Abstract
PrEP (Pre-Exposure Prophylaxis) is a relatively new drug-based HIV prevention technique and an important means to lower the HIV risk of gay men who are especially vulnerable to HIV. From the perspective of biopolitics, PrEP inscribes itself in a larger trend of medicalization and the rise of pharmapower. This article reconstructs and evaluates contemporary literature on biopolitical theory as it applies to PrEP, by bringing it in a dialogue with a mapping of the political debate on PrEP. As PrEP changes sexual norms and subjectification, for example condom use and its meaning for gay subjectivity, it is highly contested. The article shows that the debate on PrEP can be best described with the concepts ‘sexual-somatic ethics’ and ‘democratic biopolitics’, which I develop based on the biopolitical approach of Nikolas Rose and Paul Rabinow. In contrast, interpretations of PrEP which are following governmentality studies or Italian Theory amount to either farfetched or trivial positions on PrEP, when seen in light of the political debate. Furthermore, the article is a contribution to the scholarship on gay subjectivity, highlighting how homophobia and homonormativity haunt gay sex even in liberal environments, and how PrEP can serve as an entry point for the destigmatization of gay sexuality and transformation of gay subjectivity. ‘Biopolitical democratization’ entails making explicit how medical technology and health care relates to sexual subjectification and ethics, to strengthen the voice of (potential) PrEP users in health politics, and to renegotiate the profit and power of Big Pharma.
I thank Jon Catlin, V. Hunter Capps, Kathrin Braun, Helene Gerhards, David Halperin, Eloise Harris, Emmanuel Danan, and Daniel Putnam for criticism, comments, and remarks which helped enormously to develop the argumentation of this chapter.
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Notes
- 1.
Italian Theory is a label for contemporary Italian approaches of political theory, represented by Giorgio Agamben, Antonio Negri, Paolo Virno, and Roberto Esposito, among others, cf. Pasquinelli (2011).
- 2.
Race, especially in the U.S., is a crucial factor in the HIV epidemic. African Americans have higher HIV rates than other racial minorities and Whites, with Black men who have sex with men (MSM) being the most vulnerable group: “Gay and bisexual men continue to be most affected by the HIV epidemic in the U.S. At current rates, 1 in 6 MSM will be diagnosed with HIV in their lifetime, including 1 in 2 black MSM, 1 in 4 Latino MSM, and 1 in 11 white MSM. African Americans are by far the most affected racial or ethnic group with a lifetime HIV risk of 1 in 20 for men (compared to 1 in 132 for whites) and 1 in 48 for women (compared to 1 in 880 for whites)” (CDC 2016). Many Black American MSM do not identify as gay or bisexual, as U.S. gay mainstream culture is predominantly White. The complex reasons for the extreme epidemic of Black gays or non-gay-identifying MSM and the difficult attempts to bring PrEP to their communities is beyond the scope of this article (Villarosa 2017). With its focus on the mainstream gay debate in the global north, this chapter is effectively dominated by White perspectives.
- 3.
The protection efficacy refers to the difference of the risk of HIV transmission per sex act between using no protection and the respective protection technology (PrEP, condom, serosorting, etc.).
- 4.
Serosorting refers to choosing sexual partners according to their serostatus, for example if an HIV-positive person has sex with an HIV-positive partner.
- 5.
In the United States, the patent on Truvada is still protected and affordable generics are not available yet, cf. Landman (2017).
- 6.
Foucault does not differentiate systematically between biopolitics and biopower.
- 7.
- 8.
The labeling is used here to broadly map the field. The specific positions on HIV and PrEP which I label with the sub-strands or schools do not fully capture the positions of these schools. While the arguments regarding PrEP which I reconstruct are typical for the three respective schools, different arguments could be constructed through their complex frameworks.
- 9.
See Schubert (2018, S. 104–111) for a critique of the anti-normativism in contemporary governmentality studies.
- 10.
- 11.
See Patton and Kim (2012) for a critique of PrEP trials which argues that they are following a pharmaceutical paradigm which cannot account for cultural prevention techniques.
- 12.
See Halperin (1990) for the creation of ‘homosexuality’ through medical discourse.
- 13.
See also van Doorn (2013), who builds his critique of PrEP on Agamben, Negri, and Esposito. While his point that community structures should be included in public health prevention strategies is plausible, van Doorn fails to explain why PrEP is a problem and how this is connected to biopolitics.
- 14.
- 15.
The big initial PrEP studies were financed by public health institutions and not by pharma companies, see fn. 25.
