Particularity, potentiation, citizenship and pragmatism

This is a preprint of a paper submitted and accepted as a chapter in the book HIV prevention and treatment technologies in international perspective (Davis and Squire, eds, 2010). This book can be obtained from http://www.palgrave.com/page/detail/hiv-treatment-and-prevention-technologies-in-inter national-perspective-mark-davis/?isb=9780230238190 . This preprint is a draft version of the chapter. The final chapter differs. Please reference as published, below: Davis, M. and Squire, C. (2010).Particularity, potentiation, citizenship and pragmatism. In M. Davis and C.Squire (eds) HIV prevention and treatment technologies in international perspective. London: Palgrave. ISBN 9780230238190 Corinne Squire 289 Chapter 10 Particularity, potentiation, citizenship and pragmatism Mark Davis and Corinne Squire Introduction The case studies presented in this volume have addressed HIV technologies as formations of the material, embodied, social and political in modes of engagement with the HIV epidemic. As argued throughout, this notion of HIV technologies is needed to grapple with the particularities of the HIV pandemic in the treatment possibility era. This approach provides a way of conceptualising HIV medical, social, cultural and political treatment and prevention technologies and their hybrids. The perspective draws attention to the sociocultural and political aspects of HIV medical treatment technologies and to the increasingly bio-technical bases for HIV prevention. It also encourages reflection on forms of HIV prevention and social care that are not typically understood as technologies but that, as has been demonstrated, share many structural and political features with technical, biomedical means of addressing HIV. This perspective can also allow us to grapple with relations between treatment and prevention, as many of the chapters in this volume have demonstrated. Adopting this general approach and extending it in innovative ways, each of the chapters have addressed the familiar and important HIV technologies that inform national and international efforts to address the HIV epidemic. Campbell has explored and critiqued community participation in HIV interventions in subsaharan Africa. Abdullah and Squire 290 have identified the salience of locally democratic partnership in implementing HIV treatment in resource-constrained settings in South Africa. Mykhalovskiy analysed the history, benefits and drawbacks of the move to integrate HIV treatment and prevention in Canada. By drawing on qualitative interview data and group discussion, other chapters have considered intersubjective HIV technologies. Wilbraham considered the psychosocial dimensions of South African print media encouraging parental care of the sexual health of children. In UK settings, Flowers explored the transitions in living with HIV that are necessary in the era of access to ART and Davis examined the ethical implications of the knowledge produced in and around the effects of ART on the risk of HIV transmission in sexual practice. Other chapters in this volume have considered some of the effects of biomedical technologies of HIV prevention. With reference to the use of HIV antibody blood testing to ascertain serostatus, Race examined discourse concerning unsafe sex among gay men and in particular barebacking in developed world contexts. Rosengarten and Michael developed the notion of transnational clinical trials for pre-exposure prophylaxis as both problematic and productive sites for HIV prevention activity. These critical studies of HIV technologies have sought to question prevailing assumptions regarding the apparent technologisation, and specifically biomedicalisation, of approaches to the HIV epidemic. The studies have also expanded definitions of HIV technologies, and questioned the technologies themselves, thus enabling new modes of critical understanding and analysis. In this concluding chapter we would like to draw attention to four main cross-cutting themes from the case studies: particularity, played out 291 in chapters’ carefully specified and interrelated concerns; potentiation, understood here as the technical, ethical and political interrelations through which the effects of HIV technologies can change; tensions in the kinds of HIV citizenship associated with HIV technologies; and the pragmatics or ‘practical truths’ that are being negotiated in and around the everyday use of HIV technologies and how such practices and insights themselves serve as counterpoints to more distanced, generalised and uncontested efforts to govern via HIV technologies. Particularity A central endeavour in this project has been to sustain depictions that pay attention to the particular conditions and expressions of the HIV epidemic in trans- and intra-national contexts. Neglecting such particularities, even when they cannot be fully specified and addressed, is recognised as a shortfall in engagements with the pandemic (Campbell, 2003). We suggest that recognising particularity is also a necessary precondition for HIV activists and advocators, service providers, policymakers and theoreticians, if they are to articulate and act on relations and alliances between those particularities (Laclau and Mouffe, 2001 [1985]). This volume moves beyond globalising dichotomies and reductive analyses towards situated accounts of HIV technologies and their ramifications which recognise their multipolar attachments and investments (Mouffe; 2005). The volume’s notion of HIV technologies as complex assemblages embracing both HIV treatment and prevention, biomedical and sociocultural, and physical, social and symbolic resource technologies is useful because it draws all these fields into articulations of particularity. In the process, it helps resist some of the dichotomies that are common in the HIV field 292 and beyond. Chapters in this volume have exploded ‘developed