Social Science & Medicine 330 (2023) 116036

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Social Science & Medicine

journal homepage: www.elsevier.com/locate/socscimed

Biomedical bargains: Negotiating “safe sex” on antiretroviral treatment in

rural South Africa
Nicole Angotti a, b, *, Sanyu A. Mojola b, c, d, Yunhan Wen c, Abby Ferdinando a
a
Department of Sociology, American University, USA
b
MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand,
Johannesburg, South Africa
c
Department of Sociology, Princeton University, USA
d
School of Public and International Affairs, and Office of Population Research, Princeton University, USA

A R T I C L E I N F O A B S T R A C T

Handling Editor: Medical Sociology Office Wide-scale availability of antiretroviral treatment (ART) has transformed the global landscape for HIV preven­
tion, shifting emphasis away from a strictly behavioral focus on changing sexual practices towards a biomedical
Keywords: approach. Successful ART management is measured by an undetectable viral load, which helps maintain overall
Aging health and prevent onward viral transmission. The latter utility of ART, however, must be understood in the
Biomedical bargains
context of its implementation. In South Africa, ART has become easily accessible – yet ART knowledge spreads
Safe sex
unevenly, while counseling advice and normative expectations and experiences of gender and aging interact to
HIV
Antiretroviral treatment (ART) inform sexual practices. As ART enters the sexual lives of middle-aged and older people living with HIV
Treatment as prevention (TasP) (MOPLH), a population growing rapidly, how has it informed sexual decisions and negotiations? Drawing on in-
South Africa depth interviews with MOPLH on ART, corroborated with focus group discussions and national ART-related
policies and guidelines, we find that for MOPLH, sexual decisions increasingly feature compliance with
biomedical directives and concern for ART efficacy. Seeking consensus regarding the biological risks of sex on
ART becomes an important feature of sexual negotiations, and anticipated disagreements can pre-empt sexual
relationships altogether. We introduce the concept of biomedical bargains to explain what happens when dis­
agreements arise, and the terms of sex are negotiated using competing interpretations of biomedical information.
For both men and women, ostensibly gender-neutral biomedical discourses provide new discursive resources and
strategies for sexual decisions and negotiations, yet biomedical bargains are still embedded in gender dynam­
ics—women invoke the dangers of jeopardizing treatment efficacy and longevity to insist on condoms or justify
abstinence, while men utilize biomedical arguments in an effort to render condomless sex safe. While the full
therapeutic benefits of ART are critical for the efficacy and equity of HIV programs, they will nonetheless always
affect, and be affected by, social life.

1. Introduction
The wide-scale availability of antiretroviral treatment (ART) for HIV
has transformed the global landscape for HIV prevention. By reducing
the amount of HIV in the body (viral load), ART improves and prolongs
the lives of those living with HIV. Moreover, scientific research has
increasingly shown that ART can prevent sexual transmission of the
virus once an undetectable viral load (or viral suppression) is achieved
(Quinn et al., 2000; Attia et al., 2009; Cohen et al., 2016). This epide­
miological utility of ART has ushered a paradigm shift in HIV preven­
tion. While behavioral approaches aimed to prevent HIV transmission at
the individual level by changing sexual practices (e.g., through absti­
nence, fidelity and condom use), ART enables a biomedical approach
that strives to achieve viral suppression at the population level — when
all people living with HIV are treated and virally suppressed, new in­
cidents of HIV infection can also be minimized (Eaton et al., 2012). The
use of ART for treating and preventing HIV, or treatment-as-prevention
(TasP), is the scientific rationale for the “treat-all” global HIV policy
recommendation that all people living with HIV be initiated on ART
upon diagnosis (World Health Organization, 2016). Biomedical in­
terventions, however, are always social interventions (Adam, 2011).
While studies have explored why local contexts make HIV interventions

* Corresponding author. American University, Department of Sociology, 4400 Massachusetts Ave., NW Washington, DC 20016-8072, USA.
E-mail address: angotti@american.edu (N. Angotti).

https://doi.org/10.1016/j.socscimed.2023.116036
Received 3 June 2022; Received in revised form 12 June 2023; Accepted 15 June 2023
Available online 17 June 2023
0277-9536/© 2023 Elsevier Ltd. All rights reserved.
N. Angotti et al.
less effective than expected (Mojola and Wamoyi, 2019; Van Damme
et al., 2012; Auerbach et al., 2011), what requires equal scholarly
attention is how such interventions, in turn, change the social world of
those for whom they are intended.
In this article, we focus on how the wide-scale availability of ART
informs the sexual practices of middle-aged and older people living with
HIV (MOPLH, hereafter) in the rural northeast of South Africa, among
whom 23% of the population aged 40-plus is living with HIV, 63% of
whom are on ART (Rohr et al., 2020). Our study site is advantageous
because the availability of ART has been scaled up considerably in South
Africa since 2016 with universal Test and Treat (UTT), a policy imple­
mented in line with recommendations from the World Health Organi­
zation (UNAIDS, 2016). The increasing ubiquity of ART, however, does
not mean that ART’s utility in preventing the sexual transmission of HIV
is universally known. Not only does biomedical information spread
unevenly, but the way it gets interpreted and put into practice also
varies. Consequently, the meaning of “safe sex” is in flux. While con­
domless sex can become “safe” again on the condition of viral suppres­
sion, the prominence and enduring influence of behavioral approaches
to prevention focused on changing sexual behaviors remain, along with
existing cultural discourses on sex that are morally-laden, gendered and
ageist. We focus on everyday sexual practices because sex is a crucial
part of social life and the most problematized, discussed and regulated in
HIV prevention programs. With increasing reliance on biomedicine to
address HIV and unevenly spread biomedical information, how has the
wide-scale availability of ART informed MOPLH’s understanding of
“safe sex” on ART? And how has that understanding, in turn, shaped
how MOPLH negotiate it?
Based on in-depth interviews with MOPLH on ART conducted in
2018, two years after ART became widely available in South Africa to
anyone testing positive for HIV, we find that compliance with biomed­
ical directives and concern for ART efficacy weigh heavily on MOPLH’s
sexual decision-making. Seeking consensus on the biological risks of a
sexual decision becomes an important feature of sexual negotiations,
and anticipated disagreements can pre-empt sexual relationships alto­
gether. We introduce the concept of biomedical bargains to explain what
happens when disagreements arise, and the terms of sex are negotiated
using competing interpretations of biomedical information. This seem­
ingly gender-neutral concern for biological risk nonetheless has
gendered dimensions—we find that women were more likely to invoke
the dangers of jeopardizing treatment efficacy to insist on condoms or
justify abstinence, while men utilized biomedical arguments in an effort
to render condomless sex safe. For both men and women, biomedical
discourses have become an important new resource in the “cultural
toolkit” (Swidler, 1986) for making sexual decisions and negotiating the
terms of sex. When biomedical information becomes a significant part of
such available discourses, it is critical to remain attentive to how those
living with HIV differentially receive, interpret and utilize messages
around biomedical interventions.
1.1. Translating biomedical information
Our findings have important implications in a context where HIV
management is increasingly addressed through biomedicine, given the
“epistemic fault line” between “the Olympian view” of the population
science of public health and the everyday practices of individuals who
make sense of bio-technologies based on “popular knowledge, moral
reasoning and cultural presumptions” (Adam, 2011: 6). In describing
this epistemic fault line, Adam (2011) called for empirical investigation
into “how the actuarial reasoning of health science translates into per­
sonal risk strategies” (7). For people living with HIV, the scale-up of ART
may unsettle previous understandings about the biological conse­
quences of sex. While ART reduces transmissibility, this benefit is not
easily achieved— HIV is untransmissible only when viral loads become
undetectable, yet viral loads may temporarily increase due to “viral
blips” (Sörstedt et al., 2016). Viral suppression, once achieved, also
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Social Science & Medicine 330 (2023) 116036
requires continuous maintenance through good adherence (National
Institute of Allergy and Infectious Diseases, 2020). Moreover, although
individuals who are virally suppressed effectively have no risk of
transmitting HIV to their sexual partners through condomless sex, they
may risk infection from a different variant of the virus if their sexual
partner is not virally suppressed (Centers for Disease Control and Pre­
vention, 2022).
The nuances of these biomedical processes leave room for competing
interpretations of what constitutes “safe sex.” This is particularly the
case when those interpretations are informed by differential dissemi­
nation and translation of scientific information to those on the receiving
end of health directives. While messages about HIV emanate from
various sources, including religious organizations ( Trinitapoli and
Weinreb, 2012), social media (Hamid et al., 2020), as well as everyday
conversations (Watkins, 2004), we highlight the role of health workers
as the conduits of those messages, since they are the most common
source of information about HIV prevention and treatment and also
frequently invoked by respondents.
Despite the wide-scale availability of ART, health providers do not
consistently convey ART’s full therapeutic benefits, namely how viral
suppression can prevent the sexual transmission of HIV (Bor et al.,
2021). This inconsistency partly comes from providers’ discretion,
whereby messages are tailored to specific encounters with specific pa­
tients. For instance, in Uganda, Russell et al. (2016) found that providers
offered different instructions on how to self-manage HIV on ART—they
urged men to “give up on multiple partners” while imploring women to
“abstain (if you can)” (1452). Providers’ discretionary actions are also
informed by the calculation of other risk factors. In a study from Kenya,
focused on the counseling experiences of sexual partners in sero­
discordant relationships, Ngure et al. (2020) found that some providers
avoided discussing ART’s ability to reduce HIV transmissibility for fear
that doing so would encourage their clients to engage in multiple sexual
relationships; providers also feared that they would be blamed if their
clients contracted HIV. Another part of the inconsistency, however,
comes from providers’ varying degrees of knowledge of the most
up-to-date scientific findings. Lippman et al. (2020) found that less than
half (42%) of the providers surveyed in rural South Africa knew that
consistent viral suppression can prevent HIV transmission and “fewer
understood the nuances of counseling around undetectable viral load
and HIV transmission” (e10). Similarly, in a different region of South
Africa, Mabuto et al. (2021) observed that condoms were emphasized in
almost all post-test counseling sessions to “prevent HIV-related com­
plications, CD4 decline, and HIV reinfection” (1591).
Our respondents’ recollection of counseling messages is consistent
with what Lippman et al. (2020) found, although recollection cannot
completely replace direct observation of patient-provider encounters
(Mabuto et al., 2021). Our primary focus, however, is how MOPLH use
biomedical information to explain their sexual practices and how they
invoke biomedical arguments in their sexual negotiations. Yet,
biomedical discourses do not arise in a vacuum. From who gets to know
them to how they are used, biomedical discourses often interact with
norms, expectations and experiences related to gender and aging to
inform sexual practices.
