Clinic Survey - Eligible HIV-positive Individuals

Form Approved:

OMB No. 0920-new

Expiration Date: XX/XX/XXXX

Attachment 3d

Clinic Survey

Public reporting burden of this collection of information is estimated to average 40 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: CDC, Project Clearance Officer, 1600 Clifton Road, MS D-24, Atlanta, GA 30333, ATTN: OMB PRA (0920-XXXX). Do not send the completed form to this address.

General programming notes (additional programming notes are located throughout the questionnaire):

1. Every question should require a response to move forward in the application unless otherwise noted.

2. Use the following values: .D = 8, .R = 7, NA = 6.

3. Add a questionnaire type variable (one for the standard version and one for the short version).

4. For all “other-specify” variables in “check all that apply” questions, use the “other” variable name (which should end in “O”) and add an “S” on the end. If the variable name becomes too long, then drop the letter immediately preceding the consecutive letter at the end of the main part of the variable name. For example, if the “other” variable is named “KINDG_9O”(where KIND is the stem variable name and G denotes the lettered response option) the “specify” variable should be named “KING_9OS”

5. Programming notes are not included in the application; they are merely there to help with coding.

6. Interviewer instructions and inconsistency checks are notes for the interviewers, but may also include coding instructions.

7. Code book should have a brief description of the variable. This includes all calculated variables.

8. Calculate version number using variable name VERSION.

9. Calculate data collection cycle using variable name CYCYR. CYCYR = 2011.

10. For all date variables also create an automatic variable that is a copy of the date variable. For example, if the variable for date was called DATE, then the automatic variable would look like: a. variable name: TXFORM, b. type of date: String Expression, c. numeric calculation/string expression: DATE

11. Label module sections in the code book. Use the Table of Contents for guidance.

12. Calculate the time to conduct an interview from D1 to C13a or C13b.

13. Do not include the Response Cards and calendars in the program.

14. Distinguish between English and Spanish versions of the questionnaires (note this is different than the language variable used in the short questionnaire).

Preliminary Information

Interviewer instructions: Enter Preliminary Information prior to interview.

I1. Participant ID [PARID]:

Site ID [SITEID] ___ ___ ___ ___

Facility ID [FACILID] ___ ___ ___ ___

Respondent ID [INDID] ___ ___ ___ ___

Programming note:

Site ID, Facility ID, and Respondent ID all must be 4 digits with leading 0s. [PARID] is a 12 digit calculated variable based on [SITEID] + [FACILID] + [INDID]

I2. Interviewer ID: ___ ___ ___

[INTID]

Programming note for I2: Range 0-999

I2a. Handheld and computer device ID: ___ ___ ___

[DEVICEID]

Programming note for I2a: Range 0-999

I3. Interview setting: [CHECK ONLY ONE.] [INTSET]

Outpatient health facility  1

Inpatient health facility  2

Community-based organization  3

Private home  4

Public venue (i.e., coffee shop, library)  5

Other (Specify:_____________)  6 [INTSETOS]

I4. Interview date: __ __/ __ __ / __ __ __ __

[IDATE] ^{(M M / D D / Y Y Y Y)}

Programming notes for I4: Automatically calculate.

I5. Time questionnaire began: __ __:__ __  □ AM    □ PM

[STDEMO] Hour Minute

Programming notes for I5: Automatically calculate.

Demographics

SAY: “I'd like to thank you for taking part in this interview. Remember that all the information you give me will be kept secure to the extent permitted by law and your name won’t be recorded anywhere in this survey. The answers to some questions may seem obvious to you, but I need to ask you all of the questions.”

Programming note for Say box before D1: Use the word “computer” instead of “paper.”

D1. What is the highest level of education you completed? [DON’T READ CHOICES. CHECK ONLY ONE.] [EDUC]

Never attended school  1

Grades 1 through 8  2

Grades 9 through 11  3

Grade 12 or GED  4

Some college, associate’s degree, or technical degree  5

Bachelor’s degree  6

Any post–graduate studies  7

Refused to answer  77

Don’t know  88

D2. What language are you most comfortable using with your family and friends? [DON’T READ CHOICES. CHECK ONLY ONE.] [PRIM_LAN]

English  1

Spanish  2

French  3

Chinese  4

German  5

Tagalog  6

Vietnamese  7

Italian  8

Korean  9

Russian  10

Polish  11

Other (Specify:__________________________)  12 [PRIM_LAO] [PRI_LAOS]

Refused to answer  77

Don’t know  88

D3. Do you think of yourself as: [READ CHOICES EXCEPT “Other.” CHECK ONLY ONE.] [SEXOR8]

Homosexual, gay, or lesbian  1

Heterosexual or straight  2

Bisexual  3

Other (Specify:____________________)  4 [OTSEXOR] [SEXORIO8]

Refused to answer  7

Don’t know  8

SAY: “Now I’m going to ask you some questions about the past 12 months. That is from last year (DATE WITH PREVIOUS YEAR) to now (INTERVIEW DATE).”

Programming note for Say box before D4: The program should enter the appropriate dates. EXAMPLE: If IDATE is 11/11/2011 then the program should read “That is from last year, 11/11/2010 to now 11/11/2011.”

Interviewer instructions: Show respondent calendar.

	During the past 12 months, have you:	No (0)	Yes (1)	Refused (7)	Don’t know (8)
D4a.	…lived on the street? [HOMEL_9A]	0	1	7	8
D4b.	…lived in a shelter? [HOMEL_9B]	0	1	7	8
D4c.	…lived in a Single Room Occupancy (SRO) hotel? [HOMEL_9C]	0	1	7	8
D4d.	…lived in a car? [HOMEL_9D]	0	1	7	8

D5. During the past 12 months, have you been arrested and put in jail, detention, or prison for longer than 24 hours? [JAIL]

No  0

Yes  1

Refused to answer  7

Don’t know  8

D6. During the past 12 months, have you had any kind of health insurance or health coverage? This includes Medicaid and Medicare. [HTHINS_9]

No  0 Skip to D14

Yes  1

Skip to D14

Refused to answer  7

Don’t know  8

D6a. During the past 12 months, what were all the kinds of health insurance or health coverage you had? [DON’T READ CHOICES. CHECK ALL THAT APPLY.] [KINDI_9]

Private health insurance  1 [KINDI_A9]

Medicaid  2 [KINDI_B9]

Medicare  3 [KINDI_C9]

Ryan White  4 [KINDI_D9]

Tricare or CHAMPUS  5 [KINDI_E9]

Veterans Administration coverage  6 [KINDI_F9]

Other 1 (Specify:_______________)  7 [KIND_G9O] [KIN_G9OS]

Other 2 (Specify:_______________)  8 [KIND_H9O]

Other 3 (Specify:_______________)  9 [KIND_I9O]

Other 4 (Specify:_______________)  10 [KIND_J9O]

Refused to answer  77

Don’t know  88

D6b. During the past 12 months, was there a time that you didn’t have any health insurance or health coverage? [INS12_9]

No  0

Yes  1

Refused to answer  7

Don’t know  8

D7. During the past 12 months, where did most of your money or financial support come from? [DON’T READ CHOICES. CHECK ONLY ONE.] [SRC_IN_9]

Salary or wages  1

Savings or investments  2

Pension or retirement fund  3

Supplemental Security Income (SSI) or Social Security

Disability Insurance (SSDI)  4

Other public assistance (“welfare”)  5

Family, partner, or friend(s)  6

Skip to Say box before A1

Illegal or possibly illegal activities  7

No income or financial support  8

Other (Specify:_________________________________)  9 [SOIN_9O]

Refused to answer  77

Don’t know  88

Programming note for Say box before D8 and D8a: use the previous calendar year. EXAMPLE: If interview date is 12-01-11, ask about 2010; if interview date is 12-01-12, ask about 2011.

SAY: “Now I would like to ask you some questions about 2010 (2011). That is January 1st, 2010 (2011) to December 31st, 2010 (2011).”

Interviewer instructions: Show respondent calendar.

D81. In 2010 (2011), what was your combined monthly or yearly household income from all sources before taxes? When I say “combined household income,” I mean the total amount of money from all people living in the household. [DON’T READ CHOICES.]

Interviewer instructions: Show Response Card A.

SAY: “Please take a look at this card and tell me the letter that corresponds to either your monthly or yearly household income before taxes.”

Monthly Income [MTHLY_IN] Yearly Income [YRLY_IN]

a.	$0 to $417	a.	$0 to $4,999
b.	$418 to $833	b.	$5,000 to $9,999
c.	$834 to $1250	c.	$10,000 to $14,999
d.	$1251 to $1667	d.	$15,000 to $19,999
e.	$1668 to $2500	e.	$20,000 to $29,999
f.	$2501 to $3333	f.	$30,000 to $39,999
g.	$3334 to $4167	g.	$40,000 to $49,999
h.	$4168 to $6250	h.	$50,000 to $74,999
i.	$6251 or more	i.	$75,000 or more
77	Refused to answer	77	Refused to answer
88	Don’t know	88	Don’t know

Programming note for D11: Consult with Nova how to code this question.

D8a. Including you, how many people depended on this income in 2010 (2011)? [DEPND_IN]

___ ___ [77 = Refused to answer, 88 = Don’t know]

Inconsistency check: D8a must be ≥ 1 and < 50.

Access to Care

HIV Testing and Care Experiences

SAY: “Now I’m going to ask you some questions about getting tested for HIV.”

A1. What month and year did you first test positive for HIV? Tell me when you got your result, not when you got your test. [POS1S_9]

__ __/ __ __ __ __

^{(M M / Y Y Y Y )} [Month: 77 = Refused to answer, 88= Don’t know;

Year: 7777 = Refused to answer, 8888 = Don’t know]

Inconsistency check: A1 (date first tested positive for HIV) cannot be earlier than D2 (respondent’s date of birth). If A1 is earlier than March 1985, confirm response.

Programming note for inconsistency check after A1: If A1 is earlier than 03/1985, display note to the interviewer: “The date entered is earlier than 03/1985 (date of first FDA-approved HIV test). Confirm date of HIV test.” Program should move forward regardless of date. Allow a “??” response for month response.

Interviewer instructions: If A1 is “Refused to answer,” “Don’t know,” or the month is unknown (??), skip to A6.

Interviewer instructions: If A1 (date first tested positive for HIV) is 5 years or less than April 30, 2011, go to A2; otherwise skip to A6.

A2. When you tested positive in __ __ /__ __ __ __ [INSERT DATE FROM A1], at what type of facility were you tested? [DON’T READ CHOICES. CHECK ONLY ONE.] [TESLOC_9]

Private doctor’s office  1

Primary care clinic or community health center  2

Health department  3

Labor/delivery setting  4

OBGYN or family planning clinic  5

Emergency room  6

Inpatient hospital (not labor/delivery or emergency room)  7

HIV counseling and testing site  8

STD clinic  9

HIV/AIDS infectious disease clinic  10

Mobile test site  11

Correctional facility  12

Blood donation facility  13

Substance abuse treatment center  14

Insurance or employee clinic  15

Military or VA facility  16

Other (Specify:___________________________________) 17 [TESL9_OS]

Refused to answer  77

Don’t know  88

Inconsistency check: Confirm response if A2 (testing location) is “labor/delivery setting” or “OBGYN or family planning clinic” and ES7 (sex at birth) is “male”.

Programming note for A2: Insert date in question. If A2 is “labor/delivery setting” or “OBGYN or family planning clinic” and ES7 (sex at birth) is “male,” display the following message: “Respondent said he was first tested in a labor/delivery setting or OBGYN or family planning clinic. Confirm response.” Allow the program to advance.

A2a. When you tested positive in __ __ /__ __ __ __ [INSERT DATE FROM A1], what was the main reason you were tested? [DON’T READ CHOICES. CHECK ONLY ONE.] [MRTEST_9]

Concerned about exposure through sexual contact  1

Concerned about exposure through IDU  2

Part of STD screening or due to STD diagnosis  3

Due to other illness (not STD)  4

Due to pregnancy  5

Personal initiative to routinely test  6

Provider recommendation as part of routine care  7

Health department partner notification (PCRS)  8

Before blood donation  9

Needle stick follow-up or occupational exposure  10

Requirement (military, court order, or insurance).  11

Other (Specify:___________________________________)  12 [MRTE_9OS]

Refused to answer  77

Don’t know  88

Programming note for A2a: Insert date from A1 in question.

Inconsistency check: A2a (main reason tested) cannot be “due to pregnancy” if ES7 (sex at birth) is “male”.

Programming note for inconsistency check after A2a: If ES7 is “male” and response to A2a is “due to pregnancy”, display note to interviewer: “Main reason tested cannot be due to pregnancy if respondent was born male.” Do not allow the program to advance.

A3. After you tested positive in __ __/__ __ __ __ [INSERT DATE FROM A1], did someone from the health department or a health care provider offer to tell or help you tell your sex or drug use partners that they may have been exposed to HIV? [PARTNO_9]

Skip to Say box before A5

No  0

Yes  1

Skip to Say box before A5

Not applicable  6

Refused to answer  7

Don’t know  8

A3a.     Before you tested positive in __ __/__ __ __ __ [INSERT DATE FROM A1], were you ever contacted by the health department or a health care provider to tell you that you may have been exposed to HIV through your sex or drug use partners? [PARTNO_CON]

Skip to Say box before A5

No...........................................................................................  0

Yes..........................................................................................  1

Skip to Say box before A5

Not applicable..........................................................................  6

Refused to answer...................................................................  7

Don’t know..............................................................................  8

A3b.     Is there anyone you know who needs an HIV test? [HIV_KNOW]

Skip to Say box before A5

........... No..........................................................................................  0

........... Yes.........................................................................................  1

Skip to Say box before A5

........... Not applicable........................................................................  6

........... Refused to answer.................................................................  7

........... Don’t know............................................................................  8

A3c.     Do you have any sex or drug use partners now who need to be notified? [PART_NOTIFY]

Skip to Say box before A5

........... No..........................................................................................  0

........... Yes.........................................................................................  1

Skip to Say box before A5

........... Not applicable........................................................................  6

........... Refused to answer.................................................................  7

........... Don’t know............................................................................  8

Programming note for A3: Insert date from A1 in question.

SAY: “Now I’m going to ask you about HIV medical care. When I say ‘HIV medical care,’ I mean physical exams, prescriptions for HIV medicines, or lab tests such as HIV viral load and CD4 testing.”

A4. Since testing positive for HIV, what month and year did you first visit a doctor, nurse, or other health care worker for HIV medical care? [CARE_9]

__ __/ __ __ __ __

^{(M M / Y Y Y Y )} [Month: 77 = Refused to answer, 88= Don’t know;

Year: 7777 = Refused to answer, 8888 = Don’t know]

Inconsistency check: Confirm response if A4 (date first went to provider for HIV care) is earlier than the A1 (date first tested positive for HIV).

Programming note for inconsistency check after A4: If A4 is earlier than A1, display note to interviewer: “The date entered is earlier than the date first tested positive for HIV care. Go back to previous question to confirm the date.” Allow the program to advance.

