P ERSPECTIVES DE SANTE PUBLIQUE
Annexe 1. Outils de monitorage des services de PTME
Date | _ || _ | . | _ || _ | . | _ || _ || _ || _ | PMTCT N° ……….
Individual pre-test HIV counselling
Form completed by: ……… Pre-test session n°………
1- Socio-demographics
1.1. Date of birth | _ || _ | . | _ || _ | . | _ || _ || _ || _ | Age | _ || _ | 1.2. Village of permanent residence ……….
1.3. Marital status : □ never married □ married
□ living with partner □ separated
□ divorced □ widowed
1.4. Level of education: □ none □ primary
□ secondary □ post secondary
1.5. Employment □ formally employed □ self employed
□ other (specify) …………..……….
1.6. Number of children | _ || _ | of pregnancies | _ || _ | of live births | _ || _ |
2- Contraception and syphilis testing
2.1. Was she using a contraceptive before her pregnancy ? which one ………..………..
2.2. After this pregnancy, does she wish to use a contraceptive? which one ……….…………..
2.3. RPR test results □ negative □ positive □ undeterminate 2.4. Estimated date of delivery | _ || _ | . | _ || _ | . | _ || _ || _ || _ |
3- Feeding choice of the infant
3.1. How does she intend to feed her child in the first 4-6 months?
□ exclusive breastmilk □ exclusive artificial milk
□ breastmilk and other feeds □ artificial milk and other feeds If non exclusive, specify other feeds…….………...
4- HIV Testing proposal
4.1. Does she accept HIV testing □ yes □ no
4.2. Reasons for refusing HIV testing today ………..………..
4.3. Does she intend to propose HIV testing to her partner? □ yes □ no
□ no contact with the partner □ does not know
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Laboratory request form
NOTES This form should be taken to the lab by the client who wants to be tested.
The tear-off portion will be collected by the counsellors AT ALL TIME.
Laboratory No……….. Site Code………
Confirmatory Result: Oraquick 1. Positive 2. Negative 3. Indeterminate Tested by: ………..
Date | _ || _ | . | _ || _ | . | _ || _ || _ || _ | PMTCT N° ……….
Individual post-test HIV counselling
Form completed by: ……… Post-test session n°…………
1. Sharing of the HIV test results
1.1. What are the test results? □ sero+ □ sero- If present post-test counselling session on the same day as the testing,
1.2. Does she intend to share the results with someone? □ yes □ no 1.3. If yes, to whom?: ……….
If present post-test counselling session on an ulterior day as the testing,
1.4. Has the woman spoken to anyone of her serological status? □ yes □ no 1.5. If yes, to whom?: ……….
2. Feeding choice of the infant
2.1. After receiving her HIV test results, how does she intend to feed her child in the first 4-6 months?
□ exclusive breastmilk □ exclusive artificial milk
□ breastmilk and other feeds □ artificial milk and other feeds If non exclusive, specify other feeds..………...
2.2. Estimated date of delivery | _ || _ | . | _ || _ | . | _ || _ || _ || _ |
3. Participation to PMTCT intervention
3.1. Does the woman plan to deliver in Murambinda hospital maternity?
□ yes □ no (specify other)……….
If woman HIV-positive
3.2. Is the woman interested in a 2-year follow-up for her and her child?
□ yes □ no
If no, what reasons ? ……….……….
Comments from the counsellor
……….…
……….…
……….…
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Date | _ || _ | . | _ || _ | . | _ || _ || _ || _ | PMTCT N° ……….
PMTCT intervention
Form completed by: ………
Mother 1- Nevirapine
1.1. Date of distribution of nevirapine | _ || _ || . | _ || _ | . | _ || _ || _ || _ | 1.2. Date of onset of labour | _ || _ || . | _ || _ | . | _ || _ || _ || _ |
1.3. Hour of onset of labour | _ || _ || h
1.4. Did the woman take nevirapine at the onset of labour? □ yes □ no If yes go to 1.5., if no go to 1.10
1.5. Date of first nevirapine intake | _ || _ || . | _ || _ | . | _ || _ || _ || _ | 1.6. Hour of first nevirapine intake | _ || _ || h
1.7. Date of delivery | _ || _ || . | _ || _ | . | _ || _ || _ || _ |
1.8. Hour of delivery | _ || _ || h | _ || _ | mn
1.9. Second dose of nevirapine? □ yes □ no
If yes, specify the date and hour | _ || _ || . | _ || _ | . | _ || _ || _ || _ | and | _ || _ || h
Specify the reasons ………..
