ARV and E-MTCT Medicines Order Form and Patient Report

Facility Name: Start Date:

District: End Date:
Delivery Zone Date Prepared:

OPENING QUANTITY ART & e-MTCT QUANTITY

BALANCE RECEIVED CONSUMPTION LOSSES / CLOSING BALANCE MONTHS OF REQUIRED FOR
ADJUSTMENTS Days out of stock Adjusted AMC (Physical Count in Stores STOCK ON-HAND CURRENT Notes
Drug Formulation and Strength Basic Unit at start of 2 during 2 Month during 2 Month during 2 month
Month Cycle Cycle Cycle (+/-) = (C*30)/(60-E) + Pharmacy) = G/F PATIENTS
Cycle (≤ 60 days) = 4 * F-G
Closing
balance
validatio
A B C D E F G H I n
ADULT -- RECOMMENDED FORMULATIONS

1 Tenofovir/Lamivudine/Efavirenz (TDF/3TC/EFV) 300mg/300mg/400mg Pack of 30

2 Tenofovir/Lamivudine/Efavirenz (TDF/3TC/EFV) 300mg/300mg/400mg Pack of 90

3 Tenofovir/Lamivudine/Efavirenz (TDF/3TC/EFV) 300mg/300mg/400mg Pack of 180

4 Tenofovir/Lamivudine (TDF/3TC) 300mg/300mg Pack of 30

5 Tenofovir/Lamivudine/Dolutegravir (TDF/3TC/DTG) 300mg/300mg/50mg Pack of 30

6 Tenofovir/Lamivudine/Dolutegravir (TDF/3TC/DTG) 300mg/300mg/50mg Pack of 90

7 Tenofovir/Lamivudine/Dolutegravir (TDF/3TC/DTG) 300mg/300mg/50mg Pack of 180

8 Zidovudine /Lamivudine/Nevirapine (AZT/3TC/NVP) 300mg/150mg/200mg Pack of 60

9 Zidovudine/Lamivudine (AZT/3TC)300mg/150mg Pack of 60

10 Abacavir/Lamivudine (ABC/3TC) 600mg/300mg Pack of 30

11 Abacavir/Lamivudine/Dolutegravir (ABC/3TC/DTG) 600mg/300mg/50mg Pack of 30

12 Atazanavir/Ritonavir (ATV/r) 300mg/100mg Pack of 30

13 Lopinavir/Ritonavir (LPV/r) 200mg/50mg Pack of 120

14 Dolutegravir (DTG) 50mg Pack of 30

15 Efavirenz (EFV) 600mg Pack of 30

16 Nevirapine (NVP) 200mg pack of 60

17 Zidovudine (AZT) 300mg Pack of 60

PAEDIATRIC -- RECOMMENDED FORMULATIONS

1 Abacavir/Lamivudine (ABC/3TC) 120mg/60mg Pack of 30

2 Abacavir/Lamivudine/Lopinavir/Ritonavir (ABC/3TC/LPV/r) 30mg/15mg/40mg/10mg Pack of 120

3 Zidovudine/Lamivudine/Nevirapine (AZT/3TC/NVP) 60mg/30mg/50mg Pack of 60

4 Zidovudine/Lamivudine (AZT/3TC) 60mg/30mg Pack of 60

5 Lopinavir/Ritonavir (LPV/r) 80mg/20ml oral syrup Bottle of 60ml

6 Lopinavir/Ritonavir (LVP/r) 40mg/10mg Pellets Pack of 120

7 Lopinavir/Ritonavir (LVP/r) 100mg/25mg Pack of 60

8 Efavirenz (EFV) 200mg Pack of 90

9 Nevirapine (NVP) 50mg Pack of 30

10 Dolutegravir (DTG) 10mg Pack of 60

11 Abacavir (ABC) 60mg Pack of 60

E-MTCT ONLY FORMULATIONS

1 Nevirapine (NVP) 10mg/ml oral susp. 100ml

THIRD LINE (3rd) FORMULATIONS

1 Darunavir (DRV) 75mg Pack of 480

2 Darunavir (DRV) 150mg Pack of 240

3 Darunavir (DRV) 600mg Pack of 60

4 Etravarine (ETV) 25mg Pack of 120

5 Etravarine (ETV) 100mg Pack of 120

6 Etravarine (ETV) 200mg Pack of 60

7 Raltegravir (RTG) 25mg Pack of 60

8 Raltegravir (RTG) 100mg Pack of 120

9 Raltegravir (RTG) 400mg Pack of 60

10 Ritonavir (RTV) 100mg Pack of 60

11 Saquinavir (SQV) 500mg Pack of 120

MEDICINES FOR HEPATITIS B ONLY PATIENTS

1 Tenofovir (TDF) 300mg Pack of 30

2 Entecavir 0.5 mg Pack of 30

OTHER FORMULATIONS

1 Cotrimoxazole 960mg 1000

2 Cotrimoxazole 120mg 1000

3 Fluconazole 200mg 28

4 Fluconazole oral susp. 35ml

5 Fluconazole IV 100ml

6 Dapsone 100mg 100

SUMMARY: ART PATIENTS PER TREATMENT REGIMEN (Existing and New Enrollments):

TOTAL ADULT ART & e-MTCT PATIENTS Pediatric First Line Patients
No. Existing No. New
(at start of cycle being reported on) (enrolled during
the cycle being 10-<15 Yrs 10-<15 Yrs
1st Line Regimens Regimens 0-<3 Yrs 3-<10 Yrs less than 35kg greater than 35kg
reported on)

TDF/3TC/EFV Existing New Existing New Existing New Existing New

TDF/3TC/NVP ABC/3TC/LPV/r
TDF/3TC/DTG ABC/3TC/AZT

TDF/3TC/AZT ABC/3TC/DTG
AZT/3TC/NVP ABC/3TC/EFV

AZT/3TC/EFV ABC/3TC/NVP
ABC/3TC/NVP AZT/3TC/EFV

ABC/3TC/EFV AZT/3TC/LPV/r
ABC/3TC/DTG AZT/3TC/NVP

TDF/3TC/ATV/r TDF/3TC/EFV
TOTAL ADULT PATIENTS 0 0 TDF/3TC/NVP

0 0 0 0 0 0 0 0
Total Pead 1L

Adult Second Line Patients

 No. New
2nd Line Regimens No. Existing (enrolled during Pediatric Second Line Patients
(at start of cycle being reported on) the cycle being
reported on)
Regimens 0-<3 Yrs 3-<10 Yrs 10-<15 Yrs 10-<15 Yrs
TDF/3TC/ATV/r less than 35kg greater than 35kg
TDF/3TC/LPV/r Existing New Existing New Existing New Existing New
AZT/3TC/ATV/r ABC/3TC/ATV/r
AZT/3TC/LPV/r ABC/3TC/LPV/r

AZT/3TC/DTG ABC/3TC/RAL
TDF/3TC/DTG ABC/3TC/DRV/r

ABC/3TC/ATV/r AZT/3TC/ATV/r

ABC/3TC/LPV/r AZT/3TC/LPV/r
Total Adult 2L Patients 0 0 AZT/3TC/RAL

AZT/3TC/DTG
Adult Third Line Patients TDF/3TC/ATV/r
3rd Line Regimens No. Existing No. New TDF/3TC/LPV/r
(at start of cycle being reported on) (enrolled during
DRV+RTV+RAL the cycle being Total Pead 2L 0 0 0 0 0 0 0 0
reported on)
DRV+RTV+ETV
DRV+RTV+DTG Pediatric Third Line Patients
Regimens 0-<3 Yrs 3-<10 Yrs 10-<15 Yrs 10-<15 Yrs
DRV+RTV+DTG+ETV less than 35kg greater than 35kg
SQV+RTV Existing New Existing New Existing New Existing New
DRV+RTV+ETV+RAL DRV+RTV+RAL

