The nonprofit, multi-cultural Cotati Accordion Festival is Roaring back this coming September 25th and 26th LIVE in La Plaza Park in downtown Cotati, Ca.Our 30th anniversary celebration will be replete with the polka tent, the jam tent, the zydeco dance party, the Ray’s Deli and Tavern Stage, the two main stages, a kid’s area, food, beer and wine.
Headliners such as Cory Pesaturo and Sergi Teleshev will be performing along with 40 acts ranging from zydeco, klezmer, Indie, conjunto, western, to rock, and much more.
There is a free shuttle service, kids 15 and under are free when accompanied by a parent, and we will have some special surprises in honor of our 30th anniversary.
We will comply with any guidelines from the Sonoma County Department of Health. We will have masks available for anyone who wishes one, and sanitation stations to help keep people safe. Currently, because we are an outdoors event, we are deemed a safe environment.
Tickets are $21.00 at the gate for one day and $29.00 at the gate for two days. However, you can go to www.cotatifest.com and take advantage of the early bird specials with tickets at $19.00 for one day and $27.00 for two days. For more information contact us at scottgoree23@gmail.com or call Scott at 707 479-5481.
Dana Van Gorder joined the agency as its Interim Executive Director in February of 2019. In June of the same year, the Board of Directors appointed him our permanent Executive Director. On December 31 of 2021, after 2 years and 10 months of strong stewardship of the agency, Dana will retire at 65 years of age. Under Dana’s leadership, The Spahr Center has grown its HIV, LGBTQ+ youth and senior and advocacy programs; doubled its annual budget; increased its visibility and community support; strengthened its relationship with public policy makers; and created a visionary Strategic Plan to guide its work for the next five years. We are grateful for the knowledge, skill, dedication and spirit he has brought to this work. Dana deserves his retirement after a career of effective service to the LGBTQ+ and HIV communities beginning in 1981.
He has been a Legislative Aide to two openly gay and lesbian elected officials, helped guide campaigns to defeat three ballot measures seeking to quarantine people with HIV, staffed two International Conferences on AIDS, guided LGBTQ+ services for the San Francisco Department of Public Health, lobbied in Sacramento to ensure a strong state response to HIV, served as the Executive Director of a leading national HIV patient advocacy group, and is the founder of the San Francisco LGBTQ+ Community Center. He has accomplished much for both communities to which he proudly belongs. I asked Dana to comment for this letter about his thoughts on leaving the agency. This is what he had to say:
“What a complete honor and joy it has been to become friends with wonderful clients and community members, serve a strong Board, support a highly capable staff, nurture generous donors, and partner closely with supportive County officials. Together, we have ensured that the LGBTQ+ and HIV communities of Marin enjoy greater health and well-being, a stronger sense of community with one another, more visible public support, and increased empowerment. In December, I will leave my position proud of what we have built, happy to have come anywhere close to sustaining the legacy of the great Jane Spahr, and thrilled that The Spahr Center is positioned for even stronger stewardship.”
The Board and I will communicate regularly to you about the results of our search for a powerful and effective new Executive Director. In the meantime, we welcome your questions and comments, and your continued support of our lifesaving and life-affirming work.
Saturday August 28 & Sunday August 29 @ 4:30 pm. Occidental Center for the Artsproudly presents: ‘Something’s Coming..Something Good’! Join us for an afternoon of musical theatre fun for all ages in our amphitheater! Enjoy popular selections from Wizard of Oz, West Side Story, Hair and The Drowsy Chaperone, performed by talented children and adults from our community. Directed by Starr Hergenrather, Musical Direction by Miles McKenzie. The safety of our audience is always a priority. Limited capacity for this outdoor event – get your tickets early! Advance tickets required. $20 adults/ $10 children,15 and under. Discounts for OCA Members. www.occidentalcenterforthearts.org Please bring cushions or stadium chairs to sit on. Wheelchair/special needs seating will be facilitated. Fine refreshments for sale including wine/ beer. Become an OCA Member and get free tickets! 3850 Doris Murphy Ct. Occidental, CA. 95465. 707-874-9392. OCA is a nonprofit arts center staffed by volunteers.
James Hormel, the first openly gay U.S. ambassador and a philanthropist who funded organizations to fight AIDS and promote human rights, has died. He was 88.
Hormel died Friday at a San Francisco hospital with his husband, Michael, at his side and while listening to his favorite Beethoven concerto, the San Francisco Chronicle reported.
Sen. Dianne Feinstein, D-California, praised Hormel as a civil rights pioneer who lived “an extraordinary life.”
“I will miss his kind heart and generous spirit. It’s those qualities that made him such an inspirational figure and beloved part of our city,” she said.
