Development of a protocol for transitioning adolescents with HIV infection to adult care

Creating a data collection and management platform to support measurement of adolescent HIV care transition processes within low- and middle-income countries: The GRADUATE project

Few national programs and research cohorts within low- and middle-income countries (LMICs) document transition-related processes and outcomes for adolescents and young adults living with HIV (AYLH) transitioning to adulthood. Between 2017-2020, The Global fRAmework of Data collection Used for Adolescent HIV Transition Evaluation (GRADUATE) project convened a collaborative advisory group to identify key variables and definitions capturing the process, predictors, and outcomes across the transition period. In total, 114 variables identified as essential to measuring AYLH transition-related data were identified and formatted into a GRADUATE Data Exchange Standard (DES), which was added to and harmonized with the existing International epidemiology Databases to Evaluate AIDS (IeDEA) DES. In 2019, the GRADUATE DES was pilot tested at four IeDEA facilities in Malawi, South Africa, and Thailand through a cross-sectional study. Upon comparing the variables to routine medical records, available data were too limited to adequately capture transition-related processes and outcomes. However, additional data collection using GRADUATE tools was feasible and improved completeness. Of the 100 (52% female) AYLH included in the pilot study, 71% had transitioned/transferred to adult care, with 42% transitioning from an adolescent-specific model of care within an integrated family clinic to having their clinic visits scheduled on a different day of the week while 58% transferred from a pediatric facility to one offering adult HIV care. While almost all (94%) had a transition-related discussion with their healthcare providers prior to the transition, we found that 69% (95% CI 49-85%) were somewhat or very satisfied/comfortable with the post-transfer clinic and the staff. Utilization of the GRADUATE DES better characterized AYLH transitioning to adulthood across LMICs, and optimally measured transition preparation activities and outcomes. Utilization of the GRADUATE DES in other settings could facilitate comparisons and identify gaps in the care of transitioning adolescents that need to be addressed.

Experiences of adolescents living with HIV on transitioning from pediatric to adult HIV care in low and middle-income countries: A Qualitative Evidence Synthesis Protocol

In South Africa, it is estimated that approximately 320,000 adolescents living with HIV (ALHIV) will transition from pediatric to adult antiretroviral treatment (ART) by 2028. However, the age period of 10-19 years is accompanied by a myriad of barriers that challenge the transition process, and continued adherence to ART. The transition process involves ALHIV taking charge of their own health and disease management which raises challenges for their retention in care. Managing transition becomes particularly challenging in low-resource contexts as their healthcare systems are not adapted to the specific needs it requires. There is a need to garner an understanding of existing transition practices which address the specific needs of adolescents and is optimized to their requirements and available resources within a low- or middle-income country context. This review will include all qualitative and mixed method studies which will facilitate a deeper understanding the experiences of ALHIV on transition experiences. The review will specifically look at studies conducted in low- and middle-income countries. The included studies must be presented in the English language and published between 2010-2023. The search strategy will be finalized with consultation with an information specialist. All three reviewers will be present throughout all stages of the review. One reviewer will work independently on the initial screening of studies and another reviewer will assist in checks. After data is extracted, the data will be thematically analyzed with the use of Atlas.Ti computer software. No ethics approval is required and the review will be published in peer reviewed journals and submitted to conferences. PROSPERO registration number: CRD42023396459.

Primary-level and community worker interventions for the prevention of mental disorders and the promotion of well-being in low- and middle-income countries

BACKGROUND

There is a significant research gap in the field of universal, selective, and indicated prevention interventions for mental health promotion and the prevention of mental disorders. Barriers to closing the research gap include scarcity of skilled human resources, large inequities in resource distribution and utilization, and stigma.

OBJECTIVES

To assess the effectiveness of delivery by primary workers of interventions for the promotion of mental health and universal prevention, and for the selective and indicated prevention of mental disorders or symptoms of mental illness in low- and middle-income countries (LMICs). To examine the impact of intervention delivery by primary workers on resource use and costs.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, Global Index Medicus, PsycInfo, WHO ICTRP, and ClinicalTrials.gov from inception to 29 November 2021.

SELECTION CRITERIA

Randomized controlled trials (RCTs) of primary-level and/or community health worker interventions for promoting mental health and/or preventing mental disorders versus any control conditions in adults and children in LMICs.

DATA COLLECTION AND ANALYSIS

Standardized mean differences (SMD) or mean differences (MD) were used for continuous outcomes, and risk ratios (RR) for dichotomous data, using a random-effects model. We analyzed data at 0 to 1, 1 to 6, and 7 to 24 months post-intervention. For SMDs, 0.20 to 0.49 represented small, 0.50 to 0.79 moderate, and ≥ 0.80 large clinical effects. We evaluated the risk of bias (RoB) using Cochrane RoB2.

MAIN RESULTS

Description of studies We identified 113 studies with 32,992 participants (97 RCTs, 19,570 participants in meta-analyses) for inclusion. Nineteen RCTs were conducted in low-income countries, 27 in low-middle-income countries, 2 in middle-income countries, 58 in upper-middle-income countries and 7 in mixed settings. Eighty-three RCTs included adults and 30 RCTs included children. Cadres of primary-level workers employed primary care health workers (38 studies), community workers (71 studies), both (2 studies), and not reported (2 studies). Interventions were universal prevention/promotion in 22 studies, selective in 36, and indicated prevention in 55 RCTs. Risk of bias The most common concerns over risk of bias were performance bias, attrition bias, and reporting bias. Intervention effects 'Probably', 'may', or 'uncertain' indicates 'moderate-', 'low-', or 'very low-'certainty evidence. *Certainty of the evidence (using GRADE) was assessed at 0 to 1 month post-intervention as specified in the review protocol. In the abstract, we did not report results for outcomes for which evidence was missing or very uncertain. Adults Promotion/universal prevention, compared to usual care: - probably slightly reduced anxiety symptoms (MD -0.14, 95% confidence interval (CI) -0.27 to -0.01; 1 trial, 158 participants) - may slightly reduce distress/PTSD symptoms (SMD -0.24, 95% CI -0.41 to -0.08; 4 trials, 722 participants) Selective prevention, compared to usual care: - probably slightly reduced depressive symptoms (SMD -0.69, 95% CI -1.08 to -0.30; 4 trials, 223 participants) Indicated prevention, compared to usual care: - may reduce adverse events (1 trial, 547 participants) - probably slightly reduced functional impairment (SMD -0.12, 95% CI -0.39 to -0.15; 4 trials, 663 participants) Children Promotion/universal prevention, compared to usual care: - may improve the quality of life (SMD -0.25, 95% CI -0.39 to -0.11; 2 trials, 803 participants) - may reduce adverse events (1 trial, 694 participants) - may slightly reduce depressive symptoms (MD -3.04, 95% CI -6 to -0.08; 1 trial, 160 participants) - may slightly reduce anxiety symptoms (MD -2.27, 95% CI -3.13 to -1.41; 1 trial, 183 participants) Selective prevention, compared to usual care: - probably slightly reduced depressive symptoms (SMD 0, 95% CI -0.16 to -0.15; 2 trials, 638 participants) - may slightly reduce anxiety symptoms (MD 4.50, 95% CI -12.05 to 21.05; 1 trial, 28 participants) - probably slightly reduced distress/PTSD symptoms (MD -2.14, 95% CI -3.77 to -0.51; 1 trial, 159 participants) Indicated prevention, compared to usual care: - decreased slightly functional impairment (SMD -0.29, 95% CI -0.47 to -0.10; 2 trials, 448 participants) - decreased slightly depressive symptoms (SMD -0.18, 95% CI -0.32 to -0.04; 4 trials, 771 participants) - may slightly reduce distress/PTSD symptoms (SMD 0.24, 95% CI -1.28 to 1.76; 2 trials, 448 participants).

AUTHORS' CONCLUSIONS

The evidence indicated that prevention interventions delivered through primary workers - a form of task-shifting - may improve mental health outcomes. Certainty in the evidence was influenced by the risk of bias and by substantial levels of heterogeneity. A supportive network of infrastructure and research would enhance and reinforce this delivery modality across LMICs.

Association of Perceived Social Support with Viral Suppression Among Young Adults with Perinatally-Acquired HIV in the US-based Pediatric HIV/AIDS Cohort Study (PHACS)

Purpose

To determine the relationship between perceived social support and viral suppression among young adults with perinatally-acquired HIV (YAPHIV).

Participants and Methods

We included YAPHIV ≥18 years enrolled in AMP Up, a study of PHACS (Pediatric HIV/AIDS Cohort Study), with social support evaluations and ≥1 HIV viral load (VL) measured over the next year. We evaluated emotional, instrumental, and friendship social support via the NIH Toolbox. We defined social support, measured at study entry and year 3 (if available), as low (T-score ≤40), average (41-59) or high (≥60). We defined viral suppression as all VL <50 copies/mL over the one year after social support measures. We fit multivariable Poisson regression models using generalized estimating equations, and evaluated transition from pediatric to adult care as an effect modifier.

Results

Among 444 YAPHIV, low emotional and instrumental support and friendship at entry were reported by 37%, 32% and 36%. Over the next year, 44% were virally suppressed. Of 136 with year 3 data, 45% were suppressed. Average or high levels of all three social support measures were associated with higher likelihood of viral suppression. Instrumental support was associated with viral suppression among those in pediatric (adjusted proportion suppressed among those with average/high vs low support=51.2% vs 28.9%; risk ratio (RR)=1.77, 95% confidence interval (CI)=1.37, 2.29), but not adult care (40.0% vs 40.8%; RR=0.98, 95% CI=0.67, 1.44).

Conclusion

Sufficient social support increases likelihood of viral suppression among YAPHIV. Strategies to enhance social support may promote viral suppression as YAPHIV prepare for adult clinical care transition.

Development, pilot implementation, and preliminary assessment of a transition process for youth living with HIV

PURPOSE

To describe the development and pilot implementation of a transition process for youth living with human immunodeficiency virus (HIV) and to assess the perceptions of the process among youth living with HIV (YLHIV), their caregivers, and clinical staff.

DESIGN AND METHODS

A multidisciplinary core planning team developed a transition planning framework and process. With the assistance of the appropriate hospital departments, we created educational material for patients and caregivers and a flowsheet for documentation in the electronic medical record (EMR). Staff were trained on implementation of the process and documentation in the EMR. To assess the process, we surveyed staff, YLHIV, and caregivers for feedback.

RESULTS

Our transition process was informed by our goal to provide transition support that could respond to a variety of patient factors. We developed a process focused on four stages: 1. Introduction to Transition, 2. Building Knowledge and Skills, 3. Growing in Independence, and 4. Adult Care Ready. Each stage contains competencies for the patient and tasks for the care team. The pace of proceeding through the stages is determined by completion of competencies rather than patient age. Results from youth and staff showed that the transition process and informational material were helpful.

CONCLUSION

We developed a transition process for YLHIV and implemented this process in an HIV clinic. Initial survey data shows that youth, caregivers, and staff found this strategy helpful.

PRACTICE IMPLICATIONS

This pilot process may serve as a source of guidance to other clinics seeking to establish their own transition process.

Adolescent transition to adult care for HIV-infected adolescents in Kenya (ATTACH): study protocol for a hybrid effectiveness-implementation cluster randomised trial

INTRODUCTION

Successfully transitioning adolescents to adult HIV care is critical for optimising outcomes. Disclosure of HIV status, a prerequisite to transition, remains suboptimal in sub-Saharan Africa. Few interventions have addressed both disclosure and transition. An adolescent transition package (ATP) that combines disclosure and transition tools could support transition and improve outcomes.

METHODS AND ANALYSIS

In this hybrid type 1 effectiveness-implementation cluster randomised controlled trial, 10 HIV clinics with an estimated ≥100 adolescents and young adults age 10-24 living with HIV (ALWHIV) in Kenya will be randomised to implement the ATP and compared with 10 clinics receiving standard of care. The ATP includes provider tools to assist disclosure and transition. Healthcare providers at intervention clinics will receive training on ATP use and support to adapt it through continuous quality improvement cycles over the initial 6 months of the study, with continued implementation for 1 year. The primary outcome is transition readiness among ALWHIV ages 15-24 years, assessed 6 monthly using a 22-item readiness score. Secondary outcomes including retention and viral suppression among ALWHIV at the end of the intervention period (month 18), implementation outcomes (acceptability, feasibility, fidelity, coverage and penetration) and programme costs complement effectiveness outcomes. The primary analysis will be intent to treat, using mixed-effects linear regression models to compare transition readiness scores (overall and by domain (HIV literacy, self-management, communication, support)) over time in control and intervention sites with adjustment for multiple testing, accounting for clustering by clinic and repeated assessments. We will estimate the coefficients and 95% CIs with a two- sided α=0.05.

ETHICS AND DISSEMINATION

The study was approved by the University of Washington Institutional Review Board and the Kenyatta National Hospital Ethics and Research Committee. Study results will be shared with participating facilities, county and national policy-makers.

TRIALS REGISTRATION NUMBER

NCT03574129; Pre-results.

Primary Care Guidance for Persons With Human Immunodeficiency Virus: 2020 Update by the HIV Medicine Association of the Infectious Diseases Society of America

Advances in antiretroviral therapy (ART) have made it possible for persons with human immunodeficiency virus (HIV) to live a near expected life span, without progressing to AIDS or transmitting HIV to sexual partners or infants. There is, therefore, increasing emphasis on maintaining health throughout the life span. To receive optimal medical care and achieve desired outcomes, persons with HIV must be consistently engaged in care and able to access uninterrupted treatment, including ART. Comprehensive evidence-based HIV primary care guidance is, therefore, more important than ever. Creating a patient-centered, stigma-free care environment is essential for care engagement. Barriers to care must be decreased at the societal, health system, clinic, and individual levels. As the population ages and noncommunicable diseases arise, providing comprehensive healthcare for persons with HIV becomes increasingly complex, including management of multiple comorbidities and the associated challenges of polypharmacy, while not neglecting HIV-related health concerns. Clinicians must address issues specific to persons of childbearing potential, including care during preconception and pregnancy, and to children, adolescents, and transgender and gender-diverse individuals. This guidance from an expert panel of the HIV Medicine Association of the Infectious Diseases Society of America updates previous 2013 primary care guidelines.