ETV DRV+RTV+ETV
DRV+RTV DRV+RTV+DTG
RAL DRV+RTV+DTG+ETV
Total Adult 3L Patients 0 0 DRV+RTV+ETV+RAL
SQV+RTV
NUMBER OF PATIENTS TREATED WITH FLUCONAZOLE ETV

Adults Children
Condition (< 15 yrs) DRV+RTV
Acute cryptococcal meningitis RAL
Consolidation phase (Cryptococcal meningitis) Total Pead 3L 0 0 0 0 0 0 0 0
Maintainance phase (Cryptococcal meningitis)
Esophageal candidiasis

PATIENTS ON COTRIMOXAZOLE PROPHYLAXIS FACILITY CONTACT INFORMATION

Children
Drug Adults (< 15 yrs)
Cotrimoxazole (Pre-ART and ART) Name Signature:
Dapsone (Pre-ART and ART)

HEPATITIS B ONLY PATIENTS

Children
Drug Adults (< 15 yrs) Designation Phone Number:
Tenofovir 300mg tablets
Entecavir 0.5mg tablets
ARV and E-MTCT Medicines Order Form and Patient Report
Facility Name: Start Date:
District: End Date:
Delivery Zone Date Prepared:

OPENING QUANTITY ART & e-MTCT QUANTITY

BALANCE RECEIVED CONSUMPTION LOSSES / CLOSING BALANCE MONTHS OF REQUIRED FOR
ADJUSTMENTS Days out of stock Adjusted AMC (Physical Count in Stores STOCK ON-HAND CURRENT Notes
Drug Formulation and Strength Basic Unit at start of 2 during 2 Month during 2 Month during 2 month
Month Cycle Cycle Cycle (+/-) = (C*30)/(60-E) + Pharmacy) = G/F PATIENTS
Cycle (≤ 60 days) = 4 * F-G
Closing
balance
A B C D E F G H I validation
ADULT -- RECOMMENDED FORMULATIONS

1 Tenofovir/Lamivudine/Efavirenz (TDF/3TC/EFV) 300mg/300mg/400mg Pack of 30 0

2 Tenofovir/Lamivudine/Efavirenz (TDF/3TC/EFV) 300mg/300mg/400mg Pack of 90 0

3 Tenofovir/Lamivudine/Efavirenz (TDF/3TC/EFV) 300mg/300mg/400mg Pack of 180 0

4 Tenofovir/Lamivudine (TDF/3TC) 300mg/300mg Pack of 30 0

5 Tenofovir/Lamivudine/Dolutegravir (TDF/3TC/DTG) 300mg/300mg/50mg Pack of 30 0

6 Tenofovir/Lamivudine/Dolutegravir (TDF/3TC/DTG) 300mg/300mg/50mg Pack of 90 0

7 Tenofovir/Lamivudine/Dolutegravir (TDF/3TC/DTG) 300mg/300mg/50mg Pack of 180 0

8 Zidovudine /Lamivudine/Nevirapine (AZT/3TC/NVP) 300mg/150mg/200mg Pack of 60 0

9 Zidovudine/Lamivudine (AZT/3TC)300mg/150mg Pack of 60 0

10 Abacavir/Lamivudine (ABC/3TC) 600mg/300mg Pack of 30 0

11 Abacavir/Lamivudine/Dolutegravir (ABC/3TC/DTG) 600mg/300mg/50mg Pack of 30 0

12 Atazanavir/Ritonavir (ATV/r) 300mg/100mg Pack of 30 0

13 Lopinavir/Ritonavir (LPV/r) 200mg/50mg Pack of 120 0

14 Dolutegravir (DTG) 50mg Pack of 30 0

15 Efavirenz (EFV) 600mg Pack of 30 0

16 Nevirapine (NVP) 200mg pack of 60 0

17 Zidovudine (AZT) 300mg Pack of 60 0

PAEDIATRIC -- RECOMMENDED FORMULATIONS

1 Abacavir/Lamivudine (ABC/3TC) 120mg/60mg Pack of 30 0

2 Abacavir/Lamivudine/Lopinavir/Ritonavir (ABC/3TC/LPV/r) 30mg/15mg/40mg/10mg Pack of 120 0

3 Zidovudine/Lamivudine/Nevirapine (AZT/3TC/NVP) 60mg/30mg/50mg Pack of 60 0

4 Zidovudine/Lamivudine (AZT/3TC) 60mg/30mg Pack of 60 0

5 Lopinavir/Ritonavir (LPV/r) 80mg/20ml oral syrup Bottle of 60ml 0

6 Lopinavir/Ritonavir (LVP/r) 40mg/10mg Pellets Pack of 120 0

7 Lopinavir/Ritonavir (LVP/r) 100mg/25mg Pack of 60 0

8 Efavirenz (EFV) 200mg Pack of 90 0

9 Nevirapine (NVP) 50mg Pack of 30 0

10 Dolutegravir (DTG) 10mg Pack of 60 0

11 Abacavir (ABC) 60mg Pack of 60 0

E-MTCT ONLY FORMULATIONS

1 Nevirapine (NVP) 10mg/ml oral susp. 100ml 0

THIRD LINE (3rd) FORMULATIONS

1 Darunavir (DRV) 75mg Pack of 480 0

2 Darunavir (DRV) 150mg Pack of 240 0

3 Darunavir (DRV) 600mg Pack of 60 0

4 Etravarine (ETV) 25mg Pack of 120 0

5 Etravarine (ETV) 100mg Pack of 120 0

6 Etravarine (ETV) 200mg Pack of 60 0

7 Raltegravir (RTG) 25mg Pack of 60 0

8 Raltegravir (RTG) 100mg Pack of 120 0

9 Raltegravir (RTG) 400mg Pack of 60 0

10 Ritonavir (RTV) 100mg Pack of 60 0

11 Saquinavir (SQV) 500mg Pack of 120 0

MEDICINES FOR HEPATITIS B ONLY PATIENTS

1 Tenofovir (TDF) 300mg Pack of 30 0

2 Entecavir 0.5 mg Pack of 30 0

OTHER FORMULATIONS

1 Cotrimoxazole 960mg 1000 0

2 Cotrimoxazole 120mg 1000 0

3 Fluconazole 200mg 28 0

4 Fluconazole oral susp. 35ml 0

5 Fluconazole IV 100ml 0

6 Dapsone 100mg 100 0

SUMMARY: ART PATIENTS PER TREATMENT REGIMEN (Existing and New Enrollments):

TOTAL ADULT ART & e-MTCT PATIENTS Pediatric First Line Patients
No. Existing No. New
(at start of cycle being reported on) (enrolled during
the cycle being 10-<15 Yrs 10-<15 Yrs
1st Line Regimens Regimens 0-<3 Yrs 3-<10 Yrs less than 35kg greater than 35kg
reported on)

TDF/3TC/EFV Existing New Existing New Existing New Existing New

TDF/3TC/NVP ABC/3TC/LPV/r
TDF/3TC/DTG ABC/3TC/AZT

TDF/3TC/AZT ABC/3TC/DTG
AZT/3TC/NVP ABC/3TC/EFV

AZT/3TC/EFV ABC/3TC/NVP
ABC/3TC/NVP AZT/3TC/EFV

ABC/3TC/EFV AZT/3TC/LPV/r
ABC/3TC/DTG AZT/3TC/NVP

TDF/3TC/ATV/r TDF/3TC/EFV
TOTAL ADULT PATIENTS 0 0 TDF/3TC/NVP

0 0 0 0 0 0 0 0
Total Pead 1L

Adult Second Line Patients

 No. New
2nd Line Regimens No. Existing (enrolled during Pediatric Second Line Patients
(at start of cycle being reported on) the cycle being
reported on)

Regimens 0-<3 Yrs 3-<10 Yrs 10-<15 Yrs 10-<15 Yrs

TDF/3TC/ATV/r less than 35kg greater than 35kg
TDF/3TC/LPV/r Existing New Existing New Existing New Existing New
AZT/3TC/ATV/r ABC/3TC/ATV/r
AZT/3TC/LPV/r ABC/3TC/LPV/r

