Persons Interviewed with standard interview

Medical Monitoring Project

MMP Attach 2 Interview Instrument

Persons Interviewed with standard interview

OMB: 0920-0740

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0920-0740 can be found here:

Document [doc]

Download: doc | pdf

Attachment 2

Interview Instruments

Attachment 2a

Standard Questionnaire for Medical Monitoring Project (MMP)

Standard Questionnaire for

Medical Monitoring Project (MMP)

VERSION 2

Public reporting burden of this collection of information is estimated to average 45 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, Project Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0011). Do not send the completed form to this address.

DEPARTMENT OF HEALTH AND HUMAN SERVICES

ublic Health Service

Centers for Disease Control and Prevention

Atlanta, GA 30333

2007 MMP QUESTIONNAIRE

ID Codes and Dates 534

Demographics 635

Access to Health Care 1241

HIV Testing Experiences and Care 1241

Usual Source of Care 2756

HIV Treatment 41371

Adherence to HIV Treatment 48377

Preventive Therapy 55385

Reproductive/Gynecological History 58389

Health Conditions 64394

UNMET NEEDS 70399

SEXUAL BEHAVIOR 723101

Male Respondent – Female Partner 733102

Male Respondent - Male Partner 773106

Female Respondent - Male Partner 813111

Female Respondent - Female Partner 853115

Transgender Respondent 873117

Transgender Respondent - Male Partner 883118

Transgender Respondent - Female Partner 923122

Drug and Alcohol Use History 973127

Injection Drug Use 973127

Non-Injection Drug Use 1003130

Assessment of Prevention Activities 1043134

FORM 1 1113141

FORM 2 1123144

Optional Modules 1133146

Health and Well-Being 1143147

Local Questions Module 1173150

Interview Completion 11831

End of Interview 11831

Payment Verification 11831

ID Codes and Dates

Participant ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Site ID Facility ID Respondent ID

Interviewer ID: ___ ___ ___

Population Definition Period (PDP) START date: (__ __/ __ __ / __ __ __ __ )

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

Population Definition Period (PDP) END date: (__ __/ __ __ / __ __ __ __ )

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

Interview date: (__ __/ __ __ / __ __ __ __ )

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

Interview language: □ 1 English □ 2 Spanish

Note to Reviewer: The QDS version of this interview will be programmed to determine the age of the participant based on the Patient Definition Period Start Date. As described in the protocol, all participants must have been 18 years of age or older on the date written in this area.

ime core questionnaire began: __ __:__ __ □ AM □ PM

Hour Minute

Note: The QDS version of this interview will be programmed to determine the age of the participant based on the Population Definition Period Start Date. As described in the protocol, all participants must have been 18 years of age or older on the Population Definition Period Start Date.

Demographics

SAY: “I'd like to thank you for taking part in this survey. Remember that all the information you give me will be confidential and your name will not be recorded anywhere on this computer. To begin, I would like to ask you some questions about your background. The answers to some questions may seem obvious to you, but I need to ask you all of the questions.”

D1. Have you ever participated in the MMP interview?

No………..………………………………….……	 00	Skip to D2
Yes………..……………………………..………	 01
Refused to answer………………..………..……	 07	Skip to D2
Don’t know…………………………….………	 09

D1a. What month and year did you participate in the MMP interview?

__ __ / __ __ __ __

^{(
M M Y Y Y Y )}[77 = Refused, 99 = Don’t know]

D1b. Where were you interviewed?

_____________________________________ (City)

_____________________________________ (State)

[77 = Refused, 99 = Don’t know]

Interviewer instructions: If the patient was previously interviewed in a month during which 2006 data collection cycle interviews were conducted, go to Say Box before D2. Otherwise, skip to D2.

SAY: “We are only interviewing people this year who haven’t already been interviewed during 2006. Thank you very much for your time.” [DISCONTINUE INTERVIEW AND GO TO INTERVIEW COMPLETION MODULE.]

D2. What is your date of birth?

__ __/ __ __ / __ __ __ __

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

D2a. So, you were ______ [AGE] years old on _______/ ______ [BEGINNING OF THE PDP]. Is that correct?

No………..………………………………….……	 00		SAY: “Please tell me your date of birth again,” and return to D2
Yes………..……………………………..………	 01

Interviewer instructions: If respondent was less than 18 years of age on PDP start date, go to Say Box before D3; otherwise, skip to D3.

SAY: “We are only interviewing people who were 18 years or older on _______/ ______ [BEGINNING OF THE PDP]. Thank you very much for your time.” [DISCONTINUE INTERVIEW AND GO TO INTERVIEW COMPLETION MODULE.]

D3. What is the highest level of education you completed? [CHECK ONLY ONE RESPONSE.] [DON’T READ CHOICES.]

Never attended school …...…………….……..	 01
Grades 1 through 8…………………………..	 02
Grades 9 through 11……………………...…...	 03
Grade 12 or GED..……………………………	 04
Some College, Associate’s Degree, or Technical Degree…………………………………………..	 05
Bachelor’s Degree…………………….………	 06
Any post-graduate studies...……………………	 07
Refused to answer………..……………………	 77
Don’t know……………………………..………	 99

D4. Do you consider yourself to be Hispanic or Latino/a?

No…………………………………..………	 00	Skip to D5
Yes…………………………………….……	 01
Refused to answer………..……………………	 07	Skip to D5
Don’t know……………………………..………	 09

D4a. What best describes your Hispanic ancestry? [CHECK ALL THAT APPLY.] [DON’T READ CHOICES.]

Mexican……………………………………	 01
Puerto Rico…………………………………	 02
Cuban……………………..………………..	 03
Dominican…………………..……………..	04
Other (Specify: _________________)…..…..	 05
Refused to answer………..……………………..	 07
Don’t know……………………………..………	 09

D5. Which racial group or groups do you consider yourself to be in? You may choose more than one option. [CHECK ALL THAT APPLY.][READ CHOICES.]

Asian…………….…..…………………....…	 01
Black or African American……………….…	 02
American Indian or Alaska Native……….…	 03
Native Hawaiian or other Pacific Islander…	 04
White…………….…..……………..…........	 05
Other (Specify: ________________)……….	 05
Refused to answer………..……………………	 07

D6. In what country or territory were you born? [CHECK ONLY ONE RESPONSE.] [DON’T READ CHOICES.]

United States….………………….……….....	01	Skip to D7
Puerto Rico.…..………………….……….....	02
Mexico….....….……………….……………..	03
Cuba………………………………………….	 04
Other (Specify:________________)………...	 05
Refused to answer…………………………...	 07	Skip to D7
Don’t know…………………………………..	 09

D6a. How many years have you been living in the United States?

__ __ years[77 = Refused, 99 = Don’t know]

D7. In the past 12 months, have you been homeless at any time? By homeless, I mean you were living on the street, in a shelter, a Single Room Occupancy (SRO) hotel, temporarily staying with friends/family, or living in a car.

No……………….………………….……..…	 00
Yes………………………..………….............	 01
Refused to answer……………………….…..	 07
Don’t know…….…………………….………	 09

D8. In the past 12 months, have you been arrested and put in jail, detention, or prison for longer than 24 hours?

No……………….………………….……..…	 00
Yes………………………..………….............	 01
Refused to answer……………………….…..	 07
Don’t know…….…………………….………	 09

D9. In the past 12 months, have you had any kind of health insurance or coverage? I am not referring to coverage for medicines only.

No……………….………………….……..…	 00	Skip to D10
Yes………………………..………….............	 01
Refused to answer……………………….…..	 07	Skip to D10
Don’t know…….…………………….………	 09

D9a. What are all the kinds of health insurance or coverage you have had in the past 12 months? [CHECK ALL THAT APPLY.] [DON’T READ CHOICES.]

Private health insurance or HMO…...............	 01
Medicaid……………………………………..	 02
Medicare……………………………………..	 03
Tricare/Champus…………………………….	 04
Veterans Administration coverage…………..	 05
Some other health insurance (Specify:__________________________).....	 06
Refused to answer……………………….…..	 07
Don’t know…….…………………….………	 09

D9b. Was there a time in the past 12 months that you didn’t have any insurance coverage?

No……………….………………….……..…	 00
Yes………………………..………….............	 01
Refused to answer……………………….…..	 07
Don’t know…….…………………….………	 09

D10. What are the main ways your prescription medicines for HIV and related illnesses were paid for in the past 12 months? [CHECK ALL THAT APPLY.] [DON’T READ CHOICES.]

I wasn’t taking any prescription medicines for HIV or related illnesses………………….	 01
Private health care coverage............................	 02
I got my HIV medicines at a public clinic…...	 03
I paid for my HIV medicines myself (“out of pocket”).................................................................	 04
AIDS Drug Assistance Program (ADAP)…..	 05
I participated in a clinical research trial or drug study that provided my medicines….…	 06
An AIDS service organization provided me my medicines.....................................................	 07
Medicaid/Medicare…………………………	 08
Other (Specify: ______________________)	 09
Refused to answer…………………………...	 77
Don’t know…….…………………….………	 99

D11. In the past 12 months, where did most of your money or financial support come from? [CHECK ONLY ONE RESPONSE] [DON’T READ CHOICES]

Salary or wages......................................……	01
Savings/investments....….….……………..…	 02
Pension/retirement fund…….………………	03
Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI)………………………………………..	 04
Public assistance (“welfare”)..……..…..….…	05
Spouse, partner or family...…………….……	06
Friends……………………………………….	07
No income/financial support….………..…....	 08
Other (Specify:___________________)........	09
Refused to answer…………………………...	 77
Don’t know…….…………………….………	 99

D12. In the past 12 months have you applied for any form of public assistance or welfare,

including Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI)?

No……………….………………….……..…	 00
Yes………………………..………….............	 01
Refused to answer……………………….…..	 07
Don’t know…….…………………….………	 09

D13. In the past 12 months have you received any form of public assistance or welfare, including Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI)?

No……………….………………….……..…	 00
Yes………………………..………….............	 01
Refused to answer……………………….…..	 07
Don’t know…….…………………….………	 09

D14. What was your sex at birth? [CHECK ONLY ONE RESPONSE.] [READ CHOICES EXCEPT “Intersex/ambiguous”.]

Male………………………………………….	 01
Female……………………………………….	 02
Intersex/ambiguous…………….……………	 03
Refused to answer……………………….…..	 07
Don’t know…….…………………….………	 09

D15. Do you consider yourself to be male, female, or transgender? [CHECK ONLY ONE RESPONSE.]

Male………………………………………….	 01
Female……………………………………….	 02
Transgender…..……...……...………………	 03
Refused to answer……………………….…..	 07
Don’t know…….…………………….………	 09

D16. Do you think of yourself as: [CHECK ONLY ONE RESPONSE.] [READ CHOICES.]

Heterosexual or Straight…………………….	01
Homosexual, Gay, or Lesbian …………...…	02
Bisexual………………………..……………	03
Other (Specify:_____________________ )....	 04
Refused to answer……………………….…..	 07
Don’t know…….…………………….………	 09

Access to Health Care

HIV Testing Experiences and Care

SAY: “Now I’m going to ask you some questions about getting tested for HIV and the care that you are receiving for HIV.”

A1. When did you first test positive for HIV?

__ __/ __ __ __ __

^{(M
M / Y Y Y Y )} [77 = Refused, 99 = Don’t know]

Interviewer instructions: If date of first HIV positive test is after the PDP end date, confirm the date in A1. If the date is correct, go to the Say Box before A1a; otherwise, go to A1a

SAY: “We are only interviewing people who tested positive for HIV before _______/ ______ [END OF THE PDP]. Thank you very much for your time.” [DISCONTINUE INTERVIEW AND GO TO INTERVIEW COMPLETION MODULE.]

A1a. Had you ever been tested for HIV before that?

No…………………………………………..	 00	Skip to A2
Yes…………………………………………..	 01
Refused to answer…………………………..	 07
Don’t know………………………….............	 09	Skip to A2

A1b. When was your last negative test before you tested positive?

__ __/ __ __ __ __

^{(M M / Y
Y Y Y )} [77 = Refused to answer, 99 = Don’t know]

Interviewer instructions: Skip to the Say Box before A3.

A2. So when you tested positive for HIV, where were you tested? [CHECK ONLY ONE.] [DON’T READ CHOICES.]

Community health center/primary care clinic/health department general medical clinic (public source)………...……………...	 01
Hospital………….………………………….	 02
Private physician/HMO/primary care clinic (private source)……………………………...	 03
HIV counseling and testing site…...………..	 04
STD clinic…………………………………..	 05
AIDS/infectious disease clinic……………...	 06
Mobile test site (health department van, needle exchange, etc.)……………….…………………………	 07
Correctional facility (jail/prison)……………	 08
Emergency room……………………………	 09
Blood bank………………………………….	 10
Prenatal/obstetrics clinic……………………	 11
Family planning clinic………………………	 12
Drug treatment clinic………………………..	 13
Military facility……………………………..	 14
Insurance clinics/employee clinic…………..	 15
Other………………………………………... (Specify:____________________________)	 16
Refused to answer…………………………..	 77
Don’t know………………………………….	 99

A2a. What was the main reason you were tested? [CHECK ONLY ONE.][DON’T READ CHOICES.]

Illness (pneumonia, weight loss, etc.).……....	 01
I’m an IDU or MSM or I had high-risk sexual behavior……………………………..	 02
Sex partner is IDU or MSM………………...	 03
Sex partner is HIV positive…………………	 04
Sex partner was worried I might have HIV...	 05
Needle sharing partner is HIV positive…….	 06
Surgery (pre-op)…..………...……………...	 07
Needle stick follow-up/ occupational exposure………….…………………………	 08
Health department informed me of possible exposure to HIV (partner notification) ……..	 09
Blood donor………….….………………….	 10
Offered as a screening test at a clinic (STD, family planning clinic, etc.)…………………	 11
Started new relationship/wanted to stop using condoms with partner…...……………	 12
Pregnancy/prenatal visit…………………….	 13
Routine check-up/physical exam…………...	 14
I just wanted to know/was curious……...…..	 15
Other…………………………….………….. (Specify_____________________________)	 16
Refused to answer…………………………..	 77
Don’t know………………………………….	 99

A2b. What type of test did you have? [CHOOSE ONLY ONE.] [READ CHOICES.]

An anonymous test, where you didn’t give your name or you used a code, including a home test kit…………………………………	 01
A confidential test, where you gave your name for identification………………………	 02
Refused to answer…………………………..	 07
Don’t know………………………………….	 09

A2c. Was this test a rapid test where you got your results within a couple of hours?

No…………………………………………..	 00
Yes…………………………………………..	 01
Refused to answer…………………………..	 07
Don’t know………………………….............	 09

Interviewer instructions: Skip to A4.

SAY: “Now I’m going to ask you some questions about your first positive HIV test. When I say your first positive test, I mean the very first time you ever had a test result that was positive.

A3. Where were you tested when you had your first positive HIV test? [CHECK ONLY ONE.] [DON’T READ CHOICES.]

Community health center/primary care clinic/health department general medical clinic (public source)………...……………...	 01
Hospital………….………………………….	 02
Private physician/HMO/primary care clinic (private source)……………………………...	 03
HIV counseling and testing site…...………..	 04
STD clinic…………………………………..	 05
AIDS/infectious disease clinic……………...	 06
At a mobile test site (health department van, needle exchange, etc.)……………….…………………………	 07
Correctional facility (jail/prison)……………	 08
Emergency room……………………………	 09
Blood bank………………………………….	 10
Prenatal/obstetrics clinic……………………	 11
Family planning clinic………………………	 12
Drug treatment clinic………………………..	 13
Military facility……………………………..	 14
Insurance clinics/employee clinic…………..	 15
Other………………………………………... (Specify:____________________________)	 16
Refused to answer…………………………..	 77
Don’t know………………………………….	 99

A3a. When you first tested positive for HIV, what was the main reason you were tested? [CHECK ONLY ONE.][DON’T READ CHOICES.]

Illness (pneumonia, weight loss, etc.).……....	 01
I’m an IDU or MSM or I had high-risk sexual behavior……………………………..	 02
Sex partner is IDU or MSM………………...	 03
Sex partner is HIV positive…………………	 04
Sex partner was worried I might have HIV...	 05
Needle sharing partner is HIV positive…….	 06
Surgery (pre-op)…..………...……………...	 07
Needle stick follow-up/ occupational exposure………….…………………………	 08
Health department informed me of possible exposure to HIV (partner notification) ……..	 09
Blood donor………….….………………….	 10
Offered as a screening test at a clinic (STD, family planning clinic, etc.)…………………	 11
Started new relationship/wanted to stop using condoms with partner…...……………	 12
Pregnancy/prenatal visit…………………….	 13
Routine check-up/physical exam…………...	 14
I just wanted to know/was curious……...…..	 15
Other…………………………….………….. (Specify_____________________________)	 16
Refused to answer…………………………..	 77
Don’t know………………………………….	 99

A3b. When you first tested positive for HIV, what type of test did you have? [CHOOSE ONLY ONE.] [READ CHOICES.]

An anonymous test, where you didn’t give your name or you used a code, including a home test kit…………………………………	 01
A confidential test, where you gave your name for identification………………………	 02
Refused to answer…………………………..	 77
Don’t know………………………………….	 99

A3c. When you first tested positive for HIV, was it a rapid test where you got your results within a couple of hours?

No…………………………………………..	 00
Yes…………………………………………..	 01
Refused to answer…………………………..	 07
Don’t know………………………….............	 09

A4. After testing positive for HIV, did anyone (for example, someone from the health department or health care provider) offer to tell your sex (or drug using) partner(s) that they may have been exposed to HIV so they could be tested?

No…………………………………………..	 00	Skip to A5
Yes…………………………………………..	 01
Refused to answer…………………………..	 07
Don’t know………………………….............	 09	Skip to A5

A4a. What was your response when they offered to tell your partner(s)? [CHOOSE ONLY ONE.] [READ CHOICES.]

You asked the health department (or other person) not to tell any of your partner(s) …	 01
You asked the health department (or other person) to tell all of your partner(s)………...	 02	Skip to A5
You asked the health department (or other person) to tell some of your partners………	 03	Skip to A4c
Refused to answer…………………………	 77
Don’t know………………………………….	 99	Skip to A5

A4b. What was the main reason you chose not to tell any of your partner(s)? [CHOOSE ONLY ONE.] [DON’T READ CHOICES.]

I was afraid of what my partner(s) would do to me………………………….…...………..	 01
I didn’t trust the health department/person who offered to tell my partner(s)…………..	 02
I was afraid my partner(s) would find out it was me who may have infected them……....	 03
I don’t think it’s up to me to get my partner(s) tested……..………………………	 04
Other……………………………………….. (Specify:____________________________)	 05
Refused to answer…………………………..	 77
Don’t know………………………………….	 99

Interviewer instructions: Skip to A5.

A4c. What was the main reason you chose not to tell some of your partner(s)? [CHOOSE ONLY ONE.] [DON’T READ CHOICES.]

I was afraid of what some of my partner(s) would do to me…………………...………..	 01
I didn’t trust the health department/person who offered to tell some of my partner(s)…..	 02
I was afraid some of my partner(s) would find out it was me who may have infected them…….......................................................	 03
I don’t think it’s up to me to get some of my partner(s) tested……..………………………	 04
Other……………………………………….. (Specify:____________________________)	 05
Refused to answer	 77
Don’t know	 99

A5. When did you first go to a health care provider for HIV care after learning you had HIV?

__ __/ __ __ __ __

^{(M M / Y
Y Y Y )} [77 = Refused to answer, 99 = Don’t know]

Interviewer instructions: If date of first HIV care is after the PDP end date, confirm the date in A5. If the date is correct, go to the Say Box below; otherwise, skip to Interviewer instructions before A6a.

SAY: “We are only interviewing people whose first HIV care was before _______/ ______ [END OF THE PDP]. Thank you very much for your time.” [DISCONTINUE INTERVIEW AND GO TO INTERVIEW COMPLETION MODULE.]

