0920-22HR Att 3 Web-Based Survey

Data Collection Through Web Based Surveys for Evaluating Act Against AIDS Social Marketing Campaign Phases Targeting Consumers

Att 3 Web-Based Survey

OMB: 0920-0920

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Download: docx | pdf


Form Approved

OMB No: 0920-0920

Exp. Date: 05/31/2022







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 use the browser “Back” button to go back in the survey. Please use the “back” and “next” buttons within the survey itself.

SECTION 1: AWARENESS OF AND PERCEPTIONS OF CDC

  1. 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



  1. 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



  1. 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

SECTION 2: SELF-PERCEIVED RISK AND RISK BEHAVIORS



  1. Please tell us how much you disagree or agree with each of the following statement:  

I am familiar with all the ways to prevent HIV when having sex.

1 Strongly disagree

2 Disagree

3 Neither disagree nor agree

4 Agree

5 Strongly agree

99 Prefer not to answer


  1. 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



  1. You indicated that you consider yourself to be at [insert response from Q5]. What are some reasons for this? [OPEN-ENDED]

99 Prefer not to answer



  1. 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



  1. 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





[ONLY IF 8 = YES]

  1. 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

99 Prefer not to answer

SECTION 3: CONDOM AWARENESS, USE AND BELIEFS

[ONLY IF S9 = YES]

  1. In the past [6 months/12 months], how often did you and your sexual partner(s) use condoms for sex?

1 Never

2 Occasionally

3 Usually

4 Always

99 Prefer not to answer



  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.



  1. Please tell us how much you disagree or agree with each of the following statements.

Strongly disagree

Disagree

Neither disagree nor agree

Agree

Strongly agree

Prefer not to answer

  1. It takes a lot of effort for me to always have safer sex.

1

2

3

4

5

99

  1. I feel tired of always having to monitor my sexual behavior.

1

2

3

4

5

99

  1. I find it difficult to maintain my commitment to safer sex.

1

2

3

4

5

99

  1. [INSERT SAFE-SEX FATIGUE ITEM]

1

2

3

4

5

99



  1. 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. feels just as good as without condoms








e. [insert belief here]

1

2

3

4

5

88

99



  1. 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 belief here]

1

2

3

4

5

99



  1. 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. I am confident that I can talk to my sex partner about [using condoms].

1

2

3

4

5

99

  1. I am confident that I can talk to my healthcare provider about [condoms].

1

2

3

4

5

99

  1. I am confident that I know where and how to get condoms.

1

2

3

4

5

99

  1. I am confident that I can [insert behavior here].

1

2

3

4

5

99

  1. Are you currently using any type of birth control or family planning methods?

1 Yes

2 No

88 Don’t know

99 Prefer not to answer



[ONLY IF 16 = YES]

  1. What method of birth control or family planning are you currently using? [SELECT ALL]

1 Birth control pills

2 Injectable

3 Ring

4 IUD

5 Fertility Tracking/Rhythm Method

6 Condoms

7 Withdrawal

99 Prefer not to answer


  1. How many living children do you have, that you have given birth to?

(98) Do not know

(99) No response


  1. What is your ideal number of children to have in your lifetime?

(98) Don’t Know

(99) No response


  1. In the next year, what do you think is the chance that you will become pregnant?

(0) No chance

(1) Some chance

(2) A very high chance

(3) Already pregnant

(98) Don’t Know

(99) No response


SECTION 4: PrEP AWARENESS, USE AND BELIEFS

  1. PrEP, or pre-exposure prophylaxis (also known as Truvada or Descovy), is an FDA-approved medicine that can be used to prevent HIV for people who are HIV-negative. To be protected with PrEP, you have to take a pill every day. 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



  1. 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



[ONLY HIV NEGATIVE OR NOT TESTED PARTICIPANTS]

  1. [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



[ONLY HIV NEGATIVE OR NOT TESTED PARTICIPANTS]

  1. 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.



[ONLY HIV NEGATIVE OR NOT TESTED PARTICIPANTS]

  1. 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



[ONLY HIV NEGATIVE OR NOT TESTED PARTICIPANTS]

  1. 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



[ONLY HIV NEGATIVE OR NOT TESTED PARTICIPANTS]

  1. 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

  1. is expensive.

1

2

3

4

5

88

99

  1. is inconvenient.

1

2

3

4

5

88

99

  1. allows me to have sex without a condom with partners who are HIV positive.

1

2

3

4

5

88

99

  1. is for someone like me.

1

2

3

4

5

88

99

  1. is covered by insurance

1

2

3

4

5

88

99

  1. is for women like me. 

1

2

3

4

5

88

99

  1. would give me peace of mind. 

1

2

3

4

5

88

99

  1. might make me more likely to have sex without a condom. 

1

2

3

4

5

88

99

  1. would make my partner think that I am not being faithful. 

1

2

3

4

5

88

99

  1. would out me as someone who could get HIV

1

2

3

4

5

88

99

  1. is only for gay men

1

2

3

4

5

88

99

  1. is a way to care for myself.

