This analysis examines changes in excess mortality and prematurity of those deaths in the U.S. and peer countries for 2020 and 2021. Using Centers for Disease Control and Prevention (CDC) weekly excess deaths data and the World Health Organization (WHO) all-cause excess death data, we compare excess mortality in the U.S. and other large and wealthy countries through 2021 and estimates the years of life lost, a measure of the prematurity of those excess deaths, during the COVID-19 pandemic. Excess deaths are the number of deaths beyond what would have been expected in a typical year and can be due directly or indirectly to COVID-19, as well as other causes.

When compared to other countries and adjusted for population size, the U.S. had the highest excess mortality rate among similarly large and wealthy countries for the period 2020-2021—the most recent data available for all these countries. In addition the U.S. also saw a higher rate of death among younger people, and thus a larger increase in premature deaths per capita than peer countries.

The analysis is available through the Peterson-KFF Health System Tracker, an online information hub that monitors and assesses the performance of the U.S. health system.

This analysis examines the impact of the COVID-19 pandemic by race and ethnicity through the lens of premature mortality, using the measures of premature mortality rate and years of life lost among excess deaths that occurred during the pandemic.

While the pandemic has had devastating effects across all racial and ethnic groups, we find significant racial disparities in premature death during the pandemic. Consistent with pre-pandemic trends, some communities of color faced higher premature death rates during the pandemic than their White counterparts. For all groups of color, though, the pandemic was associated with a steeper increase in the premature death rate than for White people.

The analysis is available through the Peterson-KFF Health System Tracker, an online information hub that monitors and assesses the performance of the U.S. health system.

On April 21st, the US Supreme Court blocked a lower court order that would have stopped the distribution and availability of the medication abortion drug, mifepristone, across the country. The high court’s ruling allows the current FDA rules to remain in effect, keeping mifepristone available for medication abortion where and when abortion is legal as the case proceeds through the courts. Telehealth abortions can also continue, where state law permits.

The court is responding to a ruling issued by Judge Matthew Kacsmaryk, the only judge in the US District Court for the Northern District of Texas Amarillo Division, who issued a preliminary injunction in the case, Alliance for Hippocratic Medicine v. FDA. The plaintiffs are challenging the FDA’s approval of mifepristone, one of the drugs used in medication abortion, claiming the FDA’s approval process and subsequent modifications of the conditions for dispensing mifepristone (known as REMS) as being beyond the FDA’s authority. The plaintiffs also contend that an 1873 anti-obscenity law, the Comstock Act, prohibits the mailing of any medication used for abortion (for details on the case see: Legal Challenges to the FDA Approval of Medication Abortion Pills).

Judge Kacsmaryk’s ruling would have blocked the FDA’s approval of mifepristone, which dates back to the year 2000. The judge delayed the enforcement of his own decision for seven days to give the FDA time to seek emergency relief from the U.S. Court of Appeals for the Fifth Circuit. The FDA and Danco Laboratories LLC (a party in the litigation, and the holder of the new drug application for Mifeprex, the brand name for mifepristone) appealed to Fifth Circuit Court of Appeals requesting a stay of Judge Kacsmaryk’s order pending the appeal (Figure 1). The Fifth Circuit Court of Appeals then issued an order which stayed part of the district court’s preliminary injunction (finding that the drug’s approval could not be revoked) but blocked the implementation of the changes that the FDA had made in 2016 to modify the agency’s conditions on the provision and dispensation of the drug (REMS). This decision would have effectively required the conditions that the FDA had in place 2011 to be re-introduced, taken the generic alternative drug off the market (GenBioPro), and required a relabeling of the drug. In addition, it would have required the drug to only be dispensed in person by a doctor, blocking the current ability of abortion providers and pharmacies to mail the drug.

On April 14, 2023, the FDA and Danco filed an emergency appeal with the Supreme Court, requesting either a stay of the district court’s ruling pending the appeal or for the Supreme Court to take the AHM case on an expedited basis. Later that day, Justice Alito, the justice assigned to emergency requests from the Fifth Circuit, issued an administrative stay keeping mifepristone available without any changes until April 19, 2023, which was subsequently extended to April 21, 2023.

On April 21, 2023, the Supreme Court blocked the district court’s ruling, sending the case back to the US Court of Appeals for the Fifth Circuit. Access to mifepristone will not change while this litigation continues through the final decision of the Supreme Court if their review is sought again.

It is important to recognize that this Supreme Court ruling is the not Court’s final word on the availability of mifepristone. The high court has sent this back to the Fifth Circuit to consider the appeal of the preliminary injunction (that is, the temporary block on mifepristone’s approval by Judge Kacsmaryk). The Fifth Circuit Court has scheduled an expedited hearing of the case for May 17, 2023, which will be the next step for this case. Procedurally, the Fifth Circuit is only considering the FDA and Danco’s appeal of the district court’s decision to temporarily block the FDA’s approval of mifepristone while the litigation proceeds. The district court has not yet considered the case on the merits. In the meantime, access to mifepristone will remain where abortion is permitted by state law.

