Form 7 180-day Follow-up Interview

“Community-based Organization (CBO) Monitoring and Evaluation
Project of WILLOW (CMEP-WILLOW)”

Attachment 5c
180-Day Follow-up Survey

Form Approved
OMB No. 0920-XXXX
Exp. Date: XX/XX/20XX

“Community-based Organization (CBO) Monitoring and Evaluation Project of WILLOW (CMEPWILLOW)”

180-Day Follow-up Survey

Public reporting burden of this collection of information is estimated to average 18 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/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74,
Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).

CMEP-WILLOW 180-DAY FOLLOW-UP DATA COLLECTION: General Information
(to be completed by staff)
The following section will be completed by CMEP-WILLOW staff.

G1. Client ID: ___ ___ ___ ___ [QDS QA Check: This number cannot be longer than 4 digits]
G2. Staff ID: ____________
G3. Data collection date: __ __/__ __/__ __ __ __ [QDS Instructions: drop-down menu]
(MM/DD/YYYY)
G4. Data collection site: __________________
G5. Data administered by: (Choose one)
Client
Provider (in-person)
Provider (on phone)
G6. Data collection method: (Choose one)
Laptop
Handheld device
Hard copy
G7. In the past 3 months, have you… (Choose all that apply)
Participated in a face-to-face group discussion about HIV prevention, HIV testing or safer sex
practices
Participated in an on-line discussion about HIV prevention, HIV testing, or safer sex practices
Received condoms or a safe sex kit
Received HIV Case Management services
Received Partner Services
Received written information about HIV/AIDS or STDs
Received other HIV prevention services (if yes, specify ____________________)
Has not participated in discussions or received materials related HIV/AIDS or STDs
Decline to answer

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G8. In the past 3 months, has the client participated in any HIV prevention interventions (e.g., CDC
effective behavioral interventions [EBIs])? (Choose one)
Yes
No [QDS Skip: Skip to Q1]
Decline to answer
G9. If yes, which one(s)? (Choose all that apply) (Note: These interventions may be called a different name
at each agency)
Clear
Safe in the City
Connect
Safety Counts
Focus on Youth + IMPACT
SHIELD
Healthy Relationships
SIHLE
Holistic Health Recovery Program
SISTA
MIP
Sister to Sister
Partnership for Health
Street Smart
Popular Opinion Leader
Together Learning Choices
Project Start
VOICES/VOCES
PROMISE
WILLOW
RAPP
Other (specify): ___________________
RESPECT
Decline to answer

CMEP-WILLOW DATA COLLECTION: Client-level Data
(to be completed by client)
Thank you for agreeing to participate in this survey. This survey is about your attitudes and behaviors
regarding sex and sexually transmitted diseases (STDs). Many of the questions are very personal. Your
answers will be kept private. Please answer as honestly and openly as you can. Do not hesitate to ask if
you don’t understand a question or need help figuring out dates. There are no right or wrong answers.
Let’s get started.

Demographics
The first set of questions asks you to provide some general information about yourself.
1. *(G123) What was your sex at birth? (This is the biological sex on your birth certificate.) (Choose one)
Male
Female
Decline to answer
2. *(G124) How do you currently identify yourself? (Choose one)
Male
Female
Transgender – Male to female [QDS QA Check: If selected, include section about female partners]
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Transgender – Female to male
Other (Specify if your gender is not one of the choices above): _________________
Decline to answer
3. What is your current marital status? (Choose one)
Never married
Married
Separated
Divorced
Widowed
Decline to answer
4. Are you currently …? (Choose all that apply)
Employed for wages
Self-employed
Unemployed
Receiving unemployment benefits
Receiving public financial assistance (e.g., food stamps)
Receiving social security and/or disability
A homemaker
A student
Retired
Unable to work
Decline to answer

HIV & STD Testing, Medical Care, and Other HIV Services
The next set of questions is about your history with HIV and STD testing, medical care, and other HIV
services.
5. *(G208) Have you seen a primary health care provider (doctor, nurse, etc.) for HIV-related care in the
last 6 months? (Choose one)
Yes
No
Decline to answer
6. Have you been prescribed (anti-retroviral) medication for your HIV? (Choose one)
Yes
No [QDS Skip: If no, then skip to Q8]
Decline to answer
7. Have you been taking these HIV medications as directed over the last 6 months? (Choose one)
Yes
No
Decline to answer
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8. In the last 3 months (90 days), has a health care provider told you that you have/had any of the
following? (Choose all that apply)
Gonorrhea
Syphilis
Chlamydia
No, I have not been diagnosed with a STD in the last 3 months [QDS QA Check: If any of the first 3
are checked, this response should not be enabled]
Decline to answer [QDS QA Check: If any of the first 4 are checked, ‘Decline to Answer’ should not
be enabled]
9. Are you pregnant? (Choose one) [QDS QA Check: Do not ask if transgender male to female]
Yes
No [QDS Skip: Skip to Q11]
Don’t know [QDS Skip: Skip to Q11]
Decline to answer
10. Are you in prenatal care? (Choose one) [QDS QA Check: Do not ask if transgender male to female]
Yes
No
Decline to answer

