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lB SCREENING & IPT.ELIGIBILITY FORM FOR HIV INFECTED PATIENTS ABOYE_[JEARS .I

MINISTRY OF HEALTH, COMMUNITY DEVELOPMENT, GENDER, ELDERLY AND CHILDREN COLLABORATIVE TB/HIV ACTIVITIES
Patient's name: .............................................................Age: ......... Sex: M/F ............. Date: .......... / ........./ ......... ..
Reg. Number: .......................................
Date
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Cough of any duration?
Fever of any duration?
Noticeable weight loss for new patients or
a 3 kgs weight loss 1n a month m
I subsequent visits?
Excessive night sweat of any duration?
• If 'YES' to one or more questions: Continue evaluation according to the TB diagnostic flowchart of the National
Tuberculosis and Leprosy Program (NTLP) by filling table number 2 below:-
• If 'No' to all questions asses for IPT eligibility and repeat TB screening at the subsequent visit (every month)
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Sputum smear /Gene expert
Chest x - ray (if available)
Refer for clinical assessment
Started broad spectrum antibiotics
Started anti - TB treatment
• After ruling out TB disease, assess for IPT contraindications in table 3 and repeat TB screening at the subseguen_t visit(every month)
11· 3. IPT'~ariilaiq'd/c~t}oris (ti~~•alf:t.~~t.a~piy)~f;'.,:;dl;-v~· ·,:. .N 'j' 4:;11~I•incl_µsion (tick approp_riate box) . . ,. I '
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Current/ past history of hepatitis
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History of TB treatment in the past 2 years D Eligible (Answered NO to all questions in table 3)
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 Non-adherence to long term treatment
Alcohol abuse {regular and heavy alcohol DNot eligible (Answered YES to any question in table 3) '<
consumption') Parent/caregiver accepted IPT Yes No
,· Medical contra- indication to INH
c;
If accepted, date IPT started_/_/_ 4
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Symptoms of peripheral neuropathy
S.IPT- Follo-w up visit ·oate
IPT Adherence (write number of.doses missed)
If> 6 doses in 4wks,send patient for adherence
counseling) _ _ _ __
Minor adverse events continue with IPT (write code A1-A5)
Severe adverse events Yes/ No ( If yes, write code A6-A9)
IPT outcome
Refer code number
Codes
Adverse events: A 1. Tingling/ burning sensation A2. Joint pain A3. Mild skin rash
A4. Peripheral neuropathy AS. Abdominal pain A6. Severe skin rash with peeling skin
A7. Hepatitis/ jaundice A8. Disabling peripheral neuropathy A9. Convulsions
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IPT outcome
Refer code number
1. Completed 2. Stopped 3.Died 4. Transferred out
Adherence: Compensation of pills if a client has taken less than 80% (145 doses)
Refer CTC 2: Code 7
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