In general, East, Central and Southern Africa appear to be worse affected by HIV-1 infection than West Africa. So far there is little evidence to suggest that differences in either sexual behaviour or numbers of sexual partners could account for this disparity. Two risk factors in men for acquiring HIV-1, that tend to vary along this geographical divide, are lack of circumcision and genital ulcer disease (GUD) which are much less common in West Africa. Although uncircumcised men with GUD are an important high frequency HIV-1 transmitter core group, few interventions have targeted such individuals. Given the recent expansion in AIDS-related technologies, is it possible that methods effective in limiting GUD in the preantibiotic era have been overlooked? During the first and second world wars, chancroid, the commonest cause of GUD in Africa today, was controlled successfully with various prophylactics including soap and water. Many parts of Africa are undergoing social upheaval against a background of violence, and in this environment soap and water prophylaxis would now seem to merit re-evaluation as an intervention for preventing both GUD and HIV-1 in uncircumcised men. By facilitating healing of traumatic, inflammatory and infected penile lesions, pre- and post-exposure prophylaxis with soap and water could be a cheap and effective method for decreasing the risks of acquiring GUD and HIV in this vulnerable group of uncircumcised men.
PIP: The heterosexual transmission of HIV-1 is highly efficient in sub-Saharan Africa. Being uncircumcised and having genital ulcer disease (GUD) are two factors which put men at risk for acquiring infection with HIV-1. In turn, uncircumcised men with GUD are an important high frequency HIV-1 transmitter core group. While the pathogenesis of GUD remains unclear, it probably requires an initial minor abrasion of normal skin, common among uncircumcised men with poor genital hygiene and areas of mucosal discontinuity on the penis. The moist environment under the foreskin hinders the rapid healing of subpreputial abrasions and also provides a fine receptacle for the retention of sexually transmitted pathogens. Damage to the superficial subpreputial mucosa, which may be exacerbated if traumatized during sexual intercourse, forms a highly plausible entry point for HIV-1. Chancroid, the most common cause of GUD in Africa, was successfully controlled with a range of prophylactics during the first and second world wars, including basic hygiene using soap and water. Washing of the penis with soap and water should again be considered as a means of preventing both GUD and HIV-1 in uncircumcised men. By facilitating the healing of traumatic, inflammatory, and infected penile lesions, pre- and post-exposure prophylaxis with soap and water could be a cheap and effective method for decreasing the risk of acquiring GUD and HIV in such men.