In 1997, then-President Bill Clinton nominated Hormel to become U.S. ambassador to Luxembourg. Conservative Senate Republicans blocked the nomination. But two years later, Clinton used executive privilege to appoint him during the Congressional recess.
“The process was very long and strenuous, arduous, insulting, full of misleading statements, full of lies, full of deceit, full of antagonism,” Hormel said during a West Hollywood, California, bookshop visit in 2012 to promote his memoir, “Fit to Serve.”
He never received confirmation through a Senate floor vote but “ultimately a great deal was achieved,” he told the audience. “Ultimately, regulations were changed in the State Department. Ultimately, other openly gay individuals were appointed without the rancor that went into my case.”
U.S. Secretary of Transportation Pete Buttigieg, who is openly gay, has said that as a teenager he was inspired by Hormel’s confirmation fight.
“I can remember watching the news,” he said after his nomination by President Joe Biden. “And I learned something about some of the limits that exist in this country when it comes to who is allowed to belong. But just as important, I saw how those limits could be challenged.”
Hormel held the ambassadorship from June 1999 through 2000.
Clinton and his wife, former Secretary of State Hillary Clinton, said they were deeply saddened by Hormel’s death.
“Jim devoted his life to advancing the rights and dignity of all people, and in his trailblazing service in the diplomatic corps, he represented the United States with honor and brought us closer to living out the meaning of a more perfect union,” the Clintons said in a statement.
U.S. House Speaker Nancy Pelosi, who officiated at Hormel’s wedding to his husband, said Hormel “made it his mission to fight for dignity and equality for all” and noted his philanthropic contributions to health, artistic and educational organizations.
“When the AIDS epidemic descended upon San Francisco, he called on our conscience and rallied the city to help our neighbors suffering from the ferocious disease,” Pelosi said in a statement. “His work served as a model for national policy to defeat HIV/AIDS and improve the lives of all affected.”
Hormel was an heir to the Hormel Foods fortune. Born in Austin, Minnesota, Hormel married his college sweetheart, Alice McElroy Parker, and had five children before divorcing in 1965. He moved to San Francisco in 1977.
He was a former dean of students at the University of Chicago law school, where he received a degree.
Hormel co-founded the Human Rights Campaign and helped fund many activities geared to arts, education and human rights, including a gay and lesbian center at the San Francisco Public Library; the National AIDS Memorial Grove; the American Foundation for AIDS Research; and the American Conservatory Theater.
In addition to his husband, Hormel is survived by five children, 14 grandchildren and seven great-grandchildren.
Some LGBTQ OnlyFans creators say the changes could jeopardize one of their primary sources of income during the Covid-19 pandemic.
Many sex workers, such as Stacey Monroe, 27, have been using OnlyFans to create sexually explicit video content and photos during the pandemic because they can’t see clients in person safely.
Monroe said she left her career in health care to focus on advocating for transgender rights after she faced discrimination from multiple past employers because she’s a trans woman. “However, being an activist is really a volunteer job, so there was no pay,” she said. In 2018, sex work “helped me and my sister get through our housing crisis and so many other things. It became our form of survival.”
Stacey Monroe said OnlyFans’ policy change could jeopardize 40 to 50 percent of her income.Pedro Morales
Sex work has helped them maintain stability without facing employment discrimination. Now, Monroe said, 40 percent to 50 percent of her income comes from OnlyFans subscriptions.
“If I’m not able to see customers in person, then I do have to try to make OnlyFans content and things like that, so now I’m kind of in limbo trying to figure out what am I going to do on October 1 and trying to see if there’s a loophole or anything to work around the policy,” she said.
OnlyFans’ new policy will allow creators to continue to post nude photos as long as they are consistent with the platform’s acceptable use policy, but it will prohibit “the posting of any content containing sexually-explicit conduct,” a spokesperson said in a statement.
“In order to ensure the long-term sustainability of the platform, and to continue to host an inclusive community of creators and fans, we must evolve our content guidelines,” the statement says. “These changes are to comply with the requests of our banking partners and payout providers. We will be sharing more details in the coming days and we will actively support and guide our creators through this change in content guidelines.” https://iframe.nbcnews.com/U5CK7jN?app=1
The spokesperson declined to comment on when a nude photo could be considered sexually explicit or who would screen content and decide whether it violates the policy.
OnlyFans has provided a legal avenue for people to participate in sex work. Subscribers pay monthly or yearly fees in exchange for pornographic content or one-on-one live video chats with creators, among other content.
Transgender people are more likely than the general population to participate in sex work for a variety of reasons. As a result, many LGBTQ sex workers said the community is disproportionately — and negatively — affected by OnlyFans’ policy change.
A form of survival for trans people
In 2018, Monroe and her sister, who is also trans, were facing homelessness.
