Att 3q: HIV Prevention Brief Survey Instrument

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 3q: HIV Prevention

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 3q: HIV Prevention

Brief Survey Instrument

CASE ID_____________

PARTICIPANT SURVEY

We are interested in your opinions about HIV prevention. 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. When you are finished with the survey, please place it in the envelope.

BACKGROUND INFORMATION

1. Before being contacted for this study, had you ever heard of CDC or the Centers for Disease Control and Prevention?

₁ Yes

₂ No

₈₈ Don’t know

₉₉ Prefer not to answer

2. What is your current gender identity? (Select ALL that apply)

₁ Male

₂ Female

₃ Transgender Male/Transman/FTM

₄ Transgender Female/Transwoman/MTF

₅ Genderqueer

₆ Another category [Specify: ]

₉ Prefer not to answer [TERMINATE AND GO TO CLOSING]

3. What sex were you assigned at birth? (Select one)

₁ Male

₂ Female

₉₉ Prefer not to answer [TERMINATE AND GO TO CLOSING]

4. Which do you consider yourself to be?

₁ Gay or homosexual

₂ Bisexual

₃ Straight or heterosexual

₄ Queer

₅ Pansexual

₆ Another category [Specify: ________________________________________]

₈₈ None of the above/Unsure [TERMINATE AND GO TO CLOSING]

₉₉ Prefer not to answer [TERMINATE AND GO TO CLOSING]

5. Are you of Hispanic or Latino origin?

₁ Yes

₂ No

₉₉ Prefer not to answer [TERMINATE AND GO TO CLOSING]

6. Please indicate your race. Are you? You may select one or more races.

₁ White

₂ Black or African American

₃ Asian

₄ Native Hawaiian or Other Pacific Islander

₅ American Indian or Alaskan Native

₉₉ Prefer not to answer [TERMINATE AND GO TO CLOSING]

7. Have you ever been tested for HIV? An HIV test checks whether someone has the virus that causes AIDS.

₁ Yes

₂ No

₃ Don’t know [TERMINATE AND GO TO CLOSING]

₉ Prefer not to answer [TERMINATE AND GO TO CLOSING]

8. The next question is about the result of your HIV test. What was the result of your most recent HIV test?

₁ I tested positive for HIV.

₂ I tested negative for HIV.

₃ My results were unclear.

₈ I never got my results/Don’t know

₉ Prefer not to answer [TERMINATE AND GO TO CLOSING]

BEHAVIORS

These next few questions are about your personal behaviors, including sexual activity. Please remember that your answers are kept private.

Sexual Activity

9. Did you have [oral/vaginal/anal sex] with any of your partner(s) in the past [INSERT #] months?

₁ Yes

₂ No

_{8 8} Don’t know

₉₉ Prefer not to answer

9. When you had [oral/vaginal/anal] sex with your [female/male] partner(s) in the past [INSERT #] months, how often did you and your partner use a condom?

₁ Never used a condom

₂ Occasionally used a condom

₃ Usually used a condom

₄ Always used a condom

₈₈ Don’t know

₉₉ Prefer not to answer

9. In the past [INSERT #] months, did you ever, even one time, have sex without a condom?

₁ Yes

₂ No

₈₈ Don’t know

₉₉ Prefer not to answer

Behaviors with Main Sexual Partner

9. Do you currently have a main sexual partner—that is, a partner you would call your spouse, girlfriend/boyfriend, significant other, or life partner?

