Abstract
Background
Globally, the burden of tuberculosis falls more on men than women and children, and there are large gaps between men and women at all stages of exposure, disease incidence, and treatment. We examined the impact of addressing determinants of these gender gaps in Kenya, Malawi, Nigeria, and Uganda.
Methods
We created a deterministic transmission model of tuberculosis, calibrated to country-specific data on prevalence, incidence, mortality, and notifications between 2010 and 2022. We examined the potential epidemiological impact of strategies to increase treatment coverage among men and decrease the effects of social and structural determinants that increase men’s risk of developing TB. We investigated the impact (overall and by age and sex) on projected incidence and mortality in 2035, and notification rates between 2025 and 2030.
Results
Our modelling estimates that increasing treatment coverage among men could reduce incidence in 2035 between 2.4% [95% uncertainty interval (UI) 0.2-6.0%] in Malawi and 23.0% [UI 16.8-29.3%] in Nigeria. Reducing men’s excess risk of tuberculosis could similarly reduce incidence in 2035 between 9.8% [UI 7.5-12.6%] in Malawi and 30.1% [UI 24.1-40.5%] in Kenya. Impacts extend across the population with median estimates of country-level declines in incidence of between 0.9-17.8% and 1.4-22.2% in women and children, respectively, across the four countries.
Conclusions
Strategies that prioritise increasing tuberculosis treatment coverage among men and mitigating men’s higher susceptibility to tuberculosis could reduce disease burden for men, women, and children. Such gender-responsive strategies are essential to ensure a person-centred tuberculosis response and accelerate global progress towards the EndTB targets
Plain language summary
Globally, more men have tuberculosis than women or children, due to factors such as difficulty accessing care and increased exposure to risk factors such as high levels of alcohol consumption and tobacco smoking. We focussed on four countries, Kenya, Malawi, Nigeria, and Uganda, and built a mathematical model to understand the impact of increasing men’s access to diagnosis and treatment and the impact of reducing men’s exposure to risk factors. We found that strategies that focus on men not only reduce tuberculosis in men, but also across the entire population.
Similar content being viewed by others
Data availability
Data frames of all model outputs for this study are available at the GitHub repository https://github.com/alexandrasrichards/LIGHT_modelling within the Intervention results folders63. Data frames for outputs reported in this paper are available at the same GitHub repository within the Outputs folder63.
Code availability
All model development, calibration, and analyses were performed using R 4.5.039. Calibration used the hmer package (version 1.6.0), data analysis and visualisation used ggplot (3.5.2) and other packages within the tidyverse (version 2.0.0)37,64,65. The code used can be found in the GitHub repository https://github.com/alexandrasrichards/LIGHT_modelling63.
References
World Health Organization. Global tuberculosis report, World Health Organization; 2024. Available: https://www.who.int/teams/global-tuberculosis-programme/tb-reports/global-tuberculosis-report-2024 (2024).
Horton, K. C., Sumner, T., Houben, R. M. G. J., Corbett, E. L. & White, R. G. A Bayesian approach to understanding gender differences in tuberculosis disease burden. Am. J. Epidemiol. 187, 2431–2438 (2018).
Rickman, H. M. et al. Sex differences in the risk of Mycobacterium tuberculosis infection: a systematic review and meta-analysis of population-based immunoreactivity surveys. LPH. 10, e588–98 (2025).
Horton, K. C., MacPherson, P., Houben, R. M. G. J., White, R. G. & Corbett, E. L. Sex differences in tuberculosis burden and notifications in low- and middle-income countries: A systematic review and meta-analysis. PLOS Med. 13, e1002119 (2016).
Chikovore, J., Hart, G., Kumwenda, M., Chipungu, G. A. & Corbett, L. For a mere cough, men must just chew conjex, gain strength, and continue working’: The provider construction and tuberculosis care-seeking implications in Blantyre, Malawi. Glob. Health Action 8, 26292 (2015).
World Health Organization Global Tuberculosis Programme. WHO TB profiles. https://worldhealthorg.shinyapps.io/tb_profiles/ (2024).
World Health Organization. National tuberculosis prevalence surveys 2007-2016. Available: https://iris.who.int/handle/10665/341072.
Gupta, M., Srikrishna, G., Klein, S. & Bishai, W. R. Genetic and hormonal mechanisms underlying sex-specific immune responses in tuberculosis. Trends Immunol. 43, 640–656 (2022).
