“When the skies fight”: HIV, violence and pathways of precarity in South Africa

Abstract

Based on multi-sited ethnographic fieldwork in South Africa, this article explores the skies that fight, the proverbial lightning strikes that bring HIV into women’s lives and bodies. Departing from earlier studies on ARV programmes in and beyond South Africa, and broadening out to explore the chronic struggle for life in a context of entrenched socio-economic inequality, this article presents findings on women’s embodiment of and strategic resistance to structural and interpersonal violence. These linked forms of violence are discussed in light of the concept of precarity. Across two sections, the findings trace the pathways through which precarity entered women’s lives, drawing on verbal, visual and written accounts collected through participant observation, participatory photography and film, and journey mapping. In doing so, the ethnography articulates the intersection of structural and interpersonal violence in women’s lives. It also reveals the extent to which women exert a ‘constrained agency’, on the one hand, to resist structural violence and reconfigure their political relationship with the state through health activism; and, on the other hand, to shift the gender dynamics that fuel interpersonal violence through a careful navigation of intimacy and independence.

Résumé

Sur la base d’un travail ethnographique de terrain sur plusieurs sites en Afrique du Sud, l’article étudie les cieux orageux, la foudre proverbiale qui fait pénétrer le VIH dans le corps et la vie des femmes. S’éloignant d’études précédentes sur les programmes de traitement antirétroviral en Afrique du Sud et au-delà, et souhaitant étudier la lutte chronique pour la vie dans un contexte de profondes inégalités socio-économiques, cet article présente des résultats sur la traduction par les femmes de la violence structurelle et interpersonnelle et la résistance stratégique qu’elles lui opposent. Ces formes liées de violence sont examinées à la lumière du concept de précarité. Dans deux sections, les résultats retracent les voies par lesquelles la précarité est entrée dans l’existence des femmes, se fondant sur des récits oraux, visuels et écrits recueillis par l’observation des participantes, les photographies et les films participatifs ainsi que la cartographie des parcours. Ce faisant, l’ethnographie articule l’intersection de la violence structurelle et interpersonnelle dans la vie des femmes. Elle révèle aussi dans quelle mesure les femmes exercent une «action contrainte», d’une part, pour résister à la violence structurelle et reconfigurer leurs relations politiques avec l’État par le biais du militantisme pour la santé et, de l’autre, pour réorienter la dynamique de genre qui alimente la violence interpersonnelle par une navigation attentive dans l’intimité et l’indépendance.

Resumen

Basado en trabajo de campo etnográfico realizado en múltiples sitios en Sudáfrica, este artículo explora los proverbiales relámpagos que traen VIH a la vida y el cuerpo de las mujeres. A raíz de estudios anteriores sobre programas de ARV en Sudáfrica y otros países, y explorando la lucha crónica por la vida en un contexto de desigualdad socioeconómica arraigada, este artículo presenta hallazgos sobre la manifestación de violencia estructural e interpersonal en las mujeres y su resistencia estratégica a la misma. Estas formas vinculadas de violencia son discutidas en vista del concepto de precariedad. En dos secciones, los hallazgos siguen las rutas por las cuales la precariedad entró en la vida de las mujeres, basándose en relatos verbales, visuales y escritos recolectados por medio de observación participante, fotografía y película participativa, y mapeo de las experiencias de las mujeres. Al hacer esto, la etnografía expresa la intersección de la violencia estructural e interpersonal en la vida de las mujeres. Además, revela en qué medida las mujeres ejercen ‘agencia restringida’, por un lado, para resistir la violencia estructural y reconfigurar su relación política con el estado por medio del activismo en salud; y, por otro lado, para cambiar la dinámica de género que alimenta la violencia interpersonal, mediante la cuidadosa navegación de la intimadad y la independencia.

Keywords:

• South Africa
• precarity
• gender
• violence
• HIV

Introduction

“It’s like when the skies fight, when the clouds are angry and dark. They crash into each other and lightning flies across the sky. You never know where the lightning is going to hit. That’s what it’s like with HIV.” (Zama, 2011)

The rain collected and dropped down the windscreen as Zama and I sat in the car talking outside the office where she worked as an HIV treatment literacy facilitator. We had known each other for eight years, but it was only now that she started to tell me how she acquired HIV. As Zama spoke about her younger self and the men she had had sex with without feeling that she could say no, without knowing how to say no, without believing she had the right to enjoy sex, I was struck by the clanging dissonance between the studies I had read and the lives I had subsequently come to know.

