Madame Speaker, Make a Difference for Women on HIV

Scott Swenson

When it comes to PEPFAR, is Speaker Nancy Pelosi better for women and girls, or is President Bush's Global AIDS Coordinator, Dr. Mark Dybul? The Democratic Majority seems to be ignoring the pleas of public health experts.

This presidential primary season is serving as a national teach-in on race and gender issues as America confronts, once again, its history of struggling with the notion that all of us are created equal. The hope of many progressives is that by electing more women and people of color to higher offices, our government will better reflect the sensibilities of the diverse nation we are.

So it is disappointing when a staff member of Speaker Nancy Pelosi, discussing the President's Emergency Plan for AIDS Relief (PEPFAR), compares the bill now before Congress to the recently passed economic stimulus package. PEPFAR has the potential to save millions of lives, the economic stimulus package is intended for American consumers to go buy new gadgets. Public health experts and economists have their doubts about both efforts, due to politics as usual.

The comparison intended by the Pelosi staffer is that PEPFAR, like the stimulus package, will be marked-up, compromised, voted on and passed before any real debate occurs. According to sexual and reproductive health advocates who heard the comment, the comparison indicated that while their concerns about the bill had been noted, nothing would change.

Assuming the staff member reflects the Speaker's views on PEPFAR, it appears she is more interested in passing a bill quickly than making sure PEPFAR achieves its goals. Recent action in the House Foreign Affairs Committee, which compromised vital aspects of the bill before mark-up, is more evidence of the Speaker's plan to rush PEPFAR. This is particularly upsetting given changes to early drafts of PEPFAR that have been compromised by the Democrats, jeopardizing the lives of millions of women and girls.

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Compare the attitude of the Speaker's office to that of Ambassador Mark Dybul, M.D., U.S. Global AIDS Coordinator, as expressed in a letter to the International Planned Parenthood Federation in 2006. The letter clarified PEPFAR's complex ideological restrictions (three years after it first passed):

President Bush has stated that the conditions of the Mexico City Policy "shall not apply to foreign assistance furnished pursuant to [PEPFAR]." Accordingly, all U.S. Government funding solely for HIV/AIDS activities is exempt from the Mexico City Policy.

But the new Democratic Majority's compromise plan, implemented by the staff of the House Foreign Affairs Committee, applies the Mexico City Policy, also known as the Global Gag Rule, to PEPFAR. PEPFAR has nothing to do with abortion, which is what the Global Gag Rule deals with. Democrats did not remove onerous ideological restrictions, they added another one, and on abstinence-only shifted one set of confusing rules to another, just to placate social conservatives.

Amb. Dybul's 2006 letter continues,

… there are numerous reasons why the linkages between voluntary family-planning and HIV prevention and care are important, particularly as we reach out to women who are vulnerable and can face tremendous stigma and barriers in accessing care. Programs supported by the U.S. Government to prevent mother-to-child transmission include linkages with voluntary family planning to ensure quality care, with goals that include prevention of unintended pregnancy among HIV-positive women, in keeping with the World Health Organization guidelines. Evidence also shows that, particularly in high-HIV prevalence settings, voluntary family planning and antenatal care clinics can be important venues for reaching women with HIV prevention, treatment, counseling and testing, and other interventions or referrals. We have made our staff aware that voluntary family-planning clinics and programs are an important HIV/AIDS care delivery point, and play a key role in reducing morbidity and mortality from HIV/AIDS.

But the Democratic Majority's plan, being marked up in the Senate next week and scheduled for a House vote soon, missed the opportunity to apply World Health Organization guidelines with respect to women and girls. Their plan to pass the bill quickly, just like the economic stimulus package, ignored the advice of the Institute of Medicine, Government Accounting Office and Center for Public Integrity that suggested PEPFAR should be streamlined, its ideological restrictions removed, to help more people.

