極右翼的「道德戰爭」現在著眼於 PrEP 的取得
資料來源：克里斯托弗·威金斯 / 2022 年 8 月 23 日 /plus / 財團法人台灣紅絲帶基金會編譯
首先是對跨性別權利和婚姻平權的攻擊，然後是對羅訴韋德案（Roe v. Wade，註1）的推翻，現在他們為 PrEP 而來。下一個會是愛滋病藥物嗎？
右翼運動現在真的很開心，從剝奪聯邦墮胎權到在某些州禁止性別確認照護。現在，在 6 月羅訴韋德案被推翻的陰影下，德克薩斯州一項備受爭議的墮胎法的制定者——一個已經瞄準婚姻平權的人——正將目光投向愛滋病毒預防性照護上。如果他如願以償，德克薩斯人和其他美國人可能會失去獲得 PrEP 的機會，從而使成千上萬的易受影響者喪失被診斷的機會，並為拒絕 HIV 照護打開了大門。
在 2010 年至 2015 年擔任德克薩斯州檢察長後，喬納森·米切爾 (Jonathan Mitchell) 於 2018 年創立了德克薩斯州律師事務所，目標是挑戰幾十年前的最高法院裁決。米切爾幫助起草了德克薩斯州參議院第 8 號法案，這是一項限制性的 2021 年墮胎法，讓普通人成為賞金獵人，他們可以起訴任何他們認為可能參與該過程的人。
Mitchell 現在代表幾位客戶，他們反對《平價醫療法案》要求保險公司承保 PrEP 藥物，其中亦包括 2020 年在德克薩斯州北部地區聯邦法院提起的 Braidwood Management 訴 Becerra 案。
米切爾將他的法律憤怒瞄準了 Descovy 和 Truvada兩項藥物，這兩種藥物如果作為 PrEP 或暴露前預防措施，在預防 HIV 傳播方面非常有效。而這些藥物受到攻擊正因為如訴訟中所述，它們「促成了同性戀行為」。 Mitchell 認為，出於宗教原因，不應強制將 PrEP 藥物的費用納入保險的一部分。
喬納森·米切爾（Jonathan Mitchell）與托尼·珀金斯（Tony Perkins）在保守的網絡系列《華盛頓觀察》（Washington Watch）中反對政府資助的 PrEP 計畫
自職業生涯開始以來，米切爾一直在直言不諱地要求廢除他認為背離憲法語言或承認缺乏明確基礎的憲法權利的決定。考慮到最高法院繼續朝他的方向轉變，他的案件很可能成為該國法律的風向指標。
多年來，主要保守派大法官安東寧·斯卡利亞 (Antonin Scalia) 的前書記員米切爾 (Mitchell) 一直主張最高法院推翻羅伊訴韋德案，同時在德克薩斯州設計參議院第 8 號法案。他的若干法律理論和法庭案件為推翻裁決奠定了基礎。作為四年前在奧斯汀建立個人律師事務所的一部分，他曾就性別確認行動、婚姻平權和避孕規定等問題提起訴訟。
「PrEP 強制要求宗教雇主為促進和鼓勵同性戀行為、賣淫、性濫交和靜脈注射藥癮者的藥物提供保險」，訴訟稱。此外，法律要求購買健康保險的宗教雇主和宗教個人補貼這些行為以獲得健康保險，米切爾認為。
哈佛法學院網絡法律診所的律師兼臨床講師亞歷杭德拉·卡拉巴洛 (Alejandra Caraballo) 表示，米切爾的行為是一種常見策略的一部分，該策略旨在剝奪 LGBTQ+ 者的權力以滿足財大氣粗的特殊利益集團。
儘管病毒不關心宿主的性取向，但米切爾堅持認為他的客戶或他們的家人沒有感染愛滋病毒的風險。該訴訟稱，關於原告，「他們和他們的任何家庭成員都沒有從事傳播愛滋病毒的行為」。他沒有具體說明他的所有客戶是否都避免性活動。
