The battle to save the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) is already well under way, just one month after President Donald J. Trump’s inauguration and his almost immediate reinstatement of the country's global gag order on foreign funding for comprehensive sexual health services.

The global gag rule, also known as the Mexico City Policy, is a Reagan-era executive order originally announced in 1984 (at the 2nd International Conference on Population in Mexico City) which restricts any foreign nongovernmental organization, or NGO, that receives U.S. funding from using any money to provide abortions, refer their clients to abortion services or advocate for women’s right to choose in their own countries.

Since then, the controversial rule has become a political volleyball between the Republican and Democratic parties. The rule was rescinded by President Bill Clinton in 1993, reinstated by President George W. Bush in 2001 and once again revoked by President Barack Obama via executive order in 2009.

Therefore, when President Trump reinstated the rule on his first day in office in

2017, it didn’t exactly come as a surprise to those working in the global health services arena. So why are AIDS advocates up in arms about it?

A deeper look into the president’s day 1 executive order reveals some highly unsettling potentialities for the future of global AIDS funding.

Below, we break down Trump’s iteration of the global gag order — and detail how the efforts of politicians, celebrities, activists and citizens can ensure that the groundbreaking PEPFAR does not get cut by the new administration.

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“The conditions of the global gag rule are even more stringent now than they were in past iterations of it,” says Diederik Lohman, acting director of the Health and Human Rights Division at Human Rights Watch (HRW), one of several international advocacy organizations that have spoken out over the last few weeks in support of PEPFAR.

Advocates like Lohman are quick to point out that before now, the Mexico City Policy had never been applied to any U.S. money set aside to combat HIV/AIDS. However, on January 25, President Trump signed what appears to be an amped-up version of the Reagan-era order that global health advocates worry could vastly expand its reach to a wide array of health care programs—including PEPFAR, family planning service providers and women’s health clinics around the world.

While it is still largely unclear how the program will be affected under the new administration, many organizations, including The Elizabeth Glaser Pediatric AIDS Foundation (EGPAF), The Bill and Melinda Gates Foundation, The Elizabeth Taylor AIDS Foundation (ETAF), Housing Works, Until There’s A Cure and the Elton John AIDS Foundation (EJAF), among others, have already spoken out on social media to demand its continued funding.

Here’s why: According to Lohman, past versions of the Mexico City Policy applied only to NGOs seeking to receive special U.S. family planning funding—about $600 million worth of foreign aid. But President Trump specifically changed the wording in his 2017 executive order to extend the abortion gag to all global health funding. That means $9.5 billion worth of foreign aid could now be subject to strict rules that allow the U.S. government to pull its support from any NGO that has provided so much as a referral to any woman seeking to terminate her pregnancy.

“We’re obviously really concerned about what it will mean for groups that are involved in HIV prevention work,” says Lohman, particularly since many of these organizations also provide comprehensive sexual health services and education to their clients. “It could also affect many programs that are not just involved in the provision of abortion services but much more generally in family planning and supporting women with sexual and reproductive health issues.”

The global advocacy community’s support of PEPFAR — which provides $15 billion in funding for HIV testing, treatment, prevention and health care to resource-limited countries every five years — hinges on the fact that the program has proved to be one of the most effective means of curtailing HIV/AIDS in the history of the epidemic. 

According to PEPFAR’s 2017 annual report to Congress, the global endowment initiative currently provides antiretroviral (ARV) treatment to an estimated 11.5 million people with HIV worldwide. Thanks to PEPFAR, nearly 2 million babies with HIV-positive mothers in developing nations have been born virus-free since the early 2000s, and nearly 220,000 health care workers have been trained to help combat the global AIDS crisis. The program has also been credited with a 51 to 76 percent decline in new HIV infections in countries like Malawi, Zambia and Zimbabwe.

“A significant reduction in funding for PEPFAR would have disastrous consequences for access to antiretroviral treatment,” says Lohman. “I think it’s important for organizations like Human Rights Watch to be looking at what happens as a result of this policy change and articulate what the consequences are in order to hammer home the message that this was a really ill-advised policy step.”

Trump’s order to broaden the Mexico City Policy to such an extent has also raised eyebrows within the Republican administration itself. The global HIV/AIDS program has traditionally enjoyed very strong bipartisan support in the U.S. government. In fact, the program was originally instated by President George W. Bush and approved by a Republican-led Congress in 2003. At the time, President Bush specifically exempted PEPFAR from Reagan’s global gag order, as it was widely understood—even in conservative Christian circles—that it would have been impossible to treat HIV/AIDS in the developing world if the abortion order were applied.

