Baseline survey
Form Approved
OMB No. 0920-New
Expiration Date: XX/XX/XXXX
Web-based Approaches to reach black or African American and Hispanic/Latino MSM for HIV Testing and Prevention Services
Attachment 3c
Baseline survey
Public reporting burden of this collection of information is estimated to average 20 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 your interest in our study. Please take note of the following information:
1.
Your answers are private: the information you provide us will be kept
secure and known only to study staff. This information will not be
shared or used for any other research purposes.
2. This survey includes some personal questions about your sexual behaviors and HIV testing practices. You may choose to not answer any questions that make you feel uncomfortable.
3. We appreciate your willingness to be part of this study. Your participation will help us learn more about ways to get people tested. The results of this study will be used to improve HIV testing programs in the United States.
4. If you have any questions or comments, you may contact the Principal Investigator, Dr. Patrick Sullivan of Emory University, at (404) 727-2038.
Emory University, the University of Michigan, and the University of North Carolina are conducting the study, which is funded by the Centers for Disease Control and Prevention (CDC).
What is your birthdate? Enter the month, day, and year. __________________ * (Required)
[DOB]
Source: ATN Data Harmonization 2017
[using form validation, if provided date is today or in the future reject entry and prompt user correction with: “The date that you entered for your birthdate is in the future. Please correct this.”]
What state do you live in? ______ * (Required)
[STATE]
What county do you live in? ______ * (Required)
[COUNTY]
What is the 5‐digit ZIP Code for the location where you primarily live? ______ * (Required)
[ZIPCODE]
Source: ATN Data Harmonization 2017
[using form validation, if provided ZIP Code does not have 5 digits, reject entry and prompt user correction with: “You must provide a valid, 5-digit ZIP Code to participate in our study.” ]
We will now ask you some questions about your background.
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
[ORIENT]
Source: HHS/NHIS SOGI Measures
Have you been employed at any time in the past 12 months?
(0) No
(1) Yes
[EMPLOY_P12MO]
Source: Kristin Wall
What best describes your current employment status? Are you:
(1) Employed full-time
(2) Employed part-time
(3) A student (full- or part-time)
(4) Unemployed
[EMPLOYED]
Source: EngageMENt 2016/NHBS Round 4 (edited)
What was your household income last year from all sources before taxes? That is, the total amount of money earned and shared by all people living in your household
(1) $0 to $9,999 annually ($0 to $833 monthly)
(2) $10,000 to $19,999 annually ($834 to $1667 monthly)
(3) $20,000 to $34,999 annually ($1668 to $3333 monthly)
(4) $40,000 to $74,999 annually ($3334 to $6250 monthly)
(5) $75,000 or more annually ($6251 or more monthly)
[INCOME]
Source: AMIS 2016 (edited)
Including yourself, how many people depend on this income? Number of people (Must be at least 1): ______
[DEPEND]
Source: NHBS
What is the highest level of school that you have completed?
(1) Less than a high school diploma
(2) High school diploma, certificate or GED
(3) Some college, technical school, or an associate’s degree
(4) A bachelor’s degree, a master’s degree, or a doctoral degree
[EDUCATION]
Source: ATN Data Harmonization 2017 (edited)
What kind of health insurance or health care coverage do you currently have?. Check all that apply.
(1) A private health plan purchased through an employer
(2) A private health plan purchased through an exchange (e.g. Affordable Care Act, Obamacare)
(3) Government program (Medicare, Medicaid, TRICARE, Veteran’s Administration (VA))
(4) Some other health care plan
(5) Through a spouse or family member
(6) I don’t currently have any health insurance
(99) I don’t know
[INSURANCE]
Source: AMIS 2016 (edited)
What country were you born in?
[Drop-Down Menu]
[BIRTHCOUNTRY]
Source: Created
What language do you prefer to receive health information in?
(1) English
(2) Spanish
(3) French
(4) Other, please specify ______ [LANGUAGE_OTHER]
[LANGUAGE]
Source: Created
In the past 12 months, were you ever homeless? That is, were you living on the street, in a shelter, in a Single Room Occupancy hotel (SRO), or in a car?
(0) No
(1) Yes
[HOMELESS_P12MO]
Source: AMIS 2016
Have you shot up or injected any drugs other than those prescribed for you in the last 12 months? By shooting up, we mean anytime you might have used drugs with a needle, either by mainlining, skin popping, or muscling.
(0) No
(1) Yes
[INJECT_P12MO]
Source: AMIS 2016
In the past 12 months, have you used any non-injection drugs (drugs you did not inject), other than those prescribed for you?
(0) No
(1) Yes
[NONINJECT_P12MO]
Source: AMIS 2016
In the past 12 months, have you spent any nights in a jail or prison?
(0) No
(1) Yes
[INCARC_P12MO]
Source: EleMENt (edited)
In the past 12 months, did you or other adults in the household ever cut the size of your meals or skip meals because there wasn’t enough money for food?
(0) No
(1) Yes
[FOODSEC_P12MO]
Source: AMIS 2016 (edited)
Logic: If FOODSEC_P12MO equal to 1
How often did this happen?
(1) Almost every month
(2) Some months but not every month
(3) Only 1 or 2 months
[FOODSEC_FREQ]
Source: AMIS 2016 (edited)
In the past 3 months, have you made an appointment or used any of these social services? Check all that apply.