Wessels, J., Walsh, C. M. & Nel, M. Smoking habits and alcohol use of patients with tuberculosis at Standerton Tuberculosis Specialised Hospital, Mpumalanga, South Africa. Health SA 24, 6 (2019).
Davies L. R. L., et al. IFN-γ independent markers of Mycobacterium tuberculosis exposure among male South African gold miners. eBioMedicine. 93. https://doi.org/10.1016/j.ebiom.2023.104678 (2023).
Sequera, V. G. et al. Increased incarceration rates drive growing tuberculosis burden in prisons and jeopardize overall tuberculosis control in Paraguay. Sci. Rep. 10, 21247 (2020).
Kleynhans et al. A cross-sectional study measuring contact patterns using diaries in an urban and a rural community in South Africa, 2018. BMC Public Health 21, 1055 (2021).
Thindwa, D. et al. Social mixing patterns relevant to infectious diseases spread by close contact in urban Blantyre, Malawi. Epidemics 40, 100590 (2022).
Del Fava, E. et al. Individual’s daily behaviour and intergenerational mixing in different social contexts of Kenya | Scientific Reports. Sci. Rep. 11, 21589 (2021).
Miller, P. B. et al. Association between tuberculosis in men and social network structure in Kampala, Uganda. BMC Infect. Dis. 21, 1023 (2021).
Houben, R. M. G. J. et al. TIME impact a new user-friendly tuberculosis (TB) model to inform TB policy decisions. BMC Med. 14, 56 (2016).
Horton, K. C. et al. Population benefits of addressing programmatic and social determinants of gender disparities in tuberculosis in Vietnam: A modelling study. PLOS Glob. Public Health 2, e0000784 (2022).
Coussens, A. K. et al. Classification of early tuberculosis states to guide research for improved care and prevention: An international delphi consensus exercise. Lancet Respir. Med. 12, 484–498 (2024).
Stover, J., McKinnon, R. & Winfrey, B. Spectrum: A model platform for linking maternal and child survival interventions with AIDS, family planning and demographic projections. Int. J. Epidemiol. 39, i7–i10 (2010).
UN World Population Prospects. Population by select age groups - female. https://population.un.org/wpp/Download/Standard/Population/ (2024).
UN World Population Prospects. Population by select age groups - male. https://population.un.org/wpp/Download/Standard/Population/ (2024).
World Health Organization Global Tuberculosis Programme. WHO TB burden estimates. https://www.who.int/teams/global-tuberculosis-programme/data (2024).
World Health Organization. Bacillus calmette-guérin (BCG) vaccination coverage. https://immunizationdata.who.int/pages/coverage/BCG.html?CODE=Global+KEN+NGA+UGA+MWI&YEAR= (2024).
World Health Organization Global Tuberculosis Programme. Treatment success rate: HIV-positive TB cases. https://www.who.int/data/gho/data/indicators/indicator-details/GHO/treatment-success-rate-hiv-positive-tb-cases (2023).
World Health Organization Global Tuberculosis Programme. TB: Treatment success. https://www.who.int/data/gho/data/themes/topics/indicator-groups/indicator-group-details/GHO/tb-treatment-success (2024).
Richards, A. S. et al. Quantifying progression and regression across the spectrum of pulmonary tuberculosis: A data synthesis study. Lancet Glob. Health 11, e684–e692 (2023).
Horton, K. C., Richards, A. S., Emery, J. C., Esmail, H. & Houben, R. M. G. J. Reevaluating progression and pathways following Mycobacterium tuberculosis infection within the spectrum of tuberculosis. Proc. Natl. Acad. Sci. 120, e2221186120 (2023).
Ragonnet, R. et al. Revisiting the natural history of pulmonary tuberculosis: A Bayesian estimation of natural recovery and mortality rates. Clin. Infect. Dis. 73, e88–e96 (2021).
Emery, J. C. et al. Estimating the contribution of subclinical tuberculosis disease to transmission: An individual patient data analysis from prevalence surveys. eLife 12, e82469 (2023).
Law, I. & Floyd, K. Group the ATPS. National tuberculosis prevalence surveys in africa, 20082016: An overview of results and lessons learned. Trop. Med. Int. Health 25, 1308–1327 (2020).
World Health Organization Global Tuberculosis Programme. WHO TB incidence estimates disaggregated by age group, sex, and risk factor. https://www.who.int/teams/global-tuberculosis-programme/data (2024).
World Health Organization Global Tuberculosis Programme. Case notifications. https://www.who.int/teams/global-tuberculosis-programme/data (2024).
