Form 1 ACASI Questionaire
Incident HIV/ Hepatitis B virus infections in South African blood donors:Behavioral risk factors, genotypes and biological characterization of early infection (NHLBI)
Attachment 2A HIV_HBV_Objectives_1_2_ACASI_Q_12_2013_V_1.0
Objectives 1 and 2 ACASI Questionaire
OMB: 0925-0699
Attachment 2A
Objectives 1 and 2 ACASI Questionnaire
Incident HIV/Hepatitis B Virus infections in South African blood donors:
Behavioral risk factors, genotypes and biological characterization of early infection
OMB Number: 0925-XXXX Expiration Date:
Public reporting burden for
this collection of information is estimated to average 34 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC
7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-xxxx*). Do not
return the completed form to this address.
SECTION A – GENERAL STUDY DATA
This section is to be completed by the research assistant or other research staff.
A1. Subject ID (Internal study number to be assigned by Study Management System)
__ __ __ __ __ __ __
A2. Subject donor number (Number that will link with donor’s Meditech info)
_________________________________
97 Don't Know
98 Refuse to Answer
99 Not Applicable
A3. Blood collection site. (Blood collection site neumonic (clinic site code). The neumonic can be mapped back to Branch, Zone or Province – this will have to be coded during analysis phase)
_______________________________________
UID = Concatenated(A3, A1)
A4. Month of interview (Choose one)
01 January
02 February
03 March
04 April
05 May
06 June
07 July
08 August
09 September
10 October
11 November
12 December
A5. Year of interview (please enter four numbers)
__ __ __ __ yyyy
YEAR2 = A5 - 1
A6. Research Staff Initials: __ __ __ __ __
A7. Type of Participant (Choose one)
1 Study group 1 (won’t appear on screen: HIV case)
2 Study group 2 (won’t appear on screen: HBV case)
3 Study group 3 (won’t appear on screen: Control)
INSTRUCTION to RESEARCH STAFF: If study subject is not already sitting at the computer, at this time please make sure the study subject is sitting at the computer and has put the headphones on.
SECTION B - DEMOGRAPHIC DATA
APPEARS ON SCREEN and HEARD if ACASI: This study has been approved by Ethical Committees in South Africa and the USA. This study also has been approved by the Office of Management and Budget; OMB XXXX, OMB approval expires XX, XXXX, 201X.
APPEARS ON SCREEN and HEARD if ACASI: We are asking you to respond as truthfully as you can. Please keep in mind that the questions are part of a scientific study, and the researchers will make every effort to keep your responses confidential. However, there is a small chance that your responses may not be kept confidential, but your name is not collected on the questionnaire and your responses cannot be easily traced back to you. Please answer these questions to the best of your knowledge and as truthfully as you can. You may skip any questions that you are not comfortable answering.
In this section of the questionnaire the research assistant will show you how to use the computer to answer the interview questions. After completing this section, with help from the research assistant, you will be left to complete the interview in private. If you have any questions at any time or are unsure of what to do, please ask for help.
B1. What is your gender? (Choose one)
1 Male
2 Female
3 Transgender
97 Don't Know
98 Refuse to Answer
B2. What is your birth year?
__ __ __ __
9997 Don't Know
9998 Refuse to Answer
B3. What is your birth month? (Choose one)
__ __ January
__ __ February
__ __ March
__ __ April
__ __ May
__ __ June
__ __ July
__ __ August
__ __ September
__ __ October
__ __ November
__ __ December
__ __ Don't Know
__ __ Refuse to Answer
B4. What is your birth day?
__ __
97 Don't Know
98 Refuse to Answer
B5a. What is your country of birth? (Choose one)
South Africa
Zimbabwe
Malawi
Mozambique
Swaziland
Botswana
Lesotho
Namibia
Nigeria
Other
97 Don't Know
98 Refuse to Answer
If B5a is not equal to 10, then skip to instruction before B6.
B5b. Please tell us your country of birth.
_________________________________________________
READ and HEARD: From now on, you will be left alone. It means that you will have total privacy to answer all these questions. Please, if you have any questions call the research assistant for help.
B6. What is your race / ethnic origin? (Choose one)
1 Black
2 White
3 Coloured
4 Asian
6 Other
97 Don't Know
98 Refuse to Answer
B7. What is the primary language that you speak at home? (Choose one)
isiZulu
isi Xhosa
Afrikaans
Sepedi
Setswana
English
Sesotho
Xitsonga
siSwati
Tshivenda
isiNdebele
Other
98 Refuse to Answer
B8. What is your current marital status? (Choose one)
1 Single, never married.
2 Living with partner, but not married.
3 Married to one partner (including traditional marriage).
4 Married to more than one partner (including traditional marriages).
5 Separated/divorced.
6 Widowed.
97 Don't Know
98 Refuse to Answer
B9a. Is your primary sexual partner?
1 Male
2 Female
3 Transgender
4 Do not have a primary sexual partner Skip to B10.
97 Don't Know
98 Refuse to Answer
B9b. Are you currently living with your primary sexual partner? (ONLY ask if B8 = 2, 3, or 4)
0 No
1 Yes
98 Refuse to Answer
B10. What is the highest level of education you have completed? (Choose one)
0 Never been to school
1 Up to Grade 7 / Standard 5
2 Up to Grade 10 / Standard 8
3 Up to Grade 12 / Standard 10
4 Incomplete further degree or qualification (some college or technical school)
5 College or technical qualification
6 University or professional degree
97 Don't Know
98 Refuse to Answer
B11. What is your religion or affiliation? (Choose one)
Christianity
Islam
Hinduism
Judaism
African traditional beliefs
Other faiths
No religion
Don’t Know
Refuse to Answer
B12a. Do you have medical aid?
0 No
1 Yes
98 Refuse to Answer
B12b. Do you self-fund access (pay out of pocket) to private hospital?
0 No
1 Yes
98 Refuse to Answer
B13c. Are you currently working?
Yes, self-employed
Yes, employed full or part-time
No, unemployed SKIP to Section C
Don’t know
Refuse to Answer
B13b. What type of work are you doing?
Mining
Transport/cargo delivery
Military/police
Medical/healthcare
Business/sales/retail
Farming
Teacher/ education/ student
General labour (domestic worker, gardener, janitorial)
Civil service (examples including working in government office, post office)
Other
97 Don’t Know
98 Refuse to Answer
B13c. If B13b=10 Else SKIP What is your occupation?
