On HIV assemblages,inequalities and subject formation

Abstract

Drawing on our situated experience as geographers of sexualities living and working in the Minority World, this response addresses some of the concerns raised by our interlocutors around the use of assemblage thinking, socio-spatial inequalities and subject formation.

The intention of our article (Brown and Di Feliciantonio, 2022) was to explore recent biomedical developments in the treatment and prevention of HIV to contribute new geographical perspectives on HIV. We think about two, related, pharmaceutical interventions – ‘Treatment as Prevention’ (TasP), the use of anti-retroviral drugs to ensure people with HIV cannot pass the virus on to others; and Pre-Exposure Prophylaxis (PrEP) which uses the same pharmaceutical interventions to stop those who might be exposed to HIV from becoming infected. The central aim of our paper was to outline a distinctly geographical contribution to analysing these changing biomedical technologies, and their ‘capacity to reorganise social and material worlds’ (Race, 2018: 2). Drawing on our experience as geographers of sexualities, we chose to focus primarily on the experiences of gay and bisexual men in the Minority World, whilst posing questions that we believe are relevant to the experiences of people and communities elsewhere.

Our use of assemblage thinking to frame these interventions was driven by a desire to trace what things come together to shape the contemporary experiences of HIV ‘undetectability’. Through thinking with assemblages, we attend to what emerges from the coming together of human bodies, viruses, pharmaceuticals, and biomedical technologies across multiple sites and spatial scales. We hoped that the work would inspire and provoke geographers to engage with the potential of assemblage thinking in bridging fields that are rarely combined (in this case, health/HIV geographies and geographies of sexualities). We would like to thank the four commentators for engaging so generously with our paper and thinking critically about how these issues might be extended further.

In his excellent and provocative commentary about the ongoing impacts of HIV on black populations in the US and elsewhere, Aaron Mallory (2022) questions whether our use of assemblage thinking helps further understandings of the structural conditions that articulate Black populations’ relationship to HIV. In doing so, Mallory conflates assemblage thinking with wider non-representational theories in geography (perhaps understandably, given how central a Deleuzian approach to affect was to early non-representational work in geography). While we accept that assemblage thinking operates through a flatter ontology than more conventional social science approaches to social structures, we do not think that it overlooks or cannot explain how racialized inequalities shape the operation of HIV assemblages. Assemblages are made of heterogeneous components (both material and symbolic) and we understand them as ‘assemblages of assemblages’ (DeLanda, 2016). On this basis, we acknowledge that there are specific variations of the HIV assemblages which shape the experiences of Black gender and sexual minorities in the USA and elsewhere, which can account for continuing inequalities in access to treatments, in AIDS-related death rates and in the meanings attached to PrEP and TasP by different populations.

A similar critique to our assemblage approach comes from Tsang (2022) who considers how nationally-specific articulations of homonormativity interact with the undetectability assemblage in China. She argues (Tsang, 2022) that our paper ‘fails to explain – from a sociocultural perspective – why some gay and bisexual men living with HIV are undetectable in the use of TasP and PrEP … [in] South East Asia or China’. While our paper does not address Chinese examples, we contest her suggestion that our assemblage approach cannot explain these national variations. On the contrary, we believe an assemblage approach to undetectability can and should consider how national welfare regimes, and culturally specific expressions of sexual morality and familial obligations are part of the assemblage in different contexts. This approach can also account for the tension between a homonormative ‘desiring China’, that is, ‘a cultural, economic, and affective project through which Chinese people refashion themselves in order to achieve a new subjectivity under postsocialist neoliberalization’ (Ye, 2021: 2) that has come to include specific metropolitan gay communities, and the persisting precaritization and exclusion of people living with HIV (including migrant sex workers at the heart of Tsang’s commentary). Tsang’s analysis reminded us of Moussawi’s (2020) conceptualization of ‘fractal orientalism’ in his work on queer strategies in Beirut, where he suggests that Beirut is often perceived as failing to live up to Western models of tolerance and inclusion, whilst simultaneously presenting itself as more ‘cosmopolitan’ and tolerant than other parts of Lebanon or cities elsewhere in the region. We wonder if what Tsang is drawing attention to might be a form of ‘fractal homonormativity’ operating in China.