在 7 月的一次聽證會上，米切爾代表他的客戶聲稱，去年提出的一項要求健康保險公司免費提供一些預防性醫療保健的授權使他們成為「違背他們真誠宗教信仰的行為」的同謀。
卡拉巴洛警告說，米切爾提起訴訟的巡迴法院和由喬治·W·布希總統任命的案件主審法官里德·奧康納 (Reed O’Connor) 並不是 LGBTQ+ 社區的朋友。
「當涉及到此類訴訟時，您必須了解提起訴訟的背景」，Caraballo 說。「[保守派律師]知道如何利用這個系統來獲得特定的法官，比如……里德·奧康納」。
一個保守團體聯盟起訴平等就業機會委員會，要求允許他們基於宗教理由進行歧視，奧康納在 2021 年裁定他們可以繼續進行。儘管最高法院在一年前擴大了對 LGBTQ+ 人群的就業保護。奧康納取消了奧巴馬時代對 LGBTQ+ 人群的健康保險保護，並裁定《平價醫療法案》違憲（最高法院後來推翻了奧康納的裁決）。
律師和哈佛講師 Alejandra Caraballo 警告限制獲得 PrEP 和其他性健康服務的危險
「你可以在某個辦公室提交文件，你可以得到一名法官的保證——而且這些法官已堆疊如山——他們不僅是保守的，這些法官更是反動的」，卡拉巴洛說。「所以[律師]可以在他們的投訴中明確表示恐同，然後說，『嘿，這是我們的宗教信仰』」。
Caraballo 指出，由於 PrEP 不僅適用於 LGBTQ+ 人群，而且適用於任何有感染 HIV 風險的人，因此這些論點「顯然是失敗的」。
「如果這是一個運作良好的司法機構，這些索賠只會被拋到法庭外，但事實並非如此。 [它]只是被政治化到了這樣的程度」。她補充說，問題不僅在於地方法院，那裡總是有一個「不合常理」的法官，而且在美國第五巡迴上訴法院也存在問題。
「所以你會看到這些來自德克薩斯州，有時是密西西比州或路易斯安那州的非常非常瘋狂的訴訟」，她說，「因為他們在第五巡迴法院並且能夠獲得這些結果」。
卡拉巴洛還表示，美國人不能接受保守運動的這種氣勢。
「設定 [保險公司] 不必承保 PrEP 的先例是邊緣性的種族滅絕，因為它意味著是在阻止人們保護自己免受 HIV 感染」，Caraballo 警告說。 「如果他們也沒有涵蓋 PEP 或愛滋病毒的實際治療，那麼這就是讓雇主有能力說，『嘿，你感染了愛滋病毒，我不同意，你應該死』」。
5 月，人們聚集在紐約市抗議推翻 Roe v. Wade 案（斯蒂芬妮·基思/蓋蒂圖片社拍攝）。
在沒有明確評論米切爾的訴訟的情況下，第一個獲參議院確認為美國衛生與公眾服務部衛生助理部長的變性人雷切爾萊文表示，對於任何需要和想要它的人來說，獲取 PrEP 至關重要。這位兒科醫生解釋說，愛滋病毒一直是她職業生涯的重要組成部分。
「我在 HIV 流行開始時就已在那裡，我亦致力於當 HIV 流行結束時亦會在那裡」，萊文說。
她將那些早期的日子描述為淒涼。起初，藥物 AZT 未能兌現其承諾，萊文說。她將許多與 HIV 相關的醫學奇蹟（如抗反轉錄病毒治療）歸功於全世界科學家的工作，包括佛奇 (Anthony Fauci) 博士和 CDC 主任瓦倫斯基 (Rochelle Walensky) 博士以及「許多、許多、許多其他人」。她說，PrEP 是這些進步中最偉大的一項。
「我們有可以每天服用一次的藥物，達到[無法檢測]等於[無法傳播] 」，她說。「我們有可以每天服用一次的藥物，現在有每月注射一次藥物，希望最終更會減少……如果你處於危險之中，你就不會感染愛滋病毒」。
