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Sexually Transmitted Diseases Presenter Norma Sanchez, CDS II.

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Presentation on theme: "Sexually Transmitted Diseases Presenter Norma Sanchez, CDS II."— Presentation transcript:

1 Sexually Transmitted Diseases Presenter Norma Sanchez, CDS II

2 STD Overview STDs affect men and women of all backgrounds and economic levels. STDs affect men and women of all backgrounds and economic levels. Most prevalent among teens and young adults with nearly 2/3 of all STDs occurring in people under age 25. Most prevalent among teens and young adults with nearly 2/3 of all STDs occurring in people under age 25. Contributing factors in the rise of STDs include: young people have become sexually active earlier, divorce is more common and sexually active people are more likely to have multiple sex partners. Important to note that it is the behavior which puts you at risk not who you are. Contributing factors in the rise of STDs include: young people have become sexually active earlier, divorce is more common and sexually active people are more likely to have multiple sex partners. Important to note that it is the behavior which puts you at risk not who you are.

3 Types of STDs Bacterial Bacterial Chlamydia Chlamydia Gonorrhea Gonorrhea Pelvic Inflammatory Disease (PID) Pelvic Inflammatory Disease (PID) Syphilis Syphilis Viral Viral Genital Warts Genital Warts Hepatitis B and C Hepatitis B and C Herpes Herpes HIV HIV

4 Warning! This section contains graphic images of infectious diseases – This section contains graphic images of infectious diseases – You have been warned You have been warned

5 Chlamydia Caused by Chlamydia Trachomatis. Caused by Chlamydia Trachomatis. Can be transmitted during vaginal, oral, and anal sexual contact. Can be transmitted during vaginal, oral, and anal sexual contact. If symptoms appear, they will occur 1-3 weeks after exposure. If symptoms appear, they will occur 1-3 weeks after exposure. Complications: PID, sterility, premature or still births, blindness. Complications: PID, sterility, premature or still births, blindness.

6

7 Picture of a Normal Cervix

8 Cervical Ectopy

9 Inflammation of the cervix from Chlamydia infection

10 Chlamydia/GC

11 Symptoms of Chlamydia Symptoms in Women: Usually asymptomatic Usually asymptomatic Abnormal vaginal discharge Abnormal vaginal discharge Pain during sex Pain during sex Complications, if not treated: Pelvic inflammatory disease (PID) Pelvic inflammatory disease (PID)(PID) Symptoms in Men: Usually asymptomatic Usually asymptomatic Discharge from the penis (may be runny, whitish) Discharge from the penis (may be runny, whitish) Burning on urination Burning on urination Complications, if not treated Swollen and tender testicles (epididymitis) Swollen and tender testicles (epididymitis)(epididymitis) Chlamydia

12 Chlamydia Symptoms in Men Chlamydia Source: Seattle STD/HIV PTC

13 Chlamydia Symptoms in Women Mucopurulent Cervicitis Chlamydia Source: St. Louis STD/HIV PTC

14 Testing & Treatment for Chlamydia Easily detected by a urine test or a swab; and Easily detected by a urine test or a swab; and Easily cured with antibiotics; but Easily cured with antibiotics; but Any damage to the body cannot be repaired Any damage to the body cannot be repaired Chlamydia

15 Gonorrhea Caused by Neisseria gonorrhea. Caused by Neisseria gonorrhea. Symptoms may occur 2-21 days after exposure. Symptoms may occur 2-21 days after exposure. Transmitted during vaginal, anal and oral sex. Transmitted during vaginal, anal and oral sex. Can also be transmitted from infected mother to infant during birth. Can also be transmitted from infected mother to infant during birth. Complications: PID, sterility, blindness, meningitis, kidney and heart damage, skin rash, ectopic pregnancy. Complications: PID, sterility, blindness, meningitis, kidney and heart damage, skin rash, ectopic pregnancy.

