Withdrawal of HIV Funding Hits Hard in the South
Cuts to HIV programming are affecting local prevention programs across the United States, but the potential impacts on public health and healthcare costs are especially high in the South, which accounted for approximately half of the nation's new HIV diagnoses in 2023, according to data from the US Centers for Disease Control and Prevention (CDC).
As previously reported by Medscape Medical News , infectious disease experts emphasized how federal funding cuts threaten to undo decades of progress in HIV research, prevention, and treatment as programs are discontinued because of the lack of staff and money.
'States are unable to compensate for the significant shortfalls the president's budget will create, and funding losses will exacerbate physician shortages, limit access to care, curtail our ability to prevent outbreaks overseas before they reach our shores and decimate our ability to deliver lifesaving cures for generations to come,' said Tina Tan, MD, president of the Infectious Diseases Society of America (IDSA), in a statement.
'While funding for some crucial activities, such as emerging infectious diseases surveillance, is maintained, virtually all areas of health are likely to be impacted by such massive cuts to foundational infrastructure,' Tan said.
HIV programs are at particular risk. 'The drastic cuts to HIV public health and research programs proposed in the president's budget would leave America's HIV response in peril if enacted by Congress,' said Colleen Kelley, MD, MPH, professor of medicine at Emory University School of Medicine in Atlanta, and chair of the board of the HIV Medicine Association, in a statement shared by the IDSA.
'From small towns to big cities, every state across the country may lose lifesaving HIV prevention, testing and research programs,' Kelley said in the statement. 'The result will be more HIV infections nationwide, taking a devastating toll on health and the healthcare system,' she added. 'We are counting on Congress to keep Americans healthy by rejecting these ill-considered proposals,' Kelley said.
Successful Programs May Be Shuttered
One success story of HIV prevention slated to lose federal support is the Together TakeMeHome project, based out of Emory University.
Georgia currently has the nation's highest rate of new HIV infections, with an estimated HIV incidence rate of 23.1 per 100,000 people in 2022, according to data from ahead.hiv.gov.
The Together TakeMeHome project was a tremendously successful home testing program that reached hundreds of thousands of people across the United States, Kelley said in an interview. Since its inception in 2023, the program has identified approximately 7000 individuals with new HIV diagnoses, she said. 'Those people can now get care and get into treatment, and those who tested negative through the program can seek PrEP [preexposure prophylaxis] if needed,' she added.
The project will disappear 2 years ahead of schedule because of funding and personnel cuts, and the result will be more infections and more illnesses related to AIDS, Kelley said.
Since half of the Division of HIV Prevention at the CDC has been laid off, much of the capacity building programs for state health departments is gone, Kelley told Medscape Medical News . The cuts to HIV prevention programs, especially in the South where rates are high, affect more than public health; they will drive up healthcare costs overall, she said. 'People getting sick and needing more care will increase costs, as someone getting their HIV/AIDS treatment in a hospital will incur far more than the few dollars cost to provide a home HIV test,' Kelley said.
