National HIV Clinical Support Center

Clinical case summary

Share the clinical history and treatment information needed for a coordinated case review.

Before you begin: Complete all required fields. Where an answer does not apply, enter “N/A”. Add clinical visits in chronological order. Drafts can be saved after the facility email is entered. For help, call 0726 460 000.

MINISTRY OF HEALTH · NATIONAL AIDS AND STI CONTROL PROGRAMME

Clinical Summary Form

Please correct the following before submitting:

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Case and patient details

Identify the facility and provide the patient’s basic details.

Facility:

TWG:

Patient’s CCC No: (Do not write name)

Case Reporting Date:

Patient Details

Date of Birth:

ART Start Date:

Gender:

Current Weight (Kg):

Height (cm):

Clinician’s Name:

You can add three (3) email addresses by separating them with either the space bar, comma, semi-colon, tab key or return/enter key.

Facility Email Address:

Facility Tel No:

Consultation and clinical history

Describe the reason for consultation and add the clinical timeline.

What is the primary reason for this consultation:

Adverse drug reaction

Private cross-over patient

Single TDF out of stock

Drug interactions

Second line failure

Study cross-over patient

First line failure

Single AZT out of stock

Other (Please Specify)

Other Primary Reason

Clinical Evaluation: history, physical, diagnostics, working diagnosis:(excluding the information in the table below)

Clinical visit timeline · Add all available ART regimens and laboratory results in chronological order.

#	Date (yyyy-mm-dd)	CD4	HB	CrCl/ eGFR	Viral Load	Weight	ARV Regimen	Reason for Switch	New OI	Actions
{{ clinical_visit_index+1 }}	{{ clinical_visit.clinicvisitdate }}	{{ clinical_visit.cd4 }}	{{ clinical_visit.hb }}	{{ clinical_visit.crclegfr }}	{{ clinical_visit.viral_load }}	{{ clinical_visit.weight_bmi }}	{{ clinical_visit.arv_regimen }}	{{ clinical_visit.reason_switch }}	{{ clinical_visit.new_oi }}

Adherence and treatment failure evaluation

Record recent adherence support, barriers, and likely causes.

Number and findings of adherence counselling/assessment sessions done in the last 3-6 months including the following:

    Findings from MMAS-8
    Adherence barriers identified
    Recommendations

Number of home visits conducted in last 3-6 months, and findings:

Describe support structures (e.g. treatment buddy, support group attendance, caregivers) in place for this patient

Evidence of adherence concerns (e.g. missed appointments, pill counts?):

Describe daily witnessed ingestion done in last 3-6 months (Who performed it, which tool was used, how long was the session done etc.):

Describe likely root cause/s of poor adherence, for this patient (e.g. stigma, disclosure, side effects, alcohol or other drugs, mental health issues, caregiver changes, religious beliefs, inadequate preparation, etc):

Treatment failure and ART history

Document other possible causes and relevant resistance testing.

Evaluation for other causes of treatment failure

• Inadequate dosing/dose adjustments (particularly for children)::

• Drug-drug interactions:

• Drug-food interactions:

• Impaired absorption (e.g. chronic severe diarrhea):

Other Relevant ART History.

Comment on treatment interruptions, if any:

Has Drug Resistance/Sensitivity Testing been done for this patient? If yes, state date done and attach the detailed results.

Facility multidisciplinary team

Summarize the facility MDT discussion and participating members.

Has facility multidisciplinary team discussed the patient’s case?. If yes, comment on date, deliberations and recommendations.
(indicate how treatment failure was established and confirmed, proposed regimen and dosage, current source of drugs if patient already on 3rd line). If yes, state date done and attach the detailed results:

MDT members who participated in the case discussion (names and titles)

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