The Treatment as Prevention(R) Empire: Treatment Adherence as the New War on AIDS

Treatment as prevention® (TasP®) proposes a new way to end AIDS by requiring people living with HIV/AIDS (PWAs) to strictly adhere to lifelong HIV treatment, effectively making them non-infectious. Essentially, TasP attempts to stop the spread of HIV at the source. Yet, this radical prevention intervention is not without individual and collective repercussions. With an eye to the growing physical, moral, legal, and political costs of HIV treatment on adherence, this study seeks to describe how adherence has changed throughout the AIDS epidemic in order to understand its function in this present time and place of TasP in Vancouver. Through a Foucauldian genealogy, this dissertation examines how TasP adherence practices re-asserts colonial hierarchies. Guided by critical race and postcolonial theories, I argue that race and racism distinguish those who are made to live from those left to die in this new war on AIDS, a war against PWAs. Using biopower as an analytical framework, I emphasize the continued role of sovereign power, a repressive power alongside productive power. To examine adherence, I investigate specific moments in time and across place to ground Vancouver’s current TasP rationale and practices, beginning with the scientific role and methods of late 19th century colonial medicine through to present day TasP. I delve into TasP’s scientific rationale by analyzing the first uses of antiretroviral treatment for HIV prevention. Next, I outline the changes in British Columbia’s public health law along with Vancouver’s clinical guidelines and protocols. Then, I position artwork produced by PWAs as important sites of knowledge, providing insight into the multiple effects of antiretroviral therapy. To conclude, I argue that TasP works as an imperial formation as it uses force in the construction of its subjects. I suggest TasP pushes us to confront this ethical question: to what end and at whose expense are we willing to end AIDS? At its most basic level, this project seeks to disrupt the seemingly neutral scientific language of TasP by showing how scientific knowledge regarding adherence practices draw from histories relying on, recuperating, and revising the interlocking structures of colonialism, racism, sexism, poverty, and sexuality.