Enhanced Perinatal Surveillance

Attachment 3(f)
Adult and Pediatric HIV/AIDS Confidential Case Reports
for National HIV/AIDS Surveillance OMB No. 0920-0573

Supplemental Surveillance Activity 3:
Enhanced Perinatal Surveillance (EPS) Data Collection Form

1

Form Approved
OMB No. 0920-0573
Expiration Date XX/XX/20XX

Adult and Pediatric HIV/AIDS Confidential Case Reports
for National HIV/AIDS Surveillance
Enhanced Perinatal Surveillance (EPS) Data Collection Form
Public reporting burden of this collection of information is
estimated to average 60 minutes per response, including the time
for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and
reviewing the collection of information. An agency may not
conduct or sponsor, and a person is not required to respond to a
collection of information unless it displays a currently valid
OMB control number. Send comments regarding this burden estimate
or any other aspect of this collection of information, including
suggestions for reducing this burden to CDC/ATSDR Reports
Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta,
Georgia 30333; Attn: OMB-PRA (0920-0573)

2

Infant State No. ____________________________

U.S. Department of Health
& Human Services
Centers for Disease Control
and Prevention

New

Form Approved OMB No. 0920-0573 Exp. Date XX/XX/20XX



Updated

Enhanced Perinatal Surveillance (EPS)

Initials of person completing the form (Print legibly.)



Information complete for analysis?

 Yes  No

Date form completed (eg. abstraction concluded)

Date form received by main facility

Date case was reported

__ __/__ __/__ __ __ __ (mm/dd/yyyy)
How was the infant first identified?

__ __/__ __/__ __ __ __ (mm/dd/yyyy)

__ __/__ __/__ __ __ __ (mm/dd/yyyy)

 Routine case reporting—pediatric report
 Routine case reporting—maternal report
 Birth registry match

 Active case finding for enhanced perinatal surveillance
 Laboratory reporting
 Other than routine surveillance activities (Specify.)

If information on the mother is not available, was the child adopted, in foster care, or abandoned?

 Yes  No  Not applicable
1. Records abstracted (Required)
(1 = Abstracted, 2 = Attempted—record not available, 3 = Not abstracted, 4 = Attempted—will try again)
_____ Prenatal care records

_____ Pediatric medical records (non-HIV clinic or provider)

_____ Maternal HIV clinic records

_____ Birth certificate

_____ Labor and delivery records

_____ Death certificate

_____ Pediatric birth records

_____ Health department records

_____ Pediatric HIV medical records

_____ Other (Specify.) ________________________________________________________

Demographic Information
2. Infant
Reporting state (Required)

City No.

Date of birth (Required)
__ __/__ __/__ __ __ __ (mm/dd/yyyy)

State No. (Required)

Soundex code

Sex at birth

M F

Date of death
__ __/__ __/__ __ __ __ (mm/dd/yyyy)

3. Mother
Reporting state

City No.

Date of birth
__ __/__ __/__ __ __ __ (mm/dd/yyyy)

State No.

Soundex code

Date of death
__ __/__ __/__ __ __ __ (mm/dd/yyyy)

4. Mother’s country of birth

4a. If mother’s country of birth is not specified, list continent of birth if known.

5. Mother's Hispanic ethnicity

6. Mother's race (Mark all that apply.)

 Yes
 No
 Unknown
7. Marital status (at time of delivery)

 Single

 American Indian/Alaska Native  Hawaiian/Other Pacific Islander
 Asian
 White
 Black/African American
 Unknown
 Other (Specify.)____________________________________________________
 Divorced  Married  Separated  Widowed  Unknown

This report to the Centers for Disease Control and Prevention (CDC) is authorized by law (Sections 304 and 306 of the Public Health Service Act, 42 USC 242b and 242k). Response in this case is voluntary for federal
government purposes, but may be mandatory under state and local statutes. Your cooperation is necessary for the understanding and control of HIV/AIDS. Information in CDC’s HIV/AIDS surveillance system that would
permit identification of any individual on whom a record is maintained is collected with a guarantee that it will be held in confidence, will be used only for the purposes stated in the assurance on file at the local health
department, and will not otherwise be disclosed or released without the consent of the individual in accordance with Section 308(d) of the Public Health Service Act (42 USC 242m).
Public reporting burden of this collection of information is estimated to average 60 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data
needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB
control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR, Project Clearance Officer, 1600 Clifton
Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0573). Do not send completed form to this address.

