gtbr2024

2.3 TB treatment: coverage and outcomes

To minimize the ill health and mortality caused by tuberculosis (TB), everyone who develops TB disease needs to be able to promptly access diagnosis and treatment.

At the second United Nations (UN) high-level meeting on TB in September 2023, Member States adopted a target that, by 2027, at least 90% of the estimated number of people who develop TB disease should be provided with quality-assured diagnosis and treatment (1).

There are still wide gaps between the estimated number of people who develop TB each year (incident cases; see Section 1.1 for further details) and the number of people newly diagnosed with TB and officially reported as a TB case (Fig. 2.3.1). This reflects a mixture of (i) underdiagnosis and (ii) underreporting of people diagnosed with TB to national authorities. At the global level in 2023, the best estimate of the gap was 2.7 million (the difference between a best estimate of 10.84 million incident cases and 8.16 million people who were newly diagnosed with TB and officially notified as a TB case). The gap has narrowed since 2020, a year in which it widened substantially (to a best estimate of 4.3 million) amid COVID-related disruptions in the first year of the pandemic.

Fig. 2.3.1 Number of people newly diagnosed with TB and officially notified as a TB case (new and relapse cases, all forms) (black) compared with the estimated number of people who developed TB (incident cases) (green), 2010–2023, globally and for WHO regions

The shaded area represents the 95% uncertainty interval.


TB treatment coverage can be approximated as the number of people newly diagnosed with TB and officially reported as a TB case in a given year (i.e. the black lines in Fig. 2.3.1), divided by the estimated number of people who developed TB in the same year (i.e. the green curves in Fig. 2.3.1), expressed as a percentage.

Globally, there were steady improvements in TB treatment coverage between 2010 and 2019: from 51% in 2010 (95% uncertainty interval [UI]: 41–64%) to 56% (95% UI: 52–62%) in 2015 and then 69% (95% UI: 65–74%) in 2019 (Fig. 2.3.2). Disruptions during the COVID-19 pandemic then resulted in a sharp reversal of progress in 2020: treatment coverage was only 58% (95% UI: 54–61%), back to the level of 2015. Following the rebound in notifications of people newly diagnosed with TB between 2021 and 2023 (Fig. 2.3.2), TB treatment coverage at the global level appears to have recovered to above pre-pandemic levels (reaching a best estimate of 75% in 2023). Some of the strong rebound in notifications in 2022 and 2023 likely reflects a backlog of people who developed TB in previous years (and were thus not truly “incident” cases), thus distorting estimates of treatment coverage in these years, as well as estimated increases in TB incidence. Further efforts are needed to reach the global target of 90% by 2027.

Trends among the six WHO regions vary. Treatment coverage remained below pre-pandemic levels in the Region of the Americas as well as the European and Western Pacific regions in 2023. TB treatment coverage was highest in the South-East Asia Region (with a best estimate of 78%).

Fig. 2.3.2 Estimated TB treatment coverage,a globally and WHO regions, 2010–2023

The grey dashed line represents the global target of 90% by 2027 that was set at the 2023 UN high-level meeting on TB.
a Notifications of people with a new or relapse episode of TB as a percentage of estimated incident TB cases, in the same year. TB treatment coverage in the European Region in 2023 is underestimated, because at the time the data snapshot for this webpage was taken (29 July 2024), 15 countries had not yet reported notification data for 2023 to WHO. Once data from these countries have been reported, it is anticipated that treatment coverage in 2023 will be similar to the level of 2022.


Among the 30 high TB burden countries, most countries made progress in 2023 but estimated levels of treatment coverage vary considerably (Fig. 2.3.3).

Those with the highest levels in 2023 (>80%) included Brazil, India, Mozambique, Papua New Guinea, Sierra Leone, Uganda and Zambia. As highlighted above for the global level, the estimates for these and other countries may be distorted by strong post-COVID recovery efforts that have resulted in large backlogs of people who developed TB in previous years being diagnosed relatively late, in 2023. It is also possible that the notification data reflect some level of overdiagnosis of TB; for example, the proportion of notified cases diagnosed based on bacteriological confirmation in 2023 was less than 50% in Mozambique, Papua New Guinea and the Philippines (Fig. 2.2.4 of Section 2.2). The underlying estimates of TB incidence may also warrant review and would benefit from new studies (such as a national TB prevalence survey or national TB inventory study) to directly measure the underlying burden of TB disease in the population. For example, the main data source used to inform the current estimates of TB incidence in Uganda and Zambia is national TB prevalence surveys that were implemented in 2015 and 2014, respectively (Section 1.4).

Four high TB burden countries had particularly worrying levels of treatment coverage in 2023, with best estimates of less than 50%: Lesotho, Liberia, Mongolia and Myanmar.

Fig. 2.3.3 Estimated TB treatment coverage,a 2010–2023, 30 high TB burden countries


Estimated treatment coverage is much lower among children than adults (Fig. 2.3.4). Globally in 2023, treatment coverage was 55% (95% UI: 51–60%) among people aged 0–14 years. The best estimate for those aged 15 years and above was 77%.

