Tuberculosis has long been the neglected stepchild of global health – but new diagnostic tools and treatments, artificial intelligence (AI) and debt swaps to help countries meet their targets have come into play and are making a difference. 

“There is fresh momentum,” says Dr Jamie Tonsing, Senior TB advisor at the Global Fund, in a wide-ranging interview with Health Policy Watch.

“I’ve just come back from a meeting in Manila, where the discussion was all around AI for TB,” she adds.

One of these involves an AI tool that can read chest X-rays and predict whether a person is likely to have TB.

“The chest X-ray goes into the computer and the image is read by software and gives you a threshold above which a person is likely to have TB,” explains Tonsing.

“It’s a screening tool that needs to be followed by a proper molecular test. But this is very exciting because we don’t have radiologists everywhere, and TB is often in the most hard to reach, vulnerable population groups.”

Up to 50% of people with TB do not have the classical symptoms of TB, Tonsing adds.

“So the only way they will be diagnosed early and before they have symptoms is when they do a chest X-ray. And so that’s why we’re very excited by this new advance in technology.”

Those with TB can be started on treatment immediately. Children under the age of five and people living with HIV who don’t have TB but have been exposed to someone with the disease, can be given TB preventive treatment to protect them.

Over three-quarters of international financing for TB comes from Global Fund, which also spends around $150 million per year to new digital tools. These are being used in places like Bangladesh, Paraguay and Indonesia to screen people in remote areas.

Bangladesh, is using digital X-rays with AI and telemedicine to rapidly screen people for TB, while health workers in Paraguay, are using portable X-ray machines and AI technology in prisons screen and diagnose people with TB fast, according to Dr Mohammed Yassi, the Global Fund’s TB advisor.

Cheaper testing for drug-resistance

GeneXpert diagnostics have become the gold standard for TB testing, particularly for drug-resistant TB (DR TB), which is difficult to diagnosis through the traditional sputum smear technologies or chest X-rays.  GeneXpert can rapidly detect rifampicin-resistant TB (a proxy for DR-TB diagnosis) along with drug-susceptible TB.  But the diagnostic machines need electricity and are expensive to operate.

Four years ago, the World Health Organization (WHO) endorsed another rapid molecular test called Truenat, which is also able to detect DR-TB – but is cheaper than GeneXpert and can run on batteries.

The Global Fund and Stop TB Partnership have signed an agreement with Truenat’s manufacturer, Molbio Diagnostics, to provide the machines at a reduced price in all countries that are supported by the two organisations and USAID.

In theory, results from these machines are supposed to be processed in two hours. But in practice, it usually takes clinics a few days to process.

“We need to find the people we are missing. So despite all the good progress, our global detection rate is 77% and we have said we need to get that up to 90%. So all the innovations are important, but what we also really need is point-of-care rapid tests like we have for malaria and HIV,” says Tonsing.

“In the past year, the Global Fund secured a 20% reduction in the price of the most commonly used molecular diagnostic test and a 55% reduction in the price of a key treatment for multidrug-resistant TB,” according to Peter Sands, executive director of the Global Fund.

Better treatment for DR TB

People with DR-TB used to spend 12 to 24 months in hospital, and take lots of pills and injections. But in May 2022, this changed dramatically when the WHO recommended an all-oral six-month regimen known as BPaLM –  a regimen of bedaquiline (B), pretomanid (Pa), linezolid (L) and moxifloxacin (M).

“The shorter duration, lower cost, lower pill burden and high efficacy of this novel regimen should enable much better treatment and treatment outcomes.. while also helping health systems to provide care for more people,” the WHO announced.

But the challenge is to ensure that countries adopt the new guidelines. Drug resistant TB is very high in the central region of Eastern Europe, but the management of TB is still  centralised with people still being admitted to hospital for months in many countries. 

The Global Fund is investing in BPalM, and encouraging countries to adopt the regimen, allow patients to stay at home and train staff and civil society organisations about how it works.

Innovative financing

COVID has depleted many countries’ budgets, especially in the low-and middle-income countries most likely to be struggling with TB.

“Domestic budgets for TB are often not being increased commensurate with the need,” says Tonsing. “Every year, we get around $5 billion for the global TB response whereas the need is around $13 billion, so that gap is huge.”

Since 2017, the World Bank and the Global Fund have supported many countries by investing with blended finance transactions. For example, a loan buydown in India was tied to increased domestic financing for TB care and prevention. 

Debt2Health is an innovative financing mechanism designed to increase domestic financing in health by converting debt repayments into investments in public health programmes. Under individually negotiated “debt swap” agreements, a creditor nation forgoes repayment of a loan when the beneficiary nation agrees to invest all or part of the freed-up resources in a Global Fund-supported programme.

For example, in April 2021 Germany, Indonesia, and the Global Fund signed an agreement to  increase support to TB in Indonesia by converting €50 million of debt owed by Indonesia to Germany into investments in public health programmes supported by the Global Fund in Indonesia.

Still off track

“We have recovered from COVID-19 and in 2022, a record number of TB cases were identified – 7.3 million out of 10.6 million estimated cases. That’s a big new high and we  think, once we get the 2023 data, it will easily cross over eight million,” says Tonsing.

“So we’re getting back on track after being off track but but I don’t think we will be able to make it to the UN high level meeting, or even the 2030 SDG targets.”

Image Credits: Socios en Salud, Marc Bader/ The Global Fund, Dato Koridze .