Baseline HIV

Form Approved

OMB No. 0920-XXXX

Expiration Date: XX/XX/XXXX

Evaluation of Free Rapid HIV home-testing in MSM (eSTAMP): Randomized-Controlled Trial

Attachment 3d

Baseline Survey—HIV Positive Group

Public reporting burden of this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-XXXX)

Part 4 Baseline Survey – HIV Positive Group

__________________________________________________

AUTO1. Date of HIV positive group Baseline Survey: __ __ / __ __ / __ __ __ __

^{(M M / D D / Y Y Y Y)}

AUTO2. Time Began HIV positive group Baseline Survey: __ __:__ __:__ __ [24 Hour time HH:MM:SS]

Thank you for your interest in our study. Please take note of the following information: 

1. Your answers are private: the information you provide us will be kept secure and known only to study staff. This information will not be shared or used for any other research purposes.

2. This survey includes some personal questions about your sexual behaviors, HIV status and HIV testing practices. You may choose to not answer any questions that make you feel uncomfortable.

3. We appreciate your willingness to be part of this study. Your participation will help us learn more about ways to get people tested. The results of this study will be used to improve HIV testing programs in the United States.

4. If you have any questions or comments, you may contact the Principal Investigator, Dr. Patrick Sullivan of Emory University, at (404) 727-2038.

Emory University and MANILA Consulting Group, Inc. are conducting the study, which is funded by the Centers for Disease Control and Prevention (CDC).

__________________________________________________

Section A. Demographics

DM-1. What is the highest grade in school you completed?

1. Less than high school

2. Some high school

3. High school diploma or GED

4. Some college, Associate’s degree, or Technical degree

5. College graduate

6. Post graduate or professional school

77 I prefer not to answer

DM-2. What best describes your current employment status? Choose only one.

1. Employed full time

2. Employed part time

3. Unemployed

77 I prefer not to answer

DM-3. The next question is about your household income last year from all sources before taxes. That is, the total amount of money earned and shared by all people living in your household.

Please choose if you would like to answer in terms of monthly income or yearly income:

$ per month

$ per year

If DM-3 = “$ per month, go to DM-3a.

If DM-3 = “$ per year, go to DM-3b.

If DM-3 = “I prefer not to answer”, skip to DM-5.

DM-3a. What was your household income last year from all sources before taxes?

1. 0 to $1667 per month

2. $1668 to $3333 per month

3. $3334 to $6250 per month

4. $6251 or more per month

77 I prefer not to answer

99 I don't know

DM-3b. What was your household income last year from all sources before taxes?

1. 0 to $19,999 per year

2. $20,000 to $39,999 per year

3. $40,000 to $74,999 per year

4. $75,000 or more per year

77 I prefer not to answer

99 I don't know

DM-4. Including yourself, how many people depended on this income? (must be at least 1)

___ ___ Number of people

77 I prefer not to answer

DM-5. Which of these common terms best describes you?

1. Homosexual or Gay or Same gender loving

2. Heterosexual or Straight

3. Bisexual

4. Other (Specify _____)

77 I prefer not to answer

DM-6. Do you currently have health insurance?

1. No

2. Yes – Through my job

3. Yes – Through someone else’s job

4. Yes – Paid for by me or another person

5. Yes – Medicare/Medicaid

77 I prefer not to answer

DM-7. In the past 12 months, have you seen a doctor, nurse, or other health care provider about your own health?

1. No

2. Yes

77 I prefer not to answer

Section B. HIV Testing Behavior

HT-1.When did you first test HIV positive?

__ __ / __ __ __ __ [MM/YYYY]

77 I prefer not to answer

99 I don't know

Section C. Linkage to Care, Treatment, and Adherence

The next questions are about medical appointments to a see a health care provider (doctor, physician’s assistant or nurse) because of a positive HIV test result or to get care for your HIV infection.

HTP-1. Have you ever been seen by a HIV health care provider for your HIV infection?

1. No

2. Yes

77 I prefer not to answer

If HTP-1 = “No” or “I prefer not to answer”, go to HTP-2.

If HTP-1 = “Yes”, go to HTP-4.

HTP-2. What are the reasons you have NOT gone to a health care provider for your HIV infection? Check all that apply.

1. I felt good and didn’t need to go

2. I didn’t believe that I am HIV positive or want to think about it

3. I didn’t have enough money or health insurance

4. I had other responsibilities such as child care or work

5. I was homeless

6. I was too sick to go

7. I forgot to go or missed my appointment(s)

8. I was unable to get transportation

9. Going to the appointment is inconvenient (location/hours/wait-time, etc.)

10. I don’t know where to go or couldn’t find the right HIV health care provider

11. Other (specify:______)

77 I prefer not to answer

HTP-3. Of the reasons you picked, what is the main reason you did NOT go to a health care provider? Choose only one.

