1 HIV/STD Service Oklahoma State Department of HealthHIV/AIDS & STDs/STIs HIV/STD Service Oklahoma State Department of Health

2 Human Immunodeficiency VirusWhat is HIV? Human Immunodeficiency Virus A virus spread through body fluids that affects specific cells of the immune system, called CD4 cells, or T cells A virus that kills the body’s CD4 cells (T cells) and damages the immune system A virus that replicates inside the human body, so it must invade a healthy cell in the body to survive The letter “H” stands for human. HIV is a retrovirus meaning it cannot reproduce outside of the human body. To cause infection, HIV must be able to reproduce and survive. “I” is for Immunodeficiency which refers to an unhealthy immune system which is the body’s natural defense against rare infections and diseases. “V” is for virus. There are viruses that enter the body, stay for awhile then eventually go away like cold or flu viruses. However, HIV does not go away. There is treatment but no cure. HIV is the virus that causes AIDS HIV attacks/hijacks the immune system, which protects the body from infection (dangerous). HIV virus locates & destroys CD4 or T cells-white blood cells that help fight disease. The virus takes over the cell using it to replicate itself.

3 What is AIDS? Positive HIV Test + Very low CD4 count (<200) ORpresence of specific cancers or opportunistic infections = AIDS “A” stands for acquired. HIV does not run in families like diabetes and heart disease (not hereditary). Outside of perinatal (mother to baby) transmission, HIV has to initially enter the body through some external method. “I’ represents the body’s immune system that works to protect the body from infection. “D” refers to a defect in the immune system that causes it not to function properly. “S” stands for syndrome. -If you control or redirect behavior that places you at risk for HIV, AIDs is a preventable disease.- 1st bullet point: AIDS is a marker for how far the HIV infection has advanced 2nd bullet point: immune system is so weakened, the body is vulnerable and has a hard time fighting disease or certain cancers Diagnosis explanation: Only a medical doctor can diagnose someone with AIDS. For example, when a person takes a test for HIV, the test searches for HIV antibodies. Therefore, a positive result means that person is HIV positive. It is not a diagnosis of AIDS. In order for a doctor to make an AIDS diagnosis, two things must be present: a positive HIV test and presence of an indicator disease or a CD4/T cell count of less than 200. *If questions asked about specific cancers or infections* Presence of specific cancers or infections: (one or more of these) ◦Candidiasis of bronchi, esophagus, trachea or lungs ◦Cervical cancer that is invasive ◦Coccidioidomycosis that has spread ◦Cryptococcosis that is affecting the body outside the lungs ◦Cryptosporidiosis affecting the intestines and lasting more than a month ◦Cytomegalovirus disease outside of the liver, spleen or lymph nodes ◦Cytomegalovirus retinitis that occurs with vision loss ◦Encephalopathy that is HIV-related ◦Herpes simplex including ulcers lasting more than a month or bronchitis, pneumonitis or esophagitis ◦Histoplasmosis that has spread ◦Isosporiasis affecting the intestines and lasting more than a month ◦Kaposi's sarcoma ◦Lymphoma that is Burkitt type, immunoblastic or that is primary and affects the brain or central nervous system ◦Mycobacterium avium complex or disease caused by M kansasii ◦Mycobacterium tuberculosis in or outside the lungs ◦Other species of mycobacterium that has spread ◦Pneumocystis jiroveci, formerly called carinii, pneumonia ◦Pneumonia that is recurrent ◦Progressive multifocal leukoencephalopathy ◦Salmonella septicemia that is recurrent ◦Toxoplasmosis of the brain, also called encephalitis ◦Wasting syndrome caused by HIV infection AIDS is a late stage of the HIV infection Once diagnosed, the body has hard time fighting disease and certain cancers NO cure for AIDS, but there is treatment

4 Why is This Important? In the U.S. (2014)44,073 people diagnosed with HIV 20,896 people diagnosed with AIDS Estimated 50,000 new HIV infections every year. Among all those living with HIV, 1 in 8 (12.5%) are unaware of their infection. 2015: 317 newly diagnosed HIV cases in Oklahoma (5,756 currently living with HIV). More than 1.2 million people in the United States have been diagnosed with AIDS since the epidemic began in the early 1980s.

5 Myth or Fact? I can get HIV by being around people who are HIV-positive. I'm HIV-positive, now my life is over. I would NOT be able to tell if my partner or I was HIV positive. I'm straight and don't inject drugs, so I CANNOT get HIV. I can get HIV from oral sex. I CANNOT get HIV from mosquitos. My partner and I are both HIV positive, so there is no need to use a condom. I can get HIV by being around people who are HIV-positive. MYTH! HIV is only passed through 4 bodily fluids! HIV cannot be spread through saliva, tears, sweat, or urine (kissing, sharing cups/utensils, water fountains, etc.) Small traits of HIV is found in saliva but it is not enough to cause infection unless one of the 4 fluids are also present (blood, semen, vaginal fluids or breast milk). – You’d have to drink a 2 liter Coke bottle of saliva with HIV for it to be transmitted. I'm HIV-positive, now my life is over. MYTH! In the early years of the epidemic, the death rate from AIDS was extremely high. But today, antiretroviral drugs allow People Living With HIV/AIDS (PLWH) to live longer, normal, and productive lives. I would not be able to tell if I or my partner was HIV positive. FACT! You can be HIV-positive and not have any symptoms for years. The only way for you or your partner to know if you're HIV-positive is to get tested. I'm straight and don't inject drugs, so I can’t get HIV. MYTH! Most men do become HIV-positive through sexual contact with other men. However, about 16% of men and 78% of women become HIV-positive through heterosexual contact. HIV is spread mostly through unprotected sexual contact and does not discriminate against anyone. It is not who you are, but your behaviors which put you at risk of contracting HIV. Regardless of your personality or sexuality, you will be at risk if you don't take protective measures. I can get HIV from oral sex. FACT! It's true that oral sex is less risky than some other types of sex. But you can get HIV by having oral sex with either a man or a woman who is HIV-positive. I cannot get HIV from Mosquitos. FACT! Because HIV is spread through blood, people have worried that biting or bloodsucking insects might spread HIV. Several studies, however, show no evidence to support this -- even in areas with lots of mosquitoes and cases of HIV. When insects bite, they do not inject the blood of the person or animal they have last bitten. Also, HIV lives for only a short time inside an insect. My partner and I are both HIV positive, so there is no need to use a condom. MYTH! There are different strains of HIV. If a condom is not used during sexual contact, HIV-positive partners may exchange different types or strains of HIV. This can lead to re-infection, which will make the treatment of HIV more difficult. The new HIV strain may become more resistant to the current treatment, or cause the current treatment option to be ineffective. There are also two types of HIV (HIV-1 and HIV-2). HIV-2 is less easily transmitted, and the period between initial infection and illness is longer in the case of HIV-2. Worldwide, the predominant virus is HIV-1, and generally when people refer to HIV they will be referring to HIV-1. The uncommon HIV-2 type is concentrated in West Africa and is rarely found anywhere else. Also, the treatment for HIV-1 is different than it is for HIV-2. (http://www.avert.org/hiv-types.htm)

