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“Over 28 times more likely to get anal cancer”

Timothy Kincaid

December 14th, 2010

When traveling this year, consider the following:

  • The second largest weather killer in the United States is a lightning strike.
  • You are over 100 times more likely to be hit by lightning in Florida than California.

Makes ya think, doesn’t it? Perhaps vacation should be at Disneyland rather than Disney World.

But would it help you put things in perspective if you knew that the odds of getting struck by lightning in the US are about 1 in 500,000 and that only 40 to 50 people per year are killed here by a lightning strike? When you know the facts, then all of the above ceases to give you concern and instead you feel manipulated.

Keeping that in mind, look at the following condom awareness psa being aired by New York City:

YouTube Preview Image

When you get HIV, it’s never just HIV. You’re at a higher risk to get dozens of diseases, even if you take medications. Like osteoporosis, a disease that dissolves your bones; and dementia, a condition that causes permanent memory loss; and you’re over 28 times more likely to get anal cancer. It’s never just HIV. Stay HIV free. Always use a condom.

Scary!!

But is it true? And, as importantly, is it in perspective?

Osteoporosis is directly related to bone mineral density (BMD) and it is the measurement of BMD that is used to identify and – more or less – define who has or does not have osteoporosis and likely future fractures. And it is, indeed, true that HIV positive persons have higher rates of both osteoporosis and osteopenia (a similar but less sever condition). The reasons are, at present, undetermined.

So, yes it is fair and accurate to warn that HIV can, on average, increase one’s likelihood of osteoporosis (as can being a short white woman). And this condition is common enough that an increase in incidence is material and worthy of discussion.

But it’s not quite all of the story. The handsome young man whose bones were dissolving before our eyes is rather unlikely to have osteoporosis for decades, if ever. Osteoporosis (which primarily effects those over 50) is fairly easy to both treat and forestall, so this young man may need to take extra precautions (e.g. adequate calcium and vitamin D) but he is not going to wake up one morning and find that his skeleton has dissolved to soup.

Dementia is more common in people with HIV than without. Indeed, before HAART, dementia was a common consequence of HIV infection and was often the first qualification for an AIDS diagnosis. Currently it is less common, but still a major concern, especially as HIV infected persons age. (caregiver.org)

Before the arrival of highly active anti-retroviral therapy (HAART) in the second half of the 1990s, estimates of the percentage of people with AIDS who would develop HAD ranged as high as two-thirds. Many specialists, however, believed that the true figure was closer to 20 to 30 percent. More recently, experts have estimated that less than 10 percent of people on HAART develop HAD. However, because people with HIV are living longer than ever before, a greater number could ultimately develop the disorder, perhaps in its milder forms.

So far, I don’t necessarily quibble with accuracy of the psa, though the imagery suggests that these possible consequences are likely to be onset in early life, a false implication. But now let’s turn to one of my pet peeves, the ooky-spooky (and mostly bogus) anal cancer scare.

Yes, anal cancer exists. And yes it has higher rates in gay men than straight and even higher in HIV positive men. But the inclusion of anal cancer as a “higher risk” and the “28 times more likely” language tells me that this psa has no credibility whatsoever. It is not designed to inform, but to frighten.

The anal cancer scare is a favorite tactic of anti-gay activists. And it is irresponsible and immoral behavior when they seek to demonize gay men by claims that ““homosexuality is by its very nature dangerous to those who practice it.” It is no less irresponsible and immoral to use this scare tactic in the advance of a noble cause like encouraging condom use.

Anal cancer is very rare. In the US, about 5,260 people per year get this disease, of which about 40% are men (so, as you can see, women are 50% more likely to get anal cancer. Beware!!). About 720 patients die. Anal cancer is highly associated with HPV infection (though the vast majority of those infected with the HPV virus never develop anal cancer) and a vaccine is available which eliminates this risk factor.

Gay men, who are more likely to have become infected with HPV in their anus than are heterosexuals, experience anal cancer incidence of about 35 in 100,000. HIV infected persons, as are other persons with a suppressed immune system, are more likely to develop this cancer, but we still are talking tiny tiny numbers, maybe around one tenth of one percent.

Yes, HIV seroconversion is a life-changing experience. While most HIV positive people live relatively the same life as HIV negative people, there are more risks, rules, and precautions. Drug regimens must be adhered to, lifestyle choices have to be made, and health complications of some sort are almost unavoidable.

There are, indeed, many many good reasons to avoid infection with HIV. But fear of anal cancer is not one of them.

