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US policy could impact funding of hundreds of HIV organisations

Almost 1,000 HIV organisations across the globe are likely to be affected by massive funding cuts because of a controversial US policy that prohibits organisations it funds from offering or advocating for safe abortions, Bhekisisa reports according to new research.

The US global HIV programme, President's Emergency Plan for AIDS Relief (PEPFAR), is South Africa’s second largest funder for HIV response – contributing close to R20bn in the 2016/17 financial year, according to the US global HIV programme’s report.

In January 2017 US President Donald Trump reintroduced the Mexico City Policy, popularly known as the “global gag rule”. The law allows the US government to cut funding to organisations if they perform or promote abortions abroad, regardless if this is done with or without US money.

The report says until now, the impact of Trump’s gag rule has been hard to measure. To estimate how many NGOs would be impacted, the US health research non-profit, the Kaiser Family Foundation, tracked how many NGOs that supported safe abortion, received direct US funding prior to the Mexico City policy being reinstated, or between 2013 and 2015. Based on these figures, the foundation estimates that 470 foreign NGOs and at least 264 US organisations working abroad have been impacted by the clampdown in funding. This research was presented at the 22nd International Aids Conference in Amsterdam.

But the foundation’s vice president and director of global health and HIV policy Jennifer Kates says the total number of organisations hamstrung by the law could be closer to 1,000 because each US organisation is likely supporting at least one other foreign NGO. The report says she warns that the full extent of the harm caused by the policy will not be measurable until it’s too late. “It's too early to determine the actual impact on health on the ground.”

The report says in November, South African health workers said that the gag rule had led to a climate of fear not only for their organisations’ survival. It also created divisions within civil society between those organisations that agreed to stop promoting abortions in order to receive US funding and those that did not.

Abortion is legal for any reason up until the 12th week of pregnancy in South Africa and provided for free by the government. In limited circumstances, a pregnancy can be terminated between 13 and 20 weeks.

“In our workshop with over 150 organisations about the gag rule, NGOs expressed fear of even sharing their decision about whether they would sign onto the policy. This undermines the ability to track the law’s impact and but also to address potential service disruptions,” says Chloe Cooney, the director of global advocacy at Planned Parenthood Federation of America.

The report says that the rule has already stopped some South African NGOs from providing abortion information. The provision of safe abortion to young women and sex workers is one of the goals under the country’s latest national HIV plan.

But the damage goes beyond South Africa. The report says the Mozambican Association for Family Development (Amodefa) runs clinics that offer services such as HIV screening and family planning to young people. It refused to accept the new conditions for US funding. As a result, the organisation had to close half of its 20 clinics because two-thirds of its funding came from the US government. "We just stopped everything," Amodefa executive director Santos Simione says. “This massive loss of funding has resulted in drops in numbers of patients.”

Amodefa tested close 6,000 girls and young women for HIV between July and September 2017 at one of their clinics in Mozambique but that number drastically reduced to about 700 girls and women tested between October and December of the same year after funding had been cut, a report by the Centre for Health and Gender Equility (Change), found. Change is a US-based women’s rights organisation.

With some young people no longer able to go to their usual, youth-friendly clinics, the organisation now fears that some patients will choose to avoid getting tested for HIV. Or, they will choose not to access contraceptive services because they don’t want to deal with health workers that might judge them for being sexually active, says Brian Honermann, deputy director of public policy for the Foundation for Aids Research (Amfar).

A 2013 study found that although young women were well informed about where to get sexual reproductive health services, most complained about health workers’ unsupportive attitudes. In Zimbabwe, Population Services Zimbabwe closed 600 of its 1,200 rural outreach sites. By the end of Trump’s first term in 2020, Marie Stopes International estimates that the cut in services will have resulted in an additional 110,000 unintended pregnancies and 32,000 unsafe abortions in Zimbabwe.

The gag rule was announced by US Republican president Ronald Reagan in 1984. Since the Mexico City policy was introduced in 1984, every US president from the Democratic party has repealed the policy, only to have it reinstated by each Republican successor. But, the report says, the Trump’s iteration of the law is the first to apply to HIV programmes, which were previously exempt.

Abstract 1
Background: In January 2017, President Trump reinstated and expanded the Mexico City Policy. In the past, it had required foreign non-governmental organizations (NGOs) to certify that they would not “perform or actively promote abortion as a method of family planning” using funds from any source as a condition for receiving U.S. family planning assistance. In a significant expansion, it now applies to almost all U.S. global health bilateral assistance, including PEPFAR. Among the many questions about the policy"s impact is its effect on HIV programs and services. This study sought to estimate the number of NGO recipients of PEPFAR funding who could be subject to the policy as well as the amount of funding they receive.
Methods: We analyzed data from over the most recent three-year period for which such data were available (FY 2013 – FY 2015) to identify NGO recipients of bilateral HIV assistance as a proxy for the current number of recipients. We also calculated the amount of funding they receive and number of countries they work in. We further stratified these countries by the legality of abortion.
Results: We identified 470 foreign NGO prime recipients of PEPFAR bilateral HIV funding, who received $873 million. In addition, we identified 274 U.S. NGO prime recipients, accounting for $5.5 billion, who would be required to ensure that any foreign NGO sub-recipients were in compliance. Overall, this funding supported programs in 61 countries. Of these, 36 allow for legal abortion in at least one case not permitted by the policy and 24 do not; one country was not classifiable. These estimates should be considered minimums since we were unable to identify NGO sub-recipients of HIV support, who represent a much greater number and are also affected by the policy.
Conclusions: The expansion of the Mexico City Policy to encompass almost all U.S. bilateral global health assistance, including PEPFAR, greatly extends its reach. While it is still too early to know its ultimate impact on the ground, our analysis indicates that the expanded policy will likely affect hundreds of NGO recipients of PEPFAR support.

K Moss, J Kates

Abstract 2
Young women and girls in South Africa are at high risk of unintended pregnancy and HIV. Previous studies have reported barriers to contraceptive and other sexual and reproductive health (SRH) services among young women in this context. We aimed to assess young women’s SRH knowledge and experiences and to determine how they get SRH information and services in Soweto, South Africa using quantitative and qualitative methods. Young women, aged 18-24, recruited from primary health clinics and a shopping mall, reported that they have access to SRH information and know where to obtain services. However there are challenges to accessing and utilizing information and services including providers’ unsupportive attitudes, uneven power dynamics in relationships and communication issues with parents and community members. There is a need to assist young women in understanding the significance of SRH information. They need access to age-appropriate, youth-friendly services in order to have healthy sexual experiences.

Naomi Lince-Deroche, Adila Hargey, Kelsey Holt, Tara Shochet

[link url=""]Bhekisisa report[/link]
[link url=""]AIDS 2018 abstract[/link]
[link url=""]Programme session[/link]
[link url=""]African Journal of Reproductive Health abstract[/link]

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