During the early years of the AIDS crisis, most people associated the disease with gay men. Women, by contrast, were widely believed to be “biologically resistant” to HIV, and many public health experts doubted that women would contract the virus in significant numbers. As a result, U.S. government policies effectively excluded women from receiving AIDS diagnoses and related support.
In her book, Risk and Resistance: How Feminists Transformed the Law and Science of AIDS, Aziza Ahmed tells the story of the feminist lawyers and activists who fought against these policies and ultimately secured recognition of the epidemic’s impact on women. In the following interview, Veena Dubal and Ahmed discuss the legal implications of an AIDS diagnosis, the CDC’s willful ignorance around the disease’s reach, Judge Posner’s preoccupation with sex and markets, and the adverse public health consequences of carceral feminism.
** ** **
In the United States, the story of HIV/AIDS is usually told as a success story: some combination of biotechnology, liberalism, and human rights concerns led to scientific progress, which transformed HIV from a death sentence into a manageable chronic condition. As someone who came of age in the 1990s, that’s the story I inherited.
Your book tells a very different story. It suggests that what we understand as scientific progress was a much more complex process that was influenced by social movement actors. You show how feminist activists played a crucial role in defining HIV, and in confronting the state in court, regulatory meetings, and the streets.
How did you begin thinking about these issues?
The moment I realized there was a larger story to be written came in 2012, when I attended the International AIDS Conference in Washington, DC. The Smithsonian had an exhibit on AIDS around the same time, and a curator let me look through materials that weren’t on display.
Among them was a 1985 Discover magazine article. The cover read “AIDS: The Latest Scientific Facts,” and inside were cross-sectional illustrations claiming that women had “rugged” vaginas and therefore would not contract HIV in large numbers, while men had fragile urethras and rectal tissue that made them especially vulnerable.
This was startling. At that point, I was already working as a legal fellow for the International Community of Women Living with HIV and AIDS. I had met hundreds of women who were living with—and dying from—HIV. A few years earlier, the UN had declared HIV a feminized epidemic. I began to wonder how a disease that was initially framed as affecting only men came to disproportionately affect women.
I was also already aware that dominant narratives about women often mask the complexity of their lives. For example, in many regions, drug use—not sexual violence—was a primary driver of women’s HIV exposure. So I started to sense that there was something far more complicated than the prevailing story suggested.
You begin your story with the attorney Terry McGovern. What did you learn from her work, and what did the science around AIDS look like at the time?
Terry McGovern was a welfare attorney in the 1980s who founded the HIV Law Project after realizing there was a deep need for legal services for people living with HIV. Before founding the HIV Law Project, Terry was working at MFY (Mobilization for Youth) Legal Services, where people with HIV and AIDS came seeking benefits. Many legal services offices were terrified of these clients; Terry recalled colleagues spraying offices with Lysol out of fear of contagion. This was a period of profound uncertainty. HIV involved long delays between infection and symptoms, testing was limited, and global surveillance lagged for decades.
Terry realized that she couldn’t secure Social Security benefits for her clients because women weren’t receiving AIDS diagnoses under the CDC’s definition. At the time the Social Security Administration was giving presumptive benefits to people living with AIDS. Terry began working with women, including women leaving Bedford Hills Women’s Prison, where they had been supported by Katrina Haslip, a woman living with HIV who later became a central activist in the fight to change the CDC definition and get benefits from the SSA. Through Terry’s work, I began to see a larger story about law, social movements, and the production of scientific authority.
What did the CDC’s definition of AIDS look like at this point, and how did it systematically exclude women like the ones Terry was representing?
At the time, the CDC defined AIDS through symptom lists tailored to the so-called “four Hs”: homosexuals, Haitians, heroin users, and hemophiliacs. Gynecological conditions were excluded. As a result, many women whose HIV had progressed to AIDS—often through invasive cervical cancer or recurrent pelvic inflammatory disease—were unable to work but did not qualify for benefits. Instead they would have to file for disability benefits. But the disability assessment process was so slow that some women were approved only after they had died.