AZT/3TC/DTG ABC/3TC/RAL
TDF/3TC/DTG ABC/3TC/DRV/r

ABC/3TC/ATV/r AZT/3TC/ATV/r

ABC/3TC/LPV/r AZT/3TC/LPV/r
Total Adult 2L Patients 0 0 AZT/3TC/RAL

AZT/3TC/DTG
Adult Third Line Patients TDF/3TC/ATV/r
3rd Line Regimens No. Existing No. New TDF/3TC/LPV/r
(at start of cycle being reported on) (enrolled during
DRV+RTV+RAL the cycle being Total Pead 2L 0 0 0 0 0 0 0 0
reported on)
DRV+RTV+ETV
DRV+RTV+DTG Pediatric Third Line Patients
Regimens 0-<3 Yrs 3-<10 Yrs 10-<15 Yrs 10-<15 Yrs
DRV+RTV+DTG+ETV less than 35kg greater than 35kg
SQV+RTV Existing New Existing New Existing New Existing New
DRV+RTV+ETV+RAL DRV+RTV+RAL

ETV DRV+RTV+ETV
DRV+RTV DRV+RTV+DTG

RAL DRV+RTV+DTG+ETV
Total Adult 3L Patients 0 0 DRV+RTV+ETV+RAL
SQV+RTV
NUMBER OF PATIENTS TREATED WITH FLUCONAZOLE ETV

Adults Children
Condition (< 15 yrs) DRV+RTV
Acute cryptococcal meningitis RAL
Consolidation phase (Cryptococcal meningitis) Total Pead 3L 0 0 0 0 0 0 0 0
Maintainance phase (Cryptococcal meningitis)
Esophageal candidiasis

PATIENTS ON COTRIMOXAZOLE PROPHYLAXIS FACILITY CONTACT INFORMATION

Children
Drug Adults (< 15 yrs)
Cotrimoxazole (Pre-ART and ART) Name Signature:
Dapsone (Pre-ART and ART)

HEPATITIS B ONLY PATIENTS

Children
Drug Adults (< 15 yrs) Designation Phone Number:
Tenofovir 300mg tablets
Entecavir 0.5mg tablets
ARV and E-MTCT Medicines Order Form and Patient Report
Facility Name: Start Date:
District: End Date:
Delivery Zone Date Prepared:

OPENING QUANTITY ART & e-MTCT QUANTITY

BALANCE RECEIVED CONSUMPTION LOSSES / CLOSING BALANCE MONTHS OF REQUIRED FOR
ADJUSTMENTS Days out of stock Adjusted AMC (Physical Count in Stores STOCK ON-HAND CURRENT Notes
Drug Formulation and Strength Basic Unit at start of 2 during 2 Month during 2 Month during 2 month
Month Cycle Cycle Cycle (+/-) = (C*30)/(60-E) + Pharmacy) = G/F PATIENTS
Cycle (≤ 60 days) = 4 * F-G
Closing
balance
validatio
A B C D E F G H I n
ADULT -- RECOMMENDED FORMULATIONS

1 Tenofovir/Lamivudine/Efavirenz (TDF/3TC/EFV) 300mg/300mg/400mg Pack of 30 0

2 Tenofovir/Lamivudine/Efavirenz (TDF/3TC/EFV) 300mg/300mg/400mg Pack of 90 0

3 Tenofovir/Lamivudine/Efavirenz (TDF/3TC/EFV) 300mg/300mg/400mg Pack of 180 0

4 Tenofovir/Lamivudine (TDF/3TC) 300mg/300mg Pack of 30 0

5 Tenofovir/Lamivudine/Dolutegravir (TDF/3TC/DTG) 300mg/300mg/50mg Pack of 30 0

6 Tenofovir/Lamivudine/Dolutegravir (TDF/3TC/DTG) 300mg/300mg/50mg Pack of 90 0

7 Tenofovir/Lamivudine/Dolutegravir (TDF/3TC/DTG) 300mg/300mg/50mg Pack of 180 0

8 Zidovudine /Lamivudine/Nevirapine (AZT/3TC/NVP) 300mg/150mg/200mg Pack of 60 0

9 Zidovudine/Lamivudine (AZT/3TC)300mg/150mg Pack of 60 0

10 Abacavir/Lamivudine (ABC/3TC) 600mg/300mg Pack of 30 0

11 Abacavir/Lamivudine/Dolutegravir (ABC/3TC/DTG) 600mg/300mg/50mg Pack of 30 0

12 Atazanavir/Ritonavir (ATV/r) 300mg/100mg Pack of 30 0

13 Lopinavir/Ritonavir (LPV/r) 200mg/50mg Pack of 120 0

14 Dolutegravir (DTG) 50mg Pack of 30 0

15 Efavirenz (EFV) 600mg Pack of 30 0

16 Nevirapine (NVP) 200mg pack of 60 0

17 Zidovudine (AZT) 300mg Pack of 60 0

PAEDIATRIC -- RECOMMENDED FORMULATIONS

1 Abacavir/Lamivudine (ABC/3TC) 120mg/60mg Pack of 30 0

2 Abacavir/Lamivudine/Lopinavir/Ritonavir (ABC/3TC/LPV/r) 30mg/15mg/40mg/10mg Pack of 120 0

3 Zidovudine/Lamivudine/Nevirapine (AZT/3TC/NVP) 60mg/30mg/50mg Pack of 60 0

4 Zidovudine/Lamivudine (AZT/3TC) 60mg/30mg Pack of 60 0

5 Lopinavir/Ritonavir (LPV/r) 80mg/20ml oral syrup Bottle of 60ml 0

6 Lopinavir/Ritonavir (LVP/r) 40mg/10mg Pellets Pack of 120 0

7 Lopinavir/Ritonavir (LVP/r) 100mg/25mg Pack of 60 0

8 Efavirenz (EFV) 200mg Pack of 90 0

9 Nevirapine (NVP) 50mg Pack of 30 0

10 Dolutegravir (DTG) 10mg Pack of 60 0

11 Abacavir (ABC) 60mg Pack of 60 0

E-MTCT ONLY FORMULATIONS

1 Nevirapine (NVP) 10mg/ml oral susp. 100ml 0

THIRD LINE (3rd) FORMULATIONS

1 Darunavir (DRV) 75mg Pack of 480 0

2 Darunavir (DRV) 150mg Pack of 240 0

3 Darunavir (DRV) 600mg Pack of 60 0

4 Etravarine (ETV) 25mg Pack of 120 0

5 Etravarine (ETV) 100mg Pack of 120 0

6 Etravarine (ETV) 200mg Pack of 60 0

7 Raltegravir (RTG) 25mg Pack of 60 0

8 Raltegravir (RTG) 100mg Pack of 120 0

9 Raltegravir (RTG) 400mg Pack of 60 0

10 Ritonavir (RTV) 100mg Pack of 60 0

11 Saquinavir (SQV) 500mg Pack of 120 0

MEDICINES FOR HEPATITIS B ONLY PATIENTS

1 Tenofovir (TDF) 300mg Pack of 30 0

2 Entecavir 0.5 mg Pack of 30 0

OTHER FORMULATIONS

1 Cotrimoxazole 960mg 1000 0

2 Cotrimoxazole 120mg 1000 0

3 Fluconazole 200mg 28 0

4 Fluconazole oral susp. 35ml 0

5 Fluconazole IV 100ml 0

6 Dapsone 100mg 100 0

SUMMARY: ART PATIENTS PER TREATMENT REGIMEN (Existing and New Enrollments):

TOTAL ADULT ART & e-MTCT PATIENTS Pediatric First Line Patients
No. Existing No. New
(at start of cycle being reported on) (enrolled during
the cycle being 10-<15 Yrs 10-<15 Yrs
1st Line Regimens Regimens 0-<3 Yrs 3-<10 Yrs less than 35kg greater than 35kg
reported on)

