Sexual Health Knowledge Questionnaire for HIV+ MSM

Abstract

The Sexual Health Knowledge Questionnaire for HIV+ MSM (SHKQ) is an 18-item psychometric instrument designed to assess specialized, prevention-oriented sexual health knowledge among human immunodeficiency virus-positive (HIV+) men who have sex with men (MSM). Developed by Peter A. Vanable, Jennifer L. Brown, Michael P. Carey, and Rebecca A. Bostwick at Syracuse University’s Center for Health and Behavior, the instrument addresses a critical gap in behavioral medicine: while numerous measures evaluate general HIV etiology and primary prevention knowledge among seronegative populations, few tools systematically assess secondary prevention, co-infection dynamics, and transmission mechanics relevant to individuals already living with HIV. The SHKQ employs a three-option response format (“True,” “False,” and “Don’t Know”) across 18 declarative statements covering six core domains: viral load dynamics and infectivity, sexually transmitted disease (STD) co-infections, HIV superinfection and reinfection, sexual positioning mechanics (insertive vs. receptive anal intercourse), oral sex risk, and prophylactic barrier maintenance (e.g., condom lubricant compatibility). Psychometric evaluation in a clinical cohort of HIV+ MSM (N = 80; mean age = 40.6 years; mean duration of HIV diagnosis = 9.0 years) established robust 3-month test-retest reliability (r = .78, p < .001) in an untreated delayed-intervention control group. Convergent validity was demonstrated via statistically significant correlations with generalized HIV medical knowledge (r = .34, p < .005), favorable attitudes toward condom use (r = .24, p < .05), and formal education level (r = .23, p < .05). Furthermore, the SHKQ demonstrated strong evaluative sensitivity to intervention-induced cognitive change within a randomized controlled trial: participants receiving an immediate behavioral risk-reduction curriculum exhibited significant improvements from baseline (M = 9.3, SD = 3.3) to post-intervention (M = 10.7, SD = 2.4), whereas control participants demonstrated no change over a comparable 3-month window, F(1, 63) = 9.0, p < .005. The SHKQ serves as an empirically validated, brief, and diagnostically sensitive instrument for public health research, behavioral intervention trials, and clinical HIV secondary prevention settings.

Keywords

Sexual Health Knowledge Questionnaire, SHKQ, HIV positive, men who have sex with men, MSM, secondary prevention, sexually transmitted infections, viral load, HIV superinfection, Information-Motivation-Behavioral Skills model, psychometrics, behavioral medicine

Authors

The Sexual Health Knowledge Questionnaire for HIV+ MSM was conceptualized, developed, and empirically evaluated by a team of clinical psychologists and health behavior researchers at Syracuse University:

• Peter A. Vanable, Ph.D. — Professor of Psychology, Center for Health and Behavior, Syracuse University, Syracuse, New York. Dr. Vanable’s research focuses on health behavior change, sexual risk reduction, and medical adherence among individuals living with chronic infectious illnesses. (Corresponding Author: [email protected]).
• Jennifer L. Brown, Ph.D. — Research Associate / Assistant Professor, Department of Psychology and Center for Health and Behavior, Syracuse University (subsequently at the University of Cincinnati College of Medicine). Specializes in psychiatric comorbidities, addiction, and HIV risk reduction.
• Michael P. Carey, Ph.D. — Professor of Psychology, Center for Health and Behavior, Syracuse University (subsequently Director of the Centers for Behavioral and Preventive Medicine at The Miriam Hospital and Brown University). Widely recognized for developing standard psychometric instruments in HIV prevention, including the Brief HIV Knowledge Questionnaire (HIV-KQ-18).
• Rebecca A. Bostwick, M.P.A. — Project Director, Center for Health and Behavior, Syracuse University. Specializes in clinical trial operations, intervention delivery, and health communication research.

