Affix Recency ID bar code here:

Ministry of Health

Recency Surveillance and Laboratory Requisition Form

Instructions: Use one form for every new HIV positive client
aged 15 years or older identified at your site. Confirm age
before starting. Send completed form with sample (if collected) to the RTRI lab for data testing entry.
NB: Everyform should be sentto RTRI testing labfor data entry regardless ofcompletlon status.
SN Question/Item Response
1. Site MFL

2. Site Name
3. Date of enrollment/encounter (day/mo/year)
4. HTS Counselor/ProviderName
5. Initial Testing Locations or strategy where HTS was OPD TB Clinic
provided today (select one) OIPD VMMC
Casualty/ Emergency I STI

ANC first visit OVCT-Health facility

ANC-follow up visit OVCT-Community
Maternity (labor and Mobile/ Outreach
delivery)
Postnatal Clinic OKP drop-in centers
KP mobile/outreach
SNS/SNT Index testing-
Facility Other specify
OSNS/SNT Index testing
Community
5a. Ever had an HIV self-test in the past 12 months?
Yes
Note: The self-test does not quolify as tested before. Only tests No
performed by a HTS provider willbe accepted as ever tested
b. Age in years
yearsIfless than 15 years STODP
Note: If age less than 15 years STOP, not eligible OUnknown
for Recency Refuse to answer
7. Sex ofclient Male Female Decline to answer
8. Is today the first time you have received a positive OYes q11
HIV diagnosis from a provider? ONo, I received a positive diagnosis LESS THAN 6
months ago. Q9
(E.g, Client may disclose thot s/he already knew they were
positive, seek clarificotion on tlming of previous diagnosls.
No, I received a positive diagnosis MORE THANN6
months ago. STOP.

1
FO6 Recency Surveillance and Laboratory Requisition Form_V1.1_13Apr2021
 This question does not include receiving apositive HIV
diagnosis through self-testing)_
9. At last positive
diagnosis LESS THAN 6 months ago, OYesSTOP
did you agree to
participate in recency testing? No Q10
Provider to glve short explanation of
recency testing to assist
with accurate recall. OUnknown>Q10
10. Are you
currently taking or have you ever taken NoQ11
anti-retroviral therapy (ART) treatment? OYes, currently on ARTSTOP
Note: This is referring
s enrolled later
only to ART treatment (HAART) f client Yes, ever taken ART > STOP
questions will ask about PEP and PrEP history.
OUnknownQ11
11. Read the verbal informed consent Refuse to answer Q11
script. Client declines to enroll> Q12
After reaching end of script and
answering any Client accepts to participate Q13
questions, ask client if s/he would like to
participate.
12. ONLY FOR PERSONS DECLINING: U Do not have time to
Reason for declining (tick all that apply) participate
Not interested
OFear of needles or blood draw
Need partner permission to participate
Thank client, STOP.
Don't see the benefit
No reason
Other, specify:.
Questions for Persons who Consent
IMPORTANTNOTE: Do not enter any names in ID fields If ID used by
13: HTS ID/ANC ID facility has names, then leave blank.
Serlal no. in reglster

14. eHTs ID Not available

fsite Is using eHTS opp
15. For provider:
Yes, providing or will be asked
Not available
Is this client involved in PNS
(either providing
to provide additional
partner name(s)
partner name(s) and/or as a named partner)?
all that apply) (Tick Yes, identified through PNSs
No
16. Marital status OUnknown
Single
Married/cohabitating monogamous
Married/cohabitating polygamous
Separated/Divorced
OWidowed
OUnknown
17. In what Refused to answer
county do you
currently live (stay)?
Unknown
Other, specify
Refused to answer

FO6Recency Surveillance and Laboratory Requisition Form_V1.1_13Apr2021 2

 Afflix Recency ID barcode here:

18.
In what sub-county do you currently live (stay1?
OUnknown
Refused to answer
19. How long have you been living in? (RESPONSE TO Since Birth
17/18) Less than or equal to 6 months
Between 6 months and 12 months
More than 12 months
Unknown
Refused to answer
20. Have you been away from location (RESPONSE TO Yes
17/18) f 3 or more nights in the last 6 months? No
DUnknown
Refused to answer
21. Have you been tested for HIV previously before | OYesQ22
today? No Q23
Unknown023
Refused to answer 023
22. When were you last tested for HIV before today? Tested <6 months ago
Tested 6-12 months ago
Tested 13-24 months ago
Tested more than 2 years ago
Unknown
Refused to answer
23. Are you currently taking or have you ever taken
No
Post-exposure prophylaxis (PEP) anti-retroviral OYes, currently on PEP
drugs? OYes, ever taken PEP
OUnknown
Interviewer: If yes verify Q21 response if Q21 was no.
Refuse to answer
24. Are you currently taking or have you ever taken No
Pre-exposure prophylaxis (PrEP) anti-retroviral OYes, currently on PrEP
drugs? Yes, ever taken PrEP
OUnknown
intervlewer: If yes verfy Q21 response if Q21 was no.
Refuse to answer
25. Are you currently pregnant? Yes
No
Intervlewer: If cllent is male, select Not applicable (male OUnknown
clients) Refuse to answer
Not applicable (male clients)

