Follow-Up Visit Section 4

44 FOLLOW-UP VISIT SECTION 4

ID VISIT TIME BEGAN DATE NUMBER NO. HR MIN MONTH DAY YEAR Jan MARKING INSTRUCTIONS 4 4 0 Feb • Make dark marks that fill the circle completely. 0 0 0 0 0 0 0 0 0 0 Mar 0 0 00 • Make clean erasures. 1 1 1 1 1 1 1 10 1 10 1 AM Apr 1 1 01 • Make NO stray marks. 2 2 2 2 2 2 2 2 20 2 May 2 2 02 • DO NOT fold this form. Y 3 3 3 3 3 3 3 3 3 30 3 June 3 3 03 4 4 4 4 4 4 4 4 40 4 PM July 4 04 USE A NO. 2 PENCIL ONL 5 5 5 5 5 5 5 50 5 Aug 5 05 INCORRECT MARKS 6 6 6 6 6 6 6 6 Sept 6 06 CORRECT MARK ✓ ✗ 7 7 7 7 7 7 7 7 Oct 7 07 8 8 8 8 8 8 8 8 Nov 8 08 9 9 9 9 9 9 9 9 Dec 9 09

1. Let’s start with some medical conditions. Since your last visit [in (MONTH, YEAR)], were you diagnosed with some form of cancer, including Kaposi’s sarcoma, non-Hodgkin’s lymphoma, primary brain lymphoma, or Castleman’s disease?

No IF “NO,” GO TO Q 2 G Yes E T a IF YES: Where in the body was the cancer (Castleman’s b In what month and year was it first disease) and what kind of cancer did they say it was? diagnosed since your last visit [in (MONTH, YEAR)]? M 1) Site 0 1M2M3M4M5M6M7M8M9M E 0 100 200 300 400 500 600 700 800 900 J F M A M J J A S O N D D Type 0 102030405060708090 95 96 97 98 99 00 01 02 03 04 05 06 perf I 0123456789 3/8” spine C 2) Site 0 1M2M3M4M5M6M7M8M9M A 0 100 200 300 400 500 600 700 800 900 J F M A M J J A S O N D L Type 0 102030405060708090 95 96 97 98 99 00 01 02 03 04 05 06 0123456789 R E c What was the name and address of the c What was the name and address of the L physician who diagnosed the condition(s)? physician who diagnosed the condition(s)? E A Name of hospital/clinic or doctor Name of hospital/clinic or doctor S E Address Address

City State City State

PLEASE DO NOT WRITE IN THIS AREA SERIAL # Page 1 Mark Reflex® forms by NCS Pearson EM-203770-21:654321 Printed in U.S.A. 3/8” spine perf I L L T E E E E S E A A R D C G M D D 06 06 irst N N 05 05 O O 04 04 S S 03 03 A A J J J J 00 01 02 00 01 02 M M A A [in (MONTH, YEAR)]? M M 97 98 99 97 98 99 F F diagnosed since your last visit diagnosed since your J J 95 96 95 96 In what month and year was it f and year was In what month b What was the name and address of the What was the name and address physician who diagnosed the condition(s)? Name of hospital/clinic or doctor Address City State c Page 2 0 1M2M3M4M5M6M7M8M9M 0 100 200 300 4000 500 102030405060708090 600 700 800 900 0123456789 0 1M2M3M4M5M6M7M8M9M 0 100 200 300 4000 500 102030405060708090 600 700 800 900 0123456789 D 06 N 05 was it O 04 S 03 since your A J J 00 01 02 M A first diagnosed? IF “NO,” GO TO Q 4 IF “NO,” GO TO IF “NO,” GO TO Q 3 Q TO IF “NO,” GO M 97 98 99 : What was the diagnosis? : What was F What was the name and address of the What was the name and address What was the name and address of the What was the name and address J physician who diagnosed the condition? 95 96 IF YES physician who diagnosed the condition(s)? In what month and year last visit [in (MONTH, YEAR)] Name of hospital/clinic or doctor Address City State Name of hospital/clinic or doctor Address City State a a b Type Type Type No Yes No Yes c 2) 1) Kaposi’s sarcoma, non-Hodgkin’s lymphoma or primary brain lymphoma? brain or primary lymphoma non-Hodgkin’s sarcoma, Kaposi’s 3. with pneumonia? YEAR)], were you diagnosed Since your last visit [in (MONTH, 2. than other illnesses AIDS-related any with diagnosed were you YEAR)], [in (MONTH, last visit your Since The next few questions are about tuberculosis or TB for short.

4.A. Since your last visit [in (MONTH, YEAR)], did you have a skin test for TB, sometimes called a PPD? NO YES

SKIP TO Q 5 B. IF YES: When was your last test? J F M A M J J A S O N D

95 96 97 98 99 00 01 02 03 04 05 06 NO YES C. Was it positive?

GET M E 5.A. Since your last visit [in (MONTH, YEAR)] have you had an active TB infection? D I SKIP C A TO Q 6 L B. Was the TB in your lungs? R E C. Was the TB in any other part of your body (other than your lungs)? L E A S E 6.A. Since your last visit [in (MONTH, YEAR)], have you been admitted to the hospital for any reason? This includes overnight stays and outpatient procedures. No SKIP TO Q 7 Yes How many separate times were you a patient in a hospital since your last visit [in (MONTH, YEAR)]?

0 102030405060708090 0 1 2 3 4 5 6 7 8 9

GET RELEASE OF RECORDS, NOTE NAME AND ADDRESS OF HOSPITAL perf

3/8” spine B. Tell me about (that hospitalization/outpatient procedure/each of those times) starting with the most recent hospitalization/outpatient procedure. (1)a. On what date did you last go into the hospital?

MO J F M A M J J A S O N D 0 102030 DAY 0 1 2 3 4 5 6 7 8 9 YEAR 95 96 97 98 99 00 01 02 03 04 05 06

b. How many nights did you spend in the hospital at that time? IF OUTPATIENT: FILL IN ZERO.

0 102030405060708090 NIGHTS 0 1 2 3 4 5 6 7 8 9

c. For what condition or problem were you hospitalized and the name/address of the hospital? RECORD FULLY IN R’s OWN WORDS. IF AIDS RELATED, CODE IN QUESTIONS 1–3 AS APPROPRIATE

IF ONLY ONE HOSPITALIZATION (SEE RESPONSE TO 6.A.), SKIP TO QUESTION 7 SERIAL # Page 3 (2)a. For your second most recent time to the hospital, on what date did you go into the hospital?

MO J F M A M J J A S O N D 0 102030 DAY 0 1 2 3 4 5 6 7 8 9 YEAR 95 96 97 98 99 00 01 02 03 04 05 06

b. How many nights did you spend in the hospital at that time? IF OUTPATIENT: FILL IN ZERO.

0 102030405060708090 NIGHTS 0 1 2 3 4 5 6 7 8 9

c. For what condition or problem were you hospitalized and the name/address of the hospital? RECORD FULLY IN R’s OWN WORDS. IF AIDS RELATED, CODE IN QUESTIONS 1–3 AS APPROPRIATE

d. Did you have another prior hospitalization/outpatient procedure since your last visit [in (MONTH, YEAR)]?

No SKIP TO Q 7 Yes 3/8” spine perf

IF MORE THAN 2 HOSPITALIZATIONS/OUTPATIENT PROCEDURES SINCE YOUR LAST VISIT [IN (MONTH, YEAR)], MARK HERE AND USE CONTINUATION SHEET.

7. Since your last visit [in (MONTH, YEAR)], have you been hospitalized, prescribed medication, or consulted a mental health professional for treatment of depression? No Yes Don’t know

IF YES: which month and year was the most recent time? J F M A M J J A S O N D

88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 Before 1989

8.A. We are now going to ask you about specific conditions that may have been diagnosed in your immediate family. Immediate family includes your biological mother, father, brothers and sisters.

Since your last visit [in (MONTH, YEAR)], have any members of your immediate blood-related family been hospitalized, prescribed medication or consulted a mental health professional for treatment of depression?

No Yes Don’t know Not applicable (For those participants who do not have living blood-related family members or do not know them because they are adopted.) SKIP TO Q 9.A.(1)

Page 4

8.B. Since your last visit [in (MONTH, YEAR)], have any members of your immediate family been diagnosed with... NO YES DON’T KNOW a. high blood pressure or hypertension? b. angina, which often causes chest pain? c. a heart attack or myocardial infarction (MI) before age 55? d. congestive heart failure or CHF? e. a stroke or CVA? f. mini-strokes or transient ischemic attacks (TIA)? g. high cholesterol, high triglycerides, high lipids or too much fat in their blood? h. high blood sugar or diabetes?

