HIV Prevention Via Mobile Messaging for Men Who Have Sex With Men (M-Cubed): Protocol for a Randomized Controlled Trial

Background Men who have sex with men (MSM) continue to be the predominately impacted risk group in the United States HIV epidemic and are a priority group for risk reduction in national strategic goals for HIV prevention. Modeling studies have demonstrated that a comprehensive package of status-tailored HIV prevention and care interventions have the potential to substantially reduce new infections among MSM. However, uptake of basic prevention services, including HIV testing, sexually transmitted infection (STI) testing, condom distribution, condom-compatible lubricant distribution, and preexposure prophylaxis (PrEP), is suboptimal. Further, stronger public health strategies are needed to promote engagement in HIV care and viral load suppression among MSM living with HIV. Mobile health (mHealth) tools can help inform and encourage MSM regarding HIV prevention, care, and treatment, especially among men who lack access to conventional medical services. This protocol details the design and procedures of a randomized controlled trial (RCT) of a novel mHealth intervention that comprises a comprehensive HIV prevention app and brief, tailored text- and video-based messages that are systematically presented to participants based on the participants’ HIV status and level of HIV acquisition risk. Objective The objective of the RCT was to test the efficacy of the Mobile Messaging for Men (M-Cubed, or M3) app among at least 1200 MSM in Atlanta, Detroit, and New York. The goal was to determine its ability to increase HIV testing (HIV-negative men), STI testing (all men), condom use for anal sex (all men), evaluation for PrEP eligibility, uptake of PrEP (higher risk HIV-negative men), engagement in HIV care (men living with HIV), and uptake of and adherence to antiretroviral medications (men living with HIV). A unique benefit of this approach is the HIV serostatus-inclusiveness of the intervention, which includes both HIV-negative and HIV-positive MSM. Methods MSM were recruited through online and venue-based approaches in Atlanta, Detroit, and New York City. Men who were eligible and consented were randomized to the intervention (immediate access to the M3 app for a period of three months) or to the waitlist-control (delayed access) group. Outcomes were evaluated immediately postintervention or control period, and again three and six months after the intervention period. Main outcomes will be reported as period prevalence ratios or hazards, depending on the outcome. Where appropriate, serostatus/risk-specific outcomes will be evaluated in relevant subgroups. Men randomized to the control condition were offered the opportunity to use (and evaluate) the M3 app for a three-month period after the final RCT outcome assessment. Results M3 enrollment began in January 2018 and concluded in November 2018. A total of 1229 MSM were enrolled. Data collection was completed in September 2019. Conclusions This RCT of the M3 mobile app seeks to determine the effects of an HIV serostatus–inclusive intervention on the use of multiple HIV prevention and care-related outcomes among MSM. A strength of the design is that it incorporates a large sample and broad range of MSM with differing prevention needs in three cities with high prevalence of HIV among MSM. Trial Registration ClinicalTrials.gov NCT03666247; https://clinicaltrials.gov/ct2/show/NCT03666247 International Registered Report Identifier (IRRID) DERR1-10.2196/16439

Your confidentiality is important to us! All information you provide today in this survey will be held confidentially. Your answers will be used only for research purposes and we do not collect information to identify you and link you to your answers. Researchers will only see data that is anonymous. Which of the following reasons best describes why you plan to be tested [question("option title"), id="47",case="lower"]: (1) I have been feeling sick (2) Someone I had sex with has been feeling sick/is sick (3) I found out a partner I had anal sex with is HIV-positive (4) I am due for an HIV test  When do you think you should be tested for an STD? Select all that apply.
[1] When I have symptoms of an STD [2] When I've had sex without a condom

The total number of attended appointments in the past 12 months must be less than or equal to [question('value'), id='562'] (the number of scheduled appointments in the past 12 months). Please correct this.
Page entry logic: This page will show when: number of missed appointments is not exactly equal to "0"

HIV Care Engagement (HC4 -HC5)
Logic: Hidden unless: number of missed appointments is greater than or equal to "1" Shortname / Alias: attend_ ID: 419 Why did you not attend [question("value"),id="102"] of your scheduled appointments? Select all that apply.

[1] I was busy [ATTEND_BUSY]
[2] I simply forgot [ATTEND_FORGOT] [3] I had a schedule change or traveling [ATTEND_SCHEDULE] [4] My provider canceled our appointment [ATTEND_DOCTOR] [5] I did not have access to transportation [ATTEND_TRANSPORT] [6] I worried others would see/find out [ATTEND_FINDOUT] [7] I did not think it was necessary [ATTEND_NECESSARY] [8] I do not have insurance [ATTEND_INS] [9] I was worried about receiving HIV care [ATTEND_CARE] [10] I felt depressed and/or overwhelmed [ATTEND_SAD] [11] I was drunk or high [ATTEND_DRUGS] [12] Other, please specify:: _________________________________________________ [ATTEND_OTHER] [ATTEND_OTHERSP] HIV Care Engagement (HC6 -HC8) Logic: Hidden unless: Question "In the past 12 months, that is since [question('value'),id='759'], have you seen a doctor, nurse or other health provider for outpatient HIV care?" is one of the following answers ("Yes") Shortname / Alias: hivcare_3m ID: 71 In the past 3 months, that is since [question('value'), id='760'], have you had a medical visit in an HIV care setting?  What are the reasons you have never taken any antiretroviral medications? Select all that apply.
[ Page entry logic: This page will show when: ( Question "What are the reasons you have never taken any antiretroviral medications? Select all that apply." is one of the following answers ("My doctor advised to delay treatment","I recently entered medical care/haven't had time","My CD4 and/or viral load are good","I feel good and don't need them","I'm worried about the side effects","Because of my drinking or drug use","I don't want to think about being HIV positive","I don't have enough money","I don't have health insurance","I am worried about my ability to take my medicine, I often forget to take medications","I'm living on the street","I'm taking alternative or complementary medicine") AND Question "What is your HIV status?" is one of the following answers ("HIV Positive")) ART Uptake/Adherence (MA3) You said you've never taken any antiretroviral medications for the following reasons. Of these, which is the most important reason you've never taken antiretroviral medications?
Page entry logic: This page will show when: Question "What is your HIV status?" is one of the following answers ("HIV Positive")