Purpose

The primary purpose of the Sexual Health Knowledge Questionnaire for HIV+ MSM (SHKQ) is to quantify accurate, prevention-relevant health knowledge specifically calibrated to the biological, epidemiological, and behavioral realities of men living with diagnosed HIV. Historically, HIV-related psychometric inventories were developed to support primary prevention initiatives designed to prevent uninfected individuals from acquiring the virus (Carey & Schroder, 2002). Consequently, existing legacy measures predominantly evaluate rudimentary knowledge concerning basic transmission vectors (e.g., sharing utensils, casual touch, insect bites, blood transfusions). While these instruments served public health priorities during earlier phases of the epidemic, they suffer from extreme ceiling effects and construct irrelevance when administered to individuals who have been living with HIV for years or decades.

Persons living with HIV face a distinct array of medical, immunological, and interpersonal challenges that require an advanced, nuanced understanding of secondary prevention and personal health maintenance. For HIV+ MSM, sexual health decision-making involves understanding how comorbid sexually transmitted infections (such as syphilis, gonorrhea, and chlamydia) elevate viral shedding in the genital and rectal mucosa, thereby amplifying both outward transmission to seronegative partners and the biological vulnerability of the host to secondary complications. Moreover, individuals living with HIV must navigate complex epidemiological phenomena, including HIV superinfection (reinfection with a genetically divergent, drug-resistant viral strain), human papillomavirus (HPV)-mediated anal dysplasia and neoplasia, the role of systemic viral suppression, and the specific per-act risks associated with different sexual positions (insertive versus receptive anal intercourse).

The SHKQ was constructed to serve three distinct functions across academic, clinical, and intervention environments:

• Baseline Needs Assessment: In outpatient infectious disease clinics, community-based organizations, and sexual health centers, the SHKQ identifies specific informational deficits, misconceptions, and clinical blind spots among patients, allowing clinicians to tailor risk-reduction counseling.
• Curricular Evaluation in Intervention Research: As behavioral medicine researchers design secondary prevention interventions, the SHKQ serves as an evaluative endpoint to determine whether educational and skill-building workshops effectively impart critical sexual health knowledge.
• Theoretical Mediation Modeling: In behavioral science, the SHKQ operationalizes the “Information” component within formal behavioral architectures, such as the Information-Motivation-Behavioral Skills (IMB) model, allowing researchers to evaluate how factual comprehension interacts with motivational constructs and behavioral self-efficacy to predict condom use, partner notification, and serosorting practices.

Psychological Construct

The psychological construct assessed by the SHKQ is prevention-relevant sexual health knowledge for HIV-positive gay, bisexual, and other men who have sex with men. Rather than measuring generalized academic medical knowledge (e.g., biological mechanisms of reverse transcriptase or absolute CD4 cell counts), the SHKQ captures an individual’s actionable understanding of how specific sexual behaviors, viral characteristics, co-pathogens, and prophylaxis methods influence personal health and transmission dynamics. This construct is multidimensional in its operational breadth, covering six distinct thematic sub-domains:

1. Viral Load Dynamics and Infectivity Mechanics

The questionnaire evaluates comprehension of how peripheral plasma and mucosal viral load correlate with transmission probabilities. Items probe whether participants understand that achieving an undetectable viral load markedly reduces transmission risk, while simultaneously evaluating beliefs regarding complete eradication of transmission risk. In the context of early-to-mid 2000s medicine when the instrument was validated, this represented a critical distinction between proportional risk reduction and absolute risk elimination, highlighting the need for nuanced cognitive appraisals among serodiscordant couples.

2. Sexually Transmitted Infection (STI) Synergy and Disease Progression

A central biological reality assessed by the construct is the bidirectional synergy between classical STIs and HIV pathogenesis. The SHKQ assesses whether respondents understand that localized mucosal inflammation (e.g., urethritis, proctitis) recruits activated CD4+ T-lymphocytes and macrophages, substantially elevating local HIV viral shedding in semen and rectal secretions. Conversely, it tests whether patients comprehend that contracting an intercurrent bacterial or viral STI can trigger immune activation, thereby accelerating HIV disease progression and elevating plasma viral load.