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
B14a. In the last 6 months have you spent a total of four weeks or more away from your primary residence (home)?
0 No
1 Yes
97 Don't Know
98 Refuse to Answer
If B14a equals 0, then skip to B15a.
B14b. What was the primary purpose for being away during this period?
Work
Looking for work
Holiday
Other, specify: _____________________________
B15a. How many nights did you sleep at your primary residence (home) in the past six months?
Every night
Most nights
About half of the nights
Fewer than half of the nights
B15b. How long has your pattern of sleeping at your primary residence (home) been the same as it has been in the past six months?
It has been like this only in the past 6 months
It has been like this for only the past year
For one to five years
For five years or more
Section C - Previous donation and HIV testing
C1. Before your recent donation, have you ever donated blood? (Choose one)
0 No Skip to C4
1 Yes
97 Don't Know
98 Refuse to Answer
C2. Before your recent donation, how many times have you donated blood? (Choose one)
1 1 time
2 2 or more times
97 Don't Know
98 Refuse to Answer
C3. At the time of your donation, were you given information about who should not donate blood? (Check all that apply)
0 No
1 Yes, written information (pamphlets)
2 Yes, through discussion with the donor staff at the donation centre
97 Don't Know
98 Refuse to Answer
C4. Do you know of places in your community where you can be tested free of charge for HIV?
0 No
1 Yes
97 Don't Know
98 Refuse to Answer
C5. Not including HIV testing conducted as part of blood donation, have you ever been tested for HIV? (Choose one)
0 No Skip to instruction before D1
1 Yes
97 Don't Know
98 Refuse to Answer
C6. Not including HIV testing conducted as part of blood donation, how many times have you been tested for HIV? (Choose one)
0 Never
1 1 time
2 2 or more times
97 Don't Know
98 Refuse to Answer
C7a. Not including HIV testing done as part of blood donation, what was the primary reason for the most recent HIV test? (Choose one)
1 Pregnancy care
2 Health insurance
3 Doctor’s order, routine medical care, hospitalisation or surgery
4 I wanted to know my HIV status
5 Other
97 Don't Know
98 Refuse to Answer
If C7a is not equal to 5, then skip to C8a.
C7b. Please tell us the reason for the HIV test.
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
C8a. Not including HIV testing done as part of blood donation, where else have you been tested for HIV? (Choose one)
1 General Practitioner
2 Local clinic / health facility
3 Hospital
4 HIV Testing Centre (known as a Voluntary Counseling and Testing or VCT Centre)
5 Other test site
97 Don't Know
98 Refuse to Answer
If C8a is not equal to 5, then skip to Section D.
C8b. Please tell us the other test site.
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
Section D - Incentives and Motivations for Donating
READ and HEARD: The following questions will ask you about things that you may do in your daily life.
D1. Apart from your involvement in blood donation, do you do any volunteer work for any clubs, groups, societies or religious groups in your community?
0 No
1 Yes
97 Don't Know
98 Refuse to Answer
READ and HEARD: The following questions will ask you about factors that may have influenced your decision to donate blood. Use the following scale to indicate how much the factors influenced your decision to donate blood. 1- Not at all, 2 - Very little, 3 - Somewhat, 4 - Very much
D2a. My decision to donate blood was influenced by my desire to anonymously help someone else who needs blood. (Choose one)
1 Not at all
2 Very little
3 Somewhat
4 Very much
97 Don't Know
98 Refuse to Answer
D2b. My decision to donate blood was influenced by my desire to help a friend or relative who is sick or needs blood. (Choose one)
1 Not at all
2 Very little
3 Somewhat
4 Very much
97 Don't Know
98 Refuse to Answer
D2c. My decision to donate blood was influenced by a campaign on TV or radio. (Choose one)
1 Not at all
2 Very little
3 Somewhat
4 Very much
97 Don't Know
98 Refuse to Answer
D2d. My decision to donate blood was influenced by a telephone call or sms (text message) from the blood bank asking me to donate. (Choose one)
1 Not at all
2 Very little
3 Somewhat
4 Very much
97 Don't Know
98 Refuse to Answer
D2e. My decision to donate blood was influenced by my belief that it is important to give blood. (Choose one)
1 Not at all
2 Very little
3 Somewhat
4 Very much
97 Don't Know
98 Refuse to Answer
D2f. My decision to donate blood was influenced by my desire to get my blood test results. (Choose one)
1 Not at all
2 Very little
3 Somewhat
4 Very much
97 Don't Know
98 Refuse to Answer
D2g. My decision to donate blood was influenced by my belief that my blood type is in high demand. (Choose one)
1 Not at all
2 Very little
3 Somewhat
4 Very much
97 Don't Know
98 Refuse to Answer
D2h. My decision to donate blood was influenced by my belief that I am doing something important for society. (Choose one)
1 Not at all
2 Very little
3 Somewhat
4 Very much
97 Don't Know
98 Refuse to Answer
D2i. My decision to donate blood was influenced by my belief that I may need blood myself someday. (Choose one)
1 Not at all
2 Very little
3 Somewhat
4 Very much
97 Don't Know
98 Refuse to Answer
D2j. My decision to donate blood was influenced by my belief that blood donation is good for my health. (Choose one)
1 Not at all
2 Very little
3 Somewhat
4 Very much
97 Don't Know
98 Refuse to Answer
D2k. My decision to donate blood was influenced by my desire to know about my health and blood donation is a good way to find this out. (Choose one)
1 Not at all
2 Very little
3 Somewhat
4 Very much
97 Don't Know
98 Refuse to Answer
D2l. My decision to donate blood was influenced by someone offering me an incentive to donate. (Choose one)
1 Not at all
2 Very little
3 Somewhat
4 Very much
97 Don't Know
98 Refuse to Answer
D2m. My decision to donate blood was influenced by my belief that blood banks always need blood and so donating is the right thing to do. (Choose one)
1 Not at all
2 Very little
3 Somewhat
4 Very much
97 Don't Know
98 Refuse to Answer
D2n. My decision to donate blood was influenced by pressure to donate that I received from other people (such as friends, family, colleagues, fellow students, church or temple members).
1 Not at all
2 Very little
3 Somewhat
4 Very much
97 Don't Know
98 Refuse to Answer
D2o. Is there another reason that best explains why you came to donate? (Choose one)
0 No Skip to D3
1 Yes
97 Don't Know Skip to D3
98 Refuse to Answer Skip to D3
D2p. What is the reason that best explains why you came to donate?