ART Uptake/Adherence (MA4 -MA7)
Logic: Show/hide trigger exists. Hidden unless: Question "Have you ever been prescribed and taken antiretroviral medications to treat your HIV?" is one of the following answers ("Yes") Shortname / Alias: art_current ID: 76 Are you currently prescribed and taking any antiretroviral medicines to treat your HIV?  In the past 3 months, that is since [question('value'), id='760'], have you taken any antiretroviral medicines to treat your HIV?
(1) Yes Page entry logic: This page will show when: ( Question "Are you currently prescribed and taking any antiretroviral medicines to treat your HIV?" is one of the following answers ("Yes") AND Question "What is your HIV status?" is one of the following answers ("HIV Positive"))

ART Uptake / Adherence (MA8 -MA11)
Shortname / Alias: art_7d ID: 80 In the past 7 days, on how many days did you take all of your doses of your HIV medicines? In the past 30 days, how good a job did you do at taking your HIV medicines in the way you were supposed to?
(1) Very poor In the past 30 days, how often did you take your HIV medicines in the way you were supposed to?
(1) Never (2) Rarely (3) Sometimes (4) Usually (5) Almost always (6) Always Page entry logic: This page will show when: ( Question "What is your HIV status?" is one of the following answers ("HIV Positive") AND Question "Are you currently prescribed and taking any antiretroviral medicines to treat your HIV?" is one of the following answers ("Yes")) ART Uptake/Adherence (MA12) There is a pill HIV-negative men can take to reduce their risk of HIV. This is called preexposure prophylaxis, or PrEP. Have you ever heard of PrEP?

(0) No
Logic: Show/hide trigger exists. Hidden unless: Question "There is a pill HIV-negative men can take to reduce their risk of HIV. This is called pre-exposure prophylaxis, or PrEP. Have you ever heard of PrEP?" is one of the following answers ("Yes") Shortname / Alias: prep_current ID: 105 Are you currently taking PrEP to prevent HIV? (1) Yes

(0) No
Logic: Hidden unless: Question "Are you currently taking PrEP to prevent HIV?" is one of the following answers ("Yes") Shortname / Alias: prep_stop ID: 107 In the past 3 months, did you stop taking PrEP on purpose for any period of time? Do not include times when you accidentally missed one or more doses of PrEP.
(1) Yes Page entry logic: This page will show when: ( Question "Are you currently taking PrEP to prevent HIV?" is one of the following answers ("No") AND Question "What is your HIV status?" is one of the following answers ("HIV Negative","Indeterminate","I don't know"))

ID: 109
Have you ever used PrEP to prevent HIV?

(0) No
Logic: Hidden unless: ( Question "In the past 3 months, that is since [question('value'), id='760'], were you taking PrEP but stopped?" is one of the following answers ("Yes") OR Question "Have you ever used PrEP to prevent HIV?" is one of the following answers ("Yes")) Shortname / Alias: prep_stop_ ID: 110 What are some of the reasons you stopped using PrEP to prevent HIV? Select all that apply. [

Reasons Never Used PrEP
Logic: Hidden unless: ( Question "Are you currently taking PrEP to prevent HIV?" is one of the following answers ("No") AND Question "Have you ever used PrEP to prevent HIV?" is one of the following answers ("No")) Page entry logic: This page will show when: Question "What are some of the reasons you've never used PrEP? Select all that apply." is one of the following answers ("I couldn't afford it","My insurance wouldn't cover it","I didn't know where to get it","My doctor did not recommend PrEP for me","I was worried about the side effects","I started a committed relationship","I didn't think it was worth it","I contracted HIV","It was too inconvenient/didn't fit my life","I was worried someone would think I had HIV if they saw me take it","I decided I didn't need it","I have never heard of it","Other, please specify:") Page entry logic: This page will show when: Question "What are some of the reasons you stopped using PrEP to prevent HIV? Select all that apply." is one of the following answers ("I couldn't afford it","My insurance wouldn't cover it","My doctor decided PrEP was no longer appropriate for me","I didn't like the side effects","I was worried about the safety of PrEP","My kidney and liver function began to suffer","I started a committed relationship","I was using PrEP in a previous relationship with a person living with HIV","I didn't think it was worth it","I contracted HIV","It was too inconvenient/didn't fit my life","I was worried someone would think I had HIV if they saw me take it","I decided I didn't need it anymore","Other, please specify:") You said you stopped using PrEP for the following reasons. Among these, which is the most important reason you stopped using PrEP?