Interviewer instructions: If A4 (date first went to provider for HIV care) is > 3 months after A1 (date first tested positive for HIV), go to A5; otherwise, skip to A6. If A4 is “Refused to answer,” “Don’t know,” or an unknown month (??), skip to A6.

A5. What was the main reason you didn’t go to a doctor, nurse, or other health care worker for HIV medical care within 3 months of testing positive for HIV? [DON’T READ CHOICES. CHECK ONLY ONE.] [MRNOCA_9]

Felt good  1

Initial CD4 count and viral load were good  2

Didn’t believe test result  3

Didn’t want to think about being HIV positive  4

Didn’t have enough money or health insurance  5

Had other responsibilities such as child care or work  6

Experienced homelessness  7

Was drinking or using drugs  8

Felt sick  9

Forgot to go  10

Missed appointment(s)  11

Moved or out of town  12

Unable to get transportation  13

Facility is inconvenient (location, facility hours, wait-time)  14

Didn’t know where to go  15

Couldn’t find the right HIV health care provider  16

Unable to get earlier appointment  17

Unaware of recommendation to enter care within 3 months  18

Other (Specify:________________________________)  19 [MRNO_9OS]

Refused to answer  77

Don’t know  88

A6. Apart from your visit today, when was your most recent visit to a doctor, nurse, or other health care worker for HIV medical care? Please tell me the month and year. [LASCA_9]

__ __/ __ __ __ __

^{(M M / Y Y Y Y )} [Month: 77 = Refused to answer, 88= Don’t know;

Year: 7777 = Refused to answer, 8888 = Don’t know]

Inconsistency check: A6 (date of most recent visit to a provider for HIV care) cannot be earlier than A4 (date first visit to a provider for HIV care) or later than I4 (interview date).

Programming note for A6: Allow a “??” for month response.

Interviewer instructions: If A6 (date of most recent visit to a provider for HIV care) is > 6 months prior to I4 (interview date), go to A6a; otherwise, skip to Say box before A7. If A6 is “Refused to answer,” “Don’t know,” or an unknown month (??), skip to Say box before A7.

A6a. What was the main reason you didn’t visit a doctor, nurse, or other health care worker for HIV medical care during the past 6 months? [DON’T READ CHOICES. CHECK ONLY ONE. SHOW CALENDAR.] [MRNOC_10]

Felt good  1

CD4 count and viral load were good  2

Didn’t believe test result  3

Didn’t want to think about being HIV positive  4

Didn’t have enough money or health insurance  5

Had other responsibilities such as child care or work  6

Experienced homelessness  7

Was drinking or using drugs  8

Felt sick  9

Forgot to go  10

Missed appointment(s)  11

Moved or out of town  12

Unable to get transportation  13

Facility is inconvenient (location, facility hours, wait-time)  14

Didn’t know where to go  15

Couldn’t find the right HIV health care provider  16

Unable to get earlier appointment  17

Other (Specify:________________________________)  18 [MRN_10OS]

Refused to answer  77

Don’t know  88

Interviewer instructions: If participant was diagnosed with HIV infection in past three months, ask question A6b. If not, skip to say box before A7.

SAY: “You indicated you were recently diagnosed with HIV infection .”

A6b. What is the main reason that you came to visit a doctor, nurse, or other health care worker for HIV medical care soon after testing positive for HIV?  [DON’T READ CHOICES.  CHECK ONLY ONE.]

Wanted to get on treatment for HIV infection.....................  1

Facility was convenient.........................................................  2

I felt sick and needed care.....................................................  3

Aware of the recommendations to get care within 3 months  4

Had assistance (case manager, peer navigator)......................  5

            Other (Specify:________________________________)       6

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

Don’t know............................................................................  88

Sources of Care

SAY: “Now I’m going to ask you about the places where you get HIV medical care. If you don’t remember everything, that’s okay. Tell me what you remember.”

A7. During the past 12 months, was there one usual place, like a doctor’s office or clinic, where you went for most of your HIV medical care? [PLCARE_9]

No  0

Yes  1

Skip to instructions before A9

Refused to answer  7

Don’t know  8

A8. What was the main reason you didn’t have a usual place to get HIV medical care during the past 12 months? [READ CHOICES. CHECK ONLY ONE.] [UC_RS_10]

Couldn’t afford a usual source of HIV care  1

Didn’t know where to find a usual source of HIV care  2

Couldn’t get regular appointments anywhere  3

It wasn’t available in the area  4

Didn’t think it was necessary  5

Thought it was necessary, but never tried to get a usual

source of care  6

Other (Specify:___________________________________)  7 [UC_R10OS]

Refused to answer  77

Don’t know  88

Interviewer instructions: If ES7 (birth gender) and ES8 (self-identified gender) are “female,” go to A9; otherwise, skip to A10.

A9. During the past 12 months, have you received HIV care at an OBGYN or gynecological clinic? [GYNECARE]

No  0

Yes  1

Refused to answer  7

Don’t know  8

A10. During the past 12 months, did you get HIV medical care while in jail, detention, or prison? [JAIL_CAR]

No  0

Yes  1

Refused to answer  7

Don’t know  8

Participant indicated he/she has not been in jail, detention, or prison in last 12 months…  9

A11. During the past 12 months, has anyone tried to help you see a health care provider to get

HIV medical care? [GET_CARE]

Skip to A15

No  0

Yes  1

Skip to A15

Refused to answer  7

Don’t know  8

A11a. Who was that person or persons? [CHOOSE ALL THAT APPLY.] [PERSON_CAR]

A counselor  1

A social worker  2

A case manager or other professional  3

A family member or friend  4

Other (Specify:___________________________________)  5 [PERSONCAR_11OS]

Refused to answer  7

Don’t know  8

A12. During the past 12 months, has anyone tried to help you keep regular appointments with

a health care provider to take care of your HIV infection? [APPT_KEEP]

Skip to A16

No  0

Yes  1

Skip to A16

Refused to answer  7

Don’t know  8

A12a. Who was that person or persons? [CHOOSE ALL THAT APPLY.] [PERSON_KEEP]

A counselor  1

A social worker  2

A case manager or other professional  3

A family member or friend  4

Other (Specify:___________________________________)  5 [PERSONKEEP_11OS]

Refused to answer  7

Don’t know  8

SAY: “Now I’m going to ask you about general medical care. When I say, ‘general medical care,’ I mean care for any sort of medical problem.”

A13. During the past 12 months, was there one usual place, like a doctor’s office or clinic, where you went for most of your general medical care? [OCAREL_9]

No  0

Yes  1

Refused to answer  7

Don’t know  8

A14. During the past 12 months, how many times did you go to an emergency room or urgent care center for HIV medical care? [ERU_VI_9]

___ ___ [77 = Refused to answer, 88 = Don’t know]

Inconsistency check: A14 (number of times the respondent visited the emergency room or urgent care center for HIV care) must be ≤ 76.

A15. During the past 12 months, how many times were you admitted to a hospital because of an HIV-related illness? (Please don’t include visits that were made only to

the emergency room.) [HOSP]

___ ___ [77 = Refused to answer, 88 = Don’t know] If answer is 00, skip to A17.

A16. During the past 12 months, how many total days did you spend in a hospital because of an HIV-related illness? [HOSPDAY]

___ ___ [77 = Refused to answer, 88 = Don’t know]

A17. During the past 12 months, were you enrolled in an inpatient mental health facility? [ADMENH_9]

No  0

Yes  1

Refused to answer  7

Don’t know  8

A18. During the past 12 months, were you enrolled in an inpatient drug or alcohol treatment

facility? [ADDRAL_9]

No  0

Yes  1

Refused to answer  7

Don’t know  8

Met and Unmet Needs

SAY: “Now I’m going to ask about services you used or needed during the past 12 months. Remember, the past 12 months is last year (DATE WITH PREVIOUS YEAR) to now (INTERVIEW DATE).”

Programming note for Say box before met and unmet need questions: The program should enter the appropriate dates. EXAMPLE: If IDATE is 11/11/2011 then the program should read “That is from last year, 11/11/2010 to now 11/11/2011.”

Interviewer instructions: Show Response Card B. If response to A19a is “No,” “Refused to answer,” or “Don’t know,” go to A19b; otherwise, skip to A20a. If response to A19b is “Yes,” go to A19c; otherwise, skip to A20a. Follow the same pattern for A19–A35.

		During the past 12 months, did you get:	IF “NO” IN A19a–A35a ASK: During the past 12 months, have you needed:	IF “YES” IN A19b-A35b ASK: What was the main reason you haven’t been able to get this service during the past 12 months?
		CODE: No = 0, Yes = 1, Refused to answer = 7, Don’t know = 8	CODE: No = 0, Yes = 1, Refused to answer = 7, Don’t know = 8	CODE: SEE CODE LIST BELOW FOR RESPONSES. [DON’T READ CHOICES. CHECK ONLY ONE.]
A19.	HIV case management services	a. [______] [HIVC12_9]	b. [______] [HIVCMS_9]	[______] [HIVCRS_9] Other (Specify:________) [HIVC_9OS]
A20.	Counseling about how to prevent the spread of HIV	a. [______] [HIVE12_9]	b. [______] [HIVEDU_9]	[______] [HIVERS_9] Other (Specify:________) [HIVE_9OS]
Interviewer instructions: If applicable, use the state program name for ADAP when asking A22 (medicine through ADAP).
A21.	Medicine through the AIDS Drug Assistance Program (ADAP)	a. [______] [GET_ADAP]	b. [______] [NED_ADAP]	[______] [RS_ADAP] Other (Specify:________) [RS_A_9OS]
A22.	Professional help remembering to take your HIV medicines on time or correctly	a. [______] [ASS12_9]	b. [______] [ASS_9]	[______] [ASSRS_9] Other (Specify:________) [ASSR_9OS]
A23.	HIV peer group support	a. [______] [GET_GRP]	b. [______] [NED_GRP]	[______] [RS_GRP] Other (Specify:________) [RS_G_9OS]
A24.	Dental care	a. [______] [DENS12_9]	b. [______] [DENSER_9]	[______] [DENSRS_9] Other (Specify:________) [DENS_9OS]
A25.	Mental health services	a. [______] [MENC12_9]	b. [______] [MENCON_9]	[______] [MENCRS_9] Other (Specify:________) [MENC_9OS]
A26.	Drug or alcohol counseling or treatment	a. [______] [GET_SUBU]	b. [______] [NED_SUBU]	[______] [RS_SUBU] Other (Specify:________) [RS_U_9OS]
A27.	Public benefits including Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI)	a. [______] [GET_SSDI]	b. [______] [NED_SSDI]	[______] [RS_SSDI] Other (Specify:________) [RS_S_9OS]
A28.	Domestic violence services	a. [______] [GET_DOMS]	b. [______] [NED_DOMS]	[______] [RS_DOMS] Other (Specify:________) [RS_D_9OS]
A29.	Shelter or housing services	a. [______] [SHLT12_9]	b. [______] [SHLTER_9]	[______] [SHLTRS_9] Other (Specify:________) [SHLT_9OS]
A30.	Meal or food services	a. [______] [MLSF12_9]	b. [______] [MLSFOD_9]	[______] [MLSFRS_9] Other (Specify:________) [MLSF_9OS]
A31.	Home health services	a. [______] [HHSA12_9]	b. [______] [HHSASS_9]	[______] [HHSARS_9] Other (Specify:________) [HHSA_9OS]
A32.	Transportation assistance	a. [______] [TRAS12_9]	b. [______] [TRASAS_9]	[______] [TRASRS_9] Other (Specify:________) [TRAS _9OS]
A33.	Childcare services	a. [______] [CHLD12_9]	b. [______] [CHLDCR_9]	[______] [CHLDRS_9] Other (Specify:________) [CHLD_9OS]
A34.	Interpreter services	a. [______] [GET_INTS]	b. [______] [NED_INTS]	[______] [RS_INTS] Other (Specify:________) [RS_I_9OS]
A35.	Other HIV-related services	a. [______] [OTHS12_9] If “Yes,” then ask: Other 1 (Specify:________) [OTHSP_91] Other 2 (Specify:________) [OTHSP_92] Other 3 (Specify:________) [OTHSP_93] Other 4 (Specify:________) [OTHSP_94]	b. [______] [OTHSER_9] If “Yes,” then ask: Other 1 (Specify:________) [OTHSE_91] Other 2 (Specify:________) [OTHSE_92] Other 3 (Specify:________) [OTHSE_93] Other 4 (Specify:________) [OTHSE_94]	Other 1 ca. [______] [OTHSR1_9] Other 1 (Specify:________) [O112_9OS] Other 2 cb. [______] [OTHSR2_9] Other 2 (Specify:________) [O212_9OS] Other 3 cc. [______] [OTHSR3_9] Other 3 (Specify:________) [O312_9OS] Other 4 cd. [______] [OTHSR4_9] Other 4 (Specify:________) [O412_9OS]

Code list for A19c–A35c

1 Didn’t know where to go or whom to call

2 In process of getting the service

3 Waiting list is too long

4 Service isn’t available

5 Not eligible or denied services

6 Transportation problems

7 Service hours are inconvenient

8 Service costs too much/lack of insurance

9 Language barrier

10 Too sick to get service

11 Psychological barrier

12 Other (Specify:____________________)

77 Refused to answer

88 Don’t know

HIV Treatment and Adherence

SAY: “Now I’m going to ask some questions about medicines that you are taking for your HIV. These medicines are called antiretrovirals, also known as ART or HAART.”

T1. Have you ever taken any antiretroviral medicines for your HIV? [ANTIRE_9]

No………………….…………………..……  0

Yes………………………………………..……  1 Skip to T3

Skip to T19

Refused to answer……………………………  7

Don’t know…..........  8

T2. What is the main reason you have never taken any antiretroviral medicines? [DON’T READ RESPONSES. CHECK ONLY ONE.] [NANTRE_9]

Doctor advised to delay treatment  1

Participant believed he/she didn’t need medications because

felt healthy or believed HIV laboratory results were good  2

Due to side effects of medication  3

Felt depressed or overwhelmed  4

Didn’t want to think about being HIV positive  5

Worried about ability to adhere  6

Drinking or using drugs  7

Money or insurance issues  8

Homeless  9

Taking alternative or complementary medicines  10

Other (Specify:______________________________)  11 [NANT_9OS]

Refused to answer  77

Don’t know  88

Interviewer instructions: Skip to the Sexual Behavior section.

T3. When was the first time you ever took any antiretroviral medicines for your HIV? Please tell me the month and year. [FSTMY_9]

__ __/ __ __ __ __

^{(M M / Y Y Y Y )} [Month: 77 = Refused to answer, 88= Don’t know;

Year: 7777 = Refused to answer, 8888 = Don’t know]

Inconsistency checks: Confirm response if T3 (date first time took ART) is earlier than A4 (date first went to a provider for HIV care). Confirm response if T3 is earlier than A1 (date tested positive for HIV). T3 cannot be later than I4 (interview date).

