Tuberculosis remains one of the most consequential infectious disease challenges of our era, and the timing of this analysis could not be more critical. As global health funding faces significant rollbacks, a comprehensive baseline portrait of TB's reach — across HIV status, drug-resistance profiles, and demographic strata — becomes the essential reference point against which future policy and intervention will be judged.
Drawing on data from 204 countries and territories spanning 1990 to 2023, this GBD 2023 systematic analysis deployed multiple modeling platforms — including the Cause of Death Ensemble model and DisMod-MR 2.1 — to simultaneously estimate TB incidence, prevalence, mortality, and disability-adjusted life years (DALYs). A population attributable fraction framework stratified findings by HIV co-infection and drug-resistance status, including multidrug-resistant TB (MDR-TB). Additional risk factor analyses quantified the attributable burden from alcohol use, smoking, and elevated fasting plasma glucose — a meaningful methodological step that connects TB susceptibility to modifiable metabolic and behavioral exposures.
This analysis sits at the intersection of surveillance science and policy urgency. The WHO End TB Strategy targets — a 95% reduction in deaths and 90% reduction in incidence by 2035 relative to 2015 — demand consistent, granular tracking. Prior GBD iterations have established the general contours of TB burden; what distinguishes this edition is its 2023 endpoint, capturing pandemic-era disruptions to TB services and the nascent recovery period. The HIV-stratified approach is especially valuable: HIV-associated TB carries significantly higher mortality and remains concentrated in sub-Saharan Africa, where health system fragility compounds risk. The inclusion of MDR-TB burden is equally critical, as drug-resistant strains represent a growing clinical and economic threat that standard treatment pipelines are poorly equipped to address. The risk factor component is incremental rather than paradigm-shifting, though it reinforces evidence linking glycemic dysregulation to TB vulnerability — a finding with implications for integrated chronic-disease and infectious-disease programming. As a large-scale systematic review from a premier journal, this work will anchor global TB policy conversations for years.