The Next Face of Leadership on US Global AIDS Policy: Communities Speak Out

Jodi Jacobson

Letters being circulated by the global AIDS and reproductive and sexual health and rights communities call for new leadership in the Office of the Global AIDS Coordinator.  One letter focuses on the timing of the appointment and the need for an independent office; the other focuses more directly on the vision and perspectives of the person appointed.

Advocates for both global AIDS and women’s health and rights are circulating two letters, each of which seeks to influence the Obama Administration’s pick for the next Global AIDS Coordinator.  Though they differ on both the structure of AIDS leadership and the timing of the appointment, both groups agree on the need for new leadership for global AIDS policies.

The first letter, circulated by Results, an anti-poverty and global health organization, urges Obama to appoint a coordinator within 30 days of inauguration.  This letter was submitted last week to the Obama transition team, with 20 signatories.  Apart from the call for a quick appointment, another concern driving this letter is the issue of where the "base of power" for U.S. Global AIDS Policy should rest in the next Administration. 

The first US global AIDS Act established the Office of the Global AIDS Coordinator (OGAC) at the Department of State and gave the new Coordinator decision-making authority over all funding for AIDS, whether it flowed through the US Agency for International Development (USAID), Health and Human Services (HHS) or the Centers for Disease Control (CDC).  Talk of folding OGAC into a revamped development agency–USAID 2.0, so to speak– has these advocates concerned. 

According to Matthew Kavanaugh, Global Campaigns Coordinator at Results:

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There has been talk about subsuming the Global AIDS Coordinator
role under USAID or possibly of waiting for months before appointing a
permanent Global AIDS Coordinator—whomever that might be.  We think
both of these would be the wrong direction to take PEPFAR. Instead we
need to build on PEPFAR’s huge successes, especially as compared to
many other aid programs, as well as prioritizing fixing the big
problems with prevention and systems—all of which requires a powerful
Global AIDS Coordinator with a  direct line to and trust of
President-elect Obama.

John Fawcett, Global Legislative Director of Results further notes that:

In the broader context of foreign aid reform, several prominent development groups have recommended that Obama appoint (and have the Senate confirm) a USAID Administrator, and then name that person interim Global AIDS Coordinator.  While we support calls for the elevation of foreign assistance, this particular recommendation handicaps AIDS leadership at a critical moment, just when we need…bold new plans to prevent 12 million new infections, treat 4 million, care for 12 million, and fix the things that Lantos-Hyde failed to address.


The second letter, issued jointly by the International Women’s Health Coalition (IWHC) and the Sexuality Information and Education Council of the United States (SIECUS), which was submitted to the transition team on December 23rd with 49 signatories on and can now be found on Change.gov, focuses more directly on the vision and philosophy of the next AIDS Ambassador, rather than the timing of the appointment, but also is driven by concerns about the agency.  According to Bill Smith, Vice President for Public Policy at SIECUS:

We are seeking to elevate the voice of advocates and implementers who believe we cannot continue under the existing leadership of the US global HIV/AIDS response.  There are several key shortcomings in the PEPFAR reauthorization, particularly in the area of prevention, which require someone who can oversee the changes needed ranging from clarification of guidance to implementation of evidence-based programs.  An effective response to the current global HIV/AIDS epidemic requires an understanding of the social and economic factors  which drive the epidemic and a solid grounding in public health and human rights frameworks.  We have learned many valuable lessons during the first five years of implementation and now is the time to act on that knowledge by appointing someone who can guide the U.S. response to the global HIV/AIDS epidemic with visionary leadership.  We are therefore calling on the President-elect to appoint a Global AIDS Coordinator who can lead the transition from a disease-specific, medical model to one which embraces, and can carry out, a broader vision.

 

Smith also notes that a key difference in the two letters is the concern about OGAC’s "location."

The letter circulated by RESULT focuses on securing a “permanent” and independent Global AIDS Coordinator and speaks to the possibility that OGAC would be restructured to fall under the head of USAID.  It addresses the concern that this shift from an independent office, with ambassador-level leadership would make it difficult to leverage cooperation from agencies/offices such as CDC, HHS etc as OGAC would no longer wield a higher political rank. 