1.2. Aging, gender, sexual risk and negotiations
The HIV epidemic is aging—increasing numbers of adults are living
with or acquiring HIV at older ages and enrolling onto ART (Negin and
Cumming, 2010; Gómez-Olivé et al., 2020; Rohr et al., 2020). As people
transition out of child-bearing years, bio-physiologically-driven declines
in sexual desire and functioning become imbued with gendered mean­
ings (Freeman and Coast, 2013; Van der Geest, 2001; Mojola et al.,
2021). In rural South Africa, normative expectations for women
encourage them to constrain their sexuality as they age, remaining
faithful to their partner (if married) and practicing celibacy following
widowhood (Angotti et al., 2018; Mojola and Angotti, 2019). Norms for
N. Angotti et al.
women align with the disciplinary moral discourses of HIV prevention
messages, which emphasize abstinence or marital fidelity (Giami and
Perrey, 2012). For men, however, multiple partnering has been
normative both within marriage (polygamy) and outside of it (Hunter,
2005). While men might have less sex as they age, norms that support
men’s multiple partnering work against HIV-era abstinence and fidelity
injunctions, making condom use a potentially more malleable preven­
tion feature among couples trying to prevent HIV acquisition or
transmission.
Importantly, for people negotiating the terms of sex, biological risks
are only part of the calculus of risk assessment, particularly when eco­
nomic, relational and cultural considerations are at stake (Warren et al.,
2018). Male condoms, in particular, have suffered a litany of
non-biomedical objections to their use—not only because they
compromise pleasure, but because they also undermine trust and in­
timacy; they are thus deemed more appropriate for casual sexual en­
counters, not for marriage or more serious relationships (Chimbiri,
2007; Mojola, 2014). As a “male-controlled” technology, condoms have
also been harder for women to negotiate (Amaro, 1995; Matick­
a-Tyndale, 2012). Strategies such as confronting extra-marital girl­
friends or terminating relationships, have been some alternative ways
women have sought to avert HIV risk (Schatz, 2005), though such
strategies also introduce the social risk of relationship discord (Warren
et al., 2018). Relatedly, the material dimensions of sexual partnerships
are a key source of relational disadvantage—economic dependence on
men can compromise women’s ability to negotiate condom use with
male partners (Stoebenau et al., 2016). This gendered tension in condom
negotiations, however, may change as people living with HIV age. While
material considerations continue to matter, for older South Africans in
particular, economic asymmetries shift with the availability of old-age
pensions by providing women equal access to financial resources
(Schatz and Ogunmefun, 2007), which may increase their leverage to
insist on condoms. Older men’s reliance on women’s caretaking (Schatz
and Seeley, 2015) may also add new social risks to dismissing women’s
requests.
For MOPLH on ART, although these non-biomedical considerations
inform their sexual decisions, what we find note-worthy and focus on in
this paper is the heft of direct consideration given to biological risks,
biomedical directives, and concern for treatment efficacy. We identify
biomedical bargains as a mechanism used by MOPLH to seek consensus on
the biological risks of sex, using competing interpretations of biomedical
information. For MOPLH, while biomedical consequences can be
determined using non-biomedical reasoning (e.g., “I am faithful”), we
emphasize that biomedical bargains refer to arguments framed in
biomedical terms (e.g., “We are both on treatment”). When consensus is
anticipated to be difficult, MOPLH may terminate or avoid sexual re­
lationships altogether. As the terms of sex are negotiated through
ostensibly gender-neutral claims on the biomedical processes that make
sex on ART safe or unsafe, the gender dynamics of sexual negotiations
for MOPLH may also change—notably, the challenge to women’s
insistence on condoms becomes a biomedical one. Overall, we aim to
show, in the era of widespread ART, how the cultural “toolkit” (Swidler,
1986) for MOPLH’s sexual decisions and negotiations increasingly
feature biomedical arguments.
2. Data and methods
Our study takes place throughout villages comprising the Agincourt
Health and Socio-Demographic Surveillance System, which is run by the
University of the Witwatersrand and located in the rural northeast of
South Africa (Mpumalanga Province) (Kahn et al., 2012). The primary
ethnic group is the XiTsonga/Shangaan-speaking amaShangaan. HIV
testing services in the area were not widely available until the early to
mid-2000s (Snow et al., 2010). ART became available in public hospitals
in the area between 2004 and 2005, in some clinics in 2008, and more
widely by 2011 (Mee et al., 2014). In 2016, UTT changed the clinical
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Social Science & Medicine 330 (2023) 116036
guidelines for ART eligibility such that anyone testing positive for HIV
would be eligible for treatment (National Department of Health South
Africa, 2016; UNAIDS, 2016).
Data were collected as part of the HIV after 40/Izindaba Za Badala
study, a longitudinal study examining experiences of aging during a
severe HIV epidemic. The study began in 2013 with a cohort of 60
people living with and without HIV who had participated in a
2010–2011 HIV/NCD prevalence and risk factors study (Mojola et al.,
2015); a five-year follow-up was conducted in 2018. For this analysis,
we utilize data from the 2018 follow-up, since by then, ART was firmly
established in the normative landscape for HIV care (Mojola et al.,
2022). Our data include individual in-depth interviews (IDIs) and focus
on 21 participants (11 women, 10 men, aged 45-plus) from the HIV after
40/Izindaba Za Badala cohort who disclosed living with HIV and taking
ART. The IDIs addressed family lives, work, romantic relationships, and
the experience of living with HIV and chronic health conditions; clinic
experiences with ART initiation, counseling and management; and
everyday life on ART. Since our respondents were initiated on ART at
various times, we use national guidelines between 2004, the year ART
became freely available in South Africa, and 2018, the year the in­
terviews were conducted, to see how ART-related guidance has evolved
and note that guidelines between 2004 and 2018 all mention that people
on ART should regularly interact with health facilities for routine
monitoring (National Department of Health South Africa, 2004; Na­
tional Department of Health South Africa, 2010a; National Department
of Health South Africa, 2013; National Department of Health South
Africa, 2015). Even if our respondents never learned more about ART
after treatment initiation, to observe how they utilize such information
in 2018 nonetheless provides valuable insights into the local realities of
ART’s wide-scale implementation in South Africa.
