Form 1 Pattient Baseline

Appendix F

Patient Baseline Survey

You will need to provide an answer to every question in order to complete the survey. If you do not want to answer a particular question, select the refuse option. You will be able to move through the survey by clicking on the ‘Next’ and ‘Back’ buttons shown at the bottom of the screen. Please DO NOT use your internet browser’s back button because it will kick you out of the survey.

If you have any problems completing the survey or have questions concerning how to answer any of the questions, please inform [onsite study coordinator].

Demographics

To start off, we are going to ask you some questions to learn a little bit about you.

1. What is the highest level of education you have completed, so far?

Primary (grade school) or middle school

Some high school but not a graduate

High school graduate (or GED)

Some college or technical school, but not a graduate

College graduate or higher

Refuse to answer

2. Are you currently… (CHECK ALL THAT APPLY)

Working part time

Working full time

Going to school part time

Going to school full time

Refuse to answer

3. What is your current relationship status? Are you…

Single

In a relationship with a man

In a relationship with a woman

Married to a man

Married to a woman

Separated, divorced, or widowed

Refuse to answer

4. Do you currently have a steady partner (a husband, wife, girlfriend, boyfriend)?

Yes

No  (SKIP TO Q7)

Refuse to answer

5. How many months and years have you and your steady partner been together?

___ years ___ months

6. What is your steady partner’s gender?

Female

Male

Transgender male to female or transwoman

Transgender female to male or transmale

Other

Don’t Know

Refused

7. Do you have any children, including biological, adopted, step and foster children?

Yes

No

Refuse to answer

8. How much do you disagree or agree with the following statement:

   	Strongly disagree	Disagree	Neither disagree or agree	Agree	Strongly agree	Refuse to answer
   I feel like I have a stable place to live.

9. Who do you currently live with? (CHECK ALL THAT APPLY)

Nobody

Steady partner (husband, wife, girlfriend, boyfriend, fiancé or fiancée)

Mother or step-mother

Father or step-father

Siblings

Aunt or uncle

Cousin

Grandparents

Children or step-children

Other family member (specify)

A friend

Roommate(s)

Someone else (specify)

Refused

10. How safe do you feel in your current living situation?

Very safe

Somewhat safe

Somewhat unsafe

Very unsafe

Don’t Know

Refused

11. From time to time, people may have trouble taking care of their basic needs. In the past 3 months, how often have you had trouble…

    	All of the time	Most of the time	Some of the time	A little of the time	None of the time	Refuse to answer
    a. Finding a place to sleep
    b. Getting enough to eat
    c. Having enough clothing
    d. Finding a place to wash
    e. Finding a place to use the bathroom

12. As a child, did you ever live in an orphanage, foster home, group home or as a ward of the state?

Yes

No

Refuse to answer

13. Did you ever spend a day in a juvenile or adult jail, prison, detention center or other correctional facility?

Yes

No

Refuse to answer

Use of Technology

The next questions are about your cell phone service and Internet usage.

14. What service do you have for your personal cell phone?

Verizon

Sprint

T-Mobile

AT&T (Cingular)

MetroPCS

US Cellular

Tracfone

Boost Mobile

Virgin Mobile

STI Mobile

Net 10

Other: Specify:

Don’t know

Refuse to answer

15. Do you access the Internet… (CHECK ALL THAT APPLY)

At home?

At school?

At work?

At someplace other than home or work (e.g., café, library)?

On your cell phone?

I do not use the internet

Refuse to answer

Health and Wellness

Now we are going to switch gears and talk a little bit about your health and wellness.

16. In general, would you say your health is:

Excellent

Very good

Good

Fair

Poor

Refuse to answer

These questions are about how you feel and how things have been with you during the past three months. For each question, please give the one answer that comes closest to the way you have been feeling.

17. During the past 3 months, how much of the time has your physical health interfered with your social activities (like visiting with friends, relatives, etc.)?