I support the dissemination of information that clarifies and warns about avoidable health risks. But I do not support bogus fear tactics that seek to deceive and manipulate, even if the goal is admirable. And this psa is one of the most deceptive manipulation tactics that I’ve seen.

And we cannot blithely suggest that the end justifies the means, when there are real victims of this false impression of HIV. This psa stigmatizes HIV positive persons in ways that are unnecessary and cruel. Viewers leave with the impression that HIV positive persons are about to fall over dead or go stark-raving mad.

And, in the mind of many, the ails of HIV positive people reflect on gay people as a whole. Psa’s that warn of dementia or anal cancer in HIV infected persons translate to many viewers that gay people are diseased and insane. We all, HIV positive and HIV negative alike suffer the consequences of such presentation.

And, besides, they are wrong. Yes, most people with the virus will also have other issues that result. But it is not true that “It’s never just HIV.” For some few, an HIV infection will not result in any medical consequences. I can’t say exactly how many, but it may be more than those who get anal cancer.

GLAAD and Gay Men’s Health Crisis have joined forces to ask the city to pull the ad. I wholeheartedly agree.

Comments

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Mike
December 14th, 2010 | LINK

Lightning.
No e.

Rossi
December 14th, 2010 | LINK

Well if you’re getting struck by the condition that Michael Jackson had, it’s Lightening.

Timothy Kincaid
December 14th, 2010 | LINK

LOL

Thanks Mike. fixed now.

Richard Rush
December 14th, 2010 | LINK

Shouldn’t the headline for this post say
“Over than 28 times more likely to get anal cancer”?
or
Over More than 28 times more likely to get anal cancer”?

Jason D
December 14th, 2010 | LINK

The PSA is over the top and you provide a lot of good information, just a few points:

About 720 patients die. Anal cancer is highly associated with HPV infection (though the vast majority of those infected with the HPV virus never develop anal cancer) and a vaccine is available which eliminates this risk factor.”
Yes, but the recommended age for both vaccines is 11 years old, or at the least it’s most effective if you’re a virgin.
http://www.cdc.gov/vaccines/vpd-vac/hpv/vac-faqs.htm

Gay men, who are more likely to have become infected with HPV in their anus than are heterosexuals, experience anal cancer incidence of about 35 in 100,000. HIV infected persons, as are other persons with a suppressed immune system, are more likely to develop this cancer, but we still are talking tiny tiny numbers, maybe around one tenth of one percent.

While true; I always get annoyed by this almost dismissive way of looking at figures. I doubt very seriously if the few gay men who are both HIV+ and have anal cancer are at all comforted by the rarity. “Oh doc, so you mean I just have amazingly shitty luck? Well that’s a relief!”

Seeing a slideshow of a man with mouth cancer and the operation that removed his lower jaw kept me from ever picking up a can of skoal.

Similarly the slideshow of military personnel with STDs given every year of High School (fresh pics each year! We lived near the naval hospital) also gave me a lot to think about as far as condom usage and abstinence. A hell of a lot more than any simple lecture would’ve. Granted we had a health class which discussed all these disease, abstinence, condoms, UTIs, sex myths, pregnancy, but none of that is as memorable as a snapshot of someone’s butt covered in anal warts.

I’m not saying the ends justifies the means, I’m saying a picture is worth a thousand words.

Timothy Kincaid
December 14th, 2010 | LINK

I guess today is typo day

e2c
December 14th, 2010 | LINK

Err…. one thing.

I think you need to look at women’s health studies re. osteoporsis, and that includes studies on women with HIV/AIDS.

The comment about “white women” seems a bit off to me, as does the “easy to treat and resolve” statement.

Maybe that’s true of very young men who are HIV+, but I wonder if that’s the case for women (of all ages)?

Something tells me “no.”

Throbert McGee
December 15th, 2010 | LINK

How about a PSA that said “If you engage in bareback anal sex, you are manifestly an irresponsible retard and a parasite upon society, and if you buy and view bareback anal porn, you are promoting a market for irresponsible retarded social parasites to do their thing in front of a video camera”?

(Note that this avoids stigmatizing people who are infected with HIV, but instead stigmatizes only those who participate in spreading the infection.)

In any case, by the CDC’s numbers we in the “MSM” demographic account for well over half of the new HIV cases each year — so it’s possible that a non-scary, non-insulting, Hooray for condoms! Let’s stay positive about not becoming positive! approach isn’t quite enough.

