CROI 2026: The Tools Are Here. The Infrastructure Is Not.

The 33rd Conference on Retroviruses and Opportunistic Infections (CROI) convened February 22nd – 25th in Denver under extraordinary tension between a pipeline of HIV prevention, treatment, and potential cure tools that could reshape the epidemic's trajectory, and a global funding crisis actively dismantling the infrastructure required to deliver any of it. As Conference Chair Nicolas Chomont of the Université de Montréal stated in the Opening Session, "we share a responsibility to defend and sustain funding for international HIV programs and research." That charge framed every session that followed.

The Funding Crisis: New Data on the Damage

The consequences of disruptions to the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), the dissolution of the United States Agency for International Development (USAID), and National Institutes of Health (NIH) cuts are no longer hypothetical. The CROI session "Sleepless in Denver" presented the first systematic evidence of the damage. Ellen Brazier's survey data from the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium found that across 32 countries, 47% of clinics reported disruptions in HIV services, with similar rates of disruption to medication availability, laboratory services, and clinic operations. In KwaZulu-Natal, South Africa, Lindsey Filiatreau reported that 39% of clinics experienced disruptions affecting an estimated 830,000 people living with HIV.

The damage is not confined overseas. Aaron Richterman presented data from a rapid survey across three U.S. states showing that 47% of clinics reported HIV service disruptions, including medication shortages. He also demonstrated how cuts to the Supplemental Nutrition Assistance Program (SNAP), the country's largest targeted anti-poverty program serving more than 42 million Americans, directly undermine treatment outcomes. During the 2025 government shutdown, ART adherence among people living with HIV who receive SNAP benefits dropped to as low as 40%. The connection between food security and viral suppression is well established; cutting one predictably undermines the other. As Filiatreau put it, "These things [HIV services]… can be taken away overnight, but they can't be rebuilt overnight."

Prevention: An Expanding Toolkit, a Widening Access Gap

Against this backdrop, CROI delivered a prevention portfolio that is broader and stronger than at any previous conference. Final results from the PURPOSE 1 and PURPOSE 2 trials confirmed the efficacy of twice-yearly injectable lenacapavir for pre-exposure prophylaxis (PrEP). In PURPOSE 1, which enrolled cisgender adolescent and young women in sub-Saharan Africa, HIV incidence among lenacapavir recipients was 0.07 per 100 person-years, compared to 1.98 for oral emtricitabine/tenofovir alafenamide (F/TAF) and 1.94 for emtricitabine/tenofovir disoproxil fumarate (F/TDF), with only two seroconversions among more than 2,000 participants. PURPOSE 2, enrolling men who have sex with men and gender diverse people, showed HIV incidence of 0.11 per 100 person-years for lenacapavir versus 0.92 for F/TDF, with three seroconversions among 2,179 participants.

The five total seroconversions across both studies received considerable attention, with four showing lenacapavir-associated resistance mutations that researchers believe developed during PrEP rather than being transmitted. Research into why these breakthroughs occurred is ongoing. As Gilead's Stephanie Cox stated, "We don't know why these occurred… I think the efficacy is very high." San Francisco AIDS Foundation (SFAF) Medical Director Hyman Scott, MD, MPH, added context: "The breakthrough infections are important to evaluate but are extremely rare among the thousands of study participants."

The Prévenir study's final eight-year results from France reinforced that both daily and on-demand oral PrEP are safe and effective, with overall HIV incidence of 0.11 per 100 person-years across more than 3,200 users and 13,000 person-years of follow-up. Switching between daily and on-demand use was the norm rather than the exception, with 59% of daily users changing to on-demand at least once, and 52% doing the reverse. This carries a clear message for implementation: people need flexibility, and rigid one-size prescribing undermines persistence.

The prevention pipeline continues to expand. Merck's once-monthly oral PrEP candidate MK-8527 selected an 11 mg dose maintaining protective drug levels in at least 95% of participants, with Phase 3 EXPrESSIVE trials now enrolling. Gilead's PURPOSE 365 study, testing once-yearly lenacapavir for PrEP, is being designed. The SEARCH study showed that community health workers paired with digital tools reduced HIV incidence by 70% in rural populations, a reminder that prevention tools work best when embedded in community-driven delivery.

