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Unsure when to start
Jan 8, 2004

A friend of mine has a viral load of 78,000 and a cell count of 34 (3). Has had some minor opportunistic infections, but otherwise seems healthy. The doctor who saw him when he took the tests advised him to start treatment. But my friend refuses because he thinks he's still ok. What do you suggest I do to make him start the treatment?

Response from Dr. Pierone

It sounds like he may be in denial. Actually, what is denial? I think that denial is refusal to deal with a serious or life-threatening situation or problem that is glaring or obvious to other people.

Uncommonly, denial is due to limited mental capacity. Some people with borderline intellectual competency are not able to fathom the implications of a situation and simply ignore it because they don't understand.

However, in most cases of denial, the person is fully competent, but is so fearful of the threat or condition that on a subconscious level they refuse to acknowledge it. Denial is an effective defense mechanism - "out of sight, out of mind". If I don't worry about this problem maybe it won't really turn into anything and I will be ok.

How to get someone out of denial? I think that it is a process. Imagine you are walking on a train track with someone and you hear a train siren in the distance. Your ears perk up and you say lets move to the side. You quickly get off the tracks but your friend ignores this and keeps walking. The siren gets louder and closer. You raise you voice and firmly say, "OK, quit fooling around, get off the tracks now". No response. The train now appears around the bend. By this point you are shouting, gesturing, imploring, and warning your friend of his impending doom. He looks at you blankly and says 'huh?". The train bears down and you are literally screaming, he finally turns around, eyes wide and mouth agape. At this point in the process, with the train engine roaring and the impact not far off, the true threat overcomes the subconscious mechanism and he quickly tries to scamper off the track (most do make it).

Some people in denial are not going to change unless they get tangible proof that the low numbers mean something (like oral thrush or pneumocystis pneumonia). Others will eventually listen to loved ones or influential members of their peer group and overcome the subconscious resistance. When it comes to HIV treatment, you can't make someone take therapy; but you can certainly influence them by discussion, pleading, arguing, and threatening.

Some people are not in denial, but have a deep seated conviction that antiretroviral therapy is too dangerous no matter how low the CD4 count and will not consider taking it under any circumstances. This is not denial per se, but rather an error in judgment with a faulty risk versus benefit calculation.

Good luck influencing your friend and let us know how things go.



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