International organizations promote provider-initiated, 'routine' HIV testing of pregnant women seeking antenatal care as an effort to curb mother-to-child transmission. We offer an account of the perceptions of HIV testing at antenatal clinics in rural Malawi. Although it is both international and Government of Malawi policy that women must be explicitly informed of their right to refuse testing, analysis of in-depth interviews, focus group discussions and evidence from observational field journals show that rural Malawians do not perceive HIV testing as a choice, but rather as compulsory in order to receive antenatal care. This study illustrates dissonance between global expectations and local realities of the delivery of HIV-testing interventions.