Study screener - English

Form Approved

OMB No. 0920-0840

Expiration date: 02/29/2016

“Understanding Barriers and Facilitators to HIV Prevention, Care, and Treatment”

2c. PLWH Study Screener English

Public reporting burden of this collection of information is estimated to average 5 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)

Date: ____________

Eligible____________

Partner Eligible____________

Recruiter Initials____________

1. Ask caller for more information about themselves/interest in the study.

   1. Ask caller:

Why do you think you qualify for this study?

2. Tell them:

I need to ask you a few questions to determine if you are eligible for this project.

3. IF NOT CLEAR ABOVE Ask caller:
   Where did you learn about this study?

4. Do you receive care there? Yes [ ] No [ ]

2. Ask caller about their eligibility

5. How old are you? (Interview, write in age) _________________ years

5. Do you consider yourself to be male, female, or transgender?

1. ____ Male

2. ____ Female

3. ____ Transgender

4. ____ Other: _________________

5. Do you consider yourself to be of Hispanic, Latino/a, or Spanish origin? (Interviewer, check one)

[ ] No
[ ] Yes

[ ] Refused to answer

[ ] Don’t Know

5. 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.]

1. ____American Indian or Alaska Native

2. ____Asian

3. ____ Black or African American

4. ____Native Hawaiian or Other Pacific Islander

5. ____White

6. ____Refused to answer

7. ____Don’t know
   
   

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

__________Month

__________Year

__________Have not tested positive

5. During the past 6 months have you had sex with a man?

   1. Yes

   2. No

   3. DK

   4. Refused to answer

INTERVIEWER INSTRUCTION: ELIGIBLE IF:

(All must be checked)

• R is Male,

• HIV+,

• OVER 18,

• AA or Latino

• MSM

If participant does not meet above criteria for eligibility, skip to Contact Form - NOT eligible.
If participant does meet above criteria for eligibility, continue screening for targeted characteristics.

Determine their treatment cohort:

5. Are you currently taking antiretroviral medicines (HIV meds)?

Yes [ ] IF COHORT FILLED SKIP TO CONTACT FORM; OTHERWISE SKIP TO 13 (PARTNER)

No [ ] IF COHORT FILLED SKIP TO CONTACT FORM; OTHERWISE CONTINUE BELOW Q 12

5. Which of the following best describes your treatment status as of today?
   (Interviewer, READ CHOICES OUT LOUD, then check one)

1. ____ Started HIV medicines, but stopped (no longer taking them)

2. ____ Have never taken HIV medicines

3. ____ Refuse to answer

4. ____ Don’t know/Don’t Remember
   
   
   

Identify potential HIV-discordant partner:

5. Are you currently in a relationship with one or more male sex partners?
   [ ] Yes

[ ] No (Skip to Contact Form)

5. (If YES) We are interested in interviewing you and I’ll get your information in a moment. For some of the men in the study we also want to interview their male partners separately. Do you have a partner who knows of your HIV positive status and do you think he might be interested in participating in the study as well?

[ ] Yes

[ ] No (Skip to Contact Form)

5. Is this partner male or transgender?

[ ] Male

[ ] Transgender (Skip to Contact Form)

5. How old is he?

[ ] 18 or older

[ ] under 18 (Skip to Contact Form)

5. Has he been diagnosed with HIV?

[ ] Yes (NOT HIV-discordant Skip to Contact Form)

[ ] No

5. And you said he is aware of your HIV positive status, is that correct?
   [ ] Yes

[ ] No (Not eligible Skip to Contact Form)

5. How long have you been in the relationship with this partner?

[ ] more than six months

[ ] less than six months (Check interviewer notes on eligibility, if not-Eligible skip to Contact Form)

5. As I said, we are also conducting interviews with some partners. We would interview you separately and ask that you do not discuss the interviews with each other until after both are completed. Your eligibility to participate is not affected even if he chooses not to participate. No information you provide in the interview or he provides will be shared or discussed in the interview; however the interview does assume that he is aware of your HIV status. Do you think he might be interested in participating?

   1. Yes

   2. No (Skip to Contact Form)

5. OK, we need to figure out the best way to let him know about the study. I can give you information now so he can call us or if you think he would be OK with us calling him, I could take his contact information and call to tell him about the study? What would be best?

[ ] Yes, R will give information SKIP TO CONTACT FORM

[ ] Yes, have us call R GOTO Question Contact form

[ ] No, not interested in SDP Skip to Contact Form

Tell them more about the study:

• The purpose of this research project is to get your opinion about treatment, prevention, and care of those living with HIV and what motivates or discourages patients in taking their HIV medications.

• Funding for this study is provided by the Centers for Disease Control and Prevention (CDC).

• We expect to enroll about 100 people in 5 cities across the country.

• It should take about an hour, depending on your answers.

• It will be tape recorded so researchers can review the information—no names will be used.

• You will receive a [gift card of $40/$40 cash.]

• All information will be kept private.

• Your care or services from any clinic or center will not be affected in any way by your decision of whether or not to participate in the study.