More than a million Zambians live with HIV, and for over two decades the US President’s Emergency Plan for AIDS Relief (PEPFAR) has been a major source of treatment funding. Zambia has made measurable progress: new HIV infections fell from about 63,000 in 2010 to roughly 30,000 in 2025, according to UN estimates. Yet the country has been reported to resist a new US health agreement that critics say ties lifesaving aid to access to Zambia’s mineral wealth.
Reporting in March said a memo prepared for Secretary of State Marco Rubio outlined how the US could withdraw health support “on a massive scale” to pressure countries to accept US terms. The shift follows the Trump administration’s dismantling of USAID in 2025 and its move to replace traditional aid with bilateral Memorandums of Understanding (MOUs) under an “America First” global health strategy.
The State Department has characterized the approach as a transition “from a foreign assistance paradigm to an investment and growth paradigm,” and said MOUs account for more than $20.6 billion in new health funding globally. So far, 23 countries in Africa have signed bilateral health deals with the US. But Zambia—and neighboring Zimbabwe—have pushed back.
Observers say the new US approach differs sharply from past practice. Conor Savoy, a visiting fellow at the Center for Global Development and a former USAID engagement lead, said the administration is adopting a “radically different” method of negotiating health assistance.
Zimbabwe walked away from talks, describing US demands around data and biological samples as an unacceptable infringement on sovereignty. Kenya accepted a deal, though activists there have taken privacy concerns to court. Zambia has repeatedly said the US proposal does not align with its national interests.
Under the US offer, Zambia would receive $1 billion in health funding over five years—less than half the assistance it received before USAID’s closure. The agreement would require Zambia to add $340 million in new health spending and to provide access to biological specimens and data for 25 years. Reports said Zambia had a deadline in May to sign or risk losing funding.
Zambia has increased its own health spending, including on HIV programs, but experts warn the country’s health systems are not ready to absorb the full financing and operational responsibilities at short notice. Savoy noted that systems cannot be scaled up overnight to replace decades of US-supported programs.
Beyond funding and data, a key concern is alleged linkage of health deals to access to critical minerals. Zambia holds notable reserves of nickel and cobalt and is a major copper producer. The US has launched initiatives such as Project Vault to reduce reliance on China for rare-earth and other strategic minerals. Some reports suggest mineral access has been raised during negotiations, prompting fears aid is being traded for resource concessions.
Analysts warn the tactic could damage US credibility in Africa. Savoy said blending health and economic objectives risks echoing critiques the US has levelled at China’s behavior on the continent and could erode confidence in US commitments.
It is difficult to determine whether mineral access has been an explicit condition in other MOUs. The Democratic Republic of Congo, for instance, has signed a health agreement with the US and separately pursued mineral-related engagement. Some African governments may welcome US mineral investment as a way to diversify partnerships away from China; others, including activists and civil society groups, demand that health assistance not be conditioned on mining deals.
Health advocates in Zambia have called for rejecting any agreement that ties funding to mining access. Groups such as HealthGAP have reported activist opposition to conditional deals, and Oxfam warned that turning humanitarian aid into a bargaining chip threatens the well-being of thousands.
If Washington reduces financial support substantially, the consequences for patients could be swift. About 1.3 million Zambians depend on daily antiretroviral treatment; those programs contributed to more than a 70% drop in AIDS-related deaths in the past 15 years. The Zambian health ministry did not respond to requests for comment.
Edited by: Cai Nebe