06/19/2009

Page 1 of 8

Infant State No. ____________________________
8. Mother's HIV risk factor (Mark all that apply.)

 Injection drug use








Heterosexual contact with

 injection drug user
 bisexual male
 male with hemophilia with documented HIV
 transfusion recipient with documented HIV infection
 transplant recipient with documented HIV infection
 HIV-infected male, risk factor not specified

Hemophilia with documented HIV
Receipt of transfusion
Receipt of transplant (tissue/organ or artificial insemination
Perinatal exposure (i.e. mother was perinatally infected)
Unknown
Other documented risk (Discuss with the NRR coordinator in your state.)
If Other, specify ______________________________________

Prenatal Care
9. Did mother receive any prenatal care for this pregnancy?

10. Date of first prenatal care visit

 Yes  No (Go to 15.)  Not documented (Go to 15.)  Unknown

__ __/__ __/__ __ __ __ (mm/dd/yyyy)

11. Month of pregnancy during which prenatal care began

12. Date of last prenatal care visit before delivery

_______ (mos) (99 = unknown) or _______ (in weeks if month is not noted in chart)

__ __/__ __/__ __ __ __ (mm/dd/yyyy)

13. Number of prenatal care visits __________ (99 = unknown)
14. In what type of facility was prenatal care primarily delivered? (Check only one box.)

 OB/GYN clinic
 Adult HIV specialty clinic
 HMO clinic (for prenatal care)

 Private care (OB/GYN, midwife)
 Correctional facility
 ACTG site

 Other (Specify.) ______________________________
 Not documented
 Unknown

15. Was the mother screened for any of the following during pregnancy?
(Check test performed before birth, but closest to date of delivery or admission to labor and delivery.)
Yes
Group B strep
Hepatitis B (HBsAg)
Rubella
Syphilis






Date (mm/dd/yyyy)

__ __/__ __/__ __ __ __
__ __/__ __/__ __ __ __
__ __/__ __/__ __ __ __
__ __/__ __/__ __ __ __

No

Not documented











Record not available Unknown











16. Diagnosis (for the mother) of the following conditions during this pregnancy or at the time of labor and delivery
(See Instructions for Data Abstraction for definitions.)
Yes
Bacterial vaginosis
Chlamydia trachomatis infection
Genital herpes
Gonorrhea
Group B strep
Hepatitis B (HbsAg+)
Hepatitis C
PID
Syphilis
Trichomoniasis












Date of diagnosis
(mm/dd/yyyy)

__ __/__ __/__ __ __ __
__ __/__ __/__ __ __ __
__ __/__ __/__ __ __ __
__ __/__ __/__ __ __ __
__ __/_ __/__ __ __ __
__ __/__ __/__ __ __ __
__ __/__ __/__ __ __ __
__ __/__ __/__ __ __ __
__ __/__ __/__ __ __ __
__ __/__ __/__ __ __ __

No












Not documented Record not available Unknown


































17. Mother's reproductive history
___________ No. of previous pregnancies

_________ No. of previous miscarriages or stillbirths

___________ No. of previous live births

_________ No. of previous induced abortions or ______ Total No. of previous abortions

06/19/2009

Page 2 of 8

Infant State No. ____________________________
18. Complete the chart for all siblings.
Date of birth
(mm/dd/yyyy)

Age
(yrs: mos as of mm/yyyy)

HIV serostatus
(See list.)

State No.

City No.

