Impact of PEPFAR Cuts on HIV and HCV Transmission and Drug-Related Mortality

"Our findings highlight the potential impact that cuts in PEPFAR’s [US President’s Emergency Plan for AIDS Relief's] funding for OAT [Opioid Agonist Therapy] and other harm reduction services could have on HIV [Human Immunodeficiency Virus] and HCV [Hepatitis C Virus] transmission and drug-related deaths among PWID [People Who Inject Drugs]. The suspension of PEPFAR funding is also likely putting a strain on already fragile healthcare systems in LMICs [Lower- and Middle-Income Countries], still recovering from the impact of COVID-19 (Bong et al., 2020; Fejfar et al., 2023) or, in the case of Ukraine, the ongoing war with Russia. Many organisations delivering services for people who use drugs in LMICs receive significant funding - directly or indirectly - from the US government (International Network of People who Use Drugs, 2025). With little certainty that US funding will resume, affected countries need to explore alternative funding mechanisms to sustain coverage levels of OAT and other harm reduction services, potentially including integrated care models to sustain services with limited resources. This should include increases in domestic funding, seeing this currently only makes up a third of harm reduction funding in LMICs (Harm Reduction International, 2025). However, such funding and policy shifts may face political resistance because most countries implement laws and policies that criminalise drug use. This calls for policy changes and advocacy efforts to highlight the impact that harm reduction interventions can have when they receive sufficient funding and operate within supportive legal and policy environments (Cook et al., 2016). These efforts also need to emphasise that OAT and NSP are cost-effective interventions for reducing HIV and HCV related morbidity (Harm Reduction International, 2024; Wilson et al., 2025), with OAT also preventing drug-related deaths (Fairley et al., 2021; Gisev et al., 2015; Onuoha et al., 2021) and possibly being cost-saving when other social benefits are accounted for (Connock et al., 2007). This will help show that these are essential interventions with multiple benefits, as recommended by WHO since 2005 (World Health Organization, 2025). If additional funding is not found, the subsequent increased morbidity and mortality among PWID could impose a long-term economic burden on health systems in these regions."