Drug Use and Living Situation
The next of set questions are about your experience with drugs and your living situation.
11. In the last 3 months (90 days), have you injected drugs? (This includes illegal drugs and other
substances such as silicone, botox, hormones, etc.) (Choose one)
Yes
No [QDS Skip: Skip to Q13]
Decline to answer
12. In the last 3 months (90 days), how often did you share needles, syringes, or works? (That is, you let
someone else use your needles, syringes or works, or you borrowed someone else’s needles, syringes
or works to inject drugs.) (Choose one)
Never
Sometimes
Always
Decline to answer
13. In the last 3 months (90 days), were you homeless at any time? (That is, you slept in a shelter for
homeless people, on the streets, in a car, or another place not intended for sleeping. In other words,
you didn’t have a permanent address.) (Choose one)
Yes
No
Decline to answer
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14. In the last 3 months (90 days), were you in jail or prison for more than 24 hours? (Choose one)
Yes
No
Decline to answer

Sexual Risk Behaviors with Male Partners
The next series of questions will ask about sex you have had with a man. These questions are only
asking about vaginal or anal sex you have had with a man. They are NOT asking about oral sex
(giving/getting blow jobs or head).
Vaginal sex is when a man puts his penis in your vagina (hole in front). Anal sex is when a man puts his
penis into your anus (butt, hole in back). Condom use refers to the use of a male condom, unless a
female condom is mentioned.
Sex with Men in the Last 3 months (90 days)
The next questions ask about vaginal or anal sex you’ve had with men over the last 3 months (90 days).
Some of the questions will ask you to report numbers. If your answer is none, please enter 0 (zero).
15. In the last 3 months (90 days), have you had vaginal or anal sex with a man? (Choose one)
Yes
No [QDS Skip: If no, then only ask Q22-Q26, Q85-87, Q89-155]
Decline to answer

16. In the last 3 months (90 days), how many men have you had vaginal or anal sex with? (Choose one)
______# partners [QDS QA Check: If response = 0 prompt respondent that they answered Yes in Q15 to
having vaginal or anal sex with a male in the last 3 months; QDS QA Check: If Q16 ≥ 46 ask the respondent to
confirm]
Decline to answer

17. In the last 3 months (90 days), how many times have you had vaginal or anal sex with a man?
(Choose one)
______# times [QDS QA Check: Q17 ≥ Q16. If no, then tell respondent that the number of times must be
greater than or equal to the number of partners and have them verify Q16 and Q17; QDS QA Check: If
response = 0 prompt respondent that they answered Yes in Q15 to having anal sex with a male in the last 3
months]
Decline to answer

18. Of the (#) [QDS Instructions: Populate with Q17 # response] times you had vaginal or anal sex with a
man during the last 3 months, how many times did you use a condom? (Choose one)
______ # times [QDS QA Check: Q18 ≤ Q17. If no, then tell respondent that the number of times they used a
condom must be less than or equal to the number of times they had sex and have them verify Q17 and Q18;

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QDS QA Skip: If Q18 = Q17 or Q18 = 0, skip (do not ask) Qs 21, 28, 30, 32, 34, 36, 38, 40, 42, 44, 46, 48, 83, or
84]
Decline to answer

19. In the last 3 months (90 days), when you had vaginal or anal sex with a man, how often were you
drunk or high on drugs? (Choose one)
Never [QDS Skip: Skip to Q22]
Less than half the time
Half the time
More than half the time
All the time
Decline to answer

20. In the last 3 months (90 days), when you had vaginal or anal sex with a man while high or drunk,
which were you using? (Choose all that apply)
Amphetamines, meth, speed, crystal, ice or crank
Crack
Heroin (injected, smoked, or snorted)
Poppers (Amyl nitrate)
Painkillers (including Oxycontin, Percocet)
Downers (Valium, Ativan, Xanax)
Club drugs such as GHB (G), Ketamine (K)
Ecstasy (E)
Marijuana (pot)
Hallucinogens such as LSD (acid)
Cocaine (smoked, snorted, or injected)
Alcohol
Other: __________________
Decline to answer [QDS QA Check: If any of the first 13 are checked, ‘Decline to Answer’ should not be
enabled]

