The damage caused by the controversial US policy will only start showing when it's too late to reverse it, activists and researchers argue.
Almost 1000 HIV organisations across the globe are likely to be affected by massive funding cuts because of a controversial United States policy that prohibits organisations it funds from offering or advocating for safe abortions, 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 R20-billion 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.
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 nonprofit, 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 last week.
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 full extent of the harm caused by the policy will not be measurable until it's too late, she warns.
"It's too early to determine the actual impact on health on the ground."
When can you get a legal abortion in South Africa? Find out. (John McCann)
In November, South African health workers told Bhekisisa 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.
Bhekisisa understands 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 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 Center for Health and Gender Equity (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 published in the African Journal of Reproductive Health 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. Bhekisisa spoke to Marie Stopes in February.
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 Trump's iteration of the law is the first to apply to HIV programmes, which were previously exempt.
Watch: Why sex workers matter in the world's fight against HIV
In many countries, HIV infection rates remain highest among the most marginalised within society - such as sex workers, men who have sex with men and transgender people. These groups are criminalised in many countries. The gag rule's expansion to include HIV programmes will hit these populations the hardest, Luisa Orza, HIV technical lead at the International HIV/Aids Alliance, warns
"These people have built up relationships with trusted [health workers]," she says.
Stigma and discrimination against sex workers, particularly against transgender and male sex workers, weaken HIV prevention efforts and decreases their access to healthcare, a 2013 study published in the journal Culture, Health & Sexuality found.
The study interviewed 136 sex workers in Kenya, Zimbabwe, Uganda and South Africa who said that there is higher quality of care, respect for dignity and privacy at specialised sex worker clinics than in general public health facilities.
Cooney says: "The HIV response is still an emergency and we shouldn't be disqualifying good providers who can serve the communities who need them the most. This policy has very bluntly divided those who can be part of the fight against HIV."
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