HIV testing & PrEP Monthly Report Form

Facility/DIC: ___Bishoftu general Hospital_______________________________________

Date: ________________________________________________
Period start date: ____________________________________
PrEP REPORTING (FROM PREP REGISTER)
AGE (YEARS) 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50+
Catagories FSW DC FSW DC FSW DC FSW DC FSW DC FSW DC FSW DC FSW DC
SEX F M F F M F F M F F M F F M F F M F F M F F M
Oral PrEP screening
Number of PrEP target groups visited facility during the reporting period 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1
Number of clients undergoing PrEP risk assessment during the reporting period 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1

Number of clients assessed to be at high risk of HIV infection during the reporting period 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1
Number clients found eligible for and offered PrEP during the reporting period 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1
Number clients offered PrEP during the reporting period 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1
Number of clients initiating PrEP during the reporting period 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1
Number of clients declined PrEP during the reporting period 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1
Clients on oral PrEP
Number of oral PrEP clients at facility in previous month 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients transferred in 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients opting out 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of client’s get out of HIV risk 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of client’s clinician has decided to withdraw 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients transferred out 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients sero-converted 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients died 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients LTFU

Number of oral PrEP clients at facility this month_PrEP_CURR 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1

Number of clients initiated on PrEP and on their 1st month on PrEP 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1

Number of clients initiated on PrEP and on their 3rd month on PrEP 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of clients initiated on PrEP and on their 3rd month on PrEP and re-tested for HIV 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of clients on their 3rd month on PrEP re-tested for HIV and tested HIV Positive 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of clients on their 3rd month on PrEP re-tested for HIV and tested HIV negative 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of clients initiated on PrEP and on their 6th month on PrEP 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of clients initiated on PrEP and on their 12 month on PrEP 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of clients initiated on PrEP and on their 18 month on PrEP 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

50+ Total
DC
F FSW DC

0 0 3
0 0 3

0 0 3
0 0 3
0 0 3
0 0 3
0 0 3

0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0

0 0 3
0 0 3

0 0 0

0 0 0

0 0 0

0 0 0

0 0 0

0 0 0

0 0 0
 HIV testing & PrEP Monthly Report Form
Facility/DIC: ____Bishoftu General Hospital______________________________________
Date: ________________________________________________
Period start date: ____________________________________
PrEP REPORTING (FROM PREP REGISTER)
AGE (YEARS) 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50+
Catagories FSW DC FSW DC FSW DC FSW DC FSW DC FSW DC FSW DC FSW DC
SEX F M F F M F F M F F M F F M F F M F F M F F M
Oral PrEP screening
Number of PrEP target groups visited facility during the reporting period 0 0 0 0 1 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0
Number of clients undergoing PrEP risk assessment during the reporting period 0 0 0 0 1 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0

Number of clients assessed to be at high risk of HIV infection during the reporting period 0 0 0 0 1 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0
Number clients found eligible for and offered PrEP during the reporting period 0 0 0 0 1 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0
Number clients offered PrEP during the reporting period 0 0 0 0 1 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0
Number of clients initiating PrEP during the reporting period 0 0 0 0 1 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0
Number of clients declined PrEP during the reporting period 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Clients on oral PrEP
Number of oral PrEP clients at facility in previous month 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1
Number of clients transferred in 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients opting out 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of client’s get out of HIV risk 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of client’s clinician has decided to withdraw 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients transferred out 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients sero-converted 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients died 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients LTFU 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of oral PrEP clients at facility this month_PrEP_CURR 0 0 0 0 1 1 0 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 1

Number of clients initiated on PrEP and on their 1st month on PrEP 0 0 0 0 1 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0

Number of clients initiated on PrEP and on their 3rd month on PrEP 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of clients initiated on PrEP and on their 3rd month on PrEP and re-tested for HIV 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of clients on their 3rd month on PrEP re-tested for HIV and tested HIV Positive 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of clients on their 3rd month on PrEP re-tested for HIV and tested HIV negative 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of clients initiated on PrEP and on their 6th month on PrEP 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of clients initiated on PrEP and on their 12 month on PrEP 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of clients initiated on PrEP and on their 18 month on PrEP 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

