Since the start of the second Trump administration, the President’s Emergency Plan for AIDS Relief (PEPFAR), the U.S. global HIV/AIDS program credited with saving 26 million lives, has undergone significant changes and disruptions as part of a  broader foreign aid review. Recent changes include: a temporary stop work order and eventual limits to what services could be continued; the cancellation of numerous PEPFAR awards; and a reorganization of U.S. global health programs, including the launch of a new “America First Global Health Strategy” which is anchored to bilateral agreements with countries, a focus on frontline commodities and services, and a shift from disease-specific programming to a more integrated approach. While modeling estimates and field surveys have provided some information about the potential impact of these changes and disruptions, there has been limited data available for such assessments. PEPFAR’s flagship data platform has historically posted financial and program level results, including from PEPFAR’s Monitoring, Evaluation, and Reporting (MER) system (MER was launched more than a decade ago). However, the data platform was temporarily removed in early 2025 and, when restored, it did not include any program data from FY 2025.   

On April 17, 2026, the State Department released Fiscal Year (FY) 2025 fourth quarter (Q4) MER data (covering the July 1 to September 30, 2025 period), providing the first program-level data made available since the changes of last year. Data for quarters 1-3 were not released, which, per the State Department, is due to data reporting and implementation challenges due to the changes. To provide a snapshot of PEPFAR results after these changes, and given this limitation, this analysis compares PEPFAR’s FY 2025 Q4 results to Q4 results from the previous four fiscal years for a subset of MER indicators. By comparing the same time period for each fiscal year, this approach helps to capture seasonal or other reporting fluctuations that could occur. However, it does not allow for an assessment of disruptions or other changes that may have occurred for the full FY 2025 period.¹

While these data are limited (see box on methodology and data limitations) and provide only a snapshot view, they nevertheless provide insights into understanding how PEPFAR is performing following changes by the Trump administration. Overall, the data show that for some indicators, progress  declined in FY 2025 Q4, including support for prevention services such as pre-exposure prophylaxis (PrEP) and the DREAMS program for adolescent girls and young women, both of which were significantly scaled back by the administration. Reduced access to prevention could lead to increases in new HIV infections in the future. There was also a drop in the number of people with HIV newly enrolled on antiretroviral therapy (ART), an important measure of access. At the same time, without more complete data, there is ambiguity in some of the indicators. For example, both the number of HIV tests conducted and the number testing positive for HIV fell, which could represent an actual decline in new infections or simply a decline in access to testing. Finally, there are areas where progress has been maintained or potentially improved, including the total number of people with HIV on ART, which was stable, and an increase in the number of people living with both HIV and TB who are receiving ART. Going forward, the future of transparent PEPFAR data monitoring and reporting remains uncertain, as it’s unclear whether or not these data updates will continue to be provided given the shift in the U.S. global health strategy to country governments and from disease-specific programming to a more integrated approach.  Without such data, it will be difficult to understand the implications and outcomes of these significant changes. 

Findings

PEPFAR’s Q4 treatment results over the period were mixed. While there were some stable results, particularly for the number of people receiving ART, others dropped, such as those newly enrolled on ART.

• The number of individuals with HIV on antiretroviral therapy (ART) remained relatively stable in FY 2025 Q4 compared to FY 2024 Q4 (20.3 million² compared to 20.4 million) and was higher than the prior fiscal years.
• At the same time, the number newly enrolled on ART in FY 2025 Q4 was the lowest over the period, including 16% lower than FY 2024 Q4 (389.1K compared to 463.5K). This is part of a broader decline over the past five years but one of the steepest year-to-year quarter declines.
• Similarly, the number of pregnant women testing positive for HIV and receiving ART in FY 2025 Q4 was also the lowest over the period, including a 14% decline compared to FY 2024 Q4 (189.3K compared to 220.7K).   
• Finally, individuals on ART with documented viral load suppression (VLS) declined in FY 2025 Q4 by 7% compared to FY 2024 Q4 (14.6 million compared to 15.8 million), but was higher than the prior fiscal years.