versus developing’ country discourse, questioned simple notions of before and after the advent of ART and challenged reductive approaches to the tension between human agency and biomedical power. They have addressed the HIV pandemic's divergent historical moments, paying attention to the specific histories of HIV epidemics across varying global locations, nation states, and intra-national social groups. Particularity is also worked out through the volume’s address to the 'psychosocial,' most clearly in Flowers's emphasis on the neglect of psychosocial engagements with HIV epidemics. Chapter writers have also traced the related and autonomous operations of biomedical and sociocultural HIV technologies in their particular socioetemporal contexts of production, translation and application. Rosengarten and Michael's exploration of the biomedical and sociopolitical technological assemblages surrounding PrEP - pre-exposure prophylaxis - exemplifies this thoroughgoing engagement with the particularities of HIV technologies. The volume has also worked across different methodological approaches, addressing HIV technologies via the heterogeneous set of epistemological positions which can articulate them. It has included case studies derived from large-scale HIV interventions, analyses of research and policy from different country contexts, historical perspectives on HIV technologies and close focus qualitative research with people affected by HIV. For example, Campbell provided a meta-analysis of evaluations of HIV education and care programmes in South Africa and Zimbabwe up to the early 2000s - in many of which she was herself involved - programmes that remain salient for the situations of uneven treatment and care that still characterise most high HIV prevalence nations. Abdullah and 293 Squire drew predominantly on the documentation and ethnography of policy, to show how particularity in the contemporary HIV era has to do with the mixing of universal treatment possibility with uneven provision and resources. The chapters in this volume also consistently address the multipolar power relations in HIV technologies. Writers' address to 'community' is an obvious example. Campbell, Abdullah and Squire, and Mykhalovskiy, for instance, analyse the difficult term 'community' in distinct contexts of technological hierarchy and negotiation, and come to specific conclusions: respectively, that community is simultaneously invoked and erased by HIV programmes; that 'community' can have a contingent but important effect on those programmes, given certain 'partnership' technologies; and that 'community' is always positioned in opposition to other forces and has repeatedly to be reinscribed. These findings, while particular to each of the chapters' investigatory contexts, have some generality of application outside those contexts, and they are commensurable with each other. All three chapters position 'community' as a complicated and problematic term that can still have something to offer for people's collective organisation and action 'technologies' around HIV. Similarly, Wilbraham positions the politics of South African HIV prevention as nationally specific, but also transnational, and suggests that difficulties in addressing such complexity leads to prevention discourses' limited effectivity. Drawing on her own interview studies, she argues that interviewees discursively adopt the value ‘talking to children about sex’ as part of a 'sexual citizenship’ at least partly translated from 294 western, white, middle class discourse, involving open talk about feelings, rights and responsibilities. However, this talk is also, she suggests, part of a South Africa-specific commitment to engage with problems around family life and the HIV epidemic, and a manifestation of South African discourses of the sociality of childhood, and of classed urban progress, cultural change, and emergence from apartheid-mandated ignorance. A further particularity related to HIV technologies pertains to contemporary social theory. For example, it is not easy to reconcile the specificities discussed here with the canonic critique of the neo-liberal individualisation of modern systems of health care. Plainly such critiques are not sufficient, as this volume indicates. Not all HIV contexts are individualising, and within contemporary HIV governance lies a great variety of technologies of autonomy and self-subjection. A straightforward critique of neo-liberalisation of and through HIV technologies is too totalising for the transnational yet finegrained perspectives provided here. Moreover, some discourses of HIV technologies’ possibility and contingency reveal surprising turnings and unexpected lacunae that do not fit well with simple theoretical accounts of their productive or resistant, progressive or conservative nature. Chapters in this volume underline such particularities and point us towards methods of analysis that can take account of them. For example, Race and Rosengarten and Michael revealed both the problematic and productive aspects of HIV technologies. Race showed that elements of the practice of barebacking are enormously productive forms of agentic engagement with biomedical technologies, such as the HIV antibody blood test and ART, and do not necessarily lead to HIV transmission. Race acknowledged that such developments are not without 295 problems but suggested that the interrogation of these is clouded by pre-emptive accounts of changes in sexual practice and related interventions. These conflicted opportunities and challenges in HIV technologies appear in relation to the HIV virus itself. Rosengarten and Michael have shown how the persistence of assumptions of a notional HIV as a stable biological singularity misses out on how its ‘viability’, as they refer to it, depends on society, culture and selves. A commitment to understanding particularity directs us to the least noticeable and