This toolkit was originally developed by PC Burkina Faso. The original has been revised by OPATS for wide use and to include global health indicators. Please revise to align with your programming as needed.

Village or Neighborhood:______

Number of people interviewed: MenWomen

Age: 10-14 ______

15-20 ______

21-24 ______

25+ ______

  1. (to everyone)What’s AIDS? -(if necessary, ask: Have you heard of AIDS?)
  1. (to everyone)How can someone get AIDS?

Don’t read these options aloud. If the respondent lists a way, put a ‘1’ next to it.

CorrectIncorrect

______blood______Mosquito

______mother-infant______Dust

______sex______Eating with an infected person

______Saliva

______Sharing a toilet

______being near/sleeping near

______hugging someone

______through clothing

______other means

______I don’t know

  1. (to everyone)How can a person protect themselves from getting AIDS?

Don’t read these options aloud. If the respondent lists a method, put a ‘1’ next to it.

Correct

______using a condomIncorrect

______being faithful______sleeping under a mosquito net

______avoiding infected objects______female circumcision

______using several condoms at the same time

______abstinence______not approaching infected people

______not sharing a meal with an infected person

______other means

______I don’t know

  1. (to everyone) Do you think an HIV+ mother can give birth to an HIV- baby?

______Yes______No______I don’t know

  1. (to everyone) At what point in time can a mother give HIV to her baby?

Don’t read these options aloud. If the respondent lists a method, put a ‘1’ next to it.

CorrectIncorrect

______during pregnancy______never

______while giving birth ______at other times

______while breastfeeding______I don’t know

  1. (to everyone) Have you heard of a program at the hospital that protects babies against HIV?

______Yes______No______Not sure

  1. (to everyone) Do you believe men in this village/neighborhood wear condoms during sexual contact with nonregular partners/partners other than their wives ?

______Yes______No______Not sure

  1. (to everyone) Do you believe it is important to use a condom when having sex outside of marriage?

______Yes______No______Not sure

8.a. If yes…why?

8.b. If no…why not?

9. (to everyone) Are there any people with AIDS living in this village/neighborhood, or in a village nearby?

______Yes______No______Not sure

9.a. If nobody has AIDS around here, why would men wear condoms?

10. (to everyone) Could you say hello to someone living with AIDS?

______Yes______No______Not sure

11. (to everyone) If a relative of yours became sick with AIDS, would you be willing to care for him orher in your own household?

______Yes______No______Not sure

  1. (to everyone) If someone in your village had AIDS, how would people treat that person?

Non stigmatized responsesStigmatized responses

______like anyone else______we would chase him away

______we would support him______we would isolate them/put them to the side

______other______other

  1. (to everyone) If a teacher has the AIDS virus but is not sick, should s/he be allowed to continue teaching in the school?

______Yes______No______Not sure

  1. (Students) Would you accept an HIV+ student into your classroom?

______Yes______No______Not sure

  1. Where did you learn what you know about HIV/AIDS?

______from the theatre______at school______at the health clinic

______my friends______radio______other