Temporal dynamics and regional disparities in HIV/AIDS and extensively drug-resistant tuberculosis mortality in South Asia: A systemic analysis of global burden of disease data (1993-2021).

BACKGROUND

The dual epidemic of HIV/AIDS and extensively drug-resistant tuberculosis (XDR-TB) remains a critical public health challenge in South Asia. HIV/AIDS compromises immune function, heightening susceptibility to opportunistic infections like TB, while XDR-TB, characterized by resistance to isoniazid, rifampicin, fluoroquinolones, and second-line injectables, severely complicates treatment and increases mortality risk. Despite global efforts, such as the WHO's End TB Strategy, progress in South Asia has been uneven, with limited exploration of regional and sex-specific mortality disparities. This study leverages Global Burden of Disease (GBD) 2021 data to analyze temporal trends and regional variations in HIV/AIDS and XDR-TB mortality across South Asia from 1993 to 2021, aiming to guide targeted public health interventions.

METHODS

We performed a retrospective, population-based analysis of HIV/AIDS and XDR-TB mortality trends in five South Asian countries (Nepal, Pakistan, Bhutan, Bangladesh, India) and the region overall, using GBD 2021 data. Annual mortality rates (AMR) per 100,000 population were extracted for both diseases, stratified by sex. Joinpoint regression analysis was utilized to evaluate temporal trends, detecting significant changes in AMR through Annual Percent Change (APC) and Average Annual Percent Change (AAPC), reported with 95 % confidence intervals (CIs) and p-values.

RESULTS

From 1993 to 2021, HIV/AIDS and XDR-TB co-infection mortality exhibited significant increases across South Asia, with marked regional and sex-specific variations. Pakistan recorded the highest AAPC for both sexes combined (43.75 %, 95 % CI: 36.91-56.57, p < 0.000001), reflecting a persistent and substantial rise, followed by Bangladesh with an AAPC of 31.43 % (95 % CI: 24.97-40.61, p < 0.000001). Nepal showed an AAPC of 22.52 % (95 % CI: 12.09-35.81, p < 0.000001), while India and Bhutan had comparatively lower AAPCs of 8.06 % (95 % CI: 1.70-16.33, p = 0.0168) and 6.99 % (95 % CI: 3.79-10.50, p < 0.000001), respectively. Regionally, South Asia's AAPC was 7.98 % (95 % CI: 1.91-15.99, p = 0.011). Sex-stratified analyses highlighted disparities, with females in Pakistan exhibiting the highest AAPC (46.00 %, 95 % CI: 38.72-59.59, p < 0.000001), followed by females in Bangladesh (32.77 %, 95 % CI: 26.24-41.93, p < 0.000001). Joinpoint regression for South Asia identified six distinct segments, with an early peak APC of 393.84 % (1993-1995, 95 % CI: 336.40-463.07, p < 0.000001), driven by limited antiretroviral therapy (ART) and diagnostic access, followed by a significant decline from 2008 to 2021 (APC: -5.69 %, 95 % CI: -6.48 to -5.14, p = 0.0016). Country-specific trends revealed steep increases from 1993 to 2005 across all nations, with Nepal, Bangladesh, and India showing significant declines from 2018 to 2021 (e.g., India: APC -6.08 %, p = 0.0012), likely due to improved ART coverage and TB management. Pakistan, however, showed no decline, with a sustained APC of 6.50 % (2013-2021, p < 0.000001). Females in India experienced a sharper decline from 2019 to 2021 (APC: -17.38 %, 95 % CI: -22.64 to -9.38, p < 0.000001) compared to males (APC: -7.15 %, p < 0.000001), suggesting sex-specific treatment access differences.

CONCLUSION

South Asia faced substantial HIV/AIDS and XDR-TB co-infection mortality increases from 1993 to 2005, with recent declines in Nepal, Bangladesh, and India reflecting enhanced treatment access and healthcare improvements. Pakistan's persistent mortality rise underscores ongoing challenges, including drug resistance and limited healthcare infrastructure. Sex-specific disparities emphasize the need for tailored interventions.