Implementation considerations To be most effective in promoting access, HCV treatment programmes to reach children and adolescents need to be aligned and integrated as much as possible with programmes for adults, with pooled procurement and streamlined supply chain management, but recognizing that the caregivers differ. Inclusion of case-finding, testing, care and treatment of children and adolescents in national plans and guidelines A major constraint to implementation of these recommendations is that, currently, few LMICs have included adolescents and children in their national viral hepatitis strategic plans or their testing and treatment guidelines (4). As a result, most cases in adolescents and children remain undiagnosed and untreated. There are significant gaps and missed opportunities for diagnosis and documenting the HCV infection status of children of infected mothers or parents. All countries should now include HCV case-finding and testing strategies for adolescents and children and for treatment of adolescents in their national guidelines, based on the recommendations of the 2017 WHO HCV testing guidelines (4). This includes focused testing of adolescents from populations most affected by HCV infection (for example, people who inject drugs, men who have sex with men, HIV-infected persons and children of mothers with chronic HCV infection, especially if HIV-coinfected) and those with a clinical suspicion of viral hepatitis. It may also include screening of pregnant women in countries with high prevalence/burden with policies for linkage to care and follow-up of infants. Testing of HCV-exposed infants could be undertaken in a range of services – child health services, immunization clinics, under-5 clinics, malnutrition services, well-child services, services for testing of hospitalized and all sick children, tuberculosis clinics, and services for orphans and vulnerable children. Box 4.1 describes potential testing opportunities to improve hepatitis case-finding among infants and children. The recently reported national scale-up of testing and treatment among school-age children and adolescents in Egypt has demonstrated the feasibility and acceptability of case-finding and treatment among children and their caregivers (114). There is also a need to raise awareness among both health care workers and the public about the need to screen adolescents and children and the availability of curative treatments.

• Provision of care and treatment by non-specialists: Non-specialist paediatricians can treat HCV-infected children and adolescents. However, although DAA-experienced HCV-infected children and adolescents and those with cirrhosis are rarely encountered in clinical practice, such cases may be most appropriately managed under the supervision of a paediatric specialist. Data that speak to this are few.
• Paediatric formulations for young children: Current options include originator product formulations for glecaprevir/pibrentasvir (pellets) and sofosbuvir/velpatasvir (granules) or existing adult 30 mg daclatasvir and 200 mg sofosbuvir tablets. (See section 4.4.5. Resource and access considerations.)
• Service delivery for adolescents
• Delivering adolescent-friendly services: Providing services for adolescents require approaches that are adolescent focussed on and friendly to adolescents. WHO has developed standards for delivering quality services for adolescents (116). Engaging adolescents in testing for both viral hepatitis and HIV, either in health services or in the community, should be based on adolescent-friendly principles to ensure that psychological as well as medical needs are addressed. Services need to be convenient and available, with an absence of financial barriers, offer flexible opening hours and/or walk-in or same-day appointments. Separate hours and special events for adolescents may help overcome concerns that relatives or neighbours will see them seen attending viral hepatitis/HIV services.
• Vulnerable adolescents: Special considerations are needed for particularly vulnerable adolescents, those who are at higher risk of acquiring infection and have poor access to services. These include those who are homeless, those living on the streets, orphans, boys who have sex with men or who are using/injecting drugs, those in multiple or concurrent sexual partnerships and those who are sexually exploited or trafficked (25). Specific campaigns, use of social media or other Web-based approaches, and involving adolescents in identifying appropriate language may help to reach this group in some settings.
• Age of consent: A high age of consent can pose a barrier to adolescents’ access to HIV and viral hepatitis testing (117). The age of consent for HIV testing varies from country to country. Testing services should be aware of laws and policies governing the age of consent and develop appropriate procedures based on this legal framework to ensure that children and adolescents have access to testing. WHO also recommends that children and adolescents themselves be involved in the testing decision as much as possible (117). Countries should revise their age of consent policies in line with best practices, in the best interest of adolescents and in recognition of the heterogeneity and varying levels of maturity among adolescents.
• Disclosure: Adolescents may particularly need support with when and to whom to disclose a positive status (117). When appropriate, and only with the adolescent’s specific permission, health care personnel should engage the support of adults – family members, teachers and other community members. Adolescents should be counselled about the potential benefits and risks of disclosure of their HIV or HCV status to others and empowered and supported to determine if, when, how and to whom to disclose.