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Kelley is a professor within the Department of Medicine at the Emory University School of Medicine.

Colleen Kelley, MD, MPH, offers some insights on where we are today with the state of HIV prevention including the expanding PrEP options, why PEP is underutilized, and the challenges behind HIV vaccine development.  

HIV Prevention: Discussing PrEP, PEP, and Vaccine Development

Along with a 1 reported case in Massachusetts, the

New Hampshire Department of Health and Human Services (DHHS) has confirmed a person infected with eastern equine encephalitis (EEE) has died. The public health agency said the person was hospitalized due to severe central nervous system disease. The last reported human EEEV infection in New Hampshire was in 2014, when DHHS identified 3 human infections, including 2 fatalities. In the same statement, DHHS mentions there has been 1 confirmed case in Vermont this summer.

On August 16, the Massachusetts Department of Public Health (MDPH) released a statement discussing the confirmation of the first human case of EEE in the state this year. The confirmed case was discovered in an 80 year old man who was exposed to the vector borne disease in Worcester County. As a result, the risk level in the local communities of Douglas, Oxford, Sutton, and Webster has been raised to critical, and in Dudley, Northbridge, and Uxbridge the risk is increased to high.

Additionally, the neighboring communities of Auburn, Charlton, Grafton, Leicester, Mendon, Millbury, Millville, Southbridge, and Upton are now considered at moderate risk according to MDPH.

“This is the first time we have seen a person infected with EEE in Massachusetts since 2020,” Public Health Commissioner Robbie Goldstein, MD, PhD, said in a statement. “EEE is a rare but serious disease and a public health concern. We want to remind residents of the need to protect themselves from mosquito bites, especially in areas of the state where we are seeing EEE activity.

Though very rare, EEE is serious and a potentially fatal disease that can affect people of all ages. EEE is generally spread to humans through the bite of an infected mosquito. There were 12 human cases of EEE in Massachusetts in 2019 with 6 deaths, and 5 human cases with 1 death in 2020. There were no human cases of EEE in Massachusetts in 2021, 2022, or 2023.

EEE has a fatality rate of 33% to 70%, with most deaths occurring 2–10 days after the onset of symptoms.

In addition to a high mortality rate, long-term physical and mental complications, including permanent neurological deficits have been identified in many people who survive EEE.

Plymouth is approximately 40 miles south of Boston along the coast, and Worcester County is in the middle of the state, so the 2 areas are not in close proximity, but due to the elevated risk locally, the town of Plymouth decided to take action in response to outdoor parks. As of last Friday, all town public parks and fields are close daily from dusk until dawn.

“As Mass DPH has now elevated Plymouth’s EEE risk status to high, it is important to take extra precautions when outdoors and follow state and local health guidelines to avoid unnecessary risk to exposure to EEE. The health and safety of our community, residents, and visitors remain our priority,” Plymouth’s Commissioner of Health and Human Services, Michelle Bratti, said in a statement.

According to the Centers for Disease Control and Prevention (CDC) most people who are infected with the virus do not develop symptoms; however, for those that do, the date from the bite to the onset of the illness is 4 to 10 days. EEE can also result in fever or neurologic disease. The type of illness will depend on the age of the person and other factors. Those who are infected can develop meningitis.

There are no FDA-approved treatments for EEE and for patients who develop severe cases, they can be hospitalized to receive supportive treatment.

Over the weekend, MDPH detailed plans of spraying for mosquitos including aerially in areas of Plymouth County, and truck-mounted spraying in parts of Worcester County. As of Saturday, 10 communities in Massachusetts were raised to high or critical risk for EEE virus.

“The risk from EEE is high in parts of Plymouth County and critical in parts of Worcester County,” State Epidemiologist Catherine M. Brown, DVM, said in a statement. “In addition to recommending that people use mosquito repellent with an EPA-registered active ingredient and clothing to reduce exposed skin, we also recommend that evening outdoor events be rescheduled to avoid the hours between dusk and dawn. The mosquitoes most likely to spread EEE are most active during the dusk to dawn hours.”

There are preventative strategies to avoid EEE, and the MDPH has listed such measures 

For those who live in Massachusetts and want more information on EEE, it can be found 

 or by calling the DPH Division of Epidemiology at 617-983-6800.

