Where is the National Strategy on AIDS?

Karen Ocamb

During the intense healthcare reform debate President Obama occasionally mentioned HIV infections and AIDS-related illnesses as among those pre-existing conditions that could no longer be used by health insurance companies to automatically exclude consumers from health insurance coverage. Yet the broader scope and crisis of the HIV and AIDS epidemic in America failed to garner much attention.

During the intense health care reform debate President Obama occasionally mentioned HIV infections and AIDS-related illnesses as among those pre-existing conditions that could no longer be used by health insurance companies to automatically exclude consumers from health insurance coverage. Yet the broader scope and crisis of the HIV and AIDS epidemic in America failed to garner much attention.

Some HIV and AIDS activists and healthcare providers, meanwhile, are experiencing that crisis as if it were the early 1980s when the Reagan administration expressed little concern about the early AIDS epidemic even as the death toll mounted.

Since 2007, activists have clamored for a national strategy on AIDS. And now they are pleading for emergency help as the economic downturn forces drastic cuts in the budgets of non-profit AIDS organizations while new HIV infection rates rise and more people need services.

Where is the sense of urgency in the Obama White House to manage the confusion and handle the crisis, they ask?

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In 2006, candidate Obama seemed to understand the need for urgency calling for “an all-hands-on-deck effort.” The first priority of the candidate’s HIV and AIDS platform was to develop a national HIV/AIDS strategyin the first year of his presidency,” a strategy “designed to reduce HIV infections, increase access to care, and reduce HIV-related health disparities” with “measurable goals, timelines, and accountability mechanisms.”

President Obama outlined the scope of the crisis on the front page of the National Office of AIDS Policy (ONAP) website: “When one of our fellow citizens becomes infected with HIV every nine-and-a half minutes, (emphasis added) the epidemic affects all Americans.”

NOAP recently stressed the impact of HIV on women:

The statistics are sobering: Every 35 minutes, a woman tests positive for HIV in the United States. While women in the U.S. represented 8 percent of AIDS diagnoses in the 1980’s, they now account for 27 percent. The HIV epidemic in the U.S. disproportionately impacts women of color: HIV/AIDS is one of the leading causes of death among black women and Latinas.

The demographic disparities of AIDS cases (as of 2007) are dramatic: Whites, who make up 66 percent of the population, account for 30 percent of AIDS cases; Blacks/African Americans, 12 percent of the population, account for 49 percent of AIDS cases; Hispanic/Latino, 15 percent of the population, account for 19 percent of AIDS cases. Asians, American Indians/Alaska Native and Native Hawaiian/Other Pacific account for less than one percent of the AIDS cases.

The CDC statistics for men who have sex with men (MSM) are alarming. Though only an estimated 4 percent of the U.S. male population (ages 13 and older), MSMs account for nearly half (48 percent) of the more than one million people living with HIV and more than half (53 percent) of all new HIV infections each year. The CDC reports that new infections have declined among heterosexuals and injection drug users, but the “annual number of new HIV infections among MSM has been steadily increasing since the early 1990s,” which the CDC attributes to complacency resulting from the availability of antiretroviral treatment and reduced use of condoms. (See CDC Surveillance breakdown here).

But the headline-grabbing news came in August 2008 when the CDC discovered they had been underreporting the annual rate of new HIV infections. They estimated that there were approximately 56,300 new HIV infections in 2006, about 40 percent higher than the 40,000 new infections per year the CDC previously reported.

Dr. Kevin Fenton, director of the CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention, made it clear that the new estimate did not represent an actual increase in the number of new HIV infections, but resulted from more sophisticated monitoring systems.

Richard Wolitski, then-acting director of the CDC’s division of HIV/AIDS prevention, said the new estimates “reveal that the U.S. epidemic is — and has been — worse than previously estimated and serve as a wake-up call for all Americans.”

But the wake up call has been largely ignored, according to a survey released by the Kaiser Family Foundation in April 2009. That study found that “Americans’ sense of urgency about HIV/AIDS as a national health problem has fallen dramatically,” as had concern for personal risk of HIV infection.