1

2

3

4

5

88

99

  1. [insert belief statement]









[ONLY HIV NEGATIVE OR NOT TESTED PARTICIPANTS]

  1. 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 belief statement]

1

2

3

4

5

99

g. PrEP is safe to take while pregnant or breastfeeding.

1

2

3

4

5

99

h. PrEP is safe to take while using hormonal birth control

1

2

3

4

5

99


  1. Please indicate how much you disagree or agree with the following statement.

Strongly disagree

Disagree

Neither disagree nor agree

Agree

Strongly agree

Prefer not to answer

  1. Taking PrEP is a way for [Black women] to take control of their sexual health.

1

2

3

4

5

99



[ONLY HIV NEGATIVE OR NOT TESTED PARTICIPANTS]

  1. Please tell us how much you disagree or agree with each of the following statements:  

[PROGRAMMER: RANDOMIZE ORDER OF ITEMS] 

Strongly disagree 

Disagree 

Neither disagree nor agree 

Agree 

Strongly agree 

Prefer not to answer 

  1. If I wanted to, I could bring up the topic of PrEP with my healthcare provider. 

1

2

3

4

5

99

  1. I am confident that I know where and how to get PrEP. 

1

2

3

4

5

99

 


  1. Please tell us how likely it is that you will do the following in the next 6 months.

[PROGRAMMER: RANDOMIZE ORDER OF ITEMS] 

Very unlikely

Some-what unlikely

Neither unlikely nor likely

Some-what likely

Very likely

Prefer not to answer

  1. Talk to your friends or family members about PrEP.

1

2

3

4

5

99

  1. Talk to your sex partner(s) about PrEP.

1

2

3

4

5

99

  1. Talk to your healthcare provider about PrEP.

1

2

3

4

5

99

  1. Take PrEP if my healthcare provider prescribed it.

1

2

3

4

5

99



[ONLY HIV NEGATIVE OR NOT TESTED PARTICIPANTS]

  1. 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. I am confident that I can talk to my sex partner about [PrEP].

1

2

3

4

5

99

  1. I am confident that I can talk to my healthcare provider about [PrEP].

1

2

3

4

5

99

  1. I am confident that I know where and how to get PrEP.

1

2

3

4

5

99

  1. I am confident that I can [insert behavior here].

1

2

3

4

5

99



[ONLY HIV NEGATIVE OR NOT TESTED PARTICIPANTS]

  1. Please tell us how much you disagree or agree with each of the following statements about PrEP. When taking PrEP.


Strongly disagree

Disagree

Neither disagree nor agree

Agree

Strongly agree

Prefer not to answer

  1. I [may be/am] less likely to inquire about my partner’s HIV status before having sex

1

2

3

4

5

99

  1. I [may be/am] less likely to [ask for/discuss/use condoms].

1

2

3

4

5

99

  1. I [may be/am] more likely to have more adventurous sex.

1

2

3

4

5

99

  1. I think my sexual performance [will be/is] enhanced.

1

2

3

4

5

99

  1. I [may/do] feel more relaxed during sex.

1

2

3

4

5

99

  1. [I think it will be/It is] easier to express my sexual needs or desires.

1

2

3

4

5

99

  1. I think sex [will probably be/is] more loving.

1

2

3

4

5

99

  1. I [may/do] think about sex more often

1

2

3

4

5

99

  1. [INSERT EXPECTANCY ITEM]

1

2

3

4

5

99


[ONLY HIV NEGATIVE OR NOT TESTED PARTICIPANTS]

  1. In the past [4/6/12 months], how often did you talk to a health care provider about PrEP? 

1 Never

2 Rarely

3 Sometimes

4 Often

5 Very often

99 Prefer not to answer


 

  1. 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

  1. My healthcare provider respects me.

1

2

3

4

5

99

  1. I am comfortable talking to my health care provider about my sexual health.

1

2

3

4

5

99

  1. I am comfortable talking to my health care provider about HIV prevention options.

1

2

3

4

5

99

  1. My health care provider routinely offers me HIV testing.

1

2

3

4

5

99

  1. I am comfortable talking to my health care provider about PrEP.

1

2

3

4

5

99


SECTION 5. ART AWARENESS, USE AND BELIEFS [ONLY PARTICIPANTS LIVING WITH HIV]


  1. When did you first test positive for HIV?

Date (mm/yyyy) ____ ______



  1. 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



  1. 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 belief statement]

1

2

3

4

5

88

99



  1. 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



  1. 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



  1. 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.



  1. 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



  1. 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



  1. 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



  1. 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



  1. 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.



  1. 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



  1. 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



  1. 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



  1. Have you heard that if you have an undetectable viral load, you will not transmit HIV to sexual partners?

1 Yes

2 No

88 Don’t know

99 Prefer not to answer



  1. 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 belief statement]

1

2

3

4

5

88

99



  1. [In the past 6 months/In the past 12 months/At your last visit with your healthcare provider,] [have/did] you [ever] [discuss/discussed] viral suppression for sexual HIV prevention [with your healthcare provider]?

