‘America First’ aid policy reshapes how U.S. delivers global health assistance

Key Concepts

• America First Global Health Strategy: A shift in US foreign aid policy focusing on bilateral deals, recipient government co-financing, and the promotion of American products.
• Lenacapavir (Sunlenca): A long-acting HIV prevention drug administered via injection every six months, boasting near 100% efficacy.
• PEPFAR (President's Emergency Plan for AIDS Relief): The long-standing US program providing HIV treatment to approximately 20 million people globally.
• Bilateralism: The move away from USAID-led multilateral/NGO-based aid toward direct government-to-government agreements.
• Pathogen Sovereignty: The debate over the ownership and economic potential of biological samples and data exported from African nations to the US.

1. The New US Aid Framework

The Trump administration has dismantled USAID and replaced it with a "narrowly focused" bilateral model. Under this strategy:

• Co-financing: Recipient nations (e.g., Kenya, Uganda) are required to contribute significant funding to programs, with the goal of eventually assuming full financial responsibility.
• Direct Engagement: The US now works directly with host governments, bypassing international agencies and NGOs that previously implemented aid programs.
• Strategic Objectives: The policy aims to improve domestic healthcare infrastructure while simultaneously showcasing and promoting American pharmaceutical products.

2. Case Study: Lenacapavir Rollout

Lenacapavir is presented as a "game changer" in HIV prevention due to its six-month dosing schedule.

• Accessibility: While the US list price is $14,000 per dose, Gilead Sciences has entered an agreement to provide the drug at "no profit" for 2 million people in targeted nations.
• Manufacturing: Gilead has licensed six generic manufacturers to produce the drug for 120 low- and middle-income countries, with potential costs as low as $20 per dose.
• Exclusions: Several middle-income countries with high HIV burdens—such as Brazil, Mexico, and Argentina—are excluded from the low-cost generic access, limiting the drug's global reach.

3. Implementation and Infrastructure

• Kenya’s Agreement: A $1.6 billion, five-year deal where the US provides funding and Kenya pledges $850 million. Kenya must share biological samples and data for US-led disease surveillance.
• Local Production: In Uganda, companies like Cipla are positioning themselves to manufacture these drugs locally. CEO Ajay Kumar Pal notes that this could reduce Africa’s 75% reliance on imported treatments, though he emphasizes that success depends on government-led public demand and advocacy.

4. Critical Perspectives and Challenges

Experts and scholars, including Dr. Kenneth Nguri, Dr. Elizabeth Bokui, and Dr. Peter Weisswa, raise several concerns:

• Funding Reliability: History shows that commitments from African governments, often burdened by debt, may not always materialize, potentially leaving gaps in care.
• Narrow Scope: The new strategy prioritizes US-favored products over comprehensive health needs. For example, the focus on HIV prevention excludes family planning services, which many young women in these regions identify as a higher priority.
• Research Disruption: The shift in funding led to the abrupt cancellation of projects, such as Dr. Nguri’s research into combining HIV prevention with contraceptives.
• "Strings Attached": Critics argue that the requirement to export biological samples and data to the US creates an extractive relationship. Dr. Weisswa notes that while clinical trials for these drugs often occur in Africa, the intellectual property and economic benefits remain in the US.
• Geopolitical Leverage: Reports indicate that the US has used aid as leverage for other interests, such as demanding mineral ore shares from Zambia in exchange for health assistance.

5. Synthesis and Conclusion

The transition to the "America First" health strategy represents a fundamental shift from humanitarian-focused aid to a model of economic and strategic partnership. While the introduction of high-efficacy drugs like Lenacapavir offers significant medical promise, the model faces skepticism regarding its long-term sustainability, the exclusion of critical services like reproductive health, and the potential for "biopiracy" regarding the export of biological data. The ultimate success of this policy hinges on whether recipient governments can maintain their financial commitments and whether the US will invest in building local biomedical capacity rather than merely using African nations as sites for clinical trials and data extraction.