Changing epidemiological patterns of tuberculosis in China from 1990 to 2023: trends and future projections of drug-resistant and HIV-associated tuberculosis

Background China has made substantial progress in tuberculosis (TB) control over the past decades. However, continued surveillance of drug-resistant and HIV-associated TB remains essential for optimizing future TB control strategies. This study aimed to comprehensively assess the long-term burden and future trends of TB and its major subtypes in China, with particular emphasis on extensively drug-resistant TB (XDR-TB) and HIV-associated TB. Methods Data on incidence, prevalence, mortality, and disability-adjusted life years (DALYs) of TB in China from 1990 to 2023 were extracted from the Global Burden of Disease Study 2023. Historical age-standardized rates were reported with 95% uncertainty intervals, and temporal trends in HIV-negative TB, drug-susceptible TB (DS-TB), multidrug-resistant TB (MDR-TB), XDR-TB, and HIV-associated TB subtypes were quantified using average annual percent changes (AAPCs) with 95% confidence intervals. Log-transformed age-standardized rates were projected from 2024 to 2035 using damped-trend exponential smoothing, ETS(A, Ad, N), with the damping parameter selected by rolling-origin validation. Forecasts were reported with 95% prediction intervals; projections to 2050 were treated as exploratory and reported in the Supplementary material . Results From 1990 to 2023, the age-standardized incidence rates of HIV-negative TB, DS-TB, and MDR-TB declined overall in China, with AAPCs of −3.833, −3.877, and −2.859%, respectively. In contrast, XDR-TB increased markedly (AAPC 7.134%), while all HIV-associated TB subtypes also showed upward trends, particularly HIV-XDR-TB, which exhibited the fastest increase in incidence (AAPC 13.318%). Recent trends were more heterogeneous, including increases in HIV-negative TB and DS-TB incidence during 2019–2023 and declining or stable mortality trends for several drug-resistant and HIV-associated subtypes. By 2035, the incidence and prevalence of XDR-TB, HIV-DS-TB, and HIV-MDR-TB were projected to increase modestly, whereas their mortality and DALY rates were projected to decline. The XDR-TB incidence rate was projected to reach 0.172 per 100,000 population (95% prediction interval: 0.077–0.381). HIV-XDR-TB incidence was projected to remain broadly stable, with a slight decline, whereas its prevalence was projected to increase. Prediction intervals were wide for several low-burden drug-resistant outcomes. Conclusion Although the overall TB burden in China has declined substantially, subtype-specific trajectories remain heterogeneous. Future control strategies should strengthen the rapid detection and management of drug resistance, integrate TB and HIV services, and prioritize targeted prevention and care for high-risk populations.