Epidemiological trends and burden of mortality from HIV/AIDS and multidrug-resistant tuberculosis without extensive drug-resistance across Africa: A global burden of disease analysis (1990-2021).

Background: HIV/AIDS and multidrug-resistant tuberculosis (MDR-TB, non-extensively drug-resistant) together cause significant mortality in Africa, home to 67% of the 39 million people living with HIV globally and 2.5 million TB cases in 2022. This study analyzes Global Burden of Disease (GBD) 2021 data to quantify temporal trends and mortality burdens of HIV/AIDS and MDR-TB across African subregions from 1990 to 2021, focusing on regional and gender-specific patterns. Methods: Age-standardized mortality rates (ASMR) per 100,000 population for HIV/AIDS and MDR-TB were extracted from GBD 2021 for the African Union (Central, Eastern, Northern, Southern, Western subregions), stratified by gender. Joinpoint regression (Joinpoint Regression Program, version 5.0.2) calculated Annual Percent Change (APC) and Average Annual Percent Change (AAPC) with 95 % CIs and p-values (p < 0.05 for significance). Weighted Bayesian Information Criterion and permutation testing identified up to six joinpoints. This method fits piecewise log-linear models, pinpointing inflection points (joinpoints) where statistically significant changes occur. Sensitivity analyses ensured robustness, adhering to GBD protocols. Results: From 1990 to 2021, the African Union exhibited varied trends in age-standardized mortality rates (ASMR) for HIV/AIDS and multidrug-resistant tuberculosis (MDR-TB). Overall, mortality trends showed a non-significant average annual percent change (AAPC) of 1.9526 % (95 % CI: -1.7682, 6.3941; p = 0.278344), reflecting a complex epidemic trajectory. Early in the period (1990-1999), mortality surged dramatically, with annual percent changes (APCs) peaking at 99.81 % (1990-1992) due to limited treatment access. A turning point emerged around 2003, with declines becoming prominent from 2006 onward. The most substantial reductions occurred between 2006 and 2014, with an APC of (-10.3478 %; 95 % CI: -11.0939, -9.8873; p < 0.000001), driven by expanded antiretroviral therapy (ART) and improved diagnostics. Gender-specific patterns revealed steeper declines for females, particularly in Southern Africa (2007-2014, APC: -12.97 %), compared to males (2007-2013, APC: -11.36 %), highlighting the impact of targeted interventions for women. Regionally, Southern Africa bore the highest burden, with early increases (1990-1993, APC: 105.55 %) but significant declines post-2007 (APC: -11.95 %). Central Africa saw notable reductions after 2016 (APC: -15.75 %), while Northern Africa experienced a rising trend: AAPC 3.5641 % (95 % CI: 0.6866, 7.0452; p = 0.014397); driven by early spikes (1990-1992, APC: 38.89 %). Eastern and Western Africa showed modest declines, with APCs of -10.98 % (2004-2008) and -9.21 % (2006-2014), respectively. Conclusions: The study highlights significant progress in reducing HIV/AIDS and MDR-TB mortality across Africa from 1990 to 2021, largely due to expanded access to antiretroviral therapy (ART), advanced diagnostics like GeneXpert, and global health initiatives such as PEPFAR and the Global Fund. However, persistent regional disparities, with Northern Africa showing rising mortality trends and Southern Africa bearing the highest burden, underscore the need for tailored interventions. Females experienced more pronounced mortality declines in certain periods, particularly in Southern Africa, likely due to targeted interventions like PMTCT, while males showed slightly less progress overall, potentially due to factors like occupational exposures or lower ART adherence. Limitations include reliance on modeled GBD data and lack of subnational granularity.