Treating AIDS in Uganda and South Africa: semi- authoritarian technologies in gendered contexts of insecurity
The radical reconstitution of “global AIDS” (see Patton, 2002) “at the absolute center of human security” involved the imperative of expanding AIDS treatment in resource-poor settings. Within representations of global AIDS, Africa remains a “dark, untamed continent from which devastating viruses emerge to threaten the West” (Kitzinger and Miller, 1992, cited in Bancroft, 2001: p. 96). While it has become a common understanding that “African AIDS” has relied upon and perpetuated stereotypes of Africa as “Other,” particularly in sexually exotic and exceptional ways (Stillwaggon, 2003), African women’s bodies are again at the center of the “body politic” (see the classic text by Lock and Scheper-Hughes, 1996), as controlling viruses within bodies take a central role in political contestations and struggles over both global resources and local capital. Such contestations have pushed technological access to the forefront of political debates over global inequality among a wide variety of interest groups-from AIDS activists to global pharmaceutical corporations. In high-income countries, treatment with antiretroviral drugs (ARVs) became widely available in 1996, and AIDS-related mortality dropped sharply. Over the past half-decade, and in contrast to conventional wisdom that such therapies would remain beyond the reach of most HIV positive people in developing countries, improving access to ARVs has become a global priority. While this goal has yet to be realized in most African countries, South Africa has undertaken the largest public ARV treatment program in the world, and Uganda’s treatment figures are among the best in Africa. Despite such progress, ARVs can be described as semi-authoritarian technologies linked to controlled outcomes in both personal and political spheres. In addition, ARVs in Africa enter into, and
are complicit with, highly contested gender relations. As Sylvia Tamale argues, women’s subordination is predicated upon their sexuality, and the African state has a vested interest in controlling women’s bodies and sexuality to ensure the survival of power structures of patriarchy and capitalism (Tamale, 2009). Although the HIV/AIDS epidemic in Africa has most affected people in their prime reproductive years, childbearing and parenthood remain paramount reproductive projects for people who live on ARV treatment or people who are married to ARV recipients. Thus, having children continues to be the most important signifier of a normal life (Smith and Mbakwem, 2007; Richey, 2011). This chapter focuses on the treatment side of living with HIV in Africa by charting some of the reproductive negotiations surrounding these semi-authoritarian technologies in clinics in Uganda and South Africa. AIDS treatment is negotiated in highly gendered contexts that present formidable barriers for women who must adhere to treatment regimens. In Africa, women of reproductive age make up 20 percent of the general population, yet women aged 18-45 constitute 53 percent of the HIV infected population (Shelton and Peterson, 2004). Clinic level data suggests that it is worth explicit research consideration that women with AIDS continue to get pregnant, whether these women are on ARV treatment or not. Multiple studies have documented that sexual activity continues even after receiving a positive diagnosis for HIV across both so-called “developed” and “developing countries” (Myer et al., 2007). Furthermore, many sexually active, HIV positive people continue to want to bear children (Cooper et al., 2007; Myer et al., 2007). In many African countries, motherhood is understood normatively, and the stigma of childlessness often rivals the stigma associated with being infected with HIV (Cooper et al., 2007). The combination of women’s reproductive ambitions and the demands of ARV therapy produces an opportunity for negotiating both models and meanings of gender and health. Here I examine some of the complex and gendered issues that link vertical transmission of HIV to reproductive rights in the context of AIDS treatment counseling.1 In the following sections of the chapter, I begin with an introduction to empirical case studies from Uganda and South African clinics. Then I describe the context of AIDS treatment counseling in regards to pregnancy and family planning. Next, I will trace the trajectory of counseling and the important shift that resulted from bringing AIDS into the counseling context. Then, I analyze examples of negotiations from Ugandan and South African AIDS clinics focusing on social issues, poverty and gender. Finally, I elaborate on conclusions surrounding the interplay between gender and human security, as AIDS treatment continues to expand in Africa. In her (2004) study of African political regime change, Aili Tripp characterizes Ugandan President Museveni’s rule as “semi-authoritarian.” Such regimes are anti-democratic and deliberately combine the rhetoric of liberal democracy with illiberal rule. Semi-authoritarian regimes are propelled by popular support, but distribute their rewards through clientelistic channels. Key governance terms in this type of regime are “control,” “management” and of course, “continuity.” Control and management of resources, both human and material, must ensure
continuity of the regime and an ongoing access to benefits. These semiauthoritarian regimes must embrace contradictory realities of both freedom and oppression. In the neoliberal global economy, the relations between African states, development NGOs and the donors and lenders who fund them reflect these contradictory notions of global/local power dynamics, and these dynamics are reflected in accommodative bargaining (Tilly, 1999). Such bargains between donors and recipients at the policy level have felt implications for individual actors trying to negotiate issues of survival, production and reproduction (Richey, 2008a). Patients are never simply encountering local factors when they enter an AIDS clinic, but are part of a web of relationships, both economic and cultural, that link local clinics to global politics. AIDS treatment in countries like South Africa and Uganda provides significant examples of the technological link between the biological and the political. Thus, in this chapter, I suggest that it may be useful to think of anti-retroviral drugs as semi-authoritarian technologies. This is because their influx into parts of Uganda and parts of South Africa can contribute to particular political outcomes due to the technological influence of ARVs. For example, treatment with ARVs requires stability of both individuals and communities. Their high cost makes them valuable commodities for consumption, trade, or as political spoils. Also, the global emphasis on patient adherence justifies international concern with the intimate behavior of Africans’ pill-taking as a necessary part of global security. If “they” do not adhere to their pill regime, then “we,” the global community, will suffer the consequences of more virulent strands of resistant HIV, which can develop in local bodies and potentially spread around the globe. Therefore, sufficient compliance to the regimen of ARVs is necessary to avoid “an emergency,” thus producing the securitization of AIDS treatment. To understand the relationship between AIDS treatment and human security in Africa, this chapter will follow the analogy of the semi-authoritarian regime toward understanding semi-authoritarian technologies. Thus, it is critical to differentiate the opportunities, openness and life-giving powers from the constraints, barriers and limits to life that coexist under semi-authoritarianism. Questions of reproductive ambition by people living on ARV treatment call both sides into debate.