Letters now in circulation from researchers, sexual and reproductive health advocates, public health experts and people who have been on the ground working to implement PEPFAR with its existing ideological restrictions, urge Congress to take a different path. From one letter,

… 75 percent of persons living with HIV still lack access to anti-retroviral therapies (ARVs) needed to ensure they can live long and productive lives. However, there are also seven new infections for every person accessing treatment. Today, we have the benefit of five years of lessons learned and of a strong and growing body of evidence that underscores an immutable fact: We cannot end the global AIDS epidemic without concurrent and dramatically increased support for robust, evidence-based prevention strategies. To achieve our goals, the US must put evidence ahead of ideology in its effort to reauthorize PEPFAR, ensuring the maximum benefit from the resources invested.

Political expediency — avoiding a fight with a dwindling minority of social conservatives — seems more important to Democrats than making sure PEPFAR works. Political expediency seems more important than efficiently distributing the generous $50 billion to NGO's working in Africa, with less bureaucracy so they can focus on their life-saving work.

From another letter signed by experts and advocates urging the Democratic Majority to change course,

… mis-characterizations and untruths were used to remove from the draft, language supporting expanded access to contraceptives for HIV positive women receiving prevention of maternal-to-child transmission (PMTCT) services. We are simply mystified at the failure to support the World Health Organization’s (WHO) standards for these programs. WHO recommends that family planning services be provided to women in PMTCT services should they choose to prevent another pregnancy. Sound health practice appears to have fallen prey to those program implementers who simply do not believe in contraception – putting their own wishes above the health and well being of those they are charged with serving.

The 2003 legislation created barriers to sound health programming and HIV prevention work with sex workers. These men and women are often disenfranchised and without social and health support systems – and US law has put additional barriers in place, rather than paving the way for undertaking more health care interventions with them. Because this community is deeply affected by HIV/AIDS, now is the time to remove these barriers and promote best practices in working with these communities

To President Bush's credit, PEPFAR has helped prevent mother-to-child transmission in Africa in more than three million cases. PEPFAR provided counseling and testing to more than nine million people, 69 percent of whom were women. Sixty percent of the people getting treatment for AIDS from PEPFAR are women. But the reality is that this year, 2.5 million more men, women and children will become infected with HIV. Some of those women and girls will be infected by husbands who have visited sex workers. Sex workers forced into this work because of poverty, many trying to support children of their own. Sex workers made more vulnerable by President Bush's requirement effectively restricting public health outreach to them. The Democratic Majority is now complicit in this failure of leadership, by compromising the Global Gag Rule and the Anti-Prostitution Pledge, thus making this program more complex.

We cannot hope to catch up to, let alone get ahead of, infection rates, if we continue to compromise sound public health strategies for the sake of political expedience. Do people supporting the compromised bill really think we'll have a different conversation five years from now without more courageous leadership?

Senator Barbara Boxer (D-CA) has a chance to help improve the bill, as do other concerned Representatives and Senators. But it appears they will have to do it over the objection of Speaker Pelosi. The question is, will they, or will Congress once again prove how tone deaf it can be to voters demanding more accountability, more solutions, more reality and less ideology.

If ever there was a moment for women and men to demonstrate leadership in Congress and stand up for women and girls in Africa, this is that moment.

If ever there was a moment to ignore the far-right ideologues and make a principled stand for sound public health strategies, literally the difference between life and death for many women and girls, this is that moment.

If ever there was a moment to prove that electing and elevating more women and people of color really can change our politics, and not just on the surface, this, Madame Speaker, is that moment.

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Commentary Contraception

Hillary Clinton Played a Critical Role in Making Emergency Contraception More Accessible

Susan Wood

Today, women are able to access emergency contraception, a safe, second-chance option for preventing unintended pregnancy in a timely manner without a prescription. Clinton helped make this happen, and I can tell the story from having watched it unfold.

