Etravirine (Intelence®)
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 an antiretroviral experienced patient with:
a. evidence of HIV replication (viral load greater than 10,000 copies per mL); and/or
b. CD4 cell counts of less than 500 per cubic millimetre.
A patient must have failed previous treatment with, or have resistance to, 3 different antiretroviral regimens which have included:
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: | ____________________________________ |
*To be completed by the specialist or authorised prescriber initiating drug treatment, and retained by the hospital Pharmacy Department.
July 2009