- 16.
The concept of homonormativity describes and criticizes the conservative normativity of mainstream gay politics which is focusing on monogamous couplehood, marriage and domestic consumerism. Homonormativity, in difference to queer critique, does not contest, but stabilize heteronormativity, i.e. the belief that heterosexuality is a natural norm and the support of institutions of heterosexuality, sexism, and patriarchy, such as marriage. Homonormativity also constitutes a difference between ‘good’ and ‘bad’ gays and thereby leads to new forms of (internalized) homophobia, see Duggan (2002) and Murphy et al. (2008).
- 17.
The distinction between the gay and non-gay medical perspectives collapses to some degree, as many HIV medical experts are gay and HIV research developed partially out of the gay community’s HIV activism.
- 18.
- 19.
In Germany, for example, there is a correlation between the growing political power of the homophobic right-wing populist party AfD the rise of homophobic attitudes (LSVD n. d.; Decker and Kiess 2016, p. 51), and the rise of homophobic hate crimes (Beiker 2017), which many actors interpret as a causation (LSVD 2017). A social and political movement against gender equality, sexual emancipation and self-determination with many personal and thematic overlaps with right-wing movements and parties became more outspoken and powerful in Europe over the last years, cf. Hark and Villa (2015); Kuhar and Paternotte (2017). Some Westeuropean right-wing parties define tolerance for different lifestyles as ‘European’, to reject Muslims, Islam, and people of color as homophobic and uncivilized. It is important to note that this seemingly gay-friendly rhetoric is used only instrumentally for promoting anti-muslim racism (Siegel 2017). Queer organizations fight against this instrumentalization of their cause for racist projects and point out that homo- and transphobia is a general problem in society. It is not specific to Muslims, but rather promoted by (right-wing) anti-egalitarian ideologies. See for example GLADT (2009).
- 20.
Race (2016) describes the anti-PrEP attitudes in the community as a fear of sex.
- 21.
Exemplary for this liberating function of PrEP for gays in relation to guilt and condoms is a public post on Facebook (in German), which was widely shared, cf. Hartmann (2017).
- 22.
Regarding the negotiation of responsibility see Young et al. (2016).
- 23.
Emmanuel Danan (personal communication, 19. July 2018).
- 24.
Nevertheless, there are significant problems with some PrEP studies, which stem from global capitalism and pharma profit interests. Especially the Partners-Trial Baeten et al. (2012) is problematic because of offshoring, conducting risky trials in poor countries of the global south (here in Uganda and Kenya) to develop drugs to treat patients in the global north. Another problem with the Partners-Trial was that it transferred drugs from HIV positive patients who needed them the most to HIV negative persons for the use as PrEP, cf. Patton and Kim (2012). First PrEP studies in Cameroon and Cambodia in the early 2000 s were stopped due to violations of ethical standards which put participants at risk of infection, after Act Up Paris protested against the trials, see Singh and Mills (2005).
- 25.
The iPrEx-Study was mostly financed by the U.S. National Institutes of Health (NIH) (Grant et al. 2010), the Ipergay-Study mostly by the French Agency for Research on AIDS and Viral Hepatitis (ARNS) (Molina et al. 2015), and the PROUD-Study was mostly financed by the British Medical Research Coucil Clinical Trials Unit at University College London and Public Health England (McCormack et al. 2016). The presently running Discover-Study is comparing Truvada and Descovy and is fully sponsored by Gilead (AVAC 2018). Descovy is a slightly modified version of Truvada, which is supposed to have less side-effects. Gilead needs to prove the advantages of Descovy over Truvada in order to keep profits high after the patent of Truvada recently run out, which opened the market for cheaper generics of Truvada.
- 26.
Emmanuel Danan (personal communication, 19. July 2018).
- 27.
I extracted the texts of the chats exactly as they appear on the screenshots.
- 28.
See fn. 20.
- 29.
Two examples of this widespread homophobic discourse are the comment of a local German newspaper regarding the announcement to cover PrEP by German public insurances and the user comments of an earlier article on PrEP on the mainstream German news website Spiegel Online, cf. irb/dpa (2017); Queer.de (2018).
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Schubert, K. (2019). The Democratic Biopolitics of PrEP. In: Gerhards, H., Braun, K. (eds) Biopolitiken – Regierungen des Lebens heute. Politologische Aufklärung – konstruktivistische Perspektiven. Springer VS, Wiesbaden. https://doi.org/10.1007/978-3-658-25769-9_5
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