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ART Treatment Failure Screening Sheet

A. Identification: UAN/HMIS No: ____________ Address: ______________ Facility_____________B. Socio demographic data: Age (years): ________ Sex: M FC. Clinical information to be filled by nurse/health officer

1. Previous ART experience PMTCT (sd-NVP or combined) None Other_______2. Duration on ART (months) 6-12 12-24 24-36 above 36 Other_______3. CD4 profile (start from the base line) _____________________________________________4. Current CD4 count to pre- treatment baseline or below

By >50% from peak value on ART Persistently below 100 for >12 months

Discordant response with VL Other_________________________

5. Recent/current clinical WHO stage (stage 3 and/or 4 conditions or T3 and/or T4) Severe bacterial Crypto. meningitis CNS toxo

Extra pulmo. TB Kaposi Sa Wasting syndrome

PCP Lymphoma

Other (specify)__________________________________________________________6. Change in functional Status in the last six months Working Ambulatory Bedridden7. Adherence in the last six months Good Fair Poor8. Weight profile Gaining weight by 0-5% by 5-10% by > 10 %9. Does the patient have potential treatment failure? Yes No10.If suspected TF, pertinent investigations completed and referred to a physician? Yes No

D. Clinical information to be filled by ART physician11.T-stage T1 T2 T3 T412.Viral load Undetectable or 10,000c/ml Not done13.If VL 400 c/ml, linked to second line switch team Other15.Comments___________________________________________________________________

___________________________________________________________________

E. Recommendations of the switch team (to be filled by the ART physician)16.Switch team decided to: Conduct additional investigation Switch to second line

Intensify adherence support appoint for re-evaluation No TF, hence continue FLA

Other______________________________________________________________________

17.Recommended SLA and reason why?___________________________________________________________________________

___________________________________________________________________________

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A. Identification: It is good to have a documentation of this on each sheet as it may slip from the chart

B. Socio demographic data: Please document age in years and the sex of the patient as these variables

Are strongly correlated with the treatment conditions of the patient

C. Clinical information to be filled by nurse/health officer: As the nurses/HOs are the forefront and

the primary responsible clinician contacts for the patient, the basic screening and assessment is

conducted through them.

1. Previous ART experience: This information may give a clue to differentiate between primaryand secondary resistances.

2. Duration on ART (months): Screening for treatment failure starts six months after thecommencement of ART. The longer the duration the higher the index of suspicion for TF

3. CD4 profile (start from the base line): Outlines the patients CD4 increment or decrement overthe course of time and the corresponding Immunological response

4. Current CD4 count: The calculated current CD4 count determines whether the patient hasImmunological treatment failure or good immunologic response

5. Recent/current clinical WHO stage (stage 3 and/or 4 conditions or T3 and/or T4 conditions):Emergence of stage 4/T4 defining clinical conditions are markers of clinical treatment failure

6. Change in functional Status in the last six months: Deterioration of functional status in the pastSix months in conjunction with other evidences favors the diagnosis of treatment failure

7. Adherence in the last six months: Studies suggest that the most important cause of ARTtreatment failure is sub optimal adherence to ART. Problems in adherence lead to decrement of

CD4 count and ultimately predispose the patient to resistance and treatment failure.

Operationally we evaluate adherence practice in the past six months

8. Weight profile: Declining weight profile (> 5%) should alarm treatment failure9. Does the patient have potential treatment failure? Referring to the aforementioned clinical and

immunological conditions.

10.If suspected TF, pertinent investigations completed and referred to a physician: (OFT, Lipidprofile, CBC.)

F. Clinical information to be filled by ART physician11.T-stage: The physician undergoes thorough and meticulous evaluation of the treatment outcome12.Viral load: VL is requested and interpreted by the physician. VL count 0f 400 is taken as the

lowest range to exclude virologic blip and any count above that marks either problem in

adherence or resistance and treatment failure.

G. Recommendations of the switch team (to be filled by the ART physician): The out puts of thesecond line switch team will be properly tracked and documented.