1 Yes

2 No

88 Don’t know

99 Prefer not to answer

SECTION 6. HIV COMMUNICATION BEHAVIOR, BELIEFS, NORMS, AND INTENTIONS

Script: Next we would like to ask you some questions about communication and communicating with your partner(s).

  1. 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



  1. 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



  1. 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



  1. 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



  1. 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



  1. 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



  1. 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



  1. 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. Most of my friends and other people close to me think I should talk to my sexual partner(s) about ways to prevent HIV.

1

2

3

4

5

99

  1. Most of my sexual partners think I should talk to them about ways to prevent HIV.

1

2

3

4

5

99

  1. Most people who are important to me talk openly about HIV.

1

2

3

4

5

99

  1. I am confident that I can talk to my sex partner about [INSERT].

1

2

3

4

5

99

  1. I am confident that I can talk to my healthcare provider about [INSERT].

1

2

3

4

5

99

  1. [INSERT statement]

1

2

3

4

5

99



  1. 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. Talk to your friends or family members about [HIV/PrEP/condoms].

1

2

3

4

5

99

  1. Talk to your sex partner about [HIV/PrEP/condoms].

1

2

3

4

5

99

  1. Talk to your healthcare provider about [HIV/PrEP/condoms].

1

2

3

4

5

99

  1. [INSERT intention item]

1

2

3

4

5

99

  1. Be supportive of people who are living with HIV.

1

2

3

4

5

99

  1. Go with someone important to you (e.g., friend, family member) to get tested for HIV.

1

2

3

4

5

99

  1. Find out more about [INSERT].

1

2

3

4

5

99

  1. [Insert call to action related to stigma here].

1

2

3

4

5

99

  1. Share an HIV self-test with a friend, family member, or someone else if two tests were provided for free.

1

2

3

4

5

99

SECTION 7. HIV STIGMA AND DISCRIMINATION

Script: In this section, we are going to ask questions about HIV-related stigma. By stigma, we mean the attitudes or beliefs you or others have about people with HIV. If you feel uncomfortable answering any of these questions, please select “prefer not to answer” and move on to the next questions.

[ONLY PARTICIPANTS LIVING WITH HIV]

  1. Please tell us how much you agree or disagree with each of the following statements:

Strongly disagree

Disagree

[Neither disagree nor agree]

Agree

Strongly agree

Prefer not to answer

  1. I have been hurt by how people reacted to learning I have HIV.

1

2

3

4

5

99

  1. I have lost friends by telling them I have HIV.

1

2

3

4

5

99

  1. I am very careful who I tell that I have HIV.

1

2

3

4

5

99

  1. I worry that people who know I have HIV will tell others.

1

2

3

4

5

99

  1. I feel that I am not as good a person as others because I have HIV.

1

2

3

4

5

99

  1. Having HIV makes me feel [unclean/that I’m a bad person/etc.].

1

2

3

4

5

99

  1. Most people think that a person with HIV is disgusting.

1

2

3

4

5

99

  1. Most people with HIV are rejected when others find out.

1

2

3

4

5

99

  1. [INSERT STATEMENT]

1

2

3

4

5

99



  1. How worried are you that people will treat you in the following ways in the future because of your HIV status?

 

Not worried

A little worried

Worried

Very worried

Prefer not to answer

  1. Family members will [avoid me/ look down on me/treat me differently].

1

2

3

4

99

  1. Healthcare workers will [not listen to my concerns/avoid touching me/treat me with less respect].

1

2

3

4

99

  1. [Insert STATEMENT.]

1

2

3

4

99

SCRIPT: The following questions ask about the different ways people may have treated you in the past because you have HIV. If you feel uncomfortable answering any of these questions, please select “prefer not to answer” and move on to the next questions. As a reminder, your answers will be kept private. This means that your name will not be associated with your answers.

  1. In the past [6 months/12 months], how often have [people treated you in the following ways because of your HIV status/you treated people in the following ways because of their HIV status]? [Please select “Not applicable” if the situation doesn’t apply to you.]

 

[Never]

[Occasionally]

[Usually]

[Always]

[Not applic-able]

Don’t know

Prefer not to answer

  1. [I received poorer services than other people/I provided poorer services to people] in restaurants, stores, other businesses, or agencies.

1

2

3

4

77

88

99

  1. I [was treated/treated someone] unfairly at work or school.

1

2

3

4

77

88

99

  1. I [was excluded/excluded someone] from religious activities.

1

2

3

4

77

88

99

  1. I was denied or given lower quality healthcare.

1

2

3

4

77

88

99

  1. [Someone tried to get me fired from my job/I tried to get someone fired from their job].

1

2

3

4

77

88

99

  1. [My employer denied me opportunities/I denied someone opportunities at work].

1

2

3

4

77

88

99

  1. [Family members (avoided me/treated me differently/etc.)/I (avoided family members/treated family members differently)].

