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

Implementing the Transition Plan

Recommendations. The referring clinician or provider team should arrange the transitioning of all current and anticipated services, including medical, mental health, and substance use treatment if needed. Individualized psychosocial needs, such as housing, employment, education, insurance, home-based services, or transportation, should also be addressed at this time. (AIII)

When to Transition

Recommendations. The transition plan should be implemented when the patient:

  • Demonstrates understanding of his/her disease and its management (AIII)

  • Demonstrates the ability to make and keep appointments (AIII)

  • Knows when to seek medical care for symptoms or emergencies (AIII)

Whenever possible, transition should be implemented when the patient's disease is clinically stable. (BIII)

Most HIV-infected adolescents transition to adult care between 22 and 24 years of age.[27] However, developmental stage and readiness for transition may be better indicators than chronological age for determining when transition should occur. Patients with developmental delays or a chaotic and unstable life may need more time to become ready to transition. Adolescents who demonstrate independence in making their own decisions and show responsibility for their own care may be ready sooner.

The likelihood for successful transition is increased when both the pediatric/adolescent healthcare team and adult healthcare team recognize the broad spectrum of readiness in transitioning patients, ranging from those who are near full autonomy to those for whom disorder and confusion are a daily experience. For example, the transition process for a college student with well-developed career goals will be vastly different than that for a patient who is often hospitalized, nonadherent with medications, and frequently in crisis both emotionally and behaviorally. The goals and challenges of transition, as well as the support that will be needed during the process, will be individualized for each patient.

Communication Between the Adolescent Care Provider and the Adult Care Provider

Recommendations. The referring clinician should:

  • Compose a medical summary that highlights key issues for the individual patient and includes the patient's medical, psychological, and social history (AIII)

  • Schedule a case conference prior to transition (AIII)

Although the adult medical model does not generally provide time for direct communication between referring and receiving providers or provider teams, coordination between these providers can moderate the "culture shock" for a patient moving from child-, adolescent-, or family-centered care to adult-centered care. Adolescent medicine experts underscore that, for effective transitioning, a written summary is necessary but not sufficient. Direct communication between providers is essential. When the pediatric or adolescent care team is informed about the orientation plan in the adult clinic, it allows them to provide the transitioning patient with realistic expectations and helps them to prepare the patient with the necessary skills for managing his/her care in the new setting.

Use of Transition Agent or Patient Advocate

Recommendations. The adolescent care provider should designate one member of the healthcare team to oversee transition planning and implementation at both the old and new provider locations. (AIII)

The adult care provider should also designate a point person who will oversee the transition and who the patient can contact with any questions or concerns. (AIII)

The adolescent care provider or team should designate one care provider to oversee transition planning and implementation. This may be the primary care provider or another team member, such as a social worker. The coordinator should have equal visibility in and access to the pediatric and adult clinics to demonstrate continuity to the patient.

In some programs, a peer advocate, who may be someone who has recently transitioned successfully, works with the patient to create and track progress on an individualized transition plan. Peer advocates may accompany patients to the initial adult medical appointments and then provide support while they gain the independence and confidence to attend subsequent appointments by themselves.[28,29]

The adult care provider should designate a point person who the patient can call with any questions or concerns. The point person can guide the patient to appropriate services and also alert providers if there are any concerns. This may be someone different than the designated contact person for clinic patients. For example, it might be a social worker or counselor who is familiar with developmental issues for transitioning adolescents and young adults. A primary care provider may choose to be called directly, or there may be a particular nurse or other staff member who is especially adept at working with young patients.

Challenges for Pregnant Adolescents During Transition

Recommendations. Adolescent care providers should have referral agreements with obstetrical services that can provide prenatal care to HIV-infected females during transition and that offer prenatal support services. (AIII)

Pediatric and/or adolescent care providers should be able to provide individualized support and advocacy for pregnant teens who are unprepared for transition to obstetrical services. (AIII)

Adolescent care providers should consider remaining the primary care provider for the adolescent during pregnancy. (AIII)

Adolescent pregnancy is often unplanned and can interrupt the process of transition planning and skills training. As a result, the patient may be referred to an obstetrics clinic before she is ready and well-prepared for adult care. This is a time when active support is particularly important to ensure that a patient's discomfort with receiving treatment from a new provider and clinic do not lead to interruption of either prenatal or HIV care. For recommendations regarding care for HIV infected pregnant adolescents, see Care for the HIV-Infected Female Adolescent .

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