The U.S. Government and Global Tuberculosis Efforts
- Since the World Health Organization declared tuberculosis (TB) to be a global health emergency in 1993, global efforts to address TB have become more prominent, and worldwide TB incidence and mortality rates have fallen. Still, in 2019, there were an estimated 10.0 million new cases of TB globally, including 815,000 new cases in people living with HIV.
- In response to the persistent challenges related to TB, including drug-resistant TB, the U.N. General Assembly held its first-ever high-level meeting on TB in 2018 to discuss these challenges and examine progress toward global goals, including ending the epidemic by 2030.
- U.S. government (U.S.) involvement in global TB efforts was relatively limited until the late 1990s. Since that time, its efforts to address TB have grown, and now the U.S. is one of the largest donors to global TB control.
- U.S. TB activities reach more than 50 countries (including at least 20 of the 30 high burden countries where most new cases are occurring), and focus on preventing, detecting, and treating TB, including drug-resistant TB, as well as research and development.
- U.S. funding for global TB efforts was $332 million in FY 2021, up from $64 million in FY 2001. Additionally, the U.S. is the largest donor to the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund).
- As COVID-19 continues to exact a toll globally, its detrimental effects on ongoing TB efforts have already been seen, including hampering efforts to identify and treat TB patients.
Tuberculosis, an infectious disease caused by bacteria, is a leading cause of death worldwide, despite being preventable and often curable. Approximately a quarter of the world’s population has “latent” TB, meaning they have been infected by TB bacteria, but are not yet ill with the disease and cannot transmit it (see box below); about 10.0 million develop “active” TB each year, which can be spread to others. When a person with active TB coughs, sneezes, or spits, the bacteria spreads into the air where it may be inhaled by and infect others.1 According to the World Health Organization (WHO), people with active TB can infect up to 5-15 other people through close contact over the course of a year.2 TB is found all over the world, though the vast majority of TB cases are concentrated in developing countries.3
In the 1990s and early 2000s, concern about rising incidence in some areas, new outbreaks, TB/HIV co-infection, and the emergence of TB drug resistance prompted key global health actors and governments, including the U.S. government, to make preserving and advancing the progress of global efforts against TB a priority.5 In 1993, WHO declared TB to be a global health emergency.6 Since then, global efforts to address TB have become more prominent, and global TB incidence and mortality rates have fallen.7 Still, significant challenges remain, and efforts focus on achieving new global TB goals, including ending the epidemic.
Morbidity and Mortality
In 2019, there were 10.0 million new cases of people who developed active TB disease (see Table 1). Although active TB is treatable and curable in most cases,8 an estimated 1.4 million people died from TB in 2019, including an estimated 208,000 who were HIV-positive. Globally, between 2015 and 2019, TB incidence fell by approximately 2% per year. Between 2000-2019, global TB mortality among HIV-negative people fell by 31%; among HIV-positive people, TB mortality fell faster (69%) over the same period.9 Still, detecting TB cases – and then linking diagnosed cases to treatment — remains a significant challenge, one made even more complicated in the context of COVID-19, which has already disrupted case detection and treatment services in some countries.10
|Table 1: Tuberculosis (TB) Cases by Incidence and Mortality, by Region, 2019|
|WHO Region11||# of High Burden Countries||Incidence*||Mortality*
(in thousands, %)
(per 100,000 population)
(per 100,000 population)
|NOTES: * Represents WHO’s “best estimate” for each indicator. Incidence includes HIV-related cases of TB. Global mortality does not include 208,000 deaths due to HIV-related TB. Totals may not sum due to rounding.
SOURCES: WHO, Global TB Report 2020, 2020; KFF analysis of data therein.
Nearly all cases (97%) occur in low- and middle-income countries, particularly in South-East Asia, Africa, and the Western Pacific, as do most deaths. Additionally, thirty countries that have been designated by WHO as having high numbers of TB cases, otherwise known as high burden countries (HBCs), collectively account for approximately 86% of new TB cases globally.
