False-positive results can occur in those with low likelihood of infection with reverse sequence testing as well.5. STIs Symptoms Sorely Confused: The Difference Between Cold Sores, Canker Sores, and Chancres By Elizabeth Boskey, PhD Updated on August 13, 2022 Medically reviewed by Jane Van Dis, MD Many types of sores affect your mouth. The first sign of syphilis is a small sore, called a chancre (SHANG-kur). Effect of early syphilis infection on plasma viral load and CD4 count in human immunodeficiency virus-infected men: Results from the FHDH-ANRS CO4 cohort. Dumaresq J, et al. There is a strong association between syphilis and HIV infections. While most people infected with syphilis develop only one chancre, some people develop several of them. Preliminary 2021 Syphilis Data. If you are diagnosed with an STD, talk to your doctor about ways to protect yourself and your partner(s) from getting reinfected with the same STD, or getting HIV. Sex Transm Infect. When taken exactly as directed, antiretroviral drugs can reduce HIV viral load to undetectable levels in 6 months or less. Gay, bisexual, and other men who have sex with men (MSM) are experiencing extreme effects of syphilis. Later stages of syphilis can involve additional injections or a course of intravenous (IV) antibiotics. STD is short for sexually transmitted diseases. Check out these best-sellers and special offers on books and newsletters from Mayo Clinic Press. HIV Rash vs. Syphilis Rash: What Are the Differences? There is a close link between STDs and HIV. At any stage of infection, syphilis can invade the: These infections can cause a wide range of symptoms.3. : Primary syphilis causes an ulcer, and this sometimes isn't noticed because it's painless and can be inside the vagina or on the cervixafter a few weeks, two months, they can get secondary syphilis, which is a rash. Thank you, {{form.email}}, for signing up. CDC twenty four seven. Syphilis CDC fact sheet (detailed). Millions of new infections occur every year in the United States. The bacteria enter the body through minor cuts or abrasions in the skin or mucous membranes. When you visit the site, Dotdash Meredith and its partners may store or retrieve information on your browser, mostly in the form of cookies. Factors like viral load and CD4 count can impact the effects of syphilis in those living with HIV, so antiretroviral drugs can be beneficial here, too. They also account for 47 percent of all male P&S cases. Elimination of mother-to-child transmission (EMTCT) of HIV and syphilis is a global health priority. In the late stage, the disease may damage the brain, nerves, eyes, heart, blood vessels, liver, bones and joints. If left untreated, syphilis can cause a variety of serious health problems. Having a lower amount of virus in the blood also means fewer CD4 cells will be infected and killed by HIV. If not in a visible location, they are easily missed. Syphilis and HIV are very different sexually transmitted infections (STIs). HIV basics. 8. Getting tested for STIs and ensuring any sexual partner has been tested is another important step in prevention. Syphilis reemerged worldwide in the late 1990s and hereafter increasing rates of early syphilis were also reported in Denmark. What is HIV? Centers for Disease Control and Prevention. However, a rash may be the first symptom of syphilis a person notices. These painless chancres can occur in locations that make them difficult to notice (e.g., the vagina or anus). Getting tested is the only way to know your HIV status. In addition, MSM who have primary or secondary syphilis are more likely to get HIV. People with syphilis should notify their sex partners so they also can receive testing and treatment if necessary. MMWR Recomm Rep, 1998. Chancres can occur in, on, or around the penis, vagina, anus, rectum, and lips or mouth. The second case is a 24-year-old government officer with right eye posterior uveitis where the serology tests for . information and will only use or disclose that information as set forth in our notice of 6Genital sores caused by syphilis make it easier to transmit and acquire HIV infection sexually. Anyone who is sexually active should discuss their risk factors with a healthcare provider. Cookies used to track the effectiveness of CDC public health campaigns through clickthrough data. 2. This is because unusual blood test results have been documented in some people living with HIV. Tertiary syphilis is rare and develops in a subset of untreated syphilis infections. Syphilis and HIV coinfection is particularly prevalent in MSM. The present communication describes three different cases of syphilis and HIV co-infection in young men. The first case is a 25-year-old medical graduate with a primary and secondary syphilis lesions at time of presentation. venereal disease research laboratory (VDRL), fluorescent treponemal antibody absorbed (FTA-ABS). Treponemal antibodies appear earlier than nontreponemal