Author Terry Pratchett defends right-to-die film (AP)

LONDON � Writer Terry Pratchett said Tuesday that watching a man being helped to die had reaffirmed his support for assisted suicide, while anti-euthanasia groups criticized the televised death as propaganda.

The suicide, filmed for a BBC documentary, has reopened debate on Britain's decades-old law against helping another person end their life.

Pratchett watched Peter Smedley, a 71-year-old British businessman with motor neuron disease, take a lethal dose of barbiturates at a Swiss suicide clinic.

Best-selling fantasy author Pratchett was diagnosed with early onset Alzheimer's disease in 2007 and is a vocal supporter of the right to die.

He said he was moved by Smedley's death at a clinic run by the Dignitas group, broadcast Monday on BBC television.

"He said to me 'Have a good life.' And then he shook (my PA) Rob's hand and said 'Have a good life, I know I have,'" 63-year-old Pratchett told the broadcaster.

"The incongruity of the situation overtakes you. A man has died, that's a bad thing, but he wanted to die, that's a good thing."

Pratchett said he was ashamed that British people had "to drag themselves to Switzerland, at considerable cost, in order to get the services that they were hoping for."

Anti-euthanasia campaigners criticized the decision to show Smedley's death. The former Bishop of Rochester, Michael Nazir-Ali, called the program "propaganda on one side."

"I think an opportunity had been bypassed of having a balanced program � the thousands of people who use the hospice movement and who have a good and peaceful death, there was very little about them," Nazir-Ali told BBC radio.

The BBC denied bias, saying it was "giving people the chance to make their own minds up on the issue."

Assisted suicide is illegal and carries a maximum 14-year sentence in England and Wales, but few people have been prosecuted in recent years for helping friends or relatives die abroad.

After a series of legal test cases, the chief prosecutor last year drew up guidelines to clarify when criminal charges would be more or less likely.

Mitigating factors include a motive of compassion, evidence the victim had made a voluntary and informed decision to end their lives and evidence a suspect tried to talk the victim out of suicide.

In Switzerland, "passive assisted suicide" � giving another person the means to kill themselves � is legal provided the helper isn't a medical doctor and doesn't personally benefit from a patient's death.

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John Heilprin in Geneva contributed to this report.

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Doc's arthritis struggle shows illness' severity (AP)

WASHINGTON � Dr. Sue Zieman can almost set her watch by her disease: Twice a day, she gets a fever and the already arthritic joints in her arms and hands, legs and feet abruptly, painfully swell even more. During the evening flare, even the tendons in her feet puff up, rope-like worms just under her skin.

The rest of the day, her joints are so stiff that the once robust Maryland physician frequently uses a scooter to get around. Just shaking hands hurts the 47-year-old.

Inflammatory arthritis is disabling Zieman but exactly what kind and what caused it to attack suddenly is a mystery. Nor do her fellow doctors know what treatment to suggest next. She's tried all of today's arthritis medications with little relief.

Say arthritis, and people tend to shrug it off as a rite of passage of aging. The reality is much more complicated. Arthritis encompasses 100 different conditions and affects about 46 million people in the U.S.

Osteoarthritis � where cartilage gradually erodes with the wear-and-tear of aging � is by far the most common type.

But inflammatory types � such as rheumatoid arthritis, psoriatic arthritis, lupus � occur when something makes the immune system run amok and attack the body's own tissues, eating away cartilage and eventually harming bone. It can strike at far younger ages.

Zieman's saga highlights not just how much doctors still have to learn about arthritis, but how devastating a severe case can be.

"It totally stripped my identity," says Zieman, whose illness cost her career as a cardiologist and her love of sailing. "I just don't think people realize how debilitated you can be, and young."

She uses humor to help cope, nicknaming her scooter Bella and joking that "I know I'm going to turn into a pumpkin each night" when that 7 p.m. flare sends her to bed.

Infections sometimes trigger inflammatory arthritis, and that's what probably happened with Zieman. She'd just returned from a business trip to India in December 2008 when she came down with a fever, fatigue and pain in her shoulder and knee. Antibiotics didn't help.

