/ 1 “No harmony between policies” Inconsistencies in legal frameworks on adolescent HIV and sexual and reproductive health services in five Southern African countries Dr Alexandra Muller XXI International AIDS Conference 22 July 2016

/ 2 What’s special about year olds? Key HIV and SRH needs, yet their sexuality is regulated by complex legal and moral frameworks. Adolescent sexuality is contested: moral and legal restrictions on age of sexual debut, need to balance protective with emancipatory approaches Evidence shows that adolescents are sexually active and need SRH services: Young people (aged 15-24) account for 39% of all HIV infections globally High rates of pregnancy and sexual violence among adolescent girls No harmony between policies: Dr Alex Muller, 2016

/ 3 What governs ASRH? Age of majority law Sexual offences law Marriage law Children’s law Termination of pregnancy law Other criminal law (penal codes) Provisions for access to specific health services No harmony between policies: Dr Alex Muller, 2016

/ 4 The ‘Contested Terrain’ study We analysed the legal frameworks around adolescent HIV/SRH service provision in Malawi, Mozambique, Namibia, Zambia and Zimbabwe. Literature review and desktop-based analysis of laws and policies 50 in-depth interviews with representatives of adolescent organisations and policy makers Thematic data analysis Comparisons across countries and specific ASRH issues *Which inconsistencies exist? *What do service providers know? *What information is available to adolescents? No harmony between policies: Dr Alex Muller, 2016

/ 5 Inconsistencies in law and policy Laws regulating adolescent HIV & SRH services and sexual activity are inconsistent within and across the five countries. Age of consent lower for HCT than other SRH services Age of consent to sex higher than age of consent to HCT – adolescents asking for HCT in effect disclose illegal sexual activity Contradictions between laws and policies ‘Mature minor’ policy: age of consent for SRH lower than by law ‘Key population’ policy: targets individuals engaged in same-sex sexual behaviour, criminalised by law Child marriage: age of consent to marriage different in Marriage Act and constitution No harmony between policies: Dr Alex Muller, 2016

/ 6 Contradictory provider knowledge Laws regulating adolescent HIV & SRHs services and sexual activity are understood differently within and across the five countries. Participants had good knowledge about criminalised behaviour/ activities (same-sex activity, abortion) Good general knowledge about recent laws, but not their specific provisions Poor knowledge about ages of consent to medical services and sex (answers ranged from 12 – 18) Participants overestimated their obligations to report No harmony between policies: Dr Alex Muller, 2016

/ 7 Case study: same-sex activity Laws that criminalise same-sex activity (Malawi, Zambia and Zimbabwe) jeopardise ASRH services for lesbian, gay, bisexual and transgender adolescents. Inconsistent law and policy: Penal Code criminalises (male) same-sex activity, Ministry of Health policy specifies MSM as ‘key populations’ Inconsistent provider knowledge: No distinction between identity and behaviour, nor between MSM and WSW, wrong assumptions of duty to report LGBT adolescents fall through the cracks: Penal code and its interpretation as justification for not providing education/ services for LGBT adolescents No harmony between policies: Dr Alex Muller, 2016

/ 8 Summary Laws and policies on adolescent HIV & SRH conflicting and inconsistent. Providers working with adolescent have ‘newspaper’ knowledge about ASRH laws and policies – focus on the sensational or current. Greater focus on what teenagers shouldn’t do than on what they are entitled to No harmony between policies: Dr Alex Muller, 2016

/ 9 Conclusion The combination of legal inconsistencies and providers’ lack of knowledge Encourages discretionary, moral-based decision-making by service providers Jeopardises confidentiality of services Decreases reliable information sources for adolescents Increases barriers for adolescents’ access to HIV and SRH services No harmony between policies: Dr Alex Muller, 2016

/ 10 Way forward Harmonisation of laws and policies Education of providers Not just healthcare providers but everyone working with adolescents Encourage exploring of legal and moral complexity Values clarification Mandatory reporting duties Include adolescents – adolescent agency, rights-based approach No harmony between policies: Dr Alex Muller, 2016

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