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The Challenge of HIV for Feminist Theory Marsha Rosengarten Feminist Theory 2004; 5; 205 DOI: 10.1177/1464700104045409 The online version of this article can be found at: http://fty.sagepub.com/cgi/content/abstract/5/2/205

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The challenge of HIV for feminist theory

FT Feminist Theory Copyright © 2004 SAGE Publications (London, Thousand Oaks, CA and New Delhi) vol. 5(2): 205–222. 1464–7001 DOI: 10.1177/1464700104045409 www.sagepublications.com

Marsha Rosengarten Goldsmiths College, University of London Abstract In this article I consider the field of HIV treatment and prevention in light of poststructural feminist critiques of the self-evidence of matter. Both HIV and poststructural feminist theory are viewed in relation to the current state of HIV scientific research of which it has been said: ‘much remains left to the imagination’ (McCune, 2001, emphasis added). Importantly, it is in the absence of ‘real’ knowledge of bodily matter and virus, that imagination is presumed by science as a fall back. Paradoxically, recent debate within feminist theory provides an almost perverse counter to this way of characterizing the struggle against HIV. Rather than considering imagination as something outside or external to the ‘real’, there is now substantial argument suggesting that imagination is always already present and inherent to the ‘real’. In the course of this paper, these differing positions of science and feminist theory are used to challenge and extend each other. The empirical matter of HIV medical science is shown as evidence of matter beyond the normative insistence of (human) language. On this basis, a theory of performativity – devised by Judith Butler and extended by Karen Barad – is argued as grounds for a methodologically expanded science.

keywords feminist theory, HIV AIDS, HIV anti-retroviral therapy Imagination: The action of imagining or forming mental images or concepts of external objects not present to the senses; the result of this process. The mental faculty which forms images or concepts of external objects not present to the senses, and of their relations (to each other or to the subject). Scheming or devising; a devise, a plan, a plot; a fanciful project. Expectation, anticipation. The faculty of fanciful thought; fancy. The creative faculty of the mind; the ability to frame new and striking concepts. The mind; thinking; thought, opinion. (The New Shorter Oxford English Dictionary, 1993)

In this article I want to consider the field of human immunodeficiency virus (HIV) treatment and prevention in light of poststructural feminist critiques of the self-evidence of ‘biological’ matter. Both HIV and poststructural feminist theory will be viewed in relation to the current state of HIV scientific research of which it has been said: ‘much remains left to the Downloaded from http://fty.sagepub.com at PENNSYLVANIA STATE UNIV on April 10, 2008 © 2004 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.

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Feminist Theory 5(2) imagination’ (McCune, 2001: 974, emphasis added). The author of this particular phrase goes on to explain that difficulties in studying ‘the human immune system in living human beings, hinders the discovery and development of effective vaccines and therapies’ (McCune, 2001: 974). Importantly, it is in the absence of ‘real’ knowledge of bodily matter and virus, that imagination is presumed a fall back. Paradoxically, recent debate within feminist theory provides an almost perverse counter to this particular viewpoint. Rather than considering imagination as something outside or external to the ‘real’, there is now substantial argument suggesting that imagination is always already present and inherent to the ‘real’. Consequently, a different sort of hindrance to the advance of knowledge about matter is believed to occur: biological matter is no less elusive but it is the conceptual imagining of matter that makes it so. Both HIV medical science and poststructural versions of feminist theory recognize the critical significance of imagining matter yet, at the same time, differ on how or where this is understood to take place. More precisely, they differ on the ontological status of the referent. While HIV may be conceived by science as an object qualified only by the inadequacy of knowledge, for poststructural feminism its ontological status must inevitably be in dispute. In the course of this paper, these differing positions of science and feminist poststructural critique will be used to challenge and extend each other. The ‘empirical’ domain of HIV will be used to confront the limits of a poststructural approach epistemologically forestalled in its engagement with ‘biological’ matter and as a consequence of its own insights (Keane and Rosengarten, 2002). Conversely, the poststructural approach will be considered for its ability to provide analytic concepts necessary for a more attuned imagining and, consequent, reworking of the self-evidency of ‘the empirical’ of science.

Locating ‘the biological’ While feminist theory has been effective in dislodging the otherwise seemingly intransigent assertions of biological determinism, attention to the socio-political and historical nature of matter has given rise to new problems. As Elizabeth Wilson (1999: 7) points out, numerous articles claim embodiment as their focus of inquiry, yet do so without consideration of the biological. It is as if, Wilson says, ‘the nature of biology is immaterial’. Taking up this point, Mariam Fraser (2002: 610) notes the irony in this neglect whereby the very object in question – the naturalness of ‘the biological’ – may remain unchallenged. Indeed, the absence of engagement with the biological may reinstate, even reify, the dichotomies of nature/nurture, gene/environment, matter/language in ways that affirm them as foundational features of a logic already in dispute (Tuana, 2001). The frustration evidenced by these responses to the limits of current engagements with the ‘flesh’ or ‘meat’ of our materiality, in part, resonates with a difficulty I have experienced while working in the HIV field: for how is it possible to engage with the effects of the virus when the very speaking Downloaded from http://fty.sagepub.com at PENNSYLVANIA STATE UNIV on April 10, 2008 © 2004 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.