HIV Health Care Transition Readiness: Embracing the Opportunity and Challenge

Because of effective treatment and prolonged survival, thousands of young adult people living with HIV will need to transfer their health care to adult care providers. However, many lack basic essential skills and are not prepared for this transition. Many providers do not assess transition readiness on a regular basis. Validated transition readiness assessment tools can help providers guide interventions based on identified skill and knowledge deficits. Our purpose was to describe the impact of incorporating a validated Transition Readiness Assessment Questionnaire (TRAQ) into clinical practice. A retrospective chart review of 48 patients with HIV, ages 22-24 years, showed that the use of the TRAQ significantly affected provider interventions in the area of medication management (odds ratio: 0.02). Overall, the use of the TRAQ did not increase clinical interventions; however, it enabled providers to identify knowledge or skill deficits not previously addressed and to plan future clinical interventions to meet individual patient needs.

The Transition of Care From Pediatric to Adult Health-Care Services of Vertically HIV-Infected Adolescents: A Pilot Study

Objective: Clinical and psychological HIV-related problems peak during adolescence, which coincides with transition of children and adolescents infected from mothers from pediatric to adult reference centers for HIV infection. Transition often is done without specific programs. We wanted to explore transition as an opportunity to increase the efficacy of care and the psychological well-being through a specific program. Methods: Thirteen vertically infected patients aged 13-20 years were followed up for 24 months by pediatricians, infectious disease specialists, a psychologist, and a nurse. Interventions consisted in joint clinic, simplification of therapy, patient group discussions, HIV infection explanations, and psychological support, lasting 12 months. Efficacy was measured by viro-immunological outcomes and adherence to therapy and psychological tests. Clinical, viro-immunological, and psychological evaluations were performed at 0 (T0) and 12 months (T12) and 6 months after transition to an adult center (T18). Psychological outcomes were assessed using standardized questionnaires for quality of life and self-esteem. Results: In 11/13 participants, pills administrations/day were significantly reduced. Patients with undetectable viral load and CD4+ >25% increased from 61 to 77% and from 61 to 74%, respectively. Six months after transition, all patients exhibited an undetectable viral load. Adolescents' awareness of the severity of the disease and the risk of sexual transmission was generally poor. Patients classified with "severe" psychological distress according to the quality of life index decreased from 38 to 15% and well-being increased. Similar results were observed 6 months after the transition to adult care. No effect was observed on self-esteem index. Conclusions: Specific protocols for transition should be developed to optimize resilience and psychological well-being, including routine psychological support for adolescents with HIV infection transiting from pediatric to adult centers for HIV infection.

Outcomes of a Comprehensive Retention Strategy for Youth With HIV After Transfer to Adult Care in the United States

BACKGROUND

The retention of youth living with HIV (YLHIV) in adult care after transfer from pediatric care in the United States is a challenge. A targeted comprehensive retention strategy (CRS) may improve retention among YLHIV.

METHODS

A retrospective cohort study of YLHIV after transfer from pediatric to adult care for patients with at least 1 adult visit at 2 urban HIV care programs in the United States employing CRSs with internal medicine/pediatrics-trained providers, peer navigators, social workers and mental health resources. Primary outcomes were successful retention in care after transfer (≥2 provider visits in the adult clinic ≥90 days apart within 1 year of transfer) and successful transition (successful retention plus a stable HIV viral load (VL) defined as VL 1 year after transfer that was less than or equal to the VL obtained at or immediately before transfer). Logistic regression assessed factors associated with successful transition. A subgroup analysis was performed to examine rates of successful transfer and linkage from pediatric to adult clinics (attending at least 1 adult visit after transition).

RESULTS

Of the 89 patients included in the study, 79 (89%) patients had successful retention and 53 (60%) had successful transition to the adult program. Factors associated with successful transition included non-African American race [adjusted odds ratio (aOR) = 11.26, 95% confidence interval (CI): 1.32-95.51], perinatal HIV (aOR = 8.00, 95% CI: 1.39-46.02) and CD4 count > 500 cells/mm (aOR = 5.22, 95% CI: 1.54-17.70). Of those who were retained, 53/79 (67%) had stable or improved virologic control at 1 year after transition. In a subgroup analysis, 54/56 (96%) patients who were targeted to transition successfully linked to adult care.

CONCLUSIONS

Overall, YLHIV in the United States engaged in a CRS program appear to have high retention rates but suboptimal virologic control after transfer from pediatric HIV care.

Characteristics of adolescents living with HIV receiving care and treatment services in antiretroviral therapy clinics in Cambodia: descriptive findings from a cross-sectional study

Background

Adolescents living with HIV experience worse HIV care outcomes compared to adults, especially during transition from pediatric to adult care. However, data regarding adolescents are limited. This paper describes and compares characteristics of male and female adolescents living with HIV preparing for transition from pediatric to adult care in Cambodia.

Methods

This cross-sectional study was conducted in August 2016 among 328 adolescents aged 15–17, randomly selected from 11 antiretroviral therapy (ART) clinics. Data were collected using a structured questionnaire, and descriptive analyses were conducted to compare characteristics of male and female adolescents.

Results

Of total, 55.2% were male, and 40.8% were living with parents. Majority (82.6%) got HIV infection from their mothers. Overall, adolescents had received ART for an average of 8.4 years, and HIV care for 9.5 years. Additionally, 82.4% were on first line ART regimen. Mean CD4 count from the most recent test was 672 cells/mm³, and viral load was 7686 copies/mL. Overall, 95.6% were adherent to ART on Visual Analogue Scale. About half (50.7%) had never disclosed their HIV status to anyone, while the remaining had disclosed it to their siblings (24.2%), friends (13.0%), schoolteachers (2.4%), or other (5.8%). A fifth reported having had boy or girlfriends, but few (2.1%) had ever had sexual intercourse. Females were more likely to have been engaged in sexual intercourse, and none reported having used a condom in their last intercourse. Few participants reported having ever used tobacco (1.8%), or any kind of illicit drugs (0.9%), but almost a fifth (20.7%) had a history of alcohol use. The majority (82.1%) were aware that they were receiving ART. HIV-related knowledge was suboptimal among the sample.

Conclusions

This study provides a snapshot of immunological, virological, adherence, and disclosure outcomes that should be tracked during and following healthcare transition to evaluate the effectiveness of the transition program. Findings showed high ART adherence, low likelihood of disclosure outside of family circles, sub-optimal condom use, and poor knowledge of HIV. To provide individualized support for healthcare transition, pediatric and adult clinics need to ensure that these characteristics are taken into account.

Pediatric to adult healthcare transitioning for adolescents living with HIV in Nigeria: A national survey

Introduction

The period of transition from pediatric to adult care has been associated with poor health outcomes among 10–19 year old adolescents living with HIV (ALHIV). This has prompted a focus on the quality of transition services, especially in high ALHIV-burden countries. Due to lack of guidelines, there are no healthcare transition standards for Nigeria’s estimated 240,000 ALHIV. We conducted a nationwide survey to characterize routine transition procedures for Nigerian ALHIV.