All of the time

Most of the time

Some of the time

A little of the time

None of the time

Refuse to answer

18. During the past 3 months, how much of the time have any emotional problems, like depression or anxiety, interfered with your social activities (like visiting with friends, relatives, etc.)?

All of the time

Most of the time

Some of the time

A little of the time

None of the time

Refuse to answer

19. During the past 3 months, how often have you

	All of the time	Most of the time	Some of the time	A little of the time	None of the time	Refuse to answer
a. Felt lonely or sad
b. Been told you seem sad or depressed
c. Felt isolated or lonely, even when around other people
d. Felt that things were going your way
e. Had trouble sleeping
f. Had a poor appetite
g. Felt confident in your ability to handle your personal problems
h. Felt you could not cope with all the things you had to do

The next few questions are about HIV and STDs.

20. Were you born with HIV?

Yes  [SKIP TO Q22]

No

Refuse to answer

21. What month and year did you get your first positive test for HIV? If you can’t remember the month or year, please give your best guess. |__|__| |__|__|__|__|

Month Year

Don’t know

Refuse to answer

If the respondent enters a year prior to 1985: “This test was not available before 1985. Please enter a year that is between 1985–2010. Click on the continue button to return to this question.” DISALLOW DATES IN THE FUTURE.

22. Have you ever been diagnosed with a sexually transmitted infection other than HIV?

Yes

No  [SKIP TO Q24]

Refuse to answer  [SKIP TO Q24]

23. When were you last diagnosed with a sexually transmitted infection other than HIV?

0–3 months ago

4–6 months ago

7–12 months ago

More than 12 months ago

Refuse to answer

Adherence

24. Are you currently taking any medications that a doctor has prescribed to treat HIV?

Yes

No  [SKIP TO Q34]

Refuse to answer  [SKIP TO Q34]

25. When did you first start taking medications to treat HIV?

0–3 months ago

4–6 months ago

7–12 months ago

More than 12 months ago

Refuse to answer

26. How frequently are you supposed to take your HIV medications?

Once a day

Twice a day

Three times a day

Four times a day

More than four times a day

Refuse to answer

27. At what time(s) do you take your HIV medication each day? Mark all that apply.

Morning

Lunchtime

Dinnertime

Bedtime

Other (specify )

Refuse to answer

28. Many people don’t take their medication perfectly all the time. Thinking about the past 7 days, on how many of these days did you miss taking any of your HIV medications? (0–7) |__|

Don’t know

Refuse to answer

	None of the time	Almost none of the time	Less than half of the time	About half of the time	More than half of the time	Almost all of the time	All of the time	Refuse to answer
In the past 30 days, how often did you take your HIV medications as prescribed?

People may miss taking their medications for various reasons. Here is a list of possible reasons why you may have missed taking any medications in the past 30 days. Please mark all that apply

30. In the past 30 days, did you miss taking your HIV medications because you:

	Yes	No	Refuse to answer
a. Were away from home
b. Were busy with other things
c. Simply forgot
d. Had too many pills to take
e. Didn’t like the way they made me feel (side effects)
f. Did not want others to notice me taking medication
g. Had a change in my daily routine
h. Felt like the drug was toxic/harmful
i. Fell asleep/slept through dose time
j. Felt sick or ill
k. Felt depressed/overwhelmed
l. Had problem taking pills at certain times
m. Ran out of pills
n. Didn’t know how to get a refill
o. Missed my appointment with my health care provider
p. Went into jail or prison
q. Was released from jail or prison
r. Felt good
s. Were drunk or high
t. Didn’t want to deal with it
u. The person who usually gives me my medications did not give them to me
v. Other __________________________________________

These next questions are about how confident you feel to follow your HIV medication plan. Responses range from 0 (Not at all sure) to 10 (Totally sure).