8.C. Since your last visit [in (MONTH, YEAR)], have any members of your immediate family been diagnosed with cancer? No Yes Don’t Know SKIP TO Q 9.A.(1)

SKIP TO Q 9.A.(1)

IF YES: Was it: NO YES DON’T KNOW a. Skin cancer b. Colon cancer c. Prostate cancer d. Cervical cancer (female family members) e. Anal cancer f. Other cancer

Specify:

9.A.(1) Since your last visit [in (MONTH, YEAR)], have you become aware of any anal cancer screening (testing involving an anal pap smear, collecting a swab, or possible anal biopsy) available in your community? perf

3/8” spine No Yes Don’t know

(2) How likely is it that you will be screened for anal cancer, anal warts or another anal health problem in the next 6 months (outside of your regular MACS visit(s))? Not at all likely Unlikely Possibly Likely Very likely

(3) If you suspected that you had anal warts or another anal health problem, where would you go for diagnosis and/or treatment? My primary physician An STD clinic A Gay clinic or health center An anal specialist (proctologist or colorectal surgeon) A dermatologist An HIV specialist Specify: Other

(4) How concerned are you about developing anal cancer at some point in your lifetime? Not at all Slightly Moderately Fairly Very SERIAL # Page 5 9.B.(1) Since your last visit [in (MONTH, YEAR)], have you undergone an anal pap smear? (A doctor or medical practitioner took a swab of the anal canal to test for cancer cells.) No GO TO Q 9.C.(1) Yes Don’t Know GO TO Q 9.C.(1)

(2) In what month and year did you have the pap smear performed?

J F M A M J J A S O N D

95 96 97 98 99 00 01 02 03 04 05 06

(3) Were the results abnormal? No GO TO Q 9.C.(1) Yes GET MEDICAL RELEASE

Name of the doctor who performed the pap smear and where it was performed.

Name of doctor

Name of hospital/center/clinic

City State

9.C.(1) Since your visit [in (MONTH, YEAR)], have you had any biopsies of the skin, anus, rectal area or other tissues and organs? By a biopsy, we mean removal of any tissue or gland to study under a microscope. No REVIEW RESPONSE TO Q 1, IF DIAGNOSED WITH CANCER USE PROMPT

AND RE-ASK QUESTION, OTHERWISE SKIP TO Q 10 3/8” spine Yes perf

(2) How many times have you had a biopsy since your last visit [in (MONTH, YEAR)]?

1 2 3 4 5 6 7 8 9 TIMES G E (3) For each biopsy, please tell me: T a b c Name of the doctor who performed the What did they say the diagnosis biopsy, where the biopsy was performed Where in your body? or result of the biopsy was? and the date of the biopsy. M 1) Specify: Specify: E Name of doctor D Name of hospital/center/clinic I 0 102030405060708090 0 1 2 3 4 5 6 7 8 9 C 0 1 2 3 4 5 6 7 8 9 City State DATE A 2) Specify: Specify: L Name of doctor

Name of hospital/center/clinic R

0 102030405060708090 0 1 2 3 4 5 6 7 8 9 E 0 1 2 3 4 5 6 7 8 9 CityState DATE L E 3) Specify: Specify:

Name of doctor A S Name of hospital/center/clinic E 0 102030405060708090 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 Page 6 CityState DATE 10. I am now going to ask you about other conditions, NO YES ailments or disorders. Were you newly diagnosed with any of the following since your last visit [in (MONTH, AA. Liver disease YEAR)]? This includes new episodes or reoccurrences IF YES: Was it: Elevated liver function test/enzyme of chronic conditions. NO YES A. Shingles (or herpes zoster) GET Other MEDICAL Specify: B. Thrush (yeast in your mouth) RELEASE IF OTHER C. Sinusitis, a sinus infection that OR DON’T requires antibiotics KNOW Don’t know D. Bronchitis What was the name and address of the E. Pancreatitis physician who diagnosed the condition(s)? F. Prostate problems (not cancer) G. Erectile dysfunction Name of hospital/clinic or doctor H. High blood pressure or hypertension Address I. Anemia, low RBC, low hemoglobin J. High cholesterol, high triglycerides, high City State lipids or too much fat in your blood K. High blood sugar or diabetes BB. Since your last visit [in (MONTH, YEAR)], have L. Arthritis you received the injections of the combination vaccine for the prevention of Hepatitis A and B? IF YES: Was it: Rheumatoid (Read and answer each.) Osteoarthritis or No degenerative Yes Other Don’t Know Specify:

CC. Since your last visit [in (MONTH, YEAR)], have you Don’t know received the injections or vaccine for the prevention M. Angina, which often causes chest pain G of Hepatitis A? E N. Heart attack or myocardial infarction (MI) T No O. Congestive heart failure or CHF Yes M P. Stroke or CVA E Don’t Know Q. Mini-strokes or transient ischemic attacks D I (TIA) C DD. Since your last visit [in (MONTH, YEAR)], have you R. Too fast, too slow, or irregular heart beat A received the injections or vaccine for the prevention perf L of Hepatitis B? 3/8” spine S. Any blood vessels (arteries) that were R blocked or closed IF NO, SKIP TO Q U E No T. An operation or other procedure, such as L Yes E angioplasty, to open blocked blood A Don’t Know S vessels in your heart or other areas E U. A blood clot in your legs I V. A blood clot in your lungs EE. Since your last visit [in (MONTH, YEAR)], F have you had any neurological evaluation W. Seizure or convulsions B or a physical examination to look for X. Osteoporosis (bone thinning) O problems of the nervous system (brain, NO YES Y. Avascular necrosis (osteonecrosis) L spinal cord, nerves in hands and feet)? D Z. Kidney disease/Renal failure E D GET MEDICAL RELEASE

What was the name and address of the physician who diagnosed the condition(s)? IF YES: Was there a diagnosis for your NO YES condition? Name of hospital/clinic or doctor IF YES: What was the diagnosis? Address Specify:

City State

0 100 200 300 400 500 600 700 800 900 Date of diagnosis 0 102030405060708090

0 1 2 3 4 5 6 7 8 9 Name of hospital/clinic or doctor

Address GO TO PAGE 19 TO RECORD ADDITIONAL DOCTORS’ NAMES/ADDRESSES. City State

Date of diagnosis SERIAL # Page 7 3/8” spine perf i j k g h NO YES NO YES NO YES NO YES NO YES TO TO TO TO TO SKIP SKIP SKIP SKIP SKIP 9 9 9 9 9 8 8 8 8 8 7 7 7 7 7 6 6 6 6 6 5 5 5 5 5 4 4 4 4 4 3 3 3 3 3 2 2 2 2 2 1 1 1 1 1 0 0 100 200 300 4000 500 102030405060708090 600 700 800 900 0 0 100 200 300 4000 500 102030405060708090 600 700 800 900 0 0 100 200 300 4000 500 102030405060708090 600 700 800 900 0 0 100 200 300 4000 500 102030405060708090 600 700 800 900 0 0 100 200 300 4000 500 102030405060708090 600 700 800 900 GET MEDICAL RELEASE GET MEDICAL Was there a diagnosis? Was What was the diagnosis? Was there a diagnosis? Was the diagnosis? What was diagnosis? there a Was What was the diagnosis? there a diagnosis? Was What was the diagnosis? there a diagnosis? Was What was the diagnosis? : : : : : Specify: Specify: Specify: Specify: Specify: IF YES IF YES IF YES IF YES IF YES j) Psychological g) Urinary and Rectal Genital, h) Skin i) Nervous system f) Joints or Muscles Bones, Page 8 f e c b d NO YES NO YES NO YES NO YES NO YES TO TO TO TO TO SKIP SKIP SKIP SKIP SKIP 9 9 8 8 9 9 9 7 7 8 8 8 6 6 7 7 7 5 5 6 6 6 conditions 4 4 5 5 5 3 3 4 4 4 2 2 3 3 3 1 1 2 2 2 0 100 200 300 4000 500 102030405060708090 600 700 800 900 0 0 100 200 300 4000 500 102030405060708090 600 700 800 900 0 1 1 1 GET MEDICAL RELEASE GET MEDICAL 0 100 200 300 4000 500 102030405060708090 600 700 800 900 0 0 100 200 300 4000 500 102030405060708090 600 700 800 900 0 0 100 200 300 4000 500 102030405060708090 600 700 800 900 0 Was there a diagnosis? Was What was the diagnosis? there a diagnosis? Was What was the diagnosis? : : Was there a diagnosis? there a Was What was the diagnosis? there a diagnosis? Was What was the diagnosis? Was there a diagnosis? Was the diagnosis? What was : : : Specify: Specify: IF YES IF YES Specify: Specify: Specify: IF YES IF YES IF YES d) Lungs and Bronchial Tubes e) Stomach and Intestines b)Nose, Throat, Mouth and Sinuses Ears, c) Heart and Blood Vessels a) Eyes have you seen a doctor or other medical or other a doctor you seen have NEW any OTHER for practitioner or problems in the following areas? in the following or problems FF.YEAR)], [in (MONTH, visit your last Since