50+ Total
DC
F FSW DC

0 0 3
0 0 3

0 0 3
0 0 3
0 0 3
0 0 3
0 0 0

0 0 3
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0

0 0 6
0 0 3

0 0 0

0 0 0

0 0 0

0 0 0

0 0 0

0 0 0

0 0 0
 HIV testing & PrEP Monthly Report Form
Facility/DIC: ______Bishoftu general Hospital____________________________________
Date: ________________________________________________
Period start date: ____________________________________
PrEP REPORTING (FROM PREP REGISTER)
AGE (YEARS) 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50+
Catagories FSW DC FSW DC FSW DC FSW DC FSW DC FSW DC FSW DC FSW DC
SEX F M F F M F F M F F M F F M F F M F F M F F M
Oral PrEP screening
Number of PrEP target groups visited facility during the reporting period 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients undergoing PrEP risk assessment during the reporting period 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of clients assessed to be at high risk of HIV infection during the reporting period 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number clients found eligible for and offered PrEP during the reporting period 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number clients offered PrEP during the reporting period 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients initiating PrEP during the reporting period 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients declined PrEP during the reporting period 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Clients on oral PrEP
Number of oral PrEP clients at facility in previous month 0 0 0 0 1 1 0 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 1
Number of clients transferred in 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients opting out 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of client’s get out of HIV risk 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of client’s clinician has decided to withdraw 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients transferred out 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients sero-converted 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients died 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients LTFU 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of oral PrEP clients at facility this month_PrEP_CURR 0 0 0 0 1 1 0 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 1

Number of clients initiated on PrEP and on their 1st month on PrEP 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of clients initiated on PrEP and on their 3rd month on PrEP 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1

Number of clients initiated on PrEP and on their 3rd month on PrEP and re-tested for HIV 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1

Number of clients on their 3rd month on PrEP re-tested for HIV and tested HIV Positive 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of clients on their 3rd month on PrEP re-tested for HIV and tested HIV negative 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1

Number of clients initiated on PrEP and on their 6th month on PrEP 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of clients initiated on PrEP and on their 12 month on PrEP 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of clients initiated on PrEP and on their 18 month on PrEP 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

50+ Total
DC
F FSW DC

0 0 0
0 0 0

0 0 0
0 0 0
0 0 0
0 0 0
0 0 0

0 6
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0

0 6
0 0 0

0 0 3

0 0 3

0 0 0

0 0 3

0 0 0

0 0 0

0 0 0
 HIV testing & PrEP Monthly Report Form
Facility/DIC: ______Bishoftu general Hospital____________________________________
Date: ________________________________________________
Period start date: ____________________________________
PrEP REPORTING (FROM PREP REGISTER)
AGE (YEARS) 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50+
Catagories FSW DC FSW DC FSW DC FSW DC FSW DC FSW DC FSW DC FSW DC
SEX F M F F M F F M F F M F F M F F M F F M F F M
Oral PrEP screening
Number of PrEP target groups visited facility during the reporting period 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients undergoing PrEP risk assessment during the reporting period 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of clients assessed to be at high risk of HIV infection during the reporting period 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number clients found eligible for and offered PrEP during the reporting period 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number clients offered PrEP during the reporting period 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients initiating PrEP during the reporting period 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients declined PrEP during the reporting period 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Clients on oral PrEP
Number of oral PrEP clients at facility in previous month 0 0 0 0 1 1 0 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 1
Number of clients transferred in 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients opting out 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of client’s get out of HIV risk 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of client’s clinician has decided to withdraw 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients transferred out 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients sero-converted 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients died 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients LTFU 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of oral PrEP clients at facility this month_PrEP_CURR 0 0 0 0 1 1 0 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 1

Number of clients initiated on PrEP and on their 1st month on PrEP 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of clients initiated on PrEP and on their 3rd month on PrEP 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1

Number of clients initiated on PrEP and on their 3rd month on PrEP and re-tested for HIV 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1

Number of clients on their 3rd month on PrEP re-tested for HIV and tested HIV Positive 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of clients on their 3rd month on PrEP re-tested for HIV and tested HIV negative 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1

Number of clients initiated on PrEP and on their 6th month on PrEP 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of clients initiated on PrEP and on their 12 month on PrEP 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of clients initiated on PrEP and on their 18 month on PrEP 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

50+ Total
DC
F FSW DC

0 0 0
0 0 0

0 0 0
0 0 0
0 0 0
0 0 0
0 0 0

0 6
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0

0 6
0 0 0

0 0 3

0 0 3

0 0 0

0 0 3

0 0 0

0 0 0

0 0 0
 HIV testing & PrEP Monthly Report Form
Facility/DIC: ______Bishoftu general Hospital____________________________________
Date: ________________________________________________
Period start date: ____________________________________
PrEP REPORTING (FROM PREP REGISTER)
AGE (YEARS) 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50+
Catagories FSW DC FSW DC FSW DC FSW DC FSW DC FSW DC FSW DC FSW DC
SEX F M F F M F F M F F M F F M F F M F F M F F M
Oral PrEP screening
Number of PrEP target groups visited facility during the reporting period 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients undergoing PrEP risk assessment during the reporting period 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of clients assessed to be at high risk of HIV infection during the reporting period 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number clients found eligible for and offered PrEP during the reporting period 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number clients offered PrEP during the reporting period 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients initiating PrEP during the reporting period 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients declined PrEP during the reporting period 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Clients on oral PrEP
Number of oral PrEP clients at facility in previous month 0 0 0 0 1 1 0 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 1
Number of clients transferred in 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients opting out 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of client’s get out of HIV risk 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of client’s clinician has decided to withdraw 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients transferred out 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients sero-converted 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients died 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients LTFU 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of oral PrEP clients at facility this month_PrEP_CURR 0 0 0 0 1 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 1

