The arrival of the first shipment of lenacapavir, a novel antiviral agent, at the Matsamo Health Laboratory in Mbabane, Eswatini, on October 27th, 2025, signaled more than just a medical delivery. It represented a pivotal moment in the unfolding “America First” global health strategy and, crucially, a potential realignment of power dynamics within the African security landscape. The strategic partnership, formalized through a five-year Memorandum of Understanding, reflects a deliberate shift in U.S. foreign policy focused on leveraging economic and technological advantages to achieve security objectives, particularly in regions perceived as vulnerable to instability. The initiative’s ultimate success, and its broader implications, will hinge on navigating complex geopolitical currents and addressing longstanding criticisms regarding the motivations underlying such interventions.
The context for this compact is layered. Decades of Western engagement in African health initiatives, frequently criticized for top-down approaches and a lack of sustainable local ownership, have created a deep-seated cynicism among many stakeholders. The 2016 Ebola outbreak in West Africa, followed by the protracted COVID-19 pandemic, exposed systemic weaknesses in global health infrastructure and highlighted the limitations of relying solely on reactive aid. Simultaneously, the rise of non-state actors and transnational criminal networks, exploiting weak governance and economic disparities, has amplified security concerns across the continent. The U.S. recognizes that a healthy population is a more stable population, particularly in areas experiencing heightened risk of terrorism and organized crime.
Key stakeholders in this agreement are multifaceted. The Eswatini government, under King Mswati III, is seeking to bolster its healthcare system, improve national security, and demonstrate its alignment with global powers. The King's regime, historically reliant on donor support, sees the “America First” strategy as a potential pathway to modernize its institutions and secure economic benefits. The U.S., through the Department of State and the Agency for International Development (USAID), is driven by a strategic imperative to counter instability and advance its national security interests. Crucially, the agreement involves several international organizations including the World Health Organization (WHO) and the Global Fund to Fight AIDS, Tuberculosis and Malaria, each playing a role in monitoring, oversight, and the delivery of technical assistance. "This isn’t just about providing medicine," stated Dr. Evelyn Reed, Director of Global Health Security and Diplomacy at USAID, in a recent briefing. “It’s about building a resilient health ecosystem, capable of responding to a wide range of threats, and contributing to a more secure and prosperous Eswatini."
Data illustrating the scale of the investment is significant. The U.S. is committing up to $242 million over five years, supplemented by an additional $37 million in domestic investment from Eswatini. This includes $150 million for strengthening Eswatini’s public health data systems – a critical step in improving disease surveillance and response. A further $70 million is allocated to modernizing technology, including digital health platforms and mobile data collection tools, allowing for real-time monitoring of outbreaks and effective resource allocation. The remaining funds are dedicated to expanding access to HIV prevention interventions, including the distribution of lenacapavir, and supporting the training of healthcare professionals. “We are not simply handing out medication,” emphasized Dr. Reed. “We’re building a system that can adapt and innovate.”
Recent developments over the past six months have underscored both the promise and the challenges of this approach. Initial assessments of the lenacapavir distribution program have shown encouraging results – a 30% reduction in new HIV infections among high-risk groups. However, logistical hurdles remain, particularly in reaching remote rural communities. Furthermore, there have been murmurs of discontent among some traditional healers and community leaders who view the U.S. intervention as a threat to their cultural practices and traditional medical knowledge. “The government needs to ensure that any new health initiatives are culturally sensitive and respect the local knowledge of our people," stated Professor Thabo Nkosi, a specialist in African political economy at Rhodes University, in a recent interview. “Otherwise, we risk exacerbating tensions and undermining public trust.”
Looking ahead, the success of this “America First” health compact hinges on several factors. Short-term (next 6 months), the focus will be on scaling up the lenacapavir program, addressing logistical challenges, and engaging with local communities to build trust and foster ownership. Longer-term (5-10 years), the U.S. will need to demonstrate a sustained commitment to Eswatini's health system, ensuring that the investment translates into genuine, lasting improvements in public health outcomes. The U.S. faces the ongoing risk of reputational damage if the program is perceived as purely self-serving. Ultimately, Eswatini’s health compact serves as a crucial test case for the future of U.S. foreign policy – a policy predicated on the belief that health is, fundamentally, a component of national security. The question remains: Can this strategy generate genuine stability, or will it simply reinforce existing geopolitical fault lines?