US funding cuts threaten decades of progress in pediatric tuberculosis

A new study projects that US funding cuts to global health aid will have a catastrophic effect on pediatric TB, with children in Sub-Saharan Africa and Southeast Asia likely to experience a significant spike in preventable cases and deaths over the next decade-even by the most conservative estimates-unless funding is restored.

Health experts have warned for months that the abrupt and broad-scale funding cuts to global health aid from the United States in 2025 would have devastating effects on disease control and prevention worldwide. 

A new study led by Harvard T.H. Chan School of Public Health (Harvard Chan School) and Boston University School of Public Health (BUSPH) provides the first comprehensive estimates of the number of children who are expected to develop and die from tuberculosis (TB) in low- and middle-income countries (LMICs) over the next decade if the United States continues to slash funding for global health aid.

The loss of US bilateral health aid is projected to result in an additional 2.5 million pediatric TB cases and 340,000 pediatric TB deaths in LMICs between 2025 and 2034, compared to pre-2025 funding levels, according to the study in The Lancet Child & Adolescent Health. Moreover, the possible withdrawal of US support to the Global Fund to Fight AIDS, Tuberculosis, and Malaria (the Global Fund) along with reduced TB funding from other countries would likely result in an additional 8.9 million child TB cases, and more than 1.5 million child deaths during this period-more than double the expected totals if funding continued at pre-2025 levels. 

Until this year, the US had been a leading contributor to bilateral health aid for TB, primarily through the US Agency for International Development (USAID), which has helped prevent more than 75 million TB deaths worldwide. The Trump administration effectively dismantled the agency earlier this year, while also slashing funds from the U.S. President's Emergency Plan for AIDS Relief (PEPFAR). These combined actions created immediate disruptions to TB and HIV prevention, testing, treatment, research, and staffing in LMICs, where TB is most prevalent-but also where control efforts had led to noticeable improvements in TB over the 20 years.

Our analysis shows that if the recent and proposed cuts to U.S. bilateral health aid and contributions to The Global Fund continue, these losses would reverse decades of hard-won progress. For years, sustained international funding helped drive down TB incidence and mortality in high-burden countries and expand access to diagnosis and treatment for children, who are at especially high risk. The heaviest toll would fall on low-income countries in Africa and Southeast Asia, and in settings where HIV and TB overlap and health systems rely heavily on external aid."

Dr. Leonardo Martinez, study senior author, assistant professor of epidemiology at BUSPH

These findings are consistent with previous research about the effects of funding cuts for TB, but the study is the first to examine these implications in 130 countries, and exclusively among children, who have the highest age-specific risks of developing and dying from TB if exposed to the bacterium. The study is also the first to consider the implications of funding cuts to HIV programs on TB spread, as people living with HIV are also more susceptible to developing TB if exposed.

"We have made slow and steady progress with TB, but it is still the number one infectious disease killer in the world," says study lead and corresponding author Dr. Nicolas Menzies, associate professor of global health at Harvard Chan School. "These results show that this progress should not be taken for granted. If we take our foot off of the pedal, we could soon see more children dying of TB than we have for many decades."

For the study, Dr. Menzies, Dr. Martinez, and colleagues from Harvard Chan School, Boston University Chobanian & Avedisian School of Medicine, Yale School of Public Health, Imperial College School of Public Health, and the University of Sheffield School of Medicine and Population Health utilized national data from 130 LMICs on TB vaccination and services, HIV prevalence and treatment, and funding sources for TB and HIV programs. They projected how different levels of US bilateral aid and Global Fund support would affect the risk of TB (and HIV) infection, diagnosis, and treatment among children ages 14 and under from 2025-2034. The four funding reduction scenarios considered were: a continuation of pre-existing funding levels; a permanent end to US bilateral health aid from 2025 onward; an complete end to US bilateral aid in 2025 and Global Fund contributions beginning in 2026; and the previous scenario, along with a reduction in half of TB funding by other countries.

The team validated their models against recent World Health Organization and Global Burden of Disease estimates for pediatric TB, and ran several sensitivity tests to rule out bias or other errors. 

"While no model can predict the future with perfect precision, our estimates are based on the best available data and widely used methods-and they almost certainly represent a conservative picture of what could happen if funding cuts persist," says Dr. Martinez.

Altogether, these latest estimates underscore the central role of multilateral funding to reduce TB across the globe, and the urgent need to restore this funding. The researchers estimated that 90 percent of the additional projected TB deaths could be avoided if funding was restored after just one year. In absence of restored funding, they say that LMICs should seek alternative sources for support. 

"Recent successes in combating TB have resulted from a partnership between affected countries, high-income country governments, and international organizations," Dr. Menzies says. "This partnership will be even more essential with funding cuts, and may need to include a wider range of stakeholders. At the same time, we will need to work out how to provide services more efficiently, and to focus efforts on the more impactful interventions to the most highly affected populations."