ARTICLES

 

HIV advice in the media: Implications for reinventing subjectivity

 

 

Nkululeko Nkomo^*; Carol Long

Department of Psychology University of the Witwatersrand Johannesburg

 

 

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ABSTRACT

Working within a Foucauldian approach to governmentality and the ethics of self-care, this article analyzes the implications of the values upheld for caring and governing oneself in the HIV advice column of Criselda Sambeso Dudumashe, publicly HIV-positive herself. The analysis reveals that the central thrust of the advice advances the principle of investing in oneself and taking responsibility for one's physical and psychological health. Careful self-evaluation for self-improvement, however, means expending time and energy monitoring viral load, CD4 count and physical health. Likewise, monitoring one's adherence to HIV therapy requires careful evaluation of one's psychological state, including personal anxieties and fears, as well as the willingness to pursue qualified assistance from experts. Such self-government, it is argued, conjures up a subjective formation whose own discretion on how to gain control of HIV is oriented toward engaging with the best scientific practices and expert advice for its consolidation. In view of the emerging role played by similar platforms on and offline, an exploration of how the self is set in relation to itself, and how self-improvement is governed, offers insight into the contours of subjectivity in the post-AIDS era of treatment possibility.

Keywords: HIV advice, self-regulation, Foucault, ethics, governmentality, viral load, CD4 count, HIV therapy

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Introduction

In her introductory advice column, in May 2014, for South Africa's long-standing, popular and widely distributed weekly Drum magazine, appropriately entitled Beyond positive, Criselda Sambeso Dudumashe (née Kananda) provided an account of her own personal journey with HIV. She mainly addressed her grim experience with disclosing her HIVseropositivity for the first time, during a period in South Africa when not many people were educated about HIV/AIDS. Prior to the relocation of her column to Drum, her HIV advice column appeared in Bona (a SeSotho, IsiXhosa and IsiZulu word meaning "to recognize"), a popular monthly magazine that caters mostly but not exclusively to young and middle aged black women's consumer and lifestyle related issues. In addition to her advice column, website and facebook page, Criselda also hosts a weekly radio talk show programme. As described on the radio show's website, she uses the platform to deliver a message of "hope by educating simple ways of living a Positive Life with HIV by encouraging individuals to focus on personal revolution" (see Metrofm.co.za, 2015). Having declared her HIV-positive status publicly, she is today a paragon figure in the HIV community, arguably the most easily recognizable South African living openly with HIV.

For Criselda, the process of disclosure of HIV status takes on many forms, which are not always predictable. Acknowledging that disclosure of HIV-positive status can result in negative consequences, she expressed the view that the decision to disclose is a personal right that South Africa's constitution protects in its bill of rights. For her, "disclosure is a very personal and individual decision", one that takes into account "all relevant personal circumstances" (Drum, 8 May 2014: 42). Therefore, the decision to disclose is a deeply personal one; "it's not a decision you make to please others or because Criselda did it ... do it because you acknowledge that it's the right thing to do - for you" (ibid: 42). In the rest of her account, Criselda continued to present an approach for working out disclosure under different circumstances, conditions, and to different people. In the advice she offers in her introductory column in Drum, as with her advice previously in Bona, investing in one's HIV health is framed as involving the "right" personal attributes, attitudes and conducts. Of course, for Criselda, the answer to the question of what makes possible the development of the right traits and practices in relation to managing HIV is that it depends on the willingness to capacitate oneself with the information and skills required to make the choices that are in one's health and rational self-interest. Thus, if this introductory example is any guide, it is that the capacity to act independently, with all the work that this implies, is understood to be of normative and immense significance in managing life with HIV.

At the most general level, in thinking about a way of characterizing the terrain within which Criselda or other advice columnists operate in the various traditional and contemporary social media forums, Foucault's notion of "new pastoral power" offers a useful analytic construct. From this viewpoint, advice oriented magazine columns, internet blogs and televised broadcast programmes function within a general economy of "salvation", except that here salvation designates expertise led guidance that no longer revolves around "leading people to their salvation in the next world but rather ensuring it in this world" (Foucault, 1982:221). Therefore, in its secularized deployment, the new pastoral power and its related "redemptive" character denotes an arena of confessional and increasingly "popular" therapeutic avenues for seeking and providing help or advice, spanning a range of areas of social functioning and disciplinary fields (see Wilbraham, 1996; Asera et al, 1997; Rimke, 2000; Binkley, 2009; Mazanderani, 2012; Beatty & Lambert, 2013; Mazanderani, O'Neill & Powell, 2013).

In their incarnation in popular print, broadcast and social media, "practitioners" of the new pastoral power, particularly in the mold of the self-help genre - whether they be health advice columnists, psychologists, social workers or financial advisors - are linked with knowledge, professional skill and/or life experience driven expertise geared to assisting help-seekers to live physically, mentally, socially and financially healthy and enriched lives (see Fridman, 2014). That is, whether it is ΗIV, health or relationship advice, counsel on the subject of thrift or managing one's personal finances, there is no shortage of tutelary forms of expertise or life's coaches in the "globalized" public or social sphere to offer pedagogic and corrective guidance. Indeed, in the work of the new pastoral expertise more generally we can gather the prevailing value systems, rationalities, conventions and "rules of the game" under which we are expected to function within the various dimensions that make up our everyday life, not least in relation to dealing with our own health.