31. How sure are you that you can…. (0= not at all sure and 10=totally sure)

	Not at all sure 0	1	2	3	4	5	6	7	8	9	Totally sure 10	RF
a. Take your medications correctly and on time every day?
b. Work with your health care provider to reach agreement on the best medications for you overall?
c. Discuss openly with your health care provider any problems that may be related to your medications?
d. Stick to your treatment plan even when side effects begin to interfere with daily activities?
e. Integrate your treatment plan into your daily routine?
f. Stick to your treatment plan even when your daily routine is disrupted?
g. Stick to your treatment plan when you aren’t feeling well?
h. Continue with your treatment plan even when you are feeling discouraged about your health?

Please tell us how much you agree or disagree with the following statements.

	Strongly disagree	Disagree	Neither disagree or agree	Agree	Strongly agree	Refuse to answer
My parent or guardian helps me remember to take my HIV medications.
Other people (like family members, household members or friends) who know that I have HIV help me remember to take my HIV medications.

Social Support

34. People sometimes look to others for help in managing their health conditions. How often is each of the following kinds of support available to you if you need it to manage HIV?

    	None of the time	A little of the time	Some of the time	Most of the time	All of the time	Refuse to answer
    a. Someone you can count on to remind you to take your medications
    b. Someone to refill your prescriptions
    c. Someone to give you good advice about HIV medications or their side effects
    d. Someone who understands managing HIV can be hard to do
    e. Someone who pays for your medications
    f. Someone who helps you take care of problems related to HIV if they come up
    g. Someone who appreciates how hard you are working to manage your HIV
    h. Someone who can drive you to the doctor or clinic
    i. Someone to tell you what to do if you have questions about managing HIV

35. Who provides you with support you need to help manage HIV? [CHECK ALL THAT APPLY]

Nobody

Steady partner (husband, wife, girlfriend, boyfriend, fiancé or fiancée)

Mother or step-mother

Father or step-father

Siblings

Aunt or uncle

Cousin

Grandparents

Children or step-children

Other family member (specify)

A friend

Roommate(s)

Someone else (specify)

Refuse to answer

36. In general, how satisfied are you with the support you get from others to help you manage HIV?

Very dissatisfied

Somewhat dissatisfied

Somewhat satisfied

Very satisfied

Refuse to answer

37. People sometimes look to others for companionship, assistance, or other types of support that do not have to do with managing HIV. How often is each of the following kinds of support available to you if you need it?

    	None of the time	A little of the time	Some of the time	Most of the time	All of the time	Refuse to answer
    a. Someone you can count on to listen to you when you need to talk
    b. Someone to give you information to help you understand a situation
    c. Someone to give you good advice about a crisis or personal problem
    d. Someone who understands your problems
    e. Tangible support like money, food or a place to stay
    f. Someone to take care of you if you were sick
    g. Someone who shows you love and affection
    h. Someone to have a good time with
    i. Someone to get together with for relaxation

38. Who provides you with companionship, assistance, or other types of support that do not have to do with managing HIV? (check all that apply.)

Nobody

Steady partner (husband, wife, girlfriend, boyfriend, fiancé or fiancée)

Mother or step-mother

Father or step-father

Siblings

Aunt or uncle

Cousin

Grandparents

Children or step-children

Other family member (specify )

A friend

Roommate(s)

Someone else (specify )

Refused

39. In general, how satisfied are you with the overall support you get from others?

Very dissatisfied

Somewhat dissatisfied

Somewhat satisfied

Very satisfied

Refuse to answer

40. Do you currently attend any support groups?

Yes

No  [SKIP TO Q42]

Refuse to answer  [SKIP TO Q42]

41. In general, how satisfied are you with the overall support you get from the support groups you attend?

Very dissatisfied

Somewhat dissatisfied

Somewhat satisfied

Very satisfied

Refuse to answer

HIV Stigma

These next items are about some of your experiences, feelings, and opinions on how people with HIV feel and how they are treated.

