IMMEDIATE POST Follow-UP Assessment - NOVA
Development and Testing of an HIV Prevention Intervention Targeting Black Bisexually-Active Men
10BA_Att 3E_Immediate_Follow-Up
IMMEDIATE POST Follow-UP Assessment - NOVA
OMB: 0920-0863
Development and Testing of an HIV Prevention Intervention
Targeting Black Bisexually-Active Men
Attachment 3E
IMMEDIATE Follow-Up Assessment BY SITE
Form Approved
OMB No. 0920-xxxx
Expiration Date:
3E.1: PHMC
IMMEDIATE POST FOLLOW-UP ASSESSMENT
Thank you for coming in today to complete your second interview for the Connections Program. Since you just took an interview on (insert baseline interview date), we will not have to ask you some of the same questions that we asked in your first interview. For the following questions, either check the appropriate box or fill in your answer in the spaces provided. Remember, your responses will be kept private.
A. DEMOGRAPHICS
1. Are you currently employed?
1 = Full time
2 = Part time/ Occasional
3 = Unemployed
4 = Retired
5 = Unable to work (disabled)
= Prefer not to answer
2. Are you currently a full time or part time student?
1 = Full time
2 = Part time
3 = Not a student
= Prefer not to answer
3. Currently, who do you live with most of the time? (Check ALL that apply)
Alone
Parents
Friends
Other relatives
Partner, lover, or spouse
Your children
Other people not mentioned (please
specify):___________________________________________
4. What is the zip code of your current home or place where you stay? |_____|_____|_____|_____|_____|
777 Don’t Know
5. Do you consider yourself to be currently homeless?
No Yes
B. HIV AND STD TESTING/HISTORY AND PERCEIVED RISK
Now we would like to ask some questions about your health. There are several diseases or infections that can be transmitted during sex. These are sometimes called venereal diseases or sexually transmitted diseases. We will be using the term sexually transmitted disease or STD to refer to them in the next few questions. Although HIV is a sexually transmitted disease, we will be asking you about it in a different part of this survey.
1. Since you answered the baseline survey (ACASI to insert date) have you been tested for STDs? Do not include an HIV test in this answer.
YES
NO
_777 Don’t know
_888 Prefer not to answer
For which STDs were you tested? (check box)
Gonorrhea
Syphilis
Genital herpes
Chlamydia
Genital Warts (also known as HPV or Human Papilloma Virus)
Hepatitis B virus
Hepatitis C virus
Some other STD, but not HIV (Please enter your answer here_____________)
3. For any checked above -
Were you told by a health care provider that you tested positive for (name STD)? YES
NO
_777 Don’t know
_888 Prefer not to answer
4. Where did you receive recent STD test(s)? ____________________________________
You are now going to be asked some questions about your HIV status and about your experiences taking the HIV test. Please remember that this survey is kept private. It is for HIV-positive men as well as HIV-negative men.
5. Since you answered the baseline survey (ACASI to insert date) have you been tested for HIV?
YES
NO (skip to Question 7)
_777 Don’t know
_888 Prefer not to answer (skip to Section B)
6. Did you receive the test results?
NO
YES
___777 Don’t Know
___888 Prefer not to answer
7. What was the result of your last HIV test? (Choose one)
___1 HIV-Negative (Do not have HIV) (skip next question.)
___2 HIV-Positive (Do have HIV) (skip next question.)
___3 I did not get the result of my last test (go to question 8)
___4 Inconclusive/Indeterminate (the result was neither positive or negative) (go to question 8)
___888 Prefer not to answer
8. What was the result of your last HIV test when you received a result?
___1 HIV-Negative (Do not have HIV)
___2 HIV-Positive (Do have HIV)
___3 I did not get the result of my last test
___4 Inconclusive/Indeterminate (the result was neither positive or negative)
___888 Prefer not to answer
9. Where did you receive your last HIV test? ___________________________________________
Open response.
If HIV-positive, skip to Section C.
Perceived Risk for HIV
On a scale from 1 to 10, with 1 being (extremely unlikely) and 10 being extremely likely, . . .
10. How likely is it that you are infected with HIV now? _____
___ 88 Prefer not to answer
11. How likely do you think it is that you will become infected with HIV in your lifetime? _____
___ 88 Prefer not to answer
C. MENTAL HEALTH
Here is a list of problems and complaints that people sometimes have. For each one, check how much that problem has bothered or distressed you during the past week, including today. Please check whether each problem has bothered you not at all, a little bit, moderately, quite a bit, or extremely.
HOW OFTEN DO YOU EXPERIENCE . . .
1. Faintness or dizziness? (Choose one)
1 Not At All
2 A Little Bit
3 Moderately
4 Quite A Bit
5 Extremely
8 Refuse to Answer
2. Feeling no interest in things? (Choose one) 1 Not At All
2 A Little Bit
3 Moderately
4 Quite A Bit
5 Extremely
8 Refuse to Answer
3. Nervousness or shakiness inside? (Choose one) 1 Not At All
2 A Little Bit
3 Moderately
4 Quite A Bit
5 Extremely
8 Refuse to Answer
4. Pains in heart or chest? (Choose one) 1 Not At All
2 A Little Bit
3 Moderately
4 Quite A Bit
5 Extremely
8 Refuse to Answer
5. Feeling lonely? (Choose one) 1 Not At All
2 A Little Bit
3 Moderately
4 Quite A Bit
5 Extremely
8 Refuse to Answer
6. Feeling tense or keyed up? (Choose one) 1 Not At All
2 A Little Bit
3 Moderately
4 Quite A Bit
5 Extremely
8 Refuse to Answer
7. Nausea or upset stomach? (Choose one) 1 Not At All
2 A Little Bit
3 Moderately
4 Quite A Bit
5 Extremely
8 Refuse to Answer
8. Feeling blue or sad? (Choose one) 1 Not At All
2 A Little Bit
3 Moderately
4 Quite A Bit
5 Extremely
8 Refuse to Answer
9 Not Applicable
9. Being suddenly scared for no reason? (Choose one) 1 Not At All
2 A Little Bit
3 Moderately
4 Quite A Bit
5 Extremely
8 Refuse to Answer
10. Trouble getting your breath? (Choose one) 1 Not At All
2 A Little Bit
3 Moderately
4 Quite A Bit
5 Extremely
8 Refuse to Answer
11. In the past week, how much have you been bothered by...having urges to beat, injure, or harm someone? (Choose one)
1 Not at all
2 A little bit
3 Moderately
4 Quite a bit
5 Extremely
8 Prefer not to answer
12. In the past week, how much have you been bothered by...having urges to break or smash things? (Choose one) 1 Not at all
2 A little bit
3 Moderately
4 Quite a bit
5 Extremely
8 Prefer not to answer
13. Feelings of worthlessness? (Choose one) 1 Not At All
2 A Little Bit
3 Moderately
4 Quite A Bit
5 Extremely
8 Refuse to Answer
14. Episodes of terror or panic? (Choose one) 1 Not At All
2 A Little Bit
3 Moderately
4 Quite A Bit
5 Extremely
8 Refuse to Answer
15. Numbness or tingling in parts of your body? (Choose one) 1 Not At All
2 A Little Bit
3 Moderately
4 Quite A Bit
5 Extremely
8 Refuse to Answer
16. Feeling hopeless about the future? (Choose one) 1 Not At All
2 A Little Bit
3 Moderately
4 Quite A Bit
5 Extremely
8 Refuse to Answer
17. Feeling so restless that you could not sit still? (Choose one) 1 Not At All
2 A Little Bit
3 Moderately
4 Quite A Bit
5 Extremely
8 Refuse to Answer
18. Feeling weak in parts of your body? (Choose one) 1 Not At All
2 A Little Bit
3 Moderately
4 Quite A Bit
5 Extremely
8 Refuse to Answer
19. Thoughts of ending your life? (Choose one) 1 Not At All
2 A Little Bit
3 Moderately
4 Quite A Bit
5 Extremely
8 Refuse to Answer
20. Feeling fearful? (Choose one) 1 Not At All
2 A Little Bit
3 Moderately
4 Quite A Bit
5 Extremely
8 Refuse to Answer
Hostility Items
21. Feeling easily annoyed or irritated (Choose one)
1 Not at all
2 A little bit
3 Moderately
4 Quite a bit
5 Extremely
8 Prefer not to answer
22. ..temper outbursts that you could not control? (Choose one)
1 Not at all
2 A little bit
3 Moderately
4 Quite a bit
5 Extremely
8 Prefer not to answer
5 Extremely
8 Prefer not to answer
23. ....having urges to beat, injure, or harm someone? (Choose one)
1 Not at all
2 A little bit
3 Moderately
4 Quite a bit
5 Extremely
8 Prefer not to answer
24. ...having urges to break or smash things? (Choose one)
1 Not at all
2 A little bit
3 Moderately
4 Quite a bit
5 Extremely
8 Prefer not to answer
25 ...getting into frequent arguments? (Choose one)1 Not at all
2 A little bit
3 Moderately
4 Quite a bit
5 Extremely
8 Prefer not to answer
D. SPIRITUALITY
The next couple of questions ask about religion and spirituality. Please answer each of the questions as honestly as you can.
