In January 2025, President-elect Trump will be sworn in with Republican control of Congress and a conservative majority in the Supreme Court, which will potentially provide broad latitude for the adoption of a conservative agenda. Federal policymakers have many levers to make major changes that will shape the access and availability of reproductive health including abortion, contraception and maternity care in ways that could affect the whole nation, even in states where the right to reproductive health care is enshrined by the state constitution. In addition to enacting legislation, presidential executive orders, litigation, regulatory actions, and nominations to the judiciary, cabinet, and other leadership position appointments will all affect policy.

This brief reviews some of the possible actions of the incoming Trump administration and new Congress based on campaign statements, policies implemented by the first Trump administration, and proposals forwarded by allied conservative think tanks and antiabortion advocacy groups. While President-elect Trump has generally said in recent comments that he would leave abortion policy up to states, his statements at times leave open the possibility for federal changes, and he will likely come under pressure from outside groups and Congress to restrict abortion access.

Abortion

Trump takes credit for overturning Roe and has said that states should set their own abortion policy, including banning abortion. As President, he could support additional policies that would result in limits to abortion access in all states, even without enacting a national abortion ban.

Currently, 13 states ban abortion with very few exceptions and several other states limit abortion availability to early in pregnancy. While Trump has said that he would not sign a federal bill banning abortion in all states, there are many levers that an anti-abortion administration can use to severely limit abortion access. Project 2025 and other anti-abortion organizations and policymakers have outlined a clear agenda, with the goal of banning or severely restricting abortion, especially targeting medication abortion given its dominance as a method of abortion and the current FDA policy that allows for the mailing of abortion pills without the need for any in person contact with a clinician.

Abortion Access

Trump has given conflicting statements about whether he would support a national ban that would apply in all states. At times, he has suggested that he would support a nationwide ban at 15 or 16 weeks gestation, but also has said that he would not sign a national ban. He has said that he believes in exceptions for cases of rape, incest, and life of the mother, but has not forwarded a stance on health exceptions. In his recent comments, Trump has said he would leave abortion access up to states.

Enforcing the Comstock Act

Medication abortion pills account for the majority of abortions in the U.S. The Comstock Act is an 1873 anti-vice law banning the mailing of “obscene” matter and articles used to produce abortion. The Biden administration’s Department of Justice determined that the Act only applies when the sender intends for material or drug to be used for an illegal abortion, and because there are legal uses of abortion drugs in every state including to save the life of the pregnant person, there is no way to determine the intent of the sender. However, this analysis does not preclude the Trump administration from interpreting the Comstock Act differently. President-elect Trump’s statements about medication abortion have been inconsistent, at times suggesting he would not block their availability and decline to enforce the Comstock Act. Recently, Trump said he “probably” would not move to restrict medication abortion but added that “things change.” Some Republican leaders, including Vice president-elect Vance and the authors of Project 2025 —the detailed conservative policy treatise that was spearheaded by many former Trump administration leaders – have called for a literal interpretation and enforcement of the Comstock Act to halt the mailing of all abortion medications and supplies to all states. This would impact not only residents of states where abortion is banned or restricted but all states, even those that have a guaranteed right to abortion in their state constitutions.

FDA Review of Mifepristone

The new director of the FDA will have significant influence over drug approvals, restrictions, and the broader agenda and priorities of the FDA. President-elect Trump recently indicated he will probably not restrict access to medication abortion but left room to change his position. Project 2025 and other conservative groups are calling for the FDA to retract its approval of medication abortion pills. Short of reversal, they seek to revert to older FDA protocols and restrictions that would reduce the gestational period for medication abortion pills, prohibit telehealth appointments and access through pharmacies, which were approved after President Biden took office. These issues are at the core of a federal lawsuit against the FDA that has been brought by Republican states, which the Trump administration may not defend and could succeed in front of a conservative Supreme Court.

Project 2025 also calls on the FDA to ease the process for health care providers to report complications resulting from abortion pills to the FDA Adverse Events Reporting System (FAERS). Although it’s not yet clear how the new director will address mifepristone, Trump’s nominee, Dr. Martin Makary, has stated that fetuses feel pain during an abortion between 15 and 22 weeks gestation, despite conclusive evidence by major medical organizations and systematic reviews that find that a human fetus does not have the ability to experience pain at that point in pregnancy.

Pregnancy-Related Emergency Care

Since the Dobbs ruling, there have been numerous cases of deaths and near-death experiences attributed to denials and delays in providing abortion care to people experiencing miscarriages and pregnancy-related emergencies. EMTALA is the federal law that requires hospitals to provide health stabilizing treatment to patients who present to their emergency rooms, and the Biden administration issued guidance reiterating that EMTALA applies to abortion care provided in the cases of pregnancy-related emergencies. The Biden administration defended this policy in an ongoing case, but the Trump administration could withdraw the current guidance and stop defending the Biden administrations’ policy, as recommended by Project 2025, which argues that emergency abortion denials are not a problem.  President-elect Trump has not commented specifically on this issue. While Trump disavowed Project 2025 during the campaign, he has also announced appointments of a number of people tied to the effort since the election.

