introduction

It goes without saying that the body, whether masculine or feminine, is imbricated in the matrices of power at all levels, and not just, or even primarily, on the level of theory; but the feminine body, as the prime site of sexual and / or racial difference in a white, masculine, western political and sexual economy, is peculiarly the battlefield on which quite other struggles than women’s own have been waged. (Jacobus et al., 1990, p. 2)

Technology, scientific development and bodily enhancement are central in the ‘materialist turn’ currently unfolding in contemporary feminist theory. This turn is characterised by a fascination with and inhabitation of the natural sciences, with captivating results and inspiring novel theoretical avenues. However, the inhabitation of the sciences, and an enthusiasm for utilising scientific data for the destabilisation of nature/culture, politics/science, matter/discourse dichotomies, has pulled feminist theory away from engaging the sciences as a field of operations for women’s oppression. Here we are specifically thinking of the oppressive structures of health care as they impact on women’s bodies in varying ways. The role of health care in feminist work used to be highly prevalent, as a political objective for women to claim ownership of their bodies (for instance, the self-help movement of the feminist resurgence of the 1960s/1970s and the highly influential project Our Bodies Ourselves by The Boston Women’s Health Book Collective, 1984). It was also investigated as a site of practices violently oppressive to women under the guise of care or treatment (for instance, The Yellow Wallpaper, Gilman, 1981 [1892], and the work of Oakley, such as Women Confined: Towards a Sociology of Childbirth, 1980). In this light, the manner in which the concept of ‘debility’ is entering contemporary feminist theory is pertinent, as it (re)introduces the question of health care within feminist parameters.

In this article we use the concept of debility to explore how geopolitical lines of power as they pertain to the global health issue of the Human Immunodeficiency Virus (HIV) are carved across women’s bodies through health-care practices. Specifically, we will explore the way in which viral load assays are used to assess the viruses of HIV-positive pregnant women who are cared for in an HIV-specialist antenatal clinic in an acute National Health Service (NHS) Hospital in London. In the clinic, the viral load assay reads HIV inside a pregnant woman’s body by measuring the amount of virus (HIV Ribonucleic acid [RNA] particles) in the patient’s blood. This reading of virus is a complex affair. For instance, an HIV-positive pregnant woman’s conviction that she is not HIV positive may be strengthened if the viral load assay used to assess her blood sample fails to detect active virus in her blood, making it seem, to the patient, that she is in fact HIV negative. In these situations medical practitioners would be tasked with the complicated responsibility of explaining to a patient why it looked as if she were HIV positive on some machines but not on others. Anne—an HIV consultant physician at the hospital—explains:

You’ve got a woman that has come in, you want [her] to start treatment, she wants to pray, she doesn’t believe you she’s got [HIV] and the lab tells you her viral load is undetectable. You can spend a long time explaining what undetectable means, and then it’s wrong, and it’s not only wrong, it’s wrong by a couple of thousand times wrong, and you go back to the woman, who has been to church, who has done a bit of praying and say: actually the lab tests are wrong, and you’ve already got all those things we’ve talked about … You are working with somebody who is in such a different place, that the meaning of the technology to that person is so important to get right. (Interview with Anne, 11 March 2009)

The specificities of caring for HIV-positive pregnant women and preventing vertical transmission of HIV (when HIV is transmitted from mother to foetus/baby in utero/at delivery/through breastfeeding) require that HIV-positive pregnant women quickly accept care and biomedical interventions. In this article we will argue that the viral load assay reads HIV, but it does more than that. The viral load assay inscribes differences into bodies, which reveal struggles that reach beyond a reading of virus. Significantly, we claim that direct access to the virus is never possible. Because technology is always already part of the object under investigation, the real of the virus is always already caught up with systems of meaning in the (onto-epistemological) process through which HIV becomes known to us. Our position brings to mind Rosengarten’s statement that:

the virus, as it appears, is an approximation achieved through highly sophisticated but nevertheless selective and reiterative practices. There is no stable object that we refer to as ‘HIV’ or ‘the virus’. (Rosengarten, 2009, p. 28).

To engage the bodies and struggles that emerge with HIV, we will provide a materialist analysis of what is at stake in the reading of virus in the antenatal clinic. A key figure within contemporary feminist materialism is Karen Barad (see, for instance, Kirby, 2011; Hinton and van der Tuin, 2014). Barad’s agential realism is a performative account of scientific production that engages bodies as material—discursive phenomena, emerging from specific scientific practices, in specific environments and always in relation to technologies, objects and systems of meaning-making. Barad positions herself at an interesting juncture, by elaborating both Judith Butler’s notion of performativity (Butler, 1994) into intra-action and Haraway’s cyborgs (1991) into phenomena (Barad, 2007). By building on the work of both Butler and Haraway, Barad’s agential realism engages technologies and bodies prevalent in scientific development as ontological effects of scientific practice, while keeping hold of the promising potential of cyborgian human/non-human relations. We suggest that Karen Barad’s agential realism is a valuable framework of thought through which to analyse how HIV is read in the antenatal clinic and by extension how mother and child are understood as objects of intervention.

