Map of life expectancy at birth from Global Education Project.

Tuesday, January 04, 2011

The Straight Dope

You may have come across this dispute in New York City over graphic HIV prevention advertisements. The city health department is concerned that young gay men are thinking that HIV isn't so bad after all, just take a pill and you'll be fine. So they're using scare tactics, with graphic images of anal cancer and warnings of dementia and dissolving bones.

Lots of people are unhappy with the ads, on various grounds. Jarrett Barrios, an acquaintance of mine who was once a Massachusetts state senator and now head of the Gay and Lesbian Alliance Against Defamation, says they just aren't accurate -- living with HIV isn't really all that bad. Others fear the ads are stigmatizing, of both gay men and people with HIV.

Others support them however, because they really, really want young gay men to stop getting infected with HIV. On the other hand, it isn't at all clear that such scare tactics really work in changing people's behavior. The latter point is obviously a very strong one. The downsides are only acceptable if the ads have a big effect in HIV prevention. Unfortunately nobody can say for certain. The common wisdom is that in most contexts, trying to scare people into not doing stuff they otherwise want to do isn't very effective.

The American Legacy Foundation youth tobacco prevention ads, which the article asserts were comparable, were not comparable at all. Rather than trying to scare people into not smoking, they (truthfully) portrayed tobacco as a product pushed by old, greedy fat cats and hence decidedly uncool; while way cool rebellious and hot looking young people hit the fogeys with anarchistic direct actions.

I can't exactly think of a comparable tactic to use against HIV, and I wouldn't want to make the drug companies a target although it is true that they're advertising in gay-oriented literature does make it seem as though living with HIV is not a prob. They shouldn't do that. But I will tell you what it's really like to live with HIV.

It is true that if you are diagnosed in time, before you lose too many T-cells; and you get access to good medical treatment, which you have insurance or other means to pay for, you will have the opportunity to remain reasonably healthy for a long time. That is if and only if you take medications consistently, for as long as you live. You may be unlucky and have unpleasant or even intolerable side effects from the first regimens you try, although most people don't.

But over time, long term side effects are common, including disorders of lipid metabolism which can include disfiguring redistribution of fat deposits; high cholesterol; diabetes; and weight gain. Painful peripheral neuropathy is also encountered with some medications. If you don't take the pills consistently, you may develop viral drug resistance and have to switch to more complicated, less well tolerated regimens. And in spite of effective treatment, it does appear that HIV can continue to slowly damage the brain and lead to early onset dementia. You might be lucky enough to escape the worst of these consequences, but don't bet on it. Chances are your life will be shortened.

I don't want to exaggerate any of this. Lots of people with HIV do very well for decades. Your lot today will be much better than it was before there were effective treatments - these side effects beat the hell out of uncontrolled HIV disease and AIDS. But believe me, this is something you would much rather live without.

Yes,the ads are inaccurate because the dire consequences they portray aren't going to happen while you're still young, and the anal cancer thing is a bit of a red herring since that is caused by a different virus, although it's still a good reason to always use condoms so I can forgive it. I would rather see messages that are unassailably accurate and are more about positive motivation than negativity and fear. I think the health department could have done a lot better.

But I can also understand why some people are getting frustrated enough to try anything. Nobody has to get HIV from voluntary activity. And you really, really don't want to. So don't.

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