0920-22GA Att 4i_Aim2aCohortBaselineSurveyEnglish
[NCHHSTP] _Expanding PrEP in Communities of Color (EPICC) (24BY)
Att_4i_Aim2aCohortBaselineSurveyEnglish[1]
OMB: 0920-1423
Form Approved
OMB No. 0920-New
Expiration Date: XX/XX/XXXX
Expanding PrEP in Communities of Color (EPICC+)
Attachment 4i
Aim 2a Cohort Baseline Survey English
Public reporting burden of this collection of information is estimated to average 45 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-New)
Cohort Baseline Survey
Table of Contents
DEMOGRAPHICS
SOCIOECONOMIC AND RISK CORRELATES
HEALTHCARE ACCESS, COMMUNICATION, AND STI TESTING/DIAGNOSIS
HIV
PrEP ROUTING
CURRENT PrEP USE
NEW PrEP PRESCRIPTION
PrEP RESTART
PREVIOUS PrEP USE: NO PLANS TO RESTART/UNSURE
NO PRIOR PrEP USE: NO PLANS TO START/UNSURE
PrEP CHOICES
PREP ADHERENCE AND BARRIERS
TECHNOLOGY USE AND ONLINE PARTNER SEEKING BEHAVIOR
RELATIONSHIPS AND SEXUAL HEALTH PRIORITIES
SEXUAL BEHAVIORS
SUBSTANCE USE
MENTAL HEALTH
EVERYDAY DISCRIMINATION
SOCIAL SUPPORT AND ISOLATION
Welcome to EPICC!
Thank you for your participation in this important project. This survey will take approximately 30 minutes to complete.
In this survey, we will ask some questions to try to learn about you and your health. This survey also includes some questions around sensitive topics. All the information you enter in this survey is kept completely confidential. Your answers are private--the information you provide us will be kept secure and known only to study staff. The survey includes some personal questions about your sexual behavior, health, substance use, and other areas some people may consider sensitive. We take your privacy very seriously and will keep all responses confidential, so please be as honest as you can.
You can skip questions if you need to by selecting “Decline to answer,” but we encourage you to answer every question. All of this information will help this study learn more about PrEP, HIV prevention, and other important topics.
Time-based Recall Questions
Many questions ask you to think back over the past week, weeks, month, or even several months. Please read each question to see if it is asking you to think back over a certain period and note that the period will switch between some questions.
As a reminder, today's date is [current date]
A Note about Language
We want to acknowledge that some of the language used in our study questions may include some outdated language or lack the diversity of experiences that we now understand exist.
Although we do our best to use measures that reflect emerging language, at times the items available in research are not where they need to be and are drawn from items developed years ago. Wherever possible, we have updated the language or are working with developers to get new versions. Please remember that you can always decline to answer items that do not reflect you.
If you have any questions or comments, let your study staff know. Please click the button below to get started with the survey.
DEMOGRAPHICS
A1. What is your date of birth (mm/dd/yyyy)?
SOCIOECONOMIC AND RISK CORRELATES
B1. Have you ever been homeless? By homeless, I mean you were living on the street, in a shelter, in a Single Room Occupancy hotel (SRO), or in a car.
[Yes = B2, otherwise B4]
No
Yes
Decline to answer
B2. In the past 12 months, have you been homeless at any time? [Yes = B3, otherwise B4]
No
Yes
Decline to answer
B3. Are you currently homeless?
No
Yes
Decline to answer
B4. What zip code do you live in?
Decline to answer
B5. Were you born in the United States?
No
Yes
Decline to answer
B6. Do you speak a language other than English at home?
No
Yes
Decline to answer
B7. What is your current marital status?
Married
Living together as married
Separated
Divorced
Widowed
Never married
Decline to answer
B8. Are you currently in school?
No
Yes, full-time
Yes, part-time
Enrolled in a program but on a temporary leave of absence
Decline to answer
B9. What is the highest level of education you have completed?
Never attended school
Grades 1 through 8
Grades 9 through 11
Grade 12 or GED
Some college, Associate's Degree, or Technical Degree
Bachelor's Degree
Any post graduate studies
Decline to answer
B10. What best describes your employment status? Are you:
Employed full-time
Employed part-time
A homemaker
A full-time student
Retired
Unable to work for health reasons
Unemployed
Other
Decline to answer
B11. What was your household income in [YEAR BEFORE INTERVIEW] from all sources before taxes? By "household income," we mean the total amount of money earned and shared
by all people living in your household. It’s OK if you don’t know the exact amount; make your best guess.
0 to $4,999
$5,000 to $9,999
$10,000 to $12,499
$12,500 to $14,999
$15,000 to $19,999
$20,000 to $24,999
$25,000 to $29,999
$30,000 to $34,999
$35,000 to $39,999
$40,000 to $49,999
$50,000 to $59,999
$60,000 to $74,999
$75,000 to $99,999
$100,000 or more
Decline to answer
B12. Including yourself, how many people depended on this income?
Decline to answer
B13. In the past 12 months, was there a time where there wasn’t enough money in your house for rent, food, phone, or utilities such as gas or electric?
No
Yes
Decline to answer
B14. In the past 3 months, did you or other adults in the household ever cut the size of your meals or skip meals because there wasn't enough money for food?
Yes
No
Decline to answer
B15. What is your primary means of transportation?
Personal automobile or motorcycle
Friend, relative, or neighbor
Public transportation (bus, metro, train)
Bicycle
Walking
Lyft, Uber, or other ride share service
Something else
Decline to answer
B16. Have you ever been arrested?
[Yes = B17, otherwise next Section C]
No
Yes
Decline to answer
B17. Have you ever been put in jail, prison, or juvenile detention (juvy)?
No
Yes
Decline to answer
HEALTHCARE ACCESS, COMMUNICATION, AND STI TESTING/DIAGNOSIS
C1. Do you currently have health insurance or health care coverage? This includes private health insurance (for example: Blue Cross Blue Shield or parent's private insurance) and public health care insurance or coverage (for example: Medicaid or Medicare).
[Yes = C2, otherwise C3]
Yes, I have my own
Yes, I am covered by my parent/guardian
Yes, I am covered by my spouse/partner.
No
Decline to answer
C2. What kind of health insurance or coverage do you currently have? Select all that apply.
A private health plan - through an employer or purchased directly
Medicaid - for some people with low incomes
Medicare - for the elderly and people with disabilities
Some other government plan
TRICARE / CHAMPUS
Veterans Administration coverage
Some other health insurance
Decline to answer
C3. About how long has it been since you last saw a doctor, nurse, or other health care provider about your own health? Would you say it was . . .
Within the past year
More than 1 year ago but less than 2 years ago
2 to 5 years ago
More than 5 years ago
Decline to answer
C4. How sure are you that you could communicate about the following (if necessary) with healthcare providers:
|
Not at all sure |
Somewhat sure |
Moderately sure |
Very sure |
Totally sure |
Decline to Answer |
Ask your healthcare provider things about an illness you have/had that concerns you? |
|
|
|
|
|
|
Discuss openly with your healthcare provider any problems that may be related to your medications? |
|
|
|
|
|
|
Work out differences with your healthcare provider when they arise? |
|
|
|
|
|
|
Ask your healthcare provider things about your health (like tests or treatments) that concern you? |
|
|
|
|
|
|
Discuss openly with your healthcare provider your past or current drug and/or alcohol use? |
|
|
|
|
|
|
Discuss openly with your healthcare provider your sexual activity? |
|
|
|
|
|
|
The following questions ask about testing for sexually transmitted infections or STIs such as genital herpes, gonorrhea, chlamydia, syphilis, and genital or anal warts.
C5. Have you ever been tested for an STI that was not HIV? [Yes = C6, otherwise C9]
No
Yes
I don’t know
Decline to answer
C6. When were you last tested for any STIs?
Within the past 3 months
3 to 6 months ago
>6 months but less than a year ago
Longer than 1 year ago
Decline to answer
C7. In your lifetime has your doctor or a health care professional told you that you had any of the following STIs? (Check all that apply. If none apply, please check “None of these”)
Genital Herpes
Gonorrhea
Chlamydia
Syphilis
Genital or Anal Warts
Another STI, specify:
None of these
Decline to answer
C8. In the past 3 months has your doctor or health care professional told you that you had any of the following STIs? (Check all that apply. If none, please check “None of these”.)
Genital Herpes
Gonorrhea
Chlamydia
Syphilis
Genital or Anal Warts
Another STI, specify:
I can’t remember
None of these
I did not see a health care professional in the past 3 months
Decline to answer
C9. How likely are you to get tested for STIs in the next 3 months?
Very Unlikely
Somewhat Unlikely
Somewhat Likely
Very Likely
Decline to answer
HIV
In this next part of the survey, we will ask you some questions about your experiences with and thoughts about HIV. Once again, we remind you that all questions will be kept completely confidential.
D1. Have you ever had an HIV test? [Yes = D2 otherwise D3]
No
Yes
I don’t know
Decline to answer
D2. When did you have your most recent HIV test? Please enter the month and year. It is OK if you don’t know the exact date. Please make your best guess.
[Month]
[Year]
Decline to answer
D3. On a scale of 1-10 with 1 being not concerned at all and 10 being extremely concerned, overall, how concerned are you about getting HIV?
Not at all concerned Extremely concerned
0 10
Decline to answer
D4. Please consider the following statements and select how much you agree or disagree with them
|
Strongly Agree |
Agree |
Neither Agree nor Disagree |
Disagree |
Strongly Disagree |
Decline to answer |
Most people in my community would discriminate against someone with HIV |
1 |
2 |
3 |
4 |
5 |
|
Most people in my community would support the rights of a person with HIV to live and work wherever they wanted to |
1 |
2 |
3 |
4 |
5 |
|
Most people in my community would not be friends with someone with HIV |
1 |
2 |
3 |
4 |
5 |
|
Most people in my community think that people who got HIV |
1 |
2 |
3 |
4 |
5 |
|
though sex or drug use have gotten what they deserve |
|
|
|
|
|
|
PrEP Routing
HIV pre-exposure prophylaxis, or PrEP, is a medication that can be used to reduce the risk of HIV infection. PrEP is prescribed by a doctor/health care provider.
E1. Are you currently using PrEP? [Yes = skip to Section F]
Yes
No
E2. Have you previously used PrEP [No = skip to E4]
Yes
No
E3. Are you planning on restarting PrEP soon (by soon, we mean in the next 1-2 weeks)? [Yes = skip to Section H; Otherwise skip to Section I]
Yes
No
Not sure
E4. Are you planning on starting PrEP soon (by soon, we mean in the next 1-2 weeks)? [Yes = skip to section G; Otherwise skip to Section J]
Yes
No
Not sure
Current PrEP Use
F1. What kinds of PrEP have you heard about? (Choose all that apply)
|
Daily oral |
A pill taken daily |
Truvada®, Descovy®, |
|
PrEP |
|
emtricitabine/tenofovir |
||
|
|
disoproxil fumarate, |
||
|
|
emtricitabine/tenofovir |
||
|
|
alafenamide |
|
Intermittent oral PrEP |
A pill taken before and after sex. Also called PrEP 2-1-1, on- demand, intermittent, or event-driven PrEP |
Truvada®, emtricitabine/tenofovir disoproxil fumarate |
|
|
Injectable PrEP |
A shot, an injection given by a doctor/health care provider |
Apretude®, cabotegravir |
|
Other (please specify):
Decline to answer
F2. Where did you get information about PrEP in the last 6 months? (Choose all that apply).
Doctor, nurse practitioner, or other health care provider
Friend or relative
School
A person you have sex with
A person you use drugs with
HIV counselor
TV
News
Social media (Please specify):
Other (Please specify):
I have not received information about PrEP in the last 6 months
Decline to answer
F3.
Please choose
all the
kinds of
PrEP that
you have
discussed with
a doctor/health
care provider:
|
Daily oral PrEP |
A pill taken daily |
Truvada®, Descovy®, emtricitabine/tenofovir disoproxil fumarate, emtricitabine/tenofovir alafenamide |
|
|
Intermittent oral PrEP |
A pill taken before and after sex. Also called PrEP 2-1-1, on- demand, intermittent, or event-driven PrEP |
Truvada®, emtricitabine/tenofovir disoproxil fumarate |
|
|
Injectable PrEP |
A shot, an injection given by a doctor/health care provider |
Apretude®, cabotegravir |
|
Other (please specify):
Decline to answer
F4.
What kind
of PrEP
are you
currently using?
|
Daily oral PrEP |
A pill taken daily |
Truvada®, Descovy®, emtricitabine/tenofovir disoproxil fumarate, emtricitabine/tenofovir alafenamide |
|
|
Intermittent oral PrEP |
A pill taken before and after sex. Also called PrEP 2-1-1, on- demand, intermittent, or event-driven PrEP |
Truvada®, emtricitabine/tenofovir disoproxil fumarate |
|
|
Injectable PrEP |
A shot, an injection given by a doctor/health care provider |
Apretude®, cabotegravir |
|
Other (please specify):
Decline to answer
F5. When did you start this medication: [pull answer from F4]? It’s OK if you don’t know the exact date. Please provide your best guess.
[Month]
[Year]
Decline to answer
F6a. Why do you currently use PrEP? (Choose all that apply)
I’m having sex with or thinking about having sex with someone who is living with HIV
I’m having sex with or thinking about having sex with someone whose HIV status I don’t know
I want to be in control of my sexual health
I want to reduce my anxiety around sex
I want to increase my sexual satisfaction and intimacy
I want to be safe and healthy
I want to have a better future
I am having sex with multiple partners
I don’t always use condoms (or don’t like using them)
My partner(s) won’t use condoms
I had a previous HIV scare
My health care provider recommended it
I was recently diagnosed with a sexually transmitting infection (STI)
Many people in my community take PrEP
Other, please specify:
Decline to answer
[Selected multiple options=F6b, otherwise F7]
F6b. Please rank the reasons why you are currently using PrEP in order of importance, with 1 being the most important reason, 2 being the next most important reason, all the way to the least important reason.
[Answers from F6a] rank order list
Decline to answer
F7. Have you ever used any other kind of PrEP, a kind of PrEP other than what you are currently using?
[Yes=F8, otherwise F24]
No
Yes
Decline to answer
F8.
What other
kind(s) of
PrEP have
you used?
Please rank
them in
order of
use (1=first
type of PrEP used, 2 = 2nd
type of PrEP used, etc.).
|
Daily oral PrEP |
A pill taken daily |
Truvada®, Descovy®, emtricitabine/tenofovir disoproxil fumarate, emtricitabine/tenofovir alafenamide |
|
|
Intermittent oral PrEP |
A pill taken before and after sex. Also called PrEP 2-1-1, on- demand, intermittent, or event-driven PrEP |
Truvada®, emtricitabine/tenofovir disoproxil fumarate |
|
|
Injectable PrEP |
A shot, an injection given by a doctor/health care provider |
Apretude®, cabotegravir |
|
Other (please specify):
Decline to answer
[Questions F9- F17 pertain to the first PrEP method selected in F8]
F9. When did you start this medication: [pull answer #1 from F8]? It’s OK if you don’t know the exact date. Please provide your best guess.
[Month] [Year]
Decline to answer
F10. When did you stop this medication: [pull answer #1 from F8]? It’s OK if you don’t know the exact date. Please provide your best guess.
[Month] [Year]
Decline to answer
F11. Why did you switch to a different kind of PrEP from [pull answer #1 from F8]? (Choose all that apply)
Recommended by doctor/health care provider
Recommended by a friend, partner, or family member
Cost
Side effects
Insurance issues
Easier to use
Safer to use
More effective at preventing HIV infection
Required fewer visits/labs/pharmacy visits
Dosing schedule was easier to remember
People were less likely to find out I was taking PrEP
Other, specify:
Decline to answer
F12. Please rank the reasons why you switched PrEP at that time in order of importance, with 1 being the most important reason you switched, 2 being the next most important reason, all the way to the least important reason.
[Answers from F11] rank order list
Decline to answer
[If >1 PrEP method selected in F8 = F18; Otherwise skip to F24].
F18. When did you start this medication: [pull answer #2 from F8]? It’s OK if you don’t know the exact date. Please provide your best guess.
[Month] [Year]
Decline to answer
F19. When did you stop this medication: [pull answer #2 from F8]? It’s OK if you don’t know the exact date. Please provide your best guess.
[Month] [Year]
Decline to answer
F22. Why did you switch to a different kind of PrEP from [answer #2 from F9]? (Check all that apply)
Recommended by doctor/health care provider
Recommended by a friend, partner, or family member
Cost
Side effects
Insurance issues
Easier to use
Safer to use
More effective at preventing HIV infection
Required fewer visits/labs/pharmacy visits
Dosing schedule was easier to remember
People were less likely to find out I was taking PrEP
Other, specify:
Decline to answer
[Selected multiple options=F23, otherwise F24]
F23. Please rank the reasons why you switched to a different type of PrEP in order of importance, with 1 being the most important reason you switched, 2 being the next most important reason, all the way to the least important reason.
[Answers from F22] rank order list [Skip to F24]
Decline to answer
F24. How satisfied are you with the kind of PrEP you are currently using?
Very satisfied
Moderately satisfied
Neither satisfied nor dissatisfied
Moderately dissatisfied
Very dissatisfied
Decline to answer
F25. What do you think about how effective PrEP is at preventing someone from getting HIV, when it is taken the way it is prescribed?
Very/completely effective
Somewhat effective
Minimally effective
Not at all effective
Decline to answer
F26. What do you think about whether PrEP helps prevent other kinds of sexually transmitted infections (STIs), like gonorhea or chlamydia?
HIV PrEP has no effect on other STIs
HIV PrEP helps to prevent other STIs
Decline to answer
F27. To what extent do you think taking PrEP affects your likelihood to use condoms?
Significantly less likely
Somewhat less likely
Will not change
Somewhat more likely
Significantly more likely
Decline to answer
F28. Who knows that you use PrEP? (Check all that apply)
Family member(s)
Friend(s)
Romantic partner(s)
Sex partner(s)
Health care provider (other than your PrEP provider)
Other(s), please specify
No one
Decline to answer
Now we want to ask you a few questions about your experiences and feelings related to using PrEP.
F29. Please select how much you agree with the following statements:
|
Strongly Agree |
Agree |
Neither Agree nor Disagree |
Disagree |
Strongly Disagree |
Decline to Answer |
I have been rejected romantically for taking PrEP |
|
|
|
|
|
|
I have been judged by a health care provider because of taking PrEP |
|
|
|
|
|
|
I have been blamed by people in my community for spreading HIV through PrEP use |
|
|
|
|
|
|
I have been slut-shamed for taking PrEP (or told that I am a "Truvada or Descovy slut/whore") |
|
|
|
|
|
|
I have been unfairly discriminated against for taking PrEP |
|
|
|
|
|
|
I have been yelled at or scolded because of taking PrEP |
|
|
|
|
|
|
I have experienced physical violence because of taking PrEP |
|
|
|
|
|
|
F30. Please select how much you agree with the following statements:
|
Strongly Agree |
Agree |
Neither Agree nor Disagree |
Disagree |
Strongly Disagree |
Decline to Answer |
I worry people will assume I sleep around if they know I take PrEP |
|
|
|
|
|
|
I worry people will assume that I am HIV+ if they know I take PrEP |
|
|
|
|
|
|
I worry people will think my partner(s) are HIV+ if they know I take PrEP |
|
|
|
|
|
|
I worry about listing PrEP as one of my current medications during doctor appointments |
|
|
|
|
|
|
I feel ashamed to tell other people I am taking PrEP |
|
|
|
|
|
|
I worry people will think I am a bad person if they know I take PrEP |
|
|
|
|
|
|
I worry people will think I am gay if they know I take PrEP |
|
|
|
|
|
|
I worry my friends will find out that I take PrEP |
|
|
|
|
|
|
I worry my family will find out that I take PrEP |
|
|
|
|
|
|
I worry my sex partners will find out that I take PrEP |
|
|
|
|
|
|
I think people will give me a hard time if I tell them I take PrEP |
|
|
|
|
|
|
I think people will judge me if they know I am taking PrEP |
|
|
|
|
|
|
[Skip to Section K]
New PrEP Prescription
G1. Before today, had you ever heard about PrEP to reduce the risk of getting HIV infection? [YES = G2, otherwise G4]
No
Yes
Decline to answer
G2.
What kinds
of PrEP
have you
heard about?
(Choose all
that apply)
|
Daily oral PrEP |
A pill taken daily |
Truvada®, Descovy®, emtricitabine/tenofovir disoproxil fumarate, emtricitabine/tenofovir alafenamide |
|
|
Intermittent oral PrEP |
A pill taken before and after sex. Also called PrEP 2-1-1, on- demand, intermittent, or event-driven PrEP |
Truvada®, emtricitabine/tenofovir disoproxil fumarate |
|
|
Injectable PrEP |
A shot, an injection given by a doctor/health care provider |
Apretude®, cabotegravir |
|
Other (please specify):
I have not heard about any of these PrEP options
Decline to answer
G3. Where did you get information about PrEP in the last 6 months? (Choose all that apply).
Doctor, nurse practitioner, or other health care provider
Friend or relative
School
A person you have sex with
A person you use drugs with
HIV counselor
TV
News
Social media (Please specify):
Other (Please specify):
I have not received information about PrEP in the last 6 months
Decline to answer
G4.
Please choose
all the
kinds of
PrEP that
you have
discussed with
a doctor/health
care provider:
|
Daily oral PrEP |
A pill taken daily |
Truvada®, Descovy®, emtricitabine/tenofovir disoproxil fumarate, emtricitabine/tenofovir alafenamide |
|
|
Intermittent oral PrEP |
A pill taken before and after sex. Also called PrEP 2-1-1, on- demand, intermittent, or event-driven PrEP |
Truvada®, emtricitabine/tenofovir disoproxil fumarate |
|
|
Injectable PrEP |
A shot, an injection given by a doctor/health care provider |
Apretude®, cabotegravir |
|
Other (please specify):
Decline to answer
G5. What kind of PrEP are you planning to start?
|
Daily oral PrEP |
A pill taken daily |
Truvada®, Descovy®, emtricitabine/tenofovir disoproxil fumarate, emtricitabine/tenofovir alafenamide |
|
|
Intermittent oral PrEP |
A pill taken before and after sex. Also called PrEP 2-1-1, on- demand, intermittent, or event-driven PrEP |
Truvada®, emtricitabine/tenofovir disoproxil fumarate |
|
|
Injectable PrEP |
A shot, an injection given by a doctor/health care provider |
Apretude®, cabotegravir |
|
Other (please specify):
Decline to answer
G6. When are you planning on starting PrEP. It’s OK if you don’t know the exact date. Please provide your best guess.
[Month] [Year]
Decline to answer
G7. Why have you decided to start PrEP? (Choose all that apply)
I’m having sex with or thinking about having sex with someone who is living with HIV
I’m having sex with or thinking about having sex with someone whose HIV status I don’t know
I want to be in control of my sexual health
I want to reduce my anxiety around sex
I want to increase my sexual satisfaction and intimacy
I want to be safe and healthy
I want to have a better future
I am having sex with multiple partners
I don’t always use condoms (or don’t like them)
My partner won’t use condoms
I had a previous HIV scare
My health care provider recommended it
I was recently diagnosed with a sexually transmitting infection (STI)
Many people in my community take PrEP
Other, please specify:
Decline to answer
[Selected multiple options=G8, otherwise G9]
G8. Please rank the reasons why you are starting PrEP in order of importance, with 1 being the most important reason, 2 being the next most important reason, all the way to the least important reason.
[Answers from G7] rank order list
G9. What do you think about how effective PrEP is at preventing someone from getting HIV, when it is taken the way it is prescribed?
Very/completely effective
Somewhat effective
Minimally effective
Not at all effective
Decline to answer
G10. What do you think about whether PrEP helps prevent other kinds of sexually transmitted infections (STIs), like gonorrhea or chlamydia?
HIV PrEP has no effect on other STIs
HIV PrEP helps to prevent other STIs
Decline to answer
G11. To what extent do you think taking PrEP will affect your likelihood to use condoms?