(1) Education assistance [SERVICES_EDUC]
(2) Job training [SERVICES_JOBTRAIN]
(3) Job placement [SERVICES_JOBPLACE]
(4) Housing assistance/placement [SERVICES_HOUSING]
(5) Counseling [SERVICES_COUNSELING]
(6) Drug treatment services [SERVICES_DRUGS]
(7) Supplemental Nutrition Assistance Program (SNAP) or Food Stamps [SERVICES_SNAP]
(8) Electronic Benefits Transfer (EBT) [SERVICES_EBT]
(9) Mental health services [SERVICES_MENTAL]
(10) Other, please specify ______ [SERVICES_OTHER]
Source: Robin MacGowan (edited)
In the past 3 months, have you had any of these symptoms? Check all that apply.
(1) I did not have any symptoms [SYMP_NONE]
(2) Sore throat [SYMP_THROAT]
(3) Fever [SYMP_FEVER]
(4) Nausea [SYMP_NAUS]
(5) Vomiting [SYMP_VOMIT]
(6) Diarrhea [SYMP_DIARR]
(7) Headache [SYMP_HEAD]
(8) Fatigue [SYMP_FATIG]
(9) Soreness or pain in your joints [SYMP_SOREJTS]
(10) Soreness or pain in your lymph nodes [SYMP_SORELYMPH]
(11) Body rash [SYMP_RASH]
(12) Other, please specify _____ [SYMP_OTHER]
Source: EleMENt (edited)
The next set of questions will ask you about testing for human immunodeficiency virus (HIV).
Have you ever been tested for HIV?
(0) No
(1) Yes
[EVERTEST]
Source: AMIS 2016 (edited)
Logic: If EVERTEST equal to 1
In the past 2 years (since [MONTH] of [YEAR 24 MONTHS PRIOR]), how many times have you been tested for HIV? ___________
[HIVTESTS_P24MO]
Source: AMIS 2016
Logic: If EVERTEST equal to 1
When was the last time that you were tested for HIV?
Month: [LASTHIVTEST_MO]
Year: [LASTHIVTEST_YR]
Source: eSTAMP
[using form validation, if provided date is today or in the future reject entry and prompt user correction with: “The date that you entered for your birthdate is in the future. Please correct this.”]
Logic: If EVERTEST equal to 1
The last time that you tested, what was the main reason that you got tested for HIV?
(1) I get tested on a regular schedule and it was time for me to get tested again
(2) I was worried that I might have been exposed to HIV
(3) Before having sex with someone new
(4) I had sex with someone new
(5) After stopping having sex with someone
(6) I had symptoms of HIV
(7) I had symptoms of sexually transmitted infections other than HIV
(8) My doctor recommended that I get tested
(9) It is free and convenient
(10) Other, please specify _____ [LASTTEST_REASON_OTHER]
[LASTTEST_REASON]
Source: eSTAMP (edited)
Logic: If EVERTEST equal to 1
What was the result of your most recent HIV test?
(1) Negative
(2) Positive
(3) Indeterminate/test did not work
(4) I did not get the result
[LASTTEST_STATUS]
Source: AMIS 2016 (edited)
Logic: If LASTTEST_STATUS equal to 2
Was that your first positive test?
(0) No
(1) Yes
[LASTTEST_FIRSTPOS]
Source: eSTAMP (edited)
Logic: If LASTTEST_STATUS equal to 3 OR 4
Before your last test, had you ever tested positive for HIV?
(0) No
(1) Yes
[LASTTEST_EVERPOS]
Source: AMIS 2016 (edited)
Logic: If EVERTEST equal to 1
Where did you get your last HIV test?
(1) Private doctor’s office
(2) HIV counseling and testing site
(3) Public health clinic/community health center
(4) Street outreach program/mobile unit
(5) Sexually transmitted infection clinic
(6) Emergency room or Hospital (inpatient)
(7) Correctional facility (jail or prison)
(8) Home or other private location
(9) Other location, please specify__________ [LASTTEST_LOCATION_OTHER]
[LASTTEST_LOCATION]
Source: Moxie (edited)
Logic: If EVERTEST equal to 1
When you last got tested for HIV, what type of test was used?
(1) Finger-stick blood rapid test (test that required pricking your finger to collect a drop of blood)
(2) Oral fluid rapid test (test that required swabbing your gums to collect an oral fluid sample)
(3) Test that required drawing blood with a syringe
[LASTTEST_TYPE]
Source: Moxie
Logic: If EVERTEST equal to 1
On average, how often do you get tested for HIV?
(1) Every month
(2) Every 3 months
(3) Every 6 months
(4) Every year
(5) Every time I think I might have been exposed
(6) I don’t test regularly
[TEST_PATTERN]
Source: Moxie (edited)
How do you usually decide when to test for HIV? Choose the one that best fits how you currently decide to test.
(1) On a regular schedule
(2) After being exposed to HIV
(3) Between sex partners
(4) When I have symptoms of HIV
(5) When I have symptoms of sexually transmitted infections other than HIV
(6) When it is free and convenient
(7) Other, please specify ______ [TESTING_REASON_OTHER]
[TESTING_REASON]
Source: DETECT
A home HIV test can be used to test yourself for HIV in the privacy of your home or other private location by collecting fluid from your mouth or a drop of blood from your finger.