Coverage under Medicaid and ACA Marketplaces

The Hyde Amendment is a policy attached to the Congressional appropriations bill annually that bars the use of any federal funds for abortion, only allowing exceptions to pay for terminating pregnancies that endanger the life of the pregnant person or that result from rape or incest. While Trump has not spoken about the Hyde Amendment recently, he had earlier pledged to make it permanent law, as advocated by Project 2025. The report also urges policymakers to resurrect an earlier proposed Trump administration policy that would have required enrollees in ACA Marketplace plans to submit two separate payments if they choose a plan that includes abortion coverage.

Data and Research

The Trump administration could exert its influence over research and surveillance on abortion activities across multiple federal agencies. The Project 2025 report addresses abortion-related data collection and research. In particular, the report calls for CDC research on the risks of abortion, abortion survivors, and requiring reporting on the number of abortions from every state (currently voluntary) as a condition of receiving federal Medicaid funds. The plan details the need to collect data on abortion rates across various demographic groups, monitor the number of cases of infants born alive after abortions (which does not happen), abortion harms, and withhold HHS funds from states where abortion remains legal if they do not comply with these requirements. Any new requirement on states as a condition of receiving federal Medicaid funds will likely be challenged in the courts.

The new administration may also curtail scientific research and vaccine development by reinstating a previous Trump administration policy that barred NIH funding for projects that use of tissue and cell lines that are byproducts of abortions. Project 2025 characterizes this as “the destruction of human life” and a major breach of ethics that government should prohibit. It could also be used to build the case for establishing “fetal personhood” arguments that can be used to further embed abortion bans and restrictions.

There are a number of other administrative actions that were passed under President Biden that the Trump administration could revoke, including guidance that reinforced requirements for pharmacies to fulfill their obligation to provide access to reproductive health pharmaceuticals, enforcement of non-discrimination policies for health care providers, and rules that strengthened data privacy to protect those seeking reproductive health care.

Religious Refusals

Trump’s first administration prioritized expanding religious exceptions to the provision or coverage of certain health care services. During his first term, HHS created a Division on Conscience and Religious Freedom and proposed multiple policies that would expand religious exemptions for health care providers and payors. Additionally, CMS invoked the Weldon Amendment and threatened to withhold federal Medicaid dollars from California because of the state’s policy requiring abortion benefits in all state-regulated health plans. The amendment is attached annually to a federal spending bill, and bars HHS funds from going to programs or state and local governments that “discriminate” against plans, providers, or clinicians that refuse to provide, offer referrals for, pay for, or cover abortions.

Misinformation

Short of formally implementing policies, President-elect Trump and his advisors can sow confusion by the information and misinformation that they spread. For example, Trump has repeatedly stated that Democrats support abortion up to and after birth, which is false. Similarly, members of his circle of health care advisors have stated that abortion is “murder,” fetuses can feel pain, and suggested that abortion can cause cancer. All of these statements have been refuted by scientific and medical groups.

Contraception

President-elect Trump could reinstate policies that he implemented in his first term that resulted in the reduced availability of contraceptive care to low-income people through regulatory action that targeted the Title X federal family planning program. The Republican party platform states support for “access to birth control,” but a federal the Right to Contraception Act failed to pass Congress this year, due to opposition or abstention from the vast majority of the Republican Senators, including Vice President-elect Vance. Trump placed multiple restrictions on financing for contraception in his first term.

Title X Federal Family Planning Program

While in office, the Trump administration rewrote the rules governing the federal Title X program, the federal family planning program that supports contraceptive access for people with lower incomes. Title X funds have never been used to pay for abortion services. The Trump administration disqualified family planning clinics from participating in the program if they also offered abortion services (with separate funding); additionally, they prohibited participating clinics from offering referrals to abortion services at other clinics to pregnant patients seeking abortion information. These changes resulted in a steep reduction of the network of clinics receiving federal support from the Title X program. His administration also provided federal family planning funding through Title X funds to crisis pregnancy centers (CPCs) that do not provide contraception, which had been a requirement of the program until that time. While the Biden-Harris administration reversed the Trump administration changes to the program, Project 2025 calls for the restoration of the Trump-era rules, focusing the program on fertility-awareness based methods (FABM), greater support for CPCs, and Congressional passage of a federal law that would prohibit participation from clinics that offer both contraception and abortion services such as Planned Parenthood.

The new Trump administration could either revoke or not enforce the long-standing Title X program’s requirement that Title X-funded clinics provide minors with confidential contraceptive services without parental consent or notification. As a result of recent litigation challenging the rule in Texas where there is a state parental consent requirement for minors, the Biden administration is not enforcing the confidentiality rule in Texas. There are also other states that require parental consent for contraceptive services for minors. The administration could also direct more federal funds toward abstinence education, as they did during Trump’s first term.