In particular, we will illustrate how the prevention of vertical transmission of HIV consists of a complex set of relations in which bodies, technologies, place and virus are entangled in a convoluted and mutually constitutive manner. We are especially interested in thinking of the HIV-positive body as a debilitated body. In light of the prevention of vertical transmission, this debilitated body is also a relatively privileged body made available to technological enhancement, as antiretroviral drugs (ARVs) in combination with appropriate medical care may enable babies born to HIV-positive women to be HIV negative—in other words, to become non-debilitated.

the HIV-specialist antenatal clinic

The data this article is premised on was collected during a nine-month-long qualitative investigation into an HIV-specialist antenatal clinic housed in an acute NHS Hospital in an inner city area of London. The clinic is a once-weekly open clinic for HIV-positive pregnant women in the local community. Approximately forty to fifty HIV-positive pregnant women receive care in the clinic every year. The vast majority of the clinic’s patients are originally from countries in Sub-Saharan Africa. The clinic’s patient cohort reflects the wider UK HIV epidemic (Zheng et al., 2014).

McKnight attended twenty-nine specialist antenatal clinic sessions, which were all of the sessions held during the research period. She observed consultations held by all three of the health practitioners at the clinic during her time there. McKnight regularly attended the consultations of twenty-one different patients. In all, thirty women attended appointments at the clinic during the research observation. Out of these thirty patients, four were black/mixed-race and born in the United Kingdom, while the rest of the patients were black African and from countries in Sub-Saharan Africa. During the course of the project McKnight interviewed nine patients, and held second interviews with three of them; one woman was interviewed on three occasions. Five health-care practitioners were interviewed: an HIV-specialist midwife; a specialist registrar; a consultant physician; an HIV-specialist paediatric nurse; and an HIV-specialist community nurse. Second interviews were held with the HIV-specialist midwife and the specialist registrar. Ethics approval to conduct this study was granted by the National Health Services Research Ethics Committee, the Research and Development office at the hospital and the Research Ethics Committee at Goldsmiths, University of London.

A number of different data-gathering techniques were used to observe practice and care in the clinic: participant observations; in-depth unstructured qualitative interviews; and informal conversations. The data was collected in numerous forms and locations: consultations between patients and practitioners; informal chats; clinical meetings; and interviews with patients and practitioners.

During the research, specific attention was paid to the way in which HIV (positivity), pregnancy and maternity were spoken (or not spoken) about, understood, approached and discussed by practitioners and patients, as well as the expectations they placed on themselves and each other, and how these expectations were expressed, fulfilled or left unsatisfied. The way in which relationships between patients and practitioners developed and were maintained, negotiated and severed was also of interest to McKnight.

vertical transmission of HIV

There is a stark global divide between geographical locations where people have access to technologies and care that have managed to turn HIV into a chronic condition, and areas where HIV is a precursor to death (Farmer, 2004). Towards the end of the twentieth century the use of a combination of ARVs drastically altered the course of the HIV pandemic. ARVs essentially changed the prognosis of an HIV-positive person from certain death to a life with a chronic illness, and as such facilitated the disassociation between HIV and Acquired Immunodeficiency Syndrome (AIDS) (Kippax and Race, 2003, p. 6; May et al., 2011, p. S2).

According to the Centers for Disease Control and Prevention, if a pregnant woman’s HIV is diagnosed during or before her becoming pregnant and appropriate care and interventions are available and breastfeeding is avoided, the transmission rate could be reduced to less than 1 per cent (CDC, 2012). Subsequently, the prevention of vertical transmission of HIV-1 (for the remainder of the article HIV-1 will be referred to as HIV) is generally considered to be one of the most successful achievements in the management of people living with HIV. However, these developments obscure the fact that access to ARVs and appropriate medical care is not a reality for the vast majority of people living with HIV.

While UNAIDS estimates that in 2012 there were approximately 35.3 million people living with HIV (WHO, 2013, p. 4), roughly 25 million of those live in Sub-Saharan Africa (ibid., p. 3). Only 9.7 million people living with HIV had access to antiretroviral therapy (ART) in low- and middle-income countries (ibid., p. 1). It is important to stress that people living with HIV without access to ARVs will almost inevitably die as a direct result of their exclusion. That is, a tremendous number of people will succumb to what is in some global locations a manageable, chronic illness.

