Form No number No number Core questionnaire

Attachment 3c

Multi-Site HIV Testing in Mental Health Settings: Core Questionnaire

February 3, 2021

Form approved

OMB no. 0920-xxxx

Expiration date xx/xx/20xx

Multi-Site HIV Testing in

Mental Health Settings: Core Questionnaire

Public reporting burden of this collection of information is estimated to average 20 minute 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. CDC may not conduct or sponsor, and a person is not required to respond to a collection of information unless a currently valid OMB control is displayed. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: CDC Information Collections Review Office, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (XXXXXXXX).

PART I: DEMOGRAPHICS

SAY: The first questions are about your background

DEM1. What is the highest level of education you completed?

[DO NOT read choices. Check only one.]

Never attended school….………………………… …………...  0

Grades 1 through 8….…………………...……………………..  1

Grades 9 through 11..…………………….…….…. …………...  2

Grade 12 or GED...….……..…..………………… …………...  3

Some college, Associate’s Degree, or Technical Degree…... 4

Bachelor’s Degree..………….…………….……… …………...  5

Any post graduate studies ………….………………………….  6

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

Don't know……………..……………………......................  99

DEM2. How do you earn income?

[CHECK ALL THAT APPLY]

Full Time Employment…………….………….  1

Part Time Employment…………………….  2

Worker’s Compensation.…………………...…..  3

A full-time student…….…….…………………  4

Disability….………..………………….  5

SSI………..…………………………...  7

Retirement………..…………………………... 8

Other………..………………………….............. 9

Refused to answer………………………..……..  77

Don't know.……………..………………..........  99

What is your monthly income?

DEM3. 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 hotel (SRO), temporarily staying with friends or relatives, or living in a car.

No………………….……………………………  0

Yes……………………………………………… 1

Refused to answer………………………………  77

Don't know……………..……………………...  99

DEM4. Are you currently homeless?

No………………….……………….…………..  0

Yes….……………………………….…….........  1

Refused to answer………………………………  77

Don't know……………..……………………...  99

DEM5. What zip code do you live in?

[Refused = 77777, Don't know = 99999] __ __ __ __ __

DEM6. How would you describe your sexuality?

Straight……………………………………..  1

Gay or Homosexual………………………… 2

Bisexual…………………………………….  3

Refused to answer…………………………  77

Don't know……………..…………………  99

DEM7. What is your current marital status? [READ CHOICES. CHECK ONLY ONE.]

Married………………………………………….1

Living together as married……………………... 2

Separated…….……….…………………..…….. 3

Divorced…….…….…………………..……….. 4

Widowed….………..…………………………... 5

Never married………..………………………….6

Refused to answer………………………………  77

Don't know……………..……………………...  99

DEM8. Do you currently have health insurance or coverage? This includes Medicaid or Medicare.

No………………….……………………………  0 Skip to DEM9

Yes……………………………………………...  1 Refused to answer………………………………  77 Skip to DEM9

Don't know……………..……………………...  99

DEM8a.What kind of health insurance or coverage do you currently have?

[DO NOT read choices. Check all that apply.]

Private health insurance or HMO………………  1

Medicaid….……….…………………..………..  2

Medicare…….…….…………………..………..  3

TRICARE (CHAMPUS)….………..…………..  4

Veterans Administration coverage………..……  5

Some other insurance……………….…………..  6

(Specify______________________________)

Refused to answer………………………………  77

Don't know……………..……………………...  99

DEM9. Other than for mental health care, have you seen a doctor, nurse, or other health care provider in the past 12 months?

No………………….……………………………  0 Skip to HLT1

Yes……………………………………………...  1 Refused to answer………………………………  77 Skip to HLT1

Don't know……………..……………………...  99

DEM9a. At any of those times you were seen, were you offered an HIV test? An HIV test checks whether someone has the virus that causes AIDS.

No………………….……………………………  0

Yes……………………………………………...  1 Refused to answer………………………………  77

Don't know……………..……………………...  99

PART II: GENERAL HEALTH FUNCTIONING (SF-12)

SAY: The next questions are about your physical and emotional health during the past four weeks. Please choose the best answer for you for each question

HLT1. In general, would you say your health is:

Excellent…..………………….…………………..  1

Very good………………………………….……..  2

Good .…………………………………………….  3

Fair… ……………..……………….………….....  4

Poor………………………………………………  5

Refused to answer………………………………..  77

Don’t Know……………..…………………….....  99

SAY: The following items are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?

HLT2. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling or playing golf

Yes, limited a lot…..………………….………………….  1

Yes, limited a little………………………………….…..  2

No, not limited at all.……………………………………  3

Refused to answer………………………………………  77

Don’t Know……………..……………………................... 99

HLT3. Climbing several flights of stairs

Yes, limited a lot…..………………….………………….  1

Yes, limited a little………………………………….…..  2

No, not limited at all.……………………………………  3

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

Don’t Know……………..……………………................  99

SAY: During the past 4 weeks have you had any of the following problems with your work or other regular daily activities as a result of your physical health?

