LIVINGSTONE, Zambia\u2014Violet Simakala feared that U.S. President Donald Trump had taken away her access to HIV treatment.<\/p>\n
Since being diagnosed in 2007, Simakala has gotten the lifesaving medication from the Mahatma Gandhi Memorial Clinic, a government-run facility that has received significant support from the U.S. President\u2019s Emergency Plan for AIDS Relief, or PEPFAR. Since 2003, PEPFAR has directed billions of dollars into treating and preventing HIV worldwide, helping to drive<\/a> AIDS-related deaths down dramatically.<\/p>\n Within hours of his inauguration, Trump issued an executive order pausing all foreign aid, including PEPFAR. Across regions of Africa, Asia, and Latin America and the Caribbean, HIV care was immediately disrupted<\/a>.<\/p>\n Not at Mahatma Gandhi.<\/p>\n Although many of its health workers\u2019 salaries depended on U.S. funding, the clinic filled staffing gaps and maintained basic HIV services with minimal interruption.<\/p>\n \u201cThey managed,\u201d Simakala said. \u201cThere was no congestion \u2026 no wasting time,\u201d which is crucial to her, since she has three children to care for.<\/p>\n The clinic\u2019s resilience is not accidental. It is the product of a yearslong shift in how Zambia\u2019s Southern Province provides HIV services. In 2019, the U.S. Centers for Disease Control and Prevention (CDC), which administers PEPFAR funds in four Zambian provinces, began channeling money directly to those provincial governments instead of routing it through nongovernmental organizations (NGOs). The funds were administered via cooperative agreements, or CoAgs, which define who receives HIV funding, how it will be spent, and how the CDC will implement and monitor those programs.<\/p>\n For most of PEPFAR\u2019s history, NGOs served as the backbone of its operations, implementing lifesaving services on behalf of governments that often lacked the capacity to do so. Across Africa, however, a handful of places are experimenting with using PEPFAR money to directly fund partner governments instead of NGOs.<\/p>\n It was Zambia\u2019s approach that caught the Trump administration\u2019s attention. As part of its \u201cAmerica First Global Health Strategy<\/a>,\u201d Washington has praised this model as a way to lower costs and help countries build systems that can be sustained without indefinite U.S. support. The administration has negotiated more than two dozen agreements<\/a> with partner countries centered around a government-to-government funding model, with implementation expected to begin within months.<\/p>\n But experts involved in Zambia\u2019s transition warn that direct government financing is being introduced without a full understanding of what made their approach successful.<\/p>\n When PEPFAR arrived<\/span> in Zambia in 2004<\/a>, more than 200 people were dying<\/a> from AIDS-related illnesses each day. To stem the crisis, PEPFAR funded NGOs to bypass inadequate government systems and rapidly scale up testing and treatment, often operating alongside existing facilities, such as Mahatma Gandhi.<\/p>\n The results were miraculous. Within a decade, estimates for annual AIDS-related deaths in Zambia dropped from 89,000<\/a> to 27,000<\/a>. But officials understood how vulnerable this system was due to its reliance on external support.<\/p>\n \u201cIt was a standalone, and that was the biggest threat,\u201d said Callistus Kaayunga, a physician and the provincial health director of Southern Province.<\/p>\n U.S. officials shared his concern. In 2013, amid a push<\/a> from the Obama administration to make these programs more sustainable, CDC officials began redirecting PEPFAR funding to governments in Zambia\u2019s Eastern, Lusaka, Southern, and Western provinces through CoAgs. The effort stalled, provincial officials said, because the CDC was overly restrictive in how they used the funds.<\/p>\n But by 2019, new leadership in Zambia\u2019s CDC offices renewed the push, this time giving provinces more flexibility. In Southern Province, officials could use CoAg funds to hire staff, purchase equipment, and improve facility operations\u2014steps that allowed them to begin building a system that could function independently.<\/p>\n After decades of providing services, NGOs shifted into support roles, embedding mentors in clinics to identify skill and knowledge gaps and train government health workers. These trainings were open to staff across departments, not just HIV specialists, allowing facilities to deploy workers more flexibly as patient needs shifted throughout the day.