Form Approved
OMB No. 0920-1100
Expiration Date: XX/XX/XXXX
Identification of behavioral and clinical predictors of early HIV infection
(Project DETECT)
Attachment 6a
Phase 1 Enrollment Survey A (English)
Public reporting burden of this collection of information is estimated to average 45 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 (0920-1100)
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); and Sections 304, 306 and 308(d) which discuss authority to maintain data and provide assurances of confidentiality 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: 1) characterize the performance of new HIV tests for detecting established and early HIV infection at the point of care (POC), relative to each other and to currently used gold standard, non-POC tests, and 2) identify behavioral and clinical predictors of early HIV infection.
FP-1 UW Study ID: _______________
FP-2 CDC Study ID: _______________
FP-3 Visit Date: MM/DD/YYYY
FP-4 HIV status:
HIV-negative/unknown
Established Chronic HIV infection – diagnosis >3 months ago
Newly Diagnosed Chronic HIV infection – diagnosed in last 3 months
Acute HIV infection
HIV-positive, timing unknown
CONSENT
We’ve
already discussed the following two questions with you but would like
to document your answers electronically. If you have any questions
about what we’re asking, please talk to study staff before
responding.
CT-1 Do you agree to take part in the study?
Yes
No
CT-2 We ask you to agree to freeze part of the blood and oral fluid specimens you give us at the CDC for future use. We may use these samples for research in the future. Nothing that could be linked to you will be kept with the blood. We are not sure what studies might be done in the future. They might include standard tests as done at hospitals, tests for HIV or other viruses or on your immune system (ability to fight infection). We will not test for genetic problems or use the blood for cloning or commercial purposes.
I give consent for my blood to be stored at CDC for the
future use as outlined above.
I DO NOT give consent for my blood
to be stored at CDC for future research.
If CT-1 or CT-2 = No, participant has declined participation in the study. Screen will say, “Please pause the survey here and talk to study staff.” Study staff will discuss the responses with the participant and address any questions or concerns. If participant does not want to participate, study staff will end the survey and withdraw participant from the study. If participant does want to participate and responded inaccurately for any reason, study staff will help the participant navigate back to these questions and answer them correctly, so the participant can proceed with the remainder of the survey.
SOCIODEMOGRAPHICS 1
In this first set of questions, we would like to know how you describe yourself.
SU-1 Are you male, female or transgender?
Male
Female
Transgender Male to Female
Transgender Female to Male
SU-2 In the past year, have you had sex with males, females, or both males and females?
Sex includes any oral, anal or vaginal sex.
Males only
Females only
Both Males and Females
Have not had sex in the last year.
MEDICAL CARE AND HIV TESTING
The next set of questions will ask you about where you get medical care and where and how often you have been tested for HIV.
HT-1 Do you have a regular health care provider?
Yes
No
HT-2 [If SU-1 = Male, Transgender Male to Female, or Transgender Female to Male AND SU-2 = Males only or Both Males and Females:] Does your regular health care provider know that you have sex with men?
Yes
No
HT-3 In the past 12 months, approximately how many times have you seen a healthcare provider?
0 times
1-4 times
5-9 times
10 times or more
Don't know
[HIV-negative/unknown participants only:]
HT-4 Have you ever had an HIV test before today?
Yes
No
[If HT-4 = Yes:] HT-5 How do you usually decide when to test for HIV? Choose the one that best fits how you currently decide to test.
On a regular schedule
After being exposed to HIV
Between sex partners
When I have symptoms of HIV
When I have symptoms of STDs other than HIV
When it’s free and convenient
Other: _____________________
HT-6 About how often do you test for HIV?
Every month
Every 3 months
Every 6 months
Once a year
Once every 2 years
Other: __________
HT-7 What is the main reason you’re getting an HIV test today?
I get tested on a regular schedule and it was time for me to get tested again
I was worried I might have been exposed to HIV
Before having sex with someone new
I had sex with someone new
After stopping having sex someone
I have symptoms of HIV
I have symptoms of STDs other than HIV
My doctor recommended that I get tested
It’s free and convenient
Other: _____________________
HT-8 In the past 12 months, that is, since [insert calculated month and year], how many times have you been tested for HIV?