 

The IWHC/SIECUS effort seeks to ensure that OGAC operates within a broader development framework, with greater coordination, cooperation, and integration of programs that must simultaneously address both immediate medical and public health problems as well as the root causes of the spread of HIV infections.  An example would be the more effective coordination at the country level of HIV/AIDS prevention, treatment, and care with other reproductive health and family planning services, and with programs to promote basic education, eliminate child marriage, and address gender-based violence.

The full text of each letter can be found below.  Reality Check will update you on next steps.

The text of the letter being circulated by Results:

Dear President-Elect Obama:

We are writing to urge you to affirm the United States’ continued leadership on HIV/AIDS by appointing a permanent Global AIDS Coordinator within 30 days of assuming the Presidency. A strong, independent Coordinator role has been critical to providing focused leadership on the AIDS crisis and achieving tremendous results to date.

We are grateful for your support of global health while in the Senate, and for your pledge to double foreign assistance, including $50 billion for HIV/AIDS. Led by Senator Joe Biden, the Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008 (P.L. 110-293) was a major bipartisan achievement.

While the Lantos-Hyde Act charts a path forward, now is not the time to put our global AIDS program on auto-pilot.

The Global AIDS Coordinator in the Obama administration will be immediately responsible for developing a new five-year global AIDS strategy that will shape our response to the epidemic well into the next decade. Our shared goals are ambitious: 12 million new infections prevented, with a renewed emphasis on the evidence-based approaches and the needs of women and girls; care for 12 million people affected by AIDS, including 5 million orphans and vulnerable children;  four million people supported on treatment though bilateral and multilateral funding; 140,000 new health care professionals trained and retained; and improved efforts to fight co-morbidity associated with tuberculosis, malaria, and malnutrition among people living with HIV/AIDS.

The realization of these goals will require more than competent administration. It will demand vision and leadership to usher in a new era of bold U.S. action on the global AIDS epidemic.

We support calls to elevate the priority of global development within your administration. We look forward to working with you to support a strategy to reform foreign aid to make the Millennium Develop Goals truly America’s goals. However, more effective, better coordinated assistance must be pursued without diminishing focused leadership on AIDS or prematurely consolidating roles and responsibilities.

We urge you to reaffirm our commitment to the fight against HIV/AIDS by prioritizing the appointment of a Global AIDS Coordinator within the first month of your Administration.             Sincerely…..

The text of the letter being circulated by IWCH and SIECUS:

Dear President-Elect Obama:


As advocates engaged in the work of ensuring the most effective and appropriate global HIV/AIDS response that the United States can offer, we call upon you to appoint a new Global AIDS Coordinator within 30 days of assuming the Presidency.  We have reached a critical moment in the history of the global HIV/AIDS epidemic as this next phase of PEPFAR is set into motion through the Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008 (P.L. 110-293).  In order to fulfill the mission laid out therein, and to lead the response from an emergency approach to one of sustainability, new leadership is required.  


From the outset, PEPFAR has been guided by a disease-specific medical model in lieu of a broader human rights framework and public health approach which is needed to more effectively address the epidemic.  While excellence in medical care and services are a fundamental element in the global HIV/AIDS response, the new strategies undertaken by the Coordinator will have more impact if they are  guided by a keen insight into the social complexities which drive the HIV/AIDS epidemic. We cannot treat our way out of the gender inequalities, social and economic disparities and stigma and discrimination which fuel this global pandemic.  The inherent strategy steering the U.S. response to global HIV/AIDS must embrace all of these aspects– medical, social science, public health and human rights– to create and oversee PEPFAR-funded programs around the world.   A new Coordinator that upholds the highest standards of prevention, care and treatment, relying on strategies and protocols that are evidence-based, to accurately respond to the needs of those who are most affected will make more headway than has been achieved in the past.


