Att 3s: HIV Prevention with Positives Brief Survey Instrument

Form Approved

OMB No: 0920-xxxx

Exp. Date: XX/XX/XXXX

Development of CDC’s Act Against AIDS Social Marketing Campaigns Targeting Consumers

Attachment 3s: HIV Prevention with Positives

Brief Survey Instrument

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Attachment 3d: HIV Prevention with Positives

Brief Survey Instrument

CASE ID_____________

PARTICIPANT SURVEY

We are interested in your opinions about HIV prevention. We would also like to get some additional information about you. If you’re not sure, choose an answer that comes closest to what you think might be true for each question. Please remember that your answers are private. You can choose not to answer any question and can stop at any time. When you are finished with the survey, please place it in the envelope.

HIV Testing

These first few questions are about your HIV testing history. Please remember that your answers are kept private.

1. When did you first test positive for HIV? DATE (mm/dd/yyyy):__________

₁ More than 5 years ago

₂ 5 or less years ago

₈₈ Don’t know

₉₉ Prefer not to answer

2. How often did you get tested for HIV before you tested positive?

₁ Every 0-2 months

₂ Every 3-6 months

₃ Every 7-12 months

₄ Less often than once a year

₅ Other [Specify: ______________________________________________________]

_{8 8} Don’t know

₉₉ Prefer not to answer

HIV Protective Behavioral Intentions

3. Please respond to the following questions about [HIV PREVENTION STRATEGY].

	Yes	No	Don’t know	Prefer not to answer
Do you plan to [INSERT HIV PREVENTION STRATEGY] the next time you have sex?	1	2	88	99
If your sexual partner does not want to [INSERT HIV PREVENTION STRATEGY], do you plan on insisting that the two of you [INSERT HIV PREVENTION STRATEGY]?	1	2	88	99
The next time you have sex, do you plan on talking about [INSERT HIV PREVENTION STRATEGY] with your partner?	1	2	88	99

4. How likely are you to [INSERT HIV PREVENTION STRATEGY] the next time you [INSERT BEHAVIOR/have sex]?

₁ Very unlikely

₂ Unlikely

₃ Neither unlikely or likely

₄ Likely

₅ Very likely

₈₈ Don’t know

₉₉ Prefer not to answer

Norms and Attitudes

5. Please tell us how much you agree or disagree with the following statements:

	Strongly agree	Agree	Neither agree nor disagree	Disagree	Strongly disagree	Don’t know	Prefer not to answer
Most people who are important to me think I should [INSERT HIV PREVENTION STRATEGY OR BEHAVIOR]. By important to me, we mean people like friends, family, and anyone else who is an important part of your life.	1	2	3	4	5	88	99
Most of my sexual partners [INSERT BEHAVIOR]	1	2	3	4	5	88	99
Most [gay men/people] I know] [INSERT BEHAVIOR]	1	2	3	4	5	88	99

6. On a scale from 1 to 5, where 1 is extremely bad and 5 is extremely good, how would you rate [INSERT BEHAVIOR] for [preventing/transmitting] HIV?.

₁ Extremely bad

₂ Bad

₃ Neither bad nor good

₄ Good

₅ Extremely good

_{8 8} Don’t know

₉₉ Prefer not to answer

7. On a scale from 1 to 5, where 1 is extremely harmful and 5 is extremely beneficial, how would you rate [INSERT BEHAVIOR] to prevent [getting/transmitting] HIV?

₁ Extremely harmful

₂ Harmful

₃ Neither harmful nor beneficial

₄ Beneficial

₅ Extremely beneficial

_{8 8} Don’t know

₉₉ Prefer not to answer

8. How sure are you that you could [use a condom with your next sexual partner/INSERT BEHAVIOR] if…

	Very sure I could not	Somewhat sure I could not	Slightly sure I could	Somewhat sure I could	Very sure I could	Don’t know	Prefer not to answer
you wanted to?	1	2	3	4	5	88	99
[your partner did not want to use a condom]?	1	2	3	4	5	88	99
[INSERT CIRCUMSTANCE]?	1	2	3	4	5	88	99
[INSERT CIRCUMSTANCE]?	1	2	3	4	5	88	99
[INSERT CIRCUMSTANCE]?	1	2	3	4	5	88	99

9. I feel confident in my ability to [INSERT HIV PREVENTION STRATEGY].

₁ Strongly disagree

₂ Disagree

₃ Neither agree nor disagree

₄ Agree

₅ Strongly agree

₈ Don’t know

₉₉ Prefer not to answer

Positive Attitudes toward Talking about HIV with Partners, Peers, and Family

10. Please tell us how much you agree or disagree with the following statements:

	Strongly agree	Agree	Neither agree nor disagree	Agree	Strongly agree	Don’t know	Prefer not to answer
It is important to talk about [HIV/INSERT HIV TOPIC].	1	2	3	4	5	88	99
It is important to talk about [HIV/INSERT HIVE TOPIC] with [INSERT PERSON].	1	2	3	4	5	88	99
I am confident that I can talk to [INSERT PERSON] about [HIV/INSERT HIV TOPIC].	1	2	3	4	5	88	99

