HIV/AIDS Medication Adherence: Baseline/Follow Up Questionnaire
Christian Research Hospital Foundation (CRH) seeks to help the poorest and sickest of the world through education, care, and research (www.christianresearchhospital.org). Thank you for taking the time to participate in this important survey as part of a project led by CRH in collaboration with Cameroonian HIV Treatment Centers.

The name of the project is HIV/AIDS Medication Adherence. The primary purpose of this project is to gather information pertaining to HIV/AIDS Therapy Compliance to help improve future medication therapeutic management plans. The goal is to maximize efficacy, reduce toxicity, and eliminate overall cost among the sickest and poorest patients taking HIV/AIDS medications. This survey should take between 15 to 30 minutes to complete.

Participation and Eligibility

Taking part in this project is completely voluntary. If you choose to participate, you have the right to stop at any time without any penalties. After starting or submitting the survey, if you withdraw, you may contact us at (christianresearchhospital@gmail.org) and your responses will be deleted.

Consent

Before beginning the survey, it is important to inform you with the rights of being a participant. All the collected information will be confidential and will be securely stored at a locked area. The purpose of this consent form is to collect data of HIV/AIDS patients. I understand that all information collected will be kept confidential and secured. Any information collected will be given a number and the rest of the personal information will be de-identified.
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The informed consent has been read to me. I have had the opportunity to ask questions regarding the survey and they have been answered to my satisfaction. By saying “yes”, I give my informed consent voluntarily and agree to participate in this survey.
What is your name?
What is your date of birth?
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What is your phone number?
What is your address/town?
Can you provide another contact name and phone number?
What is your e-mail address?
What is the location of your HIV Cameroon Treatment Center?
Clear selection
What is the participant's gender?
Clear selection
Tobacco usage
Clear selection
Alcohol consumption
Clear selection
Highest education level
Clear selection
Marital Status
Clear selection
At what age/year were you diagnosed with HIV?
What was your HIV RNA viral load at diagnosis?
What is your current HIV RNA viral load?
What was your CD4+ count when you started HIV treatment?
What is your current CD4+ count?
What was your liver function at diagnosis?
What is your current liver function?
What was your kidney function at diagnosis?
What is your current kidney function?
Select any co-morbidities that may be present
Personal beliefs and knowledge - How much belief do you have that your current treatment will be effective?
Clear selection
Personal beliefs and knowledge - How much do you understand about your current treatment?
Clear selection
Personal beliefs and knowledge - How are you regarded by the society and family?
Clear selection
Do you have any drug allergies?
Clear selection
If 'yes' was previously selected, what medications cause allergies in the participant? Skip if NKDA.
Are you currently taking any HIV medications?  If so, please state the type of medication, dose (pills/dose, times/day, etc), and start date.
Are you currently taking any herbal, dietary, or nutritional supplements? If so, please state the type, dose (doses per day), start date, and indication? (in particular, tomatoes, carrots, onions, garlic, traditional medicine, and cocumba)
What are some side effects that you are experiencing?
What is the severity (scale 1-10) of different side effects that you have been experiencing according to the last question?
Clear selection
Do you sometimes forget to take your HIV medication therapy?
Clear selection
Over the past 2 weeks, were there any days when you did not take your HIV medication therapy?
Clear selection
Have you ever cut back or stopped taking your HIV medication therapy without telling your doctor because you felt worse when you took it?
Clear selection
When you travel or leave home, do you sometimes forget to bring along your HIV medication therapy?
Clear selection
Did you take HIV medication therapy yesterday?
Clear selection
When you feel like your symptoms are under control, do you sometimes stop taking your HIV medication therapy?
Clear selection
Taking medication every day is a real inconvenience for some people. Do you feel hassled about sticking to your HIV medication treatment plan?
Clear selection
How often do you have difficulty remembering to take all your HIV medication therapy?
Clear selection
Are your health services covered for?
Clear selection
If you selected 'yes' to the previous question about health service coverage, which program covers your health services?
Clear selection
Are you part of Christian Research Hospital’s HIV adoption/support program?
Clear selection
If you said 'No' to the last question, would you like to be part of Christian Research Hospital’s HIV adoption/support program in the future?
Clear selection
On average, about how much did you pay out-of-pocket for consultations?
On average, about how much did you pay out-of-pocket monthly for lab work?
On average, about how much did you pay out-of-pocket monthly for other drugs?
In the past month, have you taken less/no ARVs because they were not available?
Clear selection
In the past month, have you taken less/no drugs prescribed by the doctor because they were expensive?
Clear selection
If you answered 'yes' to the last question, how much were you supposed to pay?
Are you satisfied with the interval of appointments with the hospital?
Clear selection
Are you satisfied with the nursing services in your center?
Clear selection
Are you satisfied with the way your doctor attends to you at your center?
Clear selection
Are you satisfied with the way you have been counseled about the management of your drugs/disease?
Clear selection
Write down any additional comments/feedback from the patient about CRH and overall experience.
Participant's initials and date of the survey completion
CRH HIV project volunteer initials and date of the survey completion
Submit
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