Unequal Burden and Unequal Access: Socioeconomic Disparities in Tuberculosis Diagnosis and Out-of-Pocket Expenditures in South Africa and Lesotho

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Abstract Tuberculosis (TB) remains a major public health challenge in Southern Africa, where socioeconomic disparities continue to influence access to care, diagnostic pathways, and treatment outcomes. This study examines how wealth, comorbidities, and household economic vulnerability drive TB diagnosis and access to care in South Africa and Lesotho, with the aim of informing more equitable TB interventions. We analysed data from a community-based diagnostic trial comparing two TB screening strategies and assessed the socioeconomic and clinical profiles of individuals diagnosed via active case finding (ACF). Additional participants were enrolled via a passive case finding approach to allow for comparison. We examined associations between socioeconomic status (SES) and both TB-related outcomes (diagnosis pathway, treatment status) and non-TB economic outcomes (TB-associated out-of-pocket expenditures (OOP) and income change) among 417 participants, applying logistic regression and stratified analyses Higher SES was associated with linkage to care among TB-positive individuals, as indicated by the presence of a documented TB record. Participants from higher SES groups incurred greater absolute OOP expenditures, particularly in South Africa. In Lesotho, income loss and borrowing were uncommon but disproportionately affected those in the lowest SES group, who also experienced a higher financial burden relative to income. Higher educational attainment and HIV-positive status were associated with greater odds of being diagnosed with TB through passive case finding and of receiving TB treatment. No significant changes in household income were observed between baseline and follow-up 56 ±6 days later among ACF-identified participants. Overall, only 3.3% of those reporting OOP costs experienced catastrophic health expenditure (>20% of monthly income). Funding This project is part of the EDCTP2 programme (grant number RIA2018D-2498; TB TRIAGE+) supported by the European Union. Trial registration ClinicalTrials.gov ( NCT05526885 ), South African National Clinical Trials Register (SANCTR; DOH-27-092022-8096).

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