While the global disparities in relation to access to ARVs are shocking, they belie another important point that this article will draw out. Namely, the geographical division between people with access to advanced, life-enhancing biomedical technologies and those that do not have access can be maintained, even when the geographical discrepancies are dissipated. In other words, when people who would normally not have access to advanced biomedical technologies (because of their geographical and/or political location or trajectory) relocate themselves into the position of people with unrestrained access, technologies used in the management of HIV might still impede them from fully benefiting.

We argue that technologies used in the clinic to determine a patient’s virus reflect and reaffirm, on the level of the body, global issues related to unequal access to advanced biomedical technologies. These matters become apparent in the clinic because some of the older commercial assays still in use within the NHS might deceptively indicate that an individual with ‘divergent subtypes’ has a low or undetectable viral load (de Ruiter et al., 2008 p. 465). As a problematic consequence, the practitioners’ efforts to prevent vertical transmission of HIV depend on assessments produced by viral load assays, which are known to have the ability to underestimate the severity of their patient cohorts’ infections.

Therefore, we argue that in order for appropriate care to be provided to the clinic’s patients, the practitioners in the clinic need the patient’s body to be recognised as a debilitated body by the assays that they use to inform their efforts to prevent vertical transmission of HIV. If the patient’s body is not recognised as debilitated by the viral load assay, the mother’s debility is more likely to be passed on to her offspring. A debilitated body, we argue, is thus a body that has been identified as being HIV positive and is considered, as a result of a viral load reading, to have an HIV infection that is severe enough to require immediate ART (a combination of different ARVs). It is important to stress again that we are not making an argument for a more accurate reading of virus, but rather seek to flesh out the consequences of the specific manner in which HIV emerges in relation to body and technology—here specifically in terms of debility.

As such, we suggest that the complex status of the HIV-positive body undergoing ARV treatment, specifically with the aim to produce an HIV-negative baby, invites an elaboration on the dominant definitions of debility circulating at present. Livingston (2005, p. 2) in Debility and the Moral Imagination in Botswana defines debility as ‘the impairment, lack, or loss of certain bodily abilities’. Indeed, while ARVs have transformed HIV into a chronic illness and as such have an enabling effect, it is important to stress that living a life that is dependent on ART can be intensely incapacitating due to the drugs’ unwanted effects (Doyal and Anderson, 2005, p. 1733). The body on ART is also a debilitated body.

Moreover, Livingston (2005, p. 2) uses debility as a point of entry into the body as a site of ethnographic insight as she reads ‘a history of the present’ of colonialism, power and modernity on the debilitated body. For us, the viral load assay carries a certain historicity of the HIV epidemic and inscribes this historicity into the bodies that emerge in relation to this technology. Therefore, where Livingston (ibid.) predominantly approaches debility as a site that ‘gives us insight into a people’s historical experience and changing assumptions about personhood and self’, we wish to expand this definition to a more materialist conception of the body and technology.

In this sense, our aim is close to Puar’s (2009, p. 167) call for the problematisation of ‘the predominance of subject formation itself, thinking instead of disability and debility in terms of assemblages’. Although our language of agential realism in this article speaks of phenomena and does not utilise a vocabulary of assemblage, it shares Puar’s relational understanding of debility. In her article ‘Prognosis time’, Puar (ibid., p.169) argues that ‘there is no absolute self or other, rather bodies that come together and dissipate through intensifications and vulnerabilities, insistently rendering bare the instability of the divisions between capacity-endowed and debility-laden bodies’. In a similar vein we will bring to light, and argue for, the intimate relations and fluidity between the debility and capacity of bodies as they are enacted in the present, and are imagined in the future, through the various mother/foetus/HIV phenomena that emerge with the viral load assay in the space of the antenatal clinic.

However, in the same article Puar (ibid., p. 162) articulates debility in ways reminiscent of Livingston’s definition, as the opposite of bodily capacity. The bodies in our argument are debilitated bodies beyond doubt; however, our study also expands this conceptualisation. Debility is predominantly understood as a dystopic concept. Although we do not claim that the body on ART is by any means a utopic body, in our argument debility signals a bodily state of passage through which futures emerge—futures that would be unintelligible and unable to materialise without the recognition of debility.

managing HIV during pregnancy

The way in which a patient’s HIV is managed during pregnancy varies depending on a number of factors. The practitioners will decide upon an appropriate treatment, care and drug regime based on the patient’s particular medical history, as well as on her lifestyle and her wishes. In line with national treatment guidelines, the specialist practitioners would like all of their pregnant patients to be taking ARVs by the twenty-fourth week of pregnancy if they have not already begun to do so. The latter can happen in the case of women who knew their status before conception, and women who commenced treatment earlier in pregnancy, for their own health (de Ruiter et al., 2014, p. 21).