As experience with the spread of the HIV/AIDS epidemic in sub-Saharan Africa in the late 1980s, throughout the 1990s and into the early 2000s has shown, people living with HIV (PLHIV) were the most vocal advocates for solutions for HIV/AIDS based on existing scientific knowledge and biotechnologies, particularly those PLHIV who had participated in the early workshops on the science of the disease organized by aid agencies, global and national non-profit AIDS organizations (see Nguyen, 2004; Robins, 2004, 2005). Within this context, a type of citizenship revolving around HIV took shape -what in the literature has been variously termed biological, biomedical or therapeutic citizenship. The notion captures the various efforts associated with capacitating PLHIV with specialized forms of scientific and biomedical knowledge to assist them to manage life with HIV, including the establishing of forums primarily serving to facilitate the sharing of resources, knowledge and personal experiences with HIV (see Rabinow & Rose, 2006; Rose, 2007; Mfecane, 2011; Decoteau, 2014). Through dialogue, research, advice, technical assistance, and training, these initiatives have helped create a community of practice, with global, national and local reach.

It might be argued that an HIV advice column represents an exemplary popular form of expertise, enmeshed within the various levels of an HIV/AIDS community of practice, deriving its authority, in Criselda's case, from the columnist's own personal and intimate experience with HIV. In a sense, the advice columnist personifies the scientific knowledge and life experience upon which a widespread and affect-infused hope of salvation and managing life with HIV is projected. Moreover, we see the HIV advice column as a space for negotiating ways of understanding, relating and acting on self-identity on the basis of living with HIV. Criselda's HIV advice column is one of a kind in South Africa; she is a highly recognizable figure whose column has high readership numbers. The column potentially offers a prism through which the workings of governing oneself can be explored. This article thus marks an attempt to analyze the case of Criselda's HIV advice column with Bona magazine as a popular self-help practice founded on the promise of offering its subjects direction for enabling self-understanding and self-improvement in relation to dealing with HIV.

We first inquire into the values or norms propagated for living with HIV in Criselda's HIV advice column, especially in connection with concerns about HIV biomarkers such as stabilizing the viral load and CD4 count, as well as initiating and adhering to ARVs. With the shift to the so-called "post-AIDS era" (Dowsett & Mclnnes, 1996) - an allusion to HIV becoming a chronic condition thanks to the availability of ARVs and the development of more effective diagnostic tools for monitoring HIV, such as the viral load test - the topic of HIV biomarkers and their relation to a person's everyday experience with HIV has proven to be of considerable academic interest (see Persson, 2004; Persson & Newman, 2006; Sangaramoorthy, 2012; Newman et al, 2015; van Loggerenberg et al, 2015). This article seeks to build on this research by interrogating the popular technology of an advice column as a platform for self-help and undertaking health. Our second aim, not unrelated to our first, is to illustrate how target subjects are encouraged to understand and act on themselves. More specifically, we explore the form and nature of the self-regulation the advice column advances for readers who hope to attain the ideal of improving well-being.

With both these aims, our main interest is to understand the manner that the advice column acts as a productive and transformative technology in relation to constituting one's subjectivity and accomplishing health or avoiding illness. But first, to make good on this intervention, it is constructive to outline the conceptual framework underpinning the analysis.

 

Inscribing and governing subjectivity

The article draws upon Foucault's approach to analyzingthe ethics of self-care, combined with the perspective of governmentality. To a large degree, Foucault's work on the ethics of self-care in Greek and Greco-Roman antiquity during the latter part of his life extended and complemented his previous research on the connections between governmentality and subjectivity. In fact, as Dilts (2011: 131) has sympathetically observed, this undertaking could be viewed to reflect Foucault's "subtle but radical response to the rise of neoliberal subjectivity" in the late twentieth century in the developed countries of the West, but also globally. For Veyne (1993: 2), Foucault's recourse to ancient ethics of self-care helps him to account for the resurgence, although under a different conception of morality in the current neoliberal era, of the ".. .self working on the self, an aestheticization of the subject..."

Foucault (1992), but also others (see Dean, 1996; Rose, 1999; Campbell, 2010) who have drawn upon his approach, delineated four elements to representing and analyzing the implications of ethical edicts for self-care and self-governance: the "ethical substance" or aspect of the self recognized or determined for ethical scrutiny and cultivation; the "mode of subjection" or the way a particular aspect of the self is positioned for constitution or change in relation to a prescribed or recommended ethical or moral directive; an outline of the "ethical work" that the self is to perform on itself to accomplish transformation into an ethical subject in view of an avowed ethical directive or dictum; and, lastly, "the telos of the ethical subject" or the "mode of being" that the self is determined to accomplish in following the propagated moral and ethical directive or imperative. Indeed, the approach Foucault (1992: 28) adopted in his analysis presumed that "there is no specific moral action that does not refer to a unified moral conduct; no moral conduct that does not call for the forming of oneself as an ethical subject; and no forming of the ethical subject without 'modes of subjectivation' and an 'ascetics' or 'practices of the self that support them". Monitoring and constituting one's self, then, is always a moral and ethical endeavour. In turn, morality and ethics are always located in technologies of power. This shift in his approach allowed Foucault to consolidate both his interest in technologies of power and technologies of the self.

