Mapping the impact of the expanded Mexico City Policy for HIV/ family planning service integration in PEPFAR-supported countries: a risk index

Abstract

BackgroundThe previously-named Mexico City Policy (MCP) — which prohibited non U.S.-based non-governmental organizations (NGOs) from receiving U.S. family planning (FP) funding if they advocated, provided, counseled, or referred clients for abortions, even with non-U.S. funds — was reinstated and expanded in 2017. For the first time, the expanded MCP (EMCP) applies to HIV funding through the President’s Emergency Plan for AIDS Relief (PEPFAR) in addition to FP funding. Previous, and more limited, iterations of the policy forced clinic closures and decreased contraceptive access, prompting the need to examine where and how the EMCP may impact FP/HIV service integration.MethodsThe likelihood of FP/HIV service de-integration under the EMCP was quantified using a composite risk index for 31 PEPFAR-funded countries. The index combines six standardized indicators from publically available sources organized into three sub-indexes: 1) The importance of PEPFAR for in-country service delivery of HIV and FP services; 2) The susceptibility of implementing partners to the EMCP; and 3) The integration of FP/HIV funds and programming through PEPFAR and USAID.ResultsCountries with the highest overall risk scores included Zambia (3.3) Cambodia (3.2), Uganda (3.1), South Africa (2.9), Haiti (2.8), Lesotho (2.8), Swaziland (2.1), and Burundi (1.5). Zambia’s risk score is driven by sub-index 1, having a high proportion of country HIV expenditures provided by PEPFAR (86.3%). Cambodia and Uganda’s scores are driven sub-index 3, with both countries reporting 100% of PEPFAR supported HIV delivery sites were providing integrated FP services in 2017. South Africa’s risk score is driven by sub-index 2, where roughly 60% of PEPFAR funding is to non U.S.-based NGOs. Of the countries with the highest risk scores, Swaziland, Lesotho, and South Africa, are also in the top quartile of PEPFAR countries for HIV prevalence and unintended pregnancies among young women.ConclusionThis analysis highlights where and why the EMCP may have the greatest impact on FP/HIV service integration. The possible disruption of service integration in countries with generalized HIV epidemics highlights significant risks. Researchers, national governments, and non-U.S. funders can consider these risk factors to help target their responses to the EMCP and mitigate potential harms of the policy.

Foreign assistance or attack? Impact of the expanded Global Gag Rule on sexual and reproductive health and rights in Kenya

“…46 In Kenya, a high proportion of HIV programmes have been integrated with SRH, which has resulted in increased HIV testing among women and higher patient satisfaction with services, but which leaves the country more susceptible to the impacts of the expanded GGR. 47 , 48 Because the expanded GGR applies to all US global health assistance, including PEPFAR, which makes up 58% of HIV funding in Kenya, 48 this iteration of the policy brings newfound impact on HIV services. A recent survey of PEPFAR prime implementing partners across 45 countries found that Kenya was among the four countries with the highest number of PEPFAR prime recipient organisations affected by the policy.…”

Impacts of the Global Gag Rule on sexual and reproductive health and rights in the Global South: A scoping review

“…The decimation of funding to organisations providing comprehensive sexual health care and the de-integration of HIV from basic reproductive health services has resulted in a deterioration of STI prevention and treatment efforts. This has led to an increased number of people with an untreated STI, including HIV, resulting in avoidable deaths and disability (Bingenheimer & Skuster, 2017;IPPF, 2017;Rios, 2019;Sherwood et al, 2018). The policy has disproportionately affected the limited services directed towards marginalised groups, including sex workers, LGBT people, religious minorities, refugees and migrants.…”

“…The inclusion of the President's Emergency Fund for AIDS Relief (PEPFAR) in the current administration's expanded GGR is likely to result in decreased funding to and de-integration of HIV services, increasing the number of avoidable HIV infections and AIDS-related deaths (Bingenheimer & Skuster, 2017;Rios, 2019). In at least 10 PEPFAR-funded countries, over 90% of HIV sites are integrated with family planning services (Sherwood et al, 2018). A representative from a legal organisation in Kenya describe the impact of de-integration of services: '… we are going to ignore a huge part of what makes them susceptible to HIV infection, like limited information around their bodies, their health, their rights, and their right to access safe abortion' (Rios, 2019, p. 19).…”

The effect of the Protecting Life in Global Health Assistance policy in South Africa: Possible implications for local HIV/AIDS non-governmental organisations

“…[9] SA NGOs receive an estimated 60% of their funding from the USA through PEPFAR. [9,10] Therefore the likelihood of national NGOs denouncing PLGHA and forgoing US federal funding is low, given the high proportion of funding received. [9,10] In 2017, approximately USD470 million in foreign assistance was allocated to SA, of which more than USD274 million was received by SA NGOs.…”

“…[9,10] Therefore the likelihood of national NGOs denouncing PLGHA and forgoing US federal funding is low, given the high proportion of funding received. [9,10] In 2017, approximately USD470 million in foreign assistance was allocated to SA, of which more than USD274 million was received by SA NGOs. [9] There were over 4.3 million South Africans receiving antiretroviral treatment (ART) in 2017, with over 86% of these relying on local NGOs to access it, while 88% of women receiving ART in prevention of mother-to-child transmission programmes obtained treatment from local NGOs.…”