Informed consent and HIV testing
All adolescents must make their own decision to have an HIV test, without being coerced or pressured. Depending on the laws of the country, adolescents who have reached the legal age of consent (or are considered as mature minors) can consent for an HIV test. The age of consent for HIV testing varies from country to country. Where the age of consent is not specified in national policies, legislation, and/or guidelines on HIV/AIDS, countries may consider using the age of consent to medical procedures. It is important for health providers to consider the legal age of consent to test for HIV, including adolescents who are considered 'exceptions' to a standard age for consent policy, for example 'mature minors' or pregnant adolescent girls, and be guided by the best interests of individual adolescents.
In order to reduce age-related barriers to access to HTC, WHO guidance encourages countries to examine and potentially revise their current age of consent policies. During this process, they should take into account how best to address age and access issues within their own legal and social context, and consider lowering the age of consent for HTC, if necessary.
Mature minors. Many countries include concessions in their policies allowing adolescents in specific groups or situations to be considered 'mature minors'. This may include those who are living independently, are pregnant, or have no contact with parents/guardians. Additionally, exceptions are made for those who have a clinical condition that suggests infection with HIV, or whose knowledge of their HIV status is in the best interests of the adolescent. Adopting such flexibilities may offer faster approaches to achieving greater access to HIV testing than considering a review of the legal age of consent.
Health providers have a responsibility to assess the maturity and ability of individual adolescents and to decide if each person has the capacity to recognize and understand the benefits and consequences of an HIV test. In assessing such competence, it is essential for health care providers to ensure the adolescent has been given the appropriate information and that any consent for testing is adequately informed. Providing standardized means of assessing such competences and the training of health care providers to develop competency assessment skills are required.
Parental/guardian consent. For adolescents who would like to be tested, but who are below the age of consent or not considered to be exceptions, the consent of a parent or guardian (or supportive adult) is required. Nevertheless, the principle of voluntary testing persists, and the assent of the adolescent is equally crucial as the consent of the parent/guardian. Health care providers should offer adolescents an opportunity to discuss their own assent to HIV testing and counselling in private, without the presence or knowledge of his or her parents or legal guardians. If an adolescent is uncertain of whether he/she would like to be tested, the decision should not be rushed or forced. The adolescent may need time to decide and should be offered follow-up sessions to discuss their concerns and supported during the decision-making process.
Key populations. Adolescents from key populations often face additional legal and policy barriers. Many not only face stigma related to their behaviours but also possible prosecution if these activities are illegal. Fear of disclosing such behaviours can significantly discourage adolescents to access HIV testing and counselling services, as well as treatment, care and other forms of support.
Counselling. Pre- and post-test counselling sessions with adolescents should incorporate clear, explicit language, with information adapted to adolescents' literacy levels and developmental stages. This should be provided in a non-judgmental and inclusive way by respectful, accepting and understanding health care providers. All HIV testing and counselling should be voluntary without any feeling of coercion.
Specific attention should be devoted to ensuring that adolescents' privacy and confidentially are protected. These two factors help to build the essential relationship and trust. The limits of confidentiality (e.g. the advantages of sharing HIV test results with other members of the adolescent HIV care team) need to be made clear, and permission should be asked from the adolescent before disclosing information to any other people. Simple measures such as closing the consultation room door or finding a private place can further reassure the adolescent in this regard.
Involving parents/guardians. Involvement of supportive parents or guardians can be beneficial, especially for those adolescents requiring HIV treatment and care. However, it is important to assess potential negative consequences of unsupportive parents/guardians for the adolescent. Health providers should be aware of signs of possible abuse, ensure protection where possible, and have established referral mechanisms. Additional support from health care providers may be required for parents/guardians who may experience initial negative reactions to their son/daughter undergoing an HIV test or engaging in services. Taking time to speak with parents/guardians can assist in gaining their consent, if required, and enabling the adolescent to access services.
If parents/guardians accompany an adolescent to test for HIV, information on the benefits of testing and explanations regarding confidentiality should be provided to both. However, adolescents may feel uncomfortable to ask or answer questions or disclose important HIV risk information in the presence of parents/guardians. Such questions can be asked in private by asking parents/guardians to leave the room. Parents/guardians can be invited back at the end of the consultation if the adolescent feels comfortable. It is helpful to explain the benefits of seeing the adolescent alone and that it is the preferred procedure.