Community Survey - Eligible Injection Drug Users

Form Approved:

OMB No. 0920-new

Expiration Date: XX/XX/XXXX

Monitoring Outcomes of the Enhanced Comprehensive HIV Prevention Plan (ECHPP) Project

Attachment 3b

Community Survey

Public reporting burden of this collection of information is estimated to average 25 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: CDC, Project Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: OMBPRA (0920-XXXX). Do not send the completed form to this address.

Read say box below

SAY: “Most people have never been in an interview like this one, so I’m going to describe how it works before we start. I will read you the questions exactly as they are written. Some may sound awkward but I need to read them as worded so everyone in the study is asked the same questions. Some questions will ask you to recall if you did something, when you did it, or how often you did it. For others, I’ll read or show you a list of responses to choose from. Please be as accurate as you can.

______________________________________________________

Read SAY box below.

SAY: I will first ask you some questions about where you live. Please remember that all of your answers will be kept secure to the extent permitted by law.

C1. In the past 12 months, have you been homeless at any time? By homeless, I mean you were living on the street, in a shelter, in a Single Room Occupancy hotel (SRO), or in a car.

Skip to C2

No………………….……………………………  0

Yes……………………………………………… 1

Skip to C2

Refused to answer………………………………  7

Don't know……………..……………………….. 9

C1a. Are you currently homeless?

No………………….……………….…………..  0

Yes….……………………………….…….........  1

Refused to answer………………………..……..  7

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

C2. Which zip code do you live in?

[Refused = 77777, Don't know = 99999] __ __ __ __ __

SAY: The next few questions are about health insurance. By health insurance, we mean health plans people get through employment or plans that are purchased directly, as well as government programs like Medicare and Medicaid that provide medical care or help pay medical bills.

C3. Do you currently have health insurance or health care coverage?

No………………….……………………………  0 Skip to C4

Skip to C4

Yes……………………………………………...  1 Refused to answer………………………………  7

Don't know……………..……………………...  9

C3a. I’m going to read you a list of ways that people get health care insurance or coverage. Please tell me which ones on this list describe how you get your health care coverage. You can choose more than one. Did you get your current health care coverage through…[Give participant Flashcard F. READ choices. Check ALL that apply.]

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

Medicaid / [local Medicaid name] (for people with low incomes)….……….…………………..…………………………………………..... 02

Medicare (for the elderly and people with disabilities)…………..………..……….. 03

Some other Medical Assistance program / [local non-Medicaid name]….....…….. 04

TRICARE (CHAMPUS)….………..…………..  05

Veterans Administration coverage………..……  06

Some other health care plan……….………….. 07

(Specify______________________________)

Refused to answer………………………………  77

Don't know……………..……………………..  99

C4. Do you consider yourself to be: [READ CHOICES. CHECK ONLY ONE.]

Heterosexual or "Straight"…………….……......  1

Homosexual, Gay, or Lesbian………………….  2

Bisexual………………………………………..  3

Refused to answer…………………..………….  7

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

SAY: Next, I'm going to ask you some questions about having sex. Please remember that your answers will be kept secure to the extent permitted by law. GIVE RESPONDENT FLASHCARD F.1

For these questions, "having sex" means oral, vaginal, or anal sex. Oral sex means mouth on the vagina or penis; vaginal sex means penis in the vagina; and anal sex means penis in the anus (butt). I need to ask you all the questions, even if some may not apply to your situation.

Interviewer: Use your discretion in using slang terms for the following sexual behavior questions.

SEXUAL BEHAVIOR

INTERVIEWER INSTRUCTIONS: Refer to response to Gender Question (ES7).

GO TO C5

Male

GO TO C14

Female

FOR MALE RESPONDENTS ONLY

Female Sex Partners (Male respondent)

Skip to Say Box before C11

Skip to Say Box before C11

C5. Have you ever had vaginal or anal sex with a woman?

No………………….……………………………  0

Yes……………………………………………...  1

Refused to answer………………………………  7

Don't know……………..…………………….....  9

C6. In the past 12 months, that is, since <interview month> of last year, with how many different women have you had oral, vaginal, or anal sex? ___ ___ ____ ____

[Refused = 7777, Don't know = 9999]

Skip Pattern for # of Female Sex Partners:

If C6=1: Ask C7a. (RT column)

If C6> 1: Ask C7. (LT column)

If C6= 0, 7777, or 9999: Sex partner confirmation (below)

________________________________________________________________________

Sex partner confirmation:

If C6=0, 7777, or 9999, read:

I would like to clarify your response. You indicated that you haven’t had sex with a woman in the past 12 months. Is that correct?