HLT4. Accomplished less than you would like

All of the time……………………………………………….  1

Most of the time………………………………......................  2

Some of the time…………………………………………….  3

A little of the time……………………………………….…..  4

None of the time……………………………………………..  5

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

Don't know……………..……………………………………  99

HLT5. Were limited in the kind of work or other activities

All of the time……………………………………………….  1

Most of the time………………………………......................  2

Some of the time…………………………………………….  3

A little of the time……………………………………….…..  4

None of the time……………………………………………..  5

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

Don't know……………..……………………………………  99

SAY: During the past 4 weeks 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)?

HLT6. Accomplished less that you would have like

All of the time……………………………………………….  1

Most of the time………………………………......................  2

Some of the time…………………………………………….  3

A little of the time……………………………………….…..  4

None of the time……………………………………………..  5

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

Don't know……………..……………………………………  99

HLT7. Didn’t do work or other activities as carefully as usual

All of the time……………………………………………….  1

Most of the time………………………………......................  2

Some of the time…………………………………………….  3

A little of the time……………………………………….…..  4

None of the time……………………………………………..  5

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

Don't know……………..……………………………………  99

HLT8. 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……………………………………………………..  1

A little bit……………………………….................................  2

Moderately…………………………………………………… 3

Quite a bit……………………………………….……………  4

Extremely…………………………………………………….  5

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

Don't know……………..……………………………………  99

SAY: These next 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 four weeks:

HLT9. Have you felt calm and peaceful?

All of the time……………………………………………….  1

Most of the time………………………………......................  2

Some of the time…………………………………………….  3

A little of the time……………………………………….…..  4

None of the time……………………………………………..  5

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

Don't know……………..……………………………………  99

HLT10. Did you have a lot of energy?

All of the time……………………………………………….  1

Most of the time………………………………......................  2

Some of the time…………………………………………….  3

A little of the time……………………………………….…..  4

None of the time……………………………………………..  5

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

Don't know……………..……………………………………  99

HLT11. Have you felt down hearted and blue?

All of the time……………………………………………….  1

Most of the time………………………………......................  2

Some of the time…………………………………………….  3

A little of the time……………………………………….…..  4

None of the time……………………………………………..  5

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

Don't know……………..……………………………………  99

HLT12. During the past four weeks how much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)?

All of the time……………………………………………….  1

Most of the time………………………………......................  2

Some of the time…………………………………………….  3

A little of the time……………………………………….…..  4

None of the time……………………………………………..  5

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

Don't know……………..……………………………………  99

PART III: PAST MONTH DRUG AND ALCOHOL USE

SAY: Now I’m going to ask you about drugs and alcohol that you may have used over the past four week. In the past four weeks, how often have you:

DRG1. Smoked cigarettes (or used other tobacco products)?

Not at all…..………………….…………………  0

A few times………………………………….….  1

A few times each week .………………………..  2

Everyday… ……………..……………….…….  3

Refused to answer………………………………  77

Don't know……………..…………………….....  99

DRG2. Drank beer, wine or liquor?

Not at all…..………………….…………………  0

A few times………………………………….….  1

A few times each week .………………………..  2

Everyday… ……………..……………….…….  3

Refused to answer………………………………  77

Don't know……………..………………………..  99

DRG3. Smoked marijuana?

Not at all…..………………….………………….  0

A few times………………………………….…..  1

A few times each week .…………………………  2

Everyday… ……………..……………….……..  3

Refused to answer………………………………  77

Don't know……………..…………………….....  99

DRG4. Smoked crack cocaine?

Not at all…..………………….…………………  0

A few times………………………………….….  1

A few times each week .………………………..  2

Everyday… ……………..……………….…….  3

Refused to answer………………………………  77

Don't know……………..………………………..  99

DRG5. Taken (pills) stimulants: ecstasy, amphetamines, meth, speed, crank or crystal?

Not at all…..………………….……………….…  0

A few times………………………………….…..  1

A few times each week .…………………………  2

Everyday… ……………..……………….……..  3

Refused to answer………………………………  77

Don't know……………..…………………….....  99

DRG6. Taken (pills) benzodiazepines : Xanax, Valium, Klonipin or Ativan?

Not at all…..………………….………………….  0

A few times………………………………….…..  1

A few times each week .…………………………  2

Everyday… ……………..……………….……...  3

Refused to answer………………………………  77

Don't know……………..…………………….....  99

DRG7. Taken painkillers - pills such as oxycodone; oxycontin; percodan, percocet, Vicodin, Demerol, Dilaudid, Darvon, Darvocet or syrup (Codeine) that were not prescribed to you by your doctor?

Not at all…..………………….………………….  0

A few times………………………………….…..  1

A few times each week .…………………………  2

Everyday… ……………..……………….……..  3

Refused to answer………………………………  77

Don't know……………..…………………….....  99

DRG8. Taken other drugs that were not prescribed by a physician?

Not at all…..………………….………………….  0

A few times………………………………….…..  1

A few times each week .…………………………  2

Everyday… ……………..……………….……...  3

Refused to answer………………………………  77

Don't know……………..………………………..  99

Which Drugs:_______________________________________DRG8a.

DRG9. In the past six months, have you injected drugs?

No…….………………….……………………..  0 Skip to PRT1

Yes……….…………………………………….  1

Refused to answer………………………………  77

Don't know……………..……………………….  99

DRG10. In the past six months, have you shared needles or works?

No…….………………….………………………  0 Yes……….………………………………………  1

Refused to answer………………………………  77

Don't know……………..…………………….....  99

DRG11. With how many different people did you share needles in the past six months?

None…..………………….…………………….  0

1 other person……………………………………  1

2 or 3 different people ………………………….  2

4 or more different people ……………..……….  3

Refused to answer………………………………  77

Don't know……………..…………………….....  99

DRG12. In the past six months, how often have you used a needle after someone

(with or without cleaning) ?

Never…..………………….……………………..  0

A few times or less………………………………  1

A few times each month ………………………  2

Once or more each week… ……………..……….  3

Refused to answer………………………………  77

Don't know……………..…………………….....  99

DRG13. In the past six months, how often have others used a needle after you

(with or without cleaning) ?

Never…..………………….……………………..  0

A few times or less………………………………  1

A few times each month ………………………  2

Once or more each week… ……………..……….  3

Refused to answer………………………………  77

Don't know……………..…………………….....  99

DRG14. In the past six months, how often have you shared needles with someone you

knew (or later found out) had AIDS or was positive for HIV, the AIDS virus?

Never…..………………….……………………..  0

A few times or less………………………………  1

A few times each month ………………………  2

Once or more each week… ……………..……….  3

Refused to answer………………………………  77

Don't know……………..…………………….....  99

DRG15. Where did you get your needles during the past six months?

(Check all that apply)

From a diabetic…..………………….……………………….  1

On the street …………………………………………............  2 Drugstore …………………………………………………….  3

Shooting gallery or other place where users go to shoot up….  4

Needle Exchange Program …………………………………..  5

Other______________________________.............................  6

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

Don't know……………..……………………........................  99

DRG16. In the past six months, how often have you been to a shooting gallery/house or

other place where users go to shoot-up?

Never…..………………….……………………..  0

A few times or less……………………………… 1

A few times each month ………………………..  2

Once or more each week… ……………..………  3

Refused to answer………………………………  77

Don't know……………..……………………...  99

DRG17. In the past six months, how often have you been to a Crack House or other place

where people go to smoke crack?

Never…..………………….…………………….. 0

A few times or less……………………………… 1

A few times each month ………………………..  2

Once or more each week… ……………..………  3

Refused to answer………………………………  77

Don't know……………..……………………...  99

DRG18. Which statement best describes the way you cleaned your needles during the

past six months? (Please choose one)

I always use new needles…………………………….  1

I always clean my needle just before I shoot up…….  2

After I shoot up, I always clean my needle …………  3

Sometimes I clean my needle, sometimes I don't……  4

Skip to DRG20

I never clean my needle…..……………..………….  5

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

Don't know……………..……………………...........  99

DRG19. If you cleaned your needles and works in the past six months,

how did you clean them? (Check all that apply)

Soap and water or water only………………………… 1 Alcohol ………………………………………………. 2

Bleach …..…………………………………………… 3

Boiling water………………………………………….  4

Other:______________…………..…………………..  5

I did not clean my needles in the past six months ……. 6

I ALWAYS used new needles in the past six months ... 7

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

Don't know……………..……………………………… 99

DRG20. In the past six months, how often have you shared rinse-water?

Never…..………………….……………………..  0

A few times or less………………………………  1

A few times each month ……………………….  2

Once or more each week… ……………..………  3

Refused to answer……………………………….  77

Don't know……………..…………………….....  99

DRG21. In the past six months, how often have you shared a cooker?

Never…..………………….……………………..  0

A few times or less………………………………  1

A few times each month ……………………….  2

Once or more each week… ……………..………  3

Refused to answer……………………………….. 77

Don't know……………..……………………......  99

DRG22. In the past six months, how often have you shared cotton?

Never…..………………….……………………..  0

A few times or less………………………………  1

A few times each month ……………………….  2

Once or more each week… ……………..………  3

Refused to answer……………………………….  77

Don't know……………..………………………..  99

DRG23. In the past six months, how often have you divided or shared drugs with others

by using one syringe (yours or someone else’s) to squirt or load the drugs into

the other syringe(s) (backloading, for example) ?

Never…..………………….……………………..  0

A few times or less………………………………  1

A few times each month ……………………….  2

Once or more each week… ……………..………  3

Refused to answer……………………………….. 77

Don't know……………..……………………......  99

PART IV: SEXUAL PRACTICES

SAY: The next questions are about having sex. Please remember your answers will be kept private. For the following questions, sex means any vaginal intercourse or anal intercourse, but not oral sex.