Significantly less likely
Somewhat less likely
Will not change
Somewhat more likely
Significantly more likely
Decline to answer
G12. Who knows that you are planning to start PrEP? (Check all that apply)
Family member(s)
Friend(s)
Romantic partner(s)
Sex partner(s)
Health care provider (other than your PrEP provider)
Other(s), please specify
No one
Decline to answer
Strongly
Agree
Agree
Neither
Agree
nor Disagree
Disagree
Strongly
Disagree
Decline
to Answer 
I worry people will assume I sleep around if they know I take PrEP |
|
|
|
|
|
|
I worry people will assume that I am HIV+ if they know I take PrEP |
|
|
|
|
|
|
I worry people will think my partner(s) are HIV+ if they know I take PrEP |
|
|
|
|
|
|
I worry about listing PrEP as one of my current medications during doctor appointments |
|
|
|
|
|
|
I feel ashamed to tell other people I am taking PrEP |
|
|
|
|
|
|
I worry people will think I am a bad person if they know I take PrEP |
|
|
|
|
|
|
I worry people will think I am gay if they know I take PrEP |
|
|
|
|
|
|
I worry my friends will find out that I take PrEP |
|
|
|
|
|
|
I worry my family will find out that I take PrEP |
|
|
|
|
|
|
I worry my sex partners will find out that I take PrEP |
|
|
|
|
|
|
I think people will give me a hard time if I tell them I take PrEP |
|
|
|
|
|
|
I think people will judge me if they know I am taking PrEP |
|
|
|
|
|
|
[Skip to Section K]
PrEP Restart
H1. What kinds of PrEP have you heard about? (Choose all that apply)
|
Daily oral PrEP |
A pill taken daily |
Truvada®, Descovy®, emtricitabine/tenofovir disoproxil fumarate, emtricitabine/tenofovir alafenamide |
|
|
Intermittent oral PrEP |
A pill taken before and after sex. Also called PrEP 2-1-1, on- demand, intermittent, or event-driven PrEP |
Truvada®, emtricitabine/tenofovir disoproxil fumarate |
|
|
Injectable PrEP |
A shot, an injection given by a doctor/health care provider |
Apretude®, cabotegravir |
|
-
Other
(please specify):
Decline to answer
H2. Where did you get information about PrEP in the last 6 months? (Choose all that apply).
Doctor, nurse practitioner, or other health care provider
Friend or relative
School
A person you have sex with
A person you use drugs with
HIV counselor
TV
News
Social media (Please specify):
Other (Please specify):
I have not received information about PrEP in the last 6 months
Decline to answer
H3. Please choose all the kinds of PrEP that you have discussed with a doctor/health care provider:
|
Daily oral |
A pill taken daily |
Truvada®, Descovy®, |
|
PrEP |
|
emtricitabine/tenofovir |
||
|
|
disoproxil fumarate, |
||
|
|
emtricitabine/tenofovir |
||
|
|
alafenamide |
|
Intermittent oral PrEP |
A pill taken before and after sex. Also called PrEP 2-1-1, on- demand, intermittent, or event-driven PrEP |
Truvada®, emtricitabine/tenofovir disoproxil fumarate |
|
|
Injectable PrEP |
A shot, an injection given by a doctor/health care provider |
Apretude®, cabotegravir |
|
Other (please specify):
Decline to answer
H4.
What kinds
of PrEP
have you
ever used?
Please rank
them in
order of
use (1=first
type of PrEP used,
2 = 2nd
type of PrEP used, etc.).
|
Daily oral |
A pill taken daily |
Truvada®, Descovy®, |
|
PrEP |
|
emtricitabine/tenofovir |
||
|
|
disoproxil fumarate, |
||
|
|
emtricitabine/tenofovir |
||
|
|
alafenamide |
||
|
Intermittent |
A pill taken before |
Truvada®, |
|
oral PrEP |
and after sex. Also |
emtricitabine/tenofovir |
||
|
called PrEP 2-1-1, |
disoproxil fumarate |
||
|
on-demand, |
|
||
|
intermittent, or |
|
||
|
event-driven PrEP |
|
||
|
Injectable |
A shot, an injection |
Apretude®, cabotegravir |
|
PrEP |
given by a |
|
||
|
doctor/health care |
|
||
|
provider |
|
Other (please specify):
Decline to answer
H5. When did you start this medication: [pull answer #1 from H1]? It’s OK if you don’t know the exact date. Please provide your best guess.
[Month] [Year]
Decline to answer
H6. When did you stop this medication: [pull answer #1 from H1]? It’s OK if you don’t know the exact date. Please provide your best guess.
[Month] [Year]
Decline to answer
H7. Why did you stop taking this medication, [pull answer #1 from H1]? (Choose all that apply)
I couldn't afford it anymore
I didn’t think that I was at risk for HIV anymore
My insurance would not cover it, or I lost my insurance
I didn't want to keep taking a pill every day
My parent(s) or guardian(s) found out and made me stop
I kept forgetting to take my pill
I had trouble getting to follow-up appointments
I had issues getting PrEP or with the pharmacy
I was having side effects
People reacted negatively when they found out I was taking PrEP
I was worried about the long term effects of PrEP on my health
I had a medical problem that made it unsafe to continue taking PrEP
I started using condoms all of the time
I couldn’t take the medication (tasted bad, pill was too big)
Other, please specify:
Decline to answer
H8. Please rank the reasons why you stopped PrEP at that time in order of importance, with 1 being the most important reason, 2 being the next most important reason, all the way to the least important reason.
[Answers from H7] rank order list
Decline to answer
[If multiple options selected in H4 = Repeat question series H5-H8 for all selections; otherwise H9]
H9. Did you talk with your doctor/health care provider before stopping PrEP?
No
Yes
Decline to answer
H10. Please choose the statements that describe your sexual behavior after you stopped taking PrEP. (Choose all that apply)
I did not have any sexual contact after I stopped taking PrEP [Skip to H10]
I had oral sex after I stopped taking PrEP
I had anal sex after I stopped taking PrEP
I had vaginal sex when I stopped taking PrEP (put your penis in a vagina or neovagina)
Decline to answer
H11. Please choose the statements that describe your use of condoms after you stopped taking PrEP. (Choose all that apply)
I used a condom with every sexual contact after I stopped taking PrEP
I used a condom for most sexual contacts after I stopped taking PrEP
I used a condom for some sexual contacts after I stopped taking PrEP
I did not use condoms after I stopped taking PrEP
Decline to answer
H12.
What kind
of PrEP
are you
planning to
start?
|
Daily oral PrEP |
A pill taken daily |
Truvada®, Descovy®, emtricitabine/tenofovir disoproxil fumarate, emtricitabine/tenofovir alafenamide |
|
|
Intermittent oral PrEP |
A pill taken before and after sex. Also called PrEP 2-1-1, on- demand, intermittent, or event-driven PrEP |
Truvada®, emtricitabine/tenofovir disoproxil fumarate |
|
|
Injectable PrEP |
A shot, an injection given by a doctor/health care provider |
Apretude®, cabotegravir |
|
Other (please specify):
Decline to answer
H13. When are you planning on restarting PrEP. It’s OK if you don’t know the exact date. Please provide your best guess.
[Month] [Year]
Decline to answer
H14. Why have you decided to restart PrEP? (Choose all that apply)
I’m having sex with or thinking about having sex with someone who is living with HIV
I’m having sex with or thinking about having sex with someone whose HIV status I don’t know
I want to be in control of my sexual health
I want to reduce my anxiety around sex
I want to increase my sexual satisfaction and intimacy
I want to be safe and healthy
I want to have a better future
I am having sex with multiple partners
I don’t always use condoms (or don’t like them)
My partner won’t use condoms
I had a previous HIV scare
My health care provider recommended it
I was recently diagnosed with a sexually transmitting infection (STI)
Many people in my community take PrEP
Other, please specify:
Decline to answer
[Selected multiple options=H15, otherwise H16]
H15. Please rank the reasons why you are restarting PrEP in order of importance, with 1 being the most important reason, 2 being the next most important reason, all the way to the least important reason.
[Answers from H14] rank order list
Decline to answer
H16. Who knows that you are planning to restart PrEP? (Check all that apply)
Family member(s)
Friend(s)
Romantic partner(s)
Sex partner(s)
Health care provider (other than your PrEP provider)
Other(s), please specify
No one
Decline to answer
H17. What do you think about how effective PrEP is at preventing someone from getting HIV, when it is taken the way it is prescribed?
Very/completely effective
Somewhat effective
Minimally effective
Not at all effective
Decline to answer
H18. What do you think about whether PrEP helps prevent other kinds of sexually transmitted infections (STIs), like gonorrhea or chlamydia?
HIV PrEP has no effect on other STIs
HIV PrEP helps to prevent other STIs
Decline to answer
H19. To what extent do you think restarting PrEP will affect your likelihood to use condoms?
Significantly less likely
Somewhat less likely
Will not change
Somewhat more likely
Significantly more likely
Decline to answer
Strongly
Agree
Agree
Neither
Agree
nor Disagree
Disagree
Strongly
Disagree
Decline
to
Answer
I
have been rejected romantically
for
taking
PrEP
I
have been judged by a health care
provider
because
of
taking PrEP
I
have been blamed by people in
my
community
for
spreading
HIV through PrEP use
I
have been slut-shamed for taking
PrEP
(or
told
that
I
am
a "Truvada
or Descovy slut/whore")
I
have been unfairly discriminated
against
for
taking PrEP
I
have been yelled at or scolded
because
of
taking PrEP
I
have
experienced
physical
violence because of taking PrEP
Strongly
Agree
Agree
Neither
Agree
nor Disagree
Disagree
Strongly
Disagree
Decline
to Answer
I
worry
people
will
assume
I sleep
around if they know I take PrEP
I
worry
people
will
assume
that I am
HIV+ if they know I take PrEP
I
worry
people
will
think
my
partner(s) are HIV+ if they know I take PrEP
I
worry about listing PrEP as one
of
my
current
medications
during doctor appointments
I
feel
ashamed
to
tell
other people
I am taking PrEP
I
worry
people
will
think
I
am
a bad
person
if
they
know
I
take PrEP
I
worry
people
will
think
I
am gay
if
they
know I
take PrEP
I
worry
my
friends
will
find
out that I
take PrEP
I
worry
my
family
will
find
out that I
take PrEP
I
worry
my
sex
partners
will find
out that I take PrEP
I
think
people
will
give
me
a hard
time
if
I
tell
them
I
take PrEP
I
think
people
will
judge
me
if they know
I am taking PrEP
Previous PrEP users: not restarting/unsure
I1. What kinds of PrEP have you heard about? (Choose all that apply)
|
Daily oral PrEP |
A pill taken daily |
Truvada®, Descovy®, emtricitabine/tenofovir disoproxil fumarate, emtricitabine/tenofovir alafenamide |
|
|
Intermittent oral PrEP |
A pill taken before and after sex. Also called PrEP 2-1-1, on- demand, intermittent, or event-driven PrEP |
Truvada®, emtricitabine/tenofovir disoproxil fumarate |
|
|
Injectable PrEP |
A shot, an injection given by a doctor/health care provider |
Apretude®, cabotegravir |
|
-
Other
(please specify):
Decline to answer
I2. Where did you get information about PrEP in the last 6 months? (Choose all that apply).
Doctor, nurse practitioner, or other health care provider
Friend or relative
School
A person you have sex with
A person you use drugs with
HIV counselor
TV
News
Social media (Please specify):
Other (Please specify):
I have not received information about PrEP in the last 6 months
Decline to answer
I3. Please choose all the kinds of PrEP that you have discussed with a doctor/health care provider:
|
Daily oral |
A pill taken daily |
Truvada®, Descovy®, |
|
PrEP |
|
emtricitabine/tenofovir |
||
|
|
disoproxil fumarate, |
||
|
|
emtricitabine/tenofovir |
||
|
|
alafenamide |
|
Intermittent oral PrEP |
A pill taken before and after sex. Also called PrEP 2-1-1, on- demand, intermittent, or event-driven PrEP |
Truvada®, emtricitabine/tenofovir disoproxil fumarate |
|
|
Injectable PrEP |
A shot, an injection given by a doctor/health care provider |
Apretude®, cabotegravir |
|
Other (please specify):
Decline to answer
I4.
What kinds
of PrEP
have you
ever used?
Please rank
them in
order of
use (1=first
type of PrEP used,
2 = 2nd
type of PrEP used, etc.).
|
Daily oral |
A pill taken daily |
Truvada®, Descovy®, |
|
PrEP |
|
emtricitabine/tenofovir |
||
|
|
disoproxil fumarate, |
||
|
|
emtricitabine/tenofovir |
||
|
|
alafenamide |
||
|
Intermittent |
A pill taken before |
Truvada®, |
|
oral PrEP |
and after sex. Also |
emtricitabine/tenofovir |
||
|
called PrEP 2-1-1, |
disoproxil fumarate |
||
|
on-demand, |
|
||
|
intermittent, or |
|
||
|
event-driven PrEP |
|
||
|
Injectable |
A shot, an injection |
Apretude®, cabotegravir |
|
PrEP |
given by a |
|
||
|
doctor/health care |
|
||
|
provider |
|
Other (please specify):
Decline to answer
I5. When did you start this medication: [pull answer #1 from H1]? It’s OK if you don’t know the exact date. Please provide your best guess.
[Month] [Year]
Decline to answer
I6. When did you stop this medication: [pull answer #1 from H1]? It’s OK if you don’t know the exact date. Please provide your best guess.
