Academic journal article Demographic Research

Asking God about the Date You Will Die: HIV Testing as a Zone of Uncertainty in Rural Malawi

Academic journal article Demographic Research

Asking God about the Date You Will Die: HIV Testing as a Zone of Uncertainty in Rural Malawi

Article excerpt


Testing for HIV is becoming more available in Africa. Global advocates of testing see it as key to AIDS prevention. However, testing is not always perceived as a good thing by people at risk. Here, we consider testing from the perspective of people in a high-prevalence community. Using qualitative data from rural Malawi, we show that the decision to test is not as straightforward as suggested in the testing advocacy literature, but is marked by uncertainty and ambivalence. Reluctance to test is connected to the perception that testing inevitably leads to a positive diagnosis, and subsequent deterioration and death. This fear is in turn linked to overestimation of the transmissibility of HIV. We recommend that testing advocates address this concern that being tested means having a death sentence pronounced, and emphasize the benefits of testing for the majority who are HIV-negative, as well as the minority who are HIV-positive.

1. Introduction

In the past few years testing for HIV has become widely available in sub-Saharan Africa. International organizations and national governments promote testing by making it accessible and free, and by energetic campaigns encouraging citizens to seek it out. From the perspective of testing advocates it is a valuable, even critical, addition to the arsenal of HIV prevention activities. Specifically, proponents of testing expect that those who are positive will be motivated to ensure that they do not transmit their infection to others, while those who learn they are negative will be motivated to be even more risk-averse.

The availability of testing, however, is not always perceived as an unambiguously good thing by the millions in Sub-Saharan Africa who are unaware of their serostatus. People who believe they have never risked infection may see no need for testing, and they may be right. Those who believe they are certain to have contracted the virus may also see no need for testing - for, in effect, "asking God about the date you will die."

In this paper we consider testing from the perspective of ordinary people in a high-prevalence region, the same people whom the global HIV prevention community believes will most benefit from it. Using a set of ethnographic journals written by local field assistants living in rural Malawi, we show that when people talk informally with each other about AIDS, issues of risk, behavior change, and agency are perceived as neither simple nor self-evident, but are marked by great uncertainty.3 Neither the public health nor the social science literature deals well with uncertainty. Much like the policy statements disseminated by the global AIDS community and reflected in official Malawian documents, most publications on AIDS in African communities, especially those oriented to influencing programs or policies, produce definite, unequivocal statements. "AIDS orphans are a growing problem in the community" or "young people have negative attitudes towards condom use" (to name two of the current preoccupations in the literature) are presented as unambiguous truths, as certainties. In contrast, the ambivalence and equivocation that we find in AIDS-talk in rural communities in Malawi does not often find expression in policies and programs. Ambivalence and equivocation, however, may be a more accurate reflection of the realities of AIDS in rural Malawi than definite and positive statements4.

We draw a parallel between responses to HIV testing and previous responses to the epidemic itself, in order to suggest that the uncertainty that now characterizes talk about testing in rural Malawi may come to be resolved. Previous work using ethnographic journals showed that early in the epidemic there was great uncertainty about whether it was possible to prevent HIV by changing one's behavior (Kaler 2004a; Watkins 2004]).5 Men in particular appeared to be divided on the question of whether or not behavior change to reduce one's risk of contracting HIV was worth the effort (Kaler 2004a). …

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