antibodies. The McGraw-Hill Companies; 2018. https://accessmedicine.mhmedical.com. Having sex without a condom can make you vulnerable to both HIV and syphilis. (2013). For people who inject drugs, using new, clean needles is crucial to preventing transmission. Talk to a healthcare provider if you are concerned about HIV or have questions about how to protect yourself. Babies born to those who test positive for syphilis during pregnancy should receive congenital syphilis screening and a thorough exam. All information these cookies collect is aggregated and therefore anonymous. Careful follow-up is needed to make sure treatment was effective. Partner-based interventions include partner notification a critical component in preventing the spread of syphilis. In those with HIV, syphilis may progress faster and be harder to treat, although these effects are more common in people with high viral load and low CD4 count. Syphilis predicts HIVincidence among men and transgender women who have sex with men in a preexposureprophylaxis trial. It can have serious, even fatal consequences if not treated, but syphilis is easy to treat and cure once an infection has been identified. A 2017 cohort study assessed syphilis treatment in 510 people with and without HIV, finding treatment was ineffective in 10.94 percent of people. Altman K, Vanness E, Westergard RP. Accessed July 14, 2019. Syphilis also increases the risk of HIV infection and can cause problems during pregnancy. Treatment with penicillin is extremely effective (success rate of 98%) in preventing transmission to the baby. Read our. CDC twenty four seven. Having an undetectable viral load can effectively eliminate the risk of transmitting HIV via sex. Pregnancy and childbirth complications Treatment can help prevent future damage but can't repair or reverse damage that's already occurred. (August 31, 2021), A clinical guidance document for use in the diagnosis and management of syphilis. After all, STIs aren't spread every time someone has sex. Detailed fact sheets are intended for physicians and individuals with specific questions about sexually transmitted diseases. In California, there was a >700% increase in primary and secondary syphilis cases reported between 1999 and 2005. https://www.uptodate.com/contents/search. What Does Syphilis Look Like in People With Penises? 1 What is Syphilis? Clin Infect Dis. is considered necessary for demonstrating a clinically significant difference between two nontreponemal test results . Verywell Health prefers to use inclusive terminology. If you do not allow these cookies we will not know when you have visited our site, and will not be able to monitor its performance. Both HIV rash and syphilis rash can look similar. Antibiotics can often effectively treat syphilis in those with and without HIV. Syphilis & MSM (Men Who Have Sex With Men), Congenital Syphilis Diagnosed Beyond the Neonatal Period in the United States: 2014-2018, The Diagnosis, Management and Prevention of Syphilis: An Update and Review, Centers for Disease Control and Prevention. 2015 sexually transmitted diseases treatment guidelines: Syphilis. It's important to start HIV treatment with antiretroviral therapy right away to best manage the condition. Also, Chi-square test was used to compare the differences between prevalence cases and incidences cases for HIV and syphilis. It can appear 1030 years after a person gets the infection, and it can be fatal. When this happens, its called a coinfection. niaid.nih.gov/diseases-conditions/10-things-know-about-hiv-suppression, ncbi.nlm.nih.gov/pmc/articles/PMC3838065/, clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-opportunistic-infection/syphilis, bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-020-09984-9, jamanetwork.com/journals/jamainternalmedicine/fullarticle/1221715, bmcinfectdis.biomedcentral.com/articles/10.1186/1471-2334-13-605, ncbi.nlm.nih.gov/pmc/articles/PMC7360277/, ncbi.nlm.nih.gov/pmc/articles/PMC5598031/, cdc.gov/std/syphilis/stdfact-syphilis-detailed.htm, cdc.gov/std/syphilis/stdfact-msm-syphilis.htm, cdc.gov/hiv/basics/hiv-transmission/ways-people-get-hiv.html, sti.bmj.com/content/early/2020/11/20/sextrans-2020-054706, What You Need to Know About HIV Encephalopathy. Our results indicate that compared to incident cases, prevalent cases had a . Signs and symptoms may never return, or the disease may progress to the third (tertiary) stage. Therefore, it may not be obvious that a sex partner has syphilis. After treatment, its possible to get syphilis again in the future. All rights reserved. Options for non-pregnant patients who are allergic to penicillin may include: Healthcare providers should use these therapies only in conjunction with close clinical and laboratory follow-up. Dr. Stacey Rizza, an infectious diseases specialist at Mayo Clinic, says syphilis affects men and women and can present in various stages. You can add this content to your website by syndicating. Alternatively, consider