Breaking New Ground: University of Pretoria Researchers Uncover Stigma's Role in TB Treatment Success

In a groundbreaking study published today in Frontiers in Psychology, researchers from the University of Pretoria and affiliated institutions have demonstrated that both enacted and internalized stigma significantly predict treatment outcomes for newly diagnosed tuberculosis (TB) patients in Gauteng, South Africa. This finding underscores the psychological barriers that hinder TB control efforts in one of the world's highest-burden countries.

Tuberculosis remains South Africa's leading cause of death from infectious disease, with approximately 249,000 new cases and 56,000 deaths reported in 2024 alone, according to the World Health Organization's Global Tuberculosis Report 2025. Despite advances in diagnostics and shorter regimens, treatment success rates hover around 78-87%, far below the global 90% target. Factors like stigma—rooted in misconceptions about transmission and historical associations with HIV—persist as hidden obstacles to adherence and completion.

The study, led by T. Sole-Moloto from the Human Sciences Research Council (HSRC) and University of Pretoria's Department of Psychology, highlights how low levels of stigma correlate with over twofold higher odds of successful outcomes—defined as cure or treatment completion.Explore higher education opportunities in South Africa that contribute to such vital public health research.

Defining Enacted and Internalized Stigma in the TB Context

Enacted stigma refers to overt discrimination or unfair treatment experienced by persons with TB (PWTB), such as social exclusion, job loss, or mistreatment by healthcare workers. Internalized stigma, on the other hand, involves self-devaluation—feelings of shame, worthlessness, or blame internalized from societal attitudes. These forms often interconnect, with enacted experiences fueling self-stigma.

In South Africa, where TB-HIV co-infection rates are high (up to 50% in some areas), stigma compounds vulnerabilities. Patients fear disclosure, leading to delayed diagnosis, irregular adherence, and increased multidrug-resistant TB (MDR-TB) risk. Community myths portray TB as a 'curse' or punishment, exacerbating isolation, particularly in urban Gauteng townships like Ekurhuleni.

Historical data shows TB presumptives (those awaiting diagnosis) report the highest stigma levels, transitioning to internalized forms post-diagnosis, which predict poorer outcomes. This cycle not only affects individuals but burdens South Africa's National Health Insurance (NHI) rollout and TB Recovery Plan 4.0 (2025-2026).

The Study Design: Insights from Ekurhuleni Clinics

Conducted from February 2022 to March 2023 across five clinics in Ekurhuleni District—a peri-urban hotspot with high TB/HIV prevalence—the observational cohort enrolled 90 adults (≥18 years) newly diagnosed with drug-sensitive TB. Exclusion criteria ensured focus on TB alone: no HIV co-infection, English proficiency, and standard 6-month regimen initiation.

• 73.6% male, mean age 40 years.
• 58% unemployed, 40% Grade 12 educated.
• Stigma measured via 8-item Stigma Scale for Chronic Illnesses (SSCI-8): 3 internalized, 5 enacted items (Likert 1-5; total 8-40).
• Reliability: Cronbach's α >0.80 for subscales.

After 6 months, 87 had outcomes: 87% successful (22 cured, 54 completed). Bivariate logistic regression revealed low internalized stigma doubled success odds (OR=2.6, 95% CI 1.30-5.23, p=0.007); low enacted stigma tripled them (OR=2.9, 95% CI 1.28-6.62, p=0.011). A strong correlation linked the two stigmas (r=0.63, p<0.001).

Though 68% reported low stigma overall, even subtle levels impacted adherence, aligning with prior Kenyan/Indian validations of SSCI-8.Craft an academic CV highlighting public health research like this.

TB Burden in South Africa: A National Crisis

South Africa ranks among the top 30 global TB high-burden nations, with incidence ~468/100,000 (2024 est.), per WHO. Gauteng contributes ~20% of cases, driven by urbanization, poverty, and mines. The National TB Prevalence Survey (2018-2021) estimated 644/100,000 prevalence—nearly double notifications.

Post-COVID setbacks persist: 2023 deaths fell 16% from 2015 (66k to 56k), but 249k incident cases strain resources. Treatment success: 78.97% (TB DIAH 2024), lagging due to loss-to-follow-up (LTFU) and deaths. Underserved groups (informal settlements) show 2-3x higher prevalence.

Source: WHO 2025, SA NSP. Universities like Pretoria drive modeling for NSP goals: 44% incidence drop by 2030.Browse research jobs advancing TB control.

Implications for Patients: From Isolation to Adherence

For PWTB, stigma manifests as withheld disclosure (fear of rejection), irregular clinic visits, and pill-sharing—breeding resistance. Females/unemployed face amplified effects, per related studies. Successful completers often report supportive networks; high-stigma cases show LTFU/death spikes.

This Pretoria-led research validates stigma as modifiable: low-stigma patients 2.6-2.9x more likely cured/completed. It calls for routine SSCI-8 screening at diagnosis, linking to counseling.

South African Universities Spearheading TB Research

The University of Pretoria's Psychology Department, alongside HSRC and Tshwane University of Technology, exemplifies interdisciplinary higher ed impact. Lead author T. Sole-Moloto bridges public health and belonging research, training next-gen experts.

Other SA unis contribute: UCT on vaccine trials, Wits on genomics, Stellenbosch on stigma mapping. Funding via NRF/SAMRC supports PhDs/postdocs—vital amid 77% foreign staff scrutiny.Professor jobs in South African public health; Faculty positions.

Such studies position SA as End TB leader, per NSP 4.0.

Proven Interventions: Reducing Stigma for Better Outcomes

• Community Education: Campaigns debunk myths, cut anticipated stigma 20-30% (SA pilots).
• Peer Support: TB clubs/home visits reduce internalized stigma, boost adherence (cluster trials).
• HCW Training: Diffusion of Innovations cuts enacted stigma in clinics (RCTs).
• Digital Tools: Smart pillboxes normalize treatment, lower self-stigma.

Multi-level approaches (household/community) yield 15-25% outcome gains. Integrate into GeneXpert rollout. Thrive in TB stigma research postdocs.

Challenges Ahead: MDR-TB, HIV Co-infection, and Equity

While drug-sensitive TB succeeds 87%, MDR-TB lags at 60%. Stigma delays seeking, worsening resistance. HIV duality amplifies: 55% co-infected fear double discrimination. Rural/underserved gaps persist—Ekurhuleni mirrors urban biases.

Solutions: NHI mental health bundles, AI adherence apps, youth clubs. Future: Longitudinal stigma tracking, gender-disaggregated data.

Photo by Markus Winkler on Unsplash

Future Outlook: Policy Shifts and Academic Impact

SA's TB Plan targets halving self-stigma by 2026. Pretoria study informs NSP 4.0 metrics, pushing psychosocial integration. Globally, WHO endorses stigma audits.

For higher ed: More psych/public health funding, interdisciplinary PhDs. SA scholarships for TB researchers abound. Optimism: Low stigma = high success; scalable wins ahead.

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