Overview

While PEPFAR was designed at the outset as an emergency program, the importance of building sustainable capacity was recognized early on, and over time, this emphasis has increased and evolved. Most recently, PEPFAR has elevated its focus on sustainability even further, placing it “at the same level of priority as epidemic control.” To better understand how PEPFAR is defining and approaching sustained epidemic control, we examined PEPFAR’s most recent Country and Regional Operational Plan (COP) Guidance and country planning level letters (PLLs) for the 25 countries required to prepare COPs in 2022. We assessed country progress across several dimensions of sustainability as follows: the status of epidemic control and global HIV targets; progress toward meeting PEPFAR’s 16 minimum program requirements (MPRs); the HIV funding landscape; the status of health systems strengthening efforts; progress toward addressing gaps for key and other vulnerable populations; and community and civil society inclusion and engagement. Among our findings:

• Most COP countries (16 of 25) are at, or near, epidemic control, as defined by PEPFAR, including 12 that have reached epidemic control. Eight have reached the global viral suppression target (73% of people with HIV virally suppressed) set for 2020.
• While progress toward meeting the 16 PEPFAR MPRs is underway, no COP country has completed all of them; the average number completed is five and completion rates range from 6% to 75% in COP countries. Certain MPRs have higher completion rates, with implementation of test & start and elimination of user fees at the top, while increased domestic funding from partner governments is at the bottom.
• National HIV budgets in COP countries vary significantly in size and in terms of funding per person living with HIV. PEPFAR accounts for the largest share of national HIV budgets (46%), and most COP countries are dependent on external financing for their HIV response.
• Country PLLs identify a number of issues and challenges related to health systems strengthening in the following areas: supply chains and stockouts (10 countries); laboratory networks and systems (8); data systems, such as the lack of population-based estimates (7); and rightsizing the health care workforce, including using human resources for health (HRH) data to optimize staffing levels (7).
• Nearly all country PLLs (22) highlight the importance of bolstering prevention, testing, and treatment to reach children and adolescent girls and young women (AGYW), though gender-based violence is only mentioned in four countries. More than half (13) identify addressing gaps for key populations, and nearly all (23) have a technical directive focused on improving and expanding data in this area. Few however specifically mention stigma and discrimination or human rights as priority areas, despite the fact that many have legal and policy barriers that may present challenges to reaching and supporting key populations in accessing HIV services.
• Finally, the importance of engaging community partners in order to improve PEPFAR programming, with particular emphasis on the role of community-led monitoring (CLM), is mentioned in all PLLs.

This analysis provides an initial look at how PEPFAR is currently defining and approaching sustained epidemic control at the country level. As it finds, the picture is multi-layered, and there is significant variation across countries and across dimensions. Going forward, better understanding how these markers of sustainability, such as epidemic control status, financial dependency, and MPR status, fit together may help to paint a clearer narrative of country progress. Some of this information may be forthcoming, as PEPFAR is expected to release a new five-year strategy and sustainability roadmaps for some countries.

Introduction

While PEPFAR was designed at the outset as an emergency program, the importance of building sustainable capacity was recognized early on, including in its authorizing legislation. Over time, this emphasis has increased and evolved, and in 2014, PEPFAR characterized its next phase as one of achieving “Sustainable Control of the Epidemic” and introduced an “epidemic control” target. Epidemic control is defined by PEPFAR as the point at which the total number of new HIV infections falls below the total number of deaths from all causes among HIV-infected individuals, with both new infections and deaths among people living with HIV low and declining. As part of its next strategy, now under development, and through recent guidance to countries, PEPFAR has elevated its focus on sustainability even further, placing it “at the same level of priority as epidemic control” and identifying several programmatic and management characteristics necessary for achieving sustainability (see Box 1).

To better understand how PEPFAR is defining and approaching sustained epidemic control and progress in PEPFAR countries, we examined PEPFAR’s most recent Country and Regional Operational Plan (COP) Guidance and associated planning level letters (PLLs) sent to country teams. COP guidance describes program investments, requirements, activities, and targets and, as such, is one of the main vehicles for interpreting how PEPFAR seeks to operationalize its goals and objectives in the coming year. PLLs provide specific input to each country team, including notional funding levels and country-specific challenges and objectives to be addressed in their annual COPs. In our analysis of the PLLs, we categorized issues as key challenges only if they were specifically identified in the “challenges” or “priority changes” sections of the PLLs. Based on these documents, and analysis of a range of supplemental data, we assessed country progress toward sustained epidemic control across several dimensions as follows:

• The status of PEPFAR’s epidemic control target and other global HIV targets in PEPFAR countries;
• Progress toward meeting PEPFAR’s 16 minimum program requirements (MPRs), the policies and practices that countries are expected to have place to ensure success;
• The HIV funding landscape, including the size of national HIV budgets and funding composition;
• The status of health system strengthening efforts, including supply chains, laboratory networks, data systems, and the health workforce;
• Progress toward addressing gaps for key and other vulnerable populations and an assessment of the larger political and legal environment that could affect access; and
• Community and civil society inclusion and engagement.

This list is not intended to be exhaustive but, rather, to capture some of the main elements that are key to sustained epidemic control, as identified by PEPFAR and other global stakeholders. We focused our analysis on the 25 countries required to prepare COPs in 2022.¹ 

Findings

Status of Epidemic Control and Global HIV Targets in COP Countries

Epidemiologic measures, including PEPFAR’s epidemic control target, are key elements of sustained control. We looked across COP countries to describe their HIV epidemics and assess their status toward epidemic control and other global HIV targets.

