Baseline survey

HIV Knowledge, Beliefs, Attitudes, and Practices of Providers in the Southeast

(K-BAP Study)

Attachment 3a

K-BAP Provider Baseline

Screener and Survey Instrument

K-BAP HEALTHCARE PROVIDER BASELINE SURVEY SCREENER

Form Approved

OMB No. 0920-XXXX

Expiration Date: XX/XX/XXXX

Public reporting burden of this collection of information is estimated to average 30 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)

Thank you for agreeing to participate in this survey. The Centers for Disease Control and Prevention (CDC) has commissioned this special survey of providers. This is not a test, but please answer the questions as best as you can without referring to resource material. Please answer these questions as they relate to the practice where you received this survey.

SCREENER:

1. Our records indicate that you practice medicine at [PRACTICE NAME] at [ADDRESS]. Is this correct?

Yes, I practice at [PRACTICE NAME] at [ADDRESS].

No, I do not practice at [PRACTICE NAME] at [ADDRESS].

2. [If no] Please enter all zip codes of offices where you currently practice medicine: _____________

K-BAP HEALTHCARE PROVIDER BASELINE SURVEY INSTRUMENT

Thank you for agreeing to participate in this survey. The Centers for Disease Control and Prevention (CDC) has commissioned this special survey of providers. This is not a test, but please answer the questions as best as you can without referring to resource material. Please answer these questions as they relate to the practice where you received this survey.

SURVEY:

First, please tell us about yourself.

1. Please identify your clinical role?

1. Physician (MD/DO)

2. Physician Assistant

3. Nurse Practitioner (SKIP to 4)

4. Other, Specify (---) (SKIP to 4)

2. Please identify your medical specialty or subspecialty that you practice in __________(state)?

1. Internal Medicine

2. Family Medicine

3. Emergency Medicine

4. Infectious Diseases

5. OB-GYN

6. Pediatrics

7. Other, Specify (---)

3. In what year did you complete initial board certification?

(Fill in the blank or select N/A)

4. Please select the answer that best describes the setting where you primarily (≥ 50% of your time) practice medicine?

1. School or College Health Center

2. Outpatient: Hospital-based

3. Outpatient: Community Clinic

4. Outpatient: Private Practice

5. Inpatient/Hospitalist

6. Emergency Department

7. Urgent Care Center

8. Public Health Department

9. Federally Qualified Health Center (FQHC)

10. Retail Clinics (such as CVS’ Minute Clinic, Walgreens’ Healthcare Clinic, etc.)

11. Other, Specify (---)

5. Do you have American Academy of HIV Medicine (AAHIVM) specialist certification (AAHIVS)?

1. Yes

2. No

Continuing Education

6. Have you ever received training from an AIDS Training & Education Center (ATEC)?

1. Yes Date of most recent training: _________________

2. No

3. I do not remember

7. In the past 24 months, have you participated in any other CE (outside of ATEC) concerning the following topics on HIV/AIDS, STDs, or sexual history, drug/alcohol history assessment? Select all that apply.

1. HIV/AIDS

2. STDs

3. Sexual history assessment

4. Drug/alcohol history assessment

5. Cultural competency with LGBT (Lesbian, Gay, Bisexual, Transgender) patients

6. Cultural competency with racial and ethnic minorities

Collecting Patient History and Risk Assessment

8. How would you rate your training in performing the following?

	Excellent	Good	Fair	Poor	I have not received any training	N/A, I do not collect these histories
Obtain sexual history
Obtain substance use history
Conduct screening for depression

9. Do you obtain a sexual history and risk assessment from your patients? Please select the option that best characterizes your approach.

1. I routinely obtain a sexual history at the first encounter and update it on a regular (e.g., annual) basis.

2. I routinely obtain a sexual history at the first encounter and update if new information is obtained.

3. I obtain an initial sexual history as needed and update it if new information is obtained.

4. I document a sexual history only when volunteered by the patient.

5. I do not document sexual histories.

6. Other, Specify (---)

10. For what proportion of patients you see for continuous or repeated care do you perform the following?

	Most or all	More than half	About half	Less than half	Few or none
Ask about number and gender of sexual partners?
Ask about frequency and types (vaginal, anal, oral) of sex?
Explore opportunities for safer sex counseling at each visit for sexually active patients?