21. In the last 3 months (90 days), when you had vaginal or anal sex with a man while high or drunk,
how often did you use condoms? (Choose one)
Never
Sometimes
Always
Decline to answer

The next questions ask about vaginal and anal sex with your MALE primary/main and casual sexual
partners.
A primary/main partner is someone you have a special emotional connection with, live with, love,
and/or call your boyfriend/husband.
A casual partner is someone you have had sex with but do not consider to be a primary/main partner. A
casual partner may be someone you have had sex with one time or many times.
Some of the questions in this section will ask you to report numbers. If your answer is 0 (zero), please
enter 0 in the space provided.
22. Do you currently have a primary or main male partner? (Choose one)
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Yes
No [QDS QA Skip: Skip to Q27]
Decline to answer
23. How long have you been with your current primary or main male partner? (Choose one)
Less than 6 months
6 months to 1 year
1 to 5 years
Longer than 5 years
Decline to answer
24. Are you living with your primary or main male partner? (Choose one)
Yes
No
Decline to answer
25. Are you financially dependent on your primary or main male partner? (Choose one)
Yes
No
Decline to answer
26. Is your current primary or main male partner HIV-positive? (Choose one)
Yes
No
Don’t know
Decline to answer
27. In the last 3 months (90 days), how many of the (#) [QDS Instructions: Populate with Q16 # response]
men that you have had vaginal or anal sex with were primary/main partners? (Choose one)
______# primary/main partners [QDS QA Check: Q27 must be less than or equal to Q16. If not, then tell
client that the number of primary/main male partners must be less or equal to the total number of male
and ask them to confirm their answers to Q16 and Q27; QDS QA check If Q27 ≥ 10, refer respondent to the
definition of primary/main partner and ask them to confirm the number of primary/main partners; QDS QA
Check: If response = 0 skip to Q29]
Decline to answer

28. In the last 3 months (90 days), how often did you use condoms when having vaginal or anal sex with
your male primary/main partner(s)? (Choose one)
Never
Sometimes
Always
Decline to answer
29. In the last 3 months (90 days), how many of the (#) [QDS Instructions: Populate with Q16 # response]
men that you have had vaginal or anal sex with were casual partners? (Choose one)
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______# casual partners (If 0, enter 0) [QDS QA Check: Q27 + Q29 = Q16. If no, tell client that the number
of primary/main partners plus the number of casual partners must equal the total number of male partners.
Ask client to confirm Q16, 27, and 29; QDS QA Check: If response = 0 skip to Q31]
Decline to answer

30. In the last 3 months (90 days), how often did you use condoms when having vaginal or anal sex with
your male casual partner(s)? (Choose one)
Never
Sometimes
Always
Decline to answer

The next set of questions is about the characteristics of the male partners you’ve had vaginal or anal sex
with. Some of the questions will ask you to report numbers. If your answer is none, please enter 0
(zero) in the space provided.
31. In the last 3 months (90 days), did you have vaginal or anal sex with a male who had an HIV status
that was unknown to you? (Choose one)
Yes
No [QDS Skip: Skip to Q33]
Decline to answer

32. In the last 3 months (90 days), how often did you use condoms when you had a vaginal or anal sex
with your male partner(s) whose HIV status you didn’t or don’t know? (Choose one)
Never
Sometimes
Always
Decline to answer
33. In the last 3 months (90 days), did you have vaginal or anal sex with a male who was HIV-negative?
(Choose one)
Yes
No [QDS Skip: Skip to Q35]
Decline to answer

34. In the last 3 months (90 days), how often did you use condoms when you had vaginal or anal sex
with your male partner(s) who was HIV-negative? (Choose one)
Never
Sometimes
Always
Decline to answer
35. In the last 3 months (90 days), did you have vaginal or anal sex with a male only one time? (That is, a
one-night stand.) (Choose one)
Yes
No [QDS Skip: Skip to Q37]
Decline to answer
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36. In the last 3 months (90 days), how often did you use condoms when you had vaginal or anal sex
with your male partner(s) who you had vaginal or anal sex with only one time? (Choose one)
Never
Sometimes
Always
Decline to answer
37. In the last 3 months (90 days), did you have vaginal or anal sex with a male who was a stranger or
anonymous? (That is, you do not know their name and you have no way of contacting them.) (Choose
one)
Yes
No [QDS Skip: Skip to Q39]
Decline to answer

38. In the last 3 months (90 days), how often did you use condoms when you had vaginal or anal sex
with your anonymous male partner(s)? (Choose one)
Never
Sometimes
Always
Decline to answer
39. In the last 3 months (90 days), did a male sex partner give you money, drugs, a place to stay,
clothing, or something else you needed in exchange for vaginal or anal sex? (Choose one)
Yes
No [QDS Skip: Skip to Q41]
Decline to answer

