Time to Deliver a More Effective PEPFAR

Susan A. Cohen

Susan A. Cohen is Director of Government Affairs at the Guttmacher Institute, where she is responsible for facilitating and coordinating issue analysis and strategy development within the Washington, DC office.

The theme of the Toronto International AIDS Conference in August was "time to deliver." Indeed, while the U.S. deserves credit for ramping up the amount that it has been spending on the global AIDS effort, it is time-past time-to look more closely at how the U.S. is spending its money in addition to talking about how much it is spending overall. Luckily, a rare opportunity to ask just these questions of the person in charge of U.S. AIDS efforts will come on Wednesday, September 6, at 1 p.m. Under the chairmanship of Rep. Christopher Shays (R-CT), a Government Reform Committee subcommittee will hold a hearing examining the impact of the requirement that at least 1/3 of all U.S. global HIV/AIDS funding must be reserved for "abstinence until marriage" programs.

This hearing will be significant because it will be the first opportunity since Toronto for U.S. Global AIDS Coordinator Mark Dybul to testify specifically on what kind of prevention programs the U.S. is delivering.

Susan A. Cohen is Director of Government Affairs at the Guttmacher Institute, where she is responsible for facilitating and coordinating issue analysis and strategy development within the Washington, DC office.

The theme of the Toronto International AIDS Conference in August was "time to deliver." Indeed, while the U.S. deserves credit for ramping up the amount that it has been spending on the global AIDS effort, it is time-past time-to look more closely at how the U.S. is spending its money in addition to talking about how much it is spending overall. Luckily, a rare opportunity to ask just these questions of the person in charge of U.S. AIDS efforts will come on Wednesday, September 6, at 1 p.m. Under the chairmanship of Rep. Christopher Shays (R-CT), a Government Reform Committee subcommittee will hold a hearing examining the impact of the requirement that at least 1/3 of all U.S. global HIV/AIDS funding must be reserved for "abstinence until marriage" programs.

This hearing will be significant because it will be the first opportunity since Toronto for U.S. Global AIDS Coordinator Mark Dybul to testify specifically on what kind of prevention programs the U.S. is delivering. It will also be the first and no doubt the only time there will be a congressional hearing on the role of the abstinence program within the President's Emergency Plan for AIDS Relief (PEPFAR). Certainly it will be the only such hearing in this Republican-controlled Congress that will be organized and chaired by someone who has called for the repeal of the earmark. Shays and other subcommittee members will question Dybul about how this requirement is impeding the availability of resources for other key interventions such as the prevention of mother-to-child transmission. As those following the issue closely are well aware, the Government Accountability Office reported to Congress in April that the abstinence earmark has undermined the ability of the majority of PEPFAR country teams to respond to local epidemiology when it comes to funding decisions on the ground.

The motivation for establishing the 1/3 earmark is purely ideological. When Congress added this mandate to PEPFAR in 2003, the only rationale I could discern from its proponents for siphoning off such a huge chunk of prevention funds for abstinence promotion seemed to be that "A" comprises 1/3 of the letters ABC-shorthand for the comprehensive approach to prevention involving abstaining, being faithful and using condoms correctly and consistently.

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PEPFAR however, as its name denotes, is an emergency program. Public health professionals in the field, therefore, need to have the flexibility to respond to the ever-changing demands of the HIV/AIDS epidemic. The "abstinence until marriage" earmark runs counter to this imperative. Of course, programs that encourage young people to delay becoming sexually active are an important component of any prevention effort. So are efforts that help people change their behavior to have fewer concurrent sexual partners and to increase their correct and consistent use of condoms if they are sexually active. But segmenting out prevention interventions according to an arbitrary formula and assigning these interventions, as the U.S. strategy does, to particular groups of people (abstinence for youth, fidelity for married people, condoms for "high risk" groups, which translates to sex workers, truck drivers, men who have sex with men, etc.) is cumbersome and does not derive from the public health evidence or common sense. Youth who are already sexually active, for example, do not fit neatly in the U.S. construct, even though they comprise large numbers of people who could be considered high risk in high HIV prevalence countries.