6 How is HIV Spread? HIV is passed from person to personthrough the exchange of body fluids 3 Ways: Unprotected sex (anal, vaginal, or oral) with People Living With HIV (PLWH) Blood to blood contact Exposure to HIV before or during birth or through breastfeeding Sex - Anal sex is the highest form of sexual transmission for HIV. This is due to a tighter, thinner lining of the anus. Vaginal sex is next and oral sex carries the least amount of risk of the three (remind group that it is not who you are but what you do that places you at risk for HIV). Both men and women can engage in anal sex. It is important that young people know that oral sex, although it’s less risky and does not cause pregnancy, can still place them at risk for many STDs including HIV. NOTE: It is important that young people know that Oral and Anal Sex ARE FORMS OF SEX. Many do not count these as forms of sex, yet the risk is still present for HIV and other STDs. 2. Blood Contact - Sharing needles falls under blood to blood transmission due to the fact that when someone inserts a needle into his or her veins, small amounts of blood is drawn into the syringe. When that same needle/syringe is used by another person, the blood is mixed. 3. Mother-to-child transmission - HIV can be spread from a HIV-positive woman to her child during pregnancy, childbirth (also called labor and delivery), or breastfeeding. It is the most common way that children contract HIV. Pregnant women living with HIV receive HIV medicines during pregnancy and childbirth to reduce the risk of mother-to-child transmission of HIV. In some situations, a woman with HIV may have a scheduled cesarean delivery (C-section) to prevent mother-to-child transmission of HIV. Babies born to women living with HIV receive HIV medicine for 6 weeks after birth. The HIV medicine reduces the risk of infection from any HIV that that may have entered a baby’s body during childbirth. Because HIV can be transmitted in breast milk, women living with HIV should not breastfeed their babies. Baby formula is a safe and healthy alternative to breast milk. The CDC (Centers for Disease Control and Prevention) recommends that all pregnant women get tested for HIV as early as possible in each pregnancy.

7 What Fluids Can Transmit HIV?Blood Vaginal fluids Semen Breast Milk Suggestion: Add animation to this slide. Present the slide with just the “What Fluids Can Transmit HIV?”, then ask the audience to promote audience participation. Blood Vaginal fluids/secretions are fluids released from the vagina during arousal. Semen (cum & pre-cum) is the substance that is released from the penis following sexual orgasm. Pre-cum is the liquid that seeps out of the penis before ejaculation occurs. There are lower concentrations of HIV in pre-cum, making transmission less likely, but still possible. Breast milk can infect the baby following birth. This is especially an issue in other countries such as Africa who have communities who depend solely on breast milk to nourish their children. NOTE: There is not enough virus to make another person sick in: saliva, sweat, tears, urine, feces.

8 How does HIV Enter the Body?Mouth Vagina Nose Penis Eyes Anus Ears Open Skin These body fluids (blood, vaginal fluids, semen, breast milk) must come into contact with a mucous membrane or damaged tissue or be directly injected into your bloodstream (by a needle or syringe) for transmission to possibly occur. Mucous membranes are the soft, moist areas just inside the openings to your body. They can be found inside the rectum, the vagina or the opening of the penis through the urethra, and the mouth.

9 Symptoms of HIV Many people who are infected with HIV have NO symptoms at all for 10 years or more. It is estimated that 300, ,000 people in U.S. have HIV, but do not know it. Symptoms vary from person to person. Some people who are infected with HIV report having flu-like symptoms 2-4 weeks after exposure. The only way to know if you have contracted HIV is to be tested. You cannot rely on symptoms to know if you have HIV. Flu-like symptoms: (often described as “the worst flu ever”) can last anywhere from a few days to several weeks after exposure. Just because you have these symptoms doesn’t mean you have HIV. These symptoms could be caused from other infections. Fever Enlarged lymph nodes Sore throat Rash

10 *IMMEDIATELY CONTAGIOUS*Window Period The period of time after you may have been exposed to HIV, but before a test can detect it (up to 3 months) Window period - The period after exposure to HIV, but before a test can find the virus. The window period can be from 9 days to 3-6 months, depending on the type of HIV test used and the person's body. The immune system usually takes 3 to 8 weeks to make antibodies against HIV, but tests differ in how early they are able to detect the virus. A few people will have a longer window period, so if you get a negative antibody test result in the first 3 months after exposure, you should get a repeat test after 3 months. 97% of people will develop antibodies in the first 3 months after getting the HIV virus. In very rare cases, it can take up to 6 months to develop antibodies to HIV. NOTE: Most rapid tests test for antibodies only, so this is a 3 month window period. Tests that test for both antibodies AND antigens may be able to reduce the window period to 3 weeks. RNA HIV testing reduces the window period to about 10 days. NO MATTER THE TYPE OF TEST USED IF SOMEONE IS IN THE WINDOW PERIOD THEY MUST RETEST TO GET AN ACCURATE PICTURE OF THEIR HIV STATUS!!! *IMMEDIATELY CONTAGIOUS*

11 What does HIV Test Mean? Positive Negative + - HIV virus foundHave the HIV virus and can pass to others Need to begin treatment No HIV found May not have HIV (consider the window period) Retest in three months