___ ___ Number of times (0 to N)
HT-9 When was the last time you tested for HIV?
MM/YYYY
HT-10 When you last had an HIV test, what was the result?
Positive
Negative
Unknown
[IF HT-10 = Negative/Unknown:] HT-11 Have you ever tested HIV positive?
Yes
No
Unsure
[If HT-10 = Positive:]
HT-12 Was that your first positive HIV test?
Yes
No
Unsure
[If HT-12 = No OR FP-4 indicates positive:]
HT-19 What was your last viral load? If you were told that your viral load was undetectable OR detectable but so low that the test cannot tell you the actual number, please check “Undetectable”.
Undetectable
Detectable
Do not know
PRE-EXPOSURE PROPHYLAXIS
[Ask section of everyone except those HIV Positive with first positive test > 3 months ago.]
This next set of questions is about your experiences taking HIV medicines to prevent yourself from getting HIV. This can also be called Pre-Exposure Prophylaxis or PrEP.
PR-1 In the last 3 months (since [current month/year – 3 months]) have you taken HIV medicines to prevent yourself from getting HIV?
Yes
No
Don't remember
[If PR-1 = Yes:] PR-2 Are you currently taking medicines to prevent yourself from getting HIV?
Yes
No
[If PR-1 = Yes:] PR-3 When did you last start taking HIV medicines to prevent yourself from getting HIV?
MM/YYYY
Don’t know
[If PR-1 = Yes and PR-2 = No:] PR-4 When did you last stop taking HIV medicines to prevent yourself from getting HIV?
MM/YYYY
Don’t know
STD HISTORY
The next set of questions will ask about sexually transmitted infections other than HIV that you may have had in the last 3 months.
SD-1 In the last 3 months has a health care provider told you that you had an STD other than HIV?
Yes
No
SD-2 You said a healthcare provider told you that you had an STD in the last 3 months. Which one(s)? Check all that apply:
Gonorrhea
Chlamydia
Syphilis
Other
[If SD-2 = Other:] SD-3 Other Specify (Text field)
SYMPTOMS
[Ask section of everyone except “Established Chronic HIV infection”.]
The next set of questions will ask about symptoms like fever or a sore throat that you may have had in the last 3 months.
SY-1 In the past 3 months (that is, since insert date) have you had any of these symptoms? Check all that apply.
Sore throat
Fever
Nausea
Vomiting
Diarrhea
Headache
Fatigue
Soreness or pain in your joints
Soreness or pain in your lymph nodes
Body Rash
I haven’t experienced any of these symptoms in the last 3 months
For any checked symptoms:
SY-2a-SY-2j You said you had [insert symptom] in the past 3 months. Do you have [insert symptom] today?
Yes
No
SY-3a- SY-3j When did you first experience this symptom? MM/DD/YYYY
[If SY-2a-SY-2j = No:] SY-4a-SY4j When did you last experience this symptom?
MM/DD/YYYY
If reported any symptoms:
SY-5 Did you come here today because of your symptom(s)?
Yes
No
SY-6 Did you go to a doctor or health care provider before today because of your symptom(s)?
Yes
No
[If SY-6 = Yes:] SY-7 Did you get tested for HIV when you went to the doctor?
Yes
No
I don’t know
[If SY-6 = Yes:] SY-8 Did the doctor or another health care provider talk to you about testing for acute HIV infection and the “window period” for HIV tests?
Yes
No
[If SY-7 = Yes:] SY-9 What type(s) of HIV tests did they do at the doctor’s? Check all that apply.
Rapid test on oral fluid
Rapid test on finger stick
Blood draw for other HIV test
I don’t know
SY-10 Did you miss work or school because of your symptom(s)?
Yes
No
[If SY-6=Yes:] SY-11 Were you hospitalized because of your symptom(s)?
Yes
No
[If SY-5=No and SY-6=No:] SY-12 What were the reason(s) you did not go to the doctor for your symptom(s)? Check all that apply.