The Inflation Reduction Act of 2022 includes several provisions to lower prescription drug costs for people with Medicare and reduce drug spending by the federal government, including a number of changes to the Medicare Part D drug benefit. These changes include a cap on out-of-pocket drug spending for enrollees in Medicare Part D plans and requiring Part D plans and drug manufacturers to pay a greater share of costs for Part D enrollees with high drug costs. This brief provides an overview of the Part D benefit design and Part D enrollee cost-sharing requirements in 2023 and changes coming in 2024 and 2025.

What Does the Medicare Part D Benefit Look Like in 2023?

The standard design of the Medicare Part D benefit currently has four distinct phases, where the share of drug costs paid by Part D enrollees, Part D plans, drug manufacturers, and Medicare varies (Figure 1). (The Part D enrollee shares reflect costs paid by enrollees who are not receiving low-income subsidies.)

• In the deductible phase, Part D enrollees pay 100% of their drug costs, up to $505 in 2023. Not all Part D plans charge a deductible, but many enrollees in stand-alone PDPs are in a plan that charges the standard deductible in 2023.
• In the initial coverage phase, Part D enrollees pay 25% of total drug costs and Part D plans pay 75%, up to total drug costs of $4,660 in 2023. However, most Part D plans charge a mix of copayments and coinsurance in this phase rather than a standard 25% coinsurance rate.
• In the coverage gap phase, Part D enrollees pay 25% of total drug costs for both brand-name and generic drugs. Part D plans pay the remaining 75% of generic drug costs and 5% of brand drug costs, and drug manufacturers provide a 70% price discount on brands (there is no manufacturer price discount on generics).
• In the catastrophic phase, Medicare pays 80% of total drug costs (known as “reinsurance”), Part D plans pay 15%, and Part D enrollees pay 5%. Part D enrollees qualify for catastrophic coverage when the amount that they pay out of pocket plus the value of the manufacturer discount on the price of brand-name drugs in the coverage gap phase exceeds a certain threshold amount. In 2023, the catastrophic threshold is set at $7,400, and enrollees themselves will pay about $3,100 out of pocket before reaching the catastrophic phase (this estimate is based on using brand drugs only).

How Is the Medicare Part D Benefit Changing in 2024?

In 2024, costs in the catastrophic phase will change: the 5% coinsurance requirement for Part D enrollees will be eliminated and Part D plans will pay 20% of total drug costs in this phase instead of 15%.

The 5% coinsurance requirement for Part D enrollees in the catastrophic phase will be eliminated

In 2024, once Part D enrollees without low-income subsidies (LIS) have drug spending high enough to qualify for catastrophic coverage, they will no longer be required to pay 5% of their drug costs, which in effect means that out-of-pocket spending for Part D enrollees will be capped. In 2024, the catastrophic threshold will be set at $8,000. This amount includes what Part D enrollees spend out of pocket plus the value of the manufacturer price discount on brands in the coverage gap phase. At this amount, Part D enrollees who take only brand-name drugs in 2024 will have spent about $3,300 out of their own pockets and will then face no additional costs for their medications.

To understand the impact of this change, it helps to consider what Part D enrollees without LIS currently pay for high-cost medications. For example, for the five drugs with the highest per capita Part D expenditures in 2021 used by more than 10,000 Part D enrollees – Revlimid, Pomalyst, Imbruvica, Jakafi, and Ibrance, all cancer treatments – annual out-of-pocket costs per drug in 2023 range from over $11,000 to nearly $15,000, and out-of-pocket costs for each drug in the catastrophic phase alone range from around $8,000 to nearly $12,000 (see methods for details) (Figure 2). (These estimates exclude the cost of other drugs that users of these drugs might be taking.) Eliminating the 5% coinsurance requirement in the catastrophic phase in 2024 means that Part D enrollees without LIS who use these or other high-cost medications covered by Part D will see thousands of dollars in savings.

Part D plans will pay a somewhat larger share of total drug costs above the catastrophic threshold

With the elimination of the 5% coinsurance requirement for Part D enrollees in the catastrophic coverage phase, Part D plans will be required to pay 20% of total drug costs in this phase in 2024, up from 15% in 2023 and prior years.

How Is the Medicare Part D Benefit Changing in 2025?

Changes in 2025 include a new $2,000 out-of-pocket spending cap, elimination of the coverage gap phase, a higher share of drug costs paid by Part D plans in the catastrophic phase, along with a new manufacturer price discount and reduced liability for Medicare in this phase, and changes to plan costs and the manufacturer price discount in the initial coverage phase.

Out-of-pocket drug spending will be capped at $2,000

Beginning in 2025, Part D enrollees’ out-of-pocket drug costs will be capped at $2,000. This amount will be indexed to rise each year after 2025 at the rate of growth in per capita Part D costs. (This cap does not apply to out-of-pocket spending on Part B drugs.)

For Part D enrollees who take only brand-name drugs, annual out-of-pocket costs at the catastrophic threshold will fall from around $3,300 in 2024 to $2,000 in 2025 (Figure 3). In other words, Part D enrollees who take only brands and have drug costs high enough to reach the catastrophic threshold could see savings of about $1,300 in 2025 relative to what they will spend in 2024.