16 Symptoms of Gonorrhea For Women For Women Thick yellow or white discharge from vagina Thick yellow or white discharge from vagina Bleeding from vagina between periods Bleeding from vagina between periods Burning/pain when urinating/during bowel movement Burning/pain when urinating/during bowel movement Cramps and pain in lower abdomen Cramps and pain in lower abdomen For Men For Men Thick yellow or white drip from the penis Thick yellow or white drip from the penis Burning or pain when urinating Burning or pain when urinating Need to urinate more often Need to urinate more often

17 Gonorrhea

18 Complications in Men Swollen or tender testicles (epididymitis) Swollen or tender testicles (epididymitis) Disseminated gonococcal infection (DGI) Disseminated gonococcal infection (DGI) Gonorrhea

19 Swollen or Tender Testicles (Epididymitis) Source: Health Awareness Connection, Gonorrhea

20 Disseminated Gonococcal (Gonorrhea) Infection Source: CDC/NCHSTP/Division of STD Prevention, STD Clinical Slides Gonorrhea

21 Gonorrhea Symptoms in Women Usually asymptomatic Usually asymptomatic Painful urination Painful urination Abnormal vaginal bleeding Abnormal vaginal bleeding Pain during sex Pain during sex Source: CDC/NCHSTP/Division of STD Prevention, STD Clinical Slides Gonorrhea

22 Cervical GC

23 Complications in Women Bartholin’s Abscess Bartholin’s Abscess Pelvic inflammatory disease (PID) Pelvic inflammatory disease (PID) Disseminated gonococcal infection (DGI) Disseminated gonococcal infection (DGI) Gonorrhea

24 Bartholin’s Abscess Source: CDC/NCHSTP/Division of STD Prevention, STD Clinical Slides Gonorrhea

25 Pelvic Inflammatory Disease (PID) Source: Cincinnati STD/HIV Prevention Training Center Gonorrhea

26 Gonorrhea in Infants A mother can pass gonorrhea to her baby during childbirth A mother can pass gonorrhea to her baby during childbirth Gonorrhea

27 Testing & Treatment for Gonorrhea Easily detected by a urine test or swab; and Easily detected by a urine test or swab; and Easily cured with antibiotics; but Easily cured with antibiotics; but Any damage to the body cannot be repaired. Any damage to the body cannot be repaired. Gonorrhea

28 Pelvic Inflammatory Disease (PID) Usually caused by Chlamydia trachomatis or Neisseria gonorrhea. Usually caused by Chlamydia trachomatis or Neisseria gonorrhea. PID occurs when bacteria travel from the vagina through the cervix and into the uterus, fallopian tubes, or ovaries. PID occurs when bacteria travel from the vagina through the cervix and into the uterus, fallopian tubes, or ovaries. Symptoms: Symptoms: Pain in the lower abdomen or lower back. Pain in the lower abdomen or lower back. Pain in the abdomen during sex. Pain in the abdomen during sex. Fever, chills, or vomiting. Fever, chills, or vomiting. Unusual bleeding or discharge from the vagina. Unusual bleeding or discharge from the vagina. Complications: infertility, ectopic pregnancy, scar tissue in the pelvic organs, chronic abdominal pain. Complications: infertility, ectopic pregnancy, scar tissue in the pelvic organs, chronic abdominal pain.

29 Syphilis Caused by Treponema pallidum. Caused by Treponema pallidum. Transmitted during vaginal, anal and oral sex. Transmitted during vaginal, anal and oral sex. Symptoms may occur 10 days to 3 months after exposure. Symptoms may occur 10 days to 3 months after exposure. An infected mother can pass the disease to her unborn child. An infected mother can pass the disease to her unborn child. Three stages: Primary, secondary, tertiary or late. Three stages: Primary, secondary, tertiary or late.

30 Symptoms of Syphilis Primary Stage A painless sore called a chancre may be located on the genitals, lips, anus, or other area of direct contact A painless sore called a chancre may be located on the genitals, lips, anus, or other area of direct contact The chancre will last 1-5 weeks and heal without treatment The chancre will last 1-5 weeks and heal without treatment The person can easily pass it on to sex partners The person can easily pass it on to sex partners Syphilis

31 Primary Syphilis Chancre in a Man Source: CDC/ NCHSTP/ Division of STD Prevention, STD Clinical Slides Syphilis

32 Primary Syphilis Chancre in a Woman Source: CDC/ NCHSTP/ Division of STD Prevention, STD Clinical Slides Syphilis

33 Primary Syphilis The first symptom is a painless chancre at site of entry of the bacteria i.e. mouth, sex organs, breasts, or fingers which may occur 3-12 weeks after exposure. The first symptom is a painless chancre at site of entry of the bacteria i.e. mouth, sex organs, breasts, or fingers which may occur 3-12 weeks after exposure. Sore can last 1-5 weeks but then disappear. Sore can last 1-5 weeks but then disappear. Swollen glands. Swollen glands.

