The diagnostic state: Police discretion and the securitization of HIV/AIDS in the United States

How do law enforcement agencies shape public health responses during epidemics? While scholars have examined the role of established medical institutions such as the Centers for Disease Control and the World Health Organization, the police remain understudied. Through a multimethod analysis of archival materials, national survey data, and comparisons across New York and San Francisco, I argue that police functioned as informal medical knowledge producers who transformed HIV/AIDS from a public health challenge into a security threat requiring punitive intervention. Vague federal guidance opened a discretionary space that officers filled with their own ideas rather than medical evidence. I introduce the concept of the “diagnostic state” to describe how the structures of policing allowed officers to define what counts as illness and how it should be managed. In the absence of clear protocols, officers relied on visual heuristics to determine infection status, effectively constructing an extralegal diagnostic apparatus that operated parallel to—and often in contradiction with—public health guidance. These patterns established precedents that foreshadowed COVID-19 responses, illustrating the ways that institutional authority can either reinforce or disrupt efforts to address epidemics.