Two years ago, South Africa’s life expectancy reached heights never experienced before. This occurred despite the challenges posed by the twin tuberculosis and HIV epidemics. Mother-to-child transmission was at an all-time low of less than 1%. Gains made through scaling up antiretroviral treatment had made a positive impact on tuberculosis incidence and mortality. Overall mortality rates were at their lowest.

But now a pandemic has put all of that at risk.

As the world focused on flattening Covid-19 infections, TB, the bacterium behind the all-time leading cause of death in South Africa raged. Today, as the world prepares to commemorate international World Tuberculosis Day on 24 March 2022, we are faced with the reality that the gains celebrated just two years ago are under threat.

TB testing and diagnosis declined by over 20% during the last two years and for the first time since 2005, TB mortality has increased. This is especially galling since the TB partnership over the last 20 years between government and civil society has been a strong example of an effective public-private partnership that saves and improves lives. 

Yet TB is a leading cause of death in South Africa, and this should not be the case as TB is both preventable and curable. The government pays for both testing and treatment, facilitating access to quality diagnosis and treatment for all. 

Despite this, about 150,000 people with TB are unaccounted for. Half of these individuals remain undiagnosed in communities, and the other half have been diagnosed but not initiated on treatment.

Another concern is that a high number of TB sufferers are asymptomatic and might be spreading the disease without knowing it. To stem this tide, testing must be scaled up to get the TB intervention programme back on track and ensure linkage to quality care to close these gaps.

The Department of Health’s TB Recovery Plan attempts to address this. A key component of the plan is the use of “targeted universal testing for TB”. This approach, based on a demonstration study funded by the Bill & Melinda Gates Foundation, found that about 6% of routinely tested individuals in high-TB risk groups had TB.

One of the advantages of this approach is that it is not symptom-based. It, therefore, responds to the issue of asymptomatic TB found in the National TB Prevalence Survey. People with TB would be diagnosed earlier on, and this could potentially play an important role in reducing TB transmission.

Furthermore, routine testing of people living with HIV, household contacts and those with previous TB provides an opportunity to rapidly ramp up TB testing. The Department of Health has set an ambitious target to increase the number of TB tests done from two to four million in the next financial year.

The TB Recovery Plan leverages experiences from the Covid-19 response. Covid-connect, a self-screening electronic tool, has been adapted as TB Health Check. This is available both on USSD (which is similar to the SMS platform) and WhatsApp for those with data. The tool guides people through a symptom and TB risk-based screen and refers those needing a TB test to local clinics.

Other innovative approaches in the plan include sending TB test results directly to patients, as happened with Covid-19. Tech solutions will also be used to facilitate linkage to care. The way in which Covid-19 data was used in real-time to drive the pandemic response has set the bar for the management of infectious diseases, including TB.

What more can we learn from Covid-19? Covid grabbed everyone’s attention because everyone was equally at risk. TB largely affects the most vulnerable in our society, the poor, the most marginalised — because of this it’s not always seen and is certainly not always top of mind. We all have a role to play in elevating the issue and advocating for the TB Recovery Plan. All sectors and stakeholders will need to be engaged in this effort.

South Africa is an intellectual powerhouse when it comes to scientific advances and many vaccines, cutting-edge treatment and technology solutions have been developed and evaluated here. A more concerted effort is required to ensure that these advances translate into direct benefits for those with TB.

TB ultimately affects us all. But ironically, TB is curable and the treatment is free. This is a battle South Africa can win. Let’s unite to fight for what counts and get back on track towards a TB-free South Africa.

Take the first step by screening yourself using TB Health Check and following the prompts. Let’s all invest in ending TB now. MC/DM

Dr Norbert Ndjeka is South Africa’s National TB Programme Chief Director and Matshidiso Masire is the Bill & Melinda Gates Foundation regional representative for southern Africa.