A month later, Zieman became short of breath and both legs swelled. An emergency hospital admission prompted a battery of tests for infections, even super-rare ones she might have encountered abroad. Again, nothing. Maybe it was cancer? Nope.

Then the joints in her wrists and hands began swelling. Soon she couldn't lift a glass. Swelling and pain moved to her ankles and toes.

Her joints had the classic look of rheumatoid arthritis, a disease that affects 1.3 million Americans and that can begin with a low fever and fatigue.

But it wasn't a slam-dunk diagnosis. Blood tests check for specific markers of the disease, such as a substance called rheumatoid factor, and Zieman's results were negative, something that occurs occasionally.

More important, a variety of drugs hit the market in the last 15 years that can rein in the disease and target some of the immune cells doing the damage.

But drug after drug failed, and the illness was spreading to her elbows, knees, hips, even her jaw.

Within a few months, she was on leave from her cardiology job. She couldn't walk up the stairs at home and moved to a one-floor apartment that's walking � or scootering � distance from her new job in aging research at the disability-friendly National Institutes of Health.

She even had episodes of an irregular heartbeat, as inflammation struck part of the heart.

Then six months ago, she started having those bizarre twice-a-day flare-ups. When she joined some friends for a vacation in France recently, the flares just switched time zones.

That's not typical rheumatoid arthritis, leaving in question Zieman's diagnosis and what to do next.

While Zieman's case is extreme, it's not unusual for inflammatory arthritis to become debilitating so quickly, especially in young or middle-aged women, says Dr. Assil Saleh, a Washington rheumatologist and internist who, along with doctors at Johns Hopkins University and the NIH, treats Zieman.

When an infection is the suspected trigger, patients desperately want to know which bug even though it's usually long gone by the time joints swell, leaving rogue immune cells in its wake.

"Now we're left with a forest fire, and we try to extinguish it," Saleh explains. Most cases of inflammatory arthritis "are not curable but they are treatable in this day and age."

Zieman gets modest relief from very high doses of the steroid prednisone, along with injections of the drug Kineret that targets an inflammation-causing protein named interleukin-1.

She's still hopeful scientists will point her to better treatment as she enters an NIH study. Researchers will videotape her evening flare-ups and try to measure what role that interleukin-1 is playing.

And while she wants to know what's fueling her disease � "I'm as geeky as most cardiologists" � her bigger frustration is how few services help arthritis patients with daily functioning: "I need to know how to open the fridge."

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EDITOR'S NOTE � Lauran Neergaard covers health and medical issues for The Associated Press in Washington.

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Could prenatal DNA testing open Pandora's box? (AP)

NEW YORK � Imagine being pregnant and taking a simple blood test that lays bare the DNA of your fetus. And suppose that DNA could reveal not only medical conditions like Down syndrome, but also things like eye color and height. And the risk for developing depression or Alzheimer's disease. And the chances of being gay.

So far that's still science fiction. But scientists have been taking some baby steps in that direction. And some ethics experts say it's time to start talking now about what that could mean for parents and society.

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This is the second story in a two-part series on fetal DNA testing and the ethical issues raised by it.

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Scanning fetal DNA from a blood test will be "without question a major medical advance that promises to greatly improve current prenatal care," says Jaime King, an associate professor at the UC Hastings College of Law in San Francisco who studies genetic testing. But bringing it into practice "raises significant practical, legal, ethical and social challenges," she says.

"This really changes the experience of what it will be like to be pregnant and have a child," said Marcy Darnovsky of the Center for Genetics and Society in Berkeley, Calif. "I keep coming up with the word, game-changer."

She wonders if parents would withhold their commitment to a pregnancy until test results show a fetus is "good enough" to be born. And what, she asks, is good enough?

She and others worry about how well couples will be able to understand this flood of information, and just what should be revealed.

The issues have been discussed before. The DNA of a fetus has long been recoverable through medical procedures, with a small risk of miscarriage. But a blood test would be free of that risk, which should make many more women interested in it and doctors willing to test for a wider range of conditions, some experts say. And the results could come early enough to allow for an abortion before the pregnancy is even obvious.