TDF/3TC/EFV Existing New Existing New Existing New Existing New

TDF/3TC/NVP ABC/3TC/LPV/r
TDF/3TC/DTG ABC/3TC/AZT

TDF/3TC/AZT ABC/3TC/DTG
AZT/3TC/NVP ABC/3TC/EFV

AZT/3TC/EFV ABC/3TC/NVP
ABC/3TC/NVP AZT/3TC/EFV

ABC/3TC/EFV AZT/3TC/LPV/r
ABC/3TC/DTG AZT/3TC/NVP

TDF/3TC/ATV/r TDF/3TC/EFV
TOTAL ADULT PATIENTS 0 0 TDF/3TC/NVP

0 0 0 0 0 0 0 0
Total Pead 1L

Adult Second Line Patients

 No. New
2nd Line Regimens No. Existing (enrolled during Pediatric Second Line Patients
(at start of cycle being reported on) the cycle being
reported on)
Regimens 0-<3 Yrs 3-<10 Yrs 10-<15 Yrs 10-<15 Yrs
TDF/3TC/ATV/r less than 35kg greater than 35kg
TDF/3TC/LPV/r Existing New Existing New Existing New Existing New
AZT/3TC/ATV/r ABC/3TC/ATV/r
AZT/3TC/LPV/r ABC/3TC/LPV/r

AZT/3TC/DTG ABC/3TC/RAL
TDF/3TC/DTG ABC/3TC/DRV/r

ABC/3TC/ATV/r AZT/3TC/ATV/r

ABC/3TC/LPV/r AZT/3TC/LPV/r
Total Adult 2L Patients 0 0 AZT/3TC/RAL

AZT/3TC/DTG
Adult Third Line Patients TDF/3TC/ATV/r
3rd Line Regimens No. Existing No. New TDF/3TC/LPV/r
(at start of cycle being reported on) (enrolled during
DRV+RTV+RAL the cycle being Total Pead 2L 0 0 0 0 0 0 0 0
reported on)
DRV+RTV+ETV
DRV+RTV+DTG Pediatric Third Line Patients
Regimens 0-<3 Yrs 3-<10 Yrs 10-<15 Yrs 10-<15 Yrs
DRV+RTV+DTG+ETV less than 35kg greater than 35kg
SQV+RTV Existing New Existing New Existing New Existing New
DRV+RTV+ETV+RAL DRV+RTV+RAL

ETV DRV+RTV+ETV
DRV+RTV DRV+RTV+DTG
RAL DRV+RTV+DTG+ETV
Total Adult 3L Patients 0 0 DRV+RTV+ETV+RAL
SQV+RTV
NUMBER OF PATIENTS TREATED WITH FLUCONAZOLE ETV

Adults Children
Condition (< 15 yrs) DRV+RTV
Acute cryptococcal meningitis RAL
Consolidation phase (Cryptococcal meningitis) Total Pead 3L 0 0 0 0 0 0 0 0
Maintainance phase (Cryptococcal meningitis)
Esophageal candidiasis

PATIENTS ON COTRIMOXAZOLE PROPHYLAXIS FACILITY CONTACT INFORMATION

Children
Drug Adults (< 15 yrs)
Cotrimoxazole (Pre-ART and ART) Name Signature:
Dapsone (Pre-ART and ART)

HEPATITIS B ONLY PATIENTS

Children
Drug Adults (< 15 yrs) Designation Phone Number:
Tenofovir 300mg tablets
Entecavir 0.5mg tablets
ARV and E-MTCT Medicines Order Form and Patient Report
Facility Name: Start Date:
District: End Date:
Delivery Zone Date Prepared:

OPENING QUANTITY ART & e-MTCT QUANTITY

BALANCE RECEIVED CONSUMPTION LOSSES / CLOSING BALANCE MONTHS OF REQUIRED FOR
ADJUSTMENTS Days out of stock Adjusted AMC (Physical Count in Stores STOCK ON-HAND CURRENT Notes
Drug Formulation and Strength Basic Unit at start of 2 during 2 Month during 2 Month during 2 month
Month Cycle Cycle Cycle (+/-) = (C*30)/(60-E) + Pharmacy) = G/F PATIENTS
Cycle (≤ 60 days) = 4 * F-G
Closing
balance
validatio
A B C D E F G H I n
ADULT -- RECOMMENDED FORMULATIONS

1 Tenofovir/Lamivudine/Efavirenz (TDF/3TC/EFV) 300mg/300mg/400mg Pack of 30 0

2 Tenofovir/Lamivudine/Efavirenz (TDF/3TC/EFV) 300mg/300mg/400mg Pack of 90 0

3 Tenofovir/Lamivudine/Efavirenz (TDF/3TC/EFV) 300mg/300mg/400mg Pack of 180 0

4 Tenofovir/Lamivudine (TDF/3TC) 300mg/300mg Pack of 30 0

5 Tenofovir/Lamivudine/Dolutegravir (TDF/3TC/DTG) 300mg/300mg/50mg Pack of 30 0

6 Tenofovir/Lamivudine/Dolutegravir (TDF/3TC/DTG) 300mg/300mg/50mg Pack of 90 0

7 Tenofovir/Lamivudine/Dolutegravir (TDF/3TC/DTG) 300mg/300mg/50mg Pack of 180 0

8 Zidovudine /Lamivudine/Nevirapine (AZT/3TC/NVP) 300mg/150mg/200mg Pack of 60 0

9 Zidovudine/Lamivudine (AZT/3TC)300mg/150mg Pack of 60 0

10 Abacavir/Lamivudine (ABC/3TC) 600mg/300mg Pack of 30 0

11 Abacavir/Lamivudine/Dolutegravir (ABC/3TC/DTG) 600mg/300mg/50mg Pack of 30 0

12 Atazanavir/Ritonavir (ATV/r) 300mg/100mg Pack of 30 0

13 Lopinavir/Ritonavir (LPV/r) 200mg/50mg Pack of 120 0

14 Dolutegravir (DTG) 50mg Pack of 30 0

15 Efavirenz (EFV) 600mg Pack of 30 0

16 Nevirapine (NVP) 200mg pack of 60 0

17 Zidovudine (AZT) 300mg Pack of 60 0

PAEDIATRIC -- RECOMMENDED FORMULATIONS

1 Abacavir/Lamivudine (ABC/3TC) 120mg/60mg Pack of 30 0

2 Abacavir/Lamivudine/Lopinavir/Ritonavir (ABC/3TC/LPV/r) 30mg/15mg/40mg/10mg Pack of 120 0

3 Zidovudine/Lamivudine/Nevirapine (AZT/3TC/NVP) 60mg/30mg/50mg Pack of 60 0

4 Zidovudine/Lamivudine (AZT/3TC) 60mg/30mg Pack of 60 0

5 Lopinavir/Ritonavir (LPV/r) 80mg/20ml oral syrup Bottle of 60ml 0

6 Lopinavir/Ritonavir (LVP/r) 40mg/10mg Pellets Pack of 120 0

7 Lopinavir/Ritonavir (LVP/r) 100mg/25mg Pack of 60 0

8 Efavirenz (EFV) 200mg Pack of 90 0

9 Nevirapine (NVP) 50mg Pack of 30 0

10 Dolutegravir (DTG) 10mg Pack of 60 0

11 Abacavir (ABC) 60mg Pack of 60 0

E-MTCT ONLY FORMULATIONS

1 Nevirapine (NVP) 10mg/ml oral susp. 100ml 0

THIRD LINE (3rd) FORMULATIONS

1 Darunavir (DRV) 75mg Pack of 480 0

2 Darunavir (DRV) 150mg Pack of 240 0

3 Darunavir (DRV) 600mg Pack of 60 0

4 Etravarine (ETV) 25mg Pack of 120 0

5 Etravarine (ETV) 100mg Pack of 120 0

6 Etravarine (ETV) 200mg Pack of 60 0

7 Raltegravir (RTG) 25mg Pack of 60 0

8 Raltegravir (RTG) 100mg Pack of 120 0

9 Raltegravir (RTG) 400mg Pack of 60 0

10 Ritonavir (RTV) 100mg Pack of 60 0

11 Saquinavir (SQV) 500mg Pack of 120 0

MEDICINES FOR HEPATITIS B ONLY PATIENTS

1 Tenofovir (TDF) 300mg Pack of 30 0

2 Entecavir 0.5 mg Pack of 30 0

OTHER FORMULATIONS

1 Cotrimoxazole 960mg 1000 0

2 Cotrimoxazole 120mg 1000 0

3 Fluconazole 200mg 28 0

4 Fluconazole oral susp. 35ml 0

5 Fluconazole IV 100ml 0

6 Dapsone 100mg 100 0

SUMMARY: ART PATIENTS PER TREATMENT REGIMEN (Existing and New Enrollments):

