Web-based Survey - Web Survey Questionnaire

Form Approved

OMB No. 0920-0840

Expiration Date 01/31/2013

Web-based HIV Behavioral Surveillance System

Core Questionnaire

Public reporting burden of this collection of information is estimated to average 14 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 (0920-0840). Do not send the completed form to this address.

Web-based HIV Behavioral Surveillance System: Core Questionnaire

_______________________________________________________

[Note: Respondents are randomized into three groups: Group A, Group B and Group C. Each group will complete a different set of supplemental questions embedded with the questionnaire. Each set of supplemental questions is of similar length].

AUTO4. Group ___ {GROUP} AUTO5. Date of Interview: __ __/ __ __ / __ __ __ __ {IDATE}

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

AUTO6. Time Began Core Survey __ __:__ __ : __ __ [24 Hour time HH:MM:SS] {START}

Section A. Demographics (DM)

DM- 1. What is the highest level of education you completed? {HLEDUCAT}

Never attended school….………………………….………………………. 00

Less than high school….…………………...……………………………… 01

Some high school..…………………….……...……………......................... 02

High school diploma or GED………………………..……………………. 03

Some college, Associate’s Degree, or

Technical Degree …………………………………….……………….. 04

College, post graduate or professional school..………….……………… 05

I prefer not to answer.……………..…………………………………….77

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

DM-2. What was your household income last year from all sources before taxes? That is, the total amount of money earned and shared by all people living in your household. {HHINCOM}

Monthly Income	Yearly Income
0 to $1667	0 to $19,999	00
$1668 to $3333	$20,000 to $39,999	01
$3334 to $6,250	$40,000 to $74,999	02
$6251 or more	$75,000 or more	03
I prefer not to answer		77
Don't know		99

If DM-2= 99, skip to DM-3.

DM-2a. Including yourself, how many people depended on this income? {DEPEND}

[Prefer not to answer = 77; Don't know = 99] ___ ___

DM-3. What kind of health insurance or health care coverage do you currently have?

Health insurance--health plans people get through employment or purchased directly as well as government programs (like Medicare and Medicaid) that provide medical care or help pay medical bills.

Choose all that apply:

A private health plan (through an employer or purchased directly) …... 01 {TYP_INSA}

Medicaid or Medicare………………………………………………..… 02 {TYP_INSG}

Some other Medical Assistance program….………..…………………. 03 {TYP_INSH}

TRICARE (CHAMPUS)….………..………….. ……………………… 04 {TYP_INSD}

Veterans Administration coverage………..…… ……………………… 05 {TYP_INSE}

Some other health care plan……….…………………………………..... 06 {TYP_INSF}

I don’t currently have any health insurance……………..………….….. 07 { TYP_INSI}

I prefer not to answer.……………..…………………………………….77

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

DM-4. In the past 12 months, have you seen a doctor, nurse, or other health care provider about your own health? {SEEHCP}

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

I prefer not to answer.……………..…………….7

Don't know……………..……………………...  9

If DM-4 ≠ 1, skip to DM-5.

DM-4a. At any of those times you were seen by a doctor or health care provider, were you offered an HIV test? An HIV test checks whether someone has the virus that causes AIDS. {RECCHIV}

No………………….……………………………  0

Yes……………………………………………...  1

I prefer not to answer.……………..…………….7

Don't know……………..……………………...  9

DM-5. Do you consider yourself to be: {IDENTITY}

Homosexual or Gay, ………………...………… 1

Heterosexual or Straight…………….……......  2

Bisexual………………………………………..  3

I prefer not to answer.……………..…………….7

Don’t know................……………………….….  9

If Group=B, administer SD-1 through SD-4.

Group B.

SD-1. Have you ever told anyone that you are attracted to or have sex with men? {OUT_GI}

No………………….……………….…………..  0

Yes….……………………………….…….........  1

I prefer not to answer.……………..…………….7

Don't know.……………..………………..........  9

If SD-1 ≠ 1, skip to SD-3

SD-2. Which of the following people have you told that you are attracted to or have sex with men?

No Yes Does I Prefer Don’t

Not Apply Not to answer Know

1. Gay, lesbian, or bisexual friends ……... …………... 0… 1.… 8……... 7…… 9 {OUT_GIA}

2. Friends who are not gay, lesbian, or bisexual………  0…  1…. 8….... 7….. 9 {OUT_GIB}
3. Family members……………………………………  0… 1……….……. 7…. 9 {OUT_GIC}

4 .Health care provider……………………………….  0… 1……….……. 7….. 9 {OUT_GIE}

SD-3. During the past 12 months, have any of the following things happened to you because someone knew or assumed you were attracted to men?

	No	Yes	Does Not Apply	Prefer not the Answer	Don’t know
You were called names or insulted………………………. {DISC_GIA}	0	1	8	7	9
You received poorer services than other people in restaurants, stores, other businesses or agencies…………. {DISC_GIB}	0	1	8	7	9
You were treated unfairly at work or school……………… {DISC_GIC}	0	1	8	7	9
You were denied or given lower quality health care……… {DISC_GID}	0	1	8	7	9
You were physically attacked or injured………………… {DISC_GIE}	0	1	8	7	9

SD-4. How strongly do you agree or disagree with the following statement: “Most people in my area are tolerant of gays and bisexuals.” {TOL_GI}

Strongly agree……………......……..………………….  01

Agree…………………………….……….....................  02

Neither agree nor disagree……..…..………….............  03

Disagree…………………………………………….…  04

Strongly disagree……… …..………..…….….............  05

I prefer not to answer.……………..…………………… 07

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

Section B. Sexual Behavior (SX)

Female Sex Partners

SX-1. In the past 12 months (since <interview month> of <<last year>>) have you had oral, vaginal or anal sex with a woman? {M_FSX12M}

No………………….…………………………… 0

Yes……………………………………………...  1

I prefer not to answer.……………..……………7

Don't know……………..…………………….....  9

If SX-1 ≠1, skip to box before SX-6.

