The U.S. Government and Global Tuberculosis Efforts

Key Facts

• Since the World Health Organization declared tuberculosis (TB) to be a global health emergency in 1993, global efforts to address TB have become more prominent, and worldwide TB incidence and mortality rates have fallen. Still, in 2021, there were an estimated 10.6 million new cases of TB globally, including 703,000 new cases in people living with HIV.
• In response to the persistent challenges related to TB, including drug-resistant TB, the U.N. General Assembly held its first-ever high-level meeting on TB in 2018 to discuss these challenges and examine progress toward global goals, including ending the epidemic by 2030. The second high-level meeting will take place on September 22, 2023, to review progress achieved thus far.
• U.S. government (U.S.) involvement in global TB efforts was relatively limited until the late 1990s. Since that time, its efforts to address TB have grown, and now the U.S. is one of the largest donors to global TB control.
• U.S. TB activities reach more than 50 countries (including at least 20 of the 30 high burden countries where most new cases are occurring), and focus on preventing, detecting, and treating TB, including drug-resistant TB, as well as research and development.
• U.S. funding for global TB efforts was $406 million in FY 2023, up from $233 million in FY 2013. Additionally, the U.S. is the largest donor to the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund).
• The COVID-19 pandemic further complicated TB efforts, as it disrupted access to TB detection and enrollment of individuals in services, and TB cases and deaths increased during the pandemic, reversing years of decline.

Global Situation

Tuberculosis, an infectious disease caused by bacteria, is a leading cause of death worldwide, despite being preventable and often curable. Approximately a quarter of the world’s population has “latent” TB, meaning they have been infected by TB bacteria, but are not yet ill with the disease and cannot transmit it (see box below); about 10.0 million develop “active” TB each year, which can be spread to others. When a person with active TB coughs, sneezes, or spits, the bacteria spreads into the air where it may be inhaled by and infect others. According to the World Health Organization (WHO), people with active TB can infect up to 5-15 other people through close contact over the course of a year. TB is found all over the world, though the vast majority of TB cases are concentrated in a handful of countries in Southeast Asia, Africa, and the Western Pacific region. People in resource-poor settings, especially those living in poverty or in crowded living conditions with poor ventilation (e.g., prisons or mines), are disproportionately affected.

In the 1990s and early 2000s, concern about rising incidence in some areas, new outbreaks, TB/HIV co-infection, and the emergence of TB drug resistance prompted key global health actors and governments, including the U.S. government, to make preserving and advancing the progress of global efforts against TB a priority. In 1993, WHO declared TB to be a global health emergency. Since then, global efforts to address TB have become more prominent and global TB incidence and mortality rates have fallen overall. Still, significant challenges remain, with COVID-19 having further complicated TB efforts, disrupting access to TB detection and enrollment of individuals in services, and TB cases and deaths increased during the pandemic, reversing years of decline. Preparations are currently underway for a U.N. high-level meeting on TB in September 2023 to review progress toward ending TB since the first such high-level meeting five years ago.

Morbidity and Mortality

• In 2021, there were 10.6 million new cases of people who developed active TB disease. Although active TB is treatable and curable in most cases, an estimated 1.6 million people died from TB in 2021, including an estimated 187,000 who were HIV-positive. Globally, between 2015 and 2020, TB incidence fell by approximately 2% per year. Between 2000-2020, global TB mortality among HIV-negative people fell overall, and among HIV-positive people, TB mortality fell even faster. Still, detecting TB cases — and then linking diagnosed cases to treatment — remains a significant challenge, one made even more complicated in the context of COVID-19, which disrupted case detection and treatment services.
• People who suffer from other conditions that impair the immune system (e.g., HIV) are at a higher risk of developing active TB, as are people who use tobacco. TB and HIV are frequently referred to as co-epidemics (or dual epidemics) due to their high rate of co-infection. TB is a leading cause of death among people with HIV, especially in developing countries. In 2021, among the 10.6 million new active TB cases, 6.7% were people who were also HIV-positive, and of the 1.6 million people who died from TB, 11.7% were HIV-positive.
• Drug-resistant TB has emerged as a major challenge to global TB control efforts. Cases that fail to respond to standard first-line drugs are known as multidrug-resistant TB (MDR-TB), while those that fail to respond to both first- and second-line drugs are known as extensively drug-resistant TB (XDR-TB). In 2021, an estimated 450,000 people (up 3% from 2020) developed MDR-TB or resistance to rifampicin (RR-TB), the most effective first-line drug. MDR/RR-TB has been reported in most countries, with 30 countries identified as having a high burden of MDR/RR-TB specifically.