TOTAL ADULT ART & e-MTCT PATIENTS Pediatric First Line Patients
No. Existing No. New
(at start of cycle being reported on) (enrolled during
the cycle being 10-<15 Yrs 10-<15 Yrs
1st Line Regimens Regimens 0-<3 Yrs 3-<10 Yrs less than 35kg greater than 35kg
reported on)

TDF/3TC/EFV Existing New Existing New Existing New Existing New

TDF/3TC/NVP ABC/3TC/LPV/r
TDF/3TC/DTG ABC/3TC/AZT

TDF/3TC/AZT ABC/3TC/DTG
AZT/3TC/NVP ABC/3TC/EFV

AZT/3TC/EFV ABC/3TC/NVP
ABC/3TC/NVP AZT/3TC/EFV

ABC/3TC/EFV AZT/3TC/LPV/r
ABC/3TC/DTG AZT/3TC/NVP

TDF/3TC/ATV/r TDF/3TC/EFV
TOTAL ADULT PATIENTS 0 0 TDF/3TC/NVP

0 0 0 0 0 0 0 0
Total Pead 1L

Adult Second Line Patients

 No. New
2nd Line Regimens No. Existing (enrolled during Pediatric Second Line Patients
(at start of cycle being reported on) the cycle being
reported on)
Regimens 0-<3 Yrs 3-<10 Yrs 10-<15 Yrs 10-<15 Yrs
TDF/3TC/ATV/r less than 35kg greater than 35kg
TDF/3TC/LPV/r Existing New Existing New Existing New Existing New
AZT/3TC/ATV/r ABC/3TC/ATV/r
AZT/3TC/LPV/r ABC/3TC/LPV/r

AZT/3TC/DTG ABC/3TC/RAL
TDF/3TC/DTG ABC/3TC/DRV/r

ABC/3TC/ATV/r AZT/3TC/ATV/r

ABC/3TC/LPV/r AZT/3TC/LPV/r
Total Adult 2L Patients 0 0 AZT/3TC/RAL

AZT/3TC/DTG
Adult Third Line Patients TDF/3TC/ATV/r
3rd Line Regimens No. Existing No. New TDF/3TC/LPV/r
(at start of cycle being reported on) (enrolled during
DRV+RTV+RAL the cycle being Total Pead 2L 0 0 0 0 0 0 0 0
reported on)
DRV+RTV+ETV
DRV+RTV+DTG Pediatric Third Line Patients
Regimens 0-<3 Yrs 3-<10 Yrs 10-<15 Yrs 10-<15 Yrs
DRV+RTV+DTG+ETV less than 35kg greater than 35kg
SQV+RTV Existing New Existing New Existing New Existing New
DRV+RTV+ETV+RAL DRV+RTV+RAL

ETV DRV+RTV+ETV
DRV+RTV DRV+RTV+DTG
RAL DRV+RTV+DTG+ETV
Total Adult 3L Patients 0 0 DRV+RTV+ETV+RAL
SQV+RTV
NUMBER OF PATIENTS TREATED WITH FLUCONAZOLE ETV

Adults Children
Condition (< 15 yrs) DRV+RTV
Acute cryptococcal meningitis RAL
Consolidation phase (Cryptococcal meningitis) Total Pead 3L 0 0 0 0 0 0 0 0
Maintainance phase (Cryptococcal meningitis)
Esophageal candidiasis

PATIENTS ON COTRIMOXAZOLE PROPHYLAXIS FACILITY CONTACT INFORMATION

Children
Drug Adults (< 15 yrs)
Cotrimoxazole (Pre-ART and ART) Name Signature:
Dapsone (Pre-ART and ART)

HEPATITIS B ONLY PATIENTS

Children
Drug Adults (< 15 yrs) Designation Phone Number:
Tenofovir 300mg tablets
Entecavir 0.5mg tablets
ARV and E-MTCT Medicines Order Form and Patient Report
Facility Name: Start Date:
District: End Date:
Delivery Zone Date Prepared:

OPENING BALANCE QUANTITY RECEIVED LOSSES / ADJUSTMENTS MONTHS OF QUANTITY

STOCK ON-HAND
REQUIRED FOR CURRENT PATIENTS
at start of 2 during
ART 2&Month
e-MTCTCycle
CONSUMPTION during 2 Month - Cycle
( + /out) of stock during 2 Adjusted CLOSING BALANCE (Physical Count in Stores + Pharmacy)
= G/F = 4 * F-G Notes
Drug Formulation and Strength Basic Unit Month Cycle Days month Cycle
AMC(≤ 60 days)
= (C*30)/(60-E)