using the STD facts brochuresor ordering materials through CDC-INFO on Demand (please note: stock is limited). Early syphilis can be cured, sometimes with a single shot (injection) of penicillin. In the United States, about half of men who have sex with men (MSM) and who have primary syphilis or secondary syphilis also have HIV. 1. https://www.merckmanuals.com/professional/infectious-diseases/sexually-transmitted-diseases-stds/syphilis. National Institute of Allergy and Infectious Diseases. Examine suspicious lesions, body fluids, or tissues (e.g., umbilical cord, placenta) by darkfield microscopy, PCR testing, and/or special stains. Centers for Disease Control and Prevention. What Are the Side Effects of Untreated Syphilis? Syphilis can be cured with the right antibiotic medication. Prevalence of syphilis, neurosyphilis and associated factors in a cross-sectional analysis of HIV infected patients attending Bugando Medical Centre, Mwanza, Tanzania. These cookies allow us to count visits and traffic sources so we can measure and improve the performance of our site. Be sure to see a doctor if you notice any signs of syphilis. Primary syphilis causes painless sores (chancres) on the genitals, rectum, tongue or lips. Preliminary 2021 data: Syphilis. It's more useful than the instinct to chastise them for not doing what doctors and educators think they should. Sexually Transmitted Disease Surveillance, 2021. It can be treated, quite effectively, with highly active anti-retroviral therapy (called HAART or cART), but it currently can not be fully cured. When a pregnant person has syphilis, the infection can spread to their unborn baby. This appears to be more likely in people with a higher viral load and lower CD4 count. Saving Lives, Protecting People, American Sexual Health Association (ASHA), National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, U.S. Department of Health & Human Services. Patients with HIV and latent syphilis infection should be evaluated clinically and serologically at 6, 12, 18, and 24 months after therapy. Merck Manual Professional Version. Having anal, vaginal, or oral sex without a condom; Having sex while under the influence of drugs or alcohol can lower inhibitions and result in greater sexual risk-taking. Selection of the appropriate penicillin preparation is important to properly treat and cure syphilis. For further details on the management of sex partners, refer to the 2021 STI Treatment Guidelines. A baby born alive with syphilis may not have any signs or symptoms of disease. (2021). Viral load increases were also observed in those with coinfections receiving antiretroviral drugs. Babies who do not receive treatment may have developmental delays, seizures, or die. It's also possible to have both syphilis. Getting timely treatment at the first sign of syphilis is crucial to keeping syphilis from lingering and advancing to later stages and symptoms such as syphilis rash. However, this can range from 10 to 90 days. PrEP is much less effective if it is not taken consistently. Syphilis CDC detailed fact sheet. AskMayoExpert. for video Mayo Clinic Minute: Signs and symptoms of syphilis, Mayo Clinic on Incontinence - Mayo Clinic Press, Mayo Clinic on Hearing and Balance - Mayo Clinic Press, FREE Mayo Clinic Diet Assessment - Mayo Clinic Press, Mayo Clinic Health Letter - FREE book - Mayo Clinic Press, Book: Mayo Clinic Family Health Book, 5th Edition, Mayo Clinic Minute: Signs and symptoms of syphilis, Mayo Clinic Minute: Concerning rise in syphilis cases across Minnesota. Some are directly related to infections. Our website services, content, and products are for informational purposes only. Newly acquired HIV infections often have no recognizable symptoms, and HIV can cause no serious symptoms for years or even decades. That means forgetting to use a condom (external or internal) during one encounter isn't a good reason to avoid using a condom when you see them again. 8. And since you can contract syphilis more than once, partner notification reduces your risk of getting reinfected. Trichomoniasis. Healthcare providers should only use penicillin therapy to treat syphilis and prevent passing it to the baby. Adults with sexually transmitted syphilis or other genital ulcers have an estimated two- to fivefold increased risk of contracting HIV. https://www.uptodate.com/contents/search. What is HIV? 54(9): p. 217-9. Three common types have similar names and other features: Cold sores Chancres Canker sores Bicillin L-A is the first-line recommended treatment for syphilis and the only recommended treatment option for some patients. Atlanta, GA: Department of Health and Human Services; September 2021. Rash is a symptom of both HIV and syphilis, but how each rash looks and where it appears on the bodyalong with other HIV symptoms and syphilis symptomsare characteristics that differentiate one infection from the other. If you get treated for an STD, this will help