Display response options based on selections in HTP-2.

If HTP-1 = “No” or “I prefer not to answer”, go to M-1.

If HTP-1 = “Yes”, go to HTP-4 if this is the first time in this section. Else go to M-1.

HTP-4. How long did it take from the time you found out about your HIV infection to the time you first saw a health care provider?

Give result in days, weeks, months or years. (Drop down menu)

____ days OR ____ weeks OR ____ months OR years

77 I prefer not to answer

LTA-5. In the past 6 months, how many times have you seen a HIV health care provider?

____ _____ (0 to N) Number of times

77 I prefer not to answer

99 I don't know

If “0”, go to LTA-6.

If >”0”, go to LTA-7.

LTA-6. What are the reasons you did not go to a HIV health care provider in the last 6 months? Check all that apply.

1. I felt good and didn’t need to go

2. I didn’t believe that I am HIV positive or want to think about it

3. I didn’t have enough money or health insurance

4. I had other responsibilities such as child care or work

5. I was homeless

6. I was too sick to go

7. I forgot to go or missed my appointment(s)

8. I was unable to get transportation

9. Going to the appointment is inconvenient (location/hours/wait-time, etc.)

10. I don’t know where to go or couldn’t find the right HIV health care provider

11. Other (specify:______)

77 I prefer not to answer

LTA-7. When was your most recent visit to a HIV health care provider?

__ __ / __ __ __ __ [MM/YYYY]

77 I prefer not to answer

99 I don't know

HTP-5. How did you get the contact information of the health care provider that you saw on your most recent visit [insert date from LTA-7]? (Check the response that best fits your experience)

1. I called the study phone number

2. I called an AIDS/HIV hotline

3. I called the number in the OraQuick or Home Access package

4. Counselor who tested me gave it to me

5. Partner, friend or family member gave it to me

6. My regular health care provider gave it to me

7. An agency or social service organization gave it to me

8. From Internet/website

9. Other (specify):

HTP-6. Did you make the appointment?

1. No, someone else made the appointment

2. Yes, I made the appointment

77 I prefer not to answer

If HTP-6 = No, go to HTP-7. Else go to HTP-8

HTP-7. Who made your appointment with the health care provider that you saw? Check only one answer.

1. Counselor from study

2. Counselor from AIDS/HIV hotline

3. Counselor who tested me

4. Partner, friend, or family member

5. My regular health care provider

6. An agency or social service organization

7. Other (specify): ___________________________

77 I prefer not to answer

HTP-8. Did anyone go with you to your HIV health care appointment?

1. No

2. Yes

77 I prefer not to answer

HTP-9. Has your healthcare provider ordered a T-cell or CD-4 test?

1. No

2. Yes

77 I prefer not to answer

99 I don't know

If HTP-12 = “Yes” continue to HTP-10; else go to HTP-12

HTP-10. When was your most recent T-cell or CD4 test?

__ __ / __ __ __ __ [MM/YYYY]

77 I prefer not to answer

99 I don't know

HTP-11. What was the result of your most recent T-cell or CD4 test?

1. 500 or more

2. 350-499

3. 201-349

4. 200 or less

5. Results not back yet

77 I prefer not to answer

99 I don't know

HTP-12. Has your healthcare provider ordered a viral load test?

1. No

2. Yes

77 I prefer not to answer

99 I don't know

If HTP-12 = “Yes” continue to HTP-13; else go to M-1

HTP-13. When was your most recent viral load test?

__ __ / __ __ __ __ [MM/YYYY]

77 I prefer not to answer

99 I don't know

HTP-14. What was the result of your most recent viral load test?

1. Undetectable

2. Detectable

3. Results not back yet

77 I prefer not to answer

99 I don't know

Questions about HIV Medicines

M-1. Are you currently taking any HIV medicines (also known as antiretrovirals, ART, or HAART) to treat your HIV infection?

1. No

2. Yes

77 I prefer not to answer

If M-1 = “Yes”, proceed to M-2

If M-1 ≠ “Yes”, proceed to M-3

M-2. Over the past 3 months, which of the following best describes your general experience taking your HIV medicines (also known as antiretrovirals, ART, or HAART)?

1. I take them exactly as prescribed, almost never missing a dose

2. I sometimes skip a dose or forget to take my pills

3. I often skip a dose or forget to take my pills

4. I rarely take my pills as prescribed

5. I do not take my medication at all

77 I prefer not to answer

Go to next Section

M-3. What is the main reason you are not currently taking any HIV medicines (also known as antiretrovirals, ART, or HAART)? Choose only one reason.

