Transitioning HIV-Infected Adolescents Into Adult Care

Guideline and Commentary

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


August 29, 2011

In This Article

Evaluation After Transition Has Occurred

Post-Transition Assessment by the Adult Care Provider or Team

Recommendations. The adult care provider or team should devise a plan to achieve the following on an ongoing basis:

  • Assessment of whether an individual patient is adequately caring for his/her own health (AIII)

  • Assessment of barriers that the patient is facing, what support is needed, and who will provide this support (AIII)

  • Skills training and support, either through the multidisciplinary team in the clinic or by liaison with a mental health or psychosocial support provider (AIII)

Many adolescents and young adults transitioning to adult clinics will not have much experience in practicing the healthcare behaviors that often develop with maturity. The adult care provider should be alert to signs that a young patient needs additional support or skills training. Offering immediate support will reduce the risk of the patient withdrawing from care. Any 1 of the following behaviors may alert the clinician that the patient requires additional support and indicates a need to revise the individual's transition plan:

  • Multiple missed appointments

  • Discontinuation of medications

  • Substance use or other behaviors suggestive of poor adjustment

  • Loss of entitlements

  • Unstable housing

The checklist in Table 4 can be used to evaluate the success of the transition.

Table 4. Checklist for Successful Transition

  • The patient has accepted his or her chronic illness and is oriented toward future goals and hopes, including long-term survival.

  • The patient has learned the skills needed to negotiate appointments and multiple providers in an adult practice setting.

  • The patient has achieved personal and medical independence and is able to assume responsibility for his or her treatment and participate in decision-making

  • The referring provider is familiar with the new provider and practice setting, and direct communication about an individualized plan for the patient has taken place.

  • Mental health services have been transitioned at the same time as medical services.

  • Psychosocial needs are met and entitlements are in place (housing, health insurance, home care, transportation).

  • Life skills have been addressed (e.g., educational goals, job training, parenting).

  • The patient receives uninterrupted comprehensive medical care.

Follow-up From Adolescent or Pediatric Care Provider

Recommendations. If adolescents withdraw from care in the adult clinic and return to their previous pediatric/adolescent clinic, the adolescent care provider should be prepared to help the patient identify services that can provide increased support and should encourage re-engagement in adult medical care. (AIII)

After transitioning to an adult care setting, patients may continue to have contact with their pediatric/adolescent care team providers, which may reinforce a successful transition or may uncover potential pitfalls in maintaining ongoing care at the adult facility. Therefore, continued communication between adult and pediatric providers remains a crucial aspect of the transition process.

Both the patient's and the pediatric/adolescent care provider's desire to "check in" at the beginning of the transition process is part of normal and healthy closure and can mitigate the patient's sense of loss. However, transitioning patients may continue to rely on their pediatric/adolescent care provider for emotional support. This provider should defer clinical management decisions to the new provider and should be alert to the risk of hindering the patient from establishing a trusting therapeutic relationship with his/her adult care provider.

Young patients who withdraw from care in an adult clinic will often return to their adolescent or pediatric provider. When this happens, the provider should be prepared to help the patient identify services that can provide increased support and should encourage re-engagement in adult medical care.


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