The U.S. government cut on foreign aid is impacting harm reduction in low- and middle-income countries in a myriad of ways. This page provides information on HIV programmes for people who use drugs directly funded by PEPFAR and the Global Fund. It also maps out other existing donors on harm reduction and indicates where domestic investment is in place.

It draws from published and unpublished data collected for HRI’s Cost of Complacency report on the harm reduction funding landscape and Global State of Harm Reduction, both published in 2024. Importantly, it highlights the impacts on communities, community-led programmes, and organisations, and any mitigation measures in place pertaining to the funding cuts. Information has been compiled in conjunction with partners working at local and national level.

This page will be updated with further information and additional countries as the impacts of the US funding cuts evolve.

Currently this page holds information for 10 countries selected due to the significant PEPFAR funding for people who inject drugs received and the availability of data: Kazakhstan, Kenya, Kyrgyzstan, Mozambique, Nigeria, South Africa, Tajikistan, Tanzania, Uganda and Zambia.

To provide updates or for additional information, please feel free to contact us at hrfunding@hri.global

• After the Global Fund, the largest harm reduction donor providing USD 74 million, PEPFAR was the second largest donor. Total PEPFAR expenditure on programmes for people who inject drugs amounted to USD 7.9 million in 2022. Most of this recorded expenditure went towards HIV prevention programmes for people who inject drugs (81%).

• In 2022, PEPFAR funds supported the provision of opioid agonist therapy, or OAT (known as medically assisted treatment, or MAT, by PEPFAR) to 27,000 people in seven countries (India, Kenya, Kyrgyzstan, South Africa, Tajikistan, Tanzania and Uganda), which represents around 2% of the total number of estimated people who inject drugs in those countries. Around USD 0.5 million was provided in new funding for MAT in Uganda in 2021. The biggest increase in OAT expenditure between 2020-2022 was in South Africa where USD 1.3 million was provided in 2022. PEPFAR also provided significant support for OAT in Ukraine in 2022, but no data was available for that year as reporting requirements were not in place due to the Russian Invasion.

• The major PEPFAR supported countries have high HIV prevalence amongst people who inject drugs. For instance, Myanmar (34.9%), Kazakhstan (7.6%), Kenya (11.3%), Kyrgyzstan (16.5%), Mozambique (35.3%), Nigeria (10.9%), South Africa (21%), Tajikistan (8.9%), Tanzania (14%), Uganda (17%) and Zambia (24%).

• The 2024 PEPFAR planned budget for programmes reaching people who inject drugs in Kyrgyzstan, Nigeria, South Africa, Tajikistan and Tanzania exceeded USD500,000. While in the same year the planned budget for people who inject drugs was more than USD 1 million in Myanmar, India, Kenya, Mozambique and Zambia. This funding included support for HIV testing (facility, community), clinical and lab services, non-bio-medical interventions, OAT, PrEP and HIV/TB services in a few countries.

• There is a clear distinction of funding areas between the Global Fund and PEPFAR in-terms of geography and interventions; and both agencies have similar funding levels and targets on harm reduction in several countries. If the Global Fund was to fill gaps left by PEPFAR funding cuts, this would require significant increases in Global Fund allocations. Opportunities for gap filling could be possible where the two agencies were co-funding needle and syringe programmes, for example, but in several countries programming simply halted overnight when the U.S. Government funding pause was announced.

• The PEPFAR 2024 planned budget for OAT is significant in several countries and surpassed the Global Fund funding for OAT in Zambia, Mozambique and Uganda. These countries have witnessed complete or partial interruption in OAT, as well as ART services for those living with HIV and DOTs for those with TB infection . Kenya had 28 clinics offering HIV services for key populations close, while in Zambia a total of 32 drop-in centres that provided HIV services to over 20,000 key populations closed.

• The interruption in OAT has jeopardised lives of those whose lifestyle, employment and education is well on track due to OAT. The other impact includes clients returning to high-risk drug patterns leading to overdoses and loss of lives.

• Due to US Federal regulations, PEPFAR is unable to purchase needles and syringes, meaning that PEPFAR-supported programmes for people who inject drugs were funded in close collaboration with other donors to ensure comprehensive service provision. Countries have witnessed a pause in needle and syringe programmes due to the uncertainty in PEPFAR funding.

• PEPFAR funding in South, South-East and Central Asia included USD 2.5 million on harm reduction- related programmes between 2020-2022.

• The Key Population Investment Fund included some support for harm reduction, e.g. within the four countries that accounted for over half of KPIF funding in 2020 and 2021 (Kenya, Nigeria, South Africa and Uganda), USD 5 million was reported in PEPFAR’s dashboard as being spent on people who inject

• The impact of the US foreign aid pause has severe implications for people who use drugs in countries where PEPFAR is supporting HIV, HCV and TB programmes more broadly. In addition, stop work orders provided to multilateral agencies receiving PEPFAR support such as UNAIDS, UNODC and pooled mechanisms such as RCF are affecting activities at secretariat, country office and local level, disrupting services and crucial supportive processes that have implications for people who use drugs such as community-led monitoring and the roll-out of sustainability road maps.