1. I’m not currently going to an HIV health care provider

2. My health care provider advised to delay treatment

3. My CD4 count and viral load are good

4. I don’t have the money or insurance for HIV medicines

5. I don’t want to take HIV medicines

6. I feel fine/healthy and don’t need HIV medicines

7. I am concerned about side effects of HIV medicines

8. I feel depressed or overwhelmed

9. I don’t want to think about being HIV positive

10. I am concerned that I cannot stick to a medication schedule

11. I was/am homeless

12. I am taking alternative or complementary medicines

13. Other reason (specify: ______ )

77 I prefer not to answer

Go to next Section

Section D. Intention to Distribute HIV tests

A rapid home HIV test is a test you can buy at a drug store or online, test yourself at home or other private location and get a result in 15-20 minutes.

Imagine you are sent free rapid home HIV tests that use oral fluid to share with your friends or sex partners as part of this online study. They would be able to test themselves for HIV by swabbing their gums, and get their test results within 20 minutes. They could also call a free, 24-hour hotline to talk with a counselor, and find out where to get further HIV testing and medical services in their community.

ID-1a. In the next 12 months, how likely are you to give free oral rapid HIV tests to your friends?

1. Very likely

2. Somewhat likely

3. Not sure

4. Somewhat unlikely

5. Very unlikely

77 I prefer not to answer

ID-1b. In the next 12 months, how likely are you to give free oral rapid HIV tests to your sex partners?

1. Very likely

2. Somewhat likely

3. Not sure

4. Somewhat unlikely

5. Very unlikely

77 I prefer not to answer

Now imagine you are sent free home rapid HIV tests that use finger-stick blood to share with your friends or sex partners as part of this online study. They would be able to test themselves for HIV by using blood from pricking their fingers, and get their test results within 15 minutes. They could also call a free, 24-hour hotline and talk with a counselor, and find out where to get further HIV testing and medical services in their community.

ID-2a. In the next 12 months, how likely are you to give free finger-stick blood rapid HIV tests to your friends?

1. Very likely

2. Somewhat likely

3. Not sure

4. Somewhat unlikely

5. Very unlikely

77 I prefer not to answer

ID-2b. In the next 12 months, how likely are you to give free finger-stick blood rapid HIV tests to your sex partners?

1. Very likely

2. Somewhat likely

3. Not sure

4. Somewhat unlikely

5. Very unlikely

77 I prefer not to answer

If ID-2a or 2b = “Very likely” or “Somewhat likely”, skip to ID -4.

ID-3a. What are some of your reasons for not being willing to give away free oral fluid rapid HIV tests to your [complete based on answer from 1a, 1b, 2a, 2b: friends - sex partners – friends or sex partners]? Check all that apply.

1. It might affect our friendship

2. It might affect our sexual relationship

3. I think they would get upset or angry

4. They would think I have HIV

5. I don’t think the test is accurate

6. I don’t think could do the test correctly

7. I don’t think they could read the result properly

8. They should talk to a counselor when getting an HIV test

9. Other reason (Specify___________)

77 I prefer not to answer

99 I don't know

ID-3. What are some of your reasons for not being willing to give away free finger-stick blood rapid HIV tests to your [complete based on answer from 1a, 1b, 2a, 2b: friends - sex partners – friends or sex partners]? Check all that apply.

It might affect our friendship

1. It might affect our sexual relationship

2. I think they would get upset or angry

3. They would think I have HIV

4. I don’t think the test is accurate

5. I don’t think could do the test correctly

6. I don’t think they could read the result properly

7. They should talk to a counselor when getting an HIV test

8. Other reason (Specify___________)

77 I prefer not to answer

99 I don't know

ID-4. In the next 12 months, who are you most likely to give a free, at-home rapid HIV test? Choose only one.

1. A main sexual partner (Someone you feel committed to above all others)

2. A casual sexual partner (Someone you do not feel committed to above all others)

3. A family member (not sexual partner)

4. A friend (not sexual partner)

5. A stranger (not sexual partner)

6. An acquaintance (not sexual partner)

7. Other (please specify: _________)

8. Nobody

77 I prefer not to answer

99 I don't know

Section E. Baseline Sexual Behavior

We will now ask you some questions about your sex partners in the past 3 months. We only want to know about partners you had anal or vaginal sex with since [insert date from 3 months ago].

SX-1. In the past 3 months, did you have anal or vaginal sex with?

