Every day, more than 140 people die from TB in SA, yet TB is both preventable and curable.
Too many people are tested too late, allowing the disease to spread silently through communities and turning a curable illness into a fatal one.
Unlike most other diseases, anyone can contract TB – the bacteria are airborne and just the act of breathing makes us vulnerable to contracting TB. The risk of TB is higher for people with suppressed immunity, malnutrition or living with cancer or HIV.
Reducing deaths from TB depends on earlier diagnosis, yet many people are diagnosed late, often after prolonged illness and only once they reach hospitals with advanced disease. There are some opportunities for improvement.
Firstly, we need to address persistent weaknesses in where and how TB tests are offered.
Secondly, we need to address delays in care seeking and missed opportunities for testing within health facilities.
Finally, we need to close the operational barriers that impede testing.
In recent years, SA took important steps to strengthen its TB response and intensified efforts to find people with the TB disease through implementation of Targeted Universal TB Testing (TUTT).
TUTT is a strategy that promotes systematic testing among high-TB risk groups, like people living with HIV, household contacts of individuals with TB and people with previous TB, irrespective of symptoms.
SA now conducts about 3.6-million TB tests annually, representing a 50% increase compared to pre-Covid pandemic testing. The department of health has announced a national goal of conducting five-million TB tests annually.
Despite strong commitments, TB testing in SA continues to face several structural constraints.
Firstly, the cost of molecular diagnostics limits the scale of testing. Current molecular TB tests cost about R230 per test.
Secondly, inefficient clinic workflows reduce testing coverage. In busy primary healthcare facilities, this leads to missed TB testing, contributing to prolonged diagnostic delays during which transmission continues and disease severity worsens.
Thirdly, many patients, especially children and people living with HIV, can’t produce sputum, which current tests require, further reducing testing coverage.
Fourthly, people with the highest burden of TB, particularly men, often do not attend government clinics.
Just recently, the World Health Organisation updated its recommendations on TB diagnostics, endorsing the use of near-point-of-care tests and the use of tongue swabs for people who cannot produce sputum to expand access to TB diagnostics and improve diagnostic efficiency.
These new tools provide an opportunity to rethink how testing is organised across the health system. Tongue swabs offer a promising alternative sample type, enabling testing among patients who cannot produce sputum. It has also been demonstrated to be more acceptable for patients and providers and is easier to collect in clinics.
At the same time, near-point-of-care molecular platforms (such as Pluslife, a test that has been approved by the SA’s health products regulatory body) offer the potential to diagnose TB closer to the patient.
It substantially reduces costs, to about one-third the cost of current molecular tests, while demonstrating comparable diagnostic performance for TB, making large-scale expansion of TB testing more accessible and affordable.
By delivering results rapidly, within an hour, this technology could enable a test-and-treat approach. TB testing, diagnosis and treatment initiation could all happen during a single primary healthcare visit. This would reduce the time to start treatment and limit the number of patients lost between diagnosis and treatment.
Patients presenting with TB symptoms often move through multiple stages of the clinic process – registration, triage, waiting areas and clinician consultations – before TB testing is considered.
Improving TB testing requires services redesign for patient convenience and accessibility and to be much more systematic. A few simple changes could be introduced.
Firstly, we could introduce a fast-track TB queue, allowing individuals to register digitally and drop off samples without completing a full clinic visit.
Secondly, we could embed TB symptom screening and sample collection at triage or vital-sign stations. Any patient reporting TB symptoms – cough, fever, night sweats, or weight loss – should have a sample collected while waiting to see a clinician.
Thirdly, for people living with HIV, we could introduce twin TB testing with an annual viral load test (or CD4 for newly diagnosed patients) to systematically test all people living with HIV.
Lastly, we could equip facilities with a near-point-of-care testing platform, like Pluslife, to deliver results before the clinical consultation, allowing TB to be diagnosed rapidly and at a lower cost to the health system. It would enable patients to start treatment on the same day.
These approaches could directly address the most persistent diagnostic and linkage gaps in SA’s TB programme.
* Dr Tanna is a senior programme officer for TB, while Dr Pillay is director of HIV and TB delivery at the Gates Foundation
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