1.10. Have there been any intake problems? □ yes □ no
If yes, which problems ? ……….………..
2- Delivery
2.1. Site of ANC visits ………
2.2. Delivery location □ Murambinda hospital maternity □ home
□ other maternity (specify)………
2.3. Mode of expulsion □ normal □ forceps, suction cups
□ planned caesarean □ emergency caesarean
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Child
3- Birth
If twins, fill in a second form
3.1. Sex □ male □ female
3.2. Birth status □ alive □ still birth
3.3. Anthropometrics Birth weight | _ | _ | | _ | _ | g Height | _ | _ |,| _ | cm 3.4. Date of maternity discharge | _ || _ || . | _ || _ | . | _ || _ || _ || _ | 3.5. Status of the child at maternity discharge
□ alive home □ alive referred □ dead
4- Nevirapine
4.1. Date of distribution of the paediatric syrup bottle | _ || _ || . | _ || _ | . | _ || _ || _ || _ | 4.2. Date of nevirapine intake | _ || _ || . | _ || _ | . | _ || _ || _ || _ | 4.3. Hour of nevirapine intake | _ || _ || h | _ || _ | mn
4.4. Age of the child at nevirapine intake | _ || _ | hours 4.5. Age of the child at data collection | _ || _ || _ | hours
4.6. If late intake (after D3) or no intake of nevirapine, what were the reasons?………
………...
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Date | _ || _ | . | _ || _ | . | _ || _ || _ || _ | PMTCT N° ……….
Maternity discharge
Form completed by: ………
Clinical staging criteria
1. History (verbal/from hand held record card of mother):
Stage Two
Weight loss in last 6 months but <10% of bodyweight □ yes □ no
Herpes Zoster in last five years □ yes □ no
Recurrent sinusitis □ yes □ no
Stage three
Chronic diarrhoea >1 month □ yes □ no
Fever >1 month □ yes □ no
PTB within last 1 year □ yes □ no
Severe bacterial infections (pneumonia, pyomyositis) □ yes □ no Bedridden <50% of the day in last 1 month □ yes □ no
Weight loss >10% of body weight □ yes □ no
Stage four
Extra-pulmonary TB □ yes □ no
“HIV Wasting Syndrome” □ yes □ no
Mucocutaneous Herpes >1 month □ yes □ no
HIV encephalopathy □ yes □ no
Bedridden >50% of the day in last 1 month □ yes □ no
2. Physical examination:
Stage two
Minor mucocutaneous manifestations (eg. seborrhoeic dermatitis, prurigo, fungal nail infections recurrent oral ulcers, angular cheilitis) □ yes □ no
Stage three
Oral candidiasis □ yes □ no
Oral hairy leukoplakia □ yes □ no
Stage four
Presence of Stage Four illnesses i.e “AIDS?” □ yes □ no Overall clinical stage of woman □ I □ II □ III □ IV
Cotrimoxazole prescribed □ yes □ no
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Date | _ || _ | . | _ || _ | . | _ || _ || _ || _ | PMTCT N° ……….
Mother and child follow-up
From D1 to M2
D | _ | - W | _ | - M | _ |
Form completed by: ………
Mother
Date of first VCT session | _ || _ || . | _ || _ | . | _ || _ || _ || _ |
1- Clinical data and treatment
1.1. Has the mother been hospitalised since last contact? □ yes □ no 1.2. If yes, specify reason and dates: ………..
……….
1.3. Is the woman receiving the following treatments?
1.3.1. Nevirapine □ yes □ no
1.3.2. Antiretroviral for herself □ yes □ no
Specify ……….
