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The Production and Governance of Risky Sexual Subjectivity in the Era of Pre-Exposure Prophylaxis (PrEP) to HIV

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Pre-exposure prophylaxis (PrEP) to HIV is a promising yet controversial new technology in the biomedical HIV prevention toolkit. Despite PrEP’s demonstrated effectiveness in reducing the risk of HIV acquisition by up to 99% when taken daily, PrEP utilization remains not only modest overall but also inequitably distributed in patterns that directly contradict epidemiological data regarding greatest need and most significant potential benefit. While incidence rates have begun to decrease, disparities are in some cases widening, exacerbating the disproportionate representation of racialized men who have sex with men (MSM) in the epidemic. This dissertation questions: what does the failure of PrEP to catalyze a significant overall reduction in new HIV diagnoses in the United States reveal about the biomedical production and sociopolitical governance of risky sexual subjectivity? Utilizing data collected through semi-structured interviews, participant observation, and autoethnography, this project: i) elucidates PrEP’s effects on sexual subjectivity vis-�-vis the historical present of HIV prevention discourse and practice; ii) evaluates how encounters with risk shape access to and persistence on PrEP and vice versa; and iii) contextualizes clinician and PrEP non/user engagement with PrEP within broader processes of biomedicalization. For men who have sex with men (MSM), claims to moral sexual subjectivity are linked to notions of responsible risk management. By enabling condomless anal sex with significantly diminished likelihood of seroconversion, PrEP can work not only as a harm reduction intervention in epidemiological terms, but also to remodel the way MSM experience and relate to risk. The capacity of PrEP as a biopharmaceutical means to achieve these ends, however, is constrained by the risk compensation debate and the “purview paradox,” which limit uptake of this vital prevention resource among individuals vulnerable to HIV. While redressing these roadblocks is critical to enhancing PrEP’s real-world effectiveness, the goal of ending the HIV epidemic will necessitate addressing the structural conditions that produce HIV acquisition risk. Technological solutions like PrEP to social problems like HIV transmission will continue to exacerbate disparities within a capitalist health care system that profits from pathology.

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This item is under embargo until August 1, 2024.