Interviewer instructions: If response to A5 (date first went to health care provider for HIV care) is more than 3 months from response to A1 (date first tested positive for HIV), go to A6a; otherwise, skip to A7.

Note: QDS will automatically calculate the differences between dates and perform the skip.

A6a. What were the reasons you didn’t go to a health care provider soon after you learned of your HIV? [CHECK ALL THAT APPLY.] [DON’T READ CHOICES.]

Felt good, didn’t need to go …………………..…..... 01

Forgot to go……………..…………..………………  02

Missed my appointment(s)...………..………………  03

Too busy to go…………...…...……..……………...  04

Moved or out of town…………………..………......  05

Didn’t want to think about being HIV positive….....  06

Didn’t believe test result ………..……………… ….  07

Unable to get transportation ………..………..……..  08

Unable to get childcare ……..……..………..……..  09

Inconvenient (location, hours, time, etc.)....………..  10

Didn’t know where to go…………….…………......  11

Hard to find the right doctor or a good doctor for me  12

Initial CD4 count and viral load were good…..…….  13

Drinking or using drugs………….……………........  14

Living on the street…………………………….......  15

Didn’t have money …..….……….…………………  16

Didn’t have insurance…..………….………………..  17

Unable to get earlier appointment…..………….…...  18

Incarcerated…………………………………………  19

Other ………………………………………………  20

(Specify:____________________________________)

Refused to answer…………………………………..  77

Don’t know ……………..……..…………………...  99

Interviewer instructions: If response to A6a is 77 or 99, code A6b as 77 or 99 and skip to A7.

A6b. What was the main reason you didn’t go to the health care provider soon after you learned of your HIV? I am going to read a list of the reasons you just gave me. Please tell me which of these was your main reason. [CHECK ONLY ONE RESPONSE.][READ RESPONSES GIVEN IN A6a.]

Felt good, didn’t need to go …………………..…...  01

Forgot to go……………..…………..………………  02

Missed my appointment(s)...………..………………  03

Too busy to go…………...…...……..……………...  04

Moved or out of town…………………..………......  05

Didn’t want to think about being HIV positive….....  06

Didn’t believe test result ………..………………….  07

Unable to get transportation ………..………..……..  08

Unable to get childcare ……..……..………..……..  09

Inconvenient (location, hours, time, etc.)....………..  10

Didn’t know where to go…………….…………......  11

Hard to find the right doctor or a good doctor for me  12

Initial CD4 count and viral load were good…..…….  13

Drinking or using drugs………….……………........  14

Living on the street…………………………….......  15

Didn’t have money …..….……….…………………  16

Didn’t have insurance…..………….……  17

Unable to get earlier appointment…..………….…...  18

Incarcerated…………………………………………  19

Other ………………………………………………  20

(Specify:_________________________________)

Refused to answer…………………………………..  77

Don’t know ……………..……..…………………...  99

Note: If only one answer is chosen in A6a, then QDS will automatically enter that answer as the main reason for A6b. Similarly, if response to A6a is “Refused to answer” or “Don’t know,” QDS will automatically code the same response for A6b. If more than one answer is chosen in A6a, QDS will limit possible responses in A6b to only those provided in A6a. This rule applies to all ‘main reason’ questions like this.

A7. When did you last go to a health care provider for HIV care?

__ __/ __ __ __ __

^{(M M / Y
Y Y Y )} [77 = Refused to answer, 99 = Don’t know]

Interviewer instructions: If date last went to health care provider is more than 3 months prior to interview date, go to A7a; otherwise, skip to A8.

A7a. What were the reasons you didn’t go to a health care provider for HIV care during the past 3 months? [CHECK ALL THAT APPLY.] [DON’T READ CHOICES.]

Felt good, didn’t need to go …………………..…...  01

Forgot to go……………..…………..………………  02

Missed my appointment(s)...………..………………  03

Too busy to go…………...…...……..……………...  04

Moved or out of town…………………..………......  05

Don’t want to think about being HIV positive…......  06

Didn’t believe test result ………..…………………..  07

Unable to get transportation ………..………..……..  08

Unable to get childcare ……..……..………..……..  09

Inconvenient (location, hours, time, etc.)....………..  10

Didn’t know where to go…………….…………......  11

Hard to find the right doctor or a good doctor for me  12

CD4 count and viral load were good…..……………  13

Drinking or using drugs………….……………........  14

Living on the street…………………………….......  15

Didn’t have money …..….……….…………………  16

Didn’t have insurance…..………….……………….  17

Unable to get earlier appointment…..………….…...  18

Incarcerated…………………………………………  19

Other ………………………………………………  20

(Specify:____________________________________)

Refused to answer…………………………………..  77

Don’t know ……………..……..…………………...  99

A7b. What was the main reason you didn’t go to a health care provider for HIV care during the past 3 months? I am going to read a list of the reasons you just gave me. Please tell me which of these was your main reason. [CHECK ONLY ONE RESPONSE][READ RESPONSES GIVEN in A7a]

Felt good, didn’t need to go …………………..…...  01

Forgot to go……………..…………..………………  02

Missed my appointment(s)...………..………………  03

Too busy to go…………...…...……..……………...  04

Moved or out of town…………………..………......  05

Don’t want to think about being HIV positive…......  06

Didn’t believe test result ………..…………………. . 07

Unable to get transportation ………..………..……..  08

Unable to get childcare ……..……..………..……..  09

Inconvenient (location, hours, time, etc.)....………..  10

Didn’t know where to go…………….…………......  11

Hard to find the right doctor or a good doctor for me  12

CD4 count and viral load were good…..……………  13

Drinking or using drugs………….……………........  14

Living on the street…………………………….......  15

Didn’t have money …..….……….…………………  16

Didn’t have insurance…..………….………………. . 17

Unable to get earlier appointment…..………….…...  18

Incarcerated…………………………………………  19

Other ………………………………………………  20

(Specify:_________________________)

Refused to answer…………………………………..  77

Don’t know ……………..……..…………………...  99

A8. Have you ever participated in a clinical trial?

No…………………………………………..	 00	Skip to A9
Yes…………………………………………..	 01
Refused to answer…………………………..	 07
Don’t know………………………….............	 09	Skip to A9

A8a. Have you participated in a clinical trial in the past 12 months?

No…………………………………………..	 00
Yes…………………………………………..	 01
Refused to answer…………………………..	 07
Don’t know………………………….............	 09

A9. Has a doctor or health care provider ever told you that your HIV infection had progressed to AIDS?

No…………………………………………..	 00	Skip to A10
Yes…………………………………………..	 01
Refused to answer…………………………..	 07	Skip to A10
Don’t know………………………….............	 09

A9a. When were you first told you had progressed to AIDS?

__ __ / __ __ __ __

M M Y Y Y Y [77 = Refused to answer, 99 = Don’t know]

SAY: “Now, I’m going to ask you some questions about your CD4 counts, also called T cell counts. To begin, I will ask about CD4 counts you have ever had.”

A 10. Have you ever had a lab test called a CD4 count?

No…………………………………………..	 00	Skip to Say Box before A12
Yes…………………………………………..	 01
Refused to answer…………………………..	 07
Don’t know………………………….............	 09	Skip to Say Box before A12

A10a. When was your first CD4 count done?

__ __/ __ __ __ __

^{(M M / Y
Y Y Y )} [77 = Refused to answer, 99 = Don’t know]

Interviewer instructions: If the year field for A10a is 77 or 99, skip to A10c.

A10b. What was your CD4 count the first time it was measured?

[USE RESPONSE CARD A]

0-49………………………………………..	 01
50-99………………………………………..	 02
100-199……………………………………..	 03
200-349…………………………………..…	 04
350-499……………………………………	 05
500 or more…………………………………	 06
Refused to answer……………….……….…	 07
Don’t know……………..………………......	 09

Interviewer instructions: If A10b (First CD4 Count) is ”0-49”, enter “0-49” for A10c; otherwise, go to A10c.

A10c. What was the lowest CD4 count you’ve ever had?

[USE RESPONSE CARD A]

0-49………………………………………..	 01
50-99………………………………………..	 02
100-199……………………………………..	 03
200-349…………………………………..…	 04
350-499……………………………………	 05
500 or more…………………………………	 06
Refused to answer……………….……….…	 07
Don’t know……………..………………......	 09	Skip to Say Box before A11

Interviewer instructions: If A10b (first CD4 count) is lower than A10c, confirm responses to A10b and/or A10c.

A10d. What was the date of your lowest CD4 count?

__ __/ __ __ __ __

^{(M M / Y
Y Y Y )} [77 = Refused to answer, 99 = Don’t know]

SAY: “Now I’m going to ask you some questions about the past 12 months. That is from now (TODAY’S DATE) through last year (DATE WITH PREVIOUS YEAR).”

A11. How many CD4 counts have you had in the past 12 months?

____ ____ [77=Refused to answer, 99=Don’t know]

Interviewer instructions: If response to A11= “0”, skip to Say Box before A12.

A11a. What was the most recent CD4 count you’ve had during the past 12 months?

[USE RESPONSE CARD A]

0-49………………………………………..	 01
50-99………………………………………..	 02
100-199……………………………………..	 03
200-349…………………………………..…	 04
350-499……………………………………	 05
500 or more…………………………………	 06
Refused to answer……………….……….…	 07
Don’t know……………..………………......	 09

Interviewer instructions: If A11a is lower than A10c (lowest CD4 count ever), confirm responses to A10c and/or A11a.

SAY: “Now I’m going to ask you some questions about your viral load tests. To begin, I will ask about tests you have ever had.”

A12. Have you ever had a viral load test (to measure the amount of HIV in your blood)?

Skip to Say Box before A14

No………………….…………………..……  00 Yes………………………………………..……  01

Skip to Say Box before A14

Refused to answer……………………………  07

Don’t know……………..………………..........  09

A12a. When was your first viral load test done?

__ __/ __ __ __ __

^{(M M / Y
Y Y Y )} [77 = Refused to answer, 99 = Don’t know]

Interviewer instructions: If the year field for A12a is 77 or 99, skip to A12c.

A12b. What was your viral load the first time it was measured?

[USE RESPONSE CARD B]

Below the level of detection, undetectable....	 00	Skip to A12d
Detectable but less than 5,000 viral copies/ml……………………………………	 01
5,000 to 100,000 viral copies/ml……….…	 03
Greater than 100,000 viral copies/ml……….	 04
Refused to answer…………………………..	 07
Don’t know………………………….............	 09

A12c. Have you ever been told your viral load was “undetectable”?

No…………………………………………..	 00
Yes…………………………………………..	 01
Refused to answer…………………………..	 07
Don’t know………………………….............	 09

Interviewer instructions: If response to A12b is “greater than 100,000 viral copies/ml”, enter “greater than 100,000 viral copies/ml” for A12d.

A12d. What was the highest viral load you ever had?

[USE RESPONSE CARD B]

Below the level of detection, undetectable....	 00
Detectable but less than 5,000 viral copies/ml……………………………………	 01
5,000 to 100,000 viral copies/ml……….…	 03
Greater than 100,000 viral copies/ml……….	 04
Refused to answer…………………………..	 07
Don’t know………………………….............	 09	Skip to Say Box before A13

Interviewer instructions: If A12b (first viral load) is higher than A12d, confirm responses to A12b and/or A12d.

A12e. When was the last time your viral load was the highest it’s ever been?

__ __/ __ __ __ __

^{(M M / Y Y Y Y )} [77 = Refused to answer, 99 = Don’t know]

SAY: “Now I’m going to ask you about your viral load tests in the past 12 months. That is from now (TODAY’S DATE) through last year (DATE WITH PREVIOUS YEAR).”

”

A13. How many viral load tests have you had in the past 12 months?

____ ____ [77=Refused to answer, 99=Don’t know]

Interviewer instructions: If response to A13= “0”, skip to Say Box before A14.

A13a. What was the most recent viral load you’ve had in the past 12 months?

[USE RESPONSE CARD B]

Below the level of detection, undetectable....	 00	Skip to Say Box before A14
Detectable but less than 5,000 viral copies/ml……………………………………	 01
5,000 to 100,000 viral copies/ml……….…	 03
Greater than 100,000 viral copies/ml……….	 04
Refused to answer…………………………..	 07
Don’t know………………………….............	 09

Interviewer instructions: If A12c (ever told viral load undetectable) is “No”, and A13a is “Below the level of detection, undetectable”, confirm responses to A12c and/or A13a.

Interviewer instructions: If A13a is higher than A12d (highest viral load ever), confirm responses to A12d and/or A13a.

Interviewer instructions: If A12c (ever told viral load undetectable) is “No”, enter “No” for A13b.

A13b. Have you been told your viral load was “undetectable” during the past 12 months?

No…………………………………………..	 00
Yes…………………………………………..	 01
Refused to answer…………………………..	 07
Don’t know………………………….............	 09

U
SAY: “Now I’m going to ask you some questions about the places where you get medical care for HIV. If you don’t remember everything, that’s okay. Tell me what you remember.”

sual Source of Care

A14. In the past 12 months, is there one place in particular, like a doctor’s office or clinic,

where you usually go for most of your HIV care, like CD4 tests, viral load tests or prescriptions for HIV medicines?

No………………….…………………..………  00 Yes………………………………………..……  01 Skip to A16

Skip to A18a

Refused to answer……………………………..  07

Don’t know……………..………………..........  09

A15. What are the reasons you don’t have a usual source of care for treatment of HIV?

[CHECK ALL THAT APPLY.] [DON’T READ CHOICES.]

Couldn’t afford a usual source of care……..………………………..  01

Didn’t know where to find regular HIV care.………………….……  02

Couldn’t get a regular appointment anywhere……………….………  03

No HIV doctors in my area….………………………………………  04

Didn’t think it was necessary….…………………..…………………  05

Thought it was necessary, but never tried to get one ……………….  06

Didn’t know where to find a regular doctor who speaks the

same language as me……………..……………………………….  07

Have just recently been diagnosed .……………… ………………………  08

Didn’t feel the need to seek treatment for HIV …………………………  09

Other ………………………………………………………………………  10

(Specify:____________________________________________________)

Refused to answer…………………………………………………………  77

Don’t know………..………………………………………………………  99

Interviewer instructions: After recording response(s), skip to A18a.

A16. What is the name of this place? Remember, this information will be kept private.

Name:

Interviewer instructions: After recording response, go to paper Facility Visits Log and enter location information and additional information for this place. After entering this information, continue with the next question.

Note: Responses to this question and other similar facility contact questions are not collected for analysis, but only for obtaining sufficient contact information to locate respondent’s chart for medical record abstraction.

A16a. Did you get HIV care at _____________ [THIS PLACE] between _____/_____ [BEGINNING OF THE PDP] and _______/ ______ [END OF THE PDP]?

No………………….…………………..……  00 Skip to A17 Yes………………………………………..……  01

Skip to A17

Refused to answer……………………………  07

Note: QDS will automatically display PDP dates based on date entered at the beginning of interview. This applies to all other date fill-ins.

Don’t know…………….………………..........  09

A16b. Between _____/_____ [BEGINNING OF THE PDP] and _______/ ______ [END OF THE PDP], how many times had you been to this place for HIV care?

______ ______ [77 = Refused to answer, 99 = Don’t know]

A17. How often in the past 12 months, did someone at ______ [USE RESPONSE FROM

A16] talk with you about the topic of safer sex? [CHOOSE ONE.] [READ CHOICES.]

Every visit…………………….…...………..	 01
More than half of the visits………………....	 02
Half of the visits……………..………….......	 03
Less than half of the visits…………………..	 04
Never………………………………………..	 05
Refused to answer…………………………..	 07	Skip to A18
Don’t know…………………………………	 09

A17a. In the past 12 months, when the subject of safer sex was discussed in this clinic, who generally brought up the subject? [DON’T READ CHOICES.]

I always began the discussion………………	 01
My provider or another person at the facility always began the discussion……………....	 02
Sometimes I began the discussion and sometimes my provider or another person at the facility did………………………………	 03
Refused to answer…………………………..	 07
Don’t know………………………………….	 09

A18a. In the past 12 months, is there one place in particular, like a doctor’s office or clinic

where you usually go to for care for any sort of medical problem?

If DEMOGRAPHICS D14 (birth gender) and DEMOGRAPHICS D15 (self-identified gender) are “Female” and the response to A18a is “No”, “Refused”, or “Don’t Know”, skip to A19a; otherwise, skip to A20.

No………………….……………..…… 00 Yes…………………………………….. 01 Go to A18b

Refused to answer…………………….. 07

Don’t know……………..…………….. 09

A18b. What is the name of this place?

Name:

A18c. Did you get HIV care at _____________ [THIS PLACE] between _____/_____ [BEGINNING OF THE PDP] and _______/ ______ [END OF THE PDP]?

Skip to instructions before A19a

No………………….…………………..…...….  00

Yes………………………………………..……  01

Skip to instructions before A19a

Refused to answer……………………….……  07

Don’t know…………….………………..........  09

A18d. Between _____/_____ [BEGINNING OF THE PDP] and _______/ ______ [END OF THE PDP], how many times have you been to this facility for HIV care?

______ ______ [77 = Refused to answer, 99 = Don’t know]

Interviewer instructions: If DEMOGRAPHICS D14 (birth gender) and DEMOGRAPHICS D15 (self-identified gender) are “Female”, go to A19a; otherwise, skip to A20.

A19a. In the past 12 months, have you received gynecological care? (By gynecological care, I

mean pelvic exams, pap smears or treatment for specific female conditions such as

vaginal itching, pain or bleeding)

No………………….…………………..……  00 Skip to A20 Yes………………………………………..……  01

Skip to A20

Refused to answer……………………………  07

Don’t know……………..………………..........  09

A19b. What is the name of the place where you received gynecological care?

Name:

Skip to A20

19d. Did you get gynecological care at _____________ [THIS PLACE] between _____/_____ [BEGINNING OF THE PDP] and _______/ ______ [END OF THE PDP]?

No………………….…………………..……  00 Yes………………………………………..……  01

Skip to A20

Refused to answer……………………………  07

Don’t know…………….………………..........  09

A19e. Between _____/_____ [BEGINNING OF THE PDP] and _______/ ______ [END OF THE PDP], how many times have you been to this facility for gynecological care?

______ ______ [77 = Refused to answer, 99 = Don’t know]

A20. In the past 12 months, have you been to any other doctor’s office or clinic for your

HIV care? If you were in jail or prison during the last 12 months, please include those

providers as well.

No………………….…………………..……  00 Skip to A21 Yes………………………………………..……  01

Skip to A21

Refused to answer……………………………  07

Don’t know……………..………………..........  09

A20a. What is the name of the place?

Name:

A20b. Did you get HIV care at _____________ [PLACE 1] between _____/_____ [BEGINNING OF THE PDP] and _______/ ______ [END OF THE PDP]?

No………………….…………………..……  00 Skip to A20d Yes………………………………………..……  01

Refused to answer……………………………  07 _{Skip
to A20d}

Don’t know……………..……………….........  09

A20c. Between _____/_____ [BEGINNING OF THE PDP] and _______/ ______ [END OF THE PDP], how many times have you been to _____________ [PLACE 1] for HIV care? ______

______ ______ [77 = Refused to answer, 99 = Don’t know]

A20d. Is there another place?

No………………….…………………..……  00 Skip to A21 Yes………………………………………..……  01

Skip to A21

Refused to answer……………………………  07

Don’t know……………..………………..........  09

A20e. What is the name of this place?

Name:

A20f. Did you get HIV care at _____________ [PLACE 2] between _____/_____

[BEGINNING OF THE PDP] and _______/ ______ [END OF THE PDP]?

No………………….…………………..……  00 Skip to A20h Yes………………………………………..……  01

Refused to answer……………………………  07 _{Skip
to A20h}

Don’t know……………..……………….........  09

A20g. Between _____/_____ [BEGINNING OF THE PDP] and _______/ ______ [END OF THE PDP], how many times have you been to _____________ [PLACE 2] for HIV care?

