Baseline Survey

Form Approved

OMB No. 0920-0840

Expiration Date: 02/29/2016

Evaluation of Rapid HIV self-testing in MSM (eSTAMP): Field Performance Study

Attachment 1c

Baseline Survey

Public reporting burden of this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-0840)

Part 3 Baseline Survey

____________________________________________________

AUTO1. Date of Baseline Survey: __ __ / __ __ / __ __ __ __

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

AUTO2. Time Began Baseline Survey __ __:__ __:__ __ [24 Hour time HH:MM:SS]

We appreciate your willingness to be part of this study. Your participation will help us learn more about ways to get people tested for HIV. This survey includes some personal questions about your HIV testing practices and sexual behaviors. You can choose to not answer any questions that make you feel uncomfortable.

____________________________________________________

Section A. Demographics

DM-1. What is the highest grade in school you completed?

Never attended school

Less than high school

Some high school

High school diploma or GED

Some college, Associate’s degree, or Technical degree

College, post graduate or professional school

I prefer not to answer

DM-2. What best describes your current employment status? Choose only one.

Employed full time

Employed part time

Unemployed

I prefer not to answer

DM-3. The next question is about your household income last year from all sources before taxes. That is, the total amount of money earned and shared by all people living in your household.

Please choose if you would like to answer in terms of monthly income or yearly income:

$ per month

$ per year

I prefer not to answer

If DM-3 = “$ per month, go to DM-3a.

If DM-3 = “$ per year, go to DM-3b.

If DM-3 = “I prefer not to answer”, skip to DM-5.

DM-3a. What was your household income last year from all sources before taxes?

0 to $1667 per month

$1668 to $3333 per month

$3334 to $6250 per month

$6251 or more per month

DM-3b. What was your household income last year from all sources before taxes?

0 to $19,999 per year

$20,000 to $39,999 per year

$40,000 to $74,999 per year

$75,000 or more per year

DM-4. Including yourself, how many people depended on this income? (must be at least 1)

___ ___

I prefer not to answer

DM-5. Which of these common terms best describes you?

Homosexual or Gay or Same gender loving

Heterosexual or Straight

Bisexual

Other (Specify _____)

I prefer not to answer

DM-6. Do you currently have health insurance?

No

Yes – Through my job

Yes – Through someone else’s job

Yes – Paid for by me or another person

Yes – Medicare/Medicaid

I prefer not to answer

DM-7. In the past 12 months, have you seen a doctor, nurse, or other health care provider about your own health?

No

Yes

I prefer not to answer

If ES-9= “No”, go to Section B.

If ES-9 = “Yes”, go to Section C.

(Reminder:

ES-9. Have you ever been tested for HIV?

ES-10. What was the result of your most recent HIV test?)

Section B. Questions for persons who have never tested for HIV

HT-1. You mentioned earlier that you have never been tested for HIV. What are the reasons you have never been tested? Check all that apply.

I think I’m at low risk for HIV infection

I am afraid to find out I have HIV

I don’t have time

I don’t know where to go for a test

I don’t have enough money or insurance for a test

I don’t want my friends and family to know that I got tested

I don’t want my sex partners to know that I got tested

If I test positive I won’t be able to get treatment

I don’t believe that treatment is effective

If I test positive I will be rejected by my friends and family

I do not want my result to be reported to the government

No particular reason

Other reason (Specify___________)

I prefer not to answer

HT-2. Among the reasons you indicated, what is the main reason you have never been tested for HIV? Choose only one.

Display response options based on selections in HT-1.

Section C. Questions for persons who have previously tested for HIV

HT-3. You mentioned earlier that you have been tested for HIV. When did you have your most recent HIV test?

__ __ / __ __ __ __ [MM/YYYY]

I prefer not to answer

If YYYY < “1985”, display “HIV testing was not widely available before 1985. Please re-enter the correct year.” and loop back to put in the correct year.

If date in HT-3 is NOT within the past 12 months, skip to HT-5.

HT-4. In the past 12 months, that is, since [insert calculated month and year], how many times have you been tested for HIV?

___ ___ (1 to N)

I prefer not to answer

HT-5. When you last got tested in __ __ / __ __ __ __ [insert date from HT-3], where did you get tested? Choose only one.

