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HIV COVID-19 Registry

Returning?

A A A

Thank you for agreeing to take part in this important effort on behalf of the global HIV community. Our hope is that information you and others provide will help us understand how the novel COVID-19 virus impacts patients with HIV. We hope to better understand their risk of infection, track outcomes, and use this data to inform treatment.

Please note, this survey is for health care professionals caring for adult HIV patients.

The case report form should take about 5-7 minutes to complete. Patients identifiers such as name or date of birth will not be collected. All information will be kept strictly confidential and will only be shared with researchers compiling information. Information and updates will be shared via the COVID-19 HIV Alliance at https://HIVcovid.org. The success of this collaborative effort depends on active participation by our HIV community to obtain accurate and reliable information.

We ask that you share this site with your colleagues and encourage them to report any cases of COVID-19 in HIV patients. Please include information at time of recovery/improvement, hospitalization or death to allow for enough time to capture data on patients full spectrum of disease.

The COVID-19 Global HIV Alliance

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Date of Survey Entry

* must provide value

M-D-Y

Reporter Name

* must provide value

Reporter email

Reporter Role/Speciality

* must provide value

Infectious Disease Provider

Primary Care Provider

Hospitalist

Nurse

Administrator

Other

If other, please list

* must provide value

Reporter State

* must provide value

Usual HIV Provider

Patient Age

* must provide value

Gender (genetic)

* must provide value

male

female

other

Other gender

Race (may check more than one)

* must provide value

Arab

Black

East Asian

South Asian

West Asian

Middle Eastern

Pacific Islander

Caucasian

Native American

Aboriginal

First Nations

Other

Unknown

Ethnicity

* must provide value

Hispanic / Latino

Not Hispanic / Latino

Unknown / Not available

BMI

Smoking Status

* must provide value

Current smoker

Former smoker

Never smoker

Unknown

Vaping Status

* must provide value

Currently Vapes

Former Vape

Never Vaped

Unknown

Drug Abuse Status (excluding marijuana)

* must provide value

Current regular abuse

Infrequent abuse

Past abuse

Never use

Unknown

When was Initial HIV Diagnosis?

* must provide value

Concurrent with COVID-19

Less than One Year

1-5 Years

More than 5 Years

Unknown

Is CD4 Count Available Pre-COVID or During COVID Infection?
(Pre-COVID Preferred and you will be prompted for value)

* must provide value

Please enter CD4 from timeframe indication in previous question (cells/mm3)

Is HIV Viral Load Available Pre-COVID or During COVID Infection?
(Pre-COVID preferred and you will be prompted for value)

* must provide value

Please enter HIV VL from timeframe indication in previous question (copies/mL)

Pre-COVID-19 AIDS characterization (Ever had an AIDS defining illness or CD4< 200 at any time)

* must provide value

AIDS

Never met AIDS criteria

Not Known

ARV Regimen

Bictegravir/tenofovir alfenamide/emtricitabine

Dolutegravir/abacavir/lamivudine

Dolutegravir/tenofovir alfenamide/emtricitabine

Dolutegravir/tenofovir fumarate/emtricitabine (or 3TC)

Darunavir/cobicistat/tenofovir alfenamide/emtricitabine

Darunavir/ritonavir/tenofovir alfenamide/emtricitabine

Darunavir/ritonavir/tenofovir fumarate/emtricitabine (or 3TC)

Efavirenz/tenofovir fumarate/emtricitabine (Atripla)

Elvitegravir/cobicistat/tenofovir alfenamide/emtricitabine (Genvoya)

Raltegravir/tenofovir alfenamide/emtricitabine

Raltegravir/tenofovir fumarate/emtricitabine (or 3TC)

Rilpivirine/tenofovir alfenamide/emtricitabine

Other

If other ARV regimen- please specify regimen

Was the patient taking any of the following? (select all that apply)

ACE inhibitor

ARB

NSAIDS

PD5 inhibitor

Glucocorticoids

Immune modulators

Biologic agents

Was ACE inhibitor continued?

Yes

No

Was ARB continued?

Yes

No

Were glucocorticoids continued?

Yes

No

Were NSAIDS continued?