“We were sleeping in our car. We had contemplated suicide,” she said. “We just really didn’t have any options. We were going to homeless shelters, and they were telling us that we were not allowed there because we were trans and they didn’t know how to accommodate us.”
With support from their community, they were able to get back on their feet, and sex work has since helped them survive, Monroe said.
Monroe’s experiences of job discrimination and homelessness are common among trans people — including trans people who participate in sex work.
A 2015 survey found that 10.8 percent of trans respondents had participated in some form of sex work, with rates the highest among Black trans respondents (39.9 percent) and Hispanic or Latino respondents (33.2 percent). Transfeminine respondents were twice as likely to participate in the sex trade, at 13.1 percent, compared to transmasculine respondents, at 7.1 percent.
The survey found that more than two-thirds (69.3 percent) of trans sex workers reported having experienced adverse job outcomes in the traditional workforce, such as being denied jobs or promotions or being fired because of their gender identity or expression. In addition, those who lost jobs because of anti-trans bias were about 2 ½ times as likely to engage in the sex trade (19.9 percent vs. 7.7 percent of respondents who didn’t lose jobs because of anti-trans bias).
The OnlyFans log in page on a laptop in New York, on June 17, 2021.Gabby Jones / Bloomberg via Getty Images file
Monroe said sex work is a form of survival for many trans people, because it allows them to earn enough money to get safe housing.
OnlyFans has provided a safer — and legal — outlet for people to engage in sex work, especially trans people, who often face violence. At least 34 trans and gender-nonconforming people have been killed this year. Most of them were Black trans women, according to the Human Rights Campaign, and some of them were also sex workers, according to memorial posts and local reports.
Monroe said some trans people use OnlyFans to pay their bills and get health care, such as hormones, during the pandemic. As a result, the policy change could affect trans creators in many ways if it’s their primary form of income.
“A lot of us have found safety in not having to see customers in person, one, because of Covid-19, and two, because of the violence against trans people and how it’s been increasingly just getting worse and worse over the years,” she said. “It’s horrible. So we are going to be facing more safety issues, more issues with housing, medical, trying to just survive in general.”
Jeopardizing stability, safe space
Z, 27, said OnlyFans has provided them with a stable and safe source of income during the pandemic. They asked to go by their initial because they hope to get a job outside sex work in the future.
They are immunocompromised and disabled and were unable to leave their home at all before a Covid-19 vaccine was available.
They began using OnlyFans in November to sell lewd photos. They incorporated their mobility devices into shoots and described themself as openly queer. In their first month using the platform, they said, they doubled their average monthly income and were able to hire a personal care attendant to help them with their physical therapy exercises and daily activities, such as washing their hair and prepping meals.
They said the OnlyFans policy change will affect them because they don’t have an audience for the type of content that OnlyFans now says is within its terms of service, though they noted that they won’t be as affected as other creators who do more video content.
“I think that when you are specifically advertising sex worker services and then those services are no longer what you’re able to provide, nobody’s going to be there for that,” they said. “I don’t foresee getting a lot of income from people who would just want to see pictures of my smiling face every day.”
OnlyFans no longer makes up the bulk of Z’s income, but they said it does provide them with a few hundred dollars a month, which can cover their physical therapy, medication or groceries.
OnlyFans is used primarily by sex workers who sell pornographic content, but creator GothyKitten, 33, who asked to go by their username on the platform, used it to share time-lapse photos of their surgery site after they had gender-affirming surgery. They uploaded a year’s worth of images in late December.
“A couple folks have said that it really helped them with considering surgery, and everyone who asked for it said they couldn’t find any other resources as detailed,” they said. OnlyFans’ new acceptable use policy will ban “any exhibition of the anus or genitals of any person which is extreme or offensive,” and it doesn’t define “extreme” or “offensive,” leaving GothyKitten uncertain whether their content will be removed.
For now, they’ve created an account on AdmireMe.vip, a site that posted a message of support to sex workers after OnlyFans announced its policy change.https://iframe.nbcnews.com/468GgCb?app=1
For some LGBTQ OnlyFans creators, like Jack Mackenroth, 52, the platform’s new policy is disappointing but not necessarily negative. Mackenroth created an OnlyFans account to share gay pornographic content shortly after the site started in 2016.
He said that the site isn’t user friendly and that there are better platforms that were created by sex workers, like JustFor.fans, which also shared a message about OnlyFans’ policy.https://iframe.nbcnews.com/h8cOaI7?app=1
Sex workers made OnlyFans “what they are,” Mackenroth said, and now it won’t fight for the creators who helped build the site. “They seem to be fair-weather friends, and I don’t need those,” he said.
He encouraged OnlyFans creators to move their content to other platforms and diversify their sources of income.