Materials and methods

This cross-sectional survey was conducted at public healthcare facilities supported by five local HIV service implementing partners. Comprehensive HIV treatment facilities with ≥1 year of HIV service provision and ≥20 ALHIVs enrolled were selected. A structured questionnaire assessed availability of treatment, care and transition services for ALHIV. Transition was defined as a preparatory process catering to the medical, psychosocial, and educational needs of adolescents moving from pediatric to adult care. Comprehensive transition services were defined by 6 core elements: policy, tracking and monitoring, readiness evaluation, planning, transfer of care, and follow-up.

Results

All 152 eligible facilities were surveyed and comprised 106 (69.7%) secondary and 46 (30.3%) tertiary centers at which 17,662 ALHIV were enrolled. The majority (73, 48.3%) of the 151 facilities responding to the “clinic type” question were family-centered and saw all clients together regardless of age. Only 42 (27.8%) facilities had an adolescent-specific HIV clinic; 53 (35.1%) had separate pediatric/adolescent and adult HIV clinics, of which 39 (73.6%) reported having a transfer/transition policy. Only 6 (15.4%) of these 39 facilities reported having a written protocol. There was a bimodal peak at 15 and 18 years for age of ALHIV transfer to adult care. No surveyed facility met the study definition for comprehensive transition services.

Conclusions

Facilities surveyed were more likely to have non-specialized HIV treatment services and had loosely-defined, abrupt transfer versus transition practices, which lacked the core transition elements. Evidence-based standards of transitional care tailored to non-specialized HIV treatment programs need to be established to optimize transition outcomes among ALHIV in Nigeria and in similar settings.

Health-care transition from adolescent to adult services for young people with HIV

HIV-related care and treatment engagement are crucial steps to improve individual and population-level health; yet, many young people (18-25 years old) with HIV are not maintained in, or disengage from, care. Health-care transition and the transfer to adult care are particularly vulnerable points in the care and treatment of young people with HIV. In this Review, we explore barriers and facilitators to health-care transition, evaluate existing health-care transition programmes, and identify best practices for the improvement of health-care transition outcomes and health. Although we examine health-care transition across a range of geographical regions, most examples are from the settings in which the most research has been done-the USA and western Europe.

Adolescent Coordinated Transition (ACT) to improve health outcomes among young people living with HIV in Nigeria: study protocol for a randomized controlled trial

BACKGROUND

Adolescents living with HIV (ALHIV) have worse health outcomes than other populations of people living with HIV. Contributing factors include lack of standard and comprehensive procedures for ALHIV transitioning from pediatric to adult care. This has contributed to poor retention at, and following transition, which is problematic especially in high ALHIV-burden, resource-limited settings like Nigeria.

METHODS

Using a two-arm cluster randomized control design, the Adolescent Coordinated Transition (ACT) trial will measure the comparative effectiveness of a graduated transition and organized support group intervention against the usual practice of abrupt transfer of Nigerian ALHIV from pediatric to adult care. This study will be conducted at 12 secondary and tertiary healthcare facilities (six intervention, six control) across all six of Nigeria's geopolitical zones. The study population is 13- to 17-year-old ALHIV (N = 216, n = 108 per study arm) on antiretroviral therapy. Study participants will be followed through a 12-month pre-transfer/transition period and for an additional 24 months post transfer/transition. The primary outcome measure is the proportion of ALHIV retained in care at 12 and 24 months post transfer. Secondary outcome measures are proportions of ALHIV achieving viral suppression and demonstrating increased psychosocial wellbeing and self-efficacy measured by psychometric tests including health locus of control, functional social support, perceived mental health, and sexual risk and behavior.

DISCUSSION

We hypothesize that the ACT intervention will significantly increase psychosocial wellbeing, retention in care and ultimately viral suppression among ALHIV. ACT's findings have the potential to facilitate the development of standard guidelines for transitioning ALHIV and improving health outcomes in this population. The engagement of a consortium of local implementing partners under the Nigeria Implementation Science Alliance allows for nationwide study implementation and expedient results dissemination to program managers and policy-makers. Ultimately, ACT may also provide evidence to inform transitioning guidelines not only for ALHIV but for adolescents living with other chronic diseases in resource-limited settings.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT03152006 . Registered on May 12, 2017.

A review of transition experiences in perinatally and behaviourally acquired HIV-1 infection; same, same but different?

Introduction: Despite sharing common psychosocial and developmental experiences, adolescents living with perinatally and behaviourally acquired HIV-1 infection are different in terms of timing of HIV infection and developmental stage at infection. Therefore, it is of interest to identify similarities and differences between these two groups of adolescents living with HIV in their experiences, facilitators and barriers during the transition process.

Methods: A detailed literature search of peer-reviewed published papers was conducted on PubMed to identify relevant original research or viewpoints published up to September 2016. Conference abstracts and other unpublished data sources were not included.

Results: Existing published literature, mainly using qualitative methods, explores the transition from paediatric to adult healthcare provision, as experienced by these two groups of young people. Reports highlight the variation and similarities in their experiences and challenges of transition. Findings from the USA and Europe predominate, while experience from Africa and Asia is lacking, despite the importance of these regions in the global epidemic.

Conclusions: Published transition data remain limited, and there are few studies focusing on behaviourally infected adolescents and key population groups (e.g. adolescents who use drugs, lesbian/gay/transgender individuals). Robust definitions of the transition process and standardized outcome measures are required to facilitate cross-study and geographic comparisons.

The Happy Teen programme: a holistic outpatient clinic-based approach to prepare HIV-infected youth for the transition from paediatric to adult medical care services in Thailand

Introduction: We developed an 18‐month Happy Teen 2 (HT2) programme comprised of a one‐day workshop, two half‐day sessions, and three individual sessions to prepare HIV‐infected youth for the transition from paediatric to adult HIV care services. We describe the programme and evaluate the change in youth's knowledge scores.

Methods: We implemented the HT2 programme among HIV‐infected Thai youth aged 14–22 years who were aware of their HIV status and receiving care at two hospitals in Bangkok (Siriraj Hospital, Queen Sirikit National Institute of Child Health [QSNICH]). Staff interviewed youth using a standardized questionnaire to assess HIV and health‐related knowledge at baseline and at 12 and 18 months while they participated in the programme. We examined factors associated with a composite knowledge score ≥95% at month 18 using logistic regression.

Results: During March 2014–July 2016, 192 of 245 (78%) eligible youth were interviewed at baseline. Of these, 161 (84%) returned for interviews at 12 and 18 months. Among the 161 youth, the median age was 17 years, 74 (46%) were female, and 99% were receiving antiretroviral treatment. The median composite score was 45% at baseline and increased to 82% at 12 months and 95% at 18 months (P < 0.001). The range of median knowledge scores for antiretroviral management, HIV monitoring, HIV services, and family planning significantly increased from baseline (range 0–75%) to (range 67–100%) at 12 months and to 100% at 18 months (P < 0.001). Almost all youth were able to describe education and career goals at 12 and 18 months compared to 75% at baseline. In multivariable analysis, a composite knowledge score at 18 months >95% was associated with education level >high school (aOR: 2.15, 95%CI, 1.03–4.48) and receipt care at QSNICH (aOR: 2.43, 95%CI, 1.18–4.98). Youth whose mother and father had died were less likely to have score ≥95% (aOR: 0.22, 95%CI, 0.07–0.67) than those with living parents.