Timothy (TRiG)
December 15th, 2010 | LINK

This is the sort of messing with statistics which Ben Goldacre attacks so magnificently in Bad Science.

TRiG.

David Blakeslee
December 15th, 2010 | LINK

Thanks for posting on this Timothy.

Regarding your argument about “fear” and analogies of lightning strikes: the same argument could be applied to suicide in gay and lesbian children in a public school…yet protecting them is still a very worthy cause.

Shark attacks are another example…

The CDC fact sheet is interesting: http://www.cdc.gov/nchhstp/newsroom/docs/FastFacts-MSM-FINAL508COMP.pdf

It may explain why two advocacy groups for GLBT issues are on opposite sides of this debate about the PSA.

African American’s MSM are horribly overrepresented in the group of new cases of HIV. The gay advocacy group in favor of this PSA seeks to educate African Americans.

David Blakeslee
December 15th, 2010 | LINK

This PDF from 2005 highlights by graph the disproportionate prevalence of HIV in non-white MSM

http://www.kff.org/hivaids/upload/3029-071.pdf

Jim Burroway
December 15th, 2010 | LINK

David,

Do you know the name of the advocacy group in favor of the PSA?

I am skeptical of advocacy groups that attack PSA’s just because they make us “look bad.” They’ve been doing that for decades and have little show for their approach. I do agree however that PSA’s, even fear-based PSA’s, ought to be grounded in something realistic. As Timothy demostrates, I don’t think this one is.

But because of my skepticism generally over some of the prior efforts that held coddling and affirming gay men as a higher goal over delivering effective prevention messages, I am very interested in hearing from LGBT supporters of this PSA — or at least supporters of this approach for a PSA if not this PSA in particular.

Jim Burroway
December 15th, 2010 | LINK

I should add that I recognize that the problem with fear-based PSA’s is the danger they can pose in increasing stigma toward those with HIV if not done correctly, and it is all too easy to not do it correctly. As someone whose partner is HIV+, I am extremely sensitive when it comes to actions that can add to that stigma, which we have witnessed first-hand more times than anyone not in our shoes can imagine.

But I do think that we also have to recognize that past efforts (some of which have been hampered by U.S. funding policies that promoted abstinence before marriage while denying marriage to those who presumably ought to be abstinant under that unrealistic framework) have not made much of a dent in the trends since the late 1990’s. Clearly something different must be done than has been done in the past. Federal policies need to change in order to effectively address the social realities of the gay community as they are, and not as right-wing politicians would want them to be.

But at the same time, those efforts within the gay community ought to be re-examined as well. And I think the poz community is an excellent resource for that. You want a fear-based campaign to reach those who tune out the other messages? I can think of no one who can do that better than someone who is HIV+. Think of not just the health problems, how about the social isolation and stigma that you will encounter if you catch it? Your social network evaporates and people treat you like you have the plague. That is a message that I think a lot of people will notice.

cls
December 15th, 2010 | LINK

Excellent and important. This sort of scare mongering and wonky statistics is used frequently by various government agencies to justify all sorts of regulations. Instead of telling people their chances of having a problem in terms of percentages of the population they say “If you do A, you chances of X, are so many times higher.” But if the starting bases is very tiny to begin with multiples of it still end up very tiny, meaning very little additional risk in reality.

Another favorite deceptive technique to watch for is talking about a change in numbers over a specific period of time. That one is easily manipulated by using a selected starting point or ending point to make exaggerated claims. When environmentalists tried to scare the public about warming supposedly increasing hurricanes they did precisely that.

During Katrina they argued that hurricanes increased from the 1970s to the 1990s. True, it did. But the 1990s were the second lowest decade of the last century and the 1970s was the lowest, in terms of hurricanes. Take any other decade of the century as your starting point and the trend line would be downward sloping — hardly the thing to instill fear.

I automatically become skeptical of any group that uses fear as the basis for policy decisions. Fear destroys reason and it rushes people into making decisions that are far too often irrational and counterproductive.

Timothy Kincaid
December 15th, 2010 | LINK

e2c,

I’m sorry if the “short white woman” comment seemed a bit off. It was intended to note that while HIV does increase the likelihood of osteoporosis, there are others who also are at higher risk: women, those with slighter bodies, and Whites and Asians.

Timothy Kincaid
December 15th, 2010 | LINK

David,

Regarding your argument about “fear” and analogies of lightning strikes: the same argument could be applied to suicide in gay and lesbian children in a public school…yet protecting them is still a very worthy cause.