No………………….……………………………  0

Yes……………………………………………...  1

Refused to answer……………………………...  7

Don’t know…………………………………...  9

If NO (NOT correct), go to C6 (ask it again)

If IDU: go to Say box before C11

If HET: YES, (correct), Refused, or Don’t know go to <end of interview>

____________________________________________________________________________

____________________________________________________________________________

Multiple Female Partners [Read questions in this column] Refused = 7777, Don't know = 9999			One Female Partner [Read questions in this column] No = 0, Yes = 1, Refused = 7, Don't know = 9
SAY: Now I'm going to ask you about the _______ [insert number from C6 ] female sex partners you had in the past 12 months.			SAY: Now I'm going to ask you about the female sex partner you had in the past 12 months.
Question	Response	Skip Pattern	Question	Response	Skip Pattern
C7a. Of your ______ [insert number from C6] female partners in the past 12 months, with how many did you have vaginal sex?	[_____]	If 0, 7777, or 9999, skip to C7c.	C7as. In the past 12 months, did you have vaginal sex with this woman?	[_____]	If 0, 7, or 9, skip to C7cs.
C7b. In the past 12 months, with how many of these ______ [insert number from C7a] women did you have vaginal sex without using a condom?	[_____]		C7bs. In the past 12 months, did you have vaginal sex with her without using a condom?	[_____]
C7c. Of your ______ [insert number from C6] female partners in the past 12 months, with how many did you have anal sex?	[_____]	If 0, 7777, or 9999, skip to C7e.	C7cs. In the past 12 months, did you have anal sex with this woman?	[_____]	If 0, 7, or 9, skip to C7es.
C7d. In the past 12 months, with how many of these ______ [insert number from C7c] women did you have anal sex without using a condom?	[_____]		C7ds. In the past 12 months, did you have anal sex with her without using a condom?	[_____]
C7e. Of your ____ [insert number from C6 ] female partners, how many did you have sex with for the very first time in the past 12 months?	[_____]		C7es. Think about the very first time you had sex with this woman. Was it within the past 12 months?	[_____]
C7g. Of your ______ [insert number from Q14] female partners in the past 12 months, how many did you give things like money or drugs in exchange for sex?			C7gs. In the past 12 months, did you give this woman things like money or drugs in exchange for sex?
C7h. Of your ______ [insert number from C6 ] female partners in the past 12 months, how many gave you things like money or drugs in exchange for sex?			17hs. In the past 12 months, did this woman give you things like money or drugs in exchange for sex?		If C7as=1, skip to C11.

C8. In the past 12 months, 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

C9. In the past 12 months 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

C10. In the past 12 months, 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 Sex Partners (Male respondent)

SAY: Now I'm going to ask you some questions about having sex with other men. I need to ask you these questions even if some don't apply to you. Please remember your answers will be kept secure to the extent permitted by law. [GIVE RESPONDENT FLASHCARD F.2]

For these questions, "having sex" means anal sex. Anal sex means you put your penis in his anus (butt) or he put his penis in your anus (butt).

C11. Have you ever had anal sex with a man?

No………………….………….………………..  0 Skip to Say Box before C20 Yes………………………………..………….....  1

Refused to answer…………………………..…..  7 Skip to Say Box before C20

Don't know……………..………….………......  9

[77 = Refused, 99 = Don't know] __ __

C12. In the past 12 months, that is, since <interview month> of last year, with how many different men have you had anal sex?

[Refused = 7777, Don't know = 9999] ___ ___ ___ ___

If 0, 7777, or 9999,

Skip Pattern For Multiple Male Partners:

If C12 is not equal to 0, 7777, or 9999, go to Say Box below.

Otherwise, if C13 is not equal to 0, 7777, or 9999, go to Say Box before C14.

MAIN MALE PARTNERS

Multiple male Partners [Read questions in this column] Refused = 7777, Don't know = 9999			One male Partner [Read questions in this column] No = 0, Yes = 1, Refused = 7, Don't know = 9
SAY: Now I'm going to ask you about the _______ [insert number from C12] male sex partners you had in the past 12 months.			SAY: Now I'm going to ask you about the male sex partner you had in the past 12 months.
Question	Response	Skip Pattern	Question	Response	Skip Pattern
C13a. In the past 12 months, with how many of these ______ [insert number from C12] men did you have anal sex without using a condom?			C13as . In the past 12 months, did you have anal sex with this man?	[_____]	If 0, 7, or 9, skip to C13cs.
C13b. Did you know the HIV status of any of these ___ [insert number from C13a ] men?	[_____]		C13bs. In the past 12 months, did you have anal sex with him without using a condom?	[_____]
C13b.1. For how many of these men did you know their HIV status?	[_____]	If 0, 7, or 9, skip to C13c	C13bs.1. Did you know his HIV status?	[_____]	If 0,7, or 9, skip to C13cs.
C13b.2. Of those ___ [insert number from C13b.1] men, how many did you know were HIV-positive?	[_____]		C13bs.2. What was his HIV status?	HIV+…1 HIV-…2 IND…3 Ref…7 DK…9
C13b.3. How many did you know were HIV-negative?	[_____]
	[_____]
Flow check		C13b.2 + C13b.3 must = C13b.1
C13c. Of your ____ [insert number from C12] male partners, how many did you have sex with for the very first time in the past 12 months?	[_____]		C13cs. Think about the very first time you had sex with this man. Was it within the past 12 months?	[_____]
C13d. Of your ______ [insert number from Q42] male partners in the past 12 months, how many did you give things like money or drugs in exchange for sex?			C13ds. In the past 12 months, did you give this man things like money or drugs in exchange for sex?
C13e. Of your ______ [insert number from C12] male partners in the past 12 months, how many gave you things like money or drugs in exchange for sex?			C13es. In the past 12 months, did this man give you things like money or drugs, in exchange for sex?		If C12=1, skip to Q48.

