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Magical Thinking in HIV: Much More Than Denial

How Unrealistic Thoughts Keep People Away From Medical Care

May/June 2016

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Credit: Ljupco for iStock via Thinkstock

Credit: Ljupco for iStock via Thinkstock

Two bars. There have never been two bars before in the 200 or so HIV tests I had previously given.

About half an hour after an oral swab is taken, one red bar will show up, meaning the person tested negative for HIV. I tell people that they should get tested again in three months to make sure, since the test might not be able to pick up enough HIV antibodies to test positive if the patient contracted the virus in the last 90 days.

But this time there were two bars, meaning that there was a 99.98% chance that the person was HIV-positive based on this particular test.

As I walked to the curtained-off room in the ER where the patient was sitting, my mind played out possible reactions. Crying was fine. I could respond to crying and, hopefully, that flood of emotion would be coupled with acceptance of his HIV status and a willingness to get into medical care. Anger and denial were more negative responses, but I had been trained to deal with them. The concern wasn't that the patient would lash out, but that he might bolt out of the ER and away from care.

I didn't get any of the reactions I expected. Instead of tears or rage or disbelief, the young man responded nonchalantly, with a hint of disappointment. It was as if he had just lost $10 playing scratch-off lottery tickets at the gas station.


My supervisor, who had joined me when I delivered the results, asked the young man, who had already slung his backpack over his shoulder, if he had ever tested positive for HIV before. He said that he had -- a couple of times. When I asked him why he had told us during our initial discussion that he had not previously tested positive, he answered, quite correctly, that it was because we wouldn't have given him the test if he told us that he had.

I was thoroughly confused. Why, I thought, would a young man who had already been told on multiple occasions that he was HIV-positive go through all the trouble of hiding his status from us in order to take another HIV test when he knew what the results would be?

My supervisor, however, had no trouble understanding the motivations behind the patient's actions. He had been living well with HIV for more than a decade and when first diagnosed, had done much the same thing this young man just did.

"He was probably just checking to see if it had gone away," my supervisor told me. "It happens more than you might think. When you're having trouble accepting the fact that you have HIV, your thoughts can take you all kinds of places. You go long enough after being diagnosed without any major problems and get to thinking that maybe you don't have what they say you have. Maybe the test was a false positive or your body got rid of the virus somehow. You can make yourself believe a lot of things when you don't want to have HIV."

It happens more than you might think. When you're having trouble accepting the fact that you have HIV, your thoughts can take you all kinds of places.

That afternoon, four years ago, was my first introduction to the power of magical thinking in HIV, and the ways it can disrupt the best laid plans to link people who are HIV-positive to medical care.

As the name suggests, magical thinking embraces objectively irrational or fantastic beliefs reinforcing the idea that the rules and scientific facts governing empirically validated experiences do not apply to one's self or, in some cases, to a loved one.

While HIV magical thinking is a form of denial, it is more complex than simply refusing to acknowledge a positive HIV test result. Those who refuse to accept the fact that they are HIV-positive are unlikely to engage with HIV health care providers after receiving their diagnosis, but people who get caught up in magical thinking appear at all stages along the continuum of care.

In the case of this young man, his magical thinking manifested itself in the belief -- or perhaps the faint hope -- that the HIV detected on multiple occasions would have somehow gone away between his last test and the one I gave him. >>

At first glance, it might seem as if the testing encounter was a waste of resources. However, the test we performed wasn't so much about the results as it was about giving us another opportunity to connect with someone who was on the edge of becoming willing to engage in care.

In fact, before he left the emergency room that day, my supervisor was able to schedule an appointment for him with an infectious disease doctor on the following day. I couldn't tell you if that young man ever showed up for that appointment or if he's in care now, but I can say that the encounter we had probably caused him to at least consider reevaluating his thinking around his HIV diagnosis and provided him with some tools with which to do so.

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This article was provided by Test Positive Aware Network. It is a part of the publication Positively Aware. Visit TPAN's website to find out more about their activities, publications and services.

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