The purpose of this article was to present the current state of evidence and experience of youth participation approaches in HIV and sexual and reproductive health decision-making, policies and programmes. By combining a literature review of evaluation evidence with in-depth interviews and a global survey targeting young people with the experience of participation, this study opens a new window into the support needs for meaningful youth participation globally. Limited available evidence indicates that youth participation has positive effects on programme, self efficacy and empowerment outcomes for the young people engaged in policies and programmes. Young people who have participated in decision making reflected on improvements in outreach and representation of youngmembers of key affected populations, but also expressed concerns about tokenism, age-based hierarchies and access for younger adolescents, women and marginalized groups. Overall, evidence indicates a need for further investments in capacity building, training, inclusive participation spaces and research on meaningful youth participation.