The United States will resume funding HIV, tuberculosis, malaria and polio medicine and the salaries of health workers directly delivering these services to patients – at least for the 2026 financial year, according to the America First Global Health Strategy unveiled by the US State Department on Thursday.

The long-awaited strategy clarifies how the Trump administration aims to restructure the US President’s Emergency Plan for AIDS Relief (PEPFAR) and replace functions of the now defunct US Agency for International Development (USAID).

The three pillars underpinning the new strategy are to keep America safe, strong and prosperous, with aid for disease surveillance and containing outbreaks to feature in future.

US Secretary of State Marco Rubio described the strategy as “a positive vision for a future where we stop outbreaks before they reach our shores, enter strong bilateral agreements that promote our national interests while saving millions of lives, and help promote and export American health innovation around the world”.

Frontline investment to resume

Countries severely affected by the suspension of crucial US health aid when Donald Trump assumed office in January will welcome the news that around $1.3 billion in aid for HIV, TB and malaria diagnostics, drugs, and insecticide-treated bed nets will resume.

In addition, around $827 million for the salaries and benefits of healthcare workers directly serving affected patients will also resume in the 2026 financial year. 

Post 2026, the US “will cover a proportion of these costs, as countries will have required co-investment levels based on each country’s income level”.

It will “rapidly decrease”  funding that “does not go to frontline investments in commodities or healthcare workers”. The strategy flags the salaries of international organisations including Abt, RTI International and Chemonics, that had implemented aid programmes as items it will not support in future. 

However, it aims to “leverage” faith-based hospitals and clinics to deliver health services, noting that these account for over 50% of the delivery capacity in Eswatini and Uganda.

Bilateral deals

The strategy favours bilateral deals over multilateralism, acknowledging that this is how China does business.

From next month, the US plans “intensive engagement with recipient country governments, other donors, and other in-country partners to shape a set of mutually agreeable priorities for future US health assistance”.

It aims to reach bilateral agreements with recipient countries by the end of 2025 and start implementing these agreements by April 2026. 

“These bilateral agreements will ensure funding for 100% of all frontline commodity purchases and 100% of all frontline healthcare workers who directly deliver services to patients,” according to the strategy.

However, the majority of 71 US-supported countries will “transition to full self-reliance during the term of the agreement”.

Integration of diseases

All US government health foreign assistance programs will be administered by the State Department, which “offers a tremendous opportunity to integrate across disease-specific programs including HIV/AIDS, TB, malaria, and polio”, according to the strategy.

Opportunities include the integration of supply chains, health workers, laboratories and data systems.

In the past, “separate disease-specific planning processes and implementing partners within an individual country that had little connection or collaboration with one another”, the strategy notes. 

This resulted in “duplication and missed opportunities to maximise and leverage investments across multiple diseases” and made it harder to integrate programs into countries’ existing health infrastructure, as these usually offer integrated care.

Aid as leverage

The strategy openly acknowledges aid as political leverage, saying that US health foreign assistance “has the potential to be an important counterweight to China, especially in Africa, a continent of strategic importance to US national interests”. 

“Africa also contains several of the largest deposits of key minerals and rare earth elements needed as inputs into advanced technologies that fuel critical military and commercial applications,” the strategy acknowledges.

“Rather than following the China model of loan-based agreements, which is aimed at extracting painful concessions from the country, the requirements that the United States will build into its agreements will be directed squarely at the achievement of public health goals and better facilitating transition towards country self-reliance,” the strategy notes.

Promoting US products as ‘commercial diplomacy’

It also wants US-supported global health programmes to use US-manufactured diagnostic tests and medicine.

In 2024, half the malaria rapid tests and 70% of the HIV rapid tests were purchased from American manufacturers, representing over $350 million of procurements. 

On 4 September, the US announced that it would support the US-based Gilead Sciences to roll out lenacapavir, a six-month injectable that has almost 100% efficacy in preventing HIV. 

It also acknowledges that US support for the Global Fund has created new markets for US products, with around $3.5 billion in US goods and services procured since 2010.

The US government will continue to make buying American products “a key component of future health foreign assistance programs, including ensuring that pooled procurement mechanisms are designed in a manner that facilitates access to the most critical medical innovations developed by US companies”.

