Form 2a 2012 Standard Interview Questionnaire for Medical Monito
Medical Monitoring Project
Att_2a standard interview v8 3 1 b (2)
Patients Standard Interview
OMB: 0920-0740
Form Approved
OMB No.: 0920-0740
Expiration Date: 05/31/2012
2012 Standard Interview Questionnaire for
Medical Monitoring Project (MMP)
Do not use in field until May 2012
VERSION 8.3.0
Public reporting burden of this collection of information is estimated to average 45 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: CDC, Project Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0740). Do not send the completed form to this address.
_____________________________________________________________________________________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Disease Control and Prevention
Atlanta, GA 30333
2012 MMP QUESTIONNAIRE
HIV Testing and Care Experiences 13
Stigma and Discrimination (R) 43
HIV Treatment and Adherence (T) 45
Male Respondent – Female Partner 63
Male Respondent – Male Partner 75
Female Respondent – Male Partner 88
Female Respondent – Female Partner 100
Anxiety and Depression (M) 126
Gynecological and Reproductive History (G) 127
Health Conditions and Preventive Therapy (C) 131
Optional Module: Acculturation Scale (L) 139
General notes for QDS programmer (additional programming notes are located throughout the questionnaire):
Use version 2.4 of QDS.
Every question requires a response to move forward in the application unless otherwise noted.
Use the following values: .D = 8, .R = 7, NA = 6.
Add a questionnaire type variable (one for the standard version and one for the short version).
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”
QDS programming notes are not included in the application; they are merely there to help with coding.
Interviewer instructions and inconsistency checks are notes for the interviewers, but may also include coding instructions.
Code book should have a brief description of the variable. This includes all calculated variables.
Calculate version number using variable name VERSION.
Calculate data collection cycle using variable name CYCYR. CYCYR = 2012.
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
Label module sections in the code book. Use the Table of Contents for guidance.
PDP start date is January 1, 2012.
PDP end date is April 30, 2012.
RTS-PDP start date is four months prior to date of interview (e.g., if interview date is April 30, 2012, then RTS PDP start date is January 1, 2012.
RTS-PDP end date is date of interview.
Calculate the time to conduct an interview from D1 to L6.
Calculate time to conduct each module.
Do not include the Facility Visits Log, Response cards, and calendars in the QDS program.
Distinguish between English and Spanish versions of the questionnaires (note this is different than the language variable used in the short questionnaire).
Add a calculated variable MODE to distinguish between HAPI and CAPI users.
Preliminary Information (I)
Interviewer instructions: Enter Preliminary Information prior to interview.
I1. Participant ID [PARID]:
Site ID [SITEID] ___ ___ ___ ___
Facility ID [FACILID] ___ ___ ___ ___
Respondent ID [INDID] ___ ___ ___ ___
QDS 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]
QDS programming note for I2: Range 0-999
I2a. Handheld and computer device ID: ___ ___ ___
[DEVICEID]
QDS programming note for I2a: Range 0-999
I3. Interview setting: [CHECK ONLY ONE.] [INTSE_12]
Outpatient health facility 1
Inpatient health facility 2
Prison or jail facility 3
Community-based organization 4
Private home 5
Public venue (i.e., coffee shop, library) 6
Health department 7
Telephone 8
Other (Specify:_____________) 77 [INT_12OS]
I4. Interview date: __ __/ __ __ / __ __ __ __
[IDATE] (M M / D D / Y Y Y Y)
QDS programming note for I4: Automatically calculate in QDS.
I5. Are you conducting a telephone interview or face-to-face interview? [TI_F2F]
Telephone interview 1
Face-to-face interview 2
I6. Was the patient selected through real time sampling (RTS) and interviewed between [INSERT PDP START DATE] and [INSERT PDP END DATE]? [RTS_SAMP]
No 0
Yes 1
I7. Was the interview originally administered on paper? [MODEADM]
No 0
Yes 1
Demographics (D)
SAY: “I’d like to thank you for taking part in this interview. Remember that all the information you give me will be confidential and your name won’t be recorded in the survey responses. The answers to some questions may seem obvious to you, but I need to ask you all of the questions.”
Interviewer instructions: If I5 [TI_F2F] is “telephone interview,” then go to Say box below; otherwise skip to D1.
SAY: “You have chosen to complete the interview over the telephone. Before we begin, I would like to remind you that there is a set of response cards that I will ask you to refer to throughout the course of the interview. These response cards will be needed for some of the questions you will be asked during the interview. The set of cards contains a calendar, some pictures, and text to help guide you through the response options for some of the questions. Each card is labeled. Please keep this set of response cards nearby so you can use them when needed. I will let you know which questions require response cards and the label that corresponds to the card that is needed.”
D1. Have you ever participated in the MMP interview? [PARTCPT]
No
0
Skip
to D2
Skip to Say box before D2
Yes 1
Refused to
answer
7
Skip to D2
Don’t
know
8
D1a. What month and year did you participate in the MMP interview? [PARTIC]
__ __ / __ __ __ __
( 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: D1a (date respondent participated in MMP) cannot be earlier than January 2005 or later than I4 (interview date).
QDS programming note for D1a: This requires a full response for month and year. A full response could be “don’t know” or “refused” to some or all of the components of this date variable.
D1b. In what city were you interviewed?
_____________________________________ (City) [CITY_9]
[7 = Refused, 8 = Don’t know]
D1c. In what state were you interviewed?
_____________________________________ (State) [STATE_9]
[7 = Refused, 8 = Don’t know]
Interviewer instructions: If D1a (date participated in MMP) is during the 2012 data collection cycle, or “Refused to answer,” go to Say box before D2; otherwise, skip to D2.
QDS programming note for Interviewer instructions after D1c: parameters for the 2012 data collection cycle are May 1, 2012 to I4 (interview date).
SAY: “We are only interviewing people who haven’t already been interviewed during 2012 (2013). Thank you very much for your time.” [DISCONTINUE INTERVIEW AND SKIP TO INTERVIEW COMPLETION.]
QDS programming note for Say box after D1c: use 2012 if the year in I4 (date of interview) is 2012. Use 2013 if the year in I4 (date of interview) is 2013.
D2. What is your date of birth? [DOB]
__ __/ __ __ / __ __ __ __
(M M / D D / Y Y Y Y ) [Month: 77 = Refused to answer, 88= Don’t know;
Day: 77 = Refused to answer, 88= Don’t know;
Year: 7777 = Refused to answer, 8888 = Don’t know]
Inconsistency check: D2 (date of birth) cannot be earlier than January 1, 1900 or later than the I4 (interview date).
Interviewer instructions: If D2 (date of birth) is “Refused to answer” or “Don’t know,” go to D2a; otherwise skip to D2b.
QDS programming note for D2: This requires a full response for month, day, and year.
D2a. Were you at least 18 years old on January 1, 2012? [AGE_VER1]
No 0
Yes 1
Refused to answer 7
Don’t know 8
Interviewer instructions: If D2a is “No,” “Refused to answer,” or “Don’t know,” skip to Say box before D3. If D2a is “Yes,” skip to D3.
D2b. So, you were __ __ __ [INSERT AGE] years old on January 1, 2012. Is that correct? [AGEVERI]
SAY: “Please tell me your date of birth again.” Return to D2.
No 0
Yes 1
QDS programming note for D2b: Calculate using DOB on PDP start date.
Interviewer instructions: If D2b (respondent’s age on January 1, 2012) is less than 18, go to Say box before D3; otherwise, skip to D3.
SAY: “We are only interviewing people who were 18 years or older on January 1, 2012. Thank you very much for your time.” [DISCONTINUE INTERVIEW AND SKIP TO INTERVIEW COMPLETION.]
D3. 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
D4. Do you consider yourself to be Hispanic or Latino? [HISPAN_9]
No 0
Yes 1
Refused to answer 7
Don’t know 8
D5. Which racial group or groups do you consider yourself to be in? You may choose more than one option. [READ CHOICES. CHECK ALL THAT APPLY.] [RACE_9]
American Indian or Alaska Native 1 [RACE_9A]
Asian 2 [RACE_9B]
Black or African American 3 [RACE_9C]
Native Hawaiian or Other Pacific Islander 4 [RACE_9D]
White 5 [RACE_9E]
Refused to answer 77
Don’t know 88
D6. In what country or territory were you born? [DON’T READ CHOICES. CHECK ONLY ONE.] [CO_BORN]
Skip to D7
United States 1
Puerto Rico 2
Mexico 3
Cuba 4
Other (Specify: ____________________________) 5 [OTCTRY]
Skip to D7
Refused to answer 7
Don’t know 8
Interviewer instructions: If D6a (years living in the U.S.) is < 1 year, enter “0.”
D6a. How many years have you been living in the United States? [US_YRS]
__ __ __ years [Years: 777 = Refused to answer, 888 = Don’t know]
Inconsistency check: D6a (years living in the U.S.) must be ≤ the respondent’s age at the date of the interview. Range 0-776.
D7. What was your sex at birth? [READ CHOICES EXCEPT “Intersex/ambiguous.” CHECK ONLY ONE.] [BIRTGEN]
Male 1
Female 2
Intersex/ambiguous 3
Refused to answer 7
Don’t know 8
D8. Do you consider yourself to be male, female, or transgender? [READ CHOICES. CHECK ONLY ONE.] [GENDER]
Male 1
Female 2
Transgender 3
Refused to answer 7
Don’t know 8
D9. Do you think of yourself as: [READ CHOICES EXCEPT “Other.” CHECK ONLY ONE.] [SEXORI8]
Homosexual, gay, or lesbian 1
Heterosexual or straight 2
Bisexual 3
Other (Specify:____________________) 4 [SEXORI8]
Refused to answer 7
Don’t know 8
SAY: “Now I’m going to ask you some questions about the past 12 months. We will use the calendar to refer to the past 12 months. That is from last year (DATE WITH PREVIOUS YEAR) to now (INTERVIEW DATE).”
QDS programming note for Say box before D10: The QDS program should enter the appropriate dates. EXAMPLE: If IDATE is 11/11/2012 then the program should read “That is from last year, 11/11/2011 to now 11/11/2012.”
D10. |
During the past 12 months, have you |
No (0) |
Yes (1) |
Refused (7) |
Don’t know (8) |
D10a. |
…lived on the street? [HOMEL_9A]
|
0 |
1 |
7 |
8 |
D10b. |
…lived in a shelter? [HOMEL_9B] |
0 |
1 |
7 |
8 |
D10c. |
…lived in a Single Room Occupancy (SRO) hotel? [HOMEL_9C]
|
0 |
1 |
7 |
8 |
D10d. |
…lived in a car? [HOMEL_9D] |
0 |
1 |
7 |
8 |
D11. 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
Skip to D13
D12. 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
Yes 1
Skip to D13
Refused to answer 7
Don’t know 8
D12a. 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.] [KINDI12]
Private health insurance 1 [KIND_12A]
Medicaid 2 [KIND_12B]
Medicare 3 [KIND_12C]
Ryan White 4 [KIND_12D]
Tricare or CHAMPUS 5 [KIND_12E]
Veterans Administration coverage 6 [KIND_12F]
Other 1 (Specify:_______________) 7 [KIND_12G] [KIG_12OS]
Other 2 (Specify:_______________) 8 [KIND_12H] [KIH_12OS]
Refused to answer 77
Don’t know 88
D12b. 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
D13. 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 (e.g., “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_9OS]
Refused to answer 77
Don’t know 88
Programming note for Say box before D14 and D14a: use the previous calendar year. EXAMPLE: If interview date is 12-01-12, ask about 2011.
SAY: “Now I would like to ask you some questions about 2011 (2012). That is January 1st, 2011 (2012) to December 31st, 2011 (2012). For this next question, we will use Response Card A and the calendar.”
D14. In 2011 (2012), 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.]
SAY: “Please take a look at Response Card A and tell me the letter that corresponds to either your monthly or yearly household income before taxes.”
Monthly Income [MTH_IN12] Yearly Income [YR_IN12]
a. |
$0 to $416 |
j. |
$0 to $4,999 |
b. |
$417 to $833 |
k. |
$5,000 to $9,999 |
c. |
$834 to $1249 |
l. |
$10,000 to $14,999 |
d. |
$1250 to $1666 |
m. |
$15,000 to $19,999 |
e. |
$1667 to $2499 |
n. |
$20,000 to $29,999 |
f. |
$2500 to $3333 |
o. |
$30,000 to $39,999 |
g. |
$3334 to $4166 |
p. |
$40,000 to $49,999 |
h. |
$4167 to $6249 |
q. |
$50,000 to $74,999 |
i. |
$6250 or more |
r. |
$75,000 or more |
77 |
Refused to answer |
77 |
Refused to answer |
88 |
Don’t know |
88 |
Don’t know |
D14a. Including you, how many people depended on this income in 2011 (2012)? [DEPND_IN]
___ ___ [77 = Refused to answer, 88 = Don’t know]
Inconsistency check: D14a must be ≥ 1 and < 50.
Access to Care (A)
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 or later than April 30, 2012, the PDP end date, confirm response.
QDS 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. If A1 is later than April 30, 2012, display note to interviewers: ““The date entered is after 04/30/2012 (PDP end date). Go back to previous question to confirm date of HIV test.” The program will then go to the Say box before A2.
Interviewer instructions: If A1 (date first tested positive for HIV) is after April 30, 2012, go to the Say box before A2. If A1 is “Refused to answer,” “Don’t know,” or the month is unknown (??), skip to A7. If A1 (date first tested positive for HIV) is 12 months or earlier than I4 (interview date), go to A2; otherwise skip to instructions before A3.
SAY: “We are only interviewing people who tested positive for HIV before April 30, 2012. Thank you very much for your time.” [DISCONTINUE INTERVIEW AND SKIP TO INTERVIEW COMPLETION.]
Skip to interviewer instructions before A3
A2. Before your positive test in __ __ /__ __ __ __ [INSERT DATE FROM A1], did you ever have a negative HIV test? [HIVBEF_9]
No……... 0
Yes 1
Skip to interviewer instructions before A3
Refused to answer 7
Don’t know 8
QDS programming note for A2: Insert date from A1 in question.
A2b. What month and year did you get your most recent negative HIV test? Tell me when you got your result, not when you got your test. [LASTN_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: A2b (date of the most recent negative HIV test) cannot be earlier than D2 (respondent’s date of birth) or later than A1 (date first tested positive for HIV). If A2b is earlier than March 1985, confirm response.
QDS programming note for inconsistency check after A2b: If A2b is earlier than 03/1985, display note to 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 (date first tested positive for HIV) is 5 years or less than April 30, 2012, go to A3; otherwise skip to A7.
A3. 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 A3 (testing location) is “labor/delivery setting” or “OBGYN or family planning clinic” and D8 (sex at birth) is “male”.
QDS programming note for A3: Insert date in question. If A3 is “labor/delivery setting” or “OBGYN or family planning clinic” and D8 (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.
A3a. 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
QDS programming note for A3a: Insert date from A1 in question.
Inconsistency check: A3a (main reason tested) cannot be “due to pregnancy” if D8 (sex at birth) is “male”.
QDS programming note for inconsistency check after A3a: If D8 is “male” and response to A3a 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.
A4. 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
QDS programming note for A4: Insert date from A1 in question.
SAY: “For this next question we will need Response Card B.”
A4a. What was your response when someone from the health department or a health care provider offered to tell or help you tell your sex or drug use partners? [READ CHOICES CHECK ONLY ONE.] [RESNOT_9]
I asked them not to tell any of my partners 1
Skip to A4c
I asked them to tell all of my partners 3
Skip to Say box before A5
I told them that I didn’t have any partners 4
Refused to answer 7
Don’t know 8
A4b. What was the main reason you asked someone from the health department or a health care provider not to tell any of your partners? [READ CHOICES. CHECK ONLY ONE.] [NOPAR_10]
Didn’t know partners’ contact information 1
Was afraid of what partners would do 2
Didn’t trust health department/provider to tell partners 3
Was afraid partners would find out who may have infected
them 4
Wanted to tell partners personally 5
Partners are HIV positive 6
Other (Specify:___________________________________) 8 [NOP_10OS]
Refused to answer 77
Don’t know 88
Interviewer instructions: Skip to Say box before A5.