42. Please tell me the extent to which you agree or disagree with the following statements.

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree	Refuse to answer
a. In many areas of my life, no one knows that I have HIV
b. I feel set apart and isolated from the rest of the world
c. Most people with HIV are rejected when others find out
d. I worry about people discriminating against me
e. I never feel the need to hide the fact that I have HIV
f. Most of the people I live with know my HIV status
g. Most of my family and friends know my HIV status

These next set of questions assume that you have told other people that you have HIV or that others know. This may not be true for you. If the item refers to something that has not actually happened to you, please imagine yourself in that situation.

43. Whom have you told that you are HIV positive? (CHECK ALL THE BOXES THAT APPLY)

Main sexual partner (that is, a partner you would call your boyfriend or girlfriend, spouse, lover, significant other, or life partner)

Non-Main (casual) sex partner(s) (that is, somebody you did not consider to be a boyfriend or girlfriend, spouse, lover, significant other, or life partner)

Mother

Father

Other Relative

Teacher

Counselor

Any friends

Any co-workers

Any neighbors

Anyone else

None of the above (No one)  [SKIP TO Q45]

Refuse to answer

44. Please tell me the extent to which you agree or disagree with the following statements.

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree	Refuse to answer
a. I have been hurt by how people reacted to learning I have HIV
b. I regret having told some people that I have HIV

Attitudes/Beliefs

45. Please tell me the extent to which you agree or disagree with the following statements.

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree	Refuse to answer
a. It is important to tell someone you are thinking about having sex with that you have HIV.
b. It is important to ask someone you are thinking about having sex with if they have HIV.
c. It is important to tell your sex partners that you have HIV.
d. It is important to ask your sex partners if they have HIV.
e. It is important to talk about STDs with someone you are going to have sex with.
f. It is important to keep learning about HIV, its treatment, and new developments in HIV research.
g. Talking with your partners about sex can help you make decisions that may lower your risk of transmitting HIV to them.
h. It is important for my health to keep appointments with my health care provider.
i. I believe taking HIV medications can keep me healthy.
j. Taking HIV medications as prescribed can help keep me from getting sick.
k. It is important to take my HIV medications correctly and on time each day.
l. It is important to use a condom the right way each time I have sex..
m. It is important to get my viral load checked by your health care provider as often as they tell you to.
n. I know where to go for help finding a job.
o. I know where to go for information about going back to school.
p. I know where to go for support if I am worried about making ends meet.
q. I know where to go for help with budgeting or managing my money.
r. I know where to go for help with finding housing.
s. I know how to look at my health records online.
t. Monogamy is an effective prevention strategy.

HIV Knowledge

46. In this section are statements about HIV. Please indicate whether the statements are true, false, or if you don’t know the answer.

	True	False	Don’t know	Refuse to answer
a. Once someone’s HIV viral load results are “undetectable,” they should stop taking their HIV medications.
b. Certain oral health problems, such as oral candidiasis and herpes simplex, are common in people with HIV.
c. If a person does not take their HIV medications as prescribed, they can become resistant to their HIV medications.
d. HIV is cured when someone’s HIV viral load is “undetectable.”
e. If someone’s viral load is “undetectable,” they don’t need to use condoms during sex.
f. Eating a high-fat diet helps people with HIV digest their medications.
g. People who have HIV can get infected with another type of HIV.
h. Exercise is always unsafe for people with HIV.
i. Recreational drugs can make a person’s HIV medications less effective.
j. It is best for a person to stop taking their HIV medications as soon as they feel better.
k. Taking HIV medications regularly protects people from getting common illnesses, such as food poisoning.
l. After a few months, it becomes less important for people to take their HIV medications at the right time of day.
m. HIV medications reduce the amount of virus in the body.
n. Some HIV medications cause nausea and vomiting.
o. Smoking weakens the immune system.
p. Depression is not treatable.
q. Getting infected with an STD can make a person’s HIV worse.
r. There are 5 stages of HIV.
s. Lower CD4 counts are better.
t. A person can get HIV by sharing a glass of water with someone who has HIV.
u. All pregnant women who have HIV will have babies born with HIV.
v. Women are always tested for STDs during their Pap smears.
w. Drug or alcohol use can increase the risk for passing HIV to others because people are more likely to do risky behaviors when they are drunk or high.