At the time, Vice President Mike Pence, then serving in the House of Representatives, vocally supported PEPFAR; he supported it again in 2008 when the program was reauthorized by legislators of both parties.

More recently, U.S. Senate Majority Leader Bill Frist (R-Tenn.,), a trained physician, published an op-ed in The New York Times, titled “The Case for Keeping America’s AIDS Relief Plan,” that specifically called on the new administration not to cut PEPFAR funding under the global gag order. In addition to laying out the program’s endless health benefits, Frist pointed out that distributing emergency aid to countries in crisis has conferred national security benefits in the form of increased stability (from 2004 to 2013, political instability and violence fell by 40 percent in countries that received PEPFAR assistance versus just 3 percent in similar countries that did not). Frist went on to call the program “the greatest humanitarian effort undertaken by the United States in more than 60 years.” 

“Being out in front of this and making sure that there is a critical mass of both Republicans and Democrats saying this is a piece of international work that we do not want to see touched is really important,” says Lohman, speaking on behalf of Human Rights Watch. “We’re obviously going to be monitoring how the discussions develop.” 

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So what has President Trump said so far about PEPFAR and its relation to the global gag rule? Not much, according to other HIV advocates who since November’s election have also been watching closely for signs regarding the new administration’s plans for global AIDS funding.

“The last several months have been a very challenging and unsettling period,” says Mitchell Warren, executive director at AVAC, a New York City–based international nonprofit that works to accelerate the development of HIV prevention options to populations around the world. “Everybody within our agencies, within implementing partners, within the advocacy community, still don’t know what the details [of Trump’s global gag order] mean. No one knows how intentional the expansion was, and no one knows what enforcement will look like.”

On the campaign trail, Trump appeared to support the global AIDS program. Last summer, when asked at a rally in New Hampshire whether he would double the number of people receiving treatment under PEPFAR, the future president was quoted as saying: “Those are good things—fighting Alzheimer’s and AIDS. We are so close on some of them. On some of them, honestly, with all the work done, which has not been enough, we’re not very close. The answer is yes. I believe strongly in that, and we are going to lead the way.” 

That said, it is unclear whether Trump truly understood the question, as PEPFAR does not provide any international support for Alzheimer’s disease research or treatment. 

On another potentially positive note for the program, just before his inauguration, President Trump also announced that Ambassador Deborah Birx, the U.S. global AIDS coordinator and head of PEPFAR, was going to be one of the few political Obama appointees to remain at the helm of her governmental organization during the White House transition.

“That was certainly a ray of hope for us working in this field, because Ambassador Birx has done a remarkable job at reorienting the program and following the data,” says Warren. “The best sign we could get in the short term would be formally nominating her and appointing her to a full tenure as ambassador.”

Other auspicious signs from the new administration include praise for PEPFAR via Trump’s newly appointed secretary of state, Rex Tillerson. At the former Exxon Mobil CEO’s confirmation hearing, he reportedly called the program “a model for us to look to as we’re thinking about other ways in which to project America’s values.”

Tillerson’s statement also hints at a business agenda. As several recent global health studies have shown, PEPFAR not only saves lives but it’s also a really great strategy for promoting U.S. business interests in Africa.

However, HIV advocates like Warren have also witnessed a darker side to Trump’s approach to PEPFAR over the last few months, casting major doubt on the administration’s true intentions for the program.

As detailed in a New York Times report also published in January, transition staff sent out a series of leading questions to the U.S. State Department that seemed highly skeptical of the global AIDS program, asking, for example, “Is PEPFAR worth the massive investment when there are so many security concerns in Africa?” and “Is PEPFAR becoming a massive, international entitlement program?” 

“I’m not sure any of us do well trying to predict anything in the current environment,” says Warren when asked about predictions on where global AIDS funding is headed under President Trump. “But I can predict this: If we do not see the new U.S. administration provide sustained commitment and leadership to PEPFAR, we will not end the epidemic.” 

Regardless of what the Trump administration decides to do with the program, it’s clear that the United States faces a long road in its fight against global HIV/AIDS. According to the latest stats from the United Nations, an estimated 37 million people are living with HIV worldwide, and only 18.2 percent are currently receiving ARV treatment.

Meanwhile, global health advocates continue to argue online, to their local politicians and to their allies in Congress and the new administration: If President Trump does indeed want America to “lead the way” in ending the global HIV epidemic, keeping PEPFAR could quite possibly be the businessman’s best investment.