IMMEDIATE POST Follow-UP Assessment - PHMC

Development and Testing of an HIV Prevention Intervention Targeting Black Bisexually-Active Men

10BA_Att 3E_Immediate_Follow-Up

IMMEDIATE POST Follow-UP Assessment - PHMC

OMB: 0920-0863

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Development and Testing of an HIV Prevention Intervention

Targeting Black Bisexually-Active Men










Attachment 3E


IMMEDIATE Follow-Up Assessment BY SITE




Form Approved

OMB No. 0920-xxxx

Expiration Date:



3E.1: PHMC

IMMEDIATE POST FOLLOW-UP ASSESSMENT




Thank you for coming in today to complete your second interview for the Connections Program. Since you just took an interview on (insert baseline interview date), we will not have to ask you some of the same questions that we asked in your first interview. For the following questions, either check the appropriate box or fill in your answer in the spaces provided. Remember, your responses will be kept private.


A. DEMOGRAPHICS


1. Are you currently employed?

1 = Full time

2 = Part time/ Occasional

3 = Unemployed

4 = Retired

5 = Unable to work (disabled)

  1. = Prefer not to answer



2. Are you currently a full time or part time student?

1 = Full time

2 = Part time

3 = Not a student

  1. = Prefer not to answer


3. Currently, who do you live with most of the time? (Check ALL that apply)

Alone

Parents

Friends

Other relatives

Partner, lover, or spouse

Your children

Other people not mentioned (please

specify):___________________________________________




4. What is the zip code of your current home or place where you stay? |_____|_____|_____|_____|_____|

777 Don’t Know

5. Do you consider yourself to be currently homeless?


No Yes


B. HIV AND STD TESTING/HISTORY AND PERCEIVED RISK

Now we would like to ask some questions about your health. There are several diseases or infections that can be transmitted during sex. These are sometimes called venereal diseases or sexually transmitted diseases. We will be using the term sexually transmitted disease or STD to refer to them in the next few questions. Although HIV is a sexually transmitted disease, we will be asking you about it in a different part of this survey.



1. Since you answered the baseline survey (ACASI to insert date) have you been tested for STDs? Do not include an HIV test in this answer.

YES

NO

_777 Don’t know

_888 Prefer not to answer



  1. For which STDs were you tested? (check box)

Gonorrhea

Syphilis

Genital herpes

Chlamydia

Genital Warts (also known as HPV or Human Papilloma Virus)

Hepatitis B virus

Hepatitis C virus

Some other STD, but not HIV (Please enter your answer here_____________)



3. For any checked above -

Were you told by a health care provider that you tested positive for (name STD)? YES

NO

_777 Don’t know

_888 Prefer not to answer



4. Where did you receive recent STD test(s)? ____________________________________





You are now going to be asked some questions about your HIV status and about your experiences taking the HIV test. Please remember that this survey is kept private. It is for HIV-positive men as well as HIV-negative men.


5. Since you answered the baseline survey (ACASI to insert date) have you been tested for HIV?

YES

NO (skip to Question 7)

_777 Don’t know

_888 Prefer not to answer (skip to Section B)


6. Did you receive the test results?

NO

YES

___777 Don’t Know

___888 Prefer not to answer


7. What was the result of your last HIV test? (Choose one)

___1 HIV-Negative (Do not have HIV) (skip next question.)

___2 HIV-Positive (Do have HIV) (skip next question.)

___3 I did not get the result of my last test (go to question 8)

___4 Inconclusive/Indeterminate (the result was neither positive or negative) (go to question 8)

___888 Prefer not to answer



8. What was the result of your last HIV test when you received a result?

___1 HIV-Negative (Do not have HIV)

___2 HIV-Positive (Do have HIV)

___3 I did not get the result of my last test

___4 Inconclusive/Indeterminate (the result was neither positive or negative)

___888 Prefer not to answer



9. Where did you receive your last HIV test? ___________________________________________

Open response.


If HIV-positive, skip to Section C.


Perceived Risk for HIV


On a scale from 1 to 10, with 1 being (extremely unlikely) and 10 being extremely likely, . . .


10. How likely is it that you are infected with HIV now? _____

___ 88 Prefer not to answer


11. How likely do you think it is that you will become infected with HIV in your lifetime? _____

___ 88 Prefer not to answer


C. MENTAL HEALTH

Here is a list of problems and complaints that people sometimes have. For each one, check how much that problem has bothered or distressed you during the past week, including today. Please check whether each problem has bothered you not at all, a little bit, moderately, quite a bit, or extremely.



HOW OFTEN DO YOU EXPERIENCE . . .



1. Faintness or dizziness? (Choose one)

1 Not At All

2 A Little Bit

3 Moderately

4 Quite A Bit

5 Extremely

8 Refuse to Answer

2. Feeling no interest in things? (Choose one) 1 Not At All

2 A Little Bit

3 Moderately

4 Quite A Bit

5 Extremely

8 Refuse to Answer

3. Nervousness or shakiness inside? (Choose one) 1 Not At All

2 A Little Bit

3 Moderately

4 Quite A Bit

5 Extremely

8 Refuse to Answer



4. Pains in heart or chest? (Choose one) 1 Not At All

2 A Little Bit

3 Moderately

4 Quite A Bit

5 Extremely

8 Refuse to Answer



5. Feeling lonely? (Choose one) 1 Not At All

2 A Little Bit

3 Moderately

4 Quite A Bit

5 Extremely

8 Refuse to Answer

6. Feeling tense or keyed up? (Choose one) 1 Not At All

2 A Little Bit

3 Moderately

4 Quite A Bit

5 Extremely

8 Refuse to Answer

7. Nausea or upset stomach? (Choose one) 1 Not At All

2 A Little Bit

3 Moderately

4 Quite A Bit

5 Extremely

8 Refuse to Answer

8. Feeling blue or sad? (Choose one) 1 Not At All

2 A Little Bit

3 Moderately

4 Quite A Bit

5 Extremely

8 Refuse to Answer

9 Not Applicable

9. Being suddenly scared for no reason? (Choose one) 1 Not At All

2 A Little Bit

3 Moderately

4 Quite A Bit

5 Extremely

8 Refuse to Answer

10. Trouble getting your breath? (Choose one) 1 Not At All

2 A Little Bit

3 Moderately

4 Quite A Bit

5 Extremely

8 Refuse to Answer

11. In the past week, how much have you been bothered by...having urges to beat, injure, or harm someone? (Choose one)

1 Not at all

2 A little bit

3 Moderately

4 Quite a bit

5 Extremely

8 Prefer not to answer

12. In the past week, how much have you been bothered by...having urges to break or smash things? (Choose one) 1 Not at all

2 A little bit

3 Moderately

4 Quite a bit

5 Extremely

8 Prefer not to answer



13. Feelings of worthlessness? (Choose one) 1 Not At All

2 A Little Bit

3 Moderately

4 Quite A Bit

5 Extremely

8 Refuse to Answer

14. Episodes of terror or panic? (Choose one) 1 Not At All

2 A Little Bit

3 Moderately

4 Quite A Bit

5 Extremely

8 Refuse to Answer

15. Numbness or tingling in parts of your body? (Choose one) 1 Not At All

2 A Little Bit

3 Moderately

4 Quite A Bit

5 Extremely

8 Refuse to Answer

16. Feeling hopeless about the future? (Choose one) 1 Not At All

2 A Little Bit

3 Moderately

4 Quite A Bit

5 Extremely

8 Refuse to Answer

17. Feeling so restless that you could not sit still? (Choose one) 1 Not At All

2 A Little Bit

3 Moderately

4 Quite A Bit

5 Extremely

8 Refuse to Answer

18. Feeling weak in parts of your body? (Choose one) 1 Not At All

2 A Little Bit

3 Moderately

4 Quite A Bit

5 Extremely

8 Refuse to Answer

19. Thoughts of ending your life? (Choose one) 1 Not At All

2 A Little Bit

3 Moderately

4 Quite A Bit

5 Extremely

8 Refuse to Answer

20. Feeling fearful? (Choose one) 1 Not At All

2 A Little Bit

3 Moderately

4 Quite A Bit

5 Extremely

8 Refuse to Answer



Hostility Items

21. Feeling easily annoyed or irritated (Choose one)

1 Not at all

2 A little bit

3 Moderately

4 Quite a bit

5 Extremely

8 Prefer not to answer



22. ..temper outbursts that you could not control? (Choose one)

1 Not at all

2 A little bit

3 Moderately

4 Quite a bit

5 Extremely

8 Prefer not to answer

5 Extremely

8 Prefer not to answer

23. ....having urges to beat, injure, or harm someone? (Choose one)

1 Not at all

2 A little bit

3 Moderately

4 Quite a bit

5 Extremely

8 Prefer not to answer

24. ...having urges to break or smash things? (Choose one)

1 Not at all

2 A little bit

3 Moderately

4 Quite a bit

5 Extremely

8 Prefer not to answer

25 ...getting into frequent arguments? (Choose one)1 Not at all

2 A little bit

3 Moderately

4 Quite a bit

5 Extremely

8 Prefer not to answer



D. SPIRITUALITY


The next couple of questions ask about religion and spirituality. Please answer each of the questions as honestly as you can.



