An offer you can't refuse : provider-initiated HIV testing in antenatal clinics in rural Malawi

Provider-initiated, ‘routine’ HIV testing of pregnant women seeking antenatal care-- wherein women are tested unless they explicitly refuse-- is promoted by international organizations as an effort to curb mother-to-child transmission. Utilizing qualitative data from Malawi, we offer an account of the perceptions that surround-- and surely impact-- a pregnant woman’s decision to take an HIV test. We argue that idealized social relations, characterized by equality, rationality, and non-coercion between clients and providers, are presumed to be disseminated with routine testing programs. We find, however, that these stylized relations do not fit neatly in Malawi, and consequently, may lead to paradoxical outcomes for public health. We show that rural Malawians do not perceive HIV testing as a choice, but rather as compulsory and the only way by which to receive antenatal care. This study illustrates considerable dissonance between global expectations and local realities of the delivery of routine testing programs.