HIV incidence and related deaths in sub-Saharan Africa are expected to significantly increase due to the January 2025 United States presidential action that halted all foreign assistance programs that do not align with current foreign policy. The directive included a 90-day pause of all US President’s Emergency Plan for AIDS Relief (PEPFAR) funding for HIV oral pre-exposure prophylaxis (PrEP), except for pregnant women, but a return to funding PrEP appears unlikely.
Investigators estimated the impact of a funding pause for PrEP in sub-Saharan Africa. They developed a parameterized HIV transmission model that incorporates PrEP, utilizing estimates of population size, HIV prevalence, and incidence for various key populations and subpopulations in each PEPFAR-funded country in sub-Saharan Africa. They used PEPFAR reporting on the numbers of different sub-populations returning for oral PrEP for each country from July through September 2024 as the estimated number of people taking oral PrEP provided by PEPFAR.
For each country and sub-population, the researchers modeled the relative and absolute increases in new primary HIV infections due to removing PrEP over one year. They also calculated the number of secondary infections that could follow these primary infections over the next 5 years.
- By late 2024, 719,384 people from 28 countries in sub-Saharan Africa, including 205,868 from key populations, received PEPFAR-funded PrEP.
- The estimated proportion of HIV-negative key population individuals who received PEPFAR-funded PrEP ranged from 2.6% among people who inject drugs to 5.0% among female sex workers. In non-key populations, the estimated coverage was 0.1% among women and 0.05% among men.
- PEPFAR halting access to PrEP for 1 year could lead to 6,671 additional new primary HIV infections, including 5,663 in key populations. In key populations, this corresponds to relative increases in new HIV infections between 0.8% among people who inject drugs and 2.9% among female sex workers. In countries with the highest coverage, this increase ranges from 7.8% among people who inject drugs to 18.1% among men who have sex with men.
- Regarding secondary transmissions, a one-year pause could lead to an estimated 10,313 additional infections over 5 years.
The investigators urge funding through alternative international donors or domestic government sources, especially in high-coverage countries, to provide necessary PrEP coverage and prevent the damage due to PEPFAR’s funding cuts.
Reference
Stone J, et al. IAS 2025. Program number OAS0103LB.