I didn’t know where to go
I was worried about how much it might cost
I didn’t know my symptoms could be a sign of HIV infection
I thought I had the flu
I wanted to wait to get my regular HIV test
I wanted to wait until after the “window period”
Other
SUBSTANCE USE
The next set of questions is about drugs that weren’t prescribed for you by a doctor, sometimes called recreational drugs, that you have taken in the last 3 months.
DU -1 Have you used poppers in the last 3 months?
Yes
No
[If DU-1=NO:] DU-2 Have you ever used poppers?
Yes
No
DU-3 In the last 3 months have you injected drugs other than those prescribed by a medical provider?
Yes
No
[If DU-3 = NO:] DU-4 Have you ever injected drugs other than those prescribed by a medical provider?
Yes
No
[If DU-3=YES or DU-4= YES:] DU-5 Which drugs have you injected?
Heroin
Cocaine
Methamphetamine (meth or crystal)
Other
DU-6 In the last 3 months have you used cocaine?
Yes
No
[If DU-6=NO:] DU-7 Have you ever used cocaine?
Yes
No
DU-8 Have you used methamphetamine in the last 3 months?
Yes
No
[If DU-8=NO:] DU-9 Have you ever used methamphetamine (meth or crystal)?
Yes
No
DU-10 In the last 3 months, have you used Viagra, Cialis or Levitra?
Yes
No
[If DU-10=NO:] DU-11 Have you ever used Viagra, Cialis or Levitra?
Yes
No
SEXUAL BEHAVIOR
We will now ask you some questions about sexual experiences you've had in the past 3 months. We only want to know about partners you had oral, anal or vaginal sex with since [insert date from 3 months ago].
Some questions will ask specifically about your sex partners' HIV status and what you did with partners who were HIV positive, HIV negative, and partners whose HIV status you did not know. We know you can't always be sure of a partner's HIV status. Please try to answer the questions based on what you knew and what your partners told you or did not tell you about their HIV status.
We know that it may be difficult to answer some of these questions if one or more of your sex partners do not identify as male or female, or if they are transgender. Except where we ask specifically about transgender partners, please include these sex partners in your responses to the questions about sex with either men or women, whichever you think is most appropriate.
We also know that how people refer to their genitals can be unique and personal. The following questions may use words that don’t perfectly fit how you or your partners refer to your bodies. Please answer the questions about specific sex acts the best that you can.
If SU-1 = Male or Male-to-Female AND SX-1 = “Only men”, ask only Male Sex Partners of Men questions.
If SU-1 = Male or Male-to-Female AND SX-1 = “Only women”, ask only Female Sex Partners of Men questions.
If SU-1 = Male or Male-to-Female AND SX-1 = “Both men and women”, ask Female Sex Partners of Men questions first, followed by Male Sex Partner questions.
If SU-1 = Female or Female-to-Male and SX-1 = “Only men” or “Both men and women”, ask Male Sex Partners of Women questions.
If SX-1 = “Nobody” OR SU-1 = Female or Female-to-Male and “Only women”, skip all remaining sexual behaviour questions.
Female Sex Partners of Men
The next questions are about women you had vaginal or anal sex with in the past 3 months. “Vaginal sex” means you put your penis in her vagina. “Anal sex" means you put your penis in her butt.
FX-1. In the past 3 months, with how many different women did you have vaginal or anal sex?
___ ___ Number of women (1 to N)
77 I prefer not to answer
FX-2. With how many of these [FX-1] women did you have vaginal or anal sex without using a condom or not using it the whole time?
___ ___ Number of women (0 to N)
I prefer not to answer
Check to make sure FX-1 ≤ FX-2. 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 3 months. Please carefully re-enter your response.”, and loop back to enter the number.
FX-3. In the past 3 months, how many of these [FX-2] women you had vaginal or anal sex without using a condom were:
HIV positive? ___ ___ Number of women (0 to N)
HIV negative? ___ ___ Number of women (0 to N)
Women whose HIV status you did not know? ___ ___ (0 to N)
I prefer not to answer
Check to make sure that the numbers in FX-3 add up to the total N from FX-2. If not, then display “The number of HIV positive, HIV negative and HIV status unknown partners must add up to [FX-2]. Please carefully re-enter your responses.”, and loop back to enter the numbers.