PrEP
Page entry logic: This page will show when: ( Question "What is your HIV status?" is one of the following answers ("HIV Negative","Indeterminate","I don't know") AND Question "Are you currently taking PrEP to prevent HIV?" is one of the following answers ("Yes"))

Currently taking PrEP (PA13 -PA16)
Shortname / Alias: prep_7d ID: 112 In the past 7 days, on how many days did you take your dose of PrEP? In the past 30 days, how good a job did you do at taking your PrEP medication in the way you were supposed to?
(1) Very poor In the past 30 days, how often did you take your PrEP medication in the way you were supposed to?
(1) Never (2) Rarely (3) Sometimes (4) Usually (5) Almost Always (6) Always Page entry logic: This page will show when: ( Question "What is your HIV status?" is one of the following answers ("HIV Negative","Indeterminate","I don't know") AND Question "Are you currently taking PrEP to prevent HIV?" is one of the following answers ("Yes"))
(1) Before you have sex (2) After you have sex (3) Both before and after you have sex (4) Other times, please specify:: _________________________________________________ Shortname / Alias: prep_demand

ID: 117
Have you ever used PrEP "on-demand" or right before you knew you were about to have sex, as opposed to daily? Page entry logic: This page will show when: Question "What is your HIV status?" is one of the following answers ("HIV Negative","Indeterminate","I don't know") Researchers are also working on a form of PrEP that you would only take around the times you have sex. You would take two pills within 24 hours before sex and then two separate one-pill doses in the two days after sex. Researchers are working on a form of PrEP that a doctor would give as a shot into your arm. You would need to get the shot every 1 to 3 months to reduce your risk of getting HIV.
Shortname / Alias: prep_inject ID: 704 How likely would you be to use this injectable form of PrEP to reduce the risk of getting HIV?
(1) Very likely (2) Somewhat likely (3) Neither likely nor unlikely (4) Somewhat unlikely (5) Very unlikely Page entry logic: This page will show when: Question "What is your HIV status?" is one of the following answers ("HIV Negative","Indeterminate","I don't know") Future PrEP (FP4 -FP7) ID: 705 Researchers are also working on a form of PrEP that is a gel you would apply to the penis (like lubricant or lube) or put into the rectum with an applicator before and/or after sex to reduce the risk of getting HIV. Page entry logic: This page will show when: Question "What is your HIV status?" is one of the following answers ("HIV Negative","Indeterminate","I don't know") Future PrEP (FP8 -FP9) ID: 711 Researchers are also working on a form of PrEP that you would put in your rectum as a suppository. This would involve putting a pill the size of a daily vitamin pill into your rectum at least 30 minutes before having receptive anal sex (bottoming) to be sure it dissolved in time to reduce the risk of getting HIV.

ID: 712
How likely would you be to use a suppository form of PrEP that you insert into your rectum to dissolve 30 minutes before having receptive anal sex (bottoming) to reduce the risk of getting HIV? How likely would you be to use a suppository form of PrEP that you insert into your rectum to dissolve within three hours after having receptive anal sex (bottoming) to reduce the risk of getting HIV?
(1) Very likely (2) Somewhat likely (3) Neither likely nor unlikely (4) Somewhat unlikely (5) Very unlikely Page entry logic: This page will show when: Question "What is your HIV status?" is one of the following answers ("HIV Negative","Indeterminate","I don't know")

ID: 714
Below is a list that includes the currently available form of PrEP and condoms, and all the different forms of PrEP that researchers are working on. Please rank in order of the methods you would use, from most preferred (1) to least preferred (8)? Drag the items to the next column, starting with your first choice of a prevention method.
________Daily PrEP (a pill that you take every day) [PREPRANK_PILL] ________Event-level PrEP (two pills before sex and one pill for two days after sex) [PREPRANK_EVENT] ________Injectable PrEP (a shot you receive every 1-3 months) [PREPRANK_INJECT] ________Rectal suppository PrEP that is used before sex (a pill-size dose you put in your rectum) [PREPRANK_SUPPBF] ________Rectal suppository PrEP that is used after sex (a pill-size dose you put in your rectum) [PREPRANK_SUPPAF] ________Rectal gel PrEP before sex (a gel that you squeeze into your rectum with an applicator) [PREPRANK_GELBF] ________Rectal gel PrEP after sex (a gel that you squeeze into your rectum with an applicator) [PREPRANK_GELAF] ________Condoms [PREPRANK_CONDOM] Future PrEP (FP11) If you had a choice of using condoms during anal sex or taking a pill every day to prevent HIV infection, both at no cost, which would you choose?
(1) Condoms only (2) Daily pill only (3) Both condoms and daily pill Page entry logic: This page will show when: Question "What is your HIV status?" is one of the following answers ("HIV Negative","Indeterminate","I don't know")

PrEP Care Engagement (PC1 -PC2)
Logic: Hidden unless: Question "Are you currently taking PrEP to prevent HIV?" is one of the following answers ("Yes") Shortname / Alias: prepcare ID: 120 In the past 3 months, that is since [question('value'), id='760'], have you seen a doctor, nurse or other health care provider to receive tests or other care related to your PrEP use?
(1) Yes Logic: Hidden unless: (( Question "What is your HIV status?" is one of the following answers ("HIV Negative","Indeterminate","I don't know") AND Question "Are you currently taking PrEP to prevent HIV?" is one of the following answers ("No")) AND Question "In the past 3 months, that is since [question('value'), id='760'], have you seen a doctor, nurse or other health care provider about using PrEP?" is one of the following answers ("No")) Shortname / Alias: medcare ID: 123

In the past 3 months, that is since [question('value'), id='760'], have you seen a doctor, nurse or other health care provider for any other reason?
(1) Yes

(0) No
Logic: Hidden unless: (( Question "What is your HIV status?" is one of the following answers ("HIV Positive") AND Question "Are you currently prescribed and taking any antiretroviral medicines to treat your HIV?" is one of the following answers ("No")) OR ( Question "What is your HIV status?" is one of the following answers ("HIV Negative","Indeterminate","I don't know") AND Question "Are you currently taking PrEP to prevent HIV?" is one of the following answers ("No"))) Shortname / Alias: med_

ID: 124
Think about times when you have been prescribed medicine by a doctor because you were sick or for a chronic condition (e.g., diabetes, high blood pressure).

