On July 4, President Trump signed the 2025 reconciliation law that makes significant changes to the Medicaid program, including new requirements for states to implement work requirements. Starting January 1, 2027, states must condition Medicaid eligibility on meeting work requirements for individuals enrolled through the Affordable Care Act (ACA) Medicaid expansion pathway and through certain state waivers. To ease the burden on individuals, the law directs states to use available information “where possible” to verify compliance with Medicaid work activities or exemption status, without requiring additional documentation from individuals.

The Supplemental Nutrition Assistance Program (SNAP), the federal aid program addressing food insecurity among low-income households, is an important source of data that can be used to identify individuals who are in compliance with or exempt from the Medicaid work requirements. Both Medicaid and SNAP target low-income households, and many individuals receive benefits through both programs; overall, most people who receive SNAP benefits are covered by Medicaid. As a result, some states have integrated eligibility systems or otherwise share data between the two programs. In addition, SNAP has long-standing work requirements for certain “able-bodied” adults without dependents, so coordination among agencies can streamline the collection of information to verify compliance with requirements in both programs. The reconciliation law introduced changes for the population subject to work requirements in SNAP that align them more closely with the new Medicaid work requirements, but differences remain between the programs.

New Medicaid work requirements and changes to SNAP work requirements are expected to impact enrollment in both programs. The Congressional Budget Office (CBO) estimates that Medicaid work requirements will increase the number of uninsured by 5.3 million over the next ten years, and that changes in who will need to meet work requirements will reduce participation in SNAP by roughly 2.4 million people in an average month over the 2025-2034 period. The changes to SNAP work requirements to align with Medicaid mean there could be overlap in the populations projected to lose SNAP and Medicaid benefits. This brief describes the intersection between Medicaid and SNAP and discusses how information from SNAP may be leveraged by states when implementing the new Medicaid work requirements.

What are Medicaid and SNAP Work Requirements?

Beginning January 1, 2027, states must require expansion adults and enrollees in partial expansion waiver programs (Georgia and Wisconsin) to complete 80 hours of work or community service activities per month or meet exemption criteria to enroll in Medicaid and maintain coverage. At a minimum, states will be required to verify individuals’ work or exemption status when individuals apply for coverage and at eligibility renewal. The law specifies mandatory exemptions, including being in a household receiving SNAP and not exempt from SNAP work requirements. Other exemptions include parents and caretakers with children ages 13 and under, individuals who are “medically frail,” and individuals who are pregnant or postpartum, among others (Table 1). When a state is unable to verify compliance with the requirements or that an individual meets exemption criteria through data matching, it must issue a “notice of noncompliance” and deny the application or disenroll the individual from Medicaid coverage if the individual is unable to show compliance within 30 days.

SNAP has its own work requirements and exemptions, but these do not fully align with the new Medicaid work requirements and exemptions. While most adults on SNAP must meet general work requirements, individuals who are considered “able-bodied adults without dependents” (ABAWDs) must work or participate in a work program for at least 80 hours per month to receive SNAP benefits for more than three months in a 36-month period (Table 1). The reconciliation law made changes that went into effect at the end of 2025 affecting the ABAWD population subject to this 80 hour per month work requirement, including newly subjecting adults ages 55 to 64 and parents with children ages 14 and older to these requirements, as well as removing previous exemptions for veterans, people experiencing homelessness, and young adults who aged out of foster care and who are under age 24. The law also added a new exemption for American Indian and Alaska Native People and changed the criteria for optional hardship exceptions for areas facing high unemployment. These changes make the SNAP requirements more consistent with Medicaid work requirements, although differences remain. For example, unlike SNAP, Medicaid work requirements include exemptions for individuals recently released from incarceration, as well as optional short-term hardship exceptions states can adopt for individuals with inpatient or nursing facility admissions, residents of counties with a disaster declaration, and those who have traveled outside their community for medical care (Table 1).

What do we know about the intersection between Medicaid and SNAP?

About one in five Medicaid-covered adults who will likely be subject to the new work requirements also receive SNAP benefits (Figure 1). Similar eligibility requirements, particularly in Medicaid expansion states, account for this overlap in enrollment. In the 41 states (including DC) that have expanded their Medicaid programs, the income eligibility limit for adults is 138% of the federal poverty level (FPL), which is $22,024 for an individual in 2026 or $1,835 per month. The income eligibility limit for SNAP is 130% FPL gross monthly income ($1,696 for an individual in 2026) and 100% FPL net monthly income reflecting certain deductions ($1,305 for an individual in 2026); though definitions of income and household composition rules differ somewhat between SNAP and Medicaid. This estimate of the share of adults likely subject to Medicaid work requirements who are enrolled in both programs is likely an undercount as it excludes Medicaid adults with dependent children ages 14 and older. While nearly all SNAP participants are also enrolled in Medicaid, because SNAP participation is much lower than total Medicaid enrollment, the share of Medicaid enrollees who also receive SNAP is lower. This analysis focuses on adults who would likely qualify for an exemption from Medicaid work requirements due to being in a household receiving SNAP and not exempt from SNAP work requirements. When looking at the broader population of all Medicaid adults ages 19-64, the share receiving SNAP benefits rises to one in three individuals.

In part because of the overlap in eligibility between the two programs, many states use information from SNAP to assist with determining Medicaid eligibility. Most Medicaid programs are already facilitating coordination of enrollment processes and systems between Medicaid and SNAP. For example, 29 states affected by the new Medicaid work requirements allow individuals to apply for Medicaid and SNAP through a single online application and 24 states affected by the new Medicaid work requirements make eligibility determinations for Medicaid and SNAP through a single shared system. In addition, among states that will be subject to Medicaid work requirements, 15 enroll or renew individuals in Medicaid using SNAP income determinations, and 33 states use information from SNAP to identify and act on potential changes in eligibility between renewals, including 10 states and DC that do both, as of January 2025 (Figure 2).

How can states use data from SNAP to implement Medicaid work requirements?

States can use information from SNAP to identify individuals who may be exempt from Medicaid work requirements and those who are meeting the requirements. States are required to use available data from reliable sources to “data match” the work or exemption status of individuals to lessen the administrative burden on both enrollees and Medicaid staff. Although CMS has not released formal guidance, it is anticipated that states will be required to access SNAP and TANF data for the purpose of determining compliance with work requirements. Successful automation to verify compliance with Medicaid work activities or exemption status can lower the risk of eligible people not being able to enroll in Medicaid or losing their coverage due to not submitting proof of work hours or exemption status. States can use information already collected by SNAP to identify individuals in a household receiving SNAP who are not exempt from SNAP work requirements, and who are, therefore, exempt from the Medicaid requirements. SNAP data can also be used to identify individuals who qualify for exemptions because they are medically frail, are participating in a drug or alcohol addiction program, or are American Indians or Alaska Natives. States can also use income information from SNAP to verify compliance with Medicaid work requirements. While some of this information on work and exemption status is likely available for current Medicaid enrollees, SNAP can be a source of data for applicants for whom Medicaid agencies do not have this information.