PRT1. With how many men have you had sex in the past six months?

Skip to PRT2

0 men……………………………………….  0

1 man……………………………………….  1

2 or 3 men…………………………………..  2

4 or more men…………………………........  3

Skip to PRT2

Refused to answer…………………………... 77

Don't know……………..……………………. 99

PRT1a. How often did you use condoms with your male partner(s) in the past six months?

All the time……………………………........  0

Most of the time……………………….........  1

Half of the time…………………………….  2

A little of the time………………………….  3

None of the time……………………….......  4

Refused to answer…………………………... 77

Don't know……………..……………………. 99

PRT1b. With how many of your male partners did you discuss BOTH your HIV status and his HIV status before having sex?

0 men……………………………………….  0

1 man……………………………………….  1

2 or 3 men…………………………………..  2

4 or more men…………………………........  3

Refused to answer…………………………... 77

Don't know……………..……………………. 99

P

Skip to PRT3

RT2. With how many women have you had sex in the past six months?

0 women…………………………………… 0

1 woman…………………………………… 1

2 or 3 women………………………………. 2

4 or more women…………………………... 3

Skip to PRT3

Refused to answer………………………….. 77

Don't know……………..…………………...  99

If PRT1=0 and PRT2=0 then skip to TST1

PRT2a. How often did you use condoms with your female partner(s) in the past six months?

All the time…………………………………  0

Most of the time………………………........  1

Half of the time…………………………….  2

A little of the time………………………….  3

None of the time………………………........  4

Refused to answer…………………………... 77

Don't know……………..…………………… 99

PRT2b. With how many of your female partners did you discuss BOTH your HIV status and her HIV status before having sex?

0 women…………………………………… 0

1 woman…………………………………… 1

2 or 3 women………………………………. 2

4 or more women…………………………... 3

Refused to answer………………………….. 77

Don't know……………..…………………...  99

PRT3. In the past six months, how often have you had sex so you could get drugs?

Never………………………………….…….  0

A few times or less………………………….  1

A few times each month……………………  2

Once or more each week……………………  3

Refused to answer…………………………... 77

Don't know……………..…………………… 99

PRT4. In the past six months, how often have you given drugs to someone so you could

have sex with them?

Never………………………………….…….  0

A few times or less………………………….  1

A few times each month……………………  2

Once or more each week……………………  3

Refused to answer…………………………... 77

Don't know……………..…………………… 99

PRT5. In the past six months, how often were you paid money to have sex with

someone?

Never………………………………….…….  0

A few times or less………………………….  1

A few times each month……………………  2

Once or more each week……………………  3

Refused to answer…………………………... 77

Don't know……………..…………………… 99

PRT6. In the past six months, how often have you given money to someone so you could

have sex with them?

Never………………………………….…….  0

A few times or less………………………….  1

A few times each month……………………  2

Once or more each week……………………  3

Refused to answer…………………………... 77

Don't know……………..…………………… 99

PRT7. In the past six months, how often have you had sex with someone you knew

(or later found out) had AIDS or was positive for HIV, the AIDS virus?

Never………………………………….…….  0

A few times or less………………………….  1

A few times each month……………………  2

Once or more each week……………………  3

Refused to answer…………………………... 77

Don't know……………..…………………… 99

PART V: CONCERNS ABOUT HIV AND HIV TESTING HISTORY

SAY: Now I’m going to ask you a few questions about getting tested for HIV. Remember, an HIV test checks whether someone has the virus that causes AIDS.

T

Skip to TST7

ST1. Have you ever been tested for HIV?

No…………………………...…………..............  0

Yes………………..……………………..............  1

Skip to TST7

Refused to answer………………………………  77

Don't know……………..……………………...  99

TST2. In the past 2 years, that is, since [insert calculated month and year], how many times have you been tested for HIV?

[Refused = 777, Don't know = 999] ___ ___ ___ If 0, 777, or 999, skip to TST6

If TST2=1, ask:

TST3. That time you got tested for HIV in the past 2 years, did you get the result of the test? [Give dates as reference points if needed.]

No…………………………...…………..............  0

Yes………………..……………………..............  1 Skip to TST6a

Skip to TST6a

Refused to answer………………………………  77

Don't know……………..……………………...  99

If TST2>1, ask:

TST4. Of the ____ [insert number from TST2] times you were tested for HIV in the past 2 years, how many times did you get the results of those tests? [Give dates as reference points if needed].

[ Refused = 777, Don't know = 999] ­___ ___ ___ ­ If TST4= TST3 or if TST4=777 or 999, skip to TST6a

TST5. Think about the last time you didn’t get your HIV test result. What was the main reason you didn’t get your result? [DO NOT read choices. Choose only one reason type.]

Too early to get the result………………………....... 1

Thought site would contact them…………..……….. 2

Afraid of getting result..…...……..…………………. 3

Too busy to get the result………………...…………. 4

Forgot to get result………………………………….  5

Didn’t care about result/didn’t want to know……….  6

Jail-related (released before getting result)…………  7

Inconvenient (location/hours/time etc.).……………  8

Lost appointment card, paperwork, ID number ……  9

Other……………………..………………………….  10

Refused……………………………………………...  77

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

TST6. When did you have your most recent HIV test?

