In light of World Tuberculosis Day on 24 March, Prof Nathaniel Mofolo, Head of the Department of Family Medicine at UP, explores the question: can we really end TB?

South Africa is one of the countries most affected by tuberculosis (TB), bearing one of the highest burdens of drug-resistant TB and HIV-associated TB worldwide. Despite some progress – such as achieving a 20% reduction in TB incidence by 2020 – the country faces persistent challenges, including diagnostic gaps, socio-economic disparities and systemic barriers to care.

This year’s theme for World Tuberculosis Day on 24 March – ‘Yes! We Can End TB: Commitment, Investment, Results’ – highlights the urgency of multi-sectoral action. Family physicians, community healthcare workers and innovative therapies are necessary to close the treatment gap, while public education and targeted investments could contribute to dismantling enduring myths and inequities.

The global and local burden of TB

Globally, about 10.8 million people contracted TB in 2023, with 45% of cases concentrated in Southeast Asia and 24% in Africa. South Africa’s TB incidence rate of 206 cases per 100 000 people far exceeds the global average of 134, reflecting its status as a high-burden nation.

The African region reported 2 550 incident cases per 100 000 people in 2023 that were driven by HIV co-infections (6.1% of global cases) and limited healthcare access. While South Africa met the World Health Organisation’s 2020 End TB Strategy milestone, achieving a 50% reduction by 2025 demands accelerated efforts, particularly in rural areas where HIV is prevalent.

Diagnostic and treatment challenges in South Africa

There are significant barriers to early detection. Diagnosing TB in children under five remains a hurdle due to difficulties in sample collection and reliance on clinical judgement at primary care level 3. Nearly 40% of TB cases in South Africa go undiagnosed, with adolescents and elderly populations disproportionately affected. The COVID-19 pandemic exacerbated these gaps, causing a 41% decline in TB notifications in 2020 and disrupting treatment adherence. Even in 2023, 57.8% of undiagnosed cases showed radiographic evidence of TB but no symptoms, highlighting the need for expanded chest X-ray screening.

Drug resistance and healthcare worker vulnerability also pose challenges. Drug-resistant TB accounts for 3% of cases among healthcare workers, who face a threefold higher risk of infection than the general population. Paramedical staff between 25 and 29 years old are particularly vulnerable, with only 22.2% achieving cure rates due to delayed care-seeking and occupational exposure. In KwaZulu-Natal, healthcare workers with extensively drug-resistant TB experienced mortality rates exceeding 40%, underscoring systemic failures in protective measures and treatment access.

Addressing misconceptions

Myths about the disease remain widespread, one if which is that TB is a death sentence, yet the reality is that cure rates exceed 85% for drug-susceptible TB with timely treatment. Another myth is that TB spreads easily, via casual contact – not true. Prolonged exposure is required; sharing utensils poses no risk. Finally, many still believe TB affects only the poor – yet former Miss South Africa Tamaryn Green’s diagnosis underscores its indiscriminate spread.

Socio-economic impact

TB patients in South Africa endure profound economic instability, with 60% reporting income loss during the COVID-19 pandemic. Food insecurity affected 73% of households, forcing many to rely on begging or to skip meals, thereby compromising treatment adherence. Stigma remains pervasive, with 32% of patients in Limpopo attributing TB to witchcraft or curses, delaying diagnosis and fostering isolation.

Frontline defenders

Family physicians are vital in passive and active case-finding, particularly in high-risk groups. The South African TB Recovery Plan emphasises “targeted universal testing”, leveraging primary care networks to identify potential TB patients through symptom screening and contact tracing. In the Eastern Cape and KZN, community healthcare workers have reduced diagnostic delays by 30% through door-to-door screenings and adherence support. Dr Juli Switala of the Aurum Institute advocates for adolescent-focused programmes, noting that hormonal changes during puberty increase TB susceptibility – a factor often overlooked in national guidelines.

Innovations in prevention and treatment

The roll-out of the 3HP regimen (weekly isoniazid-rifapentine for three months) marks a paradigm shift in latent TB management. This regimen, launched via a public-private partnership with immunology healthcare company Sanofi, has improved adherence from 54% to 89% among high-risk groups, including people living with HIV. By 2024, 65% of South Africa’s latent TB patients had transitioned to 3HP, avoiding the traditional 12-month therapy.

Mobile health platforms like TB Connect now are also significant. This tool monitors 40% of patients in Gauteng and Western Cape, using SMS reminders and video-observed therapy to reduce default rates by 22%. These tools are particularly effective in rural areas, where clinic distances exceed 20km for 35% of patients.

Interpreting 2025’s theme: ‘Commitment, Investment, Results’

In South Africa, the theme for World Tuberculosis Day translates in three ways. In terms of commitment, ratification of the TB Recovery Plan, which allocates R1.2 billion to diagnostic expansion and healthcare worker training, by the government is crucial. As for investment, research funding for paediatric TB diagnostics and multidrug-resistant tuberculosis therapies need to be doubled by 2026. With regard to delivery, community-based care must be scaled up to ensure 90% treatment completion by 2025. There is also Deputy President Paulus Mashatile’s launch of the South African National Aids Council (SANAC) Situation Room, which aims to geo-map “missing” TB cases and achieve a 50% reduction in undiagnosed infections by 2027.

The road to elimination: gaps and opportunities

Citizens can combat TB by advocating for destigmatisation campaigns in schools and workplaces; supporting local clinics through volunteer contact-tracing initiatives; and demanding policy reforms, such as paid sick leave for TB patients.

While South Africa’s TB incidence has declined by 2.8% annually since 2015, elimination requires enhanced diagnostics; this can be achieved by deploying GeneXpert Ultra devices to 90% of primary clinics by 2026. It also requires social protection, which can be done by expanding the Social Relief of Distress Grant to cover 100% of TB patients. Finally youth engagement is vital, whereby medical students lead peer education programmes that address adolescent TB risks through school-based screenings.

Professor Graeme Hoddinott of Stellenbosch University urges “participatory research” to co-design interventions with adolescents, whose unique immunological and social needs remain neglected.

Ending TB in South Africa is achievable, but demands political will, equitable resource allocation and community solidarity. By integrating family medicine expertise, leveraging innovations and dismantling systemic stigma, the country can transform its TB narrative from crisis to control. As Deputy President Mashatile said: “You and I must champion this fight – one diagnosis, one treatment and one policy at a time.”

Disclaimer: The opinions expressed in the article are solely those of the author and do not necessarily reflect the views of the University of Pretoria.