A B C D E F G H I Closing balance validation

ADULT -- RECOMMENDED FORMULATIONS

1 Tenofovir/Lamivudine/Efavirenz (TDF/3TC/EFV) 300mg/300mg/400mg Pack of 30 0

2 Tenofovir/Lamivudine/Efavirenz (TDF/3TC/EFV) 300mg/300mg/400mg Pack of 90 0

3 Tenofovir/Lamivudine/Efavirenz (TDF/3TC/EFV) 300mg/300mg/400mg Pack of 180 0

4 Tenofovir/Lamivudine (TDF/3TC) 300mg/300mg Pack of 30 0

5 Tenofovir/Lamivudine/Dolutegravir (TDF/3TC/DTG) 300mg/300mg/50mg Pack of 30 0

6 Tenofovir/Lamivudine/Dolutegravir (TDF/3TC/DTG) 300mg/300mg/50mg Pack of 90 0

7 Tenofovir/Lamivudine/Dolutegravir (TDF/3TC/DTG) 300mg/300mg/50mg Pack of 180 0

8 Zidovudine /Lamivudine/Nevirapine (AZT/3TC/NVP) 300mg/150mg/200mg Pack of 60 0

9 Zidovudine/Lamivudine (AZT/3TC)300mg/150mg Pack of 60 0

10 Abacavir/Lamivudine (ABC/3TC) 600mg/300mg Pack of 30 0

11 Abacavir/Lamivudine/Dolutegravir (ABC/3TC/DTG) 600mg/300mg/50mg Pack of 30 0

12 Atazanavir/Ritonavir (ATV/r) 300mg/100mg Pack of 30 0

13 Lopinavir/Ritonavir (LPV/r) 200mg/50mg Pack of 120 0

14 Dolutegravir (DTG) 50mg Pack of 30 0

15 Efavirenz (EFV) 600mg Pack of 30 0

16 Nevirapine (NVP) 200mg pack of 60 0

17 Zidovudine (AZT) 300mg Pack of 60 0

PAEDIATRIC -- RECOMMENDED FORMULATIONS

1 Abacavir/Lamivudine (ABC/3TC) 120mg/60mg Pack of 30 0

2 Abacavir/Lamivudine/Lopinavir/Ritonavir (ABC/3TC/LPV/r) 30mg/15mg/40mg/10mg Pack of 120 0

3 Zidovudine/Lamivudine/Nevirapine (AZT/3TC/NVP) 60mg/30mg/50mg Pack of 60 0

4 Zidovudine/Lamivudine (AZT/3TC) 60mg/30mg Pack of 60 0

5 Lopinavir/Ritonavir (LPV/r) 80mg/20ml oral syrup Bottle of 60ml 0

6 Lopinavir/Ritonavir (LVP/r) 40mg/10mg Pellets Pack of 120 0

7 Lopinavir/Ritonavir (LVP/r) 100mg/25mg Pack of 60 0

8 Efavirenz (EFV) 200mg Pack of 90 0

9 Nevirapine (NVP) 50mg Pack of 30 0

10 Dolutegravir (DTG) 10mg Pack of 60 0

11 Abacavir (ABC) 60mg Pack of 60 0

E-MTCT ONLY FORMULATIONS

1 Nevirapine (NVP) 10mg/ml oral susp. 100ml 0

THIRD LINE (3rd) FORMULATIONS

1 Darunavir (DRV) 75mg Pack of 480 0

2 Darunavir (DRV) 150mg Pack of 240 0

3 Darunavir (DRV) 600mg Pack of 60 0

4 Etravarine (ETV) 25mg Pack of 120 0

5 Etravarine (ETV) 100mg Pack of 120 0

6 Etravarine (ETV) 200mg Pack of 60 0

7 Raltegravir (RTG) 25mg Pack of 60 0

8 Raltegravir (RTG) 100mg Pack of 120 0

9 Raltegravir (RTG) 400mg Pack of 60 0

10 Ritonavir (RTV) 100mg Pack of 60 0

11 Saquinavir (SQV) 500mg Pack of 120 0

MEDICINES FOR HEPATITIS B ONLY PATIENTS

1 Tenofovir (TDF) 300mg Pack of 30 0

2 Entecavir 0.5 mg Pack of 30 0

OTHER FORMULATIONS

1 Cotrimoxazole 960mg 1000 0

2 Cotrimoxazole 120mg 1000 0

3 Fluconazole 200mg 28 0

4 Fluconazole oral susp. 35ml 0

5 Fluconazole IV 100ml 0

6 Dapsone 100mg 100 0

SUMMARY: ART PATIENTS PER TREATMENT REGIMEN (Existing and New Enrollments):

TOTAL ADULT ART & e-MTCT PATIENTS Pediatric First Line Patients
No. Existing No. New
(at start of cycle being reported
(enrolled
on)
during the cycle being reported on)
10-<15 Yrs 10-<15 Yrs
1st Line Regimens Regimens 0-<3 Yrs 3-<10 Yrs less than 35kg greater than 35kg

TDF/3TC/EFV Existing New Existing New Existing New Existing New

TDF/3TC/NVP ABC/3TC/LPV/r
TDF/3TC/DTG ABC/3TC/AZT

TDF/3TC/AZT ABC/3TC/DTG
AZT/3TC/NVP ABC/3TC/EFV

AZT/3TC/EFV ABC/3TC/NVP
ABC/3TC/NVP AZT/3TC/EFV

ABC/3TC/EFV AZT/3TC/LPV/r
ABC/3TC/DTG AZT/3TC/NVP

TDF/3TC/ATV/r TDF/3TC/EFV
TOTAL ADULT PATIENTS 0 0 TDF/3TC/NVP

0 0 0 0 0 0 0 0
Total Pead 1L

Adult Second Line Patients

 2nd Line Regimens No. Existing No. New Pediatric Second Line Patients
(at start of cycle being reported
(enrolledon)
during the cycle being reported on)

Regimens 0-<3 Yrs 3-<10 Yrs 10-<15 Yrs 10-<15 Yrs

TDF/3TC/ATV/r less than 35kg greater than 35kg
TDF/3TC/LPV/r Existing New Existing New Existing New Existing New
AZT/3TC/ATV/r ABC/3TC/ATV/r
AZT/3TC/LPV/r ABC/3TC/LPV/r

AZT/3TC/DTG ABC/3TC/RAL
TDF/3TC/DTG ABC/3TC/DRV/r

ABC/3TC/ATV/r AZT/3TC/ATV/r

ABC/3TC/LPV/r AZT/3TC/LPV/r
Total Adult 2L Patients 0 0 AZT/3TC/RAL

AZT/3TC/DTG
Adult Third Line Patients TDF/3TC/ATV/r
3rd Line Regimens No. Existing No. New TDF/3TC/LPV/r
(at start of cycle being reported on) (enrolled during
DRV+RTV+RAL the cycle being Total Pead 2L 0 0 0 0 0 0 0 0
reported on)
DRV+RTV+ETV
DRV+RTV+DTG Pediatric Third Line Patients
Regimens 0-<3 Yrs 3-<10 Yrs 10-<15 Yrs 10-<15 Yrs
DRV+RTV+DTG+ETV less than 35kg greater than 35kg
SQV+RTV Existing New Existing New Existing New Existing New
DRV+RTV+ETV+RAL DRV+RTV+RAL

ETV DRV+RTV+ETV
DRV+RTV DRV+RTV+DTG
RAL DRV+RTV+DTG+ETV
Total Adult 3L Patients 0 0 DRV+RTV+ETV+RAL
SQV+RTV
NUMBER OF PATIENTS TREATED WITH FLUCONAZOLE ETV

Adults Children
Condition (< 15 yrs) DRV+RTV
Acute cryptococcal meningitis RAL
Consolidation phase (Cryptococcal meningitis) Total Pead 3L 0 0 0 0 0 0 0 0
Maintainance phase (Cryptococcal meningitis)
Esophageal candidiasis

PATIENTS ON COTRIMOXAZOLE PROPHYLAXIS FACILITY CONTACT INFORMATION

Children
Drug Adults (< 15 yrs)
Cotrimoxazole (Pre-ART and ART) Name Signature:
Dapsone (Pre-ART and ART)

HEPATITIS B ONLY PATIENTS

Children
Drug Adults (< 15 yrs) Designation Phone Number:
Tenofovir 300mg tablets
Entecavir 0.5mg tablets
ARV and E-MTCT Medicines Order Form and Patient Report
Facility Name: Start Date:
District: End Date:
Delivery Zone Date Prepared:

OPENING QUANTITY ART & e-MTCT QUANTITY

BALANCE RECEIVED CONSUMPTION LOSSES / CLOSING BALANCE MONTHS OF REQUIRED FOR
ADJUSTMENTS Days out of stock Adjusted AMC (Physical Count in Stores STOCK ON-HAND CURRENT Notes
Drug Formulation and Strength Basic Unit at start of 2 during 2 Month during 2 Month during 2 month
Month Cycle Cycle Cycle (+/-) = (C*30)/(60-E) + Pharmacy) = G/F PATIENTS
Cycle (≤ 60 days) = 4 * F-G
Closing
balance
validatio
A B C D E F G H I n
ADULT -- RECOMMENDED FORMULATIONS