12 Viral Load & CD4 (T4) CountCD4 (T4) Count: Number of white blood cells in the blood Viral Load: Amount of HIV in the blood CD4 Count: CD4 cells or T-cells-type of white blood cells that play a major role in protecting your body from infection. They send signals to activate your body’s immune response when they detect “intruders,” like viruses or bacteria. A CD4 count is a lab test that measures the number of CD4 cells in a sample of your blood. Your CD4 count helps show you how well your immune system is working. The higher your CD4 count, the better you are to fight HIV and other infections. A normal CD4 count is from 500 to 1,500 cells/mm3 of blood (for adults or adolescents). A very low CD4 count (less than 200 cells/mm3) is one of the ways to determine whether a person living with HIV has progressed to AIDS. Viral load: Measures amount of HIV RNA in blood (RNA is ribonucleic acid, a protein). This measurement is thought to be more accurate than a CD4 count, to decide where a person is in the disease process. The term “viral load” refers to the amount of HIV in a sample of your blood. When your viral load is high, you have more HIV in your body, and that means your immune system is not fighting HIV well, and the more likely you are to spread the HIV virus. There is really no such thing as a “normal” viral load. People who do not have HIV have no viral load at all, so there’s no “normal” range for reference, as there are for many other HIV lab tests (such as CD4 counts.) A viral load test helps provide information on your health status and how well antiretroviral therapy (ART – treatment with HIV medicines) is controlling the virus. The goal of ART is to move your viral load down, ideally to undetectable levels. In general, your viral load will be declared "undetectable" if it is under 40 to 75 copies in a sample of your blood. The exact number depends on the lab that analyzes your test. Having an “undetectable” viral load doesn’t mean that the virus is completely gone from your body, just that it is below what a lab test can find. You still have HIV and need to stay on ART to remain healthy. A form of prevention is having an “undetectable” viral load.

13 Acquiring HIV & Sharing HIVThe presence of a STD increases the possibility of: Acquiring HIV & Sharing HIV Having a sexually transmitted disease (STD) can increase a person's risk of contracting HIV, if the STD causes open sores or breaks in the skin (e.g., syphilis, herpes, chancre [shan-ker]) or does not cause breaks in the skin (e.g., chlamydia, gonorrhea). Why? Compromised immune system: Another reason why the STD and HIV relationship exists is when one acquires a STD, it compromises the immune system by weakening it. Therefore, the body is left vulnerable and it is more easy to get another disease. Additional STDs: If a Person Living With HIV (PLWH) has another STD, they are three to five times more likely than other PLWHs to transmit HIV through sexual contact. Irritation and inflammation of mucous membranes: If the STD infection causes irritation of the skin, breaks or sores make it easier for HIV to enter the body during sexual contact. Even when the STD causes no breaks or open sores, the infection can stimulate an immune response in the genital area that can make Spreading HIV more likely. WHY? Compromised immune system Additional STDs Irritation/inflammation of mucous membranes

14 Opportunistic InfectionsOpportunistic infections (OIs) are infections that occur more frequently and are more severe in individuals with weakened immune systems, including people with HIV. People with healthy immune systems can be exposed to certain viruses and have no reaction. BUT… People living with HIV can face serious threats from the same viruses. OIs are signs of a declining immune system. Most life-threatening OIs occur when your CD4 count is below 200 cells/mm3. OIs are the cause of death for people with HIV/AIDS (AIDS is not the immediate cause of death, opportunistic infections are). One of the goals of HIV treatment is to lower the risk of getting OIs. OIs can occur all over the body and can be relatively localized (meaning they affect only one part of the body) or systemic/disseminated (spread to other parts of the body and other body systems). When or If you become susceptible to OIs is often related to your CD4 count. *If questions are asked regarding specific OIs* 500 cells/mm3 to 200 cells/mm3 OPPORTUNISTIC INFECTIONS Candidiasis (Thrush) This is a fungal infection that is normally seen in patients with CD4 counts in this range. It is treatable with antifungal medications. A trained provider can usually diagnose thrush with a visual examination. Kaposi’s Sarcoma (KS) KS is caused by Human Herpes Virus-8. Before the introduction of antiretroviral therapy, as many as 1 in 5 patients with AIDS had KS. It can cause lesions on the body and in the mouth. In addition, this virus can affect internal organs and disseminate to other parts of the body without any external signs. Treatment plans can include chemotherapy to shrink the lesions, as well as antiretroviral therapy to increase CD4 cell count. A diagnosis is typically made by inspecting a lesion and performing a direct biopsy on it. SYMPTOMS Oral Symptoms include: White patches on gums, tongue or lining of the mouth Pain in the mouth or throat Difficulty Swallowing Loss of Appetite Vaginal Symptoms Include: Vaginal Irritation Itching Burning Thick, white discharge Signs and Symptoms of KS can include: Appearance of a purplish lesion on skin Appearance of a purplish lesion in the mouth Occasionally gastrointestinal complaints with disseminated KS 200 cells/mm3 to 100 cells/mm3 Pnuemocystis Jirovecii (Carinii) Pneumonia (PCP) PCP is a fungal infection and is the OI that most often causes death in patients with HIV. It is treatable with antibiotic therapy and close monitoring. If necessary, prophylaxis is available for patients who are at risk for PCP, but who are not ready to start antiretroviral medication. Diagnosing PCP usually involves a hospital stay to ensure proper testing and treatment without complications. Histoplasmosis and Coccidioidomycosis These are fungal infections that are found in many regions of the United States. They often present as severe, disseminated illnesses in patients with low CD4 counts. Diagnosis consists of blood tests and evaluation for possible exposures related to geographical areas. Progressive Multifocal Leukoencephalopathy (PML) PML is a severe neurological condition that is caused by the JC virus and typically occurs in patients with CD4 counts below 200. While there is no definitive treatment for this disease, it has been shown to be responsive to antiretroviral therapy. In some cases, the disease resolves without any treatment. Signs and Symptoms of PCP can include: Shortness of Breath Fever Dry Cough Chest Pain Signs and Symptoms of Histoplasmosis and Coccidioidomycosis can include: Fatigue Weight Loss Cough Chest pain Headache Signs and Symptoms of PML can include: Dementia Seizures Difficulty Speaking Confusion Difficulty walking 100 cells/mm3 to 50 cells/mm3 Toxoplasmosis Toxoplasmosis is caused by the parasite Toxoplasma gondii that can cause encephalitis and neurological disease in patients with low CD4 counts. The parasite is carried by cats, birds, and other animals and is also found in soil contaminated by cat feces and in meat, particularly pork. Toxoplasmosis is treatable with aggressive therapy, and prophylaxis is recommended for patients with low CD4 counts (usually less than 200). Diagnosis of this condition often requires imaging studies (CT or MRI) of the brain and a blood test. Cryptosporidiosis Cryptosporidiosis is a diarrheal disease caused by the protozoa Cryptosporidium, and it can become chronic for people with low CD4 counts. Symptoms include abdominal cramps and severe chronic diarrhea. Infection with this parasite can occur through: swallowing water that has been contaminated with fecal material (in swimming pools, lakes, or public water supplies); eating uncooked food (like oysters) that are infected; or by person-to-person transmission, including changing diapers or exposure to feces during sexual contact. Treatment and antiretroviral therapy are important. Cryptococcal Infection or Cryptococcosis Cryptococcal infection is caused by a fungus that typically enters the body through the lungs and can spread to the brain, causing cryptococcal meningitis. In some cases, it can also affect the skin, skeletal system, and urinary tract. This can be a very deadly infection if not caught and properly treated with antifungal medication. Although this infection is found primarily in the central nervous system, it can disseminate to other parts of the body, especially when a person has a CD4 count of less than 50. SYMPTOMS Signs and Symptoms of Toxoplasmosis can include: Motor Weakness Signs and Symptoms of Cryptosporidiosis can include: Chronic Watery Diarrhea Stomach cramps Weight loss Nausea Vomiting Signs and Symptoms of Cryptococcal Meningitis include: Neck Stiffness Some patients can have memory loss or mood changes Cells/mm3 Cytomegalovirus (CMV) CMV is an extremely common virus that is present in all parts of the world. It is estimated that a majority of the population have had CMV by the time they are 40 years-old. CMV can be transmitted by saliva, blood, semen and other body fluids. It can cause mild illnesses when first contracted and many people may never have symptoms. However, it does not leave the body when someone has CMV. In patients with HIV and low CD4 counts it can cause infections in the eye and gastrointestinal system. Signs and Symptoms of CMV: Sore Throat Swollen Glands Fevers In people with low CD4 counts it can cause: Blurred vision (if there is CMV infection is in the eye) Painful Swallowing Diarrhea Abdominal Pain Less than 50 Cells/mm3 Mycobaterium Aviam Complex (MAC) MAC is a type of bacteria that can be found in soil, water, and many places in the environment. These bacteria can cause disease in people with HIV and CD4 Counts less that 50. The bacteria can infect the lungs or the intestines, or in some cases, can become “disseminated”. This means that it can spread to the blood stream and other parts of the body. If this occurs, it can be a life threatening infection. If a persons CD4 count is below 50, then medications are available to prevent this infection from occurring. Signs and Symptoms of MAC: Night sweats These infections are called “opportunistic” because they take advantage of a weakened immune system, and can cause devastating illnesses.

