Form Approved
OMB No.: 0920-0920
Exp. Date: 11/30/2021
Development of Messages for the Let’s Stop HIV Together National Campaign
Attachment 3: Web-based Survey Instrument
CDC estimates the average public reporting burden for this collection of information as 30 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 Information Collection Review Office, 1600 Clifton Road NE, SD-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0920).
Development of Messages for the Act Against AIDS National Testing Campaign:
Let’s Stop HIV Together
Web-based Survey Instrument
SCRIPT: Before we start, please note that you cannot go back in the survey. If you click next too quickly or make a mistake, please just continue with the survey.
If you attempt to use the back button on your browser, you will receive an error and not be able to complete the study.
Before today, had you ever heard of the Centers for Disease Control and Prevention (CDC)?
1 Yes
2 No
88 Don’t know
99 Prefer not to answer
How much do you disagree or agree with the following statement: I trust the Centers for Disease Control and Prevention (CDC) as a source of information about HIV?
1 Strongly disagree
2 Disagree
3 Neither disagree nor agree
4 Agree
5 Strongly agree
99 Prefer not to answer
How often do you visit the CDC website to find information about HIV?
1 Never
2 Rarely
3 Sometimes
4 Often
5 Very often
99 Prefer not to answer
Thinking about the sex you’ve had over the past [6 months/12 months], do you consider yourself to be at high, medium or low risk for [getting/transmitting] HIV?
1 High risk
2 Medium risk
3 Low risk
88 Don’t know
99 Prefer not to answer
You indicated that you consider yourself to be at [insert response from Q4]. What are some reasons for this? [OPEN-ENDED]
99 Prefer not to answer.
Bearing in mind the different ways people can [get/transmit] HIV, how concerned are you about you, personally, [getting/transmitting] HIV?
1 Not at all concerned
2 Not very concerned
3 Somewhat concerned
4 Very concerned
88 Don’t know
99 Prefer not to answer
Have you ever, even once, used a needle to inject any drug that was not prescribed for you or that you took only for the experience or feeling it caused?
1 Yes
2 No
88 Don’t know
99 Prefer not to answer
In the past [6 months/12 months], have you used a needle to inject any drug that was not prescribed for you or that you took only for the experience or feeling it caused?
1 Yes
2 No
88 Don’t know
[PROGRAMMER: Ask Q9 if S12 (from Screener) equals Yes (1)]
You indicated that you had sex in the past [6 months/12 months]without a condom. For what reasons have you not used condoms for sex?[OPEN-ENDED]
99 Prefer not to answer.
Please indicate how much you disagree or agree with the following statements. Using condoms to prevent getting HIV….
[PROGRAMMER: RANDOMIZE ORDER OF ITEMS] |
Strongly disagree |
Disagree |
Neither disagree nor agree |
Agree |
Strongly agree |
Don’t know |
Prefer not to answer |
a. is expensive. |
1 |
2 |
3 |
4 |
5 |
88 |
99 |
b. is inconvenient. |
1 |
2 |
3 |
4 |
5 |
88 |
99 |
c. is for someone like me. |
1 |
2 |
3 |
4 |
5 |
88 |
99 |
d. [INSERT] |
1 |
2 |
3 |
4 |
5 |
88 |
99 |
Please indicate how much you disagree or agree with the following statements.
