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Madan Keller is policy fellow and deputy director of the Global Health Policy program at the Center for Global Development.

With the Trump Administration’s plans to cease funding for Gavi, the Vaccine Alliance as well as to reduce HHS personnel, public health both internationally and domestically, are going to be widely affected.

Sweeping Public Health Changes Creates US and Global Turmoil

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

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. 

In his X post, Kennedy wrote that he has now visited with both families of the children who have died from the measles.

"In early March, I deployed a CDC team to bolster local and state capacity for response across multiple Texas regions, supply pharmacies and Texas run clinics with needed MMR vaccines and other medicines and medical supplies, work with local schools and healthcare facilities to support contact investigations, and to reach out to communities, including faith leaders, to answer any questions or respond to locations seeking healthcare," Kennedy wrote on X. "The most effective way to prevent the spread of measles is the MMR vaccine. I’ve spoken to [Texas] Governor [Greg] Abbott, and I’ve offered HHS’ continued support. At his request, we have redeployed CDC teams to Texas. We will continue to follow Texas’ lead and to offer similar resources to other affected jurisdictions."


References
1. Texas Announces Second Death in Measles Outbreak. Texas Department of State Health Services press release. April 6, 2025. Accessed April 7, 2025.
https://www.dshs.texas.gov/news-alerts/texas-announces-second-death-measles-outbreak
2. Kennedy. X post. April 6, 2025. Accessed April 7, 2025.
https://x.com/seckennedy/status/1908965229418991682
3. Measles Cases and Outbreaks. CDC. April 4, 2025. Accessed April 7, 2025.


https://www.cdc.gov/measles/data-research/index.html

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

Second Measles Death in Texas

A new study led by Korea University College of Medicine, published in 

, demonstrates that switching from long-term tenofovir disoproxil fumarate (TDF) to besifovir (BSV) improves renal and bone safety in patients with chronic hepatitis B (CHB) without compromising antiviral efficacy. The study involved 153 patients who had been receiving TDF treatment for at least 48 weeks and were randomly assigned to receive either BSV 150 mg or continue with TDF 300 mg for another 48 weeks, with the primary endpoint assessing HBV DNA levels, a key marker of antiviral efficacy.

The results showed that 100% of patients in the BSV group and 98.5% in the TDF group achieved a virologic response, defined as HBV DNA levels of less than 20 IU/mL. This demonstrated that BSV is non-inferior to TDF in terms of antiviral efficacy (95% CI -.01 to .04; P=1.000), confirming that BSV maintains similar effectiveness while offering a safer profile.

More importantly, patients who switched to BSV experienced significant improvements in renal and bone health. The mean percentage change in estimated glomerular filtration rate (eGFR), which is used to measure kidney function, was slightly better in the BSV group (+1.67%) compared to the TDF group (-1.24%). Additionally, BSV-treated patients showed improvements in bone turnover biomarkers, and both hip and spine bone mineral density increased, suggesting enhanced bone strength compared to the TDF group.

CHB, a liver infection caused by the hepatitis B virus (HBV), is estimated to affect over 250 million people worldwide. TDF is the most widely used antiviral agent for treating CHB; however, its long-term use has been associated with adverse effects on kidney function and bone health. This has prompted the exploration of alternative treatments with better safety profiles.

These findings indicate that long-term treatment with BSV could be a safer alternative for CHB patients, especially those at risk for renal and bone complications due to prolonged TDF use. The results highlight the potential of BSV as a long-term treatment option that could offer better safety for patients with CHB.

The findings align with the ALLIANCE study, presented at CROI 2025, which compared the B/F/TAF regimen to DTG+F/TDF in HIV-HBV co-infected patients. Similar to the Korean study, TAF showed advantages in renal and bone safety, as well as improved liver health, including ALT normalization and better HBV suppression.

Both studies reflect the trend of moving away from TDF, which, despite its antiviral efficacy, is associated with long-term adverse effects. TAF and BSV offer comparable antiviral efficacy while demonstrating improved safety profiles, particularly for renal and bone health. This shift supports efforts in ID research to balance antiviral efficacy with long-term safety, particularly for chronic viral infections like HIV and hepatitis B.

Additionally, these studies highlight the growing focus on personalized treatment, considering viral suppression and the individual patient's risk for adverse effects. By prioritizing safer therapies, this research aims to improve outcomes for patients with chronic viral infections and contributes to global health efforts to address these widespread diseases.

1. Yim HJ, Seo YS, Kim JH, et al. Switching to Besifovir in Patients with Chronic Hepatitis B Receiving Tenofovir Disoproxil Fumarate: A Randomized Trial. 

. 2025;31(1):12-24. doi:10.3350/cmh.2024.0819.

2. Jeon SJ. New Study by Korea University College of Medicine Researchers Reveals a Safer Alternative for Long-Term Hepatitis B Treatment. 

https://www.prnewswire.com/news-releases/new-study-by-korea-university-college-of-medicine-researchers-reveals-a-safer-alternative-for-long-term-hepatitis-b-treatment-302424477.html

3. Avihingsanon A, et al. Virologic and Immunologic Outcomes at OLE W48 in Participants Who Switched to B/F/TAF After 96W of Initial Treatment With DTG+F/TDF. Poster #XXX presented at CROI 2025. March 9-12, 2025, San Francisco, California.

Switching from tenofovir disoproxil fumarate to besifovir dipivoxil maleate improves renal and bone health without compromising antiviral efficacy.










Janeen Madan Keller

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