Abstract
Background Rapid up-take of voluntary medical male circumcision (VMMC) in countries like Rwanda that implemented it as a national HIV prevention strategy since 2008, raised a public health concern of risk compensation. Risk compensation may occur if circumcised men increase their risky sexual behaviours (RSB) because of the awareness of circumcision’s 60% protection from heterosexual HIV/STIs transmission. The aim of this study was to assess the difference in RSBs among adolescent and adult circumcised men before and after the VMMC program implementation in Rwanda Methods Data of 11,037 men aged 15-59 years from Rwanda DHS 2005 and 2014/15 were analyzed using STATA version 13.0. We estimated the prevalence of ever paid sex , extramarital sex , more than 3 total lifetime sex partners, condom use at paid sex, first sex below age 15 and most recent sex partner being casual/commercial; among circumcised and uncircumcised men and compared between surveys. Association of these behaviours with circumcision status were also determined using bivariate and multivariate logistic regression analysis in separate and in combined datasets. Results Men who reported being circumcised almost tripled from 11%(532) in 2005 to 29%(1821) in 2014/15. In all men, RSB prevalence was lower in 2014/15 than in 2005. Circumcised men were generally more likely to engage in RSB in both surveys than uncircumcised men but less likely in 2014/15 compared to 2005. Multivariate models revealed no association of circumcision with sex below 15 years in 2005 (AOR 0.89; CI: 0.65-1.19; P>0.05) and 63% protection in 2014/15 (AOR 0.63; CI: 0.51-0.76; P<0.01). In all men, while there were too few responses to determine a true difference in non-condom use , other RSB were significantly less likely whereas paid sex was significantly more likely in 2014/15 due to an increase among the uncircumcised (AOR 1.29; CI: 1.03-1.61). Conclusion The findings did not support risk compensation. However, more responses on condom use are needed to check its disinhibition among circumcised men. Ongoing VMMC campaigns should re-inforce pre-counseling to young men 15-24 in the provinces out of Kigali to delay sexual debut even after circumcision.
Impact of excluded studies on medical male circumcision and HIV risk compensation