The trigger for the new round of discussion is a couple of papers published last December. In preliminary results, two research teams showed that they could essentially reconstruct a baby's genetic makeup by recovering fragments of fetal DNA from the mother's bloodstream. That ability, plus the rapidly falling cost of analyzing DNA, would open the door to inspecting individual genes.

That would go well beyond the more accurate prenatal blood test for Down syndrome that some companies hope to market within a year.

Within five to 10 years, doctors may be able to test for 100 or 200 diseases, albeit many of them rare, estimates Stanford University law professor Hank Greely, who studies the implications of biomedical technologies.

Prenatal testing "is going to put a lot more information about the genetics of a child into the hands of a lot more parents," said King.

That knowledge has a flip side. "How much responsibility are we expecting people to take for the genetic makeup of any child they might have?" asks Josephine Johnston, a research scholar at the Hastings Center, a bioethics think tank near New York City.

If a child is born with a condition that could have been detected, the presence of the test changes that outcome "from something that happened to you, to something that you participated in," she says.

"That's a very big burden to place on would-be parents," she said, adding that it's hard for a pregnant woman to refuse any test for a medical condition because it feels like the responsible thing to do.

Johnston has personal experience; she gave birth to a girl just two years ago. When offered a medical screening test for the fetus, she generally felt compelled to take it.

"At the moment these things happen, it's just you there by yourself," she said. Some people might like that level of control, but others "would be happier to leave things up to chance a little more."

She said if she were pregnant again and offered a wider range of tests, she'd restrict herself to "really, really serious disabilities and disorders."

King, who had a son 18 months ago, said she wouldn't have wanted to know about any risk for incurable diseases that show up in adulthood. Those are "things that would have caused us to spend a lot of time worrying about what his future would look like even though there's nothing we could do about it," she said.

In the future, such testing could also look for other genes � some of which aren't yet identified � that affect non-medical traits.

"If no limitations are put on, you can have a couple get a prenatal genetic test in the future saying their fetus has ... a 60 percent chance of having breast cancer at the age of 60 and a 30 percent chance of being gay," says Dr. Brian Skotko, a board member of the National Down Syndrome Society.

Since such information would come early enough for an abortion, Skotko says, "The ultimate question for society is, What forms of human variation are valuable?"

Then there's the possibility of direct-to-consumer companies stepping in to fill demand, King said. Couples who go that route may miss out on getting help in understanding the nuances of what the test results really mean, said Dr. Mary Norton, a Stanford professor of obstetrics and gynecology.

Once the prenatal information is available, another question arises, King said: Should a woman be allowed to get an abortion for any reason, even a trivial one like test results about height or eye color? Some state governments have passed laws outlawing abortions on the basis of sex, she said. But it's not clear whether those are constitutional, and a woman might simply not reveal her true reasons for wanting the abortion, King said.

Skotko points out that people use their own personal perspective in deciding what they want for their children. Some couples who are deaf from a genetic condition already use current technology to avoid having children with normal hearing. "It's their lens by which they view the world, and they want a child who views the world through that same lens," he said.

Greely sees other concerns. Will the testing become so routine that women won't even realize they authorized it, and then be faced with information and an abortion decision they didn't necessarily want? How can they be helped to make an informed decision on whether to be tested? And if offered a choice of genes to be tested, or results to be told about, who will help them sort through the long list to decide what they want to know? Few doctors are informed enough, and there aren't enough genetic counselors go around, he said.

The same problem arises later when it comes time to help couples understand what the results really mean, he said. "How do you tell somebody about 100 different genetic things?" he asked. "Who's going to do that? Who's going to listen to that? Who's going to pay for that?"

Results can be complex. For example, how is a woman supposed to balance a 25 percent increase in risk for one disease versus a 15 percent decrease in another, Darnovsky asks.

On a societal level, King said she's concerned that the prenatal diagnosis might become seen as a way of "curing" diseases by aborting fetuses that have them.

Greely recently spoke about prenatal diagnosis before the Presidential Commission for the Study of Bioethical issues, a federal advisory board. Valerie Bonham, executive director, said the commission may pursue the topic further as part of a project on DNA technology. "It's an important and emerging issue," she said.