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Rosengarten: The challenge of HIV of it functions as a productive/generative act complicit in the fallacy of ‘it’ (HIV) as objectively knowable? Ironically, the conundrum posed by poststructural insight can be traced to some of the most cited contributions on the problematic of representation in relation to HIV/AIDS. In the early 1980s, Paul Treichler pointed to the epidemic of signification taking place in response to HIV/AIDS and, in doing so, demonstrated the constituted and therefore contestable nature of HIV/AIDS in our imaginaries (Treichler, 1987). Similarly, when Donna Haraway (1989) and Emily Martin (1990) exposed the inherent reliance of science on language (metaphor, narrative) to give conceptual form to an otherwise presumed transparently knowable biological matter, it became clear that the iconic status of science as outside constructivism should not hold. Without intention, the analysis afforded by Treichler as well as other, more recent, studies of science has resulted in what Timmermans and Berg (2003: 109) have characterized as a ‘disciplinary chasm’ between the social and natural sciences. This chasm is particularly pronounced in relation to the HIV field. Unlike in other areas of the sciences concerned more overtly with genomics, there is a significant absence of inquiry into the social, political and ethical implications of HIV medical technologies. Curiously, styles of analyses derivative of the earlier cultural studies critiques are rarely seen with few notable exceptions (see, for example, Race, 2001; Vitellone, 2002). Although there is not space here to give any more than cursory mention to an apparent disinclination to engage a constructivist approach to the matter of HIV, it is likely that the introduction of HIV anti-retroviral drug therapies has contributed to the current situation in at least two ways. For some, it may seem that the therapies have so successfully altered HIV/AIDS from a lethal infection, to a potentially manageable chronic illness (Palella et al., 1998), that there is no need to contest the existing terrain. Linked to such optimism about the drug therapies is the absence of their availability to the vast global majority of people infected with HIV.1 Together, it is possible that ‘the will’ necessary for critique has been replaced by a certain complacency in the West about drugs and, perhaps, even by a shame of having them in light of the millions more who will die without them. Yet, without more effective knowledge of HIV and, as a consequence, more effective interventions the global situation will not change significantly. It is from this particular viewpoint that I want to cast the everyday difficulties of dealing with the drug therapies. Here I shall situate the current context of HIV medicine – structured by anti-retroviral therapies and associated diagnostic tests – as a point of connection between feminist theory and science.

A contemporary perspective on the HIV epidemic with treatment access It is now well established that a varied and complex array of unwanted effects accompany the achievement of HIV anti-retroviral combination drug therapy, here referred to as anti-retroviral therapies (ART). Some of Downloaded from http://fty.sagepub.com at PENNSYLVANIA STATE UNIV on April 10, 2008 © 2004 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.

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Feminist Theory 5(2) these so deemed ‘side’-effects are known to be potentially lethal. Others have been found so severely damaging that they are disabling and/or disfiguring.2 Added to these effects is the almost unmanageable nature of some dosing regimens that can require taking up to seven pills three times a day and at different specified periods, including before food, with food, and after. ‘Poor adherence’ to difficult dosing regimens is often held responsible for insufficient drug absorption which, in turn, can enable strains of the virus to replicate and mutate (BHIVA, 1999). The highly toxic nature of the drug therapies, yet the impossibility of leaving the virus permanently unchecked, are two prominent features of the HIV clinic. A series of complicated and uncertain decisions must be made along the lines of: when to commence combination therapy given the damaging effects of the drugs; what combination of drugs should be used given the difficulty of adhering to strict dosing regimes and possible development of drug resistance; and, also, how to negotiate questions of individual, gender and racially identified physiological differences that may influence test results, drug absorption and the manifestation of sideeffects (Rosengarten et al., 2004). Outside, although not entirely distinct from the clinic, there are concerns about cultural shifts incurred by the drugs. These concerns include debate on whether the therapies are increasing the practice of unprotected anal intercourse within gay sexual cultures (see, for example, International Collaboration on HIV Optimism, 2003; Kippax and Race, 2003); debate about the provision of an HIV post exposure prophylaxis (Kalichman, 1998); and debate on whether the increased practice of unprotected anal intercourse increases the risk of the transmission of drug resistant HIV (Little, 2001). Here I shall propose that the challenges now identified within the HIV field and directly associated with ART are, themselves, effects of the generative work of science. Rather than see the field of scientific knowledge in terms of lack, I shall argue that much of what it must surmount is inclusive of its own effects. Moreover, I shall argue that, in contrast to seeing imagination as a fall back, a filler in the absence of knowledge, there may be some gain in conceptualizing imagination as an already present materially effective conceptual force. Ultimately, my aim is to promote an exchange between those who would presume to be engaged in objective research, that is, between those who would presume their results are unaffected or unmediated by the technologies employed in the investigation and those, in contrast, who would claim that all research (and its outcomes) is mediated by language. But, as a first step and inspired, in many ways, by the inroads that feminist theory has made previously in the arena of HIV (Haraway, 1989; Martin, 1990; Treichler, 1987) and, more generally in the debates about the subject/object of science (see, for example, Keller and Longino, 1996), I shall elaborate the potential contribution a poststructural theory of performativity might offer to a science cognisant of its imaginative workings.