Private doctor’s office

HIV counseling and testing site

Public health clinic / Community health clinic

Street outreach program / Mobile unit

Sexually transmitted disease clinic

Emergency room

Hospital (inpatient)

Correctional facility (jail or prison)

Home or other private location

Other location (Specify___________)

I prefer not to answer

HT-6. When you last got tested in __ __ / __ __ __ __ [insert date from HT-3], what type of test was used?

Finger-stick blood rapid test (Test that required pricking your finger to collect a drop of blood)

Oral fluid rapid test (Test that required swabbing your gums to collect an oral fluid sample)

Test that required drawing blood with a syringe

I prefer not to answer

Section D: Awareness & previous use of home HIV tests

A home diagnostic test is one you can buy at a store or online, and use to test yourself for cholesterol, blood glucose, etc.

OT-1. Have you ever used any home diagnostic test before?

No

Yes

I prefer not to answer

OT-2. Have you ever heard about home HIV tests? A home HIV test is one that you can use to test yourself for HIV at home or another private location.

No

Yes

I prefer not to answer

If OT-2= “No” skip to Section E.

OT-3. In the past 12 months, have you used a home HIV test?

No

Yes

I prefer not to answer

If OT-3 = “Yes”, skip to OT-5.

OT-4. What are some of your reasons for not using a home HIV test? Check all that apply.

I’m concerned about the cost of a home HIV test

I’m concerned about the accuracy of such a test

I’m concerned I would not be able to perform the test correctly

I’m concerned I would not be able to read the result properly

I do not know where to get a home HIV test kit

I would rather talk to a counselor when I get an HIV test

I do not want to stick my finger to get a drop of blood

I do not want to mail my blood sample to a lab

I got tested at a different location such as my doctor’s office

I’m afraid of finding out that I have HIV

Other reason (Specify___________)

I prefer not to answer

OT-5. Among the reasons you indicated, what is the main reason you have not used a home HIV test? Choose only one.

Display response options based on selections in OT-4.

If OT-3 ≠ “Yes”, skip to Section E.

OT-6. In the past 12 months, which of these home HIV tests have you used? Check all that apply.

Display images of HomeAccess and OraQuick with these response options.

HomeAccess® HIV-1 Test System (where you prick your finger, collect a blood sample on a card and mail that card to a lab for testing)

OraQuick® In-Home HIV Test (where you collect your own oral fluid sample by swabbing your mouth, use the testing device yourself and read test results within 20 minutes)

Other rapid HIV test (Specify___________)

OT-7. In the past 12 months, how many times have you used a home HIV test?

___ ___ (1 to N)

I prefer not to answer

OT-8. You mentioned you used [insert option from OT-6] to test yourself for HIV. Where did you get the home HIV test(s)? Check all that apply.

Bought Online

From a pharmacy

From a friend

From a sex partner

From my doctor’s office

From an HIV counseling and testing site

From a Health Department

From another research study

Other location or person (Specify (not someone’s name)___________)

I prefer not to answer

If participant chose more than one option in OT-6, loop back to ask OT-8 for each option.

OT-9. People use home HIV tests for many different reasons. In the past 12 months, did you use the home HIV test(s) for any of the following reasons: Check all that apply.

It was more convenient than getting tested by a doctor or at an HIV testing site

It was more private than getting tested by a doctor or at an HIV testing site

I didn’t want other people to know I am testing

To test together with someone, before having sex

To test myself, before having sex

To test myself, after having sex

A sex partner asked me to take a home HIV test

Other reason

Don’t know / Not sure

Section E: Intentions to use and distribute rapid HIV test kits

We will be mailing you free, anonymous rapid HIV tests as part of this online study. You can use these to test yourself at home or another private location and read your results within a few minutes. The package will contain two types of tests:

Option 1: Here you could collect your own oral fluid sample by swabbing your mouth, use the testing device yourself and read your HIV test results within 20 minutes.

Option2: Here you could prick your finger to collect a blood sample, use the testing device yourself and read your HIV test results within 15 minutes.

If any test were to come back positive, you would be able to call a toll-free, 24-hour hotline and get immediate counseling.

IQ-1. How likely would you be to test yourself using the free anonymous, oral fluid rapid HIV test (Option 1)?

