Annexure III.

ICTC

ICTC Code

Monthly Input Formats for Integrated Counseling and Testing Centres (ICTC)
Sections A and C common for all ICTC Clients
Section B for all clients excluding Pregnant women
Section D for Pregnant women
Section E for HIV-TB collaboration for all ICTC clients
Identification
1. Name of ICTC:
2. Address:
City:

Pin Code:

District:

Block:
State:

3. Reporting Period:

Month

Year

4. Name of Officer In-charge (ICTC):

5. Contact number (phone):
6. Email Address:
7. Type of ICTC:
8. ICTC Location:

Section A : Summary Table : Status for the month

Indicator (All fields are auto-generated from other sections)

ICTC Clients
(excluding Pregnant
women)

1. Total clients registered at ANC this month

ICTC Clients -Pregnant

women/ Breastfeeding
Mothers

Total ICTC

116

116

2. Number of clients provided pre-test counseling

139

116

255

3. Number of clients tested for HIV

139

116

255

4. Number of Clients received results within 7 days of HIV test

139

116

255

5. Number of clients provided post-test counseling and given results

139

116

255

7. Total number of pregnant/breastfeeding women who are on lifelong

ART and babies who are initiated on syrup Nevirapine (6weeks/12
weeks)-MB Pair

7.1 Number of babies tested first time under EID

7.2 Number of babies tested for confirmatory test beyond 18 months of

age

7.3 Number of babies found HIV positive out of tested (row 7.2) beyond
18 months of age

6. Number of clients diagnosed HIV positive (after 3 specified tests)

8. Number of ICTC clients referred to RNTCP (TB Microscopy center)

14

14

9. Number of HIV infected TB patients out of above

Annexure III.h

ICTC

ICTC Code
Section B: Progress Made During the Month by the ICTC [All clients excluding pregnant women]
Client initiated

i. Details of client's visit to ICTC and HIV tests undertaken (excluding pregnant women)

Provider initiated

Total

Male

Female

TS/TG

Male

Female

TS/TG

1. Number of clients received pre-test counseling/information

85

34

11

139

2. Number of clients tested for HIV (Row is Blocked - Auto Generated from iii.a Age-wise distribution)

85

34

11

139

3. Number of clients received result within 7 days of HIV Test

85

34

11

139

4. Number of clients receiving post-test counseling and given results

85

34

11

139

5. Number of clients diagnosed HIV positive (after three tests) (Row is Blocked - Auto Generated from iii.a Age-wise
distribution)

6. Number of clients received follow-up counseling

Male

Female

TS/TG

Total

0
0

0
0

0
0

0
0

ii. HIV Status of spouse/partner

HIV Status of spouse/partner

1. Number of spouse/partners of HIV positive clients tested
2. Out of Above Number of spouse/partners diagnosed HIV positive(after 3 specified Tests)
iii. Composition of clients undergoing HIV test/diagnosed positive and route of transmission

iii.a. Age-wise distribution

iii.a. Age-wise distribution

1. 14
2. 15-24
3. 25-34
4. 35-49
5. 50
6. Not specified/unknown
Total

Total Number of clients initiated clients

undergone HIV test

Total Number of client initiated Clients diagnosed HIV positive

Total Number of Provider initiated clients

undergone HIV test

Total Number of Provider initiated Clients diagnosed HIV positive

Male

Female

TS/TG

Total

Male

Female

TS/TG

Total

Male

Female

TS/TG

Total

Male

Female

TS/TG

Total

0
3
35
25
22
0
85

0
2
3
17
12
0
34

0
0
0
0
0
0
0

0
5
38
42
34
0
119

0
0
0
0
0
0
0

0
0
0
0
0
0
0

0
0
0
0
0
0
0

0
0
0
0
0
0
0

3
2
3
3
0
0
11

2
2
0
0
5
0
9

0
0
0
0
0
0
0

5
4
3
3
5
0
20

0
0
0
0
0
0
0

0
0
0
0
0
0
0

0
0
0
0
0
0
0

0
0
0
0
0
0
0

Male
0
0
0
0
0
0
0
0
0
0

Female
0
0
0
0
0
0
0
0
0
0

TS/TG
0
0
0
0
0
0
0
0
0
0

Total

Male

Female

TS/TG

0
0
0
0
0
0
0
22
0
0
0
0
0
0
0
0
0
0
0
0

iii.b. Route of transmission reported by HIV positive cases

iii.b. Route of transmission reported by HIV positive cases
1. Heterosexual
1.a Commercial Partner
1.b Casual/non-commercial, non-regular partner
1.c Regular partner/spouse

2. Homosexual / Bisexual
3. Through blood and blood products
4. Through infected syringe and needles
5. Parent to child (for children)
6. Not specified/unknown
Total
iv. Linkages and referrals
In referral - diagnosed as HIV Positive

In referral - Tested
Departments / Agencies
1. TI NGO / CBO

Male
0

1.3.Injecting Drug Users

1.4. Migrants
1.5. Truckers
2. Non TI NGOs
3. OBG/Maternity Homes
4. RNTCP
5. Blood Bank
6. Government Health Facilities
7. ART centres
8. STI clinics
9. Care centres (CCC)
10. DIC/PLHIV Networks
11. Private Health Facilities
12. Link Worker
13.Uniform forces
14.FICTC Govt(Fixed/Mobile)
15.PPP ICTC (Fixed/Mobile)
16.Whole Blood Screening Facility (PHC/Sub
Centre/ANM)

TS/TG

0
0
0
0
0
0
0
9
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

1.1. Female Sex Workers

1.2. MSM/TG

Female

0
0
0
0
0
0
0
0
11
0
0
0
0
0
0
0
0
0

Repeat test done

(with in 12
months)

Male

0
0
0
0
0
0
0
0
0
20
0
0
0
0
0
0
0
0
0

0
0
0
0
0

Total

Out referral

Female

TS/TG

0
0
0
0
0
0
11
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
11
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

Total
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0

Total

17. Others

85

34

119

Total

96

43

139

11

11

22

v. Details of Occupation
Details of Occupation
1. Agricultural labourer
2. Non-agricultural labourer
3. Domestic servant
4. Housewife
5. Skilled worker
6. Semi skilled worker
7. Petty business/Large business/ small shop/ self employed
8. Service (Govt./ Pvt.)
9. Student
10. Truck Driver/helper
11. Local transport workers ( Auto/Taxi Driver,Handcraft Pullers, Rikshaw Pullers etc)
12. Hotel staff
13. Agricultural cultivator/landholder
14. Unemployed or retired
15. Others
Total

Total Number of clients undergone HIV test

Total Number of clients diagnosed HIV positive

Male

Female

TS/TG

Total

Male

Female

TS/TG

Total

24
8
0
0
18
5
3
0
0
7
0

4
2
2
3
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0

28
10
2
3
18
5
3
0
0
7
0

0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0

0
24
0
7
96

0
0
0
32
43

0
0
0
0
0

0
24
0
39
139

0
0
0
0
0

0
0
0
0
0

0
0
0
0
0

0
0
0
0
0

ICTC Code

Monthly Input Formats for

Section C: Laboratory Information, Consumables, Sta

i. Lab
Description
1. Total number of blood specimens from ICTC tested this month
1.i. Any other HIV tests undertaken (sentinel surveillance, etc.)
2. Number of blood specimens found indeterminate (after 3 HIV tests)
3. Number of blood samples detected Positive in the first week of the quarter ( Jan, April, July, October)
3.i. Out of above number of sample sent for Quality control to SRL/NRL
3.i.a. Out of (3.i) number reported concordant
3.i.b. Out of (3.i) number reported discordant
4. Number of blood samples detected Negative in the first week of the quarter ( Jan, April, July, October)
4.i. Out of the above number of sample sent for Quality control to SRL/NRL
4.i.a. Out of (4.i) number reported concordant
4.i.b. Out of (4.i) number reported discordant

ii. Stock of HIV Test Kits and other Consumables

Consumables

1. HIV test kit 1(No. of tests)

2. HIV test kit 2(No. of tests)
3. HIV test kit 3(No. of tests)
4. Whole Blood Finger Prick
Test (No. of tests)
5. Disposable gloves pairs

Name of Kit

Opening
Stock

Number received
this month

No. of Items
Relocated
(Inside the
District)

6. Condoms pieces
7. Sterile needles
8. Syringes
9. Vials
10. Tubes
11. Vacutainer
12. PEP Drugs
13. Safe Delivery Kits
14. DBS Kit
15. Nevirapine Tablets
16. Nevirapine Syrup 10ml
17. Nevirapine Syrup 25ml
18. Efavirenz 600mg
19. Efavirenz 600mg+Lamivudine 300mg+Tenofovir 300mg
20. Lamivudine 300mg+Tenofovir 300mg
21. Isoniazide 300mg
22. Isoniazide 100mg
23. Pyridoxine 50mg
24. Pyridoxine 25mg
25. Others (Specify)

Number of
positions
sanctioned

Number of
positions filled

1. Counselor

2. Laboratory Technician

Staff type

3. Staff Nurse

4. Outreach Workers

5. ICTC Incharge M O

6. Other Staff (Specify)

iv. Out
Type of Visit
1. Number of visits to (FSW/MSM/TG/IDU) TI project sites/Hotspots
2. Number of visits to key villages
3.a Number of visits to HIV Positive General Clients
3.b Number of visits to HIV Positive Pregnant Women/ Breastfeeding mothers.
4. Number of visits to migrant sites/ trucker halting sites
5. Number of visits to other NGO's/Stakeholders

rmats for Integrated Counseling and Testing Centres (ICTC)

bles, Staffing and Outreach Work (All ICTC Clients including pregnant women)
i. Laboratory Information for ICTC

sumables (Section is Blocked for data entry, please enter data ONLINE)
No. of Items
Relocated
(Outside the
District)

Expired items
returned

Number
Consumed

Control tests

Wastage /
Damage (if
any?)