Programming note for T3: If T3 is earlier than A4, display note to interviewer: “Date entered is earlier than the date first went to a provider for HIV care. Confirm response.” Allow program to advance. Accept “??” for month field. If T3 is earlier than A1, display a message to the interviewer saying, “Date entered is earlier than date first tested positive for HIV. Confirm response." Allow the program to advance.

SAY: “Now I’m going to ask you about antiretroviral medicines you are currently taking—ones you are taking now.”

T4. Are you currently taking any antiretroviral medicines for your HIV? [CURME_9]

No………………….…………………..……  0

Skip to Say box before T6

Yes………………………………………..……  1

Refused to answer……………………………  7

Don’t know…..........  8

T4a. What is the main reason you aren’t currently taking any antiretroviral medicines? [DON’T READ RESPONSES. CHECK ONLY ONE.] [NMANT8_9]

Doctor advised to delay or stop treatment  1

Participant believed he/she didn’t need medications because

felt health or believed HIV laboratory results were good  2

Due to side effects of medications  3

Felt depressed or overwhelmed  4

Didn’t want to think about being HIV positive  5

Worried about ability to adhere  6

Drinking or using drugs  7

Money or insurance issues  8

Homeless  9

Taking alternative or complementary medicines  10

Other (Specify:______________________________)  11 [NMA8_9OS]

Refused to answer  77

Don’t know  88

Interviewer instructions: Skip to T14.

SAY: “Now I’m going to ask you some questions about the antiretrovirals you are currently taking. I’m going to show you a card with HIV medicines on them. If you are taking any combination medicines, please tell me the name of the combination, not the separate name of each medicine in the combination. Don’t worry about telling me that you don’t take all your medicine. And please remember, none of this information will be shared with your doctor, nurse, or other health care worker.” [SHOW MEDICATION RESPONSE CARD 1 and 2.]

T5.	a. Are you currently taking [INSERT DRUG NAME SHOW RESPOND-ENT HIV PRESCRIP-TION DRUG CARD]? CODES: No = 0, Yes = 1, Refused to answer = 7, Don’t know = 8 If “Yes,” go to T6b; otherwise, skip to next drug.	b. How many pills, spoonfuls, or injections are you supposed to take of [INSERT DRUG NAME] each time you take it? CODES: Refused to answer = 77, Don’t know = 88	c. How many times per day are you supposed to take [INSERT DRUG NAME]? CODES: Refused to answer = 77, Don’t know = 88	d. Yesterday, how many times did you miss taking a dose or a set of pills, spoonfuls, or injections of [INSERT DRUG NAME]? If you only took part of your dose, please report this as the whole dose missed. CODES: Not applicable = 66, Refused to answer = 77, Don’t know = 88	e. The day before yesterday, how many times did you miss taking a dose or a set of these pills, spoonfuls, or injections of [INSERT DRUG NAME]? Again, if you only took part of your dose, please report this as the whole dose missed. CODES: Not applicable = 66, Refused to answer = 77, Don’t know = 88	f. Three days ago, how many times did you miss taking a dose or a set of these pills, spoonfuls, or injections of [INSERT DRUG NAME]? Again, if you only took part of your dose, please report this as the whole dose missed. CODES: Not applicable = 66, Refused to answer = 77, Don’t know = 88
Interviewer instructions: Only ask about combination treatments previously identified in T4a (ever taken combination treatments).
Nucleoside Analogue Combinations (Combination Treatments)
Combivir (AZT+3TC)	_____ [COMBCUR]	___ ___ [COMBET_9]	___ ___ [COMBDY_9]	___ ___ [CBMIS1_9]	___ ___ [CBMIS2_9]	___ ___ [CBMIS3_9]
Trizivir (AZT+3TC+ ABC)	_____ [TRIZCUR]	___ ___ [TRIZET_9]	___ ___ [TRIZDY_9]	___ ___ [TZMIS1_9]	___ ___ [TZMIS2_9]	___ ___ [TZMIS3_9]
Epzicom (3TC+ABC)	_____ [EPZICUR]	___ ___ [EPZIET_9]	___ ___ [EPZIDY_9]	___ ___ [EPMIS1_9]	___ ___ [EPMIS2_9]	___ ___ [EPMIS3_9]
Truvada (FTC+TDF)	_____ [TRUVCUR]	___ ___ [TRUVET_9]	___ ___ [TRUVDY_9]	___ ___ [TRMIS1_9]	___ ___ [TRMIS2_9]	___ ___ [TRMIS3_9]
Atripla (EFV/FTC/TDF)	_____ [ATRIPLA]	___ ___ [ATRTIM_9]	___ ___ [ATRDAY_9]	___ ___ [ATMIS1_9]	___ ___ [ATMIS2_9]	___ ___ [ATMIS3_9]
Interviewer instructions: Only ask about NRTI medicines previously identified in T4b (ever taken NRTI).
Nucleoside/ Nucleotide Analogue Reverse Transcriptase Inhibitors (NRTI), also known as ‘Nukes’
Epivir (lamivudine, 3TC)	_____ [LAMICUR]	___ ___ [LAMIET_9]	___ ___ [LAMIDY_9]	___ ___ [LAMIS1_9]	___ ___ [LAMIS2_9]	___ ___ [LAMIS3_9]
Videx EC (didanosine, ddI EC)	_____ [DAECCUR]	___ ___ [DAECET_9]	___ ___ [DAECDY_9]	___ ___ [DAMIS1_9]	___ ___ [DAMIS2_9]	___ ___ [DAMIS3_9]
Videx (didanosine, ddI)	_____ [DIDACUR]	___ ___ [DIDAET_9]	___ ___ [DIDADY_9]	___ ___ [DIMIS1_9]	___ ___ [DIMIS2_9]	___ ___ [DIMIS3_9]
Emtriva (emtricitabine, FTC)	_____ [EMTRCUR]	___ ___ [EMTRET_9]	___ ___ [EMTRDY_9]	___ ___ [EMMIS1_9]	___ ___ [EMMIS2_9]	___ ___ [EMMIS3_9]
Viread (tenofovir, TDF)	_____ [TENOCUR]	___ ___ [TENOET_9]	___ ___ [TENODY_9]	___ ___ [TEMIS1_9]	___ ___ [TEMIS2_9]	___ ___ [TEMIS3_9]
Hivid (zalcitabine ddC)	_____ [ZALCCUR]	___ ___ [ZALCET_9]	___ ___ [ZALCDY_9]	___ ___ [ZAMIS1_9]	___ ___ [ZAMIS2_9]	___ ___ [ZAMIS3_9]
Zerit (stavudine, d4T)	_____ [STAVCUR]	___ ___ [STAVET_9]	___ ___ [STAVDY_9]	___ ___ [STMIS1_9]	___ ___ [STMIS2_9]	___ ___ [STMIS3_9]
Retrovir (zidovudine, AZT, ZDV)	_____ [ZIDOCUR]	___ ___ [ZIDOET_9]	___ ___ [ZIDODY_9]	___ ___ [ZIMIS1_9]	___ ___ [ZIMIS2_9]	___ ___ [ZIMIS3_9]
Ziagen (abacavir, ABC)	_____ [ABACACUR]	___ ___ [ABACET_9]	___ ___ [ABACDY_9]	___ ___ [ABMIS1_9]	___ ___ [ABMIS2_9]	___ ___ [ABMIS3_9]
Interviewer instructions: Only ask about PI medicines previously identified in T4c (ever taken PI).
Protease Inhibitors (PI)
Agenerase (amprenavir, APV)	_____ [AMPRCUR]	___ ___ [AMPRET_9]	___ ___ [AMPRDY_9]	___ ___ [AMMIS1_9]	___ ___ [AMMIS2_9]	___ ___ [AMMIS3_9]
Invirase (saquinavir hard gel, SQV)	_____ [SACQCUR]	___ ___ [SACQT_9]	___ ___ [SACQDY_9]	___ ___ [SAMIS1_9]	___ ___ [SAMIS2_9]	___ ___ [SAMIS3_9]
Kaletra (lopinavir/ritonavir, LPVr)	_____ [LOPICUR]	___ ___ [LOPIT_9]	___ ___ [LOPIDY_9]	___ ___ [LOMIS1_9]	___ ___ [LOMIS2_9]	___ ___ [LOMIS3_9]
Crixivan (indinavir, IDV)	_____ [INDICUR]	___ ___ [INDIET_9]	___ ___ [INDIDY_9]	___ ___ [INMIS1_9]	___ ___ [INMIS2_9]	___ ___ [INMIS3_9]
Lexiva (fosamprenavir, FPV)	_____ [FUSACUR]	___ ___ [FUSAET_9]	___ ___ [FUSADY_9]	___ ___ [FOMIS1_9]	___ ___ [FOMIS2_9]	___ ___ [FOMIS3_9]
Reyataz (atazanavir, ATV)	_____ [ATAZCUR]	___ ___ [ATAZET_9]	___ ___ [ATAZDY_9]	___ ___ [ATZIS1_9]	___ ___ [ATZIS2_9]	___ ___ [ATZIS3_9]
Fortovase (saquinavir soft gel, SQV)	_____ [SAC2CUR]	___ ___ [SAC2T_9]	___ ___ [SAC2DY_9]	___ ___ [SQMIS1_9]	___ ___ [SQMIS2_9]	___ ___ [SQMIS3_9]
Norvir (ritonavir, RTV)	_____ [RITOCUR]	___ ___ [RITOET_9]	___ ___ [RITODY_9]	___ ___ [RIMIS1_9]	___ ___ [RIMIS2_9]	___ ___ [RIMIS3_9]
Viracept (nelfinavir, NFV)	_____ [NELFCUR]	___ ___ [NELFET_9]	___ ___ [NELFDY_9]	___ ___ [NEMIS1_9]	___ ___ [NEMIS2_9]	___ ___ [NEMIS3_9]
Aptivus (tipranavir, TPV)	_____ [TIPRCUR]	___ ___ [TIPRET_9]	___ ___ [TIPRDY_9]	___ ___ [TIMIS1_9]	___ ___ [TIMIS2_9]	___ ___ [TIMIS3_9]
Prezista (darunavir, DRV)	___ ___ [PREZCUR]	___ ___ [PREZET_9]	___ ___ [PREZDY_9]	___ ___ [PRMIS1_9]	___ ___ [PRMIS2_9]	___ ___ [PRMIS3_9]
Interviewer instructions: Only ask about NNRTI medicines previously identified in T4d (ever taken NRTI).
Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTI), also known as ‘Non-nukes’
Rescriptor (delavirdine, DLV)	_____ [DELACUR]	___ ___ [DELAET_9]	___ ___ [DELADY_9]	___ ___ [DEMIS1_9]	___ ___ [DEMIS2_9]	___ ___ [DEMIS3_9]
Viramune (nevirapine, NVP)	_____ [NEVICUR]	___ ___ [NEVIET­_9]	___ ___ [NEVIDY­_9]	___ ___ [NEVIS1_9]	___ ___ [NEVIS2_9]	___ ___ [NEVIS3_9]
Sustiva (efavirenz, EFV)	_____ [EFAVCUR]	___ ___ [EFAVET_9]	___ ___ [EFAVDY_9]	___ ___ [EFMIS1_9]	___ ___ [EFMIS2_9]	___ ___ [EFMIS3_9]
Intelence (etravirine ETV)	_____ [TMC]	___ ___ [TMCTIM_9]	___ ___ [TMCDAY_9]	___ ___ [TMMIS1_9]	___ ___ [TMMIS2_9]	___ ___ [TMMIS3_9]
Interviewer instructions: Only ask about Entry/Fusion Inhibitors previously identified in T4e (ever taken Entry/Fusion Inhibitors).
Entry/Fusion Inhibitors
Fuzeon (enfuvirtide, T–20)	_____ [ENFUCUR]	___ ___ [ENFUET_9]	___ ___ [ENFUND_9]	___ ___ [ENMIS1_9]	___ ___ [ENMIS2_9]	___ ___ [ENMIS3_9]
Selzentry (maraviroc, MVC)	_____ [MARAVIRO]	___ ___ [MARTIM_9]	___ ___ [MARDAY_9]	___ ___ [MAMIS1_9]	___ ___ [MAMIS2_9]	___ ___ [MAMIS3_9]
Interviewer instructions: Only ask about Integrase Inhibitors previously identified in T4f (ever taken Integrase Inhibitors).
Integrase Inhibitors
Isentress, (raltegravir, RAL)	_____ [RALTEGRA]	___ ___ [RALTIM_9]	___ ___ [RALDAY_9]	___ ___ [RAMIS1_9]	___ ___ [RAMIS2_9]	___ ___ [RAMIS3_9]
Interviewer instructions: Only ask about other ART medicines previously identified in T4h (ever taken other ART medicines).
Other ART Medicines
Other 1 (Specify:______) [INSERT RESPONSE FROM T4G]	_____ [OTSPAYN1]	___ ___ [ODRET1_9]	___ ___ [ODTDY1_9]	___ ___ [ODMIS1_9]	___ ___ [ODMIS2_9]	___ ___ [ODMIS3]_9
Other 2 (Specify:______) [INSERT RESPONSE FROM T4G]	_____ [OTSPAYN2]	___ ___ [ODRET2_9]	___ ___ [ODTDY2_9]	___ ___ [ODMI21_9]	___ ___ [ODMI22_9]	___ ___ [ODMS23_9]
Other 3 (Specify:______) [INSERT RESPONSE FROM T4G]	_____ [OTSPAYN3]	___ ___ [ODRET3_9]	___ ___ [ODTDY3_9]	___ ___ [ODMI31_9]	___ ___ [ODMI32_9]	___ ___ [ODMI33_9]
Other 4 (Specify:______) [INSERT RESPONSE FROM T4G]	_____ [OTSPAYN4]	___ ___ [ODRET4_9]	___ ___ [ODTDY4_9]	___ ___ [ODMI41_9]	___ ___ [ODMI42_9]	___ ___ [ODMI43_9]

Inconsistency check: The number of doses or set of pills, spoonfuls, or injections missed must be ≤ the number of times the respondent is supposed to take these pills, spoonfuls, or injections. The number of pills, spoonfuls, or injections that the respondent is supposed to take each time he or she takes them must be ≤ 35. The number of times each day the respondent is supposed to take these pills, spoonfuls, or injections must be ≤ 9. The number of times the respondent missed taking a dose or set of these pills, spoonfuls, or injections yesterday must be ≤ 9. The number of times the respondent missed taking a dose or set of these pills, spoonfuls, or injections the day before yesterday must be ≤ 9.

T6. Do any of your antiretroviral medicines have special instructions, such as “take with food” or “on an empty stomach” or “with plenty of fluids”? [MEDINSTR]

Skip to T9

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

Skip to T9

Refused to answer……………………………  7

Don’t know…..........  8

T7. During the past 3 days, how often did you follow all of those special instructions?

