Ancestors and Antiretrovirals: The Biopolitics of HIV/AIDS in Post-Apartheid South Africa

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Most generally, governmentality refers to the various "governmental" and "non-governmental" modes of governing rationalities, tactics, strategies, calculations, reflections, practices and programmes bearing on the government of conduct, including government of the self by the self see Dean, ; Lemke, , ; Collier, The implication of the theory of governmentality, then, is that we are not governed by external factors. Instead, we are enjoined to govern ourselves through a complex and discursively loaded web of practices and programmes. An advice column may be one point where the subtle workings of governmentality can be more easily seen.

Governmentality is the "conduct of conduct", or more specifically, a power relationship entailed in "acting upon an acting subject or acting subjects by virtue of their acting or being capable of action" Foucault, Materialized through a constellation of often related programmes, initiatives, campaigns and strategies, the notion captures in one sense all the work undertaken by an array of authorities, experts and individuals to steer relations of humans with their selves and with each other in order to achieve particular ends, including maintaining the health of populations and of oneself Lemke, In another sense, governmentality reflects the ways of thinking and moralizing underlying the setting and demarcation of duties, obligations, sentiments and habits accompanying the governing of relations both with oneself and others.

Within this call, anchored as it is around western notions of self-help, HIV-positive individuals are enlisted to work on themselves accordingly by undertaking measures to improve or gain control over their health. The enterprising PLHA becomes one who undertakes self-improvement in order to maximize personal gain. This strategy is reminiscent of Foucault's concept of a "generalization of the enterprise form", in which the neoliberal emphasis on profit and loss - of economic enterprise - is generalized to the ways in which individuals should calculate and maintain their own personal value, psychological life and, in this case, physical health.

Therefore, as with market initiatives of prompting or spurring consumer buying behaviour in the marketplace, health promotion campaigns in the current and global neoliberal milieu focus increasingly on cultivating self-management capabilities as a strategy for securing the health of individuals and the general populace Ayo, By stressing the imbrication of personal conducts or habits and public health initiatives, the current trajectory of health promotion fosters the shaping of individual agency through the various mechanisms by which human biological-cum-social life is rendered governable Rose, Ethics, understood through a Foucauldian lens as the relation of the self to itself possessed of the capability for moral agency, are therefore embedded in the relations of powerthrough which we are either made governable or self-governable.

Oursubjectivity is shaped by governmental initiatives, at least partly because these initiatives promote self-governance and self-regulation see Hunter, ; Davidson, Subjectivity and ethics are embedded in the relations of power through which we are either made governable or self-governable. Subjectivity is thus consequential and critical to achieving the interspersing ethical and governmental aims linked to the countless social, cultural, political and economic strategies of governing societies undertaken by a range of institutions and agents.

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Personal empowerment or self-governance are equally the channel for constructing subjectivity and its most desired outcome Cruikshank, As will be shown in this paper, the type of self-formation Criselda's HIV advice column upholds for health undertaking practices draws upon many elements we link with the trope of neoliberal subjectivity in its characteristic valorization of the credo of individualism.

Sampling decisions. Of the many popular advice columnists and experts found in South Africa's print, broadcast and online media, offering psychological, relationship, financial and general health advice, Criselda stands out for her first-person experience with the subject of her advice platform.

In fact, most people know her more for her bravery in living openly with HIV than for her professional training as a nurse. With the growing spread and adoption of social media at the macro and micro levels of everyday life, she is set to develop her "brand" online, whether by accruing friends on Facebook or by participating in public debates on various issues via Twitter.

A quick glimpse into her online footprint, for example, shows a steady upward trend, with approximately 19 and 95 followers on Facebook and Twitter, respectively. Aside from her influential public profile or persona, three key reasons have therefore motivated us to embark on the analysis of Criselda's HIV advice column. Other platforms - for example, "health Criselda's advice column is organized around representing the predicaments faced, directly or indirectly, by those who are willing to speak out about their experience with HIV and solicit the guidance of expertise.

Second, even though her readership in Bona consists largely of black women, we felt the need to place it within a developing trend both here and globally of resorting to multimedia self-help forums for self-inspection, self-correction and self-empowerment. The magazine is largely purchased by middle class Black women, but it is likely that it is passed on and read by those who cannot afford to buy it and by men.

Ancestors and Antiretrovirals: The Biopolitics of HIV/AIDS in Post-Apartheid South Africa

Because the column is written by a black woman and largely for black women, it is addressed not to a Western subject but to an African subject. The broader trend of multimedia self-help is very strongly situated in Western neoliberal values, and so the analysis of this advice column offers the possibility of analysing self-help directed specifically to an African subject.