Have you ever heard about home HIV tests?
(0) No
(1) Yes
[HOMETEST_AWARE]
Source: eSTAMP
Logic: If HOMETEST_AWARE equal to 1
In the past 12 months, have you used a home HIV test?
(0) No
(1) Yes
[HOMETEST_USE]
Source: eSTAMP
Logic: If HOMETEST_USE equal to 1
In the past 12 months, which of the following home HIV tests have you used? Select all that apply.
[Display images of HomeAccess and OraQuick]
(1) OraQuick In-Home HIV Test (where you swab your mouth, collect an oral fluid sample, and read your own test results within 20 minutes) [HOMETEST_ORAQUICK]
(2) HomeAccess 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) [HOMETEST_HOMEACCESS]
(3) Other rapid HIV test, please specify _______ [HOMETEST_OTHER]
(99) I don’t know [HOMETEST_DK]
Source: eSTAMP (edited)
The next set of questions will ask you about testing for sexually transmitted infections (STIs). A sexually transmitted infection (STI) is an infection transmitted through sexual activity such as syphilis, gonorrhea, chlamydia, herpes, or genital warts.
In the past 6 months, have you been tested for an STI that was not HIV?
(0) No
(1) Yes
[STITEST_P6MO]
Source: ATN Data Harmonization 2017 (edited)
Logic: If STITEST_P6MO equal to 1
In the past 6 months, how many times have you been tested for STIs? ___________
[STITESTS_P6MO]
Source: Created
Logic: If STITEST_P6MO equal to 1
When were you last tested for STIs?
[LASTSTITEST_MO]
[LASTSTITEST_YR]
Source: Created
[using form validation, if provided date is today or in the future reject entry and prompt user correction with: “The date that you entered for your birthdate is in the future. Please correct this.”]
The last time that you tested, what was the main reason that you got tested for STIs?
(1) I had anal, vaginal, or oral sex without a condom
(2) I shared needles or syringes with someone
(3) I had sex with someone I knew had an STI or found out afterwards that they had an STI
(4) A sex partner requested it
(5) I was worried I might have been exposed to an STI or I had symptoms of an STI
(6) I get tested on a regular schedule and it was time for me to get tested again
(7) I was starting a new relationship
(8) My doctor or other health care provider recommended I get tested
(9) I received an email, text, or phone call to remind me about testing
(10) Because I got paid to have an STI test
(11) Other, please specify ______ [LASTSTITEST_REASON_OTHER]
[LASTSTITEST_REASON]
Source: EleMENt (edited)
Logic: If STITEST_P6MO equal to 1
In the past 6 months (since [MONTH] of [YEAR 6 MONTHS PRIOR]), has a doctor, nurse or other health care provider told you that you had any of the following? Check all that apply.
(1) I have not been told that I have any[STI_NONE_P6MO]
(2) Gonorrhea [STI_NG_P6MO]
(3) Chlamydia [STI_CT_P6MO]
(4) Syphilis [STI_SYPH_P6MO]
(5) Hepatitis A [STI_HEPA_P6MO]
(6) Hepatitis B [STI_HEPB_P6MO]
(7) Hepatitis C [STI_HEPC_P6MO]
(8) Genital herpes [STI_HERPES_P6MO]
(9) Genital warts [STI_WARTS_P6MO]
(10) Human papillomavirus or HPV [STI_HPV_P6MO]
(11) Other, please specify ______ [STI_OTHER_P6MO]
Source: AMIS 2016 (edited)
Logic: If STITEST_P6MO equal to 1
In the past 6 months, have you been tested for rectal gonorrhea or chlamydia? This usually involves collection of a rectal (butt) swab either by you or a health care professional.
(0) No
(1) Yes
[STIRECTTEST_P6MO]
Source: AMIS 2016 (edited)
Are you interested in being tested for rectal gonorrhea or chlamydia? This usually involves collection of a rectal (butt) swab either by you or a health care professional.
(0) No
(1) Yes
[STIRECTTEST_INTEREST]
Source: Created
Logic: If LASTTEST_STATUS equal to 2 or LASTTEST_EVERPOS equal to 1 skip PrEP section
The next questions are about pre-exposure prophylaxis (PrEP). PrEP is taking an antiretroviral pill, also called Truvada, every day for months or years to reduce a person’s chance of getting HIV.
Before today, had you ever heard of PrEP?
(0) No
(1) Yes
[PREP_AWARE]
Source: AMIS 2016 (edited)
Logic: If PREP_AWARE equal to 1
Have you ever taken pre-exposure prophylaxis (PrEP) to reduce the risk of getting HIV?
(0) No
(1) Yes
[PREP_USE]
Source: AMIS 2016 (edited)
Logic: If PREP_AWARE equal to 1
In the next 6 months (from now until [MONTH 6 MONTHS FROM NOW] of [YEAR OF 6 MONTHS FROM NOW]), are you planning to take PrEP?
(0) No
(1) Yes
[PREP_INTEND_N6MO]
Source: Created
The next questions are about buying and using condoms.
In the past 3 months, have you bought condoms?
(0) No
(1) Yes
[BUYCONDOMS_P3MO]
Source: Created
Logic: If BUYCONDOMS_P3MO equal to 1
In the past 3 months, have you used condoms that you have bought?
