So what the heck's the matter with those people with HIV . . .

who don't take their pills? Would it seem less strange if I told you that fully half of people with high blood pressure don't take their pills at all, as opposed to 20 or 30% of people with HIV who don't manage to take them on schedule? You probably aren't deathly afraid of hypertension, but in fact, although it may lack the precise inevitability of HIV disease, it will kill you, and quite likely in a highly unpleasant way such as kidney failure or strokes.

Furthermore, the high blood pressure pills generally have only mild side effects, or none worth mentioning, for most people. You only have to take them once a day, they're small, and you don't have to be ashamed of people seeing you take them, or picking them up at the drug store. For people who are lucky enough to need only a thiazide, they are even ridiculously cheap -- less than the typical insurance co-pay. Some people need a couple of more expensive pills, such as an ACE inhibitor and a calcium channel blocker, so cost does become a little bit of an issue. If you have insurance, you might be spending $20 or $30 a month out of pocket. But doesn't that beat winding up on dialysis, or being paralyzed, or dropping dead? It does for me.

It's the same for every kind of medication. People don't use their eye drops for glaucoma, even though they are likely to go blind. They don't take beta blockers and statins after they've had heart attacks. Don't take their diabetes meds, and what's more, they keep on eating doughnuts. And so on. Maybe you're one of them. What the hell is the matter with you people? Are you irresponsible? Suicidal? Crazy? Just plain stupid?

No, unfortunately you are human. There are some standard psychological wiring issues involved here, and it's self-contradictory to call them "irrational" because rational means thinking and this is how we think. One is discounting of the future. In general, rewards or punishments that may occur in the future mean a whole lot less to us than what's happening now or is likely to happen soon. The discount is so great that the mere annoyance of having to go to the drug store and stand in line is worth more than the prospect of losing the ability to urinate in 10 or 15 years. Throw in 20 bucks and it's no contest.

Another standard psychological mechanism is denial. If you're in an unpleasant situation that you can't get out of, it's best not to think about it and worry about something else. Taking these pills every day means there's something wrong with you. Forget about it, and it goes away.

Finally, why should I necessarily believe this whole story in the first place? I feel fine. There's nothing evidently wrong with me and you're telling me to ingest powerful, unnatural chemicals that are going to mess with my natural bodily functions. That might be a good idea, and on the other hand, it might not be. I do know that taking the pills makes me feel worse. (Hypertension meds can make you pee a lot, feel dizzy when you stand up suddenly, develop a dry cough, and other annoying stuff like that.)

So maybe it's not so strange after all. Maybe people are making a "rational" decision, weighing up costs and benefits in a way that makes sense to them right now. Of course they'll probably feel differently about the whole thing when they're lying on a cot three times a week with their blood being pumped through a filter. So what can or should we do about this? We can simply say that we respect people's autonomy and they should make their own choices, or we can define this as a problem that we need to do something about. I know how most doctors feel about that question. How about you?