40. In the last 3 months (90 days), how often did you use condoms when you had vaginal or anal sex
with a man who gave you money, drugs, a place to stay, clothing, or something else you needed in
exchange for vaginal or anal sex? (Choose one)
Never
Sometimes
Always
Decline to answer
41. In the last 3 months (90 days), did you give a male sex partner money, drugs, a place to stay,
clothing, or something else they needed in exchange for vaginal or anal sex? (Choose one)
Yes
No [QDS Skip: Skip to Q43]
Decline to answer

42. In the last 3 months (90 days), how often did you use condoms when you had vaginal or anal sex
with your male partner(s) who you gave money, drugs, a place to stay, clothing, or something else
they needed in exchange for vaginal or anal sex? (Choose one)
Never
9 of 27

Sometimes
Always
Decline to answer
43. In the last 3 months (90 days), did you have vaginal or anal sex with a male who you knew was an
injection drug user? (That is, they injected illegal drugs or other substances such as silicone, botox,
hormones, etc.) (Choose one)
Yes
No [QDS Skip: Skip to Q45]
Decline to answer

44. In the last 3 months (90 days), how often did you use condoms when you had vaginal or anal sex
with your male partner(s) who injected drugs? (Choose one)
Never
Sometimes
Always
Decline to answer
45. In the last 3 months (90 days), did you have vaginal or anal sex with a male who you knew had spent
more than 24 hours in jail?
Yes
No [QDS Skip: Skip to Q47]
Decline to answer

46. In the last 3 months (90 days), how often did you use condoms when you had vaginal or anal sex
with your male partner(s) who had spent more than 24 hours in jail? (Choose one)
Never
Sometimes
Always
Decline to answer
47. In the last 3 months (90 days), did you have vaginal or anal sex with a male who had a STD like
syphilis (syphpox), Chlamydia, or gonorrhea (clap)? (Choose one)
Yes
No [QDS Skip: Skip to Q83 unless Male to Female Transgender, then skip to Q49]
Decline to answer

48. In the last 3 months (90 days), how often did you use condoms when you had vaginal or anal sex
with your male partner(s) who had syphilis, Chlamydia, or gonorrhea? (Choose one)
Never
Sometimes
Always
Decline to answer

10 of 27

Sexual Risk Behaviors with Female Partners
[QDS Check: This section is only for Male to Female Transgender]
The next series of questions will ask about sex you have had with a woman. These questions are only
asking about vaginal or anal sex you have had with a woman. They are NOT asking about oral sex
(giving/getting blow jobs or head).
Vaginal sex is when you put a penis in a vagina (hole in front). Anal sex is when you puts a penis into an
anus (butt, hole in back). Condom use refers to the use of a male condom, unless a female condom is
mentioned.
Sex with Women in the Last 3 months (90 days)
The next questions ask about vaginal or anal sex you’ve had with women over the last 3 months (90
days). Some of the questions will ask you to report numbers. If your answer is none, please enter 0
(zero).
49. In the last 3 months (90 days), have you had vaginal or anal sex with a woman? (Choose one)
Yes
No [QDS Skip: If no, then only ask Q56-Q60, Q85-87, Q89-155]
Decline to answer

50. In the last 3 months (90 days), how many women have you had vaginal or anal sex with? (Choose
one)
______# partners [QDS QA Check: If response = 0 prompt respondent that they answered Yes in Q49 to
having vaginal or anal sex with a female in the last 3 months; QDS QA Check: If Q50 ≥ Q61 ask the
respondent to confirm]
Decline to answer

51. In the last 3 months (90 days), how many times have you had vaginal or anal sex with a woman?
(Choose one)
______# times [QDS QA Check: Q51 ≥ Q50. If no, then tell respondent that the number of times must be
greater than or equal to the number of partners and have them verify Q50 and Q51; QDS QA Check: If
response = 0 prompt respondent that they answered Yes in Q49 to having anal sex with a female in the last
3 months]
Decline to answer

52. Of the (#) [QDS Instructions: Populate with Q51 # response] times you had vaginal or anal sex with a
woman during the last 3 months, how many times did you use a condom? (Choose one)
______ # times [QDS QA Check: Q52 ≤ Q51. If no, then tell respondent that the number of times they used a
condom must be less than or equal to the number of times they had sex and have them verify Q51 and Q52;
QDS QA Skip: If Q52 = Q51 or Q52 = 0, skip (do not ask) Qs 55, 62, 64, 66, 68, 70, 72, 74, 76, 78, 80, 82, 83, or
84]
Decline to answer

