Form Cdc 50.42a - Adult Hiv Confidential Case Report Form Page 3
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4Laboratory Data
(record additional tests in Comments section) (record all dates as mm/dd/yyyy)
HIV Antibody Tests (Non-type-differentiating)
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TEST 1:
HIV-1 IA
HIV-1/2 IA
HIV-1/2 Ag/Ab
HIV-1 WB
HIV-1 IFA
HIV-2 IA
HIV-2 WB
Other: Specify Test: __________________
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RESULT:
Positive/Reactive
Negative/Nonreactive
Indeterminate
RAPID TEST (check if rapid):
Collection Date: __ __ /__ __ /__ __ __ __
Manufacturer:____________________________________________________________________________________________
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TEST 2:
HIV-1 IA
HIV-1/2 IA
HIV-1/2 Ag/Ab
HIV-1 WB
HIV-1 IFA
HIV-2 IA
HIV-2 WB
Other: Specify Test: __________________
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RESULT:
Positive/Reactive
Negative/Nonreactive
Indeterminate
RAPID TEST (check if rapid):
Collection Date: __ __ /__ __ /__ __ __ __
Manufacturer:____________________________________________________________________________________________
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TEST 3:
HIV-1 IA
HIV-1/2 IA
HIV-1/2 Ag/Ab
HIV-1 WB
HIV-1 IFA
HIV-2 IA
HIV-2 WB
Other: Specify Test: __________________
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RESULT:
Positive/Reactive
Negative/Nonreactive
Indeterminate
RAPID TEST (check if rapid):
Collection Date: __ __ /__ __ /__ __ __ __
Manufacturer:____________________________________________________________________________________________
HIV Antibody Tests (Type-differentiating) [HIV-1 vs. HIV-2]
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TEST:
HIV-1/2 Type-differentiating (e.g., Multispot)
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RESULT:
HIV-1
HIV-2
Both (undifferentiated)
Neither (negative)
Indeterminate
Collection Date: __ __ /__ __ /__ __ __ __
HIV Detection Tests (Qualitative)
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TEST 1:
HIV-1 RNA/DNA NAAT (Qual)
HIV-1 P24 Antigen
HIV-1 Culture
HIV-2 RNA/DNA NAAT (Qual)
HIV-2 Culture
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RESULT:
Collection Date: __ __ /__ __ /__ __ __ __
Positive/Reactive
Negative/Nonreactive
Indeterminate
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TEST 2:
HIV-1 RNA/DNA NAAT (Qual)
HIV-1 P24 Antigen
HIV-1 Culture
HIV-2 RNA/DNA NAAT (Qual)
HIV-2 Culture
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RESULT:
Positive/Reactive
Negative/Nonreactive
Indeterminate
Collection Date: __ __ /__ __ /__ __ __ __
HIV Detection Tests (Quantitative viral load) Note: Include earliest test at or after diagnosis
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TEST 1:
HIV-1 RNA/DNA NAAT (Quantitative viral load)
HIV-2 RNA/DNA NAAT (Quantitative viral load)
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RESULT:
Detectable
Undetectable Copies/mL: _________________
Log: ______________ Collection Date: __ __ /__ __ /__ __ __ __
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TEST 2:
HIV-1 RNA/DNA NAAT (Quantitative viral load)
HIV-2 RNA/DNA NAAT (Quantitative viral load)
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RESULT:
Detectable
Undetectable Copies/mL: _________________
Log: ______________ Collection Date: __ __ /__ __ /__ __ __ __
Immunologic Tests (CD4 count and percentage)
CD4 at or closest to current diagnostic status: CD4 count: _________cells/µL CD4 percentage: ____% Collection Date: __ __ /__ __ /__ __ __ __
First CD4 result <200 cells/µL or <14%: CD4 count: _______________cells/µL CD4 percentage: ____% Collection Date: __ __ /__ __ /__ __ __ __
Other CD4 result: CD4 count:
_______________________________cells/µL CD4 percentage: ____% Collection Date: __ __ /__ __ /__ __ __ __
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Documentation of Tests
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Did documented laboratory test results meet approved HIV diagnostic algorithm criteria?
Yes
No
Unknown
If YES, provide specimen collection date of earliest positive test for this algorithm: __ __ /__ __ /__ __ __ __
Complete the above only if none of the following was positive: HIV-1 Western blot, IFA, culture, p24 Ag test, viral load, or qualitative NAAT [RNA or DNA]
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If HIV laboratory tests were not documented, is HIV diagnosis documented by a physician?
Yes
No
Unknown
If YES, provide date of diagnosis: __ __ /__ __ /__ __ __ __
Date of last documented negative HIV test (before HIV diagnosis date): __ __ /__ __ /__ __ __ __
Specify type of test: ____________________________________
Clinical
(record all dates as mm/dd/yyyy)
Diagnosis
Ol
Dx Date
Diagnosis
Ol
Dx Date
Diagnosis
Ol
Dx Date
Candidiasis, bronchi, trachea,
Herpes simplex: chronic ulcers
M. tuberculosis, pulmonary
†
or lungs
(>1 mo. duration), bronchitis,
pneumonitis, or esophagitis
Candidiasis, esophageal
Histoplasmosis, disseminated or
M. tuberculosis, disseminated or
extrapulmonary
extrapulmonary
†
Carcinoma, invasive cervical
Isosporiasis, chronic intestinal (>1
Mycobacterium, of other/unidentified
mo. duration)
species, disseminated or extrapulmonary
Coccidioidomycosis,
Kaposi’s sarcoma
Pneumocystis pneumonia
disseminated or extrapulmonary
Cryptococcosis, extrapulmonary
Lymphoma, Burkitt’s (or equivalent)
Pneumonia, recurrent, in 12 mo. period
Cryptosporidiosis, chronic
Lymphoma, immunoblastic (or
Progressive multifocal
intestinal (>1 mo. duration)
equivalent)
leukoencephalopathy
Cytomegalovirus disease (other
Lymphoma, primary in brain
Salmonella septicemia, recurrent
than in liver, spleen, or nodes)
Cytomegalovirus retinitis (with
Mycobacterium avium complex
Toxoplasmosis of brain, onset at >1 mo.
loss of vision)
or M. kansasii, disseminated or
of age
extrapulmonary
HIV encephalopathy
Wasting syndrome due to HIV
If TB selected above, indicate RVCT Case Number:
†
CDC 50.42A
Rev. 3/2013
(Page 3 of 4)
—ADULT HIV CONFIDENTIAL CASE REPORT—
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