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AMSTERDAM -- The Trump administration's reinstatement of the "Mexico City Policy" (colloquially known as the "global gag rule") which prohibits U.S. aid to any organizations that provide information, referrals, or services on legal abortion, could "roll back progress on HIV," researchers and advocacy group representatives said here.
The "Protecting Life in Global Health Assistance" policy applies to almost all U.S. global bilateral health assistance, including the PEPFAR program. Versions of the rule have been implemented by all Republican presidents starting with Ronald Reagan and rescinded by their Democratic successors. One of President Trump's first acts in January 2017 was to reinstate it with a directive to apply it to "global health assistance furnished by all departments or agencies."
Panelists at a press conference at the International AIDS Conference described how either organizations will now have to either comply with these policies in order to accept PEPFAR support or decline to comply, and not receive PEPFAR aid.
While the full impact of the policy may not be known for several years, researchers at the Kaiser Family Foundation attempted to put some numbers behind it. They identified 470 foreign non-government organization (NGO) recipients receiving $873 billion in PEPFAR bilateral HIV funding, and 274 U.S. NGO recipients, which accounted for $5.5 billion. They also found the funding supported programs in 61 countries, 36 of which allow for legal abortion in at least one case that the policy does not permit.
Jennifer Kates, PhD, of the Kaiser Family Foundation said that the research provides a sense of scope of the potential reach of the policy, but does not answer several key issues, including how many foreign NGOs are providing services that conflict with the Mexico City Policy and would have to discontinue those services in order to be certified as compliant.
"These expanded policies will likely affect hundreds of NGOs who will have to recertify," Kates said. "It's too early to understand the impact [of this policy] for the health on the ground."
A side effect of the policy was the report of several clinics closing, and Luisa Orza, of the International HIV/AIDS Alliance, described the effect of this on vulnerable populations, such as sex workers, men who have sex with men (MSM), and transgender people, who often face discrimination in government-run health facilities.
"The clinic built up a relationship with the community, so it's this massive double whammy of criminalization for that population," she said. "The integration of services ... is being undone."
However, an additional provision -- and potential loophole -- of the policy is the "affirmative defense," which states that if local laws require a healthcare provider to provide informed consent to a woman to counsel and refer her to services, this will not be considered a violation of the policy.
But Brian Honermann, deputy director, amFAR, researched this provision and found that while South Africa requires informed consent in its constitution, and there are "differing levels of protection" in Mozambique, Zambia, and Zimbabwe.
"This is really about a speech restriction [and] attempting to get in between doctor-patient relationship in foreign NGOs," he said. "Healthcare workers are in the position of potentially violating medical ethics and local law, particularly if the policy is over-interpreted [and] denying women the informed choice of all available options."
One theme that emerged was an unclear policy that this new policy was difficult for even U.S. officials to understand, and even more difficult for foreign NGOs.
"Every organization that we've talked to expresses widespread confusion. Even U.S. government officials believe the policy prohibits broader services than it does," said Chloe Cooney of Planned Parenthood. "When you imagine a U.S. government official may have some confusion about the policy, imagine what happens when you get three to four levels down."
Cooney also addressed stigma in her research, which consisted of over 150 conversations with stakeholders at the conference. She described a stigma around even talking about the policy, and that most organizations refuse to share their decision to comply with the policy publicly or they request anonymity when discussing it.
She added that Planned Parenthood initiated a call to action to the U.S. government during the IAC meeting to end the policy and also to donors and other governments to "take steps to mitigate the harm."
While researchers discussed the impact of the policy, Tikhala Itaye, chairperson of the advocacy group She Decides, shared anecdotes about small community-based NGOs that had 10-15 service providers, who have been forced to cut down to 10, five or even three. Itaye also commented on the rise in unsafe abortion in these communities.
"Girls are using glass, using hot oil, using sticks. This is the impact you're having at the community level," she said. "A political leader who was a man decided on behalf of millions ... of girls and women about their body and their rights."