SayPro Pre-Exposure Prophylaxis (PrEP) Monthly Summary Form

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SayPro Pre-Exposure Prophylaxis (PrEP) Monthly Summary Form

Pre-Exposure Prophylaxis (PrEP) Monthly Summary Form

Facility Name Level of Facility Facility Code
District Province/Region
Month of Report Year of Report

                                                                                                                                

SECTION 1: ALL New PrEP Candidates

 

  • Number of new clients who received HIV testing for PrEP screening during the period,
    by gender and age
 

Gender

Age Group (years)
15-19 20-24 25-29 30-34 35-39 40-44 45-49 50+ Total
Female                  
HIV negative                  
HIV positive                  
Male                  
HIV negative                  
HIV positive                  
Transgender                  
HIV negative                  
HIV positive                  
Total                  
HIV negative                  
HIV positive                  

 

  • Number of new clients who received HIV testing for PrEP screening during the period,
    among key populations (KP), by age
 

KP Group

Age Group (years)
15-19 20-24 25-29 30-34 35-39 40-44 45-49 50+ Total
MSM                  
HIV negative                  
HIV positive                  
Transgender                  
HIV negative                  
HIV positive                  
Sex workers                  
HIV negative                  
HIV positive                  
PWID                  
HIV negative                  
HIV positive                  
PP                  
HIV negative                  
HIV positive                  
Total                  
HIV negative                  
HIV positive                  
  • Number of clients determined to be eligible for PrEP during the period,
    by gender and age
 

Gender

Age Group (years)
15-19* 20-24 25-29 30-34 35-39 40-44 45-49 50+ Total
Female                  
Male                  
Transgender                  
Total                  

*Note: No global recommendation for PrEP among adolescents has been developed

 

  • Number of clients determined to be eligible for PrEP during the period,
    by KP group and age
 

KP Group

Age Group (years)
15-19 20-24 25-29 30-34 35-39 40-44 45-49 50+ Total
MSM                  
Transgender                  
Sex workers                  
PWID                  
PP                  
Total                  

 

  • Number of clients who started PrEP during the period,
    by gender and age
 

Gender

Age Group (years)
15-19 20-24 25-29 30-34 35-39 40-44 45-49 50+ Total
Female                  
Male                  
Transgender                  
Total                  

 

  • Number of clients who started PrEP during the period,
    by KP group and age
 

KP Group

Age Group (years)
15-19 20-24 25-29 30-34 35-39 40-44 45-49 50+ Total
MSM                  
Transgender                  
Sex workers                  
PWID                  
PP                  
Total                  

 

 

SECTION 2: PrEP Follow-Up Services

2.1  Number of returning PrEP clients receiving follow-up HIV testing during the period,
by gender and age

 

Gender

Age Group (years)
15-19 20-24 25-29 30-34 35-39 40-44 45-49 50+ Total
Female                  
HIV negative                  
HIV positive                  
Male                  
HIV negative                  
HIV positive                  
Transgender                  
HIV negative                  
HIV positive                  
Total                  
HIV negative                  
HIV positive                  

 

2.2  Number of returning PrEP clients receiving follow-up HIV testing during the period,
by KP group and age

 

KP Group

Age Group (years)
15-19 20-24 25-29 30-49 35-39 40-44 45-49 50+ Total
MSM                  
HIV negative                  
HIV positive                  
Transgender                  
HIV negative                  
HIV positive                  
Sex workers                  
HIV negative                  
HIV positive                  
PWID                  
HIV negative                  
HIV positive                  
PP                  
HIV negative                  
HIV positive                  
Total                  
HIV negative                  
HIV positive                  

 

 

 

2.3  Number of clients currently receiving PrEP from this facility,
by gender and age

Gender Age Group (years)
15-19 20-24 25-29 30-34 35-39 40-44 45-49 50+ Total
Female                  
Male                  
Transgender                  
Total                  

 

 

2.4  Number of clients currently receiving PrEP from this facility,
by KP group and age

 

KP Group

Age Group (years)
15-19 20-24 25-29 30-34 35-39 40-44 45-49 50+ Total
MSM                  
Transgender                  
Sex workers                  
PWID                  
PP                  
Total                  

 

 

 

Form completed by: Title:

 

Date (dd/mm/yyyy):
Form verified by: Title:

 

Date (dd/mm/yyyy):

 

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