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
D3. Some people feel they must donate blood because family, friends, co-workers or other people in an organization they know donate or encourage others to donate blood. Did this happen to you when you last donated blood? (Choose one)
0 No
1 Yes
97 Don't Know
98 Refuse to Answer
D4. Do you believe that the blood service uses better HIV tests than are available at other places? (Choose one)
0 No
1 Yes
97 Don't Know
98 Refuse to Answer
D5. Did you donate blood mainly because you wanted to be tested for HIV? (Choose one)
0 No Skip to D8
1 Yes
97 Don't Know
98 Refuse to Answer
D6. What were all the factors that contributed to your decision to come to the blood center to be tested for HIV? Please check all the boxes that apply to your answer. When you have selected all of your answers, please touch the "Next Question" box. (Check all the answers that apply)
a __ Only place I know of that offers HIV testing
b __ HIV testing is free
c __ HIV testing is confidential
d __ HIV testing is more accurate than at other sites
e __ HIV testing is more convenient than at other test sites
f __ Other reason
e __ Don't Know
g __ Refuse to Answer
If D6_f is equal to 0, then skip to D8.
D7. Please specify other reason
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
D8. Did you donate blood mainly because you wanted to be tested for hepatitis? (Choose one)
0 No Skip to D11
1 Yes
97 Don't Know
98 Refuse to Answer
D9. What were all the factors that contributed to your decision to come to the blood center to be tested for hepatitis? Please check all the boxes that apply to your answer. When you have selected all of your answers, please touch the "Next Question" box. (Check all that apply)
__ Only place I know of that offers Hepatitis testing
__ Hepatitis testing is free
__ Hepatitis testing is confidential
__ Hepatitis testing is more accurate than at other sites
__ Hepatitis testing is more convenient than at other sites
__ Other reason
__ Don't Know
__ Refuse to Answer
If D9_f is equal to 0, then skip to D13.
D10. Please specify other reason
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _
D11. Did a health worker such as a doctor, nurse, or someone from a clinic suggest that you go to the blood center for a blood test for HIV, hepatitis, or for some other reason? (Choose one)
0 No Skip to instruction before D13
1 Yes
97 Don't Know
98 Refuse to Answer
D12. Please tell us who suggested you come to the blood service for a blood test? (Choose one)
1 Doctor
2 Nurse
3 Someone else from the clinic
4 Other
97 Don't Know
98 Refuse to Answer
READ and HEARD: Now we will ask a few questions about what you think about HIV and HBV risks and donating: In the following section, please indicate whether you think each statement is true or false.
D13. You can donate blood if you have engaged in risk behaviors for HIV/AIDS because the blood service tests all blood and throws away any infected blood. (Choose one)
1 True
2 False
97 Don't Know
98 Refuse to Answer
D14. You can donate blood even if you engage in risk behaviors for HIV/AIDS as long as you have a negative HIV test. (Choose one)
1 True
2 False
7 Don't Know
8 Refuse to Answer
D15. You can donate blood even if you engage in risk behaviors for HIV/AIDS as long as you use condoms. (Choose one)
1 True
2 False
97 Don't Know
98 Refuse to Answer
D16. The blood test for HIV identifies everyone who is infected with the virus. (Choose one)
1 True
2 False
97 Don't Know
98 Refuse to Answer
D17. The blood test for hepatitis identifies everyone who is infected with a hepatitis virus. (Choose one)
1 True
2 False
97 Don't Know
98 Refuse to Answer
Section E - Sexual History
READ and HEARD: Now, we want to ask about the people you have had sex with and your sexual partners. We understand that these questions are about intimate and private matters, which could make you uncomfortable. Please keep in mind that the questions are part of a scientific study, and the researchers will keep your responses confidential. Your individual responses will not be known by SANBS. Please answer these questions to the best of your knowledge and as truthfully as you can.
E1. Do you consider yourself to be? (Choose one)
1 Straight/heterosexual
2 Bisexual
3 Gay/homosexual
97 Don't Know
98 Refuse to Answer
READ and HEARD: The following questions will ask you about your sexual experiences. In these questions, include only those people you have had oral, vaginal, or anal sex with. Do not include people that you have only kissed. Please try to be as accurate and honest as possible. If you cannot remember the precise answers below, please provide your best estimates.
Please note: For the next few questions the terms “sexual contact” and “sex” refer to any of the following activities, whether or not a condom or other protection was used:
Vaginal sex (contact between penis and vagina)
Oral sex (mouth or tongue on someone’s vagina, penis, or anus)
Anal sex (contact between penis and anus)
E2a. (Ask of Men Only) How many different women have you had sex with since you first began having sex?
__ __ __ __
9997 Don't Know
9998 Refuse to Answer
9999 Not Applicable
E2a.1 If Answer is Don’t Know, Else Skip. If you Don’t Know, can you give an approximate answer? __ _
E2b. (Ask of Men Only) How old were you when you had sex with a woman for the first time?
__ __
9997 Don't Know
9998 Refuse to Answer
9999 Not Applicable
E3a. (Ask of Men Only) How many different men have you had sex with since you first began having sex?
__ __ __ __
9997 Don't Know
9998 Refuse to Answer
9999 Not Applicable
E3a.1 If Answer is Don’t Know, Else Skip. If you Don’t Know, can you give an approximate answer? __ _
E3b. (Ask of Men Only) How old were you when you had sex with a man for the first time?
__ __
9997 Don't Know
9998 Refuse to Answer
9999 Not Applicable
E2a. (Ask of Women Only) How many different men have you had sex with since you first began having sex?
__ __ __ __
9997 Don't Know
9998 Refuse to Answer
9999 Not Applicable
E2a.1 If Answer is Don’t Know, Else Skip. If you Don’t Know, can you give an approximate answer? __ _
E2b. (Ask of Woman Only) How old were you when you had sex with a man for the first time?
__ __ __ __
9997 Don't Know
9998 Refuse to Answer
9999 Not Applicable
E3a. (Ask of Women Only) How many different women have you had sex with since you first began having sex?
__ __ __ __
9997 Don't Know
9998 Refuse to Answer
9999 Not Applicable
E3a.1 If Answer is Don’t Know, Else Skip. If you Don’t Know, can you give an approximate answer? __ _
E3b. (Ask of Women Only) How old were you when you had sex with a woman for the first time?
