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| Global AIDS activists protest a U.N. High-Level Meeting on Ending AIDS.
Courtesy of Health Gap
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February 22, 2017
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By
Casey Halter
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The battle to save the U.S. President’s Emergency Plan for AIDS
Relief (PEPFAR) is already well under way, just one month after
President Donald J. Trump’s inauguration and his almost immediate
reinstatement of the country's global gag order on foreign funding for
comprehensive sexual health services.
The global gag
rule, also known as the Mexico City Policy, is a Reagan-era executive
order originally announced in 1984 (at the 2nd International Conference
on Population in Mexico City) which restricts any foreign
nongovernmental organization, or NGO, that receives U.S. funding from
using any money to provide abortions, refer their clients to abortion
services or advocate for women’s right to choose in their own countries.
Since
then, the controversial rule has become a political volleyball between
the Republican and Democratic parties. The rule was rescinded by
President Bill Clinton in 1993, reinstated by President George W. Bush
in 2001 and once again revoked by President Barack Obama via executive
order in 2009.
Therefore, when President Trump reinstated the rule on his first day in office in
2017,
it didn’t exactly come as a surprise to those working in the global
health services arena. So why are AIDS advocates up in arms about it?
A
deeper look into the president’s day 1 executive order reveals some
highly unsettling potentialities for the future of global AIDS funding.
Below,
we break down Trump’s iteration of the global gag order — and detail
how the efforts of politicians, celebrities, activists and citizens can
ensure that the groundbreaking PEPFAR does not get cut by the new
administration.
***
“The
conditions of the global gag rule are even more stringent now than they
were in past iterations of it,” says Diederik Lohman, acting director
of the Health and Human Rights Division at Human Rights Watch (HRW), one
of several international advocacy organizations that have spoken out over the last few weeks in support of PEPFAR.
Advocates
like Lohman are quick to point out that before now, the Mexico City
Policy had never been applied to any U.S. money set aside to combat
HIV/AIDS. However, on January 25, President Trump signed what appears to
be an amped-up version of the Reagan-era order that global health
advocates worry could vastly expand its reach to a wide array of health
care programs—including PEPFAR, family planning service providers and
women’s health clinics around the world.
While
it is still largely unclear how the program will be affected under the
new administration, many organizations, including The Elizabeth Glaser
Pediatric AIDS Foundation (EGPAF), The Bill and Melinda Gates Foundation, The Elizabeth Taylor AIDS Foundation (ETAF), Housing Works, Until There’s A Cure
and the Elton John AIDS Foundation (EJAF), among others, have already
spoken out on social media to demand its continued funding.
Here’s
why: According to Lohman, past versions of the Mexico City Policy
applied only to NGOs seeking to receive special U.S. family planning
funding—about $600 million worth of foreign aid. But President Trump
specifically changed the wording in his 2017 executive order to extend
the abortion gag to all global health funding. That means $9.5 billion
worth of foreign aid could now be subject to strict rules that allow the
U.S. government to pull its support from any NGO that has provided so
much as a referral to any woman seeking to terminate her pregnancy.
“We’re
obviously really concerned about what it will mean for groups that are
involved in HIV prevention work,” says Lohman, particularly since many
of these organizations also provide comprehensive sexual health services
and education to their clients. “It could also affect many programs
that are not just involved in the provision of abortion services but
much more generally in family planning and supporting women with sexual
and reproductive health issues.”
The
global advocacy community’s support of PEPFAR — which provides $15
billion in funding for HIV testing, treatment, prevention and health
care to resource-limited countries every five years — hinges on the fact
that the program has proved to be one of the most effective means of
curtailing HIV/AIDS in the history of the epidemic.
According to PEPFAR’s 2017 annual report to Congress,
the global endowment initiative currently provides antiretroviral (ARV)
treatment to an estimated 11.5 million people with HIV worldwide.
Thanks to PEPFAR, nearly 2 million babies with HIV-positive mothers in
developing nations have been born virus-free since the early 2000s, and
nearly 220,000 health care workers have been trained to help combat the
global AIDS crisis. The program has also been credited with a 51 to 76
percent decline in new HIV infections in countries like Malawi, Zambia
and Zimbabwe.
“A
significant reduction in funding for PEPFAR would have disastrous
consequences for access to antiretroviral treatment,” says Lohman. “I
think it’s important for organizations like Human Rights Watch to be
looking at what happens as a result of this policy change and articulate
what the consequences are in order to hammer home the message that this
was a really ill-advised policy step.”
Trump’s
order to broaden the Mexico City Policy to such an extent has also
raised eyebrows within the Republican administration itself. The global
HIV/AIDS program has traditionally enjoyed very strong bipartisan
support in the U.S. government. In fact, the program was originally
instated by President George W. Bush and approved by a Republican-led
Congress in 2003. At the time, President Bush specifically exempted
PEPFAR from Reagan’s global gag order, as it was widely understood—even
in conservative Christian circles—that it would have been impossible to
treat HIV/AIDS in the developing world if the abortion order were
applied.