The coverage gap phase will be eliminated

The coverage gap phase, where Part D enrollees had faced 100% of their total drug costs under the original Part D benefit design and currently face 25% of costs for brand and generic drugs, will be eliminated in 2025. This means that Part D enrollees will no longer face a change in their cost sharing for a given drug when they move from the initial coverage phase to the coverage gap phase, which is the case in most Part D plans today, since most plans charge varying cost-sharing amounts, rather than the standard 25% coinsurance, in the initial coverage phase.

Part D plans and drug manufacturers will pay a larger share of costs for catastrophic coverage, and Medicare will pay a smaller share

Medicare’s share of total costs in the catastrophic phase (reinsurance) will decrease from 80% to 20% for brand-name drugs and from 80% to 40% for generic drugs beginning in 2025. This reduction will help address concerns about the substantial increase in Medicare’s reinsurance payments to Part D plans over time, which accounted for close to half (48%) of total Part D spending in 2022, up from 14% in 2006, based on data from the Medicare Trustees 2023 annual report. Medicare Part D plans’ share of costs will increase from 15% to 60% for both brands and generics above the cap, and drug manufacturers will be required to provide a 20% price discount on brand-name drugs (Figure 4).

Part D plans and manufacturers will face changes to their share of total drug costs paid in the initial coverage phase

Drug manufacturers will be required to provide a 10% discount on brand-name drugs in the initial coverage phase beginning in 2025, replacing the 70% price discount in the coverage gap phase under the current benefit design. Part D plans will pay 65% of brand-name drug costs.

What Other Changes Are Being Made to Part D?

• As of 2023, the out-of-pocket cost of insulin products is limited to no more than $35 per month in all Part D plans. In addition, adult vaccines covered under Part D, such as the shingles vaccine, are covered with no cost sharing.
• Starting in 2024, people with Medicare who have incomes up to 150% of poverty and resources at or below the limits for partial low-income subsidy benefits will be eligible for full benefits under the Part D Low-Income Subsidy (LIS) Program. The law eliminates the partial LIS benefit currently in place for individuals with incomes between 135% and 150% of poverty.
• Also starting in 2024, the calculation of the base beneficiary premium will be adjusted, as needed, to limit increases in the base premium to no more than 6% from the prior year. (Premiums for individual Part D plan premiums and annual plan-level premium increases will continue to vary, however.)
• Starting in 2025, Part D enrollees will have the option of spreading out their out-of-pocket costs over the year rather than face high out-of-pocket costs in any given month.

People who use home- and community-based services (HCBS) are at heightened risk of serious illness or death from exposure to COVID-19 and disproportionately likely to need hospital or nursing facility care if HCBS are unavailable. However, during the pandemic, there were fewer workers available and willing to provide services and extra safety precautions were required to prevent COVID-19 infection. Recognizing those challenges, the federal government provided states with new authorities to maintain access to HCBS during the public health emergency (PHE). The PHE has been in place since 2020 and will end on May 11, 2023. This policy watch explores the potential implications of ending the PHE for Medicaid HCBS programs, including new or continued workforce challenges and potential reductions in patients’ access to care.

In 2020, an estimated 6 million people used HCBS according to CBO estimates. HCBS are provided in peoples’ homes and other non-institutional settings. They include medical and supportive services that assist people with the activities of daily living (such as eating, bathing, and dressing) and instrumental activities of daily living (such as preparing meals, managing medications, and housekeeping). They are provided to people who need such services because of aging, chronic illness, or disability and may include personal care, adult daycare, home health aide services, transportation, and supported employment. Medicare generally does not cover HCBS and in 2020, Medicaid spent $162 billion on HCBS—a majority of the $245 billion in total HCBS spending. Although all states offer some HCBS through Medicaid, most services are optional for states, and states may cover different services for different types of Medicaid enrollees. To be eligible for Medicaid HCBS, individuals must have limited financial resources and significant functional impairments.

How Did States Support Medicaid HCBS During the PHE?

States used several types of authorities when responding to the COVID-19 PHE, including disaster-relief state plan amendments, 1115 waivers, and Appendix K changes to 1915c waivers. When the PHE ends on May 11, 2023, changes made through a disaster-relief state plan amendment or 1115 waiver will also end. Changes made using the Appendix K authority will expire within 6 months of the PHE ending (December 11, 2023). With 437 changes to HCBS programs made under Appendix K, it was the most widely used authority. Examples of Appendix K uses include changing processes for determining eligibility, authorizing services, and paying providers; expanding provider qualifications or which providers are eligible to be paid; and expanding the service delivery models. Some changes have ended already, others have been transitioned to permanent authorities, and some will end between May and November 2023 if not also transitioned.