• The 25 COP countries are home to almost two-thirds (65% or 24.5 million) of all people living with HIV globally and include some of the highest prevalence countries in the world. Most are in sub-Saharan Africa (21 of 25); the others are in Latin America and the Caribbean (2), Asia (1), and Eastern Europe and Eurasia (1). Adult HIV prevalence in these countries ranges from 0.3% (in Vietnam) to 27.1% (in Eswatini), with four countries having prevalence rates exceeding 15% (South Africa, Botswana, Lesotho, and Eswatini). See Figure 1.
• The majority of COP countries (16 of 25) are at, or near, epidemic control, as defined by PEPFAR. Twelve COP countries have reached epidemic control (new infections and deaths are low and declining, and new HIV infections are below the total number of deaths from all causes among HIV-infected individuals), while four countries are near that point (new infections and deaths are low and declining, but new infections are not yet lower than deaths). The remaining nine countries are not yet near epidemic control (infections and deaths remain high, and new infections are not lower than deaths).²  See Figure 1.
• COP countries range on their progress toward global viral suppression targets, with a third having reached the global target set for 2020. Across COP countries, the share of people with HIV who are virally suppressed ranges from 16% (in South Sudan) to 93% in Eswatini. In twelve countries, two-thirds or more are virally suppressed, including eight that have reached or exceeded the UNAIDS 73% viral load suppression target originally set for achievement by 2020. One country (Eswatini) has already surpassed the UNAIDS 86% viral load suppression target for achievement by 2025. See Figure 1.

Progress Toward Minimum Program Requirements

Minimum program requirements (MPRs) set by PEPFAR are considered essential policies and practices that must be in place in order to ensure the success of the program, including progress toward reaching and sustaining epidemic control. As stated in the current COP guidance, “evidence demonstrates that lack of any one of these policies/practices significantly undermines progress toward reaching and sustaining epidemic control and results in inefficient and ineffective programs.” There are currently 16 MPRs, including one that was added this year (see Box 2).

We looked at the status of progress toward the 16 MPRs in PEPFAR COP countries, based on what was reported by countries in the PLLs (although specific criteria used for measuring progress were not provided in these documents).

• While progress toward meeting MPRs is underway, no COP country has completed all 16. Only four countries (Zambia, Malawi, Zimbabwe, and Kenya) have completed more than half of the MPRs, with Kenya having completed the most (12). The average number completed is five. Eleven countries have completed a quarter or less. Completion rates ranges from 6% to 75%. See Figure 2.
• Certain MPRs have higher completion rates, with implementation of test & start and elimination of user fees at the top, while increased domestic funding from partner governments is at the bottom. Most countries (19, or 76%) have adopted and implemented test & start efforts,³  sixteen (64%) have eliminated user fees,⁴  and fourteen (61%) have aligned their services for orphans and vulnerable children (OVC) with PEPFAR standards.⁵  On the other end of the spectrum, only three countries have met the MPR to scale up case surveillance and unique patient identifiers, and no country has yet met the requirement to demonstrate that it is assuming greater responsibility for its HIV response including “demonstrable evidence of year after year” increased domestic resources. For the new MPR introduced this year, focused on demonstrating that there is progress toward advancing equity, reducing stigma and discrimination, and promoting human rights, three countries reported that they have completed this measure. See Figure 3.

See Appendix for more detail.

HIV Funding Landscapes & Sustainable Financing

Financing will be a central component of sustained epidemic control. To that end, we examined the funding landscapes in COP countries, looking at the size of national HIV budgets, funding sources (including the extent to which COP countries rely on external financing), the share of resources provided to local partners, and the larger economic environment.

• National HIV budgets in COP countries vary significantly in size and in funding per person living with HIV. National HIV budgets, from all sources, range from $35.0 million in Burundi to $2.4 billion in South Africa in 2020. HIV funding per person living with HIV ranges from $147 in Angola to $1,003 in Haiti (the average is $446). See Figures 4 and 5.
• Across COP countries, PEPFAR accounts for the largest share of national HIV budgets (46%). The next largest share is domestic governments (29%), followed by the Global Fund to Fight AIDS, Tuberculosis and Malaria (22%). PEPFAR funding ranges from less than a fifth of the HIV budget in Angola (13%) to three-quarters in Zambia (75%). See Figure 4.
• Most COP countries are dependent on external financing for their HIV response. In 19 countries, donors provided the majority of HIV funding in 2020, including 10 in which PEPFAR alone provided most funding. Only six countries (Angola, Botswana, Dominican Republic, Namibia, South Africa, and Vietnam) financed the majority of their own HIV response. In 17 COP countries, the country government contribution accounts for less than a quarter of the national HIV budget. As mentioned above, no COP country has yet met the MPR to demonstrate increased domestic resources for HIV from the country government. See Figure 4.
• In FY 2022, only six COP countries have met or exceeded PEPFAR’s goal to channel 70% of new PEPFAR funding to local partners, a goal intended to support country ownership and local capacity building. The six are Botswana and Uganda (75%), South Africa (76%), Nigeria (77%), and Kenya and Rwanda (90%). The majority of COP countries (14) have directed less than half of new funding to local partners. Overall, 55% of new funding across COP countries is being channeled to local partners, ranging from 2% in South Sudan to 90% in Kenya and Rwanda. See Figure 6.

