Experts warn loss of USAID endangers the fight against deadly TB

"USAID tried to focus on the difficult parts," of TB control, said KJ Seung, MD, a DR-TB researcher and assistant professor of medicine at Brigham and Women's Hospital in Boston. "They funded health workers, a lot of support services for patients, and innovative community projects to find new patients."

Cathy Hewison, MD, who heads the TB Working Group for Medecins Sans Frontieres (MSF), said the reduction in TB screening and active case-finding, which had been strongly supported by USAID, is a significant loss. She said many TB patients in high-burden countries either don't have access to healthcare settings where they can get tested for TB or have asymptomatic TB. Going out and finding those patients is critical for prompt treatment and cutting down transmission of the disease.

Hewison said up to 50% of people with bacterially confirmed TB don't display any symptoms, and while it was previously thought that they weren't transmitting the disease, she says there is "more and more evidence" that they are also part of transmission networks.

"If we find those people early, then they're treated early," she said. "As well as reducing transmission, we reduce the severity of their tuberculosis."

Immediate impacts in high-burden countries

Among the countries in which active case-finding has been disrupted by the loss of USAID funding is Cambodia. On January 25, Cambodian NGO KHANA received notice that a $3 million USAID grant for its Community Mobilization Initiatives to End Tuberculosis program, finalized in late 2024, was being suspended. A month later, the group received word that the award had been terminated. 

According to KHANA Executive Director Choub Sok Chamreun, the USAID money supported community health workers in nine high-burden provinces who conducted community and household screenings to identify people with TB symptoms and refer them for diagnostic testing. Once a diagnosis was confirmed, the patients were then immediately connected to government health centers for enrollment in TB treatment. A chart Chamreun shared in an email shows an instant drop in TB case notifications starting in late January.

"The pause, and subsequent termination, of USAID funded TB programs in Cambodia has resulted in a 66% decrease in TB case notifications," he said. "This means that each month, in just the nine provinces covered by this program, hundreds of people sick with TB are going undiagnosed and not able to start treatment."

Cambodia was just one of dozens of countries where the loss of USAID funding has halted TB activities and left people without work. A March report from StopTB Partnership—which works on TB response with more than 2,000 partners and 100 countries and receives roughly half of its funding from USAID—highlighted the impact. In Pakistan, all screening and active case-finding activities in 27 districts have been suspended. In Ethiopia, 5,000 health staff funded by USAID aren't working, severely affecting TB screening and detection. In Nigeria, TB outreach activities have halted.

"The suspension of US Government funding has caused widespread disruptions across multiple aspects of TB response in high-burden countries," StopTB Partnership said.

A loss for patient-support, prevention efforts

Waite says USAID money was also critical for what she calls the "soft infrastructure" of TB treatment, which includes things like TB awareness-raising efforts, stigma reduction, and support programs for people going through TB treatment, which can last for several months. 

"It's a really difficult treatment experience to go through," she said. "If you don't have that emotional support from a peer or somebody who's survived TB themselves, you're more likely to not continue your treatment as prescribed." And that can lead to poorer outcomes.

Chamreun noted that, in Cambodia, many of the people who perform these services are community health workers who are TB survivors themselves. And many are now out of work.

"The ability of CHWs [community health workers] to provide this support has taken a tremendous hit, severely limiting access to care, particularly in rural and high-risk populations," he said. "CHWs are the bridge in connecting affected communities to health care."

Another element of TB control that is seeing the effects of lost funding is TB preventive treatment, which is particularly important for young children who share households with TB patients. In September 2023, United Nations member states set a goal of reaching 45 million people with TB preventive treatment by 2027—a goal now in jeopardy. Hewison said that, since TB preventive treatment is often handled by community health workers through US-funded projects, it's now "falling through the gaps."

"Less than 40% of children worldwide who should receive TB preventive treatment have been given it," she said. "This is a very vulnerable group who—if they're in contact with somebody with tuberculosis—are likely to be infected. They're also likely to get sick, and they're likely more likely to get the severe forms of tuberculosis because their immune systems are less developed."

Seung, who's been involved with USAID projects and works closely with doctors who manage DR-TB patients in Africa, Asia, and Latin America, says he's particularly concerned about the impact on DR-TB patients, who often have a greater need for support and counseling services to adhere to longer treatment regimens. What he's been hearing is that a lot of those services have been cut off, and enrollment of new DR-TB patients has slowed to a crawl. That's a concern because people with undiagnosed DR-TB can transmit their resistant strains to others.

"I'm very worried that we're going to see a lot more DR-TB cases in the future," he said.

'Things were humming along, but we had to cut them all back'

The impact isn't only being felt in the countries most affected by TB.