3. HIV Superinfection and Seroconcordant Sex Risks

Many individuals living with HIV historically assumed that sexual activity with another seropositive individual (“serosorting”) carries zero biological risk. The construct measured by the SHKQ directly accounts for this misconception by evaluating knowledge surrounding HIV reinfection (superinfection), the transmission of antiretroviral drug-resistant viral strains between seroconcordant partners, and the persistent medical indication for barrier methods during seropositive encounters to prevent acquiring multi-class resistant virus or novel bacterial pathogens.

4. Route-Specific and Positional Transmission Mechanics

Transmission risk varies dramatically depending on anatomical exposure and sexual role. The SHKQ measures an individual’s understanding of differential transmission risks across insertive versus receptive anal intercourse, clarifying whether the respondent recognizes that an HIV-infected receptive partner (“bottom”) is biologically less likely to transmit the virus to an insertive partner (“top”) than vice versa, although significant risk persists across both modalities. Additionally, the construct covers the relative transmission profile of oral intercourse compared to penetrative anal or vaginal intercourse.

5. Barrier Methods and Chemical Compatibility

The operational construct includes practical, behavioral knowledge concerning barrier integrity. Specifically, it assesses knowledge regarding the deleterious interaction between oil-based lubricants (such as petroleum jelly or mineral oil) and latex barriers, which causes rapid structural dissolution and micro-tearing of latex condoms within minutes of exposure.

6. Specific Opportunistic Pathogens and Neoplastic Risks

Finally, the construct encompasses knowledge of non-HIV pathogens disproportionately affecting MSM. This includes understanding the etiology of rectal cancer linked to oncogenic strains of Human Papillomavirus (HPV), the fecal-oral transmission dynamics of Hepatitis A through anilingus (“rimming”), the anatomical tropism of pharyngeal gonorrhea, and the fundamental biological distinction between curable bacterial STIs (e.g., syphilis, chlamydia) and incurable viral STIs (e.g., herpes simplex virus, HPV).

Theoretical Framework

The SHKQ is grounded in contemporary health psychology and behavioral medicine, drawing primarily upon the Information-Motivation-Behavioral Skills (IMB) Model formulated by Fisher and Fisher (1992). The IMB model posits that health-related behavioral change is a direct function of three interrelated components:

1. Information: Accurate, non-heuristic, and actionable knowledge regarding personal vulnerability, transmission mechanisms, and preventive actions.
2. Motivation: Both personal attitudes toward preventive acts (e.g., condom evaluation, affective comfort) and social/normative support for safer sex.
3. Behavioral Skills: Objective competencies and subjective self-efficacy required to execute the behavior, negotiate risk with sexual partners, and properly deploy preventive technologies.

Within the IMB architecture, general knowledge about a disease is insufficient to drive behavior change. Rather, information must be directly applicable to behavioral execution and tailored to the unique epidemiological realities of the target population. For HIV+ MSM, standard primary prevention facts do not supply the cognitive foundation necessary to navigate seroconcordant relationships, negotiate viral load disclosure, or recognize how an untreated urethral infection elevates the infectivity of semen. According to the IMB framework, when individuals possess targeted, medically accurate information, cognitive barriers and health-defeating heuristics (such as the belief that two HIV+ individuals cannot harm each other through unprotected sex) are dismantled. This factual substrate is an essential, necessary condition for motivation and behavioral skills to translate into reduced risk behavior.

The SHKQ also aligns with the Health Belief Model (HBM) (Rosenstock, 1974), specifically targeting perceived susceptibility and perceived severity. Seropositive individuals who hold the erroneous belief that they can no longer experience harm from unprotected sex underestimate their personal susceptibility to drug-resistant viral superinfection, synergistic bacterial STDs, and oncogenic viral infections. By measuring accurate appraisals of these hazards, the SHKQ evaluates the cognitive prerequisites that govern perceived threat, which in turn influences cue utilization and risk-reduction behaviors.

