How do you proceed?

Children and adults living with HIV under protected refugee status currently have access to federal health programs such as Medicaid under the ACA. ^{Reference Spratt25,Reference Rangel26} OBBBA will end availability of federally funded Medicaid and CHIP beginning on October 1, 2026. ^{Reference Arrington4} Only lawful permanent residents, Cuban/Haitian entrants, Compacts of Free Association migrants, and lawfully residing children and pregnant individuals under the CHIPRA 214 option will remain eligible for Medicaid, leaving many refugees and asylees without access to care. The Congressional Budget Office estimates that changes from OBBBA will result in 1.3 million individuals going without health care. ^{Reference Boozang, Dervan and Straw27} For our patient and his mother, Medicaid eligibility will end when the bill goes into effect. Depending on the state where they reside, there may be state-funded programs for non-citizens to explore coverage, although notably large-scale federal cuts may put additional constraints on opportunities to expand or maintain these programs. ^{Reference Boozang, Dervan and Straw27} Additionally, there may be free/low-cost clinic or charity-based health care options available in some regions, though these clinics may have limited ability and resources to expand services beyond what they currently provide. ^{28,Reference Bender, Chan and Hunt29}

Alternative options for HIV medication and health care may remain available to our patient through the Ryan White HIV/AIDS Program (RWHAP) under the Health Resources & Services Administration. The RWHAP was established in 1990 to assist low-income people living with HIV to receive medical care, HIV treatment, and social services. It is roughly structured into 5 funding arms for: cities and counties most affected by HIV (part A); all 50 states to improve HIV medical and support services (part B); local community-based groups for outpatient ambulatory health services (part C); medical care for low-income women, infants, children, and youth living with HIV (part D); and AIDS education and training programs (part F). ³⁰ However, the FY 2026 Labor, Health and Human Services, Education, and Related Agencies bill advanced by the House Appropriations Committee has proposed $1.7 billion in cuts to federal HIV programs including $525.4 million in cuts (20% of the operating budget) for the RWHAP, which would eliminate parts C, D, and F. ^31,32 Budget cuts such as these, that reduce specialty medical care and support services for women, infants, children, and youth living with HIV, will further limit HIV care options for refugees and asylees given contraction of Medicaid services. If this proposed legislation is enacted, a substantial increase in HIV infections is predicted to occur. ^{Reference Forster, Schnure and Jones33}

Clinicians caring for people living with HIV who may be affected by these legislative changes should make every effort to maintain uninterrupted ART when ART is indicated. Interruption of ART is not recommended because it can lead to viral rebound, immune decompensation, and clinical progression, and treatment interruptions may also contribute to antiretroviral resistance. ^{34,Reference Gardner, Burman, Steiner, Anderson and Bangsberg35} Potential approaches to maintaining access may include short-term bridge prescriptions when feasible, evaluation for enrollment in Ryan White HIV/AIDS Program Part B AIDS Drug Assistance Program services, use of Ryan White or other 340B-covered clinic options, and referral to manufacturer patient assistance programs for eligible patients. ^36,37

How do you proceed?

In this case, there is a strong suspicion for measles infection, also known as rubeola. Infection control measures to prevent transmission, including immediate airborne isolation upon suspicion if hospitalization is required, are warranted. ^{Reference Strebel and Orenstein38,39} Guidance for providers may be offered from a health-system level. Diagnosis should be confirmed via laboratory testing, including measles IgM serology and real-time polymerase chain reaction (PCR) swab from either a nasopharyngeal/throat or urine specimen, with cases reported to local and state public health authorities. ^{Reference Strebel and Orenstein38,39} While supportive care is the mainstay of treatment, vitamin A supplementation has been found to reduce morbidity and mortality, with the recommended dosing varying by age. ^{Reference Do and Mulholland40} However, it is worth noting that vitamin A supplementation has not been well studied in the US, ^{Reference Stinchfield and Orenstein41} where vitamin A deficiency is rare. In fact, there have been reports of vitamin A toxicity associated with measles outbreaks, most recently in West Texas, ^{Reference Amenabar42,Reference Davies43} highlighting the need to ensure communication of accurate medical guidance. ^{Reference Do and Mulholland40} Any exposed contacts, such as her parents, other schoolchildren, and potentially others, should receive postexposure prophylaxis if they lack confirmed immunity, which would be either measles-mumps-rubella vaccine within 72 hours or immune globulin within 6 days. ^{39,Reference Do and Mulholland40} The measles resurgence has affected over 40 states in 2025, which has been attributed to decreasing immunization rates. ^{Reference Zucker44} Federal actions have greatly altered the CDC, including its Advisory Committee on Immunization Practices, which has led to recommendations for significant changes in the routine childhood vaccine schedule ⁴⁵ and several professional societies and initiatives—i.e., the American College of Physicians, American Academy of Pediatrics, American College of Obstetricians and Gynecologists, American Academy of Family Physicians, and Vaccine Integrity Project—to release their own vaccine guidance. ^46–51

How do you proceed?

This patient’s presentation raises suspicion for Ebola virus disease (EVD), a highly contagious hemorrhagic febrile illness. ^{Reference Feldmann, Sprecher and Geisbert52} The typical incubation period is 2–21 days. As a healthcare worker, she is at increased risk of being exposed and exposing others, particularly immunocompromised patients. It is imperative that she be isolated immediately and contact tracing be performed. It is important that appropriate Personal Protective Equipment be used, in accordance with CDC viral hemorrhage protocol. ^{Reference Brown, Choi, McLellan and Shoemaker53} The clinician will need to contact their hospital infection prevention team immediately. Public health officials can assist and should be contacted as soon as possible, including the state health department and CDC Emergency Operations Center. She is at risk of multiorgan failure, shock, and death. Diagnosis is made via whole blood quantitative reverse transcription-PCR assay. There are multiple identified strains of EVD, including Zaire ebolavirus and Sudan ebolavirus, with most recent outbreaks of EVD due to the latter. EVD has a high fatality rate, though it is substantially lower in the US than in Africa. ^{Reference Izudi and Bajunirwe54} Treatment for EVD includes supportive care (eg, intravenous fluid resuscitation, oxygen), and for Zaire ebolavirus, there are US Food and Drug Administration-approved monoclonal antibodies, specifically Inmazeb® (atoltivimab/maftivimab/odesivimab) and Ebanga™ (ansuvimab). ^{Reference Feldmann, Sprecher and Geisbert52}

In the United States, there is a tiered approach to care of the patient with Ebola Virus. Patients are first assessed at frontline facilities. If disease is suspected, they are taken to a designated assessment hospital. If the case is confirmed, the patient is transferred to an Ebola Treatment Center. This system was designed to prevent facility-level outbreaks of EVD.

The landscape of EVD care has changed greatly in the last ten years, with decreased fatality rates across the world and faster outbreak responses. However, with the dissolution of USAID and decreased funding to organizations like the World Health Organization, effective management of communicable, highly virulent diseases such as EVD is becoming more challenging. In February 2025, four of five USAID contracts dedicated to the Ebola response were terminated exactly at the time of the most recent outbreak, ^{Reference Dahir and Nolen55} greatly hindering response efforts.