There are consequences for complacency. Newsweek reported on February 26 — citing a recent report in the New England Journal of Medicine — conditions in Washington, D.C. remain near-overwhelming:

More than 1 in 30 adults in Washington, D.C., are HIV-infected—a prevalence higher than that reported in Ethiopia, Nigeria, or Rwanda. Certain U.S. subpopulations are particularly hard hit. In New York City, 1 in 40 blacks, 1 in 10 men who have sex with men, and 1 in 8 injection-drug users are HIV-infected, as are 1 in 16 black men in Washington, D.C. In several U.S. urban areas, the HIV prevalence among men who have sex with men is as high as 30 percent—as compared with a general-population prevalence of 7.8 percent in Kenya and 16.9 percent in South Africa.

Additionally, “more than 20 percent of the estimated 1 million HIV-positive Americans are unaware of their status.” Newsweek concluded: “It’s time to admit that HIV is still a major threat to Americans.”

Last April, NOAP launched a new five year AIDS Awareness campaign and on April 1 the CDC announced an expansion of their HIV testing initiative by $31.5 million, for another three years to approximately $142.5 million over all. The CDC said they tested over 1.4 million Americans since the initiative began in 2007, with more than 10,000 people newly diagnosed with HIV and “the vast majority” linked to care.

There are other signs the Obama administration is trying to respond to the crisis. This February, the White House released its proposed budget for fiscal year 2011 with increases for domestic HIV and AIDS programs. The total U.S. government-wide spending on HIV and AIDS would increase from $26 billion to $27 billion and the total discretionary funding for the Department of Health and Human Services spending on HIV and AIDS would increase from $6.9 billion to $7.1 billion in 2011. The funding calls for an expansion and focus on treatment, care and prevention “consistent with the President’s pledge to develop a National HIV/AIDS Strategy.” In addition to funding for HIV testing, the budget proposes funding for collaborative efforts to help people with HIV with co-infections of tuberculosis, hepatitis, and sexually transmitted diseases.

The budget proposal also calls for:

  • $40 million increase in funding for the Ryan White HIV/AIDS Program for care and treatment programs to a total of $2.3 billion, of which $679 million is for Ryan White Part A medical and support services in eligible metropolitan areas and transitional grant areas and $855 million is for the AIDS Drug Assistance Program – an increase of $20 million;
  • an increase of $37.9 million for prevention at the CDC;
  • a $98.7 million increase for the National Institutes of Health for research for a total of $3.2 billion in 2011.
  • Obama also proposes a $5 million increase to  $340 million for the Housing and Urban Development (HUD) Housing Opportunities for Persons with AIDS (HOPWA) program and a request (emphasis added) for $19 billion for the Housing Choice Voucher program to help more than two million extremely low- to low- income families with rental assistance. Obama’s budget also includes $117 million for the Substance Abuse and Mental Health Services Administration Budget.

There has also been some movement on the development of a national strategy on AIDS. The White House convened three consultations plus an inter-agency meeting which is posted online — and ONAP held 14 community meetings with the intention of presenting the national strategy on AIDS by June.

On Friday, (April 9), ONAP released a summary of those meetings and online suggestions in a report, Community Ideas for Improving the Response to the Domestic HIV Epidemic, which cites “a core set of common themes…including: improving access to care, reducing stigma surrounding HIV, and coordinating HIV prevention and treatment.”  ONAP Director Jeffrey S. Crowley said he hopes the report “will serve as a resource as we strive to develop a new strategic approach to tackling the HIV/AIDS epidemic in the United States and take steps to better coordinate the federal government’s response.”  

But Obama’s budget has yet to be approved by Congress and many AIDS activists are frustrated that there is still no overall coordinated AIDS strategy. Crowley promised a plan by the end of 2009 but instead issued a “Call to Action” that appeared to go largely unheeded.

The Coalition for a National AIDS Strategy issued its own call and came up with its own set of recommendations for a strategy. Jeffrey King, executive director of In The Meantime Men, an HIV-focused wellness group for African American MSMs, said the community meeting in Los Angeles occurred on the same Sunday as AIDS Project Los Angele’s popular AIDS Walk. King said only about 100 people attended, many of whom were from an HIV housing facility begging for help not to be closed. It closed anyway.

King said he is trying to keep his small agency afloat during the economic downturn. But finding funding is difficult and the director of the California Office of AIDS plays politics with funding grants, he said. The L.A. County Office of AIDS Programs and Policy has been very helpful, however.

Pedro García, director of Youth Services & Proyecto Orgullo at BIENESTAR, a grass-roots Latino-oriented non-profit that helps underserved communities of color disproportionately impacted by HIV/AIDS (including straight and LGBTs immigrants and a large transgender cliental) said his organization is also facing financial difficulties.