(continued)

	True	False	Don’t know	Refuse to answer
x. If both sexual partners have HIV, they don’t need to use condoms during sex.
y. Taking folic acid before and during pregnancy can help prevent birth defects.
z. It is healthy to eat 5 servings of fruits and vegetables a day.
aa. Taking HIV medications can lower a person’s chances of transmitting HIV to a sex partner.
bb. Taking HIV medications can lower a person’s chance of getting a superinfection from a positive partner.
cc. Not having anal or vaginal sex is the best way to avoid transmitting HIV.
dd. Men cannot get HIV from having vaginal sex.
ee. Having sex without a condom puts an HIV positive person at risk for STDs and HIV superinfection.
ff. Oral sex is less risky than vaginal or anal sex for transmitting HIV.
gg. HIV can be transmitted through saliva, sweat and tears.
hh. During anal sex, it is possible for either partner to get HIV.
ii. It is less risky for the positive partner to bottom during anal sex.
jj. Playing with sex toys is a safe way to protect oneself and others from HIV.
kk. People who inject drugs are at very high risk for HIV.
ll. Sharing needles/syringes or other injection equipment is very risky because they may contain blood.
mm. About 1 out of every 10 HIV infections in the U.S. is from injection drug use.
nn. Mother-to-child transmission of HIV is the most common way that children get HIV.
oo. If a woman is treated for HIV early in her pregnancy, the risk of transmitting HIV to her baby can be 2% or less.
pp. If a person has an STD, they are more likely to transmit HIV to others.
qq. Once a person has HIV, it can’t be cured.
rr. HIV is transmitted through the blood, semen, pre-seminal fluid, vaginal fluid, rectal secretions or breast milk of a person who has HIV.
ss. Female condoms are a good choice to lower the risk of transmitting HIV if you cannot use a male condom.

Self Efficacy

Please tell us how strongly you agree or disagree with the following statements.

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree	Refuse to answer
I am confident that I can talk to someone I’m thinking about having sex with about using condoms.
I am confident that I can talk to my sex partners about using condoms.
I am confident that I can refuse to have sex if my partner doesn’t want to use a condom.
I am confident that I can still use a condom even if I am drunk or high.
I am confident that I can protect myself from STDs.
I am confident that I can protect myself from getting an HIV superinfection.
I am confident that I can prevent transmitting HIV or other STDs to my sex partners.
I am confident that I can always use condoms correctly with my sex partners.
I am confident that I can keep my appointments with my HIV care provider.
I am confident I can tell my sex partners my HIV status.
I am confident I can ask my sex partners about their HIV status.
I am confident I can talk to my sex partners about STDs.

Sexual Behaviors

These next questions are about your sexual behavior in the past 3 months. Remember all of your answers are kept private.

59. Have you ever had vaginal or anal sex with another person?

Yes

No  [SKIP TO Q107]

Refused  [SKIP TO Q107]

60. Have you had vaginal or anal sex with another person in the past 3 months?

Yes

No  [SKIP TO Q107]

Refused  [SKIP TO Q107]

Now I’m going to be asking you some questions about the sexual partners you’ve had in the past 3 months.

FOR MALES

61. In the past 3 months, how many different female sexual partners have you had sex with? This includes steady partners, casual partners, and sex trade partners.

999=REF

[If 61=000 or 999, skip to 72]

62. How many of these partners did you have vaginal sex with? By vaginal sex we mean you put your penis in a woman’s vagina.

