An update on bloodborne viruses among people who inject drugs in South Asia

Situated between two of the world's largest opium-producing regions, South Asia faces significant public health threats associated with drug trafficking and injecting drug use. People who inject drugs (PWID) in South Asia experience disproportionately high rates of bloodborne viruses (BBVs), including human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV). These high rates are driven by factors such as drug trafficking routes, socioeconomic marginalization, poor surveillance, and inadequate harm reduction services. Pakistan has the highest reported prevalence rates, with HIV and HCV rates exceeding 30% and 50%, respectively, while India, Bangladesh, and Afghanistan report localized epidemics in urban and border areas. Co-infections, particularly HIV/HCV, further complicate clinical management and public health responses. Despite the implementation of needle-syringe programs and opioid substitution therapy in several countries, service coverage remains below recommended levels due to legal, financial, and structural barriers. Marginalized subgroups, including women and incarcerated individuals, remain underserved and often overlooked. In this review, we discuss the burden of these infections among PWID in South Asia, current control strategies, and the precarious future given the recent instability to the USAID, PEPFAR, WHO, and the Global Fund by the Trump administration.