Foucault's pivot to ethics, or the self's relation to itself, is directly connected to his work on governmentality, what he described as the "contact point" between technologies of power and technologies of the self. For him (cited in Davidson, 2005: 127), "relations to oneself" organize around "the government of the self by the self", especially "in its articulation with relations to others ... as one finds it in pedagogy, advice for conduct, spiritual direction, the prescription of models of life ..." Therefore, the question of the self's relation to itself corresponds to how the self should govern itself: this is what Foucault implies by the term "governmentality". Most generally, governmentality refers to the various "governmental" and "non-governmental" modes of governing rationalities, tactics, strategies, calculations, reflections, practices and programmes bearing on the government of conduct, including government of the self by the self (see Dean, 1996; Lemke, 2001, 2002; Collier, 2009). The implication of the theory of governmentality, then, is that we are not governed by external factors. Instead, we are enjoined to govern ourselves through a complex and discursively loaded web of practices and programmes.

An advice column may be one point where the subtle workings of governmentality can be more easily seen.

Governmentality is the "conduct of conduct", or more specifically, a power relationship entailed in "acting upon an acting subject or acting subjects by virtue of their acting or being capable of action" (Foucault, 1982: 220-221). Materialized through a constellation of often related programmes, initiatives, campaigns and strategies, the notion captures in one sense all the work undertaken by an array of authorities, experts and individuals to steer relations of humans with their selves and with each other in order to achieve particular ends, including maintaining the health of populations and of oneself (Lemke, 2015). In another sense, governmentality reflects the ways of thinking and moralizing underlying the setting and demarcation of duties, obligations, sentiments and habits accompanying the governing of relations both with oneself and others.

For instance, drawing on lessons from the epidemic in the West, across sub-Saharan Africa HIV/AIDS prevention and treatment programs have revolved around reifying and calling forth the calculating, self-regulating and self-interested subject of neoliberal governmentality, in tandem with the framing of the epidemic within discourses of community mobilization, socio-economic development and social justice (see Robins, 2004, 2005; Comaroff, 2007; Nguyen et al, 2007). Within this call, anchored as it is around western notions of self-help, HIV-positive individuals are enlisted to work on themselves accordingly by undertaking measures to improve or gain control over their health. This emerging turn in HIV/AIDS programmes worldwide, even with the variations across different countries, calls upon individuals to govern themselves. The enterprising PLHA becomes one who undertakes self-improvement in order to maximize personal gain. This strategy is reminiscent of Foucault's (2008: 242) concept of a "generalization of the enterprise form", in which the neoliberal emphasis on profit and loss - of economic enterprise - is generalized to the ways in which individuals should calculate and maintain their own personal value, psychological life and, in this case, physical health.

Therefore, as with market initiatives of prompting or spurring consumer buying behaviour in the marketplace, health promotion campaigns in the current and global neoliberal milieu focus increasingly on cultivating self-management capabilities as a strategy for securing the health of individuals and the general populace (Ayo, 2012). By stressing the imbrication of personal conducts or habits and public health initiatives, the current trajectory of health promotion fosters the shaping of individual agency through the various mechanisms by which human biological-cum-social life is rendered governable (Rose, 2007). This trend, especially as it applies to HIV/AIDS prevention campaigns or the rolling out of ARVsto PLHIV, has been noted in South Africa and around the world (Biehl, 2007; Finn & Sarangi, 2008; Mindry, 2008; de la Dehesa & Mukherjea, 2012; Hickel, 2012).

Ethics, understood through a Foucauldian lens as the relation of the self to itself possessed of the capability for moral agency, are therefore embedded in the relations of powerthrough which we are either made governable or self-governable. Oursubjectivity is shaped by governmental initiatives, at least partly because these initiatives promote self-governance and self-regulation (see Hunter, 1996; Davidson, 2005). Subjectivity and ethics are embedded in the relations of power through which we are either made governable or self-governable. Subjectivity is thus consequential and critical to achieving the interspersing ethical and governmental aims linked to the countless social, cultural, political and economic strategies of governing societies undertaken by a range of institutions and agents. Personal empowerment or self-governance are equally the channel for constructing subjectivity and its most desired outcome (Cruikshank, 1999). Indeed, as Cousins (2015: 150) has noted of HIV/AIDS initiatives in the post-apartheid period, "the relation between the parts and the well-being of the whole" constitute the objects of concern of the various activities undertaken by different public and private authorities to control, mitigate and manage the epidemic's consequences. As will be shown in this paper, the type of self-formation Criselda's HIV advice column upholds for health undertaking practices draws upon many elements we link with the trope of neoliberal subjectivity in its characteristic valorization of the credo of individualism.

 

Method

Sampling decisions

Of the many popular advice columnists and experts found in South Africa's print, broadcast and online media, offering psychological, relationship, financial and general health advice, Criselda stands out for her first-person experience with the subject of her advice platform. In fact, most people know her more for her bravery in living openly with HIV than for her professional training as a nurse. She is one of the most well-known "agony aunts" in terms of her public profile and has many achievements, including numerous awards in recognition of her advocacy work to destigmatize HIV, her own radio programme on HIV/AIDS on a prime time slot broadcast to Metro fm's listenership of over six million people who tune in each week (News24,2015), and her regular guest appearances on various South African radio and television talk shows to reflect on her experience of overcoming her diagnosis with HIV. With the growing spread and adoption of social media at the macro and micro levels of everyday life, she is set to develop her "brand" online, whether by accruing friends on Facebook or by participating in public debates on various issues via Twitter. A quick glimpse into her online footprint, for example, shows a steady upward trend, with approximately 19 000 and 95 000 followers on Facebook and Twitter, respectively.

