1. Testing African Adolescents for HIV: What Part Do Our Laws Play?
Dr. Nadia Sam-Agudu
Technical Advisor, Pediatric and Adolescent HIV
Institute of Human Virology Nigeria, Nigeria
Department of Paediatrics, University of Cape Coast, Ghana

2. Learning Objectives
At the end of this presentation, participants should be able to:
Summarize existing policy on self-consent for HIV testing services in Ghana and among high adolescent HIV-burden African countries.
Describe legal and policy reforms needed to remove barriers to accessing HIV testing for African adolescents.
Identify healthcare system practice changes required to implement legally-supported access to HIV/SRH services for African adolescents.

3. What is Going on with Adolescents and HIV?
AIDS-related mortality has increased among adolescents y old.
The impact is highest in sub-Saharan Africa, where 80% of HIV-infected adolescents live.
The WHO identifies inadequate access to HIV testing as part of the problem
The “All In to End Adolescent AIDS” initiative aims to reduce new adolescent infections by 75%, to reduce AIDS-related mortality by 65%, and to achieve zero discrimination by 2020.
However, none of these will be achieved without many more adolescents, especially in Africa, being tested for HIV.

4. What is the Epidemiology of Adolescent HIV in ssA and in Ghana?
Globally, there are 2.0 million y old adolescents living with HIV (ALHIV)
1.6 million (80%) in ssA
“All In” focuses on 25 high-burden countries, 18 in ssA
Ghana is not an “All In” country; Nigeria is
Nigeria = 200,000 ALHIV; Ghana = 15,000
Ghana’s ALHIV burden is ≥ that of “All In” coutries Haiti, Lesotho, Namibia, Thailand, Ukraine

5. What is the Epidemiology of Adolescent HIV in ssA and in Ghana?
Global AIDS-related mortality among ALHIV, 2014: 67,000
AIDS related mortality among ALHIV in ssA, 2014: 58,000, ~87% of global
Ghana: <1,000 of 15,000
Nigeria: 7,100 of 200,000
Percent of y olds testing for HIV,
ssAfrica: 13% of females, 9% of males
East and southern Africa: 22% females, 16% males
West Africa: 6% females, 3% males
Ghana, 5% females, 1% males; Nigeria 4% females, 2% males

6. Access to HIV Testing for Adolescents
It is either by law, or by provider discretion in the absence of a law
HIV testing involves consideration of sexual risk, exposure and maturity in the context of different cultures/countries?
What is the trend regarding consent and exposure of adolescents in different situations?
Note: WC Africa has highest rates of first births before 15 years (6%) and before 18 y (28%) in the world

7. What are the main barriers and high risk groups among adolescents testing for HIV?
Barriers to testing:
Perceived risk with respect to sexual exposure
Poor attitudes of healthcare providers
Parental consent requirements
Most-at-risk adolescents for HIV infection and missed opportunities for testing include:
Those perinatally infected,
Those with early sexual debut, high mobility and multiple/older partners, and pregnant and non-pregnant females.

8. What do Laws in High-ALHIV burden Countries in ssA Say about HIV testing?
Country
Estimated ALHIV Burden
(10 to 19 yrs), 2014
Legal Age of Consent for Independent HTCb
Legal Age of Consent for Consensual Sexb,c
Legal Age of Consent, Yrs, for Marriage
(Early marriage age for girls, supported under customary and/or religious practicec
Adolescent Pregnancy Rate (per 1000 females aged yrs)d
South Africa
250,000
12yrs
18 (12) 54
Nigeria
200,000
18yrs
18 (at puberty)
122
Kenya
160,000
No age limite
16 (at puberty)
106
Mozambique
120,000
16yrs
21 (under 15)
166
Tanzania
110,000
128
Zimbabwe
18 (no minimum)
112
Uganda
100,000
146
Ethiopia
98,000
15yrs
18 (7) 87
Malawi
83,000
13yrs
157
Zambia
65,000
16 (no minimum)
151
Cameroon
39,000
18 (9)
Democratic Republic of the Congo
36,000
14yrs girls/18yrs boys
18 (_f)
135
Côte d’Ivoire
29,000
18 girls, 20 boys(14)
125
Rwanda
20,000
21 (-f) 41
Botswana
17,000
18 (-f) 51
Ghana
15,000 66
Lesotho
16 girls,18 boys (no minimum) 92
Swaziland
14,000
18 (13) 89
Namibia
11,000 74

9. What are the specific Ghana laws?
Age of consent for sex, 16 y: Ref. Sections of the Criminal Offences Act, 1960 (Act 29)
Age of consent for marriage, 18 y: Ref. sections 14 and 15 of the Children's Act, 1998 (Act 560).
Age of consent for HIV testing and/or sexual and reproductive health services: Section 3.8 of the National HIV and AIDS, STI Policy, 2013 deals with consent of individuals for medical or behaviour change intervention.
Whereas medical consent for a child (ie a person under 18 years) must be obtained through a legal guardian, there are exceptions for adolescents with respect to sexual and reproductive health.
“Where it is impracticable or undesirable to obtain this consent (ie parental/guardian) because a child is between the ages of 16 and 18 yrs, a medical practitioner may institute the necessary care and intervention in the best interest of the individual. Adolescents have a right to access appropriate health information and counselling services regardless of parental consent, particularly information and counselling services concerned with sexual and reproductive health.”
The Ghana AIDS Commission Bill is currently in Parliament which seeks to enact the provisions in the National HIV Policy.

10. Review in Pediatric Research Journal, 2016

11. Regional Analyses of Access to HIV Testing and the Law
Relatively low adolescent testing rates and more restrictive consent requirements in West and Central Africa as compared to East and southern Africa.
Cote d’Ivoire just changed their age of consent for HIV testing and sexual and reproductive health (SRH) services from 18 y to 16 y in 2016

12. Way Forward and Recommendations
Enactment and implementation of laws expressly permitting independent access to HIV testing for adolescents less than 18 y of age especially in WCA. The median age at sexual debut or age at which customary/traditional marriages are allowed can be a benchmark.
It is critical for age of consent legislation that takes age of first exposure to sexual activity (within and outside of marriage) into consideration. This is especially important for girls.
Consultations among stakeholders, including adolescents and lawmakers, should be held to determine timeline and reference ages for revising HTC legislation.
WCA countries can leverage on lessons learned from ESA countries that have already lowered their age of consent for HTC
Medical practitioners should be sensitized to overcome their personal/religious/cultural biases in order to provide rights-based HIV and SRH care to adolescents and young people.

13. Thank you for your time!

14. Key References
Ghana Legal Codes: Criminal Offences Act, 1960; Children's Act, 1998 (Act 560).
Ghana National HIV and AIDS, STI Policy, 2013
UNICEF Global HIV Database, 2014 and 2015
All In to End Adolescent AIDS
Kasedde S, Luo C, McClure C, Chandan U. Reducing HIV and AIDS in adolescents: opportunities and challenges. Curr HIV/AIDS Rep 2013;10:159–68.
World Health Organization. HIV and Adolescents: Guidance for HIV Testing and Counselling and Care for Adolescents Living with HIV,
World Health Organization. The Voices, Values and Preference of Adolescents on HIV Testing and Counselling,
Sam-Agudu N, Folayan MO, Ezeanolue E. Seeking wider access to HIV testing for adolescents in sub-Saharan Africa. Pediatr Res. 2016;79(6):838–45.