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Rosengarten: The challenge of HIV

The problem of representation In her groundbreaking interrogation of the sex/gender distinction, Butler claims that the body is not ‘an independent materiality that is invested with power relations external to it, but is that for which materialisation and investiture are coextensive’ (Butler, 1993: 34). The conjoining of investiture with materialization is the key to what Fraser describes as ‘a theory of political transformation informed by, and dependent upon, the inability of (human) language to capture the material referent’ (Fraser, 2002: 613). ‘Investiture’ refers to the productive workings of power that take place through knowledge (Foucault, 1987). It thereby refutes the possibility of innocent or neutral knowing, as if a process without political effect. Moreover, it refutes the possibility of the Enlightenment dream of ‘real’ knowledge, that is, knowledge of the objectively true that is binding, fixed and can be established as such through correct use of reason (Flax, 1992: 447). Objects are neither neutral despite appearing so, nor external to how we know them. The presumption of objective knowing – in the Enlightenment sense – is a trick, an elusion of rationality. Hence, ‘objects’, as effects of knowledge, are open to question and by way of an interrogation of the discursive processes that invest them with their presumed known form and/or substance. Amongst the many possibilities available through the interrogation of all ‘givens’ and, linked to this, a refuting of claims of objectivity is an extension or opening up of the very notion of what social, political and/or ethical feminist intervention might involve. In place of the object ‘woman’, presumed to represent an ahistorical and essentially fixed universal category of beings, the processes of exclusion and normative construction, involved in its formation, come into relief. Further, the terrain of the body is open to question in a manner inclusive of but not restricted to the binary of sexual difference. It is the potential of this analytic approach that provides what I am presuming here to be a feminist driven incentive to question the work of science. The incentive is not restricted to the question of whether the work is identifiably engaged with questions of gender and sexuality. Rather it is more open to general questions of matter as presumptions about the latter’s ontological status inform and shape the social, political and ethical terrain. Here I shall pursue a question of matter in relation to the specific substance of HIV. By doing so and, most specifically, embracing the notion of a materiality coextensive with investiture, I want to tackle a series of questions that inevitably emerge from a refuting of an externally knowable or re-presentable referent: is exposure of the coextensive nature of matter sufficient in itself? What should or could direct the uses of this exposure? Or, perhaps more appropriate a question: can this exposure be incorporated within more ‘material’ intervention? Alternatively, from a more conceptual frame, is it possible to avert the problematic of representationalism (Rouse cited in Barad, 2003: 805)? In the absence of a referent (presupposed by the act of presuming to represent), can there be a coming


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Feminist Theory 5(2) together of those who would claim the need for an absolute objective account and those who would insist on the latter’s contingency? Butler’s foreclosure on (human) language to capture the material referent is central to this paper. It sits at the intersection of a vigorous debate within feminist theory (Wilson, 1999) and one that has much to add to a field of social studies of science and technology. More specifically, the impossibility of transparent re-presentation of the objects of HIV, human immune system, drug therapies and more poses a serious challenge to science. This challenge will be considered here in terms of what it might enable. I am concerned to see whether an acceptance of the instability of existing accounts of scientifically grounded objects, might permit HIV medical science to reflect on its already active imaginative role in materializing HIV. This reflection could include a more extensive and dynamic account of its own productivity in generating new or changed matter and, notwithstanding, that of the virus and the human immune system. The need and possibility for this type of account is already indicated in the work of Susan Oyama in relation to evolutionary theory. In place of an account that presumes certain matter is passed on unaffected by its relation to other matter in time, Oyama (2000: 3) presents a development model in which organisms and their environments can be understood as interconnected through a ‘stunning array of processes and, entities, and environments – chemical and mechanical, micro- and macroscopic, social and geological’. From another perspective, the generative nature of engagement with what is conventionally presupposed as Nature, unmediated by its opposite Culture, is also evidenced by those who adopt an actor-network schema to expose the constituted nature of medical matter (see, for example, Mol, 2000; Willems, 1998). It is in light of other critics of scientific matter that my choice of Butler to forge an exchange with HIV science may seem somewhat odd or perhaps even redundant. Moreover, since Butler’s work is frequently subject to accusations of failing to deal with matter it may seem rather inappropriate to bring it into dialogue with the critical and urgent matter of HIV. Within feminist critiques of science much of the criticism levelled at Butler arises in response to her emphasis on the iterative citationality aspect of performativity. It is a claim made explicit in Barad’s recent and revised work on performativity (Barad, 2003: note 26) that bears traces of the critique provided by Vicki Kirby on the problem of fixing language as the property of culture (and not also nature) (Kirby, 1999).3 According to Kirby, the attention to investiture (presumed here to also mean language or discourse) fails to recognize matter as active, irrespective of/outside discourse. Consequently, she says, ‘its [matter’s] palpability and its physical insistence, is rendered unspeakable and unthinkable’ (Kirby in Fraser, 2002: 613). Nancy Tuana (2001) expresses a not entirely dissimilar position, also, when she argues that the attention to the discursive fails to account for the active presence of matter. In Tuana’s view, the materialization of objects needs to be understood as more than a process of inscription. However, in her view, analysis is required to give insight into how the biological collaborates with bodily practices and other interventions active in changing bodily Downloaded from http://fty.sagepub.com at PENNSYLVANIA STATE UNIV on April 10, 2008 © 2004 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.

