Form Approved
OMB No. 0920-XXXX
Expiration Date: XX/XX/XXXX
Evaluation of Rapid HIV Home-Testing among MSM Trial
Attachment 3c
Baseline Survey—Intervention and Comparison Arms
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 – Intervention and Comparison Arms
AUTO1. Date of Baseline Survey: __ __ / __ __ / __ __ __ __
(M M / D D / Y Y Y Y)
AUTO2. Time Began 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 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?
Less than high school
Some high school
High school diploma or GED
Some college, Associate’s degree, or Technical degree
College graduate
Post graduate or professional school
77 I prefer not to answer
DM-2. What best describes your current employment status? Choose only one.
Employed full time
Employed part time
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?
0 to $1667 per month
$1668 to $3333 per month
$3334 to $6250 per month
$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?
0 to $19,999 per year
$20,000 to $39,999 per year
$40,000 to $74,999 per year
$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?
Homosexual or Gay or Same gender loving
Heterosexual or Straight
Bisexual
Other (Specify _____)
77 I prefer not to answer
DM-6. Do you currently have health insurance?
No
Yes – Through my job
Yes – Through someone else’s job
Yes – Paid for by me or another person
Yes – Medicare/Medicaid
77 I prefer not to answer
Section B. HIV Testing Behavior
If ES-9 = “No”, go to HT-1 else skip to HT-3.
HT-1. What are the reasons you have never been tested for HIV? Check all that apply.
I think I’m at low risk for HIV infection
I am afraid to find out I have HIV
I don’t have time
I don’t know where to go for a test
I don’t have enough money or insurance for a test
I don’t want my friends and family to know that I got tested
I don’t want my sex partners to know that I got tested
If I test positive I won’t be able to get treatment
I don’t believe that treatment is effective
If I test positive I will be rejected by my friends and family
I do not want my result to be reported to the government
Other reason (Specify___________)
77 I prefer not to answer
HT-2. Of the reasons you picked, what is the main reason you have never been tested for HIV? Choose only one.
Display response options based on selections in HT-1
If ES-9 = “No”, skip to next section.
HT-3. When did you have your most recent HIV test?
__ __ / __ __ __ __ [MM/YYYY]
77 I prefer not to answer
If YYYY < “1985”, display “HIV testing was not widely available before 1985. Please re-enter the correct year.” and loop back to put in the correct year.
If date in HT-3 is within the past 12 months, skip to HT-6
HT-4. What are the reasons you have not been tested for HIV in the past 12 months? Check all that apply.
I think I’m at low risk for HIV infection
I am afraid to find out I have HIV
I don’t have time
I don’t know where to go for a test
I don’t have enough money or insurance for a test
I don’t want my friends and family to know that I got tested
I don’t want my sex partners to know that I got tested
If I test positive I won’t be able to get treatment
I don’t believe that treatment is effective
If I test positive I will be rejected by my friends and family
I do not want my result to be reported to the government
Other reason (Specify___________)
77 I prefer not to answer
HT-5. Of the reasons you picked, what is the main reason you have not been tested for HIV in the past 12 months? Choose only one.
Display response options based on selections in HT-4.
If date in HT-3 is NOT within the past 12 months, skip to HT-7.
HT-6. In the past 12 months, that is, since [insert calculated month and year], how many times have you been tested for HIV?
Provide drop down box with all values, separate boxes with limited range.
___ ___ Number of times (0 to N)
77 I prefer not to answer
HT-7. Where did you get your most recent HIV test [insert date from HT-3]? Choose only one.
Private doctor’s office
HIV counseling and testing site
Public health clinic / Community health clinic
Street outreach program / Mobile unit
Sexually transmitted disease clinic
Emergency room
Hospital (inpatient)
Correctional facility (jail or prison)
Home or other private location
Other location (Specify___________)
77 I prefer not to answer
Section C: Awareness of Home HIV Tests
A home HIV test can be used to test yourself in the privacy of your home or other private location.
OT-1. Have you ever heard about home HIV tests?
No
Yes
77 I prefer not to answer
If OT-1= “No” skip to next section D.
OT-2. In the past 12 months, have you used a home HIV test?
No
Yes
77 I prefer not to answer
If OT-2 = “Yes”, go to OT-3. Else skip to next section D.
