Clade I Mpox Emerges as Public Health Capacity Collapses
Between October 14 and October 17, 2025, three California residents were confirmed with Clade I mpox, all requiring hospitalization, none vaccinated, none with international travel history. These represent the first known cases of community transmission of Clade I within the United States. The strain demonstrates case fatality rates of 3-10.6% compared to less than 0.2% for the Clade II virus that spread in 2022. All three cases occurred in Southern California. Health officials have found no epidemiological connections between them.
This was predictable. In May 2023, the Community Access National Network (CANN) cautioned against premature declarations of victory over mpox, warned that insufficient vaccine coverage among marginalized communities risked endemic transmission, and urged public health agencies to take community reports seriously rather than "paternalistically denying the potential or possibility of new outbreaks or breakthrough cases." Two and a half years later, the infrastructure to respond to those warnings has been systematically dismantled precisely when the more dangerous strain has arrived.
What We Failed to Build
Only 21-23% of at-risk populations nationally have received the full two-dose JYNNEOS vaccine series. This means 66-78% remain unvaccinated against a virus now spreading domestically. Even California, ranked third nationally with 43% of at-risk populations fully vaccinated, leaves more than half of vulnerable people unprotected. None of the three confirmed Clade I cases had been vaccinated.
The racial disparities are unchanged from 2022. As of April 2023, 77.9% of Black people in vaccine-eligible populations remained unvaccinated, despite experiencing mpox incidence 5.8 times higher than White people during the August 2022 peak. The vaccination-to-case ratio during the 2022 outbreak tells the story precisely: for every mpox case in a White male, 43 White males were vaccinated. For Black males, 9 were vaccinated per case. For Hispanic males, 17 per case.
JYNNEOS was added to CDC immunization schedules in October 2023. Most health plans have been required to cover vaccination without cost-sharing since January 1, 2025. Access improved. Utilization did not. Dr. Peter Chin-Hong of UCSF explained the gap: "They might have gotten the first shot back in 2022 when everyone was afraid, and people knew a lot of people who had it." As mpox faded from headlines, vaccination rates declined. Series completion rates remain at 64.5% in California. The consequence is massive population vulnerability to a virus significantly more dangerous than the 2022 strain, spreading now in the communities with the lowest vaccination coverage.
What We Are Dismantling
The federal government shutdown that began October 1, 2025, continues through October 22, now the second-longest in modern U.S. history. Only 37% of CDC staff continue working. Disease surveillance analysis has halted for certain diseases. Guidance to state and local health departments has been suspended. Communication lines are severely limited.
On October 10, approximately 600 CDC workers were cut when 1,300 employees received Reduction in Force (RIF) notices. These targeted staff in infectious disease programs, Laboratory Leadership Service, the CDC Library, chronic disease programs, global health initiatives, and health statistics. The entire CDC Washington Office was eliminated, destroying the agency's Congressional liaison capacity. Dr. John Brooks, former CDC Division of HIV Prevention official, explained the significance: "CDC has worked directly with Congress for decades to help constituents by providing data, expertise and insight when needed. These firings mean Congress no longer has a means of direct access to the agency it funds when it needs information or briefings."
This followed March 2025 HHS restructuring under Secretary Robert F. Kennedy Jr. that eliminated approximately 3,000 CDC positions, a 25% workforce reduction. The Morbidity and Mortality Weekly Report (MMWR) failed to publish for the first time in its 60-year history. Dr. Karen Remley, former CDC official and Virginia health commissioner, described the practical impact: "Sometimes that help might be sending some people to help you investigate this. Sometimes that might be talking to somebody who's the world's expert on a specific type of infection or exposure. Now, there's nobody to answer the phone."
The California Department of Public Health acknowledged: "The department continues to work with available staff at CDC, but the recent federal government shutdown and other actions at the federal level have added a layer of uncertainty to the current work environment." Joseph Osmundson, Clinical Associate Professor of Biology at NYU, stated it plainly: "The infrastructure we built during the 2022 outbreak has just been eviscerated. The very things we need to understand if we have a problem now, and if we will have a problem in the future, are being systematically dismantled."
What We Refused to Fix
Provider knowledge gaps documented in 2022 persist unchanged. A Johns Hopkins study analyzing 1,024 mpox tests across different clinical settings found anogenital examination performed in only 44.5% of emergency department visits and 40.4% of primary care visits, compared to 82.4% in infectious disease clinics. An HIV activist in New York's Hell's Kitchen reported in early 2023: "A number of my friends, as well as myself, if I'm being honest, have reported that their physicians are both unaware that reinfection with MPV [MPOX Virus] is possible and that infections can still occur in people who have been fully vaccinated, and as a result of their knowledge gap are refusing to test MPV lesions."