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Please note that the text below is not a full transcript and has not been copyedited. For more insight and commentary on these stories, subscribe to the This Week in Cardiology podcast , download the Medscape app or subscribe on Apple Podcasts, Spotify, or your preferred podcast provider. This podcast is intended for healthcare professionals only. In This Week's Podcast For the week ending June 13, 2025, John Mandrola, MD, comments on the following topics: Listener feedback on cardiac sarcoidosis, SA node ablation, surgical AF ablation, chronic kidney disease protection, and recruiting for clinical trials. One of the best parts of this podcast is the listener feedback I receive. This week, David Birnie, MD, the division chief of cardiology at the University of Ottawa and an academic electrophysiologist, active in cardiac sarcoid research, sent me feedback on a paper from Dutch and American authors that I covered 2 weeks ago on May 30. The Mostly Dutch paper studied ~1500 patients with biopsy-proved established sarcoidosis, most of which were non-cardiac. The question was how to risk stratify for an implantable cardioverter-defibrillator (ICD). The two ways were using either professional society recommendations or cardiac magnetic resonance imaging (CMR). CMR was grouped into 4 categories: one high-risk category and three low-risk categories. High-risk category was 'pathology-frequent LGE.' The three main findings were that if either professional society criteria or CMR indicated a high risk, the rate of ventricular tachycardia (VT) at 5 years was high — about 1 in 3 patients had VT. The second finding was that CMR had the better C-statistic compared with risk criteria from professional societies. The C-statistic was quite good at 0.86. The third and most sobering finding was that ICDs treat sudden death and being wrong is fatal. And yet the prediction missed some patients. And this is what Dr Birnie writes about. That is…the nuance of risk stratifying for an ICD in patients with suspected or documented cardiac sarcoidosis (CS). One of the most common ways that CS presents is with atrioventricular (AV) block at surprisingly young ages. When a 75-year-old presents with AV block it's surely due to aging. But when a 50-year-old presents with AV block, you should think about CS. Birnie writes, in an email: Specifically in CS, patients who present with advanced conduction system disease and metabolically active disease seem to be at very significant subsequent risk of VT and VF, even with normal EF. He cited a study from Circulation EP 2018, which showed that AV block, even with a normal EF, had 5-year VT rates of nearly 10%. It is not clear why that is, and research is ongoing and Birnie says it may partly actually be related to steroids. He cited one of his papers in JCE . And the title of that paper was: 'Treatment with corticosteroids was associated with an increase in ventricular arrhythmia burden in patients with clinically manifest cardiac sarcoidosis: Insights from implantable cardioverter-defibrillator diagnostics.' He adds that most of us in the field regard this subgroup as an exception to any sort of late gadolinium enhancement (LGE) cutoff or pattern 'rule.' Indeed, due to increased awareness and CMR and PET, we are increasingly diagnosing these patients earlier and earlier and there are reports where the PET scan is positive and the MRI is actually negative (Eur J Nucl Med Mol Imaging. 2016 Feb;43(2):259-269). That is, the disease is picked up so early in the process that scar has not yet formed. These findings led Dr Birnie to strongly recommend that all patients in this sub-group are recommended to have an ICD regardless of LGE. He and colleagues are currently updating the Heart Rhythm Society guidelines on all of this, hoping to be published early in 2026, co-chaired by myself and Jordana Kron. He also wanted me to plug a cardiac sarcoid conference that he's hosting Aug 24-25 in Ottawa. Thanks to Dr Birnie for updating me and TWIC listeners. Pulsed field ablation (PFA) is white hot in the EP world, So it had to happen. Heart Rhythm Case Reports , which is a really great journal, has published a case report of a group who failed to resist the urge to mess with the sinus node. Yes, a group of ablation doctors report the first case of using PFA to ablate the sinus node in a patient with purported inappropriate sinus tachycardia (IST). I don't usually cover case reports, but I want to mention this report because of the seriousness and danger involved. First some background on IST. IST has been around since I was training. I know this because we tried ablating sinus nodes in the 1990s and it went terribly. It either did not work, or injured the phrenic nerve or it caused symptomatic junctional rhythm. I tried it a handful of times earlier in my practice — and it still did not work. Many of my colleagues think ablation of the sinus node doesn't work because of the difficult anatomy of the sinus node, which is a) not in one place, b) often epicardial, and c) in close proximity to the phrenic nerve. And anatomy may indeed be problematic, but the far more important reason that ablation