ID: 129
On a scale of 0 to 100, where 0 equals no protection and 100 equals complete protection, how much protection do you think each of the following strategies offers in preventing HIV?

Please slide the yellow dot on the scale to indicate how much protection you think each strategy offers.
Taking

ID: 556
On a scale of 0 to 100, where 0 equals no protection and 100 equals complete protection, how much protection do you think each of the following strategies offers in preventing HIV?

Please slide the blue dot on the scale to indicate how much protection you think each strategy offers.
Your

ID: 243
Have you had anal sex with a male primary partner in the past 3 months? By "primary" partner we mean a man you have lived with or have seen a lot, to whom you have felt a special emotional commitment for at least 3 months. This includes times when you were a top or bottom, used or didn't use a condom, and whether or not there was ejaculation.
(1) Yes Now we want to ask you about all of the other men you have had any anal sex with in the past 3 months other than your most recent primary partner.
In the past 3 months, with how many men other than your most recent primary partner did you have anal sex? By non-primary partner, we mean someone you had sex with but do not feel committed to or don't know very well. This includes times when you were a top or bottom, used or didn't use a condom, and whether or not there was ejaculation.
_________________________________________________ Page entry logic: This page will show when: ( Question "Have you had anal sex with a male primary partner in the past 3 months? By "primary" partner we mean a man you have lived with or have seen a lot, to whom you have felt a special emotional commitment for at least 3 months. This includes times when you were a top or bottom, used or didn't use a condom, and whether or not there was ejaculation. " is one of the following answers ("No") AND ( Question "Now we want to ask you about all of the other men you have had any anal sex with in the past 3 months other than your most recent primary partner.
In the past 3 months, with how many men other than your most recent primary partner did you have anal sex? By non-primary partner, we mean someone you had sex with but do not feel committed to or don't know very well. This includes times when you were a top or bottom, used or didn't use a condom, and whether or not there was ejaculation." is exactly equal to "0" OR Question "Now we want to ask you about all of the other men you have had any anal sex with in the past 3 months other than your most recent primary partner.
In the past 3 months, with how many men other than your most recent primary partner did you have anal sex? By non-primary partner, we mean someone you had sex with but do not feel committed to or don't know very well. This includes times when you were a top or bottom, used or didn't use a condom, and whether or not there was ejaculation." ))

Sex Behaviors (SX3)
Page exit logic: Page LogicIF: Question "You indicated that you did not have any sex partners in the past 3 months, is this correct?" is one of the following answers ("Yes") THEN: Jump to page 103 -Substance Use and Substance Dependency (SU1) Page exit logic: Page LogicIF: Question "You indicated that you did not have any sex partners in the past 3 months, is this correct?" is one of the following answers ( By "primary" partner we mean a man you have lived with or have seen a lot, to whom you have felt a special emotional commitment for at least 3 months. This includes times when you were a top or bottom, used or didn't use a condom, and whether or not there was ejaculation. " is one of the following answers ("Yes")

Primary Partner (SXP1)
Validation: Min character count = 1 Shortname / Alias: mp_nicknm ID: 245 Throughout this next group of questions, we will ask you about your recent male primary partner using a nickname you have provided to make the questions specific to your partner. Examples of a nickname that you might choose are: a partner's first name, a nickname you call the partner by, the place where you both met, or an online screen name.
Please choose a nickname that will best help you know to whom we are referring. The nickname is to make the survey easier to take and you should not reveal your partner's full identity. We do not wish to know who your partner actually is.
Enter the nickname for your recent male primary partner below. * _________________________________________________ Page entry logic: This page will show when: Question "Have you had anal sex with a male primary partner in the past 3 months? By "primary" partner we mean a man you have lived with or have seen a lot, to whom you have felt a special emotional commitment for at least 3 months. This includes times when you were a top or bottom, used or didn't use a condom, and whether or not there was ejaculation. " is one of the following answers ("Yes")  (14) Other, please specify:: _________________________________________________ Page entry logic: This page will show when: Question "Have you had anal sex with a male primary partner in the past 3 months? By "primary" partner we mean a man you have lived with or have seen a lot, to whom you have felt a special emotional commitment for at least 3 months. This includes times when you were a top or bottom, used or didn't use a condom, and whether or not there was ejaculation. " is one of the following answers ( (1) Less than a week ago

Primary Partner (SXP2 -SXP6)
(2) More than a week but less than a month ago (3) One to three months ago (4) Four to six months ago (5)  (1) Yes

(0) No
Page entry logic: This page will show when: ( Question "Have you had anal sex with a male primary partner in the past 3 months? By "primary" partner we mean a man you have lived with or have seen a lot, to whom you have felt a special emotional commitment for at least 3 months. This includes times when you were a top or bottom, used or didn't use a condom, and whether or not there was ejaculation. " is one of the following answers ("Yes") AND Question "What is [question('value'), id='245',case='upper']'s HIV status?" is one of the following answers ("Positive"))

