current health status (eq-5d-5l)
sex with men

The next questions refer only to vaginal sex with men. This is when a man puts his penis, fingers or a sex toy/object in a woman's vagina. 9. Have you had vaginal sex with a man in the past 6 months?  
| (skip to question 12)   | Yes                   | Decline to answer   |
|-------------------------|-----------------------|---------------------|
| No                      | (skip to question 12) |                     |
| 0                       | 1                     | 99                  |  
| None   | 1   | 2-5   | 6-10   | More than   |    |    |
|--------|-----|-------|--------|-------------|----|----|
| 0      | 1   | 2     | 3      | 4           | 98 | 99 |  
10. How many men have you had vaginal sex with **in the past 6 months**?  
11. How often were condoms used to cover the man's penis, sex toy or object when you had vaginal sex with a man in the past 6 months?  
Now I am going to ask you questions about anal sex with a man. This is when a man puts his penis, finger, sex toy or object in your anus.  
| Sometime            |             |                       |                       |      |    |    |    |
|---------------------|-------------|-----------------------|-----------------------|------|----|----|----|
| Never               | Rarely      | s but less  than half | About  half the  time | More |    |    |    |
| than half  the time | Every  time | Unsure                | Decline to  answer    |      |    |    |    |
| 0                   | 1           | 2                     | 3                     | 4    | 5  | 98 | 99 |  
12. Have you had anal sex with a man in the past 6 months? 13. When was the last time a man put his penis in your anus?  
| (skip to question 17)   | Yes                   | Decline to answer   |
|-------------------------|-----------------------|---------------------|
| No                      | (skip to question 17) |                     |
| 0                       | 1                     | 99                  |  
  
14. How many men have you had anal sex with **in the past 6 months**?  
| Within the   | Unsure     | Decline to   |    |    |
|--------------|------------|--------------|----|----|
| past 6       | answer     |              |    |    |
| months       |            |              |    |    |
| Within the   | Within the |              |    |    |
| past week    | past month |              |    |    |
| 1            | 2          | 3            | 98 | 99 |  
15. How often did you have anal sex with a man **in the past 6 months**?  
16. How often was a condom used to cover the man's penis, finger, sex toy or object when you had anal sex with a man **in the past 6 months**?  
| None   | 1   | 2-5   | 6-10   | More than   |    |    |
|--------|-----|-------|--------|-------------|----|----|
| 0      | 1   | 2     | 3      | 4           | 98 | 99 |  
| 1-3           |                         |             |        |            |    |    |    |
|---------------|-------------------------|-------------|--------|------------|----|----|----|
| times/  month | 2-6                     | Daily       | Unsure | Decline to |    |    |    |
| times/        | answer                  |             |        |            |    |    |    |
| week          |                         |             |        |            |    |    |    |
| Never         | Less than 1  time/month | Once/  week |        |            |    |    |    |
| 0             | 1                       | 2           | 3      | 4          | 5  | 98 | 99 |  
| Sometime            |             |                       |                       |      |    |    |    |
|---------------------|-------------|-----------------------|-----------------------|------|----|----|----|
| Never               | Rarely      | s but less  than half | About  half the  time | More |    |    |    |
| than half  the time | Every  time | Unsure                | Decline to  answer    |      |    |    |    |
| 0                   | 1           | 2                     | 3                     | 4    | 5  | 98 | 99 |
current health status (eq-5d-5l)
sexually transmitted infections

The following questions ask about infections and diseases that are sexually transmitted. Once again, I assure you that your answers will be kept confidential. Please let us know if, in the past 6 months, you have been diagnosed with or treated for any of the infections we ask about now.  
17. Have you had anal warts in the past 6 months? These are **warts** inside or around your anus.  
No Yes, in the  
past 6 months  
Unsure/  
Don't know  
Decline to  
answer  
0 1 98 99  
18. Have you had warts inside your vagina, on the vulva, or in both places in the past 6 months?  
19. Have you had **herpes** around the vagina or anus in the past 6 months? These are painful blistering sores around your private parts.  
No **Yes, in the**  
past 6 months  
Unsure/  
Don't know  
Decline to  
answer  
0 1 98 99  
20. Have you had **Chlamydia in the past 6 months**? This is an infection transmitted during sexual contact.  
| No   | Inside   | Outside   | Both   | Unsure   | Decline to  answer   |
|------|----------|-----------|--------|----------|----------------------|
| 0    | 1        | 2         | 3      | 98       | 99                   |  
No Yes, in the  
past 6 months  
Unsure/  
Don't know  
Decline to  
answer  
0 1 98 99  
21. Have you had **Gonorrhea ("clap") in the past 6 months?** This is an infection transmitted during sexual contact.  
No Yes, in the  
past 6 months  
Unsure/  
Don't know  
Decline to  
answer  
0 1 98 99  
No **Yes in the past**  
6 months  
Unsure/  
Don't know  
Decline to  
answer  
0 1 98 99  
22. Have you had **pelvic inflammatory disease (PID) or infection of your fallopian tubes or**
ovaries in the past 6 months?
23. Have you had **syphilis in the past 6 months**? This is an infection transmitted during sexual contact. (The treatment is weekly painful penicillin shots.)
current health status (eq-5d-5l)
pre-procedure explanation and questions [acceptability]

