Can Trump Export Zambia’s HIV Success? |
U.S. State Department
The project was supported by a grant from the Pulitzer Center.
LIVINGSTONE, Zambia—Violet Simakala feared that U.S. President Donald Trump had taken away her access to HIV treatment.
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’s Emergency Plan for AIDS Relief, or PEPFAR. Since 2003, PEPFAR has directed billions of dollars into treating and preventing HIV worldwide, helping to drive AIDS-related deaths down dramatically.
LIVINGSTONE, Zambia—Violet Simakala feared that U.S. President Donald Trump had taken away her access to HIV treatment.
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’s Emergency Plan for AIDS Relief, or PEPFAR. Since 2003, PEPFAR has directed billions of dollars into treating and preventing HIV worldwide, helping to drive AIDS-related deaths down dramatically.
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.
Not at Mahatma Gandhi.
Although many of its health workers’ salaries depended on U.S. funding, the clinic filled staffing gaps and maintained basic HIV services with minimal interruption.
“They managed,” Simakala said. “There was no congestion … no wasting time,” which is crucial to her, since she has three children to care for.
The clinic’s resilience is not accidental. It is the product of a yearslong shift in how Zambia’s 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.
For most of PEPFAR’s 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.
It was Zambia’s approach that caught the Trump administration’s attention. As part of its “America First Global Health Strategy,” 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 with partner countries centered around a government-to-government funding model, with implementation expected to begin within months.
But experts involved in Zambia’s transition warn that direct government financing is being introduced without a full understanding of what made their approach successful.
When PEPFAR arrived in Zambia in 2004, more than 200 people were dying 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.
The results were miraculous. Within a decade, estimates for annual........