This article was written before the US Executive Branch’s withdrawal of federal support for global health programs, which may have negatively impacted the ongoing work of TB Alliance. To read UCGHI’s full message regarding the current global health landscape, see here.

Tuberculosis treatments are one of the infectious disease community’s greatest achievements that has essentially eradicated the disease in countries across the world. The disease is a bacterial infection of the lungs that in 1900 killed 194 of every 10,000 U.S. residents. Then between 1940 and 1965, eight different classes of TB treatment drugs were discovered and distributed and helped nearly eradicate the disease in high-income countries like the United States. However, inequitable drug distribution to lower-income countries spurred an even deadlier mutation of the disease to emerge in the form of multidrug-resistant tuberculosis (MDR-TB). And evidenced by the 67 active TB cases as of January 31st in Kansas City, tuberculosis is still with us even in the U.S. Worldwide TB remains the deadliest disease outside of developed countries where 1.25 million people globally died of the disease in 2023. Funding for new developments in MDR-TB treatments haven’t emerged at the rate they should to address the disease effectively. In fact, between 1967 and 2012, no new TB drugs were developed at all. The non-profit organization, TB Alliance was formed in order to fill the gap in TB treatment development by working outside of the traditional pharmaceutical industry funding model.

John Green, author of Everything is Tuberculosis: the History and Resistance of our Deadliest Infection is blunt about why TB drug development stalled. “The reason for this is [when] TB declined in rich countries, the profit incentive for new drugs went away,” he says in a CrashCourse video about TB, “And as a result, funding dried up.” Yet activists and advocates in low-income countries continue to sound the alarm. The non-profit organization, TB Alliance is responding to these calls to fill the gap in TB treatment development by working outside of the traditional pharmaceutical industry funding model.

Since 2000, TB Alliance has been working on a way to effectively treat TB, a path of research and development that has largely been shoved to the side by pharmaceutical companies in high income countries. TB Alliance states that their “ultimate vision is to have a transformative impact on the disease by introducing an ultra-short, simple, and affordable TB regimen that works in virtually all people with tuberculosis.” This treatment approach that would involve multiple drugs for all forms of TB would not only treat people more effectively by not giving time for the bacteria to mutate to its multi-drug resistant form but also will help treat MDR-TB as well.

 “The TB Alliance is a unique effort that really came out of a vision that evolved out of the poor performance TB showed in global health epidemiologically,” says Eric Goosby, M.D., TB Alliance board co-chair, co-vice chair of the UCGHI Executive Committee and professor of Medicine at UC San Francisco. The organization attracted scientists who have worked in research development of such drugs (such as chemists, microbiologists, and micro bacteriologists) who wanted to find a way to disrupt bacteria replication. “They were able to develop two drugs and develop two treatments and then make it available to the world at low cost or free wherever possible,” says Goosby.

What emerged is a drug called BPaL/M–a six-month oral treatment regimen that has brought a cure rate of 50% from the older regimen up to 90% and is a fraction of the cost.

TB Alliance was able to bypass the pharmaceutical efforts thanks to private funding from the Gates Foundation and countries such as Norway, Sweden and Finland, general support from Medecins Sans Frontieres (MSF), and multi-lateral support from the WHO. “The Gates Foundation understood the need for some capability that served as a motor to take something that worked and then market it,” says Dr. Goosby, “to make it available to a market that was not a pharmaceutical company, and I think they really filled the unique niche in that regard.”

This is an enormous development in TB and a new age for finding ways around treatment of diseases that largely affect lower-income countries that aren't tied to a pharmaceutical company’s bottom line. Community-based efforts that focused on both informing and engaging deeply with communities on implementation were an enormous part of the success of the clinical trials.

“Our partnership in this area has led to the development of the most extensive network of Community Advisory Boards (CABs) in TB drug research, as well as a robust suite of programs and tools intended to share best practices and measure the effort of community engagement on research – for TB but also other disease areas as well,” states their website.

Of course, while the drug is available, there still remains the challenge of distributing widely globally. “We're now hiring people who have drug marketing experience with other formulations in low-income countries, so we're trying to bring that expertise in,” says Dr. Goosby.

This is a hurdle that the team at TB Alliance believes they will overcome to make BPaL/M widely available in the places that need it most. And the results have the potential to be nothing short of transformative.