In the midst of election-year talk and debates about political controversies, we often forget examples of candidates’ past leadership. But we must not overlook the ways in which Hillary Clinton demonstrated her commitment to women’s health before she became the Democratic presidential nominee. In early 2008, I wrote the following article for Rewirewhich has been lightly edited—from my perspective as a former official at the U.S. Food and Drug Administration (FDA) about the critical role that Clinton, then a senator, had played in making the emergency contraception method Plan B available over the counter. She demanded that reproductive health benefits and the best available science drive decisions at the FDA, not politics. She challenged the Bush administration and pushed the Democratic-controlled Senate to protect the FDA’s decision making from political interference in order to help women get access to EC.

Since that time, Plan B and other emergency contraception pills have become fully over the counter with no age or ID requirements. Despite all the controversy, women at risk of unintended pregnancy finally can get timely access to another method of contraception if they need it—such as in cases of condom failure or sexual assault. By 2010, according to National Center for Health Statistics data, 11 percent of all sexually experienced women ages 15 to 44 had ever used EC, compared with only 4 percent in 2002. Indeed, nearly one-quarter of all women ages 20 to 24 had used emergency contraception by 2010.

As I stated in 2008, “All those who benefited from this decision should know it may not have happened were it not for Hillary Clinton.”

Now, there are new emergency contraceptive pills (Ella) available by prescription, women have access to insurance coverage of contraception without cost-sharing, and there is progress in making some regular contraceptive pills available over the counter, without prescription. Yet extreme calls for defunding Planned Parenthood, the costs and lack of coverage of over-the-counter EC, and refusals by some pharmacies to stock emergency contraception clearly demonstrate that politicization of science and limits to our access to contraception remain a serious problem.

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Today, women are able to access emergency contraception, a safe, second chance option for preventing unintended pregnancy in a timely manner without a prescription. Sen. Hillary Clinton (D-NY) helped make this happen, and I can tell the story from having watched it unfold.

Although stories about reproductive health and politicization of science have made headlines recently, stories of how these problems are solved are less often told. On August 31, 2005 I resigned my position as assistant commissioner for women’s health at the Food and Drug Administration (FDA) because the agency was not allowed to make its decisions based on the science or in the best interests of the public’s health. While my resignation was widely covered by the media, it would have been a hollow gesture were there not leaders in Congress who stepped in and demanded more accountability from the FDA.

I have been working to improve health care for women and families in the United States for nearly 20 years. In 2000, I became the director of women’s health for the FDA. I was rather quietly doing my job when the debate began in 2003 over whether or not emergency contraception should be provided over the counter (OTC). As a scientist, I knew the facts showed that this medication, which can be used after a rape or other emergency situations, prevents an unwanted pregnancy. It does not cause an abortion, but can help prevent the need for one. But it only works if used within 72 hours, and sooner is even better. Since it is completely safe, and many women find it impossible to get a doctor’s appointment within two to three days, making emergency contraception available to women without a prescription was simply the right thing to do. As an FDA employee, I knew it should have been a routine approval within the agency.

Plan B emergency contraception is just like birth control pills—it is not the “abortion pill,” RU-486, and most people in the United States don’t think access to safe and effective contraception is controversial. Sadly, in Congress and in the White House, there are many people who do oppose birth control. And although this may surprise you, this false “controversy” not only has affected emergency contraception, but also caused the recent dramatic increase in the cost of birth control pills on college campuses, and limited family planning services across the country.  The reality is that having more options for contraception helps each of us make our own decisions in planning our families and preventing unwanted pregnancies. This is something we can all agree on.

Meanwhile, inside the walls of the FDA in 2003 and 2004, the Bush administration continued to throw roadblocks at efforts to approve emergency contraception over the counter. When this struggle became public, I was struck by the leadership that Hillary Clinton displayed. She used the tools of a U.S. senator and fought ardently to preserve the FDA’s independent scientific decision-making authority. Many other senators and congressmen agreed, but she was the one who took the lead, saying she simply wanted the FDA to be able to make decisions based on its public health mission and on the medical evidence.