11. Please indicate the extent to which you agree that the following issues pose a barrier to discussing sexual education, sexual orientation, or sexual risks with your patients?

	Strongly agree	Somewhat agree	Neither agree nor disagree	Somewhat disagree	Strongly disagree
I do not have enough time.
I am not reimbursed for my time.
My patients will not feel comfortable discussing sex.
I do not feel comfortable discussing sex with some patients.
Not relevant to reason for visit.

12. [If agree about being uncomfortable discussing sex with some patients] Which of these patient characteristics make you uncomfortable discussing sex with patients? Please select all that apply.

1. Gender

2. Age

3. Race

4. Sexual orientation

5. Other, Specify (---)

13. Do you obtain a mental health history from your patients? Please select the option that best characterizes your approach.

1. I routinely obtain a mental health history at the first encounter and update it on a regular (e.g., annual) basis.

2. I routinely obtain a mental health history at the first encounter and update it if new information is obtained.

3. I obtain an initial mental health history as needed and update it if new information is obtained.

4. I document a mental health history only when volunteered by the patient.

5. I do not document mental health histories.

6. Other, Specify (---)

14. Do you obtain a substance (drug and alcohol) use history from your patients? Please select the option that best characterizes your approach.

1. I routinely obtain a substance use history at the first encounter and update it on a regular (e.g., annual) basis.

2. I routinely obtain a substance use history at the first encounter and update it if new information is obtained.

3. I obtain an initial substance use history as needed and update it if new information is obtained.

4. I document a substance use history only when volunteered by the patient.

5. I do not document substance use histories.

6. Other, Specify (---)

15. Which of the following best describes your practice on depression screening:

    1. I routinely conduct depression screening on all patients.

    2. I don’t routinely conduct depression screening on all patients. I conduct depression screening only if the patient has a personal history or family history of depression

    3. I don’t routinely conduct depression screening on all patients. I conduct depression screening only if the patient has signs or symptoms suggestive of depression.

    4. I don’t routinely conduct depression screening on all patients. I conduct depression screening if the patient has a personal history or family history of depression or if the patient has signs or symptoms suggestive of depression.

    5. I conduct depression screening in situations other than as described in choice B, C, or, D above. (please specify in what situations you would screen for depression) ___________

HIV Testing

16. Do you offer HIV testing to your patients?

1. Yes (SKIP to 17)

2. No

17. Please select the reason(s) that best describes why you do not offer HIV testing to your patients? Please select all that apply.

1. My patient population is not at risk

2. HIV testing is not standard of care for my practice type

3. HIV testing is not reimbursed

4. Patients do not have insurance

5. Patients cannot afford the test

6. I am not comfortable providing testing or discussing results

7. HIV testing is too time consuming

8. I am unsure of regulations

9. I am unsure of what test(s) to order

10. Other, Specify (---)

18. How do you offer tests for HIV? Please select the response that best characterizes your practice.

1. Repeated testing (3 – 12 months) based on patient behavior (e.g., new sexual partners, sex without condoms outside a monogamous relationship, multiple sexual partners,)

2. Routine, opt-out (You tell all patients 15 – 65 years old that you will be performing an HIV test; they may refuse) (SKIP to 19)

3. Risk-based or targeted, opt-out (If you feel the patient is at risk for acquiring HIV, you tell the patient that you will be performing an HIV test; they may refuse)

4. Risk-based or targeted, opt-in (If you feel the patient is at risk for acquiring HIV, you ask the patient if would like an HIV test; they must accept)

5. Routine, opt-in (You ask all patients 15 – 65 years old if they would like an HIV test; they must accept) (SKIP to 19)

6. Patient initiated (HIV testing is provided to any patients who request HIV testing)

7. Other, Specify (---)

19. How often do you offer HIV testing to the following patients?

	Each clinical visit	More than once per year, but not every visit	Annually	Once, docu-mented in medical record	Never, I do not conduct clinical testing, but I refer to others	Never, I do not conduct clinical testing or refer to others
Patients who are sexually active with more than one partner
Men who have sex with other men
Patients who identify as transgendered
Patients who use injection drugs
Patients that have been diagnosed with an STD
Patients with signs and symptoms of an STD

20. Do you offer rapid HIV testing, either oral swab or blood (e.g., OraQuick and Uni-Gold) in your practice?

1. Yes, it is my first-line test for all patients receiving HIV testing

2. Yes, I use this for many of my patients receiving HIV testing

3. Yes, but rarely

4. Never

21. Do you offer routine HIV testing through standard venipuncture sent to a lab?

1. Yes, it is my first-line test for all patients receiving HIV testing

2. Yes, I use this for many of my patients receiving HIV testing

3. Yes, but rarely

4. Never

22. Have you ever ordered testing specifically for acute HIV (e.g., fourth generation HIV test)?

1. Yes

2. No

STD and Hepatitis Testing

23. When a patient presents with signs and symptoms compatible with any sexually transmitted disease or a report of an STD in a sex partner, do you include a test for syphilis?

1. Yes, routinely, before STD diagnosis is confirmed

2. Yes, routinely, only after STD diagnosis is confirmed

3. Yes, occasionally

4. Rarely or Never

24. Are tests for chlamydia and/or gonorrhea from rectal specimens available in your practice?

1. Yes, culture

2. Yes, nucleic acid (DNA) tests

3. Yes, both

4. Yes, I don’t know which type

5. No

6. I don’t know

HIV Prevention through Biomedical Interventions

25. Are you familiar with the concept of providing post-exposure prophylaxis (PEP) for occupational exposure to HIV (e.g., needle stick)?

1. I have a good understanding of the concept.

2. I have a vague understanding of the concept.

3. I have heard about the concept but know little about it.

4. I have never heard about the concept.

26. Are you familiar with the concept of providing post-exposure prophylaxis (PEP) for sexual exposure to HIV?

1. I have a good understanding of the concept.

2. I have a vague understanding of the concept.

3. I have heard about the concept but know little about it.

4. I have never heard about the concept.

27. Has a patient ever requested post-exposure prophylaxis (PEP) for sexual exposure?

1. Yes

2. No

3. I do not remember

28. Have you ever prescribed post-exposure prophylaxis (PEP) for sexual exposure?

1. Yes,

2. No

3. I do not remember

29. [IF YES TO ABOVE], approximately how many patients have you prescribed post-exposure prophylaxis for sexual exposure: _______ (number)

30. Do you provide condoms to the patients in your practice?

1. No

2. Yes, by request

3. Yes, openly available

4. Yes, patients are encouraged to take condoms

5. Yes, but I’m not certain how

6. I’m not certain if condoms are available

HIV Prevention through Biomedical Interventions

31. How familiar are you with the concept of pre-exposure prophylaxis (PrEP) in order to prevent HIV infection?

1. I have a good understanding of the concept.

2. I have a vague understanding of the concept.

3. I have heard about the concept but know little about it.

4. I have never heard about the concept.

32. Has a patient ever requested pre-exposure prophylaxis (PrEP)?

1. Yes

2. No

3. I do not remember

33. Have you ever prescribed any form of pre-exposure prophylaxis (PrEP) to a patient?

1. Yes

2. No

3. I do not remember

34. [IF YES TO ABOVE] Approximately how many patients have you prescribed pre-exposure prophylaxis for sexual exposure: _______ (number)

HIV Positive Patients

35. How many patients with HIV infections do you typically care for per month?

(Fill in the blank)

36. Do you provide primary care for your HIV-infected patients (i.e., point of first contact, comprehensive care, and emphasis on prevention and coordination of care)?

1. Yes (SKIP to 37)

2. No

37. Do you provide HIV care in partnership with an Infectious Disease doctor?

1. Yes

2. No

38. Among patients for whom there are no barriers or contraindications to treatment, when would you first prescribe ART? (Select one.)

1. CD4 count <200 cells/mm3

2. CD4 count <350 cells/mm3

3. CD4 count <500 cells/mm3

4. Treat regardless of CD4 count

5. N/A, I do not prescribe ART

39. Do you routinely screen for hepatitis C among your patients living with HIV infection?

    1. Yes

    2. No

Partner Notification

40. When you diagnose someone with HIV or an STD, how do you (or your practice) handle partner notification (informing sex partners of my patient of a possible recent HIV exposure)?

