Intensifying efforts to end TB in South Africa

Pretoria - One night in September 2023, 21-year-old university student Sinalo Tungwashe, who had been experiencing flu-like symptoms for some weeks, was roused from a fitful sleep by sharp chest pains. "I was struggling to breathe," he recalls. "I knew that something was not normal. For a second, I thought I was about to die."

The following morning, he went to his local health clinic, where he was diagnosed with tuberculosis (TB), an infectious disease that most commonly attacks the lungs. South Africa has a particularly high burden of TB, with an incidence rate of 468 per 100 000 of the population. In 2022, health authorities recorded an estimated 54 000 deaths from TB. However, with support from World Health Organization (WHO) and partners, the country has become a trailblazer in its bid to tackle this epidemic.

In recent years, South Africa has focused on scaling-up efforts to find people with undiagnosed TB and link them to care as swiftly as possible. In 2021, after COVID-19 lockdowns led to a 20% drop in case finding, the country ramped up rapid diagnostic testing, completing a then-record 1.9 million tests that year; they eclipsed that record in 2023 with 2.7 million tests. Health authorities also launched a new app that allowed people to self-screen for TB at home, intensified efforts to link those who test positive to care and recently implemented an SMS notification system to deliver test results to patients. Combined with other programme interventions, this has led to a 56% reduction in the number of missing TB cases in the country - from an estimated 150 000 in 2019 to 66 000 in 2022.

South Africa has also been among the earliest adopters globally of a novel six-month all-oral regimen recommended by WHO for multi-drug resistant TB (MDR-TB), an acute form of the disease that does not respond to standard TB treatment. MDR-TB has a particularly strong presence in South Africa: the country accounted for 35% of diagnosed cases in the African Region in 2022.

"Previously, part of the problem we had was that people were struggling to stay on the longer regimens we were offering for MDR-TB," says Dr Norbert Ndjeka, Chief Director of TB Control & Management at South Africa's National Department of Health. "We used to give them an 18-month regimen, then it was nine months. Now, at least 90% of people with MDR-TB in South Africa qualify for a six-month regimen. That is really massive in terms of bringing people to care."

After follow-up tests confirmed that Tungwashe was suffering from a form of drug-resistant TB, he became one of the early beneficiaries of this new, shorter regimen. He has since made a full recovery. "Now that I've completed treatment, I can feel that my body is in a better condition," he says. "The medication, the supplements and the different vitamins I was getting helped me a lot."

South Africa's multi-pronged efforts have led to a 53% reduction in its TB incidence rate since 2015, while treatment coverage has increased from 58% to 77% since 2020. Despite this progress, stigma around TB, which is often associated with HIV co-infection, continues to be a barrier to finding and treating people with the disease. So does the impoverishing effect that TB can have on people who are often already socio-economically vulnerable.
While TB services are free in South Africa, the income loss and costs incurred by patients on travel, food, nutrition and accommodation can be significant. Having worked with the Department of Health to generate critical evidence on TB patient costs, WHO also supported the development of a multisectoral accountability framework for TB in 2022. The framework brings together different actors from government departments, civil society and the private sector under the coordination of the South African National AIDS Council.

"Since the framework's release, there has been engagement of non-health sectors to collectively define their contribution to the TB response, with the aim of also addressing the social determinants of TB through the relevant sectors," says Dr Nkateko Mkhondo, Technical Officer for TB at WHO South Africa. "This is an integral part of the country's bid to realize WHO's End TB Strategy Goals."

On the ground within their communities, TB champions have also played a pivotal role. Thembi Nkomo, who lives in the country's eastern Mpumalanga province, has managed to overcome TB more than once while also living with HIV, which makes her more susceptible to the disease.

As a member of a local non-governmental organization that seeks to raise awareness about HIV, Nkomo has taken it upon herself to also inform people about TB. "Without the support and care that I received, I wouldn't be standing here as a TB champion today," she says. "So, I will continue to advocate for people to know about this disease and to seek treatment."

As he finishes up the final year of his studies in financial management, Tungwashe is following in Nkomo's footsteps. "I want to help decrease the stigma around this disease," he says. "I want to continue telling my story and telling people that they can get better."