Health Systems Strengthening

One of the main goals of the COP process this year is to “build enduring capabilities” including “resilient and capacitated country health systems.” While standardized country-level data on health systems are not readily available, we looked at how the PLLs address and assess health system strengthening in COP countries, focusing specifically on key challenges or strategic priorities raised regarding supply chains, laboratory networks, data systems, and the health workforce. We also looked at how the PLLs address sustainability planning.

• Supply Chains: In half of COP countries, PLLs identify supply chain issues as key challenges, ranging from challenges with data systems to commodity stockouts. In ten countries,⁶  including Cameroon, Kenya, and Zimbabwe, persistent stockouts and commodity shortages, often influenced by the COVID-19 pandemic and inadequate funding for supply chain systems, are raised as key challenges.⁷  Additionally, in other countries, such as for Uganda and Namibia, the governments are called upon to take greater ownership of their supply chain systems and reduce their dependency on PEPFAR as either key challenges or elsewhere in the PLLs. Other issues identified broadly in the PLLs are allocating sufficient resources for procurement and planning for safe collection and disposal of pharmaceutical waste.
• Laboratory Networks: Building stronger laboratory networks and systems is raised in eight countries as a key challenge.⁸  Equipment breakdowns and delays in testing results were also mentioned in seven countries as key challenges.⁹  Another key challenge cited is limited laboratory capacity, especially as testing networks were utilized to address the COVID-19 pandemic. For example, the Burundi PLL notes that laboratory reagents were used for both HIV and COVID-19 testing, constraining the country’s testing capacity. For the related MPR, diagnostic network optimization, seven countries report completion, and 17 report it as “in process.”
• Data Systems: Improving data systems, such as to strengthen the ability of country governments to monitor epidemiological data and assess patient-level outcomes, was mentioned in nearly all COP countries as a key challenge. Various data quality and availability issues were identified in country PLLs, including interoperability - the ability to exchange and use information - between facilities (seven countries);¹⁰  directives to implement or improve electronic medical records (six countries);¹¹  and improved population-based estimates (seven countries).¹²  For example, the Burundi PLL identifies the lack of interoperability between data systems as well as delays in data availability as a key challenge. The Kenya PLL identifies the lack of unique identifiers for patient-level data as a key challenge that may result in Kenya’s program having high levels of patient transfers and re-tests. Only three countries report completing the related MPR, which addresses implementing unique patient identifiers and scale-up of case surveillance.
• Health Workforce: Most countries’ PLLs highlight rightsizing, aligning, or integrating human resources for health (HRH) in coordination with country governments and other stakeholders as a key challenge. For example, the Malawi PLL recommends “prioritizing the judicious allocation of HRH with” the country government and directs the country team to “identify HRH requirements based on expected future adjustments to maintain HIV service delivery and utilize this to inform transition or absorption of PEPFAR-supported staff.” Likewise, the Eswatini PLL recommends aligning and merging PEPFAR human resources support with the country government’s health care workforce architecture. There are also recommendations in many PLLs, especially for countries at or nearing epidemic control (such as the Kenya and Zimbabwe PLLs), to review data to ensure optimal and efficient staffing, to plan for lesser reliance on a PEPFAR-supported health workforce in the future, and to facilitate discussion of the workforce with the government or alignment of support with the Global Fund. Other PLLs highlight HRH challenges related to limited capacity. For example, the South Sudan PLL discusses human resource capacity limitations as a key challenge, while the Ethiopia PLL identifies the displacement and loss of health care workers due to conflict in certain regions of the country as a key challenge. OGAC reports that PEPFAR teams have collected data through a new HRH inventory for each country, which may help inform these efforts going forward, and PLLs for seven countries¹³  specifically mention this inventory in a technical directive and direct country teams to review these data to ensure optimal staffing levels.
• In six COP countries,¹⁴  the PLLs specifically call for the development of sustainability or transformation plans. For instance, Rwanda’s PLL asks for the program, along with the country government, to begin developing a framework for local entities to assume greater responsibility for its HIV services, while the Botswana PLL says the country team should “develop a plan with the GoB [Government of Botswana], multilaterals, and local partners that establishes milestones and a path for a staged shift in responsibilities.” Similarly, the Eswatini PLL directs the country team to “begin formal discussions and mapping of [the] pathway to sustainability of the national HIV response” and to “disarticulate technical and programmatic sustainability from financial.”
• Other PLLs address sustainability issues and planning in a broader manner. For example, the Dominican Republic PLL identifies building political will, removing barriers to services, and prioritizing HIV services as among its key challenges, while the Kenya PLL says, “Now that Kenya overall is at epidemic control, the program approach should be examined to: 1) center the strategy around sustainability in every aspect of the program and 2) tailor the strategy to reach the last mile at the county-level and for all populations.” Likewise, the Zambia PLL recommends that the country team “work with the Government of Zambia to ensure alignment in the vision to jointly sustain impact on the HIV epidemic” and it also suggests that the country team should “support Zambia’s public health approach and platform to strengthen primary care.”

