Pharmacist Advocacy in Pre-Exposure Prophylaxis (PrEP) Implementation amidst Religious Debate in Malaysia

The advent of Pre-Exposure Prophylaxis (PrEP) marks a pivotal moment in the global fight against HIV. Offering up to 99% efficacy in preventing sexual transmission with consistent use, PrEP, typically a daily oral dose of tenofovir/emtricitabine, empowers HIV-negative individuals at substantial risk to protect themselves [1]. Malaysia, recognizing this potential, has initiated PrEP pilot programs and integrated it into national health guidelines, aiming to curb new infections, particularly among key populations [2][3]. However, the rollout of this biomedical intervention occurs within a unique socio-religious landscape where Islamic perspectives profoundly shape health behaviours and policy acceptance. For pharmacists on the front lines of dispensing medication and counselling patients, understanding these perspectives is not just relevant but essential.

The intersection of PrEP with Islamic jurisprudence has sparked considerable debate, leading to divergent formal religious opinions even within Malaysia. This divergence stems from the application of established Islamic legal principles to this novel preventative technology. Central to Islamic bioethics is the concept of the core objectives of Islamic law (maqasid al-Shariah), particularly the preservation of life (hifz al-nafs) [4]. This principle strongly supports medical interventions that prevent disease and save lives. Furthermore, principles like public interest (maslahah) justify actions benefiting the community’s well-being, such as controlling infectious diseases.

Islam generally encourages seeking treatment and prevention, viewing health as a blessing to be protected [4].

However, PrEP often involves contexts related to behaviours Islam prohibits, such as extramarital or homosexual relations. This triggers the application of counter-principles like blocking the means to perceived wrongdoing (sadd al-dhara’i), where permissible actions might be forbidden if likely to lead to a prohibited outcome. The core tension arises in weighing these principles: does the imperative to save lives and prevent public health harm (reflecting public interest) outweigh the concern that PrEP might inadvertently facilitate or condone prohibited acts (reflecting the principle of blocking the means)? This jurisprudential tension manifested clearly in 2023, with differing religious rulings issued by Malaysian state authorities (Table I). The Perlis State Fatwa Committee declared PrEP permissible (harus) for administration by health practitioners, including accessibility for the LGBT community [1][2]. Their reasoning prioritized harm reduction, concluding through a comparative analysis (or weighing process, muwazanah) that the harm (mafsadah) of unchecked HIV transmission was greater than the potential harm of PrEP misuse encouraging illicit acts. This ruling invoked the principle of choosing the lesser of two evils (irtikab akhaff al-dararain) [1].

Conversely, state religious authorities in Kedah, Selangor, and Sabah, along with the Penang Mufti, expressed prohibitive or restrictive views, particularly concerning PrEP provision to LGBT individuals [1,5]. These rulings prioritized the principle of blocking the means, fearing PrEP would act as a pathway (dhari’ah) to encourage prohibited sexual behaviours. They argued that providing PrEP to these groups could be interpreted as condoning actions contrary to the fundamental objectives of Islamic law, defining the primary harm to be avoided as moral transgression rather than physical disease [1]. Some, like the Penang Mufti, suggested limiting PrEP only to contexts deemed licit, such as within a marriage where one partner is HIV-positive [5].

This divergence presents significant challenges for pharmacists and the healthcare system. Pharmacists may face ethical dilemmas when dispensing PrEP, caught between national health guidelines promoting access based on risk [3] and potentially restrictive state-level religious interpretations. Patients seeking PrEP might encounter stigma or refusal, leading to unequal access depending on their location or the provider’s interpretation. This situation underscores the need for clarity and support for healthcare professionals navigating these sensitive interactions. Pharmacists require the competency to provide accurate medical information and non-judgmental counselling while being aware of and respecting the diverse religious concerns patients might have.

Component	Admission value	Discharge value	Reference range
Perlis State Fatwa Committee	Permissible (Harus) for administration, including accessibility for LGBT.	Preventing greater harm (HIV spread) outweighs potential lesser harm (encouraging illicit activity)	Forbidden for users to promote homosexuality/free sex. Applicable to high-risk groups including LGBT.
Kedah State Fatwa Department	Prohibited provision to LGBT individuals.	Apprehension about exacerbating adultery/homosexual acts. Prioritizes avoiding moral harm over reducing HIV transmission.	Prohibition specifically targets the LGBT community.
Selangor State Fatwa Department	Advised against dispensing PrEP to homosexuals (interpreted as prohibition).	Facilitating PrEP for LGBT is seen as condoning behaviour contrary to Maqasid al-Shariah.	Advisory/prohibition specifically targets homosexuals/LGBT individuals.
Sabah State Mufti	Against providing PrEP to the LGBT community (inferred).	Echoes Selangor: Facilitating PrEP for LGBT might condone behaviour antithetical to Maqasid al-Shariah.	Implied prohibition targets the LGBT community.
Penang State Mufti	Advised against dispensing PrEP to homosexuals. Agrees with Selangor.	Providing PrEP to LGBT encourages ‘deviant’ behaviour.	Limited to specific licit contexts (e.g., HIV-negative wife of HIV+ husband); excludes homosexuals.
Perlis State Fatwa Committee	Permissible (Harus) for administration, including accessibility for LGBT.	Preventing greater harm (HIV spread) outweighs potential lesser harm (encouraging illicit activity)	Forbidden for users to promote homosexuality/free sex. Applicable to high-risk groups including LGBT.