In a survey of states on Medicaid HCBS in 2022, many states reported using PHE authorities to bolster their HCBS programs by expanding eligibility and services and addressing workforce challenges (Figure 1). Within the category of eligibility and enrollment, nearly all states reported making it easier for people to access HCBS through virtual evaluations (49 states), 10 states reported increasing the number of waiver slots, and 5 states reported increasing eligibility limits. In terms of services, the most common change was providing HCBS via telehealth (47 states), followed by increasing utilization limits (37 states). Half of the states added new HCBS and around a quarter removed prior authorization requirements.

Many states reported that they planned to continue the PHE policies after the authority expires, but in other cases, states expect the policies will end or have not yet decided.  Fewer than half of states that allowed virtual evaluations reported plans to continue doing so after the PHE ends, and eligibility levels will return to their pre-pandemic levels in at least four of the five states with higher limits. Most states reported that they plan to continue providing HCBS via telehealth, but prior authorization and utilization limits may return to pre-pandemic levels in half or more of states that had made changes.

During the PHE, most states (39) reported responding to workforce challenges by allowing family caregivers to be paid, but only 20 states plan to continue that policy after the PHE ends (Figure 2). In a 2022 survey, states reported that maintaining a workforce was the biggest challenge for HCBS programs and the primary effect of COVID-19 on HCBS programs was to amplify existing workforce shortages. Recent analysis on the Peterson-KFF Health System Tracker shows that, as of October 2022, the number of workers providing long-term services and supports was measurably lower than in early 2020. Allowing family caregivers to be paid providers was an important tool in responding to shortages of HCBS workers stemming from the pandemic, but this authority will be ending in many states—even as workforce shortages persist.

Most states provide HCBS through “waiver” programs that allow them to limit eligibility and, in many cases, to people with certain types of health conditions. In a 2022 survey of states, the most frequently reported waivers were those serving people with intellectual or development disabilities (47 states), and of those, 28 states allowed family caregivers to be paid providers. When the PHE ends, 14 states will continue the policy, but 8 states are planning to end it, and the outcome is undecided in 6 states. The second most reported waivers were for adults ages 65 and older or with physical disabilities (42 states), and of those, 28 states allowed family caregivers to be paid providers. That policy will continue in 11 states, end in 8 states, and is unknown in 9 states.

What to Watch in Medicaid HCBS as the PHE Ends?

Looking ahead, the loss of PHE flexibilities could further exacerbate workforce challenges for HCBS programs. Many elements of life have started to return to pre-pandemic norms, but Medicaid HCBS programs continue to face major workforce challenges. Loss of the PHE flexibilities—and in many states, the end of paying family caregivers—may further exacerbate those challenges. Some challenges may be addressed, in part, with HCBS funding from the American Rescue Plan Act, which states may spend until March 31, 2025. A recent analysis of states’ spending plans for those funds found that 32 states were increasing payment rates for HCBS providers, 39 were funding provider training and certifications, and many states were engaging in other activities that could help bolster the HCBS workforce.

Unwinding the Medicaid continuous enrollment provision may create additional challenges for people who use HCBS. Between February 2020 and March 2023, states received enhanced federal funding for Medicaid in exchange for keeping people continuously enrolled in Medicaid. States were able to resume disenrollments starting April 1, 2023 and the enhanced federal funding will phase down through December 2023 if certain conditions are met. During the unwinding, some people who use HCBS could lose their Medicaid eligibility—either because they are no longer eligible or because they face administrative barriers to complete renewals. The phasing-out of enhanced federal funding could create state budget pressure and result in fewer resources for optional services such as HCBS in response.

Longer-term it is unclear whether more significant changes for HCBS are possible, including potential changes that would attempt to reduce or eliminate HCBS waiting lists. On April 18, the White House issued a statement summarizing a series of executive actions that include provisions aimed at strengthening the HCBS workforce. Those provisions include enhancing job quality for people who provide Medicaid HCBS, providing support for family caregivers of people with dementia through Medicare, and supporting HCBS workers who want to further professionalize or join a union. The president’s budget has called for an additional $150 billion in funding for Medicaid HCBS and there are legislative proposals that would increase federal funding for HCBS. However, proposals to increase federal funding for Medicaid HCBS face long odds in a divided Congress. There are competing proposals to significantly reduce the federal government’s spending on Medicaid, though those are unlikely to gain support of the White House or Democrats in the Senate. At the same time, states face pressure to provide HCBS to the growing number of people who need long-term services and supports and wish to receive them in their homes.

KFF Health News has taken top honors in the National Institute for Health Care Management (NIHCM) Foundation’s 2023 Awards in Journalism and Research for its series “Diagnosis: Debt.” The multifaceted reporting partnership among KFF Health News, NPR, and CBS News explores the scale, impact, and causes of medical debt in America.

“Diagnosis: Debt” won first place in the digital media category, which included more than 70 entries from news organizations including The Washington Post, ProPublica, and NBC News. Judges cited the series for its powerful and compelling use of storytelling, graphics, and original data to illustrate one of the most difficult issues affecting patients today.

“Diagnosis: Debt” examined the stories behind the more than 100 million people in America who have been pushed into debt by the nation’s health care system, revealing the epidemic of medical debt that has become a defining feature of the American system. In personal, multimedia stories, “Diagnosis: Debt” documented the suffering and sacrifices this burden forces on patients and their families.

