This year’s World TB Day’s theme of increasing commitment, increasing investment and strengthening delivery of services is very appropriate in the era of a new world order and what some have called the end of the golden age of global health consequent to the policy changes by the Trump administration on foreign aid.
How should we respond to this crisis in global health as well as the investment in TB research, development and service delivery?
Based on global health solidarity we can make a case for continued donor funding or we can rethink the commitment and investment, by governments of countries with high TB burdens to invest more in TB research and service provision.
Even without donor support, South Africa has the means to eliminate TB. The government provides significant amounts of funding for diagnosing and treating TB. It provides state-of-the-art laboratory services as well as drugs and has well-qualified health workers to diagnose and treat TB.
However, we know that TB is a social disease – people with poor nutrition and those living and working in overcrowded spaces, for example, are more likely to contract TB. This implies that a whole-of-government approach is needed to eliminate TB.
A good place to start to mark World TB Day is to review where the world and South Africa stand in the fight against TB. According to the 2024 WHO report, 10.8 million people, globally fell ill with TB in 2023 with an incidence rate of 134/100 000. In addition, there were 1.25 million deaths attributable to TB (1.09m of whom were HIV negative and 161 000 who were co-infected with HIV).
What does the South Africa data tell us? Like many parts of the world, the risk factors for TB in the country are being HIV positive (and not on treatment), smoking, use abuse, diabetes and poor nutrition. Among this list, HIV is the most important risk factor in the country – with a co-infection rate of about 50%.
According to the World Health Organization’s 2024 World TB Report, 270 000 South Africans were diagnosed with TB in 2023 with an incidence rate of 427/100 000. This puts South Africa in the company of the highest burden TB countries in the world with people between 24 and 44 years of age more likely to have TB than other age groups and with men in this age group more likely to have TB. We can do much better than this!
We know that many, many people with TB are not diagnosed and are not on treatment. It is estimated that 50% of people with TB do not have symptoms and therefore do not present to clinics and because they are not diagnosed and treated, they spread TB (unknowingly) to others. Others with symptoms delay seeking care in the hope that their symptoms – like cough, chest pains, night sweats, feeling tired, loss of appetite and weight – will disappear.
As many have said repeatedly, TB is treatable and is curable. We have the means to diagnose and treat TB successfully. The treatment success rate is reported to be 71%, those with drug-resistant TB have a treatment success rate of 62% - but those with TB and HIV have a lower treatment success rate of 51%.
This means that we need to do better to ensure that people with TB and on treatment take their medication as prescribed by healthcare workers.
TB drugs are like any other antibiotic – a person prescribed with TB medication must complete the course and NOT stop when they start feeling well which is usually two months after starting on medication as TB treatment is currently 6 months long at least.
Many researchers are working on a range of diagnostics, therapies and vaccines to prevent TB, to diagnose and treatment TB.
Several vaccines, including the M72 vaccine, are being researched in South Africa. The earliest we will know if they work is around 2027/8. While we wait for a vaccine, there is a pill one can take to prevent TB. All people vulnerable to TB, including those with HIV, should take this pill—it is free in public clinics.
As said earlier, we also need to diagnose people (with and without TB) earlier and start them on treatment. This is good for the person’s health and will contribute to reducing the chances of transmitting the bacteria to others.
Researchers are working on swabs that can take samples (in addition to using sputum) and developing testing instruments that can provide a diagnosis while people wait in clinics. This will mean that people can get their results and start treatment on the same day.
Also, researchers are working on developing new TB drugs that can cure a person within 2 months – this means taking TB medication for 2 rather than 6 months. We hope to get many of these innovations within the next few years. In the meantime, we need to use the technology that we currently have – which works as well.
So what do we need to do as South Africans to eliminate TB from our country? Sure, we need to improve the social and economic conditions of people, but we also need to seek care as soon as we have TB symptoms.
For those with no symptoms – we need to advise them to seek a test for TB if they are HIV positive, if they are in contact with someone who has TB and if they have had TB in the past (even after being treated one can get reinfected or the bacteria can become active again). We need to work together like we did during COVID-19 to help each other and the country to eliminate TB in our lifetime. Yes, we can!
* Prof Yogan Pillay is the director for HIV and TB delivery at the Bill & Melinda Gates Foundation. He was previously the Country Director of the Clinton Health Access Initiative in South Africa and senior director for universal health coverage. He has worked in various capacities at the National Department of Health. In 2021, the University of Cape Town awarded him an honorary doctorate, and in the same year, he was appointed extraordinary professor in the Division of Health Systems and Public Health, Department of Global Health, Stellenbosch University.
Foster Mohale is the National Department of Health Spokesperson.