Form Approved
OMB No: 0920-1169
Exp. Date: 03/31/2020
Development of CDC’s Let’s Stop HIV Together Social Marketing Campaign for Consumers
Attachment 3p: HIV Testing
Brief Survey Instrument
Public reporting burden of this collection of information is estimated to average 15 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 (0920-1169).
Attachment 3p: HIV Testing
Brief Survey Instrument
CASE ID_____________
PARTICIPANT SURVEY
We are interested in your opinions about HIV testing. We would also like to get some additional information about you. If you’re not sure, choose an answer that comes closest to what you think might be true for each question. Please remember that your answers are private. You can choose not to answer any question and can stop at any time. Please let the person who checked you in know when you are finished with the survey.
These next questions are about your personal HIV testing behaviors. Please remember that your answers are kept private.
Have you ever been tested for HIV? An HIV test checks whether someone has the virus that causes AIDS.
1 Yes
2 No [GO TO Q9]
88 Don’t know
99 Prefer not to answer
When did you have your first HIV test? DATE (MM/YYYY):__________ [ERROR CHECK: CANNOT BE BEFORE 1985 OR BEYOND CURRENT DATE]
88 Don’t know
99 Prefer not to answer
In the past 2 years, that is, since [INSERT CALCULATED MONTH AND YEAR], how many times have you been tested for HIV?
NUMBER __________
88 Don’t know
99 Prefer not to answer
How often do you get an HIV test?
1 Every 0-2 months
2 Every 3-6 month
3 Every 7-12 months
4 Less often than once a year
5 Other [Specify: ___________________________________________]
88 Don’t know
99 Prefer not to answer
What was the result of your most recent HIV test?
1 I tested positive for HIV [GO TO Q5a]
2 I tested negative for HIV [GO TO Q5b]
3 My results were unclear [GO TO Q5b]
4 I never got my results [GO TO Q5b]
88 Don’t know
99 Prefer not to answer [TERMINATE AND GO TO CLOSING]
[IF POSITIVE] When did you test positive for HIV?
DATE (MM/YYYY):__________
88 Don’t know
99 Prefer not to answer
[IF NEGATIVE] When did you have your most recent HIV test? DATE (MM/YYYY):__________
88 Don’t know
99 Prefer not to answer
Where did you have your last HIV test?
1 Private doctor
2 STD or AIDS clinic or testing site
3 Hospital or emergency room
4 Public health department
5 Community health center
6 At home
7 Drug treatment facility
8 Other location
88 Don’t know
99 Prefer not to answer
Which of these are the main reasons for your last HIV test? Mark all that apply.
1 It just seemed like a good idea
2 It’s something you do every year
3 Just to find out
4 Worried that you are infected
5 A doctor, nurse, or other health care provider asked you to
6 The health department asked you to
7 Your sexual partner asked you to
8 Because of pregnancy
9 To get birth control
10 You found out your sexual partner cheated
11 Already had an STD
12 You were starting a new relationship
13 You get tested during your yearly exam
14 A family member or friend was diagnosed with HIV
15 Other reason [Specify: __________]
88 Don’t know
99 Prefer not to answer
Below is a list of reasons why some people have not been tested for HIV. Which of these best describes the most important reason you have not been tested for HIV in the past [INSERT CALCULATED DATE FROM Q5b] months? Check only one.
1 I think I am at low risk for HIV infection.
2 I am afraid of finding out that I have HIV.
3 I didn’t have time.
4 Some other reason [Specify: ]
5 No particular reason
88 Don’t know
99 Prefer not to answer
[GO TO Q10]
Below is a list of reasons why some people have not been tested for HIV. Which of these best describes the most important reasons you have not been tested for HIV? Mark all that apply.
1 I have not been sexually active.
2 I think I am at low risk for HIV infection.
3 My doctor never recommended it.
4 I didn’t have time.
5 I have not had sex without a condom.
6 I was afraid to find out if I was HIV positive.
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 am worried about being labeled as HIV positive.
15 Some other reason [Specify:__________]
16 No particular reason.
88 Don’t know
99 Prefer not to answer
HIV SELF-TESTING
Now I am going to ask you some questions related to 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.
Before today, have you ever heard about HIV self-testing?
1 Yes
2 No
99 I prefer not to answer
Have you ever used an HIV self-test to test yourself or someone else? Select all that apply.
