Form Approved
OMB No: 0920-1169
Exp. Date: 03/31/2020
Development of CDC’s Let’s Stop HIV Together Social Marketing Campaign for Consumers
Attachment 3q: HIV Prevention
Brief Survey Instrument
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 (0920-1169).
Attachment 3q: HIV Prevention
Brief Survey Instrument
CASE ID_____________
PARTICIPANT SURVEY
We are interested in your opinions about HIV prevention. We would also like to get some additional information about you. If you’re not sure, choose an answer that comes closest to what you think might be true for each question. Please remember that your answers are private. You can choose not to answer any question and can stop at any time. When you are finished with the survey, please place it in the envelope.
BACKGROUND INFORMATION
Before being contacted for this study, had you ever heard of CDC or the Centers for Disease Control and Prevention?
1 Yes
2 No
88 Don’t know
99 Prefer not to answer
What is your current gender identity? (Select ALL that apply)
1 Male
2 Female
3 Transgender Male/Transman/FTM
4 Transgender Female/Transwoman/MTF
5 Genderqueer
6 Another category [Specify: ]
9 Prefer not to answer [TERMINATE AND GO TO CLOSING]
What sex were you assigned at birth? (Select one)
1 Male
2 Female
99 Prefer not to answer [TERMINATE AND GO TO CLOSING]
Which do you consider yourself to be?
1 Gay or homosexual
2 Bisexual
3 Straight or heterosexual
4 Queer
5 Pansexual
6 Another category [Specify: ________________________________________]
88 None of the above/Unsure [TERMINATE AND GO TO CLOSING]
99 Prefer not to answer [TERMINATE AND GO TO CLOSING]
Are you of Hispanic or Latino origin?
1 Yes
2 No
99 Prefer not to answer [TERMINATE AND GO TO CLOSING]
Please indicate your race. Are you? You may select one or more races.
1 White
2 Black or African American
3 Asian
4 Native Hawaiian or Other Pacific Islander
5 American Indian or Alaskan Native
99 Prefer not to answer [TERMINATE AND GO TO CLOSING]
Have you ever been tested for HIV? An HIV test checks whether someone has the virus that causes AIDS.
1 Yes
2 No
3 Don’t know [TERMINATE AND GO TO CLOSING]
9 Prefer not to answer [TERMINATE AND GO TO CLOSING]
8. The next question is about the result of your HIV test. What was the result of your most recent HIV test?
1 I tested positive for HIV.
2 I tested negative for HIV.
3 My results were unclear.
8 I never got my results/Don’t know
9 Prefer not to answer [TERMINATE AND GO TO CLOSING]
These next few questions are about your personal behaviors, including sexual activity. Please remember that your answers are kept private.
Did you have [oral/vaginal/anal sex] with any of your partner(s) in the past [INSERT #] months?
1 Yes
2 No
8 8 Don’t know
99 Prefer not to answer
When you had [oral/vaginal/anal] sex with your [female/male] partner(s) in the past [INSERT #] months, how often did you and your partner use a condom?
1 Never used a condom
2 Occasionally used a condom
3 Usually used a condom
4 Always used a condom
88 Don’t know
99 Prefer not to answer
In the past [INSERT #] months, did you ever, even one time, have sex without a condom?
1 Yes
2 No
88 Don’t know
99 Prefer not to answer
Behaviors with Main Sexual Partner
Do you currently have a main sexual partner—that is, a partner you would call your spouse, girlfriend/boyfriend, significant other, or life partner?
1 Yes
2 No [GO TO Q19]
88 Don’t know
99 Prefer not to answer
Is your main partner male, female, or transgender?
1 Male
2 Female
3 Transgender Male/Transman/FTM
4 Transgender Female/Transwoman/MTF
5 Another category [Specify: ________________________________________]
88 Don’t know
99 Prefer not to answer
What is your main partner’s HIV status?
1 My main partner is HIV negative
2 My main partner is HIV positive
3 My main partner has not been tested for HIV [GO TO Q16]
88 Don’t know/my main partner has not told me their HIV status [GO TO Q16]
99 Prefer not to answer [GO TO Q16]
How do you know your main partner’s HIV status? Mark all that apply.