The problem is reach. Andrew Hill highlighted that only 2.3 million people are currently on oral PrEP, far below UNAIDS targets, and that injectable cabotegravir and lenacapavir represent just 2.9% and 0.9% of total PrEP use, respectively. We have a growing menu of prevention tools. Getting them to the people who need them is where the system breaks down.

Treatment: More Options, Longer Intervals, Patient Choice

The treatment pipeline at CROI 2026 moved toward a central goal: giving people living with HIV more choices that fit their lives. Merck presented late-breaking data from three Phase 3 trials of doravirine/islatravir (DOR/ISL), the first ever once-daily, non-INSTI two-drug regimen. In treatment-naive adults, DOR/ISL demonstrated non-inferiority to bictegravir/emtricitabine/tenofovir alafenamide (BIC/FTC/TAF), with 91.8% achieving viral suppression at Week 48 compared to 90.6%, including participants with high viral loads and low CD4 counts. The U.S. Food and Drug Administration (FDA) has set an action date of April 28, 2026 for the DOR/ISL application. For people aging with HIV who manage multiple comorbidities, a two-drug, non-INSTI regimen addresses a real clinical gap. Research presented at this same conference linked the widely used INSTI dolutegravir to neuropsychiatric effects, including blocking a brain enzyme essential for memory and emotional regulation, with one study halted for ethical reasons after participants experienced worsening symptoms. For people navigating tolerability concerns, toxicity issues, or polypharmacy, having a non-INSTI alternative with fewer active agents matters.

Gilead's ARTISTRY-1 and ARTISTRY-2 trials demonstrated that a bictegravir/lenacapavir (BIC/LEN) single-tablet regimen can maintain viral suppression for people switching from complex multi-tablet regimens (96% at 48 weeks in ARTISTRY-1) or from Biktarvy (93.5% in ARTISTRY-2). For people who have been on complex regimens for years due to resistance histories, this potential simplification addresses a real quality-of-life gap. Gilead plans to submit these results to regulatory authorities.

Long-acting injectables continued their forward march. In ViiV Healthcare's EMBRACE study, lotivibart (a broadly neutralizing antibody, or bNAb) given as an IV infusion every four months plus monthly cabotegravir maintained viral suppression in 94% of participants at 12 months. Part 2 of EMBRACE, testing lotivibart infusions every six months, is now fully enrolled. ViiV also presented early data on VH-184, a third-generation integrase inhibitor with potential twice-yearly dosing, and VH-499, a capsid inhibitor supporting twice-yearly intervals. The VOLITION study showed that 85% of treatment-naive adults opted to switch from daily pills to bimonthly long-acting cabotegravir/rilpivirine (CAB+RPV LA), with 95% maintaining suppression. Data like VOLITION's 85% opt-in rate reinforce what the HIV community has long argued: when people living with HIV are offered options that fit their lives, they take them. Payers, formulary committees, and ADAP programs should take note. Treatment is not one-size-fits-all, and coverage shouldn’t treat it as such.

Community activist Shari Margolese put it plainly at CROI's final Community Breakfast Club: "As a community we need to get much angrier about the fact that we can't get access to the drugs." Francois Venter of Ezintsha in South Africa warned that without action, "we might be sitting here again in 10 years' time" celebrating breakthroughs that never reach communities.

Cure, Comorbidities, and the Equity Question

On the cure front, the RIO trial's Phase B results offered genuine encouragement. Among the 28 people who received a placebo in Phase A and were then given bNAbs teropavimab and zinlirvimab, 54% had prolonged viral remission after stopping antiretroviral therapy (ART), with two still off treatment after more than a year. Because ART was stopped six months after the bNAb infusions, these results point to an immunological "vaccinal effect" rather than direct viral suppression. A cure remains distant, but these are the kinds of incremental, well-designed steps that build the evidence base forward.

