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.
* Required
Email address
*
Your email
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.
Participant said "yes"
What is your name?
Your answer
What is your date of birth?
MM
/
DD
/
YYYY
What is your phone number?
Your answer
What is your address/town?
Your answer
Can you provide another contact name and phone number?
Your answer
What is your e-mail address?
Your answer
What is the location of your HIV Cameroon Treatment Center?
BBH
Nkar
Shisong
Djottin
St Martin de Porres Health Medical Center (Mvog-Betsi, Yaounde)
Mokolo (Mokolo District Hospital, Maroua)
Other:
What is the participant's gender?
Female
Male
Tobacco usage
Yes
No
Alcohol consumption
Yes
No
Highest education level
Primary school
Secondary school
High School
University
Professional degree
Other:
Marital Status
Married
Single
Divorced
Widow/Widower
Infant
At what age/year were you diagnosed with HIV?
Your answer
What was your HIV RNA viral load at diagnosis?
Your answer
What is your current HIV RNA viral load?
Your answer
What was your CD4+ count when you started HIV treatment?
Your answer
What is your current CD4+ count?
Your answer
What was your liver function at diagnosis?
Your answer
What is your current liver function?
Your answer
What was your kidney function at diagnosis?
Your answer
What is your current kidney function?
Your answer
Select any co-morbidities that may be present
Tuberculosis
Kaposi's sarcoma
PCP
Oral candidiasis
Malaria
CMV
Gastroenteritis
Viral infection
Chondiloma
Toxoplasmosis
Herpes
Cryptococcal infection
Anemia
Hepatitis B/C
Other:
Personal beliefs and knowledge - How much belief do you have that your current treatment will be effective?
None
A little bit
A lot of it
Personal beliefs and knowledge - How much do you understand about your current treatment?
None
A little bit
A lot of it
Personal beliefs and knowledge - How are you regarded by the society and family?
Rejected
Accepted by a few
Accepted by most
Do you have any drug allergies?
Yes
No (NKDA)
If 'yes' was previously selected, what medications cause allergies in the participant? Skip if NKDA.
Your answer
Are you currently taking any HIV medications? If so, please state the type of medication, dose (pills/dose, times/day, etc), and start date.
Your answer
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)
Your answer
What are some side effects that you are experiencing?
Peripheral neuropathy (e.g. numbness, tingling, loss of reflexes)
Myopathy (e.g. muscle pain, chest pain)
Pancreatitis (e.g. abdominal pain, hyperlipidemia)
Lactic acidosis (e.g. extreme fatigue, dyspnea, tachycardia)
Lipoatrophy (e.g. loss of sexual interest, fat accumulation, weight gain)
Hypersensitivity reaction (e.g. fever, rash, dyspnea, cough)
Skin reaction (e.g. skin eruption, lyell syndrome)
Fatty liver (e.g. immuno-allergic, hepatic steatosis)
Neurological problems (e.g. dizziness, insomnia, nightmares, depression)
GIT problems (e.g. loss of appetite, flatulence, diarrhea, nausea, vomiting)
Kidney problems (e.g. back pain, bloody urine)
Lipodystrophy (e.g. weight loss, varicose veins, breast enlargement)
What is the severity (scale 1-10) of different side effects that you have been experiencing according to the last question?
1
2
3
4
5
6
7
8
9
10
Do you sometimes forget to take your HIV medication therapy?
Yes
No
Over the past 2 weeks, were there any days when you did not take your HIV medication therapy?
Yes
No
Have you ever cut back or stopped taking your HIV medication therapy without telling your doctor because you felt worse when you took it?
Yes
No
When you travel or leave home, do you sometimes forget to bring along your HIV medication therapy?
Yes
No
Did you take HIV medication therapy yesterday?
Yes
No
When you feel like your symptoms are under control, do you sometimes stop taking your HIV medication therapy?
Yes
No
Taking medication every day is a real inconvenience for some people. Do you feel hassled about sticking to your HIV medication treatment plan?
Yes
No
How often do you have difficulty remembering to take all your HIV medication therapy?
Never (or seldom)
Once in a while
Sometimes
Most of the time
Always
Are your health services covered for?
Yes
No
If you selected 'yes' to the previous question about health service coverage, which program covers your health services?
BEPHA
Mutual Health
Other:
Are you part of Christian Research Hospital’s HIV adoption/support program?
Yes
No
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?
Yes
No
Already
On average, about how much did you pay out-of-pocket for consultations?
Your answer
On average, about how much did you pay out-of-pocket monthly for lab work?
Your answer
On average, about how much did you pay out-of-pocket monthly for other drugs?
Your answer
In the past month, have you taken less/no ARVs because they were not available?
Yes
No
In the past month, have you taken less/no drugs prescribed by the doctor because they were expensive?
Yes
No
If you answered 'yes' to the last question, how much were you supposed to pay?
Your answer
Are you satisfied with the interval of appointments with the hospital?
Not satisfied
Somewhat satisfied
Very satisfied
Are you satisfied with the nursing services in your center?
Not satisfied
Somewhat satisfied
Very satisfied
Are you satisfied with the way your doctor attends to you at your center?
Not satisfied
Somewhat satisfied
Very satisfied
Are you satisfied with the way you have been counseled about the management of your drugs/disease?
Not satisfied
Somewhat satisfied
Very satisfied
Write down any additional comments/feedback from the patient about CRH and overall experience.
Your answer
Participant's initials and date of the survey completion
Your answer
CRH HIV project volunteer initials and date of the survey completion
Your answer
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