The TB Sustainable Development Goals of reducing incidence and deaths from TB are achievable, if we all work together. We must double down on this ambition and be even bolder in our investments, writes Yogan Pillay and Gaurang Tanna.
There are less than five years to go before the deadline for the United Nations Sustainable Development Goals. One of those key goals is to make massive strides to end TB, specifically to cut the incidence of the disease by 80% and TB deaths by 90% compared to 2015 levels. Another crucial goal in this quest is to reduce the catastrophic economic burden on vulnerable families fighting the disease.
The theme for World TB Day 2025 urges countries to strengthen their commitment to ending TB through increasing investment and improving delivery of TB services. It is imperative that countries act with greater urgency.
The world has made significant strides in this regard. The World Health Organization's Global TB Report shows that the number of TB patients in South Africa halved between 2015 and 2023, from 561 000 to 270 000. The mortality rate however only dropped by 15% from 66 000 to 56 000 over the same period. Critically, more than half of all TB sufferers faced catastrophic costs.
HIV is the largest risk factor for TB. In South Africa, about half of people with TB also have HIV, making it the largest co-morbid population in the world. Whilst the scale-up of antiretroviral treatment has contributed to declines in TB incidence and mortality, unless we are able to keep people on treatment, this risk will persist.
Diagnosing TB
TB diagnosis remains a challenge. The test positivity rate among men is nearly twice that of women, suggesting that men with TB are under-diagnosed significantly. TB in the HIV-uninfected population is also less likely to be diagnosed, as these people are less likely to access healthcare services.
TB patients experience significant delays in seeking care due to three key barriers:
Financial constraints: While diagnosis and treatment of TB in South Africa's public health sector are free, patients experience costs related to private sector care, transport, supplements and lost income that exceeded 20% of their annual household income for more than half of the patients surveyed in a study commissioned by the health department. This pushes already poor families further into poverty.
Poor health seeking: TB symptoms such as cough can be easily confused with other conditions, or minimised. By the time patients reach health facilities, TB has often progressed, increasing the risk of severe disease, transmission, and death.
Stigma: Fear of discrimination prevents individuals from seeking care.
In most countries, including South Africa until recently, one needed to have symptoms to qualify for a TB test. Asymptomatic TB presents a challenge to this paradigm. South Africa's 2018 TB Prevalence Survey found that 58% of people diagnosed with TB were asymptomatic. This suggests that new strategies are needed to ensure early diagnosis and reduce transmission.
To combat diagnostic delays, innovative, low-cost, screening and testing strategies are essential. This means detecting TB before people feel sick, especially for those at highest TB-risk. These include people living with HIV, household contacts of people with TB, people diagnosed with previous TB, those living in depressed socio-economic conditions, with poor nutritional status, smoking, excessive use of alcohol and diabetes.
South Africa can significantly reduce its TB burden by scaling-up active case-finding in health facilities and in community settings to identify TB early, ensure timely treatment, and curb transmission.
Facility based active case finding: A randomised clinical trial found that routine TB testing, irrespective of symptoms, in those at highest TB risk increased diagnosis. The Targeted Universal TB Testing (TUTT) strategy adopted by the health department, contributed to a significant increase in TB testing, substantially reversing the prior declining trends. However, not all health facilities are currently implementing TUTT with fidelity. A lower cost TB test is also needed to address affordability. The Minister of Health, Dr Aaron Motsoaledi, has announced a END-TB campaign, which aims to test at least 5 million people for TB in the coming year.
Community based active case finding: Vietnam has shown that systematically screening and testing people in high burden geographies can reduce TB prevalence. Digital chest X-rays (DCXR) present a viable alternative to symptom screening, which has low sensitivity. The Global Fund is currently funding NGOs to screen communities using DCXR. However, at a cost of R230 per person screened, assuming an average of 50 people screened per workday, this is not scalable. A shift toward lower cost ultraportable digital chest X-ray machines which can be easily transported in back packs and small vehicles, offers a transformative solution. Demand generation, task shifting and efforts to improve throughput are also required.
Whilst it is well established that TB is an airborne disease, recent research has shown that TB can spread by breathing alone (as opposed to by coughing). While more research into bioaerosols is needed, basic infection prevention and control interventions do work as we saw during the height of the COVID-19 pandemic when masks were mandatory. In addition, ventilation - opening windows in confined spaces and cough etiquette - coughing into one's sleeve or a tissue - are both useful in preventing the spread of bacteria.
Reasons for optimism
There are reasons to be optimistic that we can reach the End TB targets - even if it is after the 2030 deadline set in the SDGs.
Firstly, a number of TB vaccines are currently in trials, with the M72 vaccine funded by the Gates Foundation and Wellcome Trust currently in phase 3 trial. Interim results of the trial are expected in 2027. This may be the first new vaccine since the development of BCG more than 100 years ago, and the first TB vaccine for adolescents and adults.
Secondly, ultraportable chest x-rays for screening and low-cost point of care diagnostics are currently being developed and expected to be validated locally, with the hope that these can be deployed by 2026. These diagnostics could enable same day treatment initiation.
Thirdly, it is well known that TB patients often do not complete their 6-months of treatment as they start to feel well after 2-3 months. Research is underway to evaluate a shorter oral TB regimen together with long acting injectables. If affordable, this will decrease the burden on patients and ensure a more rapid and sustained cure for TB. Non-compliance with the TB treatment regimen leads to the development of multi-drug-resistant (MDR) and extreme drug-resistant (XDR) strains of TB, notwithstanding that many people also acquire DR-TB through transmission.
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South Africa has shown the ambition to invest in its TB programme by being the first country to expand molecular testing using GeneXpert technology throughout the country and early adoption of bedaquiline for the treatment of drug-resistant TB.
The TB Sustainable Development Goals of reducing incidence and deaths from TB are achievable, perhaps five years might be too soon. It will need us to work together. We must double down on this ambition and be even bolder in our investments.
*Dr Pillay is director for HIV and TB delivery, and Tanna is senior programme officer for TB at the Bill and Melinda Gates Foundation.
Disclosure: The Gates Foundation is mentioned in this article. Spotlight receives funding from the Gates Foundation, but is editorially independent - an independence that the editors guard jealously. Spotlight is a member of the South African Press Council and subject to the South African Press Code.
Note: We aim to deepen public understanding of important health issues by publishing a variety of views on its opinion pages. The views expressed in this article are not necessarily shared by the Spotlight editors.
