Evaluation of Pharmacy Syringe Access Linked to HIV Testing for Injection Drug Users in New York City (PHarm-HIV) Pharmlink Participant Baseline Survey (Syringe Customer)

FORM APPROVED

OMB. NO. 0920-09xx

EXPIRES XX/XX/XXXX

“Evaluation of Pharmacy Syringe Access Linked to HIV Testing for Injection Drug Users in New York City (Pharm-HIV)”

Pharmlink Participant – Baseline Survey

Public reporting burden of this collection of information is estimated to average 30 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 persons is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: PRA (0920-09XX)

_____________________________________________________________________________________

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health Service

Centers for Disease Control and Prevention

Atlanta, Georgia 30333

PharmLink Participant Baseline Survey

Date: ______________ Start Time: ___ ___ :___ ___ AM / PM End Time: ___ ___ :___ ___ AM / PM

Interviewer ID #: _______ Participant ID # ______________

INTERVIEW INTRODUCTION

READ: I am going to ask you about some of your experiences with pharmacies, HIV testing, syringe use and sexual practices. Please remember to take as much time as you need so that I can collect information that is as accurate as possible. All your responses are completely confidential. If you cannot, or do not wish to answer a particular question tell me and I will go on to the next one. Remember, there are no right or wrong answers to these questions, so just answer them as best you can. Your participation will make a difference in helping others.

Demographic Form

Section A: gENERAL iNFORMATION & DEMOGRAPHICS

1. How are you feeling today: excellent, good, fair, or poor?

0. Excellent

1. Good

2. Fair

3. Poor

- - Refused

++ Don’t know

2. All in all, would you say your health is excellent, good, fair, or poor?

0. Excellent

1. Good

2. Fair

3. Poor

- - Refused

++ Don’t know

3. What is your full birth date? Month: ________Day: ________Year:________

4. That makes you how old?

_____ _____ years

5. What is your sex?

01 Male

02 Female

- - Refused

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

01 Yes

02 No

b. What race do you consider yourself (check all that apply)?

1. Black or African-American [A7b]

2. White [A8]

3. Asian [A8]

4. Native Hawaiian or Other Pacific Islander [A8]

5. American Indian or Alaskan Native [A8]

- - Refused [A8]

++ Don’t know [A8]

A7. a. [IF HISPANIC OR LATINO(A)] Do you consider yourself to be? [READ LIST]

1. Puerto Rican [A8]

2. Central American [A8]

3. South American [A8]

4. Mexican American [A8]

5. Cuban [A8]

6. Dominican [A8]

7. Spaniard or Portuguese [A8]

8. Other [A8]

- - Refused [A8]

++ Don’t know [A8]

b. [IF BLACK] Do you consider yourself to be? [READ LIST]

1. African American

2. West Indian/Caribbean, English Speaking

3. Caribbean, Spanish speaking

4. Caribbean, French/Creole Speaking

5. Hispanic

6. African

7. Mixed

08 Other

- - Refused

++ Don’t know

8. a. Where were you born?

1. New York City

2. Puerto Rico

3. Dominican Republic

4. Cuba

5. Mexico

6. Continental US

7. Other (specify _____________________________________)

- - Refused

++ Don’t know

b. How long have you lived in New York? [Please circle one]

1. Born here

2. 20 years or longer

3. 10-19 years

4. 5-9 years

5. 1-4 years

6. Less than 1 year

- - Refused

++ Don’t know

8. What is your marital status? [Choose one]

01 Single, never married

02 Married, living as married

03 Divorced

04 Separated

05 Widowed

06 Other

- - Refused

++ Don’t know

8. Have you been enrolled in school anytime in the past 6 months?

1. No

2. Yes

- - Refused

++ Don’t know

8. What is the highest level of education or schooling that you have completed?

1. No schooling completed

2. kindergarten to 8th grade

3. Some high school [9th to 11th grade]

4. High school equivalency [GED]

5. High school graduate [12th grade]

6. Some college or technical training

7. College graduate

8. Graduate work

9. Other

- - Refused

++ Don’t know

8. a. Have you ever dropped out of school?