“The cuts in funding that took place last year impacted BIENESTAR heavily. We lost complete funding for the Youth Program from the [LA County] Office of AIDS Programs and Policy. We also were heavily impacted in cuts for Care Services programs such as Case Management, Peer Support, Treatment Education and Housing, to name a few. And in addition, BIENESTAR currently has NO funding for Latina Women at Sexual Risk – however, services for this population have not been interrupted. This is the type of commitment that BIENESTAR has toward the Latino Community.”

“What this decreased funding for programs and services translates to is more cases of HIV infection occurring in the Latino population and making the work that BIENESTAR does, that much harder to achieve,” said Oscar De La O, Executive Director of BIENESTAR.

Ronald Johnson, the African American HIV-positive deputy director of AIDS Action Council, countered the prevailing perception.

“Actually there is a sense of real urgency within the White House both by the President and the National Office of AIDS Policy,” Johnson said. “I realize its taking longer than some of us thought to see a draft [of the Strategy] but it’s our understanding that the draft is underway and I think any delay – and certainly the focus on health care reform – which benefits people living with HIV/AIDS – is a factor.”

Johnson said that evidence of the urgency is in the sheer amount of work the White House is doing to reverse “eight years of absolute neglect of the domestic HIV epidemic from the previous administration.”

He noted that for the first time, the CDC is funding prevention messages that target MSM and the new national surveillance system resulted in the revised estimates of new HIV infections each year.

Further evidence might be the April 5 announcement by Health and Human Services Secretary Kathleen Sebelius of the release of more than $1.84 billion in grants though Health Resources and Services Administration, which oversees the Ryan White HIV/AIDS program.

“These grants help ensure Americans, especially those in underserved rural and urban communities, affected by HIV/AIDS get access to the care they need through quality health care and support systems,” Sebelius said in a press release.

The grants are allocated in three areas of the Ryan White program: Part B gets about $1.145 billion sent to states and territories, with $800 million of that total designated for ADAP, with other money going to 16 states based on a formula (list of Part B awards here). Part A gets $652 million for primary care and support services, including $44.8 million for the Minority AIDS Initiative and Part C receives more than $48.1 million for early intervention services administered by community-based organizations.

But Michael Weinstein, president of the Los Angeles-based global treatment and advocacy AIDS Healthcare Foundation is not overly impressed. “The combination of flat funding and steep drug price rises has put the ADAP program in great jeopardy,” Weinstein said. “We should be able to expect something much better from the Democrats on AIDS.”

Johnson said AIDS Action Council and other AIDS groups are gearing up for the expected budget fight as Congress takes up appropriations. “We are going to press the case that even though there are increases in the president’s budget, the need and the epidemic are such that even greater funds are called for.”

But an even larger issue looms: figuring out how to integrate the AIDS appropriations into the National AIDS Strategy – overlayed with the new heath care reform bill, which Johnson said they are still reading, with its implementation “down the road. That is the work we are doing now.”
For instance, the health care reform bill eliminates the coverage cap – otherwise known as the “hole in the donut” for Medicare Part D Prescription drugs  by 2020. While non-HIV infected Americans who need prescription medications may have difficultly deciphering the year changes in the plan, for people living with HIV and AIDS the issue is expensive and could mean life or death.

“We’re still asking ourselves what this means,” Johnson said. Immediately, some people will be eligible for a $250 rebate. “It’s small but in these times, every 50 cents helps for some people,” especially since many people living with AIDS are not able to get out of the donut hole. In 2011, the 50 percent discount for name brand drugs will go into effect for people in the coverage gap.

“People living with HIV/AIDS can use ADAP to count for the true out of pocket expenses requirement,” Johnson said. But reminded that many state ADAPs are in danger of being cut for lack of funding, Johnson said, “above and beyond health care reform, we’ve strongly advocated for a $126 million emergency appropriations for ADAP this year and also for the appropriations bills that Congress will be developing for the fiscal year that begins October 1. The funding situation for ADAP continues to be a critical issue.”

With rising HIV infection rates, with budget shortfalls severely impacting the local service agencies at a time when more services are needed, with state governments cutting funding to deal with their own financial woes, and with a lack of an overall emergency strategy – the day may soon come when AIDS activists will no longer feel as if they were living in the early 1980s – they may actually be reliving them.