[Month] [Year]
Decline to answer
I7. Why did you stop taking this medication, [pull answer #1 from H1]? (Choose all that apply)
I couldn't afford it anymore
I didn’t think that I was at risk for HIV anymore
My insurance would not cover it, or I lost my insurance
I didn't want to keep taking a pill every day
My parent(s) or guardian(s) found out and made me stop
I kept forgetting to take my pill
I had trouble getting to follow-up appointments
I had issues getting PrEP or with the pharmacy
I was having side effects
People reacted negatively when they found out I was taking PrEP
I was worried about the long term effects of PrEP on my health
I had a medical problem that made it unsafe to continue taking PrEP
I started using condoms all of the time
I couldn’t take the medication (tasted bad, pill was too big)
Other, please specify:
Decline to answer
I8. Please rank the reasons why you stopped PrEP at that time in order of importance, with 1 being the most important reason, 2 being the next most important reason, all the way to the least important reason.
[Answers from I7] rank order list
Decline to answer
[If multiple options selected in I4 = Repeat question series I5-I8 for all selections; otherwise I9] I9. Did you talk with your doctor/health care provider before stopping PrEP?
No
Yes
Decline to answer
I10. Please choose the statements that describe your sexual behavior after you stopped taking PrEP. (Choose all that apply)
I did not have any sexual contact after I stopped taking PrEP [Skip to I10]
I had oral sex after I stopped taking PrEP
I had anal sex after I stopped taking PrEP
I had vaginal sex when I stopped taking PrEP (put your penis in a vagina)
Decline to answer
I11. Please choose the statements that describe your use of condoms after you stopped taking PrEP. (Choose all that apply)
I used a condom with every sexual contact after I stopped taking PrEP
I used a condom for most sexual contacts after I stopped taking PrEP
I used a condom for some sexual contacts after I stopped taking PrEP
I did not use condoms after I stopped taking PrEP
Decline to answer
[If E3=No, skip to I19]
I12.
What kind of PrEP
are considering
starting? [one response]
|
Daily oral PrEP |
A pill taken daily |
Truvada®, Descovy®, emtricitabine/tenofovir disoproxil fumarate, emtricitabine/tenofovir alafenamide |
|
|
Intermittent oral PrEP |
A pill taken before and after sex. Also called PrEP 2-1-1, on- demand, intermittent, or event-driven PrEP |
Truvada®, emtricitabine/tenofovir disoproxil fumarate |
|
|
Injectable PrEP |
A shot, an injection given by a doctor/health care provider |
Apretude®, cabotegravir |
|
Other (please specify):
Decline to answer
I13. When are you planning on possibly restarting PrEP. It’s OK if you don’t know the exact date. Please provide your best guess.
[Month]
[Year]
Decline to answer
I14. Why are you considering restarting PrEP? (Choose all that apply)
I’m having sex with or thinking about having sex with someone who is living with HIV
I’m having sex with or thinking about having sex with someone whose HIV status I don’t know
I want to be in control of my sexual health
I want to reduce my anxiety around sex
I want to increase my sexual satisfaction and intimacy
I want to be safe and healthy
I want to have a better future
I am having sex with multiple partners
I don’t always use condoms (or don’t like them)
My partner won’t use condoms
I had a previous HIV scare
My health care provider recommended it
I was recently diagnosed with a sexually transmitting infection (STI)
Many people in my community take PrEP
Other, please specify:
Decline to answer
[Selected multiple options=I15, otherwise I16]
I15. Please rank the reasons why you are considering restarting PrEP in order of importance, with 1 being the most important reason, 2 being the next most important reason, all the way to the least important reason.
[Answers from I14] rank order list
Decline to answer
I16. Who knows that you are considering restarting PrEP? (Check all that apply)
Family member(s)
Friend(s)
Romantic partner(s)
Sex partner(s)
Health care provider (other than your PrEP provider)
Other(s), please specify
No one
Decline to answer
I17. Why are you unsure about whether you want to restart PrEP? Select all that apply.
I’m concerned about potential side effects
I don’t know if I want to use this type of PrEP [pipe in type from I12]
I’m not at risk for HIV
My insurance might not cover it or I lost my insurance
I don’t want my parent(s) or guardian(s) to find out I’m taking PrEP
It will be hard to get to follow-up appointments
People might react negatively if they find out I’m taking PrEP
I’m using condoms all the time
Other, please specify:
Decline to answer
I18. Please rank the reasons why you are unsure about restarting PrEP in order of importance, with 1 being the most important reason, 2 being the next most important reason, all the way to the least important reason.
[Answers from I17] rank order list
Decline to answer
[Only if E3=No; otherwise skip to I21]
I19. What are the reasons why you are not planning to restart PrEP at this time. Select all that apply.
I can’t afford it right now
I’m not at risk for HIV
My insurance will not cover it, or I don’t have insurance
I don’t want to take a pill every day
My parent(s) or guardian(s) will find out
I will forget to take my pill
I will have trouble getting to follow-up appointments
I will have issues getting PrEP or with the pharmacy
I am concerned about side effects
People will react negatively if they find out I’m taking PrEP
I am worried about the long term effects of PrEP on my health
I have a medical problem that makes it unsafe to take PrEP
I use condoms all of the time
Other, please specify:
Decline to answer
I20. Please rank the reasons why you do not plan to restart PrEP in order of importance, with 1 being the most important reason, 2 being the next most important reason, all the way to the least important reason.
[Answers from I19] rank order list
Decline to answer
I21. What would motivate you to restart PrEP? Select all that apply.
Having sex with someone who is living with HIV
Having sex with someone whose HIV status is unknown
Having sex with multiple partners
Not using condoms regularly or partner(s) do/does not want to use condoms
Receiving more information on the safety of [pipe in PrEP modality from I12]
Receiving more information on the effectiveness of [pipe in PrEP modality from I12]
More people in your community start using PrEP
It was easier to attend follow-up visits
Fewer follow-up appointments/labs needed
Having better health insurance
Support from family and/or friends
Support from medical providers
Support from my partner(s)
Other, specify:
Decline to answer
I22. Please rank the reasons what would motivate you to restart PrEP in order of importance, with 1 being the most important reason, 2 being the next most important reason, all the way to the least important reason.
[Answers from I21] rank order list
Decline to answer
Strongly
Agree
Agree
Neither
Agree
nor Disagree
Disagree
Strongly
Disagree
Decline
to
Answer
I
have been rejected romantically
for
taking
PrEP
I
have been judged by a health care
provider
because
of
taking PrEP
I
have been blamed by people in
my
community
for
spreading
HIV through PrEP use
I
have been slut-shamed for taking
PrEP
(or
told
that
I
am
a "Truvada
or Descovy slut/whore")
I have been unfairly discriminated against for taking PrEP |
|
|
|
|
|
|
I have been yelled at or scolded because of taking PrEP |
|
|
|
|
|
|
I have experienced physical violence because of taking PrEP |
|
|
|
|
|
|
Now we want to ask you a few questions about your feelings related to possibly restarting PrEP.
I23. Please select how much you agree with the following statements:
|
Strongly Agree |
Agree |
Neither Agree nor Disagree |
Disagree |
Strongly Disagree |
Decline to Answer |
I worry people will assume I sleep around if they know I take PrEP |
|
|
|
|
|
|
I worry people will assume that I am HIV+ if they know I take PrEP |
|
|
|
|
|
|
I worry people will think my partner(s) are HIV+ if they know I take PrEP |
|
|
|
|
|
|
I worry about listing PrEP as one of my current medications during doctor appointments |
|
|
|
|
|
|
I feel ashamed to tell other people I am taking PrEP |
|
|
|
|
|
|
I worry people will think I am a bad person if they know I take PrEP |
|
|
|
|
|
|
I worry people will think I am gay if they know I take PrEP |
|
|
|
|
|
|
I worry my friends will find out that I take PrEP |
|
|
|
|
|
|
I worry my family will find out that I take PrEP |
|
|
|
|
|
|
I worry my sex partners will find out that I take PrEP |
|
|
|
|
|
|
I think people will give me a hard time if I tell them I take PrEP |
|
|
|
|
|
|
I think people will judge me if they know I am taking PrEP |
|
|
|
|
|
|
I24. What do you think about how effective PrEP is at preventing someone from getting HIV, when it is taken the way it is prescribed?
Very/completely effective
Somewhat effective
Minimally effective
Not at all effective
Decline to answer
I25. What do you think about whether PrEP helps prevent other kinds of sexually transmitted infections (STIs), like herpes?
HIV PrEP has no effect on other STIs
HIV PrEP helps to prevent other STIs
Decline to answer
I26. To what extent do you think restarting PrEP would affect your likelihood to use condoms?
Significantly less likely
Somewhat less likely
Will not change
Somewhat more likely
Significantly more likely
Decline to answer
Never used PrEP: not starting/unsure
J1. Before today, had you ever heard about PrEP to reduce the risk of getting HIV infection? [YES = J2, otherwise J4]
No
Yes
Decline to answer
J2. What kinds of PrEP have you heard about? (Choose all that apply)
|
Daily oral PrEP |
A pill taken daily |
Truvada®, Descovy®, emtricitabine/tenofovir disoproxil fumarate, emtricitabine/tenofovir alafenamide |
|
|
Intermittent oral PrEP |
A pill taken before and after sex. Also called PrEP 2-1-1, on- demand, intermittent, or event-driven PrEP |
Truvada®, emtricitabine/tenofovir disoproxil fumarate |
|
|
Injectable PrEP |
A shot, an injection given by a doctor/health care provider |
Apretude®, cabotegravir |
|
-
Other
(please specify):
Decline to answer
J3. Where did you get information about PrEP in the last 6 months? (Choose all that apply).
Doctor, nurse practitioner, or other health care provider
Friend or relative
School
A person you have sex with
A person you use drugs with
HIV counselor
TV
News
Social media (Please specify):
Other (Please specify):
I have not received information about PrEP in the last 6 months
Decline to answer
J4. Please choose all the kinds of PrEP that you have discussed with a doctor/health care provider:
|
Daily oral |
A pill taken daily |
Truvada®, Descovy®, |
|
PrEP |
|
emtricitabine/tenofovir |
||
|
|
disoproxil fumarate, |
||
|
|
emtricitabine/tenofovir |
||
|
|
alafenamide |
|
Intermittent oral PrEP |
A pill taken before and after sex. Also called PrEP 2-1-1, on- demand, intermittent, or event-driven PrEP |
Truvada®, emtricitabine/tenofovir disoproxil fumarate |
|
|
Injectable PrEP |
A shot, an injection given by a doctor/health care provider |
Apretude®, cabotegravir |
|
Other (please specify):
Decline to answer
[Year]
Decline to answer
[If E4=No, skip to J12]
J5.
What kind of
PrEP are
considering starting?
|
Daily oral PrEP |
A pill taken daily |
Truvada®, Descovy®, emtricitabine/tenofovir disoproxil fumarate, emtricitabine/tenofovir alafenamide |
|
|
Intermittent oral PrEP |
A pill taken before and after sex. Also called PrEP 2-1-1, on- demand, intermittent, or event-driven PrEP |
Truvada®, emtricitabine/tenofovir disoproxil fumarate |
|
|
Injectable PrEP |
A shot, an injection given by a doctor/health care provider |
Apretude®, cabotegravir |
|
Other (please specify):
Decline to answer
J6. When are you planning on possibly starting PrEP. It’s OK if you don’t know the exact date. Please provide your best guess.
[Month] [Year]
Decline to answer
J7. Why are you considering starting PrEP? (Choose all that apply)
I’m having sex with or thinking about having sex with someone who is living with HIV
I’m having sex with or thinking about having sex with someone whose HIV status I don’t know
I want to be in control of my sexual health
I want to reduce my anxiety around sex
I want to increase my sexual satisfaction and intimacy
I want to be safe and healthy
I want to have a better future
I am having sex with multiple partners
I don’t always use condoms (or don’t like them)
My partner won’t use condoms
I had a previous HIV scare
My health care provider recommended it
I was recently diagnosed with a sexually transmitting infection (STI)
Many people in my community take PrEP
Other, please specify:
Decline to answer
[Selected multiple options=J8, otherwise J9]
J8. Please rank the reasons why you are considering starting PrEP in order of importance, with 1 being the most important reason, 2 being the next most important reason, all the way to the least important reason.
[Answers from J7] rank order list
Decline to answer
J9. Who knows that you are considering starting PrEP? (Check all that apply)
Family member(s)
Friend(s)
Romantic partner(s)
Sex partner(s)
Health care provider (other than your PrEP provider)
Other(s), please specify
No one
Decline to answer
J10. Why are you unsure about whether you want to start PrEP? Select all that apply.