Ending the epidemic requires going beyond the medical model currently driving the U.S. global HIV/AIDS response, which means appointing a new Global AIDS Coordinator who can provide that strategic vision from the top.       Sincerely,

 

 

News Abortion

The Forgotten History of Republicans’ (Failed) Attacks on Fetal Tissue Research

Christine Grimaldi

Today's congressional inquiry not only derides fetal tissue research, but attacks abortion care. The inaugural hearing in March 2016 gave Republicans a platform to compare fetal tissue research to Nazi experimentation. Republicans derided Democrats for exaggerating the importance of fetal tissue.

Republicans in Congress sixteen years ago were more vested in supporting life-saving fetal tissue research than they were in mischaracterizing such research to score political points.

The times, and the talking points, have changed.

In 2000, GOP lawmakers in the U.S. House of Representatives conducted an investigation into fetal tissue practices based on a deceptive Life Dynamics video featuring a disgruntled former tissue procurement company employee. Dean Alberty alleged that two of his employers, Anatomic Gift Foundation (AGF) and Opening Lines, which acquired and distributed human fetal tissue to researchers, trafficked fetuses for profit. He also claimed that abortion providers altered procedures to obtain better tissue specimens. 

Life Dynamics, which remains a prominent anti-choice group, paid Alberty thousands of dollars during and after the time he worked in the tissue procurement business. Republicans summoned Alberty to be their key witness, but he later admitted under oath that he had lied about business operations in the Life Dynamics video and in an interview with the then-prominent ABC television news program 20/20.

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Alberty’s reveal came as a surprise, and an embarrassment, to Republicans during a hearing on the allegations before the House Energy and Commerce Committee Subcommittee on Health and Environment.

“Your credibility, as far as this member is concerned, is shot,” said then-Rep. Richard Burr (R-NC), who now serves in the U.S. Senate.

Sixteen years later, credibility doesn’t seem to carry the same weight for anti-choice Republican lawmakers as a new set of videos alleging problems with fetal tissue donations have simultaneously been discredited but are still being used as the basis of hearings some have called a witch hunt.

In July 2015, Rep. Trent Franks (R-AZ), sponsor of the so-called Prenatal Nondiscrimination Act of 2016, and some of his colleagues coordinated with the Center for Medical Progress (CMP), the anti-choice front group responsible for the widely discredited smear campaign alleging that Planned Parenthood profited from fetal tissue donations.

The House Energy and Commerce, Judiciary, and Oversight and Government Reform committees launched investigations upon the release of the first surreptitiously recorded videos and have continued to attack fetal tissue research, even though GOP officials in 12 states have since cleared Planned Parenthood of wrongdoing.

The first set of House hearings also failed to turn up any evidence that laws governing fetal tissue donation or research had been broken.

House Republicans nonetheless voted in October to form the Select Investigative Panel on Infant Lives, an Energy and Commerce panel relying on the CMP videos and other allegedly falsified evidence to prove their charges of “baby body parts” for sale.

Rep. Marsha Blackburn (R-TN), the panel’s chair, and other congressional committees have subpoenaed more than 2,000 pages of documents from tissue procurement company StemExpress. However, Blackburn has not brought in David Daleiden, the founder of CMP, to testify, although he now faces felony charges for his role in the original smear campaign.

Daleiden Testimony Could Undermine Republicans

Precedent doesn’t bode well for Republicans and their supposed whistleblowers.

Alberty, for example, expanded on his allegations of fetal tissue misconduct in the 20/20 interview with then-correspondent Chris Wallace, who now anchors Fox News Sunday. 20/20 separately targeted Opening Lines founder Dr. Miles Jones in an ostensibly damning undercover video included in the segment.

Alberty was unequivocal about wrongdoing. “This is purely for profit. Everything was about money,” he told Wallace. 

Wallace, for his part, narrated that Alberty had accepted thousands of dollars to act as an informant for Life Dynamics while continuing to work in the tissue procurement business. Why believe Alberty, then?

“I will stand behind my words until I die,” Alberty said. “I will go in front of Congress if I have to and testify under oath.”

