Islam and Health Policies Related to HIV Prevention in Malaysia (eBook)

​Sima Barmania, B Med Sci, MBBS, MPH, PhD, is a British medical doctor in global health, based between London, United Kingdom and Kuala Lumpur, Malaysia. She is a freelance writer, consultant, and an honorary research associate at UCL Institute of Education in London, UK. She qualified in medicine from Queen Mary University of London with an intercalated degree in community health sciences and undertook her Master's in Public Health from London School of Hygiene and Tropical Medicine. She completed her PhD in 2016 at United Nations University - Institute for Global Health, in collaboration with the National University of Malaysia, where her doctoral research explored the role of Islam in shaping HIV prevention in Malaysia. She is interested in the interface between public health, religion, and culture as well as broader interests spanning reproductive and mental health, and public health advocacy. Having had a long-running blog in the Independent, she also writes freelance for The Lancet medical journal and other media outlets. Her interests also include spirituality, world religions, and interfaith and peace education.  Michael J. Reiss, MBA, PGCE, PhD, is professor of Science Education at UCL Institute of Education in London, United Kingdom; visiting professor at the Universities of Kiel, Leeds, and York and the Royal Veterinary College; honorary fellow of the British Science Association and of the College of Teachers; docent at the University of Helsinki in Finland; and, a fellow of the Academy of Social Sciences. A former director of Education at the Royal Society, the inaugural editor of the academic journal Sex Education, and former specialist adviser to the House of Commons Education Committee PSHE (Personal, Social and Health Education) Inquiry, he is also a priest in the Church of England and president of the International Society for Science and Religion. His research and consultancy interests are in science education, bioethics, and sex education. Books of his include: Abrahams, I. & Reiss, M. J. (Eds) (2017) Enhancing Learning with Effective Practical Science 11-16, Bloomsbury; Reiss, M. J. & White, J. (2013) An Aims-based Curriculum, IOE Press; Jones, A., McKim, A. & Reiss, M. (Eds) (2010) Ethics in the Science and Technology Classroom: A New Approach to Teaching and Learning, Sense; Jones, L. & Reiss, M. J. (Eds) (2007) Teaching about Scientific Origins: Taking Account of Creationism, Peter Lang; Braund, M. & Reiss, M. J. (Eds) (2004) Learning Science Outside the Classroom, RoutledgeFalmer; Levinson, R. & Reiss, M. J. (Eds) (2003) Key Issues in Bioethics: A Guide for Teachers, RoutledgeFalmer; Halstead, J. M. & Reiss, M. J. (2003) Values in Sex Education: From Principles to Practice, RoutledgeFalmer; Reiss, M. J. (2000) Understanding Science Lessons: Five Years of Science Teaching, Open University Press; Chapman, J. L. & Reiss, M. J. (1999). Ecology: Principles and Applications, Cambridge University Press; Reiss, M. J. & Mabud, S. A. (Eds) (1998) Sex Education and Religion, The Islamic Academy; Reiss, M. J. & Straughan, R. (1996). Improving Nature? The Science and Ethics of Genetic Engineering, Cambridge University Press; Reiss, M. J. (1993) Science Education for a Pluralist Society, Open University Press; King, A. & Reiss, M. J. (Eds) (1993) The Multicultural Dimension of the National Curriculum, Falmer Press; and Reiss, M. J. (1989) The Allometry of Growth and Reproduction, Cambridge University Press.

​Chapter 1: Context Religion has perhaps never divided people as much as it does today. Religion often influences individual health behaviours in ways that can either be positive or negative. However, although public health models do take into consideration the influence of culture, there is little discussion of the impact of faith and religion on either mental or physical health. In part this is due to negative connotations arising from the historical antecedents of religious imperialism, colonialism, proselytising and hidden motivations. Yet faith-based organisations make a substantial contribution to health services, particularly in the developing world. Furthermore, religion can often drive health policy and can undermine implementation of public health programmes. In the case of HIV/AIDS, religions have helped but also have hindered by denying its existence, moralising HIV, and stigmatising and interfering with health promotion campaigns. Muslim communities, like many others, have a strong tendency to deny the existence of HIV as a problem, creating a culture of denial, and have responded with the familiar adage of "not our problem," often believing that being Muslim is a panacea to protect against HIV. However, in reality Muslim societies do not necessarily act in accordance with the teachings of the Qur’an. Muslims engage in the same behaviours that fuel the transmission of HIV elsewhere, yet with a reluctance to admit it. What transpires is a disconnect between public morality and private reality. As a result, the problem is exacerbated by making HIV prevention strategies difficult to implement. Chapter 2: What is known to date Malaysia is a country in South East Asia with a rich culture that over the past 100 years has progressed from a colonised country to one that has developed substantially economically and now is democratically ruled. The predominant religion is Islam, of the Ibn Shafi school of thought, which has a strong and ubiquitous influence on Malay society and everyday life. Despite considerable advances (e.g., in treatment options), one of the most significant threats to health both globally and specifically in Malaysia is the HIV/AIDS epidemic. Despite Islam's tendency to ignore the issues of HIV/AIDS, internationally there is an inverse correlation between HIV prevalence and Islam, in part because of male circumcision. In the early days of the HIV epidemic in Malaysia, intravenous drug use was the main driver; however, now there is a shift towards sexual transmission being the predominant driver. Increasingly Malaysian women are vulnerable to HIV with the feminisation of the epidemic.Chapter 3: Methods The main qualitative methods the authors employed were interviews to explore the experiences, attitudes, and practices of three groups of people within their social context, namely people living with HIV, religious leaders, and relevant policy makers. People living with HIV included men who have sex with men, transgender women, sex workers, and women who have acquired HIV through heterosexual transmission. Another key group were