1.. I am able to be open about my sexuality in my religious community.

1 = Strongly agree

2 = Agree somewhat

3 = Disagree somewhat

4 = Strongly disagree

5 = I don't have a religious community

8 = Prefer not to answer




2.. My religious beliefs make me feel bad about having sex with other men.

1 = Strongly agree

2 = Agree somewhat

3 = Disagree somewhat

4 = Strongly disagree

5 = I don't have religious beliefs

8 = Prefer not to answer





E. MEDICAL HISTORY FOR HIV-POSITIVE MEN

         

The next set of questions is about the medical care and treatment you have received for your HIV infection.



1. Are you receiving regular/ongoing medical care for your HIV infection?

1 Yes

0 No

8 Prefer not to answer

9 Not Applicable


2. Please enter the year and month of your most recent visit to a medical provider for your HIV infection.

__ __ / __ __ __ __ mm / yyyy

2097 Don't Know (Year)

2098 Prefer not to answer (Year)



3. What was your most recent CD4 (t-cell) count? ________



4. What was your most recent viral load? ____________



5. Are you currently taking medication for HIV?

1 Yes

0 No

8 Prefer not to answer



6. How do you usually take your medications? Choose one of the following:


1. I always take all of my pills, on time and according to directions

2. I always take all of my pills, but not always on time and according to directions

3. I sometimes miss or forget to take my pills

4. I’m not too careful about taking pills

5. I don’t take them at all




F. SELF-ESTEEM (18-items Beck Self-Esteem Self Scale )

Below is a list of adjectives that some people use to describe themselves. Please read each pair of adjectives and place an ‘X’ at the point along the line which best describes you right now.

  1. Successful











Unsuccessful


1

2

3

4

5

6

7

8

9

10



Very Much


Slightly



Very Much










  1. Attractive







Unattractive


1

2

3

4

5

6

7

8

9

10



Very Much


Slightly



Very Much










  1. P opular







Unpopular


1

2

3

4

5

6

7

8

9

10



Very Much


Slightly



Very Much










  1. I ndependent







Dependent


1

2

3

4

5

6

7

8

9

10



Very Much


Slightly



Very Much










  1. H onest







Dishonest


1

2

3

4

5

6

7

8

9

10



Very Much


Slightly



Very Much










  1. D esirable







Undesirable


1

2

3

4

5

6

7

8

9

10



Very Much


Slightly



Very Much










  1. S trong







Weak


1

2

3

4

5

6

7

8

9

10



Very Much


Slightly



Very Much










  1. Smart







Dumb


1

2

3

4

5

6

7

8

9

10



Very Much


Slightly



Very Much










  1. Powerful







Powerless


1

2

3

4

5

6

7

8

9

10



Very Much


Slightly



Very Much










  1. Lovable







Unlovable


1

2

3

4

5

6

7

8

9

10



Very Much


Slightly



Very Much










  1. Pleasant







Unpleasant


1

2

3

4

5

6

7

8

9

10



Very Much


Slightly



Very Much










  1. E fficient







Inefficient


1

2

3

4

5

6

7

8

9

10



Very Much


Slightly



Very Much










  1. R esponsible







Irresponsible


1

2

3

4

5

6

7

8

9

10



Very Much


Slightly



Very Much










  1. G enerous







Selfish


1

2

3

4

5

6

7

8

9

10



Very Much


Slightly



Very Much










  1. W orthwhile







Worthless


1

2

3

4

5

6

7

8

9

10



Very Much


Slightly



Very Much










  1. I nteresting







Boring


1

2

3

4

5

6

7

8

9

10



Very Much


Slightly



Very Much










  1. Knowledgeable







Ignorant


1

2

3

4

5

6

7

8

9

10



Very Much


Slightly



Very Much










  1. G ood







Bad


1

2

3

4

5

6

7

8

9

10



Very Much


Slightly



Very Much













G. INTERNALIZED HOMONEGATIVITY (items from Nungesser Homosexual attitudes Inventory and HIV Center for Clinical & Behavioral Studies at the New York State Psychiatric Institute =.92)


The following are some statements that people can make about being gay or bisexual. For each

statement, please indicate if you Strongly Agree, Agree, Disagree or Strongly Disagree. If you feel that a

statement does not apply to you, please select the "Not Applicable" button on the right side of the screen.




(1)

Strongly Agree

(2)

Agree

(3)

Disagree

(4)

Strongly Disagree

(8)

Refuse to Answer

(9)

Not Applicable

  1. A gay/bisexual man can have just as fulfilling a life as a straight man.

1

2

3

4

8

9

  1. Sometimes I dislike myself for being gay/bisexual/ attracted to men.

1

2

3

4

8

9

  1. I am confident that my desire for men does not make me inferior.

1

2

3

4

8

9

  1. I feel stress and conflict within myself over having sex with men.

1

2

3

4

8

9

  1. It is important to me that at least some of my friends are gay, bisexual or lesbian.

1

2

3

4

8

9

  1. Sometimes I wish I were not gay/bisexual/attracted to men.

1

2

3

4

8

9

  1. I have no regrets about my desire for men.

1

2

3

4

8

9

  1. I sometimes feel guilty because I have sex with men.

1

2

3

4

8

9





H. SEXUAL RISK


SEX WITH MALE PARTNERS


  1. How many men did you have anal sex with in the past MONTH?

______ men (If 0 SKIP to SEX WITH FEMALE PARTNERS)


998 Refuse to Answer

2. How many times in the past MONTH did you top a male partner (put your penis in his butt) WITHOUT a condom?_______

3. How many times in the past MONTH did you top a male partner (put your penis in his butt) WITH a condom?_______

4. How many times in the past MONTH did you bottom for a male partner (he put his penis in your butt) WITHOUT a condom?_______

5. How many times in the past MONTH did you bottom for a male partner (he put his penis in your butt) WITH a condom?_______


6. The last time you had anal sex with a male partner in the past month, did you have sex without a condom?


01 Yes

00 No

98 Refuse to Answer


7. What was the HIV status of this partner?

01 HIV negative

02 HIV positive

03 Do not know/unsure

98 Refuse to Answer



SEX WITH FEMALE PARTNERS


  1. How many women did you have vaginal or anal sex with in the past MONTH?

______ women (If 0 SKIP to SEX WITH TRANSGENDER PARTNERS)

998 Refuse to Answer


2. How many times in the past MONTH did you have vaginal or anal sex with a female partner WITHOUT a condom?_______


3. How many times in the past MONTH did you have vaginal or anal sex with a female partner WITH a condom?_______


4. The last time you had vaginal sex with a female partner in the past month, did you have sex without a condom?


01 Yes

00 No

98 Refuse to Answer



5. What was the HIV status of this partner?

01 HIV negative

02 HIV positive

03 Do not know/unsure

98 Refuse to Answer




SEX WITH TRANSGENDER PARTNERS


1. How many transgender partners did you have vaginal or anal sex with in the past MONTH?

______ transgender partners (If 0 SKIP to next section)

998 Refuse to Answer


2. How many times in the past MONTH did you have vaginal or anal sex with a transgender partner WITHOUT a condom?_______


3. How many times in the past MONTH did you have vaginal or anal sex with a transgender partner WITH a condom?_______



4. The last time you had vaginal sex with a transgender partner in the past month, did you have sex without a condom?


01 Yes

00 No

98 Refuse to Answer



5. What was the HIV status of this partner?

01 HIV negative

02 HIV positive

03 Do not know/unsure

98 Refuse to Answer






I. CONNECTIONS PROGRAM SATISFACTION QUESTIONS



Flesch-Kincaid = 6.0


1. The last time we interviewed you on _(insert baseline date)_ you were invited to join a program that either lasted for six sessions or one session. Which program did you attend?



_____ 1) One session program (Skip to the instructions at the end of the survey)


_____ 2) Six sessions program (Continue with question 2)




Please help us to improve our program by answering some questions about the services you

received in the Connections Program. We are interested in your honest opinions, whether they are

positive or negative. Please answer all of the questions. All of your answers will remain private.




