The ties that bind the HIV fight to contraception access

There are roughly 218 million women of reproductive age in low- and middle-income countries with an unmet need for modern contraception. There is little question that giving women the chance to prevent unintended pregnancies and choose the timing of wanted pregnancies has quality of life benefits for them and their families. Meeting women’s contraception needs also saves lives by reducing the risk of both maternal and infant mortality. 

However, for some, namely the 14.7 million women of reproductive age who are living with HIV, contraception is also a critical tool for preventing mother-to-child transmission of HIV. Each year about 160,000 new HIV cases among young children are attributable to mother-to-child-transmission – cases that could be prevented through expanded HIV treatment and contraception options. For women living with HIV, and all who would benefit from access to their choice of modern contraception, HIV advocates added our voices to others across the globe to commemorate World Contraception Day.

Contraception and expanding access to antiretroviral therapy have long been essential pillars of HIV prevention efforts, given that HIV can be passed from mothers to infants during pregnancy, delivery or breastfeeding. Fortunately, the chance of HIV transmission can be reduced to less than 5 percent if women are on consistent treatment for HIV. So, expanding access to antiretroviral therapy is both critical to the health of women living with HIV and provides the greatest potential for reducing new infant HIV infections. 

However, research shows that even in the era of increasing antiretroviral therapy coverage, mother-to-child transmission of HIV will not be eliminated while women’s contraceptive needs are left unmet. Estimates suggest that across 70 countries with high HIV burdens, contraception currently prevents over 43,000 new infant HIV infections annually. But an additional 40,000 new infant infections could be averted if unintended births among women living with HIV were prevented. Importantly, since HIV treatment lowers but doesn’t eliminate the risk of transmission, contraception use is still a vital tool to prevent infant HIV among women living with HIV on consistent treatment.  

Consequently, HIV and sexual and reproductive health advocates have long worked hand in hand to promote policies and programming that support voluntary contraception access. The repeal in January 2021of the Mexico City Policy, often called the “Global Gag Rule,” was an important policy step to strengthen the ability of international organizations to provide quality sexual and reproductive health services. The Global Gag Rule prohibits U.S. global health funding from going to international organizations that offer abortions, provide information or referrals for abortions, or advocate for wider safe abortion access, even when these organizations use their own non-U.S. resources for these activities. Ironically, the Global Gag Rule has never functioned to curtail abortion, in fact achieving the opposite effect by restricting contraceptive availability and increasing reliance on abortion. 

The Global Gag Rule has been implemented and rescinded by each Republican and Democratic president, respectively, since its inception. However, under the Trump administration the policy was the most expansive in history and had negative impacts on a wide variety of health services that extended far beyond abortion. A global survey of organizations receiving HIV funding from the United States via the President’s Emergency Plan for AIDS Relief (PEPFAR) under the Trump administration found that 28 percent of organizations stopped or reduced at least one critical health service because of the policy. These services included contraception provision, pregnancy counseling and HIV testing. 

Addressing the harm caused by the perpetual implementation and rescission of the Global Gag Rule is vital to ensuring continuity of contraception and HIV services. One solution is the Global Health, Empowerment, and Rights (HER) Act, which, if passed by Congress, would prohibit the re-imposition of the Global Gag Rule by executive order. The Act is currently being considered for inclusion under the FY22 State-Foreign Operations appropriations bill, which is set to be finalized by Sept. 30. 

Urgently calling for congressional support of the HER Act is one critical way to support women’s rights to contraception access following World Contraception Day. Contraception champions can also join the call for the Biden administration to move towards contributing the U.S.’s fair share of resources needed to close the contraception gap, an estimated $1.7 billion. These actions are more critical than ever in the face of the COVID-19 pandemic, which has resulted in contraception service disruptions to nearly 12 million women and led to 1.4 million more unintended pregnancies. 

As we continue to fight the COVID-19 pandemic, contraception must be viewed as an essential health service. Concrete policy changes, including the Global HER Act and increased funding for contraceptive commodities, are key ways to support women and their families and prevent HIV. 

Today, as HIV advocates, we recognize the versatility of contraception as a cross-cutting health promotion tool and call for the policy changes necessary to expand voluntary contraception access worldwide. 

Elise Lankiewicz is project coordinator for the Public Policy Office of amfAR, The Foundation for AIDS Research. Jennifer Sherwood is the policy manager at amfAR, where she leads amfAR’s policy portfolio on HIV and gender. She has led the development of studies examining the effects of the Global Gag Rule on PEPFAR implementing partners.