Has [question('value'), id='245',case='upper'] told you his viral load is undetectable?
(1) Yes, and I have no reason to doubt him (2) Yes, but I have some reason to doubt him Page entry logic: This page will show when: ( Question "Have you had anal sex with a male primary partner in the past 3 months? By "primary" partner we mean a man you have lived with or have seen a lot, to whom you have felt a special emotional commitment for at least 3 months. This includes times when you were a top or bottom, used or didn't use a condom, and whether or not there was ejaculation. " is one of the following answers ("Yes") AND Question "What is [question('value'), id='245',case='upper']'s HIV status?" is one of the following answers ("Negative")) Primary Partner (SXP15 -SXP17)    By "primary" partner we mean a man you have lived with or have seen a lot, to whom you have felt a special emotional commitment for at least 3 months. This includes times when you were a top or bottom, used or didn't use a condom, and whether or not there was ejaculation. " is one of the following answers ("Yes") AND Question "What is your HIV status?" is one of the following answers ("HIV Negative","Indeterminate","I don't know")) AND Question "Have you ever used PrEP to prevent HIV?" is one of the following answers ("Yes"))

Logic: Show/hide trigger exists. Hidden unless: Question "Was [question('value'), id='245',case='upper'] taking PrEP medication to prevent HIV within 24 hours before or after the time you last had anal sex? " is one of the following answers ("Yes")
Shortname / Alias: mp_pprep7 ID: 278

To your knowledge, was [question('value'), id='245',case='upper'] taking his PrEP medication once a day as prescribed by his doctor, without missing doses, in the 7 days before you last had anal sex?
(1) Yes Page entry logic: This page will show when: (( Question "Have you had anal sex with a male primary partner in the past 3 months? By "primary" partner we mean a man you have lived with or have seen a lot, to whom you have felt a special emotional commitment for at least 3 months. This includes times when you were a top or bottom, used or didn't use a condom, and whether or not there was ejaculation. " is one of the following answers ("Yes") AND Question "What is your HIV status?" is one of the following answers ("HIV Positive")) AND Question "Have you ever been prescribed and taken antiretroviral medications to treat your HIV?" is one of the following answers ("Yes"))

Last Sex with Primary Partner -Recent ART (SXP34 -SXP36)
Logic: Show/hide trigger exists.

Were you taking antiretroviral medicines to treat your HIV infection within 24 hours before or after the time you last had anal sex with [question('value'), id='245',case='upper']?
(1) Yes (0) No (7) I don't know

Logic: Show/hide trigger exists. Hidden unless: Question "Were you taking antiretroviral medicines to treat your HIV infection within 24 hours before or after the time you last had anal sex with [question('value'), id='245',case='upper']?" is one of the following answers ("Yes")
Shortname / Alias: mp_yart7 ID: 438

Were you taking your HIV medicines exactly as prescribed by your doctor, without missing any doses, in the 7 days before you last had anal sex with [question('value'), id='245',case='upper']?
(1) Yes By "primary" partner we mean a man you have lived with or have seen a lot, to whom you have felt a special emotional commitment for at least 3 months. This includes times when you were a top or bottom, used or didn't use a condom, and whether or not there was ejaculation. " is one of the following answers ("Yes") AND Question "What is [question('value'), id='245',case='upper']'s HIV status?" is one of the following answers ("Positive"))

Was [question('value'), id='245',case='upper'] taking antiretroviral medicines to treat his HIV infection within 24 hours before or after the time you last had anal sex?
(1) Yes (0) No (7) I don't know

To your knowledge, was [question('value'), id='245',case='upper'] taking his medicines exactly as prescribed by his doctor, without missing any doses, in the 7 days before you last had anal sex?
(1) Yes (0) No (7) I don't know

Logic: Show/hide trigger exists. Hidden unless: Question "Was [question('value'), id='245',case='upper'] taking antiretroviral medicines to treat his HIV infection within 24 hours before or after the time you last had anal sex?" is one of the following answers ("Yes")
Shortname / Alias: mp_ai_vl ID: 281

When was the last time [question('value'), id='245',case='upper'] told you his viral load was undetectable?
(1) Less than a week ago (2) More than a week but less than a month ago (3) One to three months ago (4) Four to six months ago (5) Seven to twelve months ago (6) More than a year ago Page entry logic: This page will show when: Question "Have you had anal sex with a male primary partner in the past 3 months? By "primary" partner we mean a man you have lived with or have seen a lot, to whom you have felt a special emotional commitment for at least 3 months. This includes times when you were a top or bottom, used or didn't use a condom, and whether or not there was ejaculation. " is one of the following answers ("Yes")

Last Sex with Male Primary Partner -Substance Use (SXP42 -SXP44)
Logic: Show/hide trigger exists.

Were you drunk or buzzed on alcohol within two hours before or during the most recent time you had anal sex with [question('value'), id='245',case='upper']?
(1) Yes By "primary" partner we mean a man you have lived with or have seen a lot, to whom you have felt a special emotional commitment for at least 3 months. This includes times when you were a top or bottom, used or didn't use a condom, and whether or not there was ejaculation. " is one of the following answers ("Yes")

Did you use any drug that was not prescribed to you within two hours before or during the most recent time you had anal sex with [question('value'), id='245',case='upper']?
(1) Yes

Logic: Hidden unless: Question "Did you use any drug that was not prescribed to you within two hours before or during the most recent time you had anal sex with [question('value'), id='245',case='upper']?" is one of the following answers ("Yes")
Shortname Page entry logic: This page will show when: Question "Now we want to ask you about all of the other men you have had any anal sex with in the past 3 months other than your most recent primary partner.
In the past 3 months, with how many men other than your most recent primary partner did you have anal sex? By non-primary partner, we mean someone you had sex with but do not feel committed to or don't know very well. This includes times when you were a top or bottom, used or didn't use a condom, and whether or not there was ejaculation." is greater than or equal to "1"

The following questions ask you about the [question('value'), id='510'] non-primary male partners you have had in the past three months.
If you are unsure of any partner's HIV status, please do not include them in either group.

