I hope I find you in good health. The foreskin(prepuce) is a folded-over flap of skin and mucosa that covers the head (glans) of the penis. In intact boys, the prepuce adheres to the glans until about the age of eight, when it loosens and becomes retractable. During circumcision, the foreskin is pulled back, a section of the foreskin is cut away and the glans is exposed. After exposure, the mucosa of the glans and remaining begins to keratinize and toughen, eventually becoming like the more durable form of skin found on other exposed parts of the body.
In recent years, evidence from observational studies in sub-Saharan Africa has shown that circumcised men have a lower risk of acquiring HIV infection than uncircumcised men.The proposed mechanism by which the circumcised state might protect against HIV infection is twofold. First, the inner surface of the foreskin contains macrophages , dendritic and Langerhans cells, which are the primary entry points for HIV infection, and is also vulnerable to traumatic epithelial disruptions during intercourse. Second, an intact foreskin exposes a man to a greater risk of ulcerative sexually transmitted infections, which in themselves are a risk factor for HIV acquisition.
In the Journal of Infectious Diseases, Jared Baeten and colleagues from the United States and Kenya collected detailed sexual data from a group of male Kenyan truckers and, using statistical models they developed infectivity measures that estimate the per-sexual-act probability of HIV transmission. Their results may help explain the rapid spread of HIV in settings where circumcision is not common and multiple sexual partnerships are. For the men in the study, the overall probably of becoming HIV-infected following a single act of intercourse was calculated to be .0063, or one in 160. Uncircumcised men had a more than two-fold increased risk of infection per sexual act compared with circumcised men one in 80 versus one in 200.

Even more compelling evidence of the protective effect of circumcision comes from a new study of couples in Uganda who had discordant HIV status; in this study the woman was HIV positive and her male partner was not. No new infections occurred among any of the 50 circumcised men over 30 months, whereas 40 of 137 uncircumcised men became infected during this time. Both groups had been given free access to HIV testing, intensive instruction about preventing infection, and free condoms (which were continuously available), but 89% of the men never used condoms, and condom use did not seem to influence the rate of transmission of HIV. These findings are part of a growing body of evidence that supports view that circumcision has some protective effect against HIV transmission.

More recently, while epidemiologists have been investigating the protective effect of male circumcision against HIV infection, there has been debate on why, 20 years into the pandemic, some countries continue to retain fairly low HIV seroprevalence, whereas in other places, sometimes even neighbouring regions, rates of infection are many times higher (see table). For example, rates of HIV-1 infection continue to be much lower in the Gambia (2.24%), Guinea (2.09%) and Benin (2.06%) than in Zimbabwe (25%), Botswana (25%) and Namibia (19%). It is no coincidence that the HIV rates are higher in areas where circumcision is not widely practiced. The table below illustrates this point more graphically, some people say you cant argue with facts.
HIV-1 seroprevalence in sub-Saharan African countries by estimated proportion of men circumcised
<20% circumcised Seroprevalence* >80% circumcised Seroprevalence*
Zimbabwe 25·84 Kenya 11·64
Botswana 25·10 Congo (Brazzaville) 7·64
Namibia 19·94 Cameroon 4·89
Zambia 19·07 Nigeria 4·12
Swaziland 18·50 Gabon 4·25
Malawi 14·92 Liberia 3·65
Mozambique 14·17 Sierra Leone 3·17
Rwanda 12·75 Ghana 2·38
Gambia 2·24
Guinea 2·09
Benin 2·06
*June 1998 UNAIDS/WHO % estimates.

In yet another study by Stephen J Reynolds and his colleagues ( Lancet 2004) circumcision was found to be strongly protective against HIV-1 infection, with a 6.7 fold in reduction in risk of HIV infection among circumcised men.
However, the association between lack of male circumcision and HIV transmission has met with fierce resistance, cautious scepticism, or, utter silence. As healthcare professionals we should now provide our communities with accurate, balanced information so that individuals can make informed choices; we should have the training and resources needed to offer safe, voluntary male circumcision in which pain is kept to a minimum..
However circumcision must not be perceived by individuals or communities as a substitute for other HIV and STD prevention strategies(e.g condom use). Rather, it should be integrated with existing AIDS prevention and reproductive health programmes in places with a high prevalence of HIV infection. More studies on this issue are still being carried out.

Till next week take care of yourself and each other. And remember, '…in all your getting, get understanding.'