Implementation guidance for health providers and planners

Ensuring access

Provision of SRH services must be grounded in a rights-based approach that recognizes the right of adolescents to full and accurate sexuality information and education that ensures they have the ability to acquire knowledge and skills to protect themselves and others. To that end, services need to prioritize access, acceptability, accuracy of information, confidentiality, respectful staff behaviour and support for autonomy of adolescent clients.

The recent WHO guidance Ensuring human rights in the provision of contraceptive information and services: guidance and recommendations supports this.

All sexually active adolescents including those living with HIV should have access to effective sexually-transmitted infection (STI) screening and treatment. In resource-limited settings, where the availability of laboratory screening/diagnosis for STIs may be limited, providers may only have the option of 'syndromic management' using algorithms to guide STI diagnosis and treatment. While this is simple and cost-effective, providers in these settings must be very attentive to the possibility of asymptomatic infections, particularly among women. These can lead to pelvic inflammatory disease, ectopic pregnancy and infertility as well as facilitating onward transmission of HIV in some cases.

Access to contraception. Adolescents living with HIV need access to a full range of contraceptive options. Dual methods — condoms, both male and female, and lubricants in conjunction with hormonal methods including emergency contraception (EC) — are essential to protect against unwanted pregnancy, STIs and HIV transmission. SRH services must also be able to address unwanted pregnancy for HIV-positive adolescent women, where the law allows, either providing or referring clients for termination of pregnancy services if requested.

Delivery of SRH services. Adolescents living with HIV must know where to access services in their local area, at times and in places that are convenient and acceptable for them. Service provision must be equitable, and appropriate for males, females and transgender people. Please refer to the Service Delivery and Retention section on adolescent-friendly services for more detailed information.

A ‘one stop shop’ approach is considered to be the preferred service delivery option for adolescents. Integration allows adolescents to access a range of services in one place, reducing some of the costs and logistical barriers that discourage adolescents from accessing SRH and other services when needed. If contraception and STI services are not available through stand-alone SRH clinics or integrated into other services, efforts must be made to establish close links, referral pathways and feedback mechanisms for contraception and STI services or to primary care facilities. Particularly where such services are far away from communities, arranging for sessional contraceptive health providers to be available as part of HIV services for adolescents or at particular times set aside for adolescents may be beneficial. Please refer to the section on Service Delivery and Retention for more detailed information and examples of integration.

Providers of SRH services should be alert to the broader needs of adolescents related to SRH and ensure that they have access to these services. Linkages to prevention of mother-to-child HIV transmission (PMTCT) will be essential for adolescent girls who are diagnosed with HIV during testing in antenatal services, or for adolescent girls who are already HIV-positive and become pregnant. Some adolescents may need referral for social protection services when they are found to be victims of abuse or assault or when they are facing extreme vulnerability due to loss of parents/caregivers or poverty. In such circumstances it is important to clearly explain the bounds of confidentiality as protection issues may take precedence.

Key populations face particular challenges in accessing SRH services as they may experience stigma due to sexual preference/behaviour, criminalization of sexual preference/behaviour and a lack of services that are appropriate for their needs. Special care must be taken to provide equal and fair medical services to gay, lesbian, bisexual and transgender adolescents and to ensure that they have access to SRH services provided by unbiased, professional and non-judgmental staff. Outreach, peer support and community-based approaches are likely to be best positioned to serve the needs of adolescent members of key populations.

Legal challenges to access are a particular concern for adolescent minors. Age of consent to sex and to access services can serve as barriers to SRH services when adolescents are fearful of possible legal consequences and/or disclosure to families. Confidentiality can pose problems for health providers as well when they feel pressured to abide by national policies or laws that force them to breach the confidentiality of their clients. In some countries, recognition of the evolving capacities of adolescents and the autonomy of mature minors can reduce the impact of age barriers to SRH services; in some cases, providers themselves may feel that it is necessary to make this judgment on a case-by-case basis.

Please refer to the HIV Testing and Counselling section for more information regarding issues of consent, including the involvement of parents and guardians.