Review
Seeking wider access to HIV testing for adolescents in
sub-Saharan Africa
Nadia A. Sam-Agudu1,2,3,4, Morenike O. Folayan5 and Echezona E. Ezeanolue6,7
More than 80% of the HIV-infected adolescents live in sub-
Saharan Africa. Acquired immune deficiency syndrome (AIDS)-
related mortality has increased among adolescents 10–19 y
old. The impact is highest in sub-Saharan Africa, where >80% of
HIV-infected adolescents live. The World Health Organization has
cited inadequate access to HIV testing and counseling (HTC) as
a contributing factor to AIDS-related adolescent deaths, most of
which occur in sub-Saharan Africa. This review focuses on stud-
ies conducted in high adolescent HIV-burden countries targeted
by the “All In to End Adolescent AIDS” initiative, and describes
barriers to adolescent HTC uptake and coverage. Fear of stigma
and family reaction, fear of the impact of a positive diagnosis,
perceived risk with respect to sexual exposure, poor attitudes
of healthcare providers, and parental consent requirements are
identified as major impediments. Most-at-risk adolescents for
HIV infection and missed opportunities for testing include, those
perinatally infected, those with early sexual debut, high mobil-
ity and multiple/older partners, and pregnant and nonpregnant
females. Regional analyses show relatively low adolescent test-
ing rates and more restrictive consent requirements for HTC in
West and Central Africa as compared to East and southern Africa.
Actionable recommendations for widening adolescent access to
HTC and therefore timely care include minimizing legal consent
barriers, healthcare provider training, parental education and
involvement, and expanding testing beyond healthcare facilities.
A dolescents 10–19 y old have recently received increased
global focus for targeted HIV research and programming.
Between 2005 and 2012, AIDS-related deaths fell by 30%
among the global people living with HIV (PLHIV) population
(1); however mortality rose by 50% among adolescents liv-
ing with HIV (ALHIV) (1,2). Globally, in 2013, an estimated
120,000 AIDS-related deaths occurred among adolescents
aged 10–19 y, with 110,000 (nearly 92%) of these deaths occur-
ring in sub-Saharan Africa (3). This represents a significant
rise in global adolescent AIDS deaths from 71,000 in 2005 (4).
AIDS is the number one killer of adolescents in Africa (5,6).
To control the impact of AIDS on the lives of adolescents living
1
Clinical Department, Institute of Human Virology Nigeria, Abuja, Nigeria; 2Division of Epidemiology and Prevention, Institute of Human Virology, University of Maryland School of
Medicine, Baltimore, Maryland; 3Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland; 4Department of Paediatrics, University of Cape Coast,
Cape Coast, Ghana; 5Department of Child ­Dental Health and Institute of Public Health, Obafemi Awolowo University, Ile Ife, Nigeria; 6Department of Pediatrics, University of Nevada
Las Vegas, Las Vegas, Nevada; 7Department of Public Health, University of Nevada Las Vegas, Las Vegas, Nevada. Correspondence: Nadia Sam-Agudu (nsamagudu@ihvnigeria.org)
Received 17 April 2015; accepted 13 December 2015; advance online publication 16 March 2016. doi:10.1038/pr.2016.28
838  Pediatric Research       Volume 79 | Number 6 | June 2016
nature publishing group
in sub-Saharan Africa, early detection and treatment as well as
the prevention of new infections are important. With respect to
new infections, female adolescents are of particular concern. In
2013, approximately 65% of all new adolescent HIV infections
were among girls, largely in sub-Saharan African countries
(3,6). Of the 1.7 million African ALHIV, an estimated 1 million
(nearly 60%), are female (7). In countries such as South Africa,
Sierra Leone and Gabon, girls represent more than 80% of new
HIV infections in adolescents (4,8). Regardless of gender, the
vast majority of African adolescents, including those already
infected with HIV, do not know their HIV status (3,6). The
rates of HIV testing among adolescents range from a low of 1%
in Congolese males to 44% in Malawian females, with a 16.4%
average testing rate between 18 high-burden African coun-
tries (8). Limited access to HIV testing and counseling (HTC),
leading to late or limited access to quality care have been cited
by the World Health Organization (WHO) and UNAIDS as a
causative factor in the increase in ALHIV mortality over the
past decade (6,9). Therefore, low rates of testing, especially in
the highest adolescent HIV-burden countries should be evalu-
ated, and barriers to wider access to testing-and therefore to
early treatment and treatment-as-prevention- should be effec-
tively addressed.