00 No [Skip to A12]

1. Yes

- - Refused [Skip to A12]

++ Don’t know [Skip to A12]

b. How old were you when you first dropped out of school?

_____ _____ years old

[-- refused]

[++ don’t know]

Now I would like to ask you some questions about your income. Please remember that everything that you tell me is confidential.

8. a. During the last 6 months, did you receive any money from:

	[INTERVIEWER: read aloud each choice from the column below and mark yes or no for each one.]	No	Yes	Refused	Don’t know
1	Regular job employed with a regular salary (full or part time) Where you get paid with a check, receive vacation benefits or had to clock in with a time card.	0	1	- -	++
2	Public Assistance, Welfare, SSI, or State or Federal Benefits (like Food stamps, State Public Aid, disability, unemployment)	0	1	- -	++
3	Have own business (like street vending, etc.)	0	1	- -	++
4	Temporary work (include odd jobs, off-books, etc)- jobs where you are paid in cash for your hourly work.	0	1	- -	++
5	Recycling cans, returning bottles for deposits, windshield wiping, or panhandling for money	0	1	- -	++
6	A parent, friend, relative, or spouse’s income	0	1	- -	++
7	Theft, robbing, stealing, conning I would like to remind you that everything you say is confidential. Your answers are kept according to number. Your name is not on any information we collect from you.	0	1	- -	++
8	Selling drugs	0	1	- -	++
9	Sex for money	0	1	- -	++
66	Other (specify)	0	1	- -	++

2. Of the places you got money from, which gave you the most?

[Read previous “Yes” items, circle only one]

1. Regular job employed with a regular salary (full or part time

2. Public Assistance, Welfare, SSI, State or Federal Benefits (Food stamps, State Public Aid, disability, unemployment)

3. Have own business.

4. Temporary work (include odd jobs, off-books, etc)

5. Recycling cans, returning bottles for deposits, windshield wiping, or panhandling for money

6. A parent, friend, relative, or spouse’s income

7. Theft, robbing, or stealing

8. Selling drugs

9. Sex for money

66. Other

- - Refused

++ Don’t know

8. a. What was your total legal income (on the books) before taxes in the past year, this includes public assistance, SSI, …etc?

1. No income

2. Less than or equal to $5,000 [about $400 per month]

3. More than $5,000 and less than $10,000 [about $800 per month]

4. More than $10,000 and less than $20,000 [about $1600 per month]

5. More than $20,000 and less than $30,000 [about $2500 per month]

6. greater than $30,000 [more than $2500 per month]

- - Refused

++ Don’t know

b. What was your total UNTAXABLE income (off the books) in the past year?

1. No income

2. Less than or equal to $5,000 [about $400 per month]

3. More than $5,000 and less than $10,000 [about $800 per month]

4. More than $10,000 and less than $20,000 [about $1600 per month]

5. More than $20,000 and less than $30,000 [about $2500 per month]

6. greater than $30,000 [more than $2500 per month]

- - Refused

++ Don’t know

Now I would like to ask you some questions about housing.

8. As a child, did you ever live in an orphanage, a foster home, a group home, or were you a ward of the state?

0 No

1 Yes

- - Refused

++ Don’t know

8. a. Have you ever been homeless?

0. No [Skip to A15e]

1. Yes

- - Refused [Skip to A15e]

++ Don’t know [Skip to A15e]

b. How old were you the first time you were homeless?

_____ _____ years old

[-- REFUSED]

[++ DON’T KNOW]

c. Have you been homeless in the past 6 months?

0. No [Skip to A15e]

1. Yes

- - Refused [Skip to A15e]

++ Don’t know [Skip to A15e]

d. Are you currently homeless?

0. No

1. Yes

- - Refused

++ Don’t know

e. In the last 12 months, were you ever hungry but didn't eat because you couldn't afford enough food?

0. No

1. Yes

- - Refused

++ Don’t know

Section B: Drug use and syringe acquisition

Now I would like to ask you some questions about cigarettes, alcohol, and drugs. I understand that these are personal questions and I assure everything you say is confidential. Please answer as honestly as you can.

