Hold the line: Fulfil the 2027 #EndTB commitments without shifting goalposts

Shobha Shukla / Bobby Ramakant *

Can we ever end tuberculosis (TB) - the deadliest infectious disease on Earth - without ensuring that every single person who takes an initial TB test receives a truly effective one? A test that accurately and rapidly detects active TB disease. A test that misses no one. Because finding TB early and accurately is not optional - it is the indispensable lynchpin, the non-negotiable gateway to the entire treatment and care pathway.

"If we miss people with active TB disease due to a poor test, then we fail to reduce avoidable human suffering and risk of TB death. More worrying is that the infection keeps spreading," said Prevent-Find-Treat ALL TB campaign leader Shobha Shukla. "There is no excuse for inaction since WHO recommended portable molecular tests are available since 2010. We must eliminate deadly delays between scientific breakthroughs and the time by when they translate into public health impact."

As per the latest WHO Global TB Report 2025, almost half (46%) of the TB patients in 2024 worldwide received a poor test – microscopy. Microscopy misses finding TB accurately in half (or more) of those who take this test. It is being used since last 144 years ago when Dr Koch made this TB scientific breakthrough. But in the last two decades, science has gifted us some highly sensitive and specific portable molecular tests to find TB early and accurately - and quite a few of these are WHO recommended.

That is why the highest-level leadership of the UN health agency - World Health Organization (WHO)- had called upon the governments (Find.Treat.All) in 2018 to completely replace microscopy with upfront WHO recommended molecular tests by 2027.

Prior to this, Government of India’s National TB Elimination Programme had released its National TB Elimination Strategy 2017-2025 under the visionary leadership of the then-head (Deputy Director General) Dr Kuldeep Singh Sachdeva. This strategy had also set forth an ambitious time plan to radically scale up upfront molecular TB testing in India during 2017-2025. Indian government programme has surpassed several of the indicators enlisted in that strategy.

In 2023, world leaders of 193 countries unanimously adopted the Political Declaration to end TB at United Nations General Assembly High Level Meeting. This Political Declaration also re-echoed the promise to replace microscopy completely with WHO recommended molecular test as an upfront or initial TB test by 2027.

Few days ago, a sign-on of 'Bangkok Declaration' is circling around on social media that is asking people to sign in their ‘personal capacities’ to replace microscopy with upfront molecular testing for TB by 2028. This supposedly came out from a meeting funded by Gates Foundation and organised by Stop TB Partnership on near point-of-care TB tests in Thailand. But the 'Bangkok Declaration' does not mention who organised it.

This 29 words Bangkok Declaration reads as follows: “We commit, in our personal capacities, to a phased replacement of smear microscopy with WHO-recommended molecular testing for the initial diagnosis of tuberculosis, to be completed by 2028.”

It is absolutely undeniable what this Bangkok Declaration states - "to phased replacement of smear microscopy with WHO-recommended molecular testing for initial TB diagnosis." But we do not agree with the timeline of 2028 - because we can do better now!

Why shift the 2027 goalpost?

With around 1 year 5 months left to deliver on 2027 TB targets enshrined in the Political Declaration endorsed by all world leaders unanimously in 2023 at UNHLM, why should we shift the goalpost on TB testing by a year? Ensuring that the first initial or upfront TB test is a molecular test is a non-negotiable when it comes to TB disease elimination strategy by 2030.

This is very doable too as most countries have significantly rolled out upfront molecular testing worldwide. For every one US$ invested in TB prevention and control, there are health and economic returns of US$ 43. So, TB investment is a smart investment too.

Deadly gap

As per the latest WHO Global TB Report 2025, globally, 54% of all TB patients notified in 2024 were diagnosed with an upfront molecular test. In African region, 53% of all TB patients notified in 2024 were diagnosed with an upfront molecular test. This number dips to 41% for Southeast Asian region though.

38% of all notified TB patients in India, 56% in South Africa, 65% in Indonesia, 69% in Nigeria, and 74% in Philippines got an upfront molecular test in 2024.

It is evident that since some years now, different countries are at different stages of replacing microcopy with upfront molecular test TB diagnosis.

100% upfront molecular TB testing for high TB risk homeless and migrant populations is possible, then why not for everyone else?

In India - a country with highest TB burden - and in Delhi state - a state with the country's highest TB incidence, the government TB elimination programme in partnership with Humana People to People India was able to achieve 100% upfront molecular test diagnosis among populations at very high TB risk: homeless and migrants.

When we can achieve 100% upfront molecular testing in high risk populations in Delhi, then why cannot we ensure this for everyone else? Best time to do the right thing was years back - second best time is now.

