HIV Positive Pregnant or breastfeeing

a. Date of 1st contact b. Name of Pregnant adolescent or

S/No c. DOB (DD/MM/YYYY) d. Age [Populate in years]
(MM/YY) breastfeeding Woman
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itive Pregnant or breastfeeing Adolescent Details
g. Identity of the Client person? h. OVC/Caregiver i. CPIMS ID of the
e. CCC Number f. Link Facility
[[1] OVC [2] Caregiver] phone contact adolescent
 k. Attended Latest Clinic in First l. Attended Latest Clinic in Second m. Attended Latest Clinic in Third ANC/PMTCT Clinic Att
j. CPIMS ID of the
Trimester/At First Contact? (0-14 Trimester/At First Contact? (15-27 Trimester/At First Contact? (>27
Caregiver
Weeks Gestation) Weeks Gestation) Weeks Gestation)
 Pregna
ANC/PMTCT
n. Latest Clinic Attendance
Viral Load within 6 Months [[1]& Place of delivery
o. Referrals Made: [[1] Missed Appointment [2]
Yes [2] No [3] NA]?; Result > 50 copies [[1] p. Referral(s) completed & Facility
Adherence Counselling [3] Other, specify]]
Yes [2] No [3] NA].
 Pregnant HIV Positive Adolescents & Breast feeding Mothers MONTH
s. Viral load Post natal
q. Date of delivery r. Post natal visit within 6 weeks? [[1]
Date & Result ([1] <50 copies/m [2] 50+
Place of delivery [[1] Facility [2] Home] Yes [2] No, & Date]
copies/ml)
ding Mothers MONTHLY TRACKER [TO BE MAINTAINED BY CASE WORKER
Post natal follow up @ 6 weeks
t. Referrals Made: [[1] Missed Appointment [2] Adherence v. Disclosure done to family
u. Referral(s) completed & Facility
Counselling [3] Family Planning [4] Other, specify]] member [[1] Yes [2] No [3] NA]
Y CASE WORKER]
x. Viral load Post[2]
y. Referrals Made: [[1] Missed Appointment natal follow up @ 6 months
w. Remarks Date & Result ([1] <50 copies/m [2] Adherence Counselling [3] Family Planning [4] Other,
50+ copies/ml) specify]]
Post natal follow up @ 6 months ac. Viral load
aa. Disclosure done to family
z. Referral(s) completed & Facility ab. Remarks Date & Result ([1] <50 copies/m [2] 50+
member [[1] Yes [2] No [3] NA]]
copies/ml)
 Post natal
ad. Referrals Made: [[1] Missed follow up @ 12 months
Appointment
ae. Referral(s) completed & af. Disclosure done to family
[2] Adherence Counselling [3] Family Planning ag. Remarks
Facility member [[1] Yes [2] No [3] NA]]
[4] Other, specify]]
 ah. Viral load Post
ai. Referrals Made: Referrals Made: [[1] natal follow up @ 18months
Missed
aj. Referral(s) completed &
Date & Result ([1] <50 copies/m [2] Appointment [2] Adherence Counselling [3] Family
Facility
50+ copies/ml) Planning [4] Other, specify]]
hs
ak. Disclosure done to family
al. Remarks
member [[1] Yes [2] No [3] NA]]
 HIV Positive Pregnant Adolescents and BF Mothers Tracker
This tool is to be used for monitoring and follow up of Pregnant adolescents & Breastfeeding mothers and will be
maintained by the case worker.
Indicator
HIV POSITIVE PREGNANT OR BREASTFEEING ADOLESCENT DETAILS
S/N.O
a. Date of 1st Contact (MM/YY)

b. Name of Pregnant adolescent or breastfeeding Woman

c. Date of Birth (D.O.B)
d. Age (Populate in Years)
e. CCC Number
f. Link Facility

g. Identity of Pregnant Client

h. Client Phone Number/Contact
i. CPIMS ID of Adolescent (Pregnant or Breastfeeding)
j CPIMS ID of Caregiver
ANC/PMTCT
Attended Clinic
Latest Attendance
Clinic & Place of
in First Trimester/At delivery
First Contact? (0-
k. 14 WeeksLatest
Attended Gestation)
Clinic in Second Trimester/At First Contact?
l. (15-27
AttendedWeeks
LatestGestation)
Clinic in Third Trimester/At First Contact?
m. (>27 Weeks Gestation)
Latest Viral Load within 6 Months (Y/N/NA)?, Result > 50
n. copies
o. Date of delivery & Place of delivery
Post-Natal Follow Up
q. Post natal
Post natal follow
visit within
up @6 6weeks?
weeks/(Yes/No/NA,
6 months/ 12&months/
Date) 18
months
s, x, ac, ah. Viral load Date & Result
t, y, ad, ay. Referrals made
u, z, ae, aj. Referral(s) completed & Facility
v, aa, af, ak. Disclosure done to family member
w, ab, ag, al. Remarks
Adolescents and
up of Pregnant adolescents BF Mothers
& Breastfeeding mothers andTracker
will be