Spanish-language materials were not available until August 2022, three months into the outbreak. Technology-dependent scheduling systems requiring monitoring of health department social media accounts favored digitally connected populations. Uninsured patients were vaccinated significantly later than privately insured patients, 83 days versus 41 days. Three years later, these barriers remain unaddressed.
The vaccination disparities - 77.9% of Black people unvaccinated, 9 vaccinated per case compared to 43 per case for White people - reflect structural access failures compounded by medical mistrust rooted in documented sterilization programs, non-consensual experimentation, and systemic racism in healthcare delivery. As CANN documented in 2022, these historical harms manifest in current provider interactions: "Moral judgments are made, stories get told, patients are admonished and made to feel ashamed. The impacts of these behaviors, both short-term and long-term, can lead to patients refusing to seek testing or treatment." The barriers are known. The solutions are known. We have chosen not to implement them.
What Works and What We Abandoned
Community-based vaccination programs work. CDC's Mpox Vaccine Equity Pilot Program launched in September 2022 received 35 vaccination project proposals, with 22 completed projects administering 25,675 vaccine doses at targeted locations including Pride events and sexual health clinics. The program partnered with community-based organizations serving gay, bisexual, and other men who have sex with men and transgender people, used trusted messengers, and eliminated eligibility documentation barriers. It was proven effective. It was never scaled to address the 66-78% of at-risk populations who remain unvaccinated.
No real-world effectiveness data exists for JYNNEOS against Clade I. The vaccine is expected to provide protection based on its mechanism and animal studies showing 100% protective efficacy against death. But antibody levels wane significantly 6-12 months post-vaccination, dropping to levels at 12 months comparable to peak single-dose levels. Whether booster doses might be needed remains unresolved. CDC currently does not recommend third doses.
Epidemiological models suggest vaccination coverage above 50% is needed to prevent mpox outbreaks in high-risk populations. California's 43% falls short. Most states are far below that threshold. As CANN wrote in 2023: "If we are ever going to eradicate MPV in the United States, we are going to have to do a significantly better job of getting vaccine supplies to those most likely to be impacted and do a better job of overcoming the cultural and hesitancy barriers that exist in those communities."
The recommendations are unchanged because the problems are unchanged. Increase investments in mobile, pop-up, and community-based healthcare delivery. Provide culturally competent care that meets people where they are. Address provider knowledge gaps through comprehensive education. Eliminate technology-dependent barriers to vaccine access. Collect complete demographic data to track and address disparities. Hold health departments accountable for being "responsive, creative, and careful as community members and advocates identify potential cases and outbreaks."
The Choice We Face
These are early days of this outbreak. But the October 2025 California cases represent something no other country has reported: Clade I mpox transmission without international travel links. Sweden, United Kingdom, Germany, Thailand, Australia all successfully prevented community transmission when they detected imported cases through rapid surveillance, contact tracing, and adequate public health capacity. No wider community transmission occurred in any of these countries.
The California cases emerged during a 22-day federal shutdown, with CDC operating at 37% staffing. State health departments report "nobody to answer the phone" when they need federal expertise. Whether this degraded capacity contributed to these cases spreading undetected, or whether it will hamper efforts to contain them, remains to be seen.
Whether California can contain these three cases depends on rapidly closing vaccination gaps in communities with lowest coverage and highest risk, restoring adequate federal public health capacity to support state and local response, and implementing the equity-centered strategies that worked in 2022 but were never sustained. The infrastructure to accomplish these goals did exist.
Three cases with no identified connections between them and no clear source of transmission suggests either multiple introductions or undetected spread. The systems that failed to prevent these cases being the first domestic transmissions must now prove they can contain them. The question is whether they still have the capacity to do so.
Collateral Damage: How Shutdown Politics Abandons Survivors at the Margins
October is Domestic Violence Awareness Month - but in 2025, awareness is no longer enough. Across the United States, people living with HIV (PLWH), hepatitis C (HCV), and substance-use disorders (SUD) are facing a convergence of crises where intimate partner violence (IPV) amplifies every barrier to care. At the same time, the U.S. Department of Justice’s grant programs - lifelines that help survivors achieve viral suppression, complete HCV treatment, and sustain recovery - are being systematically dismantled after three decades of bipartisan progress.
The numbers tell a story every HIV provider knows. One in four people living with HIV (26.3%) has experienced intimate partner violence. When abusive partners prevent medication adherence, sabotage appointments, or create chaos that interrupts treatment, survivors show 36 percent lower odds of achieving viral suppression than those without IPV histories. Women carry a disproportionate burden, but men with IPV history face nearly triple the HIV prevalence of men without, and transgender people report lifetime IPV rates between 31 and 50 percent while experiencing 66 times higher HIV prevalence than the general population.