Alberty appeared before the subcommittee the morning after the 20/20 segment aired. By that time, he had changed his story in an affidavit and a deposition that Democrats referenced to undermine his claims.

“When I was under oath I told the truth,” Alberty admitted during the hearing. “Anything I said on the video when I’m not under oath, that is a different story.”

Alberty’s name resurfaced at the select panel’s April 2016 hearing on fetal tissue “pricing,” which featured GOP exhibits reportedly taken from the CMP videos. Fay Clayton, a senior partner and founding shareholder of Robinson Curley & Clayton, P.C. and a witness for the Democrats, recalled her experience representing AGF. Alberty admitted to fabricating claims about AGF in the deposition with Clayton. 

Republicans did not know about the deposition until Democrats raised it during the 2000 hearing.

“Fetal tissue wasn’t ‘for sale’ at all,” Clayton said at the 2016 “pricing” hearing. “What was for sale was phony witness testimony, bought and paid for by opponents of abortion.”

An FBI investigation cleared Opening Lines and Jones of the trafficking charges. The U.S. Department of Justice (DOJ) also found no violations of federal statutes and closed an investigation in 2008, Robert Raben, a former DOJ official, said when he testified for the Democrats at the panel’s 2016 “pricing” hearing. 

Clayton called for members of the panel to get Daleiden under oath to tell the truth or face legal repercussions for perpetuating his claims. However, Republicans misrepresented Clayton’s testimony by saying she called for StemExpress to turn over accounting records. Blackburn soon subpoenaed those records and threatened “to pursue all means necessary” as the investigation proceeds.

Rep. Diana DeGette (D-CO), co-chair of the House Pro-Choice Caucus, has no doubts about why Republicans continue to rely on third-party witnesses rather than Daleiden.

“I don’t think they want to bring David Daleiden in because they know that he’s a shady character and an unreliable witness,” DeGette said in an interview with Rewire.

Anti-Choice Tactics Influence Current Inquiry

As the only lawmaker to serve on the past and present investigations, DeGette sometimes feels like she’s “in a real-life version of Groundhog Day.”

“We keep having these same kinds of hearings, over and over again,” DeGette said. “In my opinion, there’s continuing pressure on the Republican Party from the far-right anti-choice movement to have these hearings, even though the claim of sale of fetal tissue has been repeatedly disproved.”

Anti-choice tactics, if not the key players, behind what congressional Democrats have branded a “witch hunt” to undermine fetal tissue research are similar today.

Life Dynamics, the anti-choice group behind the Alberty video, receives the majority of its funding from fracking billionaires Dan and Farris Wilks—the main backers of Sen. Ted Cruz’s (R-TX) suspended presidential campaign. Providers told Rewire in March that a Life Dynamics document has been used to deceive and intimidate both patients and providers by threatening legal action should they go through with obtaining or providing abortion care.

Perhaps the biggest difference between the past and present inquiries is Republicans’ attitudes toward fetal tissue research—and their ability to separate research from abortion.

The shift can be summed up in one word: politics.

“I think the difference is a structural one with a political origin,” Raben, the former DOJ official, told Rewire in an interview.

Republicans in 2000 investigated fetal tissue practices as part of a standing subcommittee. House Republicans today created the select panel, sought members to serve on it, and despite the lack of any evidence, continue to fund it through tax dollars that otherwise would not be diverted to sustained attacks on fetal tissue research.

“In the face of lousy evidence, they’re going to keep going,” Raben said.

Inquiries Diverge on Science

The current inquiry not only derides fetal tissue research, but also attacks abortion care. The inaugural hearing in March 2016 gave Republicans a platform to compare fetal tissue research to Nazi experimentation. Blackburn subsequently derided Democrats for exaggerating the importance of fetal tissue.

Democrats have warned that such rhetoric could slow scientific advances on dangerous diseases, including the Zika virus, which is linked to irreparable defects in the developing fetuses that Blackburn and her Republican counterparts have pledged to protect.

In 2000, even anti-choice Republicans repeatedly deferred to science on fetal tissue research.