1 My partner told me explicitly
2 I guess based on other things my partner talked about
3 Someone else told me
4 By my partner’s appearance
5 We got tested together [ERROR CHECK: Q14≠3]
6 Saw my partner’s results [ERROR CHECK: Q14≠3 OR Q14≠88]
7 I went with my partner to get their results [ERROR CHECK: Q14≠3]
8 Other [Specify: ______________________________________________________]
8 8 Don’t know
99 Prefer not to answer
Does your main partner know your HIV status?
1 Yes
2 No
88 Don’t know
99 Prefer not to answer
[IF Q14=2, GO TO Q18]
Thinking about your main [female/male] sexual partner, do you consider [him/her] to be at low, medium, or high risk for getting HIV?
1 Low risk
2 Medium risk
3 High risk
88 Don’t know
99 Prefer not to answer
Some couples develop agreements about whether, when, and with whom sex outside the relationship is okay. Which one of the following scenarios best describes any agreements that you and your main partner have?
1 Both of us cannot have any sex with an outside partner
2 We can have sex with outside partners but with some restrictions
3 We can have sex with outside partners without any restrictions
4 We do not have an agreement
88 Don’t know
99 Prefer not to answer
Behaviors with [Casual/Non-Main] Sexual Partners
In the past [INSERT #] months, how many [casual/non-main] sexual partners – that is, somebody who you did not consider to be a spouse, girlfriend/boyfriend, significant other, or life partner – did you have oral, vaginal, or anal sex with?
1 0 [GO TO Q31]
2 1-5
3 6-10
4 11-15
5 16-20
6 Over 20
88 Don’t know
99 Prefer not to answer
In the past [INSERT #] months, how many of your [casual/non-main] partners told you their HIV status? [ERROR CHECK SHOULD NOT BE GREATER THAN #19]
1 0
2 1-5
3 6-10
4 11-15
5 16-20
6 Over 20
88 Don’t know
99 Prefer not to answer
In the past [INSERT #] months, how many of your [casual/non-main] partners did you tell your HIV status to?
1 0
2 1-5
3 6-10
4 11-15
5 16-20
6 Over 20
88 Don’t know
99 Prefer not to answer
How often did you and your last [casual/non-main] [female/male] sexual partner use condoms for anal sex?
1 Never
2 Occasionally
3 Usually
4 Always
8 8 Don’t know
99 Prefer not to answer
What is your last [casual/non-main] [female/male] sexual partner’s HIV status?
1 My last casual partner is HIV negative
2 My last casual partner is HIV positive
3 My last casual partner has not been tested for HIV [GO TO Q25]
88 Don’t know/my last [casual/non-main] partner has not told me their HIV status [GO TO Q25]
99 Prefer not to answer [GO TO Q25]
Why did you think that they were this status? Mark all that apply.
1 They told me explicitly
2 I guessed based on other things they talked about
3 Someone else told me
4 By their appearance
5 We got tested together
6 I saw their results
7 I went with them to get his results
8 Other [Specify: __________________________________________________]
8 8 Don’t know
99 Prefer not to answer
[IF Q23=2, GO TO Q26]
Thinking about your last [casual/non-main] [female/male] sexual partner, do you consider them to be at low, medium or high risk for getting HIV?
1 Low risk
2 Medium risk
3 High risk
8 8 Don’t know
99 Prefer not to answer
Did you have [vaginal/anal/oral] sex without a condom with any of your [casual/non-main] partners in the past [INSERT #] months whose HIV status you didn’t know?
1 Yes
2 No
88 Don’t know
99 Prefer not to answer
Did you have [vaginal/anal/oral] sex without a condom with any [casual/non-main] [female/male] partners in the past [INSERT #] months who you knew or thought to be HIV positive?
1 Yes
2 No
8 8 Don’t know
99 Prefer not to answer
In the past [INSERT #] months, how often did you look for [female/male] sexual partners with the same HIV status as you?
1 Never
2 Occasionally
3 Usually
4 Always
8 8 Don’t know
99 Prefer not to answer
In the past [INSERT #] months, how often did use your HIV status and your [female/male] partner’s HIV status to determine which sexual roles (i.e., insertive/top or receptive/bottom) and activities (i.e., oral and anal sex) you would engage in?