Statement |
Strongly disagree |
Disagree |
Neither Disagree nor Agree |
Agree |
Strongly agree |
Prefer not to answer |
a. [Condoms] protect against other STDs like syphilis and gonorrhea. |
1 |
2 |
3 |
4 |
5 |
99 |
b. [Correct condom use] is the best way to prevent HIV when having sex. |
1 |
2 |
3 |
4 |
5 |
99 |
c. [Condoms] are an effective HIV prevention option [when used correctly and consistently]. |
1 |
2 |
3 |
4 |
5 |
99 |
d. Because of [condoms], I am more willing to have sex with someone who has HIV. |
1 |
2 |
3 |
4 |
5 |
99 |
e. Because of [condoms], I think more people are taking sexual risks. |
1 |
2 |
3 |
4 |
5 |
99 |
f. [INSERT] |
1 |
2 |
3 |
4 |
5 |
99 |
Please tell us how much you disagree or agree with each of the following statements:
Statement |
Strongly disagree |
Disagree |
Neither disagree nor agree |
Agree |
Strongly agree |
Prefer not to answer |
|
1 |
2 |
3 |
4 |
5 |
99 |
|
1 |
2 |
3 |
4 |
5 |
99 |
|
1 |
2 |
3 |
4 |
5 |
99 |
|
1 |
2 |
3 |
4 |
5 |
99 |
Before today, have you ever heard of people who do not have HIV taking HIV medicines (PrEP: also known as Truvada or Descovy) daily, to keep from getting HIV?
1 Yes
2 No
88 Don’t know
99 Prefer not to answer
On a scale from 1 to 5, where 1 is extremely harmful and 5 is extremely beneficial, how would you rate taking PrEP daily as prescribed by a doctor to prevent getting HIV?
1 Extremely harmful
2 Harmful
3 Neither harmful or beneficial
4 Beneficial
5 Extremely beneficial
88 Don’t know
99 Prefer not to answer
[HIV-negative only] [Have you ever taken/Are you currently taking/Have you taken within the last 6 months/Have you taken within the last 12 months] PrEP to prevent getting HIV?
1 Yes
2 No
88 Don’t know
99 Prefer not to answer
[PROGRAMMER: Ask Q16 if Q15 is equal to No (2) or Don’t Know (88)]
[HIV-negative only] You indicated that you [have never used/are not currently using] PrEP to prevent getting HIV. For what reasons are you not using PrEP? [OPEN-ENDED]
99 Prefer not to answer.
[PROGRAMMER: Ask Q17 if Q15 is equal to Yes (1)]
[HIV-negative only] When did you first start taking PrEP to prevent getting HIV?
1 0 to 3 months ago
2 4 to 6 months ago
3 7 to 12 months ago
4 More than 12 months ago
88 Don’t know
99 Prefer not to answer
[HIV-negative only] I feel confident in my ability to take PrEP as prescribed by my doctor to prevent getting HIV.
1 Strongly agree
2 Agree
3 Neither disagree nor agree
4 Disagree
5 Strongly disagree
88 Don’t know
99 Prefer not to answer
[HIV-negative only] Please indicate how much you disagree or agree with the following statements. Taking PrEP to prevent getting HIV….
[PROGRAMMER: RANDOMIZE ORDER OF ITEMS] |
Strongly disagree |
Disagree |
Neither disagree nor agree |
Agree |
Strongly agree |
Don’t know |
Prefer not to answer |
a. is expensive. |
1 |
2 |
3 |
4 |
5 |
88 |
99 |
b. is inconvenient. |
1 |
2 |
3 |
4 |
5 |
88 |
99 |
c. allows me to have sex without a condom with partners who are HIV positive. |
1 |
2 |
3 |
4 |
5 |
88 |
99 |
d. is for someone like me. |
1 |
2 |
3 |
4 |
5 |
88 |
99 |
e. [INSERT] |
1 |
2 |
3 |
4 |
5 |
88 |
99 |
Please indicate how much you disagree or agree with the following statements.
Statement |
Strongly disagree |
Disagree |
Neither Disagree nor Agree |
Agree |
Strongly agree |
Prefer not to answer |
a. [PrEP] protects against other STDs like syphilis and gonorrhea. |
1 |
2 |
3 |
4 |
5 |
99 |
b. [PrEP] is the best way to prevent HIV when having sex. |
1 |
2 |
3 |
4 |
5 |
99 |
c. [PrEP] is an effective HIV prevention option [when taken every day as prescribed]. |
1 |
2 |
3 |
4 |
5 |
99 |
d. Because of [PrEP], I am more willing to have sex with someone who has HIV. |
1 |
2 |
3 |
4 |
5 |
99 |
e. Because of [PrEP], I think more people are taking sexual risks. |
1 |
2 |
3 |
4 |
5 |
99 |
f. [INSERT] |
1 |
2 |
3 |
4 |
5 |
99 |
Please tell us how much you disagree or agree with each of the following statements:
Statement |
Strongly disagree |
Disagree |
Neither disagree nor agree |
Agree |
Strongly agree |
Prefer not to answer |
|
1 |
2 |
3 |
4 |
5 |
99 |
|
1 |
2 |
3 |
4 |
5 |
99 |
|
1 |
2 |
3 |
4 |
5 |
99 |
|
1 |
2 |
3 |
4 |
5 |
99 |
[HIV-positive only] When did you first test positive for HIV?