Sib 1

__ __/__ __/__ __ __ __

___:___ as of __ __/__ __ __ __

_______________

_____________________

_______________________

Sib 2

__ __/__ __/__ __ __ __

___:___ as of __ __/__ __ __ __

_______________

_____________________

_______________________

Sib 3

__ __/__ __/__ __ __ __

___:___ as of __ __/__ __ __ __

_______________

_____________________

_______________________

Sib 4

__ __/__ __/__ __ __ __

___:___ as of __ __/__ __ __ __

_______________

_____________________

_______________________

Sib 5

__ __/__ __/__ __ __ __

___:___ as of __ __/__ __ __ __

_______________

_____________________

_______________________

Sib 6

__ __/__ __/__ __ __ __

___:___ as of __ __/__ __ __ __

_______________

_____________________

_______________________

HIV serostatus: 1 = Infected, 2 = Not infected, 3 = Indeterminate, 9 = Not documented U=Unknown

Substance Use
19. Was substance use during pregnancy noted in the medical or social work records?

 Yes  No (Go to 20.)  Record not available (Go to 20.)

 Unknown

19a. If yes, indicate which substances were used during pregnancy. (Check all that apply.)

 Alcohol
 Amphetamines
 Barbiturates
 Benzodiazepines

 Cocaine
 Crack cocaine
 Hallucinogens
 Heroin

 Marijuana (cannabis, THC, cannabinoids)
 Methadone
 Methamphetamines
 Nicotine (any tobacco product)

 Opiates
 Other (Specify.)
______________________________

 Specific drug(s) not documented

19b. If substances used, were any injected?

 Yes  No  Not documented  Unknown

Specify injected substance(s). __________________________________________

20. Was a toxicology screen done on the mother (either during pregnancy or at the time of delivery)?

 Yes, positive result (Check all that apply.)
 Alcohol
 Amphetamines
 Barbiturates
 Benzodiazepines

 Cocaine
 Crack cocaine
 Hallucinogens
 Heroin

 Marijuana (cannabis, THC, cannabinoids)
 Methadone
 Methamphetamines
 Nicotine (any tobacco product)

 Opiates
 Other (Specify.)
____________________________

 Specific drug(s) not documented

 Yes, negative result  No  Toxicology screen not documented
21. Was a toxicology screen done on the infant at birth?

 Yes, positive result (Check all that apply.)
 Alcohol
 Amphetamines
 Barbiturates
 Benzodiazepines

 Cocaine
 Crack cocaine
 Hallucinogens
 Heroin

 Marijuana (cannabis, THC, cannabinoids)
 Methadone
 Methamphetamines
 Nicotine (any tobacco product)

 Opiates
 Other (Specify.)
____________________________

 Specific drug(s) not documented

 Yes, negative result  No  Toxicology screen not documented
22. If the results of the toxocology screen indicated substance use, was the mother referred for treatment (during or after this
pregnancy)?

 Yes  No  Not documented  Unknown

06/19/2009

Page 3 of 8

Infant State No. ____________________________

Maternal Testing/Clinical Information
23. Mother’s HIV serostatus

 Mother refused HIV testing
 HIV-positive before this pregnancy
 HIV-positive during this pregnancy
 HIV-positive at time of delivery

 HIV-positive before child's birth, date unknown
 HIV-positive after child's birth
 HIV-positive, date unknown

24. Date of mother's first positive result from confirmatory testing (WB or IFA)
__ __/__ __/__ __ __ __ (mm/dd/yyyy)

25. Results of mother’s HIV screening during pregnancy
Results
(See list in 26.)

Test
(See list in 26.)

_________________________________________________

______________________

Date
(mm/dd/yyyy)

25a. First screening
__ __/__ __/__ __ __ __

25b. Second screening (if result was negative, or mother refused first screening)
_________________________________________________

______________________

__ __/__ __/__ __ __ __

25c. Third screening (if result was negative, or mother refused second screening)
_________________________________________________

______________________

__ __/__ __/__ __ __ __

Results
(See list.)

Test
(See list.)

Date of results in
labor and delivery
(mm/dd/yyyy)

Time of results in
labor and delivery
(See military time.)