We corroborate findings from the IDIs with community focus group
interviews (FGIs) with 84 women and men aged 40-plus, also conducted
in 2018. FGI participants were recruited from community gathering
places, such as markets and pension collection points. The FGIs included
semi-structured questions and vignettes depicting hypothetical sce­
narios of similarly-aged women and men (Barter and Renold, 1999). We
use FGIs for an understanding of normative expectations informing ART
use for MOPLH. With our interest in MOPLH’s sexual practices, we
analyzed the hypothetical scenario in our FGIs that was most relevant to
our inquiry, namely, whether participants think a widowed woman their
age and on ART could date or marry again.
IDIs and FGIs were conducted in XiTsonga/Shangaan by a team of
five interviewers from the study area. The interviews were translated
and transcribed into English by the interviewers and reviewed by two of
the study’s lead investigators for clarity. All respondents provided
written informed consent for study participation. Ethical approvals for
the study were provided by the authors’ institutions, as well as the
University of the Witwatersrand Human Research Ethics Committee and
the Mpumalanga Province Department of Health Research and Ethics
Committee.
To locate national ART-related policies and guidelines, we used the
Department of Health (DoH) website (https://www.health.gov.za/) and
a professional development platform used by the DoH for training health
care providers (https://www.knowledgehub.org.za/). We also con­
sulted scholarly articles citing South Africa’s ART-related policy docu­
ments (e.g., Majaya et al., 2021), which pointed to additional documents
archived on the Southern African HIV Clinicians Society website (htt
ps://sahivsoc.org/). The latest documents we could locate between
2004 and 2018 were documents published in 2016.
3. Analytical approach
We analyzed the data in NVivo 12 using an abductive approach, an
inferential, iterative process that identifies “surprising” empirical evi­
dence in light of extant theories and knowledge of context (Timmermans
and Tavory, 2012). Given the benefits of ART use, we were surprised to
N. Angotti et al.
find in the IDIs that women feared sex on ART would complicate
treatment efficacy. Suspecting the fear came from what health workers
told them, we next looked for counseling messages reported by re­
spondents and found it to largely emphasize behavioral change (e.g.,
condom use, abstinence), with an overall absence of information on how
successfully managed ART reduces sexual transmission of HIV. Recog­
nizing that this could either come from health workers’ lack of provision
or from respondents’ lack of reporting, we consulted national
ART-related policies and guidelines and observed that treatment guid­
ance often mentions ART’s overall benefit of reducing transmission
without detailed information on the nuanced nature of sexual trans­
mission on ART nor its potential sexual benefits.
Nonetheless, we found that respondents frequently used biomedical
language to explain their sexual practices. In accordance with the
abductive research cycle of “revisiting, defamiliarizing, and alternative
casing” (Timmermans and Tavory, 2012: 180), we recoded the IDIs to
identify linkages between biomedical discourses used by respondents
when discussing their sexual practices. This brought us to the concept of
sexual negotiations as a series of biomedical bargains.
In the presentation of our findings below, we retained the vernacular
English from the interviewers’ translations but inserted clarifying words
in brackets and made minor grammatical edits for readability. We used
pseudonyms to preserve respondent confidentiality.
4. Translating ART directives
Before UTT, ART eligibility was determined by severity of conditions
based on CD4 counts (which had to be low enough) or clinical staging
criteria. Between 2004 and 2016, the CD4 count threshold for ART
eligibility was raised in treatment guidelines several times (e.g., from
<200 in 2004, to <350 in 2013), recognizing the importance of timely
initiation of ART to “achieve best health outcomes” and to “prevent new
infections among children, adolescents, and adults” (National Depart­
ment of Health South Africa, 2010b: 1; National Department of Health
South Africa, 2013: 4). In 2016, UTT was implemented, which removed
prior eligibility requirements for ART (National Department of Health
South Africa, 2016).
Throughout the years, ART’s utility in reducing HIV transmission is
noted in South Africa’s policy documents and treatment guidelines. For
example, as early as 2004, the national guidelines note the secondary
goal of ART as “reducing transmission in discordant couples” (National
Department of Health South Africa, 2004: 2); in 2010, guidelines note
that timely initiation of ART needs to be ensured “for treatment and
prevention” (National Department of Health South Africa, 2010a: 7).
Although explicit references to the TasP paradigm were not mentioned
until the National Strategic Plan for 2017–2022 (South African National
AIDS Council, 2016), published after UTT’s implementation, UTT is the
culmination of a policy trend informed by the TasP logic (Brault et al.,
2019), which aims “to reduce the incidence of HIV infection in South
Africa through the provision of expanded prevention and treatment
options” (National Department of Health South Africa, 2016: 2).
