U.S. Court of Appeals Strikes Down Trump Administration's Discriminatory 'Deploy or Get Out' Policy

By: Sarah Hooper,  intern, ADAP Advocacy Association, and rising senior at East Carolina University

In January 2020, the U.S. Court of Appeals for the fourth circuit upheld a lower court ruling in Roe and Voe v. Esper, which allows the two HIV positive members of the air force to continue their service. This ruling also will prevent the discharge of any other airmen based on HIV status alone (Buhl, 2020).

Previously, the U.S. Air Force has justified the discharge of military service members living with HIV under the ‘Deploy or Get Out’ policy, which was first introduced in February of 2018. This policy stated that any service member who is deemed non-deployable for over a year would be subsequently discharged. This policy unfairly affected service members living with HIV, as the long-standing HIV policies within the Air Force and United States military consider HIV positive members non-deployable (Allen, 2018).

The plaintiffs in the Roe and Voe v. Esper case first requested a preliminary injunction in February 2018 in the district court for eastern Virginia.

The most recent case of Roe and Voe v. Esper was filed in December 2018 by Lambda Legal and the Modern Military Association of America, with pro bono co-counselors Winston and Strawn. After filing in December, the appeals court opinion concluded that since the government didn’t consider the low possibility of transmission of HIV, the Air Force denied the service members of their right as employees able to serve.

“These servicemembers, like other HIV-positive individuals with undetectable viral loads, have no symptoms of HIV. They take daily medication—usually one pill, for some people two—and need a regular, but routine blood test. They cannot transmit the virus through normal daily activities, and their risk of transmitting the virus through battlefield exposure, if the virus can be transmitted at all, is extremely low. Although transmission through blood transfusion is possible, these servicemembers have been ordered not to donate blood,” said the opinion (Lambda Legal).

According to the Center for HIV Law and Policy:

“Military policies and regulations – most of them codified in the Uniform Code of Military Justice – set forth consequences for conduct by service members living with or at risk of HIV,” (HIV Law and Policy).

According to The Body, Roe and Voe v. Esper case is one of three cases challenging military policies against service members living with HIV. Two others are currently being reviewed.

“Even though my commanding officer and doctors wanted me to stay in, the informal board recommended discharge, then a formal board of three members recommended discharge,” Roe said in reference to his experience with the Air Force.

Scott A. Schoettes is the HIV project director at the advocacy group Lambda Legal, who helped represent Roe and Voe in their plea at the court of appeals.

“The military is really the only employer in the United States that’s still allowed to do this. Everybody else you can hold accountable. You can sue under statutory protections for people living with HIV,” said Schoettes.

Roe and Voe will be able to continue serving in the Air Force under the recent court of appeals ruling.

References:

• Buhl, L. (2020, January 16). Federal Court Upholds Injunction Preventing Discharge of HIV-Positive Airmen. The Body dot com. Retrieved from https://www.thebody.com/article/appeals-court-injunction-discharge-hiv-military?ap=2008
• HIV Law and Policy Military. (n.d.). Retrieved from https://www.hivlawandpolicy.org/issues/military
• Allen, S. (2018, September 19). The Danger of 'Deploy or Get Out' Facing HIV-Positive Troops. The Daily Beast. Retrieved from https://www.thedailybeast.com/the-danger-of-deploy-or-get-out-facing-hiv-positive-troops
• Opinion: Roe and Voe v. Esper. (2020, January 10). Retrieved from https://www.lambdalegal.org/in-court/legal-docs/roe_va_20200110_opinion

Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association, but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about public health-related issues and updates.

Molecular HIV surveillance: public health tool or weapon?

By: Jeffrey R. Lewis

There is a longstanding, inherent value in the assurance of privacy in our healthcare system. Among other things, it is the keystone of the physician-patient relationship (Holman, 2017); it improves treatment adherence (Heath, 2017); and it has been proven to promote better health outcomes (2013). An ambitious new initiative to combat HIV/AIDS in the United States, however, employs technology that places patients’ privacy protections at risk.

President Trump’s “End the Epidemic by 2030” (EtE) initiative focuses on the 46 (out of 3,000) counties in the United States that account for more than half of new HIV infections. The Administration's plan also provides the opportunity to evaluate the ongoing rise in sexually transmitted diseases, which include worrying trends reported by the U.S. Centers for Disease Control and Prevention (CDC). Examples of the rise of STDs include  a 19% increase in Chlamydia, 63% increase in Gonorrhea, and 71% increase in Syphilis (CDC, 2019).

