Review of Viral Frictions: Global Health and the Persistence of HIV Stigma in Kenya By Elizabeth Pfeiffer, New Brunswick, NJ: Rutgers University Press. 2022. pp. 215.

Kristin Hedges

Grand Valley State University

I first moved to Kenya in 2000 with the Peace Corps and helped found a community-based organization to support people living with HIV (PLWHIV). We talked a lot about stigma, and we theorized that available treatment would reduce stigma—a perspective that resonated throughout the global AIDS industry. Viral Frictions is an incredible ethnographic account of why HIV stigma still exists in Kenya in the age of treatment. Elizabeth Pfeiffer’s writing is an excellent example of the power of ethnographic fieldwork in highlighting the contextual nuance of people’s lives as they navigate risks.

Pfeiffer demonstrates how local knowledge must be considered if AIDS and stigma are to be eliminated. The ethnographic examples express how failures in global policy, at times perceived as a “compliance” problem, are truly problems with the universal one-size-fits-all policies. Pfeiffer successfully meets her goal to “offer thicker more nuanced explanations for the persistence of HIV stigma” by navigating the local, regional, and global scales, highlighting “friction” at each level. Global health experts contend that stigma is a barrier to ending the AIDS epidemic, but Pfeiffer “flips these arguments” by demonstrating how global AIDS efforts have aggravated stigma and fueled persistence of infection. Key examples include how the Western racist trope of the “African AIDS problem” influenced Kenya’s early dismissal of the risk. Additionally, the initial strategy of targeting sex workers failed because it did not account for gender and sexual relations in Kenya. Furthermore, funding from the United States via the President’s Emergency Plan for AIDS Relief (PEPFAR) merged the moralities and politics of the conservative United States with evangelical Kenyan churches.

The vivid details of Pfeiffer’s fieldwork navigating dusty roads, walking through corn fields, and conducting interviews in one-room offices bring the book to life. This writing style will engage all students studying global health and is a stellar illustration of why the contextual understanding is essential for a public health campaign. Pfeiffer describes the local rumor of “the list” of women who were alleged to have been purposefully infected with HIV by a lone local resident. This example highlights the nuance of transactional sexual relationships missed by many HIV efforts due to such a narrow definition. Additionally, Pfeiffer discusses this local rumor while tracing the political historical overview of Kenyan from colonialism to the present day, weaving together racism, political violence, and ethnic conflict. This contextualization helps the reader comprehend the powerful influence of HIV stigma within the precarious lives of community members.

The term viral frictions discusses differences in HIV prevention efforts at multiple levels but also applies to frictions between viruses and within a community of endemic uncertainty. HIV is just one of many health risks circulating in the community: people also contend with Ebola, cancer, COVID, and so on. Other life-threatening risks include economic crisis, poverty, postelection violence, unemployment, and food insecurity. The global effort to “normalize” HIV as a disease like any other chronic disease fell short in East Africa simply because HIV was different: it required lifelong antiretroviral therapy (ART) and consistent social support, amid other uncertainties and risk beyond HIV. To demonstrate how HIV stigma itself was uneven, Pfeiffer analyzes how health workers within nongovernmental organizations could disclose their HIV status and receive support at work but would be stigmatized in other social contexts. Due to changes in HIV stigma, Pfeiffer found that many community members felt it was better not to disclose their HIV status. Yet global efforts to end the AIDS epidemic cite status disclosure as the linchpin to success.

Pfeiffer strives to illuminate the connection between blame, stigma, and witchcraft. The story of local witchcraft incidents includes details making the reader feel empathetic to all sides that were impacted by blame and stigma. However, while Pfeiffer does a good job describing the existing literature and theories on witchcraft, the connection between the literature and the vignette can be hard to follow. There are a few sections throughout the book that are similar, where either the ethnographic data backing up the analysis is limited or multiple stories from different people are combined within one paragraph without being fully unpacked. For example, in chapter 5, within a discussion on HIV stigma, rumors, and gossip, Pfeiffer mentions seeing young Kalenjin men with whitish clay signifying their recent circumcision; however, she never unpacks the relevance of this observation within her analysis.

The greatest strength of the book is Pfeiffer’s ability to offer thick description of the fieldwork setting that she is navigating while conducting interviews, sharing a meal, riding on local matatus, cooking chapatis, or participating in an impromptu group discussion. Pfeiffer’s ability to weave in vignettes and conversations among community members to highlight local perceptions contributes an important insight into the literature. She uses vivid details to describe the daily struggle of making ends meet and getting food on the table, while also highlighting the changing gender roles that result in women taking on more of the income-earning responsibilities. Pfeiffer dives into the impact of stigma and mental health status with an important distinction that in the local community, the stigma of having a mental health problem can be greater than the stigma of HIV infection. Pfeiffer offers an important critique of the global health programming presenting antistigma “briefcase concepts.” These concepts focus on individual-level education approaches, which do not include local social knowledge or address social determinants of health, resulting in an increase in concealing stigma rather than rejecting it. While some community members discussed how ART did reduce stigma, many felt that the stigma had not disappeared—it was simply that ART helped a person hide the symptoms of the virus and therefore reduced the number of people affected by stigma.

Pfeiffer describes other areas of friction due to global health funding focusing primarily on HIV, even though there were many other risks to health and well-being in this community. Pfeiffer highlights how people felt that PLWHIV were more “well off” than others due to benefits from the HIV center; some even speculated that people might be getting infected on purpose. A clear viral friction is the concept of “living positively,” and Pfeiffer offers an important insight and critique to this concept. While living positively with a chronic disease might be possible in the West, it translated differently locally. Where people to struggle to meet basic needs for their family, “living positively” meant that a significant amount of the limited financial resources and support would have been dedicated to the person with HIV. Patients described how they did not want to be a burden to their families. Clinic workers were trained to counsel on living positively, but this Western framework resulted in counselors blaming clients who could not maintain appointment times or overall well-being, labeling them as a “problem.”

The book discusses the literature on personhood throughout sub-Saharan Africa. Pfeiffer contextualizes the experience of PLWHIV in Mahali within this literature as they navigate their new lives. An important perspective is presented about how access to ART created a new liminal social space of “neither sick nor normal.” People with HIV can live a long life on ART; however, it requires lifestyle changes that impact their social life and personhood, such as working, reproducing, marriage, kin, and sexual relationships. Pfeiffer embeds powerful idioms from community members to demonstrate how these changes impact their personhood: they are not being “the same with other people”; “I was nothing . . . something different”; or they struggle to feel like “a real person.” Encouragingly, Pfeiffer describes how some people with HIV were not “paralyzed” by their concern of becoming different and instead find creative ways to navigate the new norm and still fulfill their social roles, such as using “support groups and the HIV clinic as social spaces to identify sexual, reproductive, marital, and emotional support partners.”