most ignored aspects of the interrelated and multipolar relations of power at play in the pandemic. At the same time, such analysis has to negotiate particularity with comprehensibility, persuasiveness, and political feasibility. As Race (this volume) argues, particularity is inevitable when addressing the multiple lived technologies of the epidemic, but it is at the same time necessary to compromise such particularity in order to find terms of engagement. A cross-cutting component of these requirements is the analysis of directions within particularity that connect HIV technologies across fields and across time, and that extrapolate into spatial and temporal futures, engendering technological breaks and shifts in the process. Such an analysis moves away from particularity towards what we are calling technological potentiation. Potentiation The common meaning of potentiation is ‘transfer of power’. This initial meaning is one way and electrical, but technologies can of course metaphorically potentiate each other; and power, taking many forms, can work in different directions (Foucault, 1980), turning 296 the well-predicted changes of electrical potentiation into moves towards possibilities. We can also understand potentiation as an instantiation of Deleuze's account of the virtual which he distinguishes from the possible (Deleuze and Parnet, 1977) in respect of the lack of relation between its ground and its actualisation: what is to come is not predictable, does not inhere in what is already with us, but this future is nonetheless seeded by the processes, rather than the contents, of the present. Potentiation concretises the move from virtual to real by specifying the different objects, states or phenomena from whose relation the virtual comes into reality, by acknowledging the shifts in power that produce that change and by predicting, necessarily imperfectly, directions of change. In these processes, potentiation in fact comes close to Laclau and Mouffe’s (1985) notion of hegemonic articulations, built up from particularities towards a universality that is always contingent and contested. From exchange and contest between HIV technologies, derive different technologies – not necessarily better, but offering other routes towards living with and understanding HIV. Countries living long-term with high-prevalence HIV epidemics are clearly going to undergo potentiations across HIV technologies of diagnosis, treatment, care and education, and in interaction with the other difficult technologies of lives lived in resource-constrained circumstances, of kinds that cannot easily be predicted over the next few decades. Magona (2008) suggests in the South African context that for women, the potentiation of technologies of sexual and other self-determinations may be one result of long-term living with the virus. Another result may be the normalising of HIV, though in a different way to that remarked in the developed world. In high-prevalence contexts this 297 often seems to be happening through discourses of ‘AIDS fatigue’, articulated by the HIV infected, affected and unaffected alike, and through small-scale but indicative practices like the use of male and female condoms as footballs, toys and jewelry. HIV-associated objects are multifunctional resources in resource-poor contexts, as well as objects with powerful meanings that might be defused by these diverse functions. Such social normalisation will no doubt always, as in developed-world biomedical normalisation, be haunted by its obverse; displayed for instance in the increasing representational separation off of ‘the HIV positive’, who are often also marked by gender and poverty (Lana, 2009; Steinberg, 2008). This move is in turn strongly resisted by some political and media articulations like, in South Africa, the Sowetan newspaper column written by Lucky Mazibuko (2008), repeatedly reminding his readers over the last ten years that HIV positive people cannot be secreted away. How does the potentiation of HIV technologies play out in this book? We have seen throughout that lines of potential change may be constructed and then extrapolated from analyses of particularity. Wilbraham for example suggests working across the limits of prevention technologies that she delimits to imagine other technologies. Moving between historical moments in the relation between technologies of HIV prevention and treatment, Mykhalovskiy suggests the possibility of reconfiguring ‘responsibility’, from the perspective of everyday HIV lives and activism. All the writers who address ‘community’ look across the fractures within this field, towards potential other futures. A powerful example of potentiation comes from writers' formulations of connections 298 between prevention and treatment technologies. Derived from their commitment to analysing particularity and multipolarity, the book chapters support the view that HIV treatment and prevention are mutually potentiating. Such mutual influence is part of many forms and levels of HIV discourse. The clinical effects of ART are said to contribute to prevention, and HIV education is claimed by local HIV organisations and international NGOs alike to assist treatment outcomes, for instance. Potentiation also occurs physiologically in the synergistic effects of various drug combinations. ART is itself comprised of substances that potentiate one another in the sense that they act on viral replication in different multiplicative ways to therefore reduce or halt it. This volume shows that the concept of potentiation can also be used to draw attention to the social practices that are part of HIV technologies. The argument of the book has been that unless the potentiations between social and biomedical technologies, and between social technologies themelves, are adequately addressed, it will not be possible to achieve planned and hoped-for effects on mortality, morbidity and HIV transmission. Potentiation