(0) No
(1) Yes
[USEBUYCONDOMS_P3MO]
Source: Created
In the past 3 months, have you received free condoms, not counting those given to you by a friend, relative, or sex partner?
(0) No
(1) Yes
[FREECONDOMS_P3MO]
Source: AMIS 2016 (edited)
Logic: If FREECONDOMS_P3MO equal to 1
In the past 3 months, have you used condoms that you received for free?
(0) No
(1) Yes
[USEFREECONDOMS_P3MO]
Source: Created
Have you used any of the following services at a community-based organization (CBO) in the past 3 months? This can include any services you used at mobile or satellite locations, including mobile testing vans. Check all that apply.
(1) HIV testing [CBO_HIVTEST]
(2) STI testing [CBO_STITEST]
(3) HIV/STI counseling (risk reduction counseling) [CBO_RISKRED]
(4) PrEP consultation [CBO_PREP]
(5) Other, please specify ______ [CBO_OTHER]
Source: Created
Logic: If LASTTEST_STATUS equal to 2 or LASTTEST_EVERPOS equal to 1 skip PrEP section
PrEP stands for pre-exposure prophylaxis. PrEP is medication for a healthy person to take to prevent getting HIV. The medication can be a pill, injected, or a gel. Some people have side effects that usually go away after the first month. In rare cases, taking the medication for long periods may damage the kidneys. The medication is prescribed by a doctor, and you would need to follow the doctor’s orders about regular check-ups. Taking these medications would provide some protection against HIV infection, but they are not 100% effective.
The following questions are about some types of PrEP medication that may be available in the future that would lower your chances of getting HIV.
Would you be willing to take one pill only once each week?
(0) No
(1) Yes
[PREP_WEEKLY_WILLING]
Source: Arin Freeman
Would you be willing to take one pill every day?
(0) No
(1) Yes
[PREP_DAILY_WILLING]
Source: Arin Freeman
Only on the days you planned to have sex, would you be willing to take one pill between 2 and 24 hours before sex?
(0) No
(1) Yes
[PREP_ONDEMAND_BEFORE_WILLING]
Source: Arin Freeman
Only on the days you planned to have sex, would you be willing to take one pill between 2 and 24 hours after sex?
(0) No
(1) Yes
[PREP_ONDEMAND_AFTER_WILLING]
Source: Arin Freeman
Logic: If PREP_ONDEMAND_AFTER_WILLING equal to 1
Of these options, which would be your preference? Please rank your top three choices.
[Drag and Drop Ranking]
(1) One pill only each week
(2) One pill 2 hours before sex
(3) One pill 2 hours after sex
(4) One pill 12 hours before sex
(5) One pill 12 hours after sex
(6) One pill 24 hours before sex
(7) One pill 24 hours after sex
[PREP_PILL_RANK]
Source: Arin Freeman
Would you be willing to have an injection that would last for several months?
(1) No
(0) Yes
[PREP_INJECT_WILLING]
Source: Arin Freeman
Logic: If PREP_INJECT_WILLING equal to 1
Of these options, which would you prefer?
(1) One injection that lasts for 2 months
(2) Two injections on the same visit that would last for 6 months
[PREP_INJECT_RANK]
Source: Arin Freeman
Would you be willing to have a small tube (rod) put under your skin (implanted) in your arm that would last for several months? It would require a tiny cut (2 millimeter) to put it in. Some need to be removed, some do not.
(0) No
(1) Yes
[PREP_IMPLANT_WILLING]
Source: Arin Freeman
Logic: If PREP_IMPLANT_WILLING equal to 1
Of these options, which would you prefer?
(1) One rod implanted that lasts for 6 months
(2) Two rods implanted on the same visit that would last for 12 months
[PREP_IMPLANT_RANK]
Source: Arin Freeman
Logic: If PREP_IMPLANT_WILLING equal to 1
Of these options, which would you prefer?
(1) An implant that had to be removed at a doctor’s office
(2) An implant that did not need to be removed – it is biodegradable
[PREP_IMPLANT_RANK2]
Source: Arin Freeman
Would you be willing to use an enema/douche within 2 hours before receptive anal sex?
(0) No
(1) Yes
[PREP_ENEMA_RAI_WILLING]
Source: Arin Freeman
Would you be willing to use a gel that you put on your penis before or after having insertive anal sex?
(0) No
(1) Yes
[PREP_GEL_IAI_WILLING]
Source: Arin Freeman
Logic: If PREP_GEL_IAI_WILLING equal to 1
Of these options, which would you prefer?
(1) Put the gel on your penis just before insertive anal sex
(2) Put the gel on your penis just after insertive anal sex
[PREP_GEL_RANK]
Source: Arin Freeman
Below is a list of the types of PrEP that we asked you about. Please select your top three choices that you would be willing to use. [Drag and Drop Ranking]
(1) Daily pill
(2) Pill 2 hours before sex
(3) Pill 2 hours after sex
(4) Pill 12 hours before sex
(5) Pill 12 hours after sex
(6) Pill 24 hours before sex
(7) Pill 24 hours after sex
(8) One injection that last 2 months
(9) Two injections that last 6 months
(10) One removable implant that last 6 months (needs a small cut to insert)
(11) Two removable implant that last 12 months (needs a small cut to insert)
(12) One implant that does not need to be removed that last 6 months (needs a small cut to insert)
(13) Two implants that do not need to be removed that last 12 months (needs a small cut to insert)
(14) Enema/douche before receptive anal sex
(15) Enema/douche after receptive anal sex
(16) Penis gel just before insertive anal sex
(17) Penis gel just after insertive anal sex
[PREP_OVERALL_RANK]
Source: Arin Freeman
We will now ask you some questions about your sex partners in the past 6 months. We only want to know about partners you had anal or vaginal sex with since [insert date from six months ago].