Although ART’s utility at reducing transmissibility has been consis­
tently emphasized in policies and guidelines, the sexual benefits have
not—instead, guidelines routinely recommend condom use. Indeed,
condomless sex on ART can be “risky” if viral loads remain detectable;
however, recommendation of strict condom use is often mentioned in
the guidelines without an explanation of the link between viral loads
and sexual transmission. This apparent omission creates a seemingly
incompatible message, evident also in the counseling practices of health
providers. Lippman et al. (2020) study, which was conducted in 2018 in
the same rural South African study site as ours, found that 78–79% of
providers reported counseling patients who are virally suppressed to
always use condoms. Moreover, only 42% of providers indicated an
awareness of ART’s benefit in preventing sexual transmission of HIV
among adherent, virally suppressed patients. Among those who were
aware, only 61% of them reported sharing this information with HIV
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Social Science & Medicine 330 (2023) 116036
positive patients (Lippman et al., 2020). This means that condom rec­
ommendations to those on ART can be made with few, inconsistent, or
even, incorrect explanations (Mabuto et al., 2021). Moreover, it also
shows that not only did information regarding ART’s prevention benefits
spread unevenly among providers, but for providers who had the in­
formation, they selectively shared it with patients.
Health provider discretion is not surprising considering the varied
circumstances encountered by people diagnosed and living with HIV. In
fact, national guidelines for adherence note that “individual ART edu­
cation is recommended” as is “one-on-one adherence support to patients
through adherence counseling” (National Department of Health South
Africa, 2016: 20). The counseling experience of Nomhle, a widowed
woman in her 50s, poignantly illustrates how health workers adapt
counseling messages to the characteristics of their clients:
They [health workers] are telling us to take our treatment in a good
way. It is like now as I’m a woman. They will ask whether I have a
partner or not. If you have one, they will tell on how you can live
your life. Even the one who doesn’t have a partner will be told on
how to live. They encouraged us who don’t have partners to live like
that. It is not good to have more than one partner as you will limit the
number of your living days on earth … They encourage us not to
have partners as they are saying sometimes we can get the ones who
will not want to use condoms and want to have sex flesh to flesh. And
that is not allowed. That’s why with me I decided to stay like that.
Not having a partner. (IDI woman, age 57)
Nohmle’s account is a case where health workers framed strict
condom use as an indispensable part of “[taking] treatment in a good
way”, to the point of encouraging abstinence when condom negotiations
were anticipated to be difficult. When condoms are so often recom­
mended by providers to people taking ART, a statement on the biological
consequences of condomless sex could be reasonably inferred—con­
doms must be indispensable for treatment to work as it should. Although
this inference is too absolute in the case of viral suppression, it never­
theless is an argument invoked by MOPLH. Indeed, most of the sexually
active MOPLH in our sample discussed condoms as necessary when
taking ART, though how frequently and consistently they used them was
not always clear and exceptions were noted, such as sex for purposes of
pregnancy. Below, James, a married man in his 40s, explained:
Interviewer: (You are using condoms) for what purpose?
James: Hey, as you see that nowadays we are living with treatment
you see … So, if things are like that you have to think and know that
you must not have sex without condoms. So, that is how we are living
to save our lives. (IDI man, age 46)
The general acceptance of condom instructions suggests an overall
deference to directives from health providers. Nonetheless, besides
condom recommendations, our data suggest that the provision of in­
formation in counseling sessions about sex on ART is neither standard­
ized nor consistent, particularly when how ART can make condomless
sex “safe” is a contingent process. The complexity of this information, as
well as its uneven spread, provide a context where disagreements on the
biological risks of condomless sex can arise.
5. Biomedical bargains
When couples disagreed about the necessity of condoms, competing
interpretations of what constitutes safe sex on ART turned sex into a
biomedical bargain—sexual partners seek to determine the biological
risks of condomless sex and arrive at a decision about the terms of sex.
Blessing, a man in his 40s, is in a relationship with a girlfriend of two
years, a widowed woman who is older than him and also on ART.
Blessing liked that she was mature, he trusted her, and she took good
care of him, a welcome change from his previous relationships.
Although his girlfriend insisted on condoms citing the need to follow the
N. Angotti et al.
health worker’s order, Blessing rebutted that condoms were unnecessary
since they were both on treatment:
She said let us use a condom. I refused. I said it is the same—I am
taking medication and you are taking medication. So she said no,
they taught us to use condoms. I ask her about the people who are
getting children while they are [meant to be] using condoms—what
is happening? They are on medication but they are giving birth …
According to me the people who are on treatment they were sup­
posed to not give birth. What happen? You see. If they were using
condoms they will not get children. There is no such thing that this
people can’t have sex without using a protection … You will find that
the father is on treatment (husband) and the mother is on treatment
(wife) but you will find that the child born being HIV negative. (IDI
man, age 46)
Here, Blessing questioned his girlfriend’s insistence on the necessity
of condoms by invoking a definitively biomedical story of an HIV
seroconcordant couple on ART whose child was born HIV-negative.
Blessing interpreted the story as evidence of the non-risk of condom­
less sex while on treatment. Although we do not know whether Blessing
completely convinced his girlfriend, we know she must have relented as
they only use condoms “sometimes”, according to Blessing. While it is
not unusual for women to insist on condoms and men to refuse, what is
notable is that Blessing’s strategy to obtain his desired terms of sex was
to persuade his girlfriend that condomless sex on ART posed no bio­
logical risks.
Kaya, a married woman in her early 50s, has a husband who is on
treatment. Kaya’s husband traveled a lot in search of work, and while
she had no definitive evidence, she was nonetheless convinced that he
had extra-marital relationships. Failing to make her husband agree with
her understanding of the necessity of condoms for ART efficacy, Kaya
initially succeeded in refusing to have condomless sex with him by
sleeping in another room. However, her husband managed to convince
her of the safety of the rhythm method [withdrawal] by providing a
biomedical interpretation where only ejaculation matters for viral
transmission:
Kaya: He said to me we have to make [have] sex. But when he feel he
wants to discharge, he will leave out from me [pull out] …
Interviewer: Where did he get that discharging information?
