An X-ray of lungs infected with TB. Picture: Luke MacGregor/Reuters

This World Tuberculosis Day, Doctors Without Borders (MSF) profiles five key strategies on which government and donors should focus their finances and efforts in order to end the deadly TB epidemic.
TB is curable, but there are numerous challenges that exist at every level of TB diagnosis and care - not only in South Africa, but around the world, where one person dies every 18 seconds from TB.
Below are the five barriers to effective TB treatment
Barrier 1: Stigma exacerbates the TB epidemic, which is already commonly associated with poverty, risk of disease and death. Around one in three people living with TB do not disclose their diagnosis outside of their household.  “Government should provide education so that people stop gossiping and discriminating against TB patients,” says Nonjabulo Madida from Ngwelezana, KwaZulu-Natal, who was declared cured of DR-TB in 2017. In addition to existing efforts to raise awareness about TB, increased activism from the TB community may help to reduce discrimination and bullying of those living with TB.
Barrier 2: Unidentified TB cases remain a serious concern in South Africa, as TB left untreated allows for further transmission of the disease and leaves people at risk. Approximately one in four people living with the disease in South Africa is never diagnosed.  Preventing TB transmission requires greater investment in screening strategies for TB in communities and health facilities, and ensuring diagnostic tools reach individuals at high risk of TB – such as people diagnosed with HIV, or household members of people known to have TB.
Barrier 3: People with DR-TB shouldn’t have to choose between their lives and their senses – it is time to offer the option to take new drugs from the start of DR-TB treatment. In Mbongolwane, KwaZulu-Natal, 16-year-old Khumbulani Shandu is confined to his home, unable to hear or see as a consequence of receiving the toxic treatments provided for drug-resistant TB (DR-TB). Standard DR-TB treatment includes a painful daily injection of kanamycin that causes hearing loss in up to 60% of those who take it. New treatments such as bedaquiline and delamanid exist, and can replace the injectable kanamycin, but people with DR-TB may only receive newer drugs after they have suffered irreparable harm, if they access them at all.
Barrier 4: Patient support is often lacking to help people cope with the lengthy and challenging treatment for TB. Drugs must be taken for 6 months for drug-sensitive TB (DS-TB), and 9-24 months for DR-TB. DR-TB medicines in particular can cause side-effects that make it difficult to lead a normal life. People living with TB also grapple with logistical challenges and costs of travelling to health facilities, and many simply cannot afford the food they need to eat to improve their odds of successful treatment. While a variety of support mechanisms are essential to support people through their TB treatment journey, one intervention for which funding is needed is to ensure national implementation of a comprehensive counselling support package by trained lay cadres and professional staff.
Barrier 5: The slow pace of decentralising care for DR-TB keeps patients reliant on overcrowded district hospitals for treatment initiation. National Department of Health policy recommends moving management of DR- TB care to primary healthcare facilities, in order to improve access to treatment for people with DR-TB, and lower costs to the health system—but implementation is inconsistent across provinces.
 “Decentralisation makes treatment more convenient for patients, and it makes it easier for clinicians to monitor treatment and manage side effects immediately, minimising poor treatment adherence,” says Dr. Nempumelelo Khumalo, a DR-TB doctor at Catherine Booth Hospital in KwaZulu-Natal. Resources are urgently needed to establish appropriate infrastructure and infection control measures at health facilities, and ensure staff are adequately trained and successfully retained in their roles in decentralised sites.
For the first time ever, world leaders will come together later this year at a United National High Level Meeting in New York, to discuss TB and the steps needed to tackle this global health emergency. This World TB Day, MSF is calling on government and donors to #StepUpForTB, and make the South African response to the TB epidemic an inspiration for the world.
Médecins Sans Frontières