999=REF

[If 62=000 or 999, skip questions 64–67]

63. How many of these partners did you have anal sex with? By anal sex, we mean you put your penis in a woman’s butt.

999=REF

[If 63=000 or 999, skip questions 68–71]

64. You said that you had vaginal sex with [FILL NUMBER 62] partners in the past 3 months. I am going to ask you whether you knew if these partners were HIV positive, HIV negative, or if you didn’t know their HIV status. How many of these [fill number 62] partners were:

64a. HIV negative?

64b. HIV positive?

64c. of unknown HIV status?

64d. Refuse to answer

65. How much of the time did you use condoms when having vaginal sex with female partners who you knew were HIV-negative?

Never

Rarely

Sometimes

Always

Refuse to answer

66. How much of the time did you use condoms when having vaginal sex with female partners who you knew were HIV-positive?

Never

Rarely

Sometimes

Always

Refuse to answer

67. How much of the time did you use condoms when having vaginal sex with female partners who you did not know their HIV status?

Never

Rarely

Sometimes

Always

Refuse to answer

68. You said that you had anal sex with [FILL NUMBER 63] female sexual partners in the past 3 months. I am going to ask you whether you knew if these partners were HIV positive, HIV negative or if you didn’t know their HIV status. How many of these [fill number 63] partners were:

68a. HIV negative?

68b. HIV positive?

68c. of unknown HIV status?

68d. Refuse to answer

69. How much of the time did you use condoms when having anal sex with female partners who you knew were HIV-negative?

Never

Rarely

Sometimes

Always

Refuse to answer

70. How much of the time did you use condoms when having anal sex with female partners who you knew were HIV-positive?

Never

Rarely

Sometimes

Always

Refuse to answer

71. How much of the time did you use condoms when having anal sex with female partners who you did not know their HIV status?

Never

Rarely

Sometimes

Always

Refuse to answer

72. In the past 3 months, how many different male sexual partners have you had sex with? This includes steady partners, casual partners and sex trade partners.

REF=999

[If 72=000 or 999, skip to 83]

73. How many of these partners did you have insertive anal sex with? By insertive anal sex, we mean you put your penis in a man’s butt.

REF=999

[If 73=000 or 999, skip questions 75–78]

74. How many of these partners did you have receptive anal sex with? By receptive anal sex, we mean a man put his penis in your butt.

REF=999

[If 74=000 or 999, skip questions 79–82]

75. You said that you had insertive anal sex with [FILL NUMBER 73] male sexual partners in the past 3 months. Again, insertive means putting your penis in his butt. I am going to ask you whether you knew if these partners were HIV positive, HIV negative or if you didn’t know their HIV status. How many of these [fill number 73] partners were:

75a. HIV negative?

75b. HIV positive?

75c. of unknown HIV status?

75d. Refuse to answer

76. How much of the time did you use condoms when having insertive anal sex with male partners who you knew were HIV-negative?

Never

Rarely

Sometimes

Always

Refuse to answer

77. How much of the time did you use condoms when having insertive anal sex with male partners who you knew were HIV-positive?

Never

Rarely

Sometimes

Always

Refuse to answer

78. How much of the time did you use condoms when having insertive anal sex with male partners who you did not know their HIV status?

Never

Rarely

Sometimes

Always

Refuse to answer

79. You said that you had receptive anal sex (a man puts his penis in your butt) with [FILL NUMBER 74] male sexual partners in the past 3 months. I am going to ask you whether you knew if these partners were HIV positive, HIV negative or if you didn’t know their HIV status. How many of these [fill number 74] partners were:

79a. HIV negative?

79b. HIV positive?

79c. of unknown HIV status?

79d. Refuse to answer

80. How much of the time did you use condoms when having receptive anal sex with male partners who you knew were HIV-negative?

Never

Rarely

Sometimes

Always

Refuse to answer

81. How much of the time did you use condoms when having receptive anal sex with male partners who you knew were HIV-positive?

Never

Rarely

Sometimes

Always

Refuse to answer

82. How much of the time did you use condoms when having receptive anal sex with male partners who you did not know their HIV status?