“This project is at the heart of our mission at KFF Health News: in-depth journalism that looks at the impact of the health system on people,” said KFF President and CEO Drew Altman, founding publisher of KFF Health News.

The project drew on a nationwide poll, the “KFF Health Care Debt Survey,” designed and analyzed by KFF’s journalists and public opinion researchers, as well as new research into debt and hospital finances, and original investigations by reporters. The investigations included a review of thousands of court records to expose debt collection by nursing homes and an analysis of hospital contracts obtained through public records requests. The most ambitious effort reflected a detailed examination of billing and collection policies at hundreds of U.S. hospitals, many of which resisted public disclosures. That reporting informed an interactive data visualization that allows readers to see the practices of hospitals near them.

The yearlong project was led by Noam N. Levey, a senior correspondent at KFF Health News, and his editor, Kelly Johnson, and included work by Aneri Pattani, a correspondent at KFF Health News; Yuki Noguchi, a correspondent on the Science Desk at NPR; Anna Werner, a consumer investigative national correspondent for CBS News; Juweek Adolphe, a web developer and designer; Bram Sable-Smith, a Midwest correspondent at KFF Health News; Megan Kalata, a writer at KFF Health News; and Terry Byrne, copy chief at KFF Health News. KFF Health News continues to explore the topic.

Medical debt has also been a focus of KFF’s recent policy analysis work, including resources such as “The Burden of Medical Debt in the United States,” “Americans’ Challenges with Health Care Costs,” and “Could Consumer Assistance Be Helpful to People Facing Medical Debt?”

Yesterday, the Biden Administration announced a plan to expand eligibility for Medicaid and ACA Marketplace health coverage to Deferred Action for Childhood Arrivals (DACA) recipients. A KFF analysis finds 47% of individuals likely eligible for DACA are uninsured compared to 10% of U.S. born individuals in their age group.

The analysis estimates that among those likely eligible for DACA:

• 84% are in a family with at least one full-time worker,
• 54% of adults work full-time,
• 43% have incomes below 200% of the federal poverty level.

DACA recipients are more likely to be in low-wage jobs without employer-sponsored health insurance. For those without employer coverage or the ability to afford individual market coverage, they are currently prohibited from enrolling in Medicaid, CHIP and ACA Marketplace coverage. A few states do provide state-funded health coverage regardless of immigration status.The Biden Administration is planning to take administrative action to provide health coverage. However, the future of the DACA program is uncertain pending federal court decisions.The updated brief provides an overview of the DACA program and its roughly 580,000 active recipients at the end of 2022.

In this Think Global Health (an initiative from the Council on Foreign Relations) opinion piece, Jennifer Kates and Kellie Moss discuss what could happen as Congress considers reauthorizing the United States’ signature initiative on global health.

Introduction

The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), the largest initiative addressing a single disease globally, provides a range of prevention, testing, and treatment services to people living with and at risk for HIV. PEPFAR reports that it has saved 25 million lives since its inception and currently supports antiretroviral treatment and other services for millions. Its efforts aim to reach the highest burden populations and improve HIV outcomes in those who are most affected, including women and adolescent girls, men and adolescent boys, children, and people in key and other priority population groups.

To get a better understanding of PEPFAR’s beneficiaries, we analyzed PEPFAR’s Monitoring, Evaluation, and Reporting (MER) indicator data for 2022, representing data from 62 supported PEPFAR countries. We looked specifically at the demographic characteristics of those served by the program, including by sex and age, and which services they used. We also analyzed data on key populations served (defined by PEPFAR to include men who have sex with men, transgender people, sex workers, people who inject drugs, and people in prisons and other closed settings) as well as PEPFAR’s priority populations (clients of sex workers, members of military and other uniformed services, displaced persons, and mobile populations), supplementing MER data with PEPFAR expenditure data, as MER data on these populations were limited, for 2022.

Overall, in 2022, PEPFAR provided testing services to 64.1 million people, including 2.2 million who newly tested positive for HIV (See Figure 1). In addition, PEPFAR supported the provision of antiretroviral treatment (ART) to 19.9 million people in 2022, or about three-quarters of all people living with HIV in PEPFAR countries (and almost half of all those on ART globally).¹  PEPFAR newly enrolled 2.1 million on ART in 2022. The majority of people served by PEPFAR in 2022 were female, including 59% of those tested and 63% of those on ART, and most were ages 15 or older (See Figures 2 and 3). Of the 15.3 million people on ART with a documented viral load result, 14.6 million (95%) were virally suppressed (See Figure 4).

PEPFAR also provided preventive services²  to 3.9 million people from key populations and 5.4 million from priority populations, and newly enrolled 1.5 million people³  on pre-exposure prophylaxis (PrEP) (See Figure 5).

More than a quarter of the 62 PEPFAR countries analyzed here have already reached global targets for epidemic control.⁴ 

Taken together, these data indicate that PEPFAR is reaching large shares of people with and at risk for HIV. Still, as noted below, there are some populations who lag behind, particularly younger age groups, with children less likely to have received ART or to be virally suppressed. Data on specific groups follow.

