• Editors' Summary
• Credits

1. The Invisible Epidemic
2. How Young People Become Infected
3. Why So Vulnerable?
4. Addressing the Epidemic
• Towards an Enabling Environment
• AIDS Education
• Mass Media Communication
• Condom Use
• Voluntary Counseling, Testing, and Referral
• HIV Treatment and Care
• Youth Livelihood Approaches
5. Reaching Out
6. Consequences of Inaction
7. HIV/AIDS: What Young People Want to Know
8. Profiles
9. Youth at the Center

• Figures
• Tables
• Side-bars
• Bibliography

• Why young women face more risk
• Culture can hurt
• Profile: Going public
• Education should start early
• Condoms for dual protection
• Orphans: A new challenge
• What can parents do?
• Reaching street children
• Putting youth at the center

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• POPLINE
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Published by the Population Information Program, Center for Communication Programs, The Johns Hopkins University Bloomberg School of Public Health, 111 Market Place, Suite 310, Baltimore, Maryland 21202, USA.

Early testing for HIV/AIDS offers many benefits, especially for young people, but in most countries it is still rare. Especially as treatments become more available for HIV infection, early testing and counseling could lead to timely care, improve the medical management of HIV-related illnesses, and provide an opportunity to reduce perinatal transmission of HIV.

Debate continues over whether taking the HIV test leads to safer behavior (404). Some researchers have demonstrated that, once aware of their HIV-positive status, some infected people change their behavior to avoid transmitting HIV (385). In addition, starting antiretroviral therapy as soon as possible lowers the viral load (102) and may therefore reduce the risk of transmitting HIV. For those who test HIV-negative, testing can provide an impetus to develop a plan for avoiding infection.

Nevertheless, few young people get tested, even in countries with the most severe HIV/AIDS epidemics. There are several reasons. First, testing facilities are scarce in many countries. Second, treatment for HIV-positive persons is often lacking, so why bother to be tested? Third, the stigma of HIV infection can discourage many young people, as it does many adults. Regardless of age, many do not seek testing until they develop symptoms or a spouse or sex partner dies of AIDS (433). They may have been transmitting HIV to others for years.

Among youth, further barriers to voluntary testing include lack of information, perception of low risk, lack of confidentiality, costs, transportation problems, and laws that require parental consent (116, 121, 286). A US study found that the number of adolescents who were tested for HIV/AIDS rose by 150% when parental consent was no longer required (235). Some countries impose administrative requirements that can discourage voluntary testing for HIV (57).

In testing for HIV, ensuring medical confidentiality is essential. The right to confidentiality is recognized by the UN Convention on the Rights of the Child (202). Yet confidentiality is often compromised. In Kenya, for example, nearly one-third of adolescents studied received their test results either in a letter or from their parents, instead of privately from a health care provider (130). In Russia efforts to trace HIV-positive cases can leave trails that compromise confidentiality (136).

Testing programs need to develop strong referral networks to help youth regardless of their HIV status. In particular, test sites can be linked with programs that help people who are HIV-negative plan how they will avoid risk and with programs that help the HIV-positive obtain medical care. Voluntary testing also provides an opportunity to refer young people for other reproductive health care, especially for pregnancy prevention and STI treatment. Referral systems are rare, however (130). Providing better referral for youth may require more extensive assessment, staff training, and clinical follow-up care than for adults (311).

Hugh Rigby for JHU/CCP

In Kampala, Uganda, a health care center offers a range of reproductive health services covering sexually transmitted infections, HIV, and family planning. Health centers need to make young people feel welcome and comfortable.

Psychological and ethical issues. Being tested for HIV/AIDS is stressful for anyone and especially so for young people (185, 311). Young people who test positive want to maintain a belief in their own invincibility but are suddenly confronted with their own mortality. It may take them months to accept their situation and to seek treatment (337). It is encouraging, however, that young people at high risk of HIV infection are more likely than other young people to seek testing and to return for the results—perhaps because they are aware that their behavior has placed them at risk (309, 383).

Many young people who test HIV-positive need special support and counseling. In many countries, however, if any HIV/AIDS counseling is offered at all, most testing facilities offer it only in single short sessions, where there is little opportunity to explore problems (286, 311). Many health care providers recognize that the quality of counseling needs improvement (91).

Providers can address young people's concerns about testing by talking with them about the process and by role-playing possible scenarios such as how to tell a partner or parents or how to face various possible test results (337). Providers also can help adolescents develop a strategy for remaining healthy, including adopting safer sex practices.

Providers often are unsure or uncomfortable about dealing with HIV/AIDS among youth. Some wonder whether it is even legal for them to test young people and to offer preventive services. In Ghana a chief concern among providers was whether it was permissible to give young people contraceptives. Many were afraid of offending community norms (230). Some health care providers who disapprove of sexual activity among adolescents scold them or deny them information (133, 183, 237). Even worse, some young female clients have been propositioned for sex by male providers (59).

Researchers in the US have developed a set of criteria to make testing facilities "teen friendly" (121). While these criteria are based on a specific economic and cultural context, they may be helpful elsewhere as well. A "teen-friendly" HIV testing facility:

• Has respect for teens,
• Offers free testing,
• Offers a broad array of teen-oriented services,
• Assures confidentiality,
• Does not require parental consent,
• Offers a choice between oral or blood-drawn tests,
• Is convenient, with access to public transportation,
• Asks few questions, and
• Requires little paperwork.