<\/p>\n The province also invested heavily in data management. Officers were placed in nearly every facility to audit HIV services and ensure that the transition stayed on track. Weekly virtual meetings allowed staff and CDC officials across the entire province to discuss any concerns that data revealed and share solutions.<\/p>\n The more difficult task, however, was for the public sector to internalize responsibility for a program long run by NGOs. \u201cThe biggest challenge \u2026 is accepting that now we are the only ones who are going to do this,\u201d Kaayunga said. \u201cWe must see it as us.\u201d<\/p>\n Armed with sufficient funds, employees, and political will, Kaayunga began integrating the parallel system\u2019s services into government facilities. For instance, at Mahatma Gandhi, patients like Simakala could access the first steps in routine HIV care, such as weight and blood pressure checks, through general outpatient departments instead of specialty clinics. The change reduced costs and wait times, making it more likely that people would return for treatment.<\/p>\n By 2024, Southern Province had assumed near-total control of its HIV response. The other provinces working with the CDC are close behind. As direct financing increased, outcomes improved<\/a>: More people were on treatment, and more stayed on it. After an initial funding surge, costs declined\u2014from $79 per patient in 2021 to $44 in 2024.<\/p>\n The provinces still rely on PEPFAR support, but Kaayunga said that there is \u201cstrong willpower and political commitment to ensure that these programs are actually sustained.\u201d<\/p>\n Not everyone believes<\/span> Zambia\u2019s model is ready for export.<\/p>\n HIV programs have long committed to serving everyone in need, including those outside formal health systems. In Zambia, PEPFAR invested in community-based volunteers who test patients at home and deliver medications, as well as NGO-run services tailored to marginalized communities. These efforts reach people who avoid clinics, whether due to stigma, distance, or cost. They are especially important for gay men, sex workers, and people who use drugs, who often face discrimination or fear legal consequences when they seek care at government facilities.<\/p>\n As the Southern Province began receiving direct financing, it prioritized clinic-based care, which is more cost-effective than maintaining specialized centers or outreach services. Community groups warn that this risks leaving behind vulnerable populations who depend on these services\u2014and undermining future progress.<\/p>\n <\/a><\/p>\n \n \tWhat foreign aid cuts mean in practice in one African country. \t <\/a><\/p>\n \n \tA better future for Palestine depends on psychological recovery. \t <\/a><\/p>\n \n \tThe change to funding governments instead of NGOs is long overdue but could easily go wrong. \t <\/p>\n Elizabeth Phiri, who lives in Livingstone\u2019s Libuyu neighborhood, has seen that risk firsthand. After her husband died of AIDS-related complications in 2012, she started working as a community-based volunteer, receiving a small stipend until her organization lost funding amid the direct financing shift about three years ago. She never considered quitting, though hundreds of other volunteers did without ever being replaced.<\/p>\n \u201cIf I stopped working, it would be difficult for my clients,\u201d she said.<\/p>\n One of those clients is Jessie Muleya, a mother of four who runs a small grocery stand from her yard. She fears that if her HIV status became public, customers would stop buying from her. Phiri is one of the few people who knows, and Muleya depends on her to deliver her treatment from a nearby government clinic every six months.<\/p>\n \u201cIf she cannot bring me medicine, then I will die,\u201d Muleya said. Phiri believes that this is also true for thousands of Zambians who rely on community outreach services.<\/p>\n Provincial officials acknowledge the value of outreach but cite limited resources. The national government plans to recruit 45,000 community-based volunteers by 2028, though they will focus on more than HIV care. Community leaders worry that these workers will quickly be overstretched, especially if the process is used to reward political cadres rather than identify people who can actually win the trust of fearful clients.<\/p>\n Despite these concerns,<\/span> the Trump administration is moving ahead with plans to expand direct government health financing through bilateral agreements, some of which have drawn criticism for being overtly transactional. Zambia\u2019s proposed deal has been particularly contentious<\/a>, with reports alleging that Washington is attempting to tie $1 billion in health financing to mining concessions.