* 1. My Zip Code:

* 2. When were you born?

* 3. My County:

* 4. Are you currently enrolled in Ryan White services?

* 5. Are you currently receiving any HIV services?

* 6. When did you first test positive for HIV?

* 7. Where did you test positive for HIV?

* 8. Other (please specify) :

* 9. How do you think you got HIV? (select ALL that apply)

* 10. My last CD4/TCell count was:

* 11. My last viral load wais:

* 12. Are you currently taking drugs to treat HIV?

* 13. Has a doctor ever diagnosed you with AIDS?

* 14. How long after testing positive did you start getting HIV services?

* 15. What would have helped you get HIV care sooner after testing positive? (Check ALL that apply)

* 16. In the last year, how often did you see your doctor about HIV?

* 17. If you have not seen a doctor in the last year, why not?

* 18. Who gave you the MOST information about HIV treatments?

* 19. When you see your case manager, does he/she explain things clearly?

* 20. When you see your doctor, does he/she explain things clearly?

* 21. When you go to the doctor for HIV care, has anyone ever talked to you about HIV prevention?

* 22. Is it easy for you to talk with your doctor about your HIV treatment?

* 23. Do you know what happens if you miss your doses of HIV drugs?

* 24. How is your physical health compared to a year ago?

* 25. How is your mental health compared to a year ago?

* 26. In the last year, how many times have you gone to the emergency room BECAUSE OF HIV, including follow-up visits?

* 27. The list below includes the Ryan White services currently offered in the Southeast Tennessee area. Check the 3 most important to you.

* 28. The list below includes services NOT currently offered as part of the Ryan White services in the Southeast Tennessee area. Which of these are the 3 most important to you?

* 29. What do you worry about most? (You may continue on the last page if needed)

* 30. Healthcare Services: Tell us about your HIV healthcare service needs. In the last year, did you NEED to....

  Did not need Needed & received Needed & DID NOT receive
See a doctor or a specialist?
Get a laboratory or other diagnostic test?
See an eye doctor?
Get help paying for drugs?
See a dentist?
See a mental health counselor?
Enroll in a drug treatment program?
Get in-home care?
Get home medical or health supplies?
See a physical therapist?
See a rehabilitation therapist?
Enroll in drug prevention program?
Use children's HIV care?
Stay in a nursing home?
Enroll in hospice care?

* 31. Support Services: Tell us about your HIV support services needs in the last year, did you NEED to...

  Did not need Needed & received Needed & DID NOT receive
See a case manager?
Talk to an HIV+ peer advocate?
Get legal assistance or advice?
Attend a support group?
Get spiritual counseling or support?
Get grief counseling?
Get education about HIV treatments?
Get help taking my HIV drugs?
Get help with translation / interpreting?
Get educational non-medical HIV services?
Get food voucher?
Get childcare?
Get transportation to medical appointments?

* 32. Other Services: In the last year, did you NEED to...

  Did not need Needed & received Needed & DID NOT receive
Get help applying for disability?
Get help applying for Medicaid?
Get help applying for Medicare?
Get help applying/choosing a Medicare drug plan?
Get help applying for food stamps?
Get help with TennCare or private insurance?
Get emergency food?
Get emergency payments for housing?
Get short term housing assistance?
Get help with paying utilities?
Get clothing?
Get financial counseling?
Get help with housework or cooking?
Get a volunteer companion (buddy)?
Get information on alternative medicine (herbs)?
Get domestic violence services?
Get help taking care of a pet?
Get employment training and/or counseling?

* 33. Barriers to Care:
During the past year, have you had difficulty getting HIV services for any of the following reasons?

  Yes No
The cost of drugs or services
Waiting list for services
Long wait to be seen at office or clinic
Lack of transportation
Lack of childcare
Language barrier / communication problems
Lack of trust that my care would be confidential
Fear of disclosing my HIV status
Services not available
Did not qualify financially
Discrimination because of gender (male / female)
Discrimination because of sexual orientation (gay/lesbian/bisexual)
Discrimination because of gender identity/expression (transgender)
Discrimination because of Race
Did not know where to go for services
DEMOGRAPHIC INFORMATION

* 34. What is your racial or ethnic background?

* 35. What is your native language?

* 36. What is your gender?

* 37. How much education do you have?

* 38. Are you currently...

What is your household size (including only legally married spouse and dependent children/adults)?

* 39. Adults:

* 40. Children:

* 41. What is your household income (including only legally married spouse and dependent children/adults)?

* 42. What type of health insurance do you have?

* 43. Is there anything else that you would like to tell us?

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