National Tuberculosis Leprosy and Lung Disease Program, Republic of Kenya Ministry of Health. Kenya tuberculosis prevalence survey 2016. Nairobi, Kenya; Available: https://www.nltp.co.ke/survey-reports-2/ (2018).
Ministry of Health National TB Control Programme. Technical report: Malawi tuberculosis prevalence survey (2013–2014) (2016).
Department of Public Health, Federal Republic of Nigeria. Report of the first national TB prevalence survey 2012, Nigeria. (2014).
Ministry of Health Uganda and Makerere University School of Public Health. Population-based survey of prevalence of tuberculosis disease in Uganda 2014–15 (report). Makerere University School of Public Health; 2016. Available: https://library.health.go.ug/index.php/communicable-disease/tuberculosis/uganda-national-tuberculosis-prevalence-survey-2014-2015-survey.
Iskauskas, A. et al. Emulation and history matching using the hmer package. J. Stat. Softw. 109, 1–48 (2024).
RStudio Team. RStudio: Integrated development environment for R. Boston, MA: RStudio, PBC. Available: http://www.rstudio.com/ (2020).
R Core Team. R: A language and environment for statistical computing. Vienna, Austria: R Foundation for Statistical Computing; Available: https://www.R-project.org/ (2024).
Turyahabwe, S. et al. Community tuberculosis screening, testing and care, Uganda. Bull. World Health Organ. 102, 400–409 (2024).
Ogoamaka, C. et al. The TB surge intervention: An optimized approach to TB case-finding in Nigeria. Public Health Action 13, 136–141 (2023).
Nidoi, J. et al. Finding the missing men with tuberculosis: A participatory approach to identify priority interventions in Uganda. Health Policy Plan. 40, 1–12 (2025).
Ugwu, C. et al. Co-creation of a gender responsive TB intervention in Nigeria: A researcher-led collaborative study. BMC Health Serv. Res. 25, 63 (2025).
Mwirigi N., Wandia R., Oira D., Kathure I., Nyaboga L. M. Breaking barriers: Targeting TB in the workplace for men. 55th union world conference on lung health, bali, 2024. pp. S583–S584. (2024).
Karamagi, E. et al. Improving TB case notification in northern Uganda: Evidence of a quality improvement-guided active case finding intervention. BMC Health Serv. Res. 18, 954 (2018).
UN Women Africa. Women breaking barriers in the fish farming industry in Uganda. Available: https://africa.unwomen.org/en/stories/feature-story/2023/08/women-breaking-barriers-in-the-fish-farming-industry-in-uganda (2023).
World Prison Brief. Uganda | world prison brief. Available: https://www.prisonstudies.org/country/uganda (2024).
Dowden, J. et al. The impact of “male clinics” on health-seeking behaviors of adult men in rural Kenya. PLOS ONE 14, e0224749 (2019).
Phiri, M. M. et al. Improving pathways to care through interventions cocreated with communities: A qualitative investigation of men’s barriers to tuberculosis care-seeking in an informal settlement in Blantyre, Malawi. BMJ Open 11, e044944 (2021).
Költringer, F. A., Annerstedt, K. S., Boccia, D., Carter, D. J. & Rudgard, W. E. The social determinants of national tuberculosis incidence rates in 116 countries: A longitudinal ecological study between 20052015. BMC Public Health 23, 337 (2023).
Gilmore, A. B. et al. Defining and conceptualising the commercial determinants of health. Lancet 401, 1194–1213 (2023).
Daniels, J. et al. Masculinity, resources, and retention in care: South African men’s behaviors and experiences while engaged in TB care and treatment. Soc. Sci. Med. 270, 113639 (2021).
Moyo S., Oladimeji O., Chikovore J., Zungu N. Tuberculosis and the Relevance of Sex- and Gender-Based Analysis. In: Gahagan J., Bryson M. K., editors. Cham: Springer International Publishing. pp. 85–97. (2021).
Chikovore J. et al. Missing men with tuberculosis: the need to address structural influences and implement targeted and multidimensional interventions. BMJ Global Health. 2020;5. https://doi.org/10.1136/bmjgh-2019-002255.
Stop TB Partnership. Gender and TB: A stop TB partnership paper. Available: https://www.stoptb.org/sites/default/files/imported/document/TB-REACH_Gender2021-web.pdf.
Oshi, D. C. et al. Enhancing Knowledge and Beliefs: The Impact of a Gender-transformative Training Program on Tuberculosis Care in Southern Nigeria. Int. J. Mycobacteriol. 13, 394–403 (2024).