Conclusions: Knowledge useful for a successful transition from paediatric to adult HIV care increased among youth participating in the HT2 programme. Youth follow‐up will continue to assess the impact of improved knowledge on outcomes following the transition to adult care services.

Growing up with perinatal HIV: changes in clinical outcomes before and after transfer to adult care in the UK

INTRODUCTION

With improved survival, adolescents with perinatal HIV (PHIV) are transitioning from paediatric to adult care, but there are few published data on clinical outcomes post-transfer. Using linked data from patients in the national UK/Ireland paediatric cohort (CHIPS) and an adult UK cohort of outpatient clinics (UK CHIC), we describe mortality and changes in immunological status post-transfer.

METHODS

Participants in CHIPS aged ≥13 years by the end of 2013 were linked to the UK CHIC database. Mixed effects models explored changes in CD4 count before and after transfer, including interactions between time and variables where interaction p < 0.05.

RESULTS

Of 1,215 paediatric participants aged ≥13 years, 271 (22%) had linked data in UK CHIC. One hundred and forty-six (53%) were female, median age at last visit in paediatric care was 17 [interquartile range, IQR 16,18] years, median duration in paediatric care was 11.8 [6.6,15.5] years, and in adult care was 2.9 [1.5,5.9] years. At last visit in paediatric care, 74% (n = 200) were on ART, increasing to 84% (n = 228, p = 0.001) at last visit in adult care. In the 12 months before leaving paediatric care, 92 (47%) had two consecutive viral loads >400 copies/mL or one viral load >10,000 copies/mL, and likewise 102 (52%) in the 12 months post-transfer (p = 0.79). Seven (3%) people died in adult care. In multivariable analysis, CD4 declined as patients approached transition with a greater decline in those with higher nadir CD4 count (mean rates of decline of 3, 13, 15, 30 cells/mm3 per year for those with nadir CD4 < 100, 100-199, 200-299 and ≥300 cells/mm3, respectively). Post-transition, CD4 continued to decline in some groups (e.g. black males, -20 (-34, -5) cells/mm3 per year post transition, p = 0.007)) while it improved in others. Overall CD4 was higher with later year of birth (14 (7, 21) cells/mm3 per later year). There was no effect of age at transfer or changing hospital at transfer on CD4.

CONCLUSIONS

Our findings suggest that CD4 in adolescents with perinatal HIV in the UK was declining in the period before transition to adult care, and there was some reversal in this trend post-transfer in some groups. Across the transition period, CD4 was higher in those with later birth years, suggesting improvements in clinical care and/or transition planning over time.

Transition of Care for Youth with HIV

Remarkable advances have been made in the treatment of HIV. Despite progress in reducing perinatal HIV transmission, there is a growing number of adolescents and emerging adults with HIV who will require transfer of care from pediatric to adult providers. Adolescents with HIV have poorer retention in care and viral suppression compared to other age groups with HIV. Barriers to successful care of youth with HIV include mental health disorders, poor medication adherence, socioeconomic instability, and HIV-related stigma. Transfer of care to adult providers is often met with reluctance on the part of the adolescent. Recommendations for effective transfer of care include clear communication between adult and pediatric providers, early initiation of a transition planning discussion, a multidisciplinary team approach, and meeting the adult provider prior to the transfer of care. Adult HIV care may be more fragmented than adolescents are familiar with, but thoughtful transition approaches can foster development of health and life skills among youth with HIV. [Pediatr Ann. 2017;46(5):e198-e202.].

Transitioning HIV-Positive Adolescents to Adult Care: Lessons Learned From Twelve Adolescent Medicine Clinics

To maximize positive health outcomes for youth with HIV as they transition from youth to adult care, clinical staff need strategies and protocols to help youth maintain clinic engagement and medication adherence. Accordingly, this paper describe transition processes across twelve clinics within the Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN) to provide lessons learned and inform the development of transition protocols to improve health outcomes as youth shift from adolescent to adult HIV care.

DESIGN AND METHODS

During a large multi-method Care Initiative program evaluation, three annual visits were completed at each site from 2010-2012 and conducted 174 semi-structured interviews with clinical and program staff (baseline n=64, year 1 n=56, year 2=54).

RESULTS

The results underscore the value of adhering to recent American Academy of Pediatrics (AAP) transition recommendations, including: developing formal transition protocols, preparing youth for transition, facilitating youth's connection to the adult clinic, and identifying necessary strategies for transition evaluation.

CONCLUSIONS

Transitioning youth with HIV involves targeting individual-, provider-, and system-level factors. Acknowledging and addressing key barriers is essential for developing streamlined, comprehensive, and context-specific transition protocols.

PRACTICE IMPLICATIONS

Adolescent and adult clinic involvement in transition is essential to reduce service fragmentation, provide coordinated and continuous care, and support individual and community level health.

Virological and Social Outcomes of HIV-Infected Adolescents and Young Adults in The Netherlands Before and After Transition to Adult Care

BACKGROUND

As a result of effective combination antiretroviral therapy (cART) and advanced supportive healthcare, a growing number of human immunodeficiency virus (HIV)-infected children survive into adulthood. The period of transition to adult care is often associated with impaired adherence to treatment and discontinuity of care. We aimed to evaluate virological and social outcomes of HIV-infected adolescents and young adults (AYAs) before and after transition, and explore which factors are associated with virological failure.

METHODS

We included 59 HIV-infected AYAs from the Netherlands who had entered into pediatric care and transitioned from pediatric to adult healthcare. We used HIV RNA load and cART data from the Dutch Stichting HIV Monitoring database (1996-2014), and collected social and treatment data from patients' medical records from all Dutch pediatric HIV treatment centers and 14 Dutch adult treatment centers involved. We evaluated risk factors for virological failure (VF) in a logistic regression model adjusted for repeated measurements.

RESULTS

HIV VF occurred frequently during the study period (14%-36%). During the transition period (from 18 to 19 years of age) there was a significant increase in VF compared with the reference group of children aged 12-13 years (odds ratio, 4.26 [95% confidence interval, 1.12-16.28]; P = .03). Characteristics significantly associated with VF were low educational attainment and lack of autonomy regarding medication adherence at transition.

CONCLUSIONS

HIV-infected AYAs are vulnerable to VF, especially during the transition period. Identification of HIV-infected adolescents at high risk for VF might help to improve treatment success in this group.

Adolescent HIV viral load in an urban hospital in Newark, New Jersey

Background and objectives

Human immunodeficiency virus (HIV) in adolescents is a growing concern. Amid psychosocial challenges, adolescents must successfully transition into adult-centered care; however, little is known about outcome measurements within this period. We assessed the trend in adolescent HIV viral loads (VLs) in a community with a high HIV prevalence, allowing physicians to better recognize the challenges of transitioning adolescents with HIV to adult care.