A4c. What was the main reason you asked someone from the health department or a health care provider to tell only some of your partners? [READ CHOICES. CHECK ONLY ONE.] [NOSOM_10]
Didn’t know some partners’ contact information 1
Was afraid of what some of his or her partners would do 2
Didn’t trust health department/provider to tell some partners 3
Was afraid some partners would find out who may have
infected them 4
Wanted to tell some partners personally 5
Some partners are HIV positive 6
Other (Specify:___________________________________) 8 [NOS_10OS]
Refused to answer 77
Don’t know 88
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.”
A5. 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 A5 (date first went to provider for HIV care) is earlier than the A1 (date first tested positive for HIV) or later than April 30, 2012, the PDP end date.
QDS programming note for inconsistency check after A5: If A5 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. If A5 is later than 04/30/2012, display a note to the interviewer: “The date entered is later than April 30, 2012 (PDP end date). Go back to previous question and confirm response.” Allow the program to advance. Allow a “??” for month response.
Interviewer instructions: If A5 (date first went to provider for HIV care) is > 3 months after A1 (date first tested positive for HIV), go to A6; otherwise, skip to A7. If A5 is “Refused to answer,” “Don’t know,” or an unknown month (??), skip to A7.
A6. 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
A7. 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: A7 (date of most recent visit to a provider for HIV care) cannot be earlier than A5 (date first visit to a provider for HIV care) or later than I4 (interview date).
QDS programming note for A7: Allow a “??” for the month response.
Interviewer instructions: If A7(date of most recent visit to a provider for HIV care) is > 6 months prior to I4 (interview date), go to A7a; otherwise, skip to Say box before A8. If A7 is “Refused to answer,” “Don’t know,” or an unknown month (??), skip to Say box before A8.
SAY: “For this next question we will use the calendar to refer to the past 6 months.”
A7a. 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.] [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
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.”
A8. 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]
Skip to A10
Yes
1
Skip to instructions before A12
Don’t know 8
A9. 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: Skip to instructions before A12.
A10. What is the name of this place where you went for most of your HIV medical care during the past 12 months?
QDS programming note: response for this question is not recorded in QDS.
Interviewer instructions: Go to paper Facility Visits Log and enter facility information for this place. Write USL in the Facility Type Code column. After entering this information, continue with the next question.
If I6 (patient sampled through RTS) is “yes,” then insert RTS-PDP start date and RTS-PDP end date for the following question. If I6 (patient sampled through RTS) is “no,” then insert PDP start date and PDP end date for the following question.
A10a. Did you get any sort of care at [USE FACILITY NAME] between [INSERT START DATE] and [INSERT END DATE]? [CAREPER1]
Skip to A11
Yes 1
Skip to A11
Don’t know 8
Interviewer instructions: If I6 (patient sampled through RTS) is “yes,” then insert RTS-PDP start date and RTS-PDP end date for the following question. If I6 (patient sampled through RTS) is “no,” then insert PDP start date and PDP end date for the following question.
A10b. Between [INSERT START DATE] and [INSERT END DATE], how many times had you been to [USE FACILTY NAME] for any sort of care? [TIMECAR]
___ ___ ___ [777 = Refused to answer, 888 = Don’t know]
Inconsistency check: The number of times the respondent visited a particular facility must be ≥ 1 and ≤ 121.
A11. About how many minutes does it usually take you to get to [USE FACILITY NAME]? [MIN_TRVL]
___ ___ ___ [777 = Refused to answer, 888 = Don’t know]
Inconsistency check: The number of minutes must be between 0 and 776.
Interviewer instructions: If D8 (birth gender) and D9 (self-identified gender) are “female,” go to A12; otherwise, skip to instructions before A13.
Skip to instructions before A13
No 0
Yes 1
Skip to instructions before A13
Don’t know 8
A12a. What is the name of the OBGYN or gynecological clinic where you received HIV care?
QDS programming note: response for this question is not recorded in QDS.
Interviewer instructions: Go to paper Facility Visits Log and enter facility information for this place. Write OBGYN in the Facility Type Code column. After entering this information, continue with the next question.
If I6 (patient sampled through RTS) is “yes,” then insert RTS-PDP start date and RTS-PDP end date for the following question. If I6 (patient sampled through RTS) is “no,” then insert PDP start date and PDP end date for the following question.
Skip to instructions before A13
A12b. Did you get any sort of care at [USE FACILITY NAME] between [INSERT START DATE] and [INSERT END DATE]? [CAREPER4]
No 0
Yes 1
Skip to instructions before A13
Don’t know 8
Interviewer instructions: If I6 (patient sampled through RTS) is “yes,” then insert RTS-PDP start date and RTS-PDP end date for the following question. If I6 (patient sampled through RTS) is “no,” then insert PDP start date and PDP end date for the following question.
A12c. Between [INSERT START DATE] and [INSERT END DATE], how many times had you been to [USE FACILITY NAME] for any sort of care? [TIMECAR4]
___ ___ ___ [777 = Refused to answer, 888 = Don’t know]
Inconsistency check: The number of times the respondent visited a particular facility must be ≥ 1 and ≤ 121.
Interviewer instructions: If response to D11 (incarceration) is “Yes,” then go to A13; otherwise skip to A14.
Skip to A14
A13. During the past 12 months, did you get HIV medical care while in jail, detention, or prison? [JAIL_CAR]
No
0
Yes 1
Skip to A14
Don’t know 8
A13a. What is the name of this place where you got HIV medical care while in jail, detention, or prison?
QDS programming note: response for this question is not recorded in QDS.
Interviewer instructions: Go to paper Facility Visits Log and enter facility information for this place. Write INC in the Facility Type Code column. After entering this information, continue with the next question.
If I6 (patient sampled through RTS) is “yes,” then insert RTS-PDP start date and RTS-PDP end date for the following question. If I6 (patient sampled through RTS) is “no,” then insert PDP start date and PDP end date for the following question.
Skip to A13d
A13b. Did you get any sort of care at [USE FACILITY NAME] between [INSERT START DATE] and [INSERT END DATE]? [CAREPER5]
No
0
Yes 1
Skip to A13d
Don’t know 8
Interviewer instructions: If I6 (patient sampled through RTS) is “yes,” then insert RTS-PDP start date and RTS-PDP end date for the following question. If I6 (patient sampled through RTS) is “no,” then insert PDP start date and PDP end date for the following question.
A13c. Between [INSERT START DATE] and [INSERT END DATE], how many times had you been to [USE FACILITY NAME] for any sort of care? [TIMECAR5]
___ ___ ___ [777 = Refused to answer, 888 = Don’t know]
Inconsistency check: The number of times the respondent visited a particular facility must be ≥ 1 and ≤ 121.
A13d. During the past 12 months, did you get HIV medical care at any other place while in jail, detention, or prison? [JAIL_C_2]
Skip to A14
Yes 1
Skip to A14
Don’t know 8
A13e. What is the name of this place where you got HIV medical care while in jail, detention, or prison?
QDS programming note: response for this question is not recorded in QDS.
Interviewer instructions: Go to paper Facility Visits Log and enter facility information for this place. Write INC in the Facility Type Code column. After entering this information, continue with the next question.
If I6 (patient sampled through RTS) is “yes,” then insert RTS-PDP start date and RTS-PDP end date for the following question. If I6 (patient sampled through RTS) is “no,” then insert PDP start date and PDP end date for the following question.
A13f. Did you get any sort of care at [USE FACILITY NAME] between [INSERT START DATE] and [INSERT END DATE]? [CAREP5_2]
Skip to A13h
No 0
Yes 1
Skip to A13h
Don’t know 8
Interviewer instructions: If I6 (patient sampled through RTS) is “yes,” then insert RTS-PDP start date and RTS-PDP end date for the following question. If I6 (patient sampled through RTS) is “no,” then insert PDP start date and PDP end date for the following question.
A13g. Between [INSERT START DATE] and [INSERT END DATE], how many times had you been to [USE FACILITY NAME] for any sort of care? [TIMEC5_2]
___ ___ ___ [777 = Refused to answer, 888 = Don’t know]
Inconsistency check: The number of times the respondent visited a particular facility must be ≥ 1 and ≤ 121.
A13h. During the past 12 months, did you get HIV medical care at any other place while in jail, detention, or prison? [JAIL_C_3]
Skip to A14
Yes 1
Skip to A14
Don’t know 8
A13i. What is the name of this place where you got HIV medical care while in jail, detention, or prison?
QDS programming note: response for this question is not recorded in QDS.
Interviewer instructions: Go to paper Facility Visits Log and enter facility information for this place. Write INC in the Facility Type Code column. After entering this information, continue with the next question.
If I6 (patient sampled through RTS) is “yes,” then insert RTS-PDP start date and RTS-PDP end date for the following question. If I6 (patient sampled through RTS) is “no,” then insert PDP start date and PDP end date for the following question.
A13j. Did you get any sort of care at [USE FACILITY NAME] between [INSERT START DATE] and [INSERT END DATE]? [CAREP5_3]
Skip to A13l
Yes 1
Skip to A13l
Don’t know 8
Interviewer instructions: If I6 (patient sampled through RTS) is “yes,” then insert RTS-PDP start date and RTS-PDP end date for the following question. If I6 (patient sampled through RTS) is “no,” then insert PDP start date and PDP end date for the following question.
A13k. Between [INSERT START DATE] and [INSERT END DATE], how many times had you been to [USE FACILITY NAME] for any sort of care? [TIMEC5_3]
___ ___ ___ [777 = Refused to answer, 888 = Don’t know]
Inconsistency check: The number of times the respondent visited a particular facility must be ≥ 1 and ≤ 121.
A13l. During the past 12 months, did you get HIV medical care at any other place while in jail, detention, or prison? [JAIL_C_4]
Skip to A14
Yes 1
Skip to A14
Don’t know 8
A13m. What is the name of this place where you got HIV medical care while in jail, detention, or prison?
QDS programming note: response for this question is not recorded in QDS.
Interviewer instructions: Go to paper Facility Visits Log and enter facility information for this place. Write INC in the Facility Type Code column. After entering this information, continue with the next question.
If I6 (patient sampled through RTS) is “yes,” then insert RTS-PDP start date and RTS-PDP end date for the following question. If I6 (patient sampled through RTS) is “no,” then insert PDP start date and PDP end date for the following question.
A13n. Did you get any sort of care at [USE FACILITY NAME] between [INSERT START DATE] and [INSERT END DATE]? [CAREP5_4]
Skip to A14
Yes 1
Skip to A14
Don’t know 8
Interviewer instructions: If I6 (patient sampled through RTS) is “yes,” then insert RTS-PDP start date and RTS-PDP end date for the following question. If I6 (patient sampled through RTS) is “no,” then insert PDP start date and PDP end date for the following question.
A13o. Between [INSERT START DATE] and [INSERT END DATE], how many times had you been to [USE FACILITY NAME] for any sort of care? [TIMEC5_4]
___ ___ ___ [777 = Refused to answer, 888 = Don’t know]
Inconsistency check: The number of times the respondent visited a particular facility must be ≥ 1 and ≤ 121.
A14. During the past 12 months, have you been to any other doctor’s office or clinic for your HIV medical care? [OHEPRO_9]
Skip to Say box before A15
Yes 1
Skip to Say box before A15
Don’t know 8
A14a. What is the name of this place where you got HIV medical care?
QDS programming note: response for this question is not recorded in QDS.
Interviewer instructions: Go to paper Facility Visits Log and enter facility information for this place. Write OTH in the Facility Type Code column. After entering this information, continue with the next question.
If I6 (patient sampled through RTS) is “yes,” then insert RTS-PDP start date and RTS-PDP end date for the following question. If I6 (patient sampled through RTS) is “no,” then insert PDP start date and PDP end date for the following question.
A14b. Did you get any sort of care at [USE FACILITY NAME] between [INSERT START DATE] and [INSERT END DATE]? [CAR1_1_9]
Skip to A14d
Yes 1
Skip to A14d
Don’t know 8
Interviewer instructions: If I6 (patient sampled through RTS) is “yes,” then insert RTS-PDP start date and RTS-PDP end date for the following question. If I6 (patient sampled through RTS) is “no,” then insert PDP start date and PDP end date for the following question.
A14c. Between [INSERT START DATE] and [INSERT END DATE], how many times had you been to [USE FACILITY NAME] for any sort of care? [TIM1_1_9]
___ ___ ___ [777 = Refused to answer, 888 = Don’t know]
Inconsistency check: The number of times the respondent visited a particular facility must be ≥ 1 and ≤ 121.
Skip to Say box before A15
A14d. During the past 12 months, have you been to any other doctor’s office or clinic for your HIV medical care? [OHEP_2_9]
No
0
Yes 1
Skip to Say box before A15
Don’t know 8
A14e. What is the name of this place where you got HIV medical care?
QDS programming note: response for this question is not recorded in QDS.
Interviewer instructions: Go to paper Facility Visits Log and enter facility information for this place. Write OTH in the Facility Type Code column. After entering this information, continue with the next question.
If I6 (patient sampled through RTS) is “yes,” then insert RTS-PDP start date and RTS-PDP end date for the following question. If I6 (patient sampled through RTS) is “no,” then insert PDP start date and PDP end date for the following question.
Skip to A14h
A14f. Did you get any sort of care at [USE FACILITY NAME] between [INSERT START DATE] and [INSERT END DATE]? [CAR1_2_9]
No
0
Yes 1
Skip to A14h
Don’t know 8
Interviewer instructions: If I6 (patient sampled through RTS) is “yes,” then insert RTS-PDP start date and RTS-PDP end date for the following question. If I6 (patient sampled through RTS) is “no,” then insert PDP start date and PDP end date for the following question.
A14g. Between [INSERT START DATE] and [INSERT END DATE], how many times had you been to [USE FACILITY NAME] for any sort of care? [TIM1_2_9]
___ ___ ___ [777 = Refused to answer, 888 = Don’t know]
Inconsistency check: The number of times the respondent visited a particular facility must be ≥ 1 and ≤ 121.
Skip to Say box
before A15
A14h. During the past 12 months, have you been to any other doctor’s office or clinic for your HIV medical care? [OHEP_3_9]
No
0
Yes 1
Skip to Say box before A15
Don’t know 8
A14i. What is the name of this place?
QDS programming note: response for this question is not recorded in QDS.
Interviewer instructions: Go to paper Facility Visits Log and enter facility information for this place. Write OTH in the Facility Type Code column. After entering this information, continue with the next question.
If I6 (patient sampled through RTS) is “yes,” then insert RTS-PDP start date and RTS-PDP end date for the following question. If I6 (patient sampled through RTS) is “no,” then insert PDP start date and PDP end date for the following question.
A14j. Did you get any sort of care at [USE FACILITY NAME] between [INSERT START DATE] and [INSERT END DATE]? [CAR1_3_9]
Skip to A14l
Yes 1
Skip to A14l
Don’t know 8
Interviewer instructions: If I6 (patient sampled through RTS) is “yes,” then insert RTS-PDP start date and RTS-PDP end date for the following question. If I6 (patient sampled through RTS) is “no,” then insert PDP start date and PDP end date for the following question.
A14k. Between [INSERT START DATE] and [INSERT END DATE], how many times had you been to [USE FACILITY NAME] for any sort of care? [TIM1_3_9]
___ ___ ___ [777 = Refused to answer, 888 = Don’t know]
Inconsistency check: The number of times the respondent visited a particular facility must be ≥ 1 and ≤ 121.
A14l. During the past 12 months, have you been to any other doctor’s office or clinic for your HIV medical care? [OHEP_4_9]
Skip to Say box before A15
Yes 1
Skip to Say box before A15 
Don’t know 8
A14m. What is the name of this place?
QDS programming note: response for this question is not recorded in QDS.
Interviewer instructions: Go to paper Facility Visits Log and enter facility information for this place. Write OTH in the Facility Type Code column. After entering this information, continue with the next question.
If I6 (patient sampled through RTS) is “yes,” then insert RTS-PDP start date and RTS-PDP end date for the following question. If I6 (patient sampled through RTS) is “no,” then insert PDP start date and PDP end date for the following question.
Skip to Say box
before A15
A14n. Did you get any sort of care at [USE FACILITY NAME] between [INSERT START DATE] and [INSERT END DATE]? [CAR1_4_9]
No
0
Yes 1
Skip to Say box before A15
Don’t know 8
Interviewer instructions: If I6 (patient sampled through RTS) is “yes,” then insert RTS-PDP start date and RTS-PDP end date for the following question. If I6 (patient sampled through RTS) is “no,” then insert PDP start date and PDP end date for the following question.
