Successes in HIV Overshadow Failures in TB
July 23, 2015
The world is celebrating a giant milestone in the fight against HIV: 15 million people are now on lifesaving treatment using highly effective antiretroviral drugs! It’s a huge win for global health, and of course for the millions whose lives have been saved. Unfortunately, there’s no reason for a similar celebration for tuberculosis, the disease that takes four thousand lives each day (and is the biggest killer of people with HIV). There’s been progress in reducing deaths and identifying new cases, but the pace of progress is agonizingly slow.
Stop TB, a global partnership of anti-TB groups, reports that tuberculosis “has killed over 30 million people since being declared a public health emergency by the UN in 1993, despite being curable with a six-month treatment which costs less than $25.” And the challenge may be farbigger than previous estimates. New, more intensive prevalence surveys in several big countries like Nigeria and Indonesia show TB prevalence rates at two or three times higher than prior assessments, so there’s good reason to believe that TB may now cause even more annual deaths than HIV. Yet for some reason TB doesn’t seem to spark near the same level of global or local interest.
Repercussions of this second-class status are profound. Look at funding levels, for example: while donors provided about $9 billion for HIV in 2014, the amount for TB ($1.4 billion) was a small fraction of that and is in decline. The Global Fund to Fight AIDS, Tuberculosis, and Malaria, which is the largest source of donor funding for TB, allocates just 18% of its funding to the disease (increased from 16% in 2013). You’ll see a similar pattern for funding research to find new drugs and vaccines. While HIV benefits from awe-inspiring improvements in treatment, the pace for TB treatment has been turtle-slow, especially to treat drug-resistant forms: just two “new” drugs in the last decades; the last TB vaccine, BCG, was discovered in 1908 and though widely used, it does little to slow the epidemic. One reason for the slow pace is that funding for TB research is actually in decline, with the 2012 estimate of $627 million below that of the previous two years. The same is true for U.S. bilateral funding for TB programs, a trend that could lead to what my colleagues call “an open invitation for eventual disease resurgence.”
At the country level, there’s a similar picture. While an exciting new diagnostic tool called GeneXpert, has allowed many more people to be diagnosed with TB, uptake has been disappointingly slow – and even after being diagnosed, many are still not treated effectively even though it’s mostly a curable disease. Those un-treated not only suffer the health consequences but they go on to infect others. Every single individual with un-diagnosed and un-treated TB can infect up to 15 others in a year. Even more worrisome are those who start but don’t complete the six-month treatment regimen since they’re far more likely to develop drug-resistant TB that’s a whole lot more dangerous and expensive to treat. Of course there are a wide range of health system and funding challenges to overcome in most countries, but one of the biggest barriers is the lack ofambition.
We should all celebrate the great news on HIV, though cognizant that there remains a lot of work to do to increase access, especially for marginalized populations. Likewise, we should acknowledge hard-won gains in tuberculosis diagnosis and treatment. But somehow the world needs to get energized on TB. Donors need to increase funding dramatically both for treatment and for research. Countries, especially those with large shares of global TB burden like India, Nigeria, South Africa, and Indonesia need to step up their efforts to find, diagnose and treat people with TB. Providers need to shift to a much more patient-centered approach that uses whatever adherence supports are needed (and no more than that) to help patients take their medicines through to cure. And advocates -- if you’re an HIV advocate, then you have to be a TB advocate, too! -- need to push TB higher up on the political agenda for donors and affected country governments.
In the new world of intensifying budget competition -- flat global health budgets, a widening post-2015 agenda, growing demand to address other non-communicable diseases -- TB is very vulnerable to becoming even more lost. That shouldn’t happen. TB and especially its drug-resistant forms remain a big global threat, including in some of the world’s most populated countries. Indeed, there are lots of reasons to be enthusiastic. Most forms of TB are curable within six months and for not a lot of money; there has been important progress in several big-burden countries like China and South Africa; new technologies have made it far easier to diagnose TB, even where laboratory capacity is limited. So rather than acquiescing to stagnant funding and lowered expectations, maybe it’s time for a more serious and energetic global commitment to TB elimination.
- Nieburg, Phil. “South Africa’s Health Challenges: An Elephant in the Room.” June 3, 2015.
- Nieburg, Phil et al. “Hope for a more reasoned U.S. approach to global TB.” April 15, 2015.
- Nieburg, Phil et al. “Tuberculosis - A Complex Health Threat: A Policy Primer on Global TB Challenges.” April, 2015.
- Interview with Dr. Peter Small. “Promising Developments in Global Tuberculosis Control.” June 28, 2014.
- Check out the whole TB series
Sources for Chart Data
Annual Deaths from HIV and TB:
- HIV data: Roser, Max. 2015. “HIV / AIDS”. Published online at OurWorldInData.org.
- TB data: World Health Organization. "Global Health Observatory (GHO) data: How many TB cases and deaths are there? Situation in 2013."
Donor Funding for HIV and TB:
- Institute for Health Metrics and Evaluation, University of Washington. 2014. "Financing Global Health 2013: Transition in an Age of Austerity (Table B5)."