Women and Adolescent Girls

• In 2022, PEPFAR provided testing services to 38.1 million women and adolescent girls (ages 15+), 1.2 million of whom newly tested positive. Those between the ages of 15-24 accounted for the largest share of women and adolescent girls tested (37% or 14 million), followed closely by those ages 25-34 (36% or 13.7 million); this latter group accounted for the largest share newly testing positive (39% or 483,000) (See Figures 6 and 7).
• PEPFAR supported ART for 12.6 million women and adolescent girls in 2022, including 1.2 million newly enrolled on ART. Most were ages 35 or older, although among those newly enrolled, those ages 25-34 represented the largest share (See Figures 6 and 7).
• Almost all (96% or 9.4 million) women and adolescent girls on ART with a documented viral load result were virally suppressed. Their age distribution is similar to that of those enrolled on ART overall, with most ages 35 and older. Viral suppression was lowest among the youngest cohort, those ages 15-24 (See Figures 6-8).
• PEPFAR also provided ART to 732,000 HIV-positive pregnant women to help reduce the risk of mother-to-child transmission during pregnancy.
• PEPFAR newly enrolled 920,000 women and adolescent girls on PrEP to prevent HIV infection.
• Finally, 2.1 million adolescent girls and young women, ages 10-24, participated in PEPFAR’s DREAMS programming in 2022.⁵ 

Men and Adolescent Boys

• In 2022, PEPFAR provided HIV testing services to 17.6 million men and adolescent boys, including 826,000 who newly tested positive. Those ages 25-34 accounted for the largest share – a third – of men and adolescent boys tested (33% or 5.8 million) and of those newly testing positive (33% or approximately 274,000) (See Figures 9 and 10).
• PEPFAR supported ART for 6.6 million men and adolescent boys in 2022, including 802,000 newly enrolled on ART. Most were ages 35 or above, although, as with women, among those newly enrolled on ART, those ages 25-34 represented the largest share (See Figures 9 and 10).
• Almost all men and adolescent boys on ART with a documented viral load result were virally suppressed (95% or 4.7 million). Their age distribution is similar to that of those enrolled on ART overall, with most ages 35 and older. Viral suppression was lowest among men ages 15-24 (89%) and highest among those 45+ (96%) (See Figures 9-11).
• PEPFAR newly enrolled 531,000 men and adolescent boys on PrEP to prevent HIV infection.
• PEPFAR also reached 2 million men and boys⁶  with voluntary medical male circumcision services in 2022.

Children

• In 2022, PEPFAR provided HIV testing services to 5.5 million children (under age 15).⁷  Approximately 74,000 children newly tested positive. Children under age 5 accounted for the largest share (39% or 2.1 million) of children tested and those newly positive (40% or approximately 30,000) (See Figures 12 and 13).
• PEPFAR supported ART for approximately 658,000 children, including 80,000 (12%) newly enrolled on ART. Almost half of those newly enrolled on ART were under age 5 (See Figures 12 and 13).
• Of children on ART with a documented viral load result, most (86% or approximately 457,000) were virally suppressed. Viral suppression was lowest among children under age 5 (77%) and higher for those ages 5-9 and 10-14 (87%, respectively) (See Figure 14).
• Approximately 846,000 children born to HIV-positive pregnant women had a virologic test within the first 12 months of age. Very few infants (approximately 11,000) newly tested positive (See Figure 15).
• 7.2 million people,⁸  including children who are orphaned, living with, affected by, or at risk of becoming infected with HIV, living with caregivers who are living with HIV, or have a combination of these factors, as well as caregivers of these children, were served by PEPFAR’s orphans and vulnerable children (OVC) programs in 2022.

Key Populations

• In 2022, PEPFAR provided preventive services to 3.9 million people from key populations.⁹ 
• PEPFAR expenditure data indicates that in 2022, PEPFAR expenditures for key populations totaled $223 million, of which 28% or $62 million was designated for a specific key population group.¹⁰  The largest share was for services for sex workers ($28 million), followed by men who have sex with men ($19 million). Services for transgender people represented the smallest share of expenditures ($1.1 million) (See Figure 16).

Priority Populations

• In 2022, PEPFAR provided preventive services¹¹  to 5.4 million people from priority populations.¹² 
• PEPFAR spending on priority populations was $101 million in 2022, of which $31 million was designated for a specific priority population group as follows: members of the military and other uniformed services ($28 million), displaced persons ($1.6 million), clients of sex workers ($708,000), and mobile populations¹³  ($697,000) (See Figure 17).¹⁴ 

