Date: ______Client ID: ______

PIPWE Questionnaire - Pre

A. Background information

1. Age: Circle the answer that describes your age

15-19 20-24 25-29 30-34 35-39 40-44 45-5455+

2. Race/Ethnicity: Circle all the answers that you think best describe your background

Black Hispanic Native American White Asian Other:______

3. Education: Circle the last schooling you completed.

Elementary School

Middle School

High School / GED

Some college, technical, or vocational school

Bachelor’s degree or more

B. Please circle Yes or No to answer the questions below.

1. Have you ever used a needle to use drugs?YesNo

2. Do you have sex with men?YesNo

3. Do you have a job?YesNo

4. Have you been in jail or prison?YesNo

5. Have you ever traded sex for money, shelter, or drugs? YesNo

6. Have you been tested for HIV?YesNo Not sure

7. Did you get the results from the HIV test? YesNo

8. If you have been tested and did not get your HIV test results, why not? ______

______

______

C. Please write a number in the blank to answer the questions below. (If you are in jail or a residential program, think about the last 4 weeks before you entered the system.)

  1. How old were you the first time you used an illegal drug? ______
  1. How many times have you had vaginal or anal sex without using a condom in the last 4 weeks? ______
  1. How many partners have you had unprotected vaginal or anal sex with in the last 4 weeks? ______

______

D. Please circle your best response to the questions below.

The last time you had vaginal or anal sex without a condom, why did you not use one?

(Circle all answers that were true for you)

PIPWE Pre Questionnaire9 30 2012

Date: ______Client ID: ______

  1. He was my husband / boyfriend / steady partner and I trust him.
  2. I don’t know how to bring up using condoms.
  3. He won’t use a condom.
  4. It feels better to me without a condom.
  5. We were both tested not long ago and we are negative for HIV.
  1. I didn’t have a condom.
  2. I was afraid he would get mad.
  3. We reduced our risk by having oral sex, masturbating each other, or doing something else that was not as likely as anal or vaginal sex to pass the virus.
  4. I make more money if I have sex without a condom.
  5. Other reason(s) ______

PIPWE Pre Questionnaire9 30 2012

Date: ______Client ID: ______

______

E. Please circle your best response to the question below.

Thinking about your sexual activity and drug use, what are your chances for getting HIV?

(Circle one)

PIPWE Pre Questionnaire9 30 2012

Date: ______Client ID: ______

No chance

at all

A very small chance

I may or may

not get HIV

I will probably

get HIV

PIPWE Pre Questionnaire9 30 2012

Date: ______Client ID: ______

______

F. Please circle all of the correct answers for each question. There may be more than one correct answer.

1. How does the virus spread from one person to another? (Circle all correct answers).

  1. Unprotected sex with a person who has HIV.
  2. Using a toilet after a person with HIV.
  3. Sharing a needle with a person who has HIV.

2. Which of the following lubricants can be used safely with latex condoms? (Circle all correct answers).

  1. Oil-based lubes, like Vaseline or baby oil.
  2. Water-based lubes, like KY or Astroglide.
  3. No lubes can be used with latex condoms.

3. You are less likely to get HIV if you do which of these? (Circle all correct answers).

  1. Use birth control pills.
  2. Wash well or douche after sex.
  3. Use latex condoms.
  4. Make sure your partners are HIV negative.
  5. Have unprotected sex with fewer partners.

4. How would you know for sure if your partner doesn’t have HIV? (Circle all correct answers).

  1. He looks healthy.
  2. He told me he is clean.
  3. I saw his test results.
  4. I trust him.

5. Pick the assertive answer that tells your partner how you feel about using a condom:

  1. “It’s important to me to make you happy. If you don’t like them, we don’t have to use them.”
  2. “I understand how you feel, but this is really important to me. Let’s talk about ways to make them fun.”
  3. “Why don’t you put your pants back on, then? I bet that doesn’t feel good either!”

______

G. Please circle your best response to the questions below.

1. The next time you have vaginal or anal sex with your main partner, what are the chances you will use a condom?

There is no chanceThere is a slight chanceI will probablyI will definitely

I will use a condomI will use a condomuse a condom use a condom

2. The next time you have vaginal or anal sex with a casual partner, what are the chances you will use a condom?

There is no chanceThere is a slight chanceI will probablyI will definitely

I will use a condomI will use a condomuse a condom use a condom

______

PIPWE Pre Questionnaire9 30 2012