In February 2015, the United Nations launched the “All-In”
initiative to end Adolescent AIDs, which aims to reduce new
adolescent infections by 75%, to reduce AIDS-related mor-
tality by 65%, and to achieve zero discrimination by 2020 (8).
Of the 25 “All In” countries that represent 90% of deaths and
85% of new infections in adolescents, 18 (72%) are in sub-
Saharan Africa (8). “All In” aims for at least 90% of ALHIV to
know their status, and part of the approach is to advocate for
wider adolescent access to HIV testing at the country level
using strategic information relevant to this population (8).
Unfortunately, without concentrated efforts, sub-Saharan
Africa may be left behind and may not meet this target by
2020. This review highlights region-specific adolescent HIV
studies and discusses challenges in, and opportunities for
providing wider access to timely HTC services for adoles-
cents in sub-Saharan Africa.
Copyright © 2016 International Pediatric Research Foundation, Inc.
 HIV Testing for African Adolescents
UPTAKE OF ADOLESCENT HIV TESTING AND COUNSELING
IN SUB-SAHARAN AFRICA
In 2007, the WHO recommended provider-initiated testing
and counseling (PITC) as an opt-out approach to HTC, where
healthcare workers provide testing as part of routine medical
care or clinical management unless the client declines (10). This
was in contrast to the client-initiated voluntary counseling and
testing, where the client proactively seeks HIV testing on their
own. The goal of the PITC strategy is to increase opportuni-
ties for HIV testing and diagnosis, especially in high-burden
areas with low testing rates. With the PITC guidelines came a
recommendation to governments “to develop and implement
clear legal and policy frameworks” to address issues of con-
sent and assent for minors including adolescents (10). Even for
client-initiated voluntary counseling and testing, issues of con-
sent and assent remain for adolescent minors, and therefore
the presence of clear, well-communicated legal policies play a
critical role in HTC scale-up among adolescents.
By 2010, 42 African countries, including all 18 All-In African
countries, had adopted a PITC policy, however, the PITC poli-
cies were not universally applied across all populations in all
countries (11). The main population targeted was pregnant
women, and by 2010, only 31 of the 42 countries offered PITC
to all adults, and PITC was offered to infants of HIV-positive
mothers, children on admission or in feeding centers in only
10 countries (11).
Table 1 shows rates of HIV testing among adolescents
who also received their results in the 18 All-In African coun-
tries, using the most current available data between 2009 and
2014. Among girls, the lowest rates were in Nigeria (4%), the
Democratic Republic of Congo (DRC) (5%) and Côte d’Ivoire
(10%), while the highest rates occurred in Uganda (31%),
Lesotho (33%), and Malawi (44%). For boys, testing rates were
lowest in the DRC (1%), Nigeria (2%), and Côte d’Ivoire (5%)
and highest in Swaziland (18%), Malawi (21%), and Rwanda
(24%) (8). These data reveal that the lowest HIV testing rates
among adolescents are occurring in West and Central African
(WCA) countries, while the highest rates are in East and
southern African (ESA) countries. It is possible that the rela-
tively lower rates of adolescent HTC in WCA countries stem
from the prevalence and/or type of epidemic in that region.
Adult HIV prevalence in WCA countries (median 1.6%) is
generally lower than in ESA countries (median 6.3%) (12).
Furthermore, in contrast to ESA’s generalized epidemic, WCA
presents more of a mixed (both generalized and concentrated)
epidemic within countries (13). This may make it more com-
plicated to locate and test HIV-infected individuals, and there-
fore result in lower HTC coverage. Regardless, none of the
adolescent HTC rates in any African country approximate the
90% target that the All-In initiative aims for. While also falling
short of the 90% benchmark, reported adult (15–49 y) HTC
in the All-In countries have been higher than that of adoles-
cents. Drawing on data current between 2010 and 2013, adult
HTC rates were 12.6, 13.2, and 17.1% in Côte d’Ivoire, DRC,
and Nigeria, respectively; higher values of 59.3% were reported
from Uganda, 63.8% from Botswana and 51.2%/71.6%
Copyright © 2016 International Pediatric Research Foundation, Inc.