WHO reports that while people of all ages are at risk, TB mostly affects adults during “their most productive years,” posing significant challenges to the livelihoods of individuals as well as to developing economies.13 Additionally, people who suffer from other conditions that impair the immune system (e.g., HIV) are at a higher risk of developing active TB, as are people who use tobacco.14 People in resource-poor settings, especially those living in poverty or in crowded living conditions with poor ventilation (e.g., prisons or mines), are disproportionately affected.15
TB & HIV
TB and HIV are frequently referred to as co-epidemics (or dual epidemics) due to their high rate of co-infection. TB is a leading cause of death among people with HIV, especially in developing countries.16 In 2019, an estimated 815,000 of the approximately 10.0 million new active TB cases affected people who were also HIV-positive, and of the 1.4 million people who died from TB, an estimated 208,000 were HIV-positive.17
Drug-resistant TB has emerged as a major challenge to global TB control efforts. Cases that fail to respond to standard first-line drugs are known as multidrug-resistant TB (MDR-TB), while those that fail to respond to both first- and second-line drugs are known as extensively drug-resistant TB (XDR-TB).18 In 2019, an estimated 465,000 people developed resistance to rifampicin, the most effective first-line drug, and of these, 78% had MDR-TB.19 MDR-TB has been reported in most countries, with 30 countries identified as having a high burden of MDR-TB specifically.20
The End TB Strategy, the internationally-recognized strategy for ending the TB epidemic, outlines interventions aimed at decreasing TB-related morbidity, death, and transmission. They include:
- early diagnosis of TB via sputum-smear microscopy,
- treatment (usually a six-month course of antibiotics for drug-sensitive TB) and patient support for all people with TB,
- scaled-up diagnosis and management of MDR- and XDR-TB,
- systematic screening for and management of TB among people living with HIV and others in high-risk groups,
- preventive treatment and vaccination22 for high-risk groups, and
- research and development (R&D) of new tools (e.g., new TB diagnostics, drugs, and vaccines) and improved approaches.
Other interventions include the development of policies and systems that support TB activities, such as improved standardized data collection, quality assurance and rational use of drugs, and monitoring and evaluation of outcomes; sustained political and financial commitment to TB efforts; health systems strengthening; and increased health workforce capacity to respond to TB.
Since the 1993 declaration of TB as a global health emergency by WHO,23 major global TB goals have most recently been set through:
Sustainable Development Goals (SDGs)
Adopted in 2015, the Sustainable Development goals (SDGs) aim to end the TB epidemic by 2030 under SDG Goal 3, which is to “ensure healthy lives and promote well-being for all at all ages.”24 The SDGs are the successor to the Millennium Development Goals (MDGs), which included a tuberculosis target under MDG 6: to halt and begin to reverse the incidence of TB by 2015.25
End TB Strategy
Endorsed by governments at the 2014 World Health Assembly, the End TB Strategy set an overarching goal of ending the global TB epidemic as well as targets for achieving, by 2035, a 95% reduction in TB deaths and a 90% reduction in TB incidence (compared with 2015 levels).26 It builds on the earlier 2006 international Stop TB Strategy,27 in which WHO outlined the goal of eliminating TB as a public health problem by 2050.28 The Global Plan to End TB outlines the steps and resources needed to achieve the End TB Strategy’s goals and is periodically updated by the Stop TB Partnership (an international network of public and private entities working to eliminate TB).29
More recently in 2018, the U.N. General Assembly held its first-ever high-level meeting (HLM) on TB, where world leaders adopted a new Political Declaration that reaffirmed global TB commitments, including the global target to successfully treat 40 million people with TB and provide preventative therapy to 30 million people by 2022.30 The Political Declaration also articulated commitments on TB research and innovation, and a framework to help countries implement these commitments – the Global Strategy for Tuberculosis Research and Innovation – was adopted by governments at the 2020 World Health Assembly.31
U.S. Government Efforts
U.S. involvement in global TB efforts was relatively limited until the late 1990s. Since that time, its efforts to address TB have grown, and now the U.S. is one of the largest donors to global TB control.32
History and Goals
In 1998, the U.S. Agency for International Development (USAID) began a global TB control program, and over the following decade, the U.S. assigned a heightened priority to and provided greater funding for bilateral and multilateral TB efforts.33
The passage of the legislation that launched the President’s Emergency Plan for AIDS Relief (PEPFAR) in 2003 placed a heightened priority on U.S. global TB efforts that continues to this day. The U.S. Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 (the legislation that created PEPFAR) included TB under its umbrella, authorizing five years of funding for bilateral TB efforts and the Global Fund to Fight AIDS, Tuberculosis and Malaria (an independent, international financing institution created in 2001 that provides grants to countries to address TB, HIV, and malaria). The Lantos-Hyde U.S. Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008, which reauthorized PEPFAR, set targets for U.S. bilateral TB efforts and authorized another five years of funding.34 (See the KFF fact sheet on PEPFAR, the KFF fact sheet on the Global Fund, and the KFF brief on PEPFAR reauthorization.)