1. I (or my staff) make calls to partners

2. I (or my staff) notify the Department of Health for assistance with partner notification

3. The Department of Health will automatically handle partner notification

4. I encourage my patient to notify their partners

5. Other, Specify (---)

6. My practice does not perform partner notification

Tell us about your state Department of Health

Each state/jurisdiction/city has different reporting requirements and reporting strategies. Please tell us about your state/jurisdiction/city.

41. Please tell us how your state/jurisdiction/city handles reporting HIV.

1. HIV is not a reportable disease in my state, jurisdiction, or city

2. I or someone in my practice must notify someone in my state, jurisdiction, or city.

3. I do not need to notify the state, jurisdiction, or city; the laboratory will report the diagnosis.

42. What is your PRIMARY source of information regarding HIV/AIDS and STD reporting procedures and regulations in your state?

1. More experienced colleague

2. Peer-reviewed journals

3. Professional organization (e.g., AMA, ANA, AAP, etc.)

4. AETC (AIDS Education and Training Center)

5. Staff member dedicated to the task of disease reporting

6. State or Local Department of Health notices

7. State or Local Department of Health website

8. The Centers for Disease Control and Prevention website

9. Printed resource material from the Department of Health

10. Search engine (e.g. Google, Medscape)

11. Other, Specify (---)

43. What is your PRIMARY source of information regarding medications and treatments for HIV/AIDS?

1. More experienced colleague

2. Peer-reviewed journals

3. Professional organization (e.g., AMA, ANA, AAP, etc.)

4. AETC (AIDS Education and Training Center)

5. Staff member dedicated to the task of disease reporting

6. State or Local Department of Health notices

7. State or Local Department of Health website

8. The Centers for Disease Control and Prevention website

9. Printed resource material from the Department of Health

10. Search engine (e.g. Google, Medscape)

11. Other, Specify (---)

Demographics

44. What is your age? _________

45. What sex were you assigned at birth, on your original birth certificate?

1. Male

2. Female

3. Transgender

46. How do you describe you gender identity?

1. Male

2. Female

3. Male-to-Female transgender (MTF)

4. Female-to-male transgender

5. Other gender identity

47. Which of the following best represents how you think of yourself?

1. Gay

2. Straight, this is not gay

3. Bisexual

4. Something else

5. I don’t know the answer

48. Do you consider yourself to be Hispanic or Latino/a?

1. Yes

2. No (SKIP to 47)

49. Which best describes your Hispanic ancestry? (Select all that apply.)

1. Mexican, Mexican American, Chicano/a

2. Puerto Rican

3. Cuban

4. Another Hispanic, Latino/a, Spanish origin. Please specify: ________________________

50. Which racial group or groups do you consider yourself to be in? (Select all that apply.)

1. American Indian or Alaska Native

2. Asian

3. Black or African-American

4. Native Hawaiian or other Pacific Islander

5. White

51. Do you provide any of the following Spanish language accommodations in your practice? Please select all that apply.

1. None

2. I speak Spanish fluently.

3. I have a medical translator on staff/on call.

4. I rely upon another staff member who is a fluent Spanish speaker to provide translation.

5. I use a telephone interpreter service.

6. I have Spanish language literature available.

7. Other, Specify (---)

52. Approximately what proportion of your patients fall into the following categories? The total should equal 100%.

1. American Indian or Alaska Native

2. Asian

3. Black or African-American

4. Native Hawaiian or other Pacific Islander

5. White

53. Approximately what proportion of your patients fall into the following categories? The total can equal more than 100%.

1. Women

2. Men who have sex with men

3. Men who have sex with women

4. Transgender (male to female or female to male)

5. Persons who inject drugs

Final Thoughts

54. What is the most important thing that public health partners could do to help you improve your skill in obtaining a sexual history with your patients?

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________

55. What is the most important thing that public health partners could do to help you in offering HIV/STD services?

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________

56. Are there any unique or special risk factors relating to HIV infection in your patient population?

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________

We thank you for taking the time to complete this survey for the Centers for Disease Control and Prevention. Your responses will help us to ensure better health for the people who live and work in your state.

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