The patient’s viral load (amount of virus in a blood sample)Footnote 1 and CD4 count (which indicates how well the immune system is working)Footnote 2 are the primary ways in which HIV infection is monitored throughout a pregnancy to ensure the efficacy of a woman’s treatment regime. The possibility of a (unborn) baby becoming infected with HIV through vertical transmission is related to a pregnant woman’s viral load; the higher it is, the greater the risk. A successful regime would ensure that her viral load was undetectable by the time she is ready to give birth. Crucially, an undetectable viral load is not the same as being HIV negative; rather this means that the activity of the virus, measured as the number of copies of virus per millilitre of plasma, is below the ‘lower limit of detection’ on the particular test assay being used. Moreover, the different assays have different lower limits and are more able to detect certain strains of HIV. Hence, a sample may be undetectable on one assay but not on another (de Ruiter et al., 2008, p. 465).Footnote 3

An undetectable viral load is an essential step in preventing the mother’s debility from being transmitted to her (unborn) baby. From then on the patient will receive all her antenatal care, through to her six-week postnatal check, at the clinic. The frequency of the patient’s appointments in the clinic depends on the length of her pregnancy and her mental/physical health. The practitioners will offer further support, according to the women’s individual needs, throughout the entire pregnancy, birth experience and postnatally.

The neonatal management of infants born to HIV-positive women varies depending on the status of the mother, for instance when the mother started taking ART, and her viral load (de Ruiter et al., 2014, pp. 45–52). Infants born to HIV-positive mothers are tested with HIV Deoxyribonucleic acid, the polymerase chain reaction (PCR) or HIV RNA tests at the following times: at some point during their first 48 hours, before being discharged from hospital, at 6 weeks of age and at 12 weeks. Additional testing is advised for infants who are at increased risk of transmission, for example if the mother has been known to breastfeed (de Ruiter et al., 2014, p. 51).

If the infant is not, and has never been, breastfed, and all of the tests have been negative at 12 weeks, BHIVA advises that the parents are told that the baby is HIV negative. At 18 months the toddler will be tested for the last time to ensure that she/he has not seroconverted, meaning that the child has not become HIV positive. The success or failure of the practitioner’s attempts to prevent vertical transmission of HIV is finalised at this point (de Ruiter et al., 2014). This means that the child’s status as either debilitated or not is determined at this stage. The non-debilitated offspring of HIV-positive women have thus never been identified as being HIV positive and are by extension not in need of ART.

assessing HIV

To assess the amount of virus in a patient’s blood there are several different commercial assays that are available within the NHS in the United Kingdom. The ‘platforms’ most commonly used to assess the London clinic’s samples are referred to as the ROCHE and ABBOTT assays. Several of the HIV-specialist practitioners explained to McKnight that they suspected the results that they received from certain viral load assays had provided them with inaccurate information. They clarified that the ROCHE platform, which was most commonly used to monitor the London clinic’s patients’ viruses, occasionally under-quantifies the viral loads of their patients, making them seem healthier than they actually are. The significance of this for the practitioners is that some of the older commercial assays still in use might (as they understand it) falsely indicate that an individual with divergent subtypes has a low or undetectable viral load (de Ruiter et al., 2008, p. 465; Sloma et al., 2009). ABBOTT is therefore the practitioners’ preferred platform, as they believe it is more sensitive to their patients’ viruses. However, due to various bureaucratic inter-NHS Trust arrangements, the practitioners in the clinic were restricted in their ability to dictate which assay was used.

The different platforms are sensitive to various strains of HIV. There are two types of HIV: HIV-1 and HIV-2. Both types have the same mode of transmission, although HIV-2 tends to be harder to transmit than HIV-1 and it is also thought to be relatively uncommon, especially outside West Africa (Heimer, 2007, p. 552). Moreover, there are several different strains of HIV-1. The most common of these strains is called group ‘M’ and approximately 90 per cent of HIV-1 infections are thought to belong to this group. Within this group there are at least nine genetically distinct subtypes, referred to as A, B, C, D, F, G, H, J and K. Furthermore, it is possible, although rare, for two different sub-strains of the virus to meet in the cell of an infected person and mix their genetic material, consequently producing a new hybrid virus. The hybrid strains that ‘survive’ and infect more than one person are referred to as ‘circulating recombinant forms’ (CRFs). The various subtypes of HIV-1 have been allocated specific geographical locations where they are understood to be most prevalent.Footnote 4 The excerpt below describes the global spread of these subtypes.

The HIV-1 subtypes and CRFs [circulating recombinant forms] are typically associated with certain geographical regions … As studies have shown, individuals are increasingly presenting with sub-types not native to the country of diagnosis …

  • Subtype A and CRF A/G predominate in West and Central Africa, with subtype A possibly also causing much of the Russian epidemic.

