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Framing Responsibility

HIV, Biomedical Prevention, and the Performativity of the Law

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Abstract

How can we register the participation of a range of elements, extending beyond the human subject, in the production of HIV events? In the context of proposals around biomedical prevention, there is a growing awareness of the need to find ways of responding to complexity, as everywhere new combinations of treatment, behavior, drugs, norms, meanings and devices are coming into encounter with one another, or are set to come into encounter with one another, with a range of unpredictable effects. In this paper I consider the operation of various framing devices that attribute responsibility and causation with regard to HIV events. I propose that we need to sharpen our analytic focus on what these devices do, their performativity—that is, their full range of worldly implications and effects. My primary examples are the criminal law and the randomized control trial. I argue that these institutions operate as framing devices: They attribute responsibility for HIV events and externalize other elements and effects in the process. Drawing on recent work in science and technology studies as well as queer theory, I set out an analytic frame that marks out a new role for HIV social research. Attentiveness to the performative effects of these devices is crucial, I suggest, if we want better to address the global HIV epidemic.

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Notes

  1. The relevant legislation and case law are highly variable internationally and from jurisdiction to jurisdiction. Where some jurisdictions criminalize only intentional HIV transmission, others, such as Switzerland, criminalize exposure to HIV whether or not transmission has occurred, while others—such as Ontario, Canada, and New South Wales, Australia—maintain nondisclosure of HIV-positive status in sexual contexts as a criminal offense.

  2. For example, following the creation of the “African Model Law” by the (USAID-funded) Action for West Africa Region group in 2004, 13 African countries proposed HIV-specific criminal laws and at least seven passed them. A number of countries in Eastern Europe and Central Asia enacted laws that criminalize HIV exposure or transmission over the same period (Bernard 2008).

  3. Numerous social and behavioral studies among various populations at risk internationally indicate that HIV disclosure is rare in many of the contexts in which sex and/or injecting drug use takes place. Worth, Patton, and Goldstein offer the following succinct commentary: “The very idea of disclosure assumes that sex takes place face-to-face between partners of equal power and with some impetus to speak” (2005, 10).

  4. In this survey of U.K. gay and homosexually active men, Dodds (2008) found that support for criminal prosecution of HIV transmission was strongly associated with a range of indicators of HIV prevention need, including never having had an HIV test and believing that HIV-positive sexual partners would disclose their status before sex.

  5. In Western countries, the legal reproduction of this myth plays out in racialized terms, where a disproportionately high number of those charged with HIV transmission offenses are heterosexual men of African origins, typically characterized in terms of sexual excessiveness and hypersexuality in media commentary surrounding their cases. See Persson and Newman (2008).

  6. Of course, this is not to suggest that HIV-positive people do not bear some responsibility for HIV prevention, but, rather, to question whether the criminal law is an appropriate mechanism for fostering this capacity. An alternative approach to the further responsibilization of HIV-positive individuals pursued by criminalization would be to educate HIV-negative and untested individuals about the different sexual scenarios they may find themselves in and the constraints affecting differently sero-positioned participants in these scenarios.

  7. For groundbreaking work that grapples with the bioethical implications of this claim in relation to HIV pre-exposure prophylaxis, and which informs my thinking here, see Rosengarten and Michael (2009, 2010).

  8. For this reason, HIV social scientists have increasingly come to insist on a distinction between efficacy and effectiveness. See Kippax (2003).

  9. For Badiou (2006), enacting fidelity to the event involves performing a “generic procedure,” which in its undecidability is necessarily experimental and potentially recasts the situation in which being takes place.

  10. I adapt this phrase from Donna Haraway (2011), who uses it to refer to the practice of taking care for the unpredicted terrain that emerges from technocultural production.

  11. As Woolgar (1991) has shown, the process of technological design incorporates specific presumptions about human capacities and behavior, which then configure users of the technology in certain ways. Here I am highlighting the way in which this process shifts responsibilities from producer to consumer, in a manner that has political and moral implications. It is known, for example, that general medication adherence rates typically stand at about 50 percent, far less than the rate of adherence that antiretroviral medications require in order to achieve the desired effects. But this knowledge tends to be bracketed from trial design and/or publicized statements of efficacy, which renders adherence a uniquely “human” or user responsibility.

  12. Barry Adam (2011) and Cindy Patton (2011) have each pointed to the disconnect between the technical or population-level analyses that currently underwrite major policy decisions and the practical concerns and insights of affected groups and individuals. In this paper I have suggested that this technical situation deserves a technical response that may be formulated most effectively in terms of framing. As Isabelle Stengers and Olivier Ralet put it: “It is always possible to maintain that [a given] solution is a solution to a problem that is technically badly formulated, that is, to a problem posed according to certain a priori imperatives that have resulted in handing over control to some experts and ignoring others” (Stengers and Ralet 1997, 218–219, emphasis original). In this context, the relevant expert-others are those who contend with the practical realities of HIV infection and HIV prevention in their local environments.

  13. For an argument about poetry’s capacity to register the affective dimensions of the epidemic in a manner that gives insight into the ways in which HIV prevention and testing campaigns are apprehended in the context of political and historical inheritances, see Hoad (2010).

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Acknowledgments

This paper was first delivered as part of a symposium of Biomedicine and Subjectivity organized by Peter Aggleton and Carlos Caceres for the 1 st International HIV Social Science and Humanities conference held in Durban, South Africa, in June 2011. It was developed for publication over the course of special study leave granted by the University of Sydney, which I spent as a visiting scholar at the Center for the Study of Gender and Sexuality (CSGS) at New York University. I would like to thank my hosts at CSGS for their constructive and generous responses to this work as it emerged—in particular Ann Pellegrini and Robert Campbell. Thanks also to Judith Auerbach, Martin French, Susan Kippax, Gail Mason, Marsha Rosengarten, and audiences at the Center for AIDS Prevention Studies at the University of California, San Francisco; the Institute for Research on Women and Gender at the University of Michigan; the Center for Human Rights and Justice at the University of Texas; and two anonymous reviewers of this journal for their discussion and suggestions. All errors are my own.

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Race, K. Framing Responsibility. Bioethical Inquiry 9, 327–338 (2012). https://doi.org/10.1007/s11673-012-9375-x

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