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53. In the last 3 months (90 days), when you had vaginal or anal sex with a woman, how often were you
drunk or high on drugs? (Choose one)
Never [QDS Skip: Skip to Q56]
Less than half the time
Half the time
More than half the time
All the time
Decline to answer

54. In the last 3 months (90 days), when you had vaginal or anal sex with a woman while high or drunk,
which were you using? (Choose all that apply)
Amphetamines, meth, speed, crystal, ice or crank
Crack
Heroin (injected, smoked, or snorted)
Poppers (Amyl nitrate)
Painkillers (including Oxycontin, Percocet)
Downers (Valium, Ativan, Xanax)
Club drugs such as GHB (G), Ketamine (K)
Ecstasy (E)
Marijuana (pot)
Hallucinogens such as LSD (acid)
Cocaine (smoked, snorted, or injected)
Alcohol
Other: __________________
Decline to answer [QDS QA Check: If any of the first 13 are checked, ‘Decline to Answer’ should not be
enabled]

55. In the last 3 months (90 days), when you had vaginal or anal sex with a woman while high or drunk,
how often did you use condoms? (Choose one)
Never
Sometimes
Always
Decline to answer

The next questions ask about vaginal and anal sex with your FEMALE primary/main and casual sexual
partners.
A primary/main partner is someone you have a special emotional connection with, live with, love,
and/or call your girlfriend/wife.
A casual partner is someone you have had sex with but do not consider to be a primary/main partner. A
casual partner may be someone you have had sex with one time or many times.
Some of the questions in this section will ask you to report numbers. If your answer is 0 (zero), please
enter 0 in the space provided.
56. Do you currently have a primary or main female partner? (Choose one)
Yes
No [QDS QA Skip: Skip to Q61]
Decline to answer
57. How long have you been with your current primary or main female partner? (Choose one)
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Less than 6 months
6 months to 1 year
1 to 5 years
Longer than 5 years
Decline to answer
58. Are you living with your primary or main female partner? (Choose one)
Yes
No
Decline to answer
59. Are you financially dependent on your primary or main female partner? (Choose one)
Yes
No
Decline to answer
60. Is your current primary or main female partner HIV-positive? (Choose one)
Yes
No
Don’t know
Decline to answer
61. In the last 3 months (90 days), how many of the (#) [QDS Instructions: Populate with Q50 # response]
women that you have had vaginal or anal sex with were primary/main partners? (Choose one)
______# primary/main partners [QDS QA Check: Q61 must be less than or equal to Q50. If not, then tell
client that the number of primary/main female partners must be less or equal to the total number of
females and ask them to confirm their answers to Q50 and Q61; QDS QA check If Q61 ≥ 10, refer respondent
to the definition of primary/main partner and ask them to confirm the number of primary/main partners;
QDS QA Check: If response = 0 skip to Q63]
Decline to answer

62. In the last 3 months (90 days), how often did you use condoms when having vaginal or anal sex with
your female primary/main partner(s)? (Choose one)
Never
Sometimes
Always
Decline to answer
63. In the last 3 months (90 days), how many of the (#) [QDS Instructions: Populate with Q50 # response]
women that you have had vaginal or anal sex with were casual partners? (Choose one)
______# casual partners (If 0, enter 0) [QDS QA Check: Q61 + Q63 = Q50. If no, tell client that the number of
primary/main partners plus the number of casual partners must equal the total number of female partners.
Ask client to confirm Q50, Q61, and Q63; QDS QA Check: If response = 0 skip to Q65]
Decline to answer

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64. In the last 3 months (90 days), how often did you use condoms when having vaginal or anal sex with
your female casual partner(s)? (Choose one)
Never
Sometimes
Always
Decline to answer

The next set of questions is about the characteristics of the female partners you’ve had vaginal or anal
sex with. Some of the questions will ask you to report numbers. If your answer is none, please enter 0
(zero) in the space provided.
65. In the last 3 months (90 days), did you have vaginal or anal sex with a female who had an HIV status
that was unknown to you? (Choose one)
Yes
No [QDS Skip: Skip to Q67]
Decline to answer

66. In the last 3 months (90 days), how often did you use condoms when you had a vaginal or anal sex
with your female partner(s) whose HIV status you didn’t or don’t know? (Choose one)
Never
Sometimes
Always
Decline to answer
67. In the last 3 months (90 days), did you have vaginal or anal sex with a female who was HIV-negative?
(Choose one)
Yes
No [QDS Skip: Skip to Q69]
Decline to answer

68. In the last 3 months (90 days), how often did you use condoms when you had vaginal or anal sex
with your female partner(s) who was HIV-negative? (Choose one)
Never
Sometimes
Always
Decline to answer
69. In the last 3 months (90 days), did you have vaginal or anal sex with a female only one time? (That is,
a one-night stand.) (Choose one)
Yes
No [QDS Skip: Skip to Q71]
Decline to answer