In the past 6 months, did you have anal or vaginal sex with:
(1) Only men
(2) Only women
(3) Both men and women
(4) Nobody
[SEXPART_GENDER]
Source: eSTAMP
Section Logic: If SEXPART_GENDER = 2 or 3
The next questions are about women you had vaginal or anal sex with in the past 6 months. “Vaginal sex” means you put your penis in her vagina. “Anal sex" means you put your penis in her butt.
In the past 6 months, with how many different women did you have vaginal or anal sex? _____
(99) I prefer not to answer
[FEMPART_NUM]
Source: eSTAMP (edited)
Logic: If FEMPART_NUM > 0
With how many of these [FEMPART_NUM] women did you have vaginal or anal sex without using a condom or not using it the whole time? __________
(99) I prefer not to answer
[FEMPART_UNPROTNUM]
Source: eSTAMP (edited)
[Validation: Cannot be greater than FEMPART_NUM
If not, then display “The number of women you had sex without using a condom or not using it the whole time cannot be more than the number of women you had vaginal or anal sex with in the past 6 months. Please carefully re-enter your response.”, and loop back to enter the number.]
Logic: If FEMPART_UNPROTNUM > 0
In the past 6 months, how many of these [FEMPART_UNPROTNUM] women you had vaginal or anal sex without using a condom were:
HIV-positive? __________ [FEMPART_UNPROTNUM_POS]
HIV-negative? __________ [FEMPART_UNPROTNUM_NEG]
Women whose HIV status you did not know? __________ [FEMPART_UNPROTNUM_UNK]
[Validation: Sum of three numbers cannot be greater than FEMPART_NUM:
If not, then display “The number of HIV positive, HIV negative, and HIV status unknown partners must add up to [FEMPART_UNPROTNUM]. Please carefully re-enter your responses.”, and loop back to enter the number.]
Section Logic: If SEXPART_GENDER = 1 or 3
The next questions are about men you had anal sex with in the past 6 months. “Anal sex" means either you put your penis in his butt or he put his penis in your butt.
In the past 6 months, with how many different men did you have anal sex? _____
(99) I prefer not to answer
[MALEPART_NUM]
Source: eSTAMP (edited)
Logic: If MALEPART_NUM > 0
With how many of these [MALEPART_NUM] men did you have anal sex without using a condom or not using it the whole time? __________
(99) I prefer not to answer
[MALEPART_UNPROTNUM]
Source: eSTAMP (edited)
[Validation: Cannot be greater than MALEPART_NUM
If not, then display “The number of men you had sex without using a condom or not using it the whole time cannot be more than the number of men you had anal sex with in the past 6 months. Please carefully re-enter your response.”, and loop back to enter the number.]
Logic: If MALEPART_UNPROTNUM > 0
In the past 6 months, how many of these [MALEPART_UNPROTNUM] men you had anal sex without using a condom were:
HIV-positive? __________ [MALEPART_UNPROTNUM_POS]
HIV-negative? __________ [MALEPART_UNPROTNUM_NEG]
Men whose HIV status you did not know? __________ [MALEPART_UNPROTNUM_UNK]
[Validation: Sum of three numbers cannot be greater than MALEPART_NUM:
If not, then display “The number of HIV positive, HIV negative, and HIV status unknown partners must add up to [MALEPART_UNPROTNUM]. Please carefully re-enter your responses.”, and loop back to enter the number.]
Logic: If SEXPART_GENDER = 1 or 2 or 3
In the past 6 months, have you received things like money or drugs for sex in exchange for having sex with someone?
(0) No
(1) Yes
[EXCHANGE]
Source: AMIS 2016 (edited)
The next questions are your experiences with health care providers.
In the past 12 months, have you seen a doctor, nurse, or other health care provider about your own health?
(0) No
(1) Yes
[PROVIDER_P12MO]
Source: AMIS 2016
Logic: If PROVIDER_P12MO equal to 0
Is there a reason why you have not been to a doctor or nurse in the past 12 months? Check all that apply
(1) Feel fine / not sick [NOCARE_FINE]
(2) Too busy [NOCARE_BUSY]
(3) Concerned about being able to pay [NOCARE_PAYCONCERN]
(4) Don’t know where to go [NOCARE_DKWHERE]
(5) Have had bad experiences in the past, please specify _____ [NOCARE_BADEXPER]
(6) Other, please specify ____ [NOCARE_OTHER]
Source: EleMENt (edited)
Logic: If PROVIDER_P12MO equal to 1
Where have you gone to see a doctor or nurse for a medical issue in the past 12 months? Check all that apply
(1) Primary care physician (doctor) [CARE_PCP]
(2) Emergency room (ER) or Urgent Care [CARE_ER]
(3) Service organization [CARE_CBO]
(4) Student health services [CARE_STUDENT]
(5) County health department [CARE_COUNTYDEPT]
(6) Other physician’s (doctor’s) office [CARE_OTHERDOC]
(7) Other, please specify ____ [CARE_OTHER]
Source: EleMENt (edited)
Logic: If PROVIDER_P12MO equal to 1
At any of those times you were seen by a doctor or health care provider, were you offered an HIV test?