1. I am going to ask you if you have ever or are currently using certain drugs.

[INTERVIEWER: PLEASE DETERMINE IF THEY HAVE EVER USED EACH DRUG BY FIRST ASKING COLUMNS b. AND c. FOR ALL ROWS, AND THEN GOING BACK TO COLUMN d.]

a. [DRUG TYPE]		b. Have you ever …	c. Age first use …	d. During the last 6 months, how often did you…? [Show Card 1]
A.	Smoked cigarettes?	0 No 1 Yes - - Refused ++ Dk	__ __
B.	Sniffed or snorted cocaine by itself?	0 No 1 Yes - - Refused ++ Dk	__ __	_____
C.	Sniffed or snorted heroin by itself?	0 No 1 Yes - - Refused ++ Dk	__ __	_____
D.	Sniffed or snorted heroin with cocaine (together)?	0 No 1 Yes - - Refused ++ Dk	__ __	_____
E.	Sniffed or snorted any other drug? Specify __________________________	0 No 1 Yes - - Refused ++ Dk	__ __	_____
F.	Used street methadone (not from a program)?	0 No 1 Yes - - Refused ++ Dk	__ __	_____
G.	Injected heroin by itself?	0 No 1 Yes - - Refused ++ Dk	__ __	_____
H.	Injected cocaine by itself?	0 No 1 Yes - - Refused ++ Dk	__ __	_____
I.	Injected heroin and cocaine together?	0 No 1 Yes - - Refused ++ Dk	__ __	_____
J.	Injected speed/ amphetamines/stimulants (uppers, black beauties)?	0 No 1 Yes - - Refused ++ Dk	__ __	_____
K.	Injected heroin and amphetamines together?	0 No 1 Yes - - Refused ++ Dk	__ __	_____
L.	Injected crack?	0 No 1 Yes - - Refused ++ Dk	__ __	_____
M.	Injected steroids or hormones?	0 No 1 Yes - - Refused ++ Dk	__ __	_____
N.	Injected any other drug? Specify ___________________________	0 No 1 Yes - - Refused ++ Dk	__ __	_____
O.	Smoked crack, ready-rock or Freebase cocaine?	0 No 1 Yes - - Refused ++ Dk	__ __	_____
P.	Smoked heroin by itself?	0 No 1 Yes - - Refused ++ Dk	__ __	_____
Q.	Smoked heroin and crack together?	0 No 1 Yes - - Refused ++ Dk	__ __	_____

INTERVIEWER: Refer to rows G-N above and question B2 to determine injector/non-injector. Review entire grid and question B2 to determine whether diabetic only.

1. Diabetic only (Answered “No” to all rows in drug use grid, answered “Yes” to B2) [Skip to B11]

2. Injector (Non prescription drugs)

3. Non-injector [Skip to B11]

2. Have you ever injected insulin, or any other drug prescribed by a doctor?

01 Yes

02 No

- - Refused

++ Don’t know

3. How old were you when you first injected drugs (not prescribed to you by your doctor)?

_____ _____ years old

-- Refused

++ Don’t know

4. When was the last time that you injected drugs?

___ ___ / ___ ___ / ___ ___ (MM/DD/YY)

- - Refused

++ Don’t know

5. In the last 3 months, how often have you injected drugs (not prescribed to you by your doctor?

0 Never [Skip to B8]

1 Once a month or less

2 2-3 days a month

3 About once a week

4 2-3 days a week

5 4-6 days a week

6 Everyday

- - Refused

++ Don’t know

6. In the past 3 months, how many people did you usually inject drugs with?

_____ _____ # of people

- - Refused

++ Don’t know

[ IF USUALLY INJECT ALONE, WRITE “00”]

