COMMENTARY

Transitioning HIV-Infected Adolescents Into Adult Care

Guideline and Commentary

Jacob Abadi, MD; Michael G. Rosenberg, MD, PhD

Disclosures

August 29, 2011

In This Article

Identifying the Adult Care Provider

Recommendation. The referring provider should identify an adult care provider or multidisciplinary team that:

  • Is experienced with caring for transitioning HIV-infected adolescents and young adults (AIII)

  • Is willing to engage in direct communication with the referring provider about the patient (AIII)

  • Accepts the patient's health insurance(AIII)

Internists and infectious disease specialists who provide adult care generally are not experienced with pediatric and adolescent developmental issues or may be averse to dealing with the behavioral issues and multiple losses that many HIV-infected adolescents face. Locating a family or hospital-based medical practice that has experience with younger patients or is willing to develop appropriate skills and knowledge may help maintain transitioning patients in care. Adult care providers who are accepting care of HIV-infected youth for the first time should work with adolescent or pediatric providers who are experienced with transitioning when developing the transition plan.

When possible, the pediatric/adolescent healthcare team should assist the adolescent in choosing an adult clinic that best suits the individual. For example, patients with comorbidities, such as hepatitis C virus co-infection, diabetes, or mental health disorders, need to be in a setting that can provide comprehensive care. Some adolescents may feel that location is the most important factor due to time and transportation restrictions. Lesbian, gay, bisexual, and transgender (LGBT) youth may be looking for an environment that is "gay-friendly."

In some pediatric/adolescent settings, it may be possible to include a family practitioner or an adult provider who divides his/her time between the adolescent and adult clinic. The adult provider then becomes a familiar member of the multidisciplinary team prior to transition.

The Importance of Using a Multidisciplinary Approach

Recommendations. HIV care should be provided in settings where patients can receive all services in one location from a multidisciplinary team. If a multidisciplinary team is not available, mental health and psychosocial support services should be available onsite or in an easily accessible location. The primary care team should be responsible for maintaining an ongoing plan for coordination of care among all service providers. (AIII)

In areas where comprehensive HIV services are not available, the patient should be referred to a primary care provider with experience in providing HIV care in addition to a provider experienced with ART management. The primary care provider should help the transitioning patient navigate the adult subspecialty clinic model. (AIII)

If gynecologic services are not available as part of a comprehensive care model in the adult HIV care program, the primary care provider should refer HIV-infected adolescents/young women to a gynecologist with expertise in counseling adolescents regarding reproductive health and perinatal transmission. (AIII)

The primary care provider and members of the multidisciplinary team also should be able to provide ongoing HIV transmission and risk-reduction counseling to adolescents. (AI)

Many HIV-infected adolescents and young adults need access to complex mental health, alcohol and substance use, and psychosocial services. Unusually high rates of mental health diagnoses have been observed in both perinatally and behaviorally infected adolescent clinic cohorts.[20,21,22,23,24,25]

The primary care provider and members of the multidisciplinary team also should be able to provide ongoing HIV transmission and risk-reduction counseling to adolescents.[26] Ideally, an adult care provider who does not work with a multidisciplinary team should have access to necessary supportive services onsite or nearby. If patients need to be referred to other facilities for services, the primary care team should be responsible for maintaining an ongoing plan for coordination of care among all service providers. All providers involved in the patient's care are then aware of care plans from other providers, and staff can then follow up with patients when appointments are missed.

Key Point
When care is complex or fragmented, assignment of a specific staff person, such as a nurse, case manager, or social worker, to a coordinating role is important to ensure that a comprehensive and effective management plan is implemented that includes optimal support and follow-up.

Onsite gynecological services, provided by either the primary care provider, a nurse practitioner, gynecologist, or nurse midwife with HIV expertise, is the best model to ensure adherence to gynecologic care. If the patient is referred to a general gynecologic service, the primary care provider needs to ensure that topics specific to HIV care, such as drug interactions between antiretroviral agents and hormonal contraceptives and "dual protection" education (consistent use of a reliable contraceptive method in addition to condoms used to prevent HIV transmission) are addressed (see Care for the HIV-Infected Female Adolescent and Contraception for HIV-Infected Women ).

Comments

3090D553-9492-4563-8681-AD288FA52ACE
Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.

processing....