When Arkansas implemented work requirements in 2018, the state used SNAP data to verify exemptions and compliance with work hours. Of the 116,000 individuals subject to work requirements in February 2019, Arkansas was able to determine that 87% of enrollees were meeting or exempt from the work requirements through data matching (Figure 3). Most individuals whose status was verified using available data fell into four categories: those who were already working at least 80 hours per month (45%), those meeting or exempt from SNAP employment and training requirements (14%), those with a dependent child in the household (12%), and those identified as medically frail (9%). Most enrollees who were not data matched ultimately did not report any work activities in that month. Arkansas did not have integrated eligibility systems, but implemented a daily file exchange between its SNAP and Medicaid systems to update exemption and compliance information across programs without manual intervention. Although Arkansas’ work requirements differ from the new federal requirements in key ways, the experience shows how states can use SNAP data when implementing the new Medicaid work requirements. 

Data sharing between Medicaid and SNAP will be easier in states that have integrated eligibility systems; however, these states may also face unique issues in addition to the challenges all states will likely face when making necessary system changes for both programs. Of the many systems changes needed, states have previously reported prioritizing enhancing capabilities to collect and match data from multiple agencies and external sources to reduce the burden on applicants and enrollees for documenting their work or exemption status. However, states may face different challenges based on their current Medicaid eligibility system integration with SNAP. States that do not currently link to SNAP will need to establish an interface to share data between agencies. Some states may face difficulty establishing this linkage and may require more time to put it into place. States with integrated Medicaid and SNAP eligibility systems needed to prioritize completing work requirement changes for SNAP that went into effect at the end of 2025, which may have delayed the initiation of work on the Medicaid changes. Any delays in preparing for Medicaid work requirements could potentially increase costs. In addition, as states implement complex SNAP and Medicaid eligibility and enrollment policy changes, they will also need to prepare for changes to the payment error rate measurement (PERM) program at the same time, requiring states to make decisions on how to apply scarce state resources and mitigate budgetary consequences. Beginning in 2028, the reconciliation law requires states to pay a portion of SNAP benefit costs, depending on the state’s payment error rate, and starting October 1, 2029, HHS will be required reduce federal Medicaid financial participation to states that exceed a three percent PERM eligibility error rate threshold.

Key Facts

• HIV, the virus that causes AIDS (acquired immunodeficiency syndrome), is one of the world’s most serious health and development challenges. Approximately 40.8 million people are currently living with HIV, and tens of millions of people have died of AIDS-related causes since the beginning of the epidemic.
• Many people living with HIV or at risk for HIV infection do not have access to prevention, treatment, and care, and there is still no cure.
• In recent decades, major global efforts, PEPFAR (the President’s Emergency Plan for AIDS Relief, the U.S. government’s global HIV initiative), and the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) have been mounted to address the epidemic, and despite challenges, significant progress has been made in addressing HIV. Current global health goals are to end AIDS as a public health threat by 2030.

• PEPFAR, in particular, has helped to change the trajectory of the HIV epidemic, and the U.S. is the single largest donor to international HIV efforts in the world, including the largest donor to the Global Fund. PEPFAR has directed over $130 billion toward HIV prevention, care, and treatment efforts since launched in 2003.
• Since the beginning of the second Trump administration, the U.S. global health response has undergone significant change, fundamentally altering the global health landscape and U.S. global HIV efforts, including through PEPFAR.

Global Response

HIV, the virus that causes AIDS (see box), has become one of the world’s most serious health and development challenges since the first cases were reported in 1981. Approximately 91.4 million people have become infected with HIV since the start of the epidemic.¹ Today, there are approximately 40.8 million people currently living with HIV, and tens of millions of people have died of AIDS-related causes since the beginning of the epidemic.² 

Over the past two decades in particular, major global efforts have been mounted to address the epidemic, and significant progress has been made. The number of people newly infected with HIV, especially children, and the number of AIDS-related deaths have declined over the years, and the number of people with HIV receiving treatment increased to 31.6 million in 2024.⁵

Still, remaining challenges continue to complicate HIV control efforts. Many people living with HIV or at risk for HIV infection do not have access to prevention, treatment, and care, and there is still no cure. HIV primarily affects those in their most productive years, and it not only affects the health of individuals, but also impacts households, communities, and the development and economic growth of nations. Many of the countries hardest hit by HIV also face serious challenges due to other infectious diseases, food insecurity, and additional global health and development problems.

Latest Estimates⁶

• Global prevalence among adults (the percent of people ages 15-49 who are infected) has leveled since 2001 and was 0.7% in 2024, though prevalence was higher for certain groups of people, including key populations (i.e., men who have sex with men, sex workers, people who inject drugs, transgender people, and people in prisons).
• There were 40.8 million people living with HIV in 2024, up from 32 million in 2010, the result of continuing new infections and people living longer with HIV. Of the people living with HIV in 2024, 39.4 million were adults and 1.4 million were children under age 15.
• Although HIV testing capacity has increased over time, enabling more people to learn their HIV status, about one in eight people with HIV (13%) are still unaware they are infected.
• While there have been significant declines in new infections since the mid-1990s, there were still about 1.3 million new infections in 2024, or about 3,500 new infections per day. The pace of decline varies by age group, sex, race, and region, and progress is unequal within and between countries.⁷
• HIV remains a leading cause of death worldwide and the leading cause of death globally among women of reproductive age.⁸ However, AIDS-related deaths have declined, due in part to antiretroviral treatment (ART) scale-up. 630,000 people died of AIDS in 2024, a 55% decrease from 1.4 million in 2010 and a 70% decrease from the peak of 2.1 million in 2004. Among women and girls, mortality has declined by 58% since 2010.
• Sub-Saharan Africa,⁹ home to approximately two-thirds of all people living with HIV globally, is the hardest hit region in the world, followed by Asia and the Pacific. Latin America, Western and Central Europe and North America, as well as Eastern Europe and Central Asia are also heavily affected.

Affected/Vulnerable Populations

• Most HIV infections are transmitted heterosexually, although risk factors vary. In some countries, men who have sex with men, people who inject drugs, sex workers, transgender people, and prisoners are disproportionally affected by HIV.
• Women and girls represent over half (53%) of all people living with HIV worldwide, and HIV (along with complications related to pregnancy) is the leading cause of death among women of reproductive age.¹⁰ Gender inequalities, differential access to service, and sexual violence increase women’s vulnerability to HIV, and women, especially younger women, are biologically more susceptible to HIV. In many countries in sub-Saharan Africa, HIV incidence among adolescent girls and young women ages 15-24 is more than three times that among adolescent boys and young men.
• Young people in particular face barriers to accessing HIV and sexual and reproductive health services, including age-appropriate comprehensive sexuality education.
• Globally, in 2024, children accounted for 1.4 million people living with HIV; among children, there were 75,000 AIDS-related deaths and 120,000 new infections, the lowest number of new infections in children since the 1980s. Since 2010, new HIV infections among children have declined by 62%, though progress has stalled in recent years.

HIV & TB

HIV has led to a resurgence of tuberculosis (TB), particularly in Africa, and TB is a leading cause of death for people with HIV worldwide.¹¹ In 2024, approximately 6% of new TB cases occurred in people living with HIV.¹² However, between 2010 and 2024, TB deaths in people living with HIV declined substantially, largely due to the scale-up of joint HIV/TB services.¹³ (See the KFF fact sheet on TB.)