Key and Other Vulnerable Populations & Stigma and Discrimination

PEPFAR has placed increasing emphasis on the importance of addressing structural barriers (including in the legal and policy environment), focusing on equity and human rights challenges for key populations (sex workers, gay men and other men who have sex with men, transgender people, people who inject drugs, and people in prisons), and closing the gaps for other vulnerable populations (including women and girls, and young people). These are major themes in this year’s COP guidance, including a new gender equality section and a new MPR. We analyzed the PLLs to assess key challenges identified in countries and also looked at the legal and policy environments in COP countries.

• The PLLs frequently identify addressing gaps for children and adolescent girls and young women (AGYW) as a key challenge, with nearly all (22)¹⁵  highlighting prevention, testing, and treatment to reach these groups. For example, the Botswana PLL identifies “persistent gaps in case-finding, linkage, treatment, and viral load coverage/suppression for pediatric and adolescent people living with HIV,” the Malawi PLL identifies maintaining enrollment in DREAMS as well as case finding and treatment efforts for adolescents, and the Mozambique PLL identifies similar challenges for children and youth treatment as well as prevention efforts for AGYW. Gender-based violence is mentioned in 4 PLLs,¹⁶  and it is highlighted as an important component of DREAMS programming in some cases. Though less of a focus, some PLLs highlight other groups of women, including pregnant and breastfeeding women (e.g., Cameroon, Ethiopia, and Tanzania) and adult women (e.g., the Democratic Republic of the Congo, Haiti, and Mozambique).
• More than half of the PLLs highlight addressing gaps for key populations as a key issue, and nearly all have a technical directive focused on improving and expanding data in this area. For example, Uganda’s PLL specifically calls for addressing barriers to HIV prevention and treatment services among key populations, such as through community-based medication distribution and support services at drop-in centers. Additionally, nearly all (23)¹⁷  of the PLLs identify the lack of robust data on key populations and services provided to them as a barrier, impeding the ability to improve and scale up key population programming. These countries are directed to describe during the COP planning meetings how they will improve their approach to strengthening key population data systems and analyses and addressing structural and other barriers to accelerating services focused on key populations.
• As the MPR related to equity, reducing stigma and discrimination, and promoting human rights is new this year, most countries (20) report it is still “in process,” and only a few specifically mention stigma and discrimination or human rights as key issues. Among the few that do are Uganda’s PLL, which flags increasing concern about stigma, discrimination, and human rights violations and addressing these barriers. Similarly, Cote d’Ivoire’s PLL mentions stigma remains high and that barriers must be addressed in order for vulnerable populations to access key services. The PLLs of three COP countries (Cote d’Ivoire, Mozambique, and South Africa) report they have been selected for participation in a stigma and discrimination pilot effort, known as the focal countries’ collaboration, that involves the Global Fund, UNAIDS, and PEPFAR. The collaboration is intended to help countries to address stigma and discrimination over three to five years and will support these countries to “focus on removal of societal, including legal barriers (specifically stigma, discrimination, punitive policy environments, and violence) that limit access to or utilization of HIV services.”
• Many COP countries have legal and policy barriers that may present challenges to reaching and supporting key populations in accessing HIV services. This is particularly notable in the case of sex work, which is criminalized in most COP countries (21). HIV transmission is criminalized in more than half (14), and drug use and possession as well as same-sex sexual acts are criminalized in almost half of the COP countries (11 each). See Figure 7.

Community and Civil Society

PEPFAR’s inclusion of community and civil society has a long history and sets it apart from most other bilateral health programs. This year’s COP guidance calls on countries to include community and civil society in every stage of programming and planning to help promote sustainability as well as accountability. We examined how the COP PLLs addressed engagement of civil society and also looked at the legal and policy environment in COP countries regarding civil society participation.

• The importance of engaging CSOs in order to improve PEPFAR programming, with particular emphasis on the role of community-led monitoring (CLM), is mentioned in all PLLs. This includes engaging with CSOs throughout the PEPFAR planning process (both during and outside the COP) and implementation. For example, some countries’ PLLs, such as for the Dominican Republic, emphasize the importance of defining the role of CSOs (as well as other stakeholders) in national strategic plans or other efforts, while others, such as for Cote d’Ivoire, direct PEPFAR programs to engage with CSOs to ensure sharing of best practices to improve alignment of health service delivery. Further, several PLLs, encourage programs to utilize CSOs to improve treatment continuity among patients as they help track and return them to care, like that of South Sudan, or to track and improve accountability for outcomes among pediatric patients, like that of Angola. As required, all PLLs include a section focused on CLM that calls for, among other things, the PEPFAR country program to support CLM funding.
• The legal and policy landscape for civil society inclusion varies in COP countries, and there are limits in some cases. Fifteen COP countries allow for one or both of the following: 1) CSOs may freely register, seek funding, and operate, and 2) there is a mechanism for the government to finance them to provide health services.¹⁸  Of these 15 countries, only three – Botswana, the Dominican Republic, and South Africa – have adopted both policies, while 12 have adopted one policy only. The remaining nine have not adopted either policy. See Figure 8.