Date (mm/yyyy) ____ ______
[HIV-positive only] About how often do you tell new sex partners that you have HIV?
1 Never
2 Some of the time
3 Most of the time
4 Always
88 Don’t know
99 Prefer not to answer
[HIV-postive only] Please indicate how much you disagree or agree with the following statements. Taking HIV medicine (antiretroviral therapy or ART) as prescribed by a doctor to treat HIV….
[PROGRAMMER: RANDOMIZE ORDER OF ITEMS] |
Strongly disagree |
Disagree |
Neither disagree nor agree |
Agree |
Strongly agree |
Don’t know |
Prefer not to answer |
a. is expensive. |
1 |
2 |
3 |
4 |
5 |
88 |
99 |
b. is inconvenient. |
1 |
2 |
3 |
4 |
5 |
88 |
99 |
c. allows me to have sex without a condom with partners who are HIV negative. |
1 |
2 |
3 |
4 |
5 |
88 |
99 |
d. is for someone like me. |
1 |
2 |
3 |
4 |
5 |
88 |
99 |
e. [INSERT] |
1 |
2 |
3 |
4 |
5 |
88 |
99 |
[HIV-positive only] On a scale from 1 to 5, where 1 is extremely harmful and 5 is extremely beneficial, how would you rate taking HIV medicine (antiretroviral therapy or ART) daily as prescribed by a doctor to treat HIV?
1 Extremely harmful
2 Harmful
3 Neither harmful or beneficial
4 Beneficial
5 Extremely beneficial
88 Don’t know
99 Prefer not to answer
[HIV-positive only] Are you currently taking HIV medicine (antiretroviral therapy or ART) as prescribed by a doctor to treat HIV?
1 Yes
2 No
88 Don’t know
99 Prefer not to answer
[PROGRAMMER: Ask Q27 if Q26 is equal to No (2) or Don’t Know (88)]
[HIV-positive only] You indicated that you are not currently taking HIV medicine (or ART). For what reasons are you not using ART? [OPEN-ENDED]
99 Prefer not to answer.
[HIV-positive only] When did you first start taking HIV medicine (antiretroviral therapy or ART) as prescribed by a doctor to treat HIV?
1 0 to 3 months ago
2 4 to 6 months ago
3 7 to 12 months ago
4 More than 12 months ago
88 Don’t know
99 Prefer not to answer
[HIV-positive only] In the past [30 days/6 months/12 months], about how often did you take your HIV medicine (antiretroviral therapy or ART) as prescribed by your doctor?
1 Never
2 Some of the time
3 Most of the time
4 All of the time
88 Don’t know
99 Prefer not to answer
[HIV-positive only] I feel confident in my ability to take my HIV medicine (antiretroviral therapy or ART) as prescribed by my doctor to treat HIV.
1 Strongly agree
2 Agree
3 Neither disagree nor agree
4 Disagree
5 Strongly disagree
88 Don’t know
99 Prefer not to answer
[HIV-positive only] To your knowledge, has your doctor (or another provider) ever ordered a viral load test for you? This would have involved drawing your blood.
1 Yes
2 No
88 Don’t know
99 Prefer not to answer
[PROGRAMMER: Ask Q32-34 if Q31 is equal to Yes (1)]
[HIV-positive only] To your knowledge, what was the result of your last viral load test? If you were undetectable, please put "0." If you're not sure, please estimate. [OPEN-ENDED]
99 Prefer not to answer.
[HIV-positive only] Are you currently virally suppressed (viral load is less than 200 copies of HIV per milliliter of blood)?