Review
(in males/females) from Malawi (14). Similar to the adolescent
group, WCA adults are experiencing the lowest HTC rates
while those in ESA countries are experiencing relatively higher
rates. The WHO PITC, Adolescent Testing and Consolidated
HIV Testing Service guidelines make testing recommen-
dations for all populations in low-level, concentrated and
generalized epidemics, but not specifically for mixed concen-
trated-generalized epidemics (9,10,15). All populations are to
be offered PITC in generalized epidemics, and key population
adolescents are to be offered testing in all epidemic type set-
tings (9,10,15). Testing services with linkage to care are to be
made accessible for adolescents in concentrated and low-level
epidemic settings (9,15). All three documents strongly recom-
mend revision of age of consent policies to increase indepen-
dent access to HTC for adolescents.
WILLINGNESS TO TEST AND BARRIERS TO HIV TESTING
AND COUNSELING AMONG ADOLESCENTS IN SUB-
SAHARAN AFRICA
Studies show that the desire to be tested for HIV among ado-
lescents is relatively high. A WHO study combining data from
workshops among 98 adolescents in the Philippines, South
Africa and Zimbabwe with an online survey of 655 participants
from 92 countries indicated that approximately two-thirds
of untested adolescents desired an HIV test (16). The WHO
study included 13 of the 18 All In African countries. Individual
country studies and surveys also indicate strong desire to test:
between 47.8 and 85.5% of adolescents and youth want to be
tested for HIV in West/Central (17–20), East (18,21–23), and
southern Africa (24–26). The proportion of adolescents will-
ing to test differed within and between some countries with
respect to factors including gender, geographical residence,
socio-cultural norms, and HIV knowledge and risk perception
of participants. Overall, the proportion of adolescents willing
to test was higher in later vs. earlier-conducted studies.
Given the low HTC rates, it appears that adolescents’ will-
ingness to be tested is not matched by their HTC uptake,
and factors reducing access to testing need to be elicited and
addressed. The WHO adolescent HTC study evaluated barri-
ers to HTC, categorizing them into personal, social, cultural,
or service-related (16). The most frequently expressed barrier
to HTC among untested adolescents was fear, including fear
of needles, parents’ reaction to a positive result, AIDS-related
illness, stigma/discrimination, and death (16). Interestingly,
while ~20% of respondents expressed fear as a barrier, this pro-
portion rose to ~53% among the African adolescents (16), sug-
gesting that addressing multiple sources of fear (for example,
debunking myths and exaggerations of truth with education
and counseling) among African adolescents may be important
to overcome barriers to testing. Other major barriers identi-
fied in the WHO study were the impact of a positive ­diagnosis,
association of HTC with bad or high-risk behavior, lack of
information, perceived risk with respect to sexual exposure,
denial, poor attitudes of healthcare providers (poor confiden-
tiality, insensitivity, and being judgmental), difficulty access-
ing testing services (transportation, cost, long waiting times,
Volume 79 | Number 6 | June 2016      Pediatric Research  839
Review Sam-Agudu et al.