“Today’s hearing is not about whether fetal tissue research is a good or bad thing, and it is definitely not about whether a woman should have a right to choose to have an abortion, which is the law of the land,” former Energy and Commerce Chair Tom Bliley (R-VA) said in 2000. “Whether we are pro life, pro choice, Republican, Democrat, or Independent, I think and hope that we can all agree that present federal law which allows for this research should be both respected and enforced.”

At that time, leading Republicans on the subcommittee also extolled, in the words of Rep. Fred Upton (R-MI), the “life-saving research” that their investigation aimed to protect.

Upton had worked in 1992 with former Rep. Henry Waxman (D-CA) to lift the ban on fetal tissue research. And he further expressed disappointment when President George H.W. Bush vetoed their effort.

“It’s really tragic,” Upton said then. “We tried to lift the substance over politics.”

President Bill Clinton signed legislation legalizing fetal tissue donations in 1993. “Being for fetal tissue transplantation is consistent with being for life,” Upton reportedly said during that era.

Republican Fetal Tissue Allies Disappear

Upton’s approach today does not reflect what happened the last time an anti-choice group manipulated evidence and fed it to congressional Republicans. The contents of CMP’s heavily edited smear videos “can’t help but make you weep for the innocents who were sacrificed in such a cavalier manner for alleged profit,” Upton wrote in a op-ed published in the weeks after the release of the first CMP recording.

Although Upton does not serve on the panel, he effectively sanctions the investigation as chair of the full House Energy and Commerce Committee. Under House rules, standing subcommittees draw funding from the budget of the full committee with jurisdiction. The full committee chair is in charge of managing additional funds from the House Administration Committee, which sets aside $500,000 per session of Congress to supplement operating budgets, according to a senior House Democratic aide with knowledge of the chamber’s rules.

The aide said the panel follows the same procedures, receiving an undisclosed amount from Energy and Commerce and an additional $300,000 from Administration.

Administration Democrats unsuccessfully protested the transfer at the end of last year. “Spending taxpayer money on this select panel is wasteful on substantive grounds and unnecessary on practical grounds,” they said.

The transfer followed the House’s informal two-thirds/one-third funding split between the majority and minority parties, with the Republicans receiving $200,000 and the Democrats $100,000, the aide said. Full committee leaders are charged with distributing the funds, meaning that Upton had to do so with the $200,000 for Blackburn, the aide said.

Rewire contacted Upton’s office with questions ranging from whether the chair approves of the panel’s approach to how much more financial resources he will direct from the full committee’s budget to the panel. Rewire asked for Upton’s views on fetal tissue research, including if he shares Blackburn’s derision for the research and if he considers fetal tissue and “baby body parts” to be separate.

In response, a committee spokesperson emailed a brief statement. “The efforts of the Select Panel have always been based on learning the facts,” the spokesperson said. “The panel has been given a one-year term to conduct that mission, and will continue their important work. Chairman Upton has been a supporter of the panel’s charge and their efforts to protect the unborn.”

Republican Leaders Disregard Appeals to Disband Panel

Although Upton’s office told Rewire that the panel was given one year, the resolution that created the panel suggested it could go longer. The resolution only specifies that the panel will come to an end 30 days after filing a final report.

Democrats have repeatedly called on House Speaker Paul Ryan (R-WI) to disband the panel, including in a letter to Ryan and Blackburn last month. The panel’s Democrats again appealed to Ryan after Blackburn subpoenaed a prominent abortion provider, shifting the target from fetal tissue procurement and research to later abortion care.

DeGette said some congressional Republicans have privately shared concerns about the panel with her, but won’t do so publicly, even as their counterparts on the panel have gone “rogue.”

“This is so out on the fringes that really, I think it’s beginning to reflect on Speaker Ryan and on the whole Republican leadership in the House,” she said.