1

2

3

4

77

88

99

  1. Healthcare workers [have not listened to my concerns/ avoided touching me/treated me with less respect/etc.].

1

2

3

4

77

88

99

  1. [Insert STATEMENT]

1

2

3

4

77

88

99

SCRIPT: In this section, we are going to ask about the attitudes and beliefs you or others have about people with HIV. There are also some questions that ask about the different ways you or others may have acted toward people with HIV in the past or would act toward people with HIV in the future. If you feel uncomfortable answering any of these questions, please select “prefer not to answer” and move on to the next questions. As a reminder, your answers will be kept private. This means that your name will not be associated with your answers. 

  1. If you found out that you had HIV, how worried would you be that people you know would reject you? That is, that other people would not want to be associated with you because of your HIV status.

1 Not worried

2 A little worried

3 Worried

4 Very worried

99 Prefer not to answer

  1. In the past [6 months/12 months], how often have [you treated people/have people treated you] in the following ways because of [their/your] HIV status?

     

    [Never]

    [Occasionally]

    [Usually]

    [Always]

    Don’t know

    Prefer not to answer

    1. I refused casual contact with someone living with HIV/ Someone refused casual contact with me.

    1

    2

    3

    4

    88

    99

    1. I judged someone living with HIV/Someone judged me.

    1

    2

    3

    4

    88

    99

    1. I socially isolated a family member or friend because they are living with HIV/A friend or someone in my family socially isolated me because I’m living with HIV.

    1

    2

    3

    4

    88

    99

    1. I talked badly about someone living with HIV/Someone talked badly about me because I’m living with HIV.

    1

    2

    3

    4

    88

    99

    1. I insulted someone living with HIV or called them names/ Someone insulted me or called me names.

    1

    2

    3

    4

    88

    99

    1. I physically attacked or injured someone living with HIV/Someone physically attacked me.

    1

    2

    3

    4

    88

    99

    1. I disclosed a family member or friend’s HIV status to others without their permission/Someone disclosed my HIV status to others without my permission.

    1

    2

    3

    4

    88

    99

    1. I asked a family member or friend to keep their HIV status a secret/Someone asked me to keep my HIV status a secret.

    1

    2

    3

    4

    88

    99

    1. I gossiped about someone’s HIV status and how they may have gotten HIV/Someone gossiped about how I may have gotten HIV.

    1

    2

    3

    4

    88

    99

    1. [INSERT STATEMENT]

    1

    2

    3

    4

    88

    99

  2. How worried would you be about people treating you in the following ways if you were diagnosed with HIV?

     

    Not worried

    A little worried

    Worried

    Very worried

    Prefer not to answer

    1. Family members will [INSERT].

    1

    2

    3

    4

    99

    1. Healthcare workers will [INSERT].

    1

    2

    3

    4

    99

    1. [INSERT STATEMENT]

    1

    2

    3

    4

    99

  3. Please tell us how much you agree or disagree with each of the following statements:

    Strongly disagree

    Disagree

    [Neither disagree nor agree]

    Agree

    Strongly agree

    Prefer not to answer

    1. People with HIV should not feel ashamed of themselves. 

    1

    2

    3

    4

    5

    99

    1. It is reasonable for an employer to fire a person living with HIV.

    1

    2

    3

    4

    5

    99

    1. People with HIV face [verbal abuse/rejection from their peers/ physical abuse/getting kicked out of their homes by their families/etc.].

    1

    2

    3

    4

    5

    99

    1. Most people with HIV do not care if they infect other people.

    1

    2

    3

    4

    5

    99

    1. People should not eat food that has been handled by a person living with HIV.

    1

    2

    3

    4

    5

    99

    1. HIV is punishment for bad behavior.

    1

    2

    3

    4

    5

    99

    1. People who are suspected of having HIV lose respect in the community.

    1

    2

    3

    4

    5

    99

    1. Most people with HIV have had many sexual partners.

    1

    2

    3

    4

    5

    99

    1. People get infected with HIV because they engage in irresponsible behaviors.

    1

    2

    3

    4

    5

    99

    1. It is okay for a healthcare professional to refuse to provide high-quality care or services to a person living with HIV.

    1

    2

    3

    4

    5

    99

    1. I am comfortable discussing HIV with friends or family members.

    1

    2

    3

    4

    5

    99

    1. [Insert statement]

    1

    2

    3

    4

    5

    99

  4. In the past [6 months/12 months], have you [seen people being treated/treated someone] poorly because of their …

    Yes

    No

    Prefer not to answer

    1. HIV status?

    1

    2

    99

    1. Gender identity?

    1

    2

    99

    1. Sexual orientation or sexual practices?

    1

    2

    99

    1. Race or ethnicity?

    1

    2

    99

    1. [Injection] drug use?

    1

    2

    99

    1. [INSERT]

    1

    2

    99

  5. In the past [6 months/12 months], have you confronted, challenged, or educated someone who was stigmatizing and/or discriminating against [you/someone] because of [your/their] HIV status?

1 Yes

2 No

88 Don’t know

99 Prefer not to answer

  1. Please tell us how much you agree or disagree with each of the following statements: Insert call to action related to [stigma/discrimination/prejudice] …

Strongly disagree

Disagree

[Neither disagree nor agree]

Agree

Strongly agree

Prefer not to answer

  1. is important to me.

