Supporting improved tuberculosis screening in South Africa
Tuberculosis (TB) is the world’s deadliest infectious disease, claiming three lives every minute. South Africa ranks eighth amongst the top 30 high-TB burden countries, accounting for three percent of all TB cases worldwide. South Africa is one of 10 countries that face a triple burden of both drug-susceptible (DS-TB) and drug-resistant (DR-TB), as well as HIV-TB coinfection. TB is the leading cause of death in the country and the high rate of HIV co-infection continues to accelerate the impact of the epidemic.
People infected with TB bacteria have a 10 percent lifetime risk of falling ill with TB. However, those with compromised immune systems, including people living with HIV, malnutrition, or diabetes, and people who use tobacco, have a much higher risk of becoming sick. The national prevalence survey has shown that TB burden is ~1.6 times higher among males than females. TB infection was also found to be higher among individuals aged 35 to 44 years old and those above the age of 65. It is estimated that approximately 150,000 TB cases are missed in South Africa annually.
When a person develops active TB disease, the symptoms, which include cough, fever, night sweats, and weight loss, maybe mild for many months. This can lead to delays in seeking care, and subsequent transmission of the bacteria to others. People with active TB can infect 10 to 15 additional people through close contact over the course of a year.
Stigma and discrimination associated with TB are among the greatest barriers to preventing care-seeking and as result, causing further infections. This means that people living with TB often do not access adequate care, support, and treatment in time. Studies show that women disproportionately bear the burden of caregiving as well as the impact of TB-related stigma.
World TB Day (WTBD) is commemorated annually on March 24 to highlight the impact of tuberculosis. This year’s global theme is ‘Invest to End TB. Save Lives.’ Worldwide, health challenges have proliferated over the past two years and this call reminds us of the unchanged need to intervene to end TB.
In South Africa, this has been extended to “Invest in Action to End TB Now! Get Screened. End Stigma. Save Lives.” This call asks leaders to dedicate sufficient resources to the TB response and urges South Africans to invest in their personal health through existing pharmaceutical and non-pharmaceutical interventions available to support TB patients and end TB. Improving awareness of TB infection among target populations and improving positive practices related to early testing, treatment initiation, and completion, as well as stigma prevention, are critical priorities of CHAI South Africa’s TB Access Program.
With funding from the Bill & Melinda Gates Foundation (BMGF), CHAI is helping the National Tuberculosis Control Program (NTCP) scale up the mobile information platform, TBCheck. The National Department of Health worked with the Praekelt Foundation and BMGF to develop TBCheck which is accessible via WhatsApp and USSD, which allows users to receive information using shortcodes and provides an easy mechanism for TB self-screening by guiding users through a series of questions about themselves and any symptoms they may be experiencing. The platform then provides suggestions on whether users should proceed to test for TB or monitor symptoms; it also alerts the user of their personal risk profile (high, low, etc.). CHAI together with NTCP also work on TBCheck implementation with Stellenbosch University (SUN) which is leading research on behavioral nudges and how these can be used to accelerate screening.
TBCheck offers an exciting opportunity to bring screening closer to those who need it most and accelerate TB case finding by reducing the time to diagnosis, treatment, and care. It moves away from the historical reliance on passive case-finding towards a behavioral change model where citizens’ can take ownership of their health, and actively seek to know their TB status. It is easy to use and subsidized by the cell service provider so all users can access care for free. Therefore, NTCP with support from CHAI and partners, is also aiming to scale up the use of TBCheck to identify and help initiate people with TB into treatment through community-based activities, thereby reducing the spread of TB and easing the burden in South Africa.
In the wake of COVID-19, it is still possible to eliminate TB by investing in tools and approaches that make it easier to reach people where they are, encourage them to take ownership of their health, and become partners in fighting this old but curable disease.