Table 1.  HIV statistics among adolescents in sub-Saharan Africaa,b

% Adolescents Estimated number % HIV prevalence
(15–19 y) of new infections among
HIV-tested and among adolescents adolescents
ALHIV Estimated Estimated
received resultsc (15–19 y), 2013 (15–19 y)c
Burden Rank, ALHIV Burden ALHIV Burden
2014 Country (10–19 y), 2014 (10–19 y), 2013 Female Male Female Male Female Male
1 South Africa 250,000 320,000 -d -d 45,000 8,800 5.6 0.7
2 Nigeria 200,000 160,000 4.0 2.0 12,000 5,300 - d
-d
3 Kenya 160,000 140,000 18.0 13.0 6,200 2,700 1.1 0.9
4 Mozambique 120,000 110,000 18.0 8.0 12,000 4,600 7.1 2.7
5 Tanzania 110,000 140,000 21.0 13.0 4,300 1,800 1.3 0.8
6 Zimbabwe 110,000 110,000 18.0 7.0 4,700 2,100 4.2 3.4
7 Uganda 100,000 110,000 31.0 17.0 10,000 4,500 3.0 1.7
8 Ethiopia 98,000 140,000 19.0 17.0 1,100 <500 0.2 0.0
9 Malawi 83,000 93,000 44.0 21.0 2,200 1,000 4.2 1.3
10 Zambia 65,000 79,000 22.0 10.0 3,100 1,900 5.7 3.6
11 Cameroon 39,000 41,000 15.0 7.0 2,700 1,200 2.0 0.4
12 Democratic Republic of the Congo 36,000 32,000 5.0 1.0 2,000 <1,000 0.7 0.2
13 Côte d’Ivoire 29,000 41,000 10.0 5.0 <1,000 <500 0.8 1.0
14 Rwanda 20,000 18,000 27.0 24.0 <500 <200 0.8 0.3
15 Botswana 17,000 11,000 -d -d <1,000 <500 5.0 2.4
16 Lesotho 15,000 21,000 33.0 12.0 2,000 <1,000 4.1 2.9
17 Swaziland 14,000 11,000 23.0 18.0 <1,000 <500 10.1 1.9
18 Namibia 11,000 13,000 29.0 14.0 <1,000 <500 -d -d
Among the highest ALHIV-burden sub-Saharan African countries targeted by All In to End Adolescent AIDS, in 2013, and where indicated, in 2014 (8). bData from UNICEF Global HIV
a

Database, October 2014 (3) and from All In to End Adolescent AIDS (8). cData compiled from most recent national surveys conducted between 2007 and 2014 (8). dNo available data (8).

service hours), and parent/guardian consent requirements
(16). Other studies conducted across sub-Saharan Africa cor-
roborate with the WHO study with respect to barriers to ado-
lescent HTC (18,20,22–24,26–32). These studies identified
major barriers as fear of a positive test, especially among those
sexually active, and fear of stigma and discrimination, includ-
ing being ostracized by friends and family. Fear of loss of cur-
rent or future partners, and the potential psychological impact
of these consequences, including depression and suicide, were
also expressed by African adolescents (22–24,26,28,30,32).
Due to its legal implications, and likely wide cross-regional
and country variation, age of consent for HTC amongst minors
under age 18 y is treated separately. The next section singles
out and discusses legal consent as relates to HTC among ado-
lescents in sub-Saharan Africa.
LEGAL AGE OF CONSENT AND ADOLESCENT HIV TESTING
IN SUB-SAHARAN AFRICA
One of the major barriers to the uptake of HTC among ado-
lescents in sub-Saharan Africa is the requirement of paren-
tal/guardian consent for minors (33). The WHO reports
that of 40 countries in the African region with defined laws
on age of consent for HTC, less than half (19, 47.5%) have
enacted laws supporting independent HTC to adolescents
less than 18 y of age (33). The remaining 21 countries that
do not have legislation supporting HTC for minors include
5 All In countries: Cameroon, Côte d’Ivoire, DRC, Nigeria,
and Tanzania (33) (Table 2). With the exception of Tanzania,
all of these countries are in West and Central Africa.
Lawmakers are often reluctant to reduce the minimum age
of consent for sexual and reproductive health (SRH) ser-
vices, including HTC, out of the desire to protect the child,
who may be viewed as too young or immature (9,33). With
respect to HTC and SRH research among adolescents, these
concerns have been countered with reassuring evidence and
testing/recruitment approaches and strategies (34–37), how-
ever, challenges still exist with enactment and implementa-
tion of laws supporting HTC for minors. Even where the
law permits access to HTC by younger adolescents or where
parental/guardian consent can be sought, the behavior of
healthcare providers may act as barriers due to the influence
of socio-cultural norms consistent with limiting dialogue
about sex, restricting services for HTC, judgmental attitudes
during service provision to adolescents and determining
appropriateness of caregivers to give consent (16,33,37–41).
