Testing differences : the implementation of western HIV testing norms in sub-Saharan Africa

Abstract

This dissertation considers how Western health interventions are incorporated in non-Western societies. It focuses specifically on ‘HIV Testing,’ a key strategy that emerged to fight the spread of HIV in the West and was later institutionalized globally and exported to other, very different parts of the world. The empirical object of study is the “3Cs,” the cluster of Western norms and ideals upon which global testing policy rests: (1) that it includes counseling, (2) that it be conducted with informed consent, and (3) that the test results be confidential. Employing several methods of field research, this project investigates how the rationalities and motivations of various actors at national and local levels affect the implementation of a key global AIDS intervention in Malawi, a high HIV prevalence, rural African setting. Fundamental differences between the West and sub-Saharan Africa form the basis of this inquiry as to how imported models fare when implemented outside of their context of origin. Towards that end, this study considers how three strata of social and institutional actors who inform the HIV Testing encounter in Malawi interpret, and put into practice, the same ideas: the Counseling and Testing Establishment (CTE), HIV Counselors, and rural Malawians. For the CTE, its proponents, the “3Cs” are Western, human rights imports that are worth defending formally, but not necessarily worth prioritizing in practice. For HIV Counselors, its implementers, knowledge of the “3Cs” as Western biomedical jargon distinguishes them from villagers, but places them in situations where the ethics of testing conflict with moral concerns they have for those whom they were trained to help; thus they adapt them in practice. And for rural Malawians, its beneficiaries, the “3Cs” have little inherent value, and are perceived largely as doing harm rather than good in their communities. Thus, the net contribution of this study is that the “3Cs” have no single meaning as a normative testing regime, but rather acquire (differential) meaning (and import) during their implementation. Indeed, unless policy makers and analysts know something about this, interventions developed from afar are unlikely to have their intended effects on the ground.