I’m concerned about potential side effects
I don’t know if I want to use this type of PrEP [pipe in type from J4]
I’m not at risk for HIV
My insurance might not cover it or I lost my insurance
I don’t want my parent(s) or guardian(s) to find out I’m taking PrEP
It will be hard to get to follow-up appointments
People might react negatively if they find out I’m taking PrEP
I’m using condoms all the time
Other, please specify:
Decline to answer
J11. Please rank the reasons why you are unsure about staring PrEP in order of importance, with 1 being the most important reason, 2 being the next most important reason, all the way to the least important reason.
[Answers from J10] rank order list
Decline to answer
[If E4=No; otherwise skip to J14]
J12. What are the reasons why you are not planning to start PrEP at this time. Select all that apply.
I can’t afford it right now
I’m not at risk for HIV
My insurance will not cover it, or I don’t have insurance
I don’t want to take a pill every day
My parent(s) or guardian(s) will find out
I will forget to take my pill
I will have trouble getting to follow-up appointments
I will have issues getting PrEP or with the pharmacy
I am concerned about side effects
People will react negatively if they find out I’m taking PrEP
I am worried about the long term effects of PrEP on my health
I have a medical problem that makes it unsafe to take PrEP
I use condoms all of the time
Other, please specify:
Decline to answer
J13. Please rank the reasons why you do not plan to start PrEP in order of importance, with 1 being the most important reason, 2 being the next most important reason, all the way to the least important reason.
[Answers from J12] rank order list
Decline to answer
J14. What would motivate you to start PrEP? Select all that apply.
Having sex with someone who is living with HIV
Having sex with someone whose HIV status is unknown
Having sex with multiple partners
Stopping using condoms regularly or partner(s) do/does not want to use condoms
Receiving more information on the safety of [pipe in PrEP modality from I12]
Receiving more information on the effectiveness of [pipe in PrEP modality from I12]
More people in your community start using PrEP
It was easier to attend follow-up visits
Fewer follow-up appointments/labs needed
Having better health insurance
Support from family and/or friends
Support from medical providers
Support from my partner(s)
Other, specify:
Decline to answer
J15. Please rank the reasons what would motivate you to start PrEP in order of importance, with 1 being the most important reason, 2 being the next most important reason, all the way to the least important reason.
[Answers from J14] rank order list
Decline to answer
Strongly
Agree
Agree
Neither
Agree
nor Disagree
Disagree
Strongly
Disagree
Decline
to answer
I
worry
people
will
assume
I sleep
around if they know I take PrEP
I
worry
people
will
assume
that I am
HIV+ if they know I take PrEP
I
worry
people
will
think
my
partner(s) are HIV+ if they know I take PrEP
I
worry about listing PrEP as one
of
my
current
medications
during doctor appointments
I feel ashamed to tell other people I am taking PrEP |
|
|
|
|
|
|
I worry people will think I am a bad person if they know I take PrEP |
|
|
|
|
|
|
I worry people will think I am gay if they know I take PrEP |
|
|
|
|
|
|
I worry my friends will find out that I take PrEP |
|
|
|
|
|
|
I worry my family will find out that I take PrEP |
|
|
|
|
|
|
I worry my sex partners will find out that I take PrEP |
|
|
|
|
|
|
I think people will give me a hard time if I tell them I take PrEP |
|
|
|
|
|
|
I think people will judge me if they know I am taking PrEP |
|
|
|
|
|
|
J17. What do you think about how effective PrEP is at preventing someone from getting HIV, when it is taken the way it is prescribed?
Very/completely effective
Somewhat effective
Minimally effective
Not at all effective
Decline to answer
J18. What do you think about whether PrEP helps prevent other kinds of sexually transmitted infections (STIs), like herpes?
HIV PrEP has no effect on other STIs
HIV PrEP helps to prevent other STIs
Decline to answer
J19. To what extent do you think taking PrEP will affect your likelihood to use condoms?
Significantly less likely
Somewhat less likely
Will not change
Somewhat more likely
Significantly more likely
Decline to answer
PrEP Choices
[If F4, G5, H12 = Daily oral PrEP then K1-K2]
[If F4, G5, H12 = Intermittent oral PrEP then K3-K4] [If F4, G5, H12 = Injectable PrEP then K5-K6]
[If F4, G5, H12 = Other or Don’t know then K13]
[If I12, J5 = Daily oral PrEP then K7-K8]
[If I12, J5 = Intermittent oral PrEP then K9-K10] [If I12, J5 = Injectable PrEP then K11-K12]
[If I12, J5 = Other or Don’t know then K13]
K1. Why have you chosen to use daily oral PrEP, rather than a different kind of PrEP? (Choose all that apply)
My doctor/health care provider recommended this kind for me
I know people who use this kind of PrEP
I think this kind of PrEP is more effective than other kinds
I think this kind of PrEP is safer than other kinds
I don’t want to have to get shots/injections
I don’t want to have to attend an appointment every two months for a shot/injection
With a shot/injection I would be concerned about long-acting side effects (that is, side effects that don’t go away for a long time because I received an injection)
I don’t think I would remember to take intermittent PrEP as prescribed
I don’t think intermittent PrEP would work for me because it is difficult to predict when I’m going to have sex
I prefer to have a regular routine of taking PrEP
Other, please specify
Decline to answer
[Selected multiple options=K2, otherwise K13]
K2. Please rank the reasons why you have chosen daily oral PrEP, with 1 being the most important reason, 2 being the next most important reason, all the way to the least important reason.
[Answers from K1] rank order list
Decline to answer
K3. Why have you chosen to use intermittent oral PrEP, rather than a different kind of PrEP? (Choose all that apply)
My doctor/health care provider recommended this kind for me
I know people who use this kind of PrEP
I think this kind of PrEP is more effective than other kinds
I think this kind of PrEP is safer than other kinds
I don’t want to have to get shots/injections
I don’t want to have to attend an appointment every two months for a shot/injection
With a shot/injection I would be concerned about long-acting side effects (that is, side effects that don’t go away for a long time because I received an injection)
I don’t want to have to take a pill every day
I think it is easier to take PrEP only when I need it
Intermittent PrEP is less expensive
Other, please specify
Decline to answer
[Selected multiple options=K4, otherwise Section K13]
K4. Please rank the reasons why you have chosen intermittent oral PrEP, with 1 being the most important reason, 2 being the next most important reason, all the way to the least important reason.
[Answers from K3] rank order list
Decline to answer
K5. Why have you chosen to use injectable PrEP, rather than a different kind of PrEP? (Choose all that apply)
My doctor/health care provider recommended this kind for me
I know people who use this kind of PrEP
I think this kind of PrEP is more effective than other kinds
I think this kind of PrEP is safer than other kinds
I don’t want to have to take a pill every day
I don’t think I would remember to take daily oral PrEP the way it is prescribed
I’m concerned that someone would find out I use PrEP if I had to take pills
I don’t think I would remember to take intermittent PrEP as prescribed
I don’t think intermittent PrEP would work for me because it is difficult to predict when I’m going to have sex
Other, please specify
Decline to answer
[Selected multiple options=K6, otherwise Section K14]
K6. Please rank the reasons why you have injectable PrEP, with 1 being the most important reason, 2 being the next most important reason, all the way to the least important reason.
[Answers from K5] rank order list
Decline to answer
K7. Why are you considering daily oral PrEP, rather than a different kind of PrEP? (Choose all that apply)
My doctor/health care provider recommended this kind for me
I know people who use this kind of PrEP
I think this kind of PrEP is more effective than other kinds
I think this kind of PrEP is safer than other kinds
I don’t want to have to get shots/injections
I don’t want to have to attend an appointment every two months for a shot/injection
With a shot/injection I would be concerned about long-acting side effects (that is, side effects that don’t go away for a long time because I received an injection)
I don’t think I would remember to take intermittent PrEP as prescribed
I don’t think intermittent PrEP would work for me because it is difficult to predict when I’m going to have sex
I prefer to have a regular routine of taking PrEP
Other, please specify
Decline to answer
[Selected multiple options=K8, otherwise K13]
K8. Please rank the reasons why you are considering daily oral PrEP, with 1 being the most important reason, 2 being the next most important reason, all the way to the least important reason.
[Answers from K7] rank order list
Decline to answer
K9. Why are you considering intermittent oral PrEP, rather than a different kind of PrEP? (Choose all that apply)
My doctor/health care provider recommended this kind for me
I know people who use this kind of PrEP
I think this kind of PrEP is more effective than other kinds
I think this kind of PrEP is safer than other kinds
I don’t want to have to get shots/injections
I don’t want to have to attend an appointment every two months for a shot/injection
With a shot/injection I would be concerned about long-acting side effects (that is, side effects that don’t go away for a long time because I received an injection)
I don’t want to have to take a pill every day
I think it is easier to take PrEP only when I need it
Intermittent PrEP is less expensive
Other, please specify
Decline to answer
[Selected multiple options=K10, otherwise Section K13]
K10. Please rank the reasons why you are considering intermittent oral PrEP, with 1 being the most important reason, 2 being the next most important reason, all the way to the least important reason.
[Answers from K9] rank order list
K11. Why are you considering injectable PrEP, rather than a different kind of PrEP? (Choose all that apply)
My doctor/health care provider recommended this kind for me
I know people who use this kind of PrEP
I think this kind of PrEP is more effective than other kinds
I think this kind of PrEP is safer than other kinds
I don’t want to have to take a pill every day
I don’t think I would remember to take daily oral PrEP the way it is prescribed
I’m concerned that someone would find out I use PrEP if I had to take pills
I don’t think I would remember to take intermittent PrEP as prescribed
I don’t think intermittent PrEP would work for me because it is difficult to predict when I’m going to have sex
Other, please specify
Decline to answer
[Selected multiple options=K12, otherwise Section K14]
K12. Please rank the reasons why you are considering injectable PrEP, with 1 being the most important reason, 2 being the next most important reason, all the way to the least important reason.
[Answers from K11] rank order list
Decline to answer
[If F4, G5, H12 = Injectable PrEP then Skip to K14]
K13. Compared to taking oral PrEP pills, how difficult do you think it would be to use injectable PrEP as prescribed (getting your PrEP shot every two months on time)?
Injectable PrEP would be LESS difficult to take as prescribed, compared to oral PrEP
SAME, the type of PrEP would not change my ability to take PrEP as prescribed
Injectable PrEP would be MORE difficult to take as prescribed, compared to oral PrEP
Decline to answer
[If F4, G5, H12 = Intermittent PrEP then Skip to Section L]
K14. Compared to [pipe in current PrEP modality], how difficult do you think it would be to use on-demand PrEP (taking two pills 2-24 hours before sex, one pill 24 hours after the first dose, and one pill 24 hours after the second dose)?
On-demand PrEP would be LESS difficult to take, compared to [pipe in current PrEP modality]
SAME, on-demand PrEP would not change my ability to take PrEP
On-demand PrEP would be MORE difficult to [pipe in current PrEP modality]
Decline to answer
PREP ADHERENCE AND BARRIERS
[If F4, G5, H12 = Daily oral PrEP then L1-L5]
[If F4, G5, H12 = Intermittent oral PrEP then L6-L10] [If F4, G5, H12 = Injectable PrEP then L11-L17]
[If I12, J5 = Daily oral PrEP then L5]
[If I12, J5 = Intermittent oral PrEP then L10] [If I12, J5 = Injectable PrEP then L17]
[ALL PARTICIPANTS SHOULD ANSWER L18 REGARDLESS OF PREP USE]
L1. In the past 7 days, how many days did you take PrEP? [Text box: 1-7]
L2. In the past 3 months, what percent of the time did you take your PrEP as prescribed (once a day)? Use the scale below. 0% would mean ‘NONE’ of the time and 100% would mean ‘ALL’ of the time. If you are unsure, make a guess.
% medication taken:
0 [ ] 100
Decline to answer
L3. What has gotten in the way of you taking your PrEP on a daily basis? (Choose all that apply)
I have not had any trouble taking my regular PrEP doses
Couldn't get my pills at the drug store or pharmacy
Ran out of my prescription and never started again
Did not have health insurance to pay for the prescriptions
Made me sick to my stomach or tasted bad
Forgot to take my pill
I got a headache, rash, or other physical symptom
It got in the way of my daily schedule
Didn't feel like taking it, needed a break
Change in living situation/moved
Worried that someone will think I have HIV
Got sick with another illness, wasn't feeling well (e.g., cold, flu, etc.)