Number of clients initiated on PrEP and on their 1st month on PrEP 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of clients initiated on PrEP and on their 3rd month on PrEP 0 0 0 0 1 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 1

Number of clients initiated on PrEP and on their 3rd month on PrEP and re-tested for HIV 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1

Number of clients on their 3rd month on PrEP re-tested for HIV and tested HIV Positive 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of clients on their 3rd month on PrEP re-tested for HIV and tested HIV negative 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1

Number of clients initiated on PrEP and on their 6th month on PrEP 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of clients initiated on PrEP and on their 12 month on PrEP 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of clients initiated on PrEP and on their 18 month on PrEP 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

50+ Total
DC
F FSW DC

0 0 0
0 0 0

0 0 0
0 0 0
0 0 0
0 0 0
0 0 0

0 6
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0

0 4
0 0 0

0 4

0 0 3

0 0 0

0 0 3

0 0 0

0 0 0

0 0 0
 HIV testing & PrEP Monthly
Facility/DIC: ___Bishoftu Hospital
Date: 21/1/12-20/1/2013
Period start date: Meskerem
PrEP REPORTING (FROM PREP REGIS
AGE (YEARS) 15-19 20-24
Catagories FSW DC FSW DC
SEX F M F F M F
Oral PrEP screening
0 0 0 0 0 0
Number of PrEP target groups visited facility during the reporting period
Number of clients undergoing PrEP risk assessment during the reporting 0 0 0 0 0 0
period
Number of clients assessed to be at high risk of HIV infection during the 0 0 0 0 0 0
reporting period
Number clients found eligible for and offered PrEP during the reporting 0 0 0 0 0 0
period
Number clients offered PrEP during the reporting period 0 0 0 0 0 0
Number of clients initiating PrEP during the reporting period 0 0 0 0 0 0
Number of clients declined PrEP during the reporting period 0 0 0 0 0 0
Clients on oral PrEP
Number of oral PrEP clients at facility in previous month 0 0 0 0 1 1
Number of clients transferred in 0 0 0 0 0 0
Number of clients opting out 0 0 0 0 0 0
Number of client’s get out of HIV risk 0 0 0 0 0 1
Number of client’s clinician has decided to withdraw 0 0 0 0 0 0
Number of clients transferred out 0 0 0 0 0 0
Number of clients sero-converted 0 0 0 0 0 0
Number of clients died 0 0 0 0 0 0
Number of clients LTFU 0 0 0 0 0 0

Number of oral PrEP clients at facility this month_PrEP_CURR 0 0 0 0 1 0

Number of clients initiated on PrEP and on their 1st month on PrEP 0 0 0 0 0 0

Number of clients initiated on PrEP and on their 3rd month on PrEP 0 0 0 0 0 0

Number of clients initiated on PrEP and on their 3rd month on PrEP and
re-tested for HIV 0 0 0 0 0 0

Number of clients on their 3rd month on PrEP re-tested for HIV and
tested HIV Positive 0 0 0 0 0 0
Number of clients on their 3rd month on PrEP re-tested for HIV and
tested HIV negative 0 0 0 0 0 0

Number of clients initiated on PrEP and on their 6th month on PrEP 0 0 0 0 0 0

Number of clients initiated on PrEP and on their 12 month on PrEP 0 0 0 0 0 0

Number of clients initiated on PrEP and on their 18 month on PrEP 0 0 0 0 0 0

V testing & PrEP Monthly Report Form

PORTING (FROM PREP REGISTER)

25-29 30-34 35-39 40-44 45-49 50+
FSW DC FSW DC FSW DC FSW DC FSW DC FSW DC
F M F F M F F M F F M F F M F F M F

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 1 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 1 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
 Total

FSW DC

0 0

0 0

0 0

0 0

0 0
0 0
0 0

6
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

0 0

0 0

0 0

0 0
0 0

0 0

0 0

0 0
 HIV testing & PrEP Monthly Re
Facility/DIC: ___Bishoftu Hospital
Date: 21/7/12-20/1/2013
Period start date: Semi-annual
PrEP REPORTING (FROM PREP REGISTE
AGE (YEARS) 15-19 20-24 25-29
Catagories FSW DC FSW DC FSW
SEX F M F F M F F
Oral PrEP screening
Number of PrEP target groups visited facility during the reporting 0 0 0 0 2 2 0
period
Number of clients undergoing PrEP risk assessment during the 0 0 0 0 1 1 0
reporting period
Number of clients assessed to be at high risk of HIV infection 0 0 0 0 1 1 0
during the reporting period
Number clients found eligible for and offered PrEP during the 0 0 0 0 1 1 0
reporting period
Number clients offered PrEP during the reporting period 0 0 0 0 1 1 0

