HIV/AIDS burden, attributable risk factors, and projections among reproductive-age adults in China, 1990–2035: A GBD 2023 analysis

BACKGROUND: HIV/AIDS remains a leading infectious disease burden globally. While highly active antiretroviral therapy has transformed HIV into a manageable chronic condition, contemporary trends and attributable risk factors among reproductive-age adults in China-a critical demographic for epidemic control-remain poorly characterized. This study provides an updated comprehensive assessment of HIV/AIDS burden in this population using Global Burden of Disease Study 2023 data, which incorporates methodological refinements and post-pandemic data not available in earlier versions. METHODS: We extracted age-standardised incidence, prevalence, mortality and disability-adjusted life-years (DALYs) for Chinese adults aged 15-49 years from GBD 2023. Joinpoint regression estimated annual percent change and identified significant trend inflection points. Population attributable fractions were analysed for unsafe sex, drug use, and intimate-partner violence. ARIMA models forecasted burden trends to 2035 with 95% uncertainty intervals. RESULTS: Between 1990 and 2023, age-standardised rates increased substantially: incidence +301% (from 0.82 to 3.29 per 100,000), prevalence +774% (4.84 to 42.29), mortality +1,623% (0.13 to 2.24), and DALYs + 1,439% (7.96 to 122.48). Males showed consistently steeper increases than females across all metrics (all p < 0.05). Unsafe sex accounted for 70% of HIV/AIDS mortality in 2023. ARIMA projections indicate that while male incidence will plateau at ~5.0 per 100,000 by 2035, female metrics will continue rising (incidence +21%, prevalence +30%), widening the sex disparity. CONCLUSION: China's HIV epidemic has transitioned to a chronic disease burden. Notably, this burden shows pronounced sex differences. Mortality is rising among people living with HIV, particularly among women. These trends highlight urgent needs for gender-differentiated prevention strategies. Our findings provide measurable targets for China's National HIV/AIDS Action Plan (2024-2030) and SDG 3.3 monitoring. They further demonstrate how standardized burden estimation supports precision public health.