Screener

2PM Screener

Qualitative research to understand consumer opinions and preferences for emerging

HIV prevention products among MSM in Atlanta, Houston, and Miami

Attachment 2a: Screener

Date: ___________

Study ID: _________

Screener Initials: ________

Form Approved

OMB No: 0920-1091

Exp. Date: 09/30/2021

Privacy Act Statement:

This information is collected under the authority of the Public Health Service Act, Section 301, "Research and Investigation," (42 U.S.C. 241); which discuss authority to maintain data and provide privacy for health research and related activities (42 U.S.C. 242 b, k, and m(d)). This information is also being collected in conjunction with the provisions of the Government Paperwork Elimination Act and the Paperwork Reduction Act (PRA). This information will only be used by the Centers for Disease Control and Prevention (CDC) staff to advance understanding of consumer preferences about emerging biomedical products designed to prevent HIV transmission among men who have sex with men.

Public reporting burden of this collection of information is estimated to average 10 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 (0920-1091)

iQual 2PM Screener

My name is __________ and let me tell you a little about the study. I am part of a study team that wants to learn about preferences and opinions regarding emerging HIV prevention products. This study consists of a face-to-face interview or a focus group interview that should take about an hour to an hour and a half of your time in a place convenient to you, as well as a brief paper survey that will be completed at the time of the interview.

I have a few questions for you to make sure you qualify for the study. All of your answers to these questions are voluntary. You do not have to answer any questions you do not want to answer. You may stop at any time. Just let me know you no longer wish to answer any questions, and I will stop. If you do not qualify for this study, the information you have given me will be destroyed. Your answers will be identified by a study identification number, not your name.

Do you have any questions before we proceed? Do I have your permission to proceed?

[SCREENER DIRECTIONS: DO NOT READ THE OPTIONS IN ALL CAPS; THESE ARE IN CASE THE READ ALL THE QUESTIONS EVEN IF INELIGIBILITY IS ESTABLISHED BEFORE YOU REACH THE LAST QUESTION. PARTICIPANT PROVIDES AN ANSWER NOT SPELLED OUT IN THE OPTIONS YOU ARE TO READ. ELIGIBILITY CRITERIA: 1)18 YEARS AND OLDER, 2) LIVE IN ATLANTA, HOUSTON, OR MIAMI MSA, 3)CAN READ AND UNDERSTAND ENGLISH, 4) HAVE HEARD OF PREP, 5) ASSIGNED SEX AT BIRTH AS MALE AND CURRENTLY DESCRIBES SELF AS MALE, 6) HIV NEGATIVE, 7) HAS HAD UNPROTECTED ANAL SEX WITHIN THE PAST 6 MONTHS AND/OR WAS DIAGNOSED WITH A BACTERIAL STI IN THE LAST 6 MONTHS, 8) NOT CURRENTLY PARTICIPATING IN ANY HIV PREVENTION STUDIES OR PROGRAMS], AND 9) IDENTIFIES AS HISPANIC/LATINO (ANY RACE), BLACK (NON-HISPANIC/LATINO), OR WHITE (NON-HISPANIC/LATINO)

S1. How old are you? _____ [18+ eligible]

S2. What is the zip code of your current place of residence? __ __ __ __ __ [eligible Atlanta, Houston, and Miami MSA zips]

S3. Are you able to read and understand English?

☐ Yes [eligible]

☐ No

S4. What sex were you assigned at birth, on your original birth certificate?

☐ Male [eligible]

☐ Female

☐ REFUSED

☐ DON’T KNOW

S5. Do you currently describe yourself as male, female, or transgender?

☐ Male [eligible]

☐ Female

☐ Transgender

☐ NONE OF THESE

S6. Just to confirm, you were assigned {FILL} at birth and now describe yourself as {FILL}. Is that correct?

☐ Yes [eligible]

☐ No

☐ REFUSED

☐ DON’T KNOW

S7. Which of the following best describe your ethnicity?

1 Hispanic or Latino

0 Not Hispanic or Latino

S8. What race, or races, do you consider yourself to be? [READ CHOICES. CODE ALL THAT APPLY.]

☐ American Indian or Alaska Native

☐ Asian

☐ Black or African American

☐ Native Hawaiian or Other Pacific Islander

☐ White

S9. In the past 6 months, that is since [MM/YYYY], have you had anal sex with a man without using a condom?

☐ Yes [eligible]

☐ No

S10. In the past 6 months, that is since [MM/YYYY], have you been diagnosed with a STI like chlamydia, gonorrhea, or syphilis?

☐ Yes [eligible]

☐ No

S11. Have you tested for HIV within the last 12 months?

☐ Yes [eligible]

☐ No

S12. What was your most recent HIV test result?

☐ HIV Negative [eligible]

☐ HIV Positive

☐ Never tested

☐ Tested but didn’t receive results

☐ Indeterminate

S13. Have you heard of PrEP, or pre-exposure prophylaxis, a daily pill to prevent HIV infection?

☐ Yes [eligible]

☐ No (Screener is completed and person is ineligible )

S12a. [If Yes…] Are you currently taking PrEP to prevent HIV infection?

☐ Yes ☐ No

S14. Are you currently involved in any HIV prevention studies or educational programs, as staff or a participant?

☐ Yes

☐ No [eligible]

[If eligible: script for requesting contact info and setting up assessment appointment]

If ineligible: “Thank you for your time. Unfortunately, you’re not eligible to participate”