FOR FEMALE RESPONDENTS ONLY

Male Sex Partners (Female respondent)

C14. Have you ever had vaginal or anal sex with a man?

Skip to C20

No………………….……………………………  0

Skip to C20

Yes……………………………………………...  1 Refused to answer………………………………  7

Don't know……………..……………………...  9

C15. In the past 12 months, that is, since <interview month> of last year, with how many different men have you had oral, vaginal, or anal sex?

___ ___ ____ ____

________________________________________________________________________

Sex partner confirmation:

If C15=0, 7777, or 9999, read:

I would like to clarify your response. You indicated that you haven’t had sex with a man in the past 12 months. Is that correct?

No………………….……………………………  0

Yes……………………………………………...  1

If NO (NOT correct), go to C15 (ask it again)

If IDU: go to Say box before C20

If HET: YES, (correct), Refused, or Don’t know go to <end of interview>

____________________________________________________________________________

____________________________________________________________________________

MULTIPLE MALE PARTNERS (FEMALE PARTICPANTS)

Multiple MALE Partners [Read questions in this column] Refused = 7777, Don't know = 9999			One MALE Partner [Read questions in this column] No = 0, Yes = 1, Refused = 7, Don't know = 9
SAY: Now I'm going to ask you about the _______ [insert number from C15] male sex partners you had in the past 12 months.			SAY: Now I'm going to ask you about the male sex partner you had in the past 12 months.
Question	Response	Skip Pattern	Question	Response	Skip Pattern
C16a. Of your ______ [insert number from Q15] male partners in the past 12 months, with how many did you have vaginal sex?	[_____]	If 0, 7777, or 9999, skip to C16c.	C16as. In the past 12 months, did you have vaginal sex with this man?	[_____]	If 0, 7, or 9, skip to C16cs.
C16b. In the past 12 months, with how many of these ______ [insert number from a] men did you have vaginal sex without using a condom?	[_____]		C16bs. In the past 12 months, did you have vaginal sex with him without using a condom?	[_____]
C16c. Of your ______ [insert number from C15] male partners in the past 12 months, with how many did you have anal sex?	[_____]	If 0, 7777, or 9999, skip to C16e.	C16cs. In the past 12 months, did you have anal sex with this man?	[_____]	If 0, 7, or 9, skip to C16es.
C16d. In the past 12 months, with how many of these ______ [insert number from C16c] men did you have anal sex without using a condom?	[_____]		C16ds. In the past 12 months, did you have anal sex with him without using a condom?	[_____]
C16e. Of your ____ [insert number from C15] male partners, how many did you have sex with for the very first time in the past 12 months?	[_____]		C16es. Think about the very first time you had sex with this man. Was it within the past 12 months?	[_____]
C16f. Of your ______ [insert number from C15] male partners in the past 12 months, how many did you give things like money or drugs in exchange for sex?			C16fs. In the past 12 months, did you give this man things like money or drugs in exchange for sex?
C16g. Of your ______ [insert number fromC15 ] male partners in the past 12 months, how many gave you things like money or drugs in exchange for sex?			C16g. In the past 12 months, did this man give you things like money or drugs in exchange for sex?		If Q14as=1, skip to Q20.

C17. In the past 12 months, did you have anal or vaginal sex without a condom with a man whose HIV status you didn't know?

No………………….……………………………  0

Yes……………………………………………...  1

Refused to answer……………………………...  7

Don’t know…………………………………...  9

C18. In the past 12 months did you have vaginal or anal sex without a condom with a man who was HIV negative?

No………………….……………………………  0

Yes……………………………………………...  1

Refused to answer……………………………...  7

Don’t know…………………………………...  9

C19. In the past 12 months, did you have vaginal or anal sex without a condom with a man who was HIV positive?

No………………….……………………………  0

Yes……………………………………………...  1

Refused to answer……………………………...  7

Don’t know…………………………………...  9

SAY: The next questions are about alcohol use. Please remember that your answers will be kept secure to the extent permitted by law. For these questions, "a drink of alcohol" means a 12 oz beer, a 5 oz glass of wine, or a 1.5 oz shot of liquor. SHOW RESPONDENT FLASHCARD K (PICTURE OF ALCOHOL DRINK SIZE)

ALCOHOL USE HISTORY

C20. In the past 12 months, how often did you drink any alcohol such as beer, wine, malt liquor, or hard liquor?

GIVE RESPONDENT FLASHCARDJ. READ CHOICES. CHECK only ONE.