Terry realized the problem wasn’t just bureaucratic delay—it was the definition of the disease itself. At the same time, activists within ACT UP, particularly Maxine Wolfe and the Women’s Caucus, were recognizing that women were being systematically ignored in the epidemic. Terry’s legal advocacy and ACT UP’s activism converged in a coordinated push to force the CDC to revise its definition of AIDS.
The CDC resisted. Officials argued that conditions like invasive cervical cancer lacked sufficient evidence as a manifestation of AIDS and worried that expanding the definition would overwhelm the healthcare system and undermine the agency’s scientific authority. Importantly, these were not right-wing antagonists; they saw themselves as progressive, LGBTQ-friendly public servants committed to evidence-based governance.
The irony, of course, is that the lack of evidence was itself a product of exclusion. There was no mandate to study women, and the existing definition already rested on limited evidence shaped by assumptions about who mattered. When Terry filed suit and the case survived a motion to dismiss, the CDC was forced to engage. As a result of this litigation, as well as sustained organizing by ACT-UP and others, it was impossible to ignore the human cost of the incorrect definition. The feminist lawyers and advocates were successful: the CDC changed the definition of AIDS and the SSA began to administer benefits to greater numbers of women.
When I first proposed this book, many people dismissed it as potentially uninteresting for a contemporary audience. AIDS was seen as “over,” especially in the United States, and the CDC was treated as a technocratic, apolitical agency. COVID made clear how wrong that view was. It revealed what the activists in this story already understood: that the CDC is deeply embedded in questions of politics and redistribution—and always has been.
One of the most transformative aspects of the book to me is how it reframes science as a site of political contestation. What your book makes clear is that science isn’t neutral terrain.
When I was presenting this work and circulating the book proposal, I was often met with anxiety about what it means to acknowledge that agencies like the CDC are political institutions. People worried that naming the politics of expertise would empower vaccine skepticism or anti-science movements—what we now associate with MAHA-style politics.
What I was trying to argue, and what you’re pointing to, is something more precise. What we ask of science matters. What we expect agencies to do matters. Expertise structures distribution. Epidemiology and public health knowledge don’t simply describe reality; they organize access to resources.
That’s not a radical claim within epidemiology itself. Many epidemiologists understand their work as iterative, contingent, and shaped by the questions they ask. Epidemiology is fundamentally about populations, and in the 1990s, we saw the emergence of feminist epidemiology, which explicitly interrogated how race and gender had been excluded from population-level analysis. If your categories exclude women, or poor people, or incarcerated people, then your findings will reproduce those exclusions. Transforming expertise means transforming who benefits from public health interventions.
One of the things your book makes visible is that science isn’t just contested epistemically—it’s contested politically. Whether science is used to justify redistribution or retrenchment depends on who is shaping it. That becomes especially clear in your discussion of law and economics. You trace how, after feminists succeeded in forcing recognition of women’s vulnerability to HIV, figures like Richard Posner and Thomas Philipson intervened to reshape AIDS policy by understanding sexual activity through a market framework.
This was striking to me. I was not aware of this work, and their analysis so thoroughly eliminated lived experience. Anyone who takes sex seriously—as something shaped by power, desire, fear, and constraint—can see how implausible their framework is. And yet it became enormously influential.
Posner was deeply interested in thinking about sex and markets, and AIDS offered an opportunity to extend law and economics reasoning into public health. In Sex and Reason and later in Private Choices and Public Health, Posner and Philipson attempt to reconceptualize AIDS as a problem of individual risk-taking in a sexual marketplace. They develop a new way to think about public health crises through the lens of “economic epidemiology.”
What’s important is that Posner engaged feminist theory seriously, at least initially. In Sex and Reason, he addresses thinkers like Catharine MacKinnon and Andrea Dworkin. But he ultimately rejects their central claim—that sex is structured by gendered power and subordination—because accepting that premise would unravel a theory of sexual bargaining that presupposed equality between the parties at the negotiating table.
By the time he writes Private Choices and Public Health, structural conditions are almost entirely assumed away. Sex becomes a transaction between rational actors. Government intervention becomes presumptively illegitimate unless it corrects a clear market failure.