A14o. Between [INSERT START DATE] and [INSERT END DATE], how many times had you been to [USE FACILITY NAME] for any sort of care? [TIM1_4_9]
___ ___ ___ [777 = Refused to answer, 888 = Don’t know]
Inconsistency check: The number of times the respondent visited a particular facility must be ≥ 1 and ≤ 121.
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.”
A15. 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]
Skip to A16
Yes 1
Skip to A16
Don’t know 8
A15a. What is the name of this place where you went for most of your general medical care during the past 12 months?
QDS programming note: response for this question is not recorded in QDS.
Interviewer instructions: Go to paper Facility Visits Log and enter facility information for this place. Write MED in the Facility Type Code column. After entering this information, continue with the next question.
If I6 (patient sampled through RTS) is “yes,” then insert RTS-PDP start date and RTS-PDP end date for the following question. If I6 (patient sampled through RTS) is “no,” then insert PDP start date and PDP end date for the following question.
A15b. Did you get any sort of care at [USE FACILITY NAME] between [INSERT START DATE] and [INSERT END DATE]? [CAREPER2]
Skip to A15d
Yes 1
Skip to A15d
Don’t know 8
Interviewer instructions: If I6 (patient sampled through RTS) is “yes,” then insert RTS-PDP start date and RTS-PDP end date for the following question. If I6 (patient sampled through RTS) is “no,” then insert PDP start date and PDP end date for the following question.
A15c. Between [INSERT START DATE] and [INSERT END DATE], how many times had you been to [USE FACILITY NAME] for any sort of care? [TIMECAR2]
___ ___ ___ [777 = Refused to answer, 888 = Don’t know]
Inconsistency check: The number of times the respondent visited a particular facility must be ≥ 1 and ≤ 121.
A15d. Did you also get HIV medical care at [USE FACILITY NAME]? [OCRHIV_9]
No 0
Yes 1
Refused to answer 7
Don’t know 8
A16. 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: A16 (number of times the respondent visited the emergency room or urgent care center for HIV care) must be ≤ 76.
A17. 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]
Interviewer instructions: If A17 (times admitted to a hospital) is “0”, “Refused to answer,” or “Don’t know,” skip to A18.
Inconsistency check: A17 (number of times the respondent was admitted to a hospital for an HIV-related illness) must be ≤ 76.
A17a. During the past 12 months, how many days total did you spend in a hospital because of an HIV-related illness? [HOSPDAY]
___ ___ [77=Refused to answer, 88=Don’t know]
Interviewer instructions: A17a cannot be “0” and must be ≤ 365.
A17b. What is the name of the hospital where you were admitted?
QDS programming note: the response for this question is not recorded in QDS.
If A17 is “1,” QDS will skip to A18.
Interviewer instructions: Go to paper Facility Visits Log and enter facility information. Write HO in the Facility Type Code column. After entering this information, continue with the next question.
A17c. During the past 12 months, were you admitted to any other hospital for HIV-related illness? [HOSAD1_9]
Skip to A18
Yes 1
Skip to A18
Don’t know 8
A17d. What is the name of this hospital?
QDS programming note: response for this question is not recorded in QDS. If A17 is “2,” QDS will skip to A18.
Interviewer instructions: Go to paper Facility Visits Log and enter facility information. Write HO in the Facility Type Code column. After entering this information, continue with the next question.
A17e. During the past 12 months, were you admitted to any other hospital for HIV-related illness? [HOSAD2_9]
Skip to A18
Yes 1
Skip to A18
Don’t know 8
A17f. What is the name of this hospital?
QDS programming note: response for this question is not recorded in QDS. If A17 is “3,” QDS will skip to A18.
Interviewer instructions: Go to paper Facility Visits Log and enter facility information. Write HO in the Facility Type Code column. After entering this information, continue with the next question.
A17g. During the past 12 months, were you admitted to any other hospital for HIV-related illness? [HOSAD3_9]
Skip to A18
Yes 1
Skip to A18
Don’t know 8
A17h. What is the name of this hospital?
QDS programming note: response for this question is not recorded in QDS.
Interviewer instructions: Go to paper Facility Visits Log and enter facility information. Write HO in the Facility Type Code column. After entering this information, continue with the next question.
A18. 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
A19. 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: “For the next set of questions we will use Response Card C. I’m going to ask about services you used or needed during the past 12 months. I'll ask you about each of the services that are listed on Response Card C. First I'll ask whether you received the service; then I'll ask whether you needed this service. If you weren't able to get this service, I’ll ask you the main reason you weren't able to get it. These questions might sound similar, but I need to ask you all of the questions”
QDS programming note for Say box before met and unmet need questions: The QDS program should enter the appropriate dates. EXAMPLE: If IDATE is 11/11/2012 then the program should read “That is from last year, 11/11/2011 to now 11/11/2012.”
Interviewer instructions: If response to A20a is “No,” “Refused to answer,” or “Don’t know,” go to A20b; otherwise, skip to A21a. If response to A20b is “Yes,” go to A20c; otherwise, skip to A21a. Follow the same pattern for A20–A37.
|
|
During the past 12 months, did you get: |
IF “NO” IN A20a–A37a ASK: During the past 12 months, have you needed: |
IF “YES” IN A20b-A37b 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.]
|
A20. |
HIV case management services
|
a. [______] [HIVC12_9]
|
b. [______] [HIVCMS_9]
|
[HIVCRS_9] Other (Specify:________) [HIVC_9OS] |
A21. |
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). |
||||
A22. |
Medicine through the AIDS Drug Assistance Program (ADAP)
|
a. [______] [GET_ADAP]
|
b. [______] [NED_ADAP]
|
[RS_ADAP] Other (Specify:________) [RS_A_9OS] |
A23. |
Professional help remembering to take your HIV medicines on time or correctly |
a. [______] [ASS12_9]
|
b. [______] [ASS_9]
|
[ASSRS_9] Other (Specify:________) [ASSR_9OS] |
A24. |
HIV peer group support
|
a. [______] [GET_GRP]
|
b. [______] [NED_GRP]
|
[RS_GRP] Other (Specify:________) [RS_G_9OS] |
A25.
|
Dental care
|
a. [______] [DENS12_9] |
b. [______] [DENSER_9] |
[DENSRS_9] Other (Specify:________) [DENS_9OS] |
A26. |
Mental health services
|
a. [______] [MENC12_9] |
b. [______] [MENCON_9] |
[MENCRS_9] Other (Specify:________) [MENC_9OS] |
A27. |
Drug or alcohol counseling or treatment
|
a. [______] [GET_SUBU]
|
b. [______] [NED_SUBU]
|
[RS_SUBU] Other (Specify:________) [RS_U_9OS] |
A28. |
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] |
A29. |
Domestic violence services
|
a. [______] [GET_DOMS] |
b. [______] [NED_DOMS] |
[RS_DOMS] Other (Specify:________) [RS_D_9OS] |
A30. |
Shelter or housing services
|
a. [______] [SHLT12_9] |
b. [______] [SHLTER_9] |
[SHLTRS_9] Other (Specify:________) [SHLT_9OS] |
A31. |
Meal or food services
|
a. [______] [MLSF12_9]
|
b. [______] [MLSFOD_9] |
[MLSFRS_9] Other (Specify:________) [MLSF_9OS] |
A32. |
Home health services
|
a. [______] [HHSA12_9] |
b. [______] [HHSASS_9] |
[HHSARS_9] Other (Specify:________) [HHSA_9OS] |
A33. |
Transportation assistance
|
a. [______] [TRAS12_9] |
b. [______] [TRASAS_9] |
[TRASRS_9] Other (Specify:________) [TRAS _9OS] |
A34. |
Childcare services
|
a. [______] [CHLD12_9] |
b. [______] [CHLDCR_9] |
[CHLDRS_9] Other (Specify:________) [CHLD_9OS] |
A35. |
Interpreter services
|
a. [______] [GET_INTS] |
b. [______] [NED_INTS] |
[RS_INTS] Other (Specify:________) [RS_I_9OS] |
A36. |
Nutritional services |
a. [______] [GET_NUTR] |
b. [______] [NED_NUTR] |
[RS_NUTR Other (Specify:________) [RS_N10OS] |
A37. |
Other HIV-related services (Specify:__________)
|
a. [______] [OTS12_12] If “Yes,” then ask: Other 1 (Specify:________) [OTSP_121] Other 2 (Specify:________) [OTSP_122]
|
b. [______] [OTSER_12] If “Yes,” then ask: Other 1 (Specify:________) [OTSE_121] Other 2 (Specify:________) [OTSE_122]
|
Other 1 ca. [______] [OTSR1_12] Other 1 (Specify:________) [O12_12OS] Other 2 cb. [______] [OTSR2_12] Other 2 (Specify:________) [O22_12OS]
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Code list for A20c–A37c
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
SAY: “Now I’m going to ask you some questions about health information. For the first question we will use Response Card D.”
A38. How often do you have problems learning about your medical condition because of difficulty understanding written information? [HLUW_12]
Always 1
Often 2
Sometimes 3
Occasionally 4
Never 5
Refused to answer 7
Don’t know 8
SAY: “Now we will use Response Card E.”
A39. How confident are you filling out medical forms by yourself? [HLMF_12]
Extremely 1
Quite a bit 2
Somewhat 3
A little bit 4
Not at all 5
Refused to answer 7
Don’t know 8
SAY: “For this next question we will use Response Card F.”
A40. How often do you have someone help you read hospital materials? [HLHM_12]
Never 1
Occasionally 2
Sometimes 3
Often 4
Always 5
Not applicable 6
Refused to answer 7
Don’t know 8
Stigma and Discrimination (R)
SAY: “Next I would like to read you a few statements that some people living with HIV have said they sometimes feel. We are asking you these questions to better understand how often people living with HIV experience these negative feelings. These statements are not things that I or anyone in this project thinks about people with HIV. These statements may be uncomfortable for you to answer. Please remember that you do not have to answer any question you don’t want to.”
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Disagree (0) |
Agree (2) |
Refused to answer (7) |
Don’t know (8) |
R1a. |
It is difficult to tell people about my HIV infection [STIGMA1A] |
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R1b. |
Being HIV positive makes me feel dirty [STIGMA1B] |
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R1c. |
I feel guilty that I am HIV positive [STIGMA1C] |
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R1d. |
I am ashamed that I am HIV positive [STIGMA1D] |
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R1e. |
I sometimes feel worthless because I am HIV positive [STIGMA1E] |
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R1f. |
I hide my HIV status from others [STIGMA1F] |
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People with HIV sometimes sense discrimination from health care providers in different ways. Has anyone in the health care system done any of the following to you since testing positive for HIV? |
No (0) |
Yes (1) |
Refused to answer (7) |
Don’t know (8) |
R2a. |
Exhibited hostility or a lack of respect toward you? [STIGMA2A] |
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R2b. |
Given you less attention than other patients? [STIGMA2B] |
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R2c. |
Refused you service? [STIGMA2C] |
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Interviewer instructions: If any of the responses inR2a-R2c is “yes,” go to R3. Otherwise, skip to Say box before T1
R3. |
Did the discrimination occur because of |
No (0) |
Yes (1) |
Refused to answer (7) |
Don’t know (8) |
R3a. |
…your HIV infection? [STIGMA3A] |
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R3b. |
…your gender? [STIGMA3B] |
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R3c. |
…your sexual orientation and practices? [STIGMA3C] |
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R3d. |
…your race or ethnicity? [STIGMA3D] |
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R3e. |
your drug injecting habit? [STIGMA3E] |
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HIV Treatment and Adherence (T)
SAY: “Now I’m going to ask some questions about medicines that you are taking for your HIV. These medicines are called antiretroviral medicines, also known as ART, HAART, or the AIDS cocktail.”
T1. Have you ever taken any antiretroviral medicines for your HIV? [ANTIRE_9]
No………………….…………………..…… 0
Yes………………………………………..……
1 Skip
to T3
Skip to T18
Don’t know….......... 8
T2. What is the main reason you have never taken any antiretroviral medicines? [DON’T READ CHOICES. 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 T18
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 A5 (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).
QDS programming note for T3: If T3 is earlier than A5, 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.
T4. Are you currently taking any antiretroviral medicines for your HIV? [CURME_9]
Skip to Say box before T5 
Yes………………………………………..……
1
Skip to T14
Don’t know….......... 8
T4a. What is the main reason you aren’t currently taking any antiretroviral medicines? [DON’T READ CHOICES. CHECK ONLY ONE.] [NMANT8_9]
Doctor advised to delay or stop 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 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 we will use the HIV Medications Card. Please tell me which of these medicines you are currently taking—ones you are taking now to treat your HIV. 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. I will also ask you how many times you missed taking your medicine. 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.”
T5. |
a. Are you currently taking [INSERT DRUG NAME]?
CODES: No = 0, Yes = 1, Refused to answer = 7, Don’t know = 8
If “Yes,” go to T5b; 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
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c. How many times per day are you supposed to take [INSERT DRUG NAME]?
CODES: Refused to answer = 77, Don’t know = 88
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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
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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
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Reverse Transcriptase Inhibitor Combinations (Combination Treatments) |
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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] |
Complera (RPV/FTC/TDF) |
_____ [COMPLERA] |
_____ [COMPL_ET] |
_____ [COMPL_DY] |
_____ [COMPL_S1] |
_____ [COMPL_S2] |
_____ [COMPL_S3] |
Nucleoside/ Nucleotide Analogue Reverse Transcriptase Inhibitors (NRTI), also known as ‘Nukes’ |
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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] |
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] |
Protease Inhibitors (PI) |
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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] |
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] |
Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTI), also known as ‘Non-nukes’ |
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Rescriptor (delavirdine, DLV) |
_____ [DELACUR] |
___ ___ [DELAET_9] |
___ ___ [DELADY_9] |
___ ___ [DEMIS1_9]
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___ ___ [DEMIS2_9]
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___ ___ [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] |
Edurant (rilpivirine, RPV) |
_____ [EDURANT] |
___ ___ [EDURA_ET] |
___ ___ [EDURA_DY] |
___ ___ [EDURA_S1]
|
___ ___ [EDURA_S2]
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___ ___ [EDURA_S3] |
Entry/Fusion Inhibitors |
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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] |
Integrase Inhibitors |
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Isentress, (raltegravir, RAL) |
_____ [RALTEGRA] |
___ ___ [RALTIM_9] |
___ ___ [RALDAY_9] |
___ ___ [RAMIS1_9] |
___ ___ [RAMIS2_9] |
___ ___ [RAMIS3_9] |
Other ART Medicines |
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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] |
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 T8
Skip to T8
Don’t know….......... 8
SAY: “We will use Response Card H for the next question. You will also need the calendar to refer to the past 3 days.”
T7. During the past 3 days, how often did you follow all of those special instructions?
[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
SAY: “We will use Response Card H. You’ll also need the calendar to refer to the past 3 days.”
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? [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
QDS programming note for T9: If respondent says that they missed a dose for any antiretroviral medication in T5d, T5e, T5f, then the program will skip T9 (last time missed ART) and go to T10.
SAY: “We will now use Response Card I.”
T9. When was the last time you missed any of your antiretroviral medicines? [CHECK ONLY ONE.] [LTMMED10]
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 T11
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.] [MSMD_12]
Problem with prescription or refill 1 [MSMD_12A]
Felt sick or tired 2 [MSMD_12B]
Change in daily routine including travel 3 [MSMD_12C]
Due to side effects of medications 4 [MSMD_12D]
Felt depressed or overwhelmed 5 [MSMD_12E]
Drinking or using drugs 6 [MSMD_12F]
Money or insurance issues 7 [MSMD_12G]
Homeless 8 [MSMD_12H]
Had too many pills to take 9 [MSMD_12I]
Forgot to take them 10 [MSMD_12J]
Other 1 (Specify:_____________________________) 11 [MSMD_12K] [MSK_12OS]
Other 2 (Specify:_____________________________) 12 [MSMD_12L] [MSL_12OS]
Refused to answer 77
Don’t know 88
SAY: “Now I’m going to ask you a question about the past 30 days. We will use Response Card J. We will also use the calendar to refer to the past 30 days.”