70. In the last 3 months (90 days), how often did you use condoms when you had vaginal or anal sex
with your female partner(s) who you had vaginal or anal sex with only one time? (Choose one)
Never
Sometimes
14 of 27

Always
Decline to answer
71. In the last 3 months (90 days), did you have vaginal or anal sex with a female who was a stranger or
anonymous? (That is, you do not know their name and you have no way of contacting them.) (Choose
one)
Yes
No [QDS Skip: Skip to Q73]
Decline to answer

72. In the last 3 months (90 days), how often did you use condoms when you had vaginal or anal sex
with your anonymous female partner(s)? (Choose one)
Never
Sometimes
Always
Decline to answer
73. In the last 3 months (90 days), did a female sex partner give you money, drugs, a place to stay,
clothing, or something else you needed in exchange for vaginal or anal sex? (Choose one)
Yes
No [QDS Skip: Skip to Q75]
Decline to answer

74. In the last 3 months (90 days), how often did you use condoms when you had vaginal or anal sex
with a female who gave you money, drugs, a place to stay, clothing, or something else you needed in
exchange for vaginal or anal sex? (Choose one)
Never
Sometimes
Always
Decline to answer
75. In the last 3 months (90 days), did you give a female sex partner money, drugs, a place to stay,
clothing, or something else they needed in exchange for vaginal or anal sex? (Choose one)
Yes
No [QDS Skip: Skip to Q77]
Decline to answer

76. In the last 3 months (90 days), how often did you use condoms when you had vaginal or anal sex
with your female partner(s) who you gave money, drugs, a place to stay, clothing, or something else
they needed in exchange for vaginal or anal sex? (Choose one)
Never
Sometimes
Always
Decline to answer

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77. In the last 3 months (90 days), did you have vaginal or anal sex with a female who you knew was an
injection drug user? (That is, they injected illegal drugs or other substances such as silicone, botox,
hormones, etc.) (Choose one)
Yes
No [QDS Skip: Skip to Q79]
Decline to answer

78. In the last 3 months (90 days), how often did you use condoms when you had vaginal or anal sex
with your female partner(s) who injected drugs? (Choose one)
Never
Sometimes
Always
Decline to answer
79. In the last 3 months (90 days), did you have vaginal or anal sex with a female who you knew had
spent more than 24 hours in jail?
Yes
No [QDS Skip: Skip to Q81]
Decline to answer

80. In the last 3 months (90 days), how often did you use condoms when you had vaginal or anal sex
with your female partner(s) who had spent more than 24 hours in jail? (Choose one)
Never
Sometimes
Always
Decline to answer
81. In the last 3 months (90 days), did you have vaginal or anal sex with a female who had a STD like
syphilis (syphpox), Chlamydia, or gonorrhea (clap)? (Choose one)
Yes
No [QDS Skip: Skip to Q83]
Decline to answer

82. In the last 3 months (90 days), how often did you use condoms when you had vaginal or anal sex
with your female partner(s) who had syphilis, Chlamydia, or gonorrhea? (Choose one)
Never
Sometimes
Always
Decline to answer

Condom Use
This section will ask you about your experience using condoms when you were having vaginal or anal
sex.

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83. In the last 3 months (90 days), how often did the male condom break or slip off during sex while
your partner was pulling out? (Choose one)
Never
Sometimes
All the time
Don’t know
Decline to answer

84. In the last 3 months (90 days), how often did you use the male condom after you had started having
sex or take the condom off before you had finished having sex? (Choose one)
Never
Sometimes
All the time
Don’t know
Decline to answer

85. Did you use a male condom the last time you had vaginal or anal sex? (Choose one)
Yes
No
Decline to answer
86. Do you plan to use a male condom the next time you have vaginal or anal sex? (Choose one)
Yes
No
Decline to answer
87. In the next 3 months, do you plan on using a male condom every time you have vaginal or anal sex?
(Choose one)
Yes
No
Decline to answer
88. In the last 3 months, did you attempt to use a female condom? (Choose one)
Yes
No
I don’t know what a female condom is
Decline to answer
89. In the next 3 months, do you plan on using a female condom? (Choose one)
Yes
No
Decline to answer

Attitudes and Beliefs Toward Condom Use
The following statements are about your attitudes toward using male condoms.
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90. My partner would get mad if I said we had to use a condom. (Choose one)
Yes
No
Decline to Answer

91. My partner would think I was having sex with another person if I said we had to use a condom.
(Choose one)
Yes
No
Decline to Answer