For example, in their account, condom use isn’t shaped by power, coercion, or inequality. Instead, it’s explained through supply and demand. The example they use—explicitly—is that if Black women have fewer Black male partners available to them, they will make concessions to keep those relationships, including agreeing to condomless sex. The feminist explanation—that power, inequality, and constrained choice shape sexual negotiation—is dismissed. Everything is reframed as a market scarcity problem.
And crucially, it’s not even a market for condoms. It’s a market for men.
Exactly. The scarcity isn’t the protective technology; it’s the partner. That reframing is astonishing when you think about it. It treats intimate human relationships as abstract exchange, stripped of history and context.
What makes this especially consequential is Posner’s influence. These ideas didn’t remain academic. They shaped World Bank reports, global health policy, and international AIDS interventions. I cite a World Bank report from the 1990s that lifts its framing almost directly from Private Choices and Public Health. Once you individualize risk in this way, policy follows suit. Responsibility is placed on individuals—especially women—to manage their own exposure. Structural conditions disappear from view.
What’s also troubling is that this individualization wasn’t limited to law and economics. Some strands of feminism, particularly liberal and carceral feminism, converged on similar conclusions. By focusing on individual negotiation and personal responsibility, even when acknowledging inequality, they reinforced a framework that ultimately blamed individuals rather than structures. Other feminists continued to try and emphasize structural concerns that make people vulnerable to contracting HIV.
And that convergence matters. It sets the stage for what comes next in the book: the turn toward carceral responses.
What struck me here is how quickly feminist attention shifted away from mass incarceration as a sociopolitical problem—even as it became clear that incarceration itself was a driver of HIV transmission. Black men, who bore the brunt of carceral reforms in policing and sentencing, were contracting HIV in prison, returning home, and transmitting it to partners. And yet feminist organizations largely failed to take up decarceration as a feminist issue. Instead, the response was often to criminalize further—to treat transmission as individual wrongdoing, rather than as a consequence of structural violence.
Yes, that omission is devastating, and it’s one of the hardest parts of this history to reckon with. Early on, it became clear that mass incarceration was a key vector of HIV transmission for women. Yet rather than challenging incarceration, many feminist organizations embraced criminal law as a solution.
This aligned with broader trends in carceral feminism. Violence against women became framed as an issue best addressed through punishment, prosecution, and expanded policing. That framework made it difficult—almost impossible—to see prisons themselves as sites of harm.
Can you talk about how disagreements among different strains of feminism ended up structurally reshaping HIV interventions—especially at the global level?
Once women are recognized as a population affected by HIV, the question becomes: who are these women, and why are they vulnerable?
Because women had not been studied systematically until that point, feminists provided the dominant interpretive framework. That framework emphasized patriarchy and women’s structural subordination. While that analysis captured something real, it also flattened complexity. It obscured factors like drug use and treated sex as the primary—sometimes exclusive—site of women’s vulnerability.
This was happening alongside a deep internal conflict within feminism, often referred to as the “sex wars.” One camp, aligned with Catharine MacKinnon and Andrea Dworkin, viewed sex as inherently subordinating for women. They saw prostitution as the epitome of women’s sexual subordination. Another camp, which included sex worker organizers, emphasized that sex could be a site of agency and that harm reduction was essential. These debates were already well underway when AIDS emerged, and the conflict shaped how feminist approached AIDS.
By the early 1990s, it was clear that sex workers were among the populations most vulnerable to HIV, with infection rates reaching 50 or 60 percent in some contexts. Harm reduction organizations responded by empowering sex workers: providing condoms, safe spaces, childcare, peer education, and collective organization.
From a public health perspective, this approach worked. It reduced transmission and improved outcomes. But for anti-prostitution feminists, harm reduction was unacceptable. They framed sex work itself as violence, and they believed the only solution was abolition—rescuing women from prostitution entirely.
And that moralizing framework–to end prostitution–ends up traveling globally, particularly through U.S. funding mechanisms.
Exactly. The United States was—and remains—the largest funder of global programs related to family planning, sexuality, and HIV. That gave it enormous power to shape public health infrastructures in the Global South.
