HIVreport.de
02
2011
Pre-cum
2
Pre-cum – What’s that?
3
HIV in Pre-cum
4
Gonorrhoeae in Pre-cum
6
Conclusions for Prevention
aidshilfe.de
HIVreport 2/2011 Pre-cum
Issue No. 02/2011
28/04/2011
Dear Readers,
Pre-Cum
Spring has arrived at the HIVreport’s editorial office. This issue introduces a fresh new
look for the HIVreport and connects it more
closely to the DAH website. All topics will
now be easier to find and will offer links to
our other information services. This is
meant to increase the HIVreport’s usefulness while making it more exciting to read.
The focus of the HIVreport’s current issue
also happens to be on excitement, or more
specifically, pre-ejaculate.
Questions about what role this small drop of
liquid has in HIV transmission have puzzled
many experts. We decided to get to the bottom of this, all the way to the pelvic floor,
where the pea-sized glands are located that
produce pre-ejaculate.
Bottom line: The established facts of HIV
prevention still apply. Pre-ejaculate is of no
concern in oral intercourse. Oral contact
with pre-ejaculate is still considered “safer
sex”. However, this is not the case with
vaginal and anal intercourse, where preejaculate may well lead to an HIV infection
(or pregnancy).
The second topic is – once again – preexposure prophylaxis (PrEP): In the two
previous HIVreports, we discussed the findings of the first phase-3 study. Unfortunately, we now have some unexpected bad
news: A PrEP study on women from southern African countries was stopped. This is
why, for the third time in a row, we are informing you about PrEP, which seems to
become a prominent topic this year.
Best regards,
Armin Schafberger, Steffen Taubert
PRE-CUM ............................................... 2
Pre-cum or Pre-ejaculate – What’s that? ........ 2
Where does it come from? ............................... 2
What’s in it, and why? ...................................... 2
A Comparison: Ejaculate ................................. 3
A Comparison: The boar .................................. 3
HIV in Pre-ejaculate ........................................... 3
A Comparison: HIV in ejaculate ....................... 3
Neisseria Gonorrhoeae in Pre-ejaculate .......... 4
Co m me n t a r y ................................................... 4
Conclusions for Prevention .............................. 6
Oral sex ............................................................ 6
HIV: Pre-ejaculate of no concern ................. 6
N. gonorrhoeae: Infection of the throat
possible ........................................................ 6
Vaginal and anal sex ........................................ 6
Pre-ejaculate as HIV risk ............................. 6
NEWS BULLETIN .................................. 7
PrEP Study Stopped .......................................... 7
Competence Networks Ends HIV Cohort ........ 7
New Website for HIVreport................................ 7
REFERENCES ....................................... 7
IMPRINT ................................................. 8
1
HIVreport 2/2011 Pre-cum
Pre-cum
“I’ve heard that pre-cum contained an extreme concentration of HIV. Others say the
exact opposite.” Questions like this are
frequently asked in the Health Support
section of the gay dating site Gayromeo as
well as on other online advice sites.
into the rear of the urethra. They are supported by the smaller Littré glands located in the
penis along the urethra.
What’s in it, and why?
Pre-ejaculate serves as a natural lubricant
during sex and subsequent ejaculation. It
flushes out residual urine and changes the
chemical environment in the urethra (from
acidic to basic). This secretion thereby acts
as a buffer in vaginal intercourse before any
sperm enters the vagina’s acidic and rather
“hostile” environment. Additionally, the secretion’s constituents are considered to have
immune defence properties [2].
Pre-cum or Pre-ejaculate –
What’s that?
The clear fluid that is secreted by the urethra
of a man’s penis after sexual arousal prior to
ejaculation is referred to as pre-ejaculate,
Cowper’s fluid, and colloquially as pre-cum.
The amount varies from a few drops up to 5
ml [1]. In rare cases, the amount may be
larger and is perceived by some men as uncomfortable or embarrassing.
The secretion of the Cowper’s gland itself is
free of sperm. Several authors have nevertheless found sperm in pre-ejaculate, sometimes even in almost half of their study
subjects [3]. There are two possible explanations for this observation: It was either residual sperm from a previous ejaculation, or
sperm from an imminent ejaculation that
prematurely exited the urethra. Given the
technically tricky “extraction” of pre-ejaculate,
Where does it come from?
Pre-ejaculate originates from glands whose
existence and name is even unknown to
many doctors. It is primarily produced by two
pea-sized bulbourethral glands (also called
Cowper’s glands) that are located below the
prostate and release their secretions directly
Male lower abdomen (cross-section)
Intestine
Groß
wieof
The
size
einethe
a pea:
Erbse:
die
Cowper’s
Cowperglands
Drüsen
Urinary bladder
Seminal duct
Prostate
Rectum
Urethra
Testis
Epididymis
2
HIVreport 2/2011 Pre-cum
line: Men drip before, boars drip after – and
seal it off.
it is almost impossible to distinguish between
pre-ejaculate and ejaculate. Sperm found in
inherently sperm-free pre-ejaculate is the
main reason why coitus interruptus, i.e. the
pull-out method, is not recommended for heterosexuals as a suitable method of contraception.
sch
HIV in Pre-ejaculate
There are only two small-scale studies from
1992 that investigated whether pre-ejaculate
contains HIV. Due to the difficult extraction of
pre-ejaculate, there is no other available research known to us.
A Comparison: Ejaculate
Semen consists of various secretions produced by the epididymis (located behind the
testes), the seminal vesicles (located behind
the prostate), the prostate and the Cowper’s
glands. The sperm cells originating from the
testes only make up a very small part of the
volume, with most of the ejaculate coming
from the prostate.
The study by Ilaria et al. [10] used DNA
measurement 2 to detect the presence of HIV,
while the study by Pudney et al. [11] employed HIV-antibody markers. Result: Immune cells 3 containing HIV were found in
most of the 23 examined pre-ejaculate samples from HIV-positive subjects.
A Comparison: The boar
Humans and pigs have a fairly similar anatomy 1. There is, however, at least one difference between man and pig in the anatomy
and function of the bulbourethral glands.
Neither of the two studies provided any information about the detection of free viruses in pre-ejaculate.
The studies did not offer any statements
about concentration (referred to as viral load)
or comparisons between the concentration of
HIV in pre-ejaculate and ejaculate.
The study findings have been interpreted to
suggest that pre-ejaculatory fluid tends to
contain less HIV than semen while still being
potentially infectious. However, based on this
research, it is not possible to determine if,
and under what circumstances, preejaculatory exhibits a higher or lower concentration of HIV.
It can be assumed (although not scientifically
proved) that the concentration of HIV in preejaculatory fluid – as well as in blood and
other secretions – is higher in the case of
acute HIV infection and will be low or no
longer detectable after several months of
successful HIV treatment.
photo: Ich-und-Du / pixelio.de
A man’s bulbourethral gland is only pea-sized
and produces hardly any secretion worth
mentioning. A boar releases about 40 grams
of fluid from a gland up to 20 cm (8 inches) in
length during, but not before, the final thrust
of ejaculation. This secretion reacts with the
proteins of the seminal vesicles, forming a
viscous gel that closes the cervix to prevent
the semen previously ejaculated into the
uterus from leaking back out [12]. Bottom
A Comparison: HIV in ejaculate
HIV is found in ejaculate as both a free virus
and in immune cells (lymphocytes and mac-
2
HIV is an RNA virus. However, when the genetic material of HIV is integrated into the genetic material of the
human cell, it must be present in the form of DNA – as
in humans. This integrated HIV DNA can be measured.
1
This is why pigs are used as subjects in medical trials
(e.g. testing new anaesthetic techniques) and as heart
valve donors. The transplantation of other tissue from
pigs to humans, such as pancreatic islet cells for the
treatment of diabetes, is currently being researched.
3
HIV can be transferred by both free viruses and viruses in cells (cell-to-cell contact).
3
HIVreport 2/2011 Pre-cum
People with living with HIV/AIDS who have a
gonococcal infection of the urethra, have
three times more often HIV in the urethra
[13]. . This will increase the risk of HIV transmission through unprotected vaginal or anal
sex. The diagnosis and treatment of gonorrhoea (and chlamydia) is therefore an important factor in preventing HIV
rophages). While the sperm themselves are
free of HIV, the virus is capable of attaching
to the sperm’s surface. Sperm washing in assisted reproduction therefore makes it possible to obtain HIV-free sperm.
HIV originates from all secretions of the ejaculate. However, it has yet to be determined
which gland(s) are primarily responsible for
the concentration of HIV in sperm, and to
what extent immune cells (macrophages) in
the lining of the urethra are able to release
HIV [7].
sch
Commentary
A Safe Feeling, Flushed Down
the Drain?
A large part of the viruses in ejaculate appears to come from the prostate and the seminal vesicles [8]. This is supported by the fact
that there is no noticeable decrease in the
concentration of HIV in sperm after a vasectomy (severing the vas deferens from the testes and epididymis).
Pre-cum encapsulates all the drama about
safer sex. Answering questions about precum is the ultimate challenge in HIV/AIDScounselling.
I’m not sure if anyone has ever noticed, but
the penis is somehow reminiscent of gremlins: When it gets wet, it gets serious.
According to an examination by Smith et al.,
the concentration of HIV in ejaculate may be
even higher after a prostate massage (using
a finger), at least in some of their male test
subjects [9].
This may require a little explanation: “Gremlins” is a 1984 film about adorable little creatures that can quickly turn into vicious
monsters. Whenever they come into contact
with something wet, bad things are bound to
happen.
Neisseria Gonorrhoeae in Preejaculate
We do know that a penis doesn’t bite when it
comes into contact with…let’s say… saliva.
But as soon as a drop of liquid comes out of it
during oral sex, the performer often recoils in
fear, because that drop can be bad news.
This goes back to 30 years of HIV prevention
telling us to “get out before it comes!” – Most
people have really taken this advice to heart.
As we have learned, anyone whose mouth
comes into contact with semen is at risk of
contracting HIV.
In science and preventive
medicine, Cowper’s fluid – as some like to
call it – has always held a special status
based on the belief that the concentration it
contains is too low for HIV to be transmitted
through oral sex. To rephrase this in a lyrical
way: The first heralds of spring won’t give you
sunburn.
The bulbourethral glands are no strangers to
gonorrhoea. Neisseria gonorrhoeae infect the
urethra and its accessory glands 4. In chronic
(untreated) gonorrhoea, they may persist in
the bulbourethral glands for a long time.
These glands are also a reservoir for bacteria.
This means that in the event of a bacterial infection, the pre-ejaculate contains N. gonorrhoeae (or chlamydia) while also carrying the
bacteria located in the urethra. Even when
there is no contact with sperm during oral
sex, N. gonorrhoeae may still infect the
throat 5. The preliminary results of the recent
PARIS study by the Robert Koch Institute indicate that one in twenty MSM had N. gonorrhoeae of the throat.
Things could be so easy: sperm nay, preejaculate yay. But honestly, most of us never
swallowed that message, or the liquid in
question, without thinking twice about it. For
many people, pre-cum is a turn-off. And it has
always been the ultimate challenge in
HIV/AIDS counselling, because this tiny drop
of bodily fluid encapsulates the entire uni-
4
N. gonorrhoeae may also infect the throat (after oral
sex), the rectum (after anal sex) and the cervix (after
vaginal sex). They may also cause so-called ascending
infections of upper organs, e.g. Fallopian tubes, prostate, spermatic cord, epididymis, …
5
Chlamydia appear to infect the throat less often that
N. gonorrhoeae
4
HIVreport 2/2011 Pre-cum
verse of safer sex, all knowledge about potential risks of infection, as well as all those
nagging fears and uncertainties that affect so
many people.
Reliable information may not always be
enough to overcome that fear entirely, but it
will at least help keep it at bay. Fortunately,
we know by now that even a whole mouthful
of semen poses only a minor risk compared
to unprotected anal sex. Perhaps this will
help us make peace with pre-ejaculate?
To put it another way: We know that nothing
can happen – but does this mean we can all
blow easy?
If not, I recommend counselling projects ot
the Deutsche AIDS-Hilfe. They know a lot
about this subject.
Here’s what happens in a real life situation:
As long as we don’t see or taste anything,
everything is fine, so a tiny drop of liquid is
not going to kill us. But as soon as the
thought of pre-ejaculate, no matter how little it
may be, enters our mind, it can unleash a
whole landslide of worries.
Holger Wicht
First of all, it’s not always just a drop; the
amount of pre-cum can vary greatly. So what
if it’s not a drop, but a trickle or even a stream
– could this be the very exception to the safer
sex rule? Wouldn’t this mean that those extremely few viruses per micro-litre all add up
to exceed the risk threshold?
Does that even qualify as pre-cum anymore?
Or could that already be semen? There are
men who produce a lot of pre-cum and there
are those who produce little semen. Consistencies vary. Both fluids pass through the
same opening in short succession. Preejaculate and ejaculate – practitioners only
draw a fuzzy distinction between these two
terms. And let’s be honest, saying that “a very
low concentration of the virus is not enough
to become infected” does not make for a very
solid argument. To make things even more
complicated, it’s also been reported that precum in the rectum may very well be dangerous after all. Any feeling of safety we may
have had is flushed down the drain!
Consider this: Last night I bit my tongue, this
morning I sliced my gums with dental floss,
and mucous membranes can’t be trusted anyway. Wouldn’t a situation like this leave the
door wide open for HIV infection?
The issue of pre-ejaculate fuels a flurry of irrational fears that are particularly difficult to
cope with because there are also some reasonable doubts involved. That’s what safer
sex is like: While striving for total commitment, we are secretly calculating the probabilities – and always expect the worst. The
residual risk has to be taken, but we fool ourselves by blowing it out of proportion, because fear is one of the most skilled
illusionists under the sun.
5
HIVreport 2/2011 Pre-cum
Safer sex (“Get out before it comes”) does
not provide protection against gonorrhoea
during oral sex. Sexually active people who
practice oral sex with various partners should
consider the possibility of having contracted
gonorrhoea – although that disease often
progresses without any apparent symptoms.
Only a routine test (throat swab to measure
bacterial DNA = PCR) can provide clarity in
this case. However, these examinations have
so far been rarely performed in medical practices.
Conclusions for Prevention
Pre-ejaculate is no easy subject. When
assessing the risk of HIV infection, it is
not essential to know whether the concentration of HIV in pre-ejaculate is slightly
lower or higher than in semen.
What’s most important is the type of sex
that was practiced and the mucous membrane that came into contact with the preejaculate. In the mouth, pre-ejaculate does
not 6 pose a risk of HIV transmission. In
the vagina, pre-ejaculate is very likely to
pose a high risk of HIV transmission.
Sex workers are advised to wear condoms
also for oral sex to prevent gonococcal infections (and other STIs, e.g. syphilis).
Oral sex
Vaginal and anal sex
HIV: Pre-ejaculate of no concern
Pre-ejaculate as HIV risk
In general, oral sex (including contact between mouth and semen) only poses a low
risk of a HIV transmission [14,15,16]. To further reduce this low risk, the safe-sex message is to avoid taking ejaculate in the mouth.
This message permits oral contact with preejaculate, and has been proved in millions of
cases over a quarter of a century.
The pull-out or withdrawal method (also
called “coitus interruptus”) is often used with
the intention to prevent pregnancy or HIV infection. Scientific studies have demonstrated
the opposite: This method provides no protection against pregnancy or HIV. Preejaculate may have a significant role in this
case.
HIV is also a “problem of quantity”. The small
quantity 7 of HIV in pre-ejaculate is not
enough for oral (!) transmission. This is because the oral mucosa is much more resilient 8 than the genital and rectal mucous
membranes, in addition to the diluting effect
of the saliva and the short period of exposure
before the fluid is swallowed.
In a study on Canadian homosexual and bisexual men, Liviana Calzavara et al. [4] identified the delayed application of condoms
during anal sex as a major HIV risk factor for
the receptive partner. They assume that preejaculate may contribute to this increased
risk.
In two studies on Australian gay men, Jin et
al. discovered a risk for the receptive partner
during anal sex when the insertive partner
withdrew before ejaculation [5]. The second
study (see HIVreport 1/2010 for detailed information) found that unprotected anal sex
without ejaculation was still half as risky as
unprotected anal sex with ejaculation [6] –
thus posing a high risk.
N. gonorrhoeae: Infection of the throat
possible
A gonorrhoea infection of the throat is a previously underestimated or rather little-known
condition. During oral sex (with ejaculation),
these pathogens can be transmitted through
contact with the urethra and pre-ejaculate.
So far, it has not been possible to scientifically prove whether pre-ejaculate is the cause of
that high HIV risk, or if there may be other
reasons involved (unintentional ejaculation,
small bleeding injuries on the partner’s penis,
ulcers on the partner’s glans or foreskin leaking HIV-infected secretions). Small amounts
of pre-ejaculate may, however, also pose a
risk of HIV transmission, since the mucous
6
Nothing is 100% safe, neither medicine and prevention nor nuclear safety or air travel. In very rare cases,
oral sex may lead to infection even if there was no oral
contact with semen.
7
A man simply doesn’t have the tremendous secretion
volume of a boar
8
After all, the oral mucosa has to withstand many
things, including spicy foods, hot tea, acidic juices and
distilled spirits.
6
HIVreport 2/2011 Pre-cum
membranes of the cervix and the intestine are
more susceptible than the mouth – even
when there are only small amounts of HIVinfected secretions.
Competence Networks Ends HIV
Cohort
Funding for the HIV/AIDS Competence Network ends in April 2011. Now that state funding has run out, the Competence Network for
HIV/AIDS will have to give up its plans for a
long-term patient database. All attempts to
raise money for the continuation of the HIV
cohort failed. The competence network plans
to keep the collected data and biomaterial until June 2016 to allow for the completion of
ongoing research projects and to give scientists the opportunity to continue working with
the compiled material for a few more years. Is
there even any point in preserving data for
such a long time when there is only “old data”
left anyway? How secure are the data and
the biomaterial when there is no longer a
funded administrative structure? Should study
participants continue their participation, or
would they be better advised to revoke their
consent? This May, the DAH will provide a
critical analysis and in-depth coverage of the
developments in the competence network
on „blog.aidshilfe.de” and “HIVreport.de” to
shed some light on these questions. tau
Armin Schafberger, Steffen Taubert
News Bulletin
PrEP Study Stopped
On 18 April 2011, Family Health International
(FHI) announced that it will stop the FEMPrEP HIV-prevention study, in which some
2,000 women from Kenya, South Africa and
Tanzania participated. The study investigated
whether a daily dose of Truvada can prevent
HIV infection and reduce the number of HIV
infections. Preliminary study results indicated
that the group of women who received
Truvada® (Tenofovir plus Emtricitabin) for
several months had the same number of infections as the control group, suggesting that
this PrEP was not able to reduce the number
of HIV infections. The exact reasons for this
are not yet known. It is unclear if the outcome
may be due to low adherence to the study
regimen, or interactions between Truvada
and other drugs or foods, or a general ineffectiveness of PrEP in vaginal intercourse (a
study among MSM in late 2010 indicated
44% protective efficiency), or if PrEP only
failed to be effective in this particular study, or
if it only happened to be effective in the iPrEx
study among MSM. A final evaluation has yet
to be made – leaving the matter open to
speculation for now.
New Website for HIVreport
Over the next few months, the HIVreport
website will be moving to be integrated into
the website of Deutsche AIDS-Hilfe. This will
connect the contents of the HIVreport even
more closely to the DAH’s other media. The
search function on aidshilfe.de will then make
it possible to conveniently list all contents of
the HIVreport. The “old” web address will remain available for the transition period. Subscribers to the HIVreport will from now on
receive their PDF file from “aidshilfe.de”. tau
These results are not expected to mean “the
end” for PrEP. Although the FEM-PrEP was
stopped, there are still other ongoing PrEP
studies whose results are expected to be released in the next few years (overview in
HIVreport of December 2010, further information on the MSM-PrEP study).
In February 2011, the U.S. Centers for Disease Control published guidelines for the use
of PrEP among MSM in response to the iPrEx
study findings: That move may have been
premature (see HIVreport 1/2011). sch
7
HIVreport 2/2011 Pre-cum
[15]
Romero J et al: Evaluating the risk of HIV
transmission through unprotected orogenital sex.
AIDS 2002, Vol 16, No 9
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[1]
Chudnovsky A, Niederberger C: Copious
Pre-Ejaculation: Small Glands - Major Headaches.
Journal of Andrology, Vol. 28, No.3, May/June
2007
[2]
Chughtai B et al: A neglected gland: a review of Cowper gland. Int J Androl. 2005; 28:7477
[16]
Baggaley RF et al.: Systematic review of
orogenital HIV-1 transmission probabilities. Int
Journal of Epidemiology 2008; 37: 1255-1265
Imprint
Publisher
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Killick SR: Sperm content of preejaculatory fluid. Hum Fertil (Camb). 2011 Mar;
14(1):48-52
Deutsche AIDS-Hilfe e.V., Wilhelmstr. 138
10963 Berlin
Tel: (030) 69 00 87- 0 , Fax: (030) 69 00 87- 42
www.aidshilfe.de
[4]
Calzavara L: Delayed Application of Condoms is a Risk Factor for HIV Infection among
Homosexual and Bisexual Men. Am J Epidemiol
2003; 157:210-217
Responsible in the sense of the German
"Pressegesetz" (law on publishing/news):
Steffen Taubert (tau)
Armin Schafberger (sch)
[5]
Jin F et al: Unprotected anal intercourse,
risk reduction behaviours, and subsequent HIV infection in a cohort of homosexual men. AIDS
2009; 23:243-252
Texts
Armin Schafberger, Holger Wicht, Steffen Taubert
[6]
Jin F et al: Per-contact probability of HIV
Transmission in homosexual men in Sydney in the
era of HAART. AIDS 2010; 24:907-913
German-English Translation: Macfarlane International Business Services GmbH & Co. KG
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Coombs RW et al: Lower Genitourinary
Tract Sources of Seminal HIV. JAIDS 2006;
41:430-438
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Le Tortorec A, Dejucq-Rainsford N: HIV
infection of the male genital tract - consequences
for sexual transmission and reproduction. Int
Journal of Andrology 33 (2010), e98-e108
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Berliner Sparkasse
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[9]
Smith DM et al: The Prostate as a reservoir for HIV-1. AIDS 2004, Vol 18 No 11, 16001602
Notice
The procedures, medication, constituents and generic drugs are communicated regardless of the
existing patent situation. Protected product names
(trademarks) are not always marked as such;
however, this must not give rise to the assumption
that the designations used are non-proprietary
names.
Deutsche AIDS-Hilfe accepts no liability for the
correctness of the information provided as well as
for any damage caused by possible errors. We
recommend that our readers refer to the manufacturers’ summary of product characteristics and
package inserts.
[10]
Ilaria G et al.: Detection of HIV-1 DNA sequences in pre-ejaculatory fluid. The Lancet, Volume 340, Issue 8833, 12 December 1992, Page
1469
[11]
Pudney J et al.: Pre-ejaculatory fluid as
potential vector for sexual transmission of HIV-1
The Lancet, Volume 340, Issue 8833, 12 December 1992, Page 1470
[12]
Busch W, Holzmann A.: Veterinärmedizinische Andrologie: Physiologie und Pathologie der
Fortpflanzung bei männlichen Tieren. Schattauer
Verlag, 2001
[13]
Moss GB et al: Human Immundeficiency
Virus DNA in Urethral Secretions in Men: Association with Gonococcal Urethritis and CD4 Cell Depletion. The Journal of Infectious Diseases 1995;
172:1469-74
The translation of this issue was made possible by the support of
[14]
Campo J et al: Oral transmission of HIV.
Reality or fiction. Review. Oral Diseases, 2006,
12, 219–228.
8