More than a million Zambians live with HIV, and for more than two decades the US President’s Emergency Plan for AIDS Relief (PEPFAR) has been a major source of treatment and program funding. Zambia has recorded measurable progress: UN estimates put new HIV infections at roughly 63,000 in 2010, falling to about 30,000 by 2025. Yet the government has resisted a new US health proposal amid reports that Washington is linking health support to broader political and economic demands—raising concerns that lifesaving aid could be conditioned on access to mineral resources.
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 closure of USAID in 2025 and its move to negotiate bilateral Memorandums of Understanding (MOUs) under an “America First” global health strategy that replaces older aid models.
The State Department describes the change as a transition “from a foreign assistance paradigm to an investment and growth paradigm,” and says MOUs account for more than $20.6 billion in new global health funding. So far, 23 African countries have signed bilateral health deals with the US. Zambia—and neighboring Zimbabwe—have pushed back.
Observers say the new approach differs sharply from past practice. Conor Savoy, a visiting fellow at the Center for Global Development and a former USAID engagement lead, called the administration’s negotiating posture “radically different.” Zimbabwe broke off talks, criticizing US demands over data and biological samples as an unacceptable breach of sovereignty. Kenya accepted a deal but faces legal challenges from privacy advocates. Zambia has repeatedly argued the US proposal conflicts with its national interests.
Under the US offer, Zambia would receive $1 billion in health funding over five years—less than half what it received before USAID was closed. The proposed 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 faced a May deadline to sign or risk losing funding.
Zambia has increased its own health spending, including for HIV programs, but experts warn the country’s systems are not ready to assume the full financial and operational burden on short notice. Savoy noted that national health systems cannot be scaled up overnight to replace decades of US-supported services.
Beyond questions about funding levels and data sharing, a central worry is that health MOUs are being used to gain leverage over access to critical minerals. Zambia has significant reserves of nickel and cobalt and is a major copper producer. Washington has launched initiatives such as Project Vault to reduce dependence on China for rare-earth and other strategic minerals, and some reports say mineral access has come up during negotiations—sparking fears that aid might be exchanged for resource concessions.
Analysts warn that mixing health assistance with economic or strategic objectives risks damaging US credibility in Africa. Savoy said blending health and economic aims could mirror the very practices the US criticizes in other actors and might erode trust in American commitments.
It is not always clear whether mineral access has been made an explicit condition in other MOUs. The Democratic Republic of Congo, for example, has signed a health agreement with the US while separately pursuing mineral-related engagement. Some African governments welcome US investment in mining as a way to diversify partnerships away from China; others—activists and civil society groups among them—insist that health assistance must not be conditioned on mining deals.
Health advocates in Zambia have urged the government to reject any agreement that ties funding to mineral access. Organizations including HealthGAP report activist opposition to conditional deals, and Oxfam has warned that turning humanitarian aid into a bargaining chip threatens the health and lives of thousands.
If Washington substantially reduces support, the consequences could be immediate. About 1.3 million Zambians rely on daily antiretroviral therapy; these programs helped drive more than a 70% decline in AIDS-related deaths over the past 15 years. The Zambian health ministry did not respond to requests for comment.
Edited by: Cai Nebe