1.NH DHHS Identifies Person Infected with Eastern Equine Encephalitis Virus in New Hampshire.The New Hampshire Department of Health and Human Services. August 27, 2024. Accessed August 28, 2024.
https://www.dhhs.nh.gov/news-and-media/nh-dhhs-identifies-person-infected-eastern-equine-encephalitis-virus-new-hampshire
2. State health officials announce season’s first human case of Eastern Equine Encephalitis in Massachusetts. MDPH. August 16, 2024. Accessed August 27, 2024.
https://www.mass.gov/news/state-health-officials-announce-seasons-first-human-case-of-eastern-equine-encephalitis-in-massachusetts
3.Plymouth to Close all Public Parks and Fields from Dusk to Dawn. Town of Plymouth. August 23, 2024. Accessed August 27, 2024. PDF.
4. Eastern Equine Encephalitis: Symptoms, Diagnosis, and Treatment. CDC. May 15, 2024. Accessed August 27, 2024.
https://www.cdc.gov/eastern-equine-encephalitis/symptoms-diagnosis-treatment/index.html
5. State officials announce plans to spray for mosquitoes in sections of Worcester and Plymouth counties due to EEE. MDPH. August 24, 2024. Accessed August 27, 2024. 
https://www.mass.gov/news/state-officials-announce-plans-to-spray-for-mosquitoes-in-sections-of-worcester-and-plymouth-counties-due-to-eee



The town of Plymouth decided to prohibit people from using the parks from dusk to dawn due to concerns over eastern equine encephalitis after a man contracted the rare disease in the state.

Concerns Over Mosquito-Borne Illness Causes Massachusetts Town to Create Curfew for Parks, Spraying in Counties

A new study out of North Carolina reveals that most patients tested for potentially serious tick-borne diseases like ehrlichiosis and spotted fever rickettsiosis are not completing the full two-step testing process necessary for a confirmed diagnosis, leaving significant gaps in public health surveillance and clinical care.

Researchers analyzed more than 4,400 patient records from a major academic center in North Carolina between 2017 and 2020. They found that while thousands received an initial (acute) blood test, only 15% returned for the follow-up (convalescent) sample needed to confirm the diagnosis.

This low rate of testing completion is a problem not only for individual patient care but for understanding how widespread these diseases are. “Unfortunately, very few people actually get the second test done,” said Ross M Boyce, MD, MSc, an infectious disease physician at the University of North Carolina, in our interview. “Nationally, it’s probably around five to eight percent of all people. So that informs a lot of the data and our knowledge of these diseases. And the lack of completion of that is really important.”

Tick-borne illnesses like ehrlichiosis and Rocky Mountain spotted fever are caused by bacteria transmitted through tick bites. They can cause symptoms such as fever, body aches, headache, and in some cases, rashes. “Certainly Rocky Mountain spotted fever and ehrlichiosis can be life-threatening if untreated,” Boyce said. “Particularly in children and older adults.”

Over the study period, completion of the convalescent testing did improve from 4% to 23% for Ehrlichia and 7% to 11% for Rickettsia though still far from ideal. Patients were more likely to complete the full testing algorithm if they lived near a health care facility, had a reactive result on the first test, or were tested for both pathogens.

Clinically, the two-part serological test is considered the gold standard, but it poses logistical hurdles. “It’s important first to note that you can’t use the test itself to make a diagnosis with just one visit,” Boyce explained. “The treatment decision has to be made just based on your clinical gut feeling.”

If a patient improves after treatment, many see no reason to return for another blood draw. “A lot of people feel better, and who wants to go back to the doctor just to confirm their result?” Boyce said. “It’s a harder case to say, well, this is important for us to know how many cases there are in an area. But it’s also important for people to confirm what it is they had.”

Even more critically, negative initial results can be misleading. “The first test can be negative just because your body hasn’t built up enough antibodies in response to the infection,” Boyce said. “Just because it’s negative during the first one does not mean that they are negative. In the same way, just because it’s positive… doesn’t mean they’re positive because they could have been exposed before.”