[SHOW CALENDAR AND RESPONSE CARD C.] [FLMDIN_9]

Never  1

Rarely  2

About half of the time  3

Most of the time  4

Always  5

Refused to answer  7

Don’t know  8

T8. Most antiretroviral medicines need to be taken on a schedule, such as “2 times a day” or “3 times a day” or “every 8 hours.” How closely did you follow your specific schedule during the past 3 days? [SHOW RESPONSE CARD C.] [MDSCHD_9]

Never  1

Rarely  2

About half of the time  3

Most of the time  4

Always  5

Refused to answer  7

Don’t know  8

T9. When was the last time you missed any of your antiretroviral medicines? [SHOW RESPONSE CARD D. CHECK ONLY ONE.] [LTMISMED]

Within the past week  1

1–2 weeks ago  2

3–4 weeks ago  3

1–3 months ago  4

Skip to Say box before T12

More than 3 months ago  5

Never skip medicines  6

Refused to answer  7

Don’t know  8

T10. The last time you missed taking your antiretroviral medicines, what were the reasons? [DON’T READ CHOICES. CHECK ALL THAT APPLY.] [MSMDR_9]

Problem with prescription or refill  1 [MSMDR_9A]

Felt sick or tired  2 [MSMDR_9B]

Change in daily routine including travel  3 [MSMDR_9C]

Due to side effects of medications  4 [MSMDR_9D]

Felt depressed or overwhelmed  5 [MSMDR_9E]

Drinking or using drugs  6 [MSMDR_9F]

Money or insurance issues  7 [MSMDR_9G]

Homeless  8 [MSMDR_9H]

Had too many pills to take  9 [MSMDR_9I]

Forgot to take them (Specify:_______________________)  10 [MSMDR_9J] [MSR_9JOS]

Other 1 (Specify:_____________________________)  11 [MSMD_9OK] [MSMD91OS]

Other 2 (Specify:_____________________________)  12 [MSMD_9OL] [MSMD92OS]

Other 3 (Specify:_____________________________)  13 [MSMD_9OM] [MSMD93OS]

Other 4 (Specify:_____________________________)  14 [MSMD_9ON] [MSMD94OS]

Refused to answer  77

Don’t know  88

SAY: “Now I’m going to ask you a question about the past 30 days.” [SHOW RESPONDENT CALENDAR.]

T11. During the past 30 days, how troubled were you by side effects from your antiretroviral medications? [SHOW RESPONSE CARD D-1.] [TRBL_EFT]

Never  1

Rarely  2

About half of the time  3

Most of the time  4

Always  5

Been on medications less than 30 days  6

Refused to answer  7

Don’t know  8

T12. How sure are you that you will be able to take all or most of your medication as directed? [SHOW RESPONSE CARD E. CHECK ONLY ONE.] [TK_MD_DR]

Not at all sure  0

Somewhat sure  1

Very sure  2

Extremely sure  3

Refused to answer  77

Don’t know  88

T12a. How sure are you that your medication will have a positive effect on your health? [SHOW RESPONSE CARD E. CHECK ONLY ONE.] [MD_POSEF]

Not at all sure  0

Somewhat sure  1

Very sure  2

Extremely sure  3

Refused to answer  77

Don’t know  88

T12b. How sure are you that if you do not take your medication exactly as instructed, the HIV in your body will become resistant to HIV medications? [SHOW RESPONSE CARD E. CHECK ONLY ONE.] [SR_HIVRS]

Not at all sure  0

Somewhat sure  1

Very sure  2

Extremely sure  3

Refused to answer  77

Don’t know  88

T13. To what extent do your friends or family members help you remember to take your medication? [SHOW RESPONSE CARD I. CHECK ONLY ONE.] [MED_SUPT]

Not at all  0

A little  1

Somewhat  2

A lot  3

Not applicable  4

Refused to answer  77

Don’t know  88

Interviewer instructions: Skip to T15.

T14. During the past 12 months, have you taken antiretroviral medicines? [ATMD12_9]

Skip to Say box before S1

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

Skip to Say box before S1

Refused to answer……………………………  7

Don’t know…..........  8

T15. During the past 12 months, what were the ways your antiretroviral medicines were paid for? [DON’T READ CHOICES. CHECK ALL THAT APPLY.] [PREMD_9]

Private health insurance  1 [PREMD_9A]

Medicaid  2 [PREMD_9B]

Medicare  3 [PREMD_9C]

AIDS Drug Assistance Program (ADAP)  4 [PREMD_9D]

An AIDS service organization provided medicines  5 [PREMD_9E]

Got medicines at a public clinic  6 [PREMD_9F]

7

Clinical trial or drug study provided medicines  7 [PREMD_9G]

Paid for medicines out of pocket  8 [PREMD_9H]

Other 1 (Specify: _____________________________)  9 [PREMO_9I] [PREM91OS]

Other 2 (Specify: _____________________________)  10 [PREMJ_9O] [PREM92OS]

Other 3 (Specify: _____________________________)  11 [PREMK_9O] [PREM93OS]

Other 4 (Specify: _____________________________)  12 [PREML_9O] [PREM94OS]

Refused to answer  77

Don’t know  88

T16. During the past 12 months, have you ever purposefully taken a “drug holiday” from your antiretroviral medicines that wasn’t recommended by your doctor? That is did you plan to not take any doses of one or more of your antiretroviral medicines for at least two whole days in a row? [DRGHOL_9]

Skip to Say box before S1

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

Skip to Say box before S1

Refused to answer……………………………  7

Don’t know…..........  8

T17. What was the main reason that you took a drug holiday from your antiretroviral medicines? [READ CHOICES. CHECK ONLY ONE.] [RDRHO_10]

Medicine has side effects or makes me feel bad  1

Got tired of taking medicines or needed a break  2

Was using drugs or alcohol  3

Was on vacation  4

Felt good  5

Other (Specify:_________________________________)  6 [RDR_10OS]

Refused to answer  77

Don’t know  88

SEXUAL BEHAVIOR

SAY: “Next, I'm going to ask you some questions about having sex. Your answers to these questions will be used to help educate people about how to decrease the spread of HIV. Please remember that your answers will be kept secure to the extent permitted by law and that you do not have to answer any questions that you do not want to. For these questions, ‘having sex’ means oral, vaginal, or anal sex. Oral sex means mouth on the vagina, penis, or anus; vaginal sex means penis in the vagina; and anal sex means penis in the anus. I need to ask you all the questions, even if some may not apply to your situation.”

Interviewer instructions: Refer to ES7 (sex at birth) and ES8 (self-identified gender):

• Go to S1 (Male Respondent–Female Partner): if ES7 andES8 are “Male,” or if ES7 is “Intersex” and ES8 is “Male.”

• Skip to S12 (Female Respondent–Male Partner): if ES7 and ES8 are “Female,” or if ES7 is “Intersex” and ES8 is “Female.”

• Skip to S21 (Transgender Respondent): if ES7 is “Male” and ES8 is “Female,” or if ES7 is “Female” and ES8 is “Male,” or if ES8 is “Transgender.”

• Otherwise, skip to Say box before U1.

Programming note: If ES7 or ES8 are “Don’t know” or “Refused to answer,” skip to Say box before UI.

Male Respondent – Female Partner

S1. During the past 12 months, have you had oral, vaginal, or anal sex with a woman? [M_FOVASX]

Skip to S6

No  0

Yes  1

Skip to S6

Refused to answer  7

Don’t know  8

S1a. During the past 12 months, with how many different women have you had oral, vaginal, or anal sex? [M_FS12_9]

___ ___ ___ ___ [7777 = Refused to answer, 8888 = Don’t know]

Interviewer instructions: If S1a is “Refused to answer” or “Don’t know,” skip to S6.

Inconsistency check: S1a must be ≥ 1. S1a must be < than 1,000.

SAY: “Now I’d like to ask about this/these sex partner(s) .”

Interviewer instructions: If S1a > 1, read Column 1, S2. If S1a = 1, read Column 2, S2s.

Programming note for column 1: Response must be greater than 1.

SAY: “Now I’d like to ask about these sex partners you had in the last 12 months.”

Interviewer instructions: If S1a > 1, read Column 1, S2. If S1a = 1, read Column 2, S2s.

Programming note for column 1: Response must be greater than 1.

Multiple Female Partners CODES: Refused to answer = 7777, Don’t know = 8888			One Female Partner CODES: No = 0, Yes = 1, Not applicable = 6, Refused to answer = 7, Don’t know = 8
Column 1			Column 2
Question	Response	Skip Pattern	Question	Response	Skip Pattern
S2a. Now I’d like you to think about the first time you had sex with these __ __ __ __ [RESPONSE FROM S2] partners after you tested positive for HIV. Did you discuss your HIV status with none, some, or all of these women? [CHECK ONLY ONE.] [M_FCSST]	None……... 1 Some…..…. 2 All…........... 3 Not applicable... 6 Don’t know……... 7 Refused...… 8		S2as. Now I’d like you to think about the first time you had sex with this woman after you tested positive for HIV. Did you discuss your HIV status with her? [M_FCSST1]	[_____]
S2b. Of the __ __ __ __ [RESPONSE FROM S2] partners with whom you had oral, vaginal, or anal sex, with how many did you have vaginal sex during the past 12 months? By “vaginal sex,” I mean you put your penis in her vagina. [M_FCSVG]	[_____]	If “0,” “Refused to answer,” or “Don’t know”, skip to S2e. If S2b is “1,” go to Column 2, S2cs.	S2bs. During the past 12 months, did you have vaginal sex with this partner? By “vaginal sex,” I mean you put your penis in her vagina. [M_FCSVG1]	[_____]	If “No,” “Refused to answer,” or “Don’t know,” skip to S2es.
Inconsistency check: Column 1, S2b must be ≤ S2. If not, the program should display a message saying, “Number of female partners you had vaginal sex with must be less than or equal to the number of female partners.”
S2c. With how many of these __ __ __ __ [RESPONSE FROM S2b] partners did you have vaginal sex without a condom during the past 12 months? When I say “without a condom,” I mean that you either didn’t use a condom at all or that you only used a condom for part of the time during sex. [M_FCSVC]	[_____]	If “0,” “Refused to answer,” or “Don’t know,” skip to S2e. If S2c is “1,” go to Column 2, S2ds.	S2cs. During the past 12 months, did you have vaginal sex without a condom with this partner? When I say “without a condom,” I mean that you either didn’t use a condom at all or that you only used a condom for part of the time during sex. [M_FCSVC1]	[_____]	If “No,” “Refused to answer,” or “Don’t know,” skip to S2es.
Inconsistency check: Column 1, S2c must be ≤ S2b. If not, the program should display a message saying, “Number of female partners you had vaginal sex without a condom must be less than or equal to the number of female partners with whom you had vaginal sex.”
SAY: “The next question is about HIV status. Remember, all of your answers are secure to the extent permitted by law and if you do not know or do not want to answer, that’s okay.”
S2d. Of these __ __ __ __ [RESPONSE FROM S2c] partners with whom you had vaginal sex without a condom, how many were HIV positive? [M_FCVCP]	[_____]	If S2 is > 1, go to Column 1, S2e. If S2 = 1 go to Column 2, S2es.	S2ds. Was this partner with whom you had vaginal sex without a condom HIV positive? [M_FCVCP1]	[_____]
Inconsistency check: Column 1, S2d must be ≤ S2c. If not, the program should display a message saying, “Number of HIV positive female partners with whom you had vaginal sex without a condom must be less than or equal to the number with whom you had vaginal sex without a condom.”
S2e. You said that you had oral, vaginal, or anal sex with __ __ __ __ [RESPONSE FROM S2] female partners. Of these partners, with how many did you have anal sex during the past 12 months? By “anal sex,” I mean you put your penis in her anus. [M_FCSAN]	[_____]	If “0,” “Refused to answer,” or “Don’t know,” skip to S3. If S2e is “1,” go to Column 2, S2fs.	S2es. During the past 12 months, did you have anal sex with this female partner? By “anal sex,” I mean you put your penis in her anus. [M_FCSAN1]	[_____]	If “No,” “Refused to answer,” or “Don’t know,” skip to S4.
Inconsistency check: Column 1, S2e must be ≤ S2. If not, the program should display a message saying, “Number of female partners you had anal sex with must be less than or equal to the number of female partners.”
S2f. Of these __ __ __ __ [RESPONSE FROM S2e] female partners, with how many did you have anal sex without a condom during the past 12 months? When I say “without a condom,” I mean that you either didn’t use a condom at all or that you only used a condom for part of the time during sex. [M_FCSAC]	[_____]	If “0,” “Refused to answer,” or “Don’t know,” skip to S3. If S2f is “1,” go to Column 2, S2gs.	S2fs. During the past 12 months, did you have anal sex without a condom with this female partner? When I say “without a condom,” I mean that you either didn’t use a condom at all or that you only used a condom for part of the time during sex. [M_FCSAC1]	[_____]	If “No,” “Refused to answer,” or “Don’t know,” skip to S4.
Inconsistency check: Column 1, S2f must be ≤ S2e. If not, the program should display a message saying, “Number of female partners you had anal sex without a condom must be less than or equal to the number of female partners with whom you had anal sex.”
SAY: “The next question is about HIV status. Remember, all of your answers are secure to the extent permitted by law and if you do not know or do not want to answer, that’s okay.”
S2g. Of these __ __ __ __ [RESPONSE FROM S2f] female partners with whom you had anal sex without a condom, how many were HIV positive? [M_FCACP]	[_____]		S2gs. Was this female partner with whom you had anal sex without a condom HIV positive? [M_FCACP1]	[_____]	If S1a=1, skip to S4.
Inconsistency check: Column 1, S2g must be ≤ S2f. If not, the program should display a message saying, “Number of HIV positive female partners with whom you had anal sex without a condom must be less than or equal to the number with whom you had anal sex without a condom.”

S3. Earlier you said that you had oral, vaginal, or anal sex with __ __ __ __ [RESPONSE FROM S1a] women. During the past 12 months, did you have sex with any of these women in exchange for things like money, drugs, food, shelter, or transportation? [M_FXCH_9]

No  0

Yes  1

Refused to answer  7

Don’t know  8

Interviewer instructions: Skip to S5.

S3a. During the past 12 months, did you have sex with this woman in exchange for things like money, drugs, food, shelter, or transportation? [M_FXC1_9]

No  0

Yes  1

Refused to answer  7

Don’t know  8

S4. Now I would like you to think about the last time you had sex with a woman. When was the

last time you had sex with a woman? Just tell me the month and year.

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

(M M / Y Y Y Y )

S4a. When you had sex that last time, did you have anal or vaginal sex without a condom with a woman whose HIV status you didn't know?

No………………….……………………………  0

Yes……………………………………………...  1

Refused to answer……………………………...  7

Don’t know…………………………………...  9

S4b. When you had sex that last time, did you have vaginal or anal sex without a condom with a woman who was HIV negative?

No………………….……………………………  0

Yes……………………………………………...  1

Refused to answer……………………………...  7

Don’t know…………………………………...  9

S4c. When you had sex that last time,, did you have vaginal or anal sex without a condom with a woman who was HIV positive?