CROI also highlighted the growing urgency of managing comorbidities in aging populations living with HIV. The POPPY study found that depression affects 32.4% of people living with HIV over 50, linked to inflammatory markers rather than psychosocial factors alone. A study of over 1,500 men showed that the combination of age 65 and over, HIV, and metabolic syndrome produced significantly worse cognitive impairment than any factor alone. Metabolic syndrome is the modifiable factor in that triad, which means clinicians and patients can act on it now. CROI data on GLP-1 receptor agonists like semaglutide point toward a potential tool for doing so: in a study of people living with HIV-associated lipohypertrophy, semaglutide produced a 19% reduction in total body fat, a 31% decrease in visceral adipose tissue, and a nearly 50% drop in C-reactive protein, a key inflammatory marker. Separate data presented at the conference found that semaglutide did not worsen depression in people living with HIV, and that people with moderate or severe depression at baseline actually showed improvements. These findings warrant dedicated research into how GLP-1 therapies can address the long-term health consequences of chronic inflammation and aging with HIV. If the evidence continues to support their role, GLP-1 receptor agonists should be evaluated for inclusion in the HIV standard of care, with appropriate insurance and program coverage to match.

The equity question came into sharp focus with data from the ENCORE cohort. Black trans women in the U.S. had an HIV incidence of 15.5 per 1,000 person-years, compared to 1.4 for White trans women. Poverty, houselessness, and lack of insurance were significant drivers, and only 4% of trans women in the cohort used long-acting injectable PrEP. Dr. Sari Reisner of the University of Michigan warned that the current administration's erasure of gender identity data from federally funded datasets will make it harder to monitor disparities and determine what works. We cannot close gaps we refuse to measure, and they know that.

What Comes Next

CROI 2026 produced a clear picture: we have tools that can change the course of the HIV epidemic, and the systems required to deliver them are being actively undermined. The path forward requires specific action. We must defend and restore funding for PEPFAR, NIH, and the global HIV infrastructure that makes science reach people. State ADAP programs and payers must expand coverage for long-acting prevention and treatment options and remove administrative barriers that delay access. To do that, they need to be adequately funded. PrEP implementation must embrace the full range of validated modalities, from daily oral to on-demand to injectable to monthly oral, with flexibility built into delivery. Care for people aging with HIV must shift toward whole-person approaches that integrate cognitive screening, metabolic risk management, and mental health support alongside viral suppression. And we must protect the community-led surveillance and data collection that allows us to see and respond to disparities, especially for trans and gender-diverse communities.

Wes Sundquist of the University of Utah, who helped develop the science behind lenacapavir, reflected at CROI on the decades-long journey that produced this tool. He warned that while the field now has "a really powerful new tool in the arsenal," forces are blocking its use. "It will be a human tragedy," he said, "if we don't overcome those." The science has done its part. The rest is a question of political will, policy design, and whether we as a community can sustain the pressure long enough for these tools to reach the people who need them.

World AIDS Day: The Resistance of Resilience

Every year since 1988 people around the planet come together on the first of December to recognize World AIDS Day. In years past we have taken pause to honor those whom we have lost and celebrate the progress made in the global HIV response.

In 2025, it is nearly impossible to focus on anything but the challenges that threaten to unravel that progress. It arrives at a time of shifting political winds, renewed debates about public health funding, and increasing threats to the systems and supports that people living with HIV rely on every day.

Yet if there is one constant in the HIV movement, it is resilience.

For more than four decades, the HIV community has endured cycles of crisis and recovery. We have faced indifference, stigma, scarcity, and political backlash. And still—through mutual aid, activism, and unshakeable hope—we have rebuilt again and again. This year, with potential federal and state cuts on the horizon, that resilience is not just inspiring, it is essential.

At this moment, the United States stands at a crossroads.

For more than 20 years, the President’s Emergency Plan for AIDS Relief (PEPFAR) has been one of the most successful global health initiatives in history. It has saved an estimated 25 million lives, strengthened fragile health systems, and brought the world closer than ever to controlling the HIV epidemic. USAID has been central to this effort—building clinical capacity, partnering with community-led organizations, expanding access to prevention, and ensuring that millions stay connected to lifesaving treatment.