Testing Limitations and the Push for Better Diagnostics

The current reliance on antibody-based testing comes with inherent delays and uncertainties. While some molecular diagnostic tools are available like PCR tests for Ehrlichia, they aren’t widely accessible or fast enough for real-time clinical decisions.

“Rickettsia has always been a challenge,” Boyce said. “It invades the endothelium, the walls of the blood vessels, and there’s not as much floating around in the actual blood. When you stick a needle in and draw someone’s blood, unless you get a good chunk of the wall, you’re not going to get a lot.”

There are CDC-run PCR tests for Rickettsia, but those are limited and slow, requiring routing through public health agencies. “There’s a lot of people working on better tests,” Boyce added. “Rocky Mountain spotted fever is the most lethal tick-borne disease in the United States, but it has close cousins, that are not lethal at all. And the serological test can’t tell them apart, they all cross-react.”

Tick-Borne Illnesses: Understudied and Underfunded

Beyond diagnostics, Boyce said tick-borne illnesses like ehrlichiosis and spotted fever rickettsiosis suffer from a lack of public awareness and funding, often overshadowed by Lyme disease, "These diseases, I think, get a short shrift compared to Lyme, and there's definitely more cases of Lyme reported every year, but these are spreading, and it's spreading because the ticks that transmit them are moving into places.”

Boyce pointed to the Lone Star tick, known to transmit Ehrlichia, which has been reported in areas as far north as Maine and Canada. “They’re on the move,” he said. “Certainly worth thinking about and getting more attention.”

Tick-borne illnesses like Rocky Mountain spotted fever may be less well-known than Lyme, but they can be deadlier and are highly preventable with timely treatment. Boyce explained urgency, “Lyme doesn’t kill people in the short term. These can. Especially in kids. Especially in older adults. Especially if you don’t get treated within five to seven days.”

Until more rapid and reliable diagnostic tools become standard, clinicians must rely on clinical judgment, timely treatment, and improved follow-up to manage these potentially severe diseases. As Boyce noted, greater public and institutional awareness is key. With tick ranges expanding and case numbers rising, Boyce and his team hope their research will help drive attention to these often-overlooked yet increasingly relevant public health threats.

Liao H, Hollingsworth BD, Cassidy CA, Zychowski D, Ursery L, Giandomenico DA, Boyce RM. Completion of paired serological testing algorithms for spotted fever rickettsiosis and ehrlichiosis, North Carolina: 2017-2020. Clin Infect Dis. 2025 Apr 3:ciaf176. doi: 10.1093/cid/ciaf176. Epub ahead of print. PMID: 40176320.

Ross M Boyce, MD, MSc, discusses the diagnostic challenges and the need for greater awareness of tick-borne illnesses in the US, considering their potential severity.


Study Reveals Low Completion Rates for Essential Testing in Ehrlichiosis and Spotted Fever Cases

This is the fourth in a series looking at HIV today.

This spring marks the 15th anniversary of the Affordable Care Act (ACA)—a landmark in American health policy that expanded coverage to millions and guaranteed no-cost access to lifesaving preventive services, including HIV and STI testing and pre-exposure prophylaxis (PrEP). What should be a milestone of progress is now clouded by uncertainty—most notably over a major Supreme Court case with HIV prevention at its core. Adding to the instability are sweeping layoffs, agency restructuring, and potential cuts to domestic HIV and public health programs—moves that have destabilized critical institutions and left communities and providers in limbo.

On April 21, 2025, the US Supreme Court will hear oral arguments in 

, a case that could unravel key ACA provisions by striking down the requirement that insurers cover preventive services without cost-sharing. If upheld, the decision could put PrEP out of reach for many Americans and deal a devastating blow to national HIV prevention efforts.

At the same time, the Trump administration has undertaken a sweeping reorganization of the US Department of Health and Human Services (HHS), resulting in the termination of approximately 10,000 employees.

 This includes the elimination of the Office of Infectious Disease and HIV/AIDS Policy, deep cuts to the CDC’s Division of HIV Prevention, the dissolution of the CDC/HRSA HIV Advisory Council, and major reductions at the NIH’s National Institute of Allergy and Infectious Diseases.

These changes have dismantled or weakened key public health units—those responsible for implementing the Ending the HIV Epidemic (EHE) initiative, leading the nation’s syphilis response, and operating surveillance systems for tracking outbreaks.