0 0 0 0 1 1 0
Number of clients initiating PrEP during the reporting period
Number of clients declined PrEP during the reporting period 0 0 0 0 0 1 0
Clients on oral PrEP
Number of oral PrEP clients at facility in previous month 0 0 0 0 1 1 0
Number of clients transferred in 0 0 0 0 0 0 0
Number of clients opting out 0 0 0 0 0 0 0
Number of client’s get out of HIV risk 0 0 0 0 0 1 0
Number of client’s clinician has decided to withdraw 0 0 0 0 0 0 0
Number of clients transferred out 0 0 0 0 0 0 0
Number of clients sero-converted 0 0 0 0 0 0 0
Number of clients died 0 0 0 0 0 0 0
Number of clients LTFU 0 0 0 0 0 0 0

Number of oral PrEP clients at facility this month_PrEP_CURR 0 0 0 0 1 0 0

Number of clients initiated on PrEP and on their 1st month on
PrEP 0 0 0 0 0 0 0

Number of clients initiated on PrEP and on their 3rd month on

PrEP 0 0 0 0 0 0 0

Number of clients initiated on PrEP and on their 3rd month on

PrEP and re-tested for HIV 0 0 0 0 0 0 0

Number of clients on their 3rd month on PrEP re-tested for HIV

and tested HIV Positive 0 0 0 0 0 0 0
Number of clients on their 3rd month on PrEP re-tested for HIV
and tested HIV negative 0 0 0 0 0 0 0
Number of clients initiated on PrEP and on their 6th month on
PrEP 0 0 0 0 0 0 0

Number of clients initiated on PrEP and on their 12 month on PrEP 0 0 0 0 0 0 0

Number of clients initiated on PrEP and on their 18 month on PrEP 0 0 0 0 0 0 0

esting & PrEP Monthly Report Form

RTING (FROM PREP REGISTER)

25-29 30-34 35-39 40-44 45-49 50+ Total
DC FSW DC FSW DC FSW DC FSW DC FSW DC
M F F M F F M F F M F F M F F M F FSW

2 0 0 2 2 0 0 0 0 0 0 0 0 0 0 2 0 0

1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 1 0 0

1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 1 0 0

1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 1 0 0

1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 1 0 0

1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 1 0 0

1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0

1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 1 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 1 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Total

DC

12

6
0
0
0
0
0
0
0
0

0
0

0
 HIV testing & PrEP Monthly Report Form
Facility/DIC: ___Bishoftu Hospital
Date: 21/1/2013-20/2/2013
Period start date:
PrEP REPORTING (FROM PREP REGISTER)
AGE (YEARS) 15-19 20-24 25-29 30-34 35-39
Catagories FSW DC FSW DC FSW DC FSW DC FSW
SEX F M F F M F F M F F M F F
Oral PrEP screening
Number of PrEP target groups visited facility 0 0 0 0 0 0 1 1 0 0 0 0 0
during the reporting period
Number of clients undergoing PrEP risk 0 0 0 0 0 0 1 1 0 0 0 0 0
assessment during the reporting period

Number of clients assessed to be at high risk of 0 0 0 0 0 0 0 0 0 0 0 0 0

HIV infection during the reporting period
Number clients found eligible for and offered 0 0 0 0 0 0 1 1 0 0 0 0 0
PrEP during the reporting period
Number clients offered PrEP during the reporting 0 0 0 0 0 0 1 1 0 0 0 0 0
period
Number of clients initiating PrEP during the 0 0 0 0 0 0 1 1 0 0 0 0 0
reporting period
Number of clients declined PrEP during the 0 0 0 0 0 0 0 0 0 0 0 0 0
reporting period
Clients on oral PrEP

Number of oral PrEP clients at facility in previous

month 0 0 0 0 1 0 0 0 0 0 1 1 0

Number of clients transferred in 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of clients opting out 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of client’s get out of HIV risk 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of client’s clinician has decided to
withdraw 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients transferred out 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients sero-converted 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients died 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients LTFU 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of oral PrEP clients at facility this
month_PrEP_CURR 0 0 0 0 1 0 1 1 0 0 1 1 0
Number of clients initiated on PrEP and on their
1st month on PrEP 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients initiated on PrEP and on their
3rd month on PrEP 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of clients initiated on PrEP and on their