Aside from her influential public profile or persona, three key reasons have therefore motivated us to embark on the analysis of Criselda's HIV advice column. First, at the time the magazine issues were collected for the research we report in this article, it was the only advice column platform in South Africa to offer guidance specifically on HIV/ AIDS related issues. Other platforms - for example, "health24.co.za", "Sis Dolly" in Drum, "3 Talk" (2002-2015) and "Hello Doctor" on SABC 3 - mainly provide general health, relationship and dating advice, and they do not focus exclusively on HIV/AIDS. Criselda's advice column is organized around representing the predicaments faced, directly or indirectly, by those who are willing to speak out about their experience with HIV and solicit the guidance of expertise.

Second, even though her readership in Bona consists largely of black women, we felt the need to place it within a developing trend both here and globally of resorting to multimedia self-help forums for self-inspection, self-correction and self-empowerment. (The magazine is largely purchased by middle class Black women, but it is likely that it is passed on and read by those who cannot afford to buy it and by men). Because the column is written by a black woman and largely for black women, it is addressed not to a Western subject but to an African subject. The broader trend of multimedia self-help is very strongly situated in Western neoliberal values, and so the analysis of this advice column offers the possibility of analysing self-help directed specifically to an African subject. Because of Criselda's similarities to her readers, her HIV advice column probably has a special appeal for this audience owing to its own columnist's widely celebrated courage to stare into the vertiginous face of HIV at a time when it was viewed as fatal and much stigmatized.

Third, the choice to use this advice column is motivated by its potential to throw up the more general and contemporary workings of the relation between knowledge, expertise and subjectivity. Advice columns are explicitly simultaneously positioned as popular media, as expert opinion and as insider perspective. They are both intimately personal and resoundingly public. For Foucault (1992), these "textual forms", often pedagogical in style and expert-driven, also enjoin people to evaluate their self-conceptions and behaviours in order to identify aspects requiring improvement or modification. Analysis of an HIV advice column offers the possibility of examining both how and to what ends PLHIV are called upon to remake themselves with respect to shaping the course of their health or illness. An advice column therefore offers an avenue for assessing both the values and justifications for current modes of constituting and transforming how PLHIV subjectively relate to their condition.

Criselda's HIV advice column spanned a period of almost five years with Bona, from May 2009 to April 2014, when she moved to Drum. Collecting advice inserts across this time-span therefore allowed us to gain significant insights into the general thrust of how the self should relate to itself. All 166 advice inserts, published across 71 issues, were sourced, and both questions and answers were included. The sample was further narrowed down in line with the central focus of the broader research project (of which this paper is a part) to focus on letters specifically addressing the issue of living on ARVs. All letters were reviewed and included in the sample if they made direct reference to ARVs. Because of the strong association between ARVs and viral load and CD4 count, letters were also included in the sample if they made reference to either of these terms. The final sample therefore consisted of 55 advice inserts.

Approach to analysis

Analysis followed two stages. We began by following Braun and Clarke's (2006) method of thematic analysis in order to generate initial themes. Braun and Clarke (2006) specify that one advantage to their method is the flexibility it offers, particularly because it allows the superimposition of theory. The initial thematic analysis began with analysis of themes pertaining to viral load, CD4 count and ARVs. As the analysis progressed, it became clear that the titles of the inserts draw attention to the experience encompassed in each case - for example, "ARVs make me look fat and pregnant". The questions were very briefly or precisely posed to highlight key aspects of the nature of the problem faced by the advice-seekers' pertaining to their viral load, CD4 count and ARVs. We used each question asked as a prompt or a guide for what to evaluate in each recommendation advanced in response to the query. Initially the content was analysed, and this revealed that ARVs, viral load and CD4 count were indeed central preoccupations in the data. Theory-led questions were then applied to the data so that we could analyse how each query was framed and what remedial action each answer suggested. Importantly, we focused our attention on aspects about self-improvement and self-evaluation implicated in each response. The overall guiding question was therefore how advice inserts accentuated the relationship one has with oneself. It became quickly clear that these questions were appropriate for every advice insert, and that the question of self-improvement and self-evaluation was central to the advice column.

A second layer of analysis applied Foucault's (1992) approach to the ethics of self-care as discussed previously. We asked the following questions of each advice insert and its recommendation: a) what ethical substance or aspect of the way the self relates to itself is identified for adjustment or reconstruction; b) how or what reasons are advanced or upheld - the mode of subjection - for obligating the self to adjust or refigure itself; c) what ethical work or particular task by the self is to be performed with reference to changing the way it views and acts on itself; and d) what telos of the ethical subject or overarching goal is presented for aspiration or accomplishment? This allowed us to pursue a more directed analysis of the two broader themes that were identified.

In order to ensure quality control, both authors independently reviewed the advice inserts in order to generate a consensual analysis. We also evaluated the data in relation to its fit to the theory, so as to avoid an analysis that inappropriately imposed theory on the data. This helped us to refine the central guiding question in relation to self-improvement, self-evaluation and the relationship of the self to the self, since these questions were centrally important in the advice column. In some of the extracts below, it is clear that these concerns, of interest theoretically in this paper, are voiced in colloquial ways in the advice columns. Although limited examples are presented in this paper, they have been chosen because they are exemplary of the data: many other data extracts could have been similarly used. We have therefore presented typical rather than exceptional data inserts. In order to facilitate the resonance of our analysis with readers, we have chosen fewer extracts that have been presented in more detail rather than more frequent but briefer extracts. This is particularly important since it is both the question asked and Criselda's answer that is of relevance to the analysis.