The current political divide, funding uncertainty, and stalled reauthorization efforts have created a dangerous vacuum. PEPFAR-supported clinics have reported staffing gaps, reduced community outreach, disruptions in treatment continuity, and delays in expanding services to key populations. These cracks—if allowed to widen—threaten decades of hard-won progress.

The message is clear: Treatment access is not guaranteed. Progress is reversible. Lives are at stake.

The uncertainty about the future of our movement does not end outside of the borders of this country. Here, at home, the dismantling of the foundations we have built our successes upon resembles the current state of the east wing. 

Policy decisions made in statehouses and on Capitol Hill have life-or-death consequences. Reductions to HIV prevention, care, housing, and treatment programs don’t simply trim budgets; they unravel the fragile ecosystems that keep people alive. Cuts disproportionately impact Black, Brown, LGBTQ+, and rural communities—people who already face higher barriers to care and greater exposure to stigma.

But we have never waited for political permission to do what is needed.

History shows us that progress in HIV policy is rarely linear. Budgets rise, then fall, with the optional attention of charity. Political champions emerge, then fade with the regularity opportunism offers. But the HIV response moves forward because the community keeps pushing forward. When lawmakers scale back, communities scale up. We see advocates testifying at hearings, organizations expanding peer-led services, and networks of people living with HIV stepping into leadership. We see researchers, healthcare providers, and activists working together to protect progress that took decades to build. 

This ability to adapt—to find new paths when old ones are blocked—is one of our greatest strengths.

When the early epidemic was met with silence, people living with HIV built their own networks of care. When treatments were inaccessible, advocates demanded—and won—more equitable access. When global leadership faltered, activists and partner nations strengthened PEPFAR and the Global Fund, saving millions of lives. When stigma has surged, communities have countered it with truth, visibility, and love.

This year’s uncertainties are not new terrain. The community has always been its own engine of progress.

Every political cycle brings the chance for renewed commitments…renewed inspiration. Funding threats today can become new opportunities tomorrow—but only if we keep momentum alive.

World AIDS Day reminds us, even during challenging times, that we must steadfastly defend the essential programs that provide medications, testing, prevention, housing, and supportive services. Once an HIV safety net is compromised, rebuilding it becomes multitudes more costly and emotionally taxing.

It also calls us to elevate the voices of those communities that are most impacted.  Resilience as it is strongest when those most impacted are centered. Policies crafted with meaningful, empowered involvement from people living with HIV are more equitable, more effective, and more enduring.

Finally it calls us to believe that hard times are temporary. When leadership changes—or when public health once again becomes a national priority—the HIV community will be ready with solutions, partnerships, and a long-term vision rooted in justice.

Resilience is not passive. It is planning, persistence, and refusing to let setbacks define the future.

The progress we’ve made— undetectable becoming untransmittable, vastly improved treatments, longer and healthier lives—is too valuable to lose. The HIV community, and its allies aren’t asking for miracles. We are demanding what we have always deserved: dignity, care, evidence-based policy, and sustained investment in human life.

On this World AIDS Day, we honor the fortitude that carried us this far, and we recommit to the work ahead. No matter how the political winds blow, we will continue fighting for a world where every person living with HIV has the access, resources, respect, and rights they need to thrive.

I urge you to take a moment and remember who we are, because the resilience to rebuild is not just our story—it is our most valuable strategy.

The Plan to Kill the World's Most Successful AIDS Program

The President's Emergency Plan for AIDS Relief (PEPFAR) stands at a critical juncture, having narrowly escaped a $400 million funding cut in July 2025 only to face a more existential threat: the Trump administration's quiet plan to fundamentally transform the world's most successful HIV/AIDS program. Leaked planning documents reveal an administration intent on dismantling PEPFAR as a public health initiative and reconstituting it as a disease surveillance and commercial enterprise platform. This transformation exemplifies the dangerous politicization of evidence-based health programs that threatens to reverse decades of progress and abandon millions of people living with HIV worldwide.

A Plan Revealed

While Congress celebrated blocking the proposed $400 million cut, leaked State Department documents obtained by The New York Times reveal a more comprehensive plan to end PEPFAR as we know it. The documents propose a 42% reduction in PEPFAR's current $4.7 billion budget and envision countries transitioning away from U.S. assistance within two to eight years. Countries closest to epidemic control—Botswana, Namibia, South Africa, and Vietnam—would see complete U.S. withdrawal within two years.