It notes that the healthcare market in Asia alone is expected to reach $5 trillion by 2030, while Africa’s healthcare market is “projected to grow rapidly to more than $250 billion by 2030”, providing “several concrete opportunities where the US government can play a role in advancing commercial diplomacy”. 

A US official who spoke anonymously to Semafor shortly before the strategy was released said that, while Africa would continue to be a focus, the US is “going to invest more in the Western Hemisphere. We’re going to invest more in Asia-Pacific. We’re investing a quarter of a billion dollars in the Philippines, which is something we’re really, really excited about.”

‘Radical reset’

Dr Jirair Ratevosian, Duke University global health expert and former PEPFAR chief-of-staff, told Health Policy Watch that the strategy is “pragmatic, performance-oriented – and a bit ruthless”, marking “a radical reset” of how the US approaches global health.

Ratevosian welcomed the protection of life-saving medicine and the jobs of frontline health workers, and the integration of services.

“The next 18 months, as these bilateral agreements are signed, are going to be crucial. Civil society, the private sector, and global health advocates need to stay at the table to make sure this transition strengthens, rather than weakens, the fight against HIV, TB, malaria, and the next pandemic.”

He also noted that the strategy fails to mention South Africa, “the epicentre of the global HIV epidemic and a critical US partner”.

“The risk here is clear: the US may end up favouring countries that are geopolitically convenient rather than those where partnership is most needed to end AIDS,” he warned.

The US has taken exception to various policy decisions taken by South Africa.

Ratevosian said that bilateral compacts with clear performance targets could make US aid more accountable and cut unnecessary overheads, “but only if countries actually can mobilise the money and systems to deliver”, he added.

“Many countries are nowhere near ready to pay 30–50% of program costs. If domestic budgets don’t materialise, we could see stock-outs, staff layoffs, and service collapse that could erase years of progress almost overnight.”

He also warned that bilateral deals could sideline the Global Fund and the global vaccine platform, Gavi, and their ability to pool resources to “create a united front against epidemics”. 

Meanwhile, AVAC warned that moving toward bilateral agreements “risks fragmenting coordination, intensifying the politicalisation of assistance, slowing disbursements, and creating uncertainty for countries already grappling with budget shortfalls”.

What about national sovereignty and generics?

Ratevosian noted that the strategy “doubles down on using foreign assistance to promote US health innovations” like lenacapavir, and this might not align with countries’ push for greater national sovereignty over their health programs.”

This was also flagged by pharmacist Andy Gray, who co-directs the World Health Organization (WHO) Collaborating Centre on Pharmaceutical Policy and Evidence-Based Practice in South Africa.

“There is an internal inconsistency in the plan, in that the US government wishes to promote countries taking responsibility for their own programme delivery, but at the same time, encourage dependence on US goods and services,” said Gray. 

“For many of the most important products, generic versions do not yet exist in the US,” noted Gray, adding that PEPFAR had been able to procure lower-priced, quality-assured generics from other countries. 

“Expecting African countries to continue to procure innovator lenacapivir from Gilead is unreasonable when lower-priced generic versions are expected within the next two years.”

UNAIDS ‘encouraged’ by HIV commitment

In its reaction, UNAIDS said it is “encouraged” by the strategy and its “strong commitment to continue to support people living with and affected by HIV”.

“The new strategy highlights several of UNAIDS’ global HIV targets as key benchmarks for US foreign health assistance, including ensuring that 95% of people living with HIV are aware of their HIV status, 95% of those who know their status are receiving lifesaving HIV treatment, and 95% of those on treatment achieve viral suppression,” UNAIDS noted.

The strategy is also committed to achieving a 90% reduction in new HIV infections and AIDS-related deaths by 2030 and eliminating mother-to-child transmission of HIV in high-burden countries.

UNAIDS added that it remains firmly committed to advancing and strengthening its “long-standing, strategic partnership with the US government and will continue to work hand-in-hand with PEPFAR to support countries to sustain durable, country-led HIV response”.

Image Credits: 2011, Sokomoto Photography for International AIDS Vaccine Initiative (IAVI), Gilead, Witkoppen Clinic, Wikimedia Commons.