3
FO6_Recency Surveillance and Laboratory Requlsition Form_V1.1 13Apr2021
 .

Escort client to
designated point for phlebotomy or next
client reaches phlebotomy then answer point in agreed recency facility flow and
ensure
26. Was client
escorted to questlons 26 and 27.
designated point for OYes Q28
phlebotomy?
27. If client not escorted to phlebotomy, what No Q27
were
the reasons? OPhlebotomist not available
Blood collection supplies
not available
28. For
provider to complete before RSLRF/sample Other Issues, specify
are taken to the RTRI OYes, confirmed positive
testing lab, If avallable:
OYes, negative> record details in
Did the client
complete retesting for Yes, result inconclusive record notes
details in
of HIV today (2nd tester testing)? confirmation No, not yet done notes
29. For provider to
complete Unknown
before RSLRF/sample are Standard CCC number format:
taken to the RTRI
testing
lab, if avalilable:
Use this field only if facility uses
CCC Number non-standard CCC number format:
30. Enrolling (into care and Not available
treatment)Staff Namme
Enrolling Staff Phone
31. Notes (fill in if required
only):

Faciity Laboratory/Phlebotomist Use

32 Name of
phlebotomist:
33 Date sample collected: (day/month/year)

34 Time sample collected: (HH:MM) 24-hour clock

35 Sample description H hmm

Venous blood
Capillary blood
None; attempted but blood draw
STOP unsuccessful
36 Type of tube used None, client refused blood draw> STOP
4ml EDTA
6ml EDTA
5ml PPT
37 Notes (if required): 1mL Microtainer tube

FO6 Recency Surveillance and Laboratory Requistion

Form_V1.1_13Apr2021
 Afflx Reconcy ID barcode here:

RTRI Tostlng Laboratory Use

38| Name of RTRI Testing Laboratory
39 RTRI Testing Lab Slte MFL

40 Name of person recelvln8

41 Was the RSLRF accompanled by a sample? Yes

NoQ53
42 Date sample recelved: (day/month/year)

13 Time sample recelved: (HH:MM) 24-hour clock

44 Sample type recelved?

h hm
mm
Whole blood
45 Sample quality on receipt (tick all that apply) Plasma
Good
Hemolysed STOP
Clotted sample > STOP
Broken sample tube STOP
Other, specify . STOP

46 Date sample tested for recency: (day/month/year)

47| Time sample tested: (HH:MM) 24-hour clock

48 Assay used for recency DAsante

Other, specify.

FO6 Recency Survellance and Laboratory Requisitlon Form_V1.1_13Apr2021

 49 Result interpretation:
Long term (LT) >Q50
Invalid if: Recent Q50
ONegative > Alert Recency Surveillance POC &
1) IfC line is not visible, OR
record in notesQ50
Invalid Alert Recency
2) If C and LT lines are vislble, record in notesQ50
Surveillance POC &
but V line is not,

If result is invalid, repeat

test again. If repeatedly
invalid after two or more
attempts, report "Invalid"
as the final result.

If result is RTRI
negative
(with "C" line but no "V"
line) record result in the
notes and repeat the test
one more
time.If results of
the repeat test are still RTRI
negative, report "RTRI-
negative" as final result.
50
Performed by (Name):
Signature Date:
Reviewed by (Name): Signature:
Interviewer: 1f RTRI test result is long-term/invalid/negative _Date:
51 For samples with a RECENT result, what quantity of >Q53
plasma was prepared? Plasma 2 1ml
Plasma <1ml
52 Sample sent for Yes VL Lab sent
Viral Load (VL): to:. (fill VL LRF)
NoIf no, indicate reason:
Datesent (day/mo/year):
53 Notes: d m y yy
Instructions after Asante testing:
1. If sample is to be
sent for VL, then
tracking forms using the Recencysample
VL LRF and process with other routine VL
samples and include on routine
2. Give Surveillance ID.
completed RSLRF designated RTRI testing lab
to
data entry person for data entry.

FO6 Recency Surveillance and Laboratory Requisition 6

Form_V1.1_13Apr2021