Responding to leading views on the domination of donor states and cooptation of recipient countries in global health programmes, Ricardo Pereira demonstrates that recipient countries hold the capacity to autonomously pursue their own strategies, policies, and ultimately attain political goals, even if highly constrained in their international choices. The analysis of donor-recipient, inter-state relations occurs in the context of the implementation of the United States President's Emergency Plan for AIDS Relief (PEPFAR) in Botswana, Ethiopia and South Africa. The author shows that the three states engage in PEPFAR because it contributes to the accomplishment of their national interests: national survival (Botswana); regime self-help (Ethiopia); and transmission of values (South Africa).