______ ______ [77 = Refused to answer, 99 = Don’t know]

A20h. Is there another place?

No………………….…………………..……  00 Skip to A21 Yes………………………………………..……  01

Skip to A21

Refused to answer……………………………  07

Don’t know……………..………………..........  09

A20i. What is the name of this place?

Name:

A20j. Did you get HIV care at _____________ [PLACE 3] between _____/_____ [BEGINNING OF THE PDP] and _______/ ______ [END OF THE PDP]?

No………………….…………………..……  00 Skip to A20l Yes………………………………………..……  01

Refused to answer……………………………  07 _{Skip
to A20l}

Don’t know……………..……………….........  09

A20k. Between _____/_____ [BEGINNING OF THE PDP] and _______/ ______ [END OF THE PDP], how many times have you been to _____________ [PLACE 3] for HIV care?

______ ______ [77 = Refused to answer, 99 = Don’t know]

A20l. Is there another place?

No………………….…………………..……  00 Skip to A21 Yes………………………………………..……  01

Skip to A21

Refused to answer……………………………  07

Don’t know……………..………………..........  09

A20m. What is the name of this place?

Name:

A20n. Did you get HIV care at _____________ [PLACE 4] between _____/_____ [BEGINNING OF THE PDP] and _______/ ______ [END OF THE PDP]?

No………………….…………………..……  00 Skip to A21 Yes………………………………………..……  01

Refused to answer……………………………  07

Skip to Q16

_{Skip to A21}

Don’t know……………..……………….........  09

Note: Only 4 options for “other HIV facilities” are provided above, but QDS coding will allow for all possible facilities that participant describes. This rule applies to all other questions like this about care facilities.

20o. Between _____/_____ [BEGINNING OF THE PDP] and _______/ ______ [END OF THE PDP], how many times have you been to_____________ [PLACE 4] for HIV care?

______ ______ [77 = Refused to answer, 99 = Don’t know]

A21. During the past 12 months, how many times did you go to an emergency room for HIV

care? (Please don’t include visits related to injuries such as accidents or other types of injuries).

______ ______ [77=Refused to answer, 99=Don’t know]

A22. During the past 12 months, how many times did you go to an urgent care center for HIV care? (Please don’t include visits related to injuries such as accidents or other types of injuries).

______ ______ [77=Refused to answer, 99=Don’t know]

A23. During the past 12 months, how many times were you admitted to a hospital because of

an HIV-related illness? (Please don’t include visits that were made only to the Emergency Room.)

______ ______ [77=Refused to answer, 99=Don’t know]

Interviewer instructions: If A23 is “0”, skip to A25.

A24. During the past 12 months, how many days total did you spend in a hospital because of an HIV-related illness?

______ ______ [77=Refused to answer, 99=Don’t know]

Note: If A23 is greater than “0” and is not “Refused to answer” or “Don’t know,” A24 cannot be coded as “0”.

A24a. What is the name of the hospital where you were admitted?

Name:

A24b. Were you hospitalized at_____________ [PLACE 1] between _____/_____ [BEGINNING OF THE PDP] and _______/ ______ [END OF THE PDP]?

No………………….…………………..……  00 Skip to A24d Yes………………………………………..……  01

Skip to A24d

Refused to answer……………………………  07

Don’t know……………..………………..........  09

A24c. Between _____/_____ [BEGINNING OF THE PDP] and _______/ ______ [END OF THE PDP], how many times have you been hospitalized at _____________ [PLACE 1] because of your HIV/AIDS?

______ _______ [77 = Refused to answer, 99 = Don’t know]

A24d. Were you admitted to any other hospital for HIV-related illness in the past 12

months?

No………………….…………………..……  00 Skip to A25 Yes………………………………………..……  01

Skip to A25

Refused to answer……………………………  07

Don’t know……………..………………..........  09

A24e. What is the name of this hospital?

Name:

A24f. Were you hospitalized at _____________ [PLACE 2] between _____/_____ [BEGINNING OF THE PDP] and _______/ ______ [END OF THE PDP]?

No………………….…………………..……  00 Skip to A24h Yes………………………………………..……  01

Refused to answer……………………………  07 _{Skip
to A24h}

Don’t know……………..……………….........  09

A24g. Between _____/_____ [BEGINNING OF THE PDP] and _______/ ______ [END OF THE PDP], how many times have you been hospitalized at _____________ [PLACE 2] because of your HIV/AIDS?

______ ______ [77 = Refused to answer, 99 = Don’t know]

A 24h. Were you admitted to any other hospital for HIV-related illness in the past 12 months? No………………….…………………..……….. 00 Skip to A25 Yes………………………………………..…….. 01

Skip to A25

Refused to answer……………………………  07

Don’t know……………..………………..........  09

A24i. What is the name of this hospital?

Name:

A24j. Were you hospitalized at _____________ [PLACE 3] between _____/_____ [BEGINNING OF THE PDP] and _______/ ______ [END OF THE PDP]?

No………………….…………………..……  00 Skip to A24l Yes………………………………………..……  01

Refused to answer……………………………  07 _{Skip
to A24l}

Don’t know……………..……………….........  09

A24k. Between _____/_____ [BEGINNING OF THE PDP] and _______/ ______ [END OF THE PDP], how many times have you been hospitalized at _____________ [PLACE 3] because of your HIV/AIDS?

______ ______ [77 = Refused to answer, 99 = Don’t know]

A 24l. Were you admitted to any other hospital for HIV-related illness in the past 12 months? No………………….…………………..………..00 Skip to A25 Yes………………………………………..…….. 01

Skip to A25

Refused to answer……………………………  07

Don’t know……………..………………..........  09

A24m. What is the name of this hospital?

Name:

A24n. Were you hospitalized at _____________ [PLACE 4] between _____/_____ [BEGINNING OF THE PDP] and _______/ ______ [END OF THE PDP]?

No………………….……………………..……  00 Skip to A25 Yes………………………………………..……  01

Refused to answer……………..………………  07 _{Skip
to A25}

Don’t know……………..….……………..........  09

A24o. Between _____/_____ [BEGINNING OF THE PDP] and _______/ ______ [END OF

THE PDP], how many times have you been hospitalized at _____________ [PLACE 4] because of your HIV/AIDS?

______ _______ [77 = Refused to answer, 99 = Don’t know]

Skip to A26

25. During the past 12 months, were you admitted to a mental health facility? No……………………..…………………...........  00

Yes………………………..………….…………  01

Skip to A26

Refused to answer………………………………  07

Don’t know……………..………………............  09

A25a. What is the name of the facility?

Name:

A25b. Were you treated at _____________ [PLACE 1] between _____/_____ [BEGINNING OF THE PDP] and _______/ ______ [END OF THE PDP]?

No………………….…………………..……  00 Skip to A25d Yes………………………………………..……  01

Refused to answer……………………………  07 _{Skip
to A25d}

Don’t know……………..……………….........  09

A25c. Between _____/_____ [BEGINNING OF THE PDP] and _______/ ______ [END OF THE PDP], how many times have you been treated at _____________ [PLACE 1]?

______ _______ [77 = Refused to answer, 99 = Don’t know]

A 25d. Were you admitted to any other mental health facility in the past 12 months? No………………….…………………..……  00 Skip to A26 Yes………………………………………..……  01

Skip to A26

Refused to answer……………………………  07

Don’t know……………..………………..........  09

A25e. What is the name of this facility?

Name:

A25f. Were you treated at _____________ [PLACE 2] between _____/_____ [BEGINNING OF THE PDP] and _______/ ______ [END OF THE PDP]?

No………………….…………………..……  00 Skip to A25h Yes………………………………………..……  01

Refused to answer……………………………  07 _{Skip
to A25h}

Don’t know……………..……………….........  09

A25g. Between _____/_____ [BEGINNING OF THE PDP] and _______/ ______ [END OF THE PDP], how many times have you been treated at _____________ [PLACE 2]?

______ _______ [77 = Refused to answer, 99 = Don’t know]

A25h. Were you admitted to any other mental health facility in the past 12 months?

No………………….…………………..……  00 Skip to A26 Yes………………………………………..……  01

Skip to A26

Refused to answer……………………………  07

Don’t know……………..………………..........  09

A25i. What is the name of this facility?

Name:

A25j. Were you treated at_____________ [PLACE 3] between _____/_____ [BEGINNING OF THE PDP] and _______/ ______ [END OF THE PDP]?

No………………….…………………..……  00 Skip to A25l Yes………………………………………..……  01

Refused to answer……………………………  07 _{Skip
to A25l}

Don’t know……………..……………….........  09

A25k. Between _____/_____ [BEGINNING OF THE PDP] and _______/ ______ [END OF THE PDP], how many times have you been treated at _____________ [PLACE 3]?

______ _______ [77 = Refused to answer, 99 = Don’t know]

A 25l. Were you admitted to any other mental health facility in the past 12 months? No………………….…………………..……  00 Skip to A26 Yes………………………………………..……  01

Skip to A26

Refused to answer……………………………  07

Don’t know……………..………………..........  09

A25m. What is the name of this facility?

Name:

A25n. Were you treated at _____________ [PLACE 4] between _____/_____ [BEGINNING OF THE PDP] and _______/ ______ [END OF THE PDP]?

No………………….…………………..……  00 Skip to A26 Yes………………………………………..……  01

Refused to answer……………………………  07 _{Skip
to A26}

Don’t know……………..……………….........  09

A25o. Between _____/_____ [BEGINNING OF THE PDP] and _______/ ______ [END OF THE PDP], how many times have you been treated at _____________ [PLACE 4]?

______ _______ [77 = Refused to answer, 99 = Don’t know]

A26. During the past 12 months, were you admitted to an inpatient drug or alcohol treatment

Skip to Say Box before A27

facility?

No……………………..…………………...........  00

Yes………………………..………….…………  01

Skip to Say Box before A27

Refused to answer………………………………  07

Don’t know……………..………………........... . 09

A26a. What is the name of the facility?

Name:

A26b. Were you treated at _____________ [PLACE 1] between _____/_____ [BEGINNING OF THE PDP] and _______/ ______ [END OF THE PDP]?

No………………….…………………..……  00 Skip to A26d Yes………………………………………..……  01

Refused to answer……………………………  07 _{Skip
to A26d}

Don’t know……………..……………….........  09

A26c. Between _____/_____ [BEGINNING OF THE PDP] and _______/ ______ [END OF THE PDP], how many times have you been treated at _____________ [PLACE 1]?

______ ______ [77 = Refused to answer, 99 = Don’t know]

Skip to Say Box before A27

26d. Were you admitted to any other inpatient drug or alcohol treatment facility in the past 12 months?

No………………….…………………..……  00 Yes………………………………………..……  01

Skip to Say Box before A27

Refused to answer……………………………  07

Don’t know……………..………………..........  09

A26e. What is the name of this facility?

Name:

A26f. Were you treated at _____________ [PLACE 2] between _____/_____ [BEGINNING OF THE PDP] and _______/ ______ [END OF THE PDP]?

No………………….…………………..……  00 Skip to A26h Yes………………………………………..……  01

Refused to answer……………………………  07 _{Skip
to A26h}

Don’t know……………..……………….........  09

A26g. Between _____/_____ [BEGINNING OF THE PDP] and _______/ ______ [END OF THE PDP], how many times have you been treated at _____________ [PLACE 2]?

______ _______ [77 = Refused to answer, 99 = Don’t know]

A26h. Were you admitted to any other inpatient drug or alcohol treatment facility in the past 12 months?

Skip to Say box before A27

No………………….…………………..……  00

Yes………………………………………..……  01

Skip to Say box before A27

Refused to answer……………………………  07

Don’t know……………..………………..........  09

A26i. What is the name of this facility?

Name:

A26j. Were you treated at _____________ [PLACE 3] between _____/_____ [BEGINNING OF THE PDP] and _______/ ______ [END OF THE PDP]?

No………………….…………………..……  00 Skip to A26l Yes………………………………………..……  01

Refused to answer……………………………  07 _{Skip
to A26l}

Don’t know……………..……………….........  09

A26k. Between _____/_____ [BEGINNING OF THE PDP] and _______/ ______ [END OF THE PDP], how many times have you been treated at _____________ [PLACE 3]?

_______ _______ [77 = Refused to answer, 99 = Don’t know]

Skip to Say Box before A27

26l. Were you admitted to any other inpatient drug or alcohol treatment facility in the past 12 months?

No………………….…………………..………..  00

Yes………………………………………..……  01

Skip to Say Box before A27

Refused to answer……………………………  07

Don’t know……………..………………..........  09

A26m. What is the name of this facility?

Name:

A26n. Were you treated at _____________ [PLACE 4] between _____/_____ [BEGINNING OF THE PDP] and _______/ ______ [END OF THE PDP]?

Skip to Say Box before A27

No………………….…………………..……  00

Yes………………………………………..……  01

Skip to Say Box before A27

Refused to answer……………………………  07
Skip to Q16

Skip to Q16

Don’t know……………..……………….........  09

A26o. Between _____/_____ [BEGINNING OF THE PDP] and _______/ ______ [END OF THE PDP], how many times have you been treated at _____________ [PLACE 4]?

______ _______ [77 = Refused to answer, 99 = Don’t know]

HIV Treatment

SAY: “Now I’m going to ask some questions about the medicines that you are taking. To begin, I’ll ask about medicines your doctor has prescribed to treat your HIV. These medicines are called antiretrovirals.

A27. Have you ever taken any antiretroviral medicines to treat your HIV? These medicines are also known as ART, HAART, or the AIDS cocktail.

No………………….…………………..……  00

Yes………………………………………..……  01 Skip to A28

Skip to Say Box before A41

Refused to answer……………………………  07

Don’t know……………..………………..........  09

A27a. What are the reasons you have never taken any antiretroviral medicines?

[CHECK ALL THAT APPLY.] [DON’T READ CHOICES.]

Doctor advised to delay treatment…..…………......  01

Recently into medical care/haven’t had time……….  02

CD4 count and/or viral load are good………...........  03

Feel good, don’t need them......……..………………  04

Worried about side effects …..………..…….….......  05

Drinking or using drugs…………..…..…….………  06

Didn’t want to think about being HIV positive.........  07

No money …………………….…………....……….  08

No insurance……….…………....……….  09

Worried about ability to adhere/often forget…........  10

Living on the street.…………………..…….….......  11

Taking alternative/complementary medicines...........  12

Other ………………………………………………  13

(Specify:_________________________________)

Other ………………………………………………  14

(Specify:_________________________________)

Refused to answer ………………………………….  77

Don’t know…………………….………………......  99

A27b. What is the main reason you have never taken any antiretroviral medicines? I am going to read a list of the reasons you just gave me. Please tell me which of these was your main reason. [CHECK ONLY ONE RESPONSE.] [READ RESPONSES GIVEN IN A27a.]

Doctor advised to delay treatment…..…………......  01

Recently into medical care/haven’t had time……….  02

CD4 count and/or viral load are good………...........  03

Feel good, don’t need them......……..………………  04

Worried about side effects …..………..…….….......  05

Drinking or using drugs…………..…..…….………  06

Didn’t want to think about being HIV positive.........  07

No money …………………….…………....……….  08

No insurance……….…………....……….  09

Worried about ability to adhere/often forget…........  10

On the street.…………………………..…….….......  11

Taking alternative/complementary medicines...........  12

Other ………………………………………………  13

(Specify:_________________________________)

Other ………………………………………………  14

(Specify:_________________________________)

Refused to answer ………………………………….  77

Don’t know…………………….………………......  99

Interviewer instructions: After recording response, skip to Say Box before A41.

A28. When was the first time you ever took any antiretroviral medicines to treat your HIV?

__ __/ __ __ __ __

^{(M M / Y
Y Y Y )} [77 = Refused to answer, 99 = Don’t know]

SAY: “I’m going show you a card with HIV medicines on them. Please tell me which of these medicines you have ever taken to treat your HIV, including those that you are currently taking. If you are taking any combination medicines, please tell me the name of the combination, not the separate name of each medicine in the combination.”

A29a. Have you ever taken any Nucleoside/Nucleotide Analogue Reverse Transcriptase inhibitors (NRTIs), also known as ‘Nukes’? [CHECK ALL THAT APPLY.] [USE MEDICATION CHART.]

Epivir (lamivudine, 3TC)  01

Videx (didanosine, ddl)  02

Emtriva (emtricitabine, FTC)  03

Viread (tenofovir, tdf)  04

Hivid (zalcitabine (ddC,)  05

Zerit (stavudine, d4T)  06

Retrovir (zidovudine, AZT, ZDV)  07

Ziagen (abacavir, ABC)  08

None.………………………………. . 88

Refused to answer………….………  77

Don’t know…………………….....  99

A29b. Have you ever taken any Protease Inhibitors (PI)? [CHECK ALL THAT APPLY.] [USE MEDICATION CHART.]

Agenerase (amprenavir, APV)  01

Invirase (saquinavir hard gel, SQV)  02

Kaletra (lopinavir/ritonavir, LPV, r)  03

Crixivan (indinavir, IDV)  04

Lexiva (fosamprenavir, FPV)  05

Reyataz (atazanavir, ATV)  06

Fortovase (saquinavir soft gel, SQV)  07

Norvir (ritonavir, RTV)  08

Interviewer Note: Tipranavir (aptivus) is not on the V.2.3 medication chart.

iracept (nelfinavir, NFV)  09

Tipranavir (aptivus)  10

None.………………………………..  88

Refused to answer………….………  77

Don’t know…………………….....  99

A29c. Have you ever taken any Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTI), also known as ‘Non-nukes’? [CHECK ALL THAT APPLY.] [USE MEDICATION CHART.]

Rescriptor (delaviridine, DLV)  01

Viramune (nevirapine, NVP)  02

Sustiva (efavirenz, EFV)  03

None.………………………………. .  08

Refused to answer………….………  07

Don’t know…………………….....  09

A29d. Have you ever taken any Nucleoside Analogue Combinations (Combination Treatments)? Please remember, if you are taking any combination medicines, tell me the name of the combination, not the separate name of each medicine in the combination. [CHECK ALL THAT APPLY.] [USE MEDICATION CHART.]

Combivir (AZT+3TC)  01

Trizivir (AZT+3TC+abacavir)  02

Epzicom (3TC+ABC)  03

Truvada (FTC+TDF)  04

None.………………………………..  08

Refused to answer………….………  07

Don’t know…………………….....  09

A29e. Have you ever taken any Entry/Fusion Inhibitors? [CHECK ALL THAT APPLY.] [USE MEDICATION CHART.]

Fuzeon (Enfuvirtide)  01

None.………………………………..  08

Refused to answer………….………  07

Don’t know…………………….....  09

A29f. Did you take any other antiretroviral medicines? [CHECK ALL THAT APPLY.]

Other medicine 1………………………  01

(Specify:________________________)

Other medicine 2....................................  02

(Specify:________________________)

Other medicine 3………………………  03

Note: Only 4 Other medicines are provided, but QDS coding will allow for all other medicines that participant specifies. This applies to all other questions like this.

Note: Drug list will be reviewed and updated as appropriate.

(Specify:________________________)

Other medicine 4………………………  04

(Specify:________________________)

Refused to answer…………………..…..  07

Don’t know……………..………………  09

A30. Are you currently taking any antiretroviral medicines to treat your HIV?

No………………….…………………..……  00

Skip to Say Box before A31

Yes………………………………………..……  01

Skip to A37

Refused to answer……………………………  07

Don’t know……………..………………..........  09

A30a. What are the reasons you aren’t currently taking any antiretroviral medicines?

[CHECK ALL THAT APPLY.] [DON’T READ CHOICES.]

