• Effective January 1, 2007, HIV infection cases must be reported by name to the Massachusetts HIV/AIDS Surveillance Program at the MDPH. This is the same way that AIDS cases have been reported to MDPH since 1983.

  • All patients diagnosed with HIV infection who are receiving medical care at your facility should be reported by name. If individuals have been previously reported using the code, the Department expects these individuals to be re-reported by name.

  • State regulations (105 CMR 300) identify HIV and AIDS as reportable diseases and mandate that healthcare providers licensed by the Commonwealth and facilities licensed by the Department (hospitals, clinics or nursing homes) report HIV and AIDS cases. Because persons with HIV infection may receive treatment from different health care providers, the primary medical care provider and/or the facility where care is provided are considered the principal source of HIV case reports. Facilities with large HIV case loads should develop a coordinated reporting plan and designate an individual responsible for reporting.

  • Providers and facilities located outside Massachusetts are not subject to the reporting regulation.

This document provides detailed instructions and guidance for completing the form. Please fill in the form as completely as possible.

DATE FORM COMPLETED

Fill in completely.

DIAGNOSTIC STATUS AT REPORT

Indicate if the patient currently has HIV (not AIDS) or AIDS.

I. HEALTH DEPARTMENT USE ONLY

To be filled in by Massachusetts Department of Public Health personnel.

II. PATIENT INDENTIFIER INFORMATION

This information must be filled in for HIV infection and AIDS cases as it appears on the medical record.

Patient's Legal Name: Fill out completely. If the patient has an alias (e.g. maiden name, married name, birth name, nickname) write the type of alias and the full alias name in the comments field.

Address & Address Type: Indicate the patient's complete current address. This address may be different from the residence at diagnosis section. Indicate the type of address at which the client is currently residing. If the choices do not adequately describe the patient's current living situation, describe the current living situation in the comments section on the back of the form.

Social Security Number: Indicate the entire social security number if it is available. If only the last four digits of the social security number are known, please indicate those. The social security number is used for de-duplication purposes only.

III. DEMOGRAPHIC INFORMATION

Sex at Birth: Indicate sex assigned at birth.

Current Gender Identity: Indicate the patient's gender identity at the time or report.

Date of Birth: Fill in numbers corresponding to the month, day, and year of birth in the designated boxes (Jan= 01, Feb=02, etc.). If the patient has an alias date of birth, indicate that in the comments section.

Example: June 8, 1955=060855

Vital Status: Indicate if the patient is currently alive or dead. If you are unsure of their status, indicate unk. (Unknown).

Date of Death & State/Territory of Death: If the patient is deceased, please indicate the date and location of their death.

Race: Select all that apply.

Ethnicity: Select a single appropriate ethnicity or unknown.

Expanded Ethnicity: If applicable, check all that apply.

Country of Birth: Indicate the patient's place of birth. If the patient was born in Puerto Rico or another US Dependency or Possession, specify the name in the space provided. If the patient was born in another country, specify the country name in the space provided.

Residence at Diagnosis: Complete all relevant items. "Residence at diagnosis" refers to location where person was living at the time they were diagnosed with AIDS or tested positive for HIV infection. The residence at diagnosis may be different than the residence listed in section 2 (II). If you are reporting at HIV (not AIDS) case, report the residence at HIV diagnosis. If you are reporting an AIDS case, report the residence at AIDS diagnosis.

IV. FACILITY OF DIAGNOSIS

Indicate the facility where the patient was diagnosed with HIV if you are reporting a HIV (not AIDS) case. Indicate the facility where the patient was diagnosed with AIDS if you are reporting an AIDS case. Indicate the appropriate facility type where the diagnosis was made.

V. PATIENT HISTORY

Check off either "Yes", "No", or "Unk." (Unknown) for EVERY item.

VI. LABORATORY DATA

Fill in the relevant boxes for all test results available. Please only indicate laboratories that you have test results for. This can include medical records or laboratory results that have been obtained from other sites, but do not include undocumented patient self-reported information. Self-reported information is collected in the Testing and Treatment History section (VIII) on the back of the form.

HIV Antibody Tests at Diagnosis
Indicate the first antibody test and test type. Other HIV antibody tests can include, but are not limited to, rapid tests and HIV-1 IFA tests.

Positive HIV detection tests
Indicate the earliest HIV-1 RNA viral load test and complete the copies/ml and/or log copies result for the test. Viral load tests for HIV-1 RNA include RT-PCR, bDNA and NASBA. Other detection tests can include, but are not limited to, P24 antigen, HIV-1 culture, and HIV-2 culture.

