DATABASE AND REPORT

GENERATION SYSTEM FOR

AUTOMATION OF WORK
AT KIMS - ARCTC
 SYNOPSIS
Objective:
To replace current paperwork database management into fully automated software
system this is much faster for report generation, Data analysis and Data retrieval. It
reduces the space requirements for maintaining Database. It can be modified according
to changing requirements of the hospital.

Introduction:
On completion, this project would expedite the work in all regards. Some of the features
of this software would be:
1. Storing, retrieving and modifying patient data at the ART Centre
2. Generation of following reports:
No of deaths of on ART patients in ART centre.
No. of ANC Cases referred from ICTC to ART.
No. of CD4 tests done.
Monthly monitoring report etc.
3. Patient Follow Up Reminder System (PAFURS)
4. Support Interface for:
Counsellor.
Clinician.
Pharmacist.
Registration Counter
5. Real time Patient Treatment Status.
6. Maintain confidentiality of patient data in various stages at ART centre.
7. User Friendly GUI for easy access, understandable even with very less Training.
8. Other features fully customized for usage by ART Centre.

Project Category:
The project is developed using Relational Database Management System (RDBMS).
A database system is essentially a sophisticated, computerized record keeping system, a
repository for a collection of computerized data files. A database system maintains
information and makes that information available on demand, for this purpose a
database system provides set of facilities to perform such operations.
RDBMS have the following facilities:
1. Retrieving data collectively.
2. Deletion of data.
3. Modification of data.
4. The data stored can be sorted or indexed at users discretion.
5. Various reports can be produced from the system. These may eitherdirection.
be standardized reports or that may be specifically generated according to
Mathematical function can be performed and the data.
6. Specific user definition. Stored in the database can be manipulated with
functions to perform the desired data integrity.
7. To maintain data integrity and database use.
8. Calculations.
9. Providing form based interface for easy accessibility.
10. For multiple users.

2
Tools/Platforms and Language:
Front End System: Visual Basic .net (2009)
Back End System: Microsoft SQL Server 2005 (As it supports unrestricted growth of data
on disk and supports large databases unlike access database)
Supported by: Windows XP, Windows Vista, Windows 7

The project is based on two tier architecture. The two tier architecture user services-
where the application is divided into two logical constituents provide services such as
user interface. (VB .net application in this case). Data Services - Provide handling and
validation of data (Microsoft SQL Server in this case)

3
VISVESVARAYA TECHNOLOGICAL UNIVERSITY,
BELGAUM

A Project Report on

DATABASE MANAGEMENT AND REPORT GENERATION

SYSTEM FOR AUTOMATION OF WORK AT KIMS ARTC (PAAC)
Submitted in partial fulfilment of requirements for the award of
BACHELOR OF ENGINEERING IN MEDICAL ELECTRONICS

SUBMITTED BY

Seema H.S. 1BM06ML022

Madhuri V 1BM06ML015
Vishal Kumar 1BM06ML030

Under the able guidance of

Internal guide: External Guide:

Dr. H.N. Suma Dr. Chinmaya P. Chigateri

Head of Department Scientific Project Coordinator
Department of Medical Electronics Comprehensive Care Support
B M S College of Engineering and ART Center, KIMS Hospital
Bangalore-19

DEPARTMENT OF MEDICAL ELECTRONICS

B M S COLLEGE OF ENGINEERING
4
 B M S College of Engineering
Bull Temple Road, Bangalore - 560019, Karnataka, India.

Department of Medical Electronics

CERTIFICATE

Certified that the project work entitled Database Management and Report Generation
System for automation of work at KIMS ARTC (PAAC) carried out by Vishal Kumar
USN 1BM06ML030, a bonafide student of B M S College of Engineering in partial
fulfilment for the award of Bachelor of Engineering in Medical Electronics of the
Visveswaraiah Technological University, Belgaum during the year 2010. It is certified
that all corrections/suggestions indicated for Internal Assessment have been incorporated
in the Report deposited in the departmental library. The project report has been approved
as it satisfies the academic requirements in respect of Project work prescribed for the said
Degree.

Name & Signature Name & Signature Signature of the

of the Guide of the HOD Principal

External Viva

Name of the examiners Signature with date

1.
2.

5
 Index

I. Introduction
1.1 Antiretroviral Treatment............................................................................13
1.2 Antiretroviral Treatment Centre................................................................16
1.2.1 The goal and principles of ART....................................................16
1.2.2 Stages of ART Treatment.............................................................17
1.2.3 ART Eligibility...............................................................................18
1.2.4 Methodology...............................................................................18
1.2.5 Base Line Investigations...............................................................19
1.2.6 ART Drugs....................................................................................19
1.2.7 Counselling Issues........................................................................19
1.3 ARTC in INDIA..............................................................................................19
1.4 Need of Automation at ARTC......................................................................19
1.4.1 Electronic Medical Record Vs. Paper Records..............................20
1.4.2 Cost Analysis.................................................................................21
1.4.3 Other Advantages.........................................................................22
1.4.4 Report Generation........................................................................24
1.4.5 Scope of Decision making through statistical analysis......24
1.4.6 An Intelligence System..................................................................24
1.5 Development Tools Used.............................................................................25
1.5.1 Advantages of SQL server.............................................................25
1.5.2 SQL Architecture...........................................................................27
1.5.3 APIs supported by SQL Server.....................................................28
1.5.4 .NET Platform................................................................................28
1.5.5 .NET architecture..........................................................................31
II. The Software Development Method
2.1 Software Development Approches. ...........................................................33
2.2 Database Design Considerations.................................................................34
2.2.1 Creating a Database Plan..............................................................35
2.2.2 Normalization...............................................................................37
2.2.3 Data Integrity................................................................................39
2.3 Front End Design Consideration..................................................................41
2.3.1 Principles of User Interface Design...............................................44
2.3.2 Flowchart of patient flow at ARTC................................................45
2.3.3 Projected ARTC operations after automation...............................46
III. The Database
3.1 Introduction.................................................................................................48
3.2 Database Access..........................................................................................49
3.3 Database Tables..........................................................................................50
3.4 Database Diagram......................................................................................59
IV. The User Interface
4.1 Introduction.................................................................................................65
4.2 Integrated Development Environment........................................................66
4.3 Windows Forms...........................................................................................67
4.3.1 The Splash Screen.........................................................................67
4.3.2 The Login Form.............................................................................69

6
 4.3.3 The Registration Form..................................................................72
4.3.4 The Identification Form................................................................73
4.3.5 Personal History Form..................................................................74
4.3.6 Family History Form......................................................................75
4.3.7 HIV Testing Data Form..................................................................76
4.3.8 History of HIV Illness.....................................................................77
4.3.9 History of ARV Treatment Form...................................................77
4.3.10 Clinical and Laboratory Investigations Form..............................78
4.3.11 Investigations Form....................................................................79
4.3.12 Examination Signs......................................................................79
4.3.13 Medical History..........................................................................80
4.3.14 System Review...........................................................................81
4.3.15 Monitoring Follow Up Tests.......................................................82
4.3.16 Contraception and Gyneocological History................................83
4.3.17 Employee Details........................................................................84
4.3.18 Patient FollowUp........................................................................84
4.3.19 Pediatric Patients Form..............................................................85
4.3.20 Report Viewer............................................................................86
4.3.21 ARV Treatment Summary Form.................................................87
4.3.22 Users Form.................................................................................87
4.3.23 MDI Form...88
V. Impact of Implementation.
5.1 Introduction.................................................................................................90
5.2 Country Response Information System(CRIS)..............................................91
5.3 Global Response Database..........................................................................92
5.4 Impact of Information and Automation System in HIV Treatment.............93
5.4.1 Case Study 1- BOTSWANAs AIDS Information System providing
data empowerin Districts......................................................................94
5.4.2 Case Study 2- Ghana CRIS Implementation..................................96
5.5 Comparison of PAAC with CRIS...................................................................97
5.5.1 Main Objective..............................................................................97
5.5.2 User Interface...............................................................................99
5.5.3 Architecture and Tools.100
5.5.4 Report Generation101
5.6 Future Improvisations in the coming versions103

Appendix 1 104
Appendix 2 - Normal Ranges 117

7
List of Figures

Figure 1.1 Prevalence of HIV (WHO 2002)

Figure 1.3.1 Growth of ARTCs in India
Figure 1.5.1 SQL Architecture
Figure 1.5.2 SQL Default Databases
Figure 1.5.3 The .NET architecture
Figure 2.1 Software Development Patterns
Figure 2.3.1 Flowchart of Patient Flow
Figure 2.3. 2 Operations of ARTC after Automation
Figure 3.1.0 the Database Hierarchy
Figure 4.2.1 The PAAC Splash Screen
Figure 4.2.2 LILOT System
Figure 4.2.3 The Login Form (Part1)
Figure 4.2.4 The Login form with employee selection drop down box
Figure 4.2.5 The Registration Form
Figure 4.2.6 Identification Data
Figure 4.2.7 The Personal History Form
Figure 4.2.8 The Family History Form
Figure 4.2.9 HIV Testing Data Form
Figure 4.2.10 History of HIV Illness
Figure 4.2.11 History ARV treatment
Figure 4.2.12 Clinical and Laboratory Investigations
Figure 4.2.13 Investigations
Figure 4.2.14 Examination Signs
Figure 4.2.15 Medical History
Figure 4.2.16 System review
Figure 4.2.17 Monitoring and Follow Up Tests
Figure 4.2.18 Contraception and Gynaecological History
Figure 4.2.19 Employee Details
Figure 4.2.20 Patient Follow Up
Figure 4.2.21 Paediatric Form
Figure 4.2.22 Report Viewer
Figure 4.2.23 Summary ARV Treatment
Figure 4.2.23 Add new User
Figure 4.2.24 The Work area MDI

8
Figure5.1 UNAIDS
Figure5.2 CRIS3
Figure 5.3 Global Response Database
Figure 5.5 CRIS Workflow
Figure 5.6 PAAC Workflow Diagram
Figure 5.7 Comparison of GUI CRIS (Left) and PAAC (Right)
Figure 5.8 Report Generation in CRIS Step 1
Figure 5.9 Report generation in CRIS Step 2
Figure 5.10 Report generation in CRIS Final Step VIEWING

9
List of Tables

Table 1.4.1 : Annual Expenditures Per Provider (in 2002 U.S. Dollars) before
Electronic Medical Record System Implementation and Expected
Savings after Implementation [4]
Table 1.4.2 : (5-Year Return on Investment per Provider for Electronic Medical
Record Implementation. [4])
Table 1.4.3 : Effect of Electronic Medical Record Feature Set Variations on Net
Benefits[4]
Table 1.4.4 : Tornado diagram showing the one-way sensitivity analysis of net 5-year
benefits per provider. Each bar depicts the overall effect on net
benefits as that input is varied across the indicated range of values,
while other input variables are held constant. The vertical line indicates
the base case.[4]
Table 3.1.1: Patient Details
Table 3.1.2: Patient Registration
Table 3.2.1 Family History
Table 3.2.2: Personal History
Table 3.2.3: Previous HIV Treatment
Table 3.2.4: HIV Testing Data
Table 3.2.5: HIV Testing Details
Table 3.31: Examination Signs
Table 3.3.2: Adverse Habits
Table 3.3.3: ARV Treatment Summary
Table 3.3.4: ARV Treatment History
Table 3.3.5: Clinical Lab Investigations
Table 3.3.6: Contraception
Table 3.3.7: Diagnosis
Table 3.3.8: History of STI
Table 3.3.9: Immunisation Record
Table 3.3.10: Investigations
Table 3.3.11: Past History HIV
Table 3.3.12: Investigations Long
Table 3.3.13: Sexual History
Table 3.3.14: Medication and Vaccination History
Table 3.3.15: Paediatric Patients
Table 3.3.16: Sputum Smear for AFB
Table 3.3.17: Monitoring Follow Up
Table 3.3.18: Previous Att
Table 3.3.19: Physical Examination
Table 3.3.20: Obstetrics and Gynaecological History
Table 3.3.21: System Review
Table 3.3.22: Past Medical History
Table 3.3.23: Reasons ART Stop
Table 3.3.24: Specific System Findings
Table 3.3.25: Patient Follow Up
Table 3.3.26: Tuberculosis History
10
Table 3.3.27: Tuberculosis Treatment
Table 3.4.1: Users
Table 3.4.2: Login Details
Table 3.4.3: NGO Linkage
Table 3.4.4: Employee Details
Table 3.4.5: Counseling Record
Table 3.4.6: Nutrition Record
Table 3.4.7: Discharge Summary
Table 3.4.8: Consultation Record
Table 3.4.9: Comments
Table 3.4.10: Identification Marks
Table 3.4.11: Nurse Treatment Record
Table 3.4.12: Nurses Notes

11
 CHAPTER 1
INTRODUCTION

12
 1. INTRODUCTION

1.1. Antiretroviral Treatment

Human Immunodeficiency virus (HIV) is a lentivirus (a member of the retrovirus family)

that causes acquired immunodeficiency syndrome (AIDS), a condition in humans in which
the immune system begins to fail, leading to life-threatening opportunistic infections.
Infection with HIV occurs by the transfer of blood, semen, vaginal fluid, pre-ejaculate,
or breast milk. Within these bodily fluids, HIV is present as both free virus particles and
virus within infected immune cells. The four major routes of transmission are unsafe sex,
contaminated needles, breast milk, and transmission from an infected mother to her
baby at birth (vertical transmission). Screening of blood products for HIV has largely
eliminated transmission through blood transfusions or infected blood products in
the developed world.

HIV infection in humans is considered pandemic by the World Health

Organization (WHO). Nevertheless, complacency about HIV may play a key role in HIV
risk. From its discovery in 1981 to 2006, AIDS killed more than 25 million people. HIV
infects about 0.6% of the world's population. In 2005 alone, AIDS claimed an estimated
2.43.3 million lives, of which more than 570,000 were children. A third of these deaths
are occurring in Sub-Saharan Africa, retarding economic growth and
increasing poverty. According to current estimates, HIV is set to infect 90 million people
in Africa, resulting in a minimum estimate of 18
million orphans. Antiretroviral treatment reduces both the mortality and
the morbidity of HIV infection, but routine access to antiretroviral medication is not
available in all countries.

HIV infects primarily vital cells in the human immune system such as helper T cells (to be
specific, CD4+ T cells), macrophages, and dendritic cells. HIV infection leads to low levels
of CD4+ T cells through three main mechanisms: First, direct viral killing of infected cells;
second, increased rates of apoptosis in infected cells; and third, killing of infected CD4+ T
cells by CD8 cytotoxic lymphocytes that recognize infected cells. When CD4+ T cell
numbers decline below a critical level, cell-mediated immunity is lost, and the body
becomes progressively more susceptible to opportunistic infections.

Most untreated people infected with HIV-1 eventually develop AIDS. These individuals
mostly die from opportunistic infections or malignancies associated with the progressive
failure of the immune system. HIV progresses to AIDS at a variable rate affected by viral,
host, and environmental factors; most will progress to AIDS within 10 years of HIV
infection: some will have progressed much sooner, and some will take much longer.
Treatment with anti-retrovirals increases the life expectancy of people infected with

13
HIV. Even after HIV has progressed to diagnosable AIDS, the average survival time with
antiretroviral therapy was estimated to be more than 5 years as of 2005. Without
antiretroviral therapy, someone who has AIDS typically dies within a year.

Figure 1.1 Prevalence of HIV (WHO 2002)

There is currently no publicly available vaccine or cure for HIV or AIDS. However, a
vaccine that is a combination of two previously unsuccessful vaccine candidates was
reported in September 2009 to have resulted in a 30% reduction in infections in a trial
conducted in Thailand. Additionally, a course of antiretroviral treatment administered
immediately after exposure, referred to as post-exposure prophylaxis, is believed to
reduce the risk of infection if begun as quickly as possible. However, due to the
incomplete protection provided by the vaccine and/or post-exposure prophylaxis, the
avoidance of exposure to the virus is expected to remain the only reliable way to escape
infection for some time yet. Current treatment for HIV infection consists of highly active
antiretroviral therapy, or HAART. This has been highly beneficial to many HIV-infected
individuals since its introduction in 1996, when the protease inhibitor-based HAART
initially became available. Current HAART options are combinations (or "cocktails")
consisting of at least three drugs belonging to at least two types, or "classes,"
of antiretroviral agents. Typically, these classes are two nucleoside analogue reverse
transcriptase inhibitors (NARTIs or NRTIs) plus either a protease inhibitor or a non-
nucleoside reverse transcriptase inhibitor (NNRTI). New classes of drugs such as entry
inhibitors provide treatment options for patients who are infected with viruses already
resistant to common therapies, although they are not widely available and not typically
accessible in resource-limited settings. Because AIDS progression in children is more
rapid and less predictable than in adults, particularly in young infants, more aggressive
treatment is recommended for children than adults. In developed countries where
HAART is available, doctors assess their patients thoroughly: measuring the viral load,

14
how fast CD4 declines, and patient readiness. They then decide when to recommend
starting treatment.