Doctor advised to delay treatment…..…………......  01

Recently into medical care/haven’t had time……….  02

CD4 count and/or viral load are good………...........  03

Feel good, don’t need them......……..………………  04

Worried about side effects …..………..…….….......  05

Drinking or using drugs…………..…..…….………  06

Didn’t want to think about being HIV positive.........  07

No money …………………….…………....……….  08

No insurance……….…………....……….  09

Worried about ability to adhere/often forget…........  10

On the street.…………………………..…….….......  11

Taking alternative/complementary medicines...........  12

Other ………………………………………………  13

(Specify:_________________________________)

Other ………………………………………………  14

(Specify:_________________________________)

Refused to answer ………………………………….  77

Don’t know…………………….………………......  99

A30b. What is the main reason you aren’t currently taking any antiretroviral medicines?

I am going to read a list of the reasons you just gave me. Please tell me which of these was your main reason. [CHECK ONLY ONE RESPONSE.] [READ RESPONSES GIVEN IN A30a.]

Doctor advised to delay treatment…..…………......  01

Recently into medical care/haven’t had time……….  02

CD4 count and/or viral load are good………...........  03

Feel good, don’t need them......……..………………  04

Worried about side effects …..………..…….….......  05

Drinking or using drugs…………..…..…….………  06

Didn’t want to think about being HIV positive.........  07

No money …………………….…………....……….  08

No insurance……….…………....……….  09

Worried about ability to adhere/often forget…........  10

On the street.…………………………..…….….......  11

Taking alternative/complementary medicines...........  12

Other ………………………………………………  13

(Specify:_________________________________)

Other ………………………………………………  14

(Specify:_________________________________)

Refused to answer ………………………………….  77

Don’t know…………………….………………......  99

Interviewer instructions: After recording response, skip to A37.

Adherence to HIV Treatment

SAY: “We need to understand how people with HIV really take their antiretroviral medicine. For the next questions, please tell us what you actually do. Don’t worry about telling us that you don’t take all your medicine. We need to know what you really do, not what you think we “want to hear.” And please remember, none of this information will be shared with your provider.”

A31. I am going to ask you about each of the antiretroviral medicines or cocktails you’re

currently taking to treat your HIV.

Interviewer instructions: [CHECK ALL MEDICATIONS THAT APPLY.] [FOR EACH MEDICATION, ASK THE FOLLOWING QUESTIONS:]

Interviewer instructions: [USE MEDICATION CHART.]

[77 = Refused to answer, 99 = Don’t know]

How many

How many How many times did

pills (or times did you miss

spoonfuls/ you miss taking a

injections) How many taking a dose or

of ________ times each dose or set of these

[medicine] day are you set of pills (or

are you supposed to these pills spoonfuls/

supposed to take these (or spoon- injections)

take each pills (or fuls/ the day

Which of these medicines time you spoonfuls/ injections) before

are you currently taking? take them? injections)? yesterday? yesterday?

Nucleoside/Nucleotide Analogue Reverse Transcriptase inhibitors (NRTIs), also known as ‘Nukes’

Epivir (lamivudine, 3TC)  01 ___ ___ ___ ___ ___ ___ ___ ___

Videx (didanosine, ddI)  02 ___ ___ ___ ___ ___ ___ ___ ___

Emtriva (emtricitabine, FTC)  03 ___ ___ ___ ___ ___ ___ ___ ___

Viread (tenofovir, tdf)  04 ___ ___ ___ ___ ___ ___ ___ ___

Hivid (zalcitabine (ddC,)  05 ___ ___ ___ ___ ___ ___ ___ ___

Zerit (stavudine, d4T)  06 ___ ___ ___ ___ ___ ___ ___ ___

Retrovir (zidovudine, AZT, ZDV)  07 ___ ___ ___ ___ ___ ___ ___ ___

Ziagen (abacavir, ABC)  08 ___ ___ ___ ___ ___ ___ ___ ___

How many

How many How many times did

pills (or times did you miss

spoonfuls/ you miss taking a

injections) How many taking a dose or

of ________ times each dose or set of these

[medicine] day are you set of pills (or

are you supposed to these pills spoonfuls/

supposed to take these (or spoon- injections)

take each pills (or fuls/ the day

Which of these medicines time you spoonfuls/ injections) before

are you currently taking? take them? injections)? yesterday? yesterday?

Protease Inhibitors (PI)

Agenerase (amprenavir, APV)  09 ___ ___ ___ ___ ___ ___ ___ ___

Invirase (saquinavir hard gel, SQV)  10 ___ ___ ___ ___ ___ ___ ___ ___

Kaletra (lopinavir/ritonavir, LPV, r)  11 ___ ___ ___ ___ ___ ___ ___ ___

Crixivan (indinavir, IDV)  12 ___ ___ ___ ___ ___ ___ ___ ___

Lexiva (fosamprenavir, FPV)  13 ___ ___ ___ ___ ___ ___ ___ ___

Reyataz (atazanavir, ATV)  14 ___ ___ ___ ___ ___ ___ ___ ___

Fortovase (saquinavir soft gel, SQV)  15 ___ ___ ___ ___ ___ ___ ___ ___

Norvir (ritonavir, RTV)  16 ___ ___ ___ ___ ___ ___ ___ ___

Viracept (nelfinavir, NFV)  17 ___ ___ ___ ___ ___ ___ ___ ___

Tipranavir (aptivus)  18 ___ ___ ___ ___ ___ ___ ___ ___

Interviewer Note: Tipranavir (aptivus) is not on the V.2.3 medication chart.

Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTI), also known as ‘Non-nukes’

Rescriptor (delaviridine, DLV)  19 ___ ___ ___ ___ ___ ___ ___ ___

Viramune (nevirapine, NVP)  20 ___ ___ ___ ___ ___ ___ ___ ___

Sustiva (efavirenz, EFV)  21 ___ ___ ___ ___ ___ ___ ___ ___

How many

How many How many times did

pills (or times did you miss

spoonfuls/ you miss taking a

injections) How many taking a dose or

of _______ times each dose or set of these

[medicine] day are you set of pills (or

are you supposed to these pills spoonfuls/

supposed to take these (or spoon- injections)

take each pills (or fuls/ the day

Which of these medicines time you spoonfuls/ injections) before

are you currently taking? take them? injections)? yesterday? yesterday?

Nucleoside Analogue Combinations (Combination Treatments)

Combivir (AZT+3TC)  22 ___ ___ ___ ___ ___ ___ ___ ___

Trizivir (AZT+3TC+ABC)  23 ___ ___ ___ ___ ___ ___ ___ ___

Epzicom (3TC+ABC)  24 ___ ___ ___ ___ ___ ___ ___ ___

Truvada (FTC+TDF)  25 ___ ___ ___ ___ ___ ___ ___ ___

Entry/Fusion Inhibitors

Fuzeon (enfuvirtide, T-20)  26 ___ ___ ___ ___ ___ ___ ___ ___

Other medicine 1  27 ___ ___ ___ ___ ___ ___ ___ ___

(Specify:___________________________)

Other medicine 2  28 ___ ___ ___ ___ ___ ___ ___ ___

(Specify:___________________________)

Other medicine 3  29 ___ ___ ___ ___ ___ ___ ___ ___

(Specify:___________________________)

Other medicine 4  30 ___ ___ ___ ___ ___ ___ ___ ___

(Specify:___________________________)

Refused to answer…………………  77

Don’t know……………..………...  99

Note: Drug list will be reviewed and updated as appropriate.

Note: QDS will automatically insert the name of the other medicines 1-4 coded in A31.

Interviewer instructions: If interview is conducted on Monday and any missed doses are reported for A31 “yesterday” or “the day before yesterday”, check “Yes” response for A32.

Interviewer instructions: If interview is conducted on Tuesday and any missed doses are reported for A31 “the day before yesterday”, check “Yes” response for A32.

A32. Did you miss any of your antiretroviral medicines last weekend – last Saturday or Sunday?

No…………………………………….	 00
Yes……………………………………	 01
Refused to answer……………………	 07
Don’t know…………………………...	 09

Interviewer instructions: If any missed doses are reported for A31 “yesterday” or “the day before yesterday” code A33 as “Within the past week”.

A33. When was the last time you missed any of your antiretroviral medicines? [CHECK ONLY ONE RESPONSE.]

Within the past week….…………………..……  05

1-2 weeks ago……………………...……..……  04

3-4 weeks ago…………………….……………  03

1-3 months ago…………………….………….  02

More than 3 months ago……………………...  01

Never skip medicines…………………………  00 Skip to A34

Refused to answer……..………………..........  07

Don’t know……………..………………..........  09

A33a. People may miss taking their antiretroviral medicines for various reasons. The last time you missed taking your antiretroviral medicines, what were the reasons? [CHECK ALL THAT APPLY.] [DON’T READ CHOICES.]

Forgot to take them………………………..............  01

Wanted to avoid side effects…………………….....  02

Was busy with other things.... ……………...............  03

Had a change in daily routine.……………...............  04

Had problems taking pills at specified times (with meals,

on an empty stomach, etc.).. …………….............  05

Couldn’t get to a doctor or clinic……………...........  06

Felt depressed or overwhelmed……………...........  07

Was on the street.…………………………..……..  08

Had too many pills to take…………………….......  09

Couldn’t afford a refill……………………............  10

Other ……….…………………….……………….  11

(Specify:__________________________________)

Other ……….…………………….……………….  12

(Specify:__________________________________)

Refused to answer…………………..……….….....  77

Don’t know…………………..…………..……….  99

A34. Most antiretroviral medicines need to be taken on a schedule, such as “2 times a day” or “3 times a day” or “every 8 hours”. How closely did you follow your specific schedule over the last 2 days? [USE RESPONSE CARD C.]

Never……………….….………………..……  00

Some of the time.…………………...……..……  01

About half of the time…………….……………  02

Most of the time…………………….………….  03

Always………………………………………....  04

Refused to answer…………….…...............…... . 07

Don’t know……………..………………..........  09

A35. Do any of your antiretroviral medicines have special instructions, such as “take with food” or “on an empty stomach” or “with plenty of fluids”?

N o………………….…………………..……  00 Skip to A38

Yes………………………………………..……  01

Skip to A38

Refused to answer……………………………  07

Don’t know……………..………………..........  09

A36. How often did you follow all of those special instructions over the last 2 days?

[USE RESPONSE CARD C.]

Never……………….….………………..……  00

Some of the time.…………………...……..……  01

About half of the time…………….……………  02

Most of the time…………………….………….  03

Always……...…………..……………………....  04

Refused to answer………..………………..........  07

Don’t know……………..………………..........  09

Interviewer instructions: Skip to A38

Skip to Say box before A39

37. Have you taken antiretroviral medicines in the past 12 months?

N o………………….…………………..………  00

Yes………………………………………..……  01

Skip to Say box before A39

efused to answer…………………………….  07

Don’t know……………..………………..........  09

A38. In the past 12 months, have you ever purposefully taken a “drug holiday” from your antiretroviral medicines that wasn’t recommended by your health care provider? That is did you plan to not take any doses of one or more of your antiretroviral medicines for at least two whole days in a row?

Skip to Say box before A39

o………………….…………………..……  00

Yes………………………………………..……  01

Skip to Say box before A39

Refused to answer……………………………  07

Don’t know……………..………………..........  09

A38a. For your most recent drug holiday, what were the reasons you took a drug holiday from your antiretroviral medicines? [CHECK ALL THAT APPLY.] [DON’T READ CHOICES.]

Medicine has side effects or makes me feel bad.......  01

Got tired of taking medicines/needed a break...........  02

Was partying / using drugs or alcohol.......................  03

Was on vacation…………………….......................  04

Felt good ………......................................................  05

Other ………………………………………………  06

(Specify:_________________________________)

Other ………………………………………………  07

(Specify:_________________________________)

Refused to answer……………………...............…....  77

Don’t know ……………..……..…………………...  99

A38b. I am going to read a list of the reasons you just gave me for taking your most recent drug holiday. What was the main reason that you took a drug holiday from your antiretroviral medicines? [CHECK ONLY ONE RESPONSE.] [READ RESPONSES GIVEN IN A38a.]

Medicine has side effects or makes me feel bad.......  01

Got tired of taking medicines/needed a break...........  02

Was partying / using drugs or alcohol.......................  03

Was on vacation…………………….......................  04

Felt good ………......................................................  05

Other ………………………………………………  06

(Specify:_________________________________)

Other ………………………………………………  07

(Specify:_________________________________)

Refused to answer……………………...............…....  77

Don’t know ……………..……..…………………...  99

SAY: “HIV can develop resistance to antiretroviral medicines especially if they aren’t taken as prescribed. Once the virus develops resistance, the medicines may not work as well.”

A39. During the past 12 months, did a health care provider where you get HIV care discuss

drug resistant virus with you?

No………………….…………………..………….. 00

Yes………………………………………..……….. 01

Refused to answer…………………………………. 07

Don’t know……………..………………................. 09

A40. During the past 12 months, did a health care provider give you a test to check if your HIV

was resistant to antiretroviral medicines?

No………………….…………………..………… 00

Yes………………………………………..……... 01

Refused to answer………………………………. 07

Don’t know……………..………………............. 09

Preventive Therapy

SAY: “Now I’m going to ask you about AIDS-related infections. Many patients with HIV take medicines to prevent or treat these infections. The first of these is called tuberculosis or TB.”

A41. Have you ever had a skin test (PPD) for TB?

No……………………..………………..............  00 Skip to A42

Yes………………………..………….…………  01

Skip to A42

Refused to answer………………………………  07

Don’t know……………..……………...............  09

A41a. When did you have your most recent TB skin test?

__ __/ __ __ __ __

^{(M M / Y
Y Y Y )} [77 = Refused to answer, 99 = Don’t know]

A41b. Was your most recent skin test positive?

No……………………..………………............... 00

Yes………………………..………….…….…… 01

Refused to answer………………………….…… 07

Don’t know……………..……………...............  09

A42. In the past 12 months, have you been seen at a Tuberculosis or TB clinic?

Skip to Say Box before A43

o………………….…………………..…….… 00 Yes………………………………………..……. 01

Skip to Say Box before A43

Refused to answer……………………………… 07

Don’t know……………..………………........... 09

A42a. What is the name of the TB clinic?

Name:

A42b. Have you been seen at any other TB clinic in the past 12 months?

No………………….…………………..……  00 Skip to Say Box before A43

Yes………………………………………..….. 01

Refused to answer……………………………  07

Skip to Say Box before A43

Don’t know……………..……………….......... 09

A42c. What is the name of this TB clinic?

Name:

A42d. Have you been seen at any other TB clinic in the past 12 months?

No………………….…………………..…… . 00 Skip to Say Box before A43

Yes………………………………………..….  01

Skip to Say Box before A43

Refused to answer…………………………… 07

Don’t know……………..………………......  09

A42e. What is the name of this TB clinic?

Name:

A42f. Have you been seen at any other TB clinic in the past 12 months?

No………………….…………………..…...… 00 Skip to Say Box before A43

Yes………………………………………..…… 01

Skip to Say Box before A43

Refused to answer…………………………….. 07

Don’t know……………..……………….........  09

A42g. What is the name of this TB clinic?

Name:

SAY: “Another infection that people with HIV can get is Pneumocystis pneumonia or PCP.”

A43. Have you ever been told by health care provider that you had PCP?

No……………………..………………..............  00 Skip to A44

Yes… ……………………..………….………… 01

Skip to A44

Refused to answer………………………………  07

Don’t know……………..……………...............  09

A43a. When were you first told that you had PCP?

__ __/ __ __ __ __

^{(M M / Y
Y Y Y )} [77 = Refused to answer, 99 = Don’t know]

A44. Has a doctor or other health care provider ever prescribed medicine for you to prevent or treat PCP? This includes medicines like Bactrim (Septra, Cotrim, Co-trimoxazole), Dapsone, Pentamidine, Atovaquone, Clindamycin + Primaquine, or Dapsone + Pyrimethamine + Folinic Acid. [USE PCP AND MAC MEDICATION CARD]

No……………………..………………..............  00

Yes… ……………………..………….………… 01

Refused to answer………………………………  07

Don’t know……………..……………...............  09

Interviewer instructions: If response to A10c (lowest CD4 count ever) was ”0-49” in, go to Say Box before A45; otherwise, skip to A46.

SAY: “Another infection that people with HIV can get is Mycobacterium avium complex or MAC.”

A45. Has a doctor or other health care provider ever prescribed medicine for you to prevent or treat MAC? This includes medicines like Clarithromycin, Azithromycin, and Rifabutin. [USE PCP AND MAC MEDICATION CARD]

No…………………………………………..	 00
Yes…………………………………………..	 01
Refused to answer…………………………..	 07
Don’t know………………………….............	 09

A46. During the past 12 months, did you receive a vaccine or shot to protect you from

influenza or the “Flu”?

No…………………………………………..	 00	Skip to A47
Yes…………………………………………..	 01
Refused to answer…………………………..	 07
Don’t know………………………….............	 09	Skip to A47

A46a. Where did you receive this vaccine? [CHECK ALL THAT APPLY.] [DON’T READ CHOICES.]

My primary HIV care provider ……………	 01
A doctor who isn’t my primary HIV care provider …………………………………..	 02
A health department clinic……………..…	 03
Another type of clinic………………………	 04
A drugstore or store (like CVS , Walgreens, Target, etc)…………………………………	 05
Other (Specify:_________________________)…	 06
Refused to answer…………………………..	 07
Don’t know………………………….............	 09

A47. In the past 5 years, have you received a vaccine or shot to help protect you from developing pneumonia? This vaccine is called Pneumovax.

No…………………………………………..	 00
Yes…………………………………………..	 01
Refused to answer…………………………..	 07
Don’t know………………………….............	 09

Interviewer instructions: If DEMOGRAPHICS D14 (birth gender) and DEMOGRAPHICS D15 (self-identified gender) are “Female”, go to Say Box before A48; otherwise, skip to Say Box before A53.

R
SAY: “I’m now going to ask some questions about pelvic exams, Pap smears, and pregnancy.”
eproductive/Gynecological History

A48. Have you ever had a pelvic (vaginal) examination?

Skip to Say Box before A51

No……………………..…………………...........  00

Yes………………………..………….…………  01

Skip to Say Box before A51

Refused to answer………………………………  07

Don’t know……………..……………….............  09

A48a. When was your most recent pelvic (vaginal) examination?

__ __/ __ __ __ __

^{(M M / Y
Y Y Y )} [77 = Refused to answer, 99 = Don’t know]

A48b. Where was this pelvic (vaginal) exam done? [CHECK ONLY ONE RESPONSE.] [READ CHOICES.]

Where you usually get HIV health care…..	 01
Where you usually get medical care that isn’t for HIV.……………………………..	 02
In a different clinic or doctor’s office (not at usual source of HIV or primary care)…...…	 03
At an OB/GYN office………………………	04
Other (Specify:___________________________)	 05
Refused to answer…………………………..	 07
Don’t know………………………….............	 09

A48c. At your most recent pelvic exam, did you have a Pap smear? A Pap smear (also called a cervical cancer test or Pap test) is a specific test used to check for cancer of the cervix.

No……………………..…………………..…...... 00

Yes………………………..………….……..…… 01 Skip to A50

Skip to Say Box before A51

Refused to answer……………………………..… 07

Don’t know………….…..……………...............  09

Skip to Say Box before A51

49. Have you ever had a Pap smear?

No……………………..……………………..... . 00

Yes………………………..………….…….…… 01

Skip to Say Box before A51

Refused to answer……………………………… 07

Don’t know………….…..……………............... 09

A49a. When was your last Pap smear?

__ __/ __ __ __ __

^{(M M / Y
Y Y Y )} [77 = Refused to answer, 99 = Don’t know]

^{A50. Have
you ever
had a Pap smear where the results weren’t
normal?}

No…………………………………………….	00	Skip to A51
Yes………………………..………….……….	01
Refused to answer……………………………	07
Don’t know………….…..……………...........	09	Skip to A51

A50a. Did you receive a follow-up exam or treatment for this abnormal result?

No…………………………………………..	 00
Yes…………………………………………..	 01
Refused to answer…………………………..	 07
Don’t know………………………….............	 09

SAY: “Now I would like to ask you some questions about any pregnancies you had after you learned you had HIV?”