[77/7777 = Refused, 99/9999 = Don't know] __ __/ __ __ __ __

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

If Auto1 – TST6 is > 5 years ago, skip to TST6b.

TST6a. When you got tested in ____/____ [insert date from TST6], where did you get tested?

Testing Site:________________________________________________________

[Write down the site name and classify it from the list of choices below. Probe with additional questions if

necessary. DO NOT read choices. Choose only one site type.]

HIV counseling and testing site……..………………1

HIV/AIDS street outreach program/Mobile Unit…  2

Sexually transmitted disease (STD) clinic………….. 3

Drug treatment program………………..………. ….  4

Needle exchange program.…...……..………….. ….  5

Correctional facility (jail or prison)……………. …  6

Family planning clinic……………..………….......  7

Prenatal/obstetrics clinic …………..…..………. ….  8

Public health clinic………………………………….  9

Community health center….…….……………….  10

Private doctors office (including HMO)……….. ….  11

Emergency room………….……...………………..  12

Hospital (inpatient)……………...….………….. ….  13

At home…………..……………………………….  14

Other………..………………………….…………  15

Refused……………………………………….... ..  77

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

TST 6b. What was the result of your most recent HIV test? [DO NOT Read choices, check only one.]

Skip to TST10

Skip to Q133

Negative………………….…………………….  1 Positive………………………….………............  2

Never obtained results………………….….........  3

Skip to TST10

Indeterminate…………..……………..…………  4 Refused to answer…………...….……………….  77

Don't know…...…………………………..........  99

TST7. How worried are you about getting HIV or AIDS?

Not at all………………….…………………  0

Slightly………………….………………….  1

Moderately………………….……………… 2

Considerably………………….……………. 3

Extremely………………….………………..  4

Refused to answer…………………………... 77

Don't know……………..……………………. 99

TST8. How worried are you that you may have already been exposed to the HIV or

AIDS virus?

Not at all………………….…………………  0

Slightly………………….………………….  1

Moderately………………….……………… 2

Considerably………………….……………. 3

Extremely………………….………………..  4

Refused to answer…………………………... 77

Don't know……………..…………………… 99

INTERVIEWER INSTRUCTIONS: Refer to answer to TST6.

LAST HIV TEST WAS DONE (Check one):

< 12 months ago....................................... Go to CON1

> 12 months ago..................................... Go to next question

Date of last test Don't know/Refused… Go to CON1

[ PERSONS WHO HAVE NOT TESTED FOR HIV IN THE PAST 12 MONTHS OR HAVE NEVER TESTED]

TST9. I am going to read you a list of reasons why some people have not been tested for HIV. Please tell me if the following are reasons why you have not been tested for HIV in the past 12 months/never tested. I will read each reason and you should answer No or Yes for each one.

[READ CHOICES, CHECK NO OR YES FOR EACH ONE.]

Have you not been tested in the past 12 months or never tested: Refused No Yes to answer

a. Because you think you are at low risk for HIV infection?....  0……..  1…….. 77

b. Because you were afraid of finding out that you had HIV?... 0……..  1……... 77

c. Because you were worried your name would be

reported to the government if you tested positive?................  0……… 1…….. 77

d. Because you were afraid of someone finding

out about the test result?.................................................…...  0……… 1…….. 77

e. Because you were afraid of losing your job, insurance,

or housing if you tested positive?..........................................  0………1…….. 77

f. Because you didn’t have the money or the insurance to

pay for the test?......................................................................  0……… 1…….. 77

g. Because you didn’t have time?….…………….……….…… 0……..  1…….. 77

h. Because you didn’t know where to go to get tested?.............  0……..  1…….. 77

i. Because you couldn’t get transportation to a testing place?..  0……..  1…….. 77

j. Because you don’t like needles?............................................  0……..  1…….. 77

Interviewer: If only one "yes" response in TST9a-j, then write the letter for the "yes" response in TST10k. If more than one "yes" response for TST9a-j, ask TST9k.

TST9k. Which of these reasons was the most important reason you have not been tested for HIV in the past 12 months? [Read each of the above reasons answered “Yes.” Write the letter of the main reason in the box below. ]

[Refused to answer=7, Don’t know=9] _______ (Skip to CON1)

[PERSONS WHO HAVE TESTED HIV POSITIVE]

TST10 Was your test in ____/_____ [insert date from TST6] your first positive test?

No………………….……………………………  0

Skip to TST10b

Yes………………………………………………  1

Refused to answer………………………………  77

Don't know…………………………………….  99

TST10a. When did you first test positive?

[77/7777 = Refused, 99/9999 = Don't know] __ __/ __ __ __ __

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

TST10b. Was this positive test result a rapid test result?

No………………….……………………………  0

Yes………………………………………………  1

Refused to answer………………………………  77

Don't know…………………………………….  99

TST10c. Did you get your confirmatory test result?