It is worth noting that Islamic jurisprudence in Malaysia has previously accommodated harm reduction strategies, offering a meaningful parallel to the current debate surrounding PrEP. The national harm reduction program, comprising methadone maintenance therapy and needle and syringe exchange programs, is a key example. When first introduced in 2005, these interventions faced significant public and religious concern. Some stakeholders viewed them as potentially inconsistent with Shariah principles and associated them with external, non-traditional public health models [6].

Nevertheless, the Malaysian government proceeded, driven by the urgency of a growing public health crisis: a rapidly escalating HIV epidemic, largely fueled by injecting drug use and disproportionately affecting the Malay Muslim population. The justification for this policy was twofold. From a scientific standpoint, clear evidence supported the effectiveness of these harm reduction strategies. From an Islamic ethical lens, the policy was grounded in the principles of necessity and the prevention of greater harm. This framing helped bridge religious and medical perspectives, leading to the argument that safeguarding life and containing the epidemic took precedence over concerns about permissiveness. This viewpoint gained traction among policymakers and religious leaders, and evaluations later confirmed the program’s success, showing it was highly cost-effective and had prevented an estimated 12,000 new HIV infections by 2015 [6]. This experience illustrates a key lesson: when faced with pressing public health needs, Malaysia has demonstrated the capacity to adopt pragmatic, evidence-based approaches that align with both scientific evidence and Islamic ethical values.

As Malaysia considers its path forward with PrEP, the experience of Indonesia offers a particularly relevant and instructive comparison. Operating in a socio-political climate where discussions about sexuality remain sensitive, Indonesia has nonetheless made pragmatic progress in advancing HIV prevention through the implementation of a national PrEP program. Initiated as a pilot in 2021 and expanded in subsequent years, the program moved forward without being stalled by prolonged public religious contention [7]. This does not suggest that religious perspectives are unimportant. Rather, it highlights how public health interventions can proceed when they are guided by the principle of necessity and when engagement with religious and community stakeholders is grounded in shared goals of harm reduction and preserving life.

Indonesia’s experience underscores that progress is possible even in culturally and religiously sensitive environments. For Malaysia, the lesson is not to sideline religious perspectives but to engage them constructively. Policymakers, healthcare professionals, religious authorities, and community stakeholders must collaborate to resolve inconsistencies, seeking common ground rooted in the shared objectives of preserving life and safeguarding public health. Open and respectful dialogue should guide policies toward equitable PrEP access, anchored in clinical necessity and population health needs, while remaining attuned to the religious and cultural values of local communities.

While jurisprudential debates offer important ethical guidance, the successful implementation of PrEP in Malaysia ultimately depends on the capacity and empowerment of frontline healthcare providers, particularly pharmacists. Their challenges extend far beyond navigating religious sensitivities and are deeply embedded in the structural and systemic constraints of the healthcare system. Many pharmacists face capability gaps, including limited training in PrEP-specific clinical knowledge and a lack of confidence in conducting sensitive sexual health counselling [8]. Opportunity-related barriers include insufficient infrastructure, such as private counselling areas, and competing demands from high workloads. Motivation gaps may arise from personal reservations about PrEP’s perceived social implications, alongside limited financial incentives in the private sector, where time-intensive clinical services are often undervalued. Therefore, even with the recent publication of the National Guidelines on HIV PrEP Program Implementation [9], overcoming these deep-seated challenges related to capability, opportunity, and perception remains the primary hurdle for successful implementation.

These overlapping constraints place pharmacists in a difficult ethical and professional position. They are expected to deliver evidence-based care in line with national guidelines that support PrEP access for at-risk populations, yet must navigate powerful forces including community stigma, institutional ambiguity, and restrictive state-level religious rulings. This conflict creates a climate of fear around PrEP dispensing, particularly in conservative regions, where concerns about social or legal repercussions are heightened. To move forward, there is an urgent need for clear national policy alignment, legal protections, and professional support systems that affirm the pharmacist’s role as a legitimate provider of HIV prevention services. Investing in targeted training, safe practice environments, and policy clarity is essential to unlocking pharmacists’ full potential in advancing equitable PrEP delivery in Malaysia.

