Sub-Saharan African countries where adolescents 15 or younger could be tested for HIV without sign-off by parents or guardians show 11% higher rates of testing for the virus among those from 15 to 18 years old than in countries where the legal age of consent for testing is 16 or older, according to a study published in the World Health Organisation’s January Bulletin.
Researchers at the Centre for Global Child Health, The Hospital for Sick Children – Toronto, say the findings, across 15 sub-Saharan countries, could have important implications not just for increasing rates of HIV diagnosis among teenagers, but by opening access to both treatment and counselling for an underserved population, potentially lowering incidence of the virus among the most vulnerable age group, the researchers note.
While deaths caused by Aids-related illnesses have declined across every other age group from 2000 to 2016, they have not dropped for adolescents, for whom HIV remains the leading cause of death in sub-Saharan Africa. Of an estimated 1.8m adolescents living with HIV worldwide, about 1.5m – or 84% – live in sub-Saharan Africa. Among them are teenagers who were infected through mother to child transmission, but never diagnosed, young people exposed to the virus through blood transfusions, as well as those who were exposed to the virus through sex or injecting drug use.
The World Health Organisation recommends that testing for the virus, with counselling and links to treatment and prevention services be routine for all adolescents. UNAIDS has projected that if, by 2020, 90% of all people living with HIV are aware of it, 90% of them are accessing treatment, and if treatment is consistent and effective enough to suppress the virus to undetectable levels in 90% of them, HIV could cease to be a global public health threat by 2030.
Recent data, however, has shown only 23% of adolescent girls and just 16% of adolescent boys reporting that they have ever been tested for the virus. Barriers to testing include fear, stigma, and access to testing sites, the researchers note.
Requirements for young people to have parental or guardian consent for testing also have been seen as possible barriers, but whether the requirements actually affect testing rates had not previously been studied.
The researchers examined testing data pertaining to more than 69,000 adolescents between the ages of 15 and 18, nearly 40,000 of them teenaged girls and the rest teenaged boys, across 15 sub-Saharan countries. Of the countries, six had laws setting the age of consent for HIV testing at 15 or younger (in South Africa and Uganda adolescents as young as 12 can be tested independently, the researchers note), and nine set the age for testing without adult consent at 16 or higher. Teenagers in all of the countries can be tested independently by the time they are 18.
The association between living in countries where laws allow younger adolescents independent access to HIV testing and higher rates of testing among adolescents was stronger in teenage girls than in teenage boys, according to the report.
Objective: To estimate the association between legal age of consent and coverage of human immunodeficiency virus (HIV) testing among adolescents in countries with high HIV-burden.
Methods: We analysed data from adolescents aged 15–18 years, who participated in Demographic and Health Surveys or AIDS Indicator Surveys between 2011 and 2016, in 15 sub-Saharan African countries. To improve balance in the distribution of measured individual- and country-level characteristics, we used propensity score matching between adolescents in countries with more versus less restrictive age of-consent laws (≤ 15 years versus ≥ 16 years). We estimated the percentage of individuals who self-reported that they have done an HIV test in the past 12 months and compared the differences in such testing rates among adolescents exposed to lower versus higher age-of consent laws. We also investigated effect modifications by sex and age.
Findings: Legal age of consent below 16 years was associated with an 11.0 percentage points higher coverage of HIV testing (95% confidence interval, CI: 7.2 to 14.8), corresponding to a rate ratio of 1.74 (95% CI: 1.35 to 2.13). HIV testing rate had a stronger association with lower age of consent among females than males. The testing rates differences were 14.0 percentage points (95% CI: 8.6 to 19.4) for females and 6.9 percentage points (95% CI: 1.6 to 12.2) for males (P-value for homogeneity = 0.07).
Conclusion: This study provides evidence to support the recent World Health Organization’s recommendations that countries should examine current laws and address age-related barriers to uptake of sexual and reproductive health services.
Britt McKinnona, Ashley Vandermorrisb