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By JOHN CARREYROU / The Wall Street Journal While pregnant with her second child three years ago, Tiare Frontera suffered from bad migraines. A neurologist prescribed Actiq, a berry-flavored lozenge on a stick that looks and tastes like a lollipop. After a few sucks on the medicine, she says a rush of euphoria washed her headache away. Soon, Mrs. Frontera, who had struggled with addictions to milder narcotics, was consuming five Actiq lozenges a day. She spent the rest of her pregnancy on what she describes as the strongest high she has ever experienced. When she gave birth, her baby son was cranky and wouldn’t sleep. Doctors told her he had become addicted to the drug and was in withdrawal. Mrs. Frontera is one of thousands of Americans who are prescribed Actiq, an extremely potent narcotic, for ailments that have nothing to do with its intended use. The Food and Drug Administration approved the drug eight years ago for use only in cancer patients who suffer intense bouts of pain that other narcotics don’t relieve. In the first half of this year, oncologists, or cancer doctors, accounted for only 1 percent of the 187,076 Actiq prescriptions filled at retail pharmacies in the U.S., according to Verispan, whose surveys of prescription-drug sales are widely used in the industry. Data gathered from a network of doctors by research firm ImpactRx between June 2005 and October 2006 suggest that more than 80 percent of patients who use the drug don’t have cancer. Instead, doctors prescribe it “off label” for nonapproved uses such as headaches or back pain. Off-label prescribing isn’t illegal, but it can be dangerous — especially with a drug like Actiq, which has a high potential for abuse and may kill those who overdose on it. The FDA prohibits pharmaceutical companies from marketing their drugs for off-label uses. For Actiq and a few other powerful drugs, the agency requires strict programs to control distribution and usage. Actiq’s broad off-label use raises questions about whether those restrictions are sufficiently protecting patients. “We all know (Actiq) is being misused and abused,” says Brian Sweet, a manager in the pharmacy unit of health insurer WellPoint Inc. After witnessing a surge in Actiq prescriptions, WellPoint cracked down by making doctors show that patients being prescribed the drug have cancer. Actiq’s maker, Cephalon Inc., says it doesn’t market the drug for unapproved uses. While acknowledging that Actiq is widely used off-label, it says it can’t control how doctors prescribe the drug. Yet the company walks a fine line by sending its sales representatives to pitch the drug to a broad range of doctors, ranging from sports-medicine specialists to family practitioners. It gives these doctors coupons for free samples. Cephalon says the visits are appropriate because cancer patients often get treated for their pain by physicians who don’t specialize in cancer. Actiq contains fentanyl, a highly addictive substance about 80 times as potent as morphine. Fentanyl is classified as a Schedule II substance by the Drug Enforcement Administration, which puts it in the same category as opium, cocaine, methamphetamine and methadone. Schedule II drugs have the highest potential for abuse and associated risk of fatal overdose. Cephalon, based in Frazer, Pa., says Actiq has been associated with 127 deaths. Two of them involved children who confused the drug for candy. Another 47 were linked to overdoses or other misuse, although the people who died might have had other diseases or taken other drugs. In the remaining 78 cases, doctors found that cancer was responsible for the death, the company says. Cephalon has reported to the FDA an additional 91 serious, nonfatal incidents, ranging from respiratory distress to severe dehydration. The U.S. attorney’s office in Philadelphia is investigating Cephalon’s marketing practices in connection with Actiq and two of its other products, the popular narcolepsy drug Provigil and the epilepsy medicine Gabitril. No charges have been filed. Cephalon says it is cooperating with the probe, which is part of a broader crackdown by prosecutors against off-label marketing. In August, the Justice Department fined Schering-Plough Corp. $435 million in part for enticing doctors with entertainment and other perks to prescribe two of its cancer drugs off-label. Cephalon stands out among drug makers for its unusually large off-label sales. Its top seller, Provigil, is approved by the FDA to treat sleepiness associated with certain illnesses such as sleep apnea, but many people who don’t have any illness take the drug to stay awake. Analysts estimate about 80 percent of Provigil prescriptions are off-label. Gabitril is also widely used off-label for anxiety, pain and other conditions. Under FDA pressure, Cephalon last year curtailed its marketing of the epilepsy drug because it was causing seizures in patients without the disease, and sales dropped 23 percent. Founded in 1987 by a former DuPont Co. scientist named Frank Baldino Jr., Cephalon expects revenue to exceed $1.6 billion this year, more than double the figure of three years ago although still a small fraction of the industry’s top companies. Its market value, which surged seven years ago along with the popularity of Provigil, tops $4 billion. Dr. Baldino earned $2.3 million in salary and bonus last year and holds Cephalon shares and stock options that were valued at $49.6 million as of the end of last year. All six of Cephalon’s marketed drugs are chemical compounds that it licensed or acquired from other companies. Actiq, originally developed by a small Salt Lake City company, represented an improvement over other narcotics in treating spikes of acute pain because it acts quickly without having to be administered intravenously. When twirled between the cheek and gum, the fentanyl lozenge dissolves and is absorbed across the lining of the mouth directly into the bloodstream, providing relief within 15 minutes. Actiq had sales of $15 million in 2000, when Cephalon acquired it. By last year, sales had grown to $412 million, making it Cephalon’s No. 2 drug. In the first nine months of this year, sales jumped to $471 million. Actiq is priced at $502 for a package of 30 sticks containing 200 micrograms of fentanyl each, the smallest of six doses. As it has turned Actiq into a big money-maker, Cephalon