1

2

3

4

  1. To what extent has our program met your needs?

Almost all of my needs have been met

Most of my needs have been met

Only a few of my needs have been met

None of my needs have been met

  1. Have the sessions you received helped you to deal more effectively with your problems?


Yes, they helped a great deal


Yes, they helped somewhat


No, they really didn’t help


No, they seemed to make things worse

  1. Overall, how satisfied are you with the Connections Program?


Extremely dissatisfied


Somewhat dissatisfied


Somewhat satisfied


Extremely satisfied

  1. How satisfied are you with the amount of respect the life coach shows to you?


Extremely dissatisfied


Somewhat dissatisfied


Somewhat satisfied


Extremely satisfied

  1. How satisfied are you with the amount of concern the life coach expresses about your problems?


Extremely dissatisfied


Somewhat dissatisfied


Somewhat satisfied


Extremely satisfied

  1. How satisfied are you with the life coach’s ability to address your concerns?


Extremely dissatisfied


Somewhat dissatisfied


Somewhat satisfied


Extremely satisfied


We would now like to know what you think specifically about the sessions you attended in the Connections Program. Below are some statements about the Connections Program. Please carefully read each statement and tell us if you Strongly Agree, Agree, Disagree or Strongly Disagree with each statement.



Strongly Agree

Agree

Disagree

Strongly Disagree

  1. I found the information in these sessions to be useful in my life.

4

3

2

1

  1. I thought the topics discussed during my sessions were interesting.

4

3

2

1

  1. I did not find the location of the sessions easy to get to.

4

3

2

1

  1. I found my session times to be convenient for my schedule.

4

3

2

1

  1. I felt the location was private enough.

4

3

2

1

  1. I felt that my sessions were too long.

4

3

2

1

  1. I liked the small gifts I received at the sessions.

4

3

2

1

  1. I am concerned that what I talked about in my sessions will not be kept private.

4

3

2

1

  1. I have learned a lot by participating in the connections program sessions.

4

3

2

1

  1. I looked forward to attending my sessions.

4

3

2

1



The Connections Program included a total of six sessions with a life coach.


17. Do you think this was about the right number of sessions for you, or would you have liked more sessions or fewer sessions?


____ 1) Right number ____ 8) Don’t know, depends


____ 2) Liked more sessions


____ 3) Liked fewer sessions


18. How many sessions did you attend? ____ _____ (Skip to Question 20 if equals 6)


(Ask Question 19 if participant missed at least one session)

19. There are many reasons why people miss appointments. Please tell us why you missed one or more of your session appointments. This information will help us to better plan our services in the future. Please check all that apply.


The reason I missed one or more sessions was because….


[] I did not feel the sessions were helping me.


[] I was concerned about my privacy and confidentiality.


[] I found the sessions boring.


[] I had to be at work.


[] I had family obligations.


[] I was in a program or institution that prevented me from attending (such as drug and

alcohol program, shelter).

[] I had difficulty with transportation (cost, getting a ride, etc.)


[] I forgot about my session.


[] I just didn’t feel like going that day.


[] Something unexpected came up. (Please explain here:________________________)


[] Another reason. (Please explain here:______________________________________)



You are almost finished with the interview. We appreciate your help. We are interested in your suggestions for improving the Connections Program.


20. What did you like the most about the Connections Program?

_______________________________________­­­­­­­­­­­­­­­­­­­­___________________________________


_______________________________________­­­­­­­­­­­­­­­­­­­­___________________________________


_______________________________________­­­­­­­­­­­­­­­­­­­­___________________________________


21. What did you like the least about the Connections Program?

_______________________________________­­­­­­­­­­­­­­­­­­­­___________________________________


_______________________________________­­­­­­­­­­­­­­­­­­­­___________________________________


_______________________________________­­­­­­­­­­­­­­­­­­­­___________________________________


22. What could our project do differently to make it better?


_______________________________________­­­­­­­­­­­­­­­­­­­­___________________________________


_______________________________________­­­­­­­­­­­­­­­­­­­­___________________________________


_______________________________________­­­­­­­­­­­­­­­­­­­­___________________________________










You have finished the interview. Please let your interviewer know. Thank you for your participation.




















Form Approved:

OMB No. 0920-XXXX

Expiration Date:




3E.2: NOVA

IMMEDIATE POST FOLLOW-UP ASSESSMENT



Thank you for coming in today to complete your second interview for Project POWER. Since you just took an interview on (insert baseline interview date), we will not have to ask you some of the same questions that we asked in your first interview. For the following questions, either check the appropriate box or fill in your answer in the spaces provided. Remember, your responses will be kept private.


A. DEMOGRAPHICS


1. Are you currently employed?

1 = Full time

2 = Part time/ Occasional

3 = Unemployed

4 = Retired

5 = Unable to work (disabled)

  1. = Prefer not to answer



2. Are you currently a full time or part time student?

1 = Full time

2 = Part time

3 = Not a student

  1. = Prefer not to answer


3. Currently, who do you live with most of the time? (Check ALL that apply)

Alone

Parents

Friends

Other relatives

Partner, lover, or spouse

Your children

Other people not mentioned (please

specify):___________________________________________




4. What is the zip code of your current home or place where you stay? |_____|_____|_____|_____|_____|

777 Don’t Know

5. Do you consider yourself to be currently homeless?


No Yes

B. HIV/STD KNOWLEDGE QUESTIONNAIRE


The following statements are about STDs (Sexually Transmitted Diseases) and HIV. Please indicate whether you think the statement is “true” or “false”. If you aren’t sure, choose “don’t know”.


  1. Douching after sex helps protect you from STDs.


  1. You can’t get the AIDS virus through a cut in your skin.


  1. You can’t always tell if your partner has as STD.


  1. Pre-ejaculatory fluids (pre-cum) carry HIV.


  1. People who have HIV generally feel sick right away.


  1. You can’t get HIV by sharing knives and forks or a bathroom with a person who has HIV.


  1. An untreated STD can possibly result in being unable to have children.


  1. Condoms with spermicide will protect you from most STDs.


  1. Women can spread STDs to men when they don’t use condoms.


  1. If a woman uses birth control pills, it lowers her risk for getting HIV.


  1. Having an STD puts you at greater risk for getting HIV.


  1. If a person has HIV, it is still safe to kiss them on the lips, as you would kiss a friend or relative.


  1. The most effective way to prevent the spread of HIV is abstinence from sex.


  1. Sheep skin condoms are better than latex condoms for preventing HIV.


  1. Using oil based lubricants such as Vaseline or Crisco with condoms will reduce the risk of getting HIV.


  1. All STDs, except for HIV, can be cured with antibiotics.



C. HIV AND STD TESTING/HISTORY AND PERCEIVED RISK

Now we would like to ask some questions about your health. There are several diseases or infections that can be transmitted during sex. These are sometimes called venereal diseases or sexually transmitted diseases. We will be using the term sexually transmitted disease or STD to refer to them in the next few questions. Although HIV is a sexually transmitted disease, we will be asking you about it in a different part of this survey.



1. Since you answered the baseline survey (ACASI to insert date) have you been tested for STDs? Do not include an HIV test in this answer.

YES

NO

_777 Don’t know

_888 Prefer not to answer



  1. For which STDs were you tested? (check box)

Gonorrhea

Syphilis

Genital herpes

Chlamydia

Genital Warts (also known as HPV or Human Papilloma Virus)

Hepatitis B virus

Hepatitis C virus

Some other STD, but not HIV (Please enter your answer here_____________)



3. For any checked above -

Were you told by a health care provider that you tested positive for (name STD)? YES

NO

_777 Don’t know

_888 Prefer not to answer



4. Where did you receive recent STD test(s)? ____________________________________





You are now going to be asked some questions about your HIV status and about your experiences taking the HIV test. Please remember that this survey is kept private. It is for HIV-positive men as well as HIV-negative men.


5. Since you answered the baseline survey (ACASI to insert date) have you been tested for HIV?

YES

NO (skip to Question 7)

_777 Don’t know

_888 Prefer not to answer (skip to Section B)


6. Did you receive the test results?

NO

YES

___777 Don’t Know

___888 Prefer not to answer


7. What was the result of your last HIV test? (Choose one)

___1 HIV-Negative (Do not have HIV) (skip next question.)

___2 HIV-Positive (Do have HIV) (skip next question.)

___3 I did not get the result of my last test (go to question 8)

___4 Inconclusive/Indeterminate (the result was neither positive or negative) (go to question 8)

___888 Prefer not to answer



8. What was the result of your last HIV test when you received a result?

___1 HIV-Negative (Do not have HIV)

___2 HIV-Positive (Do have HIV)

___3 I did not get the result of my last test

___4 Inconclusive/Indeterminate (the result was neither positive or negative)

___888 Prefer not to answer



9. Where did you receive your last HIV test? ___________________________________________

Open response.


