ARTICLE
Development of a Protocol
for Transitioning
Adolescents With HIV
Infection to Adult Care
Donna Maturo, MSN, ARNP, Alexis Powell, MD,
Hanna Major-Wilson, MSN, ARNP, Kenia Sanchez, MSW,
Joseph P. De Santis, PhD, ARNP, ACRN, & Lawrence B. Friedman, MD
Donna Maturo, Advanced Registered Nurse Practitioner,
University of Miami Miller School of Medicine, Department of
Pediatrics, Division of Adolescent Medicine, Miami, FL.
Alexis Powell, Assistant Professor of Clinical Medicine, University
of Miami Miller School of Medicine, Miami, FL.
Hanna Major-Wilson, Advanced Registered Nurse Practitioner,
University of Miami Miller School of Medicine, Department of
Pediatrics, Division of Adolescent Medicine, Miami, FL.
Kenia Sanchez, Manager Research Support, University of Miami
Miller School of Medicine, Department of Pediatrics, Division of
Adolescent Medicine, Miami, FL.
Joseph P. De Santis, Assistant Professor, University of Miami
School of Nursing & Health Studies, Coral Gables, FL.
Lawrence B. Friedman, Professor of Clinical Pediatrics and
Director of the Division of Adlescent Medicine, University of Miami
Miller School of Medicine, Department of Pediatrics, Division of
Adolescent Medicine, Miami, FL.
The Special Adolescent Clinic is a component of the Miami Family
Care Program at the University of Miami and is supported in part
by funds from Ryan White CARE Act Part D (formerly Title IV),
Grant #H12-HA00028 (Gwendolyn B. Scott, MD, PI).
Conflicts of interest: None to report.
Correspondence: Donna Maturo, MSN, ARNP, University of Miami
Miller School of Medicine, Department of Pediatrics, Division of
Adolescent Medicine, PO Box 016820 (D-820), Miami, FL 33101;
e-mail: Dmaturo@med.miami.edu.
0891-5245/$36.00
Copyright Q 2011 by the National Association of Pediatric
Nurse Practitioners. Published by Elsevier Inc. All rights
reserved.
doi:10.1016/j.pedhc.2009.12.005
16 Volume 25  Number 1
ABSTRACT
As HIV infection in childhood and adolescence has evolved
from a terminal to a chronic illness, new challenges are posed
for both medical and psychosocial teams serving these clients.
Although specialized programs for transition to adult care
have been reported for persons with cystic fibrosis, diabetes
mellitus, sickle cell disease, and other chronic illnesses, there
are few published reports of integral programs designed to
transition adolescents who were infected with HIV during
the adolescent period to adult HIV services. This article
describes a model of transition from a University-based,
federally funded adolescent HIV program to adult HIV ser-
vices, addresses barriers to transition, and provides strategies
and recommendations for improving adherence to the
transition process. J Pediatr Health Care. (2011) 25, 16-23.
KEY WORDS
Adolescents, clinical protocols, health transition, HIV
Adolescence is defined as the period between child-
hood and adulthood. Traditionally, the adolescent pe-
riod included years 13 through 19. Changing views of
this developmental period have extended the adoles-
cent or youth period to age 24 years (Centers for Dis-
ease Control and Prevention [CDC], 2008a).
Adolescence is a period of physical, psychosocial,
emotional, and cognitive growth. The diagnosis of
a chronic illness such as HIV infection during this devel-
opmental stage may have an impact on adolescent
growth and development. In addition to managing HIV
infection, the chronically ill adolescent is expected to tran-
sition to adult care services at a prescribed point. This
Journal of Pediatric Health Care
transition to adult services often is a difficult adjustment
for adolescents with HIV infection because they must
leave child/adolescent-oriented services to enter a world
of adult care that may be intimidating and depersonal-
ized. Because this transition to adult care can be difficult
and often intimidating for the chronically ill adolescent,
non-adherence to prescribed medical appointments
and treatment regimens often occurs (Cervia, 2007).
Transition to adult care is expected in healthy adoles-
cents as well as in those with chronic illnesses.