permits ways of thinking about the ART era as a mix of technological effects extending from the virus itself, to new languages of possibility and risk, and new modes of governance and self-regulation. The ART era is often typified as marked by a biomedical watershed: the advent of effective HIV treatment. It has been the argument in these chapters that the advent of ART is not a singular break in the history of the pandemic. Junctures and disjunctures abound in this history, alongside reconfigurations of existing, dynamic assemblages of HIV technologies, including those that address the treatment of HIV. In this view, the idea of technological ‘watershed’ is one way of 299 reflecting on HIV technologies in time, and finding and deliberating on new and useful formations of HIV technologies. ‘Techno-watershed’ can be therefore taken to express Rabinow’s conceptualisation of biosociality intersecting with, and helping to constitute, the history of the HIV epidemic and the technologisation of its governance (Rabinow, 1999). Moreover, such engagments with technologies in time allows the conduct, in everyday lives, the practices of social welfare, large-scale policymaking and academic theory alike, of something analogous to Rabinow’s “anthropology of the contemporary”: which enables an address to the question of “how older and newer elements are given form and worked together” (2007: 2-3). This concept of biosocial potentiation also addresses some of the problems of dichotomising, ‘for’ or ‘against’ approaches to biomedical treatment and prevention technologies. For example, Abdullah and Squire have argued that the effectiveness of ART in South Africa's Western Cape is partly reliant on the social processes that previously sustained prevention, care, and some earlier treatment activities. Local, disseminated provision of ART in primary care settings depends strongly on active alliances with interested community-based organisations. This argument suggests that it is not treatment and prevention per se that potentiate each other, but rather the actions of communities of interest and the agencies that support them. An analysis of potentiation also addresses the common assertion that ART will displace or downgrade prevention activity. This notion is heterogeneous, articulated largely as a matter of shifts in risk perception and practice and governance failure in the developed 300 world, and as capacity failure in the developing world. Abdullah and Squire argue that in the case of the Western Cape, where much attention has been devoted to developing effective partnerships and a community-based ART strategy, the tension between treatment and prevention was less pronounced, despite resource constraints, because the same practitioners and lay actors were involved in both HIV prevention and ART provision. Moreover, in high-prevalence, high-incidence, low-resourced contexts, treatment and prevention present themselves as joint imperatives more forcefully and ubiquitously - though not necessarily more effectively - than in lower-prevalence, well-resourced situations. This argument implies that relations or non-relations between treatment and prevention are not ontological, but discursive, attributable to the prevailing organisational structures and epidemiological contexts of treatment and prevention technologies. Controversy surrounding the effects of ART on prevention in contexts where treatment is generally available, predominantly in the developed world, also illustrates the value of the concept of potentiation. Typically, debates have circulated around how ART might reconfigure or disrupt HIV prevention and then by reversal, how ART can be applied to meet HIV prevention goals. This simple conceptualisation of ART and prevention interdetermination misses the potentiating aspects of the relationship, and its resonances for related biomedical and social technologies. Perhaps the best-known instantiation of this limited view is the notion of disinhibition, discussed in several chapters in this volume. As is well known, at around the time of its introduction in developed country contexts, researchers began to consider if ART was leading to the reduction of the use of 301 condoms in sexual intercourse (Dilley et al, 1997; Kelly et al, 1998) and made links between such practices and HIV antibody serostatus (Remien et al 1998). As Rosengarten and Michael noted, the concept of ART’s disinhibiting effects has been used to conceptualise these developments. But as has also been shown repeatedly, it is not easy to attribute changes in sexual practice to the advent of ART (Elford, 2006). There are also instructive countervailing applications of the disinhibition thesis. Davis noted how disinhibition, or what he calls ‘treatment optimism’, is seen by some to undermine safer sex among gay men, creating questions over the ethical use of knowledge derived from the clinical management of HIV infection. Rosengarten and Michael showed how disinhibition has been used to argue against trials of pre-exposure prophylaxis. The disinhibition thesis can thus be used to justify closer attention to the ethical qualities of the sexual practices of those using ART but also as a basis for arguments concerning the possible unethical dimensions of biotechnological methods of HIV prevention and the research methods being used to develop them. These multiple uses of the conceptual framework of disinhibition and the putative effects of ART and related knowledge are significant clues to the particularities in the potentiation of ART and HIV prevention. Knowledge and ethics are at stake in the disinhibition thesis, but with multiple applications and effects in the administration of the HIV epidemic. As Rosengarten and Michael pointed out, to engage with this situation we need to accept the ‘dynamic processual nature’ of HIV technologies, their social, cultural and political dimensions, and especially their multipolar ethical formations, as the example of disinhibition suggests. 