The majority of participants interviewed for the study, identified pre-marital HIV testing as an effective current HIV prevention policy implemented by Malaysia and was seen as a positive initiative. The beliefs, opinions and concerns of participants are presented below according to the three stakeholder groups studied; namely religious leaders, PLHIV and officials from the Ministry of Health.
Religious leaders
Amongst religious leaders who participated in the study, there was strong support for premarital HIV testing, considering that such a measure provides a solid protective mechanism.
”This is good [pre-marital HIV testing]…to protect”. (IV 33 Religious Leader)
The rationale behind the statement being that foremost premarital HIV testing was a protection for themselves, the prospective couple, both husband and wife “for their own safety”.
This participant believed that premarital HIV testing both protected from acquiring HIV and protecting people from passing on HIV being transmitted, from ‘a man to a woman’, as ‘many people do not have an education'. Incidentally, later in the interview, the participant revealed that his own brother-in-law had died of AIDS a month previously and this event could have framed his views of pre-marital HIV testing.
Premarital HIV testing was viewed by religious leaders as a proactive way in which prospective couples could know their HIV status and thus make fully informed life decisions, including whether they wished to marry or not following the test results.
“To me, it’s good that the people who are getting married know whether or not they have HIV. Some of them may have contracted it without knowing and it’s good that they have that information, getting married is a big thing. So you know, if they know that one of them has HIV, at least they will make the decision to get married based on that information, knowing that one of them has HIV, whether they want to go through with it [the proposed marriage], or if they want to go through with it, how should they live their lives together’. (IV 1 Religious Leader)
This religious leader was quite atypical in the sense that he, unlike most other religious leaders, was aware of some of the opposing views of pre-marital HIV testing, issues such as human rights and possible discrimination towards people living with HIV. Adding further:
“It’s not something that should be used as a form of discrimination…some people don’t like the idea because they think it’s like a discrimination to those with HIV…but to me, if you look at this positively, I think it’s also the right of the future spouse to know whether or not his or her husband or the wife or the future wife has HIV, because it involves basically their state of health”
It is worthwhile highlighting that the participant himself, without the interviewer mentioning human rights, articulates and justifies his argument for premarital HIV testing within a human rights framework, within a health context.
Furthermore, many religious leaders supported premarital HIV testing, specifically as they deemed the measure as being in keeping with the teachings of the Shariah (Islamic law) as articulated in the extract below:
“Well I think the Shariah would…would like to protect I guess, people against any kind of harm. So in that regard, I think this, it’s a right step to be taken. No, it’s not criminalising anybody but the Shariah would like to protect the individual’. (IV 35 Religious Leader)
It is noteworthy that the participant categorically (and on his own accord), denies that mandatory testing criminalises those who are tested, given opponents, have argued that such measures could be used for nefarious purposes, criminalising or at least stigmatising those living with HIV. There was some indication of this possible stigma, articulated in this excerpt from a religious leader indicating his reasons for backing premarital HIV testing.
”Because when someone is having a marriage, they will have a child. So we don’t want to have an HIV child”. (IV 12 Religious Leader)
The logic behind the above statement was that premarital HIV testing essentially protected the unborn child from being born with HIV. Some religious leaders were a bit more cautious and whilst supported premarital HIV testing under the premise of “hukum” (protection of ‘life, heredity, lineage etc.), thought there should be a degree of privacy and confidentiality. However, where exactly the boundaries of privacy and confidentiality should be drawn remained unclear between religious leaders; some believed that as a marital union in Islam is not merely of two people, but the joining of two families, both families and the imam should be aware of the HIV status, as described below:
“This is a very good idea, the pre-marital…but the programme… the couple are going to have a test…we doubt…the result is not sharing for the Imams and for the family, it’s not good. We do not agree.” (IV 2 Religious Leader)
Other religious leaders believed that it was the discretion of the individual to disclose their status to whom they wish.
It was clear that religious leaders were keen to safeguard people’s future and premarital HIV testing served as a way of ensuring this, described succinctly by the following participant:
‘Islam is actually a religion that looks to the future. This premarital HIV test, it’s actually a very good thing. Why? Because you want to prevent whatever the possible thing that might happen in the future. Because for example, if one of the bride or the bridegroom is positive of HIV, then it would be infected to the wife, to the husband, to the kids and so on.’ (IV 13 Religious Leader)
Ministry of health
Officials from the Ministry of Health described strong support for premarital HIV testing in Malaysia under the remit of public health, with many reiterating the sentiment described below:
“I believe it’s [pre-marital HIV testing] a good idea.” (IV 25 Ministry of Health)
Furthermore, the pre-marital HIV test was seen as both cost-effective and a worthy HIV prevention strategy, articulated by one participant.