1 Yes
2 No
88 Don’t know
99 Prefer not to answer
[HIV-positive only] How would you describe your current viral load based on your most recent viral load test? [select all that apply]
1 I have an undetectable viral load.
2 I am virally suppressed.
3 My viral load is detectable, and I am not virally suppressed.
88 Don’t know
99 Prefer not to answer
[PROGRAMMER: Ask Q35 if Q32 is 0 OR Q33=1 OR Q34=1 or 2]
[HIV-positive only] Have you ever told a sex partner that you have an undetectable viral load?
1 Yes
2 No
88 Don’t know
99 Prefer not to answer
[HIV-positive only] Have you heard that if you have an undetectable viral load, you will not pass on HIV to sexual partners?
1 Yes
2 No
88 Don’t know
99 Prefer not to answer
[HIV-postive only] Please indicate how much you disagree or agree with the following statements.
[PROGRAMMER: RANDOMIZE ORDER OF ITEMS] |
Strongly disagree |
Disagree |
Neither disagree nor agree |
Agree |
Strongly agree |
Don’t know |
Prefer not to answer |
a. If I have an undetectable HIV viral load, I am more likely to have unprotected sex. |
1 |
2 |
3 |
4 |
5 |
88 |
99 |
b. Having an undetectable HIV viral load means I can worry less about having to use condoms. |
1 |
2 |
3 |
4 |
5 |
88 |
99 |
c. [INSERT] |
1 |
2 |
3 |
4 |
5 |
88 |
99 |
Script: Next we would like to ask you some questions about communication and communicating with your partner(s).
How often do you think that your friends and other people close to you discuss ways to prevent HIV with their sexual partner(s)?
1 Never
2 Rarely
3 Sometimes
4 Often
5 Very often
99 Prefer not to answer
[PROGRAMMER: Ask Q39-41 if S13=Yes (1) from Screener)]
In the past [6 months/12 months], how often have you had one-on-one conversations with your current main sexual partner about ways to prevent HIV?
1 Never
2 Rarely
3 Sometimes
4 Often
5 Very often
99 Prefer not to answer
How sure are you that you could have one-on-one conversations with a main sexual partner about ways to prevent HIV?
1 Very sure
2 Somewhat sure
3 Neither sure nor unsure
4 Somewhat unsure
5 Very unsure
99 Prefer not to answer
Talking to a main sexual partner about ways to prevent HIV would be…
1 Very good
2 Somewhat good
3 Neither good nor bad
4 Somewhat bad
5 Very bad
99 Prefer not to answer
[PROGRAMMER: Ask Q42-44 if S16 is not equal to 0 (from Screener).]
In the past [6 months/12 months], how often have you had one-on-one conversations with a casual sexual partner about ways to prevent HIV?
1 Never
2 Rarely
3 Sometimes
4 Often
5 Very often
99 Prefer not to answer
How sure are you that you could have one-on-one conversations with a casual sexual partner about ways to prevent HIV?
1 Very sure
2 Somewhat sure
3 Neither sure nor unsure
4 Somewhat unsure
5 Very unsure
99 Prefer not to answer
Talking to a casual sexual partner about ways to prevent HIV would be…
1 Very good
2 Somewhat good
3 Neither good nor bad
4 Somewhat bad
5 Very bad
99 Prefer not to answer
Please tell us how much you disagree or agree with each of the following statements:
Statement |
Strongly disagree |
Disagree |
Neither disagree nor agree |
Agree |
Strongly agree |
Prefer not to answer |
|
1 |
2 |
3 |
4 |
5 |
99 |
|
1 |
2 |
3 |
4 |
5 |
99 |
|
1 |
2 |
3 |
4 |
5 |
99 |
|
1 |
2 |
3 |
4 |
5 |
99 |
|
1 |
2 |
3 |
4 |
5 |
99 |
|
1 |
2 |
3 |
4 |
5 |
99 |
|
1 |
2 |
3 |
4 |
5 |
99 |
Please tell us how likely it is that you will do the following in the next [6 months/12 months].