As Andy Tucker (2022) explored, in a South African context, assemblage thinking has the potential not only to explore the perpetuation of socially and geographically specific variations in the functioning of undetectability assemblages, but also to chart how the consequences of these specific inequalities are entangled with the operation of the wider assemblage in other times and places. We agree that assemblage approaches must continue to account for who and what falls out of (or were always excluded from) undetectability and other HIV assemblages.

While we believe that our assemblage approach has relevance for rethinking the geographies of HIV in many contexts, the main empirical focus of our paper was a consideration of how PrEP and undetectability have impacted on the lives of gay and bisexual men in Australia, North America, and Western Europe. We do accept, however, that globally, most PrEP users live in other national contexts, and many are heterosexual. We are grateful to all four of the commentators for helping us to think through how assemblages of undetectability might be experienced in other contexts, with other populations, and how access to PrEP (and antiretroviral treatments) are shaped by, and in turn reproduce, other intersectional inequalities.

Tucker (2022) shares our critique that, in recent years, geographers of sexualities have largely overlooked the implications of HIV, and comments that it is our ‘pivot away from biopolitics towards assemblage’ that allows our ‘intervention to land with such force’. But we also agree with his critique that our decision to focus on the experiences of gay and bisexual men in the Minority World only hints at the ways that ‘we may wish to see TasP and PrEP as part of other assemblages, and that such assemblages may themselves be shaped by and help to reshape what we understand by TasP and PrEP’ (Tucker, 2022). We agree with Tucker that there is more work to be done to examine how the sheer scale of international funding for HIV interventions in the Majority World; as well as how the impact of these interventions is shaped by funders’ identification of ‘key populations’ and their reporting mechanisms. As he highlights, these funding mechanisms bring certain sexual subjects into being as ‘legitimate entities and subjects requiring outside intervention’. We appreciate his observation that, building on DeLanda (2006), these policy and funding strategies draw attention to the ways in which assemblage thinking can help to ‘blur divisions of the socio-material, near-far, and structure-agency’.

Ingrid Young (2022) draws attention to two under-developed aspects of our analysis which we find productive. First, she raises the need to consider inequalities within national territories in relation to jurisdictional health policy and how these shape (and, potentially, limit) access to PrEP. She makes the point, in the UK context, that devolved government has led to very different policies for the implementation and roll-out of access to PrEP across England, Scotland, Wales and Northern Ireland. We agree that the initial delivery of PrEP in England through a protracted ‘impact trial’ (with capped numbers) has produced different mechanisms for negotiating access to PrEP than in Scotland, where access was rolled-out through sexual health clinics, as part of an integrated sexual health strategy. The Government’s decision to roll out PrEP, free on the NHS, in England was announced on 1 October 2020 (while our paper was in review); but it appears that, in some localities, commissioning and delivery of the new policy was slowed by the secondment of many public health staff to COVID responses.

Young (2022) challenges us to think more about the heterogeneity within gay and bisexual communities and to engage in ‘rethinking and repositioning whose bodies, practices and needs are imagined and centred within these communities and their subsequent implications for provision and access’. We accept that our decision to focus on the experiences of gay and bisexual men in the Minority World may have ended up presenting this population as more homogenous than we know it to be. For some time now, we have been interested in exploring the experiences of gay and bisexual men living in rural areas and smaller provincial cities – both to assess the barriers they might experience to accessing PrEP, but also (drawing on our assemblage model) to explore what their relationships to PrEP might reveal about contemporary gay and bisexual men’s lives outside of metropolitan areas.

