The Shifting Landscape of HIV-Tuberculosis Co-Infection in the MENA Region with a Focus on Saudi Arabia: A Systematic Epidemiological Analysis over Three Decades.

INTRODUCTION: The interaction between human immunodeficiency virus (HIV) and tuberculosis (TB) presents a persistent public health challenge, particularly with the emergence of multidrug-resistant TB (MDR-TB) and extensively drug-resistant TB (XDR-TB). The Middle East and North Africa (MENA) region shows complex TB patterns, and Saudi Arabia continues to face challenges in TB control within the regional context.

METHODS: Using Global Burden of Disease (GBD) 2023 estimates, we analyzed age-standardized disability-adjusted life year (DALY) and incidence trends for HIV and drug-susceptible TB, MDR-TB, and XDR-TB in Saudi Arabia and the MENA region from 1990 to 2023. Temporal patterns were quantified using Joinpoint regression to estimate annual percent change (APC) and average annual percent change (AAPC).

RESULTS: Across MENA and Saudi Arabia, the burden of drug-susceptible TB increased during the 1990s to early 2000s and subsequently declined in 2023 (MENA age-standardized DALY rate [ASDR]: 6.60 in 1990, peaking at 13.11 in 1999, declining to 7.39 in 2023; Saudi Arabia ASDR: 13.63 in 1990, peaking at 20.56 in 2003, declining to 4.94 in 2023). A similar temporal pattern was observed for MDR-TB (MENA ASDR (Age-Standardized DALY Rate): 0.03 in 1990, peaking at 1.04 in 2002, declining to 0.40 in 2023; Saudi Arabia ASDR: 0.03 in 1990, peaking at 1.93 in 2003, declining to 0.33 in 2023). In contrast, XDR-TB showed an overall decline in MENA (ASDR: 1.72 in 1991, declining to 0.02 in 2023), while in Saudi Arabia, ASDR declined from 2.42 in 1991 to 0.02 in 2023. MENA estimates are presented to provide regional context and enable comparison with national trends in Saudi Arabia.

CONCLUSIONS: From 1990 to 2023, the TB burden among people with HIV in Saudi Arabia declined substantially, particularly for drug-susceptible TB, indicating progress in TB control and HIV management. Drug-resistant forms (MDR-TB and XDR-TB) showed complex trends with early increases followed by stabilization or gradual reductions in absolute burden.