Background assessment for clients with HIV infection on PrEP

        Please read through the informed consent form first before you start answering the questions.

You have recently received a positive HIV test while you were taking PrEP.  To understand better your behavior in the past, and to be able to provide better information for other men who have sex with men and want to use PrEP, we would like to ask you a number of questions about your sexual behavior in the past, when you used PrEP.  These informations will be used in a case report and made available to a scientific audience. It is important for us to better understand your behavior while you were on PrEP, since there is little information available. So you can contribute to helping the community.

        Most importantly for you, your data you provide here, as well as data related to your HIV status, will be used fully anonymously. No link to you and your person will be made possible. For example we will talk about you as "A man, age XX, who turned HIV positive while taking PrEP reported the following behavior”. Furthermore, we will describe your behavior, all in a neutral and non-judgmental way. You can stop anytime with the questionnaire, and/or decide not to answer specific questions.

 

Declaration of Consent for participation in the research studyHIV infection on PrEP

 

            I have been informed of the study. I have read the written information. I have had the opportunity to ask questions about the study. I have been able to think about my participation in the study, which is completely voluntary. I have the right to withdraw my consent and leave the study at any time without having to give a reason

             The responsible researcher, declares that the above person has been informed verbally and in writing about the study mentioned above.

            Name: Dr. Deyn Natthakhet

            Position: Medical Director Silom Pulse Clinic

            Date: 20 APRIL 2017

 

I agree to participate in the study, 

Note: Please fill out the fields marked with an asterisk.

SILOM PULSE CLINIC: 60/4 Silom Road, Suriyawong, Bangkok, Thailand  Tel: (+66) 95 915 6385  Email : info@silompulse.com 

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