Closing Stock Batch Number

0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

iii. Staffing Details

Number of staff trained during the month
Number of
positions vacant

Induction

Refresher

HIV-TB

iv. Out Reach Activity by Counselors

No of visits during t
0
0
0
0
0
0

ICTC

ant women)

Units
255
0
0
0
0
0
0
0
0
0
0

Expiry Date*
(dd/mm/yy)

Quantity
Indented

Date of Indent
(dd/mm/yy)

ICTC Team Training

Others

No of visits during the month

0
0
0
0
0
0

ICTC Code

Monthly Input Formats for Integrated Counseling an

Section D: Progress during the month (only fo
i. Pregnancy, delivery and breastf

S. No

1
2
3
4

Indicators (The indicators shown in orange colour are changed in comparision with the existing format.
Please read Data Definition carfully before entering data in these fields)
Number of New ANC Registrations
Number of pregnant women provided pre-test counseling out of all registered
Number of pregnant women tested for HIV
4.(a) Among those diagnosed infected, number in first trimester
Total number of pregnant women diagnosed
4.(b) Among those diagnosed infected, number in second trimester
HIV Infected
4.(c) Among those diagnosed infected, number in third trimester

4.1

Known HIV +ve Clients (detected in previous years from same ICTC / from other ICTC)

Number of pregnant women received results with in 7 days of HIV Test

Number of pregnant women received post-test counseling and given test results

Number of pregnant women referred by the F- ICTC Govt(Fixed/Mobile) who were reactive in the HIV screening
test

7.1
8
8.1
9

Number of pregnant women confirmed HIV positive at ICTC out of the reactive referred by the F- ICTC
Govt(Fixed/Mobile)
Number of pregnant women referred by the PPP ICTC (Fixed/Mobile) who were reactive in the HIV screening test
Number of pregnant women confirmed HIV positive at ICTC out of the reactive referred by the PPP ICTC
(Fixed/Mobile)
Number of spouses/ partners of HIV negative pregnant women tested

9.1

Number of spouses/partners of HIV negative pregnant women found HIV positive

10

Number of spouses/ partners of HIV positive pregnant women tested

10.1

Number of spouses/partners of HIV positive pregnant women found HIV positive

11

Number of HIV positive pregnant women who underwent MTP/Abortion during the month

12

Number of HIV positive pregnant women expected to deliver this month

13

13.(a) In same Facility

Total number of HIV infected deliveries
13.(b) In other Govt hospital
this month:
Number of HIV infected deliveries
conducted this month in other facilitiy
( b ,c ,d) but ART/ARV services for
13.(c) Pvt Hospital/other facility
PPTCT are provided by the same facility:
13.(d) Home Delivery

14.a

Total number of normal (vaginal) deliveries of HIV positive pregnant women during this month

14.b

Total number of deliveries by caesarean section of HIV positive pregnant women during this month

15
Outcome of HIV infected deliveries this
month

15.(a) Number live male child

15.(b) Number live female child
15.(c) Still birth
15.(d) Deaths

16

Total number of pregnant/breastfeeding women who are on lifelong ART and babies who are initiated on syrup
Nevirapine (6weeks/12 weeks)-MB Pair

17

Number of HIV positive Pregnant women/Breast feeding mother only initiated on lifelong ART

18

Number of babies (only) of HIV positive mother initiated on 6 weeks/12 weeks of syrup Nevirapine

19

Number of HIV infected Pregnant women/Breast feeding mother initiated on lifelong ART(same as Sr No 17)

20

Number of HIV positive pregnant women/breastfeeding mother alive and on ART

21

Number of babies (born to HIV positive mother) given ARV prophylaxis for 6 weeks during the month

22

Number of babies (born to HIV positive mother) given ARV prophylaxis for 12 weeks during the month

23
24
25
26
27
28
29
30
31
32
33
34

Number of HIV positive pregnant mother opting for exclusive breast feeding
Number of HIV positive pregnant mother opting for exclusive Replacement feeding
Number HIV positive pregnant women registered at ART center
Number of HIV positive pregnant women whose CD4 count is < 350
Number of HIV +ve Pregnant Women referred to RNTCP Microscopic Center
Number Diagnosed with TB among HIV +ve Pregnant Women
Number of HIV Negative Pregnant Women referred to RNTCP Microscopic Center
Number Diagnosed with TB among HIV Negative Pregnant Women
Number of HIV +ve Pregnant Women tested for Syphilis
Number Diagnosed with Syphilis among HIV +ve Pregnant Women
Number of HIV Negative Pregnant Women tested for Syphilis
Number Diagnosed with Syphilis among HIV Negative Pregnant Women
ii.Age-wise distribution

