The trial multiple: The ontological politics of a South African PrEP trial

A growing body of research has problematised the multi-sited clinical trials that underpin the global bioeconomy. These accounts often oscillate between a narrow focus on ethical oversight and critiques of exploitation, leaving the lived and organisational realities of trials under-examined. Rather than evaluating clinical trials as more-or-less successful techniques for managing molecules and subjects, this paper approaches trial management as the work of coordinating multiple enactments of biomedical objects. It examines how clinical trial management is enacted through a case study of a pre-exposure prophylaxis (PrEP) trial in South Africa involving HIV-negative men who have sex with men (MSM) and transgender women. Working with and beyond extant research on relational materiality, the paper interrogates how PrEP’s apparent singularity as a prevention technology is sustained in practice, tracing how different enactments of PrEP emerge through situated configurations of practices, technologies, and narratives. It focuses on two particularly salient enactments – PrEP-as-investment and PrEP-as-salvation – and shows these are not simply competing perspectives but materially distinct realities that must be actively coordinated within the trial. Through strategies of translation, alignment, and equivalence, these divergent realities are rendered comparable while their differences are selectively maintained or marginalised. This paper contributes to geographical debates on relational materiality and biomedicine by showing that clinical trials function as spatially distributed assemblages in which coherence is actively achieved. This reframing foregrounds the practical work through which biomedical objects are made to cohere across contexts while highlighting the political implications of stabilising certain realities and excluding others.