1. Only men

2. Only women

3. Both men and women

4. Nobody

If SX-1 = “Only men”, ask only Male Sex Partner questions.

If SX-1 = “Only women”, ask only Female Sex Partner questions.

If SX-1 = “Both men and women”, ask Female Sex Partner questions first, followed by Male Sex Partner questions.

If SX-1 = “Nobody” or “I prefer not to answer”, skip to the next section.

If SX-1 is not answered, prompt “Please enter a response”.

Female Sex Partner Questions

The next questions are about women you had vaginal or anal sex with in the past 3 months. “Vaginal sex” means you put your penis in her vagina. “Anal sex" means you put your penis in her butt.

The next questions are about women you had vaginal or anal sex with in the past 3 months.

FX-1. In the past 3 months, with how many different women did you have vaginal or anal sex?

___ ___ Number of women (1 to N)

77 I prefer not to answer

FX-2. With how many of these [FX-1] women did you have vaginal or anal sex without using a condom or not using it the whole time?

___ ___ Number of women (0 to N)

77 I prefer not to answer

Check to make sure SX-27 ≤ SX-27.

If not, then display “The number of women you had sex without using a condom or not using it the whole time cannot be more than the number of women you had vaginal or anal sex with in the past 3 months. Please carefully re-enter your response.”, and loop back to enter the number.

FX-3. In the past 3 months, how many of these [FX-2] women you had vaginal or anal sex without using a condom were:

1. HIV positive? ___ ___ Number of women (0 to N)

2. HIV negative? ___ ___ Number of women (0 to N)

3. Women whose HIV status you did not know? ___ ___ (0 to N)

77 I prefer not to answer

Check to make sure that the numbers in FX-3 add up to the total N from FX-2.

If not, then display “The number of HIV positive, HIV negative and HIV status unknown partners must add up to [FX-2]. Please carefully re-enter your responses.”, and loop back to enter the numbers.

Male Sex Partner Questions

The next questions are about men you had anal sex with in the past 3 months. “Anal sex" means you put your penis in his butt, or he put his penis in your butt.

SX-2. In the past 3 months, with how many different men did you have anal sex?

___ ___ Number of men (1 to N)

77 I prefer not to answer

If SX-2 = 1 ask Partner 1 questions

If SX-2 = 2 ask Partner 1 and Partner 2 questions

If SX-2 = 3 ask Partner 1, Partner 2 and Partner 3 questions

If SX-2 = 4 ask Partner 1, Partner 2, Partner 3 and Partner 4 questions

If SX-2 ≥ 5 ask Partner 1, Partner 2, Partner 3, Partner 4 and Questions for ≥ 5 partners

SX-3. Please enter a nickname or initials for the [insert number from SX-2 if SX-2 < 4, or insert 4] most recent men you had anal sex with since [insert date from 3 months ago].

We do not want to know the names of your partners. Please choose a nickname or initials that will best help you remember that person.

Display options below based on number from SX-2

1. Partner 1 __________

2. Partner 2 __________

3. Partner 3 __________

4. Partner 4 __________

If SX-3is not answered, prompt “Please enter a response”.

Ask partner-specific questions based on number from SX-2.

Partner 1:

SX-4. What is/was your relationship with [Partner 1]?

1. Main Partner, Serious relationship, Boyfriend (Someone you feel committed to above all others)

2. Casually dating but not serious

3. Having sex with but not dating

4. One night stand/Stranger/Anonymous

77 I prefer not to answer

If SX-4 = 1, 2 or 3 go to SX-5 else skip to SX-6.

SX-5. How long have you been with [Partner 1]?

1. Less than a month

2. 1 to 3 months

3. 4 to 6 months

4. 7 to 11 months

5. 1 to 3 years

6. Over 3 years

77 I prefer not to answer

SX-6. What is [Partner 1]’s race/ethnicity? Check all that apply.

1. American Indian or Alaska Native

2. Asian

3. Black or African American

4. Hispanic or Latino

5. Native Hawaiian or Other Pacific Islander

6. White

77 I prefer not to answer

SX-7. To the best of your knowledge, what was [Partner 1]'s HIV status?

1. I know this person is HIV negative

2. I think this person is HIV negative

3. I don’t know this person’s HIV status

4. I think this person is HIV positive

5. I know this person is HIV positive

77 I prefer not to answer

SX-8. In the past 3 months, how many times did you and [Partner 1] have anal sex without using a condom or not using it the whole time?