 The cuts directly undermine the ability of state and local health departments to conduct surveillance, link patients to PrEP, or respond to emerging disease clusters. They also jeopardize implementation of the National HIV/AIDS Strategy.

In just the past few months, more than 230 HIV-related research grants have been lost at NIH.

 Any one of these changes would be alarming; together, they reflect a dangerous retreat at a critical moment—when ending the HIV epidemic was finally within reach. While reviewing structures for efficiency is reasonable, public health experts warn that these abrupt, sweeping cuts risk losing decades of institutional knowledge and threaten the stability of programs serving the most vulnerable.

All this is happening as we mark notable progress in the US HIV response over the past decade. In 2019, the first Trump administration launched the EHE initiative, setting a bold goal to reduce new HIV infections by 90% by 2030. EHE provided increased funding to high-burden areas, expanded PrEP access, and prioritized local innovation in testing and rapid treatment. The Biden administration expanded this effort through the National HIV/AIDS Strategy (NHAS) 2022–2025, which introduced a more integrated, equity-centered approach. The NHAS enhanced coordination across federal agencies—HHS, HUD, DOJ, and others—focusing on stigma reduction, measurable outcomes, and addressing the social determinants that influence health and access to care.

According to the CDC, approximately 31,800 Americans acquire HIV each year. While this marks a 12% decline since 2018, progress has been uneven. The burden remains disproportionately high among key populations—those most affected by structural barriers, stigma, and limited access to care. Geographically, the epidemic continues to concentrate in the US South, particularly in states like Georgia, Louisiana, Texas, and Florida,

 where limited Medicaid expansion, underfunded public health systems, and social discrimination further complicate prevention and treatment efforts.

We know what works. For over a decade, research and real-world experience have shown that a combination of HIV testing, rapid linkage to treatment, PrEP, and community-based outreach are the most effective ways to reduce HIV transmission. These strategies are not theoretical—they’ve already driven declines in new infections in many jurisdictions. And there’s more reason for optimism: exciting new data confirms the promise of long-acting PrEP, including injectable options that offer protection for months at a time without requiring daily pills. These innovations could be game changers for people who face challenges with adherence or access. But no matter how effective a tool is, it’s only as impactful as our willingness to invest in it. That’s why infrastructure, funding, and political commitment remain the backbone of any successful HIV response.

The economic case for prevention is also undeniable. The lifetime cost of treating one person with HIV in the US is estimated at $400,000.

 Preventing 10,000 new infections could save the US health system $4 billion in future care. Every dollar cut from prevention today risks far higher downstream costs—financially and in human lives. A recent amfAR analysis modeled the five-year consequences of eliminating CDC HIV prevention funding entirely. The projections are staggering: an estimated 143,486 additional HIV cases, 14,676 more AIDS-related deaths, and $60.3 billion in added cumulative lifetime healthcare costs.

 That’s not cost-saving—that’s policy malpractice.

 case compounds this risk. A lower court has already ruled against the ACA’s preventive services mandate. Under the Biden administration, CMS finalized a National Coverage Determination, guaranteeing no-cost access to all forms of PrEP for Medicare participants, and took separate action offering the same promise to healthcare consumers on the marketplace. These actions were premised on the U.S. Preventive Service Task Force’s (USPSTF) Grade A Recommendation, stating that “PrEP is safe and highly effective at preventing HIV.” At the heart of 

 is a challenge to USPSTF’s authority to issue coverage recommendations to CMS. If the Supreme Court affirms the lower court’s decision, insurers could begin charging copays or denying coverage for preventive services including PrEP. This would put effective prevention out of reach for many, especially those in underserved communities.

This isn’t just about numbers—it’s about ensuring that everyone, no matter where they live or who they are, has access to the tools that prevent HIV. Prevention should be easy, accessible, and affordable for all—whether you're a young person in a rural town, someone facing stigma in an urban center, or anyone navigating a healthcare system that too often leaves people behind. Slashing funding and protections makes it harder for everyone to stay healthy—and undermines decades of progress toward a more inclusive, effective public health system.

