{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,18]],"date-time":"2026-09-18T06:09:41Z","timestamp":1789711781800,"version":"4.0.1"},"reference-count":50,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,9,18]],"date-time":"2026-09-18T00:00:00Z","timestamp":1789689600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Public Health"],"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>\n                      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\n                      <jats:xref>Supplementary material<\/jats:xref>\n                      .\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>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 \u22123.833, \u22123.877, and \u22122.859%, 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\u20132023 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\u20130.381). 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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>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.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3389\/fpubh.2026.1948171","type":"journal-article","created":{"date-parts":[[2026,9,18]],"date-time":"2026-09-18T05:38:05Z","timestamp":1789709885000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Changing epidemiological patterns of tuberculosis in China from 1990 to 2023: trends and future projections of drug-resistant and HIV-associated tuberculosis"],"prefix":"10.3389","volume":"14","author":[{"given":"Jiajun","family":"Chen","sequence":"first","affiliation":[{"name":"Institute of Respiratory Diseases, Longhua Hospital, Shanghai University of Traditional Chinese Medicine","place":["Shanghai, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Peiyong","family":"Zheng","sequence":"additional","affiliation":[{"name":"Clinical Medicine Center, Longhua Hospital, Shanghai University of Traditional Chinese Medicine","place":["Shanghai, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Qinyan","family":"Zuo","sequence":"additional","affiliation":[{"name":"Institute of Respiratory Diseases, Longhua Hospital, Shanghai University of Traditional Chinese Medicine","place":["Shanghai, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shaoyan","family":"Zhang","sequence":"additional","affiliation":[{"name":"Institute of Respiratory Diseases, Longhua Hospital, Shanghai University of Traditional Chinese Medicine","place":["Shanghai, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lei","family":"Qiu","sequence":"additional","affiliation":[{"name":"Institute of Respiratory Diseases, Longhua Hospital, Shanghai University of Traditional Chinese Medicine","place":["Shanghai, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Xianwei","family":"Wu","sequence":"additional","affiliation":[{"name":"Institute of Respiratory Diseases, Longhua Hospital, Shanghai University of Traditional Chinese Medicine","place":["Shanghai, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zhenhui","family":"Lu","sequence":"additional","affiliation":[{"name":"Institute of Respiratory Diseases, Longhua Hospital, Shanghai University of Traditional Chinese Medicine","place":["Shanghai, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,9,18]]},"reference":[{"key":"ref1","doi-asserted-by":"publisher","first-page":"850","DOI":"10.1016\/S0140-6736(24)02479-6","article-title":"Tuberculosis","volume":"405","author":"Trajman","year":"2025","journal-title":"Lancet"},{"key":"ref2","doi-asserted-by":"publisher","first-page":"57","DOI":"10.1186\/s40249-023-01107-x","article-title":"Global prevalence of drug-resistant tuberculosis: a systematic review and meta-analysis","volume":"12","author":"Salari","year":"2023","journal-title":"Infect Dis Poverty"},{"key":"ref3","volume-title":"Global Tuberculosis Report 2024","year":"2024"},{"key":"ref4","doi-asserted-by":"publisher","first-page":"222","DOI":"10.1016\/S1473-3099(21)00449-7","article-title":"Global, regional, and