Zambia HIV – As the Trump administration pushes direct government financing for global HIV care, Zambia’s transition offers proof of promise—and warnings about capacity, outreach, and time.
LIVINGSTONE, Zambia—When the U.S. paused foreign aid shortly after President Donald Trump took office, residents in Southern Province feared the shutdown would reach all the way to the clinic where they rely on daily medicine and careful follow-up.
For Violet Simakala, that anxiety was immediate.. She said she worried her access to HIV treatment would vanish once U.S.. support under PEPFAR—widely credited with driving down AIDS deaths worldwide—was frozen.. Across parts of Africa, Asia and the Caribbean, HIV services were disrupted within hours.. But at the Mahatma Gandhi Memorial Clinic, the disruption was narrower than many expected.
Zambia’s direct-funding bet, stress-tested
Simakala described how the clinic kept operating with minimal congestion and without the long delays that can break the rhythm of HIV care. She said the difference mattered because she has three children and cannot afford missed appointments.
Misryoum’s reporting in Southern Province points to why that continuity held up: Zambia’s HIV program shifted years earlier toward a government-run model that reduced dependence on nongovernmental implementers.. In 2019, the U.S.. Centers for Disease Control and Prevention began channeling PEPFAR money directly to provincial governments in Zambia’s Eastern. Lusaka. Southern and Western regions through cooperative agreements.. Those agreements set the rules for who gets funds, what those funds cover, and how progress is monitored.
The logic is straightforward—at least on paper.. In many places, NGOs have been the engine for rapidly scaling testing and treatment when public systems lacked capacity.. Zambia’s approach was different.. It asked provinces to learn the job while support remained long enough to build a stable operating system.
What made Southern Province work
When PEPFAR entered Zambia in 2004, AIDS-related illness was killing more than 200 people every day.. The early gains came quickly, in part because NGOs could bypass weaker government structures and expand services fast.. But officials also understood what that speed could hide: a system that functioned only because outside partners were doing the heavy lifting.
In Southern Province, leadership and flexibility became the turning point.. After PEPFAR funding began moving toward provinces through CDC cooperative agreements—first in 2013 and then with renewed momentum in 2019—local officials said they needed less micromanagement and more room to hire. buy equipment. and keep facilities running.
Training and data systems were central to that handoff.. NGOs did not disappear; they increasingly embedded mentors in clinics to identify gaps. train government health workers. and help staff manage patient needs beyond HIV specialty care.. Facilities also strengthened monitoring by placing data officers widely across clinics and holding regular virtual meetings to troubleshoot using service records rather than guesswork.
Misryoum finds that this transition relied on a harder, more political ingredient too: convincing public agencies that they were ready to be responsible for outcomes long treated as someone else’s job. A provincial health director described the challenge as accepting the program must now be “us.”
The cost—and the risk of export
Southern Province was able to assume near-total control of its HIV response by 2024, and outcomes reportedly improved as more patients stayed on treatment. Officials also described cost declines after early transition years, suggesting that once systems stabilized, the spending burden eased.
But the model’s success doesn’t automatically translate into exportability—especially when the U.S.. moves quickly.. Critics argue that direct government financing demands time, monitoring capacity, and enough money to cushion the shift.. Even advocates of government-to-government financing acknowledge that the work is not a simple swap of funding channels; it is a rebuilding of operations.
Misryoum’s reporting highlights the strain points exposed when aid is paused and then partially restored.. Even when clinics maintained baseline services during the initial freeze, subsequent cuts reduced staffing and follow-up capability.. A former role tied to identifying patients who missed appointments was eliminated. and the impact showed up quickly in the form of treatment interruptions.
That gap matters because HIV care is not only about dispensing medication. It is about tracking who is falling behind, re-engaging patients who miss visits, and preventing small disruptions from turning into larger clinical setbacks.
Outreach vs. clinics: who gets left behind
Zambia’s transition also exposes a policy tradeoff that policymakers may want to avoid when trying to scale a “direct financing” approach: whether clinic-based efficiency crowds out outreach services that reach people most likely to avoid formal health systems.
Community-based volunteers. for example. have long helped test patients at home and deliver medication. including to people who may fear stigma or legal consequences.. In Zambia. Misryoum heard from community leaders who worry that when provinces prioritize clinic operations—often because they are easier to measure—vulnerable populations who depend on outreach can fall through the cracks.
Elizabeth Phiri’s experience reflects the human cost of that tension.. After her husband died of AIDS-related complications, she became a community volunteer.. She said she continued even after hundreds of volunteers lost funding during the shift toward direct financing. and that replacement did not arrive quickly enough.. Her client Jessie Muleya. a mother of four who sells groceries from her yard. described dependence on Phiri to bring medications from a nearby clinic every six months.
Misryoum’s analysis is that these stories underline a central policy question: can provinces build public capacity for both facility care and community outreach at the same time—especially when the U.S. begins narrowing its role?
What the U.S. is trying to do—and what’s missing
The Trump administration has framed direct government financing as a path to sustainability. part of a broader “America First Global Health Strategy” that emphasizes lower costs and country ownership.. Misryoum observed that Washington has negotiated agreements with partner countries meant to replace NGO-centric implementation with government-to-government funding.
But critics argue the execution risk is high, particularly when agreements reduce U.S.. funding over time and require benchmarks that depend on bureaucracies already under strain.. They also warn that when expertise is removed—either by shrinking or reshaping implementers—countries may lose the operational know-how that makes transitions work.
Misryoum also sees a timing problem.. Southern Province’s transition took years; what looked manageable when funding levels remained stable can become destabilizing when cuts accelerate.. And even when governments initially step in. they may struggle to retain experienced staff who were hired to run a parallel system.
For now. Zambia offers a qualified lesson: directly funding governments can be a viable starting point for protecting HIV services. but it is not a shortcut.. If the U.S.. and partner countries move faster than capacity can absorb. the very sustainability gains that officials seek can unravel—one follow-up visit. one outreach worker. and one missed appointment at a time.
The real test is continuity
Misryoum’s reporting suggests the question for policymakers is less whether the model can work in the abstract. and more whether it can maintain continuity when shocks hit.. Zambia’s southern clinics survived the initial pause better than many regions—but provinces are still absorbing the aftereffects.
The most sober warning in Southern Province may be the simplest: change is a process, and speeding it up can produce outcomes that do not match the plan.
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