1.3.3. Cotrimoxazole □ yes □ no
If yes to cotrimoxazole: since when? | _ || _ || . | _ || _ | . | _ || _ || _ || _ | 1.4 Has the woman been clinically evaluated ? □ yes □ no
If yes, which stage ? □ I □ II □ III □ IV
2- Clinical staging criteria
2.1. History (verbal/from hand held record card of mother):
Stage Two
• Weight loss in last 6 months but <10% of bodyweight □ yes □ no
• Herpes Zoster in last five years □ yes □ no
• Recurrent sinusitis □ yes □ no
Stage three
• Chronic diarrhoea >1 month □ yes □ no
• Fever >1 month □ yes □ no
• PTB within last 1 year □ yes □ no
• Severe bacterial infections (pneumonia, pyomyositis) □ yes □ no
• Bedridden <50% of the day in last 1 month □ yes □ no
• Weight loss >10% of body weight □ yes □ no Stage four
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• Extra-pulmonary TB □ yes □ no
• “HIV Wasting Syndrome” □ yes □ no
• Mucocutaneous Herpes >1 month □ yes □ no
• HIV encephalopathy □ yes □ no
• Bedridden >50% of the day in last 1 month □ yes □ no
2.2. Physical examination:
Stage two
• Minor mucocutaneous manifestations (eg. seborrhoeic dermatitis, prurigo, fungal nail infections recurrent oral ulcers, angular cheilitis) □ yes □ no Stage three
• Oral candidiasis | □ yes □ no
• Oral hairy leukoplakia □ yes □ no
Stage four
• Presence of Stage Four illnesses i.e “AIDS?” □ yes □ no 2.3. Overall clinical stage of woman □ I □ II □ III □ IV
2.4. Cotrimoxazole prescribed □ yes □ no
3. Follow up on cotrmoxazole
3.1. Are there obvious clinical manifestations of adverse drug effects? □ yes □ no If yes, has there been one of the following adverse drug effects?
3.1.1 Skin (Stevens Johnstone) □ yes □ no
3.1.2 Liver (hepatomegaly/jaundice) □ yes □ no
3.1.3 Renal (signs of renal failure – admittedly unlikely!!) □ yes □ no 3.2. Are there signs/symptoms about possible resistance to other pathogens/drug treatments?
□ yes □ no If yes, was this to
3.2.1 Strep pneumoniae □ yes □ no
3.2.2 Non typhi salmonella □ yes □ no
3.2.3 P. falciparum malaria □ yes □ no
3.2.3.1 If yes, was quinine required? □ yes □ no 3.3. Were there any difficulties in adherence/acceptability? □ yes □ no If yes, which difficulties……….
4. Contraception
4.1. Does the woman currently use a contraceptive? Which one ………
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Child
Date of birth | _ || _ || . | _ || _ | . | _ || _ || _ || _ | (1)
Date of birth | _ || _ || . | _ || _ | . | _ || _ || _ || _ | (2, if twins, and fill a second form)
5. Clinical data and treatment 5.1. Anthropometrics
Weight | _ | _ || | _ | _ | kg
Height | _ | _ |,| _ | cm
Cranial Perimeter | _ | _ |,| _ | cm Brachial perimeter | _ | _ |,| _ | cm
5.2. Has the child been hospitalised since birth/ last visit? □ yes □ no 5.3. If yes, specify reason and dates: ……….…..
……….
5.4. Is the child receiving cotrimoxazole treatment? □ yes □ no If yes since when? | _ || _ || . | _ || _ | . | _ || _ || _ || _ |
6. Follow up on cotrimoxazole
6.1. Are there obvious clinical manifestations of adverse drug effects? □ yes □ no If yes, which effects ……….………
6.2. Were there any difficulties in adherence/acceptability? □ yes □ no If yes, which difficulties………...……….
7. Feeding practice
7.1. Current feeding practice □ exclusive breastmilk □ exclusive artificial milk
□ breastmilk and other feeds □ artificial milk and other feeds
7.2. Is the child weaned? □ yes □ no
7.2.1. Date of complete weaning | _ || _ || . | _ || _ | . | _ || _ || _ || _ | □ on-going 7.2.2. Reasons for weaning ………..
………
8. HIV test
8.1. Date of HIV testing | _ || _ || . | _ || _ | . | _ || _ || _ || _ | 8.2. What are the test results? □ sero+ □ sero-
Date of the next visit | _ || _ || . | _ || _ | . | _ || _ || _ || _ |
Bus warrant given? □ yes □ no
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Annexe 2. Questionnaire des enquêtes de Connaissance, Attitudes et Pratiques en