national sex differences in the global burden of tuberculosis by HIV status, 1990\u20132019: results from the global burden of disease study 2019","volume":"22","author":"Ledesma","year":"2022","journal-title":"Lancet Infect Dis"},{"key":"ref5","doi-asserted-by":"publisher","first-page":"85","DOI":"10.1186\/s40249-022-01009-4","article-title":"Age-period-cohort analysis of pulmonary tuberculosis reported incidence, China, 2006-2020","volume":"11","author":"Dong","year":"2022","journal-title":"Infect Dis Poverty"},{"key":"ref6","doi-asserted-by":"publisher","first-page":"773","DOI":"10.1080\/23744235.2022.2092647","article-title":"Global trends, regional differences and age distribution for the incidence of HIV and tuberculosis co-infection from 1990 to 2019: results from the global burden of disease study 2019","volume":"54","author":"Wang","year":"2022","journal-title":"Infect Dis"},{"key":"ref7","doi-asserted-by":"publisher","first-page":"e0000180","DOI":"10.1371\/journal.pgph.0000180","article-title":"Integrating services for HIV and multidrug-resistant tuberculosis: a global cross-sectional survey among ART clinics in low- and middle-income countries","volume":"2","author":"Zurcher","year":"2022","journal-title":"PLoS Glob Public Health"},{"key":"ref8","doi-asserted-by":"publisher","first-page":"30","DOI":"10.1186\/s40249-025-01299-4","article-title":"Association of urbanization-related factors with tuberculosis incidence among 1992 counties in China from 2005 to 2019: a nationwide observational study","volume":"14","author":"Wang","year":"2025","journal-title":"Infect Dis Poverty"},{"key":"ref9","doi-asserted-by":"publisher","first-page":"100072","DOI":"10.1016\/j.soh.2024.100072","article-title":"Global burden of HIV-negative multidrug- and extensively drug-resistant tuberculosis based on global burden of disease study 2021","volume":"3","author":"Chen","year":"2024","journal-title":"Sci One Health"},{"key":"ref10","doi-asserted-by":"publisher","first-page":"65","DOI":"10.1186\/s40249-023-01116-w","article-title":"Cost of treatment support for multidrug-resistant tuberculosis using patient-centred approaches in Ethiopia: a model-based method","volume":"12","author":"Rosu","year":"2023","journal-title":"Infect Dis Poverty"},{"key":"ref11","doi-asserted-by":"publisher","first-page":"34","DOI":"10.1186\/s40249-024-01203-6","article-title":"Epidemiological characteristics of tuberculosis incidence and its macro-influence factors in Chinese mainland during 2014-2021","volume":"13","author":"Deng","year":"2024","journal-title":"Infect Dis Poverty"},{"key":"ref12","doi-asserted-by":"publisher","first-page":"59","DOI":"10.1186\/s40249-024-01230-3","article-title":"Epidemiological features and temporal trends of the co-infection between HIV and tuberculosis, 1990-2021: findings from the global burden of disease study 2021","volume":"13","author":"Zhang","year":"2024","journal-title":"Infect Dis Poverty"},{"key":"ref13","doi-asserted-by":"publisher","first-page":"60","DOI":"10.1186\/s40249-024-01227-y","article-title":"Global, regional, and national burden of HIV-negative tuberculosis, 1990-2021: findings from the global burden of disease study 2021","volume":"13","author":"Zhang","year":"2024","journal-title":"Infect Dis Poverty"},{"key":"ref14","doi-asserted-by":"publisher","first-page":"20","DOI":"10.1186\/s40249-024-01188-2","article-title":"Toward tuberculosis elimination by understanding epidemiologic characteristics and risk factors in Hainan Province, China","volume":"13","author":"Zhou","year":"2024","journal-title":"Infect Dis Poverty"},{"key":"ref15","doi-asserted-by":"publisher","first-page":"1873","DOI":"10.1016\/S0140-6736(25)01637-X","article-title":"Burden of 375 diseases and injuries, risk-attributable burden of 88 risk factors, and healthy life expectancy in 204 countries