15 Newly Diagnosed? START TREATMENT!HIV Treatment Newly Diagnosed? START TREATMENT! Treatment benefits: your own health & the health of others Treatment benefits explanation: Your own health: Lowering the level of virus in the body - live longer, healthier life The health of others: Reduces the risk of transmitting HIV to others *In case asked about specific details of treatment* Many different names for HIV drugs: "The Cocktail“ Antiretrovirals (ARVs) Highly Active Antiretroviral Therapy (HAART or ART) 5 different “classes” of HIV drugs. Each class of drug attacks the virus at different points in its life cycle—so if you are taking HIV meds, you will generally take 3 different antiretroviral drugs from 2 different classes. Taking more than one drug also protects you against HIV drug resistance. When HIV reproduces, it can make copies of itself that are imperfect—and these mutations may not respond to the drugs you take to control your HIV. Nucleoside/Nucleotide Reverse Transcriptase Inhibitors (NRTIs): Sometimes called "nukes." These drugs block HIV’s ability to use a special type of enzyme (reverse transcriptase) to correctly build new genetic material (DNA) that the virus needs to make copies of itself. Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs): These are called "non-nukes." They work in a very similar way to "nukes." Non-nukes also block the enzyme, reverse transcriptase, and prevent HIV from making copies of its own DNA. But unlike the nukes (which work on the genetic material ), non-nukes act directly on the enzyme itself to prevent it from functioning correctly. Protease Inhibitors (PIs): When HIV replicates inside your cells, it creates long strands of its own genetic material. These long strands have to be cut into shorter strands in order for HIV to create more copies of itself. The enzyme that acts to cut up these long strands is called protease. Protease inhibitors (stoppers) block this enzyme and prevent those long strands of genetic material from being cut up into functional pieces. Entry/Fusion Inhibitors: These medications work to block the virus from ever entering your cells in the first place. HIV needs a way to attach and bond to your CD4 cells, and it does that through special structures on cells called receptor sites. Receptor sites are found on both HIV and CD4 cells (they are found on other types of cells too). Fusion inhibitors can target those sites on either HIV or CD4 cells and prevent HIV from "docking" into your healthy cells. Integrase Inhibitors: HIV uses your cells’ genetic material to make its own DNA (a process called reverse transcription). Once that happens, the virus has to integrate its genetic material into the genetic material of your cells. This is accomplished by an enzyme called integrase. Integrase inhibitors block this enzyme and prevent the virus from adding its DNA into the DNA in your CD4 cells. Preventing this process prevents the virus from replicating and making new viruses. Fixed-dose combinations: These are not a separate class of HIV medications but combinations of the above classes and a great advancement in HIV medicine. They include antiretrovirals which are combinations of 2 or more medications from one or more different classes. These antiretrovirals are combined into one single pill with specific fixed doses of these medicines. The word “prophylaxis” means “to prevent or control the spread of an infection or disease.” Pre-exposure prophylaxis (PrEP): PrEP is a way for people who don’t have HIV to prevent getting HIV by taking a pill every day. If you take PrEP and are exposed to HIV through sex or injection drug use, these medicines can work to keep the virus from taking hold in your body. PrEP is not for everyone. CDC recommends PrEP be considered for people who are HIV-negative and at substantial risk for HIV. Post-Exposure Prophylaxis (PEP): involves taking anti-HIV medications as soon as possible after you may have been exposed to HIV to try to reduce the chance of becoming HIV positive. These medications keep HIV from making copies of itself and spreading through your body. PEP must begin within 72 hours of exposure, before the virus has time to make too many copies of itself in your body. PEP consists of 2-3 antiretroviral medications and should be taken for 28 days. PEP is used for anyone who may have been exposed to HIV during a single event, such as sexual assault. Thanks to better treatments, people with HIV are now living longer—and with a better quality of life—than ever before.