If HIV-positive, skip to Section C.


On a scale from 1 to 10, with 1 being (extremely unlikely) and 10 being extremely likely, . . .


10. How likely is it that you are infected with HIV now? _____

___ 88 Prefer not to answer


11. How likely do you think it is that you will become infected with HIV in your lifetime? _____

___ 88 Prefer not to answer



D. Condom Use Self-Efficacy Scale (CUSES)


The following questions ask about your feelings about using condoms, using the following scale:


1=Strongly Agree

2=Agree

3=Undecided

4=Disagree

5=Strongly Disagree



  1. I feel confident in my ability to put a condom on myself or my partner.


  1. I feel confident I could purchase condoms without feeling embarrassed.


  1. I feel confident I could remember to carry a condom with me should I need one.


  1. I feel confident in my ability to discuss condom usage with any partner I might have.


  1. I feel confident in my ability to suggest using condoms with a new partner.


  1. I feel confident I could suggest using a condom without my partner feeling "diseased".


  1. I feel confident in my own or my partner's ability to maintain an erection while using a condom.


  1. I would feel embarrassed to put a condom on myself or my partner.


  1. If I were to suggest using a condom to a partner, I would feel afraid that he or she would reject me.


  1. If I were unsure of my partner's feelings about using condoms, I would not suggest using one.


  1. I feel confident in my ability to use a condom correctly.


  1. I would feel comfortable discussing condom use with a potential sexual partner before we ever had any sexual contact (such as hugging, kissing, caressing, etc.)


  1. I feel confident in my ability to persuade a partner to accept using a condom when we have intercourse.


  1. I feel confident I could gracefully remove and dispose of a condom after we have intercourse.


  1. If my partner and I were to try to use a condom and did not succeed, I would feel embarrassed to try to use one again (such as not being able to unroll condom, putting it on backwards, or awkwardness).


  1. I would not feel confident suggesting using condoms with a new partner because I would be afraid he or she would think I've had a homosexual experience.


  1. I would not feel confident suggesting using condoms with a new partner because I would be afraid he or she would think I have a sexually transmitted disease.


  1. I would not feel confident suggesting using condoms with a new partner because I would be afraid he or she would think I thought they had a sexually transmitted disease.


  1. I would feel comfortable discussing condom use with a potential partner before we ever engaged in intercourse.


  1. I feel confident in my ability to incorporate putting a condom on myself or my partner into foreplay.


  1. I feel confident that I could use a condom with a partner without "breaking the mood."


  1. I feel confident in my ability to put a condom on myself or my partner quickly.


  1. I feel confident I could use a condom during intercourse without reducing any sexual sensations.

  2. I feel confident that I would remember to use a condom even after I have been drinking.


  1. I feel confident that I would remember to use a condom even if I were high.


  1. If my partner didn't want to use a condom during intercourse, I could easily convince him or her that it was necessary to do so.


  1. I feel confident that I could use a condom successfully.


28) I feel confident I could stop to put a condom on myself or my partner even in the heat of passion.



E. MENTAL HEALTH



I am going to show you a list of problems and complaints that people sometimes have. For each one, tell me how much that problem has bothered or distressed you during the past week, including today. Please tell me whether each problem has bothered you not at all, a little bit, moderately, quite a bit, or extremely.



HOW OFTEN DO YOU EXPERIENCE . . .


1. Faintness or dizziness? (Choose one)

1 Not At All

2 A Little Bit

3 Moderately

4 Quite A Bit

5 Extremely

8 Refuse to Answer

2. Feeling no interest in things? (Choose one) 1 Not At All

2 A Little Bit

3 Moderately

4 Quite A Bit

5 Extremely

8 Refuse to Answer

3. Nervousness or shakiness inside? (Choose one) 1 Not At All

2 A Little Bit

3 Moderately

4 Quite A Bit

5 Extremely

8 Refuse to Answer


4. Pains in heart or chest? (Choose one) 1 Not At All

2 A Little Bit

3 Moderately

4 Quite A Bit

5 Extremely

8 Refuse to Answer


5. Feeling lonely? (Choose one) 1 Not At All

2 A Little Bit

3 Moderately

4 Quite A Bit

5 Extremely

8 Refuse to Answer

6. Feeling tense or keyed up? (Choose one) 1 Not At All

2 A Little Bit

3 Moderately

4 Quite A Bit

5 Extremely

8 Refuse to Answer

7. Nausea or upset stomach? (Choose one) 1 Not At All

2 A Little Bit

3 Moderately

4 Quite A Bit

5 Extremely

8 Refuse to Answer

8. Feeling blue or sad? (Choose one) 1 Not At All

2 A Little Bit

3 Moderately

4 Quite A Bit

5 Extremely

8 Refuse to Answer

9 Not Applicable

9. Being suddenly scared for no reason? (Choose one) 1 Not At All

2 A Little Bit

3 Moderately

4 Quite A Bit

5 Extremely

8 Refuse to Answer

10. Trouble getting your breath? (Choose one) 1 Not At All

2 A Little Bit

3 Moderately

4 Quite A Bit

5 Extremely

8 Refuse to Answer

11. In the past week, how much have you been bothered by...having urges to beat, injure, or harm someone? (Choose one)

1 Not at all

2 A little bit

3 Moderately

4 Quite a bit

5 Extremely

8 Prefer not to answer

12. In the past week, how much have you been bothered by...having urges to break or smash things? (Choose one) 1 Not at all

2 A little bit

3 Moderately

4 Quite a bit

5 Extremely

8 Prefer not to answer


13. Feelings of worthlessness? (Choose one) 1 Not At All

2 A Little Bit

3 Moderately

4 Quite A Bit

5 Extremely

8 Refuse to Answer

14. Episodes of terror or panic? (Choose one) 1 Not At All

2 A Little Bit

3 Moderately

4 Quite A Bit

5 Extremely

8 Refuse to Answer

15. Numbness or tingling in parts of your body? (Choose one) 1 Not At All

2 A Little Bit

3 Moderately

4 Quite A Bit

5 Extremely

8 Refuse to Answer

16. Feeling hopeless about the future? (Choose one) 1 Not At All

2 A Little Bit

3 Moderately

4 Quite A Bit

5 Extremely

8 Refuse to Answer

17. Feeling so restless that you could not sit still? (Choose one) 1 Not At All

2 A Little Bit

3 Moderately

4 Quite A Bit

5 Extremely

8 Refuse to Answer

18. Feeling weak in parts of your body? (Choose one) 1 Not At All

2 A Little Bit

3 Moderately

4 Quite A Bit

5 Extremely

8 Refuse to Answer

19. Thoughts of ending your life? (Choose one) 1 Not At All

2 A Little Bit

3 Moderately

4 Quite A Bit

5 Extremely

8 Refuse to Answer

20. Feeling fearful? (Choose one) 1 Not At All

2 A Little Bit

3 Moderately

4 Quite A Bit

5 Extremely

8 Refuse to Answer


Hostility Items

21. Feeling easily annoyed or irritated (Choose one)

1 Not at all

2 A little bit

3 Moderately

4 Quite a bit

5 Extremely

8 Prefer not to answer


22. ..temper outbursts that you could not control? (Choose one)

1 Not at all

2 A little bit

3 Moderately

4 Quite a bit

5 Extremely

8 Prefer not to answer

5 Extremely

8 Prefer not to answer

23. ....having urges to beat, injure, or harm someone? (Choose one)

1 Not at all

2 A little bit

3 Moderately

4 Quite a bit

5 Extremely

8 Prefer not to answer

24. ...having urges to break or smash things? (Choose one)

1 Not at all

2 A little bit

3 Moderately

4 Quite a bit

5 Extremely

8 Prefer not to answer

25. ...getting into frequent arguments? (Choose one)

1 Not at all

2 A little bit

3 Moderately

4 Quite a bit

5 Extremely

8 Prefer not to answer


F. The Multi-Group Ethnic Identity Measure (MEIM) (Phinney, 1992)


In this country, people come from many different countries and cultures, and there are many different words to describe the different back­grounds or ethnic groups that people come from. Some examples of the names of ethnic groups are Hispanic or Latino, Black or African American, Asian American, Chinese, Filipino, American Indian, Mexican American, Caucasian or White, Italian American, and many others. These questions are about your ethnicity or your ethnic group and how you feel about it or react to it.


Please fill in: In terms of ethnic group, I consider myself to be ____________________


Use the numbers below to indicate how much you agree or disagree with each statement.