OT-3. In the past 12 months, which home HIV tests have you used? Check all that apply.
Display images of HomeAccess and OraQuick with these response options.
HomeAccess® HIV-1 Test System (where you prick yourself and collect a blood sample on a card that you mail to a lab for testing)
OraQuick® In-Home HIV Test (where you collect your own oral fluid sample, use the testing device yourself and read the results in approximately 20 minutes)
Other rapid HIV test (Specify___________)
77 I prefer not to answer
OT-4. In the past 12 months, how many times have you used a home HIV test?
Provide drop down box with all values, separate boxes with limited range.
___ ___ Number of times
77 I prefer not to answer
OT-5. Where did you get the home HIV test(s)? Check all that apply.
Bought online
From a pharmacy
From a friend
From a sex partner
From a family member
From my doctor’s office
From an HIV counseling and testing site
From a Health Department
From another research study
Other location or person (Specify (not someone’s name) ___________)
77 I prefer not to answer
OT-6. In the past 12 months, why did you use the home HIV test(s)? (Check all that apply)
It was more convenient than getting tested by a doctor or at an HIV testing site
It was more private than getting tested by a doctor or at an HIV testing site
I didn’t want other people to know I am testing
To test together with someone, before having sex
To test myself, before having sex
To test myself, after having sex
A sex partner asked me to take a home HIV test
Other reason
77 I prefer not to answer
Section D. 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:
Only men
Only women
Both men and women
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.
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:
HIV positive? ___ ___ Number of women (0 to N)
HIV negative? ___ ___ Number of women (0 to N)
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
Partner 1 __________
Partner 2 __________
Partner 3 __________
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]?
Main Partner, Serious relationship, Boyfriend (Someone you feel committed to above all others)
Casually dating but not serious
Having sex with but not dating
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]?
Less than a month
1 to 3 months
4 to 6 months
7 to 11 months
1 to 3 years
Over 3 years
77 I prefer not to answer
SX-6. What is [Partner 1]’s race/ethnicity? Check all that apply.
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
SX-7. To the best of your knowledge, what was [Partner 1]'s HIV status?
I know this person is HIV negative
I think this person is HIV negative
I don’t know this person’s HIV status
I think this person is HIV positive
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)
Both top and bottom
Top only
Bottom only
77 I prefer not to answer
Partner 2:
SX-10. What is/was your relationship with [Partner 2]?
Main Partner, Serious relationship, Boyfriend (Someone you feel committed to above all others)
Casually dating but not serious
Having sex with but not dating
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]?
Less than a month
1 to 3 months
4 to 6 months
7 to 11 months
1 to 3 years
Over 3 years
77 I prefer not to answer
SX-12. What is [Partner 2]’s race/ethnicity? Check all that apply.
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
77 I prefer not to answer
SX-13. To the best of your knowledge, what was [Partner 2]'s HIV status?
I know this person is HIV negative
I think this person is HIV negative
I don’t know this person’s HIV status
I think this person is HIV positive
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)
Both top and bottom
Top only
Bottom only
77 I prefer not to answer
Partner 3:
SX-16. What is/was your relationship with [Partner 3]?
Main Partner, Serious relationship, Boyfriend (Someone you feel committed to above all others)
Casually dating but not serious
Sleeping with but not dating
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]?
Less than a month
1 to 3 months
4 to 6 months
7 to 11 months
1 to 3 years
Over 3 years
77 I prefer not to answer
SX-18. What is [Partner 3]’s race/ethnicity? Check all that apply.
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
77 I prefer not to answer
SX-19. To the best of your knowledge, what was [Partner 3]'s HIV status?
I know this person is HIV negative
I think this person is HIV negative
I don’t know this person’s HIV status
I think this person is HIV positive
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)
Both top and bottom
Top only
Bottom only
77 I prefer not to answer
Partner 4:
SX-22. What is/was your relationship with [Partner 4]?
Main Partner, Serious relationship, Boyfriend (Someone you feel committed to above all others)
Casually dating but not serious
Having sex with but not dating
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]?
Less than a month
1 to 3 months
4 to 6 months
7 to 11 months
1 to 3 years
Over 3 years
77 I prefer not to answer
SX-24. What is [Partner 4]’s race/ethnicity? Check all that apply.