A position paper of The Society for Adolescent Medicine
(1993) defines transition as the purposeful, planned
movement of adolescents and young adults with
chronic medical conditions from a child-centered to an
adult-oriented health care system. A wealth of informa-
tion in the literature describes the transition process to
adult health care, but the majority of the transition pro-
grams exist for persons with chronic conditions such
as cystic fibrosis, spina bifida, epilepsy, and diabetes
mellitus (Betz, 2004; Brumfield & Lansberry, 2004; Freed
& Hudson, 2006; Lewis-Carey, 2001; Por et al., 2004).
Studies on transition to adult care for adolescents
with HIV infection are less developed than are those
for adolescents with other chronic illnesses. This phe-
nomenon may be related to the fact that chance of sur-
vival into adolescence for children infected with HIV
perinatally has increased because of developments in
antiretroviral therapy (Gortmaker et al., 2001). Previ-
ously these children did not survive until adolescence;
therefore, the need to help them transition to adult care
was non-existent.
Literature on transitioning adolescents with HIV infec-
tion to adult care focuses exclusively on perinatally
infected adolescents (Miles, Edwards, & Clapson, 2004;
Thorne et al., 2002; Vijayan, Benin, Wagner, Romano,
& Andiman, 2009; Wiener, Battles, Ryder, & Zobel,
2007) because more than 90% of children younger than
13 years of age were infected with HIV via the perinatal
route (also referred to as vertical or mother-to-child
transmission) (CDC, 2007). An identified gap in the liter-
ature is that no studies to date have examined the unique
transitioning needs of adolescents who were infected
with HIV during the adolescent period. The purpose of
this article is to address this gap in the literature by de-
scribing the development and implementation of a tran-
sitioning protocol for adolescents who were infected
with HIV during adolescence in a University-based, mul-
tidisciplinary, family-centered adolescent clinic.
ADOLESCENT HIV/AIDS
Adolescents are at an increased risk for HIV infection.
Since 1981, nearly 40,000 adolescents have been diag-
nosed with HIV/AIDS in the United States. Approxi-
mately 5000 adolescents are diagnosed with HIV/
AIDS annually. This age group accounts for 13% of
the 56,000 new diagnoses of HIV in the United States
(CDC, 2009).
www.jpedhc.org
Adolescents with HIV infection can be divided into
two major categories: those who acquire HIV perina-
tally or vertically from HIV-infected mothers, and those
who acquire HIV infection via high-risk behaviors such
as unprotected sex or injection drug use. Adolescents
who acquire HIV via high-risk behaviors are called
‘‘behaviorally infected adolescents’’ (National Institute
of Allergy and Infectious Diseases, 2006). With the
advances in treatment of HIV infection, children who
acquired HIV perinatally are surviving to adulthood
and comprise the largest number of adolescents living
with HIV infection in the United States (CDC, 2007).
However, more adolescents are becoming infected
via high-risk behaviors each year (CDC, 2009).
Much like HIV infection among adults, the majority of
adolescents with behaviorally acquired HIV acquire the
infection through sexual contact (88%), are male (62%),
and are African American (55%). Only about 3% of men
and 11% of women contract HIV via injection drug use
(CDC, 2009).
As mentioned previously, the majority of adolescents
acquire HIV via sexual contact. Among male adoles-
cents, the transmission category of male-to-male sexual
contact accounts for 87% of the cases in those aged 13 to
19 years and 83% of the cases in those aged 20 to 24
years. Among female adolescents, high-risk heterosex-
ual contact accounts for 88% of the cases in those aged
13 to 19 years and 87% of the cases in those aged 20 to 24
years (CDC, 2009).
Adolescents who were behaviorally infected with
HIV face unique challenges once they are diagnosed.
These adolescents may take several months to accept
the diagnosis and return for treatment (National
Institute of Allergy and Infectious Diseases, 2006).
This phenomenon often is related to the fact that these
adolescents have difficulty accepting their diagnosis,
may lack adequate support, and may engage in other
high-risk behaviors such as alcohol and drug usage.
The same behaviors, attitudes, and fractured social
support systems that rendered these adolescents at
high risk for HIV infection also contribute to poor
adherence with medical appointments and treatment
(Cervia, 2007).
