TITLE: The patient costs of care for those with TB and HIV: A cross-sectional study from South Africa

Background: This study describes the post-diagnosis care-seeking costs incurred by people 2 living with TB and/or HIV and their households, in order to identify the potential benefits of 3 integrated care. 4 Methods: We conducted a cross-sectional study with 454 participants with TB or HIV or both in 5 public primary health care clinics (PHC clinics) in Ekurhuleni North Sub-District, South Africa. We 6 collected information on visits to health facilities, direct and indirect costs for participants and 7 for their guardians and caregivers. We define ‘integration’ as receipt of both TB and HIV services 8 at the same facility, on the same day. Costs were presented and compared across participants 9 with TB/HIV, TB-only and HIV-only. Costs exceeding 10% of the participant`s income were 10 considered catastrophic. Results: Participants with both TB and HIV faced a greater economic burden (USD $74/month) 12 than those with TB only (USD $68/month) or HIV only (USD $40/month). On average, people 13 with TB/HIV made 18.4 visits to health facilities, more than TB-only participants or HIV-only 14 participants who made 16 and 5.1 visits respectively. However, people with TB/HIV had fewer 15 standalone TB (10.9) and HIV (2.2) visits than those with TB-only (14.5) or HIV-only (4.4). 16 Although people with TB/HIV had access to ‘integrated’ services, their time loss was substantially 17 higher than for other participants. Overall, 55% of participants encountered catastrophic costs. 18 Access to official social protection schemes was minimal. Conclusions: People with TB/HIV in South Africa are at high risk of catastrophic costs. To some extent, integration of services reduces the number of standalone TB and HIV of visits to the health facility. It is that catastrophic costs can be averted by service integration alone. Our results point to the need for timely social protection, particularly for HIV-positive people starting TB treatment.

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