Overall, the study found that more than one-third (38.2%) of participants; that had undergone VMMC engaged in risky sexual practices. Only area of residence and marital status seem to play a significant role in the adoption of risky sexual practices among participants that had undergone VMMC in this study.
Residing in high density locations was significantly associated with non-condom use. High density locations of Mzuzu are mostly associated with low socioeconomic status hence access and affordability of condoms may be affected [29]. Low education levels may as well affect condom uptake and usage in those residing in high density locations [3]. This result is similar with findings that were observed in the Malawi Demographic and Health Studies (MDHS) where those residing in high density locations were less likely to use condoms [3]. 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.
Furthermore, being single / unmarried and residing in low density residential areas was significantly associated with being involved in transactional sex. Those residing in low density areas in Mzuzu are associated with wealth and higher education hence the likelihood of affording to pay for sex [3]. Most of the unmarried / singles in low density urban locations are mostly either students or employed and have a source of income. Access to information among those residing in low density location could have had an influenced the better understanding of the benefits that VMMC carries and this could have been the driving force to the risky sexual practice among the single / unmarried. This was also observed in a study done in Uganda where risky sexual behaviors were evident among the singles willing to be circumcised and residing in the urban region [30]. A study conducted in Sub-Saharan countries also demonstrated that the unmarried / singles, engage more in transactional sex compared to their married counterparts [31]. The study also observed that economic status has an influence on transactional sex and residing in low density areas of Mzuzu is associated with wealth and higher levels of education. [3, 31].
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.
A study conducted 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 [32] while another study conducted in Botswana, Namibia and Swaziland showed that 9.0-15.0% of the participants believe that circumcised men are fully protected against HIV compared to 12.7% from this current study [33]. 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.
The participants’ better understanding of VMMC messages as seen from this study could be attributed to an enhanced IEC strategy by 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 [3] where access to information is high among the literate population who have undergone counselling prior to undergoing VMMC.
Nevertheless, 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 [34]. 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.
Close to half (45.7%) of the participants in this study agreed to have less fear of contracting HIV following VMMC, which may explain the discrepancy between knowledge and practice of participants that have undergone VMMC in this study 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 [30] putting forward an idea that being circumcised is likely to encourage clients to engage in risky sexual practices. Apart from the protection that VMMC offers in preventing HIV transmission, the perceived benefits of VMMC were also observed to be a driving factor for participants to go for VMMC [35].
This study found that 38.2% of the participants were involved in risky sexual practices post VMMC. Having multiple sexual partners constituted 23.7%, being involved in transactional sex 29.2% and non-condom use at 36.9% (n=187). Studies by Kibira et al, Mapoma and Bwalya also demonstrated higher proportions of circumcised participants that were involved in risky sexual practices compared to their uncircumcised counterparts [36, 37]. These findings show that there is an increase in risky sexual practices among circumcised participants. Furthermore, in a comparative study, risky sexual practices were less observed in the uncircumcised participants who showed interest to be circumcised than in the circumcised ones [38]. 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, educated and residing in the urban region [30].
These finding supports the idea that undergoing VMMC is likely to encourage participants to engage in risky sexual acts. 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 transactional sex and non-condom use) [25]. 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.
Nonetheless, the desire to have multiple sexual partners and engage in transactional 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 [30]. Further to this, a study done in Uganda showed that the HIV prevalence among the circumcised was low even with risky sexual practices [37]. 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 [37].
In addition, abstinence post VMMC also impacts on HIV transmission. In this study 32.3% (104) resumed sexual activity before six weeks and 63.5% were married. Engaging in sex with their marital partner among the married diffused their fear of contracting HIV. The risk of contracting HIV is higher in those that resume sexual activity in less than 6 weeks [39, 40].
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 transactional 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.