to prevent its complications, and prevent spreading STDs to your sex partners. Key Difference: HIV is a virus that causes a body's immune system to weaken. Consider adjusting the scale or shrink to fit in your browser settings, or consult the printing instructions applicable to your browser. Pregnant women are not immune to syphilis. Sometimes they resemble rashes caused by other diseases. Using a condom is important for preventing syphilis rash since contact with a partner's sores can transmit the infection to you. 60(5): p. 133-7. What are STDs? Last medically reviewed on June 25, 2021. This is true across all regions, sexes, and racial and ethnic groups. Once cured, syphilis doesn't return on its own. These signs and symptoms may disappear within a few weeks or repeatedly come and go for as long as a year. They are. What's the Link Between HIV and STDs? Wu MY, et al. In addition, sticking to treatment can slow HIV disease progression and lower the risk of HIV transmission. Increases in viral load were seen in 27.3 percent of those with coinfections, compared to 16.6 percent of those with HIV alone. Linking to a non-federal website does not constitute an endorsement by CDC or any of its employees of the sponsors or the information and products presented on the website. Rates of syphilis in the United States have been increasing over the past 20 years. Any person with signs or symptoms suggestive of syphilis should receive a test for syphilis. Emily is a health communication consultant, writer, and editor at EVR Creative, specializing in public health research and health promotion. Many refer to syphilis as The Great Pretender, as its symptoms can look like many other diseases. To help prevent the spread of syphilis, follow these suggestions: If tests show that you have syphilis, your sex partners including current partners and any other partners you've had over the last three months to one year need to be informed so that they can get tested. Latent syphilis can last for years. The key difference between syphilis and HIV is that syphilis is a sexually transmitted disease caused by a bacterium called Treponema pallidum, while HIV is the virus that causes a sexually transmitted disease called AIDS. Rashes during the secondary stage: Condyloma lata are large, raised, gray or white lesions. It does, however, mean that there needs to be continuing education about the risk of STIs other than HIV, particularly in the context of treatment. One of these is neurosyphilis. 2015;61:281-287. doi:10.1093/cid/civ289. People can be infected with syphilis and not know it. HIV infection. . Late latent syphilisis latent syphilis where infection occurs more than 12 months ago. Centers for Disease Control and Prevention. 10 things to know about HIV suppression. HIV encephalopathy is a serious complication of HIV that usually develops when HIV progresses to AIDS. By Emily Brown, MPH Use new syphilis infections to prioritize getting men access to pre-exposure prophylaxis (PrEP). These drugs reduce the amount of virus in the body by blocking the virus from, HIV-negative people can safely live with HIV-positive people. Verywell Health's content is for informational and educational purposes only. Jinno S, et al. If you are a Mayo Clinic patient, this could Getting treatment for HIV is a vital tool in preventing disease progression. However, rashes with a different appearance may occur on other parts of the body. How is syphilis diagnosed in those with HIV? Because of this, its important to take precautions such as using a condom during sex and receiving regular STI screenings. A double-edged sword: does highly active antiretroviral therapy contribute to syphilis incidence by impairing immunity to Treponema pallidum? The only 100% effective way to avoid STDs is to not have vaginal, anal, or oral sex. Centers for Disease Control and Prevention. Treatment typically involves a one-time injection of penicillin. Those persons who meet the criteria for treatment failure (i.e., signs or symptoms that persist or recur or a sustained [>2 weeks] fourfold or greater increase in titer) should be managed in the same manner . That's true even when they can't be perfect. Syphilis diagnosis involves the use of two different types of blood tests. Syphilis is a sexually transmitted infection. CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website. But the stages may overlap, and symptoms don't always occur in the same order. al. 10 things to know about HIV suppression. Others are related to disease treatment and sexual behavior. Types of HIV tests. Avoiding condomless sex is the best way to prevent HIV and syphilis. The disease starts as a painless sore typically on the genitals, rectum or mouth. During 2021, there were 176,713 new cases of syphilis (all stages). Not everyone has the ability to negotiate safer sex. Congenital syphilis greatly increases the risk of miscarriage, stillbirth or your newborn's death within a few days after