FF. Continued 11.A. Have you had any of the following forms of NO YES herpes, not including shingles or herpes zoster, k) Hormones or Endocrine system since your last visit [in MONTH, YEAR)]? NO YES IF YES: Was there a diagnosis? 1) Facial herpes, cold sores, or fever blisters What was the diagnosis? SKIP 2) Sores in genital region TO Specify: l 3) Sores in the anal or rectal areas 4) Sores elsewhere on your body 0 100 200 300 400 500 600 700 800 900 IF “NO” TO ALL FOUR, SKIP TO Q 12 0 102030405060708090 B. Did the first attack of herpes you ever 0 1 2 3 4 5 6 7 8 9 had occur since your last visit [in (MONTH, YEAR)]? NO YES C. Has there been a period since your last l) Blood visit [in (MONTH, YEAR)] when your (herpes) sores seemed to come more often, get worse or last longer than usual? GET MEDICAL RELEASE 12. Have you had any of the following diseases or IF YES: Was there a diagnosis? conditions since your last visit [in (MONTH, YEAR)]? What was the diagnosis? SKIP How about (EACH)? TO Specify: m HAD DISEASE OR CONDITION DISEASE

0 100 200 300 400 500 600 700 800 900 NO YES 0 102030405060708090 A.1) Syphilis 0 1 2 3 4 5 6 7 8 9 IF “NO,” SKIP TO (B) A.2) Was this a new infection or was it a continuation or relapse of a previous infection? m)Allergy and Immune system other than NO YES New infection HIV infection Continued or relapse IF YES: Was there a diagnosis? B) Any form of gonorrhea What was the diagnosis? SKIP TO IF “NO” TO (B), SKIP TO (F) Specify: n C) Urethral gonorrhea (clap or drip of the urinary passage) 0 100 200 300 400 500 600 700 800 900 perf 0 102030405060708090 D) Oral gonorrhea (of the mouth or throat) 3/8” spine 0 1 2 3 4 5 6 7 8 9 E) Rectal gonorrhea (of the rectum) NO YES n) Other F) Non-specific or nongonococcal urethritis or chlamydia (that is, a discharge from the IF YES: Was there a diagnosis? penis that's not caused by gonorrhea) What was the diagnosis? SKIP TO 1. Q11.A G.1) Genital warts (condylomata acuminata)

IF “NO,” SKIP TO (H) 0 100 200 300 400 500 600 700 800 900 0 102030405060708090 G.2) Was this a new infection or was it a continuation or

0 1 2 3 4 5 6 7 8 9 relapse of a previous infection? New infection 2. Continued or relapse

0 100 200 300 400 500 600 700 800 900 H.1) Anal warts (condylomata acuminata) 0 102030405060708090 IF “NO,” SKIP TO (I) 0 1 2 3 4 5 6 7 8 9 H.2) Was this a new infection or was it a continuation or relapse of a previous infection? What was the name and address of the physician who diagnosed the condition(s)? New infection Continued or relapse I) Any other diseases including worms, Name of hospital/clinic or doctor shigellosis, salmonellosis, amoebic dysentery, or giardiasis Address Specify:

City State SERIAL # Page 9 3/8” spine perf D D D D D D D D D D D D D D D N N N N N N N N N N N N N N N 05 05 05 05 05 05 05 05 05 05 05 05 05 05 05 O O O O O O O O O O O O O O O 04 04 04 04 04 04 04 04 04 04 04 04 04 04 04 S S S S S S S S S S S S S S S 03 03 03 03 03 03 03 03 03 03 03 03 03 03 03 A A A A A A A A A A A A A A A J J J J J J J J J J J J J J J J J J J J J J J J J J J J J J 00 01 0200 01 02 06 00 01 02 06 00 01 02 06 06 00 01 0200 06 01 0200 06 01 0200 06 01 0200 06 01 0200 01 02 06 00 01 02 06 00 01 02 06 00 01 02 06 00 01 02 06 06 00 01 02 06 M M M M M M M M M M M M M M M A A A A A A A A A A A A A A A M M M M M M M M M M M M M M M 97 98 99 97 98 99 97 98 99 97 98 99 97 98 99 97 98 99 97 98 99 97 98 99 97 98 99 97 98 99 97 98 99 97 98 99 97 98 99 97 98 99 97 98 99 f F F F F F F F F F F F F F F F In what month and year since your In what month (MONTH, YEAR)] did it last visit [in Even though begin? [IF NEEDED: the exact remember you don’t help if you could month, it would season or approximate tell me the (this time of year when it started last time)]. J J J J J J J J J J J J J J J 95 96 95 96 95 96 95 96 95 96 95 96 95 96 95 96 95 96 95 96 95 96 95 96 95 96 95 96 95 96 WHEN BEGAN (Month and Year) and WHEN BEGAN (Month e NO YES Is this a new condition? IF YES, GO TO COLUMN F DON’T KNOW d Did you experience this symptom due to taking any medication? NO YES Page 10 c And do you have that now? b Did that last for two weeks or longer? NO YES NO YES a NO YES How about (EACH)? Did you have that at any time since your last visit [in (MONTH, YEAR)]? , . , AND f , e , d , c SYMPTOM PROBLEM OR PROBLEM This includes those due to illnesses or side effects from medications. effects or side to illnesses those due includes This bleeding that is difficult to stop tired all the time) for at tired all the time) for bloating, cramps the stomach or abdomen) consecutive days night on at least 3 occasions whites of eyes, dark urine or clay colored stools) skin discoloration that lasted at least two weeks loss of at least 10 pounds (unrelated to dieting) least 3 consecutive days least 3 consecutive rash, or infection that lasted for at least 3 consecutive days glands or lymph nodes (not counting your groin) for at least 3 consecutive days fever higher than 100° for at least 3 consecutive days unusual kinds of head- aches for at least 3 consecutive days ASK b 2) (feeling Persistent fatigue 9) Nausea, vomiting 7) Diarrhea for at least 3 8) Drenching sweats at 1) for at Persistent dizziness 5) new skin condition, A 6) or enlarged Tender 3) recurring Persistent or 4) Persistent, frequent or FOR EACH “YES” IN a FOR EACH 13.A. or symptoms? problems following any of the you had have YEAR)], [in (MONTH, last visit Since your 11) Ascites (fluid buildup in 15) Unusual bleeding or 10) Abdominal pain, 12) Jaundice (yellow hue to 13) An unusual bump or 14) An unintentional weight days least 3 consecutive 3/8” spine perf 3B Sinceyourlastvisit[in(MONTH, 13.B. Continued 13.A. 1 Vivid nightmaresor 21) Jointpain 17) 2 Insomniaorproblems 22) 0 Kidneystones 20) Painfulurination 18) Musclepainorweakness 16) 9 Bloodinurine 19) FOR EACH“YES”INa ASK b ASK dreams sleeping YEAR)], haveyouexperienced: PROBLEM OR .Pain,aching,orburningin 1. .Numbness(lackof 3. Pinsandneedlesinyour 2. SYMPTOM , c your feetorlegs? legs? feeling) inyourfeetor feet orlegs? , d , e , ANDf . , YEAR)]? [in (MONTH, your lastvisit time since that atany you have (EACH)? Did How about OYES NO a If YES,indicateseverity. If NO,gotonextquestion. OYSN YES NO YES NO longer? or weeks two last for Did that b OYES NO now? that have you And do c Page 11 Left Right Left Right Left Right OYES NO medication? taking any due to this symptom experience Did you d KNOW DON’T 0 0 0 0 0 0 (0= None,1=Mild,10=Severe) 1 1 1 1 1 1 COLUMN F GO TO IF YES, condition? a new Is this OYES NO 2 2 2 2 2 2 e 3 3 3 3 3 3 Severity 4 4 4 4 4 4 5 5 5 5 5 5 WHEN BEGAN(Monthand Year) 596 95 596 95 96 95 96 95 96 95 96 95 96 95 6 6 J J J J J J J 6 6 6 6 last time)]. time ofyearwhenitstarted(this tell metheseasonorapproximate month, itwouldhelpifyoucould you don’t remember theexact begin? [IFNEEDED:Eventhough last visit[in(MONTH,YEAR)]didit In whatmonthandyearsinceyour F F F F F F F 7 7 7 7 7 7 f SERIAL # 79 99 98 97 79 99 98 97 99 98 97 99 98 97 99 98 97 99 98 97 99 98 97 M M M M M M M 8 8 8 8 8 8 A A A A A A A 9 9 9 9 9 9 10 10 10 10 10 10 M M M M M M M 00 02 01 00 00 02 01 00 02 01 00 02 01 00 02 01 00 02 01 00 02 01 00 J J J J J J J medication? to takingany this symptomdue Did youexperience OYES NO J J J J J J J A A A A A A A 03 03 03 03 03 03 03 S S S S S S S 04 04 04 04 04 04 04 O O O O O O O KNOW DON’T 05 05 05 05 05 05 05 N N N N N N N 06 06 06 06 06 06 06 D D D D D D D 14. Since your last visit, [in (MONTH, YEAR)], have you 15.B.(3) Please name those drugs that you have taken any HIV-related medications or treatments? taken or show me which ones. (That is, medications or treatments to suppress or prevent getting sick because of HIV or treat the FILL IN THE BUBBLE NEXT TO THE DRUG(S) AND sickness related to HIV or AIDS excluding acyclovir.) STOP THEN COMPLETE FORM 1 FOR EACH DRUG. No abacavir (Ziagen) (218) Yes SKIP TO Q 15.A.(1) amprenavir (Agenerase) (219) atazanavir (Reyataz) (243) Combivir (zidovudine + lamivudine) (227) 14.A IF NO: Why did you decide not to take HIV-related d4T (Zerit, Stavudine) (159) medications? READ EACH, MARK ALL THAT APPLY. delavirdine (Rescriptor) (194) Not infected with HIV GO TO Q 16 didanosine (Videx) (147) Doctor said was not necessary efavirenz (Sustiva) (220) Not sick emtricitabine (Emtriva, FTC) (239) Too expensive enfuvirtide (Fuzeon, T-20, pentafuside) (233) Don’t think they work or will help Epzicom (abacavir, lamivudine) (254) Possible side effects fosamprenavir (Lexiva) (249) Can’t take them the way the doctor wants (too many pills, too indinavir (Crixivan) (212) many times during the day or won’t remember to take them) lamivudine (Epivir, 3TC) (204) Other reason lopinavir (Kaletra) (217) Specify: nelfinavir (Viracept) (216) nevirapine (Viramune) (191) ritonavir (Norvir) (211) saquinavir (Invirase, Fortovase) (210) 15.A.(1) Since your last visit [in (MONTH, YEAR)], has a tenofovir (Viread) (234) doctor or other medical practitioner tested tipranavir (238) your blood to see if you have HIV that is Trizivir (abacavir + lamivudine + zidovudine) (240) resistant to certain drugs? Truvada (emtricitabine + tenofovir) (253) SKIP TO Q 15.B.(1) IF ON HIV MEDS No SINCE LAST VISIT zidovudine (Retrovir, AZT) (092) Yes SKIP TO Q 16 IF NOT ON HIV MEDS Other anti-retroviral from Drug List 1 SINCE LAST VISIT (Report Acyclovir in Q 16.) 3/8” spine

