“Getting caught in the cobweb”: How the timing of HIV testing matters

Background: Scholars have argued that condoms are incompatible with marriage because they violate core assumptions of love and trust. Voluntary counseling and testing (VCT) may function similarly if testing conversations are initiated at inappropriate times with a partner. A social constructivist perspective informs an analysis of how young Malawians make sense of HIV testing and how the meaning of testing varies throughout an intimate relationship. Methods: Qualitative data from eight focus groups with adults aged 18-25 and contextual data from semi-structured interviews with couples, village chiefs, and VCT counselors were subjected to thematic analysis. Participants shared their opinions on vignettes covering testing decisions, disclosure, discordance, and divorce. Results: The analysis revealed that the timing of HIV testing matters. Respondents suggested that couples should be tested during courtship; bringing up testing during marriage often raises questions around infidelity and may lead to false accusations, conflict, and breakdowns in trust. Early testing is used to avoid future disputes about whether a partner became HIV infected during marriage. For married couples, testing was conceptualized more as a strategy to prove a spouse's faithfulness than to prevent HIV. Most respondents advocated for couples VCT versus individual VCT as a way to build trust and intimacy, however, other strategies were discussed when a partner refuses testing such as withholding sex, using love to convince a partner to test, and finally, leaving a reluctant partner. Conclusions: VCT messages in sub-Saharan Africa should emphasize the importance of regular, simultaneous testing of both partners throughout their reproductive years.