Norton doesn't believe the arrival of a blood test for DNA analysis would raise all the issues some observers cite. But she thinks it's still a good idea to talk about what the new technology could mean.

"I think that it is always better and helpful and important to bring up all of these issues, whether they are likely to really become reality or not," she said.

"Once you've opened Pandora's box, it's harder to close it."

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Comfort or conflict: Earlier Down syndrome test (AP)

NEW YORK � The results of the blood test revealed only a risk, but when she saw them, she still threw up. Now she had to find out for sure.

So she lay on her back at a doctor's office, praying, comforted by her Christian faith and her mother at her side, while a needle was slipped into her belly.

Erin Witkowski of Port Jervis, N.Y., was going to find out if the baby she was carrying had Down syndrome.

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This is the first of a two-part series on prenatal testing and the ethical issues raised by it.

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For years, many women have gone through an experience like hers: a blood or ultrasound test that indicates a heightened risk of the syndrome, followed by a medical procedure to make a firm diagnosis by capturing DNA from the fetus.

Usually it's the needle procedure Witkowski had, called amniocentesis, done almost four months or more into the pregnancy. Sometimes it's an earlier test called CVS, or chorionic villus sampling, which collects a bit of tissue from the placenta. Both pose a tiny but real chance for miscarriage, and experts say highly skilled practitioners are not available everywhere.

But by this time next year there may be an alternative � one that offers accurate results as early as nine weeks into the pregnancy.

Companies are racing to market a more accurate blood test than those available now that could spare many women the need for an amnio or CVS. It would retrieve fetal DNA from the mother's bloodstream. And the answer could come before the pregnancy is obvious to others. For some women, that might mean abortion is a more tenable choice. For others it could be a mixed blessing.

Down syndrome slows mental and physical development, and people with it usually show mild to moderate disability in intellect and skills for everyday living. Physically, they often have a flat face with a short neck and smaller hands and feet. They're at risk for complications like heart defects and hearing problems. Life expectancy is about 60 years.

Most cases are diagnosed after birth now, but if the blood test is widely adopted it could become chiefly a prenatal event.

A diagnosis before birth can pose a difficult challenge for couples as they decide whether to continue the pregnancy. It's not only about child-rearing, but also about what happens as the child grows into an older adult and may need care that the aging parents struggle to provide, says Dr. Mary Norton, a Stanford University professor of obstetrics and gynecology.

Dr. Brian Skotko, a Down syndrome specialist at Children's Hospital Boston who has written a research paper for doctors on how to deliver a diagnosis, said "the vast majority of people with Down syndrome and families affirm that their contributions to their communities are significant, and their lives are very valuable."

Current prenatal screening has already cut into the number of babies born with the syndrome, which now stands at about 6,000 each year in the United States, or about 1 in every 691 babies, says Skotko, who serves on the board of the National Down Syndrome Society. He cites one study that concludes the number of Down syndrome births in the nation dropped 11 percent between 1989 and 2006, a time when it would otherwise be expected to rise 42 percent.

Initially, doctors are expected to use the new blood test with women at risk for a Down syndrome pregnancy, such as those older than 35. A negative result would indicate a woman could skip the amnio or CVS; a positive result would suggest she get one done to be sure.

Eventually it might replace the routine screening tests offered to all pregnant women. Since the test sounds fewer false alarms than current tests, fewer women would be told they need the invasive follow-up procedures, experts say. And some suggest that with further fine-tuning, it could largely replace amnio and CVS. With no miscarriage risk, more women might be willing to take it, and so more women would find out they have a Down syndrome pregnancy.

Two California companies, Sequenom Inc. and Verinata Health Inc., hope to offer the test to doctors in the United States by next April. They say it could be done in the first trimester, with Sequenom aiming as early as 10 weeks, and Verinata as early as eight weeks. Results would be available 7 to 10 days later. In addition, LifeCodexx AG of Germany says it wants to start offering its test in Europe by the end of this year, to be performed at 12 to 14 weeks initially. None of the companies would discuss its cost.