In 2015, the U.S. released its five-year U.S. Government TB Strategy 2015-2019, which outlines current U.S. TB goals.35 These goals include, by 2019, to contribute to:
- treatment of 13 million new sputum-smear positive TB cases,
- maintaining treatment success rates of 90% for individuals with drug-susceptible TB,
- diagnosing and initiating treatment of 360,000 new MDR cases of TB,
- providing antiretroviral therapy to 100% of the people diagnosed with HIV and active TB, and
- a 25% reduction in TB incidence relative to a 2015 baseline.
More recently, the U.S. government has affirmed that its TB efforts are working toward achievement of the 2022 goal, established at the HLM in 2018, of treating 40 million people with TB and providing preventative therapy to 30 million people.36
The U.S. has also placed a heightened emphasis on addressing antimicrobial resistance (i.e., drug resistance). 37 At the HLM in 2018 , the National Institutes of Health (NIH) released the Strategic Plan for Tuberculosis Research, which aims to accelerate its TB research including MDR-TB research.38 Most recently, in 2020, the U.S. released its updated National Action Plan for Combating Multidrug-Resistant Tuberculosis, which identifies interventions and articulates a strategy to respond to the domestic and global challenges of MDR-TB from 2020 through 2025.39
The U.S. Agency for International Development (USAID) serves as the lead implementing agency for U.S. global TB efforts, with other agencies also carrying out TB activities. Collectively, these efforts reach more than 50 countries, including at least 20 of the 30 high burden countries (HBCs).40 All U.S. global TB efforts are coordinated under the international working group of the Federal Tuberculosis Task Force (a coalition of federal agencies involved in U.S. global and domestic TB efforts).41
USAID TB Program
USAID’s bilateral TB program aims to support specific country needs42 in 23 priority countries where it currently carries out TB efforts, which are mainly in sub-Saharan Africa, South Asia, and Southeast Asia, and to focus on key interventions, including:
- accelerated detection and treatment of TB for all patients,
- scaled up prevention and treatment of MDR-TB,
- expanded coverage of interventions for TB-HIV co-infection (in coordination with U.S. HIV efforts under PEPFAR),
- improvements in the TB service delivery platforms and overall health system, and
- support for accelerated research and innovation.
The agency reports that in the 23 USAID priority countries, TB incidence and TB-related mortality have decreased by 29% and 47%, respectively, since 2000.43
Other U.S. TB Efforts44
The U.S. also supports TB activities through several other agencies, including:
- the Centers for Disease Control and Prevention (CDC), which provides technical support on epidemiology and surveillance, laboratory strengthening, and clinical and program operations, and also supports clinical and operational research;
- NIH, which, as the leading funder of TB research and development (R&D),45 supports basic, applied, and clinical R&D of new drugs, vaccines, and diagnostics;
- the State Department’s Office of the Global AIDS Coordinator (OGAC), which leads U.S. efforts to address TB-HIV co-infection; and
- the Department of Defense (DoD), whose overseas laboratories help to monitor the quality of TB diagnostic services and conduct operational research.