Richard Chaisson, MD, is the director of the Johns Hopkins University Center for Tuberculosis Research, where he runs the SMART4TB Consortium, a USAID-funded 5-year initiative focused on identifying more effective methods to diagnose, treat, and prevent TB. In 2022, SMART4TB received an award from USAID to fund the work, with a budget of $200 million to be paid out over 5 years. 

"The goal was to create a comprehensive program of both research capacity strengthening and evidence generation for policy for everything related to TB," Chaisson said. SMART4TB's areas of focus included research on optimizing TB diagnostic tests and treatments, preparing for rollout of future TB vaccines, TB transmission networks, and capacity strengthening in high-burden countries. 

Among the projects they have been working on is a clinical trial to evaluate the use of tongue swab samples, rather than sputum samples, on rapid molecular tests endorsed by the WHO. Another is a trial investigating whether a 2-month TB treatment regimen is as safe and effective for children as is the longer 4- to 6-month regimen. Chaisson called these "Cadillac" studies.

But in January, the Trump administration informed SMART4TB that the USAID grant had been eliminated. It was subsequently reinstated, but Chaisson and his colleagues were told that the money they had already received—roughly 30% of the $200 million budget—was all they would get. The group has had to narrow its focus to its work on TB diagnostics and treatment regimens and modify clinical trials to make them less expensive. 

"Things were humming along, but we had to cut them all back," Chaisson said. "I don't want to pretend that 30% of a huge amount of money isn't a lot of money, because it is, but it has certainly cut back our goals and ambitions substantially."

USAID was the third-largest funder of TB research in 2023, with an investment of $41 million, according to a report from the Treatment Action Group (TAG). Mike Frick, TB Project co-director at TAG, said the cuts have been "hugely disruptive" for research projects that were filling important gaps in TB knowledge, like how the disease affects pregnant women and how a future TB vaccine could best be rolled out.

"In particular corners of TB research, they [USAID] were really at the vanguard. And part of the worry, in addition to the loss of funding, is who is going to pick those issues now?" Frick said.

And it's not just the USAID cuts that will limit TB research, Chaisson added. On May 1, the National Institutes of Health (NIH), the largest funder of TB research, announced that it will no longer allow NIH grant recipients to give "subawards" to foreign contractors. That practice is common for US institutions who receive grants for TB research, which is typically conducted in the countries most affected by the disease. 

"Nobody knows what's going on," he said. "All of these grants are in suspended animation."

In addition, Frick noted, 22 TB research grants at NIH have been flagged by NIH because they meet the definition of "dangerous gain-of-function research," an area that's been highlighted by the Trump administration because of its belief that similar research may have been responsible for the SARS-CoV-2 virus. In July, TAG issued a statement opposing the suspension of the funding, saying the projects were basic science studies aimed at improving the fundamental understanding of Mycobacterium tuberculosis, the bacterium that causes TB. 

"When we reviewed the studies that received these [NIH] letters, we found that none of them are doing work that would meet the definition of gain-of-function or that would pose any kind of risk to the public," Frick said.

More cuts could be coming

Frick says what's so regrettable about cutting funding for TB research is that the investments that have been made over the past two decades into new treatments, vaccines, and diagnostic tests were starting to bear fruit. 

"It really did feel like we were on the precipice of transformative change," he said. "Those gains were starting to translate into public health impact. And to cut it off now just feels incredibly wasteful and shortsighted."

Chaisson is equally saddened and frustrated. He ticks off a number of advances that have been achieved with the help of US funding: the development of molecular diagnostic tests that can confirm TB in 90 minutes (down from 4 to 6 weeks), new drugs that shortened the regimen for DR-TB from 2 years to 6 months, and the most promising TB vaccine candidate (the M72/AS01E vaccine) in more than 100 years.

"To walk away from that is heartbreaking, because of the good that it has done and the good that it can continue to do," he said.

For Seung, the concern about the loss of USAID is that even if the State Department does eventually restore some of the funding that's been cut, it could be harder to find local groups to partner with in high-burden countries. "It's going to take them 3 or 4 years," he said. "They don't have the expertise or the relationships."

And there could be more cuts coming. According to KFF, the administration's Fiscal Year 2026 budget request calls for a $228 million reduction for TB, though Congress will have the last word. And it's unclear which of the TB activities formerly overseen by USAID will be taken over by the State Department, which has proposed integrating any remaining USAID activities into its Bureau of Global Health Security and Diplomacy.

At the same time, other countries that have been major financial contributors to global TB control efforts, like the United Kingdom and France, are also pulling back as they adjust their spending priorities amid economic challenges. Hewison says that funding can't be replaced, and it will be hard for national TB programs in low- and middle-income countries, and groups like MSF, to fill those gaps and make headway against the disease.

"TB has always been smarter than us, but we're giving it good conditions to continue to do its damage," she said.