T11. During the past 30 days, how troubled were you by side effects from your antiretroviral medications? [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
SAY: “For these next three questions we will use Response Card K.”
T12a. How sure are you that you will be able to take all or most of your medication as directed? [CHECK ONLY ONE.] [TK_MD_DR]
Not at all sure 0
Somewhat sure 1
Very sure 2
Extremely sure 3
Refused to answer 7
Don’t know 8
T12b. How sure are you that your medication will have a positive effect on your health? [CHECK ONLY ONE.] [MD_POSEF]
Not at all sure 0
Somewhat sure 1
Very sure 2
Extremely sure 3
Refused to answer 7
Don’t know 8
T12c. 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? [CHECK ONLY ONE.] [SR_HIVRS]
Not at all sure 0
Somewhat sure 1
Very sure 2
Extremely sure 3
Refused to answer 7
Don’t know 8
SAY: “Now we will use Response Card L.”
T13a. In general, how satisfied are you with the overall support you get from your friends and family members? [CHECK ONLY ONE.] [SUPRT_FF]
Very dissatisfied 0
Somewhat dissatisfied 1
Somewhat satisfied 2
Very satisfied 3
Refused to answer 7
Don’t know 8
SAY: “Now we will use Response Card M.”
T13b. To what extent do your friends or family members help you remember to take your medication? [CHECK ONLY ONE.] [MED_SUPT]
Not at all 0
A little 1
Somewhat 2
A lot 3
Not applicable 6
Refused to answer 7
Don’t know 8
Interviewer instructions: Skip to T15.
T14. During the past 12 months, have you taken antiretroviral medicines? [ATMD12_9]
Skip to T18
Skip to T18
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.] [PREM_12]
Private health insurance 1 [PREM_12A]
Medicaid 2 [PREM_12B]
Medicare 3 [PREM_12C]
AIDS Drug Assistance Program (ADAP) 4 [PREM_12D]
An AIDS service organization provided medicines 5 [PREM_12E]
Got medicines at a public clinic 6 [PREM_12F]
7
Clinical trial or drug study provided medicines 7 [PREM_12G]
Paid for medicines out of pocket 8 [PREM_12H]
Other 1 (Specify: _____________________________) 9 [PREM_12I] [PRI_12OS]
Other 2 (Specify: _____________________________) 10 [PREM_12J] [PRJ_12OS]
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 T18
Skip to T18
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
T18. During the past 12 months, have you participated in an HIV clinical trial? [CLTREC_9]
No 0
Yes 1
Refused to answer 7
Don’t know 8
SEXUAL BEHAVIOR (S)
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 confidential 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 D8 (sex at birth) and D9 (self-identified gender):
Go to S1 (Male Respondent–Female Partner): if D8 and D9 are “Male,” or if D8 is “Intersex” and D9 is “Male.”
Skip to S12 (Female Respondent–Male Partner): if D8 and D9 are “Female,” or if D8 is “Intersex” and D9 is “Female.”
Skip to S21 (Transgender Respondent): if D8 is “Male” and D9 is “Female,” or if D8 is “Female” and D9 is “Male,” or if D9 is “Transgender.”
Otherwise, skip to Say box before U1.
QDS programming note: If D8 or D9 are “Don’t know” or “Refused to answer,” skip to Say box before UI.
Male Respondent – Female Partner
Skip to S6
S1. During the past 12 months, have you had oral, vaginal, or anal sex with a woman? [M_FOVASX]
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 main and casual sex partners. By ‘main partner,’ I mean a woman you have sex with and whom you feel committed to above anyone else. This is a partner that you would call your girlfriend, wife, significant other, or life partner. By ‘casual partner,’ I mean a woman you have sex with, but don’t feel committed to or don’t know very well. To begin, I will ask you about casual sex partners.”
Interviewer instructions: If S1a > 1, read Column 1 “Multiple Female Partners,” S2. If S1a = 1, read Column 2 “One Female Partner,”S2s.
QDS 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 |
|
S2. You said that you had oral, vaginal, or anal sex with __ __ __ __ [RESPONSE FROM S1a] women during the past 12 months. Of these women, how many were casual partners? [M_FCSSX]
|
[_____]
|
If “0,” “Refused to answer,” or “Don’t know,” skip to Say box before S3.
If S2 is “1,” go to Column 2, S2as. |
S2s. You said that you had oral, vaginal, or anal sex with one woman during the past 12 months. Was this woman a casual partner? [M_FCSSX1]
|
[_____]
|
If “No,” “Refused to answer,” or “Don’t know,” skip to Say box before S3. |
|
Inconsistency check: Column 1, S2 must be ≤ S1a. If not, QDS will display a message saying, “Number of casual female partners must be less than or equal to the total number of female partners.” |
|
|||||
S2a. Now I’d like you to think about the first time you had sex with these __ __ __ __ [RESPONSE FROM S2] casual 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] casual 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 casual 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 S2e.
|
|
Inconsistency check: Column 1, S2b must be ≤ S2. If not, QDS will display a message saying, “Number of casual female partners you had vaginal sex with must be less than or equal to the number of casual female partners.” |
|
|||||
S2c. With how many of these __ __ __ __ [RESPONSE FROM S2b] casual 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 casual 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 S2e.
|
|
Inconsistency check: Column 1, S2c must be ≤ S2b. If not, QDS will display a message saying, “Number of casual female partners you had vaginal sex without a condom must be less than or equal to the number of casual female partners with whom you had vaginal sex.” |
|
|||||
SAY: “The next question is about HIV status. Remember, all of your answers are confidential and if you do not know or do not want to answer, that’s okay.” |
|
|||||
S2d. Of these __ __ __ __ [RESPONSE FROM S2c] casual partners with whom you had vaginal sex without a condom, how many were HIV positive? [M_FCVCP]
|
[_____]
|
|
S2ds. Was this casual partner with whom you had vaginal sex without a condom HIV positive? [M_FCVCP1]
|
[_____] |
If S2 is > 1, go to Column 1, S2e. If S2 = 1 go to Column 2, S2es. |
|
Inconsistency check: Column 1, S2d must be ≤ S2c. If not, QDS will display a message saying, “Number of HIV positive casual 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] casual female partners. Of these casual 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 Say box before S3.
If S2e is “1,” go to Column 2, S2fs.
|
S2es. During the past 12 months, did you have anal sex with this casual 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 Say box before S3.
|
|
Inconsistency check: Column 1, S2e must be ≤ S2. If not, QDS will display a message saying, “Number of casual female partners you had anal sex with must be less than or equal to the number of casual female partners.” |
||||||
S2f. Of these __ __ __ __ [RESPONSE FROM S2e] casual 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 Say box before 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 casual 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 Say box before S3.
|
|
Inconsistency check: Column 1, S2f must be ≤ S2e. If not, QDS will display a message saying, “Number of casual female partners you had anal sex without a condom must be less than or equal to the number of casual female partners with whom you had anal sex.” |
||||||
SAY: “The next question is about HIV status. Remember, all of your answers are confidential and if you do not know or do not want to answer, that’s okay.” |
||||||
S2g. Of these __ __ __ __ [RESPONSE FROM S2f] casual female partners with whom you had anal sex without a condom, how many were HIV positive? [M_FCACP]
|
[_____]
|
|
S2gs. Was this casual female partner with whom you had anal sex without a condom HIV positive? [M_FCACP1]
|
[_____]
|
|
|
Inconsistency check: Column 1, S2g must be ≤ S2f. If not, QDS will display a message saying, “Number of HIV positive casual 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.” |
|
|||||
Interviewer instructions: If Column 2, S2s is “Yes,” skip to S5. |
|
|||||
SAY: “Now I’m going to ask you about main partners. Remember, by ‘main partner,’ I mean a woman you have sex with and whom you feel committed to above anyone else.” |
|
|||||
S3. Earlier, you said that you had oral, vaginal, or anal sex with __ __ __ __ [RESPONSE FROM S1a] women during the past 12 months. Of these women, how many were main partners? [M_FMNSX]
|
[_____]
|
If “0,” “Refused to answer,” or “Don’t know,” skip to instructions before S4.
If S3 is “1,” go to Column 2, S3as.
|
S3s. You said that you had oral, vaginal, or anal sex with one woman during the past 12 months. Was this woman a main partner? [M_FMNSX1]
|
[_____]
|
If “No,” “Refused to answer,” or “Don’t know,” skip to S5. |
|
Inconsistency check: Column 1, S3 must be ≤ S1a. If not, QDS will display a message saying, “Number of main female partners must be ≤ the total number of female partners minus the number of casual female partners.” Column 2, S3s cannot be “No” if Column 2, S2s is “No.” |
|
|||||
S3a. Now I’d like you to think about the first time you had sex with these __ __ __ __ [RESPONSE FROM S3] main 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_FMNST]
|
None……... 1 Some…..…. 2 All…........... 3
Not applicable... 6
Don’t know……... 7
Refused...… 8
|
|
S3as. 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_FMNST1]
|
[_____]
|
|
|
S3b. Of the __ __ __ __ [RESPONSE FROM S3] main 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_FMNVG]
|
[_____]
|
If “0,” “Refused to answer,” or “Don’t know,” skip to S3e.
If S3b is “1,” go to Column 2, S3cs. |
S3bs. During the past 12 months, did you have vaginal sex with this main partner? By “vaginal sex,” I mean you put your penis in her vagina. [M_FMNVG1]
|
[_____] |
If “No,” “Refused to answer,” or “Don’t know,” skip to S3e.
|
|
Inconsistency check: Column 1, S3b must be ≤ S3. If not, QDS will display a message saying, “Number of main female partners you had vaginal sex with must be less than or equal to the number of main female partners.” |
||||||
S3c. With how many of these __ __ __ __ [RESPONSE FROM S3b] main 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_FMNVC]
|
[_____]
|
If “0,” “Refused to answer,” or “Don’t know,” skip to S3e.
If S3c is “1,” go to Column 2, S3ds.
|
S3cs. During the past 12 months, did you have vaginal sex without a condom with this main 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. [M_FMNVC1]
|
[_____] |
If “No,” “Refused to answer,” or “Don’t know,” skip to S3e.
|
|
Inconsistency check: Column 1, S3c must be ≤ S3b. If not, QDS will display a message saying, “Number of main 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.” |
||||||
SAY: “The next question is about HIV status. Remember, all of your answers are confidential and if you do not know or do not want to answer, that’s okay.” |
||||||
S3d. Of these __ __ __ __ [RESPONSE FROM S3c] main partners with whom you had vaginal sex without a condom, how many were HIV positive? [M_FMVCP]
|
[_____]
|
|
S3ds. Was this main partner with whom you had vaginal sex without a condom HIV positive? [M_FMVCP1]
|
[_____] |
If S3 is > 1, go to Column 1, S3e. If S3 = 1 go to Column 2, S3es.
|
|
Inconsistency check: Column 1, S3d must be ≤ S3c. If not, QDS will display a message saying, “Number of HIV positive main 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.” |
||||||
S3e. You said that you had oral, vaginal, or anal sex with __ __ __ __ [RESPONSE FROM S3] main female partners during the past 12 months. Of these main 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_FMNAN]
|
[_____]
|
If “0,” “Refused to answer,” or “Don’t know,” skip to S4.
If S3e is “1,” go to Column 2, S3fs.
|
S3es. During the past 12 months, did you have anal sex with this main female partner? By “anal sex,” I mean you put your penis in her anus. [M_FMNAN1]
|
[_____] |
If “No,” “Refused to answer,” or “Don’t know,” skip to instructions before S4.
|
|
Inconsistency check: Column 1, S3e must be ≤ S3. If not, QDS will display a message saying, “Number of main female partners you had anal sex with must be less than or equal to the number of main female partners.” |
||||||
S3f. Of these __ __ __ __ [RESPONSE FROM S3e] main 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_FMNAC]
|
[_____]
|
If “0,” “Refused to answer,” or “Don’t know,” skip to S4.
If S3f is “1,” go to Column 2, S3gs.
|
S3fs. During the past 12 months, did you have anal sex without a condom with this main 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_FMNAC1]
|
[_____] |
If “No,” “Refused to answer,” or “Don’t know,” skip to instructions before S4.
|
|
Inconsistency check: Column 1, S3f must be ≤ S3e. If not, QDS will display a message saying, “Number of main female partners you had anal sex without a condom must be less than or equal to the number with whom you had anal sex.” |
||||||
SAY: “The next question is about HIV status. Remember, all of your answers are confidential and if you do not know or do not want to answer, that’s okay.” |
||||||
S3g. Of these __ __ __ __ [RESPONSE FROM S3f] main female partners with whom you had anal sex without a condom, how many were HIV positive? [M_FMACP]
|
[_____]
|
|
S3gs. Was this main female partner with whom you had anal sex without a condom HIV positive? [M_FMACP1]
|
[_____] |
|
|
Inconsistency check: Column 1, S3g must be ≤ S3f. If not, QDS will display a message saying, “Number of HIV positive main female partners with whom you had anal sex without a condom must be less than or equal to the number of main female partners with whom you had anal sex without a condom.” |
||||||
Interviewer instructions: If S1a (female sex partners during the past 12 months) is > 1, go to S4; otherwise, skip to S5. |
S4. 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 S6.
S5. 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
Male Respondent – Male Partner
S6. During the past 12 months, have you had oral or anal sex with a man? [M_MOASX]
Skip to Say box before S26
No 0
Yes 1
Skip to Say box before S26
Refused to answer 7
Don’t know 8
S6a. 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 S6a is “Refused to answer” or “Don’t know,” skip to Say box before S26.
Inconsistency check: S6a must be ≥ 1. S6a must be < than 1,000.
SAY: “Now I’d like to ask about main and casual sex partners. By ‘main partner,’ I mean a man you have sex with and whom you feel committed to above anyone else. This is a partner that you would call your boyfriend, husband, significant other, or life partner. By ‘casual partner,’ I mean a man you have sex with, but don’t feel committed to or don’t know very well. To begin, I’ll ask about casual sex partners.”
Interviewer instructions: If S6a > 1, read Column 1 “Multiple Male Partners,” S7. If S6a = 1, read Column 2 “One Male Partner,” S7s.
QDS 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 |
S7. You said that you had oral or anal sex with __ __ __ __ [RESPONSE FROM S6a] men during the past 12 months. Of these men, how many were casual partners? [M_MCSSX]
|
[_____]
|
If “0,” “Refused to answer’, or “Don’t know”, skip to Say box before S8.
If S7 is 1, go to Column 2, S7as. |
S7s. You said that you had oral or anal sex with one man during the past 12 months. Was this man a casual partner? [M_MCSSX1]
|
[_____] |
If “No,” “Refused to answer”, or “Don’t know,” skip to Say box before S8.
|
Inconsistency check: Column 1, S7 must be ≤ S6a. If not QDS will display a message saying, “Number of casual male partners must be less than or equal to the total number of male partners.” |
|||||
S7a. Now I’d like you to think about the first time you had sex with these __ __ __ __ [RESPONSE FROM S7] casual 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
|
|
S7as. 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]
|
[_____] |
|
S7b. Of these __ __ __ __ [RESPONSE FROM S7] casual 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 S7e.
If S7b is “1,” go to Column 2, S7cs. |
S7bs. During the past 12 months, did you have insertive anal sex with this casual 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 S7e.
|
Inconsistency check: Column 1, S7b must be ≤ S7. If not, QDS will display a message saying, “Number of casual male partners you had insertive anal sex with must be less than or equal to the number of casual male partners.” |
|||||
S7c. With how many of these __ __ __ __ [RESPONSE FROM S7b] casual 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 S7e.
If S7c is “1,” go to Column 2, S7ds.
|
S7cs. During the past 12 months, did you have insertive anal sex without a condom with this casual 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 S7e.
|
Inconsistency check: Column 1, S7c must be ≤ S7b. If not, QDS will display a message saying, “Number of casual 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 confidential and if you do not know or do not want to answer, that’s okay.” |
|||||
S7d. Of these __ __ __ __ [RESPONSE FROM S7c] casual partners with whom you had insertive anal sex without a condom, how many were HIV positive? [M_MCICP]
|
[_____]
|
|
S7ds. Was this casual partner with whom you had insertive anal sex without a condom HIV positive? [M_MCICP1]
|
[_____] |
If S7 is > 1, go to Column 1, S7e. If S7 = 1 go to Column 2, S7es.
|
Inconsistency check: Column 1, S7d must be ≤ S7c. If not, QDS will display a message saying, “Number of HIV positive casual 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.” |
|||||
S7e. You said that you had oral or anal sex with __ __ __ __ [RESPONSE FROM S7] casual male partners. Of these casual 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 Say box before S8.