__ __ __ __
9997 Don't Know
9998 Refuse to Answer
9999 Not Applicable
E4a. Have you ever been physically abused, physically assaulted, or beaten by a sexual partner?
0 No Skip to E5
1 Yes
7 Don't Know
8 Refuse to Answer
E4b. In the six months before your donation were you physically abused, physically assaulted or beaten by a sexual partner?
0 No
1 Yes
7 Don't Know
8 Refuse to Answer
If E2a is equal to 0 and E3a is equal to 0 and B1 is equal to 1, then skip to Section H.
If E2a is equal to 0 and E3a is equal to 0 and B1 is equal to 2, then skip to Section H.
E5a. Have you ever been sexually abused, sexually assaulted or forced to have any kind of sex when you did not want to?
0 No Skip to Next Section.
1 Yes
7 Don't Know
8 Refuse to Answer
E5b. In the six months before your donation were you sexually abused, sexually assaulted or forced to have any kind of sex when you did not want to?
0 No
1 Yes
7 Don't Know
8 Refuse to Answer
E5c. In the six months before your donation were you sexually abused, sexually assaulted or forced to have any kind of sex when you did not want to with someone you consider to be an intimate partner, such as a spouse, husband, wife, boyfriend or girlfriend?
0 No
1 Yes
7 Don't Know
8 Refuse to Answer
Section F – Social/Sexual Matrix
READ and HEARD: This next set of questions is about sexual experiences you may have had. While some people have had a lot of sexual experience, others have not, so questions may or may not apply to you. Please answer these questions as accurately as possible. Remember that answers that you provide will be combined with those from all other people who complete the questionnaire and we will never disclose individual responses to any question. Specifically, we will ask about sexual activities that include vaginal, anal and/or oral intercourse. Please answer these questions to the best of your knowledge and as truthfully as you can.
F1. How many people did you have sex with in the 12 months before your blood donation?
__ __
97 Don't Know
98 Refuse to Answer
99 Not Applicable
If F1 is equal to 0, then skip to instruction Section H.
F2. How many people did you have sex with in the 6 months before your donation? (THIS INFORMATION DOES NOT APPEAR TO THE RESPONDEN: This is the seed number for the social matrix (0 up to 5 partners in last six months - persons with more than 5 partners will only be asked about 5 partners).
__ __
97 Don't Know
98 Refuse to Answer
99 Not Applicable
READ and HEARD: Now, we want to ask about the people you have had sex with and your sexual partners. If you had more than five partners in the 6 months before your blood donation, we are only going to ask you about the five most recent people you have had sex with and your sexual partners. Please start with the most recent person you had sex with before your blood donation and then move back in time.
F3. What is Partner 1's gender?
1 Male
2 Female
3 Transgender
97 Don't Know
98 Refuse to Answer
F4. How old is partner 1?
__ __
97 Don't Know
98 Refuse to Answer
F5. When did your relationship with partner 1 start? We recognize that you may not remember the exact date and so we are asking that you try to recall the month and the year.
Month ______ Year _______
97 Don't Know
98 Refuse to Answer
99 Not Applicable
F6a. Are you currently have sex with partner 1?
0 No
1 Yes
97 Don't Know
98 Refuse to Answer
99 Not Applicable
If F6a = yes, skip to F7
F6b When did your relationship with partner 1 end? We recognize that you may not remember the exact date and so we are asking that you try to recall the month and the year.
Month ______ Year _______
97 Don't Know
98 Refuse to Answer
99 Not Applicable
F7. What type of partner is partner 1? (Choose one)
Primary partner - Your husband, wife, boyfriend or girlfriend
Regular partner – Had sex with regularly, but not your primary partner (husband, wife, boyfriend or girlfriend)
Casual partner – Had sex more than once but not regularly
One time partner – Had sex only once
Anonymous partner – Did not know, met for sex, never plan to see again
Sex worker – Money or other goods were exchanged for sex
97 Don't Know
98 Refuse to Answer
F8. How would you describe partner 1's race or ethnicity? (Choose one)
1 Black
2 White
3 Coloured
4 Asian
6 Other
97 Don't Know
98 Refuse to Answer
F9. What country is partner 1 from?
South Africa
Zimbabwe
Malawi
Mozambique
Swaziland
Botswana
Lesotho
Namibia
Nigeria
Other
Don’t Know
Refuse to Answer
If F9 is equal to South Africa skip to F9b which province, Else skip to F10.
If F9 is equal to Other skip to F9c, Else skip to F10.
F9b. Which province in South Africa is partner 1 from?
Eastern Cape
Free State
Gauteng
KwaZulu Natal
Limpopo
Mpumalanga
North West
Northern Cape
Western Cape
Don’t Know
Refuse to answer
F9c. Please specify which country partner 1 is from:
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
F10a. Do you live with partner 1?
Yes
No
99 Refuse to answer
F10b. Is partner 1 currently working (Choose one)?
Yes, self-employed
Yes, employed full or part-time
No, unemployed SKIP to F11
Don’t know
Refuse to Answer
F10c. What type of work is partner 1 doing?
Mining
Transport/cargo delivery
Military/police
Medical/healthcare
Business/sales/retail
Farming
Teacher/ education/ student
General labour (domestic worker, gardener, janitorial)
Civil service (examples including working in government office, post office)
Other
97 Don’t Know
98 Refuse to Answer
F10d. If F10c=10 Else SKIP If Other, What is partner 1’s occupation?
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
If F1a is equal to 1 and F1b is equal to 0, then skip to Section G.
F12. What is partner 1's HIV status? (Choose one)
1 Positive
2 Negative
3 Unknown
98 Refuse to Answer
If F12 is not equal to 1, skip to F14
F13a. Does partner 1 take HIV medications? (Choose one)
0 No
1 Yes
97 Don't Know
98 Refuse to Answer
F14. Does partner 1 have hepatitis?
Yes
No
Don’t Know
Refused to answer
F15. Did you become sexually involved with partner 1 because you thought that he/she would provide you with some material benefit that you wanted or needed, such as food, shelter, transport, school fees, or other goods?
No
Yes
Don't Know
Refuse to Answer
Not Applicable
F15a. If yes, can you tell us what you wanted or needed? It could be food, clothes, transport, school fees, residence, fees, somewhere to stay or sleep, alcohol, drugs, cash or something else.
