Advances developed in China have led to less-complicated male circumcision, which is proving an important factor in disease prevention

Chinese advances in medical techniques that allow simpler male circumcisions are promoting the voluntary practice in Africa and elsewhere, leading to better protection from HIV/AIDS and other sexually transmitted diseases.

Studies have shown that men who have not undergone circumcision - the surgical removal of the foreskin, the retractable fold of tissue that covers the head of the penis - can be more susceptible to STDs in part because the fold makes it easier for viruses to survive.

While conventional surgery can be painful and require sutures that can cause scarring, some men are opting for simpler techniques.

Pail Arwa, 38, was circumcised in 2013. The surgery he received was different from most previous cases in the country. He tried a new device for circumcision - the ShangRing, a disposable device that eliminates the need for suturing and has been on the Chinese market since 2005.

The ShangRing, named after its Chinese inventor, Shang Jianzhong, is a disposable device consisting of two concentric rings that clamp together and expose the foreskin so it can be removed surgically, but with minimal bleeding. The ring is removed seven days after the surgery when the wound has healed.

Because the procedure doesn't require stitches, the patient is allowed to bathe and only requires oral antibiotics. The use of the ring also reduces the procedure time to about three to five minutes from about 30 before.

"I really like the ShangRing because it was an uneventful circumcision. I was able to go back to work the same day. I was very happy with how the wound healed. It looked smart," Arwa says. He chose the surgery because of hygiene concerns.

Months after Arwa's surgery, he took his 12-year-old son to get circumcised, also with the ShangRing. Arwa says he speaks up in the community about the technique's benefits whenever ShangRing circumcision is offered at local hospitals.

On June 5, ShangRing won a prequalification from the World Health Organization, which ensures that medicines and devices supplied by procurement agencies meet acceptable standards of quality, safety and efficacy. WHO's list of prequalified medicinal products is used by international agencies and increasingly by countries to guide bulk purchases of medicines.

"The significance of circumcision has already been shown in some African countries since the surgery has been widely promoted in the region in the past decade," says Cheng Feng, program director of the Research Center for Public Health at Tsinghua University.

"ShangRing will definitely expand such benefits of circumcision due to the simplicity and safety of the surgery. After it gained WHO prequalification, the device will rapidly spread its benefits around the world and provide a cheaper and effective solution to global HIV/AIDS control," he says.

The stakes remain huge. WHO says an estimated 33.4 million people are living with HIV/AIDS worldwide, among which about 22.4 million live in sub-Saharan Africa and, of those, 1.5 million live in Kenya. In 2007, the national prevalence of HIV/AIDS in Kenya was 7.1 percent among those aged 15 to 64.

According to the US Centers for Disease Control and Prevention, clinical trials have demonstrated that circumcision reduces the risk of men contracting HIV/AIDS during vaginal intercourse by 50 to 60 percent. The procedure also reduces the chances of contracting herpes simplex virus type 2 or the human papillomavirus, two pathogens believed to cause cancer of the penis, by 30 percent.

Male circumcision is recommended as an important component of a comprehensive package of preventative measures.

Conventional circumcision still represents the most common form of the procedure practiced in many African countries, such as Kenya. The classic procedure, which should be done by a surgeon, also can bring higher risks of infection.

Since 2008, a medical research team of Weill Cornell Medical College, together with another two non-profit human development organization--EngnederHealth, and FHI 360 (formerly Family Health International), has carried out a series of studies using the ShangRing for voluntary adult male circumcision in Kenya, Uganda and Zambia, according to guidelines established by WHO for clinical evaluation of new devices for adults.

Richard Lee, a Cornell expert working on the trial in Africa, says the current randomized, controlled trial seeks to assess the use of topical anesthesia for ShangRing circumcision as well as the impact of the Chinese-developed no-flip circumcision technique on the safety and effectiveness of ShangRing circumcision.

The no-flip technique simplifies the procedure since the foreskin is not flipped on top of the smaller ring before the larger one is clamped down. Instead, the smaller ring is inserted underneath the foreskin with the larger ring secured on the outside.

The team's plans call for conducting the trial over 18 months at two sites in Kenya the Homa Bay District Hospital, and Vpilingo. Preparations for the trial are underway and are awaiting local regulatory approval.

"The use of topical anesthesia in lieu of injectable anesthesia will make the procedure less painful and hopefully more widely accepted by patients. The use of the no-flip technique will ideally make ShangRing circumcision faster, simpler, and easier to teach and perform," he says.

In Southwest China's Yunnan province, the no-flip technique in ShangRing circumcision was invented by urology surgeons at Kunming Children's Hospital five years ago, where it is used on 2,000 to 3,000 children and teenagers every year.

"Circumcising a child is a harder operation than with adults. They have a small opening in the foreskin and their skin extension is also poorer than for adults," says You Hai, director of urology at the hospital.

You and his team began to try ShangRing in the operating room in 2009 and invented the no-flip technique through practice. The technique makes the surgery simpler and faster.

Although adopted clinically for less than five years, the no-flip technique's reputation has spread rapidly from China to Saudi Arabia.

You's daughter married a Saudi man in Saudi Arabia and their first son, 9 years old, was circumcised with conventional surgery at a local hospital years ago, in accordance with religious custom. "Scars were left, obviously, because the sutures were inevitable," You said.

In 2013, they took their second child a 2-year-old boy to Kunming for the no-flip technique in ShangRing circumcision. The surgical process took no more than two minutes, without complications or infection.

"Nearly 80 percent of patients take their kids to be circumcised to prevent diseases in the future. Many are from other provinces, such as Zhejiang and Fujian. This technique has not yet been promoted nationwide, yet some parents traveled to Yunnan and made a surgery appointment for their kids before arriving," says Yan Bin, a physician at the hospital's urology department.

In 2010, the department started to train doctors from Africa in the technique. Yan said they are planning to expand the training to physicians from Southeast Asia in the near future.

"The ShangRing could vastly increase access to male circumcision in countries hardest hit by the HIV epidemic," says Philip S. Li, director of Male Infertility Microsurgical Research and Training, Weill Cornell Medical College. "Especially in the area where experienced surgeons are in severe shortage, the simplified surgical method with the ShangRing gives access to more medical staff available (to use it), even the nurses."

Research shows measures such as promoting circumcision are starting to have an effect.

In 2011, a UNAIDS report showed a decline in the number of new cases of HIV in 33 countries 22 of them in southern Africa between 1997 and 2010.

While medical treatments such as the introduction of antiretroviral therapies were the main reason for the fall, the report said circumcision had also played an important role in the prevention of HIV and other sexually transmitted diseases.