Description Data Sources

ADOLESCENT DETAILS
Serial number
case worker had contact with the client. Enter the Month and Year NA
only in the format MM/YY, e.g. 11/23 for November 2023 Follow up form

Enter Name of Client as appears in the Line List Register. The case
worker should confirm the name of the client from the ANC booklet
or the mother-baby booklet at first visit and ensure the names
coincide in
appears with
thethose recorded
line list in Also
register. the line list. the DOB from the
confirm Follow up form
ANC/Mother-Baby Booklet during first home visit Follow up form
Enter the CCC
Enter the Age ofnumber
the client as at thein
as appears date
the of first
line listcontact in up
& follow years
form. Follow up form
The CCC
This is theNumber shouldthe
facility where beclient
recorded/entered in prescribed
is either attending ANC/PNC format Follow up form
clinic. Follow up form

[1] OVCworks
number [2] Caregiver
and agree on with the client on the best time to call
wherethe
Enter necessary
CPIMS IDduring follow upin the Line List & follow up form
as captured Follow up form
and in the prescribed format---
Enter the CPIMS ID as captured check
in theguideline
Line List & follow up form Follow up form
and in the prescribed format--- check guideline Follow up form
ry first trimester (0-14 weeks gestation) ([1] Yes [2] No [3] NA). NA
response
second is applicable
trimester (15-27toweeks
PNC clients at first
gestation) ([1]contact
Yes [2] No [3] NA). Mother and Child Handbook
NA
first trimester (>27 weeks gestation) ([1] Yes [2] contact
response is applicable to PNC clients at first No [3] NA). NA Mother and Child Handbook
response is applicable to PNC clients at first contact
>50 copies. Provision has been given for upto 2 viral load events Mother and Child Handbook
within the period
of delivery of pregnancy
[1] Facility [2] Home. This is only applicable to client BF Mother and Child Handbook
mothers attending PNC Mother and Child Handbook
within 6 weeks ([1] Yes [2] No [3] NA) and the date if Yes. Record
NA if ANC client Mother and Child Handbook
Enter the Viral Load Date and Result at post natal follow up @ 6
weeks/
the 6 months/
findings of the 12
casemonths/
worker18 months
during routine home visit. Some of Mother and Child Handbook
referrals that can be categorized under 'Other'
Yes [2] No [3] NA) and the health facility. are NA
Record Disclosure
if no referrals Follow up form
were made
[2] No [3] NA). If disclosure was done in the subsequent follow up Follow up form
period,
Record indicate the proceeding
any remarks periodswithin
where applicable as NAeach follow up Follow up form
instance Follow up form
 HIV EXPOSED INFANTS MONTHLY TRACKER [TO BE MAINTAINED BY CASE WORKER]
HEI Biodata/details Caregiver biodata/details HEI Follow up (At 6 weeks/ first contact) HEI Follow up (At 6 months ) HEI Follow up (At 12 months) HEI Follow up (At 18 months) OVC Outcomes Clinical Outcomes
h. Relationship of Caregiver to
k. Caregiver HIV status ([1] Positive ab. Referrals Made [[1] Immunization [2] aj. Referrals Made [[1] Immunization [2] av. [1] Negative and Exited from Follow up [2] HIV aw. Remarks
c. Age [Populate in g. Name of Caregiver for the OVC OVC ([1] Biological Mother [2] l. If Pos, Caregiver on ART [[1] m. Health Facilty for Caregiver p. Age of infant q. Immunization? ([1] On Ttrack r. Growth monitoring? [[1] s. EID testing? ([1] Done [2], Not t. Referrals Made ([1] Immunization [2] Growth u. Referral(s) Completed [[1] Yes, [2] x. Age of infant y. Immunization? [[1] On Track z. Growth monitoring? [[1] aa. EID testing? [[1] ac. Referral(s) Completed [[1] af. Age of infant ag. Immunization? [[1] On ah. Growth monitoring? [[1] ai. EID testing? [[1] ak. Referral(s) Completed [[1] an. Age of infant ao. Immunization? [[1] On ap. Growth monitoring? [[1] aq. EID testing? [[1] Done, ar. Referrals Made [[1] Immunization [2] Growth as. Referral(s) Completed [[1] Yes, [2] au. Outcomes [[1] Graduated [2] Left at Will [3] Relocated [4]
S/No a. Name of OVC/HEI b. Date of Birth d. OVC CPMIS ID e. Link Facility Name f. HEI Unique ID Number i. Caregiver contacts (Phone) j. Caregiver CPIMS ID ONLY, otherwise [2] Negative/ [3] n. CCC number for Caregiver o. Date of visit v. Remarks w. Date of visit Growth Monitoring [3] EID Testing [4] ad. Remarks ae. Date of visit Growth Monitoring [3] EID Testing [4] al. Remarks am. Date of visit at. Remarks Positive [3] HIV Positive and Started on ART [4]
months] as registered in CPIMS Biological Father [3] Other Yes, [2] No] (Positive and on ART caregiver) weeks/first contact [2] Not on Track) Done, [2] Not Done] Done) Monitoring [3] EID Testing [4] Other, specify) No [3] NA] and Facility months [2] Not on Track] Done, [2] Not Done] Done, [2] Not Done] Yes, [2] No [3] NA] and Facility months Track [2] Not on Track] Done, [2] Not Done] Done, [2] Not Done] Yes, [2] No [3] NA] and Facility months Track [2] Not on Track] Done, [2] Not Done] [2] Not Done] Monitoring [3] EID Testing [4] Other, specify] No [3] NA] and Facility Transferred [5] Died]
Unknown) Other, specify] Other, specify] LTFU [5] Transferred Out [6] Died
Caregiver, specify)