DON’T perf (2) What type of NO YES KNOW 1. test was done? 1) Phenotype 2) Genotype 0 100 200 300 400 500 600 700 800 900 0 102030405060708090 (3) Has your treatment No 0 1 2 3 4 5 6 7 8 9 (drugs) been changed as a Yes result of that test? Don’t know 2. SKIP TO Q 16 IF NOT ON HIV MEDS SINCE LAST VISIT 0 100 200 300 400 500 600 700 800 900 15.B.(1) Since your last visit [in (MONTH, YEAR)], have you taken any medication or drug on this list 0 102030405060708090 [SHOW LIST 1 AND MEDICATION PHOTO CARDS]? 0 1 2 3 4 5 6 7 8 9 No Yes SKIP TO Q 15.B.(3) 3.

(2) IF NO: Why did you decide not to take 0 100 200 300 400 500 600 700 800 900 HIV-related medications? 0 102030405060708090 READ EACH, MARK ALL THAT APPLY AND THEN 0 1 2 3 4 5 6 7 8 9 SKIP TO Q 15.C Doctor said was not necessary (4) Since your last visit [in (MONTH, YEAR)], did you Not sick stop taking all of your prescribed antiretroviral therapy for at least 2 days in a row? Too expensive Don’t think they work or will help No SKIP TO Q 15.C Possible side effects Yes Can’t take them the way the doctor wants (too many IF YES: How many times did this occur? pills, too many times during the day or won’t remember 0 102030405060708090 to take them) 0 1 2 3 4 5 6 7 8 9 Other reason Did your physician prescribe or agree to any of these? Specify: No Yes For how many days did you stop during the last time? 0 102030405060708090 Page 12 0 1 2 3 4 5 6 7 8 9

15.C.(1) Since your last visit [in (MONTH, YEAR)], have you taken any medication or drug on this list [SHOW LIST 2] to suppress or prevent getting sick because of HIV or treat the sickness related to HIV or AIDS?

No SKIP TO Q 15.D Yes

(2) Please name those drugs that you have taken. STOP FILL IN THE BUBBLE NEXT TO THE DRUG(S). FOR DRUGS NOT ON THE LIST, RECORD THE NAME UNDER “OTHER” AS STATED BY THE PARTICIPANT. COMPLETE DRUG FORM 2 FOR EACH DRUG.

atovaquone (Mepron, BW566C80) (190) ganciclovir (Cytovene, DHPG, valcyte, Other from Drug List 2 azithromycin (Zithromax) (152) valganciclovir) (125) (Report Acyclovir in Q 16.) Bactrim (Septra, TMP/SMX) (112) interleukin 2 (IL-2) (096) ciprofloxacin (Cipro) (153) Marinol (dronabinol) (547) 1. clarithromycin (Biaxin) (184) Megace (megestrol acetate) (123) co-enzyme Q (196) NAC (N-acetyl cysteine) (188) colony stimulating factor (G-CSF, Neupogen) Nandrolone (deca-durabolin) (232) 0 100 200 300 400 500 600 700 800 900 (157) Oxandrin (oxandrolone) (228) 0 102030405060708090 dapsone (113) rifabutin (Mycobutin, Ansamycin) (093) 0 1 2 3 4 5 6 7 8 9 DHEA (dihydroepiandrostenedione) (161) Serostim (human growth hormone) (245) 2. erythropoietin (Epogen, Procrit, Aranesp) (117) testosterone (Androgel, Androderm, ethambutol (Myambutol) (137) Delatestryl, Striant, Testoderm, fluconazole (Diflucan) (116) Virilon) (236) 0 100 200 300 400 500 600 700 800 900 foscarnet (foscavir) (091) 0 102030405060708090 0 1 2 3 4 5 6 7 8 9

0 100 200 300 400 500 600 700 800 900 0 102030405060708090 0 1 2 3 4 5 6 7 8 9 perf 3/8” spine

15.D. (1) Since your last visit [in (MONTH, YEAR)], have you taken any medication, drug or other therapy that was not listed to suppress or prevent getting sick because of HIV or treat the sickness related to HIV or AIDS? No SKIP TO Q 16 Yes

(2) Please name the other HIV related therapies you have taken.

1. 2. 3.

0 100 200 300 400 500 600 700 800 900 0 100 200 300 400 500 600 700 800 900 0 100 200 300 400 500 600 700 800 900 0 102030405060708090 0 102030405060708090 0 102030405060708090 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9

4. 5. 6.

SERIAL # Page 13 16. Now, I have some questions about drugs and medications that you may have taken for other health reasons. These include prescribed medications, over the counter medications, and other medications you took on your own since your last visit [in (MONTH, YEAR)]. ASK EACH ITEM UNTIL FIRST “NO” a How about (EACH)? b When specified, c Have you TO OTHER DRUG (ITEM 17a) Have you (taken/used) any what was the name of the taken/used any in the since your last visit (KIND OF DRUG) you took and past 5 days (FOR IF “NO” TO a GO TO NEXT ITEM [in (MONTH, YEAR)]? what did you take this drug for? ASPIRIN:in the last week)? NO YES NO YES 1) Steroids that you took by mouth or were injected Name:

Name: 2) Thyroid hormone or medication 3) Other hormones such as anabolic steroids Name: 4) Antibiotics such as penicillin, tetracycline, Name: erythromycin, or a sulfa drug 5) Medication taken by mouth for fungal infection Name: 6) Medication taken by mouth for worms or parasites Name:

7) Tranquilizers or sleeping pills Name: 8) Antidepressants or mood elevators Name: 9) Lithium Name:

10) Acyclovir, famciclovir or valacyclovir for herpes Name: (zovirax famvir, valtrex) IF YES, did you take it: Everyday? No Yes Only when you had active lesions or had an outbreak? No Yes

11) Viagra, Cialis, Levitra or other drugs that were prescribed Name: by a medical provider to treat erectile dysfunction

12) Aspirin taken three days or more on a weekly basis Name:

13) Cholesterol, 0 100 200 300 400 500 600 700 800 900 Name: a. triglycerides, 0 102030405060708090 lipid or any blood fat lowering 0 1 2 3 4 5 6 7 8 9 SKIP TO medications Q 16.14

Name: 3/8” spine 0 100 200 300 400 500 600 700 800 900 b. perf 0 102030405060708090 SKIP TO Q 16.14 0 1 2 3 4 5 6 7 8 9

Name: 0 100 200 300 400 500 600 700 800 900 c. 0 102030405060708090 SKIP TO Q 16.14 0 1 2 3 4 5 6 7 8 9

Name: 14) Hypertension 0 1000 2000 3000 4000 5000 6000 7000 8000 9000 a. medications 0 100 200 300 400 500 600 700 800 900 SKIP TO Q 16.15 0 102030405060708090 0 1 2 3 4 5 6 7 8 9

Name: 0 1000 2000 3000 4000 5000 6000 7000 8000 9000 b. 0 100 200 300 400 500 600 700 800 900 SKIP TO Q 16.15 0 102030405060708090 0 1 2 3 4 5 6 7 8 9

Name: 0 1000 2000 3000 4000 5000 6000 7000 8000 9000 c. 0 100 200 300 400 500 600 700 800 900 SKIP TO Q 16.15 0 102030405060708090 0 1 2 3 4 5 6 7 8 9