has faced questions about whether it is complying with a risk-management program that the FDA required upon approving the drug in late 1998. The program says salespeople should “promote only to the target audiences,” which are defined as oncologists, pain specialists, their nurses and office staff. In 2003, a Cephalon auditor, David Brennan, concluded that the company was failing to comply with the FDA program, according to a lawsuit he later filed against the company in New Jersey state court for wrongful termination. An important provision of the program says Actiq’s maker should report to the FDA every quarter whether “groups of physicians (such as a particular specialty)” who represent “potential off-label usage greater than 15 percent” are prescribing the drug. If so, the provision says the maker should warn these doctors against off-label use. Mr. Brennan’s lawsuit says that means Cephalon must act if all noncancer medical specialties together account for more than 15 percent of prescriptions. Cephalon interprets the provision differently. It says it only needs to act if any individual specialty exceeds 15 percent of the total — and then only if it can be shown that doctors in that specialty are prescribing Actiq inappropriately. Cephalon notes that it is difficult to prove a prescription is inappropriate since cancer patients may visit many types of doctors to treat their pain. It believes the 15 percent clause has yet to be triggered. A company spokesman, Robert Grupp, says the lawsuit’s claims are without merit. The FDA declined to comment. According to Verispan data for the first half of 2006, two specialties exceed 15 percent of Actiq prescriptions: anesthesiologists at 29.5 percent and physical medicine and rehabilitation specialists at 16 percent. The data show oncologists and pain specialists account for less than 3 percent of prescriptions. Cephalon doesn’t dispute the data. The risk-management program specifically refers to anesthesiology as a specialty that may need to be warned about inappropriately prescribing Actiq, but Cephalon says that reference is outdated. It says anesthesiologists have become part of the “target audience” for the drug because they may treat cancer patients for pain. Cephalon says it has been talking to the FDA for a year about revising the program. After Mr. Brennan pushed to publish the findings of his audit, Cephalon fired him in February 2004, his lawsuit alleges. Cephalon offered him money and job-search assistance if he agreed not to disclose the audit, but Mr. Brennan refused, the suit says. Mr. Grupp declined to discuss Mr. Brennan’s dismissal but noted that he is “a former disgruntled employee.” Mr. Brennan has been interviewed twice by investigators working for the U.S. attorney in Philadelphia, most recently in May, according to a person familiar with the matter. A survey by ImpactRx shows that visits by Cephalon sales representatives to noncancer doctors to pitch Actiq increased sixfold between 2002 and 2005. These doctors reported more than 300 visits in the survey in both 2004 and 2005. Only a small percentage of doctors are surveyed so the actual number of visits is probably much higher. Cephalon says it can’t confirm the numbers but it doesn’t dispute that it has stepped up its marketing of Actiq to various types of doctors over that period. Stephen Leighton, a general practitioner in Winston-Salem, N.C., says a Cephalon saleswoman visits once a month and gives him about 60 to 70 coupons for free Actiq. Patients can trade each coupon for six Actiq sticks. Dr. Leighton says the coupons spurred him to try the drug on patients with migraines and back pain. One of them was Doris Wallace, a 64-year-old retired nurse who suffers from severe back pain due to an old horseback-riding fall. Ms. Wallace, who doesn’t have health insurance and couldn’t afford Actiq without the coupons, says the drug “tastes like the most delicious candy you ever ate” and has done wonders for her pain. At the height of her use, she was consuming 24 Actiq sticks a month. The positive experience of patients like Ms. Wallace has led Dr. Leighton to prescribe Actiq more widely for different types of pain. Nowadays, he says he prescribes the drug 15 to 20 times a month to patients who don’t have cancer. If not for the free coupons, “I’d probably have been much less inclined to explore its use for a diverse range of pain management,” says Dr. Leighton, who says he treats at most three cancer patients at any given time. Dr. Leighton says he thinks the FDA-approved usage of Actiq is too narrow. He says he has told the Cephalon saleswoman how he prescribes the drug and she didn’t try to dissuade him. Mr. Grupp of Cephalon says Dr. Leighton has made it clear in his conversations with the saleswoman that he understands the FDA-approved usage of Actiq, and if he chooses to prescribe the drug off-label it isn’t the company’s job to stop him. Mr. Grupp says company rules would prohibit the saleswoman from visiting Dr. Leighton only if he never prescribed the drug for cancer pain. “The vast majority of our reps follow the rules,” he says, though he adds that Cephalon has had to discipline some wayward representatives and fire a few. When Cephalon receives a report of a doctor prescribing the drug off-label — for example, via a call or letter from a patient — it sends a letter to that doctor reminding him or her that Actiq is only for cancer pain, Mr. Grupp says. The company has sent more than 3,300 such letters, he says. Earlier this year, Dr. Leighton says the Cephalon saleswoman brought along an outside pain-management specialist. Over lunch, Dr. Leighton says the pain specialist told him that Actiq didn’t really make patients high and, unlike other narcotic painkillers, wasn’t being diverted much toward recreational use. Cephalon declined to comment on the conversation. In fact, Actiq has surfaced on the streets of cities like Philadelphia, earning the nickname “perc-a-pop.” Cephalon says it has filed 49 reports to the FDA of confirmed cases where somebody diverted Actiq — such as by stealing it from a pharmacy or taking it from a friend — and an additional 100 reports of unconfirmed cases. Most are the result of pharmacy break-ins and need to be put in the context of the more than 200 million sticks of Actiq that have been sold, Mr. Grupp says. Sales of the fentanyl-based drug are likely to increase