ID: 568
Error! You reported more positive and negative partners than previously reported total other partners. If you are unsure of any partner's HIV status, please do not include them in either group.

Hidden Value: tot_p (# of total non-primary partners -# of non-primary partners believed to be HIV positive)
Value:

Hidden Value: tot_pn (# of total non-primary partners -# of non-primary partners believed to be HIV positive -# of non-primary partners believed to be HIV negative): # of partners with an unknown HIV status
Value:

Hidden Value: tot_pn2 (# of total non-primary partners -# of non-primary partners believed to be HIV positive -# of non-primary partners believed to be HIV negative): # of partners with an unknown HIV status
Value:

Hidden Value: sex46 (# of non-primary partners believed to be HIV positive) [TOTHIVPOSCASPART]
Value:

Hidden Value: sex47 ( # of non-primary partners believed to be HIV negative) [TOTHIVNEGCASPART]
Value:

Other Male Partners (SPS3)
Page exit logic: Skip / Disqualify LogicIF: Question "So, you had [question("value"), id="295"] partners whose HIV status you did not know or were unsure of?" is one of the following answers Of the [question('option value'), id='514'] HIV negative men, how many actually TOLD you they were HIV negative?
_________________________________________________ Page entry logic: This page will show when: Question "Of these [question('value'), id='510'] men, how many did you believe were HIV positive?" is greater than or equal to "1"

Other Male Partners -HIV-Positive (SXC1 -SXC2)
ID: 305 The following questions ask about your HIV-POSITIVE partners who were NOT your primary partner.

In the past 3 months, that is since [question('value'), id='760'], with how many of your [question('value'), id='513'] HIV-positive partner(s) did you have ANY anal sex in which a condom was not used from start to finish?
_________________________________________________ Page entry logic: This page will show when: Question "Of these [question('value'), id='510'] men, how many did you believe were HIV positive?" is greater than or equal to "1"

Other Male Partners -HIV-Positive (SXC4 -SXC7)
Validation: Must be numeric Whole numbers only Positive numbers only

Logic: Hidden unless: Question "In the past 3 months, that is since [question('value'), id='760'], with how many of your [question('value'), id='513'] HIV-positive partner(s) did you have ANY anal sex in which a condom was not used from start to finish?" is greater than or equal to "1"
Shortname / Alias: pos_uai_top ID: 608 Of the [question("value"), id="607"] men you had anal sex with and did not use a condom from start to finish, with how many did you have sex without a condom while you were drunk or buzzed on alcohol within 2 hours before or during sex?

Logic: Hidden unless: Question "In the past 3 months, that is since [question('value'), id='760'], with how many of your [question('value'), id='513'] HIV-positive partner(s) did you have ANY anal sex in which a condom was not used from start to finish?" is greater than or equal to "1"
Shortname / Alias: pos_uai_drugs

ID: 618
Of the [question("value"), id="607"] men you had anal sex with and did not use a condom from start to finish, with how many did you have sex without a condom after using non-prescribed drugs within 2 hours before or during sex? Of your [question("value"), id="513"] HIV-positive partners, how many told you they were undetectable or virally suppressed?
_________________________________________________ Page entry logic: This page will show when: sex47 ( # of non-primary partners believed to be HIV negative) is greater than or equal to "1"

Other Male Partners -HIV-Negative (SXC11 -SXC12)
ID: 319 The following questions ask about your HIV-NEGATIVE partners who were NOT your primary partner.

In the past 3 months, that is since [question('value'), id='760'], with how many of your [question('value'), id='514'] HIV-negative partners were you the bottom (he put his penis in your butt)?
_________________________________________________ Page entry logic: This page will show when: sex47 ( # of non-primary partners believed to be HIV negative) is greater than or equal to "1"

Other Male Partners -HIV-Negative (SXC13)
Validation: Must be numeric Whole numbers only Positive numbers only Shortname / Alias: neg_uai_num ID: 630

In the past 3 months, with how many of your [question('value'), id='514'] HIVnegative partners did you have ANY anal sex in which a condom was not used from start to finish?
_________________________________________________ Page entry logic: This page will show when: ( Question "In the past 3 months, with how many of your [question('value'), id='514'] HIV-negative partners did you have ANY anal sex in which a condom was not used from start to finish?" is greater than or equal to "1" AND sex47 ( # of non-primary partners believed to be HIV negative) is greater than or equal to "1") Of those [question("value"), id="630"] men you had anal sex with and did not use a condom from start to finish, with how many were you the top (you put your penis in his butt) when you had sex without a condom? Of those [question("value"), id="630"] men you had anal sex with and did not use a condom from start to finish, with how many were you the bottom (he put his penis in your butt) when you had sex without a condom? Of those [question("value"), id="630"] men you had anal sex with and did not use a condom from start to finish, with how many did you have sex without a condom while you were drunk or buzzed on alcohol within 2 hours before or during sex? Of those [question("value"), id="630"] men you had anal sex with and did not use a condom from start to finish, with how many did you have sex without a condom after using non-prescribed drugs within 2 hours before or during sex?

Other Male Partners -HIV-Negative (SXC14 -SXC17)
_________________________________________________ Page entry logic: This page will show when: sex47 ( # of non-primary partners believed to be HIV negative) is greater than or equal to "1" Of your [question("value"), id="514"] HIV-negative partners, how many told you they were currently taking PrEP to prevent HIV?

