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Page 2 of 5 Original Research

In addition to oral PrEP, which is proven and registered for The public health and human rights
use as HIV prevention, there are additional PrEP options that imperative to ensure adolescent
have different routes of administration and less frequent
dosing including long-acting injectable PrEP and vaginal access to pre-exposure prophylaxis
rings. These are at various stages in the development pipeline, It is both a human rights and public health imperative to
with the dapivirine vaginal ring furthest along also currently ensure that adolescents have access to tools to minimise their
under review by regulatory agencies. This means adolescents HIV risk. Access requires an evaluation of barriers, including
4
may soon have more choices about the form of PrEP available legal barriers in the form of parental consent requirements.
2
to them (Bekker, personal communication, 9 Jun 2020). Research from the United States of America has shown that
parental consent may act as a legal barrier to adolescents
Providing at-risk populations with access to PrEP is accessing sexual and reproductive health services. One
14
described as a key objective within the South African study indicated that up to one-fifth of adolescents who were
National Strategic Plan on HIV, tuberculosis (TB) and surveyed did not want their parents to be involved in the
15
sexually transmitted infections (STIs): 2017–2022. Initially, consent process. Other studies have shown, for example,
9
the Department of Health operationalised this objective by that a greater number of adolescents volunteered for services
targeting sex workers and MSM, but this has now been such as HIV testing once they were able to provide
15
expanded to include other at-risk populations such as independent consent. Furthermore, many adolescents are
10
university students and young women. To date public deterred from accessing abortion and contraception services
sector roll-out has lagged, and PrEP is mostly available by parental consent because they fear parental
15
through demonstration projects, clinical research sites and disappointment, sanction or retaliation. Similarly, there are
concerns that parental consent might impede access to HIV
the private healthcare sector. 11,12 However, South Africa is prevention packages for adolescents for similar reasons. 4,16
now in the process of expanding access, with 3000 facilities
being able to provide oral PrEP. Within this community- The current legal framework for
based approach, self-presenting adolescents who are > 35
kg and are deemed to be at risk of HIV acquisition will be child consent to health
eligible to access oral PrEP. interventions
Self-consent to specified health interventions
Although PrEP is registered for use in persons > 35 kg, there is
no policy that deals with consent to this product by persons The Children’s Act states that full legal capacity is attained at
under 18 years. For example, the current South African HIV 18 years; however, persons below this age may, in certain
Clinicians guidelines do not address the consent approach for circumstances, legally self-consent to a range of specified
adolescent access to PrEP. These guidelines are currently being health services, as we have noted elsewhere. 2,3,16 Sections 12
13
updated, and it is understood that the new version which will and 129–135 of the Children’s Act deal with the consent
be published in November 2020 will include a recommended requirements for medical treatment, surgical operations, HIV
2,3
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consent approach for persons under 18 years. The unintended testing, male circumcision and contraceptives. The
Children’s Act refers expressly to three current forms of HIV
consequences of this lack of policy on adolescent consent to prevention, namely male circumcision, condoms (under
PrEP is that it is unclear whether adolescents can self-consent contraceptives) and HIV testing, and sets ages at which
or require parental consent for access to PrEP. adolescents may self-consent to the intervention.

In this article, we describe the current legal framework for As set out in earlier articles, consent to ‘medical treatment’
adolescent consent to health interventions including ‘medical is a general category in the Act that covers a range of non-
treatment’. We examine whether adolescents can consent specified health interventions. Section 129 provides that
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independently for PrEP in terms of the current legal a child may consent independently to ‘medical treatment’
framework. We conclude with our position on an appropriate if they are older than 12 years and they have the ‘mental
consent strategy and recommend that the Department of capacity to understand the benefits, risks, social and other
Health revise current PrEP policies to provide certainty on implications’ of the proposed treatment. If a child is
2,3
this issue. below the age of 12 years or lacks capacity, proxy consent
must be provided by a parent, guardian or care-giver
It should be noted that although this article focusses on amongst others. 2,3
adolescent consent to PrEP, it has a broader application. As
described here, a key issue in the current legal framework is Self-consent to non-specified health
whether the term ‘medical treatment’ in the Children’s Act, interventions
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2005 is broad enough to encompass prevention Whilst the Children’s Act provides clarity on consent to most
interventions such as vaccines. This has implications for medical interventions for children under 18 years, it does not
adolescent consent to the human papillomavirus (HPV) directly address the age at which adolescents might self-consent to
vaccine and other non-therapeutic health interventions. non-specified preventive interventions such as PrEP. There are

http://www.sajhivmed.org.za 77 Open Access