Never…..…………………  0

More than once a day……  1

Once a day……………………………………………… 2

More than once a week..…  3

Once a week……….........  4

More than once a month…  5

Once a month….…………….  6

Less than once a month…..…….  7

Refused to answer………………  77

Don’t know…………………………  99

If C20=0, 77, or 99, skip to say box before C22

C21. In the past 12 months, how often did you have 5 or more alcoholic drinks in one sitting?

[4 or more drinks if respondent is female.] GIVE RESPONDENT FLASHCARD J, READ CHOICES. CHECK only ONE.

Never….….…………………..…………………  0

More than once a day…..……………………….  1

Once a day……………………………………… 2

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

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

More than once a month………………………..  5

Once a month…..……………………………….  6

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

Refused to answer……………..………………  77

Don’t know………..……………………………  99

DRUG USE HISTORY

Injection Drug Use

FOR IDU, GO TO Say Box before C22a

FOR HET, SKIP TO Say Box before C30

SAY: The next questions are about injection drug use. This means injecting drugs yourself or having someone who isn't a health care provider inject you. Please remember that your answers will be kept secure to the extent permitted by law.

C22a. When was the last time you injected any drug? That is, how many days or months or years ago did you last inject?

[Interviewer: If respondent answers today, enter “000” in # of Days field]

# of Days: __ __ __

# of Months: __ __ __

# of Years: __ __ __

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

If > 12 months, skip to end of survey

SAY: The next questions are about injection drug use in the past 12 months. When I ask you about "needles," I'm talking about needles and syringes.

C22b. In the past 12 months, on average, how often did you inject? [GIVE RESPONDENT FLASHCARD J. READ CHOICES. CHOOSE only ONE.]

Never……………………..00

More than once a day……..01

Once a day…………………02

More than once a week……03

Once a week………………04

More than once a month….05

Once a month……………..06

Less than once a month….. 07

Refused to answer………...08

C23. In the past 12 months when you injected, did you get your needles at any of the following places? [GIVE RESPONDENT FLASHCARD L; READ ALL CHOICES]

No Yes Refused Don’t

to answer know

a. Pharmacy or drug store ……... …………………………….. 0… 1… 7…. 9

b. Doctor’s office, clinic, or hospital………………………….. 0… 1… 7…. 9

c. Friend, acquaintance, relative, or sex partner……………….. 0… 1… 7…. 9

d. Needle or drug dealer, shooting gallery, hit house, off the street.... 0… 1… 7 9

e. Needle exchange program……………………………………… 0… 1… 7. 9

f. Some other place……………………………………………… 0… 1… 7… 9

(Specify ___________________________)

C24. In the past 12 months when you injected, how often did you use a new, sterile needle? By a new, sterile needle, I mean a needle never used before by anyone, even you.

[GIVE RESPONDENT FLASHCARD M, READ CHOICES. CHECK only ONE.]

Never……….…….…………………..…………  0

Rarely…………….……………….……..…….  1

About half the time……………………………..  2

Most of the time…..……..……………………...  3

Always.….……………..……………………….  4

Refused to answer…..…………………………..  7

Don’t know………..……………………………  9

SAY: Next, I'm going to ask you about your injecting behaviors in the past 12 months.

C25. In the past 12 months, how often did you use needles that someone else had already injected with? [GIVE RESPONDENT FLASHCARD M, READ CHOICES. CHECK only ONE]

Never……….…….…………………..…………  0

Rarely…………….……………….……..…….  1

About half the time……………………………..  2

Most of the time…..……..……………………...  3

Always.….……………..……………………….  4

Refused to answer……………..………………..  7

Don’t know………..……………………………  9

C26. In the past 12 months when you injected, how often did you use a cooker that someone else had already used? [GIVE RESPONDENT FLASHCARD M, READ CHOICES, CHECK only ONE.]

Never……….…….…………………..………… 0

Rarely…………….……………….……..……...  1

About half the time……………………………..  2

Most of the time…..……..……………………...  3

Always.….……………..……………………….  4

Refused to answer……………..………………..  7

Don’t know………..……………………………  9

C27. In the past 12 months when you injected, how often did you use a cotton that someone else had already used? [GIVE RESPONDENT FLASHCARD M, READ CHOICES, CHECK only ONE.]

Never……….…….…………………..………… 0

Rarely…………….……………….……..……...  1

About half the time……………………………..  2

Most of the time…..……..……………………...  3

Always.….……………..……………………….  4

Refused to answer……………..………………..  7

Don’t know………..……………………………  9

C28. In the past 12 months when you injected, how often did you use water that someone else had already used? [GIVE RESPONDENT FLASHCARD M, READ CHOICES, CHECK only ONE]

Never……….…….…………………..………… 0

Rarely…………….……………….……..……...  1

About half the time……………………………..  2

Most of the time…..……..……………………...  3

Always.….……………..……………………….  4

Refused to answer……………..………………..  7

Don’t know………..……………………………  9

C29. In the past 12 months when you injected, how often did you use cookers, cottons, or water that someone else had already used? [GIVE RESPONDENT FLASHCARD M, READ CHOICES, CHECK only ONE.]

