Interventions to improve access to sexual and reproductive health services for adolescents living with HIV in sub-Saharan Africa: a scoping review

Abstract

Objective

Adolescents living with HIV (ALHIV) face barriers to accessing sexual and reproductive health (SRH) services, negatively affecting their health and quality of life. These challenges are particularly pronounced in sub-Saharan Africa (SSA), where HIV prevalence, unintended pregnancies and child marriage remain high. This review aimed to map interventions designed to improve SRH access for ALHIV in SSA, applying Levesque’s framework to identify facilitators and barriers from supply-side and demand-side perspectives.

Design

Review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR).

Data sources

PubMed, EMBASE and Web of Science were searched, alongside institutional grey literature, for English and French language studies published between 2010 and 2024.

Eligibility criteria

Studies were included if they focused on ALHIV aged 10–19 years in SSA, regardless of HIV acquisition mode and used experimental, quasi-experimental, qualitative or observational designs.

Data extraction and synthesis

Two independent reviewers screened studies in Covidence, extracted data on study design, population, intervention components and delivery settings and mapped barriers and facilitators using Levesque’s framework. Findings were synthesised narratively.

Results

of 6835 records screened, 14 studies met inclusion criteria. Interventions ranged from comprehensive strategies addressing financial, infrastructural and psychological barriers to targeted approaches like education and stigma reduction, implemented across schools, clinics, communities and digital platforms. Most studies emphasised service acceptability, with 13 of 14 highlighting cultural relevance, while approachability, physical accessibility and affordability received less attention. Key barriers included fear of HIV disclosure and stigma, whereas facilitators, including peer support, community outreach and digital platforms, enhanced engagement, trust and comfort with SRH services.

Conclusion

Improving access to SRH services for ALHIV in SSA requires adolescent-friendly, integrated, context-specific interventions that combine stigma reduction, peer and community engagement, digital innovations and financial support to overcome barriers and improve SRH outcomes.

Registration details

Open Science Framework (https://doi.org/10.17605/OSF.IO/7PBEW).

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• This scoping review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines, ensuring transparency and reproducibility.

• Levesque’s conceptual framework was applied to map supply-side and demand-side barriers and facilitators, allowing a structured and comprehensive synthesis.

• Multiple study designs and diverse data sources were included, capturing a wide range of interventions and regional contexts for adolescents living with HIV in sub-Saharan Africa.

• Study selection and data extraction were performed independently by two reviewers, reducing bias and enhancing reliability.

• The review was limited to English and French publications, and only 14 studies met inclusion criteria, which may limit applicability to regions or contexts beyond those studied.

Introduction

Adolescents represent an increasing proportion of the global population living with HIV, largely due to improved access to paediatric antiretroviral therapy (ART), with an estimated 1.57 million adolescents aged 10–19 living with HIV worldwide in 2024, with 64% receiving life-saving ART.¹ Girls are disproportionately affected, representing 70% of new HIV cases among adolescents, with 96 000 girls newly infected in 2023.¹ Sub-Saharan Africa (SSA) remains the epicentre of the adolescent HIV epidemic, with 82% of the global adolescent HIV population living in the region.¹ Despite progress in the HIV response, adolescents continue to experience poorer outcomes across the HIV care cascade, with lower rates of HIV testing, access to ART, retention, viral suppression and treatment adherence compared with adults.²

Across the globe, including in SSA, addressing the evolving needs of adolescents and ensuring access to sexual and reproductive health (SRH) services remains a key priority.³ However, adolescents living with HIV (ALHIV) face compounded vulnerabilities relative to their HIV-negative peers, navigating dual stigma associated with both their age and HIV status, which can reduce their willingness to seek SRH services due to fears of rejection and involuntary disclosure.⁴ These vulnerabilities intersect with broader risks faced by adolescents: nearly 24% of adolescent girls in relationships—about 19 million—experience intimate partner violence by age 20⁵; adolescents aged 15–19 account for 21 million pregnancies annually, half being unintended, leading to around 12 million births.⁶ The global adolescent birth rate for girls aged 10–14 years is 1.5 per 1000, rising sharply to 4.4 in SSA.⁶ SSA is home to many of the countries with the highest rates of child marriage,⁷ and the region has the highest level of unmet needs for modern contraception among adolescents.⁸ Alongside these structural challenges, sexual norms are shifting and sexual debut is occurring earlier.⁹