as Actiq goes generic. In late September, Barr Pharmaceuticals Inc. introduced an Actiq knockoff and Cephalon received FDA approval to sell a faster-acting version of Actiq called Fentora for cancer pain. Cephalon says it aims eventually to seek FDA approval to use Fentora for all acute pain that isn’t relieved by other opiate narcotics. Mrs. Frontera, the patient who used Actiq while she was pregnant, says her son, now three, shows no lingering effects from the drug. Mrs. Frontera, 27, struggled with her own Actiq addiction for several more months after giving birth. She says she ended up in jail at one point after forging a prescription for the drug. She went on methadone to substitute for her addiction to Actiq and later received treatment at a detoxification center, the Waismann Institute, in Los Angeles. Now she lives in San Luis Obispo, Calif. “It makes me angry that it was prescribed to me,” she says of Actiq. “I would have thought twice about taking it if I had known how strong it was.” Philip Delio, the neurologist who prescribed Actiq to Mrs. Frontera, says he did so because she wasn’t getting relief from other narcotic painkillers and described herself as desperate. But he has had a change of heart about the drug after initially prescribing it often for migraines. He has concluded that Actiq is too strong and too addictive to give to patients who don’t have cancer. Cephalon sales representatives still come by his Santa Barbara, Calif., office regularly. But Dr. Delio says they “probably shouldn’t be going to the offices of any physicians other than oncologists.” Sphere: Related Content Cheap Generic Viagra

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\"...Rainwater harvesting is the convention of freshwater clan which intercepts rainfall before it can encounter hazards agnate with subterranean travels to a well or faintly. Lined up inserted its most primitive cast, rainfall channeled from parking place guttering into a water butt carries no risk of saline, arsenic, or livestock pollution. Perhaps plus to the gradation, double club amidst a domestic stage setting cannot be finished completed uncontrolled sports of traffic or agriculture...\",OneWorld.

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Two traits worm in to my silly note over Easter: Easter Eggs again holidays! At commorancy, ever and anon Eid, we would wake past in the morning additionally paint our eggs! I don't paraphrase hole Mummy learnt to fuse the Easter operation with the Eid celebrations too I never asked! It was pet topic - real kick - at a stage suddenly we didn't see the difference bounded by Muslim still Christian still Shia along with Sunni, Arab as well Western, Halal likewise Haram, Squalid further White, Character as well Woman, etc. Here's a little report to utility you celebrate Easter with Easter eggs! Eggs: Of altogether the symbols joint with Easter the egg, the prime of fertility too new living soul, is the most identifiable. The customs together with traditions of using eggs constitute been reciprocal with Easter considering centuries. Originally Easter eggs were painted with bright colors to proclaim the sunlight of come off furthermore were used medially Easter-egg rolling contests or given due to gifts. Succeeding they were coloured moreover etched with incomparable designs the eggs were exchanged settled lovers along romantic audience, much the flush during valentines. Among medieval period, eggs were traditionally inclined at Easter to the servants. Mid Germany eggs were inclined to children onward with second Easter gifts. Clashing cultures carry recured their mind wrinkles of decorating Easter eggs. Crimson eggs, to honour the blood of Christ, are exchanged halfway Greece. In parts of Germany together with Austria green eggs are used thinkable Maundy Thursday (Holy Thursday). Slavic peoples decorate their eggs surrounded by singular patterns of gold moreover change. Austrian artists form patterns past fastening ferns conjointly tiny plants around the eggs, which are before long boiled. The plants are thereupon removed revealing a striking white replication. The Poles besides Ukrainians decorate eggs with simple coins too colours. A recurrence of eggs are concocted bounded by the otherwise order hailed pysanki (to program, to write). Pysanki eggs are a masterpiece of efficacy and workmanship. Melted beeswax is applied to the fresh white egg. It is suddenly dipped bounded by successive baths of dye. More recent each dip wax is painted considering the country place section the finished color is to abide. Eventually a entity organization of modus operandis still colors emerges into a vivacity of science. Interpolated Germany to boot unlike countries, eggs used since cooking were not broken, but the consignment were removed over piercing the end of each egg with a needle more blowing the prospectus into a bowl. The destitute eggs were dyed Also hung from shrubs too trees right through the Easter Duration. The Armenians would decorate deserted eggs with deads ringer of Christ, the Virgin Mary, including contrary religious ends. Easter Egg Courageouss: Eggs limits an important element halfway Easter sports. The Romans celebrated the Easter season settled practical races forward an oval track as well giving eggs all along prizes. Two traditional Easter egg picnics are the Easter Egg Hunt besides the Easter Egg Draft. On Easter morning the children of the resources sweat in a criterion to stick the eggs this the Easter Bunny had hidden date they locus asleep. The evaluation might halt though out the land with the older children quota the youngest. Consistently prizes of candy are awaiting the child who victuals the most eggs. Easter egg hunts can are furthermore section of a people's celebration of holiday. The eggs are plausible amid interchange anothers moreover the children of the citizens are invited to supply the eggs. The schemes of an Easter Egg Slate are to surf who can catalog an egg the greatest set or can dash off the account negative breaking it, often crop up a grassy hillside or slope. Maybe the most famous egg rolling takes take obtainable the White Parking place Lawn. Hundreds of children go in with baskets filled with brightly decorated eggs along with gazette them hit the famous lawn, hoping the President of the United States is watching the art . Oh Yeah! There has to be a sting at the finale!