No………………….……………………………  0

Yes………………………………………………  1

Refused to answer………………………………  77

Don't know…………………………………….  99

TST10d. When you first tested positive in ____/______ [insert date from TST10a], where

did you get tested?

Testing Site:________________________________________________________

[Write down the site name and classify it from the list of choices below. Probe with

additional questions if necessary. DO NOT read choices. Choose only one site type.]

HIV counseling and testing site……..……………… 1

HIV/AIDS street outreach program/Mobile Unit…  2

Sexually transmitted disease (STD) clinic………….. 3

Drug treatment program………………..………. ….  4

Needle exchange program.…...……..………….. ….  5

Correctional facility (jail or prison)……………. …  6

Family planning clinic……………..………….......  7

Prenatal/obstetrics clinic …………..…..………. ….  8

Public health clinic…………………………………  9

Community health center….…….……………….  10

Private doctors office (including HMO)……….. ….  11

Emergency room………….……...………………..  12

Hospital (inpatient)……………...….………….. ….  13

At home…………..……………………………….  14

Other………..………………………….…………  15

Refused……………………………………….... ..  77

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

TST10e. Have you ever been seen by a doctor, nurse, or other health care provider for a medical evaluation or care related to your HIV infection?

No………………….……………………………  0

Yes……………………………………………...  1 Skip to TST10g

Skip to TST11

Refused to answer………………………………  77

Don't know……………..……….......................  99

TST 10f. What is the main reason you have never gone to a health care provider for a medical evaluation or care related to your HIV infection? [DO NOT read choices. Choose only one reason.]

Feel good, don't need to go …………………..…………  1

Don't want to think about being HIV positive/Denial…..  2

Didn’t have money or insurance…..………….………..  3

Couldn't find health care provider/Didn’t know

where to go…………….………….................................  4

Inconvenient (location/hours/time, etc.)....……………..  5

Forgot to go/Missed appointment……………..………..  6 Skip to CON1

Too busy to go…………...…...……..…………….........  7

Drinking or using drugs………….…………….............  8

On the street…………………………………….............  9

Appointment pending………..…………………………. 10

Other……………………..……………………………..  11

Skip to CON1

Refused…………………………………………………  77

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

TST10g. When did you last go to your health care provider for HIV care?

[77/7777=Refused, 99/9999 = Don't know] __ __/ __ __ __ __

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

INTERVIEWER INSTRUCTIONS:

< 6 months since last provider visit Skip to TST11

> 6 months since last provider visit Go to next question

Interval cannot be determined (date missing) Skip to TST11

T ST10h.What is the main reason you have not gone to a health care provider for HIV care in the past 6 months? [DO NOT Read reason types. Choose only one reason.]

Felt good, didn’t need to go …………………..…..........  1

Initial CD4 count and viral load were good…………….  2

Don't want to think about being HIV positive/Denial…..  3

Didn’t have money or insurance…..………….………..  4

Couldn't find health care provider/Didn’t know

where to go…………….………….................................  5

Inconvenient (location/hours/time, etc.)....……………..  6

Forgot to go/Missed appointment……………..………..  7

Too busy to go…………...…...……..…………….........  8

Drinking or using drugs………….…………….............  9

On the street…………………………………….............  10

Appointment pending………..…………………………. 11

Other……………………..……………………………..  12

Refused…………………………………………………  77

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

TST11. Are you currently taking medicines to treat your HIV infection? These medicines are also known as antiretroviral medicines, HAART, or the AIDS cocktail.

No………………….…………………..………  0

Skip to CON1

Yes………………………………………..…….  1

Refused to answer……………………………..  77

Don't know……………..………………...........  99

TST11a. What is the main reason you are not currently taking any antiretroviral medicines?

[DO NOT read reason types. Choose only one reason.]

Feel good, don’t need them......……..………………….  1

CD4 count and viral load are good……….....................  2

Doctor advised to delay treatment…..………….............  3

Don't want to think about being HIV positive./Denial…  4

Worried about side effects …..………..…….….............  5

Don't have money or insurance……….…………....…..  6 Drinking or using drugs…………..…..…….…………..  7

On the street.…………………………..…….…............  8

Recently into medical care……………………………...  9

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

Refused…………………………………………………  77

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

PART VI: HEALTH CONDITIONS

SAY: Next, I'd like to ask you some questions about your health.

CON1. The next questions are about hepatitis, an infection of the liver.

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

Skip to CON2

No………………….……………………………  0

Yes………………………….…………............... 1

Skip to CON2

Refused to answer………………………………  77

Don't know……………..……………................  99

CON1a What type or types of hepatitis have you had? [CHECK ALL THAT APPLY.]

Hepatitis A……….……………………………..  0 Skip to CON2

Hepatitis B………………….…………..............  1

Hepatitis C……………………………...............  2 Skip to CON1e

Other……………..…………….……………….  4

If Other: Specify__________________ Skip to CON2

Refused to answer………………………………  77

Don't know……………..……………................  99

CON1b. Have you been diagnosed with chronic Hepatitis B infection?

