China Focus: Chinese surgical ring helping to fight AIDS in Africa

It's a simple device - two concentric plastic rings - but its use could help turn the tide on Africa's AIDS epidemic.

The Shang Ring circumcision device - invented in China and lauded by Bill Gates - is being used in Botswana, Ethiopia, Kenya, Namibia and 10 other African countries affected by AIDS.

Invented by wholesale trader Shang Jianzhong, from south China's Anhui Province, the Shang Ring is a disposable device comprising two plastic rings that lock together over the foreskin. Unlike conventional surgery, the Shang Ring does not require sutures, involves minimal bleeding and shortens the procedure to just three to five minutes.

"The whole circumcision process is as simple as having a cup of coffee or grabbing a hamburger," says Shang, 60.

He swore he would help other men after experiencing a traditional circumcision.

"A poorly cut foreskin left me bed-ridden for more than a month during the Spring Festival in 2002," Shang recalls. "Pain, panic, stitches, antibiotics, no taking a bath, staying in bed, a risk of a second surgery..."

Shang drew on his carpentry skills acquired in his early years and expertise gained at a local survey and design academy to make the first Shang Ring model in two months.

"It was made of wood and I tried it on my dog successfully," Shang recalls.

Shang realized that his invention had a value beyond just improving the circumcision experience, so he devoted almost half of his savings into commercializing Shang Ring and setting up a company.

The Shang Ring went on the market and 1,200 sample cases gradually drew the attention of international medical experts.

Over the next three years, clinical outcomes in local hospitals proved its effectiveness. Shang improved his original design, earning a China patent.

"On September 26, 2006, I was invited to the Second Asia-Pacific Forum on Andrology and showcased the Shang Ring. Experts from Edinburgh University and Melbourne University observed the process and said it was impressive," Shang recalls.

Since 2006, the Shang Ring has been introduced in about 3,000 Chinese hospitals and successfully used in more than a million adult male circumcisions.

Later, he met Philip Li, a doctor and associate professor at Cornell University. The first time Li saw the Shang Ring, he said to Shang, "This will change your life, and mine."

Li and other experts in China and abroad conducted a series of studies of the Shang Ring' s clinical outcomes, which were published in the Asian Journal of Andrology, Nature and AIDS. The study team standardized the Shang Ring circumcision procedures. To date, the Shang Ring has been awarded 31 patents in China and protected by more than 100 countries through the Patent Cooperation Treaty.

The results of a series of independent studies carried out around the world were published in 2005, showing male circumcision could reduce the risk of heterosexual HIV transmission by up to 63 percent.

In 2009, the Shang Ring underwent a pilot study in Kenya. Conducted by EngenderHealth, a global reproductive health organization, and Weill Cornell Medical College, it found the device highly acceptable to men and safe for further study in Africa.

"Not only is it a sutureless procedure with little or no bleeding, but it is faster to perform and takes less time to heal than conventional circumcision," said Dr. Mark Barone, senior clinical advisor at EngenderHealth. "Evidence is also mounting that the Shang Ring will be feasible in low-resource setting."

In 2014, the Bill & Melinda Gates Foundation and the United States National Institutes of Health sponsored clinical tests of the Shang Ring in Kenya. The result showed 98.5 percent of the 2,500 trial patients were satisfied and all clinical data was approved by the World Health Organization (WHO).

A report from the Joint UN Programme on HIV/AIDS (UNAIDS) said 36.9 million people were living with HIV globally in 2014, and 70 percent of them lived in sub-Saharan Africa.The WHO and UNAIDS recommend that countries include male circumcision as part of their HIV prevention programs. But because surgical circumcision requires a trained physician or surgeon, circumcision rates remain low in developing countries.

Though circumcision is minor surgery, the risks posed by traditional methods and traditional notions in Africa mean many adult males are unwilling to undergo it. Despite the urgent recommendation of the WHO and UNAIDS, just 44 percent of men in the 14 worst affected countries were circumcised - far short of the 80-percent goal.

Supported by the Bill & Melinda Gates Foundation, the Shang Ring research team organized an international training program on using the device in 2009, attracting doctors from 50 countries, including Zambia, Kenya and Uganda. "African doctors spoke highly of the device and they said they would make good use of it," Shang says. Now the program is offered every year.

"It takes less time and needs fewer surgery skills. Surgeons find it easy to master. The use of the Shang Ring will help circumcisions increase in Africa relatively quickly," says Professor Cheng Feng, of the Research Center for Public Health at Tsinghua University.

In the past five years, governments in countries like Kenya and Uganda have expressed purchasing intentions. A health official in Uganda said he hoped to increase circumcision operations to a million each year with the Shang Ring.

Traditional circumcision methods are still used in Kenya, where progress is slow, so the government plans to scale up the use of Shang Ring.

In June 2015, the WHO prequalified the Shang Ring, making it the first Chinese-manufactured device of its kind listed in UN medical equipment catalogue.

"My company has supplied 4,000 Shang Ring sets to Africa. Now we are considering applying for China' s foreign aid qualification," says Shang. "We hope this Chinese innovation will help solve a serious problem in Africa." Endi