Prevention and Treatment¹⁴

Numerous prevention interventions exist to combat HIV, and new tools such as vaccines, are currently being researched.¹⁵

• Effective prevention strategies include behavior change programs, condoms, HIV testing, blood supply safety, harm reduction efforts for injecting drug users, and male circumcision.
• Additionally, recent research has shown that engagement in HIV treatment not only improves individual health outcomes but also significantly reduces the risk of transmission (referred to as “treatment as prevention” or TasP). Those with undetectable viral loads (known as being virally suppressed) have effectively no risk of transmitting HIV sexually.¹⁶
• Pre-exposure prophylaxis (PrEP) has also been shown to be an effective HIV prevention strategy in individuals at high risk for HIV infection. In 2015, the World Health Organization (WHO) recommended PrEP as a form of prevention for high-risk individuals in combination with other prevention methods.¹⁷ Further, in 2016, the U.N. Political Declaration on HIV/AIDS stated PrEP research and development should be accelerated, and in 2022, WHO released guidelines for the use of long-acting PrEP.¹⁸ Most recently, WHO released new guidelines recommending the use of a twice-a-year, long-acting injectable PrEP.¹⁹ These products signal an expansion and diversification of HIV prevention options.
• Experts recommend that prevention be based on “knowing your epidemic” (tailoring prevention to the local context and epidemiology), using a combination of prevention strategies, bringing programs to scale, and sustaining efforts over time. Access to prevention, however, remains unequal, and there have been renewed calls for the strengthening of prevention efforts, particularly as funding cuts from donors threaten progress on prevention.²⁰

HIV treatment includes the use of combination antiretroviral therapy (ART) to attack the virus itself, and medications to prevent and treat the many opportunistic infections that can occur when the immune system is compromised by HIV. In light of research findings, WHO released a guideline in 2015 recommending starting HIV treatment earlier in the course of illness.²¹ Further, research on long-acting ART is currently underway.²²

• Combination ART, first introduced in 1996, has led to dramatic reductions in morbidity and mortality, and access has increased in recent years, rising to 31.6 million people (77% of people living with HIV) in 2024.
• The percentage of pregnant and breastfeeding women receiving ART for the prevention of mother-to-child transmission of HIV increased to 84% in 2024, up from 49% in 2010.
• While access to ART among children has increased, treatment gaps still remain, and children are less likely than adults to receive ART; treatment coverage in children was 55% compared to 77% among adults in 2024.
• Approximately 73% of all people living with HIV are virally suppressed, which means they are likely healthier and less likely to transmit the virus. Viral suppression varies greatly by region, key population, age, and sex.

Global Goals

International efforts to combat HIV began in the first decade of the epidemic with the creation of the WHO’s Global Programme on AIDS in 1987. Over time, new initiatives and financing mechanisms have helped increase attention to HIV and contributed to efforts to achieve global goals; these include:

• the Joint United Nations Programme on HIV/AIDS (UNAIDS), which was formed in 1996 to serve as the U.N. system’s coordinating body and to help galvanize worldwide attention to HIV/AIDS; and
• the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), which was established in 2001 by a U.N. General Assembly Special Session (UNGASS) on HIV/AIDS as an independent, international financing institution that provides grants to countries to address HIV, TB, and malaria (see the KFF fact sheet on the Global Fund).

The contributions of affected country governments and civil society have also been critical to the response. These and other efforts work toward achieving major global HIV/AIDS goals that have been set through:

• the Sustainable Development Goals (SDGs). Adopted in 2015, the SDGs aim to “end the AIDS epidemic,” or end AIDS as a public health threat,²³ by 2030 under SDG Goal 3, which is to “ensure healthy lives and promote well-being for all at all ages.”²⁴
• UNAIDS targets to end the epidemic by 2030. On World AIDS Day 2014, UNAIDS set targets aimed at ending the AIDS epidemic by 2030. To achieve this, countries are working toward reaching the interim “95-95-95” targets—95% of people living with HIV knowing their HIV status; 95% of people who know their HIV positive status on treatment; and 95% of people on treatment with suppressed viral loads—by 2025.²⁵ These targets are successors to the earlier 90-90-90 targets for 2020, which were missed.²⁶ Based on the 2024 data and trends (the latest data available),²⁷ 87% of people living with HIV knew their status; among those who knew their status, 89% were accessing treatment; and among those accessing treatment, 94% were virally suppressed.²⁸ Additional interim “95-95-95” targets have also been set for 2025, which place a greater emphasis on social services and reducing stigma and discrimination to address inequalities that hinder the HIV response.²⁹

Over the past decade, world leaders reaffirmed commitments to end AIDS by 2030³⁰ and adopted a Political Declaration with global commitments and targets for 2025 to address inequalities that impede the AIDS response.³¹ The next Global AIDS Strategy for the period 2026-2031 is currently under development.³²

Global Resources

UNAIDS estimates that $18.7 billion was available from all sources (domestic resources, donor governments, multilaterals, and foundations) to address HIV in low- and middle-income countries in 2024. Of this, donor governments provided $8.4 billion (or 44% of total available resources) (see Figure 1).³³ Other governments and organizations that contribute substantially to funding the global response include:

• hard-hit countries, which have also provided resources to address their epidemics;
• the Global Fund, which has approved over $29 billion for HIV efforts in more than 100 countries to date;³⁴ and
• the private sector, including foundations and corporations, which also plays a major role (the Gates Foundation, for one, has committed more than $3 billion in HIV grants to organizations addressing the epidemic, as well as provided additional funding to the Global Fund).³⁵

Looking ahead, UNAIDS estimates at least $21.9 billion annually will be needed to meet global targets to end AIDS as a global public health threat by 2030.³⁶ 

U.S. Government Efforts

The U.S. has been involved in HIV efforts since the 1980s and is the single largest donor to international HIV efforts in the world, including the largest donor to the Global Fund.³⁷ The U.S. first provided funding to address the global HIV epidemic in 1986. U.S. efforts and funding increased slowly over time through targeted initiatives to address HIV in certain countries in Africa, South Asia, and the Caribbean, but they intensified with the 2003 launch of the President’s Emergency Plan for AIDS Relief (PEPFAR), which brought significant new attention and funding to address the global HIV epidemic, as well as TB and malaria.³⁸ Since the beginning of the second Trump administration, however, the U.S. global health response has undergone significant shifts, disruption, and retraction, fundamentally altering the global health landscape and U.S. global HIV efforts through PEPFAR in particular.

PEPFAR

Created in 2003, PEPFAR is the U.S. government’s global effort to combat HIV. PEPFAR has historically involved multiple U.S. departments, agencies, and programs, particularly USAID and CDC, although that has changed (see below for more details). The program had also been carried out in close coordination with host country governments and other organizations, including multilateral organizations such as the Global Fund and UNAIDS and non-governmental organizations, including civil society.³⁹ U.S. bilateral HIV activities spanned more than 50 countries in Asia, West Africa, and the Western Hemisphere, with U.S. support for multilateral efforts reaching even more countries.⁴⁰ (For more information, see the KFF fact sheet on PEPFAR.)

Since its creation, PEPFAR, which includes all bilateral funding for HIV as well as U.S. contributions to the Global Fund and UNAIDS, has totaled over $130 billion.⁴¹ For FY 2026, Congress appropriated $6 billion in total funding for PEPFAR, including $4.7 billion for bilateral HIV programs, $45 million for UNAIDS, and $1.25 billion for the Global Fund, matching funding levels for FY 2025.⁴² (For more details on historical appropriations for U.S. global HIV/AIDS efforts, see the KFF fact sheets on the U.S. Global Health Budget: Global HIV, Including PEPFAR and the U.S. Global Health Budget: The Global Fund, as well as the KFF budget tracker.)