當然，在最需要這些藥物的社區中，獲得這些藥物仍然具有挑戰性。此外，今年夏天在蒙特婁舉行的 2022 年國際愛滋病大會上的科學家和活動家警告說，污名正在導致針對愛滋病毒檢測和治療以及提供 PrEP 處方上的倒退。
出於這個原因，萊文說，健康公平的考慮指導著美國衛生與公眾服務部Xavier Bacerra部長和她的工作：「我們必須為最需要的人提供醫療預防和治療。預防等於治療；治療等於預防」。
Anthony Michael Kreis 教授在喬治亞州立大學法學院任教，是 LGBTQ 相關法律問題的專家。克雷斯說，隱私權以及組織家庭和生活的自由都是女性和 LGBTQ+ 人群權利的核心。
「因此，隨著保守的法律運動在多布斯取得勝利，接下來自然而然的事情就是讓他們更廣泛地針對性隱私」，他說。「這意味著針對建立親密關係的權利與結婚或擁有確認性別的醫療保健的權利亦會一樣多」。
像米切爾這樣努力的針對性少數群體、性工作者、藥癮者以及其他極右翼保守運動者常針對的其他人所發動的是一種偷偷摸摸的戰爭。
「這是一種無需再呼籲將同性關係定為犯罪的方式去攻擊性的親密關係」，他說。「這不僅是重新定罪，而更是重新污名化」。
註1. Roe v. Wade ：羅訴韋德案
美國時間6月24日（週五），最高法院以6比3的比數推翻保障婦女墮胎權的兩項重要法律依據：1973年的羅訴韋德案（Roe v. Wade，以下簡稱羅案）與1992年的計劃生育訴凱西案（Planned Parenthood v. Casey，以下簡稱凱西案），此後關於女性是否允許墮胎的問題，將交由各州自行決定。今年5月2日，美國政治媒體《Politico》獨家公布一份由保守派大法官阿利托（Samuel Alito）所起草的大法官意見書草稿，內容即是關於推翻上述兩案，當時已引起公眾震驚，高院方面對草稿外洩一事予以譴責。而這次推翻先前兩案的「多布斯訴傑克森婦女健康組織案」（Dobbs v. Jackson Women’s Health Organization，以下簡稱多布斯案），則意味著近半世紀以來美國在聯邦層級對於女性墮胎權益的保護將正式終結。
當前美國最高法院九席大法官中，六名為保守派、三名為自由派，首席法官為2005年由小布什（G. W. Bush）任命的羅伯茲（John Roberts），一般認為隸屬保守派；最新進的一位則是2020年10月由特朗普任命的保守派大法官巴雷特（Amy Coney Barrett）。巴雷特是在自由派大法官金斯伯格（Ruth Bader Ginsberg）在2020年9月過世之後被選任，這項決定被外界認為更拉闊了不同派別大法官席次的差距，也因此對羅案等保守派長年攻擊的判決形成危機。
在24日推翻羅訴韋德案與凱西案的「多布斯案」，是針對2018年密西西比州推動「懷孕15周禁止墮胎」法案是否合憲進行的裁決（該法允許緊急醫療情況下有例外，但強暴與亂倫不屬於例外情況）。此次在最高法院的投票比數，亦反映了保守派與自由派席次的分佈。
Far-Right’s ‘Morality War’ Now Has Its Sights Set on PrEP Access
First, there were attacks on trans rights and marriage equality, then the overturning of Roe v. Wade, and now they’re coming for PrEP. Are HIV meds next?
