In an environment where religion pervades every aspect of society, Kelantan, the northern-most state in Peninsular Malaysia - and the only state that has been ruled by an Islamic party for over 20 years - faces challenges around condom usage, polygamy, remarriage and drug use. Marina Mahathir, president of the Malaysian AIDS Foundation, released a study on HIV-positive widows in Kota Baru, Kelantan during the 8th ICAAP. Here she talks to TerraViva's Karen Yap Lih Huey about what could be done in such delicate environment without unsettling religious norms.
TerraViva: Tell me more about polygamy in Kelantan and how it affects HIV and AIDS initiatives there. Also, in your presentation you mentioned that Kelantan is becoming anarea containing high-risk groups.
A: There is a lot of drug usage among both men and women in Kelantan. A lot of these women got infected from their husbands who were injecting drug users. So, the link between drug usage and infection is very clear.
As Kelantan custom supports remarriage by both men and women, many widowed HIV- positive women may look to marriage in order to ensure their own economic survival. Many of these will be polygamous marriages, which are sanctioned by the state and society. This poses risks to co-wives in the same arrangements.
In 2006, Kelantan also instituted mandatory premarital testing for Muslim couples. This may pose problems for those HIV-positive women intending marriage, even though normally HIV-positive people are not prevented from marrying. Issues of stigmatisation and loss of potential economic support may arise. In 2000, the fertility rate in Kelantan was the highest compared to other states in Malaysia and on average, most families in Kelantan have five children. This high fertility rate could have a direct impact on vertical transmission from mother to child.
From the study, this is what we know: A lot of these women are HIV-positive widows. They don't have any means of earning money. They are young, they are well and many of them look to men for support. So, they need to get married.
On top of that, there is no stigma of women getting married many times. The stigma is on women who are single or divorced or widowed. The women in Kelantan do marry many times and it's common. Therefore, they can do it if they wanted to. But what we found didn't really support it because in our study, only six women remarried. The others were just too engrossed with their problems of being HIV-positive and how to fight it. Remarriage didn't figure very highly.
However, it's interesting to note that they marry very poor men, not well-off men, partly because the social circle they are in is not very big hence their choices of spouses are minimal. In a way, they didn't prove our assumption. Having said that, we think there is an issue among these women. They don't have much in the way of support while the support from family is little.
TerraViva: About the high drug usage in Kelantan, is it because of the drug trade route that runs into Kelantan from neighbouring Thailand?
A: No. It's not because of the drug trade. Drug usage is all over and it's easy to obtain drugs anywhere. In Terengganu, the fisherman takes it. In the social context of Kelantan, the people are very poor. There are not much job opportunities there. And what can these people do to kill the boredom? They take drugs. It's easily available and very common in the villages. It's not a matter of being in the trafficking route. It's a matter of availability.
TerraViva: In Kelantan, people are conservative. How do you tell these people to use condoms?
A: In Islam, condom is not banned. You just have to tell the men to use. The women (in the study) didn't think the condoms are religiously wrong. But the men usually think it is. It's actually a manifestation of their own reluctance -- and it's easy for them to cult it in religious terms. So, there is room to manoeuvre there. Unlike Christianity, where the rules are clear, in Islam, they not clear. The problem is to get the right authority to say so - at least within the context of marriage. It's something that is not happening here yet.
TerraViva: How sure are you that the Muslims in Kelantan would be able to accept this and get it off the ground? Surely, you need political will or leadership.
A: Of course, I mean it takes a lot of work, but it can be done. We have to train the religious leaders. Once you talk to them and educate them, they can change. We can take examples from elsewhere. The Majlis Fatwa in Indonesia said that with married couples, it's all right to use condoms. It can be done. We are not talking about extramarital sex or affairs. So, it's perfectly legal but the point is to get the right people to say it, using the right religious context, and getting the social and psychological support. It can be done. I'm quite hopeful of that.
TerraViva: How do you see Kelantan's future?
A: I don't have to extrapolate too much from this study -- it's interesting because of the numbers and what it yields. It's also because of the Kelantan context -- the cultural context. Having said that, I feel it's important to take this study further. We don't have a study on women with HIV and AIDS in Malaysia. Anyone who wants to add it, please be my guest. Once we are back in Malaysia, I think we will publish this study and get someone to respond to it.
The most alarming thing about the study is the low level of knowledge on HIV in Kelantan. They don't know anything about HIV. It's as simple as that. And yet, the government in Kelantan is testing people and these people don't understand why. They think it's just a routine or another step before getting married. They just do it. There's an opportunity lost there. The study is a good start and hopefully we'll get someone to expand on it. Just to say that it's Kota Baru, who knows what it's like in other cities or towns where there is no way of knowing or reaching them.
(In the Kelantan study, a total of 56 HIV-positive women were recruited and both quantitative and qualitative methods were used. In Kota Baru, Kelantan, the number of HIV-positive widows has been increasing at an alarming rate. In a religious and cultural environment where polygamy is acceptable, there is uncertainty about how women with HIV manage risk and their ability to prevent HIV transmission to their partners.)