Name: 0 1000 2000 3000 4000 5000 6000 7000 8000 9000 d. 0 100 200 300 400 500 600 700 800 900 SKIP TO Q 16.15 0 102030405060708090 0 1 2 3 4 5 6 7 8 9

Name: 0 1000 2000 3000 4000 5000 6000 7000 8000 9000 e. 0 100 200 300 400 500 600 700 800 900 SKIP TO Q 16.15 0 102030405060708090 0 1 2 3 4 5 6 7 8 9 Page 14 3/8” spine perf 5 Medications 15) Continued 16. 16) 17) Other eaii medications Hepatitis diabetes used for b. h. g. d. a. e. c. f. ASK EACHITEMUNTILFIRST“NO” IF “NO”TO a a. b. c. b. a. TO OTHERDRUG(ITEM17a) 0 900 800 700 600 102030405060708090 500 0 400 300 200 100 0 0 900 800 700 600 102030405060708090 500 0 400 300 200 100 0 0 0 0 0 0 0 0 0 900 800 700 600 500 400 300 200 100 0 0 900 800 700 600 102030405060708090 500 0 400 300 200 100 0 0 900 800 700 600 102030405060708090 500 0 400 300 200 100 0 0 900 800 700 600 102030405060708090 500 0 400 300 200 100 0 0 900 800 700 600 102030405060708090 500 0 400 300 200 100 0 0 900 800 700 600 102030405060708090 500 0 400 300 200 100 0 0 900 800 700 600 102030405060708090 500 0 400 300 200 100 0 0 900 800 700 600 102030405060708090 500 0 400 300 200 100 0 0 900 800 700 600 102030405060708090 500 0 400 300 200 100 0 0 900 800 700 600 102030405060708090 500 0 400 300 200 100 0 0 900 800 700 600 102030405060708090 500 0 400 300 200 100 0 0 1020304050607080900 GOTO NEXTITEM 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 4 4 4 5 5 5 5 5 5 5 5 5 5 5 5 5 6 6 6 6 6 6 6 6 6 6 6 6 6 7 7 7 7 7 7 7 7 7 7 7 7 7 8 8 8 8 8 8 8 8 8 8 8 8 8 Page 15 9 9 9 9 9 9 9 9 9 9 9 9 9 Have you(taken/used)any a [in (MONTH,YEAR)]? since yourlastvisit SKIP TO SKIP TO SKIP TO SKIP TO SKIP TO SKIP TO SKIP TO SKIP TO SKIP TO SKIP TO SKIP TO SKIP TO SKIP TO Q 16.17 Q 16.17 Q 16.16 Q 16.16 Q 16.16 Q 17.A Q 17.A Q 17.A Q 17.A Q 17.A Q 17.A Q 17.A Q 17.A OYSN YES NO YES NO How about(EACH)? Used for: Name: Used for: Name: Used for: Name: Used for: Name: Used for: Name: Used for: Name: Used for: Name: Used for: Name: Name: Name: Name: Name: Name: what didyoutakethisdrugfor? (KIND OFDRUG)youtookand b what wasthenameof When specified, ASPIRIN:in thelastweek)? taken/used anyinthe c past 5days(FOR Have you 3/8” spine perf 9 9M 8 8M 7 7M 6 6M 5 5M 4 4M SERIAL # 3 3M 2 2M 1 1M 0 0 100 200 300 4000 500 102030405060708090 600 700 800 900 0 NO YES NO YES Page 16 Yes Specify: SKIP TO Q 18.A9 TO SKIP SKIP TO Q 18 TO SKIP Yes did you have (Blue Cross, CIGNA, etc.) (not as a HMO) (Blue Cross, CIGNA, etc.) (not as a HMO) Administration veterans military personnel or survivors of disabled Date started trial Name of hospital or clinic Name of hospital or clinic Address City State Specify: No - Yes Yes No No No 9)Assistance Program) (AIDS Drug ADAP 1) Coverage by an HMO 2) Private insurance through a group 3) Individual private insurance 4)Assistance Medicaid, Medi-Cal, or Medical 5) permanently disabled) Medicare (for people over 65 or 6) Veteran’s Armed Forces or Health care benefits for The 7) medical insurance for dependents of CHAMPUS or CHAMP-VA, 8) Other IF NO TO Q 18.A AND Q 18.B, THEN SKIP TO Q 22 TO AND Q 18.B, THEN SKIP Q 18.A IF NO TO medications? such as HMO coverage, Blue Cross, or Medicare? such as HMO coverage, Blue Cross, B. for any of your Do you have insurance coverage that pays B. of the trial? you know the name Do C. this trial? did you go for Where 19. Are you currently insured? I would now like to ask you about your medical coverage. I would now like 18.A.YEAR)], have you had any medical coverage, last visit [in (MONTH, Since your 17.A.a trial? HIV in against a vaccine been given have you YEAR)], (MONTH, visit [in your last Since

20. Since your last visit [in (MONTH, YEAR)], have you lost health insurance coverage or been denied health insurance for poor health? No SKIP TO Q 22 Yes

21. What condition caused you to lose or be denied health insurance? HIV infection Other

22. Did you have any type of dental insurance coverage at any time since your last visit [in (MONTH, YEAR)]? No Yes

23. Where do you usually go for medical care, even if you haven’t received medical care since your last visit [in (MONTH, YEAR)]? [READ ALL CHOICES AND SELECT ONLY ONE] HMO Doctor’s office or specialty clinic (non-HMO) including Urgent Care Any other clinic Emergency room Other outpatient Specify:

No regular source of medical care Don’t know perf

3/8” spine 24. Since your last visit [in (MONTH, YEAR)], have you gone to ANY of the following sources for your outpatient medical care? (ASK FOR EACH ITEM) (This does not include dental health care, mental health care, home health care, clinical trials or other research studies, including MACS.) [SHOW CARD WITH EXAMPLES OF EACH CATEGORY.]

a b Have you used (EACH) since How many times? (99 = 99 or more) your last visit [in SERVICE (MONTH, YEAR)]? NO YES GO TO 0 102030405060708090 1) HMO NEXT ROW 0 1 2 3 4 5 6 7 8 9

NO YES 2) Doctor’s office or specialty clinic GO TO 0 102030405060708090 (non-HMO) including Urgent Care NEXT ROW 0 1 2 3 4 5 6 7 8 9

NO YES GO TO 0 102030405060708090 3) Any other clinic NEXT ROW 0 1 2 3 4 5 6 7 8 9

NO YES GO TO 0 102030405060708090 4) Emergency room NEXT ROW 0 1 2 3 4 5 6 7 8 9

NO YES GO TO 0 102030405060708090 5) Other outpatient service Q 25 (Specify below) 0 1 2 3 4 5 6 7 8 9

Specify:

Page 17 3/8” spine perf SERIAL # 9 9 9 9 8 8 8 8 7 7 7 7 6 6 6 6 5 5 5 5 4 4 4 4 3 3 3 3 Page 18 2 2 2 2 1 1 1 1 (99 = 99 or more) (99 = 99 or How many times? How many 0 102030405060708090 0 0 102030405060708090 0 0 102030405060708090 0 0 102030405060708090 0 Q 26 GO TO GO TO GO TO GO TO used NO YES NO YES NO YES NO YES NEXT ROW NEXT ROW NEXT ROW ab (EACH) YEAR)]? (MONTH, Have you since your last visit [in SERVICE (such as dentist hygienist) (psychologist, other therapist/ (chiropractor, nutritionist, acupuncturist, herbalist, masseuse) health care in ing nurse services, home health aides, but not family or friends) care provider or dental care provider psychiatrist, social worker, counselor) care provider your home (visit- care from lovers, 1) Dental health 2) health Mental 3) health Other 4) form of paid Any 25.services? or providers the following of ANY used you YEAR)], have (MONTH, last visit [in your Since 3/8” spine perf .IFYES B. 7A Was thereatime since yourlastvisit[in 27.A. PleaseestimatetheTOTAL 26. 8 Was thereatimesinceyourlast visit 28. )PrescriptionMedications 3) Dentalcare 2) Medicalcare 1) $ “0” IFLESSTHAN$1] YEAR)]. medications sinceyourlastvisit[in(MONTH, (your lover, familyorfriends)paidforprescription expenses thatyouorotherpersonalsources needed? prescription medicationsthatyouthought or dentalcare,didnotobtain medical care, (MONTH, YEAR)] whenyoudidnotseek [obtain] (READEACH)youthoughtneeded? (MONTH, YEAR)] from adoctororothermedicalprovider? [READ EACH AND MARK ALL THAT APPLY] [READ EACH AND MARK ALL THAT APPLY] [READ EACH AND MARK ALL THAT APPLY] Yes No Yes No Yes No Yes No Yes No Specify: Specify: Specify: , [ROUND TONEARESTDOLLAR,CODE Other non-financialreasons Financial reasons Other non-financialreasons Financial reasons Other non-financialreasons Financial reasons 0 900 800 700 600 102030405060708090 500 0 400 300 200 100 0 0 0 : Was thereatimethatyoudidnotseek 0 0 0 0 0 0 0 0 90M 80M 70M 60M 50M 40M 30M 20M 10M M2 M4 M6 M8 9M 8M 7M 6M 5M 4M 3M 2M 1M 1 2 Why didyounotseekdentalcare? Why didyounotseekmedicalcare? prescription medications? Why didyounotobtain 3 SKIP TO Q28 SKIP TO Q28 SKIP TO (3) SKIP TO (2) when youwererefusedcare 4 5 6 out-of-pocket 7 8 9 OR [in Refused Don’t know Page 19 0A IsthereanythingmorethatIhaven’tasked 30.A. 3 Homevisit? 33. Telephone interview? 32. 1 ACASIinterview? 31. .Tell meaboutit. B. 9 Was thereatimesinceyourlastvisit 29. RECORD FULLY INR’s OWNWORDS. you thinkweshouldknow? (MONTH, YEAR)] dental care? Yes No Yes No, nothingmore Yes No Yes No Yes No when youwererefused THANK PARTICIPANT AND SKIP TO Q31 [in 3/8” spine perf NO YES SERIAL # SKIP TO Q 39 TO SKIP SKIP TO Q 40 TO SKIP [SHOW CARD TO PARTICIPANT OR TO PARTICIPANT [SHOW CARD ACASI begins here. here. begins ACASI : ASK: What were the reasons? : : Is the difficulty less, the same or greater Specify: No Yes Less than $10,000 10,000–19,999 20,000–29,999 30,000–39,999 40,000–49,999 50,000–59,999 60,000 or more Does not wish to answer No Yes Less Same Greater 2) HIV status became known to employer 3) HIV status became known to coworkers 4) Early retirement 5) Changed job as a personal decision 6) receive better health insurance benefits To 7) receive better disability benefits To 8) Other 1) Became too sick to work (READ EACH ITEM) employment status changed for any reason employment status changed for any related to HIV disease? IF YES describes your annual individual gross income your annual individual describes before taxes? READ ALOUD.] than at your last visit [in (MONTH, YEAR)]? than at your last visit [in (MONTH, meeting your basic expenses? IF YES 39.YEAR)], has your Since your last visit [in (MONTH, 37. categories which of the following At present, 38. difficulty Are you experiencing major financial Page 20 9 8 7 6 5 4 3 2 PM AM 0 1 2 3 4 5 6 7 8 9 1 0 0 100 200 300 4000 500 102030405060708090 600 700 800 900 0 10 20 30 40 50 INTERVIEWER’S NUMBER INTERVIEWER’S 0 1 2 3 4 5 6 7 8 9 HR MIN Interviewer’s signature Date interview completed TIME ENDED 0 10 35. 36. 34.

I am going to ask you a series of questions about specific behaviors, including cigarette smoking, alcohol use, sexual behavior, and recreational drug use.

40. Now I have some questions about cigarette smoking. F. How often during the past 6 months have you A. Have you ever smoked cigarettes? needed a first drink in the morning to get yourself No SKIP TO Q 41 going after a heavy drinking session? Yes Never Monthly Daily or almost daily B. Do you smoke cigarettes now? Less than monthly Weekly (As of one month ago?) No SKIP TO Q 41 G. How often during the past 6 months have you had a feeling of guilt or remorse after drinking? Yes Occasionally (less than one cigarette per day) Never Monthly Daily or SKIP TO Q 41 Less than monthly Weekly almost daily

C. How many packs do you usually smoke per day? H. How often during the past 6 months have you Less than 1/2 pack been unable to remember what happened the At least 1/2 pack; but less than one pack per day night before because you had been drinking? At least 1 but less than 2 packs Never Monthly Daily or 2 or more packs per day Less than monthly Weekly almost daily

41. The next set of questions are about alcoholic I. Have you or someone else been injured as a beverages. They may seem similar, but they are asked result of your drinking? in a slightly different way. No Please answer each of the following questions for the Yes, but not in the past 6 months past 6 months. Yes, during the past 6 months J. Has a relative or friend, or doctor or other A. How often have you had drinks containing health worker been concerned about your alcohol? drinking or suggested that you cut down? Never STOP – SKIP TO Q 41K No Less than monthly Weekly Yes, but not in the past 6 months Monthly Daily or almost daily Yes, during the past 6 months perf

3/8” spine K. Since your last visit [in (MONTH, YEAR)], have you B. During the past 6 months, how many drinks been in an alcohol treatment program, including containing alcohol have you had on a typical day inpatient and/or outpatient detox, alcoholics when you are drinking? (A “drink” is defined as anonymous, and/or any other program? one 12-ounce beer, one 5-ounce glass of wine, or one mixed drink with 1 and 1/2 ounces of 80-proof No Yes hard liquor.) 1 or 2 5 or 6 10 or more READ DEFINITION OF SEXUAL ACTIVITY: 3 or 4 7 to 9 None SEXUAL ACTIVITY includes oral sex, anal/butt sex, C. During the past 6 months, how often have you vaginal sex, and any touching of genital or anal had six or more drinks on one occasion? (A areas, with or without ejaculation. This definition “drink” is defined as one 12-ounce beer, one includes deep kissing. 5-ounce glass of wine, or one mixed drink with 1 and 1/2 ounces of 80-proof hard liquor.) Never Monthly Daily or 42. Have you engaged in any sort of sexual activities Less than monthly Weekly almost daily involving another person since your last visit [in (MONTH, YEAR)]?

D. How often during the past 6 months have you No SKIP TO Q 49 found that you were not able to stop drinking Yes once you started? Never Monthly Daily or Less than monthly Weekly almost daily 43. Have you had any sexual activity with a woman since your last visit [in (MONTH, YEAR)]?

E. How often during the past 6 months have you No SKIP TO Q 46 failed to do what was normally expected from you Yes because of drinking? Never Monthly Daily or Less than monthly Weekly almost daily GO TO QUESTION 44 ON NEXT PAGE.

