America First: does global strategy undermine recent US pledge to Global Fund?

1 December 2025. Related: Special reports, Treatment access, Activism & advocacy.

Simon Collins, HIV i-Base

On 18 September 2025, the US administration published a 36-page public-facing document that sets out a global health strategy centred on putting America first. [1]

Outline and impact on Global Fund

The America First strategy is almost entirely focused on HIV, TB and malaria and are based on negotiating new bilateral agreements by the end of 2025 with most or all of the 71 countries previously supported by PEPFAR. Although these negotiations are already underway, no details have been released.

The strategy is framed by a $4.6 billion budget that matches the recent US pledge to support the eighth replenishment round of the Global Fund, covering the next three years. [2]

However, it only commits to actually investing $1 billion to support frontline diagnostics, treatments and related services, including currently supported health workers – and only for a further year. It also refers to cutting the remaining $3.6 billion which it calls corrupt and wasteful, and that this will be rapidly reduced.

Move to bilateral country agreements: US quarantine and trade benefits

The new strategy moves away from supporting international programmes to using new bilateral agreements with each country. It also moves away from vertical funding for specific conditions to directly funding governments to develop national programmes. However, funding will depend on co-investment from these governments  and countries will need to move to self-reliance by the end of the agreement. (US policy is also contrasted to aid from China that is based on loans).

While the document recognises that PEPFAR saved 26 million lives and prevented 7.8 million babies from being born with HIV,  the primary health goal now will be to prevent infections from reaching the United States.

Rather than primarily improving global health, the America First strategy plans to use diplomacy and foreign assistance to make America safer, stronger, and more prosperous.

Safety is based on physically preventing infections from reaching the US and from protecting American citizens abroad although this is not described in detail. Financial benefits will also come from promoting US business and exporting American health innovations.

Short-term commitments for 2026

The strategy only commits the US to continuing to fund the $1 billion (out of total $4.6 billion PEPFAR funding) for the next financial year (2026). This will only cover what is defined as frontline costs – generally diagnostics, treatment and some related resources, that will then steadily be reduced.

This will include HIV treatments and diagnostics for adults and children, including for advanced HIV. Prevention medication (PrEP), including lenacapavir, will only be available to prevent mother-to-child transmission.

For malaria it will include diagnostics, treatment, vaccines and insecticide-treated nets and for TB it will cover diagnostics, treatments (including for drug-resistant TB) and preventative therapy.

Polio supplies needed to support vaccine programmes will also continue during this year.

Through 2026, the US will also continue to fund the 270,000 doctors, nurses and community health workers that are currently supported. After that financial year, these people will be steadily transferred to local healthcare employers.

The plan states it will rapidly reduce the remaining $3.6 billion that PEPFAR receives for other work that it categorises as being corrupt and wasteful. This unspecified timeline clearly appears to undermine supporting the Global Fund for the next three years. None of the details for the claims of mismanagement are referenced.

Future US funding is dependent on including both the private sector – for data monitoring and reporting – and on working with faith-based organisations.

Monitoring and data collection

One of the most destructive outcomes from US policy changes this year has come from the lack of real-time data on the impact of the funding cuts.  This is because the monitoring networks were also defunded and cut. Tens of thousands of community clinics closed overnight without being able to report the impact on the populations they cared for.

The strategy refers to the previous monitoring as overly complex and wasteful. Future monitoring will be simplified perhaps to only report overall numbers of people reached. Epidemiology will continue to focus on HIV, TB and malaria. New systems will be developed “to prevent and detect fraud, waste and abuse” and to track co-investment by national governments.

comment

Given the record since January of unpredictably cancelling thousands of already approved grants, including ongoing research studies and withdrawing from WHO without notice, the America First strategy reads as undermining the US pledge to the Global Fund in November. [2]

This would also undermine the wider global response to HIV.

However, the strategy is also dependent on the current US administration retaining its political majority, and this might be an important limitation.

Notably, the America First strategy does not include references, so many of its claims cannot be checked. The document os a clear signal for future directions but isn’t directly linked to budget and finance. Hopefully the strong pledges to the Global Fund will be honoured.

Against this background of uncertainty, it is not a good time for the UK to cut support for the Global Fund by £150 million or for other high-income countries to reduce funding. [2] 

Further details and analyses of the US strategy this year are included in a recent Kaiser review. [3]

Reference

1. America First Global Health Strategy. (18 November 2025)
   https://www.state.gov/america-first-global-health-strategy (web page)
   https://www.state.gov/wp-content/uploads/2025/09/America-First-Global-Health-Strategy-Report.pdf (direct pdf)
2. HTB. Global Fund announces $11.3 billion in pledges for eighth round of funding: still $7 billion short. (22 November 2025).
   https://i-base.info/htb/5272

3. Kaiser Family Foundation. The Trump Administration’s Foreign Aid Review: Reorganization of U.S. Global Health Programs. (15 October 2025)
   https://www.kff.org/global-health-policy/the-trump-administrations-foreign-aid-review-proposed-reorganization-of-u-s-global-health-programs