A51. How many times have you been pregnant after you learned you had HIV?

___ ___ [77 = Refused to answer, 99 = Don’t know]

Interviewer instructions: If response to A51 is “0”, 77, or 99, skip to Say Box before A53. If response to A51 is “1”, go to A51a. If response to A51 is greater than 1, skip to Say Box before A52.

A51a. Were you trying to get pregnant?

No…………………………………………..	 00
Yes…………………………………………..	 01
Refused to answer…………………………..	 07
Don’t know………………………….............	 09

A51b. What was the outcome of this pregnancy? [READ CHOICES.]

Abortion……………………………………...	 01
Stillbirth………………………………………	 02	Skip to A51d
Live birth……………………………………..	 03
Currently pregnant……………………………	 04
Refused to answer……………………………	 07
Don’t know…………………………………...	 09	Skip to A51d

A51c. What is your due date?

__ __ / __ __ / __ __ __ __ [77 = Refused to answer, 99 = Don’t know]

M M D D Y Y Y Y

Interviewer instructions: Skip to Say Box before A53.

A51d. In what month and year did this outcome occur?

__ __ / __ __ __ __ [77 = Refused to answer, 99 = Don’t know]

M M Y Y Y Y

Interviewer instructions: Skip to Say Box before A53.

SAY: Now I would like to ask about each of your pregnancies after you learned you had HIV. Let’s begin with your first pregnancy and talk about each one up to the present.

A52. For the first pregnancy after you learned you had HIV, were you trying to get pregnant?

No……………………..………………….…..... 00

Yes………………………..………….…….…… 01

Refused to answer……………………….……… 07

Don’t know………….…..………………............ 09

A52a. What was the outcome of this pregnancy? [READ CHOICES.]

Abortion……………………………………...	01
Stillbirth………………………………………	02
Live birth……………………………………..	03
Refused to answer……………………………	07
Don’t know…………………………………...	09

A52b. For the second pregnancy after you learned you had HIV, were you trying to get

pregnant?

No……………………..………………….…..... 00

Yes………………………..………….…….…… 01

Refused to answer……………………….……… 07

Don’t know………….…..………………............ 09

A52c. What was the outcome of this pregnancy? [READ CHOICES.]

Abortion……………………………………...	01
Stillbirth………………………………………	02	Skip to Interviewer instructions before A52e.
Live birth……………………………………..	03
Currently pregnant……………………………	04
Refused to answer……………………………	07	Skip to Interviewer instructions before A52e.
Don’t know…………………………………...	09

A52d. What is your due date?

__ __ / __ __ / __ __ __ __ [77 = Refused to answer, 99 = Don’t know]

M M D D Y Y Y Y

Interviewer instructions: If response to A51 is “2”, skip to Say Box before A53.

A52e. For the third pregnancy after you learned you had HIV, were you trying to get pregnant?

No……………………..………………….…..... 00

Yes………………………..………….…….…… 01

Refused to answer……………………….……… 07

Don’t know………….…..………………............ 09

A52f. What was the outcome of this pregnancy? [READ CHOICES.]

Abortion……………………………………...	01
Stillbirth………………………………………	02	Skip to Interviewer instructions before A52h.
Live birth……………………………………..	03
Currently pregnant……………………………	04
Refused to answer……………………………	07	Skip to Interviewer instructions before A52h.
Don’t know…………………………………...	09

A52g. What is your due date?

__ __ / __ __ / __ __ __ __ [77 = Refused to answer, 99 = Don’t know]

M M D D Y Y Y Y

Interviewer instructions: If response to A51 is “3”, skip to Say Box before A53.

A52h. For the fourth pregnancy after you learned you had HIV, were you trying to get pregnant?

No……………………..………………….…..... 00

Yes………………………..………….…….…… 01

Refused to answer……………………….……… 07

Don’t know………….…..………………............ 09

A52i. What was the outcome of this pregnancy? [READ CHOICES.]

Abortion……………………………………...	01
Stillbirth………………………………………	02	Skip to Say Box before A53.
Live birth……………………………………..	03
Currently pregnant……………………………	04
Refused to answer……………………………	07	Skip to Say Box before A53.
Don’t know…………………………………...	09

A52g. What is your due date?

__ __ / __ __ / __ __ __ __ [77 = Refused to answer, 99 = Don’t know]

M M D D Y Y Y Y

Note: QDS will allow for all possible pregnancies that participant describes.

Health Conditions

SAY: “The next questions are about health conditions other than HIV that you may have had. The first is about Hepatitis, an infection of the liver.”

A53. Have you ever had a blood test to check or screen for hepatitis infection?

No……………………..………………….…...... 00 Skip to A54

Yes………………………..………….…….…… 01

Skip to A54

Refused to answer…………………………….… 07

Don’t know………….…..………………...........  09

A53a. There are several different types of hepatitis, such as hepatitis A, B, and C. Which types of hepatitis infections were you tested for? [READ CHOICES.]

	Yes	No	Refused	Don’t know
Hepatitis A				
Hepatitis B				
Hepatitis C				
Other (Specify:____________________)		
Other (Specify:____________________)		

A54. Has a doctor, nurse or other health care provider ever told you that you had hepatitis?

Skip to Say box before A55

o………………….……………………………  00

Yes………………………….…………...............  01

Skip to Say box before A55

efused to answer……………………………….  07

Don’t know……………..……………................  09

A54a. What type or types of hepatitis have you had? [READ CHOICES.]

	Yes	No	Refused	Don’t know
Hepatitis A				
Hepatitis B				
Hepatitis C				
Other (Specify:____________________)		
Other (Specify:____________________)		

SAY: “There are vaccinations or shots for prevention of Hepatitis A and Hepatitis B. Now I am going to ask you whether you have received any of these vaccines. Don’t include shots of immunoglobulin (also called IgG) that you may have received to prevent infection after a known exposure to someone with Hepatitis A or B.”

A55. Have you ever received any vaccinations for hepatitis?

No………………….……………………………  00 Skip to A56a

Yes……………………………………............... . 01

Skip to Say Box before A57

efused to answer…………………..…………..  07

Don’t know……..…………………...…………  09

A56. When you were vaccinated for Hepatitis, did you receive the Hepatitis A vaccine alone (which is usually 2 shots), B vaccine alone (which is usually 3 shots), or the Combination A and B vaccine (which is usually 3 shots)? [CHECK ALL THAT APPLY.]

Hepatitis A alone………………….……………. 01

Hepatitis B alone………………….……………. 02

Hepatitis A and B in combination.……………..  03

Refused to answer…………………..…………..  07

Don’t know……..…………………...…………  09

Interviewer instructions: After recording response, skip to Say Box before A57.

A56a. What are the reasons that you didn’t receive any vaccinations to prevent hepatitis?

[CHECK ALL THAT APPLY.] [DON’T READ CHOICES.]

I have already had hepatitis……………...…...	01
I currently have hepatitis ……………………	02
My doctor told me I don’t need the vaccine …	03
Costs too much/Insurance doesn’t cover vaccinations…………………………………..	04
I plan to get vaccinated, but I haven’t had time yet……………………………………….	05
I don’t believe I am at risk for contracting hepatitis………………………………………	06
I don’t want to get the vaccination…………...	07
I don’t like needles…………………………...	08
I don’t trust doctors…………………………..	09
I don’t think the vaccination is effective....…..	10
I didn’t know the vaccine existed.....................	11
Afraid the vaccine will make me sick..............	12
Other…………………………………………. (Specify:____________________________)	13
Refused to answer……………………………	77
Don’t know	99

SAY: “Now I’m going to ask you some questions about sexually transmitted diseases or STDs”.

A57. In the past 12 months, did you have a test to check for any of the following: [READ

CHOICES.]

Yes No Refused Don’t know

a. Syphilis    

b. Gonorrhea (“clap” or “drip”)    

c. Chlamydia    

d. Herpes (HSV)    

e. Genital warts (HPV)    

Interviewer instructions: Only ask A57f if response to DEMOGRAPHICS D14 (birth gender) is “Male” and DEMOGRAPHICS D15 (self-identified gender) is “Male”, OR if response to DEMOGRAPHICS D14 is “Female” and DEMOGRAPHICS D15 is “Male” or “Transgender”.

f. Non-gonococcal urethritis (NGU)    

g. Other  

(Specify:____________________)

A58. In the past 12 months, has a doctor, nurse, or other health care provider told you that you

had any of the following: [READ CHOICES.]

Yes No Refused Don’t know

a. Syphilis    

b. Gonorrhea (“clap” or “drip”)    

c. Chlamydia    

d. Herpes (HSV)    

e. Genital warts (HPV)    

Interviewer instructions: Only ask A58f if response to DEMOGRAPHICS D14 (birth gender) is “Male” and DEMOGRAPHICS D15 (self-identified gender) is “Male”, OR if response to DEMOGRAPHICS D14 is “Female” and DEMOGRAPHICS D15 is “Male” or “Transgender”.

f. Non-gonococcal urethritis (NGU)    

g. Other  

(Specify:____________________)

A59. During the past 12 months, have you gone to an STD clinic for testing, diagnosis or

treatment of a sexually transmitted disease?

Skip to the Next Module

o………………….…………………………… 00

Yes……………………………………................ 01

Skip to the Next Module

efused to answer…………………..…………..  07

Don’t know……..…………………...…………  09

A59a. What is the name of the STD clinic?

Name:

A59b. Have you been to any other STD clinic in the past 12 months?

Skip to the Next Module

No………………….…………………..……  00 Yes………………………………………..……  01

Skip to the Next Module

Refused to answer……………………………  07

Don’t know……………..………………..........  09

A59c. What is the name of this STD clinic?

Name:

A59d. Have you been to any other STD clinic in the past 12 months?

Skip to the Next Module

No………………….…………………..……….  00 Yes………………………………………..…….. 01

Skip to the Next Module

Refused to answer……………………………  07

Don’t know……………..………………..........  09

A59e. What is the name of this STD clinic?

Name:

A59f. Have you been to any other STD clinic in the past 12 months?

Skip to the Next Module

No………………….…………………..……….. 00 Yes………………………………………..…….. 01

Skip to the Next Module

Refused to answer……………………………  07

Don’t know……………..………………..........  09

A59g. What is the name of this STD clinic?

Name:

UNMET NEEDS

SAY: “Now I am going to ask you some questions about your need for services related to HIV.”

In the past 12 months, have you needed any of these services: [Show RESPONSE CARD F.]

Interviewer instructions: If response to N1a is “No”, 07 or 09, skip to N2a; otherwise, go to N1b. If response to N1b is “Yes”, 07 or 09, skip to N2a; otherwise, go to N1c. Follow the same pattern for N1-N14.

		[Needed this service in the past 12 months?]	If “Yes” in N1a-N14a, ask: Have you been able to get this service in the past 12 months?	If “No” in N1b-N14b, ask: What was the main reason you haven’t been able to get this service?
		CODE: No = 00, Yes = 01, Refused to answer= 07, Don’t know = 09	CODE: No = 00, Yes = 01, Refused to answer= 07, Don’t know = 09	CODE: See code list below for responses. [ENTER ONLY ONE RESPONSE] [DON’T READ CHOICES.]
N1.	HIV case management services	a. [______]	b. [______]	c. [______]
N2.	Mental health counseling	a. [______]	b. [______]	c. [______]
N3.	Social services, such as insurance assistance or financial counseling	a. [______]	b. [______]	c. [______]
N4.	Assistance in finding a doctor for ongoing medical services	a. [______]	b. [______]	c. [______]
		[Needed this service in the past 12 months?]	If “Yes” in N1a-N14a, ask: Have you been able to get this service in the past 12 months?	If “No” in N1b-N14b, ask: What was the main reason you haven’t been able to get this service?
		CODE: No = 00, Yes = 01, Refused to answer= 07, Don’t know = 09	CODE: No = 00, Yes = 01, Refused to answer= 07, Don’t know = 09	CODE: See code list below for responses. [ENTER ONLY ONE RESPONSE] [DON’T READ CHOICES.]
N5.	Assistance in finding dental services	a. [______]	b. [______]	c. [______]
N6.	Adherence support services	a. [______]	b. [______]	c. [______]
N7.	Home health services, such as home nursing care or assistance	a. [______]	b. [______]	c. [______]
N8.	Chore or homemaker services (paid or volunteer)	a. [______]	b. [______]	c. [______]
N9.	Assistance in finding shelter or housing	a. [______]	b. [______]	c. [______]
N10.	Assistance with finding meals or food	a. [______]	b. [______]	c. [______]
N11.	Transportation assistance	a. [______]	b. [______]	c. [______]
N12.	Childcare services	a. [______]	b. [______]	c. [______]
N13.	Education or information on HIV risk reduction	a. [______]	b. [______]	c. [______]
N14.	Other (Specify:___________________)	a. [______]	b. [______]	c. [______]

Interviewer instructions: For N1c-N14c: [ENTER ONLY ONE RESPONSE.] [DON’T READ CHOICES.]

I don’t know where to go or who to call
Didn’t complete application process
The system is too confusing
The waiting list is too long
It isn’t available in my area
They charge too much
I don’t have the money to pay
Transportation problems
Language barrier

10. Not eligible / Denied services

11. I’m too sick to get out

12. Other (Specify)

77. Refused to answer

99. Don’t know

SEXUAL BEHAVIOR

SAY:” Next, I'm going to ask you some questions about having sex. Please remember your answers will be kept private.”

“For these questions, "having sex" means oral sex - mouth on the vagina or penis; vaginal sex - penis in the vagina; and anal sex - penis in the anus (butt). Also, “sex without a condom” includes any acts where you only used a condom part of the time. I need to ask you all the questions, even if some may not apply to your situation.”

Interviewer instructions: Use your discretion in using slang terms for the following sexual behavior questions.

Interviewer instructions: Refer to Demographics D14 (birth gender) and DEMOGRAPHICS D15 (self-identified gender):

If both are coded as “Male”, go to S1.

If both are coded as “Female”, skip to S6.

If one variable is coded as “Male” and the other as “Female”, or if Demographics D15 is coded as “Transgender”, skip to Say Box before S9.

Otherwise, skip to the next module.

Male Respondent – Female Partner

S1. In the past 12 months, with how many different women have you had oral, anal, or vaginal sex?

______ ______ ______ [77 = Refused to answer, 99 = Don’t know]

Interviewer instructions: If “0”, 77, or 99, skip to S3.

Multiple Female Partners

[Read questions in this column]

No = 00, Yes = 01, Refused to answer= 77, Don’t know = 99

One Female Partner

[Read questions in this column]

No = 00, Yes = 01, Refused to answer= 77, Don’t know = 99

Question

Response

Skip Pattern

Question

Response

Skip Pattern

S2a. Of your ______ [response from S1] female partners in the past 12 months, with how many did you have vaginal sex where you put your penis in her vagina?

[_____]

If “0”, 77, or 99 skip to S2c.

If “0”, don’t ask S2j and S2k.

S2a. In the past 12 months, did you have vaginal sex with this woman where you put your penis in her vagina?

[_____]

If “No”, 77, or 99 skip to S2c.

If “No”, don’t ask S2j and S2k.

S2b. Of these ______ [response from S2a] women, with how many did you have vaginal sex without a condom in the past 12 months?

[_____]

If “0”, 77, or 99 skip to S2e.

S2b. Did you have vaginal sex with her without a condom in the past 12 months?

[_____]

If “No”, 77, or 99 skip to S2e.

S2c. Of your ______ [response from S1] female partners in the past 12 months, with how many did you have anal sex where you put your penis in her anus (butt)?

[_____]

If “0”, don’t ask S2l and S2m.

S2c. In the past 12 months, did you have anal sex with this woman where you put your penis in her anus (butt)?

[_____]

If “No”, don’t ask S2l and S2m.

S2d. Of these ______ [response from S2c] women, with how many did you have anal sex without a condom in the past 12 months?

[_____]

S2d. Did you have anal sex without a condom with her in the past 12 months?

[_____]

S2e. Of your ____ [response from S1] female partners in the past 12 months, with how many did you discuss BOTH your HIV status and their HIV status before you had sex for the first time?

[_____]

If “0”, don’t ask S2q.

The version of this question is asked in S2q.

2f. In the past 12 months, did you have sex with any of these partners in exchange for things like money, drugs, food, shelter or transportation?

No….……………………………………..……..  00 Skip to Say Box before S2h

Yes………………………………………………  01

Refused to answer…………………..…...……...  07 Skip to Say Box before S2h

Don’t know…………….…………………........  09

S2g. Did you give them things in exchange for sex or did they give you things in exchange for sex or both? [CHECK ONLY ONE RESPONSE] [DON’T READ CHOICES.]

I gave them things in exchange for sex….…….  01

They gave me things in exchange for sex ……  02

They gave me things and I gave them things……  03

Refused to answer…………………..…...………  07

Don’t know…………….…………………........  09

SAY: “Now I would like you to think about the last time you had sex with a female partner.”

S2h. When was the last time you had oral, anal, or vaginal sex with your most recent female partner?

__ __/ __ __ __ __ [77 = Refused to answer, 99 = Don’t know]

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

S2i. Was the woman you had sex with that last time a main or casual partner?

By “main partner” I mean a woman you have sex with and who you feel committed to above anyone else. This is a partner that you would call your girlfriend, wife, significant other, or life partner. By “casual partner” I mean a woman you have sex with, but do not feel committed to or don’t know very well.

Main……………….……………….…………...  01

Casual……………………………….……..........  02

Refused to answer………………………..……..  07

Don’t know.……………..………………..........  09

Interviewer instructions: If S2a is “0” or “No”, then skip to S2l

S2j. When you had sex that last time, did you have vaginal sex where you put your penis in her vagina?

Skip to S2l

No………………….……………….…………...  00

Yes….……………………………….……..........  01

Skip to S2l

Refused to answer………………………..……..  07

Don’t know.……………..………………..........  09

S2k. During vaginal sex with that partner, did you use a condom none of the time, part of the time or the whole time? [CHECK ONLY ONE RESPONSE.] [DON’T READ CHOICES.]

None of time ….…………………….…....…….. 00

Part of the time …………………………………  01

The whole time ……………….……….....……..  02

Refused to answer.…………………..…….……  07

Don’t know……....……………………...…......  09

Interviewer instructions: If S2c is “0” or “No”, then skip to S2n

Go to confirmation

message below

2l. When you had sex that last time, did you have anal sex where you put your penis in her anus (butt)?

Skip to S2m

No………………………………………………. 00

Yes……………………………………..……….. 01

Skip to S2n

Refused to answer………………….…………..  07

Don’t know…….…………………………........  09

Confirmation message: If S2j and S2l are "No," ask the following: "So this means you only had oral sex the last time you had sex?" If “No”, return to S2j.

S2m. During anal sex with that partner, did you use a condom none of the time, part of the time or the whole time? [CHECK ONLY ONE RESPONSE.] [DON’T READ CHOICES..]

None of time ………………….…….…....…….  00

Part of the time …………………………………  01

The whole time ………………….…….....…….  02

Refused to answer…………………..…….…….  07

Don’t know……………..……………...…........  09

S2n. Before or during the last time you had sex with this partner, did you use:

[CHECK ONLY ONE RESPONSE.] [READ CHOICES.]

Alcohol…..….….………………..……………...  01 Drugs………..……………………………..……  02

Alcohol and drugs ……………………......…….  03

Neither one….……………..…..…...….………..  04

Refused to answer.………..…….……...…….…  07

Don’t know…..…..……….….….…….…...…..  09

S2o. The last time you had sex with this partner, did you know her HIV status?

No………………….……………….…………...  00 Skip to S2q

Yes….……………………………….……..........  01

Partner hadn't been tested….…………………..  02

Refused to answer………………………..……..  07 Skip to S2q

Don’t know.……………..………………..........  09

S2p. What was her HIV status?

HIV-negative……………………………..…......  01

HIV-positive…...….…………………..………..  02

Indeterminate……………………………..…….  03

Refused to answer.……………………………...  07

Interviewer instructions: If S2e is “0”, skip to S3.

