In Times of Uncertainty, Remember Your Values

Last week, the boards for Community Access National Network and ADAP Advocacy met with various partners and our respective staff and consultants to discuss the future. As with all things around prognostication, our collective crystal balls are hazy and the future remains uncertain, but not without opportunity.

I want to recognize the tension and fear many of our community members are facing and will continue to face…the tangible harms some of us will realize in the years to come. I also want to acknowledge that those fears come from harms many of us have felt in years prior.

In reflecting on the meeting, I felt rooted in a simple fact, one I hope to come back to many times as we navigate the waters ahead: In times of uncertainty, we must find ourselves as deeply tied to our values as ever. Our actions must reflect those values individually and collectively. To each organization’s board members who righteously reminded the group of these things: thank you.

The policy landscape of 2025 and the future thereafter is likely to be rife with new and old challenges. Decisions from the United States Supreme Court will increase the healthcare ecosystem’s penchant for litigation, which will leave certain policy-making in the hands of judicial officers rather than policy experts. How much? We’re going to learn. And, frankly, this is true even outside of healthcare as a sector of advocacy. All advocacy organizations will grapple with the notion of regulatory changes that can be held to a jury trial and where agency deference is limited. This does not mean advocacy no longer has a role between corporate interests and attorneys. Rather it means advocacy must focus on compelling arguments and investing in relationships with public interest firms to ensure the public’s true interests, rather than the government’s or corporate interests, are centered in arguments and outcomes. In many ways, this operational assessment is not different from rule-making and regulatory engagement.

To that end, this is also not the first time advocacy, HIV-advocacy specifically, has faced a necessity to consider our non-partisan and bipartisan origins. Collectively and within our institutional and historical knowledge, we know how to identify allies of all stripes. We know how to align ourselves on narrow policy and program issues while also not endorsing harmful policy from the same people with whom we find those narrow alliances.

At the end (and beginning) of the day, certain truths remain:

• We come from a long history of advocacy with the passion of activists whose legacies we must honor.

• We have the expertise this moment demands and we must ensure that expertise is extended to newer partners.

• HIV exists and thrives in social environments of stigma and privilege. Much of the health equity fight can find roots and advancements in HIV.

• Ending the HIV Epidemic in the United States will require returning public trust in science and investment abroad. Health equity does not end at our borders.

• Other health crises will arise as we continue this fight.

• All policy matters - elevating HIV as a critical symptom of tertiary policy issues is both noble and effective. To that end, finding a balance in an organization’s primary mission and tertiary issues can be challenging.

• Our communities are exhausted. As advocacy organizations, we have a duty to our served constituents to not “ring bells” which do not yet need to be rung. As we struggle with our capacity limitations, we must also recognize the emotional capacity limitations of those we advocate on behalf of.

• The time has already arrived to invest in the next generation of advocacy leadership. Legacy advocacy organizations must invest in succession planning and our funding sources must be willing to take risks in these investments as well. We will not change the current state of our shared stories by doing things as we have always done them. It’s time to step into the future together.

In all fairness, I want to close out this year sharing some significant investments CANN has made. CANN has been on a “growth” track for the last three years. Our funding has increased, our number of funders has increased, and our presence in state-based advocacy has increased. Some of funding partners and new community partners are not specifically involved in HIV advocacy, they do however, recognize the intersection of our shared interests in healthcare and public health policy. Their willingness to invest in CANN and take those risks is well and truly appreciated. Additionally, ensuring the “national” in our name is not limited to federal advocacy is deeply important to anchoring into our values. We do, of course, continue to advocate on federal issues and expect to expand on federal work in 2025.

CANN’s growth also includes bringing on new consultants. We have historically prioritized identifying patient community members who have an entrepreneurial spirit, passion for policy, and a thriving desire to improve the world around them as potential talent to draw from, regardless of formal education. Our singular recognition in these priorities is that in order to improve patient-community lives, policy solutions must originate from patients themselves.

In 2024, we welcomed Travis Manint as our permanent blogger and he will be taking on some additional administrative responsibilities in helping CANN maintain our quality of work product as we grow. Ranier Simons also joined CANN in a more full-time capacity tackling the pressing issues of state-based Prescription Drug Affordability Boards (PDABs) and their threat to the Ryan White program, other safety-net providers, independent pharmacies, and vulnerable patients, including people living with HIV or other potentially disabling health conditions. Ranier has also spearheaded developing work on Pharmacy Benefit Manager (PBM) reform and PBM oversight and investigative activities on both the federal and state levels. Ensuring government bodies are fully aware of the unique aspects of the healthcare ecosystem and supply chain is a core activity for us. We also welcomed Kalvin Pugh to the team as our state-based 340B policy specialist. Kalvin is already off to a strong start representing patient interests via testimony in Michigan and updating data on CANN’s 340B Action Center. We remain well-served by our business consultant, Brandon M. Macsata, and have sincerely enjoyed the event coordination services provided by Amanda Kornegay. Dave Mickler, Sergio Gomez, and David Spears have readily worked to ensure CANN’s website, infographics, and educational videos represent CANN’s “best side”. Lastly, and certainly not least, the team at Perry Communications has made deep investments in helping CANN’s message and priorities land in front of the right eyes - patients and policymakers alike.

When I accepted the position of CEO of CANN, I emphasized a deep desire to ensure our partners and community can feel proud of work - that we can and do readily honor Bill Arnold’s legacy while also stepping up to and meeting today’s needs. It is with the sweat equity of these truly remarkable human beings that I am as confident that CANN will continue to meet this priority. Speaking for myself, I am proud of the team CANN has brought together - every person - and the work we’ve brought forward this year

In a season of uncertainty, the entire CANN team, from our board members to our staff and consultants, helps us all remain committed to our values.

Healthcare in the Lame Duck

Lawmakers have returned to Washington for what many observers predict will be a subdued lame duck session. With former President Donald Trump set to return to the White House in January 2025 and Republicans poised to control both chambers of Congress in the new session, the current Democratic-led Congress faces tough decisions about which healthcare priorities can realistically advance before the year ends. Given these shifting dynamics and a continuing resolution set to expire on December 20th, many healthcare stakeholders are closely watching to see if a handful of critical policies—ranging from Medicare telehealth extensions to community health center funding—will receive even short-term relief.

Multiple programs tied to patient access and affordability are slated to expire on December 31, 2024. These include expanded Medicare telehealth flexibilities, community health center (CHC) funding, and measures preventing Medicaid Disproportionate Share Hospital (DSH) payment reductions. Efforts to stabilize Medicare physician payments, address pharmacy benefit manager (PBM) practices, and implement site-neutral payment reforms are also on the table. However, the political uncertainty, combined with constrained legislative days and an incoming administration that may set different healthcare priorities, create a complex landscape for deciding which items are addressed before the new year.

The Broader Political Context

The upcoming change in leadership is already influencing legislative calculations. Republicans, who will soon have unified control in 2025, may choose to defer major reforms or costly extensions until they can shape policy more extensively under the incoming Trump Administration. Analysts suggest that lawmakers will likely focus on minimal, must-pass measures to keep essential programs afloat while leaving more sweeping changes to the next Congress.

Several sources point to a “lamer-than-usual” lame duck session, with meaningful healthcare legislation potentially limited to urgent deadlines. The December 20th government funding cutoff provides a possible vehicle for limited healthcare fixes. Short-term extensions—buying mere months, rather than years—are a likely reality. During this time, people living with chronic conditions, those receiving services at safety-net providers, and people living in rural areas risk seeing uncertainty in care continuity if Congress cannot secure even interim solutions.

The incoming administration’s planned appointments to health agencies and global health leadership changes could realign federal priorities. While the previous administration’s approach emphasized a strong response to public health emergencies, the incoming leadership has signaled greater skepticism toward traditional vaccine policies and may focus less on infectious disease prevention, shifting attention toward other areas of healthcare. As a result, the current Congress may feel pressure to secure patient protections now, anticipating policy moves in 2025 that could reduce certain resources or alter public health strategies.

Must-Pass Healthcare Extensions: Preserving Patient Access Before 2025

Medicare Telehealth Flexibilities

One of the most urgent healthcare priorities involves extending Medicare telehealth flexibilities set to expire on December 31st. Initially expanded during the COVID-19 public health emergency, these provisions have allowed Medicare beneficiaries—including those in rural and underserved communities—to receive certain types of care without the geographic and site restrictions that once applied. The expansion has played a significant role in maintaining continuity of care, especially for behavioral health and chronic disease management services. A House Energy & Commerce Committee proposal would extend these provisions for two years, enabling policymakers to gather more data on telehealth’s cost and quality impact.

A permanent expansion faces a cost barrier. While telehealth enjoys bipartisan support, the price tag remains a challenge to achieving a long-term fix. Thus, a short-term extension appears the most likely outcome. If Congress allows the telehealth provisions to lapse, people who have integrated virtual visits into their healthcare routines—particularly for managing conditions such as HIV—might lose access to services they have come to rely on. This would create new hurdles for maintaining adherence to treatment regimens and managing ongoing care.

Medicare Physician Payment Stabilization

Another pressing issue involves Medicare physician payment rates. Under the current trajectory, doctors face a 2.83% pay cut in 2025—a continuation of multiple consecutive years of reimbursement reductions. Physician groups and bipartisan coalitions in Congress support a Medicare payment stabilization bill that would offset these reductions. Yet cost considerations and the search for budgetary offsets loom large.

Some policymakers view site-neutral payment reforms—discussed later—as a potential “pay-for” to fund these physician payment patches. The prospect of linking physician payment relief with spending cuts elsewhere may shape what Congress accomplishes now. Without a temporary fix, physicians in rural and lower-resource areas might limit the number of Medicare beneficiaries they see, potentially shrinking access to care just as winter months and other public health challenges approach.

Community Health Centers and Safety-Net Providers

CHCs, serving roughly 31 million people, face potential disruptions if their funding authorization expires at year’s end. According to George Washington University research, CHCs often operate on thin margins and rely heavily on federal support. Any gap in funding could mean reduced primary care services, delayed hiring or retention of medical staff, and less capacity to serve people who rely on these centers as their primary healthcare access point.

Medicaid DSH payments, which help hospitals serving people with lower incomes and those living in poverty, also face cuts. Without legislative action, an $8 billion reduction in DSH payments could take effect. Advocacy groups and hospital associations warn that this could erode crucial parts of the healthcare safety net, limiting services at facilities that care for populations disproportionately affected by chronic conditions and economic instability.

The lame duck session provides a narrow window to secure short-term extensions, preserving CHC and Medicaid DSH programs into early 2025. Lawmakers must balance competing priorities, including the need for cost offsets, making it uncertain whether robust, multi-year reauthorizations are possible. With Republicans waiting to implement their policy vision next year, the likely outcome may be modest stopgaps rather than a long-term solution.

Uncertainty for Other Key Programs: Ryan White and PEPFAR

Beyond the well-known year-end deadlines, advocates are also paying attention to larger federal programs that were previously reauthorized but now continue largely through appropriations. The Ryan White HIV/AIDS Program and the President’s Emergency Plan for AIDS Relief (PEPFAR) have historically enjoyed bipartisan support, delivering life-saving care, treatment, and prevention services for people living with HIV in the U.S. and abroad. However, as the next Congress and Administration look to reduce spending, longstanding programs that rely on continued federal investment but lack recent formal reauthorization could come under scrutiny.

Advocates fear that with a new majority eager to trim budgets and revisit healthcare spending priorities, both Ryan White and PEPFAR could face more critical examination. While no immediate action on these programs is expected in the lame duck session, their future stability may depend on how the incoming leadership chooses to address them in the months ahead. This uncertainty raises concerns in public health communities that rely on these programs to maintain progress in HIV prevention, treatment retention, and global health collaborations.

PBM Reform and Drug Pricing: A Fleeting Opportunity?

Pharmacy Benefit Managers have drawn increasing scrutiny from Congress for pricing practices that, according to some analyses, drive up medication costs and limit access to necessary prescriptions. There has been a rare display of bipartisan interest in addressing PBM transparency. The House-passed Lower Costs, More Transparency Act—referenced by Mercer—offers a framework for imposing new reporting requirements on PBMs and prohibiting certain practices like spread pricing in Medicaid.

Recent Federal Trade Commission (FTC) actions against the largest PBMs underscore these concerns. The FTC’s administrative complaint alleges that PBM rebating structures inflate medication costs, impairing access to more affordable alternatives. Policymakers, patient advocates, and public health officials have pointed out that PBM practices may particularly affect people living with HIV and other chronic conditions, who depend on stable access to medications. Restrictions like mandatory mail-order pharmacy rules can disrupt continuity of care, especially for those who require regular medication management.

Still, significant PBM reforms may not pass during the lame duck session. Republicans may prefer to tackle drug pricing and PBM oversight under their upcoming majority, potentially shaping legislation more to their liking. If any PBM-related measures pass now, they will likely serve as incremental changes or as offsets for other healthcare priorities rather than representing the comprehensive reform that some lawmakers and patient advocates seek.

Site-Neutral Payment Reforms: A Budgetary Lever

One of the most closely watched and potentially transformative policy changes up for discussion involves site-neutral payment reforms. Current Medicare regulations often allow higher reimbursements for services delivered at off-campus hospital outpatient departments compared to physician offices or ambulatory surgical centers. Hospitals justify these higher rates based on overhead and regulatory requirements, but policymakers, backed by advisors like the Medicare Payment Advisory Commission (MedPAC), have increasingly called for aligning payments across settings to reduce unnecessary spending.

According to Modern Healthcare reporting, robust site-neutral legislation could save over $100 billion over ten years. This makes the policy attractive as a funding mechanism—lawmakers can use those savings to pay for other priorities like extending telehealth, stabilizing Medicare physician payments, or preserving safety-net funding.

In previous Congresses, only modest site-neutral measures advanced. However, the political environment has changed. Analysts note that with a unified Republican government in 2025, policymakers may be more inclined to pass significant site-neutral reforms to secure long-term savings. During the lame duck session, a narrow measure included in the bipartisan Lower Costs, More Transparency Act—requiring site-neutral payments for certain drug administration services—could move forward as a pay-for. This smaller step might pave the way for broader reforms next year.

Hospitals, supported by the American Hospital Association, strongly oppose site-neutral policies, arguing these cuts would limit their ability to provide comprehensive services. Some advocates worry that reducing hospital outpatient department payments could disproportionately affect rural and underserved areas, threatening access to care if hospitals respond by consolidating or reducing less profitable services. Congress must weigh these concerns against the promise of substantial cost savings. Whether any notable site-neutral measures pass now or wait until next year remains uncertain.

The Upcoming Administration: Implications for Public Health Priorities

By early 2025, incoming administration appointees will shape federal healthcare priorities. As PBS NewsHour reports, the Administration’s picks signal possible skepticism toward established vaccine policies and a shift in public health approach, potentially reducing the emphasis on infectious disease prevention that guided previous eras. Meanwhile, experts warn that changes could weaken U.S. influence on global health initiatives.

This shifting focus could impact ongoing campaigns to address HIV and other chronic or communicable conditions. Without consistent federal direction and robust support, gains made under established programs may not be sustained. Advocates hope that at least some lame duck extensions can preserve the foundation of existing programs—like telehealth and CHCs—helping insulate vulnerable communities from policy swings that may come with new leadership.

Programs like Ryan White and PEPFAR, which have maintained strong bipartisan support in the past, could face new scrutiny in an environment where budget discipline and re-examining unreauthorized programs take center stage, potentially embroiling these critical pillars of HIV care and prevention in broader spending debates.

Navigating Short-Term Extensions and Long-Term Implications

Analysts predict a restrained legislative approach during the lame duck, with lawmakers likely settling for short-term solutions to avert immediate disruptions rather than enacting comprehensive reforms. This approach may feel unsatisfying to those seeking lasting certainty, but it can prevent sudden gaps in coverage and services while buying time to reassess priorities in 2025.

For example, a brief funding extension for CHCs or a short-term continuation of telehealth flexibilities could prevent abrupt care disruptions. Telehealth has already proven critical for expanding access to behavioral health services, and federal agencies have now taken further steps to preserve this access. The U.S. Drug Enforcement Administration (DEA) and U.S. Department of Health and Human Services (HHS) recently extended telemedicine flexibilities for prescribing Schedule II-V controlled substances through the end of 2025. This marks the third extension of pandemic-era policies that allow practitioners to prescribe controlled medications—such as suboxone (used in opioid use disorder treatment)—via telemedicine without an in-person evaluation. Retaining these flexibilities, even if temporary, helps sustain harm reduction efforts and essential treatment access for those managing substance use disorders.

A modest Medicare physician payment patch could also preserve provider participation while deeper structural reforms are debated. On the revenue side, modest site-neutral tweaks may generate savings to fund these stopgaps without forcing lawmakers to finalize wide-ranging changes immediately.

Meanwhile, Democrats have floated extending Affordable Care Act subsidies in a potential year-end health deal that also includes telehealth extensions and incremental improvements in physician reimbursements. Such proposals face uncertainty as Republicans prepare to take full control in 2025, but even short-term deals could maintain coverage gains and service expansions that benefit people managing chronic conditions and those relying on affordable insurance options.

Given the incoming administration’s focus on spending and efficiency, it may be prudent for stakeholders to identify areas where reducing waste, redundancy, or abuse is possible—particularly within large, long-standing programs. Offering proactive solutions aligned with fiscal priorities, while demonstrating that essential services remain intact, could help preserve support for programs like Ryan White. This approach allows advocates to show policymakers that sustained funding can go hand-in-hand with accountability and cost-effectiveness, paving the way for more secure, long-term access to critical healthcare services.

Actions for Advocates and Public Health Officials

1. Engage Legislators Before December 20th:

   With deadlines looming, advocates can communicate the importance of even short-term extensions for telehealth, CHC funding, and Medicare physician payment stabilization. Stressing the immediate impact of allowing these programs to expire can help secure stopgap measures.

2. Highlight Evidence and Outcomes:

   Data-driven arguments can persuade legislators that certain policies merit continued investment. For example, demonstrating that telehealth has improved access in rural areas or that CHCs reduce costly emergency department visits can make a compelling case for sustained support.

3. Prepare for 2025 Debates:

   The new Congress will likely reassess programs ranging from telehealth expansions to broader HIV initiatives like Ryan White and PEPFAR. Advocates should cultivate coalitions and gather patient stories now, ensuring they can respond effectively to future proposals that may challenge established healthcare priorities. By proactively preparing data and first-person accounts, stakeholders can better influence upcoming debates.

4. Monitor Agency Leadership and Policy Shifts:

   Staying informed about new federal health agency leaders and their public statements helps anticipate changes in priorities. Understanding where the Administration might diverge from past practice can help advocates and providers design strategies to maintain access and care quality—even if federal emphasis shifts away from certain public health initiatives.

