Implementation guidance for health providers and planners

Improving uptake of testing

Current approaches to creating demand for and delivery of HIV testing and counselling have not sufficiently met the needs of adolescents.

Generating demand. There is no single approach that works for all adolescents and all settings. As a group, adolescents are as diverse and heterogeneous as the settings in which they live. To generate demand for HTC services, programmes need to take into account the type of HIV epidemic taking place in the country/setting, and recognize that a wide range of approaches will be required. More recently, several new approaches captivating adolescents have emerged and are being used by programmes to engage adolescents and increase awareness of HTC. Successful examples include campaigns within adolescent environments that adopt mobile phone technology, social networking, media, sport, performing arts and the engagement of celebrities.

Messages encouraging adolescents to undergo HIV testing are also being integrated into existing health education initiatives – from school health curricula to sport development programmes and youth clubs, as well as specific messages for key populations. The use of adolescent-appropriate language and clear messages – that advocate healthy behaviours and empower adolescents to take responsibility for their own health – is necessary for all information, education and communication materials regarding HIV and HTC. Monitoring and documentation of current approaches needs to be carried out so programmes can improve and provide evidence of their validity and success. This is particularly important regarding applications for financial support for the development of innovative strategies to engage adolescents and encourage HTC.

Examples of approaches being used to engage adolescents and encourage them to test

Providing opportunities for HIV testing. Opportunities for adolescents to test must be created within existing services in which adolescents routinely receive care. In all settings, HTC should be available for adolescents who wish to test. In countries with generalized HIV epidemics, HTC should be offered at all consultations. For all adolescents living in settings with generalized HIV epidemics, and those from key populations, HIV testing is recommended. In many communities, adolescents are able to access sexual and reproductive health services – including medical male circumcision – harm reduction, antenatal, labour and post-natal services. Encounters with these health services should be viewed as opportunities for health care providers to initiate discussions, assess risk, recommend and facilitate HIV testing.

Undiagnosed perinatal HIV-infected adolescents. In high prevalence settings, an increasing number of adolescents who acquired HIV perinatally remain undiagnosed. Non-enrolment of their mothers in HIV prevention programmes and missed opportunities to test for HIV in post-natal care or other health settings has meant that many who present for care for the first time in adolescence have chronic health problems and some may already be quite ill. The emergence of these ‘slow progressors' means that, in some settings, HIV has become a common reason for acute admission and in-hospital death among adolescents. Identifying and initiating HTC with immediate linkage to treatment and care for these adolescents, particularly those with signs and symptoms consistent with an HIV diagnosis and/or suspected tuberculosis (TB), is critical to reducing the morbidity and mortality in this age group.

HIV testing is also recommended for orphaned adolescents, and those with a parent or sibling living with HIV, or who may have died of an HIV-associated illness. Health providers are critical to encouraging HIV-positive parents to facilitate the testing of all their children. Fear of disclosure, guilt and the consequences of positive diagnosis often underlie parental reluctance to have their child(ren) test for HIV. These parents are likely to require additional support to better understand the benefits of an HIV test for their child and available care and support, and well as help communicating about difficult or sensitive issues with their adolescent children.

Creating new opportunities to test. Increasing the accessibility of HTC for adolescents requires going to their environment, engaging them in the process and creating new opportunities for them to test. Community-based HTC is vital to reach adolescents who do not routinely access health services or are not aware of their risk of HIV infection. Community-based HTC has the potential to reduce/remove deterrents or barriers to HTC for adolescents – including the costs of services, judgmental attitudes of health care providers, and the stigma often associated with attending HTC services. New strategies to encourage testing among adolescents, such as self-testing and financial incentives to test are currently being researched for their viability, appropriateness and acceptability.

Adolescent-friendly HTC. All settings providing HTC to adolescents, either within health services or within the community, should be based on adolescent-friendly principles. HTC should be available, accessible and appropriate for adolescents. Services need to be convenient and available, either through flexible opening hours and/or walk-in/same-day appointments. If possible, facilities should use rapid testing, provide HTC services free of charge and ensure privacy and confidentiality. Those providing HTC services should be trained and skilled in delivering services that are non-judgemental, and that respect the diversity of adolescents, particularly those from key populations.

Involving adolescents in the planning, delivery and evaluation of HTC approaches is important. Listening to adolescents' views and preferences regarding what works for them, within their context, enables programmes and services to be responsive and provide sustainable, locally appropriate responses.