Under George W. Bush, HIV became a major policy priority through the creation of PEPFAR, the President’s Emergency Plan for AIDS Relief. Billions of dollars flowed into HIV programs worldwide. In many countries, this funding effectively reorganized entire public health systems. At the same time, a particular group of feminists—whom I describe as carceral anti-trafficking feminists—successfully pushed to attach ideological conditions to that funding. This resulted in what’s known as the anti-prostitution loyalty oath.
There were two key provisions. First, organizations receiving funds could not advocate for the legalization of prostitution or sex trafficking—terms that were defined so broadly as to include nearly all sex work. Second, organizations had to adopt an explicit policy opposing prostitution and trafficking, this was known as the pledge requirement
Initially, these provisions were unevenly enforced. But carceral anti-trafficking feminist advocates pushed for stricter implementation. Sex worker organizations were accused of trafficking. Doctors Without Borders was accused of trafficking children for doing harm reduction work on the Cambodia–Vietnam border. Programs were shut down. Organizations lost funding. I argue in the book that these interventions had life-and-death consequences. They dismantled some of the most effective HIV prevention efforts.
And those consequences fall disproportionately on people in the Global South. Your book reminded me of how my mother, who first trained as a medical student in India, described being part of programs in the 1960s and 1970s that involved going into brothels to talk with sex workers about STIs and family planning. That kind of pragmatic harm reduction had existed for decades.
Absolutely. PEPFAR-era carceral anti-trafficking feminists sought to replace those approaches with a moralized, punitive framework. Sex workers were no longer seen as partners in public health, but as victims to be rescued—or criminals to be eliminated.
Sex worker organizations were explicit in rejecting this. Many said, and I’m paraphrasing, “We don’t want sewing machines. We don’t want retraining programs. We want condoms, safety, and autonomy.” I want to be clear that they had the support of many feminists and feminist organizations who supported harm-reduction programs. Sex workers and their allies understood that there were no alternative jobs waiting for them, and that caste, migration status, and economic exclusion shaped the conditions in which they entered and remained in sex work. What U.S. policy offered instead was an imaginary solution: that prostitution could simply be ended through abolition. That fantasy ignored structural realities that made it nearly impossible for women to quickly find another job and actively undermined public health.
And the Supreme Court eventually intervenes—but only partially.
Yes. The anti-prostitution loyalty oath was challenged in court, and the case eventually reached the Supreme Court. The Court held that the pledge requirement violated the First Amendment—but only as applied to U.S.-based organizations.
Foreign organizations remained subject to the pledge. That distinction is crucial. It means that U.S. organizations have some speech rights, but organizations in the Global South do not. They must still affirm U.S. policy positions to receive funding. As a result, many sex worker organizations simply opted out of funding. Others complied at the cost of alienating the very communities they served. Either way, harm reduction suffered.
This is why I understand the outcome as a form of imperial feminism, a term I get from the work of Anne Orford. Feminist ideas developed in the U.S.—often detached from material realities elsewhere—were imposed through economic power, reshaping local practices and undermining effective public health strategies.
What stayed with me is how different this is from the early chapters of the book. In those chapters, incarcerated women, poor women, and sex workers force institutions to respond to their lived realities. In the later chapters, those same kinds of voices are overridden by elite feminist agendas backed by state power.
That contrast is intentional. The early movement succeeded because it insisted on redistribution and collective inclusion. Women didn’t ask to be morally redeemed; they demanded benefits, treatment, and recognition.
The future of public health depends on whether we’re willing to return to those earlier principles: meeting people where they are, addressing structural conditions, and redistributing resources rather than policing behavior.
I want to end by asking about the future. Given where we are now—with public health deeply politicized and redistribution increasingly off the table—do you see space for a return to the kind of redistributionist public health politics that Katrina Haslip and Terry McGovern were advancing?
There has always been a dissenting tradition within public health—what we might call critical or left public health—that emphasizes the social determinants of health. This literature is well developed. It tells us, over and over again, that upstream factors like housing, food security, labor conditions, borders, and poverty are the true drivers of health outcomes. We intervene far too late and far too narrowly. We medicalize problems that are fundamentally social.
The positive version of the story is that the knowledge already exists. What’s missing is political will. Re-centering redistribution, community power, and material conditions would radically transform public health.