Finally, the scale incorporates principles of Bandura’s (1986) Social Cognitive Theory (SCT), particularly the role of outcome expectancies. Outcome expectancies represent an individual’s belief that engaging in a specific behavior (e.g., using latex-compatible lubricant, continuing condom use with seroconcordant partners, obtaining routine pharyngeal and rectal STI screenings) will yield specific, predictable health benefits. The SHKQ systematically measures whether participants understand these causal relationships, thereby evaluating the cognitive foundation upon which behavioral self-efficacy is constructed.

Validity

The psychometric validity of the SHKQ was established through a series of empirical investigations conducted during the development and pilot testing of a behavioral risk-reduction intervention for HIV+ MSM in upstate New York (Vanable et al., 2008, 2009).

1. Content and Face Validity

Items were generated through an extensive literature review and direct qualitative consultation with HIV-infected MSM and clinical infectious disease specialists. Item content was specifically matched to the core knowledge modules of evidence-based secondary prevention curricula. Questions were designed to eliminate colloquial ambiguities and directly challenge common behavioral myths prevalent within the HIV community (e.g., the belief that oral sex carries zero risk, or that viral STIs are readily curable with standard antibiotics).

2. Convergent Validity

To evaluate convergent construct validity, researchers examined bivariate correlations between total SHKQ scores and established psychometric instruments measuring conceptually related domains in a baseline sample of 80 HIV+ MSM:

• General HIV Medical Knowledge: SHKQ scores demonstrated a statistically significant positive correlation with a 5-item scale assessing basic biomedical HIV knowledge (e.g., the immunological meaning of CD4 cell counts), with r = .34 (p < .005). This confirms that while the SHKQ taps into a related domain of biological literacy, it captures distinct behavioral and secondary prevention dimensions not accounted for by standard medical knowledge tests.
• Attitudes Toward Condom Use: Scores on the SHKQ were positively and significantly associated with favorable attitudes toward condom usage, as measured by an adapted version of the Sacco et al. (1991) Condom Attitudes Scale (r = .24, p < .05). Higher secondary prevention knowledge corresponds with more positive cognitive evaluations of prophylactic barriers.
• Formal Education Level: Total knowledge scores correlated positively with participants’ educational attainment (r = .23, p < .05), a finding consistent with health literacy psychometrics, while remaining sufficiently modest to prove that the SHKQ does not merely serve as an indirect surrogate for socioeconomic or general cognitive status.

3. Evaluative Validity and Sensitivity to Change

A crucial psychometric attribute of any educational assessment is its sensitivity to detect actual changes in cognitive mastery following an instructional intervention. The SHKQ demonstrated exceptional evaluative validity across a randomized controlled trial comparing an immediate sexual risk-reduction intervention group (n = 40) against a time-delayed intervention control condition (n = 40):

• Between-Groups Intervention Effect: Participants in the immediate two-session intervention condition who attended at least one workshop exhibited a significant increase in SHKQ scores from baseline (M = 9.3, SD = 3.3) to 3-month follow-up (M = 10.7, SD = 2.4). In contrast, participants in the delayed intervention condition exhibited flat performance over the same 3-month observation window (M = 10.1, SD = 2.4 at baseline vs. stable follow-up scores), yielding a statistically significant group-by-time interaction effect, F(1, 63) = 9.0, p < .005.
• Within-Subjects Crossover Effect: Following the 3-month control period, participants in the delayed intervention condition were administered the two-session intervention. A paired-samples t-test revealed a significant increase in sexual health knowledge from pre-intervention (M = 10.1, SD = 2.4) to post-intervention assessment (M = 12.0, SD = 2.1), t(23) = -4.8, p < .001. These robust longitudinal shifts confirm that the SHKQ is sensitive to targeted educational programming.

Reliability

Reliability evaluation for the SHKQ focused on temporal stability and scale consistency across repeated testing administrations in the target clinical population.