is a bad idea for IST is that the cause of IST is unknown and likely not cardiac. And this is a problem. If the sinus node is normal but receiving disordered neural input, then ablating the normal structure is not going to work. It's sort of the atrial fibrillation (AF) ablation problem on steroids. Yes, there are a few variants of AF clearly a forme fruste of atrial tachycardia from the pulmonary veins (PVs), as was described by the Bordeaux group 25 years ago, most AF occurs because of a mixture of triggers and substrate. We ablate the PVs and sometimes it works. Ablating the sinus node (SN) for IST is even worse, because IST is surely caused by something extracardiac. Perhaps an autoimmune condition, more often seen in women, and surprisingly, women who work in the health field. Anyways, the case report involved using PFA to ablate the SN. The patient already had a pacer because of an overzealous previous SN ablation attempt. The pacer was no longer pacing because the IST had recurred, which is often the case. The authors tell us that it worked, heart rate (HR) was reduced, and the 34-year-old women felt better with atrial pacing and had persistent junctional rhythm at 90 days — 90 days. If I had reviewed this case, I would have strongly urged the editors to not publish it. One reason is that the women had morbid obesity, so I question the diagnosis of IST. Morbid obesity can surely cause regular sinus tachycardia (ST) due to a combination of deconditioning and genetic causes. In other words, the ST may not have been inappropriate. Second issue is that we only get 90 days of follow-up. Who knows whether the HR will come back. We also get no discussion of the long-term risks of a 34-year-old with a pacemaker. This, my friends, should be avoided in the most strenuous ways. When she is my age, she will have 30-year-old leads. Then what happens when she gets infection at a generator change. Or there is lead failure. I want to also mention some of those who are advocating a combined surgical–hybrid thorascopic ablation approach wherein a surgeon does epicardial linear ablation to isolate the SN. I will cite a non-random comparison study from 2022 where the surgical approach compared favorably to the endocardial ablation approach — that we know does not work. 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And that's exactly what they found: As-treated analysis : 4.40 months survival advantage Surgeon-preference analysis: 4.96 months survival advantage The concordance between led the authors to conclude: 'Our findings support current guidelines recommending for surgical ablation during CABG in patients with atrial fibrillation and it highlights that ablation is currently underused in contemporary practice.' I am very warm to the possibility that concomitant surgical AF ablation may be a good thing to do for some patients with coronary artery disease (CAD) and CABG and AF. But this study does not support anything, nor does it suggest AF ablation is underused. Despite doing an IV analysis, which sounds great, this is still a non-randomized comparison. There is likely selection bias that cannot be overcome by matching. For instance, surgeons who do more AF ablation may see different types of patients, they may work at a better hospital and do better follow-up. These are things that randomization takes care of. That's not the main reason I don't put any weight on this study: the main reason is that the authors found no difference in the incidence of stroke in the two groups with either the as-treated or surgeon preference analysis. So, I ask, if the ablation of AF is not good enough to reduce stroke, how does it reduce death? I don't see a mechanism for reducing death — especially given all the other competing risks. What's more, the Whitlock meta-analysis of 23 RCTs showed no reduction in death with surgical ablation. So, your prior belief has to be extremely pessimistic and therefore it would take strong evidence to change. About 100 times stronger data than this. What's more, the mortality curves separate (by only 4 months) after 5 years. That seems a) like a minimal difference and b) separation over that long a time seems more related to healthier patients getting surgical ablation or better health systems. I want to continue my friendships with the cardiac surgeons. They do important work. But I would also suggest as humbly as possible that they need to improve when it comes to evidence generation. To me, there seems a huge need for proper RCTs of standardized AF ablation techniques. Endpoints should not be all-cause death. It should be AF burden and stroke incidence. Given the increasing prevenance of AF and CAD, I would think this would be a fantastic place for the new NIH leadership to invest money in. I realize that TWIC is a cardiology podcast, but we have yet another big randomized controlled trial of finerenone, the newest mineralocorticoid receptor antagonist, or MRA. As an EP doctor in the Southeastern United States, are unhealthiest geography, I see many patients for AF who also have type 2 diabetes (T2D) and chronic kidney disease (CKD). It goes with the territory. If you are an AF patient obese enough to have T2D, you likely have some CKD. 