HAART neither cures the patient nor does it uniformly remove all symptoms; high levels
of HIV-1, often HAART resistant, return if treatment is stopped. Moreover, it would take
more than a lifetime for HIV infection to be cleared using HAART. Despite this, many HIV-
infected individuals have experienced remarkable improvements in their general health
and quality of life, which has led to a large reduction in HIV-associated morbidity and
mortality in the developed world. One study suggests the average life expectancy of an
HIV infected individual is 32 years from the time of infection if treatment is started when
the CD4 count is 350/L. In the absence of HAART, progression from HIV infection to
AIDS has been observed to occur at a median of between nine to ten years and the
median survival time after developing AIDS is only 9.2 months. However, HAART
sometimes achieves far less than optimal results, in some circumstances being effective
in less than fifty percent of patients. This is due to a variety of reasons such as
medication intolerance/side effects, prior ineffective antiretroviral therapy and infection
with a drug-resistant strain of HIV. However, non-adherence and non-persistence with
antiretroviral therapy is the major reason most individuals fail to benefit from HAART.
The reasons for non-adherence and non-persistence with HAART are varied and
overlapping. Major psychosocial issues, such as poor access to medical care, inadequate
social supports, psychiatric disease and drug abuse contribute to non-adherence. The
complexity of these HAART regimens, whether due to pill number, dosing frequency,
meal restrictions or other issues along with side effects that create intentional non-
adherence also contribute to this problem. The side effects include
lipodystrophy, dyslipidemia, insulin resistance, an increase in cardiovascular risks,
and birth defects.

The timing for starting HIV treatment is still debated. There is no question that
treatment should be started before the patient's CD4 count falls below 200, and most
national guidelines say to start treatment once the CD4 count falls below 350; but there
is some evidence from cohort studies that treatment should be started before the CD4
count falls below 350. In those countries where CD4 counts are not available, patients
with WHO stage III or IV disease should be offered treatment.

Anti-retroviral drugs are expensive, and the majority of the world's infected individuals
do not have access to medications and treatments for HIV and AIDS. Research to
improve current treatments includes decreasing side effects of current drugs, further
simplifying drug regimens to improve adherence, and determining the best sequence of
regimens to manage drug resistance. Unfortunately, only a vaccine is thought to be able
to halt the pandemic. This is because a vaccine would cost less, thus being affordable
for developing countries, and would not require daily treatment. However, after over 20
years of research, HIV-1 remains a difficult target for a vaccine.
15
1.2 Antiretroviral Treatment Centre (ARTC)
An Antiretroviral Treatment Centre (ARTC) is a government supported organization
which takes responsibility of Identifying, Registering, Tracking and Curing patients who
are HIV infected or expected to get HIV infection. It works under the guideline of the
World Health Organisation (WHO) globally and under the National AIDS Control
Organisation (NACO) in India.

The goal of ART is to keep the number of HIV viruses in the blood to undetectable
levels, thereby stopping the deadly assault of HIV virus on the immune system (the
system that protects the body from foreign invaders like germs) of the diseased. At
present, three or more ARV drugs are recommended worldwide for the treatment of
people with HIV infection. As long as the HIV positive individual takes the medication on
a regular basis he/she retains close-to-normal quality of life including working capacity.
This has resulted in a dramatic decline in opportunistic infections (OI) and HIV-related
deaths. An opportunistic infection is caused by germs that normally do not bring about
disease but causes disease when the body's immune system is impaired. HIV infected is
unable to fight off infection, where the virus cripples the bodys defenses against those
germs. Opportunistic infections are a particular danger for people with AIDS. The HIV
virus itself does not cause death, but the opportunistic infections that occur because of
its effect on the immune system can.

All HIV positive persons can register at ART Centres for HIV care. These centres also
provide prophylaxis and treatment for opportunistic infections. Counselling is given for
ART preparedness and adherence.
CD4 cell count estimation, which is to be done once in six months for all HIV positive
persons is facilitated through ART centres and done free of cost. Ushus centres are
linked to Community Care Centres, where People Living with HIV/AIDS requiring
nutritional support, counselling, treatment of minor opportunistic infections is referred
to.

1.2.1 The Goal and Basic Principles of ART

Objectives of ART
1 Describe the goal of antiretroviral therapy (ART)
List key considerations in the management of chronic HIV illness in resource-
2
constrained settings
Discuss the benefits of ART, the obstacles for ART programs in resource-poor
3
countries
Discuss the prerequisites for scaling up ART programs, the pros and cons of
4
antiretroviral therapy, and what comprises optimal antiretroviral therapy

Goal of ART
16
 Prolong and improve the quality of life of people living with HIV and AIDS
Reduce the viral load as much as possible for as long as possible in order to halt
disease progression and prevent/reduce resistant variants
Achieve immune reconstitution that is quantitative (CD4 count in normal range)
and qualitative (pathogen-specific immune response)
Reduce mother-to-child transmission

Benefits of ART
A Increase voluntary testing/counseling
B Increase awareness of HIV
C Increase motivation of health care workers
D Decrease expenses for palliative and OI care
E Decrease number of orphans
F Keeps households and businesses intact
G Increase access to health facilities
H Potential to enhance prevention
a Behavioural: access to prevention education during care encounters
b Biological: decreased transmission due to lowered viral load

Recommendations for Initiating ART

If CD4 testing is available
WHO stage IV irrespective of CD4 cell count
WHO stage I, II, or III with CD4 cell count less than 200/mm

If CD4 testing is not available

WHO stage IV irrespective of TLC
WHO stage II or III with less than 1200/mm

1.2.2 Stages of ART treatment

Stage I
Asysyptomatic normal activity
Asymptomatic
Persistent generalized lypmhadenopathy

Stage II
Symptomatic & normal activity
Weight loss < 10% body weight
Minor mucocutaneous manifestations
Herpes zoster within last 5 years
Recurrent URTI

Stage III
Bed ridden <50% of the day during last month
Weight loss >10% body wt
Unexplained chronic diarrhea for more than 1 month
Unexplained prolonged fever for more than 1 month
Oral candidiasis
17
 Oral hairy leukoplakia
Pulmonary TB
Severe bacterial pneumonia

Stage IV
Bed ridden >50% during the last month
HIVwasting syndrome
PCP
Toxoplasmosis
Cryptococal Meningitis
CMV
Herpes siplex virus infection
Cryptosporidium with
Diarrhea >1 month
Oral Candidiasis
Atypical mycobacteriosis
Extra pulmonary tuberculosis
Lymphoma
Kaposis sarcoma
HIV encephalopathy

What Therapy to Begin With

The only regimens potent enough to drastically reduce viral replication, prevent
the emergence of resistance and treatment failure for a significant amount of
time involve a combination of at least three antiretroviral
There are currently 16 approved ART agents for the treatment of HIV-1 infection
(in the U.S.) encompassing six nucleoside reverse transcriptase inhibitor (NtRTI),
three non-nucleoside reverse transcriptase inhibitors (NNRTIs) and six protease
inhibitors (PIs).

Thirteen have been incorporated into WHOs guidelines

1.2.3 ART Eligibility

HIV Sero Positive by VCTC

WHO clinical staging I & II with CD4 cell count <200
WHO clinical staging III & IV
Initial screening TLC <1200
CD4 cell count <200
Gold Standard - CD4 estimation

1.2.4 Methodology

As per WHO/NACO Guidelines.

All investigations are free of cost for PLWHA as per NACO Guidelines.
4-5 counselling sessions will be conducted before initiating ART about adherence
to the treatment for life long.
Everyday 20 CD4 samples are testing at our centre except Saturday.

18
1.2.5 Base-line investigations

Complete Heamogram with TLC, HBsag, VDRL, Sputum for AFB, Chest X-ray, USG,
ABD, Liver function test, Renal function test, FNAC, Urine for Microscopy, Alb &
Sug, tool for Ovas & cyst, CD4 cell count - Gold Standard.

1.2.6 ART Drugs

Stavudine 30 mg + Lamivudine 150 mg

Stavudine 40 mg + Lamivudine 150 mg

Stavudine 30 mg + Lamivudine 150 mg + Nevirapine 200 mg

Stavudine 40 mg + Lamivudine 150 mg + Nevirapine 200 mg

Zidovudine300mg + Lamivudine 150 mg

1.2.7 Counselling Issues

Understanding of HIV/AIDS ART treatment, Disclosure and family counselling,

Discrimination and stigma, Positive linking, Interventions for psychological cronic
issues to develop support, Self help skills, Linking with Support of team, Palliative
& home based care, Death & dying, Treatment issues particularly to adherence
side effects

1.3 ARTC in India

ARTCs in India are guided by National AIDS Control Organisation (NACO). As per latest
update in March 2010 there are 269[2] ARTCs all over India. Considering the fact that
there were only 127 ARTCs in India in October 2007[2] we see that ARTCs have almost
doubled in past 3 years.

127 ARTCs OCTOBER 2007

259 ARTCs March 2010

Figure 1.3.1 Growth of ARTCs in India

1.4 Need of Automation at ARTC

19
The primary aim to automate working of KIMS ARTC is to implement paper based record
keeping system with Computerised Electronic Medical Record. An Electronic Medical
Record (EMR) has various advantages compared to a Paper based record keeping
system.

1.4.1 Electronic Medical Record vs. Paper Records

Electronic Medical Records not only help in cost saving, many cite one advantage of
medical records is that they save space. Instead of keeping huge paper files on patients,
all records are kept on computer files. Though someone must store these records in
computers, this still represents a small percentage of the space required to store
physical records. Along with saved space is reduction of paper needed by medical
offices, hospitals or insurance companies. Computer medical records do not render
paper obsolete, but they certainly do reduce needed paper significantly.

Another advantage of electronic medical records is the ability for all in a health care
team to coordinate care. This helps avoid duplication of testing, prescribing medicines
that in combination might be dangerous, and the ability for anyone on the medical team
to understand the approaches taken to a condition. A person with complex health issues
may see several specialists, and can easily become confused by overlapping or contrary
advice. When specialists and primary care doctors use the same system for electronic
medical records, then everyone on the team should be aware of all the other team
members actions and recommendations.

Electronic medical records may save time as well. Though faxing and email assisted one
doctor to get information from another doctor or a laboratory, there was generally a
wait time. When a doctor has instant access to all of a patients information, including
things like x-rays, lab tests, and information about prescriptions or allergies, he or she is
empowered to act right away, thus saving time. This may be particularly helpful in
emergency situations where a patient cannot answer questions about medical
history due to extreme illness or injury.

Many doctors are often considered to have undecipherable handwriting, and though
this is a generalization, unclear writing can lead to mistakes. Typed information is less
likely to create misunderstandings. However, electronic medical records do not rule out
the occasional typo.

In fact, one concern about the use of electronic medical records is that doctors may have
a significant learning curve when these programs are first employed. A poor typist may
actually take a long time to input information. Doctors often have to be their own
medical clerks especially during an office visit, and a doctor distracted by confusing
technology may not be as alert to a patients symptoms or needs.

There is no single electronic medical records source or system, so different hospitals and
individual clinicians are not all using the same program. This negates the possibility of
20
instant information for all on the medical team, since one program may not mesh with
another.

1.4.2 Cost Analysis

Table 1.4.1 Annual Expenditures Per Provider (in 2002 U.S. Dollars) before Electronic
Medical Record System Implementation and Expected Savings after Implementation [4]

Table 1.4.2 (5-Year Return on Investment per Provider for Electronic Medical Record
Implementation. [4])

21
Table 1.4.3 Effect of Electronic Medical Record Feature Set Variations on Net Benefits [4]

Table 1.4.4 Tornado diagram showing the one-way sensitivity analysis of net 5-year benefits per provider.
Each bar depicts the overall effect on net benefits as that input is varied across the indicated range of
[4]
values, while other input variables are held constant. The vertical line indicates the base case.

Based on a combination of savings data and projections from other published studies,
we conclude that implementing an ambulatory electronic medical record system can
yield a positive return on investment to health care organizations. The magnitude and
timing of this financial return varies, but is positive in the long run across a wide range of
assumptions. Because of their quality and cost benefits, electronic medical records
should be used in primary care, and incentives to accelerate their adoption should be
considered at the national level.

1.4.3 Other Advantages

It is true that the electronic medical record is indicative of a faster-paced informational

age in which larger quantities of information require more effective database
infrastructure, but there are many more benefits to both the medical service provider
and the consumer.
22
1. Speed - The business world of the 21st century is fast-paced. Even in medical
practices, speed equals ability to compete, especially when managing information. That
is why an electronic medical record system, or EMR, is used by most medical practices.
In addition, a fast electronic medical record system requires less time invested in trouble
shooting and allows more time invested in caring for patients.

2. Storage - An electronic medical record is an electronic database of information

capable of carrying much more information than traditional systems. An electronic
medical record system can manage records from multiple offices as well as multiple
types of records.

3. Security - An electronic medical record system secures records with backup files in
case of emergencies. In addition, only authorized users may access them. This double
security system is a "preventative medicine" for record viruses.

4. Support - Both practices and patients can access customer support from a medical
billing specialist provided through the electronic medical record software. In addition to
their support, electronic medical record software provides access to medical codes,
including, ICD.9, HIPAA, HCFA 1500, and the latest CPT code books.

5. Accessibility - The latest electronic medical record technology allows information to

be downloaded directly onto a PDA or Palm device. In addition to PDA access,
authorized individuals can access an electronic medical record online from any location.

6. Affordability - This is perhaps the most appealing part of the latest electronic medical
record technology. Every business wants to save money while at the same time adopting
time-saving technology. Because electronic medical record software uses online
technology, much of the set up costs and overhead are eliminated and reduced to
monthly usage fees.

7. Infrastructure - Part of the money-saving nature of electronic medical record

technology is the elimination of IT infrastructure and the streamlining of multiple
databases. The infrastructure is simplified into one online database, even for multiple
offices.

8. Versatility - Electronic medical record software stores medical transcription SOAP

notes and medical codes. It allows multiple users. It also connects users to personal and
online support sources.

9. Efficiency - Efficiency takes all of the duties involved in medical record and medical
office management divided by time and money. Electronic medical record software can
increase the numerators and decrease the denominators. Businesses often ask about
the bottom line.

10. Manageability - Some technology requires so much attention that a business owner
may be worried that he or she is now employed by the new technology and not the
other way around. Electronic medical record software works for businesses.

23
1.4.4 Report Generation

One of the other functions of an ARTC is to generate reports about the patients
registered at the centre. This process takes a lot of time and energy when based on
paper records. The concerned person has to go through each and every record book
searching for those parameters he is looking for as per the report demands. This Process
is highly ineffective, time consuming and prone to human errors, this is where the real
advantage of automation comes in. A computer can generate a report in matter of
seconds with zero error. Now when report generation is so easy a computer based
system can generate reports of much wider variety and numbers. The manual process
takes days and report generated is still with errors.

1.4.5 Scope of Decision Making through Statistical Analysis

According to professor Hossein Arsham Statistics is a science assisting you to make

decisions under uncertainties. Decision making process must be based on data neither
on personal opinion nor on belief. It is already an accepted fact that "Statistical thinking
will one day be as necessary for efficient citizenship as the ability to read and write." So,
let us be ahead of our time. Statistical data analysis divides the methods for analyzing
data into two categories: exploratory methods and confirmatory methods. Exploratory
methods are used to discover what the data seems to be saying by using simple
arithmetic and easy-to-draw pictures to summarize data. Confirmatory methods use
ideas from probability theory in the attempt to answer specific questions. Probability is
important in decision making because it provides a mechanism for measuring,
expressing, and analyzing the uncertainties associated with future events.

An Electronic Medical Record enables the scope of implementing a decision assisting

system for efficient functioning and endemic prediction which is impossible with non
electronic data considering the fact that reliable statistical analysis is based on
thousands of data points. It is time now that ARTCs worldwide implemented statistical
data analysis approaches towards computing various parameters.

1.4.6 An Intelligence System

Considering the fact the huge amount of data gathered from the patient receiving ARV
(Antiretroviral) Treatment right from his name, all blood data, past illnesses, family and
caretakers data etc an Intelligence System can be put into place, which can learn over a
period of time and then monitor for inconsistent data or alarm the user whenever an
inconsistency; deviating away from the normal; occurs in the normal processes of the
ARTC. This is highly recommended for the efficient working of the ARTC.

24
1.5 Development Tools Used
The choice of the developmental system largely determines the quality of the outcome
of the final software. For ARTC which takes cares of patients in the number of thousands
an effective and powerful database is required. SQL Server was chosen for this purpose
because of its many advantages. For the front end coding and design Visual Basic on the
.net platform was chosen owing to its high flexibility and power,

1.5.1 Advantages of SQL Server

SQL (Structured Query Language) is a recognized standard language designed to

organize, manage, and retrieve data from a database. SQL is essentially a programming
language for relational databases, and over the past decade SQL Server has consistently
delivered an reliable, scalable, cost-effective data management platform.
In todays economy, with corporations looking to control costs while still driving
productivity higher, the cost of acquiring and maintaining a companys software
investments is in the spotlight. Information technology (IT) departments are under
pressure to deliver more services, in shorter amounts of time, and with ever decreasing
budgets. For these reasons, IT departments worldwide are choosing technologies that
provide more business value at a lower cost. One example of a technology that is
growing rapidly in IT departments is SQL Database.

Primary advantages of SQL: - Portability (between database applications), - Industry

Standard (the de facto standard database query language), - Dynamic data definition (it
can handle alphanumerical queries in an optimized way)

Advantage of SQL over Access:

Reliability: With Access each client reads and writes directly to the raw data tables. If a
client machine crashes while writing data this will usually cause the back-end database
to also crash and become corrupt. The same thing will occur if the network fails, has a
glitch or temporarily becomes overloaded. This problem becomes more apparent as the
amount of data or the number of users increases.

With SQL Server the clients do not talk directly with the tables but with an intelligent
data manager on the server. This in turn reads and writes data from and to the tables. If
a client machine crashes, or the network hiccups, this will not affect the underlying
tables; instead the data manager realises that the transaction has not been completed
and does not commit the partially transmitted data to the database. The database
therefore continues to run without problem.

The client/server system also maintains an automatic 'transaction log'. If a backup has to
be restored the transaction log can be run and should restore all completed transactions
up to the time of the crash.

The client/server software itself is designed for mission critical systems and is orders of
magnitude more reliable than a file server system. On one system that we support the
client used to experience around one to two crashes per year (admittedly their network

25
was not exactly state of the art!) when running with an Access database. After we
converted it to SQL Server two years ago the system has not experienced a single crash.

Data Integrity: Data integrity in SQL Server is enhanced by the use of 'triggers' which can
be applied whenever a record is added, updated or deleted. This occurs at the table
level and cannot thus be forgotten about, ignored or bypassed by the client machine.
For example audit processes cannot be avoided (accidentally or deliberately) with this
scenario.

Better Performance: With Access all tables involved in a form, report or a query are
copied across the network from the server to the client's machine. The tables are then
processed and filtered to generate the required recordset. For example if looking up
details for one particular order from an orders table containing, say, 50,000 records then
the whole table (all 50,000 records) is dragged over the network and then 49,999 of
these records are thrown away (this is an over-simplification since indexing can be used
to mitigate this to some extent). Contrast this with SQL Server where the filtering takes
place on the server (if designed properly) and only 1 record is transmitted over the
network.

This can affect performance in two ways. Firstly SQL Server is highly optimised and can
usually perform the required filtering much more quickly than the client machine and
secondly the amount of data sent across the network link is vastly reduced. For most
databases the main performance bottleneck is data transmission over the network
hence reducing this can give a really dramatic improvement in performance.

Predicting likely performance improvements is very difficult but an average overall

speed improvement of 3 to 5 times, and possibly much more, would not be unexpected.

Network Traffic/Speed: As can be seen from the previous section, network traffic is
greatly reduced in a client/server scenario, often by many orders of magnitude. This
both improves network reliability (by reducing collisions, etc.) and also improves the
performance of the network for other software (as there is less traffic on the network).
Where there is a slow connection, such as over a telephone dial-up, Access is usually so
slow as to be all but unusable (obviously this does depend upon the amount of data)
whereas a SQL Server application, if designed for this environment, can still be perfectly
useable.

Low Bandwidth: This occurs when you are accessing your database over a connection
that only supports low data speeds, which, for all practical situations, means anything
other than a LAN. In all low bandwidth situations Access/JET usually performs so slowly
as to be unusable whilst a correctly designed SQL Server system can be similar in speed
to running it over a LAN.

Scalability: A file-server system such as Access is designed for small workgroups and is
scalable to perhaps 10 concurrent clients. Above this level performance starts to
degrade rapidly as more users are added. With the SQL Server client/server architecture
many hundreds, or even thousands (with the appropriate infrastructure), of concurrent
users can be supported without significant performance degradation.

26
1.5.2 SQL Architecture

SQL Server data is stored in databases. The data in a database is organized into the
logical components visible to users. A database is also physically implemented as two or
more files on disk. When using a database, one works primarily with the logical
components such as tables, views, procedures, and users. The physical implementation
of files is largely transparent. Typically, only the database administrator needs to work
with the physical implementation.

Figure 1.5.1 SQL Architecture

Each instance of SQL Server has four system databases (master, model, tempdb,
and msdb) and one or more user databases. Some organizations have only one user
database, containing all the data for their organization. Some organizations have
different databases for each group in their organization, and sometimes a database used
by a single application. For example, an organization could have one database for sales,
one for payroll, one for a document management application, and so on. Sometimes an
application uses only one database; other applications may access several databases.

Figure 1.5.2 SQL Default Databases

27
It is not necessary to run multiple copies of the SQL Server database engine to allow
multiple users to access the databases on a server. An instance of the SQL Server
Standard or Enterprise Edition is capable of handling thousands of users working in
multiple databases at the same time. Each instance of SQL Server makes all databases in
the instance available to all users that connect to the instance, subject to the defined
security permissions. When connecting to an instance of SQL Server, your connection is
associated with a particular database on the server. This database is called the current
database. You are usually connected to a database defined as your default database by
the system administrator, although one can use connection options in the database APIs
to specify another database. One can switch from one database to another using either
the Transact-SQL USE database_name statement, or an API function that changes your
current database context.

SQL Server 2000 allows one to detach databases from an instance of SQL Server, then
reattach them to another instance, or even attach the database back to the same
instance. If one has a SQL Server database file, it can be told told SQL Server when to
connect to attach that database file with a specific database name.

1.5.3 APIs Supported by SQL Server

A database API defines how to code an application to connect to a database and pass
commands to the database. An object model API is usually language independent and
defines a set of objects, properties, and interfaces, and a C or Microsoft Visual Basic
API defines a set of functions for applications written in C, C++, or Visual Basic.

SQL Server supports a number of APIs for building general-purpose database

applications, such as:

These open APIs with publicly defined specifications supported by several

database vendors:
ActiveX Data Objects (ADO)

OLE DB

Open Database Connectivity (ODBC) and the object APIs built over ODBC:
Remote Data Objects (RDO) and Data Access Objects (DAO)

Embedded SQL for C (ESQL)

The legacy DB-Library for C API that was developed specifically to be used with
earlier versions of SQL Server that predate the SQL-92 standard.

1.5.4 .NET Platform

The Microsoft .NET Framework is a software framework that can be installed on

computers running Microsoft Windows operating systems. It includes a large library of
coded solutions to common programming problems and a virtual machine that manages
the execution of programs written specifically for the framework. The .NET framework
supports multiple programming languages in a manner that allows language
interoperability, whereby each language can utilize code written in other languages; in
28
particular, the .NET library is available to all the programming languages that .NET
facilitates. The .NET Framework is a Microsoft offering and is intended to be used by
most new applications created for the Windows platform. The framework's Base Class
Library provides a large range of features including user interface, data access, database
connectivity, cryptography, web application development, numeric algorithms,
and network communications. The class library is used by programmers, who combine it
with their own code to produce applications.

Programs written for the .NET Framework execute in a software environment that
manages the program's runtime requirements. Also part of the .NET Framework, this
runtime environment is known as the Common Language Runtime (CLR). The CLR
provides the appearance of an application virtual machine so that programmers need
not consider the capabilities of the specific CPU that will execute the program. The CLR
also provides other important services such as security, memory management,
and exception handling. The class library and the CLR together constitute the .NET
Framework.

Version 3.0 of the .NET Framework is included with Windows Server 2008 and Windows
Vista. Version 3.5 is included with Windows 7, and can also be installed on Windows XP
and the Windows Server 2003 family of operating systems. Version 4 of the framework
was released as a public beta on 20 May 2009. In February 2010, Microsoft released a
.NET Framework 4 release candidate. On April 12, 2010, the final version of the .NET
Framework 4 was released.

The .NET Framework family also includes two versions for mobile or embedded device
use. A reduced version of the framework, the .NET Compact Framework, is available
on Windows CE platforms, including Windows Mobile devices such as smartphones.
Additionally, the .NET Micro Framework is targeted at severely resource constrained
devices.

Interoperability

Because interaction between new and older applications is commonly required, the .NET
Framework provides means to access functionality that is implemented in programs that
execute outside the .NET environment. Access to COM components is provided in the
System.Runtime.InteropServices and System.EnterpriseServices namespaces of the
framework; access to other functionality is provided using the P/Invoke feature.

Common Runtime Engine

The Common Language Runtime (CLR) is the virtual machine component of the .NET
framework. All .NET programs execute under the supervision of the CLR, guaranteeing
certain properties and behaviors in the areas of memory management, security, and
exception handling.

29
Language Independence

The .NET Framework introduces a Common Type System, or CTS. The CTS specification
defines all possible datatypes and programming constructs supported by the CLR and
how they may or may not interact with each other conforming to the Common Language
Infrastructure (CLI) specification. Because of this feature, the .NET Framework supports
the exchange of types and object instances between libraries and applications written
using any conforming .NET language.

Base Class Library

The Base Class Library (BCL), part of the Framework Class Library (FCL), is a library of
functionality available to all languages using the .NET Framework. The BCL
provides classeswhich encapsulate a number of common functions, including file reading
and writing, graphic rendering, database interaction, XML document manipulation and
so on.

Simplified Deployment

The .NET framework includes design features and tools that help manage
the installation of computer software to ensure that it does not interfere with previously
installed software, and that it conforms to security requirements.

Security

The design is meant to address some of the vulnerabilities, such as buffer overflows,
that have been exploited by malicious software. Additionally, .NET provides a common
security model for all applications.

Portability

The design of the .NET Framework allows it to theoretically be platform agnostic, and
thus cross-platform compatible. That is, a program written to use the framework should
run without change on any type of system for which the framework is implemented.
While Microsoft has never implemented the full framework on any system except
Microsoft Windows, the framework is engineered to be platform agnostic, and cross-
platform implementations are available for other operating. Microsoft submitted the
specifications for the Common Language Infrastructure (which includes the core class
libraries, Common Type System, and the Common Intermediate
Language), the C# language, and the C++/CLI language to both ECMA and the ISO,
making them available as open standards. This makes it possible for third parties to
create compatible implementations of the framework and its languages on other
platforms.

30
1.5.5 .NET Architecture

Figure 1.5.3 The .NET architecture

31
 CHAPTER 2
THE SOFTWARE
DEVELOPMENT METHOD

32
2. THE SOFTWARE DEVELOPMENT METHOD

A software development methodology refers to the framework that is used to structure,

plan, and control the process of developing an information system. A wide variety of
such frameworks have evolved over the years, each with its own recognized strengths
and weaknesses. One system development methodology is not necessarily suitable for
use by all projects. Each of the available methodologies is best suited to specific kinds of
projects, based on various technical, organizational, project and team considerations.

The framework of a software development methodology consists of:

A software development philosophy, with the approach or approaches of the software

development process multiple tools, models and methods, to assist in the software
development process. These frameworks are often bound to some kind of organization,
which further develops, supports the use, and promotes the methodology. The
methodology is often documented in some kind of formal documentation.

2.1 Software development approaches

Every software development methodology has more or less its own approach
to software development. There is a set of more general approaches, which are
developed into several specific methodologies. These approaches are:

a. Waterfall: linear framework type.

b. Prototyping: iterative framework type
c. Incremental: combination of linear and iterative framework type
d. Spiral: combination of linear and iterative framework type
e. Rapid Application Development (RAD): Iterative Framework Type

For the development of this project the waterfall model has been adopted which is as
described below:

Waterfall model

The waterfall model is a sequential development process, in which development is seen

as flowing steadily downwards (like a waterfall) through the phases of requirements
analysis, design, implementation, testing (validation), integration, and maintenance. The
first formal description of the waterfall model is often cited to be an article published
by Winston W. Royce in 1970 although Royce did not use the term "waterfall" in this
article. Basic principles of the waterfall model are:

- Project is divided into sequential phases, with some overlap and

splashback acceptable between phases.
- Emphasis is on planning, time schedules, target dates, budgets and
implementation of an entire system at one time.

33
 - Tight control is maintained over the life of the project through the use
of extensive written documentation, as well as through formal
reviews and approval/signoff by the user and information technology
management occurring at the end of most phases before beginning
the next phase.

Figure 2.1 Software Development Patterns

2.2 Database Design Considerations

Designing a database requires an understanding of both the business functions you want to
model and the database concepts and features used to represent those business functions.

It is important to accurately design a database to model the business because it can be time
consuming to change the design of a database significantly once implemented. A well-designed
database also performs better.

When designing a database, consider:

34
 - The purpose of the database and how it affects the design. Create a
database plan to fit your purpose.
- Database normalization rules that prevent mistakes in the database design.
- Protection of your data integrity.
- Security requirements of the database and user permissions.
- Performance needs of the application. You must ensure that the database
design takes advantage of Microsoft SQL Server 2000 features that
improve performance. Achieving a balance between the size of the database
and the hardware configuration is also important for performance.
- Maintenance.
- Estimating the size of a database.

2.2.1 Creating a Database Plan

The first step in creating a database is creating a plan that serves both as a guide to be
used when implementing the database and as a functional specification for the database
after it has been implemented. The complexity and detail of a database design is
dictated by the complexity and size of the database application as well as the user
population. The nature and complexity of a database application, as well as the process
of planning it, can vary greatly. A database can be relatively simple and designed for use
by a single person, or it can be large and complex and designed, for example, to handle
all the banking transactions for hundreds of thousands of clients. In the first case, the
database design may be little more than a few notes on some scratch paper. In the latter
case, the design may be a formal document with hundreds of pages that contain every
possible detail about the database.

In planning the database, regardless of its size and complexity, use these basic steps:

- Gather information.
- Identify the objects.
- Model the objects.
- Identify the types of information for each object.
- Identify the relationships between objects.
- Gathering Information

Before creating a database, there should be a good understanding of the job the
database is expected to perform. If the database is to replace a paper-based or manually
performed information system, the existing system will give us most of the information
we need. It is important to interview everyone involved in the system to find out what
they do and what they need from the database. It is also important to identify what they
want the new system to do, as well as to identify the problems, limitations, and
bottlenecks of any existing system. Collect copies of customer statements, inventory
lists, management reports, and any other documents that are part of the existing
system, because these will be useful to you in designing the database and the interfaces.

35
Identifying the Objects

During the process of gathering information, one must identify the key objects or
entities that will be managed by the database. The object can be a tangible thing, such
as a person or a product, or it can be a more intangible item, such as a business
transaction, a department in a company, or a payroll period. There are usually a few
primary objects, and after these are identified, the related items become apparent. Each
distinct item in your database should have a corresponding table. The primary object in
the pubs sample database included with Microsoft SQL Server 2000 is a book. The
objects related to books within this company's business are the authors who write the
books, the publishers who manufacture the books, the stores which sell them, and the
sales transactions performed with the stores. Each of these objects is a table in the
database.

Modeling the Objects

As the objects in the system are identified, it is important to record them in a way that
represents the system visually. One can use his database model as a reference during
implementation of the database. For this purpose, database developers use tools that
range in technical complexity from pencils and scratch paper to word processing or
spreadsheet programs, and even to software programs specifically dedicated to the job
of data modeling for database designs. Whatever tool you decide to use, it is important
that you keep it up-to-date. SQL Server Enterprise Manager includes visual design tools
such as the Database Designer that can be used to design and create objects in the
database

Identifying the Types of Information for Each Object

After the primary objects in the database have been identified as candidates for tables,
the next step is to identify the types of information that must be stored for each object.
These are the columns in the object's table. The columns in a database table contain a
few common types of information:

Raw data columns

These columns store tangible pieces of information, such as names, determined by a

source external to the database.

Categorical columns

These columns classify or group the data and store a limited selection of data such as
true/false, married/single, VP/Director/Group Manager, and so on.

Identifier columns

These columns provide a mechanism to identify each item stored in the table. These
columns often have id or number in their names (for example,

36
employee_id, invoice_number, and publisher_id). The identifier column is the primary
component used by both users and internal database processing for gaining access to a
row of data in the table. Sometimes the object has a tangible form of ID used in the
table (for example, a social security number), but in most situations you can define the
table so that a reliable, artificial ID can be created for the row.

Relational or referential columns

These columns establish a link between information in one table and related
information in another table. For example, a table that tracks sales transactions will
commonly have a link to the customers table so that the complete customer
information can be associated with the sales transaction.

Identifying the Relationships Between Objects

One of the strengths of a relational database is the ability to relate or associate

information about various items in the database. Isolated types of information can be
stored separately, but the database engine can combine data when necessary.
Identifying the relationships between objects in the design process requires looking at
the tables, determining how they are logically related, and adding relational columns
that establish a link from one table to another.

2.2.2 Normalisation
The logical design of the database, including the tables and the relationships between
them, is the core of an optimized relational database. A good logical database design can
lay the foundation for optimal database and application performance. A poor logical
database design can impair the performance of the entire system. Normalizing a logical
database design involves using formal methods to separate the data into multiple,
related tables. A greater number of narrow tables (with fewer columns) is characteristic
of a normalized database. A few wide tables (with more columns) is characteristic of an
non normalized database.

Reasonable normalization often improves performance. When useful indexes are

available, the Microsoft SQL Server 2000 query optimizer is efficient at selecting
rapid, efficient joins between tables. Some of the benefits of normalization include:

- Faster sorting and index creation.

- A larger number of clustered indexes.
- Narrower and more compact indexes.
- Fewer indexes per table, which improves the performance of INSERT,
UPDATE, and DELETE statements.
- Fewer null values and less opportunity for inconsistency, which
increase database compactness.

37
As normalization increases, so do the number and complexity of joins required to
retrieve data. Too many complex relational joins between too many tables can hinder
performance. Reasonable normalization often includes few regularly executed queries
that use joins involving more than four tables.

Sometimes the logical database design is already fixed and total redesign is not feasible.
Even then, however, it might be possible to normalize a large table selectively into
several smaller tables. If the database is accessed through stored procedures, this
schema change could take place without affecting applications. If not, it might be
possible to create a view that hides the schema change from the applications.

Achieving a Well-Designed Database

In relational-database design theory, normalization rules identify certain attributes that

must be present or absent in a well-designed database. A complete discussion of
normalization rules goes well beyond the scope of this topic. However, there are a few
rules that can help you achieve a sound database design:

A table should have an identifier.

The fundamental rule of database design theory is that each table should have a unique
row identifier, a column or set of columns used to distinguish any single record from
every other record in the table. Each table should have an ID column, and no two
records can share the same ID value. The column or columns serving as the unique row
identifier for a table is the primary key of the table.

A table should store only data for a single type of entity.

Attempting to store too much information in a table can prevent the efficient and
reliable management of the data in the table. In the pubs database in SQL Server 2000,
the titles and publishers information is stored in two separate tables. Although it is
possible to have columns that contain information for both the book and the publisher
in the titles table, this design leads to several problems. The publisher information must
be added and stored redundantly for each book published by a publisher. This uses extra
storage space in the database. If the address for the publisher changes, the change must
be made for each book. And if the last book for a publisher is removed from the title
table, the information for that publisher is lost.