1. Test-Retest Reliability

Because knowledge scales can be vulnerable to practice effects, memory regression, and external environmental learning, establishing the temporal stability of the instrument in the absence of an intervention was a foundational psychometric step. Test-retest reliability was evaluated using data from participants randomly assigned to the time-delayed intervention control condition who completed assessments at baseline and at the 3-month follow-up prior to receiving any intervention programming (n = 35). The bivariate correlation coefficient across this 3-month period was:

r = .78, p < .001

According to standardized psychometric benchmarks established by Cicchetti (1994) for psychological assessment instruments, a test-retest coefficient of .78 over a 90-day duration demonstrates moderate to excellent temporal agreement, indicating that the baseline knowledge construct remains highly stable over time when no structured psychoeducational intervention is introduced.

2. Internal Consistency and Item Homogeneity Considerations

In criterion-referenced and factual knowledge testing, traditional internal consistency indices such as Cronbach’s alpha or Kuder-Richardson Formula 20 (KR-20) reflect item difficulty variance across distinct factual domains rather than a unitary, homogenous psychological trait. Because the 18 items of the SHKQ sample distinct epidemiological, biological, and behavioral domains (ranging from lubricant chemistry to viral superinfection and HPV oncology), broad item difficulty distribution is intentionally preserved. Across validation samples, the SHKQ exhibits functional item discrimination, with participants’ overall scores tracking their broader exposure to health information and secondary prevention education.

Factor Analysis

In educational and health knowledge testing, instruments covering diverse biological and behavioral topics are typically evaluated as unidimensional composite indexes or multidimensional domain clusters depending on analytic intent. During the psychometric evaluation of the SHKQ:

Structural Dimensionality

Given the dichotomous scoring architecture (Correct = 1, Incorrect/Unsure = 0) of the 18 items, exploratory structural analysis was informed by tetrachoric correlation modeling. Rather than demonstrating orthogonal sub-constructs, the scale demonstrates an underlying general factor of prevention-relevant health literacy, complemented by thematic item clusters reflecting the educational modules from which the scale was derived:

• Cluster 1: Viral Load & Infectivity (Items 1, 5) — Reflecting the relationship between systemic viral suppression, transmission risk reduction, and residual risk.
• Cluster 2: STI Synergy & Disease Progression (Items 2, 3, 12) — Grouping items that describe the biological interaction between bacterial/viral co-infections, mucosal viral shedding, and accelerated immunocompromise.
• Cluster 3: Anatomical and Positional Transmission Mechanics (Items 9, 10, 15, 17) — Capturing differential probabilities across insertive vs. receptive anal sex and pharyngeal/oral exposure pathways.
• Cluster 4: Pathogen Taxonomy & Neoplasia (Items 4, 6, 8, 13) — Differentiating curable bacterial STDs (syphilis) from persistent oncogenic viruses (HPV-related rectal cancer) and enterically transmitted viral hepatitis (Hepatitis A via anilingus).
• Cluster 5: Seroconcordant Risks and Superinfection (Items 7, 11, 16, 18) — Evaluating the misconceptions surrounding sex between two HIV+ individuals, focusing on superinfection with drug-resistant strains and overall health preservation.
• Cluster 6: Barrier Prophylaxis Mechanics (Item 14) — Isolating technical knowledge concerning condom material breakdown via oil-based lubricants.

Because the primary practical objective of the SHKQ is to yield an overarching baseline index of secondary prevention knowledge for clinical and research purposes, the authors recommend utilizing the unidimensional composite score (sum of correct items, ranging from 0 to 18) as the primary outcome variable. Structural equation modeling and intervention evaluations confirm that treating the measure as a unified knowledge composite maximizes statistical power and diagnostic sensitivity across diverse cohorts.

