Working outside of the box: how HIV counselors in Sub-Saharan Africa adapt Western HIV testing norms

Soc Sci Med. 2010 Sep;71(5):986-93. doi: 10.1016/j.socscimed.2010.05.020. Epub 2010 Jun 4.


The delivery of HIV counseling and testing programs throughout Sub-Saharan Africa relies on the work performed by trained HIV counselors. These individuals occupy a critical position: they are intermediaries between the rule-making of international and national policymakers, and the norms of the communities in which they live and work. This paper explains when, how and why HIV counselors adapt Western testing guidelines (the "3Cs"--consent, confidentiality and counseling) to local concerns, attempting to maintain the fidelity of testing principles, while reducing the harm they perceive may arise as a consequence of strict adherence to them. Data for this study come from Malawi: a poor, largely rural African country, where HIV prevalence is ranked 9th highest in the world. The analysis is based on 25 interviews with HIV counselors and a unique set of field journals, and captures local experiences and the moral quandaries that counselors in rural Sub-Saharan Africa face. The findings of this inquiry provide new insights into the implementation of HIV testing in rural African settings, insights that may guide HIV prevention policy.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Africa South of the Sahara
  • Confidentiality
  • Counseling / methods*
  • HIV Infections / diagnosis*
  • Humans
  • Informed Consent
  • Interviews as Topic
  • Practice Patterns, Physicians'*
  • Professional-Patient Relations / ethics
  • Rural Health Services