₁ Yes

₂ No [GO TO Q19]

₈₈ Don’t know

₉₉ Prefer not to answer

9. Is your main partner male, female, or transgender?

₁ Male

₂ Female

₃ Transgender Male/Transman/FTM

₄ Transgender Female/Transwoman/MTF

₅ Another category [Specify: ________________________________________]

₈₈ Don’t know

₉₉ Prefer not to answer

9. What is your main partner’s HIV status?

₁ My main partner is HIV negative

₂ My main partner is HIV positive

₃ My main partner has not been tested for HIV [GO TO Q16]

₈₈ Don’t know/my main partner has not told me their HIV status [GO TO Q16]

₉₉ Prefer not to answer [GO TO Q16]

9. How do you know your main partner’s HIV status? Mark all that apply.

₁ My partner told me explicitly

₂ I guess based on other things my partner talked about

₃ Someone else told me

₄ By my partner’s appearance

₅ We got tested together [ERROR CHECK: Q14≠3]

₆ Saw my partner’s results [ERROR CHECK: Q14≠3 OR Q14≠88]

₇ I went with my partner to get their results [ERROR CHECK: Q14≠3]

₈ Other [Specify: ______________________________________________________]

_{8 8} Don’t know

₉₉ Prefer not to answer

9. Does your main partner know your HIV status?

₁ Yes

₂ No

₈₈ Don’t know

₉₉ Prefer not to answer

[IF Q14=2, GO TO Q18]

9. Thinking about your main [female/male] sexual partner, do you consider [him/her] to be at low, medium, or high risk for getting HIV?

₁ Low risk

₂ Medium risk

₃ High risk

₈₈ Don’t know

₉₉ Prefer not to answer

9. Some couples develop agreements about whether, when, and with whom sex outside the relationship is okay.  Which one of the following scenarios best describes any agreements that you and your main partner have?

₁ Both of us cannot have any sex with an outside partner

₂ We can have sex with outside partners but with some restrictions

₃ We can have sex with outside partners without any restrictions

₄ We do not have an agreement

₈₈ Don’t know

₉₉ Prefer not to answer

Behaviors with [Casual/Non-Main] Sexual Partners

9. In the past [INSERT #] months, how many [casual/non-main] sexual partners – that is, somebody who you did not consider to be a spouse, girlfriend/boyfriend, significant other, or life partner – did you have oral, vaginal, or anal sex with?

₁ 0 [GO TO Q31]

₂ 1-5

₃ 6-10

₄ 11-15

₅ 16-20

₆ Over 20

₈₈ Don’t know

₉₉ Prefer not to answer

9. In the past [INSERT #] months, how many of your [casual/non-main] partners told you their HIV status? [ERROR CHECK SHOULD NOT BE GREATER THAN #19]

₁ 0

₂ 1-5

₃ 6-10

₄ 11-15

₅ 16-20

₆ Over 20

₈₈ Don’t know

₉₉ Prefer not to answer

9. In the past [INSERT #] months, how many of your [casual/non-main] partners did you tell your HIV status to?

₁ 0

₂ 1-5

₃ 6-10

₄ 11-15

₅ 16-20

₆ Over 20

₈₈ Don’t know

₉₉ Prefer not to answer

9. How often did you and your last [casual/non-main] [female/male] sexual partner use condoms for anal sex?

₁ Never

₂ Occasionally

₃ Usually

₄ Always

_{8 8} Don’t know

₉₉ Prefer not to answer

9. What is your last [casual/non-main] [female/male] sexual partner’s HIV status?

₁ My last casual partner is HIV negative

₂ My last casual partner is HIV positive

₃ My last casual partner has not been tested for HIV [GO TO Q25]

₈₈ Don’t know/my last [casual/non-main] partner has not told me their HIV status [GO TO Q25]

₉₉ Prefer not to answer [GO TO Q25]

9. Why did you think that they were this status? Mark all that apply.

₁ They told me explicitly

₂ I guessed based on other things they talked about

₃ Someone else told me

₄ By their appearance

₅ We got tested together

₆ I saw their results

₇ I went with them to get his results

₈ Other [Specify: __________________________________________________]

_{8 8} Don’t know

₉₉ Prefer not to answer

[IF Q23=2, GO TO Q26]

9. Thinking about your last [casual/non-main] [female/male] sexual partner, do you consider them to be at low, medium or high risk for getting HIV?