(4) Strongly agree (3) Agree (2) Disagree (1) Strongly disagree


1. I have spent time trying to find out more about my ethnic group, such as its history, traditions, and customs.

2. I am active in organizations or social groups that include mostly members of my own ethnic group.

3. I have a clear sense of my ethnic background and what it means for me.

4. I think a lot about how my life will be affected by my ethnic group membership.

5. I am happy that I am a member of the group I belong to.

6. I have a strong sense of belonging to my own ethnic group.

7. I understand pretty well what my ethnic group membership means to me.

8. In order to learn more about my ethnic background, I have often talked to other people about my ethnic group.

9. I have a lot of pride in my ethnic group.

10. I participate in cultural practices of my own group, such as special food, music, or customs.

11. I feel a strong attachment towards my own ethnic group.

12. I feel good about my cultural or ethnic background.

13. My race/ethnicity is:

(1) Asian

(2) Black or African American

(3) White

(4) American Indian/ Alaska Native

(5) Native Hawaiian/Pacific Islander

14. I am Latino/Hispanic. Yes/No

15. My father's race/ethnicity is: (use numbers above).

16. My father is Latino/Hispanic. Yes/No

17. My mother's ethnicity is: (use numbers above)

18. My mother is Latina/Hispanic. Yes/No


G. Internalized Homophobia Scale


Please choose the number that best describes your response to each item:


1 = strongly agree

2 = moderately agree

3 = slightly agree

4 = neither agree or disagree

5 = slightly disagree

6 = moderately disagree

7 = strongly disagree


  1. Obviously effeminate homosexual men make me feel uncomfortable

  2. I prefer to have anonymous sexual partners

  3. It would not be easier in life to be heterosexual

  4. Most of my friends are homosexual

  5. I do not feel confident about making an advance to another man

  6. I feel comfortable in gay bars

  7. Social situations with gay men make me feel uncomfortable

  8. I don’t like thinking about my homosexuality

  9. When I think about other homosexual men, I think of negative situations

  10. I feel comfortable about being seen in public with an obviously gay person

  11. I feel comfortable discussing homosexuality in a public setting

  12. It is important to me to control who knows about my homosexuality

  13. Most people have negative reactions to homosexuality

  14. Homosexuality is not against the will of God

  15. Society still punishes people for being gay

  16. I object if an anti-gay joke is told in my presence

  17. I worry about becoming old and gay

  18. I worry about becoming unattractive

  19. I would prefer to be more heterosexual

  20. Most people don’t discriminate against homosexuals

  21. I feel comfortable about being homosexual

  22. Homosexuality is morally acceptable

  23. I am not worried about anyone finding out that I am gay

  24. Discrimination against gay people is still common

  25. Even if I could change my sexual orientation, I wouldn’t

  26. Homosexuality is as natural as heterosexuality


H. SEXUAL RISK


SEX WITH MALE PARTNERS


  1. How many men did you have anal sex with in the past MONTH?

______ men (If 0 SKIP to SEX WITH FEMALE PARTNERS)


998 Refuse to Answer

2. How many times in the past MONTH did you top a male partner (put your penis in his butt) WITHOUT a condom?_______

3. How many times in the past MONTH did you top a male partner (put your penis in his butt) WITH a condom?_______

4. How many times in the past MONTH did you bottom for a male partner (he put his penis in your butt) WITHOUT a condom?_______

5. How many times in the past MONTH did you bottom for a male partner (he put his penis in your butt) WITH a condom?_______


6. The last time you had anal sex with a male partner in the past month, did you have sex without a condom?


01 Yes

00 No

98 Refuse to Answer


7. What was the HIV status of this partner?

01 HIV negative

02 HIV positive

03 Do not know/unsure

98 Refuse to Answer



SEX WITH FEMALE PARTNERS


  1. How many women did you have vaginal or anal sex with in the past MONTH?

______ women (If 0 SKIP to SEX WITH TRANSGENDER PARTNERS)

998 Refuse to Answer


2. How many times in the past MONTH did you have vaginal or anal sex with a female partner WITHOUT a condom?_______


3. How many times in the past MONTH did you have vaginal or anal sex with a female partner WITH a condom?_______


4. The last time you had vaginal sex with a female partner in the past month, did you have sex without a condom?


01 Yes

00 No

98 Refuse to Answer



5. What was the HIV status of this partner?

01 HIV negative

02 HIV positive

03 Do not know/unsure

98 Refuse to Answer




SEX WITH TRANSGENDER PARTNERS


1. How many transgender partners did you have vaginal or anal sex with in the past MONTH?

______ transgender partners (If 0 SKIP to next section)

998 Refuse to Answer


2. How many times in the past MONTH did you have vaginal or anal sex with a transgender partner WITHOUT a condom?_______


3. How many times in the past MONTH did you have vaginal or anal sex with a transgender partner WITH a condom?_______



4. The last time you had vaginal sex with a transgender partner in the past month, did you have sex without a condom?


01 Yes

00 No

98 Refuse to Answer



5. What was the HIV status of this partner?

01 HIV negative

02 HIV positive

03 Do not know/unsure

98 Refuse to Answer







Form Approved:

OMB No. 0920-XXXX

Expiration Date:

3E.3 CSU

IMMEDIATE POST FOLLOW-UP ASSESSMENT




A. DEMOGRAPHICS


To begin the interview, I’d like to ask you some background questions. This lets us know something about the people who participate in the project. For the following questions, either check the appropriate box or fill in your answer in the spaces provided. Remember, your responses are will be kept private.


1. Are you currently employed?

1 = Full time

2 = Part time/ Occasional

3 = Unemployed

4 = Retired

5 = Unable to work (disabled)

6 = Prefer not to answer



2. Are you currently a full time or part time student?

1 = Full time

2 = Part time

3 = Not a student

  1. = Prefer not to answer


  1. Currently, who do you live with most of the time? (Check ALL that apply)

Alone

Parents

Friends

Other relatives

Partner, lover, or spouse

Your children

Other people not mentioned (please specify):_________________________________________




  1. Do you think of yourself as…

1 = Heterosexual or "Straight"

2 = Homosexual or Gay or same gender loving

3 = Bisexual

4 = Unsure/ Questioning

5 = Other ______________________________

6 = None

  1. = Prefer not to answer





16. What is the zip code of your current home or place where you stay? |_____|_____|_____|_____|___

777 Don’t Know



17. In the past 1 month, have ever spent one night without a regular place to stay? (a shelter, transitional housing facility, or a public or private place like a car or a park)

No Yes


  1. Do you consider yourself to be currently homeless?

No Yes




B. HIV AND STD TESTING/HISTORY AND PERCEIVED RISK



Now we would like to ask some questions about your health. There are several diseases or infections that can be transmitted during sex. These are sometimes called venereal diseases or sexually transmitted diseases. We will be using the term sexually transmitted disease or STD to refer to them in the next few questions. Although HIV is a sexually transmitted disease, we will be asking you about it in a different part of this survey.



1. In the past 1 month, were you told by a health care provider, such as a doctor or nurse that you had any of the following sexually transmitted diseases?



Gonorrhea 0 No 1 Yes 777 Don’t Know

Syphilis 0 No 1 Yes 777 Don’t Know

Genital herpes 0 No 1 Yes 777 Don’t Know

Chlamydia 0 No 1 Yes 777 Don’t Know

Genital Warts (also known as HPV or Human Papilloma Virus)

0 No 1 Yes 777 Don’t Know

Hepatitis B virus 0 No 1 Yes 777 Don’t Know

Hepatitis C virus 0 No 1 Yes 777 Don’t Know

Some other STD, but not HIV (Please enter your answer here_____________)

0 No 1 Yes 77 Don’t Know



2. When was the last time you had a check-up for STDs or were tested for STDs. Do not include an HIV test in this answer. Was it…



___Within the past 30 days

___2-3 months ago

___4-6 months ago

___7-12 months ago

___1-2 years ago

___3 or more years ago

___I have never had a check-up or been tested for STDs

___777 Don’t know

___888 Prefer not to answer







You are now going to be asked some questions about your HIV status and about your experiences taking the HIV test. Please remember that this survey is kept private. It is for HIV-positive men as well as HIV-negative men.