Other Male Partners
_________________________________________________ Page entry logic: This page will show when: tot_pn2 (# of total non-primary partners -# of nonprimary partners believed to be HIV positive -# of non-primary partners believed to be HIV negative): # of partners with an unknown HIV status is greater than or equal to "1"

Other Male Partners -HIV-Indeterminate (SXC20 -SXC21)
ID: 529 The following questions ask about your partners who were not your primary partner and whose HIV status you did not know.

In the past 3 months, that is since [question('value'), id='760'], with how many of your [question('value'), id='295'] partners whose HIV status you did not know were you the bottom (he put his penis in your butt)?
_________________________________________________ Page entry logic: This page will show when: tot_pn2 (# of total non-primary partners -# of nonprimary partners believed to be HIV positive -# of non-primary partners believed to be HIV negative): # of partners with an unknown HIV status is greater than or equal to "1"

In the past 3 months, that is since [question('value'), id='760'], with how many of your [question('value'), id='295'] partners whose HIV status you did not know did you have ANY anal sex in which a condom was not used from start to finish?
_________________________________________________ Page entry logic: This page will show when: Question "In the past 3 months, that is since [question('value'), id='760'], with how many of your [question('value'), id='295'] partners whose HIV status you did not know did you have ANY anal sex in which a condom was not used from start to finish?" is greater than or equal to "1" Of those [question("value"), id="651"] men you had anal sex with and did not use a condom from start to finish, with how many were you the top (you put your penis in his butt) when you had sex without a condom? Of those [question("value"), id="651"] men you had anal sex with and did not use a condom from start to finish, with how many were you the bottom (he put his penis in your butt) when you had sex without a condom? Of those [question("value"), id="651"] men you had anal sex with and did not use a condom from start to finish, with how many did you have sex without a condom while you were drunk or buzzed on alcohol within 2 hours before or during sex? Of those [question("value"), id="651"] men you had anal sex with and did not use a condom from start to finish, with how many did you have sex without a condom after using non-prescribed drugs within 2 hours before or during sex?

Non-Primary Partners -HIV-Indeterminate
_________________________________________________ Page entry logic: This page will show when: Question "Now we want to ask you about all of the other men you have had any anal sex with in the past 3 months other than your most recent primary partner.
In the past 3 months, with how many men other than your most recent primary partner did you have anal sex? By non-primary partner, we mean someone you had sex with but do not feel committed to or don't know very well. This includes times when you were a top or bottom, used or didn't use a condom, and whether or not there was ejaculation." is greater than or equal to "1" Last Non-Primary Male Partner (SXCL1) ID: 336 You will now be asked more detailed questions about the last man you had any anal sex with in the past THREE months who was not your male primary partner.
That is, not someone you have lived with or have seen a lot, and to whom you have felt a special emotional commitment. Think about the very last man you had any anal sex with in the last THREE months who was not your primary partner.
Validation: Min character count = 1 Shortname / Alias: op_nicknm ID: 337 Throughout this next group of questions, we will ask you about the last man you had any anal sex with in the past THREE months who was not your male primary partner using a nickname you have provided. Examples of a nickname that you might choose are: a partner's first name, a nickname you call the partner by, the place where you both met, or an online screen name.
Please choose a nickname that will best help you know to whom we are referring. The nickname is to make the survey easier to take and you should not reveal this man's full identity. We do not wish to know who your partner actually is.
Enter the nickname for the last man you had any anal sex with in the past THREE months who was not your male primary partner below. * _________________________________________________ Page entry logic: This page will show when: Question "Now we want to ask you about all of the other men you have had any anal sex with in the past 3 months other than your most recent primary partner.
In the past 3 months, with how many men other than your most recent primary partner did you have anal sex? By non-primary partner, we mean someone you had sex with but do not feel committed to or don't know very well. This includes times when you were a top or bottom, used or didn't use a condom, and whether or not there was ejaculation." is greater than or equal to "1" in which a condom was not used from start to finish?" is one of the following answers ("Yes") AND Question "Now we want to ask you about all of the other men you have had any anal sex with in the past 3 months other than your most recent primary partner.
In the past 3 months, with how many men other than your most recent primary partner did you have anal sex? By non-primary partner, we mean someone you had sex with but do not feel committed to or don't know very well. This includes times when you were a top or bottom, used or didn't use a condom, and whether or not there was ejaculation." is greater than or equal to "1") In the past 3 months, with how many men other than your most recent primary partner did you have anal sex? By non-primary partner, we mean someone you had sex with but do not feel committed to or don't know very well. This includes times when you were a top or bottom, used or didn't use a condom, and whether or not there was ejaculation." is greater than or equal to "1"

Last Non-Primary Male Partner -HIV Status (SXCL12 -SXCL14)
Logic: Show/hide trigger exists.  In the past 3 months, with how many men other than your most recent primary partner did you have anal sex? By non-primary partner, we mean someone you had sex with but do not feel committed to or don't know very well. This includes times when you were a top or bottom, used or didn't use a condom, and whether or not there was ejaculation." is greater than or equal to "1"  In the past 3 months, with how many men other than your most recent primary partner did you have anal sex? By non-primary partner, we mean someone you had sex with but do not feel committed to or don't know very well. This includes times when you were a top or bottom, used or didn't use a condom, and whether or not there was ejaculation." is greater than or equal to "1"  In the past 3 months, with how many men other than your most recent primary partner did you have anal sex? By non-primary partner, we mean someone you had sex with but do not feel committed to or don't know very well. This includes times when you were a top or bottom, used or didn't use a condom, and whether or not there was ejaculation." is greater than or equal to "1" In the past 3 months, with how many men other than your most recent primary partner did you have anal sex? By non-primary partner, we mean someone you had sex with but do not feel committed to or don't know very well. This includes times when you were a top or bottom, used or didn't use a condom, and whether or not there was ejaculation." is greater than or equal to "1"