1 Never
2 Occasionally
3 Usually
4 Always
8 8 Don’t know
99 Prefer not to answer
In the past [INSERT #] months, how often have you had anal sex without a condom with a [female/male] partner…
|
Never |
Occasionally |
Usually |
Always |
Don’t know |
Prefer not to answer |
|
1 |
2 |
3 |
4 |
88 |
99 |
|
1 |
2 |
3 |
4 |
88 |
99 |
RISK
Thinking about the sex you’ve had over the past [INSERT #] months, do you consider yourself to be high, medium or low risk for [(IF Q8≠1) getting/(IF Q8=1) transmitting] HIV?
1 Low risk
2 Medium risk
3 High risk
8 8 Don’t know
99 Prefer not to answer
Tell me how risky you think each behavior is for [(IF Q8≠1) getting/(IF Q8=1) transmitting] HIV. Use a scale where 0 is lowest risk and 100 is highest risk. Please assign any number in that range to each of the behaviors listed.
1 Deep kissing _____
2 Receptive anal sex (“bottom”) with a condom _____
3 Receptive anal sex (“bottom”) without a condom ______
4 Receptive oral sex (“giving a blow job”) with a condom _____
5 Receptive oral sex (“giving a blow job”) without a condom _____
6 Insertive anal sex (“top”) with a condom _____
7 Insertive anal sex (“top”) without a condom _____
8 Insertive oral sex (“getting a blow job”) with a condom _____
9 Insertive oral sex (“getting a blow job”) without a condom _____
10 Vaginal sex with a condom _____
11 Vaginal sex without a condom _____
99 Prefer not to answer
HIV PROTECTIVE BEHAVIORAL INTENTIONS
Do you plan to [INSERT HIV PREVENTION STRATEGY] [the next time you have sex/within the next [INSERT TIMEFRAME]?
1 Yes
2 No
8 8 Don’t know
99 Prefer not to answer
If your sexual partner does not want to [INSERT HIV PREVENTION STRATEGY], do you plan on insisting that the two of you [INSERT HIV PREVENTION STRATEGY]?
1 Yes
2 No
8 8 Don’t know
99 Prefer not to answer
The next time you have sex, do you plan on talking about [INSERT HIV PREVENTION STRATEGY] with your partner?
1 Yes
2 No
8 8 Don’t know
99 Prefer not to answer
How likely are you to [INSERT HIV PREVENTION STRATEGY] the next time you have sex to [INSERT BEHAVIOR]?
1 Very unlikely
2 Unlikely
3 Neither unlikely nor likely
4 Likely
5 Very likely
8 8 Don’t know
99 Prefer not to answer
Do you plan to talk to your health care provider about [INSERT HIV PREVENTION STRATEGY] at your next appointment?
1 Yes
2 No
8 8 Don’t know
99 Prefer not to answer
How likely are you to talk to your health care provider about [INSERT HIV PREVENTION STRATEGY] at your next appointment?
1 Very unlikely
2 Unlikely
3 Neither unlikely nor likely
4 Likely
5 Very likely
8 8 Don’t know
99 Prefer not to answer
HIV NORMS AND ATTITUDES
Listed below are a variety of thoughts that may pop into people’s heads when they are thinking about having [risky sex] with either a main or [casual/non-main] partner. Please tell us how often you have had these thoughts.