Christopher Wiggins / AUGUST 23 2022 / plus
The right-wing movement is really having a moment right now, from stripping the federal right to abortion to the prohibition of gender-affirming care in some states. Now, in the shadow of Roe v. Wade being overturned in June, the architect of a controversial Texas abortion law — a man who has already targeted marriage equality — is setting his sights on preventative HIV care. If he gets his way, Texans and other Americans could lose access to PrEP, leaving tens of thousands susceptible to a diagnosis and opening the door to the denial of HIV care.
After serving as Texas state solicitor general from 2010 to 2015, Jonathan Mitchell founded a Texas law firm in 2018 with the goal of challenging decades-old Supreme Court rulings. Mitchell helped draft Texas’s Senate Bill 8, the restrictive 2021 abortion law that made everyday people bounty hunters who could sue anybody they believed may have been involved with the procedure.
Mitchell now represents several clients who oppose the Affordable Care Act’s mandate that insurance companies cover PrEP medications, among other things, in Braidwood Management v. Becerra, filed in federal court in the northern district of Texas in 2020.
Mitchell aims his legal ire at Descovy and Truvada, two medications that are highly effective in preventing HIV transmission if taken as PrEP, or pre-exposure prophylaxis. The drugs are under attack because, as stated in the lawsuit, they “enable homosexual behavior.” Mitchell argues that covering the cost of PrEP drugs as part of insurance should not be mandatory for religious reasons.
Jonathan Mitchell argues his points against government-aided PrEP programs on conservative web series Washington Watch with Tony Perkins
Since the beginning of his career, Mitchell has been vocal about dismantling decisions that he believes depart from the Constitution’s language or recognizing constitutional rights that lack explicit foundations. Considering the Supreme Court’s continued shift in his direction, his cases will likely become a bellwether for the country’s laws.
For years, Mitchell, a former clerk under arch-conservative Justice Antonin Scalia, had advocated for the Supreme Court to reverse Roe v. Wade, all while designing Senate Bill 8 in Texas. Several of his legal theories and court cases laid the foundation for overturning the ruling. As part of establishing his one-person law firm in Austin four years ago, he has litigated issues like affirmative action, marriage equality, and contraception mandates.
“The PrEP mandate forces religious employers to provide coverage for drugs that facilitate and encourage homosexual behavior, prostitution, sexual promiscuity, and intravenous drug use,” the lawsuit says. Furthermore, the law requires religious employers and religious individuals who purchase health insurance to subsidize these behaviors to obtain health insurance, Mitchell argues.
Mitchell’s actions are part of a familiar tactic aimed at stripping LGBTQ+ people of their rights to appease special interest groups with deep pockets, says Alejandra Caraballo, a lawyer and clinical instructor at Harvard Law School’s Cyberlaw Clinic.
Even though viruses do not care about the sexual orientation of their hosts, Mitchell maintains that his clients or their families are not at risk for HIV infection. The lawsuit claims, regarding the plaintiffs, that “neither they nor any of their family members are engaged in behavior that transmits HIV.” He does not specify whether all of his clients refrain from sexual activity.
During a July hearing, Mitchell claimed on behalf of his clients that a mandate introduced last year requiring health insurance companies cover some preventive health care at no extra charge makes them complicit in “conduct that is contrary to their sincere religious beliefs.”
Caraballo warns that the circuit in which Mitchell filed the lawsuit and the case’s presiding judge, Reed O’Connor, — appointed by George W. Bush — are no friends of the LGBTQ+ community.
“When it comes to this kind of lawsuit, you have to know the context of where it’s filed,” Caraballo says. “[Conservative attorneys] know how to game the system to get particular judges like…Reed O’Connor.”
A coalition of conservative groups sued the Equal Employment Opportunity Commission to allow them to discriminate based on religious grounds, and O’Connor ruled in 2021 that they could proceed. This was despite the Supreme Court extending employment protections for LGBTQ+ people a year earlier. O’Connor struck down Obama-era health insurance protections for LGBTQ+ people and ruled the Affordable Care Act was unconstitutional (the Supreme Court later reversed O’Connor’s rulings).