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You're a Recs Bicycle! What's Your Faithful Motorcycle? Brought to you past Tickle

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So I know I haven't posted much lately. Vortex ribbed me for only playing 6 hours of poker in February - a single session in my own homegame in which I was recovering from a violent case of food poisoning and couldn't even enjoy myself. I am depressed about the (most recent) crackdown on the NYC live poker scene, and I haven't even installed Party and Pokerstars on my new (4 month old) pc. I hope Party hasn't confiscated my account since I last logged in. Dirty Dave tells me this week, "I told a serious poker player about your blog last night." Man. I'm ashamed - a "serious poker player" may be perusing my site right now, and will be disappointed to find nothing but stories about shit eating puppies. Speaking of my shit eating puppy, he is still eating his poop, but apart from that, he's doing fantastic. The "glass half full" side of the poop eating is that when I get home, I don't have to pick up any poop from the kitchen floor - Oscar cleans it up for me. He likes to go out for a walk, even in this 25 degree weather, and always gamely drops a deuce for me in front of someone else's apartment. Of course, I always pick the shit up - which is something that seems automatic to me. Yet, as Mrs. Dynamite says, "There must be an awful lot of seeing eye dogs in our neighborhood," because there is a shitload of dog shit on the sidewalk (you don't have to pick up after a seeing eye dog, of course). Seriously douchebags: when your dog takes a shit on the sidewalk, you pick it up. That is non-negotiable. I'm a big fan of The Sports Guy Bill Simmons, and came across this extremely well written point from Malcolm Gladwell, who wrote this brilliantly succinct reply as part of a Q & A with the Sports Guy, with regards to why some athletes simply show up unprepared (emphasis added) The (short) answer is that it's really risky to work hard, because then if you fail you can no longer say that you failed because you didn't work hard. It's a form of self-protection . I swear that's why Mickelson has that almost absurdly calm demeanor. If he loses, he can always say: Well, I could have practiced more, and maybe next year I will and I'll win then. When Tiger loses, what does he tell himself? He worked as hard as he possibly could. He prepared like no one else in the game and he still lost. That has to be devastating, and dealing with that kind of conclusion takes a very special and rare kind of resilience. Most of the psychological research on this is focused on why some kids don't study for tests -- which is a much more serious version of the same problem. If you get drunk the night before an exam instead of studying and you fail, then the problem is that you got drunk. If you do study and you fail, the problem is that you're stupid -- and stupid, for a student, is a death sentence. The point is that it is far more psychologically dangerous and difficult to prepare for a task than not to prepare. People think that Tiger is tougher than Mickelson because he works harder. Wrong: Tiger is tougher than Mickelson and because of that he works harder. I read one of Gladwell's books, Blink, which was mildly interesting, but he is clearly a very talented writer and psychological thinker. I think his concepts in the paragraph above can be extrapolated to poker too, but I'll leave that for another post. The Big Show comes to town tomorrow. until next time, KD

Tags: strong, shit, poker, pick, dog

There are many reasons to oppose Gov. Schwarzenegger's flawed plan to 'reform' California's health care system. Below are my top 5. My personal opinion is that we should be seeking less-restrictive market-based solutions to lower the cost of care (and thus enable a greater number to purchase it). 1. "Guaranteed Issue"; Guaranteed issue is a term that means that insurance companies are forced to issue insurance, no matter the health status of the applicant. Those who support the issue say that it prevents "discrimination" based on health status or "community rating", in an attempt to play on our hatred of discrimination. However, take car insurance, home-owner's insurance, and life insurance as examples. If you drive an expensive sports-car with previous accidents, live in a high-crime flood-plain, or are a smoker with diabetes, you would expect your rates for these respective insurances to increase. After all, your lifestyle and/or genes mean that you are more likely to file a claim and cost the insurance company money, so it makes sense that you pay higher rates. Guaranteed issue does nothing more than spread the blame. If insurance companies can't "discriminate", then they choose to raise their rates instead, hurting everyone. 2. Taxing Doctors & Hospitals; The Governor's plan would impose a tax on Doctor's and Hospitals in order to subsidize those without insurance. This Socialist-mentality makes no sense. Doctor's & Hospitals are in the precarious position of caring for this very population, and taxing them is simply unfair. Should we tax landlords and tenants to subsidize homeless shelters? Tax Restaurants to feed the hungry? Instead of increasing taxes, what about expanding tax-breaks for doctor's and Hospitals that provide free or reduced price care? 3. Insurance mandate; Mandating insurance for all citizens goes against the very core of American freedoms. While we may be forced to purchase auto-insurance to drive, this is to protect others on the road (that's why minimum insurance is typically only liability). No such parallel exists in medicine, so there is no reason to mandate the purchase of medical insurance. Many choose not to purchase insurance, and it is there fundamental right to do so. However, they should be held accountable for that decision. Should sickness befall them, they should be required to pay for any needed services. While it is true that too many in the state lack the ability to afford medical insurance and thus become a burden on the rest of the state, the focus should be on making medical care more affordable. 