Roundups Sexual Health

This Week in Sex: The Sexually Transmitted Infections Edition

Martha Kempner

A new Zika case suggests the virus can be transmitted from an infected woman to a male partner. And, in other news, HPV-related cancers are on the rise, and an experimental chlamydia vaccine shows signs of promise.

This Week in Sex is a weekly summary of news and research related to sexual behavior, sexuality education, contraception, STIs, and more.

Zika May Have Been Sexually Transmitted From a Woman to Her Male Partner

A new case suggests that males may be infected with the Zika virus through unprotected sex with female partners. Researchers have known for a while that men can infect their partners through penetrative sexual intercourse, but this is the first suspected case of sexual transmission from a woman.

The case involves a New York City woman who is in her early 20s and traveled to a country with high rates of the mosquito-borne virus (her name and the specific country where she traveled have not been released). The woman, who experienced stomach cramps and a headache while waiting for her flight back to New York, reported one act of sexual intercourse without a condom the day she returned from her trip. The following day, her symptoms became worse and included fever, fatigue, a rash, and tingling in her hands and feet. Two days later, she visited her primary-care provider and tests confirmed she had the Zika virus.

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A few days after that (seven days after intercourse), her male partner, also in his 20s, began feeling similar symptoms. He had a rash, a fever, and also conjunctivitis (pink eye). He, too, was diagnosed with Zika. After meeting with him, public health officials in the New York City confirmed that he had not traveled out of the country nor had he been recently bit by a mosquito. This leaves sexual transmission from his partner as the most likely cause of his infection, though further tests are being done.

The Centers for Disease Control and Prevention (CDC)’s recommendations for preventing Zika have been based on the assumption that virus was spread from a male to a receptive partner. Therefore the recommendations had been that pregnant women whose male partners had traveled or lived in a place where Zika virus is spreading use condoms or abstain from sex during the pregnancy. For those couples for whom pregnancy is not an issue, the CDC recommended that men who had traveled to countries with Zika outbreaks and had symptoms of the virus, use condoms or abstain from sex for six months after their trip. It also suggested that men who traveled but don’t have symptoms use condoms for at least eight weeks.

Based on this case—the first to suggest female-to-male transmission—the CDC may extend these recommendations to couples in which a female traveled to a country with an outbreak.

More Signs of Gonorrhea’s Growing Antibiotic Resistance

Last week, the CDC released new data on gonorrhea and warned once again that the bacteria that causes this common sexually transmitted infection (STI) is becoming resistant to the antibiotics used to treat it.

There are about 350,000 cases of gonorrhea reported each year, but it is estimated that 800,000 cases really occur with many going undiagnosed and untreated. Once easily treatable with antibiotics, the bacteria Neisseria gonorrhoeae has steadily gained resistance to whole classes of antibiotics over the decades. By the 1980s, penicillin no longer worked to treat it, and in 2007 the CDC stopped recommending the use of fluoroquinolones. Now, cephalosporins are the only class of drugs that work. The recommended treatment involves a combination of ceftriaxone (an injectable cephalosporin) and azithromycin (an oral antibiotic).

Unfortunately, the data released last week—which comes from analysis of more than 5,000 samples of gonorrhea (called isolates) collected from STI clinics across the country—shows that the bacteria is developing resistance to these drugs as well. In fact, the percentage of gonorrhea isolates with decreased susceptibility to azithromycin increased more than 300 percent between 2013 and 2014 (from 0.6 percent to 2.5 percent).

Though no cases of treatment failure has been reported in the United States, this is a troubling sign of what may be coming. Dr. Gail Bolan, director of CDC’s Division of STD Prevention, said in a press release: “It is unclear how long the combination therapy of azithromycin and ceftriaxone will be effective if the increases in resistance persists. We need to push forward on multiple fronts to ensure we can continue offering successful treatment to those who need it.”

HPV-Related Cancers Up Despite Vaccine 

The CDC also released new data this month showing an increase in HPV-associated cancers between 2008 and 2012 compared with the previous five-year period. HPV or human papillomavirus is an extremely common sexually transmitted infection. In fact, HPV is so common that the CDC believes most sexually active adults will get it at some point in their lives. Many cases of HPV clear spontaneously with no medical intervention, but certain types of the virus cause cancer of the cervix, vulva, penis, anus, mouth, and neck.

The CDC’s new data suggests that an average of 38,793 HPV-associated cancers were diagnosed each year between 2008 and 2012. This is a 17 percent increase from about 33,000 each year between 2004 and 2008. This is a particularly unfortunate trend given that the newest available vaccine—Gardasil 9—can prevent the types of HPV most often linked to cancer. In fact, researchers estimated that the majority of cancers found in the recent data (about 28,000 each year) were caused by types of the virus that could be prevented by the vaccine.