1. Based on 2021 data from UNAIDS, from: UNAIDS, HIV estimates with uncertainty bounds 1990-Present, accessed: https://www.unaids.org/en/resources/documents/2022/HIV_estimates_with_uncertainty_bounds_1990-present. ↩︎
2. These data include people who received HIV testing services and one of the following prevention activities: targeted information/education/communication, outreach/empowerment, condoms, lubricant, STI testing or screening, ART linkage, TB services, viral hepatitis services, reproductive health services, MAT, or needle syringe program services. See: PEPFAR, FY22 MER 2.6 Indicator Reference Guide, accessed: https://www.state.gov/wp-content/uploads/2021/09/FY22-MER-2.6-Indicator-Reference-Guide.pdf. ↩︎
3. These data represent people newly enrolled on PrEP to prevent HIV infection and only include those ages 15 and older. See: PEPFAR, FY22 MER 2.6 Indicator Reference Guide, accessed: https://www.state.gov/wp-content/uploads/2021/09/FY22-MER-2.6-Indicator-Reference-Guide.pdf. ↩︎
4. Based on 2021 data from UNAIDS, from: UNAIDS, AIDSinfo database, accessed: https://aidsinfo.unaids.org/. ↩︎
5. Countries designate their own primary packages of services for DREAMS interventions. These interventions are not limited to health sector services but also include services that may directly or indirectly increase girls’ risk to HIV, such as parenting/caregiver programs, cash transfers, educational subsidies, risk reduction, community engagement, violence prevention and post-violence care. See: PEPFAR, DREAMS Core Package of Interventions Summary, accessed: https://www.state.gov/wp-content/uploads/2019/08/DREAMS-Core-Package.pdf. ↩︎
6. The age of people supported by these services ranged from birth to 50+. See: PEPFAR, FY22 MER 2.6 Indicator Reference Guide, accessed: https://www.state.gov/wp-content/uploads/2021/09/FY22-MER-2.6-Indicator-Reference-Guide.pdf. ↩︎
7. Data for children <15 were classified in the data as “Unknown sex.” See: PEPFAR, FY22 MER 2.6 Indicator Reference Guide, accessed: https://www.state.gov/wp-content/uploads/2021/09/FY22-MER-2.6-Indicator-Reference-Guide.pdf. ↩︎
8. Beneficiaries served by the Orphans and Vulnerable Children (OVC) program include active, graduated, transferred, and exited beneficiaries who were served within the reporting period. See: PEPFAR, FY22 MER 2.6 Indicator Reference Guide, accessed: https://www.state.gov/wp-content/uploads/2021/09/FY22-MER-2.6-Indicator-Reference-Guide.pdf. ↩︎
9. PEPFAR, “Key Populations” webpage, accessed: https://www.state.gov/key-populations/. PEPFAR, FY22 MER 2.6 Indicator Reference Guide, accessed: https://www.state.gov/wp-content/uploads/2021/09/FY22-MER-2.6-Indicator-Reference-Guide.pdf. ↩︎
10. Funding that was not designated for a specific key population group includes funding that is not targeted, targeted at more than one key population group, or where the resources for the activities are not distinct by the key population group. PEPFAR, Financial Classifications Reference Guide, accessed: https://datim.zendesk.com/hc/en-us/articles/360015671212-PEPFAR-Financial-Classifications-Reference-Guide. ↩︎
11. Countries, along with the PEPFAR implementing partner, design a set of interventions for each priority population. See: PEPFAR, FY22 MER 2.6 Indicator Reference Guide, accessed: https://www.state.gov/wp-content/uploads/2021/09/FY22-MER-2.6-Indicator-Reference-Guide.pdf. ↩︎
12. Priority populations are defined within the context of and by each country and may include: adolescent girls and young women (AGYW), adolescent boys and young men, men, clients of sex workers, people who are displaced, fishing communities, military or others in uniformed service, mobile populations, and non-injecting drug users. See: PEPFAR, FY22 MER 2.6 Indicator Reference Guide, accessed: https://www.state.gov/pepfar-fy-2022-mer-indicators/. ↩︎
13. Mobile populations include fishing, farming, mining, and migrant workers, and truck/commercial drivers and transport workers. See: PEPFAR, FY22 MER 2.6 Indicator Reference Guide, accessed: https://www.state.gov/wp-content/uploads/2021/09/FY22-MER-2.6-Indicator-Reference-Guide.pdf. ↩︎
14. Funding that was not designated for a specific population group is referred to as “not disaggregated.” This funding includes funding that is not targeted, targeted at more than one priority population group, or where the resources for the activities are not distinct by the priority population group. See: PEPFAR, Financial Classifications Reference Guide, accessed: https://datim.zendesk.com/hc/en-us/articles/360015671212-PEPFAR-Financial-Classifications-Reference-Guide ↩︎

Program:

• Introductory remarks by Dr. Altman, president and CEO, KFF
• Remarks by Dr. Walensky
• Discussion and Q&A with Dr. Walensky and Dr. Monroe, moderated by Dr. Kates

Speaker Bios (in order of appearance)

Drew Altman, PhD

President & Chief Executive Officer, KFF

Drew Altman is president and chief executive officer of KFF, a position he has held for more than 30 years. He is a leading expert on national health policy issues and an innovator in the nonprofit field.

