<p>This paper examines persistent policy and structural barriers shaping adolescents’ and young adults’ access to HIV services in Sub-Saharan Africa (SSA). Drawing on regional evidence and illustrative country examples, it discusses how restrictive age-of-consent laws, adult-centric service delivery models, weak transition pathways from pediatric to adult care, inadequate age-disaggregated data systems, and the exclusion of adolescents from national service delivery scale-ups continue to constrain engagement across the HIV care continuum. These interconnected barriers disproportionately affect adolescent girls and young women and undermine timely testing, sustained treatment, and continuity of care. While global and regional strategies increasingly recognize adolescents as a priority population, national policy frameworks often remain misaligned with young people’s lived realities. Crucially, the paper moves beyond identifying these barriers to examine why they persist despite decades of evidence and sustained advocacy, arguing that their durability reflects institutional inertia, political economy dynamics, and structural path dependencies that insulate policy from accountability. Specifically, the paper shows how feedback loops between weak data systems and institutional indifference, combined with the systematic exclusion of adolescents from HIV governance structures, reproduce these failures across successive policy cycles. Building on this analysis, the paper proposes politically differentiated, feasibility-sensitive reform pathways that account for likely sources of institutional resistance and identify the country and programmatic contexts in which change is most likely to occur, offering a more actionable framework for advancing equitable and sustained HIV epidemic control.</p>