Modelling the impact of cuts in US PEPFAR funding for opioid agonist therapy and needle and syringe programmes on drug-related deaths and HIV and hepatitis C transmission among people who inject drugs

BACKGROUND: The US government paused funding for the US President's Emergency Plan for AIDS Relief (PEPFAR) in 2025, including disruptions in funding for opioid agonist therapy (OAT) and needle and syringe programmes (NSP). We evaluated the impact of these disruptions on HIV/HCV transmission and drug-related deaths (DRDs) among people who inject drugs (PWID) for 9 countries where PEPFAR funds OAT. METHODS: We developed a static model of HIV/HCV transmission and DRD, parameterised using country-level data. We estimated the number of PWID that may stop accessing OAT through PEPFAR (2024 data; 37,024) and used a survey of harm reduction providers to estimate decreases in NSP provision (46.4% decrease, range 21.1-71.7% across 7/9 countries). We estimated the additional primary HIV/HCV infections over 1-year of disruptions, potential secondary infections over 5-years, and relative increase in DRDs over 1-year. RESULTS: In 2024, PEPFAR funding enabled 0.6-13.5% of PWID to access OAT in 9 countries. Across these countries, an additional 3,672 (95% uncertainty interval: 1438-7059) and 6709 (3020-12,919) primary HIV and HCV infections could occur over 1-year due to disruptions in OAT and NSP, respectively, equating to an ∼8% increase in HIV and HCV infections among PWID. Impact is driven by NSP disruptions (60-87%). Additionally, 5,791 (2301-9906) and 6508 (3155-12,324) secondary HIV and HCV infections could occur over 5-years, respectively, and an 1.4% (0.3-7.5%) increase in DRDs over 1-year. CONCLUSIONS: Removing PEPFAR's funding for OAT and NSP could increase HIV/HCV transmission and DRDs among PWID. Measures need to address these funding gaps.