3rd month on PrEP and re-tested for HIV 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of clients on their 3rd month on PrEP re-

tested for HIV and tested HIV Positive 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of clients on their 3rd month on PrEP re-

tested for HIV and tested HIV negative 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients initiated on PrEP and on their
6th month on PrEP 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients initiated on PrEP and on their
12 month on PrEP 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients initiated on PrEP and on their
18 month on PrEP 0 0 0 0 0 0 0 0 0 0 0 0 0
ort Form

R)
35-39 40-44 45-49 50+ Total
DC FSW DC FSW DC FSW DC
M F F M F F M F F M F FSWDC

0 0 0 0 0 1 0 0 0 0 0 2 1

0 0 0 0 0 1 0 0 0 0 0 2 1

0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 1 0 0 0 0 0 2 1

0 0 0 0 0 1 0 0 0 0 0 2 1

0 0 0 0 0 1 0 0 0 0 0 2 1

0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 1 0 0 4

0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 1 0 0 0 1 0 2 5

0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0
 HIV testing & PrEP Monthly Report Form
Facility/DIC: ___Bishoftu Hospital
Date: 21/2/2013-20/3/2013
Period start date: Hidar
PrEP REPORTING (FROM PREP REGISTER)
AGE (YEARS) 15-19 20-24 25-29 30-34 35-39
Catagories FSW DC FSW DC FSW DC FSW DC FSW
SEX F M F F M F F M F F M F F
Oral PrEP screening
Number of PrEP target groups visited facility 0 0 0 0 0 0 0 0 0 0 0 1 0
during the reporting period
Number of clients undergoing PrEP risk 0 0 0 0 0 0 0 0 0 0 0 1 0
assessment during the reporting period

Number of clients assessed to be at high risk of 0 0 0 0 0 0 0 0 0 0 0 1 0

HIV infection during the reporting period
Number clients found eligible for and offered 0 0 0 0 0 0 0 0 0 0 0 1 0
PrEP during the reporting period
Number clients offered PrEP during the reporting 0 0 0 0 0 0 0 0 0 0 0 1 0
period
Number of clients initiating PrEP during the 0 0 0 0 0 0 0 0 0 0 0 0 0
reporting period

Number of clients declined PrEP during the 0 0 0 0 0 0 0 0 0 0 0 1 0

reporting period
Clients on oral PrEP

Number of oral PrEP clients at facility in previous

month 0 0 0 0 0 0 0 0 2 0 1 0 0

Number of clients transferred in 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of clients opting out 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of client’s get out of HIV risk 0 0 0 0 0 0 0 0 0 0 1 0 0
Number of client’s clinician has decided to
withdraw 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients transferred out 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients sero-converted 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients died 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients LTFU 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of oral PrEP clients at facility this 0 0 0 0 0 0 0 0 3 0 0 0 0
month_PrEP_CURR
Number of clients initiated on PrEP and on their
1st month on PrEP 0 0 0 0 0 1 0 0 0 0 1 0 0
Number of clients initiated on PrEP and on their
3rd month on PrEP 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of clients initiated on PrEP and on their

3rd month on PrEP and re-tested for HIV 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of clients on their 3rd month on PrEP re-

tested for HIV and tested HIV Positive 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of clients on their 3rd month on PrEP re-

tested for HIV and tested HIV negative 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients initiated on PrEP and on their
6th month on PrEP 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients initiated on PrEP and on their
12 month on PrEP 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients initiated on PrEP and on their
18 month on PrEP 0 0 0 0 0 0 0 0 0 0 0 0 0
ort Form

R)
35-39 40-44 45-49 50+ Total
DC FSW DC FSW DC FSW DC
M F F M F F M F F M F FSWDC

0 0 0 0 0 0 1 0 0 0 0 0 2

0 0 0 0 0 0 1 0 0 0 0 0 2

0 0 0 0 0 0 1 0 0 0 0 0 2

0 0 0 0 0 0 1 0 0 0 0 0 2

0 0 0 0 0 0 1 0 0 0 0 0 2

0 0 0 0 0 0 1 0 0 0 0 0 2

0 0 0 0 0 0 0 0 0 0 0 0 2

0 0 0 0 1 0 0 1 0 0 0 0 5

0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 2 0 0 1 0 0 0 0 6

0 0 0 0 0 1 0 0 0 0 0 0 3
0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0
 HIV testing & PrEP Monthly Report Form
Facility/DIC: ___Bishoftu Hospital
Date: 21/3/2013-20/4/2013
Period start date: Tahisas
PrEP REPORTING (FROM PREP REGISTER)
AGE (YEARS) 15-19 20-24 25-29 30-34 35-39
Catagories FSW DC FSW DC FSW DC FSW DC FSW
SEX F M F F M F F M F F M F F
Oral PrEP screening
Number of PrEP target groups visited facility 0 0 0 0 0 0 0 0 0 0 0 0 0
during the reporting period
Number of clients undergoing PrEP risk 0 0 0 0 0 0 0 0 0 0 0 0 0
assessment during the reporting period