A significant proportion of ALHIV, similar to their HIV-negative peers, engage in high-risk sexual activities, including inconsistent condom use, multiple sexual partnerships, transactional sex and limited disclosure of their HIV status to sexual partners, placing them at increased risk of onward HIV transmission.^{10 11} Historically, healthcare providers have discouraged ALHIV from pursuing intimate relationships or childbearing, reinforcing stigma and risk-averse counselling practices. In this context, low awareness of the undetectable=untransmittable (U=U) principle represents a critical missed opportunity to challenge these narratives, support treatment adherence and enable informed sexual and reproductive decision-making among ALHIV.¹²

Current evidence indicates that pregnant AHIV often have lower engagement with Prevention of Mother-To-Child Transmission services and face challenges adhering to maternal ART compared with adult women.¹³ Factors such as stigma, confidentiality concerns and limited social support contribute to suboptimal adherence and retention, which can negatively affect pregnancy outcomes and increase the risk of HIV transmission to infants.¹³

Over the past decade, access to SRH services has gained attention through the Sustainable Development Goals and Universal Health Coverage.¹⁴ SRH services are also integral to the WHO adolescent-responsive health services,¹⁵ and WHO has advocated since 2016 for integrating SRH services into HIV treatment for adolescents.¹⁶ Despite ongoing efforts to improve SRH access, adolescents still face numerous barriers at individual, organisational and structural levels.¹⁷ Individual barriers include limited knowledge about SRH, lack of awareness of available services, concerns about confidentiality and fears of stigma and discrimination.^{11 18} Organisational barriers encompass the limited availability of tailored SRH services, provider attitudes and insufficient provider training.^{18 19} Structural barriers include inadequate healthcare infrastructure, lack of adolescent-friendly services, geographical distance, financial constraints and legal and policy barriers.^{19 20} In addition, the existing gender inequities and social stigma associated with adolescent sexuality and HIV status negatively impact the accessibility and utilisation of SRH services by ALHIV.²¹

In recent years, increasing attention has been given to low-cost public health interventions that improve adolescents’ access to quality SRH services. These efforts target various SRH needs, including preventing sexually transmitted infections, unintended pregnancies and sexual violence.²² While previous reviews have examined sexual and reproductive health and rights (SRHR) outcomes among young people living with HIV, and assessed the impact of SRH interventions among this group in SSA,^{23 24} they have not specifically mapped interventions designed to improve access to SRH services for ALHIV. A comprehensive synthesis of these interventions, along with the facilitators and barriers experienced by ALHIV, is still lacking.

This scoping review aims to address this gap by identifying and analysing interventions aimed at improving SRH service access for ALHIV. Guided by Levesque’s framework, it analyses the dynamic relationship between supply-side and demand-side facilitators and barriers. The review maps existing interventions and offers evidence to inform the development of targeted, context-specific interventions to enhance access to SRH services for ALHIV.

Methods

Protocol and registration

We adopted the methodological framework proposed by Arksey and O’Malley²⁵ as further developed by the Joanna Briggs Institute,^{26 27} and reported the findings in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR) checklist²⁸ see online supplemental appendix 1. The protocol was registered on Open Science Framework (https://doi.org/10.17605/OSF.IO/7PBEW).

The following research questions formed the basis of this inquiry.

• What are the specific characteristics of interventions implemented in SSA to promote access to SRH services for ALHIV aged 10–19, including duration, target participants and key components?

• How do supply-side and demand-side factors, as outlined in Levesque’s framework, act as barriers or facilitators and how do these factors influence access to SRH services for ALHIV?

Eligibility criteria

We included studies focused on ALHIV of all genders, aged 10–19 years, residing in SSA, regardless of mode of HIV acquisition. We considered peer-reviewed articles and grey literature published in French and English between 2010 and 2024 to capture evidence reflecting recent shifts in adolescent HIV care, a period marked by the scale-up of paediatric ART and growing global emphasis—led by WHO—on integrating SRH services into HIV care. We reviewed studies across various designs, including experimental and quasi-experimental (eg, randomised and non-randomised controlled trials, before-and-after studies), qualitative studies and analytical observational studies (cohort, case–control and cross-sectional). Adolescent SRH interventions were defined according to the WHO framework²⁹ and included essential services such as modern contraceptives, safe abortion care, sexually transmitted infection (STI)/HIV prevention and treatment, sexual education and support for sexual and gender-based violence. We excluded studies that did not report outcomes related to SRH service access specifically for ALHIV aged 10–19 years. Studies focusing primarily on older adolescents or young adults (≥20 years), the general adolescent population without disaggregated ALHIV data or interventions unrelated to SRH services.