the Islamic religious leaders who resided in Peninsular Malaysia, including those from the mufti's office. The third group, policy makers, included representatives of the Ministry of Health. A total of 35 in-depth, semi-structured interviews were conducted face-to-face, audio-taped, transcribed, and analysed thematically. Quantitative data were obtained from the same three groups by means of a common questionnaire. In all, 252 completed questionnaires were obtained (117 from people living with HIV, 107 from religious leaders, and 28 from policy makers). The questionnaire was an abridged bilingual version of an existing, validated HIV Knowledge instrument. Analysis was undertaken using Excel and SPSS.Chapter 4: Findings Analysis of the interview transcripts identified ten central themes: Islam's view of life, health, and well-being; Knowledge about HIV; Sex outside marriage; Current HIV prevention in Malaysia; Condoms; Transgender women; Men who have sex with men; Law and authority; Stakeholder relationships; and, Action to be taken by stakeholders. The results of the qualitative component of the study highlight a myriad of different themes and issues arising in relation to HIV prevention in Malaysia. The Islamic tradition has a strong emphasis on promoting health, mitigating disease, and reducing harm, where health is seen in a holistic fashion, which incorporates body, mind, and spirituality. There is considerable awareness of HIV amongst some groups; however, this is still marred by negative associations of HIV being predominantly caused by sex outside of marriage, and this results in significant stigma, discrimination, and prejudice. In Islam, sex outside the confines of marriage is forbidden, yet there is a realisation that in reality sexual activity outside marriage exists amongst Muslims, often seen as a corollary of Western influence, and so sex education is somewhat limited. The perception of HIV prevention in Malaysia is on the whole relatively positive, commending the needle exchange programme and pre-marital HIV screening tests. However, there is a sentiment amongst some stakeholders that much more could be done to reduce HIV transmission, such as promotion of condoms, with some questioning the utility of premarital HIV screening. The differing viewpoints of stakeholders is most apparent with regards to groups such as men who have sex with men, sex workers, and transgender women. Stakeholders here taken differing stances on how best to approach the situation, with religious leaders believing that the best way of preventing HIV in these groups is to return to Islamic teaching, while those people living with HIV and NGOs deem it necessary for a more practical, less moralistic harm reduction strategy to be incorporated. Between these two poles resides the Ministry of Health, which is in the difficult position of trying to deal with an HIV epidemic as public health physicians while navigating practices that are considered un-Islamic. The questionnaires produced a wealth of findings, showing that the most common source of knowledge about HIV was the Internet, while the overall correct knowledge scores of HIV transmission differed across the three groups, being highest amongst Ministry of Health officials and lowest amongst religious leaders.Chapter 5: Discussion Many participants expressed the view that Malaysian and Islamic society was less open about sex outside of marriage and that talking about such things was taboo and akin to encouraging it. In addition, some of the religious leaders were keen to explain that there is a strong idea in Islam that one must not expose the failings or sins of others as this is between the individual and the Creator. However, what may originate as an honourable wish to not advertise a person's sins can lead to a climate of silence and denial. Beliefs about Islam are interpreted and explained by religious leaders, imams, and ustads in Malaysia. There are different religious viewpoints, with some leaders who were from a more progressive viewpoint and others who were more conservative. These attitudes related to discussions on Islamic religious beliefs pertaining to sexual behaviour and HIV prevention. It was not in dispute that sex outside marriage was forbidden; however, there was a spectrum of views amongst the religious leaders as to what was the correct way of dealing with the situation. Within the Ministry of Health, a different viewpoint is taken that endeavours to be more public health focused, for instance, in respect of condom distribution. However, Ministry of Health officials, themselves, have their own Islamic perspectives and are subject to questioning by other groups, including religious leaders and individual tax-paying Malaysian Muslim citizens. There was relatively good knowledge amongst participants who responded to the questionnaire regarding their knowledge of how HIV was transmitted across stakeholders. There was also a sense from the interviews that attitudes towards people with HIV had softened over time, but that there was still considerable stigma, discrimination, and moral and religious judgement associated with HIV transmission.Chapter 6: Conclusions and recommendations The intention of the study was not to suggest whether laws should or should not be changed, to engage in politics, or to undermine any stakeholder, but to look at the role of Islam in shaping HIV prevention policies in Malaysia from an academic perspective without judgment but with cultural and religious sensitivity. The study is the first of its kind to use primary data to endeavour to understand how Islam affects HIV prevention policy. Islam affects HIV prevention policy in Malaysia both directly and indirectly. Furthermore, Islam also affects the process of policy implementation, as well the hierarchy of power amongst different stakeholder groups. Islam is influential in understanding health and well-being, sex outside of marriage, transgender women, and men who have sex with men. Amongst those interviewed and consulted via the questionnaire, varying viewpoints were held as to what constitutes the right approach to HIV prevention in Malaysia. Often these viewpoints conflict. Nevertheless, there are also areas of broad consensus, with the onus on preventing harm in Islam, which can be powerfully leveraged and utilised in HIV prevention strategies. The authors end with recommendations about language, the utilisation of Islamic principles, the redistribution of power, the value of dialogue, the utility of correct and easily accessed information about HIV, support for NGOs, and the role of religious leaders.