In the pubs database, with the information for books and publishers stored in
the titles and publishers tables, the information about the publisher has to be entered
only once and then linked to each book. Therefore, if the publisher information is
changed, it must be changed in only one place, and the publisher information will be
there even if the publisher has no books in the database.

38
A table should avoid nullable columns.

Tables can have columns defined to allow null values. A null value indicates that there is
no value. Although it can be useful to allow null values in isolated cases, it is best to use
them sparingly because they require special handling that increases the complexity of
data operations. If you have a table with several nullable columns and several of the
rows have null values in the columns, you should consider placing these columns in
another table linked to the primary table. Storing the data in two separate tables allows
the primary table to be simple in design but able to accommodate the occasional need
for storing this information.

A table should not have repeating values or columns.

The table for an item in the database should not contain a list of values for a specific
piece of information. For example, a book in the pubs database might be co-authored. If
there is a column in the titles table for the name of the author, this presents a problem.
One solution is to store the name of both authors in the column, but this makes it
difficult to show a list of the individual authors. Another solution is to change the
structure of the table to add another column for the name of the second author, but this
accommodates only two authors. Yet another column must be added if a book has three
authors.

2.2.3 Data Integrity

Enforcing data integrity ensures the quality of the data in the database. For example, if
an employee is entered with an employee_id value of 123, the database should not
allow another employee to have an ID with the same value. If you have
an employee_rating column intended to have values ranging from 1 to 5, the database
should not accept a value of 6. If the table has a dept_id column that stores the
department number for the employee, the database should allow only values that are
valid for the department numbers in the company. Two important steps in planning
tables are to identify valid values for a column and to decide how to enforce the
integrity of the data in the column. Data integrity falls into these categories:

- Entity integrity
- Domain integrity
- Referential integrity
- User-defined integrity
- Entity Integrity

Entity integrity defines a row as a unique entity for a particular table. Entity integrity
enforces the integrity of the identifier column(s) or the primary keyof a table (through
indexes, UNIQUE constraints, PRIMARY KEY constraints, or IDENTITY properties).

39
Domain Integrity

Domain integrity is the validity of entries for a given column. You can enforce domain
integrity by restricting the type (through data types), the format (through CHECK
constraints and rules), or the range of possible values (through FOREIGN KEY constraints,
CHECK constraints, DEFAULT definitions, NOT NULL definitions, and rules).

Referential Integrity

Referential integrity preserves the defined relationships between tables when records
are entered or deleted. In Microsoft SQL Server 2000, referential integrity is based on
relationships between foreign keys and primary keys or between foreign keys and
unique keys (through FOREIGN KEY and CHECK constraints). Referential integrity ensures
that key values are consistent across tables. Such consistency requires that there be no
references to nonexistent values and that if a key value changes, all references to it
change consistently throughout the database. When you enforce referential integrity,
SQL Server prevents users from:

- Adding records to a related table if there is no associated record in

the primary table.
- Changing values in a primary table that result in orphaned records in a
related table.
- Deleting records from a primary table if there are matching related
records.

For example, with the sales and titles tables in the pubs database, referential integrity is
based on the relationship between the foreign key (title_id) in the salestable and the
primary key (title_id) in the titles table.

40
User-Defined Integrity

User-defined integrity allows you to define specific business rules that do not fall into
one of the other integrity categories. All of the integrity categories support user-defined
integrity (all column- and table-level constraints in CREATE TABLE, stored procedures,
and triggers).

2.3 Front End Design Considerations

User interface design or user interface engineering is the design
of computers, appliances, machines, mobile communication
devices, software applications, and websites with the focus on the user's experience and
interaction. The goal of user interface design is to make the user's interaction as simple
and efficient as possible, in terms of accomplishing user goalswhat is often called user-
centered design. Good user interface design facilitates finishing the task at hand without
drawing unnecessary attention to itself. Graphic design may be utilized to support
its usability. The design process must balance technical functionality and visual elements
(e.g., mental model) to create a system that is not only operational but also usable and
adaptable to changing user needs.

Interface design is involved in a wide range of projects from computer systems, to cars,
to commercial planes; all of these projects involve much of the same basic human
interactions yet also require some unique skills and knowledge. As a result, designers
tend to specialize in certain types of projects and have skills centered around their
expertise, whether that be software design, user research, web design, or industrial
design.

Processes

There are several phases and processes in the user interface design, some of which are
more demanded upon than others, depending on the project. (Note: for the remainder
of this section, the word system is used to denote any project whether it is a web site,
application, or device.)

Functionality requirements gathering assembling a list of the functionality required

by the system to accomplish the goals of the project and the potential needs of the
users.
User analysis analysis of the potential users of the system either through discussion
with people who work with the users and/or the potential users themselves. Typical
questions involve:
What would the user want the system to do?
41
 How would the system fit in with the user's normal workflow or daily activities?
How technically savvy is the user and what similar systems does the user already
use?
What interface look & feel styles appeal to the user?
Information architecture development of the process and/or information flow of
the system (i.e. for phone tree systems, this would be an option tree flowchart and
for web sites this would be a site flow that shows the hierarchy of the pages).
Prototyping development of wireframes, either in the form of paper prototypes or
simple interactive screens. These prototypes are stripped of all look & feel elements
and most content in order to concentrate on the interface.
Usability testing testing of the prototypes on an actual useroften using a
technique called think aloud protocol where you ask the user to talk about their
thoughts during the experience.
Graphic Interface design actual look & feel design of the final graphical user
interface (GUI). It may be based on the findings developed during the usability
testing if usability is unpredictable, or based on communication objectives and styles
that would appeal to the user. In rare cases, the graphics may drive the prototyping,
depending on the importance of visual form versus function. If the interface requires
multiple skins, there may be multiple interface designs for one control panel,
functional feature or widget. This phase is often a collaborative effort between
a graphic designer and a user interface designer, or handled by one who is proficient
in both disciplines.
User interface design requires a good understanding of user needs.

Microsoft
The MSN User Experience Team developed new user-centered methods to provide
structured user input on the visual design of the newly-released MSN Explorer, an
integrated software package. In the final product, users rated "appearance" above all of
the product's features. This case describes how the MSN User Experience Team derived
a design direction to set the most appropriate pace of visual change for millions of users
with widely variant preferences. It discloses how these new methods maximized the
product's visual appeal to the widest segment of the potential user base. The methods
included design mark-up, a semantic design-description task, a statement rating task, a
semantic desirability group card sort task, and a modified focus group discussion. This
case documents the value of these new methods in predicting user reaction to visual
design. Lessons learned from this collaboration are discussed from three perspectives:
user experience management, design and usability.

42
Software Tool
User interface software tools helps developers design and implement the user interface.
Research on past tools has had enormous impact on today's developersvirtually all applications
today are built using some form of user interface tool. In this article, we consider cases
of both success and failure in past user interface tools. From these cases we extract a set
of themes which can serve as lessons for future work. Using these themes, past tools can
be characterized by what aspects of the user interface they addressed, their threshold
and ceiling, what path of least resistance they offer, how predictable they are to use,
and whether they addressed a target that became irrelevant. We believe the lessons of
these past themes are particularly important now, because increasingly rapid
technological changes are likely to significantly change user interfaces. We are at the
dawn of an era where user interfaces are about to break out of the desktop box where
they have been stuck for the past 15 years. The next millennium will open with an
increasing diversity of user interface on an increasing diversity of computerized devices.
These devices include hand-held personal digital assistants (PDAs), cell phones, pages,
computerized pens, computerized notepads, and various kinds of desk and wall size-
computers, as well as devices in everyday objects (such as mounted on refrigerators, or
even embedded in truck tires). The increased connectivity of computers, initially
evidenced by the World Wide Web, but spreading also with technologies such as
personal-area networks, will also have a profound effect on the user interface to
computers. Another important force will be recognition-based user interfaces, especially
speech, and camera-based vision systems. Other changes we see are an increasing need
for 3D and end-user customization, programming, and scripting. All of these changes will
require significant support from the underlying user interface software tools.
Aesthetics
An important aspect of the empirical study of user experience is the process by which
users form aesthetic and other judgments of interactive products. Van Schaik and Ling
have made a study extending previous research by presenting test users with a context
(mode of use) in which to make their judgments, using sets of web pages from specific
domains rather than unrelated pages, studying the congruence of perceptions of
aesthetic value over time, including judgments after use of a web site, manipulating the
aesthetic design of web pages and studying the relationship between usability and
aesthetic value. The results from two experiments demonstrate that context increases
the stability of judgments from perceptions after brief exposure to those after self-
paced exposure and from perceptions after self-paced exposure to those of after site
use. The type of aesthetics that is relevant to users' perceptions appears to depend on
the application domain. The principle 'what is beautiful is usable' is not confirmed.

43
2.3.1 Principles of User Interface Design

Principles of User Interface Design are intended to improve the quality of user interface
design. According to Larry Constantine and Lucy Lockwood in their usage-centered
design, these principles are:[5]

The structure principle: Design should organize the user interface purposefully, in
meaningful and useful ways based on clear, consistent models that are apparent and
recognizable to users, putting related things together and separating unrelated
things, differentiating dissimilar things and making similar things resemble one
another. The structure principle is concerned with overall user interface
architecture.

The simplicity principle: The design should make simple, common tasks easy,
communicating clearly and simply in the user's own language, and providing good
shortcuts that are meaningfully related to longer procedures.

The visibility principle: The design should make all needed options and materials for a
given task visible without distracting the user with extraneous or redundant
information. Good designs don't overwhelm users with alternatives or confuse with
unneeded information.

The feedback principle: The design should keep users informed of actions or
interpretations, changes of state or condition, and errors or exceptions that are
relevant and of interest to the user through clear, concise, and unambiguous
language familiar to users.

The tolerance principle: The design should be flexible and tolerant, reducing the cost
of mistakes and misuse by allowing undoing and redoing, while also preventing
errors wherever possible by tolerating varied inputs and sequences and by
interpreting all reasonable actions.

The reuse principle: The design should reuse internal and external components and
behaviours, maintaining consistency with purpose rather than merely arbitrary
consistency, thus reducing the need for users to rethink and remember.

44
2.3.2 Flowchart of Patient flow at ARTC

Start

Register Patient

No
ART
Required?

Yes

Clinician Data
Entry Process

Counsellor Data
Entry Process

Refer To
Pharmacy

Follow Up after 6
months

No

If Patient
Death occurs?

Yes

STOP

Figure 2.3.1 Flowchart of Patient Flow

45
2.3.3 Projected ARTC Operations after Automation

Documents Patients
Registration

Lab
Investigations

Clinician
Central
Data
Database

Follow up
Counselor after 6 Months
Data

Pharmacy
Data

Discharge
Summary

Figure 2.3.2 Operations of ARTC after Automation

46
 CHAPTER 3
THE DATABASE

47
 3. THE DATABASE
3.1 Introduction
The ARTC database consists of an organized collection of data for one or more multiple
uses. One way of classifying databases involves the type of content, for example:
bibliographic, full-text, numeric, image. Other classification methods start from
examining database models or database architectures: see below. Software organizes
the data in a database according to a database model. As of 2010 the relational model
occurs most commonly. Other models such as the hierarchical model and the network
model use a more explicit representation of relationships. We have used the ER model
to describe the database.

A number of database architectures exist. Many databases use a combination of

strategies. Databases consist of software-based "containers" that are structured to
collect and store information so users can retrieve, add, update or remove such
information in an automatic fashion. Database programs are designed for users so that
they can add or delete any information needed. The structure of a database is tabular,
consisting of rows and columns of information. Online Transaction Processing systems
(OLTP) often use a "row oriented" or an "object oriented" data store architecture,
whereas data-warehouse and other retrieval focused applications like Google's BigTable,
or bibliographic database (library catalog) systems may use a Column oriented DBMS
architecture.

Document-Oriented, XML, knowledge bases, as well as frame databases and RDF-stores

(also known as triple stores), may also use a combination of these architectures in their
implementation. Not all databases have or need a database schema ("schema-less
databases"). Over many years general-purpose database systems have dominated the
database industry. These offer a wide range of functions, applicable to many, if not most
circumstances in modern data processing. These have been enhanced with extensible
datatypes (pioneered in the PostgreSQL project) to allow development of a very wide
range of applications.

There are also other types of databases which cannot be classified as relational
databases. Most notable is the object database management system, which stores
language objects natively without using a separate data definition language and without
translating into a separate storage schema. Unlike relational systems, these object
databases store the relationship between complex data types as part of their storage
model in a way that does not require runtime calculation of related data using relational
algebra execution algorithms.

The Classification of database is in the following manner:

48
 Registration Data

Counselor Clinician Pharmacy

Adherence Data Family Data Follow Up Lab Investigations Regimen Adherence

Others Counseling Data Identification Others TB Data Doses Used

Nurses Notes Clinical Others

Figure 3.1.0 the Database Hierarchy

3.2 Database Access

Information is recorded and filled in the prescribed area and columns by relevant staff
member of ART centre as indicated below:

(i) Patient Id: This should be made by the counsellor and completed at every visit by the
treating doctor. The card is to be given to the patient.

(ii) Pre ART Register: Information of all persons who are HIV positive and registered for
HIV care(not necessarily receiving ART) is recorded in this register. Once the person is
put on ART, (s)he is registered in the ART enrolment register and followed there. It is
important to remember that one row in pre ART register is related to one HIV+ person a)
Columns 1 to 12 are filled by the counsellor b) Columns 13 to 22 are completed by the
treating doctor. The pre ART register provides information on profile of registered
patients, documents process from Care to ART (Checklist) and provided data for the
monthly report.

(iii) Patient Anti-retroviral Treatment Record(White Card): The white card should be
filled
once the patient is registered in care (Pre ART)a) Area 1 to 3 to be filled by the
counsellor; Care and Treatment Records
i). Patient ID Card (Green Book)
ii). Pre-ART Register
iii.) ART Enrolment Register
iv. Patient Antiretroviral Treatment Record (white card) Drug Dispensing and Stock
Management Registers
v. Antiretroviral Drug Dispensing Register
vi. Antiretroviral Drug Stock Register Programme Performance Monitoring Reports
vii. Monthly/Quarterly ART centre Report

49
viii. Cohort Analysis Report Supervision, Quality Assurance and Feedback Forms
ix. ART Treatment centre Appraisal Form
x. ART Supervisory Checklist
xi. Summary Recommendations of Supervisory Visit Guidelines for Service Providers 1516
Operational Guidelines for ART Centres March 2008 b) Areas 4 to 12 to be completed by
the treating doctor. c) The columns 10 and 15 needs to be filled or reconfirmed by the
counsellor. d) Area 11 should be completed at every visit. This record is triple folded
card for patient information, for patient monitoring and programme monitoring to
assess effectiveness of ART. The Information from these records is fed into the monthly
ART centre report.

(iv) ART Enrolment Register: Once a person is put on ART, (s)he is enrolled and followed
in this register. Henceforth, no entries are made in the pre-ART register.
a) Columns 1 to 8 and column 18 are completed by counsellor or record keeper with
assistance from the counsellor
b) Columns 9 to 17 are completed by the treating doctor. The record keeper may update
the columns 9 to 12 under supervision of the treating physician. This register has list of
all patients on ART with medical details and monthly treatment status and contains
information that is fed into the monthly ART centre report and cohort analysis. This
register can be updated by the record keeper with assistance of the relevant staff ,
based on patient ART treatment records (White card).

(v) Anti-retroviral Drug Dispensing Register:

This register contains place for patients name and signature, tablets dispensed. A
separate page is maintained for each day. This register is maintained by pharmacist or
the staff nurse, if the ART centre does not have a pharmacist. It monitors daily drug
consumption, ensures accountability and contains information which is carried forward
to drug stock register.

(vi) Anti-retroviral Drug Stock Register: In this register, a separate page is maintained
for each drug or drug combination. It contains information on name of the drug, opening
stock, stock received, stock dispensed, drugs expired and the balance remaining. This
register is also maintained by the pharmacist or the staff nurse if the center does not
have a pharmacist. The drug stock register helps in monitoring drug stock, provides
information to alert stock-outs and provides data required for the monthly report.

3.3 Database Tables

The Database consists of 398 fields or attributes normalised in 47 tables. Database
Tables can be subdivided into following four categories:

1. Registration Counter
2. Counsellor Details
3. Clinician Details
4. Others

50
1.Registration Counter

2. Counsellor Details

51
2. Clinician Details

52
53
54
55
56
3. Other Details

57
58
3.4 Database Diagram

In software engineering, an entity-relationship model (ERM) is an abstract and

conceptual representation of data. Entity-relationship modeling is a database
modeling method, used to produce a type of conceptual schema or semantic data
modelof a system, often a relational database, and its requirements in a top-
down fashion. Diagrams created by this process are called entity-relationship
diagrams, ER diagrams, or ERDs.

The definitive reference for entity-relationship modeling is Peter Chen's 1976

paper. However, variants of the idea existed previously, and have been devised
subsequently.

The first stage of information system design uses these models during the requirements
analysis to describe information needs or the type of information that is to be stored in
adatabase. The data modeling technique can be used to describe any ontology (i.e. an
overview and classifications of used terms and their relationships) for a certain area of
interest. In the case of the design of an information system that is based on a database,
the conceptual data model is, at a later stage (usually called logical design), mapped to
a logical data model, such as the relational model; this in turn is mapped to a physical
model during physical design. Note that sometimes, both of these phases are referred to
as "physical design".

