Neighborhood Survey

Form Approved

OMB No. 0920-XXXX

Exp. Date: XX/XX/XXXX

Community Context Matters Study

Attachment 6

Neighborhood Interview Survey (street-recruited participants)

Public reporting burden of this collection of information is estimated to average 20 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-New)

Neighborhood Interview Survey (Street-recruited participants)

These first few questions are to understand some basic information about you

Age

1. How old are you today? __ __ (years) If less than 18 years old, STOP, not eligible for survey

Race/Ethnicity

2. Do you consider yourself Hispanic or Latino(a)?:

 Yes

 No

3. Which race do you consider yourself (choose one or more):

 American Indian or Alaska Native

 Asian

 Black or African American

 Native Hawaiian or other Pacific Islander

 White

Sex/Gender/ Sexual orientation

4. Do you consider yourself to be…?

 Male

 Female

 Transgender

5. Do you consider yourself to be:

 Heterosexual or "Straight"

 Homosexual, Gay, or Lesbian

 Bisexual

6. What was your sex at birth?

 Male

 Female

Employment

7. What best describes your employment status? Are you: (Choose one)

 Employed full-time

 Employed part-time

 A homemaker

 A full-time student

 Retired

 Unable to work for health reasons

 Unemployed

 Other (specify) 7a. __________________________

Marital Status

8. What is your current marital status? (Choose one)

 Single, not married

 Legally married

 Living together as married

 Separated

 Widowed

 Divorced

Insurance

9. Do you currently have health insurance or health care coverage?

 Yes

 No (skip to Q11)

10. What kind of health insurance or coverage do you have now? (Select all that apply)

 A private health plan (through an employer, union, or purchased directly)

 Medicaid or Medical Assistance program (for people with low incomes)

 Medicare (for the elderly and people with disabilities)

 Military (TriCare) or VA coverage

 Some other health care plan

Language preference

11. In what language do you prefer to receive your medical care? (Choose one)

 English

 Spanish

 Another language (specify or site-specific pick-list)

12. In what language do you prefer to read health-related materials? (Choose one)

 English

 Spanish

 Another language (specify or site-specific pick-list)

Education

13. What is the highest level of education you completed? (Choose one)

 Never attended school

 Grades 1 through 8

 Grades 9 through 12 without a diploma

 High school diploma or GED

 Some college, Associate’s Degree, or Technical Degree

 Bachelor’s Degree

 Any post graduate studies

Housing

14. Are you currently homeless? By homeless, I mean living on the street, in a shelter, in a car, or in a single-room only hotel (SRO).

 Yes

 No

Next we are going to ask some questions about HIV and AIDS.

Basic HIV knowledge

15. Do you know anyone who has HIV infection or AIDS?	 Yes	 No	 DK
16. A person who has HIV infection can look healthy	 Yes	 No	 DK
17. A person can get HIV infection by having vaginal or anal sex without using a condom	 Yes	 No	 DK
18. A person can get HIV infection by deep kissing (putting their tongue in their partner’s mouth) if their partner has HIV	 Yes	 No	 DK
19. There are tests that can show whether a person has HIV infection before they get sick	 Yes	 No	 DK
20. The risk for getting HIV infection is very low with a sex partner who has had a recent test for HIV that was negative (no infection found)	 Yes	 No	 DK
21. The risk for getting HIV infection is low when having oral sex or practicing mutual masturbation	 Yes	 No	 DK
22. Showering or washing your genitals/private parts after having sex will keep you from getting HIV infection	 Yes	 No	 DK

For the next 3 questions, please tell us whether you agree or disagree with the statement.

HIV Attitudes/Beliefs

23. If I got infected with HIV today I could live a long and healthy life by taking the combination drug treatments that are available	 Agree	 Undecided	 Disagree
24. I would be less likely to get infected by an HIV positive partner with undetectable virus than a HIV positive partner with detectable virus	 Agree	 Undecided	 Disagree
25. If I were having sex with an HIV-positive partner and the condom broke, it would be less risky for me if they had no detectable virus	 Agree	 Undecided	 Disagree

Now, we will ask a few questions about HIV preexposure prophylaxis, also called PrEP. PrEP means a person who does not have HIV infection takes a daily pill containing anti-HIV medicines for several months or years to keep from getting HIV.