₁ Low risk

₂ Medium risk

₃ High risk

_{8 8} Don’t know

₉₉ Prefer not to answer

9. Did you have [vaginal/anal/oral] sex without a condom with any of your [casual/non-main] partners in the past [INSERT #] months whose HIV status you didn’t know?

₁ Yes

₂ No

₈₈ Don’t know

₉₉ Prefer not to answer

9. Did you have [vaginal/anal/oral] sex without a condom with any [casual/non-main] [female/male] partners in the past [INSERT #] months who you knew or thought to be HIV positive?

₁ Yes

₂ No

_{8 8} Don’t know

₉₉ Prefer not to answer

9. In the past [INSERT #] months, how often did you look for [female/male] sexual partners with the same HIV status as you?

₁ Never

₂ Occasionally

₃ Usually

₄ Always

_{8 8} Don’t know

₉₉ Prefer not to answer

9. In the past [INSERT #] months, how often did use your HIV status and your [female/male] partner’s HIV status to determine which sexual roles (i.e., insertive/top or receptive/bottom) and activities (i.e., oral and anal sex) you would engage in?

₁ Never

₂ Occasionally

₃ Usually

₄ Always

_{8 8} Don’t know

₉₉ Prefer not to answer

9. In the past [INSERT #] months, how often have you had anal sex without a condom with a [female/male] partner…

	Never	Occasionally	Usually	Always	Don’t know	Prefer not to answer
who you knew or thought was HIV positive?	1	2	3	4	88	99
whose HIV status you did not know?	1	2	3	4	88	99

RISK

9. Thinking about the sex you’ve had over the past [INSERT #] months, do you consider yourself to be high, medium or low risk for [(IF Q8≠1) getting/(IF Q8=1) transmitting] HIV?

₁ Low risk

₂ Medium risk

₃ High risk

_{8 8} Don’t know

₉₉ Prefer not to answer

9. Tell me how risky you think each behavior is for [(IF Q8≠1) getting/(IF Q8=1) transmitting] HIV. Use a scale where 0 is lowest risk and 100 is highest risk. Please assign any number in that range to each of the behaviors listed.

₁ Deep kissing _____

₂ Receptive anal sex (“bottom”) with a condom _____

₃ Receptive anal sex (“bottom”) without a condom ______

₄ Receptive oral sex (“giving a blow job”) with a condom _____

₅ Receptive oral sex (“giving a blow job”) without a condom _____

₆ Insertive anal sex (“top”) with a condom _____

₇ Insertive anal sex (“top”) without a condom _____

₈ Insertive oral sex (“getting a blow job”) with a condom _____

₉ Insertive oral sex (“getting a blow job”) without a condom _____

₁₀ Vaginal sex with a condom _____

₁₁ Vaginal sex without a condom _____

₉₉ Prefer not to answer

HIV PROTECTIVE BEHAVIORAL INTENTIONS

9. Do you plan to [INSERT HIV PREVENTION STRATEGY] [the next time you have sex/within the next [INSERT TIMEFRAME]?

₁ Yes

₂ No

_{8 8} Don’t know

₉₉ Prefer not to answer

9. If your sexual partner does not want to [INSERT HIV PREVENTION STRATEGY], do you plan on insisting that the two of you [INSERT HIV PREVENTION STRATEGY]?

₁ Yes

₂ No

_{8 8} Don’t know

₉₉ Prefer not to answer

9. The next time you have sex, do you plan on talking about [INSERT HIV PREVENTION STRATEGY] with your partner?

₁ Yes

₂ No

_{8 8} Don’t know

₉₉ Prefer not to answer

9. How likely are you to [INSERT HIV PREVENTION STRATEGY] the next time you have sex to [INSERT BEHAVIOR]?

₁ Very unlikely

₂ Unlikely

₃ Neither unlikely nor likely

₄ Likely

₅ Very likely

_{8 8} Don’t know

₉₉ Prefer not to answer

9. Do you plan to talk to your health care provider about [INSERT HIV PREVENTION STRATEGY] at your next appointment?

₁ Yes

₂ No

_{8 8} Don’t know

₉₉ Prefer not to answer

9. How likely are you to talk to your health care provider about [INSERT HIV PREVENTION STRATEGY] at your next appointment?