and territories, including 660 subnational locations, 1990-2023: a systematic analysis for the global burden of disease study 2023","volume":"406","year":"2025","journal-title":"Lancet"},{"key":"ref16","doi-asserted-by":"publisher","first-page":"1731","DOI":"10.1016\/S0140-6736(25)01330-3","article-title":"Global age-sex-specific all-cause mortality and life expectancy estimates for 204 countries and territories and 660 subnational locations, 1950-2023: a demographic analysis for the global burden of disease study 2023","volume":"406","year":"2025","journal-title":"Lancet"},{"key":"ref17","doi-asserted-by":"publisher","first-page":"1811","DOI":"10.1016\/S0140-6736(25)01917-8","article-title":"Global burden of 292 causes of death in 204 countries and territories and 660 subnational locations, 1990-2023: a systematic analysis for the global burden of disease study 2023","volume":"406","year":"2025","journal-title":"Lancet"},{"key":"ref18","doi-asserted-by":"publisher","first-page":"e85","DOI":"10.1017\/S0950268825100095","article-title":"Trend and forecast analysis of the changing disease burden of tuberculosis in China, 1990-2021","volume":"153","author":"Zhang","year":"2025","journal-title":"Epidemiol Infect"},{"key":"ref19","doi-asserted-by":"publisher","first-page":"106816","DOI":"10.1016\/j.jinf.2026.106816","article-title":"National and subnational burden of HIV-negative MDR-TB in China, 1990-2023: spatio-temporal heterogeneity, long-term trends, and projections","volume":"93","author":"Zhang","year":"1990","journal-title":"J Infect"},{"key":"ref20","doi-asserted-by":"publisher","first-page":"S1473-3099(26)00295-1","DOI":"10.1016\/S1473-3099(26)00295-1","article-title":"Global, regional, and national burden of tuberculosis and multidrug-resistant tuberculosis by HIV status, 1990-2023: a systematic analysis for the global burden of disease study 2023","volume":"1","year":"2026","journal-title":"Lancet Infect Dis"},{"key":"ref21","doi-asserted-by":"publisher","first-page":"106728","DOI":"10.1016\/j.jinf.2026.106728","article-title":"National and subnational burden of XDR-TB in China, 1990-2023: long-term trends, regional disparities, and projections, 2024-2050","volume":"92","author":"Zhang","year":"1990","journal-title":"J Infect"},{"key":"ref22","doi-asserted-by":"publisher","first-page":"335","DOI":"10.1002\/(SICI)1097-0258(20000215)19:3<335::AID-SIM336>3.0.CO;2-Z","article-title":"Permutation tests for joinpoint regression with applications to cancer rates","volume":"19","author":"Kim","year":"2000","journal-title":"Stat Med"},{"key":"ref23","doi-asserted-by":"publisher","first-page":"439","DOI":"10.1016\/s0169-2070(01)00110-8","article-title":"A state space framework for automatic forecasting using exponential smoothing methods","volume":"18","author":"Hyndman","year":"2002","journal-title":"Int J Forecast"},{"key":"ref24","doi-asserted-by":"publisher","first-page":"1237","DOI":"10.1287\/mnsc.31.10.1237","article-title":"Forecasting trends in time series","volume":"31","author":"Gardner","year":"1985","journal-title":"Manag Sci"},{"key":"ref25","doi-asserted-by":"publisher","first-page":"437","DOI":"10.1016\/s0169-2070(00)00065-0","article-title":"Out-of-sample tests of forecasting accuracy: an analysis and review","volume":"16","author":"Tashman","year":"2000","journal-title":"Int J Forecast"},{"key":"ref26","doi-asserted-by":"publisher","first-page":"17","DOI":"10.1002\/for.938","article-title":"Prediction intervals for exponential smoothing using two new classes of state space models","volume":"24","author":"Hyndman","year":"2005","journal-title":"J Forecast"},{"key":"ref27","doi-asserted-by":"publisher","first-page":"100123","DOI":"10.1016\/j.soh.2025.100123","article-title":"Global, regional, and national temporal trend and patterns of change in the burden of leishmaniasis from 1990 to 2021: an analysis of the global