16 Treatment Extends LivesBUT, Medication CAN be: Expensive - $30,000 a year ($379,668 lifetime) Complicated –must take different pills at specific times of the day Toxic – negative side effects are common Ineffective – not all strains respond Expensive: cost of HIV treatment is high (especially without health insurance). $30,000 is generally how much one would spend on a new car. Would you rather spend money on HIV treatment or buy a new car? “Lifetime” means that $379,668 is how much money someone living with HIV would spend over the course of their whole life on treatment. Complicated: sticking to an HIV regimen can be difficult. (When to take it, what to take, how many to take, etc.) Poor adherence—not taking HIV medicines every day and exactly as prescribed—can lead to drug resistance and treatment failure. Toxic: side effects from HIV medicine - drug interactions between different HIV medicines interactions between HIV medicines and other medicines a person may be taking. Side effects from HIV medicines can vary depending on the medicine and the person taking the medicine. Different people taking the same HIV medicine can have very different side effects. Ineffective: Drug resistance-When HIV multiplies in the body, the virus sometimes mutates (changes form) and makes variations of itself. Variations of HIV that develop while a person is taking HIV medicines can lead to drug-resistant strains of HIV. HIV medicines that previously controlled a person’s HIV are not effective against the new, drug-resistant HIV. In other words, the person’s HIV continues to multiply.

17 What is an STD? an infection that can be transmitted through sexual contact with an infected individual. They are sometimes called sexually transmitted infections (STIs). STDs can be transmitted many different ways, but most can be passed by: Vaginal sex Anal sex Oral sex Skin-to-skin contact Infected Mother to child Suggestion: Add animation to the “STDs can be transmitted many different ways, but most can be passed by:” section. STD’s transmitted by exchange of body fluids: Gonorrhea Chlamydia Syphilis Trichomoniasis HIV Hepatitis STD’s transmitted by skin-to-skin contact: Genital warts Herpes Scabies Pubic Lice

18 Are STDs Curable? Chlamydia Gonorrhea* Syphilis Trichomoniasis HIVAntibiotics can cure bacterial STDs, but cannot reverse the long-term damage Treatment can improve the lives of many people living with viral STDs, (but there is NO CURE) Chlamydia Gonorrhea* Syphilis Trichomoniasis HIV Herpes HPV Hepatitis B *While gonorrhea is curable with antibiotics, a growing number of strains are now resistant to penicillin and other drugs used in treatment. The vast majority of infections, however, are treatable. Bacterial diseases such as chlamydia, gonorrhea, syphilis, and trichomoniasis are curable STDs. They can be treated by antibiotics. Viral STDs such as HIV, Herpes, HPV, and Hepatitis B are life-long STDs. There is treatment available, but no cure.

19 Why Is This Important? Often no signs or symptoms People are unaware of infection, and don’t receive treatment. Long-term damage May have passed infection to others 20 million new infections every year in the U.S. More than 50% of all people will have an STD at some point in their lifetime

20 Myth or Fact? You CANNOT get an STD from oral sex.Birth control protects against pregnancy and STDs. Once you’ve had an STD, you CANNOT get it again. Anal sex has a higher risk of spreading STDs than many other types of sexual activity. You CANNOT get an STD if your partner is a virgin. Only promiscuous or “trashy” people get STDs. You CANNOT have two STDs at once You can get an STD from a toilet seat. Women are at higher risk for STDs than men. Lesbians CANNOT get STDs. If my partner has an STD, I’ll know/see it. Myth or Fact Activity: Split group up into 2 teams. Teams have to guess if it is a myth or a fact. If they get it right, they get a point. If they can explain why, they get a bonus point. MYTH: Any exposure to genitalia or body fluids puts you at risk for getting an STD. There are many STDs that can be transmitted through oral sex, including genital herpes, genital warts (HPV), gonorrhea, hepatitis A, hepatitis B, chlamydia, chancroid, and syphilis. To prevent getting an STD from oral sex, you and your partner should get tested for all STDs, and you should always use a condom or dental dam during oral sex. 2. MYTH: The birth control pill does not protect against STDs. Couples having sex must always use condoms or another barrier along with the Pill to protect against STDs and pregnancy at the same time. 3. MYTH: You can get some STDs more than just once. Some STDs are yours for life, like herpes and HIV. Others, like chlamydia and gonorrhea, can be treated, but you may get infected again if you have sexual contact with someone who has them. 4. FACT: Anal sex does have a higher risk of spreading STDs. The lining of the anus is thin and can easily be damaged, which makes it more vulnerable to infection. 6. MYTH: Depending on how your partner defines being a virgin, it is possible for them to have contracted an STD/STI. Your partner might not have had vaginal sex, but may have had oral sex with someone (and still consider themselves a virgin), putting themselves at risk for an STD. Also, there are other STIs (herpes and HPV) that are passed through skin-to-skin contact, even if no penetration has taken place. It is important to discuss with your partner all sexual activity they have participated in and to always practice safer sex. 7. MYTH: STDs don’t discriminate. The only people who have no risk of getting an STD are people who haven’t had sex or any kind of sexual contact. 1 in 2 sexually active young people will get an STD before the age of 25. 8. MYTH: You can have multiple STDs at a time. For example, if you have just one other untreated STD, you are 10 times more likely to have HIV. Your chances are greater if you have genital warts, lesions or ulcers like those you can get with syphilis or herpes. 9. MYTH: STD/STI’s cannot be passed from a toilet seat. Even if the bacteria and viruses that can cause an STI got onto the seat, they cannot survive for long after leaving the human body. Most organisms do not last any more than a few minutes, because they dry out and die. 10. FACT: Women account for a disproportionate number of these new infections. Anatomical differences place women at greater risk than men of contracting sexually transmitted infections, and age-related physiological changes in the cervix make risk of infection even higher for adolescent women. 11. MYTH: While women who sleep with women can be at a lower risk for some forms of STDs, they can – and do – contract STDs as well. Any form of unprotected genital contact carries some risk of exposure, so safer sex practices are important, no matter what your sexual orientation. Surrounding all of these myths is the overarching notion that outside of HIV/AIDS, LGBTQ youth do not have to worry about STDs. The truth is that anyone engaging in unprotected genital contact is at risk for contracting an STD. 12. MYTH: There’s often no sign that a person has an STD. Even doctors often can't tell by looking if people have STDs. So they need to do tests, like bloodwork. People with STDs might not know they have them: STDs don't always cause symptoms. But it is possible to carry and spread the virus without ever having an outbreak.

