Enfuvirtide (Fuzeon®)
Highly Specialised Drugs Program Declaration Form*
| Patient's Name: | ____________________________________ |
| Medical Record Number: | ____________________________________ |
| Medicare Number: | ____________________________________ |
I certify that the above patient meets the Pharmaceutical Benefits Advisory Committee's criteria for funding under Section 100 of the National Health Act, 1953.
Criteria
Treatment, in combination with other antiretroviral agents, of HIV infection in antiretroviral experienced patients with treatment failure characterised by:
(a) evidence of HIV replication, despite ongoing therapy; or
(b) treatment-limiting toxicity to previous antiretroviral agents.
Patients must have failed previous treatment with 3 different antiretroviral regimens. At least 1 of each of the following classes of antiretroviral drugs must have been attempted:
(i) at least 1 non-nucleoside reverse transcriptase inhibitor; and
(ii) at least 1 nucleoside reverse transcriptase inhibitor; and
(iii) at least 1 protease inhibitor.
Specialist/ Authorised Prescriber
| Signature: | ____________________________________ |
| Name: | ____________________________________ |
| Date: | ____________________________________ |
Additional information to be provided by authorised general practitioners only:
| Provider Number: | ____________________________________ |
| Practice Address: | ____________________________________ |
| Telephone: | ____________________________________ |
*To be completed by the specialist or authorised prescriber initiating drug treatment, and retained by the hospital Pharmacy Department.
December 2004