_________________________________________________

______________________

__ __/__ __/__ __ __ __

__ __:__ __

______________________

__ __/__ __/__ __ __ __

__ __:__ __

______________________

__ __/__ __/__ __ __ __

__ __:__ __

26. Mother’s HIV screening at time of labor and delivery

26a. First screening

26b. Second screening (if applicable)
_________________________________________________

26c. Confirmatory test
_________________________________________________
Results
Positive
Negative
Indeterminate
Results not available
Not tested
Not tested but known to be infected
Refused
Unknown

06/19/2009

Tests
Rapid
Expedited EIA
EIA
Not documented

Military time
noon
=
4:30 pm =
midnight =
12:30 am =

12:00
16:30
00:00
00:30

Page 4 of 8

Infant State No. ____________________________
27. Were CD4 counts determined during pregnancy or within 6 months before pregnancy?

 Yes  No (Go to 28.)  Not documented (Go to 28.)  Record not available (Go to 28.)  Unknown
27a. If yes, list below. (If more than 3 counts in record, prioritize the CD4 counts, starting with the count closest to delivery. If CD4
counts were not determined during pregnancy, record CD4 counts within 6 months before pregnancy if possible.)
Example: CD4 count of 174 cells/µL, 12%, August 12, 2000, would be recorded as

CD4 result

Unit

Date blood drawn
(mm/dd/yyyy)

__ __ __ __

cells/µL

__ __/__ __/__ __ __ __

__ __ __ __

%

__ __/__ __/__ __ __ __

__ __

__ __

CD4 result

174

cells/µL

08/12/2000

12

%

08/12/2000

Unit

Date blood drawn
(mm/dd/yyyy)

CD4 result

Unit

Date blood drawn
(mm/dd/yyyy)

cells/µL

__ __/__ __/__ __ __ __

__ __ __ __

cells/µL

__ __/__ __/__ __ __ __

%

__ __/__ __/__ __ __ __

__ __

%

__ __/__ __/__ __ __ __

28. Were viral quantification tests (ie, viral load) performed on the mother during pregnancy or within 6 months before pregnancy?

 Yes  No (Go to 29.)  Not documented (Go to 29.)  Record not available (Go to 29.)  Unknown
28a. If yes, list all results below. (If more than 3 in record, prioritize the results of viral load tests, starting with the result closest to
delivery. If viral load tests were not performed during pregnancy, record viral loads within 6 months of pregnancy if possible.)
Result in No. of copies/mL

Result in logs

Date blood drawn
(mm/dd/yyyy)

____________________________

_______________

__ __/__ __/__ __ __ __

____________________________

_______________

__ __/__ __/__ __ __ __

____________________________

_______________

__ __/__ __/__ __ __ __

29. What was the mother's most advanced HIV serostatus during pregnancy?

 HIV infection, not AIDS
 HIV-negative

 AIDS, CD4 criteria only
 Not documented

 AIDS, indicator condition
 Record not available
 Unknown

30. Was the mother's HIV serostatus noted in her prenatal care medical records?

 Yes, HIV-positive  Yes, HIV-negative  No  No prenatal care  Record not available  Unknown
Antiretroviral Therapy
31. Were antiretroviral drugs prescribed for the mother during this pregnancy?

 Yes (Complete table.)

 No (Go to 31a.)

 Not documented (Go to 32.)

 Record not available (Go to 32.)  Unknown
Date stopped
(if yes in preceding column)
(mm/dd/yyyy)

Stop codes
(See list on
p. 8.)

  

__ __/__ __/__ __ __ __

________

_____________

  

__ __/__ __/__ __ __ __

________

__ __/__ __/__ __ __ __

_____________

  

__ __/__ __/__ __ __ __

________



__ __/__ __/__ __ __ __

_____________

  

__ __/__ __/__ __ __ __

________

__________



__ __/__ __/__ __ __ __

_____________

  

__ __/__ __/__ __ __ __

________

__________



__ __/__ __/__ __ __ __

_____________

  

__ __/__ __/__ __ __ __

________

vii.________________ __________



__ __/__ __/__ __ __ __

_____________

  

__ __/__ __/__ __ __ __

________

viii._______________ __________



__ __/__ __/__ __ __ __

_____________

  

__ __/__ __/__ __ __ __

________

Drug name
(See list on p. 8.)

