The abortion debate has heated up in the past few months, as conservative states have passed a number of extreme restrictions on when, where, and under what conditions people can terminate a pregnancy, in an effort to force the Supreme Court -- and its two new conservative justices -- to revisit the Roe v. Wade decision.
The outright bans that some states are now passing -- whether they ban abortion at the moment a fetal heartbeat can be detected, eliminate exemptions for people who are pregnant as the result of rape or incest, or make the procedure a felony for which providers could see significant prison time -- are the culmination of years of laws that have chipped slowly away at abortion access, primarily in the South.
Clinics that want to operate in these states face multiple rules,
from requirements that all providers have local hospital admitting privileges to regulations about the width of their hallways. As a result, a large swath of the country is already living in abortion deserts with no providers for hundreds of miles and waiting periods that require multiple trips or expensive hotel stays. And, the Trump administration is trying to further limit access to both abortion and contraceptive care, with strict rules governing Title X-funded clinics.
The impact of these laws and regulations -- many of which remain on hold while litigation wends its way through the court system -- will reach beyond people experiencing pregnancy and beyond abortion care. In some cases, the clinics targeted by the rules are also the ones most likely to provide other reproductive and sexual health care like cancer screening, sexually transmitted disease (STI) treatment, and HIV testing. But even when this is not the case, the effect of these laws -- which are being enacted in the very places that are already hardest hit by the HIV epidemic -- is to increase stigma and shame and decrease access to care.
Direct Impact: Fewer Clinics Mean Less Access to Health Care
The direct impact of strict regulations on HIV care depends on who provides abortion care in the area. Most people -- especially the uninsured or underinsured -- rely on clinics for any type of abortion services. Clinics can be freestanding, part of a hospital system, or an affiliate of a national organization like Planned Parenthood. They may receive federal family planning funds under Title X (though these funds cannot be used to provide abortion), or they may be privately funded.
The services offered at these clinics also vary. Some focus almost exclusively on abortions. These clinics may provide birth control counseling or prescriptions at the time of the procedure to help patients prevent subsequent unintended pregnancy, but they are not birth control clinics, and they do not provide STI or HIV testing. Other clinics -- especially those funded by Title X -- operate as full-service sexual and reproductive health centers.
This is the case with the last abortion clinic in Missouri -- Planned Parenthood's medical center in St. Louis -- which came close to shutting down earlier this month during a licensing dispute with the state. A judge issued an eleventh-hour reprieve, and the clinic remains open for now. Had it lost its license, the impact on other sexual health could have been immediate.
"What I am concerned about is that most likely these clinics are not just doing abortion, they are doing other reproductive health programs or services," said Kristin Adams, Ph.D., CHES, president and CEO of the Indiana Family Health Council. "They are doing pap smears, HIV testing, chlamydia or gonorrhea testing. So, when you talk about a Planned Parenthood that is being forced out of business because of abortion regulations, you're talking about losing these services as well." And she noted from past experience in Indiana that once you close a clinic, it's very hard to reopen it even if you have funding.
Adams, whose organization is responsible for distributing Title X funds to clinics throughout Indiana, points out that while Title X clinics don't provide HIV treatment (which is covered under different funding streams), they are more likely to provide HIV testing than private physicians -- and as such, they are often a person's entry into the HIV care system. "Indiana has a robust system [for HIV care], and we connect them with the state Health Department disease interventionists and to physicians, social services, medication assistance. Our goal is to get them into wraparound services right away." She added that some Title X clinics are also choosing to provide pre-exposure prophylaxis (PrEP) to patients, though that is not funded by the program.
The future of Title X clinics and their ability to provide abortion or even refer patients to abortion providers is up in the air. The Trump administration attempted to impose strict rules that would have banned recipients from sharing physical space with abortion providers. This would force some clinics that currently offer both services to move or remodel. The regulations also included what many are calling a domestic "gag rule" -- Title X clinics would not be allowed to refer pregnant patients to abortion providers. They could hand patients a list of health care providers in the area, but that list could not include any explanations of who would or wouldn't offer abortions. Two federal judges have placed injunctions on the rules, with one writing that they were based on "an arrogant assumption that the government is better suited to direct women's health care than their providers."
Of course, there is another issue plaguing Title X clinics as well: funding. Adams says that expenses like raises for staff, the price of medications, and vendor costs have continued to rise while funding has stayed flat, which makes it hard for some clinics to stay in business.
Indirect Impact: Stigma and Shame Prevent People From Seeking Health Care
In other places, shuttering an abortion clinic would not necessarily have an immediate impact on broader reproductive and sexual health care. Take Kentucky, for example, a state that also has only one abortion clinic and is currently litigating a series of abortion restrictions. The one provider -- located in Louisville -- is a private abortion clinic that offers no other services.
Nonetheless, activists believe that other sexual health care is being curtailed because of the political and social environment. Meg Sasse Stern, support fund director with the Kentucky Health Justice Network, helps women navigate the logistics of getting an abortion and cover the expenses for the procedure and the travel and lodging needed. She draws a connection between abortion and other sexual health care, because these are both things we "keep in the dark and only whisper about." Abortion and HIV care share an urgency because with both, it's important to find a provider quickly. But without open dialogue, "people who need these services can't access them, because they're not easy to find. They don't know where to look or who to ask, because they're embarrassed for needing the care."
Laurie Bertram Roberts of the Mississippi Reproductive Freedom Fund agrees. Her organization helps women pay for abortion and birth control and offers other services and supplies such as diapers, period supplies, condoms, emergency contraception, and sexuality education. It just started to help clients connect with providers for PrEP as well. She told TheBody that the people she talks to have no idea that PrEP even exists. "Their minds are blown that there is a pill you can take to prevent HIV." She calls this lack of information "collateral damage" from the abortion debate, which "stigmatizes certain kinds of care."
"The places that we are seeing these laws ramp up are the same states with higher burdens of HIV," adds Carl Baloney, Jr., director of government affairs with AIDS United. "They already have very strict abortion laws, and they are also seeing increasing amounts of stigma of people living with or at risk for HIV." This stigma, he says, keeps people from seeking care. "One of the issues around access and care that we found most harmful is that people are afraid to be associated with the LGBT community. MSM [men who have sex with men] or same-gender-loving men don't necessarily identify as gay and are afraid to access care at the dwindling network of providers because of the perception that if you're testing, you might be gay."
Core Commonalities: When 'Morality' Replaces Health Care
At their core, abortion restrictions -- whether they subject women to an ultrasound with the volume turned up before an abortion, make clinics widen their hallways, or prevent referrals -- are passing judgment on those seeking out services. These laws and their supporters are saying that you don't have the right to this care, that some sexual behavior is unacceptable, and that the punishment for going against these societal norms is a loss of bodily autonomy.
These are all issues that have impeded HIV care since the beginning of the epidemic, and the people most impacted by restriction to access -- poor people, queer people, people of color, and people living in the South -- are the same people who have historically been most affected by the HIV epidemic.
Mary Alice Carter, executive director of Equity Forward, summed it up this way in an email to TheBody: "Their movement is and has always been about defining what they believe is right and moral when it comes to sex, sexuality, relationships, and family. Not only do they shame and stigmatize abortion decisions, they also vilify birth control and LGBTQ people. And every time you make people feel wrong, sinful, or shameful for their choices, be it ending a pregnancy or contracting an STI, or for who they love, you force them to hide, to not seek proper care, and to delay healthy choices."