"I would have definitely taken a noninvasive test over the struggle for deciding whether to do an amnio or not," says Nancy McCrea Iannone of Sewell, N.J., who gave birth six years ago to a daughter with Down syndrome. She'd been alerted by screening results, but hesitated to get amniocentesis because of the risk of a miscarriage and the prospect of "a needle in my belly," she recalls. Ultimately, she did have one.

Iannone now counsels women who plan to deliver babies with Down syndrome. Her charitable group, Down Syndrome Pregnancy Inc., lists several reasons for getting a diagnosis before birth, such as more time to adjust, grieve and learn about the condition, preparing friends and family, and checking on available medical care and insurance.

But detecting the condition earlier in a pregnancy through the new blood test would be a mixed blessing, Iannone said.

The time between diagnosis and birth is "an unnatural state," she said, and "the longer that time period is, the harder it is."

"All you know is that they have Down syndrome. You're coping with that diagnosis in a vacuum, without a baby... It's fear of the unknown, you haven't met your baby yet. You spend a lot of time worrying."

That might weigh heavily on women who haven't decided whether to continue the pregnancy or not, she said.

Since the new blood test could deliver an answer so early � before a pregnancy is showing or the baby is kicking � it might make getting an abortion easier, several observers said. Women haven't bonded so much, and "they wouldn't have to explain to as many people," said Christie Brooks, who moderates an online support group for women who've gotten abortions for medical reasons.

"No one needs to know you're pregnant," said Skotko. "Maybe you haven't even told your husband."

Skotko said he respects that a woman's right to continue or terminate a pregnancy is a personal one for couples. But he's concerned that in the case of Down syndrome, many women may be getting bad information about what having the baby would mean. And if the new test became routine it would only exacerbate that problem, he said.

Studies show medical students are poorly trained about people with disabilities and that some doctors who make a prenatal diagnosis emphasize negative information about the condition, he said.

"We have a fleet of physicians who are saying they're untrained, unprepared and sometimes knowingly inserting their own personal bias," he said. "How are women today able to make a truly informed decision?"

Others say the blood test could thrust some women into a choice they didn't ask to make.

Hank Greely, a Stanford University law professor, said women sign forms for plenty of blood tests during prenatal care and often don't focus on them. Many California women are surprised to learn they'd authorized the screening test for Down syndrome, he said.

If these tests are someday replaced by the new blood test, many women may be told out of the blue not simply that they're at risk, but that in fact their baby almost surely has Down syndrome, Greely says.

"They're going to jump directly to the final answer, which is not necessarily something they wanted to get," Greely said. So the new test poses a challenge to the medical establishment about how to assure that women get adequate counseling to make an informed choice, he said.

Witkowski, who prayed as that needle was slipped into her swollen belly in 2009, got her answer: It was Down syndrome. As her doctor gave her the news, her baby kicked her and "I could see my belly move," she recalled.

Her doctor started talking immediately about abortion, a step Witkowski rejected. She changed doctors and gave birth to Grady in February 2010.

"When they first gave him to me," Witkowski said, "I saw tiny little hands, and he had the most beautiful eyes... He didn't have `Down syndrome' stamped on his forehead. He cried and he peed and he pooped. He was a baby."

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Online:

Current prenatal tests: http://bit.ly/iev0ZG

National Down Syndrome Society: http://www.ndss.org/

Erin Witkowski's blog: http://skiingthroughlife.wordpress.com/

Down Syndrome Pregnancy Inc.: http://downsyndromepregnancy.org

Brooks' group about pregnancy termination: http://bit.ly/jJzQuy

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Scientists probe DNA of E. coli for outbreak clues (AP)

LONDON � Scientists are quickly combing the DNA of the killer bacteria behind the world's worst E. coli outbreak to find clues about how to treat patients and prevent future epidemics.

So far, one strain from a German patient has been sequenced by Chinese and German scientists. While the genetic information is preliminary, experts say there are a few hints about where the bacteria came from and why it might be so lethal.

The E. coli causing Europe's massive outbreak is likely the product of another strain first detected a decade ago in Germany, but with some dangerous mutations, experts say. German investigators have declared the outbreak was caused by contaminated sprouts from an organic farm in northern Germany. So far, the bug has killed 33 people and sickened nearly 3,100, including several hundred who have developed life-threatening kidney failure.