302 Also addressing the potentiation of HIV prevention and treatment technologies, Mykhalovskiy’s chapter suggested that the anxiety about the impact of ART on HIV prevention is not the only relationship that has salience in the treatment possibility era and that there is good reason to address how HIV prevention is reconfiguring the practice of HIV treatment. Mykhalovskiy considered how, in the ART possibility era, the Canadian AIDS Treatment Information Exchange, a community-based treatment advocacy agency, shifted its focus from HIV treatment advocacy, becoming a national agency addressing HIV through a discourse of treatment and prevention integration. Mykhalovskiy argued that in the integration era, the epidemiological rationality of disease control and its language of transmission vectors are sometimes used to help frame the use of ART by people with HIV. ART, ostensibly a treatment for infection, and a hard-won one at that, is now understood by some as a means of preventing HIV transmission. Mykhalovskiy argues that before the development of effective treatment, biomedical HIV technologies were neglected by policymakers and often criticised by activists focused on social technologies of prevention and care. Later, during the biomedical development of ARTs, the treatment needs of people living with HIV continued to be neglected within medical and social technologies, but were strongly articulated by activists. In the ART possibility era, the medical, social, and to some extent activist focus has turned to anxiety that people with HIV might not use biomedical technologies properly, often referred to as the problem of adherence or compliance. Through contact with epidemiological rationalities, adherence acquires the additional meaning of being a requirement - alongside minimising transmission risk in sexual and drug-using practices - for avoiding HIV transmission. 303 Similarly, Flowers argued that the biotechnological fix implied by ART has attractions because it promises control of the virus and freedom from the messiness and contingency of psychosocial aspects of living with HIV such as affect, relationships, sexual mores and cultural practice. One aspect of this biotechnical fix is biomedical ‘normalisation’, for example, the assumptions that HIV antibody testing should be routine and regular because ART has made HIV positive diagnosis into a social status that is not deeply problematic. As Flowers shows in detail, the normalisation of HIV antibody testing is predicated on biologism and a narrow conceptualisation of what it means to have HIV infection. HIV antibody testing contributes to normalisation because it provides the quantitative data for calculating prevalence and incidence, the central practice of epidemiology in general. As Flowers argues, and notwithstanding the importance of testing’s relationship to good health practices, including but not restricted to ART, the HIV antibody test remains the source of significant psychosocial status change. But it seems for many that technologies of blood testing and ART are ‘proof’ that a biological utilitarianism should underpin attempts to address HIV. Combining the arguments of Rosengarten and Michael, Mykhalovskiy with that of Flowers, we can see that in the ART possibilities era, epidemiological rationalisation of the relationships between ART and HIV prevention could be said to disembed the HIV subject in the sense that it works to sever the link between the psychosocial aspects of HIV and the experience of HIV infection and its management. Some figurations of HIV technologies insist that the HIV virus is, potentially, under biological control (Davis, 304 2007). The psychosocial thus becomes extra-HIV, relegated to an idiopathic concern. The question of HIV subjectivity appeared in other chapters that considered personal experience narratives. Davis showed that self-care among people with HIV is figured as challenging and beneficial, but most importantly as a personalised enterprise, best done when both AIDS and self-care labour are hidden. This approach to HIV care may reinforce the biological reductionism of ART-era normalisation. Such invisibilised and individualised HIV self-technologies appear also in developing world ART contexts (Steinberg, 2008) operating under the pressure of HIV's stigmatisation (Flowers, this volume and Flowers et al., 2006) as much as biomedical normalisation - a phenomenon that suggests the dual action of normalising and stigmatising discourses. However, these processes stand in contrast to the Western Cape example noted by Abdullah and Squire, where, as in other settings (for example Farmer, 2001), treatment support initiatives are recognised as community-wide, public, and constituting everyone as to some degree HIV subjects and citizens. In these contexts, no absolute divide separates subjects from citizens, or the seropositive from those of other statuses. Again, these perspectives alert us to the trans- and intra-national particularities of the ART possibility era. Citizenship HIV technologies do not just exist in multipolar and particular formations that change and develop through potentiation. They are also part of larger articulations of contested technologies of broader structures of citizenship. All social relations are traversed by citizenship which is not just a matter of legal status in a locality or nation or world, but of 305 a network of power relations that cross and depart from, reinforce and contradict each other (Mouffe, 1992). Pulled into social existence by these relations, citizens are also inherently ethical beings, provoked into subjecthood by the requirement to situate oneself morally within a range of different fields (Butler, 2005). HIV technologies of all kinds biomedical, social and cultural - are themselves morally positioned by their citizenly affiliations