34 Primary chancre

35 Primary syphilis

36

37 Secondary Stage If syphilis is not treated in the first stage the symptom will go away. If syphilis is not treated in the first stage the symptom will go away. About 4 months later (early latent stage) secondary symptoms will show up. About 4 months later (early latent stage) secondary symptoms will show up. They may show up 0-10 weeks, average is 4 weeks. They may show up 0-10 weeks, average is 4 weeks. Symptoms may last 2-6 weeks, average is 4 weeks. Symptoms may last 2-6 weeks, average is 4 weeks.

38 Secondary Syphilis Rash anywhere, but primarily on palms and soles. Rash anywhere, but primarily on palms and soles. Patchy hair loss. Patchy hair loss. Sore throat. Sore throat. Swollen glands. Swollen glands. 1 week to 6 months after appearance of primary chancre. 1 week to 6 months after appearance of primary chancre. This set of symptoms will also eventually disappear. This set of symptoms will also eventually disappear.

39 Secondary Syphilis

40

41

42 Congenital Syphilis

43 Third Stage of Syphilis If a person is not treated during these two stages syphilis still remains in the body. If a person is not treated during these two stages syphilis still remains in the body. It may take several years but syphilis becomes “latent” which means: to hide. It may take several years but syphilis becomes “latent” which means: to hide. During this stage syphilis can do damage to the body. During this stage syphilis can do damage to the body.

44 Tertiary or Late Syphilis Approximately 1/3 of untreated cases of secondary syphilis will progress to this stage. Approximately 1/3 of untreated cases of secondary syphilis will progress to this stage. This stage may continue years with no obvious symptoms. This stage may continue years with no obvious symptoms. Can cause lesions on body organs such as the brain and heart. Can cause lesions on body organs such as the brain and heart.

45 Late Syphilis, Gumma

46 Special populations Women who are pregnant get tested at the beginning of their pregnancy if seen by a doctor. Women who are pregnant get tested at the beginning of their pregnancy if seen by a doctor. A woman may become infected during her pregnancy and may transmit syphilis to her child without knowing it. A woman may become infected during her pregnancy and may transmit syphilis to her child without knowing it. A baby born from a mother who has syphilis may die from complications of syphilis. A baby born from a mother who has syphilis may die from complications of syphilis.

47 End of bacterial slides There are more bacterial infections but these are the 3 that are reported to the Health Department. There are more bacterial infections but these are the 3 that are reported to the Health Department. QUESTIONS?????? QUESTIONS??????

48 Viruses Viruses are not curable. Viruses are not curable. The symptoms are treatable and can be manageable. The symptoms are treatable and can be manageable. The viruses we will talk about are: The viruses we will talk about are: Herpes Herpes Genital Warts Genital Warts Hepatitis B and C Hepatitis B and C HIV HIV

49 Genital Herpes Caused by the Herpes Simplex Virus. Caused by the Herpes Simplex Virus. Lives in CNS. Lives in CNS. Transmitted through skin to skin contact. Transmitted through skin to skin contact. Symptoms may occur 1-30 days after exposure. Symptoms may occur 1-30 days after exposure. Transmitted during vaginal, anal, and oral sex. Transmitted during vaginal, anal, and oral sex. Transmission can also occur when blisters are not present. Transmission can also occur when blisters are not present. No cure, only treatment available. No cure, only treatment available.

50 Symptoms of Genital Herpes Transmitted through skin to skin contact. Transmitted through skin to skin contact. Flu-like symptoms. Flu-like symptoms. Painful blisters/sores at the site of infection, i.e. mouth, penis, vagina, anus, cervix, lips, tongue, gums, and eyes. Painful blisters/sores at the site of infection, i.e. mouth, penis, vagina, anus, cervix, lips, tongue, gums, and eyes. Blisters can last 1-3 weeks. Blisters can last 1-3 weeks. Blisters will heal but may reappear throughout life. Blisters will heal but may reappear throughout life. Prodrome effect. Prodrome effect. Complications: May cause brain damage or death in infants. Complications: May cause brain damage or death in infants.

