Underground drugs are neither approved nor in the process of being approved by the FDA, but are widely taken without prescription by people with HIV infection. Underground drugs are claimed to attack HIV or to strengthen the immune system. The claims are not supported by clinical trials, sometimes only because the trials have not yet been done, sometimes because medical researchers are not sufficiently convinced of the drug’s potential merit to do a trial at all.     In most cases, underground drugs are not prescribed by physicians; people get them through sources like buyers’ clubs, AIDS activist groups, or associates in other countries. Because people with HIV infection feel an understandable need to have some control over their medical treatments, many physicians tacitly accept their patients’ use of underground drugs, provided the drug does no harm and provided it is not substituted for traditional drugs. Indeed, even the FDA seems to accept the existence of underground drugs, not by official endorsement, but simply by not vigorously attempting to stop their use.     Despite the passive acceptance of underground drugs, a word of caution is necessary. Underground drugs for HIV infection are often fads, hot today and gone tomorrow, that follow a distinct route. First, someone claims that the drug might do something desirable to HIV or to the immune system; next, the information spreads rapidly through the network of AIDS advocates; then, the drug is imported or made in basements and sent to large numbers of people; and finally, the drug is dropped because it has side effects, because clinical trials show it to be useless, or simply because enthusiasm fades. Numerous drugs have followed this route: ribivarin, HPA-23, and dextran sulfate are the most notable. All three drugs are now dead or near dead; but during their moment in the sun, hundreds or thousands of people went to Mexico for ribivarin, to Paris for HPA-23, or to Japan for dextran sulfate.     Dextran sulfate is a good illustration of the problems of underground drugs. The medical journal Lancet published the observation that dextran sulfate seemed to inhibit HIV in the test tube. The information spread widely; many people went to Japan, where the drug was available, to get it, and eventually buyers’ clubs imported massive amounts of it. The medical community, though never particularly impressed with the test tube data, thought it necessary to test a drug now being taken by thousands of people. The first round of studies showed that the drug was harmless even in large doses. The next round of studies explained the harmlessness: less than 1 percent of the drug, when taken by mouth, was absorbed by the body; over 99 percent of the drug went into the toilet bowl. Another round of studies was done to see if dextran sulfate would work when injected. The results showed that injected dextran sulfate not only didn’t work, but more HIV were present at the end of treatment than at the beginning.     The dextran sulfate story highlights the complicated interplay between medical researchers, AIDS advocates, and the FDA. In retrospect, all three parties seem to be acting in the best interests of people with HIV infection, and all three seemed to do what appeared to be right at the time.*191\191\2*

“Well, what else are they going to do ? I ask teenagers, ‘What are your choices?’ They could go in their rooms, close the door, and never come out again. That would be a choice. If you help people discover alternatives and allow them to make their own choices, eventually they can find the best way to deal with their problems. There really isn’t anything to do but to pick yourself up and go on, is there?”But sometimes things don’t go so well. People with epilepsy have to walk a fine line between hope and reality. Life is not always fair, but what are they going to do about it? You just have to deal with it. Counseling often can be very helpful in enabling people to see that.”I saw Karen every week or two at the beginning, but later, as things got better, our meetings would be less frequent. She would call just to let me know how things were going or if there was a problem. We got through her first date (she learned that girls with epilepsy could date and be attractive, like everyone else). We discussed who you tell about your epilepsy and when. She didn’t tell every date, but when she began to be serious about one person she made certain that he knew about her seizures. She told her close friends and also the coach of her team.”Now Karen is in college. She first went to junior college to prove to her father that she could do it, and then he agreed to let her transfer out-of-state. She is doing very well. She now has a good self-image. Her seizures are under control, although there is still an occasional seizure when she tests the limits.”*223\208\8*

Cigarette smokers have a risk of cardiovascular disease at least two times as high as nonsmokers. The risk increases with the number of cigarettes smoked each day. If you smoke one pack of cigarettes a day, your risk is twice as high as that of someone who never smoked. If you smoke two or more packs a day, your risk is three times as high as a person who never smoked. Cigars, pipes, and chewing tobacco also increase your risk, although to a lesser degree.The earlier you start smoking cigarettes, the greater the risk to your health. Nine out of 10 smokers began smoking when they were younger than 21 years. Thus, the risk and damage accumulate over a major portion of their lives. Smoking-related diseases usually do not kill rapidly, but slowly rob you of your vitality over a period of years.*231\252\8*