Because of Criselda's similarities to her readers, her HIV advice column probably has a special appeal for this audience owing to its own columnist's widely celebrated courage to stare into the vertiginous face of HIV at a time when it was viewed as fatal and much stigmatized. Third, the choice to use this advice column is motivated by its potential to throw up the more general and contemporary workings of the relation between knowledge, expertise and subjectivity.

Advice columns are explicitly simultaneously positioned as popular media, as expert opinion and as insider perspective. They are both intimately personal and resoundingly public. For Foucault , these "textual forms", often pedagogical in style and expert-driven, also enjoin people to evaluate their self-conceptions and behaviours in order to identify aspects requiring improvement or modification.

Analysis of an HIV advice column offers the possibility of examining both how and to what ends PLHIV are called upon to remake themselves with respect to shaping the course of their health or illness. An advice column therefore offers an avenue for assessing both the values and justifications for current modes of constituting and transforming how PLHIV subjectively relate to their condition.

Collecting advice inserts across this time-span therefore allowed us to gain significant insights into the general thrust of how the self should relate to itself. All advice inserts, published across 71 issues, were sourced, and both questions and answers were included. The sample was further narrowed down in line with the central focus of the broader research project of which this paper is a part to focus on letters specifically addressing the issue of living on ARVs.

All letters were reviewed and included in the sample if they made direct reference to ARVs. Because of the strong association between ARVs and viral load and CD4 count, letters were also included in the sample if they made reference to either of these terms. The final sample therefore consisted of 55 advice inserts.

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Approach to analysis. Analysis followed two stages.

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We began by following Braun and Clarke's method of thematic analysis in order to generate initial themes. Braun and Clarke specify that one advantage to their method is the flexibility it offers, particularly because it allows the superimposition of theory. The initial thematic analysis began with analysis of themes pertaining to viral load, CD4 count and ARVs. As the analysis progressed, it became clear that the titles of the inserts draw attention to the experience encompassed in each case - for example, "ARVs make me look fat and pregnant".

The questions were very briefly or precisely posed to highlight key aspects of the nature of the problem faced by the advice-seekers' pertaining to their viral load, CD4 count and ARVs.

The Bio-Politics of HIV/AIDS in Post-Apartheid South Africa.

We used each question asked as a prompt or a guide for what to evaluate in each recommendation advanced in response to the query. Initially the content was analysed, and this revealed that ARVs, viral load and CD4 count were indeed central preoccupations in the data. Theory-led questions were then applied to the data so that we could analyse how each query was framed and what remedial action each answer suggested. Importantly, we focused our attention on aspects about self-improvement and self-evaluation implicated in each response.

The overall guiding question was therefore how advice inserts accentuated the relationship one has with oneself. It became quickly clear that these questions were appropriate for every advice insert, and that the question of self-improvement and self-evaluation was central to the advice column. A second layer of analysis applied Foucault's approach to the ethics of self-care as discussed previously.

We asked the following questions of each advice insert and its recommendation: a what ethical substance or aspect of the way the self relates to itself is identified for adjustment or reconstruction; b how or what reasons are advanced or upheld - the mode of subjection - for obligating the self to adjust or refigure itself; c what ethical work or particular task by the self is to be performed with reference to changing the way it views and acts on itself; and d what telos of the ethical subject or overarching goal is presented for aspiration or accomplishment?

This allowed us to pursue a more directed analysis of the two broader themes that were identified. In order to ensure quality control, both authors independently reviewed the advice inserts in order to generate a consensual analysis. We also evaluated the data in relation to its fit to the theory, so as to avoid an analysis that inappropriately imposed theory on the data.

This helped us to refine the central guiding question in relation to self-improvement, self-evaluation and the relationship of the self to the self, since these questions were centrally important in the advice column. In some of the extracts below, it is clear that these concerns, of interest theoretically in this paper, are voiced in colloquial ways in the advice columns.

Although limited examples are presented in this paper, they have been chosen because they are exemplary of the data: many other data extracts could have been similarly used. We have therefore presented typical rather than exceptional data inserts. In order to facilitate the resonance of our analysis with readers, we have chosen fewer extracts that have been presented in more detail rather than more frequent but briefer extracts.

This is particularly important since it is both the question asked and Criselda's answer that is of relevance to the analysis. Two main themes emerged from the analysis.

First, advice-seekers, and by extension, the readership of the magazine following the advice column, are nudged to enfold the principle of investing in self-affirmation involving the responsibility of expending time and energy acquiring the capacity for risk-management for viral load increase or reduction to the CD4 count. Second, the undertaking to overcome the barriers to commencing with or adhering to HIV therapy is constructed in terms of the willingness to pursue qualified assistance on one's remedial options in the event of side effects. Each of these themes will be presented in turn, and illustrative extracts from the data will be discussed.

