Background Adolescents and young adults living with HIV (AYALWH) comprise a heterogeneous population but have a common need for successful transitioning to adult care. Many institutions have formal transitioning protocols but many obstacles to successful implementation exist.
Aims The purpose of this project was to investigate, design, and implement a Transition Clinic for AYALWH with a goal of maximizing retention during the transition and addressing their comprehensive health care needs.
Methods We initially conducted a literature review to identify best practices of engaging AYALWH to care and to identify gaps in health care needs. We then conducted several site visits to learn how other institutions prepared and engaged AYALWH for transition of care. We identified 15 AYALWH (Age 17-26) in our community who were experiencing difficulties in transitions to adult care and had unmet health care needs.
Results We determined the barriers to care for AYALWH in our community are stigma, transportation, and insurance navigation. In August of 2018 we initiated the Adolescent and Young Adult Health Care Transition Clinic. The clinic is staffed by an Adolescent Physician, an HIV care physician, an Adolescent Social Worker, and an Adult Transition Nurse and is embedded within the General Adolescent Clinic. We have seen 11 clients for a total of 23 visits since inception. We have addressed contraceptive/sexual health needs, primary care needs, behavioral health, and transition preparedness by offering a multidisciplinary approach and focusing on Youth Friendly Services. Our team spends time discussing and addressing barriers to care at each visit.
Conclusions A multidisciplinary clinic can engage and improve access to health care for AYALWH. The potential benefits of this approach include reduction in stigma, improved comprehensive care, and focused time to discuss transition to adult care for youth living with a chronic ailment. We have commenced individualizing transition preparedness for each client through an IRB approved transition survey. Future directions include assessing adherence to treatment through our transition program by measuring serial viral loads during successful transition.
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