1 Yes, I have used one to test myself
2 Yes, I have used one to test someone else
3 No, I have never used one
99 I prefer not to answer
IF Q11 = Yes, ask Q12 and Q13.
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
Where did you get your HIV self-test kit?
1 I bought it online
2 I bought it in a pharmacy or other store
3 My healthcare provider ordered one for me
4 I got it from a community organization
5 I got it from an HIV testing event
6 I got it from a sex partner
7 I got it from a friend
8 [INSERT]
9 Other (Specify____________)
88 I don’t remember
99 I prefer not to answer
What are some of your reasons for using an HIV self-test in the past? Select all that apply. [randomize options except for “other” and “I prefer not to answer”]
1 Self-testing was convenient
2 Self-testing was private
3 To test with someone before having sex
4 To test myself before having sex
5 To test myself after having sex
6 My sex partner asked me to self-test
7 [INSERT]
8 Other (Specify____________)
88 I don’t remember
99 I prefer not to answer
Among the reasons you indicated, what is the main reason you used an HIV self-test? Choose only one.
[Display response options based on selections in Q14.]
IF Q11= No, ask Q16 and/or Q17. SKIP IF PARTICIPANT IS HIV-POSITIVE.
What are some of your reasons for not using an HIV self-test in the past? Select all that apply.
[randomize options except for “other” and “I prefer not to answer”]
1 I did not know HIV self-tests were available
2 I did not know where to get an HIV self-test
3 I was concerned about the cost of HIV self-tests
4 I was concerned about the accuracy of HIV self-tests
5 I was concerned I would not be able to perform the HIV self-test correctly
6 I got tested for HIV another way, such as at a clinic or at my doctor’s office
7 I would rather talk to a counselor when I get an HIV test
8 I did not want to stick my finger to get a drop of blood
9 I did not want to swab my mouth to collect an oral fluid sample
10 I would rather be tested by someone who is trained to conduct the test
11 I did not want to mail my blood sample to a lab
12 I didn’t think I needed an HIV test
13 I was afraid of finding out the results
14 [INSERT reason]
15 Other reason (Specify__________)
99 I prefer not to answer
Among the reasons you indicated, what is the main reason you have not used an HIV self-test? Choose only one.
[Display response options based on selections in Q16.]
How likely would you be to take an HIV self-test if it were provided for free?
1 Very unlikely
2 Somewhat unlikely
3 Neither unlikely nor likely
4 Somewhat likely
5 Very likely
99 I prefer not to answer
Would being able to take an HIV self-test [increase the likelihood that you would get tested/how often you get tested for HIV]?
1 Yes
2 No
88 Don’t know
99 I prefer not to answer
What is the maximum amount you would be willing to pay for an HIV self-test?
1 I would only use it if it were free
2 Less than $10
3 $11-20
4 $21–30
5 $31-40
6 $41-50
7 More than $50
99 I prefer not to answer
Please indicate how much you disagree or agree with the following statements. (strongly disagree to strongly agree—5 point scale)
1 HIV self-testing is a good idea.
2 [OraQuick OR Mail-in] HIV self-testing is difficult to do.
3 HIV self-testing is expensive.
4 [OraQuick OR Mail-in] HIV self-test results are accurate.
5 I would trust the results from an [OraQuick OR Mail-in] HIV self-test.
6 I prefer to self-test alone.
7 I prefer to self-test with a partner.
8 HIV self-test kits are easy to get.
9 I know where I can get an HIV self-test kit [for free].
10 [OraQuick OR Mail-in] HIV self-test results are easy to understand.
11 Self-testing saves time.
12 Self-testing is convenient.
13 Self-testing is private.
14 Self-testing saves me the embarrassment of others knowing I was getting an HIV test.
15 Self-testing reduces anxiety.
16 Just thinking about self-testing scares me.
17 My partner [or others] expects me to self-test.
18 HIV self-testing is a good option if I can’t go to the clinic or my doctor’s office.
19 Self-testing would motivate me to get tested [more often/frequently/every X months]
20 [INSERT]
99 I prefer not to answer
How sure are you that you could…
1 Use the [OraQuick OR Mail-in] HIV self-test correctly
2 Understand the results of the [OraQuick OR Mail-in] HIV self-test
3 Talk with a partner about HIV self-testing
4 [INSERT]
99 I prefer not to answer
Do you plan to take an HIV self-test [in the future/next 12 months]?
1 Yes
2 No
88 Don’t know
99 I prefer not to answer
THEORETICAL CONSTRUCTS
Knowledge
When should you get an HIV test after having sex without a condom with a [woman/man]?
