Overall, the study found that a good proportion of participants; 38.2% (123) that have undergone VMMC engaged in risky sexual practices. The study shows several factors that play a role in the adoption of risky sexual practices among participants that have undergone VMMC namely: age, education, religion, residential area, occupation and marital status.
While anecdotal observations show that there is a better perceived understanding that VMMC protects against contracting HIV, the results in this study show a variation in VMMC client’s views. The study shows that a higher proportion of participants reported understanding that VMMC offers partial protection and that one can still acquire HIV if engages in unsafe sexual practices. In addition, almost all of the participants reported the need to continue using condoms post VMMC and that one can still transmit the virus despite having undergone VMMC. Further to this, more than half of the participants reported being afraid of acquiring HIV if they subject themselves to risky sexual practices despite having undergone VMMC.
A study done in South Africa showed that 75.5% of participants understood the partial protection offered by VMMC a percentage slightly lower as compared to this study . A similar study conducted in Botswana, Namibia and Swaziland showed that 9-15% of the participants believe that circumcised men are fully protected against HIV compared to 2.5% from this current study . In addition, 14–26% of the participants from a study conducted in Botswana, Namibia and Swaziland believed that an HIV-positive circumcised man cannot transmit the virus compared to 1.6% from this study . The participants’ better understanding of VMMC messages as seen from this study could be attributed to enhanced IEC from the Ministry of Health (MoH) through the use of mass media as a measure to combat rising pressure of possible risk compensation that is being imagined with the rolling out of VMMC in Malawi. This is further influenced by the availability of wide range of mass media and residing in an urban location where access to information is high among the literate population who have undergone counselling prior to undergoing VMMC.
On the other hand, 12.7% of the study participants had a perception that VMMC provides total protection against HIV acquisition and 2.5% of the study participants were not certain as to what VMMC offers in HIV prevention. These contrasting views could be attributed to message dissemination in relation to HIV and the protection that VMMC offers. VMMC being a new strategy in HIV prevention, most of the messages are focused on the HIV protection with little emphasis on the limitation of VMMC. Furthermore, to increase the uptake of VMMC in Malawi, campaigns are on the increase and message dissemination does not mostly emphasize on the limitation of VMMC. In addition, participants’ understanding and level of education could also have an impact on the uptake and interpretation of the messages that are packaged for VMMC awareness. In this regard, VMMC is being taken as a preventive measure against contracting HIV with little emphasis on its limitation putting at risk clients who may opt for VMMC and engage in risky sexual practices post VMMC owing to its protective effect.
Despite having high level of understanding as regards HIV transmission and the protection offered by VMMC, this may also be a driving factor for participants to go for VMMC. Perceived benefits of VMMC such as protection against contracting HIV and sexually transmitted infections and penile hygiene have been found to encourage men to undergo VMMC and this was also observed in a study done in Uganda . Close to half (45.7%, n=322) of the participants in this study agreed to have less fear of contracting HIV following VMMC, which may try to explain the discrepancy between knowledge and practice of participants that have undergone VMMC where 38.2% still engaged in risky sexual practice despite knowing the level of protection that VMMC offers. Contextually, VMMC seems to have opened an opportunity for participants that were previously afraid of engaging in risky sexual acts. A study by Kibira et al demonstrated that willingness to be circumcised was associated with risky sexual practice  putting forward an idea that being circumcised is likely to encourage clients to engage in risky sexual practices.
Socio demographic factors may influence the sexual practices of participants that have undergone VMMC. Residing in high density locations was significantly associated with non-condom use while those residing in low density residential areas were significantly associated with being involved in paid sex. High density locations of Mzuzu are mostly associated with low socioeconomic status hence access and affordability of condoms may be affected. Low education levels may as well affect condom uptake and usage while those residing in low density areas are associated with wealth and higher education hence the likelihood of affording to pay for sex. This result is similar with findings that were observed in the MDHS where those residing in high density locations were less likely to use condoms . In this regard, knowledge of the perceived protective effect of VMMC in such circumstances could overshadow the need to use other preventive measures like condom use hence an increase in risky sexual practices.
Though not statistically significant, the odds of having multiple sexual partners was almost twice among those that attained secondary and tertiary education and those aged 25 -29 were twice likely to have multiple sexual partners compared to those aged 18 - 24. This finding may be attributed to social factors that this age group is exposed to mostly during college time. A similar study demonstrated that circumcised younger men, residing in urban areas, with secondary or higher education, higher social class and with knowledge of protective effect of VMMC were more engaged in risky sexual practices .