It is time to repeal or at least mitigate the harm of the abstinence until marriage earmark in PEPFAR. The "Protection Against Transmission of HIV For Women and Youth Act", introduced by Reps. Barbara Lee (D-CA) and Chris Shays, would repeal the earmark and the "HIV Prevention for Youth Act", introduced by Sens. Dianne Feinstein (D-CA) and Olympia Snowe (R-ME), would go a long way towards mitigating its harm. I look forward to the Shays hearing, which holds out the promise of being the first fair and open discussion since PEPFAR was created for looking beyond the politics and at the evidence-or lack thereof- for why the U.S. has made promoting "abstinence until marriage" its single most important U.S. HIV/AIDS prevention intervention.

Analysis Law and Policy

After ‘Whole Woman’s Health’ Decision, Advocates Should Fight Ultrasound Laws With Science

Imani Gandy

A return to data should aid in dismantling other laws ungrounded in any real facts, such as Texas’s onerous "informed consent” law—HB 15—which forces women to get an ultrasound that they may neither need nor afford, and which imposes a 24-hour waiting period.

Whole Woman’s Health v. Hellerstedt, the landmark U.S. Supreme Court ruling striking down two provisions of Texas’ omnibus anti-abortion law, has changed the reproductive rights landscape in ways that will reverberate in courts around the country for years to come. It is no longer acceptable—at least in theory—for a state to announce that a particular restriction advances an interest in women’s health and to expect courts and the public to take them at their word.

In an opinion driven by science and data, Justice Stephen Breyer, writing for the majority in Whole Woman’s Health, weighed the costs and benefits of the two provisions of HB 2 at issue—the admitting privileges and ambulatory surgical center (ASC) requirements—and found them wanting. Texas had breezed through the Fifth Circuit without facing any real pushback on its manufactured claims that the two provisions advanced women’s health. Finally, Justice Breyer whipped out his figurative calculator and determined that those claims didn’t add up. For starters, Texas admitted that it didn’t know of a single instance where the admitting privileges requirement would have helped a woman get better treatment. And as for Texas’ claim that abortion should be performed in an ASC, Breyer pointed out that the state did not require the same of its midwifery clinics, and that childbirth is 14 times more likely to result in death.

So now, as Justice Ruth Bader Ginsburg pointed out in the case’s concurring opinion, laws that “‘do little or nothing for health, but rather strew impediments to abortion’ cannot survive judicial inspection.” In other words, if a state says a restriction promotes women’s health and safety, that state will now have to prove it to the courts.

With this success under our belts, a similar return to science and data should aid in dismantling other laws ungrounded in any real facts, such as Texas’s onerous “informed consent” law—HB 15—which forces women to get an ultrasound that they may neither need nor afford, and which imposes a 24-hour waiting period.

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In Planned Parenthood v. Casey, the U.S. Supreme Court upheld parts of Pennsylvania’s “informed consent” law requiring abortion patients to receive a pamphlet developed by the state department of health, finding that it did not constitute an “undue burden” on the constitutional right to abortion. The basis? Protecting women’s mental health: “[I]n an attempt to ensure that a woman apprehends the full consequences of her decision, the State furthers the legitimate purpose of reducing the risk that a woman may elect an abortion, only to discover later, with devastating psychological consequences, that her decision was not fully informed.”

Texas took up Casey’s informed consent mantle and ran with it. In 2011, the legislature passed a law that forces patients to undergo a medical exam, whether or not their doctor thinks they need it, and that forces them to listen to information that the state wants them to hear, whether or not their doctor thinks that they need to hear it. The purpose of this law—at least in theory—is, again, to protect patients’ “mental health” by dissuading those who may be unsure about procedure.

The ultra-conservative Fifth Circuit Court of Appeals upheld the law in 2012, in Texas Medical Providers v. Lakey.

And make no mistake: The exam the law requires is invasive, and in some cases, cruelly so. As Beverly McPhail pointed out in the Houston Chronicle in 2011, transvaginal probes will often be necessary to comply with the law up to 10 to 12 weeks of pregnancy—which is when, according to the Guttmacher Institute, 91 percent of abortions take place. “Because the fetus is so small at this stage, traditional ultrasounds performed through the abdominal wall, ‘jelly on the belly,’ often cannot produce a clear image,” McPhail noted.

Instead, a “probe is inserted into the vagina, sending sound waves to reflect off body structures to produce an image of the fetus. Under this new law, a woman’s vagina will be penetrated without an opportunity for her to refuse due to coercion from the so-called ‘public servants’ who passed and signed this bill into law,” McPhail concluded.

There’s a reason why abortion advocates began decrying these laws as “rape by the state.”