Jack Mackenroth attends “The Imitation Game” NYC premiere on Nov. 17, 2014. Jim Spellman / WireImage – Getty Images file
LaLa Zannell, the Trans Justice Campaign manager at the American Civil Liberties Union, said being able to change platforms is a privilege not all sex workers have.
“A person who is navigating just surviving, navigating transphobia, xenophobia and homelessness doesn’t have time to create a whole new following on a new platform,” she said.
A number of websites that sex workers used, such as Backpage and Tumblr, were also shut down or changed their policies in ways that negatively affected sex workers, she said, in part because of policy changes by financial institutions that process their payments.
OnlyFans and similar sites have also faced pressure from conservative representatives and advocacy groups. Rep. Paul Gosar, R-Ariz., applauded the policy change, calling it “a remedy to child exploitation” in a tweet last week.
Gosar wrote a letter to the attorney general about a week before the site announced its policy change requesting an investigation into OnlyFans “for promoting, and profiting from, online prostitution.” The bipartisan letter was signed by more than 100 other members of Congress.
Gosar wrote on Twitter that the Justice Department had found that minors were getting through OnlyFans’ vetting process, which requires creators to have bank accounts, government IDs and face scans to ensure that their faces match the provided ID.
The Justice Department did not immediately respond to NBC News’ request for comment.https://iframe.nbcnews.com/48BjpYS?app=1
Zannell said banning pornographic content from platforms isn’t a solution, because it will just move to new platforms. But users’ constantly changing platforms isn’t, either, she said. She added that she’d like to have a sit-down with banking institutions, as well as anti-pornography and anti-sex-trafficking groups — which she said are among those pressuring banking institutions to clamp down on sites like OnlyFans — to “actually have a real conversation and carve out a real goal where all parties online can be on neutral ground, because sex work is real work.”
Two newlywed women were found fatally shot at their southeastern Utah campsite, officials said, days after telling friends they were worried about a “creepy guy” who had been lurking nearby.
The bodies of Crystal Michelle Turner, 38, and wife Kylen Carrol Schulte, 24, were discovered Wednesday off La Sal Loop Road in Moab, Utah, about 260 miles southeast of Salt Lake City, according to a statement from the Grand County sheriff.
Kylen Schulte and Crystal Turner.Courtesy Bridget Calvert
“At this time the Grand County Sheriff’s Office is conducting an on-going homicide investigation,” the statement said. “We are currently following up with any and all leads that come to our attention during this investigation and will continue to be available to people who come forward with information. The Grand County Sheriff’s Office believes there is no current danger to the public in the Grand County area.”
The statement did not elaborate on why “there is no current danger to the public,” and a sheriff’s department representative could not be immediately reached for comment Monday.
Turner and Schulte lived a bohemian lifestyle, moving to various campsites, Schulte’s aunt, Bridget Calvert, told NBC News on Monday.
Friends and co-workers started worrying about them when Turner missed work and Schulte was a no-show at her job.
Days before going missing, Turner and Schulte met friends at a local bar and told them they were worried about someone camping nearby.
Kylen Schulte.Courtesy Bridget Calvert
“They said they needed to move their campsite because of some creepy guy at their campsite,” Calvert said. “These are outdoors girls, and they’re independent and confident. And for somebody to make them feel uncomfortable, it had to be a very valid discomfort.”
The couple, married just in April, enjoyed a carefree lifestyle moving around in their converted van.
“That’s how they lived. They enjoyed life and didn’t worry about material things,” Calvert said. “There’s no clear motive. The entire community loved them. They’re amazing people.”
Woody’s Tavern said Turner and Schulte were at that bar the weekend before their bodies were discovered and has turned over surveillance video to law enforcement.
“At no time were they approached by anyone except my staff and the entire time they were relaxed and enjoying their time with their friends and each other,” according to a statement from the tavern on Sunday. “These two women were very much in love with each other and their focus and attention were always on each other.”
Chinese tech giant Tencent’s WeChat social media platform has deleted dozens of LGBTQ accounts run by university students, saying some had broken rules on information on the internet, sparking fear of a crackdown on gay content online.
Members of several LGBTQ groups told Reuters that access to their accounts was blocked late on Tuesday and they later discovered that all of their content had been deleted.
“Many of us suffered at the same time,” said the account manager of one group who declined to be identified due to the sensitivity of the issue.
“They censored us without any warning. All of us have been wiped out.”
Attempts by Reuters to access some accounts were met with a notice from WeChat saying the groups “had violated regulations on the management of accounts offering public information service on the Chinese internet.”
Other accounts did not show up in search results.
WeChat did not immediately respond to emailed questions.
Homosexuality was classified as a mental disorder in China until 2001, when it became legal. However, this year, a court upheld a university’s description of homosexuality as a “psychological disorder.”