Information sources

We conducted the review in three scientific databases: PubMed, EMBASE and Web of Science. Given the multidisciplinary nature of the topic, we supplemented our search with manual searches of institutional websites to capture relevant grey literature. The search strategy was developed using the Population, Concept and Context framework and is detailed in online supplemental appendix 2.

Selection of sources of evidence

Two independent reviewers screened titles and abstracts, followed by full-text assessments, using Covidence software³⁰ to facilitate the review process. Discrepancies were resolved through discussion. We did not assess the quality of included studies, as is common practice in scoping reviews.

Data charting and data analysis

Data were extracted using a standardised form within Covidence and analysed using Microsoft Excel. Extracted data included author, year of publication, study location, research methods (study design, study population and settings) and intervention characteristics (duration, aim, participants, programme components). The findings were synthesised using a narrative approach. We used the conceptual framework developed by Levesque et al as an initial framework and adapted it to suit the specific context and aims of our analysis (figure 1).³¹ The Levesque framework is a comprehensive and multidimensional framework that addresses both structural and organisational barriers, including approachability, acceptability, availability, affordability and appropriateness. It also considers individual factors such as the ability to perceive, seek, reach, pay and engage with healthcare services.³¹

Figure 1. Adapted version of Levesque’s framework from the system and individual perspectives. Adapted from: Levesque JF, Harris MF, Russell G. Patient-centred access to health care: conceptualising access at the interface of health systems and populations. Int J Equity Health 2013; 12:18. Licensed under Creative Commons Attribution 2.0 (CC BY 2.0). ALHIV, adolescents living with HIV; SRH, sexual and reproductive health.

Patient and public involvement

This study was conducted without patient or public involvement.

Results

Search results

Out of 6835 records, 1236 were duplicates and 5556 were not eligible based on the title and/or the abstract. Of the 43 studies evaluated for full-text eligibility, 29 studies were excluded because of irrelevant outcomes, interventions or study designs, along with an inconsistency in the target population. The results of the search and study inclusion process are presented in a PRISMA flow diagram as figure 2.

Figure 2. PRISMA flow diagram of the selection process. Flow diagram showing the number of records identified, screened, excluded and included at each stage of the scoping review. The structure follows the PRISMA. ALHIV, adolescents living with HIV; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses; SRH, sexual and reproductive health.

Intervention characteristics

The studies employed a variety of research designs. The majority of these studies (5 out of 14) adopted a qualitative study design,32,36 4 were mixed-methods studies,37,40 combining both quantitative and qualitative approaches, 2 were randomised controlled trials (RCTs),^{41 42} 1 was a non-randomised experimental study,⁴³ another was a quasi-experimental study⁴⁴ and 1 was a pre–post cohort study.⁴⁵ Included studies were carried out in 10 different countries, especially in Southern and Eastern African countries, such as South Africa (n=3),^{35 38 40} Kenya (n=2),^{43 44} Uganda (n=3),^{41 42 45} Malawi (n=2)^{34 37} and Zimbabwe (n=2).^{32 36} Single studies were conducted in Zambia³⁹ and the Democratic Republic of Congo³³ in Central Africa. The studies predominantly focused on ALHIV, specifically those aged 15–19, along with pregnant adolescent girls, caregivers and healthcare professionals. The duration differed across studies, with some being short-term (ranging from 1 to 2 months), others medium-term (spanning several months) and a few long-term (lasting over multiple years). These studies encompassed a wide range of sample sizes, varying from 13 participants to a larger number of 1060 participants, with most studies having a higher proportion of female participants. See online supplemental table S1 for the detailed characteristics of included studies.