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The main result was expressed in relative risk reduction: At day 180, the UACR ratio results were: Finerenone alone had a 32% reduction Empagliflozin alone: 29% reduction And the combination therapy had a 52% reduction from baseline So, the reduction with combination therapy was 29% greater than that with finerenone alone and 32% greater than that with empagliflozin alone; both were highly statistically significant. Adverse events and drug discontinuation were similar, though there was a decrease in the estimated glomerular filtration rate (eGFR) of greater than 30% at day 30 in two times more patients in the combination group, though GFR improved at study end when the drugs were stopped. In addition: 'the frequency of hyperkalemia, was relatively lower by approximately 15 to 20% with combination therapy.' For the optimistic or maximizer-docs, the previous model was sequential initiation of these two drug classes. This trial shows that simultaneous initiation worked better. But there were many critical appraisal issues — so many in fact, that it makes me wonder whether this was a marketing exercise. The most obvious issue is the endpoint. While we can say that cholesterol levels, or blood pressure (BP), or creatinine, these are surrogate markers that most patients don't care about. The UACR ratio is even more esoteric and likely even less of a surrogate marker than LDL or BP. The point of kidney protection strategies is to lower kidney outcomes — new dialysis, even doubling of the creatinine, or CV events. I realize UACR ratio is easier and may be an earlier sign, but I will quote the authors own words to underscore the uncertainty: Quote: 'We speculate that, taken together, these data suggest that the reductions observed with combination therapy with empagliflozin and finerenone will probably correlate with meaningful reductions in the risk of progression of chronic kidney disease.' I mean, that is truly remarkable in the NEJM. We speculate, probably . Wow. Then there is the matter of a 6-month trial. These were 67-year-old patients How long are we supposed to use these two classes of meds? Forever? Really? Then there is the matter of the 44-day screening period before randomization. They screened 1600 patients and excluded half. Why? They don't say. Highly selected patients, though, is not nefarious — lots of trials pick the perfect patient. But I mention the screen to randomized information because it speaks to the generalizability of this data. Finally, and I sound like a broken record, whenever finerenone is used in a trial, there should be an arm for spironolactone or eplerenone. That way, we would have an idea of the incremental value, if any, of the new nonsteroidal finerenone. In the end, I think CONFIDENCE was a marketing exercise. It does not change practice, and 6-month data of a very surrogate endpoint hardly meets any regulatory standard. Two UK Cardiology Trials Struggle to Recruit Patients Journalist Sara Freeman reports from the meeting of the British Cardiovascular Society meeting in Manchester, which I was lucky enough to be asked to speak last year, on a session describing difficulty in recruiting patients for two important clinical trials. This is an important topic. I can add a third trial that is also noting slow enrollment. In the UK, the CRAAFT-HF trial compares surgical vs catheter ablation in patients with HF. This is a hugely important question. For multiple reasons: the first is that despite my friendship with Nassir Marrouche, Christian Sohns, and Philipp Sommer, the principal investigators of CASTLE and CASTLE HTx, the numbers of HF patients in trials of AF ablation are few. The event rates are low, and the evidence for AF ablation in HF is limited. CRAAFT-HF would add to that evidence base. 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The third trial that I traveled to Berlin to speak about this winter is the bravest of them all: The PROFID trial, which seeks to replicate the MADIT-II trial 20 years after. MADIT-II was ischemic CM with ejection fraction < 30% and the ICD reduced mortality with a number needed to treat of < 25. The idea behind PROFID is that sudden death rates in HF have fallen, medical therapy has improved, and the delta between the ICD arm and medical therapy arm is surely less. Well, PROFID also has had slow enrollment, for a couple of reasons: one is that there aren't that many terrible ischemic CM patients out there anymore, thanks to the IC community and rapid percutaneous coronary intervention (PCI) during ST-elevation myocardial infarction (STEMI). The second issue is that, at least in Germany, if you are a doc who randomizes a patient to PROFID and they are randomized to the medical arm, you lose reimbursement for the ICD. I highlight this topic mostly for my EP colleagues. While PFA holds all the excitement, we have stalled in terms of new major evidence development. PFA is nice, especially for patients, but if we are to maintain are stature as a profession, we need to support those who seek to answer important questions, like CRAAFT-HF, BRITISH, and PROFID.
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