____________________________________________________________________________
F16. Where did you first meet partner 1? (Choose one)
1 Bar, nightclub, restaurant, tavern, shebeen, coffee shop
2 Strip club, “Adults Only” club, sex club
3 Street, park, library, public transportation, minibus taxi, train
4 Party, braai, political function, stokvel or church
5 Internet
6 Dating service, newspaper ads
7 Gym, sports event
8 School, technicon, university, college
9 Work
10 Met some other way
97 Don't Know
98 Refuse to Answer
If F16 is not equal to 10, then skip to instruction before F17.
F16a. Please tell us where you met partner 1:
_ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _
If B1 is equal to 1 and F3 is equal to 1, then skip to F19
F17. Number of times you had vaginal sex with partner 1 in the 6 months before donation. (Choose one)
__ none
__ 1 to 3 times
__ 4 to 10 times
__ more than 10 times
__ Don't Know
__ Refuse to Answer
If F17 is equal to none, then skip to F19.
F18. When you had vaginal sex, how frequently did you use condoms? (Choose one)
__ never
__ some of the times
__ every time
__ Don't Know
__ Refuse to Answer
F19. Number of times you had anal sex with partner 1 in 6 months before your donation? (Choose one)
__ none
__ 1 to 3 times
__ 4 to 10 times
__ more than 10 times
__ Don't Know
__ Refuse to Answer
If F19 is equal to none, then skip to F25.
F20. When you had anal sex, how frequently did you use condoms? (Choose one)
__ never
__ some of the times
__ every time
__ Don't Know
__ Refuse to Answer
If F3 is equal to 2, then skip to F23.
F21. Number of times you had insertive anal sex (inserted your penis in partner 1’s anus) in the 6 months before your donation? (Choose one)
__ none
__ 1 to 3 times
__ 4 to 10 times
__ more than 10 times
__ Don't Know
__ Refuse to Answer
If F21 is equal to none, then skip to F24.
F22. When you had insertive anal sex, how frequently did you use condoms? (Choose one)
__ never
__ some times
__ every time
__ Don't Know
__ Refuse to Answer
F23. Number of times you had receptive anal sex (partner 1 inserted his penis into your anus) in the past 6 months. (Choose one)
__ none
__ 1 to 3 times
__ 4 to 10 times
__ more than 10 times
__ Don't Know
__ Refuse to Answer
If F23 is equal to 0, then skip to F25.
F24. When you had receptive anal sex, how frequently did you use condoms? (Choose one)
__ never
__ some times
__ every time
__ Don't Know
__ Refuse to Answer
F25. Number of times you had oral sex with partner 1 in past 6 months
__ none
__ 1 to 3 times
__ 4 to 10 times
__ more than 10 times
__ Don't Know
__ Refuse to Answer
Sexual Matrix is completed with same questions for up to 4 additional sexual partners.
READ and HEARD: The next set of questions is about your SECOND sexual partner, BEFORE your blood donation.
READ and HEARD: The next set of questions is about your THIRD sexual partner, BEFORE your blood donation.
READ and HEARD: The next set of questions is about your FOURTH sexual partner, BEFORE your blood donation.
READ and HEARD: The next set of questions is about your FIFTH sexual partner, BEFORE your blood donation.
Section G - Sexual partner risks
If E2a is equal to 0 and E3a is equal to 0 and B1 is equal to 1, then skip to Section H.
If E2a is equal to 0 and E3a is equal to 0 and B1 is equal to 2, then skip to Section H.
READ and HEARD: Now, we want to ask about some of the behaviors of the people you have had sex with and your sexual partners. As before when answering, please consider only the following activities, whether or not a condom or other protection was used:
Vaginal sex (contact between penis and vagina)
Oral sex (mouth or tongue on someone’s vagina, penis, or anus)
Anal sex (contact between penis and anus)
You may not know the answers to these questions. Please answer these questions to the best of your knowledge. Several of the questions refer to the period of time in the “six months before your blood donation”. This means before your most recent blood donation.
G1a. To the best of your knowledge, have you ever had sex with anyone who was an injection drug user? (Choose one)
0 No Skip to G2a
1 Yes
97 Don't Know
98 Refuse to Answer
G1b. In the 6 months before your donation, have you had sex with anyone who was an injection drug user? (Choose one)
0 No
1 Yes
97 Don't Know
98 Refuse to Answer
G2a. To the best of your knowledge, have you ever had sex with anyone who tested positive for HIV? (Choose one)
0 No Skip to instruction before G4a
1 Yes
97 Don't Know
98 Refuse to Answer
G2b. In the 6 months before your donation, have you had sex with anyone who tested positive for HIV? (Choose one)
0 No
1 Yes
97 Don't Know
98 Refuse to Answer
G3a. To the best of your knowledge, have you ever had sex with a man who has had sex with another man? (Choose one)
0 No Skip to G4a
1 Yes
97 Don't Know
98 Refuse to Answer
G3b. In the 6 months before your donation, have you had sex with a man who has had sex with another man? (Choose one)
0 No
1 Yes
97 Don't Know
98 Refuse to Answer
G4a. To the best of your knowledge, have you ever had sex with anyone who received a blood transfusion? (Choose one)
0 No Skip to G5a
1 Yes
97 Don't Know
98 Refuse to Answer
G4b. In the 6 months before your donation, have you had sex with anyone who received a blood transfusion? (Choose one)
0 No
1 Yes
97 Don't Know
98 Refuse to Answer
G5a. To the best of your knowledge, have you ever had sex with a person with haemophillia? (Choose one)
0 No Skip to G6a
1 Yes
97 Don't Know
98 Refuse to Answer
G5b. In the 6 months before your donation, have you had sex with a person with haemophillia? (Choose one)
0 No
1 Yes
97 Don't Know
98 Refuse to Answer
G6a. To the best of your knowledge, have you ever had sex with anyone who has spent three or more nights in jail, prison, or a detention center? (Choose one)
0 No Skip to G7a
1 Yes
97 Don't Know
98 Refuse to Answer
G6b. In the 6 months before your donation, have you had sex with anyone who has spent three or more nights in jail, prison, or a detention center? (Choose one)
0 No
1 Yes
97 Don't Know
98 Refuse to Answer
G7a. To the best of your knowledge, have you ever had sex with anyone who had a job that involved exposure to human blood or other body fluids? (Choose one)
0 No Skip to Section H
1 Yes
97 Don't Know
98 Refuse to Answer
G7b. In the 6 months before your donation, have you had sex with anyone who has a job that involves exposure to human blood or other body fluids? (Choose one)
0 No
1 Yes
97 Don't Know
98 Refuse to Answer
SECTION H – ALCOHOL AND DRUG USE
READ and HEARD: Now we are going to ask you some general questions regarding alcohol and drug use. Some types of alcohol or drug use can be related to the risk of becoming infected with HIV or HBV. Once again, the following questions are intended to help us determine how to improve the safety of donated blood. We are asking you to respond as truthfully as you can. The answers are confidential. Your individual responses will not be known by SANBS. Your answers will be reported together with all other people who complete the questionnaire.