HIV testing and diagnostic results were mixed in FY 2025 Q4 compared to FY 2024 Q4, although there were fluctuations over the five-year period.

• Both the number of individuals tested for HIV and the number testing positive fell. The number of individuals tested fell by 17% in FY 2025 Q4 compared to FY 2024 Q4 (19.6 million compared to 23.7 million), though was still higher than in prior years. The number testing positive similarly fell by 15% in FY 2025 Q4 compared to FY 2024 Q4 (380.2K compared to 449.8K), continuing a downward decline and reaching the lowest number over the period.
• Despite these drops, the number of pregnant women attending antenatal care who know their HIV status in FY 2025 Q4 was highest over the period, including a 10% increase compared to FY 2024 Q4 (3.9 million compared to 3.6 million).
• In addition, the number of HIV-infected infants with an HIV diagnostic sample collected within the first year increased slightly in FY 2025 Q4 compared to FY 2024 Q4 (2,272 compared to 2,225) but was lower than prior years.

Key PEPFAR prevention results saw large declines, including for PrEP.

• The number of individuals who newly initiated PrEP declined by 41% in FY 2025 Q4 compared to FY 2024 Q4 (388K compared to 659.4K), falling to FY 2022 levels. Access to PrEP with PEPFAR support had increased steadily in recent years, before this drop.
• Also declining significantly was the number of adolescent girls and young women (AGYW) who completed the DREAMS package of prevention services in FY 2025 Q4 compared to FY 2024 Q4 (a drop of 86%, from 1.9 million to 253.4k), its lowest level over the period and less than a quarter of those served in the prior years analyzed. DREAMS had been a major PEPFAR initiative to address the drivers of high HIV incidence rates among AGYW, including gender-based violence, gender inequality, poverty, and inadequate access to education. These broader services are no longer being prioritized by PEPFAR.
• Similarly, the number of children and family members served by the Orphans and Vulnerable Children (OVC) program declined significantly in FY 2025 Q4 compared to FY 2024 Q4 (1.7 million compared to 6.5 million), falling to its lowest level in the last five years, and less than a quarter of those served in Q4 of 2022.
• PEPFAR eliminated reporting on key and priority populations (those who were marginalized or faced particular barriers to HIV services, including men who have sex with men, people in prison, displaced persons or mobile communities, and others) reached with prevention and other interventions. Reporting on voluntary medical male circumcision (VMMC) was also eliminated.

PEPFAR has also provided significant support to address HIV and TB co-infection, and risk of TB among those with HIV. These results were varied.

• The number of individuals living with HIV who know their TB status slightly declined in FY 2025 Q4 compared to FY 2024 Q4 (199k compared to 208.7k) but was higher than prior years.
• The number of individuals living with HIV and TB who are receiving ART declined considerably in FY 2025 Q4, compared to previous fiscal years, including a 33% drop compared to FY 2024 (138.9k compared to 208.1k).
• Similarly, the number of individuals receiving ART who initiated TB prevention therapy declined in FY 2025 Q4 (467.7k compared to 823k), reaching its lowest level over the period and continuing a declining trend. The number for FY 2025 Q4 was a third of the number in FY 2021.
• At the same time, the number of individuals receiving ART who initiated TB treatment increased in FY 2025 Q4 compared to FY 2024 Q4, to its highest level over the period.  

PEPFAR has, for many years, also worked to address the elevated risk of cervical cancer among women living with HIV. While screening for cervical cancer declined, the share receiving treatment for cervical cancer held steady.

• The number of women living with HIV and receiving ART who were screened for cervical cancer declined in FY 2025 Q4 compared to FY 2024 Q4 (806.4K compared to 1.4 million), its lowest level over the period.
• Of the women living with HIV and receiving ART and screened positive for cervical cancer, the share receiving treatment was only slightly below the prior period (89% in FY 2025 Q4 compared to 92% in FY 2024 Q4).

