Ambivalence and the biopolitics of HIV pre-exposure prophylaxis (PrEP) implementation

Abstract

Ambivalence, the vacillation between conflicting feelings and thoughts, is a key characteristic of scientific knowledge production and emergent biomedical technology. Drawing from sociological theory on ambivalence, we have examined three areas of debate surrounding the early implementation of HIV pre-exposure prophylaxis, or PrEP, for gay, bisexual, queer, and other men who have sex with men in Canada, including epistemology and praxis, clinical and epidemiological implications, and sexual politics. These debates are not focused on the science or efficacy of PrEP to prevent HIV, but rather represent contradictory feelings and opinions about the biopolitics of PrEP and health inequities. Emphasizing how scientists and health practitioners may feel conflicted about the biopolitics of novel biomedical technologies opens up opportunities to consider how a scientific field is or is not adequately advancing issues of equity. Scientists ignoring their ambivalence over the state of their research field may be deemed necessary to achieve a specific implementation goal, but this emotion management work can lead to alienation. We argue that recognizing the emotional dimensions of doing HIV research is not a distraction from “real” science, but can instead be a reflexive site to develop pertinent lines of inquiry better suited at addressing health inequities.

Public health morality, sex, and COVID-19: sexual minority men’s HIV pre-exposure prophylaxis (PrEP) decision-making during Ontario’s first COVID-19 lockdown

“…The link between PrEP access with having health insurance benefits connected to one's employment creates clear problems when GBM lose their jobs or are self-employed. These barriers can be corrected through a national pharmacare plan and attention to the fundamental factors causing income inequities and employment insecurity among GBM (Gaspar et al, 2021).…”

“…Adam (2011) has argued that public health research has often problematized GBM's sexual decision-making and has regularly failed to account for the ways in which GBM created safer sex procedures, were sometimes put at risk by contradictions in public health messaging, and how GBM's decisions to forego condoms were grounded in intimacy, pragmatic risk calculations, as well as social vulnerabilities. The emphasis on individual level behavioural interventions has often failed to account for the structural changes necessary to address HIV and, as such, has left some groups of GBM like Black, Indigenous and working class GBM, more vulnerable to health inequities (Gaspar et al, 2021;Lee-Foon et al, 2020). As such, Adam explicates how public health has often generated findings that are 'resolutely asocial, ahistorical and out of tune with basic human psychology.…”

Prescribing as affective clinical practice: Transformations in sexual health consultations through HIV pre‐exposure prophylaxis

“…Earlier in the roll out of PrEP, Auerbach and Hoppe (2015) argued that PrEP was framed as 'hold[ing] the promise to ending the HIV pandemic', but also as 'an insidious strategy that will exacerbate HIV epidemics and attendant social ills' (p. 2). Reflecting on the role of social scientists in the Canadian HIV response, Gaspar et al (2021) expressed ambivalence towards PrEP and the 'biomedical triumphalism' that accompanied it, which appeared to have resurfaced longstanding tensions in the politics of HIV research. Early PrEP implementation studies sparked concerns and debate about its consequences for sexual cultures, prioritisation of resources in the HIV response, and impacts on other aspects of sexual health, including the prevention of STIs (Auerbach & Hoppe, 2015;Holt et al, 2019).…”

Searching for diagnostic certainty, governing risk: Patients' ambivalent experiences of medical testing

“…In exploring the complexities of these experiences, our study contributes to a growing literature in health sociology on ambivalence surrounding health technologies and diagnostic processes (e.g. Gaspar et al, 2021 ; Nettleton, 2006 ; Zarhin, 2015 ). Specifically, it advances our understanding of the emotional dissonance, or feeling of unease, that patients experience in relation to medical technologies in which their hopes are invested but which often fall short of their promise.…”