Last Non-Primary Male Partner -Partner PrEP (SXCL26 -SXCL28)
Page exit logic: Skip / Disqualify LogicIF: ( Question "What is your HIV status?" is one of the following answers ("HIV Negative") OR Question "Have you ever been prescribed and taken antiretroviral medications to treat your HIV?" is one of the following answers (  Page entry logic: This page will show when: Question "Now we want to ask you about all of the other men you have had any anal sex with in the past 3 months other than your most recent primary partner.
In the past 3 months, with how many men other than your most recent primary partner did you have anal sex? By non-primary partner, we mean someone you had sex with but do not feel committed to or don't know very well. This includes times when you were a top or bottom, used or didn't use a condom, and whether or not there was ejaculation." is greater than or equal to "1" Page entry logic: This page will show when: Question "Now we want to ask you about all of the other men you have had any anal sex with in the past 3 months other than your most recent primary partner.

Last Non-Primary
In the past 3 months, with how many men other than your most recent primary partner did you have anal sex? By non-primary partner, we mean someone you had sex with but do not feel committed to or don't know very well. This includes times when you were a top or bottom, used or didn't use a condom, and whether or not there was ejaculation." is greater than or equal to "1" (1) Less than a week ago

Last Non-Primary
(2) More than a week but less than a month ago (3) One to three months ago (4) Four to six months ago (5) Seven to twelve months ago (6) More than a year ago Page entry logic: This page will show when: Question "Now we want to ask you about all of the other men you have had any anal sex with in the past 3 months other than your most recent primary partner.
In the past 3 months, with how many men other than your most recent primary partner did you have anal sex? By non-primary partner, we mean someone you had sex with but do not feel committed to or don't know very well. This includes times when you were a top or bottom, used or didn't use a condom, and whether or not there was ejaculation." is greater than or equal to "1" (1) Yes (0) No (7) I don't know Page entry logic: This page will show when: Question "Now we want to ask you about all of the other men you have had any anal sex with in the past 3 months other than your most recent primary partner.

Last Non-Primary
In the past 3 months, with how many men other than your most recent primary partner did you have anal sex? By non-primary partner, we mean someone you had sex with but do not feel committed to or don't know very well. This includes times when you were a top or bottom, used or didn't use a condom, and whether or not there was ejaculation." is greater than or equal to "1"  Page exit logic: Skip / Disqualify LogicIF: (((((((((((((((((((((((((((((((((((( Question "In the past 3 months, that is since [question('value'), id='760'], which of the following apps and websites have you used? Select all that apply." is exactly equal to ("Facebook") OR Question "In the past 3 months, that is since [question('value'), id='760'], which of the following apps and websites have you used? Select all that apply." is exactly equal to ("Twitter")) OR Question "In the past 3 months, that is since [question('value'), id='760'], which of the following apps and websites have you used? Select all that apply." is exactly equal to ("Instagram")) OR Question "In the past 3 months, that is since [question('value'), id='760'], which of the following apps and websites have you used? Select all that apply." is exactly equal to ("Snapchat")) OR Question "In the past 3 months, that is since [question('value'), id='760'], which of the following apps and websites have you used? Select all that apply." is exactly equal to ("Facebook messenger")) OR Question "In the past 3 months, that is since [question('value'), id='760'], which of the following apps and websites have you used? Select all that apply." is exactly equal to ("Gmail")) OR Question "In the past 3 months, that is since [question('value'), id='760'], which of the following apps and websites have you used? Select all that apply." is exactly equal to ("Youtube")) OR Question "In the past 3 months, that is since [question('value'), id='760'], which of the following apps and websites have you used? Select all that apply." is exactly equal to ("Pandora")) OR Question "In the past 3 months, that is since [question('value'), id='760'], which of the following apps and websites have you used? Select all that apply." is exactly equal to ("Netflix")) OR Question "In the past 3 months, that is since [question('value'), id='760'], which of the following apps and websites have you used? Select all that apply." is exactly equal to ("Spotify")) OR Question "In the past 3 months, that is since [question('value'), id='760'], which of the following apps and websites have you used? Select all that apply." is exactly equal to ("Whatsapp")) OR Question "In the past 3 months, that is since [question('value'), id='760'], which of the following apps and websites have you used? Select all that apply." is exactly equal to ("Kik")) OR Question "In the past 3 months, that is since [question('value'), id='760'], which of the following apps and websites have you used? Select all that apply." is exactly equal to ("Match")) OR Question "In the past 3 months, that is since [question('value'), id='760'], which of the following apps and websites have you used? Select all that apply." is exactly equal to ("Ok Cupid")) OR Question "In the past 3 months, that is since [question('value'), id='760'], which of the following apps and websites have you used? Select all that apply." is exactly equal to ("Tinder")) OR Question "In the past 3 months, that is since [question('value'), id='760'], which of the following apps and websites have you used? Select all that apply." is exactly equal to ("Craigslist")) OR Question "In the past 3 months, that is since [question('value'), id='760'], which of the following apps and websites have you used? Select all that apply." is exactly equal to ("Adam4Adam")) OR Question "In the past 3 months, that is since [question('value'), id='760'], which of the following apps and websites have you used? Select all that apply." is exactly equal to ("Bareback Real Time (BBRT)")) OR Question "In the past 3 months, that is since [question('value'), id='760'],