Unfortunately, as Rewire has reported, the vaccine is often mired in controversy and far fewer young people have received it than get most other recommended vaccines. In 2014, only 40 percent of girls and 22 percent of boys ages 13 to 17 had received all three recommended doses of the vaccine. In comparison, nearly 80 percent of young people in this age group had received the vaccine that protects against meningitis.

In response to the newest data, Dr. Electra Paskett, co-director of the Cancer Control Research Program at the Ohio State University Comprehensive Cancer Center, told HealthDay:

In order to increase HPV vaccination rates, we must change the perception of the HPV vaccine from something that prevents a sexually transmitted disease to a vaccine that prevents cancer. Every parent should ask the question: If there was a vaccine I could give my child that would prevent them from developing six different cancers, would I give it to them? The answer would be a resounding yes—and we would have a dramatic decrease in HPV-related cancers across the globe.

Making Inroads Toward a Chlamydia Vaccine

An article published in the journal Vaccine shows that researchers have made progress with a new vaccine to prevent chlamydia. According to lead researcher David Bulir of the M. G. DeGroote Institute for Infectious Disease Research at Canada’s McMaster University, efforts to create a vaccine have been underway for decades, but this is the first formulation to show success.

In 2014, there were 1.4 million reported cases of chlamydia in the United States. While this bacterial infection can be easily treated with antibiotics, it often goes undiagnosed because many people show no symptoms. Untreated chlamydia can lead to pelvic inflammatory disease, which can leave scar tissue in the fallopian tubes or uterus and ultimately result in infertility.

The experimental vaccine was created by Canadian researchers who used pieces of the bacteria that causes chlamydia to form an antigen they called BD584. The hope was that the antigen could prompt the body’s immune system to fight the chlamydia bacteria if exposed to it.

Researchers gave BD584 to mice using a nasal spray, and then exposed them to chlamydia. The results were very promising. The mice who received the spray cleared the infection faster than the mice who did not. Moreover, the mice given the nasal spray were less likely to show symptoms of infection, such as bacterial shedding from the vagina or fluid blockages of the fallopian tubes.

There are many steps to go before this vaccine could become available. The researchers need to test it on other strains of the bacteria and in other animals before testing it in humans. And, of course, experience with the HPV vaccine shows that there’s work to be done to make sure people get vaccines that prevent STIs even after they’re invented. Nonetheless, a vaccine to prevent chlamydia would be a great victory in our ongoing fight against STIs and their health consequences, and we here at This Week in Sex are happy to end on a bit of a positive note.

Analysis Abortion

‘Pro-Life’ Pence Transfers Money Intended for Vulnerable Households to Anti-Choice Crisis Pregnancy Centers

Jenn Stanley

Donald Trump's running mate has said that "life is winning in Indiana"—and the biggest winner is probably a chain of crisis pregnancy centers that landed a $3.5 million contract in funds originally intended for poor Hoosiers.

Much has been made of Republican Gov. Mike Pence’s record on LGBTQ issues. In 2000, when he was running for U.S. representative, Pence wrote that “Congress should oppose any effort to recognize homosexual’s [sic] as a ‘discreet and insular minority’ [sic] entitled to the protection of anti-discrimination laws similar to those extended to women and ethnic minorities.” He also said that funds meant to help people living with HIV or AIDS should no longer be given to organizations that provide HIV prevention services because they “celebrate and encourage” homosexual activity. Instead, he proposed redirecting those funds to anti-LGBTQ “conversion therapy” programs, which have been widely discredited by the medical community as being ineffective and dangerous.

Under Pence, ideology has replaced evidence in many areas of public life. In fact, Republican presidential nominee Donald Trump has just hired a running mate who, in the past year, has reallocated millions of dollars in public funds intended to provide food and health care for needy families to anti-choice crisis pregnancy centers.

Gov. Pence, who declined multiple requests for an interview with Rewire, has been outspoken about his anti-choice agenda. Currently, Indiana law requires people seeking abortions to receive in-person “counseling” and written information from a physician or other health-care provider 18 hours before the abortion begins. And thanks, in part, to other restrictive laws making it more difficult for clinics to operate, there are currently six abortion providers in Indiana, and none in the northern part of the state. Only four of Indiana’s 92 counties have an abortion provider. All this means that many people in need of abortion care are forced to take significant time off work, arrange child care, and possibly pay for a place to stay overnight in order to obtain it.

