5. Male circumcision
The Shang Ring Device for adult male circumcision: a proof of concept study in Kenya
Barone MA, Ndede F, Li PS, Masson P, Awori Q, Okech J, Cherutich P, Muraguri N, Perchal P, Lee R, Kim
HH, Goldstein M. J Acquir Immune Defic Syndr. 2011 Feb 21.
The objective of this study was to assess safety, preliminary efficacy, and acceptability of the Shang
Ring, a novel disposable device for adult male circumcision, in Kenya where 40 HIV-negative men were
recruited in Homa Bay, Kenya. Circumcisions were performed by a trained physician or nurse working
with one assistant. Follow-up was conducted at 2, 7, 9, 14, 21, 28, 35 and 42 days after circumcision.
Rings were removed on day 7. Pain was assessed using a visual analog scale (0=no pain,10=worst
possible). Men were interviewed at enrollment and on days 7 and 42. All 40 procedures were completed
successfully. Mean procedure and device removal times were 4.8 (sd±2.0) and 3.9 (sd±2.6)
minutes, respectively. There were six mild adverse events, including three penile skin injuries, two
cases of edema, and one infection; all resolved with conservative management. In addition, there were
three partial ring detachments between days 2-7. None required treatment or early ring removal.
Erections with the ring were well tolerated, with a mean pain score of 3.5 (sd±2.3). By day 2, 80%
of men were back to work. At 42 days all participants were very satisfied with their circumcision and
would recommend the procedure to others. The results of Barone and colleagues demonstrate that the
Shang Ring is safe for further study in Africa. Acceptability of the Shang Ring among participants
was excellent. With short procedure times, less surgical skill required, and the ease with which it can be
used by non-physicians, the Shang Ring could facilitate rapid roll-out of male circumcision in sub-
Abstract : http://www.ncbi.nlm.nih.gov/pubmed/21346586
Editors’ note: WHO and UNAIDS recommend three surgical techniques for adult male circumcision: the
forceps guided method, the sleeve resection method, and the dorsal slit method
(www.malecircumcision.org). In the absence of task sharing and other methods to optimise the volume
and efficiency of male circumcision service delivery, these methods entail 20 to 30 minutes of surgical
time. This study of the Shang Ring shows promise and suggests that further data should be collected in
sub-Saharan African settings with this device. The Shang Ring consists of 2 concentric plastic rings that
are available in China in 32 sizes for use with neonates to adults. Following local anaesthesia, the
locking rings compress the foreskin with no need for sutures. In addition to the impressive number of
minutes saved per procedure, this study found the rings to be acceptable with all 32 of the men who
attended the 6 week follow-up visit stating that they would recommend circumcision generally and
specifically with the Shang Ring. Given the millions of adult male circumcisions that countries are aiming
to achieve by 2015, there is tremendous interest in the potential time-saving features of medical devices.
The WHO Technical Advisory Group on Innovations in Male Circumcision, which has a mandate to
examine data on new circumcision devices formally submitted to it, will hold its first meeting in July 2011.
You can expect further innovations in male circumcision service delivery in the future.
[Full text PDF] http://hivthisweek.unaids.org/sites/default/files/UNAIDS_CSA-RO_HIVthisweek_92_110619_8.pdf