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Rosengarten: The challenge of HIV form. Yet, how is it possible to presume a type of collaboration by the biological without returning to the initial problem of presuming ‘the biological’ as already present and knowable outside language? Performativity is the closest Butler comes to explaining the dynamics of investiture in its coextensive relation with matter. Performativity describes the process of materialization as neither ‘simple fact or static condition of a body, but a process whereby regulatory norms materialize “sex’’ and achieve this materialization through a forcible reiteration of those norms’ (Butler, 1993: 2). Bodies are never complete in terms of the norms that assume and require them. Hence, performativity is a process of ‘reiterative and citational practice by which discourse produces the effects that it names’ (Butler, 1993: 2). On the basis that bodies and other biological matter emerge through, rather than prior to reiterative processes, performativity dispenses with the notion of a referent. It is a notion of performativity shared in some senses with that of science and technology studies (STS) in that it recognizes what Barad (2003: 802) terms ‘practices/doings/actions’. However, it differs from actor-network accounts and also Barad’s in at least one distinctive way. For actor-network accounts see practices/doings/actions in terms of relations (human with human and with non-human) rather than the discursive (and hence power/knowledge). Barad, as I shall elaborate, sees the doings of ‘the non-discursive’ (for example, technological observing apparatuses) as an important aspect of iteration and, in her later work, gives precedence to these over discursive or citational practices.

The appearance of phenomena In Barad’s paper ‘Getting real: technoscientific practices and the materialization of reality’ (1998), performativity is extended beyond the citational in the materializing of objects. The exemplar is the ultrasound machine as it materializes and reinstates a notion of the fetus. Through this technology, the fetus appears as distinct from the maternal body. As such, Barad claims, it is available to anti-abortion arguments proclaiming it an entity with rights in contradistinction to the mother. Moreover, it is a rights based discourse and, more so, prior discursive conceptions of bodily identity that make the anti-abortion argument possible. For contrary to appearances, the ultrasound machine does not provide an image of an object that exists prior to the application of the technology. Although the process of materialization is shown to take place because of matter, it does not come after, or take place in a manner that is external to what is known as matter. The process involves the reception and transmission of ultrasound waves between a non-human discursive-material apparatus (ultrasound technology) and that of the ‘flesh’ of human material. The ultrasound machine is an apparatus for observation but, as it acts to make an observation, it is co-constitutive of that which comes to be observed. The performative, in which the ultrasound plays a vital part, is, no doubt, a ‘forcible reiteration of norms’ (Butler, 1993: 2). But it is outside the more usual conception of language as the substance of the performative. The norm of ‘fetus identity’ Downloaded from http://fty.sagepub.com at PENNSYLVANIA STATE UNIV on April 10, 2008 © 2004 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.

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Feminist Theory 5(2) is reinstated through an imaginary binary of sex and that of the ‘selfcontained free-floating object’ (Barad, 1998: 100). But this reinstatement of imagined norms, each requiring of reiteration to appear as ‘given’, is achieved through discursive-material means as well as through a restricted notion of performativity comprising only the discursive. ‘The fetus’ materialized by ultrasound technology is not a referent in the terms assumed by the natural sciences. Rather, as Barad explains, it is a phenomenon in the sense that it stands as objectively knowable because of the means by which it has been materialized. Its form is contingent on the type of apparatus used in its materialization. In Barad’s terminology, the entity is the effect of ‘intra-action’ of observation and object (1998: 90, 91). This recognition is derived from the work of Niels Bohr whose contributions to quantum theory include the recognition that the nature of light (waves or particles) depends on the apparatus used for its observation (Barad, 1998: 90). As Fraser (2002: 615) explains: ‘Barad’s “Bohrian” understanding of an objective referent (a phenomenon in the process of becoming) suggests that it [the objective referent] can only be recognised as such insofar as the conditions of its emergence are made explicit’ (emphasis in original). By filling the space in our intelligibility, previously occupied by the referent, the notion of ‘phenomena’ provides the possibility for a recasting of empirical matter that makes evident the conditions of its ‘imagining’. Indeed, the notion of ‘phenomena’ exposes medical science as invariably co-implicated in the objects that it presumes to be objectively true and merely requiring ‘correct’ observation. The process of discursive-material entanglement which, for Barad, involves human and non-human factors in an ethically contestable producing of phenomena is captured by the phrase ‘agential realism’: ‘. . . we are not only responsible for the knowledge that we seek but, in part, for what exists’ (Barad, 1998: 94). Unlike other fields, such as law or education, there is an immediate and necessary involvement in and not just with ‘biological’ and technoscientific devices. This, as will become clear, has important implications for the substance of HIV medical interventions. For the matter that is presumed outside and awaiting the work of science – including the virus HIV – is materialized, in part, by science. The ultrasound machine case study illustrates the coextensive nature of investiture and materiality in what comes to appear as a transparently knowable biological object. The case study also illustrates how matter matters in the materialization of ‘biological objects’. The discursive shapes the design of technologies such as the ultrasound machine. But this does not occlude the (discursively constituted or coextensive) materiality of the machine. It is the materiality of the machine, its emission and receipt of sound waves that effects an image reflective and reinstating of the discursive. This recognition of the dynamic material nature of the technology is important for extending Butler’s performativity. Indeed, it brings Butler’s performativity into direct engagement with the process of technology and, in doing so, helps reveal the discursive-constitution of scientific matter. Less emphasized – but also important to the argument I want to make here concerning HIV interventions – is the way in which the ultrasound Downloaded from http://fty.sagepub.com at PENNSYLVANIA STATE UNIV on April 10, 2008 © 2004 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.