Male Sex Partners of Women
The next questions are about men you had vaginal or anal sex with in the past 3 months. “Vaginal sex” means he put his penis in your vagina. “Anal sex" means he put his penis in your butt.
FM-1. In the past 3 months, with how many different men did you have vaginal or anal sex?
___ ___ Number of men (1 to N)
I prefer not to answer
FM-2. With how many of these [FM-1] women did you have vaginal or anal sex without using a condom or not using it the whole time?
___ ___ Number of men (0 to N)
I prefer not to answer
Check to make sure FM-1 ≤ FM-2. 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 vaginal or anal sex with in the past 3 months. Please carefully re-enter your response.”, and loop back to enter the number.
FM-3. In the past 3 months, how many of these [FM-2] men you had vaginal or anal sex without using a condom were:
HIV positive? ___ ___ Number of men (0 to N)
HIV negative? ___ ___ Number of men (0 to N)
Men whose HIV status you did not know? ___ ___ (0 to N)
I prefer not to answer
Check to make sure that the numbers in FM-3 add up to the total N from FM-2. If not, then display “The number of HIV positive, HIV negative and HIV status unknown partners must add up to [FM-2]. Please carefully re-enter your responses.”, and loop back to enter the numbers.
FM-4. Did any of the [FM-1] men you had sex with in the last 3 months also have sex with men?
Yes
No
Don’t know
Male Sex Partners of Men
The next questions are about men you had sex with in the past 3 months. “Oral sex” means you put your penis in his mouth, or he put his penis in your mouth. “Anal sex" means you put your penis in his butt, or he put his penis in your butt.
SX-1. In the past 3 months, with how many different men did you have oral or anal sex?
___ ___ Number of men (1 to N)
I prefer not to answer
SX-2. In the past 3 months, with how many different men did you have anal sex?
___ ___ Number of men (1 to SX-1)
I prefer not to answer
SX-3. In the past 3 months, of the (SX-2) men you had anal sex with, with how many different men did you have anal sex without a condom?
___ ___ Number of men (1 to SX-2)
I prefer not to answer
The next few questions will ask about times you had sex with more than one man in the same encounter. For these questions, a threesome involves sex with you and two other men. Group sex involves sex with you and at least 3 other men. When the question asks about the number of partners you had during a threesome or group sex, please write the total number of different partners you had across all encounters.
GS-1: In the past 3 months, how many times did you have sex with more than one man in the same encounter? (Threesome or group sex)
____ Number of events (times you had sex with more than one man in the same encounter)
I prefer not to answer
[If GS-1 > 0:] GS-2: In the past 3 months, how many times did you have sex with only two other men in the same encounter (a threesome)?
____ Number of events (times you had a threesome) (0 to GS-1)
I prefer not to answer
[If GS-2 > 0:] GS-3: In the past 3 months, in these [GS-2] threesomes, with how many different men did you have anal sex?
___ Total number of men with whom you had anal sex during a threesome (0 to SX-2)
I prefer not to answer
[If GS-3 > 0:] GS-4: In the past 3 months, of the [GS-3] men you had anal sex with during threesomes, with how many different men did you have anal sex without a condom?
___ Total number of men with whom you had anal sex without a condom (0 to SX-3)
I prefer not to answer
[If GS-4 > 0:] GS-5: Of the [GS-4] men with whom you had anal sex without condoms during threesomes, how many were:
___ HIV-Positive
___ HIV-Negative
___ Didn’t know his/their HIV status
[If GS-1 > 0 & GS-2 < GS-1:] GS-6: In the past 3 months, how many times did you have sex with 3 or more other men in the same encounter (group sex)?
____ Number of events (times you had sex with three or more other men) (0 to GS-1)
I prefer not to answer
[If GS-6 > 0:] GS-7: In the past 3 months, in these [GS-6] times you had group sex (sex with 3 or more other men), with how many different men did you have anal sex?
___ Total number of men with whom you had anal sex during group sex (0 to SX-2)
I prefer not to answer
[If GS-7 > 0:] GS-8: In the past 3 months, of the [GS-7] men you had anal sex with during group sex, with how many different men did you have anal sex without a condom?
___ Total number of men with whom you had anal sex without a condom (0 to SX-3)
I prefer not to answer
[If GS-8 > 0:] GS-9: Of the [GS-8] men with whom you had anal sex without condoms during group sex, how many were:
___ HIV-Positive
___ HIV-Negative
___ Didn’t know his/their HIV status
In the next section we will ask you more about the SX-2 men you had anal sex with.
Partner-Specific Questions
If SX-2 = 1 ask Partner 1 questions
If SX-2 = 2 ask Partner 1 and Partner 2 questions
If SX-2 = 3 ask Partner 1, Partner 2 and Partner 3 questions
If SX-2 ≥ 4 ask Partner 1, Partner 2, Partner 3 and Questions for ≥ 4 partners
SX-4 Please enter a nickname or initials for the [insert number from SX-2 if < 3, or insert 3] most recent men you had anal sex with since [insert date from 3 months ago].
We do not want to know the names of your partners. Please choose a nickname or initials that you will remember and that will best help you identify that person.
Display options below based on number from SX-2
Partner 1 __________
Partner 2 __________
Partner 3 __________
SX-5. For each sex partner listed, indicate, each month you had sex with that partner
Calendar created as follows:
Each named partner has a row
Each of the last 3 months is provided in a column
Response is required in each row
Partner |
Month 3 ago |
Month 2 ago |
Month current |
Nickname 1 |
|
|
|
NickName2 |
|
|
|
NickName3 |
|
|
|
Ask this question for any partners with overlap in SX-5:
SX-6 You indicated that you had sex with both [partner X] and [partner Y] in the month of [Month Z].
Which of these statements about [Month Z] is most correct?
I last had sex with [partner X] before I had sex with [partner Y]
I last had sex with [partner Y] before I had sex with [partner X]
I was having sex with both [partner X] and [partner Y] during the same time period
Don’t know
Thank you for telling us the months in which you had sex with your partners. The next page will ask some questions to help us better understand what you just told us about your sexual partnerships. Click Next to continue
SX-7 Did you have sex with [insert partner initials] once, or more than once during the last 3 months?
Once
More than once
[If had sex “more than once”, then the participant next completes the sections pertaining to dates of first and last sex].
[If had sex “once”, then the participant is skipped to the “One-time partner” section].
“More than once”
Date of first sex
SX-8 When did you first have anal sex with [insert partner initials]?
You may enter just the month and year, but if you know the exact date, please enter that instead.
If you are unsure of when you first had sex, try to select a time that you think is close. It is OK if you first had sex with [insert partner initials] longer than 3 months ago; we still would like to know the first time you had anal sex with him.
i: (drop-down box with months. “don’t know the month” is provided as option)
ii: (drop-down box with years) “don’t know the year” is provided as option)
OR
i: MM/DD/YYYY (calendar button)
[ERROR: The time you first had sex with [insert partner initials] cannot be in the future. Please correct the date.]
[ERROR: Please select either the month and year OR the date you first had sex with [insert partner initials].]
[if year is selected as “don’t know the year”:]
SX-8a. It’s OK if you can’t remember the exact year. Can you remember about how many years ago you first had sex with [insert partner initials]?
Less than 1 year ago
1 – 2 years ago
2 – 5 years ago
5 – 10 years ago
more than 10 years ago
[if month is selected as “don’t know the month” but year is known:]
SX-8b. It’s OK if you can’t remember the exact month. Think back to the time in [Year of first sex] when you first had sex with [insert partner initials]. Perhaps you had sex around a special time of the year such as your birthday, or a holiday like July 4th or Halloween. Maybe you can remember that it was warm outside or it was after a trip you took. Based on what you can recall, try to select what time during [Year of first sex] you first had sex with [insert partner initials]:
January - March
April - June
July - September
October - December
Don't know when during the year
[ERROR: The time during the year you indicated for when you first had sex with [insert partner initials] is in the future. Please correct this.]
Date of last sex
SX-9 You indicated that you last had sex with [insert partner initials] in the month of [month of last sex from SX-5]. Is this correct?
Yes
No
[If SX-9 = Yes:] SX-10 Do you know the exact date on which you last had sex with [insert partner initials]?
Yes
No
[If SX-10 = Yes:] SX-11 Please enter the date: MM/DD/YYYY (calendar button)
[If SX-10 = No:] That’s OK. The information that you have provided us with is still extremely helpful.
[If SX-9 = No:] SX-12 That’s OK. Please correct our records about when you last had sex with [insert partner initials] using the spaces below. You may pick one of the last 3 months, but if you know the exact date, please enter that instead. If you are unsure of when you last had sex, try to select a time that you think might be close.
(drop-down box with the last 6 months. “don’t know the month” is now not provided as option.)
OR
same date field as above:
MM/DD/YYYY (calendar button)
[ERROR: The date you last had sex with [insert partner initials] cannot be in the future. Please correct the date.]
[ERROR: Please select either the month and year OR the date you last had sex with [insert partner initials]]
[ERROR: The date you gave for the last time you had sex with [insert partner initials] is more than 6 months ago (before [insert date of first sex]). Please correct the date.]
[For one-time partners:]
SX-13 Do you remember the exact date that you had sex with [insert partner initials]?
Yes
No
[If SX-13 = Yes:] SX-14 What was the date that you had anal sex with [insert partner initials]?
MM/DD/YYYY
For Each Partner:
SX-15 Which of the following statements about [insert partner initials]’s age is most true?
He is more than 10 years younger than I am
He is 2-10 years younger than I am
He is within a year of my age
He is 2-10 years older than I am
He is more than 10 years older than I am
Don't know
SX-16 Is [insert partner initials] Hispanic?
Yes
No
Don’t know
SX-17 What is [insert partner initials]’s race? Check all that apply.
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Don’t know
SX-18 Is/was [insert partner initials] someone that you feel or felt committed to (someone you might call your boyfriend, significant other, life partner, or husband)?
Yes
No
Don't know
SX-19 If you had to further describe the type of sex partner [insert partner initials] is/was, which of the following would you choose? Someone who …
is a primary sexual partner
you have sex with on a regular basis, <i>but who is not a main or primary partner</i>
you have had sexual contact with more than once, <i>but not on a regular basis</i>, and who you normally socialize with
you have had sexual contact with more than once, <i>but not on a regular basis</i>, and who you don’t socialize with
you had sexual contact with only 1 time, but could find again if necessary
you had never met before you had had sexual contact and never plan to see again
you gave sex to for money or other goods or someone who gave you sex for money or other goods
SX-20 Where did you first meet [insert partner initials]?
Through friends
School or work
Online
Phone app
Circuit party or Rave
At church
Through a personal ad in a newspaper
On a telephone chat line or dating line
Bar/Club
Cruising area
On the street
Adult bookstore
Bath house
Sex club
Sex resort
Private sex party
Sports club or gym
Vacation or cruise
Social organization
Other
if “Internet”:
SX-20b Through which online service did you first meet [insert partner initials]?
CraigsList
Adam4Adam
BarebackRT
Manhunt
OkCupid
GuySpy
FindFred
Friendster
MySpace
Other, please specify: _________________
If “Phone app”:
SX-20c Through which phone app did you first meet [insert partner initials]?
Grindr
Scruff
Jackd
Hornet
Adam4Adam
Growlr
GuySpy
Skout
BoyAhoy
Other, please specify: _________________
SX-21 Did you share your HIV status with [insert partner initials] before you first had sex?
Yes
No
Don’t know
SX-22 Did [insert partner initials] share his HIV status with you before you first had sex?
Yes
No
Don’t know
[If SX-22 = Yes:] SX-23 What was [insert partner initials]’s HIV status at that time?
HIV-negative
HIV-positive
[If SX-23 ≠ “HIV-positive”] SX-24 To the best of your knowledge, what is [insert partner initials]'s HIV status today?
HIV-negative
HIV-positive
Don’t know
For HIV-negative partners:
SX-25 To the best of your knowledge, is [insert partner initials] currently taking medicine to prevent himself from getting HIV? This might also be known as Pre-Exposure Prophylaxis or PrEP.
Yes
No
I don’t know
For HIV-positive partners:
SX-26 To the best of your knowledge, is [insert partner initials] currently taking medicines for HIV?
Yes
No
I don’t know
SX-27 To the best of your knowledge, does [insert partner initials] have an undetectable viral load?