H1. How often do you drink beer, wine, liquor, or mixed drinks? (Choose one)
0 Never Skip to H4
1 1-3 times per month or less
2 1-2 times per week
3 3-6 times per week
4 Everyday
97 Don't Know
98 Refuse to Answer
H2. On average how many drinks do you have each time you drink? (When answering, one drink is a glass of wine or a beer or a mixed drink.)
Number of drinks __ __ __
997 Don't Know
H3a. Have you ever used dagga, marijuana, or hashish? (Choose one)
0 No Skip to H4a
1 Yes
97 Don't Know
98 Refuse to Answer
H3b. When was the first year you used dagga, marijuana or hashish?
__ __ __ __ yyyy
2097 Don't Know (Year)
2098 Refuse to Answer (Year)
If H3b is less than B2 then READ and HEARD: "The year that you entered for first year of dagga, marijuana, or hashish drug use is smaller than the year you were born. Please correct the year of your first dagga, marijuana, or hashish drug use." (Returns to H3b)
H3c. When was the last year you used dagga, marijuana or hashish?
__ __ __ __ yyyy
2097 Don't Know (Year)
2098 Refuse to Answer (Year)
If H3c is less than H3b then READ and HEARD: "The year that you entered for last year of dagga, marijuana, or hashish drug use is smaller than the year of your first reported dagga, marijuana, or hashish drug use. Please correct the last year of your dagga, marijuana, or hashish drug use." (Returns to H3c)
H4a. Have you ever used whoonga which is also known as nyaope? (Choose one)
0 No Skip to H5a
1 Yes
97 Don't Know
98 Refuse to Answer
H4b. When was the first year you used whoonga or nyaope?
__ __ __ __ yyyy
2097 Don't Know (Year)
2098 Refuse to Answer (Year)
If H4b is less than B2 then READ and HEARD: "The year that you entered for first year of whoonga or nyaope drug use is smaller than the year you were born. Please correct the year of your first whoonga or nyaope drug use." (Returns to H4b)
H4c. When was the last year you used whoonga or nyaope?
__ __ __ __ yyyy
2097 Don't Know (Year)
2098 Refuse to Answer (Year)
If H4c is less than H4b then READ and HEARD: "The year that you entered for last year whoonga or nyaope drug use is smaller than the year of your first reported whoonga or nyaope drug use. Please correct the last year of your whoonga or nyaope drug use." (Returns to H4c)
H5a. Have you ever used any non-injected drugs (drugs that are smoked, snorted or taken orally), examples include tik, mandrax, “glue”, cocaine (crack), methamphetamines (crystal), ecstasy ("E") and LSD? (Choose one)
0 No Skip to H7
1 Yes
97 Don't Know
98 Refuse to Answer
H5b. When was the first year you used non-injected drugs?
__ __ __ __ yyyy
2097 Don't Know (Year)
2098 Refuse to Answer (Year)
If H5b is less than B2 then READ and HEARD: "The year that you entered for first year of non-injected drug use is smaller than the year you were born. Please correct the year of your first non-injected drug use." (Returns to H5b)
H5c. When was the last year you used non-injected drugs?
__ __ __ __ yyyy
2097 Don't Know (Year)
2098 Refuse to Answer (Year)
If H5c is less than H5b then READ and HEARD: "The year that you entered for last year non-injected drug use is smaller than the year of your first reported non-injected drug use. Please correct the last year of your non-injected drug use." (Returns to H5c)
H6. If you have smoked or snorted drugs, did you share pipes or straws with another person? (Choose one)
1 Always
2 Sometimes
3 Never
97 Don't Know
98 Refuse to Answer
H7a. Have you ever used injection drugs (examples include heroin, cocaine, and amphetamines)? (Choose one)
0 No
1 Yes
97 Don't Know
98 Refuse to Answer
H7b. When was the first year you used injected drugs?
__ __ __ __ yyyy
2097 Don't Know (Year)
2098 Refuse to Answer (Year)
If H7b is less than B2 then READ and HEARD: "The year that you entered for first year of injected drug use is smaller than the year you were born. Please correct the year of your first injected drug use." (Returns to H7b)
H7c. When was the last year you used injected drugs?
__ __ __ __ yyyy
2097 Don't Know (Year)
2098 Refuse to Answer (Year)
If H7c is less than H7b then READ and HEARD: "The year that you entered for last year of injected drug use is smaller than the year of your first reported injected drug use. Please correct the last year of your injected drug use." (Returns to H7c)
H8a. Have you ever injected yourself with any substances including vitamins, steroids, or hormones which were not prescribed by a doctor or nurse? (Choose one)
0 No Skip to Section I
1 Yes
97 Don't Know
98 Refuse to Answer
H8b. Have you ever shared needles or syringes with another person to inject yourself with any substance including drugs, vitamins, steroids or hormones which were not prescribed by a doctor? (Choose one)
0 No
1 Yes
97 Don't Know
98 Refuse to Answer
Section I - Medical History
READ and HEARD: In the next set of questions we will ask about some medical treatments you may have had.
I1. Have you ever had a blood transfusion? (Choose one)
0 No Skip to I5
1 Yes
97 Don't Know
98 Refuse to Answer
I2. How many transfusion episodes have you had?
__ __
97 Don't Know
98 Refuse to Answer
I3. When was the first year you received a transfusion?
__ __ __ __
9997 Don't Know
9998 Refuse to Answer
If I3 is less than B2 then READ and HEARD: "The year that you entered for first year transfusion is smaller than the year you were born. Please correct the year of your first transfusion." (Returns to I3)
I4. When was the last year you received a transfusion?