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Rosengarten: The challenge of HIV example is part of a schema of reiteration and transformation of matter that gives rise to different materializations. In Barad’s words, there is an enfolding of phenomena whereby ‘subsequent iterations of particular situated practices . . . result in the production of new phenomena, and so on’ (1998: 93). This, I shall show, has important implications for understanding the work of HIV medical interventions. It recasts the notion of an intervention as a more productive force and not dissimilar from the Butler claim of theoretical intervention. As Butler (1993: 10) states, in reference to the work of discourse: ‘. . . there is no reference to a pure body which is not at the same time a further formation of that body’. Analogous to the claim that discourse is formative and therefore transformative, I shall endeavour to show how anti-HIV drugs and associated diagnostic tests not only work to reduce the virus. They also transform the virus and the bodies in which the virus gains currency.

Materializing HIV While the current HIV medical field would more usually be viewed by those within it as comprising a series of distinct objects with fixed properties measurable by transparent means, Barad’s work makes possible a recasting of these as an array of phenomena whose properties are already reflective of a prior imagining. Following Barad’s example of ultrasound technology, it is possible to trace the current materialization of HIV to a history of HIV medical technologies (see, for example, Flowers, 2001; Race, 2001; Kippax and Race, 2003). Exemplary in these, along the lines of Barad’s ultrasound technology, is the viral load test. It is recognized as having brought about a paradigm shift that enabled the use of antiretroviral drugs in combination. As a result, it is attributed with having brought about a radical transformation of the epidemic (Alcorn and Fieldhouse, 2000: 24). A previous diagnosis of AIDS and inevitable death has now been pre-empted to become one of chronic illness management (Davis et al., 2002; Moatti and Souteyrand, 2000). Here, I shall use the viral load test to reveal some of the means by which HIV, the embodied subject with HIV, and drug resistant HIV come to be materialized. I think maybe I might go and find I don’t have it [HIV] because how come my viral load is undetectable? It is undetectable. It used to be medium and now they [doctors] say it is ‘undetectable’. I often ask myself, if I should go to another clinic and have another antibody test there because I feel it might be negative.4

The ‘viral load test’, as its name suggests, measures virus particles in an individual’s blood sample (Mortimer and Loveday, 2001). The optimum test result is ‘undetectable’. Although for those in the medical field there is unlikely to be any doubt that a person initially tested ‘HIV positive’, by the antibody test, has had their HIV status reverted to negative as a result of ART, the conjecture conveyed in the above quote need not be considered surprising. At an obvious level it is likely to be motivated by wanting to be found free of the destructive potential of the virus and the continuing, even if significantly changed, risks and challenges this poses even in the Downloaded from http://fty.sagepub.com at PENNSYLVANIA STATE UNIV on April 10, 2008 © 2004 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.

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Feminist Theory 5(2) presence, or because, of ART. I add the qualifier ‘found’ free to highlight the significance of an iterative diagnosis that is often the case in HIV and is underscored here by the performative of the viral load test result.5 A further motivating reason for wanting to be HIV negative is the issue of relations to others. These others may be lovers, sexual partners, children, and/or other kin whose risk of infection or loss (ranging from emotional, family lineage to economic) is already significantly altered according to science in light of ‘undetectable’ results. But amongst the extensive reasons for wanting an HIV negative diagnosis, the quote conveys, more explicitly, the difficulty of thinking personhood at the intersection of a different materialization of HIV by the viral load test: is an HIV antibody positive test result now a sufficient basis for conceptualizing HIV status in the same manner as prior to the viral load test? In medical terms (including issues of longevity, infectivity) it seems not. Prior to the viral load test, knowledge of the active virus relied on the detection of visible disease symptoms (AIDS). Knowledge of the presence of the virus relied on the detection of HIV antibodies, through the HIV antibody test. Hence the virus, as it is now known, had not materialized in vivo. Moreover, the different mode of knowing it produced a different knowledge and set of practices in response to ‘it’. In its prior visible absence, disease effects provided the basis for a theory of viral replication. This theory included positing a latent stage in viral activity immediately after initial infection and lasting some years. The viral load test’s ability to materialize a surrogate marker of HIV in vivo dispensed with the notion of the latent stage and led to new strategies (Alcorn and Fieldhouse, 2000: 24). In place of monotherapy (one drug), combination therapy (two, most usually three but possibly more drugs in unison) came to dominate treating practice. And, in response to the materialization of the virus as ‘active’ from the time of infection, the strategy of ‘hit early, hit hard’ formed the edict of much clinical practice. Treatment was to start at the time of infection and involve a considerable onslaught of drugs (Ho, 1995). In retrospect, the ‘latent stage’ not only put in place a set of practices now in disrepute. It also materialized an object that no longer exists (at least in prevailing HIV medical science paradigms). Now, more than seven years on, in light of the effects of drug resistance and ‘side-effects’, modifications have been made to the ‘hit early, hit hard’ approach. Where possible, the decision about when to start therapy is delayed.6