1.. I am able to be open about my sexuality in my religious community.
1 = Strongly agree
2 = Agree somewhat
3 = Disagree somewhat
4 = Strongly disagree
5 = I don't have a religious community
8 = Prefer not to answer
2.. My religious beliefs make me feel bad about having sex with other men.
1 = Strongly agree
2 = Agree somewhat
3 = Disagree somewhat
4 = Strongly disagree
5 = I don't have religious beliefs
8 = Prefer not to answer
E. MEDICAL HISTORY FOR HIV-POSITIVE MEN
The next set of questions is about the medical care and treatment you have received for your HIV infection.
1. Are you receiving regular/ongoing medical care for your HIV infection?
1 Yes
0 No
8 Prefer not to answer
9 Not Applicable
2. Please enter the year and month of your most recent visit to a medical provider for your HIV infection.
__ __ / __ __ __ __ mm / yyyy
2097 Don't Know (Year)
2098 Prefer not to answer (Year)
3. What was your most recent CD4 (t-cell) count? ________
4. What was your most recent viral load? ____________
5. Are you currently taking medication for HIV?
1 Yes
0 No
8 Prefer not to answer
6. How do you usually take your medications? Choose one of the following:
1. I always take all of my pills, on time and according to directions
2. I always take all of my pills, but not always on time and according to directions
3. I sometimes miss or forget to take my pills
4. I’m not too careful about taking pills
5. I don’t take them at all
F. SELF-ESTEEM (18-items Beck Self-Esteem Self Scale )
Below is a list of adjectives that some people use to describe themselves. Please read each pair of adjectives and place an ‘X’ at the point along the line which best describes you right now.
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Unsuccessful |
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Unattractive |
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Unpopular |
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Dependent |
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Very Much |
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Dishonest |
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Undesirable |
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Weak |
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Very Much |
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Very Much |
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Dumb |
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Powerless |
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Unlovable |
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Unpleasant |
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Inefficient |
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Irresponsible |
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Selfish |
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Worthless |
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Boring |
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Ignorant |
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Bad |
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ndependent
G. INTERNALIZED HOMONEGATIVITY (items from Nungesser Homosexual attitudes Inventory and HIV Center for Clinical & Behavioral Studies at the New York State Psychiatric Institute =.92)
The following are some statements that people can make about being gay or bisexual. For each
statement, please indicate if you Strongly Agree, Agree, Disagree or Strongly Disagree. If you feel that a
statement does not apply to you, please select the "Not Applicable" button on the right side of the screen.
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(1) Strongly Agree |
(2) Agree |
(3) Disagree |
(4) Strongly Disagree |
(8) Refuse to Answer |
(9) Not Applicable |
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H. SEXUAL RISK
SEX WITH MALE PARTNERS
How many men did you have anal sex with in the past MONTH?
______ men (If 0 SKIP to SEX WITH FEMALE PARTNERS)
998 Refuse to Answer
2. How many times in the past MONTH did you top a male partner (put your penis in his butt) WITHOUT a condom?_______
3. How many times in the past MONTH did you top a male partner (put your penis in his butt) WITH a condom?_______
4. How many times in the past MONTH did you bottom for a male partner (he put his penis in your butt) WITHOUT a condom?_______
5. How many times in the past MONTH did you bottom for a male partner (he put his penis in your butt) WITH a condom?_______
6. The last time you had anal sex with a male partner in the past month, did you have sex without a condom?
01 Yes
00 No
98 Refuse to Answer
7. What was the HIV status of this partner?
01 HIV negative
02 HIV positive
03 Do not know/unsure
98 Refuse to Answer
SEX WITH FEMALE PARTNERS
How many women did you have vaginal or anal sex with in the past MONTH?
______ women (If 0 SKIP to SEX WITH TRANSGENDER PARTNERS)
998 Refuse to Answer
2. How many times in the past MONTH did you have vaginal or anal sex with a female partner WITHOUT a condom?_______
3. How many times in the past MONTH did you have vaginal or anal sex with a female partner WITH a condom?_______
4. The last time you had vaginal sex with a female partner in the past month, did you have sex without a condom?
01 Yes
00 No
98 Refuse to Answer
5. What was the HIV status of this partner?
01 HIV negative
02 HIV positive
03 Do not know/unsure
98 Refuse to Answer
SEX WITH TRANSGENDER PARTNERS
1. How many transgender partners did you have vaginal or anal sex with in the past MONTH?
______ transgender partners (If 0 SKIP to next section)
998 Refuse to Answer
2. How many times in the past MONTH did you have vaginal or anal sex with a transgender partner WITHOUT a condom?_______
3. How many times in the past MONTH did you have vaginal or anal sex with a transgender partner WITH a condom?_______
4. The last time you had vaginal sex with a transgender partner in the past month, did you have sex without a condom?
01 Yes
00 No
98 Refuse to Answer
5. What was the HIV status of this partner?
01 HIV negative
02 HIV positive
03 Do not know/unsure
98 Refuse to Answer
I. CONNECTIONS PROGRAM SATISFACTION QUESTIONS
Flesch-Kincaid = 6.0
1. The last time we interviewed you on _(insert baseline date)_ you were invited to join a program that either lasted for six sessions or one session. Which program did you attend?
_____ 1) One session program (Skip to the instructions at the end of the survey)
_____ 2) Six sessions program (Continue with question 2)
Please help us to improve our program by answering some questions about the services you
received in the Connections Program. We are interested in your honest opinions, whether they are
positive or negative. Please answer all of the questions. All of your answers will remain private.
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1 |
2 |
3 |
4 |
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Almost all of my needs have been met |
Most of my needs have been met |
Only a few of my needs have been met |
None of my needs have been met |
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Yes, they helped a great deal |
Yes, they helped somewhat |
No, they really didn’t help |
No, they seemed to make things worse |
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Extremely dissatisfied |
Somewhat dissatisfied |
Somewhat satisfied |
Extremely satisfied |
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Extremely dissatisfied |
Somewhat dissatisfied |
Somewhat satisfied |
Extremely satisfied |
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Extremely dissatisfied |
Somewhat dissatisfied |
Somewhat satisfied |
Extremely satisfied |
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Extremely dissatisfied |
Somewhat dissatisfied |
Somewhat satisfied |
Extremely satisfied |
We would now like to know what you think specifically about the sessions you attended in the Connections Program. Below are some statements about the Connections Program. Please carefully read each statement and tell us if you Strongly Agree, Agree, Disagree or Strongly Disagree with each statement.
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Strongly Agree |
Agree |
Disagree |
Strongly Disagree |
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The Connections Program included a total of six sessions with a life coach.
17. Do you think this was about the right number of sessions for you, or would you have liked more sessions or fewer sessions?
____ 1) Right number ____ 8) Don’t know, depends
____ 2) Liked more sessions
____ 3) Liked fewer sessions
18. How many sessions did you attend? ____ _____ (Skip to Question 20 if equals 6)
(Ask Question 19 if participant missed at least one session)
19. There are many reasons why people miss appointments. Please tell us why you missed one or more of your session appointments. This information will help us to better plan our services in the future. Please check all that apply.
The reason I missed one or more sessions was because….
[] I did not feel the sessions were helping me.
[] I was concerned about my privacy and confidentiality.
[] I found the sessions boring.
[] I had to be at work.
[] I had family obligations.
[] I was in a program or institution that prevented me from attending (such as drug and
alcohol program, shelter).
[] I had difficulty with transportation (cost, getting a ride, etc.)
[] I forgot about my session.
[] I just didn’t feel like going that day.
[] Something unexpected came up. (Please explain here:________________________)
[] Another reason. (Please explain here:______________________________________)
You are almost finished with the interview. We appreciate your help. We are interested in your suggestions for improving the Connections Program.
20. What did you like the most about the Connections Program?
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
21. What did you like the least about the Connections Program?
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
22. What could our project do differently to make it better?
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
You have finished the interview. Please let your interviewer know. Thank you for your participation.
Form Approved:
OMB No. 0920-XXXX
Expiration Date:
3E.2: NOVA
IMMEDIATE POST FOLLOW-UP ASSESSMENT
Thank you for coming in today to complete your second interview for Project POWER. Since you just took an interview on (insert baseline interview date), we will not have to ask you some of the same questions that we asked in your first interview. For the following questions, either check the appropriate box or fill in your answer in the spaces provided. Remember, your responses will be kept private.
A. DEMOGRAPHICS
1. Are you currently employed?
1 = Full time
2 = Part time/ Occasional
3 = Unemployed
4 = Retired
5 = Unable to work (disabled)
= Prefer not to answer
2. Are you currently a full time or part time student?
1 = Full time
2 = Part time
3 = Not a student
= Prefer not to answer
3. Currently, who do you live with most of the time? (Check ALL that apply)
Alone
Parents
Friends
Other relatives
Partner, lover, or spouse
Your children
Other people not mentioned (please
specify):___________________________________________
4. What is the zip code of your current home or place where you stay? |_____|_____|_____|_____|_____|
777 Don’t Know
5. Do you consider yourself to be currently homeless?
No Yes
B. HIV/STD KNOWLEDGE QUESTIONNAIRE
The following statements are about STDs (Sexually Transmitted Diseases) and HIV. Please indicate whether you think the statement is “true” or “false”. If you aren’t sure, choose “don’t know”.
Douching after sex helps protect you from STDs.
You can’t get the AIDS virus through a cut in your skin.
You can’t always tell if your partner has as STD.
Pre-ejaculatory fluids (pre-cum) carry HIV.
People who have HIV generally feel sick right away.
You can’t get HIV by sharing knives and forks or a bathroom with a person who has HIV.
An untreated STD can possibly result in being unable to have children.
Condoms with spermicide will protect you from most STDs.
Women can spread STDs to men when they don’t use condoms.
If a woman uses birth control pills, it lowers her risk for getting HIV.
Having an STD puts you at greater risk for getting HIV.
If a person has HIV, it is still safe to kiss them on the lips, as you would kiss a friend or relative.
The most effective way to prevent the spread of HIV is abstinence from sex.
Sheep skin condoms are better than latex condoms for preventing HIV.
Using oil based lubricants such as Vaseline or Crisco with condoms will reduce the risk of getting HIV.
All STDs, except for HIV, can be cured with antibiotics.
C. HIV AND STD TESTING/HISTORY AND PERCEIVED RISK
Now we would like to ask some questions about your health. There are several diseases or infections that can be transmitted during sex. These are sometimes called venereal diseases or sexually transmitted diseases. We will be using the term sexually transmitted disease or STD to refer to them in the next few questions. Although HIV is a sexually transmitted disease, we will be asking you about it in a different part of this survey.
1. Since you answered the baseline survey (ACASI to insert date) have you been tested for STDs? Do not include an HIV test in this answer.
YES
NO
_777 Don’t know
_888 Prefer not to answer
For which STDs were you tested? (check box)
Gonorrhea
Syphilis
Genital herpes
Chlamydia
Genital Warts (also known as HPV or Human Papilloma Virus)
Hepatitis B virus
Hepatitis C virus
Some other STD, but not HIV (Please enter your answer here_____________)
3. For any checked above -
Were you told by a health care provider that you tested positive for (name STD)? YES
NO
_777 Don’t know
_888 Prefer not to answer
4. Where did you receive recent STD test(s)? ____________________________________
You are now going to be asked some questions about your HIV status and about your experiences taking the HIV test. Please remember that this survey is kept private. It is for HIV-positive men as well as HIV-negative men.
5. Since you answered the baseline survey (ACASI to insert date) have you been tested for HIV?
YES
NO (skip to Question 7)
_777 Don’t know
_888 Prefer not to answer (skip to Section B)
6. Did you receive the test results?
NO
YES
___777 Don’t Know
___888 Prefer not to answer
7. What was the result of your last HIV test? (Choose one)
___1 HIV-Negative (Do not have HIV) (skip next question.)
___2 HIV-Positive (Do have HIV) (skip next question.)
___3 I did not get the result of my last test (go to question 8)
___4 Inconclusive/Indeterminate (the result was neither positive or negative) (go to question 8)
___888 Prefer not to answer
8. What was the result of your last HIV test when you received a result?
___1 HIV-Negative (Do not have HIV)
___2 HIV-Positive (Do have HIV)
___3 I did not get the result of my last test
___4 Inconclusive/Indeterminate (the result was neither positive or negative)
___888 Prefer not to answer
9. Where did you receive your last HIV test? ___________________________________________
Open response.
If HIV-positive, skip to Section C.
On a scale from 1 to 10, with 1 being (extremely unlikely) and 10 being extremely likely, . . .
10. How likely is it that you are infected with HIV now? _____
___ 88 Prefer not to answer
11. How likely do you think it is that you will become infected with HIV in your lifetime? _____
___ 88 Prefer not to answer
D. Condom Use Self-Efficacy Scale (CUSES)
The following questions ask about your feelings about using condoms, using the following scale:
1=Strongly Agree
2=Agree
3=Undecided
4=Disagree
5=Strongly Disagree
I feel confident in my ability to put a condom on myself or my partner.
I feel confident I could purchase condoms without feeling embarrassed.
I feel confident I could remember to carry a condom with me should I need one.
I feel confident in my ability to discuss condom usage with any partner I might have.
I feel confident in my ability to suggest using condoms with a new partner.
I feel confident I could suggest using a condom without my partner feeling "diseased".
I feel confident in my own or my partner's ability to maintain an erection while using a condom.
I would feel embarrassed to put a condom on myself or my partner.
If I were to suggest using a condom to a partner, I would feel afraid that he or she would reject me.
If I were unsure of my partner's feelings about using condoms, I would not suggest using one.
I feel confident in my ability to use a condom correctly.
I would feel comfortable discussing condom use with a potential sexual partner before we ever had any sexual contact (such as hugging, kissing, caressing, etc.)
I feel confident in my ability to persuade a partner to accept using a condom when we have intercourse.
I feel confident I could gracefully remove and dispose of a condom after we have intercourse.
If my partner and I were to try to use a condom and did not succeed, I would feel embarrassed to try to use one again (such as not being able to unroll condom, putting it on backwards, or awkwardness).
I would not feel confident suggesting using condoms with a new partner because I would be afraid he or she would think I've had a homosexual experience.
I would not feel confident suggesting using condoms with a new partner because I would be afraid he or she would think I have a sexually transmitted disease.
I would not feel confident suggesting using condoms with a new partner because I would be afraid he or she would think I thought they had a sexually transmitted disease.
I would feel comfortable discussing condom use with a potential partner before we ever engaged in intercourse.
I feel confident in my ability to incorporate putting a condom on myself or my partner into foreplay.
I feel confident that I could use a condom with a partner without "breaking the mood."
I feel confident in my ability to put a condom on myself or my partner quickly.
I feel confident I could use a condom during intercourse without reducing any sexual sensations.
I feel confident that I would remember to use a condom even after I have been drinking.
I feel confident that I would remember to use a condom even if I were high.
If my partner didn't want to use a condom during intercourse, I could easily convince him or her that it was necessary to do so.
I feel confident that I could use a condom successfully.
28) I feel confident I could stop to put a condom on myself or my partner even in the heat of passion.
E. MENTAL HEALTH
I am going to show you a list of problems and complaints that people sometimes have. For each one, tell me how much that problem has bothered or distressed you during the past week, including today. Please tell me whether each problem has bothered you not at all, a little bit, moderately, quite a bit, or extremely.
HOW OFTEN DO YOU EXPERIENCE . . .
1. Faintness or dizziness? (Choose one)
1 Not At All
2 A Little Bit
3 Moderately
4 Quite A Bit
5 Extremely
8 Refuse to Answer
2. Feeling no interest in things? (Choose one) 1 Not At All
2 A Little Bit
3 Moderately
4 Quite A Bit
5 Extremely
8 Refuse to Answer
3. Nervousness or shakiness inside? (Choose one) 1 Not At All
2 A Little Bit
3 Moderately
4 Quite A Bit
5 Extremely
8 Refuse to Answer
4. Pains in heart or chest? (Choose one) 1 Not At All
2 A Little Bit
3 Moderately
4 Quite A Bit
5 Extremely
8 Refuse to Answer
5. Feeling lonely? (Choose one) 1 Not At All
2 A Little Bit
3 Moderately
4 Quite A Bit
5 Extremely
8 Refuse to Answer
6. Feeling tense or keyed up? (Choose one) 1 Not At All
2 A Little Bit
3 Moderately
4 Quite A Bit
5 Extremely
8 Refuse to Answer
7. Nausea or upset stomach? (Choose one) 1 Not At All
2 A Little Bit
3 Moderately
4 Quite A Bit
5 Extremely
8 Refuse to Answer
8. Feeling blue or sad? (Choose one) 1 Not At All
2 A Little Bit
3 Moderately
4 Quite A Bit
5 Extremely
8 Refuse to Answer
9 Not Applicable
9. Being suddenly scared for no reason? (Choose one) 1 Not At All
2 A Little Bit
3 Moderately
4 Quite A Bit
5 Extremely
8 Refuse to Answer
10. Trouble getting your breath? (Choose one) 1 Not At All
2 A Little Bit
3 Moderately
4 Quite A Bit
5 Extremely
8 Refuse to Answer
11. In the past week, how much have you been bothered by...having urges to beat, injure, or harm someone? (Choose one)
1 Not at all
2 A little bit
3 Moderately
4 Quite a bit
5 Extremely
8 Prefer not to answer
12. In the past week, how much have you been bothered by...having urges to break or smash things? (Choose one) 1 Not at all
2 A little bit
3 Moderately
4 Quite a bit
5 Extremely
8 Prefer not to answer
13. Feelings of worthlessness? (Choose one) 1 Not At All
2 A Little Bit
3 Moderately
4 Quite A Bit
5 Extremely
8 Refuse to Answer
14. Episodes of terror or panic? (Choose one) 1 Not At All
2 A Little Bit
3 Moderately
4 Quite A Bit
5 Extremely
8 Refuse to Answer
15. Numbness or tingling in parts of your body? (Choose one) 1 Not At All
2 A Little Bit
3 Moderately
4 Quite A Bit
5 Extremely
8 Refuse to Answer
16. Feeling hopeless about the future? (Choose one) 1 Not At All
2 A Little Bit
3 Moderately
4 Quite A Bit
5 Extremely
8 Refuse to Answer
17. Feeling so restless that you could not sit still? (Choose one) 1 Not At All
2 A Little Bit
3 Moderately
4 Quite A Bit
5 Extremely
8 Refuse to Answer
18. Feeling weak in parts of your body? (Choose one) 1 Not At All
2 A Little Bit
3 Moderately
4 Quite A Bit
5 Extremely
8 Refuse to Answer
19. Thoughts of ending your life? (Choose one) 1 Not At All
2 A Little Bit
3 Moderately
4 Quite A Bit
5 Extremely
8 Refuse to Answer
20. Feeling fearful? (Choose one) 1 Not At All
2 A Little Bit
3 Moderately
4 Quite A Bit
5 Extremely
8 Refuse to Answer
Hostility Items
21. Feeling easily annoyed or irritated (Choose one)
1 Not at all
2 A little bit
3 Moderately
4 Quite a bit
5 Extremely
8 Prefer not to answer
22. ..temper outbursts that you could not control? (Choose one)
1 Not at all
2 A little bit
3 Moderately
4 Quite a bit
5 Extremely
8 Prefer not to answer
5 Extremely
8 Prefer not to answer
23. ....having urges to beat, injure, or harm someone? (Choose one)
1 Not at all
2 A little bit
3 Moderately
4 Quite a bit
5 Extremely
8 Prefer not to answer
24. ...having urges to break or smash things? (Choose one)
1 Not at all
2 A little bit
3 Moderately
4 Quite a bit
5 Extremely
8 Prefer not to answer
25. ...getting into frequent arguments? (Choose one)
1 Not at all
2 A little bit
3 Moderately
4 Quite a bit
5 Extremely
8 Prefer not to answer
F. The Multi-Group Ethnic Identity Measure (MEIM) (Phinney, 1992)
In this country, people come from many different countries and cultures, and there are many different words to describe the different backgrounds or ethnic groups that people come from. Some examples of the names of ethnic groups are Hispanic or Latino, Black or African American, Asian American, Chinese, Filipino, American Indian, Mexican American, Caucasian or White, Italian American, and many others. These questions are about your ethnicity or your ethnic group and how you feel about it or react to it.
Please fill in: In terms of ethnic group, I consider myself to be ____________________
Use the numbers below to indicate how much you agree or disagree with each statement.
(4) Strongly agree (3) Agree (2) Disagree (1) Strongly disagree
1. I have spent time trying to find out more about my ethnic group, such as its history, traditions, and customs.
2. I am active in organizations or social groups that include mostly members of my own ethnic group.
3. I have a clear sense of my ethnic background and what it means for me.
4. I think a lot about how my life will be affected by my ethnic group membership.
5. I am happy that I am a member of the group I belong to.
6. I have a strong sense of belonging to my own ethnic group.
7. I understand pretty well what my ethnic group membership means to me.
8. In order to learn more about my ethnic background, I have often talked to other people about my ethnic group.
9. I have a lot of pride in my ethnic group.
10. I participate in cultural practices of my own group, such as special food, music, or customs.
11. I feel a strong attachment towards my own ethnic group.
12. I feel good about my cultural or ethnic background.
13. My race/ethnicity is:
(1) Asian
(2) Black or African American
(3) White
(4) American Indian/ Alaska Native
(5) Native Hawaiian/Pacific Islander
14. I am Latino/Hispanic. Yes/No
15. My father's race/ethnicity is: (use numbers above).
16. My father is Latino/Hispanic. Yes/No
17. My mother's ethnicity is: (use numbers above)
18. My mother is Latina/Hispanic. Yes/No
G. Internalized Homophobia Scale
Please choose the number that best describes your response to each item:
1 = strongly agree
2 = moderately agree
3 = slightly agree
4 = neither agree or disagree
5 = slightly disagree
6 = moderately disagree
7 = strongly disagree
Obviously effeminate homosexual men make me feel uncomfortable
I prefer to have anonymous sexual partners
It would not be easier in life to be heterosexual
Most of my friends are homosexual
I do not feel confident about making an advance to another man
I feel comfortable in gay bars
Social situations with gay men make me feel uncomfortable
I don’t like thinking about my homosexuality
When I think about other homosexual men, I think of negative situations
I feel comfortable about being seen in public with an obviously gay person
I feel comfortable discussing homosexuality in a public setting
It is important to me to control who knows about my homosexuality
Most people have negative reactions to homosexuality
Homosexuality is not against the will of God
Society still punishes people for being gay
I object if an anti-gay joke is told in my presence
I worry about becoming old and gay
I worry about becoming unattractive
I would prefer to be more heterosexual
Most people don’t discriminate against homosexuals
I feel comfortable about being homosexual
Homosexuality is morally acceptable
I am not worried about anyone finding out that I am gay
Discrimination against gay people is still common
Even if I could change my sexual orientation, I wouldn’t
Homosexuality is as natural as heterosexuality
H. SEXUAL RISK
SEX WITH MALE PARTNERS
How many men did you have anal sex with in the past MONTH?
______ men (If 0 SKIP to SEX WITH FEMALE PARTNERS)
998 Refuse to Answer
2. How many times in the past MONTH did you top a male partner (put your penis in his butt) WITHOUT a condom?_______
3. How many times in the past MONTH did you top a male partner (put your penis in his butt) WITH a condom?_______
4. How many times in the past MONTH did you bottom for a male partner (he put his penis in your butt) WITHOUT a condom?_______
5. How many times in the past MONTH did you bottom for a male partner (he put his penis in your butt) WITH a condom?_______
6. The last time you had anal sex with a male partner in the past month, did you have sex without a condom?
01 Yes
00 No
98 Refuse to Answer
7. What was the HIV status of this partner?
01 HIV negative
02 HIV positive
03 Do not know/unsure
98 Refuse to Answer
SEX WITH FEMALE PARTNERS
How many women did you have vaginal or anal sex with in the past MONTH?
______ women (If 0 SKIP to SEX WITH TRANSGENDER PARTNERS)
998 Refuse to Answer
2. How many times in the past MONTH did you have vaginal or anal sex with a female partner WITHOUT a condom?_______
3. How many times in the past MONTH did you have vaginal or anal sex with a female partner WITH a condom?_______
4. The last time you had vaginal sex with a female partner in the past month, did you have sex without a condom?
01 Yes
00 No
98 Refuse to Answer
5. What was the HIV status of this partner?
01 HIV negative
02 HIV positive
03 Do not know/unsure
98 Refuse to Answer
SEX WITH TRANSGENDER PARTNERS
1. How many transgender partners did you have vaginal or anal sex with in the past MONTH?
______ transgender partners (If 0 SKIP to next section)
998 Refuse to Answer
2. How many times in the past MONTH did you have vaginal or anal sex with a transgender partner WITHOUT a condom?_______
3. How many times in the past MONTH did you have vaginal or anal sex with a transgender partner WITH a condom?_______
4. The last time you had vaginal sex with a transgender partner in the past month, did you have sex without a condom?
01 Yes
00 No
98 Refuse to Answer
5. What was the HIV status of this partner?
01 HIV negative
02 HIV positive
03 Do not know/unsure
98 Refuse to Answer
Form Approved:
OMB No. 0920-XXXX
Expiration Date:
3E.3 CSU
IMMEDIATE POST FOLLOW-UP ASSESSMENT
A. DEMOGRAPHICS
To begin the interview, I’d like to ask you some background questions. This lets us know something about the people who participate in the project. For the following questions, either check the appropriate box or fill in your answer in the spaces provided. Remember, your responses are will be kept private.
1. Are you currently employed?
1 = Full time
2 = Part time/ Occasional
3 = Unemployed
4 = Retired
5 = Unable to work (disabled)
6 = Prefer not to answer
2. Are you currently a full time or part time student?
1 = Full time
2 = Part time
3 = Not a student
= Prefer not to answer
Currently, who do you live with most of the time? (Check ALL that apply)
Alone
Parents
Friends
Other relatives
Partner, lover, or spouse
Your children
Other people not mentioned (please specify):_________________________________________
Do you think of yourself as…
1 = Heterosexual or "Straight"
2 = Homosexual or Gay or same gender loving
3 = Bisexual
4 = Unsure/ Questioning
5 = Other ______________________________
6 = None
= Prefer not to answer
16. What is the zip code of your current home or place where you stay? |_____|_____|_____|_____|___
777 Don’t Know
17. In the past 1 month, have ever spent one night without a regular place to stay? (a shelter, transitional housing facility, or a public or private place like a car or a park)
No Yes
Do you consider yourself to be currently homeless?
No Yes
B. HIV AND STD TESTING/HISTORY AND PERCEIVED RISK
Now we would like to ask some questions about your health. There are several diseases or infections that can be transmitted during sex. These are sometimes called venereal diseases or sexually transmitted diseases. We will be using the term sexually transmitted disease or STD to refer to them in the next few questions. Although HIV is a sexually transmitted disease, we will be asking you about it in a different part of this survey.
1. In the past 1 month, were you told by a health care provider, such as a doctor or nurse that you had any of the following sexually transmitted diseases?
Gonorrhea 0 No 1 Yes 777 Don’t Know
Syphilis 0 No 1 Yes 777 Don’t Know
Genital herpes 0 No 1 Yes 777 Don’t Know
Chlamydia 0 No 1 Yes 777 Don’t Know
Genital Warts (also known as HPV or Human Papilloma Virus)
0 No 1 Yes 777 Don’t Know
Hepatitis B virus 0 No 1 Yes 777 Don’t Know
Hepatitis C virus 0 No 1 Yes 777 Don’t Know
Some other STD, but not HIV (Please enter your answer here_____________)
0 No 1 Yes 77 Don’t Know
2. When was the last time you had a check-up for STDs or were tested for STDs. Do not include an HIV test in this answer. Was it…
___Within the past 30 days
___2-3 months ago
___4-6 months ago
___7-12 months ago
___1-2 years ago
___3 or more years ago
___I have never had a check-up or been tested for STDs
___777 Don’t know
___888 Prefer not to answer
You are now going to be asked some questions about your HIV status and about your experiences taking the HIV test. Please remember that this survey is kept private. It is for HIV-positive men as well as HIV-negative men.
3. Have you ever taken an HIV test?
___0 No (SKIP to….)
___1 Yes
___888 Prefer not to answer (SKIP to…)
4. When was your last HIV test? Please estimate if you are not exactly sure.
___ Within the past 30 days
___ 2-3 months ago
___ 4-6 months ago
___ 7-12 months ago
___ 1-2 years ago
___ 3 or more years ago
___ 777 Don’t know
___ 888 Prefer not to answer
5. What was the result of your last HIV test? (Choose one)
___1 HIV-Negative (Do not have HIV) (skip next two questions.)
___2 HIV-Positive (Do have HIV) Skip to #6.
___3 I did not get the result of my last test (go to next question)
___4 Inconclusive/Indetermnate (the result was neither positive or negative) (go to next question)
___888 Prefer not to answer
6. The last time you did get the results from an HIV test, what was your result? (Choose one) [Asked only of respondents who indicate answer choice 3 or 4 above]
___1 HIV-Negative (Do not have HIV)
___2 HIV-Positive (Do have HIV)
___3 I have never gotten any HIV test results
___888 Prefer not to answer
8. What was the month and year that you first tested positive for HIV? Please estimate if you are not exactly sure.
[Asked only of respondents who are HIV-positive]
__ __ / __ __ __ __ month year
___ 888 Prefer not to answer
If HIV-positive, skip to next section.
Perceived Risk for HIV
On a scale from 1 to 10, with 1 being (extremely unlikely) and 10 being extremely likely, . . .
9. How likely is it that you are infected with HIV now? _____
___ 88 Prefer not to answer
10. How likely do you think it is that you will become infected with HIV in your lifetime? _____
___ 88 Prefer not to answer
C. LACK of SUPPORT/ ALIENATION
Please indicate how much you agree or disagree with the following statements.
1. There is no one I can talk to about the important decisions in my life.
1 = Strongly agree
2 = Agree somewhat
3 = Disagree somewhat
4 = Strongly disagree
8 = Prefer not to answer
2. I feel no one respects who I am.
1 = Strongly agree
2 = Agree somewhat
3 = Disagree somewhat
4 = Strongly disagree
8 = Prefer not to answer
3. No one really understands my most private worries and fears.
1 = Strongly agree
2 = Agree somewhat
3 = Disagree somewhat
4 = Strongly disagree
8 = Prefer not to answer
4. There is no one I can depend on to lend me $50 if I needed it for an emergency.
1 = Strongly agree
2 = Agree somewhat
3 = Disagree somewhat
4 = Strongly disagree
8 = Prefer not to answer
5. I often feel isolated and alone.
1 = Strongly agree
2 = Agree somewhat
3 = Disagree somewhat
4 = Strongly disagree
8 = Prefer not to answer
D. DISCLOSURE
For each of the following statements, mark the response that best indicates your experience. Please be as honest as possible in your responses.
1----------2----------3-----------4----------5----------6----------7
Disagree Neither agree Agree
Strongly or disagree Strongly
I prefer to keep my sexual relationships rather private.
I keep careful control over who knows about my sexual relationships with men.
My sexual behavior is nobody's business.
If you are not careful about who you let know that you have sex with men, you can get very hurt.
I think very carefully before I let someone know that I have sex with other men.
My sexual orientation is a very personal and private matter.
E. IDENTITY/COMMUNITY AFFILIATION
The next few questions are about homosexual and bisexual men in the black community. Please indicate how strongly you agree or disagree with the following statements.
Integrated Race & Sexuality Scale (Scale limited to 4 items)
READ: Please indicate how strongly you agree or disagree with the following statements.
Black homosexual and bisexual men contribute to black communities.
1 Strongly Disagree
2 Disagree
3 Mildly Disagree
4 Mildly Agree
5 Agree
6 Strongly Agree
8 Prefer not to answer
Both my race and my sexuality are important to who I am as a man.
1 Strongly Disagree
2 Disagree
3 Mildly Disagree
4 Mildly Agree
5 Agree
6 Strongly Agree
8 Prefer not to answer
Black homosexual and bisexual men can play an important role in Black families.
1 Strongly Disagree
2 Disagree
3 Mildly Disagree
4 Mildly Agree
5 Agree
6 Strongly Agree
8 Prefer not to answer
A Black man who has sex with men can still be a strong man.
1 Strongly Disagree
2 Disagree
3 Mildly Disagree
4 Mildly Agree
5 Agree
6 Strongly Agree
8 Prefer not to answer
F. MENTAL HEALTH (BSI)
I am going to show you a list of problems and complaints that people sometimes have. For each one, tell me how much that problem has bothered or distressed you during the past week, including today. Please tell me whether each problem has bothered you not at all, a little bit, moderately, quite a bit, or extremely.
HOW OFTEN DO YOU EXPERIENCE . . .
1. Faintness or dizziness? (Choose one)
1 Not At All
2 A Little Bit
3 Moderately
4 Quite A Bit
5 Extremely
8 Refuse to Answer
2. Feeling no interest in things? (Choose one) 1 Not At All
2 A Little Bit
3 Moderately
4 Quite A Bit
5 Extremely
8 Refuse to Answer
3. Nervousness or shakiness inside? (Choose one) 1 Not At All
2 A Little Bit
3 Moderately
4 Quite A Bit
5 Extremely
8 Refuse to Answer
4. Pains in heart or chest? (Choose one) 1 Not At All
2 A Little Bit
3 Moderately
4 Quite A Bit
5 Extremely
8 Refuse to Answer
5. Feeling lonely? (Choose one) 1 Not At All
2 A Little Bit
3 Moderately
4 Quite A Bit
5 Extremely
8 Refuse to Answer
6. Feeling tense or keyed up? (Choose one) 1 Not At All
2 A Little Bit
3 Moderately
4 Quite A Bit
5 Extremely
8 Refuse to Answer
7. Nausea or upset stomach? (Choose one) 1 Not At All
2 A Little Bit
3 Moderately
4 Quite A Bit
5 Extremely
8 Refuse to Answer
8. Feeling blue or sad? (Choose one) 1 Not At All
2 A Little Bit
3 Moderately
4 Quite A Bit
5 Extremely
8 Refuse to Answer
9 Not Applicable
9. Being suddenly scared for no reason? (Choose one) 1 Not At All
2 A Little Bit
3 Moderately
4 Quite A Bit
5 Extremely
8 Refuse to Answer
10. Trouble getting your breath? (Choose one) 1 Not At All
2 A Little Bit
3 Moderately
4 Quite A Bit
5 Extremely
8 Refuse to Answer
11. Feelings of worthlessness? (Choose one) 1 Not At All
2 A Little Bit
3 Moderately
4 Quite A Bit
5 Extremely
8 Refuse to Answer
12. Episodes of terror or panic? (Choose one) 1 Not At All
2 A Little Bit
3 Moderately
4 Quite A Bit
5 Extremely
8 Refuse to Answer
13. Numbness or tingling in parts of your body? (Choose one) 1 Not At All
2 A Little Bit
3 Moderately
4 Quite A Bit
5 Extremely
8 Refuse to Answer
14. Feeling hopeless about the future? (Choose one) 1 Not At All
2 A Little Bit
3 Moderately
4 Quite A Bit
5 Extremely
8 Refuse to Answer
15. Feeling so restless that you could not sit still? (Choose one) 1 Not At All
2 A Little Bit
3 Moderately
4 Quite A Bit
5 Extremely
8 Refuse to Answer
16. Feeling weak in parts of your body? (Choose one) 1 Not At All
2 A Little Bit
3 Moderately
4 Quite A Bit
5 Extremely
8 Refuse to Answer
17. Thoughts of ending your life? (Choose one) 1 Not At All
2 A Little Bit
3 Moderately
4 Quite A Bit
5 Extremely
8 Refuse to Answer
18. Feeling fearful? (Choose one) 1 Not At All
2 A Little Bit
3 Moderately
4 Quite A Bit
5 Extremely
8 Refuse to Answer
Hostility Items
19. Feeling easily annoyed or irritated (Choose one)
1 Not at all
2 A little bit
3 Moderately
4 Quite a bit
5 Extremely
8 Prefer not to answer
20. ..temper outbursts that you could not control? (Choose one)
1 Not at all
2 A little bit
3 Moderately
4 Quite a bit
5 Extremely
8 Prefer not to answer
5 Extremely
8 Prefer not to answer
21. ....having urges to beat, injure, or harm someone? (Choose one)
1 Not at all
2 A little bit
3 Moderately
4 Quite a bit
5 Extremely
8 Prefer not to answer
22. ...having urges to break or smash things? (Choose one)
1 Not at all
2 A little bit
3 Moderately
4 Quite a bit
5 Extremely
8 Prefer not to answer
23. ...getting into frequent arguments? (Choose one)1 Not at all
2 A little bit
3 Moderately
4 Quite a bit
5 Extremely
8 Prefer not to answer
G. HIV STIGMA
The next set of questions asks about some of your feelings and opinions about HIV/AIDS. Please indicate how much you agree or disagree with the following statements:
1. People who have HIV or AIDS should be isolated from the rest of society.
1. Strongly Disagree
2. Disagree,
3. Agree
4. Strongly Agree
8. Prefer not to answer
2. People who have HIV or AIDS should only date other HIV positive people.
1. Strongly Disagree
2. Disagree,
3. Agree
4. Strongly Agree
8. Prefer not to answer
3. People who have HIV or AIDS are not sexually desirable.
1. Strongly Disagree
2. Disagree,
3. Agree
4. Strongly Agree
8. Prefer not to answer
4. People who have HIV or AIDS are more sexually promiscuous than most people.
1. Strongly Disagree
2. Disagree,
3. Agree
4. Strongly Agree
8. Prefer not to answer
5. The promiscuity of people who are gay is the reason why HIV/AIDS exists.
1. Strongly Disagree
2. Disagree,
3. Agree
4. Strongly Agree
8. Prefer not to answer
6. AIDS is a punishment from God.
1. Strongly Disagree
2. Disagree,
3. Agree
4. Strongly Agree
8. Prefer not to answer
H. TREATMENT OPTIMISM
The following section refers to combination treatments, “Drug Cocktails” or HAART for HIV/AIDS. Please indicate how much you agree with each statement.
____________
Strongly Somewhat Somewhat Strongly
Disagree Disagree Agree Agree
______
1. HIV positive persons who take HIV
medications are less likely to infect
their sex partners during unsafe sex. 1 2 3 4
2. New AIDS treatments make it
easier to relax about unsafe sex. 1 2 3 4
3. Men like me are less worried
about HIV because of new treatments. 1 2 3 4
4. My friends practice more unsafe
sex because of new HIV treatments.
1 2 3 4
5.It is safe to have anal sex without a condom
with an HIV positive man who has an
undetectable viral load. 1 2 3 4
I. DISCLOSURE FOR HIV-POSITIVE MEN
Self efficacy for disclosure of HIV status
The
following section asks questions about disclosing your HIV status to
sexual partners who are HIV-negative or who don’t know their
own HIV status. Remember, all of your answers are private.
8. I can disclose my HIV status before having sex, even to a really hot new sex partner.
1 = Absolutely sure I
cannot
2 = Somewhat sure I cannot
3 = Unsure if I can or
cannot
4 = Somewhat sure I can
5 = Absolutely sure I
can
9. I can disclose my HIV status before having sex, even to a really hot new sex partner who I think might be HIV negative.
1 = Absolutely sure I
cannot
2 = Somewhat sure I cannot
3 = Unsure if I can or
cannot
4 = Somewhat sure I can
5 = Absolutely sure I
can
10. I can disclose my HIV status before having sex even if my partner did not know I was HIV positive the first time we had sex.
1 = Absolutely sure I
cannot
2 = Somewhat sure I cannot
3 = Unsure if I can or
cannot
4 = Somewhat sure I can
5 = Absolutely sure I
can
11. I can disclose my HIV status before having sex even if I was worried that my partner wouldn't have sex with me if they knew.
1 = Absolutely sure I
cannot
2 = Somewhat sure I cannot
3 = Unsure if I can or
cannot
4 = Somewhat sure I can
5 = Absolutely sure I
can
12. I can disclose my HIV status before having sex even to a sex partner who hasn't told me their HIV status.
1 = Absolutely sure I
cannot
2 = Somewhat sure I cannot
3 = Unsure if I can or
cannot
4 = Somewhat sure I can
5 = Absolutely sure I
can
J. SOCIAL DESIRABILITY
Listed below are a few statements about your relationships with others. How much is each statement true or false for you?
1 = Definitely True
2 = Mostly True
3 = Don’t Know
4 = Mostly False
5 = Definitely False
8 = Prefer not to answer
1. I am always courteous, even to people who are disagreeable.
2. There have been occasions when I took advantage of someone.
3. I sometimes try to get even rather than forgive and forget.
4. I sometimes feel resentful when I don't get my way.
5. No matter who I’m talking to, I’m always a good listener.
Baseline Local Questions for Los Angeles
Developmental trajectories regarding sex/sexual sequences
I am going to ask you about early sexual desires and experiences.
1. At what age were you first sexually attracted to a female? ___ Years
0 I was never physically attracted to females
77 DK
88 Prefer not to answer
2. At what age did you first engage in each of the following sexual activities with a female?
Grinding/fondling/petting/rubbing ___ Years
0 Never 77 DK 88 Prefer not to answer
Kissing ___ Years
0 Never 77 DK 88 Prefer not to answer
Oral sex ___ Years
0 Never 77 DK 88 Prefer not to answer
Vaginal sex ___ Years
0 Never 77 DK 88 Prefer not to answer
Anal sex ___ Years
0 Never 77 DK 88 Prefer not to answer
3. At what age were you first sexually attracted to a male? ___ Years
0 I was never physically attracted to males
77 DK
88 Prefer not to answer
4. At what age did you first engage in each of the following sexual activities with a male?
Grinding/fondling/petting/rubbing ___ Years
0 Never 77 DK 88 Prefer not to answer
Kissing ___ Years
0 Never 77 DK 88 Prefer not to answer
Oral sex ___ Years
0 Never 77 DK 88 Prefer not to answer
Vaginal sex ___ Years
0 Never 77 DK 88 Prefer not to answer
Insertive anal sex (topping) ___ Years
0 Never 77 DK 88 Prefer not to answer
Receptive anal sex (bottoming) ___ Years
0 Never 77 DK 88 Prefer not to answer
5. At what age were you first sexually attracted to a male-to-female transgender?
___ Years
0 I was never physically attracted to transgenders
77 DK
88 Prefer not to answer
6. What age did you first engage in each of the following types of sexual activity with a male-to-female transgender?
Grinding/fondling/petting/rubbing ___ Years
0 Never 77 DK 88 Prefer not to answer
Kissing ___ Years
0 Never 77 DK 88 Prefer not to answer
Oral sex ___ Years
0 Never 77 DK 88 Prefer not to answer
Vaginal sex ___ Years
0 Never 77 DK 88 Prefer not to answer
Insertive anal sex (topping) ___ Years
0 Never 77 DK 88 Prefer not to answer
Receptive anal sex (bottoming) ___ Years
0 Never 77 DK 88 Prefer not to answer
7. At what age did you first identify as ____{list answer to #A15}? ___ Years
77 DK
88 Prefer not to answer
8. At what age did you first share with someone, other than a sexual partner, that you have had sex with males? ___ Years
77 DK
88 Prefer not to answer
9. Have you ever received instruction on how to properly put on a condom?
1 Yes
2 No
7 Don’t know
8 Prefer not to answer
(If YES to #9)
10. From where have you received instruction on proper condom use? Specify:_____________________________________________________
Additional Alcohol items
I am going to ask you some more questions about alcohol use.
1. How old were you when you first drank alcohol, not counting small tastes or sips of alcohol? ____ Years
0 - 76 = AGE
77 = Don't Know
88 = Prefer not Answer
99 = Not Applicable
2. About how old were you when you first became intoxicated or drunk from drinking alcohol? ____ Years
0 - 76 = AGE
77 = Don't Know
88 = Prefer not Answer
99 = Not Applicable
3. In the last 90 days, on a typical day when you drank alcohol, how many standard drinks did you have?
A standard drink is 12 oz regular beer, wine cooler, flavored beer; 8 oz of malt liquor beer; 5 ounces of table or sparkling wine, 3 ounces of fortified wine (includes dessert wines, ports, citrus wine), and 1.5 oz of hard alcohol or distilled spirit alone or with a mixer.
_______ # of drinks
77 = Don't Know
88 = Prefer not Answer
99 = Not Applicable
4. In the last 90 days, when you drank alcohol, how often was the beverage type {regular beer, wine cooler, flavored beer; malt liquor beer, table or sparkling wine, fortified wine, hard alcohol or distilled spirit} . . .?
For each beverage type:
4 Always
3 Often
2 Sometimes
1 Seldom
0 Never
7 Don’t know
8 Prefer not answer
Regular beer (such as Miller, Coors, Corona, . . .)
Malt liquor beer (such as Old English, Colt 45, . . .)
Premium or flavored beer or coolers (such as Smirnoff Ice and Seagram Coolers)
Table or sparkling wine (such chardonnay, merlot, etc.)
Fortified wine (include dessert wines, ports, citrus wine) (such as Cisco, Thunderbird, MD20-20 )
Hard alcohol or distilled spirits alone or with mixers (such as vodka, whisky, martinis, . . .)
Substance abuse during incarceration
SUBSTANCE USE
I am going to ask you some questions about your experience using substances while in jail or prison over the last 12 months. These substances can be smoked, swallowed, snorted, inhaled, or taken in the form of pills.
Please know that information on such use will be treated as strictly private.
|
Daily or Almost Daily |
Weekly |
Monthly |
Once or Twice |
Never |
1.Drink alcohol (including “pruno”)?
|
4 |
3 |
2 |
1 |
0 |
2. Smoke marijuana (weed, pot, etc.)?
|
4 |
3 |
2 |
1 |
0 |
3. Snort or sniff powder cocaine?
|
4 |
3 |
2 |
1 |
0 |
4. Smoke crack or rock cocaine?
|
4 |
3 |
2 |
1 |
0 |
5. Swallow, snort, bump or smoke methamphetamine (crystal meth, tina, crank, etc)?
|
4 |
3 |
2 |
1 |
0 |
6, Used poppers or inhaled nitrites?
|
4 |
3 |
2 |
1 |
0 |
7. Use club drugs (Ecstacy, GHB, Special K, etc.)?
|
4 |
3 |
2 |
1 |
0 |
8. Snort or smoke heroin?
|
4 |
3 |
2 |
1 |
0 |
9. Swallow, smoke or snort pills that were not prescribed to you? |
4 |
3 |
2 |
1 |
0 |
10. Other, Please specify _________________________
|
4 |
3 |
2 |
1 |
0 |
Additional Incarceration Items
I am going to ask you some more questions about times you may have been incarcerated.