(0) No
(1) Yes
[PROVIDER_HIVTEST_P12MO]
Source: AMIS 2016
Logic: If PROVIDER_P12MO equal to 1
The last time you saw a doctor or health care provider, did they talk to you about sex or sexual health?
(0) No
(1) Yes
[PROVIDER_TALKSEX_P12MO]
Source: AMIS 2016
Logic: If PROVIDER_P12MO equal to 1
Had you previously told any of these doctors or nurses that you saw for medical care that you had sex with men?
(1) Yes, I had told all of them previously
(2) Yes, I had told some of them previously
(3) No, I hadn’t told any of them previously
[PROVIDER_PREVDISCL_P12MO]
Source: EleMENt (edited)
Logic: If PROVIDER_PREVDISCL_P12MO equal to 2 or 3
Did any of these doctors or nurses who did not know you had sex with men ask if you have sex with men?
(0) No
(1) Yes
[PROVIDER_ASKORIENT_P12MO]
Source: EleMENt (edited)
Logic: If PROVIDER_ASKORIENT_P12MO equal to 1
Did you tell all of these doctors or nurses who asked?
(0) No
(1) Yes
[PROVIDER_TELL_P12MO]
Source: EleMENt (edited)
Logic: If PROVIDER_ PREVDISCL _P12MO equal to 2 or 3
Please indicate reasons why you did not tell them: Check all that apply
(1) I did not think it was important to tell my health care provider [NOTTELL_IMP]
(2) I thought the health care provider would make fun of me or treat me differently [NOTTELL_TREATDIFF]
(3) I thought the health care provider would refuse to provide appropriate care for me [NOTTELL_REFUSECARE]
(4) I was uncomfortable talking about having sex with men with my health care provider [NOTTELL_UNCOMFMSM]
(5) I was uncomfortable talking about sex at all with my health care providers [NOTTELL_UNCOMFSEX]
(6) I thought friends, family or other people in the community would find out [NOTTELL_FINDOUT]
(7) Other, please specify ________________ [NOTTELL_OTHER]
Source: EleMENt (edited)
Logic: If PROVIDER_ PREVDISCL _P12MO equal to 1 or 2
After sharing that you have sex with other men, did any doctor or nurse…. Check all that apply
(1) Offer counseling on reducing risk while having sex with men [POSTDISCL_MSMCOUNSEL]
(2) Avoid you [POSTDISCL_AVOID]
(3) Make fun of you or treat you differently [POSTDISCL_TREATDIFF]
(4) Refuse to help you [POSTDISCL_REFUSE]
(5) Offer counseling on how to prevent HIV [POSTDISCL_HIVCOUNSEL]
(6) Ask you about anal itching, anal sores [POSTDISCL_ANALQ]
(7) Offer testing for HIV and STIs [POSTDISCL_TESTING]
(8) Suggest you get care at another place with better services for gay or other men who have sex with men [POSTDISCL_OTHERCARE]
Source: EleMENt (edited)
Please indicate how much you agree with the following statements.
Doctors and healthcare workers sometimes hide information from patients who belong to my racial/ethnic group.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
[MISTRUST_HIDE]
Source: Medical Mistrust Index, Thompson et al, Preventive Medicine 2003
Doctors have the best interests of people of my racial/ethnic group in mind.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
[MISTRUST_BESTINTERESTS]
Source: Medical Mistrust Index, Thompson et al, Preventive Medicine 2003
People of my racial/ethnic group should not confide in doctors and healthcare workers because it will be used against them.
Strongly Disagree
Disagree
Neutral
Agree
Strongly agree
[MISTRUST_USEAGAINST]
Source: Medical Mistrust Index, Thompson et al, Preventive Medicine 2003
People of my racial/ethnic group should be suspicious of information from doctors and healthcare workers.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
[MISTRUST_SUSPICIOUS]
Source: Medical Mistrust Index, Thompson et al, Preventive Medicine 2003
People of my racial/ethnic group cannot trust doctors and healthcare workers.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
[MISTRUST_TRUST]
Source: Medical Mistrust Index, Thompson et al, Preventive Medicine 2003
People of my racial/ethnic group should be suspicious of modern medicine.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
[MISTRUST_SUSPICIOUSMED]
Source: Medical Mistrust Index, Thompson et al, Preventive Medicine 2003
Doctors and healthcare workers treat people of my racial/ethnic group as “guinea pigs”.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
[MISTRUST_GUINEAPIG]
Source: Medical Mistrust Index, Thompson et al, Preventive Medicine 2003
People of my racial/ethnic group receive the same medical care from doctors and healthcare workers as people from other groups.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
[MISTRUST_SAMECARE]
Source: Medical Mistrust Index, Thompson et al, Preventive Medicine 2003
Doctors and healthcare workers do not take the medical complaints of people of my racial/ethnic group seriously.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
[MISTRUST_COMPLAINTS]
Source: Medical Mistrust Index, Thompson et al, Preventive Medicine 2003
People of my racial/ethnic group are treated the same as people of other groups by doctors and healthcare workers.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
[MISTRUST_TREATSAME]
Source: Medical Mistrust Index, Thompson et al, Preventive Medicine 2003
In most hospitals, people of different racial/ethnic groups receive the same kind of care.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
[MISTRUST_RACEETHSAMECARE]
Source: Medical Mistrust Index, Thompson et al, Preventive Medicine 2003
I have personally been treated poorly or unfairly by doctors or healthcare workers because of my race/ethnicity.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
[MISTRUST_POORTX]
Source: Medical Mistrust Index, Thompson et al, Preventive Medicine 2003
The next questions are about your use of your phone and the internet.