Patients and methods

All HIV RNA VLs from the Molecular Virology Lab at University Hospital in Newark, New Jersey, from 2007 to 2010 were obtained. Patients were divided into pediatric (<13 years of age), adolescent (13-25 years of age), and adult (>25 years of age) age groups. Univariate and multivariate analyses assessed characteristics of patients by age and gender.

Results

A minimum of 40 pediatric, 178 adolescent, and 1335 adult patients were identified per year. There was a statistically significant increase in VLs of adolescents when compared to pediatric patients (P < .02). In 3 of the 4 years, there was a statistically significant increase in the rate of male adolescents reaching undetectable VLs compared to female adolescents. The average VL by age demonstrated increasing VLs from age 12 through age 24, while the percentage of patients reaching undetectable VLs peaked at 80% at age 8 and declined through age 24.

Conclusion

Successful transitional care programs should focus on pediatric needs to address the noticeable decrease in virologic control beginning at 8 years of age and the decreased rate of virologic suppression in females, creating concern for potential gender inequalities and increased risk of vertical transmission.

Adolescents growing with HIV/AIDS: experiences of the transition from pediatrics to adult care

The main objective of this work is to describe the formation of the Transition Adolescent Clinic (TAC) and understand the process of transitioning adolescents with HIV/AIDS from pediatric to adult care, from the vantage point of individuals subjected to this process. A qualitative method and an intentional sample selected by criteria were adopted for this investigation, which was conducted in São Paulo, Brazil. An in-depth semi-structured interview was conducted with sixteen HIV-infected adolescents who had been part of a transitioning protocol. Adolescents expressed the need for more time to become adapted in the transition process. Having grown up under the care of a team of health care providers made many participants have reluctance toward transitioning. Concerns in moving away from their pediatricians and feelings of disruption, abandonment, or rejection were mentioned. Participants also expressed confidence in the pediatric team. At the same time they showed interest in the new team and expected to have close relationships with them. They also ask to have previous contacts with the adult health care team before the transition. Their talks suggest that they require slightly more time, not the time measured in days or months, but the time measured by constitutive experiences capable of building an expectation of future. This study examines the way in which the adolescents feel, and help to transform the health care transition model used at a public university. Listening to the adolescents’ voices is crucial to a better understanding of their needs. They are those who can help the professionals reaching alternatives for a smooth and successful health care transition.

Congruence of Transition Perspectives Between Adolescents With Perinatally-Acquired HIV and Their Guardians: An Exploratory Qualitative Study

Youth with perinatally-acquired HIV infection (PHIV) routinely survive into adulthood requiring transition to adult care. Research underscores the importance of assessing transition perspective congruence between adolescents and guardians. Interviews focused on transition decisions were conducted with 18 adolescents with PHIV and their guardians recruited from a southeastern US pediatric infectious disease clinic. Transcribed responses were coded as congruent or divergent. Adolescents and guardians held congruent views that the transition process had not started. Fewer dyads agreed upon the level of adolescent and guardian involvement in transition decisions. Providers should assess congruence of adolescent and guardian perspectives regarding transition-related decisions.

Transitioning Adolescents and Young Adults With HIV Infection to Adult Care: Pilot Testing the "Movin' Out" Transitioning Protocol

BACKGROUND

Advances in care and treatment of adolescents/young adults with HIV infection have made survival into adulthood possible, requiring transition to adult care. Researchers have documented that the transition process is challenging for adolescents/young adults. To ensure successful transition, a formal transition protocol is needed. Despite existing research, little quantitative evaluation of the transition process has been conducted.

PURPOSE

The purpose of the study was to pilot test the "Movin' Out" Transitioning Protocol, a formalized protocol developed to assist transition to adult care.

METHOD

A retrospective medical/nursing record review was conducted with 38 clients enrolled in the "Movin' Out" Transitioning Protocol at a university-based adolescent medicine clinic providing care to adolescents/young adults with HIV infection.

RESULTS

Almost half of the participants were able to successfully transition to adult care. Reasons for failure to transition included relocation, attrition, lost to follow-up, and transfer to another adult service. Failure to transition to adult care was not related to adherence issues, X(2) (1, N=38)=2.49, p=.288; substance use, X(2) (1, N=38)=1.71, p=.474; mental health issues, X(2) (1, N=38)=2.23, p=.322; or pregnancy/childrearing, X(2) (1, N=38)=0.00, p=.627).

CONCLUSIONS

Despite the small sample size, the "Movin' Out" Transitioning Protocol appears to be useful in guiding the transition process of adolescents/young adults with HIV infection to adult care. More research is needed with a larger sample to fully evaluate the "Movin' Out" Transitioning Protocol.

Transition of youth living with HIV from pediatric to adult-oriented healthcare: a review of the literature

Due to advances in antiretroviral therapy, most HIV-infected children and youth now survive into adulthood. Many experts and professional societies have expressed concern about potential disruptions to care when youth living with HIV transition from pediatric to adult-oriented medical care. However, original research focused on this transition process is rare. The existing literature can be organized into the following categories: pre-transition assessments of anticipated barriers and concerns; studies describing provider practices during the transition period; and post-transition retrospective analyses after transition to adult care. Most studies had small sample sizes and focused on vertically infected youth. Further work is needed to document clinical outcomes after transition and to evaluate transition protocols that are in place at some institutions.

Common sexually transmitted infections in adolescents

Adolescents are often at higher risk for acquiring sexually transmitted infections (STIs). Medical providers should be alert for both asymptomatic and symptomatic STIs, and follow appropriate screening guidelines. Moreover, providers need to know how to best administer adolescent-friendly confidential care, treatment, and health education in the primary care setting. This article addresses the most common adolescent STIs and pertinent recommendations for screening, diagnosis, and management of infections, in addition to a brief focused discussion on human immunodeficiency virus and adolescents.

Integration versus disintegration: a grounded theory study of adolescent and young adult development in the context of perinatally-acquired HIV infection

Adolescents/young adults with perinatally-acquired HIV infection experience a number of issues that impact developmental tasks. No study to date has described the process by which this occurs. The purpose of this grounded theory study was to describe the process by which HIV infection impacts adolescent/young adult development. Interviews were conducted and analyzed with 25 participants age 18 to 24. Six core categories emerged that were used to generate a theory, integration versus disintegration, that describes how perinatal HIV impacts participants' development. The results of this study provide unique clinical considerations for pediatric and adult clinicians providing care for this population.

Bridging worlds, breaking rules: Clinician perspectives on transitioning young people with perinatally acquired HIV into adult care in a low prevalence setting

The first generation of young people with perinatally acquired HIV is moving into adulthood, precipitating a transition from pediatric to adult care. As the first research appraisal of Australian clinician perspectives on this process, this article makes a unique contribution by examining the particular challenges associated with transitioning this population into adult care in regions of low HIV prevalence among young people. Qualitative interviews were conducted with twelve pediatric and adult care clinicians and analyzed for dominant and diverging themes. Clinicians anticipated significant client vulnerabilities during transition and worked beyond the boundaries of their roles and service parameters to keep clients engaged as they moved between pediatric and adult care. Strategies to strengthen the transition process focused on communication and teamwork, informed by and responsive to the needs of individual young people and their families. Clinicians working in settings with very small numbers of young people with HIV must advocate for a hidden minority with little potential for gaining large scale recognition or system changes. New conversations are needed to design a stronger and more sustainable transition process for both young people living with HIV, and their clinicians who care for them, in low prevalence settings.