Conclusion

December 2024 places the U.S. healthcare landscape at a turning point. The lame duck session unfolds under a cloud of political transition, with an incoming administration and unified Republican control set to reshape policy debates. Lawmakers face a stacked agenda of expiring programs and urgent healthcare needs but may opt only for minimal extensions that maintain the status quo for now.

Decisions made in these final weeks of 2024—from temporary telehealth fixes to short-term CHC funding—will determine how seamlessly care continues into the new year. As Congress weighs sites of service, physician reimbursements, PBM practices, and the future of critical programs like Ryan White and PEPFAR, advocates must remain engaged. The approaching shift in power and priorities adds urgency to even the smallest policy wins now, as they may offer a critical foundation to protect patient access and maintain progress on significant public health initiatives in a potentially more challenging political climate.

New CDC Data Shows Progress on STI and Overdose Prevention

New data from the Centers for Disease Control and Prevention (CDC) marks the first significant declines in both sexually transmitted infections (STIs) and drug overdose deaths after nearly two decades of consistent increases. According to CDC's 2023 STI surveillance report, STI rates have decreased by 1.8% from 2022 to 2023, while provisional data through June 2024 indicates a 14.5% decline in national overdose deaths compared to the previous year. These improvements highlight the impact of recent targeted public health interventions, but significant barriers remain, especially in underserved populations and high-burden regions. The incoming Trump Administration's approach to public health funding raises concerns about the stability of these gains, as political shifts can lead to funding uncertainties and program disruptions.

A Closer Look at the STI Data

The CDC's 2023 STI surveillance report reveals encouraging improvements across several key metrics. Gonorrhea cases declined by 7.2%, falling below pre-pandemic levels, and primary and secondary (P&S) syphilis cases decreased by 10.2%, marking the first substantial decline in over two decades. Perhaps most notably, the rate of congenital syphilis increase slowed significantly to 3% compared to previous annual increases of up to 30%.

Despite these positive trends, persistent disparities continue to be a significant concern. Young people aged 15-24 years account for 48.2% of all reported STI cases, although they represent only 25% of the sexually active population. Gay, bisexual, and other men who have sex with men (MSM) remain disproportionately affected, making up 32.7% of all P&S syphilis cases in 2023. Racial and ethnic disparities are also evident, with Black and American Indian/Alaska Native populations experiencing significantly higher rates of all measured STIs compared to other groups.

Geographic disparities further complicate the picture. The South and West regions of the United States report the highest STI rates, with limited testing accessibility and healthcare infrastructure contributing to these regional differences. Targeted prevention measures in high-burden regions will be critical to further reducing these disparities and sustaining progress.

Progress in Overdose Prevention

CDC provisional data through June 2024 indicates a significant decline of 14.5% in national drug overdose deaths compared to the previous year. Forty-five states report decreases in overdose deaths, with North Carolina, Nebraska, and West Virginia showing the most notable reductions of 30%, 23%, and 19%, respectively. However, five Western states continue to report increases, highlighting ongoing geographic disparities in overdose prevention effectiveness.

One of the key factors contributing to these improvements is the expanded access to naloxone, particularly after its approval for over-the-counter use in March 2023. Increased naloxone availability, paired with interventions to reduce solitary drug use, is estimated to have the potential to reduce overdose deaths by up to 37.4%.

Despite this progress, access to overdose prevention services remains inconsistent. Rural areas, especially in the Western United States, face unique challenges due to limited availability of treatment options and prevention tools. This calls for more targeted interventions to bridge the gap between urban and rural areas.

Federal Investments and Policy Shifts

Recent federal funding initiatives signal a strategic shift towards integrated prevention approaches. The Biden Administration's $65.7 million prevention and treatment package, announced in August 2024, emphasizes coordinated responses to overlapping public health challenges, including STIs and substance use disorders. Of this, $27.5 million is specifically allocated for substance use prevention services across states, local governments, and tribal communities.

Additional investments include the U.S. Department of Health & Human Services’ (HHS) Minority HIV/AIDS Fund's $4.8 million support for initiatives targeting doxycycline post-exposure prophylaxis (doxy PEP) and point-of-care testing for HIV and syphilis in 13 jurisdictions. These efforts focus on regions identified as having high unmet needs, aiming to reduce barriers to STI prevention and treatment, particularly for marginalized populations.

However, funding sustainability remains an ongoing challenge, especially with the uncertainty introduced by the changing political landscape and the potential for shifts in federal priorities under the new administration. The 2023 rescission of $400 million in disease intervention specialist funds has forced staff reductions across state health departments, compromising the ability to provide essential contact tracing, partner services, and community outreach. While the Senate Appropriations Committee has proposed a $2 million increase for STI prevention programs, it falls significantly short of offsetting previous cuts, posing a substantial risk to the gains made in recent years.

Barriers to Sustained Progress

Despite progress, systemic barriers threaten the sustainability of current improvements in STI and overdose prevention. Key challenges include limited workforce capacity, geographic disparities in access to care, and medical supply chain issues.

Workforce Capacity and Geographic Barriers

The loss of $400 million in disease intervention specialist funding has significantly impacted state-level prevention efforts, leading to workforce reductions across health departments and limiting their capacity to provide necessary prevention services. The impacts of these workforce reductions are most acutely felt in the South and West regions, where both STI and overdose rates remain highest.

Healthcare delivery infrastructure also presents notable barriers. In rural and underserved communities, access to testing and prevention services remains a critical issue. Without targeted investment in these areas, disparities in healthcare access will persist, undermining the broader public health goals of reducing STI and overdose rates.

Supply Chain Vulnerabilities

Another critical challenge lies in supply chain vulnerabilities, particularly for key medications like Bicillin L-A, which is the only approved treatment for congenital syphilis. Shortages in Bicillin L-A have complicated the treatment of congenital syphilis, which already poses a substantial burden on maternal health services. The 2023 STI surveillance report highlights 3,882 reported congenital syphilis cases, including 279 stillbirths and infant deaths, emphasizing the urgent need for stable access to treatment.

Funding Instability

Funding instability continues to undermine long-term progress. The inconsistent nature of prevention program funding—often reliant on short-term grants—makes it challenging for state health departments to maintain consistent services and infrastructure. Transitioning to sustainable funding models that support long-term planning and implementation is crucial if gains are to be maintained and expanded.

Path Forward: Scaling Effective Models and Sustainable Funding

To build on recent successes in reducing STI and overdose rates, it is essential to strengthen and expand effective prevention models, address healthcare access disparities, and secure sustainable funding sources. Below are recommendations to ensure continued progress:

1. Transition to Sustainable Funding Mechanisms

Federal and state funding for STI and overdose prevention programs must transition from sporadic grants to more reliable, sustained funding streams. The restoration of the $400 million disease intervention specialist funding should be prioritized to rebuild essential workforce capacity. Without a stable financial foundation, health departments will struggle to maintain prevention programs and respond effectively to emerging challenges.

2. Expand Proven Prevention Models Nationally

Programs such as CDC's PS-24-0003, which supports HIV prevention in sexual health clinics, and PS-23-0011, which expands services in high-burden communities, have demonstrated effectiveness in improving health outcomes. Scaling these models to a national level, with an emphasis on high-burden regions, will help ensure that the successes seen in certain areas can be replicated more broadly.

3. Strengthen Healthcare Access in Underserved Areas

Addressing geographic disparities requires focused efforts to expand healthcare access in rural and underserved communities. Efforts should include increasing the availability of rapid testing, supporting mobile health units, strengthening telemedicine infrastructure, and investing in the development of local healthcare workforces. Such measures will help bridge the gaps in access and contribute to reducing the unequal burden of STIs and overdose deaths across regions.

4. Address Supply Chain Issues for Essential Medications

To mitigate the impact of medication shortages, federal policy must prioritize securing stable supply chains for essential treatments like Bicillin L-A. This might include incentives for domestic production or other strategies to ensure a consistent supply of critical medications.

5. Enhance Data Collection and Integration

Modernizing data collection and surveillance systems will enhance the ability to track health outcomes and guide resource allocation. Improved integration between public health and healthcare systems can facilitate more timely and effective responses, reduce duplicative efforts, and enhance the overall efficiency of prevention programs.

Moving Towards Sustainable Progress

Recent data showing reductions in STI and overdose rates demonstrate the positive impact of well-targeted public health interventions. However, sustaining and expanding upon this progress requires systematic policy changes and sustained commitment to prevention infrastructure. Addressing systemic barriers—including funding instability, geographic and racial disparities, workforce limitations, and supply chain challenges—will be crucial to achieving long-term success. By scaling effective programs, ensuring equitable access to healthcare services, and committing to long-term funding, there is potential not only to maintain recent gains but to significantly move towards reducing the incidence of STIs and overdose deaths nationwide.

World AIDS Day: Together, Forward.

Every December 1st, World AIDS Day serves as a time for reflection, honoring those we’ve lost to HIV/AIDS, and recommitting to the work ahead. This year, the Office of National AIDS Policy unveiled the theme “Collective Action: Sustain and Accelerate HIV Progress” on October 4th. However, by November 5th, many of us were questioning how we can sustain and, let alone accelerate, our efforts following the general election and the resulting uncertainty.

For most, World AIDS Day is an annual event. But for some of us, every day is World AIDS Day.

Since my diagnosis in 2016, this day has been deeply personal—a time for introspection. It’s a day to recognize and honor those who came before me, those who fought for better lives for themselves and their communities. I feel immense gratitude for their sacrifices. While this day often presents an opportunity to celebrate our progress, it can be challenging to celebrate when that progress remains unequal. It’s even harder to celebrate knowing the uncertainty that looms after the recent election.

Over the past few weeks, I’ve had extensive conversations with individuals in my community who are grappling with fear and anxiety about the unknown. This fear is valid. Concerns about access to gender-affirming care, uphill challenges in the public health sector, and worries for immigrants are all real. The incoming Administration has already indicated plans to target marginalized communities, dismantle essential programs and departments, and undermine critical initiatives. While campaign promises often fall short, they can sow seeds of doubt and concern about what lies ahead.

Just days after the election, I attended a meeting of the U.S. People Living with HIV Caucus. These meetings are among my favorites, always inspiring, and filled with legends of advocacy—many of whom have been at the forefront of this fight since the early days of the AIDS crisis. 

Space was allocated for meeting attendees to express their emotions regarding the election and the future. Many expressed sadness and distress about the outcome. I’m often quiet in these meetings, I feel like a small child in a room full of grown-ups. After listening to others’ perspectives, I decided to raise my hand. I spoke about my concerns for LGBTQ+ youth and the communities disproportionately affected by HIV. Despite my concerns, I expressed a sense of resolve.

Following the 2016 election, I, like many others, felt lost, and angry. Struggling to find purpose, I reached out to the local LGBTQ+ center to volunteer. I discovered that building community, learning to love, and leaning on one another provided hope amidst uncertainty.

Much has transpired in the eight years since then. Many of us who engaged during that time have continued to advocate for various issues. I’ve reminded myself and others that while we may face unknown and challenging days ahead, we have consistently fought for a better world regardless of who is in power. This has equipped us with two crucial tools for navigating an uncertain future: experience and community.

Throughout history, communities have come together to counteract the harms inflicted by those in power. Including the Gay Liberation Front, ACTUP, and the civil rights movement. Those who are knowledgeable about our collective history are better prepared to prevent it from repeating or at least minimize the damage. The knowledge of our rich history of transforming the tide gives me the most significant asset in this moment: hope.

Back in November, I posed a question: are we ready to answer the call of this moment? I don’t believe that question is any less relevant today. We never knew what that call would entail, yet here we are. This year, on World AIDS Day, and likely every day for the next four years, I hold onto the words my friend Jen Laws shared with us shortly after the election: “We are not called to this work because it is easy; we are called to this work because it is necessary.”

While we face an uncertain path ahead, we have the blueprints from our history, and the support of our communities to guide us. We must approach each day, one at a time, while clinging to hope with unwavering determination. Not because things will be easy, but because it is our inherent calling to look forward, to work collectively to not only sustain but also to shape the future of our country, and the world. It would be an ultimate disgrace to let our friends, family, and elders succumb to a plague, and for us to abandon our mission at this moment.

Bipartisan Hepatitis C Elimination Plan Presents Critical Lame Duck Opportunity

The presidential election results have created an urgent six-week window for advancing the National Hepatitis C (HCV) Elimination plan. With significant changes to federal healthcare policy likely under the incoming administration, Senators Bill Cassidy (R-LA) and Chris Van Hollen (D-MD) see the lame duck session as a critical opportunity to secure this public health initiative. The legislation's prospects benefit from Senator Cassidy's likely chairmanship of the Senate Health, Education, Labor and Pensions (HELP) Committee in the next Congress, providing potential continuity for implementation oversight despite the broader administrative transition.

The Congressional Budget Office's analysis provides compelling economic justification for swift action. Current estimates indicate between 2.5 and 3.0 million people in the United States are living with HCV, yet only one in three people diagnosed receive treatment within 12 months. This treatment gap resulted in over 14,000 deaths from HCV-related complications in 2020 alone - deaths that could have been prevented with existing curative treatments that demonstrate 95% effectiveness.

The scope of this crisis demands federal intervention. State-level efforts, while demonstrating potential, have proven insufficient for achieving elimination goals. The Cassidy-Van Hollen legislation addresses fundamental barriers beyond medication costs, including provider education, treatment infrastructure, and implementation support. These comprehensive elements, combined with projected long-term savings, position this bill as a rare opportunity for bipartisan achievement in public health policy during a period of political transition.

Economic Analysis Reveals Complex Implementation Challenges

The Congressional Budget Office's June 2024 analysis examines two treatment expansion scenarios among Medicaid enrollees, revealing both significant savings potential and implementation complexities. Under a conservative 10% peak increase in treatment rates, averted healthcare spending would reach $0.7 billion over ten years against $0.5 billion in testing and treatment costs. A more aggressive 100% peak increase could generate $7 billion in averted costs against $4 billion in treatment expenses.

These projections, however, exclude critical implementation costs that could significantly impact program effectiveness. The CBO notes successful expansion requires substantial investment in outreach activities, provider education, and infrastructure development. As treatment rates increase, identifying and engaging people who need treatment becomes progressively more complex and costly - a challenge demonstrated by state-level experiments with subscription models.

Louisiana's program illustrates both the potential and limitations of cost-focused approaches. While reducing projected costs from $760 million to $35 million annually and treating over 1,600 people since 2019, treatment rates have steadily declined. Washington state's experience proves more concerning - treatment rates fell below pre-subscription levels, dropping from 6,649 prescriptions in 2017 to 2,409 in 2021.

The CBO's analysis particularly focuses on Medicaid enrollees, noting this population includes many people at elevated risk for HCV, including people who inject drugs and people who have been involved with the criminal justice system. This targeted approach allows for more precise cost projections while addressing a key demographic in HCV elimination efforts. Notably, the standard 10-year budget window may undervalue long-term benefits, as many health complications from untreated HCV develop over decades.

State experiences reveal important lessons for federal policy design. Washington's planned initiatives - including emergency room screening programs, mobile testing units, and expanded clinic access - remained largely unrealized due to budget constraints. Louisiana's model, despite demonstrating viable cost-control mechanisms, approaches expiration without renewal funding. These outcomes emphasize the need for sustained federal support rather than relying on state-level innovation.

Carceral Settings Reveal Critical Implementation Lessons

Treatment access in prisons provides critical insight into healthcare system readiness for HCV elimination. Despite controlled environments ideal for treatment delivery, systematic failures in carceral settings expose fundamental weaknesses in current approaches. Between 2014-2019, 1,013 people died from HCV-related complications while incarcerated, with the prison death rate reaching 10.0 per 100,000 people by 2019 - more than double the 4.3 per 100,000 rate in the general population.

State-level data reveals how policy choices, rather than medical constraints, drive treatment disparities. Florida reported 7,000 untreated cases in 2021 despite court-ordered treatment expansion. Texas provided treatment to only half of its known HCV-positive population of 11,301-15,563 people. Oklahoma's statistics prove particularly alarming - its prison death rate of 71.9 per 100,000 exceeds its general population rate by more than five times, despite the corrections department requesting nearly $100 million for increased treatment.

Recent investigations have catalyzed improvements in several states' treatment protocols. The FDA's 2024 approval of point-of-care testing technology enables rapid diagnosis and treatment initiation in carceral settings. However, implementation remains inconsistent across state systems, with many maintaining restrictive eligibility criteria that delay treatment until people develop severe liver damage. Texas, for example, still lacks universal screening protocols at intake facilities, leaving countless cases unidentified and untreated.

Legal challenges have prompted some progress. Florida, under court order, treated over 3,000 people between 2018 and 2021. Texas agreed to treat at least 1,200 people annually following a 2020 settlement. However, these court-mandated improvements highlight both the potential for rapid treatment expansion and the need for comprehensive federal policy to ensure consistent care delivery.

These systemic failures in controlled environments underscore broader implementation challenges. If consistent HCV treatment proves difficult in settings with stable populations and established healthcare infrastructure, addressing treatment gaps in the general population requires even more robust support systems and sustained funding commitments.

Implementation Barriers Demand Federal Solutions

Provider engagement represents a critical barrier beyond cost reduction. Despite HCV treatment's relative simplicity compared to managing diabetes, primary care providers often hesitate to initiate treatment. A recent study found that while 94% of specialists prescribe HCV treatment, only 23% of primary care providers do so. Insurance authorization processes exacerbate this reluctance - a single prior authorization request consumes 35 minutes of staff time responding to questions often designed to find denial justifications rather than facilitate treatment.

Geographic barriers particularly impact rural communities. In Louisiana, people in certain parishes travel 50-70 miles to reach HCV treatment providers. This distance barrier disproportionately affects people receiving Medicaid who often lack reliable transportation. Rural provider shortages compound these access issues - many rural clinics lack staff trained in HCV care, while others face chronic understaffing that limits capacity for managing complex prior authorization requirements.

Louisiana's experience highlights how workforce challenges undermine treatment expansion even when medication costs are controlled. The state's STI, HIV, and Hepatitis Program struggles with chronic understaffing due to uncompetitive wages and complex contracting arrangements. These staffing limitations directly impact program effectiveness - outreach activities decrease, patient engagement suffers, and treatment initiation rates decline despite medication availability.

The proposed federal legislation addresses these systemic barriers through targeted investments in:

• Provider education and ongoing support programs

• Infrastructure development for treatment expansion

• Resources for patient engagement and retention

• Support for innovative delivery models including mobile clinics

• Integration with existing healthcare systems and substance use treatment programs

• Workforce development and training initiatives

Early state experiences demonstrate that successful implementation requires simultaneous investment across these domains. Washington's inability to realize planned initiatives - including emergency room screening programs and mobile testing units - despite cost controls highlights the need for comprehensive federal support beyond medication access.