If Texas legislators are concerned about the mental health of their citizens, particularly those who may have been the victims of sexual assault—or any woman who does not want a wand forcibly shoved into her body for no medical reason—they have a funny way of showing it.

They don’t seem terribly concerned about the well-being of the woman who wants desperately to be a mother but who decides to terminate a pregnancy that doctors tell her is not viable. Certainly, forcing that woman to undergo the painful experience of having an ultrasound image described to her—which the law mandates for the vast majority of patients—could be psychologically devastating.

But maybe Texas legislators don’t care that forcing a foreign object into a person’s body is the ultimate undue burden.

After all, if foisting ultrasounds onto women who have decided to terminate a pregnancy saves even one woman from a lifetime of “devastating psychologically damaging consequences,” then it will all have been worth it, right? Liberty and bodily autonomy be damned.

But what if there’s very little risk that a woman who gets an abortion experiences those “devastating psychological consequences”?

What if the information often provided by states in connection with their “informed consent” protocol does not actually lead to consent that is more informed, either because the information offered is outdated, biased, false, or flatly unnecessary given a particular pregnant person’s circumstance? Texas’ latest edition of its “Woman’s Right to Know” pamphlet, for example, contains even more false information than prior versions, including the medically disproven claim that fetuses can feel pain at 20 weeks gestation.

What if studies show—as they have since the American Psychological Association first conducted one to that effect in 1989—that abortion doesn’t increase the risk of mental health issues?

If the purpose of informed consent laws is to weed out women who have been coerced or who haven’t thought it through, then that purpose collapses if women who get abortions are, by and large, perfectly happy with their decision.

And that’s exactly what research has shown.

Scientific studies indicate that the vast majority of women don’t regret their abortions, and therefore are not devastated psychologically. They don’t fall into drug and alcohol addiction or attempt to kill themselves. But that hasn’t kept anti-choice activists from claiming otherwise.

It’s simply not true that abortion sends mentally healthy patients over the edge. In a study report released in 2008, the APA found that the strongest predictor of post-abortion mental health was prior mental health. In other words, if you’re already suffering from mental health issues before getting an abortion, you’re likely to suffer mental health issues afterward. But the studies most frequently cited in courts around the country prove, at best, an association between mental illness and abortion. When the studies controlled for “prior mental health and violence experience,” “no significant relation was found between abortion history and anxiety disorders.”

But what about forced ultrasound laws, specifically?

Science has its part to play in dismantling those, too.

If Whole Woman’s Health requires the weighing of costs and benefits to ensure that there’s a connection between the claimed purpose of an abortion restriction and the law’s effect, then laws that require a woman to get an ultrasound and to hear a description of it certainly fail that cost-benefit analysis. Science tells us forcing patients to view ultrasound images (as opposed to simply offering the opportunity for a woman to view ultrasound images) in order to give them “information” doesn’t dissuade them from having abortions.

Dr. Jen Gunter made this point in a blog post years ago: One 2009 study found that when given the option to view an ultrasound, nearly 73 percent of women chose to view the ultrasound image, and of those who chose to view it, 85 percent of women felt that it was a positive experience. And here’s the kicker: Not a single woman changed her mind about having an abortion.

Again, if women who choose to see ultrasounds don’t change their minds about getting an abortion, a law mandating that ultrasound in order to dissuade at least some women is, at best, useless. At worst, it’s yet another hurdle patients must leap to get care.

And what of the mandatory waiting period? Texas law requires a 24-hour waiting period—and the Court in Casey upheld a 24-hour waiting period—but states like Louisiana and Florida are increasing the waiting period to 72 hours.

There’s no evidence that forcing women into longer waiting periods has a measurable effect on a woman’s decision to get an abortion. One study conducted in Utah found that 86 percent of women had chosen to get the abortion after the waiting period was over. Eight percent of women chose not to get the abortion, but the most common reason given was that they were already conflicted about abortion in the first place. The author of that study recommended that clinics explore options with women seeking abortion and offer additional counseling to the small percentage of women who are conflicted about it, rather than states imposing a burdensome waiting period.

The bottom line is that the majority of women who choose abortion make up their minds and go through with it, irrespective of the many roadblocks placed in their way by overzealous state governments. And we know that those who cannot overcome those roadblocks—for financial or other reasons—are the ones who experience actual negative effects. As we saw in Whole Woman’s Health, those kinds of studies, when admitted as evidence in the court record, can be critical in striking restrictions down.