These questions are about the last time you had oral, vaginal or anal sex with a woman.

SX-2. Was the woman you had sex with that last time a main partner (someone you felt committed to above anyone) or a casual partner (someone you didn’t feel committed to or don’t know very well)? {M_FLPTY}

Main sex partner………......

The next few screens are about having sex with women. For these questions, "having sex" means oral, vaginal, or anal sex. Oral sex means mouth on the vagina or penis; vaginal sex means penis in the vagina; and anal sex means penis in the anus (butt).

................................ 1

Casual sex partner………....................................  2

I prefer not to answer.……………..…………….7

Don’t know………..............................................  9

SX-3. When you had sex that last time, did you have either vaginal or anal sex? {M_FLAVG}

No………………….……………….…………...  0

Yes….……………………………….……......... 1

I prefer not to answer.……………..…………….7

Don't know.……………..………………..........  9

If SX-3≠1, skip to SX-5.

SX-4. The last time you had sex with a woman, did you have either vaginal or anal sex without using a condom? {M_FLSUNP}

No………………….……………….…………...  0

Yes….……………………………….……......... 1

I prefer not to answer.……………..…………….7

Don't know.……………..………………............ 9

SX-5. The last time you had sex with this partner, did you know her HIV status? {M_FLKNO}

No………………….……………….…………... . 0

Yes….……………………………….……........... 1

I prefer not to answer.……………..………….….7

If SX-5≠ 1, skip to SX-6.

SX-5a. What was her HIV status? {M_FLHIV}

HIV-negative……………………………..…......  1

HIV-positive…...….…………………..………..  2

Indeterminate…...….…………………..……….. 3

I prefer not to answer.……………..………….….7

Male Sex Partners

The next screens are about having sex with other men. For these questions, "having sex" means oral or anal sex. Oral sex means he put his mouth on your penis or you put your mouth on his penis. Anal sex means you put your penis in his anus (butt) or he put his penis in your anus (butt).

SX-6. How old were you the first time you had oral or anal sex with a man? {M_MDEBUT}

______ years

[Prefer not to answer = 77; Don't know = 9999]

SX-6a. In the past 12 months (since <interview month> of <<last year>>), with how many different men have you had oral or anal sex? {M_SX12M}

[Prefer not to answer = 77; Don't know = 9999] ___ ___ ___ ___

If SX-6a=0, 77 or 9999 then skip to SX-22

If SX-6a> 1, skip to SX-8.

SX-7. In the past 12 months, was this male partner a: {M_M1SX}

1 Main partner (someone you felt committed to above anyone)

2 Casual partner (someone you didn’t feel committed to or don’t know very well)

7 I prefer not to answer

9 Don’t know

SX-7a. In the past 12 months, did you have anal sex with this man?: {M_MM1AS}

No………………….……………….…………... . 0

Yes….……………………………….…….......... 1

I prefer not to answer.……………..………..…….7

If SX-7a ≠ 1, skip to box before SX-10.

SX-7b. In the past 12 months, did you have anal sex without using a condom? {M_MM1UAS}

No………………….……………….…………... . 0

Yes….……………………………….…….......... 1

I prefer not to answer.……………..………..…….7

SX-7c. Did you know his HIV status? {M_MM1HSK}

No………………….……………….…………... . 0

Yes….……………………………….…….......... 1

I prefer not to answer.……………..………..…….7

If SX-7c ≠ 1, skip to box before SX-10.

SX-7d. What was his HIV status? {M_MM1HST}

HIV-negative……………………………..…......  1

HIV-positive…...….…………………..………..  2

Indeterminate…...….…………………..……….. 3

I prefer not to answer.……………..………….….7

If SX-6a = 1, skip to box before SX-10.

SX-8. In the past 12 months, were these male partners: {M_MTYP}

1 Only main partners (you felt committed to above anyone)

2 Only casual partners (you didn’t feel committed to or don’t know very well)

3 Both main and casual partners

7 I prefer not to answer

9 Don’t know

SX-8a In the past 12 months, with any of these male partners did you have anal sex? {M_MMHAS}

No………………….……………….…………...  0

Yes….……………………………….……......... 1

I prefer not to answer.……………..…………….7

Don't know.……………..………………............ 9

If SX-8a ≠ 1, skip to box before SX-10.

SX-8b. In the past 12 months, with any of these male partners did you have anal sex without using a condom?{M_MMHUAS}

No………………….……………….…………...  0

Yes….……………………………….……......... 1

I prefer not to answer.……………..…………….7

Don't know.……………..………………............ 9

If SX-8b ≠1 skip to box before SX-10.

