LEGAL AGE OF CONSENT FOR HIV TESTING AMONG ADOLESCENTS IN SUB SAHARAN AFRICA, A SYSTEMATIC REVIEW

1 LEGAL AGE OF CONSENT FOR HIV TESTING AMONG ADOLESCENTS IN SUB SAHARAN AFRICA, A

2 SYSTEMATIC REVIEW

3 Getrud Joseph Mollel

1,2

, Andrew Katende

1,2

, Maryam Shahmanesh

3,4

4 Affiliations

5 1. Ifakara Health Institute, Morogoro, Tanzania

6 2. St. Francis Referal Hospital, Morogoro, Tanzania

7 3. Africa Health Research Institute, South Africa

8 4. Institute for Global Health, University College London, UK

10 Corresponding author:

: [email protected]

. CC-BY 4.0 International licenseIt is made available under a

is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted May 21, 2022. ; https://doi.org/10.1101/2022.05.17.22275222doi: medRxiv preprint

NOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.

25 Abstract

26 Sub Saharan Africa (SSA) harbours more than 80% of adolescents living with HIV. High age of consent for

27 HIV testing has been identified as one of the key barriers to adolescents’ access to HIV testing. We conducted

28 a systematic literature review to demonstrate the status of age of consent policies in SSA and evidence of

29 relationship between age of consent policies and adolescent’s uptake of HIV testing. We obtained peer

30 reviewed literature from Medline, Embase, Scopus and Web of Science databases and policy review from

31 national HIV testing guidelines and UNAIDS data reports. Age of consent for HIV testing in the region ranged

32 between 12 and 18 years. Among 33 included countries, 14 (42.4%) had age of consent between 12 – 14

33 years, 9 (27.3%) had age of consent between 15 – 17 years and 10 countries (30.3%) still have the highest

34 age of consent at 18 years as of 2019. Lowering age of consent has been associated with increased access to

35 HIV testing among adolescents.

38 INTRODUCTION

39 Sub Saharan Africa (SSA) harbours almost half of all HIV infected individuals and more than 80% of

40 adolescents living with HIV.(1–3) AIDS related deaths have declined by more than a third globally, Eastern

41 and Southern Africa showing the steepest reduction largely due to the scale up of HIV testing and coverage of

42 antiretroviral therapy.(4) However, this improvement has not been uniform across all age groups. AIDS

43 persisted as one of the leading causes of death for adolescents in Africa (5), with significantly higher rates of

44 new infections in young girls than boys.(3) Reported reduction in AIDS related mortality among adolescents in

45 2018 was less than half the decline observed among adults aged above 20 years (16% versus 35%).(6)

46 Adolescence, defined as the age span from 10-19 years inclusively, is a complex developmental stage

47 comprised of cognitive, physical, biological and psychological growth and characterised by social, personality

48 and sexual exploration and maturation.(7,8) Adolescents have a higher likelihood of engaging in risky

49 behaviours such as unsafe sexual practises which puts them at a higher risk of contracting HIV. Those who

50 are part of HIV key populations including men who have sex with men, transgender people, intravenous drug

51 users and commercial sex workers are even at a higher risk of contracting HIV and lower access to HIV

. CC-BY 4.0 International licenseIt is made available under a

is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted May 21, 2022. ; https://doi.org/10.1101/2022.05.17.22275222doi: medRxiv preprint

52 testing especially in countries where they are criminalised.(5,9,10) Policies in many countries still restrict

53 adolescents’ independent access to HIV testing without parental consent.(4) The proportion of adolescents

54 who are aware of their HIV status is lower than that of adults.(11) Adolescent girls and young women

55 contribute 26% of new HIV infections in Eastern and Southern Africa region, yet age of consent policies

56 continue to be a barrier to HIV testing.(3,4) Furthermore, adolescents and youths represent the fastest

57 growing population group in SSA which might precipitate the observed trend of new HIV infection among

58 them, necessitating wider access to HIV testing and treatment services.(12)

59 Access to HIV testing is the gateway into HIV care and prevention. Therefore, as part of their commitment

60 to scaling up of access to HIV services to all people including adolescents, WHO called upon heads of state to

61 lower the age of consent for HIV testing.(13–15)

Wider access to HIV testing among adolescents will

62 complement several other interventions which are implemented in SSA with the aim of improving HIV

63 outcomes among this age group. Such interventions include the adolescents’ friendly clinics, addressing HIV

64 related stigma, promotion of abstinence and use of condoms, school based sex education, active case finding,

65 use of incentives, provider initiated testing and counselling, voluntary male medical circumcision and other

66 behavioural change interventions.(16–20) Adolescents require wider access to HIV testing especially for the

67 realisation of public health benefits of starting antiretroviral treatment immediately after HIV diagnosis,(21)

68 and other recent interventions such as Pre-exposure prophylaxis and HIV self-testing.(22,23) Removal of legal

69 barriers to HIV testing could improve the extent to which adolescents benefit from these interventions.(24,25)

70 We conducted a systematic literature review on age of consent policies with an objective of demonstrating the

71 status of age of consent policies in SSA and evidence of the relationship between age of consent and

72 coverage of HIV testing among adolescents in the region.

