Tuberculosis remains the world's deadliest infectious disease from a single pathogen, yet most people lack a current grasp of how dramatically — or unevenly — that burden has shifted over three decades. This GBD 2023 analysis offers the most comprehensive accounting to date, and its timing is critical: recent contractions in global health funding threaten to reverse hard-won progress precisely as the WHO's 2035 End TB targets demand acceleration.
Drawing on vital registration, surveillance, verbal autopsy, and minimally invasive tissue sampling data across 204 countries and territories from 1990 to 2023, researchers quantified TB mortality, incidence, prevalence, and disability-adjusted life-years (DALYs) stratified by HIV co-infection and drug-resistance status. The modelling framework — combining Cause of Death Ensemble modelling and DisMod-MR 2.1 — also isolated the attributable fractions of TB burden linked to alcohol use, smoking, and elevated fasting plasma glucose. While overall TB mortality declined substantially across the study period, progress on multidrug-resistant TB (MDR-TB) lagged considerably, and HIV-associated TB continued to concentrate disproportionately in sub-Saharan Africa. Trajectory analysis suggests that neither the 95% mortality reduction nor the 90% incidence reduction targets set for 2035 are on course to be met at current rates.
This analysis sits at the intersection of epidemiology and policy urgency. MDR-TB's persistent burden is particularly concerning: treatment success rates for MDR-TB remain well below those for drug-susceptible strains, and the pipeline for new regimens, though improved with bedaquiline-based combinations, is still insufficient at global scale. The HIV-TB interaction remains a compounding vulnerability — people living with HIV face roughly 20-fold higher TB risk, and integrated service delivery remains fragmented in high-burden settings. A key limitation is the reliance on modelled estimates where civil registration is incomplete, introducing uncertainty intervals that widen in low-income settings. Nevertheless, as a systematic analysis anchored in GBD 2023 methodology, this represents a confirmatory and strategically essential baseline — less a paradigm shift than an authoritative alarm signal ahead of funding disruptions that could erase decades of progress.