Imagine two HIV testing counselors, paid the same wage by the Ministry of Health. One works in an area mistrustful of government health initiatives, especially those involving blood tests, and so she puts forth a great deal of effort to mobilize people to get tested; she rides her bike to far-flung villages and holds village meetings promoting HIV testing. Her colleague, however, works in an area where people are more trusting of government health initiatives and where there is already high awareness about and acceptance of HIV testing. This second HIV testing counselor can stay in his office and play games on his mobile phone or read the newspaper while waiting for clients to come by his office to be HIV tested. The end-of-quarter report by the Ministry of Health enumerating the number of people HIV tested could show similar output by these two HIV testing counselors, even though their levels of effort were markedly different. The quantitative nature of reporting gives no indication of the quality of the work nor of accountability to intended beneficiaries (Ebrahim, 2003, 816). Because these HIV testing counselors were paid the same wages, financial incentives cannot explain their different levels of effort. I witnessed many situations like these in Malawi – where people in similar positions differed in how hard they worked for AIDS interventions. The difference I saw in what motivated these agents was their personal experience with AIDS and their consequent preferences that AIDS be prioritized.

The success of international health and development interventions depends on how they are received by local populations. Judging from the scale of resources, international actors highly prioritize AIDS intervention. Little is known, however, about the policy priorities of the people in whose name powerful donors send assistance. This chapter examines empirically what is often overlooked: Africans’ attitudes about development and health interventions for which they are the intended beneficiaries. While it is true that Africa has suffered the most from AIDS, we cannot presume that HIV is the most important problem facing Africans.

Earlier chapters substantiated that AIDS is pandemic in Africa and presented an argument that the global AIDS intervention is plagued by principal–agent problems inherent in the multitiered intervention against AIDS in Africa. That argument relies on the assertion that policy preferences for AIDS intervention are misaligned. In this chapter, I empirically substantiate the misalignment of AIDS prioritization between two important constituencies: the international donors who largely decide global priorities and the people who are their intended beneficiaries.

The chapter is structured as follows: the first section details the prioritization of AIDS in the international community, primarily among powerful donors, using data on official development assistance (ODA). I then draw from existing scholarship to examine what shapes citizens’ policy preferences, and focus on two expectations: that people living with HIV (PLHIV) stand to benefit most from AIDS interventions and will thus give higher priority to AIDS; and that HIV-affected people – people related to and potentially caring for PLHIV – will also give AIDS higher priority. The next two sections analyze public opinion data, which substantiate ordinary Africans give relatively low priority to AIDS interventions and provide evidence that experience with HIV/AIDS makes people more likely to prioritize AIDS (even if only weakly). Then I explore alternative measures of AIDS prioritization and alternative explanations for low prioritization of AIDS by ordinary Africans. The chapter concludes with a discussion of some implications of the misalignment of priorities.

My Fulbright fellowship ended with a dissemination of preliminary findings to “key stakeholders” in Lilongwe, Malawi's capital city, where most government offices are located and many international NGOs base their country headquarters. The people shaping Malawi's national response to AIDS – technocrats from government ministries and program officers representing bilateral partners (e.g., the US Department of State) or major international NGOs (e.g., Save The Children) – gathered in a conference room at the US Embassy in late 2008. I went through slides with interview quotes and histograms of survey data documenting what I learned during my fellowship. The bulk of that presentation drew from early analysis of what now makes up Chapters 5 and 6 – results showing that among Malawian villagers and their headmen, AIDS is a relatively low priority. The participants were surprised at my findings. I was, in turn, surprised at their surprise: I expected these highly educated, locally posted specialists to have already known AIDS was a low priority among citizens and to be annoyed to have sat through another dull powerpoint presentation by an academic only in Malawi for a few months. Instead, after registering their surprise, they asked questions akin to “Now what?” With that, my cynical view of the bureaucratic world of AIDS intervention in Africa shifted.

Powerful decision-makers – at least in one African capital – wanted to reconfigure their response to reflect the priorities of their intended beneficiaries. Questions they asked reflected an intuition that matching interventions to local policy priorities would increase the likelihood that an intervention would succeed. One program officer asked my opinion on whether an AIDS program “bundled” with a water well initiative would increase the AIDS program's potential for success. Their questions demonstrated how they were constrained: the higher-ups in their North American and European headquarters would continue to prioritize AIDS programs and the locally posted expatriates were not seeking strategies to change those minds.

While the previous chapter documented the perspectives and priorities of international donors and ordinary citizens, this chapter shifts perspective to detail what a headman sees as he faces the AIDS epidemic in his village. This chapter's primary goal is to describe local agents, their priorities, and the context constraining their decision-making. Local agents implementing HIV/AIDS interventions in Malawi and elsewhere in Africa include community health workers, local religious leaders and congregations, and community-based organizations, but these have already been well-studied in the scholarship on AIDS.

I highlight less well-studied agents – Malawian headmen – because as elsewhere in Africa, most of Malawi's population (80%) live in rural areas, where chieftaincy remains important in provision of goods and services. In Malawi, no local development happens without the assent and participation of village headmen, and this chapter thus contributes to our understanding of their role in health and development interventions as well as the constraints they face. The quotes from village headmen in this chapter's epigraph also suggest headmen are trusted, effective helpers of their villagers, at least as reported by headmen.

A secondary goal of this chapter is to build on existing literature about chieftaincy and representation in Africa. To this end, I first substantiate the alignment of priorities between village headmen and their local principals – the villagers among whom they live. Then I also explore what shapes headmen's priorities. Contributing to the ongoing debate on chieftaincy in Africa, this chapter is the first empirical analysis to my knowledge that examines the fit between policy priorities of villagers and those of their headmen.

AIDS took the lives of 1 million people in 2016, more than twothirds of whom lived in Africa. Although Africa has only 16% of the world's population, it is home to 65% of all new HIV infections. This chapter describes both the challenge AIDS has been in Africa as well as the responses to AIDS by ordinary Africans, their governments, and the greater international community. Because evaluating HIV/AIDS interventions requires a general understanding of HIV prevalence and transmission patterns, I start with a brief overview of the AIDS epidemic in Africa. I then describe responses to AIDS, including local community responses and large global initiatives. The next section highlights the disconnect between interventions as imagined in global capitals and as actually implemented at the grassroots level. The final section examines why there is a disconnect and proposes how to explain it.

HIV/AIDS in Africa: A Brief Overview

HIV is the acronym for human immunodeficiency virus, a virus that causes acquired immunodeficiency syndrome, or AIDS. Progression from HIV infection to AIDS disease is long, usually taking 8 to 12 years in the absence of treatment. Although people may experience mild symptoms immediately after infection, there is a long latent phase before AIDS weakens the immune system. AIDS makes the body less capable of fighting infections and ultimately leads to death from opportunistic infections. There is no vaccine for HIV and there is no cure for AIDS.

HIV is a global pathogen with African roots. The original discovery of the virus in the 1980s is credited to laboratories in the United States and France (Epstein, 1996; Crane, 2013), but the most detailed analysis suggests the virus’ origins lie somewhere in Central Africa (Vidal et al., 2000; Iliffe, 2006; Pepin, 2011), where some of the earliest evidence of HIV has been found (Nahmias et al., 1986; Worobey et al., 2008). Scientists estimate HIV was “circulating in the African population near the beginning of the 20th century” (Worobey et al., 2008, 663).

He repeated his question, “Why won't you list the names of everyone who tests positive?” He went on, suggesting the list could be kept by a respected elder in the village who would advise others on how to avoid infection. Glory, my Tanzanian teaching partner, retranslated the question, trying even simpler English words the second time to convey what the mzee (elder) at this community meeting in a rural village in Arumeru District was asking. But I understood his question perfectly the first time he asked it. My silence was not because I did not understand the question. My silence was a manifestation of my not understanding how we had failed to convince the most powerful people in this community of the importance of confidentiality in human immunodeficiency virus (HIV) testing.

After completing my first year in graduate school in 2004, I volunteered with a small nongovernmental organization (NGO) that coordinated partnerships between American university students and recent graduates of Tanzanian secondary schools to provide HIV awareness education in schools, and at large community gatherings. The village meeting where this mzee asked his question was a culmination of our efforts in the area following weeks of working in the local schools teaching HIV epidemiology and the current best practices for avoiding HIV infection. Previous volunteers were positive about these village meetings, characterizing them as celebrations marked with community acceptance of the knowledge imparted by well-trained volunteers. Of course, it is easy today to see the warts of this NGO's approach to HIV/acquired immunodeficiency syndrome (AIDS) intervention and the naïvete of its volunteers, myself included.

As a group of men played bawo and discussed current events, one shared his ideas about the origins of AIDS and questioned whether condoms are protective against HIV infection. Shortly after, a research assistant wrote down what the man said in a diary, and I quote at length his recording of the man's claims:

The Americans are very clever. You can see that they were seeing the Africans begging [for] their aid time after time. And they [the Americans] realized that this begging was due to overpopulation in the African countries and then the “whites” made a number of meetings in order to find a better solution to avoid the frequent begging from the Africans. And at the end they decided to introduce the disease that is not curable to the Africans so that they should be dying of that disease and that's why they created what is said to be AIDS. And when they saw that the population is not going down, they introduced the condom telling the people that they can avoid getting AIDS if they use the condoms and that is a trick too. The condoms do also give other infections on their own and I have never used the condoms myself and I will never use them in my life.

To recap, this Malawian man alleges AIDS was created by Americans as a form of population control in response to African aid requests. He further claims that when the disease failed to control population growth, the “whites” – presumably Americans – introduced condoms because under the guise of protecting Africans from AIDS, condoms would also keep them from reproducing. While only one man's suspicions, the freethinking ideas shared at that bawo game offer a glimpse into Malawian perceptions of international interventions against AIDS.