No………………….……………………………  0

Yes……………………………………………...  1

Refused to answer……………………………...  7

Don’t know…………………………………...  9

Male Respondent – Male Partner

S5. During the past 12 months, have you had oral or anal sex with a man? [M_MOASX]

Skip to Say box before U1

No  0

Yes  1

Skip to Say box before U1

Refused to answer  7

Don’t know  8

S5a. During the past 12 months, with how many different men have you had oral or anal sex? [M_SX12_9]

___ ___ ___ ___ [Refused to answer = 7777, Don’t know = 8888]

Interviewer instructions: If S5a is “Refused to answer” or “Don’t know,” skip to Say box before U1.

Inconsistency check: S5a must be ≥ 1. S5a must be < than 1,000.

SAY: “Now I’d like to ask about these partners.”

Interviewer instructions: If S5a > 1, read Column 1, S7. If S5a = 1, read Column 2, S7s.

Programming note for column 1: Response must be greater than 1.

MULTIPLE MALE PARTNERS CODES: Refused to answer = 7777, Don’t know = 8888			One male Partner CODES: No = 0, Yes = 1, Not applicable = 6, Refused to answer = 7, Don’t know = 8
COLUMN 1			COLUMN 2
Question	Response	Skip Pattern	Question	Response	Skip Pattern
Inconsistency check: Column 1, S6 must be ≤ S5a. If not, the program should display a message saying, “Number of male partners must be less than or equal to the total number of male partners.”
S6a. Now I’d like you to think about the first time you had sex with these __ __ __ __ [RESPONSE FROM S7] partners after you tested positive for HIV. Did you discuss your HIV status with none, some, or all of these men? [CHECK ONLY ONE.] [M_MCSST]	None……... 1 Some…..…. 2 All…........... 3 Not applicable... 6 Don’t know……... 7 Refused...… 8		S6as. Now I’d like you to think about the first time you had sex with this man after you tested positive for HIV. Did you discuss your HIV status with him? [M_MCSST1]	[_____]
S6b. Of these __ __ __ __ [RESPONSE FROM S7] partners with whom you had oral or anal sex, with how many did you have insertive anal sex during the past 12 months? By “insertive anal sex,” I mean you put your penis in his anus. [M_MCSIA]	[_____]	If “0,” “Refused to answer,” or “Don’t know,” skip to S6e. If S6b is “1,” go to Column 2, S6cs.	S6bs. During the past 12 months, did you have insertive anal sex with this partner? By “insertive anal sex,” I mean you put your penis in his anus. [M_MCSIA1]	[_____]	If “No,” “Refused to answer,” or “Don’t know,” skip to S6es.
Inconsistency check: Column 1, S6b must be ≤ S6. If not, the program should display a message saying, “Number of male partners you had insertive anal sex with must be less than or equal to the number of male partners.”
S6c. With how many of these __ __ __ __ [RESPONSE FROM S7b] partners did you have insertive anal sex without a condom? When I say “without a condom,” I mean that you either didn’t use a condom at all or that you only used a condom for part of the time during sex. [M_MCIAC]	[_____]	If “0,” “Refused to answer,” or “Don’t know,” skip to S6e. If S6c is “1,” go to Column 2, S6ds.	S6cs. During the past 12 months, did you have insertive anal sex without a condom with this partner? When I say “without a condom,” I mean that you either didn’t use a condom at all or that you only used a condom for part of the time during sex. [M_MCIAC1]	[_____]	If “No,” “Refused to answer,” or “Don’t know,” skip to S6es.
Inconsistency check: Column 1, S6c must be ≤ S6b. If not, the program should display a message saying, “Number of male partners with whom you had insertive anal sex without a condom must be less than or equal to the number with whom you had insertive anal sex.”
SAY: “The next question is about HIV status. Remember, all of your answers are secure to the extent permitted by law and you do not know or do not want to answer, that’s okay.”
S6d. Of these __ __ __ __ [RESPONSE FROM S7c] partners with whom you had insertive anal sex without a condom, how many were HIV positive? [M_MCICP]	[_____]	If S6 is > 1, go to Column 1, S6e. If S6 = 1 go to Column 2, S6es.	S6ds. Was this partner with whom you had insertive anal sex without a condom HIV positive? [M_MCICP1]	[_____]	.
Inconsistency check: Column 1, S6d must be ≤ S6c. If not, the program should display a message saying, “Number of HIV positive male partners with whom you had insertive anal sex without a condom must be less than or equal to the number with whom you had insertive anal sex without a condom.”
S6e. You said that you had oral or anal sex with __ __ __ __ [RESPONSE FROM S7] male partners. Of these partners, with how many did you have receptive anal sex during the past 12 months? By “receptive anal sex,” I mean he put his penis in your anus. [M_MCSRA]	[_____]	If “0,” “Refused to answer,” or “Don’t know,” skip to S7. If S6e is “1,” go to Column 2, S6fs.	S6es. During the past 12 months, did you have receptive anal sex with this male partner? By “receptive anal sex,” I mean he put his penis in your anus. [M_MCSRA1]	[_____]	If “No,” “Refused to answer,” or “Don’t know,” skip to S8.
Inconsistency check: Column 1, S6e must be ≤ S6. If not, the program should display a message saying, “Number of male partners you had receptive anal sex with must be less than or equal to the number of male partners.”
S6f. Of these __ __ __ __ [RESPONSE FROM S7e] male partners, with how many did you have receptive anal sex without a condom during the past 12 months? When I say “without a condom,” I mean that you either didn’t use a condom at all or that you only used a condom for part of the time during sex. [M_MCRAC]	[_____]	If “0,” “Refused to answer,” or “Don’t know,” skip to S7. If S6f is “1,” go to Column 2, S6gs.	S6fs. During the past 12 months, did you have receptive anal sex without a condom with this male partner? When I say “without a condom,” I mean that you either didn’t use a condom at all or that you only used a condom for part of the time during sex. [M_MCRAC1]	[_____]	If “No,” “Refused to answer,” or “Don’t know,” skip to S8.
Inconsistency check: Column 1, S6f must be ≤ S6e. If not, the program should display a message saying, “Number of male partners with whom you had receptive anal sex without a condom must be less than or equal to the number with whom you had receptive anal sex.”
SAY: “The next question is about HIV status. Remember, all of your answers are secure to the extent permitted by law and you do not know or do not want to answer, that’s okay.”
S6g. Of these __ __ __ __ [RESPONSE FROM S7f] male partners with whom you had receptive anal sex without a condom, how many were HIV positive? [M_MCRCP]	[_____]		S6gs. Was this male partner with whom you had receptive anal sex without a condom HIV positive? [M_MCRCP1]	[_____]	If S5a=1, skip to S8.

S7. Earlier you said that you had oral or anal sex with __ __ __ __ [RESPONSE FROM S5a] men. During the past 12 months, did you have sex with any of these men in exchange for things like money, drugs, food, shelter, or transportation? [M_MXCH_9]

No  0

Yes  1

Refused to answer  7

Don’t know  8

Interviewer instructions: Skip to Say box before U1.

S8. During the past 12 months, did you have sex with this man in exchange for things like money, drugs, food, shelter, or transportation? [M_MXC1_9]

No  0

Yes  1

Refused to answer  7

Don’t know  8

S8a. Now I would like you to think about the last time you had sex with a woman. When was the

last time you had sex with a woman? Just tell me the month and year.

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

(M M / Y Y Y Y )

S8b. When you had sex that last time, did you have anal or vaginal sex without a condom with a woman whose HIV status you didn't know?

No………………….……………………………  0

Yes……………………………………………...  1

Refused to answer……………………………...  7

Don’t know…………………………………...  9

S8c. When you had sex that last time, did you have vaginal or anal sex without a condom with a woman who was HIV negative?

No………………….……………………………  0

Yes……………………………………………...  1

Refused to answer……………………………...  7

Don’t know…………………………………...  9

S8d. When you had sex that last time,, did you have vaginal or anal sex without a condom with a woman who was HIV positive?

No………………….……………………………  0

Yes……………………………………………...  1

Refused to answer……………………………...  7

Don’t know…………………………………...  9

Female Respondent – Male Partner

S9. During the past 12 months, have you had oral, vaginal, or anal sex with a man? [F_MOVASX]

Skip to S16

No  0

Yes  1

Skip to S16

Refused to answer  7

Don’t know  8

S9a. During the past 12 months, with how many different men have you had oral, vaginal, or anal sex? [F_MM12_9]

___ ___ ___ ___ [Refused to answer = 7777, Don’t know = 8888]

Interviewer instructions: If S9a is “Refused to answer” or “Don’t know,” skip to S9.

Inconsistency check: S9a must be ≥ 1. S9a must be < than 1,000.

SAY: “Now I’d like to ask about this/these sex partner(s).”

Interviewer instructions: If S9a > 1, go to COLUMN 1, S10. If S9a = 1, go to COLUMN 2, S10s.

Programming note for column 1: Response must be greater than 1.

Multiple male Partners CODES: Refused to answer = 7777, Don’t know = 8888			One male Partner CODES: No = 0, Yes = 1, Not applicable = 6, Refused to answer = 7, Don’t know = 8
COLUMN 1			COLUMN 2
Question	Response	Skip Pattern		Question	Response	Skip Pattern
S10. You said that you had oral, vaginal, or anal sex with __ __ __ __ [RESPONSE FROM S9a] men during the past 12 months. Of these men, how many were partners? [F_MCSSX]	[_____]	If “0,” “Refused to answer,” or “Don’t know,” skip to S11. If S10 is “1,” go to Column 2, S10as.		S10s. You told me that you had oral, vaginal, or anal sex with one man during the past 12 months. Was this man a partner? [F_MCSSX1]	[_____]	If “No,” “Refused to answer,” or “Don’t know,” skip to S11.
Inconsistency check: Column 1, S10 must be ≤ S9a. If not, the program should display a message saying, “Number of male partners must be less than or equal to the total number of partners.”
S10a. Now I’d like you to think about the first time you had sex with these __ __ __ __ [RESPONSE FROM S10] partners after you tested positive for HIV. Did you discuss your HIV status with none, some, or all of these men? [F_MCSST]	None……... 1 Some…..…. 2 All…........... 3 Not applicable... 6 Don’t know……... 7 Refused...… 8			S10as. Now I’d like you to think about the first time you had sex with this man after you tested positive for HIV. Did you discuss your HIV status with him? [F_MCSST1]	[_____]
S10b. Of these __ __ __ __ [RESPONSE FROM S10] partners with whom you had oral, vaginal, or anal sex, with how many did you have vaginal sex during the past 12 months? By “vaginal sex,” I mean he put his penis in your vagina. [F_MCSVG]	[_____]	If “0,” “Refused to answer,” or “Don’t know,” skip to S10e. If S10b is “1,” go to Column 2, S10cs.		S10bs. During the past 12 months, did you have vaginal sex with this partner? By “vaginal sex,” I mean he put his penis in your vagina. [F_MCSVG1]	[_____]	If “No,” “Refused to answer,” or “Don’t know,” skip to S10es.
Inconsistency check: Column 1, S10b must be ≤ S10. If not, the program should display a message saying, “Number of male partners you had vaginal sex with must be less than or equal to the number of casual male partners.”
S10c. With how many of these __ __ __ __ [RESPONSE FROM S10b] partners did you have vaginal sex without a condom during the past 12 months? When I say “without a condom,” I mean that you either didn’t use a condom at all or that you only used a condom for part of the time during sex. [F_MCSVC]	[_____]	If “0,” “Refused to answer,” or “Don’t know,” skip to S10e. If S10c is “1,” go to Column 2, S10ds.		S10cs. During the past 12 months, did you have vaginal sex without a condom with this partner? When I say “without a condom,” I mean that you either didn’t use a condom at all or that you only used a condom for part of the time during sex. [F_MCSVC1]	[_____]	If “No,” “Refused to answer,” or “Don’t know,” skip to S10es.
Inconsistency check: Column 1, S10c must be ≤ S10b. If not, the program should display a message saying, “Number of male partners with whom you had vaginal sex without a condom must be less than or equal to the number with whom you had vaginal sex.”
SAY: “The next question is about HIV status. Remember, all of your answers are secure to the extent permitted by law and if you do not know or do not want to answer, that’s okay.”
S10d. Of these __ __ __ __ [RESPONSE FROM S13c] partners with whom you had vaginal sex without a condom, how many were HIV positive? [F_MCVCP]	[_____]	If S10 is > 1, go to Column 1, S10e. If S10 = 1, go to Column 2, S10es.		S10ds. Was this partner with whom you had vaginal sex without a condom HIV positive? [F_MCVCP1]	[_____]
Inconsistency check: Column 1, S10d must be ≤ S10c. If not, the program should display a message saying, “Number of HIV positive male partners with whom you had vaginal sex without a condom must be less than or equal to the number with whom you had vaginal sex without a condom.”
S10e. You said you had oral, vaginal, or anal sex with __ __ __ __ [RESPONSE FROM S10] male partners. Of these partners, with how many did you have anal sex during the past 12 months? By “anal sex,” I mean he put his penis in your anus. [F_MCSAN]	[_____]	If “0,” “Refused to answer,” or “Don’t know,” skip to S11. If S10e is “1,” go to Column 2, S10fs.		S10es. During the past 12 months, did you have anal sex with this male partner? By “anal sex,” I mean he put his penis in your anus. [F_MCSAN1]	[_____]	If “No,” “Refused to answer,” or “Don’t know,” skip to S11.
Inconsistency check: Column 1, S10e must be ≤ S10. If not, the program should display a message saying, “Number of male partners with whom you had anal sex must be less than or equal to the number of male partners.”
S10f. Of these __ __ __ __ [RESPONSE FROM S13e] male partners, with how many did you have anal sex without a condom during the past 12 months? When I say “without a condom,” I mean that you either didn’t use a condom at all or that you only used a condom for part of the time during sex. [F_MCSAC]	[_____]	If “0,” “Refused to answer,” or “Don’t know,” skip to S11. If S10f is “1,” go to Column 2, S10gs.		S10fs. During the past 12 months, did you have anal sex without a condom with this male partner? When I say “without a condom,” I mean that you either didn’t use a condom at all or that you only used a condom for part of the time during sex. [F_MCSAC1]	[_____]	If “No,” “Refused to answer,” or “Don’t know,” skip to S11.
Inconsistency check: Column 1, S10f must be ≤ S10e. If not, the program should display a message saying, “Number of male partners with whom you had anal sex without a condom must be less than or equal to the number of male partners with whom you had anal sex.”
SAY: “The next question is about HIV status. Remember, all of your answers are secure to the extent permitted by law and if you do not know or do not want to answer, that’s okay.”
S10g. Of these __ __ __ __ [RESPONSE FROM S10f] male partners with whom you had anal sex without a condom, how many were HIV positive? [F_MCACP]	[_____]			S10gs. Was this male partner with whom you had anal sex without a condom HIV positive? [F_MCACP1]	[_____]	If S9a=1, skip to S11a.