Table 1 describes types of interventions reported across the studies. Peer education and support interventions appeared in eight studies34,3739 43 emphasising the role of peer-led initiatives in improving adolescent SRH by fostering trust, reducing stigma, enhancing engagement and supporting treatment adherence through shared experiences and supportive environments. A significant portion of the included studies—8 out of 14—focused specifically on educational strategies,3235 37 40,43 45 emphasising the role of knowledge in promoting healthier behaviours and improving SRH. These programmes enhanced awareness of HIV, safe sex practices and treatment adherence while also addressing broader SRH issues, ensuring adolescents understood their rights and decision-making power regarding their SRH.

Table 1. Types of interventions identified in the included studies.

First author/year	Education	Peer education and support	Behaviour change campaigns	Healthcare workforce training	Outreach screening	Health financing and coverage	Supply of products, equipment and drugs	Infrastructure improvement
Kaunda-Khangamwa et al, 202137	✓	✓
Mavodza et al, 202232	✓			✓			✓
Senyonyi et al, 201241	✓		✓
Toska et al, 201738						✓
Kose et al, 202143	✓	✓		✓
Parker et al, 201333			✓
Shato et al, 202142	✓
Merrill et al, 202139		✓		✓
Levy et al, 202144		✓			✓
Mwalabu et al, 202134		✓
Vu et al, 201745	✓	✓		✓		✓		✓
Bergam et al, 202235	✓	✓
Mupambireyi et al, 201436		✓
Toska et al, 201540	✓		✓

Healthcare workforce training was highlighted in four studies,^{32 39 43 45} aimed at equipping providers to meet the unique needs of ALHIV, ensuring both medical and emotional support. Outreach screening efforts were implemented in one study.⁴⁴ The programme provided bi-monthly home visits to support HIV-positive and HIV-vulnerable pregnant adolescent girls, adolescent mothers, ensuring access to and enhancing the uptake of health and social services, such as antenatal care, skilled delivery, ART adherence and modern family planning. Financial barriers were addressed in two studies,^{38 45} highlighting their influence on access to essential SRH services, including ART.

Behaviour change campaigns were highlighted in three studies^{33 41 40} that investigated the potential of cognitive behavioural therapy (CBT) to reduce HIV transmission, particularly by addressing unsafe sex and promoting safer sexual practices. The availability of products, equipment and drugs mentioned in one study,³² underscored the need for access to ART and contraceptives. Infrastructure improvements, also noted in one study⁴⁵ involving the creation of ‘youth-friendly’ corners in health facilities, were designed to provide easy access to educational materials and counselling services, ultimately enhancing the facilities’ overall infrastructure. Additionally, qualitative insights from some studies provided valuable narratives about the experiences of ALHIV, shedding light on the complexities of disclosure, mental health and the psychosocial support necessary for their well-being.⁴⁰

Context of the interventions

A variety of contexts, including community, school and clinical settings, as well as digital platforms and home-based, were used to implement the interventions designed to improve SRH access to ALHIV. Every effort aimed to improve this population’s access to services and was tailored to address their unique needs. For instance, the WhatsApp-based intervention documented in Bergam et al in South Africa (Interactive Transition Support for Adolescents Living with HIV, or InTSHA) used digital communication to improve SRH attitudes and behaviours among adolescents, showcasing the potential of technology to engage youth in health education.³⁵

In clinical settings, a study conducted by Merrill et al in Zambia investigated the integration of a safety protocol within a clinical-based initiative aimed at addressing violence against ALHIV.³⁹ The research highlighted the critical role of health systems in enabling open, supportive discussions between adolescents and healthcare providers about sensitive topics. Another study assessed the feasibility of implementing an adapted positive prevention intervention—referred to as the Supporting Youth and Motivating Positive Action intervention—for young people living with HIV.³³ The intervention successfully established a safe and supportive environment, enabling participants to build knowledge, develop essential skills and increase their confidence in managing their sexual and reproductive health.

At the community level, the Teen-Club Clinic programme delivered a comprehensive, adolescent-focused model that offered integrated HIV and SRH services in a supportive environment in Malawi.³⁷ The model paved the way for active interactions and equal partnerships between ALHIV, health workers, parents and caregivers. Additionally, the CBT programme as part of the Teens Linked to Care and its Act Safe Module was implemented in community and clinical settings to address mental health issues such as depression and anxiety among perinatally infected adolescents.⁴¹ The Act Safe Module was designed to help adolescents reduce sexual risk and substance use by recognising what triggers risky behaviour, making healthier choices around substance use and building confidence in using condoms—ultimately supporting them in making safer decisions about their sexual health.