The U.S. partners with international institutions and supports global TB funding mechanisms. Key partners include WHO and the Stop TB Partnership. Additionally, the U.S. government is:
- the largest donor to the Global Fund, which has approved approximately $7.8 billion in funding for TB programs worldwide, and
- one of the largest donors to the Global Drug Facility (a mechanism of the Stop TB Partnership that provides grants to countries for TB drugs).46
Most U.S. bilateral funding for TB is provided through the Global Health Programs account at USAID with additional funding provided through the Economic Support Fund account,48 as well as funding through CDC.49 It includes U.S. contributions to the Global Drug Facility.
U.S. funding for global TB has grown over time, rising from $64 million in FY 2001 to $332 million in FY 2021 (Figure 1).50 (See the KFF budget tracker for more details on historical appropriations for global TB.) Additional U.S. support for TB activities is provided through its contribution to the Global Fund.
All TB funding is counted as part of overall PEPFAR funding, which also includes funding for U.S. global HIV/AIDS efforts and contributions to the Global Fund.
Key Issues for the U.S.
The U.S. is one of the largest donors to global TB control efforts and has highlighted TB as an important component of its global health investment. Looking ahead, there are several key issues and questions facing the new administration and Congress, including:
- how best to measure and respond to the impact of COVID-19 on TB programs and services;
- how to shape the next five-year U.S. global TB strategy, particularly in light of COVID-19’s impact;
- what future funding levels will be, and whether it is possible to expand the reach and impact of U.S. programs within funding constraints, including through continuing to address ways to reduce the cost of treatment;
- how to implement US-supported TB control programs in the context of weak health systems, limited laboratory capacity, and treatment barriers and complications;
- how to continue to tackle the emergence of antimicrobial resistance, specifically drug-resistant TB;
- the extent to which research and development efforts to advance new drugs and vaccines will be ramped up;
- how to better integrate U.S. global TB programs with other U.S. global health efforts, particularly HIV and maternal and child health; and
- how to further enhance coordination of US-supported TB efforts with those of other donors and international actors, particularly the Global Fund and the WHO.
These bacteria can float in the air for several hours, depending on the environment. Persons who breathe in the air containing these TB bacteria can become infected. Since initial symptoms may be mild for months, people can sometimes delay seeking care, exposing more people to the bacteria.
WHO, “Tuberculosis,” fact sheet, Oct. 2020.
WHO, “Tuberculosis,” fact sheet, Oct. 2020.
CDC, “Multidrug-Resistant Tuberculosis (MDR TB),” fact sheet, May 2016; WHO: “Tuberculosis,” fact sheet, Oct. 2020; Global TB Report 2020, 2020.
WHO, “Global Tuberculosis Programme,” World Health Assembly Resolution 44.8, 1991; WHO, WHO Report on the Global TB Epidemic 1998, 1998; WHO, “Tuberculosis,” fact sheet, August 2002; TB Alert, “TB Timeline,” webpage, http://www.tbalert.org/about-tb/tb-in-time/tb-timeline/; WHO, Global TB Report 2020, 2020.
WHO, TB: A Global Emergency, WHO report on the TB epidemic, 1994.
WHO, Global TB Report 2020, 2020.
Treatment in most cases is usually a six-month course of antibiotics.
WHO, Global TB Report 2020, 2020.
WHO, Global TB Report 2020, 2020.WHO, News release: Global TB progress at risk, October 2020. The Global Fund, Results Report 2020, December 2020.
For definition of WHO regions, see WHO, “About WHO: WHO Regional Offices,” webpage, http://www.who.int/about/regions/en/.
WHO, Global TB Report 2020, 2020. WHO, “Tuberculosis,” fact sheet, Oct. 2020.
WHO, “Tuberculosis,” fact sheet, Oct. 2020.
WHO, “Tuberculosis,” fact sheet, Oct. 2020.
USAID, Committed to Ending TB: Tuberculosis Report to Congress, FY 2016, Feb. 2018.