Agewise Distribution

1. 15-19 years
2. 20-24 years
3. 25-34 years
4. >35 Years
Total
iii. Follow up
Description
A. Visit for DBS

1. Number of infants/children visited

2. Number of infants/children tested for HIV using DBS-DNA PCR
3 (a) No of infants/children who found positive by 1st DNA PCR test
3 (b) No of infants/children who confirmed positive by confirmatory DBS DNA PCR test
4. Number of infants on exclusive breast feeding
5. Number of infants on exclusive replacement feeding
6. Number of infants on CPT
7. No. of infants registered at ART center

B. 18 months
1. Number of children of HIV positive mother beyond 18 months of age who came for follow up
2. Number of children of HIV positive mother beyond 18 months of age who were tested (antibody test)
3. Number of children of HIV positive mother beyond 18 months of age who diagnosed HIV infected
4. Number of children of HIV positive mother beyond 18 months of age registered at ART Centre
iv. Outreach Linkages for HIV Positive Women (By Out Reach Worker)
1.Number of outreach workers
2.Number of HIV positive pregnant women visited at home by the outreach worker during the month
3.Number of HIV positive pregnant women who were expected to deliver this month, visited by the outreach worker
4.Number of HIV positive women visited post delivery
i. Before 6 weeks
ii. 6 weeks to 6 months
iii. 6 months to 12 months
iv. 12 months to 18 months
v. 18 months to till baby breastfed

Monthly Input Formats for Integrated Counseling and Testing Centres (ICTC)
Section D: Progress during the month (only for Pregnant Women )
i. Pregnancy, delivery and breastfeeding
During ANC
Directly in labor

nged in comparision with the existing format.

e entering data in these fields)

During this month

During this month

116
116
116

0
0

agnosed infected, number in first trimester

agnosed infected, number in second trimester

agnosed infected, number in third trimester

registered

TC / from other ICTC)

Total

116
116
116

0
0

Test

116

116

en test results

116

116

Mobile) who were reactive in the HIV screening

sted

nd HIV positive

ed

nd HIV positive

ortion during the month

month

the reactive referred by the F- ICTC

bile) who were reactive in the HIV screening test

the reactive referred by the PPP ICTC

ity

hospital

other facility

ry

nt women during this month

egnant women during this month

male child
emale child

0
0
0
0

0
0
0
0

0
0
0
0

nly initiated on lifelong ART

ks/12 weeks of syrup Nevirapine

nitiated on lifelong ART(same as Sr No 17)

ve and on ART

ylaxis for 6 weeks during the month

ylaxis for 12 weeks during the month

st feeding
acement feeding

0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0

g ART and babies who are initiated on syrup

50
opic Center

croscopic Center
n

Women

BS DNA PCR test

ii.Age-wise distribution

iii. Follow up
First Visit
6 weeks-6 months
6 months -18
months
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

Second Visit
6 months -12
months
0
0
0
0
0
0
0
0

o came for follow up

o were tested (antibody test)
o diagnosed HIV infected

gistered at ART Centre

worker during the month

his month, visited by the outreach worker

ICTC

Total

116
116
116

0
116
116
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Number of pregnant
women tested

Number of
pregnant women
detected infected

1
65

0
0

48
2

0
0

116

0
0
0
0
0
0
0

Third Visit
12 months -18
months
0
0
0
0
0
0
0

Second Visit
12 months -18 months

0
0
0
0
Number
0
0
0
0
0
0
0
0
0

Annexure III.h

ICTC Code
This section captures the report of preceding month and does not include section D (Pregnant Women)
Monthly Input Formats for Integrated Counseling and Testing Centres (ICTC)
Section E for HIV-TB(All Clients Excluding Pregnant Women )
1. REFERRAL OF SUSPECTED TUBERCULOSIS CASES FROM ICTC TO RNTCP
Indicators
a) Number of client received pre-test counseling/information (except pregnant
132
women)
HIV Positive
b) Number of persons suspected to have TB referred to RNTCP Unit

c) Of the referred TB suspects, Number diagnosed as having:

(i) Sputum Positive TB

(ii) Sputum Negative TB

(iii) Extra-Pulmonary TB

Annexure III.h

ICTC

ction D (Pregnant Women)

g Centres (ICTC)
Women )
C TO RNTCP
132
HIV Negative
13

0
0
0