There are more examples: Goa state in India had completely replaced smear microscopy with upfront molecular test TB diagnosis 5 years ago. Lakshadweep, a Union Territory in India, had also achieved 100% upfront molecular test diagnosis and recently was declared TB free. Dr Rakesh PS, a noted TB elimination consultant presented at AIDS 2026 Affiliated Independent Event on the theme: Rethink, Rebuild and Rise to Put People First and deliver on ending AIDS and TB in next 54 months (by 2030).

Dr Rakesh PS shared that there were months every year when 10 of the inhabited Lakshadweep islands were very difficult to reach due to rough sea or bad weather. TB diagnostics was decentralised with WHO recommended molecular test in each of the 10 islands. Better technology alone is not enough but designing public health systems that respond to local realities of the people they serve is critical. Taking services closer to the communities was a game changer along with empowering local health workers to lead the response.

In the past five years, Stop TB Partnership's introducing new tools project had also rolled out artificial intelligence enabled handheld ultraportable X-Rays along with portable battery-operated molecular test Truenat and demonstrated strong impact in terms of finding TB early and accurately - and helping save lives.

The uncomfortable question is why were these high impact interventions not taken to scale, with urgency and immediacy?

So asked Sumit Mitra, a noted thought leader on bridging the deadly diagnostic divide in the Global South, who was also among the key speakers at AIDS 2026 Affiliated Independent Event hosted by over 30 organisations collectively with Prevent-Find-Treat ALL TB campaign, CNS and UNAIDS.

All is not so bleak as there is hope too - again from a country with highest TB burden - India. Indian government's National TB Elimination Programme which was then-headed (DDG) by Dr Urvashi B Singh, made a foundational shift in how it finds TB on 7 December 2024. AI-enabled X-Rays and portable molecular test were supposed to be taken in a van (Ni-Kshay Vahan) to high-risk communities and offer them TB screening and test closer to their homes. In first 100 days, government's programme found over 285,000 asymptomatic people with active TB disease - none of them would have been found so early if such an approach was not driving the TB case finding. Dr Urvashi B Singh was speaking at AIDS 2026 Affiliated Independent Event.

India's health minister told on World TB Day 2026 that in one year, Indian government could find over 1 million (10 lakhs) asymptomatic people with active TB disease - none of them would have been found so early if such a science-based approach was not driving the efforts. Early and accurate TB case finding is critical to prevent the spread of infection as well as link people to lifesaving TB treatment, care and support.

Unless we use the right TB test and stop missing TB cases among those who take a TB test, how will we ever eliminate TB?

Most strategic advocacy demand should not be to shift the 2027 goalpost but instead call for rapid scale up of upfront molecular testing as soon as possible - and latest by end of 2027 as promised by world leaders at the 2023 General Assembly.

The latest update to WHO TB Diagnostic Guidelines around World TB Day 2026 was an important turning point as, among other important recommendations, it also recommended near point-of-care portable molecular test (30 minutes TB test).

The list of WHO recommended molecular tests is expanding but the pace at which these tests are being rolled out on the ground is not matching the public health emergency and crisis which TB has posed against us historically.

Bridge the gap: No one should remain unreached

As per the latest WHO Global TB Report 2025, there were an estimated 10.7 million people worldwide with active TB disease in 2024, but four-fifth of them were diagnosed and linked to care. One-fifth (2 million) is the global gap between those we reach and we need to reach to find ALL TB and link them to lifesaving care.

In 2024, in African region, out of estimated 2.6 million people with TB disease, 1.9 million were notified. In Southeast Asia region, out of 3.7 million estimated people with TB disease, 3.1 million were found.

In the same year, out of 2.7 million people with TB, 2.5 million were notified. Out of 249,000 people with TB in South Africa, 183,000 were notified. Out of 510,000 people with TB in Nigeria, 402,000 were notified. And out of 724,000 people with TB in Philippines, 544,000 were notified.

Unless we reach ALL people with active TB disease early and diagnose ALL of them accurately, and link ALL of them to standard TB treatment, care and support, how will we end TB?

Infection prevention remains cornerstone. No one should get infected with a disease that is preventable.

Person-centred, rights-based access to TB services is an essential bedrock

TB diagnostic technology alone is not enough. Most essential is to ensure that health and social support services of the government, including those for TB, are person-centred, rights-based and gender transformative. We need to dismantle social, structural and systemic barriers people face in accessing health and social services. When populations - who are most-at risk of TB - are able to access public services with equity, safety and dignity, then only a real change will be possible in helping save lives from an ancient disease like TB.