[agency name]

Couples HIV Testing (CHT) – Staff Flow Sheet (completed by staff)

Date: ______CHT-xxx-###

AT Client Number(s) (optional): PartnerA: ______PartnerB: ______PartnerC: ______

Status of request for CHT: Complete this form for all couples, even those that are ineligible

CHT Staff Flow Sheet (vJune2015)(please turn over ->) Page 1 of 3

[agency name]

Couples HIV Testing (CHT) – Staff Flow Sheet (completed by staff)

CHT delivered CHT declined

by client

CHT ineligible, provided individual HIV testing immediately to …

__ both/allpartners

__ one partner

CHT ineligible, offered individual HIV testing

___ both/all refused

___ one partner refused

___ two partners (of three)

CHT Staff Flow Sheet (vJune2015)(please turn over ->) Page 1 of 3

[agency name]

Couples HIV Testing (CHT) – Staff Flow Sheet (completed by staff)

__ two partners (of three) refused

Reason for ineligibility / Reason client declined: ______

______

Test Type: [note: CHT is anonymous POC]

Test Type / Blood Draw
Anonymous / POC
Coded (Non-nominal) / Standard
Nominal

Criteria Met for CHT – Ontarians who are at greatest risk of acquiring HIV

Gay/bi/trans and other men who have sex with men

High risk heterosexual (if yes, choose below)

Heterosexual man or woman from African or Caribbean countries

Heterosexual man or woman from Aboriginal populations

Heterosexual man or woman who uses injection and/or non-injection drugs and/or shares drug equipment

Heterosexual man or woman whose partner is HIV positive

Heterosexual man or woman whose partner is at-risk of HIV (if yes, choose below)

Partner uses injection and/or non-injection drugs and/or shares drug equipment

Male partner has sex with men

Partner is from African or Caribbean countries

Partner is from Aboriginal populations

Protocol Steps Completed (check off as each step is completed)

Step1: Introduce CHT and Obtain Informed Consent (checklist below)

CHT Staff Flow Sheet (vJune2015)(please turn over ->) Page 1 of 3

[agency name]

Couples HIV Testing (CHT) – Staff Flow Sheet (completed by staff)

Step 2: Explore Couples Relationship

Step 3: Discuss HIV Risk Concerns and Reasons for Seeking CHT

Step 4: Discuss Couples Agreement

Step 5: Prepare for, Conduct HIV Test and Provide Results

Step 6: Develop Care, Treatment and Prevention Plan Based on Results

Step 7: Link with Follow-up Services

Informed Consent:

Both / all partners have received and reviewedCHTFrequently Asked Questions (FAQ)

Information about Couples HIV Testing (from the FAQ)

What is CHT

Potential benefits of CHT

Risks of CHT

Expectations of couples participating in CHT

Alternatives to CHT

Discussed related questions / concerns

Reviewed pre-test counselling information for HIV testing generally and information about CHT:

Information about HIV Testing generally:

NOTE: In addition to providing information specific to CHT, counsellors/sites must provide partners undergoing CHT with the same information about HIV testing generally (including both pre-and post-test counselling) as they would if tested individually. Sites are responsible for making their own decisions about how they integrate information pertaining to CHT into their current HIV testing process and check list.

Highlighted points in verbal consent form

Highlighted points in CHT Protocol Step 1: Introduce CHT and Obtain Informed Consent

Informed couple that in event one or more partners test positive, once the couples testing/counselling session is over, the counsellor will arrange a private (one-on-one) follow-up appointment with each individual who tests positive to discuss partner notification, as per usual agency practice (FAQ pg3).

Obtained express verbal consent:

to proceed with CHT from both / all partners

to proceed with individual HIV testing

Document Status of Request for CHT of page 1 of this form

Individual Test Result

HIV Test Result / Partner A / Partner B / Partner C
POC Negative
POC Negative (window period)
POC Negative (window period, declined blood draw)
POC reactive (declined blood draw)
POC reactive (blood draw taken)
POC reactive ((PHL confirmed positive)

NOTE: Consistent with agency practice, sites will continue to track individual HIV test results and the other information required for reporting to the AIDS Bureau using OCHART and the Public Health Laboratory.

If a HIV Reactive test result is obtained, the standard HIV counselling and testing procedures will be followed (in accordance with the Guidelines for HIV Counselling and Testing, Procedures for Anonymous HIV Counselling and Antibody Testing in Ontario (Ministry of Health and Long-term Care, 2008).

Referrals provided: (select all that apply)

CHT Staff Flow Sheet (vJune2015)(please turn over ->) Page 1 of 3

[agency name]

Couples HIV Testing (CHT) – Staff Flow Sheet (completed by staff)

Medical Services

HIV Clinic

AIDS Service Organization (ASO)

Counselling Services (includes support for abuse)

Mental Health Service

Addiction / Harm Reduction Services

Housing

CHT Staff Flow Sheet (vJune2015)(please turn over ->) Page 1 of 3

[agency name]

Couples HIV Testing (CHT) – Staff Flow Sheet (completed by staff)

Sexual Agreement of the Couple (Beginning of Session and End of Session)

From your experience during the session, record each partner’s understanding of their sexual agreement at the start of the session and then at the end of the session.

Put an ‘x’ in the corresponding row – and indicate the conditions, where applicable.

Agreement re: sex with outside partners / Partner A / Partner B / Partner C
START / END / START / END / START / END
Cannot have sex with outside partners
Can have sex with outside partners, without any conditions or restrictions
Can have sex with outside partners, with some conditions or restrictions
Conditions: (Select all that apply)
Safe sex/use condoms
Threesome only
Discuss first, both agree
No anal sex
No receptive anal sex
Insertive anal sex only
No kissing
No friends/exes/co-workers
Be honest
Other ______
Do not have an agreement
Couple has agreed to break up (terminate their relationship)

Risk Reduction Practices about Using Drugs (Beginning of Session and End of Session)

In your experience during the session, record each partner’s safer drug use strategies.

Safer Drug Use Practices / Partner 1 / Partner 2 / Partner 3
START / END / START / END / START / END
N/A – do not smoke/inject drugs
Do not have risk reduction strategies
(i.e., share equipment)
Always use clean equipment
Only share with people they know (partner, friends)
Only reuse own equipment
Other, please specify
______
______

Signature: ______Date: ______

CHT Staff Flow Sheet (vJune2015)(please turn over ->) Page 1 of 3