Fig. 2.3.4 Estimated TB treatment coveragea among people aged 0–14 years and people aged ≥15 years in 2023, 30 high TB burden countries, WHO regions and globally

a Notifications of people with a new or relapse episode of TB as a percentage of estimated incident TB cases. TB treatment coverage in the European Region is underestimated, because at the time the data snapshot for this webpage was taken (29 July 2024), 15 countries had not yet reported notification data for 2023 to WHO.
b Log scale.


In 2023, ten countries accounted for 67% of the global gap between the estimated number of people who developed TB (incident TB cases) and the number of people who were diagnosed with TB and officially reported as a TB case (Fig. 2.3.5). About 50% of the global gap was accounted for by five countries: India (16%), Indonesia (11%), Pakistan (7.8%), China (6.5%) and Myanmar (6.5%).

Fig. 2.3.5 The ten countries with the largest gaps between notifications of people with a new or relapse episode of TB and the best estimates of TB incidence, 2023a

Bubble map of difference between notifications and estimated incidence for 10 countries
a The ten countries ranked in order of the size of the gap between notified cases and the best estimates of TB incidence in 2023 are India, Indonesia, Pakistan, China, Myanmar, the Philippines, Nigeria, Viet Nam, Bangladesh and the Democratic Republic of the Congo.


Among people living with HIV who develop TB, both TB treatment and antiretroviral treatment (ART) for HIV are necessary to prevent unnecessary deaths from TB and HIV. Since 2019, the global coverage of ART for people newly diagnosed and reported with TB and known to be living with HIV has been maintained at a high level; for example, 89% in 2022 and 88% in 2023 (the blue curve compared with the black curve) (Fig. 2.3.6).

However, when compared with the total estimated number of people living with HIV who developed TB in 2023 (the red curve), coverage was much lower, at 58%. This was an increase from 56% in 2022. Among WHO regions, the highest coverage in 2023 was achieved in the African Region (a best estimate of 64%), and the lowest in the Western Pacific Region (a best estimate of 27%).

All coverage estimates for people with TB are far below the overall coverage of ART for people living with HIV, which was 77% (UI: 61–89%) at the end of 2023 (2). The main reason for relatively low coverage remains the big gap between the estimated number of people living with HIV who developed TB in 2023 and the number of people living with HIV who were reported to have been diagnosed with TB in 2023.

Among the six WHO regions, the biggest gaps, where a half of the people living with HIV who developed TB were not reported in 2023, were in the Eastern Mediterranean and Western Pacific regions (gaps of 56% and 48%, respectively).

Fig. 2.3.6 Estimated number of incident cases of TB among people living with HIV (red) compared with the number of people notified with a new or relapse episode of TB who were known to be people living with HIV (black) and the global number of TB patients who were started on antiretroviral therapy (blue), globally and for WHO regions, 2010–2023

The shaded area represents the 95% uncertainty interval.


Among the 30 high TB/HIV burden countries, best estimates of the coverage of ART among people living with HIV who developed TB in 2023 varied widely, from 17% in the Congo to 94% in Mozambique; only 16 of these 30 countries achieved coverage of at least 50% (Fig. 2.3.7).

Fig. 2.3.7 Estimated coverage of antiretroviral therapy for people living with HIV who developed TBa in 2023, 30 high TB/HIV burden countries, WHO regions and globally

a People living with HIV who were newly diagnosed with TB and on antiretroviral therapy, as a percentage of the estimated number of incident TB cases among people living with HIV.
b Data were not reported by China.


Globally, the treatment success rate for people treated for TB with first-line regimens was 88% in 2022 (the latest year for which treatment outcome data are available), and ranged from 72% in the WHO Region of the Americas to 93% in the WHO Eastern Mediterranean Region (Fig. 2.3.8).

Fig. 2.3.8 Treatment outcomes for people diagnosed with a new or relapse episode of TB in 2022, WHO regions and globally


Globally, there were steady improvements in the treatment success rate between 2016 and 2022: from 81% in 2016 to 88% in 2022 (Fig. 2.3.9). The treatment success rate remains lower among people living with HIV, at 79% globally in 2022, although there have been considerable improvements over time.

Fig. 2.3.9 Treatment outcomes for people diagnosed with a new or relapse episode of TB globally, 2012–2022


Among WHO regions, the best treatment success rate among people living with HIV was achieved in the African Region, where the burden of HIV-associated TB is highest (Fig. 2.3.10).

Fig. 2.3.10 Treatment outcomes for people living with HIV who were diagnosed with a new or relapse episode of TB in 2022, WHO regions and globally


Among the 49 countries in one of the three global lists of high burden countries (for TB, HIV-associated TB and MDR/RR-TB) being used by WHO in the period 2021–2025 (see Annex 3 of the core report document), 27 reported treatment outcome data disaggregated by sex; the treatment success rate in women and girls was 89% in 2022, slightly higher than (but very similar to) that among men and boys (Fig. 2.3.11).

