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PaperclipPerfector  3d ago (text post)   11885 thread views

Culture War Roundup for the week of June 22, 2026

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When their lifestyle does turn harmful, the fallout lands almost entirely on the people who opted in. A virally suppressed person on antiretrovirals transmits HIV to sexual partners at a measured rate of zero.

Who pays for these antiretrovirals and other PLWH costs?

You, me and everyone else who is a net positive tax payer. In theory, I'm not subsidizing the lifestyle of an American with HIV, or even just their life.

But we subsidize a lot of things dawg. Old people. T2DMs hitting the soda fountain while their kidneys spit out sprite. Children with leukemia. Not smokers, since they pay for their sins by saving the taxpayer money by denying themselves old age <3

In the US the tab runs through the public ledger far more than the private one (your healthcare system is deeply in the closet, and claims to be privatized). Medicaid is the single largest payer of HIV care, Medicare second, and the Ryan White program bottoms underneath both as the "payer of last resort," funded at roughly $2.6 billion in FY2024. Domestic federal HIV spending sits around $28 to $33 billion a year, the large majority of it mandatory entitlement money that swells with caseload. Per head, lifetime care runs about $420,000 discounted and north of a million undiscounted, with something like 60 to 68% of it being the antiretrovirals themselves. So yes. It is socialized. I'm not going to pretend otherwise to protect my flank. Or my ass, which is unviolated by anything but NHS negative-ply today.

But you gotta spend money to make money. And in this case, you do make money.

Then the part that should actually interest a cost-conscious person, because it cuts the other way from how you're swinging it through implication. Because U=U holds (UwU) and a virally suppressed person does not transmit, the single most cost-effective prevention tool available is putting positive people on the drugs and keeping them there. Every suppression is an infection that never happens, and every averted infection is another ~$420k to $510k lifetime tab that never opens. The modelling supports this, AFAIK: in the Botswana combination-prevention work each averted infection saved about $9,200 in downstream care and pushed the whole intervention into cost-saving or near-cost-saving territory.

ART buys a lot of QALYs for the treated person, and viral suppression also prevents expensive future infections. At U.S. drug prices, the treatment itself is costly, but interventions that get people diagnosed, treated and suppressed often become cost-saving once avoided transmission is counted.

ART for diagnosed HIV? A fucking bargain at about $21k per QALY.

https://pubmed.ncbi.nlm.nih.gov/23318310/

Well below the usual threshold of $100k per QALY.

ART for prevention? Even better, because you're averting transmissions and secondary QALY/financial losses. HIV is highly contagious (surprising nobody here, I hope, there's a reason it's everywhere and has been for decades).

Finally, ART costs money because people live for decades and keep taking drugs. Duh.

Untreated HIV is not free to the pool. You must consider opportunistic infections, ICU admissions, and onward transmission, all of which cost more than the pills. If your genuine concern is my wallet (doing fine) or yours (can't say) the wallet-minimizing policy is more treatment, started earlier, not less. I'm libertarian-adjacent, and I'd prefer that people pay for themselves really, but if we're going to pool risk and expenses, we might as well do it sensibly. Why yes, I work for the NHS.

If you're trying to pray away the gay, or AIDS, it's not going to work. Things were worse in the 80s and 90s, when the disease was a death sentence. I have little interest in considering "solutions" that involve trying to get rid of gay men being gay men (good luck, even immense social stigma and a near lethal disease couldn't do it), and it's not like most countries don't spend on primary prevention or awareness programs. I'd suggest cutting the budget for expeditions in the ME first, not that anyone listens to me about that. The drugs continue to get cheaper, and I continue to get drunker while the Ritalin wears off.

That is all I have time for, because I'm at a straight pub and I intend to enjoy myself.

These are a lot of words to say that "spreading HIV actually costs the taxpayer a ton of money and even the best way that we know how to reduce the costs still costs a ton of money and all things considered it would be better for society if people didn't engage in risky behaviors that spread HIV."

And yes, this is also true for a lot of other things - simple overeating is a much larger drain on the taxpayer than HIV, and you shouldn't pretend like that doesn't have negative externalities either.

