Justification for Change

Justification for Modification of 0920-0770, National HIV Behavioral Surveillance (NHBS)

The Centers for Disease Control and Prevention (CDC) requests to make non-substantive revisions to the currently approved National HIV Behavioral Surveillance (NHBS) OMB No. 0920-0770; expiration date 3/31/2017. The proposed revisions pertain to the content and format of the NHBS interview instrument. All other project activities and methods remain the same as in the previously approved information collection request. The proposed revisions do not change the burden (hours or cost) shown in the current inventory.

This submission includes the currently approved and the proposed instrument. Changes to the instrument format preclude provision of a “redlined” document showing changes. The attached summary of changes document provides the location of changed questions on both the proposed and the currently approved instruments.

Please see the following attachments for additional detail as needed:

1. 0920 0770 Summary of Changes

2. NHBS R4 Currently Approved Instrument

3. NHBS R4 Proposed Instrument – English

4. NHBS R4 Proposed Instrument – Spanish

Overview of NHBS

NHBS collects data on selected behaviors among individuals at increased risk for HIV infection. The project is implemented in up to 25 metropolitan statistical areas in the United States known to be most affected by the HIV epidemic. Data collection is conducted in repeated 12-month cycles among three populations: men who have sex with men (MSM), injecting drug users (IDU) and heterosexuals at increased risk (HET). During the upcoming three-year period (3/31/2014 to 3/31/2017), three NHBS data collection cycles will be implemented. The MSM cycle of NHBS is currently ongoing, and it will be followed by the IDU cycle in 2015 and by the HET cycle in 2016.

NHBS cycles involve different sampling methods, based on what is known about reaching the specific population. The MSM cycle uses venue-based sampling and the IDU and HET cycles use respondent-driven sampling. Regardless of the cycle, recruited participants complete an eligibility screener and those who are found to be eligible for the survey complete a standardized, anonymous behavioral assessment interview. The behavioral assessment collects information about demographic characteristics, behavioral risk for HIV, HIV testing, and utilization of prevention services, and it is administered by trained interviewers using handheld computers. The data collection instrument is a single document, with cycle-specific sections used only during each appropriate cycle (MSM, IDU or HET). Participants are also offered an optional, anonymous HIV test.

NHBS is an important component of CDC’s integrated HIV and AIDS surveillance systems and the data have significant implications for policy, program development, and resource allocation at the state/local and national levels.

Proposed Revisions and Justification

The estimated burden of the NHBS interview is expected to remain the same under the proposed changes. The NHBS data collection instrument document has been reformatted to better accommodate data analysis and computer-assisted interviewing. The previous format was developed for paper-based interviewing and consequently lacked important information needed to create an electronic data collection application and efficiently manage and analyze data. The proposed format includes all information needed for these activities in a single document. The new data collection instrument also includes definitions of key abbreviations, terms, and preset variables. Consequently, the new format is expected to reduce resources needed to maintain the instrument, manage the data, and conduct analyses. The instrument format does not affect participants’ NHBS experience and has no impact on the overall burden of the project.

The previously approved domains of inquiry and purpose and use of the currently approved data collection have not changed, however, as the HIV risk and prevention environment evolves, changes in data collection content are needed to ensure the most relevant data are collected to address the intended purpose. These changes included modifying questions, adding new questions, and deleting less relevant questions. The rationale for the proposed changes to instrument content is explained below.

Data Collection Instrument

We propose non-substantive revision to the OMB-approved data collection instrument. The proposed changes are based on: 1) experiences with implementation of previous cycles of data collection, weighting, and analysis; 2) 2011 Department of Health and Human Services (DHHS) Data Standards; 3) recommendations from subject matter experts and CDC programs.

In total, 192 questions were deleted and 167 questions were added; in addition, minor modifications have been made to items throughout the instrument, and two sections were restructured. Whereas the total number of questions on the data collection instrument was reduced by 25, no participant is asked all items. Based on prior NHBS data, we estimate the average NHBS participant will be asked the same number of questions as with the currently approved instrument, i.e., the average burden per participant will not change. The proposed non-substantive revisions to the data collection instrument will not change the overall estimated burden. The revisions are consistent with the previously approved domains of inquiry and with the purpose and use of the currently approved data collection. The burden per participant (5 minutes for eligibility screening, 30 minutes for the MSM cycle, 54 minutes for the IDU cycle, and 39 minutes for the HET cycle) will remain the same. The number of participants and the annual reporting and recordkeeping burden will also not change.

We describe the types of proposed revisions and provide examples below. All changes are detailed in the attached document, “NHBS 2014 Summary of Changes to Data Collection.” The new instrument format precludes providing a “redlined” instrument; however, the summary of changes document includes the location of each item in the currently approved and the proposed data collection instruments, where applicable.