₁ Very unlikely

₂ Unlikely

₃ Neither unlikely nor likely

₄ Likely

₅ Very likely

_{8 8} Don’t know

₉₉ Prefer not to answer

HIV NORMS AND ATTITUDES

9. Listed below are a variety of thoughts that may pop into people’s heads when they are thinking about having [risky sex] with either a main or [casual/non-main] partner. Please tell us how often you have had these thoughts.

	Never	Rarely	Sometimes	Often	Very Often	Prefer not to answer
They look so healthy. They can’t possibly be HIV positive.	1	2	3	4	5	99
They can’t be HIV positive because they are willing to have sex without a condom.	1	2	3	4	5	99
They seem intelligent/well-educated, so I’m sure they have been careful.	1	2	3	4	5	99
I’m sure they aren’t infected.	1	2	3	4	5	99
My positive state of mind can prevent me from being infected.	1	2	3	4	5	99
I’m too healthy to become infected.	1	2	3	4	5	99
I’ve been lucky so far, I’m sure I’ll continue to be lucky.	1	2	3	4	5	99
I don’t care if I become HIV positive.	1	2	3	4	5	99
People who are HIV positive would insist on using a condom.	1	2	3	4	5	99
My regular partner only has unsafe sex with me, so I’m safe.	1	2	3	4	5	99
I believe them when they say they are negative.	1	2	3	4	5	99
I’m always the [top/insertive] partner, therefore I’m safe.	1	2	3	4	5	99
[INSERT REASON]	1	2	3	4	5	99

9. Most of my friends …

	Strongly agree	Agree	Neither agree nor disagree	Disagree	Strongly disagree	Don’t know	Prefer not to answer
think you should always use condoms when having [vaginal/anal] sex with a new partner.	1	2	3	4	5	88	99
use condoms for [vaginal/anal] sex.	1	2	3	4	5	88	99
think negatively of me if I do not use condoms when I have [vaginal/anal] sex.	1	2	3	4	5	88	99

9. Please tell us how much you agree or disagree with the following statements:

	Strongly Agree	Agree	Neither agree nor Disagree	Disagree	Strongly Disagree	Don’t know	Prefer not to answer
Most people who are important to me think I should [INSERT BEHAVIOR]. By important to me, we mean people like friends, family, and anyone else who is an important part of your life.	1	2	3	4	5	88	99
Most of my sexual partners [INSERT BEHAVIOR].	1	2	3	4	5	88	99
Most [gay or bisexual men/people] I know [INSERT BEHAVIOR].	1	2	3	4	5	88	99
Most people in my community would be supportive of someone who [INSERT PREVENTION STRATEGY].	1	2	3	4	5	88	99

9. On a scale from 1 to 5, where 1 is extremely bad and 5 is extremely good, how would you rate [INSERT BEHAVIOR]?

Extremely Bad 1	Bad 2	Neither bad nor good 3	Good 4	Extremely Good 5	Don’t know	Prefer not to answer
1	2	3	4	5	88	99

9. On a scale from 1 to 5, where 1 is extremely harmful and 5 is extremely beneficial, how would you rate [INSERT BEHAVIOR] to prevent HIV?

