A group of medical associations and providers has filed a lawsuit challenging new federal funding requirements for Ryan White clinics involving gender-affirming care.
The new requirements, issued in a recent HRSA Notice of Funding Opportunity, require recipients of the Ryan White HIV/AIDS Program funds to not acknowledge the identities of transgender patients or use funds for gender-affirming care. The restrictions undermine the very intent of the program, the plaintiffs say, and violate anti-discrimination components of the Fifth Amendment.
“The Ryan White Program was created as a public health intervention to address the needs of low-income, vulnerable populations who otherwise would not have access to life-saving care,” Melanie Thompson, M.D., co-chair of a primary care guidance panel for the HIV Medicine Association, said in a press release. “It is crucial that Ryan White clinicians be allowed to continue to deliver the most scientifically appropriate treatments for all patients, including transgender individuals, without discrimination if we are to improve health outcomes for all and end the U.S. HIV epidemic."
The lawsuit alleges (PDF) that HHS and HRSA violated the Administrative Procedure Act by exceeding their statutory authority and imposing restrictions that conflict with the Ryan White statute. The plaintiffs ask the court to block enforcement of the funding restrictions.
The case was filed by Lambda Legal and HSF Kramer on behalf of the American Academy of HIV Medicine, the HIV Medicine Association and the International Association of Providers of AIDS Care, plus two providers.
A preliminary hearing will likely be scheduled in a few weeks. Lambda Legal is “cautiously optimistic” about the future of the case, José Abrigo, senior attorney and HIV project director at Lambda Legal, told reporters on a webinar on Thursday afternoon. He called the administration’s actions “unlawful,” and said gender-affirming care in this context includes all types of care, including primary care and mental healthcare.
Specifically, the HRSA Notice of Funding Opportunity reads: “Discretionary awards shall not be used to fund, promote, encourage, subsidize, or facilitate … denial by the recipient of the sex binary in humans, or the belief that sex is a chosen or mutable characteristic.”
Some providers are already preemptively complying with the restrictions, Abrigo said, particularly in Tennessee and Kentucky. It is unclear how many other providers will also stop gender-affirming care. In certain cases, it’s up to individual states or departments of health to enforce the restrictions. It’s possible that medical records could be audited and reviewed for indications of pronouns, per Thompson. “It does matter what someone’s gender and pronouns are listed as,” Thompson said on the webinar, explaining that medical records are shared between providers and help ensure affirming care.
If a clinic is found to be non-compliant, the repercussions are steep, Thompson added. “The penalty for being found out is severe, and puts an entire program’s funding in jeopardy,” she said on the webinar.
Forty percent of American Academy of HIV Medicine members rely on Ryan White funding, of which 40% voluntarily report providing gender-affirming medical care. For low-income trans individuals with HIV, there aren’t many alternative options, per Abrigo. They may seek care through private insurance or potentially through Medicaid, but typically the population relies on Ryan White clinics for services.
Gender-affirming care restrictions under the Trump administration have been commonplace. Over 40 hospitals have reportedly stopped some gender-affirming care services for minors in response to pressure. Last week, the Cleveland Clinic promised the Department of Justice (DOJ) to commit $2 million to detransitioning services and a “decades-long” agreement not to perform gender-affirming care on minors. Delivering most of these services is currently illegal for minors under Ohio state law. Last month, DOJ struck a similar deal with Texas Children’s.
For months, experts have been sounding the alarm about the U.S. HIV response slipping into dangerous instability. In April, the International Association of Providers of AIDS Care (IAPAC) released a data brief finding that 61% of providers have reported at least one HIV service disruption and 68% have seen operational changes such as staffing reductions, service cutbacks and program closures. This was attributed to a combination of policy decisions, funding cuts and social determinants like loss of insurance coverage.
“It’s a catastrophe in the making," José M. Zúñiga, AIPAC's president and CEO, told reporters on the webinar. "It was already happening. This adds fuel."