Diagnosed with HIV in 2001, Zama started taking antiretroviral (ARV) therapy in 2002. Following concern about the potential toxicity of ARVs, as former South African President Mbeki had claimed,¹ Zama’s positive embodied experience of ARVs prompted her to join a large-scale social movement calling on the South African government to provide ARVs through the public health sector. This movement was spearheaded by a coalition of organisations in which the Treatment Action Campaign (TAC) featured most prominently,² and it was shaped by people like Zama and all the women in this article.

I conducted the ethnographic research on which this article is based in 2010 and 2011. The ethnographic findings are rooted in South Africa’s struggle for ARVs and grow out of a longstanding political and medical anthropological research focus on the biopolitical antecedents of South African citizens’ activism across the apartheid and anti-apartheid eras.^3–6 While the findings speak to this longer political and research history, they also represent a departure from ethnographic studies of ARV programmes that were situated in the time lag between the international development of HIV medicines in 1996 and their distribution through national health systems.^7,8 From a tightly circumscribed focus on the politics of life linked to HIV medicines, the ethnography broadened its focus onto HIV-positive women’s everyday lives in post-apartheid South Africa. This article focuses in particular on the politics of life that inhere around HIV-positive women’s embodiment of and resistance to structural and interpersonal violence.

Given this historic context, I recognise that the starting place for ethnographic research matters:

“If you start from the ‘negative minimalisms’⁹ of sheer survival and bare life, of violence, suffering, deprivation, and destitution, then you provide a very different description of lives than if you begin from people’s situated concerns... [O]ur tendency to focus on the dystopic has been at the price of forgetting to think about ‘other ways of thinking’.”¹⁰

The ethnography in this article takes people as its starting place. While the findings call attention to women’s embodied and chronic struggle for life against a background of pernicious structural and interpersonal violence, they also present ‘other ways of thinking’ about the nuanced ways that women strategically resist and reconfigure violent structures and relationships. Structured across two sections, the findings suggest that women’s embodiment of direct forms of interpersonal violence, like sexual and gender-based violence, cannot be divorced from broader dynamics that fuel structural violence in South Africa.

Structural violence, a concept originally formulated by Johan Galtung,¹¹ refers to the harm people experience when social structures or institutions prevent them from meeting their basic needs. Medical anthropologist, Paul Farmer, was one of the first to integrate structural violence into HIV research. He writes,‘The arrangements are structural because they are embedded in the political and economic organization of our social world; they are violent because they cause injury to people.’¹² While revealing HIV-positive women’s struggle with the political and economic organisation of their social world and the way in which they embodied this organisation as structural violence (through, for example, the state’s refusal to provide essential ARVs), the findings also discuss women’s direct experience of violence through interpersonal relationships. In this article, the term ‘interpersonal violence’ specifically denotes violence against women (VAW) (although it is widely recognised that interpersonal violence affects all sexes and genders, and particularly those people who do not follow normative and socially-constructed gender and sexual codes).^13–15 This article follows the United Nations’ definition of VAW as ‘any act of gender-based violence that results in, or is likely to result in, physical, sexual or psychological harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or in private life’.^*

The article articulates two ‘pathways’ through which HIV becomes embodied. These pathways reflect the intersection of structural and interpersonal violence; this intersection is denoted, in this paper, through the concept of precarity:

“[Precarity designates] that politically induced condition in which certain populations suffer from failing social and economic networks of support … Such populations are at heightened risk of disease, poverty, starvation, displacement, and of exposure to violence without protection.”¹⁶

I use the concept of precarity for two reasons: first, it foregrounds the uneven effect of structural violence on different populations; and second, it highlights the relationship between multiple forms of violence and the way they become embodied. In her original writing on precarious life, Butler¹⁷ argues that the narrative construction, by international media, of ‘terrorists’ after the 9/11 attacks worked to render people ‘less than human’ by failing to acknowledge their vulnerability; in her later writing on gender, performance and precarity, Butler suggests that while vulnerability refers to a particular condition, the term precarity speaks to the mechanics that coalesce to create conditions of ‘maximised vulnerability’.¹⁶ I use the term precarity, rather than vulnerability, in order to pan out from women’s very real embodiment of violence, to draw attention to the broader workings of inequality and (bio)power that come together to reinforce structural and interpersonal violence. In doing so, the article aims to reveal how women are not only subject to linked forms of violence but are also active agents who strategically navigate their embodied precarity.

Methodology

“[E]thnographic engagement can help us chart some of the complex and often contradictory ways in which neoliberalizing health structures, moral economy, and biology are forged in local worlds where biotechnology and structural violence now exist side-by-side”¹⁸

This article is based on multi-sited ethnographic research that I conducted in South Africa and Brazil in order to locate South Africa, and the lives of the people with whom I worked, in a regional and global terrain linked to the biopolitics of biomedicine. I used visual and participatory tools in order to move away from privileging what is said and to move closer towards a more layered understanding of the quieter and perhaps less visible spaces of people’s lives.

In conducting an ethnography to explore shifting embodied and political subjectivities linked to HIV, I was aware that, as Whyte¹⁹ cautions, I would run the risk of masking the complexities of lives lived beyond a single identity – as ‘HIV-positive’, ‘woman’, ‘on ARVs’. Further, I was conscious that I needed not only to look at how people made claims and secured resources by mobilising particular identities, but that their embodied subjectivities may also speak to deeply rooted forms of structural violence. As Whyte argues, “There is a danger that we lose sight of the political and economic bases of health in our concern with identity, recognition, and the formative effects of biomedical and social technology”.²⁰ The findings in this article speak to these broader dynamics, including structural violence, that expand beyond a singular focus on HIV, and they draw specifically on ethnographic research with people living in Khayelitsha, a semi-formal housing area that lies across 45 kilometers of the Cape Flats in the Cape Town Metropole district of the Western Cape Province.

In addition to participant observation, informal conversations and life history interviews, I used visual research methods including participatory photography and film, and actor network mapping.^21–23 The participatory photography^24,25 and film²⁶ methods entailed providing digital cameras for each of the ten women who formed the core of my ethnography, and working with them to document, for example, where they felt the absence or presence of the state in their lives. All ten women had, at some point in the previous decade, worked with TAC. Their engagement with TAC enabled me to explore their perception of the state linked to their experience of ARVs, and to draw comparisons across the group and with the broader sample (I conducted an additional 40 interviews with people on ARVs, and 20 interviews with policy makers, activists and academics in Brazil and South Africa). All the women in this core group received a regular, but small, income that was supplemented by disability grants in each of their households. Six women worked with a company that made papier-mâché bowls; two worked as researchers with an HIV organisation; and two were treatment literacy practitioners with a community media company. The ten women in the core group created a set of journey maps (tracing the woman’s life from her birth to the present moment), social maps (showing family relationships and the spaces of homes, for example) and digital maps (using Google Earth and layering stories and photographs on to space). These methods, together, enabled me to conduct ethnographic research beyond what was said, to understand how meaning is made in and through practices,^27,28 senses²⁹ and space.³⁰

Ethics permission for this study was formally obtained from the University of Sussex. Each of the study participants provided written consent. Through discussions across the research process, the participants expressed how they would like to be represented, which stories should be shared most boldly, and which stories should not be shared at all. While the stories below are accounts that the women were comfortable with sharing in public arenas, all identifying characteristics have been removed.

Pathways of precarity

The principal form of precarity that emerged in my fieldwork relates to women’s embodied vulnerability, centring specifically on women’s and girls’ bodies as corporeal sites of structural and interpersonal violence. This precarity is explored along two interlinked ‘pathways’ to highlight how HIV moves along social, economic and political fissures, into and between people’s bodies and lives. In this respect, I use the term ‘pathways’ in conjunction with social epidemiological approaches to health in general^31–33 and HIV in particular.^34,35 Broadly, social epidemiological approaches cohere around three areas of focus: psychosocial approaches; the social production of disease and/or political economy of health approach; and ecosocial theory and related multi-level frameworks. The findings reflect the political economy of health approach that ‘explicitly address[es] economic and political determinants of health and disease, including structural barriers to people living healthy lives’.^33,n.p.

The two sections below explore how precarity is embodied with HIV entering women’s and girls’ lives through relational networks that travel both vertical pathways across generations and horizontal pathways between partners.