4. Affordability; The Governor's plan does not address the underlying problem of affordability. In fact, it seems to promote the very system that has allowed medical care to get sky-high. Third party payors (i.e. insurance companies) separate rational choice from medical care. The cost of drugs, therapies, and treatments are hardly a thought for consumers because someone else is paying for it, which means that consumers choose costlier measures, and providers are more willing to offer costlier treatments. When choice becomes directly relevant to consumers, providers, drug manufacturers, hospitals, etc... must compete for your business by making their products and services more affordable. Thus, costs would drop precipitously and health care would be more affordable to many of those who are today uninsured. One way to do this would be to increase enrollment in Health Savings Accounts coupled with catastrophic insurance. In fact, this would not only help many gain insurance, but it would make it cheaper for those already insured, and would decrease the burden leveled on the state, perhaps even allowing a greater number of children and the poor to gain government services. 5. Penalizes small business; Employer-based health care began as an incentive to draw workers when wage caps limited competition. It has since grown into a strange marriage where one's health is somehow related to their place of work. In todays world, let's face it...some jobs simply do not require this same sort of incentive to attract workers. Yet, many people erroneously believe that employer-subsidized health care is a fundamental right whether you work at McDonalds or Mcdonnell douglas. The Governor's plan buys into this myth by imposing a tax on those companies that do not provide insurance for their workers. Labels: Health Care

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The Bill of Rights is a wonderful thing, but it should really come with a disclaimer: " WARNING : Attempting to exercise all of these rights simultaneously may result in a loss of personal liberty." Bloomberg.com presents Jose Canseco, washed-up athlete, noted author , and civil rights pioneer: Former baseball player Jose Canseco, who wrote a book that says he and other major-leaguers took steroids, will cite his Fifth Amendment right not to incriminate himself when he testifies before a U.S. House panel tomorrow, his attorney said. Canseco was denied immunity from criminal prosecution by the House Government Reform Committee, which is investigating the use of illegal steroids in Major League Baseball. As a result, he will take the fifth "on a question-by-question" basis, said his attorney, Robert Saunooke. "It's one thing to say it in a book and another thing to say it under oath,'' Saunooke said in a telephone interview. "It's not admissible in a book." That's a sucker bet worthy of Pete Rose. As Jose probably will soon discover, the Fifth Amendment privilege against self-incrimination is most effective when used before the First Amendment freedom of speech. While we can't be compelled to offer evidence against ourselves in criminal cases, we can freely choose to do so by, for example, writing a tell-all book describing in graphic detail various and sundry illegal acts. Black's Law Dictionary (7th Edition) describes an "admission" as: "1. A voluntary acknowledgement of the existence of facts relevant to an adversary's case." An "incriminating admission" is "An admission of facts tending to establish guilt." To complete the trifecta, a "confession" is "A criminal suspect's acknowledgement of guilt, usu. in writing and often including details about the crime." Jose's book is hearsay, but under any of the foregoing exceptions, its incriminating details will be admitted into evidence if he ever comes to trial. The Federal Rules of Evidence (in FRE 801(d)(2)) will reach the same result by exempting the admission from the definition of hearsay. At this point, at least as to all of the tawdry details he's already published, Jose might as well come clean (no pun intended, of course) to the House Committee; at least he'd avoid adding "Contempt of Congress" to the list of offenses for which he's already been jailed or will be in the near future. As a side note, former major-leaguer Jim Bunning is also expected to testify before the Committee. Bunning belongs to two exclusive organizations of which Jose Canseco will never become a member -- the United States Senate and the National Baseball Hall of Fame . Labels: Law, Sports

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It's official sports fans - FDA rejects Arcoxia.

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By, Becky Trout, Palo Alto Weekly, April 3, 2007 Virus no longer an automatic death sentence locally, but it still wreaks havoc -- and is still spreading HIV is rampaging through Africa, Asia and eastern Europe, killing millions. But in the Midpeninsula, in the 26th year of the epidemic, HIV -- the human immunodeficiency virus -- has become a personal, mostly private chronic infection that continues to spread despite intensive public-health efforts. Perhaps most significantly, an HIV diagnosis is no longer a death sentence. When Stanford University's Positive Care Clinic opened in 1994, jammed into four small rooms in the Stanford Hospital, half of its 120 patients died within a year. "Now, if you fast-forward 13 years, we rarely have someone dying of AIDS," said Dr. Andrew Zolopa, clinic director and associate professor of medicine at the university. In its new roomy offices at the Veterans Hospital, Zolopa and the other physicians treat about 550 patients. Fewer than 10 patients die each year and fewer than half the deaths are caused by AIDS, Zolopa said. Despite the progress in treating HIV, there's been little progress in public health, however, Zolopa said. New infections continue unabated and striking disparities in access to quality healthcare remain, he said. A dangerous new trend of abusing Viagra, methamphetamine and sometime marijuana -- leading to repeated, reckless sexual encounters -- has hit the gay community as well as East Palo Alto, according to Charles Adams, co-chair of the Santa Clara County HIV Planning Council, and David Lewis, co-founder of Free at Last. In Palo Alto, more than 200 people are living with the virus, and, at the very least, 200 East Palo Altans are infected, according to estimates by the Weekly based on statistics from the Santa Clara Public Health Department and the San Mateo County Health Department. Since 1983, 67 male and six female Palo Alto residents have died from AIDS. Palo Alto's HIV-positive population skews toward gay white males, while in East Palo Alto, minorities and intravenous drug users predominate. But it is a virus that doesn't recognize race, class or