SX-9. In the past 12 months, did you have anal sex without using a condom with a man whose HIV status you did not know? {M_MUAUHS}

No………………….……………….…………...  0

Yes….……………………………….……......... 1

I prefer not to answer.……………..…………….7

Don't know.……………..………………............ 9

SX-9a. In the past 12 months, did you have anal sex without using a condom with a man who was HIV positive? {M_MUAHP}

No………………….……………….…………...  0

Yes….……………………………….……......... 1

I prefer not to answer.……………..…………….7

Don't know.……………..………………............ 9

SX-9b. In the past 12 months, did you have anal sex without using a condom with a man who was HIV negative? {M_MUAHN}

No………………….……………….…………...  0

Yes….……………………………….……......... 1

I prefer not to answer.……………..…………….7

Don't know.……………..………………............ 9

In the next few screens we’re going to ask some questions about your most recent male sex partner- that is, the last guy you had sex with.

To make the questions easier to ask, we’d like you to enter in this partner’s initials.

SX-10a._What is the first initial of his first name?___ What is the first initial of his last name? ___ {M_MLPNN}

SX-10b. When was the last time you had either oral or anal sex with [initials]? {M_MLCM}

[99/9999 = Don't know] __ __/ __ __ __ _

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

SX-11. Was [initials] a main partner (someone you felt committed to above anyone else) or a casual partner (someone you didn’t feel committed to or don’t know very well)? {M_MLMC}

Main sex partner………...................................... 1

Casual sex partner………....................................  2

I prefer not to answer.……………..…………….7

Don’t know………..............................................  9

SX-12. That last time you had sex with [initials], did you have receptive anal sex where he put his penis in your anus (you were the bottom)? { M_MLRAS}

No………….……………………………..…….  0

Yes……………………………………………..  1

I prefer not to answer.……………..…………….7

Don't know……..……………………...…........  9

If SX-12 = 0,7 or 9, skip to SX-14

SX-13. During that last time you had receptive anal sex, did [initials] use a condom? {M_MLRASC}

No………………….……………….…………...  0

Yes………………….….……………………….. 1

I prefer not to answer.……………..…………….7

Don't know.……………..………………..........  9

If SX-13 = 0, 7, or 9, skip to SX-14.

SX-13a. Did [initials] use the condom the whole time? {M_MLRAST}

No………………….……………….…………...  0

Yes….……………………………….…….......... 1

I prefer not to answer.……………..…………….7

Don't know.……………..………………..........  9

SX-14.When you had sex that last time, di

d you have insertive anal sex where you put your penis in his anus (you were the top)?

{ M_MLIAS}

No.……………………………………..……….. 0

Yes……………………………………………… 1

I prefer not to answer.……………..…………….7

Don't know……………..………………............. 9

If SX-14 = 0,7 or 9, skip to SX-16.

SX-15. During insertive anal sex that last time, did you use a condom? {M_MLIASC}

No………………….……………….…………...  0

Yes….……………………………….……......... 1

I prefer not to answer.……………..…………….7

Don't know.……………..………………..........  9

If SX-14 = 0,7 or 9, skip to SX-16.

SX-15a. Did you use the condom the whole time? {M_MLIAST}

No………………….……………….…………...  0

Yes….……………………………….…….......... 1

I prefer not to answer.……………..…………….7

Don't know.……………..………………..........  9

SX-16. Before or during the last time you had sex with [initials], did you use: {M_MLHI}

Alcohol…..….….………………..……………...  1

Drugs………..……………………………..……  2

Both alcohol and drugs ……………………........ 3

Neither one….……………..……..….………….  4

I prefer not to answer.……………..…………….7

Don't know…..…..……….…...…….…...….....  9

If SX-16 = 2, skip to SX-16b.

If SX-16 = 4, 7, or 9, skip to SX-17.

SX-16a. How many alcoholic drinks did you have before or during sex the last time you had sex with [initials]? {M_MLNALC}

Drink of alcohol: a 12 oz beer, a 5 oz glass of wine, or a 1.5 oz shot of liquor. (PICTURE OF ALCOHOL DRINK SIZE):

[Prefer Not to Answer = 7777; Don't know = 9999] __ __ __ __ Number of drinks

SX-16b. That last time you had sex with [initials], which drugs did you use?

Check all that apply.

Marijuana ….……………..…..…...……….……….  1{M_MLSDRA}

Powdered cocaine ….……………..…..…...….……  2{M_MLSDRE}

Poppers ….……………..…..…...….………………  3{M_MLSDRM}

X or Ecstasy ….……………..…..…...….………….  4{M_MLSDRG}

Painkillers (Oxycontin, Vicodin, Percocet) ….…….  5{M_MLSDRJ}

Downers (Valium, Ativan, Xanax) ….…………….  6{M_MLSDRK}

Crystal meth (tina, crank, ice) ….……………..……  7{M_MLSDRF}

Hallucinogens (LSD, mushrooms) ….……………...  8{M_MLSDRL}

Special K (ketamine) ….……………..…..…...….…  9{M_MLSDRH}

GHB ….……………..…..…...….………………….  10{M_MLSDRI}

Heroin ….……………..…..…...….…………….….  11{M_MLSDRC}

Speedballs (heroin and cocaine together) .…………  12{M_MLSDRB}

Crack cocaine….……………..…..…...….………...  13 {M_MLSDRD}

Other drug ......................................................……..  14{M_MLSDRN}

I prefer not to answer.……………..………………....77

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

SX-17. The last time you had sex with [initials], did you know his HIV status? {M_MLKNO}

No………………….……………….…………... . 0

Yes….……………………………….…….......... 1

I prefer not to answer.……………..………..…….7

If SX-17 = 0: SX-18

If Group = C, proceed to PR-1.

