prescription and/or administration of
ARV drugs to the birthing person.
o Select “HIV serostatus of birthing person unknown” if the physician did not
know the HIV status of the birthing person because the birthing person
refused testing or the physician did not offer testing during pregnancy.
o Select “Birth not in hospital” if the birth occurred outside a hospital; in all
likelihood ARV drugs would not have been administered.
o Select “Birthing person tested HIV negative during pregnancy” if the
birthing person tested HIV negative during pregnancy and no further testing
was documented. There must be evidence of a negative test during
pregnancy in the chart; do not use patient report.
o Select “Other” if another reason for not receiving ARV drugs was
documented. If “Other” is selected specify the specific reason.
o Select “Unknown” after an unsuccessful search for this datum.
o If more than one reason applies, enter the additional reason(s) in the
Comments section. In eHARS, enter each reason on a separate PCRF
document.
11.13 WAS THE BIRTHING PERSON SCREENED FOR ANY OF THE FOLLOWING
CONDITIONS DURING THIS PREGNANCY (Recommended, applies to health
department & health care providers)
• Select “Yes” if the birthing person was screened for the condition during this pregnancy.
If screened, enter the date of the screening; if a sample was drawn for the screening use
the date of specimen collection. Enter date in mm/dd/yyyy format; use “..” for unknown
values (e.g., 03/../2011). If the birthing person was screened for the same condition more
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than once during this pregnancy, enter the additional screening dates in the Comments
section. In eHARS, enter the additional screening information on the PCRF on the
“Birthing Person History” tab.
• Select “No” if the birthing person was not screened for the condition during this
pregnancy.
• Select “Unknown” after an unsuccessful search for this datum.
• Refer to Appendix (11.13) for additional information about each condition.
11.14 WERE ANY OF THE FOLLOWING CONDITIONS DIAGNOSED FOR THE
BIRTHING PERSON DURING THIS PREGNANCY OR AT THE TIME OF LABOR
AND DELIVERY (Recommended, applies to health department & health care providers)
• 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 laboratory tests for various
sexually transmitted diseases), laboratory results section, or in sexually transmitted
disease summary sheets (typical in public health clinics).
• Diagnoses may be presumptive or definitive depending on symptoms and laboratory
tests. If a diagnosis is made either presumptively or definitively, note the answer as
“Yes.” For specific criteria for answering “Yes” to this question refer to Appendix
(11.14). If diagnosed, enter the date of diagnosis; if the diagnosis was based on test
results, use the date of specimen collection for the date of diagnosis. Enter date in
mm/dd/yyyy format; use “..” for unknown values (e.g., 03/../2011). If the same condition
was diagnosed for the birthing person more than once during this pregnancy, enter the
additional diagnosis dates in the Comments section. In eHARS, enter the additional
diagnosis information on the PCRF on the “Birthing Persons History” tab.
• Select “No” if there is evidence that the birthing person was screened for the condition
during pregnancy but the condition was not diagnosed.
• Select “Unknown” after unsuccessful search for this datum.
11.15 WERE SUBSTANCES USED BY THE BIRTHING PERSON DURING THIS
PREGNANCY (Recommended, applies to health department & health care providers)
• Indicate whether substances were used during this pregnancy by selecting “Yes,” “No,”
or “Unknown.”
• If “Yes,” indicate for each substance selected whether the substance was
o “Used and injected” if there is evidence that the birthing person used the substance
during this pregnancy and the substance was injected.
o “Used and did not inject” if there is evidence that the birthing person used the
substance during this pregnancy but the substance was not injected.
o “Used and unknown if injected” if there is evidence that the birthing used the
substance during this pregnancy but there was no evidence to determine whether the
substance was injected.
o “Did not use” if there is evidence that the birthing person did not use that particular
substance during this pregnancy.
o “Unknown if used” if there is not sufficient evidence to determine whether the
birthing person used the particular substance during this pregnancy.
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o Leave blank if you did not search for whether specific substances were used during
this pregnancy.
o 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 laboratory 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,” specify the name of the substance(s) used.
11.16 WAS A TOXICOLOGY SCREEN DONE ON THE BIRTHING PERSON (EITHER
DURING PREGNANCY OR AT THE TIME OF DELIVERY) (Recommended, applies to
health department & health care providers).
• Select “Yes” if a screen was conducted on the birthing pregnancy during this pregnancy
or at the time of delivery. The toxicology testing must have been completed during
pregnancy, not before pregnancy. Toxicology screens are usually done using urine or
serum.
o For each substance, select “Not screened” if there’s evidence that the substance was
not included in the toxicology screen. If the substance was screened, enter the date of
the toxicology screen in mm/dd/yyyy format; use “..” for unknown values (e.g.,
03/../2011). Select “Positive” if there was a positive test result for the substance.
Select “Negative” if there was a negative test result for the substance. Select
“Unknown” if a search for the test result for the substance was documented but the
result could not be determined.
o If screening was for a substance other than those listed, select “Other” and specify
the drug metabolites in the space provided.
o If a screening for the same substance was done on more than one occasion, record
additional dates and results in the Comments section. In eHARS, enter the additional
screening information on the PCRF on the “Birthing Person History” tab.
o Heroin is a semisynthetic narcotic and opiate and should be listed as heroin, opiate,
or opioid on the urine toxicology laboratory results sheet.
o Marijuana may be listed on the urine toxicology results as cannabis, a cannabinoid,
THC or simply marijuana.
o 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.
• Check “No” if it is known that a screen was not conducted.
• Select “Unknown” after unsuccessful search for this datum.