It is through this initiative that HIV stakeholders are getting an important glimpse into a potentially useful, but troubling, new tool being used by our public health infrastructure – namely, molecular HIV surveillance.

Photo Source: CDC

Molecular HIV surveillance involves data collection and sharing between healthcare practitioners and public health departments to track individual treatment resistance, as well as trends in HIV infections. It also leverages cluster detection to identify new infections of “people normally out of reach to public health” (McClelland, 2019). This information is shared with the CDC, which in turn uses the data to determine funding allocations for state and local health departments combating HIV (CDC, 2017). But at what cost to patients already living with HIV?

What’s troubling is that there is no informed consent by patients for data collected using individuals’ blood samples. State and local health departments report de-identified data to the CDC, but there are obvious patient privacy concerns.

Major health data breaches have become a problem in recent years. In 2016, patients enrolled in California’s AIDS Drug Assistance Program (“ADAP”) (Gorman, 2018); in 2017, patients served by CVS Pharmacy under Ohio’s ADAP  (Hassan, 2018), and Aetna patients in Pennsylvania  (Gordan, 2018), all had their privacy violated. It is not outside the realm of possibility that a data breach could also happen on a larger scale, exposing people living with HIV to further stigma.

Photo Source: Insurance Journal

Although the CDC’s data collection is governed by federal guidelines which intend to protect the privacy of individuals, for those living in the shadows of the nation’s long, dark history of HIV-related stigma, these provide little comfort. The fact remains that negative attitudes toward HIV/AIDS persist.

According to the Kaiser Family Foundation, nearly one in five Americans are somewhat or very uncomfortable working with someone who is living with HIV. One in five Americans is also somewhat or very uncomfortable having a close friendship with someone who is living with HIV. And a staggering two out of five Americans report being somewhat or very uncomfortable sharing a living space with someone who is living with HIV (Kirzinger, 2019). These attitudes are from current data -  not from the early 1980s!

Because molecular HIV surveillance identifies where clusters of people living with HIV reside, there are concerns that it will further fuel HIV-related stigma, which is already high and continues to grow. Worse, patient advocacy groups and legal scholars fear the potential exists for more unfair criminal prosecutions under outdated state HIV criminalization laws that allow prosecution of those who fail to disclose their HIV status.

The CDC has defended the use of this strategy, claiming it is “important to identify growing clusters of recent and rapid transmission to intervene to interrupt transmission” (Oster, 2017). According to their data through December 2015, such clusters have surfaced in each region of the United States, with 1,923 clusters identified, ranging in size from 2-22 cases (Oster, 2017).

Some of these clusters have gained national attention, namely ones in Scott County, Indiana, and San Antonio, Texas. The former resulted in more than 200 diagnoses of new HIV infections, whereas the latter helped to identify a cluster of 24 Latino gay and bisexual men (O’Neill Institute, 2019). What is often overlooked in the discussion over both of these clusters is whether and how syringe exchange programs could have effectively prevented many new infections.

To fully understand why public identification of these clusters is problematic, one must view the current situation in the context of its potential legal implications. Draconian HIV-specific criminalization laws still exist in 34 states; another 24 states have used general criminal statutes against people living with HIV for “HIV exposure” or non-disclosure of HIV status (CHLP, 2019). These laws relegate people living with HIV to second-class citizenship for numerous reasons. According to the Center for HIV Law and Policy, state HIV criminalization laws “criminalize non-disclosure of HIV status or exposure of a third party to HIV; make exceptions to confidentiality and privacy rights of people living with HIV; provide for sentence enhancements for people living with HIV convicted of underlying crimes such as prostitution and solicitation; and require sex offender registration for people living with HIV” (CHLP, 2019).

Lambda Legal,  considered the leading advocacy organization for the LGBTQ community, takes it a step further in characterizing the harm done by state HIV criminalization laws, speculating that these laws harm public health by creating disincentives for people to get tested for HIV and  prevent others who are HIV-positive from seeking care and treatment. Lambda argues that “information from healthcare providers is often used to prosecute,” which undermines the keystone of the physician-patient relationship (Lambda Legal, 2013).

Photo Source: SERO

It isn’t hard to imagine a worst-case scenario in which molecular HIV surveillance data makes its way into a courtroom and contributes to the “unjust prosecutions” (Lambda Legal, 2013), or into the court of public opinion to “stigmatize and oppress” people living with HIV (Lambda Legal, 2013). While molecular HIV surveillance alone cannot be used in court to establish HIV transmission (Schneider, 2019), it can be used as evidence, and that alone should cause considerable concern.

