The America First Global Health Strategy outlines a promising new paradigm for U.S. global health investments. It describes the plan to negotiate time-bound transitions of global health programs, including the President’s Emergency Plan for AIDS Relief (PEPFAR), from U.S. financial and programmatic support to local management and financing. Through bilateral agreements with host-country governments, the U.S. will encourage partners to adopt proven reforms that will sustain decades of progress and ensure resources get to those who need them most. Many countries stand ready for this transition due to progress they have made toward fiscal capacity and the internationally agreed upon 95-95-95 targets which stipulate that by 2030:
- At least 95% of all people will know their HIV status.
- At least 95% of all people living with HIV will be receiving antiretroviral (ARV) treatment and continuing it.
- And at least 95% of all people on ARV therapy will have undetectable levels of the virus in their blood (known as viral suppression).
The joint success relies on diligent local execution and U.S. support coupled with sustained political will and increased domestic resources in partner countries. But as the Bush Institute outlined in its PEPFAR Beyond 2030 series, not all countries will be able to immediately assume full responsibility for HIV/AIDS efforts. Some countries need U.S. financial and technical support for longer than four to five years to achieve the internationally agreed 95-95-95 targets.
In specific countries, governments struggle with violent insurrection, poor infrastructure, and the misallocation and diversion of resources. The data-driven, community-focused approaches that are crucial to eliminating HIV as a public health threat are therefore not consistently implemented across the whole country. A successful transition of PEPFAR in these countries will demand further U.S. investments in innovation over a longer time than others.
This paper will examine two such countries, the Democratic Republic of Congo and the Republic of Mozambique, as examples for a more gradual approach to winding down PEPFAR. Both teach us critical tools to streamline U.S. oversight that is cost-effective while safeguarding decades of progress and millions of lives.
The Democratic Republic of the Congo (DRC): Targeted support for the most vulnerable
With a population of almost 113 million spread across an area approximately three times the size of Texas, few countries in the world are beset by as many challenges as the DRC. Interlocking civil conflicts that have lasted 30 years; a stunted network of roads and rail lines that limit national commerce and cohesion; and regular outbreaks of terrifying infectious diseases, such as Ebola and Mpox. Astounding numbers of Congolese women and children are subject to sexual violence, and health care is rudimentary in large sections of the country.
Despite these obstacles, the government and its partners in the DRC have made laudable progress in the fight against HIV/AIDS. AIDS-related deaths are down 75 percent from their peak in 2002, new annual HIV infections have declined by 40 percent since 2010, and coverage of anti-retroviral therapy (ART) has risen from less than 10 percent of HIV-positive people in 2010 to over 70 percent in 2024, all according to UNAIDS.
But the DRC is still far away from meeting the “95-95-95” goals. Stigma, inaccurate information, and traditional beliefs discourage testing for HIV. UNAIDS estimates that only 77 percent of HIV-positive people in the DRC know their status. Given that approximately 610,000 Congolese are known to be living with HIV, an ART-coverage rate of 70 percent means that more than 180,000 people do not have access to life-saving treatment.
Even among those who start treatment, loss to follow-up has remained stubbornly high in the DRC for many years. Patients typically take long and expensive journeys to medical facilities, and a precarious supply chain for medicines makes stock-outs a constant threat. A large constellation of faith-based and community organizations that provide approximately 40 percent of health care in the DRC are not always as well-connected to the government-managed system as they could be. Laboratories are not always equipped or staffed enough; only two in the country meet international standards for quality, both in the urban capital of Kinshasa.
A particularly tragic gap in the DRC is treatment among children. According to the United Nations, almost half of new HIV infections in the country occur in young people, but only 44 percent of HIV-positive Congolese under 18 are receiving ART.
HIV prevention and ART are not fully integrated with care for expectant and breastfeeding mothers, infants, and children, which hampers early diagnosis and treatment for these populations. However, one positive sign is that President Félix Tshisekedi responded to this crisis by launching his five-year Presidential Initiative to End Pediatric AIDS in the DRC this past June, backed by $18 million U.S. dollars in domestic funds.
Targeted U.S. assistance should continue to complement this investment. A multi-year, renewable, binding compact for PEPFAR technical and financial support should be a critical part of a long-term strategic relationship with the United States. Such an arrangement should include metrics that hold the government accountable and include U.S. assistance with the implementation of reforms like the community-based distribution of drugs, the installation of viral-load capability measurement and tracking in all provinces, and the international accreditation of more laboratories. PEPFAR funding should complement this approach by also strengthening the quality and scope of care provided by faith-based and private hospitals and clinics. These compacts should hold implementers accountable by monitoring, evaluating, and incentivizing positive outcomes and impact.