Flemming Scheutz, head of the World Health Organization's Collaborating Centre laboratory in Denmark, said the strain is particularly good at picking up new genes. Because E. coli is constantly evolving, it is riddled with genes swapped from other strains found in animals and humans, giving it countless opportunities to acquire something lethal.

"It's just very unfortunate that in this case, it recombined and took on these (dangerous) genes and that it happened to do it in the food chain," he said.

Scheutz said some previously seen related strains were also quite toxic but that scientists needed more samples to have a better understanding of how the new strain behaves. "It's like looking at a family photo with three people and the 50 others are missing," he said.

Others say the DNA sequences they've seen so far appear worrying enough.

Stephen Smith, a microbiologist at Trinity College in Dublin, said the new E. coli appears to stick to human intestines in a different way and that the bacteria might reproduce faster than other E. coli strains. More bacteria in the intestines could explain why the disease is so deadly, he said. Smith was not involved in the sequencing work.

"It could be the bacteria's genes are causing it to produce more toxin, which may affect patients differently," he said. The toxin usually targets the kidney, triggering a severe E. coli complication. But in the European outbreak, many of those patients have also suffered from neurological problems including paralysis.

Frederick Blattner of the University of Wisconsin, who has analyzed the new sequence information, said the toxin released by the German E. coli seemed extremely potent.

"With other strains, it can take a million of them in your stomach to make you sick," he said. "But with this bacteria, it might be possible to be infected with much lower numbers."

Researchers have also found the E. coli bacteria has at least eight genes that make it resistant to many antibiotics.

"That could give suggestions to doctors about what treatments to select for patients," said Bicheng Yang, a spokeswoman for BGI, the Chinese laboratory that sequenced the bacteria. In Germany, many patients with the most severe form of the disease, which involves kidney failure, have been treated with dialysis and blood transfusions.

"The next step is to do further tests at the molecular level to see what drugs might work," she said. Yang added that knowing more about the bacteria's origins could help stop future outbreaks and avoid things that could speed up the mutation process.

Gad Frankel, a microbiologist at Imperial College in London, said DNA information might help scientists figure out how the bacteria sticks to certain vegetables � and then stop it before it happens. "It's possible we could develop inhibitors to prevent the interaction between E. coli and vegetables," he said, explaining a biodegradeable spray could theoretically be made to do the job.

Experts agreed that narrowing down where the new E. coli came from was key to averting future epidemics. "The evolution of E. coli just happens when bugs get together," Smith said. "We can't stop evolution, but if we can learn today how and where it happens, we might be able to save lives in the future."

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Premature aging seen as issue for AIDS survivors (AP)

SAN FRANCISCO � Having survived the first and worst years of the AIDS epidemic, when he was losing three friends to the disease in a day and undergoing every primitive, toxic treatment that then existed, Peter Greene is grateful to be alive.

But a quarter-century after his own diagnosis, the former Mr. Gay Colorado, now 56, wrestles with vision impairment, bone density loss and other debilitating health problems he once assumed he wouldn't grow old enough to see.

"I survived all the big things, but now there is a new host of things. Liver problems. Kidney disease. It's like you are a 50-year-old in an 80-year-old body," Greene, a San Francisco travel agent, said. "I'm just afraid that this is not, regardless of what my non-HIV positive friends say, the typical aging process."

Even when AIDS still was almost always fatal, researchers predicted that people infected with HIV would be more prone to the cancers, neurological disorders and heart conditions that typically afflict the elderly. Thirty years after the first diagnoses, doctors are seeing these and other unanticipated signs of premature or "accelerated" aging in some long-term survivors.

Government-funded scientists are working to tease apart whether the memory loss, arthritis, renal failure and high blood pressure showing up in patients in their 40s and 50s are consequences of HIV, the drugs used to treat it or a cruel combination of both. With people over 50 expected to make up a majority of U.S. residents infected with the virus by 2015, there's some urgency to unraveling the "complex treatment challenges" HIV poses to older Americans, according to the National Institutes of Health.