Fig. 2.3.11 Treatment outcomes for people diagnosed with a new or relapse episode of TB disaggregated by sex for 27 high burden countries that reported data,a 2019–2022

a WHO has requested data on treatment outcomes disaggregated by sex from the 49 countries in one of the three lists of high burden countries (for TB, HIV-associated TB and MDR/RR-TB) since the 2021 round of global TB data collection. The countries from which such data are requested may be expanded in future (for example, to include all countries with case-based digital surveillance systems for TB).


The treatment success rate for people aged 0–14 years was 90% in 2022 (Fig. 2.3.12). Among the six WHO regions, the best treatment success rate among people aged 0–14 years was achieved in the Eastern Mediterranean Region.

Fig. 2.3.12 Treatment success rates for people aged 0–14 years who were diagnosed with a new or relapse episode of TB in 2022, WHO regions and globallya

a Data were reported by 140 countries on outcomes for 558 202 people aged 0–14 years, equivalent to 91% of the 615 041 cases among people aged 0–14 years that were notified in 2022.


In combination, TB treatment and provision of ART to people living with HIV and diagnosed with TB are estimated to have averted 48 million deaths between 2010 and 2023 (Table 2.3.1). The combination of TB treatment and ART for people living with HIV is estimated to have averted 9.6 million deaths between 2005, the first year following the release of an interim WHO policy on collaborative TB/HIV activities in 2004 (3), and 2023.

Table 2.3.1 Cumulative number of deaths averted by a) TB treatment as well as b) antiretroviral treatment for people diagnosed with TB who were also living with HIV, 2010–2023 (in millions), globally and by WHO region

HIV-negative people
People living with HIVᵃ
Total
WHO region Best estimate Uncertainty interval Best estimate Uncertainty interval Best estimate Uncertainty interval
African Region 5.9 4.9–6.9 5.1 4.4–5.8 11 9.8–12
Region of the Americas 1.2 1.1–1.4 0.25 0.23–0.27 1.5 1.4–1.6
South-East Asia Region 19 16–22 0.91 0.58–1.2 20 17–23
European Region 1.2 1.0–1.3 0.23 0.20–0.27 1.4 1.2–1.5
Eastern Mediterranean Region 3.9 3.4–4.4 0.048 0.034–0.063 3.9 3.4–4.5
Western Pacific Region 9.7 8.7–11 0.33 0.28–0.38 10 9.0–11
Global 41 36–46 6.8 5.9–7.7 48 43–53
a Deaths from TB among people with HIV are officially classified as deaths caused by HIV/AIDS (with TB as a contributory cause). This is the reason why the estimates make a clear distinction between people with and without HIV.


A 4-month regimen composed of isoniazid, rifapentine, moxifloxacin and pyrazinamide (HPMZ) has been recommended by WHO for the treatment of rifampicin-susceptible TB since 2022 (4). For people aged between 3 months and 16 years with non-severe TB, a 4-month regimen composed of isoniazid, rifampicin, pyrazinamide and ethambutol (2HRZ(E)/2HR) has been recommended by WHO since 2022 (5).

By the end of 2023, five countries reported using the 4-month HPMZ regimen (Bosnia and Herzegovina, Georgia, Timor-Leste, Ukraine and the United States of America), and 15 countries and areas reported using the 4-month 2HRZ(E)/2HR regimen: Australia, Dominica, Georgia, Haiti, Morocco, Saint Kitts and Nevis, Saint Vincent and the Grenadines, Singapore, Ukraine, the United Arab Emirates, the United States of America, Uruguay, Venezuela (Bolivarian Republic of), Zambia and the occupied Palestinian territory, including east Jerusalem (Fig. 2.3.13).

Fig. 2.3.13 Countries that reported using 4-month regimens for treatment of rifampicin-susceptible TB by the end of 2023

Countries that reported using 4-month regimens for treatment of rifampicin-susceptible TB by the end of 2023


Further country-specific details about the gap between TB incidence and notifications, estimated levels of TB treatment coverage and treatment outcomes are available in the Global tuberculosis report app and country profiles.

Data shown on this webpage are as of 29 July 2024 (see Annex 2 of the core report document for more details).

 

References

  1. Political declaration of the high-level meeting of the General Assembly on the fight against tuberculosis. New York: United Nations; 2023 (https://www.un.org/pga/77/wp-content/uploads/sites/105/2023/09/TB-Final-Text.pdf).

  2. Global HIV & AIDS statistics – fact sheet [website]. Geneva: UNAIDS; 2024 (https://www.unaids.org/en/resources/fact-sheet).

  3. Interim policy collaborative TB/HIV activities. Geneva: World Health Organization; 2004 (https://iris.who.int/handle/10665/78705).

  4. WHO consolidated guidelines on tuberculosis, Module 4: Treatment – drug-susceptible tuberculosis treatment. Geneva: World Health Organization; 2022 (https://iris.who.int/handle/10665/353829).

  5. WHO consolidated guidelines on tuberculosis: Module 5: Management of tuberculosis in children and adolescents. Geneva: World Health Organization; 2022 (https://iris.who.int/handle/10665/352522).