₁ Extremely harmful

₂ Harmful

₃ Neither harmful nor beneficial

₄ Beneficial

₅ Extremely beneficial

_{8 8} Don’t know

₉₉ Prefer not to answer

9. Please tell us how much you agree or disagree with the following statements.

	Strongly agree	Agree	Neither agree nor disagree	Disagree	Strongly disagree	Don’t know	Prefer not to answer
[INSERT BEHAVIOR] is expensive.	1	2	3	4	5	8 8	99
[INSERT BEHAVIOR] is inconvenient.	1	2	3	4	5	88	99
[INSERT BEHAVIOR] allows me to have sex without a condom with partners [whose HIV status I don’t know/who are HIV negative/who are HIV positive].	1	2	3	4	5	88	99
[INSERT OTHER].	1	2	3	4	5	8 8	99

HIV SELF EFFICACY

9. How sure are you that you could [INSERT BEHAVIOR] if…

	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
you that you could use a condom the next time you have [vaginal/anal] sex with a partner whose HIV status you do not know?	1	2	3	4	5	88	99
[INSERT CIRCUMSTANCE]?	1	2	3	4	5	88	99
[INSERT CIRCUMSTANCE]?	1	2	3	4	5	88	99
[INSERT CIRCUMSTANCE]?	1	2	3	4	5	88	99
[INSERT CIRCUMSTANCE]?	1	2	3	4	5	88	99

9. I feel confident in my ability to [INSERT BEHAVIOR AND CIRUMSTANCE].

₁ Strongly agree

₂ Agree

₃ Neither disagree nor agree

₄ Disagree

₅ Strongly disagree

_{8 8} Don’t know

₉₉ Prefer not to answer

INFORMATION SEEKING

9. In the last [INSERT #] months, how often have you…

	Never	Rarely	Sometimes	Often	Very Often	Prefer not to answer
looked for information about [INSERT HIV PREVENTION STRATEGY]?	1	2	3	4	5	99
talked about [INSERT HIV PREVENTION STRATEGY]?	1	2	3	4	5	99
visited a Centers for Disease Control website for HIV information?	1	2	3	4	5	99
visited the HIV Risk Reduction Tool?	1	2	3	4	5	99

PrEP/nPEP/ART AWARENESS, KNOWLEDGE & BEHAVIORS

9. If there was a pill that you could take once a day, every day, to PREVENT getting HIV, and if this pill caused mild side effects, such as nausea, headaches, and rashes in a small number of people, would you take the pill?

₁ Yes

₂ No

₈₈ Don’t know

₉₉ Prefer not to answer

9. If there was medicine that you could take right AFTER you think you have been exposed to HIV to PREVENT getting HIV, and if this pill caused mild side effects, such as nausea, headaches, and rashes in a small number of people, would you take the medicine?

₁ Yes

₂ No

_{8 8} Don’t know

₉₉ Prefer not to answer

9. Before today, have you ever heard of people who do not have HIV taking HIV medicines (PrEP or Truvada) daily, to keep from getting HIV?

₁ Yes

₂ No

₈₈ Don’t know

₉₉ Prefer not to answer

9. 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

9. In the past [INSERT #] months, have you taken HIV medicines (nPEP or non-occupational post-exposure prophylaxis) after sex because you thought it would keep you from getting HIV?

₁ Yes

₂ No

₈₈ Don’t know

₉₉ Prefer not to answer

9. In the past [INSERT #] months, have you taken HIV medicines (PrEP or Truvada) before sex because you thought it would keep you from getting HIV?

₁ Yes

₂ No [GO TO Q60]

₈₈ Don’t know

₉₉ Prefer not to answer

9. Are you currently taking [HIV medicine/PrEP/Truvada] to prevent getting HIV?

₁ Yes

₂ No [GO TO Q60]

₈₈ Don’t know [GO TO Q60]

₉₉ Prefer not to answer [GO TO Q60]

9. When did you first start taking [HIV medicine/PrEP/Truvada] 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

9. Many people don’t take their medication perfectly all the time. Thinking about the [past 30 days], how often did you take your [HIV medicine/PrEP/Truvada] as prescribed?