Yes

No

Was PD5 inhibitor continued?

Yes

No

Were immune modulators continued?

Yes

No

Were biologics continued?

Yes

No

Check all Comorbidities Patient has Prior to COVID-19 Diagnosis

* must provide value

Obstructive Lung Disease (COPD/moderate or severe asthma

Mild Asthma

Other Lung Disease

Hypertension

Coronary Artery Disease

Congestive Heart Failure

Stroke

Type 2 Diabetes

Chronic Kidney Disease (no Dialysis)

Dialysis

Compensated Cirrhosis

Decompensated Cirrhosis

Organ Transplant

Autoimmune Disease

Pregnant

Post-Partum (< 6weeks)

Cancer

None

Does patient have any concurrent AIDS defining illnesses?

* must provide value

Bacterial infections multiple or recurrent

Candidiasis of bronchi trachea or lungs

Candidiasis of the esophagus

Cervical cancer (invasive)

Coccidioidomycosis disseminated

Cryptococcosis presenting outside of the lung

Cryptosporidiosis intestinal > 1month

Cytomegalovirus (CMV) with loss of vision

Cytomegalovirus disease (other than liver, spleen, or lymph nodes)

Encephalopathy (HIV-related)

Herpes simplex virus (HSV> 1month or other than the skin)

Histoplasmosis, disseminated

Kaposi's sarcoma (KS)

Lymphoid interstitial pneumonia or lymphoid hyperplasia complex

Burkitt lymphoma

Immunoblastic lymphoma

Primary lymphoma of the brain

Mycobacterium avium complex or Mycobacterium kansasii, disseminated

Mycobacterium tuberculosis of any site in or out of the lungs

Mycobacterium or similar species disseminated beyond the lung

Pneumocystis pneumonia

Pneumonia recurrent

Progressive multifocal leukoencephalopathy (PML)

Salmonella septicemia, recurrent

Toxoplasmosis of the brain

Tuberculosis

Wasting syndrome

None

Hepatitis B Status

* must provide value

antibody protected

isolated core

vaccine non-responder, core negative

chronic hepatitis B

immune controller

unknown

Which meds do they take for chronic hepatitis B?

Hepatitis C status

* must provide value

known negative

chronic active

on treatment

successfully treated

unknown

Which meds do they take for HCV?

Date of COVID-19 diagnosis?

M-D-Y

Patient Location When Tested

* must provide value

Home or standalone testing (e.g., mobile testing site)

Nursing home or Assisted living facility

Outpatient facility

Emergency department

Inpatient/hospital

Unknown

Other

Other location at which patient was tested

How was diagnosis made?

* must provide value

Presumptive diagnosis based on symptoms only

PCR

Antibody

Metagenomic testing

CT scan

Laboratory assay, type unknown

Unknown

Other

What other method was used to make COVID-19 diagnosis?

Have they been symptomatic at any time (see symptom list below)

* must provide value

Yes

No

Date of first symptom

* must provide value

M-D-Y

Patient symptoms (select all that apply)

* must provide value

Fever

Headache

Sore throat

Cough

Shortness of breath

Arthralgia

Myalgia

Chest pain

Abdominal pain

Diarrhea

Vomiting or nausea

Rhinorrhea

Irritability/confusion

Malaise

Anosmia (loss of smell)

Aguesia (loss of taste)

None

Other

List other symptom

COVID-19 Treatment (may check more than 1)

* must provide value

Remdesivir

Lopinavir/ritonavir

Chloroquine

Hydroxychloroquine

Azithromycin

IL-6 inhibitors

Bevacizumab

JAK inhibitor

Serpin inhibitor

Ciclesonide

Glucocorticoids (including if given for any complications )

IVIG

Plasma from recovered patients

Therapeutic Anticoagulation

Unknown

None

Other

How many days did they receive remdesivir?

How many days did they receive lopinavir/ritonavir?

How many days did they receive chloroquine?

How many days did they receive hydroxychloroquine?

How many days did they receive azithromycin?

How many days did they receive IL-6 inhibitors?

How many days did they receive Bevzcizumab?

