Impacts of Protecting Life in Global Health Assistance policy in Nepal: a qualitative study.

BACKGROUND: Despite the legalization of abortion in 2002 and the concerted efforts of the Ministry of Health and Population, abortion services remain inaccessible for many Nepali women. In 2017, the United States government enacted the Protecting Life in Global Health Assistance (PLGHA) policy, which prohibited international non-governmental organizations (INGOs) from receiving United States global health assistance from providing abortion services or referrals or engaging in advocacy on liberalizing abortion laws that may have had an impact on abortion services. Though this policy was revoked in January 2021, there is a need to assess its impacts in Nepal and mitigate its lingering effects, if any. METHODS: We conducted in-depth interviews with 21 national-level stakeholders selected purposively on the basis of their experiences and expertise in sexual and reproductive health and rights (SRHR) in Nepal. Interviews were conducted two times: first between August and November 2020 when PLGHA was in place, and then between July and August 2021 after PLGHA was revoked. Interviews were digitally recorded, transcribed, translated and analysed thematically. RESULTS: Most participants reported that the implementation of PLGHA created gaps in SRHR services, affecting marginalized and underserved populations in Nepal. Participants reported that this policy has compromised the work of INGOs and civil society organizations (CSOs), posing additional risk to the sustainability of SRHR program achievements made so far. Beyond funding loss, participants also mentioned that PLGHA curtailed their freedom, with limited working areas and partnerships for CSOs leading to low or no utilization of services. Most participants welcomed the revocation of PLGHA and hoped it would have positive impacts on SRHR services by permanently repealing PLGHA. Most participants believed that the revocation of PLGHA opened opportunities for new funding and could re-establish partnerships and collaboration, though immediate results had not yet been seen. CONCLUSIONS: PLGHA had negative impacts on access to and quality of SRHR services. The Nepal government and other donor agencies need to bridge the funding gap created by the policy. The revocation of the policy has created the hope of bringing positive impacts in SRHR sector; however, the implementation of revocation at the ground level and impacts made on SRHR programs in Nepal remains to be explored.

The role of contraception in preventing HIV-positive births: global estimates and projections.

BACKGROUND: Meeting the contraceptive needs of women living with HIV (WLHIV) has primary health benefits for women, in addition to being a key element to prevent mother-to-child HIV transmission. This analysis will estimate the current number of infant HIV infections prevented by contraception in the era of increased HIV treatment coverage and; 2) model the additional HIV benefits of preventing unintended births to WLHIV. METHODS: Secondary data analysis was conducted using publicly available data from the United Nations Programme on HIV/AIDS (UNAIDS) and Population Division, Demographic Health Surveys, and peer-review literature. National data from 70 countries, that had a UNAIDS estimate for the number of WLHIV nationally, were combined into country-level models. Models estimated the current number of infant HIV infections averted by contraception annually and potentially averted if unintended births to WLHIV were prevented. Estimates take into account pregnancy and live birth rates, contraceptive coverage, contraceptive method mix and failure rates, and HIV treatment coverage during pregnancy to prevent mother to child transmission. RESULTS: Contraception use among WLHIV prevents an estimated 43,559 new infant HIV infections annually across 70 countries. Countries with the largest number of infant infections averted by contraception included South Africa (9441), Nigeria (4195), Kenya (3508), Zimbabwe (2586), and India (2145). Preventing unintended births to WLHIV could avert an additional 43,768 new infant infections per year, with the greatest potential gains to be made in South Africa (12,036), Nigeria (2770), Uganda (2552), and the Democratic Republic of the Congo (2324). CONCLUSIONS: Contraception continues to play an integral role in global HIV prevention efforts in the era of increasing HIV treatment coverage, especially in sub-Saharan Africa. Broad contraceptive availability, increased contraceptive voluntarism and method mix are key components to preventing unintended births and ending new infant HIV infections worldwide.

'Protecting Life in Global Health Assistance'? Towards a framework for assessing the health systems impact of the expanded Global Gag Rule.