Commentary Contraception

Advocates Call for Full Funding of Research on HIV and Contraception

Lillian Mworeko & Emily Bass

For women in countries and communities with limited contraceptive choices and high rates of HIV, particularly in sub-Saharan Africa, a shortage of funding for the ECHO (Evidence for Contraceptive Options and HIV Outcomes) trial is an unacceptable development.

A clinical trial known as Evidence for Contraceptive Options and HIV Outcomes (ECHO)—originally designed to answer important questions about possible connections between risk of HIV infection and the use of non-barrier hormonal contraceptives—now hangs in the balance because of a funding shortfall. For women in countries and communities with limited contraceptive choices and high rates of HIV, particularly in sub-Saharan Africa, this is an unacceptable development.

Women make up more than half of all people living with HIV worldwide, and they continue to bear the burden of new infections. Incidence rates vary by age and country, but remain unacceptably high in the context of comprehensive, state of the art prevention services. (As one example, in the VOICE trial of women’s HIV prevention options, overall incidence was nearly 6 percent.) HIV incidence rates are particularly high in adolescent girls and young women, and globally HIV is the leading cause of death of women of reproductive age. The same women who are most at risk of HIV are also in need of a variety of reliable methods of contraception—a glaringly unmet need in sub-Saharan Africa, where fewer than 20 percent of women use a modern contraceptive method.

For those women in sub-Saharan Africa who do have access to contraception, the majority use a hormonal method (an injectable or the oral contraceptive pill). Of these women, 60 percent use a long-acting injectable such as Depo or, less frequently, NET-EN. This prevalence of these methods does not accurately reflect women’s preference since in many settings, Depo is one of a limited number of options for women—and often the only long-acting, discrete method (versus a daily contraceptive pill). Expanding the range of available choices is another key policy and advocacy priority, in sub-Saharan Africa and around the world, including in the United States.

Contraception not only allows women to determine when and how often they become pregnant, it also saves their lives. Risk of maternal morbidity and mortality—already unacceptably high in many parts of the world—rises even more in the context of unplanned pregnancies. Lack of access to effective contraception is a health and human rights issue that cannot be ignored.

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At the same time, there are persistent questions about whether some contraceptive methods, particularly long-acting injectables like Depo, increase women’s risk of acquiring HIV. These questions arise from observational data. Some studies suggest that Depo does increase risk, while others do not. This is precisely the question that the ECHO trial is designed to answer.

According to the ECHO trial team, which has briefed civil society, it would cost roughly $60 million to conduct the ECHO trial—clearly a minimal investment when compared to the economic, social, and public health costs of HIV and AIDS, unplanned pregnancies, and maternal death and illness across sub-Saharan Africa. In fact, the ECHO trial seeks to answer a question raised 25 years ago: Do contraceptive methods, particularly hormonal contraceptive methods, increase women’s risk of HIV acquisition? The answer to this question is long overdue, and the lack of investment in such research reflects a lack of strategic and financial priority for a critical women’s health and rights question.

In discussing the trial, and other approaches to the current uncertainty, stakeholders have asked why the data are mixed, and whether it’s possible to gain clarity with the information available and/or with basic science studies. The main limitation of all of the existing data on both injectables and pills and potential HIV risk is that they come from observational trials that were not designed to answer the question directly. Confounding factors cannot be controlled for, and many trials rely on women’s self report about the method they were using. There simply aren’t enough women in sub-Saharan Africa using other strategies, like the implant or the intrauterine device, to gather even observational data. The existing information is, therefore, difficult to interpret, and leave unanswered critical questions that affect the lives and health of women who have urgent needs to both space or limit births and to protect themselves from HIV. The ECHO trial is designed to help answer these questions directly for Depo, the implant (Jadelle), and the copper intrauterine device—methods about which there are even less data. It has the potential to provide more definitive, actionable information than basic science research.

The ECHO trial is the type of research we have been waiting for, with great anticipation, since a 2012 World Health Organization (WHO) review of the existing data on hormonal contraceptives and HIV risk. In this review and in an update in July 2014, research is a clear priority. The document states, “WHO strongly supports the need for further research to identify definitive answers to these issues.”

