‘Global Gag’ threatens plans to improve women’s access to HIV services
HIV is the leading cause of death for women of reproductive age and Washington-led health policies show a lack of understanding of the realities and importance of health service integration on the ground.
The United States of America (USA) last week released an implementation plan to expand the notorious ‘Global Gag Rule’, or the Mexico City Policy, which prevents foreign NGOs that receive US funding from providing safe abortions as a method of family planning – even if they use non-US funds to do so.
The limit on abortion provision is nothing new. In fact, since the Mexico City Policy was first implemented by Ronald Reagan in 1984, it has been in place on and off for 17 out of 34 years.1 President Obama repealed the ban when he came to office, while President Trump reinstated it on his fourth day of office in January.2
Trump’s reinstatement of the ban came with important amendments that have alarmed those working in global health and international development. Whereas important institutions like the Presidents Emergency Plan for AIDS Relief (PEPFAR) were previously exempt from the ban, the ban has now been expanded to include not only all NGOs receiving family planning funding but all NGOs receiving any global health assistance from the USA.
The ban now includes all programming relating to nutrition, maternal and child health, HIV, malaria, tuberculosis, neglected tropical diseases, and global health security, amounting to around US$ 8 billion.
No foreign organisation receiving bilateral global health funding from the USA can “perform or actively promote abortion as a method of family planning”. They are also unable to offer referrals or give advice on abortion as part of a family planning package – even where it is legally available.
Why is this an issue? Quite simply, research shows us that restrictive abortion policy increases the number of women accessing unsafe abortions, or induced abortions, resulting in more women dying.3
In terms of HIV programming specifically, it threatens to derail efforts to promote a women-centred approach to sexual and reproductive health (SRH) for women, which focuses on rights and equality – of which integration of health services is critical.
The importance of health integration for women cannot be overstated, particularly in sub-Saharan Africa, where the majority of people living with HIV live and where the gag will hit hardest. Here, young women account for 25% of all new HIV infections, and in some settings, up to half of young women report their first sexual encounter as being forced.4
Health service integration means access to family planning, nutritional support, HIV medication, cancer screening, and so on – safely and without judgement – all in one place. The gag directly contradicts guidelines by the World Health Organization, UNAIDS and other agencies which explicitly call for more comprehensive health service delivery for women. The Sustainable Development Goals were also developed on this approach, with HIV embedded across multiple targets, such as gender, inequality, sexual reproductive health and reproductive rights.
This holistic approach seeks to tackle issues of gender equality that drive HIV. In these contexts, gender inequality is entrenched, often exacerbated by poverty and social dynamics such as intimate partner violence, sugar daddy culture, and low levels of schooling for girls. These factors compound already low levels of healthcare access for women. It is vital to support health systems in which women are active, where care is provided in a way that respects women’s autonomy in decision-making about their health, and where information and support is available to allow women to make informed choices.
The integration of sexual and reproductive health services, the decentralisation of HIV treatment and care, and investment in community or individual empowerment interventions should be the priority. Unfortunately, the impact of the Global Gag rule will be the opposite and threaten the effectiveness of women-centred health programming.