And yes, this is also true for a lot of other things - simple overeating is a much larger drain on the taxpayer than HIV, and you shouldn't pretend like that doesn't have negative externalities either.

And I never have. I'm voting for the party that supports Universal Public Ozempic.

These are a lot of words to say that "spreading HIV actually costs the taxpayer a ton of money and even the best way that we know how to reduce the costs still costs a ton of money and all things considered it would be better for society if people didn't engage in risky behaviors that spread HIV."

Are you surprised that I am internally coherent and know the facts? Don't be. The nerd who calculates QALY figures isn't. You can also use more words too, really, but I'd presume that if you found an actual logical flaw in my argument you would have pointed it out.

I'd presume that if you found an actual logical flaw in my argument you would have pointed it out.

You said "[w]hen their lifestyle does turn harmful, the fallout lands almost entirely on the people who opted in" during your assessment of the damages of HIV in this specific context of gay men. I think that's misleading: the fallout of HIV is very expensive, and society picks up some of that tab. And furthermore (as you doubtless also know) HIV is not randomly distributed across the population (nor is it distributed evenly across the population of gay men). People who get HIV are more likely to be materially disadvantaged, not less, so the taxpayers are more likely to pick up the tab.

I don't consider this a logical or process flaw in your argument so much as a factual or directional mistake.

You are welcome to calculate the relative burden or expense in terms of costs swallowed by the gay men vs externalities. The hard numbers I've quoted (with citations) are fucking chump change. Less than HSR. 1.5 Bridges to Nowhere.

A few hundred billion dollars? Then we'd be talking real money. Or a nice week in Tehran. Where exactly are the additional costs that are being imposed on the general populace? I'm sure they exist, but I don't think they sum up to very much. And the alternative of people dying of HIV is not pretty or cheap either.

I'm sure someone with more spare time (or Ritalin) can take a crack at reverse-engineering financial figures or willingness to pay to avoid being around gay people. It's not going to be me.

HIV is not randomly distributed across the population (nor is it distributed evenly across the population of gay men). People who get HIV are more likely to be materially disadvantaged, not less, so the taxpayers are more likely to pick up the tab.

And what difference does that make to anything? I have quoted the bill, we know the tab that's paid at taxpayer expense. This adds nothing, changes nothing. It's not like there's one gay dude with super-AIDS costing you $30 billion, who you could knock on the head and save everyone a lot of hassle.

And what difference does that make to anything?

I think it makes your argument worse, not better. Sure, maybe as measured by the stingy metric of financial balance in the general treasury, the benefits of gay men as a whole outweigh the costs, but "[w]hen their lifestyle does turn harmful" the (financial) cost isn't almost entirely borne on the group of people who opted in; it's disproportionately likely to be borne by society.

(To be clear, from what I can tell, realistically the group of people opting in to HIV risk can be diced finer than "gays.")

The hard numbers I've quoted (with citations) are fucking chump change. A few hundred billion dollars? Then we'd be talking real money. Or a nice week in Tehran. Where exactly are the additional costs that are being imposed on the general populace? I'm sure they exist, but I don't think they sum up to very much

You're shifting the goalposts here. It's as if you said "the horrible impact of dragons being able to breathe fire is almost entirely limited to dragons" and then I pointed out that no, dragons mostly don't fight each other, they are more likely burn down people's homes and steal their gold, and you said "well they mostly avoid populated provinces and steal from monasteries, so the general treasury is not really impacted" which I am sure is a relief to our lord the king (supposing for the sake of illustration that we're court wizards or something I guess) but doesn't really mean you were right to say that dragons breathing fire is mostly something that isn't a human concern now does it?

You, me and everyone else who is a net positive tax payer.

While your contributions are undeniably positive, if you work for the NHS, you can't be a net positive tax payer.

I can and I am. In the wrong tax bracket. Mostly being taxed of patience and the will to live.

yep it's all fun and games until we remember we live in a society with mandated health insurance with no pre-existing condition exclusions that socializes costs.

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