Don't think I need the pills anymore, I can stay healthy without them
Family and/or friends didn't help me remember
Family and/or friends told me I shouldn't take them
Nowhere to keep the pills at school or work
Didn't understand why I had to take the pills
I kept getting sick even when I did take the pills
Taking it reminded me of HIV
Other, please specify
Decline to answer
[Selected multiple options=L4, otherwise L5]
L4. Please rank the things that have gotten in the way of taking PrEP, with 1 being the most important reason, 2 being the next most important reason, all the way to the least important reason.
[Answers from L3] rank order list
Decline to answer
L5. We are interested in how you feel about the following statements. Please answer by indicating your confidence about each statement on a scale from 1 (not confident) to 10 (totally confident).
How confident are you that you can...
Take PrEP on a weekend:
Take PrEP on a weekday
Take PrEP when dealing with schedule changes: Take PrEP while traveling:
Take PrEP when out with friends:
Take PrEP at work/school:
Take PrEP when having medication side effects: Take PrEP when having a crisis:
Take PrEP when drinking or using drugs: Keep your PrEP medical appointments: Follow a plan for taking PrEP:
Decline to answer
[Skip to L18]
L6. In the past 3 months, what percent of the time did you take your full dose of intermittent PrEP as prescribed (i.e., before & after any condomless anal sex)? A full dose includes the pills taken before sex and after sex as in the figure. Use the scale below. 0% would mean ‘NONE’ of the time and 100% would mean ‘ALL’ of the time. If you are unsure, make a guess.
% medication taken:
0 [ ] 100
I did not have any condomless anal sex.
Decline to answer Figure.
[IF L6 =100%, skip to L10]
L7. In the past 3 months, what percent of the time did you do the following before having any condomless anal sex? Note: Your responses should add up to 100%. If any of the categories do not apply to you, please enter “0”. [Add logic so that these responses must sum to 100%]
Did not take any of the 4 pills: %
Took 1 of the 4 pills: %
Took 2 of the 4 pills: %
Took 3 of the 4 pills: %
Decline to answer
L8. What has gotten in the way of you taking your intermittent PrEP as prescribed (i.e., before & after having any condomless anal sex)? (Choose all that apply)
I have not had any trouble taking my PrEP doses
Couldn't get my pills at the drug store or pharmacy
Ran out of my prescription and never started again
Forgot to take my pills before sex
Forgot to take my pills after sex
Didn’t know I was going to have sex and I didn’t have any PrEP with me
Didn’t think I needed to take all the pills
Did not have health insurance to pay for the prescriptions
Made me sick to my stomach or tasted bad
I got a headache, rash, or other physical symptom
Didn't feel like taking it, needed a break
Change in living situation/moved
Worried that someone will think I have HIV
Got sick with another illness, wasn't feeling well (e.g., cold, flu, etc.)
Don't think I need the pills anymore, I can stay healthy without them
Family and/or friends didn't help me remember
Family and/or friends told me I shouldn't take them
Nowhere to keep the pills at school or work
Didn't understand why I had to take the pills
I kept getting sick even when I did take the pills
Taking it reminded me of HIV
Other, please specify
Decline to answer
[Selected multiple options=L8, otherwise L10]
L9. Please rank the things that have gotten in the way of taking PrEP, with 1 being the most important reason, 2 being the next most important reason, all the way to the least important reason.
[Answers from L7] rank order list
Decline to answer
L10. We are interested in how you feel about the following statements. Please answer by indicating your confidence about each statement on a scale from 1 (not confident) to 10 (totally confident).
How confident are you that you can...
Take PrEP on a weekend if needed: Take PrEP on a weekday if needed:
Take PrEP when dealing with schedule changes: Take PrEP while traveling if needed:
Take PrEP when out with friends if needed: Take PrEP at work/school if needed:
Take PrEP when having medication side effects: Take PrEP when having a crisis:
Take PrEP when drinking or using drugs if needed: Keep your PrEP medical appointments:
Follow a plan for taking PrEP:
Decline to answer
[Skip to L18]
L11. When was the date of your last PrEP injection? (If exact date is unknown, then use the 1st of the month of injection).
dd/mm/yyyy
Decline to answer
L12. When is the date of your next PrEP injection? (If exact date is unknown, then use the 1st of the month of injection).
dd/mm/yyyy
Decline to answer
L13. Have you ever gone more than 2 months between PrEP injections? [Yes=L14, otherwise L15]
No
Yes
Decline to answer
L14. How many times have you gone more than 2 months between PrEP injections? It is OK if you don’t know the exact answer; provide your best guess.
[Free text]
Decline to answer
L15. What has gotten in the way of you getting your PrEP injections? (Choose all that apply)
I have not had any trouble getting my regular PrEP injections
Couldn't get an injection appointment
Appointment location was too far away or couldn’t get transportation
Dissatisfied with quality of clinic services
Negative attitudes held by clinic staff
Worried about paying for the injection
Irritation at the injection site
I had some other physical symptom
Forgot to schedule or attend my appointment
It got in the way of my schedule
Didn't feel like taking it, needed a break
Change in living situation/moved
Worried that someone will think I have HIV
Got sick with another illness, wasn't feeling well (e.g., cold, flu, etc.)
Don't think I need the injections anymore, I can stay healthy without them
Family and/or friends didn't help me remember
Family and/or friends told me I shouldn't get them
Didn't understand why I had to get the injections
I kept getting sick even when I did get the injections
Getting them reminded me of HIV
Other, please specify
Decline to answer
[Selected multiple options=L16, otherwise L17]
L16. Please rank the things that have gotten in the way of taking PrEP, with 1 being the most important reason, 2 being the next most important reason, all the way to the least important reason.
[Answers from L15] rank order list
Decline to answer
L17. We are interested in how you feel about the following statements. Please answer by indicating your confidence about each statement on a scale from 1 (not confident) to 10 (totally confident).
How confident are you that you can...
Keep your injectable PrEP appointments:
Follow a plan for getting your PrEP:
Decline to answer
[ALL PARTICIPANTS]
L18. Please rate how much each of the following items influences your decision about taking PrEP.
|
Not at all |
A little bit |
A moderate amount |
A lot |
Decline to answer |
Having to talk to a healthcare provider about my sex life |
|
|
|
|
|
Having to talk to a healthcare provider about PrEP |
|
|
|
|
|
Friends finding out that I am on PrEP |
|
|
|
|
|
Sexual partner(s) finding out that I am on PrEP |
|
|
|
|
|
Family members finding out that I am on PrEP |
|
|
|
|
|
The long-term effects of PrEP on my health |
|
|
|
|
|
The possibility that PrEP might not provide complete protection against HIV |
|
|
|
|
|
The possibility that if I become HIV positive, certain medications won’t work |
|
|
|
|
|
The potential side effects of PrEP |
|
|
|
|
|
Having to remember to take a pill or get an injection |
|
|
|
|
|
Getting transportation to PrEP appointments/labs |
|
|
|
|
|
Returning for PrEP follow-up appointments and labs |
|
|
|
|
|
Getting a PrEP prescription refilled |
|
|
|
|
|
Using insurance to get coverage for PrEP costs |
|
|
|
|
|
Getting the costs of PrEP covered (including office visits or office visit co-pays, lab costs, transportation costs) |
|
|
|
|
|
TECHNOLOGY USE AND ONLINE PARTNER SEEKING BEHAVIOR
In this section, we will ask questions about your devices and your social media and internet use.
M1. On average, how many hours a day do you spend on the Internet, other than for work or school? (Round to the nearest hour) [integer 0-24]
Decline to answer
M2. Which of the following devices do you own? (Check all that apply) [If cell phone then M4, if smartphone then M3, otherwise M4]
Cell phone (basic mobile phone for calling or texting; does not have internet access, apps, or a touch screen)
Smartphone (advanced mobile phone with internet access, apps, and a touch screen)
Desktop computer
Laptop computer
Tablet computer
E-book reader
Fitness tracker or smart watch
Other, please specify
Decline to answer
M3. How often do you use apps on your smartphone (for example: TikTok, Instagram, dating apps, banking apps, Snapchat)?
More than once a day
About once a day
A few times a week
About once a week
Less than once a week
I do not use apps on my phone
Decline to answer
M4. Do you regularly share your phone with one or more other people (such as a partner, family member, or friends)?
Yes
No
Decline to answer
M5. What kind of phone service do you have?
I have a prepaid account
I have a monthly contract
I’m on a shared plan
Other, please specify
Decline to answer
M6. How many times in the past 3 months has your phone been disconnected, because the bill was not paid, or because your phone was lost or stolen?
[Never=M8, otherwise M7]
Never
Once
Twice
3 to 5 times
More than 5 times
Other, please specify
Decline to answer
M7. The last time your phone was disconnected, for how long was it disconnected?
1 day or less
2 to 7 days
1 to 4 weeks
1 month or more
Other, please specify
Decline to answer
M8. How often do you use websites or apps for the following reasons:
|
Never |
Rarely |
Sometimes |
Often |
Decline to Answer |
Make new friends |
|
|
|
|
|
Chat with friends |
|
|
|
|
|
Find a date |
|
|
|
|
|
Meet partners for sex |
|
|
|
|
|
Look for work opportunities |
|
|
|
|
|
Track your health behaviors (diet, exercise, medication management, etc.) |
|
|
|
|
|
Create event reminders (take a daily pill, exercise, etc.) |
|
|
|
|
|
M9. What are the 3 social media platforms you use most often?
YouTube
LinkedIn
Reddit
WhatsApp
Snapchat
Twitter
Facebook
Instagram
TikTok
Other, please specify
Decline to answer
M10. [Ybarra scale] In the past 12 months, have you searched online for any of the following topics for yourself? (Check all that apply)
Sexuality or sexual attraction
How to have sex or sexual positions
HIV/AIDS or other sexually transmitted diseases
Condoms or other types of birth control
PrEP (Pre-Exposure Prophylaxis)
PEP (Post Exposure Prophylaxis)
Fitness or weight issues
Drugs or alcohol
Violence or abuse
Medications or medication side effects
Depression, anxiety, or suicide
None
Decline to answer
M11. Please indicate your agreement with the following statements
|
Strongly Agree |
Agree |
Neither Agree nor Disagree |
Disagree |
Strongly Disagree |
Decline to Answer |
I know what health resources are available on the Internet. |
( ) |
( ) |
( ) |
( ) |
( ) |
( ) |
I know how to find helpful health resources on the Internet. |
( ) |
( ) |
( ) |
( ) |
( ) |
( ) |
I know how to use the Internet to answer my questions about health. |
( ) |
( ) |
( ) |
( ) |
( ) |
( ) |
I know how to use the health information I find on the Internet to help me. |
( ) |
( ) |
( ) |
( ) |
( ) |
( ) |
I have the skills I need to evaluate the health resources I find on the Internet. |
( ) |
( ) |
( ) |
( ) |
( ) |
( ) |
I can tell high quality health resources from low quality health resources on the Internet. |
( ) |
( ) |
( ) |
( ) |
( ) |
( ) |
I feel confident in using information from the Internet |
( ) |
( ) |
( ) |
( ) |
( ) |
( ) |
to make health decisions. |
|
|
|
|
|
|
I know where to find helpful health resources on the Internet. |
( ) |
( ) |
( ) |
( ) |
( ) |
( ) |
RELATIONSHIPS AND SEXUAL HEALTH PRIORITIES
N1. How do you define your primary relationship status? [Routing question, may not skip]
Single [Skip to Section O]
Casually dating/friends with benefits [Skip to Section O]
In a relationship (Have a partner/partners or spouse)
Other, please specify [Skip to Section O]
People have different sexual health priorities. For example, some people prioritize staying HIV- negative; others want to have as much fun as possible with their partners; others want to feel as close and connected to their partners as possible.
N2. For these next questions, we are interested in you and your primary romantic partner’s sexual health priorities. Thinking about you and your primary partner’s sexual health priorities, please indicate the extent to which you agree or disagree with the following statements.
|
Strongly Agree |
Agree |
Neither Agree nor Disagree |
Disagree |
Strongly Disagree |
Decline to Answer |
I feel like my partner and I are “on the same page” in terms of the decisions we make about sexual health and risk |
( ) |
( ) |
( ) |
( ) |
( ) |
( ) |
When it comes to sexual decision- making, I feel like |
( ) |
( ) |
( ) |
( ) |
( ) |
( ) |
my partner and I are “of the same mind” |
|
|
|
|
|
|
Sometimes I feel like my priorities for my sexual health are incompatible with my partner’s goals |
( ) |
( ) |
( ) |
( ) |
( ) |
( ) |
I’m confident that my partner and I generally share the same priorities when it comes to sexual health |
( ) |
( ) |
( ) |
( ) |
( ) |
( ) |
Making sexual health decisions with my partner can be difficult because we have different priorities |
( ) |
( ) |
( ) |
( ) |
( ) |
( ) |
SEXUAL BEHAVIORS
This set of questions will ask about your sexual behaviors. Sometimes sharing information about sexual behaviors can make people feel uncomfortable. We want you to remember that all this information is kept confidential and is collected only for research purposes. This information will help this study learn more about PrEP and HIV prevention. Please be as honest as possible. If you are unsure of any answers in this section, please make your best guess.