Statement |
Very unlikely |
Some-what unlikely |
Neither unlikely nor likely |
Some-what likely |
Very likely |
Prefer not to answer |
|
1 |
2 |
3 |
4 |
5 |
99 |
|
1 |
2 |
3 |
4 |
5 |
99 |
|
1 |
2 |
3 |
4 |
5 |
99 |
|
1 |
2 |
3 |
4 |
5 |
99 |
SCRIPT: We’d now like to ask you some questions about some campaign advertising that you may or may not have seen over the past [6 months/12 months] [Self-reported exposure to specific Let’s Stop HIV Together and other HIV preventioncampaigns]
Please complete the following sentence if you have heard or seen this campaign.
Let’s _________ HIV ________.
Ready, Set, ______________.
Greater Than ______________.
Undetectable =______________.
[INSERT]
In the past [6 months/12 months], did you see or hear the following campaign slogans or messages? Check all that apply.
[PROGRAMMER: RANDOMIZE ORDER OF ITEMS] |
Yes |
No |
Don’t know/ Can’t recall |
Prefer not to answer |
|
1 |
2 |
8 |
99 |
|
1 |
2 |
8 |
99 |
|
1 |
2 |
8 |
99 |
|
1 |
2 |
8 |
99 |
|
1 |
2 |
8 |
99 |
|
1 |
2 |
8 |
99 |
You said you saw or heard a(n) [INSERT CAMPAIGN NAME] campaign slogan or message. On a scale of 1 to 5, where 1 means “not effective” and 5 means “very effective,” how effective do you think this campaign slogan or message is [at INSERT BEHAVIOR]?
Not effective |
2 |
3 |
4 |
Very effective |
Prefer not to answer |
2 |
3 |
4 |
5 |
6 |
99 |
`
In the past [6 months/12 months], how often did you see or hear campaign slogans or messages for [INSERT CAMPAIGN NAME]?
1 Never
2 Rarely
3 Sometimes
4 Often
5 Very often
99 Prefer not to answer
[Ad Receptivity]
SCRIPT: Now we are going to show you some ads that could be part of a campaign about HIV. We will show you [insert number] ads, one at a time, and will ask you some questions to get your initial reactions to and feedback about each ad.
[ROTATE THE ORDER OF THE AD PRESENTATION]
Please tell us how much you disagree or agree with each of the following statements about the ad.
[INSERT AD]
[PROGRAMMER: RANDOMIZE ORDER OF ITEMS] |
Strongly disagree |
Disagree |
Neither Disagree nor Agree |
Agree |
Strongly Agree |
Prefer not to answer |
|
1 |
2 |
3 |
4 |
5 |
99 |
|
1 |
2 |
3 |
4 |
5 |
99 |
|
1 |
2 |
3 |
4 |
5 |
99 |
|
1 |
2 |
3 |
4 |
5 |
99 |
|
1 |
2 |
3 |
4 |
5 |
99 |
|
1 |
2 |
3 |
4 |
5 |
99 |
|
1 |
2 |
3 |
4 |
5 |
99 |
|
1 |
2 |
3 |
4 |
5 |
99 |
|
1 |
2 |
3 |
4 |
5 |
99 |
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1 |
2 |
3 |
4 |
5 |
99 |
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1 |
2 |
3 |
4 |
5 |
99 |
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1 |
2 |
3 |
4 |
5 |
99 |
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1 |
2 |
3 |
4 |
5 |
99 |
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1 |
2 |
3 |
4 |
5 |
99 |
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1 |
2 |
3 |
4 |
5 |
99 |
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1 |
2 |
3 |
4 |
5 |
99 |
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1 |
2 |
3 |
4 |
5 |
99 |
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1 |
2 |
3 |
4 |
5 |
99 |
|
1 |
2 |
3 |
4 |
5 |
99 |
[PROGRAMMER: ASK Q52 IF Q51b, d, j,k, n= “AGREE” OR “STRONGLY AGREE”]
How would you change this ad to make it better (words/language, image/people, etc.)? [OPEN-ENDED]
99 Prefer not to answer.
[PROGRAMMER: ASK Q53 IF Q51m= “AGREE” OR “STRONGLY AGREE”]
You indicated that you liked the ad. What did you like about the ad? [OPEN-ENDED]
99 Prefer not to answer
Overall, what do you think that this ad is trying to say? [OPEN-ENDED]
99 Prefer not to answer
[REPEAT FOR ALL EXECUTIONS. ROTATE EXECUTIONS]
Now, we are going to show you [insert number] ads.