School-based programmes integrated health education, stigma reduction and capacity-building to enhance adolescents’ knowledge, self-advocacy and overall engagement with health-promoting behaviours.⁴³ The intervention not only created a supportive learning environment but also built strong two-way connections with healthcare facilities to ensure adolescents could easily access care. It also included elements of social protection and psychosocial support—such as cash transfers, food assistance and help with school access—to reduce risky sexual behaviour and promote the overall well-being of ALHIV.³⁸

Home visitation programmes in community settings in Kenya focused on pregnant adolescent girls who were either living with HIV or vulnerable to it. These programmes aimed to improve health outcomes by strengthening family and community support and promoting key health services, including antenatal care, skilled delivery, ART adherence and access to modern family planning.⁴⁴

Moreover, peer-led initiatives delivered youth-friendly services within community settings, demonstrating the power of peer-support networks in improving access to care.34,3739 43 These support groups acted as important psychosocial interventions, helping ALHIV manage challenges such as taking medication regularly and coping with emotional difficulties. They created a sense of community, reduced feelings of stigma and supported continued use of healthcare services. By sharing experiences and supporting one another, adolescents developed skills in self-advocacy, coping and health management, which contributed to better SRH and overall well-being.

Facilitators and barriers based on Levesque’s conceptual framework

The review identified factors that either facilitated or hindered access to SRH services for ALHIV, organising the findings using Levesque’s healthcare access framework. This framework classifies factors into different health system-related dimensions and individual-related abilities. Online supplemental table S2 focuses on key dimensions and abilities of healthcare access, framed according to Levesque et al’s conceptual framework.

Dimensions of access

Approachability

Seven studies3435 37 40 43,45 highlighted facilitators and barriers related to approachability. Digital platforms, with the use of a WhatsApp-based intervention,³⁵ integrated HIV and SRH services, through the ‘one-stop-shop’,³⁷ SRH outreach programmes, with implementation of bi-monthly home visit programmes,⁴⁴ are recognised as effective facilitators for improving approachability. The integration of HIV support services into schools further improved approachability by providing designated focal contacts for easier access.³⁴ Additionally, training healthcare providers to be non-judgemental and youth-friendly, along with the establishment of ‘youth-friendly’ corners and the involvement of peer educators in health facilities, makes services more approachable.⁴⁵ However, adolescents’ anxiety about disclosing their HIV status hindered their willingness to seek support and approach healthcare services.⁴⁰

Acceptability

Acceptability was a central focus across the studies (n=13).33,4143 Comfortable, safe spaces to discuss sensitive topics,³⁵ adolescent-centred approaches,^{37 43} culturally and age-appropriate services^{37 43} and the involvement of young people in designing services³² are recognised as key factors in improving the acceptability. Training on HIV, stigma and SRH for school staff and students,⁴³ as well as efforts to reduce stigma,⁴⁴ further improve service acceptability.

Efforts like culturally relevant language use, peer-support environments and non-judgemental healthcare provider training fostered trust and comfort among participants.^{32 36 40 45} Studies also showed that incorporating creative methods, such as visual aids and sentence completion exercises, increased adolescents’ willingness to engage.³⁴ Interventions addressing stigma and promoting parental supervision were associated with improved health behaviours.^{38 44}

Availability

Within the scope of this review, availability was one of the least explored dimensions.^{32 36 45} Ensuring centralised and accessible youth-friendly HIV and SRH services played a facilitator role in improving availability.⁴⁵ By providing comprehensive, age-appropriate care in single locations, the initiatives bridged critical gaps in service delivery and improved access for ALHIV.³² However, barriers such as transport costs and inconsistent funding can hinder the consistent availability of SRH essential services.³⁶

Affordability

The issue of affordability appeared in three of the included studies.^{38 42 45} Social cash transfers and school access programmes provided financial support and social protection, enabling adolescents to overcome cost-related obstacles.³⁸ Child Development Accounts (CDAs) with matched savings improved families’ financial resources, directly supporting access to and adherence to ART.⁴² Similarly, the distribution of referral vouchers allowed ALHIV to access health services without incurring financial burdens.⁴⁵