Basic PrEP Knowledge

26. Before today, have you heard of preexposure prophylaxis (PrEP)?

 Yes

 No (skip to Q29)

27. If yes, where did you hear about PrEP (check all that apply)

 A friend

 A family member

 A sex partner

 A health care provider

 An HIV prevention counselor

 On a website

 At a community meeting

 From a poster or flyer

 Other (specify)

28. From what you heard, how effective is PrEP in reducing the risk of getting HIV infection? (Choose one)

 It doesn’t reduce the risk at all

 It reduces the risk a little bit

 It reduces the risk by about half

 It reduces the risk a lot

 It reduces the risk completely

 Don’t know

29. Do you know anyone who is taking PrEP?  Yes  No

For the next set of questions, please tell us whether you agree or disagree with the statement.

PrEP Knowledge/Attitudes

30. PrEP should only be given to people who are unable to make their partners use condoms	 Agree	 Undecided	 Disagree
31. PrEP should be given to anyone who wants to take it for HIV prevention	 Agree	 Undecided	 Disagree
32. PrEP will make people less responsible	 Agree	 Undecided	 Disagree
33. I worry about the side effects of PrEP medications	 Agree	 Undecided	 Disagree
34. It is difficult to take a pill every day	 Agree	 Undecided	 Disagree
35. Taking PrEP is simple and straightforward	 Agree	 Undecided	 Disagree
36. It is safe to take HIV medicine you order online for PrEP without seeing a doctor	 Agree	 Undecided	 Disagree

PrEP Information and Experience

37. If you wanted to learn more about PrEP in general, who would you trust to give you good information?

 A friend

 A family member

 A sex partner

 A health care provider

 An HIV prevention counselor

 A website

 A community organization

 Other (specify) 37a/ __________________________________

38. If you wanted to discuss whether PrEP is right for you, who would you trust to give you good advice?

 A friend

 A family member

 A sex partner

 A health care provider

 An HIV prevention counselor

 A website

 A community organization

 Other (specify) 38a. _________________________________

39. Have you ever taken anti-HIV medicines to protect yourself from getting HIV infection?

 Yes

 No (skip to Q42)

 Not sure/Refused (skip to Q42)

40. For how long did you take medications for prevention?

 A few days but less than a week

 At least 1 week but less than a month

 1-2 months

 More than 2 months

 Not sure/Refused

41. Where did you get the medications?

 From a clinic

 From a pharmacy

 From a friend or family member

 From another source (specify) 41a. _______________________________

 Not sure/Refused

42. If you wanted to take anti-HIV medicines for prevention, where would you go to get them?

 From a clinic

 From a pharmacy

 From a friend or family member

 From another source (specify) 42a. _______________________________

 Not sure/Refused

43. Do you know of any places near here to get anti-HIV medications without a prescription?

 Yes

 No

 Not sure/Refused

44. Where can you get PrEP medications without a prescription?

 From a clinic

 From a pharmacy

 From a friend or family member

 From another source (specify) 44a. _______________________________

 Not sure/Refused

This next set of questions is about personal behaviors that can put people at risk for getting HIV infection or passing it to others. Remember that all information you give us is private. We are not recording your name or any other information that would identify you as an individual.

Sexual Behavior Risk Screen

The following questions ask about your sexual relationships, partners and behaviors. Remember, everything you tell us is private.

45. Are you in an ongoing sexual relationship with a person who is HIV+?

 Yes  No

46. Have you ever tested positive for HIV?

 Yes

 No [If no to Q46, and yes to Q45, go to ARCH for HIV Discordant Couples, (Q62)]

47. In the last 6 months, have you had sex with men, women, or both? [check all that apply]

 Men [If male, go to ARCH for MSM (Q48), if female, go to ARCH for HET (Q55)]

 Women [If male go to ARCH for HET (Q55)]

 No sex (Skip to Q 77)

ARCH – MSM Questions (by ACASI)

48. How old are you today (years)?	__ __
49. How many men have you had sex with in the last 6 months?	__ __ __
50. In the last 6 months, how many times did you have receptive anal sex (you were the bottom) with a man?	__ __
51. How many of your male sex partners were HIV positive?	__ __
52. In the last 6 months, how many times did you have insertive anal sex (you were the top) with a man who was HIV positive?	__ __
53. In the last 6 months, have you used methamphetamines such as crystal or speed?	 Yes	 No
54. In the last 6 months, have you used poppers (amyl nitrate)?	 Yes	 No

ARCH – HET Questions (men and women)

55. How old are you today (years)?	__ __
In the last 6 months:
56. How many women/men have you had sex with?	__ __ __
57. How many of your female/male sex partners were HIV positive?	__ __ __
58. Have you been treated for syphilis or gonorrhea?	 Yes	 No
59. Have any of your sex partners injected drugs or smoked crack cocaine?	 Yes	 No
60. Have any of your sex partners had other partners during the same period of time they were having sex with you?	 Yes	 No
(Women only) 61. Have any of your male sex partners had sex with men?	 Yes	 No