O1. In the past 3 months, how many sexual partners have you had sex with? [NumSexPartner] (range 0-99) (text field)
[If NumSexPartner =0 then skip to Section P] [If NumSexPartner = 1 then O2-O5]
[If NumSexPartner > 1 then O6-O9] [ANAL RECEPTIVE]
The following questions ask about your sexual behavior during the past 3 months. Our focus in this section will be exclusively on anal sex. Therefore, only include partners with whom you had anal sex.
O2. In the past 3 months, did you have receptive anal sex with this person (you were the bottom)? [ReceptiveAI]
[Yes = O3, otherwise O?]
Yes
No
Decline to answer
O3. About this person, did they put their penis in your rectum without a condom? [ReceptiveAINoCondom]
Yes
No
Decline to answer
O4. Regarding this person… [OneRecAIHIVStatus]
They told you they were HIV negative and you had no reason to doubt it. [Negative]
They told you they were HIV positive and they were undetectable
They told you they were HIV positive but did NOT say they were undetectable.
You were not completely sure of this person’s HIV status. [StatusUnknown]
Decline to answer
O5. Was this person using PrEP? [OneRecAIPrep]
Yes
No
I don’t know
Decline to answer
[Skip to O10]
O6. In the past 3 months, with how many of these [NumSexPartner] people did you have
receptive anal sex (you were the bottom)? [ReceptiveAI]
(range 0-[NumSexPartner]) (fill-in) [If >0 then O7, otherwise O14]
Decline to answer
O7. Of these [ReceptiveAI] people, how many put their penises in your rectum without a condom? [ReceptiveAINoCondom] (Range 0-[ReceptiveAI]) (fill-in)
Decline to answer
O8. Of the [ReceptiveAI] people you had receptive anal sex with, how many… (Please enter a number in each box. Enter 0 (zero) if none. Your answers must add up to [ReceptiveAI]).
Told you they were HIV negative and you had no reason to doubt it?
Told you they were HIV positive and they were undetectable?
Told you they were HIV positive but did NOT say they were undetectable.
Were you not completely sure of their HIV status?
Decline to answer
(TOTAL) [MultRecAIHIVTotal] This number must be the sum of the previous 3 responses, and should tally as the answers are populated. Validate that [MultRecUAIHIVTotal]
= [ReceptiveAI]
O9. To your knowledge, how many of these people were taking PrEP? [MultRecAIPrep] (range 0-[ReceptiveAI]) (fill-in)
[Skip to O14]
[ANAL INSERTIVE]
[If NumSexPartner = 1 then O10-O13] [If NumSexPartner > 1 then O14-O17]
O10. We have a few more questions about your sexual behavior with the person who was your anal sex partner in the past 3 months.
In the past 3 months, did you have insertive anal sex with this person (you were the top)? [InsertiveAI]
[Yes = O11, otherwise ]
Yes
No
Decline to answer
O11. About this person, did you put your penis in their rectum without a condom?
[InsertiveAINoCondom]
Yes
No
Decline to answer
[If answered O4, skip to O13]
O12. Regarding this person… [OneRecAIHIVStatus]
They told you they were HIV negative and you had no reason to doubt it. [Negative]
They told you they were HIV positive and they were undetectable
They told you they were HIV positive but did NOT say they were undetectable.
You were not completely sure of this person’s HIV status. [StatusUnknown]
Decline to answer
[If answered O5, skip to O18]
O13. Was this person using PrEP? [OneRecAIPrep]
Yes
No
I don’t know
Decline to answer
[Skip to O18]
O14. We have a few more questions about your sexual behavior with the people who were your anal sex partners in the past 3 months.
In the past 3 months, with how many of these [NumSexPartner] people did you have
insertive anal sex (you were the top)? [InsertiveAI] (range 0-[NumSexPartner]) (fill-in) [If
>0 then O15, otherwise O22]
Decline to answer
O15. Of these [InsertiveAI] people, how many of their rectums did you put your penis into
without a condom? [InsertiveAINoCondom] (range 0-[InsertiveAI]) (fill-in)
Decline to answer
O16. Of the [InsertiveAI] people you had insertive anal sex with, how many… (Please enter a number in each box. Enter 0 (zero) if none. Your answers must add up to [InsertiveAI]).
Told you they were HIV negative and you had no reason to doubt it?
Told you they were HIV positive and they were undetectable?
Told you they were HIV positive but did NOT say they were undetectable.
Were you not completely sure of their HIV status?
Decline to answer
(TOTAL) [MultInsAIHIVTotal] This number must be the sum of the previous 3 responses, and should tally as the answers are populated. Validate that [MultInsUAIHIVTotal] = [InsertiveAI]
O17. To your knowledge, how many of these people were taking PrEP? [MultRecAIPrep] (range 0-[InsertiveAI]) (fill-in)
Decline to answer
[Skip to O22]
[VAGINAL]
We will now ask you questions about your experience with vaginal sex in the past 3 months. Our focus in this section is exclusively on vaginal sex.
[If NumSexPartner = 1 then O18-O21] [If NumSexPartner > 1 then O22-O25]
O18. In the past 3 months, did you have vaginal sex with this person (did you put your penis in their vagina)? [VI]
[Yes = O19, otherwise ]
Yes
No
Decline to answer
O19. About this person, did you put your penis in their vagina without a condom?
[InsertiveVINoCondom]
Yes
No
Decline to answer
O20. Regarding this person… [OneRecAIHIVStatus]
They told you they were HIV negative and you had no reason to doubt it. [Negative]
They told you they were HIV positive and they were undetectable
They told you they were HIV positive but did NOT say they were undetectable.
You were not completely sure of this person’s HIV status. [StatusUnknown]
Decline to answer
O21. Was this person using PrEP? [OneRecAIPrep]
Yes
No
I don’t know
Decline to answer
[Skip to routing before O26]
O22. In the past 3 months, with how many sexual partners did you have vaginal sex (you put your penis in someone’s vagina)? [VI] (range 0-[NumVagSexPartner]) (fill-in) [If >0 then O23, otherwise routing before O26]
O23. Of these [InsertiveVI] people, how many of their vaginas did you put your penis into
without a condom? [InsertiveVINoCondom] (range 0-[InsertiveAI]) (fill-in)
O24. Of the [InsertiveVI] people you had vaginal sex with, how many… (Please enter a number in each box. Enter 0 (zero) if none. Your answers must add up to [InsertiveVI]).
Told you they were HIV negative and you had no reason to doubt it?
Told you they were HIV positive and they were undetectable?
Told you they were HIV positive but did NOT say they were undetectable.
Were you not completely sure of their HIV status?
Decline to answer
(TOTAL) [MultInsVIHIVTotal] This number must be the sum of the previous 3 responses, and should tally as the answers are populated. Validate that [MultInsVIHIVTotal] = [InsertiveVI]
O25. To your knowledge, how many of these people were taking PrEP? [MultRecVIPrep] (range 0-[InsertiveVI]) (fill-in)
Decline to answer
[If O2 = NO, N6 = 0, O10 = NO, O14 = 0 then no anal sex reported, skip to O27]
O26. Now we are going to ask you to think back to any anal sex you had in the last 2 months (8 weeks). If you are unsure of any answers below, please make your best guess.
Thinking back to the past week, [pipe in date range here with calendar]: How many times did you have any anal sex?
How many times did you have any condomless anal sex?
Decline to answer
Thinking back to 2 weeks ago, [pipe in date range here with calendar]: How many times did you have any anal sex?
How many times did you have any condomless anal sex?
Decline to answer
Thinking back to 3 weeks ago, [pipe in date range here with calendar]: How many times did you have any anal sex?
How many times did you have any condomless anal sex?
Decline to answer
Thinking back to 4 weeks ago, [pipe in date range here with calendar]: How many times did you have any anal sex?
How many times did you have any condomless anal sex?
Decline to answer
Thinking back to 5 weeks ago, [pipe in date range here with calendar]: How many times did you have any anal sex?
How many times did you have any condomless anal sex?
Decline to answer
Thinking back to 6 weeks ago, [pipe in date range here with calendar]: How many times did you have any anal sex?
How many times did you have any condomless anal sex?
Decline to answer
Thinking back to 7 weeks ago, [pipe in date range here with calendar]: How many times did you have any anal sex?
How many times did you have any condomless anal sex?
Decline to answer
Thinking back to 8 weeks ago, [pipe in date range here with calendar]: How many times did you have any anal sex?
How many times did you have any condomless anal sex?
Decline to answer
O27. In the past 12 months, have you had any kind of sex with someone in exchange for things you needed (like money, drugs, food, shelter, etc.)?
No
Yes
Decline to answer
O28. In the past 12 months, have you given anything to someone else (like money, drugs, food, shelter, etc.) in exchange for them having sex with you?
No
Yes
Decline to answer
SUBSTANCE USE
The next questions refer to your alcohol and drug use. We know that this information is personal. Please remember all this information is kept confidential and is collected only for research purposes.
P1. Which of the following drugs have you used in your life (non-medical use only)? (Choose all that apply)
[If None then skip to Section Q]
Tobacco (cigarettes, chewing tobacco, cigars, e-cigarettes, etc.)
Alcohol (beer, wine, spirits, etc.)
Cannabis (marijuana, pot, weed, edibles, hash, synthetic cannabis, vaping, etc.)
Cocaine (coke, crack, etc.)
Amphetamines (speed, meth, diet pills, molly, ecstasy, Ritalin, Adderall, etc.)
Inhalants (poppers, nitrous, glue, petrol, paint thinner, etc.)
Sedatives, tranquilizers, or sleeping pills (valium, Serepax, Rohypnol, Xanax, Ambien, GHB, etc.)
Hallucinogens (LSD, acid, mushrooms, PCP, Ketamine, etc.)
Opioids (heroin, morphine, methadone, codeine, Oxycotin, Percocet, Vicodin, etc.)
Other, please specify
None
Decline to answer
P2. In the past three months, how often have you used… [only pipe in substances from above] [If all Never then skip to P6]
|
Never |
Once or twice |
Monthly |
Weekly |
Daily or almost daily |
Decline to answer |
Tobacco (cigarettes, chewing tobacco, cigars, e-cigarettes, etc.) |
|
|
|
|
|
|
Alcohol (beer, wine, spirits, etc.) |
|
|
|
|
|
|
Cannabis (marijuana, edibles, pot, weed, hash, synthetic cannabis, vaping, etc.) |
|
|
|
|
|
|
Cocaine (coke, crack, etc.) |
|
|
|
|
|
|
Amphetamines (speed, meth, diet pills, molly, ecstasy, Ritalin, Adderall, etc.) |
|
|
|
|
|
|
Inhalants (poppers, nitrous, glue, petrol, paint thinner, etc.) |
|
|
|
|
|
|
Sedatives, tranquilizers, or sleeping pills (valium, Serepax, Rohypnol, Xanax, Ambien, GHB, etc.) |
|
|
|
|
|
|
Hallucinogens (LSD, acid, mushrooms, PCP, Ketamine, etc.) |
|
|
|
|
|
|
Opioids (heroin, morphine, methadone, codeine, Oxycotin, Percocet, Vicodin, etc.) |
|
|
|
|
|
|
Other, please specify |
|
|
|
|
|
|
P3. During the past three months, how often have you had a strong desire or urge to use…
|
Never |
Once or twice |
Monthly |
Weekly |
Daily or almost daily |
Decline to answer |
Tobacco (cigarettes, chewing tobacco, cigars, e-cigarettes, etc.) |
|
|
|
|
|
|
Alcohol (beer, wine, spirits, etc.) |
|
|
|
|
|
|
Cannabis (marijuana, edibles, pot, weed, hash, synthetic cannabis, vaping, etc.) |
|
|
|
|
|
|
Cocaine (coke, crack, etc.) |
|
|
|
|
|
|
Amphetamines (speed, meth, diet pills, molly, ecstasy, Ritalin, Adderall, etc.) |
|
|
|
|
|
|
Inhalants (poppers, nitrous, glue, petrol, paint thinner, etc.) |
|
|
|
|
|
|
Sedatives, tranquilizers, or sleeping pills (valium, Serepax, Rohypnol, Xanax, Ambien, GHB, etc.) |
|
|
|
|
|
|
Hallucinogens (LSD, acid, mushrooms, PCP, Ketamine, etc.) |
|
|
|
|
|
|
Opioids (heroin, morphine, methadone, codeine, Oxycotin, Percocet, Vicodin, etc.) |
|
|
|
|
|
|
Other, please specify |
|
|
|
|
|
|
P4. During the past three months, how often has your use of [pipe in substances from last 3 months] led to health, social, legal, or financial problems?
