Baseline Data Collection

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/XXXX

GAIN Baseline Data Variables

*Time will be reported in days

Public reporting burden of this collection of information is estimated to average 4 hours 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-New)

Gay City PrEP Clients

1. Sex assigned at birth

2. Gender

3. Race

4. Ethnicity

5. Time from first contact to first PrEP visit

6. Time from first contact to first screening appointment

7. Time from first contact to first PrEP visit

8. Time from first contact to PrEP entry visit

9. HIV status at first visit

10. Time from first PrEP visit to HIV testing (linked to #9, expect this to be the same value as #7)

11. Source of HIV test from #9

12. Whether PrEP was prescribed at the first visit

13. Time from first PrEP visit to date PrEP was prescribed

14. Time from first PrEP visit to self-reported date PrEP was started

15. Time from first PrEP visit to date of connection to main health care provider

16. Time from first PrEP visit to Month 1 Visit

17. HIV status at Month 1

18. Whether connection to main health care provider was established at Month 1

19. Time from first PrEP visit to Month 3 Visit

20. HIV status at Month 3

21. Whether connection to main health care provider was established at Month 3

22. Time from first PrEP visit to Month 6 Visit

23. HIV status at Month 6

24. Whether connection to main health care provider was established at Month 6

25. Whether this is an instaPrEP client (from Sarah’s records)

26. Client status (i.e., lost to follow-up, graduated to PCP, Active, PrEP re-start)

27. Time from first PrEP visit to Week 1 follow-up call

28. Was Week 1 follow-up call successful?

29. Time from first PrEP visit to Month 1 follow-up call

30. Was Month 1 follow-up call successful?

31. Time from first PrEP visit to Month 3 follow-up call

32. Was Month 3 follow-up call successful?

33. Time from first PrEP visit to Month 6 follow-up call

34. Was Month 6 follow-up call successful?

Gay City Clients Newly Diagnosed with HIV

1. Time from first positive/reactive test to Month 1 phone call

2. Whether or not a rapid HIV test was ordered

3. Result of rapid test

4. Whether or not a laboratory test was ordered

5. Result of laboratory test

6. Whether client was referred to HIV care

7. Time from first positive/reactive test to date of first HIV care referral

8. Did client attend HIV care visit? Asked 1 week, 2 weeks, then 1 month after first reactive

9. Time from first positive/reactive to self-reported ART start date

10. Does participant know if they are virally suppressed (self-reported) at Month 1

11. Virally suppressed (self-reported) at Month 1?

12. Time from first positive/reactive to self-reported date of last viral load test at Month 1.

13. Does participant know if they are virally suppressed (self-reported) at Month 3

14. Virally suppressed (self-reported) at Month 3?

15. Time from first positive/reactive to self-reported date of last viral load test at Month 3.

16. Does participant know if they are virally suppressed (self-reported) at Month 6

17. Virally suppressed (self-reported) at Month 6?

18. Time from first positive/reactive to self-reported date of last viral load test at Month 6.

Gay City Clients Living with HIV (established)

1. Confirmed HIV+ status

2. Whether client has HIV care provider

3. Whether client is currently on ART

4. Whether client is undetectable (self-reported)

5. Time from first positive/reactive to self-reported ART start date

6. Does participant know if they are virally suppressed (self-reported) at Month 1

7. Virally suppressed (self-reported) at Month 1?

8. Time from first positive/reactive to self-reported date of last viral load test at Month 1.

9. Does participant know if they are virally suppressed (self-reported) at Month 3

10. Virally suppressed (self-reported) at Month 3?

11. Time from first positive/reactive to self-reported date of last viral load test at Month 3.

12. Does participant know if they are virally suppressed (self-reported) at Month 6

13. Virally suppressed (self-reported) at Month 6?

14. Time from first positive/reactive to self-reported date of last viral load test at Month 6.

Gay City Clients

1. Was a syphilis RPR done?

2. Syphilis RPR result

3. New or old infection

4. RPR titer

5. GC rectal done

6. CT rectal done

7. GC rectal result

8. CT rectal result

9. GC throat done

10. CT throat done

11. GC throat result

12. CT throat result

13. GC vaginal done

14. CT vaginal done

15. GC vaginal result

16. CT vaginal result

17. GC urine done

18. CT urine done

19. GC urine result

20. CT urine result

21. Sex at birth

22. Gender

23. Shifted visit date (randomly shifted)

24. Calculated age at visit

25. Race

26. Ethnicity

27. Insurance status

Madison Clinic Patients

1. Shifted visit date

2. Time from first visit (Those with first positive, those with any detectable viral loads (200 copies/mL), PEP episodes (need to filter out women), HIV testing, anyone with PrEP visits) in time period to first prescription ordered

3. Time from first prescription ordered to prescription refill

4. Duration/refill amount of any medications for PrEP, ART, or PEP

5. Time from first visit to the collection date for any HIV POC or rapid test

6. Time from first visit to the collection date for any HIV-1 RNA/viral load test

7. Time from first visit to the collection date for any DNA/TNA results

8. Time from first visit to the collection date for any HIV EIA (4^th gen) results including supplemental testing

9. For HIV-negative patients only:

   1. CT or GC PCR/NAT result (three sites)

   2. Time from first visit to collection date

   3. CT or GC collection site

   4. Syphilis EIA or RPR results

   5. RPR titer

10. Insurance status

11. Sex based on license/ID

12. Gender (still figuring out whether this will include looking at prescription hormones and/or diagnosis codes since this is not properly recorded in EPIC)

13. Calculated age at visit

14. Race

15. Ethnicity