Conclusion

This analysis examines PEPFAR’s current vision for achieving sustained epidemic control, a priority focus for the program, by providing an initial look at how PEPFAR is currently defining and approaching sustained epidemic control at the country level. As it finds, the picture is multi-layered, and there is significant variation across countries and across several dimensions that are important for sustainability, including epidemiological (PEPFAR’s epidemic control target) but also financial and structural. It finds that all countries are making progress toward sustainability, with 12 having reached epidemic control and four making significant progress on the MPRs, reporting they completed at least half. Still, progress varies, and there are some areas, such as increasing domestic funding from partner governments, where progress is particularly lagging. In that area specifically, there may be new challenges ahead, as many PEPFAR countries continue to experience the economic effects of COVID-19, and there are rising inflationary pressures, which may limit their ability to provide additional domestic resources. Moreover, in many PEPFAR countries, there are structural barriers affecting access for key populations, which, while identified by PEPFAR as important for countries to address, may be especially hard to ameliorate. Going forward, better understanding how these markers of sustainability, such as epidemic control status, financial dependency, and MPR status, fit together may help to paint a clearer narrative of country progress. Some additional information about PEPFAR’s approach and progress toward sustained epidemic control may be forthcoming, as PEPFAR is expected to release the country team-prepared COPs, PEPFAR’s next five-year strategy, and multiyear sustainability roadmaps for many PEPFAR countries.¹⁹  In addition, discussions about PEPFAR’s next reauthorization are likely to begin later this year.

1. Although PEPFAR supports activities in more than 50 countries, the other countries fall under Regional Operational Plans (ROPs), which were not included in this analysis. ↩︎
2. We simplified PEPFAR’s five category approach for epidemic control status used in this year’s COP guidance into three categories by classifying countries “at epidemic control with at least 73% viral load suppression” and countries “at epidemic control without at least 73% viral load suppression” as “at epidemic control”; maintaining PEPFAR’s “near epidemic control” category; and classifying countries “not at epidemic control but declining infections/mortality” and countries “not at epidemic control with increasing infections/mortality as “not at epidemic control.” ↩︎
3. Test and start is a policy in which at least 95% of those who are identified as HIV positive are linked to antiretroviral treatment immediately upon testing. ↩︎
4. This MPR relates to countries’ adoption and implementation of policies that eliminate fees at the point of care for direct HIV services and related services, such as antenatal care, TB, and cervical cancer in the public sector. ↩︎
5. PEPFAR standards for the OVC program include facilitating testing for all children at risk for HIV, linking children living with HIV to treatment and case management, and reducing risk of sexual violence. The share of COP countries does not include COP countries where this OVC MPR is not applicable, namely, Angola and Vietnam. ↩︎
6. These include Angola, Burundi, Cameroon, Cote d’Ivoire, the Dominican Republic, Kenya, Malawi, Tanzania, Ukraine, and Zimbabwe. ↩︎
7. Additional COP countries may not cite commodity stockout or shortages issues as challenges or priority changes but may mention it elsewhere such as in explanations for not completing certain MPRs (e.g., Eswatini cites stockouts of antiretrovirals as a barrier to completing the MPR related to differentiated service delivery). ↩︎
8. These include Burundi, Democratic Republic of the Congo, Eswatini, Haiti, Angola, Mozambique, Nigeria, and Tanzania. ↩︎
9. These include Burundi, Cote d’Ivoire, Mozambique, Nigeria, Tanzania, Zambia, and Zimbabwe. Additional COP countries may not cite laboratory equipment breakdowns or delays in testing results as major challenges or key issues but rather as explanations for not completing certain MPRs. For example, in Haiti, equipment failures and increased turnaround times for viral load samples, among other issues, are cited as barriers to completing the MPR related to diagnostic network optimization. ↩︎
10. These include Botswana, Burundi, Cote d’Ivoire, Lesotho, Mozambique, Uganda, and Vietnam. Additional countries, such as Eswatini and South Africa, mention interoperability in their MPR explanations. ↩︎
11. These include Botswana, Dominican Republic, Lesotho, Malawi, Uganda, and Zambia. Additional countries, such as Cameroon and Uganda, mention this in their MPR explanations. ↩︎
12. These include the Democratic Republic of the Congo, the Dominican Republic, Lesotho, Mozambique, Nigeria, South Africa, and Uganda. ↩︎
13. These include those of Cote d’Ivoire, Lesotho, Malawi, Namibia, South Africa, Uganda, and Zimbabwe. ↩︎
14. These include those of Botswana, Eswatini, Lesotho, Rwanda, Tanzania, and Uganda. ↩︎
15. These include Angola, Botswana, Burundi, Cameroon, Cote d’Ivoire, the Democratic Republic of the Congo, the Dominican Republic, Eswatini, Ethiopia, Haiti, Kenya, Lesotho, Malawi, Mozambique, Nigeria, Rwanda, South Africa, South Sudan, Tanzania, Uganda, Zambia, and Zimbabwe. ↩︎
16. These include the Cote d’Ivoire, Eswatini, Ethiopia, and Haiti PLLs. ↩︎
17. These include Botswana, Burundi, Cameroon, Cote d’Ivoire, the Democratic Republic of the Congo, Eswatini, Ethiopia, Haiti, Kenya, Lesotho, Malawi, Mozambique, Namibia, Nigeria, Rwanda, South Africa, South Sudan, Tanzania, Uganda, Ukraine, Vietnam, Zambia, and Zimbabwe. In the case of the Dominican Republic, its PLL discusses the lack of robust data on focus clients (“FC”) services, which refers to “migrants of Haitian origin living in the Dominican Republic and their descendants.” ↩︎
18. KFF analysis of data from the HIV Policy Lab, “S10 - Civil society,” accessed April 25, 2022, https://www.hivpolicylab.org/policy/S10. ↩︎
19. Key among these will be six COP countries (Botswana, Eswatini, Kenya, Lesotho, Namibia, and Uganda) identified as “Sustaining Impact Operating Units (OUs)” during the 2022 COP planning process that are expected to release sustainability roadmaps later this year. ↩︎