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12. Treatment/Services Referrals

Enter the data below for all children reported as perinatally exposed with or without
consequent HIV infection; the field “Has this child ever taken PCP prophylaxis” and the
associated date field need to be completed only if the child is HIV infected.
12.1 HAS THIS CHILD EVER TAKEN ANY ARVS (Required, applies to health department &
health care providers)
• This variable indicates whether the patient has ever taken any ARV drug. “Yes”
indicates there is evidence that the patient has taken ARV drugs, 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; use “..” for unknown values (e.g., 03/../2011).
• “No” indicates there is evidence that the patient has never taken ARV drugs.
• “Unknown” should be used when the person completing the form does not know
whether the patient has ever taken ARV drugs, after searching for the information or
asking the patient.
• Leave the field blank if there was no attempt to find the information.
12.2 ARV MEDICATION (Recommended, applies to health department & health care
providers)
• List the medications taken.
• This variable is used to verify that the medication taken was actually an ARV drug.
• Enter “unspecified” if an ARV drug was taken but the name is not known.
• Refer to Appendix (12.2) for further guidance.
12.3 REASON FOR ARV USE (Required, applies to health department & health care providers)
• Select reason that applies for each specific ARV drug.
• “HIV Tx” indicates that the patient used the ARV drug to treat HIV infection.
• “PrEP” indicates that the patient used the ARV drug prior to HIV diagnosis for HIV
preexposure prophylaxis (PrEP). If “PrEP” is selected, please refer to the updated
clinical practice guideline for PrEP at https://www.cdc.gov/hiv/pdf/risk/prep/cdc-hivprep-guidelines-2021.pdf. For surveillance activities, additional follow up with health
care providers may be required for certain test results for final determination of HIV
status. Food and Drug Administration (FDA) intended usage of ARV drugs for PrEP is
for persons who weigh at least 35 kg and are sexually active or inject drugs.
• “PEP” indicates that the patient used the ARV drug as postexposure prophylaxis (PEP).
•

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“PMTCT” indicates that the patient used the ARV drug to prevent HIV birthing personto-child-transmission.
• “HBV Tx” indicates that the patient used the ARV drug to treat hepatitis B virus
infection.
• “Other” indicates that the patients used the ARV drug for a reason other than those
indicated above.
DATE BEGAN (Required, applies to health department & health care providers)
• For each ARV drug indicated in 12.2, enter the earliest date that the patient took the
ARV drug, even if ARV use was sporadic.
• If the first time ARV drugs 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; use “..” for unknown values (e.g., 03/../2011).
DATE OF LAST USE (Required, applies to health department & health care providers)
• For each ARV drug indicated in 12.2, enter the most recent date of ARV use.
• For patients currently on ARV drugs, 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; use “..” 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; use “..” for unknown values (e.g.,
03/../2011).
• “Unknown” is used if treatment information in the medical chart is unclear or was
unavailable.
• Refer to Appendix (12.6) 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 (12.7) for further guidance.
•

12.4

12.5

12.6

12.7

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13. Comments (Optional, applies to health department & health care providers)

•
•
•

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 eHARS.
Information entered in the “Comments” tab on the PCRF of eHARS will not be transmitted to
CDC.

14. Local/Optional Fields (Optional, applies to health department)

•
•

This section is for collection of data that are not on the form at the state, local, and territorial
level.
This information is not sent to CDC.

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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 Prevention (DHP) needs initial reports and updates to reflect the earliest
dates that children meet each reporting criteria (i.e., perinatal exposure, HIV infection, stage 3
[AIDS], or 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, HIV surveillance programs update the case in eHARS accordingly.

•

After HIV surveillance programs receive initial reports of evidence of HIV exposure or infection
among children, surveillance programs follow up to determine whether diagnostic status of the
child changes. For example, HIV surveillance programs update 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.

•

Prior to 2023, CDC provided a separate Perinatal HIV Exposure Reporting (PHER) form to
facilitate collection of additional standardized data on HIV-exposed children. CDC revised the
PCRF to include some additional standardized data on HIV-exposed children and retired the
separate PHER form in 2023.

•

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 birthing person 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 ARV drugs during pregnancy and
labor/delivery and neonatal ARV use.

•

Maternal HIV counseling and testing, prenatal care, and refusal of treatment with ARV drugs
were added in 1996.

•

Viral load tests, receipt of additional ARV drugs during labor/delivery for the newborn, and
elective cesarean were added to the pediatric reporting form in 1999.

•

These additions enable HIV surveillance programs to identify possible reasons for failures in
preventing HIV transmission related to childbirth (i.e., receipt of maternal HIV testing, prenatal
care, and ARV drugs).

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•

As states implement pediatric HIV exposure reporting, information on receipt of prenatal,
intrapartum, and neonatal ARV use and receipt of other ARV drugs can be collected for all
children born to HIV-infected persons. 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 inMMWR 1987;36(suppl no. 1S):1S–15S, available at
https://www.cdc.gov/mmwr/pdf/other/mmsu3601.pdf; the 1994 revised classification system for
HIV infection in children less than 13 years of age in MMWR 1994;43:(No. RR-12):1–10,
available at https://www.cdc.gov/mmwr/PDF/rr/rr4312.pdf; the 2000 HIV case definition in
MMWR 1999;48(RR-13):1–31, available at
https://www.cdc.gov/mmwr/preview/mmwrhtml/rr4813a1.htm; the 2008 case definition in
MMWR 2008;57 (RR-10) 1–12, available at
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5710a1.htm; and the revised surveillance case
definition for HIV infection in MMWR 2014;63 (RR03);1–10, available at
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6303a1.htm?s_cid=rr6303a1_e.

Pediatric Cases of Public Health Importance (COPHI)
•

HIV surveillance programs should discuss certain priority cases directly with the CDC COPHI
coordinator (Scott Grytdal, [email protected]) and copy your CDC surveillance project officer.
COPHI consist of the general categories of unusual transmission circumstances, unusual HIV
strains (including HIV-2), and other special diagnostic considerations. See Technical Guidance
file Cases of Public Health Importance (COPHI) for additional information about the
identification of COPHI, including descriptions of the situations within each category, and COPHI
investigation procedures.

4. Patient Demographics
4.1

DIAGNOSTIC STATUS AT REPORT
4.1.1 PERINATAL HIV EXPOSURE
o Although all children aged less than 18 months born to an HIV-infected person were
perinatally exposed to HIV, the “Perinatal HIV Exposure” category on the case
report form is composed of those with an undetermined HIV infection status.
o A child aged less than 18 months born to an HIV-infected person will be categorized
as “Perinatal HIV Exposure” if the child does not meet the criteria for HIV infection
or the criteria for presumptively or definitely uninfected.
4.1.2 PEDIATRIC HIV
o Among children <18 months old whose birthing persons were not infected and all
children aged ≥18 months, a reportable case of HIV infection must meet at least one
of the following criteria (see Revised Surveillance Case Definition for HIV Infection
at https://www.cdc.gov/mmwr/preview/mmwrhtml/rr6303a1.htm).
1.1 Persons Aged ≥18 Months and Children Aged <18 Months whose Birthing
Persons 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 standalone virologic tests and

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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 NAAT). 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:
 One test is a combination antigen/antibody test and the other an
antibody-only test.
 One test is an antibody test and the other a NAAT.
 One test is a rapid immunoassay (a single-use analytical device that
produces results in <30 minutes) and the other a conventional
immunoassay.
 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., 2 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 type-differentiating immunoassay), or it
might be one traditionally used as a 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:
- Qualitative HIV NAAT (DNA or RNA)
- Quantitative HIV NAAT (viral load assay)
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- HIV-1 p24 antigen test
- HIV isolation (viral culture) or
- 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 HIV surveillance program has 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.
o Among children aged less than 18 months whose birthing persons 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 Birthing Persons 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 NAAT (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 NAAT before age 18
months.

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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 Birthing Persons were Not Infected), or
• All 3 of the following alternative criteria:
o Evidence of perinatal exposure to HIV infection before 18 months of age:
 A birthing person 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
birthing person 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 stage 3 (AIDS)defining clinical conditions should be reported as stage 3 (AIDS) cases; although
most of these conditions appear among adult stage 3 (AIDS) diagnostic criteria,
asterisked conditions apply only to aged <6 years, and conditions with a dagger
footnote 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)
Histoplasmosis, disseminated or extrapulmonary
Isosporiasis, chronic intestinal (>1 month’s duration)
Kaposi’s sarcoma
Lymphoma, Burkitt (or equivalent term)
Lymphoma, immunoblastic (or equivalent term)
Lymphoma, primary, of brain
Mycobacterium avium complex or M. kansasii, disseminated or extrapulmonary
Mycobacterium tuberculosis of any site, pulmonary†, disseminated, or extrapulmonary
Mycobacterium, other species or unidentified species, disseminated or extrapulmonary
Pneumocystis jirovecii (previously known as “Pneumocystis carinii”) pneumonia
Pneumonia, recurrent†
Progressive multifocal leukoencephalopathy
Salmonella septicemia, recurrent
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4.1.4

• Toxoplasmosis of brain, onset at age >1 month
• Wasting syndrome due to HIV
†
Only among adults and children aged ≥6 years.
* Only among children aged <6 years.
PEDIATRIC SEROREVERTER
o Virtually all children less than 18 months of age born to HIV-infected persons are
antibody positive at birth.
o A child aged < 18 months born to an HIV-infected person 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 (see Revised Surveillance
Case Definition for HIV Infection at
https://www.cdc.gov/mmwr/preview/mmwrhtml/rr6303a1.htm).
3.1 Uninfected
A child aged <18 months who was born to an HIV-infected person or had a positive
HIV antibody test result is classified for surveillance purposes as not infected with HIV
if all 3 of 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 NAAT (RNA or DNA) and
• At least 1 of the following 2 criteria:
o At least 2 negative HIV NAATs from specimens obtained on different
dates, both of which were at age ≥ 1 month and 1 of which was at age ≥ 4
months.
o At least 2 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 1 of the following 4 laboratory criteria are met:
o At least 2 negative NAATs from specimens obtained on different dates,
both of which were at age ≥2 weeks and 1 of which was at age ≥4 weeks.
o One negative NAAT (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 1 positive HIV
NAAT test, then it must have been followed by at least 2 negative test
results from specimens obtained on different dates, 1 of which is:
 A NAAT 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 NAAT
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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 perinatal HIV exposure, enter the patient’s city, county, state/country, and ZIP code
of residence at the time when HIV infection was first considered, either clinically or through
laboratory evaluation.
For HIV, stage 0, 1, 2, and unknown case reports, enter residence at the date of HIV infection
diagnosis. The date of diagnosis of HIV infection is the earliest date on which the surveillance
case definition for HIV infection, any stage, was satisfied in accordance with laboratory and
clinical criteria (see Revised Surveillance Case Definition for HIV Infection at
https://www.cdc.gov/mmwr/preview/mmwrhtml/rr6303a1.htm).
If a test result is not available, enter patient’s residence at the date of physician diagnosis of HIV
infection.
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 Technical Guidance file Date and Place of
Residence.

6. Facility of Diagnosis
•

6.2

For a facility offering only telemedicine services, the address for the facility should reflect the
address where the facility providing telemedicine services is located. The facility type should be
Outpatient/Other, specify with “telemedicine” being the value specified. For information about
assigning facility types in eHARS, including for facilities offering only telemedicine services, see
Technical Guidance file Data Management, Appendix B.
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 birthing person 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 associated with the
date of HIV infection diagnosis. The date of diagnosis of HIV infection is the earliest date
on which the surveillance case definition for HIV infection, any stage, was satisfied in
accordance with laboratory and clinical criteria (see Revised Surveillance Case Definition
for HIV Infection at https://www.cdc.gov/mmwr/preview/mmwrhtml/rr6303a1.htm).
• 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.

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•
•

For HIV, stage 3 (AIDS) case reports, enter the name of the facility associated with the date
of the first stage 3 (AIDS) diagnosis 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 document report source is in the document source field in the II. Health
Department Use Only section of the case report form and in III. Facility Providing
Information section of the case report form, as applicable.

7. Patient History
•
•
•

7.1

This information is often found in the birthing person’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 birthing person and child risk
factor information.
See Technical Guidance 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.
BIRTHING PERSON’S HIV INFECTION STATUS
• “Refused HIV testing” should be selected if birthing person’s refusal is documented in the
medical chart.
• If the birthing person 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 dates are not available, please review medical charts to determine when HIV diagnosis for
the birthing person occurred in relationship to the child’s birth and select:
Known HIV+ before pregnancy;
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 HIV status for the birthing person, please select:
HIV status unknown.

10. Birth History (for patients exposed perinatally with or without consequent infection)
10.4 BIRTH HISTORY
10.4.6 CONGENITAL DISORDERS
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.
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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.
o 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 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.
o 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 U.S. 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 the Birth Defects Code list below). These codes are based on
ICD-9 or ICD-10 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 laboratory 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 contact the CDC HIV Surveillance Branch surveillance project
officer assigned to the state, local, or territorial HIV surveillance program.
o BIRTH DEFECTS CODE
 The 6-digit defect codes (available at
https://www.cdc.gov/ncbddd/birthdefects/macdp.html) are based on 3- to 5-digit
ICD-9-CM or ICD-10-CM codes from birth certificates or medical records (or
ICD-9 or ICD-10 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-CM–based list (downloadable from
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

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
https://www.cdc.gov/nchs/icd/icd-10-cm.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. In eHARS, if there are more than 5 congenital defects then enter the
information on the additional congenital defects on a separate PCRF document.

11. Birthing Person History
11.13 WAS THE BIRTHING PERSON SCREENED FOR ANY OF THE FOLLOWING
CONDITIONS DURING THIS PREGNANCY
• 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 persons and newborns ranges from 5% to 35%. Intrapartum chemoprophylaxis
is IV Penicillin G. Two types of prevention strategies may be used:
o Screening all pregnant persons at 35 to 37 weeks for vaginal and rectal GBS
colonization and offering intrapartum chemoprophylaxis to those identified as GBS
carriers; or
o Risk factor-based strategy—prophylaxis given to persons 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 persons is recommended.
Babies of birthing persons 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 persons with risk
factors for hepatitis B infection and persons whose status is unknown.
• RUBELLA—Screening is usually done at the initial prenatal visit. If ‘negative’ the birthing
person should be immunized.
• SYPHILIS—All pregnant persons 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 prevalence areas or for persons with
risk factors for syphilis infection. 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 person has a reactive
nontreponemal test and a persistently negative treponemal test, a false positive test is
inferred (see Red Book Online, American Academy of Pediatrics, available at
https://publications.aap.org/redbook).
11.14 WERE ANY OF THE FOLLOWING CONDITIONS DIAGNOSED FOR THE BIRTHING
PERSON DURING THIS PREGNANCY OR AT THE TIME OF LABOR AND DELIVERY
• BACTERIAL VAGINOSIS—Clinician diagnosis of bacterial vaginosis. Sometimes
abbreviated BV.
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•

•

•

•

•

•

•
•

CHLAMYDIA (Chlamydia trachomatis)—Record positive test for chlamydia (a positive
culture, positive EIA, or detection of chlamydial antigen or nucleic acid).
o Name of laboratory 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.
o Name of laboratory 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.
o Name of laboratory tests—Neisseria gonorrhea culture (GC Culture, Gonorrhea
Culture); Thayer-Martin medium; chocolate agar; detection of nucleic acid.
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
persons and newborns ranges from 5% to 35%. Intrapartum chemoprophylaxis is IV
Penicillin G. Two types of prevention strategies may be used:
o Screening all pregnant persons at 35 to 37 weeks for vaginal & rectal GBS colonization,
offering intrapartum chemoprophylaxis to those identified as GBS carriers; or
o Risk factor-based strategy in which prophylaxis is given to persons 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 persons is recommended.
Babies of birthing persons who are HbsAg (+) must have HBIG & HBV vaccine within 12
hours of birth to prevent perinatal HBV infection.
o 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). Tests are usually done at the initial prenatal visit or at the time of labor and
delivery for persons with risk factors of hepatitis B infection and persons 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.
o Name of laboratory 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 person had PID.
SYPHILIS (Treponema pallidum)—All pregnant persons 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 with risk factors for syphilis
acquisition during pregnancy such as drug misuse, other sexually transmitted diseases
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•

during pregnancy, multiple partners, a new partner, or a partner with a sexually transmitted
disease.
o 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 person
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 birthing person. Check whether the child received a diagnosis of congenital syphilis
or was treated 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 (AIDS) status.
o Name of laboratory 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); FTAABS (Fluorescent Treponemal Antibody Absorbed Test, Fluorescent Treponemal
Antibody Adsorption); MHA-TP (Microhemagglutination assay for Antibody to
Treponema Pallidum; Microhemagglutination, Treponema Pallidum.
TRICHOMONAS (Trichomonas vaginalis)—Record clinician diagnosis of trichomonas.
Trichomonas is diagnosed by finding trichomonas on a wet mount.
o Name of laboratory tests—Trichomonas preparation (Hanging Drop Mount for
Trichomonas, Trichomonas vaginalis wet preparation; Trich Prep; wet preparation for
Trichomonas vaginalis.

12. Treatment/Services Referrals
12.2 ARV MEDICATION
• Refer to the Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection,
available at https://clinicalinfo.hiv.gov/en/guidelines/pediatric-arv/whats-new.
12.6 HAS THIS CHILD EVER TAKEN PCP PROPHYLAXIS?
• Refer to the Guidelines for the Prevention and Treatment of Opportunistic Infections in
Children with and Exposed to HIV – Pneumocystis jirovecii Pneumonia, available at
Pneumocystis jirovecii Pneumonia | NIH (hiv.gov). 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.

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12.7 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
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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