Young’s argument echoes Mallory’s (2022) point on the experience of Black gender and sexual minorities in the USA in relation to (access to) PrEP and TasP. He offers a powerful reminder that the experiences of Black gender and sexual minorities (in the USA) draw attention to the importance of addressing the intersections of race and sexuality in their articulation of different sites of knowledge production about HIV – and that sexuality/gender cannot be separated from race and the ways bodies are racialized. We thank Mallory for drawing our attention to the ways in which debates about PrEP in North American black communities have provided an opening for rethinking and redefining Black pleasures. His use of Muñoz’s (2009) conceptualization of ‘queer futurity’ is particularly useful in exploring how Black gender and sexual minorities have (re)negotiated their relationship to undetectability to not only challenge antiblackness within the HIV/AIDS epidemic, but also to ‘harness Black sexuality as a tool to transform health education through Black gender and sexual minorities’ experiences … to show how to navigate harms while creating space for the emergence of Black sexuality that is not stigmatized or feared’ (Mallory, 2022). His conceptualization does not clash with our use of assemblage thinking; in line with Deleuze and Guattari, we see assemblages as always unstable, fluid, open to change resulting from socio-cultural, economic and political forces. The ‘process of assembling and selection is never completed or fixed insofar as it describes a tendency towards stabilisation rather than the final achievement of this state’ (Duff, 2016: 17–18, emphasis in original).

Young (2022) and Tucker (2022) both comment on our critiques of ongoing debates about the biopolitics of PrEP. Young argues that we were too simplistic in our challenge to the biopolitical critiques of PrEP and TasP in relation to grassroots PrEP activism. In contrast, she argues that ‘these particular forms of biosexual activism are indeed central to subject formation and sexual practices and are constitutive of the other within HIV assemblages’ (Young, 2022). She says, ‘we ought to pay closer attention to how, where, when and for whom the biopolitical, pleasure and “community” identities are constitutive of these biotechnologies, and each other’. Young notes, from her own research experience, how sceptical and dismissive health practitioners were, initially, about the gay and bisexual men’s ability to comply and adhere to drug regimes and, in doing so, makes the points that practitioners have been forced to learn from community responses which have encouraged and enabled ‘responsible’ PrEP use. Extending this point, she stresses how these forms of biosexual activism ‘are also central to subject formation’ for and by communities. We do not necessarily disagree with her arguments and observations. But this is because, we believe, her use of biopolitics is more ‘generative’ in terms of collective subjectification, acknowledging the possibility for contestation, than the ‘negative’ one used by the most stringent biopolitical critiques of PrEP that we discuss in the paper (e.g. Dean, 2015: Preciado, 2015). As widely discussed by one of us (Di Feliciantonio, 2016, 2017), Foucauldian subjectification is not necessarily synonymous with subjection, the tension between the two can be resolved through the deconstruction of identity, not just individually, but also collectively.

In relation to PrEP, Tucker (2022) offers the very important reminder that the experiences of gay men in the Minority World are already entangled with locations in the Majority World, as these were the sites where the initial clinical trials of these new pharmaceuticals were conducted. He reminds us that these clinical trial protocols can draw an invasive medical gaze towards poor black sexual subjects who become increasingly visible as a result. We appreciate how Tucker links participation in clinical trials in poor communities in the Majority World to the debates about ‘slut shaming’ (in the Minority World) that we examined in our paper. His extension of this argument beyond straightforward associations with HIV, to consider how diverse spaces in the Majority World might be implicated in the production and maintenance of homonormativity and other expressions of sexual politics in the Minority World is also instructive. We are persuaded by his reminder of the ways in which homonormative social relations rely on and perpetuate inequalities stretched across time and space. Indeed, this is exactly the kind of rethinking of the geographies of sexual politics that we hoped our assemblage thinking (about HIV and undetectability) might provoke. More comparative and transnational research is needed to better understand the co-constitutive relationships between place, sexual politics, communities, and access to PrEP, anti-retroviral medications, and other essential services. Geographers might have an important role to play in this research, if we are willing to go beyond sub-disciplinary boundaries and engage more with the materiality of bodies and sexual practices.