That’s why we recommend the MAHA Commission adopt a bold, targeted strategy to accelerate the end of the HIV epidemic in the United States. This should include universal access to HIV prevention, treatment, and care—especially for communities most affected. A national plan rooted in science and impact can help translate decades of progress into lasting change.

While federal leadership remains essential, government action alone isn’t enough. The private sector has also been a powerful driver of innovation in HIV prevention and care. From developing long-acting PrEP to advancing digital health platforms, telemedicine, and AI-powered tools, private companies are modernizing how people access and engage with care. These technologies help close gaps in prevention, reach underserved communities, and personalize services at scale.

Congress has a role to play in all of this too. Lawmakers provide vital oversight to federal HIV efforts, from the Ryan White HIV/AIDS Program to research and prevention infrastructure. They also control the purse strings—and now is the time to fund smarter, not slash deeper. In particular, Medicaid is the largest source of insurance coverage for people with HIV in the US, covering an estimated 40% of nonelderly adults. The program ensures access to essential services like antiretroviral therapy, lab monitoring, and prevention counseling. The ACA’s Medicaid expansion has allowed more low-income individuals with HIV to receive care earlier, improving outcomes and reducing transmission.

The 15th anniversary of the ACA should be a time to celebrate what’s worked—and recommit to what’s needed. Public health progress doesn’t sustain itself. It requires vigilance, investment, and courage. We cannot afford to let politics or complacency undermine the tools we already have to end HIV—our future, and billions in taxpayer dollars, depend on it.

1. Sobel L, et al. Explaining Braidwood Management v. Becerra, the Case Challenging the ACA’s Preventive Services Requirement. 

https://www.kff.org/womens-health-policy/issue-brief/explaining-litigation-challenging-the-acas-preventive-services-requirements-braidwood-management-inc-v-becerra/

2. Stein R et al. Widespread firings start at federal health agencies including many in leadership 

. April 1, 2025. Accessed April 4, 2025. Available at: 

https://www.npr.org/sections/shots-health-news/2025/04/01/g-s1-57485/hhs-fda-layoffs-doge-cdc-nih

3.Whyte L et al. Trump Administration Weighs Major Cuts to Funding for Domestic HIV Prevention. 

. March 18, 2024. Accessed April 4, 2025. 

https://www.wsj.com/health/healthcare/trump-administration-weighing-major-cuts-to-funding-for-domestic-hiv-prevention-8dcad39b

4. Basilio H. Trump team guts AIDS-eradication programme and slashes HIV research grants 

. March 31, 2024. Accessed April 4, 2025.


https://www.nature.com/articles/d41586-025-00969-5

5. What Is Ending the HIV Epidemic in the US?Department of Health and Human Services. Updated March 20,2025. Accessed April 4, 2025. 
https://www.hiv.gov/federal-response/ending-the-hiv-epidemic/overview

6. HIV Surveillance Report, 2022; vol. 34. Centers for Disease Control and Prevention. Published May 2024. Accessed April 4, 2025. 


https://www.cdc.gov/hiv/library/reports/hiv-surveillance.html

7. Schackman BR, Gebo KA, Walensky RP, et al. The Lifetime Cost of Current Human Immunodeficiency Virus Care in the United States. 

. 2006;44(11):990-997. doi:10.1097/01.mlr.0000228021.89490.2c

8. Cuts to the CDC’s Division of HIV Prevention Will Lead to Dramatic Rise in Infections, Deaths, and Costs. 

. March 27, 2025. Accessed April 4, 2025. 


https://www.amfar.org/news/cuts-to-the-cdcs-division-of-hiv/

9. Dawson L. et al. 5 Key Facts About Medicaid Coverage for People with HIV. 

https://www.kff.org/medicaid/issue-brief/5-key-facts-about-medicaid-coverage-for-people-with-hiv/

The 15th anniversary of the Affordable Care Act is overshadowed by threats to HIV prevention efforts, including a looming Supreme Court case that could eliminate no-cost access to preexposure prophylaxis and other preventive services. Simultaneously, deep federal cuts and restructuring have destabilized critical public health infrastructure, jeopardizing decades of progress in the fight against HIV.