Currently, PEPFAR faces significant change, brought on by a re-evaluation of U.S. foreign assistance, the dissolution of USAID (the main PEPFAR implementing agency), and the cancellation of most PEPFAR awards. While U.S. policymakers had been increasingly looking at when and how to transition PEPFAR services and financing to country governments, the Trump administration has sought to narrow PEPFAR’s scope and significantly accelerate this timeline. Per a new U.S. strategy, the America First Global Health Strategy, the administration is developing bilateral agreements with countries to integrate PEPFAR programming with other global health areas and is planning to scale down funding over the next few years, with country governments required to increasingly co-finance these activities. (See the KFF fact sheet on the status of PEPFAR for more information.)

Endnotes

1. UNAIDS, Global HIV statistics 2025 fact sheet; July 2025. ↩︎
2. UNAIDS, 2025 Global AIDS Update: AIDS, Crisis and the Power to Transform; July 2025. UNAIDS, AIDSinfo website; accessed November 2025, available at: http://aidsinfo.unaids.org/. UNAIDS, 2025 Core epidemiology slides; July 2025. ↩︎
3. AIDS is the last and most severe stage of HIV infection, during which the immune system is so weak that people with AIDS acquire an increasing amount of severe illnesses. CDC HIV Website, https://www.cdc.gov/hiv/about/. ↩︎
4. UNAIDS, 2025 Global AIDS Update: AIDS, Crisis and the Power to Transform; July 2025. ↩︎
5. UNAIDS, Global HIV statistics 2025 fact sheet; July 2025. ↩︎
6. UNAIDS, 2025 Global AIDS Update: AIDS, Crisis and the Power to Transform; July 2025. UNAIDS, AIDSinfo website; accessed November 2025, http://aidsinfo.unaids.org/. UNAIDS, 2025 Core epidemiology slides; July 2025. UNAIDS, Global HIV statistics 2025 fact sheet; July 2025; UNAIDS, UNAIDS data 2025; July 2025. ↩︎
7. UNAIDS, 2025 Global AIDS Update: AIDS, Crisis and the Power to Transform; July 2025. ↩︎
8. UNAIDS, Women and HIV – A spotlight on adolescent girls and young women; March 2019. UNAIDS, We’ve got the power — Women, adolescent girls and the HIV response; March 2020. ↩︎
9. Sub-Saharan Africa constitutes as East and Southern Africa and West and Central Africa. ↩︎
10. UNAIDS, 2025 Global AIDS Update: AIDS, Crisis and the Power to Transform; July 2025. UNAIDS, Global HIV statistics 2025 fact sheet; July 2025. UNAIDS, UNAIDS 2021-2026 Strategy; Mar. 2021. ↩︎
11. WHO, Tuberculosis, fact sheet, https://www.who.int/news-room/fact-sheets/detail/tuberculosis. ↩︎
12. WHO, Global Tuberculosis Report 2025; 2025. ↩︎
13. WHO, Global Tuberculosis Report 2025; 2025. ↩︎
14. UNAIDS, 2025 Global AIDS Update: AIDS, Crisis and the Power to Transform; July 2025. UNAIDS, AIDSinfo website; accessed July 2025, http://aidsinfo.unaids.org/. UNAIDS, 2025 Core epidemiology slides; July 2025. UNAIDS, Global HIV statistics 2025 fact sheet; July 2025; UNAIDS, UNAIDS data 2025; July 2025. ↩︎
15. UNAIDS, Get on the Fast Track; 2016. Global HIV Prevention Working Group, Behavior Change for HIV Prevention: (Re) Considerations for the 21st Century; Aug. 2008. WHO, WHO recommends long-acting cabotegravir for HIV prevention, July 2022. WHO, WHO recommends injectable lenacapavir for HIV prevention, July 2025. ↩︎
16. UNAIDS, UNAIDS Explainer: Undetectable = untransmittable; July 2018. ↩︎
17. WHO, Guideline on When to Start antiretroviral Therapy and on Pre-Exposure Prophylaxis for HIV; Sept. 2015. WHO, WHO expands recommendation on oral pre-exposure prophylaxis of HIV infection (PrEP); Nov. 2015. ↩︎
18. United Nations, Political Declaration on HIV and AIDS: On the Fast-Track to Accelerate the Fight Against HIV and to End the AIDS Epidemic by 2030; June 8, 2016. WHO, WHO recommends long-acting cabotegravir for HIV prevention, July 2022. ↩︎
19. WHO, WHO recommends injectable lenacapavir for HIV prevention, July 2025. ↩︎
20. UNAIDS, 2025 Global AIDS Update: AIDS, Crisis and the Power to Transform; July 2025. United Nations, Reinvigorating the AIDS response to catalyse sustainable development and United Nations reform: Report of the Secretary-General; June 2017. ↩︎
21. UNAIDS, Get on the Fast Track; 2016. WHO, Guideline on When to Start antiretroviral Therapy and on Pre-Exposure Prophylaxis for HIV; September 2015. WHO, Press Release: NIAID START Trial confirms that immediate treatment of HIV with antiretroviral drugs (ARVs) protects the health of people living with HIV; May 28, 2015. NIAID, Starting Antiretroviral Treatment Early Improves Outcomes for HIV-Infected Individuals; May 27, 2015. ↩︎
22. NIH, News release: Long-acting HIV treatment demonstrates efficacy in people with challenges taking daily medicine as prescribed, February 21, 2024. ↩︎
23. UNAIDS states that endings AIDS as a public health threat requires a 90% reduction in HIV incidence and mortality by 2030, compared to 2010. UNAIDS, Fast-Track: ending the AIDS epidemic by 2030; 2014. ↩︎
24. United Nations, Transforming our world: the 2030 Agenda for Sustainable Development; 2015. ↩︎
25. UNAIDS, Fast-Track: ending the AIDS epidemic by 2030; 2014. ↩︎
26. These goals and targets were reiterated in the UNAIDS 2016-2021 Strategy, which also aligns with the SDGs. UNAIDS, Fast-Track: ending the AIDS epidemic by 2030; 2014. UNAIDS, UNAIDS 2016-2021 Strategy; Aug. 2015. ↩︎
27. UNAIDS, 2025 Global AIDS Update: AIDS, Crisis and the Power to Transform; July 2025. See also KFF Dashboard: Progress Toward Global HIV Targets in PEPFAR Countries, September 2023. ↩︎
28. UNAIDS, Global HIV statistics 2025 fact sheet; July 2025. ↩︎
29. UNAIDS, Press Release: UNAIDS calls on countries to step up global action and proposes bold new HIV targets for 2025; November 26, 2020. UNAIDS, “2025 AIDS Targets,” webpage, https://aidstargets2025.unaids.org/#. UNAIDS, World AIDS Day Report 2020: Prevailing Against Pandemics by Putting People at the Centre; November 2020. ↩︎
30. The 2016 U.N. General Assembly High-Level Meeting on Ending AIDS reaffirmed commitments made in the 2001 Declaration of Commitment on HIV/AIDS and the 2006 and 2011 political declarations on HIV/AIDS. UNAIDS, Declaration of Commitment on HIV/AIDS; 2001, https://www.unaids.org/sites/default/files/sub_landing/files/aidsdeclaration_en_0.pdf. UNAIDS, 2006 Political Declaration on HIV/AIDS; 2006, https://www.unaids.org/sites/default/files/sub_landing/files/20060615_hlm_politicaldeclaration_ares60262_en_0.pdf. UNAIDS, 2011 Political Declaration on HIV/AIDS; 2011, http://www.unaids.org/en/aboutunaids/unitednationsdeclarationsandgoals/2011highlevelmeetingonaids/. United Nations, 2016 Political Declaration on HIV and AIDS; 2016, https://www.unaids.org/sites/default/files/media_asset/2016-political-declaration-HIV-AIDS_en.pdf. UNAIDS, Press Release: Bold Commitments to Action Made at the United Nations General Assembly High-Level Meeting on Ending AIDS; June 10, 2016. UNAIDS, Reinvigorating the AIDS response to catalyse sustainable development and United Nations reform; 2017. ↩︎
31. These commitments and targets align with the more recent UNAIDS 2021-2026 Global AIDS Strategy, which is focused on reducing inequalities. UNAIDS, Global AIDS Strategy 2021-2026 – Ending Inequalities. End AIDS.; March 2021. United Nations, Political Declaration on HIV and AIDS: Ending Inequalities and Getting on Track to End AIDS by 2030; June 2021. UNAIDS, Press release: United Nations High-Level Meeting on AIDS draws to a close with a strong political declaration and bold new targets to be met by 2025; June 2021. ↩︎
32. UNAIDS, UNAIDS launches the development of the new Global AIDS Strategy 2026-2031, February 2025. ↩︎
33. KFF/UNAIDS, Donor Government Funding for HIV in Low- and Middle-Income Countries in 2024; July 2025. UNAIDS, 2025 Global AIDS Update: AIDS, Crisis and the Power to Transform; July 2025. ↩︎
34. Global Fund, The Global Fund Data Explorer, accessed November 2025, https://data.theglobalfund.org. ↩︎
35. Gates Foundation, HIV Strategy Overview, accessed November 2025, http://www.gatesfoundation.org/What-We-Do/Global-Health/HIV#OurStrategy. ↩︎
36. According to UNAIDS, the $21.9 billion estimate is down from the previous estimate of $29.3 billion because of cost efficiencies that were achieved across the HIV response.  UNAIDS, 2025 Global AIDS Update: AIDS, Crisis and the Power to Transform; July 2025. ↩︎
37. KFF analysis of data from the Office of Management and Budget, Agency Congressional Budget Justifications, and Congressional Appropriations Bills. KFF/UNAIDS, Donor Government Funding for HIV in Low- and Middle-Income Countries in 2024; July 2025. ↩︎
38. U.S. Congress, P.L. 108-25, May 27, 2003. KFF analysis of data from the Office of Management and Budget, Agency Congressional Budget Justifications, and Congressional Appropriations Bills. ↩︎
39. KFF, The U.S. Government and Global Health, Sep. 2022. CRS, PEPFAR Reauthorization: Key Policy Debates and Changes to U.S. International HIV/AIDS, Tuberculosis, Malaria and Programs and Funding; Jan. 2009. ↩︎
40. KFF analysis of data from congressional budget justification documents; PEPFAR, “Where We Work” webpage, https://www.state.gov/where-we-work-pepfar/; PEPFAR 2024 Country Operational Plan Guidance for all PEPFAR Countries; and CDC’s “Where We Work” webpage, https://www.cdc.gov/global-hiv-tb/php/where-we-work/. ↩︎
41. KFF analysis of data from the Office of Management and Budget, Agency Congressional Budget Justifications, and Congressional Appropriations Bills. Totals include funding for bilateral HIV and contributions to multilateral organizations (specifically, the Global Fund and UNAIDS) through regular appropriations and emergency funding for COVID-19 in FY 2021. ↩︎
42. Totals represent funding specified by Congress in annual appropriations bills and/or identified by agencies for the Department of State, USAID, CDC, and DoD. In addition, international HIV research activities are supported by the NIH Office of AIDS Research (OAR) through its annual appropriated budget, but these amounts are not considered part of PEPFAR. See KFF’s “Breaking Down the U.S. Global Health Budget by Program Area” for additional information. ↩︎