birth. Not by itself. Mayo Clinic. The average time between acquisition of syphilis and the start of the first symptom is 21 days. To test the difference between prevalent and incident cases, two nested matched case-control studies were carried out. This is why every pregnant patient should have a blood test for syphilis. As such, it is important to highlight the importance of both screening and prevention. In fact, there are several links between these two infections. The difference between the two is that these diseases can be transmitted mainly through sex. What Are the Side Effects of Untreated Syphilis? When either one is untreated, serious health problems can develop. However, babies born with syphilis can also be born too early, may die in the womb before birth or can die after birth. including other infections (e.g., HIV), autoimmune conditions, vaccinations, injecting . Sexually transmitted diseases (STDs), also known as sexually transmitted infections (STIs), are very common. The rash can appear anywhere on the body, but it typically develops on the chest, back, or arms. 4): 1-187. Centers for Disease Control and Prevention. They are spread through sexual contact. information submitted for this request. If someone is HIV-negative, having syphilis can make it easier to contract HIV. Condoms, when used correctly every time someone has sex can reduce the risk of getting or giving syphilis. Your sex partners are less likely to get HIV from you if you. Treating an HIV or syphilis rash also means treating the underlying infection. STD facts: HIV/AIDS and STDs. The disease can be present with the appearance of a single chancre (shown here on a penis) or many. Cookies used to make website functionality more relevant to you. 5 Causes of HIV 6 Treating HIV 7 Difference Between HIV and Syphilis What is Syphilis? Purpose of review Syphilis cases are on the increase especially in men who have sex with men (MSM) in urban areas of high-income countries. https://www.cdc.gov/std/syphilis/stdfact-syphilis.htm. Alternatively, consider using the STD facts brochuresor ordering materials through CDC-INFO on Demand (please note: stock is limited). There are differences in the interpretation of serological tests for syphilis in the HIV positive but how often does this matter clinically? If reactive, examine the infant thoroughly for evidence of congenital syphilis. Centers for Disease Control and Prevention. Always see a healthcare provider if you are concerned that you may have HIV or syphilis or the associated rashes so you can get the right treatment. They should ask their healthcare provider about testing for syphilis or other STDs. In 2017, a group of scientists realized that syphilis infection was rising faster than other bacterial STIs among men who have sex with men (MSM). The high risk of an HIV diagnosis following diagnosis of syphilis: a population-level analysis of New York City men. With a scientific background and a passion for creative writing, her work illustrates the value of evidence-based information and creativity in advancing public health. What STIs Can Be Detected by Blood Tests? Accessed July 30, 2019. Clinical Infectious Diseases. (March 2019), Consider adjusting the scale or shrink to fit in your browser settings, or consult the printing instructions applicable to your browser. Lee N, et al. Obstet Gynecol, 1999. We avoid using tertiary references. If we combine this information with your protected In some cases, syphilis may progress faster or be harder to treat in those living with HIV. Its possible to contract syphilis another time. These cookies may also be used for advertising purposes by these third parties. The Difference Infection vs. Disease Types Symptoms How to Test A sexually transmitted disease (STD) is a disease that is primarily spread through sexual contact. STDs pass from one person to another through vaginal, oral, and anal sex. STDs are extremely common. Health care providers with STD consultation requests can contact the STD Clinical Consultation Network (STDCCN)external icon. This, in turn, was increasingtheir risk of STIs other than HIV. What Does Syphilis Look Like in People With Penises? Guidelines for the prevention and treatment of opportunistic infections in adults and adolescents with HIV: syphilis. (2020). People living with HIV will not typically transmit HIV sexually if they are undergoing antiretroviral therapy and have an undetectable HIV viral load. Increased repeat syphilis among HIV-infected patients: A nationwide population-based cohort study in Taiwan. The differential for genital ulcers is broad and includes genital herpes, syphilis, and chancroid, along with other less common STD causes of genital ulcer (lymphogranuloma venereum, granuloma. Healthcare providers should screen all pregnant people at their first prenatal visit. This stage typically starts with the development of a rash on one or more areas of the body. Syphilis may also damage heart valves. The first thing to understand is that STI stands for 'sexually transmitted infection ' and STD stands for 'sexually transmitted disease'. Syphilis is a sexually transmitted disease (STD) caused by the bacteriumTreponema pallidum. Syphilis spreads from person to person via skin or mucous membrane contact with these sores. Click here for an email preview. HIV rash and syphilis rash may have similarities in appearance, but there are distinguishing features and factors of each. These cookies perform functions like remembering presentation options or choices and, in some cases, delivery of web content that based on self-identified area of interests. 