3. Have you ever taken an HIV test?


___0 No (SKIP to….)

___1 Yes

___888 Prefer not to answer (SKIP to…)



4. When was your last HIV test? Please estimate if you are not exactly sure.


___ Within the past 30 days

___ 2-3 months ago

___ 4-6 months ago

___ 7-12 months ago

___ 1-2 years ago

___ 3 or more years ago

___ 777 Don’t know

___ 888 Prefer not to answer



5. What was the result of your last HIV test? (Choose one)

___1 HIV-Negative (Do not have HIV) (skip next two questions.)

___2 HIV-Positive (Do have HIV) Skip to #6.

___3 I did not get the result of my last test (go to next question)

___4 Inconclusive/Indetermnate (the result was neither positive or negative) (go to next question)

___888 Prefer not to answer



6. The last time you did get the results from an HIV test, what was your result? (Choose one) [Asked only of respondents who indicate answer choice 3 or 4 above]

___1 HIV-Negative (Do not have HIV)

___2 HIV-Positive (Do have HIV)

___3 I have never gotten any HIV test results


___888 Prefer not to answer



8. What was the month and year that you first tested positive for HIV? Please estimate if you are not exactly sure.

[Asked only of respondents who are HIV-positive]

__ __ / __ __ __ __ month year

___ 888 Prefer not to answer



If HIV-positive, skip to next section.



Perceived Risk for HIV


On a scale from 1 to 10, with 1 being (extremely unlikely) and 10 being extremely likely, . . .


9. How likely is it that you are infected with HIV now? _____

___ 88 Prefer not to answer


10. How likely do you think it is that you will become infected with HIV in your lifetime? _____

___ 88 Prefer not to answer

C. LACK of SUPPORT/ ALIENATION



Please indicate how much you agree or disagree with the following statements.



1. There is no one I can talk to about the important decisions in my life.

1 = Strongly agree

2 = Agree somewhat

3 = Disagree somewhat

4 = Strongly disagree

8 = Prefer not to answer



2. I feel no one respects who I am.

1 = Strongly agree

2 = Agree somewhat

3 = Disagree somewhat

4 = Strongly disagree

8 = Prefer not to answer



3. No one really understands my most private worries and fears.

1 = Strongly agree

2 = Agree somewhat

3 = Disagree somewhat

4 = Strongly disagree

8 = Prefer not to answer



4. There is no one I can depend on to lend me $50 if I needed it for an emergency.

1 = Strongly agree

2 = Agree somewhat

3 = Disagree somewhat

4 = Strongly disagree

8 = Prefer not to answer


5. I often feel isolated and alone.

1 = Strongly agree

2 = Agree somewhat

3 = Disagree somewhat

4 = Strongly disagree

8 = Prefer not to answer

D. DISCLOSURE


For each of the following statements, mark the response that best indicates your experience. Please be as honest as possible in your responses.


1----------2----------3-----------4----------5----------6----------7

Disagree Neither agree Agree

Strongly or disagree Strongly



  1. I prefer to keep my sexual relationships rather private.

  1. I keep careful control over who knows about my sexual relationships with men.


  1. My sexual behavior is nobody's business.

  1. If you are not careful about who you let know that you have sex with men, you can get very hurt.

  1. I think very carefully before I let someone know that I have sex with other men.


  1. My sexual orientation is a very personal and private matter.


E. IDENTITY/COMMUNITY AFFILIATION

The next few questions are about homosexual and bisexual men in the black community. Please indicate how strongly you agree or disagree with the following statements.



Integrated Race & Sexuality Scale (Scale limited to 4 items)

READ: Please indicate how strongly you agree or disagree with the following statements.

  1. Black homosexual and bisexual men contribute to black communities.

1 Strongly Disagree

2 Disagree

3 Mildly Disagree

4 Mildly Agree

5 Agree

6 Strongly Agree

8 Prefer not to answer



  1. Both my race and my sexuality are important to who I am as a man.

1 Strongly Disagree

2 Disagree

3 Mildly Disagree

4 Mildly Agree

5 Agree

6 Strongly Agree

8 Prefer not to answer



  1. Black homosexual and bisexual men can play an important role in Black families.

1 Strongly Disagree

2 Disagree

3 Mildly Disagree

4 Mildly Agree

5 Agree

6 Strongly Agree

8 Prefer not to answer



  1. A Black man who has sex with men can still be a strong man.

1 Strongly Disagree

2 Disagree

3 Mildly Disagree

4 Mildly Agree

5 Agree

6 Strongly Agree

8 Prefer not to answer




F. MENTAL HEALTH (BSI)



I am going to show you a list of problems and complaints that people sometimes have. For each one, tell me how much that problem has bothered or distressed you during the past week, including today. Please tell me whether each problem has bothered you not at all, a little bit, moderately, quite a bit, or extremely.



HOW OFTEN DO YOU EXPERIENCE . . .



1. Faintness or dizziness? (Choose one)

1 Not At All

2 A Little Bit

3 Moderately

4 Quite A Bit

5 Extremely

8 Refuse to Answer

2. Feeling no interest in things? (Choose one) 1 Not At All

2 A Little Bit

3 Moderately

4 Quite A Bit

5 Extremely

8 Refuse to Answer

3. Nervousness or shakiness inside? (Choose one) 1 Not At All

2 A Little Bit

3 Moderately

4 Quite A Bit

5 Extremely

8 Refuse to Answer



4. Pains in heart or chest? (Choose one) 1 Not At All

2 A Little Bit

3 Moderately

4 Quite A Bit

5 Extremely

8 Refuse to Answer



5. Feeling lonely? (Choose one) 1 Not At All

2 A Little Bit

3 Moderately

4 Quite A Bit

5 Extremely

8 Refuse to Answer

6. Feeling tense or keyed up? (Choose one) 1 Not At All

2 A Little Bit

3 Moderately

4 Quite A Bit

5 Extremely

8 Refuse to Answer

7. Nausea or upset stomach? (Choose one) 1 Not At All

2 A Little Bit

3 Moderately

4 Quite A Bit

5 Extremely

8 Refuse to Answer

8. Feeling blue or sad? (Choose one) 1 Not At All

2 A Little Bit

3 Moderately

4 Quite A Bit

5 Extremely

8 Refuse to Answer

9 Not Applicable

9. Being suddenly scared for no reason? (Choose one) 1 Not At All

2 A Little Bit

3 Moderately

4 Quite A Bit

5 Extremely

8 Refuse to Answer

10. Trouble getting your breath? (Choose one) 1 Not At All

2 A Little Bit

3 Moderately

4 Quite A Bit

5 Extremely

8 Refuse to Answer

11. Feelings of worthlessness? (Choose one) 1 Not At All

2 A Little Bit

3 Moderately

4 Quite A Bit

5 Extremely

8 Refuse to Answer

12. Episodes of terror or panic? (Choose one) 1 Not At All

2 A Little Bit

3 Moderately

4 Quite A Bit

5 Extremely

8 Refuse to Answer

13. Numbness or tingling in parts of your body? (Choose one) 1 Not At All

2 A Little Bit

3 Moderately

4 Quite A Bit

5 Extremely

8 Refuse to Answer

14. Feeling hopeless about the future? (Choose one) 1 Not At All

2 A Little Bit

3 Moderately

4 Quite A Bit

5 Extremely

8 Refuse to Answer

15. Feeling so restless that you could not sit still? (Choose one) 1 Not At All

2 A Little Bit

3 Moderately

4 Quite A Bit

5 Extremely

8 Refuse to Answer

16. Feeling weak in parts of your body? (Choose one) 1 Not At All

2 A Little Bit

3 Moderately

4 Quite A Bit

5 Extremely

8 Refuse to Answer

17. Thoughts of ending your life? (Choose one) 1 Not At All

2 A Little Bit

3 Moderately

4 Quite A Bit

5 Extremely

8 Refuse to Answer

18. Feeling fearful? (Choose one) 1 Not At All

2 A Little Bit

3 Moderately

4 Quite A Bit

5 Extremely

8 Refuse to Answer



Hostility Items

19. Feeling easily annoyed or irritated (Choose one)

1 Not at all

2 A little bit

3 Moderately

4 Quite a bit

5 Extremely

8 Prefer not to answer



20. ..temper outbursts that you could not control? (Choose one)

1 Not at all

2 A little bit

3 Moderately

4 Quite a bit

5 Extremely

8 Prefer not to answer

5 Extremely

8 Prefer not to answer

21. ....having urges to beat, injure, or harm someone? (Choose one)

1 Not at all

2 A little bit

3 Moderately

4 Quite a bit

5 Extremely

8 Prefer not to answer

22. ...having urges to break or smash things? (Choose one)

1 Not at all

2 A little bit

3 Moderately

4 Quite a bit

5 Extremely

8 Prefer not to answer

23. ...getting into frequent arguments? (Choose one)1 Not at all

2 A little bit

3 Moderately

4 Quite a bit

5 Extremely

8 Prefer not to answer


G. HIV STIGMA

The next set of questions asks about some of your feelings and opinions about HIV/AIDS. Please indicate how much you agree or disagree with the following statements:

1. People who have HIV or AIDS should be isolated from the rest of society.

1. Strongly Disagree

2. Disagree,

3. Agree

4. Strongly Agree

8. Prefer not to answer



2. People who have HIV or AIDS should only date other HIV positive people.

1. Strongly Disagree

2. Disagree,

3. Agree

4. Strongly Agree

8. Prefer not to answer



3. People who have HIV or AIDS are not sexually desirable.

1. Strongly Disagree

2. Disagree,

3. Agree

4. Strongly Agree

8. Prefer not to answer



4. People who have HIV or AIDS are more sexually promiscuous than most people.

1. Strongly Disagree

2. Disagree,

3. Agree

4. Strongly Agree

8. Prefer not to answer



5. The promiscuity of people who are gay is the reason why HIV/AIDS exists.

1. Strongly Disagree

2. Disagree,

3. Agree

4. Strongly Agree

8. Prefer not to answer



6. AIDS is a punishment from God.

1. Strongly Disagree

2. Disagree,

3. Agree

4. Strongly Agree

8. Prefer not to answer

H. TREATMENT OPTIMISM


The following section refers to combination treatments, “Drug Cocktails” or HAART for HIV/AIDS. Please indicate how much you agree with each statement.