Number of clients assessed to be at high risk of 0 0 0 0 0 0 1 0 0 0 0 0 0

HIV infection during the reporting period
Number clients found eligible for and offered 0 0 0 0 0 0 1 0 0 0 0 0 0
PrEP during the reporting period
Number clients offered PrEP during the reporting 0 0 0 0 0 0 1 0 0 0 0 0 0
period
Number of clients initiating PrEP during the 0 0 0 0 0 0 0 0 0 0 0 0 0
reporting period

Number of clients declined PrEP during the 0 0 0 0 0 0 1 0 0 0 0 0 0

reporting period
Clients on oral PrEP

Number of oral PrEP clients at facility in previous 0 0 0 0 0 0 0 0 3 0 0 0 0

month

Number of clients transferred in 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of clients opting out 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of client’s get out of HIV risk 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of client’s clinician has decided to
withdraw 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients transferred out 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients sero-converted 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients died 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients LTFU 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of oral PrEP clients at facility this
month_PrEP_CURR 0 0 0 0 0 0 0 0 2 0 1 0 0
Number of clients initiated on PrEP and on their
1st month on PrEP 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients initiated on PrEP and on their
3rd month on PrEP 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of clients initiated on PrEP and on their

3rd month on PrEP and re-tested for HIV 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of clients on their 3rd month on PrEP re-

tested for HIV and tested HIV Positive 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of clients on their 3rd month on PrEP re-

tested for HIV and tested HIV negative 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients initiated on PrEP and on their
6th month on PrEP 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients initiated on PrEP and on their
12 month on PrEP 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients initiated on PrEP and on their
18 month on PrEP 0 0 0 0 0 0 0 0 0 0 0 0 0
ort Form

R)
35-39 40-44 45-49 50+ Total
DC FSW DC FSW DC FSW DC
M F F M F F M F F M F FSWDC

0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 1

0 0 0 0 2 0 0 1 0 0 0 0 6

0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 1 0 0 1 0 0 0 0 5

0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0
 HIV testing & PrEP Monthly Report Form
Facility/DIC: ___Bishoftu Hospital
Date: 21/1/2013-20/4/2013
Period start date: Q1
PrEP REPORTING (FROM PREP REGISTER)
AGE (YEARS) 15-19 20-24 25-29 30-34 35-39 40-44
Catagories FS DC FS DC FS DC FS DC FS DC FS DC
SEX F M F F M F F M F F M F F M F F M F
Oral PrEP screening
Number of PrEP target groups visited facility 0 0 0 0 0 0 1 1 0 0 0 1 0 0 0 0 0 0
during the reporting period
Number of clients undergoing PrEP risk 0 0 0 0 0 0 1 1 0 0 0 1 0 0 0 0 0 0
assessment during the reporting period

Number of clients assessed to be at high risk of 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 0 0 0

HIV infection during the reporting period
Number clients found eligible for and offered 0 0 0 0 0 0 2 1 0 0 0 1 0 0 0 0 0 0
PrEP during the reporting period
Number clients offered PrEP during the reporting 0 0 0 0 0 0 2 1 0 0 0 1 0 0 0 0 0 0
period
Number of clients initiating PrEP during the 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0
reporting period

Number of clients declined PrEP during the 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 0 0 0

reporting period
Clients on oral PrEP 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of oral PrEP clients at facility in previous 0 0 0 0 1 0 0 0 5 0 2 1 0 0 0 0 0 3

month
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients transferred in
Number of clients opting out 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of client’s get out of HIV risk 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0
Number of client’s clinician has decided to 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
withdraw
Number of clients transferred out 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients sero-converted 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients died 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients LTFU 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of oral PrEP clients at facility this

month_PrEP_CURR 0 0 0 0 0 0 0 0 2 0 1 0 0 0 0 0 0 1
Number of clients initiated on PrEP and on their 0 0 0 0 0 1 0 0 0 0 1 0 0 0 0 0 0 0
1st month on PrEP
Number of clients initiated on PrEP and on their 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3rd month on PrEP

Number of clients initiated on PrEP and on their 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

3rd month on PrEP and re-tested for HIV

Number of clients on their 3rd month on PrEP re- 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

tested for HIV and tested HIV Positive

Number of clients on their 3rd month on PrEP re- 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

tested for HIV and tested HIV negative
Number of clients initiated on PrEP and on their 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
6th month on PrEP
Number of clients initiated on PrEP and on their 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
12 month on PrEP
Number of clients initiated on PrEP and on their 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
18 month on PrEP
 45-49 50+ Total
FS DC FS DC
F M F F M F FS DC