“So my baby gets HIV too”: vertical pathways of precarity

Pregnancy followed by the birth, illness and potential death of a child were the metaphorical lightning strikes through which women came to learn of their HIV status. The women in this study had learnt of their own and their child’s HIV status in the late 1990s and early 2000s, before treatment or prevention of vertical HIV transmission (hereafter referred to as PMTCT, prevention of mother-to-child transmission) were available in the public sector. Studies conducted in South Africa prior to the roll-out of PMTCT in 2003, found that up to one-third of all HIV-positive children would likely have died in their first year of life without access to this treatment.³⁶

Despite the government’s initial commitment to establish the efficacy of nevirapine, a cornerstone of the PMTCT regimen in resource-poor settings,³⁷ it refused to make this medicine available in the public health sector.³⁸ An application to remove restrictions on the public provision of nevirapine was brought to the High Court in Pretoria in 2001 by a broad coalition of associations and members of civil society, including the Save our Babies and the Treatment Action Campaign (TAC).^† The court case was won, and it was then appealed. Twice. The second appeal was denied and a national PMTCT program was finally initiated in 2003.³⁹ This section illustrates the legacy of the government’s failure to roll-out effective PMTCT, and it suggests that this constitutes a form of structural violence that women and their children embody in the present.

Brenda was born in 1979. In 1999, in the course of her penultimate year at school, Brenda became pregnant. Her partner had told her that he was HIV-positive, but this disclosure held little meaning for Brenda because she did not know about HIV:

“He was the first boyfriend. So we had sex without a condom. At that time I didn’t understand HIV. That was 1999. So my boyfriend [told] me he was HIV positive, but like a joke.”

Brenda’s geographic location in a rural village in the Eastern Cape placed her on the periphery of available HIV information and health services. Without information about the routes that HIV travels, in this case through sex (without condoms) and without treatment to prevent vertical transmission, Brenda was unable to stop the virus from entering her own or her child’s body, and her first and second children both died of HIV.

Miriam wrote rather than spoke the stories of her younger self in the pages of a diary that moved like an unspoken conversation between her bag and mine. Like Brenda, Miriam was born in 1979 and was compelled to stop high school three months before her final examinations in order to take care of her mother. When Miriam returned to her mother’s home, she entered her first sexual relationship and, like Brenda, became pregnant in 1997. Unaware of how HIV is transmitted and unable to access treatment, Miriam was also unable to protect herself or prevent her daughter, Nena, from contracting HIV. Nena was born as Miriam’s mother died. Miriam wrote of her heartbreak at choosing between her mother’s death and her daughter’s life, and her decision to take her daughter out of the frail failing clinic in the heart of the Eastern Cape to the medical hub of urban Cape Town. Here her daughter received excellent, albeit belated, medical care. Like Brenda, Miriam learnt of her HIV-status when her daughter tested HIV-positive in 1998.

The pathways that enabled HIV to move into Brenda and Miriam’s lives, and into their children’s bodies, illustrate the dynamics of structural violence, linked to social epidemiology and precarity, in two ways. First, both women were placed at ‘heightened risk of exposure to disease’ through the failure of the public health system to reach rural areas with essential public health resources (like HIV information, condoms and health care). Second, the state generated ‘politically induced conditions of precarity’ through its failure to provide treatment to prevent vertical transmission from the women to their children. Early HIV research in South Africa, among miners for example,⁴⁰ similarly found that infection was not simply about individual risk but about a broader array of social, political and economic determinants. Both Brenda and Miriam have subsequently given birth to healthy babies, but Nena – Miriam’s first born – has severe cognitive dysfunction. Miriam continues to wait for Nena to be admitted to a specialist primary school. In line with Fassin’s ethnography on embodied memory,⁷ Nena, and many other children born prior to 2003, bears witness to the persistence of embodied precarity as a result of delayed treatment and the legacy of poor health care in rural South Africa.