Two main themes emerged from the analysis. First, advice-seekers, and by extension, the readership of the magazine following the advice column, are nudged to enfold the principle of investing in self-affirmation involving the responsibility of expending time and energy acquiring the capacity for risk-management for viral load increase or reduction to the CD4 count. Second, the undertaking to overcome the barriers to commencing with or adhering to HIV therapy is constructed in terms of the willingness to pursue qualified assistance on one's remedial options in the event of side effects. Each of these themes will be presented in turn, and illustrative extracts from the data will be discussed.

 

Investing in oneself in facing down HIV

An overriding point of view gleaned from the advice column is that successful reform of practices related to HIV health requires changing one's mind-set and habituating oneself to self-regulation. More specifically, readers are exhorted to place value on investing in oneself as an ethical virtue constitutive of an independent-acting subjectivity. This is promoted as a desirable state of living with HIV. Understood this way, investing in oneself for the goal of living positively with HIV designates the sort of actions, measures and initiatives concomitant with a self-caring approach to enhancing personal health, with the assistance or tutelage of medical expertise. The ability to be self-caring, as Foucault (1990, 1993) has shown, is itself lodged in one's capacity to acquire knowledge of the ways of improving oneself for the fulfilment of a desired state of being, happiness and satisfaction.

There is strong emphasis in the advice column on taking responsibility for looking after personal health and productively managing HIV. Readers are encouraged to do this by keeping watch over their HIV biomarkers and their psychosocial correlates of adjustment or resilience, which entails acquiring the information or capability to keep them in check.

Consider the example of an anonymous advice seeker who asks Criselda to explain "the difference between a CD4 count and a viral load", as well as "what should an HIV-positive person eat" to keep healthy (Bona, September, 2010: 104). Taking up the perspective and principle of investing in self-care, Criselda's response focuses on prodding the advice-seeker to take care to pay close attention to the role or influence played by the combination of emotional and psychological state on the course of the viral load and CD4 count as the most reliable bodily markers of the extent to which HIV is under control:

"The two most important blood tests for assessing how well your body is managing HIV are the viral load test, which measures the quantity of HIV in your blood, and the CD4 count, which is a measurement of your body's resistance. If your health is balanced, the viral load will go down or remain stagnant and usually, your CD4 count will rise. There are specific targets set for viral load changes that will tell your doctor if you need to be on ARVs - CD4 count should not be less than 350 and viral load less than 100 000 copies ...A healthy immune system would mean a proper healthy functioning body from eating well, treating each and every minor illness, maintaining a healthy mind that is fed positive and realistic thoughts, which will involve educating yourself about all you need to know about HIV (Bona, September, 2010:104).

An important aspect for managing HIV, this advice suggests, entails ensuring that the CD4 count is not below the target point and that copies of the virus in the body do not multiply to the extent of overwhelming one's health. The advice links enhancing the immune system's strength and vitality with the determination, disciplining and control of self facing HIV. Medical facts flow seamlessly into careful monitoring of the body ("each and every minor illness"), and then of the mind: feeding the mind healthy thoughts is directly equated with a healthy immune system.

As Criselda's intervention signals, improving the strength of one's resistance to HIV requires a keen sense of awareness and interest in regulating one's emotions. That is to say, investing in the ability to stabilize the CD4 count, viral load and emotions is important for confronting courageously the egregious consequences of being HIV-positive. What the advice in the extract mobilizes for uptake or self-consciousness, as Sangaramoorthy (2012) has shown through her work on the constitution of a "numeric subjectivity" with PLHIV, is the perspective that self-representation is a measurable or quantifiable experience inextricably linked to emotions.

The advice emphasizes self-adjustment and self-scrutiny in the quest for physical well-being, and gestures towards the obligation of learning to take responsibility in controlling HIV. This is to be accomplished by acquiring knowledge of the crucial determinants of HIV health, including the impact of both emotions and biomarkers in hindering or facilitating the on-going experience of living with HIV. Such an investment, as Criselda's advice to the anonymous advice-seeker above evinces, can have instrumental benefits if, for example, knowledge of the nutrients upon which a healthy body for also controlling the fluctuations of HIV biomarkers is adopted into a way of life. On the other hand, the benefits can be of a psychical nature or form, if they result in cultivating the capacity for the personal determination required to independently manage a life with HIV.

Take, for example, Sindiswa's case. She started on antiretroviral therapy in 2012, and initially, her CD4 count increased "from 126 to 646", though when she wrote to Criselda in 2013 it had dropped (she did not mention how far it had dropped). Her doctor changed her medication, but what she finds most distressing is that "people are starting to comment about my weight loss ... this is stressing me because I eat a very balanced diet" (Bona, November, 2013: 90). In her response to Sindiswa, Criselda starts by drawing attention to the value of taking individual responsibility for one's health in paying Sindiswa a compliment for discussing her concerns with her doctors and "having them change your medication to suit your needs" (Bona, November, 2013: 90).

For Criselda, what is important for Sindiswa to bear in mind is that for any person living with ΗIV "your CD4 count changes with your emotions; when you are happy your CD4 count is happy and vice versa" (ibid: 90). In offering her guidance to Sindiswa, Criselda advises her to "figure out what's stressing" her and to "do something about it" (ibid: 90), which as she points out, will help her manage how she feels about herself as an HIV-positive person. The ethical work of adjusting oneself that Criselda suggests involves careful scrutiny of body and mind in order not only to be a good subject but also in order to increase CD4 count. Sindiswa is congratulated on enlisting the help of doctors in her quest for self-surveillance.