___ ___ Number of times (0 to N)

77 I prefer not to answer

If SX-7 = 0 or “I prefer not to answer”, skip SX-8

SX-9. In the past 3 months, when you and [Partner 1] had anal sex without a condom were you the top (your penis in his butt), bottom (his penis in your butt) or both? (Check only one)

1. Both top and bottom

2. Top only

3. Bottom only

77 I prefer not to answer

Partner 2:

SX-10. What is/was your relationship with [Partner 2]?

1. Main Partner, Serious relationship, Boyfriend (Someone you feel committed to above all others)

2. Casually dating but not serious

3. Having sex with but not dating

4. One night stand/ Stranger/Anonymous

77 I prefer not to answer

If SX-10 = 1, 2 or 3 go to SX-11 else skip to SX-12.

SX-11. How long have you been with [Partner 2]?

1. Less than a month

2. 1 to 3 months

3. 4 to 6 months

4. 7 to 11 months

5. 1 to 3 years

6. Over 3 years

77 I prefer not to answer

SX-12. What is [Partner 2]’s race/ethnicity? Check all that apply.

1. American Indian or Alaska Native

2. Asian

3. Black or African American

4. Hispanic or Latino

5. Native Hawaiian or Other Pacific Islander

6. White

77 I prefer not to answer

SX-13. To the best of your knowledge, what was [Partner 2]'s HIV status?

1. I know this person is HIV negative

2. I think this person is HIV negative

3. I don’t know this person’s HIV status

4. I think this person is HIV positive

5. I know this person is HIV positive

77 I prefer not to answer

SX-14. In the past 3 months, how many times did you and [Partner 2] have anal sex without using a condom or not using it the whole time?

___ ___ Number of times (0 to N)

77 I prefer not to answer

If SX-14 = 0 or “I prefer not to answer”, skip SX-15

SX-15. In the past 3 months, when you and [Partner 2] had anal sex without a condom were you the top (your penis in his butt), bottom (his penis in your butt) or both? (Check only one)

1. Both top and bottom

2. Top only

3. Bottom only

77 I prefer not to answer

Partner 3:

SX-16. What is/was your relationship with [Partner 3]?

1. Main Partner, Serious relationship, Boyfriend (Someone you feel committed to above all others)

2. Casually dating but not serious

3. Sleeping with but not dating

4. One night stand/ Stranger/Anonymous

77 I prefer not to answer

If SX-16 = 1,2 or 3, go to SX-17 else skip to SX-18.

SX-17. How long have you been with [Partner 3]?

1. Less than a month

2. 1 to 3 months

3. 4 to 6 months

4. 7 to 11 months

5. 1 to 3 years

6. Over 3 years

77 I prefer not to answer

SX-18. What is [Partner 3]’s race/ethnicity? Check all that apply.

1. American Indian or Alaska Native

2. Asian

3. Black or African American

4. Hispanic or Latino

5. Native Hawaiian or Other Pacific Islander

6. White

77 I prefer not to answer

SX-19. To the best of your knowledge, what was [Partner 3]'s HIV status?

1. I know this person is HIV negative

2. I think this person is HIV negative

3. I don’t know this person’s HIV status

4. I think this person is HIV positive

5. I know this person is HIV positive

77 I prefer not to answer

SX-20. In the past 3 months, how many times did you and [Partner 3] have anal sex without using a condom or not using it the whole time?

___ ___ Number of times (0 to N)

77 I prefer not to answer

If SX-20 = 0 or “I prefer not to answer”, skip SX-21

SX-21. In the past 3 months, when you and [Partner 3] had anal sex without a condom were you the top (your penis in his butt), bottom (his penis in your butt) or both? (Check only one)

1. Both top and bottom

2. Top only

3. Bottom only

77 I prefer not to answer

Partner 4:

SX-22. What is/was your relationship with [Partner 4]?

1. Main Partner, Serious relationship, Boyfriend (Someone you feel committed to above all others)

2. Casually dating but not serious

3. Having sex with but not dating

4. One night stand/ Anonymous

77 I prefer not to answer

If SX- 22= 1,2 or 3, go to SX- 23 else skip to SX-24.

SX-23. How long have you been with [Partner 4]?

1. Less than a month

2. 1 to 3 months

3. 4 to 6 months

4. 7 to 11 months

5. 1 to 3 years

6. Over 3 years

77 I prefer not to answer

SX-24. What is [Partner 4]’s race/ethnicity? Check all that apply.

1. American Indian or Alaska Native

2. Asian

3. Black or African American

4. Hispanic or Latino

5. Native Hawaiian or Other Pacific Islander

6. White

77 I prefer not to answer

SX-25. To the best of your knowledge, what was [Partner 4]'s HIV status?

