As the US rolls out its new global health aid strategy, clinicians and public health experts say the shift could reshape how HIV, tuberculosis (TB), malaria, and other infectious diseases are prevented and treated across dozens of low- and middle-income countries. Some hope the redesign will ultimately strengthen primary care and make services more sustainable; others fear disrupted programs, gaps in care for vulnerable populations, and setbacks to progress toward universal health coverage.

Released in September, the America First Global Health Strategy marks a major overhaul of US global health assistance. It moves away from multilateral programs toward a web of bilateral agreements across 71 countries, with stricter oversight to ensure that spending directly benefits Americans. Built around three pillars — making America safer, stronger, and more prosperous — it concentrates on HIV, TB, malaria, polio, and global health security while calling out “inefficiencies,” “waste,” and a “culture of dependency” in existing programs. The stated goal is to transition most recipient countries to self-reliance over the course of each agreement.

The strategy focuses on a narrow set of infectious diseases and a defined package of US-funded drugs, supplies, and frontline workers. At the same time, it requires countries to co-finance programs and, over time, absorb a greater share of the costs into their own budgets. That shift in financial responsibility is driving much of the debate about what the changes will mean at the clinic level.

The strategy is already being tested on the ground. In early December, the US State Department signed one of the first bilateral agreements in Kenya, pledging more than $1.7 billion over 5 years, with the Kenyan government co-financing $850 million. Within days, a Kenyan court suspended implementation over data privacy concerns. Eswatini, Liberia, Rwanda, and Uganda have also signed deals that include co-financing and commitments to share health and pathogen data, while a $1.5-billion health agreement with Zambia is on hold as the two governments negotiate terms linked to the mining and business sectors.

These early agreements have raised alarms among civil society groups in Africa and globally, who say they have been negotiated without public consultations, parliamentary review, or community input. A December 10 letter signed by 50 organizations warned African heads of state and government that broad US access to health data systems and pathogen information could give Washington leverage to reduce or cancel health assistance over “perceived noncompliance” and could create new risks for patient privacy and human rights.

For clinicians working within US-funded programs, the central questions are whether core services can be protected and who will be left behind.

‘A Once-in-a-Decade’ Chance or a ‘Recipe for Disaster’?

Jirair Ratevosian, DrPH, a former senior advisor to the US President’s Emergency Plan for AIDS Relief (PEPFAR) and an associate research scientist at Yale University in New Haven, Connecticut, sees both promise and cause for concern.

“I think what is positive is that the administration is pushing for a complete reset — there’s upside to that,” he told Medscape News Global. “Programs can be more efficient through bilateral compacts that can allow rapid interventions into national health systems and national insurance schemes. But if the transition is rushed and the cuts on the US [side] are too deep and not met with increased domestic resources, then it’s a recipe for a disaster.”

US global health support has historically flowed through stand-alone, disease-specific programs for conditions such as HIV, TB, and malaria. Ratevosian argues that if countries use this transition period to better connect those services with primary care, the new strategy could indirectly help them build stronger, more integrated health systems and move toward universal health coverage, particularly in sub-Saharan Africa.

“With universal health coverage, there’s more efficiency, we can reach more people — in the same appointment, someone can get immunized, screened for diabetes, and tested for HIV — that’s something every country could strive for,” he said. “If we can get this right, it’s a once-in-a-decade opportunity to jumpstart a move toward universal health coverage.”

Whether countries can realistically co-finance these agreements is another question.

“I’d argue that probably 1 in 3 of the countries where PEPFAR has operated have almost no ability to put resources in,” Ratevosian said. “We need to address that with the right response that supports their needs and considers a country’s economic status, ability to put resources toward health, its disease burden, and democracy indicators.”

Fragmentation and Competition for Funds

Lakshmy Ramakrishnan, MSc, MA, an associate fellow with the Centre for New Economic Diplomacy at the Observer Research Foundation, New Delhi, India, said the co-financing requirement could strengthen domestic ownership of health programs.

“Theoretically, since the strategy has a co-financing component, it is quite possible that countries will take on more responsibility and ownership over healthcare, and this will be useful in the long term,” she told Medscape News Global.

But she is concerned that prioritizing a patchwork of country-by-country deals over engagement with regional bodies such as the Africa Centres for Disease Control and Prevention (CDC) could fragment the response.

“Instead of approaching Africa through a regional actor, like the Africa CDC, approaching individual countries creates a landscape where multiple sovereignties are competing for funds, and this approach may not enable the continent to flourish,” she said. If the strategy funds program-specific initiatives that overlap with existing global partnerships, “then the strategy may not be as efficient as it claims, and it may create silos.”

Key Populations and Disease-Specific Programs at Risk

For Andrew Hill, PhD, a senior visiting research fellow at the University of Liverpool in Liverpool, England, the US strategy is “deeply disturbing” and reflects what he calls a “short-sighted approach to aid.” As an HIV researcher, he’s particularly concerned about how the strategy will affect services for key populations such as sex workers, men who have sex with men, and people who inject drugs.

Whether the US will address the needs of key populations or leave it up to countries remains to be seen, Hill said. He fears a “tragic sequence of damage starting with malaria first, then TB, then HIV, and then hepatitis” if funding is reduced or re-channeled in ways that disrupt established treatment and prevention programs.

Ratevosian agrees that efforts to combat the HIV epidemic won’t succeed if certain groups are excluded. “If we implement a one-size-fits-all integration, these populations will be left out, and in a matter of weeks, we’ll see a resurgence of HIV like we’re now seeing in the Philippines and Fiji.”

The strategy states that the US will supply and fund a defined package of drugs, supplies, and frontline workers for HIV, TB, malaria, polio, and health security. After 2026, the US intends to help integrate these staff into national health budgets and will cover only a portion of drug and supply costs, adjusted to a country’s income level. That raises practical questions about how quickly domestic budgets can absorb salaries and commodity costs without interruptions in care.

Other experts have expressed concern about what they see as the strategy’s “narrow focus” on a handful of infectious diseases at a time when noncommunicable diseases account for the greatest share of global morbidity and mortality. With limited resources, health ministries may struggle to expand cancer, cardiovascular, and diabetes services while also meeting new co-financing obligations for infectious disease programs.

For clinicians and program managers in affected countries, the coming months will be critical. The US has said it aims to conclude bilateral agreements with countries that receive the highest levels of US health assistance by the end of December. How those deals are structured — and whether they protect essential HIV, TB, malaria, and primary care services while safeguarding patient data and privacy — will shape the clinical impact of the America First Global Health Strategy for years to come.

Ratevosian, Ramakrishnan, and Hill reported no relevant financial relationships.

Sophie Cousins, MIPH, is a global health journalist who has reported from more than 20 countries.