Thinking and rethinking AIDS: implications for health policy.

In the United States, we see three main phases in the construction of the history of AIDS, with each having very different implications for health and social policy. In the first, AIDS was conceived of as an epidemic disease, a "gay plague," by analogy to the sudden, devastating epidemics of the past. In the second, it was normalized as a chronic disease, similar in many ways to diseases such as cancer. In the third, the authors propose a new historical model of a slow-moving, long-lasting pandemic, a chronic infectious ailment manifested through myriad specific HIV-related diseases. The new paradigm of AIDS incorporates the positive aspects of both earlier conceptions. It emphasizes, like the plague model, the etiology, transmission, and prevention of disease but rejects its assumption of a time-limited crisis. It takes from the chronic disease model an appropriate time frame and concern with the clinical management of protracted illness but insists on the primacy of prevention. The authors criticize both infectious and chronic disease models for their individualistic conceptions of disease and their narrow strategies for disease prevention. They further argue that the traditional distinction between, and approaches to, infectious and chronic diseases need to be rethought for other diseases as well as for AIDS.