1. I know this person is HIV negative

2. I think this person is HIV negative

3. I don’t know this person’s HIV status

4. I think this person is HIV positive

5. I know this person is HIV positive

77 I prefer not to answer

SX-26. In the past 3 months, how many times did you and [Partner 4] have anal sex without using a condom or not using it the whole time?

___ ___ Number of times (0 to N)

77 I prefer not to answer

If SX- 26= 0 or “I prefer not to answer”, skip SX- 27.

SX-27. In the past 3 months, when you and [Partner 4] had anal sex without a condom were you the top (your penis in his butt), bottom (his penis in your butt) or both? (Check only one)

1. Both top and bottom

2. Top only

3. Bottom only

77 I prefer not to answer

Questions for ≥ 5 male sex partners

The next questions are about the [(SX-2) – 4] men you had anal sex with in the past 3 months other than [insert nicknames from SX-3].

SX-28. With how many of these [(SX-2) – 4] men did you have anal sex without using a condom or not using it the whole time?

___ ___ Number of men (0 to N)

77 I prefer not to answer

Check to make sure SX-28 ≤ (SX-2) – 4.

If not, then display “The number of other men you had anal sex without using a condom cannot be more than the total number of men you had anal sex with in the past 3 months. Please carefully re-enter your response.”, and loop back to enter the number.

SX-29. In the past 3 months, how many of these [SX-28] men that you had anal sex without using a condom were:

HIV positive? ___ ___ Number of men (0 to N)

With how many were you the top only? ___ ___ Number of men (0 to N)

With how many were you the bottom only? ___ ___ Number of men only (0 to N)

With how many were you both (top and bottom)? ___ ___ Number of men (0 to N)

HIV negative? ___ ___ Number of men (0 to N)

With how many were you the top only? ___ ___ Number of men (0 to N)

With how many were you the bottom only? ___ ___ Number of men only (0 to N)

With how many were you both (top and bottom)? ___ ___ Number of men (0 to N)

Men whose HIV status you did not know? ___ ___ Number of men (0 to N)

With how many were you the top only? ___ ___ Number of men (0 to N)

With how many were you the bottom only? ___ ___ Number of men only (0 to N)

With how many were you both (top and bottom)? ___ ___ Number of men (0 to N)

77 I prefer not to answer

99 I don't know

Check to make sure that the numbers in SX-25 add up to the total N from SX-24.

If not, then display “The number of HIV positive, HIV negative and HIV status unknown partners must add up to [SX-28]. Please carefully re-enter your responses.”, and loop back to enter the numbers.

Section F. Baseline Partner Risk

For the following questions, think about the [SX-2] men you had anal sex with since [insert date from 3 months ago].

PR-1. How many of these [SX-2] men were:

1. Younger than [ES1 – 5]? ___ ___ (0 to N)

2. Older than [ES1 + 5]? ___ ___ (0 to N)

3. Within 5 years of your age? ___ ___ (0 to N)

77 I prefer not to answer

Check to make sure that the numbers in PR-1 add up to the total N from SX-2.

If not, then display “The number of younger men, older men and men within 5 years of your age must add up to [SX-2]. Please carefully re-enter your responses.”, and loop back to enter the numbers.

PR-2. Where did you first meet these [SX-2] men? Check all that apply.

1. Adult novelty store (sex shop)

2. Bar/dance club

3. Bathhouse, sex club, or gay resort

4. Circuit party or Rave

5. Gym

6. Park, outdoors or other public space

7. Private sex party

8. Public restroom

9. Social organization/community event (e.g., fundraiser, Pride parade, etc.)

10. Gay specific dating and hook-up site (Manhunt, Adam4Adam, Grindr, Scruff)

11. General dating and hook-up site (Craigslist, Match.com, OKCupid)

12. Social networking sites (e.g., Facebook, Google+, Twitter)

13. Other (Specify_________ )

77 I prefer not to answer

PR-3. In the past 3 months, did you give or receive things like money or drugs in exchange for sex?

1. No

2. Yes

77 I prefer not to answer

PR-4. In the past 3 months, did you have sex with someone who ever injected drugs other than those prescribed for them?

1. No

2. Yes

77 I prefer not to answer

99 I don't know

PR-5. In the past 3 months, did you have sex with someone who has other sex partners?

1. No

2. Yes

77 I prefer not to answer

99 I don't know

PR-6. In the past 3 months, before having sex with a new partner how often did you discuss each other’s HIV status?

1. Always

2. Usually

3. Sometimes

4. Rarely

5. Never

6. No new partners in the past 3 months

77 I prefer not to answer

PR-7. In the past 3 months, did you have anal sex with more than one man in the same encounter without using a condom or not using it the whole time?

