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The Social Impact of Aids in the United States
has been fostered by changing perceptions of the dimensions of the threat posed by AIDS. Early fears that HIV infection might spread broadly in the population have proven unfounded. As the focus of public health concern has shifted from gay men, among whom the incidence of new HIV infections has remained low for the past several years, to poor black and Hispanic drug users and their sexual partners, the influence of those who have spoken on behalf of the former has begun to wane. Black and Hispanic drug users, however, not only lack the capacity to influence policy in the way that gay men did, but those who speak on their behalf often lack the singular commitment to privacy and consent that so characterized the gay organizations. And as it has become clear that initial estimates of the level of infection first put forth several years ago were too high, the willingness to reconsider traditional policies has increased.
But most important in accounting for the changing course of public health policy has been the important advances in therapeutic prospects. The helplessness and fatalism of the early years has begun to wane, and a guarded optimism has begun to emerge. The prospects for better management of HIV-related opportunistic infections and the hopes of slowing the course of HIV progression itself through prophylaxis have increased the importance of early identification of those with HIV infection. That, in turn, has produced a willingness to consider traditional public health approaches to screening, reporting, and partner notification.
Although HIV disease may not continue to be treated as an exceptional disease, the new perspectives on public health prompted by its emergence will not disappear. The emphasis on mass behavioral change through education that had begun prior to the AIDS epidemic will continue to be of critical importance. Even the most ardent advocates of the relevance of traditional public health practice, the strongest opponents of HIV exceptionalism, recognize that mass educational campaigns will remain the single most important element in the public health strategy to contain HIV infection. And much was learned in the first decade of the AIDS epidemic about how to mobilize an effective public health education campaign—about the importance of engaging those who speak on behalf of those most at risk in the process of fashioning such efforts. These lessons could be applied profitably to the patterns of morbidity and mortality that represent so much of the contemporary threat to the public health.
In assessing the impact of AIDS on the practice of public health, it is important to remember that such practice entails not only education, surveillance, reporting, and other public health control measures, but also the delivery of primary health care services. State, county, and local public health programs have become, often by default, the providers of last resort for people with HIV disease who lack private insurance coverage. The inextricable link between HIV disease and other diseases and conditions