If we are all working together, the TB Sustainable Development Goals of reducing incidence and death from TB is achievable. Yogan Pillay and Gauran Tanna write that this ambition must be doubled and investment must become even more bold.
There are less than five years before the deadline for the UN Sustainable Development Goals. One of these important goals is to make significant progress in ending tuberculosis, reducing the incidence of disease by 80% and TB deaths by 90%, especially compared to levels in 2015. Another important goal in this quest is to reduce the catastrophic financial burden of vulnerable families fighting illness.
The theme of World TB Day 2025 encourages strengthening our commitment to end TB by increasing investment and improving TB service delivery. It is essential that the country act more urgently.
The world has made great strides in this respect. The World Health Organization’s Global TB report shows that the number of tuberculosis cases in South Africa has been reduced by 561 000 to 270 000 between 2015 and 2023. Seriously, more than half of all TB patients faced catastrophic costs.
HIV is the greatest risk factor for tuberculosis. In South Africa, about half of TB cases also suffer from HIV, making it the world’s largest co-resident population. Scaling up antiretroviral therapy has contributed to lower TB incidence and mortality, but this risk persists unless people continue to treat it.
Diagnosis of tuberculosis
Tuberculosis diagnosis remains a challenge. The test positivity rate in men is almost twice that in women, suggesting that men with tuberculosis are not significantly diagnosed. These people are less likely to have access to health services, and therefore are less likely to diagnose tuberculosis in HIV-infected populations.
Tuberculosis patients experience significant delays in seeking care due to three important barriers.
Financial constraints: Although diagnosis and treatment of tuberculosis in the public health sector in South Africa is free, patients experience costs associated with private sector care, transportation, supplements and lost income, which amounts to more than 20% of the annual household income of more than half of patients surveyed in a study commissioned by the Health Bureau. This will further push the already poor families into poverty.
Healthy Hope: Tuberculosis symptoms such as cough can be easily confused with other conditions or minimized. By the time patients reached the healthcare facility, tuberculosis was often progressing, increasing the risk of severe illness, transmission and death.
Stigma: The fear of discrimination prevents individuals from seeking care.
Until recently, most countries, including South Africa, required symptoms to qualify for tuberculosis testing. Asymptomatic tuberculosis presents a challenge to this paradigm. A 2018 TB prevalence survey in South Africa found that 58% of people diagnosed with tuberculosis were asymptomatic. This suggests that new strategies are needed to ensure early diagnosis and reduce transmission.
Innovative, low cost, screening and testing strategies are essential to combat diagnostic delays. This means detecting tuberculosis before people feel sick, especially for people at the highest risk of tuberculosis. These include people living with HIV, household contacts of people with tuberculosis, people who have been diagnosed with previous tuberculosis, people living in depressed socioeconomic conditions, poor nutrition, smoking, alcohol and excessive use of diabetes.
South Africa can significantly reduce TB burden by expanding active case detection in health facility and community settings, identifying tuberculosis early, ensuring timely treatment, and ensuring curb transmission.
Facility-based active case discovery: Randomized clinical trials found increased diagnosis regardless of symptoms and symptoms with the highest risk of TB. The targeted universal TB testing (TUTT) strategy adopted by the health department contributed to a significant increase in tuberculosis testing, significantly reversing the previous downward trend. However, not all health facilities currently implement loyal TUTT. Low-cost TB testing is also necessary to address affordability. Health Minister Dr. Aaron Mossoaredi has announced an END-TB campaign aimed at testing at least 5 million TBs next year.
Community-based active case discovery: Vietnam shows that systematically screening and testing people in high-burden areas can reduce the prevalence of tuberculosis. Digital Chest X-rays (DCXR) present a viable alternative to less sensitive symptoms screening. The Global Fund is currently funding NGOs to use DCXR to screen their communities. However, this is not scalable assuming an average of 50 people are screened per hour at a cost of R230 per person screened. The shift towards low-cost, ultra-fine digital chest x-ray machines that can be easily transported by backpacks or small vehicles offers a transformative solution. Efforts are also needed to improve demand generation, task change, and throughput.
Although it is well established that tuberculosis is an airborne disease, recent studies have shown that tuberculosis can spread by breathing alone (rather than cough). Further research into bioaerosols is needed, but basic infection prevention and control interventions work, as we saw during the Covid-19 pandemic, when masks were required. Additionally, ventilation – opening windows to trapped spaces and coughing etiquette – coughing sleeves and tissues – both help prevent the spread of bacteria.
The reason for optimism
There is reason to be optimistic that we can reach our end TB target, even after the 2030 deadline set in SDGS.
First, many tuberculosis vaccines are currently being tested, and the M72 vaccine is currently funded by the Gates Foundation and the Welcome Trust in Phase 3 trials. The preliminary results of the exam are expected in 2027. It is the first new vaccine since the development of BCG over 100 years ago, and the first tuberculosis vaccine for adolescents and adults.
Second, ultrafat chest x-rays and low-cost care diagnostic diagnostics for screening have been developed and are expected to be tested locally in the hopes of being deployed by 2026. These diagnoses may allow for the initiation of same-day treatment.
Third, it is well known that TB patients do not complete the six-month treatment as they feel better after 2-3 months. Research is currently underway to assess shorter oral tuberculosis regimens along with longer acting injectables. If it’s affordable, this will reduce the burden on patients and ensure a faster and more sustained treatment for tuberculosis. Violation of tuberculosis treatment regimens leads to the development of multidrug resistance (MDR) and extreme drug resistance (XDR) strains, despite the fact that many people acquire DR-TB through transmission.
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South Africa demonstrates its ambition to invest in its TB programme by expanding its molecular testing using Geneexpert technology nationwide and by adopting bedaquiline early for the treatment of drug-resistant tuberculosis.
The tuberculosis sustainable development goals to reduce incidence and death from tuberculosis are achievable, and five years may be too early. You need to work together. We must double this ambition and make our investment even more bold.
*Dr. Pillay is Director of HIV and TB Delivery, and Tanna is Senior Program Director of TB at the Bill and Melinda Gates Foundation.
Disclosure: The Gates Foundation is mentioned in this article. Spotlight receives funds from the Gates Foundation, but is editorially independent – the independence that the editors jealously. Spotlight is a member of the South African Press Council and is subject to South African Press Law.
Note: We aim to improve our general understanding of important health issues by publishing different views on our opinion page. The views expressed in this article are not necessarily shared by the Spotlight Editor.