Political Window Demands Swift Advocacy Action

The lame duck session presents a rare confluence of political factors favoring HCV elimination policy. Senator Cassidy's likely ascension to HELP Committee chair in the next Congress, combined with his partnership with Senator Van Hollen, bridges current and future implementation efforts. The CBO's projection that a national elimination program could prevent 24,000 deaths and save $18.1 billion in healthcare costs provides compelling economic justification for swift action.

Recent developments strengthen the case for immediate passage. The FDA's approval of point-of-care testing technology enables rapid diagnosis and treatment initiation, particularly in high-impact settings. Louisiana's subscription model expiration creates urgency for federal intervention to sustain successful state initiatives. These factors, combined with potential changes to federal healthcare policy under the incoming administration, make the current legislative window critical for securing comprehensive HCV elimination policy.

The evidence from state experiences demonstrates both the promise and limitations of isolated initiatives. Federal legislation can build on these lessons, providing comprehensive support for implementation while ensuring sustained political commitment through bipartisan leadership. With only weeks remaining in the current congressional session, advocates must emphasize the unique opportunity this moment presents for achieving significant public health progress.

Conclusion

The opportunity for action is narrow, but the potential impact is immense. The bipartisan momentum behind the National Hepatitis C Elimination plan is a chance to advance public health policy at a time when it is desperately needed. The barriers are clear: implementation challenges, provider hesitancy, and geographic and economic obstacles. Yet the solutions are within reach, and the economic and human benefits are undeniable. Federal intervention can address the systemic gaps that state efforts alone cannot fill, providing comprehensive support to save lives and reduce costs.

However, uncertainty looms over the future of public health funding and support under a second Trump Administration, which looks to bring significant changes to federal healthcare priorities. This adds urgency to the current push for bipartisan action.

As advocates, the time to push is now. The lame duck session represents a rapidly closing window to secure funding, address legislative gaps, and ensure continuity into the next Congress. Swift passage of this legislation would not only demonstrate the power of bipartisan collaboration but also offer a meaningful legacy—one that saves thousands of lives and sets a precedent for effective, equitable public health initiatives in the United States. We cannot afford to let this window close without taking action.

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.

A Patient Advocate’s Perspective: The Call of this Moment

Earlier this year, I asked myself and the global public health field a serious question; Are we dedicated to the service of humanity, or are we serving our egos? That question rightfully ruffled feathers that needed to be ruffled. The reality is we live in a time that because of the loudest parties doing the very least, the “truth” is a question instead of fact.

We seem to be on a precipice when we should be finding ourselves at a critical decision point. As we approach the end of the year, an election that will undoubtedly shape our work, global conflict, the realization of climate change and the 2025 Standard Development Goals, I find myself asking a different question, “Are we ready and willing to do what is needed to meet this moment?” Additionally, are we prepared to get out of our own way or get out of the way of others if we are the obstacles?

We find ourselves in a world of increased polarization, the “us versus them” chasm that has only widened over the years, creating an environment that makes bipartisanship seem impossible. We also find ourselves at a stalemate in the HIV space; it is no longer the “sexy” disease with the global leadership and investment it has had. Our political leadership lacks follow through on its historical, robust commitments, non-profits are strained and advocates are burnt out. We have yet to acknowledge the lasting impact COVID-19 has had on all of us and the permanent damage it has done to trust in governments, science, and the goodwill of our neighbors, both domestically and globally. We have long shouted that communities who have led our movement since the early days should be involved in every element of the process. I believe that it is long past due to these same communities who are most impacted (not only by HIV and chronic illnesses but are in the center of the target of divisive political issues) should be holding the reins, they know what their communities need and want.

Self-reflection should be an essential part of our work, collectively and individually. We need to have space and time to reflect on our personal impact, influence, and commitment. In the field of public health, who does and how we decide who has power can have lasting and profound impact on the well-being of millions. Who is sitting at the top of the food chain at places like the CDC matters. Qualifications and experience over the partisan nonsense that we daily find ourselves in should be priority number one. When we allow the divisive climate to infiltrate our own ranks it has consequences. CANN’s CEO, Jen Laws, frequently reflects on the damage caused by Democrats’ role in forcing out Dr. Brenda Fitzgerald at the Centers for Disease Control & Prevention (CDC). “Fitzgerald had an objectively good background for leading the CDC, especially with her history of improving Georgia’s childhood vaccine uptake. Ending up in an environment where a known HIV vaccine scam artist was leading the CDC was absolutely catastrophic to our COVID response, public trust in public health, and renewed vaccine hesitancy.” Jen has never been one to mince words. Indeed, that short-sightedness led by partisan motivation has resulted in renewed vaccine hesitancy, HIV denialism, and weaponizing health conditions in order to oppose the civil rights of immigrants.

While ethical oversight is critical, our focus should remain on appointing leaders who are scientifically rigorous, experienced, and free from extreme ideological positions that could harm public health efforts. Effective public health leadership requires the ability to build coalitions, foster trust, and base decisions on the best available evidence—regardless of political affiliation. The COVID-19 pandemic laid bare the need for clear, consistent messaging and policies that prioritize public health over politics.

As we tackle ongoing public health challenges from infectious diseases to the opioid epidemic, rising rates of chronic illness and emerging health threats, it is imperative that future CDC leaders be chosen based on their qualifications and experience, not as a result of political maneuvering. Bipartisan collaboration ensure that the CDC and other agencies remain focused on their primary mission: protecting the health and well-being of all Americans.

This moment calls for us to return to objective truth instead of fear mongering and conspiracy, the acceptance that two things can be true at the same time, but it also calls on us to have hope that there is a future where public health is something we can agree on both sides of the aisle about. I don’t think that starts with our politicians, that starts with each of us willing to cross the street to meet our neighbors, to find what we have in common instead of the things that have separated us for far too long. We need to return to a culture where our politicians are far more concerned about their constituents instead of sound bites, where we lead with the intention of collaboration and finding bipartisan ways to renew political investment ensuring equitable access to health for everyone.

We are indeed at an inflection point, as highlighted by our friends at the O’Neill Institute. We must renew our commitment to ending HIV and the partisanship that drives disparities in access to care, degradation of our civil and human rights, and blinds us to the humanity of our neighbors.

Proposed Cigna-Humana Merger Raises Stakes for Healthcare Access Amid Election Uncertainty

Cigna Group and Humana are once again discussing a merger that could create a $140 billion insurance giant, further consolidating the U.S. healthcare system. The talks are in preliminary stages after collapsing last December over disagreements about financial terms. FierceHealthcare notes that while discussions have resumed, no formal agreements have been made yet.

The stakes of this merger extend far beyond corporate boardrooms; it directly impacts millions of people's access to essential healthcare services and affordable medications. With Cigna’s Express Scripts commanding 24% of the PBM market and Humana operating the fourth-largest PBM with 8%, the merger raises serious questions about market concentration and its impact on healthcare affordability and accessibility.

Election Outcome Could Determine Merger’s Fate

The timing of the renewed merger talks between Cigna and Humana is no coincidence, occurring just weeks before a presidential election that could heavily influence the merger’s prospects. Bloomberg reports, Wall Street analysts believe that the deal's future hinges on the election outcome, with talks likely "only tangibly moving forward if Trump wins."

Under a Trump Administration, a more favorable regulatory environment might be expected given the GOP's general preference for deregulation. However, skepticism about large corporate mergers from Trump's base and running mate JD Vance complicates this picture. Vance has even praised current FTC Chair Lina Khan, saying she is "one of the few people in the Biden Administration who I think is doing a pretty good job," indicating a potentially less favorable view of healthcare consolidation than the GOP has historically maintained. On the other hand, a Harris Administration would likely continue the Biden Administration's stricter stance on healthcare consolidation, focusing particularly on protecting underserved and rural communities.

TD Cowen analyst Ryan Langston suggests that any formal merger announcement before the election is unlikely, further underscoring the centrality of the election to the deal’s future. Meanwhile, federal scrutiny of pharmacy benefit managers (PBMs) remains high, with the Federal Trade Commission (FTC) accusing the largest PBMs of using negotiation tactics that inflate drug costs, adding another layer of complexity to the regulatory landscape.

Understanding the Scale and Implications of the Proposed Merger

The proposed Cigna-Humana merger would unite two companies with largely complementary business models. Modern Healthcare reports that Cigna dominates in commercial coverage with 16.1 million members, while maintaining a smaller Medicare presence. In contrast, Humana has fewer than 600,000 commercial customers and is withdrawing from employer-sponsored insurance, while standing as the second-largest Medicare insurer with 8.8 million members.

This complementary structure could ease some antitrust concerns, but the combined PBM operations present a more complex challenge. The American Medical Association's (AMA) position on the CVS-Aetna merger highlighted similar concerns, noting that such consolidation can limit competition and reduce patient access to specialty drugs, which may parallel the challenges presented by this merger. Healthcare Huddle's analysis suggests that a merger would create a PBM entity large enough to rival market leader CVS Caremark, potentially controlling 32% of the market. Such concentration in the PBM space has already drawn scrutiny from regulators and policymakers.

To address regulatory hurdles, Cigna is planning to finalize the sale of its Medicare Advantage business to Health Care Service Corporation for $3.3 billion, a move that Modern Healthcare suggests could ease antitrust concerns by eliminating overlapping services. Meanwhile, Humana has faced challenges, with its value dropping nearly 40% this year due to declining Medicare plan enrollments and performance shortfalls resulting in the Centers for Medicare and Medicaid Services (CMS) downgrading their Medicare Advantage (MA) plans’ star ratings.

The combined entity would have a market capitalization of around $121 billion based on October 2024 valuations. While still smaller than UnitedHealth Group's $528 billion market cap, the merger would establish a stronger competitor across both the insurance and PBM markets, potentially reshaping competitive dynamics in the healthcare sector.

PBM Consolidation: Increased Scrutiny as FTC Takes a Stand

The potential merger's impact on pharmacy benefit management deserves particular attention, especially given recent FTC actions against PBMs. Currently, three PBMs control approximately 80% of the market, with Cigna's Express Scripts commanding about 24% and Humana's pharmacy division holding 8% market share, according to Bloomberg Law analysis.

The timing is particularly sensitive given the FTC's September 2024 administrative complaint against major PBMs. As previously reported by CANN, the FTC alleges these companies engaged in anticompetitive rebating practices that artificially inflated drug prices. The FTC investigation has revealed troubling practices, with PBMs frequently prioritizing higher rebates over lower net prices, leading to the exclusion of lower-cost alternatives and driving up drug prices. A combined Cigna-Humana PBM would control 32% of the market, potentially creating an entity large enough to rival market leader CVS Caremark.

This level of concentration raises serious concerns about negotiating power and drug pricing. Bloomberg Law notes that employer groups are particularly wary of the merger, fearing it could make an already complicated market even more opaque for health plans and potentially lead to higher costs for company health plans.

Impact on Healthcare Access and Specialty Care

Healthcare consolidation has long presented significant barriers for patients who rely on specialized care, including those living with chronic conditions like HIV. For example, patients often face more restrictive formularies, meaning fewer options for necessary medications, and increased prior authorization requirements, which can delay access to critical treatments. This is especially problematic for patients with chronic conditions like HIV, where timely and consistent access to specific medications is critical for maintaining health. Research published by Tufts Center for the Evaluation of Value and Risk in Health shows that consolidation often leads to restricted specialty care access, which can be particularly detrimental to people requiring ongoing care management. For instance, patients with cancer may find it harder to access specialized oncologists or newer, targeted therapies due to narrower provider networks and limited formularies. These barriers do more than inconvenience patients—they delay treatments, ultimately impacting patient outcomes.

The National Academy for State Health Policy (NASHP) reports that consolidated health systems frequently use their market power to implement restrictive contracts that can limit patient choice. These contracts often include clauses that prevent insurers from steering patients to higher-value care providers or limit the ability to negotiate better prices, ultimately restricting patient options and driving up healthcare costs. This can particularly impact people relying on specialty medications and services, like those living with HIV who need consistent access to specialists and specific drug regimens.

Consolidated systems often impose more stringent prior authorization requirements and narrower specialty pharmacy networks, as noted in the BMC Health Services Research study. The AMA highlights that merged entities often use their power to make access to specialty drugs more restrictive, which further limits patient options and exacerbates challenges for those needing specialized care. For people living with HIV, disruptions or delays in accessing antiretroviral medications could have serious health implications.

The combined entity's negotiating power could lead to more restricted provider networks. NASHP's research shows that consolidated entities often leverage market power to demand higher reimbursement rates, resulting in narrower networks that limit access to specialists, including HIV care providers.

Navigating Complex Regulatory Hurdles

The proposed Cigna-Humana merger faces significant regulatory scrutiny at both federal and state levels. The merger is likely to undergo a 12- to 24-month regulatory review, particularly given the current antitrust enforcement environment. Regulatory challenges are expected to include a detailed examination of the potential impact on competition, particularly in the PBM market, and whether the merger could lead to increased healthcare costs for consumers. The recent FTC crackdowns on healthcare companies, which could provide additional insights into the type of scrutiny expected during the review, particularly regarding anti-competitive practices and market concentration. Both the FTC and the U.S. Department of Justice are likely to scrutinize any potential overlap in services and demand divestitures to ensure that competition remains intact. Additionally, state-level reviews could require concessions to protect local markets from becoming overly concentrated.

Kaiser Family Foundation's analysis highlights how the FTC and Department of Justice have increased their focus on both horizontal and vertical integration effects. They now examine broader implications for healthcare costs and access, beyond direct market overlap.

State-level review adds another layer of complexity. KFF notes that 34 states and DC require notification of health insurance mergers, with 13 states requiring explicit approval. This multi-state review process could extend the timeline and require concessions to address state-level concerns.

Looking Ahead: Implications for Healthcare Access and Affordability

The proposed Cigna-Humana merger represents more than a business combination—it embodies the tension between market consolidation and healthcare accessibility. While the companies argue that their complementary business models could improve efficiency, the merger's impact on PBM market concentration and healthcare access demands careful scrutiny.

The immediate path forward hinges significantly on the November 5th election outcome, with analysts suggesting meaningful progress is unlikely before then. Beyond the election, the regulatory review process could extend into 2026, as federal and state regulators examine the merger’s implications for competition, drug pricing, and healthcare access.

For healthcare stakeholders, especially those relying on specialty care and medications, the merger’s outcome could significantly impact their care access and costs. The combined entity's expanded market power in both insurance and PBM sectors could reshape provider networks, prior authorization processes, and drug formulary designs.

Advocacy organizations and policymakers must carefully monitor and engage in the regulatory review process to ensure that any approved merger includes meaningful protections for healthcare access and affordability. The FTC’s current focus on PBM practices provides an important opportunity to address long-standing concerns about drug pricing and access in any merger approval conditions.

Public Input Needed: Offer Input on HIV, STI, Vaccine, and Hepatitis Policies

The Office of Infectious Disease and HIV/AIDS Policy (OIDP) at the Department of Health and Human Services (HHS), alongside the White House Office of National AIDS Policy (ONAP), has released a Request for Information (RFI) to inform the 2026–2030 national strategic plans for HIV/AIDS, sexually transmitted infections (STIs), vaccines, and viral hepatitis. This RFI represents a key opportunity for public health stakeholders to shape policies that will directly impact prevention, treatment, and care for millions of people across the country.

Why Strategic Planning Matters

National strategic plans guide public health efforts at federal, state, and local levels. They establish priorities, direct resource allocation, and shape policies that determine the availability and quality of health services. The upcoming 2026–2030 plans aim to build on past progress while addressing new and evolving challenges.

For instance, the National HIV/AIDS Strategy for 2022–2025 set ambitious goals to reduce new HIV infections by 75% by 2025 and by 90% by 2030. Similarly, the Viral Hepatitis National Strategic Plan aims to eliminate viral hepatitis as a public health threat by 2030. These strategies are powerful tools that help us move toward improved health outcomes by setting clear goals and priorities.

What the Strategic Plans Address

Each of the four national strategies addresses unique public health challenges:

1. National HIV/AIDS Strategy – Sets forth a roadmap to end the HIV epidemic in the United States, with goals including:

   • Prevent New HIV Infections: Increasing awareness, testing, and access to prevention tools like PrEP and PEP, while reducing HIV-related stigma.

   • Improve Health Outcomes for People with HIV: Promoting early linkage to care, long-term retention, and viral suppression through integrated and culturally competent health services.

   • Reduce Disparities and Inequities: Addressing structural factors such as stigma and discrimination and focusing efforts on disproportionately affected populations.

   • Achieve Integrated, Coordinated Efforts: Promoting collaboration across sectors to integrate HIV prevention with services for STIs, viral hepatitis, and mental health, among others.

2. Sexually Transmitted Infections National Strategic Plan – Aims to respond to rising STI rates by:

   • Preventing New STIs: Increasing awareness, expanding prevention activities, and improving vaccination rates for HPV.

   • Improving Health Outcomes: Expanding screening and treatment in impacted communities.

   • Accelerating STI Research and Innovation: Supporting the development of vaccines, diagnostic tools, and treatment options.

   • Reducing STI Disparities and Inequities: Addressing stigma, expanding culturally competent services, and addressing social determinants of health.

   • Achieving Integrated, Coordinated Efforts: Promoting collaboration across STI, HIV, and viral hepatitis prevention efforts.

3. Vaccines National Strategic Plan – Focuses on eliminating vaccine-preventable diseases by:

   • Fostering Innovation in Vaccine Development: Supporting research and development of new vaccines and technologies.

   • Maintaining Vaccine Safety: Enhancing safety monitoring and public awareness of vaccine-related risks.

   • Increasing Vaccine Knowledge and Confidence: Addressing vaccine misinformation and improving public understanding of vaccine benefits.

   • Improving Access and Uptake: Reducing barriers to vaccine access and improving coverage, especially in underserved populations.

   • Supporting Global Immunization Efforts: Strengthening international collaboration on vaccine initiatives.

4. Viral Hepatitis National Strategic Plan – Targets the elimination of viral hepatitis as a public health threat, with goals such as:

   • Preventing New Infections: Increasing vaccination for hepatitis A and B and addressing transmission among people who use drugs.

   • Improving Health Outcomes: Ensuring timely testing, treatment, and retention in care for people with viral hepatitis.

   • Reducing Disparities and Inequities: Addressing stigma, enhancing culturally competent care, and focusing resources on high-risk populations.

   • Improving Surveillance and Data Usage: Enhancing data collection and sharing to better understand and address viral hepatitis trends.

   • Achieving Integrated, Coordinated Efforts: Promoting partnerships that address viral hepatitis, HIV, STIs, and substance use disorders together.