sexual orientation. Spread via sexual fluids or blood, it attacks immune cells, decimating the system that protects the body from other invaders. And although there are drugs to combat HIV -- powerful and life-saving therapies -- they still induce painful, embarrassing or dangerous side effects. In addition, the drugs only slow the progression of the disease. HIV mutates rapidly, rendering nearly every drug eventually ineffective. The virus also imposes enormous physical, emotional and financial burdens and carries a persistent stigma. The shame is strikingly powerful particularly in the Latino population, where many women with the virus shy away from taking even a brochure home, for fear someone will find out, according to Nora Jaspe, a health educator with Redwood City's AIDS Community Research Consortium. Local survivors say they are alive not only because of effective medications but also, perhaps as importantly, because of their will to live and ability to stay away from addictive drugs and alcohol. Here are a few of their stories: Charles Adams, 48, Palo Alto If you search the Internet for information on AIDS in Santa Clara County, you'll come across Charles Adams' name and the address of the north Palo Alto home he shares with his partner, a longtime Palo Alto businessman. Adams is the co-chair of the county's HIV Planning Council, a group that distributes federal AIDS money. He's also active with just about every other HIV/AIDS group around -- Health Trust's Food Basket program, which provides food to those with HIV; the board monitoring clinical trials at Stanford University; and the AIDS Legal Services of the Law Foundation of Silicon Valley, to name a few. "Having my partner has enabled me to help," Adams said. "To me, (HIV) is just part of everyday life, and it's easy to talk about. I'm really lucky I'm in such a supportive environment." Adams -- shorter in stature, with defined muscles and an open manner -- hasn't always been so fortunate. Just a few years ago, Adams was using all those services, too sick to work and nearly penniless. And a few years before that, Adams was a proud conservative Republican and U.S. Army officer. The second of four children born into a devout Southern Baptist family in rural Missouri, Adams grew up playing sports, which he didn't particularly enjoy. He dreamed of attending West Point Academy. From a young age he knew he was gay and even tried to tell his parents. In response, they guided him toward religion and more sports, he said. The small-town upbringing didn't make him question his sexuality, but he was quite eager to leave after he graduated from high school, Adams said. "I never gave being gay a second thought. . . . It was just part of life. It wasn't like I flaunted (it). I never drank or did drugs or smoked." Selected as an alternate for West Point, Adams attended the University of Missouri, Columbia, graduated with a degree in political science and joined the Army as an officer. He loved it -- the routine and discipline, the diversity and travel. HIV certainly wasn't on his mind. "We'd all read about something going on (on) the coast. How did that affect me?" Adams said. It did though. Adams got sick in 1983. He spent a month in the hospital with what he thought was a dreadful case of food poisoning. Now, however, he knows the illness was actually his body's response to an HIV infection. Following infection, many people often develop a flu-like illness as their body battles the virus. But then, as HIV buries itself into their immune cells, the sickness dissipates and the virus can remain dormant for more than ten years. Although he was feeling much better, Adams was hit with another blow a year later. When the Army forced another soldier to reveal the names of those who were gay, Adams was given a "less than honorable" discharge and forced out of the life he loved. He returned to Missouri. "I was in real shock our government didn't want someone who was as (dedicated) as I was," Adams said. His political views took a sharp turn to the left. In 1987, HIV tests came out. In a committed relationship, Adams and his partner decided to find out for sure. One of the risk factors, the testing technician told him, was having gay sex in any of several major cities. "I'd had sex in almost all of them. . . . By then I knew -- I knew HIV was possible." Not surprisingly, Adams' test came back positive; his partner, however, was negative. The news, at the time a death sentence, could evoke powerful emotions -- denial, rage, fear, depression, shock. Adams, however, took the news in stride. "I wasn't scared. You have to be responsible for your own choices," he said. Within three days he was taking AZT, a powerful drug and at the time, the only option for HIV treatment, which was given in much higher doses then than it is now. "I was really, really tired. I threw up a lot. It was really nasty," Adams said. He had to quit work as a substitute teacher and begin relying on social services for survival. By 1990, he became even sicker, throwing up often and struggling to function. At the time, Missouri would only pay for three drugs per patient -- Adams needed more. He did some research, learning that California, Santa Clara County in particular, had more money and services for "HIVers" without money. So after a few detours, Adams and his then partner moved to San Jose. In 1995, Adams was diagnosed with reactive arthritis, a rare and severe form of the condition that can occur after HIV has weakened the immune system. Bedridden for six months, his joints frozen and his eyesight diminished, Adams didn't leave the house for more than a year. Adams calls the time "a really weird period." "I've never been the type to get depressed about anything. I never felt sorry for myself. I just thought, 'I just don't want to live, if this is the way it's going to be.'" Then, gradually, life got better. Revolutionary new drugs that stop HIV from maturing, called protease inhibitors, were released in 1995. "Without them, I probably would have died. ... (They) made all the difference in the world," Adams said. He learned to walk again and figured out how to write using fat pens. And he met his current partner. "The reason I liked him so much was he asked, right away, 'What is your status?" Adams said. "There is this big 'Don't ask, don't tell' policy in the gay community." Adams' partner is negative. Slowly, as his health returned and as he became accustomed to a stable home, good food and