Moving beyond a superficial call for “non-judgmental counselling” requires more than good intentions. It demands a structured, evidence-informed training framework that equips pharmacists to navigate complex and sensitive health conversations with confidence, empathy, and cultural humility. While Malaysian pharmacists are highly trained in pharmacology and medication management, most have not received adequate preparation in delivering person-centred care for socio-ethical health issues such as HIV prevention and sexual health. These topics are often perceived as taboo and are not routinely addressed in pharmacy curricula or continuing professional development. As a result, pharmacists may feel unprepared to counsel patients effectively, particularly when religious and cultural values are deeply intertwined with health behaviours.

To address this critical competency gap, training for pharmacists must be standardized and strengthened. While the Ministry of Health provides some training for its pharmacists, especially in primary care, a mandatory training module should be introduced to systematically include all pharmacists involved in PrEP service delivery, particularly community pharmacists. This recommendation is not merely theoretical but supported by both local and international evidence. A quasi-experimental study in Malaysian tertiary hospitals has demonstrated that a structured communication skills training program grounded in the Four Habits Model and incorporating motivational interviewing significantly improved pharmacists’ communication behaviours [10]. These included the ability to greet patients warmly, explore how their conditions affect daily life, and support emotional expression. This model, already validated in the local context, offers a strong foundation for developing a PrEP-specific training module that incorporates culturally sensitive and religiously respectful communication strategies.

International models also provide useful benchmarks. In New Zealand, pharmacists must complete a comprehensive training program before offering PrEP [11]. This curriculum covers not only clinical aspects but also techniques for taking a sexual history, addressing stigma, and delivering inclusive, respectful care. For Malaysia, any such adaptation must meaningfully integrate Islamic ethical principles and religious considerations. For example, discussions on abstinence, moral responsibility, and harm prevention could be framed within Islamic values such as preservation of life and public interest. In doing so, PrEP counselling becomes not just a clinical task but a moral engagement, one that aligns pharmacists’ professional responsibilities with the broader religious and ethical fabric of Malaysian society.

Drawing from both local evidence and international best practices, a robust and contextually grounded PrEP training module for Malaysian pharmacists should be developed collaboratively. This initiative should involve the Ministry of Health, professional societies, academic institutions, and relevant community organizations, including faith-based and key population groups. The objective is to ensure pharmacists are equipped not only with clinical knowledge but also with the cultural, ethical, and communication competencies required to deliver PrEP services effectively, sensitively, and responsibly. The proposed training module should cover the following core components:

• Clinical Competency: Comprehensive, up-to-date knowledge on PrEP use, including indications for daily and on-demand regimens, baseline and follow-up testing (e.g., HIV, renal function, hepatitis B), side effect management, and drug interaction monitoring.

• Advanced Communication Skills: Training using role-play and standardized patient scenarios rooted in motivational interviewing. Emphasis on open-ended questioning, active listening, rapport-building, and creating safe spaces for discussions on sexual health and risk behaviours.

• Cultural and Religious Competency: Education on the varying religious interpretations of PrEP within Malaysia, grounded in local fatwa analyses. The aim is not to turn pharmacists into religious authorities but to prepare them to counsel patients with respect and sensitivity. This includes framing PrEP within Islamic principles such as preservation of life and public interest.

• Referral Network: Guidance on establishing effective referral pathways to PrEP-affirming general practitioners, sexual and reproductive health clinics, mental health professionals, and community-based organizations, including those that offer faith-sensitive support.

By investing in such a comprehensive program, Malaysia can elevate the pharmacist’s role from medication dispenser to trusted public health provider. This ensures that PrEP services are not only clinically sound but also ethically grounded, culturally respectful, and responsive to the needs of diverse communities. Standing at this critical intersection between healthcare delivery and religious ethics, pharmacists, by promoting patient-centred care and cultural humility, can significantly influence PrEP acceptance and effective use, ultimately contributing to Malaysia’s broader goal of HIV eradication.

CONFLICT OF INTEREST

The authors declare no conflict of interests.

ACKNOWLEDGEMENT  

The authors would like to acknowledge Honourable Muhd Helmi Kasman, Judge of the Syariah Court of Muar, and Muhamad Hazim Mohd Badri LLBS for checking the correct terminology and scope of the Shariah-related terms, and for providing constructive criticism to improve the article.

REFERENCE

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