“Prevention of social disharmony, to prevent marriage disharmony, I believe it’s very cost-effective.” (IV 25 Ministry of Health)
Adding:
“In Kuala Lumpur people have been found to be HIV positive, they have decided not to go ahead with the marriage. Of course, there are instances where they know their husbands or brides to be are HIV positive, they still carry on with the intention of getting married”
The origins of premarital HIV testing is also well described by participants and was understood to have been established gradually state by state before it became practised across the country, as described by the following participant from the Ministry of Health.
“It was started in 2001, in the state of Johor. And after that it started scaling up in others, I mean, it spread in other states and now almost every state has the programme on pre-marital screening”. (IV 3 Ministry of Health)
It was clear that the tests were restricted to Muslim Malay couples who wished to marry, amid rising rates in this population.
“Initially, it was among the Muslims because our figures show that Muslims 70% of our tests are among the Muslims. But later on, in 2009 everybody who wants to get married can go for the testing”. (IV 3 Ministry of Health)
Some participants were unsure as to which stakeholder requested the implementation of pre-marital HIV testing in Malaysia, with the consensus believing that it was prompted by the religious leaders.
“Yeah, the religious people want that test to be done but even if I ask any people, did you know this or the rules by the religious department, they still want to get this done because every day you do that, it becomes a behaviour, it becomes a norm. Same also, now premarital testing is normal almost, norm already”. (IV 3 Ministry of Health)
Although the initial seeds may have arisen from the religious leaders’ camp, discussions were conducted with the Ministry of Health who were in support of the initiative.
“Pre-marital screening test, I was directly involved in it, in this project when we were discussing with the religious department. And we have to put it right that the idea of the pre-marital screening came from the religious department of Johor, from the mufti himself, looking at the issue of HIV among Muslim in Johor during, I think, 2000-2001. So he felt that the Muslim leadership come down and reach those people who are at risk of getting HIV. So it was the religious initiative. And we supported that”. (IV 31 Ministry of Health)
The premarital HIV test is now offered to non-Muslims and is now normalised in Malay society. The following excerpt highlights the confusion on conflicting sentiments expressed by the same individual within the Ministry of Health, first insisting that the test is not compulsory or mandatory, but voluntary.
“That’s done actually mainly for Muslim couples. For the non-Muslims, it’s not compulsory because there are different perspectives of it. But again, HIV screening has always been voluntary”. (IV 11 Ministry of Health)
Then the same participant continued to explain that it is a requirement for other matters pertaining to religion and marriage.
“So they have made it mandatory for other things, so there is this issue of whether it should be made a legal requirement and all but as it is the decision of the Muslim council, then all those Muslims couples who have to marry have to undergo that”. (IV 11 Ministry of Health)
Language is used to articulate the measure in a more accepting way; so although HIV testing is not obligatory under the Ministry of Health, it is still required if you wish to marry under Ministry of Religious Affairs regulations with the HIV testing service provided under the remit of the Ministry of Health. However, there are elements that suggest that although the Ministry of Health agrees and concede power, they also express some concerns and can exert a certain amount of influence.
“I believe it’s a good idea. Of course, there are ‘pros’ and ‘cons’”. (IV 25 Ministry of Health)
“So based on the religious decree they put it as compulsory. But we said that ok if you put it as compulsory, there should be some conditions”. (IV 31 Ministry of Health)
“Because to me, personally, whether you make it compulsory or voluntarily if you don’t provide good counselling, then it will give no meaning, whether you do it on a voluntary basis or compulsory basis. Number two, after counselling you have to keep your word; if you say ok, I will do it for you, then you have to do it. I mean in term of follow-up and support”. (IV 31 Ministry of Health)
The caveat stipulated by the Ministry of Health is that with pre-marital testing there must also be pre and post-test counselling, which is in accordance with standard HIV guidelines and practice. This is one of the arguments against ‘mandatory’ HIV testing, that the focus is on the result and less on the process and raised by the participant below.
“But its fine so long as they advise the couple pre-test counselling and all, they can actually adjust, be able to adjust to the implications of the results which they might get. So that’s very, very important on how they do. Otherwise, there could be issues”. (IV 11 Ministry of Health)”
Of note, although some have mentioned that the practice could be extended to non- Muslims this has not been actualised, as yet.
“It should be voluntary, there should be more awareness; it should be a decision made between the couples”. (IV 11 Ministry of Health)
In addition, it was evident that some officials from the Ministry of Health perceived pre-marital HIV screening as akin to any other screening which was offered.
“Well, it is just like other screening that we do”. (IV 31 Ministry of Health)
In a sense, this is indicative of how premarital HIV testing has possibly become normalised in Malaysian society.