Materializing adherence and resistance ‘in vivo’ At the centre of ART clinical management is a person conceived through measures of virus and human immune cells. The effectiveness of ART, in achieving viral suppression, has relieved many of the damaging direct effects of the virus – at least in the short term, if not for ever – to instead grapple with the requirements of dosing, possible side-effects and risk of viral resistance. Moreover, the mode of dosing produces this person as an active participant in the achievement of suppression. Dosing adherence is a means of maintaining adequate drug levels within the body. Without Downloaded from http://fty.sagepub.com at PENNSYLVANIA STATE UNIV on April 10, 2008 © 2004 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.

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Rosengarten: The challenge of HIV adequate drug levels, the virus continues to replicate and, as it does so, mutate. The mutations are understood as resistant or insensitive to the drug in the presence of which they have emerged. They are of concern because their insensitivity to pharmaceutical suppression may mean existing drug options are reduced, even eliminated. The risk of few or nil drug options is compounded by drug side-effects which may also reduce or eliminate certain drug options. However, it is not difficult to find various contradictions and paradoxes arising from the notion and expectation of dosing adherence. These are present not because the discursively constituted objects of ‘adherence’ and ‘viral resistance’ are necessarily wrong in their linking and constituting of unwanted and materially harmful phenomena. Rather, the contradictions and paradoxes are present because ‘adherence’ and ‘resistance’ are materializations of discursive-material intra-activity. The relation between ‘adherence’ and ‘viral resistance’ is not absolute, in fact it can be shown as a product of the test rather than ‘nature’ per se. Further the concept of ‘resistance’ is difficult to fix, making it open to conceptual interrogation. The viral load test is instrumental in the intra-activity. It performs a critical function in the materialization of not only the virus but, also, the person with the virus. As it engages with matter in vivo, it produces an account that reflects an imaginary embodied subject, sufficiently able, to determine adherence. As Kane Race (2001: 177) explains: ‘For an HIV-positive individual, the imperative to remain “undetectable’’ assumes the alwayspresent possibility of detecting HIV; that is, it induces a process of constant monitoring and vigilance around the presence of the Other (the virus) at the level of the individual’ (emphases in original). He goes on to say that viral load test monitoring ‘implants an imperative around individual selfsurveillance upon which the subject’s capacity to retain that [“undetectable”] status depends’. Underpinning the imperative of retaining ‘undetectable’ or consistent viral load status is the presumption that pill taking is achievable through embodied will. Further, it infers that pill taking results in viral suppression. But neither, as I shall go on to elaborate, is always borne out. The construction of ‘poor’ adherence involves exclusion of the onerous nature of dosing. Yet taking pills is now well-documented within HIV social and psycho-social literature to be difficult for many and for a variety of reasons (Chesney et al., 2000; Race and Wakeford, 2000). Indeed, implicit in some of this data is the difficulty of swallowing pills or what is sometimes referred to as ‘gagging’ on tablets, even to the point of vomiting. The gagging response is not easily reconciled with an embodied will. It might even be explained, within other areas of medicine, as an ‘involuntary’ response. More importantly, from the perspective of this paper and the insistence on adherence, there are data in HIV scientific and social scientific literature that confound the presupposition that adherence necessarily achieves suppression. For example, there are individuals who report missing pills without change to their viral load. And, despite ‘good’ adherence, viral resistance can occur. In the scientific literature this is attributed to a variety of reasons. These include possible different drug Downloaded from http://fty.sagepub.com at PENNSYLVANIA STATE UNIV on April 10, 2008 © 2004 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.

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Feminist Theory 5(2) absorption rates in individuals and/or the presence of other drugs, dietary conditions, extra vitamin intakes, or genetics (Schapiro, 2001: 314; Alcorn and Fieldhouse, 2000: 157). Moreover, the very notion of ‘resistance’ may be misleading. The virus is understood to be resistant because of its altered molecular form making it unreceptive to the chemical workings of the drugs. The changed molecular structure occurs as a result of ongoing replication that involves mutation. The reading of ‘resistance’ is based, initially, on increases in the amount of virus shown by the viral load test.7 As Schapiro (2001: 312) writes: Our ability to quantify resistance in such terms as ‘fold increase’ [a type of measurement] may satisfy our desire for quantification; however, at the same time, it encourages our belief that this information alone provides an answer to our questions. Such answers are not definitive; the virus does not know that we call it ‘resistant’ when a susceptibility assay records a certain-fold increase in IC [inhibitory concentration of a drug].