51 HSV I

52 HSV II

53 Human Papillomavirus (HPV)

54 Human Papillomavirus Many types of Human Papillomavirus (HPV), some of which infect the genital area Many types of Human Papillomavirus (HPV), some of which infect the genital area Incubation period unclear Incubation period unclear Can infect men, women, and newborns Can infect men, women, and newborns The person can easily pass it on to sex partners The person can easily pass it on to sex partners HPV

55 Genital HPV: Two Types The types of HPV that infect the genital area are labeled “low-risk” or “high-risk” depending on whether they can cause cancer or not. The types of HPV that infect the genital area are labeled “low-risk” or “high-risk” depending on whether they can cause cancer or not. Low-risk HPV types can cause genital warts. Low-risk HPV types can cause genital warts. High-risk HPV types can cause serious cervical lesions, cervical cancer, and other genital cancers. High-risk HPV types can cause serious cervical lesions, cervical cancer, and other genital cancers. HPV

56 Symptoms of Genital HPV Infection Usually asymptomatic and brief (6 – 12 months) Usually asymptomatic and brief (6 – 12 months) Genital warts (usually infection with low-risk type of HPV) Genital warts (usually infection with low-risk type of HPV) Warts on the penis, vagina, anus or urethra Warts on the penis, vagina, anus or urethra Rarely may have itching, bleeding, burning, or pain along with the warts Rarely may have itching, bleeding, burning, or pain along with the warts May go away on their own, stay about the same, or get worse May go away on their own, stay about the same, or get worse HPV

57 Symptoms of Genital HPV Infection Cervical lesions (usually infection with high- risk type of HPV) Cervical lesions (usually infection with high- risk type of HPV) Usually no symptoms Usually no symptoms Detected by Pap smear Detected by Pap smear Most will go away on their own Most will go away on their own Some will persist and need to be followed by health care provider Some will persist and need to be followed by health care provider Most women with high-risk HPV types do not get cervical cancer Most women with high-risk HPV types do not get cervical cancer HPV

58 HPV Penile Warts Source: Cincinnati STD/HIV Prevention Training Center HPV

59 Genital Warts in a Woman HPV Source: CDC/NCHSTP/Division of STD, STD Clinical Slides

60 Perianal Wart Source: Cincinnati STD/HIV Prevention Training Center HPV

61 Testing & Treatment for Genital Warts Genital Warts Genital Warts No tests for genital warts No tests for genital warts Several types of treatment are available Several types of treatment are available Warts may come back Warts may come back Cervical lesions and cervical cancer Cervical lesions and cervical cancer Regular Pap smears are best way to detect serious lesions and prevent cervical cancer Regular Pap smears are best way to detect serious lesions and prevent cervical cancer Pap smear screening is recommended for all sexually active women Pap smear screening is recommended for all sexually active women HPV

62 Genital Warts Caused by Human Papilloma Virus. Caused by Human Papilloma Virus. Symptoms may occur 1-8 months after exposure. Symptoms may occur 1-8 months after exposure. Transmitted by direct skin to skin contact. Transmitted by direct skin to skin contact. Can also be passed although no visible warts are present. Can also be passed although no visible warts are present. No cure, only treatment available for the warts. No cure, only treatment available for the warts. Complications: may cause cervical, vulvar, or penile cancer. Complications: may cause cervical, vulvar, or penile cancer.

63 Symptoms of Genital Warts Small, bumpy or flat warts on the sex organs and anus. Small, bumpy or flat warts on the sex organs and anus. Itching or burning around the sex organs. Itching or burning around the sex organs. Some people have no visible warts. Some people have no visible warts.

64 Symptoms of Genital Herpes Transmitted through skin to skin contact. Transmitted through skin to skin contact. Flu-like symptoms. Flu-like symptoms. Painful blisters/sores at the site of infection, i.e. mouth, penis, vagina, anus, cervix, lips, tongue, gums, and eyes. Painful blisters/sores at the site of infection, i.e. mouth, penis, vagina, anus, cervix, lips, tongue, gums, and eyes. Blisters can last 1-3 weeks. Blisters can last 1-3 weeks. Blisters will heal but may reappear throughout life. Blisters will heal but may reappear throughout life. Prodrome effect. Prodrome effect. Complications: May cause brain damage or death in infants. Complications: May cause brain damage or death in infants.

