The Hidden Risk in the State Department’s Bilateral Health Agreement Era

What has received less attention are the countries that remain outside the current MOU framework.

A great deal has already been written and analyzed about the State Department’s bilateral health MOUs under the “America First Global Health Strategy.” Much of the discussion has focused on what is included in the agreements, financing expectations, co-investment targets, and the broader implications for country ownership and sustainability. (For a great overview of where things stand now, you can check out this new analysis from Friends of the Global Fight.)

What has received less attention are the countries that remain outside the current MOU approach.

I want to examine this question through the lens of HIV and assess how the current MOUs stack up against the epidemiological realities of the global HIV epidemic.

According to KFF’s MOU tracking dashboard, more than 30 countries have already signed bilateral health MOUs with the United States covering the 2026-2030 period. These agreements represent more than $20 billion in planned health financing commitments, including approximately $12.8 billion from the United States and $7.5 billion in country co-investment commitments. While most of the agreements include HIV/AIDS components, many also span broader program areas including malaria, tuberculosis, polio, and global health security.

To better understand the epidemiological implications of the current landscape, it is useful to focus on the nine African countries with more than one million people living with HIV. These countries represent the largest share of HIV burden in Africa and remain central to global progress toward HIV epidemic control.

Those nine countries are South Africa, Mozambique, Nigeria, Tanzania, Uganda, Kenya, Zimbabwe, Zambia, and Malawi. Among those nine countries, four do not currently have publicly reported MOUs with the United States: South Africa, Tanzania, Zimbabwe, and Zambia. See chart below.

Together, Zambia + Zimbabwe + South Africa + Tanzania account for approximately 61% of people living with HIV and nearly 47% of new HIV infections across the top nine high-burden African HIV epidemics. South Africa alone remains the largest HIV epidemic globally, with an estimated 7.9 million people living with HIV and roughly 150,000 new infections annually. It is important to note that several other high HIV burden countries have signed MOUs, including Nigeria, Mozambique, Kenya, Uganda, and Malawi.

Yet this creates a mixed landscape in which some countries with large HIV epidemics are operating within the new bilateral framework, while several of the world’s largest HIV burden countries remain outside it. From an epidemiological perspective, that raises broader questions about whether there is a clearly articulated strategy guiding engagement with the countries most central to achieving long-term global HIV control goals.

Why this matters

Using current UNAIDS global estimates (~39.9 million people living with HIV

globally):

The four non-MOU countries:

• South Africa (~7.9M)

• Tanzania (~1.8M)

• Zimbabwe (~1.3M)

• Zambia (~1.3M)

Combined:
≈ 12.3 million PLHIV

That means those four countries alone represent roughly:

• ~31% of all people living with HIV globally

• ~45-47% of people living with HIV in sub-Saharan Africa

• ~42% of new HIV infections among the top nine African burden countries

Epidemiological priorities matter because many HIV indicators globally remain fragile. While treatment continuity has generally remained stable, there are growing concerns around prevention, testing, surveillance systems, workforce retention, and community-led programming in many settings. See my recent PEPFAR data summary here. Several countries continue to face significant pressure on the broader systems that support long-term epidemic control.

Against that backdrop, there has been extensive focus on the mechanics of the MOU process itself, but comparatively little public articulation of the broader HIV elimination strategy surrounding it. Also, there has been limited discussion from the State Department about how the current bilateral MOU approach contributes to long-term epidemiological goals, including sustaining progress toward ending HIV as a public health threat and avoiding backsliding in high-burden settings.

Importantly, several countries without publicly reported MOUs, including Zimbabwe and Zambia, have made substantial progress toward UNAIDS 95-95-95 targets, while others continue to face persistent gaps in testing, treatment coverage, viral suppression, or prevention outcomes. Transitions in global health financing and program ownership inherently carry risk, particularly in high-burden settings where prevention systems and community-based infrastructure remain fragile. That reality makes a clear, coherent, and epidemiologically grounded global HIV strategy even more needed during this period of transition.

The same broader strategic questions apply across other disease areas as well, including TB and malaria.

Congress has consistently signaled that it wants measurable outcomes, sustained progress, and continued movement toward HIV epidemic control. The key policy challenge moving forward is ensuring that bilateral transition frameworks, financing negotiations, and evolving country partnerships remain aligned with those epidemiological objectives.

Over time, the success of the current U.S. bilateral framework will depend on whether high-burden countries continue reducing new infections, sustaining treatment continuity, strengthening prevention systems, and maintaining the public health infrastructure needed to prevent epidemic reversals in the years ahead.

Lastly, this remains a dynamic landscape. Some agreements may still be under negotiation or not yet publicly released, which also underscores broader concerns around transparency and visibility into the evolving framework. There may very well be ongoing engagement with several countries behind the scenes, and I hope there is progress in those discussions. But bilateral engagement alone cannot substitute for a clear and concerted global HIV strategy led by the world’s largest financier of HIV programs. Ultimately, we should ask whether the overall strategy and financing remains aligned with the broader epidemiological goal that Congress, public health leaders, and affected communities have consistently articulated: sustained progress toward ending HIV as a public health threat without backsliding in the years ahead.