Date of last documented negative HIV test
Please only indicate a result and date if a laboratory result is available. Client or patient self-reported negative tests should be completed in the Testing and Treatment History section (VIII).

HIV diagnosis by Physician: Indicate "YES" if the client was diagnosed by a physician in lieu of a positive HIV Western Blot or viral load result. If "YES", provide the date (month, day and year) that the physician documented the patient's infection. If medical records were obtained from another provider, indicate the date that they first recorded the patient was positive. Do not record an earlier date stated by the patient. The patient's self-report date of diagnosis will be recorded in the Testing and Treatment History section (VIII).

For example if Dr. X wrote on January 1, 2010, "Patient reports that they were first diagnosed in 1998", you would indicate the physician diagnosis date 01/01/10 and 98 in the year field of section 8 (VIII), #2.

Immunologic Lab Tests: Indicate CD4 laboratory results at or closest to current diagnostic status. That is, if the client currently has HIV (not AIDS), then indicate their first CD4 result (absolute count and percentage). For AIDS reports, record the CD4 count and percentage with date at or closest to the date of AIDS diagnosis. This AIDS diagnosis date is typically the date on which an AIDS-defining illness is diagnosed or the specimen collection date of a CD4 count is < 200 cells/μL.

If the client has had a result below 200 OR 14%, then indicate the absolute count and percentage with the date it was collected. Both the absolute and percentage do not have to be below the threshold in order for the client to be considered an AIDS case.

For example, if the client had a CD4 result of 159 and 15%, please indicate both results in the "First <200 or 14%".

VII. AIDS DEFINING CONDITIONS

CLINICAL RECORD REVIEWED: Please check "yes" or "no." A "yes" indicates that a medical record was reviewed to complete the form. A "no" answer indicates that another clinical source, such as a demographic information database, was consulted.

AIDS-defining condition: The most commonly reported AIDS-defining conditions are listed; make sure to indicate if the patient had another aids-defining conditions in the "Other" section using the code list provided in Appendix A. A complete list is also available from the HIV/AIDS Surveillance Unit or online at www.mass.gov/dph/cdc/aids under the Information about Reporting HIV/AIDS section.

VIII. TESTING AND TREATMENT HISTORY (TTH)

This section is based on client self-reported information and should be ascertained from the patient if it is not already currently being collected. It is used to generate a reliable HIV Incidence estimate.

1. Main source of testing and treatment information: If the patient was asked these questions, indicate the date the client was interviewed. If you obtained this information from a medical record review, indicate the date that the majority of the information was first documented.

2. Ever had a previous positive HIV test? Indicate "YES", "NO", "Don't Know/Unknown", or "Refused". If "YES", indicate the date they reported they were first tested positive. An estimated date or year only is acceptable. If you have just administered their first positive HIV test and are reporting it in the laboratory section (VI), leave this question blank and continue onto question 3.

3. Ever tested HIV negative? Indicate "YES", "NO", "Don't Know/Unknown", or "Refused". If "YES", indicate the date of their last negative HIV test. An estimated date or year only is acceptable.

4. Number of negative HIV tests in the 2 years before the first positive test: Indicate estimated or self-reported number of negative tests the client has had in the two years prior to their first positive date.

For example, if the client reports they got tested once a year in the 2 years before their first positive, you would put 02 in the boxes provided.

5. Ever taken any antiretroviral medications (ARVs)? Indicate if the client ever took ARVs prior to their HIV diagnosis or in the 3 months after their diagnosis. If it has not been three months since their diagnosis, indicate their current status.

Indicate what medications they were or are on in the space provided. If there have been multiple regimens changes prior to their first diagnosis, indicate the most recent regimen and the dates that they began and, if applicable, ended it.

Indicate the date the medication was begun and ended, if applicable. Estimates of the beginning and/or ending dates are acceptable.

IX. TREATMENT/SERVICES REFERRALS

Complete all relevant items.

Note: Partner notification assistance is available from the Massachusetts Department of Public Health. Call (617) 983-6940.

IX. COMMENTS

Include any relevant information not collected in the above sections.

PROVIDER INFORMATION

Complete provider name and address information is essential in the event the Massachusetts Department of Public Health needs to follow up on a case. Note: This information will not be transmitted to the Centers for Disease Control and Prevention.

Once form is completed, please mail it an envelope marked "confidential" to MHASP - Room 241, Massachusetts Department of Public Health, 305 South Street, Jamaica Plain, MA 02130.

If you have questions about the HIV/AIDS Confidential Case Report form, call (617) 983-6560.

Appendix A


This information is provided by the Bureau of Infectious Disease within the Department of Public Health.