WHO, Global Tuberculosis Report 2020, 2020; WHO infographic accessed here: https://www.who.int/images/default-source/tuberculosis/global-tuberculosis-report-2020/infographic-page-40d526106fdbe4ff495ac88df9f14252c.png?sfvrsn=78ec2ede_2.
WHO, Global Tuberculosis Report 2020, 2020.
Treatment for these forms of TB “is longer, and requires more expensive and more toxic drugs.” WHO, Global Tuberculosis Report 2020, 2020.
That is, people with MDR-TB have a combined resistance to rifampicin and isoniazid (another key first-line TB drug). WHO: Global Tuberculosis Report 2020, 2020. XDR-TB occurs in a small percentage of MDR-TB cases (6.2% of MDR-TB cases in 2018 were XDR-TB) and has been reported in 128 countries and territories. WHO: Global Tuberculosis Report 2019, 2019.
WHO: Global Tuberculosis Report 2020, 2020.
WHO, “The End TB Strategy,” webpage, http://www.who.int/tb/strategy/en/; WHO, “The End TB Strategy: Global strategy and targets for tuberculosis prevention, care and control after 2015,” 2014, http://www.who.int/tb/strategy/End_TB_Strategy.pdf?ua=1; WHO, “Implementing the End TB Strategy: The Essentials,” 2015, http://www.who.int/tb/publications/2015/The_Essentials_to_End_TB/en/.
No effective vaccine currently exists to prevent transmission of TB. The BCG (Bacillus Calmette-Guérin) vaccine is partially effective in preventing some serious TB complications in children, and is recommended by WHO as a component of routine childhood immunization in countries with a high TB burden. See: “Implementing the End TB Strategy: The Essentials,” 2015, http://www.who.int/tb/publications/2015/The_Essentials_to_End_TB/en/.
WHO, “TB: A Global Emergency, WHO report on the TB epidemic,” 1994.
U.N., Transforming our world: the 2030 Agenda for Sustainable Development, 2015.
U.N., “Official List of MDG Indicators,” webpage, http://unstats.un.org/unsd/mdg/Host.aspx?Content=Indicators/OfficialList.htm.
This means the incidence rate will be an average of less than 10 TB cases per 100,000 population. WHO: “Post-2015 Global TB Strategy and targets,” fact sheet, Dec. 2014; “The End TB Strategy,” webpage, http://www.who.int/tb/strategy/en/; The End TB Strategy: Global strategy and targets for tuberculosis prevention, care and control after 2015, 2014, http://www.who.int/tb/strategy/End_TB_Strategy.pdf?ua=1.
WHO, The Stop TB Strategy, March 2006.
This means that “the global incidence of TB disease will be less than 1 case per million population per year.”
Stop TB Partnership: The Global Plan to Stop TB 2006–2015, Jan. 2006; The Global Plan to Stop TB 2011-2015, 2010; The Global Plan to End TB 2016-2020, 2015; ”The Global Plan to End TB 2018-2022” webpage, http://www.stoptb.org/global/plan/plan1822.asp.
U.N., United to End Tuberculosis: An Urgent Global Response to a Global Epidemic, September 2018; U.N., Political declaration of the high-level meeting of the General Assembly on the fight against tuberculosis, October 2018.
WHO, A Global Strategy for Tuberculosis Research and Innovation, August 2020.
USAID: USAID, Expanded Response to TB, Sept. 2004 and updated Jan. 2009; USAID, Fast Facts: Tuberculosis, Oct. 2010.
U.S. Congress, Public Law 108-25, May 27, 2003; U.S. Congress, Public Law 110-293, July 30, 2008.
U.S. Government (USG), USG Global TB Strategy 2015-2019, 2015. This succeeds the prior five-year Lantos-Hyde USG TB Strategy, March 2010.
USAID, “USAID Global Accelerator to End TB” webpage, https://www.usaid.gov/global-health/health-areas/tuberculosis/resources/news-and-updates/global-accelerator-end-tb.