ARCH – HIV Discordant Couple Questions (MSM and HET)

62. Is your main sexual partner male or female?				 Yes		 No
63. Are you (is your main sexual partner) circumcised?				 Yes		 No/DK
64. Does your main sexual partner have HIV infection?				 Yes		 No/DK (skip to Q67)
65. If positive, are they taking antiretroviral medications to treat their HIV infection?				 Yes		 No/DK (skip to Q57)
66. If yes, was their most recent viral load detectable?				 Yes		 No/DK
Considering only your main sexual partner, in the last month <since month/day>, how many times did you:
Male PrEP candidate with female partner
67. Have insertive vaginal sex (your penis in her vagina)	__ __				66a. Of those times, how many times was a condom used?			__ __
68. Have insertive anal sex (your penis in her rectum/anus)	__ __				67a. Of those times, how many times was a condom used?			__ __
69. Get oral sex (your penis in her mouth)	__ __				68a. Of those times, how many times was a condom used?			__ __
Female PrEP candidate with male partner
70. Have receptive vaginal sex (his penis in your vagina)		__ __			69a. Of those times, how many times was a condom used?			__ __
71. Have receptive anal sex (his penis in your rectum/anus)		__ __			70a. Of those times, how many times was a condom used?			__ __
72. Give oral sex (his penis in your mouth)		__ __			71a. Of those times, how many times was a condom used?			__ __
Male PrEP candidate with male partner
73. Have insertive anal sex (your penis in his rectum/anus)		__ __			72a. Of those times, how many times was a condom used?			__ __
74. Have receptive anal sex (his penis in your rectum/anus)		__ __			73a. Of those times, how many times was a condom used?			__ __
75. Give oral sex (his penis in your mouth)		__ __			74a. Of those times, how many times was a condom used?			__ __
76. Get oral sex (your penis in his mouth)		__ __			75a. Of those times, how many times was a condom used?			__ __

Drug Use Risk Screen

The next questions are about use of drugs that are injected and not prescribed by a doctor. Everything you tell us is private.

77. In the last 6 months, have you injected drugs even one time that were not prescribed to you by a doctor

 Yes [If yes, go to ARCH for IDU (Q78)]

 No (Skip to Q84)

ARCH – IDU Questions

78. How old are you today (years)?	__ __
79. In the last six months, were you in a methadone maintenance program?	 Yes	 No
80. In the last 6 months, how often did you inject heroin?	 1 or more times	 0 times
80. In the last 6 months, how often did you inject cocaine?	 1 or more times	 0 times
81. In the last 6 months, how often did you share a cooker?	 1 or more times	 0 times
82. In the last 6 months, how often did you share needles?	 1 or more times	 0 times
83. In the last 6 months how often did you visit a shooting gallery?	 1 or more times	 0 times

We’re almost done. The next few questions are about your household income.

Income

When answering this next question, please remember to include your income PLUS the income of all family members living in your household.

84. What is your best estimate of your total income [the total income of all family members] from all sources, before taxes, in [last calendar year in 4 digit format]?

$ __ __ __ , __ __ __.00 (If $ provided, skip to Q89)

 Refused (go to Q85)

 Don’t know (go to Q85)

85. Was your total [family] income from all sources less than $50,000 or $50,000 or more?

 Less than $50,000 (go to Q86)

 $50,000 or more (go to Q87)

 Refused (go to Q89)

 Don’t know (go to Q89)

86. Was your total [family] income from all sources less than $35,000 or $35,000 or more?

 Less than $35,000 (go to Q89)

 $35,000 or more (go to Q89)

 Refused (go to Q 89)

 Don’t know (go to Q89)

87. Was your total [family] income from all sources less than $100,000 or $100,000 or more?

 Less than $100,000 (go to Q88)

 $100,000 or more (go to Q89)

 Refused (go to Q89)

 Don’t know (go to Q89)

88. Was your total [family] income from all sources less than $75,000 or $75,000 or more?

 Less than $75,000 (go to Q89)

 $75,000 or more (go to Q89)

 Refused (go to Q89)

 Don’t know (go to Q89)

89. Including yourself, how many people live together in your household? __ __

These are the last two questions for today.

Georisk Questions

90. Where did you meet your current or most recent sex partner? (Choose one)

• Introduced by friends

• At school or work

• On an internet/web site

• Through a mobile phone app

• At a social event or party I was invited to

• At a bar or club

• At a church or house of worship

• Other (specify) 90a. _________________

91. What zip code do you live in? __ __ __ __ __

Thank you for completing this survey.

Give participant a PrEP fact sheet and answer any questions they have about it