Form Approved
OMB No. 0920-xxxx
Exp. Date xx/xx/XXXX
GAIN Baseline Data Variables
*Time will be reported in days
Public reporting burden of this collection of information is estimated to average 4 hours 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-New)
Gay City PrEP Clients
Sex assigned at birth
Gender
Race
Ethnicity
Time from first contact to first PrEP visit
Time from first contact to first screening appointment
Time from first contact to first PrEP visit
Time from first contact to PrEP entry visit
HIV status at first visit
Time from first PrEP visit to HIV testing (linked to #9, expect this to be the same value as #7)
Source of HIV test from #9
Whether PrEP was prescribed at the first visit
Time from first PrEP visit to date PrEP was prescribed
Time from first PrEP visit to self-reported date PrEP was started
Time from first PrEP visit to date of connection to main health care provider
Time from first PrEP visit to Month 1 Visit
HIV status at Month 1
Whether connection to main health care provider was established at Month 1
Time from first PrEP visit to Month 3 Visit
HIV status at Month 3
Whether connection to main health care provider was established at Month 3
Time from first PrEP visit to Month 6 Visit
HIV status at Month 6
Whether connection to main health care provider was established at Month 6
Whether this is an instaPrEP client (from Sarah’s records)
Client status (i.e., lost to follow-up, graduated to PCP, Active, PrEP re-start)
Time from first PrEP visit to Week 1 follow-up call
Was Week 1 follow-up call successful?
Time from first PrEP visit to Month 1 follow-up call
Was Month 1 follow-up call successful?
Time from first PrEP visit to Month 3 follow-up call
Was Month 3 follow-up call successful?
Time from first PrEP visit to Month 6 follow-up call
Was Month 6 follow-up call successful?
Gay City Clients Newly Diagnosed with HIV
Time from first positive/reactive test to Month 1 phone call
Whether or not a rapid HIV test was ordered
Result of rapid test
Whether or not a laboratory test was ordered
Result of laboratory test
Whether client was referred to HIV care
Time from first positive/reactive test to date of first HIV care referral
Did client attend HIV care visit? Asked 1 week, 2 weeks, then 1 month after first reactive
Time from first positive/reactive to self-reported ART start date
Does participant know if they are virally suppressed (self-reported) at Month 1
Virally suppressed (self-reported) at Month 1?
Time from first positive/reactive to self-reported date of last viral load test at Month 1.
Does participant know if they are virally suppressed (self-reported) at Month 3
Virally suppressed (self-reported) at Month 3?
Time from first positive/reactive to self-reported date of last viral load test at Month 3.
Does participant know if they are virally suppressed (self-reported) at Month 6
Virally suppressed (self-reported) at Month 6?
Time from first positive/reactive to self-reported date of last viral load test at Month 6.
Gay City Clients Living with HIV (established)
Confirmed HIV+ status
Whether client has HIV care provider
Whether client is currently on ART
Whether client is undetectable (self-reported)
Time from first positive/reactive to self-reported ART start date
Does participant know if they are virally suppressed (self-reported) at Month 1
Virally suppressed (self-reported) at Month 1?
Time from first positive/reactive to self-reported date of last viral load test at Month 1.
Does participant know if they are virally suppressed (self-reported) at Month 3
Virally suppressed (self-reported) at Month 3?
Time from first positive/reactive to self-reported date of last viral load test at Month 3.
Does participant know if they are virally suppressed (self-reported) at Month 6
Virally suppressed (self-reported) at Month 6?
Time from first positive/reactive to self-reported date of last viral load test at Month 6.
Gay City Clients
Was a syphilis RPR done?
Syphilis RPR result
New or old infection
RPR titer
GC rectal done
CT rectal done
GC rectal result
CT rectal result
GC throat done
CT throat done
GC throat result
CT throat result
GC vaginal done
CT vaginal done
GC vaginal result
CT vaginal result
GC urine done
CT urine done
GC urine result
CT urine result
Sex at birth
Gender
Shifted visit date (randomly shifted)
Calculated age at visit
Race
Ethnicity
Insurance status
Madison Clinic Patients
Shifted visit date
Time from first visit (Those with first positive, those with any detectable viral loads (200 copies/mL), PEP episodes (need to filter out women), HIV testing, anyone with PrEP visits) in time period to first prescription ordered
Time from first prescription ordered to prescription refill
Duration/refill amount of any medications for PrEP, ART, or PEP
Time from first visit to the collection date for any HIV POC or rapid test
Time from first visit to the collection date for any HIV-1 RNA/viral load test
Time from first visit to the collection date for any DNA/TNA results
Time from first visit to the collection date for any HIV EIA (4th gen) results including supplemental testing
For HIV-negative patients only:
CT or GC PCR/NAT result (three sites)
Time from first visit to collection date
CT or GC collection site
Syphilis EIA or RPR results
RPR titer
Insurance status
Sex based on license/ID
Gender (still figuring out whether this will include looking at prescription hormones and/or diagnosis codes since this is not properly recorded in EPIC)
Calculated age at visit
Race
Ethnicity
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Lauren R. Violette |
File Modified | 0000-00-00 |
File Created | 2021-06-29 |