Kaya: I don’t know.
Interviewer: What makes you to understand what he is saying?
Kaya: What makes me to understand is that at the clinic, we have
been taught that sleeping with our partners without condomising it’s
like when you don’t take the treatment. We have been taught that the
treatment cannot function well as both of you are taking it. They are
saying if he discharges inside of you, this means it is zero [the
treatment cannot work]. By so doing [discharging outside the body],
I started to understand him and we were on one side [agreed with
one another]. (IDI woman, age 51)
In Kaya’s case, her husband’s success hinged on deconstructing
Kaya’s interpretation of the health worker’s order. When the order
problematizes ejaculating inside of Kaya’s body, and Kaya understood
that order to mean that condoms are necessary for sex on ART, Kaya’s
husband provided a biomedical narrative that contrasted with Kaya’s
but nonetheless still complied with the health worker’s—that is, what is
necessary is not condoms, but not ejaculating inside Kaya. This
competing biomedical interpretation made Kaya willing to participate in
her husband’s preferred form of sex, as the presumed biological risk of
condomless sex had been neutralized.
Both Blessing’s negotiation with his girlfriend and Kaya’s negotia­
tion with her husband constitute biomedical bargains, where sexual
partners attempt to settle disagreements on the biological consequences
of condomless sex by using different interpretations of biomedical
5
Social Science & Medicine 330 (2023) 116036
information. While biomedical arguments do not displace other rela­
tional considerations (e.g., Blessing trusted his new partner) or conse­
quences (e.g., Kaya’s refusal of unjustified condomless sex had put a
strain on her marital relationship), what is nonetheless noteworthy is
that Blessing (and Kaya’s husband) explicitly invoked biomedical
reasoning to refute their partners’ insistence on condoms in order to
render condomless sex safe, and Kaya did not relent until her husband
offered a reasonable biomedical justification.
Not all biomedical bargains end with consensus on the biological
consequences of a sexual decision—disagreement can remain, yet sexual
decisions can still be reached. Alice, a divorced woman in her 40s, has
had several relationships since separating from her husband nearly 20
years ago. Two of those relationships did not last since the men were not
treating her well; in the other two relationships, including the one with
her current partner, Alice had a hard time negotiating condoms because
the men doubted she had HIV due to her “healthy” appearance. Below,
Alice describes the sexual negotiation that ensued with her current
partner:
Alice: He said he is not used to condoms and with me - I’m the one
who insist to use them. He said he only used condoms to [with]
people he knew and see that they are ill. I told him that it is not all the
people whom you can see that they are ill. It’s like me, I told him that
he cannot see. He used to tell me that if he don’t see anything to me,
it means I don’t have HIV. So, as he don’t want to listen to what I’m
telling him, I said it is ok. You can stop using that condom. But if you
start to get ill, don’t say I didn’t warn you.
Interviewer: Ok. In the past [earlier in the interview] you told me
that the clinic told you about using condoms three days a week and
the other days you can stop using it. Are you still doing the same with
him [current partner]?
Alice: Yes, I have to. If you are taking the treatment in a good way,
the virus is not active. You can have sex without using a condom and
you won’t be infected. (IDI woman, age 47)
In Alice’s biomedical bargain with her partner, they ultimately could
not reach an agreement on whether condoms were necessary. Never­
theless, they reached a decision, because both perceived the risk as
minimal – for Alice’s partner, Alice is not “ill”; for Alice, any biological
risk of condomless sex was legitimized by being honest with her partner,
who would then take full responsibility if he chose to proceed with
condomless sex. However, Alice also articulated that taking treatment as
advised makes HIV “not active” and Alice noted earlier in the interview
that her medical file says she has “no sign of HIV”. Thus, while there is
some apparent contradiction in her assessment of risk (likely perpetu­
ated by the counseling advice she received to “use condoms 3 out of 7
days a week”, which may have been an effort on the health worker’s part
to help Alice negotiate some condom use in her relationships), the
conclusion of Alice’s sexual negotiation with her partner was seemingly
conditioned on consensus of attenuated biological risks.
Overall, our findings suggest that seeking consensus on the biological
risks of sex, together with the mechanism through which such consensus
is sought, has gendered dimensions. When disagreements between sex­
ual partners occur, biomedical directives, carrying the weight of medical
authority, gave women new leverage to insist on condoms. This made it
seemingly harder for men to refuse until they provided biomedical ar­
guments that rendered condoms unnecessary. This process illustrates a
shift in the terms of sexual negotiations to the biomedical that opens up
new opportunities for both women and men to use biomedical dis­
courses in their favor.
6. Pre-empting the bargain: abstinence as adherence
Concerns about sex are also evident when sexual relationships—and
sexual negotiations as a result—are avoided altogether in the name of
minimizing biological risks. Most of the MOPLH in our sample who were
N. Angotti et al.
not sexually active, and primarily single/widowed women, discussed
abstaining from sex out of fear of jeopardizing treatment efficacy or
compromising longevity. The perceived need for condoms on ART,
which are known to be difficult to enforce in a relationship, further
reinforced a decision to abstain altogether.
