Avoiding life-saving treatment

Jonathan alerted me to the New York Times story, “Trying to follow the trail of missing AIDS patients” by David Tuller:
“More recently, however, studies have found that 15 to 40 percent of those who start treatment are lost to follow-up within one to three years. This unsettling trend has emerged at a difficult time; financing for treatment from the United States and other donors is not keeping pace with the rate of new infections, which has generated waiting lists for the lifesaving medications in some parts of Africa.”
The “more recent studies” are a 3-year-old article by Rosen, Fox, & Gill, “Patient retention in antiretroviral therapy programs in Sub-Saharan Africa: A systematic review”, PLoS Med 4(#10, 2007): e298
“Since the inception of large-scale ART access early in this decade, ART programs in Africa have retained about 60% of their patients at the end of 2 y. Loss to follow-up is the major cause of attrition, followed by death. Better patient tracing procedures, better understanding of loss to follow-up, and earlier initiation of ART to reduce mortality are needed if retention is to be improved. Retention varies widely across programs, and programs that have achieved higher retention rates can serve as models for future improvements.”

Evidently those models for attaining higher retention rates have had no effect during the intervening 3 years. Hardly the first time that expert predictions have failed, thereby providing welcome opportunities for more research.

I’ve often been struck by the extraordinary regularities in HIV/AIDS demography. “HIV-positive” rates vary by age, race, sex, and population density in the same manner in all tested groups in the USA, and the same regularities show up in other parts of the world, mutatis mutandis (e.g. the particularly high tendency for black women to test poz); see my book and many subsequent blog posts here. Not only has the rate of non-compliance with these “life-saving” drugs remained apparently the same in Africa for at least 3 years, it is about the same as the rate in Washington DC and other parts of the USA:
“In any given month, about 40 percent of the approximately 1,900 clients actively enrolled in the D.C. AIDS Drug Assistance Program (ADAP) are not utilizing antiretroviral medications. . . . [although] almost all of these ‘nonutilizers’ have active prescriptions for antiretroviral drugs written by their physicians, nurse practitioners or physician’s assistants. . . . ADAP programs across the country report similar rates of ‘nonutilizers’ (about 40 percent)” (Drug non-adherence, imaginary epidemics, and sexual nonsense, 2009/08/30).

Question:
Why would so many people reject life-saving treatment?
Especially given that it is free or nearly so?

Ask anyone in the street whether HIV causes AIDS and whether AIDS kills, and you won’t find many who disagree. Ask anyone in southern Africa whether HIV causes AIDS and whether AIDS kills, and you won’t find many who disagree. So this huge degree of non-compliance is not because of any lack of the “awareness” of the danger of HIV/AIDS that official propaganda has been spreading for these many years.

So, again, why do so many who believe that the drugs are life-saving refuse them?