“It’s hard to be a girl in this country”: horizontal pathways of precarity

Like a Polaroid image that becomes defined with time and light, the proliferation of interpersonal violence experienced by the women I worked with, and by generations of girls that stretched before and after them, moved into sharp relief over the course of my fieldwork. In a cross-sectional study in three South African districts in the Eastern Cape and Kwa-Zulu Natal, researchers interviewed 1738 men aged 18–49 years.⁴¹ This study found that 27.6% of all men had raped a woman or girl; rape of a current or ex-partner was reported by 14.3% of the men; 11.7% had raped an acquaintance or stranger (but not a partner) and 9.7% had raped both strangers and partners. Of all the men interviewed, almost half (42.4%) had been physically violent to an intimate partner. Similarly, a longitudinal analysis of a cluster-randomised control trial undertaken in the Eastern Cape between 2002 and 2006 with 1099 women aged 15–26 years indicated, conclusively, that there was a causal link between relationship power inequity and intimate partner violence, and an increased risk of HIV infection among young South African women.⁴²

As noted above, in using the concept of precarity, I seek to move away from describing women’s ‘risk’ linked to their experiences of violence as vulnerable subjects. I do so in order to make the workings of inequality that shape the kinds of violence that women experience more visible. The findings discussed below do not seek to show causality between sexual violence and HIV. Instead, they engage in the ‘muddier middle ground’ as women negotiate intimacy and coercion in their sexual partnerships and across generations. Replacing numbers with people, this section also seeks to challenge the hegemonic and ubiquitous discourse that positions poor Black women as ‘vulnerable’ without recognising the nuanced, albeit fraught, strategies that women employ to navigate precarity. This follows de Certeau’s⁴³ notion of ‘making do’, as women simultaneously embodied, resisted and performed precarity in complex configurations that challenged linear assumptions of women as either ‘deserving subjects’ or as ‘autonomous agents’.⁴⁴

An epidemic of rape

When she was pregnant with her third child, Brenda showed me a photograph of her grandmother sitting on a bench outside her home. Her arms were stretched around the small shoulders of her two great-granddaughters. The girls, in frayed dresses and with grazed knees, looked blankly at the camera. Brenda touched the screen, tracing the faces of her relatives. Speaking with a tone of urgency, she asked me if I knew of “that school teacher… the one who’s been in Vukani [a local newspaper] … who raped 30 children in Khayelitsha? He raped these two girls”. I put my hand on her hand on the screen still showing her grandmother and nieces, generations that came before and after her; we sat in silence, shoulders touching. Later, she came out of an antenatal check-up saying, “It’s a boy”. Later, travelling back to Khayelitsha, Brenda said, “I’m glad it’s a boy. It’s hard to be a girl in this country.”

As a young girl the same age as Brenda’s nieces, Lilian’s parents left her to live with strangers. Born in Johannesburg in 1972, Lilian spearheaded TAC’s campaign to compel the government to provide PMTCT; she testified on behalf of TAC and her affidavit was used as evidence in the court case. Over time, in 2011, Lilian created a journey map where she documented the journey of her life. Starting forty years earlier, Lilian noted her birth on the top left hand side of the map. Next to this date, she wrote of the abuse she endured throughout her childhood, lacking the protection of her parents. This aspect of Lilian’s life generated conditions of embodied precarity that reinforced each other: to combat apartheid’s structural economic violence, her parents left her with strangers as they went to find work. Without any protection, Lilian was abused and raped by these strangers and then later, after running away from them, she was raped by relatives. She ran away again, and because she did not have any social or economic resources to draw on, she lived on the streets where she entered an abusive relationship and became pregnant in 1999. Like Brenda’s, her baby was very ill and she spent most of the first year of her child’s life in and out of hospital until, in June 2000, her baby died. She learnt that she was HIV positive when her child tested positive in 2000.

On the top right hand side of Lilian’s journey map is a photograph of a pregnancy scan, a foetus in profile, pictured in black and white. Next to the image she wrote, “Preg[nant] with my daughter”. The three photographs below this top image are tiered and mirror the progression of her life into activism. The first photograph is of a waiting room with a woman holding a child. The second photograph is of a grave strewn with flowers, and next to the image Lilian wrote, “Death of my child made me an activist”. She drew an arrow connecting this photograph with a third photograph of people lining up in a queue. Next to it she has written “1999. Queing [sic] in cold, to cast my vote, hoping for ‘better life’” and along the arrow to the photograph of the grave representing her dead daughter, she has written “only to be disappointed”.

