Follow-up HIV

Form Approved

OMB No. 0920-XXXX

Expiration Date: XX/XX/XXXX

Evaluation of Rapid HIV Home-Testing among MSM Trial

Attachment 3g

Follow-up Survey— HIV Positive Group

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

Follow-up Survey for HIV Positive Group

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

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

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

Thank you for your interest in this study. Please take note of the following information:

0. Your answers are private: the information you provide us will be kept private and known only to study staff.

1. This survey includes some personal questions. You can choose to not answer any questions that make you feel uncomfortable.

2. We appreciate your willingness to be part of this study. Your participation will help us learn more about ways to get people tested. The results of this study will be used to improve HIV testing programs in the United States.

3. Emory University and MANILA Consulting Group, Inc. are conducting the study, which is funded by the Centers for Disease Control and Prevention (CDC).

Section A. Study Home HIV Tests

(Asked at 3 and 6 months)

A-1. Since the last survey, that is, since [insert calculated month and year], how many study home HIV tests did you use to test yourself?

TD1a. Number of oral fluid HIV test (OraQuick) used: _____ (enter number between 0-4)

TD 1b. Number of finger-stick blood HIV test (Sure Check) used: ____ (enter number between 0-4)

If A-1a > 0 or A-1b > 0, go to A-2, else go to A-3.

A-2. What are the reasons you used the study home HIV test(s) on yourself? Check all that apply.

Curious about the home HIV test

Wanted to check or confirm my HIV status

Wanted to show someone how to use the home HIV test

Wanted to show someone my results from the home HIV test

Wanted to show someone my results before having sex with him or her

Wanted to show someone my results after having sex with him or her

Other: (please specify: ________________ )

A-3. Did you do any of the following because of the result of a study home HIV test? (Check all that apply):

1. Have sex only with partners that were the same HIV status as you

2. Exclusively be the top

3. Exclusively be the bottom

4. Always use condoms

5. Sometimes use condoms

6. Never use condoms

7. Not have anal sex

8. Only have oral sex

9. Not have vaginal sex

10. Not have sex

11. I didn’t do anything different based on the result of the HIV test

12. None of the above

77 I prefer not to answer

Section B. Test Distribution (TD)

TD-1. Since the last survey, did you give away any study home HIV test?

No

Yes

77 I prefer not to answer

99 I don't know

If TD-1=No, go to TD-2.

If TD-1= Yes, go to TD-3.

TD-2. What are the reasons you didn’t give away the study home HIV tests? Check all that apply.

1. I wanted to use it for myself

2. I was concerned this might affect our relationship

3. I thought they would get upset or angry

4. I didn’t know I could give them away

5. I was afraid they would think I have HIV

6. I was concerned about the accuracy of such a test

7. I was concerned they would not be able to perform and read the test correctly

8. I would rather they talked to a counselor when they get an HIV test

9. Other reason (Specify___________)

77 I prefer not to answer

99 I don't know

If TD-1=No, go to next section.

If TD-1= Yes, continue to TD-3.

TD-3. How many different people refused to accept the study test when you offered it to them?

______

77 I prefer not to answer

99 I don't know

TD-4. We want to ask a few questions about each person who received a study home test kit from you.

To help you remember, please write the initials or nickname of the person(s) you gave a study home test to in the space(s) in the table below. If you gave someone more than one test kit, just put his/her nickname or initials in the box next to the kit’s name. If two people have the same initials or nickname, please use different initials or nickname for each.

	Initials or Nickname of person you gave the study home test kit
OraQuick	4a or “I didn’t give away”
OraQuick	4b or “I didn’t give away”
Sure Check	4c or “I didn’t give away”
Sure Check	4d or “I didn’t give away”

Ask secondary user-specific questions based on number from TD-4

Secondary user #1 [4a]

The following questions are about [insert initials or nickname of entered in TD-4a]

TD-5. What is [insert initials or nickname of entered in TD-4a]’s age? Use your best guess if you’re not sure.

_____

TD-6. What is [insert initials or nickname of entered in TD-4a]’s gender?

1. Male

2. Female

3. Transgender (Male to Female)

4. Transgender (Female to Male)

77 I prefer not to answer

TD-7. What is [insert initials or nickname of entered in TD-4a]’s race/ethnicity? Check all that apply.

1. American Indian or Alaska Native

2. Asian

3. Black or African American

4. Hispanic or Latino

5. Native Hawaiian or Other Pacific Islander

6. White

77 I prefer not to answer

TD-8. How long have you known [insert initials or nickname of entered in TD-4a]?

1. Less than a month

2. 1 to 3 months

3. 4 to 6 months

4. 7 to 11 months

5. 1 to 3 years

6. Over 3 years

77 I prefer not to answer

TD-9. To the best of your knowledge, does [insert initials or nickname of entered in TD-4a] have sex with:

1. Men only

2. Women only

3. Both men and women

77 I prefer not to answer

99 I don't know

TD-10. To the best of your knowledge, does [insert initials or nickname of entered in TD-4a] inject drugs that are not prescribed for him/her?