The proposed transformation fundamentally alters PEPFAR's mission. Rather than providing medicines and services to treat and prevent HIV, the program would focus on "bilateral relationships" centered on detecting disease outbreaks that could threaten the United States and creating "new markets for American drugs and technologies." The documents explicitly frame the transition as "the premier example of the U.S. commitment to prioritizing trade over aid, opportunity over dependency and investment over assistance."

The Human Cost of Disruption

The human consequences of PEPFAR's disruption are already measurable and devastating. In Mozambique, researchers found that viral suppression among children receiving HIV treatment dropped 43% between February 2024 and February 2025, directly attributed to PEPFAR disruptions. South Africa has closed 12 specialized HIV clinics and seen over 8,000 health workers in its national HIV program lose their jobs.

Enid Kyomuhendo, a sex worker in Kampala, Uganda, described her experience when her clinic closed just days after she needed her antiretroviral refill: "I got so worried. I started taking alcohol. I was thinking that anytime I am going to die. It became this life of hopelessness." After two months without medication, she developed a dark, itchy rash and now worries about drug resistance—a preventable complication that could worsen her condition.

Modeling studies project even more severe consequences. A 90-day PEPFAR funding pause could result in over 100,000 excess HIV-related deaths over a year in sub-Saharan Africa alone. More than 75,000 adults and children are estimated to have already died because of the effective shutdown that began less than six months ago.

The Politicization of Public Health

PEPFAR's current crisis reflects a broader politicization of public health programs that historically enjoyed bipartisan support. The program's 2024 reauthorization became entangled in abortion rights debates, resulting in an unprecedented one-year extension instead of the traditional five-year renewal. Representative Michael McCaul (R-Texas) captured the frustration: "I'm disappointed. Honestly, I was looking forward to marking up a five-year reauthorization, and now I'm in this abortion debate." McCaul also noted that "a lot of the Freedom Caucus guys would not want to give aid to Africa."

The evangelical community's response proves particularly revealing. Despite PEPFAR's alignment with pro-life principles and its prevention of millions of deaths, white evangelical leaders have remained largely silent about the program's dismantling. As one conservative pastor noted: "If a Democratic administration were doing this—callously, illegally, and completely unnecessarily destroying a cause prayed for, advocated for, designed by, and in many cases carried out by evangelical believers—I struggle to believe that the response would be any less immediate and strident than if they were to mandate states to permit abortion."

This selective moral outrage demonstrates how partisan loyalty can override stated principles, even when millions of lives hang in the balance.

The Innovation Paradox

The timing of PEPFAR's crisis creates a particularly cruel irony. Just as revolutionary prevention tools become available, the administration has restricted prevention programming to pregnant and breastfeeding women only, cutting off access for sex workers, men who have sex with men, and people in serodiscordant relationships.

In June 2025, the FDA approved lenacapavir, a twice-yearly injectable that proved 100% effective in preventing HIV among women and 96% effective among gay and bisexual men in clinical trials. This breakthrough represents the most significant advance in HIV prevention since pre-exposure prophylaxis became available, offering a discreet, long-acting option that could overcome adherence challenges.

Yet PEPFAR's disruption threatens access to this transformative intervention. The Global Fund and Gilead Sciences have committed to providing 2 million doses over three years, but this represents a fraction of global need. PEPFAR was expected to fund approximately half of the initial procurement, but the program's uncertain future has left this commitment in doubt.

Reform Proposals and Alternative Paths

Various stakeholders have proposed different approaches to PEPFAR's future, recognizing that some transition planning is necessary while arguing against the administration's rushed timeline. Duke University researchers have outlined reform proposals that could reduce program costs by 20% over five years while maintaining essential services and planning sustainable transitions.

The Center for Strategic and International Studies has called for a realistic five-year transition plan that would include binding bilateral compacts with clear milestones, graduated timelines based on country capacity, and maintained surge capacity for outbreak response.