20th ed. According to data from the Centers for Disease Control and Prevention (CDC), the rate of syphilis in the United States has increased each year for the past 20 years. The only way to completely avoid syphilis is to not have vaginal, anal, or oral sex. Yes. privacy practices. Some patientsshould receive a second test during the third trimester (at 28 weeks) and again at delivery. For example, an STD can cause a sore or a break in the skin, which can make it easier for HIV to enter the body. Stacey Rizza, M.D. Given that there are well-established epidemics of HIV infection among MSM from large metropolitan areas, an increasing number of cases of concurrent syphilis and HIV infection were being reported. But when citing research or health authorities, the terms for gender or sex from those sources are used. They may develop in warm, moist areas like the mouth, underarm or groin region. Jarzebowski W, et al. Developed by the NYC Department of Health and Mental Hygiene Bureau of Sexually Transmitted Infections and the NYC STD Prevention Training Center. Within a few weeks of the original chancre healing, you may experience a rash that begins on your trunk but eventually covers your entire body even the palms of your hands and the soles of your feet. For detailed treatment recommendations, please refer to the 2021 CDC STI Treatment Guidelines. Print What is syphilis? However, HIV can be transmitted in a number of other ways. Getting tested and getting access to antiretroviral drugs, if appropriate, is key to keeping yourself free from HIV. Some have argued that syphilis has a different clinical presentation and is more aggressive in people with HIV; others suggest there is little difference. How common is syphilis? Thank you for taking the time to confirm your preferences. Sexual partners of patients with syphilis are at risk and should receive treatment per the 2021 STI Treatment Guidelines. Key factors for prevention include but are not limited to: Knowing your status and that of your partner is crucial to preventing HIV transmission. Congenital syphilis can lead to miscarriage, stillbirth or infant deaths. Protect yourself if you inject drugs. Aug. 25, 2019. However, syphilis transmission can occur with lesions not covered by a condom. There is no vaccine for syphilis. They help us to know which pages are the most and least popular and see how visitors move around the site. Adults with sexually transmitted syphilis or other genital ulcers have an estimated two- to fivefold increased risk of contracting HIV. Syphilis blood tests use a sample of blood taken from a vein in your arm. According to the CDC, these types of tests are typically accurate and reliable for diagnosing syphilis in individuals living with HIV. 1998-2023 Mayo Foundation for Medical Education and Research (MFMER). This association may also work the other way around. Having sex while using drugs or alcohol. Treatment of the early stages of syphilis typically involves a single injection of the antibiotic penicillin. What is STD? Examples of syphilis tests that can also be used with a CSF sample include the VDRL test and the FTA-ABS test. However, if treatment is not immediate, the baby may develop serious problems within a few weeks. Atlanta, GA: Department of Health and Human Services; April 11, 2023. STI Pictures: Chlamydia, Genital Warts, Pubic Lice & More, Syphilis Rash: Everything You Need to Know. The latent (hidden) stage of syphilis is a period when there are no visible signs or symptoms of syphilis. The key differencebetween PEP and PrEP is that PEP is post-exposure prophylaxis, where people take a short course of HIV medicines soon after possible exposure to HIV to prevent the virus from taking hold of the body, while PrEp is pre-exposure prophylaxis where people who do not have HIV take HIV medicine to reduce the risk. HIV isnt transmissible through the casual contact customary for roommates and family, Paul Edmonds was diagnosed with AIDS in 1988. What are STDs? However, syphilis typically follows a progression of stages that can last for weeks, months, or even years: A single chancre marks the onset of the primary (first) stage of syphilis, but there may be multiple sores. National Institutes of Health HIV Info. 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