Yes
No
I don’t know
For all partners:
SX-28 In the past 3 months (since [current month - 3]), how many times did you and [insert partner initials] have anal sex?
___ ___ Number of times (0 to N)
[If SX-28 = 1:] SX-29 When you had anal sex with [partner initials] did you have anal sex without using a condom or not using it the whole time?
Yes
No
[If SX-28 > 1:] SX-30 In the past 3 months (since [current month - 3]), how many times did you and [partner initials] have anal sex without using a condom or not using it the whole time?
___ ___ Number of times (0 to N)
[If SX-29 = Yes or SX-30 >0:] SX-31 In the past 3 months (since [current month - 3]), when you and [insert partner initials] had anal sex without a condom were you the top (your penis in his butt), bottom (his penis in your butt) or both? Check only one.
Both top and bottom
Top only
Bottom only
[For repeat partners:]
SX-32 In the last 3 months (since [current month - 3]), during the time you were having sex with [insert partner initials], did [insert partner initials] have sex with anyone else?
Yes
No
Don't know
The next few questions will ask about times you and [partner initials] had sex with at least one other man together in the same encounter. For these questions, a threesome involves sex with you, [partner initials], and one other man (a total of 3 men). Group sex involves sex with you, [partner initials], and at least 2 other men (a total of 4 or more men). When the question asks about the number of partners you had during a threesome or group sex, please write the total number of different partners you had across all encounters.
SX-33 In the last 3 months (since [current month - 3]), did you and [insert partner initials] ever have sex with other people in the same encounter? (Threesome or group sex)
Yes
No
Don't know
[If SX-33 = “Yes”:] GS-10: In the past 3 months how many times did you and [partner initials] have sex with only one other man in the same encounter (threesome)?
___ Number of times (encounters involving sex with [partner initials] and 1 other man)
[If GS=10 > 0:] GS-11: Think of the most recent time you had a threesome with [partner initials].
Did anyone have anal sex during this threesome?
Yes
No
[If GS-11=”Yes”] GS-12 Did anyone have anal sex without a condom during this threesome?
Yes
No
[If GS-12 =”Yes”] GS-13 Who had anal sex without a condom with each other in this threesome? Mark all that apply.
I had anal sex without a condom with [partner initials]
I had anal sex without a condom with the 3rd partner
[Partner initials] had anal sex without a condom with the 3rd partner.
GS-14 What was the HIV status of the 3rd Partner?
HIV-Positive
HIV-Negative
Didn’t know his HIV status
[If SX-33 = “Yes”:] GS-15: In the past 3 months how many times did you and [partner initials] have sex with 2 or more other men in the same encounter (group sex)?
___ Number of times (encounters involving sex with you, [partner initials] and 2+ other men)
[If GS-15 > 0:] GS-16: Think of the most recent time you had group sex with [partner initials] and at least two other men. How many men took part in this group sex encounter? Include [partner initials], but not yourself.
___ Total number of men your last group sex encounter with [partner initials]
[If GS-16 > 0:] GS-17: Of these [GS-16] men involved in the last time you had group sex with [partner initials], how many were:
___ HIV-Positive
___ HIV-Negative
___ Didn’t know their HIV status
[If GS-16 > 0. Create table with columns for each partner mentioned in GS-16.] GS-18: In the table below, please mark which pairs of guys had anal sex without a condom during your most recent group sex encounter that included [partner initials].
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Partner initials |
3rd |
4th |
Up to GS-16+1 |
You |
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Partner initials |
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3rd |
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4th |
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Up to GS-16 + 1 |
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SX-34 Was [insert partner initials] diagnosed with an STD in the last 3 months (since the beginning of [current month - 3])?
Yes
No
Don’t know
[If 2 partners named:] SX-35 Did [insert partner 1 initials] and [insert partner 2 initials] have sex with each other in the last 3 months, or do you think they probably have?
Yes
No
Don’t know
[If >2 partners named:] SX-36 If you know that two of these partners had sex with each other in the last 3 months, or think they probably have, click the box that matches both partners’ nicknames on the grid.
