0920-24DF Eligibility Screener English

Form Approved

OMB No. 0920-1421

Expiration Date: 11/30/2026

Understanding HIV/STD Risk and Enhancing PrEP Implementation Messaging in a Diverse Community-Based Sample of Gay, Bisexual, and Other Men Who Have Sex with Men in a Transformational Era (MIC-DROP)

Attachment 4a

Eligibility Screener English

Public reporting burden of this collection of information is estimated to average 5 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 (0920-1421)

IRB Approved at the Protocol Level

Jan 24, 2024

20225896

#35745358.3

MIC-DROP Screener Survey - English

In which language do you prefer to take the survey?

¿En cuál idioma prefiere tomar la encuesta?

-English (action: stay on English or redirect to English if on Spanish)

-Espanol (action: stay on Spanish or redirect to Spanish if on English)

1. Are you able to read and understand [English/Spanish] without assistance?

☐ Yes ☐ No

[LANGUAGE]

If no: disqualify and show “Sorry, you do not qualify to take this survey.”

“Thank you for your interest in the MIC-DROP study, which is focused on learning more about the HIV prevention preferences and behaviors among men who have sex with men. We would like to let you know that funding for this study is provided by the Centers for Disease Control and Prevention.  To find out if you are eligible for this study, we need to ask you a few questions. It should not take more than 5 minutes. Some of these questions are personal, including questions about sexual activity. Answering these questions is completely voluntary and you can refuse to answer a question or stop at any time. If you answer the questions and we determine that you are eligible, you will then be offered the opportunity to participate in the research study, which includes a baseline survey, follow-up surveys every 3 months for the next 24 months, and HIV and STI home testing every 6 months. If you complete that longer survey, you will receive a $50 gift card as a token of appreciation. Would you like to continue to see if you are eligible for this study?”

• [If “No,” participant is directed to a webpage reading:]

“You have indicated that you do not consent to taking the eligibility screener for our study. We require all respondents to consent to take the eligibility survey in order to participate in the study, so we cannot allow you to participate. Thank you for your interest in our study.

For information about HIV/AIDS, where you can find HIV testing, prevention and sexual health services, please visit AIDSVu.org.”

• [If “Yes,” participant is directed to a screener webform]

Screener Webform

2. What is your age? _____

[AGE]

3. What zip code do you live in? __ __ __ __ __

[ZIP CODE]

4. Do you have any plans to move in the next 2 years?

☐ Yes ☐ No

[MOVE]

5. Do you currently describe yourself as male, female, or transgender?

□ Male

□ Female

□ Transgender male

□ Transgender female

□ Another gender identity

□ Refused

[GENDER]

6. What sex were you assigned at birth, on your original birth certificate?

□ Male

□ Female

□ Refused

[SEXBIRTH]

7. What is your race and/or ethnicity? Select all that apply

□ American Indian or Alaska Native

For example, Navajo Nation, Blackfeet Tribe of the Blackfeet Indian Reservation of Montana, Native Village of Barrow Inupiat Traditional Government, Nome Eskimo Community, Aztec, Maya, etc

□ Asian

For example, Chinese, Asian Indian, Filipino, Vietnamese, Korean, Japanese, etc.

□ Black or African American

For example, African American, Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc.

□ Hispanic or Latino

For example, Mexican, Puerto Rican, Salvadoran, Cuban, Dominican, Guatemalan, etc.

□ Middle Eastern or North African

For example, Lebanese, Iranian, Egyptian, Syrian, Iraqi, Israeli, etc.

□ Native Hawaiian or Pacific Islander

For example, Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, Marshallese, etc.

□ White

For example, English, German, Irish, Italian, Polish, Scottish, etc.

[RACE]

8Do you own and use an Android or iOS smartphone?