The LGBTQ community has repeatedly found itself falling foul of censors. The Cyberspace Administration of China recently pledged to clean up the internet to protect minors and crack down on social media groups deemed a “bad influence.”
“Authorities have been tightening the space available for LGBT advocacy and civil society generally. This is another turning of the screw,” said Darius Longarino, a senior fellow at Yale Law School’s Paul Tsai’s China Center, who focuses on LGBTQ rights and gender equality.
The loyalty of LGBTQ university groups to the government and Communist Party was discussed in meeting in May between student groups and university representatives of the Communist Youth League — a department in charge of student affairs run by the Chinese Communist Party, according to three sources with knowledge of the matter.
The sources declined to be identified or say at which universities the meetings took place but said LGBTQ student groups were asked if they were anti-Party or anti-China, and whether any of their funds had originated from abroad.
“We explained that our LGBT education work was within campus only,” one university student told Reuters. “After our meeting in May we were dismantled.”
LGBTQ student groups traditionally do not get the support of university authorities in their work to raise awareness of the community, even though they are not banned outright.
Last September, Marie Pinkney beat incumbent Delaware state Sen. David McBride in the Democratic primary by a solid margin, before going on to a decisive victory in the general election. Upon winning, Pinkney became not only the first openly queer woman to be elected to the Delaware Senate but one of dozens of LGBTQ female candidates who won their elections in the last cycle.
Pinkney, a social worker, said she was inspired to run because of her work with victims of gun violence and a lack of political will to pass effective gun control legislation.
“I didn’t know if I could actually win,” Pinkney said, “but then I looked at who my state senator was, and I realized he was a serious impediment to gun violence legislation passing or even getting to the floor. That was enough for me.”
Delaware State Sen. Marie Pinkney.via Marie Pinkney
As a complete newcomer to politics challenging one of the longest-serving lawmakers in Delaware history, Pinkney’s victory came as a surprise to observers. However, a new report from the LGBTQ Victory Institute, an organization that supports LGBTQ elected officials and political hopefuls, found that the odds aren’t good for those betting against queer female candidates.
A review of the win and loss records of all 1,088 candidates endorsed by the LGBTQ Victory Fund (the political action committee associated with the Victory Institute) from 2016 to 2020 found that queer cisgender women — including lesbian, bisexual and other nonheterosexual women — won 69 percent of the time, compared to 59 percent for queer cisgender men endorsed by the political action committee.
Victory Fund does not track candidates it does not endorse, but its analysis of the 2020 LGBTQ candidates (both endorsed and unendorsed) suggests its candidates are representative of the overall LGBTQ candidate population in terms of race, sexual orientation and gender identification.
Though they are more successful at the ballot box, queer cisgender female candidates were outnumbered by their male counterparts every year covered by the Victory Institute’s report. Queer cisgender women accounted for just 35 percent of Victory Fund-endorsed candidates since 2016, whereas cisgender male candidates accounted for 59 percent.
This means that even if lesbian, bisexual and other nonheterosexual cisgender women started to run at the same rate as their male counterparts, they would not reach electoral parity with queer cisgender men until 2037, the report stated.
“LGBTQ women face unique barriers to running for office — the same sexist campaign tactics and misperceptions of their own qualifications as other women, combined with anti-LGBTQ bias — yet overcoming those obstacles makes them strong contenders by the time they run,” Annise Parker, president and CEO of the Victory Institute and former mayor of Houston, told NBC News. “LGBTQ women candidates tend to wait to run for positions they are qualified — and often overqualified — to hold and perhaps don’t trigger the same negative stereotypes directed at LGBTQ men.”
“Their experiences as women and as LGBTQ people often make them better politicians, portraying an authenticity and sensibility that resonates with voters,” Parker continued. “LGBTQ women make fantastic candidates, and when we run, we win. But we will not achieve representation equitable to LGBTQ men until we start running in much higher numbers.”
Among all female candidates, existing research suggests women and men win elections at approximately the same rate and their representational deficit has more to do with barriers to seeking office in the first place. However, endorsements by groups like EMILY’s List and E-Pac (and Victory Fund) reportedly make a large difference in their likelihood of success.
Transgender female candidates were also more likely to succeed than their transmasculine counterparts, winning 54 percent of the time, compared to trans men’s 18 percent success rate, according to the Victory Institute’s report. Nonbinary and gender-nonconforming candidates performed even better, winning 64 percent of the time. But the number of transgender and nonbinary candidates is relatively small. Only 39 of the more than 1,000 candidates tracked by the Victory Institute were transgender women, and only 11 were transgender men. There were also only 11 nonbinary or gender-nonconforming candidates over the five-year period. That said, the 2020 election cycle saw the most trans, nonbinary and gender-nonconforming candidates.