Medicaid and Family Planning

Disqualifying Planned Parenthood clinics and other providers that offer both contraception and abortion care from the Medicaid program has long been a priority of some Republican lawmakers and conservative organizations, despite a current federal Medicaid requirement to include all willing providers in the program. Medicaid covers about one in five non-elderly adult women, and is an important source of payment for many family planning providers. For decades, the program has required coverage for contraceptives and other family planning services. In his first term, Trump allowed federal Medicaid funds to be used in a Texas Family Planning Medicaid waiver program that excluded Planned Parenthood and explicitly excluded emergency contraception (EC), which prevents pregnancy after sex by preventing or delaying ovulation. The second Trump administration could approve similar waivers from more states.

For wider-reaching impact, the new Republican Congress could pass legislation stipulating that federal funds to states may not go to entities that provide abortion services, even if the funds are used to pay for non-abortion care. This proposal was included in Republican-sponsored bills that aimed to repeal and replace the ACA in 2017.

Contraceptive Coverage and the ACA

Private insurance coverage for contraceptives and other evidence-based preventive services such as cancer screenings and prenatal care is required under the ACA, but a pending federal lawsuit, Braidwood Management Inc v Becerra, challenges some of these requirements. It is unknown if Trump will fight this case and defend the ACA requirement. Project 2025 calls for the federal government to issue new requirements for contraceptives and other women’s preventive services because of the pending case.  In addition, the Biden-Harris administration recently issued a proposed regulation that would require coverage of over-the-counter contraceptive methods without the need for prescription and would re-define how contraceptives are classified for coverage purposes, potentially expanding the scope of methods that would be required to be covered by plans without cost-sharing. It is unclear if the Biden-Harris administration will finalize the regulation and how Trump will approach the issue.

Maternal Health

During the 2024 campaign, President-elect Trump stated that he would provide full coverage for in vitro fertilization (IVF), which would require Congressional action.

IVF

During the campaign, Trump said that if elected, his administration would provide access to full coverage of IVF services by requiring insurance companies or the government to pay, but he has not provided any details on how this would be funded or operationalized. While Trump says he supports IVF, there is disagreement among conservative circles. The official Republican party platform express support for IVF, but also invokes the 14^th Amendment, which can be used to promote fetal personhood policies that could potentially threaten and criminalize IVF care. Additionally, the Project 2025 authors refer to embryos as “aborted children” and oppose research using embryonic stem cells (which can be derived from the IVF process). In the past year, Republican Senators blocked federal legislation that would have established a federal right and coverage of IVF.

Maternal Mortality and Morbidity

The state of maternal health, particularly pregnancy-related mortality, morbidity, and wide racial and ethnic disparities, remains a major health concern, and at times policymakers across party lines have advanced policies to try and improve maternal health. The pregnancy-related mortality rate in the U.S. is 33.2 per 100,000 live births – the highest of any developed country – resulting in over 1,000 deaths in 2021. The first Trump administration issued a maternal health plan near the end of his term and he signed federal legislation that provided funding for maternal mortality review committees. Doula care has been forwarded as a promising approach to support pregnant people, particularly those who are at risk for adverse maternal and infant birth outcomes. This could be an area that garners some bipartisan interest. The Project 2025 document supports broader access to doulas, with the caveat that no federal funds be used to support training related to abortion care. Some states already cover doula services under Medicaid, but implementation of these benefits has been limited and challenging in many cases.

This analysis for the KFF-Peterson Health System Tracker compares the Medicare’s first-ever negotiated drug prices under a new process created by the Inflation Reduction Act of 2022 to current U.S. list prices, prices negotiated by the Department of Veterans Affairs (VA), and prices in 11 countries of similar size and wealth.

It finds that Medicare’s negotiated prices for 10 high-expenditure prescription drugs are lower than what private Medicare drug plans had been paying, but still much higher than the prices available in other countries – 78% more on average than the country with the next highest price across 11 other wealthy nations.

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

Since the Supreme Court overturned Roe v Wade in June 2022, states have been able to set policy that defines abortion access across this nation. State actions have ranged from those that have effectively banned all abortions unless the pregnancy presents an imminent life threat to states that have enshrined the right to abortion in their state constitutions. This past November, voters in 10 states weighed in on constitutional amendment ballot measures to protect abortion rights.

The states that recently approved constitutional amendments protecting abortion rights in November (Arizona, Colorado, Maryland, Missouri, Montana, and New York) now join the states—California, Michigan, Ohio, and Vermont—that already had recently added these protections to their state constitutions (Figure 1). However, in Florida, Nebraska, and South Dakota, the abortion rights amendments failed to garner sufficient votes for passage. In Nebraska, voters approved a competing measure to ban abortion after the first trimester. Nevada voters approved their state amendment but will need to weigh in again in the general election in 2026, as the state rules require constitutional amendments to pass in two general elections. This brief examines what the November election and prior efforts to enshrine abortion rights at the ballot box mean for those states and what’s next, including the future of abortion restrictions in states where voters enshrined abortion rights where abortion was banned or restricted, as well as those that do not have abortion bans.