7. Now I am going to ask you some questions about your experiences with syringes in the past 3 months.

	Never	Rarely	Less than ½ the time	Half the time	More than half the time	Always	Refused	Don’t know
A. In the past 3 months, how often did you use a needle that you knew someone had used before you?	0	1	2	3	4	5	--	++
B. In the past 3 months, how often did you use a needle that you were absolutely sure had not been used by anyone else? By this I mean you heard or could feel the cap “snap” when you turned the cap to remove it from the needle.	0	1	2	3	4	5	--	++
C. In the past 3 months, how often did you use a needle that you thought was clean but MAY not have been sterile? For example, someone gave or sold you a new needle but you did not hear or feel the click when you turned the cap?	0	1	2	3	4	5	--	++
D. In the past 3 months, how often did you clean a needle with bleach before you used it?	0	1	2	3	4	5	--	++
E. In the past 3 months, how often did you pass your needle to somebody else to use?	0	1	2	3	4	5	--	++
F. In the past 3 months, how often did you usually inject with a single needle before you got rid of it?	0	1	2	3	4	5	--	++

8. If you were to get a NEW needle on the street today, how much would you have to pay for it?

$ _____ _____. _____ ______

00 Never bought

- - REFUSED

++ DON’T KNOW

9. a. In the past 3 months, when you finished using a needle or syringe, what did you do with it most of the time? [Probe: ready to get rid of it, NOT keep it any longer]

[INTERVIEWER: Ask open-ended and circle the most appropriate Response.]

A.	Brought it to a needle exchange program?	1
B.	Brought it to a hospital or nursing home? SPECIFY(_______________________)	2
C.	Brought it to a free-standing clinic or Health Department? specify (________________)	3
D.	Brought it to a doctor’s office? specify (_________________________)	4
E.	Brought it to a pharmacy? specify (_________________________)	5
G.	Sold it?	6
H.	Returned it (if it wasn’t yours)?	7
I.	Threw it away?	8
J.	Gave it away?	9
K.	Left it where you shot up?	10
L.	Put it in a sharps container, Fitpack or soda/laundry bottle & then threw it away? SPECIFY type of container__________________________________________	11
M.	Other SPECIFY (___________________________________________________)	77
N.	Refused to Answer	- -
O.	Don’t Know	++

[INTERVIEWER: Only if answer is I or L go to B11b and ASK open-ended and circle the most appropriate response.] otherwise, skip to B12]

b. where did you throw it away most of the time?

A.	Throw it in a garbage can at home?	1
B.	Throw it in the garbage anywhere else?	2
C	Throw it on the ground, vacant lot or alley?	3
D.	Throw it in the bushes?	4
E.	Throw it down the sewer/storm drain?	5
F.	Flush it down the toilet?	6
G.	Put it in a red medical container or sharps box? SPECIFY location(__________________________)	7
H.	Put in red disposal mailbox? SPECIFY location (_________________________________)	8
I.	Other (________________________________________________)	77
J.	Refused to Answer	- -
K.	Don’t Know	++

10. I would like to ask you some questions about how you got syringes in the last 3 months.

FIRST, ASK ALL THE QUESTIONS IN COLUMN “a” FOR EACH ROW A-L. THEN, GO BACK TO

EACH QUESTION ANSWERED “YES” AND ASK THE QUESTIONS IN COLUMNS “b” AND “c”. ]

Needle Source	a. Did you get your needles from….?	b. How often did you get needles from…. [Show Card 1]	c. How many would you usually get at one time from ….?
A. Pharmacy (you went to Pharmacy yourself)	0 No 1 Yes - - Refused ++ Don't know	_______	___ ___ ___ # [ --- Refused] [+++ Don't know]
B. Needle Exchange Program (you went to NEP yourself)	0 No 1 Yes - - Refused ++ Don't know	_______	___ ___ ___ # - - Refused ++ Don't know
C. Needle Dealer or Drug Dealer	0 No 1 Yes - - Refused ++ Don't know	_______	___ ___ ___ # - - Refused ++ Don't know
D. Diabetic Friend/ Relative/ Acquaintance	0 No 1 Yes - - Refused ++ Don't know	_______	___ ___ ___ # - - Refused ++ Don't know
E. Other (Please specify _____________________)	0 No 1 Yes - - Refused ++ Don't know	_______	___ ___ ___ # - - Refused ++ Don't know