Key Findings:

• In the wake of the Supreme Court decision on Dobbs v. Jackson Women’s Health Center to overturn Roe, abortion access has become salient among key voting groups, including the population most impacted by abortion restrictions – women between the ages of 18 and 49. Among this population, there has been a fourteen percentage point increase in the share who say abortion will be “very important” to their 2022 midterm vote (59% in February to 73% in July). In addition, six in ten women voters between 18 and 49 now say they are “more motivated” to vote because of the Supreme Court’s decision (up 19 percentage points from May when the question was asked about a scenario in which Roe was overturned based on a leaked draft opinion). The vast majority (88%) of the more motivated group of women voters between 18 and 49 say they plan on voting for candidates who will protect access to abortions.
• While abortion is a motivating issue for some groups of voters, the issue still trails inflation and gas prices (74%) as the top voting issue overall. Abortion ranks alongside other top tier issues include gun control (57%), an issue on which Congress just recently passed legislation, and health care and prescription drug costs (55%), an issue that has been debated for the past several months and has gotten recent attention by Democratic lawmakers. With inflation and gas prices as the top issue overall, and for most voting groups, it is perhaps unsurprising that the share of adults who are worried about affording household expenses has increased since the beginning of the pandemic and over the past four months in particular, with the largest increases in affording basic living expenses like food (up 14 percentage points), utilities (up 12 percentage points), and mortgage or rent (up 8 percentage points). In the past two years, the share who are worried about being able to afford gas or other transportation costs has nearly doubled, growing from 40% in February 2020 to 76% in July 2022.
• Two-thirds of the public (65%) disapprove of the Supreme Court decision on Dobbs v. Jackson Women’s Health Center that overturned Roe and allows individual states to decide the legality of abortion access within each state. In addition, most adults (61%) – including majorities of Democrats, independents, women between the ages of 18 and 49, and about half of those living in states with pre-Roe abortion bans or trigger laws – say want the laws in their state to guarantee access to abortion. About a quarter of the public, including more than half of Republicans (54%) say they want the laws in their states to ban abortions.

In Wake Of Supreme Court Decision, Looming Uncertainty About The Legality of Abortion Access In States

Less than one month after the U.S. Supreme Court overturned Roe v. Wade, nearly eight in ten (78%) U.S. adults are aware of the decision and only a small share (5%) incorrectly say that Roe v. Wade is still law. Still, about one in five (18%) U.S. adults say they are not sure whether the 1973 ruling that established a woman’s constitutional right to an abortion is still the law of the land, including 18% of women ages 18-49, the group most directly affected by the ruling. Awareness of the Dobbs decision is high among Democrats, Republicans, and independents but there is a difference by age. Young adults ages 18-29, who have lived their whole lives until recently with a constitutional right to abortion, are the group most likely to say they are “not sure” whether abortion access is still guaranteed: about three in ten (27%) say they are not sure, and a small share (6%) from this group also incorrectly say Roe is still in effect.

Groups previous KFF research has identified as disproportionately impacted by the overturning of Roe are the most likely to say they are not sure if a woman still has a constitutional right to an abortion. Nearly four in ten Hispanic adults (38%) and nearly three in ten (27%) Black adults say they are not sure about the status of Roe, compared to about one in ten (11%) White adults. Similarly, adults with incomes of less than $40,000 a year are more likely to say they are not sure (32%) that Roe v. Wade has been overturned by the Supreme Court than those with higher household incomes (8%), There is a similar gap between those with (5%) and without a college degree (24%) who say they are not sure. When it comes to incorrectly stating that Roe is still the law of the land, there are no significant differences among income and education groups.

While a large majority of the public is aware that Roe v. Wade has been overturned, the confusion over the ruling is further reflected in people’s lack of certainty over whether abortion is currently or will soon be banned in their state. About one-fifth of people living in states with trigger laws or pre-abortion bans say they are “not sure” whether abortion is currently or will be banned, or not, in their state. This is similar to the share of those living in states with abortion protections who also say they are “not sure” about whether abortion will be allowed in their states. At least seven in ten are aware that either abortion is or currently will be banned in their state (73%) or that abortion will not be banned in their state (72%).

Most Disapprove Of Supreme Court Decision, Want States To pAss Laws Guaranteeing Access To Abortions

Two-thirds of the public disapprove of the Supreme Court decision overturning Roe v. Wade and giving states the ability to determine the legality of abortion within each state. Partisanship plays a strong role in attitudes, with nine in ten Democrats and seven in ten (72%) independents saying they disapprove of the Supreme Court’s decision, while seven in ten (71%) Republicans approve. Majorities across gender and racial and ethnic groups also disapprove of the Supreme Court’s decision.

Now that abortion access is up to state law, six in ten (61%) U.S. adults say they want the laws in their state to guarantee abortion access. This is more than twice the share who say they want the laws in their state to ban abortion (25%). Large majorities of Democrats (83%), independents (65%), and women ages 18-49 (68%) say they want their state to pass laws guaranteeing access to abortions. On the other hand, more than half of Republicans (54%) say they want the laws in their state to ban abortion, while about a third (37%) say they want the laws in their state to guarantee access.