If Group ≠ C, proceed to SX-18

SX-17a. What was [initials]’s HIV status? {M_MLHIV}

HIV-negative……………………………..…….  1

HIV-positive…...….…………………..………..  2

I prefer not to answer.……………..…….……….7

If Group=C, administer PR-1 through PR-7. If Group ≠ C, proceed to SX-18

Group C

PR-1. When you had sex that last time, did you give [initials] things like money or drugs in exchange for sex? {M_MLEG}

No………………….……………….…………...  0

Yes….……………………………….…….......... 1

I prefer not to answer.……………..….………….7

Don't know.……………..………………..........  9

PR-2. When you had sex that last time, did [initials] give you things like money or drugs in exchange for sex? {M_MLER}

No………………….……………….…………...  0

Yes….……………………………….………....... 1

I prefer not to answer.……………..……….…….7

Don't know.……………..………………............ 9

PR-3. Was [initials] younger than you, older than you, or the same age as you? {M_MLRA}

Younger ………………….………….………….  0 Older………………………………..………..….. 1

Same age………………………………..………  2

I prefer not to answer.……………..……….…….7

Don't know……………..………….………......  9

PR-4. What was [initials]’s age? {M_MLAGE} ___ ___ ___

[777 = Refused, 999 = Don't know]

PR-5. Which of the following best describes [initials]’s racial or ethnic background? {M_MLETH}

American Indian or Alaska Native……………  1

Asian ..……………………..……………….......  2

Black or African American ……………..……..  3

Hispanic or Latino………………………………. 4

Native Hawaiian or Other Pacific Islander……... 5

White ……………..…………………………….. 6

I prefer not to answer.……………..…………….7

Don’t know……………………………………… ₉

PR-6. As far as you know, has [initials] ever injected drugs like heroin, cocaine, or speed? {M_MLIDU}

Would you say he:

Definitely did not………………….……………  0

Probably did not………………………………..  1

Probably did……………………………………  2

Definitely did ………………….……………….  3

I prefer not to answer.………….…..…………….7

Don't know……………..………….………......  9

PR-7. As far as you know, has [initials] ever used crystal meth (tina, crank, ice)? {M_MLPCM}

Would you say he:

Definitely did not………………….……………  0

Probably did not………………………………..  1

Probably did……………………………………  2

Definitely did ………………….……………….  3

I prefer not to answer.……………..…………….7

Don't know……………..………….………......  9

SX-18. How long have you been having a sexual relationship with [initials]? {M_MLT_N}

__ __ __ Days Months Years

[Refuse to answer = 777; Don’t know = 999]

If SX-18>12 months, 777 or 999, skip to SX-20

SX-19. As far as you know, during the time you were having a sexual relationship with [initials], did he have sex with other people? {M_MLPOL1}

Would you say he:

Definitely did not………………….……………  0

Probably did not………………………………..  1

Probably did……………………………………  2

Definitely did ………………….……………….  3

I prefer not to answer.……………..…………….7

Don't know……………..………….………......  9

SX-19a. During the time you were having a sexual relationship with [initials], did you have sex with other people? {M_MLOG1}

No………………….……………….…………...  0

Yes….……………………………….……......... 1

I prefer not to answer.……………..…………….7

If SX-18≤ 12 months, skip to SX-22

SX-20. As far as you know, during the past 12 months when you were having a sexual relationship with [initials], did he have sex with other people? Would you say he: {M_MLPOG1}

Definitely did not………………….……………  0

Probably did not………………………………..  1

Probably did……………………………………  2

Definitely did ………………….……………….  3

I prefer not to answer.……………..…………….7

Don't know……………..………….………......  9

SX-20a.During the past 12 months when you were having a sexual relationship with [initials], did you have sex with other people? {M_MLOL1}

No………………….……………….…………...  0

Yes….……………………………….…….......... 1

I prefer not to answer.……………...…………….7

If SX-18 ≥ 3 years or SX-18= Don’t Know, skip to SX-22.

SX-21. Where did you first meet [initials]? {M_MLMEET}

Internet…….....….………………..…………….  01

Chat line….................................................  02

Bar/Club..………….............................………....  03

Circuit party or Rave….......................………….  04

Cruising area.………….........................………..  05

Adult bookstore…..…............................………..  06

Bath house, sex club or sex resort….....……….  07

Private sex party……...........................…………  08

Somewhere else.................................…………..  09

I prefer not to answer.……………..…….……….77

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

SX-22. In the past 12 months, how often have you gone to a place where gay men hangout, meet or socialize? These could include bars, clubs, social organizations, parks, gay businesses, bookstores, sex clubs, etc. {M_MMEET}

Never…….....….………………..…… 00

More than once a day…....................... 01

Once a day..…………......................... 02

More than once a week….................... 03

Once a week.…………........................ 04

More than once a month…..…............. 05

Once a month….....………………….. 06

Less than once a month……................ 07

I prefer not to answer.……………..….77

Don't know…..………..……..……… 99

SX-23. In the past 12 months, how often have you used the internet to meet or socialize with gay men? This includes visiting social network websites (such as Facebook or Myspace), websites directed towards gay men (such as Manhunt or Gay.com), dating websites, or the use of mobile social applications (such as Foursquare or Grindr). {M_MINT}

Never…….....….………………..…… 00

More than once a day…....................... 01

Once a day..…………......................... 02

More than once a week….................... 03

Once a week.…………........................ 04

More than once a month…..…............. 05

Once a month….....………………….. 06

Less than once a month……................ 07

I prefer not to answer.……………..…77

Don't know…..………..……..……… 99

Section C. Substance Use

Alcohol Use (AL)

AL-1. In the past 12 months, how often did you drink any alcohol such as beer, wine, malt liquor, or hard liquor? {ALC12M}

Drink of alcohol: a 12 oz beer, a 5 oz glass of wine, or a 1.5 oz shot of liquor. (PICTURE OF ALCOHOL DRINK SIZE):

Never….….…………………..…………………  0

More than once a day…..……………………….  1

Once a day……………………………………… 2

More than once a week..……………………......  3

Once a week…………………………................  4

More than once a month………………………..  5

Once a month…..……………………………….  6

Less than once a month…..…………………….  7

I prefer not to answer.……………..…………….77

Don’t know………..……………………………  99

If AL-1 = 0, 77 or 99, skip to ID-1.