Going forward, if law makers seek to restrict abortion in the states with new constitutional amendments protecting abortion rights, state courts will evaluate any abortion restrictions under the new amendment. Protections from restrictions beyond pre-viability bans will vary from state to state based on the language in their constitutional amendment and how their highest court interprets the language. After this general election, there are only two more states with abortion bans that allow citizens to propose new constitutional amendments and have not already attempted to do so.

What will be the fate of abortion restrictions?

Of the seven states that passed amendments protecting abortion rights, two (Arizona and Missouri) had pre-viability abortion bans. In these states, advocates have filed legal challenges to their abortion limits, alleging that they violate the newly established amendments. While the litigation in Arizona proceeds, the 15-week ban is not in effect and clinics are providing abortion care beyond this gestational limit.

The new constitutional amendments offer protections that prevent the state from burdening or interfering with someone’s right to abortion. This means that these constitutional amendments protecting a right to abortion may be used to do more than just challenge pre-viability gestational limits and may also be used to take on other abortion restrictions such as waiting periods, telehealth abortion restrictions, and physician only requirements. Additionally, because some of these constitutional protections go beyond the federal protections that existed under Roe and Casey, abortion restrictions such as waiting periods and the exclusion of abortion coverage in Medicaid programs, may be struck down by state courts.

This has already begun to happen in Michigan and Ohio where abortion rights advocates have challenged abortion restrictions on the basis that they violate their respective reproductive freedom amendments passed by voters in prior elections. Courts in Ohio have already blocked state laws prohibiting advanced practice clinicians from providing medication abortion, requiring in-person counseling, and a 24- hour waiting period after the counselling. Similarly, courts in Michigan have blocked laws limiting the provision of abortion to physicians and requiring a 24-hour waiting period. Michigan advocates have additionally asked a state court to rule that the ban on state funding of abortions for Medicaid enrollees is unconstitutional based on the amendment approved by Michigan voters.

Whether or not similar restrictions that have been in force in these states prior to the election (Table 1) will be blocked in Arizona and Missouri will depend on the wording of their respective abortion-related constitutional amendments and how state courts interpret these protections. While the removal of some of these restrictions is up to judicial interpretation, the Colorado ballot measure directly prevents the state from prohibiting health insurance coverage of abortion and repealed a section of the Colorado Constitution that explicitly prohibited the use of state funds to pay for abortion care, except when necessary to safeguard the life of the pregnant person. The passage of the Colorado measure removes these restrictions on state funds, which had previously prevented the state from using its own funds to provide coverage of abortion care for their Medicaid enrollees in circumstances other than the restrictions on federal funding outlined in the Hyde amendment—previously only allowing the state to cover abortions in cases of life endangerment and rape or incest. Other states, like Arizona and Missouri similarly restrict the use of state funds to provide coverage of abortion services for Medicaid recipients.

Citing the newly passed constitutional amendment, advocates in Missouri have filed a lawsuit challenging the state’s abortion ban and many restrictions. They argue the abortion ban and restrictions, including a 72-hour waiting period, telemedicine ban, and physician only provision, impermissibly interfere with the right to reproductive freedom the Missouri constitution now protects. The language in the state’s new constitutional amendment prevents the state from denying, interfering with, delaying, or otherwise restricting the right to reproductive freedom unless the government can demonstrate that the restriction has the “effect of improving or maintaining the health of a person seeking care, is consistent with widely accepted clinical standards of practice and evidence-based medicine, and does not infringe on that person’s autonomous decision-making.” This is a high bar for the state to clear if anti-abortion advocates are seeking a path to apply limited restrictions, though the Missouri Supreme Court will be the final arbiter of which restrictions will be allowed to stand.

How will the abortion initiatives affect the states that did not have abortion bans?

While five of the states that approved citizen initiatives to enshrine abortion rights in November 2024 do not have abortion bans, these state constitutional amendments provide assurance that abortion rights will be protected in the future. Regardless of how the political winds may change in a state, a constitutional amendment explicitly enshrining abortion rights will mean that lawmakers and even judges cannot enact or interpret the laws to limit abortion access, even if the composition of the state’s high court changes or the state government moves in a different direction. These constitutional protections can only be undone by a subsequent initiative that amends the state’s constitution.

Looking to the future

After the November 2024 election, there are two states (Arkansas and Oklahoma) with current bans which allow for a citizen initiated constitutional amendments and have yet to vote on an abortion measure (Figure 2). There were efforts in Arkansas (where there is a near total abortion ban) to get an initiative on the ballot, but the Arkansas Secretary of State rejected the petition for the initiative on the grounds that the signatures were not properly gathered and thus did not make it to the ballot. The Arkansas Supreme Court upheld this decision. In Florida, there is a 6-week LMP abortion ban, but the 2024 initiative failed to garner the needed 60% approval needed for passage. It is unknown whether abortion rights supporters will try again to gain approval in a future election given that the popular vote fell just 3 percentage points short of approval in the last election.

