PrEP Project Screener

Screener

Form Approved

OMB No. 0920-New

Expiration Date: XX/XX/XXXX

Understanding Decisions and Barriers about PrEP Use and Uptake Among Men Who Have Sex With Men

Attachment # 3a

Screener

Public reporting burden of this collection of information is estimated to average 5 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)

ID:_________________

Date: ______________

Testing Proof: Y / N

Recruiter___________

Location____________

iQual PrEP Project Screener

Narrative FAQ: Let me tell you a little about this study. Research Support Services, Emory University and IMPAQ International are conducting research on behalf of the Centers for Disease Control and Prevention (CDC) in order to better understand attitudes and behaviors in HIV prevention. The study consists of a face-to-face interview that should take about an hour of your time in a place convenient to you, as well as a web 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 can skip any questions you don’t want to answer, and you can end your participation at any time.

1. Are you 18 years of age or older? _________

1. No

2. Yes [eligible]

2. Where did you learn about this study?

1. Friend/Flyer/Online Ad

2. Clinic/Care Provider [Specify___________________________]

3. Other ________________

3. How do you describe your gender identity?

1. Male [eligible]

2. Female

3. Male-to-female transgender (MTF)

4. Female-to-male transgender (FTM)

5. Other gender identity, specify: ____________________

3a. What sex is on your original birth certificate?

1. Male [eligible]

2. Female

4. Do you consider yourself to be of Hispanic, Latino/a, or of Spanish origin?

1. Yes

2. No

97. Refused to answer

98. Don’t Know

5. Which racial group or groups do you consider yourself to be in? You may choose more than one option. [READ CHOICES. CODE 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

97. ____Refused to answer

98. ____Don’t Know

6. Are you able to read and understand English?

1. Yes [eligible]

2. No

7. What was your most recent HIV test result?

1. HIV Negative [eligible]

2. HIV Positive [ineligible]

3. Never tested [eligible]

4. Tested but didn’t receive results [eligible]

5. Indeterminate [eligible]

8. During the past 3 months, that is since [mm/yyyy], have you had anal sex with a man without using a condom?

1. Yes

2. No

97. Refused to answer

98. Don’t Know

STOP HERE IF SCREENING FOR PHASE 2 ONLY

Additional Phase one criteria:

9. In the past 6 months, that is since [mm/yyyy], have you discussed PrEP, or pre-exposure prophylaxis – a daily pill you can take to prevent HIV -- with a provider or counselor?

1. Yes

2. No

10. In the past 6 months, have you been offered PrEP by a doctor or nurse?

1. Yes  [PHASE 1]

2. No  [PHASE 2 – Skip to contact information]

11. [If yes] Did you accept or refuse the offer of PrEP?

1. Accept

2. Refuse [PHASE 1.A – Skip to question 16]

12. [If Yes] Did you fill the prescription for PrEP?

1. Yes

2. No [Skip to contact info]

13. [If Yes] How long ago did you first fill the prescription for PrEP?

__ 7 days or less

__ 1-2 weeks

__ 3-4 weeks

__ 1-3 months

__ 4-6 months

__ 7-12 months

__ 1-2 years

__ >2 years

14. [If Yes] In total, on how many days did you take the daily PrEP pill?

__ 0

__ 1

__ 2

__ 3 [<=7, eligible unsuccessful initiator]

__ 4

__ 5

__ 6

__ 7

__ 8 [8+, ineligible]

__ 9

__ 10

__ More than 10

15. Are you still taking the daily PrEP pill?

1. Yes

2. No

16. If you are eligible, are you available on (DATES) (TIMES) to participate in a focus group?

1. Yes

2. No  (IF UNABLE TO MAKE ANY OF THE TIMES/DATES, EXPLAIN THAT THEY MIGHT QUALIFY FOR AN IN-PERSON INTERVIEW)

17. If you are eligible, would you be willing to participate in an in-person interview at a time and a place convenient to you?

1. Yes

2. No

That’s all the questions I have, I need to collect some contact information now so we can reach you.

Continue to contact sheet then return here after call is finished to complete eligibility

INTERVIEWER INSTRUCTION: ELIGIBLE IF:

(All must be checked)

• R is Male

• HIV negative [Or never tested/ Verification not needed]

• 18 or older

• MSM

• Condomless anal sex in the last 3 months

• Refuser/Unsuccessful Initiators or PrEP eligible- but not offered

• Can read English

• Live or work in the area (Chicago, Atlanta, Raleigh-Durham)

• Able to complete In Depth Interview (does not sound/appear to be under the influence of drugs or alcohol/disoriented/confrontational/ has much trouble with screener questions/ angry)

FAQs Tell them more about the study:

• The purpose of this research project is to better understand attitudes and behaviors in HIV prevention.

• Funding for this study is provided by the Centers for Disease Control and Prevention (CDC).

• We expect to enroll about XX people in 3 cities across the country.

• The Interview/questionnaire should take about 90/30 minutes, depending on your answers.

• The Interview will be audio recorded so researchers can review the information—no names will be used.

• The focus group session should take about two hours.

• The focus group session will be video recorded, so researchers can review the information—no names will be used.

• You will receive a $75/$60/$20 token of appreciation.

• All information will be kept private.

• Your care or services from any clinic or organization will not be affected in any way by your decision whether or not to participate in the study.

Version : X.X OMB # XXXX-XXXX Expiration date: X/XX/XXXX Page 10 of 10