AL-2. In the past 12 months, how often did you have 5 or more alcoholic drinks in one sitting? {ALBINGE}

Never….….…………………..…………………  0

More than once a day…..……………………….  1

Once a day……………………………………… 2

More than once a week..……………………......  3

Once a week…………………………................  4

More than once a month………………………..  5

Once a month…..……………………………….  6

Less than once a month…..…………………….  7

I prefer not to answer.……………..…………….77

Don’t know………..……………………………  99

Injection Drug Use (ID)

The next screens are about injection drug use. This means injecting drugs yourself or having someone who isn't a health care provider inject you.

ID-1. Have you ever in your life shot up or injected any drugs other than those prescribed for you? By shooting up, we mean anytime you might have used drugs with a needle, either by mainlining, skin popping, or muscling. {EVRINJ}

No………………….……………………………  0

Yes……………………………………………..... 1

I prefer not to answer.……………..……….…….7

Don't know……………..……………………...  9

If ID-1 = 0, 7 or 9, skip to box before ND-1.

ID-2. In the past 12 months, on average, how often did you inject? {AVGINJ}

Never….….…………………..…………………  00

More than once a day…..……………………….  01

Once a day……………………………………… 02

More than once a week..……………………......  03

Once a week…………………………................  04

More than once a month………………………..  05

Once a month…..……………………………….  06

Less than once a month…..…………………….  07

I prefer not to answer.……………..…………….77

Don’t know………..……………………………  99

If ID-2 = 0, 88, or 99, skip to box before ND-1.

ID-3. Which drug do you inject most often? {DCHOICE}

Speedball – Heroin and cocaine together ……. 1

Heroin, by itself………………… …………….. 2

Cocaine, by itself……………………………… 3

Crack………………………………………….. 4

Crystal, meth, tina, crank, ice……………………..5

Something else (Specify________________)…..6

I prefer not to answer.……………..…………….7

Don't know………………………..……………  9

Non-Injection Drug Use (ND)

ND-1. In the past 12 months, have you used any non-injection drugs (drugs you did not inject), other than those prescribed for you?

{NIUSE12 }

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

I prefer not to answer.……………..…………….7

Don't know……………..……………………..  9

If ND-1 = 0, 7, or 9, skip to ND-3.

ND-2. In the past 12 months, how often did you use:

More More More Less

than than than than

once a Once a once a Once a once a Once a once a Prefer not to

Never day day week week month month month answer

a. Marijuana………………….00….01….02…….03…..........04…..…05…........06………07………77{NIU12A}

b. Powdered cocaine that is smoked

or snorted……………..…..00…..01.…02….…03…..........04……..05….........06………07………77{NIU12E}

c. Poppers ( amyl nitrite)……..00….01….02……03…...........04……..05…........06………07………77{NIU12J}

d. X or Ectasy…………………00…01…..02……03………...04…..…05…........06………07………77 {NIU12H}

e. Painkillers such as Oxycontin,

Vicodin, or Percocet………..00…01…..02……03………...04……..05…........06………07………77 {NIU12F}

f. Downers such as Valium,

Ativan, or Xanax……………00…01.…02……03…...........04…..…05…........06………07………77{NIU12E}

g. Crystal meth (tina, crank,

or ice)..……………………00…01….02……03…...........04……..05…........06………07………77 {NIU12B}

h. Hallucinogens such as LSD

or mushrooms………………00….01….02……03…...........04……..05…........ 06……..07………77 {NIU12G}

i. Special K (ketamine)……..00…..01….02……03…..........04………05…........06……..07………..77{NIU12H}

j. GHB…………………………00….01…..02……03……….04………05…........ ..06……07………77 {NIU12K}

k. Crack cocaine…………….….00….01….02……03….........04………05…..........06…….07………77 {NIU12C}

l. Other drug…………………..00…..01…..02……03……….04………05…...........06………07………77{OTHNIDR}

ND-3. In the past 12 months, have you used Viagra, Levitra or Cialis? {VIAGRA12}

No………….…………………………………..  0

Yes……………………………………………..  1

I prefer not to answer.……………..…………….7

Don't know……………..……………………...  9

Section D. HIV Testing (HT)

HT-1. Have you ever been tested for HIV? An HIV test checks whether someone has the virus that causes

AIDS.{EVERTEST}

No…………………………...…………..............  0

Yes………………..……………………..............  1

I prefer not to answer.……………..…………….7

Don't know……………..……………………...  9

If HT-1=0 and Group=A, then skip to box before PR-8.

If HT-1=0 and Group=B, then skip to box before SD-5.

If HT-1=0 and Group=C, then skip to box before PA-1.