burden of disease study 2021","volume":"4","author":"Zhang","year":"2025","journal-title":"Sci One Health"},{"key":"ref28","doi-asserted-by":"publisher","first-page":"99","DOI":"10.1186\/s40249-023-01147-3","article-title":"Epidemiological characteristics of seven notifiable respiratory infectious diseases in the mainland of China: an analysis of national surveillance data from 2017 to 2021","volume":"12","author":"Deng","year":"2023","journal-title":"Infect Dis Poverty"},{"key":"ref29","doi-asserted-by":"publisher","first-page":"105","DOI":"10.1186\/s40249-025-01365-x","article-title":"Global burden of dengue from 1990 to 2021: a systematic analysis from the global burden of disease study 2021","volume":"14","author":"Zheng","year":"2025","journal-title":"Infect Dis Poverty"},{"key":"ref30","doi-asserted-by":"publisher","first-page":"15","DOI":"10.1016\/S1473-3099(24)00263-9","article-title":"Targeted next-generation sequencing to diagnose drug-resistant tuberculosis: a systematic review and meta-analysis","volume":"24","author":"Schwab","year":"2024","journal-title":"Lancet Infect Dis"},{"key":"ref31","doi-asserted-by":"publisher","first-page":"953","DOI":"10.1186\/s12879-026-13055-6","article-title":"Diagnostic and treatment delays and associated factors among RR-TB patients under molecular drug susceptibility testing: a retrospective study in Guizhou Province, China","volume":"26","author":"Rao","year":"2026","journal-title":"BMC Infect Dis"},{"key":"ref32","doi-asserted-by":"publisher","first-page":"999","DOI":"10.2147\/IDR.S293583","article-title":"Adherence to multidrug resistant tuberculosis treatment and case management in Chongqing, China - a mixed method research study","volume":"14","author":"Xing","year":"2021","journal-title":"Infect Drug Resist"},{"key":"ref33","doi-asserted-by":"publisher","first-page":"2348","DOI":"10.12659\/MSM.904682","article-title":"Adverse events associated with treatment of multidrug-resistant tuberculosis in China: an Ambispective cohort study","volume":"23","author":"Zhang","year":"2017","journal-title":"Med Sci Monit"},{"key":"ref34","doi-asserted-by":"publisher","first-page":"259","DOI":"10.46234\/ccdcw2023.047","article-title":"Patient, diagnosis, and treatment delays among tuberculosis patients before and during COVID-19 epidemic - China, 2018-2022","volume":"5","author":"Li","year":"2023","journal-title":"China CDC Wkly"},{"key":"ref35","doi-asserted-by":"publisher","first-page":"907","DOI":"10.46234\/ccdcw2022.187","article-title":"Predictors for treatment outcomes in patients with multi-drug resistant tuberculosis - China, 2018-2020","volume":"4","author":"Zhang","year":"2022","journal-title":"China CDC Wkly"},{"key":"ref36","doi-asserted-by":"publisher","first-page":"938","DOI":"10.46234\/ccdcw2023.176","article-title":"Trends and patterns of respiratory tuberculosis mortality in rural and urban - China, 1987-2021","volume":"5","author":"Zhao","year":"2023","journal-title":"China CDC Wkly"},{"key":"ref37","doi-asserted-by":"publisher","first-page":"80","DOI":"10.1038\/nrmicro.2017.128","article-title":"Pathogenesis of HIV-1 and Mycobacterium tuberculosis co-infection","volume":"16","author":"Bell","year":"2018","journal-title":"Nat Rev Microbiol"},{"key":"ref38","doi-asserted-by":"publisher","first-page":"853","DOI":"10.3390\/microorganisms11040853","article-title":"HIV\/Mtb co-infection: from the amplification of disease pathogenesis to an \"emerging syndemic\"","volume":"11","author":"Azevedo-Pereira","year":"2023","journal-title":"Microorganisms"},{"key":"ref39","doi-asserted-by":"publisher","first-page":"1501","DOI":"10.46234\/ccdcw2025.253","article-title":"Trends in bidirectional screening and treatment outcomes for tuberculosis\/HIV comorbidity - China, 2020-2024","volume":"7","author":"Zhang","year":"2025","journal-title":"China CDC Weekly"},{"key":"ref40","volume-title":"Scaling