Despite their electoral advantage, queer cisgender women are only 37 percent of LGBTQ elected officials, and transgender women are only 4 percent, according to the Victory Institute. Only 2 percent of LGBTQ elected officials are nonbinary or gender-nonconforming, and approximately 0.5 percent are transgender men. Even queer cisgender men, who make up 56 percent of LGBTQ elected officials, are severely underrepresented when compared to all elected officials.
LGBTQ elected officials represent approximately 0.19 percent of all elected officials nationwide, according to a previous Victory Institute report. To achieve proportionate representation of the United States’ estimated 18 million LGBTQ adults (roughly 5.6 percent of the adult population, according to the most recent Gallup poll), Americans would need to elect 28,128 more LGBTQ people to office — a significant jump from the current total of 974.
As to why she thinks LGBTQ women perform relatively well at the ballot box, Pinkney said LGBTQ people, along with other marginalized groups, generally understand the importance of maintaining a high level of preparedness and taking every opportunity to succeed.
“We don’t have the room for error. We don’t have the room to mess up and make those mistakes,” she said. “It comes off as excellence, but for most marginalized communities, it just feels like everyday operation.”
Tony Christon-Walker was determined to set up an HIV prevention clinic in Birmingham, Alabama, that would succeed where others have long struggled to combat the scourge of the virus among his fellow queer Black men.
The director of prevention and community partnerships at the nonprofit AIDS Alabama, he spent much of 2019 hiring a clinic staff composed of people of color. They were trained to provide the kind of affirming care that, he said, “reflects our culture,” and that would encourage local men at risk of HIV to keep coming back.
Even facing the headwinds of the Covid-19 pandemic, the fledgling clinic, which specializes in prescribing the HIV prevention pill known as PrEP, for pre-exposure prophylaxis, made steady progress in realizing his vision.
But now clinics like this that provide vital HIV prevention services to disadvantaged populations are facing a dire — and for some of these nonprofit groups, even existential — financial crisis driven by the vagaries of an arcane federal law governing prescription drug discounts.
These safety net clinics are set to lose well over $100 million in annual HIV prevention funds due in part to a recent decision by the pharmaceutical giant Gilead Sciences to cut off what has become an increasingly valuable revenue stream supporting these organizations in their grassroots efforts to prevent the virus’s spread. The consequences are expected to be most devastating to clinics in the South, due to the region’s disproportionately large uninsured population and the fact that half of HIV transmissions in the United States occur in those states.
The imminent funding loss threatens to substantially compromise an ambitious plan the federal government launched last year to end the nation’s HIV epidemic by 2030. People of color will likely bear the brunt of the impact — at a time when the public health sector is striving to mitigate racial disparities, not see them worsen.
“This will shut us down,” said Christon-Walker, of how Gilead’s policy change will affect AIDS Alabama’s PrEP clinic. Losing the funds, he said, will “destroy our program and totally inhibit our ability to see uninsured clients, which make up the bulk of our business.”
Dependence on a ‘patchwork solution’
The financial morass centers around a 1992 federal drug pricing law called 340B. The law grants clinics that care for a disproportionate number of uninsured and low-income individuals the right to purchase pharmaceuticals at steep discounts through their in-house or contracted pharmacies. Public and private insurers typically reimburse 340B-designated clinics’ pharmacies at a dollar amount close to a prescribed drug’s list price; and in a unique setup that Gilead recently decided to end, citing ballooning costs, the California-based company has long engaged in a similar reimbursement process when providing free antiretrovirals for HIV treatment or prevention to uninsured people. Such transactions yield surplus cash — known as the “340B spread” — that these organizations spend on their services.
For expensive brand-name drugs, the 340B spread can be quite a substantial sum. By contrast, when these clinics prescribe a cheaper generic medication, the difference between the price they pay and the price at which they are reimbursed is often relatively minimal; so the prescription generates little revenue.
The Food and Drug Administration approved Gilead’s antiretroviral Truvada for use as HIV prevention in 2012. David Paul Morris / Bloomberg via Getty Images
Consequently, even as the Biden administration seeks to drive downthe cost of pharmaceuticals, the little-publicized 340B pricing law conversely — and perversely — causes many health care facilities serving low-income individuals to depend on drug prices for all kinds of health conditions remaining high to support their bottom lines.
Tim Horn, director of health care access at the HIV advocacy group NASTAD, said the 340B funding system is a “patchwork solution” to the woeful lack of investment in the nation’s medical and public health safety net, and one that amounts to “a house of cards.”
Because of the high price of antiretrovirals used to treat and prevent HIV, the 340B spread funnels hundreds of millions of dollars annually into HIV-focused safety net clinics that serve the low-income, uninsured and nonwhite populations that are disproportionately impacted by the virus. The additional funds allow these clinics to provide extra services, such as transportation assistance or case management.