However, the administration's leaked documents assume timelines that health experts consider unrealistic. Dr. Mwanza wa Mwanza, who has worked in senior roles in Zambia's HIV program for nearly a decade, noted that "three years, it's really a very short period for a heavy program like the H.I.V. program in Zambia—it's impossible."

Protecting Evidence-Based Public Health

PEPFAR's crisis extends beyond HIV/AIDS policy to represent a fundamental test of whether evidence-based public health programs can survive political weaponization. The program's documented success—26 million lives saved, nearly 8 million babies born HIV-free, and significant contributions to global health security—should make its preservation a nonpartisan priority.

Yet the administration's approach suggests that ideological considerations and commercial interests now outweigh public health evidence in policy decisions. This precedent threatens not only HIV/AIDS programs but the entire framework of global health cooperation that has made possible advances in pandemic prevention, disease elimination, and health security.

Congress retains the power to protect PEPFAR through appropriations and oversight, but sustained advocacy will be necessary to maintain political support. We must demand that policymakers prioritize evidence over ideology and recognize that global health programs serve both humanitarian and strategic American interests.

The fight for PEPFAR represents a broader struggle for the soul of American public health policy. Whether evidence-based programs can survive political polarization will determine not only the fate of millions of people living with HIV worldwide but also America's capacity to lead effective responses to future health crises.

Partisan Battles Put Public Health Programs in Jeopardy

Federal support for public health programs stood at a critical inflection point in 2024, with mounting evidence that political polarization threatens to undermine decades of progress in disease prevention and healthcare access. The O'Neill Institute's analysis of the HIV response highlights a broader pattern affecting America's entire public health infrastructure: an erosion of bipartisan cooperation is creating tangible negative impacts on healthcare delivery and outcomes.

Recent developments illustrate this crisis. The President's Emergency Plan for AIDS Relief (PEPFAR), historically celebrated as one of the most successful public health initiatives in U.S. history, received only a one-year reauthorization in March 2024 instead of its traditional five-year renewal. This shortened timeframe introduces uncertainty for partner countries and threatens program stability. Similarly, Tennessee's rejection of $8.3 million in Centers for Disease Control and Prevention (CDC) HIV prevention funding exemplifies how state-level political decisions can directly impact public health services and infrastructure.

The implementation of the Inflation Reduction Act (IRA), while advancing certain healthcare affordability goals, has created unintended consequences for safety-net providers. Changes to drug pricing and reimbursement structures are affecting 340B program revenues that support critical healthcare services for vulnerable populations.

These challenges emerge against a backdrop of chronic underfunding, with the Prevention and Public Health Fund losing $12.95 billion between FY 2013-2029. This combination of political polarization and resource constraints threatens to create long-lasting negative impacts on healthcare access and population health outcomes, demanding a renewed commitment to depoliticizing essential public health infrastructure and services.

An Erosion of Bipartisan Support

The deterioration of bipartisan cooperation in public health policy represents a significant shift from historical norms that prioritized health outcomes over political ideology. PEPFAR exemplifies this change. Created under President George W. Bush's administration in 2003, PEPFAR has saved over 25 million lives and currently provides HIV prevention and treatment services to millions across 55 countries. Despite this documented success, the program's 2024 reauthorization became entangled in partisan debates over abortion rights.

"I'm disappointed," Rep. Michael McCaul (R-Texas) stated. "Honestly, I was looking forward to marking up a five-year reauthorization, and now I'm in this abortion debate." McCaul added that "a lot of the Freedom Caucus guys would not want to give aid to Africa." The inclusion of abortion rights in the reauthorization debate reflects ongoing polarization within Congress, which has hindered the passage of traditionally bipartisan public health initiatives. This opposition led to an unprecedented short-term reauthorization through March 2025, creating instability for partner countries and threatening program sustainability.

At the state level, Tennessee's decision to reject $8.3 million in CDC HIV prevention funding reflects similar political calculations overshadowing public health considerations. The state's choice to forgo federal support impacts disease surveillance, testing services, and prevention programs that serve people living with HIV and those at risk of acquiring HIV. This rejection of federal funding occurred despite Tennessee ranking 7th among U.S. states for new HIV diagnoses in 2022.

