Stanford, CA: Stanford University Press, 2013. xii, 274 pp. (Illustrations.) US$24.95, paper. ISBN 978-0-8047-8423-8.
This book is a ground-breaking investigation into the reproductive lives of HIV-positive women. The ethnographic setting, the South Indian state of Tamil Nadu, is moreover a very illuminating one for global health. In terms of numbers of people living with HIV, India is second only to South Africa and Nigeria. In Tamil Nadu, the epidemic seems to have escaped its confinement within “high risk groups” and been transmitted to the general population. When Van Hollen began her research in 2004, HIV prevalence in Tamil Nadu was estimated to be 1.1 percent, but in four districts of the state HIV prevalence was at or above 3 percent. Responding quickly to the epidemic, Tamil Nadu became a pioneer state for HIV/AIDS prevention and care, and was reputedly successful in bringing the epidemic down by 50 percent between 2003 and 2007. As part of its battery of interventions, in 2000, Tamil Nadu initiated India’s national program of PPTCT (Prevention of Parent To Child Transmission), offering prenatal testing and a dose of nevirapine at the time of delivery to reduce HIV transmission to the child, from 15 to 40 percent to 8 to 10 percent. Van Hollen’s fieldwork, between 2004 and 2008, was embedded within this PPTCT program. It involved interviews with 70 HIV-positive women whom she recruited through HIV care networks, as well as interviews and ethnographic fieldwork within the hospitals involved in the program. Each chapter of the book tells an important story about the ways in which global health standards and practices are refracted by the state, kinship, and gender in Tamil Nadu.
Chapter 3 investigates the institutionalization of prenatal HIV testing and the ways in which the global standards of informed consent and confidentiality were put into place. Pretest counselling was not uniform; many of the women Van Hollen interviewed had been tested unaware. To satisfy health funders’ demands for increased uptake of testing, counsellors tried to make the test more palatable by describing it as “like an immunization,” emphasizing the positive effects on conjugal trust in the event of a negative result, but failing to explore the devastation of a positive result. Chapter 4 shows that the counsellors’ emphasis on married women as the “innocent” victims of the sexual transgressions of their husbands was accepted by the women in the study. Interestingly, the counsellors’ encouragement that the women discuss the test with their husbands, part of an attempt to increase testing among spouses, was interpreted as a request for their husbands’ “permission”—which the women asserted that they did not need. In accepting the HIV test without their husbands’ permission, then, Van Hollen argues that the women were exerting agency. Yet ironically, this led them to being tested before their husbands, allowing their husbands and in-laws to scapegoat them. In chapter 5, she discusses the devastation of a positive HIV test result and the stigma that became the defining characteristic of their lives. Against the anthropological consensus about sexual double standards leading to a greater stigmatization of HIV-positive women than men, Van Hollen shows that gendered processes of stigmatization are highly differentiated. In public discourse, men are condemned more than women, who are cast as the “innocent” victims. In private negotiations, the women narrate being outcast by their in-laws, gossiped about or accused of sexual immorality, whilst their husbands were quietly condoned. Yet Van Hollen unpicks these responses, showing that they derive not only from sexist ideology but also, crucially, stem from economic motivations. The blame was most intense after the death of the husband, when the in-laws were faced with the combined tragedy of losing a son and the thorny question of inheritance to the widow and her children. Further complicating matters are cultural understandings of the female reproductive body, which cast women as harbours of the HIV “worm” (kirumi). Chapter 6 examines women’s decision to keep or abort the pregnancy after a positive HIV test result. Van Hollen stresses here the centrality of motherhood within Tamil constructions of femininity, but within patrilineal and patriarchal kinship structures that pressured women to keep the babies to meet the expectations of their husband or his family. Chapter 7 highlights economic constraints and appalling stigmatization in determining where the women could give birth. Chapter 8 discusses the counselling the women receive about infant feeding, showing it to be highly situational, depending on the counsellors’ understandings of whether the women would be financially capable of replacement feeding with formula milk. She explores the women’s positive understandings of the “immune strength” (ethirppu sakti) carried in their breastmilk and the benefits for their children. From this they derive a related term, “resistance strength” (resistance sakti), to talk about their own empowerment as HIV-positive mothers. Finally, in chapter 9, she shows that HIV activist networks have succeeded in empowering HIV-positive women in two key respects: encouraging them to overcome the taboo against widow remarriage, and encouraging them to claim their inheritance.
The book shows convincingly that HIV in Tamil Nadu “runs along the grooves of kinship and marriage relations that serve at times to protect the dignity and health of these women, and at other times to expose them to public indignities” (168). Van Hollen contributes significantly to debates about the authoritarianism of reproductive medicine and the state in South Asia, and women’s gendered agency in negotiating these structures, as well as the ambivalence and destructive guises of kinship. I would have liked to know more about the caste dynamics involved, given that the majority of her informants were lower-class Dalit women. Were there any interactions between the interpretation of HIV through the lens of sexual immorality, and local discourses about the sexual availability of Dalit women’s bodies? But this is an important and accessible book, and an essential teaching resource for reading lists in medical anthropology and sociology, and global health.
Kaveri Qureshi
University of Oxford, Oxford, United Kingdom