Interventions

The End TB Strategy, the internationally-recognized strategy for ending the TB epidemic, outlines interventions aimed at decreasing TB-related morbidity, death, and transmission. They include:

• early diagnosis of TB via sputum-smear microscopy,
• treatment (usually a six-month course of antibiotics for drug-sensitive TB) and patient support for all people with TB,
• scaled-up diagnosis and management of MDR- and XDR-TB,
• systematic screening for and management of TB among people living with HIV and others in high-risk groups,
• preventive treatment, including TB preventive treatment (TPT) and vaccination for high-risk groups, and
• research and development (R&D) of new tools (e.g., new TB diagnostics, drugs, and vaccines) and improved approaches.

Other interventions include the development of policies and systems that support TB activities, such as improved standardized data collection, quality assurance and rational use of drugs, and monitoring and evaluation of outcomes; sustained political and financial commitment to TB efforts; health systems strengthening; and increased health workforce capacity to respond to TB.

Global Goals

Since the 1993 declaration of TB as a global health emergency by WHO, major global TB goals have most recently been set through the following:

• Adopted in 2015, the Sustainable Development Goals (SDGs) aim to end the TB epidemic by 2030 under SDG Goal 3, which is to “ensure healthy lives and promote well-being for all at all ages.”
• Endorsed by governments at the 2014 World Health Assembly, the End TB Strategy set an overarching goal of ending the global TB epidemic as well as targets for achieving, by 2035, a 95% reduction in TB deaths and a 90% reduction in TB incidence (compared with 2015 levels). It builds on the earlier 2006 international Stop TB Strategy, in which WHO outlined the goal of eliminating TB as a public health problem by 2050. The Global Plan to End TB outlines the steps and resources needed to achieve the End TB Strategy’s goals and is periodically updated by the Stop TB Partnership (an international network of public and private entities working to eliminate TB).
• In 2018, the U.N. General Assembly held its first-ever high-level meeting (HLM) on TB, where world leaders adopted a new Political Declaration that reaffirmed global TB commitments. The Political Declaration also articulated commitments on TB research and innovation, and a framework to help countries implement these commitments – the Global Strategy for Tuberculosis Research and Innovation – was adopted by governments at the 2020 World Health Assembly. The second U.N. high-level meeting on TB will take place on September 22, 2023.

U.S. Government Efforts

U.S. involvement in global TB efforts was relatively limited until the late 1990s. Since that time, its efforts to address TB have grown, and now the U.S. is one of the largest donors to global TB control.

History and Goals

In 1998, the U.S. Agency for International Development (USAID) began a global TB control program, and over the following decade, the U.S. assigned a heightened priority to and provided greater funding for bilateral and multilateral TB efforts.

The passage of the legislation that launched the President’s Emergency Plan for AIDS Relief (PEPFAR) in 2003 placed a heightened priority on U.S. global TB efforts that continues to this day. The U.S. Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 (the legislation that created PEPFAR) included TB under its umbrella, authorizing five years of funding for bilateral TB efforts and the Global Fund to Fight AIDS, Tuberculosis and Malaria (an independent, international financing institution created in 2001 that provides grants to countries to address TB, HIV, and malaria). The Lantos-Hyde U.S. Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008, which reauthorized PEPFAR, set targets for U.S. bilateral TB efforts and authorized another five years of funding. (See the KFF fact sheet on PEPFAR, the KFF fact sheet on the Global Fund, and the KFF brief on PEPFAR reauthorization.)

In 2022, USAID released its eight-year Global Tuberculosis (TB) Strategy 2023-2030, which outlines current U.S. TB goals. These goals include, by 2030, to contribute to:

• a 35% reduction in TB incidence relative to a 2019 baseline,
• a 52% reduction in TB mortality relative to a 2019 baseline,
• diagnosing and initiating treatment on 90% of incident (new cases of) TB and drug-resistant TB,
• maintaining treatment success rates of 90% for individuals with drug-sensitive TB and drug-resistant TB, and
• providing TB preventive treatment (TPT) to 30 million people.

These goals overlap with and reaffirm the U.S. commitment to the WHO End TB Strategy 2030 targets and SDG goal for TB.

The U.S. has also placed a heightened emphasis on addressing antimicrobial resistance (i.e., drug resistance). At the HLM in 2018, the National Institutes of Health (NIH) released the Strategic Plan for Tuberculosis Research, which aims to accelerate its TB research including MDR-TB research. More recently, in 2020, the U.S. released its updated National Action Plan for Combating Multidrug-Resistant Tuberculosis, which identifies interventions and articulates a strategy to respond to the domestic and global challenges of MDR-TB from 2020 through 2025.

Organization

The U.S. Agency for International Development (USAID) serves as the lead implementing agency for U.S. global TB efforts, with other agencies also carrying out TB activities. Collectively, these efforts reach more than 50 countries, including at least 20 of the 30 high burden countries (HBCs, which are designated by WHO as having high numbers of TB cases and collectively account for approximately 86% of new TB cases globally). All U.S. global TB efforts are coordinated under the international working group of the Federal Tuberculosis Task Force (a coalition of federal agencies involved in U.S. global and domestic TB efforts).

USAID TB Program

USAID’s bilateral TB program aims to support specific country needs in 24 priority countries where it currently carries out TB efforts, which are mainly in sub-Saharan Africa, South Asia, and Southeast Asia, and to focus on key interventions, including:

• accelerated detection and treatment of TB for all patients,
• scaled up prevention and treatment of MDR-TB,
• expanded coverage of interventions for TB-HIV co-infection (in coordination with U.S. HIV efforts under PEPFAR),
• improvements in the TB service delivery platforms and overall health system, and
• support for accelerated research and innovation.

The agency reported in early 2022 that in USAID TB priority countries, TB incidence and TB-related mortality had decreased by 25% and 41%, respectively, since 2000.

Other U.S. TB Efforts

The U.S. also supports TB activities through several other agencies, including:

• the Centers for Disease Control and Prevention (CDC), which provides technical support on epidemiology and surveillance, laboratory strengthening, and clinical and program operations, and also supports clinical and operational research;
• NIH, which, as the leading funder of TB research and development (R&D), supports basic, applied, and clinical R&D of new drugs, vaccines, and diagnostics;
• the State Department’s Office of the Global AIDS Coordinator (OGAC), which leads U.S. efforts to address TB-HIV co-infection; and
• the Department of Defense (DoD), whose overseas laboratories help to monitor the quality of TB diagnostic services and conduct operational research.

Multilateral Efforts

The U.S. partners with international institutions and supports global TB funding mechanisms. Key partners include WHO and the Stop TB Partnership. Additionally, the U.S. government is the largest donor to the Global Fund, which has approved nearly $10 billion in funding for TB programs worldwide, and one of the largest donors to the Global Drug Facility (a mechanism of the Stop TB Partnership that provides grants to countries for TB drugs).

Funding

U.S. funding for global TB has grown over the past decade, with much of the increase occurring in more recent years; U.S. funding for TB rose from $233 million in FY 2013 to $406 million in FY 2023 (see figure for the latest information). Additional U.S. support for TB activities is provided through its contribution to the Global Fund. (See the KFF fact sheet on the U.S. Global Health Budget: Tuberculosis and the KFF budget tracker for more details on historical appropriations for global TB.)

Most U.S. bilateral funding for TB is provided through the Global Health Programs account at USAID with additional funding provided through the Economic Support Fund account, as well as funding through CDC. It includes U.S. contributions to the Global Drug Facility.

Key Issues for the U.S.

The U.S. is one of the largest donors to global TB control efforts and has highlighted TB as an important component of its global health investment. Looking ahead, there are several key issues and questions facing the current administration and Congress, including:

• how best to measure and respond to the impact of COVID-19 on TB programs and services;
• what future funding levels will be, and whether it is possible to expand the reach and impact of U.S. programs within funding constraints, including through continuing to address ways to reduce the cost of treatment;
• how to implement U.S.-supported TB control programs in the context of weak health systems, limited laboratory capacity, and treatment barriers and complications;
• how to continue to tackle the emergence of antimicrobial resistance, specifically drug-resistant TB, as well as prepare programs for other emerging health threats;
• the extent to which research and development efforts to advance new drugs and vaccines will be ramped up;
• how to better integrate U.S. global TB programs with other U.S. global health efforts, particularly HIV and maternal and child health; and
• how to further enhance coordination of US-supported TB efforts with those of other donors and international actors, particularly the Global Fund and WHO.