11. The following statements refer to using heroin, cocaine, speed or crack.

Please tell me how much you agree or disagree with each of the following:

	Strongly Disagree	Disagree	Not Sure	Agree	Strongly Agree	Refuse
A. Your drug use is a problem for you	1	2	3	4	5	- -
B. Your drug use is more trouble than it’s worth	1	2	3	4	5	- -
C. Your drug use is under control	1	2	3	4	5	- -
D. You are ready to quit using drugs right now.	1	2	3	4	5	- -
E. You plan to quit using drugs in the next 30 days.	1	2	3	4	5	- -
F. You plan to quit using drugs in the next six months.	1	2	3	4	5	- -

12. a. When was the first time you bought a needle in a pharmacy without a prescription in New York State?

___ ___ / ___ ___ (MM/YY)

- - Refused

++ Don’t Know

2. How did you decide which pharmacy to go to the first time you bought a needle without a prescription in New York? [YOU MAY CIRCLE MORE THAN ON RESPONSE]

1. Needle Exchange told me about it

2. Some other agency told me about it Specify __________________

3. Heard about it from friend or family member who also uses drugs

4. Heard about it from friend or family member who does not use drugs

5. Close to where I live or hang out

6. Went to my regular pharmacy (where I go for prescriptions or other things)

7. An Outreach Worker told me about it

8. Other (Please Specify:________________________)

- - Refused

++ Don’t know

B13. How often have you visited this pharmacy (for any reason)?

0. First time [Skip to B16]

1. Once a year or less

2. A few times a year

3. About once a month

4. 2-3 times a month

5. At least once a week

6. Daily

88 Refused

99 Don’t know

B14. If you had a prescription that needed to be filled, would you fill it at this pharmacy?

0. No

1. Yes

88 Refused

99 Don’t know

15. If you had a prescription that needed to be filled would you prefer to get your syringes at a different pharmacy than where you get prescriptions?

1. No

2. Yes (prefers to go to different pharmacy)

3. N/A (Never fills prescriptions)

- - Refused

++ Don’t know

The next question is about your experiences at pharmacies.

16. FIRST, ASK ALL THE QUESTIONS IN COLUMN “a” FOR EACH ROW A-E. THEN, GO BACK TO EACH QUESTION ANSWERED “YES” AND ASK THE QUESTIONS IN COLUMNS “b” AND “c”. ]

	a. Since you started buying syringes in pharmacies without a prescription, has a pharmacist or pharmacy clerk ever...	b. How many times in the past 3 months has this happened? [IF ANSWERED "YES" IN COLUMN a.]
A. Asked you to sign a log-book or required any personal information?	0 No 1 Yes - - Refused ++ Don't know	___ ___ ___ # of times [000 None] [ --- Refused] [+++ Don't know]
B. Asked what the syringes will be used for?	0 No 1 Yes - - Refused ++ Don't know	___ ___ ___ # of times [000 None] [ --- Refused] [+++ Don't know]
C. Declined to sell you syringes?	0 No 1 Yes - - Refused ++ Don't know	___ ___ ___ # of times [000 None] [ --- Refused] [+++ Don't know]
D. Charged more than $1.00 per syringe?	0 No 1 Yes - - Refused ++ Don't know	___ ___ ___ # of times [000 None] [ --- Refused] [+++ Don't know]
E. Refused to sell you "single" syringes?	0 No 1 Yes - - Refused ++ Don't know	___ ___ ___ # of times [000 None] [ --- Refused] [+++ Don't know]

I’m going to read you some statements about getting syringes. After each statement, please tell me if you strongly agree, agree, disagree, or strongly disagree.

[Interviewer: READ EACH STATEMENT ALOUD, ASK PARTICIPANT TO SELECT

ONE RESPONSE, AND write the answer code in the space provided.]