It is also unclear if anti-abortion proponents will propose new ballot initiatives to remove the new constitutional amendments protecting the right to abortion in Missouri and Arizona. Thirteen states with abortion bans or earlier gestational limits do not have a citizen initiative process to amend their constitutions. These states will likely continue to have those laws on the books, unless a new federal law guaranteeing abortion rights is passed by Congress and signed by the president or a future Supreme Court ruling overturns the 2022 Dobbs decision.

Key Facts

• Women have been affected by HIV since the beginning of the epidemic and face unique challenges in accessing optimal prevention, care, and treatment resources.¹ 
• In 2022, women accounted for about 1 in 5 (19%) new HIV diagnoses in the U.S.² 
• Women of color, particularly Black women, have been disproportionately impacted and represent the majority of women living with HIV, as well as the majority of new diagnoses among women.
• Recent data indicates that HIV diagnoses among women fell 25% between 2010 and 2022, compared to a 12% decline across the population overall. Decreases in HIV diagnoses have occurred for nearly every racial/ethnic group besides White women (Figure 1). However, rates of HIV diagnoses among women of color are much higher.

Overview

• Today, there are more than 1.2 million people estimated to be living with HIV in the U.S., including 268,800 (22%) who are women.
• Women accounted for 19% of the 6,980 new HIV diagnoses in 2022 and are diagnosed with HIV at slightly older ages than men are.
• Between 2010-2022, while HIV diagnoses decreased by 12% among the population overall, the decline was twice as large among women (25%). Decreases in HIV diagnoses have occurred for nearly every racial/ethnic group besides White women (Figure 1). However, rates of HIV diagnoses among women of color are much higher.
• Of new HIV diagnoses among women in 2022, 83% were attributable to heterosexual sex, 17% were attributable to injection drug use, and 1% were attributed to other causes.
• Women with and at risk for HIV face several challenges to getting the services and information they need, including socio-economic and structural barriers such as poverty, cultural inequities, and intimate partner violence (IPV).

Race/Ethnicity

• Women of color, particularly Black women, are disproportionately affected by HIV, accounting for the majority of new HIV diagnoses, the majority of women living with HIV, and highest rates of HIV-related deaths among women with HIV in the U.S.
• In 2022, Black women accounted for half (50%) of HIV diagnoses among women, while only accounting for 13% of the U.S. female population. White women accounted for 24% and Hispanic/Latina women accounted for 20% of HIV diagnoses among women (Figure 2).
• HIV diagnoses decreased 58% among Multiracial women, 39% among Black women, 9% among Hispanic/Latina women, and 3% among Asian women between 2010 and 2022. In this same timeframe, HIV diagnoses increased 21% among White women.
• Rates of new HIV diagnoses are much higher for Black, Multiracial, and Hispanic/Latina women than for White women. In 2022, the rate of new HIV diagnoses for Black women was 10 times higher than the rate for White women (19.2 per 100,000 compared to 1.9); the rate for Multiracial women (8.2) was 4 times higher; the rates for Hispanic/Latina women (5.5) and American Indian/Alaska Native women (5.5) were nearly 3 times higher; the rate for Native Hawaiian/Other Pacific Islander women (4.6) was more than 2 times higher. The rate of new HIV diagnoses among Asian women (1.1) was less than that of White women (1.9).
• In 2021, HIV was the 9^th leading cause of death for Black women ages 25-34, behind diabetes. Black women accounted for the greatest share of deaths (of any cause) among women with diagnosed HIV in 2022 (57%), followed by White women (20%), and Hispanic/Latina women (15%).

Age

• Women ages 25-34 accounted for the largest share (29%) of HIV diagnoses among women in 2022, followed by those ages 35-44 (26%). (Figure 2).
• Women are diagnosed with HIV at slightly older ages than men are. Women 35 years old and older accounted for 58% of new diagnoses among women in 2022. Comparatively, men in this age group accounted for 41% of diagnoses among men.

Transmission

• In 2022, HIV diagnoses among women were mostly attributed to heterosexual sex (83%), followed by injection drug use (17%), and 1% were attributed to other causes. Heterosexual transmission accounts for a greater share of HIV diagnoses among Black and Hispanic/Latina women (90% and 87%, respectively) compared to White women (64%). Among White women, injection drug use accounts for a greater share of diagnoses (36%), relative to Black and Hispanic/Latina women (9%, 12%). (See Figure 3.)
• Mother-to-child transmission of HIV in the U.S. has decreased dramatically since its peak in 1991 due to antiretroviral therapy (ART), which significantly reduces the risk of transmission from a woman to her baby (to 1% or less). Still, some perinatal infections occur each year, the majority of which are among Black women, and there continues to be missed opportunities for preventing mother-to-child transmissions, such as testing late in pregnancy. Of the 42 infants born with HIV in 2022, two-thirds (67%) were Black.