There are a number of conventions for entity-relationship diagrams (ERDs). The classical
notation mainly relates to conceptual modeling. There are a range of notations
employed in logical and physical database design, such as IDEF1X.
The Following pages contain the database diagram for this project:

59
60
61
62
63
 CHAPTER 4
THE USER INTERFACE

64
 4. THE USER INTERFACE
Introduction
In the industrial design field of human-machine interaction, the user interface is (a place)
where interaction between humans and machines occurs. The goal of interaction
between a human and a machine at the user interface is effective operation and control
of the machine, and feedback from the machine which aids the operator in making
operational decisions. Examples of this broad concept of user interfaces include the
interactive aspects of computer operating systems, hand tools, heavy
machinery operator controls and process controls. The design considerations applicable
when creating user interfaces are related to or involve such disciplines
as ergonomics and psychology.

A user interface is the system by which people (users) interact with a machine. The user
interface includes hardware (physical) and software (logical) components. User
interfaces exist for various systems, and provide a means of:

- Input, allowing the users to manipulate a system, and/or

- Output, allowing the system to indicate the effects of the users'
manipulation.

Generally, the goal of human-machine interaction engineering is to produce a user

interface which makes it easy, efficient, enjoyable to operate a machine in the way
which produces the desired result. This generally means that the operator needs to
provide minimal input to achieve the desired output, and also that the machine
minimizes undesired outputs to the human.

Ever since the increased use of personal computers and the relative decline in societal
awareness of heavy machinery, the term user interface has taken on overtones of the
(graphical)user interface, while industrial control panel and machinery control design
discussions more commonly refer to human-machine interfaces.

Other terms for user interface include human-computer interface (HCI) and man-
machine interface (MMI).

A graphical user interface (GUI) is a type of user interface item that allows people
to interact with programs in more ways than typing such as computers; hand-held
devices such as MP3 Players, Portable Media Players or Gaming devices; household
appliances and office equipment with images rather than text commands. A GUI offers
graphical icons, and visual indicators, as opposed to text-based interfaces, typed
command labels or text navigation to fully represent the information and actions
available to a user. The actions are usually performed through direct manipulation of the
graphical elements.

65
The term GUI is historically restricted to the scope of two-dimensional display screens
with display resolutions capable of describing generic information, in the tradition of
the computer science research at Palo Alto Research Center (PARC). The
term GUI earlier might have been applicable to other high-resolution types of
interfaces that are non-generic, such as videogames, or not restricted to flat screens,
like volumetric displays.

Designing the visual composition and temporal behavior of GUI is an important part
of software application programming. Its goal is to enhance the efficiency and ease of
use for the underlying logical design of a stored program, a design discipline known
as usability. Techniques of user-centered design are used to ensure that the visual
language introduced in the design is well tailored to the tasks it must perform.

Typically, the user interacts with information by manipulating visual widgets that allow
for interactions appropriate to the kind of data they hold. The widgets of a well-designed
interface are selected to support the actions necessary to achieve the goals of the user.
A Model-view-controller allows for a flexible structure in which the interface is
independent from and indirectly linked to application functionality, so the GUI can be
easily customized. This allows the user to select or design a different skin at will, and
eases the designer's work to change the interface as the user needs evolve.
Nevertheless, good user interface design relates to the user, not the system
architecture.

4.1 Integrated Development Environment

An integrated development environment (IDE) also known as integrated design

environment or integrated debugging environment is a software application that
provides comprehensive facilities to computer programmers for software development.
An IDE normally consists of:

- a source code editor

- a compiler and/or an interpreter
- build automation tools
- a debugger

Sometimes a version control system and various tools are integrated to simplify the
construction of a GUI. Many modern IDEs also have a class browser, an object inspector,
and a class hierarchy diagram, for use with object-oriented software development

IDEs are designed to maximize programmer productivity by providing tightly-knit

components with similar user interfaces. This should mean that the programmer has
much less mode switching to do than when using discrete development programs.

66
However, because an IDE is by its very nature a complicated piece of software, this high
productivity only occurs after a lengthy learning process.

Typically an IDE is dedicated to a specific programming language, so as to provide a

feature set which most closely matches the programming paradigms of the language.
However, some multiple-language IDEs are in use, such as Eclipse, ActiveState Komodo,
recent versions of NetBeans, Microsoft Visual Studio, WinDev, and Xcode.

IDEs typically present a single program in which all development is done. This program
typically provides many features for authoring, modifying, compiling, deploying and
debugging software. The aim is to abstract the configuration necessary to piece together
command line utilities in a cohesive unit, which theoretically reduces the time to learn a
language, and increases developer productivity. It is also thought that the tight
integration of development tasks can further increase productivity. For example, code
can be compiled while being written, providing instant feedback on syntax errors. While
most modern IDEs are graphical, IDEs in use before the advent of windowing systems
(such as Microsoft Windows or X11) were text-based, using function keys or hotkeys to
perform various tasks (Turbo Pascal is a common example). This contrasts with software
development using unrelated tools, such as vi, GCC or make.

4.2 Windows Forms

Windows Forms is the name given to the graphical application programming interface
(API) included as a part of Microsoft's.NET Framework, providing access to the
native Microsoft Windows interface elements by wrapping the existing Windows API in
managed code. While it is seen as a replacement for the earlier and more
complex C++ based Microsoft Foundation Class Library, it does not offer a paradigm
comparable to modelviewcontroller. Some after-market and third party libraries have
been created to provide this functionality. The most widely used of these is the User
Interface Process Application Block, which is released by the Microsoft patterns &
practices group as a free download that includes the source code for quick start
examples. A Windows Forms application is an event-driven application supported by
Microsoft's .NET Framework. Unlike a batch program, it spends most of its time simply
waiting for the user to do something, such as fill in a text box or click a button.

4.2.1 The Splash Screen

A splash screen is an image that appears while a computer program is loading. It may
also be used to describe an introduction page on a website. Splash screens sometimes
do not cover the entire screen, but only a rectangle near the center. The splash screens
of operating systems and some applications that expect to be run full-screen usually
cover the entire screen.

67
Splash screens are typically used by especially large applications to notify the user that
the program is in the process of loading. In other words, they provide feedback that a
sometimes lengthy process is under way. Occasionally, a progress bar within the splash
screen indicates the loading progress. A splash screen disappears when the application's
main window appears.

Splash screens typically serve to enhance the look and feel of an application or web site,
and hence are often visually appealing, and may also have animations, graphics
and sound.

The Java programming language has a specific function for creating splash screens called
java.awt.SplashScreen that handles standard splash screen functions (i.e. display an
image centered on screen then disappear when the first program window opens).

On the Internet, a splash screen or splash page is a page of a web site that is a sort of
pre-home page front page. Designers may use splash pages:

to restrict access to content such as pornography, alcohol advertising or sales,

or gambling (as is required by law in many countries, including the United
States and Canada);
to direct users to the appropriate website for their country or language;
to direct users to a low-bandwidth site or one more accessible to disabled users;
as an aesthetic complement to the main page;
as an additional form of advertising.
An early use of the Splash screen on a Flash Website was to enable the site developer to
launch the site in a JavaScript controlled new window--without browser elements such
as scrollbars, address bar, etc. and in the exact size of the Flash movie. This has gone out
of style with the predominance of pop-up blockers. Instead many starting Flash Web
pages now allow their audience to choose to go to full screen viewing.

Since splash screens often increase the distance to the desired content and may take a
long time to load, they are not universally liked by users. Web splash screens are
especially inconvenient for users with slow internet connections as the first page may
take longer to load or if the user has turned off rich content (such as
images, Flash or Shockwave), the splash page may not load at all. Splash pages created
in Flash (and the associated main pages) often cannot be accessed by search engines or
handled by text readers for the blind.

Splash screens can also be created in HTML and CSS if they are designed for a purpose
other then as a loading screen and instead used for another purpose, such as giving the
option to pick the language.

68
In the software designed by us the splash screen looks like as shown in Figure 4.2.1.
PAAC (Patients AT ART Centre) is the codename of the software under development and
will be assigned an appropriate name at the time of implementation.

Figure 4.2.1 The PAAC Splash Screen

4.2.2 Login Form

At the ARTC it is required to maintain confidentiality of patient data. Data used by the
counsellor should not be used by the clinician and vice versa. Even the patient name is
required to be hidden at all times from any of the ARTC staff. The Patient is addressed
only by his unique registration number. Thus in order to include features of limited data
access and improve security the login form has been added as the first form which
appears on the screen. It has the options to choose amongst 5 different types of
employees so that the software may decide to limit the access of the login session
depending on the employee chosen. It also asks for correct login and password created
initially by the administrator which can later be changed by on site administrator. A user
cannot login until the correct username and password is provided.

Enhancing Security (LILOT Service)

As another step to enhance security besides the traditional username and password
authentication the login form also has LILOT technology. LILOT stands for LOG IN LOG
OUT TIME. This technique tracks any login which occurs and saves the login details like
username and employee type with the login time into the database and similarly at the
time of logout. Later these times can be viewed by the Administrator to track any
unexpected login authentications.

69
A flowchart representing the LILOT system is as shown below:

Login

No
Authenticated?

Yes

Emp Type,
Username, Login
Time Saved to DB

User Processes

Logout

Emp Type,
Username, Time
of Logout Saved
to DB

Exit

Figure 4.2.2 LILOT System

Thus the basic aim of login screen is met as demanded by the ARTC. The screen shot of
the login screen in the current version of the software looks as shown below:

70
 Figure 4.2.3 The Login Form (Part1)

Figure 4.2.4 The Login form with employee selection drop down box

71
4.2.3 Registration form
The first form where all patients coming to ARTC are registered is the Initial Registration
form. This form stores Name age and gender of the patient and assigns him a unique
registration number. This is the number with which the patient will later be identified at
the ARTC as name field is kept confidential. The form also stores information about
whether the patient is on ART at the time of registration or not. The Details entered in
the form are stored in the database in the respective table. The form looks as shown
below during run time:

Figure 4.2.5 The Registration Form

The Registration form is for the sole access of the nurse at the Registration counter and
access to other staff is disabled determined by the login type. The Fields marked with (*)
are mandatory. The Form Flow from the registration form is to the Identification data
form if the next button is clicked. If close button is clicked the form exits without saving
data. If save button is clicked the data gets saved into the Database and displays a
confirmation message is shown below.

72
4.2.4 The Identification Form

This form is responsible for the entry and saving of patient identification data to the
database. It contains complete detailed information of the patient as directed by NACO.
This form is also open for access by the registration staff only and confidentiality of this
form is maintained with the other staff by choosing the employee type at login time.
Only at the time of report generation the data from this form can be viewed. The form
looks as shown in figure 4.2.6 during run time.

Figure 4.2.6 Identification Data

73
4.2.5 The Personal History Form
One of the important primary functions of PAAC is to gather all of the patient data
available. Thus another form has been added which gathers all patients personal history
data and saves it to the database. This form is accessible either by the registration
counter nurse or by the counsellor and remains hidden from the other staff or is
disabled.

The Personal History form looks as shown in figure 4.2.7 during runtime.

Figure 4.2.7 The Personal History Form

74
4.2.6 The Family History Form
Another of the data addition form at the registration counter and accessible by the
counsellor also. It is used to feed family history data into the database.

Figure 4.2.8 The Family History Form

The view family Details grid view has been enabled to be able to add many family
members at a time at one instance of clicking of the save button. For example after
entering data of one family member the user clicks on the add button by which the
current details get added into the datagrid view and previous details are cleared. The
next family member details can now be added in the fields. When details of the entire
available family are added to the datagrid on one click of the save button all details are
saved to the database. This is implemented to increase user friendliness.

75
4.2.7 HIV Testing Data Form
This form is for the use of counsellor to feed in certain HIV Testing data. The two
datagrid views have been implemented to increase user friendliness by enabling
multiple content to be added at the same instance of saving process. It is shown as
displayed below.

Figure 4.2.9 HIV Testing Data Form

Certain options which appear disabled get enabled only when a specific check box or
radio button is clicked.

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4.2.8 History of HIV Illness
Several Parameters are taken into consideration when analysis of previous HIV illness is
done. This form stores data about those illnesses. To enable faster and user friendly data
entry various checkboxes have been included in the form which enable the user to add
data just by a single click.

Figure 4.2.10 History of HIV Illness

4.2.9 History ARV Treatment Form

Figure 4.2.11 History ARV treatment

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4.2.10 Clinical and Laboratory Investigations
This form appears complex in data entry point of view because of tree structure of
interlinked data fields. It basically contains data obtained from laboratory and doctor.
Radio buttons have placed for choosing only one option amongst all such as in case of
WHO Staging and Functional status. TB treatment and registration data which is very
important in HIV ART is also fed to the database through this form. Figure 4.2.12 shows
Clinical and Laboratory Investigations form during run time.

Figure 4.2.12 Clinical and Laboratory Investigations

Options to go to previous or next form are available which may be done even without
entering data in this particular form. However Save option only works when certain
mandatory fields have been filled. Close button exits the form without making any
changes to the database.

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4.2.11 Investigations Form

Figure 4.2.13 Investigations

4.2.12 Examination Signs

Figure 4.2.14 Examination Signs

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4.2.13 Medical History
Past medical history largely determines the antiretroviral treatment to be given to the
patient. Thus it becomes essential to gather data about patients adverse habits like
smoking, drinking etc, the age at which it was started. Sexual history of the patient is
also of major concern and PMC, EMC, NMC[appendix] data should be entered. Besides all
these the past and present drugs being consumed by the patient along with HBV, HCV
data should also be entered. The medical History form shown in figure 4.2.15 is helpful
for this purpose.

Figure 4.2.15 Medical History

Each group of data has been grouped in panels to enable user friendly GUI and error free
data entry. This form is accessible by the counsellor and report generation staff of the
ARTC.

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4.2.14 System Review

A brief system review of the patient is taken using the system review form. It has various
checkboxes to enter data if certain ailment is present such as pain in abdomen,
tiredness, bodyache, weight loss, headache, depression, convulsions, blurring of vision,
ear discharge, chest pain, appetite loss, breathlessness etc. The text box beside each
ailment is for entering the duration since when that particular ailment has been present
with the patient.

Figure 4.2.16 System review

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4.2.15 Monitoring and Follow up Tests
Meeting Follow-up can be best defined as the action made after a gathering discussion.
For an ARTC the main goal is success in cure. It provides a system to help regulate the
order of business and such order helps the achievement of success. A company will use
tools in their system and keep the order sustained, to maintain a vivid focus on its goal.
According to Bob Flaws[8] In all but the rarest of clinics there are slow days. If you really
want to improve your clinical skills, I recommend spending some of that "down time"
calling old patients and asking them what the net effect of their treatment with you was.
You'll probably be surprised in both directions. Nevertheless, you will have learned
something valuable: what actually did or did not work. Only based on that kind of real
feedback can we amend what we are doing, making it constantly better and better. The
Monitoring and follow up is based on collection follow up data.

Figure 4.2.17 Monitoring and Follow Up Tests

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4.2.16 Contraception and Gynaecological History
Birth control is a regimen of one or more actions, devices, sexual practices,
or medications followed in order to deliberately prevent or reduce the likelihood
of pregnancy or childbirth. There are three main routes to preventing or ending
pregnancy before birth: the prevention of fertilization of
the ovum by sperm cells ("contraception"), the prevention of implantation of
the blastocyst ("contragestion"), and the chemical or surgical induction or abortion of
the developing embryo or, later, fetus. In common usage, term "contraception" is often
used for both contraception and contragestion.

Figure 4.2.18 Contraception and Gynaecological History

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4.2.17 Employee Details

Figure 4.2.19 Employee Details

4.2.18 Patient Follow Up

Figure 4.2.20 Patient Follow Up

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4.2.19 Pediatric Form
Pediatrics is the branch of medicine that deals with the medical care of infants, children,
and adolescents. The upper age limit of such patients ranges from age 12 to 21.
A medical practitioner who specializes in this area is known as a pediatrician. The
word pediatrics and its cognates mean healer of children; they derive from
two Greek words: (pais = child) and (iatros = doctor or healer).
In Commonwealth countries, the respective spellings paediatrics and paediatrician are
usually preferred. There may be a slight semantic difference: in the USA,
a pediatrician (US spelling) is often a primary care physician who specializes in children,
whereas in the Commonwealth a paediatrician (British spelling) generally is a medical
specialist not in primary general practice. For further detail, see discussion on the broad
and narrow meanings of physician.

Figure 4.2.21 Pediatric Form

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4.2.20 Report Viewer Form

Microsoft Visual Studio 2005 includes report design functionality and Report Viewer
controls so that one can add full-featured reports to custom applications. Reports may
contain tabular, aggregated, and multidimensional data. Report Viewer controls are
provided so that one can process and display the report in your application. There are
two versions of the control. The Report Viewer Web server control is used to host
reports in ASP.NET projects. The Report Viewer Windows Forms control is used to host
reports in Windows application projects.

Figure 4.2.22 Report Viewer

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4.2.21 ARV Treatment Summary Form

Figure 4.2.23 Summary ARV Treatment

4.2.22 Users Form

Figure 4.2.23 Add new User

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4.2.23 MDI Form
MDI (Multiple Document Interface) is a Microsoft Windows programming interface for
creating an application that enables users to work with multiple documents at the same
time. Each document is in a separate space with its own controls for scrolling. The user
can see and work with different documents such as a spreadsheet, a text document, or a
drawing space by simply moving the cursor from one space to another.

An MDI application is something like the Windows desktop interface since both include
multiple viewing spaces. However, the MDI viewing spaces are confined to the
application's window or client area . Within the client area, each document is displayed
within a separate child window . MDI applications can be used for a variety of purposes -
for example, working on one document while referring to another document, viewing
different presentations of the same information, viewing multiple Web sites at the same
time, and any task that requires multiple reference points and work areas at the same
time.

Figure 4.2.24 The Work area MDI (Multiple Document Interface)

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 CHAPTER 5
IMPACT OF IMPLEMENTATION

89
 5. IMPACT OF IMPLEMENTATION
5.1 Introduction
The AIDS virus mutates rapidly, which makes it extremely skilful at developing resistance
to drugs. To minimize this risk, people with HIV are generally treated with a combination
of ARVs that attack the virus on several fronts at once.
The introduction of ARVs in 1996 transformed the treatment of HIV and AIDS, improving
the quality and greatly prolonging the lives of many infected people in places where the
drugs are available. Nevertheless, ARVs are not a cure. If treatment is discontinued the
virus becomes active again, so a person on ARVs must take them for life.
Although the price of ARVs has fallen significantly in recent years, their cost remains an
obstacle to access in the developing world. Moreover, the health infrastructure required
to deliver antiretroviral therapy is lacking in many places.

Figure 5.1 UNAIDS

Access to drugs depends not only on financial and human resources. It depends also on
people who need them being aware of their HIV status, knowledgeable about
treatment, and empowered to seek it.
Thus public information and education are important elements in widening access,
alongside efforts to build or strengthen the health services. The campaign for universal
access to life saving drugs for HIV and AIDS, started originally by grassroots AIDS
activists, is today a major focus of attention of UN agencies and others influential
organizations at national and global levels.
According to its global mandate, UNAIDS supports the reporting by Member States on
their progress as part of the Programmes responsibility to towards
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reaching UNGASS, Universal Access targets and the Millennium Development Goals and
report back to General Assembly every two years.
Without effective monitoring systems in place in countries, this global reporting would
not be possible. To strengthen the accountability and oversight of national HIV
responses, and to put the Three Ones principles into action, UNAIDS Monitoring and
Evaluation (EVA) Division supports countries in strengthening one national monitoring
and evaluation (M&E) system for the epidemic by leading the development and
harmonization of tools as well as producing a Global Progress Report.
As part of the EVA division, the Country Monitoring Systems team work on the following
M&E data tools:
Country Response Information System (CRIS): Indicator data collection and analysis
tool.
Global Response Database (GRD): Database for warehousing and reporting of
UNGASS/UA indicators.
Indicator Registry: A central repository for management of AIDS indicator metadata.
All country monitoring system tools conform to the Indicator exchange Format
(IXF3) version 3, for exchange of data and metadata. IXF3 is an SDMX compliant
protocol.

5.2 Country Response Information System (CRIS)

CRIS, the Country Response Information System version 3.0, is an information system
developed by UNAIDS Monitoring and Evaluation (EVA) Division. CRIS facilitates the
collection, reporting and analysis of project, financial and indicator data.
The accountability and oversight of national HIV responses would not be possible
without effective monitoring systems in countries. To highlight the importance of
having one national M&E system for HIV and AIDS, countries included it in the Three
Ones principles that steer the implementation of national HIV programming. As part of
its mandate, UNAIDS supports global reporting and facilitates the systems development
and capacity building at the country level.

Figure 5.2 CRIS3

Key features of CRIS 3

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In consultation with countries and international partners, UNAIDS has developed the
Country Response Information System version 3 (CRIS 3). CRIS3 is the next generation of
system software that has been designed to more effectively meet country monitoring
needs. The new functionality of unlimited disaggregation of data supports changing
analytical needs and the software design is flexible and can be customized.
CRIS has an intuitive interface making it easy to navigate, enter data and do reporting.
Adding new indicators and projects is also effortlessly accommodated. The new
functionality also allows the inclusion of a variety of plans for national monitoring (e.g.
Universal Access in the National Strategic Plan, UNGASS, PEPFAR, Global Fund, etc.),
with necessary associated projects and their own indicators, targets and reports.
The underlying database is extended automatically by the software, so no programming
expertise is required in order to modify the system. This structure also easily
accommodates unique data entry requirements. The system provides standard reports
and also features a flexible report generator which allows users to define customized
reports. In this way, CRIS helps create a picture of the effectiveness of ongoing projects
and costs associated with a countrys response to HIV and AIDS.

Enhancements

The following improvements are included in the CRIS 3 release:

Stand-alone and network solutions
Unlimited types and levels of disaggregation
Project-based to facilitate reporting
- Enhanced programmatic indicator support
- Enhanced financial data support
- Rollup of financial and indicator data
Provision for partial data
- Missing values
- Configurable entry, i.e. hiding dimensions
Indicator calculation
Statistical Data and Metadata Exchange (SDMX) support
Country-specific customization
Additional enhancements help provide each country with an information monitoring
system that is tailored to their unique needs. The countries can define:
User navigation and entry screens
Data elements and dimensions
Application look-and-feel
Customization allows for manual processes in-country to be automated, streamlining
the flow of information from a facility to the national level.

5.3 Global Response Database

UNAIDS has developed a large global database called the Global Response Database
(GRD), which serves as the main data repository for UNGASS 2003, 2005 and 2007
country data. The UNGASS indicators are used to monitor progress towards achieving

92
universal access to prevention, treatment and care services in 2010 and towards
reaching the Millennium Development Goal of arresting and halting the spread of HIV by
2015.
In adopting the 2001 Declaration of Commitment on HIV/AIDS, Member States
committed to regularly report on their progress to the General Assembly. They do this
by each submitting UNGASS indicator data using a software tool called the Country
Response Information System (CRIS).

Figure 5.3 Global Response Database

Improvements are being made in the reporting process in terms of the quality of data,
civil society participation, number of reports and the data analysis capacities, we get a
much clearer picture of the worlds response to the epidemic.
An improved reporting process also means countries themselves can better know their
epidemic enabling them to target their strategic response accordingly.
The GRD allows better analysis of the global response, country by country and region by
region, and for the first time allows multi-year trend for some of the UNGASS indicators
and disaggregation by gender and age. In addition to allowing data to be imported from
other sources, the GRD will enable the future sharing of UNGASS data with UNAIDS
Cosponsors such as UNICEF and WHO and also the UNAIDS Regional Support Teams and
countries.
The current mechanisms to share the UNGASS data from GRD are:
For policy makers and other parties interested in compressed presentation of
country data, selected GRD data are presented graphically for each country
via Country Fact Sheets.
For general public, UNGASS narrative reports and validated NCPI data in PDF format
are accessible in Monitoring Country Progress web section. Annex 2 of 2008
Global Report is accessible via2008 Report on the global AIDS epidemic.
GRD data will also be accommodated into CRIS 3 pre-installation to allow the
researchers and countries to manage and analyse the UNGASS data. Post-
installation, UNGASS data can be downloaded in IXF3 format into CRIS 3 from
the GRD export service.

5.4 Impact of Information and Automation systems in HIV

Treatment
New Country Response Information System to strengthen national M&E [9]

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Information system provides information on the past, present and project future and on
relevant events inside and outside the organization. It may be defined as a planned and
integrated system for gathering relevant data, converting it in to right information and
supplying the same to the concerned executives. The main purpose of IS is to provide
the right information to the right people at the right time. An information system is
there to empower its users. A database simply provides data, but an information
system is all about providing the best information the user needs to do their task
more effectively. It also takes into account that different users doing their own
specific tasks may need to see their information presented in differing ways. The
benefits of an information system follow when the user can quickly access,
understand and respond correctly to that information.

5.4.1 CASE STUDY 1 Botswana's AIDS Information System -

providing data, empowering districts[10]
For the first time quarterly reports on the AIDS response are being developed in the
Ghanzi District in Western Botswana. This is an important development in the district as
critical and strategic findings can now be presented to the HIV multi-sectoral committee
and local authority. This district is setting the pace for district level monitoring and
evaluation of responses to HIV as district level leaders are now able to make prompt
decisions based on data generated locally without having to wait for feedback from the
national level.

Teresa Makati, the Ghanzi District AIDS Coordinator, referring to the District
Multisectoral AIDS Committee (DMSAC) which is the district coordinating mechanism
said, I really like using the Botswana HIV/AIDS Information System (eBHRIMS) because I
am now finally able to share data with the district committee. This has helped them to be
aware of the true state of the AIDS epidemic in the district. Now they can use this data to
plan AIDS-related interventions at the district-level.

The UNAIDS Country Response Information System (CRIS) provided a basic blueprint for
the electronic Botswana HIV/AIDS Information System as it met most of the user
requirements. A district reporting functionality was built up and set the pace for the
nationwide eBHRIMS rollout in 2006. eBHRIMS is currently installed in all of Botswanas
districts, sub-districts and at the Ministry of Local Government headquarters. CRIS also
has the common XML data exchange format built into it making it possible to exchange
data with other systems. This data exchange function leverages the strengths of multiple
systems and greatly progresses the mandate of the Third One ( One agreed country-
level Monitoring and Evaluation System.). Such systems include the District Health
Information System (DHIS) and mapping software.

The eBHRIMS reporting functionality now provides districts with standardized ability to
highlight and zero in on programme successes and challenges. This system has enhanced
ownership of data at the district level and enables timely evidence informed policy
94
decisions to be made locally. Teresa Makati buttressed this point by saying, People
always talk of statistics but never really get to see them; eBHRIMS now enables you to
critically look at data.its really working!

A practical example from Ghanzi district was a downward trend in sexually transmitted
infection (STI) figures leading them to begin looking for programme implementation
attributes that may have contributed to this development. They have so far put forward
a number of explanations including; sustained education strategies which they refer to
as more preaching, a growing sexual abstinence campaign and friendlier STI health
services. If their explanations are validated, then other districts can adopt these
experiences and the national level can look at these successes to determine if existing
policy is adequate or needs improvement to further support districts.

Figure 5.4 Group members in Ghanzi analyzing trends from eBHRIMS

Ghanzi District also discovered that the number of food rations distributed to Home
Based Care (HBC) patients was much higher than those registered. The district then
closely examined all its figures (food rations and registered HBC patients) to determine if
there were any flaws in the programme. This sparked the interest of district leaders on
the details of the food rations policy for HBC patients. Based on the re-examined figures,
the district will decide to either correct its registration methods, or relay this information
to the national level if it is concluded that the problem relates to challenges in the
national policy and thus sealing any loopholes that may exist, an ideal result of
monitoring and evaluation.

These two examples actualize the words of Sam Nonofo the Ghanzi Monitoring and
Evaulation Officer who said that, eBHRIMS has rendered programme data trend
analysis a less mind boggling exercise.

Other districts have also registered marked improvements in their analysis and use of
data. In one district, eBHRIMS data enabled it to note an upsurge in teenage pregnancies
leading to re-strategizing on the ongoing HIV prevention and sexual and reproductive
health interventions for girls.

95
This is good evidence to show that decisions that were previously solely made at national
level can now be made at district level providing speedier responses and heightened
national level impetus to address HIV.

To further enhance the district responses to HIV, the Ministry of Local Government has
facilitated the development of an Evidence Based Plan (EBP) toolkit that advocates for
the use of strategic information for planning and also helps to provide members of the
DMSAC with relevant skills. The toolkit has assisted districts to undertake more efficient
planning based on routine monitoring and evaluation data generated from eBHRIMS and
other additional information on the national response. The Ghanzi District AIDS
Coordinators office proudly reported that the district registered a marked improvement
with 56% of all 2007-2008 district level activities being based on evidence as opposed to
20% of activities in 2006-2007.

This precedence set by Ghanzi and other districts that have taken up the eBHRIMS
reporting process, serves to provide great motivationthat efforts in developing
monitoring and evaluation capacity and systems are proving to be highly successful.
However, there have been challenges that Ghanzi has faced, but these have served as
lessons that other districts and the country as a whole can learn from. It is evident that
district level stakeholders are now being empowered to come up with evidence informed
district specific interventions based on regular and systematic feedback from the
information that is now available through eBHRIMS.

5.4.2 CASE STUDY 2 Ghana CRIS Implementation

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5.5 Comparison of PAAC1 with CRIS3
As indicated in above sections CRIS is a global standard information system
implemented under the guidelines of UNAIDS. The overall impact of CRIS is very positive
and has helped in collecting and gathering AIDS data and generating required reports.
We compare PAAC system developed by us with the global standard CRIS3 (latest
version) and see how improved PAAC system is, compared to CRIS.

5.5.1 Main Objective

CRIS
CRIS has been implemented with basic aim of generating reports at global level and
include data entry for data collected manually based on paper based records from the
entire country ART centres. It has no function to implement data gathering at the ARTCc
itself.

According to User Scenario 1.eng CRIS 3 FOR NATIONAL MONITORING -Prepared by

Country Monitoring Systems Team, Monitoring and Evaluation Division [11] the
objectives of CRIS are stated as below:

Rationale
In 2008 Member States reported back to the United Nations General Assembly on their
progress towards the agreed upon targets.
CRIS 3 allows countries to revisit their data, add information and use it for their own
monitoring purposes.

Objectives of the scenario

Users are able to use CRIS 3 for presenting UNGASS data in the required M&E format
and to create a repository of data for reporting on a regular basis.

Users of the scenario

M&E officers in the National AIDS Commission or Ministry of Health; other M&E staff
responsible for national reporting.

Estimated time required

The following steps, which exclude the installation of the software, are estimated to take
60-90 minutes.

Outputs
At a minimum users will produce a .PDF output of historical Ungass data and a tentative
view on a National Monitoring Plan.
Basic Monitoring workflow using CRIS3
Review and comment on the standard Monitoring workflow that CRIS3 follows.

97
 Figure 5.5 CRIS Workflow

PAAC

Main objective of PAAC is different from that of CRIS. PAAC System focuses on data
collection from ARTC which is the root level of AIDS data gathering. Implementation of
data gathering system such as PAAC at this level drastically reduces errors which occur
during manual data generation process. Reports created by PAAC at the ARTC level are
completely error free. Human error which comes at manual report generation methods
at ARTC level which is currently in practice leads to a great change in overall national
data combined together from all, ARTCs. Thus there is a need to implement data
gathering automation systems at the lower levels are very important, this need is met by
PAAC.

PAAC Workflow

Send Generated
Gather Patient
Start Receive Patient Generate Reports reports to National Stop
Data
Database

Figure 5.6 PAAC Workflow Diagram

98
5.5.2 User Interface

PAAC has been designed keeping in mind the Fitts Law[appendix]. Similar to CRIS3 it has
been designed on the windows OS platform using the .net framework. The UI is based
on windows forms as in the CRIS system. However UI of PAAC is customized for data
entry based on NACO guidelines and hence in turn complies with WHO standards.
Samples of UI compared to CRIS are as shown.

Figure 5.7 Comparison of GUI CRIS (Left) and PAAC (Right)

As seen above PAAC has a better GUI than CRIS and any normal computer user or a user
with little training can be made able enough to enter data into the PAAC system. Reports
generation is also easy to view through datagrid view computed and extracted directly
from the database. The generated report can then be exported to an Excel sheet for
sending to NACO.

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5.5.3 Architecture and Tools

CRIS

Technologies
The browser-based application runs on Microsoft technology 6 (stand-alone on XP
Professional but not on Vista and Windows 7) and is free of licensing costs. The
technologies include .Net 2.0 and AJAX. Supported databases include SQL Server
2000/MSDE or SQL Server 2005/Sql Express.
Dynamic Database
The dynamic database structure makes customization easier and more compatible with
other databases.
The application can be adapted to changing needs without additional programming. A
combination of dynamic and static reporting databases provides flexibility with ease of
reporting and performance.
Application Tools
A suite of tools is provided to customize the application to promote organization and
country use and ownership. Ultimately, Version 3 will include:
A. CRIS SQL - for querying the dynamic database using familiar concepts
B. Report Designer - for custom report creation
C. Translator Tool - to support database, user interface, and reports in multiple
languages
Supported Configurations
Depending on your current available IT environment, CRIS can be deployed in the
following configurations:
A. Internet:
1. Windows XP Professional or 2003 server + IIS web server
2. SQL Server 2000
B. Intranet:
1. Windows XP Professional server + IIS web server
2. SQL Server 2000
C. Stand-alone:
1. Windows XP Professional for IIS
2. SQL 2000 MSDE or SQL 2005 Express Edition

PAAC
Technologies
The windows forms based application runs on Microsoft .net Technology (Stand alone
on Windows XP, Windows Vista, Windows 7) and is free of licensing cost developed
solely for academic and social welfare motive. The Technologies include .Net 3.5.
Supported Database include SQL Server 2005.
Dynamic Database
The dynamic database structure makes customization easier and more compatible with
other databases.
The application can be adapted to changing needs without additional programming. A
combination of dynamic and static reporting databases provides flexibility with ease of
reporting and performance.