1. One recent analysis, submitted for publication, attempts to address some of these issues by looking at reporting continuity across facilities over time. See, Honermann B, Grimsrud A, Lankiewicz E, Sherwood J, Millett G, The impact of the United States foreign aid freeze on HIV service delivery in PEPFAR-supported countries: a facility-level analysis of 2024–2025 programme data, https://www.medrxiv.org/content/10.64898/2026.04.17.26351143v1. ↩︎
2. The number of individuals on ART in FY 2025 Q4 in the publicly available dataset is 20.3 million. The State Department’s press release about the data cites 20.6 million people. ↩︎

In this JAMA Health Forum column, KFF’s Larry Levitt examines the criticism that health insurance companies are facing from political leaders, and explores the industry’s role in both causing and addressing some of the health systems’ biggest problems, including rising costs and prior authorization review.

Health insurance makes up 8% of total employee compensation on average, and while most employees take up health insurance when it is offered, lower-wage workers are far less likely to be able to access coverage, according to an analysis on the costs, availability, and take-up of health benefits for workers with lower wages. The analysis uses survey data and information from focus groups discussions with more than 100 U.S. employers with over a quarter of a million employees.

About three in four employees are offered health insurance on average, and nearly two-thirds of those offered insurance enroll in the benefit. Workers in occupations with lower wages, such as service occupations, are much less likely to have access to health benefits at their jobs (94% of workers in higher-wage jobs vs. 44% in lower-wage jobs) and, even when they do, they are much less likely to enroll (72% vs. 49%).

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

Key Points

• On May 8, 2025, the Trump administration invoked the “Kemp-Kasten amendment” in order to withhold FY 2025 funding for the United Nations Population Fund (UNFPA, the lead U.N. agency focused on global population and reproductive health); the same determination was made during President Trump’s first term. FY 2025 funding for UNFPA was expected to total $32.5 million in core support and potentially millions more for other project activities.
• While under current law any U.S. funding withheld from UNFPA is to be made available for other family planning, maternal health, and reproductive health activities, Congress rescinded (permanently canceled) FY 2025 funding appropriated for UNFPA as part of a broader foreign aid rescission package requested by the President. Although Congress again appropriated $32.5 million in core support for UNFPA for FY 2026, it is expected that President Trump will again withhold the funds from the organization.
• The Kemp-Kasten amendment is a provision of U.S. law, first enacted by Congress in 1985 and included in appropriations language annually, that states that no U.S. funds may be made available to “any organization or program which, as determined by the president of the United States, supports or participates in the management of a program of coercive abortion or involuntary sterilization.”
• Kemp-Kasten has often been used, as determined by presidents along party lines, to withhold U.S. funding to UNFPA. While framed broadly, Kemp-Kasten was originally intended to restrict funding to UNFPA specifically, after concerns arose about China’s population control policies and UNFPA’s work in China; to date, it has only been applied to UNFPA. Evaluations by the U.S. government and others have found no evidence that UNFPA directly engages in coercive abortion or involuntary sterilization in China, and more generally, UNFPA does not promote abortion as a method of family planning or fund abortion services.
• Kemp-Kasten has been used to withhold funding from UNFPA in 20 of the past 41 fiscal years.

What is the Kemp-Kasten Amendment?

The Kemp-Kasten amendment, first enacted in 1985, is a provision of U.S. law that states that no U.S. funds may be made available to “any organization or program which, as determined by the [p]resident of the United States, supports or participates in the management of a program of coercive abortion or involuntary sterilization.”¹ It was the congressional response to a Reagan administration decision in 1984 to temporarily withhold some funding from UNFPA and to begin conditioning its funding on assurances that the agency did not engage in or provide funding for abortion or coercive family planning. This policy change was made after concerns arose about whether UNFPA supported China’s coercive population policies.² It was announced by the Reagan administration at the 2nd International Conference on Population in 1984, in conjunction with the “Mexico City Policy.”³ The Mexico City Policy originally required foreign NGOs to certify that they would not “perform or actively promote abortion as a method of family planning” with non-U.S. funds as a condition of receiving U.S. family planning assistance; the Trump administration recently expanded this restriction to encompass more funding, more organizations, and more policy areas (see the KFF explainer on the policy).

What U.S. funding does Kemp-Kasten apply to?

Kemp-Kasten applies to all funds appropriated under the State and Foreign Operations appropriations act as well as any unobligated balances from prior appropriations. This includes all funding provided to the State Department and the now-dissolved USAID, which, in turn, includes the vast majority of U.S. global health funding.⁵

When has Kemp-Kasten been in effect?

The Kemp-Kasten amendment has been in effect for 41 years. First enacted in 1985,⁶ its language has been included in the State and Foreign Operations appropriations act every fiscal year since then. (Although the provision is present in current law, language similar to Kemp-Kasten was also included in President Trump’s presidential memorandum reinstating the Mexico City Policy on January 24, 2025.⁷) While Congress has kept the amendment in place annually, it remains up to the president to determine whether or not to invoke Kemp-Kasten as a reason to withhold funding from an organization (see below).⁸

Though Kemp-Kasten technically could apply to funding provided to any organization or program (including U.S. NGOs, non-U.S. NGOs, multilateral organizations, and foreign governments), the U.S. government has issued determinations about only one organization, UNFPA, thus far. The U.S. played a key role in the launch of UNFPA in 1969 and was, until 1985, the largest government donor to the agency.⁹ However, the U.S. has withheld funding from UNFPA due to presidential determinations that it violated Kemp-Kasten as often as it has provided funding since 1985 (in 20 of the past 41 fiscal years, to date), and in some years, funding was also withheld from UNFPA based on other provisions of the law, such as the dollar-for-dollar withholding requirement¹⁰ (see below). These determinations have been made along party lines with only one exception – the first year of President George W. Bush’s administration (see Figure 1 and Table 1).

How much funding does the U.S. provide to UNFPA?

In 2024, the U.S. was the largest donor to UNFPA, having provided 17% of all contributions. Total funding from the U.S. for UNFPA was $231.8 million – $30.5 million in core support and $201.3 million for other projects – in FY 2024 (see Box 2).¹¹ See Figure 1 and Table 1 for historical funding data.

How is a determination about Kemp-Kasten made?

By law, it is up to the president to determine whether any organization or program should be ineligible for funding due to a violation of the Kemp-Kasten amendment (in practice, this authority has generally been delegated to the State Department). In most recent years, legislative language has also specified that this determination must be: 1) made no later than six months after the date of enactment of the law that includes the provision and 2) accompanied by the evidence and criteria used to make the determination.¹³

Most recently, on January 24, 2025, at the beginning of his second term, President Trump directed the Secretary of State to begin the process of making a Kemp-Kasten determination by taking “all necessary steps,” and in May 2025, the United States again invoked Kemp-Kasten to withhold funding from UNFPA. These determinations are usually made after the annual appropriations process is completed. For example, in 2017, the Trump administration’s determination was made on March 30, 2017, at the six month mark after the passage of the FY 2017 continuing resolution appropriations bill and was accompanied by a two-page justification memorandum.¹⁴

Has there ever been evidence that UNFPA supports coercive abortion or involuntary sterilizations?