This environment is why a contract quietly signed by Pence last fall with the crisis pregnancy center umbrella organization Real Alternatives is so potentially dangerous for Indiana residents seeking abortion: State-subsidized crisis pregnancy centers not only don’t provide abortion but seek to persuade people out of seeking abortion, thus limiting their options.

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“Indiana is committed to the health, safety, and wellbeing [sic] of Hoosier families, women, and children,” reads the first line of the contract between the Indiana State Department of Health and Real Alternatives. The contract, which began on October 1, 2015, allocates $3.5 million over the course of a year for Real Alternatives to use to fund crisis pregnancy centers throughout the state.

Where Funding Comes From

The money for the Real Alternatives contract comes from Indiana’s Temporary Assistance for Needy Families (TANF) block grant, a federally funded, state-run program meant to support the most vulnerable households with children. The program was created by the 1996 Personal Responsibility and Work Opportunity Reconciliation Act signed by former President Bill Clinton. It changed welfare from a federal program that gave money directly to needy families to one that gave money, and a lot of flexibility with how to use it, to the states.

This TANF block grant is supposed to provide low-income families a monthly cash stipend that can be used for rent, child care, and food. But states have wide discretion over these funds: In general, they must use the money to serve families with children, but they can also fund programs meant, for example, to promote marriage. They can also make changes to the requirements for fund eligibility.

As of 2012, to be eligible for cash assistance in Indiana, a household’s maximum monthly earnings could not exceed $377, the fourth-lowest level of qualification of all 50 states, according to a report by the Congressional Research Service. Indiana’s program also has some of the lowest maximum payouts to recipients in the country.

Part of this is due to a 2011 work requirement that stripped eligibility from many families. Under the new work requirement, a parent or caretaker receiving assistance needs to be “engaged in work once the State determines the parent or caretaker is ready to engage in work,” or after 24 months of receiving benefits. The maximum time allowed federally for a family to receive assistance is 60 months.

“There was a TANF policy change effective November 2011 that required an up-front job search to be completed at the point of application before we would proceed in authorizing TANF benefits,” Jim Gavin, a spokesman for the state’s Family and Social Services Administration (FSSA), told Rewire. “Most [applicants] did not complete the required job search and thus applications were denied.”

Unspent money from the block grant can be carried over to following years. Indiana receives an annual block grant of $206,799,109, but the state hasn’t been using all of it thanks to those low payouts and strict eligibility requirements. The budget for the Real Alternatives contract comes from these carry-over funds.

According to the U.S. Department of Health and Human Services, TANF is explicitly meant to clothe and feed children, or to create programs that help prevent “non-marital childbearing,” and Indiana’s contract with Real Alternatives does neither. The contract stipulates that Real Alternatives and its subcontractors must “actively promote childbirth instead of abortion.” The funds, the contract says, cannot be used for organizations that will refer clients to abortion providers or promote contraceptives as a way to avoid unplanned pregnancies and sexually transmitted infections.

Parties involved in the contract defended it to Rewire by saying they provide material goods to expecting and new parents, but Rewire obtained documents that showed a much different reality.

Real Alternatives is an anti-choice organization run by Kevin Bagatta, a Pennsylvania lawyer who has no known professional experience with medical or mental health services. It helps open, finance, and refer clients to crisis pregnancy centers. The program started in Pennsylvania, where it received a $30 million, five-year grant to support a network of 40 subcontracting crisis pregnancy centers. Auditor General Eugene DePasquale called for an audit of the organization between June 2012 and June 2015 after hearing reports of mismanaged funds, and found $485,000 in inappropriate billing. According to the audit, Real Alternatives would not permit DHS to review how the organization used those funds. However, the Pittsburgh Post-Gazette reported in April that at least some of the money appears to have been designated for programs outside the state.

Real Alternatives also received an $800,000 contract in Michigan, which inspired Gov. Pence to fund a $1 million yearlong pilot program in northern Indiana in the fall of 2014.

“The widespread success [of the pilot program] and large demand for these services led to the statewide expansion of the program,” reads the current $3.5 million contract. It is unclear what measures the state used to define “success.”


