In the early 2000s, my classmates and I pinned red ribbons to our bottle green school sweaters every 1st of December for World AIDS Day. The disease was understood and feared thanks to government driven campaigns targeting young people in Europe, the US, and others. I haven’t seen a red ribbon in years.

The progress made against AIDS is a remarkable global health story, to the credit of the two decades of global efforts made to tackle it. Still, almost 37 million people worldwide were known to be living with AIDS at the end of 2015. This includes 1.8 million children under the age of 15 who received the virus from their mothers. An estimated 25.6 million people living with AIDS in 2015 were in sub-Saharan Africa, where approximately 66% of new HIV infections in that year occurred.

It refuses US funding to any organization which uses any of its money (even funds received from a non-US federal source) to promote abortion access, whether that be through providing safe abortions and post-abortion care, or simply providing information about this option.

Those continuing to fight the epidemic worry that the reinstatement of the U.S.’s “Global Gag Rule” will see these numbers rise again. President Trump reinstated the Global Gag Rule, also known as the Mexico City Policy, in January, but with an extended reach. The policy was brought in by President Reagan in 1984 and lifted by every Democrat and reinstated by every Republican president since. It refuses US funding to any organization which uses any of its money (even funds received from a non-US federal source) to promote abortion access, whether that be through providing safe abortions and post-abortion care, or simply providing information about this option.

The policy earns its name by refusing to fund organizations that even mention abortion as an option. It really does ‘gag.’

What does access to safe abortion have to do with AIDS? It is not uncommon to see family planning and sexual health services housed in the same program or organization. In an interview, Alana Sharp of amfAR, The Foundation for AIDS Research, explained that although AIDS programs were exempted when the Global Gag Rule was last invoked in 2001, the policy hurt the AIDS battle nonetheless. “HIV disease burden in Sub-Saharan Africa—the location of the greatest number of HIV cases globally—primarily affects women,” she said. “Restricting women’s access to sexual and reproductive health services reduces the ability of healthcare providers to reach women living with HIV and at risk of becoming infected with HIV. In the Bush era, family planning clinics providing basic counseling, pre- and post-natal care, and pediatric services were forced to reduce the quality of services, raise patient fees, lay off healthcare workers, or shut down completely without USAID support.”

The policy earns its name by refusing to fund organizations that even mention abortion as an option. It really does ‘gag.’ A woman who knows she is HIV-positive and has an unintended pregnancy may want to discuss abortion; which may be a legal and safe option in her country. Medical doctors who specialize in HIV medicine and infectious diseases have expressed concerns over the gag rule’s prevention of providers to fully discuss healthcare with their patients.

While the news that AIDS programs have been spared Trump’s budget cuts is a relief, Trump’s extension of the Global Gag Rule to cover fifteen times more funding than before could make the effects of this incarnation of the policy particularly grim. “The Trump memorandum is excessively broad and risks having a significant impact not only on women’s health, but also on the United States capacity to address HIV,” Sharp commented.

AIDS ribbon. Photograph: Babak Fakhamzadeh
AIDS ribbon. Photograph: Babak Fakhamzadeh (CC Image from Flickr)

What we stand to lose in the fight against AIDS with the Global Gag Rule

Anti-retroviral therapies (ART), which can halt the progression of the HIV disease but not cure it, have been described as one of the medical miracles of the twentieth century. 18.2 million people living with AIDS worldwide were on ART in June 2016 (a massive leap since 2000, when less than a million people had this therapy). AIDS is a global problem, and global efforts have been made to tackle it. PEPFAR, the U.S. President’s Emergency Plan for AIDS Relief, enjoys bipartisan support and is one of the largest commitments by a single nation to combat a single disease internationally. Researchers estimate that from 2004 to 2013, PEPFAR programs helped avert 2.9 million HIV infections, prevented almost 9 million children becoming orphans across 16 countries, and saved 11.6 million years of human life by preventing premature deaths due to HIV.

In 2013, UNAIDS announced an ambitious set of goals, 90-90-90, towards ending the global epidemic by 2030. If 90-90-90 is successful, then by 2020, 90% of people with HIV will be aware of their status, 90% of people with a diagnosis will be receiving ART, and 90% of patients on ART will have such a low level of HIV virus that none will be detectable in their blood. Such ambitious targets may seem unrealistic, especially given that according to amfAR’s Sharp, only half of people living with HIV are aware of their status, and less than half of the people around the world with HIV have access to treatment. But 90-90-90 seems to have been an effective rallying call, and according to Sharp, “In the United States, cities like New York City and San Francisco are inching toward total elimination of new infections and countries like Zimbabwe, Malawi, and Zambia are now achieving the 90-90-90 targets in parts of their populations. We have the tools at our disposal right now to achieve epidemic control.”