In addition to the previous questions, you have consented to have some procedures done today for this study. These procedures are an anal Pap smear, high resolution anoscopy and a biopsy of any abnormal tissue or area that is seen.  
| No       | Yes in the past   | Unsure/   | Decline to   |
|----------|-------------------|-----------|--------------|
| 6 months | Don't know        | answer    |              |
| 0        | 1                 | 98        | 99           |  
Please tell me if you have any of the following concerns about having the following examinations or procedures. For each of these statements, please tell me whether you **agree** or disagree. Then you will be asked if you slightly or strongly agree/disagree with the statement.  
24. ANAL PAP SMEAR [OPTIONAL EXPLANATION: An anal Pap smear will be taken. This is like a cervical Pap smear. A Q-tip type swab will be inserted into the anus by the doctor or nurse practitioner to obtain cells that will be sent to the laboratory to check for abnormalities.]  
| Statement                               | Strongly   | disagree   | Neutral   | Slightly   |    |    |
|-----------------------------------------|------------|------------|-----------|------------|----|----|
| Slightly                                | Strongly   | Decline to |           |            |    |    |
| disagree                                | agree      | agree      | answer    |            |    |    |
| I                                       | am         | concerned  |           |            |    |    |
| about pain.                             | 1          | 2          | 3         | 4          | 5  | 99 |
| I feel the exam will  be uncomfortable. | 1          | 2          | 3         | 4          | 5  | 99 |
| I feel at ease.                         | 1          | 2          | 3         | 4          | 5  | 99 |
| I am prepared to  have the procedure.   | 1          | 2          | 3         | 4          | 5  | 99 |
current health status (eq-5d-5l)
25. only for visits 3

[OPTIONAL EXPLANATION: High resolution anoscopy is done with use of a plastic tube instrument inserted in the anus to look at the tissue under a special light to see if there are warts or other abnormalities in the anal area. Vinegar is used to make any abnormal areas show up better under the light. Any abnormalities seen will be biopsied, or removed, with a small cutting instrument (after more numbing medication is injected) to send to the laboratory for special analysis.]  
| Statement                               | Strongly    | disagree   | Neutral   | Slightly   |    |    |
|-----------------------------------------|-------------|------------|-----------|------------|----|----|
| Slightly                                | Strongly    | Decline to |           |            |    |    |
| disagree                                | agree       | agree      | answer    |            |    |    |
| I                                       | am          | concerned  |           |            |    |    |
| about pain.                             | 1           | 2          | 3         | 4          | 5  | 99 |
| I feel the exam will  be uncomfortable. | 1           | 2          | 3         | 4          | 5  | 99 |
| I feel at ease.                         | 1           | 2          | 3         | 4          | 5  | 99 |
| I am                                    | prepared to |            |           |            |    |    |
| have the procedure.                     | 1           | 2          | 3         | 4          | 5  | 99 |  
26. Which of the following examinations or procedures concerns you the very **most** today? (Choose one)  
| Code   | Procedure                |
|--------|--------------------------|
| 0      | No concern               |
| 1      | Anal Pap smear           |
| 2      | High resolution anoscopy |
| 3      | Biopsy                   |
| 99     | Decline to answer        |
current health status (eq-5d-5l)
for visits 3 and 5

FOR VISITS 2 AND 4  
Code **Procedure**  
0 No concern 1 Anal Pap smear  
99 Decline to answer
current health status (eq-5d-5l)
health behavior questions

