TB programs offer one of the highest known returns on health investment — $56 for each dollar invested. U.S. funding makes an enormous difference: TB incidence in the 23 countries with USAID TB funding has fallen by 25% since 2000 and by 6% from 2014 to 2017, which is six times greater than in countries not receiving U.S. bilateral assistance.
Reductions in U.S. assistance for TB would cost lives, lose valuable momentum gained from prior investments, and place people in the United States at greater risk for TB. Current USAID TB funding represents just 2% of the $8.69 billion provided to global health programs at USAID and the Department of State.
Domestic funding within affected countries is important. Yet even in the most optimistic scenarios for increased domestic funding, and assuming that Global Fund investments in TB continue, a large funding gap remains in countries eligible for Global Fund assistance: $7.4 billion over 5 years.
Of particular concern is drug resistance. Treating MDR-TB involves 250 injections and 15,000 pills over a two-year period, along with side effects that often include permanent hearing loss. The five-year survival rate for XDR‑TB is just 20%, which is worse than the rate for most forms of cancer. Even with the National Action Plan in place, USAID has reported to Congress that “additional resources will be required” to reach planned objectives. Innovations can now dramatically shorten treatment, reduce side effects, and improve outcomes — provided they reach patients in need.
The global TB epidemic increases health costs in the United States. A CDC analysis of MDR-TB and XDR-TB cases in the United States from 2005 to 2007 found that direct costs resulting from these cases totaled approximately $53 million, plus $100 million in direct-plus-productivity-loss costs. CDC estimates for the cost of U.S. TB cases in 2016 totaled $450 million. Given the nature of this disease and origin of cases, a strategy of strengthening the southern U.S. border would, by itself, do little to reduce this problem.
The rate of new TB cases declined by 1.9% between 2015 and 2016, but this must accelerate to a 4%-5% decline per year by 2020 to reach the first WHO End TB Strategy milestones. Fortunately, faster progress is possible due to recent advances in diagnosis and treatment, as well as growing political will and community engagement.
In 2018 the UN High Level Meeting (HLM) on TB provided an unprecedented political opportunity to address this long-neglected issue. At this historic meeting, 120 countries agreed to ambitious new detection, treatment, and prevention targets. In Congress, 106 members of the House and 43 members of the Senate signed bipartisan letters urging the administration to prioritize the HLM and leverage its findings to accelerate progress against TB., At the meeting, USAID announced a new initiative, the Global Accelerator to End TB, which helps countries meet the commitments outlined in the UN Political Declaration on the Fight Against Tuberculosis. This initiative would work directly with local entities, including faith-based and other community organizations, to provide accessible services in TB priority countries. USAID also committed to increasing U.S. support for India, which has the largest TB epidemic in the world.
With increasing buy-in at the highest political levels of key countries, USAID and CDC support can do even more to strengthen national programs and leverage Global Fund grants. The United States now has an unprecedented opportunity to lead the world in ending the TB threat to global health security.