Being a student and unemployed was significantly associated with being involved in paid sex. Students usually are provided with a source of income through up keep allowances from institutions of higher learning which are located within reach of social activities within the urban setting (bars and night clubs) where the unemployed counterparts may attend and be involved in the risky sexual acts. Furthermore, those unmarried or single were involved more in paid sex within the age bracket of 18 – 29. Education level could have had an influence on the young ones who understand better the benefits that VMMC carries and this could have been the driving force to their risky sexual practice. Similarly, a study done in Uganda observed that risky sexual behaviors were associated with willingness to be circumcised and this was evident among the youth aged 15 -34, educated and residing in the urban region . This finding supports the idea that undergoing VMMC is likely to encourage participants to engage in risky sexual acts. Furthermore, in a comparative study, risky sexual practices were observed less in the uncircumcised participants who showed interest to be circumcised than in the circumcised ones . Results from a study done in Zimbabwe showed a strong association between willingness to be circumcised in participants that had risky sexual practices (multiple partners, being involved in paid sex and non-condom use) . This observation may explain the continued risky sexual practices in circumcised participants as being carried forward following circumcision and likely due to the perceived protective effect.
Furthermore, the results have shown that marital status, location and occupation were associated with being involved in paid sex. Those that were unmarried, young, unemployed and coming from low density areas were more likely to engage in paid sex while those with formal employment were less likely to engage in paid sex. These findings contradict with those from a similar study that was conducted by Mapoma and Bwalya where those aged 25-59 and married were associated with risky sexual practices . These findings may be attributed to the place of study; being urban location, most of those aged 18 – 29 are either students or dependents who are being cared for and the income they generate is mostly spent on social life that may expose them to paid sex. A study across the VMMC prioritized countries in the Sub Saharan region showed that age, religion, education, job and marital status were significant with risky sexual practices .
The study found that 38.2% of the participants were involved in paid sex post VMMC. Having multiple sexual partners constituted 23.7%, being involved in paid sex 29.2% and non-condom use at 36.9% (n=187). A study by Kibira et al, also demonstrated higher proportions of circumcised participants that were involved in risky sexual practices (non-condom use 38.4%, 65.8%, multiple sex partners, and 3.7% paid for sex) . Mapoma and Bwalya in the study conducted in Zambia showed slightly lower proportions of risky sexual practices (23.9% paid for sex, 20.8% had >2 sexual partners and 18.2% did not use a condom) . These studies demonstrated proportions higher compared to the uncircumcised counterparts. These findings show that there is an increase in risky sexual practices among circumcised participants.
Risky sexual practices such as having multiple sexual partners and engaging in paid sex influenced men to go for VMMC owing to the perceived protective effect of VMMC as observed from studies that were conducted in Zimbabwe and Botswana . Further to this, a study done in Uganda showed that the HIV prevalence among the circumcised was low even with risky sexual practices . These findings may negatively affect the promotion of safer sex practices among the circumcised and could be a driving factor for clients to opt for VMMC and consequently engage in risky sexual practices. Studies done in Zimbabwe, Zambia, two from Uganda and from the 14 prioritized VMMC countries showed that VMMC participants are engaging in risky sexual practices despite the proportions not being significant. , 47].
In addition, abstinence post VMMC also impacts on HIV transmission. In this study 32.3% (104) resumed sexual activity before six weeks. Of these, higher percentage was observed among the married ones, 63.5% versus 36.5% in singles. Those that are married are unlikely to observe the six week abstinence period as they mostly engage in sex with their marital partner hence diffusing the fear of contracting HIV. The risk of contracting HIV is higher in those that resume sexual activity in less than 6 weeks as was observed from studies done in Uganda and Cape Town in South Africa ,.
Risky sexual practices are evident in the circumcised participants. Varied estimates have been observed from different studies on the risky sexual practices specifically on non-condom use, having multiple sexual partners and being involved in paid sex. Proportions of those that self-reported engaging in risky sexual practices from this study (38.2%), support the possibility of risky sexual practices arising from being circumcised. It has also been observed that the driving force for men to undergo VMMC was their risky sexual practice prior to getting circumcised. In addition, almost close to half of the participants self-reported less fear of contracting HIV post VMMC. The findings of this study have shown that VMMC participants are likely to engage in risky sexual practices owing to the perceived protective effect that VMMC offers.
Nevertheless, there are some limitations to this study. This study is cross-sectional and causal inferences cannot be drawn. It is also worth noting that the findings could also be limited by social desirability bias in participants’ self-reporting of sexual risk practices during face to face interviews and also recall bias when reporting on their sexual practices.
On the other hand, a study that incorporates both circumcised and uncircumcised participants need to be conducted to compare the findings.