  • Historically, subtype B has been the most common subtype/CRF in Europe, the Americas, Japan and Australia and is the predominant sub-type found among MSM [men who have sex with men] infected in Europe. Although this remains the case, other subtypes are becoming more frequent and now account for at least 25 per cent of new HIV infections in Europe.

  • Subtype C is predominant in Southern and East Africa, India and Nepal. It has caused the world's worst HIV epidemics and is responsible for around half of all infections.

  • Subtype D is generally limited to East and Central Africa. CRF A/E is prevalent in South-East Asia, but originated in Central Africa. Subtype F has been found in Central Africa, South America and Eastern Europe. Subtype G and CRF A/G have been observed in West and East Africa and Central Europe.

  • Subtype H has only been found in Central Africa; J only in Central America; and K only in the Democratic Republic of Congo and Cameroon.Footnote 5

Accordingly, various subtypes are understood as being native or foreign, local or global. At the time of the study the assays most commonly used to monitor the patients’ viruses in the study clinic were best suited to assessing samples with subtypes that were considered to be local, according to the practitioners. This worried the practitioners because they suspected that many of their patients might have foreign subtypes.

An HIV-positive pregnant patient’s original geographical location, or rather the location where she acquired her HIV infection (assuming that she is infected with the subtype thought to be prevalent there), could in this instance delineate her inclusion in and the extent of her participation in various processes of care. In other words, fully partaking in and benefiting from the various technologies and interventions available in any geographical location requires more than simply being in that location. Following this, HIV-positive pregnant women who are being cared for in geographical locations where HIV and death have been decoupled may not experience the same transformative possibilities promised by the availability of advanced HIV detection/assessment technologies within that location.

The implication of this is that global inequalities having to do with unequal access to life-sustaining biomedical technologies may be maintained even when the technologies are accessible. Hence, even when some groups of patients are offered access to particular kinds of biomedicine and technologies, their ability to be enhanced by these inventions may be curtailed by the way in which the technologies have been built not to detect certain kinds of differences that the HIV-specialist clinic needs them to—here specifically different subtypes of HIV. Consequently, the technologies in question make and maintain other kinds of differences—of access to treatment, of locations, of futures.

An additional complication in this scenario is the way in which patients respond to their viral load results. The time Christa (a patient) spent in the clinic illustrates this problematic. Christa was originally from the Congo and was in the second trimester of her fifth pregnancy. She had recently been informed that she was HIV positive. Observing her behaviour in the clinic, the practitioners told McKnight that they were not convinced that Christa believed their diagnosis. Christa had informed one of the practitioners that she was under a spiritual curse. In order to overcome it, she would have to ‘trust in God’ and avoid any mention of HIV. Christa had explained to the practitioners that speaking of HIV in her presence invoked the Devil and affirmed the curse. Consequently, Christa often refused to be introduced to new members of the clinical team. Moreover, she would not attend any appointments if they were held at the Department of Sexual Health because she believed that an evil spirit lived there. Her ‘non-compliance’ severely complicated the care that the practitioners wanted to provide. Furthermore, they were concerned that she would eventually abscond entirely from their supervision. In order to prevent this from happening, the practitioners decided to reorganise their clinical practice in order to accommodate her.

During a meeting, Sophia, an HIV-specialist doctor, said that the incorrect viral load results were particularly problematic when dealing with a patient like Christa, who was, according to Sophia, under the impression that she had been healed from HIV based on her viral load results from the ROCHE assay. Sophia said that it was very difficult to explain to a patient why it looked as if they were HIV positive on some machines while not on others (Field Notes, 4 February 2009, pp. 3–4).

On a practical level the specificities of HIV and pregnancy (as they are perceived by the practitioners) require that the practitioners consider the feelings they think their patients and the patients’ (potential) offspring may have in the future, when making decisions about care in the present. This is particularly significant because it alludes to some of the complexities that may occur in the specialist clinic if a pregnant patient resists or refuses the practitioners’ care plan. Thus, practitioners in an HIV-specialist antenatal clinic would base their care decisions on the patient as she is now and on how they hope she and her baby will become in the future. In a more abstract sense, they are consulting with a real present time patient, with her future self and with her future baby, as the practitioner imagines them to have the potential to become if care is successful.