ECHO was proposed to meet this identified need. It is a randomized clinical trial that would look at whether the three options—Depo, Jadelle, and the copper intrauterine device—affect HIV-negative women’s risk of acquiring HIV.

Advocates for HIV-positive women, HIV prevention advocates, and sexual and reproductive health advocates have been following this issue closely. We are united in the conviction that women should be fully informed in their contraceptive choices and that we should not have to choose between HIV prevention and safe and effective contraception. We are also united in the need to broaden the range of contraceptive options available and accessible to all women—in the context of complete data about their risks and benefits.

The concerns related to HIV risk have to be considered in the context of the health risks of pregnancy, particularly unintended pregnancies. Epidemiologists have calculated the new HIV acquisitions that might be attributable to Depo, in the event that it does increase risk, and the rates of maternal deaths and live births that would occur if Depo were to be withdrawn, without an immediately acceptable and accessible replacement. In both instances, the greatest impact on women is in east and southern Africa.

Given the level of maternal death and illness, not to mention other public health outcomes of unintended pregnanciesy, an increase in risk of HIV acquisition by users of Depo must be weighed against the risks associated with unintended pregnancies. But context does not mean conflict—and the urgent need for a mix of effective contraceptive methods does not outweigh the need for clarity about how methods affect women’s risk of HIV acquisition. No one wants to swap illness and death associated with HIV acquisition for pregnancy-related morbidity and mortality.

And, indeed, no one is advocating for Depo to be removed without providing affordable, accessible alternative contraceptives. But the status quo cannot stand because of the challenges ahead. Current WHO guidance on Depo states that “women at high risk of HIV infection should be informed that progestogen-only contraceptives may or may not increase their risk of HIV infection.”

Not only is the message confusing, but it is also incredibly challenging for those working in public health clinics to communicate. Without the ECHO trial, this confusing message will continue being given to women currently using or initiating Depo—if they receive any message at all. Even as other methods, such as the contraceptive implant, gain popularity in some regions, some women will still only have access to Depo and they will still be told “this might increase your risk; it might not”—unless a trial like ECHO takes place.

Unfortunately, the international funding community has not adequately committed to this research. Even before the current ECHO protocol was put on hold, it had already been scaled back once due to budget concerns. This trial design should be driven by scientific questions and women’s needs, not funding.

We call on the donors to ensure the trial is fully funded without additional budget cuts or delays. We call on funders who have stepped up to date, including the Bill & Melinda Gates Foundation, USAID, the South African government, the South African Medical Research Council, the Wellcome Trust, and the UK Medical Research Council to maintain and/or expand on existing funding commitments. We challenge the U.S. National Institutes of Health and the European & Developing Countries Clinical Trial Partnership to confirm their partnership with and support for this research. And we urge these funders to work together to undertake vigorous advocacy that bridges the HIV and contraceptive research agendas. Each of these organizations have spoken about the need to promote women’s health and now they must invest in doing so. The amount of funding needed is minimal compared to investments in many other HIV prevention trials. These price tags reflect vastly different research questions and infrastructure requirements—however the point remains that this is a relatively small investment to answer a question of enormous importance.

Some funders, scientists, and advocates have raised issues about whether the trial is necessary or feasible. One argument is that the world can go ahead and increase method mix, moving away from Depo and toward other methods, without the ECHO trial. This would mean expanding access to other hormonal methods without any additional information about their relationship to HIV. The question about whether the trial is feasible—whether women will enroll, accept randomization, remain on methods, and so on—is valid, and can only be answered by attempting the trial. ECHO investigators say the research would be implemented with monitoring that would gauge feasibility in real time—allowing the trial to be stopped or altered if it was necessary.

Although concerns about the trial are fair, a $60 million investment in this set of questions is one of the best research investments that could be made in reproductive health and rights in the context of women and HIV today. As women in all our diversity, this advocacy—and the clarity it can engender about our contraceptive choices—is long overdue. Women at risk of HIV deserve to know whether their choice of contraception affects their chances of acquiring HIV. Now is no time to turn back.

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