One consequence of the advice just outlined is that it marks off the distinction between the imaginary and what is realistically possible in dealing with the day-to-day complexities of living with a disease that is a repository of external and internalized positive and negative projections, stereotypes and suspicions (Campbell et al, 2005; Gilbert & Walker, 2009; Cama et al, 2015). In her advice, Criselda goes so far as to present growing to accept oneself as preceding the actualization of taking responsibility for preserving one's life with HIV: "You went down a size and that is not always a bad thing. Embrace your new weight; use the mirror to say the things you want people to say to you: I am beautiful, sexy and classy. Say these words with faith until you believe them. It all begins with a thought and thoughts become things, meaning what you say you are, you become" (Bona, November, 2013: 90). From the standpoint of the advice Criselda offers to Sindiswa, nurturing the inclination to value oneself enables the ability to muster the affective resolve for valiantly navigating the day-to-day experiences and demands of living with HIV.

The advice discussed above advances the principle of self-acceptance or affirmation, which is expressed through the call for investing in oneself. It thereby links subjective constitution and reconstruction to both power relations and self-governance. Stated differently, developing the capacity to be self-managing emerges out of a confrontation with oneself to seek professional assistance and to capacitate oneself for gaining control of HIV. Taking our cue from Foucault (1982: 220), two aspects about a relation of power make self-governance possible: "that the 'other' (the one over whom power is exercised) be thoroughly recognized and maintained to the very end as a person who acts; and that, faced with a relationship of power, a whole field of responses, reactions, results, and possible inventions may open up." The "relationship of power" in this case is between Criselda and the PLHIV seeking advice from her; "the whole field of responses" that the relationship "opens up" involves the possibility of transforming, recasting and optimizing the potential of each advice-seeker to act to manage HIV, including by resorting to specialized help for further assistance.

Indeed, one of the most significant aspects of the voluntary relationship of power between Criselda and the advice-seekers is that it is motivated by an expectation by both the advisor and the advised for change. The potential for change is embodied by the weight or force of the example of Criselda's own journey from HIV diagnosis through trials and tribulations to self-affirmation. In her example, advice-seekers come to see that the prospect of internalizing possession of the power to take charge or govern oneself is a realistic possibility. Most importantly, as the next extract vividly illustrates, the relationship between Criselda and the advice-seekers works to model and perhaps naturalize the principle of growing to accept oneself through self-ownership and the freedom of choice to act independently to seek professional guidance:

"Dear Criselda: I have been to the doctor several times trying to increase my CD4 count but it keeps dropping. I'm doing my best to eat and stay healthy. What am I doing wrong?Sy, Kwa-Thema."

"Dear Sy: Your CD4 count increases and drops according to your emotional state. It will be at its lowest when you are stressed, anxious, depressed or scared. You know your life and circumstances better so try and identify what could be causing the above, seek professional help and deal with it. Focus on living a better life, treat minor illnesses as they occur, address any fears and perceptions you might have about living with HIV" (Bona, April, 2011: 84).

In this advice, to think of HIV health as an activity involving decision-making is concomitant with the willingness to seek out expert assistance, medical or otherwise, in order to obtain guidance and develop the capability to deal independently with the on-going experience of living with HIV. Moreover, the advice to Sy that "your CD4 count increases and drops according your emotional state" is startling for what it accomplishes: it elevates the implicit logic that improving one's body is contingent on improving one's mind, and therefore promotes psychic government as a crucial aspect of managing one's health. In Criselda's "pastoral-like" lexicon, the ideal form or measuring rod of what it means to be HIV-positive depends upon the possibility of becoming responsible for one's health.

This advice suggests that working to improve one's resistance to HIV by boosting the immune system's strength and vitality in all the ways necessary or possible constitutes a desirable psychical dividend; it entails the possibility of cultivating a better view of oneself as a person living with HIV. In the next section, we examine a similar ethical call to self-improvement and self-evaluation in relation to the theme of dealing with the side effects of starting with and adhering to HIV therapy.

 

Stepping up to personal anxieties, fears and barriers to HIV therapy

The analysisabovehighlightsthe extent to which,from the perspective of Criselda's advice column, negotiation of life with HIV is viewed through the personal or individualistic investments so characteristic of contemporary neoliberalism. To borrow Rose's (1999: 256) apt and very useful phrase, the privileging of the logic of personal development typical of neoliberalism is all the "more profound because it appears to emanate from our autonomous quest for ourselves, it appears as a matter of our freedom." Furthermore, as Hamann (2009: 54) has observed of the proliferation of neoliberal rationality in the social, political and cultural spheres, "the imposition of market values" invariably leads to "the evisceration of any autonomy" or neat separation "among economic, political, legal, and moral discourses, institutions, and practices." In other words, for personal empowerment or investment to properly operate as the productive force it is, it needs to capture its subject's ethical imagination and turn it into an aspirational model or ethos of self-practice.