For HCV, the overlap is even tighter. Sixty-eight percent of women who inject drugs have HCV, and 40 to 60 percent of domestic-violence cases involve substance use. These aren’t parallel epidemics - they’re feedback loops. Violence undermines treatment; HIV or HCV status becomes a weapon of control; trauma drives relapse. Each condition magnifies the others, and when federal support for survivor-centered programs collapses, the entire structure of prevention and recovery begins to unravel.
The Bidirectional Syndemic
The relationship between intimate partner violence and HIV is both brutally direct and insidiously complex. Women in abusive relationships face a 48% higher likelihood of HIV infection than those in non-abusive relationships. Abusive partners often sabotage safer-sex practices - research shows that condom negotiation attempts frequently trigger coercion or violence. Among people living with HIV, 24% of women experience abuse after disclosing their status, and those reporting recent gender-based violence are significantly less consistent in condom use. Gay men report 26% lifetime IPV prevalence, underscoring that control operates across gender and orientation.
The link to hepatitis C exposes another layer of risk. In relationships where both partners inject drugs, power imbalances determine who controls access, dosing, and the act of injection itself. Partners with more control may withhold drugs to induce withdrawal or insist on injecting the other, reinforcing dependence and exposure. Violence-related bleeding raises the odds of HCV infection 5.5-fold, what researchers call “a previously unrecognized mechanism for HCV transmission.” Among women who inject drugs, 60% report receptive syringe sharing, a behavior shaped by depression and low self-esteem resulting from abuse.
Trauma also drives substance use itself. Eighty percent of women in drug treatment report lifetime sexual or physical assault. Reductions in PTSD severity correspond to four-fold decreases in substance use, while the reverse is rarely true - reinforcing the self-medication model in which survivors use substances to cope with violence.
This syndemic runs both ways. HIV, HCV, and substance-use disorders not only result from domestic violence - they also increase vulnerability to it. Nearly one-third of people living with HIV experience violence following serodisclosure, including coercion, control, and financial or sexual exploitation. Nearly one-third of survivors report that partners deliberately withheld essential medication, from HIV antiretrovirals to HCV or opioid-use-disorder treatments, weaponizing care itself as a means of control.
When Laws Become Weapons
HIV criminalization laws in 32 states create a deadly double bind for domestic violence survivors. Enacted largely between 1986 and 2000 - before modern antiretroviral therapy and long before the U=U consensus - these statutes criminalize potential exposure regardless of actual transmission, condom use, or viral suppression.
Twenty-four states require disclosure of HIV status before any sexual activity. Penalties range from 3 to 10 years in prison, extending to 25 or more in some states. At least five mandate sex-offender registration for HIV-related convictions.
The control dynamic is devastatingly simple. Disclosure can trigger violence - studies show 18% to 80% of women living with HIV experience violence after disclosing their status - yet non-disclosure remains a felony. Abusers exploit this legal trap, threatening to report partners to police or weaponizing the risk of decades-long sentences and sex offender registration as blackmail.
Research from Canada illustrates the toll: one-fifth of women living with HIV said criminalization laws increased violence in their relationships. The perverse outcomes are clear. In one documented case, a woman reported her partner for abuse, only to be charged herself after he alleged non-disclosure during a single encounter, despite a four-year relationship in which she had disclosed her status.
The 2025 Federal Funding Crisis
Hours after the government shut down on October 1, 2025, the Trump Administration furloughed staff in the Department of Justice’s grant-making offices, halting support for organizations that serve victims of domestic violence and other violent crimes. Officials cited the shutdown as the cause, but former staffers told Politico it didn’t have to be this way - these programs had operated during past shutdowns with existing funds.
“Their own contingency plan says that they have funds. So it’s a choice to say, ‘We want this to hurt,’” said Marnie Shiels, who worked 24 years in the Office on Violence Against Women (OVW). “I can’t know for sure what they’re thinking, but I very much fear that it is about a political motivation of wanting to get rid of this issue, get rid of this office, get rid of the staff.”
The furloughs followed a year of escalating disruptions. In February, OVW abruptly removed all eight fiscal-year 2025 funding notices, including a $40 million transitional-housing program that had served hundreds of survivors for nearly two decades. In April, the Department of Justice terminated more than 360 grants, cutting roughly $500 million in remaining funds and affecting hundreds of sub-awards for violence prevention, victim services, mental-health treatment, and reentry programs.