If S7e is “1,” go to Column 2, S7fs. |
S7es. During the past 12 months, did you have receptive anal sex with this casual 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 Say box before S8.
|
Inconsistency check: Column 1, S7e must be ≤ S7. If not, QDS will display a message saying, “Number of casual male partners you had receptive anal sex with must be less than or equal to the number of casual male partners.” |
|||||
S7f. Of these __ __ __ __ [RESPONSE FROM S7e] casual 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 Say box before S8.
If S7f is “1,” go to Column 2, S7gs.
|
S7fs. During the past 12 months, did you have receptive anal sex without a condom with this casual 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 Say box before S8.
|
Inconsistency check: Column 1, S7f must be ≤ S7e. If not, QDS will display a message saying, “Number of casual 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 confidential and if you do not know or do not want to answer, that’s okay.” |
|||||
S7g. Of these __ __ __ __ [RESPONSE FROM S7f] casual male partners with whom you had receptive anal sex without a condom, how many were HIV positive? [M_MCRCP]
|
[_____]
|
|
S7gs. Was this casual male partner with whom you had receptive anal sex without a condom HIV positive? [M_MCRCP1]
|
[_____] |
|
Inconsistency check: Column 1, S7g must be ≤ S7f. If not, QDS will display a message saying, “Number of HIV positive casual 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 without a condom.” |
|||||
Interviewer instructions: If Column 2, S7s is “Yes,” skip to S10. |
|||||
SAY: “Now I’m going to ask you about main partners. Remember, by ‘main partner,’ I mean a man you have sex with and feel committed to above anyone else.” |
|||||
S8. Earlier, you said that you had oral or anal sex with __ __ __ __ [RESPONSE FROM S6a] men. Of these men, how many were main partners? [M_MMNSX]
|
[_____]
|
If “0,” “Refused to answer,” or “Don’t know,” skip to instructions before S9.
If S8 is “1,” go to Column 2, S8as. |
S8s. You said that you had oral or anal sex with one man during the past 12 months. Was this man a main partner? [M_MMNSX1]
|
[_____]
|
If “No,” “Refused to answer,” or “Don’t know,” skip to instructions before S9. |
Inconsistency check: Column 1, S8 must be ≤ S6a – S7. If not, QDS will display a message saying, “Number of main male partners must be less than or equal to the total number of male partners minus the number of casual male partners.” Column 2, S8s cannot be “No,” if S7 is “No.” |
|||||
S8a. Now I’d like you to think about the first time you had sex with these __ __ __ __ [RESPONSE FROM S8] main 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_MMNST]
|
None……... 1 Some…..…. 2 All…........... 3
Not applicable... 6
Don’t know……... 7
Refused...… 8
|
|
S8as. 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_MMNST1]
|
[_____]
|
|
S8b. Of these __ __ __ __ [RESPONSE FROM S8] main 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_MMNIA]
|
[_____]
|
If “0,” “Refused to answer,” or “Don’t know,” skip to S8e.
If S8b is “1,” go to Column 2, S8cs. |
S8bs. During the past 12 months, did you have insertive anal sex with this main partner? By “insertive anal sex,” I mean you put your penis in his anus. [M_MMNIA1]
|
[_____]
|
If “No,” “Refused to answer,” or “Don’t know,” skip to S8e.
|
Inconsistency check: Column 1, S8b must be ≤ S8. If not, QDS will display a message saying, “Number of main male partners you had insertive anal sex with must be less than or equal to the number of main male partners.” |
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S8c. With how many of these __ __ __ __ [RESPONSE FROM S8b] main partners did you have insertive 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_MMIAC]
|
[_____]
|
If “0,” “Refused to answer,” or “Don’t know,” skip to S8e.
If S8c is “1,” go to Column 2, S8ds.
|
S8cs. During the past 12 months, did you have insertive anal sex without a condom with this main 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_MMIAC1]
|
[_____]
|
If “No,” “Refused to answer,” or “Don’t know,” skip to S8e.
|
Inconsistency check: Column 1, S8c must be ≤ S8b. If not, QDS will display a message saying, “Number of main 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.” |
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SAY: “The next question is about HIV status. Remember, all of your answers are confidential and if you do not know or do not want to answer, that’s okay.” |
|||||
S8d. Of these __ __ __ __ [RESPONSE FROM S8c] main partners with whom you had insertive anal sex without a condom, how many were HIV positive? [M_MMICP]
|
[_____]
|
|
S8ds. Was this main partner with whom you had insertive anal sex without a condom HIV positive? [M_MMICP1]
|
[_____] |
If S8 is > 1, go to Column 1, S8e. If S8 = 1 go to Column 2, S8es.
|
Inconsistency check: Column 1, S8d must be ≤ S8c. If not, QDS will display a message saying, “Number of HIV positive main 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.” |
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S8e. You said that you had oral or anal sex with __ __ __ __ [RESPONSE FROM S8] main partners during the past 12 months. Of these main 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_MMNRA]
|
[_____]
|
If “0,” “Refused to answer,” or “Don’t know,” skip to S9.
If S8e is “1,” go to Column 2, S8fs. |
S8es. During the past 12 months, did you have receptive anal sex with this main male partner? By “receptive anal sex,” I mean he put his penis in your anus. [M_MMNRA1]
|
[_____] |
If “No,” “Refused to answer,” or “Don’t know,” skip to instructions before S9.
|
Inconsistency check: Column 1, S8e must be ≤ S8. If not, QDS will display a message saying, “Number of main male partners you had receptive anal sex with must be less than or equal to the number of main male partners.” |
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S8f. Of these __ __ __ __ [RESPONSE FROM S8e] main 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_MMRAC]
|
[_____]
|
If “0,” “Refused to answer,” or “Don’t know,” skip to S9
If S8f is “1,” go to Column 2, S8gs.
|
S8fs. During the past 12 months, did you have receptive anal sex without a condom with this main 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_MMRAC1]
|
[_____]
|
If “No,” “Refused to answer,” or “Don’t know,” skip to instructions before S9.
|
Inconsistency check: Column 1, S8f must be ≤ S8e. If not, QDS will display a message saying, “Number of main male partners with whom you had receptive anal sex without a condom must be less than or equal to the number of main male partners with whom you had receptive anal sex.” |
|||||
SAY: “The next question is about HIV status. Remember, all of your answers are confidential and if you do not know or do not want to answer, that’s okay.” |
|||||
S8g. Of these __ __ __ __ [RESPONSE FROM S8f] main male partners with whom you had receptive anal sex without a condom, how many were HIV positive? [M_MMRCP]
|
[_____]
|
|
S8gs. Was this main male partner with whom you had receptive anal sex without a condom HIV positive? [M_MMRCP1]
|
[_____] |
|
Inconsistency check: Column 1, S8g must be ≤ S8f. If not, QDS will display a message saying, “Number of HIV positive main 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 without a condom.” |
|||||
Interviewer instructions: If S6a (male sex partners during the past 12 months) is > 1, go to S9; otherwise, skip to S10.
S9. Earlier you said that you had oral or anal sex with __ __ __ __ [RESPONSE FROM S6a] 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 S11.
S10. 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
SAY: “The next question is about whether you have told people that you have ever had sex with men. I'll read a list of people you may have told, please tell me which ones apply. I need to ask you all the questions, even if some may not apply to your situation.”
|
Have you told any: |
No (0) |
Yes (1) |
Not applic-able (6) |
Refused (7) |
Don’t know (8) |
S11a. |
Gay, lesbian, or bisexual friends? [ATMENA_9] |
|
|
|
|
|
S11b. |
Friends who are not gay, lesbian, or bisexual? [ATMENB_9] |
|
|
|
|
|
S11c. |
Family members? [ATMENC_9] |
|
|
|
|
|
S11d. |
Spouse or partner? [ATMEND_9] |
|
|
|
|
|
S11e. |
Doctors, nurses, or other health care workers? [ATMENE_9] |
|
|
|
|
|
Interviewer instructions: If S1 (female sex partners during the past 12 months) is “Yes,” go to S11f; otherwise, skip to S11g. |
||||||
S11f. |
Female sexual partners? [ATMENF_9] |
|
|
|
|
|
S11g. |
Someone else? [ATMENG_9]
|
|
|
|
|
|
Interviewer instructions: Skip to Say box before S26.
Female Respondent – Male Partner
S12. 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
S12a. 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 S12a is “Refused to answer” or “Don’t know,” skip to S16.
Inconsistency check: S12a must be ≥ 1. S12a must be < than 1,000.
SAY: “Now I’d like to ask about main and casual sex partners. By ‘main partner,’ I mean a man you have sex with and whom you feel committed to above anyone else. This is a partner that you would call your boyfriend, husband, significant other, or life partner. By ‘casual partner,’ I mean a man you have sex with, but don’t feel committed to or don’t know very well. To begin, I will ask you about casual sex partners.”
Interviewer instructions: If S12a > 1, go to Column 1 “Multiple Male Partners,” S13. If S12a = 1, go to Column 2 “One Male Partner,” S13s.
QDS 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 |
|
|||||||||||
S13. You said that you had oral, vaginal, or anal sex with __ __ __ __ [RESPONSE FROM S12a] men during the past 12 months. Of these men, how many were casual partners? [F_MCSSX]
|
[_____]
|
If “0,” “Refused to answer,” or “Don’t know,” skip to Say box before S14.
If S13 is “1,” go to Column 2, S13as. |
S13s. You told me that you had oral, vaginal, or anal sex with one man during the past 12 months. Was this man a casual partner? [F_MCSSX1]
|
[_____]
|
If “No,” “Refused to answer,” or “Don’t know,” skip to Say box before S14. |
|
|||||||||||
Inconsistency check: Column 1, S13 must be ≤ S12a. If not, QDS will display a message saying, “Number of casual male partners must be less than or equal to the total number of partners.” |
|
||||||||||||||||
S13a. Now I’d like you to think about the first time you had sex with these __ __ __ __ [RESPONSE FROM S13] casual 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
|
|
S13as. 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]
|
[_____] |
|
|
|||||||||||
S13b. Of these __ __ __ __ [RESPONSE FROM S13] casual 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 S13e.
If S13b is “1,” go to Column 2, S13cs.
|
S13bs. During the past 12 months, did you have vaginal sex with this casual 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 S13e.
|
|
|||||||||||
Inconsistency check: Column 1, S13b must be ≤ S13. If not, QDS will display a message saying, “Number of casual male partners you had vaginal sex with must be less than or equal to the number of casual male partners.” |
|
||||||||||||||||
S13c. With how many of these __ __ __ __ [RESPONSE FROM S13b] casual 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 S13e.
If S13c is “1,” go to Column 2, S13ds.
|
S13cs. During the past 12 months, did you have vaginal sex without a condom with this casual 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 S13e.
|
|
|||||||||||
Inconsistency check: Column 1, S13c must be ≤ S13b. If not, QDS will display a message saying, “Number of casual 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 confidential and if you do not know or do not want to answer, that’s okay.” |
|
||||||||||||||||
S13d. Of these __ __ __ __ [RESPONSE FROM S13c] casual partners with whom you had vaginal sex without a condom, how many were HIV positive? [F_MCVCP]
|
[_____]
|
|
S13ds. Was this casual partner with whom you had vaginal sex without a condom HIV positive? [F_MCVCP1]
|
[_____] |
If S13 is > 1, go to Column 1, S13e. If S13 = 1, go to Column 2, S13es.
|
|
|||||||||||
Inconsistency check: Column 1, S13d must be ≤ S13c. If not, QDS will display a message saying, “Number of HIV positive casual 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.” |
|
||||||||||||||||
S13e. You said you had oral, vaginal, or anal sex with __ __ __ __ [RESPONSE FROM S13] casual male partners. Of these casual 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 Say box before S14.
If S13e is “1,” go to Column 2, S13fs.
|
S13es. During the past 12 months, did you have anal sex with this casual 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 Say box before S14.
|
|
|||||||||||
Inconsistency check: Column 1, S13e must be ≤ S13. If not, QDS will display a message saying, “Number of casual male partners with whom you had anal sex must be less than or equal to the number of casual male partners.” |
|
||||||||||||||||
S13f. Of these __ __ __ __ [RESPONSE FROM S13e] casual 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 Say box before S14.
If S13f is “1,” go to Column 2, S13gs.
|
S13fs. During the past 12 months, did you have anal sex without a condom with this casual 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 Say box before S14.
|
|
|||||||||||
Inconsistency check: Column 1, S13f must be ≤ S13e. If not, QDS will display a message saying, “Number of casual male partners with whom you had anal sex without a condom must be less than or equal to the number of casual male partners with whom you had anal sex.” |
|
||||||||||||||||
SAY: “The next question is about HIV status. Remember, all of your answers are confidential and if you do not know or do not want to answer, that’s okay.” |
|
||||||||||||||||
S13g. Of these __ __ __ __ [RESPONSE FROM S13f] casual male partners with whom you had anal sex without a condom, how many were HIV positive? [F_MCACP] |
[_____]
|
|
S13gs. Was this casual male partner with whom you had anal sex without a condom HIV positive? [F_MCACP1] |
[_____]
|
|
|
|||||||||||
Inconsistency check: Column 1, S13g must be ≤ S13f. If not, QDS will display “Number of HIV positive casual male 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.” |
|
||||||||||||||||
Interviewer instructions: If Column 2, S13s is “Yes,” skip to S15a. |
|
||||||||||||||||
SAY: “Now I’m going to ask you about main partners. Remember, by ‘main partner,’ I mean a man you have sex with, and feel committed to above anyone else.” |
|
||||||||||||||||
S14. Earlier, you said that you had oral, vaginal, or anal sex with __ __ __ __ [RESPONSE FROM S12a] men during the past 12 months. Of these men, how many were main partners? [F_MMNSX]
|
[_____]
|
If “0,” “Refused to answer,” or “Don’t know,” skip to S15.
If S14 is “1,” go to Column 2, S14as. |
S14s. You said that you had oral, vaginal, or anal sex with one man during the past 12 months. Was this man a main partner? [F_MMNSX1]
|
[_____]
|
If “No,” “Refused to answer,” or “Don’t know,” skip to S15a. |
||||||||||||
Inconsistency check: Column 1, S14 must be ≤ S12a – S13. If S14 is greater than S12a – S13, QDS will display a message saying, “Number of main male partners must be less than or equal to the total number of male partners minus the number of casual male partners.” Column 2, S14s cannot be “No” if S13 is “No.” |
|||||||||||||||||
S14a. Now I’d like you to think about the first time you had sex with these __ __ __ __ [RESPONSE FROM S14] main partners after you tested positive for HIV. Did you discuss your HIV status with none, some, or all of these men? [CHECK ONLY ONE.] [F_MMNST]
|
None……... 1 Some…..…. 2 All…........... 3
Not applicable... 6
Don’t know……... 7
Refused...… 8
|
|
S14as. 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_MMNST1]
|
[_____]
|
|
|
|||||||||||
S14b. Of these __ __ __ __ [RESPONSE FROM S14] main 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_MMNVG]
|
[_____]
|
If “0,” “Refused to answer,” or “Don’t know,” skip to S14e.
If S14b is “1,” go to Column 2, S14cs. |
S14bs. During the past 12 months, did you have vaginal sex with this main partner? By “vaginal sex,” I mean he put his penis in your vagina. [F_MMNVG1]
|
[_____] |
If “No,” “Refused to answer,” or “Don’t know,” skip to S14e.
|
|
|||||||||||
Inconsistency check: Column 1, S14b must be ≤ S14. If not, QDS will display a message saying, “Number of main male partners you had vaginal sex with must be less than or equal to the number of main male partners.” |
|
||||||||||||||||
S14c. With how many of these __ __ __ __ [RESPONSE FROM S14b] main 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_MMNVC]
|
[_____]
|
If “0,” “Refused to answer,” or “Don’t know,” skip to S14e.
If S14c is “1,” go to Column 2, S14ds.
|
S14cs. During the past 12 months, did you have vaginal sex without a condom with this main 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_MMNVC1]
|
[_____]
|
If “No,” “Refused to answer,” or “Don’t know,” skip to S14e.
|
|
|
||||||||||
Inconsistency check: Column 1, S14c must be ≤ S14b. If not, QDS will display a message saying, “Number of main male partners with whom you had vaginal sex without a condom must be less than or equal to the number of main male partners with whom you had vaginal sex.” |
|
|
|||||||||||||||
SAY: “The next question is about HIV status. Remember, all of your answers are confidential and if you do not know or do not want to answer, that’s okay.” |
|
|
|||||||||||||||
S14d. Of these __ __ __ __ [RESPONSE FROM S14c] main partners with whom you had vaginal sex without a condom, how many were HIV positive? [F_MMNCP]
|
[_____]
|
|
S14ds. Was this main partner with whom you had vaginal sex without a condom HIV positive? [F_MMNCP1]
|
[_____] |
If S14 is > 1, go to Column 1, S14e. If S14 = 1 go to Column 2, S14es. |
|
|
||||||||||
Inconsistency check: Column 1, S14d must be ≤ S14c. If not, QDS will display a message saying, “Number of HIV positive main male partners with whom you had vaginal sex without a condom must be less than or equal to the number of main male partners with whom you had vaginal sex without a condom.” |
|
|
|||||||||||||||
S14e. You said that you had oral, vaginal, or anal sex with __ __ __ __ [RESPONSE FROM S14] main male partners during the past 12 months. Of these main 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_MMNAN]
|
[_____]
|
If “0,” “Refused to answer,” or “Don’t know,” skip to S15.
If S14e is “1,” go to Column 2, S14fs. |
S14es. During the past 12 months, did you have anal sex with this main male partner? By “anal sex,” I mean he put his penis in your anus. [F_MMNAN1]
|
[_____] |
If “No,” “Refused to answer,” or “Don’t know,” skip to instructions before S15.
|
|
|
||||||||||
Inconsistency check: Column 1, S14e must be ≤ S14. If not, QDS will display a message saying, “Number of main male partners with whom you had anal sex must be less than or equal to the number of main male partners.” |
|
|
|||||||||||||||
S14f. Of these __ __ __ __ [RESPONSE FROM S14e] main 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_MMNAC]
|
[_____]
|
If “0,” “Refused to answer,” or “Don’t know,” skip to instructions before S15.
|
S14fs. During the past 12 months, did you have anal sex without a condom with this main 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_MMNAC1]
|
[_____]
|
If “No,” “Refused to answer,” or “Don’t know,” skip to instructions before S15.
|
|
|
||||||||||
Inconsistency check: Column 1, S14f must be ≤ S14e. If not, QDS will display a message saying, “Number of main male partners with whom you had anal sex without a condom must be less than or equal to the number of main male partners with whom you had anal sex.” |
|
|
|||||||||||||||
SAY: “The next question is about HIV status. Remember, all of your answers are confidential and if you do not know or do not want to answer, that’s okay.” |
|
|
|||||||||||||||
S14g. Of these __ __ __ __ [RESPONSE FROM S14f] main male with whom you had anal sex without a condom, how many were HIV positive? [F_MMACP]
|
[_____]
|
|
S14gs. Was this main male partner with whom you had anal sex without a condom HIV positive? [F_MMACP1]
|
[_____]
|
|
|
|
||||||||||
Inconsistency check: Column 1, S14g must be ≤ S14f. If not, QDS will display a message saying, “Number of HIV positive main male 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.” |
|
|
|||||||||||||||
Interviewer instructions: If S12a (male sex partners during the past 12 months) is > 1, go to S15; otherwise, skip to S15a.
S15. 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
Interviewer instructions: Skip to S16.
S15a. 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
Female Respondent – Female Partner
Skip to Say box before S26
S16. During the past 12 months, have you had sex with a woman? [F_FSX]
No 0
Yes 1
Skip to Say box before S26
Refused to answer 7
Don’t know 8
S16a. During the past 12 months, with how many different women have you had sex? [F_F12_9]
___ ___ ___ ___ [Refused to answer = 7777, Don’t know = 8888]
Interviewer instructions: If S16a is “Refused to answer” or “Don’t know,” skip to Say box before S26.
Inconsistency check: S16a must be ≥ 1. S16a must be < than 1,000.
SAY: “Now I’d like to ask about main and casual sex partners. By ‘main partner,’ I mean a woman you have sex with and whom you feel committed to above anyone else. This is a partner that you would call your girlfriend, wife, significant other, or life partner. By ‘casual partner,’ I mean a woman you have sex with, but don’t feel committed to or don’t know very well. To begin, I will ask you about casual sex partners.”
Interviewer instructions: If S16a > 1, go to Column 1 “Multiple Female Partners,” S17. If S16a = 1, go to Column 2 “One Female Partner,” S17s.
QDS 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 |
|
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COLUMN 1 |
COLUMN 2 |
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Question |
Response |
Skip Pattern |
Question |
Response |
Skip Pattern |
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S17. You said that you had sex with __ __ __ __ [RESPONSE FROM S16a] women during the past 12 months. Of these women, how many were casual partners? [F_FCSSX]
|
[_____]
|
If “0,” “Refused to answer,” or “Don’t know,” skip to Say box before S18.
If S17 is “1,” go to Column 2, S17as. |
S17s. You said that you had sex with one woman during the past 12 months. Was this woman a casual partner? [F_FCSSX1]
|
[_____]
|
If “No,” “Refused to answer,” or “Don’t know,” skip to Say box before S18. |
|
Inconsistency check: Column 1, S17 must be ≤ S16a. If not, QDS will display a message saying, “Number of casual female partners must be less than or equal to the total number of female partners.” |
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|||||
S17a. Now I’d like you to think about the first time you had sex with these __ __ __ __ [RESPONSE FROM S17] casual partners after you tested positive for HIV. Did you discuss your HIV status with none, some, or all of these women? [CHECK ONLY ONE.] [F_FCSST]
|
None……... 1 Some…..…. 2 All…........... 3
Not applicable... 6
Don’t know……... 7
Refused...… 8
|
|
S17as. 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? [F_FCSST1]
|
[_____]
|
|
|
Interviewer instructions: If Column 2, S17s is “Yes,” skip to S19a. |
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|||||
SAY: “Now I’m going to ask you about main partners. Remember, by ‘main partner,’ I mean a woman you have sex with and feel committed to above anyone else.” |
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S18. Earlier, you said that you had sex with __ __ __ __ [RESPONSE FROM S16a] women during the past 12 months. Of these women, how many were main partners? [F_FMNSX]
|
[_____]
|
If “0,” “Refused to answer,” or “Don’t know,” skip to S19.
If S18 is “1,” go to Column 2, S18as. |
S18s. You said that you had sex with one woman during the past 12 months. Was this woman a main partner? [F_FMNSX1]
|
[_____]
|
If “No,” “Refused to answer,” or “Don’t know,” skip to S19a. |
|
Inconsistency check: Column 1, S18 must be ≤ S16a – S17. If not, QDS will display a message saying, “Number of main female partners must be less than or equal to the total number of female partners minus the number of casual female partners.” Column 2, S18s cannot be “No” if S17 is “No.” |
|
|||||
S18a. Now I’d like you to think about the first time you had sex with these __ __ __ __ [RESPONSE FROM S18] main partners after you tested positive for HIV. Did you discuss your HIV status with none, some, or all of these women? [CHECK ONLY ONE.] [F_FMNST]
|
None……... 1 Some…..…. 2 All…........... 3
Not applicable... 6
Don’t know……... 7
Refused...… 8
|
|
S18as. 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? [F_FMNST1]
|
[_____]
|
|
|
Interviewer instructions: If S16a (female sex partners during the past 12 months) is > 1, go to S19; otherwise, skip to S19a.
S19. You said that you had sex with __ __ __ __ [RESPONSE FROM S16a] 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? [F_FXCH_9]
No 0
Yes 1
Refused to answer 7
Don’t know 8
Interviewer instructions: Skip to Say box before S20.
S19a. During the past 12 months, did you have sex with this woman in exchange for things like money, drugs, food, shelter, or transportation? [F_FXC1_9]
No 0
Yes 1
Refused to answer 7
Don’t know 8
SAY: “The next question is about whether you have told people that you have ever had sex with women. I'll read a list of people you may have told, please tell me which ones apply. I need to ask you all the questions, even if some may not apply to your situation.”
|
Have you told any: |
No (0) |
Yes (1) |
Not applicable (6) |
Refused (7) |
Don’t know (8) |
S20a. |
Gay, lesbian, or bisexual friends? [ATWOMA_9] |
|
|
|
|
|
S20b. |
Friends who are not gay, lesbian, or bisexual? [ATWOMB_9] |
|
|
|
|
|
S20c. |
Family members? [ATWOMC_9] |
|
|
|
|
|
S20d. |
Spouse or partner? [ATWOMD_9] |
|
|
|
|
|
S20e. |
Doctors, nurses, or other health care workers? [ATWOME_9] |
|
|
|
|
|
Interviewer instructions: If S12 (male sex partners during the past 12 months) is “Yes,” then go to S20f; otherwise, skip to S20g. |
||||||
S20f. |
Male sexual partners? [ATWOMF_9] |
|
|
|
|
|
S20g. |
Someone else? [ATWOMG_9] |
|
|
|
|
|
Interviewer instructions: Skip to Say box before S26. |
||||||
Transgender Respondent
Skip to Say box before U1
S21. During the past 12 months, have you had vaginal or anal sex? [TRANS_SX]
No 0
Yes 1
Skip to Say box before U1
Refused to answer 7
Don’t know 8
S21a. During the past 12 months, with how many different partners have you had vaginal or anal sex? [TRANS_9]
___ ___ ___ ___ [Refused to answer = 7777, Don’t know = 8888]
Interviewer instructions: If S21a is “Refused to answer” or “Don’t know,” skip to Say box before S26.
Inconsistency check: S21a must be ≥ 1. S21a must be < than 1,000.
SAY: “Now I’d like to ask about main and casual sex partners. By ‘main partner,’ I mean someone you have sex with and whom you feel committed to above anyone else. This is a partner that you would call your significant other or life partner. By ‘casual partner,’ I mean someone you have sex with, but don’t feel committed to or don’t know very well. To begin, I will ask you about casual sex partners.”
Interviewer instructions: If S21a > 1 go to Column 1 “Multiple Partners,” S22. If S21a = 1, go to Column 2 “One Partner,” S22s.
QDS programming note for column 1: Response must be greater than 1.
Multiple Partners CODES: Refused to answer = 7777, Don’t know = 8888 |
One 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 |
S22. You said that you had vaginal or anal sex with __ __ __ __ [RESPONSE FROM S21a] partners during the past 12 months. Of these partners, how many were casual partners? [TR_CSSX]
|
[_____]
|
If “0,” “Refused to answer,” or “Don’t know,” skip to Say box before S23.
If S22 is “1,” go to Column 2, S22as. |
S22s. You said that you had vaginal or anal sex with one partner during the past 12 months. Was this partner a casual partner? [TR_CSSX1]
|
[_____]
|
If “No,” “Refused to answer,” or “Don’t know,” skip to Say box before S23. |
Inconsistency check: Column 1, S22 must be ≤ S21a. If not, QDS will display a message saying, “Number of casual partners must be less than or equal to the total number of partners.” |
|||||
S22a. Now I’d like you to think about the first time you had sex with these __ __ __ __ [RESPONSE FROM S22] casual partners after you tested positive for HIV. Did you discuss your HIV status with none, some, or all of these partners? [CHECK ONLY ONE.] [TR_CSST]
|
None……... 1 Some…..…. 2 All…........... 3
Not applicable... 6
Don’t know……... 7
Refused...… 8
|
|
S22as. Now I’d like you to think about the first time you had sex with this partner after you tested positive for HIV. Did you discuss your HIV status with your partner? [TR_CSST1]
|
[_____]
|
|
S22b. With how many of these __ __ __ __ [RESPONSE FROM S22] casual partners did you have vaginal or 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. [TR_CSWC]
|
[_____]
|
If “0,” “Refused to answer,” or “Don’t know,” skip to Say box before S23.
If S22b is “1,” go to Column 2, S22cs.
|
S22bs. During the past 12 months, did you have vaginal or anal sex without a condom with this casual 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. [TR_CSWC1]
|
[_____]
|
If “No,” “Refused to answer,” or “Don’t know,” skip to Say box before S23.
|
Inconsistency check: Column 1, S22b must be ≤ S22. If not, QDS will display a message saying, “Number of casual partners with whom you had vaginal or anal sex without a condom must be less than or equal to the number of casual partners.” |
|||||
SAY: “The next question is about HIV status. Remember, all of your answers are confidential and if you do not know or do not want to answer, that’s okay.” |
|||||
S22c. Of these __ __ __ __ [RESPONSE FROM S22b] casual partners with whom you had vaginal or anal sex without a condom, how many were HIV positive? [TR_CSHP]
|
[_____]
|
|
S22cs. Was this casual partner with whom you had vaginal or anal sex without a condom HIV positive? [TR_CSHP1]
|
[_____]
|
If S21a is > 1, go to Column 1, S23. If S21a = 1 skip to S25. |
Inconsistency check: Column 1, S22c must be ≤ S22b. If not, QDS will display a message saying, “Number of HIV positive casual partners with whom you had vaginal or anal sex without a condom must be less than or equal to the number of casual partners with whom you had vaginal or anal sex without a condom.” |
|||||
Interviewer instructions: If Column 2, S22cs is “Yes,” skip to S25. |
|||||
SAY: “Now I’m going to ask you about main partners. Remember, by ‘main partner,’ I mean someone you have sex with and whom you feel committed to above anyone else. |
|||||
S23. Earlier, you said that during the past 12 months you had vaginal or anal sex with __ __ __ __ [RESPONSE FROM S21a] partners. Of these partners, how many were main partners? [TR_MNSX]
|
[_____]
|
If “0,” “Refused to answer,” or “Don’t know,” skip to S24.
If S23 is “1,” go to Column 2, S23as. |
S23s. During the past 12 months, was this partner a main partner? [TR_MNSX1]
|
[_____]
|
If “No,” “Refused to answer,” or “Don’t know,” skip to instructions before S24. |
Inconsistency check: Column 1, S23 must be ≤ S21a – S22. If not, QDS will display a message saying, “Number of main partners must be less than or equal to the total number of partners minus the number of causal partners.” Column 2, S23s cannot be “No” if S22 is “No.” |
|||||
S23a. Now I’d like you to think about the first time you had sex with these __ __ __ __ [RESPONSE FROM S23] main partners after you tested positive for HIV. Did you discuss your HIV status with none, some, or all of these partners? [CHECK ONLY ONE.] [TR_MNST]
|
None……... 1 Some…..…. 2 All…........... 3
Not applicable... 6
Don’t know……... 7
Refused...… 8
|
|
S23as. Now I’d like you to think about the first time you had sex with this partner after you tested positive for HIV. Did you discuss your HIV status with your partner? [TR_MNST1]
|
[_____]
|
|
S23b. With how many of these __ __ __ __ [RESPONSE FROM S23] main partners did you have vaginal or 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. [TR_MNWC]
|
[_____]
|
If “0,” “Refused to answer,” or “Don’t know,” skip to S24.
If S23b is “1,” go to Column 2, S23cs.
|
S23bs. During the past 12 months, did you have vaginal or anal sex without a condom with this main 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. [TR_MNWC1]
|
[_____]
|
If “No,” “Refused to answer,” or “Don’t know,” skip to instructions before S24.
|
Inconsistency check: Column 1, S23b must be ≤ S23. If not, QDS will display a message saying, “Number of main partners with whom you had vaginal or anal sex without a condom must be less than or equal to the number of main partners.” |
|||||
SAY: “The next question is about HIV status. Remember, all of your answers are confidential and if you do not know or do not want to answer, that’s okay.” |
|||||
S23c. Of these __ __ __ __ [RESPONSE FROM S23b] main partners with whom you had vaginal or anal sex without a condom, how many were HIV positive? [TR_MNHP]
|
[_____]
|
|
S23cs. Was this main partner with whom you had vaginal or anal sex without a condom HIV positive? [TR_MNHP1]
|
[_____] |
|
Inconsistency check: Column 1, S23c must be ≤ S23b. If not, QDS will display a message saying, “Number of HIV positive main partners with whom you had vaginal or anal sex without a condom must be less than or equal to the number of main partners with whom you had vaginal or anal sex without a condom.” |
|||||
Interviewer instructions: If S21a (sex partners during the past 12 months) is > 1, go to S24; otherwise, skip to S25. |
|||||
S24. Earlier you said that you had sex with __ __ __ __ [RESPONSE FROM S21a] partners. During the past 12 months, did you have sex with any of these partners in exchange for things like money, drugs, food, shelter, or transportation? [TR_XCH_9]
No 0
Yes 1
Refused to answer 7
Don’t know 8
Interviewer instructions: Skip to Say box before S26.