__ __ __ __
9997 Don't Know
9998 Refuse to Answer
If I4 is less than I3 then READ and HEARD: "The year that you entered for last year of transfusion is smaller than the year of your first reported transfusion. Please correct the last year of your transfusion." (Returns to I4)
I5. Have you ever had minor or major surgery in a hospital, doctor’s room, or dentist’s office? (Choose one)
0 No Skip to I9
1 Yes
97 Don't Know
98 Refuse to Answer
I6. In the 6 months before your donation, have you had minor or major medical surgery in hospital? (Choose one)
0 No
1 Yes
97 Don't Know
98 Refuse to Answer
I7. In the 6 months before your donation, have you had any surgical procedures in your doctor’s room or office? (Choose one)
0 No
1 Yes
97 Don't Know
98 Refuse to Answer
I8. In the 6 months before your donation, have you had any tooth extractions or another dental procedure at a dentist’s office? (Choose one)
0 No
1 Yes
97 Don't Know
98 Refuse to Answer
I9. Have you ever had an endoscopy (a medical test where a flexible tube is used to look inside of your throat and digestive system) or colonoscopy (a medical test where tube is used to look inside your colon/large intestine)? (Choose one)
0 No Skip to I11
1 Yes
97 Don't Know
98 Refuse to Answer
I10. In the 6 months before your donation, have you had an endoscopy or colonoscopy? (Choose one)
0 No
1 Yes
7 Don't Know
8 Refuse to Answer
I11. Have you ever been immunized / vaccinated against Hepatitis B?
0 No
1 Yes
97 Don't Know
98 Refuse to Answer
I11b. If yes, can you tell us your age when you were immunized/vaccinated against Hepatitis B?
______ years old
I12. In the 6 months before your donation, did you receive an injection from a traditional healer for any reason? (Choose one)
0 No
1 Yes
97 Don't Know
98 Refuse to Answer
Section J- Other Potential Risk Factors
READ and HEARD: The next set of questions will ask you about situations or activities that could be important for our research to improve blood safety at SANBS. Some of the questions cover topics that are very personal. Please respond as accurately as you can. You may skip any question you are not comfortable answering.
J1. In the 6 months before your donation, have you spent three or more nights in jail, prison, or a detention center? (Choose one)
0 No
1 Yes
97 Don't Know
98 Refuse to Answer
J2. In the 6 months before your donation, have you had acupuncture treatments? (Choose one)
0 No Skip to J5
1 Yes
97 Don't Know
98 Refuse to Answer
J3. Who performed the acupuncture treatments? (Check all that apply)
0 A registered health care professional (such as physiotherapist, chiropractor)
1 Chinese/ Asian healer
2 Traditional healer
3 Other
97 Don’t Know
98 Refuse to Answer
J4. In the 6 months before your donation, how many times have you had acupuncture treatments? (Choose one)
1 1 time
2 2 to 5 times
3 5 or more times
97 Don't Know
98 Refuse to Answer
J5. How many tattoos do you have on your body? (Choose one)
0 0 (No tattoos) Skip to J8
1 1
2 2
3 3 or more
97 Don't Know
98 Refuse to Answer
J6. In the 6 months before your donation, have you gotten a new tattoo or had one re-applied? (Choose one)
0 No
1 Yes
97 Don't Know
98 Refuse to Answer
J7. Where did you get your most recent tattoo? (Choose one)
1 Tattoo parlor
2 Informal tattoo parlor (e.g. fleamarket or street fair)
3 At home, a friends place, or at parties/raves
4 Jail, prison or detention centre
5 Other
97 Don't Know
98 Refuse to Answer
J8. How many ear or body piercings do you have? (Choose one)
0 0 (No piercings) Skip to J11
1 1
2 2
3 3 or more
97 Don't Know
98 Refuse to Answer
J9. In the 6 months before your donation, have you had new ear or body piercings? (Choose one)
0 No
1 Yes
97 Don't Know
98 Refuse to Answer
J10. Where did you get your most recent piercing? (Choose one)
1 Pharmacy or medical clinic
2 Tattoo/piercing parlor
3 At home, a friends place, or at parties/raves
4 Informal ear-piercing (for example at a flea market or street fair)
5 Jail
6 Other
97 Don't Know
98 Refuse to Answer
J11. Have you ever had a manicure or pedicure at a beauty salon or had a shave at a barbershop? (Choose one)
0 No Skip to instruction before J14
1 Yes
97 Don't Know
98 Refuse to Answer
J12. How many times have you had manicures or pedicures or shaves at a beauty salon or barbershop? (Choose one)
1 1 time
2 2 to 5 times
3 5 or more times
97 Don't Know
98 Refuse to Answer
J13. In the 6 months before your donation, have you had a manicure or pedicure at a beauty salon or had a shave at a barber shop? (Choose one)
0 No
1 Yes
97 Don't Know
98 Refuse to Answer
J14a. Have you been circumcised? (Ask of men only – should we make this not gender specific?)
0 No Skip to J17
1 Yes
97 Don't Know
98 Refuse to Answer
J15b. At what age were you circumcised?
_ _ _
Don’t Know
Refuse to Answer
J15c. Was your circumcision performed in the 6 months before your donation?
0 No
1 Yes
97 Don't Know
98 Refuse to Answer
J15d. Was the circumcision performed in hospital?
0 No
1 Yes Skip to J17
97 Don't Know
98 Refuse to Answer
J15e. Who performed the circumcision performed?
0 General practitioner in doctor’s room
1 Traditional surgeon/healer using old methods
2 Traditional surgeon/healer using new methods (using sterile techniques)
97 Don’t know
98 Refused to Answer
J16a. (If female (B2=2)) In the 6 months before your donation, how often have you used anything to dry, clean, or tighten your vagina before or after having sex?
Every time
Some times
Once
Never Skip to J17
Not Applicable, did not have vaginal sex in the 6 months before my donation Skip to J17
Refused to answer Skip to J17
J16b. Please check all the things that you have used to dry, clean or tighten your vagina.
Water
Ice
Soap
Douche
Detergents
Disinfectants
Acids
Salt
Herbs/snuff
Medications
Cloth
Paper
Tissues
A gel used as part of a research study
Other (please specify);________________________________
J17a. In the 6 months before your donation, how often have you used anything to dry, clean, or tighten your anus before or after having sex?