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
77 I prefer not to answer
SX-25. To the best of your knowledge, what was [Partner 4]'s HIV status?
I know this person is HIV negative
I think this person is HIV negative
I don’t know this person’s HIV status
I think this person is HIV positive
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)
Both top and bottom
Top only
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 E. 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:
Younger than [ES1 – 5]? ___ ___ (0 to N)
Older than [ES1 + 5]? ___ ___ (0 to N)
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.
Adult novelty store (sex shop)
Bar/dance club
Bathhouse, sex club, or gay resort
Circuit party or Rave
Gym
Park, outdoors or other public space
Private sex party
Public restroom
Social organization/community event (e.g., fundraiser, Pride parade, etc.)
Gay specific dating and hook-up site (Manhunt, Adam4Adam, Grindr, Scruff)
General dating and hook-up site (Craigslist, Match.com, OKCupid)
Social networking sites (e.g., Facebook, Google+, Twitter)
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?
No
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?
No
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?
No
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?
Always
Usually
Sometimes
Rarely
Never
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?
No
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)
Partners were negative
Partners were positive
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 F. 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?
No
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
88 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.
No
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?
No
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?
Never
Rarely
About half the time
Most of the time
Always
77 I prefer not to answer
ID-3. In the past 3 months, which of the following substances (drugs) did you inject? Check all that apply.
Speedball – Heroin and cocaine together
Heroin, by itself
Cocaine, by itself
Crack cocaine
Methamphetamine , also known as meth, crystal meth, tina, speed
Steroids
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?
No
Yes
77 I prefer not to answer
99 I don't know
If ND-1 ≠ “Yes”, skip to ND-3.
ND-2. In the past 3 months, which of the following drugs did you use in ways other than injecting? Check all that apply.
Marijuana
Heroin
Powdered cocaine
Crack cocaine
Poppers (amyl nitrite)
X or Ectasy
Painkillers such as Oxycontin, Vicodin, or Percocet
Downers such as Valium, Ativan, or Xanax
Methamphetamine (meth, crystal meth,tina, speed, or ice)
Hallucinogens such as LSD or mushroom
Special K (ketamine)
GHB
Bath Salts
Viagra, Levitra or Cialis
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?
No
Yes
77 I prefer not to answer
99 I don't know
Section H. Randomization and Reminder Preferences
All participants finishing the baseline survey will be entered in the “Negative Group” and at this point will proceed to randomization into “Intervention Arm” or “Comparison Arm”.
If participant is randomized to “Intervention Arm”, then go to End 2.
If participant is randomized to “Comparison Arm”, then go to End 3.
End 2. If the participant is in the “Intervention Arm”:
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 use these kits to test yourself at home or any other private location. You may also give these 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 test yourself at home. You and your friends or sex partners can also watch videos (available on the study website) demonstrating how to conduct these tests. As part of this study, anyone using these kits has the option of calling a toll-free phone number with questions or to talk to a trained counselor. You can use your login and password that you created at the beginning of this survey to report your test results on the study website. Your friends or sex partners can also use the study website to report their results.
If you like, we can send you updates once we ship 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]
During the study we may call you to talk about your HIV testing practices and home-test results.
RP-3. What day of the week would you prefer that we call you on [insert telephone number from QS2]?
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
RP-4. What time of the day would you prefer that we call you on [insert telephone number from QS2]?
Morning (8:00am – 12:00pm)
Afternoon (12:00pm – 4:00pm)
Evening (4:00pm – 8:00pm)
Night (8:00pm – 12:00am)
We will be sending you an email at 3 months, 6 months, 9 months and 12 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 15 minutes to complete, and you will receive $10 for each survey that you complete. In total, you will receive 4 online follow-up surveys over the course of the next year. 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-5. What day of the week would you prefer to receive the follow-up survey email?
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
RP-6. What time of the day would you prefer to receive the follow-up survey email on [insert day from RP-5]?
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-7. 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]
Your last follow-up survey will be in 12 months. At that time we will also send you a package containing a dried blood spot (DBS) collection kit, an oral fluid home HIV test, and a blood finger-stick home HIV test. You will collect a few drops of blood by pricking your finger and return the DBS specimen in a pre-paid shipping envelope. Once we receive your specimen and the results of your rapid tests, we will send you $20 or a gift card through a method of your choice.