Such decisions mark a stark departure from historical bipartisan support for public health initiatives. Previous health emergencies, from polio to the early HIV epidemic, generated collaborative responses across party lines. The Ryan White HIV/AIDS Program, established in 1990, exemplified this approach, receiving consistent bipartisan support for reauthorization until 2009, its last reauthorization.

The shift away from bipartisan cooperation extends beyond specific programs to affect broader global health initiatives. PEPFAR's instability impacts America's global health leadership position and threatens the progress made in HIV prevention and treatment worldwide. The program's uncertain future affects procurement planning, workforce retention, and long-term strategy development in partner countries, potentially reversing decades of progress in global health security.

Funding Crisis and Infrastructure Impacts

The public health funding landscape reveals a pattern of chronic underinvestment that threatens core infrastructure capabilities. The Prevention and Public Health Fund (PPHF), established under Section 4002 of the Patient Protection and Affordable Care Act of 2010 (ACA) to provide sustained investment in prevention and public health programs, has lost $12.95 billion between FY 2013-2029 through repeated cuts and diversions. These reductions represent approximately one-third of the fund's originally allocated $33 billion, significantly limiting its ability to support essential public health services.

The CDC faces mounting infrastructure challenges due to stagnant funding. While COVID-19 response funds provided temporary relief, these emergency appropriations have been largely obligated or rescinded. The Fiscal Responsibility Act of 2023 rescinded approximately $13.2 billion in emergency response funding from public health agencies, including the CDC, creating a significant funding cliff. Programs facing severe reductions include the Advanced Molecular Detection program, which will revert to its annual base appropriation of $40 million from a one-time supplemental of $1.7 billion, severely limiting disease surveillance capabilities.

State-level impacts manifest in critical staffing shortages and outdated systems. Public health experts estimate that state and local health departments need to increase their workforce by nearly 80%, requiring an additional 26,000 full-time positions at the state level and 54,000 at the local level. The National Wastewater Surveillance System, crucial for early detection of disease outbreaks, faces reduction from $500 million in supplemental funding to a proposed $20 million in FY 2025, threatening its operational viability.

These funding constraints create cascading effects across the public health system. The Public Health Infrastructure Grant program, which has awarded $4.35 billion to strengthen foundational capabilities across 107 state, territorial, and local health departments, expires in FY 2027 without a clear sustainability plan. Similarly, the Bridge Access Program, ensuring COVID-19 vaccine access for 25-30 million adults without health insurance, ended in August 2024, leaving millions without access to updated vaccines. These funding cuts have significantly curtailed prevention services, limiting the CDC's ability to maintain disease surveillance systems and provide timely interventions.

Healthcare Access and Safety Net Impacts

The implementation of the Inflation Reduction Act (IRA) has created unintended consequences for safety-net providers, particularly through its impact on the 340B Drug Pricing Program. Research examining 340B-eligible hospitals reveals concerning trends in charity care provision, with only 9 out of 38 hospitals (23.7%) reporting increases in charity care as a percentage of annual revenues after gaining 340B eligibility. This decline in charity care occurs despite significant revenue increases from 340B participation, raising questions about program effectiveness in expanding healthcare access for vulnerable populations.

Data indicates that hospital participation in the 340B program correlates with substantial revenue growth but diminishing charity care services. The average decrease in charity care provision as a percentage of annual revenues was 14.79% across examined hospitals. This trend is particularly concerning in states with high poverty rates. For example, three West Virginia hospitals—Cabell-Huntington Hospital, Pleasant Valley Hospitals, and Charleston Area Medical Center—reported some of the largest decreases in charity care despite serving a state where 28.1% of people earn less than 150% of the Federal Poverty Level.

Federally Qualified Health Centers (FQHCs) face unique challenges under these changing dynamics. Unlike hospitals, FQHCs must reinvest every 340B dollar earned into patient care or operations to maximize access. However, the IRA's implementation of Medicare drug price negotiations and insulin cost caps affects the rebate calculations that support these reinvestments, potentially reducing available resources for patient care.