The Importance of Public Input

Public participation in the RFI process ensures that these plans reflect the real needs of communities. When stakeholders provide insights based on their experiences, it helps to ensure that strategic plans are grounded in the realities of public health challenges. The voices of people living with HIV (PLWH) and their advocates have led to a greater emphasis on reducing stigma and expanding access to essential services like mental health and substance use support. This type of feedback is needed in order to ensure that health strategies address barriers to care, particularly among marginalized populations, and incorporate promising approaches to delivering services and engaging communities.

By providing input, you can help shape strategies for integrating services across HIV, STIs, viral hepatitis, and vaccine-preventable diseases, making it easier for patients to navigate the healthcare system. Your insights could also highlight ways to leverage new technologies and data systems to improve health outcomes, ultimately influencing policies that determine the availability and quality of health services across the country.

How to Participate

To make your feedback impactful, it's important to examine the existing strategic plans (linked above) and identify areas that could benefit from improvement or expansion. Consider submitting detailed, data-driven feedback based on your experiences or expertise, connecting your observations with broader public health trends or research. Highlighting emerging issues that are currently underrepresented in the plans can also make a significant difference. Additionally, sharing effective practices from your work or community that could be scaled nationally will help ensure that these strategies are practical and inclusive.

The deadline for submitting comments is December 6, 2024, at 11:59 pm ET. You can participate by submitting your feedback through the online form. Your contribution can help create a public health system that is responsive to the needs of all communities.

Why Your Input Matters

By contributing to this RFI, you help ensure that public health strategies are grounded in evidence and lived experience, and are responsive to the communities most affected by HIV, STIs, viral hepatitis, and vaccine-preventable diseases. Your feedback can shape policies that address the most pressing needs of people impacted by these conditions, advance evidence-based approaches, reduce health disparities, and promote equity. Moreover, your input can help improve coordination across healthcare systems and levels of government, ultimately leading to better health outcomes for millions of people.

Your voice matters in shaping the future of public health. Participate in advocacy campaigns by joining public health advocacy groups working to ensure equitable health policies. Share this information with colleagues, networks, and community members who might also want to contribute their insights. Engaging in webinars or public discussions related to the strategic plans can also help you stay informed and connected, providing more opportunities to make an impact.

Final Thoughts

The 2026–2030 national strategic plans will shape public health policy in the U.S. for years to come. Your participation in the RFI process gives you a voice in crafting strategies that are effective, equitable, and responsive to community needs. By sharing your knowledge and experiences, you can help create a future where public health efforts truly serve all communities.

Together, we can make a difference—let's ensure that these plans reflect the needs of everyone, especially those most impacted.

Biden’s Inaction Leaves Copay Assistance in Limbo

Inflated prescription drug costs in the United States continue to place a significant burden on people living with chronic conditions. Copay assistance programs, designed to help people afford their medications, have become essential. Yet recent policy decisions and industry practices have put these programs at risk, potentially jeopardizing access to necessary treatments.

The Biden Administration's recently proposed 2026 Notice of Benefit and Payment Parameters (NBPP) rule omits crucial regulations that patient advocates have long been demanding. This inaction allows insurers and pharmacy benefit managers (PBMs) to continue profiting from billions of dollars of drug manufacturer copay assistance intended for patients.

The State of Copay Assistance

Copay assistance programs, primarily offered by pharmaceutical manufacturers, provide financial support to help cover out-of-pocket costs for prescription medications. As health insurance plans increasingly shift costs to patients through higher deductibles and copayments, these programs have become crucial.

According to the latest data from The IQVIA Institute, manufacturer copay assistance offset patient costs by $23 billion in 2023, a $5 billion increase from the previous year. This figure represents 25% of what retail prescription costs would have been without such assistance. Over the past five years, copay assistance has totaled $84 billion, highlighting its importance in maintaining access to medications.

Despite the significance of copay assistance, copay accumulator and maximizer programs accounted for $4.8 billion of copay assistance in 2023—more than double the amount in 2019. Implemented primarily by pharmacy benefit managers (PBMs) and insurers, these programs prevent assistance from counting towards patients' deductibles and out-of-pocket maximums. This practice effectively nullifies the intended benefit of copay assistance, leaving people to face unexpected and often unaffordable costs later in the year.

Recent scrutiny of PBMs has brought attention to these practices. As discussed in our recent article on PBMs, the Federal Trade Commission (FTC) has filed a lawsuit against the largest PBMs for alleged anticompetitive practices that inflate drug costs and limit access to medications. These developments underscore concerns about how PBM practices, including the implementation of copay accumulator programs, impact medication affordability and access.

The impact on access is serious. IQVIA reports that in 2023, patients abandoned 98 million new therapy prescriptions at pharmacies, with abandonment rates rising as out-of-pocket costs increase. This trend highlights the critical role copay assistance plays in helping people not only initiate but also maintain their prescribed treatments.

Public opinion strongly supports action on this issue. A Kaiser Family Foundation survey found that 80% of adults believe prescription drug costs are unreasonable, with broad support for various policy proposals to lower drug costs. This sentiment reflects the public's recognition of the financial challenges faced in accessing necessary medications.

The Legal and Regulatory Landscape

The regulatory environment surrounding copay assistance programs has been in flux, with significant developments in recent years. On September 29, 2023, a federal court struck down a rule that allowed insurers to decide whether copay assistance would count towards patients' out-of-pocket maximums. This ruling reinstated the 2020 NBPP rule, which required insurers to count copay assistance towards patient cost-sharing, except for brand-name drugs with available generic equivalents.

Despite this, the federal government declared that it would not enforce the court's decision or the 2020 NBPP rule until new regulations are issued. This inaction has left patients facing continued uncertainty about the status of their copay assistance.

On January 16, 2024, the Biden Administration dropped its appeal of the court decision. While this action confirms that the 2020 NBPP rule will generally apply until new rules are issued, the lack of enforcement leaves plans and insurers in a gray area regarding their copay accumulator programs.

At the state level, there has been a growing movement to address copay accumulator programs. As of 2024, 21 states, the District of Columbia, and Puerto Rico have enacted laws addressing the use of these programs by insurers or PBMs. These laws generally require any payments made by or on behalf of the patient to be applied to their annual out-of-pocket cost-sharing requirement. While these state actions provide important protections, they do not cover all insurance plans, particularly those regulated at the federal level.

The 2026 Notice of Benefit and Payment Parameters Proposal

The proposed 2026 NBPP rule, released by the Centers for Medicare & Medicaid Services (CMS), has drawn criticism from patient advocacy groups for significant omissions related to copay assistance and essential health benefits (EHB).

Notably absent from the proposed rule are regulations clarifying whether copay assistance will count toward patient cost-sharing. This omission perpetuates uncertainty created by previous conflicting rules and court decisions, allowing insurers and PBMs to continue implementing copay accumulator programs that can leave people with unexpected and unaffordable out-of-pocket costs.

The proposal also fails to include a provision to ensure that all drugs covered by large group and self-funded plans are considered essential health benefits, despite previous indications that such a provision would be forthcoming. This failure to close the EHB loophole allows employers, in collaboration with PBMs and third-party vendors, to designate certain covered drugs as "non-essential," circumventing Affordable Care Act (ACA) cost-sharing limits designed to protect people from excessive expenses.

By exploiting this loophole, plan sponsors can collect copay assistance provided by manufacturers without applying it to beneficiaries' cost-sharing requirements. This practice effectively doubles the financial burden on patients: first, by accepting the copay assistance, and second, by requiring them to pay their full out-of-pocket costs as if no assistance had been provided.

Recent research by the HIV+Hepatitis Policy Institute has revealed that over 150 employers and insurers are taking advantage of the EHB loophole. This list includes:

• Major companies such as Chevron, Citibank, Home Depot, Target, and United Airlines

• Universities including Harvard, Yale, and New York University

• Unions like the New York Teamsters and the Screen Actors Guild

• States such as Connecticut and Delaware

• Insurers, including several Blue Cross/Blue Shield plans

Patient advocacy groups have reacted strongly to these omissions. Carl Schmid, executive director of the HIV+Hepatitis Policy Institute, stated, "Every day these rules are delayed is another day that insurers and PBMs are pocketing billions of dollars meant for patients who are struggling to afford their drugs." This sentiment reflects the frustration of many who have long advocated for stronger protections.

The widespread exploitation of the EHB loophole underscores the urgent need for federal action to protect patients from these practices. The failure to address these critical issues in the 2026 NBPP proposed rule highlights a significant setback in efforts to improve medication affordability and access for people living with chronic conditions.

The Impact on Patients: Data and Experiences

The real-world impact of copay accumulator programs and the EHB loophole is reflected in both data and personal experiences. IQVIA reports that patient out-of-pocket costs reached $91 billion in 2023, an increase of $5 billion from the previous year. This rise in costs comes despite the $23 billion in copay assistance provided by manufacturers, highlighting the growing financial burden on patients.

Prescription abandonment is particularly concerning. Patients abandoned 98 million new therapy prescriptions at pharmacies in 2023, with abandonment rates increasing as out-of-pocket costs rise. More than half of new prescriptions for novel medicines go unfilled, and only 31% of patients remained on therapy for a year. These statistics highlight the direct link between cost and medication adherence.

People across the country are facing these challenges. For example, a mother whose daughter lives with cystic fibrosis shared her experience with a copay accumulator program. In early 2019, her family's out-of-pocket cost for her daughter's medication suddenly jumped from $30 to $3,500 per month when their insurance plan stopped applying copay assistance to their deductible. This unexpected change forced the family to put the cost on credit cards, creating significant financial strain and unnecessary medical debt.

Similarly, a person living with psoriasis faced steep increases in medication costs when their insurance company stopped counting copay assistance towards their deductible. The copay rose from $35 to $1,250 monthly, leaving them with only $26 from their disability payment after covering the copay.

These stories are not isolated incidents. People living with conditions such as HIV, hepatitis, multiple sclerosis, and hemophilia are facing similar challenges. The impact extends beyond financial stress, affecting medication adherence and, ultimately, health outcomes. For many, the choice becomes one between essential medications and other basic needs such as food and shelter—a decision no one should have to make.

Policy Recommendations and Advocacy Efforts

Patient advocacy groups are intensifying efforts for policy changes at both the federal and state levels. The All Copays Count Coalition, comprising over 80 organizations representing people living with serious and chronic illnesses, has been at the forefront of these efforts. In a letter to federal officials, the coalition urged for a revision of the cost-sharing rule to include clear protections ensuring that copayments made by or on behalf of a patient are counted towards their annual cost-sharing contributions. Specific recommendations include:

1. Maintaining the protections included in the 2020 Notice of Benefit and Payment Parameters.

2. Ensuring that copay assistance counts for medically appropriate medications, even when generic alternatives are available.

3. Limiting Health Savings Account-High Deductible Health Plan (HSA-HDHP) carve-outs to situations where using copay assistance would result in HSA ineligibility.

At the state level, advocacy efforts have led to the passage of laws restricting copay accumulator programs in 20 states, the District of Columbia, and Puerto Rico as of summer 2023. However, these state-level protections do not cover all insurance plans, particularly those regulated at the federal level, highlighting the need for comprehensive federal action.

Advocates are calling for:

1. Immediate enforcement of the 2020 NBPP rule, requiring insurers to count copay assistance towards patient cost-sharing in most cases.

2. Swift action to close the essential health benefits loophole for all plans, including large group and self-funded plans.

3. Increased oversight and regulation of PBM practices, particularly regarding copay accumulator and maximizer programs.

4. Passage of comprehensive federal legislation to protect those relying on copay assistance.

As Carl Schmid emphasized, "While they have gone on record that they will issue these rules, the clock is ticking and there isn't much time left." This reflects the growing frustration among patient advocates with the administration's delays in addressing these issues.

Policymakers must act swiftly to close the essential health benefits loophole and ensure that all copay assistance counts towards patients' out-of-pocket costs. Stakeholders across the healthcare ecosystem—from insurers and PBMs to pharmaceutical companies and patient advocacy groups—must collaborate to develop solutions that prioritize access and affordability. The health and well-being of millions depend on these critical policy changes.

FTC Sues Major PBMs for Unfair Practices Affecting Drug Costs

Pharmacy Benefit Managers (PBMs) have long been influential yet often obscure intermediaries in pharmaceutical pricing and distribution. They negotiate drug prices with manufacturers, develop formularies for health plans, and manage pharmacy networks. Today, the three largest—CVS Caremark, Express Scripts, and OptumRx—control about 80% of the market.

On September 20, 2024, the Federal Trade Commission (FTC) filed an administrative complaint against these major PBMs and their affiliated group purchasing organizations (GPOs). The complaint alleges that they engaged in anticompetitive and unfair rebating practices, artificially inflating insulin prices and impairing access to lower-cost alternatives.

The FTC's action marks a critical juncture in the struggle for fair drug pricing and access, emphasizing the need for robust enforcement and comprehensive PBM reform. The outcome could reshape the healthcare industry and significantly impact care across the United States.

The FTC's Case Against PBMs

The FTC alleges that PBMs have engaged in anticompetitive and unfair rebating practices that have artificially inflated the list prices of insulin and other essential medications. Grounded in Section 5 of the Federal Trade Commission Act, which prohibits unfair competition and deceptive practices, the FTC asserts that PBMs' rebate strategies and patient steering harm consumers and competition.

For example, the list price of Humalog, a widely used insulin product, increased from $21 in 1999 to over $274 in 2017—a rise of more than 1,200%. The FTC argues that this dramatic inflation is linked to PBMs' "chase-the-rebate" strategy, where they demand larger rebates from manufacturers in exchange for favorable formulary placement.

Another key aspect of the complaint focuses on patient steering practices. The FTC alleges that PBMs have systematically excluded lower-cost insulin alternatives from their formularies in favor of higher-priced options that generate larger rebates. This practice limits choice and forces many to pay more out-of-pocket for their medications.

Rahul Rao, Deputy Director of the FTC's Bureau of Competition, emphasized: "Millions of Americans with diabetes need insulin to survive, yet for many of these vulnerable patients, their insulin drug costs have skyrocketed over the past decade thanks in part to powerful PBMs and their greed."

The FTC seeks to fundamentally change how PBMs operate. The complaint aims to prohibit PBMs from excluding or disadvantaging lower-cost versions of drugs, prevent them from accepting compensation based on a drug's list price, and stop them from designing benefit plans that base out-of-pocket costs on inflated list prices rather than net costs.

FTC Chair Lina Khan stated, "The FTC's administrative action seeks to put an end to the Big Three PBMs' exploitative conduct and marks an important step in fixing a broken system—a fix that could ripple beyond the insulin market and restore healthy competition to drive down drug prices for consumers."

Impact on People Living with HIV

While the FTC's case primarily focuses on insulin pricing, PBM practices significantly affect people living with HIV (PLWH) and other chronic conditions. Recent cases highlight the challenges faced in accessing affordable medications due to PBM and insurer practices.

In April 2024, CVS Health failed in its latest attempt to dismiss a class action lawsuit alleging discrimination against PLWH by requiring them to receive medications via mail order, limiting access to essential pharmacy services and counseling. U.S. District Judge Edward Chen noted that CVS was on notice that this program could likely discriminate against PLWH, as plaintiffs had repeatedly requested to opt out.

In another case, the U.S. Department of Health and Human Services Office for Civil Rights (OCR) closed a complaint without penalties against Blue Cross Blue Shield of North Carolina (BCBS NC) after the insurer lowered the pricing tier for HIV medications. The original complaint alleged that BCBS NC had placed almost all HIV antiretroviral medications, including generics, on the highest-cost prescription tiers.

While BCBS NC changed its formulary, the lack of penalties raises concerns about enforcement and accountability. Carl Schmid, executive director of the HIV+Hepatitis Policy Institute, expressed disappointment: "It was incredibly disheartening and deeply concerning to see them let the state's largest insurer get away with such blatant discrimination."

These cases illustrate how PBM practices and insurer policies create significant barriers to care for people living with HIV. High out-of-pocket costs, restricted pharmacy access, and discriminatory formulary designs can lead to medication non-adherence, resulting in adverse health outcomes and increased healthcare costs in the long term.

In North Carolina, about 37,000 people are living with HIV, with Black people representing 58% of new HIV diagnoses despite being only 22% of the state's population. Nationally, according to the Centers for Disease Control and Prevention (CDC), approximately 1.2 million people in the United States are living with HIV. PBM practices that inflate drug costs or limit access exacerbate these disparities and hinder efforts to end the HIV epidemic.

PBM Practices Under Scrutiny

The FTC's complaint has brought controversial PBM practices into sharp focus, highlighting concerns long raised by patients, healthcare providers, and policymakers.

The FTC's interim staff report reveals that PBMs often prioritize higher rebates over lower net prices, leading to exclusion of lower-cost alternatives and driving up drug prices—a practice known as "rebate walls." Patient steering directs consumers to PBM-owned pharmacies, limiting choice and disadvantaging independent pharmacies.

A Congressional hearing in July 2024 further exposed these issues. PBM executives faced tough questioning about their role in rising prescription drug costs. Lawmakers pressed the executives on how PBMs have monopolized the pharmaceutical marketplace and pushed anticompetitive policies that undermine local pharmacies and harm patients.

Representative Virginia Foxx (R-N.C.) highlighted the lack of transparency, questioning PBM executives about the pass-through of rebates and fees to plan sponsors. The executives' responses did little to clarify the complex and opaque financial flows within the PBM industry.

PBMs defend their practices as necessary for managing drug costs. Phil Blando, Executive Director for Corporate Communications at CVS Caremark, stated, "We work to negotiate the lowest net cost for drugs... driving better health outcomes and lower out-of-pocket costs for consumers." However, critics argue that these claimed benefits are not reflected in patient experiences or overall drug pricing trends.

Real-World Impact on Patients and Pharmacies

Jeremy G. Counts, PharmD, a spokesperson for Pharmacists United for Truth and Transparency (PUTT), explains that the vertical integration of the Big Three PBMs allows them to limit access through restrictive networks, under-reimbursement, and aggressive patient steering. These practices harm independent pharmacies and jeopardize health by disrupting continuity of care.

• Restrictive Networks and Steering: PBMs often require patients to use their own pharmacies, frequently through mail order, misleading them into believing they have no other options. Even when plans allow the use of independent pharmacies, PBMs make it tedious to opt out, effectively limiting choice.

• Under-Reimbursement and Clawbacks: Independent pharmacies that serve patients despite low reimbursements face financial strain. PBMs may pay below cost or use fees and recoupment methods to claw back margins, forcing some pharmacies to turn away patients.

• Barriers to Medication Access: PBMs impose onerous prior authorization processes for medications that do not provide them with high rebates, delaying care and increasing costs. Counts notes that this has become a deadly issue in oncology care.