Never……….…….…………………..………… 0

Rarely…………….……………….……..……...  1

About half the time……………………………..  2

Most of the time…..……..……………………...  3

Always.….……………..……………………….  4

Refused to answer……………..………………..  7

Don’t know………..……………………………  9

SAY: Now I’m going to ask you about drugs that you may have used but did not inject. I will refer to these as non-injection drugs. This includes drugs like marijuana, crystal meth, cocaine, crack, club drugs, painkillers, or poppers.

Non-Injection Drug Use

C30. In the past 12 months, have you used any non-injection drugs, other than those prescribed for you?

Skip to Say Box before C32

Skip to Say box before C32

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

Refused to answer………………………………  7 Don't know……………..……………………..  9

SAY: I'm going to read you a list of drugs. For each drug I mention, please tell me how often you used it in the past 12 months. Do not include drugs you injected or drugs that were prescribed for you. GIVE RESPONDENT FLASHCARD J

C31. How often did you use:

READ EACH DRUG CHOICE. CHOOSE ONLY ONE RESPONSE PER TYPE OF DRUG.

More More More Less

than than than than

once a Once a once a Once a once a Once a once a Refused

Never day day week week month month month to

answer

k. Marijuana……………… 00……01…… 02……03…... 04……05…........ 06………07………77

a. Crystal meth (tina, crank,

or ice)..…………………… 00……01…… 02……03…... 04……05…........ 06…… 07………77

b. Crack cocaine……………....00……01….... 02……03…... 04……05…....... 06………07………77

c. Powdered cocaine that is smoked

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

d. Downers such as Valium,

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

e. Painkillers such as Oxycontin,

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

f. Hallucinogens such as LSD

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

g. X or Ecstasy…………….. 00……01…… 02……03…... 04……05…........ 06………07………77

j. Heroin that is

smoked or snorted…….. 00……01…… 02……03…... 04……05…........ 06………07………77

C31a. In the past 12 months, have you used any other non-injection drugs?

No………………….……………………………  0 Skip to Say box before

C32

Yes……………………………………………… 1

Refused to answer………………………………  7 Skip to Say box before

C32

Don't know……………..……………………... 9

Specify other drug _____________________

C31b. How often did you use:

More More More Less

than than than than

once a Once a once a Once a once a Once a once a Refused

Never day day week week month month month to

answer

m. (Other drug). .00.. 01…..02…..03…...04…… 05….....06…….07……77

HIV TESTING AND TREATMENT EXPERIENCES

SAY: Now I’m going to ask you a few questions about getting tested for HIV. Remember, an HIV test checks whether someone has the virus that causes AIDS.

Skip to Say Box before HC1

C32. Have you ever been tested for HIV?

No…………………………...…………..............  0

Yes………………..……………………..............  1

Skip to Say Box before HC1

Refused to answer………………………………  7

Don't know……………..……………………...  9

C33. Did you have an HIV test in the last 12 months [that is, since (date 12 months prior to interview date)]?

No…………………………...…………..............  0

Yes………………..……………………..............  1

C33a. When did you have your most recent HIV test?

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

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

INTERVIEWER INSTRUCTIONS:

HIV testing was not widely available before 1985. Please confirm the year. Is &[C33a] correct?

Yes…………………………………………… ₁ Go to next question

No……………………………………………  ₀ Loop back to put in the correct year

C34 For your most recent test, at what type of facility were you tested? [DON’T READ CHOICES. CHECK ONLY ONE.]

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

Refused to answer  77

Don’t know  88

C35. What was the result of your most recent HIV test? [DO NOT Read choices, check only ONE.]

Skip to Say box before HC1

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

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

Skip to Say box before HC1

Indeterminate…………..……………..…………  4 Refused to answer…………...….……………….  7

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

C36. Before your test in ____/_____ [insert date from Q35], did you ever test positive for HIV?

No………………….……………………………  0

Yes……………………………………………...  1

Refused to answer………………………………  7

Don't know……………..……………………...  9

C37. When did you first test positive?

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

(M M / Y Y Y Y )

CONF23. INTERVIEWER INSTRUCTIONS:

HIV testing was not widely available before 1985. Please confirm the year. Is &[POS1STDY] correct?

Yes……………………………………… 1 Go to next question

No………………………………………  0 Loop back to put in the correct year

C38. After you tested positive, were you asked by someone from the health department or your health care provider to give the names of your sex or drug use partners so they could be

notified that they may have been exposed to HIV?

No…….……………….……………………………  0

Yes…..……………………………………………...  1

Refused to answer…..………………………………  7

Don't know…………………..……………………...  9

C39. Did you give the names or contact information of any of your partners when asked?

No…….……………….……………………………  0

Yes…..……………………………………………...  1

Refused to answer…..………………………………  7

Don't know…………………..……………………...  9

C40. Have you ever been seen by a doctor, nurse, or other health care provider for a medical

evaluation or care related to your HIV infection?