Furthermore, confusion about testing guidelines and regu-
lations and concern for the ward’s increased vulnerability
if HIV-positive, may limit healthcare providers’ offering of
HTC as PITC (41). Nevertheless, the involvement of fam-
ily in an ALHIV’s decision to test and their ward’s ability
to cope after disclosure of a positive test has been shown to
be critical (28). As much as independent adolescent testing

840  Pediatric Research       Volume 79 | Number 6 | June 2016 Copyright © 2016 International Pediatric Research Foundation, Inc.
 HIV Testing for African Adolescents Review
Table 2.  Age of consent for sexual activity, marriage and for HIV testing and counseling, sub-Saharan African countriesa
Legal age of Legal age of Legal age of consent, years, for
Estimated consent for consent for marriage (early marriage age for % Young women Adolescent pregnancy
ALHIV Burden independent consensual girls, supported under customary (20–24 y) married or rate (per 1,000 females
Country (10–19 y), 2014 HTCb sexb,c and/or religious practicec in union by age 18 yd aged 10–19 y)d
South Africa 250,000 12 y 12 y 18 (12) 6.0 54
Nigeria 200,000 18 y 18 y 18 (at puberty) 43.0 122
Kenya 160,000 No age limite 18 y 16 (at puberty) 26.0 106
Mozambique 120,000 16 y 18 y 21 (under 15) 48.0 166
Tanzania 110,000 18 y 18 y 18 (12) 37.0 128
Zimbabwe 110,000 16 y 16 y 18 (no minimum) 31.0 112
Uganda 100,000 12 y 18 y 18 (12) 40.0 146
Ethiopia 98,000 15 y 18 y 18 (7) 41.0 87
Malawi 83,000 13 y 16 y 18 (12) 50.0 157
Zambia 65,000 16 y 16 y 16 (no minimum) 42.0 151
Cameroon 39,000 18 y 18 y 18 (9) 38.0 128
Democratic 36,000 18 y 14 y girls/18 y 18 (_f ) 39.0 135
Republic of boys
the Congo
Côte d’Ivoire 29,000 18 y 18 y 18 girls, 20 boys (14) 33.0 125
Rwanda 20,000 15 y 18 y 21 (-f ) 8.0 41
Botswana 17,000 No age limit e
16 y 18 (- )f
-f
51
Lesotho 15,000 12 y 18 y 16 girls,18 boys (no minimum) 19.0 92
Swaziland 14,000 16 y 16 y 18 (13) 7.0 89
Namibia 11,000 16 y 16 y 18 (-f ) 9.0 74
a
Among the highest ALHIV-burden sub-Saharan African countries targeted by All In to End Adolescent AIDS (8). bData from WHO: Adolescent consent to HIV testing: a review of current
policies and issues in sub-Saharan Africa (33). cData from Country Reports on Human Rights Practices (Forced and Early Marriage, and Sexual Exploitation of Children), 2013 (43).
Only data on legal age not requiring parental approval are displayed. dMost recent data up until 2013. Data from UNICEF, State of the World’s Children Report, 2014 (42). eAll or most
adolescents are eligible under several considerations including showing maturity, of reproductive age, married, pregnant, or engaged in high-risk behavior. fNo available data.

should be made available, a supportive and involved family
is desirable for optimal outcomes.
TESTING PREGNANT AND NONPREGNANT FEMALE
ADOLESCENTS IN SUB-SAHARAN AFRICA
In many African countries where adolescents have limita-
tions in access to HTC and HIV care, early marriage at <15
y, especially amongst girls, is culturally and/or legally permis-
sible (Table 2) (33,42,43). These marriages are often arranged
by parents and guardians without input from the adolescent
(33,42). Among married adolescent girls age 15–19 y in six
West African countries, only 16–26% state that they have a
final say in their own healthcare (44). In this regard, early mar-
riage and parenthood where not consistent with empowerment
to make choices such as self-testing for HIV, is not necessarily
a step toward adulthood and independence. The concept of
“emancipated minor” in many of these countries is either non-
existent or poorly defined (33,43), making access to testing and
other HIV/SRH-related services difficult for most adolescents.