21 Chlamydia How is it Spread? In the U.S. Most frequently reported STDEstimated 2.86 million cases per year Could fill the OU Football Stadium 35x! How is it Spread? 1. Vaginal, anal, or oral sex with someone who has chlamydia. 2. Infected pregnant women can pass it to their baby during pregnancy or childbirth. Suggestion: Add animation to “How is it Spread?” section. Note: If your sex partner is male you can still get chlamydia even if he does not ejaculate (cum). People who have had chlamydia and have been treated may get infected again if they have sexual contact with a person infected with chlamydia Infected pregnant women can pass it to their baby during pregnancy or childbirth. If a woman is infected while pregnant, her developing fetus is at risk, because chlamydia can be passed on during her pregnancy or delivery and could lead to eye infections or pneumonia in the infant. If chlamydia is detected early, it can be treated easily with an antibiotic taken by mouth. https://www.nichd.nih.gov/health/topics/stds/conditioninfo/Pages/types.aspx Note: Most prevalent, reportable STD in Oklahoma, as well as the U.S.

22 Chlamydia Female Male Usually NO SYMPTOMS!!! Symptoms:Abnormal vaginal discharge Burning sensation when urinating Can lead to: Pelvic Inflammatory Disease (PID) -Abdominal & pelvic pain -Long-term pelvic pain -inability to get pregnant -ectopic pregnancy Symptoms: Discharge from the penis Burning sensation when urinating Pain & swelling in one or both testicles (less common) Can lead to: Infection spreads to tube that carries sperm from the testicles -pain and/or fever Inability to have children (although rare) Most frequently reported STD in the U.S. Known as a “silent” disease (usually no symptoms are shown) A large number of cases are not reported because most people with chlamydia are asymptomatic and do not seek testing. Female: (~70% of infections) Ectopic pregnancy - pregnancy outside the uterus (potentially deadly?) If you are a woman, untreated chlamydia can spread to your uterus and fallopian tubes (tubes that carry fertilized eggs from the ovaries to the uterus), causing pelvic inflammatory disease (PID). 75% of women with chlamydia infections are asymptomatic. The CDC reports that women have reported rates of chlamydia infection 3x higher than men. Male: (~30% of infections) Men rarely have health problems linked to chlamydia. Infection sometimes spreads to the tube that carries sperm from the testicles, causing pain and fever. Rarely, chlamydia can prevent a man from being able to have children.

23 Gonorrhea How is it Spread? In the U.S.2nd most common disease reported Estimated 718,000 new cases each year How is it Spread? Gonorrhea can cause infections in the genitals, rectum, and throat. Adolescent women (ages 15 to 19) currently have the highest rates of infection. 2nd most prevalent STD reported in Oklahoma (6,542 cases reported in 2015) Vaginal, anal, or oral sex with someone who has gonorrhea. A pregnant woman can give the infection to her baby during childbirth.

24 Gonorrhea Female Male Symptoms: Symptoms:Painful or burning sensation when urinating Increased vaginal discharge Vaginal bleeding between periods Can lead to: Pelvic inflammatory disease (PID) -Scar tissue formation (fillopian tubes) -Ectopic pregnancy -Inability to get pregnant -Long-term pelvic/abdominal pain Symptoms: Burning sensation when urinating A white, yellow, or green discharge from the penis Painful or swollen testicles (less common) Can lead to: Painful condition in the tubes attached to the testicles. -Inability to have children(rare) -Sterile Note: Rectal infections of gonorrhea may either cause no symptoms or cause symptoms in both men and women that may include: •Discharge •Anal itching •Soreness •Bleeding •Painful bowel movements Untreated gonorrhea may also increase your chances of getting or giving HIV – the virus that causes AIDS. Rarely, untreated gonorrhea can also spread to your blood or joints. Some men with gonorrhea may have no symptoms at all. Most women with gonorrhea do not have any symptoms. Even when a woman has symptoms, they are often mild and can be mistaken for a bladder or vaginal infection.

25 Can be spread from an infected mother to her unborn baby.Syphilis “The Great Imitator” affects approximately 32,000 people each year in the U.S. How is Syphilis Spread? Direct contact with a syphilis sore (chancre) during vaginal, anal, or oral sex. Can be spread from an infected mother to her unborn baby. “The Great Imitator” Many signs and symptoms of syphilis are very similar from many other diseases, giving it the nickname “the great imitator”. Symptoms of syphilis vary among the different stages of disease. Many people do not have any symptoms for years, yet remain at risk for complications if left untreated. You could also be infected with syphilis and have very mild symptoms or none at all. Note: Like many other STIs, syphilis infection facilitates HIV transmission. The infection is treatable with antibiotics, but may have serious health consequences such as weight loss, rash, and permanent damage to internal organs if left untreated. Pregnant women with syphilis have a chance of delivering stillbirths, depending on how long she has been infected. Primary Syphilis Secondary Syphilis Tertiary/Late Syphilis

29 Trichomoniasis ***estimated 3.7 million***Parasite passed during vaginal sex 70% of infected people have no signs/symptoms Female Male Symptoms: Itching, burning, redness or soreness of the genitals Discomfort with urination Thin discharge (can be clear, white, yellowish, or greenish) with an unusual smell Infection usually occurs: Lower genital tract: vulva, vagina, or urethra Symptoms: Itching or irritation inside the penis Burning after urination or ejaculation Some discharge from the penis Infection usually occurs: Inside of the penis (urethra) A parasitic infection. Most common curable STI in young sexually active women in the U.S. Treatment is inexpensive and effective. Many infected persons, especially men, experience no symptoms. When trichomoniasis does cause symptoms, they can range from mild irritation to severe inflammation. Some people with symptoms get them within 5 to 28 days after being infected, but others do not develop symptoms until much later. Symptoms can come and go. Having trichomoniasis can make it feel unpleasant to have sex. Without treatment, the infection can last for months or even years. It is not common for the parasite to infect other body parts, like the hands, mouth, or anus. Trichomoniasis can increase the risk of getting or spreading other sexually transmitted infections. For example, trichomoniasis can cause genital inflammation that makes it easier to get infected with the HIV virus, or to pass the HIV virus on to a sex partner. In pregnant women, Trichomoniasis may lead to a premature delivery. Complication: can increase the risk of getting or spreading other sexually transmitted infections