In the coming years, high-quality HIV treatment regimens will increasingly go off patent. This is good news for the nation’s overall health care bill, and state Medicaid budgets in particular. But as cheaper generic antiretrovirals enter the market, safety net clinics treating people with HIV will sustain a progressive and potentially devastating loss of their 340B revenue.
Currently, however, the most pressing 340B-related financial concern in the national HIV arena revolves around revenue tied to the historically pricey PrEP.
The Food and Drug Administration approved Gilead’s antiretroviral Truvada for use as HIV prevention in 2012. PrEP’s popularity has soaredin recent years, and the Centers for Disease Control and Prevention recently estimated that about 285,000 people — overwhelmingly white gay and bisexual men — were taking it by 2019. The federal agency credits PrEP with helping drive the modest 8 percent decrease, from 37,800 to 34,800 cases, in estimated annual HIV transmissions in the U.S. between 2015 and 2019.
But PrEP’s use has remained disappointingly limited among Black and Latino men who have sex with men, who comprised a respective 25 percent and 21 percent of the 36,800 new HIV diagnoses in 2019, according to the CDC. These are disparities that 340B clinics have worked hard, and are uniquely positioned, to address.
Daniel O’Day, CEO of Gilead Sciences, testifies during a hearing on why Truvada is so expensive, on May, 16, 2019 in Washington.Bill O’Leary / The Washington Post via Getty Images
In recent years, the activist group PrEP4All has campaigned against Truvada’s high price, which Gilead has raised from $1,160 per month in 2012 to $1,842 today. The activists have claimed that Truvada’s cost has been the predominant factor limiting PrEP access in the nation — a claim echoed by Dr. Rochelle Walensky, now the CDC director, during a May 2019 congressional hearing held over Gilead’s high list price for PrEP.
And yet, PrEP is widely covered by insurance, with federal guidelines requiring that almost all private plans, as well as state Medicaid programs expanded under the Affordable Care Act, cover it with no cost-sharing. Gilead also providesfree PrEP to uninsured people.
Moreover, the high price of Truvada, and now also Descovy — an updated version of Truvada that the FDA approved as the second available form of PrEP in 2019 — has actually been a financial godsend to the 340B clinics that serve the very populations among whom HIV transmission is the highest.
According to Horn, the 340B spread for a single prescription for Truvada or Descovy amounts to about $1,200 to $1,600 monthly, or $14,400 to $19,200 annually. Clinics have been able to use this windfall to subsidize for their uninsured PrEP patients the quarterly clinic visits and laboratory tests that are required to maintain the prescription and that are not covered by Gilead’s patient assistance program.
Such funds have also been channeled into paying 340B clinics’ facility and technology costs and to pay for patient navigators, safe sex counselors, outreach workers, condoms, advertising, patient transportation, sexually transmitted infection screening and treatment, and opioid use disorder treatment. And in some cases, this money covers other medications for uninsured people, including the initial few months of HIV treatment before the federal Ryan White HIV/AIDS Program kicks in and picks up the tab.
Now, much of the 340B spread tied to PrEP is poised to vanish, potentially hobbling the services that help keep the HIV epidemic in check. Many uninsured people are expected to lose access to PrEP because of an inability to pay for their clinic visits and lab tests.
“It’s going to put a lot of our programs in serious harm’s way at best,” Jim Pickett, senior director of prevention advocacy and gay men’s health at AIDS Foundation Chicago said. “Some of them will be decimated and destroyed.”
Laboratory technician Brady Robles draws blood from a patient at the Kind Clinic in Austin, Texas. Kind Clinic
HIV advocates worry that this funding crisis will only exacerbate the racial disparities that have long characterized the nation’s epidemic.
“HIV has a disproportionate impact on Black and brown communities, especially here in Texas. I really fear that we will have more Black and Latinx people acquiring HIV if other funding sources aren’t in place,” Christopher Hamilton, CEO of Texas Health Action, an HIV- and LGBTQ-focused nonprofit health care provider, said as he echoed a concern shared among his colleagues across the country.
A ‘peculiar’ and ‘unsustainable’ system
After Gilead announced in early April that it would change its patient assistance program reimbursement policy starting in October, an outcry followed, prompting the companyto move the cut-off to January 2022.
Also in April, multiple generic versions of Truvada entered the market for the first time. Some have a list price as low as $30 per month, posing a major threat to Gilead’s highly profitable PrEP sales.
This price plunge heralds a second oncoming financial crisis for 340B organizations. Insurers are already starting to push people with PrEP prescriptions off of Descovy or the brand-name Truvada and onto the cheap generic drug. Should this shift persist, 340B revenue tied to insured people receiving PrEP will steadily deplete.
