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Role of the nurse: to prepare the patient for the DRT by ensuring the patient is adherent for at least one month prior to the test being
done. The nurse can do the resistance test, discuss with an expert to confirm that the patient is eligible, fill in the forms and take the
blood (two purple tubes).

4. Application for third-line treatment

TLART is accessed through the national Adult or Paediatric Peer Review Expert Committees, which consist of experts in
HIV. An application is required, consisting of the patient’s, medical doctor’s, and facility’s details (see Fig 1 below). Of
special importance is the inclusion of an email address as the TLART secretary needs this for communication of the final
recommendation to the nurse. If possible, it is also recommended that the pharmacy’s email address is also included as they
will have to procure the specialist medicines.

Figure 1: Initial details required in the TLART application form

APPLICATION - THIRD LINE ANTIRETROVIRAL THERAPY

PLEASE ENSURE ALL FIELDS ARE COMPLETED BEFORE SUBMITTING

Patient First Name

Patient Surname
Date of Birth Patient number
day/month/year
Identity number Age Gender

Weight BMI (kg/m ) Height (child)
2
FACILITY DETAILS

Facility Name
Province
Doctor In Charge Of Patient/
Authorised Prescriber
Doctor’s Contact Number
Doctor and Pharmacist Email
Addresses
Date
day/month/year
PAST MEDICATION HISTORY
Concurrent
The application form also requests the patient’s treatment history (including any history of TB treatment), adherence and adverse
Timelines
Reason for
TB
Past Regimens Only
effects history, as well as clinical aspects of the patient, such as the past 3 viral load and CD4 count results, and other laboratory
discontinuation
day/month/year
therapy?
results (such as creatinine and creatinine clearance, hepatitis B surface antigen, haemoglobin) (see Fig 2). The TLART Committee
uses the information from the application form and DRT test, together with an algorithm, to design an appropriate regimen for the
Date started
patient.
Date stopped
The last section of the form requests information about any other medicines the patient may be taking, as the Committee must
Date started
also take into consideration possible drug-drug interactions that may occur with TLART and adjust the recommended regimen
accordingly (see Table 2).
Date stopped
Date started
Role of the nurse: to ensure the TLART application is completed in full with the most up-to-date results, as well as to ensure a list of all
the medicines the patient is taking is included.
Date stopped
Date started
Date stopped
HIV Nursing Matters | June 2021 | page 20
Reason for discontinuation codes: SE = Side effect, F= Failure, FC = Formulary change, NC = Non adherent
CURRENT REGIMEN ONLY

Date started
day/month/year Regimen

CHILDREN: PMTCT HISTORY