Misaligned Visions: Motherhood, HIV, and the Unfulfilled Promises of the Global Health Enterprise

This dissertation examines how global health policies are negotiated and transformed in local settings. The project was motivated by an empirical puzzle. In 2011, Malawi, one of the most donor-dependent countries in the world, challenged WHO guidelines and developed a new policy for preventing mother-to-child transmission of HIV (PMTCT). Rather than giving patients treatment when their disease progressed past a certain stage, Malawi’s “Option B+” policy expanded treatment eligibility to a segment of their population: pregnant women would immediately start lifelong HIV treatment as soon as they test positive. This divergence from the WHO complicates a broad literature on the top-down diffusion of policies from global institutions. I use this case to explore general questions: Where do ideas for global health policies come from, and why and how do they change? What do global health goals, target populations, and interventions actually mean to the countries and people who are intended to benefit?Over the course of 12 months of fieldwork, I worked in healthcare facilities and conducted interviews with policymakers, NGO staff, healthcare providers, and HIV-positive women and their partners. First, I trace the development of Malawi’s policy innovation, focusing on the role of different state and non-state actors. Next, I move to the ground to understand the impact that HIV treatment has for clinical practices and patient experiences. I explore how donor emphasis on HIV treatment shapes healthcare practices and quality of care within Malawi’s prenatal clinics. I then describe how couples respond to an HIV diagnosis and understand their relationship. Finally, I look at how HIV-positive women make decisions about whether or not to take treatment.I find that Malawi’s policy innovation was motivated by the failures of WHO policies to prevent HIV infection to children. But while the policy fit state needs, it had unexpected effects on the ground. The emphasis on treating HIV-positive women divided care in prenatal clinics between women who had HIV and those who did not. For women and their partners, access to treatment re-defined HIV as an ordinary chronic condition and relieved tensions in their relationships. But taking daily treatment had unexpected physical, economic, and social costs for women. The policy design to take treatment as prevention presumed a biomedical framework for health and stable life conditions that people in Malawi do not have. I conclude by situating this case in a broader global health field characterized by unequal power dynamics between the global North and South. Global institutions define health priorities and design policies, but their visions are often disconnected from the needs of local institutions and people