1

2

3

4

5

99

  1. makes me feel empowered.

1

2

3

4

5

99

  1. will encourage others to do their part to stop HIV [stigma/discrimination/ prejudice].

1

2

3

4

5

99

  1. will encourage others to learn about [stigma/discrimination/prejudice] and how it affects people with HIV.

1

2

3

4

5

99

  1. will make my community better.

1

2

3

4

5

99

  1. is important to my family or friends.

1

2

3

4

5

99

  1. demonstrates my support for people with HIV.

1

2

3

4

5

99

  1. demonstrates my acceptance of people with HIV.

1

2

3

4

5

99

  1. will help change how others [behave toward/treat] people with HIV.

1

2

3

4

5

99

  1. will change the attitudes others have about people with HIV.

1

2

3

4

5

99

  1. [INSERT STATEMENT]

1

2

3

4

5

99



SCRIPT: Now we are going to ask some questions about ways [you/other people] have been treated [by healthcare providers/in the community] because of [your/their] HIV status.

  1. [People with HIV] sometimes sense discrimination from [healthcare providers/people in the community] in different ways. Has anyone in the [healthcare system/community] ever acted in any of the following ways toward you because you [have HIV]?


    Yes

    No

    Don’t know

    Prefer not to answer

    1. Exhibited hostility or a lack of respect toward you?

    1

    2

    88

    99

    1. Given you less attention [than other patients]?

    1

    2

    88

    99

    1. Refused you service?

    1

    2

    88

    99

    1. Avoided touching you?

    1

    2

    88

    99

    1. Wore double gloves when providing care or services to you?

    1

    2

    88

    99

    1. Talked badly about you?

    1

    2

    88

    99

    1. Insulted you or called you names?

    1

    2

    88

    99

    1. [INSERT behavior]

    1

    2

    88

    99

  2. Thinking about the times you sensed discrimination from [healthcare providers/people in the community], did you think it occurred because of your …

Yes

No

Don’t know

Prefer not to answer

  1. HIV status?

1

2

88

99

  1. Gender?

1

2

88

99

  1. Sexual orientation or sexual practices?

1

2

88

99

  1. Race or ethnicity?

1

2

88

99

  1. [Injection] drug use?

1

2

88

99

  1. Social class





  1. [INSERT descriptor]

1

2

88

99



  1. In the past [6 months/12 months], have you [been treated poorly/seen other people being treated poorly] in the community (not including healthcare settings) because of [your/their] …

Yes

No

Don’t know

Prefer not to answer

  1. HIV status?

1

2

88

99

  1. Gender?

1

2

88

99

  1. Sexual orientation or sexual practices?

1

2

88

99

  1. Race or ethnicity?

1

2

88

99

  1. [Injection] drug use?

1

2

88

99

  1. [INSERT descriptor]

1

2

88

99

SECTION 7: CAMPAIGN EXPOSURE

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]

  1. In the past [6 months/12 months], do you recall seeing advertising messages focused on ways to prevent HIV?

1 Yes

2 No

88 Don’t know

99 Prefer not to answer



[ONLY IF 75 = 1]

  1. Please list anything you can remember about those advertising messages. If you can remember any key slogans or taglines, please include those as well. [OPEN ENDED]



[ONLY IF 75 = 1]

  1. Please complete the following sentence if you have heard or seen this campaign.

  1. Let’s _________ HIV ________.

  2. Ready, Set, ______________.

  3. Greater Than ______________.

  4. Undetectable =______________.

  5. [INSERT]



[ONLY IF 75 = 1]

  1. 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. Let’s Stop HIV Together

1

2

8

99

  1. Greater Than AIDS

1

2

8

99

  1. Ready, Set, PrEP.

1

2

8

99

  1. Act Against AIDS

1

2

8

99

  1. Undetectable=Untransmittable.

1

2

8

99

  1. [INSERT]

1

2

8

99



[ONLY IF 75 = 1]

  1. 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
1

2

3

4

Very effective
5

Prefer not to answer

2

3

4

5

6

99



[ONLY IF 75 = 1]

  1. 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

SECTION 8: CAMPAIGN AD RECEPTIVITY

[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]

  1. 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. This ad grabbed my attention.

1

2

3

4

5

99

  1. This ad was confusing.

1

2

3

4

5

99

  1. This ad was convincing.

1

2

3

4

5

99

  1. I did not like this ad overall.

1

2

3

4

5

99

  1. This ad said something important to me.

1

2

3

4

5

99

  1. I learned something new from this ad.

1

2

3

4

5

99

  1. This ad gave me good reasons to [insert].

1

2

3

4

5

99

  1. This ad was empowering.

1

2

3

4

5

99

  1. This ad would motivate me to [insert].

1

2

3

4

5

99

  1. This ad stereotypes people who are at risk for getting HIV.

1

2

3

4

5

99

  1. This ad stereotypes people with HIV.

1

2

3

4

5

99

  1. This ad spoke to me.

1

2

3

4

5

99

  1. I liked this ad overall.

1

2

3

4

5

99

  1. This ad was offensive.

1

2

3

4

5

99

  1. This ad confirmed what I already knew about how to prevent HIV.

1

2

3

4

5

99

  1. This ad convinced me that [INSERT BEHAVIOR] is an effective way to prevent HIV.

1

2

3

4

5

99

  1. I like the photo/image in the ad.

1

2

3

4

5

99

  1. I can relate to the photo/image in the ad.

1

2

3

4

5

99

  1. [INSERT]

1

2

3

4

5

99



  1. How would you change this ad to make it better (words/language, image/people, etc.)? [OPEN-ENDED]

99 Prefer not to answer.



  1. You indicated that you liked the ad. What did you like about the ad? [OPEN-ENDED]

99 Prefer not to answer



  1. 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.