KNOWLEDGE, ATTITUDES, BELIEFS

11. Please tell us how much you agree or disagree with the following statements:

	Strongly agree	Agree	Neither agree nor disagree	Disagree	Strongly disagree	Don’t know	Prefer not to answer
[INSERT BEHAVIOR] is expensive.	1	2	3	4	5	88	99
[INSERT BEHAVIOR] is inconvenient.	1	2	3	4	5	88	99
[INSERT BEHAVIOR] allows me to have sex without a condom with partners whose HIV status I don’t know/who are HIV negative/who are HIV positive]	1	2	3	4	5	88	99
[INSERT BEHAVIOR] [INSERT DESCRIPTOR]	1	2	3	4	5	88	99

12. Please tell us how much you agree or disagree with the following statements:

	Strongly agree	Agree	Neither agree or disagree	Disagree	Strongly disagree	Don’t know	Prefer not to answer
People with HIV should take their antiretroviral medications as prescribed even if it’s inconvenient or a burden.	1	2	3	4	5	88	99
People with HIV have an obligation to have safe sex with people who [do not know their status/are negative]	1	2	3	4	5	88	99
When HIV positive and HIV negative [people/men] have sex with each other, they have an equal responsibility for being safe.	1	2	3	4	5	88	99
Correct condom use is the best way to prevent HIV when having sex.	1	2	3	4	5	88	99
I think there are good ways to prevent the sexual transmission of HIV from an infected to an uninfected partner other than using condoms.	1	2	3	4	5	88	99
Because of new treatments for HIV, I’m more willing to have sex without a condom with someone [whose status I do not know/who is HIV negative who is HIV positive]	1	2	3	4	5	88	99
Because of new treatments for HIV, I think more people are taking sexual risks.	1	2	3	4	5	88	99
If my viral load is undetectable, I cannot give someone HIV.	1	2	3	4	5	88	99

13. About how often do you tell new sex partners that you are HIV positive?

₁ All of the time

₂ Most of the time

₃ Some of the time

₄ Never

₈₈ Don’t know

₉₉ Prefer not to answer

ADHERENCE

14. In the past 30 days, about how often did you take your HIV medicine - antiretroviral therapy (ART) - as prescribed by your doctor?

₁ All of the time

₂ Most of the time

₃ Some of the time

₄ Never

_{8 8} Don’t know

₉₉ Prefer not to answer

15. On a scale from 1 to 5, where 1 is extremely harmful and 5 is extremely beneficial, how would you rate taking medicines to treat HIV infection (e.g. antiretroviral therapy or ART) to prevent HIV transmission?

₁ Extremely harmful

₂ Harmful

₃ Neither harmful nor beneficial

₄ Beneficial

₅ Extremely beneficial

_{8 8} Don’t know

₉₉ Prefer not to answer

People may miss taking their HIV medications for various reasons. Here is a list of possible reasons why you may have missed taking your HIV medications in the past 30 days.

16. In the past 30 days, did you miss taking your HIV medications because you…

	Yes	No	Don’t know	Prefer not to answer
Were away from home	1	2	88	99
Were busy with other things	1	2	88	99
Simply forgot	1	2	88	99
Felt you didn’t need to take it every day	1	2	88	99
Didn’t like the way they made you feel (side effects)	1	2	88	99
Did not want others to notice you taking medication	1	2	88	99
Had a change in your daily routine	1	2	88	99
Felt like the drug was toxic/harmful	1	2	88	99
Fell asleep/slept through dose time	1	2	88	99
Felt sick or ill	1	2	88	99
Felt depressed/overwhelmed	1	2	88	99
Had problem taking medication at certain times	1	2	88	99
Ran out of medication	1	2	88	99
Didn’t know how to get a refill	1	2	88	99
Missed an appointment with my health care provider	1	2	88	99
Went to jail or prison	1	2	88	99
Were released from jail or prison	1	2	88	99
Felt good	1	2	88	99
Were drunk or high	1	2	88	99
Didn’t want to deal with it	1	2	88	99
Other (Specify)____________________	1	2	88	99

17. Would you be willing to receive a [text/email] reminder each day to take your HIV medications

₁ Yes

₂ No

₈₈ Don’t know

₉₉ Prefer not to answer

17. Would you be willing to download an app to a smartphone or other mobile device that would send you reminders each day to take your HIV medications?

₁ Yes

₂ No

_{8 8} Don’t know

₉₉ Prefer not to answer

THE END

Thank you for answering these questions. Please place the survey in the envelope provided. Give the survey and your consent form to the interviewer when you go into the interview room. The interviewer will not see your responses to these questions.

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