Although they’re foetuses and they’re growing it’s a baby to be, and … there’s two lives that we’re thinking about here, all the time, which is why, when a woman is perhaps in denial, or refusing treatment for whatever reason, I can’t let that go because we have another life on board that we know we can 99 per cent prevent transmission to that baby, and that child is going to live with the consequences of this decision at this point, you can’t let that go, you have to keep working at it. You try other means you can try and reach some sort of compromise about that baby. Obviously our emphasis is [the pregnant patient] and that’s how it’s seen in maternity, that the baby has no rights until the baby is born, but that’s kind of difficult as well, isn’t it? Because obviously baby does have rights. I’m still feeling about baby in utero that it’s growing and expanding and people who have early miscarriages often view those babies as a baby in its own right and it was not nothing, you know, it was very important, significant. (Second interview with Ellen, the HIV-specialist midwife, 18 March 2009)

Christa’s case makes clear that although the process of assessing a patient’s viral load might initially appear to be simply about acquiring and coordinating information, it is also about different understandings of HIV—which are built into the technologies available to the clinic. Despite having more or less uncontested access to the most advanced biomedical technologies/interventions/medicines and information available, the practitioners constantly labour with the knowledge that these technologies may in fact obscure what they are ostensibly meant to divulge, manage and/or access. Practitioners must grapple with this knowledge while negotiating the different understandings patients have of their bodies and the status of their HIV infection. These different versions of virus do not only render HIV an instable entity, the intimate relationality of these understandings directly impacts on the course of care and thereby on the possibility for a baby to become HIV negative.

the antenatal clinic through an agential realist lens

… we have turned the viral load tests and the genotype tests into a holy grail of fact and they're not that factual. They are constructions, particularly the resistance tests. They're constructions of ideas about what resistance might be. They're being worked out in past time. They're out of date before you start looking at them for viruses that are geographically distinct from ours. We have something that we invest a certainty in and we model our thoughts and we marshal our clinical actions against a level of certainty which then proves to be wrong. It undermines what you thought you were doing. (Interview with Anne, a consultant physician, 11 March 2009)

Apparatuses do not possess inherent outside boundaries limiting them to laboratory spaces or experimental practices. Indeed, a given apparatus need not be specifically implicated in any practice that goes by the name ‘scientific’. But neither are they understood purely as technologies of the social (as opposed to the natural) …. Apparatuses are neither neutral probes of the natural world nor social structures that deterministically impose some particular outcome. Significantly, in an agential realist account, the notion of an apparatus is not premised on inherent divisions between the social and the scientific, the human and the nonhuman, nature and culture. Apparatuses are the practices through which these divisions are constituted. (Barad, 2007, p. 169)

The social science approaches dominating the field of HIV at present foreground ‘structural drivers’, behavioural patterns and social understandings of HIV. Specifically, these approaches tend to separate the social and historical from (bio)medical practice and technological intervention. Conversely, our analysis of the clinic contributes to the field by suggesting that these aspects are intimately entangled. A robust analysis of the antenatal clinic needs to be able to interrogate the relations between historical and social dynamics, (bio)medical practice and technological intervention, not their singularity. In this light, we propose that Barad’s notion of intra-action constitutes a valuable framework for analysing what is at stake in the antenatal clinic, particularly in relation to the process of assessing a patient’s viral load.

Karen Barad is unusual within contemporary feminist theory, as she combines a specific uptake of Haraway’s cyborg with, following Butler, a dedication to tracing performative ontologies. Barad takes Butler’s performativity and rearticulates this theory to account for scientific practice. As such, she not only aims to directly engage how matter comes to matter through scientific practice, she introduces the lack of essentialism that is so central to Butler’s performative account into scientific practice. Barad criticises Butler for engaging with a theorisation of bodily production, which collapses materiality and signification in an anthropocentrism that only takes certain aspects of material production into account, thereby failing to engage effectively with the causality between discursive practices and materiality. Specifically, she criticises Butler for engaging with the discursive constituency of bodily contours, but not the very fleshiness of bodily being, its insides, its atoms and its capacity to act, its agency (similar critiques have been made by Cheah, 1996; Kirby, 1997; Kerin, 1999). Through this critique, Barad invites an understanding of the construction of bodies through specific scientific practices within a complex field of power relations.

Interestingly, Barad combines her elaboration of Butler’s performativity within a feminist science studies approach that interrogates science as a field of operations laden with power dynamics and possibilities of transformation. This becomes most visible in the heavy presence of Haraway in Barad’s work. Although Haraway (1997a, 1997b) engages a wider spectrum of science and Barad focuses mainly on quantum physics, they share an engagement with science through deep theoretical work. As such, their work is closely related, not so much in a practical way (i.e. how science can be done differently) but in a more philosophical sense. Science becomes a field of operations through which we can imagine and, importantly, materialise the world differently. Indeed, in both accounts notions of future transformation, or what Barad would call ‘reconfiguration’, are central. As Fraser (2002, p. 617) writes in her reading of Barad, ‘… if technologies are intra- actively involved in the materialization and de-materialization of human bodies, then there is no reason to believe that they might not also generate the conditions for their transformation’.