Never

Rarely

Sometimes

Always

Refuse to answer

83. Have you had sex with any transgender partners in the past 3 months?

Yes

No

Refuse to answer

FOR FEMALES

84. In the past 3 months, how many different male sexual partners have you had sex with? This includes steady partners, casual partners and sex trade partners.

REF=999

[If 84=000 or 999, skip to 95]

85. How many of these partners did you have vaginal sex with? By vaginal sex we mean “straight sex” or a man put his penis in your vagina.

[REF=999]

[If 85=000 or 999, skip questions 87–90]

86. How many of these partners did you have anal sex with? By anal sex, we mean a man put his penis in your butt.

REF=999

[If 86=000 or 999, skip questions 91–94]

87. You said that you had vaginal sex with [Fill number 85] male sexual partners in the past 3 months. I am going to ask you whether you knew if these partners were HIV positive, HIV negative or if you didn’t know their HIV status. How many of these [fill number 85] partners were:

87a. HIV negative?

87b. HIV positive?

87c. of unknown HIV status?

87d. Refuse to answer

88. How much of the time did you use condoms when having vaginal sex with male partners who you knew were HIV-negative?

Never

Rarely

Sometimes

Always

Refuse to answer

89. How much of the time did you use condoms when having vaginal sex with male partners who you knew were HIV-positive?

Never

Rarely

Sometimes

Always

Refuse to answer

90. How much of the time did you use condoms when having vaginal sex with male partners who you did not know their HIV status?

Never

Rarely

Sometimes

Always

Refuse to answer

91. You said that you had anal sex with [Fill number 86] male sexual partners in the past 3 months. I am going to ask you whether you knew if these partners were HIV positive, HIV negative or if you didn’t know their HIV status. How many of these [fill number 86] partners were:

91a. HIV negative?

91b. HIV positive?

91c. of unknown HIV status?

91d. Refuse to answer

92. How much of the time did you use condoms when having anal sex with male partners who you knew were HIV-negative?

Never

Rarely

Sometimes

Always

Refuse to answer

93. How much of the time did you use condoms when having anal sex with male partners who you knew were HIV-positive?

Never

Rarely

Sometimes

Always

Refuse to answer

94. How much of the time did you use condoms when having anal sex with male partners who you did not know their HIV status?

Never

Rarely

Sometimes

Always

Refuse to answer

95. How many different FEMALE partners have you had sex with in the past 3 months? This includes steady partners, casual partners and sex trade partners.

REF=999

96. Have you had sex with any transgender partners in the past 3 months?

Yes

No

Refuse to answer

FOR TRANSGENDER, OTHER, or DK

97. How many different male partners have you had sex with in the past 3 months?

REF=999

[If 97=000 or 999, skip to 99]

98. Did you have vaginal or anal intercourse without using a condom with any of your male partners in the past 3 months?

Yes

No

Refuse to answer

99. How many different female partners have you had sex with in the past 3 months?

REF=999

[If 99=000 or 999; skip to 101]

100. Did you have vaginal or anal intercourse without using a condom with any of your female partners in the past 3 months?

Yes

No

Refuse to answer

101. How many different transgender partners have you had sex with in the past 3 months?

REF=999

[If 101=000 or 999, skip to 103]

102. Did you have vaginal or anal intercourse without using a condom with any of your transgender partners in the past 3 months?

Yes

No

Refuse to answer

READ: Now we’re going to talk about things you might exchange for sex.

	Yes	No	Refuse to Answer
In the past 3 months, has anybody given you money in exchange for sex?
In the past 3 months, has anybody given you drugs in exchange for sex?
In the past 3 months, have YOU given anyone money in exchange for sex?
In the past 3 months, have YOU given anyone drugs in exchange for sex?

Smoking and Substance Use

People have various health habits. The following questions ask about smoking, alcohol and drug use.