No…….……………….……………………………  0

Skip to C42

Yes…..……………………………………………...  1

Refused to answer…..………………………………  7

Don't know…………………..……………………...  9

C41. What is the main reason you have never gone to a health care provider for a medical

evaluation or care related to your HIV infection? [DO NOT read choices. Choose only ONE reason.]

Feel good, don't need to go …………………..……………………  01

Don't want to think about being HIV positive/Denial……………  02

Didn’t have money or insurance…..………….……………………..  03

Inconvenient (location/hours/time, etc.)....…………………………  04

Forgot to go/Missed appointment……………..……………………  05

Drinking or using drugs………….……………...............................  06

Appointment pending..………..…………………………………  07

Other……………………..…………………………………………  08

Refused.…………………………………………………………  77

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

If C41=8, ask C41a. Otherwise, skip to C45 .

C41a. Interviewer: Type in other reason Respondent never sought HIV care.

_____________________

Skip to C45.

.

C42. When did you first go to your health care provider after learning you had HIV?

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

(M M / Y Y Y Y )

INTERVIEWER INSTRUCTIONS: Refer to date of first positive HIV test

< 3 months before first provider visit Skip to C44

> 3 months before first provider visit Go to next question

Interval cannot be determined (date missing) Skip to C44

C43. Some people go to a health care provider soon after learning they are positive; others do not. What is the main reason you didn’t go to a health care provider soon after you learned of your HIV infection? [DO NOT read choices. Choose only ONE reason.]

Felt good, didn't need to go ……..…………………..…………………  01

Didn't want to think about being HIV positive/Denial…………………  02

Didn’t have money or insurance……..………….……………………..  03

Inconvenient (location/hours/time, etc.)…....………………………….  04

Forgot to go/Missed appointment………….………..…………………  05

Drinking or using drugs……………...……………................................  06

Unable to get an earlier appointment……….…………………………  07

Other…….…………………..………………………………………….  08

Refused…………………………………………………………………  77

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

If C43 = 8, ask C43a. Otherwise, go to C44.

C43a Interviewer: Type in other reason Respondent did not seek HIV care soon after diagnosis:

_________________________________

C44. When did you last go to your health care provider for HIV care?

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

(M M / Y Y Y Y )

C45. Are you currently taking antiretroviral medicines to treat your HIV infection?

No………………….……………………………  0

Skip to C47

Yes……………………………………………...  1

Refused to answer………………………………  7

Don't know…………..……………………... ….  9

C46. What is the main reason you are not currently taking any antiretroviral medicines? [DO NOT read reason types. Choose only ONE reason.]

Feel good, don’t need them……….......……..………………….  01

CD4 count and viral load are good……….……….....................  02

Doctor advised to delay treatment…………..………….............  03

Don't want to think about being HIV positive/Denial…………  04

Worried about side effects …………..………..…….….............  05

Don't have money or insurance……………….…………....…..  06

Drinking or using drugs…………………..…..…….…………..  07

Recently into medical care……..……………………………...  08

Other……………………………..……………………..............  09

Refused…………………………………………………………  77

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

If C46 = 9, ask C46a. Otherwise, go to C47

C46a Interviewer: Type in other reason Respondent is not currently taking ARVs:

____________________________

C47. In the past 12 months, have you taken anti-HIV medicines after sex because you thought it would keep you from getting HIV?

No………………….……………………………  0

Yes……………………………………………...  1 Refused to answer………………………………  7

Don't know…………..……………………... ….  9

C48. Please tell me if you got any of the anti-HIV medicines you took from the following people or places. Did you get them from…[GIVE RESPONDENT FLASHCARD N. READ ALL

CHOICES.]

	No	Yes	Refused to answer	Don’t know
Doctor or other health care provider	0	1	7	9
Sex partner, friend, relative, or acquaintance	0	1	7	9
Internet	0	1	7	9
Some other place (Specify ______________)	0	1	7	9

C48a. Interviewer: Type in other specified place ______________________________.

HEALTH CONDITIONS

SAY: The next questions are about hepatitis, an infection of the liver.

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

Skip to HC4

No………………….……………………………  0

Yes……………………………………………...  1

Skip to HC4

Refused to answer………………………………  7

Don't know…………..……………………... ….  9

HC-1a. What type or types of hepatitis have you had? [CHECK ALL THAT APPLY.]

Hepatitis A……….…………………………….  0

Hepatitis B………………….………….............  1

Hepatitis C……………………………..............  2

Other……………..…………….………………  3

If Other: Specify__________________

Refused to answer………………………………  7

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

HC-2. Have you ever taken medicine to treat your hepatitis infection?

No………………….……………………………  0

Yes……………………………………………...  1

Refused to answer………………………………  7

Don't know…………..……………………... ….  9

HC-3. When were you told you had hepatitis? [READ CHOICES. CHECK ONE.]

