Poverty Shapes TB Diagnosis and Costs in South Africa and Lesotho

Tuberculosis remains a major health challenge in Southern Africa, and not everyone faces the disease or its costs in the same way. Researchers led by Harsh Vivek Harkare set out to understand how wealth, other illnesses, and household economic vulnerability affect who gets diagnosed, how people find care, and what they pay out of pocket in South Africa and Lesotho. The team used data from a community-based diagnostic trial that compared two approaches to TB screening and focused on people found through active case finding (ACF). To get a fuller picture, they also enrolled additional people who were diagnosed the usual way, through passive case finding. By looking across income groups, education levels, and health conditions such as HIV, the study aimed to reveal where the health system and social protections are working — and where they are not — so that TB programs can be made fairer and more effective.

The study analysed 417 participants and examined links between socioeconomic status (SES) and a range of TB-related and economic outcomes. The investigators compared people diagnosed through ACF with those found by passive case finding, assessed clinical and socioeconomic profiles, and used logistic regression and stratified analyses to test associations. Key findings included that higher SES was associated with linkage to care among people with TB, as shown by the presence of a documented TB record. People from higher SES groups also spent more in absolute out-of-pocket (OOP) costs, especially in South Africa. In Lesotho, income loss and borrowing were rare overall but fell disproportionately on the poorest households, who faced a higher financial burden relative to their income. Higher educational attainment and HIV-positive status were linked to greater odds of being diagnosed via passive case finding and of receiving TB treatment. Among ACF-identified participants, household income did not change significantly between baseline and follow-up 56 ±6 days later. Only 3.3% of those reporting OOP costs experienced catastrophic health expenditure (>20% of monthly income). The project was part of the EDCTP2 programme (grant number RIA2018D-2498; TB TRIAGE+) and is registered at ClinicalTrials.gov (NCT05526885) and the South African National Clinical Trials Register (SANCTR; DOH-27-092022-8096).

These results point to an unequal picture: richer people were more likely to have documented linkage to TB care but also spent more out of pocket in absolute terms, while the poorest—particularly in Lesotho—suffered a heavier financial hit relative to their income even when direct costs were low. The association of higher education and HIV-positive status with passive diagnosis and treatment suggests that people with less education or without HIV may face barriers to being diagnosed and started on therapy. Although catastrophic payments were uncommon in this sample, the disproportionate burden on the lowest SES groups highlights ongoing vulnerability. Taken together, the findings argue for TB programs and social policies that address both access to diagnosis and the economic impact on poor households, so that care reaches those most likely to be left behind and financial hardship is reduced.