How many days did they receive JAK inhibitors?

How many days did they receive serpin inhibitors?

How many days did they receive ciclosenide inhibitors?

How many days did they receive glucocorticoids?

How many doses of IVIG did they receive?

On how many occasions did they receive plasma from COVID recovered patients? (convalescent plasma)

For how many days did they receive therapeutic anticoagulation for treatment of COVID/COVID related complications?

Other Treatment (specify)

* must provide value

Was the patient hospitalized?

* must provide value

Yes

No

Date of admission

M-D-Y

Date of discharge

M-D-Y

Highest level of hospital care

* must provide value

Supportive care (no supplemental O2)

Supplemental O2

High flow O2

Mechanical ventilator

ECMO

Unknown

Other

Other level of care (specify)

Complications During Hospitalization

* must provide value

ARDS

Bacterial Infection

Cardiomyopathy

Kidney Failure

Multiorgan failure

Sepsis

None

Unknown

Other

Other complications (specify)

What is the patient current status?

* must provide value

Resolved

Symptomatic not hospitalized

Symptomatic remains hospitalized

Deceased

Other

What is date of death?

M-D-Y

Other status (specify)

* must provide value

Date of symptom resolution (if known)

M-D-Y

Unresolved symptoms (select all that apply)

Fever

Headache

Sore throat

Cough

Shortness of breath

Arthralgia

Myalgia

Chest pain

Abdominal pain

Diarrhea

Vomiting or nausea

Rhinorrhea

Irritability/confusion

Malaise

Anosmia (loss of smell)

Aguesia (loss of taste)

None

Other

If other, please define

Date Deceased

M-D-Y

Infection Acquisition: In the 14 days before onset of illness did the patient have any of the following? (Check all that apply)

* must provide value

History of travel to an area with documented cases of COVID-19 infection

Close contact with a confirmed or probable case of COVID-19 infection

Presence in a healthcare facility where COVID-19 infections have been managed

None of the above (community acquired)

Unknown

Other COVID-19 other infection acquisition

If other suspected route of infection, please specify

* must provide value

Are there any laboratory test results available related to this patient's COVID-19 infection?

* must provide value

Yes

No

Absolute WBC count peak during COVID? (k/mm3)

Absolute Neutrophil peak during COVID? (k/uL)

Absolute Lymphocyte nadir during COVID? (k/uL)

Lowest platelet count during COVID? (k/mm3)

Highest ALT during COVID? (IU/L)

Highest AST during COVID? (IU/L)

Highest D-Dimer during COVID? (ng/mL)

Yes

No

Unknown/No Imaging Done

Did patient have hepotomegaly on imaging?

Did patient have splenomegaly on imaging?

Yes

No

Unknown/Not Done

Influenza A

Influenza B

non-SARS COV-2 Coronavirus (COVID-19)

RSV

Adenovirus

Bacterial Lung Infection

Other Respiratory Pathogen

Name of Other Pathogen

Would you like to share any additional information about presentation of this case?

Expand

May we contact you if needed to get more information about this case?

Yes

No

Date of Update Report

* must provide value

M-D-Y

Did Patient Require Admission to an ICU Within 30 Yes Days of SARS-CoV-2 Testing?

* must provide value

Yes

No

If yes number of Days in ICU

Did the patient require circulatory support Within 30 Days of SARS-CoV-2 Testing?

No circulatory support required

Vasopressors

Mechanical circulatory support

Other

If other, please describe

Expand

Initial CXR Findings (on or shortly after the day of COVID-19 diagnostic testing) (Select all that apply)

Normal

Lobar consolidation

Multifocal or patchy opacities

Interstitial abnormalities

Other CXR Findings

If other findings, please describe

Expand

CT Scan Findings (on or shortly after the day of COVID-19 diagnostic testing) (Select all that apply)

Not done

Normal

Lobar consolidation

Multifocal or patchy opacity or ground glass

Interstitial abnormalities

Other CT Scan Findings

If other CT findings, please describe

Expand

Please provide result if procalcitonin was performed and resulted (ng/mL)

Please provide result if C-Reactive protein (CRP) was performed and resulted (μg/mL)

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