On Monday, President Donald Trump reinstituted the "global gag rule" (GGR), which prevents foreign organizations that provide abortion care, counseling, information or advocacy from receiving U.S. family planning funds. This rule, which was first instituted in 1984, has been shown to decimate family planning programs and increase abortion rates in countries around the world. And, because the rule targets organizations and not specific programs or services, it negatively impacts HIV-prevention programs, as well. Unfortunately, the wording of Trump's presidential memorandum seems to expand the reach of the GGR, meaning that it could have an even bigger impact on HIV prevention efforts overseas.
Under an even older rule -- the 1973 Helms Amendment -- no U.S. funds can be used to provide abortion services, but the GGR adds many more restrictions. Any non-governmental organization (NGO) that receives U.S. family planning money cannot care for abortion clients, counsel clients about abortion, provide any information about abortion or advocate for the liberalization of abortion laws in its own country, even if it uses other money to do so. The rule originally applied only to funds from the U.S. Agency for International Development (USAID), but in 2003 it was expanded to include all family planning funding through the U.S. State Department. When the rule is in place, organizations have to choose between providing the family planning programs that best suit their communities or taking much-needed U.S. aid.
Also known as "the Mexico City Policy," the rule dates back to Ronald Reagan and has been used as a political tool by every administration since. It was abolished by Bill Clinton when he became president in 1993, reinstated by George W. Bush in 2001 and eliminated again by President Obama in 2009.
Studies have shown that when the rule is in place family planning programs have suffered and abortion rates have gone up, likely because it becomes harder to access contraception. The Planned Parenthood Association of Ghana, for example, had to close many clinics because it could not take USAID funding after the imposition of the GGR under George W. Bush. A 2015 study found that the unintended pregnancy rate in Ghana went up during that time.
Though in the past the GGR has been limited to family planning money, it has nonetheless impacted HIV prevention programs. Condoms are the most obvious link between family planning and HIV programs, as they are the only method that prevents both unintended pregnancies and sexually transmitted diseases.
The condom supply chain is certainly affected by the GGR. The Center for Health and Gender Equity (CHANGE) explains in a fact sheet that, during the Clinton Administration, the Lesotho Planned Parenthood Association received 426,000 condoms over two years from USAID. This stopped in 2001, because the organization did not comply with the reinstated GGR. No other organization in the small African country could take over the condom availability program. At the time the condom program was stopped, one in four women in Lesotho was infected with HIV.
Jamila Headley, managing director of the Health Global Access Project (Health GAP) told TheBody.com in an email, "We know that there's been a concerted effort (based on evidence of what works) to integrate HIV testing and prevention services into broader reproductive and sexual health services, which means that the same organizations that provide family planning, cancer screening and other services are also ground zero for HIV service delivery. In the past, when the U.S. has the gag rule in place, it has effectively dismantled health services in a number of communities, forcing clinics to close and making it harder to reach key populations at risk for HIV, including women and girls, LGBT individuals and sex workers."
Unfortunately, the impact will likely get worse under the new GGR, which directs the Departments of State and Health and Human Services to "implement a plan to extend the requirements of the reinstated Memorandum to global health assistance furnished by all departments or agencies." An analysis by PAI, an international NGO, suggests that, while the old GGR affected about $575 million of U.S. funding each year, this new rule could impact upward of $9 billion. That includes funding to fight diseases such as malaria, Ebola, Zika and, of course, HIV/AIDS.
Most of the U.S. funding for international HIV/AIDS prevention and treatment efforts comes through the President's Emergency Plan for AIDS Relief (PEPFAR), which began in 2003 with a five-year, $15 billion investment in HIV/AIDS prevention and treatment in 15 of the countries hardest hit by the epidemic. It has continued and grown, becoming the cornerstone of U.S. global health efforts. In fiscal year 2016, PEPFAR received $6.7 billion dollars. According to its annual report, that money supported antiretroviral treatment for nearly 11.5 million people in sub-Saharan Africa, trained over 200,000 health care workers, prevented two million babies from being born with HIV who would have otherwise been infected, reached over one million adolescents with HIV-prevention interventions and provided HIV testing and counseling to 74 million people, including more than 11 million pregnant women.
All of this progress could be in jeopardy if the international organizations that receive this money do not want to comply with the GGR. Trump's expansion of an already harmful policy will no doubt make it much harder for countries around the globe to keep up the fight against the HIV/AIDS pandemic.