1. No

2. Yes

77 I prefer not to answer

99 I don't know

If PR-7 = “Yes” continue to PR-8; else skip to PR-9.

PR-8. What is the HIV status of the men you had anal sex in the same encounter without using a condom or not using it the whole time? (Check all that apply)

1. Partners were negative

2. Partners were positive

3. Partners whose HIV status you don’t know

77 I prefer not to answer

PR-9. Below are a number of statements that some people have used to describe themselves. Please choose a number to show how well you believe that statement describes you.

Description	Not at all like me	Slightly like me	Mainly like me	Very Much like me
My sexual appetite has gotten in the way of my relationships.	1	2	3	4
My sexual thoughts and behaviors are causing problems in my life.	1	2	3	4
My desires to have sex have disrupted my daily life.	1	2	3	4
I sometimes fail to meet my commitments and responsibilities because of my sexual behaviors.	1	2	3	4
I sometimes get so horny I could lose control.	1	2	3	4
I find myself thinking about sex while at work.	1	2	3	4
I feel that sexual thoughts and feelings are stronger than I am.	1	2	3	4
I have to struggle to control my sexual thoughts and behavior.	1	2	3	4
I think about sex more than I would like to.	1	2	3	4
It has been difficult for me to find sex partners who desire having sex as much as I want to.	1	2	3	4

Obtain score by adding the items that have responses and divide by the number of items responded.

Section G. Substance Use

Alcohol Use (AL)

One drink is equivalent to a 12-ounce beer, a 5-ounce glass of wine, or a drink with one shot of liquor. Please note that a 40 ounce beer would count as 3 drinks, or a cocktail drink with 2 shots would count as 2 drinks Display images of alcohol drink size.

AL-1. During the past 30 days, have you had at least one drink of any alcoholic beverage such as beer, wine, a malt beverage or liquor?

1. No

2. Yes

77 I prefer not to answer

99 I don't know

AL-2. Considering all types of alcoholic beverages, how many times during the past 30 days did you have 5 or more drinks on an occasion?

_ _ Number of times

8 8 None

77 I prefer not to answer

99 I don't know

AL-3. During the past 30 days, what is the largest number of drinks you had on any occasion?

__ __Number of drinks

77 I prefer not to answer

99 I don't know

Injection Drug Use (ID)

The next questions are about injection drug use. This means injecting drugs yourself or having someone who isn't a health care provider inject you. Please remember that your answers will remain private.

ID-1. Have you ever injected or shot up any drugs other than those prescribed for you? By shooting up, we mean using drugs with a needle, either by mainlining, skin popping, or muscling.

1. No

2. Yes

77 I prefer not to answer

99 I don't know

If ID-1 ≠ “Yes”, skip to ND-1.

ID-2. In the past 3 months, did you inject or shoot up any drugs other than those prescribed for you?

1. No

2. Yes

77 I prefer not to answer

ID-3. In the past 3 months, how often did you use needles or syringes that someone else had already used?

1. Never

2. Rarely

3. About half the time

4. Most of the time

5. Always

77 I prefer not to answer

ID-4. In the past 3 months, which of the following substances (drugs) did you inject? Check all that apply.

1. Speedball – Heroin and cocaine together

2. Heroin, by itself

3. Cocaine, by itself

4. Crack cocaine

5. Methamphetamine , also known as meth, crystal meth, tina, speed

6. Steroids

7. Other (Specify________________)

77 I prefer not to answer

Non-Injection Drug Use (ND)

The following questions are about times when you may have used drugs but did not inject them. This includes smoking, snorting, inhaling or ingesting drugs such as marijuana, methamphetamine, cocaine, crack, club drunks, painkillers, or poppers.

ND-1. In the past 3 months, have you used any drugs in ways other than injecting?

1. No

2. Yes

77 I prefer not to answer

99 I don't know

If ND-1 ≠ “Yes”, skip to next section

ND-2. In the past 3 months, which of the following drugs did you use in ways other than injecting? Check all that apply.

1. Marijuana

2. Heroin

3. Powdered cocaine

4. Crack cocaine

5. Poppers (amyl nitrite)

6. X or Ectasy

7. Painkillers such as Oxycontin, Vicodin, or Percocet

8. Downers such as Valium, Ativan, or Xanax

9. Methamphetamine (meth, crystal meth,tina, speed, or ice)

10. Hallucinogens such as LSD or mushroom

11. Special K (ketamine)

12. GHB

13. Bath Salts

14. Viagra, Levitra or Cialis

15. Other drug

77 I prefer not to answer

99 I don't know

ND-3. In the past 3 months, have you used Viagra, Levitra or Cialis in combination with other drugs, such as Methamphetamine?