☐ Yes ☐ No

[PHONE]

IF PHONE = YES

9. Are you willing to download an app on your smartphone to participate in the study?

☐ Yes ☐ No

[SMART]

9. In the past 6 months, have you had sex with a man?

☐ Yes ☐ No ☐ Don’t know ☐ Decline to answer

[ANYSEX]

Logic: if anysex = yes

9. In the past 6 months, have you had anal sex with a man?

☐ Yes ☐ No ☐ Don’t know ☐ Decline to answer

[ANALSEX]

9. Have you ever tested for HIV?

☐ Yes ☐ No ☐ Don’t know ☐ Decline to answer

[EVERTEST]

Logic: shown if evertest = yes

9. What was the result of your most recent HIV test?

☐ Positive ☐ Negative ☐ Don’t know ☐ Decline to answer

[STATUS]

9. [If don’t know to 12 and 13] or [status not = positive ] Have you ever been diagnosed with HIV?

☐ Yes ☐ No ☐ Don’t know ☐ Decline to answer

[STATUS]

9. [If negative to 13] Are you currently taking PrEP as a pill or injection?

☐ Yes ☐ No ☐ Don’t know ☐ Decline to answer

[ONPREP]

9. Are you willing to provide contact information, including phone number, email, and mailing address so that we can send you study materials, including HIV/STI testing kits and any tokens of appreciation?

☐ Yes

☐ No

[CONTACT]

Evaluate Eligibility Criteria:

Participant is Ineligible if:

• If LANGUAGE is equal to ‘No’, or

• If AGE is less than 18, or

• If ZIP CODE is not Atlanta, Chicago, San Diego, or

• If MOVE is not equal to ‘No’, or

• If GENDER is not equal to ‘Man’, or

• If SEXBIRTH is not equal to ‘Male, or

• If PHONE is equal to ‘No’, or

• If SMART is equal to ‘No’, or

• If ANALSEX is equal to ‘No, or

• If STATUS is not equal to ‘Negative’, or

• If CONTACT is equal to ‘No’

If participant is Eligible based on screener, participant will proceed to Contact Information form.

If participant is Ineligible based on screener, participant will be directed to a page explaining that they are not eligible.

End 1. If the participant is Not Eligible:

Thank you so much for answering all of the questions; we really appreciate your time. Unfortunately, you are not eligible for this particular research study. 

Would you like to be contacted about other studies you may potentially be eligible for?

☐ Yes

☐ No

If YES:

1) You indicated that you would like to be contacted about other studies you may potentially be eligible for. Please provide your email address below. We will use this to contact you about any future studies you may be eligible for.

_________________________________________________

Thank You!

If you are currently HIV-negative, pre-exposure prophylaxis (PrEP) may be a potential option for you. PrEP is a way for people who do not have HIV to lower their risk of getting HIV by taking pills or injection. To learn more, please visit some of the links below.

If you want to learn more about HIV, where to get more information, or where to get tested in your area, please click on the following links:

• Information about HIV

  • www.cdc.gov/hiv

  • AIDSVu.org

• HIV Testing Resources

  • CDC HIV Testing Locator (https://gettested.cdc.gov/)

  • CDC HIV Testing Information Page (https://www.cdc.gov/hiv/testing/)

  • HIV.gov HIV Testing Locator (https://www.hiv.gov/locator)

  • AIDSVu HIV Testing Locator (https://aidsvu.org/services)

• PrEP Resources

  • Centers for Disease Control PrEP Resources (https://www.cdc.gov/actagainstaids/campaigns/starttalking/materials/prepresources.html)

  • Centers for Disease Control PrEP Information (https://www.cdc.gov/hiv/risk/prep/index.html)

  • The Fenway Institute: What is PrEP? (http://thefenwayinstitute.org/prepinfo/)

  • PrEP Locator (https://preplocator.org/)

  • HIV.gov PrEP Information Page (https://www.hiv.gov/hiv-basics/hiv-prevention/using-hiv-medication-to-reduce-risk/pre-exposure-prophylaxis)

If you have any questions or comments, you may contact study staff at [study email] or [phone number], or the Principal Investigator, Dr. Patrick Sullivan of Emory University at (404) 727-2038 or pssulli@emory.edu. 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 survey.

End 2. If the participant is Eligible:

Congratulations! You are currently eligible to participate in this health study.

Please click the “Next” button below to complete your registration.

Continue to Registration.