Strongly Agree -------------------------- 0

Agree -------------------------- 1

Disagree -------------------------- 2

Strongly Disagree ------------------------- 3

Not Applicable -------------------------- 4

[INTERVIEWER: Not Applicable (4) does not appear on the response card and should only be written as a response for lines J-R if the participant has never been to a syringe exchange and has no knowledge of syringe exchange Programs; All other lines must be answered Using responses 0-3.]

A. Pharmacists should sell sterile syringes to injection drug users.	------------
B. It doesn’t matter to me if people know why I’m buying syringes when I’m in line at the pharmacy.	------------
C. Pharmacists care about my health and well being.	------------
D. I think I have a good relationship with the pharmacy staff at pharmacies where I buy syringes.	------------
E. I would return to a pharmacy to buy syringes.	------------
F. I would return to a pharmacy where I bought syringes for prescription and non-prescription items.	------------
G. I would return to a pharmacy where I bought syringes for general referrals.	------------
H. Police will take notice if I go to a pharmacy to buy syringes.	------------
I. I feel comfortable trying to buy a syringe at any pharmacy even if I don’t know if they’ll sell to me before I go into the store.	------------
J. It wouldn’t matter to me if people saw me walk into a syringe exchange program.	------------
K. The staff at syringe exchange programs seem to care about my health and well being.	------------
L. Getting other services at syringe exchange programs is/would be important to me.	------------
M. Syringe exchange programs are sometimes too far for me to get to.	------------
N. It’s generally hard for me to make syringe exchange programs hours.	------------
O. Syringes I’ve bought on the street are safe [safe means never used before by anyone].	------------
P. It’s difficult for me to get a clean syringe when I need one.	------------
Q. It’s easiest for me to get a needle on the street.	------------
R. It’s easiest for me to get clean syringes at a syringe exchange program.	------------
S. I know which pharmacies to go to for syringes.	------------

Section C: Sexual Behavior

The questions in this section are about your sexual behaviors. When I say “sex”, I mean vaginal, oral, or anal sex. “Sex” includes all of these, whether they were paid or unpaid, and whether you wanted to do them or not. I want you to remember that everything you say is confidential. You can refuse to answer any question. Do you have any questions right now?

1. In the last 2 months, overall, how many women have you had sex with?

_____ _____ _____ # women

[00 NONE]

[- - REFUSED]

[++ DON’T KNOW]

2. In the last 2 months, overall, how many men have you had sex with?

_____ _____ _____ # men

[00 NONE]

[- - REFUSED]

[++ DON’T KNOW]

[IF ANSWERED ZERO (00) TO BOTH C1 & C2, SKIP TO QUESTION C4]

3. a. How many times have you had sex (vaginal or anal) in the last 30 days?

____ _____ _____ # times

[00 NONE]

[- - REFUSED]

[++ DON’T KNOW]

b. Of those times, how many times did you use a condom?

_____ _____ _____ # times

[00 NONE]

[- - REFUSED]

[++ DON’T KNOW]

4. Do you consider yourself to be: [READ ALL]

0. Straight/heterosexual

1. Gay/homosexual

2. Lesbian/homosexual

3. Bisexual

4. Transexual

5. Other

88 Refused

99 Don’t know

Section D: Testing

1. a. Have you ever been tested for HIV or AIDS?

00 No [Skip to D4]

01 Yes

88 Refused [Skip to D5]

99 Don’t know [Skip to D5]

b. What were the results?

00 Negative [Go to D1c]

01 Positive [Go to D1d]

88 Refused [Skip to D2]

99 Don’t know [Skip to D2]

2. [If tested negative] When was the last time you tested negative? (Probe for month)

___ ___/___ ___ [Go to D2]

[Month / Year]

[- - REFUSED]

[++ DON’T KNOW]

2. [If tested positive] When was the first time you tested positive? (Probe for month)

___ ___/___ ___

[Month / Year]

[- - REFUSED]

[++ DON’T KNOW]

e. After you first found out you were infected with HIV/AIDS, how much time passed before you first got care (medical treatment)?

