Age-related policies and laws limit PrEP access where its needed the most

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Access to pre-exposure prophylaxis (PrEP) for young people at risk of HIV remains limited because of age-related consent laws and policies, reveals a global review. Investigators at the department of prevention and community health, George Washington University, department of social and behavioural sciences, Yale School of Public Health, Duke University School of Medicine, New York Medical College, Valhalla and Emory University Rollins School of Public Health, Atlanta, looked at existing national laws and policies relating to SRH service access that may also impact access to pre-exposure prophylaxis for young people under 25.

Young people, and particularly young people who are members of key affected populations such as sex workers, men who have sex with men, people who use drugs, are among the most at-risk groups for HIV acquisition globally. This is the result of a convergence of several psychological, social and structural factors associated with this time in their development.

Most HIV prevention interventions for this group focus on changing behaviour, such as promoting condom use, or addressing structural drivers, as in social protection programmes. These have had varied success and are challenged by consent laws for SRH services. Seeking parental consent for these services has been identified as a major barrier to reaching this group.

The World Health Organisation recommends PrEP to all at-risk populations, without any limitation on age. But as many countries move towards regulatory approval of PrEP, insufficient consideration has been given to ‘underage’ youth and how existing policies may restrict their independent access to PrEP.

The investigators reviewed a sample of 15 countries with both low and high HIV incidence. Western countries were included to explore how countries with comparatively low HIV incidence among adolescents, but well-resourced healthcare infrastructure, may approach PrEP access among adolescents.

The laws and policies they looked at included age of consent for sexual intercourse, medical treatment, contraceptives and HIV testing. Countries could be included if they had active PrEP trials or PrEP available for distribution, and if information regarding PrEP guidelines were publicly available.

In the end, they reviewed the policies of Australia, Brazil, Ethiopia, France, India, Indonesia, Kenya, Mozambique, Nigeria, South Africa, Tanzania, Thailand, Uganda, the Ukraine and the UK.

Across the geographies, results for age of sexual consent varied but around half (47%) prohibit sex for under 18s – and in Indonesia, consent laws differed between genders. This highlights an obvious challenge for healthcare providers and young people who would like to discuss PrEP before turning 18.

In addition, laws in seven (47%) countries did not specify an age of consent to medical treatment, or were unclear about the age. France is the only country to explicitly include PrEP as part of medical treatment, but their law requires parental consent for medical treatment in people under 18 years. In their discussion, the authors note that PrEP is still often considered a medical treatment, where it should now be considered as a biomedical intervention. This would give health providers clarity in how they may discuss this tool with possible patients.

Only six (40%) countries have specific laws addressing adolescent consent for and access to contraception, despite all the countries including documentation on their use for family planning and sexual reproductive health. Again, these varied, with Ukraine requiring consent from a guardian for these services for those aged under 18. In Indonesia, contraceptive services are only provided to those who are married.

While all the countries had laws or guidelines on the age of consent for HIV testing – age limits ranged from 12 to 18 years. Of the countries with age limits, five countries (42%) require people to be 18 years or older to consent to HIV testing, while four countries (33%) require those under the age of 18 years who are not married, pregnant or a parent themselves to have parental consent for an HIV test.

Ten countries (66%) have national guidelines for PrEP to assist providers with patient care. Of these, six countries (60%) include specifications for people under the age of 18 years. These specifications ranged from the specific (it can be provided to all those over 14), to the vague (anyone at risk). But as the authors noted in their discussion, health providers may still not feel confident suggesting or providing PrEP to adolescents.

“Adolescents’ access to PrEP is dependent upon several external factors including parental consent and involvement, confidentiality, and access to healthcare providers who are knowledgeable and trained to prescribe PrEP,” explained the authors in their discussion.

“Even in countries where adolescents can independently consent to PrEP, providers may be reluctant to prescribe due to concerns about medication adherence, ability to understand the risks and benefits of PrEP, and risk compensation.”

Regardless of the challenges, PrEP provides a unique opportunity to curb new HIV infections in this group. Policymakers should work with young people to adequately address barriers to PrEP and other SRH services to improve health outcomes.

Abstract
Introduction: Youth under the age of 25 are at high risk for HIV infection. While pre‐exposure prophylaxis (PrEP) has the potential to curb new infections within this population, it is unclear how country‐specific laws and policies that govern youth access to sexual and reproductive health (SRH) services impact access to PrEP. The purpose of this review was to analyse laws and policies concerning PrEP implementation and SRH services available to youth in countries with a high HIV incidence. To the best of our knowledge this is the first systematic assessment of country‐level policies that impact the availability of PrEP to adolescent populations.
Methods: We conducted a review of national policies published on or before 12 June 2018 that could impact adolescents’ access to PrEP, SRH services and ability to consent to medical intervention. Countries were included if: (1) there was a high incidence of HIV; (2) they had active PrEP trials or PrEP was available for distribution; (3) information regarding PrEP guidelines were publicly available. We also included a selected number of countries with lower adolescent HIV incidence. Internet and legal database searches were used to identify policies relevant to adolescent PrEP (e.g. age of consent to HIV testing).
Results and Discussion: Fifteen countries were selected for inclusion in this review. Countries varied considerably in their respective laws and policies governing adolescents’ access to PrEP, HIV testing and SRH services. Six countries had specific polices around the provision of PrEP to youth under the age of 18. Five countries required people to be 18 years or older to access HIV testing, and six countries had specific laws addressing adolescent consent for‐ and access to‐ contraceptives.
Conclusions: Adolescents’ access to PrEP without parental consent remains limited or uncertain in many countries where this biomedical intervention is needed. Observational and qualitative studies are needed to determine if and how adolescent consent laws are followed in relation to adolescent PrEP provisions. Intensified efforts to amend laws that limit adolescent access to PrEP and restrict the establishment of national guidelines supporting adolescent PrEP are also needed to address the epidemic in this group.

Authors
Tamara Taggart, Keosha T Bond, Tiarney D Ritchwood, Justin C Smith

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Journal of the International AIDS Society abstract


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