If you do not report your HIV home-test results within 3 weeks after we send you the package, we can remind you to report your results.
RP-8a. How would you like us to remind you about reporting your HIV home-test results? Please rank the three options below. Enter “1” for your first preference, “2” for your second preference and “3” for your third preference.
[ ] Email me at [insert email address from QS1]
[ ] Call my phone number at [insert telephone number from QS2]
[ ] Send me a text message at [insert telephone number from QS3]
If we do not receive your blood specimen within 3 weeks after we send you the DBS collection kit, we can remind you to send in your specimen.
RP-8b. How would you like us to remind you to send in your DBS? Please rank the three options below. Enter “1” for your first preference, “2” for your second preference and “3” for your third preference.
[ ] Email me at [insert email address from QS1]
[ ] 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 $20 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 $20 or gift card 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.
End 3. If the participant is in the “Comparison Arm”:
Thank you for participating in this health study. We encourage you to find an HIV testing location near you and get tested. To find an HIV testing location near you, please visit: www.aidsvu.org
During the study we may call you to talk about your HIV testing practices and test results.
RP-9. What day of the week would you prefer that we call you on [insert telephone number from QS2]?
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
RP-10. What time of the day would you prefer that we call you on [insert telephone number from QS2]?
Morning (8:00am – 12:00pm)
Afternoon (12:00pm – 4:00pm)
Evening (4:00pm – 8:00pm)
Night (8:00pm – 12:00am)
We will be sending you an email at 3 months, 6 months, 9 months and 12 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 15 minutes to complete, and you will receive $10 as a token of appreciation for each survey that you complete. In total, you will receive 4 online follow-up surveys over the course of the next year. 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-11. What day of the week would you prefer to receive the follow-up survey email?
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
RP-12. What time of the day would you prefer to receive the follow-up survey email on [insert day from RP-11]?
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-13. 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.
[ ] Call my phone number at [insert telephone number from QS2]
[ ] Send me a text message at [insert telephone number from QS3]
Your last follow-up survey will be in 12 months. At that time we will also send you a package containing a dried blood spot (DBS) collection kit, an oral fluid home HIV test, and a blood finger-stick home HIV test. You will collect a few drops of blood by pricking your finger and return the DBS specimen in a pre-paid shipping envelope. Once we receive your specimen and the results of your rapid tests, we will send you $20 as a token of appreciation or a gift card through a method of your choice.
We also request that you test yourself at home or any other private location using the oral fluid test and the blood finger-stick test. Each of these kits contains written instructions on how to perform home-testing at home. You can also watch videos (available on the study website) demonstrating how to conduct these tests. As part of this study, anyone using these kits has the option of calling a toll-free phone number with questions or to talk to a trained counselor. After taking the tests you can use your login and password that you created at the beginning of this survey to report your results on the study website.
If you like, we can send you an update once we ship your package. You may then track the status of your shipment online.
RP-14. Would you like to receive an update informing you that we have shipped your package?
Yes
No
If RP-14 = “No”, then skip to RP-16.
RP-15. How would you like to receive an update 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]
If you do not report your HIV home-test results within 3 weeks after we send you the package, we can remind you to report your results.
RP-16. How would you like us to remind you about reporting your HIV home-test results? Please rank the three options below. Enter “1” for your first preference, “2” for your second preference and “3” for your third preference.
[ ] Email me at [insert email address from QS1]
[ ] Call my phone number at [insert telephone number from QS2]
[ ] Send me a text message at [insert telephone number from QS3]
If we do not receive your blood specimen within 3 weeks after we send you the DBS collection kit, we can remind you to send in your specimen.
RP-17. How would you like us to remind you to send in your DBS? Please rank the three options below. Enter “1” for your first preference, “2” for your second preference and “3” for your third preference.
[ ] Email me at [insert email address from QS1]
[ ] 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 $20 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 $20 or gift card 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 Baseline Survey: __ __:__ __: __ __ [24 Hour time HH:MM:SS]
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 as a token of appreciation 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. ____________________
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Freeman, Arin (CDC/OID/NCHHSTP) |
File Modified | 0000-00-00 |
File Created | 2021-01-27 |