____________

Strongly Somewhat Somewhat Strongly

Disagree Disagree Agree Agree

______


1. HIV positive persons who take HIV

medications are less likely to infect

their sex partners during unsafe sex. 1 2 3 4


2. New AIDS treatments make it

easier to relax about unsafe sex. 1 2 3 4


3. Men like me are less worried

about HIV because of new treatments. 1 2 3 4


4. My friends practice more unsafe

sex because of new HIV treatments.

1 2 3 4

5.It is safe to have anal sex without a condom

with an HIV positive man who has an

undetectable viral load. 1 2 3 4





I. DISCLOSURE FOR HIV-POSITIVE MEN

         

Self efficacy for disclosure of HIV status


The following section asks questions about disclosing your HIV status to sexual partners who are HIV-negative or who don’t know their own HIV status. Remember, all of your answers are private.


8. I can disclose my HIV status before having sex, even to a really hot new sex partner.


1 = Absolutely sure I cannot
2 = Somewhat sure I cannot
3 = Unsure if I can or cannot
4 = Somewhat sure I can
5 = Absolutely sure I can



9. I can disclose my HIV status before having sex, even to a really hot new sex partner who I think might be HIV negative.


1 = Absolutely sure I cannot
2 = Somewhat sure I cannot
3 = Unsure if I can or cannot
4 = Somewhat sure I can
5 = Absolutely sure I can



10. I can disclose my HIV status before having sex even if my partner did not know I was HIV positive the first time we had sex.     


1 = Absolutely sure I cannot
2 = Somewhat sure I cannot
3 = Unsure if I can or cannot
4 = Somewhat sure I can
5 = Absolutely sure I can



11. I can disclose my HIV status before having sex even if I was worried that my partner wouldn't have sex with me if they knew.


1 = Absolutely sure I cannot
2 = Somewhat sure I cannot
3 = Unsure if I can or cannot
4 = Somewhat sure I can
5 = Absolutely sure I can



12. I can disclose my HIV status before having sex even to a sex partner who hasn't told me their HIV status.   


1 = Absolutely sure I cannot
2 = Somewhat sure I cannot
3 = Unsure if I can or cannot
4 = Somewhat sure I can
5 = Absolutely sure I can


  

J. SOCIAL DESIRABILITY

Listed below are a few statements about your relationships with others. How much is each statement true or false for you?

1 = Definitely True

2 = Mostly True

3 = Don’t Know

4 = Mostly False

5 = Definitely False

8 = Prefer not to answer



1. I am always courteous, even to people who are disagreeable.





2. There have been occasions when I took advantage of someone.





3. I sometimes try to get even rather than forgive and forget.





4. I sometimes feel resentful when I don't get my way.



5. No matter who I’m talking to, I’m always a good listener.


Baseline Local Questions for Los Angeles



















Developmental trajectories regarding sex/sexual sequences


I am going to ask you about early sexual desires and experiences.


1. At what age were you first sexually attracted to a female? ___ Years

0 I was never physically attracted to females

77 DK

88 Prefer not to answer


2. At what age did you first engage in each of the following sexual activities with a female?

  1. Grinding/fondling/petting/rubbing ___ Years

0 Never 77 DK 88 Prefer not to answer

  1. Kissing ___ Years

0 Never 77 DK 88 Prefer not to answer

  1. Oral sex ___ Years

0 Never 77 DK 88 Prefer not to answer

  1. Vaginal sex ___ Years

0 Never 77 DK 88 Prefer not to answer

  1. Anal sex ___ Years

0 Never 77 DK 88 Prefer not to answer


3. At what age were you first sexually attracted to a male? ___ Years

0 I was never physically attracted to males

77 DK

88 Prefer not to answer


4. At what age did you first engage in each of the following sexual activities with a male?

  1. Grinding/fondling/petting/rubbing ___ Years

0 Never 77 DK 88 Prefer not to answer

  1. Kissing ___ Years

0 Never 77 DK 88 Prefer not to answer

  1. Oral sex ___ Years

0 Never 77 DK 88 Prefer not to answer

  1. Vaginal sex ___ Years

0 Never 77 DK 88 Prefer not to answer

  1. Insertive anal sex (topping) ___ Years

0 Never 77 DK 88 Prefer not to answer

  1. Receptive anal sex (bottoming) ___ Years

0 Never 77 DK 88 Prefer not to answer


5. At what age were you first sexually attracted to a male-to-female transgender?

___ Years

0 I was never physically attracted to transgenders

77 DK

88 Prefer not to answer


6. What age did you first engage in each of the following types of sexual activity with a male-to-female transgender?

  1. Grinding/fondling/petting/rubbing ___ Years

0 Never 77 DK 88 Prefer not to answer

  1. Kissing ___ Years

0 Never 77 DK 88 Prefer not to answer

  1. Oral sex ___ Years

0 Never 77 DK 88 Prefer not to answer

  1. Vaginal sex ___ Years

0 Never 77 DK 88 Prefer not to answer

  1. Insertive anal sex (topping) ___ Years

0 Never 77 DK 88 Prefer not to answer

  1. Receptive anal sex (bottoming) ___ Years

0 Never 77 DK 88 Prefer not to answer


7. At what age did you first identify as ____{list answer to #A15}? ___ Years

77 DK

88 Prefer not to answer


8. At what age did you first share with someone, other than a sexual partner, that you have had sex with males? ___ Years

77 DK

88 Prefer not to answer


9. Have you ever received instruction on how to properly put on a condom?

1 Yes

2 No

7 Don’t know

8 Prefer not to answer

(If YES to #9)

10. From where have you received instruction on proper condom use? Specify:_____________________________________________________



Additional Alcohol items

I am going to ask you some more questions about alcohol use.

1. How old were you when you first drank alcohol, not counting small tastes or sips of alcohol? ____ Years

0 - 76 = AGE

77 = Don't Know

88 = Prefer not Answer

99 = Not Applicable


2. About how old were you when you first became intoxicated or drunk from drinking alcohol? ____ Years

0 - 76 = AGE

77 = Don't Know

88 = Prefer not Answer

99 = Not Applicable


3. In the last 90 days, on a typical day when you drank alcohol, how many standard drinks did you have?

A standard drink is 12 oz regular beer, wine cooler, flavored beer; 8 oz of malt liquor beer; 5 ounces of table or sparkling wine, 3 ounces of fortified wine (includes dessert wines, ports, citrus wine), and 1.5 oz of hard alcohol or distilled spirit alone or with a mixer.

_______ # of drinks

77 = Don't Know

88 = Prefer not Answer

99 = Not Applicable


4. In the last 90 days, when you drank alcohol, how often was the beverage type {regular beer, wine cooler, flavored beer; malt liquor beer, table or sparkling wine, fortified wine, hard alcohol or distilled spirit} . . .?

For each beverage type:

4 Always

3 Often

2 Sometimes

1 Seldom

0 Never

7 Don’t know

8 Prefer not answer

  1. Regular beer (such as Miller, Coors, Corona, . . .)

  2. Malt liquor beer (such as Old English, Colt 45, . . .)

  3. Premium or flavored beer or coolers (such as Smirnoff Ice and Seagram Coolers)

  4. Table or sparkling wine (such chardonnay, merlot, etc.)

  5. Fortified wine (include dessert wines, ports, citrus wine) (such as Cisco, Thunderbird, MD20-20 )

  6. Hard alcohol or distilled spirits alone or with mixers (such as vodka, whisky, martinis, . . .)

Substance abuse during incarceration

SUBSTANCE USE


I am going to ask you some questions about your experience using substances while in jail or prison over the last 12 months. These substances can be smoked, swallowed, snorted, inhaled, or taken in the form of pills.