In short, Barad synthesises an analytical framework that foregrounds the interface body/technology as the site where mechanisms of power, systems of (normative) meaning, invest themselves in the materiality at hand. Following Butler, Barad understands scientific practice as performative; the objects and bodies under scientific investigation, their very ontology, are an effect of performative practice. Furthermore, the body/technology interface, in accordance with Haraway’s utopic cyborg myth, constitutes the site where a radically open future is to be configured.

In more specific terms, Karen Barad developed a performative account of materialisation that, in line with Haraway’s cyborg myth, is open to intra-action with non-human entities. Barad (2007, p. 153) writes, ‘ “Human” bodies are not inherently different from “nonhuman” ones. What constitutes the human (and the nonhuman) is not a fixed or pregiven notion, but neither is it a free-floating ideality … material apparatuses produce material phenomena through which specific causal intra-actions, where “material” is always already material-discursive—that is what it means to matter’. It is important to note that Barad emphasises intra-action as opposed to interaction as there are no pre-existing entities to interact with one another. In this account, the primary ontological units are not biological bodies, or scientific objects of any kind, but it is within phenomena that these entities come to be, in relation with one another, as their ontology is an effect of specific intra-active practices. Within a phenomenon bodies and objects gain their meaning and materialise in a specific way, through the manner in which they intra-act with one another. As an important consequence and in line with cyborg embodiment, the boundaries between women’s bodies, the apparatuses of scientific development and technology evaporate.

Following this line of thought, we suggest that while the practitioners have located the virus as being inside a patient’s body, the actions they carry out on the virus, its movement through time and space, within and outside of the host’s body, together with the technologies used to identify it within each of these contexts, always place the precise nature of its material reality under question. In order to provide care to the patients within the clinic, the practitioners must anticipate varying interpretations of these technologies and prepare ways of negotiating them.

In contrast to our agential realist conception, the virus is understood by the practitioners to have a ‘true’ identity, however inaccessible this appears to be. For the practitioners in the clinic, the virus’s potential future effects on the body of the patient and her (unborn) baby evidence the virus’s reality. Hence, the practitioners would argue that there is a reality to which truth refers, and that accessing this truth is a matter of making, having access to and engaging ‘better’ human and non-human actors; that is, more sensitive biomedical technologies and committed practitioners. This belief is widely acknowledged within the scientific community and it subsequently participates in the materialisation of HIV in the clinic. Moreover, this belief also plays a significant role in the shaping of the field of HIV in that it dictates the way in which the problem of HIV is conceptualised and confronted both socially and biomedically.

According to the practitioners, the technologies have the potential to obscure their access to the patient’s real virus (as they understand it to exist as a material object within her body but never observable/assessable to them in real time). This is because the technologies are known to have the potential to facilitate the creation and endorsement of treatment regimes that may increase (or decrease) the likelihood of vertical transmission. In other words, the technologies are known to have the potential to irrevocably harm (or heal) the practitioner’s patient cohort.

Accurately assessing a patient’s HIV is thus, for the practitioners, a matter of acquiring and coordinating human and non-human actors that are able to display HIV as they imagine it exists in a patient’s body, unaffected by the technologies currently involved in its representation. This belief participates in the way in which the problem of HIV is framed, understood and potentially confronted and delineates the practitioners’ efforts to combat the virus in the clinic. Accordingly, the practitioners act on their patient’s virus, even though the information they have about it is potentially out of date and suspect. Immediate action is nonetheless required in order to prevent the virus from being transmitted to the unborn baby, and thus becoming what the practitioners fear it may become (i.e., out of their control) in the future, if it is left alone. Consequently, the practitioners suspect that the practices in which they engage have the ability to facilitate the creation of ‘inaccurate’ bodies and viruses. However, while practitioners would agree that practice enacts the virus within the clinic, they also operate with a belief that there is a virus external to practice.

Contrary to the belief of the practitioners, we suggest that their practices to uncover the virus become an inherent part of HIV as an object of knowledge production and intervention in the antenatal clinic. HIV is not a discrete object inside the pregnant woman’s body, but a performative effect of the practitioners’ practices. This suggestion does not deny the materiality of the virus, but explicitly acknowledges that any effort to make this materiality known and intelligible always already renders the virus a material-discursive entity.

the viral load assay as an apparatus of bodily production

Within an onto-epistemology of agential realism, (scientific) apparatuses have a central place because they are the site of intra-action. Boundaries between the component entities of the phenomenon are determined through the apparatus; they do not pre-exist. For Barad, an apparatus is not purely scientific. It is not a mere laboratory set-up, but a more complex and encompassing set consisting of myriad systems of meanings and materialisations.