HT-2. In the past 2 years, that is, since [insert calculated month and year], how many times have you been tested for HIV? {TEST2YRS}

___ ___ ___

[Prefer not to answer = 77; Don't know = 999]

HT-3. When did you have your most recent HIV test? {RCNTST}

[Prefer not to answer = 77; Don’t know= 99/9999] __ __/ __ __ __ __

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

HT-3a.When you got tested in ____/____ [insert date from HT-3], where did you get tested? {LOCHIV_T}

Private doctor’s office……………….. …. ……… 01

HIV counseling and testing site……………………...... 02

Public health clinic/community health clinic…….  03

Street outreach program/mobile unit………… ……… 04

Sexually transmitted disease clinic…………….......  05

Hospital (inpatient)……………...….……………….  06

Correctional facility (jail or prison)……………..…  07

Emergency room………….……...………………...  08

At home…………..………………………………...  09

Other………..………………………….………………. 10

I prefer not to answer.……………..…………...……….77

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

If HT-3a = 09 or HT-3a = 10 proceed to HT-4.

If HT-3a ≠ 09 or HT-3a ≠ 10, skip to HT-5.

HT-4 – HT-4b display only after FDA approval of over-the-counter rapid HIV test

The next screens are about your experiences with rapid HIV tests that are sold over the counter and allow you to test yourself in your home. These tests have a collection pad device that you use to swab the inside of your mouth, between the teeth and upper and lower gum. You then place the collection device into a solution and read the result between 20-40 minutes.

HT-4. When you last got tested in ____/____ [insert date from HT-3] at home or in another location, did you use an over-the-counter rapid HIV test you can administer yourself to determine your HIV status? {RAPID}

No……………………………………………. 0

Yes…………………………………………… 1

If HT-4 = 0, skip to HT-6.

HT-4a. Under which circumstances did you use the over-the- counter rapid HIV test? Check all that apply. { REARAPID}

I used it to test myself regularly…………...........................................	 1
I used it to test myself before having sex with a new partner………	 2
I asked my sex partner to test himself/herself before having sex with me……………………………………………………………...	 3
I used it to test myself after having sex with someone I knew was HIV negative……………………………………………………….	 4
I used it to test myself after having sex with someone I knew was HIV positive or whose HIV status I didn’t know………………….	 5

Other reason (Specify___________)…………………………………. 6

If HT-4a≠1, then skip to HT-5.

HT-4b. In the past 12 months, how often have you used an over-the-counter rapid HIV test to test yourself regularly? {FRERAPID}

I used it to test myself every 3 months or less……………..	1
I used it to test myself every 4-6 months………………..	2
I used it to test myself every 7-12 months………………	3
I used it to test myself at some other time interval………	4

HT-5. What was the result of your most recent HIV test? {RCNTRSLT}

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

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

Indeterminate…………..……………..…………  4 I prefer not to answer.……………..………….….7

Don't know…...…………………………..........  9

If HT-5=1,7 or 9 and Group=A, then skip to box before PP-8

If HT-5=1,7 or 9 and Group=B, then skip to box before SD-5

If HT-5=1, 7 or 9 and Group=C, then skip to box before PA-1

HT-6. Before your test in ____/_____ [insert date from HT-3], did you ever test positive for HIV? {EVRPOS}

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

I prefer not to answer.…………………………….7

Don't know……………..……………………...  9

If HT-6 = 1, skip to HT-7a.

If HT-6= (0, 7 or 9) and Group=A, then skip to box before PP-8

If HT-6= (0, 7 or 9) and Group=B, then skip to SD-5

If HT-6= (0, 7 or 9) and Group=C, then skip to PA-1

[PERSONS WHO HAVE TESTED HIV POSITIVE]

HT-7. Was your test in ____/_____ [insert date from HT-3] your first positive test? {RCNFRST}

No………………….……………………………  0

Yes…………………………………………….… 1

I prefer not to answer.……………..…………….7

Don't know…………………………………….  9

If HT-7 = (1, 7, or 9), skip to HT-8.

HT-7a. When did you first test positive? {POS1ST}

[77/7777 = Prefer not to answer; 99/9999 = Don't know] __ __/ __ __ __ __

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

HT-8. Are you currently taking antiretroviral medicines to treat your HIV infection? {CURRAMED}

No………………….…………………..………  0

Yes………………………………………..…….  1

I prefer not to answer.……………..…………….7

Don't know……………..………………...........  9

If HT-8= (1, 7 or 9) and Group=A, then skip to box before PP-8

If HT-8= (1, 7 or 9) and Group=B, then skip to SD-5

If HT-8= (1, 7 or 9) and Group=C, then skip to PA-1

HT-8a. What is the main reason you are not currently taking any antiretroviral medicines? {WHNOMEDS}

Not currently going to a health care provider for my HIV infection…. 00

CD4 count and viral load are good……….……….................................. 01

Don't have money or insurance for antiretroviral medicines....………. 02 Don't want to take antiretroviral medicines…………………………… 03

Other……………………………..…………………….............. ……... 04

I prefer not to answer.………………………………...…..…………….7

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

Group A.

If Group=A, administer PP-8 through PP-12.