Of course, the Supreme Court has not always expressed an affinity for scientific data, as Justice Anthony Kennedy demonstrated in Gonzales v. Carhart, when he announced that “some women come to regret their choice to abort the infant life they once created and sustained,” even though he admitted there was “no reliable data to measure the phenomenon.” It was under Gonzales that so many legislators felt equipped to pass laws backed up by no legitimate scientific evidence in the first place.

Whole Woman’s Health offers reproductive rights advocates an opportunity to revisit a host of anti-choice restrictions that states claim are intended to advance one interest or another—whether it’s the state’s interest in fetal life or the state’s purported interest in the psychological well-being of its citizens. But if the laws don’t have their intended effects, and if they simply throw up obstacles in front of people seeking abortion, then perhaps, Whole Woman’s Health and its focus on scientific data will be the death knell of these laws too.

News Economic Justice

Colorado Voters Could Get a Chance to Boost the State’s Minimum Wage

Jason Salzman

A campaign fact sheet cited an April survey showing that 59 percent of the 2,400 U.S. small businesses polled favor raising the minimum wage, and that about 40 percent of those polled already pay entry-level employees "far above" the required minimum wage in their location.

Colorado’s minimum wage would increase from $8.31 to $12 by 2020 if Colorado voters approve a ballot initiative that could be headed to the November ballot.

Patty Kupfer, campaign manager for Colorado Families for a Fair Wage told reporters Monday that Colorado Families for a Fair Wage, a coalition of groups, submitted more than 200,000 signatures to the Colorado secretary of state, more than double the number required to make the ballot.

Hundreds of volunteers and dozens of organizations collected signatures, Kupfer said.

“Raising the minimum wage is fair and it’s smart,” Kupfer said. “It’s fair because people working full time should earn enough to support their families. It’s smart because when working people have more money in their pockets, they spend it here in Colorado, boosting our economy and helping our community thrive.”

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Speaking at the news conference staged in front of stacked boxes of petitions, Marrisa Guerrero, identified as a certified nursing assistant, said she works seven days a week and still relies on subsidized housing.

“Making $300 a week is not enough to pay rent and buy groceries for a family like mine,” said Guerrero, adding that she’d “really like” to see an increase in the minimum immediately, but “2020 would work wonders.”

After 2020, the state’s minimum wage would be adjusted annually for cost-of-living increases under the initiative.

Tyler Sandberg, a spokesperson for Keep Colorado Working, an organization opposing the initiative, appeared at the news conference and told reporters that he was “especially” worried about the initiative’s impact on small businesses.

“The big corporations, the wealthy areas of Denver and Boulder, might be able to afford [it], but small businesses, rural and poor communities, cannot afford this,” Sandberg told reporters. “So you are going to put people out of work with this. You’re going to harm the same people you’re trying to help.”

“It’s one size that doesn’t fit all. It’s the same for a small business as it is for Pepsi Cola,” said Sandberg, whose organization includes the Colorado Restaurant Association, the Colorado Association of Commerce and Industry, and the National Association of Independent Business.

Asked by Rewire to respond to Sandberg’s argument against a higher wage, Kupfer said, “Research shows small businesses support increasing the minimum wage. The truth is, when workers make more, that means more customers in local Colorado businesses. Both in rural and urban parts of the state, when working people do well, our communities thrive.”

A campaign fact sheet cited an April survey showing that 59 percent of the 2,400 U.S. small businesses polled favor raising the minimum wage, and that about 40 percent of those polled already pay entry-level employees “far above” the required minimum wage in their location.

“In my company, we have customer service representatives being paid $15 per hour,” Yoav Lurie, founder of Simple Energy, told reporters at the news conference. “While others might choose to pay customer service reps minimum wage, we have found that higher pay leads to improved performance and better retention and better customer satisfaction.”

Workers who rely on tips would see their minimum hourly wage increase by about 70 percent, from $5.29 to $8.98, while other workers would get a 44 percent increase by 2020. The initiative states that “no more than $3.02 in tip income may be used to offset the minimum wage of employees who regularly receive tips.”

Colorado passed a constitutional amendment in 2006 that bumped the minimum wage to $6.85. It’s been raised according to inflation since then.  The federal minimum wage is $7.25 and has not been increased since 2009.

Colorado’s Republican legislators killed legislation this year to allow cities to raise the minimum wage.