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Partner 1 |
Partner 2 |
Partner 3 |
Partner 1 |
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Partner 2 |
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Partner 3 |
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Thank you for telling us about [Partner X].
Next, we'd like to ask you about [Partner X+1].
Partner 1 section replicated for partners 2 and 3, but excluded here for brevity.
Questions for ≥ 4 male sex partners
The next questions are about the [(SX-2) – 3] men you had anal sex with in the past 3 months other than [insert nicknames from SX-4].
SX-37 Were any of the [(SX-2)-3] men you had anal sex with in the past 3 months someone that you feel or felt committed to (someone you might call your boyfriend, significant other, life partner, or husband)?
Yes
No
Don't know
[If SX-37 = Yes:] SX-38 How many of the men you had anal sex with in the past 3 months were someone that you feel or felt committed to (someone you might call your boyfriend, significant other, life partner, or husband)?
____ Number of partners
SX-39 If you had to further describe the type of sex partners for the other [(SX-2)-3] men you had anal sex with in the past 3 months, which of the following would you choose? Pick only one description for each partner, then place a number next to each partner type description. If none of your [(SX-2)-3] partners fit that description use a zero (0).
____ a primary sexual partner
____ you have sex with on a regular basis, <i>but who is not a main or primary partner</i>
____ you have had sexual contact with more than once, <i>but not on a regular basis</i>, and who you normally socialize with
_____you have had sexual contact with more than once, <i>but not on a regular basis</i>, and who you don’t socialize with
_____you had sexual contact with only 1 time, but could find again if necessary
_____you had never met before you had had sexual contact and never plan to see again
_____you gave sex to for money or other goods or someone who gave you sex for money or other goods
Check to make sure that the numbers in SX-39 add up to (SX-2) - 3. If not, then display “The number of partners must add up to [(SX-2) - 3]. Please carefully re-enter your responses.”, and loop back to enter the numbers.
SX-40. With how many of these [(SX-2) – 3] men did you have anal sex without using a condom or not using it the whole time?
___ ___ Number of men (0 to N)
Check to make sure SX-40 ≤ (SX-2) – 3. If not, then display “The number of other men you had anal sex without using a condom cannot be more than the total number of men you had anal sex with in the past 3 months. Please carefully re-enter your response.”, and loop back to enter the number.
SX-41. In the past 3 months, how many of these [SX-40] men that you had anal sex without using a condom were:
HIV positive? ___ ___ Number of men (0 to N)
HIV negative? ___ ___ Number of men (0 to N)
Men whose HIV status you did not know? ___ Number of men (0 to N)
Check to make sure that the numbers in SX-41 add up to the total N from SX-40. If not, then display “The number of HIV positive, HIV negative and HIV status unknown partners must add up to [SX-40]. Please carefully re-enter your responses.”, and loop back to enter the numbers.
DEMOGRAPHICS 2
This next section will ask a few last questions about your work, income, and housing situation.
DE-1 What is the highest grade in school you completed?
Less than high school
Some high school
High school diploma or GED
Some college, Associate’s degree, or Technical degree
College graduate
Post graduate or professional school
I prefer not to answer
The next question is about 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.
DE-2 Please choose if you would like to answer in terms of monthly income or yearly income:
$ per month
$ per year
DE-3 What was your household income last year from all sources before taxes?
0 to $1667 per month
$1668 to $3333 per month
$3334 to $6250 per month
$6251 or more per month
I prefer not to answer
I don't know
DE-4 What was your household income last year from all sources before taxes?
0 to $19,999 per year
$20,000 to $39,999 per year
$40,000 to $74,999 per year
$75,000 or more per year
I prefer not to answer
I don't know
DE-5 In the past 12 months, have you been homeless at any time? By homeless, I mean you were living on the street, in a shelter, a Single Room Occupancy hotel (SRO), temporarily staying with friends or relatives, or living in a car?
Yes
No
Don't know
[If DE-5 ≠ No:] DE-6 Are you currently homeless?
Yes
No
Don't know
DE-7 Do you currently have health insurance? (This includes Medicare, Medicaid, Apple Health, and others.)
Yes
No
Don't know
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | CDC User |
| File Modified | 0000-00-00 |
| File Created | 2021-03-29 |