107. Do you smoke cigarettes?

Yes

No [SKIP TO Q109]

Refuse to answer [SKIP TO Q109]

108. Are you seriously considering stopping smoking within the next 3 months?

Yes

No

Refuse to answer

109. On average, how often in the past 3 months have you had a drink containing alcohol (e.g., a glass of beer or wine, a mixed drink, or any other kind of alcoholic beverage)?

Never  [SKIP TO Q111]

Once a month

2 or 3 times a month

Once or twice a week

3 or 4 times a week

Nearly every day

Daily

Refuse to answer

110. On average, how often in the past 3 months have you had 4 or more drinks of alcohol within a couple of hours (e.g., 2–4 hours)?

Never

Once a month

2 or 3 times a month

Once or twice a week

3 or 4 times a week

Nearly every day

Daily

Refuse to answer

111. Have you ever used… [MARK ALL THAT APPLY]

     	Yes	No	Refuse to answer
     a. Marijuana?	[GO TO Q112a]
     b. Cocaine (powder, crack, or freebase)?	[GO TO Q112b]
     c. Heroin?	[GO TO Q112c]
     d. Methamphetamine?	[GO TO Q112d]
     e. MDMA (ecstasy)	[GO TO Q112e]
     f. GHB (liquid X)	[GO TO Q112f]
     g. Ketamine (special K)	[GO TO Q112g]

112. Have you used any of the following within the past 3 months?

	Yes	No	Refuse to answer
a. Marijuana?
b. Cocaine (powder, crack, or freebase)?
c. Heroin?
d. Methamphetamine?
e. MDMA (ecstasy)
f. GHB (liquid X)
g. Ketamine (special K)

Quality Outcome/Patient Satisfaction

These next questions are about your experiences with this clinic.

113. How long have you received your HIV-related medical care here?

Less than 1 year

1 to 2 years

3 to 5 years

More than 5 years

Refuse to answer

114. When was your last HIV-related medical care visit?

Within the last 3 months

4 to 6 months ago

More than 6 months ago

Refuse to answer

115. Think about your last experience with your HIV health care provider(s) at this clinic. Now, please tell me the extent to which you agree or disagree with the following statements.

	Strongly disagree	Disagree	Neither disagree nor agree	Agree	Strongly Agree	Refuse to answer
a. My health care provider(s) made sure I understood what my lab test results (such as CD4 and viral load) meant for my health.
b. My health care provider(s) spent enough time with me.
c. I asked my health care provider(s) all of the questions I had about my HIV care.
d. I felt comfortable talking about personal or intimate issues with my health care provider(s).
e. I was involved in making decisions about my care with my health care provider(s).
f. When I asked my health care provider(s) questions about my HIV care, I understood their answers.
g. I found my health care provider(s) to be accepting and non-judgmental of my life and my choices.
h. My health care provider(s) and I work as a team.
i. I have a strong, trusting relationship with my health care provider(s).

This next series of questions are about communication with your health care provider(s). Please answer yes or no for each statement.

116. My health care provider(s) explained the side effects of my HIV medications in a way I could understand.

Yes

No

I am not taking any medications prescribed by my doctor to treat HIV

Refuse to answer

117. My health care provider(s) suggested ways to help me remember to take my HIV medications.

Yes

No

I am not taking any medications prescribed by my doctor to treat HIV

Refuse to answer

	Yes	No	Refuse to answer
My health care provider(s) explained to me what kinds of medical tests I should be getting and how often I should get them.
My health care provider(s) talked to me about how to avoid transmitting HIV to other people and how to protect myself from getting infected again with HIV.
My health care provider(s) talked to me about how to protect myself from getting STDs or how to avoid transmitting them on to others if I already had one.
My health care provider(s) or case manager(s) asked me how I was feeling emotionally and made a referral to a mental health provider, counselor or support group if I needed help.
My health care provider(s) asked me about my drug and alcohol use and made a referral if I needed help.

123. I would rate my health care providers’ knowledge of the newest developments in HIV medical standards as

Excellent

Very good

Average

Fair

Poor

Refuse to answer

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