Appropriateness

10 out of 14 studies highlighted how healthcare services are tailored to the specific needs of individuals, ensuring appropriateness.3334 38 39 41,45 Facilitators included the integration of formal and alternative services, ensuring a comprehensive approach to diverse health needs.³⁷ Additionally, the provision of targeted support, such as treatment literacy, youth-friendly services and psychosocial counselling, ensures that services are both relevant and appropriate to ALHIV.⁴³

Another key facilitator is the use of personalised care models, such as home visitation and case management, which tailor services to the individual needs of adolescents.⁴⁴ Safety protocols and referral systems are also important in ensuring that youth facing complex issues, such as violence or mental health concerns, receive appropriate care.³⁹

Culturally relevant tools further enhance the appropriateness of SRH services by engaging adolescents in ways that resonate with their experiences.^{33 34} Furthermore, economic empowerment programmes enhance the appropriateness of services by addressing financial and socioeconomic barriers through tailored support, such as financial literacy workshops and mentorship sessions.⁴² Finally, psychological support mechanisms, like CBT, address the specific psychological and behavioural needs of ALHIV by providing education on HIV management, sexual behaviour and substance use.⁴¹

Abilities related to access

Ability to perceive

Nine studies discuss the ability to perceive.3234,36 38 40 41 44 45 Youth-friendly services improve adolescents’ understanding of HIV and SRH services, enhancing their ability to perceive available care and how it meets their needs.³² Tools like the ‘My Story’ book supported adolescents in reflecting on and articulating their health experiences, strengthening their awareness of personal health needs.³⁴

Additionally, education and counselling help adolescents recognise health issues that need professional care.⁴⁵ Through psycho-education and cognitive-behavioural strategies, adolescents developed a better understanding of their risky behaviours and triggers, gaining greater awareness of the risks associated with HIV transmission and substance use.⁴¹

Ability to seek

The ability to seek was highlighted in 10 studies.3235,41 44 45 An example of a facilitator that enhances the ability to seek care is providing platforms where adolescents can access information and receive support on sensitive SRH topics.³⁵ Strategies, such as mHealth platforms, reduce stigma and make it easier for adolescents to seek relevant health information, addressing issues like disclosure, relationships and HIV knowledge.³⁷

The availability of a ‘one-stop approach’ in community-based settings makes it more convenient for adolescents to seek care, while private health booths and discrete access further support their ability to seek services without fear of judgement.³² Structured referral processes for more severe issues, such as violence or suicidal thoughts, help adolescents navigate to the appropriate care.³⁹

Support systems, such as HIV support groups and positive parenting, also play a key role in empowering adolescents to seek care.³⁸ Peer support and educational initiatives build confidence and knowledge, enabling adolescents to seek the SRHR services they need.⁴⁵ Structured and flexible approaches, such as group counselling and self-disclosure training, enable adolescents to seek help and manage their health more effectively, fostering a sense of support and empowerment to access the care they need.⁴¹ However, barriers like transport costs and fear of stigma can hinder the ability to seek services.^{36 40}

Ability to reach

Discussed in four studies, it highlights factors such as overcoming geographical, logistical and social barriers that limit access to healthcare.^{32 36 44 45} Home visitation approaches, which deliver health services directly to participants’ homes, help overcome geographical and mobility barriers.⁴⁴

Community-based care models, offered in local communities, improved accessibility by reducing travel needs and making care more reachable.³² Youth-friendly corners and peer-support groups further facilitate access by creating welcoming, non-stigmatising environments where adolescents feel encouraged to participate in their care.⁴⁵ In contrast, barriers like transport costs and inconsistent support groups limit access to care.³⁶

Ability to pay

Factors affecting adolescents’ ‘ability to pay’ were explored in three studies.^{38 42 45} For example, social cash transfers, food security programmes and support for school access reduce economic pressures, making it easier for individuals to afford health services and other basic needs.³⁸

Approaches such as CDAs with matched savings boost participants’ financial capacity to cover ART and healthcare costs, easing the economic burden on families.⁴² Additionally, the use of vouchers reduces direct healthcare costs, improving ALHIV’s access to and affordability of STI and family planning services, while also reducing HIV-related risk behaviours.⁴⁵

Ability to engage

This ability emerged as the dominant dimension, explored in 13 of the included studies.32,3537 Facilitators included promoting bi-directional conversations³⁵ and creating youth-friendly, non-judgemental care environments,⁴⁴ empowering adolescents to actively engage with healthcare providers and services. Programmes that include peer counselling, mentorship and psychosocial support^{42 43} enhanced active participation, while educational sessions improved understanding of treatment plans and health-related decision-making.³⁷ Interventions that involve adolescents, such as gender-specific groups or personalised materials,³³ improved engagement by making services more relevant and accessible.

