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.
On April 21, the US Supreme Court will hear oral arguments in Braidwood Management vs Becerra, a case that could unravel key ACA provisions, and potentially put PrEP usage out of reach for many Americans due to costs.
Image credit: Tim Mossholder, Pexels
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 Braidwood Management vs Becerra, 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.1
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.2 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.3 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.4 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.5
This is part of an ongoing news series on HIV and looking at various elements around it including funding, policy, prevention, and treatment.
Check out these articles from the series:
HIV Prevention: Discussing PrEP, PEP, and Vaccine Development
The Business Sector's Advocacy to Maintain Funding for HIV Prevention, Research, Treatment
The Case for HIV Prevention and Screening: Pay Today or Pay Tomorrow
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,6 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 $400,000.7 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.8 That’s not cost-saving—that’s policy malpractice.
The pending Braidwood 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 Braidwood 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.1
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.9
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.
