At the international level, inequality in wealth between developed and developing nations has produced essentially two types of AIDS: chronic AIDS in the Western world, where resources are available for treatment with zidovudine and other drugs, and acute AIDS in the developing world, where there are no funds for such treatments.3
On the national level, AIDS as a chronic illness means a shift in the priority it receives in national health policy and a growing inequity in how resources for its treatment are allocated among the population. Despite initially being seen as confined to gay men, once transmission to women, children, and heterosexual men was identified, its control was given high priority from public health officials and government agencies. Political activity by gay men, most of whom were white, deliberately played on fears of virulence and heterosexual transmission and was effective in securing government support for research and treatment.4
Advocates for research and funding for the management of AIDS must compete with advocates for people suffering from other chronic, life-threatening illnesses—for example, cancer, diabetes mellitus, and hypertension. The recognition that most new cases of AIDS occur among heterosexuals has changed public perceptions and policy in several ways. First, AIDS has become normalized in the sense that more of the population is viewed as vulnerable to infection. Although this is helpful in reducing the stigma associated with the disease and takes some of the pressure off the gay community, it has broken down some of the political alliances that mobilized advocacy for people with AIDS in the 1980s. Secondly, the incidence of AIDS is several times higher among African American and Hispanic men, women, and children than among white men, women, and children. Given that minority populations have lower rates of health insurance coverage, treating AIDS means increasing public expenditures on a broad scale. As a chronic illness, AIDS is another problem in a health care system already riddled with problems.4
Chronic illnesses, because of their uncertain course and often complicated, multisystem treatments, require the mobilization of a network of family, friends, health care professionals, and services for their management. Organizations that arose to assist people dying of AIDS, whose social networks had been decimated by the epidemic, have had to change their orientation to providing episodic assistance during acute crises. Project Angel Heart in Denver, Colorado, provides meals to people with AIDS who cannot prepare meals for themselves or who need supplemental nutrition because of their treatment regimens. Although their clients may have long periods during which they do not need the service, clients may stay on the rolls for many years instead of only a few months. Medical regimens and appointments with physicians, therapists, nutritionists, and other specialists require enormous expenditures of time, energy, and resources on the part of not only people with AIDS but also their friends and family. The health of caregivers may be adversely affected as well.5
Writing in 1988, Susan Söntag asserted that “It seems that societies need to have one illness which becomes identified with evil, and attaches blame to its `victims.' ”6
Certainly, in the early 1980s, AIDS, with its virulence, epidemic spread, wasting of the body, and sexual mode of transmission, served that social purpose well. Now that it is viewed as a chronic, life-threatening but not immediately fatal illness present in the general population, its power as a metaphor for evil is diminished. The development of the category HIV positive, a result of treatment that can forestall the progression to AIDS, has also alleviated some of the public fear of the disease and those who have it. This is good news for those with AIDS; however, chronic illness brings its own social challenges.