From transmission to transition: lessons learnt from the Thai paediatric antiretroviral programme

Background

The Thai HIV programme is a leader in the public health approach to HIV treatment. Starting at transmission of HIV and ending with transition to adult services this paper assesses the paediatric HIV treatment continuum from three perspectives: service-user, provider and policy maker, to understand what works well and why.

Methods

A qualitative research design was used to assess and triangulate the stakeholder perspectives. Semi-structured interviews were conducted with ART service-users (n = 35), policy actors (n = 20); telephone interviews with prior caregivers of orphans (n = 10); and three focus group discussions with service-providers (hospital staff and volunteers) from a district, provincial and a university hospital.

Findings

Children accessing HIV care were often orphaned, cared for by elderly relatives and experiencing multiple vulnerabilities. Services were divided into three stages, 1. Diagnosis and linkage: Despite strong policies there were supply and demand-side gaps in the prevention of mother-to-child transmission ‘cascade’ preventing early diagnosis and/or treatment. 2. Maintenance on ART - Children did well on treatment; caregivers took adherence seriously and valued the quality of services. Drug resistance, adherence and psychosocial issues were important concerns from all perspectives. 3. Adolescents and transition: Adolescent service-users faced greater complexity in their physical and emotional lives for which providers lacked skills; transition from the security of paediatric clinic was a daunting prospect. Dedicated healthcare providers felt they struggled to deliver services that met service-users' diverse needs at all stages. Child- and adolescent-specific elements of HIV policy were considered low priority.

Conclusions

Using the notion of the continuum of care a number of strengths and weaknesses were identified. Features of paediatric services need to evolve alongside the changing needs of service users. Peer-support volunteers have potential to add continuity and support at all stages. It is critical that adolescents receive targeted support, particularly during transition to adult services.

Perinatally acquired HIV infection: long-term neuropsychological consequences and challenges ahead

Over the past three decades, perinatal HIV infection in the United States has evolved from a fatal disease to a manageable chronic illness. As the majority of youth with perinatal HIV infection age into adolescence and adulthood, management of this stigmatizing, transmittable disease in the backdrop of a cadre of environmental stressors presents challenges beyond those of other chronic illnesses. The neurologic and neuropsychological consequences of this neurotropic virus have important implications for the successful navigation of responsibilities related to increasingly independent living of this aging population. This article will review the neurologic and neuropsychological consequences of perinatal HIV infection and concomitant factors in the era of highly active antiretroviral therapy and will provide an overview of the neuropathology, pathogenesis, neuroimaging findings, and treatment of perinatal HIV infection, as well as recommendations for service provision and future research.

Primary care guidelines for the management of persons infected with HIV: 2013 update by the HIV medicine association of the Infectious Diseases Society of America

Evidence-based guidelines for the management of persons infected with human immunodeficiency virus (HIV) were prepared by an expert panel of the HIV Medicine Association of the Infectious Diseases Society of America. These updated guidelines replace those published in 2009. The guidelines are intended for use by healthcare providers who care for HIV-infected patients. Since 2009, new antiretroviral drugs and classes have become available, and the prognosis of persons with HIV infection continues to improve. However, with fewer complications and increased survival, HIV-infected persons are increasingly developing common health problems that also affect the general population. Some of these conditions may be related to HIV infection itself or its treatment. HIV-infected persons should be managed and monitored for all relevant age- and sex-specific health problems. New information based on publications from the period 2009-2013 has been incorporated into this document.

Development of a young persons’ HIV clinic in a District General Hospital: a case note review resulting in informed change

In recognition of the increasing number of HIV-infected young people attending the HIV department at a district general hospital, a case note review was conducted. There was a high prevalence of psychosocial problems and medical complexity among this cohort. As a result, tailored young persons’ services were developed. Effective utilisation of the existing skill-mix and resources were key to success.

Transitioning HIV-infected youth into adult health care

With advances in antiretroviral therapy, most HIV-infected children survive into adulthood. Optimal health care for these youth includes a formal plan for the transition of care from primary and/or subspecialty pediatric/adolescent/family medicine health care providers (medical home) to adult health care provider(s). Successful transition involves the early engagement and participation of the youth and his or her family with the pediatric medical home and adult health care teams in developing a formal plan. Referring providers should have a written policy for the transfer of HIV-infected youth to adult care, which will guide in the development of an individualized plan for each youth. The plan should be introduced to the youth in early adolescence and modified as the youth approaches transition. Assessment of developmental milestones is important to define the readiness of the youth in assuming responsibility for his or her own care before initiating the transfer. Communication among all providers is essential and should include both personal contact and a written medical summary. Progress toward the transition should be tracked and,once completed, should be documented and assessed.

Systematic review of transition from adolescent to adult care in patients with sickle cell disease

Awareness and practice of appropriate treatment for childhood sickle cell disease (SCD) has improved, and survival rates have increased significantly. Today, most patients will eventually require treatment in the adult-care setting. Adolescents who are transferred out from successful pediatric programs face numerous challenges regarding continuity of care, and mortality rates remain high in this age group. Here, we describe a systematic literature review conducted to examine the barriers to and approaches for successful transition of patients with SCD from adolescent to adult care. Articles were primarily located through the US National Library of Medicine (Pubmed.gov) and were omitted if their principal focus was not SCD transition treatment. A secondary search of 5 additional sources was conducted regarding relevant guidelines or meta-analyses. Current publications describe barriers to continuity of care in this group, proposals for improving the transition process, and contemporary models for SCD care transition. Clinical recommendations include development of a flexible, patient-centric transition plan and education for health care providers.

A new tool for the paediatric HIV research: general data from the Cohort of the Spanish Paediatric HIV Network (CoRISpe)

There are approximately from 1,100 to 1,200 HIV-infected children in a follow-up in Spain. In 2008 an open, multicentral, retrospective and prospective Cohort of the Spanish Paediatric HIV Network (CoRISpe) was founded. The CoRISpe is divided into the node 1 and node 2 representing geographically almost the whole territory of Spain. Since 2008 seventy-five hospitals have been participating in the CoRISpe. All the retrospective data of the HIV-infected children have been kept in the CoRISpe since 1995 and prospective data since 2008. In this article we are going to present the notion of CoRISpe, its role, the structure, how the CoRISpe works and the process how a child is transferred from Paediatric to Adults Units. The main objective of the CoRISpe is to contribute to furthering scientific knowledge on paediatric HIV infection by providing demographic, sociopsychological, clinical and laboratory data from HIV-infected paediatric patients. Its aim is to enable high-quality research studies on HIV-infected children.

Antiretroviral therapy outcomes among adolescents and youth in rural Zimbabwe

Around 2 million adolescents and 3 million youth are estimated to be living with HIV worldwide. Antiretroviral outcomes for this group appear to be worse compared to adults. We report antiretroviral therapy outcomes from a rural setting in Zimbabwe among patients aged 10-30 years who were initiated on ART between 2005 and 2008. The cohort was stratified into four age groups: 10-15 (young adolescents) 15.1-19 years (adolescents), 19.1-24 years (young adults) and 24.1-29.9 years (older adults). Survival analysis was used to estimate rates of deaths and loss to follow-up stratified by age group. Endpoints were time from ART initiation to death or loss to follow-up. Follow-up of patients on continuous therapy was censored at date of transfer, or study end (31 December 2008). Sex-adjusted Cox proportional hazards models were used to estimate hazard ratios for different age groups. 898 patients were included in the analysis; median duration on ART was 468 days. The risk of death were highest in adults compared to young adolescents (aHR 2.25, 95%CI 1.17-4.35). Young adults and adolescents had a 2-3 times higher risk of loss to follow-up compared to young adolescents. When estimating the risk of attrition combining loss to follow-up and death, young adults had the highest risk (aHR 2.70, 95%CI 1.62-4.52). This study highlights the need for adapted adherence support and service delivery models for both adolescents and young adults.

The transition of adolescents with chronic respiratory illness to adult care

Medical transition aims to safely steer children with chronic illness through adolescence and into adulthood, whilst maintaining optimal management of their underlying medical condition. It is an evolving process with ongoing research and development. Though it has not been proven to prolong life, evidence points to an improved quality of life via greater understanding and management of lifelong illness. The presumption is this will ultimately prevent or delay untimely loss of life and/or complications in those who have been stable throughout childhood. In this article we review the problems associated with adolescence, the current drive towards successful transition and the role of the adult physician in achieving this.

Working together as a team: adolescent transplant recipients and nurse practitioners

Nurse practitioners are a critical part of the transplant team, enhancing the quality of patient care with their knowledge and skill with respect to disease-specific populations of patients. Adolescent transplant recipients are a vulnerable population and require specific considerations. Nurse practitioners can successfully tailor care to the adolescent developmental stages in order to promote quality of life, adherence to the medical regimen, and successful transition to adult transplant centers and to minimize risk-taking behaviors. Teamwork between the patient's family and the entire transplant team is important to optimize not only the patient's health but also to ensure quality of life after transplant. Adolescents can be especially challenging after transplant, given their complex and evolving psychosocial and cognitive development. Nurse practitioners are in a unique position to be central in adolescents' successful adaptation to their medical condition. Facilitating identification and management of medication-related side effects, awareness of emotional health and quality of life, adherence to the medical regimen, and eventual transition to adult caregivers all remain critically important steps in care that are ideally suited for advance practice leadership.

"It's like losing a part of my family": transition expectations of adolescents living with perinatally acquired HIV and their guardians

The increased life expectancy of perinatally HIV-infected adolescents necessitates the transition from pediatric to adult infectious disease care. Significant differences exist between pediatric and adult HIV clinic models, and adequate preparation is critical for successful transition. The expectations of youth on the cusp of this transition and their guardians have not previously been explored. Semistructured interviews were conducted with 40 perinatally infected adolescents (mean age, 17.3 years; 90% African American; 57.5% female; 57.5% in high school) currently receiving care in a pediatric infectious disease clinic in the southeast United States and 17 guardians about their expectations related to the pending transition to adult care. Interviews were transcribed and coded for emergent themes. Many adolescents had difficulty articulating expectations of their transition to an adult clinic, reporting they did not know what to expect. Others looked forward to increased responsibility and control, while some expressed concerns over leaving their current providers and having to establish new relationships. Most guardians viewed the transition to adult care as a tool to facilitate maturity. Several indicated they had not discussed transition with their child and were waiting for their child to initiate a conversation about it. Given the importance providers place on preparing youth for transition, it is surprising that many adolescents had no expectations about this impending change. This indicates a need for improved communication between providers and adolescents to enhance preparation and ultimately transition success. Additionally, guardians play an important role in the transition process and may need support to discuss this process with their child.

Working Together as a Team: Adolescent Transplant Recipients and Nurse Practitioners

Nurse practitioners are a critical part of the transplant team, enhancing the quality of patient care with their knowledge and skill with respect to disease-specific populations of patients. Adolescent transplant recipients are a vulnerable population and require specific considerations. Nurse practitioners can successfully tailor care to the adolescent developmental stages in order to promote quality of life, adherence to the medical regimen, and successful transition to adult transplant centers and to minimize risk-taking behaviors. Teamwork between the patient's family and the entire transplant team is important to optimize not only the patient's health but also to ensure quality of life after transplant. Adolescents can be especially challenging after transplant, given their complex and evolving psychosocial and cognitive development. Nurse practitioners are in a unique position to be central in adolescents' successful adaptation to their medical condition. Facilitating identification and management of medication-related side effects, awareness of emotional health and quality of life, adherence to the medical regimen, and eventual transition to adult caregivers all remain critically important steps in care that are ideally suited for advance practice leadership.

Health care transition for youth living with HIV/AIDS

There are ~1 million people in the United States living with HIV/AIDS, and >50,000 new infections occur each year. With an estimated 13% of all new infections occurring among young people aged 13 to 24 years and an increasing number of perinatally infected youth surviving to adulthood, there is now an increasing need to transition both perinatally and behaviorally infected youth to the adult health care setting. Recently, pediatric providers and professional societies have prioritized the development of transition programs for adolescents with chronic disease to address the many challenges these youth face in the process. Although multiple position papers have called for continuous, coordinated, culturally appropriate, compassionate, family-centered transition programs for youth with special health care needs and have recognized the need for evidence-based models, few data exist on what strategies are most effective. To date, published data on health care transition for HIV-positive youth are limited and include only 2 studies, which considered behaviorally infected youth. In this state-of-the-art review, we discuss the unique transition challenges to consider for this population, including socioeconomic and health insurance status, the special role of the pediatric or adolescent provider as family, stigma and disclosure issues, cognitive development and mental health issues, medication adherence, and sexual, reproductive, and gender health concerns. Future research will need to include the experiences of transition in low-resource settings and examine clinical outcomes and factors that may predict success or failure of the transition process.

Transition of adolescents with HIV to adult care: characteristics and current practices of the adolescent trials network for HIV/AIDS interventions

The transition process from pediatric to adult health care for adolescents with chronic diseases is always challenging and can be even more so for adolescents with HIV disease. The purpose of this study was to describe characteristics and current practices surrounding the transition of adolescents from the clinics of the Adolescent Trials Network for HIV/AIDS Interventions to adult medical care. This report focuses on the processes of transition, perceived barriers and facilitators, and anecdotal reports of successes and failures. Practice models used to assist adolescents during transition to adult medical care are described. Interviews were conducted with 19 key informants from 14 Adolescent Trials Network clinics. Findings revealed no consistent definition of "successful" transition, little consensus among the sites regarding specific elements of a transition program, and a lack of mechanisms to assess outcomes. Sites that viewed transition as a process rather than an event consistently described more structured program elements.