65 Condyloma (Warts)

66

67

68 Anal Warts

69 Penile Warts

70 Gardisil Current vaccine for Gardisil starting for young girls at age 9. Current vaccine for Gardisil starting for young girls at age 9. If on Medi-Cal they can be up to age 20 to receive a free physical and vaccine. If on Medi-Cal they can be up to age 20 to receive a free physical and vaccine. If not on Medi-Cal and is enrolled through CHDP it is up to age 18. If not on Medi-Cal and is enrolled through CHDP it is up to age doses, over a 6 month period 3 doses, over a 6 month period

71 Hepatitis B and C Hepatitis - Inflammation of the liver. Hepatitis - Inflammation of the liver. Transmitted during vaginal, anal, and oral sex, sharing razors, toothbrushes, needles. Transmitted during vaginal, anal, and oral sex, sharing razors, toothbrushes, needles. Can also be passed from infected mother to child during birth. Can also be passed from infected mother to child during birth. HBV can live on environmental surfaces for up to 7 days. HBV can live on environmental surfaces for up to 7 days. Complications: Cirrhosis, liver cancer and death. Can also cause premature birth or spontaneous abortion. Complications: Cirrhosis, liver cancer and death. Can also cause premature birth or spontaneous abortion.

72 Symptoms of Hepatitis Nausea, vomiting. Nausea, vomiting. Fatigue. Fatigue. Loss of appetite. Loss of appetite. Jaundice. Jaundice. Dark-colored urine/light-colored stools. Dark-colored urine/light-colored stools. Enlarged liver/liver pain. Enlarged liver/liver pain.

73 Herpes in a Woman Source: Cincinnati STD/HIV Prevention Training Center Herpes Source: CDC/NCHSTP/Division of STD, STD Clinical Slides

74 Herpes in a Man Source: Cincinnati STD/HIV Prevention Training Center Herpes

75 Herpes Complications HSV-2 causes serious problems when it is passed to newborns during birth. HSV-2 causes serious problems when it is passed to newborns during birth. Herpes

76 Testing & Treatment for Genital Herpes Can be detected by: Can be detected by: culturing the lesion culturing the lesion blood test blood test Herpes cannot be cured, but symptoms can be treated with medicines called antivirals. Herpes cannot be cured, but symptoms can be treated with medicines called antivirals. You can still spread herpes even if you are taking antiviral medicine! You can still spread herpes even if you are taking antiviral medicine! Herpes

77 Genital Herpes Caused by the Herpes Simplex Virus. Caused by the Herpes Simplex Virus. Lives in CNS. Lives in CNS. Transmitted through skin to skin contact. Transmitted through skin to skin contact. Symptoms may occur 1-30 days after exposure. Symptoms may occur 1-30 days after exposure. Transmitted during vaginal, anal, and oral sex. Transmitted during vaginal, anal, and oral sex. Transmission can also occur when blisters are not present. Transmission can also occur when blisters are not present. No cure, only treatment available. No cure, only treatment available.

78 You can get herpes anywhere... Source: Cincinnati STD/HIV Prevention Training Center Herpes

79 It gets worse!!!

80 Blue Waffle

81 Hepatitis B and C Hepatitis - Inflammation of the liver. Hepatitis - Inflammation of the liver. Transmitted during vaginal, anal, and oral sex, sharing razors, toothbrushes, needles. Transmitted during vaginal, anal, and oral sex, sharing razors, toothbrushes, needles. Can also be passed from infected mother to child during birth. Can also be passed from infected mother to child during birth. HBV can live on environmental surfaces for up to 7 days. HBV can live on environmental surfaces for up to 7 days. Complications: Cirrhosis, liver cancer and death. Can also cause premature birth or spontaneous abortion. Complications: Cirrhosis, liver cancer and death. Can also cause premature birth or spontaneous abortion.

82 HIV Human Immunodeficieny Virus HIV is the virus that causes AIDS

83 AIDS Acquired Immune Deficiency Syndrome When your body is no longer able to protect you from disease because your immune system has been compromised.