In 2014, the White House announced the National Strategy for Combating Antibiotic-Resistant Bacteria (CARB) and issued an executive order directing the U.S. government to “work domestically and internationally to reduce the emergence and spread of antibiotic-resistant bacteria.” USAID, “Antimicrobial Resistance and the Threat of Multidrug-Resistant TB,” webpage, https://2012-2017.usaid.gov/what-we-do/global-health/tuberculosis/antimicrobial-resistance-and-threat-multidrug-resistant-tb; White House, Executive Order – Combating Antibiotic-Resistant Bacteria, 2014. See also: USG, National Strategy for Combating Antibiotic-Resistant Bacteria, 2014, https://www.cdc.gov/drugresistance/pdf/carb_national_strategy.pdf; White House, “Fact sheet: Obama Administration Releases National Action Plan to Combat Antibiotic-Resistant Bacteria, 2015, https://obamawhitehouse.archives.gov/the-press-office/2015/03/27/fact-sheet-obama-administration-releases-national-action-plan-combat-ant.
NIH/NIAID, NIAID Strategic Plan for Tuberculosis Research, September 2018.
The National Action Plan for Combating Multidrug-Resistant Tuberculosis was first released in 2015 and then updated in 2020 to reflect its 2020-2025 strategy. USG, National Action Plan for Combating Multidrug-Resistant Tuberculosis, December 2015. USG, National Action Plan for Combating Multidrug-Resistant Tuberculosis, October 2020.
USAID and CDC’s TB efforts together reach more than 50 countries, including those reached through regional efforts as well as PEPFAR-supported TB/HIV efforts. USG, USG Global TB Strategy 2015-2019, 2015; USAID, Report to Congress on the Prevention of Tuberculosis, June 2020; USAID, “Tuberculosis: Countries,” webpage, updated May 8, 2020, https://www.usaid.gov/global-health/health-areas/tuberculosis/countries; CDC, “Global HIV & Tuberculosis: Where We Work,” webpage, updated October 20, 2020, https://www.cdc.gov/globalhivtb/where-we-work/index.html.
CDC, “Federal TB Task Force,” webpage, http://www.cdc.gov/tb/about/taskforce.htm.
As outlined in a partner country’s national TB strategic plan, per the current and prior USG global TB strategies.
USAID, Accelerating Action to End TB fact sheet, February 2020.
U.S. Government (USG), USG Global TB Strategy 2015-2019, 2015.
Treatment Action Group, 2019 Report on Tuberculosis Research Funding Trends, 2005–2018, 2019.
Global Fund: “Data Explorer,” accessed December 2020, https://data.theglobalfund.org/home; Global Drug Facility, “The Global Drug Facility: Access and Opportunity,” brochure, 2009.
KFF analysis of data from the Office of Management and Budget, Agency Congressional Budget Justifications, Congressional Appropriations Bills, and U.S. Foreign Assistance Dashboard website, ForeignAssistance.gov.
Prior to FY13, TB funding was also provided through the Assistance for Europe, Eurasia and Central Asia (AEECA) account, which was eliminated in FY13 and incorporated into other accounts (e.g. GHP and ESF).
Represents specified funding for international TB programs in the President’s budget request, ForeignAssistance.gov, and Congressional appropriations bills. Additional support for international TB programs is provided through bilateral HIV programs at the State Department to address TB/HIV co-infection, for technical support and research activities through the CDC, and for research activities at the NIH. Prior to FY20, global TB funding at CDC was provided through the “HIV/AIDS, Viral Hepatitis, STI and TB Prevention” funding line; in the FY20 Request, the administration proposed to create a new “Global Tuberculosis” funding line under global health programs at CDC and to transfer $7.2 million from the “HIV/AIDS, Viral Hepatitis, STI and TB Prevention” funding line to “Global Tuberculosis” for both FY18 and FY19. The FY20 appropriations bill formalized this transfer. Funding amounts provided through this transfer are not currently available for the years prior to FY18.
FY21 is based on funding provided in the “Consolidated Appropriations Act, 2021” (P.L. 116-260) and is a preliminary estimate. Funding amounts provided through CDC are not currently available for FY01-FY17.