support, Adams became an activist. "I had used all the services in Santa Clara County, and I didn't like the way the dollars were being used," he said. "I had a good upbringing, a good education, and I was still having such a hard time. . . . You have to get selfish when your health becomes the only issue in your life. Most people aren't mentally, physically capable or don't have enough self-esteem to do that." Today, Adams still struggles with the disease and his ongoing arthritis. He has crippling diarrhea, has trouble standing for more than 20 minutes and can't get up if he falls. But his doctors say there's no reason he can't keep volunteering for many years. "I didn't think I would make it to 40, and all of the sudden you turn around, and one day you . . . have a life." Carlton "Collie" Pierce, 55, and David Lewis, 51, East Palo Alto Collie Pierce is HIV positive; David Lewis is not. Pierce has glasses, a pocked face and a single golden earring. Lewis is imposing, with a trademark mustache and graying hair. Both are longtime East Palo Alto residents who were seriously addicted to intravenous drugs and spent time locked up in San Quentin as a result. And now, they're both working to help others in the grasp of drugs escape. Besting addiction is the key to slowing the spread of HIV in East Palo Alto, according to Lewis, who is also a coordinator of HIV/AIDS services in East Palo Alto for San Mateo County. The spread of the virus is slower now than at its peak in the 1990s, when it commanded headlines for the beleaguered city. Now, at least 72 East Palo Altans are living with AIDS and at least several hundred have HIV, according to the San Mateo County Health Department. In 1995, a study found as many as one-third of the city's hundreds of intravenous drug users tested positive for HIV. Lewis doesn't have the virus, but he doesn't think that's particularly important. "In our community, it doesn't really matter," he said. Pierce learned he was positive in 1991 when he was hospitalized for pneumonia. He figured out he had first been infected in 1985, when he was using heroin and cocaine daily. "Just like so many other people, I didn't know it," Pierce said. "It's so scary that they go on living normal lives ... (sleeping with) multiple partners. ... I was one of those people." "My attitude was it would not and it could not happen to me. When I found out, I went on a death mission." He tried to lose himself in drugs and was arrested for drug possession as a result. His return trip to San Quentin, with HIV, was different, Pierce said. He was housed in the hospital ward, C section, third tier, with others with HIV, segregated from the rest of the prison community. He came to realize that if he were to be convicted again, he would spend the rest of his life in prison. Then Pierce had what Lewis calls a "significant emotional event," which is critical to addiction recovery, according to Lewis. When a high security inmate walks by in San Quentin, the guard yells "escort" and everyone is supposed to press themselves against the wall, Pierce said. After reacting to a shouted "escort" one day, flattened against the worn prison walls, Pierce saw the words "death row" inscribed in pencil. "For me, C section, third tier with HIV positive (people) was like death row. . . . I related to that (inscription)," Pierce said. "That was my last trip to prison. I made a commitment to do anything I could not to return." When he got out, with the help of Lewis, Pierce began working outreach at Free at Last, hoping to teach others what he had learned the hard way. He's been clean and sober for 11 years. "I try to be the best advocate I can. That's why I am so very open. People need to know," Pierce said. "It still goes on. You might not hear about it. But it still goes on; that's why they call it 'the quiet killer.' People are still spreading it; people are still dying." Pierce himself has been fortunate. He hasn't taken an HIV drug since 1999 and feels fine. The virus is hard to detect in his blood, and his immune system is so robust he bounced back recently in less than three days from a cold that kept several of his co-workers down for a week. Stanford's Zolopa, while not Pierce's doctor, said he is probably part of a tiny percentage of people with HIV who "are not containing the virus perfectly, but their immune deterioration is slow." He will probably eventually need medicine, Zolopa said. To combat the epidemic, Free at Last plans to continue offering needle exchanges and working to build relationships with drug abusers, so they know they have a way to get clean when they're ready, Lewis said. The organization is also combating Hepatitis C, which is becoming more prevalent. Hep C is a virus, transmitted with dirty needles, that attacks the liver. Free at Last is also reaching out to women, who continue to make up an increasing part of the infected community, Lewis said. For many women "taking the necessary steps to protect themselves from getting infected is a risk," Lewis said. Stephanie Marshall, 38, Hilmar, Calif. Hilmar is a small town in the Central Valley, a few miles south of Turlock. Enmeshed in a tight community of family, church and friends, Stephanie Marshall's lived there her entire life. Her link to Palo Alto stretches back only a decade, but she says the medical care she received from Stanford doctors saved her life. Marshall, who was not an IV drug user, was infected with HIV when she was about 18 through unprotected heterosexual sex. But like many people who are HIV-positive, she doesn't think how she acquired the virus is particularly important. "We get this illness because of choices we made. ... We have to stand up and take responsibility," Marshall said. "We choose not to use protection. It's nobody's fault but our own. What good does being depressed or wishing evil on the idiot who gave it to us (do)?" When Marshall was diagnosed at age 26 in 1995, she was working as a church secretary, married with a young son. Both her husband and son tested HIV negative. Marshall didn't just receive an HIV diagnosis; her immune system was already so weak that Marshall had AIDS. "I knew nothing about AIDS. We don't have a large homosexual community. I didn't know anybody who had it. It just wasn't in my radar," Marshall said. She quickly learned. "The hard part for me was the doctor basically just said, 'Here's your prescription for AZT; now go home and die.'" Self-described as "sassy," dying wasn't in Marshall's plans. She