Stigma, shame and isolation are common barriers that prevent adolescents from discussing their health or sticking to treatment plans.⁴⁰ It also revealed that overcoming engagement challenges with community support, financial empowerment and culturally sensitive interventions helps create a more supportive environment.3738 42,44

Discussion

This scoping review allowed us to map and synthesise existing literature on the access to SRH services for ALHIV, reviewing barriers and facilitators of access while adopting Levesque et al’s healthcare model of access as an analytical framework.³¹ Among the 14 studies included, strategies to improve access to SRH services ranged from simple, uni-dimensional approaches to complex, multi-faceted programmes addressing diverse needs, such as financial barriers, cognitive therapy and infrastructure improvements.⁴⁵ The programmes were implemented across a variety of settings, including schools, clinics, communities and digital platforms.³⁵

A closer look at the findings suggests that peer education, digital platforms and community-based strategies stand out for their potential to address multiple dimensions of access, as outlined in the Levesque framework and should therefore be considered strategic priorities for improving access to SRH services among ALHIV. Each of these approaches contributes uniquely while complementing one another. Peer-education improves approachability and acceptability by building trust, reducing stigma and creating a safe space for open dialogue through shared experiences.⁴⁶ In parallel, digital platforms improve availability and appropriateness by providing confidential, on-demand SRH support—crucial for ALHIV facing mobility, privacy or stigma-related barriers.⁴⁷ Complementing these, community-based programmes enhance accommodation and appropriateness by bringing services closer to adolescents and tailoring them to local social and cultural contexts. They also engage families, schools and local organisations to foster supportive SRH care environments.⁴⁸ Together, these interventions create reinforcing effects that address access more holistically. As such, they should be considered strategic priorities for future investment, adaptation and scale-up in adolescent-focused SRH programming.

The findings also align with those of previous studies, which highlight both physical and economic barriers that hinder adolescents’ access to SRH services in SSA.^{14 45} Both studies highlight the importance of cultural acceptance and community support in improving access to SRH services, while also identifying financial and logistical barriers, such as cost and distance to healthcare facilities, as key challenges. Our findings complement the scoping review by Agyepong et al⁴⁹ which reported that interventions addressing adolescent mental, sexual and reproductive health in West Africa were largely small-scale and evaluated using non-experimental designs, highlighting important evidence gaps.⁴⁹ While their review adopted a broad adolescent health perspective, our study extends this literature by focusing specifically on ALHIV across SSA and by applying Levesque’s access to healthcare framework to provide a more detailed understanding of barriers and facilitators to SRH service access. The findings highlight the need for future research to focus on addressing both the physical and financial barriers—such as cost and distance to healthcare facilities—while exploring ways to strengthen community engagement and cultural acceptance in improving SRH service access for ALHIV.

The majority of the included studies explored specific dimensions and abilities of access to SRH services, with 7 studies addressing approachability,3435 37 40 43,45 while 13 focused on acceptability,33,4143 highlighting a tendency to prioritise cultural relevance over service visibility. Effective utilisation of SRH services requires a balance between cultural appropriateness and ensuring that services are easy to find and approach.⁵⁰ Strategies like community outreach, targeted awareness campaigns can improve visibility while respecting cultural values.⁵¹

The review highlighted that acceptability and appropriateness were central themes in the included studies, while availability and affordability were less frequently discussed, with only four studies addressing the ability to reach services and three focusing on the ability to pay. While the cultural and social aspects of SRH services receive significant attention, less focus is placed on the physical and financial barriers that may limit access. Key barriers identified in the reviewed studies include the physical inaccessibility of services, healthcare providers’ behaviour and shortages of supplies, all of which directly impact adolescents’ ability to access and use SRH services.

