Global analysis of pre-exposure prophylaxis to need ratios in 2025

BACKGROUND: Despite substantial progress, global HIV incidence remains far above the UNAIDS 2030 target of 220 000 annual acquisitions. Pre-exposure prophylaxis (PrEP) is highly effective, including long-acting agents with 96-100% efficacy, but population-level impact depends on delivery at scale. OBJECTIVE: To assess global PrEP coverage relative to need and estimate the implications for HIV epidemic control. METHODS: We conducted a cross-sectional analysis of country-level HIV acquisitions and PrEP coverage across 184 countries using UNAIDS and supplementary data sources. For countries lacking 2025 data, the most recent estimates were used; PEPFAR-supported countries without current data were adjusted using a 34% reduction to reflect impact of funding cuts. We calculated the PrEP-to-need ratio (PrEP users per new HIV acquisition) and defined a target of 40 : 1, based on number-needed-to-treat estimates from recent trials. RESULTS: Globally, 1.28 million new HIV acquisitions and 2.39 million PrEP users were identified, yielding a PnR of 1.88. Sixty-eight percentage of countries had low coverage (<1 : 1), including 78% of LMICs, which accounted for 89% of new acquisitions. Only four countries (2%) achieved the target PnR. Estimated PrEP coverage declined by 34% in PEPFAR-supported settings, with reductions up to 81% in some countries. Achieving target PnR globally would require approximately 51 million PrEP users. CONCLUSIONS: At present, PrEP is preventing only a fraction of the 1.3 million annual acquisitions, which are likely to rise over the coming years. Achieving global targets will require rapid expansion to tens of millions of users, alongside affordable pricing and renewed investment in prevention infrastructure.