Every time
Some times
Once
Never Skip to J25
Not Applicable, did not have anal sex in the 6 months prior to my last donation Skip to J24
Refused to answer Skip to J25
J17b. Please check all the things that you have used to dry, clean or tighten your anus before having sex.
Water
Ice
Soap
Douche
Herbs/snuff
A gel used as part of a research study
Other (please specify);________________________________
J18a. In the 6 months before your donation, have you had Raatib, ritual scarring, ritual piercing, ritual circumcision, blood sharing or been stabbed?
0 No Skip to J20
1 Yes
97 Don't Know
98 Refuse to Answer
J18b. Can you please tell us which activity? (Check all that apply)
Raatib
Ritual scarring
Ritual piercing
Ritual circumcision
Blood sharing
Been stabbed
Other (please specify);________________________________
J19. What was the reason for the activity?
Cultural, ritual, religious
Administering a substance in my skin for treatment or prevention
Letting out blood
Sealing a “blood pact”
Other
Don't Know
Refuse to Answer
J20. In the 6 months before your donation, did you visit a traditional healer and receive traditional medicine other than cuts and/or scarification?
0 No
1 Yes
97 Don't Know
98 Refuse to Answer
J21. In the 6 months before your donation, did you live in an environment where you were frequently bitten by mosquitos?
0 No
1 Yes
97 Don't Know
98 Refuse to Answer
J22. In the 6 months prior to your last donation, did you live in an environment where you were frequently bitten by bed bugs or lice?
0 No
1 Yes
97 Don't Know
98 Refuse to Answer
J23. In the 6 months prior to your last donation, did you have an injury such as a knife or stab wound or were you in an accident where you lost blood from a cut or injury?
0 No
1 Yes
97 Don't Know
98 Refuse to Answer
READ and HEARD: Now, we would like to know about any personal contact you have had with persons who have HIV or hepatitis. In each question, please include only family members, personal friends or acquaintances. (If you are a health care worker, please do NOT include any individuals you have given professional care to, we will ask about those contacts in a minute).
J31. How many people do you personally know who do NOT have AIDS, but have tested positive for HIV, the virus that causes AIDS? (Choose one)
0 0 (none)
1 1
2 2 to 4
3 5 or more
97 Don't Know
98 Refuse to Answer
J32. How many people do you personally know who currently have AIDS or have died of AIDS? (Choose one)
0 0 (none)
1 1
2 2 to 4
3 5 or more
97 Don't Know
98 Refuse to Answer
J33. How many people do you personally know who have hepatitis? (Choose one)
0 0 (none)
1 1
2 2 to 4
3 5 or more
97 Don't Know
98 Refuse to Answer
J34. How many people do you personally know who have died of hepatitis? (Choose one)
0 0 (none)
1 1
2 2 to 4
3 5 or more
97 Don't Know
98 Refuse to Answer
J35. In the 6 months have you been in close contact with anybody who had Hepatitis (yellow jaundice), e.g. people you live or work with?
0 No
1 Yes
97 Don't Know
98 Refuse to Answer
Section K - Work Place Exposures
K1. Do you work where you are exposed to human bodily fluids (e.g. blood, urine, feces, saliva)? (Choose one)
0 No Skip to Section L if Study group 1 (A7=1), Skip to Question L9 if Study group 2 (A7=2), Else Skip to Instruction After L9.
1 Yes
97 Don't Know
98 Refuse to Answer
K2. In the 6 months before your donation, in your professional work have you had a needle stick injury (accidentally been stuck by a needle or other sharp instrument used for providing medical care to someone else)? (Choose one)
0 No
1 Yes
97 Don't Know
98 Refuse to Answer
K3. In the 6 months before your donation, did you in your professional work have someone else's blood, body fluids, or excrement splashed into your eyes, mouth or in an open skin lesion? (Choose one)
0 No
1 Yes
97 Don't Know
98 Refuse to Answer
If Study Group 3 (A7=3), Skip to Instruction After L9.
Section L - Exposure and Treatment
Study Group 1 Only (A7=1)
READ and HEARD: This is the final section of the questionnaire. It may be difficult for you to respond to these questions. Again, the responses are anonymous and will help us improve blood safety in South Africa.
L1. Did you know your HIV status before your donation? (Choose one)
0 No
1 Yes
97 Don't Know
98 Refuse to Answer
L2. How do you think you may have become infected with HIV?
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ __ __ __ __ __
L3. When do you think you may have been infected with HIV? (Year)
__ __ __ __ yyyy
2097 Don't Know (Year)
2098 Refuse to Answer (Year)
L4. When do you think you may have been infected with HIV? (Month) (Choose one)
__ __ January
__ __ February
__ __ March
__ __ April
__ __ May
__ __ June
__ __ July
__ __ August
__ __ September
__ __ October
__ __ November
__ __ December
__ __ Don't Know
__ __ Refuse to Answer
L5. Are you currently taking antiretroviral medicines, also called ARVs? (Choose one)
0 No
1 Yes skip to L7?
97 Don't Know
98 Refuse to Answer
L6. Have you taken antiretrovirals (ARVs) in the past? (Choose one)
0 No
1 Yes
97 Don't Know
98 Refuse to Answer
L7. (Ask of Women Only) If Female: Did you know you were HIV-positive prior to or during your most recent pregnancy?
0 No
1 Yes
96 Not applicable, never been pregnant SKIP to After L9.
97 Don't Know
98 Refuse to Answer
L8. (Ask of Women Only) Did you take antiretrovirals during your most recent pregnancy to try to prevent HIV transmission to your baby?
0 No
1 Yes
96 Not Applicable
97 Don't Know
98 Refuse to Answer
Study Group 2 Only (A7=2)
L9. How do you think you may have become infected with HBV?
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ _ __ __ __ __ __
READ and HEARD: Thank you for taking the time to complete this questionnaire. If you have any questions or concerns, please talk to the research assistant or nurse. You can also contact the medical director at our blood bank.
READ and HEARD: You have finished the questionnaire. From now on, please do not touch the computer or screen. Please, talk to the research assistant, the person who assisted you at the beginning of this questionnaire. This assistant will close the screen and acknowledge you for your participating in this study.
ETIME = ENDTIME - STARTTIM
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | REDS III-INTERNATIONAL |
| Author | BSRI Employee |
| File Modified | 0000-00-00 |
| File Created | 2021-01-28 |
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