Undermining HIV Prevention Now Will Cost Billions Later

According to the CDC's latest Influenza Surveillance Report, Seasonal influenza activity remains elevated but continues its downward trend for the second consecutive week. Despite the recent decrease, the 2024–2025 flu season has been classified as “high severity” for all age groups, marking the first such designation since the 2017–2018 season.

As of Week 13, the CDC estimates at least 45 million illnesses, 580,000 hospitalizations, and 25,000 deaths due to influenza. The cumulative hospitalization rate now stands at 121.9 per 100,000 population, which is the highest rate recorded since the 2010–2011 flu season.

Public health laboratories reported 1,049 influenza virus detections this week:

No cases of A(H5) avian influenza or human-to-human transmission were identified.

: 3.2% for influenza-like illness (ILI), remaining above the national baseline of 3% for 18 consecutive weeks

: 9,364 new hospitalizations reported this week

: 9 new deaths, bringing the seasonal total to 168

Pediatric deaths include 7 from influenza A and 2 from influenza B, bringing the 2024–2025 season close to the previous two years (187 in 2023–2024, and 207 in 2022–2023)

: Detected in one A(H1N1) and one A(H3N2) virus

: Not recommended due to ongoing resistance

: 1.4% of all emergency visits, decreasing across all age groups

According to the CDC’s integrated respiratory surveillance:

The CDC continues to recommend annual influenza vaccination for everyone aged 6 months and older as long as influenza viruses are circulating. Early antiviral treatment is strongly encouraged for individuals at high risk of complications.

Centers for Disease Control and Prevention. Weekly U.S. influenza surveillance report: Key updates for week 13, ending March 29, 2025. FluView. April 4, 2025. Accessed April 7, 2025. 

https://www.cdc.gov/fluview/surveillance/2025-week-13.html

Key updates from the Centers for Disease Control and Prevention on influenza activity, hospitalizations, pediatric deaths, and current trends across the United States.

US Influenza Activity Is Declining But Still Remains Elevated

The Texas Department of State Health Services is reporting that a second measles death has occurred in the state. The patient was a school-aged child and died in what officials are saying was a case of measles pulmonary failure. The patient tested positive for measles and was hospitalized in Lubbock. The child was not vaccinated and had no reported underlying conditions.

As of April 6, 499 cases in Texas have been reported in the outbreak, according to an X post yesterday by Department of Health and Human Services (HHS) Secretary Robert F. Kennedy, Jr.

Most of the cases are in children, and a total of 56 people have been hospitalized.

Since the state’s previous reporting (April 1), there have been 77 new cases.


Kennedy also wrote that there have been 642 confirmed measles cases in the US to date.

The cases have been reported by 22 jurisdictions: Alaska, California, Colorado, Florida, Georgia, Kansas, Kentucky, Maryland, Michigan, Minnesota, New Jersey, New Mexico, New York City, New York State, Ohio, Oklahoma, Pennsylvania, Rhode Island, Tennessee, Texas, Vermont, and Washington.

It is important to note that these numbers keep growing as more reported cases come in and contribute to the national accounting by the CDC. The federal agency reports the latest national numbers on Fridays, so it is likely the outbreak numbers will increase in the coming days.





The CDC says there are now 6 active, ongoing outbreaks. States that have the highest number of cases within their outbreaks are Texas, New Mexico, Kansas, Oklahoma, and Ohio. It is also been calculated that 93% of confirmed cases (567 of 607) are outbreak-associated. For comparison, 16 outbreaks were reported during 2024, and 69% of cases (198 of 285) were outbreak-associated. 

Related to infectious disease and public health policy, there have been reports that the entire department of the Office of Infectious Disease and HIV/AIDS Policy (OIDP) is going to be laid off. This department is part of the Department of Health and Human Services (HHS) and falls under its massive downsizing and restructuring plan that was announced recently. HHS said it was going to reduce its workforce by laying off 10,000 full-time employees, and when combined with HHS’ other efforts, expects to reduce the workforce by 20,000 employees. The restructuring would result in a total downsizing from 82,000 to 62,000 full-time employees. 

A child who was not vaccinated succumbed to measles pulmonary failure. Additionally, increased cases and hospitalizations continue to grow greatly in the state. 

Colleen Kelley, MD, MPH

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