On the demand side, individuals’ ability to perceive, engage with and seek services was dominantly addressed in the reviewed articles, highlighting the importance of considering personal and behavioural factors when evaluating SRH service access. The reviewed studies identified fear of disclosing HIV status, societal stigma, shame and a lack of open discussions about SRH issues as potential barriers that can discourage adolescents from seeking SRH services and adhering to HIV treatment. These findings are supported by studies conducted in Ethiopia, Rwanda and Nepal.52,55 Future research and interventions should not only target tangible barriers, such as service availability and costs but also tackle the emotional and societal factors that prevent adolescents from seeking care. Creating a supportive environment where ALHIV feel safe to disclose their HIV status and access services without fear of stigma or shame is essential for improving SRH outcomes.

Age-specific considerations emerged as an important gap in the reviewed literature. While the review included adolescents aged 10–19 years, very young adolescents (10–14 years) experience distinct SRH vulnerabilities and social influences compared with older adolescents (15–19 years).⁵⁶ These differences include lower autonomy, heightened influence of social norms and greater reliance on caregivers, underscoring the need for age-tailored approaches to SRH service delivery and engagement.⁵⁶

In addition to supply and demand side factors, systematic factors are also critical in addressing SRH access for ALHIV. Although this aspect was not the main focus of the review, the included studies did not adequately address broader systemic issues such as healthcare policies, governance and social determinants of health. Systemic barriers, such as inadequate healthcare policies, poor coordination among stakeholders and unequal distribution of resources, can hinder the availability and impact of SRH services for ALHIV. These factors need to be considered alongside supply and demand side factors to create a more comprehensive and equitable approach to improving access to SRH services for ALHIV.

Another important consideration is the sustainability of SRH interventions in the context of reduced donor funding. Although funding sources were not systematically captured in this review, many adolescent SRH interventions in SSA are donor-supported. Reductions in external funding may threaten the continuity and scale-up of effective programmes, highlighting the importance of integrating SRH services into national health systems and strengthening domestic financing mechanisms.⁵⁷

The strengths and limitations of this review are consistent with those of other scoping reviews.^{58 59} The study employed a rigorous methodology and used Levesque’s conceptual framework to synthesise findings on SRH service access for ALHIV in SSA. This approach allowed for the systematic categorisation of barriers and facilitators into five dimensions and abilities, providing a detailed and comprehensive overview. However, several limitations inherent to scoping reviews should be acknowledged. While our inclusion criteria allowed for publications in English and French, all 14 included studies were published in English, as no French-language studies met the eligibility criteria reporting SRH access outcomes specifically for ALHIV. As a result, the available evidence may under-represent Lusophone and Francophone settings. In addition, no formal quality appraisal of the included studies was conducted, consistent with scoping review methodology, meaning that findings reflect reported evidence rather than assessed methodological quality.

Furthermore, there were notable regional disparities in the available evidence, with most studies originating from Anglophone countries in Southern and Eastern Africa. This uneven geographical representation may limit the transferability of findings to under-represented regions, where differing social norms, health system structures and funding environments could influence adolescents’ access to SRH services. While this scoping review successfully mapped existing literature across SSA, these methodological and contextual limitations should be considered when interpreting the findings and identifying future research priorities.

Conclusions

This scoping review mapped interventions aimed at improving access to SRH services for ALHIV in SSA, highlighting strategies that enable engagement with care as well as persistent barriers that limit access. Peer support, community-based programmes and digital platforms consistently facilitated acceptability, approachability and engagement, demonstrating effective approaches to improving access for ALHIV.

Despite these facilitators, ALHIV continue to face significant barriers, including stigma, limited availability of adolescent-tailored interventions, financial and logistical constraints and uneven reach across regions. Very young adolescents (10–14 years) remain under-represented in intervention research, indicating a critical gap for age-specific access strategies.

These findings underscore the need for integrated, adolescent-centred and context-specific interventions that combine peer and community engagement, digital innovations, stigma reduction and financial or logistical support. Future research should focus on addressing sustainability, affordability and regional disparities to inform interventions that effectively improve access to SRH services for ALHIV and reduce inequities in care.

Data availability statement

Data sharing not applicable as no datasets generated and/or analysed for this study.