Amukalani, a widow in her late 40s, had a husband who died of
AIDS. Amukalani did not doubt her husband’s loyalty due to their very
loving relationship. She admitted that despite her unsatiated desire for
sex following his passing, the benefits of abstinence for her treatment
efficacy and longevity outweighed her desire:
Amukalani: [Men] can also create me problems. Nowadays there are
different kind of sicknesses. That’s why I decided to stay [abstain]
and take care of my children … Sometimes those [sexual] feeling are
coming as I’m a human being … When this comes, I do fasting and
prayer. By so doing, this will pass. I always do like that and this is not
a problem to me … It is like if you are on treatment and you don’t do
sex, you are safe[r] than the one who is on treatment and do sex. If
you commit yourself to sex, it means you are killing yourself.
Interviewer: What do you hope for your life over the next few years?
Amukalani: I think if I don’t stop taking the treatment … we [I] can
survive … I managed to follow the instructions. I found that I’m still
strong. Also I’m happy as I abstained from having sex. That would be
my problem I think so. I would have children and then my CD4
counts dropped down and by so doing, I would have been dead. (IDI
woman, age 49)
In rural South Africa, it is not uncommon for older women, partic­
ularly widows, to abstain from sex, both because of declining sexual
desire and the association of sex at older ages with lack of respectability
(Angotti et al., 2018; Mojola and Angotti, 2019). For Amukalani, reli­
gious teachings from her church also encouraged celibacy for widows
and Amukalani relied on her church for emotional support. What is
noteworthy is that Amukalani, and other single/widowed women, are
also citing biological considerations as a key reason for abstinence. In
this way, they invoke abstinence as necessary for good treatment
adherence, and sex itself has become equivalent to compromised ART.
The abstinence as adherence narrative was further highlighted in our
FGIs. In one vignette, respondents were asked to reflect on a hypothet­
ical scenario where Thandi, a recently widowed woman in their age
group who is now on ART, ponders the possibilities for her romantic life.
Participants mostly agreed that dating should not be her priority and
even if she dates, she should prioritize her health and treatment:
(FGI with Women in their 60s):
W1: If she takes treatment, eats healthy food, her life will be good -
there will be no need for her to have partner.
W2: You feel safe when you are older because nowadays there are
diseases, so it is better to be alone.
(FGI with Men and Women in their 50s):
W3: If Thandi is still young, she can date, because now they are
teaching at clinics when you go there for testing, and they will tell
you that if you are dating now, you have to live like this. If Thandi
find a boyfriend, she have to tell him that she is HIV positive, and if
he like to date Thandi, there are protections that they will use, and
they can live longer if they follow the rules.
W4: If Thandi is a matured woman, if Thandi is like me, she can say
that I’m old enough, yes there is protections, but the important thing
is, if you check some women who have their husband and the other
one who does not have husband, their life is different … She
[Thandi] can say that I should stop here [abstain], I want to
concentrate on my tablets, and it doesn’t kill anyone, there is no one
who dies if she can’t date.
As Amukalani and the FGIs show, the biomedical understanding that
6
Social Science & Medicine 330 (2023) 116036
“sex compromises ART” does not exist in a social vacuum—W3 laid out
all the relational requirements before Thandi can date and live longer,
while W4 (and W2) rendered a partnered life as more perilous than
“concentrating on tablets.” What they anticipated and thus pre-empted
by abstaining is a story like Nomhle’s. After she was widowed,
Nomhle (cited earlier), had a new boyfriend for three months. He often
stayed at Nomhle’s house, gave her orders and demanded food. In the
end, Nomhle ended the relationship with him, citing his demand for sex
as unbearable:
Interviewer: What happens if you have sex flesh to flesh?
Nomhle: The body soldiers will drop down. That is why I decided to
stay single and don’t have a partner. I’m sticking to these words. It is
not because I’m old, but I would do like that even if I was still young.
By not having a partner you are safe. [My previous partner] was
demanding sex every day and I’m not used to that. That’s why I was
refusing and he was complaining. By the day he got you, you will not
sleep at night. He will be busy with you and even if you are tired he
wouldn’t rest. You see! By the following day in the morning, it was
difficult to wake up as you are tired. What was that? [It was because]
I was dropping my body soldiers [referring to CD4 count] down. But
thankfully because I was taking the treatment in a good way, that is
why I didn’t drop …. I don’t dream of a man … I’m feeling good by
staying like this [abstaining]. (IDI woman, age 57)
For Nomhle, having a relationship with persistent men means diffi­
culty using condoms and using condoms, in her understanding, is
imperative for treatment to work and “body soldiers” to prosper.
Although her partner’s disrespect certainly accelerated Nomhle’s deci­
sion to end the relationship, in Nohmle’s articulation, a fundamental
reason to terminate this relationship and abstain thereafter was her
belief that condomless sex will decrease her body soldiers. Nomhle also
explicitly denied that she abstained because of her older age, declaring
she would have done the same even if she were “still young”.
With both biomedical information regarding the necessity of con­
doms while on ART and non-biomedical information on men’s behavior,
older (single/widowed) women discussed abstaining as an integral part
of adherence. In so doing, they pre-empted any bargains, negotiations
and risks in anticipation of partners who may not agree with their
assessment of the biological risks of sex or who would otherwise un­
dermine their efforts to try to avert those risks. Although abstinence is
commonly recommended by health workers and encouraged by cultural
discourses, “concentrating on the tablet” gives abstinence a new
meaning. Prioritizing treatment efficacy and longevity thus becomes a
new discursive resource for older (single/widowed) women to justify
their sexual decisions.