On average, how many hours per day do you spend on your phone?
(1) Less than 1 hour per day
(2) 1-2 hours per day
(3) 2-3 hours per day
(4) 3-4 hours per day
(5) More than 4 hours per day
[PHONE_HOURS]
Source: Medical Mistrust Index, Thompson et al, Preventive Medicine 2003 (edited)
On average, how often have you used the internet in the past 12 months? Choose the answer that best describes your use.
(1) Almost constantly
(2) Several times per day
(3) About once per day
(4) Several times per week
(5) Once per week
(6) Less than once per week
(7) Never
[INTERNET_P12MO]
Source: AMIS 2016 (edited)
In the past 12 months, which of the following apps or websites have you used to interact with other men? Check all that apply.
Facebook [SITE_FACEBOOK]
Twitter [SITE_TWITTER]
Instagram [SITE_INSTAGRAM]
Snapchat [SITE_SNAPCHAT]
Gmail [SITE_GMAIL]
YouTube [SITE_YOUTUBE]
WhatsApp [SITE_WHATSAPP]
Kik [SITE_KIK]
Match [SITE_MATCH]
OK Cupid [SITE_OKCUPID]
Tinder [SITE_TINDER]
Craigslist [SITE_CRAIGSLIST]
Adam4Adam [SITE_A4A]
Bareback Real Time (BBRT) [SITE_BBRT]
Daddyhunt [SITE_DADDYHUNT]
Dudesnude [SITE_DUDESNUDE]
Gay.com [SITE_GAYCOM]
Grindr [SITE_GRINDR]
Hornet [SITE_HORNET]
Manhunt [SITE_MANHUNT]
Jack’d [SITE_JACKD]
Growlr [SITE_GROWLR]
Scruff [SITE_SCRUFF]
SilverDaddies [SITE_SILVERDADDIES]
Squirt [SITE_SQUIRT]
Tumblr [SITE_TUMBLR]
Whisper [SITE_WHISPER]
YikYak [SITE_YIKYAK]
Wickr [SITE_WICKR]
Some other app, specify: _____________ [SITE_OTHER]
Source: AMIS 2016 (edited)
In the past 12 months, how often did you use mobile phone apps (such as gay chat, dating, and hookup apps) to meet or socialize with gay men? Choose the answer that best describes your use.
(1) More than once per day
(2) Once per day
(3) More than once per week
(4) Once per week
(5) More than once per month
(6) Once per month
(7) Less than once per month
(8) Never
[DATEAPPS_P12MO]
Source: AMIS 2016
In the past 12 months, how often have you used dating websites directed towards gay men to meet or socialize with gay men? Choose the answer that best describes your use.
(1) More than once per day
(2) Once per day
(3) More than once per week
(4) Once per week
(5) More than once per month
(6) Once per month
(7) Less than once per month
(8) Never
[DATESITE_P12MO]
Source: AMIS 2016
Thank you for participating in this health study. Once we confirm your enrollment, we will be sending you a free package containing one or more HIV rapid test kits. You may use these kits to test yourself at home or any other private location. You may also give thee kits to your friends or sex partners so that they can test themselves privately and learn their HIV status. Later, you may have the option of ordering additional STI test kits, condoms, and lubricant free of cost.
Each kit contains written instructions on how to test yourself at home. You and your friends or sex partners can also watch videos demonstrating how to conduct these tests. As part of this study, anyone using these kits has the option of calling a toll-free phone number with questions or to talk to a trained counselor. You can use the link in your email report your test results. Your friends or sex partners can use the website link listed on their test box to report their results.
During the study we may call you to talk about your HIV testing practices and home-test results.
What day of the week would you prefer that we call you?
No preference
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
[CALL_DAY]
Source: eSTAMP
What time of the day would you prefer that we call you?
No preference
Morning (8:00am – 12:00pm)
Afternoon (12:00pm – 4:00pm)
Evening (4:00pm – 8:00pm)
[CALL_TIME]
Source: eSTAMP
We will be sending you an email in 4 months with a link to take a follow-up survey.
The follow-up survey will take about 30 minutes to complete, and you will receive $30 for completing the entire follow-up survey, which may be split into multiple parts.
If you do not complete the follow-up survey within 5 days of the first email, we will send you a reminder email to complete the survey. If you do not complete the survey after we have sent a total of 3 reminder emails, we will attempt to contact you using an alternate method.
How would you like us to remind you to take the follow-up survey if you have not responded to the reminder emails? Please rank the two options below. Enter “1” for your first preference and “2” for your second preference.