If HT-5 = 2, Display “Researchers are studying whether antiretroviral medicines could possibly be taken to prevent HIV. and then proceed to PP-8

If HT-5≠ 2, or HT-1 = 0 Display “Researchers are studying whether anti-HIV medicine (also called antiretrovirals)-- a pill -- could possibly be taken to prevent HIV infection.” and then proceed to PP-8

PP-8. Before today, have you ever heard of people who do not have HIV taking (<<antiretroviral medicines/anti-HIV medicines>>), to keep from getting HIV? {ANTRPREV }

No………………….…………………..………  0

Yes………………………………………..…….  1

I prefer not to answer.……………..………….….7

Don't know……………..………………............. 9

If HT-1=0 or HT-5≠ 2, skip to PP-9a.

If HT-5= 2 and HT-8≠ 1, then skip to HC-1

PP-9. In the past 12 months, have you given your antiretroviral medicines to a sex partner who was HIV-negative because you thought it might keep them from getting HIV? {HPANTM2P}

No………………….…………………..………  0

Yes………………………………………..…….  1

I prefer not to answer.……………..…………….7

Don't know……………..………………...........  9

If HT-5= 2 and HT-8≠ 1, then skip to HC-1

PP-9a. In the past 12 months, have you taken anti-HIV medicines after sex because you thought it would keep you from getting HIV? {AHMPOSX}

No………………….…………………..………  0

Yes………………………………………..…….  1

I prefer not to answer.……………..…………….7

Don't know……………..………………............. 9

PP-10.In the past 12 months, have you taken anti-HIV medicines before sex because you thought it would keep you from getting HIV? {AHMPRESX}

No………………….…………………..………  0

Yes………………………………………..…….  1

I prefer not to answer.……………..…………….7

Don't know……………..………………............. 9

PP-11. Did you get any of the anti-HIV medicines you took from the following people or places?

No Yes Don’t

know

a. Doctor or other health care provider……………………………. 0…… 1…… 9 {RECANTMA}

b. Sex partner, friend, relative, or acquaintance……………………. 0…… 1…… 9{RECANTMB}

c. Internet……... ……………………………...…………………… 0…… 1…… 9{RECANTMC}

d. Some other place………………………………………………… 0…… 1…… 9{SPEC_RX}

PP-12. Would you be willing to take anti-HIV medicines every day to lower your chances of getting HIV? {WANTHIVD}

No………………….…………………..………  0

Yes………………………………………..…….  1

I prefer not to answer.……………..…………….7

Don't know……………..………………............. 9

If Group=A, then skip to box before HC-1

If Group=B, then skip to box before SD-5

If Group=C, then skip to box before PA-1

Group B.

If Group=B, administer SD-5 through SD-8.

How strongly do you agree or disagree with each statement below?

	Strongly Agree	Agree	Neither agree or disagree	Disagree	Strongly Disagree	Don’t Know
SD-5. Most people in my area would discriminate against someone with HIV {PHIVDISC}	01	02	03	04	05	09
SD-6. Most people in my area would support the rights of a person with HIV to live and work wherever they wanted to{PSUPPHIV}	01	02	03	04	05	09
SD-7. Most people in my area would not be friends with someone with HIV{PERFRHIV}	01	02	03	04	05	09
SD-8. Most people in my area think that people who got HIV through sex or drug use have gotten what they deserve{PPUNISHH}	01	02	03	04	05	09

If Group=A, administer HC-1 through HC5-a.

Group A.

Health Conditions and Services

HC-1. Has a doctor, nurse or other health care provider ever told you that you had hepatitis? {EVRHEP}

No………………….…………………..………  0

Yes………………………………………..…….  1

I prefer not to answer.……………..…………….7

Don't know……………..………………............. 9

HC-1a. Has a doctor, nurse or other health care provider ever told you that you had genital herpes? {EVRHERP}

No………………….…………………..………  0

Yes………………………………………..…….  1

I prefer not to answer.……………..…………….7

Don't know……………..……………….............9

HC-1b. Has a doctor, nurse or other health care provider ever told you that you had genital warts? {EVRGWAR}

No………………….…………………..………  0

Yes………………………………………..…….  1

I prefer not to answer.……………..…………….7

Don't know……………..……………….............9

HC-1c. Has a doctor, nurse or other health care provider ever told you that you had human papillomavirus or HPV {EVRHPV}

No………………….…………………..………  0

Yes………………………………………..…….  1

I prefer not to answer.……………..…………….7

Don't know……………..……………….............9

If HC-1 = 1, proceed to HC-1a.

Otherwise, skip to HC-2.

HC-1d. What type or types of hepatitis have you had? Check all that apply.

Hepatitis A……….……………………………..  0 {TYPHEPA}

Hepatitis B………………….…………..............  1 {TYPHEPB}

Hepatitis C……………………………...............  3 {TYPHEPC}

Other……………..…………….……………….  4 {TYPHEPD}

I prefer not to answer.……………..…………….7

Don't know……………..……………................  9

HC-2. In the past 12 months (since [___/___]), has a doctor, nurse or other health care provider told you that you had gonorrhea? {GONORR}

No.………………….…………………..………  0

Yes………………………………………..…….  1

I prefer not to answer.……………..…………….7

Don't know……………..……………….............9

HC-2a. In the past 12 months, (since [___/___]), has a doctor, nurse or other health care provider told you that you had chlamydia? {CHLMYD}

No.………………….…………………..………  0

Yes………………………………………..…….  1

I prefer not to answer.……………..…………….7

Don't know……………..……………….............9

HC-2b. In the past 12 months, (since [___/___]), has a doctor, nurse or other health care provider told you that you had syphilis? {SYPHILIS}

No.………………….…………………..………  0

Yes………………………………………..…….  1

I prefer not to answer.……………..…………….7

Don't know……………..……………….............9

If HC-2(a, b, AND c) = 1, skip to HC-4.