S11. Earlier you said that you had oral, vaginal, or anal sex with __ __ __ __ [RESPONSE FROM S12a] men. During the past 12 months, did you have sex with any of these men in exchange for things like money, drugs, food, shelter, or transportation? [F_MXCH_9]

No  0

Yes  1

Refused to answer  7

Don’t know  8

S11a. During the past 12 months, did you have sex with this man in exchange for things like money, drugs, food, shelter, or transportation? [F_MXC1_9]

No  0

Yes  1

Refused to answer  7

Don’t know  8

S12. Now I would like you to think about the last time you had sex with a woman. When was the

last time you had sex with a woman? Just tell me the month and year.

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

(M M / Y Y Y Y )

S12a. When you had sex that last time, did you have anal or vaginal sex without a condom with a woman whose HIV status you didn't know?

No………………….……………………………  0

Yes……………………………………………...  1

Refused to answer……………………………...  7

Don’t know…………………………………...  9

S12b. When you had sex that last time, did you have vaginal or anal sex without a condom with a woman who was HIV negative?

No………………….……………………………  0

Yes……………………………………………...  1

Refused to answer……………………………...  7

Don’t know…………………………………...  9

S12c. When you had sex that last time,, did you have vaginal or anal sex without a condom with a woman who was HIV positive?

No………………….……………………………  0

Yes……………………………………………...  1

Refused to answer……………………………...  7

Don’t know…………………………………...  9

Drug and Alcohol Use

Alcohol Use

SAY: “Now I’m going to ask you about alcohol use.”

U1. During the past 12 months, how often did you drink alcohol? [SHOW CALENDAR AND RESPONSE CARD G.] [ALCOHO_9]

Daily  1

Weekly  2

Monthly  3

Less than monthly  4

Never  5

Skip to Say box before U7

Refused to answer  77

Don’t know  88

Interviewer instructions:

If S1 (male respondent had sex with a woman during the past 12 months) and S5 (male respondent had sex with a man during the past 12 months) are “No,” “Refused to answer,” or “Don’t know,” skip to Say box before U3.

If S9 (female respondent had sex with a man during the past 12 months) is “No,” “Refused to answer,” or “Don’t know,” skip to Say box before U3.

U2. During the past 12 months, did you drink alcohol before or during sex? [ALCOHOL1]

No  0

Yes  1

Refused to answer  7

Don’t know  8

SAY: “Now I am going to ask you some questions about the past 30 days.” [SHOW RESPONDENT CALENDAR.]

U3. During the past 30 days, on how many days did you have an alcoholic drink? [DRINK_9]

___ ____ [Refused to answer = 77, Don’t know = 88]

Inconsistency check: U3 (number of days had an alcoholic drink during the past 30 days) must be between 0 and 30.

Interviewer instructions: If U3 (number of days consumed alcohol during the past 30 days) is “0,” “Refused to answer,” or “Don’t know,” skip to Say box before U7.

SAY: “For the next questions, a drink of alcohol is a 12 oz beer, a 5 oz glass of wine, or a 1.5 oz shot of liquor.” [SHOW ALCHOHOL RESPONSE CARD.]

U4. During the past 30 days, how many alcoholic drinks did you have on a typical day when you were drinking? [NDRINK_9]

____ ____ [Refused to answer = 77, Don’t know = 88]

Inconsistency check: U4 (number of drinks on a typical day during the past 30 days) must be between 1 and 76.

Interviewer instructions: If ES7 (birth gender) is “Female” or “Intersex/ambiguous,” skip to U6.

U5. During the past 30 days, on how many days did you have 5 or more alcoholic drinks in one sitting? [DRINK5_9]

____ ____ [Refused to answer = 77, Don’t know = 88]

Inconsistency check: U5 (number of days had 5 or more drinks during the past 30 days) must be ≤ 30 or ≤ U3 (number of days had a drink during the past 30 days).

Interviewer instructions: Skip to Say box before U7.

U6. During the past 30 days, on how many days did you have 4 or more alcoholic drinks in one sitting? [DRINK4_9]

____ ____ [Refused to answer = 77, Don’t know = 88]

Inconsistency check: U6 (number of days had 4 or more drinks during the past 30 days) must be ≤ 30 or ≤ U3 (number of days had a drink during the past 30 days).

Non-Injection Drug Use

SAY: “Now I’m going to ask you about drugs that you may have used, but didn’t inject. I will refer to these as non-injection drugs. This includes drugs like marijuana, crack, club drugs, and painkillers. Tell me about the drugs you used that were not for medical purposes. Please remember that your answers will be kept secure to the extent permitted by law and that you do not have to answer any questions that you do not want to.”

Skip to Say box before U11

U7. During the past 12 months, did you use any non-injection drugs? [ANID12_9]

No  0

Yes  1

Skip to Say box before U11

Refused to answer  7

Don’t know  8

SAY: “I'm going to read you a list of non-injection drugs. For each one I mention, please tell me how often you used it during the past 12 months. Don’t include drugs you injected or drugs that were used for medical purposes.”

Interviewer instructions: If the respondent’s drug use was sporadic during the past 12 months, ask the respondent to choose the response option that best characterizes his or her use.

	During the past 12 months, how often did you use: [SHOW RESPONSE CARD G.]	Daily (1)	Weekly (2)	Monthly (3)	Less than monthly (4)	Never (5)	Refused to answer (7)	Don’t Know (8)
U8a.	…methamphetamines, also called crystal meth, tina, crank, ice? [CRYMTC_9]	1	2	3	4	5	7	8
U8b.	…other amphetamines or stimulants? [AMPHET_9]	1	2	3	4	5	7	8
U8c.	…crack? [CRACK1_9]	1	2	3	4	5	7	8
U8d.	…cocaine that is smoked or snorted? [COCSMO_9]	1	2	3	4	5	7	8
U8e.	…downers, such as Valium, Ativan, or Xanax? [DOWNER_9]	1	2	3	4	5	7	8
U8f.	…painkillers, such as Oxycontin, Vicodin, or Percocet? [PAINKI_9]	1	2	3	4	5	7	8
U8g.	…hallucinogens, such as LSD or mushrooms? [HALLUC_9]	1	2	3	4	5	7	8
U8h.	…X, also called Ecstasy? [XECT_9]	1	2	3	4	5	7	8
U8i.	…Special K, also called ketamine? [SPECK_9]	1	2	3	4	5	7	8
U8j.	…GHB? [GHB_9]	1	2	3	4	5	7	8
U8k.	…heroin or opium that is smoked or snorted? [HEROIN_9]	1	2	3	4	5	7	8
U8l.	…marijuana? [MARIJU_9]	1	2	3	4	5	7	8
U8m.	…poppers, also called amyl nitrate? [POPPER_9]	1	2	3	4	5	7	8
U8n.	…steroids or hormones? [STRHOR_9]	1	2	3	4	5	7	8
U8o.	…any other non-injection drug (Specify:___________)? [ONINJD_9] [ONINJ9OS]	1	2	3	4	5	7	8

Inconsistency check: If U7 (non-injection drug use) is “Yes” and all of the responses to U8a-U8o are “Never,”, then the program should display a message saying, “You said that you used non-injection drugs during the past 12 months. Please tell me the name of the drug you used and how often you used it during the past 12 months.” Interviewer return to previous questions.

Interview instructions:

If S1 (male respondent had sex with a woman during the past 12 months) and S5 (male respondent had sex with a man during the past 12 months) are “No,” “Refused to answer,” or “Don’t know,” skip to Say box before U11.

If S9 (female respondent had sex with a man during the past 12 months) is “No,” “Refused to answer,” or “Don’t know,” skip to Say box before U11.

U9. During the past 12 months, did you use any non-injection drugs before or during sex? [NID_BFSX]

Skip to Say box before U11

No  0

Yes  1

Skip to Say box before U11

Refused to answer  7

Don’t know  8

Interview instructions: If U8a is “Daily,” “Weekly,” “Monthly,” or “Less than monthly,” check the shaded box (column 1) in U10a. Follow the same pattern for b–o. If no shaded boxes (column 1) are checked in U10a-o, skip to Say box before U11.
		During the past 12 months, did you use: [ONLY READ QUESTIONS WHERE THE SHADED BOX (COLUMN 1) IS CHECKED.]	No (0)	Yes (1)	Refused to answer (7)	Don’t Know (8)
	U10a.	…methamphetamines before or during sex? [CRAMT2_9]	0	1	7	8
	U10b.	…other amphetamines or stimulants before or during sex? [AMPHT2_9]	0	1	7	8
	U10c.	…crack before or during sex? [CRACK2_9]	0	1	7	8
	U10d.	…cocaine that is smoked or snorted before or during sex? [COCSM2_9]	0	1	7	8
	U10e.	…downers, such as Valium, Ativan, or Xanax, before or during sex? [DOWNE2_9]	0	1	7	8
	U10f.	…painkillers, such as Oxycontin, Vicodin, or Percocet before or during sex? [PAINK2_9]	0	1	7	8
	U10g.	…hallucinogens, such as LSD or mushrooms before or during sex? [HALLU2_9]	0	1	7	8
	U10h.	…X, also called Ecstasy before or during sex? [XECT2_9]	0	1	7	8
	U10i.	…Special K, also called ketamine before or during sex? [SPECK2_9]	0	1	7	8
	U10j.	…GHB before or during sex? [GHB2_9]	0	1	7	8
	U10k.	…heroin or opium that is smoked or snorted before or during sex? [HEROI2_9]	0	1	7	8
	U10l.	…marijuana before or during sex? [MARIJ2_9]	0	1	7	8
	U10m.	…poppers, also called amyl nitrate, before or during sex? [POPPE2_9]	0	1	7	8
	U10n.	…steroids or hormones before or during sex? [STRHO2_9]	0	1	7	8
	U10o.	… [RESPONSE FROM U9o] before or during sex? [ONINJ2_9]	0	1	7	8

Inconsistency check: If U9 (non-injection drug use before or during sex) is “Yes” and all of the responses to U10a-U10o are “Never,”, then the program should display a message saying, “You said that you used non-injection drugs before or during sex during the past 12 months. Please tell me the name of the drug you used and how often you used it before or during sex during the past 12 months.” Interviewer return to previous questions.

Injection Drug Use

SAY: “The next questions are about injection drug use. This means injecting drugs yourself or having someone else inject you. Please remember that your answers will be kept secure to the extent permitted by law and that you do not have to answer any questions that you do not want to.”

U11. During the past 12 months, have you shot up or injected any drugs that weren’t used for medical purposes? By shooting up, I mean anytime you might have used drugs with a needle, either by mainlining, skin popping, or muscling. [INJECT12]

Skip to Say box before P1

No  0

Yes  1

Skip to Say box before P1

Refused to answer  7

Don’t know  8

SAY: “Now I'm going to read you a list of drugs. For each drug I mention, please tell me how often you injected it during the past 12 months.”

Interviewer instructions: If the respondent’s drug use was sporadic during the past 12 months, ask the respondent to choose the response option that best characterizes his or her use.

	During the past 12 months, how often did you inject: [SHOW RESPONSE CARD G.]	Daily (1)	Weekly (2)	Monthly (3)	Less than monthly (4)	Never (5)	Refused to answer (7)	Don’t Know (8)
U12a.	…heroin and cocaine together, also called speedballs? [HERCOC_9]	1	2	3	4	5	7	8
U12b.	…heroin alone? [HEROII_9]	1	2	3	4	5	7	8
U12c.	…cocaine alone? [COCAII_9]	1	2	3	4	5	7	8
U12d.	…crack? [CRACKI_9]	1	2	3	4	5	7	8
U12e.	…methamphetamines, also called crystal, meth, tina, or crank? [CRAMTI_9]	1	2	3	4	5	7	8
U12f.	…other amphetamines or stimulants? [AMPHEI_9]	1	2	3	4	5	7	8
U12g.	…Oxycontin? [OXYCON_9]	1	2	3	4	5	7	8
U12h.	…steroids or hormones? [STRHRI_9]	1	2	3	4	5	7	8
U12i.	…any other drug (Specify:__________)? [OINJDI_9][OINJD9OS]	1	2	3	4	5	7	8

Inconsistency check: If U11 (injection drug use) is “Yes” and all of the responses to U12a-U12i are “Never,”, then the program should display a message saying, “You said that you used injection drugs during the past 12 months. Please tell me the name of the drug you used and how often you used it during the past 12 months.” Interviewer return to previous questions.

Interview instructions:

If S1 (male respondent had sex with a woman during the past 12 months) and S5 (male respondent had sex with a man during the past 12 months) are “No,” “Refused to answer,” or “Don’t know,” skip to Say box before U15.

If S9 (female respondent had sex with a man during the past 12 months) is “No,” “Refused to answer,” or “Don’t know,” skip to Say box before U15.

U13. During the past 12 months, did you inject drugs before or during sex? [INJ_BFSX]

Skip to Say box before U15

No  0

Yes  1

Skip to Say box before U15

Refused to answer  7

Don’t know  8

Interview instructions: If U12a is “Daily,” “Weekly,” “Monthly,” or “Less than monthly,” check the shaded box (column 1) in U14a. Follow the same pattern for b–i. If no shaded boxes are checked in U12, skip to Say box before U15.
		During the past 12 months, did you inject: [ONLY READ QUESTIONS WHERE THE SHADED BOX (COLUMN 1) IS CHECKED.]	No (0)	Yes (1)	Refused to answer (7)	Don’t Know (8)
	U14a.	…heroin and cocaine together before or during sex? [HERCO2_9]	0	1	7	8
	U14b.	…heroin alone before or during sex? [HERII2_9]	0	1	7	8
	U14c.	…cocaine alone before or during sex? [COCAI2_9]	0	1	7	8
	U14d.	…crack before or during sex? [CRACI2_9]	0	1	7	8
	U14e.	…methamphetamines before or during sex? [CRAMI2_9]	0	1	7	8
	U14f.	…other amphetamines or stimulants before or during sex? [AMPHI2_9]	0	1	7	8
	U14g.	…Oxycontin before or during sex? [OXYCO2_9]	0	1	7	8
	U14h.	…steroids or hormones before or during sex? [STRHI2_9]	0	1	7	8
	U14i.	…[RESPONSE FROM U14i] before or during sex? [OINJI2_9]	0	1	7	8

Inconsistency check: If U13 (injection drug use before or during sex) is “Yes” and all of the responses to U14a-U14i are “Never,”, then the program should display a message saying, “You said that you used injection drugs before or during sex during the past 12 months. Please tell me the name of the drug you used and how often you used it before or during sex during the past 12 months.” Interviewer return to previous questions.

SAY: “Now I am going to ask you some questions about sharing needles and equipment.”