• Aggressive Patient Pursuit: For profitable medications, PBMs aggressively pursue patients and their prescriptions, sometimes transferring prescriptions without permission or shipping medications without their knowledge.

These practices not only harm independent pharmacies but also jeopardize health by disrupting access to necessary medications.

Healthcare consultant Rita Numerof calls the FTC's investigation a "pivotal moment" in reforming the industry to serve patients' best interests.

The Need for Enforcement

The lack of punitive action in cases like the BCBS NC complaint raises concerns about the effectiveness of current enforcement mechanisms. Carl Schmid of the HIV+Hepatitis Policy Institute pointed out, "Without action to improve federal and state regulation, oversight, and enforcement, such discriminatory practices will continue." The BCBS NC case demonstrates that while policy changes can be achieved through advocacy and complaints, there is often little consequence for discriminatory practices.

Counts emphasizes that "PBMs are masters at derailing legislative attempts to rein them in." He argues that FTC enforcement is critical, as PBMs often ignore laws unless compelled to comply. Counts asserts that attacking the problem from multiple fronts is essential, and FTC action provides immediate and targeted intervention.

PBM Response and Industry Perspective

In response to mounting scrutiny, PBM executives have defended their practices. During the July 2024 Congressional hearing, leaders from CVS Caremark, Express Scripts, and OptumRx maintained that they do not engage in patient steering or discriminatory practices. They argued that PBMs play a crucial role in negotiating lower drug prices and improving healthcare affordability.

David Joyner, president of CVS Caremark, stated, "We're making health care more affordable and accessible for the millions of people we serve every day."

However, these assertions have been met with skepticism. The House Committee on Oversight and Accountability, led by Chairman James Comer (R-Ky.), has accused PBM executives of making statements that contradict findings about self-benefitting practices.

Legislative Efforts: The Pharmacists Fight Back Act

In addition to regulatory actions by the FTC, legislative initiatives are crucial for comprehensive reform. The Pharmacists Fight Back Act (H.R. 9096), introduced by Representatives Jake Auchincloss (D-MA) and Diana Harshbarger (R-TN), aims to:

1. Establish Standard Pharmacy Reimbursement:

   • Proposes a reimbursement model based on the National Average Drug Acquisition Cost (NADAC) plus a state dispensing fee and an additional 2%. This model prevents underpayment to independent pharmacies and curbs price gouging by PBM-owned pharmacies.

2. Prohibit Predatory PBM Tactics:

   • Seeks to ban practices such as steering patients to PBM-owned pharmacies, exclusionary network designs, retroactive fees, spread pricing, and reimbursement clawbacks.

3. Mandate Rebate Transparency and Application:

   • Requires that 80% of all PBM-negotiated rebates and fees reduce patients' out-of-pocket costs, with the remaining 20% lowering insurance premiums.

Counts stresses the urgency of passing this legislation to save pharmacies and reduce drug pricing: "Its immediate passage is critical to stopping the pharmacy closure and drug pricing crisis in this country."

Potential Outcomes and Industry Impact

If successful, the FTC's action could reshape the pharmaceutical industry by forcing PBMs to prioritize lower net drug prices, benefiting patients with more affordable medications and increased pharmacy choice. A ruling against PBMs could set a legal precedent, opening the door for further regulatory action or private lawsuits against PBMs and other healthcare intermediaries.

Independent pharmacies stand to benefit considerably from potential reforms. If the FTC's action results in more transparent pricing practices and limitations on patient steering, these businesses may be better able to compete with PBM-owned pharmacies.

However, given PBMs' significant resources and influence, changes may be hard-fought and take time to implement. There is the possibility that PBMs may find new ways to maintain their market position and profitability.

Impact on Independent Pharmacies

Independent pharmacies are closing at an alarming rate—nine per day, with 2,275 closures so far in 2024. This trend reduces access to personalized care and diminishes competition, further consolidating PBMs' market power.

Counts conducted a study in Virginia, matching pharmacy closures against openings using data from the Virginia Board of Pharmacy. He found that "community pharmacies are closing at twice the rate they are opening, and this rate is accelerating." Without significant reform, including FTC enforcement and the passage of H.R. 9096, the pharmacy infrastructure in the United States will continue to erode.

Conclusion and Call to Action

The FTC's actions, along with legislative efforts like the Pharmacists Fight Back Act, are critical steps toward creating a fairer pharmaceutical industry that prioritizes access and affordability.

We urge readers to:

1. Stay Informed: Follow developments in PBM regulation and reform efforts.

2. Research Legislation: Contact your representatives to inquire about pending legislation.

3. Engage with Advocacy Groups: Support organizations like PUTT (www.truthrx.org) and the HIV+Hepatitis Policy Institute (www.hivhep.org).

4. Share Experiences: Raise awareness by sharing your experiences with PBM practices. PUTT is collecting stories to highlight the real-world impact of PBM practices. Visit their PBM Horror Stories page to share your story anonymously.

Collective action is essential to ensure meaningful and lasting change in drug pricing and access. The FTC's action is a significant step, but it's up to all of us to ensure this momentum leads to a more transparent, equitable, and patient-centered healthcare system in the United States.

The Great Disenrollment: Examining Medicaid's Post-Pandemic Shift

The Medicaid unwinding process that began in April 2023 has significantly impacted healthcare access and coverage retention across the United States. The unwinding, triggered by the end of pandemic-era continuous enrollment provisions, led to substantial shifts in Medicaid enrollment and revealed both strengths and weaknesses in our healthcare system. The process disproportionately affected communities of color and highlighted the need for targeted policy interventions to maintain healthcare access for vulnerable groups, including people living with HIV (PLWH).

The Scope of Medicaid Unwinding

During the COVID-19 pandemic, the Families First Coronavirus Response Act implemented the continuous enrollment provision in March 2020. This policy prohibited states from disenrolling Medicaid beneficiaries in exchange for enhanced federal funding, ensuring that people maintained health coverage during a time of unprecedented health and economic uncertainty. As a result, Medicaid enrollment surged from 71 million people in February 2020 to 94 million by April 2023, according to a Kaiser Family Foundation (KFF) analysis.

The end of the continuous enrollment provision on March 31, 2023, initiated a complex process of eligibility redeterminations for all Medicaid enrollees—a task of immense scale and complexity. By the end of the unwinding period, over 25 million people had been disenrolled from Medicaid, while over 56 million had their coverage renewed, as reported by KFF. The overall disenrollment rate stood at 31%, with significant variation across states. For instance, Montana reported a 57% disenrollment rate, while North Carolina's rate remained below 20%.

Systemic Challenges in the Unwinding Process

One of the most concerning aspects of the unwinding process was the high rate of procedural disenrollments. Of those who lost coverage, 69% were disenrolled for procedural reasons, such as not returning renewal paperwork, rather than being determined ineligible. This suggested that many people who lost coverage may have still been eligible for Medicaid but faced significant challenges navigating the renewal process successfully.

The Government Accountability Office (GAO) highlighted that administrative barriers contributed significantly to these procedural disenrollments. These barriers included:

1. Outdated Technology Systems: At least 11 states reported that their systems were old or difficult to use, making it challenging to produce real-time analytics essential for processing renewals effectively. This technological lag complicated efforts to implement necessary changes swiftly and efficiently.

2. Staffing Shortages: High turnover rates among eligibility workers led to vacancy rates reaching up to 20% in some states. Reports of low morale and burnout further affected the workforce's ability to handle the increased workload during the unwinding process.

3. Communication Barriers: States struggled to effectively engage people in the renewal process, particularly those facing language barriers. Non-English speakers often encountered longer wait times and struggled to reach assistance through call centers. These issues were compounded by a lack of robust state communication and engagement strategies.

4. Complex Paperwork: The renewal process often involved complicated forms and documentation requirements, which proved challenging for many enrollees to navigate, especially those with limited literacy or language skills.

Dr. Benjamin Sommers, a health policy expert at Harvard T.H. Chan School of Public Health, noted during the process, "The high rate of procedural disenrollments is particularly troubling. It indicates that we're not just seeing people leave Medicaid because they no longer qualify, but because they're struggling with the administrative hurdles of the renewal process."

These challenges led to frustration among enrollees and advocacy groups, highlighting the need for more streamlined and accessible renewal processes. The experience underscored the importance of investing in modernized eligibility systems, adequate staffing, and comprehensive communication strategies to ensure that eligible patients can maintain their coverage during future eligibility redeterminations.

National Enrollment Trends and State-Level Variations

Despite significant disenrollments during the unwinding process, Medicaid enrollment remained higher than pre-pandemic levels. As of May 2024, 81 million people were enrolled in Medicaid, an increase of about 10 million compared to pre-pandemic enrollment. However, this growth was not uniform across all populations. While adult enrollment remained over 20% above February 2020 levels, child enrollment was only about 5% higher.

Several factors influenced these disparities:

1. The pandemic's economic impact led to more adults becoming eligible for Medicaid due to job losses and income reductions.

2. States that expanded Medicaid under the Affordable Care Act saw more substantial increases in adult enrollment.

3. Children's enrollment remained relatively stable due to higher pre-pandemic enrollment rates and broader eligibility criteria through programs like the Children's Health Insurance Program (CHIP).

The impact of the unwinding process varied significantly across states, reflecting differences in policies, system capacities, and approaches. States that expanded Medicaid under the Affordable Care Act generally showed higher retention rates. Additionally, states that adopted strategies to streamline the renewal process, such as increasing ex parte (automated) renewals, saw better outcomes.

For example, Arizona, North Carolina, and Rhode Island achieved ex parte renewal rates exceeding 90%, while states like Pennsylvania and Texas had rates of 11% or less. These differences underscored the importance of state-level policies and systems in determining unwinding outcomes.

The Centers for Medicare & Medicaid Services (CMS) reported that states with higher ex parte renewal rates tended to have modernized eligibility systems that could effectively leverage data from other programs to confirm eligibility. This reduced the administrative burden on patients and helped maintain continuous coverage.

These variations highlighted the critical role of state-level decision-making and infrastructure in shaping Medicaid enrollment outcomes during and after the unwinding process. They also pointed to potential best practices for maintaining coverage and streamlining enrollment processes in the future.

Racial and Ethnic Disparities in Medicaid Disenrollment

A particularly concerning aspect of the unwinding process is its disproportionate impact on communities of color. According to the Southern Poverty Law Center (SPLC), more than half of the people who lost coverage were people of color. This disparity is exacerbated by existing barriers to healthcare access. The SPLC notes that communities of color face more barriers to healthcare access, such as limited internet, transportation, and inflexible job schedules.

The impact is particularly severe in states that have not expanded Medicaid. The SPLC report highlights that "residents from Alabama, Florida, Georgia, and Mississippi make up over 40% of the adults in the coverage gap nationwide. People of color make up about 60% of the coverage gap nationwide."

The Human Impact of Coverage Loss

The impact of coverage loss extends beyond statistics. Personal stories highlight the real-world consequences of the unwinding process. Justin Gibbs, a 53-year-old from Ohio, had to go without blood pressure medication for a week after losing his Medicaid coverage in December, according to CNN. Such disruptions in care can have serious health implications, particularly for people managing chronic conditions.

A KFF survey reveals the broader health impacts of coverage loss. Among those who became uninsured after losing Medicaid:

• 75% reported worrying about their physical health

• 60% worried about their mental health

• 56% said they skipped or delayed getting needed health care services or prescription medications

Impact on HIV Care and Policy Implications

The Medicaid unwinding process also highlighted significant challenges in maintaining healthcare access for people living with HIV (PLWH). While specific data on Medicaid disenrollment among PLWH during the unwinding were limited, general trends among vulnerable populations indicated potential risks. A KFF report found that many of those who lost Medicaid coverage experienced increased out-of-pocket costs, interruptions in medication adherence, and deteriorating health outcomes. These challenges were particularly critical for PLWH, for whom continuous access to antiretroviral therapy (ART) is essential.

Key considerations for PLWH during the unwinding process included:

1. Continuity of ART: Ensuring uninterrupted access to antiretroviral medications is mandatory for maintaining viral suppression and overall health.

2. Role of Ryan White HIV/AIDS Program: This program played a critical role in filling coverage gaps, but it's not a substitute for comprehensive health insurance.

3. Targeted Outreach: Community-based organizations and AIDS Service Organizations (ASOs) were essential in providing specialized support and enrollment assistance to PLWH.

4. Data Collection: Improving data collection on Medicaid disenrollment rates among PLWH can inform targeted interventions and policy adjustments.

The unwinding process underscored the need for policies that safeguard continuous healthcare access for PLWH. Implementing strategies that address these specific needs can help prevent coverage disruptions and improve overall health outcomes for people living with HIV.

Economic Implications of the Unwinding Process

The Medicaid unwinding process had significant economic implications for patients, healthcare providers, and states. For people who lost Medicaid coverage, the consequences often included financial instability and increased medical debt. A study by the Urban Institute found that adults who experienced a gap in Medicaid coverage were more likely to report problems paying medical bills and to have medical debt.

Healthcare providers, particularly safety-net hospitals and community health centers, faced increased rates of uncompensated care as a result of the unwinding process. This strained their financial resources and potentially affected their ability to provide care to their communities. The Commonwealth Fund noted that increased uninsured rates could lead to higher healthcare costs in the long term due to delayed care and increased emergency room visits.

For states, the unwinding process presented complex economic challenges. As the enhanced federal matching rate provided during the pandemic phased out, many states grappled with increased administrative costs associated with the unwinding process. A report from the Brookings Institution highlighted that states faced a complex set of trade-offs as they navigated the unwinding process, balancing the need to control Medicaid spending with the imperative to maintain access to care for vulnerable populations.

The full economic impact of the unwinding process continues to unfold, with ongoing implications for state budgets, healthcare provider finances, and patient economic well-being. These insights will be important in shaping future Medicaid policies and developing strategies to mitigate economic challenges associated with coverage transitions.

Policy Recommendations and Best Practices

To address these challenges, several key strategies have been identified:

• Streamlining Renewal Processes: Increasing ex parte (automated) renewal rates can reduce the burden on people and minimize procedural disenrollments. For instance, Louisiana achieved a 49% ex parte renewal rate by leveraging data from other public benefit programs and improving data matching processes.

• Targeted Outreach: Conducting outreach to vulnerable populations, including communities of color and people with chronic conditions, can help reduce disenrollments. The Ohio Department of Medicaid partnered with community-based organizations for door-to-door outreach in areas with high procedural disenrollments.

• Implementing Continuous Eligibility: Policies that provide 12-month continuous eligibility can stabilize coverage and reduce churn. Oregon implemented a two-year continuous eligibility policy for children under six.

• Enhanced Federal Oversight: Strengthening monitoring and enforcement of federal requirements ensures state compliance. CMS should leverage new authorities to require corrective action plans from states with high procedural disenrollments.

• Improving Data Collection: Robust data collection and timely reporting enable quick identification of problems. States should report disaggregated data on disenrollments by race, ethnicity, and other demographics to address disparities.

• Leveraging Technology: Modernizing eligibility systems improves accuracy and efficiency. Implementing text messaging, email communication, and mobile-friendly online portals helps people update information and complete renewals more easily.

• Expanding Presumptive Eligibility: Allowing qualified entities to make preliminary eligibility determinations provides temporary coverage while full applications are processed, ensuring continuous access to care.

Addressing Systemic Inequities and Long-Term Solutions

The unwinding process exposed systemic inequities within the healthcare system, particularly affecting communities of color and rural areas. Long-term solutions include:

• Investing in Underserved Communities: Enhancing access to healthcare services in marginalized areas.

• Improving Health Literacy: Providing education to help people understand their health coverage options and navigate the system.

• Strengthening Social Safety Nets: Expanding programs that address social determinants of health, such as housing, nutrition, and transportation.

Without significant policy interventions, coverage losses could lead to worse health outcomes and increased disparities, as emphasized by the Urban Institute.

Conclusion

The Medicaid unwinding process revealed both challenges and opportunities in our healthcare system. It highlighted the need for more efficient, equitable, and resilient approaches to health coverage. Key lessons include the importance of streamlined processes, targeted outreach, and robust oversight.

Moving forward, policymakers, healthcare providers, and advocates must work together to implement solutions that ensure continuous, accessible care for all, especially vulnerable populations. This effort is not just about health policy—it's a matter of equity and human rights.

As we continue to navigate the evolving healthcare landscape, our goal should be to build a system that provides stable, continuous coverage and leaves no one behind. This commitment is essential for improving health outcomes, reducing disparities, and strengthening our nation's overall health infrastructure.

Gaming as a New HIV Prevention Tool

The latest data from the Centers for Disease Control and Prevention (CDC) indicate that people aged 13 to 34 accounted for more than half (56%) of all new HIV diagnoses in the United States in 2022. This concerning trend underscores a critical need for HIV prevention methods that resonate with younger demographics and at-risk communities. Gamification—the strategic integration of game elements into non-game contexts—may offer a promising solution. By leveraging the inherent appeal of games to engage, motivate, and provide personalized feedback, gamification has the potential to transform HIV prevention efforts. It can bridge knowledge gaps, promote behavior change, and empower people, thereby contributing significantly to public health goals aimed at ending the HIV epidemic.

Gamification: A Powerful Tool for Public Health

Gamification involves incorporating game mechanics such as points, challenges, and rewards into websites, apps, or learning systems to enhance user engagement and motivation. The goal is to inspire collaboration and interaction, fostering higher engagement and loyalty among consumers, employees, and partners. According to a report by Deloitte, "Gamification has proliferated to the point that elements have entered consumers' daily lives, transforming inconvenient tasks into fun activities."

The effectiveness of gamification stems from its ability to tap into fundamental psychological and behavioral principles. One framework that helps in understanding these principles is the Octalysis Framework, developed by gamification expert Yu-kai Chou. The Octalysis Framework identifies eight core drives that motivate human behavior:

1. Epic Meaning & Calling: The belief that one is doing something greater than oneself.

2. Development & Accomplishment: The internal drive for making progress, developing skills, and eventually overcoming challenges.

3. Empowerment of Creativity & Feedback: Engaging users in a creative process where they have to repeatedly figure things out and try different combinations.

4. Ownership & Possession: Users are motivated because they feel ownership over something.

5. Social Influence & Relatedness: Activities driven by social elements, including mentorship, social acceptance, and competition.

6. Scarcity & Impatience: The desire to have something because it is rare or immediately unattainable.

7. Unpredictability & Curiosity: The drive stemming from not knowing what will happen next.

8. Loss & Avoidance: The motivation to avoid negative consequences.

By incorporating these core drives, gamification strategies can effectively engage and motivate users.

For instance, rewards and recognition act as powerful motivators, encouraging users to actively participate and achieve desired outcomes. This aligns with the Octalysis Framework's core drive of Development & Accomplishment, where users are motivated by a sense of progress and achievement.