  1. 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]



  1. 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



  1. 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



  1. Please explain what, if anything, you did not like about this message. [OPEN-ENDED]

99 Prefer not to answer



  1. 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]



  1. 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. I liked this tagline.

1

2

3

4

5

99

  1. This tagline grabbed my attention.

1

2

3

4

5

99

  1. [INSERT]

1

2

3

4

5

99

[INSERT TAGLINE OPTIONS HERE]

SECTION 9: THEORETICAL CONSTRUCTS

[PERCEIVED NORMS]

SCRIPT: This section asks questions about how the people in your life think and feel about HIV.

  1. 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. Most people who are important to me are accepting of people with HIV.

1

2

3

4

5

99

  1. Most people who are important to me think it is wrong to discriminate against people with HIV.

1

2

3

4

5

99

  1. Most people who are important to me stereotype people with HIV.

1

2

3

4

5

99

  1. Most people who are important to me would think negatively of me if I [insert behavior] to prevent HIV.

1

2

3

4

5

99

  1. [HIV-positive only] Most people who are important to me think I should take HIV medicines (antiretroviral therapy or ART) as prescribed by my doctor.

1

2

3

4

5

99

  1. Most people who are important to me [insert].

1

2

3

4

5

99

  1. [insert perceived norms item here].

1

2

3

4

5

99



SCRIPT: This section asks questions about what you know and believe about HIV.

[KNOWLEDGE]

Demonstrated Knowledge

  1. Please indicate whether the following statements about HIV are true, false, or if you don’t know the answer.

Statement

True

False

Don’t know

Prefer not to answer

  1. People who are HIV negative can take medications (called pre-exposure prophylaxis or PrEP) to prevent getting infected with HIV if they have sex with someone who is HIV positive.

1

2

88

99

  1. [PrEP/condoms/etc.] protects against other sexually transmitted diseases (STDs) like syphilis and gonorrhea.

1

2

88

99

  1. If a person with HIV takes medicine that lowers the amount of virus in their body so much that it cannot be detected by standard blood tests, there is effectively no risk of that person transmitting HIV to an HIV negative sex partner.

1

2

88

99

  1. If a person with HIV has an undetectable viral load, there is effectively no risk of that person transmitting HIV to an HIV negative sex partner.

1

2

88

99

  1. There are medicines available to treat HIV.

1

2

88

99

  1. [INSERT STATEMENT]

1

2

88

99



Self-Perceived Knowledge

  1. Please indicate how much you disagree or agree with the following statements.

Strongly disagree

Disagree

Neither disagree nor agree

Agree

Strongly agree

Prefer not to answer

  1. I know [all I need to know about HIV].

1

2

3

4

5

99

  1. [INSERT STATEMENT]

1

2

3

4

5

99



[ATTITUDES]

  1. Please answer the following questions by choosing the answer that best describes your opinion.

Very un-important

Somewhat un-important

Neither unimportant nor important

Somewhat important

Very important

Prefer not to answer

  1. Having access to [INSERT] is…

1

2

3

4

5

99

  1. Keeping myself healthy is…

1

2

3

4

5

99

  1. Doing things to help my future is…

1

2

3

4

5

99

  1. Knowing my HIV status is…

1

2

3

4

5

99

  1. [INSERT STATEMENT]

1

2

3

4

5

99

[Beliefs]

  1. 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/using drugs].

    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

  2. Please tell us how much you agree or disagree with each of the following statements: [INSERT BEHAVIOR HERE]…

Statement

Strongly disagree

Disagree

Neither disagree nor agree

Agree

Strongly agree

Prefer not to answer

  1. will help me stay strong.

1

2

3

4

5

99

  1. will help me make informed decisions.

1

2

3

4

5

99

  1. keeps me healthy.

1

2

3

4

5

99

  1. will help my future.

1

2

3

4

5

99

  1. is fast, free, and confidential.

1

2

3

4

5

99

  1. is something everyone should do in their lifetime.

1

2

3

4

5

99

  1. [INSERT STATEMENT]

1

2

3

4

5

99



[Self-Efficacy]

  1. 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. I am confident that I know what choices I have to prevent getting or transmitting HIV.

1

2

3

4

5

99

  1. I am confident that I can [insert behavior here].

1

2

3

4

5

99

  1. that I can speak up to stop HIV.