1 Tenofovir/Lamivudine/Efavirenz (TDF/3TC/EFV) 300mg/300mg/400mg Pack of 30 0

2 Tenofovir/Lamivudine/Efavirenz (TDF/3TC/EFV) 300mg/300mg/400mg Pack of 90 0

3 Tenofovir/Lamivudine/Efavirenz (TDF/3TC/EFV) 300mg/300mg/400mg Pack of 180 0

4 Tenofovir/Lamivudine (TDF/3TC) 300mg/300mg Pack of 30 0

5 Tenofovir/Lamivudine/Dolutegravir (TDF/3TC/DTG) 300mg/300mg/50mg Pack of 30 0

6 Tenofovir/Lamivudine/Dolutegravir (TDF/3TC/DTG) 300mg/300mg/50mg Pack of 90 0

7 Tenofovir/Lamivudine/Dolutegravir (TDF/3TC/DTG) 300mg/300mg/50mg Pack of 180 0

8 Zidovudine /Lamivudine/Nevirapine (AZT/3TC/NVP) 300mg/150mg/200mg Pack of 60 0

9 Zidovudine/Lamivudine (AZT/3TC)300mg/150mg Pack of 60 0

10 Abacavir/Lamivudine (ABC/3TC) 600mg/300mg Pack of 30 0

11 Abacavir/Lamivudine/Dolutegravir (ABC/3TC/DTG) 600mg/300mg/50mg Pack of 30 0

12 Atazanavir/Ritonavir (ATV/r) 300mg/100mg Pack of 30 0

13 Lopinavir/Ritonavir (LPV/r) 200mg/50mg Pack of 120 0

14 Dolutegravir (DTG) 50mg Pack of 30 0

15 Efavirenz (EFV) 600mg Pack of 30 0

16 Nevirapine (NVP) 200mg pack of 60 0

17 Zidovudine (AZT) 300mg Pack of 60 0

PAEDIATRIC -- RECOMMENDED FORMULATIONS

1 Abacavir/Lamivudine (ABC/3TC) 120mg/60mg Pack of 30 0

2 Abacavir/Lamivudine/Lopinavir/Ritonavir (ABC/3TC/LPV/r) 30mg/15mg/40mg/10mg Pack of 120 0

3 Zidovudine/Lamivudine/Nevirapine (AZT/3TC/NVP) 60mg/30mg/50mg Pack of 60 0

4 Zidovudine/Lamivudine (AZT/3TC) 60mg/30mg Pack of 60 0

5 Lopinavir/Ritonavir (LPV/r) 80mg/20ml oral syrup Bottle of 60ml 0

6 Lopinavir/Ritonavir (LVP/r) 40mg/10mg Pellets Pack of 120 0

7 Lopinavir/Ritonavir (LVP/r) 100mg/25mg Pack of 60 0

8 Efavirenz (EFV) 200mg Pack of 90 0

9 Nevirapine (NVP) 50mg Pack of 30 0

10 Dolutegravir (DTG) 10mg Pack of 60 0

11 Abacavir (ABC) 60mg Pack of 60 0

E-MTCT ONLY FORMULATIONS

1 Nevirapine (NVP) 10mg/ml oral susp. 100ml 0

THIRD LINE (3rd) FORMULATIONS

1 Darunavir (DRV) 75mg Pack of 480 0

2 Darunavir (DRV) 150mg Pack of 240 0

3 Darunavir (DRV) 600mg Pack of 60 0

4 Etravarine (ETV) 25mg Pack of 120 0

5 Etravarine (ETV) 100mg Pack of 120 0

6 Etravarine (ETV) 200mg Pack of 60 0

7 Raltegravir (RTG) 25mg Pack of 60 0

8 Raltegravir (RTG) 100mg Pack of 120 0

9 Raltegravir (RTG) 400mg Pack of 60 0

10 Ritonavir (RTV) 100mg Pack of 60 0

11 Saquinavir (SQV) 500mg Pack of 120 0

MEDICINES FOR HEPATITIS B ONLY PATIENTS

1 Tenofovir (TDF) 300mg Pack of 30 0

2 Entecavir 0.5 mg Pack of 30 0

OTHER FORMULATIONS

1 Cotrimoxazole 960mg 1000 0

2 Cotrimoxazole 120mg 1000 0

3 Fluconazole 200mg 28 0

4 Fluconazole oral susp. 35ml 0

5 Fluconazole IV 100ml 0

6 Dapsone 100mg 100 0

SUMMARY: ART PATIENTS PER TREATMENT REGIMEN (Existing and New Enrollments):

TOTAL ADULT ART & e-MTCT PATIENTS Pediatric First Line Patients
No. Existing No. New
(at start of cycle being reported on) (enrolled during
the cycle being 10-<15 Yrs 10-<15 Yrs
1st Line Regimens Regimens 0-<3 Yrs 3-<10 Yrs less than 35kg greater than 35kg
reported on)

TDF/3TC/EFV Existing New Existing New Existing New Existing New

TDF/3TC/NVP ABC/3TC/LPV/r
TDF/3TC/DTG ABC/3TC/AZT

TDF/3TC/AZT ABC/3TC/DTG
AZT/3TC/NVP ABC/3TC/EFV

AZT/3TC/EFV ABC/3TC/NVP
ABC/3TC/NVP AZT/3TC/EFV

ABC/3TC/EFV AZT/3TC/LPV/r
ABC/3TC/DTG AZT/3TC/NVP

TDF/3TC/ATV/r TDF/3TC/EFV
TOTAL ADULT PATIENTS 0 0 TDF/3TC/NVP

0 0 0 0 0 0 0 0
Total Pead 1L

Adult Second Line Patients

 No. New
2nd Line Regimens No. Existing (enrolled during Pediatric Second Line Patients
(at start of cycle being reported on) the cycle being
reported on)
Regimens 0-<3 Yrs 3-<10 Yrs 10-<15 Yrs 10-<15 Yrs
TDF/3TC/ATV/r less than 35kg greater than 35kg
TDF/3TC/LPV/r Existing New Existing New Existing New Existing New
AZT/3TC/ATV/r ABC/3TC/ATV/r
AZT/3TC/LPV/r ABC/3TC/LPV/r

AZT/3TC/DTG ABC/3TC/RAL
TDF/3TC/DTG ABC/3TC/DRV/r

ABC/3TC/ATV/r AZT/3TC/ATV/r

ABC/3TC/LPV/r AZT/3TC/LPV/r
Total Adult 2L Patients 0 0 AZT/3TC/RAL

AZT/3TC/DTG
Adult Third Line Patients TDF/3TC/ATV/r
3rd Line Regimens No. Existing No. New TDF/3TC/LPV/r
(at start of cycle being reported on) (enrolled during
DRV+RTV+RAL the cycle being Total Pead 2L 0 0 0 0 0 0 0 0
reported on)
DRV+RTV+ETV
DRV+RTV+DTG Pediatric Third Line Patients
Regimens 0-<3 Yrs 3-<10 Yrs 10-<15 Yrs 10-<15 Yrs
DRV+RTV+DTG+ETV less than 35kg greater than 35kg
SQV+RTV Existing New Existing New Existing New Existing New
DRV+RTV+ETV+RAL DRV+RTV+RAL

ETV DRV+RTV+ETV
DRV+RTV DRV+RTV+DTG
RAL DRV+RTV+DTG+ETV
Total Adult 3L Patients 0 0 DRV+RTV+ETV+RAL
SQV+RTV
NUMBER OF PATIENTS TREATED WITH FLUCONAZOLE ETV

Adults Children
Condition (< 15 yrs) DRV+RTV
Acute cryptococcal meningitis RAL
Consolidation phase (Cryptococcal meningitis) Total Pead 3L 0 0 0 0 0 0 0 0
Maintainance phase (Cryptococcal meningitis)
Esophageal candidiasis

PATIENTS ON COTRIMOXAZOLE PROPHYLAXIS FACILITY CONTACT INFORMATION

Children
Drug Adults (< 15 yrs)
Cotrimoxazole (Pre-ART and ART) Name Signature:
Dapsone (Pre-ART and ART)

HEPATITIS B ONLY PATIENTS

Children
Drug Adults (< 15 yrs) Designation Phone Number:
Tenofovir 300mg tablets
Entecavir 0.5mg tablets
ARV and E-MTCT Medicines Order Form and Patient Report
Facility Name: Start Date:
District: End Date:
Delivery Zone Date Prepared:

OPENING QUANTITY ART & e-MTCT QUANTITY

BALANCE RECEIVED CONSUMPTION LOSSES / CLOSING BALANCE MONTHS OF REQUIRED FOR
ADJUSTMENTS Days out of stock Adjusted AMC (Physical Count in Stores STOCK ON-HAND CURRENT Notes
Drug Formulation and Strength Basic Unit at start of 2 during 2 Month during 2 Month during 2 month
Month Cycle Cycle Cycle (+/-) = (C*30)/(60-E) + Pharmacy) = G/F PATIENTS
Cycle (≤ 60 days) = 4 * F-G
Closing
balance
validatio
A B C D E F G H I n
ADULT -- RECOMMENDED FORMULATIONS