Please rank the ads from 1 to [insert number], where 1 is the ad [that you most prefer] and [X] is the ad [that you least prefer].
[INSERT RANKING EXERCISE HERE]
Now, we are going to show you [insert number] messages that might appear in campaign ads.
[RANDOMLY PRESENT EACH OF THE X MESSAGES BELOW]
Please tell us how much you disagree or agree with each of the following statements about the message. [INSERT MESSAGE]
Statement |
Strongly disagree |
Disagree |
Neither Disagree nor Agree |
Agree |
Strongly Agree |
Prefer not to answer |
a) I liked this message. |
1 |
2 |
3 |
4 |
5 |
99 |
b) This message was easy to understand. |
1 |
2 |
3 |
4 |
5 |
99 |
c) This message would motivate me to [insert]. |
1 |
2 |
3 |
4 |
5 |
99 |
d) I believe this message. |
1 |
2 |
3 |
4 |
5 |
99 |
e) This message was written for someone like me. |
1 |
2 |
3 |
4 |
5 |
99 |
f) [INSERT] |
1 |
2 |
3 |
4 |
5 |
99 |
[PROGRAMMER: ASK Q57 IF Q56C= “DISAGREE” OR “STRONGLY DISAGREE”]
You indicated that the message is not motivating. What would you change about the message to to make it more motivating to you? [OPEN-ENDED]
99 Prefer not to answer
Please explain what, if anything, you did not like about this message. [OPEN-ENDED]
99 Prefer not to answer
Please explain what, if anything, you liked about this message. [OPEN-ENDED]
99 Prefer not to answer
[DO NOT FORCE RESPONSE FOR EITHER ITEM ABOVE]
[INSERT MESSAGE OPTIONS HERE]
Now, we are going to show you [insert number] taglines that might appear in future ads and ask you some questions about the taglines.
[RANDOMLY PRESENT EACH OF THE X TAGLINES BELOW]
Please tell us how much you disagree or agree with each of the following statements about the tagline. [INSERT TAGLINE]
[PROGRAMMER: RANDOMIZE ORDER OF ITEMS] |
Strongly disagree |
Disagree |
Neither Disagree nor Agree |
Agree |
Strongly Agree |
Prefer not to answer |
|
1 |
2 |
3 |
4 |
5 |
99 |
|
1 |
2 |
3 |
4 |
5 |
99 |
|
1 |
2 |
3 |
4 |
5 |
99 |
[INSERT TAGLINE OPTIONS HERE]
[PERCEIVED NORMS]
SCRIPT: This section asks questions about how the people in your life think and feel about HIV.
Please tell us how much you disagree or agree with each of the following statements. By “people who are important to me,” we mean sexual partners, friends, family, and anyone else who is an important part of your life or who you respect.
[PROGRAMMER: RANDOMIZE ORDER OF ITEMS] |
Strongly disagree |
Disagree |
Neither Disagree nor agree |
Agree |
Strongly agree |
Prefer not to answer |
|
1 |
2 |
3 |
4 |
5 |
99 |
|
1 |
2 |
3 |
4 |
5 |
99 |
|
1 |
2 |
3 |
4 |
5 |
99 |
|
1 |
2 |
3 |
4 |
5 |
99 |
|
1 |
2 |
3 |
4 |
5 |
99 |
|
1 |
2 |
3 |
4 |
5 |
99 |
|
1 |
2 |
3 |
4 |
5 |
99 |
[Beliefs]
Please indicate how much you disagree or agree with the following statements.