Lawyer and Harvard instructor Alejandra Caraballo warns of the dangers of limiting access to PrEP and other sexual health services
“You can file in a certain office, and you can get guaranteed a judge — and those judges have been stacked — that isn’t just conservative; these judges are reactionary,” Caraballo says. “So [lawyers] can be explicitly homophobic in their complaint and say, ‘Hey, this is our religious belief.’”
Caraballo notes that because PrEP isn’t just for LGBTQ+ people but for anyone at risk of HIV, the arguments “plainly fail.”
“If this was a functioning judiciary, these kinds of claims would just be tossed out of court, but it’s not. [It’s] just been politicized to such an extent.” She adds that the problem isn’t just the district court in which there could always be an “off the wall” judge, but it’s also a problem with the U.S. Court of Appeals for the Fifth Circuit.
“So you see these really, really insane lawsuits coming out of Texas, sometimes Mississippi or Louisiana,” she says, “because they’re in the Fifth Circuit and are able to get these kinds of outcomes.”
Caraballo also says Americans cannot accept the conservative movement’s momentum.
“Setting a precedent that [insurance companies] don’t have to cover PrEP is borderline genocidal because it’s literally preventing people from protecting themselves from getting HIV,” Caraballo warns. “And if they’re also not covering PEP or actual treatment of HIV, then that’s giving the employer the ability to say, ‘Hey, you got HIV, I don’t approve, you should die.’”
People gather in NYC in May to protest the overturning of Roe v. Wade (photo by Stephanie Keith/Getty Images).
Without explicitly commenting on Mitchell’s lawsuit, Admiral Rachel Levine, the first transgender person confirmed by the Senate as U.S. Department of Health and Human Services assistant secretary for health, says PrEP access is crucial for anyone who needs and wants it. HIV has been an essential part of her career, the pediatrician explains.
“I was there at the beginning of the HIV epidemic, and I am committed to being there at the end of the HIV epidemic,” says Levine.
She describes those early days as bleak. In the beginning, the drug AZT failed to live up to its promise, Levine says. She credits the work of scientists worldwide, including Dr. Anthony Fauci and Dr. Rochelle Walensky, director of the CDC, and “many, many, many others,” with the many medical miracles associated with HIV, like antiretroviral treatment. PrEP, she says, is among the greatest of these advances.
“We have medication that you can take once a day where [undetectable] equals [untransmittable],” she says. “We have medicine you can take once a day, and now a shot once a month, hopefully eventually less often…. If you’re at risk, you will not contract HIV.”
Of course, in communities with the greatest need for these medications, access remains challenging. Additionally, scientists and activists at this summer’s International AIDS Conference 2022 in Montréal warned that stigma is leading to backsliding regarding testing for and treating HIV and prescribing PrEP.
For that reason, Levine says health equity considerations guide her work and that of HHS secretary Xavier Bacerra: “We have to get medical prevention and treatment to people that need it most. Prevention equals treatment; treatment equals prevention.”
Professor Anthony Michael Kreis teaches at the Georgia State University College of Law and is an expert in LGBTQ-related legal issues. Kreis says the right to privacy and the freedom to organize one’s family and life are all central to the rights of women and LGBTQ+ people.
“And so, with the victory that the conservative legal movement has gained in Dobbs, the next natural thing is for them to move to target sexual privacy more broadly,” he says. “That implicates the right to have intimate relationships as much as it does the right to marry or have gender-affirming health care.”
Efforts like Mitchell’s are a sneaky way to wage war against sexual minorities, sex workers, drug users, and others routinely targeted by the far-right conservative movement.
“It’s a way to attack sexual intimacy without calling for the criminalization of same-sex relations again,” he says. “It’s an attempt not to re-criminalize but to re-stigmatize.”