S2q. Before you had sex with this partner for the first time, did you discuss BOTH your HIV status and her HIV status?

No………………….………….………………...  00

Yes………………………………..…………......  01

Refused to answer…………………………..…...  07

Don’t know……………..………….……….......  09

Male Respondent - Male Partner

S3. In the past 12 months, with how many different men have you had anal or oral sex?

___ ___ ___ [Refused to answer = 77, Don’t know = 99]

Interviewer instructions: If “0”, 77, or 99, skip to the next module

Multiple male Partners

[Read questions in this column]

No = 00, Yes = 01, Refused to answer= 77, Don’t know = 99

One male Partner

[Read questions in this column]

No = 00, Yes = 01, Refused to answer = 77, Don’t

know = 99

Question

Response

Skip Pattern

Question

Response

Skip Pattern

S4a. Of your ______ [response from S3] male partners in the past 12 months, with how many did you have anal sex? By anal sex, I mean penis in the anus (butt).

[_____]

If “0”, 77, or 99 skip to S4c.

If “0”, don’t ask S4d and S4i – S4l.

S4a. In the past 12 months did you have anal sex with this man? By anal sex, I mean penis in the anus (butt).

[_____]

If “No”, 77, or 99 skip to S4c.

If “No”, don’t ask S4d and S4i – S4l.

S4b. Of these ______ [response from S4a] men, with how many did you have anal sex without a condom in the past 12 months?

[_____]

S4b. Did you have anal sex without a condom with him in the past 12 months?

[_____]

S4c. Of your ____ [response from S3] male partners in the past 12 months, with how many did you discuss BOTH your HIV status and their HIV status before you had sex for the first time?

[_____]

If “0”, don’t ask S4p.

The version of this question is asked in S4p.

Interviewer instructions: If S4a is “0” or “No”, then skip to S4e

S4d. In the past 12 months, when you had anal sex with those ______ [response from S4a] partners, did you have insertive anal sex (where you were the top) or receptive anal sex (where you were the bottom) or both? [CHECK ONLY ONE RESPONSE.] [DON’T READ CHOICES.]

I was insertive partner……………….….………. 01

I was receptive partner………………..………… 02

Both………………….………………..………… 03

Refused to answer…………………..…...……..  07

Don’t know…………….…………………........  09

S 4e. In the past 12 months, did you have sex with any of the ______ [RESPONSE FROM S3] partners in exchange for things like money, drugs, food, shelter, or transportation?

No….……………………………………..…….  00 Skip to Say Box before S4g

Yes………………………………………………  01

Refused to answer…………………..…...……...  07 Skip to Say Box before S4g

Don’t know…………….…………………........  09

S4f. Did you give them things in exchange for sex or did they give you things in exchange for sex or both? [CHECK ONLY ONE RESPONSE.] [DON’T READ CHOICES.]

I gave them things in exchange for sex….……... 01

They gave me things in exchange for sex……… 02

They gave me things and I gave them things…… 03

Refused to answer…………………..…...……..  07

Don’t know…………….…………………........  09

SAY: “Now I would like you to think about the last time you had sex with a male partner.”

S4g. When was the last time you had anal or oral sex with your most recent male partner?

__ __/ __ __ __ __

^{(M M / Y
Y Y Y )} [77 = Refused to answer, 99 = Don’t know]

S4h. Was this man a main partner or casual partner? By “main partner” I mean a man you have sex with and who you feel committed to above anyone else. This is a partner that you would call your boyfriend, husband, significant other, or life partner. By “casual partner” I mean a man you have sex with, but do not feel committed to or don’t know very well.

Main……………….……………….………….... 01

Casual……………………………….……..........  02

Refused to answer………………………..……..  07

Don’t know.……………..………………..........  09

Interviewer instructions: If S4a is “0” or “No”, then skip to S4m

S4i. When you had sex that last time, did you have receptive anal sex where he put his penis in your anus (butt)?

No………………….……………….…………...  00 Skip to S4k

Yes….……………………………….……..........  01

Skip to S4k

Refused to answer………………………..……... 07

Don’t know.……………..………………...........  09

S4j. During receptive anal sex with that partner, did he use a condom none of the

time, part of the time, or the whole time? [CHECK ONLY ONE RESPONSE.] [DON’T READ CHOICES.]

None of time ….…………………….…....…….  00

Part of the time …………………………………  01

The whole time ……………….……….....…….  02

Refused to answer.…………………..…….……  07

Don’t know……....……………………...…......  09

Go to confirmation messages Below

4k. When you had sex that last time, did you have insertive anal sex where you put your penis in his anus (butt)?

No……………………………………………….  00

Skip to S4l

Yes……………………………………..………..  01

Skip to S4m

Refused to answer………………….…………..  07

Don’t know…….………………………….........  09

Confirmation message: If S4i and S4k are "No," ask the following: "So this means you only had oral sex the last time you had sex?" If “No”, return to S4i.

S4l. During insertive anal sex with that partner, did you use a condom none of the time, part of the time, or the whole time? [CHECK ONLY ONE RESPONSE.] [DON’T READ CHOICES.]

None of time ………………….…….…....…….  00

Part of the time …………………………………  01

The whole time ………………….…….....…….  02

Refused to answer…………………..…….……. 07

Confirmation message: If S4i and S4k are "No," say the following: "So this means you only had oral sex the last time you had sex?" If “No”, return to S4i.

S4m. Before or during the last time you had sex with this partner, did you use:

[CHECK ONLY ONE RESPONSE.] [READ CHOICES.]

Alcohol…..….….………………..……………...  01 Drugs………..……………………………..……  02

Alcohol and drugs ……………………......…….  03

Neither one….……………..……..….………….  04

Refused to answer.………..…..……...…….…..  07

Don’t know…..…..……….…...…….…...….....  09

S4n. The last time you had sex with this partner, did you know his HIV status?

No………………….……………….…………...  00 Skip to S4p

Yes….……………………………….……..........  01

Partner hadn't been tested….…………………..  02

Refused to answer………………………..……..  07 Skip to S4p

Don’t know.……………..………………..........  09

S4o. What was his HIV status?

HIV-negative……………………………..…….  01

HIV-positive…...….…………………..………...  02

Indeterminate……………………………..……..  03

Refused to answer.……………………………..  07

Interviewer instructions: If S4c is “0”, then skip to S5

S4p. Before you had sex with this partner for the first time, did you discuss BOTH your HIV status and his HIV status? No………………….………….………………...  00

Yes………………………………..…………...... 01

Refused to answer…………………………..…... 07

Don’t know……………..………….……….......  09

S5.

The next question is about whether you have told people that you are attracted

to men and/or have sex with men. I'll read a list of people you may have told, please tell me which ones apply. I need to ask you all the questions, even if some may not apply to your situation. Have you told any: [CHECK ALL THAT APPLY.] [READ CHOICES.]

Gay, lesbian, or bisexual friends…………………………. 01

Friends who are not gay, lesbian, or bisexual……………. 02

Family members……………………..………................... 03

Spouse or partner……..…………….………...………….. 04

Health care providers…………………………………….. 05

Someone else…………………………………………………………. 06

Haven’t told anyone….…………………….…………….. 07

Refused to answer……………………………..……………………… 77

Don’t know………….………………………………………………… 99

Confirmation message: if no boxes are checked, interviewer must confirm that respondent hasn’t told anyone, and then check the “Haven’t told anyone” response.

Interviewer instructions: Skip to the next module.

Female Respondent - Male Partner

S6. In the past 12 months, with how many different men have you had oral, anal, or vaginal sex?

___ ___ ___

[Refused to answer = 77, Don’t know = 99]

Interviewer instructions: If S6 is “0”, 77, or 99, skip to S7.

Multiple Male Partners

[Read questions in this column]

No = 00, Yes = 01, Refused to answer = 77, Don’t know = 99

One male Partner

[Read questions in this column]

No = 00, Yes = 01, Refused to answer = 77, Don’t know = 99

Question

Response

Skip Pattern

Question

Response

Skip Pattern

S6a. Of your ____ [response from S6] male partners in the past 12 months, with how many did you have vaginal sex where he put his penis in your vagina?

[_____]

If “0”, 77, or 99 skip to S6c.

If “0”, don’t ask S6j and S6k.

S6a. In the past 12 months did you have vaginal sex with this man where he put his penis in your vagina?

[_____]

If “No”, 77, or 99 skip to S6c.

If “No”, don’t ask S6j and S6k.

S6b. Of these ____ [response from S6a] men, with how many did you have vaginal sex without a condom in the past 12 months?

[_____]

S6b. Did you have vaginal sex without a condom with him in the past 12 months?

[_____]

S6c. Of your ____ [response from S6] male partners in the past 12 months, with how many did you have anal sex where he put his penis in your anus (butt)?

[_____]

If “0”, 77, or 99 skip to S6e.

If “0”, don’t ask S6l and S6m.

S6c. In the past 12 months, did you have anal sex with this man where he put his penis in your anus (butt)?

[_____]

If “No”, 77, or 99 skip to S6e.

If “No”, don’t ask S6l and S6m.

S6d. Of these______ [response from S6c] men, with how many did you have anal sex without a condom in the past 12 months?

[_____]

S6d. Did you have anal sex without a condom with him in the past 12 months?

[_____]

S6e. Of your ____ [response from S6] male partners, with how many did you discuss BOTH your HIV status and their HIV status before you had sex for the first time?

[_____]

If “0”, don’t ask S6q.

The version of this question is asked in S6q.

S6f. In the past 12 months, did you have sex with any of these partners in exchange for things like money, drugs, food, shelter or transportation?

No….……………………………………..……..  00 Skip to Say Box before S6h

Yes……………………………………………… 01

Refused to answer…………………..…...……...  07 Skip to Say Box before S6h

Don’t know…………….…………………........  09

S6g. Did you give them things in exchange for sex or did they give you things in exchange for sex

or both? [CHECK ONLY ONE RESPONSE.] [DON’T READ CHOICES.]

I gave them things in exchange for sex….……  01

They gave me things in exchange for sex………  02

They gave me things and I gave them things…  03

Refused to answer…………………..…...………  07

Don’t know…………….…………………........  09

SAY: “Now I would like you to think about the last time you had sex with a male partner.”

S6h. When was the last time you had oral, anal, or vaginal sex with your most recent male partner?

__ __/ __ __ __ __

^{(M M / Y
Y Y Y )} [77 = Refused to answer, 99 = Don’t know]

S6i. Was this man a main partner or casual partner? By “main partner” I mean a man you have sex with and who you feel committed to above anyone else. This is a partner that you would call your boyfriend, husband, significant other, or life partner. By “casual partner” I mean a man you have sex with, but do not feel committed to or don’t know very well.

Main……………….……………….…………...  01

Casual……………………………….……..........  02

Refused to answer………………………..……..  07

Don’t know.……………..………………..........  09

Interviewer instructions: If S6a is “0”or “No”, then skip to S6l

S6j. When you had sex that last time, did you have vaginal sex where he put his penis in your vagina?

No………………….……………………………  00 Skip to S6l

Yes……………………………………………...  01

Refused to answer………………………………  07 Skip to S6l

Don’t know……………..…………....................  09

S6k. During vaginal sex with that partner, did he use a condom none of the time, part of the

time, or the whole time? [CHECK ONLY ONE RESPONSE.] [DON’T READ CHOICES.]

None of time ….…………………….…....…….. 00

Part of the time …………………………………  01

The whole time ……………….……….....…….  02

Refused to answer.…………………..…….……  07

Don’t know……....……………………...…......  09

Interviewer instructions: If S6c is “0”or “No”, then skip to S6n

Go to confirmation message below

6l. When you had sex that last time, did you have anal sex where he put his penis in your anus (butt)?

Skip to S6m

No……………………………………………….  00

Yes……………………………………..……….. 01

Skip to S6n

Refused to answer………………….…………… 07

Don’t know…….………………………….........  09

Confirmation message: If S6j and S6l are “No”, ask the following: “So this means you only had oral sex the last time you had sex?” If “No”, return to S6j.

Confirmation message: If S6c is “No” and S6l is “Yes”, ask the following: "So you said before you didn’t have anal sex with any of your male partners in the past 12 months. Is this correct? [Revise answers to S6c and/or S6l as needed]

S6m. During anal sex with that partner, did he use a condom none of the time, part of the time, or the whole time? [CHECK ONLY ONE RESPONSE.] [DON’T READ CHOICES.]

None of time ………………….…….…....…….  00

Part of the time …………………………………  01

The whole time ………………….…….....…….  02

Refused to answer…………………..…….…….  07

Don’t know……………..……………...…........  09

S6n. Before or during the last time you had sex with this partner, did you use:

[CHECK ONLY ONE RESPONSE.] [READ CHOICES.]

Alcohol…..….….………………..……………...  01 Drugs………..……………………………..……  02

Alcohol and drugs ……………………......…….  03

Neither one….……………..…..…...….………..  04

Refused to answer.………..…….……...…….…  07

Don’t know…..…..……….….….…….…...…..  09

S6o. The last time you had sex with this partner, did you know his HIV status?

No………………….……………….…………...  00 Skip to S6q

Yes….……………………………….…….........  01

Partner hadn't been tested….…………………..  02

Refused to answer………………………..……..  07 Skip to S6q

Don’t know.……………..………………..........  09

S6p. What was his HIV status?

HIV-negative……………………………..…......  01

HIV-positive…...….…………………..………..  02

Indeterminate……………………………..…….  03

Refused to answer.……………………………...  07

Interviewer instructions: If S6e is “0”, skip to S7.

S6q. Before you had sex with this partner for the first time, did you discuss BOTH your HIV status and his HIV status?

No………………….………….………………...  00

Yes………………………………..…………......  01

Refused to answer…………………………..…...  07

Don’t know……………..………….……….......  09

Female Respondent - Female Partner

S7. In the past 12 months, how many different women have you had sex with?

___ ___ ____ [Refused to answer = 77, Don’t know = 99]

Interviewer instructions: If S7=”0”, 77 or 99, skip to the next module

S7a. When was the last time you had sex with your most recent female partner?

__ __/ __ __ __ __ [77 = Refused to answer, 99 = Don’t know]

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

S7b. Was the woman you had sex with that last time a main or casual partner?

Main……………….……………….…………...  01

Casual……………………………….……..........  02

Refused to answer………………………..……..  07

Don’t know.……………..………………..........  09

S7c. Before or during the last time you had sex with this partner, did you use:

[CHECK ONLY ONE RESPONSE.] [READ CHOICES.]

Alcohol…..….….………………..……………...  01 Drugs………..……………………………..……  02

Alcohol and drugs ……………………......…….  03

Neither one….……………..…..…...….………..  04

Refused to answer.………..…….……...…….…  07

Don’t know…..…..……….….….…….…...…..  09

S7d. The last time you had sex with this partner, did you know her HIV status?

No………………….……………….…………...  00 Skip to S7f

Yes….……………………………….……..........  01

Partner hadn't been tested….…………………..  02

Refused to answer………………………..……..  07 Skip to S7f

Don’t know.……………..………………..........  09

S7e. What was her HIV status?

HIV-negative……………………………..…......  01

HIV-positive…...….…………………..………..  02

Indeterminate……………………………..…….  03

Refused to answer.……………………………...  07

S7f Before you had sex with this partner for the first time, did you discuss BOTH your HIV status and her HIV status?

No………………….………….………………...  00

Yes………………………………..…………......  01

Refused to answer…………………………..…...  07

Don’t know……………..………….……….......  09

S8. The next question is about whether you have told people that you are attracted to women and/or have sex with women. I'll read a list of people you may have told, please tell me which ones apply. I need to ask you all the questions, even if some may not apply to your situation. Have you told any: [CHECK ALL THAT APPLY.] [READ CHOICES.]

Gay, lesbian, or bisexual friends…………………………. 01

Friends who are not gay, lesbian, or bisexual……………. 02

Family members……………………..………................... 03

Spouse or partner……..…………….………...………….. 04

Health care providers…………………………………….. 05

Someone else…………………………………………………………. 06

Haven’t told anyone….…………………….…………….. 07

Refused to answer……………………………..………………………77

Don’t know………….………………………………………………..99

Confirmation message: If no boxes are checked, interviewer must confirm that respondent hasn’t told anyone, and then check the “Haven’t told anyone” response.

Interviewer instructions: Skip to the next module.

T
SAY: “Next I'll ask you questions about male partners. By “male partner,” I mean males who are not transgender or post-operative transgender men (FTM) or non- or pre-operative transgender women (MTF).If a question does not apply to you, you can just tell me so.“

ransgender Respondent

S9. In the past 12 months, with how many different non-transgender men have you had oral, anal or vaginal sex?

___ ___ ____ [Refused to answer = 77, Don’t know = 99]

S10. In the past 12 months, with how many different post-operative transgender men (FTM) have you had oral, anal or vaginal sex?

___ ___ ____ [Refused to answer = 77, Don’t know = 99]

S11. In the past 12 months, with how many pre- or non-operative transgender women (MTF) have you had oral, anal or vaginal sex?

___ ___ ____ [Refused to answer = 77, Don’t know = 99]

Interviewer instructions: If S9 + S10+ S11 = “0”, “Refused to answer”, or “Don’t know”, skip to Say Box before S13.

Transgender Respondent - Male Partner

Multiple male Partners

[Read questions in this column]

No = 00, Yes = 01, Refused to answer= 77,

Not Applicable = 88, Don’t know = 99

One male Partner

[Read questions in this column]

No = 00, Yes = 01, Refused to answer= 77,

Not Applicable= 88, Don’t know = 99

Question

Response

Skip Pattern

Question

Response

Skip Pattern

S12a. Of your ______ [sum of S9-S11] male partners in the past 12 months, with how many did you have vaginal sex? By vaginal sex, I mean penis in the vagina.

[_____]

If “0”, 77, 88, 99, skip to S12c.

If “0”, don’t ask S12j and S12k.

S12a. In the past 12 months, did you have vaginal sex with this partner? By vaginal sex, I mean penis in the vagina.

[_____]

If “No”, 77, 88, 99, skip to S12c.

If “No”, don’t ask S12j and S12k.

S12b. Of these ______ response from S12a] partners, with how many did you have vaginal sex without a condom in the past 12 months?

[_____]

S12b. Did you have vaginal sex without a condom with this partner in the past 12 months?

[_____]

S12c. Of your ______ [sum of S9-S11] male partners in the past 12 months, with how many did you have anal sex? By anal sex, I mean penis in the anus (butt)?

[_____]

If “0”, 77, 88, 99, skip to S12e.

If “0”, don’t ask S12l and S12m.

S12c. In the past 12 months, did you have anal sex with this partner? By anal sex, I mean penis in the anus (butt)?

[_____]

If “No”, 77, 88, 99, skip to S12e.

If “No” don’t ask S12l and S12m.

S12d. Of these ______ [response from S12c] partners, with how many did you have anal sex without a condom in the past 12 months?

[_____]

S12d. Did you have anal sex without a condom with this partner in the past 12 months?

[_____]

S12e. Of your ____ [sum of S9-S11] male partners in the past 12 months, with how many did you discuss BOTH your HIV status and their HIV status before you had sex for the first time?

[_____]

If “0”, don’t ask S12s.

The version of this question is asked in S12s.

S12f. In the past 12 months, did you have sex with any of these partners in exchange for things like money, drugs, food, shelter or transportation?

Skip to Say Box before S12h

No….……………………………………..……..  00

Yes………………………………………………  01

Skip to Say Box before S12h

Refused to answer…………………..…...……...  07

Don’t know…………….…………………........  09

S12g. Did you give your partners things in exchange for sex or did your partners give you things in exchange for sex or both? [CHECK ONLY ONE RESPONSE.] [DON’T READ CHOICES.]

I gave my partners things in exchange for sex….…….  01

My partners gave me things in exchange for sex …….  02

They gave me things and I gave them things…….……  03

Refused to answer…………………..…...……………  07

Don’t know…………….………………….................  09

SAY: “Now I would like you to think about the last time you had sex with a male partner. Remember by “male partner,” I mean males who are not transgender, post-operative transgender men (FTM) and non- or pre-operative transgender women (MTF).”