To date, there has been no evidence that UNFPA supports coercive abortion or involuntary sterilizations. Several evaluations by the U.S. government (including one by an assessment team sent to China by the State Department in 2002) as well as other groups, such as the British All-Party Parliamentary Group on Population, Development, and Reproductive Health (in 2002) and the Interfaith Delegation (in 2003), have found no evidence of direct engagement by UNFPA in such activities in China or elsewhere.¹⁵ In addition, UNFPA does not promote abortion as a method of family planning or fund abortion services.¹⁶ In years when a determination has been made that UNFPA violated Kemp-Kasten, the U.S. government has stated that the determination was based on its conclusion that UNFPA support to or partnering with the Chinese government for other population and reproductive health activities was sufficient grounds for invoking the amendment to withhold funding. In the March 30, 2017, determination by the Trump administration, for example, the justification memorandum stated that: “While there is no evidence that UNFPA directly engages in coercive abortions or involuntary sterilizations in China, the agency continues to partner with the NHFPC [China’s National Health and Family Planning Commission] on family planning, and thus can be found to support, or participate in the management of China's coercive policies for purposes of the Kemp-Kasten amendment.”

What other legislative requirements apply to U.S. funding for UNFPA?

In addition to Kemp-Kasten, there are several other provisions of law that Congress has enacted in recent years to set conditions on U.S. funding for the agency.¹⁷ These provisions:

• require UNFPA to keep U.S. funding to the agency in a separate account, not to be commingled with other funds;
• prohibit UNFPA from funding abortion;
• prohibit UNFPA from using any U.S. funds for their programming in China;
• reduce the U.S. contribution to UNFPA by one dollar for every dollar that UNFPA spends on its programming in China (“dollar-for-dollar withholding”); and
• in some years, state that not more than half of funding designated for the U.S. contribution to UNFPA is to be released before a particular date, which varies by fiscal year (this provision is not currently in effect).

What happens to funding that is withheld from UNFPA?

For several years, including FY 2025 and FY 2026, Congress has required that funding withheld from UNFPA be reallocated to U.S. global family planning, maternal, and reproductive health activities. (However, despite this requirement, the withheld FY 2025 contribution to UNFPA will not be reallocated to those purposes since shortly after the Trump administration made its Kemp-Kasten determination that year, Congress rescinded, or permanently canceled, the funding as part of a larger foreign aid rescission package requested by the President.¹⁸) The enactment of this provision first affected reallocation of FY 2002 funds.¹⁹ It is now typically included in the State and Foreign Operations appropriations act each year.²⁰