HIV-infected adolescents engaging in high-risk
behaviors such as experimentation with sex, drugs,
and alcohol can have a myriad of psychological,
socioeconomic, developmental, and medical needs
(Kadivar, Garvie, Sinnock, Heston, & Flynn, 2006). As
a chronic illness, HIV is unique because of HIV-related
stigma, the relationship to poverty, the fact that multiple
members of the same family may be living with or have
died from HIV infection, and the disproportionate num-
ber of ethnic minorities who are affected by the disease
(Cervia, 2007). Given these factors, it is clear that HIV in-
fection is vastly different from other chronic illnesses.
These adolescents, therefore, need special attention
in terms of transitioning to adult care.
January/February 2011 17
HIV RISK FACTORS FOR INFECTION AMONG
ADOLESCENTS
Various factors that contribute to the increased risk of
acquisition of HIV infection in the adolescent popula-
tion have been identified. These risk factors include de-
velopmental influences, sexual risk factors, substance
abuse, lack of knowledge, and poverty (CDC, 2008a).
Developmentally the adolescent period is a time for
identity development. Adolescents strive for autonomy
and separation from the family and attachment to a peer
group. The autonomy and separation lead to explora-
tion that may result in exposure to certain high-risk
behaviors such as sexual activity and substance use
(Rice & Dolgin, 2007).
High-risk or unprotected sexual behaviors are respon-
sible for the majority of HIV infections (CDC, 2008b).
Data from the Youth Risk Behavior Survey conducted
by the CDC (2008b) has noted that about 8% of adoles-
cents reported a sexual debut before the age of 13 years,
and nearly 50% have been sexually active by the high
school years. Of the adolescents who engaged in sexual
activity, only 62% had used condoms during their last sex-
ual encounter. In addition, roughly half of the students
surveyed had used alcohol in the past 30 days and 38%
had used marijuana (CDC, 2008b). This documented
combination of high-risk sexual behavior and substance
abuse may be responsible for fueling the HIV epidemic
among adolescents and young adults in the United States,
where increasing numbers of new infections are
occurring among those younger than 25 years (National
Institute of Allergy and Infectious Diseases, 2006).
Although both male and female adolescents are at risk
for HIV related to high-risk sexual behaviors, female ad-
olescents often engage in sexual relationships with older
male partners who are more likely to be infected with
HIV. Female adolescents may not be able to negotiate
condom use with these older partners. Male adolescents
who engage in same-sex sexual activity are at the highest
risk for HIV infection, especially if engaging in unpro-
tected anal intercourse, the sexual behavior that carries
the highest risk for HIV infection. Both male and female
adolescents are at an increased risk for HIV infection if
a sexually transmitted infection is present that provides
a portal of entry for HIV (Fleming & Wasserheit, 1999).
Substance abuse behaviors contribute to HIV trans-
mission both directly and indirectly. Injection drug
use provides a direct portal of entry for HIV (CDC,
2008a). Adolescents who engage in alcohol use and
the use of other illegal substances indirectly increase
the risk of HIV infection because the use of alcohol
and other substances is known to decrease inhibitions
and impair judgment, which could result in participa-
tion in high-risk sexual behaviors (CDC, 2008a).
Many adolescents lack accurate information regarding
HIV transmission risk factors and HIVrisk. Because of this
lack of knowledge, some adolescents may not perceive
18 Volume 25  Number 1
themselves at risk for HIV. Because of the inability to per-
ceive risk, many adolescents are not concerned about
HIV infection and may engage in high-risk sexual behav-
iors that may result in acquisition of HIV (CDC, 2008a).
The combination of poverty and ethnic minority
status results in an increased risk for HIV infection,
because ethnic minority adolescents are more likely
to live in poverty. In fact, one in four African Americans
and one in five Hispanics live in poverty (U.S. Census
Bureau, 2003). Poverty influences health risk because
it is related to a lack of knowledge; in addition, de-
creased access to health care, a lack of knowledge,
and restricted access to health care limits health promo-
tion and disease prevention initiatives (CDC, 2008a).
THE SPECIAL ADOLESCENT CLINIC
The Special Adolescent Clinic (SAC) is a part of
a University-based system that traditionally serves
low-income and underserved populations. SAC is
a component of the Division of Adolescent Medicine
in the Department of Pediatrics. In addition to the cli-
ents who receive services at the SAC, The Division of
Adolescent Medicine also provides care to adolescents
who are not infected with HIV. Adolescents who are not
infected with HIV are not seen in the SAC.
Providing this clinic specifically for HIV-infected
adolescents helps decrease one of the major barriers to
care, that is, HIV-related stigma (Cervia, 2007). Research
with people with HIV infection has noted that HIV-
related stigma stems
from multiple sources
such as family, peers,
SAC .provides
the community, and centralized services
even health care for a ‘‘one-stop
providers. HIV-re-
lated stigma contrib-
shop’’ approach,
utes to feelings of where most medical
worthlessness, self- and psychosocial
esteem, isolation, de-
pression, substance
services are
abuse, decreased rendered at one
quality of life, and de- clinic site.
creased physical and
mental health out-
comes (Holzemer et al., 2009). To address this barrier to
care, the SAC staff is committed to providing culturally
sensitive, age and developmental level appropriate,
non-judgmental care that accounts for the unique physi-
cal and psychosocial care needs of adolescents infected
with HIV.
HIV-infected adolescents are referred to SAC from
many sources such as the Florida Department of
Health, Florida Department of Children and Families,
medical clinics, in-patient hospital settings, assorted
community-based organizations, and private physicians.
Journal of Pediatric Health Care
 This team collaborates on treatment of the client’s
TABLE. Demographic profile of SAC clients
illness and presenting problems on varying levels.
(N = 104, age range 13-25 years)
The ultimate coordinating goal is to build confidence
Variable n % and trust in the professional relationship by fully involv-
Age stratification (y) ing clients in their plan of care, providing quality health
13 to 17 8 7.7 care, and assisting with clients’ decision making
18 to 24 79 76.0 throughout the duration of care.
$25 17 16.3 Because of the age of the clients, as well as their par-
Race/ethnicity
ticular demographics and family history, they often re-
Black 83 79.8
Hispanic 18 17.3 quire additional assistance to adhere to their plan of
White 2 1.9 care for HIV management. Upon enrollment, all SAC
Other 1 1.0 clients are oriented to the services offered, which in-
Gender clude medical care, individual and group therapy, edu-
Male 47 45.2
cational workshops, peer counseling, opportunities for
Female 55 52.9
Transgender 2 1.9 research participation, and the transition protocol.
Mode of transmission Throughout their enrollment at SAC, clients are in-
High risk sexual 90 86.5 formed and counseled regarding the time limitations
Perinatal 10 9.6 of services. Case presentations during clinic staff meet-
Sexual abuse 4 3.9
ings provide insight as well as updates on the status of
Injection drug use 0 0.0
Socioeconomic status a client’s readiness for transition as well as progress
Below federal poverty line 80 76.9 toward the goal of transition to adult services.
At or above federal poverty line 24 23.1 Because SAC is an adolescent HIV clinic, certain bar-
History of sexual abuse riers exist for adolescents because of the nature of HIV
Positive history of sexual abuse 35 33.7
infection. The SAC is structured to decrease barriers to
Negative history of sexual abuse 69 66.3
care for adolescent clients. Research has demonstrated
that HIV-infected adolescents experience a number of
barriers to care, including financial and psychological
Once a diagnosis of HIV infection is established, adoles- barriers (Goulart & Mandover, 1991; Valdiserri, Gerber,
cents are referred to the SAC to ensure that comprehen- Dillon & Campbell, 1995). These barriers affect adher-
sive care of the adolescent with HIV infection is ence with care appointments and ultimately adherence
provided. to antiretroviral therapy (Murphy et al., 2003). Adoles-
SAC has recognized the unique needs of this adoles- cents with HIV infection experience financial barriers
cent population and provides centralized services for because many lack health insurance and may not
a ‘‘one-stop shop’’ approach, where most medical and have knowledge of how to navigate complex public as-
psychosocial services are rendered at one clinic site. sistance programs (Valdiserri et al., 1995). Psychologi-
With this approach to delivery of clinical services, cal factors such as a lack of trust of adult health care
Rosen (1995) has found that clients and families are providers and feelings of invincibility may impede
spared repeated visits and quality of care is enhanced adherence with medical appointments and prescribed
by communication among the involved health care pro- treatment (Goulart & Mandover, 1991). To assist in ad-
fessionals. This method of accessibility is beneficial dressing these barriers, the SAC adheres to the treat-
when compared with traditional adult care settings ment recommendations of the Society for Adolescent
where adjunctive services often are provided at inde- Medicine (1994), which propose that services for ado-
pendent locations. lescents with HIV infection need to be provided in clin-
At the inception of this transition protocol in Decem- ical settings that promote comfort and trust in health
ber 2004, 102 clients were enrolled at SAC. Currently the care providers, include comprehensive medical and
SAC provides care for approximately 104 HIV-infected psychosocial care, and assist adolescents with adher-
adolescents. A more detailed demographic profile of ence issues.
the clients can be found in the Table.
Demographic data from SAC clients indicate that they DEVELOPMENT OF THE TRANSITION
require coordinated care from a multidisciplinary team. PROTOCOL
A culturally sensitive staff that demonstrates an accept- The development of this transition protocol, called
ing, non-judgmental attitude is vital to serving these ‘‘Movin’ Out,’’ was facilitated by a host of factors. First,
youth. The SAC team is interdisciplinary and includes because HIV-infected adolescents who required inpa-
two physicians (one adolescent medicine pediatrician tient services often were hospitalized on adult units,
and one adult infectious disease physician), two pediat- we had the desire to link adolescent services with adult
ric nurse practitioners, two social workers, a psycholo- services for care of HIV-infected adolescents and young
gist, a research nurse, a dietician, and a peer educator. adults. The adult providers would consult adolescent

www.jpedhc.org January/February 2011 19

 FIGURE. The ‘‘Movin’ Out’’ transitioning model. ID, Infectious disease; SAC, Special Adolescent
Clinic.
PHASE ONE
Discussions begin with PHASE TWO
identified clients, Client meets the adult ID
regarding the transition physician formally for the
process. first time at SAC.

PHASE THREE
Client has check up at
SAC, conducted by the
adult ID physician.

PHASE FOUR
Client is seen at the adult
clinic for first
appointment, by the adult
ID physician.

PHASE FIVE
One year follow-up is
conducted with client by
psychosocial team.

Note: The model displayed depicts the phases of the process for a client transitioning from SAC to an adult clinic. Arrows portray
direction of movement from one phase to the next. As evidenced by the reciprocal arrows between phases 3 and 4 and the
disconnected arrow between phases 5 and 4, one can see how clients revert from one phase to another. The arrows
emanating from phase 1 show that this is an ongoing process that involves the full support of the medical and psychosocial
teams throughout the entire process.

medicine providers to help co-manage the adolescent’s
care. Because these adolescents would transition to
adult care in the near future, it was evident that a collab-
orative approach between adolescent and adult ser-
vices was necessary.
The second factor was the need to address the attri-
tion rates of adolescents when they were transferred
to adult services. Previous attempts to transition these
HIV-infected adolescents at 21 years of age were met
with a high number of failures. Subsequently the ado-
lescent and adult HIV providers agreed that these cli-
ents would be followed up by adolescent medicine
until age 25 years. Previously a client’s chronologic
age was the sole determining variable for candidacy
into the antiquated transition protocols.
The protocol was developed by a multidisciplinary
group of health care providers at the SAC. SAC health
care providers were told by adult HIV health care
providers that newly transitioned adolescents were
not adhering to medical appointments. At the same
time, SAC health care providers were receiving anec-
dotal information from the adolescents who were tran-
sitioned to adult care regarding their experiences with
the adult care model. To address these issues, SAC
health care providers conducted a review of the litera-
ture for an evidence-based protocol to assist adoles-
cents with the transition. Upon discovering that
a protocol for this problem was non-existent, SAC
health care providers, in collaboration with a physician
from the adult HIV program, developed the transition-
ing protocol. The protocol is based on adolescent
growth and development theory, anecdotal evidence
from adolescents and adult providers, and the assump-
tion that transition to adult care requires extensive effort
and support for the transitioning adolescent. This sup-
port is necessary because adolescents are moved from

20 Volume 25  Number 1 Journal of Pediatric Health Care

a warm, nurturing, adolescent-focused setting to a chal-
lenging, often impersonal adult care site (Catallozzi &
Futterman, 2005).
After being transitioned to adult services, many
clients experienced anxiety upon detaching from the
established connections made at SAC. These clients
continued to seek
further support .early, creative, and
from the SAC team continuous
months after leaving
the clinic. Other education with the
clients were non- client regarding the
adherent with the specific processes of
adult clinic visits, be-
cause they were accessing health
forced to navigate care in general is
through the adult needed.
systems on their
own. Lastly, others
attended their clinic appointments sporadically or
failed to keep appointments altogether.
THE TRANSITIONING PROTOCOL
The transitioning protocol has five phases (Figure).
The phases described within this model are fluid in
that clients are allowed to revert to a prior phase or be-
come stagnant within a particular phase. Also, through-
out every phase of the model, the client receives
counseling from the multidisciplinary team, and his or
her progress in continuing the protocol is monitored
by the team. Although the concept of transition is intro-
duced to the client during initial orientation to the SAC
clinic, the formal transition process is initiated at age 23
years based on the patient’s chronological age, psycho-
logical hardiness, and level of maturity. The chronolog-
ical age of 23 years serves as a baseline age to begin
this process and is based on the findings of Por and
colleagues (2004), who reported that health care pro-
fessionals caring for and helping to transition adoles-
cents with chronic conditions supported this criteria
of readiness based on maturity and not on chronologi-
cal age exclusively.
In Phase One of the protocol, the SAC team begins
by identifying clients who are appropriate for transi-
tion. This step is performed on a weekly basis at the
multidisciplinary meetings. By the time the client rea-
ches age 23 years, the team begins discussing with
the client at each visit the need to transition from ado-
lescent medicine to the adult services. This topic is of-
ten met with resistance and refusal from the client.
However, each clinic encounter is a viable opportunity
for the health care team to provide the client with ed-
ucation, support, and realistic expectations for future
health care.
When the client is 24 years of age, Phase Two of the
protocol is introduced. The client meets with the adult
www.jpedhc.org
infectious diseases (ID) physician for the first time.
This planned introduction occurs at the SAC. Common
reactions expressed by clients include, ‘‘I will meet the
doctor, but I’m not leaving adolescent medicine!’’ This
statement provides evidence of the varying degrees of
acceptance among clients regarding transition. Many
clients have even attempted to falsify their age in at-
tempts to sabotage efforts by the team to continue
with the transition. The clinical social work team pro-
vides an ongoing assessment of the client’s readiness
and works together with the Department of Psychiatry
and other targeted services to ease the transition pro-
cess. A peer educator is available throughout all phases
of the transition to provide continuing support to the
client.
Phase Three of the protocol begins with the client’s
next 3-month routine medical appointment, falling
near the client’s 24th birthday. This appointment takes
place at the SAC but is conducted by the adult ID phy-
sician. The following routine visits also take place at
the adolescent clinic with the same adult physician.
These visits provide the opportunity to establish rap-
port and also help alleviate the anxiety the client may
have in leaving familiar and trusted providers to transfer
to an unfamiliar clinic and new providers. At the conclu-
sion of the final visit with the adult ID physician, the cli-
ent schedules the subsequent medical appointment to
occur in the adult HIV clinic, with the assistance of
the SAC social workers. Clients know they will see the
same physician at the adult clinic that they have been
seeing in the adolescent clinic at their last few visits,
which provides reassurance. The total number of visits
with the adult provider during this phase may vary from
client to client, depending on adherence with medical
appointments.
Prior to the scheduled appointment at the adult
clinic, the SAC team places a reminder call to the client.
At this point the SAC clinician has completed a referral
form, provided it to the adult physician, and placed
a copy in the adolescent’s medical record. On the day
of the appointment, the SAC social worker or the peer
educator accompanies the client to the adult HIV clinic.
The goal of having an SAC staff member accompany the
client facilitates the navigation of a new and often intim-
idating adult system. All future medical appointments
are scheduled through the adult clinic.
After the client has attended at least two appoint-
ments at the adult clinic, a member of the SAC team con-
tacts the client by telephone to complete a survey
evaluating the transition process. An in-depth interview
is conducted to solicit anxieties, apprehensions, and
fears that the client may have experienced. Specifically,
questions targeting their feelings about the transition
experience, their preferences, and suggestions for im-
provement are explored. All feedback is reviewed by
the adolescent and adult teams and considered for im-
proving this transition process. After this transition is
January/February 2011 21
completed, the SAC social workers continue to provide
ongoing adherence counseling and support for 1 full
year. After follow-up is complete, the client’s case is of-
ficially closed at the SAC clinic and Phase Four is com-
pleted.
Anecdotal preliminary analysis of the experiences
of the adolescents indicate that early, creative, and
continuous education with the client regarding the
specific processes of accessing health care in general
is needed. Clients also might benefit from organized
site visits to community agencies offering HIV services
to help them learn to navigate the medical and psy-
chosocial systems of established HIV care. One such
example is illustrated by a particular SAC client who
was having difficulty transitioning. The team assisted
the client with an introductory visit to interview the
new provider and view the adult clinic the client
had chosen in the community. This additional step
helped alleviate the uneasiness the client experienced
regarding transitioning, thus contributing to a success-
ful transition. Most adolescents experience anxiety
during the transition process, and first attempts at
transition often produce failures in the form of non-
adherence with medical appointments and antiretro-
viral therapy.
SAC clinic experience suggests that a transition team
comprised of physicians, nurse practitioners, nurses,
social workers, psychologists, and peer educators
who dedicate a specific time to focus on clients’ exact
transition needs is imperative to ensure a successful
transition to adult care. In order to facilitate future tran-
sitioning successes, a transitioning protocol that is rele-
vant to the clinic setting and the client population such
as the one described in this article is necessary.
Despite the development and implementation of the
protocol, certain barriers to transition continue to exist
for this patient population. Adult care providers often
lack knowledge of how to help the newly transitioned
adolescents access public assistance programs to help
them fund their health care. In addition, many public
assistance programs such as the AIDS Drug Assistance
Program have experienced funding cuts that have af-
fected their ability to assist these adolescents. Certain
psychosocial issues such as transportation, employ-
ment issues, family support, and food and housing is-
sues surface to confront these adolescents. Adult
programs often lack the financial resources to help
patients with these psychosocial issues. Health care
providers working with this subpopulation of adoles-
cents need to be aware that these barriers may affect
adherence to medical appointments as well as to
adherence to antiretroviral therapy.
TESTING THE TRANSITION PROTOCOL
Implementation of this transition protocol began in
2004. At present, 17 patients are in the process of
transitioning to adult HIV care. SAC team members
22 Volume 25  Number 1
currently are conducting a pilot study of the medical re-
cords of more than 40 clients who have completed the
transition protocol. This pilot data will be used to test
the transitioning model and to help identify
facilitators and bar-
riers to the transition Bridging the gap
process. As men- between adolescent
tioned previously,
because literature medicine and adult
on the transition ex- care is critical for
perience for adoles- maintaining
cents who are
infected with HIV continuity of care and
during adolescence increasing
is lacking and a pro- adherence with
tocol to address this
issue has not been medical
developed, the re- appointments and
sults of this pilot treatment.
study will fill an im-
portant gap in the
knowledge base of this particular population of HIV-
infected adolescents. Results of the evaluation of the
transition protocol are forthcoming.
SUMMARY
As HIV-infected adolescents and young adults live
longer and healthier lives, the need to transition into
adult care is imminent and imperative. Bridging the
gap between adolescent medicine and adult care is crit-
ical for maintaining continuity of care and increasing
adherence with medical appointments and treatment.
Transitioning from a familiar youth setting can be an
overwhelming, fearful, and anxiety-provoking experi-
ence for these adolescents. To facilitate a successful
transition from adolescent to adult care, a specific tran-
sitioning protocol is essential to help these adolescents
transition to the next phase of their lives.
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Betz, C. L. (2004). Transition of adolescents with special health care
needs: Review and analysis of the literature. Issues in Compre-
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Brumfield, K., & Lansbury, G. (2004). Experiences of adolescents
with cystic fibrosis during their transition from pediatric to adult
health care: A qualitative study of young Australian adults.
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