1. Revisions based on experiences with implementation of previous cycles of data collection, weighting, and analysis.

Many items were modified throughout the data collection instrument to reduce cognitive burden and recall bias. These changes are expected to improve the participants’ NHBS experience, but are not expected to alter burden. In the example below the response options for item ID2 have been reduced from 8 options to 4. Response options are read to participants; reducing the number of options is expected to facilitate comprehension and response. In addition, the question wording has been modified to remove the word “average,” which may not be well understand by all NHBS participants.

Current question:

ID-2. In the past 12 months, on average, how often did you inject?

READ CHOICES. CHOOSE only ONE.]

Never..….….…………………..……………………………… … 0

More than once a day…..…………………….…………… 1

Once a day….…………………………………………………… 2

More than once a week..………………….…………..... 3

Once a week…………………………............................ 4

More than once a month………………………..………. 5

Once a month…..……………………………………..……… 6

Less than once a month…..……………………………… 7

Refused to answer……………………………..…………… 77

Don’t know..………..………………………………….……… 99

Proposed question:

ID2.		In the past 12 months, when you were injecting, about how often did you inject any drug? [READ choices.]
INJOFTEN		Injection frequency past 12 months - IDU
		More than once a day	1
		Once a day	2
		More than once a week	3
		Once a week or less	4
		Don’t Know	9
		Refuse to Answer	7

2. Revisions to meet Department of Health and Human Services data requirements

Three questions measuring English and Spanish language proficiency (DM3b1, DM3b2, DM3b2spec) and 6 questions measuring disability (HC11a – HC11f) were added to comply with DHHS data standards. One previous question measuring language proficiency (DM-3b) was deleted to avoid redundancy.

3. Revisions based on recommendations from subject matter experts and CDC programs.

Many revisions to the data collection instrument resulted from the addition of a partner-by-partner (PxP) question series about sexual behavior patterns. The PxP series of questions replaces a previous sexual behavior section, which asked similar questions, but in less detail and not by partner. This change follows recommendations from consumers of information from NHBS, including subject matter experts and CDC stakeholders, and better meets needs for information to tailor HIV prevention efforts. The series collects information from participants about up to 3 sex partners they have had in the past 3 months and their sexual behaviors with them. Information on specific partners provides higher quality data and allows for collection of information critical for improved estimates of HIV risk used to allocate HIV prevention resources. Further, providing information on specific partners, rather than all partners in a given time period, is less cognitively challenging for participants and allows for more efficient questionnaire flow and data analysis. To reduce burden and redundancy, similar sexual behavior items asked in other sections were deleted. For example, the currently approved data collection instrument includes three series of 28 questions regarding participants’ last male and last female partner. These series were deleted to reduce redundancy with information collected in the PxP series about the participants’ most recent partner (male or female). To further reduce burden, the number of items asked about a participants second and third partners was limited to a subset of the items asked about the participant’s most recent partner, that is, using the proposed instrument, participants may be asked a maximum of 41 items about their most recent partner, whereas a maximum of 22 items will be asked about their second and third partners. Further, because not all participants will have had more than 1 partner in the past 3 months, not all participants will be asked the full PxP question series. Based on prior NHBS data, approximately 20% of participants will be asked about 3 partners, 30% will be asked about 2 sex partners, and 50% will be asked only about 1 partner.

4. Structural revisions to improve instrument flow and organization. Structural changes do NOT impact participant burden. The following sections were restructured:

• HIV testing (HT) – the HIV testing section has been restructured to improve flow and simplify skip logic. In the currently approved instrument, all participants are asked questions about their recent HIV testing history, concluding with questions about participants’ HIV status. Participants who report being HIV-positive are then asked follow-up questions related to HIV care and treatment. However, for HIV-positive participants, data on recent testing are not needed because testing stops after diagnosis. Further, HIV-positive participants may confuse HIV testing with viral load testing and provide inconsistent responses. In the proposed instrument, questions about participants’ HIV status are asked first and used to direct participants to the appropriate questions: HIV-negative participants are asked about their recent HIV testing history, whereas HIV-positive participants are asked questions related to HIV care and treatment.

• Social Experiences (SO) – A social experiences section has been created to house questions measuring stigma and discrimination, community tolerance, disclosure of sexual identity, and internet use that did not fit well into their previous section (Sexual Behavior).

Impact of Changes on the Estimated Burden

The proposed non-substantive revisions to the data collection instrument will not change the overall estimated burden. The revisions are consistent with the previously approved domains of inquiry and with the purpose and use of the currently approved data collection. The burden per participant (5 minutes for eligibility screening, 30 minutes for the MSM cycle, 54 minutes for the IDU cycle, and 39 minutes for the HET cycle) will remain the same. The number of participants and the annual reporting and recordkeeping burden will also not change. All other project activities and methods remain the same as in the previously approved information collection request.