I fail to make the connection.

David Blakeslee
December 15th, 2010 | LINK

Jim,

The advocacy group in favor of the PSA is “Gay Men of African Decent”

Never heard of them…but they are interviewed here:

http://www.nbcnewyork.com/news/local-beat/HIV-PSA-Hard-to-Stomach-111900114.html

Fear is the motivating factor in all sorts of political actions…and religious actions.

I wish virtue motivated us more!

prayers for you partner.

Mana
December 15th, 2010 | LINK

Scare-mongering PSAs are never a good idea. When your audience figures out it was all theatrics, they’re less likely to take future warnings seriously.

Not to mention that it’s insulting. What, the facts aren’t good enough, you have to blow them out of proportion, misrepresent and add some scary music to make people listen? With PSA treatment like that no wonder the public is so used to being spoon-fed that their critical thinking skills are in the gutter.

Throbert McGee
December 15th, 2010 | LINK

@Mana: “Scare-mongering PSAs are never a good idea.”

I disagree. I would say, instead, that it’s never a good idea to rely ONLY on scare-mongering PSAs as your sole approach. For that matter, it’s not a good idea to use ONLY non-judgmental, reassuring, sunshine-and-lollipops language in your PSAs.

In a campaign to promote certain behaviors and discourage other ones, there’s a valid place for a little bit of scare-tactics and a dash of judgmental-sounding stigma, judiciously mixed in with more lighthearted and upbeat encouragement.

e2c
December 16th, 2010 | LINK

@ Timothy: Not sure how I can state this any more clearly, but … I was trying to be very specific re. the way in which the number of women (mostly non-white women) with HIV/AIDS is downplayed; the way in which women’s health (in all aspects) still takes a backseat to men’s health in research and education (of both the medical community as well as the general public), and finally, how women with AIDS are very poorly served by many, many health agencies and – in all too many cases – stigmatized by their own communities. (Black and Hispanic women with HIV/AIDS being two major examples of that unfortunate demographic.)

I’m a woman, so I’m very skeptical of any claims that osteoporosis is both easy to diagnose and treat – let alone that it would be easy to treat in a woman with HIV/AIDS.

Men have the better of us when it comes to bone density. (And, as an aside, I remember activists like Larry Kramer making the most horrible brush-off comments regarding women and HIV/AIDS back in the early 90s – would have to do some digging in the Washington Post archives to come up with the specific examples I’m thinking of, though.)

all of the above is in no way meant to diminish the importance of good preventive medicine for uninfected men and for good health care/meds for men with HIV/AIDS.

But I do think that women are the most ignored and generally ill-cared-for (in multiple respects) HIV+ population in this country – also that proportionately more of those women are low-income and from minority groups.

(Of course, all of this is dwarfed by the enormity of the HIV/AIDS epidemic in other parts of the world, so…)

Timothy Kincaid
December 16th, 2010 | LINK

e2c,

I was directing my commentary at the issues and images specifically covered in this ad: ie gay men.

Your comments about the inequality of research or even acknowledgment of women’s health issues – especially around HIV/AIDS and women of color – are very valid and, sadly, quite true. And while it is not exactly the focus of this commentary, it is important to be reminded that the face of AIDS in the US is no longer “white gay man” and is increasingly “African-American woman.”

As for osteoporosis being “fairly easy to both treat and forestall,” I will readily admit that I’m not qualified to make any medical pronouncements and am only relying on what I read in connection with writing this commentary. Perhaps I should have clarified that osteoporosis is fairly easy to forestall if early signs are detected or a risk is suspected through calcium monitoring and moderate exercise – though that too may be simplistic.

e2c
December 16th, 2010 | LINK

@ Timothy: No worries!

Men and osteoporosis vs. women and osteoporosis: I don’t know enough about how this affects men to be able to comment intelligently, but I do know that for women, it’s very important to start taking supplements, doing weight-bearing exercise, eating healthy amounts of calcium (etc.) pretty early in life in order to forestall broken hips and whatnot – and even that’s no guarantee.

Women are supposed to get a baseline dexa (bone density scan) in their early-mid 30s and then keep on being monitored (via periodic dexa scans) from then on in.

Apologies for taking this so far off topic, but the statement about osteoporsis hits a lot of nerves. And I truly wonder what the deal is with women who are HIV+/have AIDS and bone density. My guess is that it’s not a good situation…

all the best,
e.

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