1. No

2. Yes

77 I prefer not to answer

99 I don't know

TD-11. Who is [insert initials or nickname of entered in TD-4a]? Check only one.

1. A main sexual partner (Someone you feel committed to above all others)

2. A casual sexual partner (Someone you do not feel committed to above all others)

3. A family member (who is not sexual partner)

4. A friend (who is not sexual partner)

5. A stranger (who is not sexual partner)

6. An acquaintance (who is not sexual partner)

7. Other (please specify: _________)

77 I prefer not to answer

99 I don't know

For study participants who gave only 1 HIV test(s) to [4a]:

BOX: The following questions are about that [insert “OrQquick” or “Sure Check” based on response from TD-4] HIV test you gave to [insert initials or nickname of entered in TD-4a].

For study participants who gave more than 1 HIV test(s) to [4a]:

BOX: The following questions are about the FIRST HIV test [insert “OraQuick” or “Sure Check” based on response from TD-4] you gave to [insert initials or nickname of entered in TD-4a].

TD-12. To the best of your knowledge, when did [insert initials or nickname of entered in TD-4a] use the [insert “OraQuick” or “Sure Check” based on response from TD-4] test that you gave him/her?

______/_______ Month/Day

77 I prefer not to answer

99 I don't know

TD-13. What was the result of the [insert “OraQuick” or “Sure Check” based on response from TD-4] HIV test you gave to [insert initials or nickname of entered in TD-4a]?

1. Negative

2. Positive

3. Invalid

77 I prefer not to answer

99 I don't know the result of the test

For study participants who gave more than1 HIV test(s) to [4a] go to TD-14, else skip to TD-16:

BOX: The following questions are about the SECOND or MOST RECENT HIV test ([insert “OraQuick” or “Sure Check” based on response from TD-4]) you gave to [insert initials or nickname of entered in TD-4a].

TD-14. To the best of your knowledge, when did [insert initials or nickname of entered in TD-4a] use the SECOND or MOST RECENT HIV test ([insert “OraQuick” or “Sure Check” based on response from TD-4]) you gave him/her?

______/_______ Month/Day

77 I prefer not to answer

99 I don't know

TD-15. What was the result of the SECOND or MOST RECENT HIV test ([insert “Oraquick” or “Sure Check” based on response from TD-4]) you gave to [insert initials or nickname of entered in TD-4a]?

1. Negative

2. Positive

3. Invalid

77 I prefer not to answer

99 I don't know the result of the test

TD-16. To the best of your knowledge, did [insert initials or nickname of entered in TD-4a] call the study number for information, counseling or a referral?

1. No

2. Yes

77 I prefer not to answer

99 I don't know

If TD-13 or TD-15 = “Positive” go to TD-17, else go to TD-20

TD-17. To the best of your knowledge, did [insert initials or nickname of entered in TD-4a] already know she/he was HIV-positive?

1. No

2. Yes

77 I prefer not to answer

99 I don't know

TD-18. To the best of your knowledge, did [insert initials or nickname of entered in TD-4a] go to a health care provider for more tests or to start care after the HIV positive test result from the [insert “OraQuick” or “Sure Check” based on response from TD-4]HIV test?

No

Yes

77 I prefer not to answer

99 I don't know

TD-19. Did you help [insert initials or nickname of entered in TD-4a] to see a doctor after she/he found out that she/he was infected (e.g., encouraging them to call the study number, going with them to see a HIV health care professional)?

No

Yes

77 I prefer not to answer

99 I don't know

If TD-11 = “main sexual partner” or “casual sexual partner” AND TD-4 indicates that [4a] received only 1 test go to TD-10

If TD-11 ≠ “main sexual partner” or “casual sexual partner” go to next section.

TD-20. You mentioned [insert initials or nickname of entered in TD-4a] is a sexual partner. Did the result of the test influence your decision to have sex?

1. No

2. Yes

77 I prefer not to answer

TD-21. Did you have anal or vaginal sex with [insert initials or nickname of entered in TD-4a] after [insert initials or nickname of entered in TD-4a] used the study home HIV test?

1. No

2. Yes

77 I prefer not to answer

99 I don't know

If TD-21 = “Yes” , go to TD-22. Else go to End Section Box

TD-22. Think about the time or times you had anal or vaginal sex with [insert initials or nickname of entered in TD-4a] after [insert initials or nickname of entered in TD-4a] used the study home HIV test. Did you have sex without condoms with [insert initials or nickname of entered in TD-6a]?

1. No

2. Yes

77 I prefer not to answer

99 I don't know

IF TD-6 is not “Female” and TD-22 = “Yes”, go to TD-23. Else go to End Section Box.