92. Condoms ruin the mood. (Choose one)
Yes
No
Decline to Answer

93. Sex doesn’t feel as good when you use a condom. (Choose one)
Yes
No
Decline to Answer

94. Sex with male condoms doesn’t feel natural. (Choose one)
Yes
No
Decline to Answer

95. Using condoms breaks up the rhythm of sex. (Choose one)
Yes
No
Decline to Answer

96. Using condoms would help build trust between my partner and me. (Choose one)
Yes
No
Decline to Answer

Self-Efficacy about Negotiation and Condom Use
The next questions ask about which kinds of situations are more difficult for you to use condoms when
you have sex with your partner. Even if the situation has not happened to you, try to imagine how you
would handle it if it ever happened.
97. Can you discuss condom use with your partner? (Choose one)
Yes
Maybe
No
Decline to answer
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98. Can you insist on condom use if your partner does not want to use one? (Choose one)
Yes
Maybe
No
Decline to answer

99. Can you stop and look for condoms when you are sexually aroused? (Choose one)
Yes
Maybe
No
Decline to answer

100. Can you insist on condom use every time you have sex even when you are under the influence of
drugs or alcohol? (Choose one)
Yes
Maybe
No
Decline to answer

101. Can you insist on condom use every time you have sex even when your partner is under the
influence of drugs? (Choose one)
Yes
Maybe
No
Decline to answer

102. Can you insist on condom use every time you have sex even if you or your partner uses another
method to prevent pregnancy? (Choose one)
Yes
Maybe
No
Decline to answer

103. Can you put a condom on your partner without spoiling the mood? (Choose one)
Yes
Maybe
No
Decline to answer

Self-Efficacy about Using Condoms
The next questions are about your confidence in using condoms. Even if you’ve never used condoms
before, think about how confident you would be if you were to use them in the future.
HOW CONFIDENT (SURE) ARE YOU THAT YOU COULD…
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104. Put a condom on a hard penis. (Choose one)
Not at all
Somewhat
Very sure
Decline to answer

105. Unroll a condom down correctly on the first try. (Choose one)
Not at all
Somewhat
Very sure
Decline to answer

106. Start over with a new condom if you placed it on the wrong way. (Choose one)
Not at all
Somewhat
Very sure
Decline to answer

107. Unroll a condom fully to the base of the penis. (Choose one)
Not at all
Somewhat
Very sure
Decline to answer

108. Squeeze air from the tip of a condom. (Choose one)
Not at all
Somewhat
Very sure
Decline to answer

109. Take a male condom off without spilling the semen or cum. (Choose one)
Not at all
Somewhat
Very sure
Decline to answer

110. Take a male condom off before partner loses their hard on. (Choose one)
Not at all
Somewhat
Very sure
Decline to answer

111. Dispose of a used condom properly. (Choose one)
Not at all
Somewhat
Very sure
Decline to answer

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112. Use lubricant with a condom. (Choose one)
Not at all
Somewhat
Very sure
Decline to answer

Knowledge about HIV
The next questions are about your knowledge of HIV. Select “True” or “False.”
113. You have to take a test to know if you have HIV. (Choose one)
True
False
Decline to answer
114. A positive HIV test means that you have AIDS. (Choose one)
True
False
Decline to answer
115. Condoms can help protect you from transmitting or becoming infected with HIV. (Choose one)
True
False
Decline to answer
116. Having sex with someone who has HIV is the only way to get HIV. (Choose one)
True
False
Decline to answer
117. It is important to use a condom if both you and your partner have HIV. (Choose one)
True
False
Decline to answer
118. There are different types of HIV infections. (Choose one)
True
False
Decline to answer
119. Female condoms can stop you from getting HIV. (Choose one)
True
False
Decline to answer

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120. Having anal sex without a condom makes it easier to get HIV. (Choose one)
True
False
Decline to answer
121. Having a STD can make it easier to get HIV. (Choose one)
True
False
Decline to answer
122. Having a STD can make it harder to manage your HIV. (Choose one)
True
False
Decline to answer

Coping Style
There are a lot of things people can do when they have problems. These questions are about ways
you’ve dealt with your problems recently. Tell me how often you have done each of the below in the
last three months.
IN THE LAST 3 MONTHS, HAVE YOU…
123. Tried to keep your feelings to yourself? (Choose one)
Never
A few times
Lots of times
All of the time
Decline to answer
124. Tried to keep your feelings from interfering with other things too much? (Choose one)
Never
A few times
Lots of times
All of the time
Decline to answer
125. Tried to keep others from knowing how bad things are? (Choose one)
Never
A few times
Lots of times
All of the time
Decline to answer