|
Never |
Rarely |
Sometimes |
Often |
Very Often |
Prefer not to answer |
|
1 |
2 |
3 |
4 |
5 |
99 |
|
1 |
2 |
3 |
4 |
5 |
99 |
|
1 |
2 |
3 |
4 |
5 |
99 |
|
1 |
2 |
3 |
4 |
5 |
99 |
|
1 |
2 |
3 |
4 |
5 |
99 |
|
1 |
2 |
3 |
4 |
5 |
99 |
|
1 |
2 |
3 |
4 |
5 |
99 |
|
1 |
2 |
3 |
4 |
5 |
99 |
|
1 |
2 |
3 |
4 |
5 |
99 |
|
1 |
2 |
3 |
4 |
5 |
99 |
|
1 |
2 |
3 |
4 |
5 |
99 |
|
1 |
2 |
3 |
4 |
5 |
99 |
|
1 |
2 |
3 |
4 |
5 |
99 |
Most of my friends …
|
Strongly agree |
Agree |
Neither agree nor disagree |
Disagree |
Strongly disagree |
Don’t know |
Prefer not to answer |
|
1 |
2 |
3 |
4 |
5 |
88 |
99 |
|
1 |
2 |
3 |
4 |
5 |
88 |
99 |
|
1 |
2 |
3 |
4 |
5 |
88 |
99 |
Please tell us how much you agree or disagree with the following statements:
|
Strongly Agree |
Agree |
Neither agree nor Disagree |
Disagree |
Strongly Disagree |
Don’t know |
Prefer not to answer |
|
1 |
2 |
3 |
4 |
5 |
88 |
99 |
|
1 |
2 |
3 |
4 |
5 |
88 |
99 |
|
1 |
2 |
3 |
4 |
5 |
88 |
99 |
|
1 |
2 |
3 |
4 |
5 |
88 |
99 |
On a scale from 1 to 5, where 1 is extremely bad and 5 is extremely good, how would you rate [INSERT BEHAVIOR]?
Extremely Bad |
Bad 2 |
Neither bad nor good 3 |
Good 4 |
Extremely Good 5 |
Don’t know |
Prefer not to answer |
1 |
2 |
3 |
4 |
5 |
88 |
99 |
On a scale from 1 to 5, where 1 is extremely harmful and 5 is extremely beneficial, how would you rate [INSERT BEHAVIOR] to prevent HIV?
1 Extremely harmful
2 Harmful
3 Neither harmful nor beneficial
4 Beneficial
5 Extremely beneficial
8 8 Don’t know
99 Prefer not to answer
Please tell us how much you agree or disagree with the following statements.
|
Strongly agree |
Agree |
Neither agree nor disagree |
Disagree |
Strongly disagree |
Don’t know |
Prefer not to answer |
|
1 |
2 |
3 |
4 |
5 |
8 8 |
99 |
|
1 |
2 |
3 |
4 |
5 |
88 |
99 |
|
1 |
2 |
3 |
4 |
5 |
88 |
99 |
|
1 |
2 |
3 |
4 |
5 |
8 8 |
99 |
HIV SELF EFFICACY
How sure are you that you could [INSERT BEHAVIOR] if…
|
Very sure I could not |
Somewhat sure I could not |
Slightly sure I could |
Somewhat sure I could |
Very sure I could |
Don’t know |
Prefer not to answer |
|
1 |
2 |
3 |
4 |
5 |
88 |
99 |
|
1 |
2 |
3 |
4 |
5 |
88 |
99 |
|
1 |
2 |
3 |
4 |
5 |
88 |
99 |
|
1 |
2 |
3 |
4 |
5 |
88 |
99 |
|
1 |
2 |
3 |
4 |
5 |
88 |
99 |
I feel confident in my ability to [INSERT BEHAVIOR AND CIRUMSTANCE].
1 Strongly agree
2 Agree
3 Neither disagree nor agree
4 Disagree
5 Strongly disagree
8 8 Don’t know
99 Prefer not to answer
INFORMATION SEEKING
In the last [INSERT #] months, how often have you…
|
Never |
Rarely |
Sometimes |
Often |
Very Often |
Prefer not to answer |
|
1 |
2 |
3 |
4 |
5 |
99 |
|
1 |
2 |
3 |
4 |
5 |
99 |
|
1 |
2 |
3 |
4 |
5 |
99 |
|
1 |
2 |
3 |
4 |
5 |
99 |
PrEP/nPEP/ART AWARENESS, KNOWLEDGE & BEHAVIORS
If there was a pill that you could take once a day, every day, to PREVENT getting HIV, and if this pill caused mild side effects, such as nausea, headaches, and rashes in a small number of people, would you take the pill?
1 Yes
2 No
88 Don’t know
99 Prefer not to answer
If there was medicine that you could take right AFTER you think you have been exposed to HIV to PREVENT getting HIV, and if this pill caused mild side effects, such as nausea, headaches, and rashes in a small number of people, would you take the medicine?
1 Yes
2 No
8 8 Don’t know
99 Prefer not to answer
Before today, have you ever heard of people who do not have HIV taking HIV medicines (PrEP or Truvada) daily, to keep from getting HIV?