6 months ago or less.…………………………….…….  0

More than 6 months, but less than 1 year ago.……..….  1

At least 1 year but less than 5 years ago ………………  2

At least 5 years but less than 10 years ago……..……  3

10 years ago or more…...……………..……………….  4

Refused to answer…………………..…………………  7

Don't know……………..…………...…………………  9

HC-4. There are vaccines or shots that can prevent some types of hepatitis. Have you ever had a

hepatitis vaccine?

No………………….……………………………  0

Yes……………………………………………...  1

Refused to answer………………………………  7

Don't know…………..……………………... ….  9

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

SAY: Now, I’m going to ask you some questions about sexually transmitted diseases, or STDs, other than HIV and hepatitis.

HC-5. In the past 12 months, that is, since (__/____), were you tested for… [READ choices. CHECK YES or NO for each one.]

No Yes Refused Don’t Know

To answer

a. Gonorrhea?…………..…………..  0......…  1……..  7…… …… 9

b. Chlamydia?…………....................  0......…  1……..  7……..….. 9

c. Syphilis?…………… ……………  0........  1… ….  7……..….. 9

d. Some other STD (except HIV)?….  0......…  1……..  7……..….. 9

d.1 If Yes: Specify__________________

HC-5a. You indicated you were tested for ________ in the past 12 months. Were you told that you had this disease?

No Yes Refused Don’t Know

To answer

a. Gonorrhea?…………..…………..  0......…  1……..  7………… 9

b. Chlamydia?…………....................  0......…  1……..  7……..….. 9

c. Syphilis?…………… ……………  0........  1…….  7……..….. 9

d. Some other STD (except HIV)?….  0......…  1……..  7……..….. 9

d.1 If Yes: Specify__________________

HC-6. Have you ever had a skin test (PPD) for TB?

No………………….…………………..……  0 Skip to P1 Yes………………………………………..……  1

Skip to P1

Refused to answer……………………………  7

Don’t know…..........  8

HC-6a. When did you have your most recent TB skin test?

__ __/ __ __ __ __

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

[Month: 77 = Refused to answer, 88= Don’t know; Year: 7777 = Refused to answer, 8888 = Don’t know]

HC-6b. Was your most recent skin test positive?

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

Refused to answer……………………………  7

Don’t know…......... .  8

ASSESSMENT OF PREVENTION ACTIVITIES

Say: Next I'd like to ask you about HIV prevention activities that happen around here.

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

No…………….………………….……………..  0

Yes…………………………………..………….. 1

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

Don’t Know………….…………………………. 9

P1a. Have you used any of the free condoms you received?

No………………….……………………………  0

Yes………………………..………….…………. 1

Refused to answer……………………………….  7

Don’t Know…………………………………….  9

If HET, skip to P4

P2. In the past 12 months, have you gotten any new sterile needles for free, not including those given to you by a friend, relative, or sex partner?

Skip to P3

No…………….………………….……………..  0

Yes…………………………………..………….. 1

Skip to P3

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

Don’t Know………….…………………………. 9

P2a. Have you used any of the free sterile needles you received?

No………………….……………………………  0

Yes………………………..………….………….  1

Refused to answer……………………………….  7

Don’t Know…………………………………….  9

P3. In the past 12 months, have you gotten any new cookers, cotton, or water for free, not including those given to you by a friend, relative, or sex partner?

Skip to P4

No…………….………………….……………..  0

Yes…………………………………..………….. 1

Skip to P4

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

Don’t Know………….…………………………. 9

P3a. Have you used the free cookers, cotton, or water that you received?

No………………….……………………………  0

Yes………………………..………….………….  1

Refused to answer……………………………….  7

Don’t Know…………………………………….  9

P4. In the last 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 put you at risk for HIV infection/transmission?

No………………….……………………………  0

Yes………………………..………….………….  1

Refused to answer……………………………….  7

Don’t Know…………………………  9

P5. In the past 12 months, have you had a one-on-one conversation with an outreach worker, counselor, or prevention program worker about ways to prevent the spread of HIV? Don’t count the times when you had a conversation as part of an HIV test.

No………………….……………..……..............  0 Skip to P6

Yes…………………………….………............... 1

Refused to answer…………………….………...  7 Skip to P6

Don’t Know…………………………………….  9

If C35=2, go to P5a. Otherwise, skip to P6.

P5a. Did you have any of these one-on-one conversations after you found out you were HIV-positive?

No………………….……………………………  0

Yes………………………..………….………….  1

Refused to answer……………………………….  7

Don’t Know…………………………………….  9

P5b. During those one-on-one conversation(s), did you:

[ASK EACH QUESTION, MARK NO OR YES FOR EACH]

No Yes Refused Don't

to answer Know

1. Discuss ways to talk to a partner about safe sex?....  0…  1 …  7………. 9

If yes, ask:

2. Practice ways to talk to a partner about safe sex?......  0....  1…  7………. 9

3. Discuss ways to effectively use condoms?…...…….  0…  1…  7………. 9

If yes, ask:

4. Practice ways to effectively use condoms?............... 0… 1….. 7………. 9

[If injected drugs in past 12 months, ask:]

5. Discuss how to prepare for safe injections?…...…… 0… 1….. 7………. 9

If yes, ask:

6. Practice safe drug-injecting practices?……….....…… 0… 1….. 7………. 9

P6. In the past 12 months have you been a participant in any organized session(s) involving a small group of people to discuss ways to prevent the spread of HIV? Don't include discussions you had with a group of friends.

