Introduction

This implementation guide conforms with the following key reporting requirements as identified by the Univeristy of Zambia (University of Zambia, Medical Library, 2017).

How to Report

HIV CBS is routinely generated individual-level information that must be captured using a single case report containing information pertaining only to that person which forms a longitudinal record of treatment and care outcomes. DISI's reference platform architecture provides a centralized data repository that will enable implementers to monitor and measure the full spectrum of the disease from diagnosis to death.

Laboratory data elements must be reported in one or more of the following ways.

1. Lab data can be submitted directly to an EMR electronically provided the communication stream adheres to country laws in regards to privacy & confidentiality. Lab results must be shared with the requesting organization/provider or individual as applicable.
2. Lab data can be submitted directly to a centralized data repository, stripped of all personally identifiable information (PII) and later be routed to an analytics platform for reporting.
3. Lab data can be submitted to an EMR via a health information exchange (HIE). It will be the responsibility of the interoperability layer to facilitate the mediation of the message to the correct destination system.

What to Report

The following list of data elements should be provided for the purpose of HIV case reporting.

• The data elements in scope for this implementation guide are defined by the HIV CBS Minimum Dataset.

• Test requested (must use the LOINC code system for harmonization)
• Device ID
• Test result - measured as copies per milliliter of blood (copies/mL)
• Specimen ID
• Patient age
  • This is calculated using the patient's date of birth.
• Patient gender
• Patient residence country
• Lab order requesting provider name
• Lab order requesting provider zip code
  • Currently not in scope
• Lab examination performing provider name
• Lab examination performing provider zip code
  • Currently not in scope
• Specimen type (must use appropriate codes issued by LOINC or SNOMED)
• Lab order date & time
• Sample collection date
• Patient name (Last name, First name, Middle Initial)
• Patient street address
• Patient contact details with area code
• Patient date of birth
• Lab order requesting provider address
• Lab order requesting provider contact details
• Patient's family members' HIV status
  • Currently not in scope
• Patient's date of enrolment in HIV care
• Patient's date of starting ART
• Patient's ARV regimen (including any regimen switches)
  • Date prescribed
  • Date dispensed
    • Currently not in scope
  • Dose quantity
    • Currently not in scope
• Patient's TB status
  • Currently not in scope
• Patient's transfer out date
  • Receiving organization
• Patient's date of death
• Patient's interruption in treatment (IIT) - lost to follow-up (LTFU)
• Patient's pregnancy status
  • Currently not in scope
• Patient visit dates
• Reason for the patient visit
  • Currently not in scope

Use Cases

The use case diagram for this implementation guide identifies the key functions on offer in order to assist with the various CBS sentinel events associated with HIV.

References