Instrument / Measurement Tool

• Test Type: Standardized factual knowledge questionnaire / health literacy assessment.
• Format: 18 declarative statements evaluated via a three-option forced-choice categorical response format (“True,” “False,” or “Don’t Know”).
• Item Count: 18 discrete items.
• Administration Time: Approximately 5 minutes.
• Administration Modality: Self-administered paper-and-pencil, computer-assisted personal interview (CAPI), or audio computer-assisted self-interviewing (ACASI) to minimize social desirability bias.
• Target Population: Adult gay, bisexual, and other men who have sex with men (MSM) who have received a confirmed diagnosis of HIV-1 or HIV-2 infection.
• Scoring Instructions:
  • Each item is scored dichotomously as either Correct (1 point) or Incorrect (0 points).
  • Selecting “Don’t Know” is scored as 0 points (incorrect) to discourage guessing and preserve measurement precision.
  • Items where “True” is the correct response (1 point): 1, 2, 3, 4, 6, 9, 11, 13, 15, 17, 18.
  • Items where “False” is the correct response (1 point): 5, 7, 8, 10, 12, 14, 16.
  • Total Score Calculation: Sum the points across all 18 items. Theoretical range = 0 to 18. Higher aggregate scores indicate greater mastery of sexual health and secondary prevention knowledge.

Permissions & Fee and Test Year

The Sexual Health Knowledge Questionnaire for HIV+ MSM was developed between 2006 and 2008 as part of an intervention trial supported by research grants from the National Institute of Mental Health (NIMH Grant R21-MH65865 and Fellowship F31MH081751). The psychometric properties and scale items were formally published and presented in 2008 and 2009 by Peter A. Vanable and colleagues.

The SHKQ is placed in the public domain for academic, clinical, and non-commercial research use. Researchers, behavioral interventionists, and healthcare providers may utilize, administer, and reproduce the instrument without paying royalty fees. Inquiries regarding permission for broad institutional implementation, modifications, or cross-cultural adaptation may be directed to the corresponding author:

Peter A. Vanable, Ph.D.
Department of Psychology & Center for Health and Behavior
Syracuse University
430 Huntington Hall, Syracuse, NY 13244
Email: [email protected]

References

• Carey, M. P., & Schroder, K. E. (2002). Development and psychometric evaluation of the brief HIV Knowledge Questionnaire. AIDS Education and Prevention, 14(2), 172–182. https://doi.org/10.1521/aeap.14.2.172.23902
• Cicchetti, D. V. (1994). Guidelines, criteria, and rules of thumb for evaluating normed and standardized assessment instruments in psychology. Psychological Assessment, 6(4), 284–290. https://doi.org/10.1037/1040-3590.6.4.284
• Fisher, J. D., & Fisher, W. A. (1992). Changing AIDS-risk behavior. Psychological Bulletin, 111(3), 455–474. https://doi.org/10.1037/0033-2909.111.3.455
• Johnson, B. T., Carey, M. P., Marsh, K. L., Levin, K. D., & Scott-Sheldon, L. A. (2003). Interventions to reduce sexual risk for the human immunodeficiency virus in adolescents, 1985–2000: A research synthesis. Archives of Pediatrics & Adolescent Medicine, 157(4), 381–388. https://doi.org/10.1001/archpedi.157.4.381
• Sacco, W. P., Levine, B., Reed, D. L., & Thompson, K. (1991). Attitudes about condom use as an AIDS-relevant behavior: Their factor structure and relation to condom use. Psychological Assessment: A Journal of Consulting and Clinical Psychology, 3(2), 265–272. https://doi.org/10.1037/1040-3590.3.2.265
• Vanable, P. A., & Carey, M. P. (2006). Behavioral medicine interventions in HIV/AIDS: Challenges and opportunities for promoting health and adaptation. In A. R. Kuczmierczyk & A. Nikcevic (Eds.), A clinician’s guide to behavioral medicine: A case formulation approach. New York: Brunner-Routledge.
• Vanable, P. A., Carey, M. P., Brown, J. L., Bostwick, R. A., & Blair, D. (2008, March). A pilot intervention trial to promote sexual health and stress management among HIV+ MSM. Poster presented at the 29th Annual Meeting & Scientific Sessions of the Society of Behavioral Medicine, San Diego, CA.
• Vanable, P. A., Carey, M. P., Brown, J. L., Littlewood, R., Bostwick, R. A., & Blair, D. (2009). What HIV+ men who have sex with men say is needed to promote sexual risk reduction. AIDS and Behavior, 13(5), 903–912. https://doi.org/10.1007/s10461-009-9571-0

13. Items of the Scale (Questionnaire)