In addition to relatively high HIV incidence, sub-Saharan
African countries have some of the highest pregnancy rates
among adolescents in the world (Table 1). The high rate of ado-
lescent pregnancies reflects poor access to family planning for
this population and indicates the need for a more integrated
and comprehensive approach to adolescent sexual health,
including family planning and HTC. With the exception
of Rwanda, all the All-In African countries are also priority
countries for the elimination of mother-to-child transmis-
sion of HIV (45). Pregnant adolescent females living with HIV
are a subgroup of African ALHIV that has received relatively
little attention. These adolescents often have to contend with
the double stigma of teen or preteen pregnancy and HIV; in
African societies, both of these phenomena are regarded as
indicative of sexual promiscuity. Unless pre- and early preg-
nancy HTC services for this marginalized group are scaled up,
exposed infants and uninfected partners will continue to be at
risk for HIV infection.
To date, only two studies, both from South Africa, have spe-
cifically evaluated HTC among pregnant adolescents accessing
prevention of mother-to-child transmission of HIV (PMTCT)
services (46,47). One study was a cross-sectional survey in
Kwazulu Natal (KZN) (46); the other was a cohort study with
follow-up, in Eastern Cape (47). Ever-tested for HIV rates were
similar (≥ 98%) between adolescent and adult mothers in the
KZN study (46), likely facilitated by legislation supporting
HTC for adolescents 12 y and older in South Africa (33). In
the Eastern Cape study, adolescents were 1.4 times less likely to
have tested for HIV prior to booking (47). Compared to adult

Copyright © 2016 International Pediatric Research Foundation, Inc. Volume 79 | Number 6 | June 2016      Pediatric Research  841
Review Sam-Agudu et al.
women, adolescents experienced later entry into care, lower
ART uptake or inappropriate ART administration, lower early
infant diagnosis rates, and increased mother-to-child trans-
mission of HIV (MTCT), stillbirth, and mortality (46,47).
These studies highlight gaps in PMTCT service delivery for
adolescents and higher risk of MTCT among adolescent HIV-
positive mothers, even in the setting of optimized legal access
to HTC. It is evident that legal access to HTC should be cou-
pled with timeliness of testing and successful linkage to com-
prehensive services, particularly among adolescent females
before and during pregnancy.
THE CASE FOR EXPANDING ADOLESCENT ACCESS TO
HIV TESTING AND COUNSELING BY LOWERING AGE OF
CONSENT
In 2014, the Joint United Nations Programme on HIV/AIDS
(UNAIDS) introduced new global HIV targets to be achieved
by 2020. These targets were dubbed “90-90-90”: to have 90%
of all people living with HIV knowing their status, 90% of all
people diagnosed with HIV receiving sustained antiretroviral
therapy, and 90% of all people receiving antiretroviral therapy
achieving viral suppression (48). Up to 81% of African adoles-
cents already living with HIV do not know their HIV status
(38,39,49–51). One study from Zimbabwe reported that 80%
of ALHIV in their study cohort were infected from MTCT and
15% from sexual transmission (51). Apart from the large gap
in access to HTC, the lack of adolescents’ knowledge of their
HIV status is partially attributable to low disclosure rates of
HIV-positive status previously known to others (39,50,52).
Expanding independent access to HTC allows maturing ado-
lescents, especially the perinatally-infected and those not dis-
closed to, to discover their HIV status and to begin to take
charge of their own health (25,40).
Restriction of independent HTC as an SRH service to indi-
viduals 18 y and older can be argued to be slowing progress
in the provision of appropriate, impactful interventions for
HIV prevention and quality HIV care amongst African ado-
lescents (33,53). With the exception of Tanzania, ESA All In
countries have more adolescent-friendly HTC laws and have
higher adolescent HTC coverage than WCA countries, whose
laws restrict self-consent for HTC to 18 y and above (Tables
1and 2). Legally-enabling environments are likely to promote
not only the provision of clinical services but the conduct of
research and the establishment of targeted health programs
relevant to HIV among adolescents. Subsequently, adolescent-
specific research findings can contribute to impactful policies
on HIV prevention and control among African adolescents.
Therefore, restrictions on independent access to critical adoles-
cent SRH services including HTC may be contributing to a lack
of, or weak policies for this population. This may be especially
true for WCA, where the HIV epidemic is of a mixed nature
(13) and PLHIV, including adolescents, may be more difficult to
reach, test, and treat with current strategies and policies.