30 Genital Herpes Two Types of Viruses: HSV-1 and HSV-2How is Herpes Spread? Vaginal, oral, or anal sex OR skin-to-skin contact with someone who has the virus Symptoms: One or more blisters on or around the genitals, rectum, or mouth The blisters break & leave painful sores that take weeks to heal These symptoms are sometimes called “having an outbreak” Herpes Simplex Virus 1 (HSV-1): mainly transmitted by oral to oral contact periodic appearance of “cold sores” or painful ulcers around the mouth area Infected persons will often experience a tingling, itching or burning sensation around their mouth, before the appearance of sores can also be transmitted to the genitals through oral-genital contact, leading to genital herpes. Herpes Simplex Virus 2 (HSV-2): Can cause genital herpes (one or more genital or anal blisters or open sores called ulcers) mainly spread during sex through skin-to-skin contact (through contact with genital surfaces, skin, sores or fluids of someone infected with the virus) the occasional appearance of painful genital ulcers. Genital ulcers can have an important negative effect upon a person’s mental wellness and personal relationships. symptoms of new genital herpes infections often include fever, body aches, and swollen lymph nodes. can be transmitted from skin in the genital or anal area that looks normal. HSV-1 and HSV-2: are both highly infectious and can be transmitted to neonates (newborn babies), which is rare, but which can be fatal. Note: Majority of genital and perirectal herpetic outbreaks in the U.S. are caused by HSV-2 NO CURE: There is no cure for herpes. However, there are medicines that can prevent or shorten outbreaks. One of these herpes medicines can be taken daily, and makes it less likely that you will pass the infection on to your sex partner(s). Women are more susceptible to the herpes virus A majority of people with the virus are unaware that they are infected, increasing the likelihood of transmitting the infection to their partners. Although anti-viral drugs are available to manage genital herpes, no cure exists. Herpes increases a person’s susceptibility to HIV and causes HIV-infected individuals to be more infectious. How is Herpes Spread? Fluids found in a herpes sore carry the virus, and contact with those fluids can cause infection. You can also get herpes from an infected sex partner who does not have a visible sore or who may not know he or she is infected because the virus can be released through your skin and spread the infection to your sex partner(s). Symptoms: You may not notice mild symptoms or you may mistake them for another skin condition, such as a pimple or ingrown hair. An “outbreak”: The first time someone has an outbreak they may also have flu-like symptoms such as fever, body aches, or swollen glands. Repeat outbreaks of genital herpes are common, especially during the first year after infection. Repeat outbreaks are usually shorter and less severe than the first outbreak. Although the infection can stay in the body for the rest of your life, the number of outbreaks tends to decrease over a period of years. Note: If you touch your sores or the fluids from the sores, you may transfer herpes to another part of your body, such as your eyes. Do not touch the sores or fluids to avoid spreading herpes to another part of your body. If you touch the sores or fluids, immediately wash your hands thoroughly to help avoid spreading your infection. Note: Genital herpes can cause sores or breaks in the skin or lining of the mouth, vagina, and rectum. The genital sores caused by herpes can bleed easily. When the sores come into contact with the mouth, vagina, or rectum during sex, they increase the risk of giving or getting HIV if you or your partner has HIV. If you have herpes, you should tell your sex partner(s) and let him or her know that you do and the risk involved. Using condoms may help lower this risk but it will not get rid of the risk completely. Having sores or other symptoms of herpes can increase your risk of spreading the disease. Even if you do not have any symptoms, you can still infect your sex partners. Usually characterized by NO or very mild symptoms… NO CURE. 1 in 6 people aged have genital herpes. Most people who have herpes do not know it!

31 Human Papillomavirus (HPV)Mainly transmitted mainly through vaginal & anal sex, but also through oral sex and skin-to-skin contact Most people with HPV do not know they are infected and never develop symptoms or health problems There is no treatment for HPV. However, there are treatments for the health problems that HPV causes: Genital warts Cervical pre-cancer Other HPV-related cancers HPV is VERY common: There are many types of HPV. Of more than 100 strains, more than 30 different types of HPV are sexually transmitted. Certain “high risk” strains of HPV have been linked to cervical cancer; however, many common strains of HPV, including genital warts, are considered "low-risk." Most of the "low risk" infections resolve themselves on their own without any treatment. There are 6.2 million new cases of HPV diagnosed in the U.S. each year. Regular screenings for changes in the cervix (pap smears) are the best known ways to prevent possible complications from HPV infection (for women). HPV is VERY common! Most sexually-active men and women will get at least one type of HPV at some point in their lives (estimated 80%).

32 Hepatitis “inflammation of the liver” How is it spread?Hepatitis A Hepatitis B Hepatitis C How is it spread? Person ingests infected fecal matter—even in very small amounts—from contact with contaminated objects, food, or drinks Blood, semen, or other body fluids from a person with the virus - even in very small amounts - enters the body of a non-infected person Blood from a person infected with the virus - even in very small amounts - enters the body of a non-infected person How long does it last? A few weeks – several months Mild illness (a few weeks) – Lifelong or chronic condition Mild illness (a few weeks) – Lifelong How serious is it? Most recover from mild illness with no lasting liver damage, but death can occur (although rare) 15-20% develop chronic liver disease including cirrhosis, liver failure, or liver cancer 75-85% develop chronic liver disease, 5-20% develop cirrhosis, and 1-5% will die “Hepatitis” means inflammation of the liver: The liver is a vital organ that processes nutrients, filters the blood, and fights infections. When the liver is inflamed or damaged, it may not be able to function properly. Hepatitis A: can be sexually transmitted by oral sex (oral to anal contact). Not near as common to be sexually transmitted as B & C. The Hepatitis B virus can also be transmitted from: •Birth to an infected mother •Sex with an infected person •Sharing equipment that has been contaminated with blood from an infected person, such as needles, syringes, and even medical equipment, such as glucose monitors •Sharing personal items such as toothbrushes or razors •Poor infection control has resulted in outbreaks in health care facilities Vaccine available for A and B: should be done for all infants at birth (most of you are already vaccinated) Symptoms: Many people with hepatitis do not have symptoms and do not know they are infected. If symptoms occur with an acute infection, they can appear anytime from 2 weeks to 6 months after exposure. Symptoms of chronic viral hepatitis can take decades to develop. Symptoms of hepatitis can include: fever, fatigue, loss of appetite, nausea, vomiting, abdominal pain, dark urine, grey-colored stools, joint pain, and jaundice. Usually characterized by NO or very mild symptoms, but NO CURE. How long does Hepatitis last? Hepatitis A: can last from a few weeks to several months. Hepatitis B: can range from a mild illness, lasting a few weeks, to a serious life-long or chronic condition. More than 90% of unimmunized infants who get infected develop a chronic infection occurs, whereas 6%–10% of older children and adults who get infected develop chronic Hepatitis B. Hepatitis C: can range from a mild illness, lasting a few weeks, to a serious life-long infection. Most people who get infected develop chronic Hepatitis C. How serious is it? Hepatitis A: •People can be sick for a few weeks to a few months •Most recover with no lasting liver damage •Although very rare, death can occur Hepatitis B: •The risk for chronic infection depends on age when infected. When infected as an infant, 90% will develop a chronic infection •15%–25% of chronically infected people develop chronic liver disease, including cirrhosis, liver failure, or liver cancer Hepatitis C: •75%-85% of people who get infected with the Hepatitis C virus develop a chronic infection •5%-20% of people with chronic Hepatitis C develop cirrhosis •1%–5% will die from cirrhosis or liver cancer

