Adolescent HIV Testing Uptake during Prevention-Focused Wellness Visits in Tanzania

Background: Adolescents are less likely to access HIV testing and counseling (HTC) than adults in HIV endemic, low-resource settings. Tanzanian policy indicates that adolescents under 18 who meet the mature minor or best interest of child principles have a right to HIV testing without parental consent although in practice this rarely occurs among young adolescents. Currently, there is no routine preventative health service delivery platform for adolescents in Tanzania, and targeted HIV and sexual and reproductive health (SRH) services often fall short. The VITAA study includes deep stakeholder engagement and a cluster RCT to 1) assess acceptability of a new school-facilitated and clinic-based Adolescent Wellness Visit (AWV) delivered during the last year of primary school, and 2) estimate HTC uptake over 2.5 years among participants by study arm. AWVs include screenings for nutrition, vision, dental, and mental health plus optional SRH and HTC services to have broad appeal and applicability for all adolescents. The purpose of this study is to describe HIV testing uptake in the AWV intervention and to examine qualitative insights from clinicians around decision-making to support adolescent HTC.

Methods: 20 government primary schools were randomized to intervention and control groups. Standard 7 classrooms (mean age 13, range 11-17) at 10 intervention schools were eligible to participate in AWVs at nearby health facilities in Dar es Salaam and Coast regions, Tanzania. Providers were trained on national adolescent-friendly SRH and HIV guidelines, and how to conduct nutrition, vision, dental, and mental health screenings and referrals. Data included adolescent exit surveys and medical record reviews, and 10 focus group discussions (FGD) with health providers. Analyses included descriptive statistics and team-based thematic qualitative analysis.

Results: 509 of 1,095 enrolled adolescents were in the intervention arm and completed AWVs. Of those, 175 (34%) requested an HIV test and 172 received the test. When asked why they requested the test, nearly all participants responded they “just wanted to know their status.” 87% of adolescents perceived themselves as not at risk and 10% said they had some risk.

FGDs revealed that most providers reported being comfortable giving HIV tests to young adolescents; however, that was in part because they knew the adolescents’ parents had consented to the study which included possible HIV testing. There were few instances of providers declining to test adolescents because they felt they were not at risk or the parents were not present. Providers discussed adolescent friendly tactics to increase comfort during HTC. Some providers also discussed challenges where adolescents wanted to make their own decisions about HIV testing but felt conflicted about parental approval.

Discussion: Adolescents are eager to know their HIV status, despite most feeling low risk. Providers gained confidence in their ability to follow national policy with the added reassurance of parental consent with the study. This study demonstrates high uptake of HIV testing when paired with holistic health screenings and normalized by school cohort involvement. Clinical providers supported HIV testing for young adolescents, however support may be tempered by parental study consent.