100
Application Tools
A suite of tools is provided to customize the application to promote organization and
use:
A. SQL - for querying the dynamic database using familiar concepts
B. Report Designer - for custom report creation
C. Data Entry Forms for easy flawless data entry process
Supported Configurations
Depending on your current available IT environment, PAAC can be deployed in the
following configurations:
A. Stand-alone:
1. Windows XP Professional, Windows Vista, Windows 7
2. SQL Server 2005

5.5.4 Report Generation

CRIS Report generation is done by manually selecting the fields required for the report
which might become tiring in certain cases. It is as shown below:

Figure 5.8 Report generation in CRIS Step 1

Figure 5.9 Report generation in CRIS Step 2

101
 Figure 5.10 Report generation in CRIS Final Step VIEWING

Only one statement describes report generation with PAAC. Its just a single click
away. All commonly used reports definitions have already been fed into the PAAC
system and hence the report is generated in a single click as shown:

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5.6 Future Improvisations in the coming versions

This very ambitious PAAC project has a lot of scope for future improvisations. A few
expected additions to the present system are as listed below and subject to more
additions based on more exploration and discovery:

1. PAAC NeuroSense: The highly linked and defined range of data fields
used by PAAC provoke implementation of a neural networks based
intelligence system (NeuroSense) which can monitor the entire data
entry and report generation process in real time. Suggest users for all
human errors occurring into the system and provide reports and
reminders as per requirements.
2. Direct Upload of data through internet: As final aim of PAAC is to
generate data to be used by NACO and WHO a system can be put into
place by which there is dynamic data upload to an e mail or website.
3. Direct data input from Laboratory Analysers: PAAC system can be
interfaced with digital laboratory devices and patients data can be
directly saved into the database eliminating the need of a data entry
person.
4. Patient Identification based on Facial Recognition or smart cards.
5. Addition of more other reports.
6. Cloud Based Database system: As database saved in hospital systems are
prone to crashes a cloud based DBMS system can be implemented in
future where there is no data loss.
7. Improving Data Security.
8. Graphical Reports: Next Version of PAAC will include Graphs and plots as
a way of representing reports

REGISTRATION CLINICIAN

REPORTING
DEVICES

DATA
BASE

COUNSELOR

DOCUMENT
INPUT

PHARMACY

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Appendix 1
Acquired: Anything that is not present at birth but develops some time later. In
medicine, the word "acquired" implies "new" or "added." An acquired condition is "new"
in the sense that it is not genetic (inherited) and "added" in the sense that was not
present at birth.

Anonymous testing: Testing in which no name is used -- there is total anonymity -- to

identify the person tested. For example, the State of Florida requires that each county
have a site for anonymous HIV testing.

Antibody: An immunoglobulin, a specialized immune protein , produced because of the

introduction of an antigen into the body, and which possesses the remarkable ability to
combine with the very antigen that triggered its production.

Antiviral: An agent that kills a virus or that suppresses its ability to replicate and, hence,
inhibits its capability to multiply and reproduce.
See the entire definition of Antiviral

AZT: Zidovudine (formerly called azidothymidine [abbreviated AZT]), a drug used against
human immunodeficiency virus (HIV), the virus that causes AIDS. The brand name is
Retrovir.

ART: Antiretroviral therapy (ART) Treatment that suppresses or stops a retrovirus. One
of the retrovirus is the human immunodeficiency virus (HIV) that causes AIDS.

ATT: It is a antituberculosis therapy used for paradoxical response which usually

develops after two weeks of treatment, is well known. A paradoxical response is defined
as the clinical or radiological

Angular Chelitis: a disease that most often occurs among the elderly but is caused by
parasitic fungi, along with bacterial involvement, or a deficiency in vitamin B rather than
age; angular cheilitis appears as skin lesions on the lips, particularly as breaks in the
tissue at the corners of the oral cavity (commissures).

Anaemia: The condition of having less than the normal number of red blood cells or less
than the normal quantity of hemoglobin in the blood. The oxygen-carrying capacity of
the blood is, therefore, decreased.

Amylase: Normal levels are 25-125 milliunits/mL. Amylase is secreted by the saliva
glands as well as in the pancreas. Elevated levels may be an early sign of inflammation of
the pancreas, or pancreatitis. This is a serious side effect of some common medications
used to treat HIV and its conditions.

Anti HCV: Anti-HCV test detects the presence of antibodies to the virus, indicating
exposure to HCV. This test cannot distinguish between someone with an active or a
previous HCV infection. Usually, the test is reported as "positive" or "negative." There is
104
some evidence that if the test is "weakly positive," it may be a false positive. The Centers
for Disease Control and Prevention (CDC) suggests that weakly positive tests be
confirmed with the HCV RIBA test before being reported.

Atopy: The genetic tendency to develop the classic allergic diseases -- atopic
dermatitis,allergic rhinitis (hay fever), and asthma. Atopy involves the capacity to
produce IgE in response to common environmental proteins such as house dustmite,
grass pollen, and food allergens. From the Greek atopos meaning out of place

BMI: Body Mass Index (BMI) is a number calculated from a persons weight and height
information. BMI equals a persons weight in kilograms divided by height in meters
squared or BMI=kg/m2.

Blood Pressure (Systolic): the systolic pressure, represents the force of blood against
your artery walls that the heart must use to circulate the blood.

Blood Pressure(Diastolic): the diastolic pressure, represents the force of blood against
your artery walls when the heart is resting---or between beats.

Blood Urea: Blood Urea Nitrogen (BUN) is a waste product produced in the liver and
excreted by the kidneys. High values may mean that the kidneys are not working as well
as they should. BUN is also affected by high protein diets and/or strenuous exercise
which raise levels, and by pregnancy which lowers it.

Blood Sugar: Normal levels are 75-125mg/dl.

sugar is glucose, and glucose values are used to check for diabetes. Some drugs may
alter glucose levels, such as Pentam (IV pentamidine) or drugs that affect the pancreas.
Insulin resistance is one cause of high blood glucose. Insulin resistance occurs when
insulin (the hormone that moves sugar into cells) is less effective than usual in your
body. This may occur with long-term use of anti-HIV drugs, from HIV itself or from both
HIV and the drugs. It is treatable with medications.

CD4 Count: Number of CD4 cells (T-helper lymphocytes with CD4 cell surface marker),
used to assess immune status, susceptibility to OIs, need for ART and OI prophylaxis, and
for defining AIDS (CD4 <200).

Cd4 %:CD4 tests measure the number of T cells containing the CD4 receptor. Results are
usually expressed in the number of cells per microliter (or mm3) of blood. While CD4
tests are not an HIV test in that they do not check the presence of viral DNA, or specific
antibodies, they are used to assess the immune system of patients

Cancer: An abnormal growth of cells which tend to proliferate in an uncontrolled way

and, in some cases, to metastasize (spread).

CDC: The Centers for Disease Control and Prevention , the US agency charged with
tracking and investigating public health trends. The stated mission of the CDC is "To
promote health and quality of life by preventing and controlling disease, injury, and

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disability." The CDC is a part of the U.S. Public Health Services (PHS) under the
Department of Health and Human Services (HHS).

Centers for Disease Control and Prevention: The US agency charged with tracking and
investigating public health trends. The stated mission of the Centers for Disease Control
and Prevention, commonly called the CDC, is "To promote health and quality of life by
preventing and controlling disease, injury, and disability."

Cure:

1. To heal, to make well, to restore to good health. Cures are easy to claim and, all too
often, difficult to confirm.
2. A time without recurrence of a disease so that the risk of recurrence is small, as in
the 5-year cure rate for malignant melanoma .
3. Particularly in the past, a course of treatment. For example, take a cure at a spa.

Culture: HIV culture tests are used to detect the presence of the human
immunodeficiency virus in serum, saliva, or urine. Such tests may detect HIV antibodies,
antigens, or RNA.

Coated Tongue: Nonspecific term used to describe the condition of the tongue resulting
from whitish or otherwise discolored accumulations of food debris, bacterial plaques,
and hyper plastic filiform papillae.

CTX : Cotrimoxazole (trimethoprimsulphamethoxazole, CTX) is a widely available, easy

to administer, safe and low-cost antibiotic, which is known to have a broad spectrum
ofaction against several HIV-related and non-HIV-related pathogens. In wealthy
countries, it has been used widely for primary and secondary prophylaxis to prevent
Pneumocystis jiroveci pneumonia and Toxoplasma gondii encephalitis

Clubbing: A condition in which the ends of the fingers and toes are enlarged and the
nails are shiny and abnormally curved.

Convulsions: a sudden uncontrollable attack; "a paroxysm of giggling"; "a fit of

coughing"; "convulsions of laughter"

Cyanosis: A bluish color of the skin and the mucous membranes due to insufficient
oxygen in the blood.

CXR(PA view): A chest x ray is a procedure used to evaluate organs and structures within
the chest for symptoms of disease. Chest x rays include views of the lungs, heart, small
portions of the gastrointestinal tract, thyroid gland and the bones of the chest area.

Cholesterol: Normal cholesterol levels are 150-250mg/dl. Cholesterols are fatty

substances in the body. Their levels help measure the risk for conditions such as heart
disease and wasting. Triglycerides often decrease in people with HIV, possibly due to
malnutrition or wasting in advanced stages of disease. High cholesterol and triglycerides
may occur among people living with HIV for many years. They can also be a side effect of
anti-HIV drugs.
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Cryptococcal meningitis: Neurology An opportunistic infection of the meninges and
spinal cord by Cryptococcus neoformans At-risk Pts AIDS, lymphoma, DM Clinical Severe
headache, confusion, photosensitivity, blurred vision, fever, speech difficulties
Management Amphotericin B plus flucytosine, then consolidation with fluconazole or
itraconazole Prognosis Untreated, coma, death.

Cytomegalovirus infection: Cytomegalovirus (CMV) is a virus related to the group of

herpes viruses. Infection with CMV can cause no symptoms, or can be the source of
serious illness in people with weak immune systems.

Dermatitis: The simple definition of dermatitis is inflammation of the skin.

Disseminated Mycobacteruim avium complex :Abbreviated MAC. An opportunistic

infection caused by two similar slow-growing bacteria called Mycobacterium avium and
Mycobacterium intercellulare that are found in the soil and in dust particles.

DLC: The DLC, or differential leukocyte count is associated with TLC but is more specific
in that a DLC test shows the amount of each type of white blood cell (they have different
sizes and different shapes).

ELISA: ELISA stands for "enzyme-linked immunosorbent assay." This is a rapid

immunochemical test that involves an enzyme (a protein that catalyzes a biochemical
reaction). It also involves an antibody or antigen (immunologic molecules).

Essential:

1. Something that cannot be done without.

2. Required in the diet, because the body cannot make it. As in an essential amino
acid or an essential fatty acid.
3. Idiopathic. As in essential hypertension. "Essential" is a hallowed term meaning
"We don't know the cause."

ESR: ESR stands for Erythrocyte Sedimentation Rate which measures the extent of
inflamation in the body. Anaemia, TB and cancer are known to spike ESR readings.
Normal range - 3 to 13 mm/hour for children and for adult males below 15mm/hr and
women, below 20mm/hr.
Westergren's is method for estimating the sedimentation rate of red blood cells in
whole blood by mixing venous blood with an aqueous solution of sodium citrate and
allowing the mixture to stand in an upright standard pipet and, after one hour, reading
the millimeters the cells have descended.

ExtraPulmonary: not connected with the lungs. outside of or unrelated to the lungs.

Forceps Birth: extraction of the child from the maternal passages by application of
forceps to the fetal head; designated low or midforceps delivery according to the degree
of engagement of the fetal head and high when engagement has not occurred.

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FDA: The Food and Drug Administration, an agency within the U.S. Public Health Service,
which is a part of the Department of Health and Human Services.

Fitts's law: It is a model of human movement in human-computer

interaction and ergonomics which predicts that the time required to rapidly move to a
target area is a function of the distance to and the size of the target. Fitts's law is used
to model the act of pointing, either by physically touching an object with a hand or
finger, or virtually, by pointing to an object on a computer display using a pointing
device. It was proposed by Paul Fitts in 1954.

Genital Ulcers: Ulcerative lesions on the genitals, usually caused by a sexually

transmitted condition such as herpes, syphilis or chancroid. The presence of genital
ulcers may increase the risk of transmitting HIV.

Heterosexual: A person sexually attracted to persons of the opposite sex. Or a person

who has sexual relations with the opposite sex. Colloquially known as "straight."

HIV: Acronym for the Human Immunodeficiency Virus , the cause of AIDS (acquired
immunodeficiency syndrome). HIV has also been called the human lymphotropic virus
type III, the lymphadenopathy-associated virus and the lymphadenopathy virus . No
matter what name is applied, it is a retrovirus. (A retrovirus has an RNA genome and a
reverse transcriptase enzyme. Using the reverse transcriptase , the virus uses its RNA as
a template for making complementary DNA which can integrate into the DNA of the host
organism).

HIV test: A test for the human immunodeficiency virus, the cause of AIDS . HIV tests are
designed to detect antibodies to the HIV virus or the HIV virus itself.

Herpes Simplex: is a virus that causes infection of skin and mucous membrane and
rarely infects other parts of the body.

Human immunodeficiency virus: HIV, the cause of AIDS. HIV has also been called the
human lymphotropic virus type III, the lymphadenopathy-associated virus and the
lymphadenopathy virus. No matter what name is applied, it is a retrovirus. (A retrovirus
has an RNA genome and a reverse transcriptase enzyme. Using the reverse
transcriptase, the virus uses its RNA as a template for making complementary DNA
which can integrate into the DNA of the host organism). Although the American research
Robert Gallo at the National Institutes of Health believed he was the first to find HIV, it is
now generally accepted that the French physician Luc Montagnier (1932-) and his team
at the Pasteur Institute discovered HIV in 1983- 84.

Hemoptysis: Hemoptysis is the coughing up of blood or bloody sputum from the lungs or
airway. It may be either self-limiting or recurrent.

Herbes Zoster: Also called shingles, zona, and zoster. The culprit is the varicella-zoster
virus. Primary infection with this virus causes chickenpox (varicella). At this time the
virus infects nerves (namely, the dorsal root ganglia) where it remains latent (lies low)
for years.

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Hb: Hb is the standard abbreviation for hemoglobin, the oxygen-carrying protein
pigment in the blood, specifically in the red blood cells. In the very common laboratory
test for hemoglobin (Hb), it is measured as total hemoglobin and the result is expressed
as the amount of hemoglobin in grams (gm) per deciliter (dl) of whole blood, a deciliter
being 100 milliliters.

HbsAg: (hepatitis B surface antigen) - This refers to the outer surface of the hepatitis B
virus that triggers an antibody response. A "positive" or "reactive" HBsAg test result
means that the person is infected with the hepatitis B virus. This can be an "acute" or a
"chronic" infection. Infected people can pass the virus on to others through their blood.

Immune: Protected against infection. The Latin immunis means free, exempt.

Immune system: A complex system that is responsible for distinguishing us from

everything foreign to us, and for protecting us against infections and foreign substances.
The immune system works to seek and kill invaders.

Immunodeficiency: Inability to mount a normal immune response. Immunodeficiency

can be due to a genetic disease or acquired as in AIDS due to HIV.

Infection: The growth of a parasitic organism within the body. (A parasitic organism is
one that lives on or in another organism and draws its nourishment there from.) A
person with an infection has another organism (a "germ") growing within him, drawing
its nourishment from the person.

Intern: In medicine, a doctor who has completed medical school and is engaged in a year
of additional training at a hospital before residency. An intern may, for example, be in
pediatrics or medicine (internal medicine). The internship year is often quite rigorous.

IUD: IUD is a birth control device, such as a plastic or metallic loop, ring, or spiral that is
inserted into the uterus to prevent implantation of a fertilized egg in the uterine lining.

ID No as per Child health: A short summary record of the child and followed
appointments.

Invasive cervical cancer: Cancer that has spread from the surface of the cervix to tissue
deeper in the cervix or to other parts of the body.

In Patient: A patient who is admitted to a hospital or clinic for treatment that requires at
least one overnight stay

IDU Outreach: This package is designed to help organize workshops that orient and train
public health policy-makers, programme developers, programme managers,
implementers and field workers in outreach to injecting drug users.

Jaundice: Yellow staining of the skin and sclerae (the whites of the eyes) by abnormally
high blood levels of the bile pigment bilirubin. The yellowing extends to other tissues
and body fluids.

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Kaposi sarcoma: Kaposi's sarcoma (KS; pronounced kuh-PO-seez sar-KO-muh) is a very
rare form of cancer (see cancer entry). The word "sarcom" refers to any form of cancer
that affects muscle, bone, liver, kidneys, lungs, spleen, bladder, and other organs and
tissues.

Labour: Childbirth, the aptly-named experience of delivering the baby and placenta from
the uterus to the vagina to the outside world. There are two stages of labor. During the
first stage (called the stage of dilatation), the cervix dilates fully to a diameter of about
10 cm. In the second stage (called the stage of expulsion), the baby moves out through
the cervix and vagina to be born.

Laboratory: A place for doing tests and research procedures and preparing chemicals,
etc. Although "laboratory" looks very like the Latin "laboratorium" (a place to labor, a
work place), the word "laboratory" came from the Latin "elaborare" (to work out, as a
problem, and with great pains), as evidenced by the Old English spelling "elaboratory"
designating "a place where learned effort was applied to the solution of scientific
problems."

Lancet: A small pointed knife; a surgical instrument with a short, wide, sharp-pointed,
two-edged blade; a little knife with a small point. Lancets are used today to prick the
skin (a finger, foot, ear lobe, etc.) to obtain a small quantity of capillary blood for testing.

Laboratory Testing: Laboratory tests for detecting HIV infection are of three types

1. Screening tests
2. Supplemental tests
3. Confirmatory tests

MDR: multidrug-resistant tuberculosis (MDR-TB) in high HIV-prevalence settings such as

sub-Saharan Africa.

MSM: Men who have sex with men or males who have sex with males (MSM) refers to
men who engage in sexual activity with other men, regardless of how they identify
themselves; many choose not to accept social identities of gay or bisexual.

MCV: Mean corpuscular volume (MCV)

Measures the average size of your RBCs. The MCV is elevated when your RBCs are larger
than normal (macrocytic), for example in anemia caused by vitamin B12 deficiency.
When the MCV is decreased, your RBCs are smaller than normal (microcytic) as is seen in
iron deficiency anemia or thalassemias.

Mantoux Test: A tuberculin test in which a small amount of tuberculin is injected under
the skin.

NonDOTS: Our major indicator of DOTS expansion is DOTS population coverage (DPC),
defined and reported by WHO as the percentage of national population living in areas
(e.g., districts, counties) implementing DOTS. Population coverage is used by WHO as
the primary measure of DOTS expansion, along with estimated case detection rate.