and are engaged in contests between the different kinds of citizenship that generate, claim and derive from them. It is notable both how plastic citizenship can be, and how thoroughly imbricated it is with HIV technologies. This embedded significance suggests that citizenship can be taken to be both a presiding principle and an effect of HIV technologies. Because it draws together notions of autonomy and constraint and ethical tensions surrounding social and sexual relations, citizenship can be taken to be the prime governmental site of HIV technologies. It can assist in making HIV technologies work effectively, as in the rollout of ART in the Western Cape, and it can be a site for the exercise of disciplinary requirements on citizens, as in the case of parent-oriented sex education, considered by Wilbraham. HIV citizenship is unavoidably subject to tension and contestation; flux and contradictions are axiomatic to critical understandings of it. Citizenship's place in HIV technologies is sometimes manifested in obvious ways -for instance, within Europe, in the conflation of legal arguments about ‘reckless’ transmission or transmission risk, with political arguments about the citizenship status of migrants, in a number of cases (Monk, 2009). As Race points out (this volume, xxx), 306 prevention technologies earlier in the pandemic focused on responsibilising every citizen, not making prevention the responsibility specifically of HIV positive or possibly HIV positive people. Within this dispensation, we were all to some degree HIV citizens. Recent feminised and racialised prosecutions indicate the degree to which developed-world prevention technologies now operate with differentiated citizens, exiled progressively from full citizenship by actual or possible HIV positivity, femininity, and migrant or illegal status. Conversely, HIV citizenship technologies still work inclusively in some high-prevalence contexts, at least within policy and activist discourse, setting up zones of equivalence (Mouffe, 1992) between people who are HIV positive and everyone else, since all are to some extent ‘living with’ the virus, though in different and particular ways. HIV citizenship technologies may also articulate HIV citizenship with other citizenships, as shown by for instance the expansion of Treatment Action Campaign initiatives, from HIV treatment activism towards addressing gender-based violence and xenophobic protests and attacks in South Africa. As in the last example, the fields of citizenship technologies surrounding HIV break up putative characterisations of such citizenship as monolithically biomedical. Race has shown that safer sex, a sociomedical technology that addresses the prevention of HIV transmission, is also a political and cultural intervention in the HIV epidemic, attributable to the actions of HIV positive and HIV affected citizens. While addressing HIV, safer sex also addresses the ethical basis for sexual relationality and claims on autonomy in the face of a life-threatening epidemic. For this reason, controversy over so-called barebacking, and related debates regarding the use of HIV antibody status to make 307 decisions about whether or not to use condoms for sexual intercourse, need to be seen as reconfigurations of the safer sex technology under pressure from HIV prevention imperatives. As Race demonstrated, barebacking can be understood as a formation of safer sex in the sense that it is a technology of citizenly ethics and care, with a level of psychosocial reflexivity that canonic forms of safer sex may not attain (Fleet, 2009). Along with such case studies of HIV technologies and their subjects, citizenship emerged in the book as an important framing concept for treatment and prevention programmes. Abdullah and Squire asserted that the specific configurations of HIV treatment citizenship in the Western Cape, connected to histories of political action and the long-lived cultural politics of ubuntu, or collective human responsibility, as well as to contemporary and local social-political associations, enabled successful ART rollout. ‘Citizenship’ is not by itself an answer, however. Wilbraham examined HIV prevention technologies in South Africa to explore how these “require and fabricate” (this volume, xxx) forms of HIV citizenship that have clear limits in relation to HIV prevention. Citizenship's variability here works against itself: in its sexualised and individualised form it contests a citizenship of parental, particularly maternal, responsibility which reveals its contingency. Mykhalovskiy's chapter recapitulated citizenly contest, between responsibilised and individualised subjects of HIV technologies. In Davis's chapter, such contests were potentiating: bioinformational citizenship and self-care appeared as technologies of hope that can be effective despite their personalised and secreted characters. This chapter suggested that HIV's bioinformational citizenship needs to be seen biosocially and more broadly, that the sexual citizenship of rational individuals must 308 be reformulated within the frame of informational biocitizenship and the ethics of uncertainty (Rabinow, 2004). Two chapters addressed HIV technologies’ relations with citizenship in informatively transnational frames. Campbell’s chapter examined technologies of ‘community participation’ and ‘empowerment’ that underpin many programmes funded by international aid agencies in southern Africa. Campbell argued that, far from encouraging forms of HIV citizenship that can moderate the effects of the HIV epidemic and promote risk reduction and social care, these programmes extend power inequalities and perpetuate ineffective interventions. She revealed how community participation and capacity building can defeat itself. What makes HIV programmes effective is known and includes such factors as: social spaces for dialogue and critical thinking; shared purpose; acknowledgement of local capacities; and ‘bridging capital’ which supports effective relationships between local individuals and communities and external and international development agencies. As Campbell shows, many programmes are disappointing because they are poorly administered, superficially thought about and unwilling to address existing hegemonic technologies of socioeconomic and cultural power. Funders and administrators often fail to interrogate themselves or acknowledge that problems in implementation may be associated with their own practices. Factors that inhibit the programmes are located in the minds or communities of those being addressed. Such approaches perpetuate simplistic, top-down programme implementation at the expense of the fully exercised community participation to which programmes are discursively committed. Campbell pointed out how community participation technologies can 309 therefore have dual effects, assisting community members to gain more control of their circumstances, but also helping those administering the programmes to assert their own control over communities. Such appropriations of participation and empowerment discourses, because they fail to interrogate the dynamics of power and inequality and the ethics of relationality involved in HIV programmes, undo democratic citizenship and promote an oligarchic version. Following a similar argument, Wilbraham addressed questions of citizenship through transcripts of group discussions about parenting and children’s sexual behaviour in relation to HIV transmission. The discussions were generated by examining an extract from Lovelines, a popular magazine column addressing parenting in the context of the HIV epidemic. Wilbraham’s analysis showed that expert knowledge shapes HIV citizenship, especially through the classing and racing of what counts as expertise regarding sexual health and parenting. Magazine experts call on parents to inoculate their children against HIV risk, so that HIV citizenship is equated with responsibility towards others. Like Campbell, Wilbraham argued that such forms of expertise can be colonising, limiting and constraining, when they could be enabling. But also, consistent with the contested nature of HIV citizenship, Wilbraham showed how such expertise can be taken up as a form of empowerment and a means of reconfiguring parenting practices for the current circumstances of the epidemic. Wilbraham argued that HIV prevention technologies cannot therefore be understood as universal or designed to perfect the transmission of expertise. What can be done is to expand the “critical space” (this volume, xxx) for dialogue regarding, for example, parenting and HIV, such that 310 circulating imperatives and normativities can be variously exploited or dispensed with through reflexive practice. Wilbraham’s ‘critical space’ is reminiscent of consciencization and resonates with Campbell, who referred to Freire-style principles of critical literacy (this volume: xxx) to ground her formulation of effective HIV work. Several other chapters touch on similar principles of carefully worked-through accountability, dialogue and negotiation. Davis for instance argued that because the implications of ART knowledge are not solely technical but also deeply ethical, sustained, critical conversations are needed to address the implications and nuances for HIV citizenship. These kinds of address to the imbrication of citizenship and HIV technologies will continue to be crucial for the development of transnational understandings of the pandemic and of HIV programmes. Pragmatism A frame of understanding with particular salience and insistence for HIV technologies is that of pragmatism. Pragmatism is commensurable with the operation and analysis of technologies, because it is concerned with what can be effected, the diverse and complicated technological assemblages that achieve such effects, and the articulations of contingent, equivalent relationships within and between them. Pragmatism is indeed required for negotiations of citizenship of the kind that appear in this book and for reaching some provisional end to the particularities explored here. In addition, pragmatism, since it is directed towards real possibilities of technologies, towards 311 potentiation and not just the virtual, also allows us to follow specific lines of technological coproduction or potentiation (West, 1989). Pragmatism is a variant of realism anchored in the field of human action. It allows us to understand the work of highly ideologically committed HIV programmes such as Partners In Health and the Treatment Action Campaign that nevertheless manage to operate within the messy nexuses of local and international politics and socioeconomic divisions. It gives us a double vision of both the fantasised control by HIV's subjectification offered by psychosocial technologies, like those Wilbraham describes as if there could indeed be a subject with complete safety, no risk, no HIV - and the possibilities for effective personal and collective action enabled at times by such technologies. It helps us get a grip on the place of HIV in ‘postcolonial’ contexts as responses to the pandemic’s reprise of colonial violence (Mbembe, 2001), and in the developed world where HIV is either secreted or expelled (Patton, 2002). At the same time it lets us use an antagonistic relation to these repetitions and exclusions to construct a provisional and revisable future (Mouffe, 2005) towards which HIV technologies can work. The final theme we would thus like to address concerns pragmatics: the importance of situated, reflexive practices for effective HIV technologies. Pragmatism expresses themes already discussed: it encompasses the potentiating effects of HIV technologies, articulated together; questions over the ontological status of watersheds and dichotomies in HIV narratives; and tensions within HIV citizenship to do with volition and 312 