1 Tenofovir/Lamivudine/Efavirenz (TDF/3TC/EFV) 300mg/300mg/400mg Pack of 30 0

2 Tenofovir/Lamivudine/Efavirenz (TDF/3TC/EFV) 300mg/300mg/400mg Pack of 90 0

3 Tenofovir/Lamivudine/Efavirenz (TDF/3TC/EFV) 300mg/300mg/400mg Pack of 180 0

4 Tenofovir/Lamivudine (TDF/3TC) 300mg/300mg Pack of 30 0

5 Tenofovir/Lamivudine/Dolutegravir (TDF/3TC/DTG) 300mg/300mg/50mg Pack of 30 0

6 Tenofovir/Lamivudine/Dolutegravir (TDF/3TC/DTG) 300mg/300mg/50mg Pack of 90 0

7 Tenofovir/Lamivudine/Dolutegravir (TDF/3TC/DTG) 300mg/300mg/50mg Pack of 180 0

8 Zidovudine /Lamivudine/Nevirapine (AZT/3TC/NVP) 300mg/150mg/200mg Pack of 60 0

9 Zidovudine/Lamivudine (AZT/3TC)300mg/150mg Pack of 60 0

10 Abacavir/Lamivudine (ABC/3TC) 600mg/300mg Pack of 30 0

11 Abacavir/Lamivudine/Dolutegravir (ABC/3TC/DTG) 600mg/300mg/50mg Pack of 30 0

12 Atazanavir/Ritonavir (ATV/r) 300mg/100mg Pack of 30 0

13 Lopinavir/Ritonavir (LPV/r) 200mg/50mg Pack of 120 0

14 Dolutegravir (DTG) 50mg Pack of 30 0

15 Efavirenz (EFV) 600mg Pack of 30 0

16 Nevirapine (NVP) 200mg pack of 60 0

17 Zidovudine (AZT) 300mg Pack of 60 0

PAEDIATRIC -- RECOMMENDED FORMULATIONS

1 Abacavir/Lamivudine (ABC/3TC) 120mg/60mg Pack of 30 0

2 Abacavir/Lamivudine/Lopinavir/Ritonavir (ABC/3TC/LPV/r) 30mg/15mg/40mg/10mg Pack of 120 0

3 Zidovudine/Lamivudine/Nevirapine (AZT/3TC/NVP) 60mg/30mg/50mg Pack of 60 0

4 Zidovudine/Lamivudine (AZT/3TC) 60mg/30mg Pack of 60 0

5 Lopinavir/Ritonavir (LPV/r) 80mg/20ml oral syrup Bottle of 60ml 0

6 Lopinavir/Ritonavir (LVP/r) 40mg/10mg Pellets Pack of 120 0

7 Lopinavir/Ritonavir (LVP/r) 100mg/25mg Pack of 60 0

8 Efavirenz (EFV) 200mg Pack of 90 0

9 Nevirapine (NVP) 50mg Pack of 30 0

10 Dolutegravir (DTG) 10mg Pack of 60 0

11 Abacavir (ABC) 60mg Pack of 60 0

E-MTCT ONLY FORMULATIONS

1 Nevirapine (NVP) 10mg/ml oral susp. 100ml 0

THIRD LINE (3rd) FORMULATIONS

1 Darunavir (DRV) 75mg Pack of 480 0

2 Darunavir (DRV) 150mg Pack of 240 0

3 Darunavir (DRV) 600mg Pack of 60 0

4 Etravarine (ETV) 25mg Pack of 120 0

5 Etravarine (ETV) 100mg Pack of 120 0

6 Etravarine (ETV) 200mg Pack of 60 0

7 Raltegravir (RTG) 25mg Pack of 60 0

8 Raltegravir (RTG) 100mg Pack of 120 0

9 Raltegravir (RTG) 400mg Pack of 60 0

10 Ritonavir (RTV) 100mg Pack of 60 0

11 Saquinavir (SQV) 500mg Pack of 120 0

MEDICINES FOR HEPATITIS B ONLY PATIENTS

1 Tenofovir (TDF) 300mg Pack of 30 0

2 Entecavir 0.5 mg Pack of 30 0

OTHER FORMULATIONS

1 Cotrimoxazole 960mg 1000 0

2 Cotrimoxazole 120mg 1000 0

3 Fluconazole 200mg 28 0

4 Fluconazole oral susp. 35ml 0

5 Fluconazole IV 100ml 0

6 Dapsone 100mg 100 0

SUMMARY: ART PATIENTS PER TREATMENT REGIMEN (Existing and New Enrollments):

TOTAL ADULT ART & e-MTCT PATIENTS Pediatric First Line Patients
No. Existing No. New
(at start of cycle being reported on) (enrolled during
the cycle being 10-<15 Yrs 10-<15 Yrs
1st Line Regimens Regimens 0-<3 Yrs 3-<10 Yrs less than 35kg greater than 35kg
reported on)

TDF/3TC/EFV Existing New Existing New Existing New Existing New

TDF/3TC/NVP ABC/3TC/LPV/r
TDF/3TC/DTG ABC/3TC/AZT

TDF/3TC/AZT ABC/3TC/DTG
AZT/3TC/NVP ABC/3TC/EFV

AZT/3TC/EFV ABC/3TC/NVP
ABC/3TC/NVP AZT/3TC/EFV

ABC/3TC/EFV AZT/3TC/LPV/r
ABC/3TC/DTG AZT/3TC/NVP

TDF/3TC/ATV/r TDF/3TC/EFV
TOTAL ADULT PATIENTS 0 0 TDF/3TC/NVP

0 0 0 0 0 0 0 0
Total Pead 1L

Adult Second Line Patients

 No. New
2nd Line Regimens No. Existing (enrolled during Pediatric Second Line Patients
(at start of cycle being reported on) the cycle being
reported on)
Regimens 0-<3 Yrs 3-<10 Yrs 10-<15 Yrs 10-<15 Yrs
TDF/3TC/ATV/r less than 35kg greater than 35kg
TDF/3TC/LPV/r Existing New Existing New Existing New Existing New
AZT/3TC/ATV/r ABC/3TC/ATV/r
AZT/3TC/LPV/r ABC/3TC/LPV/r

AZT/3TC/DTG ABC/3TC/RAL
TDF/3TC/DTG ABC/3TC/DRV/r

ABC/3TC/ATV/r AZT/3TC/ATV/r

ABC/3TC/LPV/r AZT/3TC/LPV/r
Total Adult 2L Patients 0 0 AZT/3TC/RAL

AZT/3TC/DTG
Adult Third Line Patients TDF/3TC/ATV/r
3rd Line Regimens No. Existing No. New TDF/3TC/LPV/r
(at start of cycle being reported on) (enrolled during
DRV+RTV+RAL the cycle being Total Pead 2L 0 0 0 0 0 0 0 0
reported on)
DRV+RTV+ETV
DRV+RTV+DTG Pediatric Third Line Patients
Regimens 0-<3 Yrs 3-<10 Yrs 10-<15 Yrs 10-<15 Yrs
DRV+RTV+DTG+ETV less than 35kg greater than 35kg
SQV+RTV Existing New Existing New Existing New Existing New
DRV+RTV+ETV+RAL DRV+RTV+RAL

ETV DRV+RTV+ETV
DRV+RTV DRV+RTV+DTG
RAL DRV+RTV+DTG+ETV
Total Adult 3L Patients 0 0 DRV+RTV+ETV+RAL
SQV+RTV
NUMBER OF PATIENTS TREATED WITH FLUCONAZOLE ETV

Adults Children
Condition (< 15 yrs) DRV+RTV
Acute cryptococcal meningitis RAL
Consolidation phase (Cryptococcal meningitis) Total Pead 3L 0 0 0 0 0 0 0 0
Maintainance phase (Cryptococcal meningitis)
Esophageal candidiasis

PATIENTS ON COTRIMOXAZOLE PROPHYLAXIS FACILITY CONTACT INFORMATION

Children
Drug Adults (< 15 yrs)
Cotrimoxazole (Pre-ART and ART) Name Signature:
Dapsone (Pre-ART and ART)

HEPATITIS B ONLY PATIENTS

Children
Drug Adults (< 15 yrs) Designation Phone Number:
Tenofovir 300mg tablets
Entecavir 0.5mg tablets