gtbr2025

Tuberculosis and gender

Tuberculosis (TB) affects individuals of all sexes and genders.1 However, men aged 15 years and older bear a disproportionately high burden of disease, face greater barriers to diagnosis and treatment, and may experience worse treatment outcomes than women.2 The impact of these disparities extends beyond men’s health; recent work suggests that transmission from affected men is responsible for most new infections in women, girls, men, boys (1) and, probably, in people with diverse sexual orientations, gender identities and expressions, and sex characteristics (SOGIESC).

Addressing disparities through gender-responsive approaches to TB prevention and care is critical for achieving equitable health outcomes and accelerating progress towards ending the TB epidemic.

Gender disparities in TB burden and outcomes

In 2024, an estimated 54% of people who developed TB were men, 35% were women, and 11% were children and young adolescents (Section 1.1). National TB prevalence surveys consistently show a higher burden of disease among men than women, with men accounting for 66–75% of adults with TB (Fig. 1) (2–4).

Fig. 1 The male to female ratio of bacteriologically confirmed adult TB cases detected in national TB prevalence surveys implemented 2007–2024a

a Due to laboratory challenges during the survey in the United Republic of Tanzania, it was only possible to directly estimate the prevalence of smear-positive (as opposed to bacteriologically confirmed) pulmonary TB. Results from the survey completed in Timor-Leste in 2023 are not yet published.

Globally, notifications are higher among men than women (Section 2.1), and ratios of prevalence to notifications (P:N) suggest greater gaps in detection and reporting among men in most settings (Fig. 2).

Fig. 2 The P:N ratio by sex for adult TB cases in national TB prevalence surveys implemented 2007–2024a

a The P:N ratio is for smear-positive pulmonary TB, except for Bangladesh, the Democratic People's Republic of Korea, Kenya, Myanmar (2018), Namibia (2018), Uganda, Viet Nam (2017) and Zimbabwe where it was based on bacteriologically confirmed pulmonary TB (following updates to WHO guidance on case definitions used for TB surveillance published in 2014). Prevalence estimates are from a cross-sectional survey, and therefore only represent one point in time. Notification data are from the main year of the survey. Results from the survey completed in Timor-Leste in 2023 are not yet published.

Treatment outcomes also differ by sex: across 31 high burden countries reporting sex-disaggregated treatment outcomes in 2024 (among 49 countries belonging to at least one of the three global watchlists), treatment success rates were slightly higher among women and girls (90%) than among men and boys (87%). However, the proportion of people diagnosed with TB who died after starting TB treatment was 45% higher among men and boys than among women and girls (Section 2.3). Globally in 2024, men accounted for 50% of TB deaths among HIV-negative individuals, while women comprised 34%, and children and young adolescents 16%. Men also accounted for the largest proportion of TB deaths among people living with HIV (51%), followed by women (47%) (Section 1.2).

Understanding drivers of gender disparities

Gender disparities in TB are shaped by biological, sociobehavioural and structural factors, influenced by underlying gender roles and norms.

Health-related risks of TB differ between men and women. Globally, alcohol use disorders and smoking are more prevalent among men (5, 6), while HIV infection is more prevalent among women, although coverage of antiretroviral treatment is lower among men than women (7).

Structural determinants of TB (e.g. poverty, and living, working and gathering conditions) also contribute to gender disparities in TB. Incarceration and occupational exposures (e.g. in the mining sector) increase men’s risk of disease, while precarious informal employment and lack of social protections are cited as key barriers for men accessing TB care (8). TB patient cost surveys indicate that the risk of experiencing catastrophic costs may vary by gender and primary income earner status; however, both male- and female-headed households are vulnerable in different contexts (9).

Community, rights and gender assessments have revealed that women, men and people with diverse SOGIESC face distinct barriers in accessing TB services, including stigma, discrimination, criminalization and exclusion from health systems (10). Gender norms and expectations further constrain access: cultural restrictions and financial dependence may limit women’s access to care (11), while harmful masculine norms may discourage men from seeking care (8, 12).

Ensuring gender-responsive TB prevention and care

The 2023 United Nations high-level meeting on TB reaffirmed global commitments to a people-centred, community-based and gender-responsive TB response (13). Achieving these commitments requires collection and analysis of disaggregated data, programmatic action to address disparities, and gender mainstreaming. These factors are discussed below.

Collection and analysis of disaggregated data

Disaggregated data are essential to identify disparities. Such data should be incorporated into routine surveillance, programme reviews and research activities. Gender analysis should then support targeted action to address inequalities across the TB continuum of care.

In Nigeria, for example, national TB prevalence survey data spurred the expanded collection and analysis of surveillance data disaggregated by sex, helping to identify gaps in detection and reporting (14).

Further disaggregated data are needed to assess gendered differences in economic burden, social impacts and long-term consequences (e.g. post-TB lung disease), and to explore the intersection of gender with other social and political identities.

Programmatic action to address disparities

Collection and analysis of disaggregated data must inform action. TB programmes should implement gender-responsive policies tailored to the needs of different populations.

Prevalence survey results have led to the implementation of targeted TB screening activities to find and treat men in several countries. In Myanmar, screening focused on areas where men predominate (e.g. construction, mining, migrant worker communities and prisons) and was conducted outside regular working hours. Similarly, in the Philippines, screening focused on male-dominated workplaces (e.g. taxi companies and construction sites), and was accompanied by the development of male-specific communication materials and TB clinics operating outside regular office hours (15). Implementation partners and researchers have explored men-only clinics in Lesotho (16), male-friendly TB services in Uganda (17), screening in occupational settings (18), and screening in sociocultural congregate settings in Nigeria (19) and Zambia (20).

These examples demonstrate how programmes can adapt services to reach greater numbers of men and overcome gender-related barriers to care. Further action is needed through multisectoral approaches to address risks of exposure and disease.

Gender mainstreaming

Gender mainstreaming – that is, integrating gender considerations into both programmatic approaches and institutional operations so that all are included – is essential to ensure that TB policies and programmes do not reinforce inequalities (21). This requires the meaningful participation of women, men and people with diverse SOGIESC in the design, implementation and evaluation of TB prevention and care strategies, to ensure that gendered concerns and experiences are considered, and to assess the implications of strategies across genders.

Conclusion

Gender disparities in TB burden, access to care and outcomes are well established. Men bear a higher burden of TB and face significant barriers to care; these challenges also impact the health of women, girls, boys and people with diverse SOGIESC.

Addressing these disparities requires comprehensive, gender-responsive strategies that engage affected populations where they live, work and socialize, while tackling the social and structural determinants, health system barriers and gender norms that perpetuate inequities. Expected benefits extend across the population to women, girls, men, boys and people with diverse SOGIESC.

A gender-responsive approach to TB prevention and care is critical to achieving the goal of ending TB for all.

1 Gender is a social construction that refers to “the roles, behaviours, activities, and attributes that a given society at a given time considers appropriate” for women and girls (22); men and boys; and people with diverse sexual orientation, gender identity and expression, and sex characteristics (SOGIESC) (23). Gender interacts with sex – a biological classification based on genetic, epigenetic and hormonal differences (24) – and with other social and political identities (e.g. age, ethnicity, socioeconomic status, disability and geographic location) to influence biological, sociobehavioural, structural and cultural determinants of health, and to compound inequalities.

2 Although gender is not binary, much of the available data are limited to distinctions between men and women, so our understanding of TB burden and experience among people with diverse SOGIESC is limited (25–27).

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