Skip to P7

No………………….……………………………  0

Yes………………………..………….………….  1

Skip to P7

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

Don’t Know…………………………...………... 9

If C35=2, go to P6a. Otherwise, skip to P7.

P6a. Were any of these sessions specifically designed for people who are HIV-positive?

No………………….……………………………  0

Yes………………………..………….………….  1

Refused to answer……………………………….  7

Don’t Know…………………………………….  9

P6b. During those organized group session(s), did you:

[ASK EACH QUESTION, MARK NO OR YES FOR EACH.]

No Yes Refused Don't

to answer Know

1. Discuss ways to talk to a partner about safe sex?....  0…  1 …  7………. 9

If yes, ask:

2. Practice ways to talk to a partner about safe sex?........  0....  1…  7………. 9

3. Discuss ways to effectively use condoms?…...……..  0…  1…  7………. 9

If yes, ask:

4. Practice ways to effectively use condoms?..................  0…  1…  7………. 9

[If injected drugs in past 12 months, ask:]

5. Discuss how to prepare for safe injections?…...…….  0… 1…  7………. 9

If yes, ask:

6. Practice safe drug-injecting practices?……….....…… 0… 1…  7………. 9

P7. In 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?

No………………….……………………………  0

Yes………………………..………….………….  1

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

Don’t Know…………………………...………... 9

P8. During the past 12 months, have you seen any public campaigns or ads that are specifically related to HIV or sexual health?

No  0

Yes  1

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

P10. 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?

No  0

Yes  1

Refused to answer  7

Don’t know  8

P11. 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

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.”

		During the past 12 months, did you get:	IF “NO” ASK: During the past 12 months, have you needed:	IF “YES” 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	{Use code list on next page}
M1.	Mental health services	a. [______] [MENC12_9]	b. [______] [MENCON_9]	[______] [MENCRS_9] Other (Specify:________) [MENC_9OS]
M2.	Drug or alcohol counseling or treatment	a. [______] [GET_SUBU]	b. [______] [NED_SUBU]	[______] [RS_SUBU] Other (Specify:________) [RS_U_9OS]
M3.	Domestic violence services	a. [______] [GET_DOMS]	b. [______] [NED_DOMS]	[______] [RS_DOMS] Other (Specify:________) [RS_D_9OS]
M4.	Shelter or housing services	a. [______] [SHLT12_9]	b. [______] [SHLTER_9]	[______] [SHLTRS_9] Other (Specify:________) [SHLT_9OS]
M5.	Home health services	a. [______] [HHSA12_9]	b. [______] [HHSASS_9]	[______] [HHSARS_9] Other (Specify:________) [HHSA_9OS]

Code list for M1-M5

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

BEFORE BEGINNING THE LOCAL QUESTIONS, THE INTERVIEWER ANSWERS THE FOLLOWING QUESTION. DO NOT READ THIS TO THE RESPONDENT.

154.   How confident are you of the validity of the respondent’s answers?

  Confident….…………………..……………… 1

Some doubts………………………..…………  2

Not confident at all…………………..….......... 3

If response is 2 or 3, please explain why you are not confident in the respondent's answers:

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

Auto5. Time core questionnaire ended: __ __:__ __  1 AM  2 PM

To the Interviewer: Do you have any additional comments to add?

If yes, enter comments below:

Interviewer Comments

Flashcards

FLASHCARD F.1

Definition of "Having Sex"

Oral, vaginal, or anal sex.

• Oral sex means mouth on the vagina or penis

• Vaginal sex means penis in the vagina

• Anal sex means penis in the anus (butt)

FLASHCARD F.2

Definition of "Having Sex"

Oral or anal sex.

• Oral sex means mouth on the penis

• Anal sex means penis in the anus (butt)

FLASHCARD J

0. Never

1. More than once a day

2. Once a day

3. More than once a week

4. Once a week

5. More than once a month

6. Once a month

7. Less than once a month

FLASHCARD K

FOR USE WITH ALCOHOL QUESTIONS

1 Shot of Liquor 1 Regular Beer 1 Glass of Wine
(Whisky, Vodka, Gin, etc.) 12 oz. 5 oz.
1.5 oz.

FLASHCARD L

a. Pharmacy or drug store

b. Doctor’s office, clinic, or hospital

c. Friend, acquaintance, relative, or sex partner

d. Needle or drug dealer, shooting gallery, hit house, off the street

e. Needle exchange program

FLASHCARD N

0. Sex partner

1. Friend or acquaintance

2. Relative

3. Needle or drug dealer

4. Stranger

FLASHCARD M

0. Never

1. Rarely

2. About half the time

3. Most of the time

4. Always

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Author	Brittani Robinson
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