Recent cross-continental and global technical reports
and guidelines have featured little or no input from the
WCA region (9,54). Furthermore, recent significant funding
842  Pediatric Research       Volume 79 | Number 6 | June 2016
initiatives targeted to pediatric and adolescent HIV treatment
and prevention in sub-Saharan Africa such as the Accelerating
Children’s HIV/AIDS Treatment and DREAMS initiatives
(55–57) have involved few or none of the high-burden West
and Central African countries. There have been high-level
calls for quality strategic information and increased HIV/
SRH research participation among all adolescents, especially
in Africa (5,6,9). Southern and East Africa have led the region
in implementing innovative approaches to adolescent HIV
services, leaving West and Central Africa trailing behind (54).
However, sub-Saharan Africa as a whole needs more efforts
to improve HIV diagnosis and access to quality care and to
reduce AIDS-related deaths among adolescents (8,9,33). One
of the first steps in changing the status quo is the identifica-
tion of as many ALHIV as possible: the road to 90-90-90 for
African adolescents starts with wider access to independent
HTC.
ENABLING STRATEGIES AND INTERVENTIONS TO IMPROVE
ADOLESCENT HIV TESTING AND COUNSELING
A rights-based approach should guide access to adolescent SRH
and HIV care (37,58), including testing for HIV. Adolescents
should be informed of their right to access stigma-free HIV
testing and related services provided by respectful, compe-
tent staff, and they should participate in the development and
implementation of relevant policies and practices. In order to
achieve this, an enabling environment should be created within
legal, socio-cultural, research and healthcare delivery contexts.
Additionally, interventions should target barriers within these
different contexts while taking transmission dynamics into
consideration. For example, adolescents under age 14 y have
no significant gender differences with respect to HIV preva-
lence, suggesting a nonsexual mode of HIV acquisition (59).
However, beyond 14 y, female adolescents have much higher
HIV incidence and prevalence as compared to males (7,8,59–61)
(Table 1). Pregnant adolescent females (46,47), adolescents
with early sexual debut, married, or partnered but living sepa-
rately, engaging in transactional sex, especially in rural areas
(62,63), having multiple or older sexual partners (59,60,64),
and those experiencing high mobility and labor migration
(65,66), have also been identified to be at increased risk of
HIV infection and unfavorable outcomes. Lastly, the signifi-
cant proportions of perinatally-infected individuals surviving
into young adolescence and young adulthood should not be
overlooked (51,61,67). While advocating for and strengthen-
ing HTC uptake and coverage, linkage to quality care should
be available to make HTC ultimately beneficial. Recent studies
have cited early loss-to-follow-up, refusal of care, and nonre-
ceipt of baseline CD4 as barriers to engagement in care among
newly-identified ALHIV (68–70). We recommend the fol-
lowing measures to create an enabling environment for HTC
among adolescents, including those at highest risk:
• Enactment of laws expressly permitting independent
access to HTC for adolescents less than 18 y of age
across the WHO Africa region, but especially in WCA.
Copyright © 2016 International Pediatric Research Foundation, Inc.
 HIV Testing for African Adolescents
The median age at sexual debut or age at which custom-
ary/traditional marriages are allowed can be used as a
benchmark. It is critical for every country to have age of
consent legislation that takes age of first exposure to sex-
ual activity (within and outside of marriage) into con-
sideration. This is especially important for girls. These
laws should also be consistent with what HTC and SRH
guidelines recommend in each country. Consultations
among stakeholders, including adolescents and lawmak-
ers, 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, to
move this agenda forward.
• Development of guidelines and laws for adolescents to
independently provide consent for participation in SRH
and HIV research. These guidelines and laws should be
consistent with those governing the age of consent for
routine SRH and HIV services. WCA countries have an
opportunity to legislate concurrently for HIV/SRH ser-
vices and related research since few countries may have
pre-existing laws to that effect.
• Involve both uninfected adolescents and ALHIV in
policy-making and practice, from grassroots dialogue
as advocates and advisors, to participation in health-
care delivery as peer counselors. Specifically for WCA,
adolescents can play a role in increasing identification
of undiagnosed ALHIV in highly-affected communities,
groups or social circles. Other PLHIV who have already
been tested and in care, including family members, can
serve as index clients whose adolescent contacts may be
tested for increased coverage.