During just the last 12 months, how many times have you been incarcerated (held in jail, prison, or detention)? _____ times
77 Don’t know
88 Prefer not answer
During just the last 12 months, about how much time have you spent in jail or prison or detention altogether? Days _______
Months _______
77 Don’t know
88 Prefer not answer
During the last 12 months, were you ever offered a voluntary HIV test during incarceration?
1 Yes
2 No, I did not receive any HIV test while incarcerated
3 No, but I was forced to take an HIV test
7 Don’t know
8 Prefer not to answer
During the last 12 months, did you participate in or receive any of the following services while incarcerated? (please select all that apply)
Group HIV prevention class
One-on-one discussions about HIV prevention
Testing for other sexually transmitted diseases
Reading HIV prevention brochures
Viewing HIV prevention videos
Receiving condoms
STD or HIV partner-notification services
Other, specify
77. Don’t know
88. Prefer not to answer
For clients who self-identify as HIV-positive, only:
5. During the last 12 months, did you participate in or receive any of the following services related to your HIV infection while incarcerated? (please select all that apply)
HIV antiretroviral treatment
HIV transitional case management
HIV treatment education
Other, specify
None of the above
77. Don’t know
88. Prefer not to answer
99. N/A, I was not diagnosed at or before my last incarceration
The next questions are about any time that you spent in jail or prison during the 12 months prior to today. Unless otherwise specified, sex refers vaginal, anal, or oral sex. It includes times in which you were forced or pressured into having sex with someone.
6. During the past 12 months, did you ever have sex with someone when you were in prison or jail?
1 = Yes
2 = No (Skip to #4)
8 = Prefer not Answer
7. During the past 12 months, who did you have sex with when in prison or jail? (please select all that apply)
1 = Men
2 = Women
3 = Transgender male to female
8 = Prefer not Answer
8. During the past 12 months, when you were in prison or jail, did you have . . .
a. Oral sex with anyone?
1 = Yes
2 = No
8 = Prefer not Answer
b. Vaginal or anal sex with a female staff member?
1 = Yes
2 = No
8 = Prefer not Answer
c. Anal sex with a male member?
1 = Yes
2 = No
8 = Prefer not Answer
Skip next item if c is NO.
d. The time(s) that you had sex with a male staff member, were you the . . .?
1 = top, the insertive partner
2 = bottom, the receptive partner
3 = both top and bottom
Skip next item if b and c are both NO
e. What were the reasons that you had sex with a staff member? Select all that apply.
To get commissary items
To get medications
To get contraband (eg. cell phones, drugs, cigarettes, weapons)
To get money
For pleasure
For protection
For access or privileges
Because of force or threat
Other, specify ________________________
8(cont) During the past 12 months, when you were in prison or jail, did you have . . .
f. Anal sex with a transgender inmate?
1 = Yes
2 = No
8 = Prefer not Answer
***Skip next item if ‘f’ is NO.
g. The time(s) that you had sex with a transgender inmate, were you the . . . ?
1 = top, the insertive partner
2 = bottom, the receptive partner
3 = both top and bottom
8(cont) During the past 12 months, when you were in prison or jail, did you have . . .
h. Anal sex with a male inmate?
1 = Yes
2 = No
8 = Prefer not Answer
********Skip next item if h is NO.
i. The time(s) that you had sex with a male inmate, were you the . . .?
1 = top, the insertive partner
2 = bottom, the receptive partner
3 = both top and bottom
j. What were the reasons that you had sex with an inmate? Select all that apply.
To get commissary items
To get medications
To get contraband (eg. cell phones, drugs, cigarettes, weapons)
To get money
For pleasure
For protection
For access or privileges
For support
Because of force or threat
Because of boredom
As part of gang-related initiation
Other, specify ________________________
During the past 12 months while you were in jail or prison, has anyone ever . . .
9. Touched you, felt you, or grabbed you in a way that you felt was sexually threatening?
Response categories: 1 = Yes
2 = No
= Prefer not Answer
10. Required or forced you to perform sexual acts (on them or someone else) as a way to protect yourself from current or future harm?
Response categories: 1 = Yes
2 = No
8 = Prefer not Answer
The final few questions are about your lifetime sexual experiences with men, women, or transgender women while in juvenile detention, jail, or prison. If you, did not have sexual contact with a person of that gender while incarcerated, select Not Applicable.
11. How old were you when you first had any sexual contact with a male while in juvenile detention, jail, or prison? ___ Years
77 DK
88 Prefer not to answer
99 NA, Never any sexual contact with a male while incarcerated
12. How old were you when you first had any sexual contact with a female while in juvenile detention, jail, or prison? ___ Years
77 DK
88 Prefer not to answer
99 NA, Never any sexual contact with a female while incarcerated
13. How old were you when you first had any sexual contact with a transgender woman while in juvenile detention, jail, or prison? ___ Years
77 DK
88 Prefer not to answer
99 NA, Never any sexual contact with a transgender woman while incarcerated
SEXUAL RISK
SEX WITH MALE PARTNERS
How many men did you have anal sex with in the past MONTH?
______ men (If 0 SKIP to SEX WITH FEMALE PARTNERS)
998 Refuse to Answer
2. How many times in the past MONTH did you top a male partner (put your penis in his butt) WITHOUT a condom?_______
3. How many times in the past MONTH did you top a male partner (put your penis in his butt) WITH a condom?_______
4. How many times in the past MONTH did you bottom for a male partner (he put his penis in your butt) WITHOUT a condom?_______
5. How many times in the past MONTH did you bottom for a male partner (he put his penis in your butt) WITH a condom?_______
6. The last time you had anal sex with a male partner in the past month, did you have sex without a condom?
01 Yes
00 No
98 Refuse to Answer
7. What was the HIV status of this partner?
01 HIV negative
02 HIV positive
03 Do not know/unsure
98 Refuse to Answer
SEX WITH FEMALE PARTNERS
How many women did you have vaginal or anal sex with in the past MONTH?
______ women (If 0 SKIP to SEX WITH TRANSGENDER PARTNERS)
998 Refuse to Answer
2. How many times in the past MONTH did you have vaginal or anal sex with a female partner WITHOUT a condom?_______
3. How many times in the past MONTH did you have vaginal or anal sex with a female partner WITH a condom?_______
4. The last time you had vaginal sex with a female partner in the past month, did you have sex without a condom?
01 Yes
00 No
98 Refuse to Answer
5. What was the HIV status of this partner?
01 HIV negative
02 HIV positive
03 Do not know/unsure
98 Refuse to Answer
SEX WITH TRANSGENDER PARTNERS
1. How many transgender partners did you have vaginal or anal sex with in the past MONTH?
______ transgender partners (If 0 SKIP to next section)
998 Refuse to Answer
2. How many times in the past MONTH did you have vaginal or anal sex with a transgender partner WITHOUT a condom?_______
3. How many times in the past MONTH did you have vaginal or anal sex with a transgender partner WITH a condom?_______
4. The last time you had vaginal sex with a transgender partner in the past month, did you have sex without a condom?
01 Yes
00 No
98 Refuse to Answer
5. What was the HIV status of this partner?
01 HIV negative
02 HIV positive
03 Do not know/unsure
98 Refuse to Answer
| File Type | application/msword |
| File Title | 3E: IMMEDIATE POSTTESTS BY SITE |
| Author | iqe6 |
| Last Modified By | Thelma Elaine Sims |
| File Modified | 2010-05-10 |
| File Created | 2010-05-10 |
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