“Every Other Baby … Starts With Women’s Care Center”

Real Alternatives has 18 subcontracting centers in Indiana; 15 of them are owned by Women’s Care Center, a chain of crisis pregnancy centers. According to its website, Women’s Care Center serves 25,000 women annually in 23 centers throughout Florida, Illinois, Indiana, Michigan, Minnesota, Ohio, and Wisconsin.

Women’s Care Centers in Indiana received 18 percent of their operating budget from state’s Real Alternatives program during the pilot year, October 1, 2014 through September 30, 2015, which were mostly reimbursements for counseling and classes throughout pregnancy, rather than goods and services for new parents.

In fact, instead of the dispensation of diapers and food, “the primary purpose of the [Real Alternatives] program is to provide core services consisting of information, sharing education, and counseling that promotes childbirth and assists pregnant women in their decision regarding adoption or parenting,” the most recent contract reads.

The program’s reimbursement system prioritizes these anti-choice classes and counseling sessions: The more they bill for, the more likely they are to get more funding and thus open more clinics.

“This performance driven [sic] reimbursement system rewards vendor service providers who take their program reimbursement and reinvest in their services by opening more centers and hiring more counselors to serve more women in need,” reads the contract.

Classes, which are billed as chastity classes, parenting classes, pregnancy classes, and childbirth classes, are reimbursed at $21.80 per client. Meanwhile, as per the most recent contract, counseling sessions, which are separate from the classes, are reimbursed by the state at minimum rates of $1.09 per minute.

Jenny Hunsberger, vice president of Women’s Care Center, told Rewire that half of all pregnant women in Elkhart, LaPorte, Marshall, and St. Joseph Counties, and one in four pregnant women in Allen County, are clients of their centers. To receive any material goods, such as diapers, food, and clothing, she said, all clients must receive this counseling, at no cost to them. Such counseling is billed by the minute for reimbursement.

“When every other baby born [in those counties] starts with Women’s Care Center, that’s a lot of minutes,” Hunsberger told Rewire.

Rewire was unable to verify exactly what is said in those counseling sessions, except that they are meant to encourage clients to carry their pregnancies to term and to help them decide between adoption or child rearing, according to Hunsberger. As mandated by the contract, both counseling and classes must “provide abstinence education as the best and only method of avoiding unplanned pregnancies and sexually transmitted infections.”

In the first quarter of the new contract alone, Women’s Care Center billed Real Alternatives and, in turn, the state, $239,290.97; about $150,000 of that was for counseling, according to documents obtained by Rewire. In contrast, goods like food, diapers, and other essentials for new parents made up only about 18.5 percent of Women’s Care Center’s first-quarter reimbursements.

Despite the fact that the state is paying for counseling at Women’s Care Center, Rewire was unable to find any licensing for counselors affiliated with the centers. Hunsberger told Rewire that counseling assistants and counselors complete a minimum training of 200 hours overseen by a master’s level counselor, but the counselors and assistants do not all have social work or psychology degrees. Hunsberger wrote in an email to Rewire that “a typical Women’s Care Center is staffed with one or more highly skilled counselors, MSW or equivalent.”

Rewire followed up for more information regarding what “typical” or “equivalent” meant, but Hunsberger declined to answer. A search for licenses for the known counselors at Women’s Care Center’s Indiana locations turned up nothing. The Indiana State Department of Health told Rewire that it does not monitor or regulate the staff at Real Alternatives’ subcontractors, and both Women’s Care Center and Real Alternatives were uncooperative when asked for more information regarding their counseling staff and training.

Bethany Christian Services and Heartline Pregnancy Center, Real Alternatives’ other Indiana subcontractors, billed the program $380.41 and $404.39 respectively in the first quarter. They billed only for counseling sessions, and not goods or classes.

In a 2011 interview with Philadelphia City Paper, Kevin Bagatta said that Real Alternatives counselors were not required to have a degree.

“We don’t provide medical services. We provide human services,” Bagatta told the City Paper.

There are pregnancy centers in Indiana that provide a full range of referrals for reproductive health care, including for STI testing and abortion. However, they are not eligible for reimbursement under the Real Alternatives contract because they do not maintain an anti-choice mission.

Parker Dockray is the executive director of Backline, an all-options pregnancy resource center. She told Rewire that Backline serves hundreds of Indiana residents each month, and is overwhelmed by demand for diapers and other goods, but it is ineligible for the funding because it will refer women to abortion providers if they choose not to carry a pregnancy to term.