1 Yes
2 No
88 Don’t know
99 Prefer not to answer
Before today, have you ever heard of people who do not have HIV taking HIV medicines (nPEP or non-occupational post-exposure prophylaxis) after they may have been exposed to HIV through sex or needle-sharing, to keep from getting HIV?
1 Yes
2 No
88 Don’t know
99 Prefer not to answer
In the past [INSERT #] months, have you taken HIV medicines (nPEP or non-occupational post-exposure prophylaxis) after sex because you thought it would keep you from getting HIV?
1 Yes
2 No
88 Don’t know
99 Prefer not to answer
In the past [INSERT #] months, have you taken HIV medicines (PrEP or Truvada) before sex because you thought it would keep you from getting HIV?
1 Yes
2 No [GO TO Q60]
88 Don’t know
99 Prefer not to answer
Are you currently taking [HIV medicine/PrEP/Truvada] to prevent getting HIV?
1 Yes
2 No [GO TO Q60]
88 Don’t know [GO TO Q60]
99 Prefer not to answer [GO TO Q60]
When did you first start taking [HIV medicine/PrEP/Truvada] to prevent getting HIV?
1 0 to 3 months ago
2 4 to 6 months ago
3 7 to 12 months ago
4 More than 12 months ago
88 Don’t know
99 Prefer not to answer
Many people don’t take their medication perfectly all the time. Thinking about the [past 30 days], how often did you take your [HIV medicine/PrEP/Truvada] as prescribed?
1 None of the time
2 A little of the time
3 Some of the time
4 Most of the time
88 Don’t know
99 Prefer not to answer
People may miss taking their medications for various reasons. Here is a list of possible reasons why you may have missed taking your [HIV medicine/PrEP/Truvada in the past 30 days. Please mark all that apply
In the past 30 days, did you miss taking your [HIV medicine/PrEP/Truvada] because you:
|
Would you be willing to receive a [text/email] reminder each day to take your [medication/pill/PrEP/Truvada]?
1 Yes
2 No
88 Don’t know
99 Prefer not to answer
Would you be willing to download an app to a smartphone or other mobile device that would send you reminders each day to take your [medication/pill/PrEP/Truvada]?
1 Yes
2 No
88 Don’t know
99 Prefer not to answer
True or false: There are medications available to treat HIV.
1 True
2 False
88 Don’t know
99 Prefer not to answer
True or false: If a person’s viral load is “undetectable,” they are cured and no longer have HIV.
1 True
2 False
88 Don’t know
99 Prefer not to answer
Please tell us how much you agree or disagree with each of the following statements:
|
Strongly agree |
Agree |
Disagree |
Strongly disagree |
Prefer not to answer |
|
1 |
2 |
3 |
4 |
99 |
|
1 |
2 |
3 |
4 |
99 |
|
1 |
2 |
3 |
4 |
99 |
[IF Q3=3, GO TO Q63]
[IF Q4≠3, GO TO Q63]
[IF Q5=1, GO TO Q63]
[IF Q6≠1, GO TO Q63]
[ALL OTHERS GO TO CLOSING]
IDENTITY & DISCRIMINATION
This next set of questions asks about how you identify in terms of race, ethnicity, sexual orientation, and gender identity. Some of the questions also ask about your experiences with how others have reacted to your identity.
Please tell us how much you disagree or agree with each of the following statements.
|
Strongly agree |
Agree |
Neither agree nor disagree |
Disagree |
Strongly disagree |
Prefer not to Answer |
|
1 |
2 |
3 |
4 |
5 |
99 |
|
1 |
2 |
3 |
4 |
5 |
99 |
|
1 |
2 |
3 |
4 |
5 |
99 |
|
1 |
2 |
3 |
4 |
5 |
99 |
|
1 |
2 |
3 |
4 |
5 |
99 |
|
1 |
2 |
3 |
4 |
5 |
99 |
Thank you for answering these questions. Please place the survey in the envelope provided. Give the survey and your consent form to the interviewer when you go into the interview room. The interviewer will not see your responses to these questions.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Poehlman, Jon |
| File Modified | 0000-00-00 |
| File Created | 2023-08-26 |