President Trump’s State of the Union speech kicked off the year with some dramatic gestures toward “global leadership,” promising to put the United States at the forefront of a crusade to end the AIDS crisis worldwide. But between the lines, Trump’s global humanitarian agenda is actually undermining health care in the communities most deeply afflicted by HIV/AIDS.

Trump’s boasts about tackling the AIDS crisis fly in the face of one of his key foreign-aid policies: the so-called Global Gag Rule. As one of Trump’s first executive orders, issued just after the 2017 Women’s March in Washington, the rule expanded a Reagan-era policy barring US funding for family-planning services that could be deemed to be supporting, referencing, or even explaining abortion in any way. Under previous Republican administration, organizations receiving State Department aid had to agree to anti-abortion speech restrictions, regardless of the host country’s abortion laws, in an effort to extend the anti-abortion agenda of US conservatives overseas. Groups would either have to censor the medical advice they gave to clients or face devastating funding cuts if they could not—or were unwilling to—comply with Washington’s directives.

In recent weeks, Trump has doubled down with a domestic version of the gag rule—a newly issued rule that restricts all care and counseling related to abortion through health programs for low-income communities, known as Title X. The cumulative impact of the global and domestic gag rules has been a worldwide frontal assault on medical ethics, gender equality, and HIV/AIDS care in vulnerable populations, at home and abroad.

Studies on the long-term impact of the gag rule, under both the Trump and Bush administrations, link the policy to devastating impacts on local health-care infrastructures, including the closure of clinics and cutbacks to distribution of contraceptives. Though the gag rule is primarily aimed at abortion, the restrictions it places on health-care provision have also been linked to an ongoing erosion of HIV/AIDS-related public-health aid in the Global South.

Trump’s version of the gag rule is even more sweeping than previous iterations, since it impacts not just USAID family-planning programs, but all US government aid programs that support service organizations abroad. According to the Center for Health and Gender Equity (CHANGE), Trump’s expanded gag rule jeopardizes funds for a range of aid efforts: “HIV and AIDS…maternal and child health; malaria; tuberculosis; nutrition; non-communicable diseases; water, sanitation and hygiene,” and other community needs—cumulatively affecting “nearly $9 billion in U.S. funds annually.” About $6 billion of the impacted funding streams are dedicated to HIV/AIDS assistance, which is primarily provided through the President’s Emergency Plan for AIDS Relief (PEPFAR). The overlap of reproductive-health care and HIV/AIDS care is crucial: According to an analysis of the impact of the gag rule on PEPFAR by the research group amFAR, “contraception coverage is a known contributor to HIV prevention, averting an estimated 173,000 infant infections each year in sub-Saharan Africa alone,” and recent research on the gag rule shows that “countries where [it] was most likely to disrupt HIV and [family-planning] service integration were also those with the highest HIV prevalence.”

The gag rule is creating massive resource gaps across the public health-care infrastructure in many poor regions of the world. For example, Uganda’s wide-ranging public-health initiative, Reproductive Health Uganda, suffered a 30 percent budget cut (about $300,000), which triggered the closure of several major outreach projects. The loss particularly affects HIV/AIDS programs, which constituted about 70 percent of US aid for Ugandan NGOs in 2015, or about $46 million.

The International Planned Parenthood Foundation (IPPF), has forgone an estimated $100 million under the Global Gag Rule, in order to preserve its range of services. The decision to avoid the gag rule has damaged funding for partner programs in 31 countries. Health care for HIV/AIDS and other sexually transmitted diseases, which constitutes about 20 percent of overall services, is especially vulnerable. IPPF reports that Family Health Organization Kenya “lost about $1.5 million for integrated health projects for the most marginalized communities to prevent and treat HIV,” leading to funding cuts and two clinic closures. Family Planning Association of Malawi may have to shutter its one-stop center for sexual-health services in a city with 60 percent HIV/AIDS prevalence. Executive Director Thokozani Mbendera stated that under the gag rule, “Teenage pregnancies, unwanted pregnancies and other health issues will manifest.… The one-stop centre will cease to function.”

In amFAR surveys of PEPFAR-funded organizations, about a third of respondents across 31 countries had altered their services because of the gag rule. The result was “a reduction in the provision of critical non-abortion-related information, including for contraception and HIV.” The greatest impact on services, according to the analysis, was “documented in countries with major HIV epidemics, such as South Africa, Eswatini, and Mozambique.” Access to funding has been blocked for programs such as adolescent health counseling, local condom distribution, and HIV testing, with some programs being driven to shutter completely.

In Kenya, Evelyn Samba, Kenya Country director for the German humanitarian group DSW, described how the gag rule has exacerbated existing gender barriers and undermined women’s reproductive and sexual rights.

Many women have lost control over their sexuality because they no longer have access to life-saving information on sexual reproductive health…. adolescent girls in the worst affected parts of Kenya have lost their ability to make informed choices and negotiate for safe because they no longer have to condoms and to contraceptives.

For HIV/AIDS programs, previous iterations of the policy under the second Bush administration specifically exempted PEPFAR programs, while Trump’s makes no such distinction. So the dangers of the expanded gag rule are manifold, according to CHANGE President Serra Sippel: First, the gag rule exacerbates “attitudes toward abortion that perpetuate stigma and consequently create barriers [for community members] to advocate for safe abortion access within their countries’ policies.” But beyond abortion, “it is particularly egregious that the Trump administration took steps to expand the restriction to PEPFAR, knowing that it will have a grave impact on HIV and AIDS in countries hardest hit by the epidemic. ”

Though Trump boasted about aiding impoverished women and combating HIV/AIDS around the world, in communities most impacted by his anti-abortion agenda, Washington’s “humanitarian” salvation is a poison pill. For HIV/AIDS-afflicted communities in the Global South, people without basic access to contraception, and remote villages that depend on threadbare humanitarian aid clinics for supplies of life-saving drugs, the gag rule that purports to “protect life” could end up being a death sentence.