This account points to Lilian’s belief that the democratic state is intimately entwined with her and her child’s capacity to live; the ‘politics of life’ are iterated by Lilian’s conviction that the state should ameliorate precarity by creating conditions for a ‘better life’, for her child to live without HIV and for herself to live with HIV on ARVs. Her rationale for becoming an activist, therefore, was to challenge the way the democratic state was implicated in her experience of structural violence; the state created conditions of vulnerability through its failure to provide treatment to prevent vertical transmission. Lilian now has a young boy who, she says, is ‘living proof’ of her work as an activist to challenge the government to end this particular form of structural violence, embodied through her own and her children’s vulnerability to HIV, by compelling the government to provide PMTCT.

Eschewing Shweshwe: navigating risk and pleasure

In my home I had a bright red Shweshwe-patterned bowl made by Miriam. It held condoms, femidoms and lubricant received from an LGBTQ organisation for free and covered with rainbows and statements like “homophobia is un-African”. Knowing about femidoms and condoms, the women in the study were most interested in the lubricant. They oscillated between wanting the lubricant and not wanting the messages on the packaging. I left it at that, but later realised that all the sachets were gone. An unspoken agreement ensued: I kept the bowl stocked with lubricant and the women kept taking them. Weeks later, Miriam told me that she thought lubricant was an excellent invention.

This vignette speaks to a broader tension that emerged in my fieldwork: women enjoyed intimacy and sex, on the one hand, but found it difficult to negotiate the actual conditions of sex with their partners on the other. Three conditions, in particular, contributed to horizontal pathways of precarity linked to embodied risk through women’s sexual relationships with men. First, the majority of the women in the core group felt unable to insist on safe sex with their partner. Second, they found it difficult to negotiate the frequency of sex. Third, they struggled to balance their desire for intimacy and support from their partner with the knowledge that their partners had other sexual relationships. These conditions congealed into horizontal pathways of embodied precarity: through unsafe sex with partners who had unprotected sex with multiple partners, the women risked contracting new strains of HIV and developing viral resistance to their ARVs.

A few months into my fieldwork, Lilian told me that she had found out that her partner was having sex with other women. By the end of my fieldwork, Lilian had become angry. Unwilling to withstand his infidelity, she ended their relationship. Miriam’s partner, Samkelo, also had multiple sexual relationships; she learnt about this by reading the text messages on his phone. When Miriam confronted Samkelo, he said that she was his only partner and that the last time he tested (in 2005) he was HIV negative. Samkelo did not believe that he needed to test again and felt that he, and not Miriam, was at risk when having unprotected sex. Despite this rationale, he refused to wear condoms. Miriam felt compelled to have sex with him in order to keep him in her and her children’s lives, but was concerned about contracting other viral strains and developing resistance to her ARVs.

Miriam’s son, Khanyo, stays with Samkelo – his father – and attends the school across the road from Samkelo’s home. Miriam chose to keep Khanyo in this school as a strategic measure to compel Samkelo to take parental responsibility for their son. These measures also distributed the financial responsibility of Miriam’s two children across two households, and enabled Miriam to maintain her economic independence and to negotiate the frequency of her contact with Samkelo.

I first learnt about Samkelo on Miriam’s birthday. Like Brenda, and all ten women I worked with, Miriam had a camera that she used to take photographs. That day Miriam took me through the photographs that she had recently taken, showing me the fabric of one of her friend’s skirt. It was a fine pattern of white lines on a blue background that is called Shweshwe; it indicates that the wearer is married. Miriam told me that she would never get married because, “Men are macho when they get married. If I got married the xhosa tradition would kill me. That’s why you’ll never see me wearing Shweshwe”. By opting out of marriage, Miriam was able to insist on living in her own home with Nena and by remaining in a sexual relationship with Samkelo, she ensured that her son’s father stayed in his child’s life and shared responsibility for her children as a co-parent.

Eight of the ten women in the core group lived in a separate home from their partner. Earning their own income and living in their own home, or with their parents, were central strategies for the women to negotiate their desire for intimacy and partnership alongside their concerns about the risks that intimacy entailed for their bodies and their lives. Brenda, however, lived with her partner, and therefore employed different strategies for negotiating the embodied implications of his insistence on unprotected sex.