Very likely

Somewhat likely

Not sure

Somewhat unlikely

Very unlikely

I prefer not to answer

IQ-2. How likely would you be to test yourself using the free, anonymous finger-stick blood rapid HIV test (Option 2)?

Very likely

Somewhat likely

Not sure

Somewhat unlikely

Very unlikely

I prefer not to answer

If IQ-1 = “Very likely” or “Somewhat likely”, and IQ-2 = “Very likely” or “Somewhat likely”, skip to IQ-5.

IQ-3. What are some of your reasons for not being willing to use a free, anonymous rapid HIV test? Check all that apply.

I’m afraid of finding out that I have HIV

I live with people who might see the test kits arrive by mail

I live with people who might see me performing an HIV test

I do not want to swab my mouth to collect an oral fluid sample

I do not want to prick my finger to collect a blood sample

I’m concerned about the accuracy of an oral fluid rapid HIV test

I’m concerned about the accuracy of a finger-stick blood rapid HIV test

I’m concerned I would not be able to perform the test correctly

I’m concerned I would not be able to read the result properly

I would rather talk to a counselor when I get an HIV test

I would rather be tested by someone who is trained to conduct the test

Other reason (Specify___________)

I prefer not to answer

IQ-4. Among the reasons you indicated, what is the main reason you are not willing to use a free, anonymous rapid HIV test? Choose only one.

Display response options based on selections in IQ-3.

Now imagine you could give away free, anonymous rapid HIV tests to your friends or sex partners. They can use these to test themselves at home or another private location, and read their results within a few minutes. Suppose the same two types of tests were available:

Option 1: Here they could collect their own oral fluid sample by swabbing their mouth, use the testing device themselves and read their HIV test results within 20 minutes.

Option2: Here they could prick their finger to collect a blood sample, use the testing device themselves and read their HIV test results within 15 minutes.

If any test were to come back positive, they would be able to call a toll-free, 24-hour hotline and get immediate counseling.

IQ-5. How likely would you be to give away a free anonymous, oral fluid rapid HIV test (Option 1) to your friends or sex partners?

Very likely

Somewhat likely

Not sure

Somewhat unlikely

Very unlikely

I prefer not to answer

IQ-6. How likely would you be to give away a free, anonymous finger-stick blood rapid HIV test (Option 2) to your friends or sex partners?

Very likely

Somewhat likely

Not sure

Somewhat unlikely

Very unlikely

I prefer not to answer

If IQ-5 = “Very likely” or “Somewhat likely”, and IQ-6 = “Very likely” or “Somewhat likely”, skip to IQ-9.

IQ-7. What are some of your reasons for not being willing to give away free, anonymous rapid HIV tests to your friends or sex partners? Check all that apply.

I’m concerned this might affect our friendship

I’m concerned this might affect our sexual relationship

I think they would get upset or angry

I’m afraid they would think I have HIV

I’m concerned about the accuracy of an oral fluid rapid HIV test

I’m concerned about the accuracy of a finger-stick blood rapid HIV test

I’m concerned they would not be able to perform the test correctly

I’m concerned they would not be able to read the result properly

I would rather they talk to a counselor when they get an HIV test

I would rather they get tested by someone who is trained to conduct the test

Other reason (Specify___________)

I prefer not to answer

IQ-8. Among the reasons you indicated, what is the main reason you are not willing to give away free, anonymous rapid HIV tests to your friends or sex partners? Choose only one.

Display response options based on selections in IQ-7.

If IQ-5 ≠ “Very likely” or “Somewhat likely”, and IQ-6 ≠ “Very likely” or “Somewhat likely”, skip to IQ-10.

IQ-9. To whom would you most likely give away free, anonymous rapid HIV tests? Check all that apply.

Main sex partner (someone you feel committed to above all others)

Casual sex partner (someone you do not feel committed to above all others)

One-time sex partner (someone you have sex with only once and probably never again)

Exchange sex partner (someone you have sex with in exchange for money, food or drugs)

Family member (who is not a sex partner)

Friend (who is not a sex partner)

Stranger (who is not a sex partner)

Acquaintance (who is not a sex partner)

Someone else (Specify___________)

I prefer not to answer

IQ-10. How likely would you be to test yourself together with your friends or sex partners using free, anonymous rapid HIV tests? This means that both of you take the rapid test together in the same place.

