Trends in age at male circumcision and its determinants in Rwanda

Voluntary medical male circumcision (VMMC) is a well-established public health intervention proven to reduce the risk of human immunodeficiency virus (HIV) infection. Its protective benefit is greatest when performed early, ideally within the first few days after birth or before sexual debut. Over the past decade, Rwanda has made remarkable progress in scaling up circumcision services as part of its comprehensive HIV prevention strategy. Despite these advances, there remains limited evidence on the timing of circumcision and the factors that influence when men choose to undergo the procedure. Understanding these determinants is essential for optimizing the preventive effectiveness of VMMC and improving service uptake across different age groups.

This study employed a retrospective cross-sectional design using data from the Rwanda Demographic and Health Surveys (RDHS) conducted in 2010, 2015, and 2020. The analysis included 15,965 men aged 15-59 years. Kaplan-Meier survival curves and log-rank tests were used to examine differences in the timing of circumcision across population subgroups, while Cox proportional hazards regression models were applied to identify factors associated with earlier circumcision. All analyses incorporated sampling weights and accounted for the complex survey design of the RDHS to ensure nationally representative estimates.

The prevalence of male circumcision among Rwandan men increased from 13.3% in 2010 to 30.6% in 2015 and further to 52.4% in 2020. The median age at circumcision was 15 years (95% CI: 14-16) in 2010, increased to 17 years (95% CI: 17-18) in 2015, and declined to 16 years (95% CI: 16-16) in 2020. In 2020, men with higher education had a 30% higher hazard of circumcision compared with those with no formal education (AHR = 1.30; 95% CI: 1.04-1.63; p = 0.020), indicating that circumcision occurred earlier among more educated men. Similarly, watching television frequently was associated with a 21% higher hazard of circumcision (AHR = 1.21; 95% CI: 1.10-1.33; p < 0.001), suggesting that media exposure accelerated uptake. In contrast, older men were slower to undergo circumcision compared with those aged 15-19 years, with hazards decreasing among those aged 20-24 years (AHR = 0.41; 95% CI: 0.36-0.46; p < 0.001) and 25-29 years (AHR = 0.24; 95% CI: 0.20-0.28; p < 0.001). Likewise, men residing in rural areas had a 21% lower hazard of circumcision relative to their urban counterparts (AHR = 0.79; 95% CI: 0.72-0.85; p < 0.001), indicating delayed uptake in rural settings.

Male circumcision uptake in Rwanda has increased markedly over the past decade, with the most significant gains observed among younger men. Sustained efforts that strengthen health education, expand media-based awareness campaigns, and implement targeted approaches for older and rural populations could further promote earlier circumcision uptake and enhance the effectiveness of national HIV prevention programs.