U15. When you injected during the past 12 months, did someone use the same needle after you used it? [SHR_NDL]

No  0

Yes  1

Refused to answer  7

Don’t know  8

U16. When you injected during the past 12 months, did someone use the same cookers, cotton, or rinse water after you used it? [SHR_WRKS]

No  0

Yes  1

Refused to answer  7

Don’t know  8

Prevention Activities

Say: “Next I'd like to ask you about HIV prevention activities.”

Skip to instructions before P2

P1. During the past 12 months, have you gotten any free condoms, not counting those given to you by a friend, relative, or sex partner? [COND12_9]

No  0

Yes  1

Skip to instructions before P2

Refused to answer  7

Don’t know  8

P1a. From what type of place or places did you get these free condoms?

[DON’T READ CHOICES. CHECK ALL THAT APPLY.] [CONFR_9]

Community-based organization  1 [CONFR_9A]

Family planning clinic  2 [CONFR_9B]

STD clinic  3 [CONFR_9C]

Doctor’s office or other health clinic  4 [CONFR_9D]

IDU outreach organization (including needle exchange)  5 [CONFR_9E]

Social venue (bar, club, bathhouse, gym, bookstore)  6 [CONFR_9F]

Special event  7 [CONFR_9G]

Other 1 (Specify:______________________________)  8 [CONFR_9H] [CONF_9HO]

Other 2 (Specify:______________________________)  9 [CONFR_9I] [CONF_9IO]

Other 3 (Specify:______________________________)  10 [CONFR_9J] [CONF_9JO]

Other 4 (Specify:______________________________)  11 [CONFR_9K] [CONF_9KO]

Refused to answer  77

Don’t know  88

Interviewer instructions: If U11 (injection drug use during the past 12 months) is “Yes,” go to P2. If U11 is “No,” “Refused to answer,” or “Don’t know,” skip to P4.

P2. During the past 12 months, have you gotten any new sterile needles for free, not including those given to you by a friend, relative, or drug-using partner? [STENEE_9]

No  0

Yes  1

Refused to answer  7

Don’t know  8

P3. During the past 12 months, have you gotten any new cookers, cotton, or rinse water for free, not including those given to you by a friend, relative, or drug-using partner? [KITS_9]

No  0

Yes  1

Refused to answer  7

Don’t know  8

P4. During the past 12 months, have you discussed your personal drug and sex behaviors with an outreach worker, counselor, or prevention program worker and talked about how these behaviors could increase the risk of transmitting HIV to someone else?

No………………….……………………………  0

Yes………………………..………….………….  1

Refused to answer……………………………….  7

Don’t Know…………………………  9

P5. During the past 12 months, not including when you may have been tested for HIV, have

you had a one-on-one conversation with an outreach worker, counselor, or prevention program worker about ways to protect yourself or your partners from getting HIV or other sexually transmitted diseases? [TALKHI_9]

No  0

Yes  1

Refused to answer  7

Don’t know  8

P6. During the past 12 months, have you had a one-on-one conversation with a doctor, nurse, or other health care worker about ways to protect yourself or your partners from getting HIV or other sexually transmitted diseases? [PRVDRTLK]

No  0

Yes  1

Refused to answer  7

Don’t know  8

P7. During the past 12 months, have you participated in an organized session involving a small group of people to discuss ways to protect yourself or your partners from getting HIV or other sexually transmitted diseases? [GROU12_9]

No  0

Yes  1

Refused to answer  7

Don’t know  8

P8. During the past 12 months, have you seen any public campaigns or ads that are specifically for HIV positive people about how they can stop the spread of HIV?

Skip to Say box before C1; if female skip to say box before G1

No  0

Yes  1

Skip to Say box before C1; if female skip to say box before G1

Refused to answer  7

Don’t know  8

P9. Where did you see or hear these campaigns or ads? [READ CHOICES. CHECK ALL THAT APPLY.]

At a clinic  1

Radio  2

TV  3

Buses, subway, or other public transportation  4

Internet  5

Other (Specify:__________________________)  6

Refused to answer  7

Don’t know  8

Gynecological and Reproductive History

Interviewer instructions: If ES7 (birth gender) and ES8 (self-identified gender) are “Female,” go to Say box before G1; otherwise, skip to instructions before C1

SAY: “I’m now going to ask some questions about pelvic exams and Pap smears. A pelvic exam is a vaginal examination. A Pap smear, also called a cervical cancer test or Pap test, is a test used to check for cancer of the cervix. Often a pelvic exam and Pap smear are performed at the same time.”

G1. During the past 12 months, have you had a pelvic examination? [PLV_EX_9]

No  0

Yes  1

Refused to answer  7

Don’t know  8

G2. During the past 12 months, have you had a Pap smear? [PAP_EX_9]

No  0

Yes  1

Refused to answer  7

Don’t know  8

SAY: “Earlier you told me that you first tested positive for HIV on __ __/__ __ __ __ [INSERT DATE FROM A1]. Now I would like to ask you about pregnancies you may have had since testing positive for HIV.”

Coding note: If A1 is “don’t know” or “refused to answer,” then only say, “Now I would like to ask you about pregnancies you may have had since testing positive for HIV.”

Skip to instructions before C1

G3. Since testing positive for HIV in __ __/__ __ __ __ [INSERT DATE FROM A1], have you been pregnant? [PREGPS_9]

No  0

Yes  1

Skip to instructions before C1

Refused to answer  7

Don’t know  8

G3a. Since testing positive for HIV in __ __/__ __ __ __ [INSERT DATE FROM A1], how many times have you been pregnant? [PREG_9]

___ ___ ___ [777 = Refused to answer, 888 = Don’t know]

Inconsistency check: G3a (number of times the respondent has been pregnant since testing positive for HIV) must be ≤ 100.

Coding note: If A1 (date first tested positive) is “don’t know” or “refused to answer,” then G3a reads as follows: Since testing positive for HIV how many times have you been pregnant? [PREG_9].

G3b. Since testing positive for HIV in __ __/__ __ __ __ [INSERT DATE FROM A1], have you given birth to any children? [BRTH_CLD]

Skip to instructions before G5

No  0

Yes  1

Skip to instructions before G5

Refused to answer  7

Don’t know  8

Interviewer instructions: If response to G3a (number of times pregnant since testing positive) is “1” and G3b (gave birth) is “Yes,” skip to instructions before G5.

Coding note: If A1 (date first tested positive) is “don’t know” or “refused to answer,” then G3b reads as follows: Since testing positive for HIV have you given birth to any children? [BRTH_CLD]

G3c. Since testing positive for HIV in __ __/__ __ __ __ [INSERT DATE FROM A1], how many times have you given birth? If you gave birth to twins, please count this as one birth. [NUM_BRTH]

___ ___ [77 = Refused to answer, 88 = Don’t know]

G4. Were you pregnant during the last 12 months?

Skip to instructions before G5

No  0

Yes  1

Skip to instructions before G5

Refused to answer  7

Don’t know  8

[Interviewer instructions: If the woman has been pregnant in the last 12 months, ask G5. If she has not been pregnant in the last 12 months, skip to Health Conditions and Preventative Therapy section.]

G5. During your most recent pregnancy in the last 12 months, did you take any antiretroviral medications prescribed by your doctor to prevent your baby from getting infected with HIV?

No  0

Yes  1

Refused to answer  7

Don’t know  8

G6. Did you find out you were HIV-positive during this pregnancy?

Skip to instructions before C1

No  0

Yes  1

Skip to instructions before C1

Refused to answer  7

Don’t know  8

G6a. Did you find out you were HIV-positive because a doctor, nurse, or healthcare provider encouraged you to have an HIV test (as part of your prenatal care)?

No  0

Yes  1

Refused to answer  7

Don’t know  8

Inconsistency check: G3c (number of times the respondent has given birth since testing positive for HIV) must be ≤ 35. G3c cannot be greater than G3.

Health Conditions and Preventive Therapy (C)

SAY: “Now I’m going to ask you some questions about CD4 tests.”

Skip to Say box before C4

C1. Have you ever had a CD4 test? [CD4_DO_9]

No  0

Yes  1

Skip to Say box before C4

Refused to answer  7

Don’t know  8

C1a. What was the month and year of your first CD4 count? [CD4FM_9]

__ __/ __ __ __ __

^{(M M / Y Y Y Y )} [Month: 77 = Refused to answer, 88= Don’t know;

Year: 7777 = Refused to answer, 8888 = Don’t know]

Inconsistency check: Confirm response if C1a (date of first CD4 count) is earlier than the A4 (date of first visit to a provider for HIV care) or later than A6 (date of most recent visit to a provider for HIV care).

Programming note for C1a: Allow for “??” for month. If C1a (date of first CD4 count) is earlier than the A5 (date of first visit to a provider for HIV care), display the following confirmatory response: “Respondent said that date of first CD4 count was earlier than date first went to a HIV provider. Confirm response.” Allow program to advance. If C1a (date of first CD4 count) is later than the A6 (most recent care visit), display the following confirmatory response: “Respondent said that date of first CD4 count was later than date of most recent visit to an HIV provider. Confirm response.” Allow program to advance.

C1b. What was the result of your first CD4 count? [SHOW RESPONSE CARD H.] [CD4FCT_9]

0–49  1

50–99  2

100–199  3

200–349  4

350–499  5

500 or more  6

Refused to answer  7

Don’t know  8

C2. What was the month and year of your most recent CD4 count? [CD4MR11]

__ __/ __ __ __ __

^{(M M / Y Y Y Y )} [Month: 77 = Refused to answer, 88= Don’t know;

Year: 7777 = Refused to answer, 8888 = Don’t know]

Inconsistency check: Date cannot be earlier than C1a (date of first CD4 count). Date cannot be later than I4 9date of interview).

Programming note for C2: Allow for “??” for month.

C2a. What was the result of your most recent CD4 count?

[USE RESPONSE CARD H.] [CDRMR_11]

0-49  1

50-99  2

100-199  3

200-349  4

350-499  5

500 or more  6

Refused to answer  7

Don’t know  8

SAY: “Now I’m going to ask you about CD4 counts during the past 12 months. Remember, that is from last year (DATE WITH PREVIOUS YEAR) to now (INTERVIEW DATE).”

Programming note for Say box before C3: The program should enter the appropriate dates. EXAMPLE: If IDATE is 11/11/2011 then the program should read “That is from last year, 11/11/2010 to now 11/11/2011.”

C3. During the past 12 months, how many CD4 counts have you had? [CD12_N_9]

___ ___ [77=Refused to answer, 88=Don’t know]

Inconsistency check: C3 (number of CD4 counts in the past 12 months) must be ≤ 76.

SAY: “Now I’m going to ask you some questions about HIV viral load tests. HIV viral load tests measure the amount of HIV in your blood.”

Skip to Say box before C7

C4. Have you ever had an HIV viral load test? [VL_DO_9]

No  0

Yes  1

Skip to Say box before C7

Refused to answer  7

Don’t know  8

C5. What month and year was your first viral load test done? [VL_FM_9]

__ __/ __ __ __ __

^{(M M / Y Y Y Y )} [Month: 77 = Refused to answer, 88= Don’t know;

Year: 7777 = Refused to answer, 8888 = Don’t know]

Inconsistency check: Confirm response if C5 (date of the first viral load test) is earlier than A4 (date of first visit to a provider for HIV care). Confirm response if C5 (date of the first viral load test) is later than A6 (date of most recent visit to a provider for HIV care).

Programming note for C5: Allow for “??” for month. If C5 is earlier than A4, display the following confirmatory response: “Respondent said date of first viral load test was earlier than date of first visit to a provider. Confirm response.” Allow the program to advance. If C5 is later than A6, display the following confirmatory response: “Respondent said date of first viral load test was later than date of most recent visit to a provider. Confirm response.” Allow the program to advance.

C5a. What was the result of your first viral load test? [SHOW RESPONDENT RESPONSE CARD M.] [VL_FIR_9]

Below the level of detection, undetectable  1

Detectable but less than 5,000 viral copies/ml  2

5,000 to 100,000 viral copies/ml  3

Greater than 100,000 viral copies/ml  4

Refused to answer  7

Don’t know  8

C5b. What was the month and year of your most recent viral load test? [VLMR_11]

__ __/ __ __ __ __

^{(M M / Y Y Y Y )} [Month: 77 = Refused to answer, 88= Don’t know;

Year: 7777 = Refused to answer, 8888 = Don’t know]

Programming note for C5b: Allow for “??” for month.

C5c. What was the result of your most recent viral load test?

[USE RESPONSE CARD I.] [CDRRV_11]

Below the level of detection, undetectable  1

Detectable but less than 5,000 viral copies/ml  2

5,000 to 100,000 viral copies/ml  3

Greater than 100,000 viral copies/ml  4

Refused to answer  7

Don’t know  8

SAY: “Now I’m going to ask you about your viral load tests during the past 12 months. That is from last year (DATE WITH PREVIOUS YEAR) to now (INTERVIEW DATE).”

Programming note for Say box before C6: The program should enter the appropriate dates. EXAMPLE: If IDATE is 11/11/2011 then the program should read “That is from last year, 11/11/2010 to now 11/11/2011.”

C6. During the past 12 months, how many viral load tests have you had? [VL12_N_9]

___ ___ [77=Refused to answer, 88=Don’t know]

Inconsistency check: C6 (number of viral load tests) must be ≤ 76.

SAY: “Now I’m going to ask you about an AIDS-related infection. Many patients with HIV take medicines to prevent or treat these infections. One of these is called tuberculosis or TB.”

C7. Have you ever had a skin test (PPD) for TB? [TEST_PPD]

No………………….…………………..……  0 Skip to C8 Yes………………………………………..……  1

Skip to C8

Refused to answer……………………………  7

Don’t know…..........  8

C7a. When did you have your most recent TB skin test? [PPD_MY]

__ __/ __ __ __ __

^{(M M / Y Y Y Y )} [Month: 77 = Refused to answer, 88= Don’t know;

Year: 7777 = Refused to answer, 8888 = Don’t know]

C7b. Was your most recent skin test positive? [PPD_POS]

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

Refused to answer……………………………  7

Don’t know…..........  8

SAY: “Now I’m going to ask you about getting checked for hepatitis.”

C8. Have you been tested for hepatitis in the past 12 months?

Skip to HC4

No………………….……………………………  0

Yes……………………………………………...  1

Skip to HC4

Refused to answer………………………………  7

Don't know…………..……………………... ….  9

SAY: “There are vaccines or shots to prevent hepatitis. I’m going to ask you whether you’ve had these vaccines. Don’t include shots that you may have had after contact with someone who had Hepatitis A or B.”

C8a. Have you ever had a vaccine or shot to prevent hepatitis? [HEPVAC_9]

No  0

Yes  1

Refused to answer  7

Don’t know  8

SAY: “Now I’m going to ask you about sexually transmitted diseases, also called STDs. Syphilis, gonorrhea, chlamydia, and genital herpes are examples of STDs.”

C9. During the past 12 months, have you had a test or exam to check for an STD? [EXMSTD_9]

Skip to C11

No  0

Yes  1

Skip to C11

Refused to answer  7

Don’t know  8

C10. In the past 12 months, did you have a test to check for any of the following: [READ

CHOICES.]