Geography

• Although HIV diagnoses among women have been reported throughout the country, the impact of the epidemic is not uniformly distributed.
• Ten states account for two-thirds of women living with diagnosed HIV (67% in 2022); with 5 states accounting for nearly half (47%) (Figure 4). While the District of Columbia ranked 18^th among states in terms of the number of women living with diagnosed HIV (3,629 in 2022), the rate per 100,000 women living with an HIV diagnosis was the highest, nearly 7 times the national rate for women (1,189 per 100,000 compared to 174 per 100,000 nationally), similar to the share in other high populous urban areas.
• Thirty-five counties account for almost half (46%) of all women living with an HIV diagnosis in the U.S., with Bronx County, New York having the greatest number (9,454) and highest rate (1,552 per 100,000) of women living with an HIV diagnosis.

Transgender Women

• Transgender women are disproportionately affected by HIV and face stigma, discrimination, and exclusion in accessing testing, treatment, and health care, relative to other women.
• Since the beginning of the HIV epidemic, national surveillance of and research on the impacts of HIV on transgender women, as well as transgender and gender-diverse people more broadly, has been limited.
• Although transgender women account for a small share of people estimated to be living with HIV (1%) among transgender women, 14% are estimated to be living with HIV.
• In 2022, transgender women accounted for 87% of 994 new HIV diagnoses among transgender and gender-diverse people. Among transgender women, looking across race/ethnicity, Black transgender women had the highest share of HIV diagnoses (41%), followed by Hispanic/Latina transgender women (39%), whereas White transgender women accounted for 13% of diagnoses. HIV diagnoses among transgender women were mostly attributed to sexual contact (89%).
• Among transgender women, 83% received care for HIV, while 67% were virally suppressed, similar to the share in the overall population of people with HIV.

Sexual and Reproductive Health

• HIV interacts with women’s reproductive health on many levels, impacting menstruation, reducing fertility, and predisposing pregnant people to greater risk of complications. In addition, antiretroviral therapy may impact contraceptive efficacy. During pregnancy, people with HIV can take additional measures to prevent mother-to-child-transmission of HIV such as adherence to antiretroviral regimens and labor and delivery procedures.
• Mothers living with HIV can reduce the risk of transmission to their babies via breastfeeding to less than 1% through antiretroviral therapy.
• Women with other sexually transmitted infections (STIs) are at increased risk for contracting HIV. Women with HIV are at increased risk for developing or contracting a range of conditions, including human papillomavirus (HPV), which can lead to cervical cancer, and severe pelvic inflammatory disease.
• Sexual and reproductive health clinics provide an important entry point for reaching women at risk for and living with HIV. Nearly two-thirds (63%) of women receiving care at sexual and reproductive health clinics report it as their usual source of medical care.
• Research efforts are exploring a number of new HIV prevention technologies which could be particularly beneficial for women, such as cervical barriers and microbicides. The long-acting injectable lenacapavir has also been shown to be highly effective in preventing HIV among women but is not yet approved in the U.S. Once approved, this will be an important addition to the prevention toolkit for women, particularly given its relatively low burden of twice annual injections.

Intimate Partner Violence (IPV) and HIV

• Women living with HIV are disproportionately affected by intimate partner violence (IPV), including physical, sexual, and emotional abuse compared to the general population. Intimate partner violence (IPV), sometimes referred to as domestic violence, has been shown to be associated with increased risk for HIV among women, as well as poorer treatment outcomes for those who are already positive.
• In the U.S., 35% of women living with HIV experienced physical (i.e. non-sexual) IPV in their lifetime, compared to 24% of men living with HIV.
• In many cases, the factors that put women at risk for HIV are similar to those that make them vulnerable to experiencing trauma or IPV: women in violent relationships are at a greater risk for contracting STIs, including HIV, than women in non-violent relationships, and women who experience IPV are more likely to report risk factors for HIV. These experiences are interrelated and can become a cycle of violence, HIV risk, and HIV acquisition.
• Women may also be at increased risk of experiencing violence upon disclosure of their HIV status to partners.

HIV Prevention

• The CDC recommends routine HIV screening for all adults, including women, ages 13-64, in health care settings, as well as repeat screening at least annually for those at high risk. The CDC also separately recommends that all pregnant women be screened for HIV, and that those at high-risk for HIV have repeat HIV screening in the third trimester. Testing of newborns is also recommended if the mother’s HIV status is unknown.
• Additionally, the United States Preventive Services Task Force (USPSTF) recommends HIV testing (including specifically for pregnant women), IPV screening, many STI screenings, and pre-exposure prophylaxis (PrEP) which means that most insurers are required to cover these services without cost-sharing.
• Despite these recommendations, only 37% of women in the U.S. ages 18-64 report having been tested for HIV at some point. Black women are much more likely to report having been tested in the past year compared to White women (21% compared to 6%).
• PrEP is a safe and highly effectivepreventive medication that reduces the risk of acquiring HIV through sex by 99%. Women have been underrepresented in PrEP uptake and use and not all forms of PrEP are approved for people assigned female at birth. Recent developments in PrEP research have shown lenacapavir to be highly effective in preventing HIV among cisgender and transgender women.