TD-23. When you had sex without condoms with [insert initials or nickname of entered in TD-4a] after [insert initials or nickname of entered in TD-4a] took the test, were you …

(Check only one)

1. Both top and bottom

2. Top only

3. Bottom only

77 I prefer not to answer

99 I don't know

End Section Box: Repeat TD-5 to TD-23 for 4b, 4c, 4d if applicable. Else go to next section.

Section D. Linkage to Care, Treatment, and Adherence

(Asked at 6 months follow up only)

The next questions are about medical appointments to a see a health care provider (doctor, physician’s assistant or nurse) because of a positive HIV test result or to get care for your HIV infection.

LTA-1. In the past 6 months, have you seen health care provider for your HIV infection?

1. No

2. Yes

77 I prefer not to answer

If LTA-1 = “Yes” go to LTA-2.

If LTA-1 = “No” or 77 go to LTA-3.

LTA-2. Did being part of the study affect your decision to see a HIV health care provider?

1. No

2. Yes

77 I prefer not to answer

Yes: ___________________________

LTA-3. What are the reasons you have NOT gone to a health care provider for your HIV infection? Check all that apply.

1. I felt good and didn’t need to go

2. My previous CD4 count and viral load were good

3. I didn’t believe that I am HIV positive or want to think about it

4. I didn’t have enough money or health insurance

5. I had other responsibilities such as child care or work

6. I was homeless

7. I was too sick to go

8. I forgot to go or missed my appointment(s)

9. I was unable to get transportation

10. Going to the appointment is inconvenient (location/hours/wait-time, etc.)

11. I don’t know where to go or couldn’t find the right HIV health care provider

12. Other (specify:______)

77 I prefer not to answer

Section E. Perpetration and Coercion

(Asked at 6 months only)

The next few questions are about things that may have happened when people used the home HIV tests. Please remember that all answers will be kept private.

CA-1. During the course of the study did you pressure someone to use one of the study home HIV tests?

No

Yes

77 I prefer not to answer

99 I don't know

If CA-1 = “Yes” go to CA-2, else go to CA-5.

CA-2. Who was this someone?

1. Sex partner

2. Family member

3. Friend

4. Stranger

5. Other

77 I prefer not to answer

If CA-2 = “sex partner” go to CA-3, else go to CA-5.

CA-3. During the course of this study, did you do any of the following? (Check all that apply)

1. Pressure a sexual partner to use one of the study home HIV tests.

2. Threaten to leave or break up with a sexual partner if they did not test using one of the study home HIV tests

3. Yell or curse at a sexual partner who refused to test using one of the study home HIV tests

4. Break up with a sexual partner who refused to test using one of the study home HIV tests

5. Threaten to hit a sexual partner if they did not test using one of the study home HIV tests

6. Hit, punch, or kick a sexual partner who refused to test using one of the study home HIV tests

7. Physically force a sexual partner to test using one of the study home HIV tests

77 I prefer not to answer

CA-4. During the course of this study, did you do any of the following after a sexual partner tested using one of the study home HIV tests? (Check all that apply)

1. Threaten to leave or break up with a sexual partner because of their test result

2. Yell or curse at a sexual partner because of their test result

3. Break up with a sexual partner because of their test result

4. Threaten to hit a sexual partner because of their test result

5. Hit, punch, or kicked a sexual partner because of their test result

77 I prefer not to answer

CA-5. During the course of the study did someone pressure you to use one of the study home HIV tests?

No

Yes

77 I prefer not to answer

If CA-5 = “Yes” go to CA-6, else go to end of section

CA-6. Was this someone a sex partner, family member, friend, stranger or other?

1. Sex partner

2. Family member

3. Friend

4. Stranger

5. Other

77 I prefer not to answer

If CA-6 = “sex partner” go to CA-7, else go to end of section

CA-7. Did any of the following occur between you and a sexual partner prior to you using one of the study home HIV tests? (Check all that apply)

1. He/she pressured you to test yourself

2. He/she threatened to leave or break up with you if you did not test yourself

3. He/she yelled or cursed at you when you refused to test yourself

4. He/she broke up with you when you refused to test yourself

5. He/she threatened to hit you if you did not test yourself

6. He/she hit, punched, or kicked you when you refused to test yourself

7. He/she forced you to test yourself

77 I prefer not to answer

CA-8. Did any of the following occur between you and a sex partner after you tested yourself using one of the study home HIV tests? (Check all that apply)

1. He/she threatened to leave or break up with you

2. He/she yelled or cursed at you

3. He/she broke up with you

4. He/she threatened to hit you

5. He/she hit, punched, or kicked you

77 I prefer not to answer

_______________________________________________

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

SURVEY END:

If A8 = “Positive” and HTP-1 = “No” go to End1 else go to End2.

END1. Would you like a study staff person to get in touch with you to help you find a health care provider in your area?

No

Yes

END2. Thank you for taking our survey! Your response is very important to us. 

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

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

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

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