Sara emphasised there was no cure, just symptom control but that with medication most infected people could be managed as outpatients. In the developed countries HIV was now a chronic disease with which people could live for many years. She described the opportunistic infections that required treatment and some of the malignancies that can occur in the later stages of the disease.

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Treating malignancies required the chemotherapy to be balanced with the anti-HIV medication so patients tended to be treated by the HIV clinic rather than the oncologists.

Classification of the three stages of the disease were non-symptomatic, symptomatic illness and AIDS-defining illness such as infections with Mycobacterium avium complex (MAC),), Tuberculosis, Pneumocystis Carinii Pneumonia (PCP).

Children with HIV are not treated by BLT but referred to Great Ormond Street Hospital.

Caesarian section is offered to pregnant women as it can cut the transmission to less than 1%.

Drug users may select care from another hospital in London, but the national needle-exchange scheme has helped reduce the rate of blood to blood transmission through shared needles.

Cytomegalovirus (CMV) - retinal damage is the usual presentation and can rapidly lead to loss of vision. It can affect most internal organs. Treatment involves intravenous ganciclovir or foscarnet and being cytotoxic requires a 'piggyback' of intravenous saline mirroring the volume administered and careful observation of renal function. Careful handling and disposal of the IV equipment is important to protect the staff.

Candidiasis may be oral or vaginal, patients may be admitted because if affects the oesophagus, making swallowing difficult, then anti-HIV medication that includes large tables and capsules becomes hard to continue. Oral Nystatin, a soft diet with supplements and medications in suspension may be sufficient but in severe cases naso-gastric feeding may be required.

Herpes Simplex may be oral or genital, It can be very painful as can chickenpox or shingles. Education about safe sex, hand washing and single use of towels to avoid auto-inoculation are important and pain relief may be required.

Toxoplasmosis tends to affect the brain and may be contracted from raw or undercooked meat, or cat droppings. Monitoring mobility and observing for signs of weakness, fits and psychological problems are important, as is the body temperature, as a patient's condition can deteriorate rapidly.

Pneumocystis Carinii Pneumonia (PCP) - may present as fever, dry cough, chest tightness or difficulty breathing and an apparently fit patient can deteriorate quickly. Cardiovascular observations especially reduced blood-oxygen levels on walking (desaturation) are important.

Mycobacterium Avium Complex (MAC) - may produce fever, painful intestines and weight loss, but about 90% of patients with late-stage disease at post-mortem examination have signs of infection. Weight loss may require assessment by the dietician and oral supplements, a food-chart may also be useful. Fatigue and diarrhoea may require help with the activities of daily living.

Tuberculosis is a problem in Tower Hamlets and if it is pulmonary then respiratory isolation is used. A multi-drug resistant infection may require six months of isolation and treatment. TB meningitis is a risk.

Isolation brings its own problems, including agitation and aggression towards staff as patients feel they are 'in prison', loss of control over activities, depression and for some auditory and visual hallucinations. Anxious patients may seek staff attention and be very demanding.

Soap and water is used for hand-washing and alcohol sprays for rapid hand disinfection. Visitors may need to be educated in the use of masks for respiratory infection. Teaching sessions are provided in the ward for hospital staff.

An art therapist visits isolated patients, but volunteer visitors are not used as there are confidentiality issues.

The ward is well funded, although money is no longer 'ring-fenced', the pharmaceutical companies support drug trials. A day shift would have three trained nurses and one 'A grade' to ten patients.

David explained that drug resistance is now about 10% due to virus mutation following missed doses, continuing with a failing drug, drug interaction, especially with those used to treat tuberculosis, and cross-resistance mutation.

HIV replicates very fast, so if the medication dose is every 8 hours the patient's lifestyle needs to ensure the dose is taken at exactly the right time. Some of the tablets and capsules are large, the suspensions can be bitter. At this point the session chair volunteered to taste one and confirmed it was very bitter and that it got worse over the next few minutes. Adherence to the medication regime has be 95% to get adequate viral suppression.

The ward has a multi-disciplinary team with a nurse sponsored by a pharmaceutical company to look after adherence. She sees each patient at the start of therapy and when it is changed. Patients are well informed about the medications and given a lot of support.

David suggested predicting which patients will adhere to the regime was difficult, as it involved a range of factors including health beliefs, lifestyle and whether the patient had told family and friends the diagnosis. He emphasised the problems when the patient felt well but the medication and side effects left them feeling ill. The lipolysis that can accompany some protease inhibitors, leading to loss of body fat and a gaunt face, may be a problem.

He showed a short video of patients discussing their feelings and how they had chosen and coped with medication regimes, in order to manage a chronic disease so they died of old age and not the disease.

Brett said he felt anxiety was a part of many a chronic medical illness. Currently most gay men are relatively well when first diagnosed, but African patients, especially refugees, could be very ill by that point. HIV was still the subject of taboo. In Africa it was mainly an illness for which only palliative care was available, they were in a strange country, separated from family and friends. Some suffered Post Traumatic Stress Disorders after war experiences.  Although psychosis was rare it made treatment difficult.

A brief outline of the therapeutic relationship and risk assessment led into a discussion of the 1983 Mental Health Act and how the Clinical Nurse Specialist worked alongside the clinical psychologists and general nurses.

Testing the children of people with HIV could be a problem, as the general practitioner had to refer the child to Great Ormond Street and because of the history of the disease being treated as a sexual health one there was a high level of privacy. A general practitioner was only informed of the disease with the explicit permission of the patient. Most patients did not inform their GP and so came to the hospital clinics for treatment of any illness, whether HIV related or not.