Access to Care & Treatment

• As is the case for all people, there are several sources of care and treatment for women living with and at risk for HIV in the U.S., including government programs such as Medicaid, Medicare, and the Ryan White Program for those who are eligible.
• Looking across the care continuum, women see progress but continue to face challenges related to diagnosis, linkage to care, and viral suppression. At the end of 2022, among all women living with HIV, 90% were diagnosed, 48% were retained in care, and 57% were virally suppressed, similar to the shares among men.
• Among women with HIV, 21% were diagnosed late – that is, were diagnosed with AIDS within 3 months of testing positive for HIV, the same share as among men. This suggests that one in five women are not adequately being served by HIV testing services and are not getting into care within ideal timeframes.

1. Unless otherwise noted, the term “women” in this factsheet refers to sex assigned at birth. ↩︎
2. Unless otherwise noted, HIV data come from KFF analysis of the Centers for Disease Control and Prevention (CDC) data in the CDC’s National Center for HIV, Viral Hepatitis, STD, and Tuberculosis Prevention tool: Atlas Plus. https://www.cdc.gov/nchhstp/about/atlasplus.html ↩︎

Introduction

Fluoridating water has been a long-standing public health practice in most communities across the U.S. and has been supported and recommended by the federal government for decades. Even so, ever since the first U.S. community began fluoridating its water in 1945 there have also been concerns raised about this practice and many communities choose not to fluoridate. In recent years, in fact, there has been growing scrutiny of the practice, and debates in many parts of the country about whether to continue fluoridation. President-elect Trump’s announced nomination of Robert F. Kennedy Jr. to be the Secretary of Health and Human Services has raised questions about the potential for the federal government to influence water fluoridation practices across the country. Kennedy has long been critical of water fluoridation and has said the incoming Trump administration will recommend that fluoride be removed from public water on day one. Meanwhile, key professional associations, public health experts, and many policymakers continue to support fluoridation as an important tool for improving dental health in the U.S., and perhaps one of the most important public health interventions ever implemented.

To help inform policy discussions about this topic, this brief provides an overview of the role of the federal government in water fluoridation decisions and the current status of water fluoridation in the U.S. While the federal government cannot require communities to fluoridate their water or remove fluoridation already in place, it does regulate maximum levels and provides guidance to state and local communities on optimal levels of fluoride. If guidance were to change – for example, suggesting that fluoride was not recommended — it could have ripple effects across the country.

The Federal Government’s Role and Current Recommendations for Water Fluoridation

The federal government does not have legal authority to require state and local communities to fluoridate their water, nor to remove fluoridation in areas where it is already policy. Instead, these decisions – just like many public health policy decisions in the U.S. – are made at the state and local levels. There are some states (for example: California, Delaware, Georgia, Illinois, Kentucky, Louisiana, Minnesota, Mississippi, Nebraska, Nevada, Ohio and South Dakota) that require water systems of a certain size within their state to provide fluoridated water, while others leave this decision to city, county, or other officials or leave the choice up to voters who decide via local referendums. At the same time, the federal government – specifically the Environmental Protection Agency (EPA) – does have the primary authority to set and regulate the maximum level of fluoridation in public water systems.

The federal government reviews data and other evidence about the safety and effectiveness of fluoridation and issues recommendations and guidance on best practices for state and local decision-makers to consider. The Department of Health and Human Services (HHS), in particular the Centers for Disease Control and Prevention (CDC), provides recommendations about best practices for achieving public health benefits from fluoridation. The first federal guidelines regarding fluoridation of water systems came from the U.S. Public Health Service (USPHS) in 1945, with a recommended maximum concentration level. Updated guidelines in 1962 revised this maximum, and included, for the first time, a recommended fluoride level, citing its ability to prevent dental caries; the most recent update to these federal guidelines was in 2015.

The federal government also sets and enforces nationwide standards for maximum allowable fluoridation levels. The EPA, acting via the authority provided through the Safe Drinking Water Act of 1974, is responsible for setting federal standards for maximum fluoridation levels in water systems to protect against risks from excessive exposure to fluoride. This includes setting a primary, legally enforceable standard for water fluoridation levels, and a secondary “non-enforceable” standard. If a water system’s fluoridation levels exceed the primary enforceable standard, legal action can be taken against the water provider; if levels exceed the secondary, non-enforceable standard, it does not trigger legal or federal action, but public notice of the exceedance must be provided to persons served by the system no later than 12 months after the levels were exceeded. EPA delegates this regulatory and enforcement authority to states that meet certain capacity requirements. States may also set their own maximum fluoride levels, as long as they are at least as stringent as federal standards.