Implied in the facts of ‘resistance’ is the variability of HIV as a force. This variability can be categorized in a range of ways. As just outlined, there is the variability that occurs through ongoing mutation and including variability that occurs in the presence of the drugs as a sign of ‘resistance’. There is also the variability that may become evident with the withdrawal of drugs. ‘Wild type’ is a term used to characterize a strain of virus that may be identified after withdrawal of drug therapies (Frenkel and Mullins, 2001). With regard to HIV, it may be a form more virulent as well as drug sensitive. For those struggling with how to respond to the development of viral resistance, the variability of ‘fitness’ or viability for replication and destruction can be weighed against drug resistant mutations ‘whose infectivity, replication, or protein maturation . . . is impaired’ (Schapiro, 2001: 312). The variability between ‘wild type’ and a less ‘fit’ drug resistant form structures or materializes a debate over whether to continue or cease therapies in the presence of drug resistance (Deeks et al., 2001). From a science perspective, the materialization of viral variability could be argued as enabled by the viral load test in at least two ways: the viral load test is part of the knowledge (and network) construction of drug interventions; through viral load readings the drug therapies are used with the effect of changing what is observed (materialized) as a materially altered virus.8

The palpable presence of HIV, drugs and body matter From the perspective of the Butler/Barad critique, the materialization of variability illustrates the enduring and transformative capacity of what is conceptually fixed as HIV. Drug resistant and ‘wild type’ virus occur because the object of virus is never stable. Yet the concept of instability appears to be a difficult one to sustain. Or, perhaps more precisely, it is difficult to imagine within a linear cause/effect and subject/object framing. Drugs do not just result in viral suppression. Nor do they, directly, produce viral resistance. And, while dosing is a participant in changes to the virus, the changes are not reducible to an act of self-will over or external to the Downloaded from http://fty.sagepub.com at PENNSYLVANIA STATE UNIV on April 10, 2008 © 2004 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.

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Rosengarten: The challenge of HIV virus. Indeed, the conceptualizing of what an enduring and transformative virus involves is already delimited by the presumption of objective unmediated knowing. Even the lay person familiar with HIV medical science is aware of how the viral load test is subject to temporal and spatial inclusions and exclusions. Viral load tests must be repeated at regular intervals because results change. They are carried out in peripheral blood and the results must then be extrapolated, without certainty, to other locales in the body also subject to viral activity and damage (Wainberg and Friedland, 1998). Linked to these qualifiers, is the question of what ‘undetectable’ means for infectivity. Factors such as the presence of other infections and/or genetic differences are believed to affect viral capacities (Quinn et al., 2000). Importantly, then, the properties identified as those of the virus are already recognized, within science, as provisional. But the provisional status is understood as due to environmental and genetic factors. Although the virus is already recognized, by science, as dynamic and bearing a capacity to be transformed, this recognition does not extend to the function of diagnostic methods. The latter may be recognized as unable to provide a complete or permanent knowledge of the virus. They are not seen as active in materializing the virus in ways that infer a type of immutable essence. Yet, as evidenced by the empirical of HIV science, the properties of HIV are materialized through the knowledge or object sought; the object presumed to be measured by the diagnostic tests; and what is enlisted by the test in a type of collaboration with the object under observation. HIV is materialized to inevitably bear the mediating effects of technology or, as Butler (1993: 34) might say, it is an effect of the coextensive nature of materialization and investiture. To recognize that HIV is a phenomenon – effected by the process of its identification – does not take away from its palpable presence, its insistence as a force to be contested. Nor does it take away from the ability of medical science to intervene – although not so directly as it presupposes – in the biological substance of its imaginary. But it does return us to the question of Butler’s theory of performativity and its application to a science oriented conception of matter. The Butler/Barad mode of interrogation illuminates a more extensive work of science in the making of the substance in which it deals. By providing tools to enable a more selfreflexive critique of medical science, it enables critical reflection on the role of imagination at the very point where science and its object/s for intervention are presumed distinct. This recasting, to consider the preexistent presence of imagination, contests the self-evidency of many of the difficulties faced by HIV medical science. It therefore opens up the field to more and different ways of considering these difficulties, even a reframing of the nature of the difficulty. In reference to the concerns of this essay, it also opens up the potential of a feminist critique currently being called into question for its in/ability to engage with the substance of matter.


