WHO, UNICEF, UNFPA, UNESCO & GNP+ Adolescent HIV Testing and Counselling (HTC) and care for adolescents living with HIV (ALHIV) 2013 Guidelines WHO, UNICEF, UNFPA, UNESCO & GNP+ Rachel Baggaley, coordinator, Key Populations and Innovative Prevention Jane Ferguson, coordinator, Adolescent Health WHO Geneva 22/09/2018

Why adolescent guidelines? Adolescents (10-19 years of age) have significantly lower HTC, ART & PMTCT access & coverage than other population groups (i.e. adults & paediatrics) Retention in care and adherence to ART is often sub-optimal 3 groups of adolescents need consideration: adolescents infected vertically, diagnosed early & started on ART >500,000 infants/young children now on ART – little experience of care & treatment for adolescents adolescents infected vertically, not diagnosed early & not started on ART Significant mortality & morbidity before & after 'late' ART adolescents acquiring HIV horizontally, through sexual or parenteral transmission 39% of new HIV infections are in 15-25 year olds Adolescents: no longer children, not yet adults Adolescence is a period of rapid development – they acquire new capacities & face new challenges. Health workers often feel unable to address adolescents’ needs

HIV testing & counselling (HTC) for adolescents HTC with linkage to prevention treatment and care is recommended for adolescents from key affected populations in all settings (generalized, low and, concentrated epidemics) Low quality evidence, strong recommendation In generalized epidemics, HTC with linkage to prevention treatment and care is recommended for all adolescents Low quality evidence, strong recommendation We suggest that in low and concentrated epidemics, HTC with linkage to prevention treatment and care be accessible for adolescents Very low quality evidence, conditional recommendation

Consent for HIV testing The requirement for parental/guardian/caregiver consent can be a barrier for adolescents in accepting HTC, care, & services The ages at which adolescents can consent for HTC varies widely from 12 to ≥ 18 years of age Many countries have 'exceptions' – mature minors, pregnant adolescents, child-headed households Countries where age of consent for HTC has been lowered (e.g. to 12 years) –no adverse consequences have been reported There are no global guidelines for age of consent since it is not possible to address with GRADE –reflecting human rights and ethical issues. Rather it is proposed that countries review consent polices to facilitate access to HTC & other health service delivery for adolescents

Disclosure recommendations Disclosure to adolescents All adolescents should be disclosed to about their HIV status All adolescents should be disclosed to about the HIV status of their parents/guardians Low quality evidence, strong recommendation Disclosure by adolescents We suggest that adolescents be counselled about the potential benefits and risks of disclosure of their HIV status and empowered and supported to determine if, when, how, and to whom to disclose Very low quality evidence, conditional recommendation Disclosure of HIV status can have many benefits, e.g. disclosure for support from family, partner, friends. But disclosure to sexual partners and for adolescents from key populations may have challenges, e.g. stigma, discrimination, criminalization

Service delivery recommendations: support retention in care & adherence to ART Community based care and support We suggest that HIV care and treatment programmes include community-based approaches to improve adherence and retention of adolescents living with HIV Low quality evidence, Conditional recommendation Health worker training We suggest that training of health care providers can contribute to improved adherence to treatment and retention in care among adolescents living with HIV

Recommendations: ART service delivery Decentralization of HIV care & treatment Integration with TB, ANC, & IDU services Task shifting for HIV care & treatment Interventions to optimize adherence to ART strong recommendations, low quality evidence