People living with HIV see very little difference between molecular HIV surveillance as an effective “tool” fighting the epidemic and HIV criminalization. They see it more as  a weapon aimed at further isolating, stigmatizing, and punishing people living with HIV. We should be listening to them rather than trying to reassure them.

In our quest to eradicate HIV/AIDS in the United States (and across the globe), it is important to keep the ongoing struggle in perspective. As we pursue new approaches toward ending the epidemic – including leveraging new technologies that can pinpoint HIV clusters and link more people to care – we must not become over-zealous and ignore the very real concerns expressed over molecular HIV surveillance by our family, friends, colleagues, neighbors, and even strangers living with HIV.

HIV-positive people should be afforded the very same privacy protections as their HIV-negative counterparts. That is what this community expect, deserves, and should be guaranteed.

Editor's Note: Mr. Lewis has worked on issues impacting the HIV/AIDS community for many years. The views expressed our his own. He can be reached at jeffreyrobertlewis@gmail.com.

References:

• Centers for Disease Control & Prevention (2017). Surveillance Overview. U.S. Department of Health & Human Services. Retrieved online at https://www.cdc.gov/hiv/statistics/surveillance/index.html. 
• Centers for Disease Control & Prevention (2019). Sexually Transmitted Disease Surveillance 2018. U.S. Department of Health & Human Services. Retrieved online at https://www.cdc.gov/std/stats18/default.htm. 
• Center for HIV Law and Policy (March 2019). HIV Criminalization in the United States: A Sourcebook on State and Federal HIV Criminal Law and Practice (Third Edition). Retrieved online at http://www.hivlawandpolicy.org/sourcebook. 
• Eustace-McMillan, Loni (1999, December 17). Protecting Private Medical Information: Liability for Unauthorized Disclosure. University of Houston Law Center. Retrieved online at https://www.law.uh.edu/healthlaw/perspectives/Privacy/991217Protecting.html. 
• Gorman, Anna (2018, April 6). Former California State Contractor Sued Over Breach Of HIV Patient Privacy. California Healthline. Retrieved online at https://californiahealthline.org/news/former-california-state-contractor-sued-over-breach-of-hiv-patient-privacy/. 
• Gordon, Elena (2018, January 17). Aetna Agrees To Pay $17 Million In HIV Privacy Breach. NPR. Retrieved online at https://www.npr.org/sections/health-shots/2018/01/17/572312972/aetna-agrees-to-pay-17-million-in-hiv-privacy-breach. 
• Hassan, Carma (2018, April 1). Lawsuit claims CVS unintentionally revealed HIV status of 6,000 customers. CNN. Retrieved online at https://www.cnn.com/2018/04/01/health/cvs-lawsuit-hiv-status-customers/index.html. 
• Heath, Sara (2017, August 22). 5 Ways to Improve Medication Adherence in Chronic Care Patients; Providers need to uncover the patient barriers to help improve medication adherence in chronically sick patients. Patient Engagement Hit. Retrieved online at https://patientengagementhit.com/news/5-ways-to-improve-medication-adherence-in-chronic-care-patients. 
• Holman, Tayla (2017, June 27). How to Build Patient Trust to Improve the Doctor-Patient Relationship. Dignity Health. Retrieved online at https://www.dignityhealth.org/articles/how-to-build-patient-trust-to-improve-the-doctor-patient-relationship. 
• Kempner, Martha (2019, March 4). New Study Triggers Concerns Over Use of Molecular HIV Surveillance. TheBodyPro. Retrieved online at https://www.thebodypro.com/article/concerns-over-use-of-molecular-hiv-surveillance. 
• Kirzinger, Ashley, Lunna Lopes, Bryan Wu, and Mollyann Brodie (2019, March 26). KFF Health Tracking Poll – March 2019: Public Opinion on the Domestic HIV Epidemic, Affordable Care Act, and Medicare-for-all. Kaiser Family Foundation. Retrieved online at https://www.kff.org/health-reform/poll-finding/kff-health-tracking-poll-march-2019/. 
• Lambda Legal (2013, December 13). 15 Ways HIV Criminalization Laws Harm Us All. Retrieved online at https://www.lambdalegal.org/publications/15-ways-hiv-criminalization-laws-harm-us-all. 
• Macsata, Brandon M. (2019, May 2) The ADAP Blog. When State & Local Public Health "Policies" Fuel HIV Stigma. ADAP Advocacy Association. Retrieved online at https://adapadvocacyassociation.blogspot.com/2019/05/when-state-local-public-health-policies.html. 
• McClelland, Alexander, Adrian Gula, and Marilou Gagnon (2019, February 10). The rise of molecular HIV surveillance: implications on consent and criminalization. Critical Public Health. Retrieved online at https://www.tandfonline.com/doi/citedby/10.1080/09581596.2019.1582755?scroll=top&needAccess=true. 
• Mesika, Robert (2012, July). The Ethics of HIV Criminalization. ETHICAL INQUIRY: JULY 2012. International Center for Ethics, Justice and Public Life. Retrieved online at https://www.brandeis.edu/ethics/ethicalinquiry/2012/July.html. 
• O’Neill Institute for National & Global Health Law (2019, Augsut). Quick Take: Using Cluster Detection to End the HIV Epidemic. Georgetown Law. Retrieved online at https://oneill.law.georgetown.edu/wp-content/uploads/Quick-Take_HIV-Cluster-Detection_August-2019.pdf. 
• Oster, M.D., Alexa, et. al. (2017, March 24). National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. Use of molecular surveillance data to identify clusters of recent and rapid HIV transmission. U.S. Centers for Disease Control & Prevention. Retrieved online at https://www.seaetc.com/wp-content/uploads/2017/01/Use-of-Molecular-Surveillance-Data-to-Identify-Alexandra-Oster.pdf. 
• Schneider, Jacon (2019, September 12). Is HIV Molecular Surveillance Worth The Risk? The Center for HIV Law & Policy. Retrieved online at http://www.hivlawandpolicy.org/fine-print-blog/hiv-molecular-surveillance-worth-risk. 
• Serenko*, Natalia, and Lida Fan (2013). Patients’ perceptions of privacy and their outcomes in healthcare. Int. J. Behavioural and Healthcare Research, Vol. 4, No. 2. Retrieved online at http://aserenko.com/IJBHR_Serenko_Fan.pdf. 

Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association, but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about public health-related issues and updates.

Award Honorees Embody Our Commitment to the Public Health Safety Net

By: Brandon M. Macsata, CEO, ADAP Advocacy Association

The ADAP Advocacy Association announced earlier this week the honorees for its Annual ADAP Leadership Awards, which recognize individual, community, government and corporate leaders who are working to improve access to care and treatment for people living with HIV/AIDS — including under the AIDS Drug Assistance Program (ADAP). The 2017-2018 award honorees reflect the theme of the organization's 11th Annual ADAP Conference, “Mapping a New Course to Protect the Public Health Safety Net,” being held in next month in Washington, DC.

As in years past, it is always difficult selecting the honorees for the various awards because so much amazing work continues to be done fighting the HIV/AIDS epidemic. But some work always stands out and it deserves our recognition! It is our way of saying, thank you.

The following awards will be presented during the Annual ADAP Leadership Awards Dinner, which will be hosted on Friday, September 21st:

• ADAP Lifetime Achievement awarded posthumously to Gary R. Rose. As we noted earlier this year, Gary was One for the Roses.

• “William E. Arnold” ADAP Champion awarded to Evelyn Foust, Director of the North Carolina DHHS Communicable Diseases Branch. Evelyn has been instrumental in the implementation of the ADAP premium assistance in the state. 

• ADAP Emerging Leader awarded to Tori Cooper. Learn more about her groundbreaking work. Tori currently serves as a prevention specialist at Positive Impact Health Centers in Atlanta, GA.

• ADAP Corporate Partner awarded to Lambda Legal for their tireless work on behalf of so many people living with HIV/AIDS, including most recently with Harrison v. Mattis & Doe v. Mattis. 

• ADAP Lawmaker awarded to the Honorable John McCain, Arizona’s senior U.S. Senator, for his courageous thumbs down vote against repealing the Affordable Care Act. Sen. McCain's surprise vote ensured countless people living with HIV/AIDS continued to receive care. Former President Barack Obama even called McCain to thank him!

• ADAP Community Organization awarded to the Community Research Initiative ("CRI"), based in Boston, MA. CRI embodies the community-based focus that has long been associated with appropriate and timely access to care and treatment for people living with HIV/AIDS. Serving over 12,000 clients in the greater metropolitan area of Boston, CRI not only manages Massachusetts’ AIDS Drug Assistance Program, but it has also been on the front lines in fighting Hepatitis C, training service providers on culturally competent care, and advocating for successful prevention strategies, just to name a few. Learn more at https://crine.org. 