Statement |
Strongly disagree |
Disagree |
Neither Disagree nor Agree |
Agree |
Strongly agree |
Prefer not to answer |
a. [INSERT] protects against other STDs like syphilis and gonorrhea. |
1 |
2 |
3 |
4 |
5 |
99 |
b. [INSERT] is the best way to prevent HIV when having sex. |
1 |
2 |
3 |
4 |
5 |
99 |
c. [INSERT] is an effective HIV prevention option [when taken every day as prescribed]. |
1 |
2 |
3 |
4 |
5 |
99 |
d. Because of [INSERT], I am more willing to have sex with someone who has HIV. |
1 |
2 |
3 |
4 |
5 |
99 |
e. Because of [INSERT], I think more people are taking sexual risks. |
1 |
2 |
3 |
4 |
5 |
99 |
f. Treatment and support programs are available to people in my community who might test positive for HIV. |
1 |
2 |
3 |
4 |
5 |
99 |
g. If a person with HIV has an undetectable viral load, there is effectively no risk of that person transmitting HIV to a sex partner. |
1 |
2 |
3 |
4 |
5 |
99 |
h. HIV is an important health problem facing this nation today. |
1 |
2 |
3 |
4 |
5 |
99 |
i. [INSERT] |
1 |
2 |
3 |
4 |
5 |
99 |
[Self-Efficacy]
Please tell us how much you disagree or agree with each of the following statements:
Statement |
Strongly disagree |
Disagree |
Neither disagree nor agree |
Agree |
Strongly agree |
Prefer not to answer |
|
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Before today, have you ever heard of people who do not have HIV taking HIV medicines (nPEP or non-occupational post-exposure prophylaxis) after they may have been exposed to HIV through sex or needle-sharing, to keep from getting HIV?
1 Yes
2 No
88 Don’t know
99 Prefer not to answer
In the past [6 months/12 months], how often did you use your HIV status and your partner’s HIV status to determine which sexual roles (i.e., insertive/top or receptive/bottom) or activities (i.e., oral and anal sex) you would engage in?
1 Never
2 Occasionally
3 Usually
4 Always
88 Don’t know
99 Prefer not to answer
Before today, have you ever heard of [insert]?
1 Yes
2 No
88 Don’t know
99 Prefer not to answer
In the past [6 months/12 months], how often did you [insert]?
1 Never
2 Occasionally
3 Usually
4 Always
88 Don’t know
99 Prefer not to answer
SCRIPT: This section asks questions about HIV self-testing and your experiences with HIV self-testing. HIV self-testing (also called “home HIV testing” or “in-home HIV testing”) allows people to take an HIV test in their own home or other private location. There are two types of HIV self-testing:
Home Access® HIV-1 Test System (you prick your finger, collect a blood sample on a card and mail that card to a lab for testing, you get your results anonymously by phone)OraQuick® In-Home HIV Test (you collect your own oral fluid sample by swabbing your mouth, use the testing device yourself and read test results within 20 minutes)
If any test were to come back positive, you would be able to call a toll-free, 24-hour hotline and get immediate counseling.
Before today, have you ever heard about HIV self-testing?
1 Yes
2 No
99 Prefer not to answer
Have you ever used an HIV self-test to test yourself or someone else? Select all that apply.
1 Yes, I have used one to test myself
2 Yes, I have used one to test someone else
3 No, I have never used one
99 I prefer not to answer
IF Q69 = Yes, ask Q70 -73.
Which of these HIV self-tests have you used? Select all that apply.
1 Home Access® HIV-1 Test System (where you prick your finger, collect a blood sample on a card and mail that card to a lab for testing)
2 OraQuick® In-Home HIV Test (where you collect your own oral fluid sample by swabbing your mouth, use the testing device yourself and read test results within 20 minutes)
3 [INSERT]
4 Other HIV self-test (Specify__________)
88 I don’t remember
99 I prefer not to answer
Where did you get your HIV self-test kit?