When new opportunities appeared in May, they came with expanded “out-of-scope” rules that barred activities “framing domestic violence or sexual assault as systemic social-justice issues.” The language aligned with a January 2025 executive order, “Defending Women from Gender Ideology Extremism,” and a subsequent directive ordering agencies to remove “gender ideology” from contracts, websites, and correspondence. PEN America later documented more than 350 banned words, including gender, women, trans, LGBTQ+, diversity, and disability - effectively erasing the terminology needed to describe many of the populations these programs serve.
The effects reach beyond domestic-violence services. NIH canceled dozens of HIV-related research grants in March; five CDC HIV-prevention branches were dissolved; and hepatitis funding was cut by $77 million. Proposed reductions to the Ryan White HIV/AIDS Program total $239 million.
For organizations serving survivors living with HIV, hepatitis C, or substance-use disorders, these converging cuts are existential - removing both their funding streams and, in some cases, their ability to even describe who they serve. Shiels noted that leadership had “said that they want federal employees to feel ‘trauma,’” and recalled the president’s remark that “a little fight with the wife shouldn’t be a crime.” The contrast, she said, “shows they don’t understand or care about these issues.”
The Office on Violence Against Women - created in 1995 and made independent in 2004 - has awarded more than $4.7 billion in grants since its inception, including $684 million across 880 awards in FY 2024. That bipartisan infrastructure recognized what decades of data confirm: 55 percent of women living with HIV have experienced intimate-partner violence, a link directly associated with lower care engagement, higher viral loads, and worse health outcomes.
Now, the systems built to protect those lives hang by a thread.
What We Must Do Now
The convergence of domestic violence, HIV, hepatitis C, and substance use disorders is not theoretical - it’s the reality providers see every day. Survivors’ viral loads rebound when housing instability forces them back to abusive partners. Hepatitis C treatment stalls when the only culturally competent program loses its grant. Trauma-informed care disappears, and relapse follows. The nation’s Ending the HIV Epidemic and hepatitis C elimination goals cannot succeed while survivors are forced to choose between safety and survival.
Rebuilding that safety net demands more than temporary fixes. The Department of Justice must reopen its grant-making offices - shutdown or not - and restore continuity for organizations on the front lines. Congress must fully fund these programs and eliminate restrictions that prevent them from even naming the people they serve. States must modernize or repeal HIV criminalization laws that trap survivors in violent relationships under the guise of public health.
A syndemic is not fate; it is a policy choice repeated, ignored, and justified until it becomes another fading bruise on a battered cheek. The systems we built to keep people alive are being dismantled in plain sight - not through neglect, but intent. And when government decides that survival itself is partisan, silence becomes complicity.
September Shutdown Could Cripple Open Enrollment as HIV Patients Face Coverage Crisis
Congress faces a September 30th government funding deadline that could shut down federal agencies just as Americans prepare to experience unprecedented healthcare premium increases during the November open enrollment period. The seven-week stopgap funding bill released by House Republicans would only extend government operations through November 21st, creating the possibility of multiple shutdowns right as people living with HIV and millions of others discover that their healthcare costs will increase dramatically for 2026.
The timing creates a perfect storm of healthcare disruption. Enhanced ACA subsidies expire December 31, 2025, but insurers have already built the expected 75% premium increases into their 2026 rates. When open enrollment begins November 1, Americans shopping for coverage will immediately see these massive premium spikes, creating intense political pressure on Congress just as government funding battles reach their peak.
For people living with HIV who rely on ACA marketplace plans, this convergence threatens treatment continuity at the worst possible moment. Many earn too much to qualify for Ryan White HIV/AIDS Program services but depend on enhanced subsidies to make coverage affordable. The prospect of 75% premium increases forces impossible choices between maintaining viral suppression and financial stability.
Premium Sticker Shock Meets Shutdown-Threatened Infrastructure
Insurers nationwide have proposed a median premium increase of 18% for 2026, more than double last year's 7% median increase. The majority explicitly cite the expected expiration of enhanced premium tax credits as driving rates an additional 4 percentage points higher than they would otherwise charge.
Average out-of-pocket premium payments will increase by more than 75% when enhanced subsidies expire, translating to roughly $700 more annually for the typical family. People earning between 100% and 150% of the federal poverty level would see their average premiums rise from $0 to $387 per year. In Maryland, carriers requested 17.1% increases, but rates would drop to 7.9% if Congress extends enhanced subsidies, illustrating the immediate financial impact of political inaction.
These massive increases hit Americans during November open enrollment while government infrastructure faces shutdown disruption. The September 30 deadline threatens systems needed for November 1 enrollment, and even the Republican stopgap bill expires November 21 during the critical enrollment period.