S12h. When was the last time you had oral, anal, or vaginal sex with your most recent male partner?

__ __/ __ __ __ __

^{(M M / Y
Y Y Y )}[77 = Refused to answer, 99 = Don’t know]

S12i. Was this man a main partner or casual partner? By “main partner” I mean a man you have sex with and who you feel committed to above anyone else. This is a partner that you would call your boyfriend, husband, significant other, or life partner. By “casual partner” I mean a man you have sex with, but do not feel committed to or don’t know very well.

Main……………….……………….…………...  01

Casual……………………………….……..........  02

Refused to answer………………………..……..  07

Don’t know.……………..………………..........  09

Interviewer instructions: If S12a is “0”or “No”, then skip to S12l

Skip to S12l

12j. When you had sex that last time, did you have vaginal sex? By vaginal sex, I mean penis in the vagina.

No………………….……………….…………...  00

Yes….……………………………….……..........  01

Skip to S12l

Refused to answer………………………..……..  07

Don’t know.……………..………………..........  09

S12k. During vaginal sex with that partner, did your partner use a condom none of the time, part of the time, or the whole time? [CHECK ONLY ONE RESPONSE.] [DON’T READ CHOICES.]

None of time ….…………………….…....…….. 00

Part of the time ………………………………… 01

The whole time ……………….……….....…….. 02

Refused to answer.…………………..…….…… 07

Don’t know……....……………………...…...... 09

Interviewer instructions: If S12c is “0”, or “No” then skip to S12n

Go to confirmation

message below

12l. When you had sex that last time, did you have anal sex? By anal sex, I mean penis in the anus (butt)?

Skip to S12m

No………………………………………………. 00

Yes……………………………………..……….. 01

Skip to S12n

Refused to answer………………….…………..  07

Don’t know…….…………………………........  9

Confirmation message: if S12j and S12l are "No" ask the following: "So this means you only had oral sex the last time you had sex?" If “No”, return to S12j.

S12m. During anal sex with that partner, did you or your partner use a condom none of the time, part of the time, or the whole time? [CHECK ONLY ONE RESPONSE.] [DON’T READ CHOICES.]

None of time ………………….…….…....…….  00

Part of the time …………………………………  01

The whole time ………………….…….....…….  02

Refused to answer…………………..…….…….  07

Don’t know……………..……………...…........  09

S12n. Before or during the last time you had sex with this partner, did you use:

[CHECK ONLY ONE RESPONSE.] [READ CHOICES.]

Alcohol…..….….………………..……………..  01 Drugs………..……………………………..……  02

Alcohol and drugs ……………………......…….  03

Neither one….……………..…..…...….………..  04

Refused to answer.………..…….……...…….…  07

Don’t know…..…..……….….….…….…...…..  09

S12o. Was this partner transgender?

Skip to S12q

No……………………………………………….  00

Yes……………………………………..………..  01

Skip to S12q

Refused to answer………………….…………...  07

Don’t know…….…………………………........ 09

S12p. Was the partner male to female or female to male? [CHECK ONLY ONE RESPONSE.] [DON’T READ CHOICES.]

Male to female………………………………… 01

Female to male.………………………………… 02

Refused to answer………………….…………... 07

Not applicable…….…………………………..... 08

Don’t know…….…………………………........ 09

S12q. The last time you had sex with this partner, did you know their HIV status?

No………………….……………….…………...  00 Skip to S12s

Yes….……………………………….……..........  01

Partner hadn't been tested….…………………..  02

Refused to answer………………………..……..  07 Skip to S12s

Don’t know.……………..………………..........  09

S12r. What was your partner’s HIV status?

HIV-negative……………………………..…......  01

HIV-positive…...….…………………..………..  02

Indeterminate……………………………..…….  03

Refused to answer.……………………………...  07

Interviewer instructions: If S12e is “0”, skip to Say Box before S13.

S12s. Before you had sex with this partner for the first time, did you discuss BOTH your HIV status and your partner’s HIV status?

No………………….………….………………...  00

Yes………………………………..…………......  01

Refused to answer…………………………..…...  07

Don’t know……………..………….……….......  09

Transgender Respondent - Female Partner

SAY: “Now I’m going to ask you about other partners that you may have had in the past 12 months. I'll ask you questions about your female partners. By “female partner,” I mean females who are not transgender, post-operative transgender women (MTF), and non- or pre-operative transgender men (FTM).”

S13. In the past 12 months, with how many different non-transgender women have you had oral, anal or vaginal sex?

___ ___ ____

[Refused to answer = 77, Don’t know = 99]

S14. In the past 12 months, with how many different post-operative transgender women (MTF) have you had oral, anal or vaginal sex?

___ ___ ____

[Refused to answer = 77, Don’t know = 99]

S15. In the past 12 months, with how many different pre- or non-operative transgender men (FTM) have you had oral, anal or vaginal sex?

___ ___ ____

[Refused to answer = 77, Don’t know = 99]

Interviewer instructions: If S13 + S14 + S15 = “0”, “Refused to answer”, or “Don’t know”, skip to the next module.

Multiple female Partners [Read questions in this column] No = 00, Yes = 01, Refused to answer= 77, Not Applicable= 88, Don’t know = 99				One female Partner [Read questions in this column] No = 00, Yes = 01, Refused to answer = 77, Not Applicable= 88, Don’t know = 99
Question	Response	Skip Pattern		Question	Response	Skip Pattern
S16a. Of your ______ [sum of S13-S15] female partners in the past 12 months, with how many did you have vaginal sex? By vaginal sex, I mean penis in the vagina.	[_____]	If “0”, 77, 88, or 99, skip to S16c. If “0”, don’t ask S16j and S16k.		S16a. In the past 12 months, did you have vaginal sex with this partner? By vaginal sex, I mean penis in the vagina.	[_____]	If “No”, 77, 88, or 99, skip to S16c. If “No”, don’t ask S16j and S16k.
S16b. Of these ______ [response from S16a] partners, with how many did you have vaginal sex without a condom in the past 12 months? Sex without a condom includes any acts where you only used a condom part of the time.	[_____]			S16b. Did you have vaginal sex without a condom with this partner in the past 12 months? Sex without a condom includes any acts where you only used a condom part of the time.	[_____]
S16c. Of your ______ [sum of S13-S15] female partners in the past 12 months, with how many did you have anal sex? By anal sex, I mean penis in the anus (butt).	[_____]	If “0”, 77, 88, or 99, skip to S16e. If “0”, don’t ask S16l and S16m.		S16c. In the past 12 months, did you have anal sex with this partner? By anal sex, I mean penis in the anus (butt).	[_____]	If “No”, 77, 88, or 99, skip to S16e. If “No”, don’t ask S16l and S16m.
S16d. Of these ______ [response from S16c] partners, with how many did you have anal sex without a condom in the past 12 months?	[_____]			S16d. Did you have anal sex without a condom with this partner in the past 12 months?	[_____]
S16e. Of your ____ [sum of S13-S15] female partners in the past 12 months, with how many did you discuss BOTH your HIV status and their HIV status before you had sex for the first time?	[_____]		If “0”, don’t ask S16s.	The version of this question is asked in S16s.

S16f. In the past 12 months, did you have sex with any of these partners in exchange for things like money, drugs, food, shelter or transportation?

Skip to Say Box before S16h

No….……………………………………..……..  00

Yes………………………………………………  01

Skip to Say Box before S16h

Refused to answer…………………..…...……...  07

Don’t know…………….…………………........  09

S16g. Did you give your partners things in exchange for sex or did your partners give you things in exchange for sex or both? [CHECK ONLY ONE RESPONSE.] [DON’T READ CHOICES.]

I gave my partners things in exchange for sex….……… 01

My partners gave me things in exchange for sex ……… 02

They gave me and I gave them things…… ……………. 03

Refused to answer…………………..…...…………..…..  07

Don’t know…………….…………………..................... 09

SAY: “Now I would like you to think about the last time you had sex with a female partner. Remember by “female partner,” I mean females who are not transgender, post-operative transgender women (MTF), and non- or pre-operative transgender men (FTM).”

S16h. When was the last time you had oral, anal, or vaginal sex with your most recent female partner?

__ __/ __ __ __ __

^{(M M / Y Y
Y Y )} [77 = Refused to answer, 99 = Can't recall]

S16i. Was the woman you had sex with that last time a main or casual partner?

Main……………….……………….…………...  01

Casual……………………………….……..........  02

Refused to answer………………………..……..  07

Don’t know.……………..………………..........  09

Interviewer instructions: If S16a is “0”or “No”, then skip to S16l

Skip to S16l

16j. When you had sex that last time, did you have vaginal sex? By vaginal sex, I mean penis in the vagina.

No………………….……………….…………...  00

Yes….……………………………….……......... . 01

Refused to answer………………………..……..  07

Skip to S16l

Not Applicable….………..………………..........  08

Don’t know.……………..………………..........  09

S16k. During vaginal sex with that partner, did you use a condom none of the time, part of the time, or the whole time? [CHECK ONLY ONE RESPONSE.] [DON’T READ CHOICES.]

None of time ….…………………….…....…….. 00

Part of the time ………………………………… 01

The whole time ……………….……….....…….. 02

Refused to answer.…………………..…….…… 07

Don’t know……....……………………...…...... 09

Interviewer instructions: If S16c is “0”or “No”, then skip to S16n

S16l. When you had sex that last time, did you have anal sex? By anal sex, I mean penis in the anus (butt)?

No………………………………………………. 00 Go to confirmation

message below

Skip to S16m

Yes……………………………………..……….. 01

Skip to S16n

Refused to answer………………….…………..  07

Not Applicable….………..………………..........  08

Don’t know…….…………………………........  09

S16m. During anal sex with that partner, did you use a condom none of the time, part of the time, or the whole time? [CHECK ONLY ONE RESPONSE.] [DON’T READ CHOICES.]

None of time ………………….…….…....…….  00

Part of the time …………………………………  01

The whole time ………………….…….....…….  02

Refused to answer…………………..…….…….  07

Don’t know……………..……………...…........  09

S16n. Before or during the last time you had sex with this partner, did you use:

[CHECK ONLY ONE RESPONSE.] [READ CHOICES.]

Alcohol…..….….………………..……………..  01 Drugs………..……………………………..……  02

Alcohol and drugs ……………………......…….  03

Neither one….……………..…..…...….………..  04

Refused to answer.………..…….……...…….…  07

Don’t know…..…..……….….….…….…...…..  09

S16o. Was this partner transgender?

No………………………………………………. 00 Skip to S16q

Yes……………………………………..……….. 01

Skip to S16q

Refused to answer………………….…………...  07

Don’t know…….…………………………........ 09

S16p. Was the partner male to female or female to male? [CHECK ONLY ONE RESPONSE.] [DON’T READ CHOICES.]

Male to female………………………………… 01

Female to male.………………………………… 02

Refused to answer………………….…………... 07

Not applicable…….…………………………..... 08

Don’t know…….…………………………........ 09

S16q. The last time you had sex with this partner, did you know their HIV status?

No………………….……………….…………...  00 Skip to S16s

Yes….……………………………….……..........  01

Partner hadn't been tested….…………………..  02

Refused to answer………………………..……..  07 Skip to S16s

Don’t know.……………..………………..........  09

S16r. What was your partner’s HIV status?

HIV-negative……………………………..…......  01

HIV-positive…...….…………………..………..  02

Indeterminate……………………………..…….  03

Refused to answer.……………………………...  07

Interviewer instructions: If S16e is “0”, skip to the next module.

S16s. Before you had sex with this partner for the first time, did you discuss BOTH your HIV status and your partner’s HIV status?

No………………….………….………………...  00

Yes………………………………..…………......  01

Refused to answer…………………………..…...  07

Don’t know……………..………….……….......  09

Drug and Alcohol Use History

I
SAY: “The next questions are about drug and alcohol use. Please remember your answers will be kept private and that you can refuse to answer any question you are not comfortable with. First I’m going to ask you about injection drug use. This means injecting drugs yourself and/or having someone who isn't a health care provider inject you.”
njection Drug Use

U1. Have you ever in your life shot up or injected any drugs that weren’t used for medical purposes? By shooting up, I mean anytime you might have used drugs with a needle, either by mainlining, skin popping or muscling.

No………….……………………………………  00 Skip to Say Box before U8

Yes……………………………………………..  01

Skip to Say box before U8

Refused to answer…………………………..…  07

Don’t know……………..……………………...  09

U2. When was the last time you shot up or injected any drugs (that weren’t used for medical purposes)?

__ __/ __ __ __ __

^{(M M / Y
Y Y Y )} [77 = Refused to answer, 99 = Don’t know]

Interviewer instructions: If date in U2 is greater than 12 months from the interview date, skip to Say Box before U8; otherwise, go to Say Box before U3.

SAY: I'm going to read you a list of drugs. For each drug I mention, please tell me how often you injected it in the past 12 months.”

U3. How often did you inject: [CHOOSE ONLY ONE RESPONSE PER TYPE OF DRUG.] [USE RESPONSE CARD G.] [READ EACH DRUG CHOICE.]

More More More Less

than than than than

Didn't once Once once a Once a once a Once a once a Ref Don’t

use a day a day week week month month month Know

a. Heroin and cocaine

together (speedballs).. 00...01..02...03...04….05…...06…..07….77….99

b. Heroin alone……….. 00...01..02...03...04….05…...06…..07….77….99

c. Cocaine alone……… 00...01..02...03...04….05…...06…..07….77….99

d. Crack………………. 00...01..02...03...04….05…...06…..07….77….99

More More More Less

than than than than

Didn't once Once once a Once a once a Once a once a Ref Don’t

use a day a day week week month month month Know

e. Methamphetamines

(crystal, meth, tina,

crank, ice)…………. 00...01..02...03...04….05…...06…..07….77….99

f. Other amphetamines. 00...01..02...03...04….05…...06…..07….77….99

g. Oxycontin………..… 00...01..02...03...04….05…...06…..07….77….99

h. Steroids/Hormones… 00...01..02...03...04….05…...06…..07….77….99

i. Other injected drug.… 00...01..02...03...04….05…...06…..07….77….99

(Specify: _______________________________________)

U4. During the past 12 months when you injected, how often did you use a new, sterile needle? By a new, sterile needle, I mean a needle never used before by anyone, even you.

[CHECK ONLY ONE RESPONSE.] [USE RESPONSE CARD C.] [READ CHOICES.]

Never……….…….…………………..…………  00

Rarely…………….……………….……..…….  01

About half the time……………………………..  02

Most of the time…..……..……………………...  03

Always.….……………..……………………….  04

Refused to answer…..…………………………..  07 Skip to U6

Don’t know………..……………………………  09

U5. During the past 12 months, how often have you shared needles or rigs with other people? This means more than one person using the same needle. [CHECK ONLY ONE RESPONSE.] [USE RESPONSE CARD C.] [READ CHOICES.]

Never……….…….…………………..…………  00

Rarely…………….……………….……..…….  01

About half the time……………………………..  02

Most of the time…..……..……………………...  03

Always.….……………..……………………….  04

Refused to answer……………..………………..  07

Don’t know………..……………………………  09

U6. During the past 12 months when you injected, how often did you share drug using equipment or works? This would include cookers, cottons or rinse water. [CHECK ONLY ONE RESPONSE.] [USE RESPONSE CARD C.] [READ CHOICES.]

Never……….…….…………………..…………  00

Rarely…………….……………….……..……...  01

About half the time……………………………..  02

Most of the time…..……..……………………...  03

Always.….……………..……………………….  04 Refused to answer……………..………………..  07

Don’t know………..……………………………  09

U7. During the past 12 months, how often did you divide up drugs with a syringe someone already injected with? [CHECK ONLY ONE RESPONSE.] [USE RESPONSE CARD C.] [READ CHOICES.]

Never……….…….…………………..…………  00

Rarely…………….……………….……..……..  01

About half the time…………………………….  02

Most of the time…..……..……………………...  03

Always.….……………..……………………….  04 Refused to answer……………..………………..  07

Don’t know………..……………………………  09

Non-Injection Drug Use

SAY: “Now I’m going to ask you about alcohol and drugs that you may have used but did not inject. I will refer to these as non-injection drugs. This includes drugs like marijuana, crystal, cocaine, crack, club drugs, painkillers, or poppers. Again, we are interested in drugs you did not use for medical purposes.”

Go to instruction below

8. In the past 12 months, have you used alcohol or any non-injection drugs?

No………………….…………………..………  00

Yes………………………………………..……  01 Skip to Say Box before U9

Go to instruction below

Refused to answer………………………………  07

Don’t know……………..……………………..  09

Interviewer instructions: If responses to U3a-i indicate injection drug use in the past 12 months, skip to Say Box before U14a; otherwise, skip to the screener question for the Optional Module.

SAY: The next few questions ask about the past 30 days, rather than the past 12 months.

U9. During the past 30 days, on how many days did you have a drink containing alcohol?

___ ____ [Refused to answer = 77, Don’t know = 99]

Interviewer instructions: If U9 is “0”, 77, or 99, skip to Say Box before U13.

U10. During the past 30 days, how many drinks did you have on a typical day when you were drinking? By a drink I mean a can of beer, a glass of wine or a shot of hard liquor.

___ ____ [Refused to answer = 77, Don’t know = 99]

Interviewer instructions: If DEMOGRAPHICS D14 (birth gender) is “Female” or “Intersex/ambiguous”, skip to U12.

U11. On how many days in the past 30 days did you have 5 or more drinks?

____ ____ [Refused to answer = 77, Don’t know = 99]

Interviewer instructions: After recording response, skip to Say Box before U13.

U12. On how many days in the past 30 days did you have 4 or more drinks?

____ ____ [Refused to answer = 77, Don’t know = 99]

SAY: “I'm going to read you a list of drugs, including alcohol. For each one I mention, please tell me how often you used it in the past 12 months. Don’t include drugs you injected or drugs that were used for medical purposes.”

U13. How often did you use: [CHOOSE ONLY ONE RESPONSE PER TYPE OF DRUG.] [USE RESPONSE CARD G.] [ READ EACH DRUG CHOICE.]

More More More Less

than than than than

Didn't once Once once a Once a once a Once a once a Ref Don’t

use a day a day week week month month month Know

a. Alcohol…………….………...00...01..02...03...04….05…...06…..07….77….99

Interviewer instructions: If U9 is not “0”, 77 or 99 AND U13a is “Didn’t use”, return to Say Box before U9.

More More More Less

than than than than

Didn't once a Once a once a Once a once a Once a once a Ref Don’t

use day day week week month month month Know

b. Methamphetamines (crystal,

meth, tina, crank, ice)……. 00...01..02...03...04….05…...06…..07….77….99 c. Other amphetamines.…..……00...01..02...03...04….05…...06…..07….77….99

d. Crack ……………………….00...01..02...03...04….05…...06…..07….77….99

e. Cocaine that is smoked

or snorted………………….....00...01..02...03...04….05…...06…..07….77….99

f. Downers such as Valium,

Ativan, or Xanax.…………..00...01..02...03...04….05…...06…..07….77….99

g. Painkillers such as Oxycontin,

Vicodin, or Percocet, .…… 00...01..02...03...04….05…...06…..07….77….99

h. Hallucinogens such as LSD

or mushrooms……….…… 00...01..02...03...04….05…...06…..07….77….99

i. X or Ecstasy……………….. 00...01..02...03...04….05…...06…..07….77….99

j. Special K (ketamine)………...00...01..02...03...04….05…...06…..07….77….99

k. GHB poppers……………… 00...01..02...03...04….05…...06…..07….77….99

l. Heroin/opium that is

smoked or snorted…….. …...00...01..02...03...04….05…...06…..07….77….99

m. Marijuana……………….. 00...01..02...03...04….05…...06…..07….77….99

n. Poppers ( amyl nitrate)....... 00...01..02...03...04….05…...06…..07….77….99

o. Steroids/Hormones............ 00...01..02...03...04….05…...06…..07….77….99

U13p. Did you use any other non-injection drugs that I haven’t asked about?