1 I bought it online
2 I bought it in a pharmacy or other store
3 I got it from a clinic or doctor’s office
4 I got it from a community organization
5 I got it from an HIV testing event
6 I got it from a sex partner
7 I got it from a friend
8 [INSERT]
9 Other (Specify____________)
88 I don’t remember
99 I prefer not to answer
What are some of your reasons for using an HIV self-test in the past? Select all that apply. [randomize options except for “other” and “I prefer not to answer”]
1 Self-testing was convenient
2 Self-testing was private
3 To test with someone before having sex
4 To test myself before having sex
5 To test myself after having sex
6 My sex partner asked me to self-test
7 [INSERT]
8 Other (Specify____________)
88 I don’t remember
99 I prefer not to answer
Among the reasons you indicated, what is the main reason you used an HIV self-test? Choose only one.
[Display response options based on selections in Q72.]
[PROGRAMMER: IF Q69=”No”, ask Q74 and/or Q75. SKIP IF PARTICIPANT IS HIV-POSITIVE]
What are some of your reasons for not using an HIV self-test in the past? Select all that apply. [randomize options except for “other” and “I prefer not to answer”]
1 I did not know HIV self-tests were available
2 I did not know where to get an HIV self-test
3 I was concerned about the cost of HIV self-tests
4 I was concerned about the accuracy of HIV self-tests
5 I was concerned I would not be able to perform the HIV self-test correctly
6 I got tested for HIV another way, such as at a clinic or at my doctor’s office
7 I would rather talk to a counselor when I get an HIV test
8 I did not want to stick my finger to get a drop of blood
9 I did not want to swab my mouth to collect an oral fluid sample
10 I would rather be tested by someone who is trained to conduct the test
11 I did not want to mail my blood sample to a lab
12 I didn’t think I needed an HIV test
13 I was afraid of finding out the results
14 [INSERT reason]
15 Other reason (Specify__________)
99 I prefer not to answer
Among the reasons you indicated, what is the main reason you have not used an HIV self-test? Choose only one.
[Display response options based on selections in Q74.]
How likely would you be to take an HIV self-test if it were provided for free?
1 Very unlikely
2 Somewhat unlikely
3 Neither unlikely nor likely
4 Somewhat likely
5 Very likely
99 I prefer not to answer
Would being able to take an HIV self-test [increase the likelihood that you would get tested/how often you get tested for HIV]?
1 Yes
2 No
88 Don’t know
99 I prefer not to answer
What is the maximum amount you would be willing to pay for an HIV self-test?
1 I would only use it if it were free
2 Less than $10
3 $11-20
4 $21–30
5 $31-40
6 $41-50
7 More than $50
99 I prefer not to answer
SCRIPT: Finally, we’d now like to ask a few more questions about you.
Do you personally know anyone who has HIV or has died from AIDS?
1 Yes
2 No
88 Don’t know
99 Prefer not to answer
Is that person a family member, a close friend, an acquaintance or coworker, or someone else?
1 Yes, close friend or family member
2 Yes, acquaintance or coworker
3 Someone else
88 Don’t know
99 Prefer not to answer
What is your current marital status?
1 Never married
2 Married
3 Separated
4 Divorced
5 Widowed
99 Prefer not to answer
In what ZIP Code do you currently live? If you prefer not to answer, you may leave the question blank.
______________ (5 digits only)
Which best describes your total personal income during the past year?
1 Less than $20,000
2 $20,001 to $30,000
3 $30,001 to $40,000
4 $40,001 to $50,000
5 $50,001 or more
99 Prefer not to answer
Do you currently have health insurance or health care coverage?
1 Yes
2 No
88 Don’t know
99 Prefer not to answer
Please tell us if you disagree or agree with the following statement:
Statement |
Strongly disagree |
Disagree |
Neither disagree nor agree |
Agree |
Strongly agree |
Prefer not to answer |
I trust the Centers for Disease Control (CDC) as a source for HIV information. |
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| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | LSHT Web-Based Survey_updated 021618 |
| Author | Boudewyns, Vanessa |
| File Modified | 0000-00-00 |
| File Created | 2021-01-13 |