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 HIV EXPOSED INFANTS MONTHLY TRACKER
This tool is to be used for monitoring and follow up of HEI OVCs and will be maintained by the case worker.
Indicator Description
HEI BIODATA/DETAILS line list register as well and inform case manager in case there
a. Name of OVC/HEI are discrepancies
appears for correction.
in the Mother-Baby Booklet & follow up form during first
b. Date of Birth (DOB) home visit
months from date of birth recorded in mother-baby booklet &
c. Age (Populate in Months) follow
Enter theup form
CPIMS ID/ Number as captured in the Line List & follow
d. OVC CPMIS ID/ Number up form and
caregiver attends in thePNCprescribed format---ischeck
or if caregiver guideline
not biological mother,
e. Link Facility Name other facility
properly can beasapplicable
recorded appears in the medical records at the link
f. HEI
Name Unique ID Number
of Caregiver for the OVC as registered in facility
This is the name of the caregiver of the OVC as registered in
g. CPIMS CPIMS.
[1] Biological Mother [2] Biological Father [3] Other
h. Relationship of Caregiver to OVC Caregiver,
is not theirs specify
(partner/relative/friend etc). Confirm if phone number
i. Caregiver contacts (Phone) is reachable
Enter the Caregiver CPIMS ID (Column j of as captured in the
j. Caregiver CPIMS ID Line List andONLY,
[1] Positive in the prescribed
otherwise [2]format--- refer[3]
Negative/ to guideline
Unknown are
k. Caregiver HIV status applicable
Indicate whether caregiver (if positive), regardless of caregiver
l. Health Facilty for Caregiver (Positive and on ART relationship,
If HIV Positive, Caregiver on ART? Indicate health is on ARTwhere
facility [1] Yes,
theor not [2] No
caregiver receives HIV care and
m. caregiver) treatment
up to confirm services
at facility with case manager. CCC number should
n. CCC number for Caregiver be recorded in format prescribed
HEI Follow up (At 6 weeks/ first contact/ 6 months/ Date12ofmonths/
home visit 18 months)
that falls on the HEI follow up time. Record
o, w, ae, am. Date of visit
Age of infant weeks/first contact or months (if at 6 date in the format DD/MM/YYYY
p, x, af, an. months or beyond) Record
Track. Ifage notof onHEI at date
track, caseofworker
home needs
visit to take appropriate
q, y, ag, ao. Immunization? action according to SOP
If not on track, case worker needs to take appropriate action
r, z, ah, ap. Growth monitoring? according
on track, case to SOPworker needs to take appropriate action according
s, aa, ai, aq. EID testing? to SOP
[1] Immunization [2] Growth Monitoring [3] EID Testing [4]
t, ab, aj, ar. List Referrals Made Other,
[1] Yesspecify
[2] No [3] NA. Indicate NA if previous follow up period
u, ac, ak, as. Referral(s) Completed and Facility outcome is Died/Relocation/Left at Will
v, ad, al, at. Remarks General remarks
OUTCOMES Died. The case worker should ensure that the HEI clinical and
au. OVC Outcomes OVC
[6] outcomes
Died. The case are worker
well aligned
should ensure that the HEI clinical and
av. Clinical Outcomes OVC outcomes are well aligned
aw. Remarks General remarks
Data Sources

Follow up form
Follow up form
Follow up form
Follow up form
Follow up form
Follow up form
Follow up form
Follow up form
Follow up form
Follow up form
Follow up form
Follow up form
Follow up form
Follow up form

Mother and Child handbook

Mother and Child handbook
Follow up form
Follow up form
Follow up form
Follow up form
Follow up form
Follow up form

Follow up form
Follow up form
Follow up form