For people with Medicare, the Medicare Part D outpatient prescription drug benefit is provided by private plans, either Medicare Advantage plans that offer Part D drug coverage (MA-PDs) or, for those in traditional Medicare, stand-alone prescription drug plans (PDPs). While most beneficiaries are enrolled in Medicare private plans on an individual basis, some have coverage through a group plan sponsored by an employer or union providing retiree health benefits, either group MA plans that cover Medicare Part A and B benefits, which can also include Part D coverage, or group PDPs that cover prescription drugs only.

Analysis of recently released data from the Centers for Medicare & Medicaid Services (CMS) shows that 56.1 million people are enrolled in Medicare Part D as of February 2026, including both non-group and group plan enrollment, with more than half of Part D enrollees (56%) in MA-PDs and 44% in stand-alone PDPs, reflecting higher overall enrollment in Medicare Advantage than in traditional Medicare (Figure 1).

Between February 2025 and February 2026, enrollment growth in non-group MA-PDs (including both individual plans and special needs plans, or SNPs) exceeded growth in non-group PDP enrollment, which has flattened out but still increased modestly for 2026 (1 million and 0.5 million, respectively). Reflecting the availability of lower-premium PDPs and likely also shifts in enrollment from higher-premium to lower-premium PDPs, the average monthly enrollment-weighted premium for non-group PDPs fell from $39 to $36 between February 2025 and February 2026 (premiums for employer group plans are not available).

Over the same period, enrollment in group MA-PDs declined for the first time since 2010 and enrollment in group PDPs increased by the largest amount since 2013 (-1.2 million and 1.2 million, respectively). Overall, PDP enrollment increased by 1.7 million between 2025 and 2026, mainly due to the increase in employer group PDP enrollment.

A Total of 56 Million Medicare Beneficiaries Are Enrolled in Part D, Including Both MA-PDs and PDPs, as of Early 2026

As of February 2026, 56.1 million Medicare beneficiaries are enrolled in Part D plans, with more than half (56% or 31.3 million) enrolled in MA-PDs. Enrollment in MA-PDs has generally increased steadily over time, although there was a modest reduction in overall MA-PD enrollment between February 2025 and February 2026 (from 31.4 million to 31.3 million) (Figure 1). This appears to reflect a shift in enrollment among employer group plan enrollees from group MA-PD plans to group MA-only plans with separate PDPs (as discussed below; for more details on Medicare Advantage enrollment in 2026, see KFF analysis “Medicare Advantage Enrollment Grew by About 1 Million People, Mainly Due to Special Needs Plans”).

PDP enrollment now stands at 24.9 million, including beneficiaries in both non-group PDPs and employer group PDPs, or 44% of all Part D enrollees (up slightly from 42% in 2025) (Figure 1). The overall number of PDP enrollees increased for the third year in a row and is up by 1.7 million between February 2025 and February 2026, with most of the growth (1.2 million or 70%) in employer group PDPs.

Growth in Non-Group MA-PDs Continues To Outpace Growth in Non-Group PDPs

Among non-group Part D plans, enrollment in non-group MA-PDs stands at 28.6 million as of February 2026, up 1.0 million from 2025, while enrollment in non-group PDPs now stands at 18.6 million, up by 0.5 million from 2025 (Figure 2). Enrollment in non-group PDPs is lower than its peak of 20.6 million in the late 2010s but modestly higher than in 2024, when 17.9 million enrollees were in non-group PDPs. Modest growth in non-group PDP enrollment for 2026 occurred even as the overall number of PDPs fell for the third year in a row and the number of non-group PDP options for the average Medicare beneficiary dropped from 14 in 2025 to 11 in 2026. (By comparison, the average Medicare beneficiary has 32 non-group MA-PD options in 2026, excluding SNPs.)