1

2

3

4

5

99

SECTION 10. AWARENESS AND USE OF OTHER HIV PREVENTION STRATEGIES

  1. 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



  1. 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



  1. Before today, have you ever heard of [insert]?

1 Yes

2 No

88 Don’t know

99 Prefer not to answer



  1. 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

SECTION 11: HIV SELF-TESTING

SCRIPT: Now we would like to ask you a few questions about your HIV testing experiences. The questions in this section are about HIV tests you may have at a doctor’s office, community-based organization, health fair, or other out-of-home location.

  1. Have you been tested for HIV in the past [INSERT TIME FRAME]?

1 Yes

2 No

99 Prefer not to answer



[ONLY IF 102 = 2]

  1. Below is a list of reasons why some people have not been tested for HIV. Which of these statements best describes the most important reason you have not been tested for HIV in the past [INSERT TIME FRAME]? Select [only one reason/all that apply].

1 I haven’t been sexually active.

2 I think I’m at low risk for HIV infection.

3 My doctor never recommended it.

4 I didn’t have time.

5 I haven’t had sex without a condom.

6 I’m afraid of finding out that I have HIV.

7 I didn’t want to think about HIV or about being HIV positive.

8 I don’t like needles or giving blood.

9 I don’t trust the results to be kept private.

10 I had to wait too long for the results.

11 I didn’t know where to get tested.

12 I trust my sexual partner.

13 I don’t care about the results.

14 I’m worried about being labeled as HIV positive.

15 Some other reason [Specify:__________]

16 No particular reason.

17 [INSERT REASON]

88 Don’t know

99 Prefer not to answer



[ONLY IF 102 = 2]

  1. Below is a list of reasons why some people have not been tested for HIV. Which of these statements describe the most important reasons you have not been tested for HIV [in the past INSERT TIME FRAME]? Select [only one reason/all that apply].

1 I haven’t been sexually active.

2 I think I’m at low risk for HIV infection.

3 My doctor never recommended it.

4 I didn’t have time.

5 I haven’t had sex without a condom.

6 I’m afraid of finding out that I have HIV.

7 I didn’t want to think about HIV or about being HIV positive.

8 I don’t like needles or giving blood.

9 I don’t trust the results to be kept private.

10 I had to wait too long for the results.

11 I didn’t know where to get tested.

12 I trust my sexual partner.

13 I don’t care about the results.

14 I’m worried about being labeled as HIV positive.

15 I’m worried about being labeled as HIV positive.

16 I don’t want people to think I’m promiscuous.

17 Some other reason [Specify:__________]

18 No particular reason.

17 [INSERT REASON]

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:

  • A Rapid Self-Test is done entirely at home or in a private location and can produce results within 20 minutes. You can buy a rapid self-test kit at a pharmacy or online The only rapid self-test currently available in the US is the OraQuick In-Home oral fluid test.

  • A Mail-In Self-Test includes a specimen collection kit that contains supplies to collect dried blood from a fingerstick at home. The sample is then sent to a lab for testing and the results are provided by a health care provider. Mail-in self-tests can be ordered through various online merchant sites. Your health care provider can also order a mail-in self-test for you.

If any test were to come back positive, you would be able to call a toll-free, 24-hour hotline and get immediate counseling.

  1. Before today, have you ever heard about HIV self-testing?

1 Yes

2 No

99 Prefer not to answer



[ONLY IF 105 = 1]

  1. 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



[ONLY IF 106 = 1 OR 2]

  1. Which of these HIV self-tests have you used? Select all that apply.

1 Mail-in test (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



[ONLY IF 106 = 1 OR 2]

  1. Where did you get your HIV self-test kit?

1 I bought it online [from Together.TakeMeHome.orgor TakeMeHome.org]

2 I bought it in a pharmacy or other store

3 I got it from a clinic or doctor’s office

4 A provider ordered a test for me

5 I got it from a community organization

6 I got it from an HIV testing event

7 I got it from a sex partner

8 I got it from a friend

9 [INSERT]

10 Other (Specify____________)

88 I don’t remember

99 I prefer not to answer



[ONLY IF 106 = 1 OR 2]

  1. 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 It was required for a PrEP prescription.

8 I was part of a research study.

9 To test after potential exposure to HIV.

10 COVID-19 made it more difficult for me to access traditional places where testing is provided.

11 [INSERT]

12 Other (Specify____________)

88 I don’t remember

99 I prefer not to answer



[ONLY IF 106 = 1 OR 2]

  1. Among the reasons you indicated, what is the main reason you used an HIV self-test? Choose only one.



[ONLY IF 106 = 3]

  1. 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 was concerned I would not be able to read the test results correctly.