1. U.S. Congress, FY 2017 Consolidated Appropriations Act (P.L. 115-31), May 5, 2017; KFF, The U.S. Government and International Family Planning & Reproductive Health: Statutory Requirements and Policies, fact sheet. ↩︎
2. Congressional Research Service (CRS), The U.N. Population Fund: Background and the U.S. Funding Debate, RL32703, July 2010; “Policy Statement of the United States of America at the United Nations International Conference on Population (Second Session), Mexico City, Mexico, August 6-14, 1984,” undated. ↩︎
3. “Policy Statement of the United States of America at the United Nations International Conference on Population (Second Session), Mexico City, Mexico, August 6-14, 1984,” undated; United Nations Division of Economic and Social Affairs/Population Division, “United Nations Conferences on Population,” webpage, undated, http://www.un.org/en/development/desa/population/events/conference/index.shtml. ↩︎
4. “Policy Statement of the United States of America at the United Nations International Conference on Population (Second Session), Mexico City, Mexico, August 6-14, 1984,” undated. ↩︎
5. KFF, The U.S. Congress and Global Health: A Primer; and KFF U.S. Global Health Budget Tracker, available at: https://www.kff.org/interactive/u-s-global-health-budget-tracker/. ↩︎
6. Via FY 1985 supplemental appropriations, per CRS, The U.N. Population Fund: Background and the U.S. Funding Debate, RL32703, July 2010. ↩︎
7. Specifically, in this memorandum, President Trump stated, “I further direct the Secretary of State to take all necessary actions, to the extent permitted by law, to ensure that U.S. taxpayer dollars do not fund organizations or programs that support or participate in the management of a program of coercive abortion or involuntary sterilization.” ↩︎
8. However, after UNFPA ended its program in China in 1997 but then began a new program there in 1999, this resulted in Congress withholding funding from UNFPA that year. ↩︎
9. CRS, The U.N. Population Fund: Background and the U.S. Funding Debate, RL32703, July 2010; PAI, Why the United States Should Maintain Funding for UNFPA, May 2015. ↩︎
10. In FY 1999, Congress prohibited UNFPA funding in response to the initiation of a new UNFPA program in China (this was unrelated to Kemp-Kasten), and in some other years when the U.S. made a contribution to UNFPA, UNFPA’s China program meant some UNFPA funding was withheld under the “dollar-for-dollar withholding” provision. ↩︎
11. KFF analysis of data from State Department, U.S. Contributions to International Organizations: Reports to Congress, available at: https://www.state.gov/u-s-contributions-to-international-organizationshttps://bidenwhitehouse.archives.gov/briefing-room/presidential-actions/2021/01/28/memorandum-on-protecting-womens-health-at-home-and-abroad/https://www.whitehouse.gov/briefing-room/presidential-actions/2021/01/28/memorandum-on-protecting-womens-health-at-home-and-abroad/. ↩︎
12. UNFPA, Annual Report 2013, 2014. ↩︎
13. Typically included in annual State and Foreign Operations appropriations since FY 2008, including in FY 2017 under the terms of the continuing resolution. CRS, The U.N. Population Fund: Background and the U.S. Funding Debate, RL32703, July 2010; KFF analysis of appropriations bills. ↩︎
14. State Department: Letter to Bob Corker, Chairman, Committee on Foreign Relations, from Joseph E Macmanus, Bureau of Legislative Affairs, State Department, dated April 3, 2017, and accompanying “Determination Regarding the ‘Kemp-Kasten Amendment,’” dated March 30, 2017, and “Memorandum of Justification for the Determination Regarding the "Kemp-Kasten Amendment,” undated. Available online (follows the article) at: https://www.buzzfeednews.com/article/jinamoore/the-us-wont-give-any-more-money-to-the-un-population-fund. ↩︎
15. CRS, The U.N. Population Fund: Background and the U.S. Funding Debate, RL32703, July 2010. ↩︎
16. UNFPA, “Frequently Asked Questions,” webpage, updated January 2025, http://www.unfpa.org/frequently-asked-questions#abortion. ↩︎
17. KFF, The U.S. Government and International Family Planning & Reproductive Health: Statutory Requirements and Policies, fact sheet. ↩︎
18. KFF analysis of Congressional Appropriations Bills. ↩︎
19. “Although such reallocation began in practice in FY 2002, it was first authorized by Congress in legislation beginning in FY 2004 with reference to FY 2002 and FY 2003 funds,” per KFF, The U.S. Government and International Family Planning & Reproductive Health: Statutory Requirements and Policies, fact sheet. ↩︎
20. The activities to which Congress directs reallocated funds varies by fiscal year; in FY 2003, for example, reallocated funding supported assistance to vulnerable children and victims of trafficking in persons. CRS, The U.N. Population Fund: Background and the U.S. Funding Debate, RL32703, July 2010. ↩︎

Employer-sponsored health insurance is the largest source of health coverage for people under 65, covering 165.6 million people in March 2025, but its reach is uneven. About four in five (80%) adult workers under age 65 work for an employer that offers health insurance to at least some employees—a share that falls to 60% for lower-paid workers. Additionally, some workers do not enroll even when coverage is offered: employer-sponsored health insurance covered only 22.5% of people under 65 with incomes below 200% of poverty—compared to 82.5% of people with incomes of at least 400% of poverty.

This analysis examines who among people under 65 have employer coverage and which workers are offered and eligible for coverage at their jobs, using the Annual Economic and Social (March) Supplements of the Current Population Survey.

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