84 Which bodily fluid is not HIV infectious? 1. Semen 2. Blood 3. Vaginal Secretions 4. Saliva 5. Breast Milk

85 Infectious Non-infectious 1) Blood 2) Semen 3) Vaginal Secretions 4) Breast milk 1) Sweat 2) Saliva 3) Urine 4) Tears 5) Mucus

86 Behaviors/Activities/Events 1) Unprotected Sexual Intercourse -Anal, Vaginal, and Oral 2) Sharing Needles -To inject: IV drug use, steroids, medicine - What about piercing: ears, nose, body and tattoos?????? 3) Vertical Transmission- Mother to baby 4) Blood Transfusions/Blood Products 5) Accidental Blood to Blood Contact

87 Monogamy - Two people who are lifetime partners Serial Monogamy - Having multiple monogamous relationships If practicing serial monogamy, one should use condoms Barriers LATEX 98% Effective POLYURETHANE 95%Effective Male Condoms Dental Dams Male Condoms Female Condoms Water Based Lubricants are recommended for use with condoms

88

89 Acceptance Bravery Self-respect Trust Integrity No Sex Education No Risk Confidence Esteem Abstinence means no Sex, Drugs & Alcohol Abstinence is the only 100% effective way not to get HIV

90 Only way to be 100% sure Abstinence Abstinence

91 Reduced Risk Behaviors Monogamy Monogamy Condom Use (latex 98%, polyurethane 95%) Condom Use (latex 98%, polyurethane 95%) Water based lubricants Water based lubricants Dental Dams Dental Dams

92 Harm Reduction What is it? What is it?

93 Testing The test looks for the presence of HIV antibodies. The test looks for the presence of HIV antibodies. Anyone who is sexually active should be tested for HIV. Anyone who is sexually active should be tested for HIV. Especially: Youth/Adolescents, People of Color, and Women. Especially: Youth/Adolescents, People of Color, and Women.

94 Testing Confidential Anonymous Free testing available at the Health Department. Results are available in 2 weeks. Test can be done by blood sample. Mobile Unit available at certain locations offer OraQuick® Rapid Testing, preliminary results are ready in minutes. 12 and over can test without parent permission.

95 Results Non reactive: What does it mean? Non reactive: What does it mean? Reactive: What does it mean? Reactive: What does it mean? Is it reportable? Is it reportable?

96 Criteria for AIDS Diagnosis 1. Opportunistic Infection (There are 26). The most common are: PCP - Pneumo Cystis Carinii Pneumonia KS - Kaposi’s Sarcoma (MSM) Esophageal Candidiasis TB - Tuberculosis (Mycobacterium) MAC 2. T-cells fall below 200 per cm (Healthy people have between T-cells)

97 TESTING Confidential Anonymous Free testing available at the Health Department. Rapid Test results in 30 mins If you have a preliminary positive, then confirmatory results are available in 2 weeks Test will be done by blood sample/draw Mobile Unit available at certain locations offer OraQuick ® Rapid Testing, preliminary results are ready in minutes. 12 and over can test without parent permission.

98 Relatively few cases were diagnosed among Asian, American Indian/Alaska Native, and Native Hawaiian/other Pacific Islander females, and females reporting multiple races, although the rates for these groups were higher than the rate for white females. Relatively few cases were diagnosed among Asian, American Indian/Alaska Native, and Native Hawaiian/other Pacific Islander females, and females reporting multiple races, although the rates for these groups were higher than the rate for white females.

99 Woman are always at higher risk for STD’s and HIV Infection then men 1. True 2. False 3. I don’t know

100 CDC estimates that 1 in five people living with HIV infection in the United States do not know they are infected. CDC estimates that 1 in five people living with HIV infection in the United States do not know they are infected. Getting tested for HIV is the first step to protecting yourself and others. Getting tested for HIV is the first step to protecting yourself and others. Knowing your own HIV status and that of your male sexual partners is critical because 85% of newly diagnosed HIV infections in US women and girls result from sex with an infected male partner. Knowing your own HIV status and that of your male sexual partners is critical because 85% of newly diagnosed HIV infections in US women and girls result from sex with an infected male partner. Early diagnosis of HIV allows for counseling and prompt treatment. HIV treatment prolongs life and reduces the risk of further HIV transmission. Early diagnosis of HIV allows for counseling and prompt treatment. HIV treatment prolongs life and reduces the risk of further HIV transmission. Encouraging your partner to wear a condom every time you engage in sexual activity is another important way to protect yourself Encouraging your partner to wear a condom every time you engage in sexual activity is another important way to protect yourself

101 Questions and Answers Hope we didn’t ruin lunch!


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