During his first week in office, US President Donald J Trump issued a presidential memorandum to reinstate and broaden the reach of the Mexico City policy. The Mexico City policy (which was in place from 1985-1993, 1999-2000 and 2001-2009) barred foreign non-governmental organisations (NGOs) that received US government family planning (FP) assistance from using US funds or their own funds for performing, providing counselling, referring or advocating for safe abortions as a method of FP. The renamed policy, Protecting Life in Global Health Assistance (PLGHA), expands the Mexico City policy by applying it to most US global health assistance. Thus, foreign NGOs receiving US global health assistance of nearly any type must agree to the policy, regardless of whether they work in reproductive health. This article summarises academic and grey literature on the impact of previous iterations of the Mexico City policy, and initial research on impacts of the expanded policy. It builds on this analysis to propose a hypothesis regarding the potential impact of PLGHA on health systems. Because PLGHA applies to much more funding than it did in its previous iterations, and because health services have generally become more integrated in the past decade, we hypothesise that the health systems impacts of PLGHA could be significant. We present this hypothesis as a tool that may be useful to others' and to our own research on the impact of PLGHA and similar exogenous overseas development assistance policy changes.

The impacts of the global gag rule on global health: a scoping review.

BACKGROUND: The 1984 Mexico City Policy is a U.S. federal policy that has prohibited foreign nongovernmental organizations that receive U.S. international family planning assistance from using their own, non-U.S. funds to provide, counsel on, or refer for abortion services as a method of family planning, or advocate for the liberalization of abortion laws- except in cases of rape, incest, and life endangerment. The policy became known as the global gag rule (GGR) due to its silencing effect on abortion advocacy. Historically, it has only been attached to family planning funding, until 2017 when a presidential memorandum expanded the policy to nearly all US$8.8 billion in global health foreign assistance. In light of the aforementioned expansion, this scoping review aimed to describe and map the impacts of the GGR on global health, which in turn would identify research and policy gaps. This is the first time that all of the existing literature on the policy's impact has been synthesized into one article and comprehensively reviewed. METHODS: The review utilized Arksey and Malley's five-stage methodological framework to conduct a scoping review. Fourteen peer-reviewed databases and 25 grey literature sources were searched for publications between January 1984 and October 2017. Organizations and individuals working on GGR research and impact were also contacted to access their works from the same time period. These publications reported on impacts of the global gag rule on 14 domains in global health. RESULTS: The searches yielded 1355 articles, of which 43 were included. Overall, 80% of the identified sources were qualitative. The misunderstanding, miscommunication, and chilling effect of the policy underpinned the GGR's impacts. The frequently reported impacts on family planning delivery systems (34 articles) and the loss of U.S. funding (21 articles) were often related. Sources reported on the impact of the GGR on HIV and AIDS programs, advocacy and coalition spaces, and maternal and child health. Only three studies (6.9%) quantified associations between the GGR and abortion rates, concluding that the policy does not decrease rates of abortion. DISCUSSION: The GGR's development and implementation was consistently associated with poor impacts on health systems' function and outcomes. More peer-reviewed and quantitative research measuring and monitoring the policy's impact on health outcomes are needed. More research and policy analysis exploring the GGR's development and its implementation on the ground will improve knowledge on GGR consequences, and potentially shape its reform.

Behaviour change techniques in brief interventions to prevent HIV, STI and unintended pregnancies: A systematic review.

BACKGROUND: Behaviour-change interventions have been consistently considered an essential part of comprehensive HIV, STI and unintended pregnancy prevention. In 2015, the World Health Organization reviewed and assessed existing evidence on brief behavioural interventions, leading to the publication of Brief sexuality-related communication: recommendations for a public health approach. This guideline recommends the use of brief behaviour intervention and communication programmes to promote sexual health and to prevent HIV, STIs, and unintended pregnancies in primary health services, particularly sexual and reproductive health services. OBJECTIVE: With the purpose of informing the development of a brief behaviour intervention in sexual and reproductive health, we conducted a systematic review of brief intervention to prevent HIV, STI and unintended pregnancies, to identify behaviour change techniques (BCTs) used in health care settings. METHODS: Participants from all ages and genders were included. Brief interventions delivered in ≤ 60 minutes were included. Data was extracted, and interventions were coded following the Behaviour Change Techniques Taxonomy (BCTTv1) guidelines. RESULTS: Of the 6.687 articles identified, 355 were reviewed and 37 studies were included. In effective interventions, we identified 48 behaviour change techniques (BCTs). A core set of 8 frequently used behaviour change techniques was identified: "Problem solving", "Feedback on behaviour", "Social support (unspecified)", "Instructions on how to perform the behaviour", "Information about health consequences", "Information about social and environmental consequences", "Demonstration of the behaviour" and "Credible source". CONCLUSIONS: The technical content of brief behaviour interventions was identified in a reliable and standardized way providing preliminary indications on potentially effective techniques to achieve behaviour change.

