Hannah Gibbs finds that giving medical advice can be surprisingly difficult

When I started university in 1994, it was time to wave goodbye to several of my friends, most of whom were also moving away to study. We all agreed to meet up during the holidays, and I expected them to return with a host of drunken anecdotes or maybe a new boy/girl friend. What I did not expect, however, was for one of them to come back with HIV.

"Fred" (not his real name) has been a friend of mine for several years; we met through our mutual piano teacher and became friends through repeatedly bumping into one another at exams. Six years into the friendship, dur- ing his first year away at university, he came out and told me that he is gay. Things took a more serious turn when I received a message from Fred, who told me that his new boyfriend was HIV positive. Being active on the gay scene, Fred was of course very aware of the presence of HIV, only this was the first time that he had been close to anyone who had the virus. It transpired that they had not yet done anything intimate as they were still in the early stages of their relationship, but things were moving that way, and Fred thought he'd ask me, as a medic, if I had any advice.

What do you say? Simply talking about the importance of safe sex and condoms seemed patronising, and, to be honest, I was a bit reluctant to go into the intimacies of anyone's sex life-whether homo- or heterosexual. So I told him that what he did with his partner was his own business, but urged him to be careful. A few months later, Fred was no longer seeing his boyfriend, and I went to visit him during the summer holidays. It was then that the subject of HIV testing came up.

Fred was wondering whether he should have a test, given the circumstances of his last relationship. Upon further discussion it came out that in addition to being worried about the risk from his ex, Fred had also had unprotected sex with two other people on different occasions. I was initially shocked to hear this-Fred is intelligent and sensible, and living in the late 1990s when the risks are well known and publicised; I could not believe that he had ignored the warnings. I soon realised, however, that this was a rather hypocritical view. During placements in general practice I have seen many girls requesting the "morning after pill," following either drunken unprotected intercourse, or the splitting of a condom. People in these situations tend to be considered more "responsible" for taking measures to prevent an unplanned pregnancy, and I am certain that none of these people are also offered HIV prophylaxis. There is advice in hospitals on what to do following a needlestick injury, but I cannot find any references to postcoital prophylaxis. In answer to Fred's query, I passed on the knowledge that HIV antibodies can take up to three months to be detected following infection, and advised Fred to think very carefully about getting tested. And, more importantly, to get some proper advice from a trained person, not just from a medic friend when both parties are semi-inebriated.

For some time after this I did not hear from Fred. I assumed that, like myself, he was busy, and being away on placements I tended to neglect people that weren't living in and around Cardiff. I did think of Fred, however, during my infectious diseases week, when I was asked to examine a patient with a lung tumour and malignant effusion. I assumed that the man, who looked in his sixties, had been a smoker and had developed lung cancer as a result. I was later told the patient was only in his early forties and suffering from AIDS. I thought that it was very upsetting that anyone should have to suffer so much over a disease that is preventable, and wondered whether Fred had got round to being tested.

During one of our infrequent holidays, I went back home and saw Fred in the middle of town. It was a big surprise, and once we had greeted each other we went for a coffee. I assumed that Fred would have graduated and found a job by now, but he told me that he had been ill recently and so had put things on hold. And just by looking at Fred, I knew what he meant by being ill. Whether it was the small plaster on his arm covering the site of a blood test, or whether it was something else about him, I don't know, but I realised then that Fred had caught HIV. We skirted around the issue for a few minutes. Fred finally said that he had caught HIV and had been in hospital for four months with AIDS related pneumonia.

What on earth do you say when a close friend tells you something like that? "I'm sorry" seems so lame, and there's not a lot you can say or do in the middle of a shopping precinct. As "tomorrow's doctors," we are taught so much about how to break bad news and how to communicate effectively with patients in difficult situations, but nothing I had been taught was any help in responding when a friend tells you this. Although in the past we had been able to talk for hours about anything, it was surprising initially how awkward it was trying to have a normal conversation, with this bombshell hanging over you. In some ways it is similar to on the wards when, as inexperienced freshers, we had to take histories from patients who had advanced cancer, and tried to be overly happy and positive, knowing that the prognosis isn't great.

But HIV is different-it's not something that you can send to the surgeons to cut out, and even with the combination treatment available, the prognosis varies so much between individuals. Later that evening we went to the pub, and things were a bit easier, as long as we stayed off the subject. But it was always there- Fred has to take 14 tablets per day, and four of them were sitting in a box next to the ashtray, to be taken at the correct time.

Fred doesn't know how he caught the virus- he can speculate about the route of transmission, but he said that he has almost always been careful. Unfortunately, it seems that one of the isolated incidents may have been enough, and these events have resulted in huge conse- quences. The impact it has on me, his friend, is negligible compared with what Fred has had to go through, but for me it has put a human side on a condition that is still subject to major prejudice and stereotyping. When we were in the pub, we had a swig out of each other's bottles, and even small things such as this made me think, initially-what if I had a tiny cut on my mouth, what if he has, too? As I know that HIV cannot be transmitted in this way, I felt ashamed at myself for even considering it, but with a condition that raises this much fear and uncertainty, it is not unnatural to have many concerns and questions.

Fred has asked me several times what I know of the prognosis for HIV, and I am unable to give any answers. Nobody can say what the future holds HIV sufferes whether it be tomorrow, next week, or next century, but at the moment I am not ready to lose my wonderful, talented friend, and I hope that he is one of the luckier ones.

Fred's name and certain other details have been changed in order to protect his identity.