<\/p>\n The Trump administration nevertheless sees these direct-financing agreements as key to long-term sustainability and reducing reliance on U.S. support, even as experts warn that the model requires time, money, monitoring, and expertise.<\/p>\n \u201cIt needs very strong deliverables and measurable achievements. And it needs money,\u201d said Carolyn Bolton, the chief medical officer at Zambia\u2019s Centre for Infectious Disease Research. Even if countries adopted the CoAg approach or another direct financing model, she added, the process will take \u201ca lot of trust and a lot of time. Triple what you think.\u201d<\/p>\n Those conditions, critics believe, are not being met.<\/p>\n \u201cThey\u2019re doing it at warp speed in the wake of these massive and devastating aid cuts<\/a> and with a highly limited, capacity-constrained bureaucracy,\u201d said Jocilyn Estes, of the Center for Global Development. \u201cThe direction isn\u2019t wrong. The execution risk is just enormous.\u201d<\/p>\n In Zambia, annual PEPFAR investments in HIV services increased 25 percent<\/a> during the early years of the transition; it was only after the provinces were able to start taking over the work of implementing partners that costs came down.<\/p>\n The new agreements, by contrast, begin with lower<\/a> funding levels than what Washington provided in the 2024 fiscal year and decrease over the course of five years. Partner governments are expected to increase their own investments, but those won\u2019t be enough to offset the reduction in U.S. support.<\/p>\n Then there is the question of who will guide the transition. The Trump administration has either hamstrung<\/a> or outright eliminated the two major implementers of PEPFAR programs<\/a>\u2014the CDC and the U.S. Agency for International Development<\/a>\u2014leaving the State Department to administer the remaining USAID programs without the experts who actually ran them.<\/p>\n At the same time, disruptions to routine data collection\u2014a consequence of Trump\u2019s PEPFAR cuts\u2014have made it harder to track progress in most countries. This is especially concerning, because the new bilateral agreements condition future funding on meeting specific benchmarks.<\/p>\n Time may be the biggest constraint. Five years\u2014when U.S. financing ends under most of these agreements\u2014is not nearly enough time for governments to integrate and pay for the programs that NGOs have been running for decades. It took Southern Province that long to complete its transition, and it\u2019s still not ready to go entirely without U.S. support.<\/p>\n While facilities there withstood the temporary shock of Trump\u2019s initial funding pause, they are still absorbing the effects of subsequent cuts. Even after Zambian officials stepped in with some relief, Southern Province could not retain dozens of former CoAg employees.<\/p>\n Selina Theo\u2019s position, which included identifying people living with HIV who had missed appointments, was eliminated in September 2025. She says the impact is already visible: \u201cI see a lot of clients experiencing interruption in treatments now that there isn\u2019t someone who is dedicated to make follow-ups.\u201d<\/p>\n Zambia\u2019s Southern Province is proof that directly funding governments offers a starting point for the long-term preservation of HIV services. But it also shows how fragile those gains can be\u2014and how quickly they can unravel if support is withdrawn too soon.<\/p>\n \u201cChange is a process,\u201d Kaayunga said. \u201cIf you speed up change, chances are that you may actually end up with an outcome that you didn\u2019t desire.\u201d<\/p>\n<\/p><\/div>\n
\n
\nRead More<\/span><\/h2>\n
\n
\n
\n
\n <\/span>\n Can Sierra Leone Still Keep Its Mothers Alive? <\/h3>\n
![\"This](\"https:\/\/foreignpolicy.com\/wp-content\/themes\/foreign-policy-2017\/assets\/src\/images\/icons\/audio.svg\")
\n <\/p>\n<\/div><\/div>\n<\/div>\n<\/li>\n
\n
\n ![\"Palestinian](\"https:\/\/foreignpolicy.com\/wp-content\/uploads\/2026\/03\/GazaYouthSchool_GettyImages-2243056128.jpg?w=800&quality=80\")
\n <\/span>\n Gaza\u2019s Reconstruction Must Begin With Its Youth <\/h3>\n
\n <\/p>\n<\/div><\/div>\n<\/div>\n<\/li>\n
\n
\n ![\"A](\"https:\/\/foreignpolicy.com\/wp-content\/uploads\/2025\/12\/usaid-health-hiv-GettyImages-2199141618.jpg?w=800&quality=80\")
\n <\/span>\n The Trump Administration\u2019s Epochal Shift on Foreign Aid <\/h3>\n
\n <\/p>\n<\/div><\/div>\n<\/div>\n<\/li>\n<\/ul><\/div>\n<\/div><\/div>\n
\n