Medication access challenges extend beyond 340B implications. Pharmacy Benefit Managers (PBMs) have responded to IRA provisions by adjusting formularies, sometimes excluding medications that previously generated significant rebates. This particularly impacts insulin coverage, where certain products have been dropped from formularies despite the IRA's intent to improve insulin affordability. These decisions create new barriers to medication access for people who rely on safety-net providers for healthcare services.

Public Health Consequences

The convergence of political polarization and funding constraints creates measurable negative impacts on disease prevention efforts, weakening the capacity of public health systems to effectively address emerging and ongoing health threats. Data from the CDC shows that despite a 12% decrease in new HIV diagnoses over the past five years, driven largely by a 30% reduction among young people, progress in reducing new infections has stalled. The lack of sufficient funding, compounded by political challenges, has limited the capacity to expand prevention services, enhance outreach, and maintain necessary treatment programs. The 31,800 new HIV diagnoses reported in 2022 highlight how flat funding and political barriers have hindered further advances. These barriers prevent scaling up successful prevention strategies, limit access to innovative treatments, and constrain efforts to address disparities in vulnerable communities. Notably, significant disparities persist, particularly among gay men across all racial and ethnic groups, transgender women, Black people, and Latino people. These populations continue to face systemic barriers to healthcare access, stigma, and a lack of targeted resources, all of which contribute to ongoing inequities in health outcomes.

Vaccine hesitancy, intensified by political division, threatens population health outcomes. The CDC reports that routine vaccination rates for kindergarten-age children have not returned to pre-pandemic levels, while exemption claims have increased. Nearly three-quarters of states failed to meet the federal target vaccination rate of 95% for measles, mumps, and rubella during the 2022-23 school year, increasing outbreak risks.

Health disparities are exacerbated when political decisions override public health considerations. Tennessee's rejection of CDC funding exemplifies how political choices can disproportionately impact communities already experiencing health inequities by reducing access to essential prevention and treatment services. Such decisions particularly affect regions where HIV rates among transgender women increased by 25%, and Latino gay men now account for 39% of all HIV diagnoses among men who have sex with men.

Community health center sustainability faces mounting challenges as funding mechanisms become increasingly unstable. The expiration of COVID-19 emergency funding, combined with uncertain 340B revenues and growing workforce shortages, threatens these essential safety-net providers. Public health experts estimate an 80% workforce gap in state and local health departments, hampering their ability to deliver essential services and respond to emerging health threats.

Uncertain Future Under New Administration

With Donald Trump’s return to the White House, the future of the nation's public health programs remains uncertain. The president-elect’s stance on health policy has historically emphasized deregulation, work requirements, and reductions in safety net programs, and early indications suggest a continuation of these priorities.

The new administration is poised to bring changes that could scale back Medicaid, reduce the Affordable Care Act’s consumer protections, and restrict reproductive health access—all of which have the potential to exacerbate existing health inequities and widen the gap in healthcare access for marginalized populations. Furthermore, the inclusion of vaccine skeptic Robert F. Kennedy Jr. among Trump’s advisors could undermine public confidence in vaccination campaigns and other science-backed public health interventions.

Although Trump has not explicitly targeted programs like PEPFAR, the Ryan White Program, or other core public health initiatives, the broader agenda of cutting federal funding and shifting health policy decisions to the state level raises significant concerns. These shifts could ultimately weaken the country’s safety net programs, leading to an increase in uninsured rates and preventable health disparities.

The reemergence of a more partisan approach to healthcare policy, especially one with a focus on cost-cutting and minimal regulatory oversight, risks destabilizing public health progress made over the last several decades. Public health stakeholders—ranging from healthcare providers to patient advocates—will need to prepare for a period of heightened uncertainty and potentially significant changes to the public health landscape.

The coming months will likely determine how public health priorities and programs evolve in this new political era. Advocacy groups, healthcare professionals, and policymakers must remain vigilant and ready to respond as the Trump administration shapes its healthcare policy agenda, one that could either sustain or significantly alter the course of public health in the United States. Such shifts threaten to undermine the nation’s public health stability, with repercussions for healthcare costs, access, and the ability to prevent and control emerging health threats.