Jen’s Half Cents: Attacks on Abortion and Trans Care are Attacks on Medication Access

Coming into HIV advocacy, I was quickly introduced to this idea that access to life saving and life improving medications is a human right, best public health practice, and a public policy goal, something all stakeholders, public and private, held “on high” and were working toward. Everywhere I turned, “we must ensure access to life saving and quality of life improving medications”. I mean everywhere. This mantra was hammered home to me because antiretrovirals are medications that both save lives and improve the quality of life for people living with HIV and, thanks to the advent of pre-exposure prophylaxis (PrEP), people at risk for acquiring HIV. It is often the firm position of HIV advocates that restricting access to these medications is threat to life and quality of life and any such restrictions are an assault upon our lives. We fight day in and day out for programs and policies that safeguard access to care (medication and services). Every advancement is a fight and we have to muster up the same, very old arguments about the value of a patient’s life always being greater than the dollar sign attached to a medication.

That core piece is access to medication.

As the previous presidential administration issued rules that restricted international funding for those entities providing abortion services or referrals, I got antsy. Increasingly nervous and frustrated. In 2019, quite predictably, advocates confirmed those rules found impact primarily by reducing international aid to HIV services. Those rules also included one that required international partners to pledge to “denounce” sex work, a rule the Supreme Court upheld. Similarly, a whole slate of domestic policy moves sought to limit access to non-discrimination protections provided to people who sought or had an abortion and those who provided or referred a patient to abortion services. Those same rules sought to exempt transgender people and our care from non-discrimination protections. Of an important note: most abortions in the United States are medication abortions, not surgical.

If you’re new to these issues, let me help some. One of the first and most prominent methods of gender affirming medical care is by accessing medications falling under an umbrella of “hormone replacement therapy”, almost all of those medications are approved by the Food and Drug Administration and none of them have a specific indication to include gender affirmation (even cisgender folks – here’s looking at every old, cis guy who uses testosterone to feel young again). However, because medical experts generally agree these medications meet the needs of patients experiencing a wide variety of conditions, these medications are typically able to be written “off-label” or outside of their FDA approved indication. After years of advocacy and some last-minute push from the Obama administration regarding the Affordable Care Act’s Section 1557 (the non-discrimination provision of the law) , most private payers began covering some very basic transition-related hormone therapies (they were covering cisgender men seeking testosterone and other medications related to sexual performance for decades prior). The same rule prohibited covered entities from discriminating against people who had abortions, wanted abortions, or performed abortions. But Reed O’Connor, a long-time villain in the fight to defend the ACA, said “no” on the last day of 2016 and the guys who left the White House in 2021 agreed with him.

So here we are with this groundwork, this public health understanding that when people need care, they need as comprehensive care as they can get – as close to “one-stop-shop” as possible. And that’s true especially for people and communities experiencing the greatest disparities in health outcomes. Well-known among HIV advocates are the disproportionate number of women of color and transgender people living with and being diagnosed with HIV. The one thing all of these people, these patients need is medication access.

I need to not mince words, access to abortion is absolutely an issue of life improving care for someone who isn’t ready or doesn’t want a child. Adoption is not an option for a person who does not wish to complete a pregnancy and forcing them to do so by criminalization or by way of policy is state-sponsored seizure of that person’s body. Forcing a trans person (youth or adult) by criminalization or by way of policy is state-sanctioned violence. Denying people access to the medications that help them maintain their lives and the lives they wish to live is, at its core, an egregious attack on medication access.

Indeed, the next process-driven attack on the ACA is being pursued by plaintiffs that claim “moral injury”, if they should have to cover PrEP or contraception – issues of medication access. Kelly v. Beccera is, once again, in front of our previously mentioned judge, Reed O’Connor. We already know how this is gonna go. Meanwhile, we’re waiting on SCOTUS to decide the fate of Roe v. Wade (and possibly Casey), states are in the middle of a fight to beat everyone else to the punch. From proposing legislation that would criminalize access to abortion pills, to passing laws that criminalize providing gender affirming care to people under the age of 18, to passing laws that protect a person’s right to abortion and several states proposing bills that would protect families seeking safe-haven in order to provide children with gender affirming care, the landscape of US health care is becoming very fractured and much like some horror story of a wild west shoot out. Take a moment to ask if a state passes a law designed similar to Texas’ S.B. 8, wherein a private actor may sue a person for seeking or performing an abortion, that person runs to a state protecting those rights – or a parent ensuring their child is getting gender affirming care – exactly where does that fall? That’s not conjecture – how many families do you personally know who can afford the legal fight over jurisdiction?

Sure, we know where the executive branch of the federal government is gonna fall on this, at least until early 2025. But what then? Hope for the best?

HIV service providers need to get good with identifying quality lawyers and establishing relationships with their local or state queer and abortion advocacy organizations. And HIV advocacy needs to leverage our power to assist and uplift, not usurp, this issue. At the core of our work, we’ve maintained access to life saving and life improving medication is a must. We must not fail that mission now.