Date: Sat, 12 Nov 1994 23:29:49 -0600 (CST) From: Kevyn Jacobs Subject: FOR MEN ONLY: KANSAS HIV PREVENTION SURVEY PLEASE COMPLETE AND RETURN TO: UNIVERSITY OF MISSOURI-KANSAS CITY INSTITUTE FOR HUMAN DEVELOPMENT ATTN: PHYLLIS NARAGON 2220 HOLMES STREET KANSAS CITY, MO 64108-2676 IMPORTANT: BE SURE TO WRITE "KP" (for 'Kansas Project') ON THE RETURN ADDRESS PART OF THE ENVELOPE. ============================================================== KANSAS HIV PREVENTION SURVEY TARGETS MEN-WHO-HAVE-SEX-WITH-MEN AND GAY-IDENTIFIED MEN The focus for HIV prevention has shifted and the state HIV Prevention Community Planning Group needs and wants local opinions to provide the best grassroots programs for HIV prevention. The HIV Prevention Community Planning Group (CPG) is looking for gay men and Men-Who-Have-Sex-With-Men (MSM), to fill out an assessment survey on HIV prevention needs for men in Kansas. The Community Planning Group is made up of gay men, persons living with HIV and AIDS, HIV Prevention Service providers, and interested state and local health agencies. This survey is being conducted for two reasons: 1. To get input on current prevention efforts targeted to Gay men and Men-Who-Have-Sex-With-Men (MSM); 2. To get a better sense of the circumstances that contribute to unsafe sex and injection drug use practices (alcohol, perceived monogamous relationships, etc.) to develop better HIV prevention efforts. The survey results will be used by the statewide HIV Community Planning Group to make recommendations to the Kansas Department of Health and Environment, for the types of HIV prevention programs needed in Kansas. This is an opportunity to give direct input at the state level for HIV prevention programs. It is very important that survey respondents answer the questions as completely and honestly as possible. All of responses are anonymous and no name will be requested or used. Please print this survey out, complete it, and mail it in - BE SURE TO WRITE "KP" ON THE RETURN ADDRESS PORTION OF THE ENVELOPE. Please help in this vital undertaking and distribute this survey to at least one friend. ================================================================ ============================CUT HERE============================ ================================================================ COUNTY OF RESIDENCE________________________________ 1. How old are you? _______ 2. What is your race or ethnicity? (check one) ______(1) White or Caucasian, not Hispanic ______(2) Black or African American, not Hispanic ______(3) Hispanic or Latino ______(4) Asian or Pacific Islander ______(5) American Indian/Alaskan Native ______(6) A Member of another group (specify)_______________ 3. What is your religious or spiritual affiliation, if you have one? _______________________________________________________________ 4. What is your current employment status: (check one) ______(1) Employed full-time ______(2) Employed part-time ______(3) Unemployed ______(4) Disabled and unable to work 5. What is your current living situation? Do you live with... (check all that apply) ______(1) A lover, spouse, or romantic partner ______(2) Self ______(3) Other (please specify)_______________________ 6. How much education have you COMPLETED? (check highest level completed) ______(1) Did not graduate from High School - What Grade did you complete?_____ ______(2) High School (or High School Equivalency) ______(3) Trade or Vocational school ______(4) Junior College ______(5) 4-year college ______(6) Post-graduate degree (M.A., M.S., M.B.A., Ph.D., M.D.) 7. How would you describe your current relationship status? Would you say that you are... ______(1) In a steady relationship and that you and your partner have no outside sex partners. ______(2) In a steady relationship, but that you have some outside sex partner(s) ______(3) Sexually active, but not currently in a steady relationship ______(4) Not Sexually Active 8. How would you describe your sexual orientation? Would you say that you are.... ______(1) Gay or homosexual ______(2) Bisexual ______(3) Two Spirited (Native American) ______(4) heterosexual ______(5) Other (specify)_______________ 9. Have you ever been tested for HIV? ______(1) Yes ______(2) No 10. Where was your last test for HIV