Other
(specify)

Drug
refused

Date drug started
(mm/dd/yyyy)

Gestational age
drug started
(weeks; round down)

i. _______________ ___________



__ __/__ __/__ __ __ __

_____________

ii. _______________

__________



__ __/__ __/__ __ __ __

iii.________________

__________



iv.________________

__________

v.________________
vi.________________

Drug stopped
Yes No ND

(After completing table, go to 32.)

31a. If no antiretroviral drug was prescribed during pregnancy, check reason.

 No prenatal care
 HIV serostatus of mother unknown

06/19/2009

 Mother known to be HIV-negative during pregnancy  Not documented  Unknown
 Mother refused
 Other (Specify.) __________________
Page 5 of 8

Infant State No. ____________________________
32. Was mother's HIV serostatus noted in her labor and delivery records?

 Yes, HIV-positive

 Yes, HIV-negative

 No

 Record not available  Unknown

33. Did mother receive antiretroviral drugs during labor and delivery?

 Yes (Complete table.)

 No (Go to 33a.)

Drug Name
(See list.)

Other
(specify)

 Not documented (Go to 34.)

Drug
refused

 Record not available

 Unknown

(Go to 34.)

Date received
(mm/dd/yyyy)

Time received
(See military time.)

Oral

Type of administration
IV
Not documented

i. ___________________

____________



__ __/__ __/__ __ __ __

__ __:__ __







ii. __________________

____________



__ __/__ __/__ __ __ __

__ __:__ __







iii. __________________

____________



__ __/__ __/__ __ __ __

__ __:__ __







iv. __________________

____________



__ __/__ __/__ __ __ __

__ __:__ __







v. __________________

____________



__ __/__ __/__ __ __ __

__ __:__ __







vi. __________________

____________



__ __/__ __/__ __ __ __

__ __:__ __







vii. __________________

____________



__ __/__ __/__ __ __ __

__ __:__ __







(After completing table, go to 34.)

Military time: noon = 12:00; midnight = 00:00

33a. If no antiretroviral drug was received during labor and delivery, check reason.



 HIV serostatus of mother

Precipitous delivery/STAT
Cesarean delivery
Prescribed but not administered





during pregnancy

 No (Go to 36.)

________________________

 Mother refused

34. Was mother referred for HIV care after delivery?

 Yes

 Mother tested HIV-negative  Other (Specify.)

unknown
Birth not in hospital

 Not documented (Go to 36.)

 Not documented
 Unknown

 Record not available (Go to 36.)  Unknown

35. If yes, indicate first CD4 result or first viral load after discharge from hospital (up to 6 months after discharge).
35a. CD4 result

 Not done  Not available

35b. Viral load

 Not done  Not available

Result

Unit

Date blood drawn
(mm/dd/yyyy)

Result in copies/mL

__ __ __ __

cells/µL

__ __/__ __/__ __ __ __

_________________

%

__ __/__ __/__ __ __ __

__ __

Result in logs
____________

Date blood drawn
(mm/dd/yyyy)
__ __/__ __/__ __ __ __

Birth History

 Single  Twin  >3  Record not available  Unknown
37. Birth information  Birth not in hospital
 Record not available
36. Type of birth

Time

Date (mm/dd/yyyy)

Time

(See military time.)

Date (mm/dd/yyyy)

(See military time.)

Onset of labor

__ __:__ __

__ __/__ __/__ __ __ __

Rupture of membranes

__ __:__ __

__ __/__ __/__ __ __ __

Admission to labor and delivery

__ __:__ __

__ __/__ __/__ __ __ __

Delivery

__ __:__ __

__ __/__ __/__ __ __ __

Military time: noon = 12:00; midnight = 00:00

38. Gestational age at time of delivery ______________________ (in weeks; round down to nearest whole week)
39a. If Cesarean delivery, mark all the following indications that apply.

