EmailMeForm
Name
*
First
Last
Email
*
In which island/country do you currently practice?
Your primary profession/discipline
Your highest earned degree/credential
Do you provide HIV prevention counseling and testing services to clients/patients?
Yes
No
If No for both, Stop here. You are done with this form and can click on Register below.
...If you provide services for clients/patients with HIV or Hepatitis C, please continue...
If Yes; How many YEARS have you been providing services directly to clients/patients living with:
HIV (round up to the nearest whole year)
HCV (round up to the nearest whole year)
Do you provide services directly to clients/patients living with HIV or Hepatitis C?
Yes
No
Do you provide HCV prevention counseling and testing services to clients/patients?
Yes
No
Do you prescribe HIV pre-exposure prophylaxis (PrEP) to clients/patients?
Yes
No
Do you prescribe antiretroviral therapy (ART) to clients/patients?
Yes
No
Estimate the NUMBER of clients/patients living with HIV to whom you provided direct services in the past YEAR
Estimate the NUMBER of clients/patients living with HCV to whom you provided direct services in the past YEAR
Estimate the PERCENTAGE of your clients/patients living with HIV in the past YEAR who are receiving antiretroviral therapy
None
1-24%
25-49%
50-74%
>75%
Estimate the PERCENTAGE of your clients/patients living with HCV in the past YEAR who are receiving antiretroviral therapy
None
1-24%
25-49%
50-74%
>75%
What is your gender? Please select
Female
Male
Other. Please identify gender below
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