S25. During the past 12 months, did you have sex with this partner in exchange for things like money, drugs, food, shelter, or transportation? [TR_XC1_9]
No 0
Yes 1
Refused to answer 7
Don’t know 8
Serosorting
SAY: “For these next questions, I will read you a statement and then I’ll ask you to tell me if you strongly disagree, somewhat disagree, are neutral, somewhat agree, or strongly agree. Some of the statements may not apply to your situation; however, tell me whether you think you would disagree or agree. We will use Response Card G for these four questions.”
S26. If my partner tells me he or she is HIV positive, I am more likely to have unprotected sex with him or her. [CHECK ONLY ONE.] [SEROSRT1]
Strongly disagree 1
Somewhat disagree 2
Neutral 3
Somewhat agree 4
Strongly agree 5
Refused to answer 7
Don’t know 8
S27. If my partner tells me he or she is HIV positive, we don’t have to worry about using condoms. [CHECK ONLY ONE.] [SEROSRT2]
Strongly disagree 1
Somewhat disagree 2
Neutral 3
Somewhat agree 4
Strongly agree 5
Refused to answer 7
Don’t know 8
S28. If I have an undetectable HIV viral load, I am more likely to have unprotected sex. [CHECK ONLY ONE.] [SEROSRT3]
Strongly disagree 1
Somewhat disagree 2
Neutral 3
Somewhat agree 4
Strongly agree 5
Refused to answer 7
Don’t know 8
S29. Having an undetectable HIV viral load means I can worry less about having to use condoms. [CHECK ONLY ONE.] [SEROSRT4]
Strongly disagree 1
Somewhat disagree 2
Neutral 3
Somewhat agree 4
Strongly agree 5
Refused to answer 7
Don’t know 8
Drug and Alcohol Use (U)
Cigarette and Alcohol Use
SAY: “The next questions are about smoking cigarettes.”
Skip to Say box before U2
U1. Have you smoked at least 100 cigarettes in your entire life? [CIG_EVR]
No 0
Skip to Say box before U2
Yes 1
Refused to answer 7
Don’t know 8
SAY: “Now we will use Response Card N.”
U1a. How often do you smoke cigarettes now? [READ CHOICES] [CIG_OFT]
Daily 1
Weekly 2
Monthly 3
Less than monthly 4
Never 5
Refused to answer 7
Don’t know 8
SAY: “Now I’m going to ask you about any alcohol that you may have had. We will use Response Card N.”
U2. During the past 12 months, how often did you drink alcohol? [READ CHOICES] [ALCOHO_9]
Daily 1
Weekly 2
Monthly 3
Less than monthly 4
Never 5
Skip to Say box before U8
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 S6 (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 U4.
If S12 (female respondent had sex with a man during the past 12 months) and S16 (female respondent had sex with a woman) are “No,” “Refused to answer,” or “Don’t know,” skip to Say box before U4.
If S21 (transgender respondent had sex during the past 12 months) is “No,” “Refused to answer,” or “Don’t know,” skip to Say box before U4.
U3. 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. We will use the calendar to refer to the past 30 days.”
U4. 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: U4 (number of days had an alcoholic drink during the past 30 days) must be between 0 and 30.
Interviewer instructions: If U4 (number of days consumed alcohol during the past 30 days) is “0,” “Refused to answer,” or “Don’t know,” skip to Say box before U8.
SAY: “We will use the Alcohol Response Card for these next questions. For these questions a drink of alcohol is a 12 oz beer, a 5 oz glass of wine, or a 1.5 oz shot of liquor.”
U5. 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: U5 (number of drinks on a typical day during the past 30 days) must be between 1 and 76.
Interviewer instructions: If D8 (birth gender) is “Female” or “Intersex/ambiguous,” skip to U7.
U6. 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: U6 (number of days had 5 or more drinks during the past 30 days) must be ≤ 30 or ≤ U4 (number of days had a drink during the past 30 days).
Interviewer instructions: Skip to Say box before U8.
U7. 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: U7 (number of days had 4 or more drinks during the past 30 days) must be ≤ 30 or ≤ U4 (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.”
Skip to Say box before U12
U8. During the past 12 months, did you use any non-injection drugs? [ANID12_9]
No
0
Yes 1
Skip to Say box before U12
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. For these questions we will use Response Card N.”
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:
|
Daily (1) |
Weekly (2) |
Monthly (3) |
Less than monthly (4) |
Never (5) |
Refused to answer (7) |
Don’t Know (8) |
U9a. |
…methamphetamines, also called crystal meth, tina, crank, ice? [CRYMTC_9] |
1 |
2 |
3 |
4 |
5 |
7 |
8 |
U9b. |
…other amphetamines or stimulants? [AMPHET_9] |
1 |
2 |
3 |
4 |
5 |
7 |
8 |
U9c. |
…crack? [CRACK1_9] |
1 |
2 |
3 |
4 |
5 |
7 |
8 |
U9d. |
…cocaine that is smoked or snorted? [COCSMO_9] |
1 |
2 |
3 |
4 |
5 |
7 |
8 |
U9e. |
…downers, such as Valium, Ativan, or Xanax? [DOWNER_9] |
1 |
2 |
3 |
4 |
5 |
7 |
8 |
U9f. |
…painkillers, such as Oxycontin, Vicodin, or Percocet? [PAINKI_9] |
1 |
2 |
3 |
4 |
5 |
7 |
8 |
U9g. |
…hallucinogens, such as LSD or mushrooms? [HALLUC_9] |
1 |
2 |
3 |
4 |
5 |
7 |
8 |
U9h. |
…X, also called Ecstasy? [XECT_9] |
1 |
2 |
3 |
4 |
5 |
7 |
8 |
U9i. |
…Special K, also called ketamine? [SPECK_9] |
1 |
2 |
3 |
4 |
5 |
7 |
8 |
U9j. |
…GHB? [GHB_9] |
1 |
2 |
3 |
4 |
5 |
7 |
8 |
U9k. |
…heroin or opium that is smoked or snorted? [HEROIN_9] |
1 |
2 |
3 |
4 |
5 |
7 |
8 |
U9l. |
…marijuana? [MARIJU_9] |
1 |
2 |
3 |
4 |
5 |
7 |
8 |
U9m. |
…poppers, also called amyl nitrate? [POPPER_9] |
1 |
2 |
3 |
4 |
5 |
7 |
8 |
U9n. |
…steroids or hormones? [STRHOR_9] |
1 |
2 |
3 |
4 |
5 |
7 |
8 |
U9o. |
…any other non-injection drug (Specify:___________)? [ONINJD_9] [ONINJ9OS] |
1 |
2 |
3 |
4 |
5 |
7 |
8 |
Inconsistency check: If U8 (non-injection drug use) is “Yes” and all of the responses to U9a-U9o are “Never,”, then QDS will 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 S6 (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 U12.
If S12 (female respondent had sex with a man during the past 12 months) and S16 (female respondent had sex with a woman) are “No,” “Refused to answer,” or “Don’t know,” skip to Say box before U12.
If S21 (transgender respondent had sex during the past 12 months) is “No,” “Refused to answer,” or “Don’t know,” skip to Say box before U12.
U10. During the past 12 months, did you use any non-injection drugs before or during sex? [NID_BFSX]
Skip to Say box before U12
No 0
Yes 1
Skip to Say box before U12
Refused to answer 7
Don’t know 8
Interview instructions: If U9a is “Daily,” “Weekly,” “Monthly,” or “Less than monthly,” check the shaded box (column 1) in U11a. Follow the same pattern for b–o. If no shaded boxes (column 1) are checked in U11a-o, skip to Say box before U12. |
||||||
|
|
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) |
|
U11a. |
…methamphetamines before or during sex? [CRAMT2_9] |
0 |
1 |
7 |
8 |
|
U11b. |
…other amphetamines or stimulants before or during sex? [AMPHT2_9] |
0 |
1 |
7 |
8 |
|
U11c. |
…crack before or during sex? [CRACK2_9] |
0 |
1 |
7 |
8 |
|
U11d. |
…cocaine that is smoked or snorted before or during sex? [COCSM2_9] |
0 |
1 |
7 |
8 |
|
U11e. |
…downers, such as Valium, Ativan, or Xanax, before or during sex? [DOWNE2_9] |
0 |
1 |
7 |
8 |
|
U11f. |
…painkillers, such as Oxycontin, Vicodin, or Percocet before or during sex? [PAINK2_9] |
0 |
1 |
7 |
8 |
|
U11g. |
…hallucinogens, such as LSD or mushrooms before or during sex? [HALLU2_9] |
0 |
1 |
7 |
8 |
|
U11h. |
…X, also called Ecstasy before or during sex? [XECT2_9] |
0 |
1 |
7 |
8 |
|
U11i. |
…Special K, also called ketamine before or during sex? [SPECK2_9] |
0 |
1 |
7 |
8 |
|
U11j. |
…GHB before or during sex? [GHB2_9] |
0 |
1 |
7 |
8 |
|
U11k. |
…heroin or opium that is smoked or snorted before or during sex? [HEROI2_9] |
0 |
1 |
7 |
8 |
|
U11l. |
…marijuana before or during sex? [MARIJ2_9] |
0 |
1 |
7 |
8 |
|
U11m. |
…poppers, also called amyl nitrate, before or during sex? [POPPE2_9] |
0 |
1 |
7 |
8 |
|
U11n. |
…steroids or hormones before or during sex? [STRHO2_9] |
0 |
1 |
7 |
8 |
|
U11o. |
… [RESPONSE FROM U9o] before or during sex? [ONINJ2_9] |
0 |
1 |
7 |
8 |
Inconsistency check: If U10 (non-injection drug use before or during sex) is “Yes” and all of the responses to U11a-U11o are “Never,”, then QDS will 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. Remember, your answers will be kept confidential.”
Skip to Say box before P1
U12. 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]
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. We will use Response Card N for these questions.”
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: |
Daily (1) |
Weekly (2) |
Monthly (3) |
Less than monthly (4) |
Never (5) |
Refused to answer (7) |
Don’t Know (8) |
U13a. |
…heroin and cocaine together, also called speedballs? [HERCOC_9] |
1 |
2 |
3 |
4 |
5 |
7 |
8 |
U13b. |
…heroin alone? [HEROII_9] |
1 |
2 |
3 |
4 |
5 |
7 |
8 |
U13c. |
…cocaine alone? [COCAII_9] |
1 |
2 |
3 |
4 |
5 |
7 |
8 |
U13d. |
…crack? [CRACKI_9] |
1 |
2 |
3 |
4 |
5 |
7 |
8 |
U13e. |
…methamphetamines, also called crystal, meth, tina, or crank? [CRAMTI_9] |
1 |
2 |
3 |
4 |
5 |
7 |
8 |
U13f. |
…other amphetamines or stimulants? [AMPHEI_9] |
1 |
2 |
3 |
4 |
5 |
7 |
8 |
U13g. |
…Oxycontin? [OXYCON_9] |
1 |
2 |
3 |
4 |
5 |
7 |
8 |
U13h. |
…steroids or hormones? [STRHRI_9] |
1 |
2 |
3 |
4 |
5 |
7 |
8 |
U13i. |
…any other drug (Specify:__________)? [OINJDI_9][OINJD9OS] |
1 |
2 |
3 |
4 |
5 |
7 |
8 |
Inconsistency check: If U12 (injection drug use) is “Yes” and all of the responses to U13a-U13i are “Never,”, then QDS will 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 S6 (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 U16.
If S12 (female respondent had sex with a man during the past 12 months) and S16 (female respondent had sex with a woman) are “No,” “Refused to answer,” or “Don’t know,” skip to Say box before U16.
If S21 (transgender respondent had sex during the past 12 months) is “No,” “Refused to answer,” or “Don’t know,” skip to Say box before U16
U14. During the past 12 months, did you inject drugs before or during sex? [INJ_BFSX]
Skip to Say box before U16
No 0
Yes 1
Skip to Say box before U16
Refused to answer 7
Don’t know 8
Interview instructions: If U13a is “Daily,” “Weekly,” “Monthly,” or “Less than monthly,” check the shaded box (column 1) in U15a. Follow the same pattern for b–i. If no shaded boxes are checked in U13, skip to Say box before U16. |
||||||
|
|
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) |
|
U15a. |
…heroin and cocaine together before or during sex? [HERCO2_9] |
0 |
1 |
7 |
8 |
|
U15b. |
…heroin alone before or during sex? [HERII2_9] |
0 |
1 |
7 |
8 |
|
U15c. |
…cocaine alone before or during sex? [COCAI2_9] |
0 |
1 |
7 |
8 |
|
U15d. |
…crack before or during sex? [CRACI2_9] |
0 |
1 |
7 |
8 |
|
U15e. |
…methamphetamines before or during sex? [CRAMI2_9] |
0 |
1 |
7 |
8 |
|
U15f. |
…other amphetamines or stimulants before or during sex? [AMPHI2_9] |
0 |
1 |
7 |
8 |
|
U15g. |
…Oxycontin before or during sex? [OXYCO2_9] |
0 |
1 |
7 |
8 |
|
U15h. |
…steroids or hormones before or during sex? [STRHI2_9] |
0 |
1 |
7 |
8 |
|
U15i. |
…[RESPONSE FROM U14i] before or during sex? [OINJI2_9] |
0 |
1 |
7 |
8 |
Inconsistency check: If U14 (injection drug use before or during sex) is “Yes” and all of the responses to U15a-U15i are “Never,”, then QDS will 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.”
U16. 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
U17. 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
U18. When you injected during the past 12 months, did you use drugs that had been divided with a syringe? [DIV_SYRN]
No 0
Yes 1
Refused to answer 7
Don’t know 8
Prevention Activities (P)
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 
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.] [CONF_12]
Community-based organization 1 [CONF_12A]
Family planning clinic 2 [CONF_12B]
STD clinic 3 [CONF_12C]
Doctor’s office or other health clinic 4 [CONF_12D]
IDU outreach organization (including needle exchange) 5 [CONF_12E]
Social venue (bar, club, bathhouse, gym, bookstore) 6 [CONF_12F]
Special event 7 [CONF_12G]
Other 1 (Specify:______________________________) 8 [CONF_12H] [COH_12OS]
Other 2 (Specify:______________________________) 9 [CONF_12I] [COI_12OS]
Refused to answer 77
Don’t know 88
Interviewer instructions: If U12 (injection drug use during the past 12 months) is “Yes,” go to P2. If U12 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, 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
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 a doctor, nurse, or other health care worker about ways to protect yourself or your partners from getting HIV or other sexually transmitted diseases? [PRTLK_12]
No 0
Yes 1
Refused to answer 7
Don’t know 8
P6. During the past 12 months, not including when you may have been tested for HIV, 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? [GROU1_12]
No 0
Yes 1
Refused to answer 7
Don’t know 8
Anxiety and Depression (M)
SAY: “Now I’m going to ask you some questions about your mood. When answering, please think about how often the following has occurred during the past 2 weeks. We will use Response Card O for these questions. We will also use the calendar to refer to the past 2 weeks.”
|
Over the past 2 weeks, how often have you been bothered by any of the following problems?
|
Not at all (1) |
Several Days (2) |
More than half the days (3) |
Nearly every day (4) |
Refused to answer (7) |
Don’t know (8) |
M1a. |
Little interest or pleasure in doing things [ANX_DEPA] |
|
|
|
|
|
|
M1b. |
Feeling down, depressed, or hopeless [ANX_DEPB] |
|
|
|
|
|
|
M1c. |
Trouble falling or staying asleep, or sleeping too much [ANX_DEPC] |
|
|
|
|
|
|
M1d. |
Feeling tired or having little energy [ANX_DEPD] |
|
|
|
|
|
|
M1e. |
Poor appetite or overeating [ANX_DEPE] |
|
|
|
|
|
|
M1f. |
Feeling bad about yourself—or that you are a failure or have let yourself or your family down [ANX_DEPF] |
|
|
|
|
|
|
M1g. |
Trouble concentrating on things, such as reading the newspaper or watching television [ANX_DEPG] |
|
|
|
|
|
|
M1h. |
Moving or speaking so slowly that other people could have noticed, Or the opposite—being so fidgety or restless that you have been moving around a lot more than usual [ANX_DEPH] |
|
|
|
|
|
|
Gynecological and Reproductive History (G)
Interviewer instructions: If D8 (birth gender) and D9 (self-identified gender) are “Female,” go to Say box before G1; otherwise, skip to instructions before L0.