requirement, related concerns of ethical relationality, and diverse levels and directions of power. Several authors in this volume assert the need to acknowledge the practical, everyday efforts of affected communities and the agencies that assist them, making reference to such notions as ‘pragmatic citizenship’ (Abdullah and Squire), ‘situated dialogues’ (Campbell, Wilbraham and Davis), and ‘phronesis’ (Mykhalovskiy). These authors also identified a necessary move away from the political and the rhetorical towards what could be called a focus on ‘administrative governmentality’ in HIV analyses (Abdullah and Squire). Campbell showed how the language of ‘community participation’ can become a mandate for decidedly disempowering forms of administrative practice. Likewise, Mykhalovskiy noted how the discourse of treatment and prevention integration may not support the good health of people with HIV or of the public in general. These arguments serve to draw attention to the necessarily critical dimensions of the pragmatic uses of HIV technologies. Abdullah and Squire advocate for an acknowledgement of the technologies of partnership that have helped make the ART rollout in the Western Cape an exemplar. They reference specific practices that helped the rollout, including ART’s devolvement to primary health care environments, and the integration of locally-decided education for ART, healthy lives and safer sex. The point of their argument is not that these formulations will work everywhere. The Western Cape rollout has wider relevance since its principal feature was to acknowledge local enabling and constraining factors in everyday practices. This pragmatism is important in that it allows consistent attention to the particularities of HIV technologies, something that also enables the potentiations deriving from spatiotemporal 313 relationships between technologies. Pragmatism extends to citizenship technologies: as Abdullah and Squire describe, the Western Cape rollout relied on a presiding understanding of equivalence co-existing with antagonism. The HIV affected and non-affected can join in action on the basis of their commonalities, without erasing particularities. This form of citizenship can help mobilise individuals and communities under a guarantee of equivalence that does not depend on sameness. It is an approach consistent with the elements Campbell specifies as comprising ‘AIDS competent communities’, in particular, shared purpose, solidarity and effective partnerships between communities of interest and national and international agencies of HIV governance. Mykhalovskiy suggested something similar when arguing the salience of phronesis practical wisdom - for thinking about the integration of HIV treatment and prevention. Mykhalovskiy argued that the most tenable method of integrating treatment and prevention depends on proper community engagement and the acknowledgment of the expertise and capacities of communities that are in the best position to address client needs. At the same time, Mykhalovskiy described accommodation, the reconfiguration of responsibility and the future-oriented directions of the technologies with which he is concerned. Similarly, Flowers and Davis argued that approaches to ART and its implications for HIV prevention need to take account of the lived experience of those affected by HIV and the ethical implications that arise. Flowers's chapter worked consistently with the pragmatics of ‘experience’, with phenomena like stigmatisation that, despite apparently sufficient explanations and interventions, resist and persist. Davis's finishing emphasis on technologies of hope again returned us to pragmatism's critical, 314 tangential relation to metaphysics. By stepping outside conventional epistemological categories, pragmatism - and this chapter - takes a stepwise and revisible path, rather than a faith-infused leap, towards an ideal future in which hope is an outcome and strategy, not a teleology or method of subjectification. Conclusion The case studies presented in this book help establish means for addressing the ART possibility era in ways that resist crude determinisms and globalisations. The book’s method has been to seek out nuance and particularity where there has typically been simplification and dualism. The analyses have been diverse, including meta-analyses of prevention evaluation science, institutional ethnographies, focus groups and interviews with those affected by the epidemic, and accounts of HIV technologies informed by cultural studies and science and technology studies. Chapter writers have creatively undermined or reversed orthodox accounts of the epidemic after ART and related technological turnings in its governance, to establish new modes of analysis. They have explored alterities and counterdiscourses, hitherto submerged or ignored, to elaborate on the conditions of possibility for HIV subjects. The writers have brought the psychosocial features of HIV back into relationship with an ascendant bio-technological rationalisation of pandemic governance, to reveal the problematic aspects of some HIV technologies. Writers have offered new insights concerning the persisting difficulties of the post-ART era, such as the putative effects of ART on HIV prevention and vice versa. One of the richest dimensions of this volume is how each chapter has variously revealed ethical, political and cultural in connection with technical and administrative technologies of the 315 treatment possibility era. The writers have not ignored how ART and other HIV technologies can and do have life changing effects for individuals, those who care for them, communities and nations. Nor have they underestimated the value of HIV prevention for people with HIV and those affected by the epidemic, including the capacities that ART and other biomedical interventions may have in this respect. 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