Half (51%) of those living in states with abortion bans or trigger laws in place say they want their state to guarantee abortion access, while one-third (32%) say they want abortions to be banned. In states where abortion access is protected, seven in ten (68%) support laws guaranteeing abortion access and one in five (22%) want the laws in their state to ban abortion. Overall, about one in eight (13%) say they don’t want their state to pass laws banning abortion nor do they want their state to pass laws guaranteeing abortion access.

Voting Issues In the Midterm Election

Inflation and rising gas prices take the top spot for voters when thinking about their midterm vote this fall, with three-quarters (74%) of registered voters saying inflation and gas prices are “very important” to their midterm vote. Abortion access (55%) is clustered with two other issues making up a second tier, including gun violence (57%) and health care and prescription drug costs (55%). Less than half of voters rank the other issues as “very important,” including the federal budget deficit (46%), climate change (39%), the COVID-19 pandemic (33%), and the war in Ukraine (28%).

Among all the issues polled, gun violence and abortion access rank highest among Democratic voters, with about eight in ten saying each is “very important” to their vote. Nearly nine in ten (89%) Republican voters say inflation and gas prices are “very important” when considering who to vote for this November, 29 percentage points higher than Democrats. Inflation and gas prices are also the top issue for independents, with more than three-fourths (77%) saying it is “very important” to their vote.

Abortion Access As A Voting Issue

Following the release of the Dobbs decision, the importance of abortion access as a midterm voting issue has increased somewhat for voters. In a shift from polling before the Roe decision, a slight majority (55%) say abortion access is important to their vote, up from 46% in February. This increase is especially prevalent among key constituencies: Democrats, Democratic women, and all women voters ages 18 to 49 –  groups that largely want states to guarantee access rather than ban access. In February, half (50%) of Democrats said it was a top issue, but now, about three in four (77%) say so. Similarly, back in February, 55% of Democratic women voters said it was an important issue compared to 82% now. Three in four women of reproductive age also now cite abortion access as a very important issue to their vote, compared to 59% in February before the Dobbs decision.

Although abortion is now a more salient issue among women voters 18-49, like many other groups surveyed, inflation and gas prices also top the list of concerns for this group heading into the midterms, with 76% saying it is very important to their vote. On the other hand, six in ten Republican women voters of all ages said abortion was a “very important” voting issue for them in February, and now 44% say the same about abortion access. This change may reflect that the overturn of Roe makes “abortion” no longer a pressing issue for this group of voters, or that this group may not view “abortion access” as a very important issue.

Majorities of women of reproductive age, across partisans, say abortion is important to their vote with at least half saying it is “very important.” More than eight in ten (84%) Democratic women between the ages of 18 and 49 say abortion access is “very important” in deciding who they will vote in the fall, as do nearly three-fourths of independent women voters of the same age group. Access to abortion ranks lower for Republican women under 50, but still half say the issue is “very important.” While the issue certainly resonates more with women, majorities of all voters 18-49 across partisans say abortion access will be at least somewhat important to their midterm vote.

Overall, about half of voters (54%) say the Supreme Court decision overturning Roe v. Wade has made them “more likely” to consider a candidate’s position on abortion when deciding which candidate to vote for while 3% say it has made them “less likely” and four in ten (42%) say it has not made a difference. Large majorities of Democratic voters (72%), Democratic women voters (72%), and women voters between the ages of 18 and 49 (64%) – all groups of which large majorities disapprove of the Supreme Court’s decision – say the decision has made them “more likely” to consider a candidate’s position on abortion.

The latest KFF poll finds a slight uptick in the share of voters who say the decision has made them “more motivated” to vote, compared to a similar question asked prior to the final decision (but after a draft was leaked) that asked whether they would be more motivated if Roe was overturned. Forty-three percent of voters now say the Supreme Court decision overturning Roe v. Wade has made them “more motivated” to vote (compared to 37% back in May). About half (53%) continue to say the decision has “not made a difference” in their motivation to vote. There are large upticks are among Democratic voters (64% compared to 55%), and there is a nearly twenty percentage point increase among women voters ages 18-49. Six in ten (61%) women voters 18-49 say the decision has made them “more motivated” to vote, compared to four in ten (42%) back in May.

The Supreme Court decision did not have a significant impact on voters’ preference on candidates they plan to vote for in the midterm elections. Eight in ten Democratic voters (83%) say they plan on voting for a candidate who wants to protect access to abortion (similar to 79% in May) as do 56% of independent voters (54% in May), while half of Republicans voters (51%) say they plan on voting for a candidate who wants to limit abortion access (56% in May). The vast majority of all voters who say they are more motivated to vote (82%) as well as women voters 18-49 who are more motivated (88%) say they plan to vote for candidates who will protect abortion access. The share of women 18-49 who say they plan on voting for a candidate who wants to protect abortion access increased 10 percentage points, from 60% to 70%.

How Do Republican Women Feel About Supreme Court Decision And Abortion Access?

The recent Supreme Court decision and state actions on abortion restrictions have split Republican women into two groups: a larger group who support the Court’s decision and want abortion to be restricted, and a smaller, yet substantial, share who disapprove of the decision to overturn Roe and want their states to guarantee access to abortion.