up TB Preventive Treatment in China. Global Tuberculosis Report 2025","year":"2025"},{"key":"ref41","doi-asserted-by":"publisher","first-page":"839","DOI":"10.2147\/hiv.s284722","article-title":"TB and HIV epidemiology and collaborative service: evidence from Ethiopia, 2011-2015","volume":"12","author":"Gelaw","year":"2011","journal-title":"HIV AIDS"},{"key":"ref42","doi-asserted-by":"publisher","first-page":"101298","DOI":"10.1016\/j.eclinm.2022.101298","article-title":"Mortality in HIV and tuberculosis patients following implementation of integrated HIV-TB treatment: results from an open-label cluster-randomized trial","volume":"44","author":"Naidoo","year":"2022","journal-title":"EClinicalMedicine"},{"key":"ref43","doi-asserted-by":"publisher","first-page":"2295","DOI":"10.3390\/cells12182295","article-title":"Single-cell transcriptomics of Mtb\/HIV co-infection","volume":"12","author":"Kulkarni","year":"2023","journal-title":"Cells"},{"key":"ref44","doi-asserted-by":"publisher","first-page":"325","DOI":"10.1186\/s12879-020-05040-4","article-title":"Tuberculosis and its association with CD4+ T cell count among adult HIV positive patients in Ethiopian settings: a systematic review and meta-analysis","volume":"20","author":"Geremew","year":"2020","journal-title":"BMC Infect Dis"},{"key":"ref45","doi-asserted-by":"publisher","first-page":"e1004409","DOI":"10.1371\/journal.pmed.1004409","article-title":"Barriers to engagement in the care cascade for tuberculosis disease in India: A systematic review of quantitative studies","volume":"21","author":"Jhaveri","year":"2024","journal-title":"PLoS Med"},{"key":"ref46","doi-asserted-by":"publisher","first-page":"1123","DOI":"10.1016\/j.cmi.2023.10.023","article-title":"Tuberculosis prevention: current strategies and future directions","volume":"30","author":"Vasiliu","year":"2024","journal-title":"Clin Microbiol Infect"},{"key":"ref47","doi-asserted-by":"publisher","first-page":"811","DOI":"10.1016\/j.ijid.2022.07.047","article-title":"The impact of HIV and tuberculosis interventions on south African adult tuberculosis trends, 1990-2019: a mathematical modeling analysis","volume":"122","author":"Kubjane","year":"2022","journal-title":"Int J Infect Dis"},{"key":"ref48","doi-asserted-by":"publisher","first-page":"100086","DOI":"10.1016\/j.soh.2024.100086","article-title":"Trends in epidemiological characteristics and etiologies of diarrheal disease in children under five: an ecological study based on global burden of disease study 2021","volume":"3","author":"Chu","year":"2024","journal-title":"Sci One Health"},{"key":"ref49","doi-asserted-by":"publisher","first-page":"123","DOI":"10.1186\/s40249-020-00742-y","article-title":"Analysis and predication of tuberculosis registration rates in Henan Province, China: an exponential smoothing model study","volume":"9","author":"Zhang","year":"2020","journal-title":"Infect Dis Poverty"},{"key":"ref50","doi-asserted-by":"publisher","first-page":"e37","DOI":"10.1017\/s0950268822000036","article-title":"Spatial epidemiological characteristics and exponential smoothing model application of tuberculosis in Qinghai plateau, China","volume":"150","author":"Shang","year":"2022","journal-title":"Epidemiol Infect"}],"container-title":["Frontiers in Public Health"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fpubh.2026.1948171\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,18]],"date-time":"2026-09-18T05:38:07Z","timestamp":1789709887000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fpubh.2026.1948171\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9,18]]},"references-count":50,"alternative-id":["10.3389\/fpubh.2026.1948171"],"URL":"https:\/\/doi.org\/10.3389\/fpubh.2026.1948171","relation":{},"ISSN":["2296-2565"],"issn-type":[{"value":"2296-2565","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,18]]},"article-number":"1948171"}}