conducted? ______(1) AIDS Test site ______(2) Doctor/HMO (Health Maintenance Organization) ______(3) Public Health Department ______(4) Hospital/emergency room/outpatient clinic ______(5) jail or prison ______(6) Drug treatment facility ______(7) Blood Donation Center ______(8) Other (please specify)_________________ 11. When you had your last HIV test, did you receive counseling about how to lower your chances of transmission? ______(1) Yes ______(2) No ______(3) Don't Know 12. With your last HIV test, did you receive any referrals for support services? ______(1) Yes (Please specify)_______________ ______(2) No ______(3) Don't Know 13. Based on your own experiences in getting HIV-tested, do you agree or disagree with the following statements: YES NO ______ ______ a. The HIV test is to far away ______ ______ b. The test site was accessible by public transportation ______ ______ c. Parking was difficult at the test site. ______ ______ d. I saw other people of my race. ______ ______ e. All instructions and information at the test site were provided to me in my own language. ______ ______ f. I was treated well at the HIV test site. ______ ______ g. The HIV test site is sensitive to people of my sexual orientation. ______ ______ h. The HIV site is sensitive to people of my race. ______ ______ i. The HIV test site was too public. 14. IF YOU ARE WILLING to disclose your HIV status, please indicate below: ______(1) HIV Negative (don't have the virus) ______(2) HIV Positive (Had the Virus) ______(3) Don't Know 15. Since Obtaining your HIV test results, have you made any changes in your sexual or drug use behaviors? ______(1) Yes ______(2) No If yes, which of the following changes have you made in your sexual or drug use behaviors? ______(1) Started using condoms during sex. ______(2) Tell people about my HIV status before I have sex with them. ______(3) Reduced number of sexual partners. ______(4) Reduced frequency of sex. ______(5) Stopped using alcohol/drugs (non-IV) prior to having sex. ______(6) Stopped having sex. ______(7) Reduced the use of alcohol/drugs (non-IV). ______(8) Reduced use of IV drugs. ______(9) Reduced sharing needles and/or works. ______(10) Stopped using IV drugs. ______(11) Stopped sharing needles and/or works. ______(12) Started disinfecting needles and/or works. ______(13) Other (specify)___________________________ 16. Please check all of the following sources where you received HIV prevention information. ______(1) Safer Sex or HIV prevention seminar. ______(2) HIV Counselor or AIDS services program. ______(3) Drug/Alcohol counselor. ______(4) Counselor or therapist who does not specialize in HIV. ______(5) Doctor ______(6) Nurse or other health professional. ______(7) Sexual Partner ______(8) Friend, who is not a sexual partner. ______(9) Outreach worker. ______(10) Family Member. ______(11) Minister or religious person. ______(12) Television program. ______(13) Radio program (specify station)___________________________ ______(14) Gay-oriented magazine/paper article (specify publication)__________________________________ ______(15) Ethnic-oriented magazine/paper article (specify publication)__________________________________ ______(16) Local newspaper article (specify publication)__________________________________ ______(17) Pamphlet or brochure ______(18) Billboard ______(19) Telephone Hotline ______(20) Other (specify)___________________________________________ 17. What sources in which you received prevention information have been the MOST HELPFUL IN EDUCATING YOU about ways to reduce your risk for HIV transmission? ______________________________________________________ ______________________________________________________ ______________________________________________________ 18. What sources of prevention information have been MOST EFFECTIVE IN GETTING YOU TO ACT in a way that lowers your risk for HIV transmission? ______________________________________________________ ______________________________________________________ ______________________________________________________ 19. Please check if you agree or disagree with the following statements: YES NO ______ ______ (1) I don't know where to get HIV tested. ______ ______ (2) The HIV test site is too far away. ______ ______ (3) The HIV test is too expensive. ______ ______ (4) I'm not sure I could handle a positive test result. ______ ______ (5) I don't think I need the test because I'm not at risk. ______ ______ (6) I'm afraid I might run into someone I know at the test site. ______ ______ (7) People might think I'm gay. ______ ______ (8) People could find out my results without my permission. ______ ______ (9) HIV test sites are not sensitive to people of my sexual orientation. ______ ______ (10) HIV test sites are not sensitive to people of my race. 20. During the past 12 MONTHS, have you met sexual partners... (Check all that apply) ______ (1) through friends ______ (2) At a dance club or bar ______ (3) At the baths ______ (4) At a health club ______ (5) in the park ______ (6) on the street ______ (7) at work ______ (8) through personal ads ______ (9) on the adult erotic phone lines. ______ (10) in an indoor public place (the baths, rest rooms, etc.) ______ (11) Other (specify)________________________________________ ______ (12) You have not met sexual partners that you didn't already know in the last 12 months. 21. During the past 12 months, have you had sex with... (check ONLY one response) ______(1) one primary partner ONLY. ______(2) one primary partner AND one or more casual partners. ______(3) one or more casual partners who are friends. ______(4) one or more casual partners who are strangers. ______(5) no one, you have not had sex. 22. Do you generally have sex with... ______(1) men only ______(2) women only ______(3) both, but mostly men ______(4) both, but mostly women ______(5) you have never had sex. 23. How often do you and/or your partner wear a condom while having oral/anal/vaginal sex? ORAL SEX ______(1) every time ______(2) sometimes ______(3) rarely ______(4) never ______(5) no sexual activity ANAL SEX ______(1) every time ______(2) sometimes ______(3) rarely ______(4) never ______(5) no sexual activity VAGINAL SEX ______(1) every time ______(2) sometimes ______(3) rarely ______(4) never ______(5) no sexual activity 24. How frequently, during the past 12 months, have you used alcohol or drugs before or during sex? ______(1) every time ______(2) sometimes ______(3) rarely ______(4) never 25. Please circle how often have you used the following, during the past 12 months. Would you say frequently, sometimes, rarely, or never: frequently sometimes rarely never a. marijuana 1 2 3 4 b. crack 1 2 3 4 c. cocaine (besides crack) 1 2 3 4 d. speed, crystal or 1 2 3 4 amphetamines e. heroin 1 2 3 4 f. alcohol 1 2 3 4 g. poppers or inhalants 1 2 3 4 h. hallucinogenics 1 2 3 4 26. Have you ever injected drugs? ______(1) Yes ______(2) No 27. If yes, in the last 12 months, how frequently have you injected drugs? Would you say this occurred... ______(1) once ______(2) 2-5 times ______(3) 6-12 times ______(4) more than 12 times 28. In the past 12 months have you shared your works (syringes and needles) when you injected drugs? ______(1) Yes ______(2) No 29. In the last 12 months have you cleaned your works (syringes and needles) with bleach before sharing them? ______(1) Yes ______(2) No 30. Have you ever been in an alcohol or drug treatment program? ______(1) Yes ______(2) No 31. Please circle whether you agree, disagree or if the statement is not applicable to you. Agree Disagree N/A a. Finding a sex partner who will have safer sex is difficult. 1 2 3 b. I would be uncomfortable talking about AIDS with a potential sex partner. 1 2 3 c. I worry about whether potential sex partners will enjoy using a condom. 1 2 3 d. I don't enjoy wearing a condom. 1 2 3 32. What types of support WOULD YOU HAVE NEEDED or DO YOU NEED not to become infected? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ================================================================ ============================CUT HERE============================ ================================================================ PLEASE COMPLETE AND RETURN TO: UNIVERSITY OF MISSOURI-KANSAS CITY INSTITUTE FOR HUMAN DEVELOPMENT ATTN: PHYLLIS NARAGON 2220 HOLMES STREET KANSAS CITY, MO 64108-2676 IMPORTANT: BE SURE TO WRITE "KP" (for 'Kansas Project') ON THE RETURN ADDRESS PART OF THE ENVELOPE. ==============================================================