Two-thirds of Republican women approve of the Supreme Court’s decision overturning Roe and about half of Republican women (51%) say they want laws in their states to ban abortion. On the other hand, one-third of Republican women disapprove of the Court’s decision and four in ten (41%) say they want the laws in their states to guarantee access to abortion.

About one in four (23%) Republican women voters say they are now more motivated to vote in the 2022 midterm election which is similar to the share (25%) who say they plan on voting for a candidate who wants to protect access to abortion. More than half (56%) of Republican women voters say they plan on voting for a candidate who wants to limit access to abortions and 17% say a candidate’s position on abortion does not make a difference in their vote.

 

Cost Of Gasoline Tops Public’s Economic Worries, Areas For Desired Government Action

As concerns about inflation and gas prices top voters’ priorities for the 2022 midterm election, the majority of adults in the U.S. say they are at least somewhat worried about affording a variety of household expenses. Three in four adults (76%) say they are either “very worried” or “somewhat worried” about being able to afford gas and other transportation costs. More than six in ten adults also say they are “very worried” or “somewhat worried” about affording unexpected medical bills (64%), their monthly utilities like electricity and heat (62%), and food (61%). Half say they are worried about affording their mortgage or rent (51%), and four in ten or more are worried about affording health care expenses like their health insurance deductibles (48%), prescription drugs (46%), and health insurance premiums (40%).

The share of adults who are worried about affording household expenses has increased since the beginning of the pandemic and over the past four months in particular, with the largest increases in affording basic living expenses like food (up 14 percentage points), utilities (up 12 percentage points), and mortgage or rent (up 8 percentage points). In the past two years, the share who are worried about being able to afford gas or other transportation costs has nearly doubled, growing from 40% in February 2020 to 76% in July 2022.

When asked to choose the area of the economy where they most want President Biden and Congress to take action, one in three adults (33%) say they want government action to address the rising cost of gas, while one in four prioritize addressing the rising cost of housing and rent (25%), and a similar share want federal attention on rising food prices (23%). Although gasoline costs are a top priority for adults across income groups, housing and food costs are more likely to be prioritized by lower-income households than those with higher incomes. More than a quarter of adults from households with less than a $40,000 annual income, as well as those in households earning between $40,000 and $89,999, say they want the federal government to address housing costs (31% and 28%), and at least one in five want federal attention on the cost of food (27% and 21%).

Republicans are about twice as likely as Democrats to say that the federal government should address the rising cost of gas (53% of Republicans vs. 23% of Democrats), while Democrats are twice as likely as Republicans to want Biden and Congress to focus on rising housing and rent costs (28% of Democrats vs. 13% of Republicans) and five times as likely to prioritize lowering the cost of health insurance (15% vs. 3%).

This KFF Health Tracking Poll/COVID-19 Vaccine Monitor Poll was designed and analyzed by public opinion researchers at the Kaiser Family Foundation (KFF). The survey was conducted July 7 - 17, 2022, online and by telephone among a nationally representative sample of 1,847 U.S. adults. Interviews were conducted in English (n=1760) and in Spanish (n=87). The sample includes 1,585 adults reached through the SSRS Opinion Panel either online (n=1545) or over the phone (n=40), including an oversample of parents with a child under age 5 (n=471) and parents with a child in another age group (n=757). The SSRS Opinion Panel is a nationally representative probability-based panel where panel members are recruited randomly in one of two ways: (a) Through invitations mailed to respondents randomly sampled from an Address-Based Sample (ABS) provided by Marketing Systems Groups (MSG) through the U.S. Postal Service’s Computerized Delivery Sequence (CDS); (b) from a dual-frame random digit dial (RDD) sample provided by MSG. For the online panel component, invitations were sent to panel members by email followed by up to 4 reminder emails.

Another 250 interviews were conducted from a random digit dial telephone sample of prepaid cell phone numbers obtained through MSG. Phone numbers used for the prepaid cell phone component were randomly generated from a cell phone sampling frame with disproportionate stratification aimed at reaching Hispanic and non-Hispanic Black respondents. Stratification was based on incidence of the race/ethnicity groups within each frame. The sample also included 12 respondents reached by calling back respondents that had previously completed an interview on the KFF Tracking poll.

The combined cell phone and panel samples were weighted to match the sample’s demographics to the national U.S. adult population using data from the Census Bureau’s 2021 Current Population Survey (CPS). Weighting parameters included sex, age, education, race/ethnicity, region, and education. The sample was also weighted to match patterns of civic engagement from the September 2017 Volunteering and Civic Life Supplement data from the CPS. The sample was also weighted to match frequency of internet use from the National Public Opinion Reference Survey (NPORS) for Pew Research Center.  The weights take into account differences in the probability of selection for each sample type (prepaid cell phone and panel). This includes adjustment for the sample design and geographic stratification of the cell phone sample, within household probability of selection, and the design of the panel-recruitment procedure.

The margin of sampling error including the design effect for the full sample is plus or minus 4 percentage points. Numbers of respondents and margins of sampling error for key subgroups are shown in the table below. Sample sizes and margins of sampling error for other subgroups may be higher and are available by request. Sampling error is only one of many potential sources of error and there may be other unmeasured error in this or any other public opinion poll. KFF public opinion and survey research is a charter member of the Transparency Initiative of the American Association for Public Opinion Research.