1 1 0 0 0 0 2 3

1 1 0 0 0 0 2 3

0 1 0 0 0 0 0 3

1 1 0 0 0 0 2 4

1 1 0 0 0 0 2 4

1 1 0 0 0 0 2 3

0 0 0 0 0 0 0 3

0 0 0 0 0 0 0 0

0 0 2 0 1 0 0 15

0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0

0 0 1 0 0 0 0 5
1 0 0 0 0 0 0 3
0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0
 HIV testing & PrEP Monthly Report Form
Facility/DIC: Bishoftu Hospital
Date: 21/4/2013-20/5/2013
Period start date:
PrEP REPORTING (FROM PREP REGISTER)
AGE (YEARS) 15-19 20-24 25-29 30-34 35-39 40-44
Catagories FS DC FS DC FS DC FS DC FS DC FS DC
SEX F M F F M F F M F F M F F M F F M F
Oral PrEP screening
Number of PrEP target groups visited facility 0 0 0 0 0 0 0 2 1 0 0 0 0 1 0 0 0 0
during the reporting period
Number of clients undergoing PrEP risk 0 0 0 0 0 0 0 2 1 0 0 0 0 1 0 0 0 0
assessment during the reporting period

Number of clients assessed to be at high risk of 0 0 0 0 0 0 0 2 1 0 0 0 0 1 0 0 0 0

HIV infection during the reporting period
Number clients found eligible for and offered 0 0 0 0 0 0 0 2 1 0 0 0 0 1 0 0 0 0
PrEP during the reporting period
Number clients offered PrEP during the reporting 0 0 0 0 0 0 0 2 1 0 0 0 0 1 0 0 0 0
period
Number of clients initiating PrEP during the 0 0 0 0 0 0 0 2 1 0 0 0 0 1 0 0 0 0
reporting period

Number of clients declined PrEP during the 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

reporting period
Clients on oral PrEP

Number of oral PrEP clients at facility in previous 0 0 0 0 0 0 0 0 3 0 0 0 0 0 0 0 0 2

month

Number of clients transferred in 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of clients opting out 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of client’s get out of HIV risk 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of client’s clinician has decided to
withdraw 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients transferred out 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients sero-converted 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients died 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients LTFU 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of oral PrEP clients at facility this
month_PrEP_CURR 0 0 0 0 0 0 0 2 4 0 0 0 0 1 0 0 0 2
Number of clients initiated on PrEP and on their
1st month on PrEP 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients initiated on PrEP and on their
3rd month on PrEP 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of clients initiated on PrEP and on their

3rd month on PrEP and re-tested for HIV 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of clients on their 3rd month on PrEP re-

tested for HIV and tested HIV Positive 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of clients on their 3rd month on PrEP re-

tested for HIV and tested HIV negative 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients initiated on PrEP and on their
6th month on PrEP 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients initiated on PrEP and on their
12 month on PrEP 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients initiated on PrEP and on their
18 month on PrEP 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
m

45-49 50+ Total

FS DC FS DC
F M F F M F FS DC

0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0

0 0 1 0 0 0 0 6

0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0

0 0 1 0 0 0 0 10

0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0
 HIV testing & PrEP Monthly Report Form
Facility/DIC: Bishoftu Hospital
Date: 21/5/2013-20/6/2013
Period start date:
PrEP REPORTING (FROM PREP REGISTER)
AGE (YEARS) 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50+ Total
Catagories FS DC FS DC FS DC FS DC FS DC FS DC FS DC FS DC
SEX F M F F M F F M F F M F F M F F M F F M F F M F FS DC
Oral PrEP screening
Number of PrEP target groups visited facility 0 0 0 0 0 0 0 0 0 0 2 1 0 0 0 0 0 0 0 0 0 0 0 0 0 3
during the reporting period
Number of clients undergoing PrEP risk 0 0 0 0 0 0 0 0 0 0 2 1 0 0 0 0 0 0 0 0 0 0 0 0 0 3
assessment during the reporting period

Number of clients assessed to be at high risk of 0 0 0 0 0 0 0 0 0 0 2 1 0 0 0 0 0 0 0 0 0 0 0 0 0 3

HIV infection during the reporting period
Number clients found eligible for and offered 0 0 0 0 0 0 0 0 0 0 2 1 0 0 0 0 0 0 0 0 0 0 0 0 0 3
PrEP during the reporting period
Number clients offered PrEP during the reporting 0 0 0 0 0 0 0 0 0 0 2 1 0 0 0 0 0 0 0 0 0 0 0 0 0 3
period
Number of clients initiating PrEP during the 0 0 0 0 0 0 0 0 0 0 2 1 0 0 0 0 0 0 0 0 0 0 0 0 0 3
reporting period