In recent years, the activist group PrEP4All has campaigned against Truvada’s high price, which Gilead has raised from $1,160 per month in 2012 to $1,842 today. BSIP / Universal Images Group via Getty
Determining how much money is at stake with the 340B spread tied to PrEP — even Gilead says it does not know the true sum — largely requires querying each clinic individually. The Health Resources and Services Administration recently ascertained from 195 health centerssplitting a $54 million HIV-prevention grant from the agency that in 2020, these clinics prescribed PrEP to 63,000 people — up from 20,000 the previous year. According to the agency, which had no comment for this article, 96 percent of these centers participate in the 340B program. And while it is unknown what percentage of these PrEP recipients are uninsured, overall about a quarter of HRSA-funded health centers’ patients lack health insurance.
NBC News asked nearly 120 HIV prevention-focused 340B clinics for their PrEP-patient figures. The vast majority were unresponsive or refused to share their data. Many said they were wary of alienating Gilead, given the clinics’ further dependency on charitable grants from the company, which is the dominant manufacturer of HIV-treatment pharmaceuticals.
Nevertheless, NBC News was able to tally that at the very least, some 7,000 uninsured 340B clinic patients nationwide are receiving free PrEP from Gilead’s patient assistance program monthly. This modest figure alone translates to a pending minimum loss in 340B-spread revenue to such clinics of $100 million annually starting in January. Given the low response rate to queries — data on roughly 3,000 of these patients came from publicly available information concerning California, and the remainder came from just 24 clinics elsewhere — and given the implication of the HRSA figures, the true dollar figure is likely considerably higher.
“It is peculiar that all of these organizations have been able to get all this funding for receiving a free drug,” said Carl Schmid, executive director at HIV + Hepatitis Policy Institute in Washington, D.C. “But that’s the system that we have been living with, and people have been counting on that for years.”
During an April 8 call between HIV advocates and Gilead to discuss the impending financial changes, Eric Leue, vice president of prevention services at the HIV-prevention clinic Friends for Life in Memphis, Tennessee, was clearly distraught as he pleaded with company representatives to reconsider their change in policy. Noting that Memphis has one of the nation’s highest HIV diagnosis rates, Leue said, Gilead’s “unconscionable”impending reimbursement cutwill force his clinic to close, and that overall, it “will set this county and our population back by at least another decade.”
Coy Stout, vice president of market access strategy at Gilead, explained in an interview that the company never intended to establish the 340B revenue stream in question. In 2004, eight years before PrEP was even approved, Gilead made a fateful decision regarding the administration of its patient assistance program. Instead of having a single contracted mail-order pharmacy send free antiretrovirals to uninsured people directly, as pharma companies typically do, Gilead decided it would reimburse the nation’s pharmacies for purchasing the company’s HIV antiretrovirals and hepatitis B antivirals. According to Stout, the intention was to make filling prescriptions convenient for uninsured patients.
Gilead did not expect pharmacies to purchase substantial quantities of the company’s antiretrovirals at 340B discount prices, because the Ryan White HIV/AIDS Program covers HIV treatment for the uninsured and underinsured.
But the U.S. government would establish no such safety net program to pay for PrEP.
So particularly in the 13 states that have not expanded Medicaid, which are concentrated in the South, there are now substantial — and ever growing — numbers of uninsured people receiving free PrEP from Gilead’s patient assistance program through 340B clinics.https://iframe.nbcnews.com/V9XOgMB?app=1
As for insured people receiving PrEP at 340B clinics, responses from the 24 clinics pointed to some 2,850 such individuals receiving brand-name Truvada and 5,900 receiving Descovy. These figures, which experts believe represent vast underestimates of actual national totals, translate to at least $125 million in annual 340B revenue that stands to diminish given insurers’ efforts to push patients onto cheap generic versions.
To put the cumulative pending loss of 340B-spread funds into context, the federal government funded the “Ending the HIV Epidemic” plan by increasing the HIV-related budget by $267 million in 2020 and by $405 million in 2021. The Biden administration’s 2022 budget request has sought to raise this additional outlay to $670 million.
HIV policy advocates like Schmid have been pushing Congress, the Health Resources and Services Administration and the CDC for increased funding to address the lost revenue tied to PrEP’s 340B spread. The CDC traditionally forbids clinics from spending agency grant money to pay for the lab tests and clinic visits for uninsured people on PrEP. However, it does allow Ending the HIV Epidemic-related grants to cover such costs.
From Gilead’s perspective, its patient assistance program is well over budget and, according to Stout, is “unsustainable.” He further stressed that the company is not able simply to turn around and donate the lost 340B spread to the impacted clinics. Under federal tax law, charitable contributions on Gilead’s part cannot be directly geared around their own commercial products.
“It makes good business sense for Gilead to change the policy,”NASTAD’s Tim Horn said, “but it’s just very, very unfortunate timing.”