Now I am going to ask you a few questions about yourself. [from ACTG self report, questions E, H, QL0742(A5257)/ 12-31-08] 27. Are you on HIV medication(s)?  
| (skip to question 29)   | Yes        | Unsure/   |
|-------------------------|------------|-----------|
| No                      | Don't know |           |
| 0                       | 1          | 98        |  
  
28. Rate your **ability** to take all of your HIV medications as specifically prescribed.  
| Unsure/ Don't  know   |      |      |      |            |           |     |                    |    |
|-----------------------|------|------|------|------------|-----------|-----|--------------------|----|
| poor                  | Poor | Fair | Good | Very  good | Excellent | N/A | Decline to  answer |    |
| 1                     | 2    | 3    | 4    | 5          | 6         | 97  | 98                 | 99 |
current health status (eq-5d-5l)
smoking questions

29. Have you smoked cigarettes in the past 6 months?  
AMC Smoking  
| No                    |     |
|-----------------------|-----|
| (skip to question 31) | Yes |
| 0                     | 1   |  
  
30. On average over the past 6 months, how many cigarettes have you smoked per day? (1 pack equals 20 cigarettes) ______________________ (number of cigarettes)
current health status (eq-5d-5l)
cost/transportation questions

| Hourly Wage           | Annual Income           |
|-----------------------|-------------------------|
| $0.00 - $4.99         | $0.00 - $9,999          |
| $5.00 - $7.25         | $10,000 - $14,999       |
| $7.26 - $9.99         | $15,000 - $19,999       |
| $10.00 - $14.99       | $20,000 - $29,999       |
| $15.00 - $19.99       | $30,000 - $39,999       |
| $20.00 - $24.99       | $40,000 - $49,999       |
| $25.00 - $29.99       | $50,000 - $59,999       |
| $30.00 - $34.99       | $60,000 - $69,999       |
| $35.00 - $39.99       | $70,000 - $79,999       |
| $40.00 - $49.99       | $80,000 - $99,999       |
| More than $50.00/hour | More than $100,000/year |  
31. Which one best describes your hourly wage or annual income? 32. Did you miss work today for this visit?  
| No                                                                | Yes                 |
|-------------------------------------------------------------------|---------------------|
| 0                                                                 | 1                   |
| 33. How did you get to the clinic today?  Response                | Code                |
| Drive yourself                                                    | 1                   |
| Get a ride from someone else in a personal vehicle                | 2                   |
| Take public transportation such as the metro bus or metro rail    | 3                   |
| Take a taxi                                                       | 4                   |
| Walk or ride bike, or                                             | 5                   |
| Get there some other way (SPECIFY) ____________                   | 6                   |
| Decline to answer                                                 | 99                  |
| 34. If you took private/public transportation, what was the fare? | $__________________ |  
35. How much time (including travelling time) will you miss from your usual activities because of this appointment?  
| Response                                         | Code            |
|--------------------------------------------------|-----------------|
| Less than 15 minutes                             | 1               |
| 15 to 30 Minutes                                 | 2               |
| 31 Minutes to 60 Minutes (1 Hour)                | 3               |
| 61 Minutes to 90 Minutes                         | 4               |
| 91 Minutes to 120 Minutes (2 Hours)              | 5               |
| 120 Minutes to 180 Minutes (2 to 3 Hours)        | 6               |
| 180 Minutes to 240 Minutes (3 to 4 Hours)        | 7               |
| 240 Minutes to 300 Minutes (4 to 5 Hours)        | 8               |
| 300 Minutes to 360 Minutes (5 to 6 Hours)        | 9               |
| More than 360 Minutes (More than 6 Hours)        | 10              |
| 36. How far did you travel for this appointment? | __________miles |  
37. If you drove, how much do you expect to pay for the parking? $_________________  
  
  
38. If you are accompanied to your appointment by someone who missed work, what is the gender and age of this person?  
| Accompanied   | Not    |     |    |
|---------------|--------|-----|----|
| accompanied   |        |     |    |
| Male          | Female | Age | 0  |
| 1             | 2      |     |    |  
39. Did you have to get a caretaker today to attend to your children and/or an adult person living in your household in order to come to your appointment?  
| No                       |     |
|--------------------------|-----|
| (Questionnaire complete) | Yes |
| 0                        | 1   |  
  
  
40. How much do you expect to pay the caretaker for today? (If no payment, skip to next question)
$____________  
  
41. Did the caretaker miss work in order to help you?