	Yes (1)	No (0)	Refused (7)	Don’t know (8)
a. Syphilis [SYPHIL]				
b. Gonorrhea (“clap” or “drip”) [GONO]				
c. Chlamydia [CHLAM]				
d. Herpes (HSV) [HERP]				
e. Genital warts (HPV) [GENWAR]				

Interviewer instructions: Only ask C10f if response to DEMOGRAPHICS ES7 (birth gender) is “Male” and DEMOGRAPHICS ES8 (self-identified gender) is “Male,” OR if response to DEMOGRAPHICS ES7 is “Female” and DEMOGRAPHICS ES8 is “Male” or “Transgender.”

f. Non-gonococcal urethritis (NGU) [NGONOUR]				
g. Other [OSTD1] (Specify:______________ [OSTD2]				

C11. During the past 12 months, has a doctor, nurse, or other health care worker told you that you had any of the following: [READ CHOICES.]

		No (0)	Yes (1)	Refused to answer (7)	Don’t know (8)
a.	Syphilis [DIASYP_9]				
b.	Gonorrhea (clap or drip) [DIAGON_9]				
c.	Chlamydia [DIACHL_9]				
d.	Herpes (HSV) [DIAHER_9]				
e.	Genital warts (HPV) [DIAGEN_9]				
f.	Any other STD (Specify:__________) [OSTD3_9] [OSTD_9OS]				

C12. During the past 12 months, have you been to a clinic for STD treatment? [STDCLI_9]

No  0

Yes  1

Refused to answer  7

Don’t know  8

SAY: “Now I’m going to ask about vaccinations.”

Skip to C13b

C13. During the past 12 months, did you get a vaccine or shot to protect you from seasonal flu? [VACFL_10]

No  0

Yes  1

Skip to Say box at End of Interview

Refused to answer  7

Don’t know  8

C13a. Where did you get your most recent seasonal flu vaccine? [READ CHOICES. CHECK ONLY ONE.] [LOCVA_10]

Doctor’s office  1

Health department clinic  2

Drugstore or store (i.e. CVS, Walgreens, Target)  3

Employer  4

Other (Specify:_________________________)  5 [LOC_10OS]

Refused to answer  7

Don’t know  8

Interviewer Instructions: Skip to Say box at End of Interview.

C13b. What was the main reason you did not get a seasonal flu vaccine during the past 12 months? [DO NOT READ CHOICES.] [C13B_FLU]

I could not find a place that offered the vaccine……………  1

My provider did not offer me the vaccine………………… 2

I was concerned about side effects from the vaccine  3

I was concerned about the safety of the vaccine…………… 4

I did not think I needed it  5

I did not have enough insurance or money  6

Other (Specify_______________________________)  7 [C13B_FOS]

Refused to answer  77

Don’t know  88

Don’t know  88

EMPLOYMENT AND PRODUCTIVITY

SAY: “Now I’m going to ask you some questions about employment and recent work experiences. ”

E1	Are you currently employed? Yes No (If No, skip to Q7) Refused to answer Don’t know
E2	About how many hours altogether did you work in the past 7 days? Number of hours (00-97)
E3	About how many hours does your employer expect you to work in a typical 7-day week? (If it varies, estimate the average.) Number of hours (00-97)
E4	How many days does your employer expect you to work in a typical 7-day week? Number of days (0-7)
E5	Now please think of your work experiences over the past 4 weeks (28 days). In the spaces provided below, write the number of days you spent in each of the following work situations. In the past 4 weeks (28 days), how many days did you… Q5a. …miss an entire work day because of problems with your physical or mental health related to HIV/AIDS? (Please include only days missed for your own health, not someone else’s health.) Number of days (00-28) Q5b. …miss an entire work day for any other reason (including vacation)? Number of days (00-28) Q5c. …miss part of a work day because of problems with your physical or mental health related to HIV/AIDS? (Please include only days missed for your own health, not someone else’s health.) Number of days (00-28) Q5d. …miss part of a work day for any other reason (including vacation)? Number of days (00-28) Q5e. …come in early, go home late, or work on your day off? Number of days (00-28)
E6	About how many hours altogether did you work in the past 4 weeks (28 days)? (See examples below) Number of hours in the past 4 weeks (28 days) Examples for calculating Hour Worked in the Past 4 Weeks 40 hours per week for 4 weeks = 160 hours 35 hours per week for 4 weeks = 140 hours 40 hours per week for 4 weeks with 2 8-hour days missed= 144 hours 40 hours per week for 4 weeks with 3 4-hour partial days missed= 148 hours 40 hours per week for 4 weeks with 2 8-hour days missed and 3 4-hour partial days missed= 112 hours
E7	Are you currently unemployed because you lost your most recent job due to HIV/AIDS? Yes No Refused to answer Don’t know
E8	When did you stop working at that job which you lost due to HIV/AIDS? Year Month Refused to answer Don’t know
E9	What was your yearly individual income, before taxes, from the most recent year of your current job or most recent job which you lost due to HIV/AIDS? Yearly Income $0 to $4,999 $5,000 to $9,999 $10,000 to $14,999 $15,000 to $19,999 $20,000 to $29,999 $30,000 to $39,999 $40,000 to $49,999 $50,000 to $74,999 $70,000 to $99,999 $100,000 to $149,999 $150,000 to $199,999 $200,000 to $249,000 $250,000 or above* Refused to answer Don’t know
E10	Choose the occupation category that best describes your current or previous job [If none of the categories fits you exactly, please respond with the closest category to your experience.] (Select only one.) Executive, administrator, or senior manager (e.g., CEO, sales VP, plant manager) Professional (e.g., engineer, accountant, system analyst) Technical support (e.g., lab technician, legal assistant, computer programmer) Sales (e.g., sales representative, stockbroker, retail sales) Clerical and administrative support (e.g., secretary, billing clerk, office supervisor) Service occupation (e.g., security officer, food service worker, janitor) Precision production and crafts worker (e.g., mechanic, carpenter, machinist) Operator or laborer (e.g., assembly line worker, truck driver, construction worker)
E11	In the past 4 weeks, how many fewer hours did you spend on unpaid household activities because of your physical or mental health problem related to HIV/AIDS? (See examples below) Number of hours (00-97) Note: Household activities don’t include any paid employment. Examples of household activities are inside housework, food cooking and clean-up, household management, shopping, obtaining services, travel for household activity, direct child care and physically looking out for or helping household children and adults including providing them with transportation for their own personal needs.

Interview Completion

End of Interview

SAY: “Thank you again for taking part in this interview. Please remember that all the information you have given me will be kept secure to the extent permitted by law.”

Interviewer instructions:

Offer assistance with information and resources, according to local protocol.

Don’t pay the respondent if the respondent already participated in the clinic-based interview during the 2011 data collection cycle OR the respondent is less than 18 years old.

Pay the respondent if the interview was partially or fully completed.

Payment Verification

E1. Payment made: [PAYMENT]

No  0

Yes  1 Skip to E2

E1a. Why was payment not made? [PAYNMAD]

Skip to E3

Participant refused payment  1

Other (Specify:_____________________________)  2

[OPAY]

E2. Receipt signed (or initialed): [RECEIPT]

No  0

Yes  1 Skip to E3

E2a. Why was receipt not signed? [RECNS]

Participant refused to sign  1

Other (Specify:_____________________________)  2

[ORECEI]

Data Validity

E3. How confident are you of the validity of the respondent’s answers? [CONF]

Confident  1

Some doubts  2

Not confident at all  3

E4. Record any additional comments, including disruptions that might have taken place during the interview, reason the interview might have been stopped, or why the respondent’s answers may not have been reliable. [ADDCOM1]

Programming note for E4: Include a NA response option if Interviewers do not have any additional comments.

Response Cards

Response Card A

Monthly Income Yearly Income

a. $0 to $417 a. $0 to $4,999

b. $418 to $833 b. $5,000 to $9,999

c. $834 to $1250 c. $10,000 to $14,999

d. $1251 to $1667 d. $15,000 to $19,999

e. $1668 to $2500 e. $20,000 to $29,999

f. $2501 to $3333 f. $30,000 to $39,999

g. $3334 to $4167 g. $40,000 to $49,999

h. $4168 to $6250 h. $50,000 to $74,999

i. $6251 or more i. $75,000 or more

Response Card B

HIV case management services

Counseling about how to prevent the spread of HIV

Medicine through the AIDS Drug Assistance Program (ADAP)

Professional help remembering to take your HIV medicines on time or correctly

HIV peer group support

Dental care

Mental health services

Drug or alcohol counseling or treatment

Public benefits including Supplemental Security Income (SSI) or Social Security

Disability Insurance (SSDI)

Domestic violence services

Shelter or housing services

Meal or food services

Home health services

Transportation assistance

Childcare services

Interpreter services

Other HIV-related services

Response Card C

Never Rarely About half of the time Most of the time Always

Response Card D

Within the past week

1–2 weeks ago

3–4 weeks ago

1–3 months ago

More than 3 months ago

Never skip medicines

Response Card D-1

Never

Rarely

About half of the time

Most of the time

Always

Been on medications less than 30 days

Response card e

Not at all sure Somewhat sure	Very sure Extremely sure
 0 1 2 3

Response card f

Very dissatisfied Somewhat dissatisfied	Somewhat satisfied Very satisfied
 0 1 2 3

RESPONSE CARD G

Daily Weekly Monthly Less than Monthly Never

Alcohol Response Card

Response card h

0–49

50–99

100–199

200–349

350–499

500 or more

Response card i

Below the level of detection, undetectable

Detectable but less than 5,000 viral copies/ml

5,000 to 100,000 viral copies/m

Greater than 100,000 viral copies/ml

Medication Response card 1

Medication Response card 2

2011 Calendar

January

February

March

Su	Mo	Tu	We	Th	Fr	Sa
						1
2	3	4	5	6	7	8
9	10	11	12	13	14	15
16	17	18	19	20	21	22
23	24	25	26	27	28	29
30	31

Su	Mo	Tu	We	Th	Fr	Sa
		1	2	3	4	5
6	7	8	9	10	11	12
13	14	15	16	17	18	19
20	21	22	23	24	25	26
27	28

Su	Mo	Tu	We	Th	Fr	Sa
		1	2	3	4	5
6	7	8	9	10	11	12
13	14	15	16	17	18	19
20	21	22	23	24	25	26
27	28	29	30	31

April

May

June

Su	Mo	Tu	We	Th	Fr	Sa
					1	2
3	4	5	6	7	8	9
10	11	12	13	14	15	16
17	18	19	20	21	22	23
24	25	26	27	28	29	30

Su	Mo	Tu	We	Th	Fr	Sa
1	2	3	4	5	6	7
8	9	10	11	12	13	14
15	16	17	18	19	20	21
22	23	24	25	26	27	28
29	30	31

Su	Mo	Tu	We	Th	Fr	Sa
			1	2	3	4
5	6	7	8	9	10	11
12	13	14	15	16	17	18
19	20	21	22	23	24	25
26	27	28	29	30

July

August

September

Su	Mo	Tu	We	Th	Fr	Sa
					1	2
3	4	5	6	7	8	9
10	11	12	13	14	15	16
17	18	19	20	21	22	23
24	25	26	27	28	29	30
31

Su	Mo	Tu	We	Th	Fr	Sa
	1	2	3	4	5	6
7	8	9	10	11	12	13
14	15	16	17	18	19	20
21	22	23	24	25	26	27
28	29	30	31

Su	Mo	Tu	We	Th	Fr	Sa
				1	2	3
4	5	6	7	8	9	10
11	12	13	14	15	16	17
18	19	20	21	22	23	24
25	26	27	28	29	30

October

November

December

Su	Mo	Tu	We	Th	Fr	Sa
						1
2	3	4	5	6	7	8
9	10	11	12	13	14	15
16	17	18	19	20	21	22
23	24	25	26	27	28	29
30	31

Su	Mo	Tu	We	Th	Fr	Sa
		1	2	3	4	5
6	7	8	9	10	11	12
13	14	15	16	17	18	19
20	21	22	23	24	25	26
27	28	29	30

Su	Mo	Tu	We	Th	Fr	Sa
				1	2	3
4	5	6	7	8	9	10
11	12	13	14	15	16	17
18	19	20	21	22	23	24
25	26	27	28	29	30	31

2012 Calendar

January

February

March

Su	Mo	Tu	We	Th	Fr	Sa
1	2	3	4	5	6	7
8	9	10	11	12	13	14
15	16	17	18	19	20	21
22	23	24	25	26	27	28
29	30	31

Su	Mo	Tu	We	Th	Fr	Sa
			1	2	3	4
5	6	7	8	9	10	11
12	13	14	15	16	17	18
19	20	21	22	23	24	25
26	27	28	29

Su	Mo	Tu	We	Th	Fr	Sa
				1	2	3
4	5	6	7	8	9	10
11	12	13	14	15	16	17
18	19	20	21	22	23	24
25	26	27	28	29	30	31

April

May

June

Su	Mo	Tu	We	Th	Fr	Sa
1	2	3	4	5	6	7
8	9	10	11	12	13	14
15	16	17	18	19	20	21
22	23	24	25	26	27	28
29	30

Su	Mo	Tu	We	Th	Fr	Sa
		1	2	3	4	5
6	7	8	9	10	11	12
13	14	15	16	17	18	19
20	21	22	23	24	25	26
27	28	29	30	31

Su	Mo	Tu	We	Th	Fr	Sa
					1	2
3	4	5	6	7	8	9
10	11	12	13	14	15	16
17	18	19	20	21	22	23
24	25	26	27	28	29	30

July

August

September

Su	Mo	Tu	We	Th	Fr	Sa
1	2	3	4	5	6	7
8	9	10	11	12	13	14
15	16	17	18	19	20	21
22	23	24	25	26	27	28
29	30	31

Su	Mo	Tu	We	Th	Fr	Sa
			1	2	3	4
5	6	7	8	9	10	11
12	13	14	15	16	17	18
19	20	21	22	23	24	25
26	27	28	29	30	31

Su	Mo	Tu	We	Th	Fr	Sa
						1
2	3	4	5	6	7	8
9	10	11	12	13	14	15
16	17	18	19	20	21	22
23	24	25	26	27	28	29
30

October

November

December

Su	Mo	Tu	We	Th	Fr	Sa
	1	2	3	4	5	6
7	8	9	10	11	12	13
14	15	16	17	18	19	20
21	22	23	24	25	26	27
28	29	30	31

Su	Mo	Tu	We	Th	Fr	Sa
				1	2	3
4	5	6	7	8	9	10
11	12	13	14	15	16	17
18	19	20	21	22	23	24
25	26	27	28	29	30

Su	Mo	Tu	We	Th	Fr	Sa
						1
2	3	4	5	6	7	8
9	10	11	12	13	14	15
16	17	18	19	20	21	22
23	24	25	26	27	28	29
30	31

Clinic Survey OMB #0920-new 14

July 13, 2011