When it became clear that FDA scientists would continue to be overruled for non-scientific reasons, I resigned in protest in late 2005. I was interviewed by news media for months and traveled around the country hoping that many would stand up and demand that FDA do its job properly. But, although it can help, all the media in the world can’t make Congress or a president do the right thing.

Sen. Clinton made the difference. The FDA suddenly announced it would approve emergency contraception for use without a prescription for women ages 18 and older—one day before FDA officials were to face a determined Sen. Clinton and her colleague Sen. Murray (D-WA) at a Senate hearing in 2006. No one was more surprised than I was. All those who benefited from this decision should know it may not have happened were it not for Hillary Clinton.

Sometimes these success stories get lost in the “horse-race stories” about political campaigns and the exposes of taxpayer-funded bridges to nowhere, and who said what to whom. This story of emergency contraception at the FDA is just one story of many. Sen. Clinton saw a problem that affected people’s lives. She then stood up to the challenge and worked to solve it.

The challenges we face in health care, our economy, global climate change, and issues of war and peace, need to be tackled with experience, skills and the commitment to using the best available science and evidence to make the best possible policy.  This will benefit us all.

News Family Planning

Judge Thwarts Ohio GOP’s Attack on Planned Parenthood Funding

Michelle D. Anderson

“This law would have been especially burdensome to communities of color and people with low income who already often have the least access to care—this law would have made a bad situation worse,” said Iris E. Harvey, president and CEO of Planned Parenthood of Greater Ohio.

An effort to defund Ohio Planned Parenthood affiliates by Gov. John Kasich (R) and the Republican-held legislature has come to an end.

Judge Michael R. Barrett of the U.S. District Court of the Southern District of Ohio on Friday ruled in Planned Parenthood’s favor, granting a permanent injunction on an anti-choice state law.

The court ruling will keep Richard Hodges, the Ohio Department of Health director, from enforcing HB 294.

The 2015 law, sponsored by Rep. Bill Patmon (D-Cleveland) and Rep. Margaret Conditt (R-Butler County), would have redirected $1.3 million in state and federal taxpayer funds from Planned Parenthood’s 28 clinics in Ohio.

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The law would have required the state department to keep federal funds and materials that the health department receives from being distributed to entities that perform or promote non-therapeutic abortions, or maintain affiliation with any entity that does.

Funding that would’ve been cut off from the state health department went to the Violence Against Women and Breast and Cervical Cancer Mortality Prevention acts, the Infertility Prevention Project, Minority HIV/AIDS and Infant Mortality Reduction initiatives, and the Personal Responsibility Education Program.

Planned Parenthood in a lawsuit argued that the Republican legislation violated the First Amendment and the Due Process Clause and Equal Protection Clause of the 14th Amendment.

Barrett had temporarily blocked the law after Planned Parenthood affiliates filed the lawsuit and requested a preliminary injunction. The judge had issued an opinion contending that some legislators passed the law to make it difficult for people to access abortion care, as Rewire reported.

Iris E. Harvey, president and CEO of Planned Parenthood of Greater Ohio, praised the judge’s temporary order.

“This law would have been especially burdensome to communities of color and people with low income who already often have the least access to care—this law would have made a bad situation worse,” Harvey said in a statement.

Kellie Copeland, NARAL Pro Choice Ohio’s executive director, said in a statement that the Ohio legislature passed the anti-choice measure in an effort to appeal to conservative voters in early primary states during Kasich’s presidential campaign.

Copeland said that while the legislation made no effort to reduce the number of abortions performed, “it actively blocked critical health care for low-income women and families.”

Planned Parenthood said those services included 70,000 free STD screenings, thousands of HIV tests for at-risk community residents, and the largest infant mortality prevention program in the state.

In the 23-page court order and opinion, Barrett, an appointee of President George W. Bush, acknowledged that the law would have deterred “patients from seeking these potentially life-saving services.”

Planned Parenthood noted that the recent ruling in Ohio makes it among the ten states where courts have blocked anti-choice laws following June’s landmark Whole Woman’s Health v. Hellerstedt U.S. Supreme Court ruling.

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