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
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Modified | 0000-00-00 |
| File Created | 2021-01-23 |