A health-focused compact should supplement blended investments led by the U.S. International Development Finance Corporation to establish preferential access to the DRC’s mineral resources, including the Lobito Corridor. The DRC also offers promising opportunities for partnerships with U.S. companies envisioned in the America First Global Health Strategy, such as with Gilead Sciences and the Global Fund to Fight AIDS, Tuberculosis, and Malaria to roll out injectable lenacapavir to prevent HIV. Anti-corruption measures and transparency in data and the allocation and expenditure of resources will be essential components of any bilateral agreement to ensure long-term private-sector engagement.
The Republic of Mozambique: Building financial and political resilience
Fifty years after independence, Mozambique remains among the poorest places in the world. The World Bank assesses that almost 63 percent of the country’s 33 million people live in poverty, primarily in rural areas. Stretching more than 1,400 miles along the East African coast, Mozambique inherited transportation networks that were designed to carry the exports of landlocked neighbors rather than knit the nation together from North to South.
The aftermath of colonization left the country with fewer than 100 doctors at independence in 1975, and the proceeding Marxist government nationalized all hospitals and clinics – legacies that still affect the delivery of health care today.
A vicious terrorist campaign waged since 2017 by an offshoot of the Islamic State has killed more than 5,000 people and displaced over one million more in Mozambique’s northernmost province, Cabo Delgado. The conflict is both a massive humanitarian crisis and a drain on the national government’s finances. Disputed elections in 2024 touched off violent protests and left the country polarized. In terms of HIV, 2.4 million Mozambicans are known to be living with the disease, the third-highest number of people living with the disease in the world, according to UNAIDS.
Even so, with enormous support from PEPFAR and the Global Fund to Fight AIDS, Tuberculosis, and Malaria, Mozambique is close to meeting the “95-95-95” goals. AIDS-related mortality declined by 19 percent between 2015 and 2023, according to the Mozambican Ministry of Health, and the annual number of new HIV infections is down by 56 percent. More than 2.1 million people were on ART in Mozambique in 2023, 650 times more than when PEPFAR started in the country in 2004. Mozambique also has been one of the more successful cases within PEPFAR of shifting from international implementers to local organizations.
This success reinforces how grave the tragedy of HIV has been in Mozambique and how much work is left to do. The Mozambican government’s own numbers tell a grim story: 81,000 people contracted HIV in the country in 2023 and 44,000 others died from complications due to AIDS in the same year. Some 300,000 people who need ART are not receiving it. There are wide disparities in the prevalence of HIV by province, as well as a disproportionate impact on adolescent girls and young women, who make up one-third of new infections.
Perhaps the biggest constraint to transferring PEPFAR and other U.S. government health programs to national ownership is Mozambique’s overwhelming reliance on external funding for health care. According to an estimate from 2023, the central government and other domestic actors only finance five percent of the response to HIV/AIDS in Mozambique with the rest financed from PEPAR and the Global Fund. Eighty-two percent of Mozambicans on ART receive their treatment from PEPFAR-funded facilities.
This is not something that is easily fixed in a couple of years. Any U.S.-Mozambican bilateral agreement on health will have to start from the premise that the draw-down in funding for core costs from PEPFAR and other U.S. government health programs will have to be gradual, lasting longer than the four to five years envisioned in the America First Global Health Strategy.
A principal component of any such agreement must be assisting the government and the private sector to raise enough revenue to build these expenses into Mozambique’s budget in a sustainable way over time and to design and implement complementary private-sector insurance and other blended-finance models. Tying the bilateral agreement to the promise of investments in health infrastructure and delivery by the new Mozambican Sovereign Wealth Fund (which manages revenue from natural gas reserves) should be part of the strategy. These negotiations will have to include the entire Mozambican cabinet, with leadership from the Ministry of Economy and Finance and the Ministry of Health.
Like DRC, continued PEPFAR funding through a multi-year, renewable compact should focus on building self-reliance in Mozambique across the country. This should include continuing to train doctors, nurses, clinical officers, and community health workers; expanding community-led monitoring; bringing innovations in community-based access to treatment to scale across the country; and greatly expanding pre-exposure prophylaxis, especially among vulnerable young women. Coordination with the Global Fund, breaking down the silos between care and treatment for HIV and tuberculosis, the delivery of other health care, especially for noncommunicable diseases, is another opportunity. Many of these efforts will require changes in policy and clinical practice by the Mozambican government, which should be an explicit part of the bargain, spelled out in any bilateral agreement.
Conclusion
The America First Global Health Strategy presents an important roadmap for bringing PEPFAR to its proper conclusion. It is time for governments, the private sector, and civil society in each partner country to take control of the management and financing of their national fight against HIV/AIDS.
But not every country is ready to do so immediately. The bilateral agreements or compacts under the strategy will have to extend beyond four or five years in some countries, but must not sacrifice accountability, reciprocity, and transparency. We can and should ask our partners to do more, but in places like the DRC and Mozambique, we will have to be more patient.
