"Sometimes I get myself in trouble with pediatricians, because I'm always trashing them," says maverick Jeffrey M. Birnbaum, MD, a pediatrician himself, with a laugh. By practice, he's a pioneer in the uncharted territory of adolescent HIV/AIDS medicine. Birnbaum leads the staff at Health and Education Alternatives for Teens, an HIV/AIDS clinic for young adults housed in Kings County Hospital Center in Brooklyn, N.Y., where the nation's largest perinatal pediatric HIV/AIDS population is a simple stroll down the corridor.

Sporting a long salt-and-pepper ponytail and black Levi's, Birnbaum looks more like a rock-and-roll roadie than a physician who also has a master's degree from Columbia University in public health with a focus on vaccine-preventable diseases and international treatment. He fields calls to the clinic himself and has his patients call him "Jeff." A continent hopper who has practiced medicine from the Eastern Bloc to the tropics, Birnbaum has come full circle back to his native Brooklyn to attend to what he sees as a special medical population.

So what's his beef with other pediatricians? For starters, Birnbaum says, he would like children's doctors to recognize that treating adolescents in a pediatric setting requires a multidisciplinary approach geared specifically toward the adolescent. Teens have needs that often outgrow the pediatric protocol. In Birnbaum's young-adult setting, teens are given more autonomy and authority over their choices. He stresses that it is important to meet these patients on their own terms. "They couldn't care less about their treatment," he says, "if I'm not taking their concerns into consideration and paying attention to stuff that's real to them on a day-to-day basis." Those issues include discussing being sexually active, fear of death, and the side effects of medications–along with typical rites-of-passage drama such as zits and cutting classes.

Furthermore, when it comes to his philosophy of adolescent treatment, Birnbaum holds steadfast especially to one belief: If patients are to join his clinic, they must already know they are HIV-positive or their parents must be willing to let them know. In the pediatric setting, on the other hand, children are often allowed to go for years–even into their teens–before they are told that they are HIV-positive.

Doctors and parents avoid disclosing HIV status to children, Birnbaum says, because in the pediatric setting the doctor gives the child's health information primarily to the parent or guardian, who dispenses any medications to the patient. But is Mom or Auntie going to be as forthcoming and disciplined further down the line with doling out condoms and safer-sex education? Birnbaum says he worries that "a lot of people don't know how to talk to these kids about sex, because in the pediatric-care setting they're so used to dealing with young children." And he believes the reality of HIV and AIDS when it comes to sexually evolving young adults calls for a change in protocol, especially if they have never been told that they are carrying HIV: "You should be able to talk to these kids directly about sex without having to get some sort of permission from their parents."

Birnbaum's laissez-faire approach to his patients' medication adherence is also considered unorthodox. If they have made a decision to go off their medication, he lets them learn from their own failing health. He wants them to feel a sense of control, so he treats them like young adults. "You're not going to force medication into the kid," he says. "You have to get the kids to make the decision that this is something that they want to do. The only way that they will do that is to have the opportunity to refuse it at some point."

What does he hope for the future? Short of a one-dose-a-day treatment regimen, Birnbaum would like to see adolescents be treated by experts on teens, not simply by pediatricians who often aren't versed in their needs and differences as emerging young adults. "Let the people who like to do the work with adolescents," he emphasizes, "do the work with them."