After her final hospital check-up before her scheduled caesarean, we navigated our way back to the home where Brenda lived. As we drove past the ‘Three thousands’, the metal shacks the size of a small room that cost R3, 000 (US$205), Brenda said that this would be her last child. Her partner was HIV-positive and he did not want to use condoms. She felt unable to insist on using condoms because she was living in his home and not in her own recently purchased ‘Three thousand’. She had not finished paying it off and rented to her cousins to pay the final instalments. Her tactical response to the difficulties entailed in owing money, in negotiating sex, and in preventing pregnancy, was tubal ligation. Brenda’s decision to have her tubes tied – just before her son, Mpilo, was born – was one way for her to navigate the pressures placed on her by her partner’s insistence on unsafe sex; she was not, however, able to protect herself from contracting other strains of HIV, and this placed her at higher risk for developing resistance to her ARVs.

From static descriptions of violence to the dynamics of precarity

Like the HIV movement itself, the findings of the ethnography fan out from a tightly circumscribed focus on the politics of life linked to AIDS medicines to draw in a broader focus on HIV-positive women’s everyday lives in post-apartheid South Africa after the ARV-rollout. Recent research in South Africa confirms that high levels of unemployment and resultant food insecurity continue to affect the wellbeing of HIV-positive individuals and their households.^45–47 Looking beyond South Africa, ethnographic studies on ARV programmes in Brazil,⁸ Mozambique,⁴⁸ Kenya⁴⁹ and Tanzania¹⁰ similarly point to the contexts in which ‘lives are lived’ to show that ARVs, alone, are not sufficient for enabling life.

The findings in this study explore the contexts in which HIV-positive women’s ‘lives are lived’; the dynamics of violence, in particular, were articulated along two pathways of precarity. While the findings are not broadly representative, they reflect a broader field of research in which the routes that HIV travels into women’s lives are explored along the lines of sexual and gender-based violence.^50,51 Building on these studies, the findings indicate the interlinked dynamics of structural and interpersonal violence, and they point to some of the political, social and economic structures that become embodied as forms of precarity. “In other words, from the etymology, precarious does not correspond to the static description of a condition, it involves a dynamic relation of social inequality.”⁵²

Further, while the findings engage with the dynamics of social inequality through the lens of structural and interpersonal violence, they also suggest that women exert a ‘constrained agency’, on the one hand, to resist structural violence and reconfigure their political relationship with the state (through activism calling for access to AIDS medicines); and, on the other hand, to shift the gender dynamics that fuel interpersonal violence (through a careful navigation of intimacy and independence). Therefore, the pathways of precarity through which violence entered women’s lives reveal a muddier middle ground between structures that ‘act down’ and agents that ‘act up’. Three conclusions emerge from this middle ground.

The findings suggest, first, that a focus on gender inequality linked to interpersonal violence can place blame on individuals (largely men) without recognising and addressing the social, economic and political ‘ecosystem’ in which men and women are located.⁵³ Ascribing HIV transmission, in epidemiological terms, solely to interpersonal gender violence does not, in itself, engage with the complex pathways that women navigate between desire and risk in their sexual relationships, and in extremely difficult socio-economic contexts. In this respect, the ethnography found that women are subtly, and sometimes with great difficulty, negotiating their intimate relationships with men by forming separate households and by working and establishing their financial independence. This was not a straightforward matter of asserting agency or submitting to intersecting structures of inequality; here the findings challenge structural theories that position agency in relation to structure⁵⁴ without looking at ‘space’ in between.

For we see that although Brenda enjoyed her sexual relationship with her partner, she felt unable to insist on using a condom when having sex because she was reliant on her partner for her home. If we consider her decision to have her ‘tubes tied’ in light of this picture, it seems that Brenda’s life fits a narrative of the economically dependent woman struggling to negotiate sex in an unequal relationship. This narrative could be understood as transactional: providing sex in exchange for a home. But this would be inaccurate. Brenda’s decision to have her ‘tubes tied’ was a tactical one, just as her decision to stay in her partner’s home was a conscious, albeit constrained, choice. By looking at the multiple pathways that HIV travelled into women’s bodies in the accounts above, we do not only see the socio-economic structures that “make it hard to be a girl in this country”. We also see the myriad tactics that women employ along these pathways to seek medical care for their children, to establish their financial independence, and to negotiate the risks and desires that surface in sexual relationships. In this respect, these findings propose a different reading of ‘empowerment’: one in which women do not need ‘rescuing’ by development actors but instead, perhaps, require recognition and support for their careful navigation of precarious life in the face of obdurate inequality and persistent structural violence.⁴⁴ Further, and as discussed elsewhere, women not only exerted their constrained agency in their social and sexual relationships, but also very much in their political relationship with the state as activists.⁶