HIV/AIDS National Strategic Plans of Sub-Saharan African countries: an analysis for gender equality and sex-disaggregated HIV targets.

National Strategic Plans (NSPs) for HIV/AIDS are country planning documents that set priorities for programmes and services, including a set of targets to quantify progress toward national and international goals. The inclusion of sex-disaggregated targets and targets to combat gender inequality is important given the high disease burden among young women and adolescent girls in Sub-Saharan Africa, yet no comprehensive gender-focused analysis of NSP targets has been performed. This analysis quantitatively evaluates national HIV targets, included in NSPs from eighteen Sub-Saharan African countries, for sex-disaggregation. Additionally, NSP targets aimed at reducing gender-based inequality in health outcomes are compiled and inductively coded to report common themes. On average, in the eighteen countries included in this analysis, 31% of NSP targets include sex-disaggregation (range 0-92%). Three countries disaggregated a majority (>50%) of their targets by sex. Sex-disaggregation in data reporting was more common for targets related to the early phases of the HIV care continuum: 83% of countries included any sex-disaggregated targets for HIV prevention, 56% for testing and linkage to care, 22% for improving antiretroviral treatment coverage, and 11% for retention in treatment. The most common target to reduce gender inequality was to prevent gender-based violence (present in 50% of countries). Other commonly incorporated target areas related to improving women's access to family planning, human and legal rights, and decision-making power. The inclusion of sex-disaggregated targets in national planning is vital to ensure that programmes make progress for all population groups. Improving the availability and quality of indicators to measure gender inequality, as well as evaluating programme outcomes by sex, is critical to tracking this progress. This analysis reveals an urgent need to set specific and separate targets for men and women in order to achieve an equitable and effective HIV response and align government planning with international priorities for gender equality.

Gender norms as health harms: reclaiming a life course perspective on sexual and reproductive health and rights.

Despite their demographic significance and the lifetime impact of gender disparities on their health and rights, women considered older than reproductive age are excluded from most investments in global public health. While development policies linking human rights with access to sexual and reproductive healthcare have yielded progress towards improving the status of women and girls, older women have not benefited from these initiatives. Yet as women grow older, they experience a range of health conditions rooted in their reproductive biology - from ageing with fistula, to cervical and breast cancers. Current approaches to global women's health ignore these serious conditions, harming older women through the perpetuation of gender norms that construe women's health through a narrow reproductive lens. Meanwhile, older women are generally absent from global ageing discourse, which lacks a gender perspective, creating a dual invisibility as the field of global women's health presumes ageing women are accounted for. Reclaiming the sexual rights framework suggested by the International Conference on Population and Development and the Beijing Platform for Action, we call for the revision of global health policies to incorporate a life course approach to women's health as a matter of human rights.

Gender-based violence and HIV across the life course: adopting a sexual rights framework to include older women.

It is widely known that older women are at lesser risk for sexual violence than younger women, but current inattention to older women in the gender-based violence (GBV) field has minimized the experiences of older women survivors at great detriment to their health and rights. For example, health providers seldom ask older women about their sexual activity and relationships, a neglect that leads to older women being excluded from necessary HIV testing and care as well as support services for abuse. This oversight is increasingly worrisome given the rise in new HIV infections among adults age 50 and older in recent years, with the majority of transmissions stemming from individuals unaware of their HIV-positive status. Building on sexual rights scholarship, this paper argues for an approach to public health interventions for GBV and HIV that acknowledges older women--their sexuality, sexual agency, and activity-- so that health providers and advocates acknowledge and serve older survivors.

WHO guideline for brief sexuality-related communication: implications for STI/HIV policy and practice.

Brief sexuality-related communication (BSC) aims to identify current and potential sexual concerns and motivate those at risk to change their sexual behaviour or maintain safe sexual behaviour. BSC in primary health care can range from 5 to 60 minutes and takes into account biological, psychological and social dimensions of sexual health and wellbeing. It focuses on opportunistic rather than systematic or continuous communication and can be used in conjunction with already established prevention programs. The informational and motivational techniques of BSC enable health care providers to communicate more effectively with their patients, encouraging them to take steps to avoid HIV and sexually transmitted infections. The WHO Department of Reproductive Health and Research, following a review and assessment of existing evidence with regards to BSC, has recently published the guideline on Brief Sexuality-Related Communication: Recommendations for a Public Health Approach.