The Trump administration’s disregard for women’s rights is reflected in its attempt to remove the Affordable Care Act’s mandate that insurers cover birth control and its expansion of the “global gag rule” banning U.S. funding to international organizations that so much as discuss abortion. The latter policy is now set to prevent women across the globe from receiving a powerful new HIV medication when it is made available, while men will have unfettered access to it.
Previous administrations, both Democratic and Republican, have made the United States the world’s leader in fighting HIV through the President’s Emergency Plan for AIDS Relief (PEPFAR). Thanks in part to U.S. research, people living with HIV the world over have access to HIV-fighting antiretroviral treatments. These treatments now include a potent medication called dolutegravir, which blocks an essential step in how the human immunodeficiency virus replicates itself.
Compared to other antiretrovirals, this so-called wonder drug controls HIV more rapidly and consistently, has fewer side effects, and likely lowers the rate of mother-to-child transmission of the virus. A cocktail combining dolutegravir with other generic first-line treatments in a once-daily pill recently became available for just $75 per year, cheaper than the older options currently in use.
In May 2018, just as governments around the world were beginning to incorporate dolutegravir into their national treatment strategies, a Botswanan research group reported a worrisome finding: Among 596 infants born to HIV-positive mothers who took dolutegravir during the first trimester of pregnancy, there was an increase in neural tube defects like spina bifida. These occurred in four women taking dolutegravir, or 0.7 percent, compared to 0.1 percent among women taking older antiretrovirals. The study’s final report, with a larger sample size and clearer answers about the true magnitude of any risk, is expected in spring 2019.
But the World Health Organization has already updated its guidelines to recommend that every woman with HIV who is of reproductive age — meaning between 15 and 49 years old — should have access to family planning methods in order to safely benefit from dolutegravir. PEPFAR will publish its own revised guidance on the new medication in the coming weeks.
As we wait for more evidence about the safety of dolutegravir during pregnancy, the solution is simple: ensure that women living with HIV have access to contraception so they can benefit from this medication. But that has become an often-insurmountable problem due to the global gag rule and the Trump administration’s decision to withhold U.S. contributions to the United Nations Population Fund, a major funder of women’s health services around the world and especially in sub-Saharan Africa, where AIDS is the leading cause of death for women of reproductive age.
Take Mozambique as an example. There, 15 percent of young women have HIV. At least 90 HIV and family planning clinics in the country closed in 2017 after the Mozambican Association for Family Development lost 60 percent of its funding because it continued to offer women information about abortion.
Health officials and clinicians will have their hands tied when trying to implement the WHO and PEPFAR recommendations on dolutegravir. In addition to funding cuts to the United Nations Population Fund that leave pharmacy shelves empty of birth control medications, HIV doctors wanting to thoroughly counsel women about dolutegravir and neural tube defects could risk losing every cent of their clinic’s U.S. funding should they even mention the word abortion.
In part because Mozambique’s Ministry of Health could not ensure access to contraceptives, it has recommended that dolutegravir not be prescribed to women of reproductive age. All men there, however, will soon be able to get the drug.
Mozambique isn’t alone. As made clear by recent reports from the Foundation for AIDS Research and Health GAP, global health organizations serving millions of women across dozens of African, Asian, and Latin American countries have been forced to dramatically curtail their reproductive health services to comply with the Trump administration’s policies, actions that now imperil the rollout of dolutegravir.
Denying the new medication to women on the basis of sex would be a gross violation of their right to health: a recent modeling study estimated that people taking dolutegravir die from AIDS-related causes less than half as often as those taking drugs currently available across most of Africa. That analysis suggests that any policy truly seeking to “protect life” would in fact favor expanded access to dolutegravir and birth control medications.
American women could soon face similar barriers due to the White House’s relentless efforts to impose a domestic gag rule. Proposed changes to the Affordable Care Act and Title X, both set to take effect in early 2019, would imperil access to contraceptives nationwide and likely prevent many American women with HIV from access to dolutegravir.
Government officials should not be able to dictate the kind of health care facts that physicians can share with their patients about their own bodies. The Trump administration’s efforts to do so are striking examples of government overreach, and it is now set to endanger the health of women living with HIV around the world.
These harmful changes can be stopped. A record number of women were elected to the 116th Congress. Among its first acts, the new Democratic majority in the House of Representatives should pass the Global Health, Empowerment, and Rights (HER) Act to permanently repeal the global gag rule. Rep. Nita Lowey (D-N.Y.) and Sen. Jeanne Shaheen (D-N.H.) reintroduced the bill in both chambers of Congress on Feb. 7. They should also insist on overdue funding for the United Nations Population Fund, and amplify public pressure against the Trump administration’s attempts to undermine women’s reproductive rights at home by pushing back against changes to the Affordable Care Act and Title X.
AIDS activists from across Africa gathered recently in Rwanda to consider key issues surrounding dolutegravir. They wrote in a powerful consensus statement, “We, the women living with HIV at this meeting, conclude that blanket exclusions that deny women equitable access to this optimal HIV treatment are not warranted or justified.” Each woman, they wrote, is not just “a vessel for a baby, but an individual in her own right, who deserves access to the very best evidence-based treatment available and the right to be adequately informed to make a choice that she feels is best for her.”
The uncertainty now surrounding dolutegravir need not result in a double standard based on gender. Instead, it should serve as a call for better integrating comprehensive reproductive health services into HIV care.
Making this a reality, however, will require kicking the Trump administration’s dangerous policies toward women out of the clinic. The world looks to the women of the 116th Congress to show the way.
Meredith Kernan is a second-year student at Columbia Business School; she previously worked for a non-governmental organization on antiretroviral therapy pricing and procurement across Africa. Cameron Nutt is a fourth-year student at Harvard Medical School.