In her essay ‘Getting real’ (2007 [1998]), Barad uses an agential realist analysis to show how the intra-actions of scientific objects and bodies matter, in both senses of the term. Specifically, she sets out to analyse the ‘piezoelectric crystal’ as a vital component of the observing apparatus of ultrasonography—the apparatus that is utilised to make visible a foetus inside a women’s body. ‘[I] argue that the piezoelectric crystal is a material instrument, the “soul” of an observing apparatus, through which not simply signals but discourses operate’ (Barad, 2007, p. 190). In particular, she centralises the piezoelectric transducer within the larger apparatus of sonography, which then in turn constructs the foetus into an image. In a similar fashion, we suggest that the viral load assay is an apparatus utilised to make the HIV virus inside a pregnant woman’s body visible in the antenatal clinic. However, we do not understand the assay as a technology that merely makes the virus visible (or fails to do so). Rather, we understand it as an apparatus of bodily production, constitutive of the woman/foetus/HIV relationality under investigation and treatment. More specifically, practitioners’ beliefs about the virus, the unborn baby, the future of mother and child and histories of the pandemic (in terms of the readability of various subtypes of virus) also operate through this technology—with very real and material effects.

Returning to the essay ‘Getting real’, Karen Barad writes that:

[T]he transducer does not allow us to peer innocently at the fetus, nor does it simply offer constraints on what we can see; rather, it helps produce and is part of the body it images. That is, the marks on the computer screen … refer to a phenomenon that is constituted in the intra-action of the ‘object’ (commonly referred to as the ‘fetus’) and the ‘agencies of observation’. Significantly, the objective referent for the properties that are observed is the phenomenon, not some presumably pre-existing, determinately bounded and propertied object. (Barad, 2007, p. 202)

In a similar fashion, we suggest that the viral load assay is a material discursive apparatus that constitutes HIV inside a pregnant woman’s body in particular ways. Specifically, the viral load assay in intimate relation to the practitioners’ agencies of observation produces woman/foetus/HIV as a specific phenomenon, which then becomes the object of intervention through ARV treatment and specialist antenatal care. It is exactly at this point where the aforementioned differences in virus subtypes arise with palpable consequences.

The viral load assays used by the antenatal clinic in the hospital were specifically attuned to assessing sub-types of HIV that were and are most common in white gay males in the United Kingdom. These assays pre-date the changing demographics of HIV in the United Kingdom that has seen black Africans, in particular black African women, as being disproportionately affected by HIV. As such, the technology includes histories of the pandemic, of its movement through time, from place to place and between bodies. Furthermore, through the performative act of reading the virus inside the woman’s body, the agencies of observation, practitioners’ beliefs about the realness or accuracy of the virus and her future, are also included in the assay as a technology. These histories and beliefs are materialised into the pregnant woman’s body, through the level in which the virus is read inside her body, and consequentially influence her access to ARV treatment.

Woman/foetus /HIV as a phenomenon carries the history of the pandemic, but also the promise of a different future. It is in this promise and for this future that an agential realist analysis of woman/foetus /HIV and the viral load assay becomes especially pertinent. The manner in which the virus is read through the viral load assay opens up or forecloses a future for mother and child less affected by HIV. In this sense, the promise of a different future is contingent on the emergence of a debilitated body through the viral load assay.

conclusion

In the introduction to this article, we argued that the current focus on debility is pertinent to feminist theory as it allows a reintroduction of health care as a matter of feminist concern. Our work shows the importance of theorising the manner in which health-care practices affect women’s bodies and enable certain futures to emerge, and foreclose others. However, our study also shows the importance of feminist empirical work to the development of theory. The antenatal clinic invites an understanding of debility as a bodily state that is a state of privilege. Only when HIV is read as sufficiently debilitating do care efforts in terms of timely ARV treatment open up. The pregnant patient needs to be read as a debilitated body in order for her child to have a future free from HIV. However, being read as debilitated is a privilege that the vast majority of people living with HIV will never experience.

Our argument for an expanded conceptualisation of the concept of debility provides a significant contribution to current feminist debates on debility—particularly as they utilise a conceptualisation of debility as the opposite of bodily capacity. In our study, debility cuts through a conceptual dualism of capacity/debility. Debility is not merely a dystopic concept or state of being, but a bodily state of passage through which certain futures emerge. In this sense, debility is not the opposite of bodily capacity, but rather the condition of possibility for a non-debilitated body to come into existence—here specifically a baby born without HIV. This futurity is a thoroughly intricate affair, as it is entangled with the viral load assay, practices of reading, histories of the HIV epidemic and diasporic positionalities. To state that debility provides a future is to call on all these components in an effort to make explicit the ways in which they materialise through and across women’s bodies. In contrast to focusing on the differences between bodily capacity and debility, our study brings forward the capacity of debility, as a geopolitical temporality that begs further investigation.