Very likely

Somewhat likely

Not sure

Somewhat unlikely

Very unlikely

I prefer not to answer

If IQ-10 = “Very likely” or “Somewhat likely”, skip to IQ-13.

IQ-11. What are some of the reasons you would not test yourself together with your friends or sex partners using free, anonymous rapid HIV tests? Check all that apply.

I do not want them to find out my test result

I do not want to find out their test result

I’m concerned they would tell someone my test result

I think they would get upset or angry

I’m concerned this might affect our friendship

I’m concerned this might affect our sexual relationship

I’m concerned we might be drunk or high on drugs

Other reason (Specify___________)

I prefer not to answer

IQ-12. Among the reasons you indicated, what is the main reason you are not willing to test yourself together with your friends or sex partners using free, anonymous rapid HIV tests? Choose only one.

Display response options based on selections in IQ-11.

If IQ-10 ≠ “Very likely” or “Somewhat likely”, skip to IQ-15.

IQ-13. With whom would you most likely test together using free, anonymous rapid HIV tests? Check all that apply.

Main sex partner (someone you feel committed to above all others)

Casual sex partner (someone you do not feel committed to above all others)

One-time sex partner (someone you have sex with only once and probably never again)

Exchange sex partner (someone you have sex with in exchange for money, food or drugs)

Family member (who is not a sex partner)

Friend (who is not a sex partner)

Stranger (who is not a sex partner)

Acquaintance (who is not a sex partner)

Other person (Specify___________)

I prefer not to answer

IQ-14. Where would you be most likely to test yourself together with your friends or sex partners using free, anonymous rapid HIV tests? Check all that apply.

At my house

At their house

At a bar or dance club

At a bathhouse or sex club

At a private sex party

At a circuit party

In a car

Other location (Specify___________)

I prefer not to answer

Section F. Lab experience, vaccine trials history & PrEP/PEP use

LE-1. Have you ever had a job in which you conducted laboratory activities or experiments?

No

Yes

I prefer not to answer

LE-2. Have you ever had a job drawing blood or obtaining biological specimens?

No

Yes

I prefer not to answer

LE-3. Have you ever participated in an HIV vaccine clinical trial?

No

Yes

I prefer not to answer

LE-4. Are you currently taking any anti-HIV medicines to prevent getting HIV infection such as pre-exposure prophylaxis (PrEP) or post-exposure prophylaxis (PEP)?

No

Yes

I prefer not to answer

Section G. Sex behavior questions

RB-1. In the past 12 months, with how many different men did you have anal sex? “Anal sex" means you put your penis in his butt, or he put his penis in your butt. .

___ ___ (0 to N)

I prefer not to answer

RB-2. With how many of these [RB-1] men did you have unprotected anal sex? For this question, "unprotected anal sex" means you put your penis in his anus (butt), or he put his penis in your anus (butt), without using a condom or not using it the whole time.

___ ___ 0 to N)

I prefer not to answer

Check to make sure RB-2 ≤ RB-1.

If not, then display “The number of men you had unprotected anal sex with cannot be more than the number of men you had anal sex with in the past 12 months. Please carefully re-enter your response.”, and loop back to enter the number.

RB-3. How many of these [RB-2] men with whom you had unprotected anal sex within the past 12 months, do you know, think or believe were:

HIV positive? ___ ___ (0 to N)

HIV negative? ___ ___ (0 to N)

Men whose HIV status you did not know? ___ ___ (0 to N)

Check to make sure that the numbers in RB3 add up to the total N from RB2.

If not, then display “The number of HIV positive, HIV negative and HIV status unknown partners must add up to [RB-2]. Please carefully re-enter your responses.”, and loop back to enter the numbers.

Section F. Token of appreciation information

We will now ask you some questions about how you would like to receive $20 for completing this survey.

PI-1. How would you like to receive your $20 token of appreciation? Choose only one method.

Cash token of appreciation through PayPal (requires a bank account)

Amazon.com electronic gift card (will be sent by email)

I do not wish to claim my token of appreciation

If PI-1 = “Cash token of appreciation through PayPal”, then go to PI-2.

If PI-1 = “Amazon.com electronic gift card”, then skip to PI-4.