Investing in oneself in facing down HIV. An overriding point of view gleaned from the advice column is that successful reform of practices related to HIV health requires changing one's mind-set and habituating oneself to self-regulation. More specifically, readers are exhorted to place value on investing in oneself as an ethical virtue constitutive of an independent-acting subjectivity.

This is promoted as a desirable state of living with HIV. Understood this way, investing in oneself for the goal of living positively with HIV designates the sort of actions, measures and initiatives concomitant with a self-caring approach to enhancing personal health, with the assistance or tutelage of medical expertise. The ability to be self-caring, as Foucault , has shown, is itself lodged in one's capacity to acquire knowledge of the ways of improving oneself for the fulfilment of a desired state of being, happiness and satisfaction.

There is strong emphasis in the advice column on taking responsibility for looking after personal health and productively managing HIV.

Claire Laurier Decoteau, PhD

Readers are encouraged to do this by keeping watch over their HIV biomarkers and their psychosocial correlates of adjustment or resilience, which entails acquiring the information or capability to keep them in check. Consider the example of an anonymous advice seeker who asks Criselda to explain "the difference between a CD4 count and a viral load", as well as "what should an HIV-positive person eat" to keep healthy Bona, September, Taking up the perspective and principle of investing in self-care, Criselda's response focuses on prodding the advice-seeker to take care to pay close attention to the role or influence played by the combination of emotional and psychological state on the course of the viral load and CD4 count as the most reliable bodily markers of the extent to which HIV is under control:.

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  6. If your health is balanced, the viral load will go down or remain stagnant and usually, your CD4 count will rise. There are specific targets set for viral load changes that will tell your doctor if you need to be on ARVs - CD4 count should not be less than and viral load less than copies A healthy immune system would mean a proper healthy functioning body from eating well, treating each and every minor illness, maintaining a healthy mind that is fed positive and realistic thoughts, which will involve educating yourself about all you need to know about HIV Bona, September, An important aspect for managing HIV, this advice suggests, entails ensuring that the CD4 count is not below the target point and that copies of the virus in the body do not multiply to the extent of overwhelming one's health.

    The advice links enhancing the immune system's strength and vitality with the determination, disciplining and control of self facing HIV. Medical facts flow seamlessly into careful monitoring of the body "each and every minor illness" , and then of the mind: feeding the mind healthy thoughts is directly equated with a healthy immune system. As Criselda's intervention signals, improving the strength of one's resistance to HIV requires a keen sense of awareness and interest in regulating one's emotions.

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    That is to say, investing in the ability to stabilize the CD4 count, viral load and emotions is important for confronting courageously the egregious consequences of being HIV-positive. What the advice in the extract mobilizes for uptake or self-consciousness, as Sangaramoorthy has shown through her work on the constitution of a "numeric subjectivity" with PLHIV, is the perspective that self-representation is a measurable or quantifiable experience inextricably linked to emotions.

    The advice emphasizes self-adjustment and self-scrutiny in the quest for physical well-being, and gestures towards the obligation of learning to take responsibility in controlling HIV. This is to be accomplished by acquiring knowledge of the crucial determinants of HIV health, including the impact of both emotions and biomarkers in hindering or facilitating the on-going experience of living with HIV. Such an investment, as Criselda's advice to the anonymous advice-seeker above evinces, can have instrumental benefits if, for example, knowledge of the nutrients upon which a healthy body for also controlling the fluctuations of HIV biomarkers is adopted into a way of life.

    On the other hand, the benefits can be of a psychical nature or form, if they result in cultivating the capacity for the personal determination required to independently manage a life with HIV. Take, for example, Sindiswa's case. She started on antiretroviral therapy in , and initially, her CD4 count increased "from to ", though when she wrote to Criselda in it had dropped she did not mention how far it had dropped.

    Her doctor changed her medication, but what she finds most distressing is that "people are starting to comment about my weight loss In her response to Sindiswa, Criselda starts by drawing attention to the value of taking individual responsibility for one's health in paying Sindiswa a compliment for discussing her concerns with her doctors and "having them change your medication to suit your needs" Bona, November, In offering her guidance to Sindiswa, Criselda advises her to "figure out what's stressing" her and to "do something about it" ibid: 90 , which as she points out, will help her manage how she feels about herself as an HIV-positive person.

    The ethical work of adjusting oneself that Criselda suggests involves careful scrutiny of body and mind in order not only to be a good subject but also in order to increase CD4 count. Sindiswa is congratulated on enlisting the help of doctors in her quest for self-surveillance. In her advice, Criselda goes so far as to present growing to accept oneself as preceding the actualization of taking responsibility for preserving one's life with HIV: "You went down a size and that is not always a bad thing.