Among Employer Group Plans, Enrollment Decreased in Group MA-PDs and Increased in Group PDPs

Among employer group Part D plans, enrollment in group MA-PDs decreased by 1.2 million between 2025 and 2026 (down from 3.9 million to 2.7 million), while group PDP enrollment increased by 1.2 million (from 5.1 million to 6.3 million) (Figure 3). This was the first year-over-year reduction in employer group MA-PD enrollment since 2010, and the largest year-over-year increase in employer group PDP enrollment since 2013. That year, employer group PDP enrollment increased by 2.2 million (from 2.1 million to 4.3 million) as a result of the ACA’s elimination of the tax deductibility of federal subsidies for retiree drug coverage and the availability of manufacturer price discounts during the coverage gap in employer group plans, which changed the financial incentives around traditional retiree drug coverage and prompted a shift to employer group PDP coverage.

The decline in employer group MA-PD enrollment and concurrent growth in employer group PDP enrollment for 2026 may reflect a strategy among employer/union groups of converting retiree health benefit offerings from contracts with MA-PDs that combine both medical and prescription drug benefits to contracting separately for medical benefits from MA-only plans and prescription drug benefits from stand-alone PDPs. This strategy would enable groups to take advantage of the Part D premium stabilization demonstration and receive additional premium subsidies provided by the federal government, which are available only to PDPs that choose to participate, not MA-PDs. For employer group PDPs, participation in the demonstration in 2026 provides a $10 per member per month premium subsidy.

Humana and Centene Saw the Largest Increases in PDP Enrollment in 2026

Part D enrollees faced wide PDP premium changes and variation across plans for 2026, as in previous years, triggering shifts in PDP enrollment. Several national PDPs are charging premiums well below $10 in many regions in 2026, giving current beneficiaries, as well as people new to Medicare, options for relatively low-cost drug coverage if they want to remain in (or choose to enroll in) traditional Medicare. This is the case even as some PDPs charged premium increases of up to $50 for 2026, the maximum increase allowed for plans participating in the Part D premium stabilization demonstration. Reflecting the availability of lower-premium PDPs and likely also shifts in enrollment from higher-premium to lower-premium plans, the average monthly enrollment-weighted premium for non-group PDPs fell from $39 to $36 between February 2025 and February 2026 (premiums for employer group plans are not available).

Humana and Centene (sponsor of WellCare PDPs) gained the most PDP enrollees between February 2025 and February 2026, likely due to reducing monthly premiums for some or all of their PDPs in many regions between 2025 and 2026 and offering low or zero premium PDP options in several regions. Enrollment in Humana’s PDPs increased by 61% (1.4 million) from 2.3 million to 3.7 million, while Centene’s PDP enrollment increased by 11% (0.9 million) from 7.8 million to 8.7 million (Figure 4, “Enrollment” tab). (Humana also gained the most Medicare Advantage enrollees overall for 2026 among all Medicare Advantage plan sponsors.) Both Humana and Centene have lower average enrollment-weighted premiums across their non-group PDP offerings in 2026 than in 2025 (Figure 4, “Average premiums” tab).

Other plan sponsors experienced smaller changes in enrollment over this period. CVS Health and Health Care Service Corporation, which lost PDP enrollees between 2025 and 2026, and UnitedHealth Group, which had a modest increase in PDP enrollment, have higher enrollment-weighted average premiums across their non-group PDP offerings in 2026 than in 2025.

In a given year, a small portion of the population is responsible for a very large percentage of total health spending. This collection of charts explores the variation in health spending across the population through an analysis of 2023 Medical Expenditure Panel Survey (MEPS) data. The analysis finds that five percent of the population accounted for nearly half of all health spending, spending an average of $72,918 annually in 2023. People with health spending in the top one percent spent an average of $150,467 per year.

The analysis also examines spending variation by age, gender, race, insurance coverage status and presence of certain health conditions. Adults who have been diagnosed with a serious or chronic disease have significantly higher out-of-pocket spending.

The chart collection is part of the Peterson-KFF Health System Tracker, an online information hub dedicated to monitoring and assessing the performance of the U.S. health system.

On September 18, 2025, the U.S. government (USG) released its new America First Global Health Strategy, which details how the U.S. will engage in global health efforts moving forward. As part of this new strategy, the U.S. has announced that it will be establishing bilateral health cooperation agreements with countries that receive U.S. global health assistance. These agreements, or Memorandums of Understanding (MOUs), between the U.S. and partner countries represent five-year plans (for the period 2026-2030) outlining U.S. engagement in each country’s health efforts with the goal of “helping countries move toward more resilient and durable health systems.” Central to these plans is transitioning country programs from U.S. assistance to long-term country ownership, with a pledge from each partner country to increase its domestic health spending, or co-investment in health, over the next five years as the U.S. decreases its health assistance. The U.S. began signing these agreements in late 2025 and this process is ongoing. Implementation is slated for later this year.

This tracker provides an overview of the MOUs signed to date. Data are based on press releases issued by the State Department, U.S. embassies, and partner country Ministries of Health, as well as MOU documents (if publicly available). See Methods for more information. This tracker will be updated as agreements are signed and more data become available.

Methods

This tracker provides information on U.S. MOU bilateral global health agreements to date. Information is sourced from publicly available U.S. Department of State, U.S. embassies, and partner country Ministries of Health press release statements and MOU texts, and will be updated as more information becomes available and when additional agreements are signed. Currently, MOU text, which contains the most detailed information of these sources, is publicly available for only a limited number of countries; for these countries, data were sourced directly from these MOU documents.

Program areas are captured using keyword searches; for global health security (GHS) specifically, country agreements were categorized as targeting GHS if they specifically mentioned GHS, or if they included descriptions of outbreak preparedness and response activities and containing health threats. Due to the limited nature of press release statements, this tracker may not comprehensively capture the global health program areas targeted in each country’s agreement.

Summary

Actions taken by the Trump administration and Congress will likely have major impacts on health and health care for immigrant families, including children. About one in four children in the U.S. has at least one immigrant parent, and the vast majority of these children are U.S. citizens. President Trump’s increased immigration enforcement activity has contributed to significant levels of fear and uncertainty among the immigrant community, which can negatively affect the health and well-being of immigrant families and make them more reluctant to access health coverage as well as health care. Longstanding research also shows that such fears can have lifelong negative impacts on the physical and mental health of children.

This brief provides data on the health and health care experiences of immigrant parents and their children in the U.S. amid the current policy environment. Immigrant parents include naturalized citizens, lawfully present immigrants, and likely undocumented immigrants who report having a child under age 18 living in the home with them. As noted, the vast majority of children with an immigrant parent are citizens (in some cases by birthright citizenship, which President Trump has sought to restrict in a case currently before the Supreme Court). This brief is based on a KFF survey conducted in partnership with The New York Times in Fall 2025, prior to the recent ramp up of public Immigration and Customs Enforcement (ICE) activity in Minneapolis and several other areas of the country. It builds on the 2023 KFF/LA Times Survey of Immigrants and two additional surveys conducted by KFF in 2024 and  2025. Separate reports from the Fall 2025 survey examine immigrants’ health care experiences overall, experiences amid increased immigration enforcement, and the political implications of immigrant voters’ views on immigration enforcement.