39. Mode of delivery

 Vaginal (Go to 40.)  Unknown
 Elective Cesarean delivery
 Non-elective Cesarean delivery
 Cesarean delivery, unknown type
 Record not available (Go to 41.)
40. Instrument used
06/19/2009

 HIV indication (high viral load)
 Previous Cesarean (repeat)
 Malpresentation (breech, transverse)
 Prolonged labor or failure to progress
 Mother’s or physician’s preference

 Fetal distress
 Placenta abruptia or p. previa
 Other (eg, herpes, disproportion)
Specify ________________________________

 Not specified

 None  Forceps  Vacuum  Forceps and vacuum  Not specified
Page 6 of 8

Infant State No. ____________________________
41. Child's birth weight (lbs/oz or grams)
_______ lbs ________ oz

42. Was mother's HIV serostatus noted on the child's birth record?

or _________ grams

 No

 Yes, HIV-positive  Yes, HIV-negative  Record not available  Unknown
Pediatric History

43. Were antiretroviral drugs prescribed for the child during the first 6 weeks of life?

 Yes (Complete table.)  No (Go to 43a.)  Not documented (Go to 44.)  Record not available (Go to 44.)  Unknown
Drug
refused

Date drug started
(mm/dd/yyyy)

Time started
(See military
time.)

ART
Completed?
Yes No ND UNK

Stop date
(if therapy not completed)
(mm/dd/yyyy)

Stop codes
(See list on
p. 8.)

i._________________ ____________



__ __/__ __/__ __ __ __

__ __:__ __



__ __/__ __/__ __ __ __

_______

ii.________________ _____________



__ __/__ __/__ __ __ __

__ __:__ __



__ __/__ __/__ __ __ __

_______

iii.________________ ____________



__ __/__ __/__ __ __ __

__ __:__ __



__ __/__ __/__ __ __ __

_______

iv.________________ ____________



__ __/__ __/__ __ __ __

__ __:__ __



__ __/__ __/__ __ __ __

_______

v.________________ _____________



__ __/__ __/__ __ __ __

__ __:__ __



__ __/__ __/__ __ __ __

_______

vi.________________ ____________



__ __/__ __/__ __ __ __

__ __:__ __



__ __/__ __/__ __ __ __

_______

vii.________________ ____________



__ __/__ __/__ __ __ __

__ __:__ __



__ __/__ __/__ __ __ __

_______

viii._______________ ____________



__ __/__ __/__ __ __ __

__ __:__ __



__ __/__ __/__ __ __ __

_______

Drug name
(See list on p. 8.)

Other
(specify)

Military time: noon = 12:00; midnight = 00:00

43a. If no antiretroviral drug was prescribed during the first 6 weeks of life, indicate reason.

 HIV serostatus of mother unknown
 Mother known to be HIV-negative during pregnancy
 Mother refused

44. Infant’s HIV antibody testing
Results
(See list.)

 Other (Specify.) ____________________________________________
 Not documented

45. Results of DNA/RNA screening

Test
(See list.)

Date blood drawn
(mm/dd/yyyy)

Results
(See list in 44.)

i. ________________

______________

__ __/__ __/__ __ __ __

i. ________________





__ __/__ __/__ __ __ __

ii. _______________

______________

__ __/__ __/__ __ __ __

ii. ________________





__ __/__ __/__ __ __ __

iii. _______________

______________

__ __/__ __/__ __ __ __

iii. ________________





__ __/__ __/__ __ __ __

iv. ________________





__ __/__ __/__ __ __ __

v. ________________





__ __/__ __/__ __ __ __

Results
Positive
Negative
Indeterminate
Results not available
Infant not tested
Mother refused
Unknown

Tests
Rapid
Expedited EIA
EIA
Not
documented

46. What is the child's current HIV infection status?

 AIDS
 HIV-negative

 Confirmed HIV infected (not AIDS)
 Indeterminate as of
__ __/__ __/__ __ __ __ (mm/dd/yyyy)

48. Was PCP prophylaxis prescribed during the first year of life?

 Yes Date received __ __/__ __/__ __ __ __
 No  Not documented  Record not available  Unknown
06/19/2009

Test
DNA
RNA

Date blood drawn
(mm/dd/yyyy)

47. If child's HIV serostatus is indeterminate, indicate reason.

 Moved from state
 Provider out of state
 Child <18 months of age

 Lost to follow-up
 Died before serostatus determined
 Not documented

49. Was child breastfed?

 Yes

Duration _______ days _____ weeks

 No

 Duration not documented
 Not documented  Record not available  Unknown
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Infant State No. ____________________________
50. Were birth defects noted during the first year of life?

