Editorial

2 www.thelancet.com Vol 382 July 6, 2013

For the AAP policy statement see http://pediatrics.

aappublications.org/content/early/2013/06/19/

peds.2013-1073.full.pdf+html?sid=4f1549c9-8fd0-

414d-89cf-fdec237f9dc9

Adolescence can be a diffi cult period in a person’s life—even more so if that individual has grown up HIV positive. Paediatric care providers and multiple courses of combination antiretrovirals will have supported the child’s survival into adolescence. The prospect of moving from these familiar and trusted sources of care into adult services may seem daunting to a teenager and their family. Furthermore, poor transition of care could result in interrupted treatment and detrimental eff ects on health. A new policy statement by the American Academy of Pediatrics (AAP) to manage this move eff ectively is therefore welcome.

The number of young people infected with HIV is increasing in the USA, in part, because most children with the virus now survive into adulthood thanks to advances in antiretroviral therapy. Additionally, adolescents continue to be newly infected through high-risk behaviours. The Centers for Disease Control and Prevention estimated that in 2009 there were around 77 000 young people aged 13–24 years infected with HIV living in the USA.

The AAP policy statement recommends that the patient and his or her family be introduced to the concept of transition in early adolescence (around 12 years of age) with the young person being fully informed of his or her HIV status before the process is initiated. The authors state that actual transition of care should be considered between the ages of 18 years and 25 years, and health-care coverage for the young person should be assessed regularly to ensure that coverage and access to drugs remains uninterrupted during transition. The referring care provider should also consider aspects outside the physical health of the individual such as mental health problems, and social situations such as homelessness or loss of a parent.

Research has shown that most paediatric practices in the USA neither initiate transition planning early in adolescence nor off er transition support services. Transition of care should be seamless. However, this outcome requires careful thought, planning, and communication. The AAP now needs to monitor whether their new policy statement encourages this approach. ■ The Lancet

Caring for those growing up with HIV

Heart disease in EuropeCardiovascular disease is one of Europe’s biggest killers— causing almost half of all deaths—yet a study published in the European Heart Journal provides some encouraging news: coronary heart disease mortality in the European Union (EU) has signifi cantly decreased in nearly all countries since the early 1980s, in both men and women.

Importantly, despite fears that increases in diabetes and obesity might be beginning to off set the benefi cial eff ect of improved treatment and reduced smoking rates on coronary heart disease mortality, the study provided no evidence to suggest that the mortality rate decrease was beginning to slow or reverse across the EU. Analysis of mortality trends in younger people (aged <45 years)—an important indicator for future public health—showed that recent decreases in heart disease mortality were generally as great or greater than overall and earlier decreases.

However, among the positive results are some concerning trends in individual countries. Although the UK had, alongside Denmark, Malta, the Netherlands, and Sweden, one of the largest decreases in coronary

heart disease mortality between 1980 and 2009, the results suggest this decrease might be plateauing. When the sexes were assessed separately, mortality in men in Romania was shown to have signifi cantly increased, and in several other countries the decrease in mortality was small and non-signifi cant. Coronary heart disease mortality seems to have begun to signifi cantly increase in younger populations in Greece and Lithuania, where overall rates of major risk factors such as smoking and obesity are relatively high, possibly explaining some of the between-country disparities in mortality.

The overall results largely refl ect the great strides made in treatment, but, as the investigators of this study acknowledge, mortality rates alone do not provide a complete picture; the focus should also be on reduction of incidence of disease, by improvement of primary prevention and management of risk factors. The good news should serve as encouragement that research eff orts have been worthwhile, but must not lead to complacency. ■ The Lancet

For the European Heart Journal study see Eur Heart J 2013;

published online June 25. DOI:10.1093/eurheartj/eht159

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