Form Cdc 50.42b - Pediatric 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) [HIV-1 vs. HIV-2]
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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 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:
Positive/Reactive
Negative/Nonreactive
Indeterminate
Collection Date: __ __ /__ __ /__ __ __ __
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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)
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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)
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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: __ __ /__ __ /__ __ __ __
Documentation of Tests
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Did documented laboratory test results meet approved HIV diagnostic algorithm criteria?
Yes
No
Unknown
If YES, provide date of earliest positive test for this algorithm (specimen collection date if known): __ __ /__ __ /__ __ __ __
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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HIV-Infected
Yes
No
Unknown
Date of diagnosis: __ __ /__ __ /__ __ __ __
If laboratory tests were not documented,
is patient confirmed by a physician as:
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Not HIV-Infected
Yes
No
Unknown
Date of diagnosis: __ __ /__ __ /__ __ __ __
Clinical (record all dates as mm/dd/yyyy)
Diagnosis
Ols
Date
Diagnosis
Ols
Date
Bacterial infection, multiple or recurrent (including
Kaposi’s sarcoma
Salmonella septicemia)
Candidiasis,
Lymphoid interstitial pneumonia and/or pulmonary lymphoid hyperplasia
bronchi, trachea, or lungs
Candidiasis,
Lymphoma, Burkitt’s (or equivalent)
esophageal
Coccidioidomycosis,
Lymphoma, i
disseminated or extrapulmonary
mmunoblastic (or equivalent)
Cryptococcosis,
extrapulmonary
Lymphoma,
primary in brain
Cryptosporidiosis,
Mycobacterium avium complex or M. kansasii,
chronic intestinal (>1 mo. duration)
disseminated or extrapulmonary
Cytomegalovirus disease
M. tuberculosis,
(other than in liver, spleen, or nodes)
disseminated or extrapulmonary
†
Cytomegalovirus retinitis (with loss of vision)
Mycobacterium, of other/unidentified species,
disseminated or extrapulmonary
HIV encephalopathy
Pneumocystis pneumonia
Herpes simplex: chronic ulcers (>1 mo. duration), bronchitis,
Progressive multifocal leukoencephalopathy
pneumonitis, or esophagitis
Histoplasmosis,
Toxoplasmosis of brain,
disseminated or extrapulmonary
onset at >1 mo. of age
Isosporiasis, chronic intestinal (>1 mo. duration)
Wasting syndrome due to HIV
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Has this child been diagnosed with pulmonary
If Yes, initial diagnosis:
Definitive
Date:
If TB selected above,
†
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tuberculosis?
Yes
No
Unknown
indicate RVCT Case Number:
Presumptive
Unknown
CDC 50.42B
Rev. 3/2013
(Page 3 of 4)
—PEDIATRIC HIV CONFIDENTIAL CASE REPORT—
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