If PI-1 = “I do not wish to claim my token of appreciation” then skip to RP-1.

Receiving your token of appreciation by PayPal requires that you have a bank account. You will NOT be required to provide information about your bank account to this survey, only to PayPal. If you do not have bank account, please return to the previous question and select another option for your token of appreciation.

We will send your PayPal token of appreciation to the email address you provided during registration, unless you prefer for us to use another email address.

PI-2. Do you want us to use the email address [insert email address from QS1] to send your PayPal token of appreciation?

Yes

No

If PI-2 = “No”, then go to PI-3 else skip to RP-1.

PI-3. Please enter the new email address where you would like us to send your PayPal token of appreciation.

____________________

We will send your electronic gift card to the email address you provided during registration, unless you prefer for us to use another email address.

PI-4. Do you want us to use the email address [insert email address from QS1] to send your electronic gift card?

Yes

No

If PI-4 = “No”, then go to PI-5 else skip to RP-1.

PI-5. Please enter the new email address where you would like us to send your electronic gift card.

____________________

Section G. Reminder Preferences

We will now be sending you a free package containing 1 blood collection kit and 2 rapid HIV test kits. This package will include instructions on how to collect your blood on a filter card and mail it back to us in a prepaid shipping envelope. It will also contain instructions on how you should test yourself with both rapid HIV test kits provided; the oral fluid and the finger-stick kits. You can also watch online videos (available on the study website and on the cell phone application) demonstrating how to conduct these tests. As part of this study, anyone using these kits has the option of calling a toll-free phone number with questions or to talk to a trained counselor.

If you like, we can send you an update once we mail your package. You may then track the status of your shipment online.

RP-1. Would you like to receive an update informing you that we have mailed your package?

Yes

No

If RP-1 = “No”, then skip to RP-3.

RP-2. How would you like to receive an update informing you that we have mailed your package?

Email me at [insert email address from Registration QS1]

Send me a text message at [insert telephone number from Registration QS3]

When you’re ready to take the tests, you can use your login and password that you created at the beginning of this survey to report your results on the study website. You will receive a $10 gift card for reporting both of your test results. Therefore, you may wish to write down your login and password in a safe place to help you remember what they are later. Also, after we receive the filter card with your blood sample we will send you an email with a link to the study website where you can specify how you want to receive an additional $20 gift card.

If you do not report the results of your HIV self-tests or if the laboratory does not receive your blood sample within 3 weeks after the package was mailed, we will send you reminder text messages or emails to complete these tasks. If you do not respond after we have sent a total of 3 reminders, we will be contacting you by phone.

RP-3. How would you like us to remind you about reporting your HIV self-test results or returning your blood sample if you have not responded to the reminder emails? Please rank the two options below.

[ ] Send me an email at [insert email address from Registration QS1]

[ ] Send me a text message at [insert telephone number from Registration QS3]

During the study we may call you to talk about your HIV testing practices and self-test results.

RP-4. What day of the week would you prefer that we call you on [insert telephone number from QS2]?

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

RP-5. What time of the day would you prefer that we call you on [insert telephone number from QS2]?

Morning (8:00am – 12:00pm)

Afternoon (12:00pm – 4:00pm)

Evening (4:00pm – 8:00pm)

Night (8:00pm – 12:00am)

RP-6. What is your time zone?

Eastern

Central

Mountain

Pacific

____________________________________________________

Thank you for completing our survey! Your response is very important to us. 

Your token of appreciation or gift card will be sent to you by email at the address you indicated earlier. If you have not received your token of appreciation within 10 days, please first check your spam filter/junk email folder, and then email us at (study email address).  Please send this email from the email address you provided during registration i.e. [insert email address from QS1].

Your free package containing 1 blood collection kit and 2 rapid HIV test kits will be mailed to you at the address you indicated earlier. If you have not received your package within 20 days, please email us at (study email address).  Please send this email from the email address you provided during registration i.e. [insert email address from QS1].

To find an HIV testing location near you, please visit: www.aidsvu.org

To get more information about HIV, please visit: www.cdc.gov/hiv

Otherwise, you can close your browser window. Thank you for your time.

End survey.

AUTO3. Time Ended Baseline Survey: __ __:__ __: __ __ [24 Hour time HH:MM:SS]

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