refused to take AZT, however. Why take a drug that would make her so sick? And as she got sicker, she decided to let everyone in the community know. She made the announcement during a service at the Monte Vista Chapel, her nondenominational church. "The doctors got up and explained how you get it and how you don't get it. The elders laid hands on me," Marshall said. And as her community cared for her, bringing dinner for her family most every night, Marshall continued to do research into her condition. Then she fell in with a group that didn't believe HIV caused AIDS. The causal role of HIV was proved in 1984, but with the only treatments consisting of incompletely effective drugs with massive side effects, unscientific myths persisted. Marshall went to Santa Cruz for a bit to live with an aunt. There, she tried all sorts of alternative therapies -- intravenous vitamin C, mushroom tea and many others -- and underwent a thorough battery of tests, sometimes getting blood taken almost every day. Nothing capable of causing her symptoms, other than HIV, could be found. Marshall began to accept the virus was responsible for her illness. Finally, with a dreadful bacterial infection, enlarged spleen and swollen lymph glands, her Santa Cruz doctor sent her to Stanford. She met Zolopa in 1997. At the time, she weighed only 90 pounds and was wasting away, Zolopa said. He asked why she wasn't taking AZT, Marshall recalled. Marshall explained she didn't want to take such a harmful drug. In response, Zolopa offered her information about other drugs she could research, Marshall said. She hadn't known there were other drugs available. "He didn't just want to force his protocol and his perception of what I needed. (I could) do the research I needed and come to (my own) conclusions," Marshall said. Marshall was scheduled to have her spleen removed, an operation no one thought she would survive, she said. Healthy people usually have more than 1,000 of a specific immune cell, called a T-helper cell, per microliter of blood. Marshall, at her lowest, had only three. An individual has AIDS if his or her T-cell count slips below 200. Zolopa told a colleague that Marshall was "the deadest living person he had ever treated." Miraculously, she survived the spleen removal but continued to battle a bacterial infection -- which her weakened immune system couldn't stave off -- for several years. Now, Marshall drives to Palo Alto only four times a year. Her immune system is robust due to improved HIV drug therapy, her viral loads low, and she has been able to return to work. "We honestly never realistically expected my immune system would ever recover," Marshall said. Marshall's son is grown now, and she was divorced last year. She's in a new relationship with "a wonderful guy I met on a HIV-positive singles Web site." "We understand where we're both coming from. ... We have each others' back." Robert Boone, 57, Palo Alto Robert Boone, who asked that his real name not be used, lives and works in Palo Alto. Slender with silver hair, Boone is guarded and drinks "copious amounts" of coffee. Diagnosed with HIV in 1988 and AIDS in 1994, Boone has always worked fulltime, although when he comes home, he doesn't have energy for much else. Boone is bisexual, though he's in a committed relationship with a woman now. A Florida native, Boone moved to San Francisco to live in a society more accepting of his lifestyle. For about 13 years, Boone said he was very promiscuous. "Did I play safe? Obviously not safe enough," Boone said. "In 1980, I decided it was time to grow up and be respectable," Boone said. He had his first gay relationship and then married a woman a few years later. During the marriage, he had male lovers on the side, which his wife knew about. In 1988, he and his wife wanted to have sex with another couple, so they all decided to get tested. The others were negative; Boone tested positive. "I definitely knew it was in the realm of possibility. Was I expecting it? Probably not," Boone said. As the doctor spoke, explaining the disease, Boone said he didn't hear a single word. The doctor had to discuss the diagnosis with his wife. "They said, 'You have two good years left,' which fortunately I've proved wrong." Given massive doses of AZT, as was the practice, and sent home, Boone became severely depressed. "I did the dumb thing of not trying to get treated for it," Boone said. His marriage started to unravel. "It put a real damper on our sex life, to say the least," Boone said. "I'm just as much at fault. But finally she said, 'I just can't deal with you being sick.'" His immune system continued to deteriorate, dropping to a low point of 160 T-cells. Nonetheless, Boone still worked 40 hours a week. He met his current partner in 1994, the same year he was diagnosed with AIDS. "Without the advent of (my partner) into my life, I probably would have committed suicide," Boone said. This time, he sought out medical treatment for depression. "Things started to level out and then go upwards." Boone jokes that he got his "green card to Palo Alto" in 1995. Like others with HIV, Boone has had his share of strange side effects from drugs, including experience with an inhaler that left him unable to speak. Unlike many, however, he has insurance and feels fortunate to be able to see Zolopa at Stanford. "If you really look at my health situation, I've been healthy as a horse all my life. Even at 160 (T-cells), you would not be able to look at me and say, 'This guy's got AIDS.'" Brown said he has a love/hate relationship with the drugs. "Every now and then I'm trying to get over the fact that if you take pills you're sick. I'm not sick, but I take pills." AIDS is like diabetes now, Boone said, something you can live with. "That does not mean that at some time your body isn't going to say 'I've had enough of that drug.' That's the scary part ... and, and, and 'Is this the beginning of the end?'" Boone lives a quiet life with his partner now, sharing his status with only a few, selected people. "I've given up the men in my life," Boone joked. Boone is slow to preach or judge others' behavior. "I told my mom, 'It doesn't matter how I've got it, the fact is, I've got it.' ... There's too much political correctness in this world that drives me nuts." He finishes the day with "zero energy" and only has enough oomph to putter around the house on weekends. But he, unlike many, many of his friends, is still alive. 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