BACKGROUND: In 2021, key populations (KPs) most at risk of HIV and their partners made up 70% of new HIV cases globally. Accordingly, among large funders of HIV programming like the President’s Emergency Plan for AIDS Relief (PEPFAR), it is critical to understand trends in planned funding (budgets) for KPs and whether actual spending (expenditures) is aligned with what is budgeted.
METHODS:

PEPFAR data were accessed for countries with budgets for 2020-2023 (n=49) and analyzed by UNAIDS-defined regions. For the subset of PEPFAR countries with both budget and expenditure data available for 2020-2022 (n=45), descriptive analysis and t-tests were used to assess differences in the percent of KP budget spent as compared to the total percent of country budget spent.

RESULTS: The percent of budgets allocated to KPs varied by region (Figure 1a) and budget trends and expenditure trends did not always align (Figure 1a & 1b). In 2023, the percent budget allocated to KPs was lowest in Eastern and Southern Africa (4.40%) and highest in Asia (50.50%). Comparing budgets to expenditures, the median percent KP budget spent (87.9% - IQR 41.8) was similar to the total budget spent in 2020 (85.5, IQR 18.3), and less than the percent total spent in 2021 (KP: 75.8% - IQR 29.4, Total: 87.3%, 14.8) and 2022 (KP: 87.1% - IQR: 23.7, Total: 93.7%, IQR: 5.6). This difference was only statistically significant in 2021 (t = -3.24, df = 45, p<0.05).


CONCLUSIONS: Even in regions with more generalized epidemics, PEPFAR KP budgets are proportionally small considering the relative burden of HIV incidence among KPs, but trending upwards over the last several years. It will be important to monitor underspending of KP budgets moving forward to ensure budgeted dollars are reaching the intended populations.

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