George A. S., Amde W., Bello K., Jacobs T., Ravindran S. T. K. Shaping the African research agenda for gender transformative approaches to sexual and reproductive health and rights: A scoping review taking stock to re-align and move forward. Afr. J. Reprod. Health 29. Available: https://www.ajrh.info/index.php/ajrh/article/view/5693.
Calderwood, C. J. et al. HIV, malnutrition, and noncommunicable disease epidemics among tuberculosis-affected households in east and southern Africa: A cross-sectional analysis of the ERASE-TB cohort. PLOS Med. 21, e1004452 (2024).
Wong, E. B. et al. Convergence of infectious and non-communicable disease epidemics in rural South Africa: A cross-sectional, population-based multimorbidity study. Lancet Glob. Health 9, e967–e976 (2021).
Falzon, D., Zignol, M., Bastard, M., Floyd, K. & Kasaeva, T. The impact of the COVID-19 pandemic on the global tuberculosis epidemic. Front. Immunol. 14, 1234785 (2023).
Kenya Ministry of Health, National Tuberculosis, Leprosy and Lung Disease Programme. Kenya national strategic plan for 2023/24 to 2027/28. Available: https://nltp.co.ke/national-strategic-plan-2019-2023-3/.
Smith, J. P. et al. Characterizing tuberculosis transmission dynamics in high-burden urban and rural settings. Sci. Rep. 12, 6780 (2022).
LIGHT modelling code. Zenodo. https://doi.org/10.5281/zenodo.18755975.
Wickham H. ggplot2: Elegant graphics for data analysis. Springer-Verlag New York; Available: https://ggplot2.tidyverse.org (2016).
Wickham, H. et al. Welcome to the tidyverse. J. Open Source Softw. 4, 1686 (2019).
Acknowledgements
ASR, MDP, JN, JC, PM, BJK, JSB, CU, RP, SBS, and KCH are supported by the UK Foreign, Commonwealth, and Development Office (Leaving No-one Behind Transforming Gendered Pathways to Health for Tuberculosis). KCH is also supported by the US National Institutes of Health (R-202309-71190). SBS is also supported by the Start4All programme, funded by Unitaid. The views expressed do not necessarily reflect the UK Government’s official policies. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Authors appreciate support from members of the national tuberculosis programmes in each of the countries in this analysis, including Wendy Nkirote, Aiban Ronoh, and Immaculate Kathure (National Tuberculosis, Leprosy, and Lung Disease Program, Kenya), Obioma Chijioke-Akaniro (National Tuberculosis, Leprosy and Buruli Ulcer Control Programme, Nigeria), Kuzani Mbendera, and Tisungane Mwenyenkulu (National Tuberculosis Control Programe, Malawi), and Stavia Turyahabwe (Ministry of Health, Uganda), Geofrey Amanya and Muzamiru Bamuloba (National Tuberculosis and Leprosy Program, Uganda) who shared their insights and understanding of TB epidemiology with the research team. Authors also appreciate support from Andy Iskauskas (University of Durham) and Nicky McCreesh (London School of Hygiene and Tropical Medicine) for their assistance in the calibration methodology. Authors also acknowledge support from management, research, research uptake, and programme management teams within The LIGHT Consortium.
Author information
Authors and Affiliations
Contributions
A.S.R, K.C.H., P.M., and S.B.S conceived the study. A.S.R ad K.C.H. designed the methodology and the software. K.C.H., J.C., P.M., J.S.B., B.J.K., and S.B.S. acquired the funding for the study, and K.C.H. and S.B.S. provided the resources and supervision. A.S.R. conducted the investigation, the formal analysis, data visualization and created the initial draft of the work. All authors validated the results and contributed to the review and editing of the final manuscript.
Corresponding author
Ethics declarations
Competing interests
The authors declare no competing interests.
Peer review
Peer review information
Communications Medicine thanks Jonathon R. Campbell and the other anonymous reviewer(s) for their contribution to the peer review of this work.
Additional information
Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Supplementary information
Rights and permissions
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
About this article
Cite this article
Richards, A.S., Phiri, M.D., Nidoi, J. et al. Modelling the impact of increasing tuberculosis treatment coverage and addressing determinants of risk in men. Commun Med (2026). https://doi.org/10.1038/s43856-026-01536-3
Received:
Accepted:
Published:
DOI: https://doi.org/10.1038/s43856-026-01536-3