Number of clients declined PrEP during the 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

reporting period
Clients on oral PrEP

Number of oral PrEP clients at facility in previous 0 0 0 0 0 0 0 2 4 0 0 0 0 1 0 0 0 2 0 0 1 0 0 0 0 10

month

Number of clients transferred in 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of clients opting out 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of client’s get out of HIV risk 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of client’s clinician has decided to
withdraw 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients transferred out 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients sero-converted 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients died 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients LTFU 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of oral PrEP clients at facility this
month_PrEP_CURR 0 0 0 0 0 0 0 2 4 0 2 1 0 1 0 0 0 2 0 0 1 0 0 0 0 13
Number of clients initiated on PrEP and on their
1st month on PrEP 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of clients initiated on PrEP and on their

3rd month on PrEP 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of clients initiated on PrEP and on their

3rd month on PrEP and re-tested for HIV 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of clients on their 3rd month on PrEP re-

tested for HIV and tested HIV Positive 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of clients on their 3rd month on PrEP re-

tested for HIV and tested HIV negative 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients initiated on PrEP and on their
6th month on PrEP 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients initiated on PrEP and on their
12 month on PrEP 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients initiated on PrEP and on their
18 month on PrEP 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
 HIV testing & PrEP Monthly Report Form
Facility/DIC: Bishoftu Hospital
Date: 21/5/2013-20/6/2013
Period start date:
PrEP REPORTING (FROM PREP REGISTER)
AGE (YEARS) 15-19 20-24 25-29 30-34
Catagories FS DC FSW DC FSW DC FSW DC
SEX F M F F M F F M F F M F
Oral PrEP screening
Number of PrEP target groups visited facility 0 0 0 0 1 0 0 2 0 0
during the reporting period
Number of clients undergoing PrEP risk 0 0 0 0 1 0 0 2 0 0
assessment during the reporting period

Number of clients assessed to be at high risk of 0 0 0 0 1 0 0 2 0 0

HIV infection during the reporting period
Number clients found eligible for and offered 0 0 0 0 1 0 0 2 0 0
PrEP during the reporting period
Number clients offered PrEP during the reporting 0 0 0 0 1 0 0 2 0 0
period
Number of clients initiating PrEP during the 0 0 0 0 1 0 0 2 0 0
reporting period

Number of clients declined PrEP during the 0 0 0 0 0 0 0 0 0 0 0 0

reporting period
Clients on oral PrEP

Number of oral PrEP clients at facility in previous 0 0 0 0 0 0 0

month

Number of clients transferred in 0 0 0 0 0 0 0 0 0 0 0 0

Number of clients opting out 0 0 0 0 0 0 0 0 0 0 0 0
Number of client’s get out of HIV risk 0 0 0 0 0 0 0 0 0 0 0 0
Number of client’s clinician has decided to
withdraw 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients transferred out 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients sero-converted 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients died 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients LTFU 0 0 0 0 0 0 0 0 0 0 0 0
Number of oral PrEP clients at facility this
month_PrEP_CURR 0 0 0 0 0 0 0 5 3 0 1 0
Number of clients initiated on PrEP and on their
1st month on PrEP 0 0 0 0 0 0 0 2 1 0 0 0
Number of clients initiated on PrEP and on their
3rd month on PrEP 0 0 0 0 0 0 0 0 0 0 0 0

Number of clients initiated on PrEP and on their

3rd month on PrEP and re-tested for HIV 0 0 0 0 0 0 0 0 0 0 0 0

Number of clients on their 3rd month on PrEP re-

tested for HIV and tested HIV Positive 0 0 0 0 0 0 0 0 0 0 0 0

Number of clients on their 3rd month on PrEP re-

tested for HIV and tested HIV negative 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients initiated on PrEP and on their
6th month on PrEP 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients initiated on PrEP and on their
12 month on PrEP 0 0 0 0 0 0 0 0 0 0 0 0
Number of clients initiated on PrEP and on their
18 month on PrEP 0 0 0 0 0 0 0 0 0 0 0 0
ly Report Form

GISTER)
35-39 40-44 45-49 50+ Total
FSW DC FSW DC FSW DC FSW DC
F M F F M F F M F F M F FSWDC

0 0 0 0 0 0 0 0 0 0 0 0 0 3

0 0 0 0 0 0 0 0 0 0 0 0 0 3

0 0 0 0 0 0 0 0 0 0 0 0 0 3

0 0 0 0 0 0 0 0 0 0 0 0 0 3

0 0 0 0 0 0 0 0 0 0 0 0 0 3

0 0 0 0 0 0 0 0 0 0 0 0 0 3

0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 2 0 0 1 0 0 0 1 0 0 0 0 13

0 0 0 0 0 0 0 0 0 0 0 0 0 3
0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0