Key takeaways include:

• Immigrant parents report experiencing increased economic challenges, including paying for health care. About half (52%) of immigrant parents say that it has been harder to earn a living since January 2025. Additionally, over half (55%) say they have had problems paying for health care, housing, or food in the past 12 months, with these shares increasing since 2023.
• Immigration-related fears are negatively impacting the health of immigrant parents and their children, including citizens and lawfully present immigrants. About a quarter of immigrant parents (27%), including six in ten (60%) likely undocumented immigrant parents, say that any of their children have expressed worries or concerns about the possibility of something bad happening to someone in their family because they are an immigrant.Nearly half (47%) of immigrant parents report experiencing negative health impacts due to immigration-related worries since January 2025, and about one in five (18%) say that their child’s well-being has been impacted.
• Immigrant parents report health care access challenges for themselves and their children. About one in five (22%) immigrant parents report being uninsured, twice the share of those without a child in the home (11%). About one in seven (15%) immigrant parents say they have a child who is uninsured, with this share rising to about a quarter (27%) among parents who are likely undocumented and to about one in five of those with lower incomes (annual household income of less than $40,000)  (22%) or limited English proficiency (LEP) (21%).
• Three in ten (30%) immigrant parents say any of their children missed, delayed, or skipped health care in the past 12 months due to immigration-related fears (14%), not being able to find services at a convenient time or location (13%), or cost or lack of insurance (12%). This includes about six in ten (58%) likely undocumented immigrant parents as well as 23% of naturalized citizen parents and 26% of lawfully present immigrant parents who say any of their children missed, delayed, or skipped care.

Economic Challenges

About half (52%) of immigrant parents say that it has been harder to earn a living since January 2025, and over half (55%) say that they have had problems paying for health care, housing, or food in the past 12 months. These shares are higher compared to those without a child in the home, among whom 45% say it has been harder to earn a living and 42% report problems paying for health care, housing, or food. Among immigrant parents, the shares reporting problems paying for basic needs increased between 2023 and 2025, rising from 22% to 42% for health care, from 22% to 36% for rent or mortgage, and from 21% to 32% for food.

Impacts of Immigration-Related Fears on Health

About a quarter of immigrant parents (27%), including about one in five naturalized citizens (20%) and lawfully present immigrants (23%), say that any of their children have expressed worries or concerns about the possibility of something bad happening to someone in their family because they are an immigrant (Figure 2). Among likely undocumented parents, the share rises to 60%. Additionally, about four in ten Hispanic immigrant parents (39%) as well as those with household incomes of less than $40,000 per year (41%) say their children have expressed these worries or concerns.

Nearly half (47%) of immigrant parents say they have experienced negative health impacts due to immigration-related worries since January 2025 (Figure 3). These negative health impacts include increased stress, anxiety, or sadness (47%); problems sleeping or eating (29%); or worsening health conditions like diabetes or high blood pressure (19%) due to immigration-related worries.Reported negative health impacts are higher among parents (47%) compared to those without a child in the home (35%).

About one in five (18%) immigrant parents say their child’s well-being has been negatively impacted by immigration-related worries since January 2025 (Figure 4). These impacts include problems sleeping or eating (14%); changes in school performance or attendance (12%); or behavior problems (12%). Reports of impacts on children are particularly high among likely undocumented immigrant parents (46%), parents with lower incomes (30%), and immigrant parents with LEP (24%), although over one in ten naturalized citizen (12%) and lawfully present immigrant (15%) parents report their children experienced at least one negative impact.

Health Coverage and Access to Health Care

Immigrant parents are twice as likely to be uninsured as their counterparts without a child in the home (22% vs. 11%), and 15% of immigrant parents report having at least one uninsured child as of 2025. The share of immigrant parents who report having an uninsured child rises to about a quarter (27%) among those who are likely undocumented and about one in five of those with lower incomes (22%) or LEP (21%) (Figure 5). 

Three in ten (30%) immigrant parents say any of their children missed, delayed or skipped health care in the past 12 months due to immigration-related fears (14%), not being able to find services at a convenient time or location (13%), or cost or lack of insurance (12%) (Figure 6). While rates of delayed or skipped health care for children are higher among immigrant parents who are likely undocumented (58%), with 43% citing immigration concerns, about one in four naturalized citizen (23%) and lawfully present (26%) parents also say their children delayed or skipped care, with about one in ten identifying immigration concerns as a reason (8% and 10%, respectively).

Further, one in five (20%) immigrant parents say they or a family member have avoided seeking medical care since January 2025 due to immigration-related concerns (Figure 7). This is twice the share of those who are not parents (9%). There have been reports of increased presence of ICE (Immigration and Customs Enforcement) at health care facilities following the Trump administration’s  reversal of previous policy that had protected against enforcement in these and other “sensitive locations” like schools and places of worship. These actions could further exacerbate fears among immigrant families and may lead to greater avoidance of medical care and other activities going forward for parents and children.

States are facing constrained budgets, putting pressure on HIV care and prevention programs, including the Ryan White HIV/AIDS Program. Ryan White, the nation’s HIV safety-net, is funded each year through discretionary federal appropriations, state dollars, and other sources. However, funding does not necessarily match the number of people who need support or the cost of services.

The largest component of Ryan White provides grants to states, including for their AIDS Drug Assistance Programs (ADAPs), which provide HIV treatment and insurance assistance for people with HIV. In the past, ADAPs have used waiting lists and other cost-containment measures when programs could not meet the needs of all those eligible, and in the early 2000s, waiting lists were common. Significant waiting lists were last cleared with an influx of emergency federal funding in 2013 and then were used occasionally for a few years. They have not been used for over a decade and, to date, have not returned. However, several states facing budget pressures have recently moved to institute other cost-containment measures, including restricting eligibility and scope of services, and some are considering waiting lists for the future.  This represents the first time such broad cost-containment measures have been taken since the waitlist era.

Ultimately, such changes could result in people with HIV losing access to care and treatment, which could worsen health outcomes (increasing morbidity and mortality) and leading to new HIV infections (four in ten new HIV transmissions are associated with someone who is aware of their HIV status but not in care).

State ADAPs Respond to Strain by Limiting Enrollment and Services Offered

Florida recently annoucned changes to its ADAP, which would dramatically limit eligibility and scope of assistance. Specifically, the state plans to reduce income¹ eligibility for the program from 400% of the federal poverty level (FPL) to 130% FPL (for an individual, which is the equivalent of eligibility decreasing from a maximum income of $63,840 to $20,748 annually).

Additionally, the state plans to remove Biktarvy from its formulary. Biktarvy is the most widely prescribed antiretroviral (ARV) medication nationally (accounting for 52% of the U.S. ARV market) and the only single tablet regimen (STR) included among the national HIV treatment guidelines list of recommended initial treatment regimens. Some studies have shown that STRs improve adherence by reducing pill burden.

The state also plans to roll back its insurance assistance program. ADAPs can help cover insurance costs in addition to directly purchasing medications. Ending insurance assistance poses unique challenges, as insurance coverage allows individuals to meet both HIV-related and other health care needs and helps protect clients in the face of unexpected medical costs (e.g. through out-of-pocket maximums).² With expiration of enhanced Affordable Care Act premium tax credits, out-of-pocket premiums for people in ACA plans are increasing substantially this year.

The changes in Florida have received significant push back from advocates, patients, and providers, and the state was sued for proceeding with these changes without formal rule making. (The state then issued a proposed rule which it followed with emergency rulemaking. Litigation continues seeking to block implementation).