Current HHS/USPHS guidelines (last updated in 2015) recommend an optimal fluoride concentration of 0.7 mg per liter (mg/L) in community water systems (CWS) while EPA regulations set the primary standard for the maximum level of fluoride in water systems at 4.0 mg/L and the secondary, non-enforceable standard at 2.0 mg/L. Both HHS/CDC and the EPA have discretion to update their guidance and recommendations and have done so in the past. Updating the USPHS guidelines involves a years-long, interagency and multi-stakeholder process that is likely to include review and input from external experts and a period for public comment and discussion. For example, following an internal process that developed its initial updated fluoridation recommendations, HHS published its proposed changes in 2011.  After further review and public comment periods, the final updated recommendations were published in 2015, and included a change to the recommended fluoride concentration in CWS, from 1.2 mg/L to 0.7 mg/L. The EPA set its 4.0 mg/L primary standard for fluoride in 1986, and by law the agency is required to review of drinking water standards (including fluoridation standards) at least every six years. The EPA’s most recent review of drinking water standards, released in July 2024, concluded that the current maximum fluoride level guideline is “not a candidate for revision at this time.” In the future, the EPA could decide to initiate a new review and assessment process for its fluoride guidelines.

Benefits and Risks from Water Fluoridation

Water fluoridation has been found to be effective in reducing the risk and severity of dental caries (tooth decay) in children (as well as adults). According to CDC, a review of the best available evidence shows water fluoridation reduces tooth decay by about 25% in children and adults, and evidence also shows that children living in communities where water is fluoridated have, on average, more than two fewer decayed teeth compared to similar children living in non-fluoridated communities. A comprehensive review of relevant studies, updated in 2024, concluded that evidence shows that initiation of water fluoridation reduces dental caries in children. A study from Juneau, Alaska found that cessation of fluoridation in that community was associated with increases in the number of dental caries, and the number of related procedures and treatments among Medicaid-eligible children.

At the same time, questions have been raised about health risks from exposure to high levels of fluoride concentrations, beyond current federal standards. Extended exposure to high levels of fluoride may have negative effects, such as contributing to dental fluorosis, a discoloration of teeth in young children. Recently, there have been more concerns raised about high levels of fluoride exposure and potential links to other conditions. For example, a 2024 U.S. National Toxicology Program (NTP) monograph suggests a potential link between high fluoride levels (above 1.5 mg per liter, more than double the USPHS recommended amounts for community water fluoridation) and lower IQ in children, but studies reviewed for that publication were from areas outside the U.S. with naturally high fluoride concentrations in their water. The monograph concludes that more studies are needed to fully understand the potential for lower levels (under 1.5 mg/L) of fluoride exposure to affect children’s IQ. Based in part on these findings, in September 2024, a US district judge ordered the EPA to take further regulatory action on fluoride, citing the potential risks to children’s neurological development; the EPA says it is reviewing the court decision, but no additional regulatory actions have been taken to date.

Status of Water Fluoridation in the U.S.

As of 2022, the CDC estimates that 72.3% of the U.S. population that is connected to community water systems (CWS) receives fluoridated water, or 62.8% of the U.S. population overall. Not all people are connected to CWS, as a proportion of the population accesses water through wells or other private sources. The overall percentage of the U.S. population with access to fluoridated water has barely changed over the last two decades: in 2006, CDC reported that 61.5% of the population was connected to fluoridated water, compared with 62.8% in 2022. Sometimes, naturally occurring fluoride exists in water systems, and in fact, can be higher than government benchmarks, including maximum recommended levels. According to CDC, as of 2020 about 1 million people in the U.S. (0.31% of the U.S. population) were connected to CWS that had naturally occurring fluoride levels equal to or greater than the EPA’s recommended limit of 2 mg/L.

Access to fluoridated water varies significantly across the country. As of 2022, data from 51 jurisdictions (50 states and Washington, D.C.) show there are seven jurisdictions where over 95% of the population is connected to fluoridated CWS (D.C., Kentucky, Minnesota, Illinois, North Dakota, Virginia, and Georgia) (Figure 1). However, in nine states less than 50% of the population is connected to fluoridated CWS (Hawaii, New Jersey, Oregon, Idaho, Montana, Louisiana, Alaska, Utah, New Hampshire, and Mississippi). These data largely reflect state and local statutes and regulations on fluoridation. Some states require fluoridation for communities above a certain population (including Kentucky, Minnesota, and Illinois), and have relatively high fluoridation rates as a result. Other states leave these decisions up to localities, many of which have decided not to fluoridate their water supplies. In Hawaii, the state with the lowest fluoridation coverage, no locality fluoridates their water systems (with the exception of military bases). Similarly, In New Jersey and Oregon, the states with the second and third lowest coverage rates, local fluoridation decisions have been contentious. More generally, localities are revisiting existing fluoridation policies and considering ending the practice, which typically has to be voted on by water supply recipients.

Rural areas and smaller communities are less likely to have access to fluoridated drinking water. People who live in rural areas are more likely to rely on private wells, which are not usually treated with fluoride, as opposed to public treated water systems. Additionally, smaller communities may face financial barriers that limit their ability to adequately treat their CWSs, decreasing access to fluoridated water for their residents.