• ADAP Media awarded to Larisa Epatko with PBS News Hour for her "5 good news stories about the fight against HIV/AIDS," which was posted on June 13, 2018. 

• ADAP Grassroots Campaign awarded to Let’s Kick A$$ for their "Long-Term Survivors Stories Public Service Announcement," which features Long-Term Survivors sharing their personal stories what it means them to be a long-term survivor. 

• ADAP Social Media Campaign awarded to Jennifer Vaughan for her YouTube channel,"Jennifer’s Positive HIV Life,"with over 10,000 subscribers and with almost 2 million views on her 90+ videos about living with HIV/AIDS.

Information about the awards (including former honorees) is listed online at  www.adapadvocacyassociation.org/awards.html.

Tickets for the awards dinner can be purchased online. This year's awards dinner will be headlined by the one and only, Josh Robbins (who also happens to be a past award honoree).

Congratulations to the honorees of the 2017-2018 ADAP Leadership Awards!

UPDATE: Hey Trump! Hands Off Our Ryan White HIV/AIDS Program!

By: Brandon M. Macsata, CEO, ADAP Advocacy Association

The ADAP Blog last week addressed troubling news that the U.S. Department of Health & Human Services ("HHS") planned to divert funds from existing programs to pay for the rising cost associated with the Trump Administration's controversial "zero-tolerance" immigration policy. This statement was indeed true (as fact checked by Snopes),[1] though fortunately the impact is debatable since none of the diverted funding came from the current year's program. What it did accomplish was to ignite a firestorm among many in the HIV grassroots community.

The good news, especially for the HIV grassroots community, is none of the transferred funding will impact Ryan White-funded supports or services to people living with HIV/AIDS for the current program year. The transfer included expired Ryan White funds from FY 2016, which hadn't been spent and was due to be returned to the U.S. Treasury. Basically the news is still bad, but not nearly as bad as initially thought.

Though news about HHS transferring funds only broke last week by Slate, it has subsequently been determined that the transfer request was made in January 2017. As reported by POLITICO, nearly $200 million in funds were moved to address the refugee crisis, including "at least $17 million in unspent funds on the Ryan White HIV/AIDS program."[1]

Emily Holubowich, executive director of the Coalition for Health Funding, raised an excellent point in the POLITICO article when she argued, "If there’s leftover money from Ryan White, it should go to support programs for poor people with HIV and AIDS, not this outrageous separation policy."[3]

This point is exactly why the flames are still burning among many grassroots activists at the state and local levels. It begs the question, couldn't those Ryan White dollars have been used to expand drug formularies under the AIDS Drug Assistance Programs ("ADAP") to pay for anti-diarrhea medications, or Hepatitis C ("HCV") therapies for people co-infected with HCV, or lipodystrophy treatments? These concerns were spelled out in a blog earlier this year.

Photo Source: NY Magazine

Furthermore, at what point does the HIV community draw a red line with the Trump Administration and its Family-Research Council ("FRC") cronies known for their anti-immigrant, racist, homophobic, and misogynistic views? This Administration has been attacking people living with HIV/AIDS for the last eighteen months by proposing harsh federal budgets; demonstrating a flagrant disregard for the public health system; ignoring key leadership posts; sanctioning discrimination by healthcare workers; undermining the Patient Protection and Affordable Care Act, and most recently deleting 20 years of critical medical guidelines. Make no mistake...Trump and the FRC have brought the fight to people living with HIV/AIDS.

Overall the Ryan White program, in general, and ADAPs, specifically, are extremely well-run programs. This is a message that the community should embrace, and not run away from out of fear. The best defense is a good offense!

__________

[1] Garcia, Arturo (2018, July 13). Are Federal HIV Treatment Funds Being Used for Immigrant Internment? Snopes. Retrieved from: https://www.snopes.com/fact-check/hiv-treatment-funds-immigrants/.
[2] Diamond, Dan (2018, July 18). Trump’s migrant fiasco diverts millions from health programs. POLITICO. Retrieved from: https://www.politico.com/story/2018/07/18/trump-migrants-health-programs-692955.
[3] Diamond, Dan (2018, July 18). Trump’s migrant fiasco diverts millions from health programs. POLITICO. Retrieved from: https://www.politico.com/story/2018/07/18/trump-migrants-health-programs-692955.