According to Brown (2005), neoliberalism as a governing rationality or an ethical regime of relating to oneself inscribes almost all of social and political reality with a market sensibility, whereby developing and improving on present capabilities maximizes "future value" or prospects. Binkley (2009) has argued that neoliberal self-government as anchored around increased freedom and privatization therefore centrally involves investing in oneself, in a similar way to the neoliberal subject's habit of investing money, time, or even affection for oneself in anticipation of a desired present or future return. For example, as the next extract from Criselda's HIV advice column illustrates, investing in oneself - maximizing one's value - involves the ethical work of orderly, sensibly and moderately conducting oneself to reach the objective of overcoming one's fears or anxieties to commencing with HIV therapy:

"Dear Criselda: Is it true that you can start behaving in a crazy way when you start with taking ARVs? I rent a backroom and am about to start treatment. I can't afford to go around acting like a crazy person. Please help! Sophie, Kwa-Guqa."

"Hi Sophie: I would not quite refer to this as going mad or acting crazy. There are, how ever, some side effects to certain antiretroviral medication, which includes suffering from hallucinations (seeing things that aren't really there). But not all antiretrovirals have this as a side effect. Before you start treatment, talk to your doctor about your fears and concerns. Ask questions that will give you as much information as possible and help you to deal with any possible consequences of taking your medication ... Well done for asking about this myth and for not taking it as the gospel truth" (Bona, February, 2011: 82).

Much like a worker in the labour market enjoined to invest in the development of the skills, knowledge and abilities "that increases the capacity to earn income, to achieve satisfaction" (Read, 2009: 28), in Sophie's case, acquiring the knowledge to manage the side effects of HIV therapy promises gains for her health and for the psychic income of freely exercising responsibility for her well-being.

Beyond asking her doctor the types of questions that empower her to deal with the frightening consequences of starting with HIV therapy, as important for Sophie is psychic and bodily capacitation to enable her to reduce the social attention that side effects could draw to her. Persson (2004, 2005) has shown with her participants who reported a range of body shape changes owing to their long-term use of HIV therapy that ARVs hold both the possibility of both resurfacing and concealing HIV status, depending on the commensurability of the medication with the person. Thus, if the willingness to attain information on side effects produces the capacity to start with ARVs, this itself would be an accomplishment for Sophie; in learning to govern herself by investing in her own health, she will normalize or adjust to HIV therapy. Mobilized through a form of "economic rationality" or "grid of intelligibility" (see Foucault, 2008), Sophie is told that reducing the costs of the side effects of initiating ARVs - or increasing the opportunity gains of HIV therapy - is a personal responsibility.

Living productively with HIV is possible through acquiring the requisite knowledge and also the psychical skills and capabilities required. For this reason, the problem of negotiating the side effects of ARVs is all the more challenging in view of the necessity of stepping up to the anxieties or fears of commencing with or adhering to the therapy.

In a globalized culture already streaked with the tendency for psychologizing all manner of social problems (see Rose, 1998, 2008; Hook, 2004; Rutherford et al, 2011; Scharff, 2016), for Criselda, the initiative of gathering the information to help one manage the side effects of starting with HIV therapy is itself rooted in an imperative to overcome personal anxieties, fears and barriers. Indeed, the reader's worry about the possibility of side effects (referred to by Criselda as a "myth", although side effects are indeed possible) is addressed by applauding Sophie's bravery and focusing on the pursuit of autonomy and knowledge. A concern about the physical becomes solved through psychic work. That way, one is enabled to pursue the deep and very personal transformations that are needed to combat life with HIV.

In encouraging its advice-seekers and readers to be little more than self-interested subjects with the potential to optimize their choices, as the following extract shows, the advice column draws on a particular type of psychological discourse. The personal adjustment and development required for solving the physiological problems of HIV is championed through the work of capacitating oneself from a psychological or emotional point of view:

"Dear Criselda: I am an HIV-positive person, but I refused to take the treatment because of their side effects, especially body disfigurement (severe body changes). But since the government announced that as of April this year there will be only one pill to treat HIV, I will start the treatment. What are the side effects of this new pill? Maureen, via email".

"Dear Maureen:.. .You are not alone; everyone is worried about side effects before they start treatment... Many people put up with side effects when they could change to another treatment and this is not good. Before starting treatment, learn about the side effects that can occur with the drugs you are going to use. Ask your doctor, nurse, or HIV pharmacist about how likely they are to occur. Ask how many people stop treatment because of them (usually very few). Even rough estimates will give you a good idea of what to expect. Ask other people taking the drugs for their experience. This way you will know what to look out for. Taking ARVs can never replace counselling to help deal with fear, anxiety and other health challenges. Ask your doctor questions that would help you deal with your fears. No need to fear; information gives you power" (Bona, March, 2013:51).

Self-help, here, means that expertise intervenes to produce a relationship of help in the self's relation to itself; self-help implies asking experts for advice. Within a Foucauldian perspective, as Butler (1997: 3) has noted, "the form this power takes is relentlessly ... a turning back upon oneself or even a turning on oneself." While the relationship is initiated through expertise, it is dependent on those seeking help investing in their bodies, minds and emotions in bringing about their own self-transformation. In the exchange between Criselda and Maureen, the potential for self-help builds a bridge between the specific issue of tolerating side effects (when one "could change to another treatment") and the much larger issue of substituting helplessness for individual empowerment. The psychological work involved in achieving this ideal involves dealing with one's "fear, anxiety and other health challenges" related to commencing with HIV therapy.

