At a moment when global health financing is contracting sharply, a three-decade accounting of tuberculosis' toll carries unusual urgency. Understanding exactly where TB deaths and drug-resistant cases are concentrated — and how far the world still sits from the WHO's 2035 elimination targets — directly informs which interventions deserve emergency prioritization and which populations remain most exposed.
This GBD 2023 analysis covers 204 countries and territories from 1990 through 2023, systematically disaggregating TB burden by HIV co-infection status and multidrug-resistant TB (MDR-TB). Using the Cause of Death Ensemble model alongside DisMod-MR 2.1 for morbidity estimation, the authors simultaneously modeled incidence, prevalence, and mortality stratified by age, sex, HIV status, and drug-resistance profile. Disability-adjusted life-years (DALYs) were computed as the combined sum of years of life lost and years lived with disability. A comparative risk assessment framework was separately applied to quantify the population-attributable fractions of alcohol use, tobacco smoking, and elevated fasting plasma glucose — three modifiable behavioral and metabolic risk factors — on the overall TB disease burden.
This is arguably the most comprehensive single systematic TB burden analysis to date, and its framing is deliberately timed: reductions in global health funding since 2023 threaten to reverse hard-won epidemiological gains. The GBD approach introduces methodological rigor that WHO surveillance alone cannot match, particularly in high-burden, low-registration settings where verbal autopsy and minimally invasive tissue sampling data fill critical gaps. However, the limitations are real — GBD estimates carry significant uncertainty intervals in data-sparse regions, and behavioral risk factor attributions depend on modeled exposure data that may not capture recent trends. The study does not establish causality and cannot fully account for disruptions like COVID-19-era diagnostic backlogs that inflated apparent TB burden in some years. Still, for policymakers and researchers, the three-way stratification by HIV status, MDR-TB, and modifiable risks in a single analytical framework is genuinely novel, and the gap between observed trends and WHO End TB targets quantified here may serve as the clearest available benchmark for measuring the cost of funding withdrawal.