Pediatric Hiv Exposure Reporting (Pher) - U.s. Department Of Health & Human Services Page 3
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414a. If no antiretroviral drug was received during labor and delivery, check reason.
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Precipitous delivery/STAT
HIV serostatus of mother
Mother tested HIV-
Other (Specify.)
Cesarean delivery
unknown
negative during
________________________
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Prescribed but not administered
Birth not in hospital
pregnancy
Not documented
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Mother refused
Unknown
15. Was mother referred for HIV care after delivery?
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Yes
No (Go to 18.)
Not documented (Go to 17.)
Record not available (Go to 17.)
Unknown
16. If yes, indicate first CD4 result or first viral load after discharge from hospital
(up to 6 months after discharge).
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16a. CD4 result
16b. Viral load
Not done
Not available
Not done
Not available
Result
Unit
Date blood drawn
Result in copies/mL
Result in logs
Date blood drawn
(mm/dd/yyyy)
(mm/dd/yyyy)
__ __ __ __
cells/µL
__ __/__ __/__ __ __ __
________________
_____________
__ __/__ __/__ __ __ __
__ __
%
__ __/__ __/__ __ __ __
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17. Birth information
Birth not in hospital
Record not available
Time
Date
Time
Date
(See military
(mm/dd/yyyy)
(See military
(mm/dd/yyyy)
time.)
time.)
Onset of labor
__ __:__ __
__ __/__ __/__ __ __ __
Rupture of membranes
__ __:__ __
__ __/__ __/__ __ __ __
Admission to labor
__ __:__ __
__ __/__ __/__ __ __ __
Delivery
__ __:__ __
__ __/__ __/__ __ __ __
and delivery
Military time: noon = 12:00; midnight = 00:00
18. If Cesarean delivery, mark all the following indications that apply.
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HIV indication (high viral load)
Mother’s or physician’s preference
Other (e.g., herpes, disproportion)
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(Specify)_______________________
Previous Cesarean (repeat)
Fetal distress
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Not specified
Not applicable
Malpresentation (breech, transverse)
Placenta abruptia or p. previa
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Prolonged labor or failure to progress
19. Was mother’s HIV serostatus noted on the child’s birth record?
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No
Yes, HIV-positive
Yes, HIV-negative
Record not available
Unknown
20. Were antiretroviral drugs prescribed for the child during the first 6 weeks of life?
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Yes (Complete table.)
No (Go to 20a.)
Not documented
Record not available
Unknown
Drug name
Other
Drug
Date drug started
Time started
Drug stopped
Stop date
Stop codes
(See list.)
(specify)
refused
(mm/dd/yyyy)
(See military
Yes No ND
UNK
(if therapy not completed)
(See list on
time.)
(mm/dd/yyyy)
p. 8.)
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i. ____________
___________
__ __/__ __/__ __ __ __ _____ : _____
__ __/__ __/__ __ __ __
__________
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□ □ □ □
ii. ____________
___________
__ __/__ __/__ __ __ __ _____ : _____
__ __/__ __/__ __ __ __
__________
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□ □ □ □
iii. ____________
___________
__ __/__ __/__ __ __ __ _____ : _____
__ __/__ __/__ __ __ __
__________
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□ □ □ □
iv. ____________
___________
__ __/__ __/__ __ __ __ _____ : _____
__ __/__ __/__ __ __ __
__________
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v. ____________
___________
__ __/__ __/__ __ __ __ _____ : _____
__ __/__ __/__ __ __ __
__________
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vi. ____________
___________
__ __/__ __/__ __ __ __ _____ : _____
__ __/__ __/__ __ __ __
__________
Military time: noon = 12:00; midnight = 00:00
20a. If no antiretroviral drug was prescribed during the first 6 weeks of life, indicate reason.
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HIV serostatus of mother unknown
Other (Specify.) __________________________________________
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Mother known to be HIV-negative during pregnancy
Not documented
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Mother refused
Please include comments or clinical information you consider relevant to the overall understanding of this child’s HIV
exposure or infection status. State the date and source of the information.
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