Theme: Epidemiology & Public Health Research Year: 2025
Background:
In January 2025, the US government issued a “stop order” directive, pausing all foreign aid programmes. This includes a 90-day pausing of all PEPFAR funding for HIV pre-exposure prophylaxis (PrEP) except for pregnant women, with a return in funding for key populations looking increasingly pessimistic. We estimated the impact of this funding pause for people who inject drugs (PWID).
Methods:
We developed a static HIV transmission model incorporating PrEP, parameterised using systematic reviews of population size estimates of PWID, HIV prevalence among PWID, and efficacy of PrEP in reducing the risk of HIV acquisition (39-90%). We used PEPFAR reporting on numbers of PWID returning for PrEP in the 4th quarter of 2024 as the estimated number receiving and using PrEP through PEPFAR. For each country, we estimated the proportion of HIV-negative PWID receiving PrEP through PEPFAR and modelled the relative increase in new HIV infections among PWID resulting from removing this.
Results:
At the end of 2024, 10,593 PWID across 22 countries received PrEP through PEPFAR. Notably, 90% of these PWID receiving PrEP were in Sub-Saharan Africa, particularly Nigeria (5,093 PWID, 48%), Zambia (1,617, 15%) and Tanzania (1,329, 13%). The estimated proportion of HIV-negative PWID receiving PrEP through PEPFAR ranged from 10% in Zambia and Zimbabwe (Figure). The impact of immediately stopping PEPFAR’s provision of PrEP depends on coverage; in higher coverage countries such as Zambia and Zimbabwe, there could be a 13.7% (95%credibility interval: 6.7-29.1) and 8.0% (3.6-18.7) increase in new HIV infections among PWID over 1-year, respectively.
Conclusion:
Measures are required to mitigate against the detrimental impact resulting from ceasing PEPFAR’s provision of PrEP for PWID, particularly in countries with higher coverages of PrEP. This needs to include funding through alternative international donors or domestic government budgets.
Disclosure of Interest Statement:
No conflicts to declare.
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