Game mechanics such as challenges, levels, and progress bars transform potentially mundane tasks into interactive and enjoyable experiences. Continuous feedback and a clear sense of progress reinforce positive behaviors and encourage sustained engagement. This relates to the core drive of Empowerment of Creativity & Feedback, where users feel empowered by their ability to influence outcomes and track their progress.

Moreover, gamification can foster a sense of community and healthy competition among users, providing social support and enhancing motivation. This leverages the power of Social Influence & Relatedness, where users are motivated by connection, comparison, and collaboration.

By understanding and applying these core drives, gamification can create engaging experiences that motivate users to adopt and maintain healthy behaviors—crucial in the context of HIV prevention.

Real-World Applications in Healthcare

The application of gamification in healthcare is not merely theoretical. Real-world examples demonstrate its impact:

• Medisafe, a medication reminder app with over 5 million users, reports that two-thirds of patients with hypertension, diabetes, and depression using their app have improved their medication adherence. The app uses personalized reminders, progress tracking, and rewards for adherence, effectively applying gamification principles to improve health outcomes.

• Re-Mission, a set of online games designed for young people with cancer, allows players to control a nanobot that fights cancer cells and manages side effects. This makes the challenging experience of cancer treatment more engaging and empowering.

These examples illustrate how gamification can activate patients, encouraging them to take ownership of their health and become active participants in their care. By making health education more engaging and effective, gamification can lead to better understanding and retention of information—important factors in HIV prevention.

A l'Assaut du Sida (AADS): A Case Study in Gamified HIV Prevention

"A l'Assaut du Sida" (AADS), meaning "Tackling AIDS," is a compelling example of gamification's potential to drive meaningful change in HIV prevention. This interactive mobile game app, developed by SYL, a Côte d’Ivoire-based technology company, has reached over 300,000 young people in the country.

The app's development and distribution were a collaborative effort between SYL, UNAIDS, UNICEF, the Global Fund, and the Côte d’Ivoire Ministry of Health. This partnership ensured the app's alignment with national HIV prevention goals, access to funding and resources, and widespread promotion. A key factor in AADS's success was its strategic promotion during the African Cup of Nations football tournament. By leveraging the popularity of this major sporting event, the app effectively engaged young people, particularly boys and men who are often harder to reach with traditional HIV prevention campaigns.

AADS addresses significant knowledge gaps about HIV among youth in Côte d’Ivoire. A survey revealed that only 40% of respondents knew that antiretroviral treatment for HIV exists. The app provides comprehensive content covering topics such as stigma, human rights, gender equality, and gender-based violence, educating users on crucial aspects of HIV prevention and care.

The positive impact of AADS is evident in both its reach and user feedback. Young players reported learning a great deal about HIV and related topics through the app's engaging quiz format. Côte d’Ivoire’s Minister of Health, Pierre Dimba, acknowledged the app’s success, stating, "This fun and educational online game is a response to young people's need for true and accurate information via social media."

Looking ahead, national partners are working to distribute a scholastic version of the game to schools nationwide, demonstrating their commitment to scaling up this innovative approach to HIV prevention. The app's low cost and adaptability make it a sustainable model for HIV prevention efforts, particularly in the context of potentially decreasing international funding.

Reaching the LGBTQ+ Gaming Community: A Critical Audience

The gaming community has witnessed a significant increase in the representation of LGBTQ+ players, creating a unique opportunity for targeted HIV prevention efforts. Within this diverse community, a significant subculture known as "gaymers" has emerged. The term "gaymers" is a blend of "gay" and "gamers" and is commonly used within the LGBTQ+ gaming community. It refers to LGBTQ+ gamers who share a passion for video games and often form their own networks and communities both online and offline.

According to a 2024 GLAAD study, 17% of active gamers identify as LGBTQ+, representing a 70% increase from 2020. This growth is even more pronounced among younger gamers, with 23–28% of gamers under 35 identifying as LGBTQ+. The rise of the gaymer subculture underscores the increasing visibility and representation of LGBTQ+ people in gaming.

The Growing Presence of Transgender and Nonbinary Gamers

The prevalence of transgender and nonbinary gamers has also risen notably. Between 2015 and 2018, they comprised approximately 1–2% of the gaming population. By 2021, this number increased to around 5%. Additionally, research from the International Journal of Environmental Research and Public Health estimates that 1.2–2.7% of the adolescent population are gender-diverse. This growing representation underscores a significant and expanding audience within the gaming community that can be reached through tailored interventions.

The Appeal of Gaming for LGBTQ+ People

Video games offer a sense of escapism and a platform for self-expression, allowing players to immerse themselves in alternative realities and explore different identities free from real-world constraints. This can be especially appealing for LGBTQ+ people who may face challenges or discrimination based on their sexual orientation or gender identity. Games that allow for character customization, narrative exploration, and community interaction can be profoundly liberating and affirming.

Multiplayer games provide opportunities for social connection and community building. These online spaces can foster a sense of belonging, particularly for those who may feel isolated or lack access to supportive LGBTQ+ communities in their offline lives. The ability to interact anonymously can also allow people to explore and express their identities more freely.

Challenges and Opportunities

Despite the potential of reaching LGBTQ+ people through gaming, significant challenges exist. Homophobia, transphobia, and bigotry persist within the gaming community, creating hostile environments for many LGBTQ+ players. This underscores the need for interventions that not only provide information about HIV prevention but also address issues of stigma, discrimination, and online harassment.

However, the increasing representation of LGBTQ+ gamers presents substantial opportunities:

• Growing Audience: The rising number of LGBTQ+ gamers, particularly among younger demographics, means that gaming platforms can be effective channels for HIV prevention messaging.

• Tailored Content: Understanding the specific preferences and motivations of transgender and nonbinary gamers allows for the development of interventions that are culturally relevant and engaging.

• Community Engagement: Multiplayer and community-based games offer opportunities for social connection, peer support, and the dissemination of health information within a supportive environment.

Tailored Strategies for Engagement

Developing gamified HIV prevention strategies that resonate with LGBTQ+, transgender, and nonbinary gamers is a massive opportunity. Public health data underscores the importance of this approach, as these groups are at a disproportionately high risk for acquiring HIV. For instance, the CDC reports that men who have sex with men (MSM) accounted for 67% of new HIV infections in 2022, and an estimated 14% of transgender women in the United States are living with HIV.

Interventions focusing on themes of self-discovery, community building, and personal empowerment may be particularly effective. Research from Quantic Foundry indicates that transgender and nonbinary gamers often prioritize games that allow for:

• Self-Expression and Creativity: Games that offer customizable avatars, inclusive narratives, and opportunities for creative input engage transgender and nonbinary gamers effectively.

• Exploration of Identity: Interactive experiences that allow players to explore different aspects of their identity in a safe and affirming environment can be particularly impactful.

• Community Building: Features that foster social connections and peer support can enhance engagement and provide valuable platforms for disseminating HIV prevention information.

Addressing Unique Challenges

Incorporating elements that address the specific challenges faced by LGBTQ+ people—such as stigma, discrimination, and barriers to healthcare access—can enhance the relevance and impact of these interventions. By fostering a sense of community and belonging within the gaming environment, gamified strategies can promote peer support and encourage positive health behaviors.

For example, gamified interventions could include:

• Narratives that Reflect Diverse Experiences: Storylines that incorporate LGBTQ+ characters and experiences promote inclusivity and resonance.

• Resources and Support: In-game links to resources on HIV prevention, testing, and support services tailored for these communities.

• Safe Online Spaces: Moderated environments that protect players from harassment and discrimination, ensuring a positive and affirming gaming experience.

The Potential for Impact

The increasing representation of LGBTQ+ people in gaming underscores the potential of this medium as a channel for targeted HIV prevention efforts. By aligning game design with the preferences and motivations of these gamers, public health initiatives can more effectively reach these at-risk populations and contribute to reducing HIV transmission rates.

Moving Forward

Gamification holds immense potential to transform HIV prevention efforts among young people and at-risk communities, including the LGBTQ gaming community. To fully realize this potential, we should consider:

• Increased Investment: Funding agencies should prioritize gamification in HIV prevention research grants, providing resources for the development and evaluation of innovative interventions.

• Collaborative Partnerships: Building partnerships between game developers, public health organizations, LGBTQ advocacy groups, and researchers is essential. Such collaboration ensures that games are culturally relevant and resonate with diverse audiences.

• Rigorous Evaluation: Implementing evidence-based design and conducting rigorous evaluations are key for assessing the effectiveness of gamified interventions and making necessary adjustments.

• Ethical Design: Ethical considerations, particularly related to data privacy, informed consent, and cultural sensitivity, must be at the forefront of game development.

Advancing Policy

Policymakers, healthcare providers, educators, and community organizations all have a role to play in advancing gamified HIV prevention:

• Policymakers can support legislation that promotes digital health innovation and ensures equitable access to technology.

• Healthcare Providers can incorporate gamified tools into their practice to enhance patient education and engagement.

• Educators can utilize gamified interventions like AADS in school curricula to provide comprehensive sexual education.

• Community Organizations can collaborate with developers to create interventions that address the specific needs of their communities.

As we move forward, embracing innovation and collaboration is essential. By leveraging the power of gamification, we can create engaging, effective, and inclusive HIV prevention strategies that resonate with at-risk communities. Gamification has the potential not only to educate and inform but also to empower and inspire, creating a generation equipped with the knowledge, skills, and motivation to protect themselves and their communities from HIV.

Together, we can level up our efforts and make significant strides toward ending the HIV epidemic.

Why Mental Health is Central to Ending the HIV Epidemic

Have you ever felt like you were living two lives—one presented to the world, while the other is buried under secrecy and shame? For many people living with or at risk of HIV, this dual reality is painfully familiar. World Suicide Prevention Day might trend on social media, but hashtags rarely touch on the quiet, insidious epidemic where HIV meets a mental health crisis that too often remains in the shadows.

We’ve made significant strides in treating HIV, but the virus isn’t the only battle. There’s another battle just as critical: the mental toll—the invisible wounds and lingering trauma often overlooked despite medical advances. And all the progress in the world won’t matter if we ignore the mental and emotional realities of those living with HIV. We need more than medicine—we need a mindset shift that sees mental health as equally important and valid as physical health.

It’s time to confront the deeper issues directly: the stigma, the trauma, the daily fears. We need a mental healthcare system that understands, listens, and treats the whole person—not just the virus. Until we address these challenges head-on, we aren’t truly ending the HIV epidemic.

Navigating Mental Health Challenges with HIV

Living with HIV is not solely a medical challenge; it is a continuous mental marathon. The numbers show that we’re dealing with more than just a virus. People living with HIV are 100 times more likely to die by suicide than other populations. Anxiety disorders affect 15.5% of people living with HIV, compared to 3.6% in the general population, and depression is 2 to 5 times more common. Even more concerning, up to 70% have experienced trauma—20 times the rate of the general population.

These numbers represent real people navigating complex challenges. While not every person living with HIV faces mental health issues, for many, these struggles are a significant part of their experience. As one researcher notes, "The significantly higher prevalence compared to the general population suggests that anxiety disorders are a critical global public health concern among people living with HIV, requiring urgent prevention and treatment efforts."

To fully understand the scope of these challenges, we must consider "weathering"—the cumulative wear and tear on the body and mind from chronic stress and adversity. Dr. Sannisha K. Dale explains that for people living with HIV, this process is worsened by relentless stigma, discrimination, limited access to resources, systemic inequities, and other enduring social barriers. Weathering isn’t just about feeling worn down; it accelerates aging in a very real, biological way, leading to more chronic illnesses, cognitive decline, and other issues that hit harder and sooner for people with HIV. Research in iScience shows this accelerated aging can start almost immediately—within three years of acquiring HIV—due to cellular changes that affect overall health.

And it’s not just biology. Behavior plays a significant role too. A study in Translational Psychiatry reveals that maladaptive coping mechanisms like smoking or substance use, often developed in response to constant adversity, can accelerate aging and complicate HIV management. This highlights the importance of addressing both psychological and behavioral factors in HIV care, not just the virus itself.

Take Malcolm, a 66-year-old who’s been living with HIV for 28 years. Despite his resilience, he faces daily struggles: managing not only his HIV but also high blood pressure, Type 2 diabetes, and the mental toll of juggling multiple health conditions. As he puts it, "I'm just happy to be here," but that statement carries the weight of a lifetime of survival amid a complex landscape of healthcare challenges, stigma, and aging with HIV. Malcolm’s experience highlights the compounded difficulties faced by many older adults with HIV, where trauma is often a chronic companion rather than a singular event.

His story reflects a broader pattern: trauma, whether from the loss of friends to the epidemic, ongoing health challenges, or societal discrimination, often persists and manifests as PTSD, depression, substance use, and other mental health struggles. As such, the need for comprehensive care that addresses both the psychological scars and the physical realities of living with HIV has never been more urgent.

As Dr. Dale puts it, "Systemic oppression and mental health struggles faced by people living with HIV throughout their lives may accelerate the aging process and continue to negatively impact their physical health and wellbeing as they age." This isn’t just a health crisis—it’s a call to fundamentally rethink how we approach care and compassion for those most affected, demanding action that is both immediate and transformative.

Understanding weathering in the context of HIV is critical to developing effective care strategies. Research from the HIV Vaccine Trials Network makes it clear: it’s not just about treating the virus; it’s about recognizing the full scope of what people are up against—mental health challenges, trauma, and social determinants of health. Only by addressing all these factors can we create interventions that truly support healthier aging and improve the quality of life for people living with HIV.

Why Mental Health is Key to Effective HIV Care

Mental health and HIV care are inextricably linked, with research showing that untreated mental health conditions can significantly undermine adherence to antiretroviral therapy (ART), complicating efforts to achieve viral suppression and maintain overall health. The Substance Abuse and Mental Health Services Administration (SAMHSA) highlights this connection, stating, "Untreated behavioral health conditions can significantly hinder HIV care engagement, medication adherence, and overall health outcomes."

Yet, accessing mental healthcare while living with HIV is often a challenge. Limited services, cultural gaps among providers, and pervasive stigma are just some of the hurdles. This is compounded by a fragmented healthcare system that treats HIV care and mental health services separately. To address these gaps, we need to urgently improve provider education and competency in addressing both HIV and mental health needs. The World Health Organization and UNAIDS advocate for integrating mental health and HIV care. Their call for a holistic approach goes beyond just medical checklists—it’s about addressing psychological and social factors too. Integrated care models have shown promise, improving both mental health outcomes and adherence to HIV treatment.

Studies have shown that integrating mental health services into HIV care can significantly improve outcomes. This approach has been shown to reduce depressive symptoms by 25-50%, enhance adherence to antiretroviral therapy (ART), and increase the rates of viral suppression up to 95%. Collaborative care models, where mental health professionals and HIV providers work together, have proven effective in reducing hospitalizations, improving patient engagement, and promoting overall better health for people living with HIV.

However, getting there isn’t easy. SAMHSA's Center for Integrated Health Solutions identifies big hurdles, like funding limitations, workforce shortages, and resistance to organizational change. Despite these challenges, integrated care remains a critical goal—one that could significantly improve the health and well-being of people living with HIV.

And we can't ignore the impact of stigma. The Well Project notes that stigma in healthcare settings can worsen trauma and deter people from seeking care. Training providers in trauma-informed care and cultural competency is essential to creating safe, inclusive spaces for people living with HIV.

How Politics and Society Shape the HIV Experience

The mental health of people living with HIV is profoundly influenced by the broader social and cultural context in which they live. Systemic stigma, discrimination, and social exclusion intersect with issues like racism, homophobia, transphobia, and economic inequality, creating significant barriers to care and support. Research published in the American Journal of Public Health illustrates how these overlapping forms of discrimination increase stress, social isolation, and complicate access to healthcare. The study presents a framework demonstrating how HIV-related stigma, when combined with other forms of social marginalization, can negatively impact treatment adherence and overall health outcomes for people living with HIV.

HIV criminalization laws are another piece of this complex puzzle. As highlighted by Xtra Magazine, Canada and the U.S. still lead the world in criminalizing HIV, perpetuating stigma and further alienating those affected. Furthermore, the World Health Organization notes that discriminatory policies in employment, housing, and education create additional barriers, directly impacting mental well-being. Media and entertainment also plays a critical role. Sensationalized coverage and inaccurate portrayals continue to fuel harmful stereotypes, adding to the stigma people living with HIV experience.

Cultural and religious beliefs in certain communities can further exacerbate HIV-related stigma, leading to isolation, rejection, or even violence. UNAIDS emphasizes the importance of addressing these deeply ingrained attitudes.

However, positive messaging also has the power to reshape perceptions. The Undetectable = Untransmittable (U=U) campaign is a key example. HIV.gov explains that effective ART leading to undetectable viral loads prevents transmission, challenging outdated misconceptions and empowering those living with HIV.

This messaging has made a significant impact. Research has shown that U=U reduces anxiety and changes perceptions, helping people with HIV feel less like a threat. Similarly, PrEP (pre-exposure prophylaxis) offers another powerful tool, proving highly effective in preventing HIV transmission and fostering open, honest conversations about sexual health.

Building Resilience: Strategies for Mental Wellness

Supporting the mental health of people living with or at risk of HIV means thinking beyond a one-size-fits-all approach. We need to tackle this from multiple angles. Integrated care models that combine mental health and HIV services are proving to be effective. Programs like the Collaborative Care Model and the Mental Health Integration Programme show how treating the whole person—not just the virus—leads to better outcomes.

Trauma-informed care is crucial for creating environments where people feel truly safe and supported. This means training healthcare workers in sensitive communication, empowering patients in their care, and recognizing how trauma affects health behaviors and outcomes.

Monte Ephraim, a clinical social worker, sums it up: “Everyone has the possibility of living a satisfying and meaningful life, regardless of what happened to them or what health challenges they are living with.” Their approach centers on acknowledging trauma, promoting healing through relationships, and building resilience.

Community-based organizations are also vital. They offer support groups, peer counseling, and advocacy, using the power of shared experiences to reduce isolation and build resilience. For people living with HIV, resilience isn’t just a buzzword—it’s a lifeline. Research highlights that engaging in helpful coping mechanisms, like relying on social support, spirituality, creative expression, and activism can improve resilience. Practices like mindfulness, stress reduction, and positive psychology can also help. Each person’s way of coping will differ, and that’s perfectly fine. What’s important is finding what brings peace and comfort, in whatever form that takes.

Moving Forward: A Call to Action

If we’re serious about ending the HIV epidemic, we have to face the reality that mental health isn’t just part of the equation—it’s central to it. This isn’t a side issue or an optional extra. It's a fundamental piece of the puzzle that must be integrated into every aspect of HIV care and prevention.

To make progress, we need a strong commitment from all fronts—policymakers, healthcare providers, and communities:

• Policymakers: Fund mental health services, integrate mental health care into all HIV programs, mandate trauma-informed training, and address social determinants of health.