Skip to CON2

No………………….……………………………  0

Yes………………………….…………............... 1

Refused to answer………………………………  77

Don't know……………..……………................  99

CON1c. Are you currently receiving treatment for your chronic Hepatitis B infection?

No………………….……………………………  0

Skip to CON2

Yes………………………….…………............... 1

Refused to answer………………………………  77

Don't know……………..……………................  99

CON1d. Have you received treatment for your chronic Hepatitis B infection in the past?

No………………….……………………………  0

Yes………………………….…………............... 1

Refused to answer………………………………  77

Don't know……………..……………................  99

CON1e. Have you been diagnosed with chronic Hepatitis C infection?

Skip to CON2

No………………….……………………………  0

Yes………………………….…………............... 1

Refused to answer………………………………  77

Don't know……………..……………................  99

CON1e. Are you currently receiving treatment for your chronic Hepatitis C infection?

No………………….……………………………  0

Skip to CON2

Yes………………………….…………............... 1

Refused to answer………………………………  77

Don't know……………..……………................  99

CON1e. Have you received treatment for your chronic Hepatitis C infection in the past?

No………………….……………………………  0

Yes………………………….…………............... 1

Refused to answer………………………………  77

Don't know……………..……………................  99

CON 2. Now I’m going to ask you some questions about sexually transmitted diseases or STDs.

In the past 12 months, has a doctor, nurse, or other health care provider taken a blood sample or asked you for a urine sample to test for STDs?

No………………….……………………………  0

Yes………………………….…………............... 1

Refused to answer………………………………  77

Don't know……………..……………................  99

CON 2a. In the past 12 months, has a doctor, nurse, or other health care provider told you that you had any of the following STDs? [READ CHOICES, CHECK NO OR YES FOR EACH ONE]

No Yes Refused Don’t

to answer Know

a. Syphilis……………..…  0......…  1……..  77………… 99

b. Gonorrhea (clap or drip).. 0......…  1……..  77………… 99

c. Chlamydia…………..….  0......…  1……..  77……..….. 99

d. Genital herpes (HSV) .… 0........  1…….  77……..….. 99

e. Trichomoniasis ………..  0........  1…….  77……..….. 99

f. Any Other STDs…..……  0......…  1……..  77……..….. 99

g. If Yes: Specify__________________

PART VII: MENTAL HEALTH SYMPTOMS (BASIS 24)

Questionnaire copyright © 2001 McLean Hospital.

SAY: The next questions are about your emotional health over the past week. During the past week, how much difficulty did you have:

SYM1. Managing your day-to-day life?

No difficulty……………………………………...  0

A little difficulty………………………………....  1

Moderate difficulty………………………………  2

Quite a bit of difficulty………………………….  3

Extreme difficulty……………………………….  4

Refused to answer………………………………..  77

Don't know……………..……………………….  99

SYM2. Coping with problems in your life?

No difficulty……………………………………...  0

A little difficulty………………………………....  1

Moderate difficulty………………………………  2

Quite a bit of difficulty………………………….  3

Extreme difficulty……………………………….  4

Refused to answer………………………………..  77

Don't know……………..……………………….  99

SYM3. Concentrating?

No difficulty……………………………………...  0

A little difficulty………………………………....  1

Moderate difficulty………………………………  2

Quite a bit of difficulty………………………….  3

Extreme difficulty……………………………….  4

Refused to answer………………………………..  77

Don't know……………..……………………….  99

SAY: During the past week, how much of the time did you:

SYM4. Get along with people in your family?

None of the time………………………………….  0

A little of the time………………………………... 1

Half of the time………………………………….  2

Most of the time………………………………….  3

All of the time……………………………………  4

Refused to answer………………………………..  77

Don't know……………..……………………….  99

SYM5. Get along with people outside your family?

None of the time………………………………….  0

A little of the time………………………………... 1

Half of the time………………………………….  2

Most of the time………………………………….  3

All of the time……………………………………  4

Refused to answer………………………………..  77

Don't know……………..……………………….  99

SYM6. Get along well in social situations?

None of the time………………………………….  0

A little of the time………………………………... 1

Half of the time………………………………….  2

Most of the time………………………………….  3

All of the time……………………………………  4

Refused to answer………………………………..  77

Don't know……………..……………………….  99

SAY: During the past week, how much of the time did you:

SYM7. Feel close to another person?

None of the time………………………………….  0

A little of the time………………………………... 1

Half of the time………………………………….  2

Most of the time………………………………….  3

All of the time……………………………………  4

Refused to answer………………………………..  77

Don't know……………..……………………….  99

SYM8. Feel like you had someone to turn to if you needed help?

None of the time………………………………….  0

A little of the time………………………………... 1

Half of the time………………………………….  2

Most of the time………………………………….  3

All of the time……………………………………  4

Refused to answer………………………………..  77

Don't know……………..……………………….  99

SYM9. Feel confident in yourself?