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Conclusion Although the question of the referent provided the starting point for this essay, the nature of HIV – according to science – suggests the question, itself, is redundant. This is not because HIV science cannot operate without a fixed and stable conception of the matter in which it is endeavouring to intervene. Quite the contrary (even if unsatisfactory when evaluated in light of toxic effects of viral suppression). The question is redundant because the empirical of HIV medical science cannot, in its own terms, be regarded as evidence of this type of object. Its form is contingent on the matter used to study it. Indeed, as a particular formulation of the performative process, a conception of coextensivity (matter-investiture) recognizes that a notion of matter as stable or inert is the product of a discursive insistence. Butler’s performativity allows for the presence of matter as that which eludes and invariably challenges the transformative effects of investiture. This performative account of matter, therefore, provides a critical point at which science and feminist poststructural theory might, together, explore the limits and generative capacities of reiteration – citational and otherwise – in the apparent (as always provisional), transformative function of virus and bodies as well as medical and theoretical interventions. Using Barad, it has been possible to highlight the value of characterizing scientific intervention as a form of agential realism, whereby science is already ethically implicated in its otherwise seemingly ‘given’ objects. This, I believe, is critical to an interrogation of the role of science and offers the basis for a more imagination cognisant approach that could, for instance, add a consideration of the mediating effects of representation to the mix of variables accounted for in a methodological critique. Such an inclusion would recast the object of HIV or ‘viral load’ as a phenomenon, invariably provisional on the tools of its materialization. It would, in other words, give recognition to the already present role of imagination in scientific rigour. One of the outcomes of such a recognition might be a broadening of the scope of methodological consideration and, following on from this, some conceptual refinement of the object targeted for intervention. Alternatively, or additionally, such a recognition might engender a new conceptual framing of the empirical in ways that breach Timmermans and Berg’s (2003: 109) ‘disciplinary chasm’. For example, a new conceptual framing might utilize different disciplinary approaches to deal with phenomena, such as ‘gagging’, with the consequence of moving beyond the current confines of the mind/body split. However, Butler’s theory of performativity alerts us to more than the need for an extended scientific terrain. Most critically, it underscores the double import of the notion of citation or language as a means of materializing phenomena. Citationality is the insistence that effects the fallacy of stability, even inertion. It is language or discourse that must be exposed in the materialization of matter if we (I am speaking inclusively here to encompass science) are to begin to understand the already present productive workings of conceptual imagining in matter. Performativity, in Butler’s Downloaded from http://fty.sagepub.com at PENNSYLVANIA STATE UNIV on April 10, 2008 © 2004 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.

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Rosengarten: The challenge of HIV conception, gives emphasis to an operation that must take place because bodies do not, ‘in fact’, accord materially with their normative investiture. Whatever the substance of our materiality (with and/or without HIV) our means of grasping this is reliant on the inevitable work of investiture. To make this claim is to recognize the generative effects of the grasp. For, the very process of forging a relation of contact or engagement involves a type of intra-activity in the materialization of the object conceived. According to the empirical of science, it is the palpable presence of matter that continues to elude the realist grasp. Butler’s performative is based on this recognition. It is the rationale for the citational repetition. Within the HIV field this repetition is evident by way of the insistence on claiming the discrete and stable objects of ‘resistant’ and ‘wild type’ virus while it is also apparent that these are dynamic intra-relational entities. Viral resistance and reversion to ‘wild-type’ demonstrate that matter – as science might claim it – is not, in itself, inert but, rather, insistent in ways that have continued and will continue to be invested by the processes of observation. To turn this around, it is also possible to claim that the effects of HIV interventions – for instance drugs interacting with virus and human matter – challenge the normative effects of the performative. In other words, the empirical of science exposes the work of imagination in the conceptualization of its objects as stable.

Acknowledgements This essay is based on research undertaken as part of a study titled ‘Transitions in HIV Management’ funded by the Innovative Health Technologies Programme, Economic and Social Research Council, UK. I would like to thank Lisa Adkins, Roslyn Diprose, Mariam Fraser, Kane Race and Nicole Vitellone for valuable feedback in the course of its development and special thanks to Susan Squier for her encouragement and editorial assistance.

Notes 1. There are over 40 million people infected with HIV, 95% of whom are without access to ART (Global Health Fund, see http://www.theglobalfund.org/en/). 2. The range of known possible side-effects is extensive. They can be the effect of an allergic reaction to the drug/s or as a result of the toxicity of the drug itself. They may include potentially lethal damage to major organs, disfiguring and disabling lipoatrophy and lipodystrophy (fat wasting and fatting deposits on specific parts of the body), and extremely painful peripheral neuropathy (damage to nerve endings in the feet and hands). 3. See Kirby (1999) for a Derridean style critique of the limited way in which language presumed to be a feature of culture when it can also be demonstrated at work in what is distinguished from culture as nature. 4. This is an extract from an interview I conducted with an African British female with HIV at a London HIV clinic in 2003. 5. Race et al. (2001: 2) state: ‘If HIV diagnosis created the possibility of being diagnosed as sick while feeling healthy, viral load testing has created the possibility of being diagnosed as acceptably healthy while feeling very unwell.’ Downloaded from http://fty.sagepub.com at PENNSYLVANIA STATE UNIV on April 10, 2008 © 2004 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.

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Feminist Theory 5(2) 6. The delay is made possible by reference to the CD4 T cell count, another diagnostic measure which provides a surrogate marker of the state of the body’s immune system (BHIVA, 1999). 7. Other tests such as phenotype and genotype testing may be used to establish more knowledge of the resistance. 8. Following viral load test detection of increases in virus particles, other tests may be used to establish the nature of the mutated strain and sensitivity to other possible drugs.

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Marsha Rosengarten is a lecturer in sociology at Goldsmiths College, University of London and an honorary research fellow, National Centre in HIV Social Research, University of New South Wales, Australia. Previous publications include feminist poststructural critiques of matter, HIV medical technologies and other areas of medical innovation and intervention including organ transplantation and xenotransplantation.

Address: Department of Sociology, Goldsmiths College, University of London, Lewisham Way, New Cross, London SW14 6NW, UK. Email: m.rosengarten@ gold.ac.uk