• Healthcare Providers: Implement trauma-informed approaches, conduct routine mental health screenings, and build strong referral networks.

• Communities: Challenge stigma, support local organizations, and advocate for policy changes that promote mental health and HIV care.

We’re not just fighting a virus; we’re fighting for the dignity, health, and well-being of people living with HIV. This battle calls for a holistic, compassionate approach that treats the whole person—mind and body. It’s about creating a healthcare system that goes beyond the virus to address the real, lived experiences of those affected.

By integrating mental health care, tackling stigma, and fostering supportive communities, we can help ensure a future where people living with HIV not only survive but thrive. Let’s not just aim for zero new transmissions or deaths; let’s strive for a world where every person living with HIV is valued, empowered, and has the chance to live their fullest life.

Ensuring Equitable Access to PrEP for Minors in the South

In 2022, young people under 35 accounted for over half (56%) of all new HIV diagnoses in the United States. The Southern states bore a disproportionate burden of this epidemic, accounting for more than half of new HIV diagnoses that year. Particularly high rates among youth in this region highlight the urgent need for effective HIV prevention strategies tailored to young people. This alarming statistic underscores the urgent need to ensure that all young people, regardless of where they live or their family circumstances, have access to effective HIV prevention tools, including pre-exposure prophylaxis (PrEP). The CHOOSE study (Combatting HIV Or Other STIs Early), currently underway, offers a promising approach to increasing PrEP uptake among young gay, bisexual, and other men who have sex with men (YGBMSM) aged 13-24, a population at elevated risk for HIV. CHOOSE leverages the power of mobile health technology to provide tailored information, support, and reminders to help young people choose and adhere to PrEP.

However, the promise of CHOOSE and other similar PrEP initiatives for young people is threatened by a wave of restrictive policies and legal decisions in the United States, creating significant barriers for minors seeking to protect their health, especially those who live in the South. In Texas, the 5th Circuit Court of Appeals ruled that Title X-funded clinics must notify parents before providing sexual and reproductive healthcare services to minors, including contraception. This ruling has far-reaching implications for PrEP access, as Title X clinics are often the only source of sexual health services for young people, particularly those without access to private insurance. Similarly, in Tennessee, the state government's politically motivated decision to reject federal HIV prevention funding and redirect resources away from organizations serving marginalized communities, including those providing PrEP, further jeopardizes the health of young people.

These actions demonstrate a concerning trend of policies that prioritize parental control over the health and well-being of young people, even when those policies contradict evidence-based public health strategies and potentially put youth at risk. We must address these barriers to ensure that all young people in the South have equitable access to PrEP and other life-saving HIV prevention tools. Failing to do so will not only do material harm to vulnerable people but also hinder our collective progress towards ending the HIV epidemic.

The Landscape of PrEP Access for Minors

PrEP has proven highly effective in reducing the risk of HIV acquisition, particularly for young gay, bisexual, and other men who have sex with men. When taken as prescribed, PrEP can reduce the risk of sexual HIV transmission by up to 99%. Studies have shown that a majority of young people on PrEP demonstrate adequate adherence, further supporting its effectiveness as a prevention tool. However, realizing the full potential of PrEP for young people hinges on ensuring equitable access, a goal hindered by a complex and often restrictive legal landscape surrounding minors' consent to healthcare. While PrEP offers a powerful tool for HIV prevention, accessing this medication can be challenging for young people, particularly due to the complex legal landscape surrounding minor consent to healthcare.

The legal framework for minor consent to healthcare varies significantly across states, creating a patchwork of access for young people seeking PrEP and other sexual health services. Many state laws governing a minor's ability to give informed consent for STI and HIV services do not explicitly mention PrEP. This lack of clarity within these statutes leaves it unclear whether minors can consent to PrEP independently and confidentially. This ambiguity can deter healthcare providers from offering PrEP to minors and leave young people uncertain of their rights. The situation is particularly concerning in the South, where restrictive parental consent laws are prevalent and often extend to sexual and reproductive healthcare services more broadly.

The 5th Circuit ruling in Texas, requiring parental notification for Title X services, exemplifies this trend. Planned Parenthood, a leading provider of sexual and reproductive healthcare, condemned the ruling as "a significant and dangerous departure from decades of precedent that has allowed all young people to confidentially get basic health care like birth control through Title X." This ruling, and the legislation it protects, creates significant barriers for young people seeking basic sexual and reproductive healthcare, including PrEP. For example, a young person in Texas seeking PrEP who fears being outed to unsupportive parents due to their sexual orientation might forgo seeking this essential prevention method altogether to avoid mandatory parental notification, putting their health at risk. For those experiencing family conflict, abuse, or rejection due to their sexual orientation or gender identity, mandatory parental notification can be particularly dangerous, deterring them from seeking essential care.

However, recent actions by the federal government offer a glimmer of hope. In a case involving Oklahoma, the Supreme Court upheld the Biden administration's right to redirect federal family planning funds from states that restrict access to abortion information. This decision demonstrates the potential for using federal funding as leverage to incentivize states to comply with public health guidelines and protect access to care, even in politically charged areas like sexual and reproductive health.

Even in states where minors can legally consent to PrEP, confidentiality is not always guaranteed. Some states allow or require providers to notify parents or guardians, potentially compromising young people's privacy and putting them at risk. Additionally, the inadvertent disclosure of sensitive health information through insurance Explanation of Benefits (EOBs) sent to parents or guardians can further erode confidentiality. These policies fail to recognize the unique vulnerabilities of young people and the importance of confidential healthcare access in fostering trust and encouraging early intervention.

Political Interference: The Case of Tennessee

While restrictive laws present a significant barrier to PrEP access for minors, the case of Tennessee illustrates how political agendas can further undermine public health efforts, even in the absence of explicit legal restrictions. In 2023, the Tennessee government made the controversial decision to reject $6.2 million in annual funding from the Centers for Disease Control and Prevention (CDC) specifically designated for HIV treatment and prevention programs, including those supporting PrEP access. This decision, projected to result in 166 additional HIV transmissions and 190 additional deaths over 10 years, jeopardized years of progress in reducing new HIV diagnoses and expanding PrEP uptake in a state with one of the highest HIV burdens in the country.

This funding rejection was not driven by evidence-based public health priorities but rather by a politically motivated agenda to defund organizations like Planned Parenthood and shift resources away from communities deemed undesirable by those in power. The state government attempted to justify its actions by claiming a desire to prioritize other populations, such as first responders, but these groups have significantly lower HIV transmission rates, making this rationale dubious at best.

Following a public outcry and intense advocacy efforts by HIV organizations, the Tennessee legislature ultimately approved $9 million in state funding for HIV, and the CDC intervened by directly allocating $4 million to community-based organizations, resulting in a net increase in funding. While this outcome appears positive on the surface, the disruption caused by the initial funding rejection and the ongoing uncertainty surrounding the state's commitment to evidence-based HIV prevention strategies raise serious concerns.

The Tennessee case exemplifies the dangers of political interference in public health. The initial funding cuts disproportionately impacted marginalized communities, including young people, people of color, and LGBTQ+ people, who already face significant barriers to accessing healthcare. The attempt to redirect funding away from proven prevention strategies towards less vulnerable populations further demonstrates a disregard for health equity and the principles of evidence-based policymaking. This case also highlights the critical role of advocacy in holding policymakers accountable and protecting the health of vulnerable communities. The mobilization of HIV organizations and community members was essential in securing a partial reversal of the funding decision, demonstrating the power of collective action in challenging harmful policies.

The Promise of Telehealth and Other Innovative Solutions

As we grapple with the legal and political barriers hindering PrEP access for minors, it's important to explore innovative solutions that can circumvent these obstacles and reach young people where they are. Telehealth has emerged as a particularly promising approach, offering the potential to expand access, enhance confidentiality, and reduce stigma, especially in the South, where geographic barriers and social conservatism can be significant.

Studies have shown that telehealth interventions can effectively increase PrEP initiation among young people. For example, the PrEPTECH study demonstrated that a telehealth platform providing online education, home testing, and PrEP prescriptions significantly increased PrEP uptake among young men who have sex with men (MSM) and transgender women (TW) in Florida and California. Telehealth offers a convenient and discreet way for young people to access PrEP services, potentially overcoming logistical barriers and reducing the stigma associated with seeking sexual healthcare in person.

However, while telehealth holds promise, it's not a panacea. It's essential to recognize the limitations of telehealth and develop comprehensive strategies that address adherence challenges, digital equity, and the broader social determinants of health that can impact PrEP access and effectiveness. For example, young people may need additional support to adhere to daily PrEP regimens, and those without reliable internet access or digital literacy skills may face challenges navigating telehealth platforms.

Therefore, a multi-pronged approach is needed that combines telehealth with other innovative solutions tailored to the unique needs of young people. Youth-friendly clinics that prioritize confidentiality and provide non-judgmental care can create safe spaces for young people seeking sexual health services, including PrEP. Mobile testing units can bring PrEP services directly to communities with limited access to healthcare, and community-based outreach programs can raise awareness, reduce stigma, and connect young people to PrEP providers. By embracing a combination of strategies, we can create a more robust and equitable system for delivering PrEP to young people in the South.

Policy Recommendations and Call to Action

To truly protect future generations from the burden of HIV, we must move beyond simply acknowledging the barriers to PrEP access for minors in the South and embrace a proactive policy agenda that centers the needs of young people. This requires an approach that leverages our collective expertise and influence as advocates, healthcare professionals, and policymakers.

First, we must challenge the existing legal framework that hinders minor access to PrEP. Advocating for clear and consistent state laws explicitly granting minors the right to consent to PrEP confidentially is paramount. Removing ambiguity in statutory language and eliminating provider discretion will ensure legal clarity and empower young people to seek PrEP without fear of parental notification. Simultaneously, we must push for stronger confidentiality protections for all sexual and reproductive healthcare services for minors, recognizing the unique vulnerabilities and potential risks associated with mandatory parental notification.

Second, we must address the systemic inequities that disproportionately impact PrEP access for young people of color, LGBTQ+ people, and those living in rural communities. Adopting the PrEP Equity Ratio (PER) and other equity metrics as standard practice in program design and evaluation is necessary for monitoring progress and holding stakeholders accountable for achieving equitable PrEP access.

Third, we must actively engage in the political process to safeguard and increase federal funding for HIV prevention programs, particularly those targeting youth and communities of color. The Tennessee case exemplifies the vulnerability of public health funding to political interference. We must advocate for policies that protect these funding streams and ensure that resources are allocated based on epidemiological evidence and public health needs, not ideological agendas.

Finally, we must leverage the power of innovation to expand PrEP access and address the unique needs of young people. This includes supporting the expansion of telehealth services, promoting youth-friendly clinics, and investing in community-based outreach programs tailored to the specific challenges faced by young people in the South.

This is not a passive call to action; it is a call to mobilize our expertise, resources, and influence to create a policy environment that prioritizes the health and well-being of all young people. The time for bold action is now. Let us work together to ensure that no young person is denied the opportunity to protect themselves from HIV.

Data Gaps Exist for Transgender Patients Living with HIV, Despite Need

The current unequal representation and inadequate amounts of data on transgender people in terms of HIV poorly represents this subpopulation group in the LGBTQ+ community in the US. Diana Tordoff writes about this issue in an article published in STAT, where she writes that the scarce amount of data concerning trans people affects how policy is shaped in the country.

Per a study published by the National Institute of Health, several barriers hindering participation from trans people were things like logistical concerns, mistrust, lack of awareness, and psychosocial/emotional concerns related to being “outed”. This separate study provides probable insight on why there may be less amounts of data on transgender people in terms of HIV.

The Centers for Disease Control (CDC) recently published data about HIV prevalence among trans people based on public health surveillance data, however gender identity data is not collected consistently across local jurisdictions. As a result, mathematical models can’t be built effectively to help policymakers if there are poor amounts of data regarding trans people and their experience with HIV.

Tordoff writes that there are likely hundreds of mathematical models focused on HIV. Only seven of these models include trans people at all. There are two key problems that Tordoff and her co-authors note in models that do include trans people. The first problem is that there are models only including trans women and not trans men or nonbinary people. Tordoff notes that there seems to be regurgitated information across such models and this first problem may be a reason why.

In a separate study published by the National Institute of Health, researchers state that by acknowledging less visible identities, transgender individuals may be better represented by research studies. The study also refers to recent research highlighting the experience that transgender people have had in completing questionnaires for research studies. Questionnaires will often only include the choices “male” or “female”, and even if there are options like “transgender male” or “transgender female”, researchers are at risk of ignoring nonbinary identities.

The second problem is that such models assume trans women exclusively partnering with cisgender men, however there are other choices that trans women make when choosing who to partner with.

There’s evidence that access to gender-affirming care (e.g., hormones) can increase adherence to other types of disease prevention among trans people (PrEP and getting STI-tested). In general, researchers and advocates have long called for the inclusion of SOGIE data (sexual orientation, gender identity expression) to get a better understanding of these sidelined populations.

Tordoff notes a separate study where Minalga looked at 41 milestone HIV trials between 1991-2023 and this study found that out of more than 170,000 total participants, less than 1% were identified as part of the trans community and 94% of those were trans women.

Minalga notes that when data from such studies gets analyzed and published, that data does not make it back to trans people.

The analysis notes that lack of data on trans people is harmful to trans people and policies, but it is also harmful to other areas of health that aren’t publicly tied to LGBTQ+ populations. An example of this is clinicians not having enough data on how interventions or treatment may work for trans patients. A lack of this data often leads clinicians to extrapolate data from cisgender people despite some physicians not being comfortable with that.

The Centers for Medicare and Medicaid Services (CMS) introduced optional questions on SOGIE data for state Medicaid programs to collect from applicants. CMS recommended collecting information on sex assigned at birth, gender identity and sexual orientation.

Although this data would not be nationally representative, self-reported SOGIE data has never been collected on such a large scale according to Nathaniel Tran at the University of Illinois at Chicago School of Public Health in JAMA. This is good because only a few states collect this type of data.

Legislation continues to restrict gender-affirming care across the country, preventing the collection of additional meaningful data on queer populations.

Queer people living in states that restrict access to gender-affirming care don’t trust the state to protect their personal data. On the other hand, most clinicians simply don’t know much about LGBTQ+ populations in the first place. Trans people are often frustrated by the way they are considered in the research they participate in. Despite the need, data gaps will continue to hamper policy changes designed to improve access to care and services for this already underserved population.

HCV Prevalence Burden Higher Among HIV-Positive MSM

In a study published in the Oxford Academic, researchers established the New York Acute C Surveillance Network to study potential risk behaviors leading to primary Hepatitis C Virus (HCV) infection and reinfection among men who have sex with men (MSM) with HIV. The study was performed over the span of two decades from 2000-2018 to determine both incidence factors and risk factors for HCV reinfection among MSM with HIV in New York City. 

The World Health Organization published a systematic review outlining that there is an elevated HCV prevalence among HIV-positive MSM and that this burden is higher among this community compared to the general population. The study found that primary HCV infection rates among MSM with HIV were lower than among individuals who inject drugs but that reinfection rates are higher for MSM and higher compared to individuals who inject drugs. Researchers define HCV clearance as an undetectable HCV viral load at or greater than 12 weeks after the end of treatment.

The study asked participants about behavioral risk factors for primary HCV infection. First, the study asked about receipt of semen ejaculated into the rectum with condomless receptive anal intercourse (CRAI). Second, the study asked about methamphetamine use during sex and if the route of use was by injection.

Besides risk factors for primary infection, the study also assessed MSM with HIV for reinfection beginning on January 1, 2000. Researchers defined HCV reinfection as the detection of new HCV viremia after clearance of a previous infection. The date of onset of reinfection was recorded in two ways–either by detection of new HCV viremia or of alanine aminotransferase (ALT) elevation. A study published by the National Library of Medicine (NLM) defines ALT as a surrogate marker and predictor of liver disease and liver-related mortality.

Data collected and considered as risk factors for reinfection were:

• Date of birth 

• Race

• Ethnicity 

• Health insurance type (public or private)

• HCV genotype

• Interferon (IFN) λ3

• Haplotype 

• Calendar year of clearance of primary HCV

• Mode of clearance of primary HCV 

• Timing of HCV clearance 

• CD4 cell count 

• HIV VL suppression: defines as <50 copies/mL 

The study determined the incidence rates of first reinfection, second reinfection and overall reinfection. 

Researchers observed 304 MSM with HIV with clearance of a primary HCV infection for reinfection. At the time of clearance, the median age of participants was recorded to be 45 years of age. About 18% were black and 21% were hispanic. Public health coverage funded for 160 participants and private health coverage funded for 140 participants. 

About 10% of participants were spontaneously cleared for HCV and 90% were cleared by treatment either with an IFN-based regimen or a direct-acting antiviral (DAA) regimen. The study recorded that 37% of participants were cleared with an IFN-based regimen and 61% were cleared with a DAA regimen.

Researchers found that for recurrent events with reinfection as an outcome, receiving semen in the rectum was associated with HCV reinfection but that sexualized methamphetamine use was not associated with reinfection. Reinfection therefore was associated with sexual behaviors but not with drug use behaviors. 

The study further discussed that MSM that participated in sexualized methamphetamine use belonged to sexual networks that had a high HCV prevalence enough to result in onward HCV transmission. On the other hand, those not participating in sexualized methamphetamine use were part of sexual networks in which HCV prevalence was low enough to result in fewer transmissions of HCV. Researchers noted that semen transmits most HCV infections among MSM with HIV and that those who participate in sexualized methamphetamine use are more likely to receive HCV-containing semen in their rectums.

The study notes additional issues that likely result in an increased transmission of HCV among MSM with HIV. 

First, delays in insurance companies prescribing DAA treatments are likely a factor in the increased transmission of HCV. Second, MSM have not accepted condom use as a means to prevent HCV infection. Third, DAA treatments can’t help individuals who do not attend care. Individuals who have untreated HCV are less likely to engage in HIV care, further perpetuating these high-prevalence sexual networks. 

With the findings that researchers gathered, they note that there is a need for novel interventions to prevent sexual transmission of HCV among MSM.

Grindr Launches At-Home STI Testing Initiative

In an approach to combat elevated sexually transmitted infection (STI) rates among gay, bi, trans and queer people, the social dating app Grindr rolled out a new initiative providing users the chance to order at-home STI testing kits. Ellen Jenne wrote about this very issue in a recent blog post highlighting the new service the app rolled out to address elevated rates of STI infections among gay and bisexual men who have sex with me (GBMSM) in London.