|
Never |
Once or twice |
Monthly |
Weekly |
Daily or almost daily |
Decline to answer |
Tobacco (cigarettes, chewing tobacco, cigars, e-cigarettes, etc.) |
|
|
|
|
|
|
Alcohol (beer, wine, spirits, etc.) |
|
|
|
|
|
|
Cannabis (marijuana, edibles, pot, weed, hash, synthetic cannabis, vaping, etc.) |
|
|
|
|
|
|
Cocaine (coke, crack, etc.) |
|
|
|
|
|
|
Amphetamines (speed, meth, diet pills, molly, ecstasy, Ritalin, Adderall, etc.) |
|
|
|
|
|
|
Inhalants (poppers, nitrous, glue, petrol, paint thinner, etc.) |
|
|
|
|
|
|
Sedatives, tranquilizers, or sleeping pills (valium, Serepax, Rohypnol, Xanax, Ambien, GHB, etc.) |
|
|
|
|
|
|
Hallucinogens (LSD, acid, mushrooms, PCP, Ketamine, etc.) |
|
|
|
|
|
|
Opioids (heroin, morphine, methadone, codeine, Oxycotin, Percocet, Vicodin, etc.) |
|
|
|
|
|
|
Other, please specify |
|
|
|
|
|
|
P5. During the past three months, how often have you failed to do what was normally expected of you because of your use of [pipe in substances from last 3 months]?
|
Never |
Once or twice |
Monthly |
Weekly |
Daily or almost daily |
Decline to answer |
Tobacco (cigarettes, chewing tobacco, cigars, e-cigarettes, etc.) |
|
|
|
|
|
|
Alcohol (beer, wine, spirits, etc.) |
|
|
|
|
|
|
Cannabis (marijuana, edibles, pot, weed, hash, synthetic cannabis, vaping, etc.) |
|
|
|
|
|
|
Cocaine (coke, crack, etc.) |
|
|
|
|
|
|
Amphetamines (speed, meth, diet pills, molly, ecstasy, Ritalin, Adderall, etc.) |
|
|
|
|
|
|
Inhalants (poppers, nitrous, glue, petrol, paint thinner, etc.) |
|
|
|
|
|
|
Sedatives, tranquilizers, or sleeping pills (valium, Serepax, Rohypnol, Xanax, Ambien, GHB, etc.) |
|
|
|
|
|
|
Hallucinogens (LSD, acid, mushrooms, PCP, Ketamine, etc.) |
|
|
|
|
|
|
Opioids (heroin, morphine, methadone, codeine, Oxycotin, Percocet, Vicodin, etc.) |
|
|
|
|
|
|
Other, please specify |
|
|
|
|
|
|
P6. Has a friend or relative or anyone else ever expressed concern about your use of [pipe in substances EVER used]?
|
No, never |
Yes, in the past 3 months |
Yes, but not in the past 3 months |
Decline to answer |
Tobacco (cigarettes, chewing tobacco, cigars, e-cigarettes, etc.) |
|
|
|
|
Alcohol (beer, wine, spirits, etc.) |
|
|
|
|
Cannabis (marijuana, edibles, pot, weed, hash, synthetic cannabis, vaping, etc.) |
|
|
|
|
Cocaine (coke, crack, etc.) |
|
|
|
|
Amphetamines (speed, meth, diet pills, molly, ecstasy, Ritalin, Adderall, etc.) |
|
|
|
|
Inhalants (poppers, nitrous, glue, petrol, paint thinner, etc.) |
|
|
|
|
Sedatives, tranquilizers, or sleeping pills (valium, Serepax, Rohypnol, Xanax, Ambien, GHB, etc.) |
|
|
|
|
Hallucinogens (LSD, acid, mushrooms, PCP, Ketamine, etc.) |
|
|
|
|
Opioids (heroin, morphine, methadone, codeine, Oxycotin, Percocet, Vicodin, etc.) |
|
|
|
|
Other, please specify |
|
|
|
|
P7. Have you ever tried to cut down on using [pipe in substances ever used] but failed?
|
No, never |
Yes, in the past 3 months |
Yes, but not in the past 3 months |
Decline to answer |
Tobacco (cigarettes, chewing tobacco, cigars, e-cigarettes, etc.) |
|
|
|
|
Alcohol (beer, wine, spirits, etc.) |
|
|
|
|
Cannabis (marijuana, edibles, pot, weed, hash, synthetic cannabis, vaping, etc.) |
|
|
|
|
Cocaine (coke, crack, etc.) |
|
|
|
|
Amphetamines (speed, meth, diet pills, molly, ecstasy, Ritalin, Adderall, etc.) |
|
|
|
|
Inhalants (poppers, nitrous, glue, petrol, paint thinner, etc.) |
|
|
|
|
Sedatives, tranquilizers, or sleeping pills (valium, Serepax, Rohypnol, Xanax, Ambien, GHB, etc.) |
|
|
|
|
Hallucinogens (LSD, acid, mushrooms, PCP, Ketamine, etc.) |
|
|
|
|
Opioids (heroin, morphine, methadone, codeine, Oxycotin, Percocet, Vicodin, etc.) |
|
|
|
|
Other, please specify |
|
|
|
|
P8. Have you ever used any drug by injection (non-medical use only)?
No, never
Yes, in the past 3 months
Yes, but not in the past 3 months [If P2 = Never then skip to Section Q]
P9. During the past 30 days, did you use [pipe in substances ever used] immediately before or during sex? (Check all that apply.) [SexOnDrugs]
|
No, never |
Yes |
Decline to answer |
Tobacco (cigarettes, chewing tobacco, cigars, e-cigarettes, etc.) |
|
|
|
Alcohol (beer, wine, spirits, etc.) |
|
|
|
Cannabis (marijuana, edibles, pot, weed, hash, synthetic cannabis, vaping, etc.) |
|
|
|
Cocaine (coke, crack, etc.) |
|
|
|
Amphetamines (speed, meth, diet pills, molly, ecstasy, Ritalin, Adderall, etc.) |
|
|
|
Inhalants (poppers, nitrous, glue, petrol, paint thinner, etc.) |
|
|
|
Sedatives, tranquilizers, or sleeping pills (valium, Serepax, Rohypnol, Xanax, Ambien, GHB, etc.) |
|
|
|
Hallucinogens (LSD, acid, mushrooms, PCP, Ketamine, etc.) |
|
|
|
Opioids (heroin, morphine, methadone, codeine, Oxycotin, Percocet, Vicodin, etc.) |
|
|
|
Other, please specify |
|
|
|
MENTAL HEALTH
Depression
PHQ-2/GAD-2 screener
Q1. Over the past 2 weeks, how often have you been bothered by any of the following problems?
|
Not at all (0) |
Several days (1) |
More than half the days (2) |
Nearly every day (3) |
Decline to answer |
Little interest or pleasure in doing things |
|
|
|
|
|
Feeling down, depressed, or hopeless |
|
|
|
|
|
Feeling nervous, anxious or on edge |
|
|
|
|
|
Not being able to stop or control worrying |
|
|
|
|
|
[Those with a combined score > 3 on items 1 & 2 (PHQ-2) complete remaining 6 items of the PHQ-8.
Those with a combined score > 3 on items 3 & 4 (GAD-2) complete remaining 5 items of the GAD-7.]
PHQ-8
Q2. Over the past 2 weeks, how often have you been bothered by any of the following problems?
|
Not at all (0) |
Several days (1) |
More than half the days (2) |
Nearly every day (3) |
Decline to answer |
Trouble falling or staying asleep, or sleeping too much? |
|
|
|
|
|
Feeling tired or having little energy? |
|
|
|
|
|
Poor appetite or overeating? |
|
|
|
|
|
Feeling bad about yourself - or that you are a failure or have let yourself or your family down? |
|
|
|
|
|
Trouble concentrating on things, such as reading the newspaper or watching television? |
|
|
|
|
|
Moving or speaking so slowly that other people could have noticed, or the opposite - being so fidgety or restless that you have been moving around a lot more than usual? |
|
|
|
|
|
Anxiety
GAD-7
Q3. Over the past 2 weeks, how often have you been bothered by any of the following problems:
|
Not at all (0) |
Several days (1) |
More than half the days (2) |
Nearly every day (3) |
Decline to answer |
Worrying too much about different things? |
|
|
|
|
|
Trouble relaxing? |
|
|
|
|
|
Being so restless that it is hard to sit still? |
|
|
|
|
|
Becoming easily annoyed or irritable? |
|
|
|
|
|
Feeling afraid as if something awful might happen? |
|
|
|
|
|
EVERYDAY DISCRIMINATION
R1. In your day-to-day life, how often do any of the following things happen to you? [If all answers = less than once a year or never then skip to Section S]
|
Almost daily |
At least once a week |
A few times a month |
A few times a year |
Less than once a year |
Neve r |
Decli ne to answ er |
You are treated with less courtesy than other people are. |
|
|
|
|
|
|
|
You are treated with less respect than other people are. |
|
|
|
|
|
|
|
You receive poorer service than other people at restaurants or stores. |
|
|
|
|
|
|
|
People act as if they think you are not smart. |
|
|
|
|
|
|
|
People act as if they are afraid of you. |
|
|
|
|
|
|
|
People act as if they think you are dishonest. |
|
|
|
|
|
|
|
People act as if they’re better than you are. |
|
|
|
|
|
|
|
You are called names or insulted. |
|
|
|
|
|
|
|
You are threatened or harassed. |
|
|
|
|
|
|
|
R2. What do you think are the main reasons for why you experienced this discrimination? (Choose all that apply)
Your ancestry or national origins
Your gender identity
Your race
Your age
Your religion
Your height
Your weight
Some other aspect of your physical appearance
Your sexual orientation
Your education or income level
Your HIV status
Your disability status
Other, please specify
Decline to answer
R3. How hard was it to bounce back when you experienced discrimination due to your: [for each selected item above]
Very easy
Easy
Hard
Very hard
Decline to answer
SOCIAL SUPPORT AND ISOLATION
Emotional support
S1. Please respond to each statement:
|
Never |
Rarely |
Sometimes |
Usually |
Always |
Decline to answer |
I have someone who will listen to me when I need to talk. |
|
|
|
|
|
|
I have someone to confide in or talk to about myself or my problems. |
|
|
|
|
|
|
I have someone who makes me feel appreciated. |
|
|
|
|
|
|
I have someone to talk with when I have a bad day. |
|
|
|
|
|
|
Informational support
S2. Please respond to each statement:
|
Never |
Rarely |
Sometimes |
Usually |
Always |
Decline to Answer |
I have someone to give me good advice about a crisis if I need it. |
|
|
|
|
|
|
I have someone to turn to for suggestions about how to deal with a problem. |
|
|
|
|
|
|
I have someone to give me information if I need it. |
|
|
|
|
|
|
I get useful advice about important things in life. |
|
|
|
|
|
|
Instrumental support
S3. Please respond to each statement:
|
Never |
Rarely |
Sometimes |
Usually |
Always |
Decline to answer |
Do you have someone to help you if you are confined to bed? |
|
|
|
|
|
|
Do you have someone to take you to the doctor if you need it? |
|
|
|
|
|
|
Do you have someone to help with your daily chores if you are sick? |
|
|
|
|
|
|
Do you have someone to run errands if you need it? |
|
|
|
|
|
|
Social Isolation
S4. Please respond to each statement:
|
Never |
Rarely |
Sometimes |
Usually |
Always |
Decline to answer |
I feel left out. |
|
|
|
|
|
|
I feel that people barely know me. |
|
|
|
|
|
|
I feel isolated from others. |
|
|
|
|
|
|
I feel that people are around me but not with me. |
|
|
|
|
|
|
Companionship
S5. Please respond to each statement:
|
Never |
Rarely |
Sometimes |
Usually |
Always |
Decline to answer |
Do you have someone with whom to have fun? |
|
|
|
|
|
|
Do you have someone with whom to relax? |
|
|
|
|
|
|
Do you have someone with whom you can do something enjoyable? |
|
|
|
|
|
|
Can you find companionship when you want it? |
|
|
|
|
|
|
That concludes our survey! Thank you for participating!
If you have any questions or comments regarding this survey, please provide them below.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |
© 2024 OMB.report | Privacy Policy