By aspiring to overcome the anxieties, fears and barriers to beginning ARV treatment, PLHIV are enlisted to take responsibility for reducing the risks of non-adherence to anti-HIV drugs. This ideal arguably serves not only their own individual health, but also the vision of a South African society pushing back the HIV/AIDS epidemic. Criselda's recommendation to Maureen to "learn about the side effects that can occur with the drugs", and to ask health practitioners about the likelihood of their occurrence, is also a broader call to adhere to ARV treatment and to undertake personal risk reduction and risk management. This link of risk management to personal investment is constitutive of subjectivity: taking personal responsibility is offered as a way not only to reduce health risks but also to take back control of personal destiny (see Ericson et al, 2000).

National and global HIV/AIDS treatment guidelines (see SANAC, 2011; WHO, 2012; WHO, UNICEF, UNAIDS, 2013), with their attempts at espousing and cascading the best scientific practices, are filled with expressions of "indicators", "benchmarks" and "objectives" as a way of highlighting the collective risk of ARV side effects and resistance for PLHIV. Criselda draws on this language too in her column. For example, Nobenani's HIV-positive brother has been on ARV treatment for two years, but "now he feels healthy and strong" and "wants to stop the treatment" (Bona, July, 2012: 110). According to Criselda, "ARVs are currently regarded as a lifelong commitment, as per the World Health Organization's guidelines ... Scientists advise that when a person stops treatment they risk having resistance to drugs should their health deteriorate and ARVs are once again necessary ... once the decision is made, it's for life" (ibid: 110). Perched on the absolute certainty of scientific guidelines the advice to Nobenani also serves to promote self-responsibilization, thereby individualizing the responsibility for adherence, and to encourage recourse to expertise.

In the sweep of Criselda's advice to Nobenani, a special responsibility is constructed for her audience to proactively manage personal risks to their health. Taking responsibility when commencing with or adhering to HIV therapy is linked to the personal benefit of averting the problem of ARV treatment resistance in the longterm. Indeed, not only the individuals who write to Criselda but her audience in general are enjoined to re-actualize their selves through a subjective formation of self-governance, self-improvement and self-evaluation.

 

Concluding remarks

In this article, we have presented an appraisal of Criselda's popular platform for seeking HIV advice and its implications for reinventing subjectivity. This popular advice column, we have argued, offers a potential lens for interrogating the possible ways in which subjectivity is rearticulated in the post-AIDS era of treatment possibility and self-management. For Criselda, the key to rising above the threat posed by an unmanaged life with HIV lies in the principle of personal investment. Investment in the acquisition of knowledge and skills is insufficient without concomitant self-affirmation and self-monitoring, including of one's psychological state. Resorting to expert knowledge and guidance provides an opportunity for realizing self-control by acquiring the capability to successfully monitor key indicators of HIV progression, and by commencing with and adhering to ARV treatment. In effect, this advances a subjective vantage point from which to survey the ethical imperatives of gaining control of HIV and curtailing its risk for society. Crucially, a subjective vantage point is offered from which to monitor the self. From this position, overcoming HIV is a choice like any other and, armed with facts and professional assistance, it is possible to start managing it.

To the advice-seekers and Criselda's broad readership, the HIV advice column offers the promise and hope that, by taking its message seriously, PLHIV can succeed on their own, even against the sometimes debilitating and burdensome obstacles of living with HIV and the demanding work encompassed in ploddingthrough the side effects of using HIV therapy. Moreover, the advice columnist's own exemplary battle against HIV suggests that becoming self-governing is and should be the greater objective for PLHIV.

There are necessarily limits to the extent to which the analysis offered in this paper can explore implications for reinventing subjectivity. An advice column by definition allows access only to a questioning voice and to Criselda's answer. What is not available for public scrutiny is how advice seekers respond to her advice or how the broader readership accepts or rejects her position. How people engage with the advice Criselda offers will be mediated by the complexities of their life circumstances, contexts and already multiply constituted subjectivities. The self-help genre is itself located in a very specific context that may foreground Western rationalist approaches to personhood. For many PLHIV in South Africa, a plurality of value systems and rationalities exist, along with their accompanying discourses for representingselfhood, includingAfrican "moral-aesthetic" views about personhood and their implications for perspectives on health and illness. The public form of the advice column, however, offers an important lens on how selfhood is shaped and governed.

The analysis offered in this article suggests a strong emphasis on the individualization of responsibility, the value of expertise and the imperative to improve and monitor the self. A very normative and self-governing subject is presented as the ideal, and in the process other kinds of subjectivities are potentially devalued. A critique of Criselda's advice column suggests important possibilities for resisting self-entrepreneurialism and for undermining the seemingly rational processes of self-governance.

At the same time, however, in the face of challenges to HIV adherence that risk lives, it is important to conclude by considering the potentially transgressive or transformative possibilities. For us, her advice column - as with similar platforms and the typical solutions they offer for thinking and acting on oneself - presupposes, and thus constitutes, a certain aspirational space that lies between knowledge, expertise and subjectivity. Most especially, they take the form of demystifying and democratizing the nexus of knowledge and expertise in ways that promise to unshackle subjectivity from its own inhibiting characteristics, processes and vices that limit its ability to realize its potential for assuming agency over life and the future. Equally important, they also simulate actual supportive gathering forums enabling their audience to be encouraged and learn from one another or from those who are willing to articulate their private but most likely shared health and illness predicaments or trajectories. The challenge perhaps is to simultaneously undermine and embrace this aspirational space so as to both unsettle and explore the reinvention of subjectivity in the post-AIDS era.

 

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* Corresponding author: nkululeko.nkomo&wits.ac.za