But these values, in the end, did not work.
When PEPFAR was first funded in 2003, one-third of its budget for HIV-prevention programs was earmarked by Congress to fund abstinence education, though that amount was reduced in 2008. These interventions—including messages printed on billboards and broadcast over the radio—were shown to be ineffective in reducing HIV risk or changing sexual behavior.
The Mexico City Policy has proven to be similarly counterproductive: It’s been associated with an increase in abortions, including unsafe abortions, in the affected countries. NGOs that cannot access U.S.-government funding due to the gag rule are also key providers of contraception, which is thought to lower abortion rates.
It’s unclear how the new global gag rule will be implemented, and how PEPFAR’s support of other organizations will be affected.
Morrison told me the administration’s actions seem dissonant: Keeping Birx in her position—which he called a “smart decision”—“was the done with the right hand, and the Mexico City order comes with the left hand,” he said.
“It hasn’t been explained,” Morrison added. “We don’t know the true costs will be, how this will be implemented in practice, and we don’t know what the legality is.”
And while abortion is illegal in some sub-Saharan countries where PEPFAR operates, many make exceptions for cases of pregnancies resulting from rape, or when the mother’s health or life may be on the line. Other countries place no such restrictions. For instance, abortion is fully legal in South Africa, a PEPFAR partner country, where 6.8 million people were estimated to be living with HIV in 2014.
Health centers that receive PEPFAR funding provide a wide array of services. So a clinic that includes a family-planning program in a country like South Africa may also receive PEPFAR funding for an HIV-treatment program. Under the new policy, that clinic may now be unable to counsel a pregnant 18-year-old girl who was raped that abortion is an option for her, or the clinic would lose its U.S. funding, even if those family-planning services aren’t funded by the U.S.
“I'm very worried, and I'm not sure that any of this was thought through,” Morrison said, adding, however, that it would be “wrong to jump to catastrophic conclusions.” But, in the continued absence of clear direction from the White House, he believes NGOs may begin to “self censor,” and preemptively cut services for fear of losing funding.
For now, the situation remains unclear, says Morrison. But figuring out “whether the left hand contradicts the right is going to have to happen somewhere downstream soon.”