1. No

2. Yes

77 I prefer not to answer

99 I don't know

Section H. Token of Appreciation Information

Thank you for completing the survey! We will now ask you some questions about how you would like to receive $20 for completing this survey.

PI-1. How would you like to receive your $20? Choose only one method.

Token of appreciation through PayPal (requires a bank account)

Amazon.com electronic card (will be sent by email)

I do not wish to claim my $20

If PI-1 = “Token of appreciation through PayPal”, then go to PI-2.

If PI-1 = “Amazon.com electronic card”, then go to PI-4.

If PI-1 = “I do not wish to claim my $20” then go to Section H.

Receiving a token of appreciation by PayPal requires that you have a bank account. You will NOT be required to provide information about your bank account to this survey, only to PayPal. If you do not have a bank account, please return to the previous question and select another option.

We will send your PayPal token of appreciation to the email address you provided during registration, unless you prefer for us to use another email address.

PI-2. Do you want us to use the email address [insert email address from QS1] to send your PayPal token of appreciation?

Yes

No

If PI-2 = “No”, then go to PI-3 else skip to Section H.

PI-3. Please enter the new email address where you would like us to send your PayPal token of appreciation. ____________________

We will send your electronic gift card to the email address you provided during registration, unless you prefer for us to use another email address.

PI-4. Do you want us to use the email address [insert email address from QS1] to send your electronic gift card?

Yes

No

If PI-4 = “No”, then go to PI-5 else skip to Section H.

PI-5. Please enter the new email address where you would like us to send your electronic gift card. ____________________

End 1.

Thank you for participating in this health study. We will now be sending you a free package containing 4 HIV rapid test kits - 2 oral fluid tests and 2 blood finger-stick tests. You may distribute these free kits to your friends or sex partners so that they can test themselves privately and learn their HIV status. Later, you will have the option of ordering additional test kits free of cost.

Each of these kits contains written instructions on how to perform HIV testing at home. Your friends or sex partners can also watch videos (available on the study website) demonstrating how to conduct these tests. They have the option of calling a toll-free phone number if they have any questions or wish to talk to a trained counselor. After taking the test they can enter the number printed on the kit into the study website and report their results.

If you like, during the study we can send you updates once we send your package. You may then track the status of your shipment online.

RP-1. Would you like to receive updates informing you that we have shipped your package?

Yes

No

If RP-1 = “No”, then skip to RP-3.

RP-2. How would you like to receive updates informing you that we have shipped your package?

Email me at [insert email address from QS1]

Send me a text message at [insert telephone number from QS3]

We will be sending you an email at 3 months and 6 months with a link to take a short follow-up survey. Before beginning each survey, you will be asked to enter your login and password that you created at the beginning of this survey. Therefore, you may wish to write down your login and password in a safe place to help you remember them later.

Each follow-up survey will take about 10 minutes to complete, and you will receive $10 for each survey that you complete. In total, you will receive 2 online follow-up surveys over the course of the next 6 months. You will receive your first follow-up survey in 3 months.

To make sure that we send the follow-up survey emails at a time that is convenient for you, we would like to know when you prefer to receive these emails.

RP-3. What day of the week would you prefer to receive the follow-up survey email?

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

RP-4. What time of the day would you prefer to receive the follow-up survey email on [insert day from RP-3]?

Morning (8:00am – 12:00pm)

Afternoon (12:00pm – 4:00pm)

Evening (4:00pm – 8:00pm)

Night (8:00pm – 12:00am)

If you do not complete the follow-up survey within 5 days, we will send you a reminder email to complete the survey. If you do not complete the survey after we have sent a total of 3 reminder emails, we will be contacting you using an alternate method.

RP-5. How would you like us to remind you to take the follow-up survey if you have not responded to the reminder emails? Please rank the two options below. Enter “1” for your first preference and “2” for your second preference.

[ ] Call my phone number at [insert telephone number from QS2]

[ ] Send me a text message at [insert telephone number from QS3]

Thank you for taking our survey! Your response is very important to us. 

Your token of appreciation or gift card will be sent to you by email at the address you indicated earlier. If you have not received your token of appreciation within 10 days, please first check your spam filter/junk email folder, and then email us at X@X.  Please send this email from the email address you provided during registration i.e. [insert email address from QS1].

To find an HIV testing location near you, please visit: www.aidsvu.org

To get more information about HIV, please visit: www.cdc.gov/hiv

Otherwise, you can close your browser window. Thank you for your time.

AUTO3. Time Ended HIV positive group Baseline Survey: __ __:__ __: __ __ [24 Hour time HH:MM:SS]