• Specialized certificate- or license-granting training on
adolescent HIV, adolescent SRH service provision and
adolescent health-related legislature, for healthcare pro-
viders. Emphasis should be put on skill-building in ado-
lescent drug adherence and SRH counseling.
• HIV seroprevalence, SRH surveys, and other HIV-related
data should include younger adolescents 10–14 y old as
well as disaggregate data to reflect trends in 10- to 19-y
olds. Health surveys and other epidemiologic HIV data
often exclude younger adolescents and have poorly-
defined or poorly-disaggregated age categories with
respect to adolescents (54,67). This limits the ability of
funders and policy-makers to make evidence-based rec-
ommendations positively impacting on all adolescents
and has further implication for mixed epidemic countries
where detailed subnational data is necessary to know
where testing should be concentrated. Furthermore,
more data is needed on the source of infection for ALHIV
(behavioral, perinatal through MTCT, or other) (7), espe-
cially in WCA, for targeted test and treat strategies.
Specific programming and research interventions to improve
HTC among African adolescents should include the following:
Copyright © 2016 International Pediatric Research Foundation, Inc.
Review
• Provision of adolescent-friendly healthcare facility HTC
points of service, with strategies in place to tightly link
and retain newly-diagnosed adolescents in care.
• Expanding testing opportunities beyond healthcare
facilities, specifically for female adolescents, for example
among rural or out-of-school youth, street hawkers and
market traders, in boarding schools, at points of pur-
chase for condoms, and in antenatal care clinics. Given
the high birth rates and worse maternal-infant outcomes
for HIV- infected adolescent mothers, expanded HTC
among adolescent females should be coupled with treat-
ment for Sexually-Transmitted Infections and family
planning to prevent unwanted pregnancies.
• Strategies to improve caregiver involvement in test-
ing, post-test disclosure and access to care for ALHIV
regardless of mode of access to testing. Healthcare work-
ers should counsel and support parents and guardians to
disclose to their adolescent wards. In addition, parents
and guardians of independently-tested ALHIV who need
or wish to disclose should be educated and counseled to
accept the positive diagnosis and to support their wards.
• Behavior change communications programs, ideally
with post-implementation measurement of impact,
targeted specifically to adolescent, family, healthcare
worker, law- and policy-maker stakeholders.
• Engaging ALHIV and families of adolescents living
positively with HIV to provide education and improve
uptake of HTC among their untested peers, within and
outside of the healthcare facility. Reassurance and alle-
viation of commonly-held testing fears among adoles-
cents by experienced healthcare workers, other PLHIV
and educated family members may make a large impact
on poor HTC uptake.
CONCLUSION
In sub-Saharan Africa, where adolescent HIV burden is high,
testing rates are low and outcomes most grim, several barriers
continue to limit access to HTC. Adolescents desire to be tested
for HIV, but those infected are often identified late or not at
all, due to late or restricted access often influenced by cultural
norms and biases. Removing legal barriers is only one step
toward adolescents knowing their HIV status and accessing
early and quality HIV care. Robust implementation research
studies are needed to provide new knowledge to improve pro-
gramming and policy for highly accessible HIV testing and
care, such as: improved PMTCT service access for pregnant
HIV-positive adolescents, community-based interventions to
increase adolescent HTC in rural hard-to-reach communities,
school-based interventions that integrate HIV education and
on-site HIV testing, family involvement, and mobile testing.
This paper adds its voice to the calls for high-burden African
countries to urgently address HIV testing and counseling bar-
riers towards the improvement of HIV treatment outcomes for
all infected adolescents.
Volume 79 | Number 6 | June 2016      Pediatric Research  843
Review Sam-Agudu et al.
ACKNOWLEDGMENTS
We thank the African adolescents with whom we have worked over the
years for their perseverance as we elucidate best practices for keeping them
in excellent health. Above all, we thank them for educating us as we work
towards this goal.
STATEMENT OF FINANCIAL SUPPORT
There was no financial support for this work.
Disclosure: The authors have no conflicts of interest to disclose.
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