Second, a singular focus on interpersonal sexual violence might fuel the problematic construction of a binary in which women are positioned as passive victims of men who are, conversely, held to be active perpetrators.^{cf. 55,56} This binary has been increasingly identified as problematic in studies on sexual rights and diversity¹⁵ and also in research on the positive role that men play through collective action to address SGBV⁵⁷ and in studies on the harmful effects of hegemonic masculinities for both men and women.⁵⁸

While the presence of gender inequality, and its brutal manifestation as sexual violence in girls’ and women’s lives was a strong feature of my fieldwork, I was still confronted by the explanatory limitations of epidemiological assertions that stipulated a correlation between gender inequality and higher rates of HIV infection among women compared to men. I do not dispute this correlation; in fact, part of the rationale underpinning my research lay in the multiple and intersecting inequalities that seemed to drive HIV, in epidemiological terms, into women’s lives and bodies. This was most striking when, in 2008, young women in South Africa were almost four times as likely to be HIV-positive compared to young men of the same age (20 – 24).⁵⁹ Overall prevalence in this age group has subsequently declined, but the characteristics of prevalence according to sex remained the same: young women are still more likely to be HIV-positive than men.⁶⁰

In trying to make sense of these figures, I came across studies that linked these statistics to sexual violence: articles with titles like “AIDS has a woman’s face”⁶¹ or “Troubling the angels”⁶² proliferated in studies that explored this correlation. Other research suggested that sexual violence and its relationship to HIV occurs against an inflected backdrop of pervasive and entangled inequalities in South Africa, where gender, sexuality, race and class powerfully intersect to reinforce poor Black women’s vulnerability.^13,63 This has been observed in South Africa,⁶⁰ but also further up the continent, in Sierra Leone⁶¹ for example, where life and livelihoods are, like most places in the world, relational and navigated materially through affect and intimacy.

Third, by paying attention to the linkages between structural and interpersonal violence, it becomes more possible to direct analytical and policy attention on the role of state institutions in perpetuating structural violence; a singular focus on interpersonal violence runs the risk of masking this broader context in favour of ‘blaming’ men or ‘cultures of violence’. Not only does the state enter the body of individuals or populations through disciplining techniques or the provision of HIV medicines that enable bodies to return to health,⁶⁴ but the findings show how the state’s absence, too, exerts an effect on the body. For Miriam, the state was absent in the Eastern Cape, as it was in many of the women’s lives, in so much as it did not provide essential ARV therapies that would have prevented HIV from moving into her daughter’s body, that would have stopped her daughter from starting life on the cusp of death. The absence of the state was visible too, in the responsibility that was conferred on women, implicitly, to provide unpaid care for kin who could not access health care in rural parts of the country, or who could not access essential medicines that would sustain their lives even when health centres were accessible and functional.

In conclusion, the study suggests that successful policy interventions need to recognise the politics and dynamics of violence that inhere in political and social institutions and manifest through interpersonal relationships at an individual level. The ethnography further reveals the value of looking more closely at how, and where, individuals experience precarity, hold agency and negotiate the fraught conditions of their vitality. By situating research on gender, violence and HIV in a middle ground, between conceptualisations of structural violence as ‘top-down’¹² or resistance as ‘globalisation from below’,⁶⁵ it might therefore become more possible to identify the pathways through which women come to both embody and resist precarity.

Acknowledgements

I wish to acknowledge the academic support of Dr Hayley MacGregor and Prof Melissa Leach. Thank you, Nondumiso Hlwele, for your invaluable insight and research support. I wish to acknowledge all the people I came to know during my fieldwork, for letting me into their worlds, and for coming into mine. The research was funded through a Commonwealth Scholarship and the Oppenheimer Memorial Trust.

Notes

* http://www.un.org/documents/ga/res/48/a48r104.htm; accessed November 2015.

† http://www.saflii.org/za/cases/ZACC/2002/15.html#fn5