Page 21 3/8” spine perf ? 9 9 9 9 9 9 8 8 8 8 8 8 7 7 7 7 7 7 6 6 6 6 6 6 5 5 5 5 5 5 4 4 4 4 4 4 3 3 3 3 3 3 SERIAL # 2 2 2 2 2 2 since your last since your 1 1 1 1 1 1 0 100 200 300 4000 500 102030405060708090 600 700 800 900 0 0 100 200 300 4000 500 102030405060708090 600 700 800 900 0 0 100 200 300 4000 500 102030405060708090 600 700 800 900 0 0 100 200 300 4000 500 102030405060708090 600 700 800 900 0 0 100 200 300 4000 500 102030405060708090 600 700 800 900 0 0 100 200 300 4000 500 102030405060708090 600 700 800 900 0 What’s your best estimate?) What’s b How many women did you do that with How many women did since your last visit [in (MONTH, YEAR)]? since your last visit (Give me the actual number) (IF NEEDED: (Give me the actual since your last visit [in (MONTH, YEAR)] (MONTH, visit [in your last since include intercourse include intercourse 9 9 8 8 7 7 NO YES NO YES NO YES NO YES NO YES NO YES Did you do 6 6 a (MONTH, YEAR)]? this/engage in this 5 5 activity with a woman since your last visit [in 4 4 Page 22 3 3 2 2 1 1 0 100 200 300 4000 500 102030405060708090 600 700 800 900 0 0 100 200 300 4000 500 102030405060708090 600 700 800 900 0 time for vaginal time you had oral IF NO INTERCOURSE WITH WOMEN, SKIP TO Q 45.10 TO WITH WOMEN, SKIP IF NO INTERCOURSE ? time for vaginal sex, even if it time for oral sex, even if it KIND OF ACTIVITY KIND OF The next questions are about different kinds of sexual activity men have with women. are about different kinds of sexual The next questions sex, even if it broke, tore, or slipped? sex even if it broke, tore, or slipped? IF MULTIPLE PARTNERS: IF MULTIPLE condom every IF MULTIPLE PARTNERS: IF MULTIPLE condom every broke, tore, or slipped? IF ONE PARTNER: Did you use a condom every broke, tore, or slipped? IF ONE PARTNER: Did you use a condom every IF NONE, SKIP TO ITEM (7). TO IF NONE, SKIP IF NONE, SKIP TO ITEM (4). TO IF NONE, SKIP visit [in (MONTH, YEAR)] visit [in (MONTH, PARTNERS: IF MULTIPLE in her vagina when you did not use a condom (or when a condom failed)? IF ONE PARTNER: Did you ejaculate/cum in her vagina when you did not use a condom (or when a condom failed)? Here we define sexual intercourse as inserting your penis into your partner’s mouth, vagina, or anus/butt, with or without or anus/butt, partner’s mouth, vagina, penis into your as inserting your sexual intercourse Here we define ejaculation. IF MULTIPLE PARTNERS: IF MULTIPLE (or her mouth when you did not use a condom when a condom failed)? IF ONE PARTNER: you did Did you ejaculate/cum in her mouth when failed)? not use a condom (or when a condom IF ONLY ONE PARTNER: USE COLUMN a. ONE PARTNER: IF ONLY USE COLUMN b. PARTNERS: IF MULTIPLE B. not have you had sexual activity that did how many (other) women With A. with intercourse had sexual have you (if any) women many different How 5) how many of those women did you use a With 2)you use a how many of those women did With 4) put your penis in her vagina (vaginal sex). You 1) put your penis in her mouth (oral sex). You 6) how many women did you ejaculate/cum With 3) in how many women did you ejaculate/cum With 44. YEAR)]. [in (MONTH, last visit your with since activity had sexual you have women different how many talk about Now lets 45. 3/8” spine perf 45. Continued 6 Haveyouhadanysortofsexualactivitywithamansinceyourlastvisit[in(MONTH, YEAR)]? 46. 7 Nowletstalkabouthowmanydifferentmenyouhavehadsexualactivitywithsinceyourlastvisit[in(MONTH, YEAR)]. 47. 0 You usedyourtonguetotouchorlickher 10) 1 You usedyourtonguetotouchorlickher 11) )With howmanywomendidyouejaculate/cum 9) )You putyourpenisinheranus/butt(analsex). 7) )With howmanyofthosewomendidyouusea 8) IF MULTIPLE PARTNERS: USECOLUMNb. IF ONLY ONEPARTNER: USECOLUMNa. .Howmanydifferentmen(ifany)haveyouhadsexualintercoursewith A. .With howmany(other)menhaveyouhadsexualactivitythatdidnot B. anus/butt (“rimming”). failed)? you didnotuseacondom(orwhen Did youejaculate/cuminheranus/buttwhen IF ONEPARTNER: condom (orwhenafailed)? in heranus/buttwhenyoudidnotusea IF MULTIPLE PARTNERS: genitals (vagina,clitoris). IF NONE,SKIP TO ITEM(10). Did youuseacondomevery IF ONEPARTNER: broke, tore,orslipped? condom every IF MULTIPLE PARTNERS: even ifitbroke,tore,orslipped? Yes No YEAR)] anus/butt—or yourpartnerputhispenisinmouthoranus/butt,withwithoutejaculation. your lastvisit[in(MONTH, YEAR)] ? Herewedefinesexualintercourseasfollows:youputyourpenisinpartner’smouthor SKIP TO Q49 KIND OF ACTIVITY timeforanalsex,evenifit timeforanalsex, 0 900 800 700 600 102030405060708090 500 0 400 300 200 100 0 0 900 800 700 600 102030405060708090 500 0 400 300 200 100 0 ? 1 1 2 2 3 3 4 4 5 5 Page 23 since yourlastvisit[in activity withawoman 6 6 this/engage inthis (MONTH, YEAR)]? a 7 7 Did youdo OYES NO YES NO YES NO OYES NO OYES NO 8 8 9 9 includeintercourse since yourlastvisit[in(MONTH, (Give metheactualnumber)(IFNEEDED: since yourlastvisit[in(MONTH,YEAR)]? How manywomendidyoudothatwith b What’s yourbestestimate?) 0 900 800 700 600 102030405060708090 500 0 400 300 200 100 0 0 900 800 700 600 102030405060708090 500 0 400 300 200 100 0 0 900 800 700 600 102030405060708090 500 0 400 300 200 100 0 0 900 800 700 600 102030405060708090 500 0 400 300 200 100 0 0 900 800 700 600 102030405060708090 500 0 400 300 200 100 0 1 1 1 1 1 since 2 2 2 2 2 3 3 3 3 3 4 4 4 4 4 5 5 5 5 5 6 6 6 6 6 7 7 7 7 7 8 8 8 8 8 9 9 9 9 9 3/8” spine perf 9 9 9 9 9 9 8 8 8 8 8 8 7 7 7 7 7 7 6 6 6 6 6 6 5 5 5 5 5 5 4 4 4 4 4 4 NOT SURE DON’T KNOW/ 3 3 3 3 3 3 SERIAL # 2 2 2 2 2 2 1 1 1 1 1 1 0 100 200 300 4000 500 102030405060708090 600 700 800 900 0 0 100 200 300 4000 500 102030405060708090 600 700 800 900 0 0 100 200 300 4000 500 102030405060708090 600 700 800 900 0 0 100 200 300 4000 500 102030405060708090 600 700 800 900 0 0 100 200 300 4000 500 102030405060708090 600 700 800 900 0 0 100 200 300 4000 500 102030405060708090 600 700 800 900 0 NO YES since your last visit [in (MONTH, since your 5b.1) 5b.2) 5b.3) b How many men did you do that with men did you do that How many NEEDED: What’s your best estimate?) your What’s NEEDED: YEAR)]? (Give me the actual number) (IF me the actual number) YEAR)]? (Give NOT SURE DON’T KNOW/ NO YES NO YES NO YES NO YES NO YES NO YES Did you do NEG. POS. a (MONTH, YEAR)]? this/engage in this this/engage activity with a man activity with since your last visit [in since your Page 24

time, time, even IF NO INTERCOURSE WITH MEN, SKIP TO Q 48.13 TO MEN, SKIP WITH INTERCOURSE IF NO time, even if it broke, tore, very time, even if it broke, tore, or time, even if it broke, KIND OF ACTIVITY KIND OF very you did not use a condom? these men? IF NONE, SKIP TO ITEM (4). ITEM TO IF NONE, SKIP IF MULTIPLE PARTNERS: IF MULTIPLE his anus/butt when you did not use a condom (or when a condom failed)? IF ONE PARTNER: you did not use a condom (or when a condom failed)? IF MULTIPLE PARTNERS: IF MULTIPLE men did you use a mouth, with how many condom e PARTNERS: IF MULTIPLE condom their mouths when you did not use a (or when a condom failed)? IF ONE PARTNER: you Did you ejaculate/cum in his mouth when did not use a condom (or when a condom failed)? PARTNERS: IF MULTIPLE did you their anus/butt, with how many men use a condom e or slipped? IF ONE PARTNER: anus/butt, did you use a condom every even if it broke, tore, or slipped? slipped? IF ONE PARTNER: you put your penis in his Thinking of the times a condom every mouth, did you use slipped? if it broke, tore, or IF NONE, SKIP TO ITEM (7). TO IF NONE, SKIP The next questions are about different kinds of sexual activity some men engage in with other men. other in with engage some men activity of sexual kinds different about are next questions The IF ONLY ONE PARTNER: USE COLUMN a. COLUMN USE PARTNER: ONE IF ONLY b. USE COLUMN PARTNERS: IF MULTIPLE 1) put your penis in his mouth. You 2) times you put your penis in his Thinking of the 3) in how many men did you ejaculate/cum With 4) put your penis in his anus/butt. You 6a.) Did you ejaculate/cum in his anus/butt when 5a.) Thinking of the times you put your penis in his 6b.) how many men did you ejaculate/cum in With 5b.) Thinking of the times you put your penis in If 5a = No, 5a.1) What was the HIV status of your partner when For those men with whom you did not use a condom, For those men with whom you did not any of these men HIV positive? 5b.1) Were any of these men HIV negative? 5b.2) Were If 5b.1 or 5b.2 = Don’t Know/Not Sure, skip to 6b. you unsure of the HIV status of any of 5b.3) Were If any unprotected anal sex (Q5b < Q4) then read: If any unprotected anal sex (Q5b < Q4) 48.

48. Continued IF ONLY ONE PARTNER: USE COLUMN a. a Did you do b this/engage in this How many men did you do that with IF MULTIPLE PARTNERS: USE COLUMN b. activity with a man since your last visit [in (MONTH, YEAR)]? since your last visit (Give me the actual number) (IF NEEDED: KIND OF ACTIVITY [in (MONTH, YEAR)]? What’s your best estimate?)

NO YES 0 100 200 300 400 500 600 700 800 900 7) He put his penis in your mouth. 0 102030405060708090 IF NONE, SKIP TO ITEM (10). 0 1 2 3 4 5 6 7 8 9

IF MULTIPLE PARTNERS: 0 100 200 300 400 500 600 700 800 900 8) Thinking of the times when a man put his penis 0 102030405060708090 in your mouth, with how many men was a 0 1 2 3 4 5 6 7 8 9 condom used every time, even if it broke, tore, or slipped? IF ONE PARTNER: NO YES Thinking of the times when he put his penis in your mouth, was a condom used every time, even if it broke, tore, or slipped?

IF MULTIPLE PARTNERS: 0 100 200 300 400 500 600 700 800 900 9) With how many men did ejaculate/cum go into 0 102030405060708090 your mouth when they did not use a condom 0 1 2 3 4 5 6 7 8 9 (or when a condom failed)?

IF ONE PARTNER: NO YES Did ejaculate/cum go into your mouth when he did not use a condom (or when a condom failed)?