1 0–2 months after having sex without a condom
2 3–6 months after having sex without a condom
3 7–12 months after having sex without a condom
4 More than 12 months after having sex without a condom
5 When you start to feel sick
88 Don’t know
99 Prefer not to answer
Do you get an HIV test after any situation when you think you might have been exposed to HIV?
1 Yes
2 No
88 Don’t know
99 Prefer not to answer
Where can you get an HIV test? Mark all that apply.
1 HIV counseling and testing site
2 STD or AIDS clinic or testing site
3 Hospital or emergency room
4 Community health clinic
5 Private physician office
6 Drug treatment program
7 At home
8 Correctional facility (jail or prison)
9 Military
10 Other [Specify: _________________________________________________]
88 Don’t know
99 Prefer not to answer
Please tell us how much you agree or disagree with each of the following statements: Someone who is HIV-negative and not taking medicines to prevent HIV (e.g., PrEP/Truvada,) should get tested for HIV every 6 months if they…
|
Strongly agree |
Agree |
Neither agree or disagree |
Disagree |
Strongly disagree |
Don’t know |
Prefer not to answer |
|
1 |
2 |
3 |
4 |
5 |
88 |
99 |
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1 |
2 |
3 |
4 |
5 |
88 |
99 |
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88 |
99 |
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88 |
99 |
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88 |
99 |
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88 |
99 |
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2 |
3 |
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88 |
99 |
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1 |
2 |
3 |
4 |
5 |
88 |
99 |
Attitudes and Beliefs
On a scale from 1 to 5, where 1 is extremely bad and 5 is extremely good, how would you rate getting tested for HIV at least every [INSERT] months?
Extremely Bad |
Bad 2 |
Neither bad or good 3 |
Good 4 |
Extremely Good 5 |
Don’t know |
Prefer not to answer |
1 |
2 |
3 |
4 |
5 |
88 |
99 |
Please tell us how much you agree with each of the following statements: Getting tested at least every [INSERT] months….
|
Strongly agree |
Agree |
Neither agree or disagree |
Disagree |
Strongly disagree |
Don’t know |
Prefer not to answer |
|
1 |
2 |
3 |
4 |
5 |
88 |
99 |
|
1 |
2 |
3 |
4 |
5 |
88 |
99 |
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1 |
2 |
3 |
4 |
5 |
88 |
99 |
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1 |
2 |
3 |
4 |
5 |
88 |
99 |
Please tell us your opinion regarding the importance of each of the following statements.
|
Very import-ant |
Some-what impor-tant |
Neither impor-tant nor unimpor-tant |
Some-what unimpor-tant |
Very unimpor-tant |
Don’t know |
Prefer not to answer |
|
1 |
2 |
3 |
4 |
5 |
88 |
99 |
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1 |
2 |
3 |
4 |
5 |
88 |
99 |
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88 |
99 |
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88 |
99 |
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5 |
88 |
99 |
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1 |
2 |
3 |
4 |
5 |
88 |
99 |
Please tell us how much you agree or disagree with each of the following statements: Getting tested for HIV…
|
Strongly agree |
Agree |
Neither agree or disagree |
Disagree |
Strongly disagree |
Don’t know |
Prefer not to answer |
|
1 |
2 |
3 |
4 |
5 |
88 |
99 |
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1 |
2 |
3 |
4 |
5 |
88 |
99 |
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88 |
99 |
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88 |
99 |
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88 |
99 |
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88 |
99 |
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5 |
88 |
99 |
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1 |
2 |
3 |
4 |
5 |
88 |
99 |
Please tell us how much you agree or disagree with each of the following statements:
|
Strongly agree |
Agree |
Neither agree or disagree |
Disagree |
Strongly disagree |
Don’t know |
Prefer not to answer |
|
1 |
2 |
3 |
4 |
5 |
88 |
99 |
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1 |
2 |
3 |
4 |
5 |
88 |
99 |
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88 |
99 |
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88 |
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88 |
99 |
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88 |
99 |
Self-Efficacy
Please tell us how much you agree or disagree with the following statement: I am confident that I can get an HIV test.