₁ None of the time

₂ A little of the time

₃ Some of the time

₄ Most of the time

₈₈ Don’t know

₉₉ Prefer not to answer

People may miss taking their medications for various reasons. Here is a list of possible reasons why you may have missed taking your [HIV medicine/PrEP/Truvada in the past 30 days. Please mark all that apply

9. In the past 30 days, did you miss taking your [HIV medicine/PrEP/Truvada] because you:

	Yes	No	Don’t know	Prefer not to answer
Were away from home	1	2	88	99
Were busy with other things	1	2	88	99
Simply forgot	1	2	88	99
Felt you didn’t need to take it every day	1	2	88	99
Didn’t like the way they made you feel (side effects)	1	2	88	99
Did not want others to notice you taking medication	1	2	88	99
Had a change in your daily routine	1	2	88	99
Felt like the drug was toxic/harmful	1	2	88	99
Fell asleep/slept through dose time	1	2	88	99
Felt sick or ill	1	2	88	99
Felt depressed/overwhelmed	1	2	88	99
Had problem taking medication at certain times	1	2	88	99
Ran out of medication	1	2	88	99
Didn’t know how to get a refill	1	2	88	99
Missed an appointment with my health care provider	1	2	88	99
Went to jail or prison	1	2	88	99
Were released from jail or prison	1	2	88	99
Felt good	1	2	88	99
Were drunk or high	1	2	88	99
Didn’t want to deal with it	1	2	88	99
Other (Specify)____________________	1	2	88	99

9. Would you be willing to receive a [text/email] reminder each day to take your [medication/pill/PrEP/Truvada]?

₁ Yes

₂ No

₈₈ Don’t know

₉₉ Prefer not to answer

9. Would you be willing to download an app to a smartphone or other mobile device that would send you reminders each day to take your [medication/pill/PrEP/Truvada]?

₁ Yes

₂ No

₈₈ Don’t know

₉₉ Prefer not to answer

9. True or false: There are medications available to treat HIV.

₁ True

₂ False

₈₈ Don’t know

₉₉ Prefer not to answer

9. True or false: If a person’s viral load is “undetectable,” they are cured and no longer have HIV.

₁ True

₂ False

₈₈ Don’t know

₉₉ Prefer not to answer

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

	Strongly agree	Agree	Disagree	Strongly disagree	Prefer not to answer
Because of new medicines for HIV [treatment/prevention], I think people are taking more sexual risks.	1	2	3	4	99
Because of new medicines for HIV [treatment/prevention], I’m more willing to have sex without a condom with someone [whose HIV status I don’t know/who is HIV negative].	1	2	3	4	99
Most of my friends would think negatively of me if I started taking [HIV medicine/PrEP/Truvada] to prevent HIV.	1	2	3	4	99

[IF Q3=3, GO TO Q63]

[IF Q4≠3, GO TO Q63]

[IF Q5=1, GO TO Q63]

[IF Q6≠1, GO TO Q63]

[ALL OTHERS GO TO CLOSING]

IDENTITY & DISCRIMINATION

This next set of questions asks about how you identify in terms of race, ethnicity, sexual orientation, and gender identity. Some of the questions also ask about your experiences with how others have reacted to your identity.

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

	Strongly agree	Agree	Neither agree nor disagree	Disagree	Strongly disagree	Prefer not to Answer
I feel good about being a [INSERT DEMOGRAPHIC].	1	2	3	4	5	99
I often regret that I am a [INSERT DEMOGRAPHIC].	1	2	3	4	5	99
In general, I am glad to be a [INSERT DEMOGRAPHIC].	1	2	3	4	5	99
Overall, I often do not like being a [INSERT DEMOGRAPHIC].	1	2	3	4	5	99
Being a [INSERT DEMOGRAPHIC] is important to me.	1	2	3	4	5	99
If someone says something bad about [INSERT DEMOGRAPHIC] they say something bad about me.	1	2	3	4	5	99

The End

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.

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