Survey for Participants Currently Not on PrEP

Qualitative research to understand consumer opinions and preferences for emerging

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

Attachment 2f: Survey not on PrEP

Emerging Prevention Products for MSM

Survey for Participants Currently not on PrEP

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)

Respondent ID:____________

Thank you for agreeing to participate in this survey. Your input is very important to us.

STUDY ID NUMBER: _____________

Section 1: Questions about You

D1. How old are you?

_________ years

D2. Which of the following best describe your ethnicity?

1 Hispanic or Latino

0 Not Hispanic or Latino

D3. Which race or races, do you consider yourself to be?

Select 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

D4. What is your country of birth?

1 United States

0 Other Specify: _________________

D5. What is the highest level of education that you have completed?

1 Less than high school

2 High school diploma or GED

3 Some College, associate degree, or Technical Degree

4 Bachelor’s/4-year College Degree

5 Any post-graduate degree

D6. Which of the following best represents how you think of yourself?

1 Lesbian or gay

2 Straight, that is not lesbian or gay

3 Bisexual

4 Something else

7 I don’t know the answer

D7. Do you currently have health insurance or health care coverage (including Medicare or Medicaid)?

1 Yes

0 No

7 I don’t know

9 I prefer not to answer

Section 4: Questions about PrEP

P1. Have you ever been offered PrEP by a health care provider or counselor?

0. No

1 Yes

P2. Have you ever taken PrEP in the past?

0. No

1 Yes

P3. What the most important reason you are not taking PrEP now?

Select one response

I don’t know enough about PrEP

I rarely have anal sex

I use condoms all the time

I don’t like taking pills

I am worried about what others may think

I don’t think PrEP works very well

I am worried about possible side effects

I don’t know how I would pay for PrEP

I don’t know how I could access PrEP

Other. Specify: _____________________________

P4. Where have you heard about PrEP the most?

Select one response

Sex partners

Friends or family

Health providers or counselors

Sex or dating websites

Other social media (e.g. Facebook, Instagram, Snapchat

News media

Advertisements around town

Other. Specify: __________________________________

P5. Which one of the following statements best reflects your thoughts about taking PrEP in the future?

Select one response

I plan to take PrEP someday

I plan to take PrEP in the next 6-12 months

I plan to take PrEP in the next 1-5 months

I plan to start PrEP in the coming weeks

I don’t know enough about PrEP to answer

I plan to never take PrEP

I am not sure

Thank you for your valuable input on this survey!