Down to the Wire in Zambia: What Happens When Health Aid Becomes Leverage
Negotiation over U.S. support could trigger disruption in Zambia’s HIV response—and call into question the future of US global health partnerships.
Zambia is approaching a critical deadline. According to sources, government officials have less than a couple weeks to decide on the terms of a new bilateral agreement with the United States—one that may condition continued health assistance on broader economic concessions.
Congressional leaders are already raising alarms. In a recent letter to the State Department, they warned that “holding lifesaving assistance hostage for American access to Zambian copper mines is a disturbing break from the long held bipartisan support for PEPFAR.”
At the same time, a petition (see below) filed in the Constitutional Court of Zambia challenges the government’s handling of these bilateral agreements, arguing that they were negotiated and advanced without proper parliamentary scrutiny and public transparency.
The petition, brought by civil society organizations, raises concerns that the agreements may include provisions related not only to health assistance but also to access to Zambia’s natural resources and sensitive health data. It further argues that conditioning health aid in this way could undermine constitutional protections around sovereignty, accountability, and public participation.
For more than two decades, the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) has operated with a clear premise: lifesaving health services should not be contingent on unrelated political or economic objectives. That approach has enabled scale, trust, and measurable results. Zambia is a clear example. The country has made substantial progress toward epidemic control, expanded access to treatment, and improved life expectancy over the past two decades.
At the same time, Zambia has emerged as a leader in the next phase of HIV prevention. In February 2024, Zambia became the first country in sub-Saharan Africa to introduce long-acting injectable PrEP—cabotegravir—outside of a study setting. This was a significant milestone for global HIV prevention. The rollout of cabotegravir required meaningful system adaptation. Health workers needed training, procurement and supply chains had to adjust, and communities had to build trust in a new prevention modality. Zambian health officials – who were actively sharing their implementation experience at HIV meetings - have already navigated these challenges and, in doing so, developed real-world experience in delivering long-acting prevention at scale.
That experience now positions the country to take the next step with lenacapavir. Its potential impact depends not only on the product itself but on the strength of the systems that deliver it. Zambia’s experience with cabotegravir means it is not starting from scratch. It is among the few countries positioned to transition relatively quickly from introduction to broader scale.
This makes the current standoff particularly scary. The U.S. government has been actively elevating lenacapavir as a cornerstone of the next phase of the HIV response—framing it as a breakthrough that could accelerate progress toward epidemic control. Senior officials have repeatedly highlighted its potential and the importance of rapid, equitable rollout across high-burden countries
Side note: I can’t help but feel that the heavy emphasis on lenacapavir is starting to outpace a broader strategy—leaning into future innovation while some of the core service delivery challenges in front of us remain unresolved.
But that ambition depends on continuity. It depends on stable partnerships, predictable financing, and trust between governments and communities. Countries like Zambia—early adopters that have already done the hard work of building delivery platforms—are central to whether lenacapavir succeeds or stalls.
As I noted in a recent piece on Zimbabwe—another early adopter of lenacapavir—even short disruptions to HIV programs can rapidly reverse progress. Modeling from that context shows that interruptions measured in months, not years, can lead to substantial increases in infections and deaths.
At the start of 2025, approximately 84% of Zambia’s HIV program funding came from PEPFAR. This level of support has enabled the country’s progress, but it also means that disruptions, even temporary ones, carry significant risk.
A recent mathematical modeling study published in Open Forum Infectious Diseases underscores just how quickly those risks materialize. A disruption lasting three months could result in more than 50,000 additional infections and over 30,000 additional deaths. If the disruption extends to one year, the impacts increase substantially. Over longer time horizons, the projections point to a full resurgence of the epidemic, with hundreds of thousands of additional deaths.
The underlying dynamics are well understood—and increasingly visible in the latest PEPFAR data (see more on that here). Prevention services tend to be affected first, with declines in testing, reduced access to PrEP, and interruptions in outreach. As a result, infections begin to rise quickly. Treatment programs may initially appear stable, but that stability erodes over time as new infections go undiagnosed and health system functions weaken. Mortality follows with a lag, but the trajectory becomes increasingly difficult to reverse.
It is also important to recognize that PEPFAR supports far more than commodities. It underpins the broader health system architecture, including laboratory networks, data systems, supply chains, and community-based service delivery. When these systems are disrupted, the effects are not isolated. And in Zambia, these risks are already visible. Recent disruptions have affected service delivery, including clinic operations, prevention programs, and laboratory systems.
The implications extend well beyond Zambia. How this moment is handled will signal to partners around the world whether U.S. health assistance remains a stable, long-term investment—or becomes subject to geopolitical negotiation. Many civil servants and civil society leaders are working intensively behind the scenes to reach a path forward, and their efforts matter.
Health programs should not be used as leverage in non-health negotiations when lives are directly at stake. Doing so introduces avoidable risk into systems that depend on continuity and trust. Ultimately, it risks undermining the administration’s own “America First” global health approach, which depends on credible, durable partnerships to succeed—whether they like to admit it or not.
References:
Mulenga LB, Musokotwane K, Sivile S, Zyambo KD, Chilengi R, Lishimpi K, Sinyangwe G, Fwoloshi S, Phiri C, Phiri H, Kampamba D, Kaftan DJ, Nyimbili S, Citron DT, Kim HY, Bershteyn A. Impacts of US Bilateral Aid Disruptions on HIV Resurgence in Zambia: A Mathematical Modeling Study. Open Forum Infect Dis. 2025 Sep 11;12(9):ofaf511. doi: 10.1093/ofid/ofaf511. PMID: 41018701; PMCID: PMC12461847.