At
the time, Vice President Mike Pence, then serving in the House of
Representatives, vocally supported PEPFAR; he supported it again in 2008
when the program was reauthorized by legislators of both parties.
More
recently, U.S. Senate Majority Leader Bill Frist (R-Tenn.,), a trained
physician, published an op-ed in The New York Times, titled “The Case for Keeping America’s AIDS Relief Plan,”
that specifically called on the new administration not to cut PEPFAR
funding under the global gag order. In addition to laying out the
program’s endless health benefits, Frist pointed out that distributing
emergency aid to countries in crisis has conferred national security
benefits in the form of increased stability (from 2004 to 2013,
political instability and violence fell by 40 percent in countries that
received PEPFAR assistance versus just 3 percent in similar countries
that did not). Frist went on to call the program “the greatest
humanitarian effort undertaken by the United States in more than 60
years.”
“Being
out in front of this and making sure that there is a critical mass of
both Republicans and Democrats saying this is a piece of international
work that we do not want to see touched is really important,” says
Lohman, speaking on behalf of Human Rights Watch. “We’re obviously going
to be monitoring how the discussions develop.”
***
So
what has President Trump said so far about PEPFAR and its relation to
the global gag rule? Not much, according to other HIV advocates who
since November’s election have also been watching closely for signs
regarding the new administration’s plans for global AIDS funding.
“The
last several months have been a very challenging and unsettling
period,” says Mitchell Warren, executive director at AVAC, a New York
City–based international nonprofit that works to accelerate the
development of HIV prevention options to populations around the world.
“Everybody within our agencies, within implementing partners, within the
advocacy community, still don’t know what the details [of Trump’s
global gag order] mean. No one knows how intentional the expansion was,
and no one knows what enforcement will look like.”
On
the campaign trail, Trump appeared to support the global AIDS program.
Last summer, when asked at a rally in New Hampshire whether he would
double the number of people receiving treatment under PEPFAR, the future
president was quoted as saying:
“Those are good things—fighting Alzheimer’s and AIDS. We are so close
on some of them. On some of them, honestly, with all the work done,
which has not been enough, we’re not very close. The answer is yes. I
believe strongly in that, and we are going to lead the way.”
That
said, it is unclear whether Trump truly understood the question, as
PEPFAR does not provide any international support for Alzheimer’s
disease research or treatment.
On another potentially positive note for the program, just before his inauguration, President Trump also announced
that Ambassador Deborah Birx, the U.S. global AIDS coordinator and head
of PEPFAR, was going to be one of the few political Obama appointees to
remain at the helm of her governmental organization during the White
House transition.
“That
was certainly a ray of hope for us working in this field, because
Ambassador Birx has done a remarkable job at reorienting the program and
following the data,” says Warren. “The best sign we could get in the
short term would be formally nominating her and appointing her to a full
tenure as ambassador.”
Other
auspicious signs from the new administration include praise for PEPFAR
via Trump’s newly appointed secretary of state, Rex Tillerson. At the
former Exxon Mobil CEO’s confirmation hearing, he reportedly called the program “a model for us to look to as we’re thinking about other ways in which to project America’s values.”
Tillerson’s
statement also hints at a business agenda. As several recent global
health studies have shown, PEPFAR not only saves lives but it’s also a really great strategy for promoting U.S. business interests in Africa.
However,
HIV advocates like Warren have also witnessed a darker side to Trump’s
approach to PEPFAR over the last few months, casting major doubt on the
administration’s true intentions for the program.
As detailed in a New York Times report
also published in January, transition staff sent out a series of
leading questions to the U.S. State Department that seemed highly
skeptical of the global AIDS program, asking, for example, “Is PEPFAR
worth the massive investment when there are so many security concerns in
Africa?” and “Is PEPFAR becoming a massive, international entitlement
program?”
“I’m
not sure any of us do well trying to predict anything in the current
environment,” says Warren when asked about predictions on where global
AIDS funding is headed under President Trump. “But I can predict this:
If we do not see the new U.S. administration provide sustained
commitment and leadership to PEPFAR, we will not end the epidemic.”
Regardless
of what the Trump administration decides to do with the program, it’s
clear that the United States faces a long road in its fight against
global HIV/AIDS. According to the latest stats from the United Nations,
an estimated 37 million people are living with HIV worldwide, and only
18.2 percent are currently receiving ARV treatment.
Meanwhile,
global health advocates continue to argue online, to their local
politicians and to their allies in Congress and the new administration:
If President Trump does indeed want America to “lead the way” in ending
the global HIV epidemic, keeping PEPFAR could quite possibly be the
businessman’s best investment.