“At a time when so many Hoosier families are struggling to make ends meet, it is irresponsible for the state to divert funds intended to support low-income women and children and give it to organizations that provide biased pregnancy counseling,” Dockray told Rewire. “We wish that Indiana would use this funding to truly support families by providing job training, child care, and other safety net services, rather than using it to promote an anti-abortion agenda.”

“Life Is Winning in Indiana”

Time and again, Bagatta and Hunsberger stressed to Rewire that their organizations do not employ deceitful tactics to get women in the door and to convince them not to have abortions. However, multiple studies have proven that crisis pregnancy centers often lie to women from the moment they search online for an abortion provider through the end of their appointments inside the center.

These studies have also shown that publicly funded crisis pregnancy centers dispense medically inaccurate information to clients. In addition to spreading lies like abortion causing infertility or breast cancer, they are known to give false hopes of miscarriages to people who are pregnant and don’t want to be. A 2015 report by NARAL Pro-Choice America found this practice to be ubiquitous in centers throughout the United States, and Rewire found that Women’s Care Center is no exception. The organization’s website says that as many as 40 percent of pregnancies end in natural miscarriage. While early pregnancy loss is common, it occurs in about 10 percent of known pregnancies, according to the American Congress of Obstetricians and Gynecologists.

Crisis pregnancy centers also tend to crop up next to abortion clinics with flashy, deceitful signs that lead many to mistakenly walk into the wrong building. Once inside, clients are encouraged not to have an abortion.

A Google search for “abortion” and “Indianapolis” turns up an ad for the Women’s Care Center as the first result. It reads: “Abortion – Indianapolis – Free Ultrasound before Abortion. Located on 86th and Georgetown. We’re Here to Help – Call Us Today: Abortion, Ultrasound, Locations, Pregnancy.”

Hunsberger denies any deceit on the part of Women’s Care Center.

“Clients who walk in the wrong door are informed that we are not the abortion clinic and that we do not provide abortions,” Hunsberger told Rewire. “Often a woman will choose to stay or return because we provide services that she feels will help her make the best decision for her, including free medical-grade pregnancy tests and ultrasounds which help determine viability and gestational age.”

Planned Parenthood of Indiana and Kentucky told Rewire that since Women’s Care Center opened on 86th and Georgetown in Indianapolis, many patients looking for its Georgetown Health Center have walked through the “wrong door.”

“We have had patients miss appointments because they went into their building and were kept there so long they missed their scheduled time,” Judi Morrison, vice president of marketing and education, told Rewire.

Sarah Bardol, director of Women’s Care Center’s Indianapolis clinic, told the Criterion Online Edition, a publication of the Archdiocese of Indianapolis, that the first day the center was open, a woman and her boyfriend did walk into the “wrong door” hoping to have an abortion.

“The staff of the new Women’s Care Center in Indianapolis, located just yards from the largest abortion provider in the state, hopes for many such ‘wrong-door’ incidents as they seek to help women choose life for their unborn babies,” reported the Criterion Online Edition.

If they submit to counseling, Hoosiers who walk into the “wrong door” and “choose life” can receive up to about $40 in goods over the course their pregnancy and the first year of that child’s life. Perhaps several years ago they may have been eligible for Temporary Assistance for Needy Families, but now with the work requirement, they may not qualify.

In a February 2016 interview with National Right to Life, one of the nation’s most prominent anti-choice groups, Gov. Pence said, “Life is winning in Indiana.” Though Pence was referring to the Real Alternatives contract, and the wave of anti-choice legislation sweeping through the state, it’s not clear what “life is winning” actually means. The state’s opioid epidemic claimed 1,172 lives in 2014, a statistically significant increase from the previous year, according to the Centers for Disease Control and Prevention. HIV infections have spread dramatically throughout the state, in part because of Pence’s unwillingness to support medically sound prevention practices. Indiana’s infant mortality rate is above the national average, and infant mortality among Black babies is even higher. And Pence has reduced access to prevention services such as those offered by Planned Parenthood through budget cuts and unnecessary regulations—while increasing spending on anti-choice crisis pregnancy centers.

Gov. Pence’s track record shows that these policies are no mistake. The medical and financial needs of his most vulnerable constituents have taken a backseat to religious ideology throughout his time in office. He has literally reallocated money for poor Hoosiers to fund anti-choice organizations. In his tenure as both a congressman and a governor, he’s proven that whether on a national or state level, he’s willing to put “pro-life” over quality-of-life for his constituents.