33 Risk Information for HIV/STDsNO RISK OF TRANSMISSION Abstinence (sex): not having oral, vaginal or anal sex Abstinence (drugs): not using drugs (HIV, Hepatitis) No genital contact (HPV, HSV) Mutual monogamy between non-infected partners REDUCED RISK OF TRANSMISSION Protected Sex: Use of condoms or other barriers (female condoms and dental dams) Fewer sexual partners Regular HIV/STD testing Never sharing needles (HIV, Hepatitis) No Risk: Abstinence (sex): No bodily fluids exchanged. Someone can choose to be abstinent even if they are not a virgin. Abstinence can be chosen for any period of time (a day, a week, a month, a year, etc.) Abstinence (drugs): Not using injection drugs. Mutual Monogamy-When you and your partner are both STD free (have been tested), and you only have sex with each other. Reduced Risk: Protected Sex: Use a new condom for every act of vaginal, anal and oral sex throughout the entire sex act (from start to finish). Note: BIRTH CONTROL DOES NOT PROTECT AGAINST HIV/AIDS OR ANY OTHER STDs! (is not a barrier) Female Condoms: A pouch used during vaginal or anal intercourse to prevent pregnancy and reduce the risk of STDs. When used correctly all of the time, female condoms are 95% effective. Dental Dams: Dental dams are small, thin, square pieces of latex that are used for oral sex. They get their name from their use in dental procedures. Dental dams prevent STDs during oral sex by keeping vaginal and anal fluids that may contain bacteria and viruses away from the mouth. Fewer sexual partners: Less exposure equals less chance of virus transmission. IF APPROPRIATE AUDIENCE: Not sharing needles Regular HIV/STD testing: HIV: Everyone aged 15 through 64 should get tested one time, regardless of their risk factors. People who have occasional exposure to HIV risks should be tested at least once a year. People who are at high risk for HIV infection should get tested every 3 to 6 months. All pregnant women should be tested during the 1st trimester of pregnancy. If at high risk for HIV: again in the 3rd trimester.

34 Facts About Condoms Condoms are 98% effective in reducing transmission rates if used consistently and correctly. Don’ts: DON’T use expired condoms DON’T unroll the condom before putting it on the penis DON’T leave condoms in hot places (wallet, car, etc.) DON’T use oil-based products (baby or cooking oils, hand lotion, Vaseline, etc.) as lubricants with latex condoms DON’T use your fingernails or teeth while opening the condom wrapper. DON’T reuse a condom or use more than one condom at a time (‘double wrapping’) Do’s: DO keep condoms in a cool, dry place DO throw the condom away after it’s been used 4-year study on HIV & condoms: 245 couples – one partner HIV+ and one HIV- 123 used a condom “correctly and consistently” 0 cases of HIV transmission

35 S T O P RISKY BEHAVIOR USE REFUSAL SKILLS SAY NO TALK IT OUTRefuse to engage in unsafe behavior Body Language Says “NO!” Repeat Refusal S USE TALK IT OUT Use language that protects the relationship T RISKY BEHAVIOR OFFER AN EXPLANATION O REFUSAL SKILLS Do not let anyone pressure you into doing something you do not feel comfortable with, or that you do not feel is safe or right for you. Practice “refusal skills”. This can be used not just for physical relationships but any situation where you are feeling pressured to do something. Examples: drinking, drugs, shoplifting. PROVIDE ALTERNATIVES P

36 Get Yourself Tested! HIV: Syphilis: Chlamydia & Gonorrhea:--Everyone aged 15 through 64 should get tested at least once --People who have occasional exposure to HIV risks = at least once a year --People who are at high risk for HIV infection = 3-6 months Syphilis: --If you are pregnant --Are a man who has sex with other men --Have sex for drugs or money --Have HIV or another STD --Had sex with someone who tested positive for syphilis Chlamydia & Gonorrhea: Age 24 or younger and having sex = once every year Age 25 or older = if you have had more than one sex partner or with a new sex partner Talk with a doctor about getting tested if you have had sex with someone who tested positive for chlamydia or gonorrhea. HIV: Everyone aged 15 through 64 should get tested one time, regardless of their risk factors. People who have occasional exposure to HIV risks should be tested at least once a year. People who are at high risk for HIV infection should get tested every 3 to 6 months. All pregnant women should be tested during the 1st trimester of pregnancy. If at high risk for HIV: again in the 3rd trimester. Syphilis: Get tested for syphilis if you: Are pregnant Are a man who has sex with men Have sex for drugs or money You have HIV or another STD You’ve had sex with someone who tested positive for syphilis Chlamydia & Gonorrhea: For women: If you are age 24 or younger and having sex, get tested once every year. If you are age 25 or older, get tested if you have more than one sex partner or a new sex partner. If you have had sex with someone who tested positive for chlamydia or gonorrhea. For men: Talk with a doctor about getting tested if you have had sex with someone who tested positive for chlamydia or gonorrhea.

37 Where to Get Tested https://gettested.cdc.gov www.stdcheck.com County Health Departments Check out Apps on your phone: “STD Info, Symptoms & Testing” “STD Testing Centers Locator” “Planned Parenthood Care” “HIV/AIDS Test”

38 Resources OSDH-HIV/STD Service: 405-271-4636 OSDH-HIV/STD Service: National HIV/AIDS Hotline: