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