SayPro Pre-Exposure Prophylaxis (PrEP) Facility Record Form

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SayPro Pre-Exposure Prophylaxis (PrEP) Facility Record Form

  Date (dd/mm/yyyy) Person Completing Form
A. Facility Information  
  Facility Name District  
Date of Initial PrEP Client Screening Visit

(dd/mm/yyyy):         /     /

PrEP Client Number (if applicable)  

 

B. Client Demographics
First/Given Name: Middle Name: Surname:
Address: Telephone:

 

Telephone (alternative):

Date of Birth (dd/mm/yyyy)    ____ /____ /_____ Age (years):
Client ID Number: Marital Status:   [ ]Single        [ ]Married       [ ]Divorced              [ ]Widowed        [ ]Separated  [ ]No response

 

C. Sexual and Drug Injection Core Risk Classification
1. Do you consider yourself: male, female, transgender, or other?

[ ]Male

[ ]Female

[ ]Transgender, male to female (MTF)

[ ]Transgender, female to male (FTM)

[ ]Other (specify): ______________________

[ ]No response

2. What was your sex at birth?

[ ]Male

[ ]Female

[ ]Other (specify): _______________

[ ]No response

 

3. Do you have sex with: [ ]Men only        [ ]Women only       [ ]Both men and women      [ ]No response
4. Have you exchanged sex as your main source of income in the last 6 months? [ ]Yes    [ ]No    [ ]No response
5. In the last 6 months, have you injected illicit or illegal drugs? [ ]Yes    [ ]No    [ ]No response
6. Are you incarcerated? [ ]Yes    [ ]No    [ ]No response

 

D. Key Population Classification (an individual can belong to more than one category)  
If client answers “Male” to [ ]uestion 1 and answers “Men only” or “Both men and women” to [ ]uestion 3, then categorize as man who has sex with men (MSM) [ ]
If client answers “Transgender MTF” or “FTM” to [ ]uestion 1, then categorize as transgender (TG)
(cross-check with [ ]uestion 2)
[ ]
If client answers “Yes” to [ ]uestion 4, then categorize as sex worker (SW) [ ]
If client answers “Yes” to [ ]uestion 5, then categorize as person who injects drugs (PWID) [ ]
If client answers “Yes” to [ ]uestion 6, then categorize as person in prison (PP) [ ]
If client is not transgender (TG) and answers “No” or “No response” to [ ]uestions 3-7, classify as None [ ]
 

 

Man who has sex with men (MSM)    

Transgender (TG)                    

Sex worker (SW)   

Person who injects drugs (PWID) 

Person in prison (PP)

Other (specify)

None

Final Classification:

(Mark ALL that apply*)

[ ]MSM

[ ]TG

[ ]SW

[ ]PWID

[ ]PP

[ ]Other (specify):_______

[ ]None

*Some clients may belong to more than one category due to overlapping risk behavior.  
E. IF FEMALE: Pregnancy & Breastfeeding F. Baseline Laboratory Tests
Client currently pregnant?        [ ]Yes  [ ]No

Client currently breastfeeding?[ ]Yes  [ ]No

Date of last HIV test (dd/mm/yyyy):   ____ /____ /_____

Date of creatinine test (dd/mm/yyyy): ____ /____ /_____       [ ]Not done

Calculated creatinine clearance (CrCl): _____________   [ ]Not done

Date of creatinine clearance (CrCl) (dd/mm/yyyy):           /     /

               

G. Hepatitis B Testing, Vaccination, and Treatment                              
Date of HBsAg test (dd/mm/yyyy):         /     / Test result: [ ]Negative     [ ]Positive    [ ]Not done
If positive, client on treatment? [ ]Yes  [ ]No  [ ]Unknown If negative, dates HBV vaccination provided (if available): (dd/mm/yyyy)

1)  ____ /____ /______      2)  ____ /____ /______

3)          /         /                                       [ ]Not done

 

H. Sexually Transmitted Infections (STI) 
STI symptom screen date (dd/mm/yyyy):  ____ /____ /______   Result (*see codes): _________________  [ ]Not done

*    STI symptom codes (select all that apply): U=Urethral discharge.  G=Genital ulcers or lesions. V=Vaginal discharge.
I=Itching.  L=Lower abdominal pain (women only).   S=Scrotal swelling.  B=Bubo in inguinal area.
D=Dysuria (pain with urination). P=Pain with intercourse (women only)O=Other (specify)

If STI syndromic management, syndrome treated (**see codes): _________________________________  [ ]Not done

**  STI syndrome codes (select all that apply): GUS=Genital ulcer syndrome.   VDS=Vaginal discharge syndrome.
LAP=Lower abdominal pain.    MUS=Male urethritis syndrome.  SSW=Scrotal swelling.  O=Other (specify)

STI treatment start date (dd/mm/yyyy):             /     /              [ ]Not started treatment

 

I. Initiation of PrEP Treatment
PrEP start date  Date initiated (dd/mm/yyyy):           /     /
PrEP (ARVs) prescribed [ ]TDF/FTC    [ ]TDF/3TC    [ ]TDF    [ ]Other (specify):
PrEP discontinued Date discontinued (dd/mm/yyyy):             /     /
Reasons for stopping PrEP:  [ ]Tested HIV+    [ ]No longer at substantial risk       [ ]Side effects    [ ]Client preference    [ ]Abnormal creatinine result

[ ]Other (specify):

HIV status at time of discontinuation: [ ]Negative     [ ]Positive    [ ]Unknown
 Re-start of PrEP
PrEP re-start date Date re-initiated (dd/mm/yyyy):           /     /
PrEP (ARVs) prescribed [ ]TDF/FTC    [ ]TDF/3TC   [ ]TDF   [ ]Other (specify):
PrEP discontinued Date discontinued (dd/mm/yyyy):           /     /
Reasons for stopping PrEP:   [ ]Tested HIV+   [ ]No longer at substantial risk       [ ]Side effects    [ ]Client preference   [ ]Abnormal creatinine result

[ ]Other (specify):

HIV status at time of discontinuation:  [ ]Negative    [ ]Positive    [ ]Unknown

 

J. Transfer Out, Death, and Loss to Follow-Up
[ ]Transferred out (TO) Date TO (dd/mm/yyyy):                ___ /___/______

 

Name of clinic transferred to:

[ ]Died Date of death (dd/mm/yyyy):         /     /
[ ]Lost to follow-up (LTFU)   Date confirmed LTFU (dd/mm/yyyy):         /     /

 

PrEP Follow-Up Visits

Date of visit (dd/mm/yyyy)
(starting with screening visit)
___ /___ /_____ ___ /___ /_____ ___ /___ /_____ ___ /___ /_____ ___ /___ /_____ ___ /___ /_____ ___ /___ /_____
HIV test                    Test result:

 

                                      Tests Used:

 

[ ]Negative

[ ]Positive

[ ]Inconclusive

First:

_____________

Confirmatory: _____________

[ ]Negative

[ ]Positive

[ ]Inconclusive

First:

_____________

Confirmatory: _____________

 

[ ]Negative

[ ]Positive

[ ]Inconclusive

First:

_____________

Confirmatory: _____________

 

[ ]Negative

[ ]Positive

[ ]Inconclusive

First:

_____________

Confirmatory: _____________

 

[ ]Negative

[ ]Positive

[ ]Inconclusive

First:

_____________

Confirmatory: _____________

 

[ ]Negative

[ ]Positive

[ ]Inconclusive

First:

_____________

Confirmatory: _____________

 

[ ]Negative

[ ]Positive

[ ]Inconclusive

First:

_____________

Confirmatory: _____________

 

Signs and symptoms
of acute HIV infection?
[ ] Yes

[ ] No

[ ] Yes

[ ] No

[ ] Yes

[ ] No

[ ] Yes

[ ] No

[ ] Yes

[ ] No

[ ] Yes

[ ] No

[ ] Yes

[ ] No

PrEP Side effects

(see codes insert a dash if none)

             
CrCl calculation

(baseline and every 6 months)

             
Risk reduction counseling and commodities provided?
(tick if yes)
[ ] [ ] [ ] [ ] [ ] [ ] [ ]
PrEP prescription

ARVs prescribed (tick)

[ ]TDF/FTC

[ ]TDF/3TC

[ ]TDF

[ ]Other (specify):

 

[ ]TDF/FTC

[ ]TDF/3TC

[ ]TDF

[ ]Other (specify):

 

[ ]TDF/FTC

[ ]TDF/3TC

[ ]TDF

[ ]Other (specify):

 

[ ]TDF/FTC

[ ]TDF/3TC

[ ]TDF

[ ]Other (specify):

 

[ ]TDF/FTC

[ ]TDF/3TC

[ ]TDF

[ ]Other (specify):

 

[ ]TDF/FTC

[ ]TDF/3TC

[ ]TDF

[ ]Other (specify):

 

[ ]TDF/FTC

[ ]TDF/3TC

[ ]TDF

[ ]Other (specify):

 

Next scheduled PrEP visit date (dd/mm/yyyy) ___/___/_____ ___/___/_____ ___/___/_____ ___/___/_____ ___/___/_____ ___/___/_____ ___/___/_____
Additional notes

 

 

 

 

 

 

 

 

 

           
SIDE EFFECT CODES:   A=Abdominal pain.   S=Skin rash.     Nau=Nausea.     V=Vomiting.     D=Diarrhea.     F=Fatigue.     H=Headache.     L=Enlarged lymph nodes.     R=Fever.
                                                      O=Other (specify)

 

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