PrEP Her, Empower Her
Please fill out this needs assessment form
What is your age?
*
Gender
*
Please Select
Cisgender Female (Assigned female at birth)
Cisgender Male (Assigned male at birth)
Transgender Female
Transgender Male
Nonbinary
What county in SC do you reside?
*
What is your race?
*
Black/African American
Caucasian
Hispanic/Latino
Asian
Native American
Other
1. Have you ever heard of HIV pre-exposure prophylaxis (PrEP)?
Yes
No
Not sure
2. If yes, where did you hear about PrEP?
doctor/clinic
social media
pharmacy
church/community group
friend/family
other
3. Before today, how much did you know about what PrEP does?
Nothing
A little
Some
A lot
4. Do you think PrEP is effective at preventing HIV when taken as prescribed?
Yes
No
Not sure
5. Would you consider taking PrEP if it were recommended by your healthcare provider?
Yes
No
Maybe
6. What concerns would make you hesitate to take PrEP?
side effects
cost/insurance
stigma
partner disapproval
daily pill burden
distrust of medical system
I have no concerns
7. What would make it easier for you to access PrEP?
free/low-cost
clinic near me
telehealth visits
same-day start
pharmacy pick-up
transportation support
childcare available during visits
8. How comfortable are you with using telehealth (video or phone) for HIV prevention car, including counseling and prescription management?
Very uncomfortable
Somewhat uncomfortable
Somewhat comfortable
Very comfortable
9. If offered a hybrid program ( in-person for testing and initial visit, tele-visits for follow-up and prescription refill), how likely would you be to use it?
Very unlikely
Unlikely
Likely
Very Likely
10. Is there anything else you would want providers to know about barriers or preferences for HIV prevention services? (short open-ended)
Thank You for your time!
Print Form
Save
Submit Survey
Should be Empty: