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

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w w w . e l s e v i e r . c o m / l o c a t e / b j i d

The

Brazilian

Journal

of

INFECTIOUS

DISEASES

Original

article

Adolescents

growing

with

HIV/AIDS:

experiences

of

the

transition

from

pediatrics

to

adult

care

Daisy

Maria

Machado

a,∗

_,

_Eliana

_Galano

b

_,

_Regina

_Célia

_de

_Menezes

_Succi

a

_,

Carla

Maria

Vieira

c

_,

_Egberto

_Ribeiro

_Turato

c

a_Department_of_Pediatrics,_Escola_Paulista_de_Medicina,_Universidade_Federal_de_São_Paulo_(Unifesp),_São_Paulo,_SP,_Brazil b_Escola_Paulista_de_Medicina,_Universidade_Federal_de_São_Paulo_(Unifesp),_São_Paulo,_SP,_Brazil

c_Researcher_Laboratory_of_{Clinical-Qualitative}_Research,_Department_of_Medical_Psychology_and_Psychiatry,_Faculdade_de_Ciências

Médicas,UniversidadeEstadualdeCampinas(UNICAMP),Campinas,SP,Brazil

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Articlehistory:

Received14May2015 Accepted28December2015 Availableonline2March2016

Keywords:

HIV AIDS

Healthcaretransition Adolescent

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ThemainobjectiveofthisworkistodescribetheformationoftheTransition Adoles-centClinic(TAC)andunderstandtheprocessoftransitioningadolescentswithHIV/AIDS frompediatrictoadultcare,fromthevantagepointofindividualssubjectedtothis pro-cess.Aqualitativemethodandanintentionalsampleselectedbycriteriawereadoptedfor thisinvestigation,whichwasconductedinSãoPaulo,Brazil.Anin-depthsemi-structured interviewwasconductedwithsixteenHIV-infectedadolescentswhohadbeenpartofa tran-sitioningprotocol.Adolescentsexpressedtheneedformoretimetobecomeadaptedinthe transitionprocess.Havinggrownupunderthecareofateamofhealthcareprovidersmade manyparticipantshavereluctancetowardtransitioning.Concernsinmovingawayfrom theirpediatriciansandfeelingsofdisruption,abandonment,orrejectionwerementioned. Participantsalsoexpressedconﬁdenceinthepediatricteam.Atthesametimetheyshowed interestinthenewteamandexpectedtohavecloserelationshipswiththem.Theyalsoask tohavepreviouscontactswiththeadulthealthcareteambeforethetransition.Theirtalks suggestthattheyrequireslightlymoretime,notthetimemeasuredindaysormonths, butthetimemeasuredbyconstitutiveexperiencescapableofbuildinganexpectationof future.Thisstudyexaminesthewayinwhichtheadolescentsfeel,andhelptotransform thehealthcaretransitionmodelusedatapublicuniversity.Listeningtotheadolescents’ voicesiscrucialtoabetterunderstandingoftheirneeds.Theyarethosewhocanhelpthe professionalsreachingalternativesforasmoothandsuccessfulhealthcaretransition.

∗ _{Corresponding}_author.

E-mailaddress:daisymmachado@gmail.com(D.M.Machado). http://dx.doi.org/10.1016/j.bjid.2015.12.009

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Introduction

Globally,thereisincreasedhealthcareburdenof perinatally-infectedhumanimmunodeﬁciencyvirus(HIV)-infected ado-lescentswho surviveinto adulthood.Theadvent ofhighly activeantiretroviraltherapy(HAART),alongsidevarious pro-phylacticmeasures,hasdecreasedmorbidityand mortality ratesinthis group.1 _The_majority_of_these_patients_receive theirmedicalcareinapediatricoradolescentmedicalsetting. Thetransitionintoadulthoodisacriticalstageofhuman development,duringwhichyoungindividuals leave adoles-cencebehindandtakeonnewrolesandresponsibilities.2

Althoughthesechangesprovideopportunitiesforpositive growthexperiences,theyareaccompaniedbynew vulnerabil-ities.

The World Health Organization deﬁnes adolescence between10 and 19 yearsof age,beginning atthe onset of puberty.3 _Although_the_majority _age_is ₁₈_years _in_most_of countries, reachingthis agedoes notensureacquisition of adultbehavior.

Healthcaretransition(HCT)isdeﬁnedasthepurposeful plannedmovementofadolescentsandyoungadultswith spe-cialhealthcareneedsfromchild-centeredtoadult-centered healthcare.4 Formany adolescents,this transitionis disor-ganizedandresultsinbothimpairedadherencetotreatment andlossofconsistenthealthcare.5

HIV-infectedyoungpeoplebetweenbirthand24yearsof ageareconsideredadevelopmentallydiversegroup.6 Adoles-cents withHIVmay haveexperiencedseveralpsychosocial stressorssuchasstigma,parentalillnessandloss,thatcan makeHCTanevenmorecomplexprocess.7_It_is_important_that youngpeoplecontinuetoreceiveappropriatecarethroughout andfollowingthetransitionfrompediatrictoadultservices.

Previousstudies haveshownseveralobstacles to transi-tion,including a lackofcommunication betweenpediatric andadultproviders,8_adult_services_that_are_not_equipped_to meettheneedsofadolescents,and differencesinpediatric andadulthealthcarephilosophies (i.e.,thefamily-focused approachversustheresponsibleself-carefocusedindividual). Inaddition,theadolescent’semergingneedforindependence andthefamily’sneedto‘letgo’9_are_challenges_faced_by par-ents,adolescents,andhealthcareproviders.

IthasbeengenerallyagreedthatHCTforadolescentswith chronicillnessesisaprocessthatstarts withapreparation programinthepediatricsetting,followedbyactivetransfer strategies,and ﬁnally,aperiodofconsolidationand evalu-ationintheadultsetting.4 _At_the_present _time,_there_is_no evidenceofasuperiormodelforthistransitionintermsof patientsatisfaction,costeffectiveness,ormediumand long-termoutcomes.10

Inthisarticle,wepresenttheexperiencesoftheHCTof agroupofperinatallyHIV-infectedadolescents,whosevoices weidentifyascrucialtoabetterunderstandingoftheirneeds.

Objectives

The purposes of this study were to describe the implementation of the Transition Adolescent Clinic

(TAC) and identify the needs, feelings, and experi-ences of HIV-infected adolescents included in an HCT program.

Study

setting

TheTransitionAdolescentClinic(TAC)

Since2007,theTransitionAdolescentClinic(TAC)isa com-ponentoftheDivisionofPediatricInfectiousDiseasesinthe DepartmentofPediatricsthatfollowsperinatallyHIV-infected adolescentsolderthan16yearsofage.Thisspecialclinicwas developedafter aseriesoffailures inpreviousattemptsof transitioningtheseadolescentstoanadult-centeredclinicat theageof18years.Therefore,theaimofTACwastofacilitate thetransitionofthisvulnerablepopulationfrompediatricto adultcare.TheTACteamisinterdisciplinaryandincludesﬁve physicians(fourpediatriciansand oneadultinfectious dis-easephysician),twopediatricnursepractitioners,onesocial worker, and one psychologist. Thisclinic is locatedat the samefacilityasthePediatricAIDSUnit,andwhenthe ado-lescentsreach16yearsofage,theystepintoatransitioning program. This follows a model based on the perspective that botha multidisciplinary team and a good interaction between thepediatric andadultservices areessential toa successful HCT. Upon discovering that a protocol for this issuewasnon-existentatthetime,4_the_TAC_team_developed the threestepsofatransitioning protocoldescribed asthe following:

Step 1: When adolescents reach 16 years of age, the pediatricians begin the discussions with them regarding the transition process. During this period, the readiness to transition is evaluated through speciﬁc parameters, by both a pediatrician and a psychologist4 (Table1).

Step2:Adolescentsandyouths(18yearsorolder)meetthe adultinfectiousdiseasesphysicianformallyfortheﬁrsttime attheTAC.Theybegintohaveroutineclinicappointmentsat theTAC,conductedbytheadultinfectiousdiseasephysician. Onepediatricianremainsresponsibletodiscusstheprogress ofthetransitionprocess withtheadultinfectious disease physician.

Step 3:Adolescents and youths start havingthe appoint-ments at the adultinfectious disease clinic, with two to threeextraappointmentsatthe TACduringthefollowing 12months,todetectbarrierstotransitionthatcontinueto exist.DiscussionsareundertakeninvolvingtheTACteamfor closingthetransitionprocess.

Althoughtherearesomestepsindicatedbyage,theoverall formaltransitionprocessisnotbasedonthepatient’s chrono-logicalage,butonthelevelofmaturityandpreparednessof theyoungpatient,whichcanbeassessedbyspeciﬁc parame-terspreviouslydescribed.4

This transition program is delivered at the local level, althoughit issupportedbyapolicyestablishinganational standardforcareregardingtheissue.

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Table1–Evaluationofreadinesstotransition:parametersrelatedtothehealth-diseaseprocessandtotheadolescence period.

Parametersrelatedtothehealth-diseaseprocess Parametersrelatedtotheadolescenceperiod Abilitytotakeresponsibilityfortheirowntreatment

Adequateknowledgeaboutthediseaseandtreatment Awareabouttheimportanceofadherenceto treatmentinallitsdimensions

GoodacceptanceandelaborationofHIVdiagnosis Havingdiscussedaboutdisclosuretothirdparties withthehealthcareteam

AlreadyvisitedtheHIV-infectedadultsettings Clinicallystable

Consciousbalancingtoensureexperiencingsexualityinasafemanner Demonstrationofresponsibilityandindependence

Adequatesocialsupportnetwork(reductionofriskexposure) Plansandprojectsforthefuture

Emotionalstability

Absenceofrecentlossesorsituationsofextremefragility Preparedforlife-skillsdevelopment

Methods

In-depthinterviews,usingsemi-structuredinterviewscripts, wereconductedwith16HIV-infectedadolescentsandyouths (ages 16–25 years) who were followed at the Division of Pediatric AIDS at Federal University of São Paulo, Brazil. All interviews (lasting 30–45min) were conducted between November 2010and April2011 bya single member ofthe research team and were audio-taped and transcribed. The verbatim transcripts were independently analyzed by two membersoftheresearchteam,usingcontentanalysis. Dis-crepancieswerediscussedbetweenanindependentreviewer andthe tworesearchteamanalystsuntilaconsensuswas reached.

Theresearch was approved by the Institutional Review BoardsattheFederalUniversityofSãoPaulo,Brazil.Informed consent,parentalconsent,andinformedassentwereobtained asappropriate.

Data

analysis

Thefirstphaseofdataanalysisconsistedoffree-floating read-ingsoftheinterviews,sothattheresearcherswouldbeable tofamiliarizethemselveswiththematerial.Thereviewingof transcriptswasfacilitatedthroughuseofNVivo9qualitative software(QRSInternational,2011).Foremergingconceptsand themes,the firstand secondauthors codedthe transcripts independently, using a standard definition foreach theme derived from the data. Disagreements in coding required adjustmentsuntilbothcodersagreedon all codesthrough aniterativeprocess.Interviewswereperformeduntilnonew information was being elicited from successive interviews (consideredastheoreticalsaturation).11

Results

Demographics

Thenumber ofpatients includedinthetransitionprogram rangedfrom two tofour per year, retrospectively,over the previous4years.From120HIV-infectedadolescentsbeing fol-lowedinaregularbasis,16participantswereinterviewed:six thatwereatStep1ofthetransitionprogram,sixatStep2,and

fouratStep3.Halfofparticipantswerefemale(n=8;50%)and 69%white(n=11),withamedianageof17years(Table2).

Weidentiﬁedthefollowingcategoriesofthemes,organized byphaseofexperience(i.e.,stepsinthetransitionprogram). Somethemesrepeatedlyemergedfromadolescentsat differ-entstepsofthetransitionprogram.

Turningpointsintheirlivesandhowtheyhandledchanges inlifestyle

Somedecisiveeventsintheirlifehistorywereeasilyidentiﬁed bytheadolescents,includingeventssuchaslossofrelatives, HIVdisclosure,hospitalizations,andadoption.Suchmoments mighthavehadsomeimpactonhowtheadolescentsdealt withchangesandtransformationsintheirlives,includingthe transitioninhealthcare.Theimportanceofhavingsupportof familyorfriendswasnotedtoberemarkable.

ID8:“AfterIwasadmittedforasurgeryIhadabigchange...I

begantobetteracceptmyproblem...whatIhad...myfamily...it wassoimportantandgavemesomuchsupport...I’mstillalive, ﬁghtingtolive!(Male,17years,Step1).

ID1:“...WhenIwaswithmymotherIreceivedvisits...myaunts usedtoseeme...Iwasveryhappythere...then,whenmymother died,IwenttolivewithmyfatherandIhadnomorevisits...”

(Male,20years,Step2).

Forsomeparticipants,thesemomentswereexperienced withsadness,anger,andfeelingsofabandonment.

ID6:“...aftershediednobodywantedtobemylegalguardian, andsincethattimeIwasemancipated...Istartedgettingvery rebellious...Ididnotwanttodoanything,evengotoschool...I

didnotwanttostayathomebecauseitremindedme(oftheloss oftherelative)”(Female,20years,Step3).

Twoadolescents(ID12andID13)whowereraisedbyfoster parentsreportedtheadoptioneventwithenthusiasmandjoy.

ID13: “Oh, I think it (the turning point) was when I was adopted...Iwasinthatinstitution...so,Iwasadopted,itwas good...mylifechanged,youknow?Youhaveamother...itmakes adifference!”(Male,17years,Step1).

Oneparticipant(ID5)hadaverybadexperiencewith dis-closureofhisHIVstatuswhenhewas11yearsold.Hewas byhimselfwhenhefoundout abouthisHIVseropositivity, andhefeltlonelyandbecameextremelyrebellious.Then,he becamedepressedandstoppedhistreatmentseveraltimes.

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Table2–Biopsychosocialcharacteristicsofstudypopulation.

ID Age Gender Transition Turningpointinlife Familiarcharacteristics Characteristicsofvulnerability besidesbeingHIV-positive

ID1 20 Male Step1 Mother’sdeath Fatherimprisoned;

aggressivestepmother

Abusedbyparentsortheir carers

ID2 17 Female Step2 Father’sdeath Supportiverelatives Orphanedbythedeathofboth

parents

ID3 19 Female Step2 Brother’sdeath Supportivegrandfatherbut

alsowithlimitantchronic illness

Orphanedandlivingwitha disability

ID4 20 Male Step2 HIVdisclosure Supportiverelatives Orphanedbythedeathofboth

parents

ID5 25 Male Step3 HIVdisclosure Supportivefather;mother

dead

Orphanedbythedeathofone parent

ID6 Female Step3 Aunt’sdeath Relativesrefuseherofﬁcial

guard

Orphanedbythedeathofboth parents;discriminated

ID7 17 Male Step1 HIVdisclosure Supportivefather;mother

dead

Orphanedbythedeathofone parent

ID8 17 Male Step1 Severeillness Supportiveparents None

ID9 19 Female Step2 HIVdisclosure Supportiverelatives Orphanedbythedeathofboth

parents

ID10 23 Female Step3 Father’sdeath Supportivemother None

ID11 18 Female Step1 Birthofhalfbrother Supportivegrandmother Orphanedbythedeathofone parent;discriminated

ID12 16 Female Step1 Adoption Supportivefosterparents Orphanedbythedeathofboth

parents

ID13 17 Male Step1 Adoption Supportivefosterparents Orphanedbythedeathofboth

parents

ID14 20 Male Step2 Wedding Supportivemother;father

disappeared

Abandonedbythefather ID15 23 Female Step3 Changinghealthteam Supportivegrandmother Orphanedbythedeathofboth

parents;discriminated

ID16 17 Male Step1 HIVdisclosure Supportivemother;father

disappeared

Abandonedbythefather; discriminated

Afterafewyears,hewasoneofthosewhohadagreatdealof difﬁcultywiththetransitionprocess.

Otheradolescentsreportedthatthechangesenabledthem togrowandmature.

ID 11:“I try to go on... it’snot difﬁcultforme...I manage” (Female,18years,Step1)

ID8:“Ifacethechangesalwaysinapositiveway...Ifeelreadyfor bothproblemsorgoodthings...I’msupposedtohandleit”(Male, 17years,Step1).

Theperceptionofcareinthepediatricsetting

Thebondbetweentheseadolescentsandthepediatricteam arecharacteristicoffamilyties.Theenvironmentisperceived aswarm,welcoming,and onethatenhances thequalityof interpersonalrelationships.From theperspectiveof adoles-cents,care goes beyondthe disease.Theprofessionals are partoftheir history and are interested intheirdailylives, reinforcingasenseofsecurityandconﬁdence.Ontheother hand,thefactofhavinggrownupwiththishealthcareteam makesthemreluctanttofacethetransition,asitcouldbring thethreatofdisruptionofimportantemotionalconnections.

ID8: “Igrew upclose to you (thehealth team)...youare like mymother,anotherfamily...youhavealwaysbeenwelcoming” (Male,17years,Step1).

ID10:“Iwasalwaystreatedasadaughterhere...”(Female,23 years,Step3).

ID14:“Iamusedtoallofyou,Iconsideryouasfriends,relatives,I likeverymuchthisplaceandyou...itwouldbeweirdtogothere...”

(Male,20years,Step2).

Howtheyfeelaboutbeingtransitionedfrompediatricto adultmedicalcare

Astheadolescentsparticipatinginthestudywereatvarious stagesofthetransitionprocess,theymadecomments reﬂect-ingverydifferentexperiences.Concernsinmovingawayfrom theirpediatriciansandfeelingsofdisruption,abandonment, or rejectionwere frequentlymentioned.Othersused recur-ring wordssuggesting feelingsof denialand insecurity, as theywereunpreparedtoaddresstheirownhealthcareneeds. Findingsalsoshowedmomentsofexpectationorresilience.

ID5:“Oh...there(theadultcare)isbad,right?Iwasusedto com-inghere...Ididnotwanttogothere,Ididnotgo... Ididnot go...”(Step3,treatmentinterruptionduringtransition).(Male, 25years,Step3)

ID13: “Then you suddenly change...and be afraid of the different...ofnotbeingpreparedforchanging.”(Male,17years, Step1)

ID2: “I’mnotprepared...notyet...ah,Idonotknow...Inever wentthere,I’mnotreadytodoso”.(Female,19years,Step2)

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ID12:”ItisbecauseIwanttostayherealittlebitlonger...then Iwillstarttocomealone,notwithmymother...”(Female,16 years,Step1)

Ontheotherhand,thereweretestimoniesshowing com-plianceorinterestinchanging.

ID8: “... and I said, oh! No problem... I can deal with changes...”(Male,17years,Step1).

ID7:“It’snormal,I’molder,Ihavetostayrightthere...it’sweird tobeamongchildren.”(Male,17years,Step1).

Howaretheirbeliefsabouttheadultcare?

Beliefs regarding the adult care were mostly loaded with negativeattributes.Theenvironmentwasdescribedas unwel-coming,withrigidandhurriedprofessionalswhofocusonly onthedisease.

ID8:“Ijustthinktheydon’thavethatmuchaffectionasyoudo withpatients,thethingismoredrought,moreserious...”(Male, 17years,Step1).

ID16:“Idon’tmeantheyarebaddoctors,buttheydon’tcareas youdo,theyareinahurry...let’sgo...let’sgo...”(Male,17years, Step1)

Whataretheyaskingfor?Whataretheirsuggestions?

Theadolescentsexpressedtheneedformoretimetobecome adaptedandinvolvedinthetransitionprocess.Havinggrown upunderthecareofateamofhealthcareprovidersmade manyparticipantstobereluctanttowardtransitioning.

ID1:“Youshouldgoslowly,right?...sothatyouget,youknow, tolearnmore(aboutthenewhealthteam)...”(Male,19years, Step1).

ID15:“...I’vebeenalwaystreatedasadaughteroverhere;itwas notnicetogothere”(Female,23years,Step3).

ID4:“Ithink(thetransitionshould be)after25yearsold,you know,theagethatyouwillhavemoreresponsibility,whenyou goafteryourownstuff,right?”(Male,20years,Step2).

Participantsalsoexpressedgreatconﬁdenceinthe pedi-atricteam.Atthesametimetheyshowedinterestinthenew teamandexpectedtohavecloserelationshipswiththem.

ID1:“...sometimesIthink...whenIwanttotalktosomeone...to

whomamIgoingtotalk?whowillgivemetheattentionasIhave here...youknow,thesesortofconversationsthatwehavehadso far?”(Male,20years,Step1).

They commented on the fact that the healthcareteam shouldknowtheprofessionalswhowillbefollowingthem. Theadolescentsexpectthemtobegentleandopentotheir needs.

ID15:“Iwouldnotthinktwicetobetreatedbackhere...because

thisisawelcomingplace...ineverysense,it’snotonly profes-sional.Youfeelyourselfloved,so...tochangetoanotherplace...

youhavetoﬁndsomeoneelsethatmakesyoufeellovedtoo.” (Female,23years,Step3).

They alsoask tohave previous contactswith the adult healthcareteambeforethetransition.

ID11:“Ibelieveweshouldknowtheotherteamﬁrst,thiswould bringmoresecurity...”(Female,18years,Step1)

ID13: “First I need to know more about there, how is the service... howitworks...see theplace,meetthephysicians.” (Male,17years,Step1)

Discussion

Thepresentstudyprovidesrichdataabouttheexperienceof perinatallyHIV-infectedadolescentsatdifferentphasesofthe transitionprocess.ItpresentstheimplementationoftheTAC andexaminesthewayinwhichtheadolescentsfeel,wantto shapeandhelptotransform,throughtheirvoices,thehealth caretransitionmodelusedatapublicuniversity.

Despitethedevelopmentofatransitionprogram,the ado-lescentsstillfacedbarrierstothisprocessandrevealedagreat variabilityinexperiences.

They startedshowingusthatthere wassomethingthat wasnotworking.Therewasasortof“misunderstanding”in thewaythehealthcareteamwasdealingwiththismoment intheirlives.Thisfactwascomplicatingthepatients’ adher-encetotreatmentandfollow-up.Apreviousstudyhasshown thatthepresenceofanxietyinthispopulationissigniﬁcantly relatedtononadherence.12_Also,_a_recent_study_has_shown_that almost20%ofHIV-infected21-year-oldshadlosstofollow-up (LTFU)intheyearafterturning22years.Receivingcareatan adultinsteadofapediatricHIVclinicwasassociatedtoLTFU.13 Welistenedtotheirconcernsandrethoughtthetransition process,asotherauthorsfromseveralpartsoftheworldhave starteddoingaswell.4_Their_talks_suggested_that_they_require slightlymoretime,notthetimemeasuredindaysormonths, butthetimemeasuredbyconstitutiveexperiencescapableof buildinganexpectationoffuture.Thetimefortransitionhas nothingtodowithchronologicalagelimits.Buildinglifeplans anddevelopingaclearunderstandingoftheirdestinationis not easyatthe beginning ofthe transitionprocess. Some-timesitistoopainfultothinkaboutthefuture.Theplacein societythatawaitsthemisnotexactlywelcoming.Nojobis guaranteed,nopositionissafe,andnoexpertiseislasting use-ful.Consistentdiscussionsareneededbeforethetransitionto allowtheseyoungpeopletomanageseveralissues indepen-dently.Also,adult-orientedprovidershavetobepreparedto receivepatientswithchildhood-onsetor-acquiredconditions anddealingwiththeirparticularities.

The present work permitted the opening of collective spaces forreﬂection, analysis, and exchangeofknowledge amongprofessionalsand,aboveall,forinteractionand lis-teningtothedemandsoftheparticipants.Howtoconduct thetransitionprocessinhealthcare?Howitisorcanitbe? Howitshouldorshouldnotdevelop?Whenshouldbeprocess begin?Manyofthesequestionscannotproducecognitive cer-taintyordeﬁnitiveanswers.Suchquestionswillnecessarily giverisetofurtherdebate.Recently,otherprotocolsof tran-sition were described forHIV-infectedadolescents.14,15 _Life transitionsare always challenging.They are inevitable and necessary, buthowtheyoccurmightresultinmoreor less suffering.Thehierarchyofvalueswehaveseeninthecurrent model ofcareemphasizesthe technological aspectsrather thanitshumanisticcomponents.Listeningtotheadolescents’

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voicesiscrucialtoabetterunderstandingoftheirneeds.There arethosewhocanhelptheprofessionalsreachingalternatives forasmoothandsuccessfulhealthcaretransition.

Conﬂicts

of

interest

Theauthorsdeclarenoconﬂictsofinterest.

Acknowledgements

WewouldliketothankthemembersoftheTACteamwho sharedtheirtimeandexperiencesaspartoftheresearch pro-cess(TenoriS,MD;GouveaAFB,MD;doCarmoFB,MD;Beltrão SV,MD;RuﬁnoAM,nurse;deJesusRM,nurse;JulianaMaria FigueiredodeSouza,socialworker).Wearegratefultothe ado-lescentswhosharedtheirlifeexperienceswithus.Supported byagrantfromFundac¸ãodeAmparoàPesquisadoEstadode SãoPaulo,Brazil(FAPESP#10/15463-8).

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