1 Strongly agree
2 Agree
3 Neither agree nor disagree
4 Disagree
5 Strongly disagree
88 Don’t know
99 Prefer not to answer
How sure are you that you could get an HIV test at least every [INSERT] months if you…
|
Very sure I could not |
Somewhat sure I could not |
Slightly sure I could |
Somewhat sure I could |
Very sure I could |
Don’t know |
Prefer not to answer |
|
1 |
2 |
3 |
4 |
5 |
88 |
99 |
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1 |
2 |
3 |
4 |
5 |
88 |
99 |
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3 |
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5 |
88 |
99 |
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88 |
99 |
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88 |
99 |
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88 |
99 |
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88 |
99 |
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1 |
2 |
3 |
4 |
5 |
88 |
99 |
Norms
Please tell us how much you agree or disagree with each of the following statements.
|
Strongly agree |
Agree |
Neither agree or disagree |
Disagree |
Strongly disagree |
Don’t know |
Prefer not to answer |
|
1 |
2 |
3 |
4 |
5 |
88 |
99 |
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2 |
3 |
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5 |
88 |
99 |
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88 |
99 |
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88 |
99 |
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88 |
99 |
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3 |
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5 |
88 |
99 |
Behavioral Intentions
Please tell us how likely you are to do the following:
|
Very likely |
Some-what likely |
Neither likely nor unlikely |
Some-what unlikely |
Very unlikely |
Don’t know |
Prefer not to answer |
|
1 |
2 |
3 |
4 |
5 |
88 |
99 |
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1 |
2 |
3 |
4 |
5 |
88 |
99 |
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1 |
2 |
3 |
4 |
5 |
88 |
99 |
INFORMATION SEEKING
In the last [INSERT #] months, how often have you…
|
Very often |
Often |
Some-times |
Rarely |
Never |
Don’t know |
Prefer not to answer |
a. looked for information about HIV testing? |
1 |
2 |
3 |
4 |
5 |
88 |
99 |
b. searched online for a location to get an HIV test? |
1 |
2 |
3 |
4 |
5 |
88 |
99 |
c. called an HIV testing hotline? |
1 |
2 |
3 |
4 |
5 |
88 |
99 |
d. texted your zip code for a location to get an HIV test? |
1 |
2 |
3 |
4 |
5 |
88 |
99 |
e. talked about HIV testing? |
1 |
2 |
3 |
4 |
5 |
88 |
99 |
f. visited a Centers for Disease Control website for HIV information? |
1 |
2 |
3 |
4 |
5 |
88 |
99 |
COMMUNICATION BEHAVIORS
Do you currently have a main sexual partner?
1 Yes
2 No [GO TO Q41]
88 Don’t know
99 Prefer not to answer [GO TO Q41]
In the past [INSERT #] months, how often have you had one-on-one conversations with your current main sexual partner about HIV testing?
1 Very often
2 Often
3 Sometimes
4 Rarely
5 Never
88 Don’t know
99 Prefer not to answer
In the past [INSERT #] months, how often have you discussed the following topics with your current main sexual partner?
|
Very often |
Often |
Some-times |
Rarely |
Never |
Don’t know |
Prefer not to answer |
|
1 |
2 |
3 |
4 |
5 |
88 |
99 |
|
1 |
2 |
3 |
4 |
5 |
88 |
99 |
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1 |
2 |
3 |
4 |
5 |
88 |
99 |
|
1 |
2 |
3 |
4 |
5 |
88 |
99 |
Do you currently have a [casual/non-main] sexual partner?
1 Yes
2 No [GO TO CLOSING]
88 Don’t know
99 Prefer not to answer [GO TO CLOSING]
In the past [INSERT #] months, how often have you had one-on-one conversations with a current [casual/non-main] sexual partner about ways to prevent HIV?
1 Very often
2 Often
3 Sometimes
4 Rarely
5 Never
88 Don’t know
99 Prefer not to answer
In the past [INSERT #] months, how often have you discussed the following topics with a current [casual/non-main] sexual partner?
|
Very often |
Often |
Some-times |
Rarely |
Never |
Don’t know |
Prefer not to answer |
|
1 |
2 |
3 |
4 |
5 |
88 |
99 |
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1 |
2 |
3 |
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5 |
88 |
99 |
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3 |
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5 |
88 |
99 |
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1 |
2 |
3 |
4 |
5 |
88 |
99 |
Thank you for answering these questions. Please place the survey in the envelope provided. Give the survey and your consent form to the interviewer when you go into the interview room. The interviewer will not see your responses to these questions.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Poehlman, Jon |
| File Modified | 0000-00-00 |
| File Created | 2022-06-27 |