Florida, however, is not alone. New data from the National Association of State and Territorial AIDS Directors (NASTAD) indicate that 23 states (including Washinton, D.C.) have implemented or are considering ADAP cost-containment measures.³ Eighteen (18) ADAPs, including Florida‘s, have already made or are making changes and five additional states report that they are considering introducing such measures in the future. Further, 12 of the 19 states already implementing cost-containment measures are considering additional changes for the future.

For example, in addition to Florida, Pennsylvania, Kansas, Delaware, and Rhode Island have also reduced income eligibility for their programs (though to a lesser degree). Other changes states are exploring or implementing include reducing formularies (though, so far, none as consequential as removing Biktarvy), reducing funding for medical and support services, making recertification more stringent (which can create churn and lead to program disenrollment), implementing annual client spending caps, and restricting or ending health insurance assistance.

To date, no state has implemented a waiting list, a measure widely seen as a last resort. However, Arkansas, Louisiana, and New Jersey report considering implementing one as a future cost-containment measure.

Multiple Factors Are Exerting Budget Pressures on ADAP

There are a range of factors affecting ADAP budgets. These include, but are not limited to, the following:

Federal ADAP Funding Not Keeping Pace With Inflation

Since 1996, Congress has allocated (or “earmarked”) a set amount of funding for ADAPs during the annual appropriations process. After modest funding levels in the late 1990s, followed by significant growth in the early 2000s, ADAP inflation-adjusted appropriations have declined by 31% since 2005.⁴ The decline is largely attributable to more than a decade of flat funding in nominal dollars. When adjusted to 1996 dollars, the FY25 appropriation ($438.8 million) has similar purchasing power as the program’s FY1999 funding level ($434.0 million).⁵ In other words, in the last 20 years, ADAP funding has not kept pace with inflation, even before accounting for enrollment growth and increased costs (discussed below).

In the NASTAD report ADAPs identified growing client enrollment, growing drug costs, and rising insurance costs as the top three drivers of budget concerns. These concerns are explored further below:

Increased Client Enrollment

While modern era federal ADAP funding has not kept pace with inflation, the number of ADAP clients served has increased significantly. The number of clients served increased by 56% from 2007 (the first year with available data for the full year) to 2024 (the most recent year with available data), rising from 165,382⁶ to 257,644 clients served. Adjusted for inflation, appropriations per client served dropped from about $3,600 in 2007 to approximately $1,700 in 2024. Additionally, the national HIV treatment guidelines have evolved to recommend HIV treatment at the time of diagnosis -as opposed to starting at signs of disease progression- which has led to more people with HIV having an indication for treatment.

Rising HIV Drug Costs

Another factor impeding the reach of ADAP dollars is the increasing cost of drugs for HIV treatment. A recent analysis found that the average wholesale price (AWP) of recommended initial antiretroviral regimes in 2012 ranged from an AWP of $24,970 to $35,160, increasing to $36,080 to $48,000 in 2018. Costs have generally increased since then. Data in the treatment guidelines show that the AWP for Biktarvy (again the number one treatment regimen for people with HIV and only STR recommended by the treatment guidelines start list) was $61,000 in 2025. The 2025 AWP for other recommended (two-pill) regimens ranged from $34,320 to $65,196. While ADAPs do not pay the full AWP because they have access to price discounts through the 340B drug pricing program and supplemental manufacturer rebates, increasing drug prices may still affect them; it is a main concern cited by ADAPs regarding cost challenges. Additionally, ADAPs ability to generate rebates (which make up a growing share of their budgets) through Medicare have diminished due to programmatic changes, including adoption of the out-of-pocket cap in Part D – by introducing the cap, ADAPs and other 340B entities, have less opportunity to generate rebates on claims because they make fewer cost-sharing payments.

Increased Insurance Premium Costs and Expiration of Enhanced Tax Credits

As mentioned above, ADAPs can also purchase health insurance for eligible clients. However, the cost of individual market coverage is on the rise, with the expiration of the enhanced premium tax credits being a particular driver and premium increases also playing a role.

ACA premium tax credits help make marketplace plans more affordable for people with low to moderate incomes. They were first enhanced as part of the American Rescue Plan Act in 2021 and extended by Congress through 2025, but have since expired due to the lack of a bipartisan Congressional agreement to continue them. The enhanced tax credits had improved insurance affordability for ADAPs purchasing coverage on behalf of clients, including for those previously eligible for the less generous ACA subsidies and, newly, for those with incomes over 400% FPL, a group for whom premium costs were limited to 8.5% of income. Without the enhanced credit those 100-400% FPL revert to the original, less generous, ACA tax credits and those over 400% FPL have lost financial assistance altogether. For enrollees keeping the same plan, expiration of the enhanced premium tax credits is estimated to more than double what subsidized enrollees previously paid annually for premiums—a 114% increase from an average of $888 in 2025 to $1,904 in 2026.

Additionally, after holding relatively steady since 2020, premiums increased steeply between 2025 and 2026, with the average premium cost for benchmark plans increasing by 26%⁷, with significant variation across states. Some southern states with high HIV prevalence saw especially large average increases (e.g. 33% in Florida and 35% in Texas). These premium increases occurred for a range of reasons including, but not limited to, higher health care costs, use of expensive GLP-1 drugs, the threat of tariffs, and the expiration of the enhanced premium tax credits. While the vast-majority of ADAP clients have modest incomes, these costs will be borne out most acutely for the 7% of clients served by insurance purchasing who have incomes over 400% FPL, a group who lost the enhanced tax credits that previously capped premium costs as a share of their income. ADAPs covering individuals in this higher income group face a two-fold setback – loss of enhanced tax credits and no protections against rising premiums. 

Additionally, individuals who lose ADAP insurance coverage due to cost-containment measures may find financing coverage independently more challenging due to reduced tax credit generosity and increases in premiums.

Looking Ahead

While ADAPs have sought to leverage additional state funds, drug rebates, and capture limited emergency and supplemental funding, these efforts have not remedied budget shortfalls, leading many to institute cost-containment measures. ADAPs may increasingly face budget pressures that could lead to additional such measures in the future. This could leave growing numbers of people with HIV ineligible for safety-net services, particularly if states further lower income eligibility limits or institute waiting lists. The expiration of enhanced tax credits amplifies these challenges, both increasing costs for programs and leaving those who are ineligible for ADAPs with fewer affordable alternatives. Limiting access to Ryan White services will in turn affect the ability of people with HIV to stay engaged in HIV treatment, a cornerstone of national efforts to address the HIV epidemic.

Endnotes

1. Except for cost-sharing assistance which will remain available for those up to 400% FPL. ↩︎
2. It is a federal requirement that insurance purchased through Ryan White be cost-effective compared to direct drug purchasing and  allows programs to generate 340B revenue.  ↩︎
3. 44 states, including DC, responded to the survey. In addition, information on FL was publicly available. It is possible, but unknown if, the remaining states are implementing or considering cost-containment measures. ↩︎
4. Adjusted using annualized CPI-U. ↩︎
5. Full year CPI-U data for 2026 not yet available. ↩︎
6. KFF and NASTAD. National ADAP Monitoring Project. 2009. https://www.kff.org/wp-content/uploads/2013/01/7861_es.pdf ↩︎
7. The second-lowest-cost silver (benchmark) premium for a 40-year-old in each county and weighted by county plan selections. ↩︎