HC-3. Even though a doctor, nurse or other health care provider did not tell you that you had Gonorrhea, in the past 12 months, (since [___/___]), were you tested for gonorrhea? {GONOTEST}

No.………………….…………………..………  0

Yes………………………………………..…….  1

I prefer not to answer.……………..…………….7

Don't know……………..……………….............9

HC-3a. Even though a doctor, nurse or other health care provider did not tell you that you had Chlamydia in the past 12 months, (since [___/___]), were you tested for chlamydia? {CHLATEST}

No.………………….…………………..………  0

Yes………………………………………..…….  1

I prefer not to answer.……………..…………….7

Don't know……………..……………….............9

HC-3b. Even though a doctor, nurse or other health care provider did not tell you that you had Syphilis, in the past 12 months, (since [___/___]), were you tested for syphilis? {SYPHTEST}

No.………………….…………………..………  0

Yes………………………………………..…….  1

I prefer not to answer.……………..…………….7

Don't know……………..……………….............9

HC-4. There are vaccines or shots that can prevent some types of hepatitis.

Have you ever had a hepatitis vaccine? {HEPVACC}

No………………….……………………………  0

Yes……………………………………............... 1

I prefer not to answer.……………..…………….7

Don't know……..…………………...…………  9

If HC-4 = 0, 7 or 9, skip toHC-5.

HC-4a. What type or types of hepatitis vaccine have you had? {TYPEVACC}

Hepatitis A vaccine..……………………………. 1

Hepatitis B vaccine……………………………... 2

Both Hepatitis A and B vaccines……………….. 3

I prefer not to answer.……………..…………….7

Don't know………………..………….................. 9

HC-5. A vaccine to prevent human papillomavirus (HPV) infection is available and is called the HPV shot, cervical cancer vaccine, GARDASIL®, or CERVARIX®. Have you ever received the HPV vaccine? {HPVSHOT}

No………………….……………………………  0

Yes………………………………….………….. 1

I prefer not to answer.……………..…………….7

Don't know……………..……………................. 9

If HC-5 ≠ 1, skip to box before PA-1.

HC-5a. How old were you when you received your first dose of the HPV vaccine? {AGEVAC}

___ ____ years

Section F. Assessment of Prevention Activities (PA)

PA-1. In the past 12 months, have you gotten any free condoms, not counting those given to you by a friend, relative, or sex partner? {COND12}

No…………….………………….…………….. . 0

Yes…………………………………..………….. 1

I prefer not to answer.……………..…………….7

Don’t Know………….…………………………. 9

PA-2. In the past 12 months, have you had a one-on-one conversation with an outreach worker, counselor, or prevention program worker about ways to prevent HIV? Don’t count the times when you had a conversation as part of an HIV test. {TALKHIV}

No………………….……………..……..............  0

Yes…………………………….……….............. 1

I prefer not to answer.……………..…………….7

Don’t Know…………………………………….  9

PA-3. In the past 12 months, have you been a participant in any organized session(s) involving a small group of people to discuss ways to prevent HIV? Don't include discussions you had with a group of friends. {GROUP12}

No………………….……………………………  0

Yes………………………..………….………….  1

I prefer not to answer.……………..…………….7

Don’t Know…………………………...……….. 9

If County = {CDC grantee funded to conducted Enhanced Comprehensive HIV/AIDS Prevention project}, then go to PA-4, else, go to PA-5.

PA-4. In the past 12 months, have you seen or heard any media messages with "<<media campaign name" logo or image? {MEDIMESS}

No………………….……………………………  0

Yes………………………..………….………….  1

I prefer not to answer.……………..…………….7

Don’t Know…………………………...………... 9

If PA-4 = 0, skip to PA-5.

PA-4a. What was your response to the message? {MESSRESP}

Very positive …………………..…………………... 01

Positive …………………………………………….  02

Neutral…..………….………………………………  03

Negative....………………………………………….  04

Very Negative……………..……………………….  05

I prefer not to answer.……………..…………………..07

Don’t Know………….……………............................ 09

PA-5. For this national study, we are recruiting a large number of men like you. Can you tell us the name of a new or different social networking website where we could reach other men like you who might like to complete this survey?”________________________________. {REFSITES}

And Finally…

PA-6. If you had to choose one activity with a guy you liked what would it be {IACTIV}

Romantic dinner…………………..…………………... 01

Walk along the beach…………………..…………….... 02

Kissing fully clothed…………………..………….….... 03

Snuggling without hooking up…………………..…….. 04

I prefer not to answer.……………..…………………...07

Don’t Know………….…………….................................09

PA-7. Who is the sexiest man on the planet? {SEXIEST}

________________________________________________

AUTO7. Time Ended Core Survey: __ __:__ __ : __ __ [24 Hour time HH:MM:SS] {ENDCORE}

SURVEY END:

Thank you for taking our survey. Your response is very important to us.

To find an HIV testing location near you, please visit:

www.hivtest.org

To get more information about HIV, please visit:

www.cdc.gov/hiv

Otherwise, you can close your browser.

FLASHCARD

FOR USE WITH ALCOHOL QUESTIONS

1 Shot of Liquor 1 Regular Beer 1 Glass of Wine

(Whisky, Vodka, Gin, etc) 12 oz. 5 oz.

1.5 oz.

Note: A 40 ounce beer would count as 3 drinks, or a cocktail drink with 2 shots would count as 2 drinks.

2