7 I got tested for HIV another way, such as at a clinic or at my doctor’s office

8 I would rather talk to a counselor when I get an HIV test

9 I did not want to stick my finger to get a drop of blood

10 I did not want to swab my mouth to collect an oral fluid sample

11 I would rather be tested by someone who is trained to conduct the test

12 I did not want to mail my blood sample to a lab

13 I didn’t think I needed an HIV test

14 I was afraid of finding out the results

15 [INSERT reason]

16 Other reason (Specify__________)

99 I prefer not to answer

  1. Among the reasons you indicated, what is the main reason you have not used an HIV self-test? Choose only one.



[ONLY IF 106 = 3]

  1. How likely would you be to take an HIV self-test if…

Statement

Very unlikely

Somewhat unlikely

Neither unlikely nor likely

Somewhat likely

Very likely

Prefer not to answer

  1. it was provided for free

1

2

3

4

5

99

  1. it was delivered to my house

1

2

3

4

5

99

  1. you were able to order it online

1

2

3

4

5

99

  1. you were able to call and get one

1

2

3

4

5

99

  1. [insert reason here]

1

2

3

4

5

99





  1. 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



  1. 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



  1. Please indicate how much you disagree or agree with the following statements about HIV self-testing.

[PROGRAMMER: RANDOMIZE ORDER OF ITEMS]

Strongly disagree

Disagree

Neither disagree nor agree

Agree

Strongly agree

Don’t know

Prefer not to answer

a. HIV self-testing is a good idea.

1

2

3

4

5

88

99

b. HIV self-testing is expensive.

1

2

3

4

5

88

99

c. I prefer to self-test alone.

1

2

3

4

5

88

99

d. I prefer to self-test with a partner.

1

2

3

4

5

88

99

e. HIV self-test kits are easy to get.

1

2

3

4

5

88

99

g. I know where I can get an HIV self-test kit [for free].

1

2

3

4

5

88

99

h. Self-testing saves time.

1

2

3

4

5

88

99

i. Self-testing is convenient.

1

2

3

4

5

88

99

j. Self-testing is private.

1

2

3

4

5

88

99

k. Self-testing reduces anxiety.

1

2

3

4

5

88

99

l. Just thinking about self-testing scares me.

1

2

3

4

5

88

99

m. My partner [or others] expects me to self-test.

1

2

3

4

5

88

99

n. HIV self-testing is a good option if I can’t go to the clinic or my doctor’s office.

1

2

3

4

5

88

99

o. Self-testing would motivate me to get tested [more often/frequently/ every # months].

1

2

3

4

5

88

99

p. [INSERT]

1

2

3

4

5

88

99


  1. How sure are you that you could…

[PROGRAMMER: RANDOMIZE ORDER OF ITEMS]

Very Sure

Somewhat Sure

Neither Sure nor Unsure

Somewhat Unsure

Very Unsure

Prefer not to answer

a. use a mail-in test (where you prick your finger, collect a blood sample on a card and mail that card to a lab for testing)

1

2

3

4

5

99

b. use the 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)

1

2

3

4

5

99

c. use [another type of HIV self-test]

1

2

3

4

5

99

d. understand the results of the HIV self-test

1

2

3

4

5

99

e. talk with a partner about HIV self-testing

1

2

3

4

5

99

p. [INSERT]

1

2

3

4

5

99



  1. Do you plan to take an HIV self-test [in the future/next 12 months]?

1 Yes

2 No

88 Don’t know

99 Prefer not to answer



  1. If you could order up to two free HIV self-tests online every 90 days, how many kits would you order each time?

1 One kit

2 Two kits

88 Don’t know

99 Prefer not to answer



  1. What would you most likely do with the second kit?

1 Save it for later

2 Give it to a partner

3 Give it to someone other than a partner

4 [Insert option]

88 Don’t know

99 Prefer not to answer





SECTION 12. PERSONAL RELEVANCE AND OTHER SOCIODEMOGRAPHIC VARIABLES

SCRIPT: Finally, we’d now like to ask a few more questions about you.

  1. 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



[ONLY IF 119 = 1]

  1. 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



  1. What is your current marital status?

1 Never married

2 Married

3 Separated

4 Divorced

5 Widowed

99 Prefer not to answer



  1. In what ZIP Code do you currently live? If you prefer not to answer, you may leave the question blank.

______________ (5 digits only)



  1. 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 to $74,999

6 $75,000 to $99,999

7 $100,000 or more

99 Prefer not to answer



  1. Do you currently have health insurance or health care coverage?

1 Yes

2 No

88 Don’t know

99 Prefer not to answer



  1. 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.

1

2

3

4

5

99



  1. Places where I can get medical care are very conveniently located.

1 Strongly disagree

2 Disagree

3 Neither disagree nor agree

4 Agree

5 Strongly agree

99 Prefer not to answer



  1. In the past 12 months, how often did you go without the medical care or medications that you needed because you needed the money for food, clothing, housing, etc.?

1 Never

2 Occasionally

3 Usually

4 Always

99 Prefer not to answer



  1. In the past 12 months, how often did you skip meals or cut meal size because there was not enough money for food?

1 Never

2 Occasionally

3 Usually

4 Always

99 Prefer not to answer



  1. In the past 12 months, how often did you have problems finding a safe place to hang out or sleep?

1 Never

2 Occasionally

3 Usually

4 Always

99 Prefer not to answer




File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleLSHT Web-Based Survey_updated 021618
AuthorBoudewyns, Vanessa
File Modified0000-00-00
File Created2023-08-28
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