Hey Trump! Hands Off Our Ryan White HIV/AIDS Program!

By: Brandon M. Macsata, CEO, ADAP Advocacy Association

Earlier this week, Slate reported that the U.S. Department of Health & Human Services ("HHS") planned to divert funds from existing programs to pay for the rising cost associated with the Trump Administration's controversial "zero-tolerance" immigration policy. The policy, which separates children from their families on the southern border, is overseen by the HHS Office of Refugee Resettlement, and it is burning through so much cash that it needs more. In the crossfire is millions of dollars in funding designated for HIV/AIDS services under the Ryan White CARE Act.[1]

According to the reporting by Slate, HHS is planning for a surge in immigrant minors over the next three months:[2]

"The internal documents estimate that if 25,400 beds are needed, ORR would face a budget shortfall of $585 million for ORR in fiscal year 2018, which ends on Sept. 30. Under this scenario, that shortfall would increase to $1.3 billion in the first quarter of fiscal year 2019, adding up to a total shortfall of $1.9 billion for the period between Oct. 1, 2017, and Dec. 31, 2018. The documents stress that these budget estimates represent maximum possible expenditures and that actual expenses may be lower. The Department of Health and Human Services did not respond to multiple requests for comment about these figures or anything else relating to the documents."

In order to offset the budgetary shortfall, HHS will seek supplemental appropriations from Congress, as well as reallocate existing funds from within the department — including Ryan White funding. Slate's reporting also indicates the process of transferring those HIV/AIDS funds is underway.

The ADAP Advocacy Association has strongly condemned this decision. In an era when people living with HIV/AIDS are already facing enough uncertainty over the current government's commitment to fighting the epidemic, it was the latest setback to achieving an AIDS-free generation.

The pushback from a leading national patient advocacy group was swift when news broke that the Trump Administration would use Ryan White HIV/AIDS program dollars to fund its widely unpopular family separation policy at the southern border. AIDS United CEO Jesse Milan, Jr. issued a strongly-worded statement on the funding reallocation:[2]

"As a payer of last resort, the Ryan White Program covers services for people that have no other means to pay for them. Any shortages in funding to the program would result in essential services not provided to potentially thousands of Americans. This could mean people not receiving life-saving medications or losing insurance coverage because funding was not available to cover their premiums. For an administration that just recently proclaimed its commitment to ending the HIV epidemic in this country, stripping funding from the largest HIV-specific federal program defies all logic."

The fact that the money being diverted is "unspent" money makes no difference to people living with HIV/AIDS who rely on Ryan White-related supports and services. There are always creative ways to spend or transfer federal money within an agency's budget,[4] because it happens all of the time. And considering there are ongoing challenges facing ADAP consumers limiting their access to care, such as restrictive drug formularies, that money should be spent on people living with HIV/AIDS. (Editor's Note: Read our previous blog on open drug formularies, "ADAP Open Drug Formulary Programs Improve Access to Care & Treatment; So why are there so few?")

Numerous national LGBTQ groups also condemned the news, including Lambda Legal and Human Rights Campaign. It appears that this development is fluid, and we will continue to closely monitor it.

__________

[1] Stern, Mark Joseph. (2018, July 10). Trump’s Office of Refugee Resettlement Is Budgeting for a Surge in Child Separations. Slate. Retrieved from: https://slate.com/news-and-politics/2018/07/trumps-office-of-refugee-resettlement-is-budgeting-for-a-surge-in-child-separations.html
[2] Stern, Mark Joseph. (2018, July 10). Trump’s Office of Refugee Resettlement Is Budgeting for a Surge in Child Separations. Slate. Retrieved from: https://slate.com/news-and-politics/2018/07/trumps-office-of-refugee-resettlement-is-budgeting-for-a-surge-in-child-separations.html
[3] Milan, Jr., Jesse. (2018, July 10). AIDS UNITED STATEMENT ON TRUMP ADMINISTRATION PLANS TO REALLOCATE RYAN WHITE FUNDING FOR CHILD SEPARATION TIED TO ZERO TOLERANCE BORDER POLICY. AIDS United. Retrieved from: https://www.aidsunited.org/News/Default.aspx?id=1197
[4] EveryCRSReport.com (2013, June 6). Transfer and Reprogramming of Appropriations: An Overview of Authorities, Limitations, and Procedures. R43098. Retrieved from https://www.everycrsreport.com/reports/R43098.html.