7. Discussion
This study illustrates how everyday sexual practices of MOPLH in
rural South Africa have been influenced by the wide-scale availability of
ART. We find that biomedical discourses have entered the cultural
toolkit of MOPLH’s meaning-making and are being invoked in their
sexual decision-making. Specifically, when ART is the new norm for
MOPLH, biomedical directives, biological risks and concern for treat­
ment efficacy feature prominently in to how sexual decisions and ne­
gotiations are framed, resulting in what we call biomedical bargains. We
observe that women characterize sex as an act that jeopardizes treat­
ment to insist on condoms or rationalize abstinence, while men, when
justifying condomless sex, provide biomedical arguments that render
condoms unnecessary. Importantly, the permeation of biomedical dis­
courses does not mean that gendered relational, cultural and economic
considerations no longer matter – rather, they undergird biomedical
discourses and inform men and women’s proclivity for one interpreta­
tion of biomedical information over another. In our data, provision of
biomedical arguments by men seemingly neutralizes women’s leverage
N. Angotti et al.
to insist on condoms, which might suggest the reproduction of gender
privilege in biomedical bargains. The explanations for this observation,
however, require fuller investigation—couples interviews with a larger
sample of sexually active MOPLH could offer better insight into sexual
partners’ negotiations, decision-making and differential relationship
power (Reczek, 2014; Harrington et al., 2016).
The concept of biomedical bargains, however, usefully extends
beyond our case. More broadly, it captures how biomedical knowledge
gets incorporated into personal assessments of risk, how those assess­
ments are framed in biomedical terms, and ultimately, how they are
deployed to influence the health practices of others. Negotiations con­
cerning partners’ contraceptive use (Harrington et al., 2016), as well as
the use of protective measures such as mask-wearing and social
distancing to minimize the risk of contracting COVID while dating
(Williams et al., 2021), suggest two examples of situations where
biomedical bargains were evident, as individuals and couples drew on
biomedical information to identify health risks, navigate concerns, and
seek agreement on approaches for managing those risks.
In the case of the HIV pandemic, we recognize that the preoccupation
with treatment efficacy that we observed could be attributed to the se­
lection bias of our sample, since all our respondents were already on
ART and thus accustomed to the intrusion of biomedical interventions in
their lives. Nevertheless, our observation must be understood in the
context of the increasing reliance on biomedicine for HIV programs. The
epitome of such biomedicalization is the TasP approach, in whose name
the scale-up of ART in South Africa was implemented (South African
National AIDS Council, 2016). TasP’s utility rests upon ART’s ability to
prevent HIV transmission on the condition of viral suppression (National
Institute of Allergy and Infectious Diseases, 2019). This scientific dis­
covery is the core idea behind the global awareness campaign of “Un­
detectable = Untransmittable” (U=U), which aims to end HIV and
HIV-related stigma by championing the message that people living with
HIV and who have an undetectable viral load cannot transmit HIV to
their sexual partners (Prevention Access Campaign (no date)). What we
observe on the ground, however, is how scientific information about
ART spreads unevenly, which is enabled by ambiguity in treatment
guidelines on the relationship between viral suppression and sexual
transmission as well as health providers’ discretionary practices (Lipp­
man et al., 2020). Our data thus reveal a period of uncertainty—some
people on ART seem aware of the sexual benefits of ART, while others
regard blanket condom recommendations as the safest way to have sex
on ART. This uncertainty unsettles what safe sex means and requires
people living with HIV to reimagine how to practice sex—biomedical
discourses thus enter the cultural toolkit, and biomedical bargains are
struck to seek consensus on the biological risks of sex on ART.
From a policy perspective, people living with HIV deserve complete
and accurate information to make informed decisions about their sexual
lives, a first step towards efficacy and equity for TasP implementation.
However, from a sociological perspective, even perfectly spread infor­
mation will nonetheless be translated, interpreted and then strategized
by individuals in the context of their daily praxis (Watkins, 2004; Merry,
2006; Adam, 2011). While the permeation of biomedicine has become
an indispensable part of MOPLH’s everyday life, biomedical in­
terventions will always interact with non-biomedical dimensions of life
to inform health practices.
Data availability
The authors do not have permission to share data.
Acknowledgments
An earlier version of this paper was presented at the Annual Meetings
of the American Sociological Association, August 5-9, 2022, in Los
Angeles, CA. We thank the anonymous reviewers for their helpful
comments and critiques, as well as Kim Blankenship, Molly Dondero and
7
Social Science & Medicine 330 (2023) 116036
Tracy Weitz, who provided comments on earlier drafts. We are indebted
to all the respondents who participated in this study, the people of the
Agincourt sub-district for their long involvement with the MRC/Wits
Rural Public Health and Health Transitions Research Unit, as well as the
Izindaba Za Badala (HIV after 40) field teams, especially Meriam
Maritze. We are grateful for funding support from the National Institute
on Aging – R01 AG049634 - HIV after 40 in Rural South Africa: Aging in
the Context of an HIV Epidemic (PI Sanyu Mojola). The content of this
paper is solely the responsibility of the authors and does not necessarily
represent the official views of the National Institutes of Health. We are
also grateful to the MRC/Wits Rural Public Health and Health Transi­
tions Research Unit and Agincourt Health and Socio-Demographic Sur­
veillance System, a node of the South African Population Research
Infrastructure Network (SAPRIN) and the funding agencies that support
it: the Department of Science and Innovation, the University of the
Witwatersrand, the Medical Research Council, South Africa, and previ­
ously the Wellcome Trust, UK (grants 058893/Z/99/A, 069683/Z/02/Z,
and 085477/Z/08/Z – PI Stephen Tollman). This work has also
benefited from research, administrative, and computing support from
the Office of Population Research (OPR) at Princeton University.
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