Towards the embodiment of biosocial resistance? How to account for the unexpected effects of antiretroviral scale-up in the Central African Republic

Abstract

At the fringes of the unprecedented medication scale-up in the treatment of HIV, many African countries have experienced dramatic antiretroviral drug stock-outs. Usually considered the result of irrational decisions on behalf of local politicians, programme managers and even patients (who are stigmatised as immoral), these problems seem not to be so exceptional. However, ethnographic attention to the social consequences of the presence and absence of antiretroviral drugs in the Central African Republic (CAR) suggests that these stock-outs entail far more than logistical failures. In 2010 and 2011 in the CAR, major antiretroviral treatment (ARV) stock-outs resulted in the renewal of ‘therapeutic’ social ties and also significant social resistance and defiance. While this paper explores reasons for the shortage, its focus is on subsequent popular reactions to it, particularly among people who are HIV-positive and dependent on ARVs. The exceptional and ambiguous consequences of these drug stock-outs raise new concerns relevant to the politics of global public health.

Keywords:

• HIV/AIDS
• Central African Republic
• antiretroviral drugs
• biosocial resistance
• scriptural economies

Acknowledgements

I am very thankful to the people in Bangui who allowed me to participate in and enter their everyday lives. I am grateful to Johanne Collin, Laurence Monnais-Rousselot and Vinh-Kim Nguyen for their comments on this part of my research. I thank the anonymous reviewers for their time, careful reading, and constructive suggestions. Any mistakes or lapses of judgement remain my sole responsibility. I am also very grateful to Session Mwamufiya for his astute comments and English revisions.

Funding

This research has been supported by a PhD fellowship from the Méos, a research group on medication as social object at the University of Montreal and a Young Researcher Fellowship from Sidaction, Paris, France.

Notes

1. The facts and biographies described in this article are the product of fieldwork (David, 2013) conducted while I was a doctoral candidate at the University of Montreal and the University of Lyon in CAR from 2005 to 2008 for my dissertation and the collection of ethnographic data on two returns in 2010 and 2011 for 2 and 3 months, respectively. Names and details have been changed to conceal the identity of the persons concerned. The project was approved by the Ethics Committee of Health Research at the University of Montreal and by the Scientific Committee of the Faculty of Health Sciences, University of Bangui.

2. This free access was implemented after international recognition that the price of antiretrovirals was a major obstacle to treatment access and treatment adherence. This is a major exception in global health international policies since the Bamako Initiative in 1987 set up the recovery of medical costs through user fees and drugs payment.

3. The material dependence of Bangui on its province is very important. For example, food dependency is evident in the popular neighbourhood, Kodro, a forgotten space, as described by Adrien-Rongier in 1981. ARVs would reveal new material dependencies blurring the frontier between town and country and question rural Africa as materially dependent and culturally delayed.

4. Resistance tests were rarely performed and tests for viral load were also quite rare, although enshrined in the guidelines of the Ministry of Health.

5. Indeed, these ‘structured treatment interruptions’ ultimately proved less effective in the long term with respect to mortality and morbidity associated with HIV (Lawrence et al., 2003). However, the toxicity of ARVs and immunological and virological parameters were not statistically different for some authors (Dybul et al., 2003). In our case, the main stress on the patient represented by an ‘unstructured’ treatment interruption is probably not without effect on the fate of the virus. Fortunately, this interruption is not unstructured ethically and scientifically measurable, even if it is encountered in practice. A qualitative methodology is then crucial to account for these situations.

6. One of these indicators was the rate of infected pregnant women on ARV therapy. The rate was lower than expected, but as I have described in the first part of this paper, the number of pregnant women who received a test was much higher than expected and could have resulted in more difficulties keeping the rate of pregnant women on ART, as noted in the grant.

7. Michel de Certeau defines the scriptural economy as the moment when ‘writing acquires an interest in history, in order to recover, watch or educate…[it transforms] nature by registering. It is violence, cutting and slashing the irrationality of superstitious people or enchanted regions' (de Certeau, 1980/1990, p. 212).

Additional information

Funding

Funding: This research has been supported by a PhD fellowship from the Méos, a research group on medication as social object at the University of Montreal and a Young Researcher Fellowship from Sidaction, Paris, France.