74 METHODS

75 We did a guideline review to summarise the age of consent for HIV testing in SSA followed by a systematic

76 review of literature to assess the relationship between age of consent and access to HIV testing amongst

77 adolescents in SSA. The PICO aspects of the review were as follows; population of interest was adolescents

. CC-BY 4.0 International licenseIt is made available under a

is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted May 21, 2022. ; https://doi.org/10.1101/2022.05.17.22275222doi: medRxiv preprint

78 aged between 10-19 years, the intervention assessed was low age of consent, and the outcome was access

79 to HIV testing among adolescents which was compared between countries with lower age of consent versus

80 those with higher age of consent.

81 Inclusion and exclusion criteria

82 We included the latest HIV testing guidelines supplemented with the UNAIDS global HIV reports and studies

83 that were in the English language and from SSA countries. We defined SSA as countries geographically

84 located South of the Sahara, as per the United Nations’ definition. We included studies that discussed the age

85 of consent for HIV testing in adolescents in SSA region. Studies that included children, youths and young

86 people were included in the initial search criteria due to the age overlap in definition of these age groups.

87 Adolescence is defined as the age between of 10 to 19 years inclusively, while a child is defined as any person

88 from birth up to the age of 18 years, a young person is defined as the age of 10 up to 24 years, and a youth

89 is any person between the ages of 15 to 24.(8,26). Studies that did not include adolescents were then

90 excluded at later literature screening stages.

91 For the outcome of access to HIV testing we included studies that explored how age of consent influences

92 HIV testing among adolescents aged between 10 to 19 years in SSA countries. We included studies which

93 were conducted after 2013 as this was the year that WHO issued a review of consent age policies in SSA and

94 called for governments consider lowering the age at which adolescents can independently access to HIV

95 testing. (15,27) We did not limit studies based on their methodology. We included both quantitative and

96 qualitative studies together with reviews of laws and policies related to age of consent for HIV testing. To

97 assess changes in age of consent policies, we compared the age of consent reported in the 2013-WHO review

98 to that stated in countries’ latest HIV testing guidelines and UNAIDS country data reports by 2019.

99 We excluded studies if the focus was on age of consent for inclusion in HIV research.

100 Search strategy

101 We searched for peer reviewed articles from Medline, Embase, Scopus and Web of science, and grey

102 literature and policies from HIV testing guidelines, WHO guidelines and UNAIDS reports.

Table 1

summarises

103 the key words, medical subject headings (Mesh) terms and proximity operators we used to search for the

104 relevant literature.

. CC-BY 4.0 International licenseIt is made available under a

is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted May 21, 2022. ; https://doi.org/10.1101/2022.05.17.22275222doi: medRxiv preprint

105 Literature screening

106 GJM conducted the literature search and screened all material according to the inclusion criteria. KA reviewed

107 the materials against the inclusion and exclusion criteria. MS supervised literature search, screening and

108 synthesis of results. Mendeley referencing software v.1.19.5 was used for literature management.

109 Ethical considerations

110 We only included published materials without any inclusion of individual participants’ data. We therefore did

111 not seek for further ethical approval

112

113 RESULTS

114 We found 376, 446, 452 and 298 articles from Medline, Embase, Scopus and Web of science respectively. We

115 obtained a total of 360 publications after removal of duplicates. We further excluded 261 and 76 articles at

116 tittle screening and abstract screening stages respectively. 23 articles were eligible for full text screening

117 where we further excluded 15 due to the following reasons; 2 articles discussed about consent for inclusion to

118 HIV research and trials, full text literature for 1 article could not be found, 2 articles discussed HIV testing for

119 children younger than 10 years old and 10 articles did not include discussion about age of consent among

120 factors affecting HIV testing for adolescents.

Figure 1

shows the PRISMA flow diagram for literature

121 screening. We finally included 8 articles from SSA. These included four quantitative studies,(28–31) one

122 qualitative study,(32) and three reviews of HIV-specific policies, laws and legislative frameworks that affect

123 adolescents’ access to HIV testing in SSA (33–35).

124 We extracted age of consent from national HIV testing guidelines of Kenya, (36) Uganda,(37) Rwanda,(38)

125 Ethiopia,(39) Malawi,(40) Zimbabwe,(41) Cameroon,(42) Ghana,(43) Swaziland,(44) Lesotho (45) and South

126 Africa(46). We supplemented with a legal framework review from Tanzania (47) and UNAIDS country data

127 reports of 2018 and 2019 (4,48). We included 33 SSA countries in total.

128 Age of consent for HIV testing

129 The lowest age of consent for HIV testing among the countries included in this review was 12 years, while the

130 highest was 18 years.

Table 2

shows the age of consent as reported in the WHO’s review of 2013 as

131 compared to the country’s age of consent as indicated in the latest HIV testing guidelines or UNAIDS reports.

132 In 2013, 5 (12.4%) countries had age of consent between 12 to 14 years, 15 to 17 years in 8 (24.2%) and 18

. CC-BY 4.0 International licenseIt is made available under a

is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted May 21, 2022. ; https://doi.org/10.1101/2022.05.17.22275222doi: medRxiv preprint

133 years in 12 (36.4%) countries. 6 (18.2%) countries had not defined age of consent for HIV testing for

134 adolescents while 2 countries (Kenya and Botswana ) were reported in 2013 as countries that apply maturity

135 assessment by the healthcare provider rather than chronological age to determine adolescent’s ability to

136 consent for HIV testing.(15). By 2019, the age of consent for HIV testing was 12 to 14 years in 14 (42.4%)

137 countries, 15 to 17 years in 9 (27.3%) countries and 18 years in 10 (30.3%) countries. Between 2013 and

138 2019, Cameroon and Central African Republic lowered the age of consent from 18 years to 14 years, whereas

139 Cote d’ivoire, Niger and Tanzania lowered it from 18 years to 16 years. This left Angola, Bukina Fasso, DRC,

140 Djibouti, Ghana, Madagascar, Mali, Nigeria, Sierra Leone and Sudan with the highest age of consent for HIV

141 testing in the region. The lowest age of consent in the region was 12 years in Uganda, South Africa, Rwanda,

142 Lesotho and Swaziland.

Figure 2

shows a diagramatic presentation of changes in number of countries with

143 respect to age of consent in 2013 as compared to 2019.

144 Association between age of consent and HIV testing

145 McKinnon and colleagues quantitatively explored the association between age of consent and uptake of HIV

146 testing among adolescents by using demographic and health survey data from 15 SSA countries. They found

147 that age of consent below 16 years was associated with 11% (95%CI: 7.2-14.8) increase in uptake of HIV

148 testing among adolescents.(28) Another study which used demographic and health survey data assessed

149 predictors of HIV testing among adolescents and youths in Uganda, Congo, Mozambique and Nigeria also

150 concluded that participants aged 20-24 years had higher odds of HIV testing than adolescents aged 15-19

151 years (aOR– 2.19; 99%CI 1.99-2.40). This finding was attributed to the fact that older participants could

152 independently consent for HIV testing without requirement of parental consent. The overall uptake of HIV

153 testing was low whereby only one third of the 23,367 included participants reported to have ever tested for

154 HIV. They observed the highest coverage of HIV testing amongst adolescents in Uganda, where age of

155 consent policies allow adolescents to access HIV testing from the age of 12 years.(29) These results are in

156 congruence with adolescents’ views expressed in a qualitative assessment of HIV testing experience among

157 adolescents, health care workers and parents in Kenya.(32) In this study, adolescents preferred to have

158 independent access to HIV testing without parental consent requirements. They reported that they would

159 prefer post-test counselling support and a choice on how to handle disclosure of their HIV status. While

160 adolescents’ opinion should be taken into consideration when designing policies to improve their uptake of

. CC-BY 4.0 International licenseIt is made available under a

is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted May 21, 2022. ; https://doi.org/10.1101/2022.05.17.22275222doi: medRxiv preprint

161 HIV testing services, parents on the other hand preferred to be informed about HIV status of their children

162 even when it’s contrary to adolescents’ preference.(32) Mixed findings were also reported from cross sectional

163 studies aimed at assessing parents’ attitudes towards implementation of HIV testing at schools in South Africa

164 following findings of a high desire for a school-based HIV testing services among adolescents.(30,31) Among

165 801 parents who participated in the survey, 46% reported that students can access HIV testing at school

166 without requirements of parental consent, whereas 39% reported that HIV results should be communicated

167 to the adolescents in the presence of their parents.(30) Healthcare workers in Kenya also reported that they

168 sometimes deny adolescents testing services unless they are pregnant, married or parents, (32) despite the

169 fact that the HIV testing guideline in Kenya allow adolescents aged above 15 years to access HIV testing

170 without parental consent.(36)

171 Policies and legal frameworks in relation to HIV testing

172 We included three articles that discussed policies, laws and legal frameworks affecting adolescents’ access to

173 HIV testing in SSA. These included one desk review of HIV related laws of Angola, Benin, Burkina Fasso,

174 Burundi, Cape Verde, Central African Republic, Chad, Comoros, Congo, Cote d’Ivoire, Democratic Republic of

175 Congo, Equatorial Guinea, Gambia, Guinea, Guinea Bissau, Kenya, Liberia, Madagascar, Mali, Mauritania,

176 Mauritius, Mozambique, Niger, Senegal, Sierra Leone, Tanzania, Togo and Uganda,(33) a review of health

177 policy gaps that affect adolescents access to HIV services in Rwanda,(34) and a review of South African

178 legislative reform for improvement of adolescents’ access to sexual and reproductive health services including

179 HIV testing.(35) The review from 28 SSA countries examined HIV related laws against WHO’s

180 recommendations to lower the age of consent for HIV testing and ensure access to HIV testing, counselling

181 and treatment among adolescents. Of the reviewed laws, 11 countries had explicitly stated the age at which

182 adolescents can independently access HIV testing whereby only 7 of them had the age of consent set below

183 18 years. Criteria for independent access to HIV testing for HIV testing other than chronological age included

184 sufficient maturity, emancipated minor, pregnant or married adolescents, adolescents who are married or

185 those at higher risk of acquiring HIV infection for Kenya, Comoros, Mauritius, Madagascar, Togo, Sierra Leone

186 and Niger. None of the laws had an explicit definition of maturity with respect to HIV testing. Age of consent

187 for HIV testing in Kenya HIV testing policies was found to be different from the age stated in the law. This

188 review highlighted the need of reforms to address inadequacy of HIV specific laws in SSA in enhancing

. CC-BY 4.0 International licenseIt is made available under a

is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted May 21, 2022. ; https://doi.org/10.1101/2022.05.17.22275222doi: medRxiv preprint

189 adolescents’ independent access to HIV testing.(33) Additionally, Binagwaho and his colleagues used a human

190 right approach to argue that adolescents have a right to access confidential HIV testing services and their

191 results to only be disclosed if they agree to it. They called for a reduction of age of consent for HIV testing

192 from 21 years which was a default age at which an adolescent acquired majority and ability to consent for

193 HIV testing in Rwanda to coincide with adolescents sexual behaviours.(34) Current HIV testing guidelines in

194 Rwanda allows for independent consent for HIV testing for adolescents from the age of 12 years and mature

195 enough to understand implications of HIV testing and to be able to cope in case of positive results.(38)

196 Through its legislative reforms, South Africa also allowed independent consent for HIV testing from mature

197 adolescents aged 12 years and above.(35) However, adolescents who are above 12 years and rendered by

198 healthcare provider to be not mature enough to understand the benefits of HIV testing are still required by

199 the South African HIV testing guideline to provide parental consent.(46)

200

201 DISCUSSION

202 We found that the majority of the countries have the age of consent for HIV testing between 12 and 14 years

203 and all countries have explicitly mentioned the age at which adolescents can independently access HIV test.

204 This is substantial progress compared to 2013 where 6 countries had not defined the age of consent for HIV

205 testing. Access to HIV testing is an entry point to HIV treatment services and prevention of further new

206 infection and the limited data in this review suggests that age of consent is associated with uptake of HIV

207 testing amongst adolescents. However, despite progress in removing age of consent as a barrier towards HIV

208 testing, adolsecents in the region still contribute more than one third of new HIV infections.(3)

209 There were only two studies that quantitatively assessed the association of HIV testing and legal age of

210 consent where a higher uptake was reported among countries with low age of consent (28,29). Suboptimal

211 response of countries may be attributed to paucity of evidence showing the extent to which adolescents’’ HIV

212 testing improves after lowering age of consent. A study among adolescents from 32 states of the US where

213 requirement of parental consent for adolescents to access HIV testing was waived reported that there was no

214 significant statistical association between legal ability to consent and uptake of HIV testing (aOR-0.3%

215 (95%CI 0.1,1.1)).(49) However the results could have been swayed by several limitations of the study

. CC-BY 4.0 International licenseIt is made available under a

is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted May 21, 2022. ; https://doi.org/10.1101/2022.05.17.22275222doi: medRxiv preprint

216 including recall and social desirability bias and default exclusion of non-internet users who could have been

217 systematically different from internet using adolescent who participated in the study. Arguably, everyone

218 including adolescents have rights to access HIV testing services especially now when universal access to

219 health care is among the priority global health agendas in developing countries and globally. However, it is

220 necessary to understand the added advantage of lowering the age of consent together with establishing the

221 role of contextual factors that might limit adolescents’ access to HIV testing even in the settings of low age of

222 consent.

223 Secondly, there are no evidence based maturity assessment methods to determine adolescents who should be

224 allowed to access HIV testing without parental consent. Most national guidelines point towards the use of

225 sexual maturity such as being pregnant, being a parent or in a higher risk of contracting HIV as a gateway for

226 independent access to HIV testing among adolescents. The use of sexual related indicators of maturity

227 systematically excludes adolescents who are not sexually active but could have been perinatally infected-long

228 term slow progressors.(50,51) It also segregates against adolescents who are not yet sexually active but may

229 benefit from HIV testing as a gateway into HIV prevention counseling. Furthermore, such criteria provide

230 independent access to HIV testing after exposure to the risk of infection.

231 Additionally, we found that it is largely left at health workers’ individual discretion to decide whether

232 adolescents are mature enough to access HIV testing. Definition of maturity is bound to differ between

233 individuals, and across cadres i.e., nurses, medical doctors, social scientists, psychologists, lawyers and

234 counsellors. It may also differ depending on social construct, culture and development of both the provider

235 and the client.(52) Adolescent health experts from various fields including ethics, sociology, law and medicine

236 who convened in 2015 recommended assessment of adolescent’s capability for decision making in clinical care

237 should include understanding of the legal requirements, conducive and non-judgemental environment and

238 objective assessment of social, emotional and cognitive development.(53) Guidelines for evaluation of

239 adolescents capacity to consent for HIV testing could also be adopted from “Gillick competence” assessment

240 criteria which originated from the United Kingdom, used mainly to assess adolescents cognitive ability to

241 consent for a variety medical services such as sexual health service and immunization.(54,55) Countries in

242 SSA could adopt and validate such kind of assessments which would enable timely HIV diagnosis among

. CC-BY 4.0 International licenseIt is made available under a

is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted May 21, 2022. ; https://doi.org/10.1101/2022.05.17.22275222doi: medRxiv preprint

243 adolescents. It would also give access to adolescents who may not have been exposed already, and open the

244 window for HIV prevention counselling to them and their peers.

245 Studies showed that parents required to be notified about adolescents’ HIV status despite of their disclosure

246 preferences which contributes to healthcare workers hesitancy in offering HIV test for adolescents even in

247 settings of favourable consent policies.(30,32) Unwanted and uninformed disclosure to third parties including

248 parents might discourage adolescents from accessing HIV testing service even after lowering the legal age of

249 consent. Parents’ and healthcare workers should therefore be sensitized on importance of lowering the age of

250 consent to allow truly autonomous access of HIV testing among adolescents. Furthermore, social networks

251 including families, peers and surrounding societies may play an important demand-side influence on

252 adolescent’s decision and ability to seek for HIV testing.(56) Their perceptions on adolescents’ autonomous

253 access to HIV testing should therefore be explored and addressed in order to maximise benefits of lower age

254 of consent on adolescents’ access to HIV testing.

255 This review adds to the existing literature that calls for lowering the age of consent for HIV testing in SSA

256 region while assessing and addressing other factors that might impede benefits of lower age of consent. It

257 has triangulated findings from legal reviews, HIV testing guidelines and qualitative and quantitative studies.

258 This review was not without limitations. We did not include articles and national guidelines which were not

259 published in English which may bias the results. We also included only 33 countries from the region. However,

260 this was done based on the countries which were included in the WHO 2013 report to allow comparison, and

261 availability of data on age of consent policies.

262

263 CONCLUSION

264 Age of consent for HIV in SSA region ranges from 12 to 18 years. Majority of countries in SSA countries

265 currently allow adolescents aged between 12 to 14 years to independently consent for HIV testing. However,

266 there were countries that continued to maintain the highest age of consent (18 years). There is a need for

267 context specific evaluation of benefits of lower age of consent and other factors that impede adolescents’

268 access to HIV testing even in settings of favourable consent policies.

269

. CC-BY 4.0 International licenseIt is made available under a

is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted May 21, 2022. ; https://doi.org/10.1101/2022.05.17.22275222doi: medRxiv preprint

270 Conflicts of interest

271 The authors declare no conflict of interest

272

273 Contributions from authors

274 GJM conceived the idea, formulated the research question, conducted literature search, screening of materials

275 and drafted the manuscript

276 KA reviewed the literature search against eligibility criteria and reviewed the manuscript.

277 MS supervised the literature search and reviewed the manuscript

278

279 Funding source

280 There was not funding sought for completion of this review

281

282

283

284

285

286

287

288

289

290

291

292

293

. CC-BY 4.0 International licenseIt is made available under a

is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted May 21, 2022. ; https://doi.org/10.1101/2022.05.17.22275222doi: medRxiv preprint

294

295 References;

296 1. UNICEF. All IN #EndAdolescentAIDS. 2015.

297 2. Kharsany ABM, Karim QA. HIV Infection and AIDS in Sub-Saharan Africa : Current Status, Challenges

298 and Opportunities. 2016;34–48.

299 3. UNAIDS. SEIZING THE MOMENT, GLOBAL AIDS UPDATE. 2020.

300 4. UNAIDS. UNAIDS DATA 2019. 2019.

301 5. Idele P, Gillespie A, Porth T, Suzuki C, Mahy M, Kasedde S, et al. Epidemiology of HIV and AIDS Among

302 Adolescents: Current status, Inequities and Data gaps. JAIDS Journal of Acquired Immune Deficiency

303 Syndromes. 2014;66:S144–53.

304 6. UNAIDS. Start Free Stay Free AIDS Free 2019 report. 2019.

305 7. WHO. Global Accelerated Action for the Health of Adolescents (AA-HA!) Implementation Guidance,

306 2016-2030. 2016. 1–155.

307 8. UNCRC. CRC General Comment No. 4: Adolescent Health and Development in the Context of the

308 Convention on the Rights of the Child. Vol. 4, Crc/Gc/2003/4. 2003.

309 9. WHO, UNAIDS. GLOBAL STANDARDS FOR QUALITY HEALTH-CARE SERVICES FOR ADOLESCENTS. Vol. 1.

310 2015.

311 10. Bekker L-G, Johnson L, Wallace M, Hosek S. HIV and adolescents : focus on young key populations.

312 JAIDS. 2015;18(Supplement 1).

313 11. Wong VJ, Murray KR, Phelps BR, Vermund SH, Mccarraher DR. Adolescents, young people, and the 90

314 – 90 – 90 goals : a call to improve HIV testing and linkage to treatment. AIDS. 2017;(Supplement

315 3):191–4.

316 12. UNAIDS. THE YOUTH BULGE AND HIV. 2018.

317 13. United Nations. Political Declaration on HIV and AIDS: On the Fast Track to Accelerating the Fight

318 against HIV and to Ending the AIDS Epidemic by 2030. 2016.

319 14. Piot P, Abdool Karim SS, Hecht R, Legido-Quigley H, Buse K, Stover J, et al. Defeating AIDS - Advancing

320 global health. The Lancet. 2015;386(9989):171–218.

321 15. Fox K, Ferguson J, Ajose W, Singh J, Marum E, Baggaley R. ADOLESCENT CONSENT TO HIV TESTING: A

322 REVIEW OF CURRENT POLICIES AND ISSUES IN SUB- SAHARAN AFRICA. WHO publications. 2013;(2):1–

323 26.

324 16. Kranzer K, Simms V, Bandason T, Dauya E, McHugh G, Munyati S, et al. Economic incentives for HIV

325 testing by adolescents in Zimbabwe: a randomised controlled trial. The Lancet HIV. 2018;5(2):e79–86.

326 17. Penda CI, Moukoko CEE, Koum DK, Fokam J, Meyong CAZ, Talla S, et al. Feasibility and utility of active

327 case finding of HIV-infected children and adolescents by provider-initiated testing and counselling:

328 evidence from the Laquintinie hospital in Douala, Cameroon. BMC pediatrics. 2018;18(1):259.

. CC-BY 4.0 International licenseIt is made available under a

is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted May 21, 2022. ; https://doi.org/10.1101/2022.05.17.22275222doi: medRxiv preprint

329 18. Simms V, Dauya E, Dakshina S, Bandason T, McHugh G, Munyati S, et al. Community burden of

330 undiagnosed HIV infection among adolescents in Zimbabwe following primary healthcare-based

331 provider-initiated HIV testing and counselling: A cross-sectional survey. PLoS Medicine. 2017;14(7):1–

332 15.

333 19. Kaufman MR, Smelyanskaya M, Van Lith LM, Mallalieu EC, Waxman A, Hatzhold K, et al. Adolescent

334 sexual and reproductive health services and implications for the provision of voluntary medical male

335 circumcision: Results of a systematic literature review. PLoS ONE. 2016;11(3):1–23.

336 20. Reif LK, McNairy ML, Lamb MR, Fayorsey R, Elul B. Youth-friendly services and differentiated models

337 of care are needed to improve outcomes for young people living with HIV. Current Opinion in HIV and

338 AIDS. 2018;13(3):249–56.

339 21. Nash D, Yotebieng M, Sohn AH. Treating all people living with HIV in sub-Saharan Africa : a new era

340 calling for new approaches. Journal of virus eradication. 2018;4(Supplement 2):1–4.

341 22. Ahmed N, Pike C, Bekker LG. Scaling up pre-exposure prophylaxis in sub-Saharan Africa. Current

342 opinion in infectious diseases. 2019;32(1):24–30.

343 23. Harichund C, Moshabela M. Acceptability of HIV Self-Testing in Sub-Saharan Africa: Scoping Study.

344 AIDS and Behavior. 2018;22(2):560–8.

345 24. Armstrong A, Nagata JM, Vicari M, Irvine C, Cluver L, Sohn AH, et al. Global Research Agenda for

346 Adolescents Living With HIV. JAIDS. 2018;78(16–21).

347 25. Wong VJ, Murray KR, Phelps BR, Vermund SH, Mccarraher DR. Adolescents, young people, and the 90

348 – 90 – 90 goals : a call to improve HIV testing and linkage to treatment. AIDS. 2017;(Supplement

349 3):191–4.

350 26. UNICEF. Adolescent and Youth Engagement Strategic Framework. 2017.

351 27. WHO. HIV AND ADOLESCENTS: GUIDANCE FOR HIV TESTING AND COUNSELLING AND CARE FOR

352 ADOLESCENTS LIVING WITH HIV. WHO publications. 2013.

353 28. McKinnon B, Vandermorris A. National age-of-consent laws and adolescent HIV testing in sub-saharan

354 Africa: A propensity-score matched study. Bulletin of the World Health Organization. 2019;97(1):42–

355 50.

356 29. Asaolu IO, Gunn JK, Center KE, Koss MP, Iwelunmor JI, Ehiri JE. Predictors of HIV testing among youth

357 in sub-Saharan Africa: A cross-sectional study. PLoS ONE. 2016;11(10):1–12.

358 30. Madiba S, Mokgatle M. Parents Support Implementation of HIV Testing and Counseling at School:

359 Cross-Sectional Study with Parents of Adolescent Attending High School in Gauteng and North West

360 Provinces, South Africa. AIDS research and treatment. 2016;2016:4842814.

361 31. Madiba S, Mokgatle M. Students want HIV testing in schools a formative evaluation of the

362 acceptability of HIV testing and counselling at schools in Gauteng and North West provinces in South

363 Africa. BMC Public Health. 2015;15(1):1–9.

364 32. Wilson KS, Beima-Sofie KM, Moraa H, Wagner AD, Mugo C, Mutiti PM, et al. “At our age, we would

365 like to do things the way we want:” A qualitative study of adolescent HIV testing services in Kenya.

366 AIDS. 2017;31 Suppl 3(Supplement 3):S213–20.

. CC-BY 4.0 International licenseIt is made available under a

is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted May 21, 2022. ; https://doi.org/10.1101/2022.05.17.22275222doi: medRxiv preprint

367 33. Eba PM, Lim H. Reviewing independent access to HIV testing, counselling and treatment for

368 adolescents in HIV-specific laws in sub-Saharan Africa: implications for the HIV response. Journal of

369 the International AIDS Society [Internet]. 2017;20(1):21456. Available from:

370 http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=med13&NEWS=N&AN=28799324

371 34. Binagwaho A, Fuller A, Kerry V, Dougherty S, Agbonyitor M, Wagner C, et al. Adolescents and the right

372 to health: eliminating age-related barriers to HIV/AIDS services in Rwanda. AIDS care [Internet].

373 2012;24(7):936–42. Available from:

374 http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=med8&NEWS=N&AN=22292484

375 35. Strode A, Essack Z. Facilitating access to adolescent sexual and reproductive health services through

376 legislative reform: Lessons from the South African experience. South African Medical Journal

377 [Internet]. 2017;107(9):741–4. Available from:

378 http://www.samj.org.za/index.php/samj/article/download/12055/8223

379 36. Ministry of Health Kenya. The Kenya HIV Testing Services Guidelines. 2015.

380 37. Ministry of Health Uganda. National HIV Testing Services Policy and Implementation Guidelines,

381 Uganda. 2016.

382 38. Ministry of health Rwanda. Republic of Rwanda: National Guidelines for Prevention and Management

383 of HIV and STIs. 2016.

384 39. Ministry of Health Ethiopia. National Guidelines for Comprehensive Hiv Prevention, Care and

385 Treatment. 2017.

386 40. Ministry of Health Malawi. Malawi Guidelines for Clinical Management of HIV in Children and Adults.

387 2016.

388 41. Ministry of Health Zimbabwe. Zimbabwe National Guidelines on HIV Testing and Counselling. 2014.

389 42. Ministry of Health Cameroon. NATIONAL GUIDELINE ON THE PREVENTION AND MANAGEMENT OF

390 HIV IN CAMEROON. 2015.

391 43. Ministry of Health Ghana. NATIONAL HIV and AIDS, STI POLICY. 2013.

392 44. Ministry of Health Swaziland. Swaziland integrated HIV guidelines 2015. 2015;

393 45. Ministry of health Lesotho. Guidelines for the use of antiretroviral drugs for HIV prevention and

394 treatment. 2016;1–145.

395 46. South Africa Department of Health. National consolidated guidelines for the prevention of mother-to-

396 child transmission of HIV and the management of HIV in children, adolescdents and adults. 2015.

397 47. SRHR AFRICA TRUST TANZANIA. Age of Consent: Legal Review Tanzania Country Report. 2019.

398 48. UNAIDS. UNAIDS data 2018. 2018.

399 49. Nelson KM, Underhill K, Carey MP. Consent for HIV Testing Among Adolescent Sexual Minority Males:

400 Legal Status, Youth Perceptions, and Associations with Actual Testing and Sexual Risk Behavior. AIDS

401 and Behavior. 2019;(0123456789).

402 50. Radhakrishna M, Durga K, Rao RK, Mallikarjuna, Doodipala, Reddy, et al. Factors associated with

403 conversion of long-term non-progressors to progressors: A prospective study of HIV perinatally

404 infected paediatric survivors. Indian Journal of Medical Research. 2013;138(322–328).

. CC-BY 4.0 International licenseIt is made available under a

is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted May 21, 2022. ; https://doi.org/10.1101/2022.05.17.22275222doi: medRxiv preprint

405 51. Grabar S, Selinger-Leneman H, Abgrall S, Pialoux G, Weiss L, Costagliola D. Prevalence and

406 comparative characteristics of long-term nonprogressors and HIV controller patients in the French

407 Hospital Database on HIV. Aids. 2009;23(9):1163–9.

408 52. Pillay BJ, Singh JA. ‘Mental capacity’, ‘sufficient maturity’, and ‘capable of understanding’ in relation

409 to children: how should health professionals interpret these terms? South African Journal of

410 Psychology. 2018;48(4):538–52.

411 53. Michaud PA, Blum RW, Benaroyo L, Zermatten J, Baltag V. Assessing an adolescent’s capacity for

412 autonomous decision-making in clinical care. Journal of Adolescent Health. 2015;57(4):361–6.

413 54. Griffith R. What is Gillick competence? Human Vaccines and Immunotherapeutics. 2016;12(1):244–7.

414 55. Young A. Key developments in case law: assessing competence in minors. Practice Nursing.

415 2019;2019(3):140–2.

416 56. Denison JA, McCauley AP, Lungu N, Sweat MD. Families matter: Social relationships and adolescent

417 HIV testing behaviors in Ndola, Zambia. Vulnerable Children and Youth Studies. 2014;9(2):132–8.

418

419

420

421

422

423

424

425

426

427

428

429

430

431

432

433

434

435

436

. CC-BY 4.0 International licenseIt is made available under a

is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted May 21, 2022. ; https://doi.org/10.1101/2022.05.17.22275222doi: medRxiv preprint

437 Tables and figures

438

Table 1: Search strategy

Search term 1

“Informed consent” OR consent* OR “legal age” OR law* OR legislature OR

“Parental consent”

AND

Search term 2

Adolescen* OR teen* OR youth* OR child* OR “young adult” OR “young

people”

AND

Search term 3

(HIV adj2 test*) OR (HIV adj2 diagnos *) OR (HIV adj2 screen*) –

Medline and

embase proximity operator

(HIV w/1 test*) OR (HIV w/1 diagnos*) OR (HIV w/1 screen*) -

Scopus proximity

operator

(HIV NEAR/1 test*) OR (HIV NEAR/1 diagnos*) OR (HIV NEAR/1 screen*) –

Web of science proximity operator

AND

Search term 4

“Africa South of the Sahara” OR “Sub-Saharan Africa*” OR “Subsaharan Africa*” OR

“Central Africa*” OR Cameroon* OR “Central African Republic*” OR Chad* OR

Congo* OR Gabon* OR “East* Africa*” OR Burundi* OR Djibouti* OR Eritrea* OR

Ethiopia* OR Kenya* OR Rwanda* OR Somalia* OR Sudan* OR Tanzania* OR

Uganda* OR “South* Africa*” OR Angola* OR Botswana* OR Lesotho* OR Malawi*

OR Mozambi* OR Namibia* OR Swazi* OR Eswatini OR Zambia* OR Zimbabwe* OR

“West* Africa*” OR “East* Africa*” OR Benin* OR “Burkina Faso*” OR “Cape

Verde*” OR “Cote d’Ivoire*” OR Gambia* OR Ghana* OR Guinea* OR Liberia* OR

Madagascar* OR Mali* OR Maurit* OR Niger* OR Senegal* OR “Sierra Leone*” OR

Togo*

439

* Mesh terms

. CC-BY 4.0 International licenseIt is made available under a

is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted May 21, 2022. ; https://doi.org/10.1101/2022.05.17.22275222doi: medRxiv preprint

440 Table 2:

Legal age of consent for HIV testing in SSA countries

441

Country

Age of consent

(years) reported in

2013(15)

Current age of consent (years)

Angola

18 (4)

Benin

14 (4)

Botswana

16 (4)

Burkina Fasso

18 (4)

Burundi

16 (48)

Cameroon

14 (42)

Central African Republic

14 (4)

Cote d ivoire

16 (48)

DRC

18 (48)

Djibouti

18 (48)

Eswatini/Swaziland

12 (44)

Ethiopia

15 (39)

Ghana

18 (43)

Kenya

15 (36)

Lesotho

12 (45)

Liberia

14 (4)

Madagascar

18 (4)

Malawi

13 (40)

Mali

18 (4)

Mozambique

14 (4)

. CC-BY 4.0 International licenseIt is made available under a

is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted May 21, 2022. ; https://doi.org/10.1101/2022.05.17.22275222doi: medRxiv preprint

Namibia

14 (4)

Niger

16 (4)

Nigeria

18 (4)

Rwanda

12 (38)

Senegal

14 (4)

Sierra Leone

18 (4)

South Africa

12 (46)

Sudan

18 (4)

Togo

14 (4)

Uganda

12 (37)

United republic of Tanzania

16 (47)

Zambia

16 (4)

Zimbabwe

16 (41)

442

ND- Age of minority with regard to HIV testing not defined

443

NA- Age is not applicable in criteria to decide adolescents who can consent for HIV testing, but

444

maturity of the adolescents

445

446

447

448

449

450

451

452

453

454

455

. CC-BY 4.0 International licenseIt is made available under a

is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted May 21, 2022. ; https://doi.org/10.1101/2022.05.17.22275222doi: medRxiv preprint

456

Figure 1: Prisma diagram

457

458

459

460

461

462

463

464

465

466

467

468

469

470

471

472

473

474

475

476

477

478

479

480

481

482

483

484

Total number of articles identified after

database search

n = 1572

Tittle screening

n = 360

1212 excluded on screening for

duplicates

Abstract screening

n = 99

Full text screening

n = 23

261 excluded on tittle screening

76 excluded on abstract screening

stage

15 excluded on full text screening

8 articles included

. CC-BY 4.0 International licenseIt is made available under a

is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted May 21, 2022. ; https://doi.org/10.1101/2022.05.17.22275222doi: medRxiv preprint

485 Figure 2:

Age of consent in 2013 versus the age of consent in 2019

486

487

488

ND- Age of consent not defined, NA- Chronological age not applicable for consent

489

490

491

492

. CC-BY 4.0 International licenseIt is made available under a

is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted May 21, 2022. ; https://doi.org/10.1101/2022.05.17.22275222doi: medRxiv preprint