[Drag and drop ranking]
(1) Email me
(2) Call my phone number
(2) Send me a text message
[SURVEY_REMINDER_PREF]
Source: eSTAMP
Your follow-up survey will be available in 4 months. At that time, we will also send you a package containing a dried blood spot (DBS) collection kit and a second at-home rapid HIV test. You have the option to collect a few drops of blood by pricking your finger and return the DBS specimen in a pre-paid shipping envelope. If you choose to return the DBS specimen, once we receive your specimen and you report the results of your rapid tests, we will send you $10 through a method of your choice.
If needed, we can send a reminder about reporting your HIV home-test results or returning your DBS card.
How would you like us to remind you about reporting your HIV home-test results and mailing your DBS specimen? Please rank the three options below. Enter “1” for your first preference, “2” for your second preference and “3” for your third preference.
[Ranking Grid]
(1) Email me
(2) Call my phone number
(3) Send me a text message
[TEST_REMINDER_PREF]
Source: eSTAMP
How would you like to receive your token of appreciation?
(1) Amazon
(2) Target Gift Card
(3) Walmart Gift Card
(6) Starbucks
[TOKEN_BL]
Source: Created
Please provide the email you would like your gift card code sent to: * _________________
[GIFTCARD_EMAIL]
Source: Created
Action: Calculate Completion Score [SCORE]. If greater than 75%, then send to End 1. Otherwise, send to End 2.
End 1.
ACTION: Webhook pushes survey completion to SMART
Thank you for completing this survey!
Once we have
verified your survey, your token of appreciation will be provided to
you in the method that you indicated earlier. If you have not
received your token of appreciation within one month, please email us
at [email protected].
Please send this email from the email address you provided.
You should expect to receive a discreet package containing your HIV self-tests in the next few weeks and will be alerted if you are randomized to receive either of the study apps. You will receive a token of appreciation for reporting any home test results.
In four months, you will be expected to complete another survey and be sent additional home testing kits at that time, each of which you will receive a token of appreciation for completing.
If you are currently HIV-negative, pre-exposure prophylaxis (PrEP) may be a potential option for you. PrEP is a way for people who do not have HIV to lower their risk of getting HIV by taking a pill every day. To learn more, please visit some of the links below.
If you want to learn more about HIV, where to get more information, or where to get tested in your area, please click on the following links:
Information about HIV
HIV Testing Resources
CDC HIV Testing Locator (https://gettested.cdc.gov/)
CDC HIV Testing Information Page (https://www.cdc.gov/hiv/testing/)
HIV.gov HIV Testing Locator (https://www.hiv.gov/locator)
AIDSvu HIV Testing Locator (https://aidsvu.org/services)
PrEP Resources
Centers for Disease Control PrEP Resources (https://www.cdc.gov/actagainstaids/campaigns/starttalking/materials/prepresources.html)
Centers for Disease Control PrEP Information (https://www.cdc.gov/hiv/risk/prep/index.html)
PrEP Locator (https://preplocator.org/)
HIV.gov PrEP Information Page (https://www.hiv.gov/hiv-basics/hiv-prevention/using-hiv-medication-to-reduce-risk/pre-exposure-prophylaxis)
If you have any questions or comments, you may contact study staff at [email protected] or (404) 727-4340, or the Principal Investigator, Dr. Patrick Sullivan of Emory University, at (404) 727-2038 or [email protected]. To get more information about HIV, please visit: www.cdc.gov/hiv.
Otherwise, you can close your browser window. Thank you for your time.
End 2.
ACTION: Webhook pushes survey completion/results to SMART
Thank you for completing this survey!
Once your survey has been validated, your token of appreciation will be provided to you in the method that you indicated earlier. If you have not received your token of appreciation within one month, please email us at [email protected]. Please send this email from the email address you provided. Thank you for your time, this will be your last study activity.
If you are currently HIV-negative, pre-exposure prophylaxis (PrEP) may be a potential option for you. PrEP is a way for people who do not have HIV to lower their risk of getting HIV by taking a pill every day. To learn more, please visit some of the links below.
If you want to learn more about HIV, where to get more information, or where to get tested in your area, please click on the following links:
Information about HIV
HIV Testing Resources
CDC HIV Testing Locator (https://gettested.cdc.gov/)
CDC HIV Testing Information Page (https://www.cdc.gov/hiv/testing/)
HIV.gov HIV Testing Locator (https://www.hiv.gov/locator)
AIDSvu HIV Testing Locator (https://aidsvu.org/services)
PrEP Resources
Centers for Disease Control PrEP Resources (https://www.cdc.gov/actagainstaids/campaigns/starttalking/materials/prepresources.html)
Centers for Disease Control PrEP Information (https://www.cdc.gov/hiv/risk/prep/index.html)
PrEP Locator (https://preplocator.org/)
HIV.gov PrEP Information Page (https://www.hiv.gov/hiv-basics/hiv-prevention/using-hiv-medication-to-reduce-risk/pre-exposure-prophylaxis)
If you have any questions or comments, you may contact study staff at [email protected] or (404) 727-4340, or the Principal Investigator, Dr. Patrick Sullivan of Emory University, at (404) 727-2038 or [email protected]. To get more information about HIV, please visit: www.cdc.gov/hiv.
Otherwise, you can close your browser window. Thank you for your time.
Version : X.X OMB # XXXX-XXXX Expiration date: X/XX/XXXX
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Weiss, Kevin |
| File Modified | 0000-00-00 |
| File Created | 2021-01-14 |