NO YES 0 100 200 300 400 500 600 700 800 900 10) He put his penis in your anus/butt. 0 102030405060708090 IF NONE, SKIP TO ITEM (13). 0 1 2 3 4 5 6 7 8 9 perf 3/8” spine IF MULTIPLE PARTNERS: 0 100 200 300 400 500 600 700 800 900 11b.) Thinking of the times when a man put his penis 0 102030405060708090 in your anus/butt, with how many men was a condom used every time, even if it broke, tore, 0 1 2 3 4 5 6 7 8 9 or slipped? DON’T KNOW/ If any unprotected anal sex (Q11b < Q10) then read: NOT Of the men who did not use a condom, NO YES SURE 11b.1) Were any of these men HIV positive? 11b.1) 11b.2) Were any of these men HIV negative? 11b.2) If 11b.1 or 11b.2 = Don’t Know/Not Sure, skip to 12b. 11b.3) Were you unsure of the HIV status of any of 11b.3) these men?

IF ONE PARTNER:

11a.) Thinking of the times when he put his penis in NO YES your anus/butt, was a condom used every time, even if it broke, tore, or slipped?

DON’T If 11a = No, KNOW/ NOT 11a.1) What was the HIV status of your partner when NEG. POS. SURE he did not use a condom?

IF MULTIPLE PARTNERS: 0 100 200 300 400 500 600 700 800 900 12b.) With how many men did ejaculate/cum go into your anus/butt when they did not use a 0 102030405060708090 condom (or when a condom failed)? 0 1 2 3 4 5 6 7 8 9 IF ONE PARTNER: 12a.) Did ejaculate/cum go into your anus/butt when he did not use a condom (or when a NO YES condom failed)?

Page 25 3/8” spine perf 9 8 7 6 5 YES 4 3 SERIAL # 2 NO 1 0 100 200 300 4000 500 102030405060708090 600 700 800 900 0 What’s your best estimate?) What’s How many men did you do that with did you do men How many b since your last visit [in (MONTH, YEAR)]? last visit [in (MONTH, since your (Give me the actual number) (IF NEEDED: actual number) (IF (Give me the NO YES Did you do Did you a this/engage in this this/engage activity with a man activity with since your last visit since your [in (MONTH, YEAR)]? [in (MONTH, Page 26 SKIP Q 48.14 and continue with Q 48.15. SKIP SKIP TO Q 49 TO SKIP SKIP TO Q 48.18 TO SKIP Q 48.18 TO SKIP KIND OF ACTIVITY KIND OF met any new partners to engage in any type of sexual activity since your last visit [in (MONTH, YEAR)]? last visit [in (MONTH, met any new partners to engage in any type of sexual activity since your SKIP TO Q 48.18 TO SKIP Man Woman Negative Positive I don’t know No Yes Main partner or someone you have a longstanding relationship with, live with, or partner with you have a longstanding relationship with, Main partner or someone a longstanding, or person with whom you have not developed partner, one-time Casual partner, close relationship with No Yes No Yes a) on the internet b) at a party (including a circuit party) c) through an advertisement in a newspaper or other newsletter d) at a bar e) at a bath house f)or other outdoor public place in a park g) in a bathroom, bookstore, or other indoor public place h) at a place where drugs were used or exchanged i) other place not listed above ave you consider relationship with, of these persons to be a main partner or someone you have a longstanding only one live with, or partner with? You mentioned that you had sex with more than one person since your last visit [in (MONTH, YEAR)]. Would you YEAR)]. Would you had sex with more than one person since your last visit [in (MONTH, mentioned that You How would you describe this individual? How would you describe Some men meet new sexual partners through different sources and in different settings. Since your last Some men meet new sexual partners through different sources and in different of the following YEAR)], have you met one or more new male sexual partners in any MACS visit [in (MONTH, settings? Was your main partner a man or a woman? Was anus/butt (“rimming”). anus/butt (“rimming”). A. IF ONLY ONE PARTNER: USE COLUMN a. COLUMN USE PARTNER: ONE IF ONLY b. USE COLUMN PARTNERS: IF MULTIPLE 48.18) H 48.16) partner in the last 6 months? Did you have unprotected intercourse (anal or vaginal) with your main 48.17) What is the HIV status of your main partner? 48.14)YEAR)]. since your last visit [in (MONTH, sexual activity) with only one person said you had (intercourse or You 48.15) If the participant had a total of only one sex partner (male or female) since the last visit (Male Q 47.A + 47.B = 1, or Q 47.A or female) since the last visit (Male a total of only one sex partner (male If the participant had Female Q 44.A + 44.B = 1), ask question 48.14. If the participant had more than one sex partner since the last visit, the participant had more than one + 44.B = 1), ask question 48.14. If Female Q 44.A 13) touch or lick his your tongue to used You 48. Continued 48.19) 3/8” spine perf 9 Now let’s talkaboutotherdrugsyoumayhaveused. As Ireadeachone,pleasetellmewhetheryouusedit 49. even oncesinceyourlastvisit[in(MONTH, YEAR)]? Other kindsofstreet/clubdrugs Ecstasy, XTC,XorMDMA Speed, MethorIce Other formsofcocaine Crack orcocainethatyousmoke “Poppers” likenitriteinhalants(amyl,butyl Pot, MarijuanaorHash (Show listofperformanceenhancingdrugsto Sexual performanceenhancingdrugsother Speedball (heroinandcocainetogether) Heroin or isopropylnitrites) prompt andassistwithrecall.) for adiagnosederectiledysfunction than thoseprescribedbyamedicalprovider Specify: Specify: Specify: Specify: Specify: Specify: 0 0 0 0 0 0 1 1 1 1 1 1 2 2 2 2 2 2 3 3 3 3 3 3 4 4 4 4 4 4 5 5 5 5 5 5 6 6 6 6 6 6 7 7 7 7 7 7 Page 27 visit [in(MONTH, (EACH) Haveyou (taken/used) any since yourlast ab 8 8 8 8 8 8 NEXT ROW NEXT ROW NEXT ROW NEXT ROW NEXT ROW NEXT ROW NEXT ROW NEXT ROW NEXT ROW GO TO GO TO GO TO GO TO GO TO GO TO GO TO GO TO GO TO GO TO Q 50 How about OYES NO YES NO YES NO YES NO YES NO YES NO OYES NO OYES NO YES NO OYES NO YEAR)]? 9 9 9 9 9 9 AL EKYMONTHLY WEEKLY DAILY since yourlastvisit[in How oftendidyou (use/take) (DRUG) (MONTH, YEAR)]? OFTEN LESS 3/8” spine perf 9 9 90 90 8 8 80 80 7 7 70 70 6 6 60 60 SERIAL # 5 5 50 50 4 4 40 40 3 3 30 30 SKIP TO Q 54 TO SKIP SKIP TO Q 56 TO SKIP 2 2 20 20 1 1 10 10 0 0 0 0 No Yes Never Less than half the time About half the time Most of the time Always Less than half the time Half the time Most of the time Always No Yes No Yes No Yes often did you clean your works with bleach? often did you clean you been in a drug treatment program, including inpatient and/or outpatient detox, methadone maintenance programs, halfway houses, narcotics anonymous, prison or jail-based programs and/or any other program? participated in a needle exchange program? participated in a needle exchange program? you get them from a needle exchange? you shared water to rinse your needles with your needles to rinse water you shared anyone? Interviewer Instructions: Thank the participant. Record the time ended on page 20. B. many times? How C. different people? how many With B. Of the times you obtained needles, how often did C. Do you have another source of clean needles? 54.YEAR)], how your last visit [in (MONTH, Since 56.YEAR)], have Since your last visit [in (MONTH, 55.A.YEAR)], have you visit [in (MONTH, Since your last 53.A. have YEAR)], visit [in (MONTH, last Since your Page 28 9 9 9 9 9 9 90 90 90 90 90 90 8 8 8 8 8 8 80 80 80 80 80 80 7 7 7 7 7 7 70 70 70 70 70 70 6 6 6 6 6 6 60 60 60 60 60 60 5 5 5 5 5 5 50 50 50 50 50 50 4 4 4 4 4 4 40 40 40 40 40 40 3 3 3 3 3 3 30 30 30 30 30 30 SKIP TO Q 53 TO SKIP SKIP TO Q 56 TO SKIP 2 2 2 2 2 2 20 20 20 20 20 20 1 1 1 1 1 1 10 10 10 10 10 10 0 0 0 0 0 0 0 0 0 0 0 0 No Yes No Yes No Yes No Yes Speed by itself Speedball (cocaine and heroin together) Speedball (cocaine and heroin together) Cocaine by itself Heroin by itself you shared a needle or works with anyone? By you shared a needle or works with anyone? works I mean needles, syringes and/or a cooker? many times have you used needles or works that were first used by someone else and then passed to you? most, how many times did you inject [DRUG] per most, how many times month? recreational drugs in a shooting gallery? drugs in a shooting recreational you injected recreational drugs (skin popped, drugs recreational you injected needle)? up with a shot B. how many different people? With C. inject drugs? Do you currently D. the period when you injected the Thinking about B. that you injected any of these times Were 51.YEAR)], have (MONTH, Since your last visit [in 52.A.YEAR)], how Since your last visit [in (MONTH, 50.A. have YEAR)], [in (MONTH, your last visit Since