Actual numbers of people with AIDS will increase as more people live with the disease rather than die from it. For example, if in one village five people are infected in a year and die within the same year, AIDS affects five people in the village. If, however, five people are infected a year and everyone survives ten years, a decade later AIDS will affect fifty people in the village. The situation is in fact better, but the numbers look worse. Looking at rates of new infections gives a slightly more accurate picture of whether AIDS is increasing or decreasing, but even there, the problem is that an apparent increase or decrease may simply reflect more or less people with the illness being tested and diagnosed.

However, some parts of the world have reported increases in new infections. New infections in Uganda, for example, increased by an alarming 21% between 2013 and 2015. The study reporting this increase also reported trends in vulnerable populations. Young women in violently abusive relationships were 50% more likely to be HIV positive[1] . Sex workers and men who have sex with men had particularly high prevalence of HIV. Sex work is heavily stigmatised resulting in a lack of available services and poverty reduces the agency that women have to enforce clients’ to practice protected sex. One Ugandan sex worker described being ill and hungry and “you look for a man who can help you. Then that man will give you conditions… if you are going to have sex with him with a condom he will give you Uganda Shillings (UGX) 2,000 then he says that if it is without a condom he will give you 20,000.” Homosexuality is illegal in Uganda and the level of homosexual violence is terrifying, with reports of lynchings, homes burned down, and police violence including sexual assault. It’s unsurprising, then, that these two at risk populations often don’t come forward for HIV testing and care.

Planning to Prevent Mother to Child AIDS Transmission

The HIV virus can be passed from a mother to her child during pregnancy, childbirth, or breastfeeding, and, without intervention, up to 45% of HIV-positive women can pass the virus on to their babies. When a pregnancy is planned, women can be supported, and helped both to plan for safer conception (this may be particularly important in couples where only one member is HIV-positive; a study in Uganda found that HIV-positive men typically want more children than HIV-positive women). Multiple research studies have found that women with HIV tend to want fewer children than HIV-negative children, and it’s estimated that if the HIV-positive women currently using contraception in Sub-Saharan Africa were to lose access to it, there would be 419 more HIV-positive births every day.

Contraceptive use in many of the world’s poorest countries have drastically increased in the last few years, with more than 30% of women and girls in sub-Saharan Africa now using a modern method of contraception. However, funding cuts have already threatened to derail this progress, even before the Global Gag Rule was reinstated.

According to Sharp, in 2001, when George W. Bush reinstated the Global Gag Rule, shipments of contraceptives and condoms purchased with U.S. funds stopped completely in 16, mostly African, countries.

Although 77% of HIV-positive pregnant women had access to antiretroviral medicines to prevent transmission in 2015, the WHO estimates that 150,000 children became infected that year, mostly through the pregnancy, childbirth or breastfeeding of their HIV-positive mothers.

As long as the Global Gag Rule stands, the fight against AIDS is bleaker, as is healthcare in many low and middle-income countries in general.

Access to family planning, enabling women to decide when to have a child and to start ART as soon as they decide to try and conceive (so that the fetus will have some protection from HIV even at the early stage when a woman may not yet realize she is pregnant) could be a valuable tool against AIDS. However, although the WHO identified the prevention of unintended pregnancies amongst women living with HIV as one of four key elements to ending mother-to-child transmission, research from the Centre for Infectious Disease Research in Zambia has highlighted that while PEPFAR has made massive contributions to preventing mother to child transmission, it hasn’t given much attention to preventing unwanted pregnancies.

As long as the Global Gag Rule stands, the fight against AIDS is bleaker, as is healthcare in many low and middle-income countries in general. “At minimum, we can expect to see the same impacts and negative externalities on HIV programs as we have seen with USAID family planning programs: shuttering of clinics that provide abortion counseling, reduced access to sexual and reproductive health, and increased rates of unintended pregnancy, maternal mortality, and abortion,” cautions Sharp. “By gagging US partners from providing women with the tools and information needed to keep themselves safe from infection, we risk backtracking on the progress we have thus far achieved. This is particularly critical today, when young women and adolescent girls are not only one of populations at highest risk of infection but also the population with the greatest disease burden. Failing these women may extend the fight against the epidemic for generations. Another concern is PEPFAR’s reliance on local partnerships in delivering HIV services. As part of its sustainability agenda, PEPFAR has shifted over time toward progressively partnering with more local implementing partners as a way of increasing domestic capacity and strengthening health systems. This strategy may leave PEPFAR programs especially vulnerable to the impacts of the Global Gag Rule in countries with legal abortion as even providers who are willing to agree to the terms of the Global Gag Rule may not be legally permitted under local law to deny women information about their health options regarding abortion.”

Concerned about the Global Gag Rule and want to do something about it? In the US, Democratic Senator Jeanne Sheehan proposed legislation that would permanently repeal the Global Gag Rule in January 2017. The Global Health, Empowerment, and Rights (HER) Act is currently supported by a bipartisan group of senators; Americans, whether based at home or abroad, can contact their senators to ask them to support this act and voice their own concerns about the Global Gag Rule and its place in American foreign policy.

[1] UAC (2015) ‘An AIDS Free Uganda, My Responsibility: Documents For the National HIV and AIDS Response, 2015/2016 – 2019/2020’