Skip to Say Box before U14a

No………………….…………………..………  00

Yes………………………………………..……  01

Skip to Say Box before U14a

Refused to answer………………………………  07

Don’t know……………..……………………..  09

U13q. What other drug did you use? (Specify: _______________________________________)

U13r. How often did you use ___________________________ [response to U13q] ?

More More More Less

than than than than

once a Once a once a Once a once a Once a once a Ref Don’t

day day week week month month month know

Other drug……………......... 01…02....03.....04…….05…...06…..07….77….99

SAY: “Now I’m going to ask you about your use of alcohol or drugs before or during sex.”

Interviewer instructions: The following question is asked separately for respondents who answered “More than Once a Day” through “Less than Once a Month” for each drug provided in U3d-f, U13a-d, U13i-k, AND/OR U13n. If using a paper questionnaire, record responses on FORM 1.

U14a -U14h. In the past 12 months, did you use _________ [drug used] before or during sex?

No………….…………………………………..  00

Yes……………………………………………..  01

Refused to answer…………………………..….  07

Don’t know……………..……………………...  09

Interviewer instructions: If DEMOGRAPHICS D14 (birth gender) is “Female” AND DEMOGRAPHICS D15 (self-identified gender) is “Female”, skip to screener question for the Optional Modules; otherwise, go to U15.

Skip to next module

15. In the past 12 months, have you used Viagra, Levitra or Cialis?

No………….…………………………………..  00

Yes……………………………………………..  01

Skip to next module

Refused to answer…………………………..….  07

Don’t know……………..……………………...  09

Interviewer instructions: The following questions are asked separately for respondents who answered “More than Once a Day” through “Less than Once a Month” for each drug provided in U14a-h If using a paper questionnaire, record responses on FORM 2.

U16a – U16h.

When you used __________ [drug used] before or during sex, did you use Viagra, Levitra or Cialis at the same time?

No………….…………………………………..  00

Yes……………………………………………..  01

Refused to answer…………………………..….  07

Don’t know……………..……………………...  09

Note: Only the drugs that respondent indicates use of in U3d-f, U13a-d, U13i-k and/or U13n are automatically inserted in QDS.

Assessment of Prevention Activities

Say: “Next I'd like to ask you about HIV prevention activities that happen around here.”

Skip to Interviewer instructions before P2

1. In the past 12 months, have you received any free condoms?

No…………….………………….……………..  00

Yes…………………………………..…………..  01

Skip to Interviewer instructions before P2

Refused to answer………………….…...............  07

Don’t know………….………………………….  09

P1a. From what type of organization(s) did you get those condoms?

[CHECK ALL THAT APPLY.] [ DON’T READ CHOICES..]

HIV/AIDS-focused community-based organization..  01

GLBTQ community health center…..………………  02

GLBTQ organization (not a health center/HIV org.).  03

Needle exchange program.…...……..………………  04

IDU outreach organization.....……..…..……………  05

Adult HIV/AIDS specialty clinic…………………...  06

Sexually transmitted disease clinic………………....  07

Community health center/public health clinic…..….  08

Family planning clinic……………..………………..  09

Prenatal/obstetrics clinic …..…………..……………  10

Drug treatment program………………..…………...  11

Private doctors office (including HMO)…………….  12

Other ………………………………………………  13

(Specify:_________________________________)

Refused to answer……………………...............…....  77

Don’t know ……………..……..…………………...  99

P1b. Have you used any of the free condoms you received?

No………………….……………………………  00

Yes………………………..………….………….  01

Refused to answer……………………………….  07

Don’t know…………………………………….  09

P1c. Do you think getting these free condoms made you more likely to use condoms during sex?

No………………….……………………………  00

Yes………………………………………………  01

Refused to answer………………………………  07

Don’t know……………..………………………  09

Interviewer instructions: If the date for Drug Use U2 is within 12 months of the interview date (i.e., IDU in past 12 months), go to P2; otherwise, skip to P4.

Skip to P3

2. In the past 12 months, have you received any free new sterile needles?

No…………….………………….……………..  00

Yes…………………………………..…………. . 01

Skip to P3

Refused to answer………………….…...............  07

Don’t know………….………………………… . 09

P2a. From what organization(s) did you get those needles?

[CHECK ALL THAT APPLY.] [ DON’T READ CHOICES.]

HIV/AIDS-focused community-based organization..  01

GLBTQ community health center…..………………  02

GLBTQ organization (not a health center/HIV org.).  03

Needle exchange program.…...……..………………  04

IDU outreach organization.....……..…..……………  05

Adult HIV/AIDS specialty clinic…………………...  06

Sexually transmitted disease clinic………………....  07

Community health center/public health clinic…..….  08

Family planning clinic……………..………………..  09

Prenatal/obstetrics clinic …..…………..……………  10

Drug treatment program………………..…………...  11

Private doctors office (including HMO)…………….  12

Other ………………………………………………  13

(Specify:_________________________________)

Refused to answer……………………...............…....  77

Don’t know ……………..……..…………………...  99

P2b. Have you used any of the free new sterile needles you received?

No………………….……………………………  00

Yes………………………..………….………….  01

Refused to answer……………………………….  07

Don’t know…………………………………….  09

P2c. Do you think getting these free new sterile needles made you more likely to use new sterile needles to inject?

No………………….……………………………  00

Yes………………………………………………  01

Refused to answer………………………………  07

Don’t know……………..………………………  09

Skip to P4

3. In the past 12 months, have you received any free kits that have items like cookers, cotton, or water for rinsing needles or preparing drugs?

No…………….………………….……………..  00

Yes…………………………………..…………. . 01

Skip to P4

Refused to answer………………….…...............  07

Don’t know………….………………………….  09

P3a. From what type of organization(s) did you get those kits? [CHECK ALL THAT APPLY.]

[DON’T READ CHOICES.]

HIV/AIDS-focused community-based organization..  01

GLBTQ community health center…..………………  02

GLBTQ organization (not a health center/HIV org.).  03

Needle exchange program.…...……..………………  04

IDU outreach organization.....……..…..……………  05

Adult HIV/AIDS specialty clinic…………………...  06

Sexually transmitted disease clinic………………....  07

Community health center/public health clinic…..….  08

Family planning clinic……………..………………..  09

Prenatal/obstetrics clinic …..…………..……………  10

Drug treatment program………………..…………...  11

Private doctors office (including HMO)…………….  12

Other ………………………………………………  13

(Specify:_________________________________)

Refused to answer……………………...............…....  77

Don’t know ……………..……..…………………...  99

P3b. Have you used any of the free kits you received?

No………………….……………………………  00

Yes………………………..………….………….  01

Refused to answer……………………………….  07

Don’t know…………………………………….  09

P3c. Do you think getting these free kits made you more likely to use clean cookers, clean cotton, and clean water when you injected?

No………………….……………………………  00

Yes………………………………………………  01

Refused to answer………………………………  07

Don’t know……………..………………………  09

P4. In the past 12 months, not including when you may have been tested for HIV,

Skip to P5

ave you had a one-on-one conversation with an outreach worker, counselor, or prevention program worker about ways to protect yourself or your partners from getting HIV or other sexually transmitted diseases?

No………………….……………..……..............  00

Yes…………………………….………...............  01

Skip to P5

Refused to answer…………………….………...  07

Don’t know…………………………………….  09

P4a. What organization(s) did this person work for?[CHECK ALL THAT APPLY.] [ DON’T READ

CHOICES.]

HIV/AIDS-focused community-based organization..  01

GLBTQ community health center…..………………  02

GLBTQ organization (not a health center/HIV org.).  03

Needle exchange program.…...……..………………  04

IDU outreach organization.....……..…..……………  05

Adult HIV/AIDS specialty clinic…………………...  06

Sexually transmitted disease clinic………………....  07

Community health center/public health clinic…..….  08

Family planning clinic……………..………………..  09

Prenatal/obstetrics clinic …..…………..……………  10

Drug treatment program………………..…………...  11

Private doctors office (including HMO)…………….  12

Other ………………………………………………  13

(Specify:_________________________________)

Refused to answer……………………...............…....  77

Don’t know ……………..……..…………………...  99

P4b. During those one-on-one conversation(s), did you:

[ASK EACH QUESTION, MARK NO OR YES FOR EACH]

No Yes Refused Don't Know

P4b-1. Discuss ways to talk to a partner about safe sex?........  00.... 01…  07……. 09

P4b-2. Practice ways to talk with a partner about safe sex?....  00.... 01…  07……. 09

P4b-3. Discuss ways to use condoms effectively?..................  00.... 01…  07……  09

P4b-4. Practice ways to use condoms effectively?…...………...  00.... 01………. 07……..09

Interviewer instructions: If date in Drug Use U2 is within 12 months of interview date (IDU in past 12 months) ask P4b-5 and P4b-6; otherwise, skip to instructions before P4c.

P4b-5. Discuss safe drug-injecting practices?..............................  00.... 01…  07………. 09

P4b-6. Practice how to prepare for safe injections?…...…….  00.... 01…  07………. 09

Interviewer instructions: If P4b-1 or P4b-2 is “Yes” (discussed or practiced talking to a partner), go to P4c; otherwise skip to instructions before P4d.

P4c. Do you think you talk with your partner(s) differently about safe sex now because of those one-on-one conversations?

No………………….…………………………...  00

Yes………………………..………….…………  01

Refused to answer…………………..…..............  07

Don’t know…………………………...………..  09

Interviewer instructions: If P4b-5 or P4b-6 is “Yes” (discussed or practiced safer drug-injecting practices), go to P4d; otherwise skip to P5.

P4d. Do you think you practice safe drug-injecting now because of those one-on-one conversations?

No………………….……………………………  00

Yes………………………..………….………….  01

Refused to answer…………………..…...............  07

Don’t know…………………………...………...  09

P5. In the past 12 months, not including discussions with friends, have you been a

participant in any organized session(s) involving a small group of people to discuss ways to prevent HIV?

Skip to end of module

No………………….……………………………  00

Yes………………………..………….………….  01

Skip to end of module

Refused to answer…………………..…...............  07

Don’t know…………………………...………...  09

P5a. What organization(s) conducted or sponsored these sessions?

[CHECK ALL THAT APPLY.] [ DON’T READ CHOICES.]

HIV/AIDS-focused community-based organization..  01

GLBTQ community health center…..………………  02

GLBTQ organization (not a health center/HIV org.).  03

Needle exchange program.…...……..………………  04

IDU outreach organization.....……..…..……………  05

Adult HIV/AIDS specialty clinic…………………...  06

Sexually transmitted disease clinic………………....  07

Community health center/public health clinic…..….  08

Family planning clinic……………..………………..  09

Prenatal/obstetrics clinic …..…………..……………  10

Drug treatment program………………..…………...  11

Private doctors office (including HMO)…………….  12

Other ………………………………………………  13

(Specify:_________________________________)

Refused to answer……………………...............…....  77

Don’t know ……………..……..…………………...  99

P5b. During these organized group session(s), did you:

[ASK EACH QUESTION, MARK NO OR YES FOR EACH]

No Yes Refused Don't

Know

P5b-1. Discuss ways to talk to a partner about safe sex?........  00.... 01…  07………. 09

P5b-2. Practice ways to talk with a partner about safe sex?....  00.... 01…  07………. 09

P5b-3. Discuss ways to effectively use condoms?..................  00.... 01…  07………. 09

P5b-4. Practice ways to effectively use condoms?…...……..  00.... 01…  07………. 09

Interviewer instructions: If the date in Drug Use U2 is within 12 months of the interview date (IDU in past 12 months), go to P5b-5; otherwise, skip to instructions before P5c.

P5b-5.Discuss safe drug-injecting practices?...........................  00.... 01…  07………. 09

P5b-6. Practice how to prepare for safe injections?…...…….  00.... 01…  07………. 09

Interviewer instructions: If P5b1 or P5b2 is “Yes” (discussed or practiced talking to a partner), go to P5c, otherwise, skip to instructions before P5d.

P5c. Do you think you talk with your partner(s) differently about safe sex now because of these organized group session(s)?

No………………….……………………………  00

Yes…………………………..…………………..  01

Refused to answer……………………………….  07

Don’t know..…………………………................  09

Interviewer instructions: If P5b-5 or P5b-6 is “Yes” (discussed or practiced safer drug-injecting practices), go to P5d; otherwise, go to the screener question for the Local Questions Module.

P5d. Do you think you practice safe drug-injection now because of these organized group session(s)?

No….…………………..………………..............  00

Yes………………………..………….………….  01

Refused to answer…………………..…...............  07

Don’t know………………………...…………...  09

Time core questionnaire ended: ___ ___:___ ___ □ AM □ PM

Hour Minute

Interviewer instructions: Go to screener question for the Optional Module.

FORM 1

Use this form to record responses for Drug and Alcohol Use History U14a – U14h ONLY if the interviewer is administering the paper version of the questionnaire. [CHECK THE APPROPRIATE RESPONSE.]
Only ask about substances respondent mentioned using in the past 12 months. This refers to any responses of “More than once a day” through “Less than once a month” for U3d-f (injection drug use) U13a-d, U13i-k, and/or U13n (alcohol and non-injection drug use):		No	Yes	Refused to answer	Don’t know
U14a.	In the past 12 months, did you use alcohol before or during sex?
U14b.	In the past 12 months, did you use crack before or during sex?
U14c.	In the past 12 months, did you use crystal, meth, tina, crank, ice, or methamphetamines, before or during sex?
U14d.	In the past 12 months, did you use other amphetamines, before or during sex?
U14e.	In the past 12 months, did you use X or ecstasy before or during sex?
U14f.	In the past 12 months, did you use special K (ketamine) before or during sex?
U14g.	In the past 12 months, did you use GHB before or during sex?
U14h.	In the past 12 months, did you use poppers before or during sex?

FORM 2 Use this form to record responses for Drug and Alcohol Use History U16a – U16h ONLY if the interviewer is administering the paper version of the questionnaire. [CHECK THE APPROPRIATE RESPONSE.]
Only as these questions if DEMOGRAPHICS D14 (birth gender) = “Male” AND DEMOGRAPHICS D15 (self-identified gender) = “Male”, AND DRUG AND ALCOHOL USE HISTORY MODULE U15 (VIAGRA, LEVITRA OR CIALIS) = “Yes”. Only ask about substances respondent mentioned in the past 12 months. This refers to any responses of “More than once a day” through “Less than once a month” for alcohol, crack, ‘club drugs’ and poppers coded in injection drug use and/or alcohol and non-injection drug use:		No	Yes	Refused to answer	Don’t know
U16a.	Did you use Viagra, Levitra, or Cialis at the same time you were using alcohol before or during sex?
U16b.	Did you use Viagra, Levitra, or Cialis at the same time you were using crack before or during sex?
U16c.	Did you use Viagra, Levitra, or Cialis at the same time you were using crystal, meth, tina, crank, ice, or methamphetamines before or during sex?
U16d.	Did you use Viagra, Levitra, or Cialis at the same time you were using other amphetamines before or during sex?
U16e.	Did you use Viagra, Levitra, or Cialis at the same time you were using X or ecstasy before or during sex?
U16f.	Did you use Viagra, Levitra, or Cialis at the same time you were using special K (ketamine) before or during sex?
U16g.	Did you use Viagra, Levitra, or Cialis at the same time you were using GHB before or during sex?
U16h.	Did you use Viagra, Levitra, or Cialis at the same time you were using poppers before or during sex?

Optional Modules

O1.

Interviewer: This question is for you.

Does your site ask questions from the Health and Well-being module? [CHECK ONLY ONE.]

Yes………………........……..…...……	 01
No…………………………………….	 02

Interviewer instructions: If you checked “Yes” go to “Health and Well Being”, if you checked “no”, go to the screener question for the Local Questions Module.

Health and Well-Being

SAY: “The next questions ask for your views about your overall health; not just related to HIV. This information will help keep track of how you feel and how well you are able to do your usual activities.”

1. In general, would you say your health is:

Excellent	Very good	Good	Fair	Poor

1	2	3	4	5

2. The following questions are about activities you might do during a typical day. Does your

health now limit you in these activities? If so, how much?

	Yes, limited a lot	Yes, limited a little	No, not limited at all

a Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf 1 2 3
b Climbing several flights of stairs 1 2 3

3. During the past 4 weeks, how much of the time have you had any of the following problems

with your work or other regular daily activities as a result of your physical health?

	All of the time	Most of the time	Some of the time	A little of the time	None of the time

a Accomplished less than you would like 1 2 3 4 5
b Were limited in the kind of work or other activities 1 2 3 4 5

4. During the past 4 weeks, how much of the time have you had any of the following problems

with your work or other regular daily activities as a result of any emotional problems (such

as feeling depressed or anxious)?

	All of the time	Most of the time	Some of the time	A little of the time	None of the time

a Accomplished less than you would like 1 2 3 4 5
b Did work or other activities less carefully than usual 1 2 3 4 5

During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)?

Not at all	A little bit	Moderately	Quite a bit	Extremely

1	2	3	4	5

These questions are about how you feel and how things have been with you during the past 4 weeks. For each question, please give the one answer that comes closest to the way you have been feeling. How much of the time during the past 4 weeks...

	All of the time	Most of the time	Some of the time	A little of the time	None of the time

a Have you felt calm and peaceful? 1 2 3 4 5
b Did you have a lot of energy? 1 2 3 4 5
c Have you felt downhearted and depressed? 1 2 3 4 5

During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting friends, relatives, etc.)?

All of the time	Most of the time	Some of the time	A little of the time	None of the time

1	2	3	4	5

Interviewer instructions: If you checked “Assessment of Prevention Activities”, go to the Assessment of Prevention Activities Module; otherwise, skip to the screener question for the Local Questions Module

Local Questions Module
1.	Interviewer: This question is for you. Does your site ask local questions?
		No………..…………...………………........………..…...…… 00	Skip to the Interview completion
		Yes………………………………….…………...……........…. 01	Go to Local Questions

Interview Completion

End of Interview

SAY: “Thank you again for taking part in this survey. Please remember that all the information you have given me will be kept private. ”

Interviewer instructions:

Offer assistance with information and resources, according to local protocol.

If interview was discontinued due to prior interview during the current calendar year OR respondent age < 18, don’t pay the respondent.

If interview was discontinued due to first HIV positive test after the PDP, OR interview was partially/fully completed, pay the respondent and have him/her sign the receipt.

Interviewer: Please enter the following items after completion of the interview.

Payment Verification

		C1.	Payment made:
				No……………………………………..………..…….. 00
				Yes ...…………………………………...……...……  01	Skip to C2
		C1a.	Why was payment not made?
				Participant refused payment…………………………...01	Skip to C3
				Other…………………………………...……...…….…02
		C1b.		(Specify:) ______________________________________	Skip to C3

		C2.	Receipt signed (or initialed):
				No…………………………………..………..………..00
				Yes...…………………………………...……...……… 01	Skip to C3
		C2a.	Why was receipt not signed?
				Participant refused to sign..…………………………... 01	Skip to C3
				Other…………………………………...……...……… 02
		C2b.		(Specify:) ______________________________________






		C3. How confident are you of the validity of the respondent’s answers?
				Confident..………….…………………..……….......…01
				Some doubts..................…………………..…………...02
				Not confident at all............………………………….....03

	C4. Record any additional comments, including disruptions that might have taken place during the interview, reason the interview might have been stopped, or why the respondent’s answers may not have been reliable.

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

NOTE: The drawings of the Medicines are too large and were leftout of this file. Please check paper copy of attachment 2.

File Type	application/msword
File Title	Attachment 2
Author	evu0
Last Modified By	ziy6
File Modified	2006-11-09
File Created	2006-11-09

Persons Interviewed with standard interview

Medical Monitoring Project

MMP Attach 2 Interview Instrument