0. The same day

1. Within a week

2. Within a month

3. Within 3 months

4. Within 6 months

5. Within 1 year

6. More than 1 year

88 Refused

99 Don’t know

2. When was the first time you were tested for HIV? (Probe for month)

___ ___/___ ___

[Month / Year]

[- - REFUSED]

[++ DON’T KNOW]

3. About how many times have you been tested for HIV? (Probe: Ever in life)

_____ _____ _____ # times [Skip to D5]

[000 NONE] [Go to D4 if never been tested]

[- - REFUSED] [Skip to D5]

[++ DON’T KNOW] [Skip to D5]

4. Why have you never been tested for HIV?

0. Don’t want to know results

1. Don’t trust the results

2. Don’t feel I’m at risk

3. Don’t know where to go to be tested

4. Don’t want others to know my results (if positive)

5. Don’t trust counseling staff

88 Refused

99 Don’t know

4. Were you or will you be tested today?

00 No

01 Yes [Skip to D7]

88 Refused

99 Don’t know

4. Why did you choose not to get tested today?

0. Was already tested within the past 6 months

1. Don’t want to know results

2. Don’t trust the results

3. Don’t feel I’m at risk

4. Prefer an anonymous testing site (confidentiality)

5. Don’t want to get tested at the pharmacy

88 Refused

99 Don’t know

D7. Have you ever received information on HIV at a pharmacy?

00 No [Skip to D10]

01 Yes

- - Refused [Skip to D10]

++ Don’t know [Skip to D10]

D8. What type of information on HIV have you received? [please circle all that apply]

0. HIV Testing

1. HIV Testing Referrals

2. HIV Treatment

3. HIV Treatment Referrals

4. HIV Prevention information

- - Refused

++ Don’t know

9. Did you feel comfortable being referred to HIV testing by your pharmacist or pharmacy technician?

0. No

1. Yes

-- Refused

++ Don’t know

9. Would you come back to this pharmacy the next time you need to get an HIV test or an HIV testing referral?

0. No

1. Yes

-- Refused

++ Don’t know

9. Would you feel comfortable getting referrals or information about other types of services from a pharmacist or pharmacy staff?

0. No

1. Yes

-- Refused

++ Don’t know

9. Will you go to this or any other pharmacy in order to get any referrals to services that you may need?

0. No

1. Yes

-- Refused

++ Don’t know

13. Do you have a regular doctor or medical provider?

00 No

01 Yes

-- Refused

++ Don’t know

13. How often do you visit your regular doctor or medical provider?

0. Once a week

1. 2-3 times a month

2. Once a month

3. Once every 2-6 months

4. About once a year

5. Less than once a year

-- Refused

++ Don’t know

15. Where do you usually go to see a doctor, nurse, or physician’s assistant for medical care?

01 Doctor’s office or clinic

02 Medicaid/HMO

03 Emergency room in a hospital

04 Drug treatment clinic

05 Nowhere [MK36]

06 Other

-- Refused

++ Don’t know

15. When you go there, do you usually (more than 90% of the time) see the same doctor, nurse, or physician’s assistant?

01 No

02 Yes

-- Refused

++ Don’t know [

15. In the past 6 months, were you covered by health insurance of any sort?

01 No [SKIP TO D19]

02 Yes

-- Refused

++ Don’t know

15. In the last 6 months, were you covered by:

No Yes Ref___ DK

A. Medicaid 0 1 8 9

B. An HMO plan (through your policy

or spouse/family policy) 0 1 8 9

C. Private insurance (through your

policy or spouse/family member policy) 0 1 8 9

D. VA hospital or medical coverage/benefits 0 1 8 9

E. Other types of health insurance (through

your policy or spouse/family policy) 0 1 8 9

This includes Child Health Plus Care (CHP)

I’d like to ask you about your opinions about HIV testing. Please tell me if you agree or disagree with the following statements.