None of the time………………………………….  0

A little of the time………………………………... 1

Half of the time………………………………….  2

Most of the time………………………………….  3

All of the time……………………………………  4

Refused to answer………………………………..  77

Don't know……………..……………………….  99

SAY: During the past week, how much of the time did you:

SYM10. Feel sad or depressed?

None of the time………………………………….  0

A little of the time………………………………... 1

Half of the time………………………………….  2

Most of the time………………………………….  3

All of the time……………………………………  4

Refused to answer………………………………..  77

Don't know……………..……………………….  99

SYM11. Think about ending your life?

None of the time…………………………………. 0

A little of the time………………………………...1

Half of the time………………………………….  2

Most of the time………………………………….  3

All of the time……………………………………  4

Refused to answer………………………………..  77

Don't know……………..……………………….  99

SYM12. Feel nervous?

None of the time…………………………………. 0

A little of the time……………………………….. 1

Half of the time………………………………….  2

Most of the time………………………………….  3

All of the time……………………………………  4

Refused to answer………………………………..  77

Don't know……………..……………………….  99

SAY: During the past week, how much of the time did you:

SYM13. Have thoughts racing through your head?

Never……………………………………………..  0

Rarely………………………………...................... 1

Sometimes………………………………………..  2

Often……………………………………………..  3

Always…………………………………………...  4

Refused to answer………………………………..  77

Don't know……………..……………………….  99

SYM14. Think you had special powers?

Never……………………………………………..  0

Rarely………………………………...................... 1

Sometimes………………………………………..  2

Often……………………………………………..  3

Always…………………………………………...  4

Refused to answer………………………………..  77

Don't know……………..……………………….  99

SYM15. Hear voices or see things?

Never……………………………………………..  0

Rarely………………………………...................... 1

Sometimes………………………………………..  2

Often……………………………………………..  3

Always…………………………………………...  4

Refused to answer………………………………..  77

Don't know……………..……………………….  99

SYM16. Think people were watching you?

Never……………………………………………..  0

Rarely………………………………...................... 1

Sometimes………………………………………..  2

Often……………………………………………..  3

Always…………………………………………...  4

Refused to answer………………………………..  77

Don't know……………..……………………….  99

SYM17. Think people were against you?

Never……………………………………………..  0

Rarely………………………………...................... 1

Sometimes………………………………………..  2

Often……………………………………………..  3

Always…………………………………………...  4

Refused to answer………………………………..  77

Don't know……………..……………………….  99

SAY: During the past week, how much of the time did you:

SYM18. Have mood swings?

Never……………………………………………..  0

Rarely………………………………...................... 1

Sometimes………………………………………..  2

Often……………………………………………..  3

Always…………………………………………...  4

Refused to answer………………………………..  77

Don't know……………..……………………….  99

SYM19. Feel short-tempered?

Never……………………………………………..  0

Rarely………………………………...................... 1

Sometimes………………………………………..  2

Often……………………………………………..  3

Always…………………………………………...  4

Refused to answer………………………………..  77

Don't know……………..……………………….  99

SYM20. Think about hurting yourself?

Never……………………………………………..  0

Rarely………………………………...................... 1

Sometimes………………………………………..  2

Often……………………………………………..  3

Always…………………………………………...  4

Refused to answer………………………………..  77

Don't know……………..……………………….  99

SAY: During the past week, how much of the time did you:

SYM21. Did you have an urge to drink alcohol or take street drugs?

Never……………………………………………..  0

Rarely………………………………...................... 1

Sometimes………………………………………..  2

Often……………………………………………..  3

Always…………………………………………...  4

Refused to answer………………………………..  77

Don't know……………..……………………….  99

SYM22. Did anyone talk to you about your drinking or drug use?

Never……………………………………………..  0

Rarely………………………………...................... 1

Sometimes………………………………………..  2

Often……………………………………………..  3

Always…………………………………………...  4

Refused to answer………………………………..  77

Don't know……………..……………………….  99

SYM23. Did you try to hide your drinking or drug use?

Never……………………………………………..  0

Rarely………………………………...................... 1

Sometimes………………………………………..  2

Often……………………………………………..  3

Always…………………………………………...  4

Refused to answer………………………………..  77

Don't know……………..……………………….  99

SYM24. Did you have problems from your drinking or drug use?

Never……………………………………………..  0

Rarely………………………………...................... 1

Sometimes………………………………………..  2

Often……………………………………………..  3

Always…………………………………………...  4

Refused to answer………………………………..  77

Don't know……………..……………………….  99

THE INTERVIEWER ANSWERS THE FOLLOWING QUESTION. DO NOT READ THIS TO THE RESPONDENT.

VLD1.   How confident are you of the validity of the respondent’s answers?

  Confident….…………………..……………… 1

Some doubts………………………..…………  2

Not confident at all…………………..….......... 3

VLD1TXT. If response is 2 or 3, please explain why you are not confident in the respondent's answers:

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

CMH Questionnaire 1