Dr. Altman built KFF with the mission the organization pursues today–to serve as a nonpartisan source of trusted information for policymakers, the media, the health policy community, and the public. He is also founding publisher of KFF Health News, the largest health newsroom in the U.S., which reports on health issues and distributes its articles through major news outlets across the country.

Dr. Altman was commissioner of the Department of Human Services for the state of New Jersey, director of Health and Human Services at The Pew Charitable Trusts, vice president of the Robert Wood Johnson Foundation, and served in a senior position in the Health Care Financing Administration in the Carter administration. He is a member of the National Academy of Medicine and the Council on Foreign Relations.

Dr. Altman earned his doctorate in political science at the Massachusetts Institute of Technology and completed his postdoctoral work at Harvard University before moving on to public service. He holds an honorary doctorate from the Morehouse School of Medicine.

Rochelle P. Walensky, MD, MPH

Director of the Centers for Disease Control and Prevention

Rochelle P. Walensky, MD, MPH, is the Director of the Centers for Disease Control and Prevention and the Administrator of the Agency for Toxic Substances and Disease Registry. She is an influential scholar whose pioneering research has helped advance the national and global response to HIV/AIDS. Dr. Walensky is also a well-respected expert on the value of testing and treatment of deadly viruses.

Dr. Walensky served as Chief of the Division of Infectious Diseases at Massachusetts General Hospital from 2017-2020 and Professor of Medicine at Harvard Medical School from 2012-2020. She served on the front line of the COVID-19 pandemic and conducted research on vaccine delivery and strategies to reach underserved communities.

Dr. Walensky is recognized internationally for her work to improve HIV screening and care in South Africa and nationally for motivating health policy and informing clinical trial design and evaluation in a variety of settings.

She is a past Chair of the Office of AIDS Research Advisory Council at the National Institutes of Health, Chair-elect of the HIV Medical Association, and previously served as an advisor to both the World Health Organization and the Joint United Nations Programme on HIV/AIDS.

Originally from Maryland, Dr. Walensky received her Bachelor of Arts from Washington University in St. Louis, her Doctor of Medicine from the Johns Hopkins School of Medicine, and her Master of Public Health from the Harvard School of Public Health.

Jennifer Kates, PhD

Senior Vice President, KFF

Director of Global Health & HIV Policy

Dr. Jen Kates is Senior Vice President and Director of Global Health & HIV Policy at KFF, where she oversees policy analysis and research focused on the U.S. government’s role in global health and on the global and domestic HIV epidemics. She has also helped to lead KFF’s work on the COVID-19 pandemic. Widely regarded as an expert in the field, she regularly publishes and presents on global health and HIV policy issues and is particularly known for her work analyzing donor government investments in global health; assessing and mapping the U.S. government’s global health architecture, programs, and funding; and tracking and analyzing major U.S. HIV programs and financing, and key trends in the HIV epidemic, an area she has been working in for close to thirty years. Prior to joining KFF in 1998, Dr. Kates was a Senior Associate with The Lewin Group, a health care consulting firm, where she focused on HIV policy, strategic planning/health systems analysis, and health care for vulnerable populations. Among other prior positions, she directed the Office of Lesbian, Gay, and Bisexual Concerns at Princeton University.

Dr. Kates has served on numerous federal and private sector advisory committees on global health and HIV issues, including the Presidential Advisory Council on HIV/AIDS (PACHA), PEPFAR’s Scientific Advisory Board, the NIH Office of AIDS Research Advisory Council, the CDC/HRSA Advisory Committee on HIV, Viral Hepatitis and STD Prevention and Treatment (CHACHSPT), the board of the Global Fund to Fight AIDS, Tuberculosis and Malaria, and the Governing Council of the International AIDS Society. She is also a lecturer at the Johns Hopkins School of Advanced International Studies.

Dr. Kates received her Ph.D. in Health Policy from George Washington University. She holds a Bachelor’s degree from Dartmouth College, a Master’s degree in Public Affairs from the Princeton School of Public and International Affairs and a Master’s degree in Political Science from the University of Massachusetts.

Judy Monroe, MD

President & CEO, CDC Foundation

Dr. Judith Monroe, president and CEO of the CDC Foundation, has dedicated her career to protecting people and saving lives. She joined the CDC Foundation in February 2016 as president and CEO, following her role as a deputy director of the U.S. Centers for Disease Control and Prevention (CDC) and director of CDC’s Office of State, Tribal, Local and Territorial Support.

In her work at the CDC Foundation, Dr. Monroe advances priority programs that improve the health of people across America and around the world. The CDC Foundation mobilizes philanthropic and private-sector resources to support CDC’s critical health protection work, managing hundreds of programs in the United States and in more than 140 countries.

Dr. Monroe received her doctor of medicine from the University of Maryland and a bachelor of science degree from Eastern Kentucky University. She completed her residency in family medicine at the University of Cincinnati, a rural faculty development fellowship through East Tennessee State University, and a mini-fellowship in obstetrics through the University of Wisconsin. She also participated in the State Health Leadership Initiative at Harvard University’s Kennedy School of Government and received an honorary doctorate from Purdue University in Health and Human Services.