South West London HIV & GUM Clinical Services Network
SWAGNET ANTIRETROVIRAL ADVICE
The ART Advice Team consists of Drs Phillip Hay, Phillip Rice, Tariq Sadiq, and John Watson. Available members will meet every Tuesday at St George's and will discuss all requests submitted by email or fax. Requests must be received before 9am on Tuesday if they are to be considered that week. A reply will usually be sent to clinicians by Friday afternoon of the same week via email with a hard copy to follow in the post. So that optimal advice can be given please provide full details by following the procedure below : type details directly onto this form and return it as an attachment to art.advice@stgeorges.nhs.uk alternatively print off the form and complete by hand then Fax to 020 8725 2736 please send copies of ALL relevant resistance assay reports (send by fax or scan & attach to an email)
ART Advice request submitted on ………….….(date) 1- Clinician details Name : Main Place of work : Address : Phone contact (urgent) : Phone contact (routine) : Email address : Fax :
by email / fax (delete)
2- Patient details Patient Number : DOB : Sex : HIV acquisition group : Ethnicity : Initials : Age :
2 Date of HIV diagnosis : Date of AIDS diagnosis (if applicable) :
3- Treatment History, with CD4 and viral load responses First CD4 : Lowest CD4 : Date : Date :
Enter other results below with most recent first :
Date :
Viral load :
CD4 :
Concurrent ART:
Details of all ART regimes : Regime Start date Stop date Reasons for stop/switch
3 4-Resistance tests Please list all resistance test done and where Include exact date in relation to treatment history. Please FAX copies of ALL relevant resistance tests to 020 8725 2736 and note here how many you have sent and the date of them.
5-Therapeutic drug monitoring If relevant to present regimen.
6-Co-morbidities Hepatitis B or C status Peripheral neuropathy. Lipodystrophy Abnormal Liver function at present (Bilirubin, Albumin, INR, AST or ALT and Alk phos) Any Hyperlactaemia on previous regimens Any concern re cardiac risk factors Other relevant medical problems
7- Other relevant medication / recreational drug use
4 8-Adherence Has the patient seen a specialist adherence support provider?
What adherence problems have their been with previous regimens?
How does the patient cope or what are their preferences regarding; Tablet number Tablet size Swallowing of tablets Freq of dosing e.g od, bd , tds. Food restrictions including requirement to take with food and DDI restrictions.
Does the patient have a tendency to stop regimens without advice? What has the patients’ tolerance of previous regimens been like (include an assessment of all drug classes used).
9-Patient issues What do they want to do Wishes for pregnancy Feelings about S/C Injections Any Lifestyle issues
10-Considered regimen if any
5 Teams recommendations and why
Case flagged for use at ART Discussion Group
YES / NO