Abstract
In Commodities of Care: The Business of HIV Testing in China, Elsa L. Fan shows how global health interventions that focus on HIV testing for MSM (men who have sex with men) have unintended consequences for health service organizations and patients. Methodologically, Fan followed HIV testing in China, working with three different institutions to provide multiple perspectives on the design, implementation, and effects of HIV testing. She argues that donor requirements for HIV testing transform MSM from subjects of care into commodities of care. Organizations prioritize finding and testing MSM to receive funding often at the expense of providing comprehensive health services and building community among men with same-sex desire.
Fan’s research took place at a time when donors favored technical and cost-effective interventions that have measurable quantitative outcomes. HIV testing among key populations, like MSM, was seen as the magic bullet solution to slow the spread of HIV. The idea was that if one knows their HIV status, they could adjust their sexual practices accordingly, thus decreasing transmission. Fan successfully shows that it is not so simple and her findings provide an important critique of this model.
A key strength of this book is how Fan demonstrates the ways that donor metrics affect organizational practices. With performance-based metrics, organizations are paid according to the number of MSM tested, which can create perverse incentives. Fan often heard rumors that organizations “cheat,” such as having one person test at multiple locations or testing men who may not identify as MSM, to increase their numbers (chapter one). In addition, the narrow focus on testing leads organizations to miss the bigger picture of preventing infection or supporting those who test positive. For example, one organization, Blue Heart, tested at bathhouses. While they found many MSM to test, they did little in terms of following up with the men who tested positive (chapter three). This is not to say that organizations do not want to provide comprehensive care. But, as Fan argues, because they depend on donor funding, “they cannot afford not to care about these metrics” (p. 103).
Donor metrics also affect the organizational field as a whole. In chapter four, Fan describes divides between different activists and community-based organizations. Some organizations that were established before the influx of donor funding saw themselves as “community based,” that is, “real” and focused on their mission of MSM advocacy, whereas newly established organizations were “project-based,” that is, “fake” and only in it for the money. Rather than work together, organizational leaders often accused one another of being inauthentic in their work. The scale-up of HIV testing led to a growth of HIV organizations, but it also undermined solidarity among a community of activists and organizations working on MSM advocacy.
In addition to organizational practices, Fan’s book examines how HIV testing affects men with same-sex desires. In chapter two, she describes a process of “making up MSM,” where organizations seek to instill a reconceptualized selfhood that links men’s sexual attraction to other men as part of their HIV risk. Workshops organized by ACF, an organization Fan spent substantial time with, mirrored other “coming out” testimonials seen by researchers in the HIV field, in this case, emphasizing coming out about sexual desires and then taking sexual responsibility by testing. However, while reconceptualization of the self is an organizational goal, it is less clear how men themselves feel about their sexuality and HIV status.
It is toward the end of the book, in chapter five, that Fan highlights men’s stories. Here, there are fascinating data on their range of experiences. Through HIV testing, some come to accept their same-sex desires and their positive status, which aligns with the organization’s goals. But Fan also finds that others want to maintain their heteronormative marriage, choosing to disclose their HIV status to their wives and children but not their same-sex desires. Other men disclosed to their spouses but not to their parents, and some rejected sex altogether and chose a path of abstinence. These findings are important. More perhaps could have been done to critically analyze organizations’ workshop practices and to draw out the contrasts between what organizations hope to do and the varied and nuanced ways that men interpret their HIV status and sexuality.
Overall, the book’s strengths lie in its empirical analysis of how metrics affect organizations and patients. Fan’s book continues the conversation among global health scholars on the unintended and sometimes negative consequences of metrics and audit culture. This book would be well suited for both graduate and undergraduate courses on gender and global health.