19. It is important to me to know my HIV status.

00 Agree

01 Disagree

88 Refused

99 Don’t know

19. I would share my status with partners (sexual and/or those I use drugs with).

00 Agree

01 Disagree

88 Refused

99 Don’t know

19. I would want to know the HIV status of my partners (sexual and/or those I use drugs with).

00 Agree

01 Disagree

88 Refused

99 Don’t know

19. I know where to go to get tested.

00 Agree

01 Disagree

88 Refused

99 Don’t know

19. There are enough places to get tested.

00 Agree

01 Disagree

88 Refused

99 Don’t know

19. Do you know anyone who has HIV/AIDS?

00 No [skip to E1a]

01 Yes

88 Refused

99 Don’t know

19. Can you tell me who? (Read list, mark all that apply)

A.	Spouse	1
B.	Girlfriend/Boyfriend/Sex partner	2
C.	Parent	3
D.	Grandparent	4
E.	Brother or Sister	5
F.	Other Relative	6
G.	Friend	7
H.	Other (Specify: )	8

Section L: discrimination

[INTERVIEWER: READ] I am now going to ask a few questions about situations where you were made to feel like you were being treated unfairly. Some of these questions are difficult to answer. Take as long as you need to answer each question as accurately as you can.

E1. a. In your lifetime, have you ever been discriminated against, prevented from doing something, or been hassled or made to feel inferior because of any of the following?

[PROBE: This could be something that you simply felt]

[INTERVIEWER: READ ALL OF THE CHOICES AND CHECK ALL THAT APPLY]

		NO	YES
A.	Age	0	1
B.	Race	0	1
C.	Sex (gender)	0	1
D.	Sexual Orientation	0	1
E.	Poverty	0	1
F.	Drug Use	0	1
G.	Having Been in Jail or Prison	0	1
H.	Religion	0	1
I.	Mental Illness [Can you specify?______________________________________]	0	1
J.	Physical Illness [Can you specify?_____________________________________]	0	1
K.	Other [Can you specify?_____________________________________]	0	1
L.	No, I have never been discriminated against [END]	0	1
M.	Refused	8
N.	Don’t Know	9

[INTERVIEWER: IF ONLY CHOSE 1, SKIP TO E2a]

b. Which one of these impacted MOST on your life?

[INTERVIEWER: READ OPTIONS IDENTIFIED IN E1a ABOVE AND CHOOSE ONE]

0. Age

1. Race

2. Sex (gender)

3. Sexual orientation

4. Poverty

5. Drug use

6. Having been in jail or prison

7. Religion

8. Mental illness [Can you specify? _________________]

9. Physical illness or disability [Can you specify? ________________]

10. Other [Can you specify? _________________]

88 Refused

99 Don’t know

E2. a. In the past 6 months, have you ever been discriminated against, prevented from doing something, or been hassled or made to feel inferior because of any of the following?

[PROBE: This could be something that you simply felt.]

[INTERVIEWER: READ ALL OPTIONS AND CHECK ALL THAT APPLY]

		NO	YES
A.	Age	0	1
B.	Race	0	1
C.	Sex (gender)	0	1
D.	Sexual Orientation	0	1
E.	Poverty	0	1
F.	Drug Use	0	1
G.	Having Been in Jail or Prison	0	1
H.	Religion	0	1
I.	Mental Illness [Can you specify?______________________________________]	0	1
J.	Physical Illness [Can you specify?_____________________________________]	0	1
K.	Other [Can you specify?_____________________________________]	0	1
L.	No, I have never been discriminated against [END]	0	1
M.	Refused	8
N.	Don’t Know	9

[IF NOT DISCRIMINATED AGAINST OR CHOSE ONLY 1, END]

b. In the past month, which one of these impacted MOST on your life?

[INTERVIEWER: READ OPTIONS IDENTIFIED IN E2a ABOVE AND CHOOSE ONE]

00 Age

01 Race

02 Sex (gender)

03 Sexual orientation

04 Poverty

05 Drug use

06 Having been in jail or prison

07 Religion

08 Mental illness [Can you specify? _________________]

09 Physical illness or disability [Can you specify? ________________]

10 Other [Can you specify? _________________]

88 Refused

99 Don’t know

THANK YOU FOR PARTICIPATING IN THIS SURVEY TODAY!