Grindr partnered with Prepster at The Love Tank to deliver this initiative. PrEPster is a program part of the broader ‘The Love Tank’ community organization, a not-for-profit community interest community (CIC) providing education and research to under-served communities. This trailblazing partnership is why the initiative of providing at-home STI testing kits to users of the Grindr app is now introduced in London.

Grindr writes that this initiative will not only help users obtain knowledge of their health status but also help the app serve as a role model for other social networking apps to also make an emphasis on sexual health matters.

The initiative has already been successful in other countries like Ireland, Georgia, New Zealand and the US. The rate of STI diagnosis among GBMSM in London is recorded to be 15 times higher compared to that of the general population. This statistic is a reason why the initiative has been introduced in London and Grindr also writes that these numbers represent true people with actual struggles relating to fear and discrimination.

In their Grindr Unwrapped for 2023, the app shared statistics about what city users explored the most to attempt a connection with another user and London ranked first. Although a statistic from the previous year, the city’s popularity for being searched the most in one year highlights the importance of introducing the initiative in London overall.

The at-home self-test kits address common fears around STI testing such as physical transportation, fear of judgment and limited clinic hours. The at-home self-test kits address physical transportation barriers in allowing users to test at the convenience of their own homes at any time and be free of any judgment they would otherwise face in a physical clinic location.

Additionally, Grindr promises to not share information it obtains from its users when collecting data to send the kits to users.

Here is how the free and confidential service works:

• Access: Users access the service directly from their profile by clicking on the button “Free STI Kit”

• Eligibility: After clicking the “Free STI Kit” button, users will be guided through the basic steps to confirm their eligibility for the free testing kit.

• Privacy: Once confirmed, the kit will be discreetly delivered to the user’s address. Users can then collect their samples in the privacy of their own homes.

• Return: After collecting samples, users can return the kit using the provided free postage.

• Results: Within a couple of days of returning the kit, users receive their results via notifications through SHL’s secure platform.

• Confidentiality: Throughout the entire process, from ordering to receiving results, users’ information remains strictly confidential and is never shared with Grindr.

This public health push from one of the world’s largest social dating apps provides clear access, guided steps and convenient knowledge of health status. Ordering an STI self-test kit to reduce common burdens faced from members of the GBMSM community will help individuals achieve peace of mind in their community in an attempt to lower the overall heightened STI rates among these individuals.

Innovation as a Change Agent for Patients Leaving Incarceration

For Dontrace Young, leaving incarceration means stepping back into a world saturated with risk. Two of his cousins died from opioid overdoses in their early twenties, and drug use touches nearly every branch of his family tree. He knows the statistics – that the risk of a fatal overdose skyrockets in the weeks after leaving jail. But thanks to a program at the New Orleans jail, Dontrace is now equipped with Narcan and the knowledge to use it, skills that could save his life or the life of someone he loves. Dontrace’s story highlights a harsh truth: for many people leaving incarceration, access to healthcare is not a guarantee, and navigating a complex and often unwelcoming system can feel impossible. This challenge is not unique to those involved with the justice system.

Across the United States, systemic inequities create significant barriers to healthcare access, disproportionately impacting communities of color and those living in poverty. In rural areas, lack of insurance further exacerbates healthcare disparities. While technological innovation promises to revolutionize healthcare, these advancements often fail to reach the margins, sometimes even widening existing gaps. As the Stanford Social Innovation Review notes, an over-reliance on technology without addressing systemic issues can actually worsen health disparities. However, two innovative programs – one in New Orleans and one in Connecticut – offer a different approach, demonstrating that achieving health equity requires meeting people where they are and addressing the social factors that influence well-being.

Overdose Prevention: Preparing for Reentry in New Orleans

Inside the walls of the Orleans Justice Center, a program spearheaded by Dr. Anjali Niyogi is working to equip people leaving incarceration with a life-saving tool: knowledge. Recognizing the heightened risk of overdose for those reentering society after time in the carceral system, Dr. Niyogi founded the Formerly Incarcerated Transitions (FIT) Clinic, a program that provides a bridge between incarceration and healthcare access. A core component of the FIT Clinic’s work involves regular visits to the jail, where a team led by Dr. Niyogi, and including formerly incarcerated community health workers Haki Sekou and Danielle Metz, provides overdose prevention training and distributes Narcan to those preparing for release. The need for such a program cannot be overstated. As a 2007 study in the New England Journal of Medicine revealed, the risk of overdose is 129 times higher for people in the weeks after they leave jail. Factors like reduced tolerance and the increasingly prevalent presence of fentanyl in the drug supply contribute to this alarming statistic. By providing education and resources within the jail setting, Dr. Niyogi aims to mitigate this risk and provide people with the tools they need to stay safe.

Central to the program’s success is the involvement of Sekou and Metz. Having both experienced incarceration themselves, they possess an intimate understanding of the challenges faced by those leaving the justice system. Their presence helps to break down barriers and build trust with a population often wary of traditional healthcare providers. As Sekou explains, “They think doctors are going to use them as a guinea pig. That’s one of the words they use commonly.” By offering a listening ear, sharing their own stories, and providing practical support, Sekou and Metz create a space where people feel seen, heard, and empowered to prioritize their health. For people like Dontrace Young, the FIT Clinic’s impact extends far beyond overdose prevention training. The program connected Dontrace with resources to address his mental health, offering a pathway to a healthier future. By building trust, providing essential knowledge, and fostering connections to ongoing care, the FIT Clinic exemplifies the power of meeting people where they are and addressing health needs within the broader context of their lives.

Healthcare on Wheels: Reaching the Underserved in Connecticut

Recognizing that access to healthcare extends far beyond the doctor’s office, a team at Yale University has launched a groundbreaking initiative: the nation’s first mobile pharmacy. Housed in a retrofitted Winnebago, this innovative program brings a full range of pharmacy services directly to communities facing significant barriers to care, including people experiencing homelessness, those with chronic illnesses, and people with substance use disorders. The mobile pharmacy, the brainchild of Dr. Sandra Springer, a specialist in HIV and addiction treatment at Yale Medical School, aims to bridge the gaps in traditional healthcare delivery. “If we’re going to provide health care and you’re going to provide medication, you better be able to provide that medication,” asserts Dr. Springer. “We should be trying to help people get those services.” The mobile unit, staffed by a team of pharmacists and healthcare providers, travels to locations such as homeless encampments, food pantries, and community clinics, ensuring that essential medications and healthcare services are available to those who need them most.

This innovative approach tackles multiple barriers to care simultaneously. For those without reliable transportation, the mobile pharmacy eliminates a significant hurdle. For people experiencing homelessness, who may feel stigmatized or unwelcome in traditional healthcare settings, the mobile unit offers a safe and accessible alternative. And for those struggling with chronic conditions, the mobile pharmacy provides consistent access to medications and support, reducing the likelihood of complications and hospitalizations.

The mobile pharmacy’s impact extends far beyond simply filling prescriptions. The team provides a range of services, including chronic disease management for conditions like diabetes and hypertension, wound care for those struggling with infections or injuries, and connections to mental health and addiction treatment resources. Jillian Corbin, executive director of the St. Vincent de Paul Place daytime shelter in Norwich, where the mobile pharmacy has become a lifeline for many, attests to its transformative impact: “When the staff from the pharmacy van first arrived in February, the impact to the community was immediate and life-changing.” By meeting diverse needs with compassion and expertise, Yale’s mobile pharmacy serves as a powerful model for how to bring healthcare directly to those who are too often left behind.

Redefining Innovation: Lessons from the Margins

The programs in New Orleans and Connecticut offer a powerful counter-narrative to the prevailing notion of healthcare innovation as synonymous with technological advancement. They illuminate a critical truth: true progress towards health equity requires a fundamental shift in how we define and approach innovation. As Infectious Diseases of Poverty asserts, “social innovation can best be understood as innovation in social relations, in power dynamics and in governance transformations, and may include institutional and systems transformations.” These programs are not simply delivering services; they are transforming systems by dismantling barriers, challenging assumptions, and centering the needs of those most often relegated to the margins. This requires a commitment to investing in what the Stanford Social Innovation Review calls “health-focused social innovations,” rather than solely prioritizing technology-driven solutions that may fail to address the root causes of health disparities, or make them worse.

What makes these programs so effective? They embody key principles of equitable innovation:

• Community Engagement: Both programs prioritize the active involvement of their target populations. The FIT Clinic relies on formerly incarcerated community health workers who bring invaluable lived experience and trust to their work. Yale’s mobile pharmacy team collaborates with local organizations and community members to ensure their services are accessible and responsive to local needs.

• Culturally Responsive Care: These programs recognize that healthcare is not one-size-fits-all. They approach each interaction with cultural sensitivity, understanding that historical trauma, systemic racism, and other forms of oppression profoundly impact health outcomes and shape people’s experiences with healthcare systems.

• Trust and Relationships: Building authentic relationships based on trust and mutual respect is paramount. For those who have experienced stigma, discrimination, or mistreatment within healthcare settings, trust is not a given. Both programs address this by prioritizing empathy, transparency, and a genuine commitment to meeting people where they are, both physically and emotionally.

• Addressing Social Determinants of Health: These programs understand that health outcomes are shaped by a complex interplay of social, economic, and environmental factors. By providing transportation, addressing food insecurity, and connecting patients to essential resources, they go beyond treating immediate medical needs and work to create conditions that support overall well-being.

The success of these programs is a call to action for all of us working towards a more just and equitable healthcare system. We must:

• Support and invest in community-based programs: Funding should be directed towards initiatives that prioritize social innovation, community engagement, and culturally responsive care.

• Shift funding priorities: While technology has a role to play, we must move away from an over-reliance on expensive technological solutions that often fail to reach those most in need.

• Advocate for policy change: Systemic change requires advocating for policies that address the root causes of health disparities, such as poverty, discrimination, and lack of access to quality education and employment opportunities.

• Amplify marginalized voices: Those most impacted by health inequities must be at the forefront of designing and implementing solutions. We must listen to, learn from, and follow the lead of those with lived experience.

By embracing a broader vision of healthcare innovation – one that centers equity, community, and the lived experiences of those most marginalized – we can begin to create a healthcare system that truly works for everyone.

The Promise of a Cure: Why Are We Still Failing People with HCV?

Hepatitis C virus (HCV) infection affects millions of Americans, contributing to thousands of preventable deaths each year. While a cure for HCV, in the form of direct-acting antiviral (DAA) medications, has been available for over a decade, achieving widespread treatment access has been a persistent challenge. This challenge is particularly acute among younger adults, who experience the highest rates of new HCV transmissions, often associated with injection drug use.

Historically, the high cost of DAAs led many state Medicaid programs to implement restrictive coverage policies, limiting treatment access based on factors like liver disease severity, sobriety, and prescriber specialty. In 2022, CANN highlighted in a blog post, these policies not only created barriers to care but also undermined public health efforts to interrupt HCV transmission. Advocacy and legal action have played a crucial role in dismantling these restrictions, as evidenced by the Center for Health Law and Policy Innovation's (CHLPI) successful litigation efforts in 13 states, which served as a model for similar efforts nationwide.

While this progress is encouraging, the fight to eliminate HCV as a public health threat is far from over. We must address the remaining barriers to care, particularly those that continue to disproportionately impact people who use drugs and those that persist within managed care organizations.

The Promise and Progress of HCV Treatment

Direct-acting antivirals represent a monumental advancement in HCV treatment. These medications offer cure rates of 95% or higher, achieving sustained virologic response in the vast majority of people treated. The benefits of DAA treatment extend far beyond individual health outcomes. Expanding access to these curative therapies holds immense promise for improving public health by reducing HCV-related mortality, interrupting transmission chains, and generating long-term cost savings.

The Centers for Disease Control and Prevention (CDC) has estimated that approximately 14,200 HCV-related deaths occurred in the United States in 2019 alone, a stark reminder of the urgent need for effective treatment. Treating HCV not only saves lives but also prevents ongoing transmission of the virus. When a person achieves sustained virologic response, they are no longer able to transmit HCV to others. Furthermore, a study published in JAMA Network Open found that HCV treatment is associated with reduced healthcare costs in the long term, as cure prevents the need for expensive interventions related to managing complications like cirrhosis and liver cancer.

The dismantling of restrictive Medicaid policies has been instrumental in increasing treatment access. A JAMA Health Forum study analyzing data from 39 state Medicaid programs found that easing or eliminating restrictions on DAAs led to a significant increase in treatment uptake. Specifically, these policy changes were associated with an increase of 966 DAA treatment courses per 100,000 Medicaid beneficiaries per quarter compared to states that maintained restrictions. This finding underscores the tangible impact of removing barriers to care.

Further progress is evident in the growing trend of states removing prior authorization requirements for DAAs. The 2024 National Snapshot Report from CHLPI and National Viral Hepatitis Roundtable (NVHR) reveals that, for the first time, more states have eliminated prior authorization for most patients than those that still require it. This shift toward streamlining access represents a critical step in ensuring timely treatment initiation.

Persistent Barriers to HCV Treatment Access

Despite the progress made in expanding HCV treatment access, significant barriers remain, particularly for people who use drugs. The 2024 National Snapshot Report from CHLPI and NVHR reveals that nine states still impose substance use restrictions, requiring sobriety or counseling as a prerequisite for DAA treatment. These restrictions are not only medically unnecessary but also demonstrably harmful, as the JAMA Network Open study found a significant association between sobriety requirements and reduced HCV treatment rates. The HealthHIV State of Harm Reduction survey further underscores this point, with respondents reporting that stigma and community resistance pose substantial obstacles to accessing drug user health services, including HCV care.

Retreatment restrictions present another hurdle for people seeking HCV care. According to the 2024 National Snapshot Report, 15 states impose stricter criteria for retreatment than for initial therapy, often denying access based on factors like adherence challenges or previous treatment failure. These policies fail to recognize the complex social and structural factors that can contribute to reinfection or treatment interruptions, particularly among people who use drugs.

Furthermore, disparities in treatment rates among Medicaid recipients persist. The CDC's Vital Signs report found that Medicaid recipients who are Black were 7% less likely to initiate timely DAA treatment compared to White recipients. These disparities reflect the systemic inequities that permeate the healthcare system and demand targeted interventions to ensure equitable access to care.

Discrepancies between state Medicaid policies and managed care organization (MCO) practices present an additional layer of complexity. While many states have eased restrictions on DAAs, the JAMA Health Forum study revealed that these policy changes did not translate into increased treatment uptake in states where DAAs were predominantly reimbursed by MCOs. This finding aligns with the 2022 National Summary Report from CHLPI and NVHR, which found that MCOs often impose more restrictive criteria for HCV treatment access than their fee-for-service counterparts.

These persistent barriers raise serious ethical concerns. Denying treatment based on substance use or adherence challenges perpetuates harmful stereotypes and undermines the principles of patient autonomy and healthcare equity. As Jen Laws argues, "We don't get to tell patients how to prioritize their care based on a payer or provider's biases." The HealthHIV harm reduction survey echoes this sentiment, with respondents emphasizing the importance of meeting people "where they're at" and respecting their right to make informed decisions about their health.

Other administrative barriers, such as requirements to fill prescriptions at specialty pharmacies, further complicate access. The 2022 National Summary Report highlights the challenges posed by specialty pharmacies, which often impose additional restrictions and logistical hurdles that can delay or prevent treatment initiation, particularly for people experiencing homelessness or housing instability.

Harm Reduction and HCV Elimination: A Holistic Approach

Achieving HCV elimination requires a holistic approach that goes beyond simply removing treatment restrictions. We must recognize that HCV treatment access is inextricably linked to broader harm reduction efforts. As Jen Laws aptly stated, "If we are to meaningfully invest in harm reduction policies at the intersection of drug use and HCV, we have to get a handle on what's working and what's not." This means embracing a comprehensive strategy that addresses the social, economic, and structural factors that contribute to HCV risk and disparities.

A 50-state survey of harm reduction laws conducted by the Network for Public Health Law revealed significant variations in the legal landscape surrounding syringe access and naloxone distribution. These variations underscore the need for a coordinated national effort to expand access to these life-saving interventions. The HealthHIV State of Harm Reduction survey further highlights the importance of harm reduction in HCV prevention and care, with respondents emphasizing the need for services that prioritize their safety and well-being.

A truly comprehensive approach to HCV elimination must encompass the following key elements:

• Removal of All Remaining Medicaid Restrictions: Eliminating all restrictions based on substance use, retreatment history, and other arbitrary factors is essential for ensuring equitable access to DAAs.

• Ensuring Parity Between State Medicaid Policies and MCO Practices: States must strengthen oversight and enforcement mechanisms to ensure that MCOs adhere to state Medicaid policies and do not impose additional barriers to HCV treatment.

• Expanding Access to Harm Reduction Services: Increasing the availability of syringe exchange programs, naloxone distribution, and other harm reduction services is critical for preventing new HCV transmissions and connecting people who use drugs to care. However, even in states that do have syringe exchange programs, access can vary widely, with many programs facing funding limitations, geographic restrictions, and community resistance. For example, a 2017 report indicated that 26 states had either no syringe exchange programs or limited these services to one or two major cities. Research suggests that existing programs meet only a fraction of the estimated need, highlighting the need for continued advocacy and policy reform.

• Addressing Social Determinants of Health: HCV elimination efforts must address the underlying social and economic factors that contribute to HCV risk and disparities, such as poverty, homelessness, and lack of access to healthcare. The HealthHIV harm reduction survey found that inadequate housing and transportation were significant barriers to clients engaging in care. Investing in housing, transportation, and other social support services is necessary for creating a more equitable and effective HCV response.

The Biden Administration's proposed HCV elimination plan offers a transformative framework for addressing many of these challenges. The plan's key elements include a subscription-based payment model for medications, investment in rapid point-of-care testing, and increased federal support for community-based healthcare infrastructure and provider training. However, as CANN CEO Jen Laws emphasizes, successful implementation requires more than just affordable drugs. The plan must prioritize reinvestment of cost savings into public health systems, support community-based testing and integrated treatment models, and address logistical barriers to care. Federal legislation mandating opt-out HCV screening in hospitals, universal screening in prisons, and cost-sharing limits on commercial insurance plans would further strengthen the plan's foundation.

Conclusion

While significant progress has been made in expanding HCV treatment access, the fight to eliminate HCV as a public health threat demands a sustained and multifaceted effort. The Biden Administration's proposed plan offers a promising roadmap, but its success hinges on congressional budget approval and addressing the systemic barriers that continue to impede progress.

To effectively combat HCV, we must move beyond a narrow focus on medication access and embrace a holistic approach that prioritizes harm reduction, addresses social determinants of health, and ensures equitable access to care for all. CANN’s latest HIV/HCV Co-Infection Watch report provides a valuable resource for understanding the current landscape of HCV treatment access and harm reduction programs across the United States, empowering advocates and communities to push for meaningful change. Together, we can translate the promise of a cure into a reality for all Americans affected by HCV.