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Neonatal Complications: risk of offspring developing diabetes , maternal risks
of pregnancy, Diabetic retinopathy ,Diabetic nephropathy ,Hypertension ,Cardiovascular
disease ,Thyroid disease ,Peripheral and autonomic neuropathy

Oral Contraceptives: A birth control pill taken by mouth. Most oral contraceptives
include both estrogen and progesterone. When given in certain amounts and at certain
times in the menstrual cycle, these hormones prevent the ovary from releasing an egg
for fertilization.

Out Patient: A patient who is not an inpatient (not hospitalized) but instead is cared for
elsewhere -- as in a doctor's office, clinic, or day surgery center.

Onychomycosis: Fungal infection of the nails. Fungal infections can involve either the
toenails or the fingernails. Nail fungal infection is usually caused by the dermatophyte
fungi Trichophyton rubrum which can invade the nail bed. See dermatophytic
onychomycosis.

Oral Hairy Leucoplakia: A white lesion appearing on the lateral surface of the tongue
and occasionally on the buccal mucosa of patients with AIDS. The lesion appears raised,
with a corrugated or hairy surface as a result of keratin projections.

Oral Candidiasis/ Candida oesophagitis: Infectious disease A yeast infection of the adult
oral mucosa, caused by Candida albicans, an opportunistic pathogen linked to immune
compromiseeg, with AIDS.

Opportunistic Infections: An opportunistic infection (OI) is an infection that occurs only

when the host's defense systems (ie, the immune system) are weakened. The common
characteristic of all agents that cause opportunistic infections is that they rarely affect
individuals with healthy immune systems.For example, the disease AIDS (acquired
immunodeficiency syndrome) is a classic cause of immune system depression and is
associated with many opportunistic infections, including toxoplasmosis, pneumocystis
pneumonia (PCP), and others.

Pediatrics: "Pediatrics is concerned with the health of infants, children and adolescents,
their growth and development, and their opportunity to achieve full potential as adults."
(Richard E.Behrman in Nelson's Textbook of Pediatrics)

Perinatal: Pertaining to the period immediately before and after birth. The perinatal
period is defined in diverse ways. Depending on the definition, it starts at the 20th to
28th week of gestation and ends 1 to 4 weeks after birth. The word "perinatal" is a
hybrid of the Greek "peri-meaning "around or about" and "natal" from the Latin "natus"
meaning "born."

PAP Smear: A Pap smear can detect certain viral infections (such as human
papillomavirus [HPV]) and other cancer-causing conditions.

PPTCP: Prevention of parent to child transmission.

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Pulse: pulse is the expansion and contraction of the blood as it is pumped around the
circulation

PMTCT: Preventing mother to child transmission when an HIV-infected woman passes

the virus to her baby. This can occur during pregnancy, labour and delivery, or
breastfeeding

PEP: The abbreviation PEP stands for a number of things in medicine including post-
exposure prophylaxis. Prophylaxis means a defense or protection.

Place of Rx: place of Rx is a significant increase in number of reported AIDS cases took
place

PPTCT: Parent-to-child transmission (PPTCT) of HIV, or perinatal transmission

PLHA Network: PLHA is "people living with HIV/AIDS".

Pulmonary TB: Pulmonary tuberculosis (TB) is caused by the bacteria Mycobacterium

tuberculosis (M. tuberculosis).

Persistent Glandular Lymphadenopathy: Abnormally enlarged lymph nodes. Commonly

called "swollen glands."

Pruritic Papular Eruptions: A person with pruritic papular eruption (PPE) has an itchy
rash that occurs on the legs. The cause of pruritic papular eruption is unknown. PPE is
most common in those with HIV infection.

Persistent Diarrhoea: Persistent diarrhoea is an important cause of illness and death in

children in developing countries. Moreover, as acute diarrhoea is more widely and
successfully treated with oral rehydration therapy (ORT), the proportion of diarrhoea
deaths associated with persistent diarrhoea will probably increase.

Pneumocystis pneumonia: A fungal infection of the lungs that is particularly common

and life-threatening in premature or malnourished infants and in immune suppressed
person.

Pharmacy: A location where prescription drugs are sold. A pharmacy is, by law,
constantly supervised by a licensed pharmacist.

Pneumonia: Inflammation of one or both lungs with consolidation. Pneumonia is

frequently but not always due to infection. The infection may be bacterial, viral, fungal
or parasitic. Symptoms may include fever, chills, cough with sputum production, chest
pain, and shortness of breath.

Pregnancy : The state of carrying a developing embryo or fetus within the female body.
This condition can be indicated by positive results on an over-the-counter urine test, and
confirmed through a blood test, ultrasound, detection of fetal heartbeat, or an X-ray.
Pregnancy lasts for about nine months, measured from the date of the woman's last

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menstrual period (LMP). It is conventionally divided into three trimesters, each roughly
three months long.

Pregnant: The state of carrying a developing fetus within the body.

Prenatal: Occurring or existing before birth.

PLT: Platelet Count ,Blood platelets, ('little plates') are some of the tiniest components
of blood, vital for clotting of the blood and protection from bleeding. Normal range -
0.15 tp 0.4 million/Cu.mm

Public health: The approach to medicine that is concerned with the health of the
community as a whole. Public health is community health. It has been said that: "Health
care is vital to all of us some of the time, but public health is vital to all of us all of the
time."

Prophylaxis: : A measure taken for the prevention of a disease or condition.

Registration Number : It is a unique Identification Number given to each patient at the

time of Registration by which he is identified during the entire treatment process at
the ART Centre.

Radiograph: The making of film records (radiographs) of internal structures of the body
by passing x-rays or gamma rays through the body to act on specially sensitized film.

Rx: The symbol "Rx" is usually said to stand for the Latin word "recipe" meaning "to
take." It is customarily part of the superscription (heading) of a prescription.

Respiratory Rate: The number of breaths per minute or, more formally, the number of
movements indicative of inspiration and expiration per unit time.

Regularity: A weekly digest of HIV treatment news. This bulletin provides

straightforward, easy-to-read summaries of the key HIV developments with links to
more detailed articles. Easy to skim through to find the most relevant information, it
wont take you hours to keep up to date.

Recurrent bacterial pneumonia: is an infection of the lungs

RBC: RBCs are produced in your bone marrow, and they carry oxygen and carbon dioxide
through your body. The RBC count is the number of red blood cells found in a small
amount of blood called a cubic milliliter, or mL. Normal levels for men range from 4.5-
6.1 million/mL, and for women 4.0-5.3 million/mL. It's not uncommon for people with
HIV to have RBC values below normal.Slightly lower values should not be cause for
alarm. However, greatly lower numbers can be a sign of anemia. Symptoms include
fatigue, shortness of breath, pale skin color and menstrual problems. Anemia can be
caused by some medicines and/or illness. Low RBC counts occur with lower hemoglobin
and hematocrit levels. Anemia may be treated with iron supplements, erythropoietin
(Epogen) or in severe instances, a blood .

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Saliva: a watery secretion in the mouth produced by the salivary glands that aids in the
digestion of food. Saliva also serves to moisten and cleanse the mouth, including the
tongue and teeth, and contains substances that can play a role in the prevention of
infection. Saliva aids digestion by moistening food and contains enzymes that begin the
digestion process. Also known as spit.

Syndrome: A set of signs and symptoms that tend to occur together and which reflect
the presence of a particular disease or an increased chance of developing a particular
disease.

Sputum: The mucus and other matter brought up from the lungs, bronchi, and trachea
that one may cough up and spit out or swallow. The word "sputum" is borrowed directly
from the Latin "to spit." called also expectoration.

Scabies: Scabies is a relatively contagious infection caused by a tiny mite.

SGOT and SGPT+alk.PO4: Among the most sensitive and widely used liver enzymes are
the aminotransferases. If the liver is injured, the enzymes spill out, raising the enzyme
levels in the blood and signaling the liver damage. Two key enzyms are AST and ALT. The
enzyme aspartate aminotransferase (AST) is also known as serum glutamic oxaloacetic
transaminase (SGOT); and alanine aminotransferase (ALT) is also known as serum
glutamic pyruvic transaminase (SGPT). Normal range - SGOT - 8 to 40 units/ litre; SGPT -
5-35 units/litre

STI: Sexually transmitted infections (STI) is a group of infections that may transmit
through vaginal, oral and anal sexual intercourse.The classical STI include, gonorrhoea,
syphilis and chlamydia infection, but also blood-borne virus such as HIV infection,
hepatitis B and hepatitis Ccould be sexually transmitted.

Smear: smear is a microscopic examination of cells taken from the cervix. A Pap smear
can detect certain viral infections (such as human papillomavirus [HPV]) and other
cancer-causing conditions.

STI Clinic: It is a clinic for sexually transmitted infection.

Tubal Ligation: Tubal ligation is a permanent voluntary form of birth control

(contraception) in which a woman's Fallopian tubes are surgically cut or blocked off to
prevent pregnancy.

Temperature: Temperature is a measurement of the average kinetic energy of the

molecules in an object or system and can be measured with a thermometer or a
calorimeter. It is a means of determining the internal energy contained within the
system.

TB/RNTCP: Tuberculosis (TB) is an infectious disease caused by a Bacterium,

Mycobacterium tuberculosis. It is spread through the air by a person suffering from TB.

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Tuberculosis Lymph nodes: infection of the lymph nodes by tuberculosis. Tuberculosis
infection of the cervical lymph nodes is scrofula.

Toxoplasmosis: An infection caused by a single-celled parasite named Toxoplasma

gondii that may invade tissues and damage the brain, especially of the fetus and
newborn.

Triglycerides: Triglycerides can range from 47-175mg/dl.Triglycerides are fatty

substances in the body. Their levels help measure the risk for conditions such as heart
disease and wasting. Triglycerides often decrease in people with HIV, possibly due to
malnutrition or wasting in advanced stages of disease. High cholesterol and triglycerides
may occur among people living with HIV for many years. They can also be a side effect of
anti-HIV drugs.

Therapy: The treatment of disease.

Tuberculosis: A highly contagious infection caused by the bacterium called

Mycobacterium tuberculosis. Abbreviated TB. Tubercles (tiny lumps) are a characteristic
finding in TB. Diagnosis may be made by skin test, which if positive should will be
followed by a chest X-ray to determine the status (active or dormant) of the infection.
Tuberculosis is more common in people with immune system problems, such as AIDS,
than in the general population. Treatment of active tuberculosis is mandatory by law in
the US, and should be available at no cost to the patient through the public health
system. It involves a course of antibiotics and vitamins that lasts about six months. It is
important to finish the entire treatment, both to prevent reoccurrence and to prevent
the development of antibiotic-resistant tuberculosis. Most patients with tuberculosis do
not need to be quarantined, but it is sometimes necessary.

TLC: A leukocyte is the more scientific name for a white blood cell, one of several
components that make up the blood that flows through the body. White blood cells are
commonly known as the cells that do much of the work in keeping the body healthy,
simply because they are a key factor in the immune system. The TLC test result is used to
show how the immune system is working. In other words, when the white blood cell
count (total leukocyte count) is low the body may not be able to fight off infection and
illness.

Urine: Liquid waste. The urine is a clear, transparent fluid. It normally has an amber
color. The average amount of urine excreted in 24 hours is from 40 to 60 ounces (about
1,200 cubic centimeters). Chemically, the urine is mainly an aqueous (watery) solution of
salt (sodium chloride) and substances called urea and uric acid. Normally, it contains
about 960 parts of water to 40 parts of solid matter. Abnormally, it may contain sugar (in
diabetes), albumen (a protein) (as in some forms of kidney disease), bile pigments (as in
jaundice ), or abnormal quantities of one or another of its normal components.

User Interface: A user interface is the system by which people (users) interact with
a machine. The user interface includes hardware (physical) and software (logical)
components. User interfaces exist for various systems, and provide a means of:

1. Input, allowing the users to manipulate a system, and/or.

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 2. Output, allowing the system to indicate the effects of the users' manipulation.

Viral: Of or pertaining to a virus. For example, "My daughter has a viral rash ."

Virus: A microorganism smaller than a bacteria, which cannot grow or reproduce apart
from a living cell. A virus invades living cells and uses their chemical machinery to keep
itself alive and to replicate itself. It may reproduce with fidelity or with errors
(mutations)-this ability to mutate is responsible for the ability of some viruses to change
slightly in each infected person, making treatment more difficult

Vasectomy: A vasectomy is a surgical procedure designed to make a man sterile by

cutting or blocking both the right and left vas deferens, the tubes through which sperm
pass into the ejaculate.

VCTC: Voluntary HIV Counseling and Testing services (VCTCs) as a key to HIV/AIDS
prevention strategies in India.

Viral Load: A blood test that measures the quantity of active HIV in the blood. Results
are expressed as the number of copies per milliliter of blood plasma. Viral load testing
along with CD4 count is used to determine when to initiate and/or change HIV
medication regimens.

Varicella Zoster: A herpesvirus that causes chickenpox and shingles.

VDRL: The VDRL test is a screening test for syphilis. It measures substances, called
antibodies, that can be produced in response to Treponema pallidum, the bacteria that
causes syphilis. The test is similar to the newer rapid plasma reagin (RPR) test. The test is
usually performed on blood. The VDRL test can be performed on spinal fluid if syphilis
(neurosyphilis) may be present in individual's brain.

Vacuum Birth: Obstetrics Operator-assisted delivery in which suction is applied to the

skull and the fetus delivered vaginally Complications Brachial plexus injury due to
shoulder dystocia, scalp injuries, intracranialespecially, subgalealhemorrhage due to
tentorial tearing and skull fractures, CNS depression, convulsions, mechanical ventilation

WHO Clinical Stage: WHO is the directing and coordinating authority for health within
the United Nations system. It is responsible for providing leadership on global health
matters, shaping the health research agenda, setting norms and standards, articulating
evidence-based policy options, providing technical support to countries and monitoring
and assessing health trends.

WBC: Lymphocytes are WBCs that produce antibodies and keep the immune system
working. They make up 10-45% of your WBCs. There are two main types: B cells and T
cells, and they fight infection in different ways. CD4+ cells -- a type of T cell -- are cells
that HIV uses to infect and/or destroy. You may have heard the term "CD4+ count" or "T
cell count." This refers to a kind of T cell that controls the activity of other immune cells.

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Appendix 2 - Normal Ranges
Each lab typically provides "normal" ranges of values along with the test results,
although some labs may differ in the exact ranges of the normal values. Remember to
ask you physician for a copy of your laboratory results for your own personal records, so
that you can monitor trends in your lab tests.

Red Blood Cells (RBCs) Female: 4.0-5.3 million cells per cubic
Male : 4.5-6.1 millimeter (million/mm3)

Hemoglobin (HB or HGB) Female: 12-16 grams per deciliter (g/dl)

Male: 14-18 grams per deciliter (g/dl)

Hematocrit (HCT) Female: 37-47 %

Male: 42-52 %

White Blood Cells (WBCs) 4.3-10.8 thousand cells per cubic

millimeter (thousand/mm3)

Basophil % of White Blood Cells 0-3 %

Eosinophil % of White Blood 0-7 %

Cells

Lymphocyte % of White Blood 12-50 %

Cells

Monocyte % of White Blood 0-12 %

Cells

Neutrophil % of White Blood 40-73 %

Cells

Lymphocyte Subsets

Total T Lymphocytes (CD3) 990-1,910 cells per cubic millimeter

(cells/mm3)

Total CD4 T-cells 590-1,120 cells per cubic millimeter

(cells/mm3)

Total CD8 T-cells 330-790 cells per cubic millimeter

T-lymphocyte percentage (CD3 61-85 %

%)

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CD4 T-cell percentage (CD4 %) 28-58 %

CD8 T-cell percentage (CD8 %) 19-48 %

Platelet Count 140,000-440,000 cells per cubic millimeter

(cells/mm3)

Liver Function Tests

ALT (SGPT or Alanine 0-45 units/liter (u/L)

aminotransferase)

AST (SGOT or Aspartate 0-41 units/liter (u/L)

aminotransferase)

Lactic Dehydrogenase (LDH) 50-115 units/liter (u/L)

Phosphatase (alkaline) 36-125 units/liter (u/L)

Bilirubin (total) 0.1-1.2 milligrams per deciliter

(mg/dl)

Kidney Function Tests

BUN (Blood Urea Nitrogen) 7-28 milligrams per deciliter

(mg/dl)

Creatinine 0.6-1.5 milligrams per deciliter

(mg/dl)

Uric Acid 3-7 milligrams per deciliter

(mg/dl)

Red Blood Cell Indices

Mean Corpuscular Hemoglobin 27-33 picogram per red blood cell

(MCH)

MCH Concentration (MCHC) 32-36 %

Mean Corpuscular Volume 79-100 femtoliters

(MCV)

Amylase 53-160* units/liter (u/L)

Calcium (urine) Female: < 250 mg/day

Male: < 300

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Cholesterol 120-220 milligrams per deciliter
(mg/dl)

Creatine Phospokinase (CK or female: 10-79 units/liter (u/L)

CPK) male: 17-148

Glucose 70-125 mg/dl

Magnesium 0.6-1.0 mmol/l

Potassium 3.5-5.3 mmol/l

Sodium 135-146 mmol/l

Protein 6.0-8.3 grams per deciliter (g/dl)

Total Albumin 3.2-5.5 grams per deciliter (g/dl)

Globulin 1.5-3.8 grams per deciliter (g/dl)

Triglycerides 35-160 milligrams per deciliter

(mg/dl)

Urea Nitrogen (see BUN) 7-28 milligrams per deciliter

(mg/dl)

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 National AIDS
Database

Mainframe

Server Server

Servers

Data Data

Workstation
Workstation

ARTC 1 ARTC 2

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