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126. Wished the situation would go away? (Choose one)
Never
A few times
Lots of times
All of the time
Decline to answer
127. Hoped a miracle would happen? (Choose one)
Never
A few times
Lots of times
All of the time
Decline to answer
128. Drank alcohol to deal with your problems? (Choose one)
Never
A few times
Lots of times
All of the time
Decline to answer
129. Had sex to deal with your problems? (Choose one)
Never
A few times
Lots of times
All of the time
Decline to answer
130. Used drugs (other than alcohol) to deal with your problems? (Choose one)
Never
A few times
Lots of times
All of the time
Decline to answer
131. Thought your problems were no big deal? (Choose one)
Never
A few times
Lots of times
All of the time
Decline to answer

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132. Tried to forget about the whole thing? (Choose one)
Never
A few times
Lots of times
All of the time
Decline to answer
133. Gone on as if nothing had happened? (Choose one)
Never
A few times
Lots of times
All of the time
Decline to answer
134. Knew what had to be done, so you doubled your efforts to make things work? (Choose one.)
Never
A few times
Lots of times
All of the time
Decline to answer
135. Made a plan of action and followed it? (Choose one.)
Never
A few times
Lots of times
All of the time
Decline to answer
136. Just concentrated on what you had to do next? (Choose one)
Never
A few times
Lots of times
All of the time
Decline to answer
137. Talked to someone to find out more about the situation? (Choose one)
Never
A few times
Lots of times
All of the time
Decline to answer

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138. Talked to someone about your feelings? (Choose one.)
Never
A few times
Lots of times
All of the time
Decline to answer
139. Talked to someone who could help do something about the problem? (Choose one.)
Never
A few times
Lots of times
All of the time
Decline to answer
140. Rediscovered what is important in life? (Choose one.)
Never
A few times
Lots of times
All of the time
Decline to answer
141. Saw the situation as an opportunity to change or grow in a good way? (Choose one)
Never
A few times
Lots of times
All of the time
Decline to answer

Social Support Network
The next questions are about the people in your social network. Social network refers to the people
that you are connected to through different types of relationships, including your friends and family
members.
142. How many friends and/or family members loan you money, take care of you, or help you in an
emergency?
_________ (Enter total # of people, or 0 if none) [QDS Skip: If 0, skip to Q144]
Decline to answer

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143. How often do you talk to these people who loan you money, take care of you, or help you in an
emergency either on the phone or in-person? (Choose one)
About everyday
Twice a week
Once a week
Twice a month
Once a month or less
Decline to answer
144. How many friends and/or family members can you really talk to, rely on, and can understand you?
_________ (Enter total # of people, or 0 if none) [QDS Skip: If 0, skip to Q146]
Decline to answer
145. How often do you talk to these people whom you can really talk to, rely on, and who can understand you
either on the phone or in-person? (Choose one)
About everyday
Twice a week
Once a week
Twice a month
Once a month or less
Decline to answer
146. How many friends and/or or family members provide you with information or advice?
_________ (Enter total # of people, or 0 if none) [QDS Skip: If 0, skip to Q148]
Decline to answer
147. How often do you talk to these people who provide you with information or advice either on the phone
or in-person (Choose one)
About everyday
Twice a week
Once a week
Twice a month
Once a month or less
Decline to answer
148. How many friends and/or family members can you talk to about what it is like to have HIV?
_________ (Enter total # of people, or 0 if none) [QDS Skip: if 0, skip to Q150]
Decline to answer
149. How often do you talk to these people either on the phone or in-person? (Choose one)
About everyday
Twice a week
Once a week
Twice a month
Once a month or less
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Decline to answer
150. How many of the people in your life are domineering, try to tell you how to run your life, or give
unwanted advice?
_________ (Enter total # of people, or 0 if none) [QDS Skip: If 0, skip to Q152]
Decline to answer
151. How often do you talk to these people who are domineering, try to tell you how to run your life, or give
unwanted advice either on the phone or in-person? (Choose one)
About everyday
Twice a week
Once a week
Twice a month
Once a month or less
Decline to answer
152. How many friends and/or family members tell you that you should use a condom when you have sex?
_________ (Enter total # of people, or 0 if none) [QDS Skip: If 0, skip to Q154]
Decline to answer
153. How often do you talk on the phone or in-person to these people who tell you that should use a condom
when you have sex?
About everyday
Twice a week
Once a week
Twice a month
Once a month or less
Decline to answer
154. How many of your friends and/or family members tell you that you don’t need to wear a condom during
sex?
_________ (Enter total # of people)
Decline to answer [QDS Skip: If 0, skip to end of interview]
155. How often do you talk to these people either on the phone or in-person who tell you that you don’t need
to wear a condom during sex? (Choose one)
About everyday
Twice a week
Once a week
Twice a month
Once a month or less
Decline to answer

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