 Yes  No (Go to 51.)  Record not available (Go to 51.)
 Unknown

50a. If yes, specify type(s). _______________________________
Code _____._____

Code _____._____

Code _____._____

51. If child is deceased, please obtain the following from the death certificate. (Print legibly. Include ICD-9 or ICD-10 codes only if code
appears on death certificate.)
Cause of death

ICD-9 code

or

ICD-10 code

Immediate___________________________________________________________________________________

___________

___________

Underlying __________________________________________________________________________________

___________

___________

Underlying __________________________________________________________________________________

___________

___________

Underlying __________________________________________________________________________________

___________

___________

Contributing _________________________________________________________________________________

___________

___________

Note. Please be sure that a date of death has been entered on page 1, under Demographic Information (2. Infant).
Please include comments or clinical information you consider relevant to the overall understanding of this child's HIV exposure
or infection status. State the date and source of the information.

Antiretroviral drugs and stop codes
NNRTI
Delavirdine (Rescriptor)
Efavirenz (Sustiva)
Nevirapine (Viramune, NVP)
NRTI
Abacavir (Ziagen, ABC)
Combivir (AZT & 3TC)
Didanosine (ddI, Videx)
Emtriva (Emtricitabine or FTC)

NRTI (cont)
Epzicom (Abacavir/3TC, Kivexa)
Lamivudine (3TC, Epivir)
Stavudine (d4T, Zerit)
Trizivir (AZT & 3TC & Abacavir)
Truvada (Tenofovir DF/Emtricitabine)
®
Videx EC (Didanosine)
Viread (Tenofovir)
Zalcitabine (ddC, Hivid)
Zidovudine (AZT, Retrovir)

Protease inhibitor
Amprenavir (Agenerase)
Darunavir (Prezista)
Indinavir (Crixivan)
Kaletra (Lopinavir, Ritonavir)
Lexiva (Fosamprenavir)
Nelfinavir (Viracept)
Reyataz (Atazanavir or ATV)
Ritonavir (Norvir)
Saquinavir (Fortavase, Invirase)
Tipranavir (Aptivus)

Other
Adefovir dipivoxil (bis-POM,
PMEA, Preveon)
Atripla (Efavirenz & Tenofovir &
Emtricitabine)
Fuzeon (Enfuvirtide or T20)
Hydroxyurea (Droxia, Hydrea)
Intelence
Selzentry
Isentress
If an antiretroviral drug not
on this list, call CDC

Stop codes (2 codes allowed; if more, choose the 2 most important)
S1 = Adverse events (toxicity, lack of tolerance)
S2 = ART completed
S3 = Drug resistance detected
S4 = Poor adherence
S5 = Inadequate effectiveness

S6 = Strategic treatment interruption (planned drug holiday)
S7 = Drug interactions
S8 = Mother’s choice
S9 = Pregnancy
S10 = Child determined not to be HIV infected

S11 = Improving effectiveness
S12 = Improving convenience
S13 = Reason not indicated; unknown
S14 = Mother couldn’t afford drugs
Sxx = Other reason

List of abbreviations
ACTG
ART
EIA
HARS
HMO
ICD-9
ICD -10
IFA
ND
NNRTI

AIDS Clinical Trials Group
antiretroviral therapy
enzyme immunoassay
HIV/AIDS Reporting System
health maintenance organization
International Classification of Diseases, Ninth Revision
International Classification of Diseases, Tenth Revision
immunofluorescent assay
not documented
nonnucleoside reverse transcriptase inhibitor

06/19/2009

NRTI
NRR
OB-GYN
PCP
PI
PID
STAT
WB

nucleoside reverse transcriptase inhibitor
no risk factor reported
obstetric-gynecologic or obstetrician-gynecologist
Pneumocystis jirovecii pneumonia [jirovecii is now preferred to carinii;
abbreviation is the same]
protease inhibitor
pelvic inflammatory disease
immediately (statim)
Western blot

Page 8 of 8