Healthcare.gov and state marketplaces require functioning federal systems to process applications and verify income for subsidy eligibility. Historical shutdown impacts show services degrade rapidly during funding lapses. The timing compounds administrative challenges from the Trump administration's Marketplace Integrity and Affordability Rule, requiring people in $0 premium plans to verify eligibility or face minimum $5 monthly charges starting in 2026.
Insurers cannot adjust these rates after open enrollment begins. Blue Cross Blue Shield of Vermont warns that healthier members will leave at a disproportionately higher rate than those with significant healthcare needs, worsening the risk pool. This death spiral dynamic makes immediate Congressional action an absolute necessity, both politically and practically, as Americans navigate premium increases while government systems fail to function.
Political Standoff Intensifies as Healthcare Costs Hit Constituents
Traditional shutdown politics change fundamentally when constituents experience immediate healthcare cost increases during an election cycle. Senate Minority Leader Chuck Schumer argues Democrats hold a stronger position because Republicans face blame for both the shutdown and healthcare cost increases their policies created.
House Speaker Mike Johnson insists ACA subsidy negotiations belong in December when they expire, calling them "a December policy debate and decision, not a September funding matter." This ignores the practical reality that Americans need certainty when making coverage decisions during November open enrollment. Families cannot wait until December to learn whether their January 2026 premiums will be affordable.
The electoral pressure becomes intense when 22 million Americans face premium increases. TD Cowen's analysis notes that "many Congressional Republicans are also eager to extend these subsidies for fear of health insurance sticker shock in advance of the November 2026 midterms." Only Senator John Fetterman has indicated willingness to vote for Republican funding without healthcare provisions, suggesting Democrats maintain unity while Republicans need Democratic cooperation they have refused to seek.
The Trump Administration compounds uncertainty through potential "pocket rescissions" that could cancel federal funding without Congressional approval. Budget Director Russell Vought defended this controversial tactic, noting "the money evaporates at the end of the fiscal year." This raises constitutional questions about Congressional spending authority and creates a trust crisis for Democrats who fear GOP leaders could agree to healthcare provisions in negotiations only to have the Administration cancel funding through rescissions after a continuing resolution passes. Lawmakers must consider both immediate shutdown impacts and the Administration's demonstrated willingness to bypass Congress on funding decisions.
State and Local Healthcare Programs Face Immediate Funding Disruption
Government shutdowns immediately disrupt state and local healthcare programs through suspended grant payments and federal workforce reductions. During shutdowns, 45% of HHS staff are furloughed, including personnel who process grants to state health departments and community organizations providing HIV services. The 2013 shutdown left 477 grant payment requests totaling $165 million unpaid while programs continued operating on dwindling reserves.
State health departments must issue stop work orders to community organizations when Ryan White grant payments cease during shutdowns. State AIDS Drug Assistance Programs face immediate medication supply crises as federal funding stops flowing to programs serving 265,000 low-income Americans with HIV medications. Unlike programs with multi-year appropriations, these discretionary programs lose payment authority immediately when government shuts down.
Community health centers serving 32.5 million Americans operate on margins where federal grants constitute 11-18% of revenue. Recent funding disruptions provide a preview of shutdown impacts: Virginia's 16 of 31 federally qualified health centers lost federal funding access, forcing three Richmond facilities to close entirely. Centers typically maintain 100 days to six months of reserves, making extended shutdowns particularly devastating.
The Women, Infants, and Children program loses funding within days of shutdown, cutting services to 6.3 million participants including 39% of all U.S. infants. State health departments lack reserves to float these federal programs, forcing immediate service reductions that disproportionately impact communities already facing healthcare access barriers.
Healthcare Access Cannot Wait for Political Theater
People living with HIV and other chronic conditions cannot afford treatment interruptions while Congress debates funding priorities. Those caught between Ryan White eligibility limits and unaffordable marketplace premiums face a healthcare access crisis manufactured by political inaction.
Healthcare advocates must demand that any continuing resolution include immediate extension of enhanced ACA subsidies through 2026. Congressional Republicans who claim to support these subsidies must prove their commitment by including them in September funding legislation, not promising future action that may never materialize.
State and local health officials should prepare contingency plans for potential grant payment disruptions while advocating with their Congressional delegations about immediate shutdown impacts on essential services. Community health centers and organizations serving people living with HIV need to communicate directly with patients about potential service disruptions and alternative care options.
Congress must choose between responsible governance that prioritizes patient care or political theater that forces impossible choices between treatment adherence and financial survival. For people living with HIV and millions of others depending on stable healthcare access, the time for action could not be shorter.