SAY: “Now I’m now going to ask some questions about Pap smears. A Pap smear, also called a cervical cancer test or Pap test, is a test used to check for cancer of the cervix.”
G1. During the past 12 months, have you had a vaginal or cervical Pap smear? [PAP1_12]
Skip to Say box before G3
No 0
Yes 1
Skip to Say box before G3
Refused to answer 7
Don’t know 8
Skip to Say box before G3
Normal 1
Not normal 2
Skip to Say box before G3
Refused to answer 7
Don’t know 8
G2a. Did you receive a follow-up exam or tests for this abnormal result? [PAP2A_12]
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.”
QDS 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.”
G3. Since testing positive for HIV in __ __/__ __ __ __ [INSERT DATE FROM A1], have you been pregnant? [PREGPS_9]
Skip to instructions before L1
No
0
Yes 1
Skip to instructions before L1
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.
QDS 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].
Skip to instructions before G4
G3b. Since testing positive for HIV in __ __/__ __ __ __ [INSERT DATE FROM A1], have you given birth to any children? [BRTH_CLD]
No
0
Yes 1
Skip to instructions before G4
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 G4.
QDS 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]
Interview instructions: If response to A1 (date first tested positive) is 12 months or less from today, skip to instructions before L0.
Inconsistency check: G3c (number of times the respondent has given birth since testing positive for HIV) must be ≤ 35. G3c cannot be greater than G3a.
QDS coding note: If A1 (date first tested positive) is “don’t know” or “refused to answer,” then G3c reads as follows: Since testing positive for HIV how many times have you given birth? If you gave birth to twins, please count this as one birth. [NUM_BRTH] If G3c is greater than G3a (number of times been pregnant), display a message saying: “Number of times given birth cannot be greater than number of times pregnant.”
SAY: “Now I would like to ask you about pregnancies during the past 12 months. Remember, that is from last year (DATE WITH PREVIOUS YEAR) to now (INTERVIEW DATE).”
QDS programming note for Say box before G4: The QDS program should enter the appropriate dates. EXAMPLE: If IDATE is 11/11/2012 then the program should read “That is from last year, 11/11/2011 to now 11/11/2012.”
Skip to instructions before L1
G4. During the past 12 months, have you been pregnant? [PREG12]
No
0
Yes 1
Skip to instructions before L1
Refused to answer 7
Don’t know 8
Interviewer instructions: If G3a (number of times pregnant since testing positive) is “1,” skip to instructions before L0.
G4a. During the past 12 months, how many times have you been pregnant? [NMPREG12]
___ ___ [77 = Refused to answer, 88 = Don’t know]
Inconsistency check: G4a (number of times the respondent has been pregnant during the past 12 months) must be ≤ 12.
G4b. During the past 12 months, have you given birth to any children?
Skip to instructions before L1
No
0
Yes 1
Skip to instructions before L1
Refused to answer 7
Don’t know 8
Interviewer instructions: If response to G4a (number of times pregnant during the past 12 months) is “1” and G4b (given birth during the past 12 months) is “Yes,” skip to instructions before L0.
G4c. During the past 12 months, how many times have you given birth? If you
gave birth to twins, please count this as one birth. [NUM_BR12]
___ [7 = Refused to answer, 8 = Don’t know]
Inconsistency check: G4c (number of times the respondent gave birth during the past 12 months) must be ≤ 2. G4c cannot be greater than G4a.
QDS coding note: If G4c is greater than G4a (number of times been pregnant during past 12 months), display a message saying: “Number of times given birth cannot be greater than number of times pregnant.”
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
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 A5 (date of first visit to a provider for HIV care) or later than A7 (date of most recent visit to a provider for HIV care.)
QDS 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 A7 (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.
SAY: “Now we will use Response Card P.”
C1b. What was the result of your first CD4 count? [CD4FCT_9]
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).
QDS programming note for C2: Allow for “??” for month.
SAY: “Please use Response Card P again.”
C2a. What was the result of your most recent CD4 count? [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).”
QDS programming note for Say box before C3: The QDS program should enter the appropriate dates. EXAMPLE: If IDATE is 11/11/2012 then the program should read “That is from last year, 11/11/2011 to now 11/11/2012.”
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
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 A5 (date of first visit to a provider for HIV care). Confirm response if C5 (date of the first viral load test) is later than A7 (date of most recent visit to a provider for HIV care).
QDS programming note for C5: Allow for “??” for month. If C5 is earlier than A5, 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 A7, 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.
SAY: “Now we will use Response Card Q.”
C5a. What was the result of your first viral load test? [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? [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]
QDS programming note for C5b: Allow for “??” for month value.
SAY: “Please use Response Card Q again.”
C5c. What was the result of your most recent viral load test? [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).”
QDS programming note for Say box before C6: The QDS program should enter the appropriate dates. EXAMPLE: If IDATE is 11/11/2012 then the program should read “That is from last year, 11/11/2011 to now 11/11/2012.”
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: “The next question is about hepatitis, an infection of the liver. 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.”
C7. 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: “Another infection that people with HIV can get is Pneumocystis pneumonia or PCP.”
C8. Have you ever been told by a doctor, nurse, or other health care worker that you had PCP? [PCP_9]
No 0
Yes 1
Refused to answer 7
Don’t know 8
SAY: “Now I’m going to ask you some questions about sexually transmitted diseases or STDs. STDs are also known as venereal disease (VD) or sexually transmitted infections (STIs).”
C9.
|
During the past 12 months, have you had a test or exam to check for any of the following: [READ CHOICES.] |
No (0) |
Yes (1) |
Refused to answer (7) |
Don’t know (8) |
C9a. |
Syphilis [EXSYP_12] |
|
|
|
|
C9b. |
Gonorrhea (clap or drip) [EXGON_12] |
|
|
|
|
C9c. |
Chlamydia [EXCHL_12] |
|
|
|
|
C9d. |
Anogenital herpes (HSV) [EXHER_12] |
|
|
|
|
C9e. |
Anogenital warts (HPV) [EXGEN_12] |
|
|
|
|
Interviewer instructions: If D8 (birth gender) and D9 (self-identified gender) are “Female,” go to C9f; otherwise, skip to C9g. |
|||||
C9f. |
Trichomoniasis (“tric”) [EXTRI_12] |
|
|
|
|
C9g. |
Any other STD (Specify:__________) [OESTD_12] [OST_12OS] |
|
|
|
|
|
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) |
C10a. |
Syphilis [DIASYP_9] |
|
|
|
|
C10b. |
Gonorrhea (clap or drip) [DIAGON_9] |
|
|
|
|
C10c. |
Chlamydia [DIACHL_9] |
|
|
|
|
C10d. |
Anogenital herpes (HSV) [DIHER_12] |
|
|
|
|
C10e. |
Anogenital warts (HPV) [DIGEN_12] |
|
|
|
|
C10f. |
Proctitis [DIPRO_12] |
|
|
|
|
Interviewer instructions: If D8 (birth gender) and D9 (self-identified gender) are “Female,” go to C10g; otherwise, skip to Say box before C10j. |
|||||
C10g. |
Trichomoniasis (“tric”) [DITRI_12] |
|
|
|
|
C10h. |
Cervicitis [DICER_12] |
|
|
|
|
C10i. |
Pelvic inflammatory disease (PID) [DIPID_12] |
|
|
|
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Interviewer instructions: If D8 (birth gender) and D9 (self-identified gender) are “Male,” go to C10j; otherwise, skip to C10k. |
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C10j. |
Non-gonococcal urethritis (NGU) [DINGU_12] |
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C10k. |
Any other STD (Specify:__________) [OSTD3_9] [OSTD_9OS] |
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C10.
Interviewer instructions: If any of the responses to C9a-C9g are “yes, ” or any of the responses to C10a-C10k are “yes,” then go to C11; otherwise skip to Say box before C12.
C11. During the past 12 months, where did you go for testing, diagnosis, or treatment of a
sexually transmitted disease? [READ CHOICES. CHECK ALL THAT APPLY.] [STLO_12]
Private doctor 1 [STLO_12A]
Family planning clinic 2 [STLO_12B]
OBGYN or gynecological clinic 3 [STLO_12C]
STD clinic 4 [STLO_12D]
Emergency room 5 [STLO_12E]
Health department 6 [STLO_12F]
Community health center 7 [STLO_12G]
Other 1 (Specify) 8 [STLO_12H] [STH_12OS]
Other 2 (Specify) 9 [STLO_12I] [STI_12OS]
Refused to answer 77
Don’t know 88
SAY: “Now I’m going to ask about vaccinations. To begin, I’m going to ask about the human papillomavirus or HPV vaccine. Other names for this vaccine are Gardasil and Cervarix.”
C12. Have you ever had a vaccine for HPV? [HPV_EVR]
No 0
Yes 1
Refused to answer 7
Don’t know 8
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 Instructions before L0
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 interviewer instructions before L0.
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
Optional Module: Acculturation Scale (L)
Interviewer instructions: If D6 (birth country) is “United States” or “Puerto Rico,” skip to Interview completion.
Interviewer instructions:
Skip to Say box before
E1
L0. Does your project area ask Optional Module questions?
No
0
Yes 1
Skip to Interview completion
L1. What is your native language? By native language, I mean the language used in your country of origin or the one you used when you were growing up. [DON’T READ CHOICES. CHECK ONLY ONE.] [ORIG_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 [ORIG_LAO] [ORI_LAOS]
Skip to Interview completion
Refused to answer 77
Don’t know 88
L2. In general, what languages do you read and speak? [READ CHOICES. CHECK ONLY ONE.] [ACLT_L1]
Only [RESPONSE FROM L1] 1
[RESPONSE FROM L1] better than English 2
Both equally 3
English better than [RESPONSE FROM L1] 4
Only English 5
Refused to answer 7
Don’t know 8
L3. What languages did you use as a child? [READ CHOICES. CHECK ONLY ONE.] [ACLT_L2]
Only [RESPONSE FROM L1] 1
More [RESPONSE FROM L1] than English 2
Both equally 3
More English than [RESPONSE FROM L1] 4
Only English 5
Refused to answer 7
Don’t know 8
L4. What languages do you usually speak at home? [READ CHOICES. CHECK ONLY ONE.] [ACLT_L3]
Only [RESPONSE FROM L1] 1
More [RESPONSE FROM L1] than English 2
Both equally 3
More English than [RESPONSE FROM L1] 4
Only English 5
Refused to answer 7
Don’t know 8
L5. In which languages do you usually think? [READ CHOICES. CHECK ONLY ONE.] [ACLT_L4]
Only [RESPONSE FROM L1] 1
More [RESPONSE FROM L1] than English 2
Both equally 3
More English than [RESPONSE FROM L1] 4
Only English 5
Refused to answer 7
Don’t know 8
L6. What languages do you usually speak with your friends? [READ CHOICES. CHECK ONLY ONE.] [ACLT_L5]
Only [RESPONSE FROM L1] 1
More [RESPONSE FROM L1] than English 2
Both equally 3
More English than [RESPONSE FROM L1] 4
Only English 5
Refused to answer 7
Don’t know 8
Interview Completion (E)
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 confidential.”
Interviewer instructions:
Offer assistance with information and resources, according to local protocol.
Don’t pay the respondent if the respondent already participated in an MMP interview during the 2012 data collection cycle OR the respondent is less than 18 years old.
Pay the respondent if the respondent’s first HIV positive test was after the PDP, OR the interview was partially or fully completed.
Payment Verification
Interviewer instructions: if I5 is “telephone interview,” go to E1; otherwise skip to E2.
E1. Have arrangements for payment been made? [ARRANGE]
No 0
Yes 1
Interviewer instructions: Skip to E4.
E2. Payment made: [PAYMENT]
No 0
Yes
1 Skip to E3
E2a. Why was payment not made? [PAYNMAD]
Skip to E4
Other (Specify:_____________________________) 2
[OPAY]
E3. Receipt signed (or initialed): [RECEIPT]
No 0
Yes
1 Skip to E4
E3a. Why was receipt not signed? [RECNS]
Participant refused to sign 1
Other (Specify:_____________________________) 2
[ORECEI]
Data Validity
E4. How confident are you of the validity of the respondent’s answers? [CONF]
Confident 1
Some doubts 2
Not confident at all 3
E5. 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]
QDS programming note for E4: Include a NA response option if Interviewers do not have any additional comments.
Facility Visits Log – Medical Monitoring Project 2012
Record information on facilities as indicated in the questionnaire. Only obtain contact information (street address/city/state) for facilities with which you are not familiar or those outside of your MMP project area’s jurisdiction. Interviewers should not write in the shaded row or column. After the interview is completed, this information should be entered into the DCC Tracking System.
Box A Interview Date: ___ ___/___ ___/ ___ ___ ___ ___
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Box B
___ ___ ___ ___ ___ ___ ___ ___ ____ ___ ___ ___ Site ID Facility ID Respondent ID |
Box C Interviewer ID: ___ ___ ___ |
Facility Type Code1 (from question) |
What was the name of this facility? |
What is the MMP 8-digit facility ID number? Data manager use only |
What was the name of the health care provider you usually saw there? |
About how many times did you go to this facility during the past 12 months? |
What was the street address of this facility? (complete as needed) |
What city and state was this facility in? (complete as needed) |
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First name |
City |
State |
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SAMP Data manager use only |
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Facility Type Codes:
USL = usual HIV care INC = care while incarcerated OTH = other HIV care OBGYN = OB or GYN care MED = general medical care HO = inpatient hospital
SAMP = facility where patient was sampled
Response cards
Response card A
Monthly Income Yearly Income
a. $0 to $416 j. $0 to $4,999
b. $417 to $833 k. $5,000 to $9,999
c. $834 to $1249 l. $10,000 to $14,999
d. $1250 to $1666 m. $15,000 to $19,999
e. $1667 to $2499 n. $20,000 to $29,999
f. $2500 to $3333 o. $30,000 to $39,999
g. $3334 to $4166 p. $40,000 to $49,999
h. $4167 to $6249 q. $50,000 to $74,999
i. $6250 or more r. $75,000 or more
Response card B
I asked them not to tell any of my partners
I asked them to tell only some of my partners
I asked them to tell all of my partners
I told them that I did not have any partners
Response card C
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
Nutritional services
Interpreter services
Other HIV-related services
Nutritional services
Response card D
Always Often Sometimes Occasionally Never
Response card E
Extremely Quite a bit Somewhat A little bit Not at all
Response card F
Never Occasionally Sometimes Often Always
Response card G
Strongly disagree Somewhat disagree Neutral/no opinion Somewhat agree Strongly agree
Response card H
Never Rarely About half of the time Most of the time Always
Response card I
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 J
Never
Rarely
About half of the time
Most of the time
Always
Been on medications less than 30 days
Response card K
Not at all sure Somewhat sure |
Very sure Extremely sure
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Response card L
Very dissatisfied Somewhat dissatisfied |
Somewhat satisfied Very satisfied
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Response card M
Not at all A little |
Somewhat A lot
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RESPONSE CARD N
Daily Weekly Monthly Less than Monthly Never
Alcohol Response card
RESPONSE CARD O
Not at all Several days More than half the days Nearly every day
Response card P
0–49
50–99
100–199
200–349
350–499
500 or more
Response card Q
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
2011 Calendar
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
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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 |
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
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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 |
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
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
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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
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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 |
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
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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
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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
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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
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| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | OMB Number: 0920-0740 |
| Author | chx5 |
| File Modified | 0000-00-00 |
| File Created | 2021-01-31 |
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