The glaciers of High Mountain Asia, a region which is known as “Asian Water Tower,” supply vital water resources to downstream dryland cities across several countries. Climate change threatens this region by accelerating glacier retreat and altering the timing, quantity, quality and variability of meltwater supply. This article examines how these changes affect water security across glacier-fed river basins and downstream dryland cities. We find that enhanced melt may temporarily augment water availability, but it also heightens the risks of flooding and glacial lake outburst floods (GLOFs) and may encourage socioeconomic development and water demand that become unsustainable after “peak water.” Continued glacier shrinkage will ultimately reduce runoff and threaten long-term water security. Much existing infrastructure and many water governance arrangements were designed using historical records of rainfall, snowfall, ice thickness, runoff timing and peak discharge hydrographs. As these baselines change, design thresholds, reservoir operations and water allocation rules need to be updated using new observations and basin-specific projections. These changes pose particular challenges for dryland cities, where inefficiencies in irrigation systems and limited reservoir regulation constrain the capacity to manage increasingly variable glacier runoff. To address these interconnected challenges, we propose an integrated basin management framework that combines legally and environmentally feasible glacier protection, meltwater storage and seasonal water regulation in upstream areas; ecosystem restoration, carbon sequestration and water retention in midstream areas; and improved water use efficiency, allocation and risk management in downstream cities. Implementation requires transparent monitoring and careful assessment of the environmental, technical, financial, legal and social trade-offs associated with different interventions.