"In those with long-term HIV infection, the persistent activation of immune cells by the virus likely increases the susceptibility of these individuals to inflammation-induced diseases and diminishes their capacity to fight certain diseases," the federal health agency's chiefs of infectious diseases, aging and AIDS research wrote, summing up the current state of knowledge on last September's National HIV/AIDS and Aging Awareness Day. "Coupled with the aging process, the extended exposure of these adults to both HIV and antiretroviral drugs appears to increase their risk of illness and death from cardiovascular, bone, kidney, liver and lung disease, as well as many cancers not associated directly with HIV infection."

In San Francisco, where already more than half of the 9,734 AIDS cases are in people 50 and over, University of California, San Francisco AIDS specialists are collaborating with geriatricians, pharmacists and nutritionists to develop treatment guidelines designed to help veterans of the disease cope with getting frail a decade or two ahead of schedule and to remain independent for as long as possible.

"Wouldn't it be helpful to be able to say, are you at high risk, low risk or moderate risk for progressing to dependency in the next five, the next 10 years, being less mobile, less able to be functional in the workplace. Are you going to be safe in your home, are you going to remember to take all those medications? How are they going to interact?" explained Dr. Malcolm John, who directs UCSF's HIV clinic. "All those questions need to be brought into the HIV field at a younger age."

Research so far suggests that HIV is not directly causing conditions that mimic old age, but hastens patients toward ailments to which they may have been genetically or environmentally predisposed. Plus, their immune systems are being weakened over time even when they are being successfully treated for AIDS, John said.

"That's probably true for a lot of these things. We aren't saying HIV's starting the problem, but it's added fuel on top," he said.

Stokes, a patient of John's who goes by only his last name, is a prime example. At 53, HIV-positive since 1985 and in substance abuse recovery for the last 11 years, he says he is happier than he ever has been. Yet the number of ailments for which he is being treated would be more commonly found in someone 30 years his senior: a condition called Ramsay Hunt syndrome that causes facial paralysis, a rare cartilage disorder for which he has undergone four ear surgeries, bone death in the hip and shoulder, deterioration of his heart muscle, osteoporosis and memory loss.

A specialist recently diagnosed a Kaposi's sarcoma spot on Stokes' ankle. Although the cancer is not life-threatening, the sight of young men disfigured by KS lesions was a harbinger of the early AIDS crisis, and its presence on his own body is unsettling.

At his therapy group for men with HIV, aging "comes up frequently," he said. "I say, `Just think what we have come through to have a life today.'" At the same time, he acknowledges sometimes feeling self-conscious about his physical appearance and worries if "people are not attracted to me and unwilling to go the length of what it means to be with me, no matter how brilliant my mind or my zest for life."

Loneliness, financial worries and concerns about who will care for them and where can weigh on long-term AIDS survivors in the same way as all adults living in a society that values youth, Charles Emlet, a social work professor at the University of Washington, Tacoma, said.

As they get older and sicker, many feel "doubly stigmatized," he said. Some people who have lived with the virus for a long time have been getting by on private disability benefits that will run out when they turn 65, forcing them to move to less expensive locations or to consider turning to estranged family members. Like soldiers from a distant war, many lost partners and their closest friends to AIDS.

Such emotional side effects, combined with the physical toll of managing chronic health problems, put older AIDS patients at risk for depression. At the same time, Emlet has uncovered evidence that a majority of long-term survivors also share another trait that typically comes with advanced age: that is, the ability to draw strength from their difficult experiences.

"The older adults I've interviewed, many of them talk about how much it means to them to give back, to do something positive with the years they never expected to have," he said.

Peter Greene can relate to that. At times, like the days he is so exhausted he can't get out of bed or the pain from his multiple maladies is too intense, he asks himself "the Carrie Bradshaw question--are we really lucky to still be alive?"

As frightening and uncertain as this phase of AIDS is, he thinks he knows the answer.

"I've tried to make the time I have count, and really, now that I have the body of an 80-year-old, I probably have the wisdom of an 80-year-old as well, which counts for a lot," Greene said. "Everything becomes clear at the end of your life and in some ways, thinking you've been dying all these years, you get moments of clarity that I don't think everyone gets."

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