Please know that information on such use will be treated as strictly private.



Over the last 12 months, during the times you were incarcerated, how often did you…

 

 

Daily or Almost Daily

Weekly

Monthly

Once or Twice

Never

1.Drink alcohol (including “pruno”)?

 

4

3

2

1

0

2. Smoke marijuana (weed, pot, etc.)?


4

3

2

1

0

3. Snort or sniff powder cocaine?


4

3

2

1

0

4. Smoke crack or rock cocaine?


4

3

2

1

0

5. Swallow, snort, bump or smoke methamphetamine (crystal meth, tina, crank, etc)?


4

3

2

1

0

6, Used poppers or inhaled nitrites?


4

3

2

1

0

7. Use club drugs (Ecstacy, GHB, Special K, etc.)?


4

3

2

1

0

8. Snort or smoke heroin?


4

3

2

1

0

9. Swallow, smoke or snort pills that were not prescribed to you?

4

3

2

1

0

10. Other, Please specify _________________________


4

3

2

1

0

Additional Incarceration Items

I am going to ask you some more questions about times you may have been incarcerated.

  1. During just the last 12 months, how many times have you been incarcerated (held in jail, prison, or detention)? _____ times

77 Don’t know

88 Prefer not answer

  1. During just the last 12 months, about how much time have you spent in jail or prison or detention altogether? Days _______

Months _______

77 Don’t know

88 Prefer not answer

  1. During the last 12 months, were you ever offered a voluntary HIV test during incarceration?

1 Yes

2 No, I did not receive any HIV test while incarcerated

3 No, but I was forced to take an HIV test

7 Don’t know

8 Prefer not to answer


  1. During the last 12 months, did you participate in or receive any of the following services while incarcerated? (please select all that apply)


  1. Group HIV prevention class

  2. One-on-one discussions about HIV prevention

  3. Testing for other sexually transmitted diseases

  4. Reading HIV prevention brochures

  5. Viewing HIV prevention videos

  6. Receiving condoms

  7. STD or HIV partner-notification services

  8. Other, specify

77. Don’t know

88. Prefer not to answer

For clients who self-identify as HIV-positive, only:


5. During the last 12 months, did you participate in or receive any of the following services related to your HIV infection while incarcerated? (please select all that apply)


  1. HIV antiretroviral treatment

  2. HIV transitional case management

  3. HIV treatment education

  4. Other, specify

  5. None of the above

77. Don’t know

88. Prefer not to answer

99. N/A, I was not diagnosed at or before my last incarceration


The next questions are about any time that you spent in jail or prison during the 12 months prior to today. Unless otherwise specified, sex refers vaginal, anal, or oral sex. It includes times in which you were forced or pressured into having sex with someone.



6. During the past 12 months, did you ever have sex with someone when you were in prison or jail?

1 = Yes

2 = No (Skip to #4)

8 = Prefer not Answer

7. During the past 12 months, who did you have sex with when in prison or jail? (please select all that apply)

1 = Men

2 = Women

3 = Transgender male to female

8 = Prefer not Answer

8. During the past 12 months, when you were in prison or jail, did you have . . .

a. Oral sex with anyone?

1 = Yes

2 = No

8 = Prefer not Answer

b. Vaginal or anal sex with a female staff member?

1 = Yes

2 = No

8 = Prefer not Answer

c. Anal sex with a male member?

1 = Yes

2 = No

8 = Prefer not Answer


Skip next item if c is NO.


d. The time(s) that you had sex with a male staff member, were you the . . .?

1 = top, the insertive partner

2 = bottom, the receptive partner

3 = both top and bottom


Skip next item if b and c are both NO

e. What were the reasons that you had sex with a staff member? Select all that apply.

  1. To get commissary items

  2. To get medications

  3. To get contraband (eg. cell phones, drugs, cigarettes, weapons)

  4. To get money

  5. For pleasure

  6. For protection

  7. For access or privileges

  8. Because of force or threat

  9. Other, specify ________________________

8(cont) During the past 12 months, when you were in prison or jail, did you have . . .


f. Anal sex with a transgender inmate?

1 = Yes

2 = No

8 = Prefer not Answer

***Skip next item if ‘f’ is NO.

g. The time(s) that you had sex with a transgender inmate, were you the . . . ?

1 = top, the insertive partner

2 = bottom, the receptive partner

3 = both top and bottom




8(cont) During the past 12 months, when you were in prison or jail, did you have . . .

h. Anal sex with a male inmate?

1 = Yes

2 = No

8 = Prefer not Answer


********Skip next item if h is NO.

i. The time(s) that you had sex with a male inmate, were you the . . .?

1 = top, the insertive partner

2 = bottom, the receptive partner

3 = both top and bottom


j. What were the reasons that you had sex with an inmate? Select all that apply.

  1. To get commissary items

  2. To get medications

  3. To get contraband (eg. cell phones, drugs, cigarettes, weapons)

  4. To get money

  5. For pleasure

  6. For protection

  7. For access or privileges

  8. For support

  9. Because of force or threat

  10. Because of boredom

  11. As part of gang-related initiation

  12. Other, specify ________________________



During the past 12 months while you were in jail or prison, has anyone ever . . .

9. Touched you, felt you, or grabbed you in a way that you felt was sexually threatening?


Response categories: 1 = Yes

2 = No

  1. = Prefer not Answer


10. Required or forced you to perform sexual acts (on them or someone else) as a way to protect yourself from current or future harm?


Response categories: 1 = Yes

2 = No

8 = Prefer not Answer


The final few questions are about your lifetime sexual experiences with men, women, or transgender women while in juvenile detention, jail, or prison. If you, did not have sexual contact with a person of that gender while incarcerated, select Not Applicable.


11. How old were you when you first had any sexual contact with a male while in juvenile detention, jail, or prison? ___ Years

77 DK

88 Prefer not to answer

99 NA, Never any sexual contact with a male while incarcerated


12. How old were you when you first had any sexual contact with a female while in juvenile detention, jail, or prison? ___ Years

77 DK

88 Prefer not to answer

99 NA, Never any sexual contact with a female while incarcerated


13. How old were you when you first had any sexual contact with a transgender woman while in juvenile detention, jail, or prison? ___ Years

77 DK

88 Prefer not to answer

99 NA, Never any sexual contact with a transgender woman while incarcerated



SEXUAL RISK


SEX WITH MALE PARTNERS


  1. How many men did you have anal sex with in the past MONTH?

______ men (If 0 SKIP to SEX WITH FEMALE PARTNERS)


998 Refuse to Answer

2. How many times in the past MONTH did you top a male partner (put your penis in his butt) WITHOUT a condom?_______

3. How many times in the past MONTH did you top a male partner (put your penis in his butt) WITH a condom?_______

4. How many times in the past MONTH did you bottom for a male partner (he put his penis in your butt) WITHOUT a condom?_______

5. How many times in the past MONTH did you bottom for a male partner (he put his penis in your butt) WITH a condom?_______


6. The last time you had anal sex with a male partner in the past month, did you have sex without a condom?


01 Yes

00 No

98 Refuse to Answer


7. What was the HIV status of this partner?

01 HIV negative

02 HIV positive

03 Do not know/unsure

98 Refuse to Answer



SEX WITH FEMALE PARTNERS


  1. How many women did you have vaginal or anal sex with in the past MONTH?

______ women (If 0 SKIP to SEX WITH TRANSGENDER PARTNERS)

998 Refuse to Answer


2. How many times in the past MONTH did you have vaginal or anal sex with a female partner WITHOUT a condom?_______


3. How many times in the past MONTH did you have vaginal or anal sex with a female partner WITH a condom?_______


4. The last time you had vaginal sex with a female partner in the past month, did you have sex without a condom?


01 Yes

00 No

98 Refuse to Answer



5. What was the HIV status of this partner?

01 HIV negative

02 HIV positive

03 Do not know/unsure

98 Refuse to Answer




SEX WITH TRANSGENDER PARTNERS


1. How many transgender partners did you have vaginal or anal sex with in the past MONTH?

______ transgender partners (If 0 SKIP to next section)

998 Refuse to Answer


2. How many times in the past MONTH did you have vaginal or anal sex with a transgender partner WITHOUT a condom?_______


3. How many times in the past MONTH did you have vaginal or anal sex with a transgender partner WITH a condom?_______



4. The last time you had vaginal sex with a transgender partner in the past month, did you have sex without a condom?


01 Yes

00 No

98 Refuse to Answer



5. What was the HIV status of this partner?

01 HIV negative

02 HIV positive

03 Do not know/unsure

98 Refuse to Answer







3


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